gi/hepatology test review brenda shinar, md may 2013
TRANSCRIPT
Manage nonalcoholic steatohepatitis
• 30% of adults in US have NAFLD and 20% of these patients have NASH
• Risk factors for progession to cirrhosis:– Age > 50 years– BMI > 28– Serum triglycerides >150– ALT > 2x ULN
• Treatment for all:– Weight loss– Monitor AST/ALT q 3-6
months– Statins are okay
• AASLD Guidelines For Biopsy Proven NASH:– Diabetics: Pioglitazone 45
mg/day (1B)– Non-diabetics: Vitamin E
800 U/ day (1B)
Manage acute diarrhea
• Definition:– Acute < 14 days– Chronic > 4 weeks
• Osmotic, secretory, inflammatory or malabsorptive
• Most acute cases of diarrhea are self-limited and require no further evaluation
• FEATURES that require additional evaluation:– Fever> 38.5 C (101.3 F)– Bloody stool– Pregnancy– Elderly or
immunocompromised– Hospitalized– Food handler – Recent antibiotics– Volume depleted– Severe abdominal pain
Diagnose acute mesenteric ischemia
• 1) Acute arterial mesenteric ischemia
– Pain out of proportion– Afib, unanticoagulated– Thromboembolus to SMA– Known vasculopath– High mortality: dead bowel
• 2) Chronic arterial mesenteric ischemia
– Hungry– Afraid to eat due to pain– Weight loss– Known vasculopath
• 3) Subacute venous-hypertension related mesenteric ischemia
– Unusual hypercoagulable state– Polycythemia Vera, Paroxysmal
Nocturnal Hemoglobinuria (PNH)– Occlusive portal vein clot propagates
to SMV
• 4) Colonic ischemia – Elderly– Hypotension /Dehydration event– Mucosal ischemia especially
watershed areas (splenic flexure and sigmoid)
– Increase perfusion pressure to treat; avoid hypotension
– No need for angiogram
Manage recently resolved acute diverticulitis
• Diverticulosis:– Intrinsic weakness where vessel
penetrates the colon wall– Simultaneous or excessive haustral
contractions– Inadequate dietary fiber– COMMON in Western populations – 40% by age 60 and 60% by age 80
• Diverticulitis: (fever, LLQ pain, WBC) (1 in 5 with diverticulosis):
– Uncomplicated– Recurrent uncomplicated– Complicated– Smoldering
• CT is diagnostic test of choice
• Management decisions:– Outpatient or inpatient– Antibiotics (gm neg and anaerobes)– Bowel rest
• *Following resolution (2-6 weeks later) the entire colon needs endoscopic evaluation to look for mimickers, ie. cancer/polyps
• Preventing future episodes:– Surgical resection of diseased segment– High fiber diet– No association between seeds, nuts, or
popcorn consumption
Diagnose diffuse (distal) esophageal spasm
• RARE:– 3% of patients with chest
pain – 3% of patients with
dysphagia
• Pathophysiology:– Excessive number of
simultaneous contractions of normal or high amplitude in the distal
esophagus
• Diagnosis:– Clinical history: worse with cold
liquids– Manometry– Barium swallow is not sensitive
• Treatment:– Diltiazem– Trazodone or Imipramine– Botulism toxin– Sildenafil– Hot water– Peppermint oil
Treat new-onset Crohn disease• Diagnosis of Crohn disease
– 80% involve small bowel– Transmural inflammation
• 5-ASA tx ineffective– Skip lesions– Mouth to anus
• Assess severity clinically and endoscopically– Crohn Disease Activity Index
(CDAI) or Harvey-Bradshaw index (see right)
• Initiate treatment– Step up vs. Top down
• ANTI-TNF THERAPY WITH OR WITHOUT 6-MP OR AZATHIOPRINE RESULTED IN HIGHEST REMISSION RATES
(SONIC trial; NEJM September,2010) • Alternative is to start simultaneous
azathioprine or 6-MP and steroids with goal of stopping steroids in 3 months
Treat severe alcoholic hepatitis• Diagnosis:
– AST/ALT 2-3:1– Transaminases NOT over 500– Bilirubin and Coags increasing– WBC may be very high
• General Management for ALL patients– Alcohol abstinence– Prevention and treatment of
withdrawal– Fluid management– Nutritional support– Infection surveillance– Prophylaxis against
gastrointestinal bleeding
• Maddrey discriminant function > 32 = severe– Prednisolone 40 mg q day x 28 days– Stop after 7 days if no
improvement in bili and DF– Pentoxifylline NOT helpful in those
who fail steroids– Pentoxifylline in those in whom
steroids are contraindicated• Infection (SBP)• Renal failure• GI bleeding
• Mortality @ 1 month– SEVERE 25-25% mortality– MILD- MOD <10% mortality
Manage obscure GI bleeding associated with aortic stenosis
Angiodysplasia of the GI tract
Ectatic, thin-walled, tortuous dilated vessels
lined by only endothelium in the submucosa
• THREE associated conditions:– End-stage renal disease– Von Willebrand disease– Aortic stenosis
• Acquired VW disease?
• Treatment:Endoscopic
SurgeryHormone
Angiogenesis inhibitorsAortic valve replacement
Diagnose hepatocellular carcinoma
Screening recommendations are the following:Ultrasound imaging every 6 months
DO NOT check AFP levels
Manage toxic megacolon in a patient with ulcerative colitis: early surgery prevents mortality from 22% to 1.2%
• Radiologic dilatation PLUS– Maximum colon diameter > 6 cm– Usually right sided/transverse
• Clinical presentation– Fever >38⁰C– Heart rate > 120 bpm– WBC > 10,500– Anemia
• PLUS One of the following:– Altered sensorium– Hypotension– Dehydration– Electrolyte abnormalities
Manage high-grade dysplasia in a patient with Barrett esophagus
American Gastrointestinal Association Guidelines 2011 for Management of High-Grade Barrett’s dysplasia is to
undergo Endoscopic Ablation:
• Radiofrequency ablation• Photodynamic Therapy
• Endoscopic mucosal resectionNOT
• Esophagectomy!
• HIGH grade Barrett’s without definitive treatment requires repeat
surveillance in 3 months!
Manage short-bowel syndrome with acid suppression therapy
Likelihood or resuming an oral diet
– Amount of bowel remaining– Type of bowel remaining– Presence of a colon and
ileocecal valve– Intestinal adaptation
Citrulline concentration– < 20 micromol/Liter predicts
permanent intestinal failure – 95% PPV, 86% NPV
Treatment of short bowel syndrome
– PPI or H2 blocker for gastric acid suppression (oversecretors)
– Replacement of stomal/fecal fluid losses
– Electrolyte replacement– Loperamide– Thickeners
Treat a patient at risk for NSAID-induced GI toxicity with a PPI
Patients with ONE or MORE of the MODERATE risk factors should be given PPI therapy for PRIMARY prevention of
gastrointestinal toxicity to NSAIDS!
Diagnose lactose malabsorptionDiagnosis:
– Osmotic diarrhea– Stool osm= 290- 2x (stool sodium
+ stool potassium– >100 mosm/kg = osmotic
diarrhea
Prevalence of Lactase Deficiency in Adults:
– Caucasian: 7-20%– Hispanic: 50%– African American: 60-75%– Native American: 80-95%– >90% Eastern Asia