Gastroenterology Presentation (& some Abdominal Surgery Stuff!)
Gastroenterology Presentation
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Transcript of Gastroenterology Presentation
Gastroenterology
Swedish Family Practice Residency Didactics
July 31, 2001
A quick trip through the GI track with brief stops at the esophagus, stomach, liver,
colon, rectum and anus.And a little diarrhea.
The Upper GI Tract
• Esophagus
• Stomach
• Pancreas
• Gallbladder
• Liver
Esophageal Disorders
• Disorders of motility
• GERD
• Inflammatory and
infectious disorders
• Tumors
Symptoms from the Esophagus
• Dysphagia
• Odynophagia
• Chest pain
• Regurgitation
Disorders of Motility
• Achalasia – Cancer, Parkinson’s, Chagas Disease (trypanosomiasis)
• Spasm – Diffuse, Localized
• Scleroderma
Diagnostic Studies
• Barium swallow
• Manometry
Treatment• Long-acting nitrates• Calcium channel blockers• Dilation of LES (Achalsia)• Surgery (Spasm, Scleroderma)• Manage reflux (Scleroderma)• Prokinetic drugs (Scleroderma)
GERD
• Frequent – 10% of US population
• Occasional – 30% of US population
Symptoms of GERD
• Heartburn• Water Brash • Regurgitation• Dysphagia/odynophagia• Chest pain, hoarseness,
chronic cough, wheezing
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)
Treatment of GERDMild Symptoms
• Dietary modification• Lifestyle modification• Trial of patient directed
therapy with OTC antacids or H2 antagonists
Treatment of GERDNon-responders, non-erosive disease
• H2 antagonists• PPI’s• Promotility agents• 8-12 weeks of therapy
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
Treatment of GERDComplicated GERD
• GI workup with endoscopy• PPI’s• High-dose H2 antagonists• Antireflux surgery – no data on
new procedures
Inflammatory Disorders of the Esophagus
• Pill-induced esophagitis – NSAID’s, steroids, doxycycline
• Infective esophagitis – HIV, HSV, cytomegalovirus, candida
• Corrosive – alkalis or acids
Diagnosis and Treatment
Endoscopy
Treatment based on
results of endoscopy
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
Diseases of the Stomach
• Acid peptic disorders of the stomach and duodenum
• Infections
• Motor disorders
• Cancer
Acid Peptic Disorders
• 5 – 10% of the US population will have PUD in their lifetime, 50% will recur
• .0001% mortality rate
Cause of PUD
Imbalance between protective and aggressive factors
Protective factors
• Mucus and bicarbonate secretion of epithelial cells
• Surface membrane of mucosal cells
• PG E-1 and PG E-2
Aggressive Factors
• Gastic acid
• NSAID’s
• Corticsteroids
• Smoking
• Alcohol (?)
• Stress (?)
• Diet (probably not)
• H-pylori
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
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
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
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)
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
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)
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
Diseases of the Lower GI Tract, cont.
• Diverticulosis (90% have
no symptoms)
• Diverticulitis (infectious)
• Infectious diarrhea
Diagnosis of Infectious Diarrhea - History
• Work• Travel• Eating• Ill contacts• Recent antibiotics• HIV or immunocompromised
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
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
Treatment
Pathogens requiring treatment – shigella, giardiasis, E. coli, pseudomembranous entercolitis, V. cholera
Treatment
Pathogens that may require treatment – campylobacter, salmonella, amebiasis (5% carriage rate in the US, many are not pathogenic)
Treatment
• Most viral and bacterial causes of diarrhea resolve without treatment
• Antibiotics may prolong or worsen diarrhea
Diseases of the Lower GI Tract, cont.
• Cancer – small bowel (rare), colon (6% incidence)
• Anorectal diseases – cancer, hemorrhoids, pruritis ani, fissures
• And hepatitis