Gastroenterology for the Boards - Part I

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Gastroenterology for the Boards - Part I

• Adib Chaaya, MD
• ACP, ACG, ASGE
• 11/19/2008

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Lips
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Lips

• Herpes blisters

• Impetigo
• Honey crust
• Group A strep
• Azithro / Clarithro

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Lips
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Lips /Peutz-Jeghers Syndrome

• Associated with benign harmatoma
• Polyps of the intestine
• Complicated with cancers (mainly small bowel),
  and cancers of the lung, breast, uterus and ovary

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Tongue
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Tongue
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Tongue / Geographic Tongue

• Temporary loss of the papillae
• No treatment needed

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Mouth Ulcers
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Mouth Ulcers

• Painful
• Aphthous ulcers (Celiac, IBD)
• Behcets Disease
• Herpes
• Pemphigus vulgaris

• Painless
• SLE
• AIDS
• Reiters Syndrome

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Esophagus

• 66 y/o M p/w dysphagia for solid food initially
  that gradually progressed to dysphagia to solids.
• What is the first test to order?

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Esophagus

• Barrium swallow showed a stricture of the
  esophagus
• What is your next step?

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Esophagus/ Dysphagia
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Esophagus/ Dysphagia

• Dysphagia
• Weight loss think Cancer
• Intermittent web, ring
• Solid and liquid neuromuscular, diffuse
  esophageal spasm, scleroderma, achalasia
• Chronic GERD peptic stricture

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Risk factors for Esophageal Ca

• Smoking (SCC)
• Alcohol (excessive ingestion)- (SCC)
• Barretts esophagus
• Achalasia

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Esophagus /Benign Stricture

• 34 y/o M p/w Dysphagia. Work up showed benign
  peptic stricture treated with dilatation and a
  PPI.
• He improved a lot and has no more dysphagia.
• How long would you continue the use of the PPI?

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Esophagus

• Achalasia
• Lack of peristalsis
• Incomplete relaxation of LES
• Dg on esophageal manometry
• Pneumatic dilation or surgical myotomy
• Diffuse Esoph Spasms
• Simultaneous contractions with intermittent
  normal peristalsis
• Nitrate, calcium channel blocker

• Nutcracker Esophagus
• High amplitude peristaltic contractions
• Hypertensive LES
• High LES pressure
• Normal LES relaxation
• Ineffective motility
• With scleroderma
• Weak peristalsis
• Low LES

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Esophagus

• 35 y/o F has dysphagia for solids and liquids.
  Barium swallow showed dilated esophagus with bird
  beak appearance.
• What is you next best test
• 24 h PH monitoring
• EGD
• Motility studies
• Trial of PPI

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Achalasia vs pseudoachalasia

• Cancer of the fundus can invade around the
  esophagus and cause symptoms similar to
  achalasia.
• Biopsies of the lower esophagus must be done to
  rule out malignancy.

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When to do motility studies?

• Achalasia
• Esophageal spasm
• Scleroderma

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Esophagus

• 25 y/o F p/w couple of month history of severe
  heartburn.
• What do you do?
• EGD
• PH monometry
• Trial of PPI
• Clinical monitoring

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Esophagus/ GERD

• Lifestyle modification
• Weight loss
• Stop smoking
• Elevate head of bed
• Allow enough time between dinner and sleeping

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Esophagus/ GERD

• H2Receptor blocker
• PPI
• Most rapid and complete symptom relief
• Faster mucosal healing
• Endoscopy
• Screen for Barretts in long standing symptoms
• If alarm symptoms
• Dysphagia
• Anemia/Bleeding
• Weight loss

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Esophagus/ GERD

• Antireflux surgery
• Same efficacy as PPI
• Before surgery esophageal manometry is necessary
• pHmetry
• To confirm the diagnosis in non erosive GERD
• Evaluate patients not responding to therapy
• Evaluate extraesophageal manifestations of GERD

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Esophagus/ GERD

• GERD is the most common cause of non cardiac
  chest pain
• The diagnosis is confirmed by 24h pHmetry or
  successful trial of PPI (usually high dose and
  for long term)

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Esophagus / Barretts

• 63 y/o M with Barretts esophagus is found to
  have NO dysplasia . Started on PPI.
• What is your next step?
• EGD in 1 year
• Esophagectomy
• EGD in 3 years.
• NPO/ TPN and monitoring

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Esophagus / Barretts

• Barretts occurs in patients with early age at
  onset and long standing heartburn
• Adenocarcinoma is now as frequent as squamous
  cell carcinoma
• Barretts is present in up to 10 of patients
  with GERD
• Screening for Barretts is appropriate in
• Older patients (gt50)
• Long-standing GERD symptoms (gt5 years)
• Especially white men

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Management of Barretts

• No dysplasia PPI EGD Q2-3 years with biopsies
  to r/o dysplasia
• Low grade dysplasia PPI EGD Q6-12 months with
  biopsies to r/o high grade dysplasia.
• High grade dysplasia esophagectomy

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Esophagus

• 27 y/o F with history of GERD p/w throat pain and
  odynophagia she takes doxyclcline for acne.
• What is your differential diagnosis?
• How do you confirm it?

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• What is your differential diagnosis?
• Pill induced esophagitis
• How do you confirm it?
• EGD shows esophagitis with a solitary
  small ulcer in the lower esophagus..

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Esophagus/ Odynophagia
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Esophagus/ Odynophagia

• Pill esophagitis always on the board
• HIV patient with odynophagia
• Candida
• HSV
• CMV
• Idiopathic ulcer
• Severe esophagitis secondary to GERD can cause
  odynophagia

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Differential diagnosis for Odynophagia

• Monilia
• white lesion
• Bx/brushing shows hyphae
• Candia is the most common cause
• Treatment fluconazole

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Differential diagnosis for Odynophagia

• HSV
• Many small ulcers
• Bx multinucleated giant cells
• Tt acyclovir

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Differential diagnosis for Odynophagia

• CMV
• 1-2 ulcers
• Bx CMV inclusion bodies
• Tt gancyclivir

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Esophagus

• 45 y/o p/w chest pain. Was having for 2 days
  retching and vomiting.
• X ray showes Left pleural effusion. Pleural tap
  showed high amylase.
• What is your next step?
• Gastrographine study
• CPK
• EDG
• CT scan

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Esophagus / Boerhaave syndrome

• Mimics acute MI
• Mediastinal emphysema can develop
• Diagnosed by swallowing gastrographine (for the
  Boards)
• Treatment
• Esophageal and gastric suction
• Antibiotics
• Surgical drainage
• Repair of laceration

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Stomach / PUD

• What are the 2 most common causes of PUD?
• NSAID
• H.Pylori
• Steroids
• Idiopathic

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Stomach / PUD

• H.Pylori is responsible of
• 50 to 80 of duodenal ulcers
• 40 to 60 of gastric ulcers
• 80 of gastric cancers
• 90 of gastric lymphomas (if MALTgt treat H
  pylori)
• The lifelong incidence of ulcer disease in those
  infected with H.Pylori is only 20

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Stomach / PUD

• Gastric ulcers should be biopsied to R/O
  malignancy, as opposed to duodenal ulcers.
• H.Pylori should be checked, usually on biopsy, if
  not possible serology is appropriate
• Detection of H.Pylori
• Endoscopic
• Culture
• Histology
• Urease testing

• Non Endoscopic
• Antibody tests
• Urea breath test
• Fecal antigen test

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Stomach / PUD

• Treatment regimens
• PPI/Amox/Clarithromycin
• PPI/Flagyl/Clarithromycin
• PPI/Peptobismol/Flagyl/Tetracycline
• 14 days better than 10 days

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Stomach / PUD

• Risk factors for NSAID induced GI complications
• Advanced age (gt75)
• Pre-existing ulcer disease
• Multiple NSAIDs or high dose NSAIDs
• Concomitant steroid therapy or anticoagulant
  therapy
• Comorbid diseases

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Stomach / PUD

• Eradicating H.Pylori in NSAID users is still
  controversial
• But if NSAID induced gastropathy with H.Pylori,
  eradication is indicated
• NSAID gastropathy is a dose related phenomenon
• COX-2 selective NSAID result in fewer GI ulcers

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Stomach / GI prophylaxis

• When indicated to give GI prophylaxis
• Ventilator for gt 48 hours
• Coagulopathy

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Stomach / H pylori

• 41 y/o patient with history of duodenal ulcer
  treated for H pylori gastritis, but returns with
  the same symptoms
• Which of the following would best indicate
  continous infection with H pylori?
• IgG serology for H pylori
• Duodenal aspirate for H pylori
• Breath urease test /stool Ag for H pylori

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MALT / ZE

• 70 to 80 of MALT will regress when H.Pylori is
  eradicated
• Think about ZE when
• Recurrent ulcers on treatment
• Chronic diarrhea
• Other endocrine disorders (MEN)

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Stomach

• 46 y/o with type I diabetes presents for N/V,
  early satiety, vague epigastric pain for the past
  4 months. His condition will improve with
• PPI
• Low fat diet, small meals, control of DM, and
  Reglan
• Eradication of H.Pylori if present

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Stomach /Gastroparesis

• Causes
• Drugs
• Systemic disease (DM, Scleroderma..)
• Idiopathic, post viral
• Diagnosis
• Gastric Emptying Scan
• Treatment
• Prokinetics
• Surgery
• Nutritional support

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Stomach

• 51 y/o M h/o severe CAD has diffuse abdominal
  pain for 3 hours after eating any kind of food.
• The pain decreases with decreasing amount of food
  eaten.
• What is you diagnosis?
• What is you next step?

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Stomach / Abdominal Angina

• What is you diagnosis? gtabdominal angina
• What is you next step? gt mesenteric angiogam

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Acute Diarrhea

• 25 y/o female presents with 2 day hx of crampy
  abdominal pain and bloody diarrhea
• What is your differential?
• What if she is 75 y/o and has CAD and PVD?
• How do you manage this patient? Would you start
  abx?

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Acute Diarrhea

• The most common causes of acute bloody diarrhea
• Infectious dysentery
• IBD
• Ischemic colitis

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Acute Bloody Diarrhea

• Common causes of infectious dysentery
• Campylobacter, Salmonella
• Shigella, E.Coli (entero-invasive AND
  entero-hemorrhagic)
• Yersinia, Entameba histolitica, Aeromonas,
  Plesiomonas
• Seafood induced dysentery
• Vibrio parahemolyticus (mainly watery but can be
  bloody / patient in general with liver diseases)
• Plesiomonas shigelloides (AKA shigella)
• Campylobacter jejuni
• Clostridium Difficile

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Acute Diarrhea in HIV

• HIV with non bloody diarrhea
• Cryptosporidium
• Isospora Belli
• Cyclospora
• Microsporidia
• Giardia
• MAI

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Chronic Diarrhea

• 47 y/o obese female nurse presents for chronic
  diarrhea for the past 4 months. Stool studies and
  colonoscopy were normal. Stool Na 30, K 40.
• What is the fecal osmotic gap in her?
• Would a stool pH be helpful in this case?
• What is your differential?

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Chronic Diarrhea

• Fecal osmotic gap
• 280 2 x (NaK)
• If gt50? osmotic diarrhea
• Iflt50? secretory diarrhea
• With laxative abuse, the stools are acid (low
  pH), they will turn red with alkalinization

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Chronic Diarrhea

• Causes of osmotic diarrhea (gapgt50)
• Lactose intolerance
• Laxative abuse
• Intestinal malabsorption (celiac disease)
• With fasting ? less than 500g of stools

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Chronic Diarrhea

• Causes of secretory diarrhea (gaplt50)
• Enterotoxin mediated infectious diarrhea
• Hormone mediated (gastrin, VIP, serotonin,
  calcitonin)
• Secreting villous adenoma
• Microscopic colitis
• With fasting ? more than 500g of stools

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Chronic Diarrhea

• Inflammatory diarrhea
• Neutrophils in the stools, colonic ulcerations
• Causes
• IBD
• Radiation colitis
• Enteroinvasive infections

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Chronic Diarrhea

• Large volume
• Think about a proximal origin (small bowel..)
• Small volume
• Distal source (colonic..)
• Always look at the medications
• Endocrine causes DM, Hyperthyroidism
• C.diff and Giardia can give chronic diarrhea

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Chronic Diarrhea/ Short Bowel Syndrome

• 45 y/o male lost 150 cm of ileum after an MVA and
  extensive abdominal surgery.
• He presents with constant diarrhea.
• How would you manage this patient?

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Chronic Diarrhea/ Short Bowel Syndrome

• If resection is lt 100 cm, cholestyramine helps
  because the diarrhea is caused by colonic
  irritation by bile salts (bile salt diarrhea)
• If resection is gt 100 cm, the bile salt pool is
  depleted and cholestyramine will NOT help.
• Memorize
• RESECTION lt 100cm ? CHOLESTYRAMINE

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Chronic Diarrhea/ Fat Malabsorption

• Qualitative test for fat malabsorption
• Sudan stain in the stools (looks for fat cells)
• Quantitative test for fat malabsorption
• 24 hour stool fat
• 24 hour fecal collection following ingestion of
  100 gm fat diet for 3 days
• Fecal fat gt 7 gm/d is diagnostic of fat
  malabsorption.

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Chronic Diarrhea/ Fat Malabsorption

• What is the differential diagnosis?
• Pancreatic insufficiency
• Small bowel disease

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Fat Malabsorption / Small Bowel Disease

• Small bowel disease
• Check D-Xylose test
• 25 gm po
• check blood xylose levels in 1 hour if lt 25mg/ml
  gt malabsorbtion due to small bowel disease
• Check also 5 hour urine xylose if lt 5 gm
  gtmalabsorbtion
• If D-Xylose test normal gt pancreatic disease
• If abnormal gt check breath test or stool
  cultures to r/o bacterial overgrowth, and do a
  small bowel biopsies (whipple, amyloidosis,
  crohns, crypto, giardia, tropical sprue)

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Fat Malabsorption / Pancreatic Insufficiency

• For pancreatic insufficiency
• Check abdominal radiography (look for
  calcifications)
• Enzyme secretion lt10 of the normal

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Chronic Diarrhea

• 42 y/o male with iron deficiency anemia and
  chronic diarrhea. GI work-up including EGD,
  colonoscopy, capsule endoscopy is negative.
• Whats your diagnosis?
• Whats the next step?
• Whats the gold standard for the diagnosis?
• What is the skin manifestation associated with
  this condition?

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Some additional info???
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Chronic Diarrhea / Celiac disease

• Celiac sprue is caused by sensitivity to gluten
  and is characterized by malabsorption and
  diarrhea
• Antibodies to Gliadin, Endomysium and tissue
  transglutaminase are used for the diagnosis
• Small bowel biopsy is the gold standard for the
  diagnosis gt blunting and flattening of villi,
  elongated crypts and increase cellularity of the
  lamina propria
• Complications include lymphoma, ulcerative
  jejunoileitis
• Dermatitis herpetiformis is the associated skin
  condition
• Tropical sprue is infectious in source and is
  identical to celiac sprue, Klebsiella and E.coli
  are incriminated.

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Chronic Diarrhea / Tropical Sprue

• Tropical sprue is infectious in source and is
  clinically identical to celiac sprue, Klebsiella
  and E.coli are incriminated.
• Residents of certain tropical area (India,
  Southeast Asia, Cuba, Porto Rico, Haiti and
  Dominican Republic).
• Watery, non bloody diarrhea.
• In about 2-3 months , jejunal malabsorbtion
  results in folate deficiency, which causes
  anorexia
• In 6 months vitB12 deficiency also happens
• Grosso-modo malabsorbtion of fat/folate /vit B12

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Thank you !!!!