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Internal Medicine GI Board Review

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Internal Medicine GI Board Review Wallene Yang, M.D. April 5, 2010 Dysphagia Structural - Progressive, solids then liquids Etiologies - Schatzki ring - stricture ... – PowerPoint PPT presentation

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Title: Internal Medicine GI Board Review


1
Internal Medicine GI Board Review
  • Wallene Yang, M.D.
  • April 5, 2010

2
Gastroenterology (9) 1921 as follows Diseases
of the mouth and salivary glands 01 Esophageal
disease 25 Stomach or duodenum 02 Small
intestinal disease 25 Colonic and anorectal
disease 26 Pancreatic disease 13 Biliary tract
disease 02 Liver disease 38 Gastrointestinal
complications of HIV infection 01 Undiagnosed
gastrointestinal hemorrhage 01 Miscellaneous
gastroenterology 0-1
3
Dysphagia
  • Structural
  • - Progressive, solids then liquids
  • Etiologies
  • - Schatzki ring
  • - stricture
  • - malignancy
  • Motility
  • - Liquids and solids
  • Etiologies
  • - scleroderma
  • - achalasia

4
Achalasia
  • Features
  • Incomplete relaxation of LES
  • Lack of peristalsis in the esophageal body
  • Often hypertensive LES
  • Presents with dysphagia to both solid and liquid
  • Diagnosis
  • Barium esophagram
  • EGD
  • Manometery
  • Treatment
  • High risk surgical patients botox
  • Low risk surgical patients pneumatic dilation,
    myotomy

5
Achalasia
  • On esophagram Birds beak
  • EGD dilated esophagus w/ food and liquid debris
  • Be careful pseudoachalasia can look the same on
    esophagram

6
GERD
  • Clinical presentations
  • Hearburn
  • Chest pain
  • Dysphagia
  • Brash
  • Atypical symptoms
  • Complications
  • erosive esophagitis
  • Strictures
  • Barretts esophagus
  • Testing
  • 24 hr ph probe
  • Bravo capsule
  • EGD

7
Barretts Esophagus
  • Metaplastic change of mucosa form squamous to
    specialized columnar
  • Premalignant condition for adenoCa of esophagus
  • Risk of cancer is low
  • Occurs in approximately 10 of those weekly GERD
  • Low grade dysplasia (surveillance)
  • High grade dysplasia (esophagectomy)

8
AdenoCa vs SCC
  • SCC
  • Associated with smoking
  • Associated with ETOH
  • Associated with toxic ingestions
  • More common in African Americans
  • More common in lower SES
  • AdenoCa
  • Associated with Barretts
  • More common in Caucasian males

9
Stomach
  • Gastritis and PUD
  • H. Pylori and MALT Lymphoma
  • Gastric Cancer
  • ZE syndrome

10
H. pylori
  • Involved in 75 of non-NSAID related gastric
    ulcers
  • Involved in 75 of DU

11
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12
Intestines
  • Diarrhea
  • Secretory, osmotic, inflammatory, motility
  • Infectious diarrhea- c. diff, immunocompromised
    patients
  • Celiac Disease
  • - Inflammatory Bowel Disease
  • UC
  • Crohns disease

13
Diarrhea
  • gt 200 gm/day of stool, increased frequency
  • Loose or watery consistency, increased frequency,
    gt3BM a day
  • Osmotic, secretory, inflammatory, motility
  • Acute lt2 weeks, chronic gt4 wks

14
Stool Osmotic Gap
  • Stool osmotic gap 290-2(stool Na stool K)
  • Remember stool osm that is greater than serum
    osm means contamination!

15
Osmotic Diarrhea
  • Stool osmotic gap gt50
  • Stops with fasting
  • Common causes lactase deficiency (most common),
    Mg containing laxatives, antacids, sorbitol,
    fructose, pancreatic insufficiency, celiac
    disease, bacterial overgrowth

16
Secretory diarrhea
  • Stool osmotic gap lt50
  • Higher volume, usually gt1 L/d
  • At risk for electrolyte deficiency
  • A 24-48 hour fast does NOT stop the diarrhea,
    except in fatty acid and bile acid related
    diarrheas

17
Causes of Secretory Diarrhea
  • Enterotoxins from E. coli, cholera and S. Aureus
  • Villous adenomas
  • Gastrinomas
  • VIPomas that produce VIP
  • Microscopic colitis
  • Collagenous colitis
  • Bile acids

18
Inflammatory Diarrhea
  • IBD
  • NSAID induced colitis

19
Celiac Sprue
  • Malabsorption due to small bowel villous atrophy
    caused by immune-mediated gluten sensitivity
  • Can have iron deficiency anemia, dermatitis
    herpetiformis, bloating, loose stools,
    asymptomatic

20
Diagnosis of Celiac Sprue
  • TTG IgA and endomysial Ab IgA best
  • Antigliadin antibodies sensitive but not
    specific.
  • Gold standard is EGD with bx of duodenum
  • Villous blunting can occur with other diseases
  • Treat with gluten free diet

21
Inflammatory Bowel Disease
  • Ulcerative Colitis
  • Crohns Disease
  • Colon only
  • Diffuse, contiguous, starting from rectum
  • Mucosal
  • 2/3 pt are pANCA
  • Any GI Segment
  • Focal, asymmetric
  • Transmural inflammation
  • /- Perianal
  • /- Fistula
  • /- Granuloma
  • 1/2 pt are ASCA

22
Treatment for IBD
Disease Severity
Severe
Surgery
Immunomodulators Corticosteroids
Mild
Aminosalicylates/Antibiotics
23
Highlights regarding Treatment of IBD
  • Azathioprine takes up to 3 months to work so used
    as maintenance drug
  • Steroids work for short term induction medication
  • Before giving TNF alpha drug have to place PPD!
  • If acute exacerbation, always rule out c. diff!

24
Highlights of Surveillance in IBD
  • Starting approximately 8-10 years after initial
    diagnosis of UC, need surveillance colonoscopy
    every 1-2 years with biopsies to look for
    dysplasia
  • If high grade dysplasia found anywhere in colon,
    need to have total colectomy

25
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