GI- adults Flashcards
Bilirubin- pathophysiology
Inc unconjugated bile:
- Inc production - hemolytic anemia
- Dec uptake by liver - CH, Gilbert syndrome
- Dec conjugation - Crigler-Najjar syndrome, Gilbert syndrome
Inc conjugated bile:
- Liver doesn’t secrete - damage to liver, Dubin-Johnson syndrome, Rotor syndrome
- Biliary tree is obstructed - intrahepatic (cirrhosis, Ca, granuloma), extrahepatic (stones, stricture, Ca)
Bilirubin- cause
Clay-colored stools
Dark tea-colored urine
Pruritis
Bilirubin- S/S & PE
Jaundice - inc of unconjugated or conjugated bilirubin
Cholelithiasis- pathophysiology
Cholesterol - 90% In Gallbladder Pigment stones: - Black - formed in sterile bile - heme - Brown - bacterial metabolism in biliary infection
Cholelithiasis- cause
Cholesterol stones - 4Fs
- Fat
- Forty
- Female
- Fertile
Cholelithiasis- epidemiology
> 40
F>M
Western Countries
Cholelithiasis- S/S & PE
Asymptomatic
- 80% stay this way
Symptomatic - intermittent blockage of cystic duct by a stone
Biliary Colic - intense, dull discomfort, RUQ radiates to back -> R shoulder blade
- N/V and diaphoresis
- Last 30min ->60min then subsides
- triggered - eating fatty meal
No positive PE signs
Incidental findings
Cholelithiasis- diagnosis
U/S - echogenic foci that cast an acoustic shadow
- gravitationally dependent - will move w/ movement
- may look like sludge, but is not
Cholelithiasis- labs & imaging
Labs - Nl, even during biliary colic
Cholelithiasis- treatment
Asymptomatic - do NOT perform cholecystectomy
Typical biliary symptoms + gallstones
- acute pain - NSAIDs or opioids
- Cholecystectomy or medical dissolution of stones
Atypical symptoms + gallstones
- Cholecystectomy - lower relief rates then w/ typical symptoms
Typical symptoms, but no stones visualized
- May have function gallbladder disorder
Cholelithiasis- prognosis
Symptom relief post-surgery
Complications - bile leak, bleeding, abscess formation, biliary injury, bowel injury
> 12% develop diarrhea - can’t digest food as well
Acute Cholecystitis- pathophysiology
Acute inflammation of the gallbladder
Calculous - gallstones
- Cystic duct become obstructed by a stone -> leads to inflammation
- Bacterial inflammation? - eColi, klebsiella, streptococcus, clostridium
Acalculous - no gallstones
- unknown
- some may have biliary sludge in cystic duct, vasculitis, obstructing adenocarcinoma of the gb, unusual infection, or systemic disease - TB, sarcoidosis, TB, syphilis
- Underlying SEVERE illness - burn, postpartum, postop, TPN
Acute Cholecystitis- epidemiology
Calculous:
- F>M
- 40-60y
Acalculous
- critically ill, bedridden, on TPN
- 5-10% w/ cholecystitis
- M>F
Acute Cholecystitis- S/S & PE
RUQ pain, Fever, Leukocytosis
Diarrhea
N/V
Hx of fatty food
Lasts - several hours >4-6
Hx of previous spontaneous resolving attacks
Ill appearing
Fever
Tachy
Voluntary/involuntary guarding on abdominal exam
Rebound tenderness in RUQ
Tender to Palpation RUQ
Pos Murphys Sign - when pressed -> inspiratory arrest and inc discomfort
Able to palpate an enlarged, tender gallbladder?
Acute Cholecystitis- diagnosis
U/S:
- cholelithiasis - supports, but doesn’t diagnosis
- Gallbladder wall thickened or edema
- sonographic Murphy’s sign
- Pericholecystic fluid & dilation of bile duct
HIDA scan - done if still not confirmed diag
- Technetium labeled HIDA injected IV -> taken by hepatocytes -> excreted into bile
- Neg = can visualize gallbladder
- Pos = can’t visualize gallbladder
Acute Cholecystitis- labs & imaging
Leukocytosis - Left shift (Inc bands)
LFTs - inc
Acute Cholecystitis- treatment
ADMIT!
Pain - NSAIDs or opioids
Abx - given for acute until resolution or chole
- Comm acquired acute - Cefazolin, cefuroxime, or ceftriaxone
Cholecystectomy or cholecystostomy
- Emergent for: progressive s/s - fever, hemodynamic instable, intractable pain; suspicion or gallbladder gangrene or perforation
- Low risk: chole during initial hosp - laparoscopic
- Risk>benefits, but not emergent: gallbladder drainage w/ percutaneous cholecystostomy; once acute episode resolved -> assess for risk, maybe schedule surgery
Acute Cholecystitis- prognosis
If not treated:
- can get better in 7-10 days
- Gangrenous cholecystitis
- Perforation - abscess or peritonitis
- Cholecystoenteric fistula
- Gallstone ileus
- Emphysematous cholecystitis
Chronic Cholecystitis- pathophysiology
Chronic inflammation of gallbladder wall
With gallstones
Chronic Cholecystitis- cause
Episodes of acute/subacute cholecystitis or gallstones -> persistent irritation to gallbladder wall -> fibrosis & thickening of gallbladder
Chronic Cholecystitis- S/S & PE
Multi episodes of biliary colic
Chronic Cholecystitis- labs & imaging
U/S - cholelithiasis, wall thickening from scarring
Chronic Cholecystitis- treatment
Cholecystectomy
Porcelain Gallbladder- pathophysiology
Calcification of gallbladder wall
Porcelain Gallbladder- cause
Chronic cholecystitis?
Porcelain Gallbladder- S/S & PE
Asymptomatic
Porcelain Gallbladder- diagnosis
Incidentally - Xray
- US or CT to confirm
Porcelain Gallbladder- treatment
Inc RISK FOR CARCINOMA
Resection
Choledocholithiasis- pathophysiology
Stones within the common bile duct
Choledocholithiasis- S/S & PE
RUQ /epigastric pain - prolonged then typical biliary colic Nausea Vomiting Jaundice?
Choledocholithiasis- diagnosis
U/S - 1st
Choledocholithiasis- labs & imaging
AST/ALT - inc early
Bili, ALP, GGT - inc later
Choledocholithiasis- treatment
If high risk for CBD stone -> ERCP w/ stone removal + cholecystectomy
Acute Cholangitis (Ascending Cholangitis)- pathophysiology
Statis and infection in biliatry tract
Biliary obstruction + bacterial infection
Obstruction:
- calculi, stenosis, malignancy
- > inc intrabiliary pressure -> permeability of bile ductulus -> easier for bacteria to transfer from portal circulation to biliary tract
-> easier for bacteria to g from bile to circulation -> septicemia
Bacteria - Ecoli, Klebsilella, Enterobacter
Acute Cholangitis (Ascending Cholangitis)- S/S & PE
Charcot triad - Fever, abdominal pain (RUQ), jaundice
Reynolds Pentad - Confusion, hypotension, fever, abdominal pain, jaundice
- suppurative cholangitis
Fever & abdominal pain - most common - RUQ, diffuse Jaundice - less common Older pts and immunosuppressed - atypical presentation - HTN only?
Acute Cholangitis (Ascending Cholangitis)- diagnosis
Suspect: 1 from each
- fever, shaking/chills, lab evidence of inflammatory response (WBC or inc CRP)
- Jaundice, abnormal LFTs
Definite: above and also has
- Biliary dilation on imaging
- evidence of an etiology on imaging - stricture, stone, stent
Acute Cholangitis (Ascending Cholangitis)- labs & imaging
Leukocytosis - neutrophil predominance
LFTs - Cholestatic patter -> Inc ALP, GGT and Bili
Blood cultures - pos?
- all should have done
- if ERCP - culture bile or stent
Acute Cholangitis (Ascending Cholangitis)- treatment
Charcots Triad + abn LFTs:
- ERCP - diagnose and drain
NO Charcots Triad:
- Transabdominal U/S - look for CBD dilation or stone
- Sene -> ERCP w/in 24 hrs for drainage/stone removal
- nl -> MRCP - only use if not 100% sure
Admit to hosp Watch for sepsis Abx - Ampicillin-sulbactam - Unasyn - Piperacillin-tazobactam - Zosyn - Ticarcillin-clavulanate - Ceftiazone + Metronidzaole - modify w/ culture results - 7-10 days Biliary drainage - ASAP - ERCP - TOC - Percutaneous transhepatic cholangiography or open surgical decompression
Acute Cholangitis (Ascending Cholangitis)- prognosis
11-20% mortality
At risk for recurrence - Cholecystectomy recom
Benign stenosis - surgery or endoscopic therapy
Malignant stenosis - recurrent obstruction common - stent?
Mirizzi Syndrome- pathophysiology
Hepatic duct obstruction from extrinsic compression
- from impacted stone in cystic duct
Mirizzi Syndrome- cause
Alcohol abuse
Chronic viral Hep
Hemochromatosis
Nonalcoholic fatty liver disease
Autoimmune hep Prim and sec biliary cirrhosis Prim sclerosing cholangitis Meds Polycystic liver dis RS heart failure Wilson dis Celiac dis Alpha-1 antitrypsin def
Mirizzi Syndrome- S/S & PE
Jaundice
Fever
RUQ pain
Mirizzi Syndrome- diagnosis
U/S - 1st
ERCP - 2nd
Mirizzi Syndrome- labs & imaging
ALP - inc
Bili -inc
Mirizzi Syndrome- treatment
Surgery - cholecystectomy
- poor candidate - lithotripsy
Mirizzi Syndrome- prognosis
High frequency of bladder Ca
Cirrhosis- pathophysiology
Progressive hepatic fibrosis
- fibrosis & regenerative nodes in live
Fibrosis -> Architectual distortion -> disruptt nl portal blood flow -> inc BP and impairs liver function
Cirrhosis- cause
Most Common: Alcohol abuse Chronic viral Hep Hemochromatosis Nonalcoholic fatty liver disease
Autoimmune hep Prim and sec biliary cirrhosis Prim sclerosing cholangitis Meds Polycystic liver dis RS heart failure Wilson dis Celiac dis
Cirrhosis- S/S & PE
Nonspecific symptoms - fatigue, anorexia, weakness, weight loss/wasting
Specific hepatic dysfunction:
Skin
- Jaundice - yellow of skin, eyes, membranes, >2-3 mg/dl
- Spinder angioma - vascular lesions; trunk, face, upper limbs
- Palmar erythema - palm w/ central pallor
Chest/Feminization
- Gynecomastia - 2/3 of pt
- Men - loss of chest/axillary hair, inversion of normal male public hair pattern; testicular atrophy
Abdominal findings
- Ascites - distended, fluid wave, flank dull to percussion
- Liver palpation - enlarged, nl, or small; can feel - firm and nodular
- Splenomegaly
- Capute medusa
- Cruveilhier-Baumgarten murmur - venous hum heard w/ portal HTN, over epigastrium
- Umbilical hernia
Neurologic
- cognitive deficits & impaired neuromuscular fnt
- Disturbances in sleep pattern often initial changes, mood changes, inappropriate behavior, disorientation, somnolence, confusion, unconsciousness, bradykinesia
- Asterixis - flapping of outstretched, dorsiflexed hand
- Hyperactive or hypoactive, slurred speech, nystagmus, ataxia, focal neuro deficit, coma
Hepatic Encephalopathy
- Ammonia neruotoxin - don’t need to be elevated
- Not specific - DO NOT use to screen
Extremity Changes
- Muehrcke nails - paired whitte horizontal bands separated by normal color
- Terry nails - proximal 2/3 of nail plate white, distal 1/3 is red, clubbing, Dupuytren’s contracture
Cirrhosis- diagnosis
Live biopsy - gold
- not needed dif clinical, lab and radiologic data strongly support presence
U/S - liver may be small & nodular, inc echogenicity w/ irregular appearing areas
Fibroscan - noninvasive test of hepatic fibrosis
- staging of fibrosis -> helps determine treatment
Child-Pugh score - severity of liver disease
5-6 = A - well compensated -> 100-85% survival
7-9 = B - signif functional compromise -> 80-60% survival
10-15 = C = decompensated -> 45-35% survival
MELD score - used to prioritize liver transplant
- > 10 - refer
- > 15 - candidate for transplant
- Predicts outcomes
- Bili, Creatinine, INR, Na
- The higher the score - the worse the outcome
Cirrhosis- labs & imaging
AST/ALT - inc ALP - inc GGT - much higher Bili - inc w/ progression Albumin - dec w/ progression PT - inc w/ progression Hyponatremia Serum Cr - inc Cytopenia - thrombocytopenia, leukopenia, anemai
Cirrhosis- treatment
NO Alcohol!
Vaccinate - hep
Med adjust for hepatic impairment
Treat chronic hep
Compensated - >12y survival
Decompensated
- <6m w/ a Child-Pugh score >12 or MELD >21
- <6m - hosp w/ acute liver illness
- lower mean arterial pressure - worse the survival
Transplant: Indications - Acute liver failure - highest priority - Cirrhosis w/ complication - neoplasm - liver based metabolic conditions - wilson dis, CF, hemochromatosis Contraindications - uncorrectable cardiopulm dis - AIDs - Ca outside of liver - uncontrolled sepsis - persistent nonadherence w/ medical care - lack of adequate social support Alcoholic liver dis - min of 6m none!
Cirrhosis- complications
Complications:
Variceal hemorrhage
- varices from portal HTN
- high mortality rates from bleeding episodes
- Asymptomatic -> hematemesis, melena
- everyone w/ cirrhosis needs to be screened - EGD
- if found - variceal band ligation
- Prevent - BB - low portal pressure and Dec risk of bleeding
Ascites
- Most common
- accumulation of fluid in peritoneal cavity
- Treated - diuretics, Na restriction - alcohol abstinence
- Diuretic therapy - spironolactone + furosemide 100:40 mg/day
- Paracentesis - tense ascites, need to rapidly decompress abdomen
-> remove 4-5L - anything more and albumin needs to be given
- TIPS - transjugular intrahepatic portosysttemic shunts - w/ refractory ascites
Spontaneous Bacterial Peritonitis
- infection of ascetic fluid
- Fever, abdominal pain, abdominal tenderness, AMS
- Diagnosis - fluid cultures or inc polymorphonuclear leukocyte count (>250) on eval of ascetic fluid
- High morality - start empiric abx ASAP - cefotaxime 2g IV Q8h
- if had it before - need to take daily abx forever - Norfloxacin or Bactrim
Hepatic Hydrothorax
- pleural effusion - w/ no other cause
- R sided - movement of ascites into pleural space from defects in diaphragm
- Treat - diuretics and Na restriction, thoracentesis if needed
Hepatopulmonary syndrome
- abnormal arterial O2 - intrapulmonary vascular dilatations
- Dyspnea, platypnea (better when laying down), impaired O2
- imaging - nonspecific
- PFTs - nl
- progressive
- therapy - liver transplant, O2 therapy - no meds work
Hepatorenal syndrome
- Renal failure
- Renal perfusion dec by hepatic dysfunction
- Diag - exclusion of other renal issues
Hepatic Encephalopathy
- Lactulose - dec ammonia from GI tract, titrate until having 2-3 stools a day, enema or PO
- nonabsorbable abx - rifaximin - added to lactulose or cant tolerate lactulose
- if combined - may have mortality benefit
- recurrent - need to be on forever
Hepatocellular carcinoma
- inc risk of developing
- think if - decomp in a previously stable pt
- asymptomatic - upper abdominal pain, weight loss, early satiety, palpable abdominal mass
- labs - nonspecific, maybe inc AFP
- only effective screening - U/S x 6m
- Treat - surgery, liver transplant
Portopulmonary HTN
- pulmonary htn in pts w/ portal htn
- Fatigue, dyspnea, peripheral edema, chest pain, syncope
- Diagnosis - echo - confirmed w/ R heart cath
- very hard to treat
- high mortality during liver transplant
Inflammatory Bowel Disease- cause
Crohn
Ulcerative Colitis
Inflammatory Bowel Disease- epidemiology
15-40yo
Jewish decent
1st deg relative w/ IBD
Smoking - inc risk of Crohn’s
- protective against UC
Western diet - inc risk
Ulcerative Colitis- pathophysiology
Idiopathic inflammatory condition
- involves mucosal surface of colon -> diffuse friable areas and erosions w/ bleeding
Starts distally -> progresses proximally
Continuous - no skip areas
Ulcerative Colitis- S/S & PE
Bloody diarrhea - BM frequent and small volume
Tenemesmus - straining, feeling like you have to poop all the time
Mainly distal - constipation + frequent blood and mucus discharge
Incontinence
Colicky abdominal pain
Onset of symptoms - gradual and progressive
Systemic symptoms - fever, weight loss, fatigue
Arthritis - nondestructive, peripheral large joints
- ankylosing spondylitis
Uveitis/episclertitis
Erythema nodosum
Pyoderma gangrenosum
VTE
Arterial thromboembolism
Autoimmune hemolytic anemia
Primary sclerosing cholangitis - liver and gallbladder disease
PE - usually nl
- abdominal pain w/ palpation
- fever
- hypotension
- tachy
- pallor
- blood on rectal exam
Ulcerative Colitis- diagnosis
Chronic diarrhea >4w
Evidence of active inflammation on endoscopy
- loss of vascular markings from swelling of mucosa -> looks erythematous
- Petechiae, exudates, edema, erosions, friability to touch, spontaneous bleeding
Chronic changes on biopsy
- Crypt abscesses
- Crypt branching
- Shortening and disarray
- Crypt atrophy
- Epithelial cell abnormalizes - mucin depletion, Paneth cell metaplasia
- Inflammatory features - inc lamina propria cellularity, basal plasmacytosis, lymphoid aggregates, lamina propria eosinophils
Exclude all other causes
Pattern:
- involves rectum
- extends proximally in continuous, circumferential
- No normal areas of mucosa
Ulcerative Colitis- labs & imaging
Anemia ESR/CRP - inc Electrolyte abnormalities - diarrhea/dehydration Fecal calprotectin - inc - differentiate b/t UC and IBS
Xray
- proximal constipation
- mucosal thickening - thumbprinting from edema
- colonic dilation - severe
Double contrast barium enema
- diffusely reticulated pattern w/ punctate collections of barium in microulcerations
- collar button ulcers
- shortening of colon
- loss of haustra
- polyps or pseudopolyps
- avoid in those severely ill -> can cause toxic megacolon
CT and MRI
- lower sensitivity than barium enema at detecting subtle early disease
- Thickening of bowel wall
Ulcerative Colitis - treatment
Ulcerative Proctitis or Proctosigmoiditis
Topical 5-aminosalicylic acid (5-ASA) - 1st line
- Suppositories - dis just distal to part of rectum
- Mesalamine 1 PR BID
- Enema + suppository - dis extends furth
- Enema BID + suppository BID
- symptomatic relief and dec bleeding - w/in few days
- complete healing >4-6w -> continue for 8 weeks - then taper
- 1st episode + proctitis -> disc, no maintenance therapy
- Proctosigmoiditis or >1relapse /year -> maintenance therapy
Alternatives - topical steroids, PO 5-ASA
Left sided colitis, extenside colitis, pancolitis
- combo therapy - PO 5-ASA, suppositories 5-ASA or steroid, and enemas 5-ASA or steroid
Refractory
- Refer
- further oral immunosuppressants
Ulcerative Colitis- severity
Severity: Mild - <4 stools/day - nl ESR - no severe abdominal pain, fever, wt loss, profuse bleeding
Mod
- > 4 loose, bloody stools/day
- mild anemia - no trans
- mod abdominal pain
- Minimal signs of systemic toxicity - low grade fever
- No wt loss
Severe
- Frequent loose bloody stools >6/day
- Severe abdominal pain
- Systemic symptoms - fever, tachy, anemia, Inc ESR
- May have rapid weight loss
Ulcerative Colitis- prognosis
Prognosis:
- w/ treatment - exacerbations/flares alternating w/ long periods of symptomatic remission - some won’t be able to get remission
- Dis extension
- Colectomy - 20-30% - acute complications or intractable disease
- slightly higher mortality - then rest of population
Chrohn Disease- pathophysiology
Transmural inflammation of GI tract - throughout whole GI tract
- ilium & R colon - most common
Skip areas - classic
Cause - Uknown
Chrohn Disease - epidemiology
15-35
Chrohn Disease - S/S & PE
Crampy abdominal pain Strictures - lead to repeated obstruction Diarrhea - fluctuating over time - gross bleeding - less common than UC Fistulas - entervesical, enterocutaneous, enteroenteric, enterovaginal Malabsorption Abscess formulation Aphthous ulcers
Fatigue, wt loss Arthritis Eye - uveitis, iritis, episcleritis Skin - erythema nodosum, pyodermo gangrenosum Primary sclerosing cholangitis VTE & arterial thromboembolism Nephrolithiasis Vit B12 def Pulm involvement Sec amyloidosis
PE - nl
- Perianal skin tags, sinus tracts, abdominal tenderness, wt loss, pallor
Chrohn Disease- diagnosis
Colonoscopy
- focal ulcerations next to nl areas
- polypoid mucosal changes - give cobblestone appearance
- Skip areas
- Rectal sparing
Wireless capsule Endoscopy
- no radiation
- don’t do - w/ suspected stricture
Crohn’s Disease Activity Index - CDAI
- stool patterns, abdominal pain rating, general wellbeing, complications, abdominal mass, anemia, weight change
Harvey-Bradshaw Index (HBI)
- general wellbeing, abdominal pain, number of liquid stools, abdominal mass, complications
Chrohn Disease- labs & imaging
CBC CMP ESR/CRP - CRP higher than in UC Serum Iron Vit D Vit B12 Fecal calprotection - diff b/t IBS Antibody test - pANC and ASCA pos - diff b/t CD and US
Barium Swallow - upper GI series
- narrowing o lumen w/ nodularity & ulceration
- Sring sign
- Cobblestone appearance
- Fistulas/abscess formation
- Bowel wall thickening
- Stricturing
CT - w/ ingestion of a neutral contrast agent to distend small bowel
- best study if abscess suspected
MRI
- mural thickening, high mural signal intensity (edema), layered patter of enhancement = acute small bowel inflammation
Chrohn Disease- treatment
Mild - Mod Disease
Ileum or proximal colon involvement
- Budesonide 9mg QD x 4-8 weeks -> taper Q2-4 w = 8-12 w total
- Corticosteroid
- AE - HA, acne, adrenal suppression, osteoporosis, immunosuppression, edema, psychiatric distrubances, exacerbation of CV dis, hyperglycemia
- Alternatives - budesonide - prednisone, oral 5-ASA - controversial
Diffuse Colitis or Left colonic involvement
- PO prednisone 40mg QD x 1w -> taper
- Atlern - Sulfasalazine
Oral lesionx
- topical meds - triamcinolone acetonide
Severe Disease
- Top Down
- Refer
- Bioloigic + immunomodulatory for induction
- TNFinhibitor - infliximab (remicade), adalimumab (Humaria), certolizumab (Cimizia)
- + azathioprine, 6-mercaptopurine, or methotrexate
- Glucocorticoid - immediate symptom relief - <8w
- Maintenance - long term w/ biologic
Relapse - begin sec course of glucocorticoid
Surgery - for complications or persistent symptoms
- perf, abscess, fistula, hemorrhage, stricture, neoplasm
Chrohn Disease- prognosis
Step Therapy - start w/ less potent meds - but fewer side effect
- use more potent meds if initial not effective
Top-down therapy - start w/ more potent therapies early in the course of disease before they become glucocorticoid- dependent
Goal - remission - endoscopic, histologic, clinical
- demonstrating complete mucosal healing
Intermittent exacterbat -> periods of remission
>1/2 develop structuring or penetrating disease
Will require surgery
80% require hosp
Predictors of severe course
- <40, perianal or rectal disease, smoking, low education level, initial need for glucocorticoids
Constipation- cause
Inadequate fiber & water consumption
Meds - opiates, anticholinergic, CCBs, antacids, Fe, Ca
Neurologic conditions - MS, Parkinson disease, dementia, stroke
Prolonged immobility - SCI, complete bed rest
Metabolic - DM, hypothyroidism, uremia, hypercalcemia, hypokalemia
Functional fecal retention - chronic stool-withholding
- common in kids
Anatomic abnormalities - neoplasms, anal fissures, lesions, proctitis, perirectal abscess, anorectal stenosis
Functional - inc rectal compliance, Pelvic floor dysfunction
Constipation - S/S & PE
Hard or lumpy stools Feeling of incomplete voiding Straining Abdominal discomfort or bloating Manual maneuvers <3 defecation x week Loose stools rare w/out laxative use
Constipation - treatment
Fiber - psyllium, methylcellulose, calcium polycarbophil
Hyperosmolar agent - sorbitol, lactulose, PEG (miralax)
Stimulant - glycerin suppository, bisacodyl, senna, senna/colace
Enema - mineral oil, tap water enema, Na phosphate
Opioid antagonist - methylnaltrexone, naloxegol
Fecal Impaction- pathophysiology
Mass of compacted feces in large intestine
Can’t be evacuated spontaneously
Rectum or distal sigmoid - common
Fecal Impaction - epidemiology
Elderly
Fecal Impaction - S/S & PE
Chronic constipation
Rectal discomfort
Abdominal pain & cramping
Bloating
Overflow fecal incontinence or paradoxical diarrhea - leaking aroudn it
Inc urinary frequency, incontinence, obstruction
Detect impacted feces on rectal examination
Fecal Impaction - diagnosis
Xray/CT - show impaction and associated bowel obstruction
Fecal Impaction - treatment
Manual disimpaction
Enema administration
Osmotic laxative
Address underlying cause - adequate fiber & H2O, bulking agents, stool softeners
Fecal Impaction - complications
Large bowel obstruction w/ colonic perf - high mortality
Celiac Disease- pathophysiology
Immune disorder - triggered by environmental agent - gliaden
- people genetically predisposed
Gluten-sensitive enteropathy and nontropical sprue
Inflammation of the small bowel 2nd to ingesting gluten-containing food
Celiac Disease - cause
wheat, barley, rye, oats
Celiac Disease - epidemiology
Caucasian
Norther European ancestry
10-40
Celiac Disease - S/S & PE
Diarrhea w/ bulky, foul smelling, floating stools - steatorrhea, flatulence Wt loss, weakness Abdominal distension Infant and kids - FTT IDA Osteopenia & osteoporosis
Dermatitis Herpetiformis - grouped pruritic papules and vesicles
- elbows, dorsal forearms, knees, scalp, back & butt
DM 1
Down Syndrome
Liver disease
Menstrual & reproductive issue - recent miscarriage, infertility, later menarche, early menopause, preterm delivery, low birth weight
Celiac Disease- diagnosis
Who Screened? - done while on gluten diet
GI S/S, extrintestinal S/S suggestive of Celiacs - serologic testing
Low probably -> serologic
- no sig s/s of malabsorption
- no FHx
- Chinese, Japanese, or sub-Saharan African descent
High probability -> serologic + small bowel biopsy
- Classic presentation
- Risk - 1st/2nd relative w/ confirmed CD, DM, autoimmune thyroiditis, down syndrome, turner syndrome
Celiac Disease - labs & imaging
Tissue tranglutaminase (tTga)-IgA - 1st line
Anti-endomysial (EMA-IgA) - also can be done
If serology + -> small bowel biopsy - confirm diagnosis
If neg -> doesn’t exclude celiac reason:
- IgA def
- low gluten/gluten free diet
- false neg - common mild
Endoscopy w/ small bowel biopsy
Seen:
- atrophic mucosa w/ loss of folds
- visible fissures
- nodularity
- scalloping
- prominent submucosal vascularity
Biopsy:
- Graded using marsh-Oberhofer classification
- 4 biop needed to confirm dx
- inc intrepithelial lymphocytes
- atrophic mucosa w/ villi loss
- epithelial apoptosis
- crypt hyperplasia
Celiac Disease - treatment
Gluten Free diet Refer - RD Replete a nutritional def Eval bones - DEXA Pneumococcal vaccine Improvement of dermatitis herpetiformis - more delayed than response - 6-12m Screen Fm members
Celiac Disease - prognosis
Inc mortality - CV and Ca
Inc Malignancy - lymphoma and GI
Colorectal Cancer- pathophysiology
Leading cause of cancer in US
Colorectal Cancer- cause
Risk: Hereditary syndromes - Familial adenomatous polyposis (FAP) - Lynch syndrome (HNPCC) IBD Abdominal Radiation Cystic Fibrosis
Obesity, DM
Red/processed meat
Smoking
alcohol consumption
Colorectal Cancer- epidemiology
AA
M>F
Acromegaly
Renal transplant + long term immunosuppression
Colorectal Cancer- S/S & PE
Change in bowel habits
Unexplained IDA
Rectal bleeding + change in bowel habits
Rectal mass or abdominal mass
Abdominal pain
Asymptomatic - discovered on routine screening
Emergent admit - intestinal obstruction, peritonitis, acute GI bleeding
Colorectal Cancer- diagnosis
Colonoscopy
- Endoluminal masses - from mucosa and protrude into lumen
- Friable, necrotic, ulcerated lesions - may bleed
- "”Apple core””
Colorectal Cancer- labs & imaging
CT Colonography - virtual colonoscopy
- computer-simulated endoluminal perspective of air-filled distended colon
- Still requires bowel prep
- abnormal -> f/u w/ colonoscopy for excision & tissue diagnosis
CEA - tumor marker
- low diagnostic ability to detect primary colorectal cancer
- significant overlap w/ benign disease
- low sensitivity for early-stage disease
- Useful for - F/U of pts w/ diagnosed CRC
- > 5 preop -> worse prognosis
- don’t normalize after surgery -> look for persistent disease
Colorectal Cancer- treatment
Carcinoma in polyp - endoscopic removal alone - as long as margins are clear
Larger tumors - surgical resection -> surgery
Radiation therapy - most commonly used for rectal
- not routine for completely resected colon
Colonoscopy Screening Guidelines- pathophysiology
Inc risk
- personal hx of CRC or adenomatous polyp
- Fm w/ CRC 0r doc advanced polyp
- personal or fm hx of genetic syndromes that cause CRC - familial adenomatous polyposis, lynch syndrome, juvenile polyposis syndrome, peutz[jeghers syndrome, mutyh-associated polyposis
- inflammatory bowel disease
- Prior hx of abdominal radiation for child malignancy
Other risk
- HIV pos Men
- AA
Colonoscopy Screening Guidelines- cause
Age start screening - w/ avg risk
- 50
- 45 - AA
Discontinue screening - avg risk
- to 75 -> unless have <10y to live
- b/t 76-85 - pt preference, prior test results, comorbidities
Colonoscopy Screening Guidelines- S/S & PE
"Choices of test: average risk Colonoscopy - 10 yr - avg risk - highest sensitivity - CRC and adenomatous - lesion removal - reduced incidence and mortality
Fecal immunochemical testing (FIT)
- yearly - 1 stool sample for occult blood
- measure hemoglobin in stool
- pos -> colonoscopy ASAP
CT colonography
- 5 yr
- polyps/finding of CRC -> colonoscopy ASAP
- still need bowel prep
Sigmoidoscopy + FIT - timing vary Sigmoidoscopy alone - 5-10 yr - minimal pt prep - no sedation required Guaiac-based FOBT - 3 sample yearly Stool DNA testing - one stool sample, performed every 3 years
Colonoscopy Screening Guidelines- diagnosis
Choice of screening - FH of CRC or advanced poly
Colonoscopy - GOLD
- if refuse -> FIT yearly
When to start - FH of CRC or advanced polyp
1 1st deg relative diag <60
- begin screening at 40 or 10y before Fm diagnosis - whichever is earlier
- Colonoscopy - 5yr
> 2 FDR diag at any age
- screen at 40 or 10y before youngest FDR diagnosis - earlier wins
- Colonoscopy - 5yr
FDR >60y
- begin screening at age 40
- Same screening options/freq as avg risk
When to stop - FH or CRC or advanced polyp
1FDR >50 - end at 79yo
>2 FDR <40 - end at 85y
- life expectancy of <10 - stop
Colonoscopy Screening Guidelines- labs & imaging
High Risk Syndrome
- Lynch syndrome - 20-25 yo or 2-5 yr prior to earliest age of CRC diag
- Familial adenomatous polyposis (FAP) - yearly colonoscopy - starting at age 10-12 for classic; 1-2 yr at 25yo for attenuated FAP
- Peutz-Jeghers syndrome - EGD, video capsule endoscopy, colonoscopy at 8yo
Anal Fissure- pathophysiology
Tear, cut or crack in the lining of distal half of anal canal
Anal Fissure- epidemiology
Infants
Middle aged adults
Local trauma - constipation, anal sex, diarrhea, vaginal delivery
Secondary - IBD, malignancy, STI
Anal Fissure- S/S & PE
Anal pain
Pain intensifies w/ defecation
- ripping/tearing
- lasts for hours after
- mild anal bleeding
Posterior midline - most common ->less purfusion - mild ischemia
Anterior midline - 2nd most cmmon
- doesn’t extend above dentate line
- not w/in midline - think other issues
Acute - looks fresh, superficial - like papercut
Chronic - raised edges, fibrotic appearance - accompanied by skin tag
Anal Fissure- diagnosis
H&P
Direct visualization
Reproduce pain w/ digital palpation of posterior anal verg
Anal Fissure- treatment
Fiber + H2O +/- stool softeners -> prevent hard BM which can be the cause
Sitz bath - anus immersed in warm water for 10-15 min BID-TID
- relaxes anal sphincter & improves blood flow to mucosa
Topical analgesics - pain control
- 2% lidocaine jelly
Topical vasodilators - promote healing -> inc local blood flow & dec anal sphincter pressure
- Nifedipine gel BID-QD
- Topical nitroglycerin BID
- SE - HA & hypotension
- DONT USE - w/in 24 hr of Viagra, cialis, levitra
Reeval after 1month
- if persist -> complete 1 more m of Smale treatment
Sx persist after 2m -> refer to endoscopy - rule out Crohn
- Crohn -> refer GI
- no Crohn -> refer to colorectal surgeon
- botox or lateral sphincterotomy recommended
Hemorrhoid- pathophysiology
Swollen veins in rectum and anus
- lead to discomfort, prolapse, bleeding
External - distal to dentate line
- arise from superior hemorrhoidal cushion
- Somatic innervation -> more sensitive to pain/irritation
Internal - proximal to dentate line
- arise from inferior hemorrhoidal line
- Visceral innervation -> less sensitive to pain/irritation
Mixed - both above and below dentate line
Hemorrhoid- cause
Advancing age Chronic constipation, straining Preo Pelvic tumors Diarrhea Prolonged sitting Anal sex Anticoag and antiplatelet meds Obesity Low fiber diet
Hemorrhoid- S/S & PE
40% - asymptomatic
Bleeding
- painless
- associated with BM
- bright red and coats strool at end of defecation
Pruritis or irritation - perineal area common
Mild fecal incontinence, mucus discharge, or wet sensation
Acute onset of perianal pain - w/ palpable ““lump”” from thrombosis
Protuberant purple nodules - covered by mucosa
Hemorrhoid- diagnosis
Classic symptoms + visualization
Anoscopy - allows visualization of internal hemorrhoids
Grade 1 - no prolapse
Grade II - prolapse w/ defecation, spontaneously reduces
Grade III - prolapse w/ defecation or other times, needs manual reduction
Grade IV - permanently prolapsed/irreducible, visible externally, may strangulate
Hemorrhoid- treatment
When to Refer to surgeon
- symptomatic low grade (I-II) - refractory 6-8 w of medical treatment
- Symptomatic high grade (III-IV) hemorrhoids
- thrombosed hemorrhoids
Office-based procedure: only for internal
Rubber band ligation
- most common procedure
- rubber band rings are placed on internal hemorrhoids
- complication - bleeding & pain
Sclerotherapy
- injecting solution that causes an inflammatory reaction - destroying tissue
- Can be used for those who have an elevated bleeding risk
Infrared coag - infrared light waves -> necrosis
Surgery
External hemorrhoidectomy
- symptomatic & refractory to conservative measures
- Symptomatic and refractory to office-based procedures
- Large or severely symptomatic external hemorrhoids
- pts w/ substantial external skin tag
- Combined internal and significant external hemorrhoids
Internal hemorrhoidectomy
- prolapsed internal hemorrhoids that can be manually reduced - Grade III
- prolapsed and incarcerated internal hemorrhoids - Grade IV
- Symptomatic internal hemorrhoids refractory to conservative measures
- Symptomatic internal hemorrhoids refractory to office - based procedures
- Combine internal and external hemorrhoids
Diverticulosis- pathophysiology
Diverticulum - sac-like protrusion of colonic wall
- develop at points of weakness
- don’t have a disease - just an outpouching in intestine
Diverticulosis - cause
Inc age Low fiber, high fat, red meat diet - nut, seeds, corn -> not w/ inc risk Lack of physcial acitivty BMI >25 Smoking >40pk year hx Meds - NSAIDs, opiates, steroids
Diverticulosis - S/S & PE
asymptomatic/symptomatic
Diverticular bleeding - painless hematochezia
- most common cause of brisk hematochezia
Diverticulitis - inflammation of diverticulum
Diverticular colitis - inflammation in the interdiverticular mucosa - w/out involvement of diverticular orifices
Symptomatic uncomplicated diverticular disease - persistent abdominal pain attributed to diverticular w/out over colitis
IBS- pathophysiology
Functional disorder of GIT w/ chronic abdominal pain and altered bowel habits
IBS - epidemiology
W>M 10-15% Fibromyalgia Chronic fatigue syndrome Depression Anxiety
IBS - S/S & PE
Chronic abdominal pain - crampy, variable intensity, location and character can vary widely, defecation often improves the pain, stress can worsen the pain
Altered bowel habits:
- Diarrhea
- Constipation
- Alternating diarrhea and constipation
- Nl bowel habits alternating w/ diarrhea or constipation
IBS - diagnosis
Rome IV criteria
Recurrent abdominal pain on avg at least once a week, past 3 months associated w/ >2 of the following:
- related defecation
- associated w/ a change in stool frequency
- associated w/ a change in stool appearance
IBS- treatment
Dietary mods - FODMAPs
- fermentable oligo di and monosaccharides and polyols, lactase and gluten avoidance
Inc fiber - w/ constipation dominant
- miralax
- lubiprostone - miralax doesn’t work
Antidiarrheals - w/ diarrhea dominant
- Imodium
- Bile acid sequestrat if failed - cholestramine
Abdominal pain
Antispasmodic -inhibits gastrointestinal smooth muscle
- Dicyclomine (Bentyl)
- Hyoscyamine (Levsin)
TCAs - slow intestinal time and help w/ abdominal pain
- amytriptyline, nortipryline, imipramine
Abx - mod/severe IBS w/out constipation if failed other
- Rifaximin
IBS- prognosis
Refer to GI:
- more than minimal rectal bleeding
- Wt loss
- Unexplained IDA
- Nocturnal symptoms
- FH of colorectal Ca, celiac disease, inflammatory bowel disease
Education & reassurance
GERD- cause
Hiatal Hernia - treat like GERD
GERD- S/S & PE
Heart burn - postprandial or positional
Acid taste or reflux
Dysphagia
Atypical presentation
PE - NL
Symptoms DOESN’T = tissue damage
GERD- diagnosis
Ambulatory esophageal pH monitoring - GOLD - not 1st line -> if failing treatment
PPI trial - 1st line diagnosis
Upper endoscopy - if alarm symptoms
Barium esophagography - barium swallow
GERD- labs & imaging
Labs - nl
Hpylori testing - not recommended
GERD- treatment
Lifestyle changes - 1st line - avoid supine position w/in 3 hours postprandial - Elevation of head of bed 6in or use a wedge - Encourage weight loss - dec portion size - eliminate or dec aggravating food Antacids Gaviscon H2 blocker - pepcid - famotidine - 20 - Tagament - cimetidine - DONT USE - cytocrone P450 - Axid - nizatidine Proton Pump Inhibitors - PPI - Omeprozole - Prilosec - Lansoprazole - Prevacid - Rabeprazole - Acephex - Esomeprazole - Nexium - Pantoprazole - Protonix - Ddexlansoprazole - Dexilant - Omeprazole and Na bicarbonate - education - Take before meals - might need a holidy Metoclopramide - Reglan - helps w/ parastolsis -> keeps things down - short term Surgery: Fundoplication - 360, partial anterior, partial posterior Endoscopic Link - band around that allows normal swelling
Barrett’s Esophagus- pathophysiology
Chronic acid injury
Squamous epithelium -> metaplastic columnar epithelium
Barrett’s Esophagus- cause
Complication of GERD
Barrett’s Esophagus- diagnosis
Endoscopic biopsy
Barrett’s Esophagus- treatment
Screen every 3-5 yrs - if chronic GERD
Low-grade dysplasia, high-grade dysplasia, adenocarcinoma - ablation
Adenocarcinoma - esophagectomy
Peptic stricture- cause
Complication of GERD
Peptic stricture- S/S & PE
Gradual and progressive dysphagia w/ solid foods -> m - y
Reduce heartburn - anatomical barrier to reflux
Peptic stricture- diagnosis
Endoscopic biopsy - exclude malignant causes of stricture
Peptic stricture- treatment
Dilation - single to several session
PPIs - long term
Achalasia- pathophysiology
Poorly relaxing LES
Achalasia - S/S & PE
Gradual, progressive dysphagia - solids and liquids Substernal discomfort Postprandial fullness Regurg of undigested food Wt loss
PE - nl
Achalasia- diagnosis
Barium esophagography/esophagram
Achalasia- labs & imaging
Esophageal manometry
Endoscopy
Achalasia- treatment
Pneumatic dilation
Surgery myotomy
Botulinum toxin injection - short term
CCB or long-acting nitrates
Esophageal Dysphagia- pathophysiology
Diffuse esophageal spasms
Esophageal Dysphagia - S/S & PE
Simultaneous and repetitive contractions
Nl peristalsis?
LES - nl
Present - chest pain, +/- dysphagia
Esophageal Dysphagia- diagnosis
Nitrates
CCB
- not great
Strictures- pathophysiology
Loss of diameter
20mm - nl
<15mm - dysphagia
- if less severe - can cause intermittent dysphagia to large pieces of food
Strictures - cause
Intrinsic - most common
- acid/peptic
Extrinsic - not from tissue itself
Complication of GERD
Strictures- treatment
Esophageal dilation Refractory - pill induced irritation - uncontrolled GERD - inadequate dilation diameter
Rings/Webs- pathophysiology
Rings - circumferential mucosa or muscle in the distal esophagus
Webs - occupy only part of the esophageal lumen, always mucosal, usually proximal
Rings/Webs- - risks
Risk - esophagus and pharynx cancer
Rings/Webs- S/S & PE
Solid food dysphagia
Aspiration
Regurg
Plummer Vinson Syndrome TRIAD
- proximal esogeal webs, IDA, Dysphagia
Rings/Webs- diagnosis
Endoscopy
Barium radiography - webs
- some are proximal - can get fractured before even see it
Rings/Webs- treatment
Mechanical disruption
Schatzki’s Ring- pathophysiology
Near LES
Schatzki’s Ring- cause
Complication of GERD
Schatzki’s Ring- S/S & PE
Intermittent solid food dysphagia and food impaction
Symptoms depend on luminal diameter
- 13-20mm - variable symptoms
Schatzki’s Ring- diagnosis
Barium swallow
Schatzki’s Ring- treatment
PPIs
Esophageal Cancer- pathophysiology
SCC - aggressive, locally invasive w/ distant mets
Adenocarcinoma - not locally invasive w/ mets
Esophageal Cancer- epidemiology
SCC:
- Black Males
- ETOH and tobacco
- prior esophageal injury
- Associated w/ HPV
- Associated w/ achalasia
Adenocarcinoma
- white Males
- Obesity
- GERD, Barretts esophagus
- Scleroderma
Esophageal Cancer- S/S & PE
Rapid progressing solid food dysphagia
Wt loss
Esophageal Cancer- diagnosis
CT - look for mets
Endoscopic U/S - depth of invasion
Esophageal Cancer- treatment
Early - surgery
Advanced - chemo/radiation -> surgery
Late - palliative treatment - dilation, stent, gastrostomy tube
Zenker’s Diverticula- pathophysiology
Sac protruding from esophageal wall
Incomplete relaxation of UES
Zenker’s Diverticula- S/S & PE
Oropharyngeal dysphagia Regurg of undigested food Halitosis Cough Aspiration pneumonia
Zenker’s Diverticula- diagnosis
Barium swallow
Zenker’s Diverticula- treatment
Surgical resection
Pill-induced Dysphagia- pathophysiology
Ingestion of irritant meds
Swallowing a pill w/out water or while supine
Pill-induced Dysphagia- S/S & PE
Severe retrosternal chest pain
odynophagia
Dysphagia
Pill-induced Dysphagia- imaging
Endoscopy - see ulceration
Pill-induced Dysphagia- treatment
Rapid healing w/ removal of offender
Infectious Esophagitis- pathophysiology
Seen in Immunocompromised pt
- HIV
Infectious Esophagitis- cause
Candida albicans
Herpes Simplex
CMV
Infectious Esophagitis- S/S & PE
Odynophagia
Dysphagia
Infectious Esophagitis- diagnosis
Endoscopy biopsy and brushings
Eosinophilic Esophagitis- pathophysiology
Hx of allergies or atopy
Eosinophilic Esophagitis- S/S & PE
Episodic dysphagia/food impaction
Eosinophilic Esophagitis- labs & imaging
Labs - eosinophilia or Inc IgG
Endoscopy
- white exudates or papules
- Red furrows
- Corrugated concentric rings
- Strictures
Eosinophilic Esophagitis- treatment
Allergy testing PPI Avoidance of allergy ICS Refer - allergy
Mallory-Weiss Syndrome- pathophysiology
Mucosal tear from vomiting/retching
- in esophagus
Mallory-Weiss Syndrome- cause
Alcoholism
Mallory-Weiss Syndrome- S/S & PE
Hematemesis
Sudden onset
Mallory-Weiss Syndrome- diagnosis
Upper endoscopy
Mallory-Weiss Syndrome- treatment
Fluid resuscitation
Blood transfusion
Endoscopic hemostatic therapy - active bleeding
Epinephrine injection, cautery, mechanical compression
Varices- pathophysiology
Dilated submucosal veins
Inc risk of bleed
- size
- red signs on endoscopy
- liver disease severity
- active alcohol abuse
Varices- cause
Portal HTN
Cirrhosis
Varices- S/S & PE
Hematemesis
Melena
Sudden/insidious onset
Varices- treatment
Acute resuscitation Emergent endoscopy Meds - abx - vasoactive drugs - Vit K - lactulose Ballon tube tamponade Portal decompressive procedures
Prevent Rebleeding: Endoscopic techniques - band ligation - sclerotherapy BB Transvenous Intrahepatic Portosystemic Shunt Surgical portosystemic shunts Liver transplant
Varices- prognosis
Prevent 1st Bleed
- Cirrhosis - diagnostic endoscopy
- If present - BB or prophylactic band ligation
- if none - repeat every 1-2y
