MGH PM - Gastroenterology I Flashcards
Esophageal and gastric disorders - Dysphagia - 2 types:
- Oropharyngeal.
2. Esophageal.
Oropharyngeal dysphagia - Definition:
Inability to propel food from mouth through UES into esophagus.
Esophageal dysphagia - Definition:
Difficulty shallowing and passing food from esophagus into stomach.
Achalasia - Etiologies:
- Idiopathic (MC).
- Pseudoachalasia (due to GE jxn tumor).
- Chagas.
Achalasia - Sx:
- Dysphagia (solid and liquid).
- Chest pain (1/3 of pts).
- Regurgitation.
Achalasia - Dx:
- Barium swallow ==> Bird beak.
- Manometry ==> Simultaneous, low amplitute contractions of esophageal body + Incomplete relax of LES (+/- LES HTN).
- EGD r/o pseudoachalasia (retroflex).
Achalasia - Rx:
Expert pneumatic dilation (<4% eso perf).
Same results as HELLER MYOTOMY (NEJM 2011).
Other esophageal disorders:
- Webs ==> Upper/mid esoph, congenital, GVHD, Fe-def anemia.
- Rings ==> Lower esoph; ? due to GERD.
- Zenker’s (pharyngoesoph jxn).
Webs, rings, and Zenker’s - Dx:
W/ barium swallow.
Webs, rings, and Zenker’s - Rx:
Endo/surg.
Infxn esophagitis:
ODYNOPHAGIA > dysphagi.
==> Often immunosuppressed w/ Candida, HSV, CMV.
Pill esophagitis:
ODYNOPHAGIA > dysphagia.
==> NSAIDs, KCl, bisphosp., doxy and tetracycline.
Eosinophilic esophagitis (Clin Gastro and Hep 2012) - Seen in:
Yound, or middle-aged.
==> Mostly FEMALES.
Eosinophilic esophagitis - Dx:
Req >15 eos/hpr on bx + EXCLUDE GERD (eg, empiric PPI trial.
Eosinophilic esophagitis - Rx:
3Ds:
- Diet ==> Eliminate milk, soy, eggs, wheat, nuts, and fish.
- Drugs ==> Swallow inh steroids.
- Dilation.
GERD - Pathophysio:
- Excessive TRANSIENT relaxations of LES.
- Incompetent LES.
- Mucosal damage (esophagitis) due to prolonged contact w/ acid can evolve to STRICTURE.
GERD - Risk factors:
- Hiatal hernia.
- Obesity.
- Gastric hypersecretory states.
- Delayed emptying.
GERD - Precipitants:
- Supine position.
- Fatty foods.
- Caffeine.
- Alcohol.
- Cigarettes.
- CCB.
- Pregnancy.
GERD - Clinical manifestations - 2 categories:
- Esophageal.
2. EXTRAesophageal.
GERD - Clinical manifestations - Esophageal:
- Heartburn.
- Atypical chest pain.
- Regurgitation.
- Water brash.
- Dysphagia.
GERD - Clinical manifestations - Extraesophageal:
- Cough.
- Asthma (often poorly controlled).
- Laryngitis.
- Dental erosions.
GERD - Diagnosis (Gastro 2008, Am J Gastro 2010, Annals 2012):
Based on hx and empiric trial of PPI (Se & Sp: 78% & 54%) (Annals 2004).
GERD - Diagnosis (Gastro 2008, Am J Gastro 2010, Annals 2012) - EGD if:
- Failure to respond to bid PPI.
- Alarm features ==> dysphagia, vomiting, wt loss, evid of blood loss.
- Female >50y w/ sx >5y + nocturnal sx, hiatal hernia, obesity, cigs.
GERD - Diagnosis (Gastro 2008, Am J Gastro 2010, Annals 2012) - If dx uncertain + EGD nl …?
HIGH RES MANOMETRY w/ 24-h esoph pH monitoring +/- impedance.
GERD - Treatment (NEJM 2008) - 3 categories:
- Lifestyle.
- Medical.
- Refractory cases.
GERD - Treatment (NEJM 2008) - Lifestyle:
- Avoid precipitants.
- Lose weight.
- Avoid large and late meals.
- Elevate head of bed.
GERD - Treatment (NEJM 2008) - Medical:
PPI achieve relief in 80-90% (titrate to lowest dose that achieves sx control.
==> surgery among pts who initially respond to acid suppression (JAMA 2011).
GERD - Treatment (NEJM 2008) - Refractory cases:
Confirm w/ pH testing.
- If acidic or sx correlate w/ reflux episodes ==> Surgical fundoplication (implantation of magnetic esophageal sphincter device being studied) (NEJM 2013).
- If nl pH or no sx correlation ==> TCA, SSRI or baclofen (Gastro 2010).
GERD - Complications (NEJM 2009, Gastro 2011):
- Barrett.
2. Adenocarcinoma.
GERD - Complications (NEJM 2009, Gastro 2011) - Barrett:
DX by bx of intestinal metaplasia above GE jxn.
==> Screen for BE if >2 of the following risk factors:
- > 50y.
- Male.
- White.
- Chronic GERD.
- Hiatal hernia.
- High BMI.
GERD - Complications (NEJM 2009, Gastro 2011) - Esophageal adenocarcinoma:
- If BE ==> risk 0.12%/y.
- If low-grade dysplasia ==> risk 2.3%/y.
- If high-grade dysplasia ==> risk 6%/y.
==> 40% of pts w/ esoph adenoca report no hx of GERD sx.
GERD - Complications (NEJM 2009, Gastro 2011) - Management:
- Barrett w/o dysplasia ==> Surveillance EGD q3-5 y.
- Low-grade dysplasia ==> q6- 12mo.
- 4 quadrant bx q 2cm.
==> Chemopreventive benefit of ASA under study.
GERD - Complications (NEJM 2009, Gastro 2011) - Management of HIGH grade dysplasia:
- U/S to r/o invasive cancer.
2. Endoscopic mucosal resection of any visible mucosal irregularity + Ablation of dysplasia (RF or photodynamic).
Dyspepsia (“indigestion”) - Definition:
Upper abdominal sx:
- Discomfort.
- Pain.
- Fullness.
- Early satiety.
- Bloating.
- Burning.
Dyspepsia - Etiologies - 2 Categories:
- Functional (“nonulcer dyspsepsia” or NUD 60%).
2. Organic (40%).
Functional dyspepsia (60%):
Some combination of visceral afferent hypersensitivity + abnormal gastric motility (Rome III criteria in Gastro 2006; 130:1377).
Organic dyspepsia (40%):
- GERD.
- PUD.
- Rarely gastric cancer.
- Other ==> Meds, diabetic gastroparesis, lactose intolerance, biliary pain, chronic pancreatitis, mesenteric ischemia.
Dyspepsia - Alarm features:
Features that suggest ORGANIC CAUSE and warrant EGD.
Tx of functional dyspepsia (Gastro 2005, Alim Pharm Ther 2012):
- H.pylori eradication ==> Empiric Rx if positive serology. NNT=14 (Cochrane 2006).
- PPI effective in some (? misdx GERD), others: TCA, prokinetics, buspirone.
PUD - Epidemiology and etiologies (Lancet 2009) - Lifetime prevalence:
10%. (but incidence decreases ==> H.pyroli and potent acid suppression Rx).
==> However, hosp for complic unD’d in general and INCREASE in elderly, likely 2o to incr. NSAID use.
PUD - Epidemiology and etiologies (Lancet 2009) - H.pylori infection:
80% of DU and 60% of GU.
==> 50% of population colonized w/ H.pylori, BUT ONLY 5-10% will delevop PUD.
PUD - Epidemiology and etiologies (Lancet 2009) - ASA and NSAIDs:
- 45% erosions.
- 15-30% GU.
- 0.1-4% UGIB.
PUD - Epidemiology and etiologies (Lancet 2009) - Hypersecretory states (often mult. recurrent ulcers):
- Gastrinoma (Z-E, also p/w diarrhea, <1% of PUD).
- Carcinoid.
- Mastocytosis.
PUD - Epidemiology and etiologies (Lancet 2009) - Malignancy:
5-10% of GU.
PUD - Epidemiology and etiologies (Lancet 2009) - Other:
- Smoking.
- Stress ulcers.
- XRT (X-ray therapy).
- Chemo.
- CMV/HSV (immunosupp).
- Bisphosphonates.
==> STEROIDS alone generally NOT a risk factor, but may exacerbate NSAID-induced ulceration.
PUD - Clinical manifestations:
Epigastric abdominal pain ==> Relieved with food (DU) or worsened with food (GU).
PUD - Complications:
- UGIB.
- Perforation + Penetration.
- Gastric outlet obstruction.
PUD - Diagnostic studies - Test for H.pylori:
- Stool antigen or EGD + Rapid urease test ==> Now dx tests of choice + to confirm erad (4-6 wk post txment).
==> FALSE (-) if on abx, bismuth, PPI, so stop prior to testing if possible.
- Serology ==> Decr. utility, useful only to exclude infection in low prevalence areas (most of U.S.).
PUD - Diagnostic studies - EGD:
Req to def make dx.
==> Consider if fail empiric Rx or alarm features.
==> Bx GU to r/o malig.
==> Relook in 6-12wk if apparently benign ulcer >2.5cm, complicated or sx persist.
PUD - Treatment (NEJM 2010, Gut 2012) - If H.pylori (+), eradicate:
- Triple Rx: clarith + [amox, MNZ, or levoflox] + PPI bid x 10-14d (if clarith resist rate <20%).
- Quadruple Rx: MNZ + TCN + Bismuth + PPI (if clarith resist rate >15% or amox allergy).
- Sequential Rx: PPI + amox x 7d ==> PPI +clarith + MNZ x 7d (Lancet 2013).
==> BESIDES PUD, test and Rx if: gastric MALToma, atrophic gastritis, FHx gastric ca.
PUD - Treatment (NEJM 2010, Gut 2012) - If H.pylori (-):
Gastric acid suppression w/ PPI.
PUD - Treatment (NEJM 2010, Gut 2012) - Other:
- Discontinue ASA + NSAIDs; add PPI.
- Lifestyle changes: d/c smoking and probably EtOH; diet does not seem to play a role.
- Surgery: if refractory to med Rx (1st r/o NSAID use) or for complications (see above).
PUD - Prophylaxis if ASA/NSAID required (JACC 2008):
- PPI if: ==>
(a) h/o PUD/UGIB.
(b) also on clopidogrel (although ? decr. antiplt effect).
(c) At least 2 of the following: >60, steroids or dyspepsia; prior to start test & Rx H.pylori.
- Consider misoprostol; consider H2RA if ASA monotherapy (Lancet 2009).
- Consider Δ to COX-2 inhibit (decr. PUD and UGIB but incr. CV events) if low CV risk and not on ASA.
- Stress ulcer: risk factors = ICU and coagulopathic, mech vent, h/o GIB, steroid use; Rx w/ PPI.
GI bleeding - Definition:
Intraluminal blood loss anywhere from the oropharynx to the anus.
GI bleeding - Classificatiion:
- UPPER ==> Above the ligament of Treitz.
2. LOWER ==> Below the ligament of Treitz.
GI bleeding - Signs:
- Hematemesis = Blood in vomitus (UGIB).
- Hematochezia = Bloody stools (LGIB or rapid UGIB).
- Melena = Black tarry stools from digested blood (usually UGIB, but can be anywhere above and including the right colon).
Etiologies of UGIB:
- PUD (50%).
- Varices (10-30%).
- Gastropathy/gastritis/duodenitis (15%).
- Erosive esophagitis/ulcer (10%).
- Mallory-Weiss tear (10%).
- Vascular lesions (5%).
- Neoplastic disease ==> Esophageal, gastric, GIST.
- Orophareyngeal bleeding and epistaxis ==> Swallowed blood.
Varices (10-30%):
Esophageal +/- gastric, 2o to portal HTN.
==> IF ISOLATED GASTRIC ==> r/o splenic vein thrombosis.
Gastropathy/gastritis/duodenitis (15%):
- NSAIDs.
- ASA.
- Alcohol.
- Stress.
- Portal hypertensive.
Erosive esophagitis/ulcer (10%):
- GERD.
- XRT.
- Infectious (CMV, HSV, Candida if immunosuppressed).
- Pill esophagitis (bisphosphonate, NSAIDs; +/- odynophagia).
Vascular lesions (5%):
- Dieulafoy’s lesion.
- AVMs, angioectasias, HHT ==> Submucosal, anywhere in GI tract.
- Gastric antral vascular ectasia (GAVE).
- Aortoenteric fistula.
Dieulafoy’s lesion:
Superficial ectatic artery usually in cardia ==> SUDDEN + MASSIVE UGIB.
Gastric antral vascular ectasia (GAVE):
“Watermelon stomach”, tortuous, dilated vessels;
a/w ==> cirrhosis, atrophic gastritis, CREST syndrome.
Aortoenteric fistula:
AAA or aortic graft erodes into 3rd potion of duodenum.
==> p/w “herald bleed”; if suspected, diagnose by endoscopy or CT.
LGIB - Etiologies:
- Diverticular hemorrhage (33%).
- Neoplastic disease (19%).
- Colitis (18%).
- Angiodysplasia (8%).
- Anorectal (4%).
==> Other: postpolypectomy, vasculitis.
Diverticular hemorrhage - MC where?
60% of diverticular bleeding localized to right colon.
Neoplastic disease (19%)?
Usually OCCULT BLEEDING, rarely severe.
Colitis (18%):
- Infectious.
- Ischemic.
- Radiation.
- IBD (UC»_space; CD).
Angiodysplasia (8%):
Ascending colon + Cecum.
Anorectal (4%):
- Hemorrhoids.
- Anal fissure.
- Rectal ulcer.
Clinical manifestations - UGIB > LGIB?
- N/V.
- Hematemesis.
- Coffee-ground emesis.
- Epigastric pain.
- Vasovagal.
- Melena.
Clinical manifestations - LGIB > UGIB:
- Diarrhea.
- Tenesmus.
- BRBPR (Bright red blood per rectum).
- Hematochezia.
(11% UGIB; Gastro 1988).
GI bleeding - Initial management - Assess severity:
- Tachycardia (can be masked by bB use) suggests ==> 10% volume loss
- Orthostatic hypotension ==> 20% loss.
- Shock ==> >30% loss.
GI Bleeding - Initial management - Resuscitation:
Placement of 2 large-bore (18-gauge or larger) IV lines.
==> Volume replacement: NS or LR to achieve normal VS, UOP (Urine output), and mental status.
GI bleeding - Initial management - Transfuse:
- Blood bank sample for type and cross.
- Use O-neg if emerg.
- Transfuse as needed.
==> For UGIB (esp. w/ portal HTN) use more RESTRICTIVE Hb goal (eg, 7g/dL) (NEJM 2013).
GI bleeding - Initial management - Reverse coagulopathy:
FFP and Vit K to normalize PT.
==> Plts to keep count >50.000.
GI bleeding - Initial management - Triage:
Consider ICU if unstable VS or poor end organ perfusion.
==> Intubation for emergent EGD, if ongoing hematemesis, shock, poor resp status, Δ MS.
==> OutPt management if SBP >110, HR <100, Hb >13 (male) or >12 (female), BUN <18, melena, syncope, heart failure, liver disease (Lancet 2009).
GI bleeding - Workup - History:
WHERE (anatomic location) + WHY (etiology).
- Acute or chronic, prior GIB, # of episodes, other GI dx.
- Hematemesis, vomiting PRIOR to hematemesis (Mallory-Weiss), melena, hematochezia.
- Abdominal pain, wt loss, anorexia, Δ in stool caliber.
- Gastric irritants (ASA/NSAIDs), antiplatelet drugs, anticoagulants, known coagulopathy.
- Alcohol (gastropathy, varices), cirrhosis, known liver disease, risk factors for liver disease.
- Abdominal/rectal radiation, history of cancer, prior GI or aortic surgery.
GI Bleeding - Physical exam:
==> VS most important, orthostatic Ds, JVP.
- Localizable abd tenderness, peritoneal sings, masses, LAN, signs of prior surgery.
- Signs of liver disease (HSM, ascites, etc).
- Rectal exam: masses, hemorrhoids, anal fissures, stool appearance, color, occult blood.
- Pallor, jaundice, telangiectasias (alcoholic liver disease or HHT).
GI bleeding - Lab studies:
- Hct (may be normal in first 24h of acute GIB before equilibration).
==> Down 2-3% ==> 500mL blood loss.
==> Low MCV ==> Fe def and chronic blood loss.
- PT, plt, PTT, BUN/Cr (ratio >36 in UGIB b/c GI resorption of blood +/- prerenal azotemia).
- LFTs.
GI bleeding - Diagnostic studies - NGT:
Can aid localization:
- FRESH blood ==> Active UGIB.
- Coffee-grounds ==> Recent UGIB.
- Nonbloody bile ==> Lower source, but does not exclude active UGIB (15% missed).
==> (+) occult blood test of NO value.
GI bleeding - Diagnostic studies - UGIB:
- EGD w/in 24h for dx and poss Rx.
- Decr. LOS and need for surgery, consider erythro 250mg IV 30 min prior ==> Empty stomach of blood ==> Incr. Dx/Rx yield.
(Am J Gastro 2006).
GI bleeding - Diagnostic studies - LGIB:
- FIRST r/o UGIB before attempting to localize presumed LGIB ==> (10-15% actually UGIB, 3-5% small bowel).
- THEN colonoscopy (identifies cause in >70%).
- Consider rapid purge w/ PEG solution 4L over 2h.
- No clear benefit of colonoscopy w/in 12 vs 36-60h (AJG 2010).
- CT angio promising (Radiology 2010).
GI bleeding - Unstable or recurrent UGIB/LGIB:
- Tagged RBC scan ==> Localize bleeding rates >0.1mL/min for surg but UNRELIABLE.
- Arteriography ==> Can localize if bleeding rates >0.5mL/min and can Rx (coil, vaso, glue) emergent exploratory laparotomy (last resort).
GI bleeding - Rx - Varices (Hep 2007, NEJM 2010) - Pharmacologic:
- Octreotide 50μg IVB ==> 50μg/h infusion (84% success). Usually x5 d, but most benefit w/in 24-48h.
- Abx: cirrhotics w/ any GIB should receive prophylaxis: Cftx IV or norfloxacin PO (Hep 2004, Gastro 2006).
GI bleeding - Rx - Varices (Hep 2007, NEJM 2010) - NON pharmacologic:
- Endoscopic band ligation (>90% success).
- Arteriography with coiling/glue occasionally for gastric varices.
- Balloon tamponade mainly rescue procedure and bridge to TIPS.
- TIPS for refractory esoph variceal bleed (consider early if persistent bleed on EGD or Child-Pugh C; NEJM 2010), or for persistent gastric variceal bleed; c/b enceph, shunt occl.
- Surgery (portocaval/ splenorenal shunts) rarely used now.
GI bleeding - Rx - PUD (AJG 2012) - If active bleeding or nonbleeding visible vessel (NBVV) on EGD:
- PPI (eg omeprazole 80mg IVB ==> 8mg/h) before EGD ==> Decr. need for endoscopic Rx and decr. LOS continue IV dose x 72h following EGD: Decr. rebleed rate.
==> Convert to PO after 72h. - ? Octreotide if no access to EGD.
GI bleeding - Rx - PUD (AJG 2012) - If active bleeding or nonbleeding vissible vessel (NBVV) on EGD - Endoscopic therapy (ET):
- Epi inj + Either bipolar cautery or hemoclip; rebleeding risk: 43% (NBVV) to 85% (active bleed) w/o ET vs. 15-20% w/ ET vs. <7% w/ ET + PPI (most w/in 48h).
- Clear liquids 6h after ET if hemodynamically stable.
- Arteriography w/ vasopressin or embolization; surgery (last resort).
GI bleeding - Rx - PUD (AJG 2012) - If adherent clot:
PPI as above +/- endo removal of clot (if experienced ctr) to r/o NBVV; rebleeding risk 22% w/o ET vs 5% w/ ET.
GI bleeding - Rx - PUD (AJG 2012) - If flat, pigmented spot or clean base:
No endo Rx indicated; rebleed risk <10% oral PPI bid.
==> Consider early hospital d/c (see criteria in NEJM 2008).
GI bleeding - Rx - PUD (AJG 2012) - If pt on ASA for CV disease and PUD GIB endoscopically controlled, …?
Resume ASA with hemostasis (BMJ 2012).
GI bleeding - Rx - Mallory-Weiss:
Usually stops SPONTANEOUSLY.
==> Endoscopic Rx if active.
GI bleeding - Rx - Esophagitis/gastritis:
PPI, H2-blockers.
GI bleeding - Rx - Diverticular disease:
Usually stops spontaneously (75%).
==> Endoscopic Rx (eg epinephrine injection, cautery, banding or hemoclip), arterial vasopressin or embolization, surgery.
GI bleeding - Rx - Angiodysplasia:
Usually stops spontaneously (85%).
==> Endo Rx (cautery or argon plasma), arterio w/ vasopressin, surgery.
Obscure GIB (Gastro 2007, GIE 2010) - Definition:
Continued bleeding (melena, hematochezia) despite (-) EGD + colo.
==> 5% of GIB.
Obscure GIB (Gastro 2007, GIE 2010) - Etiologies:
- Dieulafoy’s lesion.
- Small bowel angiodysplasia.
- Ulcer or cancer.
- Crohn.
- Aortoenteric fistula.
- Meckel’s diverticulum (2% of pop., remnant of vitelline duct w/ ectopic gastric mucosa).
- Hemobilia.
Obscure GIB (Gastro 2007, GIE 2010) - Diagnosis:
Repeat EGD w/ push enteroscopy/colonoscopy when bleeding is ACTIVE.
==> If (-), video capsule to evaluate small intestine (Gastro 2009).
==> If still (-), consider 99mTc-pertechnetate scan (“Meckel scan”), enteroscopy (single-balloon, double-balloon or spiral), tagged RBC scan and arteriography.
