Week 8 Chronic GI Problems Flashcards
Common side effects of proton pump inhibitors (PPI) include all of the following except:
A Abdominal pain
B Diarrhea
C Vitamin B12 deficiency
D Melena
D Melena
Common side effects include abdominal pain, diarrhea and vitamin B12 deficiency (with long term use). Melena is not a side effect and warrants investigation for an upper GI bleed.
When examining the liver, which of the following is correct?
A The normal liver often extends down just below the right costal margin
B The liver edge should not be palpable
C The liver span is 6 cm to 15 cm in the right midclavicular line
D Dullness indicates that the patient likely has a hepatic mass
A The normal liver often extends down just below the right costal margin
The normal liver often extends down just below the right costal margin and can be felt easier during inspiration. The liver span is 6-12 cm. The liver is a solid organ so is dull when percussed. Percussion can estimate the size of the liver
How can the nurse practitioner assess for possible ascites on exam? (Select all that apply)
A Test for shifting dullness
B Test for a fluid wave
C Test for Murphy’s sign
D Measure the abdominal girth
A Test for shifting dullness
B Test for a fluid wave
A protuberant abdomen with bulging flanks suggests possible ascites. Testing for shifting dullness and for a fluid wave are techniques to confirm the presence of ascites although both signs may be misleading.
When percussing the abdomen, the nurse practitioner would expect a normal finding of
A predominantly tympany, with possible scattered areas of dullness
B dullness in both flanks.
C a large area of dullness throughout the lower abdomen
D tenderness in the right lower quadrant.
A predominantly tympany, with possible scattered areas of dullness
A normal finding to percussion of the abdomen is predominantly tympany, with possible scattered areas of dullness due to fluid and stool. Dullness of the flanks may indicate ascites. A large dull area may indicate a possible mass or enlarged organ. The abdomen should be non-tender to light palpation/percussion.
A patient reports a decrease in the frequency of stools and asks about treatment for constipation. Which findings are part of the Rome IV criteria for diagnosing constipation? (Select all that apply.)
A Feeling of incomplete evacuation
B Fewer than five stools per week
C Hard or lumpy stools
D Abdominal cramps relieved with defecation
E Symptoms present for three months
A Feeling of incomplete evacuation
C Hard or lumpy stools
E Symptoms present for three months
According to the Rome IV criteria, symptoms must have begun 6 months prior and persisted for at least 3 months and include a feeling of incomplete evacuation, lumpy or hard stools, fewer than 3 stools per week, and not meeting criteria for irritable bowel syndrome.
Which are characteristics of Crohn’s disease (CD)? (Select all that apply.)
A Fistulous tracts may occur as disease complications
B The disease does not have extraintestinal manifestations
C Inflammation affects all layers of the intestinal tract wall
D The disease may be limited to the small intestine
E The inflammation is diffuse and continuous
A Fistulous tracts may occur as disease complications
C Inflammation affects all layers of the intestinal tract wall
D The disease may be limited to the small intestine
CD may be complicated by fistulous tracts. Inflammation affects all layers of the intestinal wall tract. The disease may be limited to the small intestine. UC causes inflammation that is diffuse and continuous. CD is associated with uveitis, psoriasis, and arthritis.
A 22-year-old male reports lower abdominal cramping and occasional blood in stools. The provider suspects inflammatory bowel disease. Which test will the provider order to determine whether the patient has ulcerative colitis (UC) or Crohn’s disease (CD)?
A Barium enema
B Colonoscopy
C Genetic testing
D Small bowel series
B Colonoscopy
Colonoscopy is useful in differentiating UC from CD. Barium enema has limited use in diagnosis, but is used to detect distension, strictures, tumors, fistulas, or obstructions. Genetic testing may be helpful in the future with further advances. Small bowel series are used infrequently to determine small bowel involvement.
A school-age child has recurrent diarrhea with foul-smelling stools, excessive flatus, abdominal distension, and failure-to-thrive. A two-week lactose-free trial failed to reduce symptoms. What is the next step in diagnosing this condition?
A Lactose hydrogen breath test
B Sweat chloride test for cystic fibrosis
C Stool for ova and parasites
D Serologic testing for celiac disease
D Serologic testing for celiac disease
This child has symptoms consistent with celiac disease, especially FTT and foul-smelling stools. Since the lactose-free trial did not reduce symptoms, the likelihood of lactose intolerance is less and thus testing is not likely to be helpful. The symptoms are recurrent, so giardiasis is less likely. CF is still possible, but most children with CF are diagnosed as infants and have accompanying respiratory symptoms of some type.
What is the probable underlying pathology of irritable bowel syndrome (IBS)?
A Alteration in processing of sensory information
B Changes in intestinal secretory mucosa
C Intestinal tissue disease
D Malabsorption of specific nutrients
A Alteration in processing of sensory information
Recent research has yielded information about alterations in sensory processing that are different in persons with IBS. Changes in intestinal mucosa, intestinal tissue disease, and malabsorption syndromes are structural disorders and this is a functional disease.
A patient is diagnosed with mild to moderate ulcerative colitis. Which medication will be prescribed initially to establish remission?
A Azathioprine
B Budesonide
C Infliximab
D Sulfasalazine
D Sulfasalazine
Sulfasalazine is a 5-aminosalicyclic acid used to induce remission in UC and is a first-line medication. Budesonide is a synthetic corticosteroid used for moderate to severe disease, but not as a first-line agent. Azathioprine is an immunomodulator used to minimize the need for corticosteroids. Infliximab is a biologic medication and is more useful for treating Crohn’s disease.
The parent of a 3-month-old reports that the infant arches and gags while feeding and spits up undigested formula frequently. The infant’s weight gain has dropped to the fifth percentile from the 12th percentile. There are no red flags. What is the best course of treatment for this infant?
A Reassure the parent that these symptoms will likely resolve by 12 to 24 months
B Perform esophageal pH monitoring to determine the degree of reflux
C Begin a trial of extensively hydrolyzed protein formula for two to four weeks
D Institute an empiric trial of acid suppression with a proton pump inhibitor (PPI)
C Begin a trial of extensively hydrolyzed protein formula for two to four weeks
Formula-fed infants may be given a trial of a hydrolyzed protein formula to see if improvement occurs to determine if there is a cows milk allergy. An empiric trial of a PPI may be used in children and adolescents. PPI use less than age 1 is not FDA approved. However, a PPI or H2 Blocker may be appropriate for infants with clear diagnosis of GERD. Esophageal pH monitoring may be performed in consultation with a specialist but not as first-line evaluation. The infant has warning signs of GERD that require further investigation and not just reassurance.
The nurse practitioner diagnoses an adult patient with GERD and educates the patient to do which of the following?
A Eat larger, less frequent meals
B Sleep in a flat position, without the use of pillows
C Dietary changes are not necessary if taking a PPI
D Exercise regularly and wear loose, comfortable clothes
D Exercise regularly and wear loose, comfortable clothes
Patients with GERD should eat smaller, more frequent meals, elevate the head of the bed when sleeping, avoid common triggers in the diet, and exercise regularly to maintain or lose weight and avoid tight clothes.
A patient with a history of chronic alcoholism reports weight loss, pruritis, and fatigue. The patient’s urine and stools appear normal. What do these findings indicate?
A Early liver cirrhosis
B Late liver cirrhosis
C Liver failure and ascites
D Acute viral hepatitis
A Early liver cirrhosis
Early symptoms of cirrhosis are characterized by this patient’s symptoms. As the condition worsens, stools and urine change color and the patient develops anorexia, nausea, and vomiting. Liver failure and ascites are late and will include abdominal pain. Acute viral hepatitis is a less likely diagnosis in this patient based on his history of alcoholism and reported symptoms.
Which of the following statements about non-alcoholic fatty liver disease (NAFLD) is correct?
A It is an uncommon cause of elevated liver transaminase
B The risk of developing NAFLD is higher in patients who are pre-diabetic or diabetic
C Children are not affected by the disease
D It produces symptoms of fatigue, jaundice, and right upper quadrant pain early in the disease
B The risk of developing NAFLD is higher in patients who are pre-diabetic or diabetic
Fatty liver affects up to 20% of Americans including adults and children. Risk factors include obesity, hypercholesterolemia and DM. It most often asymptomatic early in the disease, and jaundice may appear once the disease has progressed.
A patient is diagnosed with cancer of the colon and is scheduled for surgical resection. A carcinoembryonic antigen (CEA) test prior to surgery is not elevated. What is the significance of this finding?
A A negative CEA indicates a reduced need for surgery
B The CEA should be repeated every 3 months
C The test is not informative and will not be repeated
D This result indicates a better prognosis for cure
C The test is not informative and will not be repeated
A negative CEA indicates that this test is not informative and will not be useful postoperatively. A positive CEA indicates the usefulness of this test and the measurement should be repeated every 3 months after surgery to detect tumor recurrence. It does not indicate whether surgery should be performed and does not predict cure rates.
What is cirrhosis
end-stage consequence of progressive hepatic fibrosis affecting normal liver function
serious, irreversible dx
results from exposure to persistent toxins and results in liver failure and death
common causes of cirrhosis
chronic hepatitis B & C
alcoholic liver dx
nonalcoholic fatty liver dx (NAFLD)
nonalcoholic steatphepatitis (NASH)
Meds associated with cirrhosis
acetaminophen amiodarone methotrexate isoniazid varied abx carbon tetrachloride
advanced stages of cirrhosis results in
shunting of portal and arterial blood supply causes: -portal HTN -obstructive biliary channels -destruction of liver cells -hepatocellular carcinoma liver failure
micronodular cirrhosis
associated with alcoholic liver dx
occurs when repeated presence of an offending agent prevents the regeneration of normal tissue, results in small nodules that have limited functional abilities
as it progresses liver becomes smaller and nodules become larger with diffuse fat accumulation
macronodular cirrhosis
seen in chronic viral hepatitis and hepatocelluar carcinoma, with larger nodules that can contain their own blood supply
larger nodules resemble scar tissue and have limited functional abilities
mixed cirrhosis
combination of both micronodular and macronodular cirrhosis, has mixed characteristics and liver functions are varied
how do we prioritize patients with cirrhosis as candidates for liver transplant
Model for end-stage liver dx (MELD) is a diagnostic tool based on underlying cause of cirrhosis and the Cr, bilirubin, and INR and is used as a prediction tool for liver transplantation
MELD is a 3-month predication of survival
cirrhosis prognosis
depends on cause and classification
if alcohol or drug related, the major factor that determines survival is the ability to STOP drinking or taking those drugs
cirrhosis S/S
asymptomatic, can have insidious onset pruritus weight loss fatigue weakness malaise dark urine pale stools anorexia w/ N/V hematemesis abdominal pain (ascites) chest pain (cardiomegaly) menstrual abnorms impotence/sterility neuropsychiatric symptoms (diff. concentrating, irritability, confusion r/t liver failure) jaundice - late-stage symptoms
cirrhosis exam findings
jaundice, spider angiomata, gynecomastia, ascites, splenomegaly, palmar erythema, digital clubbing, and asterixis may be presenting signs
low-grade fever, anorexia, RUQ pain
decrease in MAP
nodular, firm, enlarged or shrunken liver
venous hum r/t portal HTN augmented by valsalva maneuver
rectal and esophageal varices
peripheral edema
weight loss, tremors, cheilosis or glossitis, Dupuytren contracture, horizontal white bands on nail beds (Meuhrcke nails), Terry nails, testicualr atrophy, changes in body hair distribution in F
sweet breath aka fetor hepaticus
cirrhosis diagnostics
CBC w/ diff
serum glucose, electrolytes, BUN, Cr, LFTs
US
alpha fetoprotein hepatitis screen fasting serum ferritin transferrin saturation total iron-binding capacity serum protein electophoresis serum cerulikasmin fibrotest
fibroscan
MRE
esophagogastroscopy (routine to assess for varcies)
liver biopsy
labs that indicate hepatocelluar inflammation or injury
hypoalbuminemia elevated serum protein hyperbilirubinemia elevated lier enzymes (AST & ALTs) alkaline phophatase and y-glutamyl transpeptides levels elevated
further testing based on H&P
how to diagnosis cirrhosis
fibroscan and fibrotest are more frequently used to dx cirrhosis over liver biopsy bc they are less invasive and present less risk to pt
PCP role in cirrhosis management
eliminate causative factors
promote healthy lifestyle - diet & exercise
goal - delay long-term consequences of cirrhosis
monitor for compliance and side effects
work with specialist
immunize with polyvalent pneumococcal vaccine, yearly flu vaccine, and Hep A & B vaccines (unless immune)
eliminate reversible causes - NSAID use
Co-management of cirrhosis
management is complex, requires coordinated care with gastroenterologist & other specialists
mental health specialists for addiction
social services
home health
support groups
cirrhosis complications
increased risk for hepatocelluar carcinoma portal HTN esophageal varcies depression - use of antidepressants not indicated r/t toxicity/oversedation ascites spontaneous bacterial peritonitis (SBP) hepatorenal syndrome (HRS) hepatic encehalopathy
cirrhosis management
depends on causes:
viral hepatitis: anitviral therapy
manage/ tx complications
lab findings in cirrhosis
liver transaminase can be normal or elevated
in advanced dx increased PT & INR; decreased albumin, and CBC abnorms - pancytopenia (increased bleeding risk)
what to consider when dx pt w/ cirrhosis
Immediate referral to hepatologist considered for dx of cirrhosis
Pt presents with sudden change in bowel habits after age 50, weight loss, blood in stool, anemia, fam hx of colon cancer or IBD, or acute constipation in elderly
What should you do?
Immediate referral to GI
constipation mostly affects
women children older adults low SES obese pts non-whites pt who eat diet low in fiber
diff between AST & ALT
both respond to hepatocelluar damage
ALT - more SPECIFIC to liver, can evaluate acute vs chronic liver injury
AST - can be elevated in extrahepatic reasons - thryoid, celiac, muscular d/o
liver enzymes in alcoholic liver dx
AST/ALT ratio > 2 strongly suggestive of alcoholic liver dx
constipation definition
decrease in frequency of bowel movements to fewer than 3x/week with symptoms of hard stools, straining, and incomplete defecation
Rome Criteria IV for constipation
two or more of the following must be present for at least 3 months with onset 6 months before dx:
- fewer than 3 BM’s per week
- passage of hard or lumpy stools
- sensation of straining w/ more than 25% of defecations
- use of manual maneuvers to aid defecation in more than 25% of defecations
- soft, easily passed stools are not present without the use of medication such as laxatives and there is insufficient criteria for IBS
true clinical diagnosis of constipation
finding of large amount of feces in rectal ampulla on DRE or excessive feces in colon, rectum, or both on abdominal xray
medications associated with constipation
NSAIDs, opioids, tramadol antacids anticholinergics antidepressants (SSRIs & tricyclics) antiemetics antihistamines anticonvulsants antihypertensives (clonidine, CCB, diuretics) antiparkinsonian meds antipsychotics bile acid binders (Questran) Ca supplements iron supplements
Bristol stool chart
type 1: separate hard lumps (hard to pass)
type 2: sausage-shaped but lumpy
type 3: like sausage but with cracks on surface
type 4: like sausage or snake, smooth and soft
type 5: soft blobs with clear cut edges (passed easily)
type 6: fluffy pieces with ragged edges, mushy stool
type 7: watery, no solid pieces, entirely liquid
acute constipation
can be indicative of pathologic condition, requires immediate attention
to identify ileus, intra-abdominal infection (appendicitis, diverticulosis), toxic megacolon, obstructing lesion
usually occurs from dietary changes, travel, stress and often resolves on its own with minimal intervention
chronic constipation
primary (idiopathic) or secondary
primary causes: IBS, disordered colonic transit, evacuation disorders (dyssynergic defecation)
secondary causes: medical/psychogenic conditions, meds, structural abnorms, lifestyle, ignoring urge to defecate, inadequate fiber or fluid intake, meds, pregnancy, anxiety, colorectal CA, colonic obstruction, ovarian CA, hypothyroidism, hypopituitary d/o, DM, hypokalemia, hypercalcemia, motility d/o, rectal fissure, scleroderma, MS, Parkinsons, ALS, IBS
dyssynergic defecation
inability of abdominal and pelvic floor muscles to coordinate correctly and empty stool
important to identify bc diff tx is effective
constipation exam
exclude or verify symptoms, not uncommon to have normal findings
orthostatic hypotension/tachycardia - dehydration
weight loss - anorexia or carcinoma
oral - poor dentition, lesions, dehydration
abdominal scars - past surgery
peristalsis and bowel sounds can be increased or decreased - obstruction or ileus
increased dullness over areas of stool
palpate mass
rebound tenderness - peritoneal inflammation
GYN - rectocele
DRE - anal abnorms, sphincter tone & function, pain, lesions, rectal prolapse, impaction, hemorrhoids, fissures
neuro exam - autonomic dysfunction or neuropathy
constipation diagnositcs
abdominal xray or CT and CBC w/ diff required to exclude obstruction, ileus, megacolon, and volvulus if abd discomfort, N/V is present
if no alarm symptoms or above symptoms present, reasonable to start with a trial of laxatives before additional diagnsotics
alarm symptoms
sudden change in bowel habits after age 50 weight loss blood in stool anemia fam hx colon CA IBD
alarm symptoms diagnostics
alarm symptoms mandate an evaluation for an obstructing neoplasm w/ colonoscopy
CBC, TSH, chem profile, Ca and blood glucose
UA & culture
non-pharmacological management of constipation
stool diary
increase fluids
increase fiber to 25- 30 g/day over a period of weeks; increase slowly r/t bloating, gas, abdominal discomfort
bowel habits, allow enough time for bowel elimination, use toilet 30 mins after eating meal, place feet on stool while on toilet
when does fiber not help with constipation?
in patients with slow transit constipation or outlet dysfunction
pharmacological management of constipation
stool softeners or emollients probiotics osmotic laxatives stimulant laxatives enemas secretagogues opioid antagonists
constipation complications
ileus ischemic bowel megacolon hernia hemorrhoids fecal impaction rectal or uterine prolapse
constipation management phases
phase 1: lifestyle changes phase 2: bulk-forming laxatives phase 3: stool softeners phase 4: osmotic laxatives phase 5: stimulant laxatives phase 6: intestinal secretagogues phase 7: severely constipated pts may require both oral laxatives and ememas or suppositories
phase 1 constipation management
lifestyle changes:
- exercise regularly
- develop regular bowel habits
dietary changes:
- increase dietary fiber to 25- 30 g/day (prunes, bananas, bran, beans, broccoli, spinach, carrots, corn, potato, apple, pears with skin
- decrease fats, particularly cheese
- increase fluids to 1.5- 2L/day
phase 2 constipation management
use bulk-forming laxatives:
- psyllium (metamucil) 2.5-30 g daily in divided doses
- methylcelulose (Citrucel) 2 g daily divided doses
- Calcium polycarbophil (FiberCon) 1 tab w/ 8 oz of water 1-4xD, followed by second glass of water
phase 3 constipation management
use stool softeners:
- docusate sodium: 100mg PO 2xD w/ 8 oz water
phase 4 constipation management
use osmotic laxatives:
- Miralax: 17g in 8 ox water PRN dialy
- milk of mg: 30 mL PO PRN at bedtime
- Lactulose: 15- 30mL PO daily 2xD
phase 5 constipation management
use stimulant laxatives:
- bisacodyl: 5- 15 mg PO daily
- senna: 2 tabs PO PRN bedtime
- bisacodyl (dulcolax) suppository: 1 per rectum every 3 days PRN
phase 6 constipation management
use intestinal secretagogues:
- lubiprostone 24 mcg 2xD for chronic constipation
- linacloride 145 mcg daily chronic constipation
- plecanatide 3 mg PO daily
phase 7 constipation management
severely constipated patients may require both oral laxatives and enemas or suppositories
evaluation of children w/ constipation
if no improvement with tx or suspect organic constipation, order the following: - celiac panel - TSH - Ca - glucose then refer to GI
KUB if impaction suspected or atypical presentation/dx unclear
Your patient has ulcerative colitis and is on a low residue diet. Which foods do you recommend that they avoid?
a. Potato skins, potato chips, and brown rice
b. Vegetable juices and cooked and canned vegetables
c. Ground beef, veal, pork, and lamb
d. White rice and pasta
a. Potato skins, potato chips, and brown rice
Which of the following treatments for ulcerative colitis is contraindicated?
a. A high-calorie, non spicy, caffeine-free diet that is low in high-residue foods and milk products
b. Corticosteroids in the acute phase
c. Antidiarrheal agents
d. Colectomy with permanent ileostomy in severe cases
c. Antidiarrheal agents
Your patient has an acute exacerbation of Crohn’s disease. Which laboratory test values would you expect be decreased?
a. Sedimentation rate
b. Liver enzyme levels
c. Vitamins A, B complex, and C levels
d. C-reactive protein
c. Vitamins A, B complex, and C levels
Your patient has celiac disease. They are prone to osteoporosis resulting from impaired calcium metabolism as a result of
a. Increased calcium absorption by the small intestine
b. Increased absorption of fat-soluble vitamin D
c. The binding of calcium and magnesium in the intestinal lumen by unabsorbed dietary fatty acids
d. Decreased magnesium absorption
c. The binding of calcium and magnesium in the intestinal lumen by unabsorbed dietary fatty acids
Your 52 yo patient presents with jaundice, dark urine, and light-colored stools, stating that they are slightly improved over last week’s symptoms. Which stage of viral hepatitis do you suspect?
a. Incubation
b. Prodromal
c. Icteric
d. Convalescent
c. Icteric
Your patient has transmural inflammation, granulomas, focal involvement of the colon with some skipped areas, and sparing of the rectal mucosa. What is the primary differential diagnosis?
a. Ulcerative colitis
b. Crohn’s disease
c. Infectious colitis
d. Ischemic colitis
b. Crohn’s disease
gastroesophageal reflux (GER)
retrograde movement of gastric contents from stomach to esophagus
can occur multiple times a day
postprandial reflux regurgitation w/ or w.o vomiting
cause of GER
relaxation of lower esophageal sphincter, stomach contents reflux up can be d/t increased abdominal pressure or exceeding pressure in sphincter
GER occurance
common physiological issue in 40- 70% of infants
GER management
educate on natural course and warning signs provide reassurance consider lifestyle and dietary changes - small frequent meals/feeds - avoid dairy if breastfeeding infant - change to hypoallergenic formula - do not lie infant down after feeding - use of thickeners for formula
When do symptoms of GER improve or resolve in infants?
typically improves by 6 months of age
usually resolves by 12- 18 months of age
continue lifestyle and dietary changes as necessary for symptom relief
What do you do if symptoms of GER do not improve or resolve by 18 months?
Consider GERD dx or other etiologies if warning signs develop
Refer to pedi gastro
GER clinical features infants
normal VS and growth parameters normal weight gain "happy spitters" little diffificulty with feedings symptoms not bothersome
GERD clinical features infants
onset typically after 1 week old, before 6 months of age
poor weight gain or weight loss
feeding refusal or prolonged feedings
postprandial irritability
dysphagia or odynophagia
recurrent vomiting
heartburn
chest pain, epigastric pain
regurgitation/ vomiting beyond 18 months of age
chronic cough/wheezing/hoarseness
sandifer syndrome (neck tilting in infants)
warning signs/red flags for GER/GERD that require further evaluation
onset after 6 months fever FTT bilious or bloody vomiting persistent, forceful vomiting nocturnal vomiting onset of vomiting after 6 months of age GI bleeding persistent diarrhea or constipation abdominal tenderness or distension, hepatosplenomegaly apnea or cyanosis Sandifer syndrome lethargy bulging fontanelle micro- or macrocephaly seizures neuro developmental delays or disorders
URGENT referral to pedi GI
GERD management infants
lifestyle and dietary changes for 2- 4 weeks
No symptom improvement = empiric trial of acid suppression therapy x 4 weeks (PPI, H2 blocker)
improved = continue meds for 8- 12 weeks then reevaluate
NO improvement= consider ddx, further studies, consult pedi GI
GERD ddx infants
colic cow's milk allergy hiatal hernia achalasia pyloric stenosis
GERD lifestyle management adults
diet changes - avoid triggers (alcohol, spicy foods, chocolate, caffeine, fatty foods, carbonated beverages)
weight loss if obese
exercise regularly
small frequent meals
chew food slowly
wear loose fitting clothing
smoking cessation
chew sugarless gum after meals
avoid lying down for at least 3 hours after eating
sleep w/ HOB elevated or in left lateral position
sit upright after meals
GERD pharmacological management
for infants, children, & adults trial w/ 4 weeks of acid suppression - H2 blocker or PPI
PPI = 1st line “azole”
H2 blockers “dine”
antacids can be used PRN for breakthrough symptoms
GERD RF
obesity pregnancy tight clothes hiatal hernia smoking, alcohol, fat, coffee gastric and esophageal dysmotility large meals meds - anticholinergics, nitrates, CCB
GERD symptoms (adults)
discomfort or burning behind sternum worse after eating/lying better after antacids regurgitation chronic cough globus hoarseness sore throat postnasal drip dysphagia throat clearing asthma/wheezing
GERD dx
made on hx, PE, and response to tx
diagnostic tests referred for atypical symptoms, warning signs, or concerns for other diagnosis
adult with GERD and alarm symptoms or not responding to tx
Refer GI
Upper endoscopy with biopsy
Barret’s esophagus screening
guidelines are AGAINST routine screening
ONLY screen in pt w/ GERD and alarm symptoms/red flags or if have multiple RF ( chronic GERD, smoke, > 50 y.o., male, hiatial hernia, obese)
frequency depends on dysplasia degree:
- no dysplasia, just Barett’s = upper endo every 3- 5 years
- low grade dysplasia = monitor every 6- 12 months
- high grade dysplasia = tx required (consult w/ GI, long term PPI tx)
celiac dx
autoimmune d/o of GI tract, triggered by gluten in diet
- gliaden penetrates = immune response = changes on surface of GI tract = villa damaged, unable to absorb nutrients = deficiencies
typically affects small intestine
celiac dx symptoms
Asymptomatic, can have elevated LFTs constipation diarrhea weight loss nausea dermatitis herpetiformis brittle nails, acne, eczema mouth ulcers/tooth erosion joint/muscle pain fatigue
poor growth, delayed puberty, amenorrhea, irritability (children)
dermatitis herpetiformis
pruritic papules & vesicles
excoriation of skin
extensor surfaces
management: gluten free diet
- oral dapsone - speeds resolution
- topical corticosteroids - itching
celiac dx labs/ diagostics > 2 y.o.
Iga and tTG - need to be on gluten rich diet
iron, folic acid, Vit D, Vit B12 - check for deficiencies
endoscopy w/ biopsy
celiac dx labs < 2 y.o.
Iga, tTG, and IgG deamidated gliadin peptides (DGPs)
celiac dx lab values for dx
IgA & tTA elevated
if > 10x upper limit of normal consider endomysial antibody & HLA-DQ (can dx celiac w/o endo/biopsy)
if < 10x upper limit of normal proceed w/ endo & biopsy to confirm
celiac dx management
life-long gluten free diet: - no wheat, barley, rye; beer nutrition referral monitor and tx deficiencies monitor growth and development bone mineral density @ dx w/ older adults & w/ children who are noncompliant w/ tx
colon cancer USPSTF screening guidelines
Screen all adults aged 45- 75 years old
Adults 76-85 years: selectively offer screening, individual basis
screening tests for colon cancer
HShFOBT or FIT yearly stool DNA-FIT every 1- 3 years CT colonography every 5 years flexible sigmoidoscopy ever 5 years flexible sigmoidoscopy every 10 years + annual FIT colonoscopy every 10 years
RF for colorectal CA
age > 50 prior colorectal CA UC hereditary and genetic factors familial polyposis syndromes long-term cigarette smoking high-fate and high-caloric diet
gold standard for colorectal cancer
colonoscopy
first degree relative w/ hx of colorectal cancer, when do you screen this patient?
screen with colonoscopy starting at age 40 or 10 years younger than the relative’s age at diagnosis
Crohn’s dx RF
15- 35 y.o.
family hx increases risk ~ 10%
smoking
living in urban areas
UC RF
15- 35 y.o. & 60- 80 y.o.
fam hx increases risk ~ 2%
high fat diet
hx of salmonella or campylobacter infection
Crohn’s dx characteristics
mouth to anus
skip lesions
transmural inflammation w/ lymphocytic infiltration
non-caseating granuloma (chronic inflammation)
complications: crypt abscess; fistulas
UC characteristcs
colon
continuous
mucosal and submucosal inflammation
complications: crypt abscess, pseudo polyp
Crohn’s dx symptoms
abdominal pain diarrhea w/ or w/o gross bleeding fatigue weight loss mouth/skin ulcers eye inflammation joint pain/swelling fever rectal fissures/fistula
growth failure/delayed puberty in children
Crohn’s dx evaluation
CBC - anemia - elevated WBC Elevated C-reactive protein, ESR LFTs -AST/ALT elevated Electrolyte abnormalities - glucose - iron deficiency - vitamin B12 deficiency - vitamin D deficiency renal function - BUN - Cr
Stool inflammatory markers
- fecal calprotectin or lactoferrin - elevated due to intestinal inflammation, but if not elevated does NOT r/o IBD
stool for ova and parasites, C.diff
Imaging: CT if acutely ill
Gold standard: colonoscopy
Crohn’s dx colonoscopy
cobblestone appearance - patches of normal and inflamed mucosa
Crohn’s dx management
Refer to GI for initial dx and management:
- GI determines meds (corticosteroids, immunomodulators, biologics)
assess severity educate - compliance - med S/E - diet @ risk for deficiencies, well-balanced diet, no specific diet - exercise - support - vaccinations - complications: obstructions, increased risk of colorectal CA
Ulcerative colitis symptoms
bloody diarrhea frequency, urgency colickly abdominal pain/cramps tenesmus fever fatigue weight loss pain with defecation nocturnal defecation delayed growth and sexual maturation in children
extraintenstinal: eye inflammation, mouth/skin ulcers, erythema nodosum, pyoderma, phelbitis, kidney stones, muscle/joint pain, steatosis
UC complications
severe bleeding/hemorrhage
fulminant colitis/toxic megacolon
perforation
UC evaluation
stool studies:
- C. difficile toxin, routine stool cultures (Salmonella, Shigella, Campylobacter, Yersinia), and specific testing for Escherichia coli
- Microscopy for ova and parasites (three samples) and a Giardia stool antigen test
CBC (anemia), electrolytes (abnorms r/t diarrhea), albumin (low), ESR, CRP (elevated), renal & LFTs, iron, Mg
- assess disease severity
Fecal calprotectin or lactoferrin (elevated)
sigmoidoscopy or colonoscopy w/ biopsy
- symmetric, continuous alterations in mucosal and submucosal layers
- biopsy confirms dx
UC management
Refer GI Meds: - 5-aminosalicyclic acid (mesalamine) 1st line - oral corticosteroids - TNF inhibitors
UC PCP role
monitor growth, pubertal changes
nutritional status, monitor deficiencies
- well-balanced diet
- some pts do well with low-residue/fiber diet or no lactose
bone health - screen for osteoporosis
UC tx goal
achieve and maintain remission and improve QOL and decrease complications
mild UC
Mild diarrhea that may or may not be bloody (up to four episodes per day)
●Mild, crampy abdominal pain
●Straining with bowel movements
●Bouts of constipation
moderate UC
Frequent episodes of bloody diarrhea (more than four per day)
●Feeling tired or weak due to anemia (a low red blood cell count)
●Mild to moderate abdominal pain
●Low-grade fever
severe UC
Very frequent episodes of bloody diarrhea (six or more per day)
●Feeling tired or weak due to anemia (a low red blood cell count)
●Severe abdominal pain and cramping
●A racing heartbeat
●Fever
●Weight loss, which can happen quickly
IBS
common GI complaint, previously said to be functional, ROME IV describes it as “gut-brain” disorder characterized by change in bowel habits & abdominal pain:
IBS-C (constipation)
IBS-D (diarrhea)
IBS-M (mixed bowel habits)
unsubtyped IBS
normal intestines, no inflammation, no organic cause
IBS symptoms
abdominal discomfort, bloating, distension
abdominal pain r/t defecation
altered stool frequency or passage: diarrhea/constipation
passage of mucus
triggered by eating
absence of red flags
nausea, back ache, fatigue, urinary symptoms
abdominal pain at least 3 months MUST be present for dx
ROME IV criteria for IBS
- symptoms present for at least 3 months and initial symptom onset must have occurred at least 6 months prior to the dx of IBS
- abdominal pain that occurs a minimum of once/week for previous 3 months, in combo with 2 or more of the following:
- defecation-related pain
- pain r/t change in stool frequency
- pain associated with change in appearance of stool (lumpy and hard or loose and watery)
ABSENCE of alarm symptoms/red flags
IBS diagnosis based on
hx
PE
absence of alarm features
IBS evaluation
CBC w/ diff, glucose, electrolytes, BUN, Cr, ESR, CRP, TSH
stool specimen for OB or fecal leukocytes (if recent travel)
tTG-IgA antibodies for celiac dx
KUB if excess gas/bloating or constipation
2 week trial of lactose-free diet to r/o intolerance or hydrogen breath test
colonoscopy for acute changes in bowel habits
diagnostic screening negative reevaluate symptoms in 3- 6 weeks
IBS management
diet - recognize triggers and avoid them - refer dietician for low FODMAP diet 1-2 months - food diary - soluble fiber IBS-C and insoluble fiber IBS-D - 64 oz of fluid daily meds - fiber supplements - antispasmodics - antidiarrheal agents - anticonstipation agents - psychotropic agents (SSRIs, tricyclics) supportive care education - set time each day to use bathroom - peppermint oil can help with spasms - no associated pathology, no future complications - probiotics - exercise reassurance - does NOT increase risk of colorectal CA
avoid what meds in IBS
stimulant laxatives
ROME IV criteria for IBS in children
must include ALL of the following at least once per week for at least 2 months before dx:
abdominal pain at least 4 days per month associated with one or more of the following:
- related to defecation
- change in frequency of stool
- change in form of stool
- IBS-C; pain does not resolve with resolution of constipation (if pain resolves = functional constipation)
- symptoms not fully explained by another medical dx
ABSENCE of alarm symptoms
classic clinical features of celiac dx in infant/child
diarrhea
steatorrhea
weight loss
growth failure
Rome criteria IV for constipation in infants & children
must include 2 or more of the following occuring at least once/week for a min of 1 month with insufficent criteria of IBS:
- 2 or less defecations in toilet per week of at least 4 y.o.
- at least 1 episode of fecal incontinence per week
- hx retentive posturing or excessive volitional stool retention
- hx of painful or hard BMs
- presence of large fecal mass in rectum
- hx of larger diameter stools that can obstruct toilet
- symptoms not fully explained by another dx
factors r/t constipation in infant/child
inadequate fluid intake dehydration from illness or hot weather change in diet painful BMs anal fissures neurogenic causes (HD, cerebral palsy) hypothyroidism meds family/life adjustments inappropriate toilet training irregular toileting patterns physical/sexual abuse behavioral problems
constipation evaluation in child/infant
xrays and labs NOT recommended unless alarm symptoms
labs for suspicion of thyroid dx, celiac dx, or hypercalcemia
constipation management in child
establish regular bowel routine
miralax - 1st line
bowel retraining
maintenance w/ meds PRN miralax, milk of mg, mineral oil, stimulant laxatives for min of 2 months and stopped 1 month after resolution
alarm S/S in children w/ constipation
constipation starting early in life < 1 month passage of meconium > 48 h fam hx Hirschsprung dx ribbon stools blood in stool w/ absence of anal fissures FTT bilious vomiting abnorm thyroid function severe abdominal distension decreased lower extremity strength/tone/reflex perianal fistula abnorm position of anus absent of anal or cremasteric reflex tuft of hair on spine sacral dimple gluteal cleft deviation extreme resistance or fear during anal inspection anal scars
A 9-year-old male presents with fatigue and recurrent bloody diarrhea over the last 5 days. He has had two similar episodes of bloody diarrhea in the past year, but these were attributed to gastroenteritis and resolved without intervention. His exam is significant for BMI greater than 95th percentile for age, abdominal exam shows diffuse tenderness without rebound, guarding, or hepatosplenomegaly.
What laboratory tests are appropriate to order at this time?
CBC, ESR, CRP and albumin along with stool testing for blood
Albumin levels are often low in children with IBD due to a combination of poor oral intake and chronic intestinal inflammation resulting in chronic protein loss and malabsorption
Stool studies including stool ova and parasites, Clostridium difficile testing, and stool culture should also be obtained.
Of note, up to 20% of children with IBD may present with normal laboratory values.
The 9 y.o. child with fatigue and bloody diarrhea labs are significant for an elevated ESR and CRP and a microcytic anemia; stool studies are normal. When you call the parents with results, they ask about the next steps in evaluation.
What are the next appropriate steps to evaluate this patient?
Refer to pediatric gastroenterology for colonoscopy with or without esophagogastroduodenoscopy (EGD)
If small bowel disease is suspected, then abdominal imaging with either upper GI series with small bowel follow-through (UGI/SBFT) or magnetic resonance enterography should be ordered in addition to endoscopy.
Clinically, he is more likely to have UC than Crohn’s based on the insidious onset of symptoms and hematochezia
A 27-year-old female presents to establish care. In the past, she has been diagnosed with IBS along with iron-deficiency anemia due to heavy menses. She is currently on iron therapy, an oral contraceptive pill, and a “drug for colon spasm.” She continues to have multiple loose stools daily that are nonbloody along with abdominal pain, and fatigue. She denies any alcohol or drug use. On exam, she has normal vitals, a BMI of 19 kg/m2 (down from 22 one year prior) and an unremarkable abdominal exam. On skin exam, she has painful erythematous lesions on her shins that are 2 to 3 cm in diameter and oral aphthous ulcers.
Is IBS or IBD more likely in this patient?
Based on her history and physical exam, it is more likely that she has IBD than IBS and more likely that she has CD rather than UC.
Crohn’s dx: fatigue, weight loss, fever, perianal fistula or abscess, perianal skin tag, abdominal mass RLQ, arthritis, erythema nodosum, oral ulcers, clubbing, uveitis
UC: fatigue, sometimes weight loss, hematochezia, passage of blood/mucus, arthritis, erythema nodosum, pyoderma gangrenosum, oral ulcers, clubbing, uveitis/scleritis, sclerosing cholangitis, autoimmune hemolytic anemia, venous/arterial thromboembolism
A 35-year-old male was diagnosed with ulcerative colitis 5 years ago. On his initial colonoscopy, he was found to have extensive colitis (disease beyond the splenic flexure but not in the cecum). He has been in remission for the last year.
Does this patient have an elevated risk for colon cancer? If so, when does he need repeat colonoscopy?
Patients with UC and disease limited to the rectum or mid-sigmoid probably do not have increased risk for colon cancer above baseline. In this patient with more proximal disease, his risk for colon cancer increases compared to baseline at 7 to 8 years after disease onset with a risk of 0.5% per year thereafter.
Therefore, colonoscopy will be necessary in the next 2 to 3 years for colon cancer evaluation.
Risk factors for cancer include longer duration of disease, younger at onset, severity of inflammation, primary sclerosing cholangitis, and family history of colorectal cancer.
A 35 y.o. patient in remission the past year calls with an acute exacerbation of symptoms including fever and more than 5 bloody stools daily.
What are the next appropriate steps to evaluate this patient?
Once remission has been achieved, patients with extensive disease are no more likely to relapse than those with mild disease (limited to rectum or sigmoid colon).
Given that he has been in remission for a year, evaluation for infectious causes is necessary including:
• Salmonella
• Shigella
• Campylobacter
• Clostridium difficile
• Yersinia
• Amebiasis
• Escherichia coli 0:157:H7
• STIs including Neisseria gonorrhoeae and Chlamydia trachomatis
Which of the following should be included in the initial evaluation of a child with chronic diarrhea suspected to have inflammatory bowel disease (IBD)?
A Stool culture
B Therapeutic trial of corticosteroids
C Liver ultrasound
D Urinalysis
A Stool culture
Stool culture should be obtained to rule out potential infectious etiology (or concurrent infection and IBD) and should be part of the initial evaluation of a child with chronic diarrhea suspected to have IBD. The diagnosis of IBD should be confirmed prior to starting systemic corticosteroids as they may affect diagnosis, and long-term use has significant morbidity. While primary cholangitis and livery dysfunction is associated with IBD, liver ultrasound is not part of the initial workup for IBD. Unless a patient reports urinary symptoms, urinalysis is not part of the initial workup for IBD.
Which of the following endoscopic findings is expected in a patient with ulcerative colitis (UC)?
A Esophageal varices
B Inflammation anywhere in the GI tract from the oral cavity to the rectum
C Ulcerations and inflammation of the gastric mucosa
D Inflammation of the rectum in a continuous pattern, limited to the colon
D Inflammation of the rectum in a continuous pattern, limited to the colon
Ulcerative colitis (UC) is characterized by inflammation of the rectum in a continuous pattern, is limited to the colon, and to the mucosa and submucosa of the intestinal lining. Crohn’s disease (CD) is characterized by inflammation anywhere in the GI tract and may have transmural involvement. Ulcerations and inflammation of the gastric mucosa are consistent with gastritis and peptic ulcer disease. Esophageal varices occur when there is increased portal pressure, such as that found in patients with cirrhosis.
Which of the following is not a risk factor for the development of ulcerative colitis (UC)?
A History of Campylobacter infection
B A first-degree relative with ulcerative colitis
C History of nontyphoid Salmonella infection
D Smoking
D Smoking
While smoking is a risk factor for Crohn’s disease (CD), smoking is not a risk factor for the development of ulcerative colitis (UC), and may be protective. History of infection with nontyphoid Salmonella and Campylobacter increase the risk of developing UC, as does having a first-degree relative with UC.
A 35-year-old woman presents to primary care clinic for a 6- to 7-month history of diffuse, cramping abdominal pain. The pain, which is 3/10 in intensity, occurs 3 to 4 times per week typically after eating and is relieved by defecation. She also endorses occasional nausea, bloating, constipation (only has 1-2 hard stools per week), and passage of mucus with defecation. She denies fevers, rash, night sweats, weight loss, blood per rectum, melena, or tenesmus. Her exam is normal, vital signs are normal, and past medical history is negative. She is not on any medications. She has had new stressors in her life and has noticed that her symptoms have been worse since onset of these stressors.
What is this patient’s most likely diagnosis? What does the Rome IV criteria include as diagnostic criteria for IBS?
This patient most likely has irritable bowel syndrome (IBS). The Rome IV diagnostic criteria for IBS, endorsed by the American Gastroenterological Association (AGA), include the following:
•Recurrent abdominal pain at least 1 day per week in the last 3 months associated with 2 or more of the following:
o association with defecation;
o change in frequency of stool;
o change in form (appearance) of stool;
o criteria must be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis.
Manning criteria can also be used for diagnosis. Patient must meet 3 or more of the following criteria: • feeling of incomplete evacuation; • passage of mucus; • visible abdominal distention; • pain relief with defecation; • looser stool at pain onset; • more frequent stools at pain onset.
**The diagnosis of a functional bowel disorder always presumes the absence of a structural or biochemical explanation for the symptoms.
What is the proposed pathophysiology for IBS?
Three factors are thought to play a role in the pathophysiology of IBS:
o altered gut reactivity (motility, secretion)
o hypersensitive gut with enhanced visceral perception and pain
o disordered gut-brain interaction
Other theories include: o altered inflammatory mediators o altered gut serotonin regulation o bacterial overgrowth o genetic predisposition
What workup is recommended for patients with possible IBS?
History and physical will help assess whether “alarm signs” or “red flags” are present. Such findings (weight loss, anemia, fever, family history of inflammatory bowel disease or colon cancer, recent antibiotics, age of onset older than 50 years old, nocturnal symptoms, abdominal mass, blood in stool) would require more extensive evaluation.
If no “red flags” are present, limited workup is recommended by the AGA. This includes a screening stool hemoccult and CBC.
• Decision to obtain ESR, comprehensive metabolic panel (CMP), and stool studies are left to the discretion of the provider and can be ordered depending on the patient’s clinical picture and risk factors.
AGA recommends obtaining colonoscopy as part of workup if patient is older than 50 years old and has not had routine colon cancer screening with colonoscopy, or if there are red flag symptoms.
Symptom-specific workup can be obtained as follows:
o Constipation-predominant (IBS-C): consider therapeutic trial of fiber as part of workup. Consider partial colonic obstruction or non-IBS causes of dysmotility as well.
o Diarrhea-predominant (IBS-D): consider stool culture, ova and parasites, celiac sprue workup, or bowel biopsy (depending on clinical picture).
If new symptom onset when patient is 45 years or older, consider colonoscopy to rule out microscopic colitis; if workup is negative, consider therapeutic trial of loperamide.
o Pain-predominant: consider abdominal x-ray and if negative for small bowel obstruction (SBO), consider therapeutic trial of an antispasmodic medication.
What are treatments available for IBS?
General treatment (for mild symptoms): - Symptom diary to determine food triggers (common causes are sorbitol, lactose, caffeine, eating in excess, beans, raw vegetables) and psychosocial triggers.
Pharmacologic treatment (for moderate to severe symptoms):
- Constipation-predominant (IBS-C):
- increased dietary fiber (goal 25 g per day) (safe) – soluble fiber preferred over insoluble
- polyethylene glycol (MiraLAX) – osmotic laxative
- lubiprostone – chloride channel activator that increases intestinal fluid secretion to improve intestinal transit5
- linaclotide– guanylate cyclase c agonist; increased intestinal chloride and bicarbonate secretion leads to acceleration of intestinal transit, may also have analgesic effect
- plecanatide – guanylate cyclase c agonist
- Diarrhea-predominant (IBS-D)
- loperamide – antidiarrheal, inhibits peristalsis; recommended to use is as needed
- alosetron – 5-HT receptor antagonist, decreases colonic motility. Approved for use in women with severe IBS-D who have failed conservative treatment for greater than 6 months. Adverse events include ischemic colitis and severe constipation.
- eluxadoline – mu-opioid receptor agonist + delta opioid receptor antagonist + kappa opioid receptor agonist; reduces visceral pain and diarrhea with constipation side effect. Avoid use in patients who do not have a gallbladder, carries FDA warning for risk of pancreatitis.
oPain-predominant:
- hyoscyamine, dicyclomine, peppermint oil – antispasmodics that reduce smooth muscle contractions and visceral hypersensitivity
- antidepressants (TCAs, SSRIs – see below)
- antibiotic (Rifaximin) – alters gut microbiota; given as 2-week course
- probiotics
• Psychological treatment (initiated when symptoms are severe enough to impair health-related quality of life):
- Cognitive behavioral therapy (CBT), dynamic psychotherapy, hypnosis and stress management, and relaxation
-Tricyclic antidepressants (TCAs)
- typically used for IBS if pain is frequent or severe
- most commonly used is amitriptyline
- Selective serotonin reuptake inhibitors (SSRIs)
- Appears to work as well as TCAs, are generally safer and have fewer side effects than TCAs. The most commonly used are fluoxetine, paroxetine, duloxetine, and sertraline.
Which of the following medications may be used in the treatment of abdominal pain related to irritable bowel syndrome (IBS)?
A Prednisone
B Amitriptyline
C Morphine
D Lidocaine patches
B Amitriptyline
Tricyclic antidepressants (TCAs) such as amitriptyline and desipramine and selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, citalopram, and fluoxetine can be used in the treatment of the abdominal pain that may be associated with IBS. Prednisone, morphine, and lidocaine patches do not have a role in the treatment of IBS.
Which of the following is not a “red flag” in the evaluation of IBS?
A Rectal bleeding
B Anemia
C Weight loss
D Abdominal pain
D Abdominal pain
Abdominal pain may be a feature of IBS and can be treated with tricyclic antidepressants (TCAs) such as amitriptyline and desipramine and selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, citalopram, and fluoxetine. Warning signs for malignancy, inflammatory bowel disease, or other intraabdominal pathology include rectal bleeding, anemia, weight loss, fever, family history of colon cancer, onset of symptoms after 50 years old, and a major change in baseline symptoms.
Which of the following diagnostic test should be done on all patients with suspected IBS?
A Stool ova and parasites
B Colonoscopy
C Abdominal CT
D None of the above
D None of the above
Irritable bowel syndrome (IBS) should be considered in patients with abdominal pain associated with defecation. The diagnosis is often made by history, using the Rome or Manning criteria to discern between IBS and other illnesses. According to the Rome IV criteria (2016), IBS is defined as recurrent abdominal pain associated with a change in stool form and/or frequency. Symptoms must be present for at least three months. Elements of the history that would warrant further investigation include weight loss, fever, blood in stool, progressive symptoms, symptoms onset after age 50, recent antibiotic use, family history of colon cancer, abdominal mass, blood in stool, or enlarged lymph nodes. In the absence of these red flags, data does not support the routine performance of any specific diagnostic tests in patients with suspected IBS, and testing should be considered on a case-by-case basis to rule out other etiologies of abdominal pain. Stool ova and parasites could be considered if intestinal infection is suspected. Colonoscopy and abdominal CT should be considered if patient has red flags such as abdominal mass, blood in stool, family history of colon cancer, or if colon cancer screening is indicated by age.
Your patient is a 4-month-old who presents for her well-child checkup. He is growing well and has no issues with feeding, but mom is very concerned that he has only 1 dirty diaper every 2 days. He makes urine regularly and does not seem to be uncomfortable when passing stool. Mom wants a medicine to make him more regular.
How do you counsel mom regarding her concerns?
Constipation is a common problem for patients of all ages. Common complaints include hard or infrequent (usually less than 3 times per week) stools, excessive straining to produce stool, a feeling of incomplete evacuation or pain, or excessive time spent on the toilet or in unsuccessful attempts to pass stool.
In pediatric patients who cannot communicate, signs of constipation often include hard or pebble-like stools, or parental reports of excessive straining or pain during efforts to pass stool. It is notable that infants may also have a very wide range of normal stool frequency, including only 1 stool a week.
In the case above, the child does not appear constipated, as he does not have discomfort when passing stool. Reassurance and education are appropriate.
If the 4 month old with 1 dirty diaper a week were constipated, what treatments are available for infants with constipation?
Breastfed infants often have multiple stools each day, while formula supplementation may decrease the frequency of the stool. This pattern can be exacerbated during key points in advancing the diet of children, including the introduction of solid foods and the introduction of cow’s milk.
Insertion of a glycerin suppository or rectal stimulation can cause reflexive sphincter relaxation, though routine use is not recommended due to the risk of fissure formation or other injury.
Younger infants may benefit from introduction of corn syrup as an osmotic agent, but by 4 months of age, most infants are able to digest the sucrose of corn syrup making it less useful. Fructose and sorbitol remain harder to digest, thereby acting as an osmotic laxative, and can be found in fruit juices such as apple and prune juice.
On further questioning of the 4 month old who stools once/week, mom mentions that he has always had issues with stooling. Even as a baby he took several days to clear “that baby poop they have when they’re first born.”
What serious causes of constipation should be considered in infants?
Hirschsprung disease is an extreme form of slow-transit constipation that affects 1 in 5000 births with a male to female ratio of 4:1.
be recognized at birth if meconium is not passed in the first 48 hours of life, however approximately 60% of patients with Hirschsprung will be diagnosed outside the neonatal period. Common symptoms include recurrent abdominal distention, emesis, failure to thrive, and acute enterocolitis
Confirmation of diagnosis requires rectal biopsy and histologic examination. While a full-thickness biopsy is most sensitive, it requires sedation and surgery. Most commonly a suction technique is performed, often at the bedside, to obtain a sample for study. Treatment is surgical removal of the affected portions of intestine.
A 44-year-old man presents to your office with complaints of several days of abdominal fullness and difficulty passing stool. He is able to pass small amounts of hard stool every few days but feels that he always needs to strain to completely evacuate. He has no other medical problems or complaints at this time. His diet, mostly fast food, has not recently changed.
What are some categories of constipation that may be at work, and what treatment would you first recommend?
Causes for chronic constipation can be broken down into 3 categories:
- Normal-transit (functional) constipation – a normal system that may have transient alterations leading to constipation
- Slow-transit constipation – reduced motility due to individual differences in bowel function
- Rectal evacuation (defecatory) disorders – variations that limit or inhibit normal passage of stool out of the body
Patients with normal transit times often have perceptions of difficulty passing stool, bloating, or abdominal pain and discomfort and may have hard stools. Treatment which increases in dietary fiber or the addition of an osmotic laxative typically produces good responses. Failure to respond to these therapies may be an indication of altered transit times that will require further management.
Slow transit time is most commonly seen in young women and typically begins after puberty. Histological evaluation of patients with slow transit time have shown alterations in the number of myenteric plexus neurons which secrete substance P, an excitatory neurotransmitter, as well as abnormal levels of vasoactive intestinal peptide, nitric oxide, and the interstitial cells of Cajal thought to regulate motility. Dietary choices that lead to low stool volumes may contribute to symptoms, so initial attempts at a high-fiber diet to increase stool weight may improve symptoms. Stimulant laxatives work by increasing intestinal motility and secretions, though can cause cramping or dependence with long-term use.
Increases in dietary fiber are often used to treat normal and slow transit constipation, but can produce side effects of bloating, distension, and flatulence. Fiber works by increasing the stool volume and stimulating peristalsis. Historically, fiber supplements have had unpleasant tastes or textures, though a myriad of products are now available that are more palatable and easier to administer. The slow increase in fiber to reach goals of 20 to 25 g daily can help offset side effects, though newer preparations of fiber supplements are more resistant to bacterial degradation, a primary source of flatus production.
Your 44 y.o. M patient w/ constipation tries increasing the fiber in his diet without much success. He wants to know what other options are available and why you would recommend one over the others.
Common remedies such as increased fluid intake and physical activity do not appear to be effective in cases of chronic constipation, unless dehydration is the source of symptoms.
Osmotic laxatives and poorly absorbed sugars (eg, polyethylene glycol or lactulose) work by drawing water into the intestines along an osmotic gradient. Most take several days to work but are less likely to cause the bloating and flatus of fiber, or the cramping associated with stimulants. Caution should be used in patients with sensitive electrolyte or volume status (such as those with renal or heart failure) as absorption of sodium, magnesium, or phosphorus is possible. Dehydration is also a concern in otherwise healthy patients considering the mechanism of action.
Stimulant laxatives (eg, senna) work in various ways to promote intestinal motility and secretions. They work quickly, often in hours, but are often associated with abdominal cramping. Most are substrates for bacterial degradation or intestinal enzyme hydrolysis whose byproducts are responsible for neuromuscular stimulation in the intestinal walls.
Stool softeners (eg, docusate sodium) are detergents that allow water to more effectively interact with solid stool. Their use in treatment of constipation is not well established and may be more appropriate as an adjunct to other methods or for prevention, rather than treatment, of constipation.
Enemas and suppositories work primarily by distending the rectum, promoting increased peristalsis and relaxation of the internal sphincter, but may also function to soften the stool directly (tap water, molasses), provide lubrication (soap suds, mineral oil), provide an osmotic load for increased water secretion by the intestine (phosphate), or topically stimulate colonic muscle contraction (bisacodyl suppositories).
Medications such as opioids and tricyclic antidepressants (TCAs) are a very common source of decreased colonic motility. When possible, reduction of dosages is the most effective method of reversing constipation. The use of stimulant laxatives to combat colonic dysmotility is also effective when the causative agents cannot be reduced.
For patients with chronic opioid use, in which these agents limit neuronal stimulation that produces bowel motility, pharmacotherapy for opioid-induced constipation (OIC) primarily focuses on improving bowel motility. Increasingly, the use of peripherally acting mu-opioid receptor antagonists (PAMORAs) is considered. These agents are proven effective to reduce the incidence of constipation without precipitating increased pain. Their use is usually considered when more routine medications (such as senna) are ineffective.
A 3-year-old girl in the process of toilet training presents after parents noticed several accidental loose stools while sleeping over the past 2 nights. Prior to this she had several days of struggling and crying while trying to stool, but now that she is having diarrhea. They want to know if using an antidiarrheal medication is warranted.
What is the most likely cause of her loose stools?
Children may develop constipation despite normal transit times after repeatedly withholding stool, which leads to stretching of the rectum and lower colon resulting in lower tone, retention, and eventually impaction, leading to a defecatory disorder. Secondary encopresis may develop as liquid stool begins to leak around the impaction, often leading to an initial misdiagnosis of diarrhea.
Often functional constipation begins in relation to pain or discomfort with stooling and avoidance of repetition of these symptoms. Perianal fissures, mild infections (such as perianal Streptococcus), or perianal abscess may be inciting factors for pain or discomfort. Other causes of functional retention in children include desire for control during toilet training, psychological stressors, or unintentional retention while distracted or otherwise occupied for long periods of time.
What treatment would you recommend for the 3 year old with impaction from constipation and encopresis?
For children with impactions, initial removal of the impaction is key. Manual disimpaction is often uncomfortable and can be traumatic for smaller children. Aggressive use of laxatives and enemas over 2 to 5 days is often more efficacious. Failure of these methods may indicate the need for hospital admission and administration of polyethylene glycol via nasogastric tube. Following disimpaction, continued use of laxatives to maintain consistent daily evacuation is indicated to allow the colon to return to normal caliber and tone. Once these habits are reestablished, a gradual wean from medication can begin while increasing the amount of soluble fiber in the diet.
Setbacks are common and often require occasional stimulant laxative use or even a return to daily laxative use to maintain daily evacuation. If compliance is in question or in situations that may be difficult to assess, an abdominal x-ray can be used to evaluate for completeness of evacuation. For adults, after any impaction has been removed, the use of biofeedback to retrain the evacuation process and assist in relaxation of the pelvic floor during straining can be used in combination with laxatives as needed to assist in soft, daily stool production
A 37-year-old woman presents with complaints of difficulty passing stool over the past several years. She has tried multiple therapies including fiber, polyethylene glycol, bisacodyl suppositories, and docusate. Various combinations of these will help but nothing consistently gives her regular stools. On history, she mentions that straining sometimes helps, but at other times, the more she bears down, the less movement she notices.
What physical exam findings might be seen in cases of constipation?
Physical examination in constipation includes evaluation of the perineum for evidence of scarring, fistulas, fissures, or external hemorrhoids which may lead to painful stooling.
Visualization of the perineum during a Valsalva maneuver allows determination of the perineal descent, typically a position change of 1 to 3 cm.
Failure of the pelvic floor to move significantly may be an indication of failure to relax the pelvic floor muscles during defecation.
In adults or children who have failed to respond to initial therapies, digital rectal examination should also be performed to assess for retention or impaction of stool, rectal masses, or anal stricture. In small children, monitoring abdominal girth can also provide an indication of progressive constipation.
A 37-year-old woman presents with complaints of difficulty passing stool over the past several years. She has tried multiple therapies including fiber, polyethylene glycol, bisacodyl suppositories, and docusate. Various combinations of these will help but nothing consistently gives her regular stools. On history, she mentions that straining sometimes helps, but at other times, the more she bears down, the less movement she notices.
which type of constipation fits this patient’s history?
Defecatory disorders in adults are most often related to dysfunction of the pelvic floor or anal sphincter, but may be related to other physical or anatomical variations.
In older children and adults, alterations of the anorectal angle during straining may make passage of stool difficult. Other potential causes include rectal intussusception, rectocele, or excessive perineal descent, though these are less common. Symptoms such as narrow caliber stools, abdominal distention, and lack of encopresis are consistent with distal obstructions. Treatment of defecatory disorders is based on the type of disorder present and will usually require consultation with gastroenterology or surgery.
A 37-year-old woman presents with complaints of difficulty passing stool over the past several years. She has tried multiple therapies including fiber, polyethylene glycol, bisacodyl suppositories, and docusate. Various combinations of these will help but nothing consistently gives her regular stools. On history, she mentions that straining sometimes helps, but at other times, the more she bears down, the less movement she notices.
What types of further workup are available to determine the source of her symptoms?
In patients for whom a defecatory or anatomic disorder is suspected, physiological testing is available. Colonic transit testing is accomplished by performing serial radiographs following a radiopaque marker in a capsule. Anorectal manometry can provide pressure measurements during contraction and relaxation of the internal and external anal sphincters as well as evaluate rectal sensation.
Laboratory testing is usually indicated in cases when constipation is a portion of a larger collection of symptoms. Measurements of thyroid function, calcium and electrolytes, complete blood count (CBC), or a urinalysis may be indicated based on the patient history. In any patient older than 50 years, new-onset constipation should elicit a screening examination for colon cancer.
What is the most common type of constipation in childhood?
A Constipation is not common in childhood
B Functional constipation
C Constipation due to neurologic disorder
D Constipation due to metabolic disorder
B Functional constipation
Constipation is common in childhood, and accounts for approximately 5% of pediatric clinic visits and 25% of referrals to pediatric gastroenterologists. Functional constipation is the most common cause of constipation in childhood, which is defined as hard or infrequent stools in the absence of any other disorder. Constipation due to a neurologic disorder such as Hirschsprung disease or spinal disorders is rare, as is constipation due to a metabolic disorder such as thyroid disease, celiac disease, or cystic fibrosis.
Which of the following medications works primarily as an osmotic laxative?
A. Methylcellulose
B. Docusate
C. Lactulose
D. Senna
C. Lactulose
Lactulose is an osmotic laxative and causes secretion of water into the colonic lumen. Methylcellulose is a bulk laxative and works by absorbing water to soften stool consistency and increase mass. Docusate is a detergent and acts as a stool softener. Senna is a stimulant laxative and works by increasing intestinal motility and secretion of water into the bowel.
A 38-year-old man comes to primary care clinic after he underwent routine lab work for a new health insurance policy. He was notified that his “liver tests” were abnormal and was advised to see his primary care provider. He brings in a copy of the lab report that shows an aspartate aminotransferase (AST) level of 170 U/L and an alanine aminotransferase (ALT) level of 188 U/L. His total bilirubin and alkaline phosphatase levels are within normal limits.
He has not had fever, malaise, abdominal pain, nausea, vomiting, anorexia, or yellowing of his eyes or skin. He denies seeing any changes in his urine or stools. Specifically, his urine is yellow (normal), stools are “not pale” and he has not had any diarrhea. He denies any arthralgias and does not have a history of diabetes. Regarding his alcohol consumption, he has an average of about two glasses of wine with meals about 3 times a week, but never has more than 3 drinks in any one occasion. He does not take any medications, including any over-the-counter (OTC) medications or herbal supplements. He denies any intravenous (IV) drug use. When he was 8, he had an appendectomy and needed a blood transfusion. He does not have a history of diabetes. As far as he knows, no one in his immediate family has been sick with any recent “flu-like” illnesses and there is no family history of liver disease.
On exam, he is well appearing and is afebrile; his blood pressure is 128/64 mm Hg, pulse is 92 bpm, and respiratory rate is 16 bpm. His BMI is 32 kg/m2. His skin does not have jaundice or scleral icterus. He has no gynecomastia. His abdominal exam is specifically notable for a liver span of 10 cm in the right midclavicular line. He does not have palmar erythema or telangiectasias. His neurologic exam is normal.
Beyond your history and physical exam, what is the first step to take in the evaluation of a person with abnormal liver function tests who does not have symptoms?
repeat the tests to confirm that there is a true abnormality.1 An estimated 13% of patients undergoing routine medical evaluation are found to have abnormal liver enzymes; these enzyme levels may be persistently elevated in up to 5% of patients
Predominant elevations of the transaminases (AST and ALT) are indicative of hepatocellular injury. It is important to recall that ALT is more specific to the liver than the AST. AST is also found in cardiac muscle, skeletal muscle, the kidneys, brain, pancreas, lungs, leukocytes, and erythrocytes.
You note that the 38 y.o. patient’s LFTs lab work was from over 4 weeks ago.
Because of his previously noted abnormal lab work, you decide to obtain a repeat “hepatic profile.” His hepatic profile is notable for: AST (SGOT) = 210 g/dL [4-40 g/dL]; ALT (SGPT) = 205 g/dL [4-40 g/dL]; alkaline phosphatase = 98 U/L [40-100 U/L); total protein = 6.5 g/dL [6.0-8.0 g/dL] albumin = 4.0 g/dL [3.5-5.0 g/dL]; and total bilirubin = 1.0 mg/dL [0.2-1.2 mg/dL].
How would you describe the patient’s pattern of abnormal liver tests?
This pattern would be consistent with hepatocellular injury. With the normal alkaline phosphatase and bilirubin levels and only mildly elevated transaminases, there is not a high suspicion for a cholestatic or obstructive picture.
In an asymptomatic person with elevated transaminases, there are several diagnostic possibilities to consider.
What are the 8 main hepatic causes of chronically elevated aminotransferase levels?
Hepatic causes of chronically elevated aminotransferase levels:
• Alcohol abuse
• Medications
• Chronic hepatitis B and C infection
• Steatosis and nonalcoholic steatohepatitis (currently called nonalcoholic fatty liver disease or NAFLD)
• Autoimmune hepatitis
• Hemochromatosis
• Wilson disease (in patients younger than 40 years old—particularly if there is coexistent psychiatric illness)
Alpha1-antitrypsin deficiency
A finding (or history) of obesity, signs of insulin resistance, hypertension, and/or hyperlipidemia should increase your concerns that the patient with elevated ALTs/ASTs could have NAFLD.
Since the patient denies excess alcohol use and does not have an AST:ALT split, you are less concerned that his liver injury pattern is from alcohol use.
What is your next step in evaluating this asymptomatic patient’s abnormal liver tests
Hepatitis C antibody this indicates chronic hepatitis C
Hepatitis B surface antigen, surface antibody, and core antibody indicate chronic hepatitis B, if present.
Serum iron and total iron-binding capacity (TIBC) Iron overload would suggest hemochromatosis
Serum ceruloplasmin Decreased levels would suggest Wilson disease (if patient is 40 years old or younger).
Serum protein electrophoresis (SPEP) Increase in polyclonal immunoglobulins would suggest autoimmune hepatitis; a marked decrease in alpha-globulin bands would suggest alpha1-antitrypsin deficiency
The asymptomatic patient with elevated AST/ALTs:
hepatitis B and C profiles are completely negative. He has normal iron, TIBC, and a normal transferrin saturation. His serum ceruloplasmin level is normal. In addition, he has a normal serum protein electrophoresis (SPEP).
Because of his mild obesity, you decide to image his liver.
What imaging modalities can confirm the presence of steatosis?
Ultrasonography, CT, or MRI can confirm hepatic steatosis, although all of these imaging modalities can miss mild steatosis.
You order an ultrasound of the liver, and it confirms that the patient has hepatic steatosis. Since there is no definitive treatment recommended for NAFLD, you do encourage the patient to address his underlying risk factors. You advise weight loss, exercise, blood pressure control, and control of his lipid and glucose levels, as indicated.
How do you counsel this patient on NAFLD?
NAFLD consists of hepatic steatosis, inflammation, and fibrosis, without alcohol use to a level that would account for the liver damage. NAFLD is likely the most common form of liver disease in the United States. About 20% of obese patients with NAFLD will go on to develop steatohepatitis and up to 3% of these will have cirrhosis. An estimated 75% of patients with insulin resistance are thought to have some amount of fatty liver disease. As mentioned, there is no definitive treatment for NAFLD. Therapeutic interventions currently target addressing the underlying risk factors.
A 3-month-old female presents with “vomiting every time she eats” for the last month. Mom is concerned because she does not appear to be keeping down much milk at all. She is breastfeeding every 3 to 4 hours. Her growth is appropriate. She does not seem to be in pain with these episodes, which are nonbilious and nonbloody. She sleeps up to 6 hours at night. On exam, she is happy and developmentally appropriate for her age. Her abdomen is soft and nontender, with no masses.
What is this child’s diagnosis?
The infant’s history and exam are consistent with physiologic gastroesophageal reflux (GER), or passage of stomach contents into the esophagus or mouth. In contrast, gastroesophageal reflux disease (GERD) is present when symptoms or complications of GER arise. These complications may include irritability, feeding refusal, dysphagia, failure to thrive, brief resolved unexplained events (BRUE), recurrent pneumonia, or reactive airway disease.
Are any diagnostic tests indicated for the 3 month old with GER?
No testing is necessary at this point in this patient. History and physical exam are usually sufficient to diagnose GER.
What advice do you give the mother of the 3 month old with GER?
the symptoms may get worse before they get better, but infants usually “outgrow” their symptoms. Reassurance and offering nonpharmacologic interventions are often the only treatment necessary for physiologic GER. In addition, explaining the pathophysiology can be helpful to curious parents (transient relaxation of lower esophageal sphincter, often occurring because of muscular immaturity as well as reflexive relaxation associated with large-volume feeds—100 to 150 mL/kg/day in neonates as opposed to an average adult intake of 30 to 50 mL/kg/day).
ensuring the patient is not being overfed as well as appropriate post-meal positioning by encouraging caregivers to not lay the infant supine for 20 to 30 minutes following feeds. The flat-prone and left-side-down positions are associated with fewer reflux episodes but should only be done while the infant is awake.2 In addition, thickening feeds with rice cereal is a controversial but potentially beneficial intervention. The advantage of fortifying feeds includes increasing caloric density and thus decreasing total volume of feeds, along with decreasing observed regurgitation and esophageal regurgitant height
Changing to hypoallergenic (extensively hydrolyzed) formula benefits only a small subset of patients with milk protein intolerance. Anti-regurgitant formulas that can be found in convenient/grocery stores decrease observed regurgitation but not the actual number of reflux episodes.2
One month later, mom returns with the now 4 month old baby, who has S/S of GER. The infant is now arching with feeds and cries with the episodes of emesis. The emesis is still nonbilious and nonbloody. The exam is unchanged, and weight gain is appropriate.
What pharmacologic and nonpharmacologic treatment options are available?
This infant’s symptoms are now consistent with symptomatic GERD. Other causes of vomiting (neurologic, infectious, structural, metabolic/toxic, etc) are unlikely with this history and exam.
brief therapeutic trial if symptoms are mild to moderate and the diagnosis seems reasonably certain. H2-blockers (ranitidine or famotidine) are most often used initially. Prokinetic agents have a role only in patients in whom delayed gastric emptying is thought to play a role in symptoms. Proton pump inhibitors (PPIs) (omeprazole or lansoprazole) are usually used if symptoms are refractory to H2-blocker therapy, and need a trial of at least 3 to 4 weeks to evaluate efficacy; shorter treatment duration or use on an “as needed” basis are not recommended.
A 50-year-old overweight male complains of heartburn with intermittent chest pain and a bitter taste in his mouth at night. He reports at least 1 to 2 meals daily lead to a sensation of “throwing up in my throat.” His medical history is significant for hypertension and hyperlipidemia. On exam, he is a well-appearing male in no distress with BMI of 30 kg/m2. Abdomen is soft and nontender, with no masses or organomegaly.
How confident can you be in this patient’s diagnosis?
This patient has typical GERD symptoms (heartburn, regurgitation, chest pain). A practitioner can diagnose GERD with greater than 90% certainty when heartburn and regurgitation present together in a patient’s history.4 GERD may also present with extra-esophageal symptoms such as coughing, wheezing, chest discomfort, halitosis, sore throat, or vocal changes. However, one must keep their differential wide as other disorders—including coronary artery disease, achalasia, pill or eosinophilic esophagitis—can also cause symptoms characteristic of GERD.4
