UCSF FM Board Review: High Yield GI for the Generalist

Jack Chase, MD FAAFP FHM Director of Operations, Family Medicine Inpatient Service San Francisco General Hospital Assistant Professor, UCSF Dept of Family and Community Medicine

Department of Family & Community Medicine Conflict Statement • None

Department of Family & Community Medicine Goals & Objectives

• Cases reflect common presentations

• Slides emphasize: • Basic GI epidemiology • Evidence-based approaches • Strength of Recommendation Taxonomy (SORT)

• We will cover highest yield topics in didactic, there are bonus sections at the end of the notes

Department of Family & Community Medicine Didactic Topics

• and H. pylori • Dyspepsia • Disease • • Inflammatory Bowel Disease • Colorectal Cancer Screening

Department of Family & Community Medicine 67 year old man presents to the office with dizziness and 2 days of black stool. He regularly takes ibuprofen for knee pain.

PE: 105/60, P110 Pale adult man, fatigued Epigastric TTP, diminished distal pulses From www.gastrohep.com

Department of Family & Community Medicine Which of the following are the most common causes of upper GI bleeding?

A. NSAIDs and Dieulafoy’s lesion 72% B. Esophageal varices and H. pylori C. Foreign body ingestion and gastric cancer 15% D. H. pylori and NSAIDs 11% 3% 0% E. None of the above

Department of Family & Community Medicine PEPTIC ULCER DISEASE Ramakrishnan and Salinas, AFP (2007); Wilkins et al, AFP (2012); Fashner and Gitu, AFP (2015); Consistent with Int’l consensus on management of non-variceal UGIB (2010)

Upper GI bleeding: • 400K admit/yr, inpatient mortality 13% • Risks: NSAIDS (OR 4.8); H. pylori (OR 1.7)

Peptic Ulcer Disease = 70% of UGIB: • Diagnosis: clinical & endoscopic – = most common presentation in elderly – EGD: risk assessment and endoscopic tx • Immediate: for all clinically unstable patients • If age > 55, alarm sx, Tx-refractory (LOE A) • EGD < 24 hrs for all UGIB (LOE C)

Department of Family & Community Medicine The patient’s EGD shows a gastric ulcer with adherent clot. His hemoglobin is 8.2 mg/dL. Which of the following is indicated:

A. Admission for 72 hours 59% B. Test and treat H. pylori C. PPI therapy

D. Endoscopic of the ulcer 16% 14% 9% E. All of the above 3%

Department of Family & Community Medicine PEPTIC ULCER DISEASE

Treatment: • PPI & H. pylori eradication (LOE A) • Endoscopic therapy for high risk lesions • Hospitalization x 72 hours in high risk patient (LOE C) • Transfuse Hgb < 7mg/dl (LOE C) • 2nd look EGD in high risk pts (LOE C)

EGD with thermocoagulation of ulcer (middle image), From Wilkins et al, AFP (2012)

Department of Family & Community Medicine Helicobacter pylori AFP: Ramakrishnan and Salinas (2007); Fashner and Gitu (2015); ACG Guideline on the Management of H. pylori Infection (2007); Toronto Consensus for Treatment of H. pylori in Adults (2016) • Colonizes gut in ½ world population, 30-40% in US

• Found in 95% duodenal ulcers, 70% gastric ulcers. Contributes to risk of gastric adenocarcinoma (RR 3- 6x) and MALT lymphoma

• Test and treat strategy validated (LOE A)

• Eradication improves PUD healing and decreases recurrence (LOE A)

Department of Family & Community Medicine The recommended duration of for H. pylori treatment with PPI/metronidazole/amoxicillin/clarithromycin is:

A. 72 hours 91% B. 7 days C. 14 days D. 28 days E. Lifelong therapy 7% 0% 1% 1%

Department of Family & Community Medicine H. Pylori –Test and Treat Diagnosis: • Non-Endoscopic (sens/spec): – Serum IgG : good test for exposure not for eradication – Urea Breath Test (97/100) – Fecal EIA (92/94) • useful for confirmation to 4 weeks post-tx, avoid PPI x 2 weeks • Endoscopic: – Urease test (95/100) > histology (94/99) > culture (--/100)

Treatment update 2016: • 14 days for all patients (due to evidence on treatment failure): – PPI, Clarithromycin, Amoxicillin, Metronidazole – Bismuth, PPI, metronidzole, tetracycline – No role for probiotics

Department of Family & Community Medicine An 82 year old woman at PCP visit reports 4 months of early satiety, intermittent vomiting and chronic 4/10 mid- abdominal pain. +10 lbs weight loss over 3 months despite trying to “bulk up”.

PE: P95, 100/50, BMI19, From www.gastrohep.com epigastric tenderness, no palpable mass

Department of Family & Community Medicine The approximate risk of cancer among all patients presenting with dyspepsia:

A. 2% 65% B. 15% C. 25% D. 75% 21% 14%

0%

Department of Family & Community Medicine Dyspepsia AGA Dyspepsia Guideline (2008); Loyd and Mcclellan, AFP (2011)

Dyspepsia: postprandial fullness, early satiation, epigastric pain or burning.

DIFFERENTIAL DIAGNOSIS OF DYSPEPSIA PREVALENCE (based on EGD of pts w/ Sx) Functional (nonulcer) dyspepsia Up to 70 percent Peptic ulcer disease 15 to 25 percent Reflux 5 to 15 percent Gastric or esophageal cancer < 2 percent Abdominal cancer, especially pancreas, hepatoma Rare

Biliary disease, CHO , , Infiltrative Rare diseases, IBD, ischemic bowel, systemic disorders, metabolic disturbances, parasitic infection, Rx effect Adapted From Loyd and Mcclellan, AFP (2011)

Department of Family & Community Medicine Which of the following is NOT an indication for immediate endoscopy in dyspepsia:

A. Odynophagia 77% B. Age > 55 C. Melena

D. Palpable mass on exam 14% 7% E. Fever 0% 1%

Department of Family & Community Medicine Dyspepsia

Alarm Symptoms -> No Alarm Symptoms: Direct to EGD: (LOE C) • Test and treat for H.pylori • Age > 55 years (LOE A) • Dysphagia • Odynophagia • PPI > H2RA – mild • Protracted vomiting improvement in dyspepsia (LOE A) • Anorexia/weight loss

• Melena or anemia • Palpable mass • Jaundice

Department of Family & Community Medicine ED calls you re: 38 year old woman with N/V and 10/10 abdominal pain radiating to the back. She is 6 weeks postpartum. She had recurrent postprandial RUQ pain during pregnancy.

PE: 110/50, P125 Ill appearing, uncomfortable From www.gastrohep.com Epigastric TTP, voluntary guarding, hypoactive BS

Labs: Lipase 6712

Department of Family & Community Medicine The optimal timing for this patient’s cholecystectomy is:

A. During the current 66% hospitalization once clinically stable B. “Interval”surgery after delay of 30% 6-8 weeks 4% C. After she finishes breastfeeding 0% D. No surgery, employ watchful waiting

Department of Family & Community Medicine Bellows, Berger and Crass, AFP (2005); Abraham et al., AFP (2014)

• 12% in US w/ GS disease (risks: family history, female, age, racial background, , minimal physical activity, pregnancy and multiparity, rapid weight loss.)

Diagnosis: • Ultrasound (sens >95/spec >98) preferred imaging test (HIDA scan prn) (LOE C)

Treatment: • Asymptomatic GS: watchful waiting (LOE B)

• Laparoscopic cholecystectomy – LOE A: Most cost effective tx for symptomatic ; early surgery decreases LOS in acute ; Lap cholecystectomy indicated during index hospitalization for gallstone – LOE B: Lap chole on first open operative day in biliary pain – LOE C: when indicated, it is safe to perform in any pregnancy trimester

Department of Family & Community Medicine In choledocholithiasis: ERCP for CBD stone; Surgical management if proximal

Department of Family & Community Medicine 27 year old woman presents to urgent care with myalgia, N/V, yellow eyes and fever for 4 days. She recently returned from traveling in Southeast Asia. She did not receive medical evaluation before.

PE: 110/50, P110 From www.medicinenet.com Mild ill appearing, NAD, scleral icterus, RUQ TTP, normal BS

Department of Family & Community Medicine HEPATITIS ACUTE CHRONIC

• Viral: HAV/HBV > • Viral: HBV & HCV HCV, EBV, CMV, HIV, • Alcohol HSV • Congestive (eg. RHF) • Alcohol • Auto-immune • Shock • Medications, herbs • Toxic (APAP, Amanita • Storage diseases mushroom, other Rx) • α1-AT deficiency

Department of Family & Community Medicine Your patient ate at many roadside stands on her trip and drank water from non-purified sources. You are concerned about her risk of Hepatitis A. What is the incubation period for HAV?

A. a) 2-6 hours 66% B. b) 2-6 days C. c) 2-6 weeks 33% D. d) 2-6 months

1% 0%

Department of Family & Community Medicine HEPATITIS A

• Fecal/oral transmission

• Incubation: 2-6 weeks

• Duration: 2 wks to 3 mos – Children - often mild, usually anicteric – Adults - often symptomatic with jaundice

• 99% fully recover with lifetime immunity – Fulminant hepatitis rare; no chronic sequelae

Department of Family & Community Medicine HEPATITIS A SEROLOGY

ALT IgG anti-HAV

HAV

IgM anti-HAV

0 1 2 3 4 5 6 // 12 14

Months after exposure

Department of Family & Community Medicine HEPATITIS A Matheny and Kingery, AFP (2102)

Vaccinate! – Universal for infants (LOE C) – Pre-exposure travel prophylaxis (LOE C) – High risk individuals (HBV/HCV infected, , immunocompromise) (LOE C)

Treatment: – Supportive: hydration, antipyretics, nutrition – minimize transmission risk (eg. hand washing)

Department of Family & Community Medicine HEPATITIS B

• 350 million persons worldwide with chronic HBV – 1 million deaths/yr due to complications (ESLD, HCC)

• 1.25 mil in US = chronically infected (decreasing incidence)

• Transmission: IVDU, sexual contact, vertical transmission, transfusion (highest risk prior to 1971), needle stick/splash

• Incubation period 60 - 150 days

Department of Family & Community Medicine Your patient is an inquisitive 1st year medical student on her GI pathology didactic block. She asks you which of the following describes risk of chronic infection in adults?

A. HBV > HCV > HAV 70% B. HCV > HBV > HAV C. HCV > HAV > HBV 29% D. HAV > HBV > HCV

0% 1%

Department of Family & Community Medicine HBV – Disease Course

• 95% of adults: self-limited disease – 30-50% > 5 yo have clinical illness • viral prodrome, jaundice

• Chronic HBV risk decreases with age at infection – 90% infants, 25-50% 1-5 yo, 5% adults – Chronic Hep B = (+) HBsAg > 6 months

• Rarely fulminant, case-fatality ~1%

Department of Family & Community Medicine Hepatitis B Prevalence

From www.cdc.gov

Department of Family & Community Medicine Your patient shared injection needles on her trip 2 months ago with her partner, who has chronic active HBV. Which of the following tests are likely to be

positive today in the office: 35%

A. Hep B surface antigen 24% 25% B. Hep B surface antibody 9% C. Hep B core antibody (IgM and total) 7% D. A & C E. A & B

Department of Family & Community Medicine ACUTE HEPATITS B SEROLOGY

ALT Anti-HBc (total)

Anti-HBc IgM

HBs Ag Anti-HBs

0 1 2 3 4 5 6 /// 12 24 Months after exposure

Department of Family & Community Medicine HBV Serology HBsAg HBcAb* HBsAb Not Infected, not vaccinated - - - Vaccine - - + Resolved HBV Infxn (immune) - + + Acute or chronic HBV* + + - Resolved HBV infection - + - False positive anti-HBcAb Low level/occult infection Resolving acute infection Passive vertical transmission HBcAb

*Anti HBcAb measured by IgM and total

Department of Family & Community Medicine You are called to care for the newborn infant of your HBV + patient in the hospital. The nurse asks which of the following you want to administer:

A. Hepatitis B vaccine 86% B. Hepatitis B immune globulin (HBIG) C. Interferon alfa D. A & C E. A & B 4% 5% 3% 3%

Department of Family & Community Medicine HBV Prevention Wilkins, Zimmerman, Schade, AFP (2010)

• Screen high risk patients (eg. pregnant women and if endemic in county of origin) (LOE C)

• Vaccinate! – all infants, health care workers (LOE A), HCV infected

• Give HBV vaccine and Hep B immune globulin (HBIg) to infants of infected mothers at birth (LOE A) – Decreases vertical transmission by 90%

Department of Family & Community Medicine HBV Prevention and Treatment Wilkins, Zimmerman, Schade, AFP 2010 Chronic HBV infection: – Evaluate all pts who meet treatment criteria (LOE C) • Interferon, antiviral NRTI’s (Lamivudine, Epivir, Adefovir, Telbivudine, Tenofovir)

– Give HAV vaccine to all pts w/ chronic HBV (LOE C)

– Avoid hepatotoxins, prevent transmission, evaluate and treat complications (HCC, ESLD)

– HCC can occur at any point in chronic HBV, including prior to development of cirrhosis

Department of Family & Community Medicine

• ~3-4 million persons in US; 185 mil worldwide – Majority are unidentified and untreated

• Transmission: IVDU (60% acute infections), blood transfusion > organ transplant before July 1992, unregulated tattoos, hemodialysis, rare sexual transmission

• Incubation period: 2 - 22 weeks

Department of Family & Community Medicine Course of Disease in HCV

• Acute – Majority asymptomatic – 1/3 with jaundice (very rare fulminant disease)

• Chronic – 80% HCV-infected develop chronic hepatitis – 20% will develop cirrhosis, ESLD and/or HCC

Department of Family & Community Medicine A 51 year old man new to your practice has chronic active hepatitis C. He is healthy otherwise. Prior to considering treatment, you would like to order: 46% 46% A. Quantitative HCV RNA (“viral load”) B. biopsy (or alternative fibrosis assessment) C. HCV genotype 4% 3% 1% D. A & C E. A, B & C

Department of Family & Community Medicine Hepatitis C Testing Wilkins et al. AFP (2015); AASLD/IDSA Guideline (2016)

• Screening test = Anti-HCV antibody test (Sens 95%/Spec 99%)

• No screening for low risk individuals (LOE A)

• Single universal screening if born 1945–1965 (LOE B)

• Annual screening if high risk (eg. ongoing IVDU, HIV+ MSM) (Class II, level A)

• Quantitative HCV RNA test (viral load) should be used to confirm positive screening test (Class I, level A)

• Before treatment: quantitative RNA, HCV genotype and advanced imaging or biopsy for fibrosis (LOE A)

Department of Family & Community Medicine Treatment of Hepatitis C Wilkins et al. AFP (2015); AASLD/IDSA (2016)

• Treatment recommended for all chronically HCV-infected patients unless short life expectancy. (LOE A) • Direct acting antiviral agents are treatment of choice, selection based on genotype, resistance patterns, presence of cirrhosis

• Post-exposure prophylaxis is not recommended for acute HCV (LOE C)

• Vaccinate HCV+ patients against HAV/HBV (LOE C)

• Patients with chronic HCV infection should be assessed for degree of liver fibrosis and cirrhosis (LOE C)

• Assess all HCV infected patients for alcohol use and advise abstinence from alcohol (LOE B)

Department of Family & Community Medicine 38 year old man presents to PCP with intermittent RLQ AP and bloody BM, weight loss and intermittent joint pain.

PE: 118/70, P93 Thin adult man, NAD, RLQ TTP, hyperactive BS, R Achilles tendon From www.medscape.com erythema/edema

Department of Family & Community Medicine That inquisitive medical student with HBV was so appreciative of your care that she is now rotating in your office. She asks you what region of the world has the highest prevalence of IBD:

84% A. Southeast Asia B. US and Western Europe C. Latin America

D. Pacific Rim 11% 2% 2%

Department of Family & Community Medicine Inflammatory Bowel Disease Wilkins, Jarvis and Patel, AFP (2011); Adams and Bornemann, AFP (2013)

• Chronic, relapsing inflammatory disorder of the GI tract

• Most common in United States and Western Europe – Industrialized countries, higher latitudes – US Prevalence ~1.3 million – Familial Pattern – Bimodal age distribution

• Gender distribution: From www.radiology.vcu.edu – Crohn’s – slight female predominance – UC – similar between men & women

Department of Family & Community Medicine Inflammatory Bowel Disease

Crohn’s Disease • Transmural , often discontinuous • Involvement from mouth to anus

Ulcerative • Primarily involves mucosal and submucosal layers of colon & • Antecedent Salmonella or Campylobacter infection (RR 8-10x in 1 year)

Extraintestinal Manifestations • Dermatologic (erythema nodosum, pyoderma gangrenosum) • Hepatic (primary sclerosing cholangitis, ) • Opthalmic (scleritis, uveitis) • Rheumatologic (peripheral migratory arthropathy, ankylosing spondylitis)

Department of Family & Community Medicine Your patient is found to have multiple areas of involvement in the terminal and colon with transmural inflammation on biopsy. Which is the most likely diagnosis? 84% A. B. C. D. Crohn’s disease 13% 1% 1%

Department of Family & Community Medicine Crohn’s Disease AGA Guideline (2014), Wilkins, Jarvis and Patel, AFP (2011);

Diagnosis: • Symptoms/signs: fever, abd pain, arthralgia, weight loss, GI bleeding, skin findings • Serum: CBC, CRP, ESR, CMP, fecal calprotectin • Colonoscopy with biopsy; EGD for upper GI symptoms (LOE C) • CT or MRI enterography

Treatment: • Choice of agent depends on risk assessment – Agents include corticosteroids, thiopurines (azathioprine, 6-MP), anti-TNF-α agents, methotrexate

• Two phases of treatment: induction of remission, maintenance of remission

Department of Family & Community Medicine Ulcerative Colitis AGA Guideline (2015); Adams and Bornemann, AFP (2013); Kornbluth et al. ACG Guideline 2010 Diagnosis: • Symptoms/signs: fever, abd pain, urgency, tenesmus, focal tenderness, arthralgia/arthritis, weight loss, GI bleeding, skin findings • Serum: CBC, CRP, ESR, CMP, C difficile assay and stool culture • Flex sigmoidoscopy or colonoscopy with biopsy

Treatment: • Depends on risk for colectomy • Two phases of treatment: induction of remission & maintenance • Agents include (from low risk to high risk) 5-Aminosalicylic acid, corticosteroids, thiopurines, vedolizumab (WBC migration inhibitor), anti-TNF- α agents, cyclosporine • Proctocolectomy for medical treatment failure

Cancer Surveillance: • accelerated and interval based on involved segment of bowel

Department of Family & Community Medicine 61 year old woman, establishing care with new primary care provider, requests information about colon cancer screening.

Department of Family & Community Medicine Colorectal Cancer Screening ACP Best Practice Guideline 2012; AAFP Surveillance Guidelines; American Cancer Society; Short et al. AFP (2015) - Third most common cancer in men and women

- Average risk adults start at 50 (LOE A)

- High risk groups: AGA recommends referral to specialist for screening (starts earlier and interval may be more frequent) - Personal history of CRC - Personal history of adenoma - Personal history of Ulcerative Colitis or Crohn’s Colitis - 1st degree relative with colorectal cancer - Genetic syndromes: HNPCC/Lynch, Familal Adenomatous Polyposis

- After age 75, individualize screening based on risk, benefit and comorbidities/life expectancy

Department of Family & Community Medicine Which of the following test frequency for initial colorectal cancer screening is correct?

A. Fecal Immunochemical Test: q2 years 92% B. CT Colonography: q3 years C. Flexible sigmoidoscopy: q10 years D. Colonoscopy: q10 years 3% 0% 5%

Department of Family & Community Medicine Colorectal Cancer Screening ACP Best Practice Guideline 2012; AAFP Surveillance Guidelines; American Cancer Society; Short et al. AFP (2015)

- Screening options (* if positive, f/u with colonoscopy): - FOBT qYr* - CT colonography q5 yrs* - FIT qYr* - Flexible sigmoidoscopy q5 yrs* - Fecal DNA q3 yrs* - Colonscopy q10 yrs

- Subsequent testing if + screening depend on colonoscopy results

- Do not repeat colonoscopy on average risk patients with normal findings > q10 yr (LOE C)

- Consider GI specialty consultation and accelerated screening for high risk patients

Department of Family & Community Medicine References • AAFP • AASLD • ACP • American Cancer Society • American College of • American Gastroenterological Association • Cochrane Reviews • New England Journal of Medicine • US Preventive Services Taskforce

With acknowledgement and appreciation to Brian Desmond MD for use of original slide set

Department of Family & Community Medicine Thank you!

Department of Family & Community Medicine BONUS MATERIAL

• GERD • Barrett • Cirrhosis and Hepatocellular Cancer • • Pancreatic Cancer • • NAFLD / Fatty

Department of Family & Community Medicine A 43 year old man presents with intermittent epigastric burning of six months duration.

ROS (-) wt loss, stool changes, early satiety, dysphagia or vomiting.

PE: normal VS, BMI 34, From effectivehealthcare.ahrq.gov benign abdominal exam

Department of Family & Community Medicine Diagnosis of this condition requires the following studies?

a) History and physical exam b) Barium swallow c) Upper endoscopy d) CT abdomen & pelvis

Department of Family & Community Medicine GERD Delaney & Moayyedi, AFP (2009); Seehusen & Escano, AFP (2012) based on AHRQ and BMJ clinical evidence reviews

• In US: 26 million with daily symptoms; 35% lifetime prevalence

• Diagnosis: based on symptoms and tx response – Testing not generally indicated.

• Poor correlation between EGD findings and symptoms – 25 - 40% with positive endoscopy

• Endoscopy indications: alarm symptoms, known Barrett’s esophagus, treatment failures (LOE C).

Department of Family & Community Medicine Which treatment has the strongest evidence for initial management of this condition?

a) Elevate HOB at night; no mint, chocolate, spicy or acidic foods b) Famotidine c) Pantoprazole d) Nissen fundoplication

Department of Family & Community Medicine GERD TREATMENT

Medication: • PPI’s > H2B > antacids/placebo (LOE A) – Use lowest effective strength for shortest duration – PPI AE’s: Increased enteric infection including C.difficile, community acquired pneumonia, interstitial nephritis and osteoporotic fractures

Surgery: • Laparoscopic Nissen fundoplication is preferred option (mixed evidence) – Good efficacy but higher complication rate vs medication – Indications: failed med tx, Barrett’s, esophagitis, stricture, pulmonary sequela

Behavioral Modification (weak/mixed evidence): • Eat 2 hrs before bed, elevate HOB, weight loss • Avoid chocolate, coffee, peppermint (lower LES tone) & acidic foods

Department of Family & Community Medicine Your patient with GERD undergoes endoscopy at an outside hospital, which shows Barrett’s metaplasia without high risk lesions. What is the next step in management?

a) PPI b) Test and treat H. pylori c) Esophagectomy d) A & B

Department of Family & Community Medicine Barrett Esophagus Zimmerman, AFP (2014); AGA position paper (2011) consistent with ACP/ACG/AGA joint guidelines

• Risks: male, caucasian/hispanic, > 50 yo, GERD , smoking, hiatal , obesity

• 0.12% - 0.33 % BE pts/yr develop cancer

Diagnosis: – EGD if alarm signs (see dyspepsia) and/or risk factors. – Routine screening not recommended in uncomplicated GERD (LOE C)

Treatment: – PPI’s for acid suppression; test & treat H.pylori (LOE A) • PPI’s reduce dysplasia, but not proven to prevent cancer – Low risk lesions: serial EGD (LOE C) – High risk lesions: RFA or endoscopic mucosal resection. (LOE C)

Department of Family & Community Medicine Cirrhosis and Hepatocellular CA Starr and Raines, AFP (2011) Consistent with AASLD and National Cancer Institute guidelines Cirrhosis: • Causes: HCV 47%, EtOH 18%, HBV 15%, idiopathic 14%, other • Diagnosis: • Symptomatic: presence of complications +/- imaging • Asymptomatic: biopsy +/- imaging

• Hepatocellular cancer screening with q6-12 month AFP and ultrasound (LOE B) • HCC can occur in non-cirrhotic patients (HBV >> HCV) • Higher risk in HBV/HDV and HIV co-infected patients

Department of Family & Community Medicine Your 51 year old man with chronic HCV is lost to follow- up for 8 years. He returns to the office with ascites, fever and AP. Paracentesis shows 289 PMN/cc. You order:

a) Admission to the hospital b) Lasix and aldactone c) Ceftriaxone and albumin d) A & C e) All of the above

Department of Family & Community Medicine Cirrhosis and Hepatocellular CA Starr and Raines, AFP (2011) Consistent with AASLD and National Cancer Institute guidelines – If MELD score > 15 or ESLD complications, refer to transplant center (LOE A)

Complications of cirrhosis/ESLD • Ascites: diuretics and salt restriction (LOE A) • SBP (ascites PMN > 250/mm3): Abx + albumin (LOE A) • Encephalopathy: dissacharides or rifaximin (LOE B) • Varices: EGD screening w/in 12 mo in compensated cirrhosis; w/in 3 months if decompensated (LOE B) • Medium/large size: β-blockade and/or ligation (LOE A) • Bleeding: Abx prophylaxis + EGD w/in 24 hrs (LOE A) • Prophylaxis: non-selective B-blocker (goal HR < 60) in patients with documented varices. Avoid if ESLD-related hypotension.

Department of Family & Community Medicine A 55 yo man presents to urgent care with 10/10 epigastric pain radiating to the back, nausea and vomiting. He has been drinking heavily. Following a physical exam, the next appropriate steps are:

a) Abdominal u/s, serum lipase, LFT’s b) Abdominal CT, serum lipase, LFT’s c) Abdominal u/s, serum amylase, LFT’s d) Abdominal CT, serum amylase, LFT’s

Department of Family & Community Medicine Acute Pancreatitis Carroll, Herrick, Gipson, Lee, AFP (2007); Quinlan, AFP (2014)

• Most common causes: Gallstones (40%), alcohol (35%) – Idiopathic, post-ERCP (4%), medications (2%), trauma (1.5%), other rare (anatomic, autoimmune, hypertriglyceridemia, hypercalcemia, infection)

• Mortality < 1% in mild disease, 10-30% in severe disease – Risk scoring (eg. Ranson, APACHE II)

Diagnosis: – study of choice: CT (LOE C) for > mild disease (LOE C) – Lipase (@ ~200 U/L: >95% spec, ~67% sens) – LFT’s: evaluate obstructive disease, transaminases

Department of Family & Community Medicine Treatment of Acute Pancreatitis Carroll, Herrick, Gipson, Lee, AFP (2007); Quinlan, AFP (2014)

• Supportive: aggressive IVF, NPO, analgesia, antiemetics

• Gallstone pancreatitis: cholecystectomy within 48h reduces LOS (vs waiting for resolution of pain and transaminitis); ERCP decreases mortality and complications.

• Urgent ERCP for cholangitis/sepsis, obstruction, worsening/persistent jaundice (LOE A)

• Enteral nutrition > TPN in severe pancreatitis, assoc. with lower LOS and complications (LOE A)

• Antibiotics: imipenem/cilastatin decreases infection in pancreatitic necrosis (LOE B). Threshold for use > 30% necrosis (LOE C).

• Drain infected necrosis or persistent fluid collections with CT-guided aspiration or surgical debridement (LOE C)

Department of Family & Community Medicine 67 year old man presents to PCP with progressive anorexia and new onset of yellow eyes. He also reports fatigue and depression.

PE: 105/45, P74 Thin adult man, scleral icterus, temporal wasting From emedicine.medscape.com mild Epigastric TTP, no palpable mass

Department of Family & Community Medicine The majority of pancreatic cancers are:

a) Ductal adenocarcinoma of pancreatic head b) Neuroendocrine tumors c) Ductal adenocarcinoma of pancreatic tail d) Acinar cell carcinoma

Department of Family & Community Medicine Pancreatic Cancer Hidalgo, NEJM (2010); De La Cruz, Young, Ruffin, AFP (2014)

• 90%: ductal adenocarcinoma, 4th largest CA-related death in US – Majority: pancreatic head tumors (present with “painless” jaundice) – Overall 5 year survival < 5% – Median survival when resectable (12-19 mo), unresectable (8-10 mo) – 25-75% prevalence of depression as a concurrent symptom

• Risks: smokers (RR 2.5-3.6), 5-10% have FHx of pancreatic CA, obesity, mellitus, familial cancer syndromes

Diagnosis: – Pancreatic protocol CT is standard for diagnosis and staging (LOE C) – Serum 19-9: not effective screening (low spec/sens) • OK for monitoring in tumors which synthesize CA 19-9

Department of Family & Community Medicine Pancreatic Cancer Hidalgo, NEJM (2010); De La Cruz, Young, Ruffin, AFP (2014)

Treatment: • Decision on surgery requires multidisciplinary consultation and should define resectable/borderline resectable (15-20%) vs unresectable (LOE C)

• Resectable disease: Whipple procedure (if candidate) • Neoadjuvant chemo may improve survival by 2-3 months (LOE B) • <20% who undergo surgery are alive at 5 years

• Unresectable disease: chemotherapy +/- XRT • ChemoXRT may increase survival by 2-3 months (LOE B)

Complications: • Endoscopic biliary stents for biliary obstruction (65-75%) or enteral stents for gastric outlet obstruction (10-25%) can provide palliative relief in unresectable disease (LOE B)

• LMWH > warfarin in recurrent malignant VTE (LOE B)

Department of Family & Community Medicine Alcoholic Hepatitis Cochrane Review (2008); Starr and Raines, AFP (2011)

Screen all patients for alcohol use disorder (LOE B)

Diagnosis: – Jaundice, tender hepatomegaly, leukocytosis, fever, vomiting – Laboratory: • AST/ALT 2:1, transaminase elevation < 300 • Alkaline phosphatase < 400 • Bilirubin elevated • Macrocytosis (EtOH myelotoxicity +/- vit deficiency)

Treatment: - Largely supportive: abstinence, nutrition, sobriety support - Steroids vs pentoxyfylline if Maddrey’s Discriminant Function > 32

Department of Family & Community Medicine NASH/NAFLD (“Fatty Liver”) Wilkins et al. AFP (2013), AGA Guideline (2012)

• Established risks: Obesity, DM2, dyslipidemia, • Emerging risks: PCOS, hypothyroid, OSA, hypopituitarism, hypogonadism, pancreato-duodenal resection • Prognosis: 30% progress, 60% no change, 10% improve

Diagnosis: – U/S + liver biopsy if increased risk for steatohepatitis & fibrosis (LOE C) – If + NAFLD: Screen for metabolic syndrome, insulin resistance (LOE C)

Treatment: – Diet, weight loss, exercise (LOE C) – Vitamin E in non-diabetic adults with NASH (LOE B) – Avoid heavy alcohol intake (>14/wk in men, >7/wk in women) – Insufficient evidence on medications, bariatric surgery, antioxidants, bile acids

Department of Family & Community Medicine 1. D 8. B 15. A 2. E 9. D 16. C 3. C 10. E 17. D 4. A 11. E 18. E 5. E 12. B 19. B 6. A 13. D 20. A 7. C 14. D

Department of Family & Community Medicine