General GI
#Celiac disease
Iron deficient anemia, diarrhea, malabsorption, weight loss, failure to thrive, dermatitis herpetiformis
-GI symptoms began:
-Oral ulcers, rashes, neuropathy?
-family history of Celiac or other autoimmune disease?
-IgA TTG + total IgA level ordered; positive **/**/****
-if second test necessary: deaminated gliadin peptide antibodies
- patient instructed to continue gluten challenge for minimum 2 weeks prior to testing
-small bowel biopsy performed **/**/****
-HLA-DQ2 and HLA-DQ8 to rule out disease in borderline cases (100% sensitivity)
-CBC, ferritin, vitamin D/A, vitamin B12, LFTs, folate; zinc/copper, TSH, morning cortisol
-recommended family screening of 1st degree relatives
-DEXA:
-referred to dietician for gluten free diet; patient instructed to specify "celiac disease" instead of gluten free at restaurants
-follow up in 4-6 months for clinical improvement, recheck serology and vitamin deficiencies
-follow up serology in 12 months, and q1yr
-repeat biopsy in 24 months, repeat DEXA if abnormal
-patient counseled on importance of dietary compliance for symptom control and prevention of T cell lymphoma
-avoid ARBs, checkpoint inhibitors, mycophenolate mofetil, MTX
-consider autoimmune enteropathy, CVID, tropical sprue, Whipple disease
-symptoms not improving?
-correct diagnosis?
-inadvertent gluten? Review meds with pharmacist
-microscopic colitis? SIBO? Carb malabsorption? IBS/IBD?
#celiac disease, refractory
10% of patients with celiac disease and recurrent symptoms have a concurrent diagnosis. Conditions to consider include HIV infection, irritable bowel syndrome, small intestinal bacterial overgrowth, microscopic colitis, and pancreatic insufficiency
Symptoms
#Nausea and vomiting
-Zofran 4mg IV Q4 PRN
-Compazine 10mg Q6
-EKG x 1 to evaluate QTc
#Constipation
-Senna 8.6mg PO QHS
-Miralax 17g in 8oz water PRN for constipation
#constipation
Constipation can be secondary or functional (idiopathic); medications are the most common cause of secondary constipation.
Colonoscopy is the initial evaluation of constipation in elderly patients with acute constipation and patients with unintentional weight loss, family history of colorectal cancer, unexplained anemia, and age older than 50 years with no previous colonoscopy
Medications are the most common cause of secondary constipation. Other causes of this common condition include mechanical obstruction, systemic illnesses, altered physiologic states, and psychosocial conditions. Once secondary causes have been excluded, chronic constipation is considered functional. Functional constipation is subtyped into categories of slow transit, normal transit, or dyssynergic defecation. Slow-transit constipation is defined as the delayed passage of fecal contents through the colon based on objective transit testing. Normal-transit constipation is functional constipation in which colonic transit times are adequate. Dyssynergic defecation refers to difficulty with or inability to expel stool as a result of some combination of abnormalities in contraction and/or relaxation of the muscles of the pelvic floor during defecation
Colonoscopy is the initial evaluation of constipation in elderly patients with acute constipation and patients with unintentional weight loss, family history of colorectal cancer, unexplained anemia, and age older than 50 years with no previous colonoscopy. This patient is age 52 years, and colonoscopy should be performed as the initial study to evaluate for mechanical causes of constipation.
Treatment options for chronic constipation include serotonergic prokinetic agents (prucalopride [Option B]), bulking agents (psyllium [Option C]), stimulant laxatives (senna, bisacodyl), osmotic laxatives (polyethylene glycol, lactulose, sorbitol), stool softeners (docusate), secretagogues (lubiprostone, linaclotide, plecanatide), and/or biofeedback. These therapeutic modalities are appropriate after evaluation for a cause of constipation.
Physiologic testing, including colon transit testing with a radiopaque marker study (Option D), scintigraphy, or the wireless motility capsule, is reserved for patients with constipation symptoms that do not respond to initial trials of lifestyle modification and laxative therapy.
Cancer
#Lynch syndrome
Consider 600mg daily aspirin per CAPP2 trial, number needed to prevent colorectal cancer at 10 years of ~25
Motility
#ileus
Etiology: surgery, inflammation, hematoma, hypokalemia, hypomagnesemia, medication (opioid, anticholinergic)
Treatment: NPO, NG tube set to continuous wall suction, IVF, aggressive electrolyte repletion (K>4), avoidance of opioids and anticholinergics
#IBS
The diagnosis of irritable bowel syndrome requires symptoms of recurrent abdominal pain at least 1 day a week for 3 months, along with at least two of the following: pain related to defecation, change in stool frequency, or change in stool consistency.
Fecal calprotectin testing to assess for inflammatory bowel disease and stool testing for giardiasis and celiac disease should be considered in patients with chronic diarrhea
#SIBO
Causes of fat malabsorption include pancreatic dysfunction, infections (e.g., giardiasis and Whipple disease), celiac disease, tropical sprue, and small intestinal bacterial overgrowth.
Small intestinal bacterial overgrowth can be diagnosed in the appropriate clinical context with both typical symptoms (abdominal discomfort, flatulence, bloating, and diarrhea) and a positive result on a glucose breath test
#osmotic diarrhea
Chronic diarrhea can be classified as osmotic, secretory, steatorrhea, inflammatory, motility, or miscellaneous
In patients with liquid stool, a calculated osmotic gap of greater than 100 mOsm/kg suggests osmotic diarrhea.
The fecal osmotic gap is calculated as follows: 290 – (2 × [stool sodium + stool potassium]).
#achalasia
Achalasia is associated with dysphagia with both solids and liquids, along with nonacidic regurgitation of undigested food.
Achalasia treatment includes botulinum toxin injection, pneumatic balloon dilation, peroral endoscopic myotomy, or laparoscopic myotomy
#dumping syndrome
Dumping syndrome results from rapid gastric emptying after gastric surgery; symptoms can include abdominal pain, epigastric fullness, diarrhea, nausea, vomiting, borborygmi, and bloating.
First-line treatment of dumping syndrome is smaller, more frequent meals.
Classic vasomotor symptoms can include palpitations and tachycardia, faintness or syncope, diaphoresis, and flushing and pallor. Symptoms typically occur within 1 hour of eating. Treatment should be tiered, beginning with dietary modifications and patient education by a trained dietitian. Dietary interventions can include the pursuit of smaller and more frequent meals (at least six per day); delayed intake of fluids by at least 30 minutes after intake of solids; avoidance of rapidly absorbable carbohydrates and alcohol; increased intake of high-fiber, high-protein foods; and lying down after a meal for 30 minutes. The use of dietary supplements, such as guar gum or pectin, to increase food viscosity can also be helpful.
Pharmacologic interventions can be considered when the previously mentioned measures fail, although no pharmacologic treatment has been approved for dumping syndrome
Abdominal pain
#diverticulitis
Uncomplicated diverticulitis is treated with oral antibiotics (ciprofloxacin or metronidazole) and a liquid diet.
Hospitalization and intravenous antibiotics are required to treat acute diverticulitis in patients who cannot tolerate an oral diet; patients with severe comorbidities, advanced age, or immunosuppression; and patients for whom oral antibiotics have been ineffective
CTX+flagyl
Zosyn
Merrem
>2-3 years since last CSP, per guidelines, should have repeat after resolution of inflammation to evaluate for obstruction/malignancy
Peritonitis/persistent sepsis —> surgery
Diverticulitis
“Immunocompetent patients not requiring hospitalization and without evidence of significant inflammation, who are not medically frail, able to tolerate oral intake, and with adequate follow-up capabilities, can safely avoid a course of antibiotics and the potential adverse effects associated with antibiotics, including but not limited to the disruption of their microbiome
“Clinicians should treat with antibiotics when the patient has complicated diverticulitis, has comorbid unstable conditions, is immunosuppressed, or has signs of a systemic inflammatory response
Internists could also initially treat with antibiotics when symptoms have lasted longer than five days, the patient cannot tolerate oral intake, and he or she has other significant comorbidities, said Dr. Lin. “Also, patients who initially are managed with conservative care who do not improve or who have new or worsening symptoms should be started on antibiotics.”
Ciprofloxacin with metronidazole is probably the most commonly used antibiotic regimen for patients with diverticulitis, and amoxicillin and clavulanic acid is a reasonable single agent,
Per DINAMO trial, supportive therapy non inferior to antibiotics at 90 days for mild acute diverticulitis
Mora-López L, Ruiz-Edo N, Estrada-Ferrer O, et al; DINAMO-study Group. Efficacy and safety of nonantibiotic outpatient treatment in mild acute diverticulitis (DINAMO-study): a multicentre, randomised, open-label, noninferiority trial. Ann Surg. 2021;274:e435-e442. [PMID: 34183510] doi:10.1097/SLA.0000000000005031
Per AJG 2017:An average red meat intake of less than 51 g/d, dietary fiber intake of about 23 g/d, roughly two hours of vigorous physical activity weekly, a normal body mass index, and never smoking were associated with lower diverticulitis incidence in men
-Liu PH, Cao Y, Keeley BR, et al. Adherence to a healthy lifestyle is associated with a lower risk of diverticulitis among men. Am J Gastroenterol. 2017;112:1868-1876. [PMID: 29112202] doi:10.1038/ajg.2017.398
#narcotic bowel syndrome
Narcotic bowel syndrome is characterized by paradoxical worsening of abdominal pain despite dose escalation; complete cessation of narcotic use is the only effective treatment
Malignancy:
#Peutz Jeugers
The diagnosis of Peutz-Jeghers syndrome (PJS) is based on the presence of two of the following three criteria: two or more PJS-type hamartomatous polyps in the gastrointestinal tract; multiple melanotic macules in the mouth, buccal mucosa, nose, eyes, genitalia, or fingers; and family history of PJS.
#Fundic gland polyps
Fundic gland polyps are the most common benign epithelial gastric polyp and require no endoscopic follow-up.
#Gastric ulcer
Routine repeat upper endoscopy for gastric ulcer is not recommended.
Repeat upper endoscopy for gastric ulcer is reasonable for ulcers that appear suspicious for malignancy, ulcers that were not biopsied originally, ulcers with an unclear cause, or continued symptoms despite adequate therapy
#Gastric metaplasia
Gastric intestinal metaplasia is a premalignant condition; patients have up to a 10-fold increased risk for gastric cancer compared with the general population
#Hepatic adenoma
Factors posing an increased risk for malignant transformation of hepatic adenomas include adenomas greater than 5 cm in diameter, adenomas with β-catenin activation, or adenomas found in men.
Oral contraceptives should be discontinued in women with hepatic adenomas with follow-up CT or MRI at 6-month intervals to confirm stability or regression in the size of the lesion
Hepatobiliary:
#Acute cholecystitis
Acute cholecystitis can be diagnosed by ultrasonography showing gallbladder wall thickening and/or edema and a positive Murphy sign elicited during ultrasonography.
Treatment of acute cholecystitis includes analgesia, intravenous antibiotics with gram-negative and anaerobic coverage, and cholecystectomy before hospital discharge.
Vascular
#Chronic mesenteric ischemia
The diagnosis of chronic mesenteric ischemia requires exclusion of alternative causes of postprandial abdominal pain and weight loss, along with compatible imaging findings.
CT or magnetic resonance angiography findings suggesting chronic mesenteric ischemia include severe stenosis (>70%) of two of the three mesenteric arteries
#Acute mesenteric ischemia
Early acute mesenteric ischemia most commonly presents with abrupt onset of severe periumbilical abdominal pain followed by the urge to defecate and an unremarkable abdominal examination.
CT angiography is the recommended imaging modality for the diagnosis of acute mesenteric ischemia
#Colonic ischemia
Colonic ischemia is the most common form of ischemic bowel disease and usually results from a nonocclusive low-flow state in microvessels.
Colonic ischemia presents with abrupt-onset lower abdominal discomfort and cramping, followed within 24 hours by hematochezia
Abdominal CT is indicated to assess the severity, phase, and distribution of colonic ischemia. CT findings are nonspecific, including segmental bowel wall thickening and pericolonic fat stranding, often in the distribution of the “watershed” areas of the colon (splenic flexure and rectosigmoid junction). Colonoscopy is the primary method to diagnose colonic ischemia, usually after CT has shown a thickened segment of colon.
#Unintentional weight loss
Consider EGD. PMID 28350752. 46% of patients with weight loss and GI symptoms had abnormalities on EGD.
Dysphagia
Solid or liquid?
Oropharyngeal or esophageal?
-coughing, gagging, point to where it gets stuck
History of eosinophilia?
Pill esophagitis?
History of GERD?
Anemia? Consider Plummer Vinson test
EOE
>15 eosinophil per hpf