Transcript - Catalyst - University of Washington

Gastroenterology for the MS3
Sabeena Setia, MD
Clinical Assistant Professor
Department of Medicine
University of Washington
[email protected]
Outline
• Case-based review of common and
important GI diseases
• Objectives:
– Review clinically relevant pathophysiology
– Differentiate sick from not-sick
– Be able to generate a thoughtful workup and
diagnosis-based management plan
– How to call a GI consult
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?
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a)Place a RIJ 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 thiamine
0% 0% 0% 0%
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
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•
•
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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
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
UPPER GI BLEED
Stable vs Unstable?
DOESN’T DEPEND ON HCT
Hct does not fall immediately with acute bleed
Requires 24 –72 hours for extravascular fluid
to enter intravascular space and result in
decreased Hct
Transfusion threshold
Screening, Randomization, and Follow-up
• Randomized
clinical trial
• Patients with GI
bleeding
• Restrictive: no
transfusion until
Hgb < 7 g/dL
• Liberal: no
transfusion until
Hgb < 9 g/dL
• Clinical outcomes
Villanueva C et al. N Engl J Med 2013;368:11-21.
Restrictive: improved outcomes
45% relative-risk
reduction in
mortality
Liberal group:
Rates of further
bleeding
Transfusion
reactions
Cardiac events
Length of stay
Villanueva C et al. N Engl J Med 2013;368:11-21.
Mr. V
• 48 y.o. M vomits red blood in ED
– Reports melena x 24 hours
– Vomiting at home: “a bucket full”
• 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
What are the next steps in
management for Mr. V?
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a) Admit to ICU, intubate and start PPI
b) Admit to ICU, intubate, start
octreotide, PPI and antibiotics
c) Call GI, start octreotide and PPI
d) Admit to floor and start octreotide,
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PPI, antibiotics
Case 2
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Two large bore IV’s placed, IV NS started
Admit to ICU
Intubated
Octreotide and PPI infusions started
PRBCs, FFP, platelets transfused
Started 7 day course of antibiotics
Prompt endoscopy performed
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
The EGD for Mr. V shows small varices, what is
the appropriate treatment and discharge plan?
a. Endoscopic Ligation and Non
selective B-blocker for life
b. Endoscopic Ligation and repeat EGD
yearly
c. Endoscopic Ligation, Non selective Bblocker and repeat EGD regularly
Esophageal Varices
All patients with new diagnosis of cirrhosis need a
screening EGD
How often do they need follow up?
• No varices, with compensated cirrhosis-> EGD q3yrs
– If they decompensate, rescreen and repeat EGD
annually
• No varices with decompensated cirrhosis->EGD usually
yearly
World J Gastroenterol. May 14, 2014; 20(18): 5442–5460.
Esophageal Varices
Documented Small varices <5mm  consider Beta-blockers
– if BB, then no follow up needed unless they
compensate or bleed
– if no BB, then repeat EGD every 2 years
Medium-Large  beta-blocker
Medium-large WITH stigmata or Childs B/C then BB OR
ligation
– if EVL then repeat EGD q2 weeks until obliteration,
then q3 months, then 6-12 months
Esophageal Varices
All patients diagnosed with cirrhosis need a screening EGD
www.elsevierimages.com
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
0%
Ciprofloxacin
Half Normal Saline
Lactated Ringers ...
Albumin
After 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?
Spironolactone
Furosemide
100:40
Salt Restriction
Second Line
Diuretics
TIPS
Repeated
Paracentesis
World J Gastroenterol. May 14, 2014; 20(18): 5442–5460.
Liver signs: Acute or Chronic?
Acute Liver Injury
Chronic Liver Disease
• Swollen, enlarged liver
• Tender liver
• Jaundice
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Muscle wasting
Spider angiomata
Ascites, edema
Fragile skin
Bruising
Ms. C
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 Tbili 11.6mg/dL
ALT 1599 U/L INR 1.9
albumin 3.2
How do you manage Ms. C’s illness?
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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
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d) Admit to hospital
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.
What is the appropriate strategy to offer Ms. L
to screen her for colorectal carcinoma?
a) Digital rectal examination with stool guaiac,
now
b) Fecal occult blood testing every other year
c) Flexible sigmoidoscopy every 5 years
d) Colonoscopy every 10 years
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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. 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
0%
Angiodysplasia
Colorectal cancer
Peptic ulcer dise...
Diverticular blee...
Ms. F
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 Ms. F’s likely diagnosis?
a) Esophageal adenocarcinoma
b) Systemic sclerosis
c) Gastric carcinoma
d) Zenker’s Diverticulum
a) Esophag...
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d
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
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Laxative
abuse
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c) Irritable bowel syndrome
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Small bowel overgrowth syndrome
Mr. F
21 yo gentleman presents with
8-10 bowel movements per day, abd
pain, and tenesmus x 3 months
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)Endoscopy
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Mr. G
• 68 yo gentleman presents with
severe epigastric pain of 1 day
duration
• Drinks 2 glasses of wine a day
• Amylase and lipase are >5 x ULN
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
Acute Pancreatitis
Search for a cause
– ALL PATIENTS GET RUQ US
– 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
No role for antibiotics unless necrosis is extensive
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.
0%
Norovirus
Staph aureus
E. coli
Salmonella spp.
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)
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RUQ U/S
b)
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Diagnostic paracentesis
c)
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Discharge home with a Z-pack
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d)
Admit for observation
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
0%
Colonoscopy
Small bowe...
Upper endo...
CT scan ABD
Celiac Disease
True statements regarding the serologic
diagnosis of celiac disease include:
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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
0% 0% 0%
screen
Tis
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Celiac disease con’d
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True statements regarding celiac disease
include all the following except:
The prevalence in the U.S. is ~ 1:300
Diagnosis requires a compatible small bowel
biopsy with clinical response to gluten
withdrawal
Affects those mainly of Northern European
decent and is strongly associated with HLA DQ
locus
Rarely presents in adulthood
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?
CT Abdomen/Pelvis
Start Vancomycin/Zosyn
Consult general surgery
Insert chest tube
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CT
a)
b)
c)
d)
Mr. B
64 yo 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
0%
Referral for uppe...
Start an SSRI
Start a PPI
Start oxycodone
Mr. B, Part Two
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
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
0%
Beta blocker
Botulinum toxin i...
Calcium channel b...
Endoscopic dilation
Mr. Y
76 year old Korean-speaking 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?
Acute abdominal series
RUQ Ultrasound
MRCP
CT Abdomen/Pelvis
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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
THE END
Thanks for your attention!