Transcript I.M. GI Board Review

General GI Board Review
Elizabeth Paine, MD
July 18, 2015
**I have no financial interests or commitments to disclose regarding my presentation**
Esophagus
• Proximal 1/3 esophagusstriated muscles under
CNS control
• Distal 2/3 esophagussmooth muscle under
vagal and myenteric
nervous system control
• UES and LES are normally
in a contracted state
• Initiation of swallow
relaxes both of the
sphincters
Question
70 year old female with PMH of Parkinson’s disease,
HTN, DM presents with dysphagia and occasional
choking while eating for past several weeks. She
notices dysphagia as soon as she initiates a swallow.
CXR is normal. Which modality is the most
sensitive in the diagnosis of this patient’s
dysphagia?
A.
B.
C.
D.
Esophageal manometry
Modified barium swallow
EGD
Chest CT
Question
70 year old female with PMH of Parkinson’s disease,
HTN, DM presents with dysphagia and occasional
choking while eating for past several weeks. She
notices dysphagia as soon as she initiates a swallow.
CXR is normal. Which modality is the most
sensitive in the diagnosis of this patient’s
dysphagia?
A.
B.
C.
D.
Esophageal manometry
Modified barium swallow
EGD
Chest CT
Dysphagia
• Oropharyngeal Dysphagia
- Structural disorders
- Neurological disorders
(Stroke, ALS, myasthenia gravis, Parkinson’s,
myotonic dystrophy)
• Esophageal Dysphagia
Esophageal Dysphagia
Solids Only:
Characteristic
Etiology
Treatment
Intermittent
Schatzki’s ring
Dilation
Progressive + heartburn
Peptic stricture
Dilation + PPI
Progressive + weight loss
Esophageal cancer
Depends on stage
Solids and Liquids:
Characteristic
Etiology
Treatment
Intermittent + chest pain
Diffuse esophageal
spasm
PPI + nitrates/CCB
Progressive + heartburn
Scleroderma
PPI
Progressive + no GERD
Achalasia
Heller myotomy,
pneumatic dilation
Schatzki’s Ring
• 45yo M with
longstanding
GERD presenting
with 6 months of
intermittent solid
food dysphagia
Odynophagia
• Ulcerative Esophagitis
- Due to infection or pill
- Viral (HSV,CMV)
- Candida - most common
• Pill-Induced Esophagitis
- Tetracyclines, FeSO4,
Bisphosphonates,
NSAIDs, Quinidine,
Potassium
Question
• 55 y/o man presents with progressive dysphagia for
both solids and liquids, intermittent regurgitation of
food, and wt loss of 30 lbs over the course of 1 year.
Symptoms not relieved with PPI. Barium esophagram
shows a dilated esophagus with an air/fluid level and
tapered narrowing of the distal esophagus. What is the
most likely diagnosis?
A. Esophageal cancer
B. Esophageal stricture
C. Achalasia
D. Esophageal ring
Achalasia
• Failure of the LES to relax with
swallowing
• Progressive dysphagia for solids
and liquids and regurgitation
• Barium esophagram with
esophageal dilation with classic
“bird’s beak” appearance
distally
• Esophageal manometry shows
lack of relaxation of the LES
with swallowing and aperistalsis
of the esophageal body
Achalasia treatment
• Laparoscopic Heller
myotomy
• Pneumatic dilation
• Botox injection just
proximal to LES
• Nitrates/CCB offer
temporary relief
Pseudoachalasia
• If obstruction at LES is caused by a malignant
lesion, the disorder is designated
“pseudoachalasia”
• Mimics manometric findings of achalasia
• EGD is recommended in all suspected cases of
achalasia
GERD
• Most common cause of
non-cardiac chest pain
• Inappropriate LES
relaxation
• Empiric PPI - first dx/tx
• Refractory GERD needs
EGD, pH monitoring
and/or eso manometry
Indications for EGD
• Failure of treatment
• Age > 50
• Symptoms > 5 years
• Alarm symptoms
- Wt Loss
- Dysphagia
- Anemia
GERD Treatments
•
•
•
•
Life style modifications
PPI
H2 Blockers
Fundoplication
Risks of PPI
•
•
•
•
Enteric infections (C. difficile)
Pneumonia
Hip fractures (Osteoporosis)
B12 deficiency
Dyspepsia
• Definition
• Alarm signs
- Age >55 years with new-onset symptoms
- Family history of gastric cancer
- Unintentional wt. loss
- GI bleeding
- Dysphagia/Odynophagia
- Gastric outlet obstruction signs/symptoms
Dyspepsia
Question
59 y/o white male with h/o GERD for the last 5-6 years.
Symptoms have gotten worse lately. OTC tums don’t help
much. Recent cardiac work up was negative. Denies N/V
or weight loss. Also has HTN, DM, and Obesity. He is a
smoker. Meds include HCTZ , Metformin. Other than BMI
of 32 rest of PE is normal. Which of the following is the
most appropriate management of this patient?
A.
B.
C.
D.
Ambulatory esophageal pH monitoring
Barium swallow study
EGD
H2 Blockers
Question
59 y/o white male with h/o GERD for the last 5-6 years.
Symptoms have gotten worse lately. OTC tums don’t help
much. Recent cardiac work up was negative. Denies N/V
or weight loss. Also has HTN, DM, and Obesity. He is a
smoker. Meds include HCTZ , Metformin. Other than BMI
of 32 rest of PE is normal. Which of the following is the
most appropriate management of this patient?
A.
B.
C.
D.
Ambulatory esophageal pH monitoring
Barium swallow study
EGD
H2 Blockers
Barrett’s Esophagus
• Normal squamous epithelium of the distal
esophagus is replaced by columnar epithelium
• Obese/white/male/smoker with GERD
• Pre-malignant condition
• Increased risk of esophageal adenocarcinoma
• Long segment BE > 3 cm
• Histologically diagnosed by detection of
specialized intestinal metaplasia and goblet
cells
Barrett’s Esophagus
Management of Barrett’s esophagus
(AGA guidelines 2011)
Finding
Management
No dysplasia
Low-grade dysplasia
High-grade dysplasia
without eradication tx
Mucosal irregularity within
Barrett’s
Invasive cancer
EGD every 3-5 years
EGD every 6-12 months
EGD every 3 months
Endoscopic mucosal
resection
Surgery
Esophageal Squamous Cell Cancer
• More common in men, especially black men
• Risk factors:
Smoking, alcohol, nitrosamine exposure, corrosive
injury to esophagus, achalasia, HPV
• Clinical presentation: Dysphagia, weight loss, GI
bleed, anorexia
• Dx: Endoscopy. Mass usually involves upper
esophagus
• Rx: Surgery/Chemo/Radiation
Question
39y/o male with PMH of seasonal
allergies for past several years presented
with c/o chest discomfort after he ate
pork chops for lunch 2-3 hrs ago. He
can’t swallow anything and feels food
stuck in his chest. He has had 2 such
episodes in the past. Physical
examination is unremarkable. EGD is as
shown. Histologic examination of the
mucosa shows intense inflammation of
the lamina propria with more than 15
eosinophils per HPF. No strictures are
seen. What is the diagnosis?
A.
B.
C.
D.
Achalasia
Severe GERD
Eosinophilic esophagitis
Schatzki’s ring
Question
39y/o male with PMH of seasonal
allergies for past several years presented
with c/o chest discomfort after he ate
pork chops for lunch 2-3 hrs ago. He
can’t swallow anything and feels food
stuck in his chest. He has had 2 such
episodes in the past. Physical
examination is unremarkable. EGD is as
shown. Histologic examination of the
mucosa shows intense inflammation of
the lamina propria with more than 15
eosinophils per HPF. No strictures are
seen. What is the diagnosis?
A.
B.
C.
D.
Achalasia
Severe GERD
Eosinophilic esophagitis
Schatzki’s ring
Eosinophilic Esophagitis
• Young adults with dysphagia and
food impaction and with h/o other
allergic disorders
• Endoscopic Dx :
- Mucosal longitudinal furrowing
- Circumferential rings
• Pathology shows > 15-20 Eos/HPF
• TX : PPI and swallowed fluticasone
H.Pylori Diagnosis
• Stool Antigen Test
• Urea Breath test
• Serum antibody
test
• Endoscopic
histology (gold
standard)
Treatment of H.pylori
• Triple Therapy
PPI BID+ Amox 1 Gm + Clarithromycin 500mg BID
X 10-14 days
• With PCN Allergy
PPI BID + Metronidazole 500mg BID +
Clarithromycin 500 mg BID X 10-14 Days
• Quadruple Therapy
PPI BID+ Bismuth 525 mg QID + Metronidazole
500 mg BID + Tetracycline 500 mg QID X 10-14
days
Peptic Ulcer Disease Causes
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•
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•
•
•
H.Pylori
NSAIDS
ZE Syndrome
Malignancy
Crohn’s disease
Viral infections
Peptic Ulcer Disease Complications
• Bleeding (most common)
(Risk factors: Age and NSAIDS)
• Perforation
• Gastric outlet obstruction
• Anemia
Management of PUD
•
•
•
•
•
Stop NSAIDS
Eradicate HP if present
PPI BID x 8 weeks
Follow up EGD in 8 weeks for gastric ulcers
Surgery for those refractory to medical
therapy
Zollinger-Ellison Syndrome
• Involves gastrinoma causing ulcers and diarrhea
• Gastrinomas are frequently in the duodenum or
pancreas
• Can be associated with MEN 1
• Initial tests are 3 fasting serum gastrin levels off
PPI on different days
• Additional testing includes secretin stimulation
test, octreotide scan, CT/MRI to localize
gastrinoma, EUS
Upper GI Bleeding Causes
• Non-Variceal:
Gastric and DU Ulcers
Mallory-Weiss tear
GAVE (watermelon stomach)
AVMs (Age, CRI, AV, OWR)
Hemosuccus pancreaticus
• Variceal
Esophagitis/Gastritis
Malignancy
Hemobilia
Dieulafoy lesion
Aortoenteric fistula
Question
57 year old male presents with c/o weakness and
melena for 3 days. No significant abdominal pain.
He is orthostatic on exam. Stool is heme positive.
NG suction with coffee-grounds material. HCT 30.
What is the next step in management?
A.
B.
C.
D.
E.
EGD
UGI series
Angiography
Insert large-bore IV’s and T/C match for blood
EGD/Colon exam
Question
57 year old male presents with c/o weakness and
melena for 3 days. No significant abdominal pain.
He is orthostatic on exam. Stool is heme positive.
NG suction with coffee-grounds material. HCT 30.
What is the next step in management?
A.
B.
C.
D.
E.
EGD
UGI series
Angiography
Insert large-bore IV’s and T/C match for blood
EGD/Colon exam
Management of UGI Bleed
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•
•
•
•
•
Fluid resuscitation
Blood transfusion
2 large bore IV’s or Central Line Placement
PPI infusion initially
Octreotide infusion (Variceal Bleed)
EGD
Epinephrine inj + Coag and/or clips
• IR or Surgery if endoscopy fails
Management of UGI Bleed
• Evaluate severity of bleed
– NGT lavage that does not clear = emergent
endoscopy
– Coffee ground or NGT that clears in
hemodynamically stable patient can wait
– Hemodynamically unstable patient should be
admitted to the ICU
• Remember ABCs
• Elevated BUN (normal creat) = UGI bleed
• Look for signs of liver disease
Gastric Adenocarcinoma
• Risk factors:
smoking, blood type A,
H.Pylori, family history of
gastric cancer,
environmental
• Clinical Presentation:
wt. loss, abd pain, early
satiety, GOO, anemia
• Diagnosis: Endoscopy with
biopsy
• EUS for depth of invasion
Gastroparesis
• Causes
- Idiopathic
- DM
- Postoperative
- Autoimmune disorders
• Diagnosis
- Rule out mechanical obstruction with EGD/UGI
- 4 hr Gastric emptying test
Gastroparesis Management
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•
•
•
•
•
•
Low fat and low fiber diet
Small/frequent meals
Antiemetics
Prokinetics
GES
Feeding jejunostomy tube
TPN
Gastric Bypass
• Roux-en-Y is the most
common in US
• PE is the most
common cause of
death post-procedure
• IDA
• B12 deficiency
• Calcium and Vit D
deficiency
Dumping Syndrome
• Early:
- within 30 minutes of eating
- nausea, bloating, and diarrhea
• Late:
- 1-3 hrs after eating
- hypoglycemia, tachycardia, sweating
• Treatment:
- low carb diet
- small meals
- more protein and fat in diet
Gastric volvulus
• Abnormal rotation of the stomach
around its axis
• Acute volvulus: pain in the upper
abdomen or lower chest, inability to
pass NG tube, vomiting
• Radiographic findings
• Surgical emergency but if patient is
a poor surgical candidate,
endoscopic methods can be tried
• Chronic volvulus usually has vague
upper abdominal symptoms
Images from Uptodate.com
Autoimmune gastritis
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•
•
•
•
Type of atrophic gastritis
Associated with autoimmune thyroid disease
Pathologic changes in gastric body and fundus
Antibodies to intrinsic factor and/or parietal cells
Can develop B12 deficiency with pernicious
anemia
• At increased risk for gastric carcinoids and
adenocarcinoma
• Lower risk of having H.pylori
Intestinal angioedema
• Present with colicky abdominal pain
• CT with bowel wall edema
• Can occur with ACEI/ARB therapy and with C1
inhibitor deficiency
• If drug induced, drug needs to be
discontinued
• If due to C1 esterase deficiency, treat with C1
inhibitor, ecallantide, or icatibant
Lower GI Bleeding Etiologies
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•
•
•
•
•
Diverticuli
Ischemic colitis
AVMs
Post-polypectomy bleed
Meckel’s Diverticulum
UGI cause in 10-15%
Hemorrhoids
NSAIDs/ulcers
IBD
Dieulafoy lesion
Radiation colitis
Acute Diverticular Bleeding
• Painless bleeding with
hypotension/syncope
• Usually elderly patients
• 85% of cases have
spontaneous remission
• Diagnosis/treatment:
- Volume resuscitation
with fluids/blood
- Colonoscopy & endo tx
- Angiography
Ischemic colitis
• Due to decreased
mesenteric blood flow and
hypoperfusion in
“watershed” areas
• Due to non-occlusive
ischemia
• Sudden LLQ pain with
tenesmus, then passage of
red-to-maroon stool
• Virtually never embolic
• Dx with colonoscopy or CT
• Rx: Supportive care with
IVF, pain control, risk
factor modification, +/antibiotics
Management of LGIB
• Identify contributing factors by history (NSAIDS,
antiplatelets, anticoagulants, radiation)
• Volume resuscitation with blood and IVF
• Colonoscopic treatment with epi/coag/clips
• Tagged RBC scan
• Angiography with possible embolization
• Small bowel eval with push enteroscopy or
Pillcam
Obscure GI bleeding
• Dieulafoy lesion
• Hemobilia
• AVM (think of this in
renal patients)
• Meckel’s diverticulum
• Missed lesions
Meckel’s diverticulum
• Outpouching of the ileum
• Can have ectopic gastric
mucosa
• Maroon painless bleeding
per rectum
• Can present with intestinal
obstruction or
appendicitis-like symptoms
• Can be diagnosed by
Meckel’s scan
(99mmtechnetiumpertechnetate study)
Acute diverticulitis
• Acute LLQ pain with fever and leukocytosis
• Diagnosis:
- CT scan with contrast
- Avoid colonoscopy
• Treatment:
- Needs to cover Gram negatives and anaerobes
- Cipro/Flagyl
- Ampicillin-sulbactam
Pericolonic diverticular abscess
• IF < 3-4 cm:
- antibiotics
- supportive
care
• IF > 3-4 cm:
- CT guided
drainage
- antibiotics
Acute Mesenteric Ischemia
• Do not confuse with ischemic colitis
• Pain out of proportion to examination, acutely ill
• Due to loss of blood flow to SB and/or ascending
colon
• Commonly embolic
• Older patients with h/o CHF, recent MI, cardiac
arrhythmias
• Do angiography unless there are signs of
perforation
Chronic mesenteric ischemia
• “Intestinal angina”
• Postprandial abdominal pain, abdominal bruit,
weight loss
• Caused by atherosclerosis of intestinal arteries
• Often have signs of other PVD and smoking hx
• Diagnosis often based on sx although MRA or
spiral CT have been used
• Tx: angioplasty with stent placement in
patients who can tolerate this
Question
54 y/o WF with protein S
deficiency presents with a 2
day history of severe
epigastric abdominal pain
with nausea/vomiting. She
had this CT in the ER. What
is the cause of her pain?
A. Peptic ulcer disease
B. Mesenteric venous
thrombosis
C. Biliary colic
D. Functional abdominal
pain
Question
54 y/o WF with protein S
deficiency presents with a 2
day history of severe
epigastric abdominal pain
with nausea/vomiting. She
had this CT in the ER. What
is the cause of her pain?
A. Peptic ulcer disease
B. Mesenteric venous
thrombosis
C. Biliary colic
D. Functional abdominal
pain
Colon Cancer
Risk factors:
– Age > 50
– H/o adenomatous
polyps
– H/o breast, ovarian,
or endometrial CA
– Family History (1st
degree)
– Ulcerative
colitis/Crohn’s colitis
– Lifestyle (fat, fiber,
obesity)
3rd most common cancer in
males (behind prostate and
lung) and female (behind breast
and lung)
Colon Cancer Screening
Average risk: begin at 50
Above-average risk
• FS q5y, FIT qy
- if adenoma found –
• 1 first degree relative with CRC
or adenoma <60 y/o or 2 first
degree relatives with CRC or
adenoma: q5y
- begin age 40 or 10y younger than
proceed with colonoscopy
• Colonoscopy q10y
- if incomplete: do BE
• CT colonography q5y
earliest diagnosis
• Personal history of polyp: q5y
- Advanced polyp (>1cm, villous
features, high-grade dysplasia): 3y
- 3 or more polyps: 3y
Colon cancer screening with poor prep
• Good or excellent prep is critical for screening
• Definition of adequate exam
• If prep is poor, procedure needs to be
repeated after additional prep is given or
patient is re-prepped
• By ASGE guidelines, patients with inadequate
prep need a repeat colonoscopy within 1 year
Familial Adenomatous Polyposis (FAP)
• Classic version has >100
adenomatous polyps
• Classic has 100% CA risk
• Proctocolectomy by age 20
• Periampullary duodenal
cancer # 1 cause of cancer
death after colectomy
FAP Variants
• Gardner syndrome
- FAP + osteomas,
desmoid tumors
- supernumerary teeth
• Turcot’s variant
- FAP + brain tumors
(GBM or medulloblastoma)
• Attenuated APC
- 10-100 adenomatous polyps
What’s wrong with this patient?
Familial Hamartomatous Polyposis
Syndromes
Peutz-Jeghers Syndrome
Juvenile Polyposis
• Multiple hamartomatous
polyps & lip/buccal
hyperpigmentation
• Hamartomas mostly in
distal colon
• High cancer risk (>90%)
- small bowel, colon, breast,
• Congenital malformation of
GI,GU tract and heart
ovarian, pancreaticobiliary
• Common presentation= abd
pain due to intussusception
or obstruction by large
polyp
• Increased cancer risk
- surveillance q1-3y
Hereditary Nonpolyposis Colon Cancer
(HNPCC) or Lynch Syndrome
• Colon CA in 3 relatives (one first degree) over 2
generations & with one diagnosed < 50 yo
– microsatellite instability (MSI)
– MMR gene mutations
• Lynch I: limited to colon and rectum
• Lynch II: increased risk of CA in female genital tract,
breast, other sites
• Surveillance: q1-2 yrs beginning age 20-25 or 10 yrs
before the age of youngest family member
• q1 year after the age of 40
Colon Cancer
• If a distal lesion is found, the entire colon
needs to be “cleared” prior to treatment due
to a high risk of concomitant lesions
• XRT is not used for colonic lesions
– Remember this because the colon “moves
around” and the XRT beam can’t localize the
tumor
– XRT is indicated for rectal cancer
Classification of Diarrhea
Acute
Infectious
Chronic
Ingestion
Watery
Osmotic
Inflammatory
Secretory
Infectious
Fatty
IBD
Malabsorption
Acute Diarrhea
• Duration
– Acute (< 3 weeks)
• Infectious, drugs, ingestion of osmotic substances.
• Usually self-limited (given a competent
immune system)
• Treatment usually only with severe
dehydration/toxic
Infectious Diarrheas
Bacteria
Key points
Treatment
Staph aureus
Foodborne in dairy, mayo-based
salad, poultry. n/v, short incubation
Supportive
ETEC (E.coli)
Traveler’s diarrhea
Supportive, can use FQ
Bacillus cereus
Reheated fried rice
Supportive
Vibrio cholera
Profuse watery diarrhea
Copious rehydration. Can use
doxycycline
Giardia
Malabsorption and steatorrhea,
daycare, creek water.
FQ or nitazoxanide
Campylobacter
Bloody diarrhea. Uncooked poultry,
unpasteurized milk
Supportive, erythromycin if
septic
E.Coli 0157:H7
Can cause HUS. Poorly cooked beef
Supportive, avoid abx
Vibrio vulnificus
Raw seafood, injury in seawater. Skin
infection. Can be deadly in cirrhotics.
Doxycycline
Shigella
Acute bloody diarrhea with tenesmus, 3rd generation cephalosporin
daycare
Salmonella
Eggs, chicken, turtles, iguanas, other
reptiles. Bloody diarrhea
Supportive, avoid antibiotics
unless septic, febrile
Diarrhea Pearls
•
•
•
•
•
Guilian-Barre Campylobacter
Raw eggs  Salmonella
HUS  E.coli O157:H7
Antibiotics  C. diff
Bloody diarrhea followed by RUQ pain, fever +/Jaundice  Amebiasis (tx flagyl + paromomycin)
• Abd pain, bloating, frothy stool Giardia
• Rice water stools Vibrio
Clostridium difficile
• Often will have a leukocytosis
• Management depends on severity and recurrence
• Initial episode:
- Mild: metronidazole 500mg TID x 10-14 days
- Severe: vancomycin 125mg po QID x 10-14 days
• First relapse: repeat same treatment as initial episode
• Second relapse: tapering vancomycin or fidaxomicin
200mg po BID x 10 days
• Subsequent relapse: fidaxomicin if not used previously
vs. fecal transplant
Chronic Diarrhea
• Duration
– Chronic (> 3 weeks)
• More complex work-up and treatment
Chronic
Watery
Osmotic
Inflammatory
Secretory
Infectious
Fatty
IBD
Malabsorption
Osmotic vs. Secretory Diarrhea
Osmotic
Secretory
Daily stool volume
<1L
>1L
Effect of fasting
Stops
Continues
Stool Na
30
100
Stool K
30
40
290-2(Na + K)
>125 (>50)
<50
pH
Usually acidic
Usually neutral
Osmotic Diarrhea Etiologies
• Bacterial overgrowth
• Lactase deficiency/malabsorption
• Drugs (colchicine, neomycin, magnesiumcontaining laxatives, lactulose)
• Celiac disease
• Tropical sprue
• Pancreatic insufficiency
• Whipple’s disease
Laxative abuse
•
•
•
•
•
High volume, frequent, watery diarrhea
Often associated with crampy abdominal pain
Osmolar gap >50
Usually female and may be in medical field
Stool magnesium often >108 mg/dL (45 mmol/L
or 90 mEq/L) with magnesium-based laxatives
• Testing for laxatives
Secretory Diarrhea
• Most common cause is
infection
• Enterotoxins from
infections interacting
with receptors causing
increased anion
secretion
• Congenital defect in
transport molecules
• Exogenous agents
– Drugs and poisons
Etiologies:
• Enterotoxins from E.coli,
V. cholera, S. aureus
• Villous adenomas
• Gastrinomas
• VIPomas with secretion
of VIP
• Lymphocytic colitis
• Collagenous colitis
• Bile acids
Secretory “Structural” Diarrhea
• There must be an adequate mucosal
surface area for transport to occur
– Compromise water absorption
– Ileal resection length
• >100cm: Malabsorption due to decreased bile acids
• <100cm: Bile acid diarrhea
Carcinoid syndrome
• Clinical symptoms: flushing,
diarrhea, hypotension,
hyperthermia, tachycardia
• Screen with urine 5-HIAA
• Most tumors located in
terminal ileum but can be
located rarely in the
bronchus
• Treat symptoms with
octreotide
Fat Malabsorption
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•
•
•
Celiac Disease
Small-Intestinal Bacterial Overgrowth
Short-bowel syndrome
Pancreatic Insufficiency
Celiac Disease
• Abd discomfort, bloating,
diarrhea, weight loss,
flatulence
• IDA, Vit A,D,E,K, Folic acid
deficiency
• Steatorrhea & enteropathy
• Aphthous stomatitis
• Associated with dermatitis
herpetiformis or other
autoimmune disorders
Celiac Disease
• Gluten-sensitive enteropathy
• Allergy to wheat, rye, barley, oats
• Diagnosis
–
–
–
–
Anti-tissue transglutaminase (tTG) most useful
IgG/IgA antigliadin antibodies
Anti-endomysial antibody less sensitive
HLA –DQ2 or HLA-DQ8
• Treat with gluten free diet
• Steroids for refractory disease
Celiac Disease
Whipple’s Disease
• Tropheryma whipplei (G + Bacilli)
• PAS positive material in macrophages
• Dx by PCR on Biopsy or CSF
Whipple’s Disease
• Clinical Features
- Intermittent episodes of polyarthritis
- Diarrhea with wt. loss
- CNS: Dementia, myoclonus, ophthalmoplegia
- Psych: Depression and personality changes
- Card: pericarditis, myocarditis
• Treatment:
IV Ceftriaxone x 2 weeks followed by oral Bactrim
x 12-18 months
Toxic megacolon
• Acute toxic colitis with
colonic dilation
• Complication of ischemic
colitis, infectious colitis,
C.diff, IBD, etc
• Signs of sepsis
• Can result in perforation
• Management: IVF, replete
electrolytes, IV antibiotics,
colonic decompression,
consult surgeon
• Surgery indications
Chronic constipation management
•
•
•
•
•
•
•
Increase fluid and fiber intake
Bulking laxatives
Stool softeners
Osmotic agents
Stimulant laxatives
Enemas – soap suds, mineral oil, gastrograffin
Lubiprostone and linaclotide
Colonic inertia
• Severe form of slowtransit constipation
• Disordered colonic
motor function
• Sitz marker test
• Conservative
measures tried first
• If symptoms persist,
may need surgery
Question
55 y/o F presented with a 2-month
history of profuse watery diarrhea up
to 5 times per day without bleeding,
abdominal pain or vomiting. She had
lost 5lbs but there was no history of
iritis, arthritis, rashes or aphthous
ulcers. Exam was normal. Labs
revealed a normal CBC, CMP, and CRP.
There was no growth on stool culture.
Colonoscopy was normal without
ulceration. Her biopsies are shown.
What is causing her symptoms?
A.
B.
C.
D.
Crohn’s disease
Ulcerative colitis
Microscopic colitis
Irritable bowel syndrome –
diarrhea predominant
Question
55 y/o F presented with a 2-month
history of profuse watery diarrhea up
to 5 times per day without bleeding,
abdominal pain or vomiting. She had
lost 5lbs but there was no history of
iritis, arthritis, rashes or aphthous
ulcers. Exam was normal. Labs
revealed a normal CBC, CMP, and CRP.
There was no growth on stool culture.
Colonoscopy was normal without
ulceration. Her biopsies are shown.
What is causing her symptoms?
A.
B.
C.
D.
Crohn’s disease
Ulcerative colitis
Microscopic colitis
Irritable bowel syndrome –
diarrhea predominant
Irritable bowel syndrome
• Chronic crampy abdominal pain, alternating
bowel habits, improves with defecation
• Rome criteria
• Treatment:
- Reassurance
- Dietary modifications including low FODMAP
diet
- Adjunctive medical therapy
Inflammatory Bowel Disease
Crohn’s disease Ulcerative colitis
Lesions
Focal, skip, deep
Shallow, continuous
Clinical Course
Indolent
More acute
Steroids
Less responsive
Very responsive
Granuloma
Pathognomonic
None
Rectal
Involvement
Perianal disease
Rectal sparing
Rectum involved
Abscesses, fistulas None
IBD Clinical Pearls
•  GI CA  UC >>> Crohn’s
• Toxic megacolon  Both
– BE contraindicated in acute exacerbation
• Smoking & CD   risk exacerbation
• Smoking & UC  UC symptoms can start
w/tobacco cessation
Crohn’s Disease: Pearls
• Bimodal age distribution
– Peak 20-30s
– Smaller one in 70-80s
– ASCA+ in 50-60%
• Granulomas are pathognomonic…
…but seldom seen
• “String sign” in TI on SBFT
• 30% colon, 40% SB, 30% both
– “mouth to anus”
Ulcerative Colitis: Pearls
• Area of involvement
– proctitis
– left-sided colitis
– pancolitis (“universal
colitis”)
• 70-80% P-ANCA +
IBD Treatments
• 5 ASA
– Several designer drugs
– “col” = colon (Asacol, Colazal…)
• Steroids—avoid if possible
– Budesonide (Entocort)
• Azathioprine/6-MP
– Immunomodulator
– Steroid-sparing agent
– Monitor for adverse effects
• Methotrexate
• Antibiotics
• Anti-TNF therapies
– Fistulizing disease
– Unresponsive to conventional therapy
IBD Extraintestinal Manifestations
•
•
•
•
•
•
Usually seen in colitis therefore more common in UC
Seronegative arthropathy
Uveitis, Ankylosing Spondylitis (HLA-B27)
Erythema nodosum
Pyoderma gangrenosum
Primary sclerosing cholangitis (HLA-B8)
– PSC, check ALP annually  2X ULN  ERCP/MRCP
• Osteoporosis
• HLA associated manifestations do not correlate with
course of colitis
UC and Cancer
• Duration & extent of disease, age at dx increases risk
– Ulcerative Proctitis has no  risk CA
– 10 years  2%
– 20 years  15%
• Pancolitis- begin at 8 years (AGA guidelines)
• Left sided colitis- begin at 15 years (AGA guidelines)
• Colonoscopies are generally performed q1-2 years after
surveillance is started, depending on findings
• High-grade dysplasia or cancer  colectomy
• Low grade dysplasia management is controversial
Physical Exam Pearls
• Emaciation, cheilosis, glossitis
– Severe malabsorption
• Associated dermatitis herpetiformis
– Celiac sprue
• Associated pyoderma gangrenosum
-- IBD
• Arthritis
– IBD or Whipple’s
• Pulmonic stenosis and tricuspid regurgitation
– Carcinoid syndrome
Physical Exam Pearls
• Associated neuropsychiatric findings
– Whipple’s disease
• Abdominal mass
– Malignancy, Crohn’s, diverticulitis
• Localized abdominal tenderness
– Inflammatory condition
• Perianal ulcers/fistulas, reduced sphincter
tone/incontinence/right sided abdominal pain
-- Crohn’s
• Peripheral or autonomic neuropathy
– May correlate with visceral neuropathy in DM and
intestinal pseudo-obstruction
Questions?