gastroenterology presentation
TRANSCRIPT
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Gastroenterology
Swedish Family Practice Residency Didactics
July 31, 2001
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A quick trip through the GI track with brief stops at the esophagus, stomach, liver,
colon, rectum and anus.And a little diarrhea.
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The Upper GI Tract
• Esophagus
• Stomach
• Pancreas
• Gallbladder
• Liver
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Esophageal Disorders
• Disorders of motility
• GERD
• Inflammatory and
infectious disorders
• Tumors
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Symptoms from the Esophagus
• Dysphagia
• Odynophagia
• Chest pain
• Regurgitation
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Disorders of Motility
• Achalasia – Cancer, Parkinson’s, Chagas Disease (trypanosomiasis)
• Spasm – Diffuse, Localized
• Scleroderma
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Diagnostic Studies
• Barium swallow
• Manometry
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Treatment• Long-acting nitrates• Calcium channel blockers• Dilation of LES (Achalsia)• Surgery (Spasm, Scleroderma)• Manage reflux (Scleroderma)• Prokinetic drugs (Scleroderma)
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GERD
• Frequent – 10% of US population
• Occasional – 30% of US population
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Symptoms of GERD
• Heartburn• Water Brash • Regurgitation• Dysphagia/odynophagia• Chest pain, hoarseness,
chronic cough, wheezing
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Diagnosis of GERD• Therapeutic trial• Endoscopy (if complicated)• Manometry (for placement of pH
probe or prior to reflux surgery)• pH acid perfusion test (for
diagnosis of unresponsive GERD)
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Treatment of GERDMild Symptoms
• Dietary modification• Lifestyle modification• Trial of patient directed
therapy with OTC antacids or H2 antagonists
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Treatment of GERDNon-responders, non-erosive disease
• H2 antagonists• PPI’s• Promotility agents• 8-12 weeks of therapy
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Warning Symptoms Suggesting Complicated GERD
• Dysphagia • Bleeding • Weight loss • Choking (acid causing coughing, shortness
of breath , or hoarsness) • Chest pain• Longstanding symptoms requiring
continuous treatment
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Treatment of GERDComplicated GERD
• GI workup with endoscopy• PPI’s• High-dose H2 antagonists• Antireflux surgery – no data on
new procedures
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Inflammatory Disorders of the Esophagus
• Pill-induced esophagitis – NSAID’s, steroids, doxycycline
• Infective esophagitis – HIV, HSV, cytomegalovirus, candida
• Corrosive – alkalis or acids
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Diagnosis and Treatment
Endoscopy
Treatment based on
results of endoscopy
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Esophageal Tumors• 90% are malignant• Most are squamous cell• Most are associated with heavy
alcohol and tobacco use• 8% of Barrett’s develop into
adenocarcinomas• 5% 5-year survival but improving
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Diseases of the Stomach
• Acid peptic disorders of the stomach and duodenum
• Infections
• Motor disorders
• Cancer
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Acid Peptic Disorders
• 5 – 10% of the US population will have PUD in their lifetime, 50% will recur
• .0001% mortality rate
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Cause of PUD
Imbalance between protective and aggressive factors
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Protective factors
• Mucus and bicarbonate secretion of epithelial cells
• Surface membrane of mucosal cells
• PG E-1 and PG E-2
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Aggressive Factors
• Gastic acid
• NSAID’s
• Corticsteroids
• Smoking
• Alcohol (?)
• Stress (?)
• Diet (probably not)
• H-pylori
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H. pylori and PUD• Almost all patients with H. pylori
have antral gastritis• Eradication of H. pylori eliminates
gastritis• Nearly all patients with DU have H.
pylori gastritis• 80% of patients with GU have H.
pylori gastritis
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H. Pylori Diagnosis• Serology ($20-$200) – 90% sensitive, 95%
specific – not good for following treatment• Biopsy ($250) – 98% sensitive – 98% specific• Urea breath test ($80-$100) – 95% specific,
98% specific – can be used to document eradication
• Stool antigen test ($100-$150) – 90% sensitive, 95% specific – can be used to confirm eradication
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Natural History• 20 – 50% heal untreated
• 80% heal in 4 weeks of treatment
• 75% recur in 6 – 12 months
• More recur in patients with
H. pylori, smokers, NSAID users
• Milk and tobacco slow healing
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Treatment of PUD• H2 blockers - $25 a month for
generics• Maintenance dose same as
treatment dose• 20% recur on maintenance vs. 70%
on no treatment• PPI’s - $125 a month (Prilosec soon
out in generic)
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Treatment of H. pylori• No therapy is 100%• Treatment markedly decreases
recurrences of DU• Use of H2 blockers and PPI’s
increases eradication rate and hastens relief of symptoms
• PPI’s have intrinsic in vivo activity against H. pylori
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Diseases of the Lower GI Tract
• Constipation – 2% of US population report chronic constipation
• Irritable bowel syndrome – a diagnosis of exclusion (CBC, colonoscopy, stool O&P, lactose difficiency, endoscopy)
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Diseases of the Lower GI Tract, cont.
• Malabsorption – long differential (consider if weight loss, muscle wasting, hair loss, malnutrition)
• Inflammatory bowel disease – UC and Crohn’s disease
• Mesenteric vascular disease
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Diseases of the Lower GI Tract, cont.
• Diverticulosis (90% have
no symptoms)
• Diverticulitis (infectious)
• Infectious diarrhea
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Diagnosis of Infectious Diarrhea - History
• Work• Travel• Eating• Ill contacts• Recent antibiotics• HIV or immunocompromised
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Treatment of Mild Symptoms
• Maintain hydration: sports drinks, diluted fruit juices, watery soups, pedialyte, WHO formula, IV fluids
• Solids as tolerated but avoid milk and milk products
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Diagnosis of Infectious Diarrhea
• Stool C&S, O&P (x1), fecal blood and leukocytes if no improvement in 48 hours or severe disease with bloody stools, fever, dehydration
• Consider sigmoidoscopy
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Treatment
Pathogens requiring treatment – shigella, giardiasis, E. coli, pseudomembranous entercolitis, V. cholera
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Treatment
Pathogens that may require treatment – campylobacter, salmonella, amebiasis (5% carriage rate in the US, many are not pathogenic)
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Treatment
• Most viral and bacterial causes of diarrhea resolve without treatment
• Antibiotics may prolong or worsen diarrhea
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Diseases of the Lower GI Tract, cont.
• Cancer – small bowel (rare), colon (6% incidence)
• Anorectal diseases – cancer, hemorrhoids, pruritis ani, fissures
• And hepatitis