Gastroenterology Ambulatory Medicine Clerkship

1. GastroenterologyAmbulatory Medicine Clerkship Scott Grisolano, MD Division of Gastroenterolgy and Hepatology KUMC

2. Outline • Physical exam • History taking • Evaluation of abdominal pain • Common Clinical Scenarios • Differential diagnosis

3. Physical Exam - Abdomen • Inspection • Skin • Hernia • Contour • Pulsations, peristalsis • Auscultation • Bowel sounds • Bruits • Percussion, Palpation • Liver, spleen, masses, aneurysm • Peritoneal irritation • Rigid abdomen, guarding, rebound tenderness • How was the ride to the ER? • blunted: elderly, severely ill

4. HEENT Scleral icterus Conjunctival pallor Skin Jaundice Spider angiomata Gynecomastia Petechiae, bruising Caput medusae Extremities Palmer erythema Abdomen HSM Ascites Neurological mentation Asterixis Anorectal Perianal exam DRE Stool

5. Painful History • Location • Onset, frequency, duration, severity • Quality • Radiation • Factors that exacerbate or improve symptoms such as food, antacids, exertion, defecation • Associated symptoms: fevers, chills, weight, N, V, diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool • Family history of bowel disorders • Medications: OTC (acetaminophen, aspirin, and NSAIDs) • Menstrual history in women

6. Embryology - Pain - Artery - Organ • Foregut – Epigastrium – Celiac – S, D • Midgut – Periumbilical – SMA – J, I, TC • Hindgut – Hypogastrium – IMA – TC, R

7. Pain • Visceral pain (viscus) • diffuse, poorly localized • gnawing, burning, cramping • Somatic pain (abdominal wall, parietal peritoneum) • more intense, better localized • Referred pain • same dermatome • sharp, well localized; resembles somatic

8. Abdominal Pain - Triage • Acute • Sick patient? • High level of suspicion in immunosuppressed, elderly • Abdominal examination • Chronic

9. Abdominal Pain - Triage • History • differential diagnosis • Examination • vital signs • Labs • CBC • CMP • Liver biochemistries • Amylase, lipase • UA • Pregnancy test • Abdominal x-ray

10. Ruptured or Perforated Viscus - PUD, ectopic pregnancy, dissecting aneurysm Obstruction of Viscus - adhesions, hernia, volvulus, intussusception Ischemia - mesenteric, PE, MI Inflammation - pancreatitis, cholecystitis, appendicitis, diverticulitis Peritonitis

11. Abdominal Pain - Triage • History • differential diagnosis • Examination • vital signs • Labs • CBC • CMP • Liver biochemistries • Amylase, lipase • UA • Pregnancy test • Abdominal x-ray

12. RUQ Pain • Liver, biliary tree • May radiate to back, epigastrium • Pancreatitis • Cardiac • Pleural/pulmonary • Nephrolithiasis

13. Epigastric Pain • Acute pancreatitis • PUD • GER • Cardiac • Pleural/pulmonary

14. Lower Abdominal Pain • Distal intestinal tract • Urinary tract • Pelvic structures • Colonic, SB source = diarrhea, hematochezia • Rectal source = urgency, tenesmus

15. Lower Abdominal Pain • LLQ • Diverticulitis • Colitis • Infectious, ischemic, IBD • RLQ • Appendicitis • ileocolitis

16. Lower Abdominal Pain • Females • Menses, dysmenorrhea, dyspareunia • Possibility of pregnancy • Vaginal discharge, bleeding • Adnexal cysts • Ovarian torsion • Ectopic pregnancy • PID

17. Specific Conditions • PUD • Gallbladder disease • Acute pancreatitis • Small bowel obstruction • GI bleeding

18. Specific Conditions • PUD • Gallbladder disease • Acute pancreatitis • Small bowel obstruction • GI bleeding

19. PUD • Duodenal ulcer • symptoms of occur when acid is secreted in the absence of a food buffer • symptoms occur 2-5 hours after meals or on empty stomach • Gastric ulcer • more severe pain occurring soon after meals, with less frequent relief by antacids or food

20. PUD • Epigastric pain in 2/3 symptomatic patients • may localize to the RUQ, LUQ • burning, gnawing, or hunger-like in quality, may be vague • Sudden development severe, diffuse abdominal pain may indicate perforation • Vomiting is the cardinal feature in pyloric outlet obstruction • Hemorrhage may be heralded by nausea, hematemesis, melena, or dizziness

21. PUD - Etiology • Helicobacter pylori • NSAIDs

22. < 5%

24. 30-50%

25. Alarm Symptoms / Red Flags • Age > 50 • Weight loss • Dysphagia • Persistent vomiting • Palpable abdominal mass • Occult gastrointestinal bleeding • Otherwise unexplained anemia • Family history UGI malignancy • Previous gastric surgery

26. Specific Conditions • PUD • Gallbladder disease • Acute pancreatitis • Small bowel obstruction • GI bleeding

27. Gallbladder • Biliary colic • Pain reaches crescendo then resolves completely • Pain is visceral in origin (no true gallbladder wall inflammation) • Pain resolves when the gallbladder relaxes, permitting stones to fall back from the cystic duct • Acute cholecystitis • RUQ pain lasting > 4-6 hours should raise suspicion for acute cholecystitis • Symptoms of malaise, fever more likely

28. Cholecystitis – Clinical Presentation • Abdominal pain • RUQ, epigastrium • may radiate to the right shoulder or back • Pain is steady and severe • nausea, vomiting, and anorexia • Prolonged RUQ pain (> 4-6 hours), especially if associated with fever, should arouse suspicion for acute cholecystitis as opposed to an attack of simple biliary colic

29. Differential Diagnosis • Acute pancreatitis • Appendicitis • Acute hepatitis • Peptic ulcer disease • Diseases of the right kidney • Right-sided pneumonia • Fitz-Hugh-Curtis syndrome • perihepatitis caused by gonococcal infection • Sub-hepatic, intra-abdominal abscess • Perforated viscus • Cardiac ischemia

30. Cholecystitis – Labs • Bilirubin, AP generally normal in uncomplicated cholecystitis • biliary obstruction is limited to the gallbladder • If bilirubin, AP elevated this should raise concerns about complicating conditions such as cholangitis, choledocholithiasis • mild elevation in serum aminotransferases and amylase, and hyperbilirubinemia with jaundice have been reported even in the absence of these complications • These abnormalities may be due to the passage of small stones, sludge, or pus

31. Cholecystitis – Physical Exam • Ill appearing, febrile, and tachycardic • Lie still on exam table because cholecystitis is associated with local parietal peritoneal inflammation that is aggravated by movement • Abdominal examination usually demonstrates voluntary and involuntary guarding • "Murphy's sign" may be a useful diagnostic maneuver

32. Acute Calculous Cholecystitis

33. Specific Conditions • PUD • Gallbladder disease • Acute pancreatitis • Small bowel obstruction • GI bleeding

34. Acute Pancreatitis - Etiology • Gallstones (45%) • Alcohol abuse (35%) • Post-ERCP, medications, metabolic, hereditary, infectious, connective tissue disease, trauma, congenital anatomic abnormalities, tumors (10%) • Idiopathic (10%) • Overall mortality 10 -15% • severe disease as high as 30% • Males (alcohol) > Females (choledocholithiasis) 80%

35. Acute Pancreatitis – Clinical Presentation • Mid-epigastric abdominal pain • Steady, boring pain • Radiation to the left upper back • Anorexia, nausea  vomiting  diarrhea • Low grade fever • Presentations associated with complications • Shock • Multi-system failure

36. Abdominal tenderness Fever (76%) Abdominal guarding (68%) Abdominal distension (65%) Tachycardia (65%) Hypoactive bowel sounds Jaundice (28%) Dyspnea (10%) Hemodynamic changes (10%) Melena or hematemesis (5%) Cullen’s sign The Grey-Turner sign Left pleural effusion Acute Pancreatitis – Physical Exam

37. Acute Pancreatitis - Diagnosis • Serum amylase • Not specific for pancreatitis • intestinal ischemia, renal insufficiency, small bowel obstruction, macroamylasemia, parotitis • Short half-life: elevates early, returns to normal early (within 2-3 days) • Serum lipase • More specific to pancreas • Long half-life: levels rise later, stay elevated for longer (7-14 days) • Liver enzymes • ALT, AST, alkaline phosphatase, total bilirubin • ALT > 150 in patient with cholelithiasis suggests gallstone pancreatitis

38. Acute Pancreatitis - Diagnosis • Ultrasound • Most useful initial test for common bile duct dilation and gallstones • Contrast CT Scan • Not necessary for diagnosis of acute pancreatitis • May help identify etiology in rare instances (tumor) • Useful to assess complications - fluid collections or pancreatic necrosis

41. Pseudocyst - takes > 4 weeks to develop pseudocyst

42. Ranson Criteria ->3 indicates severe AP At Admission Age > 55; WBC > 16K; Glucose > 200; LDH >350; AST > 250 During first 48 hours Hct decrease by > 10% with hydration BUN increase > 5 mg/dL Calcium < 8 mg/dL pO2 < 60 mm Hg Evidence of fluid sequestration (> 6L replacement needed) Acute Pancreatitis - Severity Staging

43. Specific Conditions • PUD • Gallbladder disease • Acute pancreatitis • Small bowel obstruction • GI bleeding

44. Small Bowel Obstruction • Post-operative adhesions • Hernia • Tumors

45. SBO - Symptoms • Abdominal distention, vomiting, crampy pain • Abdominal pain • Periumbilical, crampy • paroxysms of pain every 4-5 minutes • presence of constant abdominal pain or change of pain from colicky to constant suspect strangulation • Patients may or may not complain of obstipation and inability to pass flatus since colon requires 12-24 hours to empty after the onset of bowel obstruction

46. SBO – Physical Exam • Fever, tachycardia: associated with strangulation • Inspection • surgical scars, degree of distention • Auscultation • may reveal high-pitched or hypoactive bowel sounds • Percussion, Palpitation • Tenderness to percussion, rebound, guarding, and localized tenderness suggests peritonitis • Tympany usually present due to air-filled loops of bowel or stomach • abdominal mass may indicate an abscess, volvulus, or tumor • Search for inguinal, femoral, and incisional hernias • Rectal examination • gross or occult blood can be found with neoplasm, ischemia, and intussusception.

47. SBO – Labs • Leukocytosis: may indicate presence of strangulation • Metabolic alkalosis: seen with frequent emesis • Metabolic (lactic) acidosis: ischemic bowel

48. SBO – X-rays • Upright chest film to rule out the presence of free air • Supine and upright abdominal films • Multiple air-fluid levels with distended loops of small bowel are seen in small bowel obstruction, although occasionally can be seen in setting of paralytic ileus • Presence of air in the colon or rectum makes the diagnosis of complete obstruction less likely, particularly if symptoms have been present for more than 24 hours • Plain films: • equivocal in 20-30% of patients • normal, nonspecific in 10-20%

49. SBO – CT scan • Presence, level (transition point), severity, and cause may be identified • Other abdominal pathology can be detected • Absence of air, fluid in distal small bowel or colon denotes complete obstruction • Intestinal pneumatosis and hemorrhagic mesenteric changes can be seen in advanced strangulation • In most cases of SBO, no obvious source of obstruction is seen, since adhesions cannot be detected by CT scan

50. SBO - Management • "never let the sun rise or set on a small bowel obstruction"