GI Board Review

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GI Board Review

• 6/18/08
• Christine Williams, MD
• UNC Internal Medicine

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Ascites

• 3 major pathophysiologic events leading to
  ascites
• Increased hydrostatic pressure
• Increased capillary permeability
• Decreased protein/albumin

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Serum albumin-ascites gradient (SAAG)

• HIGH ALBUMIN GRADIENT gt 1.1g/dL (hydrostatic)
• Cirrhosis (ascitic fluid protein lt2.5)
• Alcoholic hepatitis
• Congestive Heart Failure (ascitic fluid protein
  gt2.5)
• Masssive hepatic metastases
• Constrictive pericarditis
• Budd-Chiari
• IVC clot
• Schistosomiasis

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Serum albumin-ascites gradient (SAAG)

• LOW ALBUMIN GRADIENT lt1.1
• Infection
• Malignancy
• Peritoneal carcinomatosis
• Peritoneal tuberculosis
• Pancreatitis
• Serositis
• Nephrotic syndrome

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Primary Sclerosing Cholangitis

• Inflammation, fibrosis and strictures of the
  medium and large intra- and extrahepatic biliary
  ducts
• 90 with PSC have underlying UC
• 5 prevalence in those with UC
• Mengt women 31
• Increased risk of cholangiocarcinoma

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Primary Sclerosing Cholangitis Clinical
Presentation

• MAJORITY ARE ASYMPTOMATIC elevated alk phos,
  unexplained LFT elevation w/cholestatic pattern
• Fatigue Pruritis
• Jaundice
• Less commonly fevers, chills, night sweats, RUQ
  pain (2/2 episodic bacterial cholangitis)
• About 50 pANCA

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PSC Diagnosis

• ERCP
• MRCP
• Ultrasound may suggest abnormal ducts but is
  usually not diagnostic
• Can involve all parts of the biliary tree
• Early stage dz may only show shallow ulcerations
• Onion-skin obliteration of bile ducts on bx
• However, liver bx is often not diagnostic but can
  be used for staging

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Onion-skinning of bile ducts in PSC
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Complications of cholestasis

• Pruritis
• Steatorrhea
• Fat soluble vitamin (ADEK) deficiency
• Screen with PT/INR, serum levels ADE
• Metabolic bone disease (osteoporosis)
• Severe fatigue

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PSC Complications

• Cholangiocarcioma
• 10-30 lifetime risk
• no proven routine screening guideline
• Dominant biliary strictures
• Cholangitis
• Cholelithiasis
• Colon cancer
• Surveillance colonoscopy w/bx q 10 cm
• Treatment requires liver transplant

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Hepatitis B Whom to test?

• Hyperendemic areas
• Africa, SE Asia, Middle East, Pacific islands,
  central South America, Haiti, DR
• (basically anywhere there are no penguins)
• Men who have sex with men
• IV drug users
• Dialysis patients
• Pregnant women
• HIV
• Family, household and sexual contacts of HBV pts

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HEP B Evaluation

• Risk factors for HCV/HIV, alcohol use, family hx
  of HBV and liver dz
• CBC, LFTs, albumin, PT
• HBV replication testing
• HBeAg
• Anti HBe
• HBV DNA
• Anti-HAV IgG
• Anti-HCV ab, Anti-HDV ab
• Iron and TIBC to screen for hemachromatosis
• Alpha-fetoprotein (AFP) for HCC screening
• RUQ ultrasound for HCC screening

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Liver Biopsy

• Chronic hepatitis
• HBsAg for gt6 months
• Serum HBV DNA gt105 copies/ml or gt20,000 IU/ml
• Persistent or intermittent elevation in
  transaminases ALT 2x uln
• Serum HBV DNA 104 to 105 copies/mL (2,000 -20,000
  IU/ML) w/transaminases lt2x normal limit
• Normal ALT ?normal histology

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Whom to treat?

• Chronic hepatitis
• Compensated cirrhosis and HBV DNA gt2,000 IU/ml
• Decompensated cirrhosis and detectable HBV DNA by
  PCR
• HBV related polyarteritis nodosa or membranous
  nephropathy

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Dx of Rectovaginal Fistulas in Crohns

• Pelvic MRI
• Endoanal ultrasound
• Exam under anesthesia
• Methylene blue test
• dye in rectum translocates and stains an
  intravaginal tampon

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Rx of Rectovaginal Fistulas in Crohns

• Antibiotics metronidazole
• Immunosuppressives 6-mercaptopurine or
  azathioprine
• Biologic agents Remicade/infliximab or
  Humira/adalimumab
• Combined medical and surgical therapy is often
  required for management

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Peptic ulcer dz beyond H. pylori

• H. pylori and NSAIDs account for most gastric and
  duodenal ulcers
• Drugs
• corticosteroids, platelet active agents (plavix),
  sirolimus, bisphosphonates
• Tumors
• Gastrinoma, Carcinoid syndrome (control w/h2
  blockade), Basophilia in myeloproliferative
  disorders
• Anatomic
• Antral exclusion post-gastric surgery, duodenal
  obstruction (webs, annular pancreas pyloric
  stenosis)
• Infection
• HSV-1, CMV
• Vascular
• Insufficiency due to crack cocaine and
  methamphetamine
• Atherosclerosis or other causes of arterial
  insufficiency
• Radiation chemo
• Sarcoidosis
• Often associated with cirrhosis, stress ICU,
  organ transplant, COPD, Rheumatic disease

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Zollinger-Ellison Syndrome (gastrinoma)

• Suspect in patients with multiple peptic ulcers,
  recurrent ulcer dz, duodenal or jejunal ulcers,
  family hx of MEN1
• Diarrhea due to high volume load, excessive acid
  leading to neutralization of bicarb inactivating
  pancreatic enzymes ? steatorrhea
• Inhibition of sodium and h2o absorption by the
  small intestine due to high gastrin
  concentrations leading to secretory diarrhea

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Making the diagnosis of ZE

• Fasting serum gastrin concentration gt1000 pg/ml
  (normal is lt110)
• Single measurement of gastric pH important to
  exclude secondary hypergastrinemia due ot
  achlorhydria in patients with pernicious anemia
  or atrophic gastritis
• Secretin stimulation test for non-diagnostic
  fasting gastrin levelstimulates gastrin
  secretion only in gastrinoma cells (normal
  gastric G cells are inhibited)
• Serum chromogranin A I stypically elevated but
  this is less sensitive and specific than serum
  gastrin level

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Multiple Endocrine Neoplasia 1

• Type 1 PPP
• Primary hyperparathyroidism
• Pituitary tumors (prolactinoma, GH)
• Pancreatic neuroendocrine tumors (gastrinoma,
  insulinoma, VIPoma, glucagonoma, polypeptide
  secreting or nonhormone secreting)

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Multiple Endocrine Neoplasia 2

• Type 2A
• Medullary thyroid ca
• Pheochromocytoma
• Parathyroid hyuperplasia
• Type 2B
• Medullary thyroid ca
• Pheochromocytoma
• Other mucosal neuromas, intestinal
  gangioneuromas, marfanoid

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TAKE HOME GI POINTS

• Dx PSC with ERCP or MRCP
• Dx rectovaginal fistula in Crohns with MRI or
  endorectal ultrasound
• SAAG gt 1.1 hydrostatic pressure
• Fasting serum gastrin level to look for ZE
  syndrome