GI Flashcards
Pill esophagitis
Meds: NSAIDs, KCl, quinidine, bisphosphonates, Fe, Vit C, Abx
Sxs: odynophagia, dysphagia, retrosternal chest pain
Mgmt: drink 1-2 full glasses of water after pill, sit upright for at least 1 hour after
Infectious esophagitis
Et: HSV, CMV, Candida, HIV
RF: h/o immune suppression, usually HIV, organ transplant or chemo, asthmatics using steroid inhalers
Sxs: odynophagia, dysphagia, atypical CP
Dx: EGD w/bx and cytology; HIV testing
Mgmt:
- HSV: Acyclovir 200mg PO 5x/day x 7-10 days
- CMV: Ganciclovir 5mg/kg IV q 12hr x 3-4wk
- Candida: Nystatin swish/swallow; clotrimazole troches, ketoconazole, fluconazole
Eosinophilic Esophagitis
Et:
- food/environmental antigens stimulate inflammatory response
RF: chldren w/h/o allergics or atopy: allergies, asthma, eczema
Sxs:
- long h/o dysphagia to solids
- heartburn
- children: abd pain, vomiting, CP, FTT
Dx:
- CBC w/diff (eosinophilia)
- Elevated IgE
- Barium swallow
- EGD w/biopsy: small-caliber esophagus w/strictures or corrugated concentric rings**; exudates, red furrows
Mgmt:
- PPI PO BID x 2mo trial - f/u w/endoscopy and bx
- consider allergist
- common allergenic foods: peanuts, dairy, eggs, wheat, soy, shellfish
- topical corticosteroids: budesonide, fluticasone
Oropharyngeal dysphagia
Difficulty initiating swallow; high aspiration risk
Et: CVA, PD, MS, ALS, deconditioning
Sxs: wet quality of speech, coughing while eating
- h/o aspiration pneumonia
Dx: speech therapy eval w/swallow study
Mgmt:
- modify diet: thickened liquids
- swallow training
- alternate feed route (PEG)
Mechanical aphagia
Food impaction = GI emergency
- h/o recently ingested food lodged in esophagus
Sxs: drooling and difficulty controlling secretions
Dx: refer to GI asap for EGD w/mechanical disimpaction
- repeat EGD in 6wk for bx
Mgmt:
- PPI or Glucagon: antisecretory
- do NOT get esophagram
- complications: Boerhaave’s syndrome
Peptic Stricture
MC d/t GERD, typically GEjxn
Sxs: gradual onset solid food dysphagia
Dx: barium esophagram
- EGD w/bx
Mgmt: balloon dilation; bougie dilator
Zenker’s diverticulum
Diverticulum at pharyngoesophageal junction
Sxs: dysphagia, regurgitation, halitosis, nocturnal choking
Dx: esophagram
Mgmt: upper esophageal myotomy +/- diverticulectomy if symptomatic
Achalasia
Idiopathic motility disorder characterized by loss of peristalsis in distal 2/3 and impaired relaxation of LES*
Sxs:
- failure of esophagus to relax; gradual onset
- regurgitation, vomiting, wt loss, fullness, angina, choking, aspiration, pneumonia
- liquid and solid dysphagia**
- nocturnal regurgitation**
Dx:
- barium swallow: Bird’s beak*
- manometry: INC LES pressure w/out reflexes
Mgmt:
- isosorbide, nifedipine, verapamil
- botox injection
- balloon stretching*
- esophageal “heller” myotomy” - open w/fundoplication, cut nerves to plexus to relax LES and then tighten area so you don’t have reflux
Mallory-Weiss Tear
Longitudinal tears in mucosal membrane, distal esophagus*
Cause: retching against closed glottis
RF: alcohol, hiatal hernia
Sxs: specks of BRB or coffee-ground emesis of mild hematemesis after forceful retching
- most have no PE findings, possibly tachycardia
+/- melena
Dx:
- Upright CXR: if hemodynamically unstable; evaluate for free air (Boerhaave syndrome - complete esophageal rupture)
- EGD after resuscitation*
- UGIB = inc BUN
Mgmt:
- assess hemodynamic stability, need for resuscitation
- PPIs, antiemetics
- d/c w/OP EGD f/u
- consider RF for bleeding and consider admit
- active bleeding = endoscopic hemostatic therapy
GERD general
Cause:
- incompetent LES (pressure <10 mmHg)
- transient reflux
- hiatal hernia
- abnormal esophageal clearance
- delayed gastric emptying
Heartburn reproducible by meals, bending or recumbency
Partial relief w/self-treatment
Sxs:
- heartburn, dysphagia, chest pain, cough, wheezing, hoarseness
- nocturnal awakenings, nighttime sxs - anatomical deficits (not just dietary/lifestyle)
- solid dysphagia: mechanical obstruction
- liquid and solid dysphagia: spasm, scleroderma, achalasia
Atypical sxs:
- nocturnal/chronic coughing
- hoarseness
- atypical CP
- sore throat
- asthma, reactive airway disease
PE:
- dental erosions
- pharyngitis
- halitosis
- neck masses
- wheezing
- abd tenderness/masses
Can progress to Barrett’s and adenocarcinoma
GERD dx/tx
Dx
- gold standard: pH monitor
- PPI trial
- serial EGD w/bx to r/o mucosal changes
- manometry, motility measures
Mgmt:
- reduce acidic foods, caffeine, wt loss, upright position for sleeping, stress reduction
- H2Ras
- Trial PPI*
- Refractory: Nissen fundoplication
- Pt w/long-standing GERD (>5y) especially >50yo should have upper endoscopy to detect/screen for Barrett’s*
PPIs
- dec acid secretion but don’t prevent reflux
- AE: HA, N, abd pain, bloating
- bone density: dec absorption of Ca d/t acid suppression = supplement Ca, Vit D
- Anemia d/t dec iron absorption
- SI bacterial overgrowth and B12 def
- Inc pneumonia in elderly
- Inc r/o C. diff
- hypoMg
Gastritis
MC w/alcohol or critically ill pt
RF: NSAIDs, stress, H. pylori
Sxs: often asx
- may have epigastric pain
- NV, upper abd pain, acute UGI bleed
Dx: EGD - petechiae, erosion, hemorrhage, inflammation on biopsy
Mgmt:
- remove alcohol
- treat H. pylori
- IV PPI if GI bleed is present, ulcer prophylaxis for critically ill pt
PUD
D/t acidic gastric juice corroding gastric epithelium
- more common in males
- duodenal 5x more than gastric
- gastric more common in elderly
RF: NSAIDs, H. pylori, stress, tobacco, Zollinger ellison
Sxs: aching, burning pain
- duodenal ulcer: better with food
- gastric ulcer: worse with food
Duodenal ulcer bleed MC on posterior surface of duodenal bulb
Perfs more likely anterior d/t lack of protective viscera - free air = emergency
Dx:
- gold standard: EGD w/urease test
- UGIB: Inc BUN
- if bleeding on EGD: epi injection, electrocautery, laser ablation
Mgmt:
- heal ulcer w/acid suppression and kill h. pylori [triple or quad therapy]
- gastric: PPI x 8wk
- duodenal: PPI x 4wk
- d/c NSAIDs
- surgery for complications (bleeding, perf, obstruction)
- perf = Graham steele closure
Acute cholecystitis
80% d/t obstruction of cystic duct by gallstone impacted in Hartmann’s pouch*
- acalculus: after trauma, critically ill, recent major surgery
Sxs: acute RUQ/epigastric pain, radiates to right scapula
+ Murphy’s sign
- palpable gallbladder
- h/o biliary colic now longer/more intense
Dx:
- CBC: leukocytosis
- Inc bili, ALT, alk phos
- Abd U/S* - cholithiasis, U/S Murphy’s sign, GB wall thickening, pericholecystic fluid
Mgmt:
- NPO, NG placement
- IV pain mgmt
- IV abx: Unasyn, Zosyn, Ertapenem
- Early lap chole/surgery consult
Chronic cholecystitis
MC symptomatic gallbladder disease
Biliary colic: transient gallstone obstruction of cystic duct w/RUQ pain
- may also be epigastric or LUQ may radiate to back or scapula
Dx: U/S*
- MRCP/ERCP, HIDA Scan
- ALT/AST modestly elevated
Mgmt:
- NSAIDs/opioids for acute pain relief
- Lap Chole
- Ursodiol to dissolve stones if not surgical candidate
Cholelithiasis
RF: fat, female, fertile, forty
- rapid wt loss, DM, hemolytic anemia, pregnancy, hypertrig
Protective: low carb, high fiber, exercise, cardio, high Mg diet, coffee
Sxs: most asx; large can cause acute cholecystitis, CA
Dx: U/S
Mgmt:
- most require no treatment
- possible cholecystectomy if sx persist
ETOH hepatitis
Men, highest risk = 12 drinks/day
Sxs
- Rapid onset jaundice, liver failure
- HE, ascites, tender hepatomegaly, dark urine/acholic stool
Dx: >2:1 elevated AST>ALT
- Inc bili, INR
- leukocytosis, neutrophilia
- U/S r/o biliary obstruction*
Hepatorenal syndrome: renal failure
Mgmt:
- addiction help, nutrition
- Maddrey discriminant index > 32 = treat w/prednisolone or pentoxifyline
Acute hepatic failure
Rapid liver failure + Hepatic encephalopathy
- acute: w/in 8wk after onset of liver injury
- cause: MC APAP [other: INH, pyrazinamide, rifampin, AEDs, abx, viral hep, liver ischemia, Budd-Chiari, autoimmune hep, fatty liver]
Sxs:
- encephalopathy: vomiting, coma, asterixis*, hyperreflexia, cerebral edema, Inc intracranial pressure
- ammonia = neurotoxin
- coagulopathy: dec hepatic production of coag factors
- HPM, jaundice
Dx:
- Inc ammonia, PT/INR>1.5, LFTs, hypoglycemia
Mgmt: encephalopathy - lactulose: neutralize ammonia - rifaximin, neomycin: DEC bacteria producing ammonia in GI tract - protein restriction
Definitive: transplant
Viral hepatitis
Prodrome:
- malaise, arthralgia, fatigue, URI, anorexia
- NV, abd pain, loss of appetite
+/- acholic stool
Icteric phase: jaundice
Fulminant:
- encephalopathy, coagulopathy
- jaundice, edema, ascites, asterixis, hyperreflexia
Dx:
- Inc ALT > Inc AST
- both > 500-1000 if acute
+/- bilirubinemia
Mgmt: clinically recover w/in 3-16wk
- 10% HBV and 80% HCV become chronic
Hepatitis A
Transmission: fecal oral
- contaminated water, food, international travel, daycare workers, MSM, shellfish
Sxs:
- adults spiking fever
- kids usually asx
Dx:
- acute: +IgM HAB ab
- past exposure: +IgG HAV ab w/neg IgM
Mgmt:
- self-limiting, sx tx
- HAV Ig post-exposure prophylaxis
- vaccine
Hepatitis E
Transmission: fecal oral
- water-borne outbreak
Dx: + IgM anti-HEV
Mgmt:
- self-limiting
- highest morality during pregnancy (especially thrid tri) ** inc r/o fulminant hep
Hepatitis C
Transmission: parenteral
- IVDU, blood transfusion prior to 1992
Dx: \+ anti-HCV ab in 6wk doesn't imply recovery acute: HCV RNA +, anti-HCV +/- resolved: HCV RNA -, anti-HCV +/- chronic: HCV RNA +, anti-HCV +
Mgmt: antivirals
- screen for HCC via AFP, U/S
Hepatitis D
Requires Hepatitis B co-infection*
Hepatitis B
Transmission: parenteral, sexual, perinatal, percutaneous
Sxs:
- acute: 70% subclinical, 30% jaundice
- chronic asx carrier: +HBsAg, +HBe ab, low HBV DNA, normal LFTs
- chronic infection: + HBsAg, Inc ALT/AST, Inc HBV DNA and evidence of hepatocellular damage on liver biopsy
Mgmt:
- acute: supportive
- chronic: tx may be indicated if Inc ALT, inflammation on biopsy, or +HBeAg
- alpha-INF 2b, lamivudine, adefovir, tenofovir, entecavir
Prophylaxis w/Hep B vaccine at 0, 1, 6 months
Hepatitis B labs
HBsAg: 1st evidence of infection before symptoms, if + >6mo = chronic infection
HBsAb: distant resolved infection OR vaccination (if alone)
- signifies immunity, pt not infectious, chronic infection if don’t establish this in 6mo
HBcAb: IgM (acute infection), IgG (chronic infection or resolved)
HBeAg: Inc viral replication, Inc infectivity
- >3mo = Inc likelihood of developing chronicity
HBeAb: waning viral replication, Dec infectivity
Chronic viral hepatitis
Disease > 6mo duration
- only Hep B, C, D
- may lead to ESLD or HCC
Dx: ALT, AST < 500
Liver cirrhosis
Irreversible liver fibrosis w/nodular regeneration leading to increased portal pressure
- MC cause: EtOH
- Other cause: HCV, NASH, hemochromatosis, autoimmune hepatitis, PBC/PSC, drug toxicity
Sxs: constitutional
- ascites, HSM, gynecomastia, spider angioma, caput medusa, muscle wasting, ,bleeding, palmar erythema, Dupuytren’s contracture
Complications:
- hepatic encephalopathy: confusion, lethargy, asterixis, increased ammonia levels
tx: rifaximin, lactulose - esophageal varices
- SBP: fever, PMNs > 250 in peritoneal fluid
Dx:
- U/S
- Staging w/Child-Pugh [total bili, serum albumin, PT, ascites, hepatic encephalopathy]
- MELD for ESRD
Tx:
- ascites: Na restriction, diuretics, paracentesis
- pruritis: cholestyramine
- definitive mgmt: liver transplant
- screen for HCC w/US and AFP q 6mo
Constipation
Sxs:
- excess straining
- sense of incomplete evacuation
- failed or lengthy attempts to defecate
- hard stools
- Dec frequency of stools
Alarm: rectal bleeding, heme + stool, wt loss, obstructive sxs, recent onset of sxs, rectal prolapse, change in caliber of stool, >50yo
Dx: clinical (DRE)
- TSH, BMP, glucose
- abdominal Xray, barium enema
Mgmt:
- lifestyle: fiber, fluids, exercise
- bulk laxatives: psyllium, methylcellulose [ADR: inc flatulence/bloating - inc water intake]
- stool softener: docusate [ADR: bitter taste, N/D, cramping]
- osmotic laxative: PEG, Mg
- stimulant laxative: Senna, Bisocodyl [do NOT use for chronic constipation]
- Lineclotide, lupiprostone - if not pregnant
Crohn’s disease
Peak: 20-40yo
Affects any portion of GI tract, mouth to anus
MC affects: terminal ileum, Right colon
Sxs:
- diarrhea, hematochezia, recurrent abdominal pain, wt loss, malaise, anorexia, SBO
- extraintestinal: uveitis/episcleritis, oral ulcers, skin changes, joint pain
Dx: endoscopy (upper/lower)
- cobblestoning of bowel wall
- rectal sparing
- skip lesions
- granulomatous ulcers
- fistulas
- “string sign”
Mgmt:
- anti-inflammatory meds, steroids, immunosuppressants, anti-diarrheal
- surgery to relieve obstructive sxs
- stricturoplasty
- goal: preserve length, remove affected area
- lleocecal anastomosis common
Ulcerative colitis
Sxs:
- insidious or acute presentation
- rectal bleeding, diarrhea, constipation, abdominal pain
Complications:
- CRC likely, unless colectomy; incidence begins 8-10y after onset of UC
- toxic megacolon
- acute perforation (very thin walls)
Dx: colonoscopy (only if no active disease)
- continuous lesions
- profound leukocytosis
Mgmt:
- Med: supportive
- surgical: acutely if complications; chronic if unmanaged with meds- can CURE and dec CA risk
- emergent colectomy w/toxic megacolon
- protocolectomy w/terminal ileostomy +/- J pouch = remove colon and rectum
- total colectomy
Irritable bowel syndrome
Chronic condition characterized by abd pain and bowel dysfunction
2:1 F:M, unusual if onset after 50y
RF: physical or sexual abuse, previous enteric infection, stress
Sxs:
- pain relief w/defecation
- RLQ/LLQ tenderness to palpation
Dx: diagnosis of exclusion
- CBC, stool studies, anti-TTG, abdominal Xray, flex sig, colonoscopy, hydrogen breath test, serum CRP
ROME Criteria: recurrent abdominal pain 1d/wk x 3mo associated with 2 or more:
- related to defecation
- a/w change in stool frequency
- a/w change in stool form
Mgmt:
- decrease stress, cut out trigger foods (caffeine, lactose, fructose), low FODMAP diet
- probiotics may be helpful
- treat sxs - constipation, diarrhea accordingly
Lactose intolerance
Lactase - enterocyte brush-border disaccharidase found in small intestine
MC genetic deficiency syndrome worldwide
Sxs: after/during ingestion of lactose-containing product = bloating, flatulence, diarrhea (w/o steatorrhea), crampy abdominal pain
Dx:
- clinical w/history or improvement on lactose-free diet
- Hydrogen breath test for carb malabsorption
Mgmt:
- dec/eliminate dairy products
- enzyme replacement supplement (lactaid)
- supplement calcium and vitamin D
Polyp
Adenoma: pre-cancerous
most CRC begins as small, benign clumps of cells called adenomatous polyps/adenoma
MC: left side of colon
Sxs: typically asx
- rectal bleeding is the most common: intermittent, variable color
Dx: colon w/bx and polypectomy
Mgmt: polypectomy, may require further resection
Screening:
- FOBT or FIT q year
- Stool DNA q 1-3y
- Double contrast barium enema q 5y
- CT colonography q 5y
- flex sig q 5y
- flex sig + annual Fit q 10y
- colon q 10y
- 1st deg relative or someone younger than 60 had CRC or adenoma - start 10y earlier than earliest diagnosis
Colorectal Cancer
95% adenocarcinomas
Start screening at 45y or symptomatic
Must r/o in adult with rectal bleeding even in presence of hemorrhoids
Sxs:
- R colon: thin wall w/large lumen, liquid feces, fatigue, weakness, wt loss, tumors erode through wall quicker
- L colon: small lumen, semisolid feces, change in bowel habits, observation, bleeding
- Rectal: BRBPR/hematochezia, persistent
Dx:
- check supraclavicular LAD
- tumor marker: CEA
- colonoscopy w/bx
- look for mets w/CT or PET
Mgmt: wide surgical resection including regional LN drainage +/- Radiation/chemo
- cecal: R hemicolectomy w/ileocolic anastomosis
- transverse: transverse colectomy w/ascending and descending colon anastomosis
- hepatic flexure: extended R colectomy w/ileocecal anastomosis
- splenic flexure: L hemicolectomy w/transverse and sigmoid colon anastomosis
- sigmoid: sigmoid colectomy w/colo-colo anastomosis
Anal fissure
90% occur posterior (closest to spine), if not there, then anterior position; right or left are abnormal
Et: young adult; most a/w constipation
RF:
- trauma: constipation/strain, high sphincter tone, explosive diarrhea
- immunosuppressive conditions
- others: childbirth, anal intercourse, foreign body insertion
Sxs:
- pain out of proportion to the appearance
- ranges from mild irritation to severe pain
- sharp, stinging, tearing, burning a/w and after defecation
- pain may last several min - hours; scant BRBPR on toilet paper
- itching, perianal irritation
Dx: clinical
Mgmt:
- relieve constipation, facilitate easy BM (stool softener)
- most heal w/conservative tx in 8wk
- Inc fiber/fluid, keep anal area clean/dry
- warm sitz baths after BM to inc blood flow and promote healing
- topical anesthetic (benzocaine)
Chronic fissure: 4-6wk, appear fibrotic, failure to respond to conservative therapy suggests Inc internal anal sphincter pressure
- tx w/vasodilating ointment (diltiazem); botox injection; lateral internal sphincterotomy
Fecal impaction
atypical presentation of constipation
RF: opioids, bed rest, neurogenic or spinal cord disorders
Sxs: NV, abd pain, anorexia, distension, paradoxical diarrhea
Dx: confirmed by DRE
Mgmt: digital disimpaction, enema, suppository
Hemorrhoids
Engorged tissue d/t Inc intra-abdominal pressure from pregnancy, ascites, obesity
- bleed
- bleed and prolapse
- manual reduction
- cannot be reduced
Sxs: swollen, inflamed vein in anus/rectum
- BRBPR +/- Pain**, pruritic, mucoid d/c
- external: acute intravascular thrombosis
Dx:
- external: below dentate line = painful
- internal: above dentate line = painless
- new onset hematochezia = colonoscopy to r/o other causes
Mgmt: conservative tx
- tx constipation
- lifestyle: avoid prolonged sitting, dec toilet time, keep anal area clean and dry, increase fluid intake, high fiber, stool softener, warm sitz bath, topical steroid less than 1 week
- symptomatic require tx
- internal hemorrhoid: band ligation 1-4; 3-4 = injection sclerotherapy, hemorrhoidectomy
Thrombosed external hemorrhoid
Acute onset very painful, tense, bluish perianal nodule precipitated by coughing, straining, lifting
Tx: removal of clot if <48hr
- pain eases over 2-3d
- oral/topical analgesics
- stool softener
- sitz bath
Incisional hernia
bulge in abdomen deep to scar
worse with cough or strain
PE: palpable
Repair w/mesh; mandatory repair if bowel involved
Inguinal hernia
Most Asx lump or swelling in groin
Sxs: heavy/dull sensation when straining or lifting may radiate to scrotum
- pain = incarceration or strangulation
PE: visual, index finger to external ring and pt cough
If asx/reducible = does not need surgery
**MC hernia: indirect inguinal
Mgmt: totally intraperitoneal laparoscopic surgery w/mesh
Umbilical hernia
soft protuberance at umbilical, often asx
PE: visual, palpable
Repair rarely recommended until 2+ yo
Mgmt: surgical repair if sx w/possible mesh if large (>2cm)
Ventral hernia
includes incisional, umbilical, epigastric, spigelian
- all defects in wall
surgical repair if symptomatic
Richter’s hernia
Takes only part of the bowel, stool can still pass through
Dx: PE
- CT w/PO contrast to see defect*
Femoral hernia
bowel obstruction d/t strangulation or incarceration
Mgmt:
- MC: totally extraperitoneal repair
- TAPP: transabdominal pre-peritoneal patch - keep mesh away from bowels
IPOM: intra-abdominal preperitoneal onlay put over defect
Diarrhea: inflammatory vs. noninflammatory
Inflammatory:
- blood/mucus more present
- less output
- sicker pt; often febrile
e. g.
- cholera
- v. vulnificus
- salmonellosis
- campylobacteriosis
- shigellosis
- e. coli
- c. diff
- traveler’s diarrhea
Noninflammatory:
- more vomiting and more output
e. g.
- norovirus
- staph aureus
- Bacillus cereus
- giardiasis
- cryptosporidiosis
Norovirus
MC infectious GE in kids/adults in the U.S.
Et: person to person transmission: fecal-oral; vomitus aerosol
- small infecting dose
- contaminated food, H2o, fomites
Sxs:
- year-round outbreaks in colder months
- “stomach flu” - no ENT sxs
- sudden onset vomiting (peds) or sudden onset diarrhea (adults) lasting 1-3d**
- low grade transient fever
- dehydration w/young or elderly
Dx: clinical
- PCR used for health dept during outbreak
Mgmt: supportive w/ORS
Staph aureus
Eating food that has been sitting out or undercooked
Enterotoxin*
- ingested from contaminated food
Sxs:
- 2-7hr after exposure*
- NV, abdominal cramps*
- fever, diarrhea uncommon*
Clinical dx, supportive tx
Bacillus cereus
Rice
- spore former, not killed by boiling
Enterotoxin*
- ingested from contaminated food
Sxs:
- 2-7hr after exposure*
- NV +/- diarrhea
Clinical dx, supportive tx
Giardiasis
Et: giardia intestinalis
- MC parasitic cause of infectious diarrhea
- streams, backpackers, beavers
Transmission: fecal-oral
- zoonotic: beavers, dogs, cattle
Sxs: incubation time 1-2wk; 60% as
- acute: malaise, NVD, belching, gas, cramping, wt loss, steatorrhea
- chronic: wax/wane overm months if not treated
Dx: immunoassay EIA stool sample
Mgmt: ORS
- tinidazole or nitazoxanide
Cryptosporidiosis
Et: C. parvum > C. hominis
Transmission: fecal-oral
- commonly waterborne
- cattle - gets into streams
Sxs:
- profuse, watery diarrhea
- crampy abd pain (cholera-like) - hits Small intestine
Dx: immunoassay EIA stool sample
Mgmt: refer
- ORS, nitazoxanide
Cholera
Et: vibrio cholera
- GNB costal waters
- may be epidemic w/raw, undercooked oysters*
- poor sanitation or contaminated water
Transmission: bacterial ingestion (requires large infecting dose)
- colonizes SI, produces cholera toxin, modulates CFTR = Cl secretion = Na/H2o into SI lumen
Endemic: asx - mild noninflammatory diarrhea
Epidemic: severe, dehydrating life-threatening inflammatory diarrhea w/electrolyte abn and hypovolemic shock
** rice water stool
Severe: cholera gravis* - lose 1L an hour, likely dead w/in 12hr
Dx: dark-field microscopy* = comma shaped darting bacteria
- stool culture
Mgmt:
- early/aggressive fluid replacement (200-350mL/kg)
- IV: Dhaka solution, high in K/bicarb
- start ORS concurrent to IV or w/in 3-4hr of stabilization
- Doxy (adults) or azithro (peds)
- supplemental zinc
Vibrio vulnificus
GNB costal US waters
Seafood - only eat RAW oysters in cold months
Transmission:
- ingestion of bacteria*
- enters GI tract - most pt die from bacteremia/sepsis
Sxs:
- hemorrhagic bullae: vibrio (costal water) or aeromonas (lake water)
- fatal in advanced liver disease (cirrhosis)
Dx: recognize
Tx: refer
Salmonellosis (nontyphoidal)
Et: flag facultative anaerobic GNB
RF: inc w/young or old, corticosteroids, immunosuppression, comorbidity
Transmission:
- zoonotic* - chicken, eggs, reptiles
Sxs:
- gastroenteritis
- inflammatory diarrhea
- concern for infective endocarditis or aortic invasion
Dx: stool culture
- positive blood or urine culture = aortic involvement until proven otherwise
Tx: FQ or ceftriaxone
Salmonellosis (typhoidal)
Anaerobic GNB
- MC: south-central, SE Asia
- dec incidence in US bc water treatment, dairy pasteurization
Trans: crowded, impoverished populations w/inadequate sanitation and exposed to unsafe H2o/food
Sxs:
- enteric fever
- constitutional sxs predominate
- constipation
- “pea-soup” diarrhea (actually uncommon)
Dx: blood culture; stool/urine culture
Mgmt:
- FQ* or ceftriaxone
Campylobacteriosis
Et: s-shaped, gull-winged, bipolar GNBs
- raw/poorly cooked chicken
- MC bacterial zoonosis in U.S.
- Unpasteurized milk, dairy
Trans: ingestion of bacteria, usually d/t cross-contamination
Sxs:
- common: asx, mild, inflammatory diarrhea
- rare, serious inflammatory diarrhea: GSB
- complications: reactive arthritis, post-infectious IBS
Dx: stool culture
Mgmt:
- supportive, usually self-limiting
- Azithro* if preg, I/c, elderly, high fever, bloody stools, sxs > 1wk
Shigellosis
Et: daycare, MSM
- as few as 10 infecting organisms can cause disease
Sxs:
- abrupt, bloody diarrhea, abd pain, tenesmus, systemic toxicity
- may develop HUS leading to ARF [#1 cause of AKI in peds]
- may develop to TTP
Dx: stool cx
Mgmt:
- adults = FQ
- peds = Azithro, TMP-SMX
E. coli 0157:H7
EHEC: Shiga-toxin producing E. coli
- shiga toxin gets absorbed causing injury to endothelial cells of glomerulus capillaries w/intra-vascular coagulation may lead to HUS
Trans:
- cattle reservoir
- MC ground beef
- waterborne
Sxs: asx - lethal
- initial: abd pain, watery diarrhea often bloody in 1-4 day (80%)
- accounts for 35% of bloody diarrhea
- afebrile
- MC complication = HUS
Dx:
- stool culture
- fecal shiga toxin testing (new stool PCR)
Mgmt: supportive
- abx controversial
C. diff background
Et:
- anaerobic gram + spore-former; toxin producing bacillus
- p-cresol odor = horse stable
- MC HAI diarrhea
RF:
- > 65yo, comorbidities
- abx use (clindamycin** > FQ)
- PPIs, H2Ras
- > 1wk in hospital
PP:
- enterotoxin A and cytotoxin B result in colonic inflammation
- colonic inflammation destroys mucosal wall leading to massive swelling, wall disintegrates and leakage
Greatest RF:
- Hospital exposure
- Abx
- PPI/H2Ra
C. diff Sxs
HAI
- sx onset >48hr after admission or <4wk from d/c
Community acquired
- sx onset community or <48hr after admission
- inc risk: peripartum women, children
Relapse: 2nd episode occurring <8wk from index case
- first time: repeat abx course, probiotics, combo abx
- second time: refer to GI
Sxs Spectrum
- asx, colonization
- diarrhea w/o colitis
- nonpseudomembranous colitis +/- diarrhea
- pseudomembranous colitis
- toxic megacolon - r/o perf
- fulminant colitis - perf, septic shock
C. diff dx/tx
Dx:
- 3+ unformed stool samples w/in 24hr in pt w/RF
- C. diff NAAT (PCR)
- leukocytosis
- hypoalbuminemia
- abd series: dilated loops of bowl
- abd CT: pericolonic fat stranding
- colonoscopy
Mod-sev disease:
- peripheral leukocytosis (>15)
- AKF
- hypotension
Tx:
- mild: metronidazole 500mg PO
- mod-sev: vanco 125-250mg PO
- if ileus = IV metro
- d/c offending abx
- toxic megacolon = colectomy
- fecal transplant
- out of isolation >24hr after diarrhea ceases
Traveler’s diarrhea
MC illness among travelers
RF:
- contaminated food/water
- eating in restaurants
- street food
bacteria (80%)
- ETEC: watery diarrhea
- campy
- salmonella, shigella
ETEC:
- malaise, anorexia, abdominal cramps
- sudden onset watery diarrhea, non-inflammatory
- NV 10-25%
- low-grade fever 30%
- duration 1-5 day
Prophylaxis
- important trip
- comorbid disease
- previous bouts
- rifaximin (expensive) or bismuth subsalicylate
Mgmt:
- non-inflam: fluids, anti-diarrhea agents, pepto
- inflam: azithro, FQ, rifaximin
Chronic diarrhea
Meds: SPAMCAN
- SSRIs
- PPIs
- ARBs
- Metformin
- Colchicine
- Allopurinol
- NSAIDs
PE: signs of malabsorption, IBD, dehydration, thyroid disease, LAD
Dx: labs
- endoscopy r/o
- H2 breath test, FOBT
- 24hr stool collection for weight
- 72hr fecal fat
- stool osmolality
- fecal leukocytes, stool lactoferrin
Mgmt: tx underlying cause
Anti-diarrheal:
- loperamide scheduled dose
- diphenoxylate w/atropine
- cholestryamine
- codeine sulfate
- clonidine (DM, secretory diarrhea)
GI refer: severity, endoscopy need, dx being considered, dx requires long-term mgmt
Osmotic diarrhea
Excess amounts of poorly absorbed substances act as an osmotic agent by drawing free water into lumen
Cause:
- carb malabs: lactose intolerance, sugar-free
- malabs: SB dz, short gut, SBO
- osmotic lax: Mg, PEG
- factitious diarrhea: stool osm < serum osm
** Stool volume dec w/fasting
Dx:
- electrolyte is unaffected by osmotically-active substance
- INC stool osmotic gap > 100-125**
290 - [stool Na + stool K] x 2
Secretory diarrhea
Intestinal secretion > absorption
Cause:
- intestinal resection/diffuse mucosal disease: dec abs surface for nutrients, lytes, fluid
- abn mediators: bacterial toxins, non-osmotic lax, bile salt malabs, neuroendocrine tumors
Sxs:
- nocturnal sx*, freq large volume (>1L/d)
- small/normal osmotic gap (<50)*
Dx:
- abnormal ion transport = dec absorption of electrolytes
Microscopic colitis
Idiopathic inflammatory disease of colon - chronic, watery diarrhea
MC: women, 65yo
Cause: unknown
- meds: NSAIDs, PPIs, paroxetine
- smokers
Types:
- collagenous colitis: presence of thickened subepithelial collagen band formed beneath surface epithelium
- lymphocytic colitis: intraepithelial lymphocytic infiltrate
Dx: colonoscopy random bx
Mgmt: refer to GI
Motility disorder diarrhea
systemic disease or prior surgery resulting in diarrhea secondary to rapid transit or stasis of contents
MC: IBS
Other:
- scleroderma
- post-vagotomy
- hyperthyroidism
- diabetic autonomic neuropathy
Malabsorption diarrhea
Results in osmotic or secretory diarrhea
Wt. loss
Steatorrhea
Nutritional def
Causes:
- celiac sprue
- short bowel syndrome
- SBBO
- pancreatic insufficiency
Bile salt malabsorption
Bile salts needed to digest fat
Malabsorption (terminal ileum)
- more bile acids lost to colon
- draw fluid/’lytes into colon causing diarrhea and deficit in bile acids
Causes:
- pancreatic insufficiency
- hepatobiliary disease
- Inc acid secretion
- disease/resection of terminal ileum
Mgmt: cholestyramine 4mg PO daily BID
- bind free bile acids so they cannot pass out of colon
Celiac sprue
Immune-mediate destruction of enterocytes
- inflammatory response in small bowel to GLUTEN [BROW - barley, rye, oats, wheat]
MC: women, white, northern euro, downs syndrome
- environment, genetics (HLA-DQ2/8)
A/w enteropathy-associated T-cell lymphoma
Sxs:
- sx w/in first 2y of life (FTT) and 2nd peak 30-40s
- fatigue, mild IDA, unexplained increased AST/ALT
- diarrhea*, steatorrhea, flatulence, wt loss but hungry
- infertility, amenorrhea
- Dermatitis herpetiformis: multiple intensely itchy macules/papules
- symmetrical on extensor surfaces of arms, legs, butt, trunk, neck
Dx:
- eval on regular diet
- IgA TTG
- Gold standard: EGD w/random small bowel bx = villous blunting/atrophy
- path: scallops on small intestine rings
Mgmt:
- gluten free, dietician
- vit D and Ca supplement
- eat CRAP: corn flour, rice flour, arrowroot, potatoes
Small bowel bacterial overgrowth
Cause:
- anatomical: diverticulosis, surgical history, strictures
- motility: DM, scleroderma, Crohns
Bacteria damage small bowel enterocytes; intraluminal consumption of nutrients by bacteria
Sxs:
- generalized malabsorption
- diarrhea, abdominal bloating, dyspepsia, nausea**
Dx: exclusion
- gold standard: proximal jejunum aspirate and culture (>10 bugs/mL) - not routinely done
- Carb breath tests: biphasic pattern
Mgmt: tx underlying disease
- PO broad spectrum abx x 1-2wk: Flagyl, Rifaximin, Cipro
+/- cyclic abx, +/- probiotics
Whipple’s disease
Multi-system disease d/t infection with Tropheryma whipplei (GPB)
MC: white men, 40-60yo
Sxs:
- migratory arthralgias, abd pain, wt loss, diarrhea (steatorrhea)**
- intermittent low grade fevers, chronic cough, LAD
- cognitive dysfunction
Dx:
- duodenal bx
- PCR confirms RNA
Mgmt: long-term Abx (1yr)
- Rocephin IV 2g daily x 2wk, then Bactrim PO bid x 1yr
- repeat bx at 6 and 12 months
Short bowel syndrome
Removal of large segment of small intestine = malabsorption
Sxs: depend on length/site of resection and body adaptation
Monitor for sequelae: osteoporosis, anemia, liver disease
Mgmt:
- supportive: fluids, electrolytes, vitamins, minerals
- anti-diarrheals: loperamide
- cholestyramine
- SBBO: abx prn
B3 (Niacin) deficiency
Alcoholics
Pellagra* = dermatitis, dementia, diarrhea
- symmetric rash, hyperpigmented red, blistering and painful/pruritic
- occurs in areas of sun exposure
- neuro sxs: insomnia, anxiety, disorientation, delusions, dementia, encephalopathy
Dx: Niacin level
Mgmt:
- 40-250 mg/day
B1 (Thiamine) Deficiency
Neuropathic sxs
- mild sensory loss +/- burning sensation in toes/feet and LE cramping
- untreated = pt develop generalized polyneuropathy w/distal sensory loss in hand/feet
Wernicke’s encephalopathy
Berberi: alcoholics
Peripheral neuropathy and signs of cardiac involvement (edema, CHF)
Fulminant cardiac syndrome with cardiomegaly, tachycardia
cyanosis, dyspnea, vomiting
altered sensorium
hoarseness d/t laryngeal nerve paralysis (classic sign)
Dx: blood/urine assays not always reliable
- clinically suspect = treat
Tx: Thiamine IV or IM 100 mg/day
Vitamin A deficiency
Developing country
Night blindness
Xerophthalmia
Bitot’s spots: build-up of keratin located superficially in conjunctiva which are oval, triangular, irregular shape
B2 (Riboflavin) deficiency
Glossitis
Cheilosis
Stomatitis
Vitamin C (Ascorbic Acid) deficiency
Scurvy
- ecchymosis, bleeding gums, malaise
- arthralgias, hyperkeratosis, impaired wound healing
Vitamin C involved in collagen synthesis
Vitamin D deficiency
Osteomalacia
- use to walk, now bone pain and require wheelchair
- waddling gait and bone pain = refer to endocrine
- x-ray: pseudofractures
- increased Alk Phos, increased PTH
- low Ca/P, 25 hydroxy D
Rickets
- inadequate mineralization of growing bone
- infants need supplementation at 2 months old
- present with delayed age of standing/walking, delayed growth, delayed closing of fontanelles
- hypocalcemic seizures in first year of life
- refer to peds endocrine
Vitamin D absorption and treatment
- Absorbed from diet/sun
- converted to 25-hydroxy vit D by liver
- converted to active form, 1,25 dihydroxy vit D by kidney (when PTH is present, low blood calcium)
- active vit D travels to intestines and causes increased reabsorption of dietary calcium, increased bone calcium mobilization, and decreased PTH release
Definition
- severe def: 25(OH)D < 5
- moderate: 5-10
- insufficiency: 10-20
- repelete goal is 20-50 maintain
> 60yo - vit D supplement 800-2000 IU/day
dark skinned babys exclusively breastfed are greater risk of rickets and should supplement 400IU/d
