Gastroenterology

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Gastroenterology
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Gastrointestinal Bleeds

• Upper GI Bleeds
• Etiology
• Mallory-Weiss tear
• Varices
• Gastritis
• Ulcer peptic

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• Signs and Symptoms
• Hematemesis(bright red or coffee grounds)
• Hypotension
• Tachycardia
• Bleeding that produces 60cc of blood or more will
  produce black, tarry stool.

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• Diagnosis
• Gastric lavage with normal saline
• Rectal exam with fecal occult blood testing
• CBC
• Endoscopy
• Arteriography

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• Treatment
• Depends on the etiology and severity
• IV fluids and blood
• Endoscopy with epinephrine injection
• IV proton pump inhibitor
• Most Mallory-Weiss tears resolve spontaneously

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• Lower GI Bleeds
• Etiology
• Cancer or polyps
• Upper GI bleed ( need to rule it out)
• Colitis
• Angiodysplasia
• Hemorrhoids
• Angiodysplasia

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• Signs and Symptoms
• Bright red blood per rectum(hematochezia)
• Melena (black or maroon tarry stool)
• Signs of blood loss
• Diarrhea( as seen with colitis)

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• Diagnosis
• Gastric lavage to rule out upper GI source
• Rectal exam
• CBC
• Coloscopy
• Arteriography

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• Treatment
• Fluids
• Blood
• Embolization or surgery

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• Diarrhea
• Abnormal passage of fluid or semisolid with
  increased frequency.
• History
• Quantity of diarrhea
• Small bowel involvement usually large volume ,
  watery diarrhea
• Large bowel involvement usually small volume
  diarrhea

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• Length of symptoms
• Acute lt 2 weeks
• Persistent gt 2 weeks
• Chronic gt 4 weeks
• 2)Associated Sx
• Fever, Chills, abdominal pain , nausea , vomiting
  and weight loss

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• Food intake prior to onset of diarrhea
• Travel history
• Medications
• Recent antibiotic use or hospitalization
  increasing risk for clostridium difficile colitis
• Lactose intolerance.

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• ACUTE DIARRHEA
• Work up
• Fecal leukocytes may be suggestive of infectious
  or inflammatory causes.
• Stool culture for enteric pathogens
• Stool test for C.difficile toxins ( for
  pseudomembranous colitis.
• Stool exam for oval and parasites

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• Common Infectious Pathogens
• Bacterial
• Noninvasive
• Staphylococcus aureus
• Bacillus cereus
• Vibrio cholerae
• Enterotoxigenic E coli

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• b)Invasive Campylobacter associated with
  Guillain-Barre syndrome.
• Salmonella( raw egg) ,Shigella,
  enterohemorrhagic E. Coli, C.difficile.
• c) Viral Rotavirus, Norwalk.
• d)Protozoa Giardia lamblia (after hiking trip)
• Entamoeba histolytica

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• Bloody diarrhea CASES
• Campylobacter
• Amoeba ( E.Histolytica)
• Shigella
• E.Coli
• Salmonella

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• Scenario 1
• A patient vomits within 6 hours of eating
  something with mayonnaise ( potato salad at a
  picnic on a hot day.

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• Scenario 2 3
• A patient has vomiting /diarrhea after eating
  reheated rice from letfover chinese food.
• A patient has vomiting and severe watery diarrhea
  after eating spoiled shellfish .

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• A patient has flatulence and foul-smelling
  diarrhea after a camping trip.
• A patient has watery diarrhea following a
  recent course of antibiotics .

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• Management
• Oral or intravenous rehydration
• Electrolyte replacement
• Antibiotic therapy when infection suspected.
• Antimotility agent (loperamide) in noninfectious
  diarrhea.

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• Chronic Diarrhea
• Osmotic Ingestion of nonabsorbable solute
  leading to osmotic water in the stool( lactose
  intolerance.
• Secretory Oversecretion of water by the small
  and large bowel which may be caused by bacteria
  ,bacterial toxins, laxative.

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• Inflammatory Gastrointestinal mucosal irritation
  and inflammation leading to an exudative
  diarrhea( IBD).
• Malabsorption A problem with either digestion
  (i.e. , lack of digestive enzymes or bile acids)
  or transport ( problem with the small bowel
  mucosa).Examples chronic pancreatitis , bile
  acid malabsorption

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• Workup
• Fecal electrolytes and calculation of osmotic
  gap.
• D-xylose test
• 72 hour fecal fat analysis

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• Constipation
• Definition Stool frequency lt 3 times per week.
• Etiology
• Low fiber, low fluid intake
• Obstruction
• Disturbed colonic motility
• Medications
• Hypothyroidism

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• Treatment
• Increase fiber to 30 g/day
• Increase fluid intake
• Bulk-forming and emollient laxatives

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Gastroesophageal Reflux Disease

• Definition Reflux of acidic gastric contents
  into the esophagus.
• Causes of Gerd
• Relaxed or incompetent lower esophageal
  sphincter (LES)
• Hiatal hernia
• Delayed gastric emptying
• Decreased esophageal motility

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• Causes of Lowered LES tone
• Foods coffee, chocolate
• ETOH
• Cigarettes
• Drug Nitrates , Ca channel blockers
• Hormones Estrogen ,progesterone

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• Causes of delayed gastric emptying
• Diabetes mellitus
• Gastroparesis
• Gastric outlet obstruction
• Fatty foods

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• Signs and Symptoms
• Substernal burning pain
• Dysphagia
• Hypersalivation ( water brash)
• Cough ( particularly noctural

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• Diagnosis
• A trial of proton pump inhibitor will be given
  to relieve symptoms without further work-up.
• Treatment
• 1- Lifestyle modification
• Elevate head of bed
• Discontinue foods that decrease LES tone avoid
  foods lt3 hours before bed

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• 2-Pharmacologic
• H2 blocker
• Proton pump inhibitor
• 3- Surgical
• Surgical correction such as fundoplication

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• Complications of GERD
• Esophagitis Esophageal damage , bleeding and
  friability due to prolonged exposure to gastric
  contents
• Peptic stricture occurs in about 10 of
  patient with GERD
• Barretts esophagus
• Esophageal Cancer

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Peptic Ulcer Disease

• Duodenal Ulcer
• Pathophysiology increase acid production.
• Etiology
• H. pylori
• NSAIDs/Steroids inhibiting mucosal barrier
  production
• Zollinger-Ellison syndrome

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• Clinical Features
• Burning gnawing epigastric pain that occurs with
  an empty stomach pain relieved within 30 min by
  food
• Nighttime awakening ( when stomach empties)
• Nausea ,vomiting
• Associate with blood type 0

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• Diagnosis
• Endoscopy
• H.pylory
• 1-Endoscopy with biopsy
• 2-Seroloy Anti-H.Pylori IgG indicates current
  or prior infection.
• 3-Urease breath test

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• Treatment of PUD
• Discontinue NSAIDs, steroids and smoking
• Triple therapy for H.pylory(proton pump
  inhibitor, amoxicillin and clarithomycin)
• Surgery is indicated when ulcer is refractory to
  12 weeks of medical treatment or if hemorrhage
  ,obstruction or perforation is present.

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• Gastric Ulcer
• Definition Ulcer located in the stomach
• Pathophysiology decreased protection against
  acid normal or low acid production.
• Etiology
• H. pylori
• NSAIDs/steroids

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• Clinical features
• Burning gnawing epigastric pain that occurs with
  anything in the stomach pain is worst 30 min
  after food.
• Anorexia /weight loss
• Vomiting
• Associated with blood type A

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• Diagnosis
• Via endoscopy 3 of GUs are associated with
  gastric cancer .
• Treatment
• Same as for DU

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Hepatitis

• Definition
• Systemic infection or inflammation of the liver
  due to viral agents ,toxins or alcohol.
• Etiology
• Viral hepatitis A,B,C,D, E or G
• ETOH
• ToxinAcetaminophen , aflatoxin

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• Signs and Symptoms
• Right upper quadrant pain
• Nausea ,vomiting ,malaise ,fever
• jaudice

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• Hepatitis A virus
• Definition
• RNA virus
• Spread by fecal-oral route
• 15 to 50-day incubation
• No chronic carrier or infection state

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• Diagnosis
• Anti-HAV IgMacute infection
• Anti-HAV IgG immunity from prior infection
• Treatment
• Treatment is symptomatic
• Self-limited ,no progression to chronic liver
  disease

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• Prevention
• Anti-HAV immunoglobulin in 90 effective if given
  within 2 weeks
• HAV vaccine is given to all with chronic liver
  disease ( especially hepatitis C ) travel to
  high-risk countries , high-risk behavior ,
  high-risk communities.

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• Hepatitis B
• Definition
• DNA virus
• Spread by percutaneous or mucous membrane
  exposure to blood , semen and saliva
• 45-to -160 day incubation

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• Diagnosis
• Hbs Ag positive infection is present
• Anti-HBc IgM the infection is acute( window
  period)
• Anti-HBs IgG past infection or vaccine(
  indicates immunity)

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• Prevention
• Vaccine
• Hepatitis B immune globulin
• Treatment
• Lamivudine
• Complications
• 1 will develop fulminant hepatic necrosis
• 10 of adults will develop chronic carrier state
  or chronic hepatitis with increased risk of Ca

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• Hepatitis B exposure Scenarios
• Exposed newborn give HBIG vaccine
• Infected Blood exposure test for hepatitis B and
  if negative ,give HBIG alone

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• Hepatitis C virus
• Definition
• RNA virus
• Spread by blood and body fluid contact ( common
  from past blood transfusions and tattoos , IV
  drugs)
• Incubation 15 to 160 days
• Most common hepatitis in the U.S

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• Diagnosis
• Anti-HCV IgG presents 1 to 6 months after
  infectivity and indicates chronic or past
  infections
• PCR for hepatitis C RNA measures viral load or
  disease activity.
• Treatment
• Interferon and ribavirin