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GI Review (Walsh)

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Barrett's Esophagus
Intestinal goblet cell metaplasia above GE junction

Sequela of chronic untreated GERD

Risk of esophageal adenocarcinoma 1-2% per year
Esophageal Cancer
Adenocarcinoma increasing (50%)
- Fastest growing incidence of all cancers in the U.S.
- GERD/Barrett's, obese white men
- Virchow node (L. supraclavicular lymph node)

Squamous cell carcinoma decreasing
- Smoking, EtOH, African American men

Deadly: 5% 5 year survival rate
Esophageal Diverticula
Zenker's: located in upper esophagus

Symptoms: regurgitation of undigested food, foul breath odor, dysphagia, neck lump

Diagnosis: barium swallow (esophagram, upper GI series)
Esophageal Motility Disorders
Sxs: dysphagia liquids>solids, chest pain
Achalasia
- Pathologic: progressive loss of ganglion cells from LES

Spasm (DES, nutcracker esophagus)
- Functional: anxiety, imbalance of excitatory/inhibitory pathways

Secondary
- Scleroderma: fibrosis
Esophageal Varices
Portal hypertension of any etiology
- Cirrhosis most common cause in adults

Emergent upper GI bleed
- Early endoscopic treatment critical (band, sclerotherapy)
- Refer for transplant if cirrhosis

Prophylactic beta blockers
- 30% bleed w/in one year of dx
- 70% will re-bleed
- 1/3 re-bleeds are fatal
Esophageal Webs
Proximal esophageal stricture (upper third)

Plummer Vinson Syndrome
- Chronic iron deficiency anemia

Dysphagia to solids>liquids
Esophagitis
Etiology: GERD>>>infection, radiation, corrosives
50% of patients w/ GERD develop esophagitis

Sxs: Hearburn, reflux ("waterbrash"), chest pain, dysphagia, dyspepsia

Dx: Endoscopy + biopsy
Gastroesophageal Reflux Disease
Transient LES relaxations (not "excess acid")

Most common cause of non-cardiac CP
- 40% of U.S. adults affected
- EGD for red flag symptoms: Dysphagia, odynophagia, wt. loss, anemia, OB+ stool
- 24 hour pH study "gold standard" for definitive dx.

PPIs most effective treatment
- Healing erosions
- Controlling symptoms
- Preventing complications
Hiatal Hernia
Associated with development of GERD

Prevalence: 70% in patients >70 years old
- Sliding vs. paraesophageal
- Most asymptomatic! Not a disease! Surgical referral ELECTIVE if sliding; necessary only if paraesophageal, strangulated, volvulus, etc.
- Size does not correlate w/ symptoms

Western countries
- Low fiber diet, constipation/straining w/ BM
- Obesity
Mallory Weiss Tears
Hematemesis of BRB; 50% on first emesis

Hiatal hernia in 30-100% of patients

Excessive alcohol in 40-75% of patients

Spontaneous healing in 80-90% of patients ~48 hrs
- Delayed EGD may miss dx
Peptic Stricture
Complication of GERD-induced esophagitis
- GE junction (distal esophagus)

Sxs: Dysphagia to solids, food impaction, CP

Tx: Dilatation; PPI to prevent recurrence
Gastric Adenocarcinoma
Decreasing incidence
- Eradication of h. pylori
- Refrigeration (decreased intake of pickled vegetables, salted fish)
- Smoking cessation

Still 2nd most common cause of cancer deaths worldwide
- 5 year survival 10-50% based on stage

Elderly, M>F, Asian/S. American prevalence
Gastritis
inflammation of the gastric mucosa secondary to multiple etiologies

Histologic Dx

Chronic H. pylori, NSAIDS, Autoimmune

Tx:
- Control symptoms and prevent complications (PPI, H2s, sucralfate, etc.)
- Treat the underlying disease
Gastropathy
Conditions in which there is epithelial or endothelial damage without inflammation on biopsy

Histologic Dx

NSAIDS, alcohol, uremia, portal hypertensive, bile/pancreatic juice reflux
No significant inflammation (edema, hyperplasia, hemorrhage)

Tx:
- Control symptoms and prevent complications (PPI, H2s, sucralfate, etc.)
- Treat the underlying disease
Gastroparesis
Nausea, vomiting, early satiety, post-prandial bloating, epigastric pain, dyspepsia, reflux

Etiology: Idiopathic, Diabetes, Meds

Dx: Gastric emptying study (nuclear medicine)

Tx:
- Prokinetics: Risk tardive dyskinesia w/ Reglan (metoclopramide)
- PPI for associated GERD
- Diet (low fat, small frequent meals, separate liquids)
- Treat underlying disease
- Enterra in severe, refractory cases
Peptic Ulcer Disease
Prevalence: 4.5 million people in U.S. per year

Sxs: Nausea, vomiting, dyspepsia, epigastric pain (2-3 hrs post meal, gnawing/burning, relieved by food, awakens at night), weight loss, melena, OB+ stool

Dx: EGD w/ biopsy for H. pylori and cancer
- Repeat EGD ~6 weeks later to confirm healing in all GUs

Prevent recurrence
- Long term PPI QD if age >60, GI bleed, or needs continued use of NSAIDS/ steroids/ clopidogrel/ warfarin
- No NSAIDS if at all possible
- Confirm H. pylori eradication (stool Ag, urease breath test)
Pyloric Stenosis
Most common cause of intestinal obstruction in infants (hypertrophy)
- First-born children, M>F, 1/750 births
- Projectile vomiting
- PE: "Olive" shaped mass RUQ
- Ultrasound diagnostic but not usually needed (H&P classic)
- Medical emergency; surgical consult

Leading cause of benign (only 5% benign) gastric outlet obstruction in adults (PUD complication)

Tx
- Dilatation, stents, surgery (pyloroplasty)
- Prevention of recurrent DU
- D/C NSAIDS
- Long-term PPI prophylaxis
Stress Gastritis
inflammation of the gastric mucosa secondary to multiple etiologies

Hospitalized, critically ill/injured patients

Anticipation and prophylaxis key to preventing complications

IV PPI and resume enteral feeding as early as possible
Zollinger Ellison Syndrome
Etiology: Gastrinoma
- Islet cell tumor of pancreas (50% malignant)
- Duodenum most common location (50%)

Sx: Recurrent PUD, diarrhea, malabsorption
- 0.1% of all GUs in the U.S.

Dx: Hypergastrinemia
- Measure fasting serum gastrin level OFF PPI

Tx: High-dose PPIs, tumor resection if amenable
Acute and Chronic Cholecystitis
RUQ pain radiating to R. shoulder/back, post high fat meal, associated w/ nausea, vomiting, dyspepsia
- "Murphy's" sign

Calculous, acalculous

Indication for cholecystectomy
Carcinoma of the Biliary Tract
Gallbladder CA (adenocarcinoma)
- Chronic cholecystitis

Bile Duct CA (cholangiocarcinoma)
- PSC
- Infections

Poor prognosis
Primary Sclerosing Cholangitis
M>F, 20's-30's

Cholestatic elevation LFTs

Associated w/UC (present in ~75% of pts)

High risk cholangioCA
Cholelithiasis
"The 4 (or 5, or 6) F's": Fat, Forty, Female, Fertile, Feather, FH

Ultrasound best diagnostic test

Symptomatic biliary colic is indication for elective cholecystectomy
Choledocholithiasis
Recurrent biliary colic post chole

US or MRCP diagnosis

ERCP tx if acute obstruction
Acute Pancreatitis
Cholelithiasis more common in females, alcohol more common in males
- Gallstones 40%
- Alcohol 35% (acute-on-chronic)
- Idiopathic 10%
- Post-ERCP 4%
- Trauma 2%
- Drugs 2%

Signs: fever, tachycardia, abdominal tenderness w/ guarding, +/-jaundice

CT scan always indicated for severe acute pancreatitis
- Ranson or Apache scores
Carcinoma of the Pancreas
4th leading cause of cancer death
- 37,600 new cases 2008
- 34,200 deaths 2008
- M=F

5 year survival <5%

95% adenocarcinomas, 75% of which are located in the panc head/neck

Sxs: epigastric pain, nausea, early satiety, weight loss, diarrhea, new-onset DM
- Painless jaundice most characteristic sign
Chronic Pancreatitis
Most common cause: alcohol abuse

Complications: pancreatic pseudocyst, cancer, DM

Tx: pain management and pancrealipase supplementation, dietician referral
Alcoholic Liver Disease
(aka Alcoholic hepatitis)

Elevated AST > 2x ALT; disproportionally high GGT

Fatty Liver on US and Biopsy; history critical (ALD vs NAFLD)

Cirrhosis picture biochemically
- low platelets, low albumin, high bilirubin, AST>ALT, high ALP
- reversible w/ sobriety IF no cirrhosis already
Autoimmune Hepatitis
Screen: ANA

Biopsy definitive dx

Immunosuppressant tx: steroids, azathioprine
Benign and Malignant Hepatic Tumors
Adenomas, FNH, hemangiomas, cysts
- US/CT diagnostic test

Hepatocellular CA
- Risk of cirrhosis and chronic HBV

Metastatic carcinoma
- Most common "liver cancer"
- Dx'ic test: biopsy
Biliary Cirrhosis (Primary Biliary Cirrhosis)
Not necessarily cirrhotic at diagnosis (but progresses)
- Start Ursodeoxycholic acid at dx (Urso, Actigall)

F>>M, ages 30's-60's

Autoimmune; AMA(+)

Fatigue, RUQ pain, pruritis (debilitating)
Cirrhosis
Stage 4 (final stage) fibrosis of liver

Progressive disease (rate to decompensation aka ESLD varies) curable with transplant

Many causes, most of which can recur post transplant
- HCV (26%)
- EtOH (21%)
- NASH (18%)
- HCV + EtOH (15%)
- HBV (15%)
- All others (5%): Wilson's, Autoimmune, Hemochromatosis, A1AT deficiency, PBC, PSC, drug-induced, etc.)
Chronic Viral Hepatitis - HBV
Preventable; vaccinate!

Asian Americans should ALL be screened (HBsAg)

Carcinogen; screen for hepatocellular CA (AFP, US)!

NO ALCOHOL!! EVER!! NOT EVEN ONE DRINK!!
Chronic Viral Hepatitis - HCV
Becomes chronic in ~80% of those infected

Most common indication for liver transplant in the U.S.

Curable with IFN/ribavirin combination therapy in 50%+

NO ALCOHOL!! EVER!! NOT EVEN ONE DRINK!!
Fatty Liver
Most common cause of chronic, asymptomatic, elevation of transaminases in U.S.
- 30% of U.S. population has fatty liver

Spectrum of disease (NAFLD 90%---NASH 10%)
- 30% of NASH develop cirrhosis/ESLD/HCC/need transplant

Hepatic manifestation of metabolic syndrome
- Treatment: treat the Insulin Resistance
Hemochromatosis
Most common autosomal recessive disorder
- Caucasian > African American 6:1

Bronze skin, arthropathy, fatigue, ED, DM, cardiomegaly

Therapeutic phlebotomy prevents ESLD
Hepatic Abscess
Rare; untreated 100% fatal (all need abx and drainage)

Biliary: Ascending cholangitis, tumors, strictures of biliary tree

Hematogenous: Sepsis, endocarditis, IVDA, trauma

Infectious: Appendicitis, diverticulitis, IBD (E. Coli 33%)

Cryptogenic ~50%
Portal Hypertension
Most common cause: ESLD (End Stage Liver Disease)
- Also consider portal vein thrombosis

Complications: varices, gastropathy, splenomegaly, encephalopathy

Beta blocker tx and refer for transplant evaluation
Portal-systemic encephalopathy (Aka Hepatic encephalopathy)
Failure to clear gut-derived toxins (ammonia, crosses B-B barrier

Symptoms:
- Asterixis
- AMS
- Eventual coma

Tx:
- Lactulose TID (titrate)
- Rifaxamin BID (second line)
- Prevent constipation, infection, bleeding/anemia, dehydration, high protein load; avoid benzos, EtOH
Toxic and drug-induced Hepatitis
Acetominophen most common culprit fulminant liver failure (suicide attempts and inadvertent)
- NSAIDS common cause LFTs

Prescription medications, herbs, chemical exposures

Elevated ALT>AST

Asymptomatic unless acute/fulminant liver failure OR chronic progressive to ESLD
Viral Hepatitis (acute?) Hep A
Transmission: Food borne/fecal-oral

Vaccine preventable

Acute illness slowly resolves; immune once infected
Viral Hepatitis (acute?) Hep E
Transmission: fecal/oral, contaminated water
(Hx of travel to endemic areas: Asia, Africa, Mexico)

self resolves
Wilson's Disease
Low ceruloplasmin (screen)

Elevated serum free copper and 24 hour urine copper excretion (must measure together)

Kayser-Fleischer rings
Acute Appendicitis
Most common cause acute abdomen needing surgery

McBurney's point (maximal tenderness) and Rovsing's, Psoas, Obturator signs

15-20% of appendectomy specimens negative for appendicitis (CT reduces this number)
Anal Fissure
Ow! And BRBPR on paper

Conservative therapy

Chronic fissure requires surgical tx
Antibiotic-associated Colitis
May occur within 3+ months of any antibiotic use

C. difficile ubiquitous in medical environments

Treatment with Flagyl and probiotics
Anorectal Abscess/Fistula
Infected anal gland

Surgical treatment

No antibiotics unless immune compromised or cellulitis
Celiac Sprue
Often misdiagnosed as IBS

Sxs: post-prandial bloating, cramps, gas, diarrhea

Diagnostic testing must be performed while consuming gluten:
- Best screening test: TTG and total IgA
- Diagnostic test: small bowel biopsy showing villous atrophy and chronic inflammation
Colorectal Cancer
2nd most common cause of cancer deaths in U.S.

Risk factors: age >50, smoking, heavy EtOH, obesity, diabetes, chronic constipation/low fiber diet, FH, IBD-UC, previous adenomatous polyps

PREVENTABLE disease
- Begin routine screening for average risk patients at age 50 (45 for African Americans if following AGA recs)
Diverticulosis/
Herniations of colonic mucosa & submucosa thru bowel wall muscle.
- Over time colonic musculature hypertrophies leading to out-pouching of colonic wall especially in sigmoid colon

Risk: Age, low fiber diet/chronic constipation

Pain located to LLQ
Diverticulitis
Inflammation & often perforation of colonic diverticulum
- Left lower abdominal tenderness & mass, rebound tenderness/guarding

Test of choice: Abd. CT scan (CBC and ESR or CRP also helpful)

Treatment:
- Clear liquid diet
- Cipro + Flagyl x 7-10 days
- Fiber supplementation for secondary prevention
Hemorrhoids
Dilation & Enlargement (varicosity) of venous plexus

50% by age 50

No surgical treatment unless symptomatic (bleeding, pain) despite conservative measures

Tx:
Fiber, fluids, sitz baths, topical corticosteroids and analgesics) very effective at relieving symptoms
Hereditary Colorectal Cancer and Polyposis Syndromes - HNPCC (aka Lynch Syndrome)
Amsterdam Criteria
- 3 relatives (one first degree to other two) w/ colon CA
- 2 successive generations
- 1 under age 50

80% risk colon CA

First colonoscopy surveillance age 20

Also screen for ovarian, endometrial, and urothelial cancer
Hereditary Colorectal Cancer and Polyposis Syndromes - FAP (Includes Gardner Syndrome)
Hundreds to thousands of polyps (attenuation)

100% risk of colon CA by age 40 if APC mutation present

First colonoscopy at puberty

Prophylactic colectomy when polyps appear or age 25, whichever earlier
Ileus
Hypomotility in the absence of mechanical obstruction

Post op most common cause (50% incidence)

Silent, distended, tympanitic abdomen

Small and large intestinal gas/dilatation on plain xray
Crohn's Disease
Full thickness bowel inflammation

"Skip" lesions anywhere in GI tract

Increased risk of stricture, abscess, fistula

Treatment: 5ASA drugs first-line; steroid taper for acute flare
Ulcerative Colitis
Mucosal inflammation only

Continuous colorectal inflammation starting in rectum

Increased risk of colon cancer

Treatment: 5ASA drugs first-line; steroid taper for acute flare
Intestinal Obstruction: Small Bowel (SBO)
Diagnostic test: Abdominal series and/or CT scan
- bowel dilation >3cm, air fluid levels

Adhesions most common cause
Intestinal Obstruction: Large Bowel
Diagnostic test: Abdominal series and/or CT scan
- bowel dilation >6cm

Tumors most common cause
Intestinal (colon) Polyps
a growth that sticks out of the lining of the colon or rectum

Prevent colon CA by screening for/removing adenomatous polyps (reduces incidence of colon cancer by 90%)

History of Adenomatous Polyps increases risk of colon cancer therefore need "high risk" surveillance (e.g. q 5 years colonoscopy)

Smoking, EtOH, African/Alaskan/Filipino/Jewish Americans have increased incidence of colon polyps
Irritable Bowel Syndrome
ROME III Criteria for Dx
- 3 months of abd. pain, change in stool form, and change in stool frequency
- Absence of red flags

Constipation, Diarrhea, or mixed

Individualized treatment including psychosocial care and patient education
Ischemic Bowel Disease
Ischemic colitis most common

Risk factors: anything that increases risk of thromboembolism/atherosclerosis (HTN, OCPs eg); also sickle cell, cocaine, trauma, colon CA, enteritis, hypoperfusion states
- Non-occlusive most common, 10% mortality
e.g. hypovolemia S/P acute GI bleed
- Occlusive rare, 90% mortality
e.g. thromboembolus w/ acute mesenteric infarct

CT single best test
Peritonitis
Secondary: most common
- Ruptured appendicitis, perforated PUD, or diverticulitis, cancer, acute pancreatitis, trauma/FB, Crohn's/abscess, ovarian cyst, anastamotic leak, barium, etc.)

90% mortality if untreated
- ICU: hemodynamic, pulmonary, renal support
- Systemic empiric broad spectrum antibiotics
- Nutrition/metabolic support
- Exp. Lap/treat the cause (don't explore acute pancreatitis!)
- Expect surgical site infections in up to 15%

Primary: rare
- Most common cause is SBP (spontaneous bacterial peritonitis) of ESLD (end stage liver dz)
- 50% mortality if untreated (see #1-3 above)
Pilonidal Disease
Epidem: Age 15-30, M>F, Caucasians
- Risks: hormonal changes of puberty, obesity, sitting, increased sweating, poor personal hygiene, coarse hair

Pathology: Folliculitis abscess sinus tract drains to surface
- S/S: Pain and purulent discharge; painful fluctuant sacrococcygeal mass

Tx:
- Acute: I&D (not curative)
Chronic sinus or complicated disease: Surgical excision
Proctitis
Etiol: IBD, infection, radiation, trauma, chemical
Adults, males, Jewish prevalence

Dx: Sigmoidoscopy/colonoscopy w/ biopsies and cultures

Complications: abscess, fistula, perforation, recurrence

inflammation of the rectal mucosa
Rectal Foreign Bodies
Increasing incidence secondary to anal eroticism
- M>F, 28:1, bimodal age range: 20's and 60's

Sx: Pain
- Multi-self-removal attempts result in lacerations, edema, perforation

Care typically delayed due to embarrassment
- Take careful history; if sexual assault is suspected, report to authorities

Defer exam until type and location determined by Xray
Lactase Deficiency
Exceedingly common: 30 million in U.S. by age 20
- African/Asian/Native Americans > Caucasians (??)

Symptoms: gas, bloating, cramps, diarrhea post ingestion of dairy products

Tx: Lactose free diet
- Lactase supplementation
- Calcium + D supplementation
Malabsorption Syndromes: Steatorrhea
positive quantitative fecal fat

Check 72 hour fecal fat to confirm

Many other tests for small bowel dz (D-xylose, H Breath test, EGD w/ Bx)
Malabsorption Syndromes: Pancreatic malabsorption
Acute and chronic pancreatitis

Tx: Digestive enzymes (pancrealipase w/ meals); replete nutrients; dietician referral
Malabsorption Syndromes: Small bowel malabsorption
Celiac dz, Crohn's dz, tropical sprue, Whipple's disease, short bowel syndrome

Tx: treat the underlyling dz, replete nutrients
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