1.12 gi 2013 april


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1.12 gi 2013 april

  1. 1. Gastrointestinal DiseaseCaseA 38 year old woman presents to the office with complaints of upper abdominal pain. She describespain as intermittent gnawing discomfort, often worse after meals. She denies any change in bowelhabits, dark stool or blood in the stool. She has not had any weight loss.• What is your differential diagnosis?• What other features of the history and physical exam would you focus on?The patient reports none of the “alarm” symptoms on history. On exam she has some mildmidepigastric tenderness, no palpable masses. Rectal exam is normal, stool is negative for occultblood.• How would you proceed with your work-up?• Should she have an endoscopy?• Should she be tested for H. Pylori?Her H. Pylori serology is positive. You opt to treat empirically.• What regimen would you use?The patient completes her treatment and 1 month later reports that her symptoms have completelyresolved. The following year she comes in for her annual exam and mentions that she is havingfrequent “heartburn”• What lifestyle modifications would you recommend?• How would you treat her?• Does she need an endoscopy?America’s OB/GYN Board Review Course™ MillerApril 2013 97
  2. 2. Gastrointestinal DiseaseDyspepsiaDefinitions• Dyspepsia refers to pain or discomfort centered in the upper abdomen (mainly inor around the midline as opposed to the right or left hypochondrium).• Functional dyspepsia (normal dyspepsia)- normal endoscopy• Structural dyspepsia – abnormal endoscopy Peptic ulcer disease (duodenal and peptic ulcer) Gastritis Esophagitis Gastric carcinomaFunctional dyspepsia (60%)• Defined as 3 month h/o dyspepsia with no structural or biochemical explanation• Etiology unclear• Associated with GI dysmotility, altered visceral sensation, psychiatric d/o• Most common form of dyspepsia• Treatment controversial• A number of medications have been tried (H2 blockers, prokinetic agents, PPI)• Patient education, validation importantPeptic Ulcer Disease (15-25%)• Pain occurs 2-5 hours after eating• Pain described as gnawing, burning• Most often localized to the epigastrum, may radiate to back• Usually episodic• Frequently nocturnal• Relieved by food• 95% duodenal ulcers, 70% of gastric ulcers caused by H. Pylori• 70% of gastric ulcer caused by H. PyloriGastritis• The term gastritis is used to denote inflammation associated with mucosal injury• Most often caused by drugs (NSAIDs, alcohol) or Helicobacter pyloriAlarm symptoms: (Don’t want to miss gastric carcinoma!)• Age > 55 with new-onset dyspepsia• Unintended weight loss• GI Bleeding• Progressive dysphagia• Odynophagia• Unexplained iron deficiency anemia• Persistent vomiting• Palpable mass or lymphadenopathyAmerica’s OB/GYN Board Review Course™ MillerApril 2013 98
  3. 3. • Family h/o UGI carcinoma• JaundiceH. Pylori• In U.S. H. Pylori present in 10% of 18-30 yo, 50% in > 60 yo• More common in black and Hispanic population and lower socioeconomic groups• Transmission is oral-oral or fecal-oral• Disrupts protective mucosal layer resulting in cell injury• Diagnosiso Blood test for specific antibodieso Urea breath testo Stool testso Endoscopy with tissue examination/cultureTreatment Regimens for H.PyloriAmerica’s OB/GYN Board Review Course™ MillerApril 2013 99
  4. 4. Gastoresophageal reflux disease (GERD) Clinical symptoms include heartburn, regurgitation and dysphagia May mimic angina pectoris Can lead to esophagitis Complications may include reflux-induced asthma, laryngitis, cough Less commonly may lead to Barrett’s esophagus, stricture, cancer Treatmento Lifestyle modification• Small frequent meals• Elevate head of bed• Avoid alcohol, caffeine, smoking, caffeine• Avoid citrus, tomato foods, chocolate, mints, fatty foods• Weight managemento Medications• Over-the-counter antacids• H2 Blockers (Ranitidine 150 mg BID)• Proton pump inhibitorsIndications for endoscopy for GERD• Failure of empiric therapy• Alarm symptomso Over 50 yo with new onset sxso GI BleedingAmerica’s OB/GYN Board Review Course™ MillerApril 2013 100REGIMEN SIDE EFFECT CURE RATE2- Drug RegimensAmoxicillin + PPI Low-medium <70-80%Clarithromycin +PPI Low-medium >70-90%3-Drug RegimensClarithromycin + metronidazole + PPI Medium >80-90%Clarithromycin + Amoxicillin + PPI Low-medium >80-90%Amoxicillin + Metronidazole + PPI Medium >80-90%Tetracycline + Metronidazole + Sulcrafate Medium >80-90%4-Drug RegimensBismuth + Metronidazole + Tetracycline+ H2 Blocker Medium-high >80-90%Bismuth + Metronidazole + Amoxicillin + PPI Medium-high >70-90%Bismuth + Metronidazole + Tetracycline +PPI Medium-high >80-90%Bismuth + Metronidazole + Clarithromycin + PPI Medium-high >80-90%Combination ProductsHelidac (Bismuth, metronidazole, tetracycline) + H2blockerMedium-high Up to 82%Prevpac (Amoxiciliin, Clarithromycin,PPI) Low-medium 81-92%Pylera (Bismuth, metronidazole, tetracyline Low-medium 84-94%
  5. 5. o Unintended Weight losso Anemiao Dysphagia/odynophagiao Long duration of frequent symptomsDiarrheaAcute < 14 days Most due to infectious and are self-limitedPersistent >14 daysChronic >30 days IBS, IBD, malabsorption, secretoryAmerica’s OB/GYN Board Review Course™ MillerApril 2013 101Evaluation of Acute Diarrhea
  6. 6. Irritable Bowel Syndrome• Female to male ratio of 2-3 :1• Most common between ages of 20-40Clinical Manifestations• Crampy abdominal pain for > 3 months, usually lower quadrants, often on the leftAmerica’s OB/GYN Board Review Course™ MillerApril 2013 102Specific Therapy for Diarrhea
  7. 7. • Altered bowel habits – diarrhea and/or constipation• May have bloating, nausea, dyspepsia, early satiety, increased flatulence orbelching• Patients with IBS often complain of a broad range of non-gastrointestinalsymptoms including impaired sexual function, dysmenorrhea, dyspareunia, andincreased urinary frequency and urgency.Work-up for IBS1. Careful history and physical (exam should be normal)2. Rule out dietary causes and/or medications (lactose , mg –containing antacidscause diarrhea, anticholinergics, ca-channel blockers can cause constipation)3. Look for other underlying etiologies such as depression, anxiety, physical, sexualor substance abuse4. Look for alarm symptomsa. > 50 yo with new sxsb. GI bleedingc. Unintended weight lossd. Family history of colon cancere. Recurring feverf. Anemiag. Chronic severe diarrhea.5. Lab evaluation should include CBC, chemistries, and stool for WBC, Cx, O&P, c.diff (to r/o infectious etiology)6. Recommend flex sig/colonoscopy for patients with any alarm symptoms or forpersistent symptomsTreatment of IBS• Cure is not expected, but symptoms can be modified• Most important element is reassuring, therapeutic patient-physician relationship• Therapy should includeo Avoidance of foods the increase symptomso High fiber diet (25-35 gm fiber/day)o Medication efficacy has not been established in RCTso Trial of medications may be warranted• Antidiarrheal agents (loperamide, diphenoxylate)• Anticholinergics (belladonna, dicylomine, hycosamine) forpain/gas/bloating• Tricyclic antidepressants may be helpful in pain-dominantIBS• Tegaserod (Zelnorm)America’s OB/GYN Board Review Course™ MillerApril 2013 103
  8. 8. o Removed from marketo Was for constipation-dominant IBS in womenInflammatory Bowel Disease• Incidence peaks in 2ndand 3rddecade• Usually present with recurrent diarrhea and abdominal pain, fever• Often anemic, may have leukocytosis, thrombocytosis• May have electrolyte abnormalities and elevated ESR• Diagnostic test = colonoscopy• Extraintestinal manifestations of IBD include iritis, episcleritis, arthritis, and skininvolvement, as well as pericholangitis and sclerosing cholangitis.Crohns disease Ulcerative ColitisInvolves all layers of the bowelCan occur anywhere in GI tractLesions discontinuous with skip areasMost commonly present with nonbloodydiarrheaMay recur after surgeryInvolves only mucosa and submucosaOnly involves rectum and lg bowelLesions continuous with abruptdemarcationMost commonly present with bloodydiarrheaSurgery usually curativeMedications for IBD• Aminosalicylates (sulfasalazine, mesalamine) – used for maintenance therapy• Steroids – used for acute attacks• Immunosuppressants (Azathioprine) – useful for patients unable to toleratesteroids• Tumor Necrosis Inhibitors (Inflixamab) – used to induce remission in patientsunresponsive to other treatmentsComplications of IBD• Perforation, toxic megacolon (UC > Crohns)• Strictures• Fistulas and Abcesses (Crohns > UC)• Colon cancer – risk increases with extent and duration of diseaseScreening for Colon CancerRisk factor Age to initiate screening Interval of screeningAverage risk 50 years45 years for African AmericanFOBT yearlySigmoidoscopy q 5 yrsColonoscopy q 10 yrsFamily history Screen as average risk Interval as in average riskAmerica’s OB/GYN Board Review Course™ MillerApril 2013 104
  9. 9. 1 second degree or third degreerelativeFamily history1 first degree or 2 second degreerelatives > 60 yrs40 years Colonoscopy q 5-10 yearsFamily history1 first degree or 2 second degreerelatives < 60 yrs40 years or 10 years prior to theindex case, whichever comes firstColonoscopy q 5-10 yearsFamilial adenomatous polyposis(FAP)10-12 years Yearly sigmoidoscopy. If genetictest positive, colectomyrecommendedHereditary nonpolyposiscolorectal cancer (HNPCC)20-25 years or 10 years prior tothe youngest dx of colon cancerin the familyColonoscopy q 1-2 yearsInflammatory bowel disease Begin screening after 8-10 yearsof diseaseYearly colonoscopyOral Defense Tips I refer patients with dyspepsia for endoscopy if they have any “alarm symptoms”(weight loss, blood in stool, unexplained anemia) or they are using chronicNSAIDs My initial treatment for dyspepsia is to do blood testing for H. Pylori and treat ifpositive (Prevpac as directed) I would counsel a woman with GERD symptoms to have small frequent meals,elevate the head of the bed, avoid alcohol, caffeine, smoking, caffeine, avoidcitrus, tomato foods, chocolate, mints, fatty foods, and control weight. My initial approach to the assessment of diarrhea is to determine duration ofsymptoms, and look for signs of dehydration or inflammation (blood, fever). Ifthe sxs are less than 48 hours, there is no fever or blood in the stool and no signsof dehydration, I recommend fluid, rest and bland diet. My initial approach to the treatment of IBS is to recommend a high fiber diet (25-35 gm/day) and I ask the patient to keep a food diary. I recommend colon cancer screening to ALL women starting at 50 years old andto African American women starting at 45 years old.STUDY QUESTIONSYearly screening colonoscopy should be recommended for patients with:A. Irritable bowel syndromeAmerica’s OB/GYN Board Review Course™ MillerApril 2013 105
  10. 10. B. Occult blood on rectal examC. Familial adenomatous polyposisD. A first degree family member diagnosed with colon cancer underthe age of 60.A 32 year old woman returns from a camping trip and develops acute diarrhea.The most likely organism is:A. E. ColiB. V.choleraC. CampylobacterD. GiardiaUpdated 02/13America’s OB/GYN Board Review Course™ MillerApril 2013 106