Diagnostic Methods Diagnostic Test
Measures
24 Hour 5Hydroxyindolacetic Acid
Breakdown product of serotonin
Amylase
Lipase Liver Function Tests
Digestive enzyme made mostly by the pancreas and salivary glands
Digestive enzyme made mostly by the pancreas that breaks down triglycerides Group of blood labs designed to give infomration about the state of the liver
Test Interpretation
Indications
Carcinoid Syndrome
Acut Acute e pancr pancrea eati titi tiss
Panc Pancre reat atic ic pseu pseudo docy cyst st
Pancreatic ca cancer
Mumps
Result
Parameters
Normal
2 - 9 mg
Carcinoid Syndrome
50 - 500 mg
Moderately HIGH
Salivary gland inflammation
Perforated peptic ulcer
Pancreatic cancer
Acute pancreatitis
Moderately HIGH
Pancreatic pseudocyst
Pancreatic disease
HIGH
Total protein Albumin ALT AST A lk lk al al in in e p ho ho sp sp ha ha ta tas e T ot ot al al bi bi lili ru ru bi bi n Conjugated bilirubin
HIGH
Cholangitis
Normal
Hepatitis Pregnancy Excessive IV fluid Cirrhosis Liver disease Chronic alcoholism Heart failure Nephrotic syndrome Burns Dehydration Waldenström's macroglobulinemia
LOW
Total amount of protein in the serum
Nutritional status
Liver function
Albumin
Major protein component of blood
Liver disease
HIGH
Multiple myeloma Hyperglobulinemia Granulomatous diseases Some tropical disease
Normal
Hepatitis
Liver damage LOW
Patient prep involves avoiding serotonin-rich foods (bananas, pineapples, avocados, mushrooms, and walnuts) Can be obtain through serum, urine, pleural fluid, or peritoneal fluid
Acute cholecystitis Perforated peptic ulcer Acute pancreatitis Pancreatic pseudocyst Panc Pancre reat atic ic canc cancer er Seru Serum m sam sampl ple e Acute cholecystitis Acute pancreatitis Pancreatic pseudocyst
HIGH
Serum protein disorders
Total Serum Protein
Pancreatic cancer Mumps Salivary gland inflammation
Other
Acute hepatocellular dysfunction Cirrhosis
The liver makes 12 g of albumin daily. Serum prealbumin can be used as a more sensitive test to assess rapid liver damage (acute viral or toxic etiologies)
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Alanine Aminotransferase (ALT)
Measures
Hepatocellular enzyme
Test Interpretation
Indications
Liver damage
Important enzyme in amino acid metabolism
Hepatic Function Panel
Group of assays concerning the function of the liver
(GGT)
Acute cholecystitis
Normal
Liver damage Severe muscle injury Hepatitis Cirrhosis Hemolysis 10 - 60 U/L
Moderately HIGH
Acute cholecystitis
HIGH
MI PE Skeletal muscle trauma Alcholoic cirrhosis Viral hepatitis Cirrhosis Drug-induced Drug-induced hepatitis Cell necrosis
Heart
Effectiveness of the extrinsic pathway of coagulation
γ-Glutamyltransferase
Moderately HIGH
HIGH
Prothrombin Time
Alkaline Phosphatase (ALP)
Parameters 10 - 60 U/L
Liver inflammation
Liver
Aspartate Aminotransferase (AST)
Result Normal
High Level of AST Brain Skeletal muscle
Moderate Level of AST
RBCs
Warfarin th therapy
Liver di disease
Enzyme involved with the transport of amino acids into cells
Bile duct destruction
Some drugs and patient conditions alter AST levels. Hemolysis causes elevation due to RBC contents.
Potassium Carbon dioxide Urea Calcium Phosphorus Normal
Enzyme at high levels in rapidly dividing or metabolically active cells
Moderate ALT content in kidneys, heart, and skeletal muscle ALT is ubiquitous at lower concentrations.
Only a screening test of coagulation Will not being to prolong until one of the PT-based clotting factor decreases to < 30 - 40% of normal
Vitamin K deficiency Sodium Chloride Glucose Creatinine Albumin
Other
Liver disease
Cholestasis
Biliary obstruction
Liver damage
Hepatocellular disease
Hepatobillary disease
Biliary stasis
HIGH
HIGH
30 - 135 U/L Active bone formation Pregnancy Some intestinal disorders Cirrhosis Bile duct destruction Alcohol-induced hepatic changes Hepatocellular disease Hepatobillary disease Hepatitis (can be normal) Cirrhosis (can be normal)
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Alanine Aminotransferase (ALT)
Measures
Hepatocellular enzyme
Test Interpretation
Indications
Liver damage
Important enzyme in amino acid metabolism
Hepatic Function Panel
Group of assays concerning the function of the liver
(GGT)
Acute cholecystitis
Normal
Liver damage Severe muscle injury Hepatitis Cirrhosis Hemolysis 10 - 60 U/L
Moderately HIGH
Acute cholecystitis
HIGH
MI PE Skeletal muscle trauma Alcholoic cirrhosis Viral hepatitis Cirrhosis Drug-induced Drug-induced hepatitis Cell necrosis
Heart
Effectiveness of the extrinsic pathway of coagulation
γ-Glutamyltransferase
Moderately HIGH
HIGH
Prothrombin Time
Alkaline Phosphatase (ALP)
Parameters 10 - 60 U/L
Liver inflammation
Liver
Aspartate Aminotransferase (AST)
Result Normal
High Level of AST Brain Skeletal muscle
Moderate Level of AST
RBCs
Warfarin th therapy
Liver di disease
Enzyme involved with the transport of amino acids into cells
Bile duct destruction
Some drugs and patient conditions alter AST levels. Hemolysis causes elevation due to RBC contents.
Potassium Carbon dioxide Urea Calcium Phosphorus Normal
Enzyme at high levels in rapidly dividing or metabolically active cells
Moderate ALT content in kidneys, heart, and skeletal muscle ALT is ubiquitous at lower concentrations.
Only a screening test of coagulation Will not being to prolong until one of the PT-based clotting factor decreases to < 30 - 40% of normal
Vitamin K deficiency Sodium Chloride Glucose Creatinine Albumin
Other
Liver disease
Cholestasis
Biliary obstruction
Liver damage
Hepatocellular disease
Hepatobillary disease
Biliary stasis
HIGH
HIGH
30 - 135 U/L Active bone formation Pregnancy Some intestinal disorders Cirrhosis Bile duct destruction Alcohol-induced hepatic changes Hepatocellular disease Hepatobillary disease Hepatitis (can be normal) Cirrhosis (can be normal)
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Measures
Test Interpretation
Indications
Result
Parameters
Not as subject to elevation from drugs as ALP/GGT If ↑ ALP but 5'-nucleotidase 5'-nucleotidase is normal, look for a source outside the liver (bone, kidney, or spleen)
↑ ALP
5'-Nucleotidase
Hepatic enzyme
Cholestasis Liver metastases
Normal Moderately HIGH Gallbl Gallbladd adder er disea disease se
Other
Hepato Hepatocel cellul lular ar funct function ion
0.2 - 1.2 U/L Acute cholecystitis Choledocholithiasis ↑ Production from heme
Exposure to light may alter bilirubin chemical and spectral properties because of the formation of photobilirubin
Defective heme removal
Total Bilirubin
Total amount of bilirubin in the blood HIGH Degree of hemolytic disease
Some hereditary disease
Gilbert syndrome Neonatal jaundice Severe Crigler-Najjar syndrome Alcoholic hepatitis Infectious hepatitis Autoimmune conditions Intrahepatic obstruction Extrahepatic obstruction
Conjugated Bilirubin Unconjugated Bilirubin Diagnostic Peritoneal Lavage
> 50% of elevated total bilirubin level is conjugated < 15 - 20% of the total bilirubin is unconjugated Surgical diagnostic procedure to determine if there is free floating fluid in the abdominal cavity
Intrahep Intrahepatic atic cholesta cholestasis sis
Hepatoce Hepatocellula llularr damage
Extrahepatic biliary obstruction Acclerated RBC hemolysis
↑ Total bilirubin
Using conjugated and unconjugated bilirubin, you can differentiate differentiate between hepatic disease and hemolysis
Hepatitis Drugs
Abdominal trauma
Intraperitoneal hemorrhage
Ruptured intestine
Ruptured organs
Can test for cell counts and chemical analysis
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Measures
Test Interpretation
Indications
Result Bacterial Peritonitis
Ascites
Pancreatic Ascites Malignant Peritonitis
Paracentesis
Cell counts
Procedure to obtain peritoneal fluid for diagnosis or therapeutics
Cytology
HIGH SAAG ( ≥ 1.1)
Testing Gram stain LOW SAAG (< 1.1) Chemical testing
Non-Liver Targeting Pathogens
Hepatitis
Inflammation / infection of the liver Liver Targeting Pathogens
Epstein-Barr virus Cyctomegalovirus Herpes simplex virus Yellow fever Mumps Rubella Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Hepatitis G
WBC AST ALT Total Bilirubin
Parallels bilirubin
Antigens and Antibodies
Pathogen-specific
Urine
Anti-HAV
Antibody against HAVAg
Hepatitis A
IgG
Other
Cirrhosis CHF Alcoholic hepatitis Myxedema Portal vein thrombosis Bacterial peritonitis Malignancy Nephrotic syndrome Pancreatitis TB Peritonitis Normal or low Striking ↑ Striking ↑ Follows AST and ALT elevations
Alkaline Phosphatase
IgM Traveling to endemic areas
Parameters ↑ WBC ↑ Neutrophils (+) Culture ↑ Amylase Blood fluid (nontraumatic tap)
Mild proteinuria Bilirubinuria Acute infection Previous exposure Noninfectivity Immunity
Total anti-HAV may be used to screen people at risk who may need vaccination
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Measures
HBsAg
Outer surface coat antigen
Indications
Test Interpretation Result
POSITIVE
Hepatitis B
Anti-HBs
Antibodies against HBsAg
Anti-HBc
Antibodies against the core antigen C
POSITIVE
IgM Hepatitis B
IgG
HBeAg Anti-HBe
Secretory form of HBcAg
HBV DNA
Pieces of DNA from hepatitis B
POSITIVE Hepatitis B
Antibody for HBeAg
POSITIVE
Hepatitis B
LOW
Parameters First evidence of infection
Frequent cause of cyroglobulinemia
HCV RNA Anti-HCV RIBA Antibody Levels
Hepatitis D
Requires coinfection with hepatitis B
Hepatitis E
Generally benign and selflimiting
Acute Hepatitis Panel
Assessment of a patient with acute hepatitis symptoms
Persists throughout clinical illness
Infection with HBV Implies infectivity Recovery from HBV infection Noninfectivity Vaccination Immunity Appears soon after HBsAg but before anti-HBs Acute hepatitis B Persists 3 - 6 months Persists beyond IgM Immunity Viral replication Infectivity Less viral replication Less infectivity Post-recovery from acute hepatitis B in serum and liver
Parallels HBeAg More sensitive and precise marker of viral replication and infectivity Often silently progressive
Anti-HCV by ELISA
Hepatitis C
Other
Diagnostic
Rise slowly
Anti-HDV Worsening hepatitis B
POSITIVE
↑ Risk for liver cancer HDV RNA
Acute hepatitis after travel to endemic area
Pregnancy (10 - 20% mortality rate) Anti-HEV
POSITIVE
More severe in patients with underlying chronic liver disease Hep C virus antibody
Hep B core IgM antibody
Hep B surface antigen
Hepatitis A IgM antibody
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Measures
Radiograph
Use of X-rays to view a nonuniformly composed object
Fluoroscopy with Barium
Use of X-rays to obtain realtime moving images of internal structures
Gastrointestinal Endoscopy
Direct visualization of the GI tract
Foreign bodies
Free air
Obstruction
T ran si t ti mes
M uc osa l ab no rm ali ti es
Need to biopsy lesions
Any GI disease
Risks
Refractory GERD PUD
Esophagogastroduodenenoscopy
Result
Calcifications
Dysphagia
Direct visualization of esophagus, stomach, and duodenum
Test Interpretation
Indications
Malabsorption Dilation of esophageal strictures Removal of polyps / neoplasms
Parameters
Other
Enteroscopy "Push" endoscopy of small bowel
Perforation Bleeding Infection Cardiopulmonary complications 2⁰ to sedation Death Odynophagia Screening for Barrett's esophagus Upper GI bleeding Treatment of varices / bleeding Rupture of esophageal webs Stent placement
Radiofrequency ablation
Flexible Sigmoidoscopy
Visualization descending colon, sigmoid colon, and rectum
Colonoscopy
Visualization of entire colon and portion of terminal ileum
Inflammatory diarrhea
Need a view of the distal colon only
Colorectal cancer screening
Anemia evaluation
Bleeding
Assesment of IBD
Requires sedation
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Measures
Endoscopic Retrograde Cholangiopancreatography
Combines the use of endoscopy and fluoroscopy to diagnose and treat certain biliary and pancreatic ductal diseases
Endoscopic Ultrasound
Ultrasound on an endoscope
Video Capsule Endoscopy
Pill-sized cameras travel the GI tract and capture video
Allow visualization of entire small bowel in most patients
High-Resolution Endoscopy
Magnifiable endoscopy
Chromoendoscopy
Dyes / stains applied to tissue to enhance location and diagnosis of lesions
Narrow Band Imaging
Enhances mucosal morphology and vascularity
Result
Pancreatic cancer
Choledocholithiasis
Malignant and benign biliary strictures Recurrent acute / chronic pancreatitis
Sphincter of Oddi dysfunction
Parameters
Other
Pancreatic malignancies
Ampullary adenomas Stone extraction Sphincterotomy Stent p lacement Stricture dilation Drain fluid Biopsy Staging of rectal, esophageal, and gastric tumors Identification of pancreatic tumors Aspiration biopsies
Tumors
Obscure bleeding
Survey in polyposis syndromes
Refractory malabsorption syndromes
Gold-standard for visualizing small bowel Avoid in patients with GI distress, fistulas, pregnancy, or swallowing disorders
Uncertain diagnosis of Crohn's disease
Screening
Double Balloon Endoscopy
Test Interpretation
Indications
Varices GERD complications Esophagitis
Allows procedures (when compared to VCE)
Flat lesions
Requires general anesthesia (can take 3 hours) Two balloons are attached to distal end of the enteroscope
Barrett's esophagus
Occult lesions
Neoplasia
Adenoma
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Test Interpretation
Diagnostic Test
Measures
Autofluorescence
Uses short light wave source to exploit natural tissue fluorescence
Transabdominal Ultrasound
Ultrasound through the abdominal wall
Radionuclide Imaging
Tagged (technitum-99m) red blood cells to detect obscure bleeding
Gastrointestinal bleed
Cholescintigraphy
Use of Tc-iminodiacetic acid (IDA) to visualize the gallbladder
Cystic duct obstruction by gall stone
Computerized Topography
Computer-processed x-rays produce tomographic images of specific areas in an object
Magnetic Resonance Imaging
Strong magnetic fields and radiowaves are used to form images of the body
CT / MR Enterography Virtual Colonoscopy
Liver Biopsy
Use of contrast to distend small bowel Computer-assisted high-resolution two-dimensional image of abdomen / pelvis generated by spiral CT
Histologic analysis of hepatic tissue
Indications
Result
Parameters
Other
Liver disease Biliary disease Pediatric appendicitis
Trauma Infectious / inflammatory lesions Obstruction
Unexplained pain Pancreatitis Liver malignancies
Pancreas malignancies
Liver lesions
Biliary tract lesions
Mucosal abnormalities
Colon cancer screening
Ab no rm al L FT s
S us pec ted n eop las m
Confirmation of diagnosis / prognostication
Evaluation of granulomatous disease
Unexplained jaundice or suspected drug reaction
Management of posttransplantation care
Low specificity and sensitivity (but being constantly improved) Requires prep and rectal tube Contraindications ↑ PT Thrombocytopenia Ascites Difficult body habitus Suspected hemangioma Complications RUQ, brief pain Bleeding Biliary peritonitis Bacteremia Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Measures
Fecal Occult Blood Testing
Qualitiative method of determine the presence of blood in stool
Hemoccult Sensa Screening
Part of the screening for colon cancer
Test Interpretation
Indications
Result
Parameters
The oxidation of guaiac by hydrogen perioxide causes blue color when exposed to "heme" found in stool Cancer
Sensa FOBT Enhancer that allows greater sensitivity and ease of interpretation
GI bleeding
Requires 3 serial stools Avoid NSAIDs or aspirin prior to or during specimen collection
↑ Risk of colon cancer
False Positives
Hemoccult Sensa Testing
Method for detecting non-visible blood in stool
Specimens innoculated onto card ≥ 3 days (ideally) prior to development For immediate results, wait at least 3 5 minutes before development
Red meats Aspirin NSAIDs Alcohol in excess Other drugs Iodine preparation False Negatives Ascorbic acid ↑ Citrus fruit / juice > 250 mg/day intake Iron supplements
Bowel infection
Fecal Leukocytes
Other
Microorganism overgrowth
NEGATIVE
WBCs in stool Variable
Inflammatory bowel disorders POSITIVE
Norovirus Rotavirus CMV* ETEC EHEC Giardia lamblia Entamoeba histolytica* Crytosporidium S. aureus C. perfringens Salmonella Yersinia Vibrio parahemo. C. difficile Aeromonas Shigella Camplyobacter EIEC Ulceraive colitis Crohn's disease Radiation colitis Ischemic colitis
Bacterial stool culture re not routinely gram stained due to futility. Entamoeba histolytica causes attacking WBC rupture, and fecal leukocytes may not be seen.
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Measures
Clostridium Difficile Toxin
Predominant causative enterotoxin for pseudomembranous colitis
Tissue Culture
Gold-standard test for C. difficile infection
Test Interpretation
Indications
Result
Identification of bacteria in stool
Other
93 - 100% specific Diarrhea
Recent antibiotic use
ELISA 63 - 99% specific Rarely performed
Pseudomemberanous colitis
Salmonella
Bacterial Stool Cultures
Parameters
Fresh stool to lab < 2 hours
Shigella Acceptable
Campylobacter Require a Special Request for Indentification
Vibrio Aeromonas Yersinia E. coli O157:H7
An ima l c on ta ct
Chi ld re n a t d ay ca re
Fecal Acid-Fast Stain
Acid-fast stain of stool
IFA Indirect ImmunoFluorescence Assay
Use of fluorescent monoclonal antibodies to identify microorganisms
Giardia lamblia
H. Pylori Serologic Enzyme-Linked Immunoassay
Detects either IgG or IgA to Helicobacter pylori
Active / past H. pylori infection
Urea Breath Test
Radioactively labeled CO2 (by ingesting radioactive 13C urea) is exhaled and detected
H. pylori infection
Rotavirus EIA
Detection of rotavirus
Gastroenteritis
Norovirus PCR
Detection of norovirus that is only performed for epidemiologic reasons
Immunocompromised
Preserved in Cary-Blair medium < 96 hours
Rejected
Hospitalized > 3 days
"Ghost" Cells
Cyclospora oocytes
Cryptosporidium parvum Cyclospora cayetanensis Superior sensitivity and equal specificity to O&P if performed < 1 hour
Cryptosporidium parvum
Antibodies can persist for years 50% of adults > 60 years old are positive
Gastritis Peptic ulcers
Excellent sensitivity and specificity Non-invasive test of choice to document successful treatment of H. pylori Sensitivity
93%
Specificity
96%
Nursing homes Long-term care facilities Cruise ships
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods Diagnostic Test
Fecal Fat
Measures
Measures amount of fat present in stools
Indications
Malabsorption disorders
Celiac / tropical sprue
Whipple's disease
Zolinger-Ellison syndrome
Crohn's disease
Test Interpretation Result
Parameters
Other Quantitative Stool Fat Test Gold-standard ↑ Fat diet for 2 days before and during collection Qualitative Stool Fat Test Sudan stain of stool sample and microscopic evaluation
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Clinical Medicine Condition / Disease
Cause
Functional Abdominal Disorders
Common GI disorders without discernable cause
Atypical chest pain
Any disease of the gastrointestinal system
Test
Treatment
Result
Medications
Altered Bowel Habits
Nausea ± vomiting Pyrosis Odynophagia Jaundice
Altered processing of visceral stimuli Diagnoses of exclusion
Dyspepsia Diverticulitis Diarrhea Constipation Bleeding Dysphagia Early satiety Anorectal symptoms Visceral Abdominal Pain Poorly localized Produced by dermatome Somatic Abdominal Pain Well localized Initiated by pain receptors in parietal peritoneum
Acute Etiologies
Abdominal Pain
Pain as a result from complex interaction of sensory receptors in the GI tract, spinal cord nuclei, and CNS
Acute pancreatitis Ac ute a ppe ndi cit ie s Intestinal ischemia Bowel obstruction Incarcerated hernia
Acute cholecystitis Di ve rt icul it is PUD Infectious diarrhea Gynecological causes
Referred Abdominal Pain Poorly localized Felt in areas that may be remote from disease site
Chronic Etiologies GERD IBS Chronic pancreatitis
Other Causes Altered gut motility Exaggerated visceral responses to noxious stimuli
IBS
Dyspepsia
Abdominal Pain
Gastrointestinal Disease
Laboratory
Signs and Symptoms
Non-ulcer dyspepsia IBD Infectious diarrhea Only patients with chronic symptoms require management
Dyspepsia
Diverticular Disease
Diverticulitis
Constipation
Painful, difficult, or disturbed digestion
Group of disease that are characterized by pouch formation in the weak spots in the colonic wall
Inflammation of colonic diverticula
Functional defecation disorder due to slowed transit through the colon, obstruction, or irritable bowel syndrome
Pain
Discomfort
Diverticulosis
Diverticulitis
LLQ pain ± palpable mass
Suprapubic pain
"Left-sided" appendicitis
May present as an acute GI bleed Malaise Diarrhea Vomiting ↑ Urinary frequency Difficult-to-pass stools
Fever Constipation Nausea Dysuria Infrequent stools Sense of incomplete Abdominal distention evacuation Bloating Pain Etiologies Functional Drugs Endoc ri ne / me tabol ic N euro log ic Structural lesions
Endoscopy
> 55 years old OR alarm symptoms
Non-Endoscopic Indicated Patients
Test and treat for H. pylori Initiate trial of PPI Risk Factors ↓ Low fiber diet Red meat Obesity ↑ Age
CBC
CT
X-Ray CBC TSH BMP Colon Transit Study Anorectal Manometry Colonoscopy
Leukocytosis with left shift Gold-standard Assess disease severity Free air Ileus Obstruction
Evaluation
Clear liquids 7 - 10 days of antibotics Close follow-up Surgical consult (if not improved in 72 hours) R/O Underlying causes Laxatives Medical therapy ↑ Fiber diet (≈ 30 g / day) Adequate hydration Regular exercise Bowel training Digital disimpaction
Ciprofloxacin + Metronidazole
Co-morbidities increase the likelihood of severity. Complications Bleeding Intra-abdominal abscesses Fistulas Obstruction
Rome Criteria (> ¼ of defecations) Straining Lumpy or hard stools Sense of incomplete evacuation Sense of anorectal obstruction Manual maneuvers Prokinetic Agents And/or < 3 defecations and no loose stools Lubiprostone
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Laboratory Test
Treatment
Result
Medications
Other
Acute Etiologies
Nausea and Vomiting
Sensation and action of ejecting stomach contents
Appendicitis Pancreatitis
Cholecystitis Peritonitis
Small or large bowel obstruction Chronic Etiologies Esophageal disorders
Gastric malignancy PUD
Difficultyswallowing both liquids and solids Difficultyswallowing Mechanical Disorders solids Etiologies Pill-inducedesophagitis
Etiology can be outside the GI tract.
Motility Disorders
Dysphagia
Difficult swallowing
Odynophagia
Painful swallowing due to the inflammation of esophageal mucosa
AIDS Immunosuppressive disease Ingestion of caustic substances
Infection
Doxycycline Tetracycline
Medications
EGD
Pyrosis
Early Satiety
Exposure of esophageal epithelium to gastric acid causes a burning sensation
Decreased appetite
Barium Studies Heartburn
Esophageal Manometry 24 Hour Esophageal Probes
Malignancy (especially in older patients) Delayed gastric emptying Gastric outlet obstruction caused by Non-Malignant PUD Etiologies Adhesions of small bowel obstruction Small bowel obstruction of Crohn's disease Systemic Illness Diabetes
Malignancies Thyroid disease Mechanical Triggers / Irritants
Pruritus Ani
Irritation of the skin at the exit of the rectum
Diagnostic
Diarrhea / constipation Soaps Anorectal lesions Wipes T ig ht -f it ti ng c lo th es O ve r- cl ea ns in g Dermatologic Conditions Atopic dermatitis
Xylocaine Remove offending agents Mild topical steroids (1% hydrocortisone)
Lichen planus
Psoriasis Infections Intertrigo Scabies
Tomatoes, citrus foods and beverages, and caffienated drinks can cause pruritus ani.
Exquisite hygiene
Antihistamines HPV / HSV Pinworms
Antipruritics
Pramoxine
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Tenderness
Anal Fissure
Split, tear, or erosion in the epithelium of anal canal
Laboratory Test
Result
Pain Large or hard-to-pass stools Trauma (rarely)
Internal Hemorrhoid
Venous edema in the anus that breaches the anal wall
External Hemorrhoid
Increased venous pressure within the external hemorrhoidal veins
Diarrhea
Infectious Diarrhea
Reversal of the normal net absorptive status of water and electrolytes that results in water secretion into the gut and enhanced anion secretion from enterocytes
Diarrhea caused by a pathogen
Painless bleeding after defectation
Usually self-limited and last less than one day
Monitor Symptoms For…
Hopsitalized patients / recent antibiotic use
Systemic illness with diarrhea (especially in pregnant) Bloody Diarrhea (MESSY CACA)
In elderly (> 70 years old) or in I-C patients
Medical disease E. coli Shigella Salmonella Yersinia Campylobacter Amoeba C. difficile (E. histolytica) Aeromonas Watery Diarrhea Viral
Parastic
Diarrhea
Inflammation of the gastrointestinal tract due to viral infection
Dehydration Duration Inflammation
Warning Signs
Severe abdominal pain
Noroviruses / Norwalk Virus Rotaviruses Adenovirus
Stool Anion Gap
Rotavirus Norovirus Adenovirus S. aureus B. cereus Vibrio Giardia Cryptosporidia E. histolytica Abdominal pain Familial outbreaks Nursing homes Cruise ships Highly contagious Vaccine available Year-round
Stool Studies Indications
Fecal Leukocytes in Inflam. Diarrhea
< 50 (secretory) > 125 Oral Rehydration (osmotic) Solution Persistent or recurring History of fever or tenesmus Other warning BRAT Diet signs exist 73% sensitive 84% specificity
Other Posterior anal fissures are the more common form, followed by anterior.
Rubber band ligation Infrared coagulation
Sitz baths Topical steroids Stool softeners Removal of clot (if thrombosed)
Painful
Readily seen on perianal exam
Bacterial
Viral Gastroenteritis
For Prolapse
Visible with anoscopy
Rarely bleed
Medications
Stool softeners Protective ointments Sitz baths Topical steroids Nitroglycerin 2% ointment Botulinum toxin Surgical referral (if fissure fails to heal) Pain treatment Topical steroids
Bleed easily
Etiologies
Treatment
3.5 g NaCl 1.5 g KCl 20 g glucose
Recovery is often prolonged compared to internal hemorrhoids.
2 million deaths / year worldwide Loperamide
Optional 2.5 g sodium bicarb 1 L water Bananas Rice Applesause Toast
Bismuth Subsalicylate
Lomotil Avoid milk products
Diarrhealmedications (except with Shigella, C. difficilie, and E. coli O157)
Enteropathogens Tracked by CDC E. coli Salmonella Shigella Y. enterocolitica, Vibro histolytica / cholera, Listeria, Cyclospora Campylobacter Cryptosporidium
Antibiotictherapy
Transmission Fecal-oral Person-to-person Contaminated foods Most common in the US during the winter months
Clinical Medicine Condition / Disease
Cause
Giardia Lamblia
Flagellated protozoa associated water transmission in contaminated streams, day care centers, or well water
Entamoeba Histolytica Parastic Diarrhea in the Immunocompromised
Signs and Symptoms
Laboratory Test
Vibrio Parahaemolyticus
Gram negative rods
Vibrio Cholera
Gram negative rod that activates adenylate cyclase enzyme in intestinal cells
E. Coli O157:H7
Gram negative rod that is tranmitted through undercooked beef, unpasteurized juices (apple ciders), or spinach
Traveler's Diarrhea
Microbial contamination of food and water usually by enter-toxigenic E. coli
Salmonella
Gram negative rod that is one of the most common causes of infectious diarrhea
Samonella Typhi
Gram negative rod that causes typhoid fever
Shigella
Gram negative rod associated with day cares, nurseries, and longterm care
Cyclospora
Isospora
Cryptosporidium
Microsporidia
Watery diarrhea Abdominal cramping Symptoms no more than 3 days after seafood or contaminated water ingestion Wound infection Rice-water stools
Abdominal cramping
Hypotension (< 2 hours due to severe diarrhea) Mild or severe Hemorrhagic colitis symptoms
Medications
No fever (usually) Hemolytic Uremic Syndrome Microangiopathic Acute renal failure hemolytic anemia Thrombocytopenia History of travel in less-developed areas
Diarrhea (maybe bloody) Abdominal cramping
Fever Myalgia Headache
Septicemia / bacteremia (2 - 14%)
Osteomyelitis (10%)
Endocarditis (10%) Pulse-temperature discordance Fever
Arthritis (10%) 10 - 14 days after ingestion Headaches
Myalgia
Malaise
HIV with CD4 Count
POSITIVE Metronidazole treatment
More common in tropical and subtropical regions
Metronidazole treatment (even if asymptomatic) Albendazole < 100
Antiprotozoal treatment
Diarrhea Fever
Bloody, purulent stools
Tenesmus
1 - 3 days after ingestion Usually self-limited to < 7 days
Many of these organisms are present in the environment and water supply.
TMP / SMX No treatment necessary
Deoxycycline
Antibiotics (if required)
Floroquinolone
Oral rehydration solution
Patients with liver disease and iron overload states are more susceptible. 12 - 24 hour incubation 50% mortality if untreated Toxins have a dose effect.
Single-dose fluoroquinilone / doxycycline Incubation is dependent on whether the organism is toxin-producing or not. Associated with warm weather 20,000 cases / year in US No anti-motility medications
Supportative care
Antibiotics are not beneficial
Antibiotictherapy (may decrease the duration of illness)
Cirpofloxacin Rifaximin Associations Incidence is higher in children < 5 years old and adults > 60 years old. Diseases is worse in old, young, and immunosuppressed.
Ciprofloxacin (in severe cases)
Vaccine for travelers Asymptomatic carrier state is possible. Bacteria will pass through cells lining the small intesting and go to liver, spleen, and bone marrow.
Ciprofloxacin for 10 days
Anorexia Lower abdominal cramps
Other
50% rate of spontaneous resolution
Bloody diarrhea
Severe abdominal pain
Watery diarrhea
Treatment
20,000 cases / year in US
Nausea Cramps Flatulence
Foul-smelling watery diarrhea
Giardia Life Cycles Antigen Stool Cysts are ingested Testing Gastric acid releases trophozoites into duodenum and jejunum Attachment to villi Abdominal pain Cramping Anaerobic parastic protozoan that Diarrhea Colitis causes necrosis of the large (may be bloody) intestine Travelers Homosexual
Infectious diarrhea that does not usually affect normal hosts
Result
Floroquinolone Antibiotictherapy TMP/SMX
Children are prone to infection. No anti-motility medications
Clinical Medicine Condition / Disease
Cause
Yersinia Enterocolitica
Gram negative rod acquired after ingestion of contaminated food (pork) or water
Signs and Symptoms
Gram negative rod that is a very common cause of infectious diarrhea
Clostridium Difficile
Spore-forming, Gram positive rods that are the most common cause of nosocomial diarrhea
Fever Symptoms for 1 - 2 weeks Chronic form can Can mimic last months Crohn's disease Lymphadenopathy
Gram positive cocci
Bacillus Cereus
Gram positive rods
Clostridium Perfringens
Gram positive rods
Barrett's Esophagus
Intestinal metaplasia of the esophagus
Medications
Diarrhea
Bacteremia
Transmission
Systemic disease with high mortality.
Antibiotic-Induced
Doxycycline Antibiotic treatment (if severly ill)
Azithromycin Antibiotictreatment
Contaminated food, water, or milk Animal contact (½ from chickens)
Clindamycin Fluoroquinolones PCN Cephalosporins
Other
No treatment is indicated
Self-limiting but may last > 1 week
Diarrhea from hell
Pre-formed toxin
Staphococcus Aureus
Treatment
Result
Abdominal pain
Dysentery
Campylobacter Jejuni
Laboratory Test
Associations Guillain-Barre Syndrome (ascending paralysis) Reactive arthritis Up to 1 week incubation period
Fluoroquinolone
75% sensitivity EIA Testing for Need 3 (-) tests to Toxins A and B rule out Highly specific > 99% sensitivity PCR Highly specific
Flagyl
Alcohol foam does not kill the spores. No anti-motility medications
Oral vancomycin (severe disease or refractory) Fidaxomicin
Symptoms < 4 hours
Food contact with infected skin or human carrier Transmission Potato salad Meats Custard-filledpastries Ice cream 1 - 6 hour incubation (emetic form) Pre-formed toxin > 6 hour incubation (diarrheal illness) Fried rice Transmission Meats Sauces Abdominal cramping Watery diarrhea No fever, nausea, or Symptoms last vomiting < 24 hours Pigbell (rare) Transmission
Meats Poultry
Reflux
≈ 55 years old (at diagnosis)
Pathogenesis Chronic gastroesophageal reflux Reflux esophagitis Squamous epithelial injury Intestinal metaplasia
Refrigeration prevents germination of spores.
Heat Labile Toxin
POSITIVE
Screening and surveillance Endoscopic Biospy
Diagnostic
Endoscopic ablation therapy
Esophagectomy
2♂:1♀ Whites > hispanics
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Laboratory Test
Regurgitation Heatburn (30 - 60 minutes after meals)
Sour brash Dysphagia
Gastroesophageal Reflux Disease
Chronic symptom of mucosal damage caused by stomach acid coming up from the stomach into the esophagus
Extraesophageal / Atypical Symptoms Asthma
Cough
Non-cardiac chest pain
Laryngitis
H oar se ne ss
L os s o f de nt al e na me l
Upper Endoscopy
Infectious Esophagitis
Inflammation of the esophagus due to infection
Schatzki's Ring
Narrowing of the lower part of the esophagus
Hematemesis
Melena
Thin membranes in the esophagus
Zenker's Diverticulum
Outpouching of the upper esophagus
Symptom onset in ages > 50 warrants furtherinvestigation Etiologies Incompetent lower esophageal sphincter TLESR Irritant effects of refluxate Delayed gastric emptying Abnormal esophageal clearance Scleroderma
Symptoms > 10 years Barrett's Screening EGD
Age > 50 White ♂ Common Etiologies Candida CMV Herpes simplex HIV idiopathic ulceration
Odynophagia Dysphagia
EGD with Biopsies
Diagnostic
Chest pain
Internal diameter < 13 mm
Recurs in 60 - 90% of patients 3 - 6 years after dilation
Dilation
GERD symptoms
PPIs
Cervical web Dysphagia Iron-deficient anemia Etiologies
Narrowing of the esophagus as a result of healing ulcerative esophagitis
Congenital Epidermolysis bullo sa Post-Barrett's ablation Post-perforation Regurgitation Halitosis
Eosinophilic infiltration of the esophagus from allergic or idiopathic etiology
Correct iron-deficiency anemia
Bullous pephigoid Pemphigus vulgaris GVHD Post-surgical Dysphagia ♂ > 60 years old
Involves the posterior wall of the pharynx Usually contiguous with the gastroesophageal junction Reflux esophagitis (8 - 20%) Dysphagia
Eosinophilic Esophagitis
Manometry
Function of esophageal muscle contractions and esophageal sphincters
Other
Plummer-Vinson Syndrome
Esophageal Web
Peptic Strictures
Weight loss
Medications
Normal in ½ cases Does not detect Lifestyle modifications mild disease Detects strictures, Prokinetics ulceration, and H2RA Barium abnormal folds Medical Antacids Radiography Reveals abnormal Treatment Mucosal motility or protectants clearance TLESR inhibitors Ambulatory Detects pathologic pH Testing acid reflux Nissen fundoplication
Complicated Disease / Alarm Symptoms Dysphagia
Treatment Result Type and extent of PPI (empirical) tissue damage
Food impaction
"Reflux" Strictures
Mucosal rings
Linear furrowing
Ulceration
"Feline" esophagus
Eosinophilicabscess
Esophageal polyps
Barium Swallow
Abnormal
Acid suppression
PPIs
Dilation
H2RA
PPIs Swallowed fluticasone Leukotrieneinhibitors Mast cell inhibitors / antihistamines Endoscopic dilation
Histology
> 15 eosinophils / HPF
Elimination diets Viscous budesonide suspension Systemic steroids
Associations Asthma Allergic rhinitis Urticaria Hay fever Atopic dermatitis Food allergy Medicine allergy Higher concern for perforation with dilation
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms Gradual,progressive dysphagia
Achalasia
Disease of unknown etiology Ag es 25 - 6 0 characterized by the absence of Weight loss esophageal smooth muscle Substernal discomfort / peristalsis with increased tonus of fullness after eating the lower esophageal sphincter
Regurgitation of undigested foods Sym pt om s ar e chr oni c Chest pain Poor esophageal emptying
Nocturnalregurgitation
Anterior chest pain
Diffuse Esophageal Spasm
Simultaneous, nonperistaltic contractions of the esophagus
Nutcracker Esophagus
Esophageal movement disorder characterized by peristaltic waves of abnormally high amplitude
Scleroderma Esophagus
Atrophy and fibrosis of the esophageal smooth muscle common in patients with progressive systemic sclerosis, Raynaud's phenomena, or CREST
Esophageal Cancer
Intermittent dysphagia
Provoked by stress, large food boluses, or hot or cold liquids
Chest pain
Severe acid reflux
Dysphagia
Strictures
Erosion
Progressive solid food dysphagia
Weight loss
50 - 70 years old
Most present in late stages
Neoplasm of the esophagus
Laboratory Test
Result Only method conclusivelyfor diagnosis
Surgery
Lung or bony metastases
Polypoid, infiltrative, or ulcerative lesion
Radiation
Cisplatin / 5 FU Chest CT
Endoscopic Ultrasound
Botox
Nitrates
CCBs
Most common connective tissue disorder involving the esophagus.
Assessment
Staging
Staging Tis - Carcinoma in situ T1 - Invades lamina propria or submucosa
20 - 50% 5-year survival
Unresectable disease for palliation
Cisplatin / 5 FU
21% 5-year survival
Pneumonia
Malnutrition
Nitrates
Markedlydilated, flaccid esophagus
Mediastinal widening
Barium Esophogram
Other
Nifedipine
Low amplitude Botulinum toxin injection waves Simultaneous cork Barisum screw Esophagocontractions graphy "Rosary bead" appearance Intermittent, Symptom reduction and reassurance simultaneous contractions of Manometry high amplitdue along with periods of normal peristalsis Intermittent high pressure Manometry Strong contractions ↓ or absent LES pressure Manometry Markedly diminished Barium Swallow
Medications
Pneumatic dilation
Manometry Complete absence of peristalsis Surigcal myotomy
Local tumor extension into the traceo-bronchial tree
Hoarsness
Medical treatment
CXR
Complications
Chest / back pain
Treatment
Endoscopic Treatment
↑ Life expectancy to 33 weeks from 27 weeks Stenting for palliation Photodynamic therapy
ChemoRad
T2 - Invades muscularis propria T3 - Invades adventitia T4 - Invades adjacent structures Nx - Cannot be assessed N0 - No regional nodal metastases N1 - Regional nodal metastases M0 - No distant metastases M1 - Distant metastases Stage Groupings I - T1 N0 M0 IIA - T2-3 N0 M0 IIB - T1-2 N1 M0 III - T3 N1 M0, T4 any N M0 IV - Any T Any N M1 IVA - Any T Any N M1a IVB - Any T Any N M1b
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Laboratory Test
Bloody emesis Hematemesis
Intraluminal blood loss anywhere from the oropharynx to anus
Coffee Ground Emesis
Hematochezia
Correlates with severity of bleed at initial evaluation
Sign of upper GI bleeding
Old blood from stomach Red blood ± stool Bright red blood per rectum
Hematocrit
Melena
Stabilize patient EGD Colonoscopy NG lavage Radionuclide imaging
Determine Source of Bleeding
Foul, unforgettable smell
Upper GI Bleed Above the ligament of Treitz
Re st ing t achyc ar dia (10% volume loss)
Or tho st as is (10 - 20% volume loss) Shock (20 - 40% volume loss)
Fluid resuscitation MCV
NSAIDs Steriods in the setting of NSAIDs
Lower GI Bleed
Associated Medications
Below the ligament of Treitz
Warfarin Heparin Plavix Pradaxa
Bleeding (erosion into a vessel)
Gastrointestinal Ulcers
Medications
Angiography May take 2 days to reflect the extent Treat underlying source of bleeding Prevent re-bleeding
Dark tarry stools
Gastrointestinal Bleeding
Treatment
Result
Discontinuity or break in the epithelium of the GI tract
Risk Factors
NSAIDs Helicobacter pylori Acid Steroids with NSAIDs Anti-coagulation Ethanol
Normal in acute blood loss
Blood transfusion Discontinue all anticoagulants and antiplatelet agents
Other 100 new cases / 100k Etiologies of Upper GI Bleed Peptic ulcer disease Varices Arteriovenous malformation Mallory Weiss tear Tumors and erosions Dieulafoy's lesion Esophagitis Aorto-enteric fistula Etiologies of Lower GI Bleeding Diverticular disease Neoplastic disease Colitis Unknown Angiodysplasia Hemorrhoids / fissures
PPIs (if suspect upper bleed)
BUN
Rise out of proportion to creatinine level
Octreotide drip Protonix drip Antibiotics Platelets (for renal disease or Plavix patients) Variceal Bleeds
PPIs Eradication of H. pylori (if present) Endoscopic therapy If endoscopic
Angiogram Surgery
therapy fails…
Airway management
Esophageal or Gastric Varices
Abnormally dilated vessel with a tortuous course secondary to portal hypertension
Medical Treatment Massive upper GI bleed with hemodynamic instability Intervetions
Octreotide Antibiotics (for cirrhotics) EGD with endoscopic banding Compression with Minnesota tube TIPS
Dieulafoy's Lesion
Mallory-Weiss Tear Diverticular Bleeding
Dilated submucosal artery erodes into the muscosa with subsequent rupture of the vessel
Bleeding is often massive and recurrent
Laceration in the mucosa usually near the GE junction
Occurs after retching
Rupture of an outpouching of the mucosa and submucosa through the muscular layer of the colon
Acute, painless hematochezia
80 - 90% stop bleeding spontaneously Supportative care
Usually stops spontaneously
Most diverticular bleeds are rightsided. Risk of rebleed appears to increase with time.
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms Diarrhea (nocturnal or bloody)
Fatigue
Weight loss
Fever
CMP
Anorexia
Nausea / vomiting
SED / CRP
Abdominal pain
Arthralgias
Erythemanodosum Episcleritis Uveitis
Pyodermagangrenosum
Inflammatory Bowel Disease
Result
CBC
TSH with Reflex T4
Workup for diarrhea
Celiac Serologies
Worrisome Signs
Group of inflammatory conditions of the colon and small intestines
Laboratory Test
Frequent UTIs / pneumaturia
High fever / abdominal mass
Severe abdominal pain
Nausea / vomiting
Obstruction
Severe rectal pain
Small Bowel FollowThrough
Differentiate CD and UC
Tends to skip areas
Transmural
Stricturing
Stool culture
Clostridium difficile
Fistulizing Ulcerative Colitis
Ova and parasite
More superficial disease
Fecal leukocytes or fecal calprotectin
Tenesmus
Stricturing of the bile ducts with risk for cholangitis
Asymptomatic
Hematochezia
Itching
Fibrotic strictures Obstruction Fistulae Avoid if possible DEXA Lifestyle modifications Vitamin D and calcium Minimize steriods Biphosphonates
Usually continuous
Primary Sclerosing Cholangitis
Osteoporosis Prevention
Stool Studies
Starts in the rectum
Dysplasia Malignancy Toxic colitis Hemorrhage Intractable symptoms
UC Surgical Indications
CD Surgical Indications
Can affect any portion of the GI tract
Fecal urgency
Ulcerative Colitis Corticosteroids 5-ASA Immunomodulators TNF-α inhibitors Leukocyte trafficking inhibitors Janus kinase inhibitors Crohn's Disease Corticosteroids Immunomodulators 5-ASA TNF-α inhibitors Leukocyte trafficking inhibitors
CT / MR Enterography
Crohn's Disease
Limited to the colon
Treatment
Medications
Mesalamine
Sulfasalazine
6-MP
Azathioprine
Adalimumab
Other Descriptions of UC by Extent of Involvement proctitis - anus / rectum proctosigmoiditis - to sigmoid colon left-sided colitis - to splenic flexure pancolitis / universal colitis - total colon Descriptions of CD by Extent of Involvement ileitis - ileal ileocolitis - ileal and colonic colitis - colon only perianal - worse prognosis Use as little steroid as possible ↑ Risk for Colon Cancer in IBD Colitis Concomitant PSC Family history of colon cacer ↑ Time and degree of inflammation
Infliximab
Golimumab
Vedolizumab
Rule out infection
Flare Management
Routine labs Follow-up 5-ASA (UC) or budesonide (CD)
Tofacitinib
Methotrexate
Anti-TNF Alkaline Phosphate LFTs p-ANCA MRCP / ERCP
HIGH
Diagnostic
High-risk for colon cancer No effective medical therapy
Hepatologist referral
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms Burning pain localized to the epigastrium
Pain in non-radiating
Nighttimeawakenings from pain
Asymptomatic (30 - 40% of NSAID users with ulcers) COPD
Laboratory Test H. Pylori Serology False Negatives
EGD
Cirrhosis
Peptic Ulcer Disease
Breach in the mucosa of the stomach that leads to ulcer formation
Associations Systemic mastocytosis Uremia
High-Risk Patients for NSAID Damage
Age > 65 Higher dose NSAIDs Corticosteroids Anticoagulants H. pylori infection
Indications for EGD
Treatment
Result
H. pylori Eradication
PPIs Antibiotics
PPI Clarithromycin Amoxicillin
Triple Therapy for 2 Weeks
Odynophagia Dysphagia Iron deficiency
Perforation Age > 55
Gastric outlet obstruction PUD (majority in duodenal bulb)
ZollingerEllison Syndrome
Stress-Induced Ulcers
Gastric Cancer
Diarrhea
Indications to Check Serum Gastrin
Tumor of gastrinsecreting G cells
Ulcers in distal duodenum and jejunum
Multiple ulcers
Ulcers associated with severe esophagitis
Ulcers due to multifactorial, mucosal ischemia due to decreased mesenteric blood flow
Neoplasm of the stomach
Extensive family history of PUD
Ulcer resistant to medical treatment
Post-op ulcer recurrence
Unexplained diarrhea Hypercalcemia
> 1000 pg/mL
Secretin Stimulation Test
Most sensitive (94%) and specific (100%)
Multiple, swallow ulcers Extensive burns Cranial trauma Asymptomatic Indigestion (early disease) Early satiety Nausea Anorexia Virchow and sister Mary Weight loss Joseph nodes Palpable stomach Pallor Hepatomegaly Late Symptoms
Cox-2 selective therapy
Diet H. pylori Atrophic gastrit is Polyps (rare) Radiation
Surgical resection (if not metastatic) Vagotomy Somatostatin analogs Metastatic Disease
Successful in 90%
Gastrinoma Triangle (90%) Pancreas ductular epithelium (50%) Duodenum (40%) Stomach, liver, bones, and LN (<10%) 30 - 50% metastasize 83% 15-year survival without metastasis 30% 10-year survival with metastasis
Interferon α Cytotoxic chemotherapy Surgical resection Chemoembolization Typically found at the gastric fundus
PPIs
Histology
EGD
GOO SBO
Bleeding Etiologies
Misoprostol PPI High-dose H2 blockers
Mucosal Protection
Histamine-2 blockers
Critically Ill
Pleural effusions GE obstruction
500k new cases / year 4 million recurrences / year > 80% prev. in developed nations
Preventing Complications of NSAIDs
High-dose PPI
Fasting Serum Gastrin
Endoscopic Ultrasound and Somatostatin Receptor
Other
Bismuth Confirmation of eradication Allows characterization of May require retreatment in 20% the lesion and biopsy Antacids GI bleeding H2 blockers Unintended weight loss PPIs Family Hx of GI Gastrectomy Surgery (rare) malignancy Vagotomy
Complications Hemorrhage
Medications
EUS Barium Swallow CT / MRI
Adenocarcinoma (95%) Surgical resection Carcinoid, squamous cell Lymphoma Safe, easy, and Neoadjuvant chemotherapy and able to obtain radiation therapy tissue Able to obtain 5-FU tissue and good for staging Adjuvant Doxorubicin Chemotherapy Diagnostic Cisplatin
2nd most common cancer with very high incidence in Korea, Japan, and China
♂>♀
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Laboratory Test
RUQ pain after a fatty meal
Asymptomatic
Treatment
Result
Medications
Gold-standard
No treatment for asymptomatic
Ideally after 8 hour fast
Cholecystectomy
Types of Stones
Cholelithiasis
Cholecystitis
Gallstone
Impacted stone in the gallbladder neck or cystic duct
Cholesterol Stones (gallbladder) Black Pigment Stones (gallbladder) Brown Pigment Stones (bile ducts)
5 F's Drugs Cirrhosis Chronic hemolysis
Fever
Nausea
Vomiting
Severe RUQ / epigastric pain (> 6 hours)
Acalculous Cholecystitis
Cholecystitis in the absence of gallstones
Critically ill
Emphysematous Cholecystitis
Type of acalculous cholecystitis due to gallbladder infection by a gas-forming organism
Choledocholithiasis
Ascending Cholangitis
Stone, occluded stent, or stricture in bile duct
Sphincter of Oddi Dysfunction
Stenosis or dyskinesia of the sphincter of Oddi
Malignant Biliary Obstruction
WBC AST AP Gallbladder Ultrasound
HIDA
CT / MRI
HIGH HIGH HIGH or Normal
IV fluids Analgesics
Not ideal choices
Cholecystectomy (48 - 72 hours)
IV antibiotics Cholecystectomy
HIGH
See Acalculous Cholecystitis
Gallbladder Ultrasound
Bubbles in gallbladder wall
Intermittent RUQ discomfort similar to cholelithiasis
Alkaline Phosphatase Gallbladder Ultrasound
Reynold's Pentad
Supportative Care
Impacted stone leads to acute gallbladder inflammation and may cause a secondary bacterial infection
If GU is (-) but still IV antibiotics suspect cholecystitis
AP
Charcot's Triad
NPO
1st line test
Same labs as cholecystitis
Complications
10% of general population Risk Factors (5 F's, 2 C's, 2 D's) Female, f at, f ertile, age > 40, and f amily history Crohn's disease or cirrhosis Diabetes or Drugs
Bile duct infection
(+) Murphy's sign
Gallstone in the common bile duct
Gallbladder Ultrasound
Other
Cholangitis Pancreatitis Fever RUQ pain Jaundice Charcot's triad Hypotension AMS
Biliary colic type of pain
Insidious onset of painless jaundice
Neoplasm blocks the biliary duct
CT / MRI MRCP WBC Direct Bilirubin AP Blood Cultures LFTs Gallbladder Ultrasound HIDA AP Direct Bilirubin Total Bilirubin
(+) Courvoisier sign
CT / MRI
HIGH
Percutaneous cholecystostomy (if too ill for surgery)
Emergent surgery
ERCP with stone extraction
Stone ± dilated ducts proximal of Cholecystectomy after ERCP stome HIGH HIGH HIGH Can be (+)
IV antibiotics IV fluids ERCP
Narrowing causes bile stasis proximal to stone that leads to bile duct infection.
Cholecystectomy after ERCP (if stones) ERCP with manometry
Diagnostic Sphincterotomy HIGH HIGH
Poor prognosis Surgery
> 10 more likely to be from cancer Chemotherapy (for later stages) Dilated duct proximal to obstructions ERCP with stent placement (pallative) Double duct sign
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms Change in bowel movements
Steatorrhea
Pale Skin Petechiae Mouth Changes
Malabsorption
Abnormality in the absorption of nutrients
Weight loss Bacterial overgrowth Mucosal disease Pancreatic insufficiency Fat absorption issue Anemia Vitamin K Vitamin deficiency Dental changes
Peripheral Neuropathy
Vitamin B12
Muscle Wasting / Edema
Proteinmalabsorption
Carbohydrate malabsorption Associated Clinical Syndromes
Abdominal Distention
Lactase deficiency Celiac disease Amyloidosis Hypoparathyroidism Whipple's disease Bacterial overgrowth Adrenal insufficiency Diarrhea with steatorrhea Nutritional deficiencies Flatule nce Nut rie nt de fic ie nci es
Giardiasis Tropical sprue Lymphoma Hyperthyroidism Lymphoma Short gut syndrome Carcinoid syndrome Weight loss Bloating Chronicdiarrhea Lactose intolerance B or bo rygm i
Persistent diarrhea resembling traveler's diarrhea Extra-Intestinal Manifestations
Celiac Disease
Intestinal mucosal injury secondary to an immune response to gluten in genetically susceptible individuals
Short stature Amenorrhea Arthropathy Folate / vitamin K deficiency
Fatigue ↓ Fertility Iron deficiency anemia Osteopenia / osteoporosis Muscle atrophy Neurologic symptoms Dental enamel Autoimmune hypoplasia myocarditis Definite Associated Conditions Autoimmune thyroid Dermatitis herpetiformis disease Type 1 DM RA Sjögren's syndrome Down's syndrome Probable Associated Conditions Sarcoidosis Congenital heart disease Cystic fibrosis IBD Autoimmune hepatitis Myasthenia gravis
Laboratory Test CBC CMP PT / INR TSH Folate B12 Lipid Panel Qualitative Stool Fat Test Quantitative Stool Fat Test
Result
Treatment
Gold-standard
Identifies mucosal D-Xylose Test malabsorption in SI Most useful for Breath Test diagnosinglactase deficiency Distinguishes Schilling Test causes of B12 deficiency Helpful in diagnosis
AntiEndomysial IgA
Most specific
Anti-tTGA
Serology test of choice
Gluten-Free Diet
> 90% sensitivity > 95 specificity
IgA or IgG Antigliadin
Less sensitive
Total IgA
May be indicated if IgA deficient
DQ2 / DQ8 Genetic Screen
Not fully necessary
There is a higher incidence of lymphoma associated with celiac disease. Malignancy
Other autoimmune diseases
Gold-standard Villous atrophy
Mucosal Biopsy
Lymphocytic infiltration of lamina propria Crypt hyperplasia
↑ Intraepithelial lymphocytes
Other Luminal Phase Nutrients are hydrolyzed and solubilized Mucosal Phase Futher processing takes place at the brush border of the epithelial cell with transfer into the cell Transport Phase Nutrients are moved from the epithelium to the portal venous or lymphatic circulation Associated Drugs and Foods Cholestyramine ↑ Fiber diets Tetracycline Antacids Sorbitol Fructose Xenical Metformin Colchicine Methotrexate Sulfasalazine Phenytoin Common in Middle East and India Rare in Japan and China 10% of US American Gluten is found in wheat, rye, barley, and any foods made with these grains.
Helpful in determining severity
CT / MRI / ERCP
Medications
Complications Nutritional deficiencies
Musculoskeletal injuries and deformities
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Skin
Dermatitis Herpetiformis
Chronic blistering skin condition
Oral (rare)
Gastrointestinal
Tropical Sprue
Inflammatory disease of small bowel secondary to overgrowth of coliforms
Laboratory Test
Multiple intensely pruritic papules and vesicles that occur in groups Vesicles Erosions Erythematousmacules Abdominal bloating Cramping Pain Diarrhea Constipation
Dapsone therapy
Folate / B12 supplementation Amylase Lipase BUN Hct
(+) Cullen's sign
Gallstones (35%)
Alcohol (30%)
Obstruction
Medications Ultrasound
Inappropriate activation of trypsinogen causing inflammation
Infections
Metabolic
Toxins
Vascular
Trauma
Post-ERCP
Inherited
Idiopathic Ranson Criteria Admission
Age > 55 Glucose > 200
CT WBC > 16 LDH > 350
↓ Hct > 10 Calcium < 8 PO2 < 60
↑ BUN > 5 Fluid deficit > 6 L Base deficit > 4 Criteria
Collection of pancreatic juice encased by granulation tissue that persists > 4 weeks after episode of acutepancreatitis
Emergent ERCP to removed stones
MRCP
<2 ( < 5 % m or ta li ty ) 5-6 (40 % mo rt al ity )
3-4 ( 15 - 20 % m or ta li ty ) >7 ( > 99% mo rt ali ty)
A bd om in al p ai n
A bd om in al pr es su re
Infection
Rupture
"Sentinel loop of SB" "Colon cut-off sign" Enlarged hypoechoic pancreas Gallstones Biliary ductal dilation
IV fluids
Pain medications
Monitor in ICU
Modality of choice for pancreatic parenchyma
AST > 250 48 Hours Later
Pancreatic Pseudocyst
HIGH HIGH More specific > 25 > 44
Calcified gallstone Pancreatic rest Abdominal X-Ray
Etiologies
Other
Strict gluten-free diet
Megaloblastic anemia
(+) Gray Turner's sign
Medications
Life-long condition
Extended antibiotic therapy Diarrhe a
Abdominal pain
Acute Pancreatitis
Treatment
Result
ERECP
Pancreatic enlargement Peripancreatic edema Necrosis Extrapancreatic fluid Assesses complications Evaluate biliary tree and pancreatic duct Evaluate biliary tree and pancreatic duct
Abdominal CT in 72 hours to assess necrosis / complications Severe Pancreatitis Prophylatic antibiotics if > 30% necrosis
Jejunal feeds early
Drainage (if infected) Surveillance
Most common in India and southeast Asia Also known as bacterial overgrowth syndrome Acute intersitial pancreatitis Mild pancreatitis with pancreatic edema Acute necrotizing pancreatitis Severe pancreatitis with necrosis of parenchyma and blood vessels Complications ARDS, sepsis, renal failure Fluid collections Pancreatic necrosis (sterile) Pancreatic necrosis (infected) Pancreatic abscess Pseudocyst
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Laboratory Test Amylase
Persistent / recurrent episodes of epigastsric and LUQ pain
Lipase
Treatment
Result Usually not elevated
Abstince from alcohol Pancreatic enzymes replacement + H2 blocker / PPI + ↓ fat diet
Fecal Fat Pain with no radiologic evidence
Steatorrhea Fecal Elastase
Narcotics
Diagnostic Pain
Chronic Pancreatitis
Secretin Stimulation Test
Diabetes
Chronic inflammatory process leading to irreversible fibrosis of pancreas
Abdominal X-Ray Etiologies
Other Most acute pancreatitis does not go to chronic pancreatitis. Tropical Chronic Pancreatitis Due to childhood malnutrition in underdeveloped countries Chronic Obstruction of Pancreatic Duct Pancreatic duct strictures Pancreatic tumor Papillary stenosis There are no blood tests to diagnose chronic pancreatits.
Celiac plexus or splanchnic nerve block Surgery
Pancreatic calcifications Pancreatic calcifications
ERCP with sphincterotomy or stent placement
Medications
Pancreatic enzyme replacement
CT Chronic alcohol use (70%)
Chronic obstruction of pancreatic duct
Tropical chronic pancreatitis
Autoimmune pancreatitis
Genetic
Idiopathic (20%)
Jaundice
Weight loss
Painless (in pancreatic head)
Abdominal pain (in pancr. body / tail)
(+) Courvoisier's sign
(+) Trousseau's sign
Atrophied pancreas
MRCP / ERCP
"Chain of lakes" (areas of dilation and stenosis along pancreatic duct)
Pancreatic Adenocarcinoma
Sister Mary Joseph node
Supraclavicular LN
Lungs Peritoneum
Liver Bone
Cancer of the pancreas
Risk Factors T oba cco use
Chr oni c pa nc re at it is
Exposure to Bnaphthylamine or benzidine
Non-insulin dependent DM arising in nonobese person > 50 years old Hereditarychronic pancreatitis
H/O Partial gastrectomy or cholescystectomy
Peutz-Jeghers BRCA 2 mutation
Surgery
Alkaline Phosphatase Bilirubin
CT
Double duct sign
MRI
Assessment
Endoscopic Ultrasound
If no lesion seen on CT / MRI and still have high suspicion
Puestow procedures Subtotal pancreatectomy Total pancreatectomy (± autologous islet cell transplantation) Whipple procedure (if in head)
Diagnostic
CA 19-9
Signs of Metastatic Disease
Insulin therapy
Resection (no vascular invasion, lymphatic involvement, or metastasis)
Distal pancreatectomy + splenectomy (if in tail)
Also get 5-FU chemoradiation
5-FU chemoradiation Not always (if locally advanced and not needed if imaging resectable) is convincing
Tissue Diagnosis
ERCP with brushing + intraductal biopsy CT-guided biopsy (risk of seeding) EU with FNA (best option)
Gemcitabine
Metastatic
Pain control
Palliative stents
4th leading cause of cancer-related deaths 1.3 ♂ : 1 ♀ 15 - 20% of patients are candidates for pancreatectomy. 50% metastatic at time of diagnosis Medial Survival Resectable - 15 - 17 months Locally-advanced - 6 - 10 months Metastatic - 3 - 6 months
Clinical Medicine Condition / Disease
Cause
Signs and Symptoms
Abdominal pain (44%)
Change in bowel habit (43%)
Laboratory Test
Result
Treatment Colectomy / hemicolectomy + lymph node dissection
Colonsopy
Gold-standard Colostomy (sometimes required)
Hematochezia / melena (40%)
Weakness (20%)
Anemia without other GI symptoms (11%)
Weight loss (6%)
Endoscopic removal (early stages)
Abdominal and Pelvis CT
Staging
Radiofrequency ablation
Unusual Presentations Local invasion or malignant fistula formation into adjacent
Ablation of Metastases CXR
Diagnostic
Fever of unknown origin
Neoplasm of the colon and/or rectum
Streptococcus bovis bacteremia
Clostridium septicum sepsis
Needle Biopsy
If suspected to be metastatic disease
Risk Factors
Age
Personal history of colon polyps or cancer CBC
Family history of colon cancer Diagnostic
Carcinoid
Rare neuroendocrine tumor that arise at several body sites
Inherited syndromes
Type II diabetes
Metabolicsyndrome
Ethnicity
Inflammatorybowel disease
Diets ↑ red and processed meats
Physcialinactivity
Obesity
Smoking
Heavy alcohol use
Familial adeomatous polyposis
Hereditary NonPolyposis Colorectal Cancer
Abdominal pain
± Intermittent obstruction
Locations in GI Tract (most common first)
Ileum Rectum Appendix Colon Stomach
Ethanol ablation Cryosurgery
Other
10% of new cancer diagnoses 1 in 18 people will develop colorectal cancer. 19% of cases have metastatic disease 5-FU / Leukovorin at the time of diagnosis. / Oxaliplatin Metastatizes most commonly to liver and lung Staging T1 - Through muscularis mucosa, extends into submucosa T2 - Through the submucosa and into musclaris propria T3 - Through the muscularis propria and into subserosa but not to any neighboring organs Capecitabine T4 - Through the wall of the colon or rectum and into nearby tissues and organs
Hepatic artery embolization
Intra-abdominal or retroperitoneal abscesses
Colorectal Cancer
Metastatses resection (primarily liver)
Medications
CMP
PET
24 Hour Urine HIAA Chromogranin A, B, and C Biopsy Imaging
If suspected to be metastatic disease
N0 - No LN involvement N1 - 1 - 3 nearby LN involvement N2 - ≥ 4 nearby LN involvement Resected stage II M0 - No distant spread M1 - Distant spread present Chemotherapy Resected stage III Stage Grouping Metastatic / I - T1-2 N0 M0 5-FU / Leukovorin unresectable IIa - T3 N0 M0 IIb - T4 N0 M0 Radiation therapy (rectal cancer) IIIa - T1-2 N1 M0 IIIb - T3-4 N1 M0 Healthy diet with IIIc - T3-4 N1 M0 emphasis on plant IV - T3-4 N2 M1 sources Radiation is not typically used for Maintain healthy colon cancer due to its high toxicity BMI to the gut. Prevention FOLFIRI Colonoscopy Screening Limit red meats Q 1 year - IBD once disease present Encourage for > 15 years Q 3 - 5 years - Cancer or physical activity Vitamin D / adenomatous polyps have already calcium been detected Q 5 years - Family history of Occult blood colorectal cancer Stool DNA Colonoscopy Q 10 years - Everyone else FOLFOX Polyps CT colonoscopy Screening Flexible Some are adenomatous and some sigmoidoscopy are hyperplastic Double-contrast Hyperplastic polyps are not barium enema considered pre-malignant Surgery (localized disease)
Diagnostic
Metastatic Disease
Surgery Hepatic artery embolization No great evidence for systemic therapy
Arise from enterochromaffin cells Metastatic potential of localized carcinoid tumors correlates with tumor size, location, and histologic grade. Appendiceal carcinoids are the most common neoplasm found in the appendix.
Clinical Medicine Condition / Disease
Cause
Jaundice
Hyperbilirubinemia
Laboratory
Signs and Symptoms Yellowing of the oral mucosa, conjunctiva, and skin Dark urine
Very light stool
RUQ pain
Nausea / vomiting ± Jaundice
Hepatitis A
Inflammation of the liver due to HAV infection
Transmission Incubation Period Complications Chronic Sequelae Transmission
Fecal-oral Average = 30 days 15 - 30 days Fulminanthepatitis Cholestatic hepatitis None Parenteral Blood Body fluids
Test
Result
Bilirubin
HIGH
ALT AST Hepatitis A IgM Antibody
HIGH HIGH
Hepatitis A IgG Antibody
Inflammation of the liver due to HBV infection
HbSAb
HbCAb
30 - 50% < 5 years old Chronic Infection
Premature Mortality from Chronic Liver Disease
2 - 10% teenagers / adults
HbEAg
HbEAb 15 - 25%
Risk Factors Travelers to intermediate and ↑ HAV-endemiccountries
Acute infection
Homo- / bisexual ♂ Drug users Chronic liver disease ↑ Rate communities (Alaska natives and Amercian Indians)
Vaccination
Infection Prior infection Vaccination Immunity Hepatologist referral Active or prior infection Not positive with vaccination Activereplication of virus Chronic infection Antiviral therapy No active replication
HBV DNA in Blood
Infection
HbCAb
Present or cleared infection
Parental Transmission Very little sexual
Hepatitis C
Alcoholic Liver Disease
Liver damage due to heavy alcohol use
Non-Alcoholic Fatty Liver Disease
Chronic alcohol liver disease without significant alcohol consumption
HCV RNA
HCV infection
2 - 26 weeks
Chronic Hepatitis
70%
Persistent Infection
85 - 100%
RUQ pain
Nausea / vomiting
Jaundice
History of heavy alcohol use / binge drinking
Asymptomatic
Obesity
Predicts response and guides duration HCV Genotype 6 Phenotypes
Hyperlipidemia
Entacavir
Tenofovir
Genotype 1
24 weeks of treatment Treatment difficult to tolerate Telaprevir Boceprevir Combination with pegylated interferon-α + ribavirin
2x ALT
AST
Bilirubin INR
Calculated discriminant function (uses bilirubin and INR) Neither go above 500 U/L Prednisone ± pnetoxyfylline HIGH (if DF > 32) HIGH Weight loss and exercise
ALT Mildly elevated
Diabetes / insulin resistance
Lamivudine
Pegylated interferon-α + ribavirin Genotype 2 / 3
Inflammation of the liver due to HCV infection
Interferon
Telbivudine
Average = 6 - 7 weeks Incubation Period
Other
Immunity HbSAg
Average = 60 - 90 days
Hepatitis B
Medications
Prior infection
Incubation Period 45 - 180 days
Treatment
AST
Tight glucose control Management of hyperlipidemia and hypertension
Interferon-α
Ribavirin
Telaprevir
Boceprevir
Prevention Prevent perinatal HBV transmission Routine vaccination of all infants Vaccination of adolescents Vaccination of high risk groups High Risk Groups Houshold member of HBV-infected patients Sexual parteners of HBV-infected patients Health care workers Prisoners Travelers to endemic areas visiting ≥ 6 months #1 indication for liver transplant Prevention No vaccine Avoid sharing needles Use barrier protection if multiple sexual partners
Clinical Medicine Condition / Disease
Cause
Chronic Hepatitis
Persistent / recurrent hepatitis
Signs and Symptoms
Laboratory Test
Result
Treatment
Medications
Other
Other Etiologies Hemochromatosis
Autoimmune hepatitis
Wilson's disease
α-1-antitrysin deficiency
Medication effects
Cirrhosis Bleeding Varices
End result of chronic inflammation from a variety of etiologies Breached abnormallydilated blood vessels
Portal hypertension
Ascites
CBC
↓ Platelets
Gastro-esophageal varices
Splenomegaly
Albumin INR
LOW HIGH
Lack of toxin clearance
Encephalopathy
Bilirubin
HIGH
Hematemesis
Melena
IV octreotide
β-Blockers
Hematochezia in a patient with cirrhosis Hypotension
Emergent endoscopy
Tachycardia Check for fluid
Ultrasound
Ascites
Spontaneous Bacterial Peritonitis
Encephalopathy
Accumulation of fluid in the peritoneal cavity
Shifting abdominal dullness
Fluid wave
Abdominal pain
Fever
Bacterial infection of ascites Renalinsufficiency
Brain disease
Euphoria
Confusion
Asterixis
Coma
Precipitating Factors Infection Hyponatremia Sedatives Blood transfusion
Bleeding Hypokalemia Azotemia TIPS
Hemangioma
Replacement of a diseased liver with a healthy liver
Most common benign tumor of the liver
Hepatitis C Cyrptogenic / NASH
Serum Albumin Ascities Albumin CBC with Differential Ascites Culture
Check for portal vein thrombosis (with acute accumulation) Portal hypertension if > 1.1 > 250 PMNs
All patients with cirrhosis should have an upper endoscopy to look for varices. 60% develop ≤ 10 years of cirrhosis diagnosis
Salt restriction (2 g / day) Spironolactone Diuretic therapy
Large volume paracentesis Furosemide TIPS for refractory ascites Antibiotics (3rd generation cephalosporin)
Identify organism Hold diuretics
R/O Infection
Correct electrolytes Lactulose
Rifaximin 85% 1-year survival 70% 3-year survival
Indications
Liver Transplantation
Pathologic Diagnosis Fibrosis Regenerated nodules Vascular distortion See PowerPoints for grading of cirrhosis.
Alcohol (abstinent ≥ 6 months) PBC PSC
Autoimmune hepatitis
Hepatitis B
As ympt oma ti c
F ound inci de nt al ly
Most are very small.
Clinical Medicine Condition / Disease
Cause
Hepatic Adenoma
Liver cancer associated with long-term estrogen use
Focal Nodular Hyperplasia
Nonneoplastic response to a congential vascular malformation
Hepatocellular Carcinoma
Cancer secondary to either viral hepatitis infection or cirrhosis
Signs and Symptoms
Possible rupture
Laboratory Test
Treatment
Result
Bleeding
Medications
Other
Resection
Asymptomatic
Must be multphasic
Chronic liver injury or cirrhosis (80%) Imaging Cirrhosis symptoms
Arterial phase hypervascularity Delayed phase "wash-out"
Resection Embolization Radiofrequency ablation (possiblycurative) Transplantation (curative)
Milan Criteria for Transplant 1 HCC < 5 cm 3 HCCs with none that are > 3 cm
Pharmacology Drug
Generic Examples / Brand Name
Triple Therapy for Heliobacter Eradication
Metronidazole / PPI / Clarithromycin
Quadruple Therapy for Heliobacter Eradication
Pepto Bismol / Metronidazole / Tetracycline / Randitidine
Mechanism of Action
Indications
Pharmacokinetics
Kill Heliobacter pylori
Peptic ulcer disease
Eradication: 75 - 90%
Maalox Mylanta Amphojel
Kill Heliobacter pylori
Peptic ulcer disease
Triple therapy failure
O: 5 - 15 minutes Duration: 1 - 2 hours
Peptic ulcer disease
Neutralize gastric acid
Renal failure CHF Hypertension
GERD
cimetidine ranitidine nizatidine
Block histamine production in parietal cells
P ep ti c u lc er di se as e
D uo de na l u lc er
Gastric ulcer
GERD
A: Oral, IV, or IM O: 30 min Duration: 10 hours
Considerations PCN allergy P re vi ou s a nt ib io ti c us e
GI effects Metallic taste D is ul fi ra m re ac ti on Photosensitivity
Pill count Side effects Cost Considerations PCN allergy P re vi ou s a nt ib io ti c us e Pill count
lansoprazole
Proton Pump Inhibitors
rabeprazole
esomeprazole
Inhibit active proton pumps
dexlansoprazole
pantoprazole
Sucralfate
Carafate
Forms cytoprotective complex that covers ulcers
DU maintenance
A: Oral or IV Adminster: 30 min before breakfast GERD Peak: 1 - 2 hours (Zegerid = 30 min) Omeprazole Omeprazole / NaHCO3 Duration: Longer Acute Duodenal Ulcer Lansoprazole Rabepazole Omeprazole Acute Gastric Ulcers Omeprazole / NaHCO3 Lansoprazole Lansoprazole NSAID Ulcers Esomeprazole Omeprazole Lansoprazole Heliobacter Eradication Rabepazole Esomeprazole Omeprazole Omeprazole / NaHCO3 Esophageal Erosion Lansoprazole Maintenance Dexlansoprazole Rabepazole A: Oral on empty Duodenal ulcer healing stomach D: 1 g QID Peptic ulcer disease
(lansoprazole) Esophageal erosion healing
Duodenal ulcer maintenance
CYP450 inhibitors (omeprazole, Zegerid, and esomeprazole) Metabolic alkalosis (Zegerid)
S id e e ffe ct s Cost
Fluid overload Alkalosis Diarrhea / constipation Hypermagnesemia Hypercalcemia Aluminum neurotoxicity Drug interactions Headache Nausea Abdominal pain Thrombocytopenia
Heal 90% of DU at 8 weeks and 80% of GU at 12 weeks. Cimetidine has drug interactions with CYP450 inhibitors (theophylline, lidocaine, phenytoin, and warfarin).
Headache Nausea Abdominal pain
Do not cut, crush, or chew pills because they are entericcoated. Breakdown symptoms (particularly at night) can happen while on PPI therapy PPIs may fail to heal moderate to severe esophagitis.
famotidine
omeprazole
Monitoring / Other
GI effects Altered taste D is ul fi ra m re ac ti on
B la ck tong ue / s to ol s
Tums
H2 Receptor Antagonist
Adverse Effects
Amoxicillin / PPI / Clarithromycin
Alka-Seltzer
Antacids
Contraindications
Eradication: 70 - 85%
Diarrhea Long-Term Effects B12 / calcium dysabsorption Fractures C. difficile-associated diarrhea Pneumonia
Constipation Gastric bezoar A lu mi nu m a cc um ul at io n Hypophosphatemia
Drug Interactions Warfarin D ig ox in Quinol ones These drugs need to be separated by ≥ 2 hours.
Pharmacology Drug
Misoprostol
Metoclopramide
Generic Examples / Brand Name
Cytotec
Mechanism of Action
Synthetic prostglandin E1 analog
NSAID ulcers
Blocks dopamine receptors in the gut
GERD
Increases LES tone, gastric tone, and transit time
Diabetic gastroparesis
Domperidone
Peripherally-acting dopamine agonist
Baclofen
Lioresal
GABA agonist that reduces tLESs
Bulk Laxatives
methycellulose
psyllium
polycarbophil
Docusate Sodium
PEG 3350
lactulose
Colace
Increase stool bulk Decrease transit time Increase motility Retain water
Draws water into intestines along an osmotic gradient Surfactant agent that allows water to enter the bowel more readily
Pharmacokinetics
Bisacodyl
Saline Laxatives Castor Oil
Diarrhea Abdominal cramping Flatulence Nausea Headache
Chemotherapy-induced nausea and vomiting
GERD
Constipation
Requires an IND permit from the FDA
A: Oral with ≥ 8 oz of water O: 1 - 3 days
Bowel obstruction Stricture Crohn's disease
A: Oral O: 1 - 3 days
Constipation (ineffective)
Bloating / gas Shoud be titrated Mechanical obstruction of colon and esophagus Bloating Nausea Gas Cramping (lactulose > PEG 3350)
Constipation
A: Oral
Patients that need to avoid straining or prevent constipation
Lubricant laxative
Constipation
Stimulant laxative
Constipation
Stimulant laxative
Constipation
Correctol
A: Oral O: 6 - 12 hours D: Not recommended for daily use
Elderly
Anal seepage
Children < 6 years old
Pruritus Incontinence Malabsorption of fat-soluble vitamins (long-term use)
< 1 hour of antacid or milk ingestion
Severe cramping Diarrhea Electrolyte imbalance Abdominal cramping Melanosis coli
A: Oral O: 6 - 12 hours
Senokot-S
magnesium citrate sodium phosphate
Modest efficacy
Symptoms refractory to PPIs
Duclolax
magnesium hydroxide
Monitoring / Other
Headache Sedation EPS (especially in elderly)
GERD
Ex-Lax
Anthraquinones
Adverse Effects
Pregnancy
CNS effects Diarrhea
A: Oral O: 1 - 3 days
Mineral Oil
Contraindications
Need to reduce risk for NSAID ulcer
Reglan
Motilium
Osmotic Laxatives
Indications
Pulls water into the intestines along an osmotic gradient
Acute evacuation of stool
Stimulant laxative
Constipation
Fluid / electrolyte depletion Cramping / bloating Hypermangesemia / hyperphosphatemia (in renal disease)
A: Oral O: 1 - 6 hours D: Not for daily use
A: Oral O: 1 - 6 hours D: Not for daily use
Elderly
Cramping Severe diarrhea Dehydration Premature labor
Mineral oil and docusate are useful in same clinical situation, but docusate is safer.
↑ Risk of aspiration and lipoid pneumonia if taken before bed or in a recumbent position
Pharmacology Drug
Enemas and Suppositories
Lubiprostone
Generic Examples / Brand Name glycerin suppositories
Mechanism of Action
Indications
Distends the rectum
Pharmacokinetics
Acute constipation
Contraindications
Softens hard stool sodium phosphate enema
Amitiza Increase luminal fluid secetion
Monitoring / Other
Fecal impaction
Stimulates colonic mucose contraction
Locally activates ClC-2 chloride channels in the microvilli cell membrane
Adverse Effects Hyperphosphatemia (NaPO4 enema) Electrolyte abnormalities
A: Rectal :-( O: 15 - 30 min
Nausea (29%) Diarrhea (12%) Headache (11%)
A: Oral with meals Bowel Movements: Every 1 - 2 days Chronic idiopathic constipation
Pills cannot be crushed or chewed.
IBS constipation
Acclerate intestinal transit
Linaclotide
Linzess
Activates gyanylate cyclase C in the interstinal epithelium
Chronic idiopathic constipation
A: Oral ≥ 30 minutes before first meal
Children < 6 years old
Diarrhea (16%) Abdominal pain (7%)
D: 145 μg daily
Increase luminal fluid secretion IBS constipation
Acclerate intestinal transit
Antimotility Agents
Absorbents
loperamide diphenoxylate / atropine
Acute bacterial diarrhea
Opiate derivative that slows intestinal transit
Diarrhea
Absorb toxins, bacteria, gases, and fluids
Diarrhea
calcium polycarbophil
Pepto-Bismol
Octreotide
Sandostatin
Emetrol
Mixture of fructose, dextrose, and phosphoric acid
Safe, but efficacy not well established
Children / teenagers with viral illness
Decrease water secretion into the bowel
Traveler's diarrhea
Diarrhea
Decrease water secretion into the bowel
Diarrhea associated with carcinoid tumors
AIDS-related diarrhea
Short-gut syndrome
Chronic idiopathic diarrhea
Blocks release of SE and other peptides
Abdominal pain Diarrhea Dysglycemia (in diabetics)
Unknown Vomiting Sedation Anticholinergic effects
dimenhydrinate diphenhydramine
Narrow-angle glaucoma BPH CV disease Seizure disorders
Motion sickness
Nausea
dolasteron
palonosetron
A: Oral, IV, IM, or rectal
Chemotheapy-induced nausea and vomiting
promethazine
granisetron ondansetron
Vomiting
Block D2 receptors
Block serotonin receptors in gut wall
Chemotheapy-induced nausea and vomiting
Post-operative nausea and vomiting
Radiotherapy-induced nausea and vomitting (granisteron and ondansetron)
A: Oral or IV
Minima l effi cacy
Caution in…
scopolamine
prochlorperazine
Less effective than loperamide in most cases. Drug Interactions Warfarin Probenecid MTX Not more effective than opioids in chronic idiopathic diarrhea
Nausea
chlopromazine
Serotonin Receptor (5-HT3) Antagonist
Black tongue and stools
Aspirin sensitivity Pregnancy
meclizine
Phenothiazines
Loperamide is the drug of choice for most cases of diarrhea.
paregoric attapulgite
Bismuth Subsalicylate
Antihistamines / Anticholinergics
Dizziness Constipation
EPS Sedation Anticholinergic effects Drug interactions Headache Dizziness Constipation Asthenia ↑ LFTs QT prolongation (rare)
Better treating vomiting than nausea Not as effective for motion sickness
Pharmacology Drug
Corticosteroids
Generic Examples / Brand Name
dexamethasone
Mechanism of Action
Unknown
haloperidol
Butyrophenones droperidol
Cannabinoids
dronabinol nabilone
Blocks dopamine stimulation of CTZ Inhibits neurotransmitter release
Indications
Neurokinin-1 Antagonist
Contraindications
Chemotheapy-induced nausea and vomiting
Not 1st line
A: Oral, IV, or IM Post-operative nausea and vomiting
Pallative care Euphoria Drowsiness Hallucination
A: Oral Chemotherapy-induced nausea and vomiting (when other agents fail)
Paranoia Anamnestic effects
A: Oral
Enhance GABA
Anticipatory nausea and vomiting
Inhibits substance P / neurokinin 1 receptors
Chemotherapy-induced nausea and vomiting
fosaprepitant
Post-operative nausea and vomiting
Monitoring / Other Increase the efficacy of other antiemetics
lorazepam
aprepitant
Adverse Effects
Moderately emetogenic chemotherapy
alprazolam
Benzodiazepines
Pharmacokinetics
CYP3A4 substrates CYP2C9 inducers
