Approach to Common Problems in Gastroenterologyreviews.berlinpharm.com/20191019/Approach_to... ·...

28th Reviews in Internal Medicine for 3rd Year Medicine Resident 2019

Approach to Common Problems in

Gastroenterology

Symptomatology in GI & liver diseases

• Ascites

• Jaundice

• Acute & chronic diarrhea

• Acute & chronic abdominal pain

• Constipation & bowel habit change

• Nausea & vomiting

• GI hemorrhage

• Abdominal mass

Approach to ascites

Abdominal distension

• Ascites• Ileus, gut obstruction• Huge abdominal mass/ cyst• Obesity• Pregnancy

1.5 L 4-5 L100 cc

Diagnosis of ascites

Ultrasound Shifting dullness Fluid thrill

Causes of ascites

Cirrhosis 84%

Heart failure 3%Malignancy 2,5%

TB 1%Mixed 5%

Others 4,5%

Runyon BA. Ann Intern Med 1992

Pathophysiology of ascites formationThoracic duct

Ascites

SinusoidalPeritoneal diseases

Post sinusoidal

BCSSOSRight-sided HFPulmonary HT

CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.

TBCarcinomatosisPancreatitisCNT diseasesNephrogenous

Portal HT Non-portal HT

History taking

• Risks of cirrhosis: alcohol, HBV, HCV, NASH• Symptoms of cirrhosis: pedal edema, jaundice,

massive UGIH• Thrombophilia: pills, spontaneous abortion, DVT• Fever, chest symptoms, closed contact TB• Weight gain or weight loss• Underlying diseases; cancer, autoimmune diseases,

DM, CKD, thyroid• Abdominal pain• Surgery

Physical examination

• GA: pedal edema, jaundice, signs of CLD

• Abdomen:

Surgical scar, superficial vein dilatation

Sister Mary Joseph nodule

Hepatosplenomegaly, abdominal mass

PR

• Lymphadenopathy

• Neck vein & heart

Superficial vein dilatation

Dilated abdominal vein & flow direction

Normal Portal HT IVC obstruction

IVC Obstruction

Sister Mary Joseph nodule

Galvan VG Ann Int Med 1998; 128: 410

Percussion of spleen

Castell’ s method Traube’s space dullness

Rectal shelf

Ascites

SinusoidalPeritoneal diseases

Post sinusoidal

BCSSOSRight sided HFPulmonary HT

CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.

TBCarcinomatosisPancreatitisCNT diseasesNephrogenous

Portal HT Non-portal HT

Leg edema, wt. gainSplenomegaly

Dilated superficial v.Jaundice

Signs of CLDRisk factors

HepatomegalyHigh JVP

RV heaving, TRPericardial rub

Weight loss, feverLymphadenopathy

Rectal shelfSister Mary-Joseph nodule

Investigations in patients with ascites

• Abdominal paracentesis• Blood chemistry• Ultrasound, Doppler U/S, CT• CXR• Peritoneoscopy with biopsy

Ascitic fluid analysis

Routine• Cell count• Cell differential• Total protein• Albumin

Optional• ADA, PCR for mycobacteria• Cytology• ANA, LE cell• Amylase (>1000)• Bilirubin (>6 mg/dl)• Triglyceride (>200 mg/dl)• LDH, ALP

Ascites

SinusoidalPeritoneal diseases

Post sinusoidal

BCSSOSRight sided HFPulmonary HT

CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.

TBCarcinomatosisPancreatitisCNT diseasesNephrogenous

Portal HT Non-portal HT

SAAG>1.1 <1.1

>2.5 >2.5 <2.5 TP

Accuracy97%

• Different time points• Borderlined value• Very low serum albumin• Globulin >5 g/dL (1%)• Hypotension • Chylous ascites• Mixed ascites

• High TP in cirrhosis (20%)• Diuretic effect: high TP• Mixed ascites: low TP (30-

50%)

Limitations of ascitic fluid analysis

SAAG Total protein

Cirrhosis

Budd-Chiari Syndrome (BCS)

• Hepatomegaly

• Heterogeneous enhancement

• PHT: ascites, splenomegaly

Early central enhancement

Delayed peripheral enhancement

BCS; Flip flop phenomenon

BCS with IVC involvement

Constrictive pericarditis

Tuberculous peritonitis

• Common in alcoholic cirrhosis• Symptoms

- Fever 54%- Weight loss 44%- Chest symptoms 30-40%

• Subtype- Exudative (moist type)- Plastic (dry type) “doughy abdomen”

• Investigations- ADA (>39 IU/ml; sens 100%, spec 97%)- CT- Peritoneal biopsy (gold standard)

TB peritonitis

CT Peritoneoscopy

Malignancy-related ascites

• Peritoneal carcinomatosis Mesothelioma

Primary effusive lymphoma

Metastasis

• Massive liver metastasis

• HCC with decompensated cirrhosis

• Budd-Chiari syndrome

• Ruptured HCC (bloody ascites)

• Retroperitoneal lymph node with chylous ascites

• Pseudomyxoma peritonei

Carcinomatosis peritonei

Common cancers • Ovarian • Pancreatic• Cholangiocarcinoma• Gastric• Colorectal• Breast, lung

Carcinomatosis peritonei

Diagnosis• Cytology

- 3 samples- 50 mL of fresh ascites- immediate processing

• CT scan• Biopsy

Sensitivity96.7%

Linitis plastica with carcinomatosis peritonei

CA ovary with carcinomatosis peritonei

Mesothelioma

Nephrogenous ascites

• ESRD• History of dialysis-associated hypotension• Diagnosis by exclusion• Ascitic profile: non-specific

Mixed ascites

• 5% of patients with ascites

• Portal HT + secondary causes

Alcoholic cirrhosis + TB peritonitis

Cirrhosis with carcinomatosis peritonei

• Clues; wide SAAG ascites plus

– high ascitic lymphocyte

– high total protein

Gross appearance

A B C D E

Ascites

SinusoidalPeritoneal diseases

Post sinusoidal

BCSSOSRight sided HFPulmonary HT

CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.

TBCarcinomatosisPancreatitisCNT diseasesNephrogenous

Portal HT Non portal HT

HemoperitoneumChylous ascitesPseudomyxomaBilious ascites

Chylous ascites

• Milky and creamy ascitic fluid

• Triglyceride content >200 mg/dLCardenas A et al, AJG 2002:1896-1900

Diseases

Neoplasm LymphomaOvarian, breast, pancreas, colon, carcinoidLymphangiomyomatosis

Congenital Primary lymphatic hypoplasiaIntestinal lymphangiectasia

Infection Filariasis, TB, MAC

Inflammation RadiationPancreatitisRetroperitoneal fibrosis

Trauma Post operation, abdominal injury

Etiology of chylous ascites

Bilious ascites

Total bilirubin >6 mg/dL

Cardenas A et al, AJG 2002:1896-1900

Diseases

Trauma Abdominal injuryPost operation / biopsy / paracentesis

Gynaecologicconditions

Ruptured ectopic pregnancyRuptured ovarian cyst

Liver Ruptured liver mass: HCC, HA, metastasisCirrhosis: ectopic varices, idiopathic

Vascular Splenic artery aneurysm, hemangioma, peliosishepatis

Peritoneal disease Carcinomatosis peritonei

Coagulopathy Warfarin overdose

Etiology of hemoperitoneum

Hemoperitoneum; hematocrit sign

Ruptured HCC

Ruptured hepatic adenoma

Pseudomyxoma peritonei

Pseudomyxoma peritonei

Ascites

SinusoidalPeritoneal diseases

Post sinusoidal

BCSSOSRight sided HFPulmonary HT

CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.

TBCarcinomatosisPancreatitisCNT diseasesNephrogenous

Portal HT Non portal HT

HemoperitoneumChylous ascitesPseudomyxomaBilious ascites

Approach to chronic diarrhea

Etiologies of chronic diarrhea1. INFECTIOUS CAUSES e.g. bacteria, viruses, parasites, fungus

- include TB, Syphilis, Gonorrhoea, Lymphogranuloma venerium, Malaria, Psittacosis, Leptospirosis, Measles

2. DRUGS e.g. Cathartics & Laxatives, Antibiotics, Antacids (MgSO4, CaCO3), Antimalarials, Neomycin, Colchicine, Digitalis, Thyroid extracts, Iron, Biguanides, PAS, Mercury, CCl4, Misoprostol, Theophylline, Herbal medicine

3. GI TRACT DISEASES e.g. Ulcerative colitis, Crohn's disease, Coeliac diseases, Tropical sprue, Whipple's diseases, Necrotizing enteritis, Eosinophilic gastroenteritis, IPSID, Microscopic colitis, Giant hypertrophic gastritis, Hypertrophic hypersecretory gastropathy, Allergic enteropathy, Cronhite-Canada syndrome, Ischemic bowel diseases, Radiation enteritis, Diverticulitis, GI tumor/malignancy, GI lymphoma, GI fistula, Short bowel syndrome, GI obstruction, intestinal lymphangiectasia, Constrictive pericarditis

4. PANCREATIC DISEASES e.g. Chronic pancreatitis, Ca pancrease, Cystic fibrosis, Z-E syndrome

5. OTHER INTRA-ABDOMINAL CONDITIONS e.g. Appendiceal abcess, Pelvic inflammatory diseases, Pyelonephritis/perinephric abcess, Ectopic pregnancy, Endometriosis, Cholycystitis acute/chronic, Neural crest tumor

6. ENDOCRINE DISEASES e.g. Hyperthyroid, Addison's diseases, Diabetic diarrhea, Cushing' syndrome, Hypoparathyroidism, Carcinoid syndrome, Z-E syndrome, Medullary Ca thyroid, Pheochromocytoma, VIPoma, Gastrinoma, Somatostatinoma

7. METABOLIC DISEASES e.g Uremic colitis, Hypervitaminosis D, Pellegra, Pernicious anemia, Folate deficiency, alcoholism, Congenital chloridorrhoea, Enteric hyperoxaluria, Amyloidosis, Abetalipoproteinemia

8. CONNECTIVE TISSUE DISEASES e.g. SLE, Progressive systemic sclerosis, Polyarteritis nodosa, Dermatitis herpetiformis

9. BLOOD DISEASES e.g. Hodgekin's lymphoma, Non-hodgekin's lymphoma, Acute lymphoblastic leukemia, Chronic myeloid leukemia, IPSID, Mastocytosis, Hypogammaglobulinemia

10. OTHER CONDITIONS e.g. Factitious diarrhea, Idiopathic secretory diarrhea, Epidemic secretory diarrhea (Brainerd)

>200 etiologies !!!

Battery of tests!!!

History taking

• General: onset and duration, stool character, frequency, amount & volume of stool, relationship with meals

• Associated symptoms: nausea, vomiting, tenesmus, abdominal pain, constipation, etc.

• Malnutrition: anemia, edema, bruise

• Social history: diet (lactose, food allergy), occupation, environment, traveling, contact with diarrhea

• Past history & underlying illness: DM, PU, thyrotoxicosis, autoimmune disease, surgery, radiation, pancreatitis, etc.

• Family history: IBD, polyposis syndrome, MEN

• Systemic enquiry: fever, weight loss, amenorrhea, impotence, change of voice, polyuria, polydipsia, arthralgia/arthritis, rash, eye symptoms, paresthesia, difficult walking, sweating, tremor, proteinuria, bone pain, etc.

• Drugs: antibiotics, laxatives, etc.

Important history

• Co-morbid

• Drugs

• Food & beverages

• Surgery & radiation

• Immunosuppression & HIV

Important history

• Co-morbid

• Drugs

• Food & beverages

• Surgery & radiation

• Immunosuppression & HIV

DM

• Drug-induced; metformin

• SIBO

• Diabetic diarrhea

Common drug-induced diarrhea

• Laxatives

• Colchicine

• Antibiotics; clindamycin, amoxicillin, ampicillin, cephalosporins, erythromycin etc.

• Chemotherapeutic agents; 5-flurouracil, methotrexate, irinotecan, cisplatin, doxorubicin etc.

• Metformin

• Alpha glucosidase inhibitors; acarbose, miglitol

• Mg antacids (Mg hydroxide), phosphates

• Enteral feeds

• Cholinesterase inhibitors

Important history

• Co-morbid

• Drugs

• Food & beverages

• Surgery & radiation

• Immunosuppression & HIV

Food & beverages

Chronic diarrhea

ปลาดิบ Capillariasis

FODMAPSs Osmotic diarrhea

Milk Lactose intolerance

Alcohol Chronic pancreatitis

Steatorrhea

SIBO

Bile acid diarrhea

Short bowel syndrome

Bowel Surgery

Anastomotic strictureAdhesionBlind loopIC valve resectionVagotomy

Ileal resection 60-100 cm

Ileal resection >100 cm

SB <200 cm

Physical examination

• Signs of malnutrition

• Clues for diagnosis

– Dermatitis herpetiformis -> Coeliac disease

– Vasculitis -> Autoimmune disease

– Oral/genital ulcer -> Behcet’s disease

– Uveitis, episcleritis -> Ulcerative colitis

– Exophthalmos -> thyrotoxicosis

– Peripheral neuropathy -> amyloidosis, DM

– Oral hairy leucoplakia -> AIDS

Bitot spot

Koilonychia

Glossitis

Angular stomatitis

Pellagra Edema

Patients with diarrhea >4 weeks

1

R/O functional diarrhea2

Duration

Exclude conditions mimic chronic diarrhea

5

SB vs LB Character HIV

3

Find clinical clues4

Categorization

Investigations & empirical treatment

Patients with diarrhea >4 weeks

1

R/O functional diarrhea2

Duration

Exclude conditions mimic chronic diarrhea

5

SB vs LB Character HIV

3

Find clinical clues4

Categorization

Investigations & empirical treatment

Step 1: Exclude conditions mimic chronic diarrhea

• Post-infectious IBS• Protozoa; giardiasis• Clostridium difficile• IBD, aggravated by

infection

Protracted acute diarrhea

Abrupt onset

Pseudo-diarrhea Incontinence

PRStool <200 g/d

Bristol stool scale 1-4

Patients with diarrhea >4 weeks

1

R/O functional diarrhea2

Duration

Exclude conditions mimic chronic diarrhea

5

SB vs LB Character HIV

3

Find clinical clues4

Categorization

Investigations & empirical treatment

Step 2: R/O functional diarrhea

• Young female

• Mild, intermittent

• No nocturnal symptoms

• Mucous diarrhea +, tenesmus +

• Cramping pain relieved by defecation

• Precipitated by stress, spicy food

• Onset >50 yr.

• Severe, progressive

• Nocturnal diarrhea

• Bloody diarrhea or IDA from chronic blood loss

• Fever, weight loss

• Familial Hx of IBD, CRC

Functional diarrhea Organic diarrhea

Patients with diarrhea >4 weeks

1

R/O functional diarrhea2

Duration

Exclude conditions mimic chronic diarrhea

5

SB vs LB Character HIV

3

Find clinical clues4

Categorization

Investigations & empirical treatment

Duration of diarrhea

<6 months 6 months-2 years >2 years

Any causes

Exclude bacteria & virus IBS-D

Laxative-inducedDiabetic diarrhea

Lactose intoleranceMicroscopic diarrhea

Factitious diarrhea

• Large volume

• Moderate frequency

• No urgency

• No tenesmus

• No/ minimal mucus

• Periumbilical pain

• Weight loss

• Signs of malnutrition

• Small volume

• High frequency

• Urgency

• Tenesmus

• Mucus & blood

• LLQ pain

• No weight loss

• No signs of malnutrition

Small bowel diarrhea Large bowel diarrhea

Secretory Osmotic

Steatorrhea Inflammatory

Stool characteristics

Stool pHStool osmolalityStool volumeFasting

Sudan stainStool fat >6 g/d Stool wbc & rbc

Secretory Osmotic

Stool volume >1000 ml/d <300 ml/d

Stool osmolality

Stool osmotic gap

<[Na+K]x2

<50 mOsm

>[Na+K]x2

>100 mOsm

Stool Na >90 mmol/L <60 mmol/L

Stool pH >6 <5

Effect of fasting Not improved Improved

Secretory diarrhea

• Drugs; non-osmotic laxatives, antibiotics

• VIPoma, carcinoid tumor

• Villous adenoma

• Congenital defect

– Cl-/HCO3 exchange

– Na+/H+ exchange

• Intestinal resection

• Diffuse mucosal diseases

Osmotic diarrhea

• Laxatives induced

• Diet-induced; candy, sorbitol, mannitol, xylitol

• Drugs-induced; colchicine, cholestyramine, neomycin, lactulose, PAS

• Disaccharidase deficiency; fructose, lactose

• All prolonged malabsorption diarrhea

Steatorrhea

• Chronic pancreatitis, CA pancreas, IPMN

• Oristat

• Diseases of terminal ileum; TB, CD, ileal resection >100 cm

• Obstructive jaundice, PBC, cirrhosis

Lipase

Bile salts

• SIBO

• ZE syndrome

• Lymphangiectasia

• TB, lymphoma, carcinomatosis

pH

Lymph

Inflammatory diarrhea

Infections

• Bacteria; Aeromonas, Plesiomonas, C. difficile, TB

• Viruses; CMV

• Parasites; Amoeba histolytica, Balantidium coli, Trichinella spiralis, Trichuris trichiura, Schistosoma mansoni/mekongi

Non-infection

• IBD, Behcet’s disease, eosinophilic gastroenteritis

• Ischemic colitis, radiation

• Malignancy; colon cancer, lymphoma

HIV

Virus

Bacteria

Mycobact.

FungusParasite

Protozoa

Lymphoma

CMV, HIV

CampylobacterShigella

SalmonellaC. difficile

TB, MAC

CryptococcosisHistoplasmosis

CryptosporidiumIsospora

MicrosporidiumCyclosporaGiardiasis

CD4, OI, environmentMultiple organisms !!!

Patients with diarrhea >4 weeks

1

R/O functional diarrhea2

Duration

Exclude conditions mimic chronic diarrhea

5

SB vs LB Character HIV

3

Find clinical clues4

Categorization

Investigations & empirical treatment

Remarkable weight loss

• Malabsorption syndrome

• Thyrotoxicosis

• Malignancy

• TB

• Parasite; Capillariasis

• IBD

• IPSID, lymphoma

• AIDS-related diarrhea

Prolonged fever

• AIDS-related diarrhea

• Infectious diarrhea; Amoebiasis, TB, CMV, C. difficile, Actinomycosis, Histoplasmosis

• IBD

• Autoimmune disease: SLE

• Lymphoma

RLQ pain

Infections

• Salmonella

• Campylobacter

• Yersinia

• TB enteritis

• Histoplasmosis

• Actinomycosis

• Amoeboma

Non-Infection

• Lymphoma

• Crohn’s disease

• Ischemic colitis

• Carcinoid tumor

Peptic ulcer

• Antacid-induced diarrhea

• Zollinger-Ellison syndrome

• Gastro-colic fistula

Generalized lymphadenopathy

• IPSID

• Lymphoma

• Leukemia

• AIDS-related diarrhea

• Disseminated tuberculosis

• Whipple’s disease

Clubbing of fingers

• IBD

• IPSID

• Coeliac disease

• Cystic fibrosis

• Whipple’s disease

• Malignancy (paraneoplastic)

• Grave’s disease

• Cronkhite-Canada syndrome

• Sarcoidosis

Eosinophilia

• Parasites: Strongyloidiasis, Gnathostomiasis, Giardiasis, Capillariasis

• Eosinophillic enterocolitis

• Lymphoma

• Autoimmune disease: SLE, vasculitis

• Drugs-induced: sulphonamide, aspirin, cephalosporins

• Food allergy

Hypokalemia

• VIPoma

• Laxative abuse

• Conn’s syndrome

• Thyrotoxicosis

• Villous adenoma

• Prolonged watery diarrhea

Megaloblastic anemia

• SIBO

• Diseases of terminal ileum

• Diphyllobothrium latum

Other hints

• Flushing; carcinoid syndrome, mastocytosis

• Tachycardia; thyrotoxicosis, carcinoid syndrome

• Peripheral neuropathy; DM, amyloidosis

• Proteinuria; amyloidosis, SLE

• Vasculitis; autoimmune diseases

• Postural hypotension; DM, Addison’s disease

• Dermatitis herpetiformis; coeliac disease

• Ataxia; abetalipoproteinemia

Dermatitis herpetiformis; coeliac disease

Pyoderma gangrenosum; IBD

Papular pruritic eruption; HIV

Patients with diarrhea >4 weeks

1

R/O functional diarrhea2

Duration

Exclude conditions mimic chronic diarrhea

5

SB vs LB Character HIV

3

Find clinical clues4

Categorization

Investigations & empirical treatment

• CBC, ESR, MCV, MCH, MCHC, UA

• Stool exam(conc.), culture, stool weight, stool fat

• Stool C. difficile toxin assay

• Blood chemistry, FBS, BUN, Creatinine, chol, trig, alb, glob etc.

• Serum electrolytes, Ca, PO4, Mg, Zn

• PT, ferritin, B12 level, folate level, serum carotene

• Thyroid function test

Battery of tests in chronic diarrhea• Anti-HIV

• Tissue tranglutaminase (tTG)

• Urine 5-HIAA, calcitonin

• Tumors markers eg. CEA, CA19-9

• Autoimmune: ANA, p-ANCA, ASCA, anti-DNA, etc.

• VIP, gastrin, glucagon levels

• Radiologic & endoscopic examinations

• etc.

Empirical treatment

• Metronidazole; C. difficile, giardiasis, SIBO

• Albendazole; capillariasis

• Cholestyramine; bile acid diarrhea

• Pancreatic enzyme; chronic pancreatitis

Good Luck!