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GI Board Review Elizabeth Paine, MD Division of Digestive Diseases The University of Mississippi Medical Center.

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Presentation on theme: "GI Board Review Elizabeth Paine, MD Division of Digestive Diseases The University of Mississippi Medical Center."— Presentation transcript:

1 GI Board Review Elizabeth Paine, MD Division of Digestive Diseases The University of Mississippi Medical Center

2 Esophagus Proximal 1/3 esophagus- striated muscles under CNS control Distal 2/3 esophagus- smooth muscle under vagal and myenteric nervous system control UES and LES are normally in a contracted state Initiation of swallow relaxes both of the sphincters

3 Question 70 year old female with PMH of Parkinson’s disease, HTN, DM presents with dysphagia and occasional choking while eating for past several weeks. She notices dysphagia as soon as she initiates a swallow. CXR is normal. Which modality is the most sensitive in the diagnosis of this patient’s dysphagia? A. Esophageal manometry B. Modified barium swallow C. EGD D. Chest CT

4 Dysphagia Oropharyngeal Dysphagia - Structural disorders - Neurological disorders (Stroke, ALS, myasthenia gravis, Parkinson’s, myotonic dystrophy) Esophageal Dysphagia

5 Esophageal Dysphagia Solids Only: Solids and Liquids: CharacteristicEtiologyTreatment IntermittentSchatzki’s ringDilation Progressive + heartburnPeptic strictureDilation + PPI Progressive + weight lossEsophageal cancerDepends on stage CharacteristicEtiologyTreatment Intermittent + chest painDiffuse esophageal spasm PPI + nitrates/CCB Progressive + heartburnSclerodermaPPI Progressive + no GERDAchalasiaHeller myotomy, pneumatic dilation

6 Schatzki’s Ring 45yo M with longstanding GERD presenting with 6 months of intermittent solid food dysphagia

7 Odynophagia Ulcerative Esophagitis - Due to infection or pill - Viral (HSV,CMV) - Candida - most common Pill-Induced Esophagitis - Tetracyclines, FeSO4, Bisphosphonates, NSAIDs, Quinidine, Potassium

8 Question 55 y/o man presents with progressive dysphagia for both solids and liquids, intermittent regurgitation of food, and wt loss of 30 lbs over the course of 1 year. Symptoms not relieved with PPI. Barium esophagram shows a dilated esophagus with an air/fluid level and tapered narrowing of the distal esophagus. What is the most likely diagnosis? A. Esophageal cancer B. Esophageal stricture C. Achalasia D. Esophageal ring

9 Achalasia Failure of the LES to relax with swallowing Progressive dysphagia for solids and liquids and regurgitation Barium esophagram with esophageal dilation with classic “bird’s beak” appearance distally Esophageal manometry shows lack of relaxation of the LES with swallowing and aperistalsis of the esophageal body

10 Achalasia treatment Laparoscopic Heller myotomy Pneumatic dilation Botox injection just proximal to LES Nitrates/CCB offer temporary relief

11 Pseudoachalasia If obstruction at LES is caused by a malignant lesion, the disorder is designated “pseudoachalasia” Mimics manometric findings of achalasia EGD is recommended in all suspected cases of achalasia

12 GERD Most common cause of non-cardiac chest pain Inappropriate LES relaxation Empiric PPI - first dx/tx Refractory GERD needs EGD, pH monitoring and/or eso manometry Indications for EGD Failure of treatment Age > 50 Symptoms > 5 years Alarm symptoms - Wt Loss - Dysphagia - Anemia

13 GERD Treatments Life style modifications PPI H2 Blockers Fundoplication

14 Risks of PPI Enteric infections (C. difficile) Pneumonia Hip fractures (Osteoporosis) B12 deficiency

15 Dyspepsia Definition Alarm signs - Age >55 years with new-onset symptoms - Family history of gastric cancer - Unintentional wt. loss - GI bleeding - Dysphagia/Odynophagia - Gastric outlet obstruction signs/symptoms

16 Dyspepsia

17 Question 59 y/o white male with h/o GERD for the last 5-6 years. Symptoms have gotten worse lately. OTC tums don’t help much. Recent cardiac work up was negative. Denies N/V or weight loss. Also has HTN, DM, and Obesity. He is a smoker. Meds include HCTZ, Metformin. Other than BMI of 32 rest of PE is normal. Which of the following is the most appropriate management of this patient? A.Ambulatory esophageal pH monitoring B.Barium swallow study C.EGD D.H2 Blockers

18 Barrett’s Esophagus Normal squamous epithelium of the distal esophagus is replaced by columnar epithelium Obese/white/male/smoker with GERD Pre-malignant condition Increased risk of esophageal adenocarcinoma Long segment BE > 3 cm Histologically diagnosed by detection of specialized intestinal metaplasia and goblet cells

19 Barrett’s Esophagus

20 Management of Barrett’s esophagus (AGA guidelines 2011) FindingManagement No dysplasiaEGD every 3-5 years Low-grade dysplasiaEGD every 6-12 months High-grade dysplasia without eradication tx EGD every 3 months Mucosal irregularity within Barrett’s Endoscopic mucosal resection Invasive cancerSurgery

21 Esophageal Squamous Cell Cancer More common in men, especially black men Risk factors: Smoking, alcohol, nitrosamine exposure, corrosive injury to esophagus, achalasia, HPV Clinical presentation: Dysphagia, weight loss, GI bleed, anorexia Dx: Endoscopy. Mass usually involves upper esophagus Rx: Surgery/Chemo/Radiation

22 Question 39y/o male with PMH of seasonal allergies for past several years presented with c/o chest discomfort after he ate pork chops for lunch 2-3 hrs ago. He can’t swallow anything and feels food stuck in his chest. He has had 2 such episodes in the past. Physical examination is unremarkable. EGD is as shown. Histologic examination of the mucosa shows intense inflammation of the lamina propria with more than 15 eosinophils per HPF. No strictures are seen. What is the diagnosis? A. Achalasia B. Severe GERD C. Eosinophilic esophagitis D. Schatzki’s ring

23 Eosinophilic Esophagitis Young adults with dysphagia and food impaction and with h/o other allergic disorders Endoscopic Dx : - Mucosal longitudinal furrowing - Circumferential rings Pathology shows > Eos/HPF TX : PPI and swallowed fluticasone

24 H.Pylori Diagnosis Stool Antigen Test Urea Breath test Serum antibody test Endoscopic histology (gold standard)

25 Treatment of H.pylori Triple Therapy PPI BID+ Amox 1 Gm + Clarithromycin 500mg BID X days With PCN Allergy PPI BID + Metronidazole 500mg BID + Clarithromycin 500 mg BID X Days Quadruple Therapy PPI BID+ Bismuth 525 mg QID + Metronidazole 500 mg BID + Tetracycline 500 mg QID X days

26 Peptic Ulcer Disease Causes H.Pylori NSAIDS ZE Syndrome Malignancy Crohn’s disease Viral infections

27 Peptic Ulcer Disease Complications Bleeding (most common) (Risk factors: Age and NSAIDS) Perforation Gastric outlet obstruction Anemia

28 Management of PUD Stop NSAIDS Eradicate HP if present PPI BID x 8 weeks Follow up EGD in 8 weeks for gastric ulcers Surgery for those refractory to medical therapy

29 Zollinger-Ellison Syndrome Involves gastrinoma causing ulcers and diarrhea Gastrinomas are frequently in the duodenum or pancreas Can be associated with MEN 1 Initial tests are 3 fasting serum gastrin levels off PPI on different days Additional testing includes secretin stimulation test, octreotide scan, CT/MRI to localize gastrinoma, EUS

30 Upper GI Bleeding Causes Non-Variceal: Gastric and DU Ulcers Esophagitis/Gastritis Mallory-Weiss tear Malignancy GAVE (watermelon stomach) Hemobilia AVMs (Age, CRI, AV, OWR) Dieulafoy lesion Hemosuccus pancreaticus Aortoenteric fistula Variceal

31 Question 57 year old male presents with c/o weakness and melena for 3 days. No significant abdominal pain. He is orthostatic on exam. Stool is heme positive. NG suction with coffee-grounds material. HCT 30. What is the next step in management? A.EGD B.UGI series C.Angiography D.Insert large-bore IV’s and T/C match for blood E.EGD/Colon exam

32 Management of UGI Bleed Fluid resuscitation Blood transfusion 2 large bore IV’s or Central Line Placement PPI infusion initially Octreotide infusion (Variceal Bleed) EGD Epinephrine inj + Coag and/or clips IR or Surgery if endoscopy fails

33 Management of UGI Bleed Evaluate severity of bleed – NGT lavage that does not clear = emergent endoscopy – Coffee ground or NGT that clears in hemodynamically stable patient can wait – Hemodynamically unstable patient should be admitted to the ICU Remember ABCs Elevated BUN (normal creat) = UGI bleed Look for signs of liver disease

34 Gastric Adenocarcinoma Risk factors: smoking, blood type A, H.Pylori, family history of gastric cancer, environmental Clinical Presentation: wt. loss, abd pain, early satiety, GOO, anemia Diagnosis: Endoscopy with biopsy EUS for depth of invasion

35 Gastroparesis Causes - Idiopathic - DM - Postoperative - Autoimmune disorders Diagnosis - Rule out mechanical obstruction with EGD/UGI - 4 hr Gastric emptying test

36 Gastroparesis Management Low fat and low fiber diet Small/frequent meals Antiemetics Prokinetics GES Feeding jejunostomy tube TPN

37 Gastric Bypass Roux-en-Y is the most common in US PE is the most common cause of death post-procedure IDA B12 deficiency Calcium and Vit D deficiency

38 Dumping Syndrome Early: - within 30 minutes of eating - nausea, bloating, and diarrhea Late: hrs after eating - hypoglycemia, tachycardia, sweating Treatment: - low carb diet - small meals - more protein and fat in diet

39 Gastric volvulus Abnormal rotation of the stomach around its axis Acute volvulus: pain in the upper abdomen or lower chest, inability to pass NG tube, vomiting Radiographic findings Acute gastric volvulus is a surgical emergency. However, if the patient is a poor surgical candidate, endoscopic methods can be tried. Chronic volvulus usually has vague upper abdominal symptoms Images from Uptodate.com

40 Lower GI Bleeding Etiologies DiverticuliHemorrhoids Ischemic colitisNSAIDs/ulcers AVMs IBD Post-polypectomy bleedDieulafoy lesion Meckel’s DiverticulumRadiation colitis UGI cause in 10-15%

41 Acute Diverticular Bleeding Painless bleeding with hypotension/syncope Usually elderly patients 85% of cases have spontaneous remission Diagnosis/treatment: - Volume resuscitation with fluids/blood - Colonoscopy & endo tx - Angiography

42 Ischemic colitis Due to decreased mesenteric blood flow and hypoperfusion in “watershed” areas Due to non-occlusive ischemia Sudden LLQ pain with tenesmus, then passage of red-to-maroon stool Virtually never embolic Dx with colonoscopy or CT Rx: Supportive care with IVF, pain control, risk factor modification, +/- antibiotics

43 Management of LGIB Identify contributing factors by history (NSAIDS, antiplatelets, anticoagulants, radiation) Volume resuscitation with blood and IVF Colonoscopic treatment with epi/coag/clips Tagged RBC scan Angiography with possible embolization Small bowel eval with push enteroscopy or Pillcam

44 Obscure GI bleeding Dieulafoy lesion Hemobilia Missed lesions Meckel’s

45 Meckel’s diverticulum Outpouching of the ileum Can have ectopic gastric mucosa Maroon painless bleeding per rectum Can present with intestinal obstruction or appendicitis-like symptoms Can be diagnosed by Meckel’s scan ( 99mm technetium- pertechnetate study)

46 Diverticulitis Acute LLQ pain with fever and leukocytosis Diagnosis: - CT scan with contrast - Avoid colonoscopy Treatment: - Needs to cover Gram negatives and anaerobes - Cipro/Flagyl - Ampicillin-sulbactum

47 Pericolonic diverticular abscess IF < 3-4 cm: - antibiotics - supportive care IF > 3-4 cm: - CT guided drainage - antibiotics

48 Acute Mesenteric Ischemia Do not confuse with ischemic colitis Pain out of proportion to examination, acutely ill Due to loss of blood flow to SB and/or ascending colon Commonly embolic Older patients with h/o CHF, recent MI, cardiac arrhythmias Do angiography unless there are signs of perforation

49 Chronic mesenteric ischemia “Intestinal angina” Postprandial abdominal pain, abdominal bruit, weight loss Caused by atherosclerosis of intestinal arteries Often have signs of other PVD and smoking hx Diagnosis often based on sx although MRA or spiral CT have been used Tx: angioplasty with stent placement in patients who can tolerate this

50 Question 54 y/o WF with protein S deficiency presents with a 2 day history of severe epigastric abdominal pain with nausea/vomiting. She had this CT in the ER. What is the cause of her pain? A.Peptic ulcer disease B.Mesenteric venous thrombosis C.Biliary colic D.Functional abdominal pain

51 Risk factors: – Age > 50 – H/o adenomatous polyps – H/o breast, ovarian, or endometrial CA – Family History (1 st degree) – Ulcerative colitis/Crohn’s colitis – Lifestyle (fat, fiber, obesity) Risk factors: – Age > 50 – H/o adenomatous polyps – H/o breast, ovarian, or endometrial CA – Family History (1 st degree) – Ulcerative colitis/Crohn’s colitis – Lifestyle (fat, fiber, obesity) 3rd most common cancer in males (behind prostate and lung) and female (behind breast and lung) Colon Cancer

52 Average risk: begin at 50 FS q5y, FIT qy - if adenoma found – proceed with colonoscopy Colonoscopy q10y - if incomplete: do BE CT colonography q5y Above-average risk 1 first degree relative with CRC or adenoma <60 y/o or 2 first degree relatives with CRC or adenoma: q5y - begin age 40 or 10y younger than earliest diagnosis Personal history of polyp: q5y - Advanced polyp (>1cm, villous features, high-grade dysplasia): 3y - 3 or more polyps: 3y Colon Cancer Screening

53 Classic version has >100 adenomatous polyps Classic has 100% CA risk Proctocolectomy by age 20 Periampullary duodenal cancer # 1 cause of cancer death after colectomy FAP Variants Gardner syndrome - FAP + osteomas, desmoid tumors - supernumerary teeth Turcot’s variant - FAP + brain tumors (GBM or medulloblastoma) Attenuated APC adenomatous polyps FAP Variants Gardner syndrome - FAP + osteomas, desmoid tumors - supernumerary teeth Turcot’s variant - FAP + brain tumors (GBM or medulloblastoma) Attenuated APC adenomatous polyps Familial Adenomatous Polyposis (FAP)

54 What’s wrong with this patient?

55 Peutz-Jeghers Syndrome Multiple hamartomatous polyps & lip/buccal hyperpigmentation High cancer risk (>90%) - small bowel, colon, breast, ovarian, pancreaticobiliary Common presentation= abd pain due to intussusception or obstruction by large polyp Juvenile Polyposis Hamartomas mostly in distal colon Congenital malformation of GI,GU tract and heart Increased cancer risk - surveillance q1-3y Familial Hamartomatous Polyposis Syndromes

56 Hereditary Nonpolyposis Colon Cancer (HNPCC) or Lynch Syndrome Colon CA in 3 relatives (one first degree) over 2 generations & with one diagnosed < 50 yo – microsatellite instability (MSI) – MMR gene mutations Lynch I: limited to colon and rectum Lynch II: increased risk of CA in female genital tract, breast, other sites Surveillance: q1-2 yrs beginning age or 10 yrs before the age of youngest family member q1 year after the age of 40

57 Staging of Colon Cancer Stage Involvement 5 year survival TNM I/Duke’s A mucosa/ submucosa95% TNM II/Duke’s B muscularis or serosa 70%/85% TNM III/Duke’s C regional LN’s35%-65% TNM IV/Duke’s D metastasis5% Note: CEA levels are only helpful for recurrence of colon & only if elevated pre-colectomy & normal afer surgery

58 If a distal lesion is found, the entire colon needs to be “cleared” prior to treatment due to a high risk of concomitant lesions XRT is not used for colonic lesions – Remember this because the colon “moves around” and the XRT beam can’t localize the tumor – XRT is indicated for rectal cancer Colon Cancer

59 Stage C Colon Cancer Common Board Question Stage C = tumor penetrated into and/or through muscularis propria of bowel wall + pathologic evidence of colon cancer in lymph nodes Treatment is with 5-Fluorouracil and leukovorin

60 Classification of Diarrhea

61 Acute Diarrhea Duration – Acute (< 3 weeks) Infectious, drugs, ingestion of osmotic substances. Usually self-limited (given a competent immune system) Treatment usually only with severe dehydration/toxic

62 Infectious Diarrheas BacteriaKey pointsTreatment Staph aureusFoodborne in dairy, mayo-based salad, poultry. n/v, short incubation Supportive ETEC (E.coli)Traveler’s diarrheaSupportive, can use FQ Bacillus cereusReheated fried riceSupportive Vibrio choleraProfuse watery diarrheaCopious rehydration. Can use doxycycline GiardiaMalabsorption and steatorrhea, daycare, creek water. FQ or nitazoxanide CampylobacterBloody diarrhea. Uncooked poultry, unpasteurized milk Supportive, erythromycin if septic E.Coli 0157:H7Can cause HUS. Poorly cooked beefSupportive, avoid abx Vibrio vulnificusRaw seafood, injury in seawater. Skin infection. Can be deadly in cirrhotics. Doxycycline ShigellaAcute bloody diarrhea with tenesmus, daycare 3rd generation cephalosporin SalmonellaEggs, chicken, turtles, iguanas, other reptiles. Bloody diarrhea Supportive, avoid antibiotics unless septic, febrile

63 Diarrhea Pearls Guilian-Barre  Campylobacter Raw eggs  Salmonella HUS  E.coli O157:H7 Antibiotics  C. diff Bloody diarrhea followed by RUQ pain, fever +/- Jaundice  Amebiasis (tx flagyl + paromomycin) Abd pain, bloating, frothy stool  Giardia Rice water stools  Vibrio

64 Clostridium difficile Often will have a leukocytosis Management depends on severity and recurrence Initial episode: - Mild: metronidazole 500mg TID x days - Severe: vancomycin 125mg po QID x days First relapse: repeat same treatment as initial episode Second relapse: tapering vancomycin or fidaxomicin 200mg po BID x 10 days Subsequent relapse: fidaxomicin if not used previously vs. fecal transplant

65 Duration – Chronic (> 3 weeks) More complex work-up and treatment Chronic Diarrhea

66 Osmotic vs. Secretory Diarrhea

67 Osmotic Diarrhea Etiologies Bacterial overgrowth Lactase deficiency/malabsorption Drugs (colchicine, neomycin, magnesium- containing laxatives, lactulose) Celiac disease Tropical sprue Pancreatic insufficiency Whipple’s disease

68 Laxative abuse High volume, frequent, watery diarrhea Often associated with crampy abdominal pain Osmolar gap >50 Usually female and may be in medical field Stool magnesium often >108 mg/dL (45 mmol/L or 90 mEq/L) with magnesium-based laxatives Testing for laxatives

69 Secretory Diarrhea Most common cause is infection Enterotoxins from infections interacting with receptors causing increased anion secretion Congenital defect in transport molecules Exogenous agents – Drugs and poisons Etiologies: Enterotoxins from E.coli, V. cholera, S. aureus Villous adenomas Gastrinomas VIPomas with secretion of VIP Lymphocytic colitis Collagenous colitis Bile acids Etiologies: Enterotoxins from E.coli, V. cholera, S. aureus Villous adenomas Gastrinomas VIPomas with secretion of VIP Lymphocytic colitis Collagenous colitis Bile acids

70 Secretory “Structural” Diarrhea There must be an adequate mucosal surface area for transport to occur – Compromise water absorption – Ileal resection length >100cm: Malabsorption due to decreased bile acids <100cm: Bile acid diarrhea

71 Carcinoid syndrome Clinical symptoms: flushing, diarrhea, hypotension, hyperthermia, tachycardia Screen with urine 5-HIAA Most tumors located in terminal ileum but can be located rarely in the bronchus Treat symptoms with octreotide

72 Fat Malabsorption Celiac Disease Small-Intestinal Bacterial Overgrowth Short-bowel syndrome Pancreatic Insufficiency

73 Celiac Disease Abd discomfort, bloating, diarrhea, weight loss, flatulence IDA, Vit A,D,E,K, Folic acid deficiency Steatorrhea & enteropathy Aphthous stomatitis Associated with dermatitis herpetiformis or other autoimmune disorders

74 Celiac Disease Gluten-sensitive enteropathy Allergy to wheat, rye, barley, oats Diagnosis – Anti-tissue transglutaminase (tTG) most useful – IgG/IgA antigliadin antibodies – Anti-endomysial antibody less sensitive – HLA –DQ2 or HLA-DQ8 Treat with gluten free diet Steroids for refractory disease

75 Celiac Disease

76 Whipple’s Disease Tropheryma whipplei (G + Bacilli) PAS positive material in macrophages Dx by PCR on Biopsy or CSF

77 Whipple’s Disease Clinical Features - Intermittent episodes of polyarthritis - Diarrhea with wt. loss - CNS: Dementia, myoclonus, ophthalmoplegia - Psych: Depression and personality changes - Card: pericarditis, myocarditis Treatment: IV Ceftriaxone x 2 weeks followed by oral Bactrim x months

78 Toxic megacolon Acute toxic colitis with colonic dilation Complication of ischemic colitis, infectious colitis, C.diff, IBD, etc Signs of sepsis Can result in perforation Management: IVF, replete electrolytes, IV antibiotics, colonic decompression, consult surgeon Surgery indications

79 Colonic inertia Severe form of slow- transit constipation Disordered colonic motor function Sitz marker test Conservative measures tried first If symptoms persist, may need surgery

80 Question 55 y/o F presented with a 2-month history of profuse watery diarrhea up to 5 times per day without bleeding, abdominal pain or vomiting. She had lost 5lbs but there was no history of iritis, arthritis, rashes or aphthous ulcers. Exam was normal. Labs revealed a normal CBC, CMP, and CRP. There was no growth on stool culture. Colonoscopy was normal without ulceration. Her biopsies are shown. What is causing her symptoms? A.Crohn’s disease B.Ulcerative colitis C.Microscopic colitis D.Irritable bowel syndrome – diarrhea predominant

81 Irritable bowel syndrome Chronic crampy abdominal pain, alternating bowel habits, improves with defecation Rome criteria Treatment: - Reassurance - Dietary modifications including low FODMAP diet - adjunctive medical therapy

82 Crohn’s diseaseUlcerative colitis LesionsFocal, skip, deepShallow, continuous Clinical CourseIndolentMore acute SteroidsLess responsiveVery responsive GranulomaPathognomonicNone Rectal Involvement Rectal sparingRectum involved Perianal diseaseAbscesses, fistulasNone Inflammatory Bowel Disease

83  GI CA  UC >>> Crohn’s Toxic megacolon  Both – BE contraindicated in acute exacerbation Smoking & CD   risk exacerbation Smoking & UC  UC symptoms can start w/tobacco cessation IBD Clinical Pearls

84 Crohn’s Disease: Pearls Bimodal age distribution – Peak 20-30s – Smaller one in 70-80s – ASCA+ in 50-60% Granulomas are pathognomonic… …but seldom seen “String sign” in TI on SBFT 30% colon, 40% SB, 30% both – “mouth to anus”

85 Area of involvement – proctitis – left-sided colitis – pancolitis (“universal colitis”) 70-80% P-ANCA + Ulcerative Colitis: Pearls

86 5 ASA – Several designer drugs – “col” = colon (Asacol, Colazal…) Steroids—avoid if possible – Budesonide (Entocort) Azathioprine/6-MP – Immunomodulator – Steroid-sparing agent – Monitor for SEs Methotrexate Antibiotics Anti-TNF therapies – Fistulizing disease – Unresponsive to conventional therapy IBD Treatments

87 Usually seen in colitis therefore more common in UC Seronegative arthropathy Uveitis, Ankylosing Spondylitis (HLA-B27) Erythema nodosum Pyoderma gangrenosum Primary sclerosing cholangitis (HLA-B8) – PSC, check ALP annually  2X ULN  ERCP/MRCP Osteoporosis HLA associated manifestations do not correlate with course of colitis IBD Extraintestinal Manifestations

88 Duration & extent of disease, age at dx increases risk – Ulcerative Proctitis has no  risk CA – 10 years  2% – 20 years  15% Pancolitis- begin at 8 years (AGA guidelines) Left sided colitis- begin at 15 years (AGA guidelines) Colonoscopies are generally performed q1-2 years after surveillance is started, depending on findings High-grade dysplasia or cancer  colectomy Low grade dysplasia management is controversial UC and Cancer

89 Physical Exam Pearls Emaciation, cheilosis, glossitis – Severe malabsorption Associated dermatitis herpetiformis – Celiac sprue Associated pyoderma gangrenosum -- IBD Arthritis – IBD or Whipple’s Pulmonic stenosis and tricuspid regurgitation – Carcinoid syndrome

90 Physical Exam Pearls Associated neuropsychiatric findings – Whipple’s disease Abdominal mass – Malignancy, Crohn’s, diverticulitis Localized abdominal tenderness – Inflammatory condition Perianal ulcers/fistulas, reduced sphincter tone/incontinence/right sided abdominal pain -- Crohn’s Peripheral or autonomic neuropathy – May correlate with visceral neuropathy in DM and intestinal pseudo-obstruction

91 Questions?


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