1. Swedish Family Practice Residency Didactics July 31, 2001

2. A quick trip through the GI track with brief stops at the esophagus, stomach, liver, colon, rectum and anus.And a little diarrhea.

3. The Upper GI Tract Esophagus Stomach Pancreas Gallbladder Liver

4. Esophageal Disorders Disorders of motility GERD Inflammatory and infectious disorders Tumors

5. Symptoms from the Esophagus Dysphagia Odynophagia Chest pain Regurgitation

6. Disorders of Motility Achalasia – Cancer, Parkinson’s, Chagas Disease (trypanosomiasis) Spasm – Diffuse, Localized Scleroderma

7. Diagnostic Studies Barium swallow Manometry

8. Treatment Long-acting nitrates Calcium channel blockers Dilation of LES (Achalsia) Surgery (Spasm, Scleroderma) Manage reflux (Scleroderma) Prokinetic drugs (Scleroderma)

9. GERD Frequent – 10% of US population Occasional – 30% of US population

10. Symptoms of GERD Heartburn Water Brash Regurgitation Dysphagia/odynophagia Chest pain, hoarseness, chronic cough, wheezing

11. 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)

12. Treatment of GERD Mild Symptoms Dietary modification Lifestyle modification Trial of patient directed therapy with OTC antacids or H2 antagonists

13. Treatment of GERD Non-responders, non-erosive disease H2 antagonists PPI’s Promotility agents 8-12 weeks of therapy

14. 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

15. Treatment of GERD Complicated GERD GI workup with endoscopy PPI’s High-dose H2 antagonists Antireflux surgery – no data on new procedures

16. Inflammatory Disorders of the Esophagus Pill-induced esophagitis – NSAID’s, steroids, doxycycline Infective esophagitis – HIV, HSV, cytomegalovirus, candida Corrosive – alkalis or acids

17. Diagnosis and Treatment Endoscopy Treatment based on results of endoscopy

18. 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

19. Diseases of the Stomach Acid peptic disorders of the stomach and duodenum Infections Motor disorders Cancer

20. Acid Peptic Disorders 5 – 10% of the US population will have PUD in their lifetime, 50% will recur .0001% mortality rate

21. Cause of PUD Imbalance between protective and aggressive factors

22. Protective factors Mucus and bicarbonate secretion of epithelial cells Surface membrane of mucosal cells PG E-1 and PG E-2

23. Aggressive Factors Gastic acid NSAID’s Corticsteroids Smoking Alcohol (?) Stress (?) Diet (probably not) H-pylori

24. 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

25. 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

26. 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

27. 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)

28. 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

29. 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)

30. 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

31. Diseases of the Lower GI Tract, cont. Diverticulosis (90% have no symptoms) Diverticulitis (infectious) Infectious diarrhea

32. Diagnosis of Infectious Diarrhea - History Work Travel Eating Ill contacts Recent antibiotics HIV or immunocompromised

33. 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

34. 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

35. Treatment Pathogens requiring treatment – shigella, giardiasis, E. coli, pseudomembranous entercolitis, V. cholera

36. Treatment Pathogens that may require treatment – campylobacter, salmonella, amebiasis (5% carriage rate in the US, many are not pathogenic)

37. Treatment Most viral and bacterial causes of diarrhea resolve without treatment Antibiotics may prolong or worsen diarrhea

38. Diseases of the Lower GI Tract, cont. Cancer – small bowel (rare), colon (6% incidence) Anorectal diseases – cancer, hemorrhoids, pruritis ani, fissures And hepatitis