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GI Board Review

GI Board Review. Esophagus. GERD. Middle aged overweight male with retrosternal burning and regurgitation worse with citrus and smoking. GERD. Symptoms Retrosternal burning – post prandial/recumbant Regurgitation Dysphagia Water Brash Chronic Cough

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GI Board Review

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  1. GI Board Review

  2. Esophagus

  3. GERD Middle aged overweight male with retrosternal burning and regurgitation worse with citrus and smoking.

  4. GERD • Symptoms • Retrosternal burning – post prandial/recumbant • Regurgitation • Dysphagia • Water Brash • Chronic Cough • Historical clues: Pregnancy, Scleroderma, Obesity, hiatal hernia • Gold standard – 24 hour pH probe

  5. GERD • Complications • Barrett’s • Adenocarcinoma • Strictures/Rings • Hoarseness/Asthma • Empiric treatment – Sensitivity of 80% • When refer for endoscopy? • Evaluate for Barrett’s/anatomy • Don’t respond to therapy • Alarm symptoms – dysphagia, bleeding, weight loss, anemia, odynophagia • Chronic

  6. GERD - treatment • On the Boards, remember to be cost effective • Lifestyle modification(Weight loss most important and avoidance of foods that cause LES relaxation i.e. peppermint, chocolate, alcohol, fatty foods) • Acid suppression • PPI > H2 blocker(80% control symptoms) • PPI better in endoscopically proven esophagitis • Promotility – Reglan/Cisapride (Minimal Data) • Surgery – Nissen Fundoplication • Equivalent to PPI therapy – 0.2% mortality • 2/3 will be on acid suppression in 5 years • No evidence that prevents Barrett's or CA • Endoscopic Therapy (Stretta, Endocinch, etc) • Rarely performed.

  7. Barrett’s Esophagus 55 year old white male with 10 years of pyrosis, mildly improved over past year, on PPI daily.

  8. Barrett’s Esophagus • Middle aged and older, M>F (2:1) • Whites and Hispanics predominantly • About 5-10% of patients with GERD (though in multiple studies, also present in 0%-25% of asymptomatic patients) • Defining characteristic: Change in squamous esophageal epithelium to intestinal metaplasia • 0.5% per person per year chance of developing adenocarcinoma • Treatment • Control GERD Symptoms – PPI vs. surgery • No therapy definitively shown to reduce risk of progression to malignancy • Surveillance endoscopy

  9. Esophageal Cancer 75 year old female with history of tobacco use and alcohol use with progressive solid food dysphagia and 15 pound weight loss over past year.

  10. Esophageal Cancer • Essentially equal prevalence in United States of esophageal SCC and adenocarcinoma • Squamous Cell – proximal esophagus • Smoking • Tylosis • Achalasia • Plummer-Vinson • Lye • Ethanol • Sprue/Scleroderma • Adenocarcinoma – Distal esophagus • GERD/Barrett’s, Obesity, Tobacco

  11. Esophageal Cancer • Symptoms • Progressive Solid Food Dysphagia • 75% also weight loss/anorexia • Endoscopy with Biopsy – Diagnostic • Staging • 1. CT chest/abd/pelvis vs. PET for Mets • 2. EUS for T and N staging

  12. Dysphagia

  13. Dysphagia • History and Physical • Solid vs. liquid • Intermittent vs. progressive • Oropharyngeal vs. Esophageal • Barium swallow (13mm pill) • EGD (with possible dilation) • Esophageal manometry

  14. Peptic Stricture • Progressive solid food dysphagia • History of GERD • No weight loss • Patients have normal appetite • Majority (60-70%) are peptic in origin • Result of chronic esophageal inflammation

  15. Esophageal Ring 38 year old female with frequent heartburn, controlled on PPI, with intermittent solid food dysphagia.

  16. Achalasia 35 year old male with progressive solid and liquid food dysphagia and fatigue, with regurgitation of undigested food.

  17. Achalasia“failure to relax” • 1/100,000 • M:F 1:1 • Age 25-60 (If older>60, think pseudoachalasia especially gastric cancer) • Increased risk for squamous cell cancer • Hallmarks: • Aperistalsis • Failure of LES to relax • Dysphagia to solid and liquid • Postural changes to help swallowing • Regurgitation of undigested food • Autoimmune vs. Viral • Chagas Disease (Trypanosoma cruzei)

  18. Achalasia - diagnosis • Barium Swallow – Dilated esophagus with column of barium and “Birds Beak” taper. Test of choice if suspected • Endoscopy – rule out pseudoachalasia • Manometry (Used to confirm diagnosis) • (1)Loss of peristalsis, • (2)failure of LES to relax, • (3)possibly LES high pressure • Chest X-ray – wide mediastinum and air fluid level

  19. Eosinophilic Esophagitis 20 year old male with history of asthma and eczema with recurrent food impactions.

  20. Eosinophilic Esophagitis • Atopic history and food impactions • Ringed esophagus / linear furrows • >15 eosinophils per high power field • Some (minority) have peripheral eosinophilia • Oral fluticasone 220 mcg/puff 2 puffs bid for 6-8 weeks. Recurrence frequent. • Other possible treatments: • PPI, singulair (large doses up to 100 mg), elimination diets (children predominantly) and dilation

  21. Scleroderma • Historical Key: 70 year old woman with sclerodactyly telangiectasias, Raynaud’s with GERD, resistant to PPI • 75% have esophageal involvement • Severe GERD, frequently resistant to PPI • Incompetent LES and lack of peristalsis • Control GERD with PPI

  22. Stomach

  23. Upper GI bleed

  24. Presentation • Hematemesis (Not to be confused with hemoptysis) • Melena (Black, Tar-Like – not solid) • Nausea/vomiting common with PUD • Orthostasis (Bedside orthostatics) • Abdominal pain • Hematochezia (10% of maroon stool from upper source – On test will be unstable)

  25. Upper GI Bleed • Peptic Ulcer Disease – 55% • Esophageal Varices – 14% • AVM’s / GAVE – 6% • Mallory-Weiss tear – 5% • Dieulafoy’s – 1% • Cameron’s lesion • Tumors • Esophagitis (Most common cause of UGIB in hospitalized patients, likely due to NGT and reflux in supine position)

  26. Peptic Ulcer Disease 65 year old female with arthritis, taking ibuprofen, with melena and lightheadedness.

  27. Definite: Prior PUD Advanced age Concomitant use of glucocorticoids Concomitant use of anticoagulants High doses or combinations of NSAIDs, including low-dose aspirin Comorbid illness (RA, CAD, etc) Ethanol use Possible: H. pylori infection smoking Risk Factors for NSAID-induced Ulcers

  28. Helicobacter pylori • Most peptic ulcers caused by Helicobacter pylori • 60-80% of GU’s and 90% DU’s • 2 clinical presentations of H. pylori • Antrum predominant • Increased acid production, Duodenal Ulcers, no cancer • Body predominant • Decreased acid production, Gastric Ulcers, Gastric Cancer (<1% of those infected, Cag A strain) • Eradication of Hp dramatically decreases PUD and its complications

  29. Tests for H. pylori • Serologic Antibody(90% sens / 90% spec) • Remains positive for several years • Do not use for evaluation for eradication • Endoscopy with Histology (95% sens / 98% spec) • Endoscopy w/Rapid Urease Test (CLO) (90% /98%) • Urease Breath Test (C13 / C14) (95% / 95%) • Best test for eradication • Stool Antigen (92% / 90%) • All tests (except serology) less reliable if on PPI in last 2 weeks, or antibiotics or bismuth in past 4 weeks.

  30. Rx of H. pylori • Standard : Amoxicillin, Clarithromycin, PPI bid x 14 days • 75-80% eradication rate • Major antibiotic resistance to clarithromycin and metronidazole. • If allergic to PCN, substitute metronidazole for amoxicillin

  31. Peptic Ulcer Disease – Rebleed Risk (within 72 hours) Baseline PPI PPI/EGD Tx Clean Base 3-5% ---- ---- Pigmented Spot 7-10% ---- ---- Adherent Clot 22-30% 0% 6.7% Visible Vessel 43-52% 12% 6.7% Active Bleeding 55-90% 73% 6.7%

  32. Pigmented Spot Clean based Rebleed = 7% Rebleed = 3% Active Bleeding Visible Vessel Rebleed=90% Rebleed= 52%

  33. Mallory-Weis Dieulofoy's GAVE Tumor AVM

  34. Zollinger-Ellison • Gastrin producing neuroendocrine tumor • 1% of PUD (Never seen clinically but all over board exams) • 90% will have PUD (frequently solitary duodenal ulcer but may be multiple and in unusual places i.e. jejunum) • Frequently with abdominal pain and chronic secretory diarrhea • 70% Duodenum/30% Pancreas • 1/3 metastatic at diagnosis

  35. Zollinger - Ellison • Fasting Gastrin >1000 diagnostic if acidic pH in stomach (separate low acid states (atrophic gastritis and pernicious anemia) from ZE) • 150-1000 abnormal but can be secondary to meds (PPI) or H pylori causing atrophic gastritis • Secretin Stimulation Test (secretin infusion promotes gastrin release by gastrinoma cells but not gastric G cells) • Positive test - Increased Gastrin by at least 120-200 pg/ml within 20 minutes after secretin infusion • Localize with octreoscan/EUS of pancreas

  36. MEN1 • Pancreatic islet cell tumors seen with MEN1 about 80% of time (parathyroid, pituitary, pancreas) • 50-60% with MEN1 have gastrinoma, but… • About 20% with gastrinoma have MEN1 • Most common pancreatic islet cell tumor associated with MEN1 is a “nonfunctioning” islet cell tumor (i.e. releases hormone that does not cause symptoms like PPP)

  37. Gastric Cancer • Diffuse (Infiltrating cells, i.e. linitis plastica) vs. Intestinal Type (glandular) • Most common in Far East (if Japanese or Korean patient with stomach complaint, think of gastric cancer) • Risk Factors • 1st degree relative (3x) • H. pylori – Chronic Atrophic Gastritis • Dietary – Nitrates • Tobacco

  38. Gastric Cancer Epidemiology

  39. Pancreas

  40. Acute pancreatitis • Alcohol or gallstone predominant etiologies • Drugs – DDI, diuretics, estrogen, valproic acid, 5-ASA, azathioprine, TCN, sulfa • Interstitial (85%) vs. necrotizing (15%) • Organ failure in 10% vs. 54% • Mortality Rate 3% vs. 17% • 33% of patients with sterile necrosis develop infected necrosis • 47% mortality with MSOF • Interesting fact – Pain radiates to back only about 50% of time.

  41. Complications • SIRS: ARDS, Shock, ARF, GI Bleed • Necrosis: Infection • Pseudocyst/Abscess • Pancreatic Ascites, Fistula (pleural effusion) • Chronic Pancreatitis • Splenic Vein Thrombosis, Pseudoaneurysm

  42. Treatment • Mild – NPO, pain control, fluid resuscitation • Severe pancreatitis – Likely ICU • Adequate pain relief, • Adequate IV fluid replacement, especially initially (decrease Hct over first 24 hours to reduce risk of necrosis) • ERCP for gallstone panc (cholangitis/jaundice) (suspect if ALT or AST>3x ULN) • Nutritional support • Enteral feeding better than TPN due to decreased episodes of hyperglycemia and sepsis • Current teaching to place feeding tube beyond Ligament of Treitz (controversial)

  43. Enteral Nutrition and Severe Pancreatitis # PTS Kalfarentos et al Br J Surg 1997; 84:1665

  44. Treatment • Severe pancreatitis • Contrast CT recommended at some point beyond the first 3 days in severe pancreatitis to rule out necrotizing pancreatitis. • Otherwise, minimal role for early CT • No role for prophylactic antibiotics with sterile necrosis (controversial) • If concern for infected necrosis (usually after 7 days), CT guided aspiration.

  45. Chronic pancreatitis

  46. Chronic Pancreatitis • Chronic epigastric pain/maldigestion related to fibrotic pancreas • Diagnosis usually made after disease is well established. • Most frequently associated with alcohol abuse • Maldigestion with steatorrhea/weight loss • Fat soluble vitamin and B12 deficiency • DM common in advanced disease

  47. Chronic Pancreatitis • Lipase and amylase normal or only slightly elevated • May mimic pancreatic cancer or autoimmune pancreatitis (IgG4, ANA) with duodenal or biliary obstruction • Complications: pseudocyst, splenic vein thrombosis, pancreatic cancer (4% lifetime risk)

  48. Diagnosis (difficult) Clinically useful tests for CP Function Structure Secretin stim test ERCP/EUS Bentiromide test CT scan Serum trypsinogen US Fecal chymotrypsin KUB Fecal fat Sensitivity

  49. Treatment • Pain relief • Non-enteric coated pancreatic enzymes (Viokase) with PPI • Narcotics • Celiac plexus block (CT vs. EUS) • ERCP with stent or stone removal • Surgical resection or Peustow procedure • Maldigestion (steatorrhea) • Coated Pancreas enzyme (Creon)

  50. Pancreatic Cancer • 2nd most common GI cancer and 4th most common cancer death in US • Rare before age 45, M>F, African Americans>Whites • 28,000 cases per year (27,000 deaths) • 85-90% originate from pancreatic ductal cells • Rarer cancers of acinar cells or neuroendocrine cells • Painful or painless jaundice, acholic stool, dark urine, weight loss • Elevated CA 19-9 • Diabetes frequently diagnosed within past 2 years

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