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Home , Abdominal angina, Fecalith, Psoas sign

1/20/2016

GASTROENTEROLOGY Part One of Two

Dipali Yeh, M.S. PA-C Rutgers Physician Assistant Program Certification/Recertification Examination Review Course June 2015

Rutgers, The State University of New Jersey

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Infectious

• Immunocompromised • Risks: AIDS/DM/Steroids • / • CMV/HSV-other clinical features • Diagnosis: endoscopy – CMV esophagitis: large ulcers – Herpes: shallow ulcers – Candida: white plaques • Treatment: specific to the type of infection – CMV esophagitis: valgancyclovir/foscarnet – Herpes: acyclovir – Candida: Amphotericin B

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Pill-induced esophagitis

• Offending agents – Tetracycline – Doxycycline –KCl –NSAIDs • PPttiresentation – Odynophagia/dysphagia/retrosternal chest pain – Several hrs-days after ingestion • Endoscopy: varied findings • Study of choice: double contrast esophagram • Treatment: – Prevention – Remove offending agent

1 1/20/2016

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Radiation Esophagitis

• Presentation – Dysphagia several months following radiation treatment

• Acute >>> Chronic • Mucosal edema/inflammation>>>impaired peristalsis/motility

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Reflux Esophagitis

• Etiology – Lower sphincter fails as barrier to stomach contents • Predisposing factors –GERD, PUD – Prolonged • Presentation – , retrosternal burning – Radiation into the neck – Postprandial component • Findings – Superficial ulcerations – Distal • Definitive diagnostic: endoscopy

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Motility Disorders

• Achalasia • Scleroderma • Esophageal spasms • Zenker’s

2 1/20/2016

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Achalasia

• Etiology unknown • Common in adults 30-60 yrs • Presentation – Gradual dysphagia: solids + liquids – Cough/choking/aspiration/pneumonia • Diagnostics – Barium swallow: Bird’s beak – endoscopy – Manometry: most sensitive • Treatment – Pharmacological: Ca+ channel blockers, isosorbide, local LES botox injections – Surgical: Dilatation, myotomy

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http://commons.wikimedia.org/wiki/File%3AAcha.JPG By Farnoosh Farrokhi, Michael F. Vaezi. [CC‐BY‐2.0], via Wikimedia Commons

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Scleroderma

• 90% patients have esophageal involvement • Part of CREST syndrome • Clinical: GERD, dysphagia to solids & liquids • Diagnosis – Barium swallow: aperistalsis – Manometry: most sensitive; decreased LES tone • Treatment: proton pump inhibitors – omeprazole (Prilosec), pantoprazole (Protonix) • Complication: GERD

3 1/20/2016

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Esophageal spasms

• Etiology: not understood; possible nitric oxide deficiency

• Clinical: chest pain/dysphagia

• Diagnosis: “corkscrew” esophagus on barium

• Treatment: Ca+ channel blockers, hycosamine, tricyclic antidepressants

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http://commons.wikimedia.org/wiki/File%3ADiffuser_Oesophagusspasmus_002‐13.jpg By Hellerhoff (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC‐BY‐3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

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Zenker’s diverticulum

• Outpouching of posterior hypopharynx • History: esophageal spasms, hiatal • Older patients/insidious onset • Clinical: dysphagia/regurgitation/halitosis • Diagnosis: Barium swallow • Asymptomatic = no treatment • Symptomatic = myotomy/diverticulectomy

4 1/20/2016

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Mallory-Weiss tear

• Tear in the GE junction • Forceful vomiting/retching • Clinical feature: , self-limiting • Diagnosis: generally clinically, also endoscope • Treatment: – Most heal w/in 48 hours – Endoscopic epi/thermal coagulation

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Esophageal neoplasms

• General Considerations – 50-70yrs old – M:F=3:1 – Squamous cell: 95% – Adenocarcinoma – Risk Factors • Squamous Cell: tobacco and alcohol abuse • Adenocarcinoma: Barrett’s, obesity

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Esophageal neoplasms

• Clinical features – Dysphagia>solid food + wt loss – Pneumonia/Voice hoarseness – Chest pain • Diagnosis – iiiillnitially-bbiarium study d – definitive-endoscopy • Treatment: surgery • Prognosis: 5-yr survival rate < 20%

5 1/20/2016

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Esophageal strictures

• Complication of GERD/Esophagitis • Clinical presentation – Dysphagia to solid foods over months-years • Diagnosis-biopsy • Treatment – Endoscopic dilatation – Long term PPIs – Refractory: endoscopic triamcinolone

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Esophageal varices

• General considerations – Most common cause of UGIB secondary to portal HTN • Risk factors ↑ chance of bleeding –Size – Red wale markings – di sease severi ty – Active ETOH use • Presentation – High-grade: hematemesis/hypovolemia – Low-grade: + iron-deficiency anemia

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Esophageal varices

Treatment • Acute – Hemodynamic stability: fluids/blood products – Pharmacological • Octreotide-vasoactive agent • Vitamin K-abnormal PT • Lactulose-encephalopathy • Antibiotic prophylaxis • Endoscopic • Sclerotherapy • Mechanical tamponade • TIPS procedure

• Mortality – 30% during 1st bleeding episode – 50% within 6 weeks

6 1/20/2016

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Esophageal obstructive entities

• Esophageal Webs • Schatzkiʼs ring – Plummer-Vinson – GERD/ – Proximal esophagus – Distal esophagus – Presentation – Presentation • Food impaction • Food impaction – Barium swallow – Barium swallow •shelf • Lower esophageal narrowing

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GERD

• 3 mechanisms – Transient LES relaxation, increased intra-abdominal pressure, spontaneous reflux • Risk factors – Alcohol, caffeine, obesity, smoking • Clini cal f eat ures – Heartburn – Chest pain/halitosis/cough • Diagnosis: – Ambulatory 24hr pH monitoring: most sensitive/gold standard – Endoscopy • refractory to secretory therapy • Alarm symptoms (next slide) • Long-standing history (Barrett’s)

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GERD

• Alarm symptoms – Refractory heartburn – Dysphagia – Unintentional Weight loss – GI bleed/anemia

7 1/20/2016

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Diagnostic testing in Upper GI Pathology

• 1. Endoscopy – Refractory to secretory therapy – Patients with alarm symptoms (next slide) – Chronic reflux – Barrett’s predisposition

• 2. ambulatory pH monitoring – Confirm GERD – GERD sx + negative endoscopy – Refractory to longstanding PPI treatmetn – Refractory to antireflux surgery

• 3. Manometry – peristaltic abnormalities; – Preop antireflux surgery

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GERD Treatment options

• Lifestyle/diet modifications: 20% effective – *weight loss • Three main options – Antacids • Maalox, mylanta, gaviscon – H2 bl ock ers • Cimetidine, ranitidine, famotidine, nizatidine – Proton pump inhibitors • Omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, dexlansoprazole – ..also…Prokinetics (metoclopramide)/Baclofen only after diagnostic eval • Surgery – Nissen fundoplication – Stretta procedure – Endocinch

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GERD Treatment approach

• Intermittent/mild symptoms: – Weight loss – Antacids – H2blockers twice daily • Moderate symptoms: – Once a d ay PPI x 8 week s: th erapy of ch oi ce – If symptoms continue thereafter, maintenance PPI – H2 blockers + PPI combination therapy • Risks associated with PPIs – If (+)osteoporosis, can remain on PPI therapy – Risk factor for Clostridium difficile – short term PPIs: CAP – No need for alteration with clopidogrel (re: adverse cardiovascular events)

8 1/20/2016

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Gastritis

• Atrophic – Risk for gastric CA, pernicious anemia, autoimmune • Hemorrhagic – ICU/Burn • Infectious – H. pylori- most common cause • Presentation – Nondescript abd pain, anorexia, , • Treatment – Etiology-dependent

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Helicobacter pylori • Gram-negative spiral-shaped bacillus • Clinical presentation: nausea/ • Diagnosis: based on history – Urea breath test (most sensitive)/fecal antigen assay – Endoscopy-but not for uncomplicated disease

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Helicobacter pylori

• Treatment • combination therapy x 14d –1st line: Triple therapy: PPI + amox + clarithromycin – Quadruple therapy: PPI + bismuth + 2 antibiotics • (cl arith romyci n + amoxi cilli n, t et racycli ne + met ronid azol e)

9 1/20/2016

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PUD

• Break in the mucosa • Duodenal > gastric • Risks: smokers/long-term NSAID use • 2 major causes – Chronic NSAID use – Hpylori infection- most common

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PUD

• Clinical features – Hallmark: epigastric pain – Duodenal: improves with food – Gastric: worsens with food • Diagnosis: upper endoscopy • Treatment – Avoid irritating factors – Combination therapy – misoprostol

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Gastric neoplasms

• 3 types – Adenocarcinoma: 90-95% – Lymphoma – (Zollinger-Ellison Syndrome)

10 1/20/2016

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Gastric neoplasms

• Adenocarcinoma – 50-70yrs old – M:F = 2:1 – 5 year survival < 20% – Risk factors • Genetic: Familial/Blood Group A • Environmental: H. pylori/smoking/low socioeconomic • Predispositions: chronic /pernicious anemia

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Gastric neoplasms

• Adenocarcinoma – Clinical features • Early: can be asymptomatic • Later: cachexia, dyspepsia, weight loss, GIB • Virchow’s node • Sister Mary Joseph nodule • Krukenberg tumor

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Gastric neoplasms

• Adenocarcinoma – Diagnosis • endoscopy with biopsy – (>55 yrs old w/ new sx/fails antisecretory treatment) • Malignant ulcer: irregular folds & base – Treatment • 30% of patients-surgery=curative • Combination chemo + radiation improves survival

11 1/20/2016

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Gastric neoplasms: Lymphoma

• 95% are non-Hodgkin B cell lymphoma • Risk factor: H pylori • Clinical features: same as adenocarcinoma • Diagnosis: endoscopic biopsy • Treatment: combination chemotherapy w/without radiation

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Gastric neoplasms: ZES

• Zollinger-Ellison Syndrome (Gastrinoma) • Refractory PUD • 1/3 associated with MEN-1 • Clinical features – PUD sypymptoms refractor y to treatment – Heartburn 20% – Secretory 60-70% – Abdominal pain 80%

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Gastric neoplasms: ZES

• Diagnosis – Fasting serum gastrin level > 150pg/ml (nl 100) – pH < 2.0 – SRS w/ SPECT: identifies 60% of gastrinomas • Treatment – MMdiledical: PPIs are th e d rug of ch oi ce – Surgical= curative before hepatic spread – 15-year survival rate=95% w/o hepatic mets at dx

12 1/20/2016

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Cholelithiasis/

• Majority: cholesterol stones • Bilirubin stones.think SCD/IBD/Hemolytic anemias •F>M • Risk factors –Age – Obesity – Rapid weight loss – Insulin resistance – Family history

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Cholelithiasis/Cholecystitis

• Clinical features – – Nausea, vomiting – Murphy’s sign: inhibit inspiration – Fever • Diagnosi s – Leukocytosis; ↑ LFTs/Amylase/Lipase= – RUQ sono: (+); GB wall thickening – HIDA: no filling in cholecystitis; most specific test – ERCP: indicates biliary obstruction

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Cholelithiasis/Cholecystitis

• Treatment – Medical • IV fluids •Bowel rest • Antibiotics X 7-10d » Ampicillin + aminoglycoside » Cephalosporin + ampicillin-sulbactam

• Pain management: morphine/meperidine

13 1/20/2016

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Cholelithiasis/Cholecystitis

• Treatment – Surgical: laparascopic cholecystectomy – Dissolution therapies • Chenodeoxycholic acid • UDCA

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Choledocholithiasis/Cholangitis

• Common stones • Risk factors – Infection – Biliary stasis – s/p cholecystectomy • Most common cause>acute bacterial cholangitis – E. coli, Klebsiella, Enterococcus, Enterobacter

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Choledocholithiasis/Cholangitis

• Charcot’s triad: Cholangitis – RUQ pain, fever, in 50-70% of patients • Reynold’s pentad – Charcot’s triad + AMS + hypotension – Indicates development of sepsis • Diagnosis – Initial: RUQ Sono – Gold Standard: ERCP

14 1/20/2016

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Choledocholithiasis/Cholangitis

• Treatment – GB stones present: Lap chole + bile duct exploration – Isolated CBD stones: Endoscopic therapy then lap chole

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Primary sclerosing cholangitis

• Biliary system fibrosis and thickening • Etiology: possibly autoimmune; (+)association with Ulcerative • Mean age at diagnosis: 39 •M: F = 7: 3

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Primary sclerosing cholangitis

• Clinical features – Progressive jaundice – Pruritus – Anorexia, fatigue, • Diagnosis – Elevated alk ali ne ph osph atase • Treatment – Acute: ciprofloxacin – Liver transplant: survival rate > 80% at 1yr

15 1/20/2016

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Acute Viral

• Acute vs chronic •Causes – Viral: most common – Toxins (alcohol, acetaminophen) • Acute – A&E are self-limited w/ no long-term sequelae – (“it was something I AtE”: fecal-oral transmission) – B/C/D are parenterally infectious

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Hepatitis C

• At-risk population – Injection drug users – Organ/blood trasnfusion before 1992 – Hemophilia w/blood product transfusion before 1987 – ESRD on HD – Children born to infected mothers – HIV patients

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Acute Viral Hepatitis

• Clinical features – Fatigue – Malaise – Anorexia – RUQ pain – PE: jaundice , RUQ tenderness

16 1/20/2016

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Acute Viral Hepatitis

• Diagnosis • Hepatitis A: IgM • • Anti-HDAg, RNA – Hepatitis E • Anti-HEV IgM antibodies

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Hepatitis B Serology

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Hepatitis C Serology

Anti-HCV HCV RNA Interpretation ++(+)HCV infection +-Resolution/acute (low viral load)

-+Early/false + RNA --(-)HCV infection

17 1/20/2016

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Acute Viral Hepatitis

• Treatment – Hepatitis A: self-limited; no specific treatment – Hepatitis B: tx based on HBeAg; entecavir/tenofovir/peg-IF – Hepatitis C: peg-interferon/ribavirin • Needlestick: monitor RNA/LFTs @ 2wk, 4wk, 6mo – Hepatitis D: no treatment has been evaluated – Hepatitis E: self-limited; no specific treatment

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Acute Viral Hepatitis

• Prevention – Hepatitis A vaccine • Endemic area travelers, MSM, HCPs, chronic liver dz – Hepatitis B vaccine • Vaccinate at 0, 1, 6 months –Hepatiti s C • Follow standard precautions/ no vaccine exists – Hepatitis D • Hep B vaccination – Hepatitis E-public hygiene

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Chronic Viral Hepatitis

• Viral infection: most common cause of chronic hepatitis • Applies to B, C, D • HBV/HCV=leading cause of /hepatocellular CA • Clinical features –Fatig,gue, nausea ,j, jaundice , RU QpQ pain – Advanced symptoms: dark urine, itching, wt loss

18 1/20/2016

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Chronic Viral Hepatitis

• Diagnosis – ALT/AST 2—5x normal –ALT>AST – Alk phos minimally ↑ unless (+)cirrhosis – Liver biopsy determines disease severity

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Chronic Viral Hepatitis

• Treatment – Hep B: peg-interferon & nucleoside/tide analogues (lamivudine) – Hep C: curable; • Current standard treatment: ribavirin + PEG IFN – Hep D: high doses of PEG IFN – Autoimmune: corticosteroids + azathioprine

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Cirrhosis

• Irreversible fibrosis & nodular regeneration • 2 main causes – Chronic Hepatitis C – Alcohol • 2 main complications – Portal HTN – Liver insufficiency

19 1/20/2016

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Cirrhosis

• Clinical features – Weakness, fatigue, weight loss – Nausea, vomiting, anorexia – PE: , muscle atrophy, palmar erythema, spider angiomata* – Late stage disease • • Encephalitis • Esophageal varices

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Cirrhosis

• Diagnosis – Leukopenia/anemia – ↓ albumin/↑ AST – ↑ Alk phos/antimitochondrial abs: primary biliary cirrhosis – Ascites: SAAG >/=1.1 g/dL=portal HTN – Low platelets (< 150 ,000 mm)

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Cirrhosis

• Treatment – Abstinence from alcohol/hepatotoxic drugs – Ascites • Salt restriction/bed rest/spironolactone • If ↑K, give furosemide – Vari ces • Propranolol to ↓ portal pressures • Octreotide • Endoscopic therapy – Encephalopathy – Spontaneous bacterial

20 1/20/2016

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Cirrhosis

• Treatment – Encephalopathy • Lactulose 15-30mL twice daily • TIPS procedure –Surgery • Liver transplant: definitive

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Liver Neoplasms

•Benign – Cavernous hemangioma – Hepatocellular adenoma • Malignant-can be primary or metastatic – Liver is common site of mets from lung/breast • Primary hepatocellular CA risk factors – Hepatitis B/C – Cirrhosis – Aflatoxin B1 exposure (Aspergillus)

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Liver Neoplasms

• Clinical features – Anorexia, cachexia, abd pain, weight loss – (+)bruit/friction rub on auscultation • Diagnosis – Leukocytosis – Tumor mark er: serum AFP : > 200 ng/ ml – If hx cirrhosis, surveillance u/s q6mo – CT/MRI with contrast =imaging modality of choice – Needle bx not recommended for resectable tumors

21 1/20/2016

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Liver Neoplasms

• Treatment – Benign: only treat if risk of rupturing hepatic capsule – Early stage w/ no liver dysfunction: surgical resection – Local tumor ablation – Liver transplant • PPirognosis – 5yr-survival w/ surgical resection: 50-70% – Liver transplant w early disease at detection 5-year survival: 70-80%

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Acute Pancreatitis

• Most common causes: gallstones and alcohol abuse • Also serum triglycerides >1K mg/dl, neoplasm, idiopathic • Atlanta Revisions (2013) – mild (absence organ failure/local complications) – Moderate (local complications and/or transient organ failure) – Severe (organ failure >/= 48hrs) • Clinical features – Hallmark: abdominal pain, nausea, vomiting – Tachycardia, hypotension in severe cases – Grey-Turner sign: flank ecchymosis – Cullen sign: umbilical ecchymosis

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Acute Pancreatitis

• Diagnosis –Lab tests • ↑ serum amylase/lipase<

22 1/20/2016

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On admission After 48 hours of admission

• Age > 55 years • Fall in hematocrit >10% • WBC > 16,000/uL • Increase in BUN to > 5 • Glucose >200 mg(g/dL (>11 mg/dL mmol/L) • Calcium < 8 mg/dL • LDH > 350 IU/L • PO2 < 60 mmHg • SGOT (AST) > 250 IU/L • Base deficit > 4 meq/L • Fluid sequestration > 6 Liters

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AP risk assessment

• >55 yrs • BUN > 20 • BMI >30 • Rising BUN •AMS • HCT > 44% • Comorbid disease • Rising HCT • SIRS cri teri a (2/3) • Elevated creati ni ne – HR>90bpm • Pleural effusions – RR>20 or PaCO2>32 • Pulmonary infiltrates – T>38 or <36 • Extrapancreatic collections – WBC <4 or >12K or >10% bands

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Acute Pancreatitis

• Treatment – Keep NPO – Hydromorphone (Dilaudid) – AGGRESSIVE Fluid resuscitation (achieve urine output 0.5ml/kg/hr) • Crystalloids • Most beneficial in the first 12 -24 hours – Nausea/Vomiting • promethazine (Phenergan), ondansetron (Zofran) • NG suction if intractable – When to progress to a solid diet

23 1/20/2016

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Chronic pancreatitis • 80% of cases secondary to alcohol abuse in the US • Also: cholelithiasis, PUD, hyperlipidemia • ? Evidence cigarette smoking alone as etiology • Classic triad: – pancreatic calcification//DM-20% of patients • Clinical features – Abdominal pain

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Chronic pancreatitis

• Diagnosis – ↑ fecal fat due to exocrine pancreatic insufficiency – DM due to endocrine insufficiency – Pancreatic calcifications on abd x-ray: 20-30% • Treatment – DDfiiiefinitive: treat und erl liying cause – Analgesics: tramadol (Ultram) – Pancreatic enzyme therapy – Steroids if autoimmune etiology

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Pancreatic neoplasms

•4th most common cause of CA in the US • Risk factors – Age, tobacco use, etoh abuse, previous abd radiation – Genetic predisposition • 75% occur in the pancreatic head • Clinical features – Abd pain, nausea, vomiting – Diarrhea – Weight loss, jaundice – Courvoisier’s sign: palpable GB

24 1/20/2016

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Pancreatic neoplasm

• Diagnosis –Labs • Anemia, impaired glucose tolerance, steatorrhea –Imaging • CT scan with contrast: preferred imaging –Tuoumor mark esers • CA 19-9 • Treatment – No mets: surgery, then chemo= 5yr survival 20% – Unresectable tumor: chemo + radiation – Mets: manage pain/complications

GASTROENTEROLOGY End of Part One Please go on to Part Two

Rutgers, The State University of New Jersey

25 1/20/2016

GASTROENTEROLOGY Part Two of Two

Dipali Yeh, M.S. PA-C Rutgers Physician Assistant Program Certification/Recertification Examination Review Course June 2015

Rutgers, The State University of New Jersey

PANCE/PANRE Review Course

Appendicitis

• Most common acute surgical emergency • in < 30% of patients • Usually between 10-30 yrs old • Clinical manifestations –Earlypy: periumbilical pain , then localize to RL Q – Associated: nausea, vomiting, anorexia – Psoas sign –

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Appendicitis

• Diagnosis – Leukocytosis in 80% of cases – Preferred imaging: CT scan • Treatment – Laprascopic appendectomy – Abx: cef otetan/ ti carcilli n-clllavulanate (Ti (Tii)mentin) – If perforation: ceftriaxone (Rocephin) & metronidazole (Flagyl)

1 1/20/2016

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Celiac disease

• Inflammatory condition of • Precipitation foods: wheat, rye, barley • Immunological response to gluten • High-risk groups –1st degree relatives –Type I DM – Autoimmune thyroid disorder • HLA-DQ2/DQ8(+) patients • Clinical features: wt loss, diarrhea, abd distention • Dermatitis herpetiformis

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Celiac Disease

• Diagnosis – IgA endomysial antibody – IgA tTg antibody – Confirmation: small intestine biopsy • Treatment – IIinstitute gl uten-ffdiree diet – Supplementation: vitamin D, calcium, B12, folate – Bone density studies (70% patients have osteopenia/osteoporosis)

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Constipation

• Occurs in 10-15% of adults • More common in women •1st step in eval: what is “” • Most common causes – Inadequate fluid/fiber intake – Poor bowel habits • Primary etiology: slow transit time • Secondary etiology: medication SE/systemic disorders • Diagnosis: if refractory to treatment, colonic transit studies

2 1/20/2016

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Constipation

• Treatment – Dietary/lifestyle measures • 30g fiber/d, fluids, discontinue meds precipitating – Osmotic laxatives • Magnesium hydroxide, lactulose, polyethylene glycol – SuStimulant laxati ve • Bisacodyl, senna, cascara

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Constipation→

• Complication: Fecal Impaction – Decreased appetite, abd pain, distention – Clinical presentation • Firm palpable on DRE – Treatment • Initial: saline/mineral oil enema • Subsequent: digital disimpaction – Long-term goal: maintain soft stool/regular BMs

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Diverticular disease

• – Uncomplicated mucosa/submucosa herniations – 50-80% of patients > 80yrs old – Western diet – Most common: sigmoid colon – Asymptomatic/uncomplicated=no imaging – Recommended: high fiber diet/fiber supplements – 10-25% patients develop

3 1/20/2016

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Diverticular disease: Diverticulitis

• Clinical manifestations – Anorexia, LLQ pain, fever – LLQ tenderness on PE – 5% have diverticular bleeding • Diagnosis – LLkeukocytosi i70s: 70-80% of pati ents – CT scan: inflammation – Barium study: not in acute setting; risk perforation – Colonoscopy: after acute syndrome has resolved

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Diverticular disease: Diverticulitis • Treatment – Uncomplicated w/mild symptoms •1st line: • ciprofloxacin/levofloxacin + metronidazole x 7-10d • TMP/SMX + metronidazole x 7-10 days •2nd line • amox/clavulanic acid or moxifloxacin • Clear liquid diet & advance as tolerated – Unresponsive to outpatient treatment/unable to tolerate PO • Admit + IV antibiotics • 1st line • piperacillin/tazobactam, ampicillin/sulbactam •2nd line • Ampicillin + metronidazole + quinolone or aminoglycoside

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Diverticular disease: Diverticulitis

– Surgery: perforation/obstruction – Abscess formation > 4cm: CT-guided drainage, then surgery in 6wks – Avoid nuts/seeds/popcorn? Recent studies negate this – Maintain high-fiber diet (>30 g/d)

4 1/20/2016

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Inflammatory bowel disease

• & Crohn’s disease • Common in developed countries •M=F • Peak incidence 15-30, 2nd peak 7th decade • Risk factor: Fam hx/Ashkenazi Jew descent • Cigarette smoking: bad for Crohn’s/good for UC

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CROHN’S UC

Smoking • Poor prognosis • Improved course

Sites of GI • Esophagus>anus • Colon (rectal involvement • (rectal sparing) involvement)

Lesions • “Skip lesions” • Continuous disease Transmural •(+) • (-) involvement

• Abd pain/ Symptoms •RLQ pain/diarrhea/fatigue

Surgery • Not curative • Can be curative

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Inflammatory bowel disease • Pyoderma gangrenosum •Skin • Erythema nodosum (pretibial) • Vasculitis

• Iritis •Eyes •Conjunctivitis • Uveitis

• Arthritis • Joints-most common • Ankylosing spondylitis

• Sclerosing cholangitis •Liver • Hepatitis

5 1/20/2016

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Inflammatory bowel disease

• Diagnosis – Colonoscopy: preferred imaging except with peritoneal signs – Biopsy: determine histopathology – Crohn’s: cobblestone appearance/skip lesions – UC: diffuse erythema →proximally – Avoid endoscopy in acute disease →perforation/toxic

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Crohn’s Disease

http://commons.wikimedia.org/wiki/File%3ACD_colitis.jpg By Samir at en.wikipedia [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC‐BY‐SA‐3.0 (http://creativecommons.org/licenses/by‐sa/3.0/)], via Wikimedia Commons

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Inflammatory bowel disease: Treatment

• 5-ASA-for maintenance – Sulfasalazine (Azulfide) – Mesalamine (Asacol, Pentasa) • Corticosteroids-for acute attacks – Prednisone/methylprednisone • Immunomodulators-for refractory disease – 6-mercaptopurine – Methotrexate – Cyclosporine – WBC/LFTs<

6 1/20/2016

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Inflammatory bowel disease: Treatment

• Antibiotics-for acute infectious flare-ups – metronidazole (Flagyl) – ciprofloxacin (Cipro)/levofloxacin (Levaquin) • Surgery – Crohn’s: reserved for complications-segmental resection – UC: curati ve, total proctocol ectomy • Cancer: UC/Crohnʼs patients – Screening colonoscopy q1-2 yrs 8-10 yrs after dx

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Intussusception

• Invagination of proximal into distal segment • 95% cases>children • Risk factors: viral , CF, Meckelʼs • Risk factors in adults: Neoplasm • Clinical features – Currant jelly stool, palpable mass – Adult: abdominal pain, nausea, vomiting, diarrhea • Diagnosis – barium enema in children, CT in adults • Treatment – barium enema in children, surgery in adults

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Irritable Bowel Syndrome

• Recurrent abd pain associated with defecation/∆ bowel habits • It is the most common cause of chronic/recurrent abd pain in the US (affects up to 20% of adults) •F>M •Sypymptoms associated with menses/stress

7 1/20/2016

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Irritable Bowel Syndrome

• Clinical features – Symptoms vary widely – Lower abd pain relieved with defecation – Alarm features • Anemia • Weight loss • FH colon CA • Major symptom ∆/1st symptom after age 50 – PE: usually normal

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Irritable Bowel Syndrome

• Diagnosis – Diagnosis of exclusion – Colonoscopy if alarm features • Treatment – Strong provider-patient relationship & reassurance – Fiber th erapy – Antispasmodics – Antidepressants – Psychological cognitive therapy/hypnosis

PANCE/PANRE Review Course

Intestinal ischemia

• Predisposing conditions – Older age – Arterial embolus conditions (arrhythmias, heart failure, valve disease) – Arterial occlusion conditions (trauma, vasculitis, AAA) – Low-flow states (sepsis, dialysis) – Extensive surgery>esophagus/stomach/ – Most common site: SMA

8 1/20/2016

PANCE/PANRE Review Course

Intestinal ischemia

• Clinical presentation – Acute: pain out of proportion to exam – Chronic: postprandial abdominal – Also: fever, nausea, vomiting, diarrhea – PE: hypotension, tachycardia, ↓ bowel sounds • Diagnosi s – Labs: leukocytosis, hemoconcentration, metabolic acidosis – Plain film: air-fluid levels, thumb-printing sign –MDCT Angiography: 95% s/s

PANCE/PANRE Review Course

Intestinal ischemia

• Treatment – Initial: volume replacement, optimize cardiac output – Antibiotics: broad-spectrum • ciprofloxacin (Cipro) + metronidazole (Flagyl) • piperacillin & tazobactam (Zosyn) –Evdeceogvidence of gan gee:ogrene: to th eOe OR

PANCE/PANRE Review Course

Colonic polyps

• Classifications – Nonadenomatous=benign – Adenomatous=malignant potential • Types: sessile, flat, pedunculated • Nonadenomatous – Account for 90% of large bowel – Found in 50% of patients > 60 yrs old • Adenomatous – Have malignant potential – Malignancy risk increases with size (>2cm=highest risk)

9 1/20/2016

PANCE/PANRE Review Course

Colonic polyps

• Clinical features – Generally asymptomatic • Diagnosis – Preferred method: colonoscopy – Flex-sig detects 50-60% of polyps • Treatment – Endoscopic polypectomy: ↓ mortality/incidence of colorectal CA – Surgical resection when endoscopic resection is not possible

PANCE/PANRE Review Course

Colorectal cancer

•3rd most common cancer in the US/2nd leading cause of cancer death • 95% are adenocarcinoma arising from adenomas • Sites of development: 38% cecum, 35% sigmoid, rectal • Risk factors –Agpyge: 90% occur in patients >50yrs old –(+)FH – Hx IBD (Ulcerative colitis/Crohns)

PANCE/PANRE Review Course

Colorectal cancer

• Clinical features – Slow-growing-no symptoms for years – Asymptomatic-detected by FOBT – Fatigue/weakness>iron-deficiency anemia – ∆ bowel habits circumferentially – Hematochezia/tenesmus/urgency – Proximal lesions: bleeding – Distal: obstruction/perforation

10 1/20/2016

PANCE/PANRE Review Course

Colorectal cancer

Diagnosis/Screening • Procedure of choice: colonoscopy • Barium enema/CT – Colonoscopy unable to reach cecum – Nearly obstructing tumor; prevents passage of scope

PANCE/PANRE Review Course Colorectal cancer

Screening options beginning at age 50 for average‐risk individuals

• Colonoscopy • Q10 yrs • Flex sig • Q5yrs • CT colography • Q5yrs • Barium enema • Q5yrs •FOBT/FIT • Annually

•CEA • to monitor patients; not (CEA> 5ng/ml=poor detection prognosis)

PANCE/PANRE Review Course

Colorectal cancer

• Single first-degree relative diagnosed >/= 60 – Begin screening at age 40 – Guidelines as average-risk individual – Preferred: colonoscopy q10 years • Single first-degree relative diagnosed

11 1/20/2016

PANCE/PANRE Review Course

Colorectal cancer: Treatment

• Primary treatment: Surgery • Chemotherapy • Metastatic disease • Adjuvant with Stage III (node +) • 5-flourouracil • Capecitabine • Irinotican • Oxaliplatin • Radiation • Peritoneal/rectal involvement • Rare for disease with mets

PANCE/PANRE Review Course

Colorectal cancer

• Chemoprevention – NSAIDS including aspirin • Dietary prevention – More fruits/vegetables/fiber – No reduction on 3 randomized trials on 3-8 yr follow up

PANCE/PANRE Review Course

Small

•Causes – 60% adhesions – 10% – Others: neoplasms, IBD, • Clinical features – EElarly • diffuse, crampy colicky abd pain • Vomiting, hyperactive BS –Late • Steady abd pain, better localized • (-)BS, quiet

12 1/20/2016

PANCE/PANRE Review Course

Small Bowel Obstruction

• Diagnosis – Abdominal X-ray • Dilated bowel loops • (+)air-fluid levels –CT •Helpgyp determine etiology • Gas in the wall>>strangulation • Treatment – NGT – IV fluids, opioid pain medication, antiemetics – Surgery: for strangulated source , avoid in paralytic

PANCE/PANRE Review Course

Large Bowel Obstruction

• Slower, less dramatic in presentation • Most common cause: neoplasm • Other: strictures, hernias, volvulus, fecal impaction • Clinical features – Abd distention,,,g, anorexia, nausea, vomiting – Late stage: feculent vomiting, no BS

PANCE/PANRE Review Course

Large Bowel Obstruction

• Diagnosis – Abdominal x-ray: free air, bird’s beak volvulus – CT scan: confirm etiology • Treatment – Surgery more likely with LBO – EEdndoscopy to red uce any vol vul us – Surgery: ostomy very likely; temp vs permanent

13 1/20/2016

PANCE/PANRE Review Course

Toxic megacolon

• TRUE EMERGENCY • Extreme dilatation & immobility of colon • Complication – UC, Crohn’s, pseudomembranous colitis •Higpgh risk of perforation • Clinical features – Fever, abd cramps, distention – (+)rigid abdomen & rebound tenderness – (+)shock, hypovolemia

PANCE/PANRE Review Course

Toxic megacolon

• Diagnosis – Abdominal x-ray: colonic dilatation > 6cm • Treatment – Broad-spectrum antibiotics – NG suctioning & colonic decompression – IV fl uid s – Surgery: possible colectomy/colostomy

PANCE/PANRE Review Course

http://commons.wikimedia.org/wiki/File%3AToxisches_Megacolon_bei_Colitis_ulcerosa.jpg By Hellerhoff (Own work) [CC‐BY‐SA‐3.0 (http://creativecommons.org/licenses/by‐sa/3.0)], via Wikimedia Commons

14 1/20/2016

PANCE/PANRE Review Course

Hernias

• Protrusion of organ/structure from itʼs proper cavity • Classifications – Reducible: able to return contents – Incarcerated: contents cannot be returned – Strangulated: incarcerated hernia w/ compromised blood supply • Types – Umbilical: congenital/pregnancy/obesity – Hiatal: causes GERD – Incisional: vertical incisions: F:M=2:1 – Inguinal: Direct & Indirect – Femoral: increased strangulation rate

PANCE/PANRE Review Course

Hernias

• Clinical features – If strangulated, localized sharp, intense abd pain – (+)anorexia/vomiting • Diagnosis – Leukocytosis – CT/US can b e d one • Treatment –surgery

PANCE/PANRE Review Course

Anal fissure

• Frequently affects young adults; M=F • Most at posterior midline • Any off “midline”=red flag – Crohn’s, neoplasm, syphilis, HIV

15 1/20/2016

PANCE/PANRE Review Course

Anal fissure

• Clinical features/diagnosis – Based on HX & PE (severe anal pain s/p BM) – Diagnostic triad • Fissure, sentinel tag, hypertrophied anal papilla • Treatment – Fiber, fl uid i nt ak e – Sitz baths – Topical NTG/diltiazem gel to reduce sphincter tone – Lateral internal sphincterotomy: failed medical management

PANCE/PANRE Review Course

http://commons.wikimedia.org/wiki/File%3AAnal_fissure_1.jpg By Bernardo Gui (Own work) [Public domain], via Wikimedia Commons

PANCE/PANRE Review Course

Perianal abscess/fistula

•Causes – Most by infections of anal glands – Also: trauma, anorectal surgery, malignancy • Fistula: complication of chronic perianal abscess

16 1/20/2016

PANCE/PANRE Review Course

Perianal abscess/fistula

• Clinical features/Diagnosis – Abscess • Perianal pain/swelling • Local erythema, swelling, fluctuance – Fistula • Recurrent abscess in same location • Persistent purulent drainage from non-healing abscess

PANCE/PANRE Review Course

Perianal abscess/fistula

• Treatment – Abscess • Local incision and drainage • Antibiotic therapy alone w/o I&D-inadequate • Antibiotics: immunocompromised, ↑ risk of infection • Antibiotics not usually indicated after I&D

– Fistula: surgical

PANCE/PANRE Review Course

Pilonidal disease

• Abscess in the sacrococcygeal cleft • Associated with subsequent sinus development • M:F=4:1 • Clinical features: painful, fluctuant area • Treatment – Surgical drainage – Antibiotic supplements – Subsequent: follicle removal/unroof sinus tract

17 1/20/2016

PANCE/PANRE Review Course

Hemorrhoids

• Varices of hemorrhoidal plexus • Causative factors – Constipation, diarrhea, pregnancy, prolonged straining • Internal: above dentate line • Clinical features – Internal: painless BRBPR – External: pain & swelling when thrombosed

PANCE/PANRE Review Course

Hemorrhoids

• Treatment – External • Analgesics • Sitz baths/fiber intake • Stool softeners • Severe cases: excision

PANCE/PANRE Review Course

Thrombosed external hemorrrhoid

http://commons.wikimedia.org/wiki/File%3APerinanalthrombose_01.jpg By Ole Gebbensleben, York Hilger and Henning Rohde [CC‐BY‐2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

18 1/20/2016

PANCE/PANRE Review Course

Hemorrhoids Treatment Grades Findings

• Bleed, but (-)prolapse • High fiber diet, increased Grade I water intake, rubber band ligation, sclerotherapy

Grade II • Prolapse but reduce • Dietary modification, rubber spontaneously band ligpygation, sclerotherapy

• Protrude and require • Dietary modification, rubber Grade digital reduction III band ligation, sclerotherapy, • surgical hemorrhoidectomy

• Chronically protrude; • Urgent/surgical irreversible; risk hemorrhoidectomy Grade strangulation IV

PANCE/PANRE Review Course

Anal Cancer

• 80% related to HPV • Most: squamous cell CA • Clinical: bleeding, pain, palpable mass • Diagnosis: CT/MRI-look for mets/LN involve – Need biopsy • Treatment – First line: chemotherapy – <3cm tumor: wide local excision – Tumors not responsive to CT/recur • Abdominoperineal resection

PANCE/PANRE Review Course

Diarrhea

• Classifications – Acute vs Chronic • Acute: < 2weeks • Chronic>4weeks – Infectious vs noninfectious • Infectious more common – Inflammatory vs noninflammatory • Inflammatory: (+)blood diarrhea • Noninflammatory: (-)blood

19 1/20/2016

PANCE/PANRE Review Course

Acute Diarrhea

• Inflammatory • Noninflammatory – Campylobacter – Cryptosporidium – Entamoeba – Escherichia coli – Salmonella – Giardia lamblia – Shigella – Norovirus –Yersinia – Rotavirus – Vibrio cholera

PANCE/PANRE Review Course

Acute Diarrhea

Organism Etiology Diagnosis Clinical Features/ Treatment

Campyloba Raw poultry, Stool azithromycin or floroquinolone for severe disease; associated with Guillain- cter jejuni unpasteurized culture Barre milk

Entamoeba Tropical Stool Metronidazole species regions culture tinidazole w/crowding and poor sanitations Salmonella Eggs, poultry, Stool No antimicrobials unless high risk or systemic disssemination, in which case: species unpasteurized culture florquinolone milk

Shigella Food/water Stool Often mild & self-limited. If needed, fluoroquinolones. Do not give opioids species contaminated culture w/human feces Yersinia Undercooked Stool Present with appendicitis-like symptoms; in children: polyarthritis or erythema enterocoliti pork, culture nodosum. Self-limited. If severe, treat with tetracycline or fluoroquinolone. ca contaminated water

PANCE/PANRE Review Course

Acute Diarrhea

Organism Etiology Diagnosis Clinical Features/Treatment cryptosporidium Recreational drinking water; Stool culture Primarily fluid-hydration. resistant to chlorine Nitazoxanide FDA-approved Swimming pools; daycare

E. coli Undercooked ground beef; Stool culture/toxin Usually self-limited; associated unpasteurized milk with hemolytic-uremic syndrome in children Giardia lamblia Recreational water/wilderness Cysts/trophozoites in stool Acute diarrhea: watery, profuse travel Chronic diarrhea: greasy, malodorous Metronidazole, Tinidazole Norovirus Shellfish; food handled with fecal Clinical Limited disease 12-48 hours; contamination diarrhea in adults, nausea and vomiting in children; supportive care Rotavirus Undercooked pork, contaminated Immunoassay on stool Watery diarrhea x 1 week; water supportive care

Vibrio cholerae Contaminated water/shellfish, food Stool culture Prompt hydration; tetracycline vendors and azithromycin shorten excretion of vibrios

20 1/20/2016

PANCE/PANRE Review Course

Chronic Diarrhea • Osmotic • Secretory • *Symptoms ↓ • *little ∆ w/fasting w/fasting –VIPoma – Lactulose – Gastrinoma – Antacids – Laxative abuse – sorbitol Inflammatory Conditions: UC/Crohn’s Disease Motility Disorders -scleroderma -IBS -DM -Hyperthyroidism -Celiac Disease -Chronic Pancreatitis Chronic infections: Giardia, cryptosporidium, CMV

PANCE/PANRE Review Course

Diarrhea

• Clinical features – Greasy, malodorous stool: malabsorption disorder – (w/ blood/pus): inflammatory disorder – (+)abd pain: IBS/IBD – (+)hx community outbreaks: viral/food source etiology

PANCE/PANRE Review Course

Diarrhea

• (+)heme pos stool + fecal leukocytes=IBD • (+)fecal fat=malabsorption condition • Send stool culture for bacterial agents/parasites/toxins • Mucosal bx may be required to r/o inflammatory process

21 1/20/2016

PANCE/PANRE Review Course

Diarrhea Treatment • Antidiarrheal agents – Reserved for mild-mod disease – 1st line: Loperamide (Immodium) 4mg/d then 2mg/d s/p BM • Opioids – ↓ urgency and fecal liquidity – Indication: chronic , intractable intractable diarrhea – Contraindication: • Bloody diarrhea • High fever • Systemic toxicity • Antibiotics – Not indicated in acute diarrhea – Immunocompromised/dehydration – Antibiotics for specific organisms

PANCE/PANRE Review Course

Diarrhea: PEARLS

– Giardia: Metronidazole – E. histolytica: Metronidazole – Shigella: TMP/SMX (Bactrim DS) or ciprofloxacin – Campylobacter: Erythromycin or ciprofloxacin – C. difficile: Discontinue antibiotics if possible. Consider metronidazole if diarrhea persists – Traveler's diarrhea: Ciprofloxacin or TMP/SMX (Bactrim DS)

PANCE/PANRE Review Course

Diarrhea: PEARLS

• Contraindications: – Antibiotics are contraindicated in Salmonella infections unless caused by S. typhosa or the patient is severely ill. – Avoid alcoholic beverages with metronidazole due to the possibility of a disulfiram reaction. – Antibiotics are not indicated in foodborne toxigenic diarrhea .

22 1/20/2016

PANCE/PANRE Review Course

Diarrhea: PEARLS

• Precautions: – loperamide should be used with caution in patients suspected of having infectious diarrhea (especially if E. coli 0157:H7 suspected) or antibiotic- associated colitis. – Antiperistaltic agents may speed recovery from traveler's diarrhea when used in com binati on with an anti bi ooti c. – Doxycycline, TMP/SMX, and ciprofloxacin may cause photosensitivity; use sunscreen.

PANCE/PANRE Review Course

Phenylketonuria

• Rare, autosomal recessive • Unable to metabolize phenylalanine and convert it to tyrosine • Screen patients at birth • Diagnosis s/p age 3>brain damage • Complications if untreated – Developmental delay – Movement disorder • Management: low phenylalanine diet

PANCE/PANRE Review Course

Lactose intolerance

• Lactase-enzyme produced in small intestine to digest lactose • Clinical features, bloating, , diarrhea s/p ingestion of dairy products • Result: osmotic diarrhea •Management – Avoid milk/dairy products – Use OTC lactase enzyme tablets/drops

23 1/20/2016

PANCE/PANRE Review Course

Vitamin/Nutritional Deficiencies

Vitamin Function Deficiency Toxicity A Vision/antioxidant Night blindness Skin disorders Dry, scaly skin Hair loss Hip fractures

D Calcium and Rickett’s: Hypercalcemia phhhosphate children RlRenal stones regulation Osteomalacia: adults

E Cellular aging and Areflexia, gait *least toxic vascular integrity disturbances, Inhibits Vit K, so can result in loss of vibration bleeding, GI discomfort sense

K Clotting Bleeding Anemia/jaundice

PANCE/PANRE Review Course Vitamin/Nutritional Deficiencies

Vitamin Function Deficiency Toxicity Niacin Energy/fat metabolism Pellagra (3 D’s) flushing -diarrhea -dermatitis -dementia B1 (Thiamine) Carbohydrate Beriberi Lethargy, ataxia metabolism (Dry) w/neuropathy and poor coordination (Wet) w/cardiac dysfunction and Wernicke’s encephalopathy

B6 (Pyroxidine) Protein metabolism Dermatitis/cheilosis Photosensitivity/pheripheral neuropathy B12 Oxidation-reduction Cheilosis/glossitis N/A (Riboflavin) Anemia, leukopenia Folate DNA synthesis Megaloblastic anemia N/A Vitamin C Antioxidant/collagen Scurvy Renal stones, diarrhea (ascorbic acid) synthesis Fatigue, depression, poor wound healing

PROPERTIES On passing, 'Finish' button: Goes to Next Slide On failing, 'Finish' button: Goes to Next Slide Allow user to leave quiz: At any time User may view slides after quiz: At any time User may attempt quiz: Just Once

24 1/20/2016

PANCE/PANRE Review Course

Thank you and good luck!

PANCE/PANRE Review Course References • A Guide to and History Taking, 11th Ed., Barbara Bates. J.B. Lippincott Co. • Cecil Textbook of Medicine, (2012), Goldman and Ausiello. Saunders • Current Medical Diagnosis & Treatment 2015, McPhee and Papadakis. Lange, McGraw Hill • www.cdc.gov • http://commons.wikimedia.org/wiki/File%3AToxisches_Megacol on_bei _Colitis _ulcerosa .jpg • http://commons.wikimedia.org/wiki/File%3AAnal_fissure_1.jpg • http://commons.wikimedia.org/wiki/File%3APerinanalthrombose _01.jpg • http://commons.wikimedia.org/wiki/File%3ADiffuser_Oesophag usspasmus_002-13.jpg • http://commons.wikimedia.org/wiki/File%3AAcha.JPG • 5-minute Clinical Consult (2013) Lippincott Williams and Wilkins • Conn’s Current Therapy 2014 1st ed. (2013) Bope and Kellerman

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