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It's a Gas - A Review of Gastroenterology

Peter F. Bidey, DO

7/22/2015

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It’s a Gas- A Review of Gastroenterology

Peter F. Bidey, D.O.Clinical Instructor -Family Medicine

Philadelphia College of Osteopathic MedicineACOFP Intensive Update and Board Review

August 23, 2015Chicago, IL

Gastrointestinal Tract

Common Presentation of Disease

• Pain– Abdominal or chest

• Altered indigestion– Nausea/vomiting– Odynophagia- painful swallowing– Dysphagia- difficulty swallowing– Anorexia- lack of appetite

• Altered bowel movements– Constipation– Diarrhea

• Bleeding

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Esophagus

• Achalasia– Functional obstruction- obstruction from abnormal

function in the absence of a visible mass or lesion – Etiology is unknown– Due to defective innervation of smooth muscle in the

esophageal body and lower esophageal sphincter (LES)

– Symptoms- progressive issues with swallowing with regurgitation leading to chest pain and weight loss

– Diagnosis- motility testing– Botulinum toxin

Esophagus

• Esophageal Stricture– Complication of gastroesophageal reflux disease (GERD)– Increased frequency in conditions that lead to increased acid

exposure– Also occurs post esophageal surgery, caustic injections, pill

esophagitis, and radiation exposure

• Eosinophilic Esophagitis– Usually presents in adults and teenagers with dysphagia and

food impactions– Can see stacked circular rings, strictures, and white papules on

EGD– Diagnosis- biopsy showing increased number of eosinophils.

Esophagus/Stomach

• Reflux Esophagitis– Subset of patients with symptoms of GERD that have

endoscopic or histopathologic evidence of esophageal inflammation

• GERD– A condition that develops when reflux of stomach contents

causes troublesome symptoms and/or complications

– Heartburn is the usual symptom worsening when lying prone at night or after eating foods or drugs that decrease LES tone

– Can have chest pain, regurgitation, dysphagia, hoarseness, cough, nausea, lump in throat

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Esophagus/Stomach-GERD

• Secretin• Cholecystokinin• Glucagon• Somatostatin• Gastric inhibitory peptide (GIP)• Vasoactive intestinal peptide

(VIP)• Progesterone• Beta-adrenergic agonists• Alpha-adrenergic antagonists• Anticholinergic agents• Fat• Chocolate• Ethanol

• Peppermint• Theophylline• Caffeine• Gastric acidification• Smoking• Pregnancy• Prostaglandins E2, I2• Serotonin• Meperidine• Morphine • Dopamine• Calcium channel-blocking agents• Diazepam• Barbiturates

Factors that Decrease LES Pressure


• Complications of GERD– Stricture- most common and usually in distal esophagus– Perforation/Hemorrhage– Pneumonia- due to aspiration– Barrett’s Esophagus

• Some studies shows EtOH and smoking increase epithelium change from squamous to columnar histology

• 2-5% of cases lead to adenocarcinoma

• Diagnosis– History and Physical– Use of Proton pump inhibitors as trial– Barium swallow– EGD


• GERD Treatment– Lifestyle and Dietary Modification

• Avoid Triggers– Smoking and foods that decrease LES pressure

• Weight loss• Elevation of HOB

– Antacids• Do not prevent GERD- use only for intermittent on-demand symptoms• Magnesium Trisilicate, Aluminum Hydroxide, or Calcium Carbonate• Caution with magnesium compounds in renal disease• Can interfere with INH, Digoxin, and Tetracyclines

– Surface agents• Promote healing and protects peptic injury adhering to surface• Sucralfate• Mainly used in pregnancy

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• GERD Treatment– Histamine 2 receptor antagonists

• Decrease the secretion of acid by inhibiting H2R on gastric parietal cell

• Development of tachyphylaxis can limit use as maintenance therapy– Use in mild and intermittent symptoms

• Can interfere with Coumadin, Theophylline, and Dilantin

– Proton pump inhibitors (PPIs)• Most potent inhibitor of gastric acid secretion by irreversibly

binding to and inhibiting H-K ATPase pump• Take 30 minutes before first meal of day• Can interfere with Coumadin and Dilantin

Esophagus/Stomach-PPIs

• Uses of PPIs– Dyspepsia – Peptic Ulcer disease (PUD) – Gastroesophageal Reflux Disease (GERD) – Erosive Esophagitis– Laryngopharyngeal Reflux Disease – Barrett’s esophagus– Prevention of stress gastritis– Gastrinomas and other conditions that cause

hypersecretion of acid – Zollinger-Ellison Syndrome

Stomach-Gastritis /Peptic Ulcer Disease /Duodenal Ulcer Disease

• Symptoms– Presents with chronic, mild gnawing, or burning abdominal or

chest pain resulting from superficial or deep erosion of GI mucosa

– Timing of pain sometimes differs between ulcer site– Pepsin and acid are major factors causing damage

• Causes– Medications-ASA & Steroids– Diet-EtOH and Spicy Foods– Smoking– Organisms– Stress/ARI/Sepsis– Trauma-NG tube & EGD

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Stomach-H pylori

– Extremely common and found in ½ world population

– Most common in poorest countries

– Close to 90% of infected individuals shows signs of inflammation on EGD but many are asymptomatic

– 15% of infected individuals will develop a clinical significant ulcer

– Vast majority of patients with acid-peptic disease have H pylori infection

– Treatment that does not eradicate H pylori infection is associated with increase in acid-peptic disease reoccurrence in patients

Stomach-H Pylori Treatment

• ACG Guidelines

– PPI BID + Clarithromycin 500mg BID + Amoxicillin 1000mg BID for 10-14 days

• Can use Metronidazole 500mg BID if PCN allergic or previous received macrolide or unable to tolerate bismuth quadruple therapy

– Bismuth subsalicylate 525mg QID + Metronidazole 250mg QID + Tetracycline 500mg QID + PPI BID for 10-14 days

Stomach-Gastroparesis

– Delayed gastric emptying

– Symptoms include nausea, bloating, vomiting, and either constipation or diarrhea

– Common complication of poorly controlled diabetes mellitus, with consequent autonomic dysfunction

– Complications include bezoars from retained gastric contents, bacterial overgrowth, erratic blood glucose control, and possible weight loss

– Treatment includes prokinetic agents-Reglan• Side effects- hallucinations, insomnia, restlessness, and

anxiety

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Small Intestine & Colon-Diarrhea

• Mechanisms of Diarrhea

– Osmotic/malabsorption

– Secretory

– Motility Disorder

– Inflammatory


Signs and Symptoms Dx to be Considered

Arthritis Ulcerative colitis, Crohn's disease, Whipple's disease, enteritis resulting from Yersinia enterocolitica, gonococcalproctitis

Liver disease Ulcerative colitis, Crohn's disease, colon cancer with metastases to liver

Fever Ulcerative colitis, Crohn's disease, amebiasis, lymphoma, tuberculosis, Whipple's disease, other enteric infections

Marked weight loss Malabsorption, inflammatory bowel disease, colon cancer, thyrotoxicosis

Eosinophilia Eosinophilic gastroenteritis, parasitic disease (particularly Strongyloides)

Lymphadenopathy Lymphoma, Whipple's disease, AIDS

Neuropathy Diabetic diarrhea, amyloidosis

Small Intestine & Colon-DiarrheaSigns and Symptoms Dx to be Considered

Postural hypotension GI bleeding, diabetic diarrhea, Addison's disease, idiopathic

orthostatic hypotension

Flushing Malignant carcinoid syndrome, pancreatic cholera syndrome

Erythema Systemic mastocytosis, glucagonoma syndrome

Proteinuria Amyloidosis

Collagen-vascular disease Mesenteric vasculitis

Peptic ulcers Zollinger-Ellison syndrome

Chronic lung disease Cystic fibrosis

Systemic arteriosclerosis Ischemic injury to gut

Frequent infections Immunoglobulin deficiency

Hyperpigmentation Whipple's disease, celiac disease, Addison's disease

Good response to corticosteroids Ulcerative colitis, Crohn's disease, Whipple's disease,

Addison's disease, eosinophilic gastroenteritis, celiac disease

Good response to antibiotics Blind loop syndrome, tropical sprue, Whipple's disease

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• Acute Diarrhea– Usually <2-3 weeks

– Causes• Viral, bacterial, parasitic, and fungal

• Food poisoning

• Drugs or food additives– Digitalis, propranolol, quinidine, diuretics, colchicine, antibiotics,

lactulose, antacids, laxatives, chemotherapeutic agents, bile acids, and meclomen.

• Fecal impaction

• Pelvic inflammations

• Heavy Metal poisoning (acute or chronic)


• Traveler’s Diarrhea

– Bacterial Infections

• Mediated by enterotoxins produced by E coli

• Mediated by invasion of mucosa and inflammation (invasive E coli and Shigella)-Bloody

• Mediated by combinations of invasion and enterotoxins (Salmonella)-Bloody

– Viral or parasitic infections


• Diarrhea in Patients with AIDS– Cryptospordium– Amebiasis– Giardiasis– Isospora belli– Herpes simplex– Cytomegalovirus– Mycobacterium avium-intracellulare complex– Salmonella typhimurium– Cryptococcus– Candida– AIDS enteropathy

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• Chronic and Recurrent Diarrhea– Irritable bowel syndrome– Inflammatory bowel syndrome– Parasitic and fungal infections– Malabsorption syndromes– Drugs and food additives– Colon cancer– Diverticulitis– Fecal impaction– Heavy metal poisoning– Raw milk-related diarrhea

Small Intestine & Colon-Celiac Disease

• Small bowel disorder which is triggered by the ingestion of gluten

• Variable signs and symptoms, most patients have some component of:– Bloating

– Intermittent diarrhea

– Abdominal pain

• Some patients have no GI complaints or mimic symptoms of other disorders


• Testing-who?– Individuals with GI symptoms of recurrent diarrhea,

malabsorption, weight loss, and bloating– Individuals with Fe-def anemia, folate or B12 def without

explanations– Individuals currently having symptoms and are a type 1 DM or

have first degree relatives with celiac disease

• Diagnosis– Immunoglobulin A– anti-tissue transglutaminase antibody– Biopsy of intestinal villa-confirmatory

• Treatment– Gluten-free diet

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• Dermatitis herpetiformis is an itchy, blistering skin disease that also stems from gluten intolerance

• The rash usually occurs on the elbows, knees and buttocks

• Dermatitis herpetiformis can cause significant intestinal damage identical to that of celiac disease– However, it may not produce

noticeable digestive symptoms

• This disease is treated with a gluten-free diet, in addition to medication to control the rash

Small Intestine & Colon-Inflammatory Bowel Disease

• Crohn’s Disease– Transmural and

granulomatous in character, occurring anywhere along the GI tract

– Appears usually with “skip lesions”

– Has a cobblestoningappearance due to deep ulcerations and submucosal thickening

• Ulcerative colitis

– Superficial and limited to the colonic mucosa

– Rectal bleeding> 90%

– Diarrhea - 10– 30%

– Rectal involvement almost 100%

Small Intestine & Colon-Crohn’s Disease

• Usually occurs in the distal ileum but again can appear anywhere in GI tract

• Complications:– Perforation, fistula

formation, abscess formation, and small bowel obstruction

– Protein-losing enteropathy– Possible increased

incidence of intestinal cancer

• Other manifestations– Joints-migratory arthritis– Skin-erythema nodosum– Eyes-uveitis & iritis– Buccal mucosa- aphthous

ulcers– Bile ducts-sclerosing

cholangitis– Liver-autoimmune chronic

active hepatitis– Nephrolithiasis– Amyloidosis– Thromboembolic events

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Small Intestine & Colon-Ulcerative Colitis

• Restricted to mucosa of colon and rectum• Similar presentation to Crohn’s disease and some

complications (bloody diarrhea & protein-losing enteropathy) but no typical obstruction, perforation, and fistula formation

• Like Crohn’s disease some patient’s only have 1 to 2 flares during lifetime

• Higher risk of carcinoma-unknown cause• Toxic megacolon is a complication and can

perforate

Small Intestine & Colon-Inflammatory Bowel Disease-

Treatment• Crohn’s Disease

– Sulfasalazine, Corticosteroids, and Mercaptopurine

• Ulcerative Colitis– Sulfasalazine, Corticosteroids, Mesalamine, and Olsalazine

• Both Crohn’s disease and Ulcerative colitis can go into remission after initial treatment with Sulfasalazine and corticosteroids

• The natural history of the disease has periods of remission interrupted with active disease; during these periods medical treatment is directed to supportive treatment and to induce remission

Small Intestine & Colon-Inflammatory Bowel-Treatment

• These diseases can recur after surgical resection of involved regions of the GI tract therefore operative management is limited to relief of life-threatening obstruction or bleeding

• Immunosuppressive agents, such as Mercaptopurine and Azathioprine, have variable response rates and high rates of side effects; therefore they are limited to cases that have failed to respond to Sulfasalazine and glucocorticoids

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Small Intestine & Colon-Irritable Bowel Disease

• Most common referral to gastroenterologist• Most common diagnosed gastrointestinal condition• Characterized by chronic abdominal pain and altered

bowel habits in the absence of any organic cause• Pain is usually campy in nature and not associated

with anorexia, malnutrition, or weight loss• Altered bowel habits alternate between constipation

and diarrhea usually• Bloating or perceived abdominal distention also a

common feature• Cause is unknown

Small Intestine & Colon-Irritable Bowel Disease

• Stress has a considerable influence on the symptoms

• Symptoms frequently occur with stressful life events and stressful events in early life may predispose to the development of IBS

• Diagnosis of exclusion– Manning criteria

• Pain relieved with defecation

• More frequent stools at the onset of pain

• Looser stools at the onset of pain

• Visible abdominal distention

• Passage of mucus

• Sensation of incomplete evacuation

Small Intestine & Colon-Irritable Bowel Disease-Treatment

• Fiber Supplements: Psyllium or Methylcellulose with fluids may help with constipation symptoms

• Anti-diarrheal medications: Loperaminde can help control diarrheal symptoms

• Anticholinergic medications: May help relieve bowel spasms

• Eliminate high gas foods including carbonated beverages, green leafy vegetables, raw fruits and vegetables, broccoli, etc.

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Small Intestine & Colon-Irritable Bowel-Treatment

• Antidepressants

– Tricyclic antidepressants or selective serotonin reuptake inhibitors

• Tricyclic antidepressants may help decrease abdominal pain as well as diarrhea– Side effects include constipation and drowsiness

• SSRIs may help decrease pain and constipation and also help with depression symptoms

– Counselling may be beneficial if stress tends to increase symptoms

Colon-Diverticular Disease

• Nearly 80% of patients with diverticular disease are asymptomatic except for chronic constipation

• Patients with symptomatic disease usually have griping and unpredictable lower abdominal pain especially in LLQ

• The sigmoid colon is involved in 95% of cases

Colon-Diverticular Disease

• Two major complications of diverticular disease:

–Diverticulitis

–Diverticular Bleeding• About 1/5 of patients with diverticular disease will

experience one of two complications in their lifetime

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Colon-Diverticulitis

• A patient with diverticulitis may present with peritoneal signs– Rebound tenderness, guarding, or absence of bowel signs– The patient may develop symptoms of abdominal pain and

fever with possible progression to abscess formation with or without perforation• The perforations are usually self contained• However, these perforations lead to an increased incidence of

fistula formation and intestinal obstruction is high

– Treatment-Uncomplicated Diverticulitis• Bowel rest or clear liquids• Fluoroquinolone + Flagyl for 10-14 pending resolution of

symptoms• Colonoscopy 6 weeks post resolution if not recently performed

Colon-Diverticular Bleeding

• A patient with diverticular bleeding may present with frankly bloody stools or stools that are positive for occult blood

– Diverticular bleeding is usually painless and not associated with a focus of inflammation

Colon-ACG CRC Screening Guidelines

• Cancer prevention tests should be offered first-the preferred test is colonoscopy every 10 years, beginning at age 50– African Americans CRC screening should begin at age 45

• Cancer detection screening should be offered to patients who decline cancer prevention screening– Annual FIT testing for blood is preferred

• Alternative CRC prevention tests– Flexible sigmoidoscopy every 5-10 years– CT colonography every 5 years

• Alternative cancer detection tests– Annual Hemoccult Sensa– Fecal DNA testing every 3 years

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• Screening for a positive family history without HNPCC consideration indicated– Single first-degree relative with CRC or advanced

adenoma diagnosed at age ≥60• Screen as average risk

– Single first-degree relative with CRC or advanced adenoma diagnosed at age ≤60 or two first-degree relatives with CRC or advanced adenoma• Screen with colonoscopy every 5 years beginning at age

40 or 10 years younger than age of diagnosis of the youngest affected relative


• Familial Adenomatous Polyposis– Should pursue genetic testing and counseling

– Annual screening until colectomy

– Patients with retained rectum need flexible sigmoidoscopy every 6-12 months

• Hereditary Non-Polyposis Colorectal Cancer– Should undergo genetic tumor testing

– If positive, colonoscopy every 2 years at age 20-25 until age 40 and then annually

Colon-USPSTF CRC Screening Guidelines

• Recommends against screening for colorectal cancer in adults ages 76-85 years

– There may be considerations that support this screening for individual patients

• Recommend against screening for colorectal cancer in adults older than age 85 years

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References

• Mills JC, Stappenbeck TS. Gastrointestinal Disease. In: Hammer GD, McPhee SJ. eds. Pathophysiology of Disease: An Introduction to Clinical Medicine, Seventh Edition. New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com/content.aspx?bookid=961&Sectionid=53555694. Accessed July 7, 2015.

• American College of Gastroenterology– http://gi.org/guideline/colorectal-cancer-screening/

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