GI disorders Flashcards
What is cirrhosis?
- End-stage consequence of progressive hepatic fibrosis affecting normal liver function
- Complex irreversible disease
Most common causes of cirrhosis
- Hepatitis B and C
- Alcoholic liver disease
- NAFLD → fat in liver
- NASH → fat and inflammation leading to liver damage
Signs of early disease in cirrhosis
- Pruritus
- Weight loss
- Fatigue, weakness, malaise
- Dark urine, pale stools (bile isn’t excreted)
Signs of advanced disease in cirrhosis
- Anorexia
- N/V, hematemesis
- Abdominal pain, ascites
- Chest pain (d/t/ cardiomegaly)
- Menstrual abnormalities, impotence, sterility
- Neuropsychiatric symptoms → difficulty concentrating, irritability, confusion
What is the significance of the presence of neuropsychiatric symptoms with cirrhosis?
Need to consider hepatic encephalopathy
Signs of late stage cirrhosis
Jaundice
Abdominal physical exam findings with cirrhosis
- Jaundice, ascites, increased abdominal girth, fluid wave
- Nodular firm, enlarged, or shrunken liver (late stage)
- Splenomegaly (d/t portal HTN)
Other physical exam findings (not abdominal) for patients with cirrhosis
- Gynecomastia, testicular atrophy
- Venous hum → machinery-like noise
- Rectal/esophageal varices
- Peripheral edema (feet, legs, hands)
- Delirium, lethargy, coma, tremors (late stage)
- Cheilosis or glossitis (d/t reduced vitamins)
- Spider angiomas on face, chest, abdomen
- Palmar erythema
Are diagnostic tests significant in diagnosing cirrhosis in early stages?
No - no significant diagnostic findings
- Presence of lab abnormalities raises concern for potential liver dysfunction
- No single diagnostic biochemical marker is available
Lab findings indicative of hepatocellular inflammation or injury (consistent with cirrhosis)
- Hypoalbuminemia
- Elevated serum protein
- Hyperbilirubinemia
- Elevated liver enzymes (AST and ALT)
What additional tests should be ordered to evaluate cirrhosis if AST and ALT are elevated?
- Alkaline phosphatase
- Gamma glutamyl transpeptidase (GGT)
How would the provider manage variceal bleeds in a patient with cirrhosis?
- Non selective beta blocker → propranolol, nadolol (to prevent esophageal varices rupture)
- Endoscopic variceal ligation
How would the provider manage ascites in a patient with cirrhosis?
- Order a diagnostic paracentesis
- Dietary sodium restriction (1-2 g/day)
- Spironolactone (diuresis)
- Furosemide (consider kidney function)
- Monitor electrolytes, BUN, creatinine
- Co-manage with specialists
Important patient education for patients with cirrhosis
- Eliminate alcohol, NSAID use
- Pneumococcal vaccine
- Yearly flu vaccine
- Hep A and B vaccines
Rome IV criteria to diagnose constipation
Two or more of the following:
- Less than 3 bowel movements/week
- Passage of hard or lumpy stools
- Sensation of straining in more than 25% of defecations
- Feeling of incomplete evacuation or anorectal obstruction in more than 25% of defecations
- Manual maneuvers to aid defecation in more than 25% of defecations
True/false: If a patient presents with symptoms of constipation, but otherwise healthy (normal lab results, weight, etc.), the provider does not need to perform further workup
True - go ahead and treat if patient meets Rome IV criteria
Primary causes of constipation
- Irritable bowel syndrome (IBS)
- Colonic transit (normal or slow transit)
- Defecatory disorders
Secondary causes of constipation
- Medical and psychogenic conditions
- Medications
- Structural abnormalities
- Lifestyle
Alarm symptoms of constipation that warrant referral to GI specialist
- Sudden change in bowel habits after 50 years old
- Weight loss
- Blood in stool
- Anemia
- Family history of colon cancer or IBD
- Acute constipation in the elderly
Information that should be collected in health history for patients with complaint of constipation
- Review 24 hour dietary and fluid review
- Perform complete medication review and laxative use (including OTC medications)
Constipation physical examination findings
- BP - orthostatic hypotension
- Tachycardia
- Weight loss
- Oral exam - dentition, dentures, etc.
- Abdominal scars (if surgical history)
- Bowel sounds → increased or decreased sounds suggest obstruction or ileus
- Increased dullness to percussion over areas of stool
- Masses may be palpated
- Rebound tenderness (peritoneal inflammation)
- Check for rectocele
- DRE
- Neurologic examination → autonomic dysfunction or neuropathy
Constipation diagnostic testing
- What is necessary to exclude obstruction, ileus, megacolon, or volvulus
- Abdominal x-ray
- Abdominal CT scan
- CBC w/ diff
When is a colonoscopy indicated when assessing a patient with constipation?
If they have any alarm symptoms
If metabolic disorders are suspected as the cause of constipation, what lab tests should be ordered?
- CBC
- TSH
- Chem profile (serum calcium, blood glucose)
If chronic cystitis is suspected as cause of constipation, what lab tests should be ordered?
UA and culture
Immediate ED referral indications for patients complaining of constipation
- Volvulus and obstruction → requires emergent surgical evaluation
- Ileus and pseudo-obstruction → NG suction and IV fluids
Conservative constipation management
- Keep a stool diary
- Increase fiber intake
- Initiate physical activity
- Develop regular bowel habits
- Increase fluids
Pharmacologic management of constipation
- Stool softeners (docusate sodium) or emollients
- Probiotics
- Osmotic laxatives (Miralax, PEG, lactulose, sorbitol)
- Stimulate laxatives (senna, bisacodyl)
- Biofeedback
GERD indications for referral to GI specialist
- Unintentional weight loss
- Dysphagia for solids and liquids
- Odynophagia
- Unexplained anemia
- Chronic tobacco and alcohol exposure
GERD red flags warranting imaging and further work up
- GI bleeding
- Anemia
- Dysphagia and odynophagia
- Unintentional weight loss
- Early satiety
- Age older than 55 years old
- Recurrent vomiting
- Epigastric mass
Clinical presentation of GERD
- Heartburn → burning, retrosternal discomfort
- Indigestion, acid regurgitation, sour stomach, bitter belching
- Respiratory and oropharyngeal tracts (cough, regurgitation)
- Dysphagia, odynophagia
- Non cardiac chest pain
- OSA
GERD physical exam findings
Physical findings are not as important as a careful history
- Loss of dental enamel
- Cough and wheezing
- Cutaneous evidence of smoking → scleroderma, thickened tight shiny skin, sclerodactyly, facial telangiectasia
- Weight loss
- Epigastric tenderness
- Hemoccult-positive stool from esophageal erosions, ulcerations, severe inflammation
- Abdominal mass
When is diagnostic testing warranted for patients with GERD?
- Patients who have failed empirical trial suggesting an alternative diagnosis
- Sudden onset of symptoms in patients 50+ years old
- Have alarm symptoms
- Long standing symptoms of sufficient duration to put patients at risk for BE
Essential diagnostics to rule out anemia (intestinal bleeding) as a potential cause of GERD
- CBC
- Fecal h. pylori antigen
- Fecal hemooccult
Essential diagnostics to rule out mechanical obstructions as cause of GERD
- Barium radiograph
- EGD preferred
- Gold standard for patients with refractory GERD (medically unresponsive)
Additional diagnostic tests for GERD
- Gastric emptying scans
- Dynamic barium videography
- Ambulatory pH testing
- High resolution esophageal manometry and pH testing
GERD management
- Lifestyle modifications
- Acid suppression therapy (H2 antagonists, PPIs)
- Promotility agents → metoclopramide, regalan
- Endoscopic therapy if does not respond to meds after 2 months
- Surgery
What are the two main types inflammatory bowel disease (IBD)?
- Ulcerative colitis (UC)
- Crohn disease (CD)
What is ulcerative colitis?
- Chronic inflammation of the lining of the colonic mucosa and submucosal layer
- Involves the colon and rectum
- Diffuse, continuous inflammation
What is Crohn disease?
- Chronic inflammation of all layers of the intestinal tract wall (transmural inflammation)
- Any portion from the mouth to the anus
- Patchy, skip lesions, cobblestone appearance
Possible causes of IBD (UC and CD)
- Altered intestinal microbial flora
- Genetics (first degree relatives)
- Smoking
IBD clinical presentation
- Abdominal pain and loose, watery diarrhea
- Generalized or right/left lower quadrant pain
- Tenesmus (urge to defecate despite having empty bowels)
- Rectal bleeding
- Fatigue, weight loss, anorexia, fever, chills, N/V, joint pain and mouth sores (CD)
IBD physical exam findings
- Fever,
- Tachycardia
- Weight gain or loss
- Tenderness to palpation of lower abdomen
- Frank rectal blood on DRE
- Perianal lesions
- CD → conjunctival inflammation, oral aphthous ulcers, skin lesions
IBD diagnostic studies
- Blood tests → CBC, platelet count, CRP, ESR, electrolytes, LFTs, blood glucose, BUN, creatinine, vitamin D, B12, folate levels, serogenetic markers
- Stools tests
- Imaging → CT or MRI, small bowel series
- Procedures → sigmoidoscopy, colonoscopy, endoscopy, mucosal biopsy
IBD (UC and CD) pharmacologic management
- First line treatment for UC → 5-ASA (mesalamine products)
- Corticosteroids
- Immunomodulators
- Biologics
- Antibiotics
IBD (UC and CD) management
- Conservative and procedures
- Low fiber diet, lean proteins, refined grains; avoid alcohol, caffeine, spicy foods, high fiber foods
- Monitor growth and pubertal changes in adolescents (malabsorption disorder)
- Surgery
- UC → total colectomy
- CD → small bowel or colonic resection
What is irritable bowel syndrome (IBS)?
- “Gut-brain” disorder
- Occurs more frequently in women
- Functional disorder (can’t be explained by labs, imaging, etc.)
Indications for referral to GI for patients with IBS
- Change in bowel habits after 50 years old
- Family history of celiac disease, colon cancer, IBD
- Evidence of GI bleeding
- Weight loss
- Fever
- Nocturnal symptoms
- Recent antibiotic therapy
- Continuing symptoms
Symptoms of IBS required for diagnosis
- Abdominal discomfort
- Altered bowel habits
- Constipation
- Infrequent stools
- Straining
- Passage of hard stools
- Feelings of incomplete or difficult evacuation
Clinical presentation of IBS
- Abdominal pain MUST be present
- Pain described as:
- Non radiating, intermittent, crampy
- Located anywhere but usually in LLQ
- Associated with diarrhea, constipation, pattern of alternating diarrhea and constipation
The absence of what symptoms must be absent to diagnose IBS?
Absence of nocturnal symptoms
Important things to ask when collecting HPI for patients with IBS
- Recent travel
- Use of OTC medications
- Recent GI infections
- Family history
- Diet
Physical exam components for IBS diagnosis
- Perform abdominal, pelvic, and rectal exam
- May note increased tympany to percussion, palpable and tender cordlike sigmoid colon, tenderness on rectal exam
Are diagnostic tests indicated for IBS diagnosis?
Want to establish an early diagnosis, exclude the presence of alternative or coexisting diagnoses
- Avoid unnecessary diagnostic testing
- Labs will come back normal
- Can test further if red flags are present
What is the focus of IBS treatment?
Symptomatic treatment
- Dietary modifications
- Medications
- Supportive and behavioral therapy
- Education
- Reassurance
Dietary modification and diet management for patients with IBS
- Trial food allergy testing and food elimination diet
- Referral to dietician for low FODMAPs diet
- Keep food diary
Pharmacologic therapy for patients with IBS
- Fiber
- Metamucil, benefiber, fibercon, citrucel
- Antispasmodics
- Dicyclomode (bentyl)
- Antidiarrheal medications
- Loperamide (imodium)
- Anti-constipation medications (osmotic laxatives)
- Miralax, lactulose
- Psychotropic medications
- TCAs and SSRIs
What is the primary risk factor for stomach cancer?
H. pylori infection
Risk factors for esophageal cancer
- Alcohol
- Smoking
- Tylosis
Common presentation of GI cancers (depends on the location)
- Dysphagia and odynophagia
- Hoarseness
- N/V
- Cramping
- Abdominal distention aggravated by eating
- Weight loss
- Palpable masses
- Melena
- Anemia
Physical examination findings for GI cancers (depending on the location)
- Cachexia
- Signs of obstruction
- Lymphadenopathy
- Palpable mass
- Organomegaly
Diagnostic testing used for GI cancers
- Biochemical assay
- CBC w/ diff
- Barium esophagography
- Endoscopy and endoscopic US
- Chest x-ray
- Air contrast enema
- Colonoscopy
- Flexible sigmoidoscopy (for colon cancer)
- CT scan
- Fine needle biopsy
What are current USPSTF recommendations for colon cancer screening?
USPSTF recommendation for colon cancer screening now 45-75 years old (every 10 years)
- If family history of colon cancer in first degree relative, will be done every 5 years
- If healthy but have first degree relative with known colon cancer (e.g. patient’s mom was 47 with colon cancer), will need to get screening done 10 years before family members cancer diagnosis
What is celiac disease?
- Immune-mediated systemic disorder triggered by dietary exposure to wheat, barley, and rye gluten
- Co-occurs with other autoimmune disease (e.g. DM type 1, thyroiditis, liver disease, IgA neuropathy, juvenile chronic arthritis)
Classic symptoms of celiac disease
- Diarrhea
- Steatorrhea
- Weight loss
- Growth failure → need to monitor growth and development in peds patients
Non-classical symptoms of celiac disease
- GI symptoms → abdominal pain, constipation
- Extraintestinal symptoms
- Abnormal liver enzymes
- Arthralgia/arthritis, myalgias
- Dermatitis herpetiformis, alopecia, rashes
- Fatigue, headache, anemia, stomatitis
- Psychiatric disorders, seizures, neuropathy
- Short stature, delayed puberty, infertility
- Osteoporosis
Physical examination findings for celiac disease
- ENT → stomatitis
- Neuropsychiatric
- Growth and development
- Abdomen → hepatosplenomegaly, distention
- Skin → alopecia, rashes
- Joints, bones
Labs that should be drawn to diagnose celiac disease
- IgA tTGA and IgA EMA
- If positive, refer to endoscopy with biopsy for definitive diagnosis
- Prior to testing, gluten should be eaten in more than one meal every day for 6 weeks
- After 6 months of eating a gluten free diet, test IgA tTGA again, then yearly
- Bone density testing
Celiac disease management
- Follow strict gluten free diet for life
- Alternative therapies:
- Enzyme therapy
- Genetically engineered grains
- Inhibiting tTGA in intestines
- Correcting intestinal barrier defects
- Keep patients UTD on vaccinations
