Gastroenterology

1
Gastroenterology
2
Gastroesophageal Reflux

• Most common reason for the use of antacids in the
  United States
• 5-10 of Americans have heartburn daily
• Cause multi-factorial, decreased L.E.S pressure
  is seen approximately 25 of the time when the
  reflux occurs
• Drugs known to lower LES pressure calcium
  channel blockers, beta-agonists, anti-cholinergic
  medications, alphablockers, theophylline,
  progesterone, morphine, dopamine and nitrates

3
Gastroesophageal Reflux (Contd)

• Esophageal complications esophagitis, bleeding,
  stricture, Barretts esophagus, adenocarcinoma
• Extra-esophageal complications Laryngitis,
  Laryngeal carcinoma , Tracheal stenosis, Asthma,
  Aspiration pneumonitis, Chronic cough, Dental
  erosion
• Diagnostic Tests pH monitoring (gold standard),
  esophogram,manometry,PPI Trial
• Treatment Lifestyle Modification, Pharmacologic
  Therapy, Antireflux surgery

4
Esophagitis

• Can be caused by an infection or irritation of
  the esophagus
• Infection can occur because of bacteria, viruses
  (herpes), fungi, and yeast (Candida)
• A primary condition or secondary to
  gastroesophageal reflux, hiatal hernia, vomiting,
  surgery, medications, Lye, Radiation
• Symptoms Dysphagia, Odynophagia, Heart Burn
  (reflux), oral lesions (herpes)

5
Esophagitis (Contd)

• TestsBarium esophagogram, Acid perfusion tests,
  Culture, Esophagoscopy with/without biopsy (gold
  standard)
• Treatment depends on the specific cause
• Complications severe discomfort, swallowing
  difficulty, malnutrition /dehydration, scarring,
  Barrett's esophagus, cancer

6
Barretts Esophagus

• Esophageal squamous epithelium replaced with
  metaplastic columnar epithelium
• Incidence up to 10/lifetime
• Variable
• Usually men gt55
• GERD commonly present
• Dx EGD with biopsy
• Treatment
• Treat reflux aggressively PPI
• Surveillance for dysplasia
• No dysplasia q 3-5 years
• Dysplasia confirm with expert pathologist/
• GI specialist
• Mortality reduction - unproven

7
Varices

• Bleeding accounts for 1/3 of all deaths in
  patients with cirrhosis and portal hypertension
• Preventive beta blockers, banding, evaluation
  for liver transplantation
• Treatment  banding, balloon tamponade, TIPS,
  Octreotide and vasopressin, Portacaval shunts
• Complications recurrent bleeding, hypovolemic
  shock, esophageal stricture, encephalopathy,
  infection

8
Zenker's Diverticulum

• The most common type of esophageal diverticulum,
  etiology is uncertain
• More common in men than women, usually presents
  over 60 years of age
• Symptoms dysphagia, regurgitation, coughing,
  aspiration, unexplained weight loss, halitosis,
  feeling of food sticking
• Diagnosis endoscopy, barium esophagography
• Treatment
• Recurrent symptomatic
• Usually surgery

9
Mallory-Weiss Syndrome

• Incidence is 4 out of 100,000
• From prolonged and forceful vomiting, coughing or
  convulsions, excess ETOH
• Sx hematemesis and/or melena secondary to
  mucosal tears at the GE junction
• Resolves within 10 days without special
  treatment, recurrent bleeding uncommon
• Occasionally may need EGD to stop bleeding.
  Surgery is rarely required

10
Achalsia

• A diffuse motor disorder incomplete relaxation
  of the L.E.S and absence of peristalsis (this
  cardinal finding sufficient to make a diagnosis
  of achalasia)
• Symptoms dysphagia, regurgitation, and the
  classic x-ray finding of gradual tapering of
  distal esophagus(birds beak)
• Esophageal manometry (gold standard)
• Treatment
• Esophageal dilatation
• Surgery
• Botulinum toxin injections into L.E.S

11
Cause of Nonanginal Chest Pain

• 0-1 features of typical Angina
• Substernal
• Worse with exertion/emotion
• Relieved by rest/NTG
• Nonspecific or "psychogenic" chest pain,
  sometimes occurs acutely as panic disorder, is
  the leading cause of non-anginal chest pain
• MAY COEXIST WITH CAD

12
Cause of Nonanginal Chest Pain (Contd)

• May be attributable to musculoskeletal problems,
  respiratory causes of chest pain
• Esophagitis, peptic ulcer, gallbladder disease,
  pancreatitis, and hiatal hernia may lead to chest
  discomfort
• Gall bladder disease has long been thought to be
  capable of inducing various types of anginal and
  nonanginal chest pain
• Mitral valve prolapse may be associated with
  symptoms of non-anginal chest pain

13
Dysphagia

• Common in aging persons, approximately 7 to 10
  percent of adults older than 50 years
• Oropharyngeal dysphagia dysfunctional transfer
  from pharynx to esophagus
• Stroke is the leading cause of oropharyngeal
  dysphagia
• Esophageal dysphagia disordered peristaltic
  motility(Neuromuscular Disorder) or (Mechanical
  Obstruction)

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Dysphagia (Contd)

• Neuromuscular Motility disorder progressive
  difficulty in swallowing solid food and liquids,
  Achalasia and scleroderma are the leading
  motility disorders
• Mechanical Obstruction typically dysphagia of
  solid food but not liquids (carcinomas,
  strictures and Schatzki's rings)
• Patient history will identify 80 - 85 of the
  causes of dysphagia. (Consider malignancy)
• Further testing may be indicated to confirm a
  diagnosis or to establish risk of aspiration

15
Odynophagia

• A strong feeling of burning, squeezing pain while
  swallowing
• Dysphagia may or may not be present
• May have symptoms of chest pain, food stuck in
  the throat, or heaviness or pressure in the neck
  or upper chest
• May be caused by destruction of the mucous
  membrane, infection, chemicals, or motor
  disorders of the esophagus

16
Upper GI Bleeding

• Hematemesis and/or melena (black tarry stools)
• Hematochezia (maroon or bright red blood per
  rectum) when massive
• Multiple etiologies PUD, Mallory-Weiss,
  Variceal, Carcinoma
• Diagnosis-clinical presentation
• /- NG lavage

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Upper GI Bleeding (Contd)

• PUD bleeding risk stratity by EGD for
  rebleeding
• Active bleeding 90
• Visible vessel 50
• Clot 25-30
• Flat spot/clean ulcer 3-10
• With low risk may be safely fed/discharge

18
Upper GI Bleeding (Contd)

• Endoscopic treatment
• Thermal coagulation (heater probe, gold probe,
  BICAP)
• Injective therapy (epinephrine)
• Combination therapy commonly used for high risk
  causes i.e. active bleeding
• Endoclips
• Antisecretory therapy
• PPI unproven benefit
• Omeprazole i.v. decreases rebleeding after
  endoscopic treatment
• H2 blockers disappointing results
• Octreotide reduce rebleeding RR 0.5
• 50-100 mcg bolus, 25-50 mcq/hr for up to 3 days

19
Upper GI Bleeding (Contd)

• Surgery
• Secondary prevention of recurrent bleeding UI
  caps
• Incidence 1/month
• Treatment of H. pyloni
• Avoid risk factors
• Maintenance H2B or PPI for high risk

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Dyspepsia

• 25 percent (13 to 40 percent) of population
• The most common cause of dyspepsia is
  functional or nonulcer, dyspepsia (specific
  etiology is not identified)
• 3 Options endoscopy all patients, trial of
  empiric antisecretory drug therapy, testing for
  H. pylori infection followed by Rx if positive
• Ranking of options is controversial, and no
  definitive recommendations can be made
• 1/3 - 1/2 spontaneous resolution of symptoms

21
Nausea and Vomiting

• Definition
• Nausea-unpleasant sensation of being about to
  vomit
• Retching-similar to vomiting without expulsion of
  gastric contents
• Regurgitation-effortless return of gastric
  contents typical of GERD
• Vomiting-forceful expulsion
• Vomiting
• Controlled humoral/neuronal stimuli to CNS
  chemo receptor trigger zone and nucleus tractus
  solitorius

22
Nausea and Vomiting (Contd)

• Selected different Dx
• Rumination
• Daily, effortless regurgitation of undigested
  foods usually in mentally impaired children (and
  adults) reassurance and behavioral therapy are
  primary treatment
• Eosinophilic Gastroenteritis
• Rare disorder eosinophilic infiltration of the
  gut suspect in history of allergy, peripheral
  eosinophilia responsive to steroids
• Cyclic Vomiting Syndrome
• Repeated episodes of nausea/vomiting (hours/days)
  separate by symptom-free episodes treatment
  supportive

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Diagnostic Approach to Nausea and Vomiting

• Guided by history and exam examples
• Early morning vomiting in female pregnancy
• Abdominal tenderness and feculent emesis bowel
  obstruction
• Vertigo labyrinthitis
• Addition of new medications drug induced
• Enamel erosion, calluses on dorsum on hands
  bulimia

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Diagnostic Approach to Nausea and Vomiting
(Contd)

• If history/exam doesnt suggest specific cause,
  evaluate for
• Low grade intestinal obstruction CT, small
  bowel series
• Metabolic causes TSH, Free T4, Glucose, CaH
• Mucosal abnormalities EGD with bx
• Psychogenic, bulimic, rumination

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Treatment

• Emetogenic chemotherapy
• Prn
• Lorazepam 1-3 mg q 4-6 hr
• Prochlorperazine (15 mg spansule bid) or
• Metoclopramide (30 mg qid) diphenhydramine (50
  mg qid) for restlessness
• Oral 5-HT3 antagonist (Ondanestron 16 mg/d or
  Granisetron 2 mg/d Dexamethasone 20 mg
  orally/i.v.
• Motion sickness/vestibular antihistamines
• Postoperative and drug induced
• 5 HT3 antagonist
• Dopamine antagonist

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Acute Pancreatitis Etiology

• Etiology
• Gallstones 45
• Alcohol 35
• Others
• Post ERCP
• Tumor
• Drugs
• Anatomic variation
• Cystic Fibrosis
• Symptoms
• Acute upper abdominal pain steady
• Alcohol related 1-3 days after binge

27
Acute Pancreatitis Etiology (Contd)

• Tests
• Amylase
• Usually elevated for 3-5 days and gt3x upper
  limits of normal
• Elevated in nonpancreatic processes (cirhosis,
  renal failure, alcoholism, intestinal infarct,
  fallopian tubes)
• Lipase
• Elevation occur earlier and last longer than
  Amylase
• ABD US/CT-ABD with contrast (R/O necrosis as
  nonenhancing areas gt3 cm in size

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Acute Pancreatitis Treatment

• Early ERCP for gallstone pancreatitis and then
  elective cholecystectomy usually prior to
  hospital discharge
• Pain control Meperdine traditional but no
  clinical benefit over Morphone or Fentanyl
• Prophylactic antibodies reduce mortality in
  severe necrotizing pancreatitis (gt30 Necrosis)
• Imipenem, fluoroquinolones
• Enteral Feeds
• Considered safe
• May reduce complications
• High protein, low fat (Peptamen)
• Start slow
• 100-300 cc fluids q 4hr day 1
• Same volume add nutrients day 2

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Complications of Acute Pancreatitis

• Pseudocyst or abscess formation
• Gastrointestinal hemorrhage secondary to
  ulceration or varices
• Right-side hydronephrosis
• Splenic rupture or hematoma
• Shock
• A.R.D.S.
• Acute renal failure secondary to ATN
• Psychosis
• Metabolic abnormalities including hyperglycemia
  and hypocalcemia

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Chronic Pancreatitis

• Most common etiology alcohol
• Diagnosis based on clinical criteria in the
  setting or recurrent abdominal pain assisting by
  imaging
• Pain epigastirc, radiates to back postprandial
• Pancreatic insufficiency 90 of pancreas usually
  destroyed. Loose, greasy, foul smelling stools
  that are difficult to flush. Diabetes is usually
  insulin requiring
• Amylase/Lipase commonly normal
• Imaging U.S., CT Scan, MRI, ERCP, Endoscopic
  U.S., Plain flims

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Chronic Pancreatitis - Pain Control

• Mostly the art of medicine not science
• Non-specific
• Analgesics
• Anti-depressants
• Decrease intra pancreatic pressure
• Inhibition of gastric acid secretion H2B/PPI
  reduce PH stimuli to pancreatic secretion
• Pancreatic enzymes
• Nerve blocks
• Endoscopic stents for structures
• Surgery decompression, denervation, resection

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Celiac Sprue

• Chronic malabsorption disease of the small
  intestine in genetically suspectable individuals
• USA 1/250
• Serologic tests for antibodies identify most
  patients
• Antiendomysial
• Anti gliadin

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Celiac Sprue (Contd)

• Distal duodenal biopsy is the gold standard for
  the diagnosis of celiac disease
• Common signs/symptoms
• Malabsorption weight loss
• Fe deficient anemia
• Osteoperosis (in men)
• Abdominal pain
• Treatment strict gluten-free diet
• No wheat, rye, barley

34
Acute Diarrhea

• More than 3 times per day, less than 14
  days,usually spontaneously resolves
• Bacterial, viral, parasitic, non-infectious
• Rehydrate, Diet, anti-diarrhetics
• Antimicrobials for persistent shigella,
  salmonella or campylobacter infections
  especially immunocompromised, artificial
  prostheses, persistent parasitic causes
• Limit antimicrobials in immunocompetent
  individuals (antimicrobial resistance)

35
Acute Diarrhea (Contd)

• With fever and blood (invasive pathogen)
• Shigella, Campylobacter, Salmonella
• Leukocytes in feces, fecal culture, thick
  bloodsmear for malaria
• Antibiotics for serious,persistent infection
• No fever or blood(Non-invasive pathogens)
• Enterotoxic E.coli, Giardia, Rotavirus, Norwalk,
  Parasites
• Traveler's diarrhea (85 of cases)
• No leukocytes in feces, fecal culture (low yield)
• Correct dehydration, spontaneous recovery except
  treat parasite infection

36
Chronic Diarrhea

• Lasts for more than 2 weeks
• Infectious Parasites Cryptosporidium,
  Cyclospora, Entamoeba, Giardia,microsporidia
  Bacteria Campylobacter, Clostridium difficile,
  E.coli, Listeria, Salmonella, Shigella, Viral
  HIV, rotavirus, Norwalk
• NonInfectious drugs, crohns disease, endocrine
  diseases, food additives (sorbitol, fructose, and
  others), food allergies, GI surgery or radiation,
  tumors, intestinal ischemia, lactose, caffeine,
  ETOH

37
Chronic Diarrhea (Contd)

• Usually related to functional disorders like
  irritable bowel syndrome, celiac disease, or
  inflammatory bowel disease
• Should consider testing if patients are febrile
  or have bloody stool
• Avoid antimotility agents in bloody diarrhea
  especially when caused by E. coli O157H7, (risk
  of hemolytic-uremic syndrome)
• Endoscopy more specific than radiographic studies
  in detecting the etiology of chronic diarrhea

38
Constipation

• Less than three stools per week
• Usually from excess absorption of water from slow
  passage in the colon
• Possible causes, motility disorder and pelvic
  floor disorder, endocrine disorder
• Older people, not a result of aging but chronic
  illnesses, diet, neurologic and psychiatric,
  medicines, lack of exercise
• In infancy and childhood most constipation is
  functional rather than organic

39
Constipation (Contd)

• Most common cause inadequate fiber content
• No clear agreement to which tests are usefull
• Organic, metabolic, endocrine disease need to be
  excluded
• Treatment of constipation is symptomatic
• Eat regular, eight (8-oz)glasses of water daily,
  regular exercise, move bowels when urged
• Best Tx, a diet rich in fiber (30 - 35 grams
  daily)
• Avoid stimulant laxatives, a suppository or
  gentle enema is better

40
Intestinal Ischemia

• Acute mesenteric ischemia mortality rates 71,
  diagnosis before infarction is most important
  factor to improve outcome
• Chronic mesenteric ischemia (intestinal angina)
  is characterized by postprandial abdominal pain,
  and marked weight loss
• Colon ischemia the most common form, most cases
  do not have a recognizable cause, most resolve
  spontaneously, usually has an excellent prognosis

41
Lower GI Bleeding

• Causes bleeding diverticulum, carcinoma,
  angiodysplasia, Crohns disease, ulcerative
  colitis, dysentery,hemorrhoids, fissure
• Beets may simulate hematochezia
• Most causes are initially self limited
• Colonoscopy with epinephrine injection or bipolar
  coagulation if severe hematochezia
• Angiography or nuclear medicine studies can be
  useful to localize lower GI bleeding

42
Occult GI Bleeding

• Positive fecal occult blood test, and/or iron
  deficiency anemia (IDA), without visible blood
• More commonly a bleeding source in the upper GI
  tract (29 to 56 percent) than in the lower
  gastrointestinal tract (20 to 30 percent)
• Likelihood of finding a bleeding source higher
  in patients with IDA (61 to 71) than those with
  positive FOBT (48 to 53 percent)
• Colonoscopy and upper endoscopy remain the major
  investigative methods

43
Obscure GI Bleeding

• Bleeding of unknown origin that persists or
  recurs after negative endoscopic evaluation
• Requires evaluation of the small bowel, may
  require repeat upper and lower endoscopy
• Biopsy to detect celiac sprue, a cause of IDA
• Push Enteroscopy, Enteroclysis, Radioisotope
  bleeding scans (high false-positives)
• Angiography can identify highly vascular
  nonbleeding lesions such as angiodysplasia and
  neoplasms
• Wireless capsule endoscopy for small bowel
  lesions (Given Imaging)

44
Anal / Rectal Disease

• Most frequent causes of anorectal bleeding are
  hemorrhoids, fissures and polyps
• High index of suspicion for cancer
• Evaluation of bright red blood per rectum
• lt40 and obvious source no additional eval
• 40-50 sigmoidoscopy
• gt50 colonsocopy

45
Anal / Rectal Disease (Contd)

• Pruritus ani is more likely to represent a
  chronic itch/scratch cycle than infection
• Any pruritic lesion that persists after adequate
  treatment should be biopsied
• Anal pain with fever and inability to void
  signals perineal sepsis and is an emergency
• Biopsy all "warts" before ablative treatment
  Verrucous carcinoma can appear to be a wart
• Cancer can coexist with benign lesions, so
  complete assessment is necessary

46
Crohns Disease

• Can involve entire GI tract, mouth to the anus,
  terminal ileum is most commonly affected, 2 - 3
  have upper GI involvement
• Corticosteroids should not be used as long-term
  agents to prevent relapse
• Azathioprine/mercaptopurine have demonstrable
  maintenance benefits after inductive therapy with
  corticosteroids
• Severe cases with failure to improve within 7-10
  days with intensive management consider surgery

47
Ulcerative Colitis

• Most serious complications Toxic Megacolon (20
  mortality rate)
• Risk of colon cancer doubles every 10 years, 5
  will develop colon cancer
• If entire colon involved, risk of cancer may be
  as great as 32 times the normal rate
• Yearly colonoscopy with biopsy for patients who
  have had the disease gt than 8-10 years
• Surgery to remove entire colon is curative,
  25-40 eventually undergo this procedure

48
Microscopic Colitis

• A cause of chronic diarrhea, its etiology is
  unknown, (Collagenous and Lymphocytic Colitis)
• Biopsy is the only way to make the diagnosis (the
  colon appears normal during endoscopy)
• In pts with chronic diarrhea and a normal
  colonoscopy (without biopsy) or barium enema, 10
  will have microscopic colitis
• Flexible sigmoidoscopy with multiple biopsies
  from the left colon will detect almost all
  patients with microscopic colitis and may
  preclude the need for a colonoscopy

49
Irritable Bowel Syndrome (IBS)

• The most widely accepted diagnostic criteria for
  IBS are the Rome II Criteria
• Rome II Criteria
• 12 weeks or more, need not be consecutive in
  preceding 12 months of abdominal discomfort/pain
  with 2 of the following
• Relieved with defecation
• Change in frequency of stool
• Change in form

50
Irritable Bowel Syndrome (IBS) (Contd)

• Diagnosis can be based upon typical clinical
  findings
• Doesnt require exhausting diagnostic evaluation
• Blood count, sed rate, FOBT, O/P stool, and if
  gt50 colonic evaluation
• Red flags (weight loss, anemia, occult GI
  bleeding, nocturnal awakening) are inconsistent
  with diagnosis
• Prevalence 10-20 and only 10-30 of those seek
  medical care

51
Irritable Bowel Syndrome (IBS) (Contd)

• Psychological stress exacerbates symptoms in
  everyone not just IBS
• Medication for symptom control
• Pain/floating antispasmodic, TCA, SSRI
• Constipation fiber
• Diarrhea loperamide
• Alosetron (Lotronex) women severe diarrhea
  predominant
• Tegaserod (Zelnorm) women severe constipation
  predominant

52
Cirrhosis

• The eleventh leading cause of death by disease in
  the United States
• In the United States, chronic alcoholism and
  hepatitis C are the most common causes
• Three criteria (1) diffuse disease, (2) the
  presence of fibrosis and (3) replacement of
  normal architecture by abnormal nodules
• Diagnosis should include the cause of the liver
  disease

53
Cirrhosis (Contd)

• Maintain a balanced diet containing 1 to 1.5 g of
  protein per kg per day
• Premalignant condition, risk of hepatocellular
  carcinoma
• Hepatocellular carcinoma is a leading cause of
  death in patients with cirrhosis
• Once cirrhosis has developed, hepatitis C is the
  most common cause of hepatocellular Ca
• Screening with alpha-fetoprotein and
  ultrasonography every six months

54
Ascites

• In patients with cirrhosis and Ascites
• Ascites is the most common form of clinical
  decompensation
• Carries a poor prognosis, 50 mortality within 2
  years
• Prone to spontaneous bacterial peritonitis
  (diagnostic tap is mandatory if suspect
  infection)
• Patients with new-onset ascites or clinical
  deterioration should undergo paracentesis
• Evaluation for liver transplantation should be
  considered in all patients

55
Ascites (Contd)

• Follow a sodium-restricted diet
• Diuresis, with spironolactone (Aldactone) as
  first-line therapy and occasional use of a
  supplemental loop diuretic
• Diagnosis of spontaneous bacterial peritonitis
  (SBP) heralds advanced liver disease
• Antibiotic prophylaxis for SBP as a preventive
  strategy cannot be definitely recommended
• TIPSS (Transjugular intrahepatic portal-systemic
  stent-shunt) is an efficacious treatment for
  patients with refractory ascites

56
Hemochromatosis

• The most common single-gene disorder in the U.S.
  white population (one in 250 to 300)
• HFE gene test to confirm the diagnosis, and
  screen adult family members
• Many patients have no manifestations
• Liver biopsy remains the "gold standard" for
  assessing the degree of fibrosis
• Risk of hepatocellular carcinoma is 200 times
  higher (risk of cancer persists even after
  excess iron stores have been depleted)

57
Hepatitis A

• Seroprevalence in US 38
• Children lt5 yr 10 gt50 yr 74
• Accounts for 20-40 of all viral hepatitis
• Spread fecal-oral route maternal-fetal
  transmission not reported
• Usually results in acute, self-limited illness or
  asymptomatic infection (majority of cases)
• Fulminant disease more common when co-infected
  with HBV or HCV, especially when older
• Labs
• ALT gt AST usually gt1000 IU/dl
• Bilirubin gt10 mg/dl is common
• IgM anti-HAV-gold standard for diagnosis

58
Hepatitis A (Contd)

• Treatment - supportive
• 85 full clinical/biochemical recovery in 3 mo.
• Prevention handwashing
• Survive on fingertips up to 4 hours
• Household dilute bleach (1100 dilution)
• Postexposure proplyaxis
• Immune globulin and HAV vaccination usually
  administrated together
• Immune globulin effective within 2 weeks of
  exposure
• Vaccine recommended for higher risk groups
  (chronic liver disease, occupational risk,
  children in states with higher risk (gt2x national
  average))

59
Hepatitis B

• Global public health problem
• 300 million HBV carriers
• 250,000 deaths yearly
• In USA 0.1-2 prevalence of HBV carriers
• Transmission
• Perinatal
• 90 if mother HBeAg positive (30 if negative)
• Infection at or after birth
• C/S doesnt prevent
• Breastfeeding doesnt increase risk

60
Hepatitis B (Contd)

• Transfusion
• Decreasing 2 routine screening by HBsAg and
  anti-HBC
• Risk 163,000 during window period
• Sexual
• 50 of cases in U.S.
• Nosocomial
• Most commonly transmitted blood-borne virus more
  common from patient to health care provider
• Percutaneous exposure and risk of infection
• HBV 6-30
• HCV 0-7
• HIV 0.3

61
Hepatitis B (Contd)

• Treatment for chronic HBV infections
• Considered when HBsAg gt6 months, evidence of
  active virus replication (HBeAg and HBV DNA
  positive) and active liver disease (chronic
  hepatitis on biopsy, elevated ALT)
• Interferon Therapy
• 12-24 weeks in doses of 5 Million Units
  (MU)/daily or 10 Million Units (MU) 3x/week
• Pegylated interferon may be helpful
• Results
• Supresses HBV replication (? HBV-DNA, HBeAg)
• Improvement in liver disease (normal ALT)
• Prevention of cirrhosis, hepatocellular caranoma,
  survival (SCANT DATA)

62
Hepatitis C

• Acute process often asymptomatic prevalence in
  U.S. 1.8
• 80 develop chronic hepatitis
• 10-15 of these develop cirrhosis of which 10
  may develop decompensated disease or
  hepatocellular carcinoma (HCC)
• Most common cause of chronic liver disease and
  most frequent indication for liver transplant

63
Hepatitis C (Contd)

• Transmission
• Primarily through exposure to infected blood
• anti-HCV screening started in 1992
• Heterosexual monogamous relationships
• Risk low 0-0.5/year
• May not be higher than general population
• Dont need barrier protection
• Perinatal
• 2 when EIA positive, 7 when HCV RNA positive
• NO data on preventive by C/S
• Breastfeeding doesnt appear to transmit
• Test infant at 2 and 6 months for HCV RNA and at
  15 months for anti-HCV

64
Hepatitis C (Contd)

• Lab Testing
• EIA (3rd generation) sensitivity and specificity
  99 - excellent test
• Qualitative HCV RNA test should follow to
  confirm acute or chronic HCV infection
• Quantitative HCV RNA test (qPCR, bDNA) provides
  important prognosis information to treatment
• Screen for HCC despite lack of data
• AFP and hepatic U.S. screening commonly done on
  cirrhotics, not all HCV positive patients

65
Hepatitis C (Contd)

• Treatment
• Highest response with Pegylated Interferon and
  Ribavarin
• Genotype 1
• Treat for 48 weeks if minimum of 2 log decrease
  detected at 12 weeks
• Ribavarin 1000-1200 mg usual dose
• Genotype 2,3
• Treat 24 wk
• Ribavarin 800 mg

66
Cholangitis

• 85 of cases due to impacted stone in duct
• Charcots Triad (RUQ abdominal pain, fever and
  jaundice) present in 70 of cases
• Diagnosis increased WBC, increased LFTS, blood
  cultures, ERCP(gold standard), cholangiogram,
  ultrasound
• Management ERCP with stone removal, Antibiotics
  that cover gram-negative organisms, consider
  cholecystectomy

67
Gallbladder Disease

• Acute Cholecystitis
• 90 of cases - gallstone obstructs the cystic
  duct,10 of cases - absence of gallstones
  (acalculous cholecystitis)
• Diagnostic tests Ultrasound (most useful),
  Cholescintigraphy, Abdominal CT scanning
• Management definitive therapy -cholecystectomy
• Pregnant patient -conservative therapy
  (antibiotics and supportive care)

68
Gallbladder Disease (Contd)

• Choledocholithiasis
• 15 of patients with gallbladder stones have
  stones in common bile duct
• Tests ERCP (gold standard), cholangiography
• Ultrasound visualizes about 50 of common bile
  duct stones, can detect CBD dilatation in 75 of
  cases
• Complications cholangitis, acute pancreatitis
• Management stone removal by ERCP, early
  cholecystectomy