07 Sewell GI Part 1

UCSF, Department of Medicine, CME

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GASTROENTEROLOGY

Justin L.Sewell, MD,MPH,FACPAssistantProfessorofMedicineDivisionofGastroenterologyUCSanFrancisco|ZuckerbergSanFranciscoGeneral

Disclosures

l Norelationships orconflicts ofinterest todisclose

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Agenda

l Case-based overviewofGIcontent mostpertinent to IMboards

l Additional boards-relevant informationwith guideline references

l Pauseforquestions aftereachsession butaskanytime

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Highest yieldGItopics forIMBoards (GIcontent9-10%)l Esophagus:GERD,Barrett’s,varices,(cancer,motility)l Stomach/duodenum: Hpylori,PUD,non-ulcer

dyspepsia,GIbleeding,gastritis,(gastriccancer)l Smallintestine:Crohn’sdisease,gastroenteritis,(celiac,

ischemic boweldiseases)l Colorectal:colon cancer,diverticulardisease,ulcerative

colitis,IBS,antibioticcolitis,appendicitis,hemorrhoids,(constipation, incontinence,polyposis syndromes)

l Pancreas:acutepancreatitis,(pancreaticcancer,chronic pancreatitis)

l Liverandbiliary:separatesession

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Case #1l 42 year old Caucasian man withheartburnl Intermittent retrosternal burning ~2yearsl Increasing use of antacids & OTC H2RAs, with only transient

relief of symptomsl 1-2 packs cigarettesQD, 1-2 glasseswine QHSl Regurgitation of sour material at night, but no dysphagial Elevates head of bed and has lost weight without benefit

Case #1– What isthemostappropriatenextstepinmanagement?

1. Perform upper endoscopy2. Trialofhigh-dose PPIfor4-6weeks3. Stopallcaffeine andalcohol4. Esophageal pHtesting5. TakeH2RAscheduled rather than prn

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Case #1– What isthemostappropriatenextstepinmanagement?

1. Perform upper endoscopy2. Trialofhigh-dose PPIfor4-6weeks3. Stopallcaffeine andalcohol4. Esophageal pHtesting5. TakeH2RAscheduled rather than prn

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Indications for endoscopy inGERD

Menandwomenwith:l Alarmsymptomsl GERDrefractorytoPPIl Severeerosiveesophagitisl Recurrentdysphagiawith

historyofstricturel KnownBarrett’sesophagus

Menonlywith:l GERD>5yearsAND

additionalriskfactorsforesophagealcancer(singlescreeningEGD)l Nocturnal reflux

l Obesityl Central adiposityl Smokingl Hiatal hernia

8Shaheen NJ.Ann Intern Med 2012; 157(11):808-16.


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Case #1

l Symptoms partially improved on PPIà EGDl EGD: 2 cm tong ue of salmon colored mucosa in the distal

esophagus, otherwise unremarkablel Biopsies: intestinal metaplasia with no dysplasia

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Case#1– Which isthe most appropriatenextstep?

1. Repeat EGD for surveillancewithin 1 year

2. Test for H. pylori infection and treat if present

3. Radiofrequency ablation of the Barrett’s mucosa

4. Refer to surgeon for anti-reflux surgery

5. Double the dose of his PPI to BID and followsymptomatically

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1. Repeat EGD for surveillancewithin 1 year

2. Test for H. pylori infection and treat if present

3. Radiofrequency ablation of the Barrett’s mucosa

4. Refer to surgeon for anti-reflux surgery

5. Double the dose of his PPI to BID and followsymptomatically

Case#1– Which isthe most appropriatenextstep? Case #1– Barrett’s surveillance

l Riskofprogressiontocancerislow(<1%peryear)

l Nodysplasia:EGDevery3-5yearsl Lowgradedysplasia:repeat6months,thenannually

l Highgradedysplasia:confirmby2nd pathologistà ablationoresophagectomyduetoconcomitantadenocarcinomain30-40%

12ASGE Standards of Practice Committee. Gastrointest Endosc 2012;76(6):1087-94.


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Case #1– Barrett’smanagement

l Medical orsurgical anti-reflux therapiesdo notcauseregression of Barrett’s; goalistocontrol symptoms andminimize cancer risk

l Radiofrequency ablation (RFA) eradicates80-95% ofdysplasia andreduces lifetimecancer riskfrom 9%to1%

l Anti-reflux surgeryreservedfor failures ofoptimalmedical therapyor patientpreference

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Case #1

l Eradicate Hpylori whendiagnosedl Reduces riskof PUD,gastriccancer

l However thisdoesnotaffect progression ofBarrett’s andcouldtheoretically worsen GERD

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GERD

l Cardiac versusGERD-induced chest paincan bedifficulttodifferentiatel PPItriall Cardiactestinginhigher-riskpatients

l GERDcancauseglobusanddysphagiaàPPItriall Functionalheartburnandnonerosiverefluxdiseaseare

commonandarelessresponsivetoacidsuppressionl Esophageal pHmonitoring required todiagnose

l PPIshouldbetaken30-60minutesbeforeeatingforoptimalacidsuppression

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GERD

l GERD can beexacerbated byl Impairedsalivaryflow(Sjögrens,XRT)l Esophagealdysmotility(scleroderma)l Gastricdistension(gastroparesis,dietaryhabits)l ReducedLESpressure(chocolate,alcohol,nicotine,CCBs,nitrates,antidepressants,progesterone, benzodiazepines)

l Atypical(extraesophageal) GERDmanifestationsinclude: chronic cough, hoarseness, laryngitis,asthma


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Dysphagia

l Dysphagia:sourcesuggestedbysymptomsl Intermittent solid: Schatzki ring, eosinophilic esophagitisl Progressive solid: stricture/achalasia (slow) orneoplasm (rapid)l Solid and liquid: dysmotility

l EGDusuallyfirsttestthoughcanconsideresophagraml Manometry testing ifEGDnondiagnostic

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Dysphagia

l Dysphagia:sourcesuggestedbysymptomsl Intermittent solid: Schatzki ring, eosinophilic esophagitisl Progressive solid: stricture/achalasia (slow) orneoplasm (rapid)l Solid and liquid: dysmotility

l EGDusuallyfirsttestthoughcanconsideresophagraml Manometry testing ifEGDnondiagnostic

l Achalasia:lackofperistalsisandnon-relaxingLESl Oropharyngeal dysphagiausuallyduetoneuromuscular

disorders,andisassociatedw/coughing,nasalregurgitation,choking

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Eosinophilic esophagitis

l Eosinophilic esophagitisl Intermittent solidfooddysphagiaorfoodimpaction,M>F

l Ringedor“feline”esophagusl Eosinophilicinfiltrateonbiopsyl Treatwitheliminationdiet,swallowed inhaledsteroids,PPIs

Dellon ES.Gastroenterology 2014; 147(6):1238-54. 2 0

Case #2

l 62y/owomanwith4monthsofepigastricabdominalpain,worsepost-prandially

l IncompletelyrelievedbyOTCH2RAsl Occasionalnauseabutnovomitingl Mildanorexial 5poundweightlossl ASA81mg/dandPRNibuprofenforarthritisl PEx:mildepigastricTTP,otherwiseunremarkable


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Case#2Whichofthefollowingisthebestapproachatthistime?1. EmpiricHpyloritreatment

2. Hpylori testingandtreatmentifpositive

3. EmpiricprotonpumpinhibitorRx

4. Upperendoscopy

5. SwitchibuprofentoaCOX-2NSAID

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Case#2Whichofthefollowingisthebestapproachatthistime?1. EmpiricHpyloritreatment

2. Hpylori testingandtreatmentifpositive

3. EmpiricprotonpumpinhibitorRx

4. Upperendoscopy

5. SwitchibuprofentoaCOX-2NSAID

Non-invasive H.pylori testing

H.pylori negative

Chronicdyspepsia

H.pylori positive

Eradication therapy Empiric treatment:Protonpumpinhibitor

Endoscopy

Improvement ImprovementNo improvement

YES

NO

Alarmsigns or symptomsAge>55

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Case #2– Hpylori testing

l Rarely treat empiricallyl Active infection: urea breath test, stoolantigen,endoscopicbiopsy

l Active/prior infection: serology


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Case #2– EmpiricPPI

l Empiricacid-suppressionhassomeefficacyindyspepsia,andisreasonableinyoungpatientswithnoalarmsymptoms

l COX-2selectiveNSAIDshaveless GItoxicityl Newdyspepsiainpatientsoverage50,dyspepsiawithalarmsymptomsorfamilyhistoryofgastriccancer,shouldhaveEGDtoruleoutcancer

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Hpylori

l Usuallyacquiredinchildhood,persontopersontransmissionl Inverseassociationwithsocioeconomicstatusl Oftenasymptomatic

l 10-20% PUDl <0.01%gastric CA

l Treatment:l Triple: PPI, clarithromycin, amoxicillin x10-14 daysl Quadruple: PPI,bismuth, metronidazole, tetracycline x10-14daysl Other antibiotic options include levofloxacin, rifabutin, nitazoxanide

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Pepticulcerdisease

l GUsrequirebiopsy&repeatEGDtoexcludeCAl Multiplenon-healingulcers,orulcersw/diarrhea:suspectZES.Bestinitialtest:fastingserumgastrin

l Elevatedgastrinseeningastricoutletobstruction,PPIuse,perniciousanemia,renal insufficiency,diabetes,andgastrinoma

l Gastrinlevels>1000highlysuspiciousforZES;200-1000bestevaluatedwithsecretinstimulationtest(paradoxicalriseingastrinaftersecretinadministered)

Non-ulcer dyspepsia

l Alsocalled functional dyspepsial Symptomswithout source identifiedl TCA’sor SSRI’scanbeeffective

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UGI bleed

l HighriskGIBpatientstakingNSAIDS:l KnownPUD,advancedage,warfarinl TestandtreatforHpyloril Co-prescribePPI

l Stress,caffeine,prednisonedonotcausePUD

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UGI bleed

l UGIBmaypresent ashematochezia ifbrisk,andconversely, slow right-sided colonic bleedingmaycausemelena

l NGtube only85%sensitive inUGIBl MostUGIBwill stop spontaneouslyl MostUGIBcanbeeffectively managedbyEGDorangiography

l Surgeryindicated ifpersistent orrecurrentexsanguination

Common causes of upperGIbleeding

PUD(50%)

Mallory-Weiss tear (10%)

Varices/portalhypertension(20%)

Erosive gastritis (10%)32

UGI bleed

l Mortality risk~10%l Increasedwithadvanceage, shock,hematochezia,cirrhosis

l EGD:diagnostic, therapeutic, prognosticl IRandsurgery arebackupl Medicaltherapy with PPIbolus +continuousinfusion; octreotide ifportal HTN

l Norole forH2RA’s


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Case #3

l 47y/omaleexecutiveadmittedwithsevereabdominalpainradiatingtohisback

l Drinks2-3cocktailsperday,occasionallymorel PExnotableformid-abdominaltendernesswithhypoactivebowelsounds

l Lipase9,200l Initialmanagement: NPO,analgesiaandhydration

Case #3

l Additional labs:lWBC11,000l Bili1.6,AST95,ALT32,AlkP120l Triglycerides220l Calcium8.5

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Case#3What isthemost appropriate nextdiagnostic step?1. Ultrasound oftheabdomen2. Empiric antibiotics3. MRCP4. Surgical consultation5. Trend CBC andlivertests, follow exam

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Case#3What isthemost appropriate nextdiagnostic step?1. Ultrasound oftheabdomen2. Empiric antibiotics3. MRCP4. Surgical consultation5. Trend CBC andlivertests, follow exam

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Case #3

l U/S:normal GB andCBD, pancreas is“obscured byoverlying bowel gas”

l Antibiotics notrecommendedl Byhospital day#8,his lipasehasnormalized buthis abdominal pain isworsening slightly, andhehasdevelopednewfeversto101.8,with arisingWBC

Tenner S.Am JGastroenterol 2013; 108(9):1400-15. 3 8

Case#3Whichofthefollowingisthebestapproachatthistime?1. Initiate oral feeds, as lipase is normal

2. Empiric antibiotics

3. Epidural catheter and PCA

4. ERCP

5. CT scan of the pancreas

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Case#3Whichofthefollowingisthebestapproachatthistime?1. Initiate oral feeds, as lipase is normal

2. Empiric antibiotics

3. Epidural catheter and PCA

4. ERCP

5. CT scan of the pancreas

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Case #3– CT scanwith necrosis

Normalenhancement

Lackofenhancement


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Case #3– Pancreatic necrosis

l Persistent symptoms withacutepancreatitis shouldraiseconcern for complications

l Pancreatic necrosis predicts poor outcomel Antibiotics not recommended unless highsuspicion

ordocumented infected necrosisl Carbapenems haveexcellent pancreatic penetrationl Ifpatient appears infected and haspancreatic

necrosis, consider FNAwithgramstain/culturel Infected necrosis (positive gramstain) predicts high

mortalityrateandrequires surgical debridement

Tenner S.Am JGastroenterol 2013; 108(9):1400-15.

Case #3– ERCP forpancreatitis

l ERCPifbiliarysourceforpancreatitissuspectedl ALTisfirsttorisefollowedbybilirubinandalkPl Biliarydilation(US,CT,MRCP)

l WaitforpancreatitistoimproveunlessobstructingCBDstoneonimagingorsuspectedcholangitis

42Tenner S.Am JGastroenterol 2013; 108(9):1400-15.

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Case #3– Acutepancreatitismanagement

l Canassessprognosisw/RansonorAPACHEIIl Serialamylase/lipase levelsnotusefulinpredictingcourse

l ObtainCTifseverepancreatitisissuspected(organfailure,lackofimprovement,increasingpain,fever,WBC,hypotension)

l NecrosisonCThasworstprognosis

Tenner S.Am JGastroenterol 2013; 108(9):1400-15. 4 4

l Prophylacticantibioticsnotindicatedl Earlystudiesevaluatedagentswithpoorpancreaspenetrationandincludedpatientswithmilddisease

l Besttherapyisgoodsupportivecareandaggressivehydration(250-500mL/hour,bolusifhypovolemic)

Tenner S.Am JGastroenterol 2013; 108(9):1400-15.

Case #3– Acutepancreatitismanagement


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Case #3– Whentofeed

l Patientscaneatwhenpain-freeandhungryl Liquiddietandlow-fatsoliddietareequivalentl Post-duodenalenteralfeedingmaybeappropriateinpatientswithacutepancreatitisbutdoesnot improveoutcomescomparedwithon-demandoralfeeding

Bakker OJ. NewEngl JMed 2014; 371(21):1983-93.Tenner S.Am JGastroenterol 2013; 108(9):1400-15.

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Acutepancreatitis – etiologies

l Mostcommonetiologies:gallstonesandalcoholl Lesscommon:hypertriglyceridemia,post-ERCP,pregnancy,hypercalcemia,viral,hereditary,autoimmune

l Medications:Erythromycin,tetracycline,6-MP/AZA,sulfas,5-ASAs,NSAIDs,estrogens,thiazides

Chronicpancreatitis

l Exocrineandendocrinemanifestationsl Imaging:dilatedduct,calcificationsl Enzymesbetterforsteatorrhea thanpainl Forpaincanconsiderceliacplexusblock,surgicaloptions

l Cancausebiliaryobstructionl Pancreasdivisum:failureoffusionofdorsalandventralglands;foundin5%ofpopulation;maypredisposetochronicpancreatitis

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Let’stakea detourinto…radiology

l Common abdominal x-raysyoumightseeonboards

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What isthis?

1. Toxicmegacolon2. Smallbowel

obstruction3. Sigmoidvolvulus4. Perforatedviscus

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What isthis?



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What isthis?



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Case #4

l 22y/omanc/o1yearofworsening bloating&gasl Frequentmalodorous,floating,greasystoolsl 20lbweightlossin6monthsl Deniesabdominalpain,buthasdecreasedfoodintakeasitprovokesdiarrhea

l Healsocomplainsofanitchyrashonhiskneesandelbows

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Case #4

l Physicalexam:shortstature,mucosalpallor,angularcheilosis,scatteredpapulesandvesicleswithexcoriationoverthekneesandelbows,andmildpretibialedema

l Labtestsaresignificantformicrocyticanemiaandalowserumalbumin

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GIrashesyouneed toknow…

DermatitisHerpetiformis E.nodosum Pyoderma

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Case#4Whichofthefollowingisthemostlikelycauseofthispatient’ssyndromeandmalnutrition?

1. Whipple’s Disease

2. Crohn’s Disease

3. Celiac Disease

4. Pancreatic exocrine insufficiency

5. Smallbowelbacterialovergrowth


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Case#4Whichofthefollowingisthemostlikelycauseofthispatient’ssyndromeandmalnutrition?

1. Whipple’s Disease

2. Crohn’s Disease

3. Celiac Disease

4. Pancreatic exocrine insufficiency

5. Smallbowelbacterialovergrowth

Case #4

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Case #4

l Severeceliac diseasewithprofound malabsorptionl Gluten bound byparticular HLAtypesresults in

inflammatory cascade damaging SBmucosal Presentation ranges from asymptomatic tomildiron

deficiency toIBSsymptoms toseveremalabsorptionl Dx: EGD(villous atrophy, increased IELs) and/or

serologicmarkers (anti-tissue transglutaminase Ab)l Smallbowelmucosa andauto-antibodies can

normalizewithgluten freediet

Green PH. New EnglJ Med 2007; 357(17):1731-43. 6 4

Case #4l Tx:gluten-freedietl Newagent= larazotide(preventstightjunctionopeningà decreasedglutenuptake)

l Long-termcomplicationsincludeelevatedriskofSBCAs (AdenoCA,lymphoma)andosteoporosis

l Associationwithotherautoimmunediseases,suchasRAandthyroiddisease

l Whipple’sdisease,bacterialovergrowth,Crohn’sdisease&pancreaticinsufficiencycanalsocausemalabsorption

Green PH. New EnglJ Med 2007; 357(17):1731-43.


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Case #5

l 48yearold mancomplains ofwaterydiarrhea of4months’ duration

l Hehas4-6largevolume waterymovements daily

l Hehasrequired hospitalization twice fordehydration

l Oneach admission, exam, labs,culturesunrevealing

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Case#5Whichofthefollowingstudieswouldprovidethestrongestevidenceforasecretory etiologyforhisdiarrhea?

1. The presence of fecal leukocytes

2. A history of recent antibiotic use

3. A history of lactose intolerance

4. High stool osmolar gap

5. A fasting fecal volume >2.5L / 24 hours

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1. The presence of fecal leukocytes

2. A history of recent antibiotic use

3. A history of lactose intolerance

4. High stool osmolar gap

5. A fasting fecal volume >2.5L / 24 hours

Case#5Whichofthefollowingstudieswouldprovidethestrongestevidenceforasecretory etiologyforhisdiarrhea?

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Case #5

l Maindiarrheamechanismsaresecretory,osmotic/malabsorptive,inflammatory,functional

l DifferentiateonanalysisofstoolforfatandWBC,responsetofasting,stoolosmolargap

l Osmolargap


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Case #5

l Secretorydiarrheaistypicallylargevolume(>1L/d)anddoesnotdiminishwithfasting

l Causesofsecretorydiarrhea:l Bacterialandparasiticinfections(i.e.,gastroenteritis)l Bilesaltmalabsorptionfromilealresectionl Medicationsl Smallintestinalbacterialovergrowth(SIBO)l Hormonesecretingtumorsl Microscopiccolitis

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Diarrhea

l Celiacdiseasecancausebothsecretoryandosmotic(malabsorptive)diarrhea

l Osmoticdiarrhea:lactoseintolerance,magnesiumintake

l Inflammatorydiarrhea: usuallyduetobacterialcolitisorIBD

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Steatorrhea

l Elevated fecal fatsuggestsmaldigestionormalabsorption

l Fattydiarrheacanbeduetodefective:l Lipolysis(pancreaticinsufficiency)l Micellarization(bilesaltinsufficiency)l Absorption(intestinalepithelium)l Delivery(lymphatics)

+ à

IBS

l Functional GIdisorder affecting 10-20% ofadults inUS

l Abdominal painordiscomfort associatedwith altered bowel habits;pain improvedwith improved bowel habits

l IBSisasyndrome – there aremanypotential causes/contributors

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Functionaldisease

Abnormalmotility

Lifestress

Psycho-social

Visceralhypersensitivity

InfectionsHormones Foods

Coping

Socialsupport

Childhood

Family

Foods

Infections

Gas

IBSManagement

l Treattheprimary bowel symptoml Antidepressant therapyl Trialofantibiotics forsmallintestinalbacterial overgrowth

l Cognitive behavioral therapy

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Otherdiarrheal syndromes

l Ecoli0157:H7associatedwithHUS(renalfailure, thrombocytopenia, hemolyticanemia)

l Diabeticwithdiarrhea:considerSIBO,osmotic(sorbitol),“diabeticdiarrhea”

l Considerfactitiousdiarrheainmedicalpersonnelwithunexplaineddiarrhea

l Inhospital-acquireddiarrhea,considerCdifficileandmedications

carbohydratesfats

proteinsmagnesium

trace elementsvitamins Water and

electrolytes

shortchainfatty acids

iron,calcium,copper

folate

vitaminB12bilesalts

Colonicdiseasedoesnotcausemalabsorption

What’s (mal)absorbed where?


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Cdifficile

l Riskfactors:hospitalization,antibiotics,chemotherapy,immunesuppression,PPIs

l Communityacquired C.difficile increasinglycommon

l C.difficile sporesarehardyandhighlyinfectiousl Haveahighindexofsuspicionintheelderly,immunosuppressed,immunocompromised,andpatientswithIBD

Case #6

l 87y/omanwithhistoryofAFib,HTN,CAD,andDMpresentstoERwith1dayofcrampyleftlowerquadrantabdominalpainandbloodystool

l PEx:BP106/75,pulse112,mildLLQTTP,andmaroonstoolonrectalexam

l Hct36%,WBC12Kl CTAbdshowsleftcolonwallthickeningl Thepatientisadmittedtothehospitalandgentlefluidresuscitationisinitiated

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Case#6Whichofthefollowingisthemostappropriatenextstep?

1. Visceral angiogram

2. Flexible sigmoidoscopy

3. Thrombolytic therapy

4. Renal dose dopamine

5. Stool forCdifficile toxin

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Case#6Whichofthefollowingisthemostappropriatenextstep?

1. Visceral angiogram

2. Flexible sigmoidoscopy

3. Thrombolytic therapy

4. Renal dose dopamine

5. Stool forCdifficile toxin


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Case #6

l Ischemiccolitis:seenwitholderage,atherosclerosis,arrhythmiasandhypotension

l Youngerindividuals:stimulantdruguse,enduranceathletes

l Classicpresentationissudden,crampyabdominalpainassociatedwithhematochezia

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Case #6

l Watershedregionsmostcommonlyinvolvedthoughstudiessuggestmultipledistributions

l Rectalsparingduetocollateralflowviathehemorrhoidalplexus(internaliliacartery)

l Embolicdiseaseusuallymoresevere

Brandt LJ. Am JGastroenterol 2015; 110(1):18-44. 8 4

Case #6

l Flexsigwill reveal rectal sparingandlocalizedsignsofmucosalischemia(ulcerations,hemorrhage)

l Notpathognomonic,buthighlysuggestivel PresentationnotsuggestiveofCdifficile(typicallynonbloodyandwouldnotseetheseendoscopicfindings)

Brandt LJ. Am JGastroenterol 2015; 110(1):18-44.


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Case #6

l Supportivemanagementwithgoalofeuvolemia,normotension

l Pressorsmayworsenvisceralvasoconstrictionl Worseningabdominalexamwithperitonealsigns,lacticacidosissuggesttoxicmegacolonand/orperforationà requires urgentsurgicalevaluation

l Prognosisisgenerallygoodl 80%resolve,15%chronicischemia,5%fulminant

Brandt LJ. Am JGastroenterol 2015; 110(1):18-44. 8 6

Vascular boweldisease

Ischemic colitis Acutemesentericischemia

Chronicmesentericischemia

Bowelsite Colon Smallbowel SmallbowelOnset Acute Acute Chronic/recurrentTypicalpathophysiology

Hypoperfusion EmbolismThrombosis

Atherosclerosis

Presentation Acutecramping andhematochezia

Acute,severe pain“outofproportiontoexamination”

Recurrent post-prandialpain“foodfear”

Naturalcourse 80%resolves15%chronic5%fulminant

Deathifnotrapidlytreated

Gradualchronicworsening

Treatment Conservative Emergentsurgery Elective surgicalorendovasculartherapy

Inflammatory boweldisease

l IBDresults fromuncontrolled immuneresponse inthegut

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Inflammatory boweldisease

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Environmentaltriggers

Moderatelyinflamed

Failure to down-regulate

Chronic uncontrolledinflammation = IBD

Down-regulate

Normal gutcontrolled inflammation

Normal gutcontrolled inflammation


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Pathologicfeatures UlcerativeColitis Crohn’sdiseaseTransmuralinvolvement No(exceptfulminant) Yes“Skiplesions” No YesFibrosis Minimal CommonFistulae No CommonGranulomas No Yes,in20%Smallboweldisease No Yes,75%Rectalinvolvement Always Occasional

Clinical features UlcerativeColitis Crohn’sdiseaseDiarrhea Verycommon CommonBloodper rectum Verycommon OccasionalAbdominalpain Common VerycommonConstitutional symptoms Common CommonStrictures/abscesses/fistulae No CommonPerianaldisease No CommonExtra-intestinalmanifestations Occasional OccasionalRecurrenceaftersurgery No Common,>50%Malignancy Occasional Occasional

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Colitis

l NSAIDusemayresultinsymptomsmimickingIBDormayexacerbateexistingIBD

l RiskCRCinIBDproportionaltoextentofcoloninvolvedanddurationofillness

l EIM: arthritis,uveitis,erythemanodosum,pyodermagangrenosum,sclerosingcholangitis

Medicaltherapy

5ASA

Antibiotics

Steroids

Immuno-modulators

Biologics

Supportiveagents

Cancerscreening inIBD

l Ulcerative colitis proximal totherectum orCrohn’s diseasewith significant colonicinvolvement

l Diseaseduration > 8yearsl Colonoscopy q1-2 yearswith targetedbiopsies plus random biopsies ORchromoendoscopy

92Laine L.Gastrointest Endosc 2015; 81(3):489-501.


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LowerGIB

l 10%w/hematocheziahaveUGIsourcel >80%LGIBstopsspontaneously,25%recurl Diverticulosismostcommoncausel TaggedRBCscan(bloodloss0.1cc/min,6cc/hr)l Angiography(bloodloss0.5cc/min,30cc/hr)l Colonoscopycanbepursuedbutrequiresrapidprep

Diverticulardisease

l Common inelderlyl Notreatment indicatedl Complications: LGIBanddiverticulitisl Diagnosis ofdiverticulitis warrants futurecolonoscopy torule out cancer

l Consider surgeryifrecurrent diverticulitis

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Hemorrhoids

l Hemorrhoidalveinsarevenouscushionstomaintaincontinence

l Whenlargeanddilatedtheyareclinicallyreferredtoashemorrhoids

l Management:keepstoolssoft;surgicalinterventionpossibleifrecurrentbleeding

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Constipation

Age<50,noalarmsymptoms

l Considermedicationsassource

l Increasedfluidandfiberintake

l Stoolsofteners(polyethyleneglycol,docusatesodium)

l Anthraquinonelaxatives(senna,bisacodyl)

Age>50oralarmsymptoms;noresponsetoinitialtherapyl Colonoscopyl Defecographyandanorectal

manometryifdyssynergicdefecationislikely

Variablepatientdefinition,mostoftenduetobehavioralordietarycauses


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Case 7

l A62y/omanhasapositiveFOBTcollectedviadigitalrectalexam

l Takesadailylow-doseASAforcardioprotectionl ReportsoccasionalBRBwhenhewipeswithtoiletpaperforyears,especiallywithstraining

l Nofamilyhistoryofcolorectalcancerl NootherGIsymptoms

98

Case7Whichofthefollowingisthebestapproachatthistime?

1. Repeat FOBT on spontaneously defecated stool

2. Colonoscopy

3. Flexible Sigmoidoscopy

4. Barium Enema

5. CT colonography

99

Case7Whichofthefollowingisthebestapproachatthistime?

1. Repeat FOBT on spontaneously defecated stool

2. Colonoscopy

3. Flexible Sigmoidoscopy

4. Barium Enema

5. CT colonography

100


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Case #7

l CouldbefalsepositiveFOBTduetoDREorhemorrhoids,butapositivetestalwaysrequiresacompletecolonoscopy

l Norolefor“confirmatory”retesting

102

Colorectalcancerscreening

l ApprovedCRCscreeningmethods:l Colonoscopy(q10years)l Flexiblesigmoidoscopy(q5years)l CTcolonography (q5years)l FOBT/FIT(annually)l BEhasfallenoutoffavor(q5years)

l Anypositiveexamà colonoscopyl CEAnotusedforscreeningl FecalDNAnotwidelyused

Levin B.Gastroenterology 2008; 134(5):1570-95.

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Polyps&colorectalcancer

l IncreasedCRCriskl Personalorfamilyhistoryofpolypsorcancer

l 10yearsbefore ageofaffected family member orage40,whichever is earlier

l IBD:after8-10years ofdiseasel Subsequentcolonoscopyintervalsifaveragerisk

l 10yearsifnopolypsl 5yearsis< 2smalladenomasl 3yearsif>2small,oranylarge(10mm+)adenomas

Lieberman DA. Gastroenterology 2012; 143(3):844-57. 1 0 4

Cancersyndromes

l FamilialAdenomatousPolyposis:AD,1/3newmutations,cancerin30sw/ocolectomy

l Gardner's =FAPw/extracolonicosteomas,desmoidtumors,congenitalhypertrophyofthepigmentedretinalepithelium

l Bothcausedbysamemutation(APC),atumorsuppressergene

l MaincauseofdeathinFAPandGardner’spatientss/pcolectomyisperiampullaryneoplasia;nextaredesmoidtumors


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l Turcot's =FAPw/CNSmalignanciesl Lynch Syndrome=HereditaryNon-PolyposisColorectalCancer(HNPCC).AD,incompletepenetrance,R-sidedCRCs,betterprognosisthanFAPl Increasedriskofovarian,endometrial,breast,gastric,

ampullaryCAl CausedbymutationsinDNAmismatch-repairgenes

Cancersyndromes

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CASE #8

l 59y/oChinesewomanrecentlyimmigrated toUSwith4monthsofprogressivedyspepsia,describedasaperiumbilicalgnawingorfullness

l 12lbweightlossandearlysatietyl EGDrevealsdiffusegastricatrophyanda1.5cmulcerinthefunduswithexophyticedgesl Ulcerbiopsies– granulationtissuel Gastricbodybiopsies–organismsconsistentwithH

pylori

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CASE#8Whichofthefollowingisthebestapproachatthistime?

1. Treat for H pylori, then repeat EGD

2. Treat for H pylori, repeat EGD if symptoms persist

3. Treat for H pylori, check UGIS if symptoms persist

4. Treat for H pylori, noneed to repeat EGD

5. PPI BID, no need to treat forH pylori if symptoms resolve

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CASE#8Whichofthefollowingisthebestapproachatthistime?

1. Treat for H pylori, then repeat EGD

2. Treat for H pylori, repeat EGD if symptoms persist

3. Treat for H pylori, check UGIS if symptoms persist

4. Treat for H pylori, noneed to repeat EGD

5. PPI BID, no need to treat forH pylori if symptoms resolve


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CASE #8

l Proximal location, Hpylori, recent Asianimmigrant, exophytic marginsconcerning formalignancy

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CASE #8

l Allgastriculcersrequirerepeatendoscopyaftermedicaltreatment toconfirmhealingandexcludeneoplasia

l Patientwithmultiple, small,antralulcers,especiallywithknownriskfactors(suchasNSAIDs)istheexception

l RepeatEGDnotrequiredfortypicalduodenalulcers,ascancerriskisverylow

ASGE Standards of Practice Committee. Gastrointest Endosc 2010; 71(4): 663-8. 1 1 2

Gastric cancer

l Riskfactors:Hpylori,achlorhydria(partialgastrectomy,atrophicgastritis),intestinalmetaplasia,adenomatousgastricpolyps,smoking,alcoholabuse

l Majorityisadenocarcinomal Gastriclymphomaisthemostcommonsiteofextranodallymphoma

l MALTlymphoma:related toHpylori,canoftenbecuredwithHP eradicationalone


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Esophageal cancer

l Esophagealadenocarcinomariskfactors:malegender,Caucasian,Barrett’s,smoking,obesity,alcoholabuse

l Squamouscell esophagealcancerriskfactors:alcoholabuse,smoking,causticingestion,achalasia,tylosis,dietarynitrates

l StagewithCTscanà endoscopicultrasoundifnometsonCT

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l Veryuncommon, butcanincludeadenocarcinoma, carcinoid, GIST,lymphoma

l Riskfactors: celiacdisease, Crohn’s disease,familial polyposis, HIV(lymphoma)

Small bowelcancer

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Pancreatic cancer

l Incidenceincreasing,nowthe4th leadingcauseofcancerdeathinUS(lung,colon,breast)

l Riskfactors:smoking,alcoholabuse,chronicpancreatitis

l Mainlyadenocarcinoma,70%inpancreaticheadl SystemicmanifestationsofPancCA:polyarthritis,subcutaneousfatnecrosis,migratorythrombophlebitis

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Otherpancreatic cancers

l IPMN,cystadenocarcinoma,neuroendocrinel Isletcell tumors:

l insulinomas→ hypoglycemial glucagonomas→ hyperglycemia&rash(necrolyticmigratoryerythema)

l gastrinoma→pepticulcerdisease,diarrheal VIPoma→ waterydiarrhea,hypokalemia


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Pancreatic cysts

l Serouscystadenoma (or carcinoma),mucinous cystadenoma (orcarcinoma),IPMN,pseudocysts

l Common incidentalomas

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Pancreatic cysts – newguidelines

l Highriskfeatures: >3cminsize, solidcomponent, dilated PD

l 0-1high-risk feature:MRIin1yearthenq2yearsx2

l >1high-risk feature:EUSwith FNAl IfEUSwithout concerning featuresàMRIl Iflesion intail, easiertoresect surgically

118Vege SS.Gastroenterology 2015; 148(4):819-22.

TheEnd

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07 Sewell GI Part 1

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