Learning Objectives Diseases of Digestive System
Total Page：16
File Type：pdf, Size：1020Kb
Load more
Recommended publications
-
Evaluation of Abnormal Liver Chemistries
ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries Paul Y. Kwo, MD, FACG, FAASLD1, Stanley M. Cohen, MD, FACG, FAASLD2, and Joseph K. Lim, MD, FACG, FAASLD3 1Division of Gastroenterology/Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA; 2Digestive Health Institute, University Hospitals Cleveland Medical Center and Division of Gastroenterology and Liver Disease, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; 3Yale Viral Hepatitis Program, Yale University School of Medicine, New Haven, Connecticut, USA. Am J Gastroenterol 2017; 112:18–35; doi:10.1038/ajg.2016.517; published online 20 December 2016 Abstract Clinicians are required to assess abnormal liver chemistries on a daily basis. The most common liver chemistries ordered are serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase and bilirubin. These tests should be termed liver chemistries or liver tests. Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with alkaline phosphatase levels. Cholestatic injury is defined as disproportionate elevation of alkaline phosphatase level as compared with AST and ALT levels. The majority of bilirubin circulates as unconjugated bilirubin and an elevated conjugated bilirubin implies hepatocellular disease or cholestasis. Multiple studies have demonstrated that the presence of an elevated ALT has been associated with increased liver-related mortality. A true healthy normal ALT level ranges from 29 to 33 IU/l for males, 19 to 25 IU/l for females and levels above this should be assessed. The degree of elevation of ALT and or AST in the clinical setting helps guide the evaluation. -
Outcomes and Predictors of In-Hospital Mortality Among Cirrhotic
Turk J Gastroenterol 2014; 25: 707-713 Outcomes and predictors of in-hospital mortality among cirrhotic patients with non-variceal upper gastrointestinal bleeding in upper Egypt LIVER Khairy H Morsy1, Mohamed AA Ghaliony2, Hamdy S Mohammed3 1Department of Tropical Medicine and Gastroenterology, Sohag University Faculty of Medicine, Sohag, Egypt 2Department of Tropical Medicine and Gastroenterology, Assuit University Faculty of Medicine, Assuit, Egypt 3Department of Internal Medicine, Sohag University Faculty of Medicine, Sohag, Egypt ABSTRACT Background/Aims: Variceal bleeding is one of the most frequent causes of morbidity and mortality among cir- rhotic patients. Clinical endoscopic features and outcomes of cirrhotic patients with non-variceal upper gastroin- testinal bleeding (NVUGIB) have been rarely reported. Our aim is to identify treatment outcomes and predictors of in-hospital mortality among cirrhotic patients with non-variceal bleeding in Upper Egypt. Materials and Methods: A prospective study of 93 cirrhotic patients with NVUGIB who were admitted to the Original Article Tropical Medicine and Gastroenterology Department, Assiut University Hospital (Assiut, Egypt) over a one-year period (November 2011 to October 2012). Clinical features, endoscopic findings, clinical outcomes, and in-hospital mortality rates were studied. Patient mortality during hospital stay was reported. Many independent risk factors of mortality were evaluated by means of univariate and multiple logistic regression analyses. Results: Of 93 patients, 65.6% were male with a mean age of 53.3 years. The most frequent cause of bleeding was duodenal ulceration (26.9%). Endoscopic treatment was needed in 45.2% of patients, rebleeding occurred in 4.3%, and the in-hospital mortality was 14%. -
Abdominal Pain - Gastroesophageal Reflux Disease
ACS/ASE Medical Student Core Curriculum Abdominal Pain - Gastroesophageal Reflux Disease ABDOMINAL PAIN - GASTROESOPHAGEAL REFLUX DISEASE Epidemiology and Pathophysiology Gastroesophageal reflux disease (GERD) is one of the most commonly encountered benign foregut disorders. Approximately 20-40% of adults in the United States experience chronic GERD symptoms, and these rates are rising rapidly. GERD is the most common gastrointestinal-related disorder that is managed in outpatient primary care clinics. GERD is defined as a condition which develops when stomach contents reflux into the esophagus causing bothersome symptoms and/or complications. Mechanical failure of the antireflux mechanism is considered the cause of GERD. Mechanical failure can be secondary to functional defects of the lower esophageal sphincter or anatomic defects that result from a hiatal or paraesophageal hernia. These defects can include widening of the diaphragmatic hiatus, disturbance of the angle of His, loss of the gastroesophageal flap valve, displacement of lower esophageal sphincter into the chest, and/or failure of the phrenoesophageal membrane. Symptoms, however, can be accentuated by a variety of factors including dietary habits, eating behaviors, obesity, pregnancy, medications, delayed gastric emptying, altered esophageal mucosal resistance, and/or impaired esophageal clearance. Signs and Symptoms Typical GERD symptoms include heartburn, regurgitation, dysphagia, excessive eructation, and epigastric pain. Patients can also present with extra-esophageal symptoms including cough, hoarse voice, sore throat, and/or globus. GERD can present with a wide spectrum of disease severity ranging from mild, intermittent symptoms to severe, daily symptoms with associated esophageal and/or airway damage. For example, severe GERD can contribute to shortness of breath, worsening asthma, and/or recurrent aspiration pneumonia. -
Chapter 156: Upper Gastrointestinal Bleeding
8/23/2018 Principles and Practice of Hospital Medicine, 2e > Chapter 156: Upper Gastrointestinal Bleeding Stephen R. Rotman; John R. Saltzman INTRODUCTION Key Clinical Questions What is the timing and treatment of peptic ulcer disease? What are the factors in diagnosis and treatment of aortoenteric fistula? What treatments are available for each etiology of upper GI bleeding? What is the appropriate management and follow-up of variceal bleeding? How do you estimate the severity of bleeding so that you can triage appropriate patients to the ICU, medical floor, or observation unit? Which patients are more likely to rebleed and hence require continued observation in the hospital aer their bleeding has apparently stopped, and for how long? Upper gastrointestinal (GI) bleeding is responsible for over 300,000 hospitalizations per year in the United States. An additional 100,000 to 150,000 patients develop upper GI bleeding during hospitalizations. The annual cost of treating nonvariceal acute upper GI bleeding in the United States exceeds $7 billion. Upper GI bleeding is defined as a bleeding source in the GI tract proximal to the ligament of Treitz. The presentation varies depending on the nature and severity of bleeding and includes hematemesis, melena, hematochezia (in rapid upper GI bleeding), and anemia with heme-positive stools. Bleeding can be associated with changes in vital signs, including tachycardia and hypotension including orthostatic hypotension. Given the range of presentations, pinpointing the nature and severity of GI bleeding may be a challenging task. The natural history of nonvariceal upper GI bleeding is that 80% of patients will stop bleeding spontaneously and no further urgent intervention will be needed. -
Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations
Open Access Original Article DOI: 10.7759/cureus.14353 Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations Takumi Notsu 1 , Kyoichi Adachi 1 , Tomoko Mishiro 1 , Kanako Kishi 1 , Norihisa Ishimura 2 , Shunji Ishihara 3 1. Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN 2. Second Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, JPN 3. Gastroenterology, Shimane University Hospital, Izumo, JPN Corresponding author: Kyoichi Adachi, [email protected] Abstract Background This study was performed to examine the prevalence of asymptomatic angiodysplasia detected in upper gastrointestinal endoscopic examinations and of hereditary hemorrhagic telangiectasia (HHT) suspected cases. Methodology The study participants were 5,034 individuals (3,206 males, 1,828 females; mean age 53.5 ± 9.8 years) who underwent an upper gastrointestinal endoscopic examination as part of a medical check-up. The presence of angiodysplasia was examined endoscopically from the pharynx to duodenal second portion. HHT suspected cases were diagnosed based on the presence of both upper gastrointestinal angiodysplasia and recurrent nasal bleeding episodes occurring in the subject as well as a first-degree relative. Results Angiodysplasia was endoscopically detected in 494 (9.8%) of the 5,061 subjects. Those with angiodysplasia lesions in the pharynx, larynx, esophagus, stomach, and duodenum numbered 44, 4, 155, 322, and 12, respectively. None had symptoms of upper gastrointestinal bleeding or severe anemia. Subjects with angiodysplasia showed significant male predominance and were significantly older than those without. A total of 11 (0.2%) were diagnosed as HHT suspected cases by the presence of upper gastrointestinal angiodysplasia and recurrent epistaxis episodes from childhood in the subject as well as a first-degree relative. -
Eosinophilic Gastroenteritis Presenting with Severe Anemia and Near Syncope
J Am Board Fam Med: first published as 10.3122/jabfm.2012.06.110269 on 7 November 2012. Downloaded from BRIEF REPORT Eosinophilic Gastroenteritis Presenting with Severe Anemia and Near Syncope Nneka Ekunno, DO, MPH, Kirk Munsayac, DO, Allen Pelletier, MD, and Thad Wilkins, MD Eosinophilic gastrointestinal disorders or eosinophilic digestive disorders encompass a spectrum of rare gastrointestinal disorders that includes eosinophilic esophagitis, eosinophilic gastroenteritis, and eosinophilic colitis. Eosinophilic gastroenteritis is a rare inflammatory disease characterized by eosino- philic infiltration of the gastrointestinal tract. The clinical manifestations include anemia, dyspepsia, and diarrhea. Endoscopy with biopsy showing histologic evidence of eosinophilic infiltration is consid- ered definitive for diagnosis. Corticosteroid therapy, food allergen testing, elimination diets, and ele- mental diets are considered effective treatments for eosinophilic gastroenteritis. The treatment and prognosis of eosinophilic gastroenteritis is determined by the severity of the clinical manifestations. We describe a 24-year-old woman with eosinophilic gastroenteritis presenting as epigastric pain with a history of severe iron deficiency anemia, asthma, eczema, and allergic rhinitis, and we review the litera- ture regarding presentation, diagnostic testing, pathophysiology, predisposing factors, and treatment recommendations. (J Am Board Fam Med 2012;25:913–918.) Keywords: Case Reports, Eosinophilic Gastroenteritis, Gastrointestinal Disorders copyright. A 24-year-old nulliparous African-American woman During examination, her height was 62 inches, was admitted after an episode of near syncope asso- weight 117 lb, and body mass index 21.44 kg/m2. Her ciated with 2 days of fatigue and dizziness. She re- heart rate was 111 beats per minute, blood pressure ported gradual onset of dyspepsia over 2 to 3 121/57 mm Hg, respiratory rate 20 breaths per minute, months. -
Gastroesophageal Reflux Disease (GERD)
Guidelines for Clinical Care Quality Department Ambulatory GERD Gastroesophageal Reflux Disease (GERD) Guideline Team Team Leader Patient population: Adults Joel J Heidelbaugh, MD Objective: To implement a cost-effective and evidence-based strategy for the diagnosis and Family Medicine treatment of gastroesophageal reflux disease (GERD). Team Members Key Points: R Van Harrison, PhD Diagnosis Learning Health Sciences Mark A McQuillan, MD History. If classic symptoms of heartburn and acid regurgitation dominate a patient’s history, then General Medicine they can help establish the diagnosis of GERD with sufficiently high specificity, although sensitivity Timothy T Nostrant, MD remains low compared to 24-hour pH monitoring. The presence of atypical symptoms (Table 1), Gastroenterology although common, cannot sufficiently support the clinical diagnosis of GERD [B*]. Testing. No gold standard exists for the diagnosis of GERD [A*]. Although 24-hour pH monitoring Initial Release is accepted as the standard with a sensitivity of 85% and specificity of 95%, false positives and false March 2002 negatives still exist [II B*]. Endoscopy lacks sensitivity in determining pathologic reflux but can Most Recent Major Update identify complications (eg, strictures, erosive esophagitis, Barrett’s esophagus) [I A]. Barium May 2012 radiography has limited usefulness in the diagnosis of GERD and is not recommended [III B*]. Content Reviewed Therapeutic trial. An empiric trial of anti-secretory therapy can identify patients with GERD who March 2018 lack alarm or warning symptoms (Table 2) [I A*] and may be helpful in the evaluation of those with atypical manifestations of GERD, specifically non-cardiac chest pain [II B*]. Treatment Ambulatory Clinical Lifestyle modifications. -
Gastroesophageal Reflux Disease
The new england journal of medicine clinical practice Gastroesophageal Reflux Disease Peter J. Kahrilas, M.D. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastroin- testinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment? The Clinical Problem From the Division of Gastroenterology, Gastroesophageal reflux disease is the most common gastrointestinal diagnosis re- Feinberg School of Medicine, Chicago. Ad- corded during visits to outpatient clinics.1 In the United States, it is estimated that dress reprint requests to Dr. Kahrilas at the Feinberg School of Medicine, 676 St. Clair 14 to 20% of adults are affected, although such percentages are at best approxima- St., Suite 1400, Chicago, IL 60611-2951, tions, given that the disease has a nebulous definition and that such estimates are or at [email protected]. based on the prevalence of self-reported chronic heartburn.2 A current definition of N Engl J Med 2008;359:1700-7. the disorder is “a condition which develops when the ref lux of stomach contents causes Copyright © 2008 Massachusetts Medical Society. troublesome symptoms (i.e., at least two heartburn episodes per week) and/or complications.”3 Several extraesophageal manifestations of the disease are well rec- ognized, including laryngitis and cough (Table 1). -
Obscure Gastrointestinal Bleeding in Cirrhosis: Work-Up and Management
Current Hepatology Reports (2019) 18:81–86 https://doi.org/10.1007/s11901-019-00452-6 MANAGEMENT OF CIRRHOTIC PATIENT (A CARDENAS AND P TANDON, SECTION EDITORS) Obscure Gastrointestinal Bleeding in Cirrhosis: Work-up and Management Sergio Zepeda-Gómez1 & Brendan Halloran1 Published online: 12 February 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose of Review Obscure gastrointestinal bleeding (OGIB) in patients with cirrhosis can be a diagnostic and therapeutic challenge. Recent advances in the approach and management of this group of patients can help to identify the source of bleeding. While the work-up of patients with cirrhosis and OGIB is the same as with patients without cirrhosis, clinicians must be aware that there are conditions exclusive for patients with portal hypertension that can potentially cause OGIB. Recent Findings New endoscopic and imaging techniques are capable to identify sources of OGIB. Balloon-assisted enteroscopy (BAE) allows direct examination of the small-bowel mucosa and deliver specific endoscopic therapy. Conditions such as ectopic varices and portal hypertensive enteropathy are better characterized with the improvement in visualization by these techniques. New algorithms in the approach and management of these patients have been proposed. Summary There are new strategies for the approach and management of patients with cirrhosis and OGIB due to new develop- ments in endoscopic techniques for direct visualization of the small bowel along with the capability of endoscopic treatment for different types of lesions. Patients with cirrhosis may present with OGIB secondary to conditions associated with portal hypertension. Keywords Obscure gastrointestinal bleeding . Cirrhosis . Portal hypertension . -
Abnormal Liver Enzymes
Jose Melendez-Rosado , MD Ali Alsaad , MBChB Fernando F. Stancampiano , MD William C. Palmer , MD 1.5 ANCC Contact Hours Abnormal Liver Enzymes ABSTRACT Abnormal liver enzymes are frequently encountered in primary care offi ces and hospitals and may be caused by a wide variety of conditions, from mild and nonspecifi c to well-defi ned and life-threatening. Terms such as “abnormal liver chemistries” or “abnormal liver enzymes,” also referred to as transaminitis, should be reserved to describe infl am- matory processes characterized by elevated alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase. Although interchangeably used with abnormal liver enzymes, abnormal liver function tests specifi cally denote a loss of synthetic functions usually evaluated by serum albumin and prothrombin time. We discuss the entities that most commonly cause abnormal liver enzymes, specifi c patterns of enzyme abnormalities, diagnostic modalities, and the clinical scenarios that warrant referral to a hepatologist. he liver is the largest solid organ in the human elevated liver function tests (LFTs), they would more body, as well as one of the most versatile. It accurately describe as liver inflammation tests. LFTs manufactures cholesterol, contributes to hor- should instead refer to serum assessments of hepatic mone production, stores glucose in the form synthetic function, such as albumin and prothrombin Tof glycogen, processes drugs prior to systemic exposure, time. Disease categories, such as viral inflammation and and aids in the digestion of food and production of injury from alcohol use, may be differentiated by fol- proteins. However, the liver is also vulnerable to injury, lowing patterns and trends of enzyme elevations. -
Ischaemic Colitis: Practical Challenges and Evidence-Based Recommendations For
Ischaemic Colitis: Practical Challenges and Evidence-Based Recommendations for Management Alexander Hung1*, Tom Calderbank1*, Mark A Samaan1, Andrew A Plumb2, George Webster1 Author affiliations 1Department of Gastroenterology, University College London Hospitals, London, UK 2Department of Radiology, University College London Hospitals, London, UK *Authors contributed equally Correspondence to Mark A Samaan Department of Gastroenterology University College London Hospitals 250 Euston Road London NW1 2PG [email protected] Running title Ischaemic Colitis Management Word count 3212 Key Words Ischaemic colitis, colonic ischaemia ABSTRACT Ischaemic colitis (IC) is a common condition with rising incidence and, in severe cases, a high mortality rate. Its presentation, severity and disease behaviour can vary widely and there exists significant heterogeneity in treatment strategies and resultant outcomes. In this article we explore practical challenges in the management of IC and where available, make evidence-based recommendations for its management based on a comprehensive review of available literature. An optimal approach to initial management requires early recognition of the diagnosis followed by prompt and appropriate investigation. Ideally, this should involve the input of both gastroenterology and surgery. CT with intravenous and oral contrast is the imaging modality of choice. It can support a clinical diagnosis, define the severity and distribution of ischaemia and has prognostic value. In all but fulminant cases, this should be followed (within 48 hours) by lower GI endoscopy to reach the distal-most extent of the disease, providing endoscopic (and histological) confirmation. The mainstay of medical management is conservative/supportive treatment, with bowel rest, fluid resuscitation and antibiotics. Specific laboratory, radiological and endoscopic features are recognised to correlate with more severe disease, higher rates of surgical intervention and ultimately worse outcomes. -
Angiodysplasia of Colon Or GI Tract
Angiodysplasia of Colon or GI Tract Background Phillips first described a vascular (blood vessel) abnormality that caused bleeding from the large bowel in a letter to the London Medical Gazette in 1839. During the 1920s, cancers were considered the major source of GI bleeding/hemorrhage. However, in the 1940s and 1950s, diverticular disease was recognized as an important source of bleeding. In 1951, Smith described active bleeding from a diverticulum visualized through a sigmoidoscope. Galdabini first used the name angiodysplasia in 1974; however, confusion about the exact nature of these lesions resulted in a multitude of terms that included AVM = arteriovenous malformation, hemangioma, telangiectasia, and vascular ectasia. These terms have varying pathophysiologies, with a common presentation of GI bleeding and may be used interchangeably by many physicians. Angiodysplasia is a degenerative lesion of previously healthy blood vessels found most commonly in the right-side of colon. 77% of angiodysplasias are located in the cecum and ascending colon, 15% are located in the jejunum and ileum (small intestine), and the remainder are distributed throughout the GI tract. These lesions typically are nonpalpable and small (<5 mm). Angiodysplasia is the most common vascular abnormality of the GI tract. After diverticulosis, it is the second leading cause of lower GI bleeding in patients older than 60 years. Angiodysplasia may account for approximately 6% of cases of lower GI bleeding. It may be observed incidentally at colonoscopy in as many as 0.8% of patients older than 50 years. The prevalence for upper GI lesions is approximately 1-2%. Small bowel angiodysplasia may account for 30-40% of cases of GI bleeding of obscure origin.