Gastroenterology

Swedish Family Practice Residency Didactics

July 31, 2001

A quick trip through the GI track with brief stops at the esophagus, stomach, liver,

colon, rectum and anus.And a little diarrhea.

The Upper GI Tract

• Esophagus

• Stomach

• Pancreas

• Gallbladder

• Liver

Esophageal Disorders

• Disorders of motility

• GERD

• Inflammatory and

infectious disorders

• Tumors

Symptoms from the Esophagus

• Dysphagia

• Odynophagia

• Chest pain

• Regurgitation

Disorders of Motility

• Achalasia – Cancer, Parkinson’s, Chagas Disease (trypanosomiasis)

• Spasm – Diffuse, Localized

• Scleroderma

Diagnostic Studies

• Barium swallow

• Manometry

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

GERD

• Frequent – 10% of US population

• Occasional – 30% of US population

Symptoms of GERD

• Heartburn• Water Brash • Regurgitation• Dysphagia/odynophagia• Chest pain, hoarseness,

chronic cough, wheezing

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)

Treatment of GERDMild Symptoms

• Dietary modification• Lifestyle modification• Trial of patient directed

therapy with OTC antacids or H2 antagonists

Treatment of GERDNon-responders, non-erosive disease

• H2 antagonists• PPI’s• Promotility agents• 8-12 weeks of therapy

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

Treatment of GERDComplicated GERD

• GI workup with endoscopy• PPI’s• High-dose H2 antagonists• Antireflux surgery – no data on

new procedures

Inflammatory Disorders of the Esophagus

• Pill-induced esophagitis – NSAID’s, steroids, doxycycline

• Infective esophagitis – HIV, HSV, cytomegalovirus, candida

• Corrosive – alkalis or acids

Diagnosis and Treatment

Endoscopy

Treatment based on

results of endoscopy

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

Diseases of the Stomach

• Acid peptic disorders of the stomach and duodenum

• Infections

• Motor disorders

• Cancer

Acid Peptic Disorders

• 5 – 10% of the US population will have PUD in their lifetime, 50% will recur

• .0001% mortality rate

Cause of PUD

Imbalance between protective and aggressive factors

Protective factors

• Mucus and bicarbonate secretion of epithelial cells

• Surface membrane of mucosal cells

• PG E-1 and PG E-2

Aggressive Factors

• Gastic acid

• NSAID’s

• Corticsteroids

• Smoking

• Alcohol (?)

• Stress (?)

• Diet (probably not)

• H-pylori

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

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

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

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)

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

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)

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

Diseases of the Lower GI Tract, cont.

• Diverticulosis (90% have

no symptoms)

• Diverticulitis (infectious)

• Infectious diarrhea

Diagnosis of Infectious Diarrhea - History

• Work• Travel• Eating• Ill contacts• Recent antibiotics• HIV or immunocompromised

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

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

Treatment

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

Treatment

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

Treatment

• Most viral and bacterial causes of diarrhea resolve without treatment

• Antibiotics may prolong or worsen diarrhea

Diseases of the Lower GI Tract, cont.

• Cancer – small bowel (rare), colon (6% incidence)

• Anorectal diseases – cancer, hemorrhoids, pruritis ani, fissures

• And hepatitis