Gi Board review: Part II

1. Gi Board review: Part II Molly McVey

2. A 45-year-old man is evaluated for a 1-week history of nonbloody diarrhea that occurs ten times per day and is accompanied by mild abdominal cramping. He has a 5-year history of ulcerative colitis for which he takes mesalamine.On physical examination, temperature is 37.9 °C (100.2 °F), blood pressure is 110/80 mm Hg (no orthostatic changes), and pulse rate is 100/min. Abdominal examination discloses hyperactive bowel sounds and mild diffuse tenderness but no peritoneal signs. • Abdominal CT • Colonoscopy • Right upper quadrant US • Stool studies for C.diff An acute abdominal series is normal Which of the following is the most appropriate diagnostic test to perform?

3. A 37-year-old woman is evaluated in the emergency department for the acute onset of pain after 2 weeks of bloody diarrhea. The diarrhea has escalated to 15 times per day. She has ulcerative colitis that was diagnosed 2 years ago. She currently takes azathioprine.On physical examination, she appears ill. Following aggressive fluid resuscitation, temperature is 38.9 °C (102.0 °F), blood pressure is 70/40 mm Hg, pulse rate is 148/min, and respiration rate is 35/min. Abdominal examination discloses absent bowel sounds, distention, and diffuse marked tenderness with mild palpation.Laboratory studies reveal a leukocyte count of 16,800/µL (16.8 × 109/L). Abdominal radiograph is shown to the right.Which of the following is the most appropriate management? • CT scan • Immediate surgery • Start infliximab • Start IV hydrocortisone

4. IBD • Crohn disease and Ulcerative colitis • Most commonly diagnosed in 2nd and 3rd decade, but second peak in 7th and 8th decades • Dx: histopathology is gold standard

5. Inflammatory Bowel Disease

6. Extraintestinal manifestations • Ocular: episcleritis, iritis and uveitis • Oral aphthous ulcers (seen more in Crohns) • Enteropathic arthritis • Sacroiliitis and ankylosing spondylitis • Erythema nodosumand pyodermagangrenosum • Primary sclerosing cholangitis (seen more in UC)

7. A 19-year-old woman is evaluated for a 3-month history of progressively worsening diarrhea, abdominal pain, and weight loss. Her brother was diagnosed with Crohn disease at age 16 years.On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 110/65 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. Abdominal examination reveals tenderness to palpation in the right lower quadrant with no guarding or rebound tenderness. Perianal and rectal examinations are normal.Colonoscopy discloses evidence of moderately to severely active Crohn disease involving the terminal ileum; the diagnosis is confirmed histologically. Magnetic resonance enterography shows active inflammation involving the distal 20 cm of the ileum without other bowel inflammation or obstruction. There is no evidence of abscess or phlegmon.Which of the following is the most effective maintenance treatment? • Ciprofloxacin and metronidazole • Infliximab • Mesalamine • Prednisone • Surgical resection

8. Treatment of IBD

9. Constipation • History and physical • Labs: CBC, TFTs, calcium and glucose • Workup >50yo OR alarm symptoms colonoscopy • Tx: gradual increase of fiber and miralax is first line • Magnesium containing antacids should be avoided in CKD • Stool softeners (docusate) – use with hemorrhoids/hard stools • Stimulants (bisacodyl/senna) – slow-transit constipation • Lubiprostone – constipation predominant IBS • Methylnaltrexone – opioid induced constipation

10. IBS • More common in women, <50yo, lower SEC • Rome III criteria: recurrent abdominal pain or discomfort at least 3 days a month in past 3 months (onset >6 months prior) associated with 2+ of the following: • improvement of defecation • onset associated with change in frequency of stool • onset associated with change in form (appearance) of stool • Subtypes: • IBS with constipation – can tx with lubiprostone (not first line) • IBS with diarrhea – recommend celiac testing, food diary; tx with fiber, loperamide or low dose TCA • Mixed IBS – recommend celiac testing, food diary • Unsubtyped IBS

11. A 67-year-old man is evaluated in the emergency department for the acute onset of severe diffuse abdominal pain that began 1 hour ago. He has a history of arteriosclerotic cardiovascular disease, and he underwent three-vessel bypass surgery 2 years ago. His current medications are lisinopril, atenolol, simvastatin, and aspirin.On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 78/56 mm Hg, pulse rate is 142/min, and respiration rate is 29/min. Abdominal examination discloses diffuse mild abdominal tenderness to palpation with no guarding or rebound and no masses.Laboratory studies reveal a leukocyte count of 14,000/µL (14 × 109/L), a bicarbonate level of 14 meq/L (14 mmol/L), and an elevated serum lactate level. CT scan shows small-bowel wall thickening and intestinal pneumatosis.What is the most likely diagnosis? • Acute mesenteric ischemia • Crohn disease • Intussusception • Pancreatitis

12. Abdominal pain other…. • Diverticulitis: LLQ pain, fever, leukocytosis; CT is test of choice; following resolution need to evaluate with colonoscopy • Acute mesenteric ischemia: • >50yo, underlying cardiac or vascular dz, present with acute onset of severe abdominal pain, exam does NOT match symptoms • Plain film and CT maybe normal early • Plain film: dilated loops of bowl, thumbprinting of SB and right colon • CT: intestinal pneumatosis and bowel wall thickening • CTA/MRA better early; gold standard is classic angiography • Chronic mesenteric ischemia (“intestinal angina”) • Symptom onset ~30min after eating; weight loss; workup with CTA or MRA; tx with surgical revascularization • Colonic ischemia

13. A 50-year-old woman is evaluated during a routine examination. She is in excellent health and has no gastrointestinal symptoms. She has no history of colorectal neoplasia.Physical examination is normal. She is sent home with high-sensitivity guaiac fecal occult blood test (gFOBT) cards and is asked to collect two specimens each from three consecutive stools. One of the six samples is positive.What is your next step in management? • Colonoscopy now • Fecal immunochemical test in 1 year • Flexible sigmoidoscopy now • gFOBT in 1 year • Repeat gFOBT now

14. Colorectal cancer screening • Average risk: no risk factors • Begin screening at age 50 (age 40 for black patients) and continue till age 75 or <10 yr life expectancy • Increased risk: • 1st degree relative: age 40 or 10 years younger than age at which relative was diagnosed with CRC; survey every 5 yrs • IBD: 8 years after diagnosis then survey every 1-2 yrs • Others refer to chart in MKSAP • Surveillance: • Low risk (1-2 adenomas, <1cm, tubular morphology and low grade dysplasia): repeat colon in 5-10 years • High risk (>3 adenomas, >1cm, villous morphology or high grade dysplasia): repeat in 3 years

15. CRC Screening

16. A 32-year-old woman is evaluated for a 10-day history of malaise, right upper quadrant discomfort, and progressive jaundice. She has had no recent travel outside of the United States, does not drink alcohol, and has no recent ingestions of drugs, including acetaminophen or herbal remedies. Up until this time, she has been healthy. She has a history of type 1 diabetes mellitus for which she takes insulin glargine and insulin detemir. She has no other medical problems.On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is 106/68 mm Hg, pulse rate is 90/min, and respiration rate is 18/min. BMI is 24. Mental status is normal. Jaundice and scleral icterus are noted. Abdominal examination reveals tender hepatomegaly. • Acute viral hepatitis • Fulminant liver failure • Hemochromatosis • Primary biliary cirrhosis Abdominal ultrasound demonstrates hepatic enlargement with edema surrounding the gallbladder. There is no biliary ductal dilatation. The portal vein and spleen are normal. What is the most likely diagnosis?

17. Abnormal liver studies • Elevated AP and bilirubin: think biliary injury or abnormalities of bile flow • Elevated AP: think also bone injury or pregnancy • Serum albumin and prothrombin time: synthetic function • Elevation of AST and ALT: think hepatocellular injury

18. Acute Hepatitis • Hep A: • High risk: travelers, MSM • Symp: malaise, fatigue, nausea and RUQ pain, jaundice 1-2 wks • Dx: IgM Ab • Hep B: causes acute and chronic hepatitis • Adults infected usually develop acute infection that resolves • Children infected typically develop chronic infection • Management: • Acute: supportive (antivirals reserved for fulminant liver failure) • Chronic active (elevated enzymes or active inflammation): antiviral therapy (goal to convert HBs AG status to negor suppression of viral replication) • Chronic immune-tolerant: monitor enzymes • Extrahepatic manifestations: PAD and kidney disease (Membranous glomerulonephritis) • Prevention: vaccination of newborns and high risk (health care workers)

19. Hepatitis B serologies

20. Hepatitis C • Risk factors: IV drug use or blood transfusion prior to 1992 • Dx: HCV Ab and HCV RNA to confirm • Often coinfected with HIV • Tx: Peginterferon and ribavirin; NS3/4A PI for genotype 1 • Goal is undetectable viral load

21. A 45-year-old man is admitted to the hospital for new-onset right upper quadrant pain, ascites, fever, and anorexia. His medical history is notable for hypertension and alcoholism. His only medication is hydrochlorothiazide.On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 110/50 mm Hg, pulse rate is 92/min, and respiration rate is 16/min. BMI is 24. Spider angiomata are noted on the chest and neck. The liver edge is palpable and tender. There is abdominal distention with flank dullness to percussion. • Etanercept • Infliximab • Pentoxifylline • prenisolone The Maddrey discriminant function score is 36. Ultrasound discloses coarsened hepatic echotexture, splenomegaly, and a moderate to large amount of ascites. Diagnostic paracentesis reveals spontaneous bacterial peritonitis, and intravenous ceftriaxone is administered. Upper endoscopy is notable for small esophageal varices without red wale signs and no evidence of recent bleeding. What is the treatment of choice?

22. Metabolic liver disease • NFLD and NASH • Hereditary Hemochromatosis • Elevated liver enzymes, elevated ferritin • Liver biopsy to evaluate for cirrhosis • Tx: phlebotomy • Alpha antitrypsin deficiency • Wilson Disease • Usually dx when young with elevated enzymes, decreased ceruloplasmin, low alkphos

23. Cholestatic Liver Disease • Primary Biliary Cirrhosis • Middle-aged women, fatigue, dry eye, pruritus • Antimitochondrial antibody • Histology: focal duct obliteration • Tx: symptomatic (pruritus, dry eyes and dry mouth); ursodeoxycholic acid shows survival benefit • Primary Sclerosing Cholangitis • Affects intra- and extrahepatic bile ducts • Associated with IBD and increased risk of cholangiocarcinoma • Symp: pruritus, abdominal pain and jaundice • Elevated alkphos(3-10x nml) • Smooth muscle antibodies and antinuclear antibodies • Dx: cholangiography (“beads on a string”) • Tx: transplant

24. 45-year-old man is admitted to the hospital for a 2-day history of fever and abdominal pain. His medical history is notable for cirrhosis due to chronic hepatitis C, esophageal varices, ascites, and minimal hepatic encephalopathy. His medications are furosemide, spironolactone, nadolol, lactulose, zinc, vitamin A, and vitamin D.On physical examination, temperature is 36.5 °C (97.7 °F), blood pressure is 100/50 mm Hg, pulse rate is 84/min, and respiration rate is 20/min. BMI is 28. Abdominal examination discloses distention consistent with ascites. The abdomen is nontender to palpation. • Cefotaxime • Cefotaxime and albumin • Furosemide and spironlactone • Large-volume paracentesis Abdominal ultrasound discloses cirrhosis, splenomegaly, and ascites. The portal and hepatic veins are patent, and there is no hydronephrosis. Diagnostic paracentesis discloses a cell count of 2000/µL with 20% neutrophils, a total protein level of 1 g/dL (10 g/L), and an albumin level of 0.7 g/dL (7 g/L), consistent with spontaneous bacterial peritonitis. What is the treatment of choice?

25. Complications of Liver Disease • Portal hypertension: gastric and esophageal varices • Ascites • Spontaneous bacterial peritonitis: • PMNs>250, tx with 3rd gen cephalsporin (+ albumin if ARF) • PPx: norfloxacin or bactrim if fluoroquinolone allergy • Hepatic encephalopathy: • Tx: lacutolosethen add rifaximin if refractory • Hepatorenal syndrome • Hepatopulmonary syndrome • Hypoxemia; dx with contrast bubble study • Portopulmonary syndrome • Portal HTN with Pulmonary HTN, elevated PA pressures • HCC: survey cirrhotics every 6 months with US or CT/MRI

26. Hepatic tumors, cysts and abscesses • Hepatic cysts: • Simple: asymptomatic • Cystadenoma: symptomatic, irregularity on US, need surgical resection • Focal nodular hyperplasia: “central scar” on CT/MRI • Hepatic adenoma: • women on contraceptives • Surgical resection if >5cm or if want to become pregnant; <5cm – dc contraceptives • Hepatic hemangioma: benign • Liver abscesses: drainage + antibiotics

27. A 70-year-old man is referred for abdominal aortic aneurysm (AAA) screening. He is asymptomatic and takes no medications. He has a 50-pack-year smoking history.On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is 125/60 mm Hg, pulse rate is 72/min, and respiration rate is 16/min. BMI is 30. Abdominal examination discloses mild tenderness to palpation over the epigastrium and no rebound tenderness or guarding.Abdominal ultrasound discloses a normal-appearing liver without splenomegaly or liver masses. Numerous gallstones are noted. There is no evidence of AAA.What is the most appropriate next step in management? • Abdominal CT scan • Laparoscopic cholecystectomy • Ursodeoxycholic acid • Observation

28. Gallstones • Asymptomatic gallstones: observe • Acute cholecystitis: • Dx: US • Tx: IVFs and abx initially then lap chole 48-96hrs later • Acalculouscholecystitis: • Predisposing factors: critical illness, burns, advanced age, atherosclerotic vascular disease, AIDS, infection with Salmonella or cytomegalovirus, polyarteritisnodosa, and systemic lupus erythematosus • Tx: supportive (IVFs and abx), cholecystectomy or drainage

29. An 85-year-old man is evaluated in the emergency department for a 2-day history of confusion and poor appetite. His medical history is significant for type 2 diabetes mellitus. His medications are insulin glargine and metformin.On physical examination, he is toxic appearing, cool, and clammy. Temperature is 36.5 °C (97.7 °F), blood pressure is 90/70 mm Hg, pulse rate is 110/min, and respiration rate is 32/min. BMI is 27. The cardiopulmonary examination is normal. The abdomen is unremarkable to palpation. • Cholecystectomy • ERCP • Hepatobiliaryimiodiacetic acid scan • MRCP Abdominal ultrasound discloses a normal liver. There is no bile duct dilatation. Gallstones are present in the gallbladder. Ampicillin-sulbactam is begun. Which of the following is the most appropriate next step in management?

30. Biliary cancer • Gallbadder cancer: • Risk factors: age>50, female, obesity, polyp >1cm, gallstone >3cm, chornicSalmonella typhiinfection and procelain GB cholelithiasis • Prophylactic chole: GB polyp >10mm, gallstone >3cm or porcelain GB • Cholangiocarcinoma: • Associated with PSC; poor prognosis • Ampullary carcinoma: • Associated with FAP or Peutz-Jeghers– recommend surveillance endoscopy • Biliary cysts: • Causes duct dilatation, 20fold increase risk of cholangiocarcinoma • Tx: surgical removal

31. A 72-year-old man is evaluated in the emergency department for a 2-week history of gnawing epigastric pain followed by one episode of coffee-ground emesis 6 hours ago. He has a history of prosthetic mitral valve replacement and chronic atrial fibrillation, and he had a transient ischemic attack 1 year ago. He has no history of liver disease. His current medications are warfarin and metoprolol. He is started on intravenous omeprazole.On physical examination, blood pressure is 120/85 mm Hg (no orthostatic changes), pulse rate is 90/min, and respiration rate is 16/min. The abdomen is tender to palpation in the epigastrium. There are no stigmata of chronic liver disease. • Fresh frozen plasma • IV vitamin K • Oral vitamin K • Upper endoscopy Which of the following is the most appropriate management?

32. Upper GI Bleed • Most common causes: PUD, esophageal varices, esophagitis, malginancy, angioectasia, Mallory-Weiss tear and Dieulefoy lesions • Workup: • Type of blood loss: slow vs brisk • Hemodynamic status (quantifies the amount of blood loss) • Tachycardia (15-30% blood loss) and hypotension (>30% blood loss) • Orthostatic (large volume loss) • CBC, INR, BUN, Cr • Management: airway, access (2 large-bore Ivs), resuscitation (fluids and pRBCs) • Nonvariceal bleed: IV PPI • Supratherapeutic INR: FFP (only delay endoscopy if INR>3) • Variceal bleed: octreotide and IV abx • Endoscopy after stabilization but within 24 hrs (within 12 hr for variceal) • Monitor high risk patients for 72hrs on IV PPI

33. A 65-year-old man is evaluated in the emergency department for painless bright red blood per rectum that began 6 hours ago. He has no other medical problems and takes no medications.On physical examination, temperature is 36.6 °C (97.9 °F), blood pressure is 130/78 mm Hg, pulse rate is 96/min, and respiration rate is 18/min. Abdominal examination is normal. Rectal examination discloses no external hemorrhoids; bright red blood is noted in the rectal vault.Laboratory studies reveal a hemoglobin level of 10.4 g/dL (104 g/L), a leukocyte count of 6000/µL (6 × 109/L), and a platelet count of 380,000/µL (380 × 109/L).What is the most likely causes of this patient’s bleeding? • Colon cancer • Diverticulosis • Duodenal ulcer • Ischemic colitis

34. Lower GI Bleed • Most common causes: diverticulosis, internal hemorrhoids, postpolypectomy, angioectasia • Evaluation: • If suspect an upper bleed upper endoscopy and if negative then proceed to colonoscopy • Lower source colonoscopy

35. Obscure GI bleed • Repeat upper or lower endoscopy • Angiography: active overt bleeding (>1ml/min), sens poor • Technetium-labeled nuclear scan: active bleeding, but not specific • Capsule endoscopy • Push enteroscopy • Spiral enteroscopy • Single and Double Balloon enteroscopy • Small bowel radiography