27th Reviews in Internal Medicine for 3rd Year Medicine Resident 2018

Approach to Common Problems in

Gastroenterology

Symptomatology in GI & liver diseases

• Ascites

• Jaundice

• Acute & chronic abdominal pain

• Acute & chronic diarrhea

• 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,

variceal bleeding• 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

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

• Heterogenousenhancement

• PHT: ascites, splenomegaly

Early central enhancement

Delayed peripheral enhancement

BCS; Flip flop phenomenon

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; positive 96.7%

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

• CT scan• Biopsy

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

• Clue; 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 (pediatric) 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 / abdominal paracentesis

Gynaecologic conditions 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

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 jaundice

Jaundice

Elevated serum bilirubin (>2.5-3 mg/dl)

Jaundice

Hepatocellular CholestasisHemolysis1

2 Intravascular Extravascular AcuteAcute on chronic

Intrahepatic Extrahepatic

AnemiaDark urine

Prodromal symptomsSigns of chronic liver diseasesRisk factors

PruritusAcholic stoolBiliary painPalpable gallbladderAbdominal massWeight loss

Color of urine

NormalHemolysisDirect

hyperbilirubinemia

Acholic stool

Palmar erythema Dupuytren’s contractureClubbing of fingers

Gynecomastia Parotid gland enlargementSpider nevi

Kayser-Fleischer ring

Sunflower cataract

Ascites & superficial vein dilatation

Abdominal massPalpable gallbladder

Hepatocellular jaundice

Acute on chronicAcute • Signs of chronic liver diseases• Recurrent jaundice

• Virus HAV, HBV, HEV EBV, CMV, HSV

• AIH• Drugs, toxin• Acute BCS, SOS• Hemophagocytosis

• HBV• AIH• Alcohol• Wilson disease• Acute hepatitis (other

causes) on top cirrhosis

• Risk factors: IVDU, tattoo etc.• Travel• Vaccination; HAV, HBV• Fever, abdominal pain• Family history• Drugs/ toxin/ Herb/ CAM• Alcohol• Underlying diseases

• Signs of CLD / PHT• Hepatosplenomegaly• (KF ring, Parkinsonism)

Virus

NASH

Wilson

HH

BCSDrugs

AIH

Alcohol

Hepatitis

Risk factorsTravel, vaccination

Drug listTemporal relationship

Familial historyKF, Parkinsonism

Hepatomegaly, ascitesProthrombotic states

Female, autoimmuneHigh globulin

ObeseMetabolic syndrome

Heavy drinkerSigns of CLD

AST & ALT activity

Predominated AST

Rapid decline

• <5x: Chronic• >5-8x: Acute• >40x:

• Ischemic• Drugs, toxins

• Extrahepatic: rbc, heart, skeletal m.• Alcohol• Reye’s syndrome• Cirrhosis

• Ischemic• Drug (short T1/2)• Acute biliaryobstruction• Fulminant hepatitis

Level

ALT Bilirubin

0 7 14 21 Day

Acute hepatitis

ALPProdromal symptoms

Jaundice

HAV HEV HBV HDV HCV

Transmisssion Feco-oral Feco-oral Blood, SexualVertical

HBsAg-dependent

Blood

Presentation Acute AcuteChronic*

AcuteChronic

AcuteChronic Chronic

Risk factors Travel

Vaccine

Travel IVDU, tattoo, blood Tx, unsafe sex, family HxVaccine

IVDU IVDU, tattoo, blood Tx

Hepatotrophic viral hepatitis

*AIDS, post organ transplantation

EBV HSV CMV

Presentation

Acute Acute Acute

Host Adolescent ImmunocompromisedPregnancy

Immunocompromised

Symptoms & signs

Mononucleosis-like Skin lesions (50%) Retinitis, colitis, pneumonitis

Non-hepatotrophic viral hepatitis

Herbs & CAM

Mushroom

Amanita virosa Amanita verna

Intrahepatic cholestasis

Extrahepaticcholestasis

Common bile duct obstruction

Periampullary cancer CBD stone

Cholestaticjaundice

IntrinsicExtrinsic

compressionIntraluminal

CBD stoneParasite

CholangiocarcinomaPSC, IgG4-relatedAIDS cholangiopathyInjury (TACE/Surgery)

Malignancy; pancreas, duodenum, ampulla

Metastatic LNLymphomaPancreatitis

Intrahepatic

Extrahepatic

Cholangiocyteinjury

MiscellaneousInfiltrative

TB, fungusMetastatic CALymphomaAmyloidosisSarcoidosis

PBCDrugsGVHDCystic fibrosis

SepsisPregnancyParaneoplasticTPN

• Onset of pruritus vs jaundice• Hepatomegaly• Biliary pain• Palpable gallbladder• Abdominal mass• Rate of rising of bilirubin

Viral hepatitis Serology

HAV Anti HAV IgM

HBV HBsAg, anti HBc IgM

HEV Anti HEV IgM, anti HEV IgG

EBV Blood smear, Anti EBV IgM

HSV Tzanck smear, HSV PCR, liver biopsy

CMV CMV viral load, histology

Investigations for viral hepatitis

Diseases Serology

AIH ANA, SMA, IgG, (liver biopsy)

Alcohol CBC, LFT + GGT, U/S

Wilson disease Slit lamp, ceruloplasmin, 24 hr urine copper

Acute BCS Doppler U/S or CT BM study and Ix for hematologic diseases

Drugs Diagnosis by exclusion, (liver biopsy)

Investigations for non-viral hepatitis

Diseases Serology

PBC AMA, (liver biopsy)

PSC ERCP/ MRCP

CBD stone (U/S), CT, EUS, ERCP

Cholangiocarcinoma CT, CA19-9, +ERCP, biopsy

Periampullary cancer CT, CA19-9, biopsy

Investigations for cholestasis

Ultrasonography

IHD dilatation

Hypovascular mass Delayed peripheral enhancement

Cholangiocarcinoma

CA head of pancreas

Double duct sign

Good Luck!