Gastroenterology - Details

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Pt over 65,dysphagia, wt loss, food impaction ( eosinophilic esophagitis, anemia, long standing> 5 year GERD

Functional dyspepsia: When is EDG warranted before PPI trial?

At least one month of epigastric discomfort, postprandial fullness, and epigastric pain with no evidence of organic dz on EDG.

Functional dyspepsia: definition

Test and treat for H. pylori. If negative PPI trial for 8 wks. If sx persist, consider TCA or Buspar or EDG.

How do you treat functional dyspepsia?

Abx, biophosphanates, steroids, iron, metformin, opiates, NSAIDS, KCL,

Which medications can exacerbate functional dyspepsia?

CKD, bone fx, C. diff infn. , CAP, decrease B12 and iron, mg absorbtion.

PPI side effects:

HBsAg, Anti HBs, and total HBcore Ab. Because if you have a pt with negative HBsAg and positive Anti HBs, they can either be immunized or have a latent HB infection which can reactivate.

Hep B screen : Which tests?

Healthcare workers, immigrants from Asia, Africa ME, East Europe and South America, pregnant women, chronic dz ie. DM, CKD, dialysis, MSM, household contacts, IVDU, homeless, sex active and not monomogous, and travel to endemic areas, pt which will be starting TNF or biologics.

Who do you screen for Hep B?

Elevated ALT ( > 19 women, > 30 men), +/- eAg, + eAb, fibrosis, DNA > 20,000

Who do you refer for treatment of Hep B?

Normal ALT, -eAg, +eAb, No fibrosis, DNA < 2000 or undetectable. The Goal is to remain here.

What is the definition of inactive carrier of Hep B?

AFP and US Q 6-12 mo if cirrhosis, High Risk: Asian men > 40, women > 50, African American, FHx of HCC in First degree relative, confection with HDV and HIV

Surveillance for HCC in chronic Hep B/ HBsAg +

Recent infection or flare up of chronic infection. Window period before Anti- HBs develops. IgG indicates a remote or chronic infection.

What does IgM Anti HBc mean? What does IgG Anti HBc mean?

High infectivity and active viral replication. High risk of transmission and development of HCC.

What does HBeAg imply?

Repeat testing and check IgM to r/o recent infection and HBV DNA to r/o chronic or occult infection.

How do you manage an isolated anti HBcore?

10%, , and 0.3%.

Transmission: transplacental, and vaginal.

Neonatal 95% goes to chronic stage. Adult 5% to chronic.

What percent goes to chronic stage? Neonatal and adult

Close contact of acute Hep B and infants get HBV vaccine and HGIB.

What do you give for post exposure prophylaxis for Hep B?

Monitor viral load through pregnancy. If > 200,000, treat with antivirals in the third trimester. Safe to vaccinate in pregnancy.

How do you manage a pregnant pt with acute HepB?

1. HBsAg + in pt from endemic area. 2. HBs Ag > 6 mo, + HBV DNA, +HBeAg Most go on to inactive carrier stage with low risk of HCC.

Definition of chronic Hep B and phases

HBV DNA, HBeAg and Ab, HIV, HCV, if IVDU check HDV, ETOH screen, CMP, CBC, INR, Fe and TIBC to r/o heachromatosis, US and AFP, Fib 4

How do you evaluate a positive Hep B screen?

Hep C Ab with reflex for viral load. If positive check Hep C genotype,HBsAg, Hep A, HIV

How do you screen for HCV?

1. Born b/w 1945 and 1965, 2. Hx of IVDU or intranasal DU, 3. hemodialysis, 4. children born to HCV + moms, 5. blood transfusion before 1992, 6. Incarceration, 7. HIV, 8. Unexplained LFT elevation, 9. MSM

Who do you screen for HCV?

Quantitative HCV RNA with reflex to genotype, CBC, CMP PT/INR, Hep A and B, HIV, NS5A drug resistance test. Stage liver disease: Noninvasive testing with 1. APRI score( AST and platelet count) or 2. FibroSURE, 3. liver US Ideally all three should be done. Need F3 or higher to get payment for Rx.

What is the w/u for HCV +?

HCV RNA + with F3 or higher fibrosis who are stable and compliant.

Who do you treat for HCV infection?

Restage every 1-2 years, Immunized against Hep A and B, support sobriety, Councel risk of progression ( Etoh, Tylenol ( < 2000/d ok) If cirrhotic , tylenol < 1000/d and no NSAIDS, wt loss, d/c MJ as it increases risk of progression to cirrhosis, smoking cessation, HCC surveillance with AFP and US Q 6-12 mo for 3 years, referral to GI for vatical screening.

What is surveillance for pt who do not meet criteria for Rx?

60-80% of acute infection becomes chronic. Most is asymptomatic ( 70%) 30% of chronic infection normalizes and 70% stays chronic. 30% goes on to cirrhosis in 30years and 2% of that goes on to HCC.

What is the natural hx of HCV infection?

NS5A and NS5B ; Harvoni is a combination of both. Genotype 2 and 3 more responsive to treatment. Goal of treatment is undetected HCV by PCR

What is the treatment of HCV?

Repeat to confirm along with S Fe, anti HCV, Hep B sAg, CMP, A1c and PT/INR, CBC. Check meds. If > 5x normal need immediate evaluation. Second level testing for cirrhosis: ANA, sm muscle Ab, Alpha 1 antitripsin, ceruloplamin and TSH.

Incidental elevated LFT management

CBC (low platelet), INR ( prolonged), ALT ( > 20 women, > 30 men) Fib 4 and fibroscans ( shear wave elastography)

Cirrhosis: How to diagnose

1. Liver failure - 2. Esphageal varies 3. SBP 4. Ascites 5. Hepatic encephalopathy, 6. HCC 7. Hepatopulmonary syndrome 8. Hepatorenal syndrome

Cirrhosis complication

Diet 1 gm/kg protein. Sodium restrict if ascites, Vit E, pioglitazone and Liraglutide. Ascites: Spironolactone alone or with Lasix 100 mg: 40 ratio, Hepatic encephalopathy: Lactulose to have 3 BM/d Varices: EDG surveillance 1-2 years/ propranolol SBP: secondary Ab prophylaxis ( Norfloxacin indefinite) Check MELD score for End Stage Liver Dz and refer for transplant if > 10 Screen for HCC every 6 mo with AFP and US Vaccinate for Hep A and B. Avoid harmful meds

Cirrhosis treatment:

Anticonvulsants, Antipsychotics, Antifungals, Abx ( macrolide B lactam, TMP/SMX), CaB, Metformin/ Sulfonylurea, PPI, Pain ( tylenol > 1000/d, NSAIDS, Tramadol, Opiate : Caution with methadone and Fentanyl)

Which medication to avoid in cirrhosis?

Steatosis on liver US.

NASH definition

Variable: 15-30% will develop fibrosis and 12 % go to cirrhosis Check Fib 4 as noninvasive estimate of liver scarring and refer if fibrosis.

NASH prognosis

Obesity, DM, Hyperlipidemia, HTN, OSA,

NASH associated conditions.

Wt loss > 10%, Avoid ETOH, Diet: Low CHO, Drink coffee- benefit, vaccinate Hep A and B, Statins, Exercise. Monitor AST and ALT and repeat US in 6-12 mo.

NASH Treatment

O-CLAM Omeprazole 20 mg/d, Amox 1 gm bid, Clarithromycin 500 mg bid x 14 days. If PNC allergy use Metronidazole

H. pylori treatment

Eval for blood, fever travel hx. Self limiting: Hydrate If > 7 days and abx use in last 3 mo, check C. diff, O&P if daycare, travel or HIV, Salmonella, Shigella and toxic Ecoli if fever or blood. Rx Immodium if no blood. Pepto Bismol.

Acute Diarrhea management

TTG IgA ( tissue transglutaminase Ab. If positive referral to GI for EDG for sm bowel bx. Monitor Ab levels in response to gluten free diet ( no wheat, why, or barley)

How to test for Celiac disease

Dermatitis Herpetiform: itchy rash on elbow and knee with erythematous papule and vesicles.

Celiac extra intestinal manifestation

Avoid HFC, Low lactulose, gluten, sugars and starches.

How do you treat gluten sensitivity?

Screen > age 50 or if high risk 10 years earlier that affected family member . Screen with FOBT annually, flex sig Q 5 years, colonoscopy q 10 yr., FIT/DNA every 1-3 years. If > 2 polyp adenoma recheck in 3 years, If < 2 polyps repeat in 5 years. If hyper plastic repeat in 10 years. Stop screening after 85. Individualize b/w 76-85 High risk: Hx of polyp Low risk polyp: 1-2 small, < 1 cm, tubular adenoma: Screen colonoscopy Q 5 years High risk polyp: > 3 adenomas, > 1cm, villous: Screen colonoscopy every 3 years Personal hx of colon cancer : Screen at 1,3, and 5 years.

Colon cancer screen and surveilance

Bloody diarrhea with abdominal pain and cramps for 6 mo. fever, fatigue, wt loss and anemia. Extraintestinal sx: joint pain, ankylosing spondylitis, erythema nodosum, episcleritis, uveitis, pyoderma gangronosum.

Ulcerative colitis symptoms

Continuous with rectal involvement and ilitis, polyps and high risk of cancer: Inflamatory markers: elevated CRP and renal calprotectin.

UC involvement

Mesalamine products: oral, rectal topical or suppository. Budesonide foam, oral steroids or immunomodulators ( Remicaid)

Treatment or UC

If more than 1/3 of colon involved screen 8 years after dx., then every 1-2 years.

UC surveillance

Lack blood, skip and cobblestoning. areas with rectal sparing and perirectal dz. Sting sign of ileum. Granulomas on bx. Associated access, stricture and obstruction. Smoking is a risk factor.

Crohn's disease pathophysiology

3 months of diarrhea alternating with constipation. Pellet like stool with mucous and abdominal pain relieved by dedication. R/O lactase der, sorbitol, caffeine, celiac and cancer.

Dx of Irritable Bowel Syndrome

LLQ pain and tenderness, fever, elevated WBC. Caused by micro perforations.

Diverticulitis presentation

CT of abdomen: R/O access

Dx of diverticulitis

Bowel rest and Abx: Metronidazole with Cipro or TMP/SMX or Augmentin 875/125 bid for 10-14 days. If peritoneal signs hospitalize for IV Abx.

Treatment of diverticulitis

20% recurrent with 50% recurring after second episode.

Diverticulitis prognosis

Abcess, fistula, perforation, young and immunocompromised and after second episode.

Diverticulitis Indication for surgery (sigmoid colectomy)

75% alcohol and gallstones: Other: high TG > 1000, elevated Ca, Trauma, acidosis (DKA), cancer or obstuction at ampulla of matter, post ERCP, biliary microlithiasis, viral, Drugs: oral hypoglycemics, sulphate, azathioprine, tetracycline, estrogen, diuretics)

Pancreatitis causes;

Lipase x3 nl ( specific), amylase ( nonspecific), CRP (predicts severity), US to check for gallstones, CT with contrast is gold standard, ERCP if have elevated bili > 5 Other labs in w/u: LFT, CBC, TG, UA and ABG, CXR to r/o PUD, Cholecystitis, Perforation, hepatitis, mesenteric ischemia

Dx or Pancreatitis

Ranson's criteria predicts mortality

Pancreatitis prognosis

Supportive- 90% resolve in couple days, IVF, NPO, pain control and prophylactic abx if suspect necrosis.

Pancreatitis treatment

1. L pleural effusion: resolves spontaneously 2. Infected pancreatic necrosis: Requires surgery 3. Pseudocyst 10% or cases: May take 4 wk to develop. < 5 cm resolves spontaneously. If larger or persists > 6mo need surgical drainage. 4. Abcess: Need CT percutaneous aspiration 6. Splenic vein thrombosis with gastric varies.

Pancreatitis complication

Asymptomatic or abdominal pain radiating to back. Ass. N/V Pain worse after eating. Steatorrhea and DM (Brittle)

What are the sx of chronic pancreatitis?

CT with contrast: Ductal calcification,

How do you diagnose chronic pancreatitis?

Pain management: NSAIDS and tylenol Cessation of alcohol and smoking small meals low in fat pancreatic enzymes and MCT, Amitriptyline 10 mg Pregabalin 75 mg bid Nerve blocks Surgery required in 50% of pts: Whippleor sphincterectomy with stent.

Treatment of chronic pancreatiti

CA 19-9

What is the serum marker for pancreatic cancer

Check ALT Q 6 mo, HBeAg Q 6-12 mo, Fib 4 yearly . Referr for >F2

What is the surveillance for HBeAg + with no cirrhosis

Check ALT, HBV DNA Q 3 mo for a year, Fib 4 if ALT > 2x, Rx if DNA > 2000

What is the surveillance for HBeAg- , DNA < 2000

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