Module 10

Describe achalasia

• “Failure of relaxation”

• Failure of the LES to relax (open)

• Causes:

  -Idiopathic

  -Esophageal myenteric plexus degeneration

  -CN-X damage

• Common cause of dysphagia, no pain

• X-ray with barium swallow

  -”Bird beak” appearance

What is the treatment for achalasia?

• Pneumatic dilation

• Botox (botulinum toxin type A)

What are the causes of GERD?

• Abnormal esophageal sphincter

• Foods, EtOH, medications (anticholinergics, nitrates, calcium channel blockers), stress, smoking (nicotine), hiatal hernia, pregnancy, peppermint!

• Obesity, peptic ulcer

What are the S/S for GERD?

• Heartburn > 2x week - worse at night

• “Chest pain”, dysphagia, sore throat

• Cough:

  -Acid in the distal esophagus stimulates a vagally mediated esophagealtracheobronchial cough reflex

  -Can trigger asthma attack

What are the complications of GERD?

• Esophagitis

  -Long term esophagitis can become Barrett’s

• Barrett’s esophagus (metaplasia)

  -1% of Barrett’s esophagus becomes esophageal cancer (dysplasia)

What are the testing for GERD?

• Endoscopy

• Barium X-ray

What are the treatments for GERD?

• Prop upper body up when sleeping

  -Sleep on the right vs left side

  ~Variability in stomach orientation

  ~Whatever works best for you

• Eat smaller meals

• Less fatty foods (fad relaxes LES)

• Antacids

• H₂ blockers

• PPI’s (proton pump inhibitors)

Describe peptic ulcer disease

• Ulcerations of stomach lining

  -Gastric

  -Duodenal

  -Esophageal → GERD

• Causes:

  -H. Pylori (MCC), NSAIDS (>50%)

  -Smoking, EtOH, age

  -Gastrinoma - gastrin producing tumor of the pancreas or duodenum

  ~Increased gastrin → increased HCL

What are the S/S for peptic ulcer disease?

• Upper abdominal pain

  -Duodenal ulcer - decreased pain with eating, increased pain in 1-2 hrs

  -Gastric ulcer - increased pain during/after eating

• N/V, weight loss, hemoptysis

• Melena (black tarry feces)

What are the complications of peptic ulcer disease?

• Perforation

• Bleeding

• Obstruction (edema from inflammation)

• Peritonitis

What are the testing for peptic ulcer disease?

• X-ray

• Upper GI endoscopy

• H. pylori → blood, breath, stool

What are the treatments for peptic ulcer disease?

• Acid lowering drugs: H₂ blockers, PPI’s

• Add antibiotics if H. pylori infection

• Surgery if complications occur: (bleeding, perforation, obstruction, or peritonitis)

Describe celiac sprue (celiac disease)

• AKA: gluten induced enteropathy

• Immune sensitivity to gliadin (fat soluble part of gluten)

• Etiology

  -FHx. Caucasian, European, women > men

What is the pathophysiology of celiac sprue?

• Atrophy/flatting of intestinal villi

  -Decreased absorption of some vitamins, proteins, fats and carbohydrates → diarrhea, weight loss, low energy

What are the S/S for celiac sprue?

• Abdominal pain, N/V, bloating, gas, indigestion

• Constipation or diarrhea

• Fatty stools

• Anemia, joint pain, muscle cramps, osteoporosis, depression, fatigue, malnutrition, weight loss

• Dermatitis herpetiformis (itchy blistery skin rash)

What are the testing and Tx for celiac sprue?

• Testing:

  -Decreased Vit K levels - fat malabsorption

  ~Increased PT

  -Biopsy

  -Blood test:

  ~Anti-gliadin Ab

  ~Anti-endomysial Ab

  ~Tissue transglutamase Ab

• Tx:

  -No cure, avoid gluten

Describe diarrhea

• Acute - more than 3 loose or watery stools within 24 hrs and lasting less than 2 weeks

  -Persistent - 2 to 4 weeks, chronic > 4 weeks

• Pathophysiology

  -Decreased water reabsorption and increased peristaltic activity of the large intestine

What are the causes of diarrhea?

• GI disorders

  -IBD (UC, Crohn’s), celiac disease

• Food allergies

• Artificial sweeteners - sorbitol

• Viral, bacterial, parasites

  -Water, food, travel

• Medication

  -Antibiotics

Describe osmotic diarrhea

• Artificial sweeteners

  -Ex: sorbitol, feeding tubes with full strength formulas

Describe secretory diarrhea

• Viral (rotavirus)

• Bacterial (E. coli, vibrio cholera), C. dif. (AAPMC)

• Parasites (gardia)

• IBC (ulcerative colitis, Crohn’s disease)

• Celiac disease, colon CA

Describe motility diarrhea (fast transit time)

• SI resection, hyperthyroidism

• IBS, laxative abuse

• Diabetic neuropathy

What are the S/S of diarrhea?

• Frequent loose stools

• Abdominal pain and cramping

• Fever, chills, malaise

• Dehydration (especially in infants)

• Bloody stools

What are the testing for diarrhea?

• Culture

• Ova and parasite (O&P) test

• CT

• Rectal exam

What are the treatments for diarrhea?

• BRAT (bananas, rice, applesauce, toast) = a bland diet

• Anti-motility agents (loperamide)

• Treat the underlaying cause

Describe constipation

• Infrequent bowel movements < 3x week

• Causes:

  -Dehydration, decreased fiber, age

  -Quitting smoking (nicotine is a laxative)

  -Decreased exercise

  -Pregnancy

  -Hypercalcemia (tums)

  -Medication SE (opiates, anticholinergics, iron)

  -Colon cancer, rectal cancer

  -Neurogenic disorders (Parkinson’s, stroke)

What are the S/S of constipation?

• Abdominal pain, straining, N/V

• Bloating, rectal bleeding, hemorrhoids

What are the testing for constipation?

• Sigmoidoscopy/colonoscopy

• Barium enema

What are the treatments for constipation?

• Stools softeners (Dulcolax)

• Laxatives (mineral oil, senna)

• Glycerol suppository

• Fleet (saline) enema

• Manual disimpaction (glove and scoop)

Describe diverticulitis

• Diverticula = herniation of mucosa and submucosa through the muscularis layer

• Diverticulosis = multiple diverticula, no inflammation, asymptomatic

• Diverticulitis = Inflammation of a diverticula, painful

• MC in sigmoid colon → LLQ pain

• >50% of Americans > 60 years old have diverticulosis

• MC in elderly people

• Risk factors:

  -Elderly, genetics, obesity

  -Smoking, low fiber diet

  -Low physical activity

  -Aspirin and other NSAIDS

What are the S/S for diverticulosis?

• LLQ abdominal pain with tenderness, cramping, N/V

• Constipation/diarrhea, fever, leukocytosis

What are some complications of diverticulosis?

• Perforations → bleeding

• Abscess, peritonitis

• Fistula (M/F: colon-bladder fistula, F: colon-vagina fistula)

• Scarring can lead to intestinal obstruction

What are the testing for diverticulosis?

• CBC - increased WBC

• CT, abdominal US, colonoscopy

What are the Tx for diverticulosis?

• High fiber diet - increases the bulk in the stool and thereby reduces the pressure within the colon

• During an episode - liquid diet/jello

• Antibiotics

• Surgery (if severe complications)

Describe IBD (inflammation bowel disease)

• Crohn’s disease, ulcerative colitis

• Inflammation of the GI system → treated with anti-inflammatory medications

• Have extra (outside) intestinal manifestations + GI symptoms

• Patient’s may have to undergo surgery

Describe IBS (irritative bowel syndrome)

• A functional disorder, not a disease

• No inflammation → no anti-inflammatory medications

• Vague symptoms, only in the intestinal medications

  -Alternating constipations/diarrhea, cramping, bloating, flatulence

  -Abdominal relieved by defecation

• No surgical intervention

• Tx: diet modification, OTC constipation or diarrhea meds, possibly anti-depressants

Describe ulcerative colitis

• Inflammation of colon that causes ulceration

  -Most common at rectum and sigmoid colon

• Causes:

  -Unknown - however infection, genetic, immunologic factors are suggested causes

  -Age: 20 - 40 yrs

  -FHx, Ashkenazi Jews

What are the S/S for ulcerative colitis?

• Left sided pain more common

• Frequent large volume diarrhea (10+/day) with blood and purulent mucus

  -Dehydration, weight loss, anemia (iron deficiency)

• Tenesmus (urge to defecate), abdominal pain

• Remission/exacerbation of symptoms (good days and bad days)

What are some complications of ulcerative colitis?

• Fissures, fistulas, perforations, obstructions, sepsis

• Risk of colon cancer increases if patient that UC for > 10 yrs

What are the testing for ulcerative colitis?

• Blood test:

  -Increased CRP, increased WBC

  -pANCA positive

  -ASCA negative

• Colonoscopy - continuous lesions, pseudopolyps, ulcers

• Biopsy

What are the Tx for ulcerative colitis?

• Immunosuppressants to control inflammation

• Surgery (remove affected areas)

Describe Crohn’s disease

• Inflammation of the GI - both small and large intestine

  -Most common sites affected: ileocecal region, ascending and transverse colon

• Causes:

  -Unknown - infections, genetics (Ashkenazi Jews), immunologic factors are suggested causes

  -FHx - 10-20%, age: 20-40 yrs

  -Smoking increases the risk of developing severe disease

What are the S/S of Crohn’s disease?

• Abdominal pain, cramping, diarrhea (dozens/day), bloody stools (sometimes)

• “Skip” lesions (not continuous)

  -May occur anywhere from mouth to anus

• Weight loss

• If ileum involved: malabsorption of Vit B₁₂, Vit D

• Fistula formation between loops of intestine or between bladder, rectum, or vagina

What are the testing for Crohn’s disease?

• Blood test:

  -Increased CRP, increased WBC = inflammation

  -pANCA negative

  -ASCA positive

• Endoscopy and colonoscopy - cobblestoning, skip lesions

• Biopsy

Example of AST:ALT ratio for viral hepatitis/NASH

• AST = 100 and ALT = 200

• AST:ALT = 100/200 = 0.5

• AST:ALT < 1

• ALT > AST

Example of AST:ALT ratio for alcoholic hepatitis

• AST = 300 and ALT = 100

• AST:ALT = 300/100 = 3

• AST:ALT > 2

• AST > 2*ALT

Example of AST:ALT ratio for cirrhosis

• AST = 500 and ALT = 333.3

• AST:ALT = 500/333.3 = 1.5

• 1 < AST:ALT <2

• 1 < AST:ALT <2 = ALT < AST < 2*ALT

Describe viral hepatitis

• Viral types: A, B, C, D, E, G

  -Vaccines are available for types A and B

  -Contaminated food/water transmission

  ~Types A and E

  -Blood (IV drugs abusers) or sexual transmission

  ~Types B and C

  -Types D - co-infection with hepatitis B

  -Types B and C - leads to cirrhosis and HCC (liver cancer)

What are the S/S for viral hepatitis?

• Fatigue, flue-like symptoms

• Abdominal pain, N/V

• Jaundice

What are the testing for viral hepatitis?

• Viral antigen/antibody tests

• Increased bilirubin, increased ALT, increased AST

• AST:ALT < 1

What are the mild S/S for alcoholic hepatitis (acute)?

• N/V, anorexia, weight loss

• Abdominal pain, fever

• Hepatomegaly, jaundice

What are the labs for alcoholic hepatitis (acute)?

• AST:ALT > 2:1

• Increased gamma-GT

• Increased bilirubin

What is the histology (biopsy) of alcoholic hepatitis (acute)?

• Ballooning degeneration

  -Ballooning → enlarging → hepatomegaly

• Mallory bodies (misfolded keratin)

• Steatosis (fatty changes)

Describe alcoholic cirrhosis (chronic)

• There are two simplified differences between alcoholic cirrhosis and all the other causes of cirrhosis:

  -1. Hepatomegaly: portal HTN happens in all cirrhosis, regardless of the cause

  -2. Ballooning degeneration and Mallory bodies

  ~The steatosis is also seen in NASH because steatosis = fatty liver

• Cirrhosis will have the ration of 1 < AST:ALT < 2, regardless of the cause

Describe NASH (non-alcoholic steatohepatitis)

• Fat deposition in the liver that causes inflammation and fibrosis (scar tissue)

• 1-2% of Americans

• Cause:

  -Hight cholesterol, high TG’s, type 2 DM

What are the S/S for NASH?

• “Silent” liver disease

  -May take decades to progress

• Dull abdominal pain

• Jaundice, fatigue

What are the testing for NASH?

• Increased ALT and increased AST, AST:ALT < 1

• Increased bilirubin

• Ultrasound picks up fatty liver

• Biopsy to determine if cirrhosis is present

Describe cirrhosis

• Cirrhosis = end stage liver disease = chronic liver failure

• Cause: viral hepatitis, alcoholic hepatitis, NASH

• Liver color: yellow, green, or brown

• Liver size (depends on underlaying cause):

  -Viral hepatitis - normal or small

  -Alcoholic hepatitis - enlarged

• Histology:

  -Loss of normal parenchyma

  -Fibrotic tissue and nodules

Describe portal HTN

• Cirrhosis results in obstruction to the flow of blood and bile

• Blood flow into the liver backs up in the portal vein

  -Esophageal varices

  ~High risk of hemoptysis

  ~MC symptom

  -Splenomegaly

  ~Increased BT

  -Caput medusa

• Tx:

  -TIPS

What are the S/S for cirrhosis?

• Fatigue, N/V, edema, jaundice, pruritus, GI bleeding, ascites

• Portal hypertension → esophageal varices, caput medusa, and splenomegaly

• Bleeding disorders, hypoglycemia, encephalopathy

• Increased estrogen → gynecomastia in men, spider angiomas (both genders)

What are the test for cirrhosis?

• Increased AST, increase ALT, increased in y-GT

• 1 < AST:ALT < 2

• Increased bilirubin

• Increase PT, increased aPTT

  -If splenomegaly → increased BT

• Increased estrogen

• CT scan

• Liver biopsy

Describe Wilson disease

• Hepatolenticular degeneration

• Autosomal recessive

• Pathophys:

  -Defect of copper metabolism

  -Toxic levels of copper accumulate in the liver, brain, kidneys, and corneas

What are the S/S for Wilson disease?

• Neuromuscular abnormalities

  -Intention tremors

  -Dysarthria (indistinct speech)

  -Dystonia (disordered muscular tonicity)

• Kayser-Fleischer rings

• Hepatomegaly → cirrhosis

What are the Dx for Wilson disease?

• Increased urine copper

• Decreased ceruloplasmin levels

  -Copper transporting plasma protein

Biliary terminology

• Chole - gallbladder

• Doco - duct

• Lithiasis - stone

• Cholelithiasis - stones in the gallbladder

  -Often asymptomatic, sometimes it hurts

• Cholecystitis - inflammation of the gallbladder

  -Due to a gallstone impacted in the cystic duct

• Choledocholithiasis - stones in the common bile duct

  -Partial obstruction, leading to congestion

• Cholangitis - inflammation of common bile duct

  -Due to an impacted gallstone

  -MCC: bacterial infection → ascending cholangitis

  -Other: autoimmune condition called primary sclerosing cholangitis

Describe cholelithiasis (gallstones)

• An accumulation of hardened cholesterol and/or calcium-bilirubinate deposits in the gallbladder

• Pathophys:

  -Impaired metabolism of cholesterol, bile acids and/or bilirubin

  -Supersaturation of cholesterol leads to crystal formation

• If gallstone leaves the gallbladder and occludes the cystic duct, it will lead to inflammation and pain → cholecystitis

What are the risk factors of cholelithiasis?

• The 6 F’s

  -Female

  -Forty’s (middle aged)

  -Fat

  -Fair complexion (light colored skin)

  -Fertile (HRT, OCP, multiparous)

  -FHx

• Other RF: native Americans, DM, pregnancy

What are the S/S for cholelithiasis?

• Often asymptomatic, but it if isn’t…

  -RUQ colicky pain < 6 hrs

  ~Post-prandial pain after a fat heavy meal

  -Pertinent negatives

  ~No leukocytosis or fever

  ~No N/V

  ~No jaundice

What are the Dx and Tx for cholelithiasis?

• Dx:

  -RUQ U/S - acoustic shadowing (stones)

• Tx:

  -If asymptomatic - nothing

  -If symptomatic - laparoscopic cholecystectomy

  ~Elective outpatient surgery, not an emergency

Describe cholecystitis

• Cystic duct obstruction causing inflammation of the gallbladder

• Cause: gallstone stuck in cystic duct

• Risk factors: cholelithiasis (6 F’s)

What are the S/S for cholecystitis?

• RUQ pain - constant pain

  -Radiates to R lower scapula (referred pain)

  -Worse after high fat meal

• N/V, fever, leukocytosis

• Diaphoresis

• Pertinent negatives

  -No jaundice

What are the testing for cholecystitis?

• Positive Murphy’s sign

• Rebound tenderness

• CBC - increased WBC’s

• RUQ U/S - pericholecystic fluid, gallbladder wall thickening (mucosal edema)

What is the Tx for cholecystitis?

• Surgery - emergency laparoscopic cholecystectomy

Describe choledocholithiasis

• Stones obstructing the common bile duct

• Cause: cholelithiasis → migration of gallstones into the common bile duct

• Patho:

  -Bile production is still occurring, but is unable to pass beyond the obstruction

  ~Partial obstruction can also lead to congestion over time

  -Bile congests in bile duct and liver, causing liver damages

• Complications:

  -Cholangitis and/or gallstone pancreatitis

What are the labs for choledocholithiasis?

• Increased AST, ALT - liver damage

• Increased bilirubin - jaundice

• Decreased vitamin K → increased PT

What are the S/S for choledocholithiasis?

• RUQ pain > 6 hrs

• Jaundice

• N/V

• Clay colored stools

• Pertinent negatives:

  -No fever, no leukocytosis

What are the Dx for choledocholithiasis?

• RUQ U/S: dilated bile duct above the stone - bile congestion

• ERCP - also used for treatment

Describe cholangitis

• AKA: ascending cholangitis or acute cholangitis

• Bacterial infection of the whole biliary tree due to choledocholithiasis

What are the S/S for cholangitis?

• Charcot’s triad

  -RUQ pain

  -Fever

  -Jaundice

• N/V

• Clay colored stools

• Potential life threatening if Reynold’s Pentad is present

• Hepatomegaly is possible

What are the Dx for cholangitis?

• ERCP

  -Increased AST, ALT - liver damage

  -Decreased Vitamin K → increased PT

  -Increased total bilirubin - jaundice

  -CBC - leukocytosis

What are the Tx for cholangitis?

• Emergency ERCP + antibiotics

Describe pancreatitis

• Acute or chronic inflammation of the pancreas

• Causes:

  -Choledocholithiasis → blockage of pancreatic duct or ampulla of vater → enzymes auto-digest the tissue → possible necrosis

  -Direct cell injury from alcohol, drugs, or viral infection

  -Trauma

  -Cystic fibrosis

What are the S/S for pancreatitis?

• Epigastric pain (mild to incapacitating) → radiation to the back

• Fever (inflammation)

• N/V → paralytic ileus secondary to pancreatitis or resultant peritonitis

• Tachycardia/hypotension → decreased blood volume from inflammatory mediators → increased vascular permeability

• Transient hyperglycemia → glucagon release from damaged alpha cells

• Possible jaundice → bile duct obstruction or swollen pancreas pushing on CBD

What are the testing for pancreatitis?

• CBC → increased WBC, hyperglycemia

• Enzymes → increased lipase (gold standard) and increased amylase

• CT - best test

What are the Tx for pancreatitis?

• NPO, pain meds, IV fluids

• ERCP if the pancreatitis is due to a gallstone