Tracking Key Issues in Gastroenterology Peter F. Bidey, DO

8/6/2014

Peter F. Bidey, D.O. Clinical Instructor -Family Medicine Philadelphia College of Osteopathic Medicine ACOFP Intensive Update and Board Review August 23, 2014 Chicago, IL

 Pain • Abdominal or chest

 Altered indigestion • Nausea/vomiting • Odynophagia- painful swallowing • Dysphagia- difficulty swallowing • Anorexia- lack of appetite

 Altered bowel movements • Constipation • Diarrhea

 Bleeding

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 Achalasia • Functional obstruction- obstruction from abnormal function in the absence of a visible mass or lesion • Etiology is unknown • Due to defective innervation of smooth muscle in the esophageal body and lower esophageal sphincter (LES) • Symptoms- progressive issues with swallowing with regurgitation leading to chest pain and weight loss • Diagnosis- motility testing • Botulinum toxin

 Esophageal Stricture • Complication of gastroesophageal reflux disease (GERD) • Increased frequency in conditions that lead to increased acid exposure • Also occurs post esophageal surgery, caustic injections, pill esophagitis, and radiation exposure

 Eosinophilic Esophagitis • Usually presents in adults and teenagers with dysphagia and food impactions • Can see stacked circular rings, strictures, and white papules on EGD • Diagnosis- biopsy showing increased number of eosinophils

 Reflux Esophagitis • Subset of patients with symptoms of GERD that have endoscopic or histopathologic evidence of esophageal inflammation

 GERD • A condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications

• Heartburn is the usual symptom worsening when lying prone at night or after eating foods or drugs that decrease LES tone

• Can have chest pain, regurgitation, dysphagia, hoarseness, cough, nausea, lump in throat

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Factors that Decrease LES Pressure

 Secretin  Peppermint  Cholecystokinin  Theophylline  Glucagon  Caffeine  Somatostatin  Gastric acidification  Gastric inhibitory  Smoking peptide (GIP)  Pregnancy  Vasoactive intestinal  Prostaglandins E2, I2 peptide (VIP)  Serotonin  Progesterone  Meperidine  Beta-adrenergic agonists  Morphine  Alpha-adrenergic  Dopamine antagonists  Calcium channel-  Anticholinergic agents blocking agents  Fat  Diazepam  Chocolate  Barbiturates  Ethanol

 Complications of GERD • Stricture- most common and usually in distal esophagus • Perforation/Hemorrhage • Pneumonia- due to aspiration • Barrett’s Esophagus  Some studies shows EtOH and smoking increase epithelium change from squamous to columnar histology  2-5% of cases lead to adenocarcinoma  Diagnosis • History and Physical • Use of Proton pump inhibitors as trial • Barium swallow • EGD

 GERD Treatment • Lifestyle and Dietary Modification  Avoid Triggers  Smoking and foods that decrease LES pressure  Weight loss  Elevation of HOB • Antacids  Do not prevent GERD- use only for intermittent on-demand symptoms  Magnesium Trisilicate, Aluminum Hydroxide, or Calcium Carbonate  Caution with magnesium compounds in renal disease  Can interfere with INH, Digoxin, and Tetracyclines • Surface agents  Promote healing and protects peptic injury adhering to surface  Sucralfate  Mainly used in pregnancy

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 GERD Treatment • Histamine 2 receptor antagonists  Decrease the secretion of acid by inhibiting H2R on gastric parietal cell  Development of tachyphylaxis can limit use as maintenance therapy  Use in mild and intermittent symptoms  Can interfere with Coumadin, Theophylline, and Dilantin • Proton pump inhibitors (PPIs)  Most potent inhibitor of gastric acid secretion by irreversibly binding to and inhibiting H-K ATPase pump  Take 30 minutes before first meal of day  Can interfere with Coumadin and Dilantin

Uses of PPIs • Dyspepsia • Peptic Ulcer disease (PUD) • Gastroesophageal Reflux Disease (GERD) • Erosive Esophagitis • Laryngopharyngeal Reflux Disease • Barrett’s esophagus • Prevention of stress gastritis • Gastrinomas and other conditions that cause hypersecretion of acid • Zollinger-Ellison Syndrome

 Symptoms • Presents with chronic, mild gnawing, or burning abdominal or chest pain resulting from superficial or deep erosion of GI mucosa • Timing of pain sometimes differs between ulcer site • Pepsin and acid are major factors causing damage  Causes • Medications-ASA & Steroids • Diet-EtOH and Spicy Foods • Smoking • Organisms • Stress/ARI/Sepsis • Trauma-NG tube & EGD

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• Extremely common and found in ½ world population • Most common in poorest countries • Close to 90% of infected individuals shows signs of inflammation on EGD but many are asymptomatic • 15% of infected individuals will develop a clinical significant ulcer • Vast majority of patients with acid-peptic disease have H pylori infection • Treatment that does not eradicate H pylori infection is associated with increase in acid-peptic disease reoccurrence in patients

ACG Guidelines • PPI BID + Clarithromycin 500mg BID + Amoxicillin 1000mg BID for 10-14 days  Can use Metronidazole 500mg BID if PCN allergic or previous received macrolide or unable to tolerate bismuth quadruple therapy

• Bismuth subsalicylate 525mg QID + Metronidazole 250mg QID + Tetracycline 500mg QID + PPI BID for 10-14 days

• Delayed gastric emptying • Symptoms include nausea, bloating, vomiting, and either constipation or diarrhea • Common complication of poorly controlled diabetes mellitus, with consequent autonomic dysfunction • Complications include bezoars from retained gastric contents, bacterial overgrowth, erratic blood glucose control, and possible weight loss • Treatment includes prokinetic agents-Reglan  Side effects- hallucinations, insomnia, restlessness, and anxiety

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Mechanisms of Diarrhea • Osmotic/malabsorption

• Secretory

• Motility Disorder

• Inflammatory

SIGNS AND SYMPTOMS DX TO BE CONSIDERED  Arthritis  Ulcerative colitis, Crohn's disease, Whipple's disease, enteritis resulting from Yersinia enterocolitica, gonococcal proctitis  Liver disease  Ulcerative colitis, Crohn's disease, colon cancer with metastases to liver  Ulcerative colitis, Crohn's  Fever disease, amebiasis, lymphoma, tuberculosis, Whipple's disease, other enteric infections  Malabsorption, inflammatory bowel disease, colon cancer,  Marked weight loss thyrotoxicosis

 Eosinophilic gastroenteritis, parasitic disease (particularly  Eosinophilia Strongyloides)

 Lymphadenopathy  Lymphoma, Whipple's disease, AIDS  Neuropathy  Diabetic diarrhea, amyloidosis

SIGNS AND SYMPTOMS DX TO BE CONSIDERED

 Postural hypotension  GI bleeding, diabetic diarrhea, Addison's disease, idiopathic orthostatic hypotension  Flushing  Malignant carcinoid syndrome, pancreatic cholera syndrome  Erythema  Systemic mastocytosis, glucagonoma syndrome  Proteinuria  Amyloidosis  Collagen-vascular disease  Mesenteric vasculitis  Peptic ulcers  Zollinger-Ellison syndrome  Chronic lung disease  Cystic fibrosis  Systemic arteriosclerosis  Ischemic injury to gut  Frequent infections  Immunoglobulin deficiency  Hyperpigmentation  Whipple's disease, celiac disease, Addison's disease  Good response to  Ulcerative colitis, Crohn's disease, corticosteroids Whipple's disease, Addison's disease, eosinophilic gastroenteritis, celiac disease  Good response to antibiotics  Blind loop syndrome, tropical sprue, Whipple's disease

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Acute Diarrhea • Usually <2-3 weeks • Causes  Viral, bacterial, parasitic, and fungal  Food poisoning  Drugs or food additives  Digitalis, propranolol, quinidine, diuretics, colchicine, antibiotics, lactulose, antacids, laxatives, chemotherapeutic agents, bile acids, and meclomen.  Fecal impaction  Pelvic inflammations  Heavy Metal poisoning (acute or chronic)

Traveler’s Diarrhea • Bacterial Infections  Mediated by enterotoxins produced by E coli  Mediated by invasion of mucosa and inflammation (invasive E coli and Shigella)-Bloody  Mediated by combinations of invasion and enterotoxins (Salmonella)-Bloody

• Viral or parasitic infections

 Diarrhea in Patients with AIDS • Cryptospordium • Amebiasis • Giardiasis • Isospora belli • Herpes simplex • Cytomegalovirus • Mycobacterium avium-intracellulare complex • Salmonella typhimurium • Cryptococcus • Candida • AIDS enteropathy

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 Chronic and Recurrent Diarrhea • Irritable bowel syndrome • Inflammatory bowel syndrome • Parasitic and fungal infections • Malabsorption syndromes • Drugs and food additives • Colon cancer • Diverticulitis • Fecal impaction • Heavy metal poisoning • Raw milk-related diarrhea

Small bowel disorder which is triggered by the ingestion of gluten Variable signs and symptoms, most patients have some component of: • Bloating • Intermittent diarrhea • Abdominal pain Some patients have no GI complaints or mimic symptoms of other disorders

 Testing-who? • Individuals with GI symptoms of recurrent diarrhea, malabsorption, weight loss, and bloating • Individuals with Fe-def anemia, folate or B12 def without explanations • Individuals currently having symptoms and are a type 1 DM or have first degree relatives with celiac disease  Diagnosis • Immunoglobulin A • anti-tissue transglutaminase antibody • Biopsy of intestinal villa-confirmatory  Treatment • Gluten-free diet

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 Dermatitis herpetiformis is an itchy, blistering skin disease that also stems from gluten intolerance  The rash usually occurs on the elbows, knees and buttocks  Dermatitis herpetiformis can cause significant intestinal damage identical to that of celiac disease • However, it may not produce noticeable digestive symptoms  This disease is treated with a gluten-free diet, in addition to medication to control the rash

 Crohn’s Disease  Ulcerative colitis • Transmural and • Superficial and limited granulomatous in to the colonic mucosa character, occurring • Rectal bleeding> 90% anywhere along the GI tract • Diarrhea - 10– 30% • Appears usually with • Rectal involvement “skip lesions” almost 100% • Has a cobblestoning appearance due to deep ulcerations and submucosal thickening

 Usually occurs in the  Other manifestations distal ileum but again • Joints-migratory arthritis can appear anywhere • Skin-erythema nodosum in GI tract • Eyes-uveitis & iritis  Complications: • Buccal mucosa- • Perforation, fistula aphthous ulcers formation, abscess • Bile ducts-sclerosing formation, and small cholangitis bowel obstruction • Liver-autoimmune • Protein-losing chronic active hepatitis enteropathy • Nephrolithiasis • Possible increased • Amyloidosis incidence of intestinal • Thromboembolic events cancer

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 Restricted to mucosa of colon and rectum  Similar presentation to Crohn’s disease and some complications (bloody diarrhea & protein-losing enteropathy) but no typical obstruction, perforation, and fistula formation  Like Crohn’s disease some patient’s only have 1 to 2 flares during lifetime  Higher risk of carcinoma-unknown cause  Toxic megacolon is a complication and can perforate

 Crohn’s Disease • Sulfasalazine, Corticosteroids, and Mercaptopurine  Ulcerative Colitis • Sulfasalazine, Corticosteroids, Mesalamine, and Olsalazine  Both Crohn’s disease and Ulcerative colitis can go into remission after initial treatment with Sulfasalazine and corticosteroids  The natural history of the disease has periods of remission interrupted with active disease; during these periods medical treatment is directed to supportive treatment and to induce remission

 These diseases can recur after surgical resection of involved regions of the GI tract therefore operative management is limited to relief of life- threatening obstruction or bleeding

 Immunosuppressive agents, such as Mercaptopurine and Azathioprine, have variable response rates and high rates of side effects; therefore they are limited to cases that have failed to respond to Sulfasalazine and glucocorticoids

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 Most common referral to gastroenterologist  Most common diagnosed gastrointestinal condition  Characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause  Pain is usually campy in nature and not associated with anorexia, malnutrition, or weight loss  Altered bowel habits alternate between constipation and diarrhea usually  Bloating or perceived abdominal distention also a common feature  Cause is unknown

 Stress has a considerable influence on the symptoms  Symptoms frequently occur with stressful life events and stressful events in early life may predispose to the development of IBS  Diagnosis of exclusion • Manning criteria  Pain relieved with defecation  More frequent stools at the onset of pain  Looser stools at the onset of pain  Visible abdominal distention  Passage of mucus  Sensation of incomplete evacuation

 Fiber Supplements: Psyllium or Methylcellulose with fluids may help with constipation symptoms

 Anti-diarrheal medications: Loperaminde can help control diarrheal symptoms

 Anticholinergic medications: May help relieve bowel spasms

 Eliminate high gas foods including carbonated beverages, green leafy vegetables, raw fruits and vegetables, broccoli, etc.

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Antidepressants • Tricyclic antidepressants or selective serotonin reuptake inhibitors  Tricyclic antidepressants may help decrease abdominal pain as well as diarrhea  Side effects include constipation and drowsiness  SSRIs may help decrease pain and constipation and also help with depression symptoms • Counselling may be beneficial if stress tends to increase symptoms

Nearly 80% of patients with diverticular disease are asymptomatic except for chronic constipation

Patients with symptomatic disease usually have griping and unpredictable lower abdominal pain especially in LLQ

The sigmoid colon is involved in 95% of cases

Two major complications of diverticular disease: • Diverticulitis • Diverticular Bleeding  About 1/5 of patients with diverticular disease will experience one of two complications in their lifetime

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 A patient with diverticulitis may present with peritoneal signs • Rebound tenderness, guarding, or absence of bowel signs • The patient may develop symptoms of abdominal pain and fever with possible progression to abscess formation with or without perforation  The perforations are usually self contained  However, these perforations lead to an increased incidence of fistula formation and intestinal obstruction is high

A patient with diverticular bleeding may present with frankly bloody stools or stools that are positive for occult blood • Diverticular bleeding is usually painless and not associated with a focus of inflammation

Occurs due to herniation of the mucosa and submucosa through the muscularis Possible cause is low fiber diet and highly refined foods leading to chronic constipation It is an “affluent disease” Prevalence is on the rise Incidence increases with age, beginning at 40

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 Cancer prevention tests should be offered first-the preferred test is colonoscopy every 10 years, beginning at age 50 • African Americans CRC screening should begin at age 45  Cancer detection screening should be offered to patients who decline cancer prevention screening • Annual FIT testing for blood is preferred

 Alternative CRC prevention tests • Flexible sigmoidoscopy every 5-10 years • CT colonography every 5 years  Alternative cancer detection tests • Annual Hemoccult Sensa • Fecal DNA testing every 3 years

 Screening for a positive family history without HNPCC consideration indicated • Single first-degree relative with CRC or advanced adenoma diagnosed at age ≥60  Screen as average risk • Single first-degree relative with CRC or advanced adenoma diagnosed at age ≤60 or two first-degree relatives with CRC or advanced adenoma  Screen with colonoscopy every 5 years beginning at age 40 or 10 years younger than age of diagnosis of the youngest affected relative

Recommends against screening for colorectal cancer in adults ages 76-85 years • There may be considerations that support this screening for individual patients

Recommend against screening for colorectal cancer in adults older than age 85 years

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 Mills JC, Stappenbeck TS, Bunnett N. Mills J.C., Stappenbeck T.S., Bunnett N Chapter 13. Gastrointestinal Disease. In: McPhee SJ, Hammer GD. McPhee S.J., Hammer G.D. eds. Pathophysiology of Disease, 6e. New York, NY: McGraw-Hill; 2010. http://accessmedicine.mhmedical.com/con tent.aspx?bookid=339&Sectionid=42811313 . Accessed June 16, 2014.  American College of Gastroenterology • http://gi.org/guideline/colorectal-cancer- screening/

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