Transcript - Catalyst - University of Washington

Gastroenterology for the
Medicine Clerkship
Daniel Doan, MD
VA Primary Care
Department of Medicine
University of Washington
[email protected]
Original slides prepared by Moe Hagman, MD
Outline
• Case-based review of common and
important GI diseases you will encounter
• Objectives:
– Differentiate sick from not-sick
– Be able to generate workups and diagnosisbased management plan
– Answer frequently pimped questions
– Ace the GI section on the shelf
– How to call a GI consult
The esophagus and stomach
Mr. D
45 yo man presents to ER vomiting
blood. He is able to give you a
brief history
He drinks 10 beers a day and has
been using aspirin for back pain.
BP 90/52, HR 122. Exam shows
stigmata of chronic liver disease.
While waiting for labs to come back,
what’s the next management step?
a) Place a central line and start normal saline
b) Place 2 large bore PIVs and start propranolol
c) Place 2 large bore PIVs and start normal
saline
d) Administer IV thiamine
Upper GI bleed
• A patient vomiting frank blood cannot protect their
airway
• Physical exam should include orthostatic vital signs
– Drop in SBP of 20mm Hg or drop in DBP of 10mm Hg
– Orthostatic hypotension = blood loss of at LEAST 15%
– Supine hypotension = blood loss of 40%
• Consider them unstable unless proven
otherwise
Classification of GI Bleeding
• UGIB: Bleeding from above the Ligament of Treitz
– Melena
– Coffee ground emesis
• LGIB: Bleeding from below the Ligament of Treitz
– Hematochezia – passage of fresh blood through
rectum
– Darker hematochezia can indicate brisk UGIB
• Small bowel bleeding: From Ligament of Treitz to
IC valve
Useful Terms in GI Bleeding
•
•
•
•
•
•
Melena
Hematochezia
Bright red blood
Hematemesis
Coffee grounds
Occult
Black, tarry, foul smelling
Maroon or Bright red
Red
Blood in vomitus
Black, particulate vomit
Evident only on testing
BAD
Major causes of upper GI bleeding
11%
PUD
4%
Esophageal varices
4%
AVM
MWT
1%
Dieulafoy's
5%
Neoplasm
Erosions
55%
6%
14%
Other
Jutabha. Med Clin North Am 1996
Stable vs. Unstable?
Don’t be fooled by the crit!
Hct does not fall immediately with acute bleed
Requires 24 –72 hours for extravascular fluid
to enter intravascular space and result in
decreased Hct
Orthostatic vitals/rectal exam can be helpful
Transfusion threshold
•
•
•
•
Randomized clinical trial
Patients with GI bleeding
Restrictive: no transfusion until Hgb < 7 g/dL
Liberal: no transfusion until Hgb < 9 g/dL
Restrictive: Improved outcomes
• Restrictive group: Less is more!
• 45% relative-risk reduction in
mortality
• Liberal group:
• Higher rates of further bleeding
• More transfusion reactions
• More cardiac events
• Increased length of stay
Mr. V
• 48 year old man vomits red blood in ED and
reports ongoing melena for the past 24 hours
• PMH: EtOH abuse, HCV, no prior GI bleeding
• Meds: None
• PE: BP 74/48, HR 135, Sat 93%, afebrile
– Abd: distended, shifting dullness, nontender
– Rectal: maroon stool
– + spider angiomas, scleral icterus
– Neuro: lethargic but oriented, +asterixis
• Labs: Hct 16, plt 45, INR 2.1, TB 3.5
In addition to resuscitation, what is
the next best step?
a) Admit to floor and start octreotide
b) Admit to floor and start octreotide and
PPI
c) Admit to ICU, intubate, start
octreotide and PPI
d) Admit to ICU, intubate, start
octreotide, PPI, and antibiotics
Infections and GI Bleeding in Cirrhosis
• At presentation: 20-25%
• Prior to discharge: 50%
• Types of infections
–
–
–
–
UTI: 12-29%
SBP: 7-29%
Pneumonia: 6-10%
Bacteremia: 4-11%
• Significant associated mortality
• Antibiotics x 7 days (usually ceftriaxone)
Esophageal Varices
• All patients with new diagnosis of cirrhosis need a
screening EGD
• Compensated cirrhosis -> EGD every 3 years
• Decompensated cirrhosis -> EGD annually
• Long term management
• Beta-blockers (propranolol)
• Endovascular ligation
• Serial EGD surveillance
World J Gastroenterol. May 14, 2014; 20(18): 5442–5460.
Ms. B
• A 40 year old woman
presents to PCP
complaining of difficulty
swallowing and frequent
regurgitation.
• Barium radiography
reveals the following:
What therapy is most likely to give
Ms. B a durable treatment?
a) Beta blocker
b) Calcium channel
blocker
c) Botulinum toxin
injection
d) Endoscopic dilation
Mr. B
• 47 year old middle manager at a
software company with recurrent
vague aching discomfort in the mid
upper abdomen for 3 months. He’s
been taking Motrin with some relief
in symptoms.
• No heartburn. Occasional bloating.
• No improvement with OTC H2
blocker.
What is the appropriate next step
for Mr. B ?
a) Referral for upper
endoscopy
b) Start a PPI
c) Start an SSRI
d) Start oxycodone
e) Stop NSAIDs
Dyspepsia – Alarm Features
• History
–
–
–
–
–
–
New onset >55 years old
Dysphagia/odynophagia
Early satiety
Vomiting
Anemia/bleeding
Unexplained wt loss
• PMH
– PUD
– Malignancy
– Gastric surgery
• Family Hx
– GI malignancy
• Exam
– Lymphadenopathy
• Sister Mary Joseph sign
– Abdominal mass
Talley NJ, et al. Am J Gastroenterol. 2005; 100:2324-37.
Dyspepsia - Causes
• GERD
• Peptic ulcer disease
• Functional (non-ulcer) – 60% of cases
Dyspepsia - Treatment
• If alarm features
– EGD
• If no alarm features
– Try to stop any NSAIDS
– Empiric acid suppression
• PPI x 4-8 weeks
– Or, in patient populations with high H. pylori
prevalence, test and treat
Talley NJ. Gastroenterology. 2005; 129:1753-5.
H. pylori testing
• Test in patients with
– Peptic ulcer disease (PUD)
Resolution at
12 months
H. pylori NOT
treated
H. pylori
treated
Gastric ulcer
61%
97%
Duodenal
ulcer
65%
98%
– Gastric mucosa-associated lymphoid tissue (MALT)
lymphoma
• Treatment leads to tumor regression in 60-90%
– Uninvestigated dyspepsia without alarm features
Chey WD, et al. Am J Gastroenterol. 2007; 102:1808-25.
H. pylori testing
• EGD with gastric biopsy
– Gold standard, associated risks of endoscopy
• Serology
– Inexpensive
– NPV good, PPV depends
– Remains positive for 6-12 mo after eradication
• Urea breath test
• Stool antigen
False negatives within
2
wks of PPI or abx, more
expensive than serology
Chey WD, et al. Am J Gastroenterol. 2007; 102:1808-25.
GERD
• Symptoms or mucosal damage caused by the
abnormal reflux of stomach contents into the
esophagus
• Diagnosis
– Empiric acid suppression
• High dose PPI – sensitivity 75%, specificity 55%
– EGD
– Ambulatory reflux monitoring
– Esophageal manometry
DeVault KR, et al. Am J Gastroenterol. 2005; 100:190-200.
Mr. B
• Endoscopy with biopsy yields a diagnosis of gastric
mucosa associated lymphoid tumor (aka MALToma).
• The stomach biopsy also shows H. pylori.
• Staging shows limited stage disease.
What is the appropriate first line
therapy for treating this tumor?
a)
b)
c)
d)
Propranolol
H. pylori eradication
Radiation
Azathioprine
Mrs. S
• 56 year old woman without past
medical history presents to clinic
reporting 6 month history of food
“getting stuck” in her mid-chest
• Her photo is shown
Consultant. July 2003.
What is Mrs. S’s likely diagnosis?
a) Esophageal adenocarcinoma
b) Scleroderma
c) Gastric carcinoma
d) Zenker’s Diverticulum
The pancreas
Mr. G
• 68 year old man presents with
severe epigastric pain of 1 day
duration
• Drinks 2 glasses of wine a day
• Lipase is >5 x ULN
• VS: 37.3 HR 94 BP 110/86
Which order is least useful for Mr. G?
a) LR at 200 cc/hr
b) Check triglycerides level
c) NPO except medications
d) Ampicillin/sulbactam
e) IV opiate pain medication
Acute Pancreatitis
Search for a cause
– All patients should get RUQ ultrasound
– Gallstones and ETOH are most common
– Mass, hypertriglyceridemia, trauma (MVA, ERCP)
– If young person with pulm or GI disease, think about
cystic fibrosis
– In older patients think of malignancy
Therapy
– Hydration, hydration, hydration! Often 5-10 L.
– Bowel rest
– Pain control
– No role for antibiotics unless infection suspected
The small bowel
Mr. B
• 52 year old male referred for evaluation of
anemia detected on routine blood work
• No significant complaints or past history
• Reports occasional loose stools but no
abdominal pain or weight loss
• Exam - Pale with slight temporal wasting; skin
w/out lesions; abdomen nondistended/nontender
Mr. B (continued)
• Labs – Hct 23, MCV 120
– B12 < 60 (>224), folate nl; ferritin 3
– albumin 3.2, calcium 8.2
– fecal fat > 60 droplets per hpf
The most appropriate diagnostic test for
Mr. B is:
a) Colonoscopy
b) Small bowel xray
c) Upper endoscopy
with small bowel
biopsy
d) CT scan ABD
Celiac Disease
True statements regarding the serologic
diagnosis of celiac disease include:
a)
b)
c)
d)
Tissue transglutaminase IgA is the most
sensitive serologic test
Anti gliadin antibodies have a high
positive predictive value for celiac disease
Serologic tests are not affected by dietary
gluten restriction
Total IgA is not recommended as part of
the initial screen
Celiac disease cont’d
True statements regarding celiac disease include all
the following except:
a) The prevalence in the U.S. is ~ 1:300
b) Diagnosis requires a compatible small bowel biopsy with
clinical response to gluten withdrawal
c) Affects those mainly of Northern European decent and is
strongly associated with HLA DQ locus
d) Rarely presents in adulthood
Ms. A
• 45 year old woman presents to
the ER with 3 days of
abdominal pain, distension,
nausea, and vomiting
• History of Crohn’s disease,
multiple abdominal surgeries
• Vital signs stable, abdominal
exam shows distended
abdomen without peritoneal
signs
• Abdominal radiograph shows
SBO
Ms. A
All of the following are conservative
management strategies for SBO except:
a) IVF
b) Electrolyte replacement
c) NG tube
d) Escalating doses of opiate pain control
e) NPO
Small bowel obstruction
• Partial vs. complete
– Passage of gas/formed stool -> partial
– Absence -> complete
• Why it matters
– 80% partial obstructions resolve non-operatively
– 40% complete obstructions resolve nonoperatively
• When in doubt, involve general surgery
Conservative Management of SBO
•
•
•
•
•
•
NPO, IVF
Avoid bowel slowing medications
Keep K>4, Mg>2
NG-tube (quickens resolution)
Ambulation
Serial abdominal exam
The Liver and Gallbladder
Mr. C
A 63 year old man with known
cirrhosis secondary to
hepatitis C presents to the ER
with tense ascites. A large
volume (6L) paracentesis is
performed.
What should you now give Mr. C to
prevent complications?
a)
b)
c)
d)
Ciprofloxacin
Lactated Ringers solution
Half Normal Saline
Albumin
After the procedure, Mr. C feels better. In reviewing
his chart, you discover that he has frequent ascites
and also had a history of variceal bleeding one year
ago. What treatments do you recommend?
a)Furosemide
b)Furosemide and spironolactone
c)Propranolol alone
d)Furosemide, spironolactone, propranolol
Management of ascites
• Every patient with new ascites needs a
paracentesis. Why?
• SAAG (serum ascites albumin gradient)
Serum albumin – ascites albumin
>1.1: Portal HTN (cirrhosis, CHF, budd chiari)
<1.1: Malignancy, pancreatitis, nephrotic syndrome
Management of Ascites
Salt Restriction
Second Line
Diuretics
Spironolactone
Furosemide
100:40
Repeated
Paracentesis
TIPS
World J Gastroenterol. May 14, 2014; 20(18): 5442–5460.
Cirrhosis
• Most common causes: Hep C, EtOH, NASH, hemochromatosis
• Complications: Hemorrhage, encephalopathy, hyponatremia,
SBP, hepatorenal syndrome
• Management:
– Serial ultrasound to screen for HCC
– Avoidance of EtOH
– Hepatic encephalopathy (lactulose or rifaximin)
– Ascites (diuretics, paracentesis)
– Liver transplant
Ms. E
• A 38 yo previously healthy woman
in clinic in Montana with 1 wk of
nausea, jaundice, fatigue, confusion
after treatment 3wks ago for UTI
with TMP/SMX
• Labs:
– AST 1240 U/L
– ALT 1599 U/L
– Tbili 11.6mg/dL
– INR 1.9
– Albumin 3.2
How do you manage Ms. E’s illness?
a) Have her come back tomorrow for lab
check
b) Refer to an allergist for sulfa-drug allergy
testing
c) Referral to hepatology clinic in 1-2 weeks
d) Admit to hospital
Liver signs: Acute or Chronic?
Acute Liver Injury
Chronic Liver Disease
• Swollen, enlarged liver
• Tender liver
• Jaundice
•
•
•
•
•
Muscle wasting
Spider angiomata
Ascites, edema
Fragile skin
Bruising
Liver lab patterns
Liver “damage” tests: AST, ALT, GGT, bilirubin, alkaline phosphatase
Liver “function” tests: Albumin, INR, platelets
Hepatocellular
• AST/ALT elevation
• Relatively normal alk phos,
GGT
• Possible bilirubin elevation
Cholestatic
• Bilirubin elevation
• Alk phos elevation, GGT
elevation
• Relatively normal AST/ALT,
though can be elevated if
severe congestion
Causes of liver/biliary disease
Very high transaminases: Shock, toxins, viral, autoimmune
Hepatocellular
•
•
•
•
•
•
•
•
Drugs, toxins (EtOH, tylenol)
Viral hepatitis
NAFLD
Heart failure
Ischemia
Hemochromatosis
Autoimmune hepatitis
Wilson’s disease
Cholestatic
• Choledocholithiasis
• Primary sclerosing
cholangitis
• Primary biliary cholangitis
• External compression
• Infiltrative diseases
• Meds (anabolic steroids,
terbinafine)
Test tip!
Disease
Epidemiology
LFT pattern
Tests
Autoimmune
hepatitis
F>M, bimodal
distribution
Transaminitis >
Cholestatic
anti-SM, soluble
liver antigen (SLA),
SPEP (igG)
Primary biliary
cirrhosis
F>M, onset 40-50s
Elevated alk phos
AMA, SPEP (IgM)
Cholestatic >
Transaminitis
MRCP
Primary sclerosing M>F, age 30-40,
cholangitis
assoc. IBD
Mr. C is back
• It’s been 6 months since this patient was
started on therapy. His ascites is present,
but now much better controlled. He comes
back to the ER with 1 day of fever and
malaise.
• Abdominal exam shows a non-distended
abdomen with a fluid wave, and he is soft
and not tender.
• WBC 8, BUN/CR normal. CXR is clear.
Urinalysis is benign.
What’s the appropriate next step for
Mr. C?
a) RUQ U/S
b) Diagnostic paracentesis
c) Discharge home with cipro
d) Admit for observation
Mr. Y
• 76 year old man brought in to the
ER by family for confusion.
• Exam shows temperature 38.6,
jaundice, and right upper quadrant
abdominal tenderness.
• Labs show bilirubin 11.9 and
alkaline phosphatase 453. WBC is
14, Hct 42, Plt 225.
What test would you next like to
get for Mr. Y?
a)
b)
c)
d)
Acute abdominal series
RUQ Ultrasound
MRCP
CT Abdomen/Pelvis
The colon
Ms. L
• A 52 year old woman is establishing care in your clinic.
She has no significant past medical history, and no
family members who have had cancer.
• She has the following positive test:
What is the next most appropriate test to offer
Ms. L to screen her for colon cancer?
a) Digital rectal examination
b) Repeat fecal occult blood testing every other
year
c) Colonoscopy
d) CT colonography
e) FOBT shouldn’t have been obtained, do
nothing
Ms. L continued
• What if she had an mother with colon cancer?
• What if she had a cousin with colon cancer?
• What if she had a cousin and an aunt with
colon cancer?
Ms. Y
• 77 year old woman with atrial fibrillation who takes
dabigatran. She presents with a one day history of
bright red bleeding per rectum which has self
resolved. She has no dizziness or palpitations.
• HR is 78
• Hct is 31
What is Ms. Y’s most likely diagnosis?
a)
b)
c)
d)
Angiodysplasia
Peptic ulcer disease
Colorectal cancer
Diverticular
bleeding
Ms. Z
28 year old woman presents to clinic complaining
of abdominal discomfort and alternating
diarrhea and constipation starting one year ago.
ROS is negative for weight loss,
melena/BRBPR, or family history of colon
cancer. PMH shows depression.
What is Ms. Z’s likely diagnosis?
a) Inflammatory bowel disease
b) Laxative abuse
c) Irritable bowel syndrome
d) Small bowel overgrowth syndrome
Mr. F
• 21 yo man presents with 3
months of 8-10 bowel
movements per day, abd pain,
and tenesmus
• BMs are loose and bloody
• Skin exam is shown
What’s the appropriate next step for Mr. F?
a) Triamcinolone ointment
b)Sulfasalazine
c) Stool studies
d)Colonoscopy
Test tip!
Ulcerative Colitis
Crohn’s Disease
Crypt abscesses and superficial
inflammation colon/rectum only
Linear ulcerations with “skip” areas
involving entire GI tract
p-ANCA positive in 75%
p-ANCA positive in 10%
Anti-saccharomyces cerevisiae
antibodies (ASCA) present 10%
ASCA present 60%
Smoking alleviates symptoms
Smoking risk factor for disease
Ms. E
• 19 yo woman calls with c/o
watery loose stools one day
after a picnic. Other family
members have similar
symptoms. But she’s had a
nosebleed as well and she feels
weak.
• Labs: BUN 55, Cr 4.0, WBC 13,
Hct 35, Plt 33
What pathogen is most likely the
cause of Ms. E’s symptoms?
a)
b)
c)
d)
Norovirus
Staph aureus
E. coli
Salmonella spp.
Mr. F comes back to clinic
• Colonoscopy showed Crohn’s disease
• Started on prednisone and then
azathioprine and symptoms initially
improved
• Now he has vague diffuse abdominal
pain that is different than prior
symptoms
• No fever. BP 100/60, HR 90.
• Mild diffuse TTP. No
rebound/guarding.
Mr. F
What’s the next step for Mr. F?
a) Run away screaming, you’re an
internist for heaven’s sake
b) CT abdomen
c) Consult general surgery
d) Insert chest tube
e) Start vancomycin/zosyn
The rectum
Mr. H
• 75 year old man comes in within 24 hours of
acute pain in his rear
• History of hemorrhoids, current pain is similar
but has not responded to preparation H or sitz
bath
• Exam shows the following:
www.uptodate.com
What is the next appropriate step?
a) Reassurance, continue conservative
management
b) Reduce the lesion, then conservative
management
c) General surgery referral within 7-10 days
d) Same day general surgery referral
Hemorrhoids
• Conservative management
– Fiber supplementation
– Topical steroids
– Sitz bath
• Thrombosed hemorrhoids
– Best surgical results if <72h
– Otherwise lidocaine
How to call GI consult
• Know your patient/story
• Specific reason for consult
• Is it urgent or not
– Will they need an intervention in next few hours?
• What do YOU think is going on?
• If patient is bleeding YOU MUST DO rectal
exam
• Know labs and current vital signs
Questions?
[email protected]