Gastrointestinal Disorders – Evaluation and Differential Diagnosis

1. Gastrointestinal Disorders – Evaluation and Differential Diagnosis Ted D. Williams PharmD Candidate OSU/OHSU College of Pharmacy

2. Learning Objectives • Demonstrate the ability to associate laboratory values, physical findings, and diagnostic test results with specific disorders • Rule out unlikely disorders based on laboratory values, physical findings, and diagnostic test results • Synthesize information from multiple courses to identify possible causes for physical findings • Synthesize information from multiple courses to determine potential therapies • Distinguish etiology and pathophysiology of discussed bowel disorders • Distinguish etiology and pathophysiology of discussed hepatic disorders

3. Overview • Present previous material within the context of physical assessments • Procedural vs. disease state organization • Laboratory Tests • Physical Exam • Diagnostic Procedures • Specific Disorders • Bowel Disorders • Hepatitis

4. What this lecture is and is not • It is NOT a • Systematic Review of the Literature • Exhaustive Reference • Evidence Based Medicine • It is • Practical for pharmacists • From personal clinical experience • Highlights to keep in mind while practicing • Q&A

5. What’s on the exam • I’m not sure… • If you’re really worried about it, do the reading, it’s pretty much all there • If you want some “clinical pearls” then come to lecture

6. INs and OUTs • If INs and OUTs are good, the patient is good • If the INs and OUTs are not good, the patient is not good

7. Take a history • Without a history, you are shooting in the dark…(and burning cash and time) • Do you often have “belly” pain? • Where does it hurt? • What did you eat today (or the last day you felt like eating)? • When was the last time you were in the hospital? Why did you go? • What medications are you taking? • How are things going in the bathroom? • From these questions, I can make a pretty accurate guess of what’s wrong. • Labs, Ultrasound, CT Scan, etc, just confirm what I guessed from the history or identify insidious disease processes • When you hear hoof beats, think horses, not zebras

8. Patient Case • ER note indicates blood in the stools • Patient admitted to the floor • Where can the blood be coming from? • Larynx through the rectum • What are the different characteristics of the observed blood?

9. Laboratory Findings • Signs of Blood Loss • Signs of Liver Damage • Signs of Pancreas Damage • Signs of Infection

10. Blood in stools (OUTs) • Rectal • Colon • Small intestine • Gastric • Esophageal

11. Other findings • Pain • Location • Quality • Severity

12. Legs of the stools • It’s Bloody, but what else? • Constipation • Diarrhea • Upper GI (gastric and esophageal) may not have additional stool findings other than tarry stools

13. The other end • Nausea • Vomiting • Coffee Ground Emesis • Bright red blood • Chronic vs. acute

14. Abdominal Exam • Stop and think • What are you expecting? • What would be abnormal? • Inspection • Peristalsis suggests…. • Auscultation • Absent bowel sounds in…. • Continuous bowel sounds in… • Percussion • Tympany in what regions…. • Palpation • When/Where would firmness be expected? • When/Where would pain be expected

15. Abdominal Findings • Ask about “belly pain” before touching the patient…do no harm • Inspection • Ascites • 80% of cases are from hepatitis • Hernia • Hematoma • Jaundice • Pallor • Kaput Medusa • A fairly infrequent, if distinct finding • Spider Angiomas • Ostomies

16. Jaundice • Hepatic Injury • Bile Duct Obstruction • Pancreatitis Image Downloaded from http://bhtimes.blogspot.com/2007/03/lukashenka-makes-business-decree.html

17. Ascites Downloaded from http://www.lf2.cuni.cz/Projekty/interna/foto/001/pic00087.jpg Downloaded from http://depts.washington.edu/physdx/liver/tech.html

18. Ascites vs. Obesity Downloaded from wikipedia.org

19. Hernia

20. Ostomies Downloaded from http://wjso.com/content/figures/1477-7819-5-52-2-l.jpg

21. Spider angiomas Downloaded from http://a248.e.akamai.net/7/248/430/20080912143522/www.merckmedicus.com/ppdocs/us/hcp/content/white/chapters/images/A02997-f15-30.jpg

22. Abdominal Findings • Auscultation • Hyperactive or absent • Bruits • Percussion • Dullness over enlarged organs and fluid • Tympany over air pockets • Palpation • Confirm quadrant pain verbally • Palpate areas where the patient doesn’t think there is much pain, working your way closer to the painful areas without hurting them • Deep palpation only for non-painful areas/patients • Fluid wave indicates…..

23. Abdominal Exam Summary • History tells you what you should find on exam • Confirm the history on examination (horses) • Rule out other (zebras)

24. Diagnostic Testing • “-scopy” • Fiber optic camera • Colonoscopy • One or two bend • Looking for polys, ulceration, and inflammation • Endoscopy • Esophageal • Gastric • Duodenal • Supposed to be pretty uncomfortable

25. Ulcerative Colitis vs. Crohn’s Disease • Ulcerative Colitis • Isolated to the colon • Crohn’s Disease • Can appear anywhere (or everywhere) in the small and large intestines • Often has perianal fistula • I’ll spare you from that picture • Additional reading has a very good, comparision of pathophysiology and treatment for those who are interested

26. Clostridium difficile (C. diff) • Bacterial overgrowth in the digestive tract • Foul, frequent diarrhea • Often associated with broad spectrum antibiotics • e.g. fluoroquinolones • Often associated with contamination in hospitals • remember to wash those hands • Treatment • Metronidazole • East coast hospitals are seeing metronidazole-resistant C. difficile • Oral Vancomycin

27. Hepatitis • Alcoholic • Viral/Infectious • Toxins

28. Hepatocyte Organization Image Downloaed from http://www.niaaa.nih.gov/NR/rdonlyres/43DD68F0-77FF-4AC9-9911-8BC657791E83/0/lobulep295.gif

29. Liver morphology

30. Portal Hypertension Pathophysiology

31. Portal Hypertension Complications • Esophageal Varices • Gastric Varices • Ascites • Hepatorenal syndrome • For now, just know they are interrelated

32. Esophageal Varices

33. Bleeding Varices • Bleeding varices

34. Damaged Hepatocytes • AST/ALT leaks out • Bilirubin can’t be processed • Jaundice • Clotting factors are not manufactured • Increased bleeding • Add to this occult bleeding… • Ammonia processing decreased

35. Hepatic Encephalopathy • Build up of Ammonia in the blood • Signs • Asterixis • AMS (altered mental status) • MMSE (mini-mental status exam) • Can vary from apparent developmental delay to profound confusion and disorientation • Family and friends can monitor for these signs • Counseling, counseling, counseling

36. Liver Disease Party Pack • Lactulose • Reduce blood ammonia by converting to ammonium in the GI Tract and rapid excretion • Titrate to effect (i.e. Q 1-2hr, 4-5 BM per day) • Low compliance (taste and efficacy) • Diuresis • Reduce fluid build up • Furosemide • Spironolactone • 2:5 ratio, e.g. 20mg furosemide, 50mg spironolactone • Propranolol • Reduce portal pressure • Block Beta-2 mediated mesenteric arteriole smooth muscle dilation • Reduced cardiac output

37. Viral Hepatitis • Type A,B,C,D,E • F?,G?,H? • Onset is weeks to months (vs alcoholic with onset of years) • Acute Forms of Hepatitis (Fecal Oral transmission) • A, E • Restaurant-acquired hepatitis • Chronic Forms of Hepatitis (Blood Borne) • B,C,D • People get this from blood transfusions in the 80’s and from a BF/GF who was a IV drug user • Surprisingly few patients get this from using IV drugs themselves

38. Liver Transplant • MELD Criteria • Model for End Stage Liver Disease • Rates Severity an prognosis of the patient • Patient compliance to medication protocols is key!

39. Fatty Liver • Dr Leid will talk about this one… • Diet and exercise…damn!

40. Liver Disease Summary • Very, very common in hospitals • Know the party pack • make sure everyone is on it unless contraindicated • Acute life threatening side effects • Simply a matter of time, unless they get on the transplant list

41. Final Summary • You practice will depend on how you use this material • Community • Identify chronic GI disorders and refer for better treatment options • Counsel on side effects of non-compliance • Talk through Physical exam and assess likely problems • Ambulatory care • Monitor disease progression • Monitor therapy efficacy • Inpatient • Speak knowledgeably with physicians about patients • Ensure proper labs are being ordered • Make sure everyone is on appropriate medications (e.g. party pack)

42. Additional Resources • http://oregonstate.edu/~williate/p1wiki • Search for key words like ascites • Harrison’s Online (via Access Medicine at OHSU) • Mosby’s Guide to Physical Examination 6th edition