Am 11.20 oxentenko

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Am 11.20 oxentenko

  1. 1. GI Disorders in Women: Clinical PearlsAmy S. Oxentenko, MD, FACP, FACG Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, MN March, 2012
  2. 2. Disclosure of Financial RelationshipsAmy S. Oxentenko, MD, FACP, FACG Has no relationships with any entity producing, marketing, re-selling, ordistributing health care goods or services consumed by, or used on, patients.
  3. 3. Case #1
  4. 4. A 32 y/o female presents for evaluation of “diarrhea” andabdominal pain that she has had for 5 years. She gets lowerabdominal pain and bloating 1-2 times per week. On thosedays, she reports 3-5 loose stools, predominantly in themorning or after meals. Stools are non-bloody, non-greasyand never nocturnal. Stooling brings relief of her pain. Shedenies weight loss. PMH is unremarkable. She takes nomeds. She has no family hx of GI problems. Exam is normal.Which of the following is the next best step? A. No further tests; reassurance B. CBC & IgA tissue transglutaminase C. Stool cultures D. EGD w/ small bowel biopsies E. Colonoscopy w/ random biopsies
  5. 5. A 32 y/o female presents for evaluation of “diarrhea” andabdominal pain that she has had for 5 years. She gets lowerabdominal pain and bloating 1-2 times per week. On thosedays, she reports 3-5 loose stools, predominantly in themorning or after meals. Stools are non-bloody, non-greasyand never nocturnal. Stooling brings relief of her pain. Shedenies weight loss. PMH is unremarkable. She takes nomeds. She has no family hx of GI problems. Exam is normal.Which of the following is the next best step? A. No further tests; reassurance B. CBC & IgA tissue transglutaminase C. Stool cultures D. EGD w/ small bowel biopsies E. Colonoscopy w/ random biopsies
  6. 6. Be Comfortable Diagnosing IBS Spiller RC, et al. Am J Gastroenterol 2010:105;775-75. Brandt LJ, et al. Am J Gastroenterol 2009;104:S1-35.
  7. 7. Irritable Bowel Syndrome Hard and lumpy Loose or watery
  8. 8. Clinical Pearl Diarrhea-predominant irritable bowel syndrome is a diagnosis that can be made with little exclusionary testingrequired, other than a CBC and IgA tTG, in the absence of alarm symptoms.
  9. 9. Case #2
  10. 10. A 38 y/o female presents to the ER with recurrent abdominal pain,nausea and bilious vomiting. Six months ago, she had a Roux-en-Ygastric bypass for obesity. She has had 3 episodes in 1 month.Pain is crampy, periumbilical, and crescendos over 1-2 hours andis relieved after vomiting undigested food and bilious fluid. Duringthe last 2 episodes, ER eval with labs (CBC, liver biochemistries),abdominal radiographs and RUQ ultrasounds were normal. Shetakes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but noother meds. No other PMH. Her gallbladder was not removed w/the laparoscopic bypass.Which of the following is the most likely cause of symptoms? A. Overeating B. Biliary colic C. Internal hernia D. Stenosis of the gastric pouch E. Medication side effect
  11. 11. A 38 y/o female presents to the ER with recurrent abdominal pain,nausea and bilious vomiting. Six months ago, she had a Roux-en-Ygastric bypass for obesity. She has had 3 episodes in 1 month.Pain is crampy, periumbilical, and crescendos over 1-2 hours andis relieved after vomiting undigested food and bilious fluid. Duringthe last 2 episodes, ER eval with labs (CBC, liver biochemistries),abdominal radiographs and RUQ ultrasounds were normal. Shetakes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but noother meds. No other PMH. Her gallbladder was not removed w/the laparoscopic bypass.Which of the following is the most likely cause of symptoms? A. Overeating B. Biliary colic C. Internal hernia D. Stenosis of the gastric pouch E. Medication side effect
  12. 12. Gastric Gastric pouch remnant Bilio- Roux limbpancreatic limb Common channel Roux-en-Y Bypass
  13. 13. ***Lesser ***Greater malabsorption malabsorptionShort Roux limb Long Roux limbLong common channel Short common channel
  14. 14. Early Emergent Complications• Anastomotic leaks – Early complication – Only feature may be unexplained tachycardia
  15. 15. Early Emergent Complications• Anastomotic leaks – Early complication – Only feature may be unexplained tachycardia• Internal hernias – Occurs early or late – Nausea, vomiting (? bilious) – Increased w/ laparoscopy; only occurs with bypass• Both need surgery!!! Klein S, et al. Gastroenterology 2002;123:882-932.
  16. 16. Other Common Complications• Marginal ulceration – May cause bleeding or stricture at G-J site – May create stomal stenosis – ? NSAIDs, ? smoking• Bleeding – Can occur at any anastomotic site – Think of remnant stomach and duodenum – After routine EGD, may need GI expertise to evaluate
  17. 17. Other Common Complications• Biliary stone disease – ERCP scope 124 cm; cannot reach papilla in RYGB pts • Typical Roux limb 100-150 cm – Approach dependent on clinical acuity and local expertise papilla• Nutritional deficiencies – Iron, B12, Ca++, vitamin D – Folate (give if childbearing) – Thiamine (esp 1st 6 months)
  18. 18. Clinical PearlThere are many potential structural, absorptive and nutritionalcomplications of bariatric surgery; knowledge of the post-bariatric anatomy is essential in being able to effectively manage these patients.
  19. 19. Case #3
  20. 20. 34 y/o female referred for “IBS” who is 16 weekspregnant. She had diarrhea in teens which resolved inher 20’s and recurred early in pregnancy. Has 4-6 BMdaily with nocturnal stools. No abdominal pain. Takesa prenatal MVI, iron and levo-thyroxine. Her pre-pregnancy BMI = 17, with 5 lb weight gain thus far.Conceived her baby with IVF. Her TSH is normal.Which of the following is the next best step? A. Tissue transglutaminase IgA B. Colonoscopy C. Begin scheduled loperamide D. Stool bacterial cultures E. Begin nortriptyline
  21. 21. 34 y/o female referred for “IBS” who is 16 weekspregnant. She had diarrhea in teens which resolved inher 20’s and recurred early in pregnancy. Has 4-6 BMdaily with nocturnal stools. No abdominal pain. Takesa prenatal MVI, iron and levo-thyroxine. Her pre-pregnancy BMI = 17, with 5 lb weight gain thus far.Conceived her baby with IVF. Her TSH is normal.Which of the following is the next best step? A. Tissue transglutaminase IgA B. Colonoscopy C. Begin scheduled loperamide D. Stool bacterial cultures E. Begin nortriptyline
  22. 22. General and GI Manifestations of Celiac Disease General Gastrointestinal Short stature Diarrhea, steatorrhea Weight loss* Flatulence, distension Failure to thrive Abdominal discomfort Lethargy Anorexia, nausea, vomiting Delayed puberty Constipation** Edema Angular cheilosis, glossitisRubio-Tapia A, Murray JA. * 10%+ obeseCurr Opin Gastroenterol 2010; 26:116-22. ** 20% constipated
  23. 23. Extraintestinal Manifestations: Celiac DiseaseCategory ExamplesHematologic Anemia (iron*, B12, folate); functional asplenia (HJ-bodies)Musculoskeletal Osteopenia/osteoporosis; osteomalacia; arthropathyNeurologic Seizures; peripheral neuropathy; ataxiaReproductive Infertility; recurrent miscarriagesSkin Dermatitis herpetiformisOther Enamel defects; abnormal liver biochemistries; vitamin- deficient states, cardiomyopathy, depression/mood •*Prevalence of CD in pts with IDA: •3-9% (no GI sxs) •10-15% (GI sxs) Rubio-Tapia A, Murray JA. Curr Opin Gastroenterol 2010; 26:116-22.
  24. 24. How to Diagnose Celiac Disease• TTG IgA single best screening test – IgA levels not warranted for all• Small bowel biopsies in: – All with positive serologies – Negative serology but clinical suspicion – Iron deficiency anemia – Other unexplained extraintestinal features• Treatment: Lifelong, strict gluten-free diet – Wheat, barley, rye (oats for 1st year)
  25. 25. Celiac Follow-Up• Baseline: – Dietician, DEXA (latter for adults only) – CBC, folate, ferritin, B12, Ca++, zinc, copper, vit D, INR, retinol, albumin, ALT, alk phos• Follow-up visit 3-6 months: – Assess clinical sxs, serologies• Annual visits thereafter: – Assess clinical sxs, serologies, dietician – Follow-up abnormal labs; DEXA if first abnormal• Repeat biopsies ONLY for those: – Asymptomatic presentations – Persistent or recurrent sxs Leffler D. JAMA
  26. 26. Clinical Pearl Celiac disease now commonly presents with “atypical” or extraintestinal features; heightenedawareness of these features is key to thinking of the diagnosis.
  27. 27. Case #4
  28. 28. 28 y/o female presents with constipation for 5 years.Reports one BM every 5-7 days. She has to strain andhas a sense of incomplete evacuation. She has had todigitalize on occasion to evacuate a stool. No blood.Had a significant tear with her vaginal delivery 6 yearsago, requiring forceps delivery. No FHx colon cancer.Weight stable. Exam normal with the exception ofparadoxical contraction of the external anal sphincter.What is the most likely diagnosis? A. Irritable bowel syndrome B. Slow-transit constipation C. Rectal prolapse D. Hirschsprung’s E. Pelvic floor dysfunction
  29. 29. 28 y/o female presents with constipation for 5 years.Reports one BM every 5-7 days. She has to strain andhas a sense of incomplete evacuation. She has had todigitalize on occasion to evacuate a stool. No blood.Had a significant tear with her vaginal delivery 6 yearsago, requiring forceps delivery. No FHx colon cancer.Weight stable. Exam normal with the exception ofparadoxical contraction of the external anal sphincter.What is the most likely diagnosis? A. Irritable bowel syndrome B. Slow-transit constipation C. Rectal prolapse D. Hirschsprung’s E. Pelvic floor dysfunction
  30. 30. How to Define Constipation? • In the past: – < 3 stools per week • More recent: – Effort to defecate – Consistency and form • Bristol stool form scale • Correlates w/ transit timesBrandt LJ, et al. Am J Gastroenterol 2005;100:S5-21.
  31. 31. 3 Subtypes of Primary Constipation• Slow-transit constipation – Prolonged transit due to myopathy or neuropathy• Pelvic floor dysfunction – Also referred to as dyssynergic defecation – Impaired abdominal, rectoanal and pelvic floor muscle coordination• Constipation-predominant IBS – Pain or discomfort a predominant symptom; transit and pelvic function normal Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.
  32. 32. Alarm Features for Constipation?• Age > 50 years• Short duration symptoms (< 6 months)• Family hx colorectal cancer• Blood in stools• Weight loss *** These patients need an evaluation which includes colonoscopy ***
  33. 33. Work-Up for Constipation• CBC, calcium, TSH, fasting glucose• If ≥ 50 or alarm features  colonoscopy• If features of pelvic floor dysfunction  a) Anorectal manometry/balloon expulsion b) Colonic transit study • 1) radio-opaque markers, or • 2) scintigraphy, or • 3) pH capsule
  34. 34. Clinical Features of Pelvic Floor Dysfunction• Risk factors: childbirth, abuse, chronic constipation, other pelvic trauma• Excessive straining, toilet rocking or repositioning• Sense of incomplete evacuation• Sense of anorectal blockage*• Digitation for stool evacuation* Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.
  35. 35. Examination Features of Pelvic Floor Dysfunction• Abnormal perineal descent• Abnormal resting and squeeze tone• Paradoxical contraction of puborectalis or external anal sphincter Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.
  36. 36. Pelvic Floor DysfunctionNormal Rest Normal defecation Those with pelvic floor dysfunction have paradoxical contraction of puborectalis and external sphincter
  37. 37. Management of Pelvic Floor Dysfunction• Refer for biofeedback program• Significantly improves (for at least 1 year): • Spontaneous BMs • Dyssynergia • Balloon expulsion time • Colonic transit time• If there is concomitant prolapse, fix pelvic floor dysfunction first Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94. Rao SSC, et al. Am J Gastroenterol 2010;105:890-6.
  38. 38. Clinical Pearl Constipation associated with a sense ofanorectal blockage, the need for digitation to evacuate stool, and paradoxical contraction of the puborectalis is suggestive of pelvic floor dysfunction; anorectal manometry is indicated.
  39. 39. Case #5
  40. 40. A 58 year old female presents for an evaluation of diarrhea thathas been present for 4 months. She has crampy pain, bloatingand weight loss of 10 pounds. She denies any blood in herstool, but notes it to be foul smelling and greasy appearing. Norecent medication changes. No travel. She does have a historyof prior cervical cancer 4 years ago, s/p resection,chemotherapy and radiation. Labs reveal a hemoglobin of 10.4g/dL, MCV of 102 fL and albumin of 3.1 g/dL. She states thatdairy avoidance has somewhat, but not fully, helped. TTG IgA isnormal. Colonoscopy with ileal inspection is normal.Which of the following is the next best step? A. CT of the pancreas B. Lactose breath test C. PET scan D. Lactulose breath test E. Flex sig w/ biopsies
  41. 41. A 58 year old female presents for an evaluation of diarrhea thathas been present for 4 months. She has crampy pain, bloatingand weight loss of 10 pounds. She denies any blood in herstool, but notes it to be foul smelling and greasy appearing. Norecent medication changes. No travel. She does have a historyof prior cervical cancer 4 years ago, s/p resection,chemotherapy and radiation. Labs reveal a hemoglobin of 10.4g/dL, MCV of 102 fL and albumin of 3.1 g/dL. She states thatdairy avoidance has somewhat, but not fully, helped. TTG IgA isnormal. Colonoscopy with ileal inspection is normal.Which of the following is the next best step? A. CT of the pancreas B. Lactose breath test C. PET scan D. Lactulose breath test E. Flex sig w/ biopsies
  42. 42. ©2011 MFMER | 3149421-42
  43. 43. Causes of Bacterial Overgrowth Small bowel diverticulaStructural Small bowel strictures (radiation, IBD, NSAIDs) Enterocolonic fistula Blind loops, afferent limbsSurgical Ileocecal valve resection Chronic pseudoobstruction (Scleroderma)Dysmotility Amyloidosis Diabetic neuropathy Achlorhydria/atrophyDiminished Gastric resectionAcid Acid suppression Chronic liver or kidney diseaseOther Chronic pancreatitis Immunodeficiencies Celiac disease Elderly (15% prevalence)
  44. 44. Diagnosis of SIBO• Small bowel cultures – Anaerobic & aerobic; > 105 organisms/mL – Jejunum; most taken from duodenum• Hydrogen breath testing – Lactulose (rise by 20 ppm first 90 min) – Glucose (rise by 12 ppm first 90 min) – 2nd criteria = double peak (small bowel, colon) – False (+): rapid transit, recent food – False (-): methane producer (10%), antibiotics• Empiric Trial of Antibiotics
  45. 45. Breath Testing SIBO A B CA) Lactulose breath test without SIBOB) Lactulose breath test w/ SIBOC) Lactulose breath test w/ SIBO & double-peak patternFrom Dukowicz AC, et al. Gastroenterol Hepatol 2007;3:118-119. ©2011 MFMER | 3149421-45
  46. 46. Treatment of SIBO• Modify underlying risk factor (minority) – Diabetes, surgery, etc.• Nutritional support – Correct deficiencies (vit B12, vit D, Ca++) – Lactose malabsorption (secondary)• Antibiotic therapy – Single 7-10 days (46-90% improve for months) – Recurrence 44% at 9 months – Some may need repeat courses (1 week/month)
  47. 47. Treatment for Bacterial OvergrowthCiprofloxacin 250 mg BIDNorfloxacin 800 mg QDMetronidazole 250 mg TIDTrimethoprim-SMX 1 DS BIDDoxycycline 100 mg BIDTetracycline 250 mg QIDAmoxicillin-clavulanate 500 mg TIDRifaximin 800-1200 mg QD Quigley EMM, et al. Infect Dis Clin N Am 2010; 24: 943-59.
  48. 48. Clinical PearlSmall intestinal bacterial overgrowth is typically diagnosed with small bowel cultures or hydrogen breath testing; management includescorrecting nutritional abnormalities and antibiotic therapy. ©2011 MFMER | 3149421-48
  49. 49. Thank you!oxentenko.amy@mayo.edu

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