1. GI Board Review

2. Esophagus

3. GERD Middle aged overweight male with retrosternal burning and regurgitation worse with citrus and smoking.

4. GERD Symptoms Symptoms Retrosternal burning – post prandial/recumbant Retrosternal burning – post prandial/recumbant Regurgitation Regurgitation Dysphagia Dysphagia Water Brash Water Brash Chronic Cough Chronic Cough Historical clues: Pregnancy, Scleroderma, Obesity, hiatal hernia Historical clues: Pregnancy, Scleroderma, Obesity, hiatal hernia Gold standard – 24 hour pH probe Gold standard – 24 hour pH probe

5. GERD Complications Complications Barrett’s Barrett’s Adenocarcinoma Adenocarcinoma Strictures/Rings Strictures/Rings Hoarseness/Asthma Hoarseness/Asthma Empiric treatment – Sensitivity of 80% Empiric treatment – Sensitivity of 80% When refer for endoscopy? When refer for endoscopy? Evaluate for Barrett’s/anatomy Evaluate for Barrett’s/anatomy Don’t respond to therapy Don’t respond to therapy Alarm symptoms – dysphagia, bleeding, weight loss, anemia, odynophagia Alarm symptoms – dysphagia, bleeding, weight loss, anemia, odynophagia Chronic Chronic

6. GERD - treatment On the Boards, remember to be cost effective On the Boards, remember to be cost effective Lifestyle modification (Weight loss most important and avoidance of foods that cause LES relaxation i.e. peppermint, chocolate, alcohol, fatty foods) Lifestyle modification (Weight loss most important and avoidance of foods that cause LES relaxation i.e. peppermint, chocolate, alcohol, fatty foods) Acid suppression Acid suppression PPI > H2 blocker(80% control symptoms) PPI > H2 blocker(80% control symptoms) PPI better in endoscopically proven esophagitis PPI better in endoscopically proven esophagitis Promotility – Reglan/Cisapride (Minimal Data) Promotility – Reglan/Cisapride (Minimal Data) Surgery – Nissen Fundoplication Surgery – Nissen Fundoplication Equivalent to PPI therapy – 0.2% mortality Equivalent to PPI therapy – 0.2% mortality 2/3 will be on acid suppression in 5 years 2/3 will be on acid suppression in 5 years No evidence that prevents Barrett's or CA No evidence that prevents Barrett's or CA Endoscopic Therapy (Stretta, Endocinch, etc) Endoscopic Therapy (Stretta, Endocinch, etc) Rarely performed. Rarely performed.

7. Barrett’s Esophagus 55 year old white male with 10 years of pyrosis, mildly improved over past year, on PPI daily.

8. Barrett’s Esophagus Middle aged and older, M>F (2:1) Middle aged and older, M>F (2:1) Whites and Hispanics predominantly Whites and Hispanics predominantly About 5-10% of patients with GERD (though in multiple studies, also present in 0%-25% of asymptomatic patients) About 5-10% of patients with GERD (though in multiple studies, also present in 0%-25% of asymptomatic patients) Defining characteristic: Change in squamous esophageal epithelium to intestinal metaplasia Defining characteristic: Change in squamous esophageal epithelium to intestinal metaplasia 0.5% per person per year chance of developing adenocarcinoma 0.5% per person per year chance of developing adenocarcinoma Treatment Treatment Control GERD Symptoms – PPI vs. surgery Control GERD Symptoms – PPI vs. surgery No therapy definitively shown to reduce risk of progression to malignancy No therapy definitively shown to reduce risk of progression to malignancy Surveillance endoscopy Surveillance endoscopy

9. Esophageal Cancer 75 year old female with history of tobacco use and alcohol use with progressive solid food dysphagia and 15 pound weight loss over past year.

10. Esophageal Cancer Essentially equal prevalence in United States of esophageal SCC and adenocarcinoma Essentially equal prevalence in United States of esophageal SCC and adenocarcinoma Squamous Cell – proximal esophagus Squamous Cell – proximal esophagus Smoking Smoking Tylosis Tylosis Achalasia Achalasia Plummer-Vinson Plummer-Vinson Lye Lye Ethanol Ethanol Sprue/Scleroderma Sprue/Scleroderma Adenocarcinoma – Distal esophagus Adenocarcinoma – Distal esophagus GERD/Barrett’s, Obesity, Tobacco GERD/Barrett’s, Obesity, Tobacco

11. Esophageal Cancer Symptoms Symptoms Progressive Solid Food Dysphagia Progressive Solid Food Dysphagia 75% also weight loss/anorexia 75% also weight loss/anorexia Endoscopy with Biopsy – Diagnostic Endoscopy with Biopsy – Diagnostic Staging Staging 1. CT chest/abd/pelvis vs. PET for Mets 1. CT chest/abd/pelvis vs. PET for Mets 2. EUS for T and N staging 2. EUS for T and N staging

12. Dysphagia Dysphagia Solids Intermittent Ring or Stricture Progressive Esophageal CA Solids/liquids Intermittent DES Progressive Achalasia / Scleroderma

13. Dysphagia History and Physical History and Physical Solid vs. liquid Solid vs. liquid Intermittent vs. progressive Intermittent vs. progressive Oropharyngeal vs. Esophageal Oropharyngeal vs. Esophageal Barium swallow (13mm pill) Barium swallow (13mm pill) EGD (with possible dilation) EGD (with possible dilation) Esophageal manometry Esophageal manometry

14. Peptic Stricture Progressive solid food dysphagia Progressive solid food dysphagia History of GERD History of GERD No weight loss No weight loss Patients have normal appetite Patients have normal appetite Majority (60-70%) are peptic in origin Majority (60-70%) are peptic in origin Result of chronic esophageal inflammation Result of chronic esophageal inflammation

15. Esophageal Ring 38 year old female with frequent heartburn, controlled on PPI, with intermittent solid food dysphagia.

16. Achalasia 35 year old male with progressive solid and liquid food dysphagia and fatigue, with regurgitation of undigested food.

17. Achalasia “failure to relax” 1/100,000 1/100,000 M:F 1:1 M:F 1:1 Age 25-60 (If older>60, think pseudoachalasia especially gastric cancer) Age 25-60 (If older>60, think pseudoachalasia especially gastric cancer) Increased risk for squamous cell cancer Increased risk for squamous cell cancer Hallmarks: Hallmarks: Aperistalsis Aperistalsis Failure of LES to relax Failure of LES to relax Dysphagia to solid and liquid Dysphagia to solid and liquid Postural changes to help swallowing Postural changes to help swallowing Regurgitation of undigested food Regurgitation of undigested food Autoimmune vs. Viral Autoimmune vs. Viral Chagas Disease (Trypanosoma cruzei) Chagas Disease (Trypanosoma cruzei)

18. Achalasia - diagnosis Barium Swallow – Dilated esophagus with column of barium and “Birds Beak” taper. Test of choice if suspected Barium Swallow – Dilated esophagus with column of barium and “Birds Beak” taper. Test of choice if suspected Endoscopy – rule out pseudoachalasia Endoscopy – rule out pseudoachalasia Manometry (Used to confirm diagnosis) Manometry (Used to confirm diagnosis) (1)Loss of peristalsis, (1)Loss of peristalsis, (2)failure of LES to relax, (2)failure of LES to relax, (3)possibly LES high pressure (3)possibly LES high pressure Chest X-ray – wide mediastinum and air fluid level Chest X-ray – wide mediastinum and air fluid level

19. Eosinophilic Esophagitis 20 year old male with history of asthma and eczema with recurrent food impactions.

20. Eosinophilic Esophagitis Atopic history and food impactions Atopic history and food impactions Ringed esophagus / linear furrows Ringed esophagus / linear furrows >15 eosinophils per high power field >15 eosinophils per high power field Some (minority) have peripheral eosinophilia Some (minority) have peripheral eosinophilia Oral fluticasone 220 mcg/puff 2 puffs bid for 6-8 weeks. Recurrence frequent. Oral fluticasone 220 mcg/puff 2 puffs bid for 6-8 weeks. Recurrence frequent. Other possible treatments: Other possible treatments: PPI, singulair (large doses up to 100 mg), elimination diets (children predominantly) and dilation PPI, singulair (large doses up to 100 mg), elimination diets (children predominantly) and dilation

21. Scleroderma Historical Key: 70 year old woman with sclerodactyly telangiectasias, Raynaud’s with GERD, resistant to PPI Historical Key: 70 year old woman with sclerodactyly telangiectasias, Raynaud’s with GERD, resistant to PPI 75% have esophageal involvement 75% have esophageal involvement Severe GERD, frequently resistant to PPI Severe GERD, frequently resistant to PPI Incompetent LES and lack of peristalsis Incompetent LES and lack of peristalsis Control GERD with PPI Control GERD with PPI

22. Stomach

23. Upper GI bleed

24. Presentation Hematemesis (Not to be confused with hemoptysis) Hematemesis (Not to be confused with hemoptysis) Melena (Black, Tar-Like – not solid) Melena (Black, Tar-Like – not solid) Nausea/vomiting common with PUD Nausea/vomiting common with PUD Orthostasis (Bedside orthostatics) Orthostasis (Bedside orthostatics) Abdominal pain Abdominal pain Hematochezia (10% of maroon stool from upper source – On test will be unstable) Hematochezia (10% of maroon stool from upper source – On test will be unstable)

25. Upper GI Bleed Peptic Ulcer Disease – 55% Peptic Ulcer Disease – 55% Esophageal Varices – 14% Esophageal Varices – 14% AVM’s / GAVE – 6% AVM’s / GAVE – 6% Mallory-Weiss tear – 5% Mallory-Weiss tear – 5% Dieulafoy’s – 1% Dieulafoy’s – 1% Cameron’s lesion Cameron’s lesion Tumors Tumors Esophagitis (Most common cause of UGIB in hospitalized patients, likely due to NGT and reflux in supine position) Esophagitis (Most common cause of UGIB in hospitalized patients, likely due to NGT and reflux in supine position)

26. Peptic Ulcer Disease 65 year old female with arthritis, taking ibuprofen, with melena and lightheadedness.

27. Risk Factors for NSAID-induced Ulcers Definite: Prior PUD Prior PUD Advanced age Advanced age Concomitant use of glucocorticoids Concomitant use of glucocorticoids Concomitant use of anticoagulants Concomitant use of anticoagulants High doses or combinations of NSAIDs, including low-dose aspirin High doses or combinations of NSAIDs, including low-dose aspirin Comorbid illness (RA, CAD, etc) Comorbid illness (RA, CAD, etc) Ethanol use Ethanol use Possible: H. pylori infection smoking

28. Helicobacter pylori Most peptic ulcers caused by Helicobacter pylori Most peptic ulcers caused by Helicobacter pylori 60-80% of GU’s and 90% DU’s 60-80% of GU’s and 90% DU’s 2 clinical presentations of H. pylori 2 clinical presentations of H. pylori Antrum predominant Antrum predominant Increased acid production, Duodenal Ulcers, no cancer Increased acid production, Duodenal Ulcers, no cancer Body predominant Body predominant Decreased acid production, Gastric Ulcers, Gastric Cancer (<1% of those infected, Cag A strain) Decreased acid production, Gastric Ulcers, Gastric Cancer (<1% of those infected, Cag A strain) Eradication of Hp dramatically decreases PUD and its complications Eradication of Hp dramatically decreases PUD and its complications

29. Tests for H. pylori Serologic Antibody (90% sens / 90% spec) Serologic Antibody (90% sens / 90% spec) Remains positive for several years Remains positive for several years Do not use for evaluation for eradication Do not use for evaluation for eradication Endoscopy with Histology (95% sens / 98% spec) Endoscopy with Histology (95% sens / 98% spec) Endoscopy w/Rapid Urease Test (CLO) (90% /98%) Endoscopy w/Rapid Urease Test (CLO) (90% /98%) Urease Breath Test (C13 / C14) (95% / 95%) Urease Breath Test (C13 / C14) (95% / 95%) Best test for eradication Best test for eradication Stool Antigen (92% / 90%) Stool Antigen (92% / 90%) All tests (except serology) less reliable if on PPI in last 2 weeks, or antibiotics or bismuth in past 4 weeks. All tests (except serology) less reliable if on PPI in last 2 weeks, or antibiotics or bismuth in past 4 weeks.

30. Rx of H. pylori Standard : Amoxicillin, Clarithromycin, PPI bid x 14 days Standard : Amoxicillin, Clarithromycin, PPI bid x 14 days 75-80% eradication rate 75-80% eradication rate Major antibiotic resistance to clarithromycin and metronidazole. Major antibiotic resistance to clarithromycin and metronidazole. If allergic to PCN, substitute metronidazole for amoxicillin If allergic to PCN, substitute metronidazole for amoxicillin

31. Peptic Ulcer Disease – Rebleed Risk (within 72 hours) BaselinePPI PPI/EGD Tx Clean Base3-5%---- ---- Pigmented Spot7-10%---- ---- Adherent Clot22-30%0% 6.7% Adherent Clot22-30%0% 6.7% Visible Vessel43-52%12% 6.7% Visible Vessel43-52%12% 6.7% Active Bleeding55-90%73% 6.7%

34. Zollinger-Ellison Gastrin producing neuroendocrine tumor Gastrin producing neuroendocrine tumor 1% of PUD (Never seen clinically but all over board exams) 1% of PUD (Never seen clinically but all over board exams) 90% will have PUD (frequently solitary duodenal ulcer but may be multiple and in unusual places i.e. jejunum) 90% will have PUD (frequently solitary duodenal ulcer but may be multiple and in unusual places i.e. jejunum) Frequently with abdominal pain and chronic secretory diarrhea Frequently with abdominal pain and chronic secretory diarrhea 70% Duodenum/30% Pancreas 70% Duodenum/30% Pancreas 1/3 metastatic at diagnosis 1/3 metastatic at diagnosis

35. Zollinger - Ellison Fasting Gastrin >1000 diagnostic if acidic pH in stomach (separate low acid states (atrophic gastritis and pernicious anemia) from ZE) Fasting Gastrin >1000 diagnostic if acidic pH in stomach (separate low acid states (atrophic gastritis and pernicious anemia) from ZE) 150-1000 abnormal but can be secondary to meds (PPI) or H pylori causing atrophic gastritis 150-1000 abnormal but can be secondary to meds (PPI) or H pylori causing atrophic gastritis Secretin Stimulation Test (secretin infusion promotes gastrin release by gastrinoma cells but not gastric G cells) Secretin Stimulation Test (secretin infusion promotes gastrin release by gastrinoma cells but not gastric G cells) Positive test - Increased Gastrin by at least 120-200 pg/ml within 20 minutes after secretin infusion Positive test - Increased Gastrin by at least 120-200 pg/ml within 20 minutes after secretin infusion Localize with octreoscan/EUS of pancreas Localize with octreoscan/EUS of pancreas

36. MEN1 Pancreatic islet cell tumors seen with MEN1 about 80% of time (parathyroid, pituitary, pancreas) Pancreatic islet cell tumors seen with MEN1 about 80% of time (parathyroid, pituitary, pancreas) 50-60% with MEN1 have gastrinoma, but… 50-60% with MEN1 have gastrinoma, but… About 20% with gastrinoma have MEN1 About 20% with gastrinoma have MEN1 Most common pancreatic islet cell tumor associated with MEN1 is a “nonfunctioning” islet cell tumor (i.e. releases hormone that does not cause symptoms like PPP) Most common pancreatic islet cell tumor associated with MEN1 is a “nonfunctioning” islet cell tumor (i.e. releases hormone that does not cause symptoms like PPP)

37. Gastric Cancer Diffuse (Infiltrating cells, i.e. linitis plastica) vs. Intestinal Type (glandular) Diffuse (Infiltrating cells, i.e. linitis plastica) vs. Intestinal Type (glandular) Most common in Far East (if Japanese or Korean patient with stomach complaint, think of gastric cancer) Most common in Far East (if Japanese or Korean patient with stomach complaint, think of gastric cancer) Risk Factors Risk Factors 1 st degree relative (3x) 1 st degree relative (3x) H. pylori – Chronic Atrophic Gastritis H. pylori – Chronic Atrophic Gastritis Dietary – Nitrates Dietary – Nitrates Tobacco Tobacco

38. Gastric Cancer Epidemiology

39. Pancreas

40. Acute pancreatitis Alcohol or gallstone predominant etiologies Alcohol or gallstone predominant etiologies Drugs – DDI, diuretics, estrogen, valproic acid, 5-ASA, azathioprine, TCN, sulfa Drugs – DDI, diuretics, estrogen, valproic acid, 5-ASA, azathioprine, TCN, sulfa Interstitial (85%) vs. necrotizing (15%) Interstitial (85%) vs. necrotizing (15%) Organ failure in 10% vs. 54% Organ failure in 10% vs. 54% Mortality Rate 3% vs. 17% Mortality Rate 3% vs. 17% 33% of patients with sterile necrosis develop infected necrosis 33% of patients with sterile necrosis develop infected necrosis 47% mortality with MSOF 47% mortality with MSOF Interesting fact – Pain radiates to back only about 50% of time. Interesting fact – Pain radiates to back only about 50% of time.

41. Complications SIRS: ARDS, Shock, ARF, GI Bleed SIRS: ARDS, Shock, ARF, GI Bleed Necrosis: Infection Necrosis: Infection Pseudocyst/Abscess Pseudocyst/Abscess Pancreatic Ascites, Fistula (pleural effusion) Pancreatic Ascites, Fistula (pleural effusion) Chronic Pancreatitis Chronic Pancreatitis Splenic Vein Thrombosis, Pseudoaneurysm Splenic Vein Thrombosis, Pseudoaneurysm

42. Treatment Mild – NPO, pain control, fluid resuscitation Mild – NPO, pain control, fluid resuscitation Severe pancreatitis – Likely ICU Severe pancreatitis – Likely ICU Adequate pain relief, Adequate pain relief, Adequate IV fluid replacement, especially initially (decrease Hct over first 24 hours to reduce risk of necrosis) Adequate IV fluid replacement, especially initially (decrease Hct over first 24 hours to reduce risk of necrosis) ERCP for gallstone panc (cholangitis/jaundice) (suspect if ALT or AST>3x ULN) ERCP for gallstone panc (cholangitis/jaundice) (suspect if ALT or AST>3x ULN) Nutritional support Nutritional support Enteral feeding better than TPN due to decreased episodes of hyperglycemia and sepsis Enteral feeding better than TPN due to decreased episodes of hyperglycemia and sepsis Current teaching to place feeding tube beyond Ligament of Treitz (controversial) Current teaching to place feeding tube beyond Ligament of Treitz (controversial)

43. Enteral Nutrition and Severe Pancreatitis # PTS Kalfarentos et al Br J Surg 1997; 84:1665

44. Treatment Severe pancreatitis Severe pancreatitis Contrast CT recommended at some point beyond the first 3 days in severe pancreatitis to rule out necrotizing pancreatitis. Contrast CT recommended at some point beyond the first 3 days in severe pancreatitis to rule out necrotizing pancreatitis. Otherwise, minimal role for early CT Otherwise, minimal role for early CT No role for prophylactic antibiotics with sterile necrosis (controversial) No role for prophylactic antibiotics with sterile necrosis (controversial) If concern for infected necrosis (usually after 7 days), CT guided aspiration. If concern for infected necrosis (usually after 7 days), CT guided aspiration.

45. Chronic pancreatitis

46. Chronic Pancreatitis Chronic epigastric pain/maldigestion related to fibrotic pancreas Chronic epigastric pain/maldigestion related to fibrotic pancreas Diagnosis usually made after disease is well established. Diagnosis usually made after disease is well established. Most frequently associated with alcohol abuse Most frequently associated with alcohol abuse Maldigestion with steatorrhea/weight loss Maldigestion with steatorrhea/weight loss Fat soluble vitamin and B12 deficiency Fat soluble vitamin and B12 deficiency DM common in advanced disease DM common in advanced disease

47. Chronic Pancreatitis Lipase and amylase normal or only slightly elevated Lipase and amylase normal or only slightly elevated May mimic pancreatic cancer or autoimmune pancreatitis (IgG4, ANA) with duodenal or biliary obstruction May mimic pancreatic cancer or autoimmune pancreatitis (IgG4, ANA) with duodenal or biliary obstruction Complications: pseudocyst, splenic vein thrombosis, pancreatic cancer (4% lifetime risk) Complications: pseudocyst, splenic vein thrombosis, pancreatic cancer (4% lifetime risk)

48. Diagnosis (difficult) Clinically useful tests for CP FunctionStructure Secretin stim test ERCP/EUS Bentiromide testCT scan Serum trypsinogenUS Fecal chymotrypsinKUB Fecal fat Sensitivity

49. Treatment Pain relief Pain relief Non-enteric coated pancreatic enzymes (Viokase) with PPI Non-enteric coated pancreatic enzymes (Viokase) with PPI Narcotics Narcotics Celiac plexus block (CT vs. EUS) Celiac plexus block (CT vs. EUS) ERCP with stent or stone removal ERCP with stent or stone removal Surgical resection or Peustow procedure Surgical resection or Peustow procedure Maldigestion (steatorrhea) Maldigestion (steatorrhea) Coated Pancreas enzyme (Creon) Coated Pancreas enzyme (Creon)

50. Pancreatic Cancer 2 nd most common GI cancer and 4 th most common cancer death in US 2 nd most common GI cancer and 4 th most common cancer death in US Rare before age 45, M>F, African Americans>Whites Rare before age 45, M>F, African Americans>Whites 28,000 cases per year (27,000 deaths) 28,000 cases per year (27,000 deaths) 85-90% originate from pancreatic ductal cells 85-90% originate from pancreatic ductal cells Rarer cancers of acinar cells or neuroendocrine cells Rarer cancers of acinar cells or neuroendocrine cells Painful or painless jaundice, acholic stool, dark urine, weight loss Painful or painless jaundice, acholic stool, dark urine, weight loss Elevated CA 19-9 Elevated CA 19-9 Diabetes frequently diagnosed within past 2 years Diabetes frequently diagnosed within past 2 years

51. Treatment Biggest risk factors – Hereditary pancreatitis, smoking, BRCA-2, chronic pancreatitis Biggest risk factors – Hereditary pancreatitis, smoking, BRCA-2, chronic pancreatitis Only 20% resectable at diagnosis Only 20% resectable at diagnosis Surgery Surgery Head – Whipple procedure Head – Whipple procedure Tail – Distal pancreatectomy/Splenectomy Tail – Distal pancreatectomy/Splenectomy Palliation – Intestinal/Biliary bypass Palliation – Intestinal/Biliary bypass ERCP – Biliary/Duodenal Metal Stent ERCP – Biliary/Duodenal Metal Stent Chemo - 5FU and Gemcitabine Chemo - 5FU and Gemcitabine Role of XRT controversial Role of XRT controversial

52. Pancreatic Neuroendocrine Tumors Insulinoma Insulinoma Usually solitary, 5-10% malignancy Usually solitary, 5-10% malignancy Hypoglycemia - 48 hour fast Hypoglycemia - 48 hour fast Glucagonoma Glucagonoma Necrolytic migratory erythema, weight loss, diarrhea Necrolytic migratory erythema, weight loss, diarrhea 75% malignancy rate 75% malignancy rate VIPoma (aka Verner-Morrison Syndrome or WDHA (Watery diarrhea, hypokalemic and achlorhydria) VIPoma (aka Verner-Morrison Syndrome or WDHA (Watery diarrhea, hypokalemic and achlorhydria) Secretory diarrhea, flushing, achlorhydria, hypokalemia Secretory diarrhea, flushing, achlorhydria, hypokalemia Elevated fasting VIP Level Elevated fasting VIP Level Increased risk of neuorendocrine tumors in MEN1, Von Hippel- Lindau, neurofibromatosis 1, tuberous sclerosis Increased risk of neuorendocrine tumors in MEN1, Von Hippel- Lindau, neurofibromatosis 1, tuberous sclerosis

53. Choledocholithiasis IOC EUSus ERCP MRCP

54. Common Bile Duct stones/Cholangitis Obstructive jaundice WITH pain Obstructive jaundice WITH pain Rising LFTS after Lap Chole – either retained stone in CBD vs. Bile leak Rising LFTS after Lap Chole – either retained stone in CBD vs. Bile leak Answer is ERCP Answer is ERCP Cholangitis Cholangitis Charcot Triad: RUQ Pain, Fever, Jaundice Charcot Triad: RUQ Pain, Fever, Jaundice Reynolds Pentad : Shock, MS changes Reynolds Pentad : Shock, MS changes ERCP stone extraction/biliary stent placement ERCP stone extraction/biliary stent placement IR placed percutaneous GB drain IR placed percutaneous GB drain Antibiotics : Floroquinolone or Unasyn/Zosyn Antibiotics : Floroquinolone or Unasyn/Zosyn

55. Gallstones Presentation: Usually asymptomatic Presentation: Usually asymptomatic Biliary colic, acute cholecystitis, CBD obstruction (acute elevation of ALT, AST, Alk phos and TB with direct predominance), pancreatitis Biliary colic, acute cholecystitis, CBD obstruction (acute elevation of ALT, AST, Alk phos and TB with direct predominance), pancreatitis If no symptoms from stones, then no treatment If no symptoms from stones, then no treatment Type: 75-80% cholesterol stones Type: 75-80% cholesterol stones Risk factors: 4F’s - fat, fertile, female, forty Risk factors: 4F’s - fat, fertile, female, forty Ethnicity, rapid weight loss Ethnicity, rapid weight loss 20% pigmented stones 20% pigmented stones Black – hemolysis and cirrhosis (calcium bilirubinate) Black – hemolysis and cirrhosis (calcium bilirubinate) Brown – Anaerobic bile duct infections (Rare in US) Brown – Anaerobic bile duct infections (Rare in US) Diagnosis: Ultrasound best, CT, MRCP Diagnosis: Ultrasound best, CT, MRCP Treatment – If symptomatic, cholecystectomy. If not surgical candidate, ursodiol. Treatment – If symptomatic, cholecystectomy. If not surgical candidate, ursodiol.

56. Biliary Tree Tumors Carcinoma of GB is the leading cause of biliary tree tumors. Carcinoma of GB is the leading cause of biliary tree tumors. Risks include: Risks include: Gallstones Gallstones Choledochal cysts Choledochal cysts GB polyps (primarily single and >1 cm) GB polyps (primarily single and >1 cm) Porcelain GB Porcelain GB Cholangiocarcinoma-rare but increasing incidence. Risks include: UC PSC Thorotrast Choledochal cysts Clonorchis and Opisthorchis Treatment - Surgery in minority vs. Palliative stent

57. Colon

58. Acute Diarrhea Virus Virus Norovirus Norovirus Rotavirus Rotavirus Adenovirus Adenovirus Protozoa Protozoa Giardia Giardia Entamoeba histolytica Entamoeba histolytica Cryptosporidium (HIV) Cryptosporidium (HIV) Cyclospora Cyclospora Toxin mediated Toxin mediated Bacteria Salmonella Campylobacter Shigella E.Coli (0157:H7) C. Difficile Yersinia Vibrio Listeria

59. Norovirus Nursing homes, hospitals, cruise ships, restaurants Nursing homes, hospitals, cruise ships, restaurants Incubation 24-48 hours (also highest shedding) Incubation 24-48 hours (also highest shedding) Abd cramps followed by vomiting and diarrhea Abd cramps followed by vomiting and diarrhea Nonbloody watery diarrhea Nonbloody watery diarrhea Myalgias and malaise, low grade fever Myalgias and malaise, low grade fever Lasts 48-72 hours Lasts 48-72 hours Symptomatic treatment Symptomatic treatment

60. Campylobacter Food borne disease – 3 day incubation Food borne disease – 3 day incubation Typically with fever, severe abdominal pain (may mimic appendicitis) and bloody diarrhea Typically with fever, severe abdominal pain (may mimic appendicitis) and bloody diarrhea Lasts on average 7 days Lasts on average 7 days Associated with Reactive Arthritis, Guillain-Barre Syndrome, and pericarditis Associated with Reactive Arthritis, Guillain-Barre Syndrome, and pericarditis Treatment – Mainly supportive as disease usually self limited Treatment – Mainly supportive as disease usually self limited If severe, use Erythromycin (other possibilities include Flouroquinolones, Macrolides, and Aminoglycosides) If severe, use Erythromycin (other possibilities include Flouroquinolones, Macrolides, and Aminoglycosides) Most resistant to septra Most resistant to septra

61. Salmonella Non-typhoid Salmonella typhimurium and Salmonella enteritidis Salmonella typhimurium and Salmonella enteritidis Largest number of food borne outbreaks in US Largest number of food borne outbreaks in US Eggs, poultry, undercooked beef, and pet reptiles and rodents Eggs, poultry, undercooked beef, and pet reptiles and rodents Nausea, vomiting, diarrhea, fever, abd pain Nausea, vomiting, diarrhea, fever, abd pain 4-10 days of diarrhea 4-10 days of diarrhea Antibiotics have not been shown to be of benefit in routine cases Antibiotics have not been shown to be of benefit in routine cases Flouroquinolones or bactrim in severe cases or comorbidity (HIV) Flouroquinolones or bactrim in severe cases or comorbidity (HIV) May become chronic carriers May become chronic carriers

62. EHEC (0157:H7) Enterohemorrhagic Escherichia coli Enterohemorrhagic Escherichia coli Undercooked ground beef, petting zoos, daycare Undercooked ground beef, petting zoos, daycare Differ from other E. coli in the production of Shiga Toxins Differ from other E. coli in the production of Shiga Toxins Enter circulation and target endothelial cells causing vascular damage and prothrombotic state Enter circulation and target endothelial cells causing vascular damage and prothrombotic state Incubation 3-4 days Incubation 3-4 days >90% will have bloody diarrhea >90% will have bloody diarrhea Abdominal Pain Abdominal Pain Often lack a fever Often lack a fever HUS: 6-9% --- 50% dialysis, 3-5% mortality HUS: 6-9% --- 50% dialysis, 3-5% mortality Treatment – Supportive Treatment – Supportive Avoid antimotility agents and antibiotics (risk of causing HUS) Avoid antimotility agents and antibiotics (risk of causing HUS)

63. Shigella Not susceptible to acid, so few organisms cause infection Not susceptible to acid, so few organisms cause infection Fever, abdominal cramps, mucoid or bloody diarrhea Fever, abdominal cramps, mucoid or bloody diarrhea 3 day incubation, 7 day duration 3 day incubation, 7 day duration Rare cause of HUS and reactive arthritis Rare cause of HUS and reactive arthritis Associated with seizures and encephalopathy in children Associated with seizures and encephalopathy in children Treatment – antibiotic recommended (FQ) Treatment – antibiotic recommended (FQ) Reduce shedding and person to person transmission Reduce shedding and person to person transmission Decrease fever and diarrhea by 2 days Decrease fever and diarrhea by 2 days

64. Clostridium dificile Associated with antibiotic usage, older age, and possibly PPI Associated with antibiotic usage, older age, and possibly PPI NAP1/BI/027 strain with larger quantities of toxins A and B, worse outcomes, and associated with leukemoid reaction. NAP1/BI/027 strain with larger quantities of toxins A and B, worse outcomes, and associated with leukemoid reaction. Think C diff in inpatient on antibiotics with WBC 20K. Think C diff in inpatient on antibiotics with WBC 20K. Treatment - Fluids, Avoid/Hold antibiotics Treatment - Fluids, Avoid/Hold antibiotics Metronidazole 500mg TID or 250mg QID Metronidazole 500mg TID or 250mg QID Oral Vancomycin 125 – 250 mg po QID Oral Vancomycin 125 – 250 mg po QID 20% Relapse rate – retreat with Flagyl or Vancomycin 20% Relapse rate – retreat with Flagyl or Vancomycin

65. Other Infectious Causes Amebiasis (Entamoeba histolytica) Amebiasis (Entamoeba histolytica) Invade and penetrate colonic mucosa Invade and penetrate colonic mucosa Subacute moderate diarrhea with abdominal pain and bloody stools and weight loss Subacute moderate diarrhea with abdominal pain and bloody stools and weight loss Treatment – Metronidazole 500-750 mg tid for 7-10 d Treatment – Metronidazole 500-750 mg tid for 7-10 d Giardia lamblia (Chronic, large volume) Giardia lamblia (Chronic, large volume) Contaminated water source (stream, well), or person to person (daycare, MSM) Contaminated water source (stream, well), or person to person (daycare, MSM) Watery diarrhea, malaise, steatorrhea, abd cramps and bloating Watery diarrhea, malaise, steatorrhea, abd cramps and bloating Treatment: Metronidazole 250 mg tid for 5 days Treatment: Metronidazole 250 mg tid for 5 days

66. Chronic Diarrhea

67. Chronic Diarrhea (>4wks) Diarrhea Watery OsmoticSecretory InflammatoryFatty Initial Testing: Large Volume (Small Bowel) vs. Small Volume (colon) 1. Stool Osmolar Gap = 290 – 2(Na +K) 100 osmotic 2. Fecal Occult Blood Testing and Fecal Leukocytes 3. Fecal Fat - >7g over 24 hours with 100 g fat diet (tends to be higher (i.e. 30g/day) with maldigestion than malabsorption)

68. Chronic Diarrhea Osmotic Osmotic Mg, PO4, Carb Maldigest Mg, PO4, Carb Maldigest Fatty Fatty Short gut/Resection Short gut/Resection Bacterial overgrowth Bacterial overgrowth Mucosal Disease/Celiac Mucosal Disease/Celiac Pancreatic insufficiency Pancreatic insufficiency Inflammatory Inflammatory Inflammatory Bowel Inflammatory Bowel Ischemia Ischemia Diverticulitis Diverticulitis Chronic infection Chronic infection Secretory Non-osmotic laxative Post-cholecystectomy Bile acid malabsorption IBS Gastrinoma VIPoma Mastocytosis Carcinoid syndrome Hyperthyroid Vasculitis Microscopic colitis Lymphoma, colon ca

69. History for Chronic Diarrhea Osmotic gets better with fasting – others don’t Osmotic gets better with fasting – others don’t Bloody BM’s – Inflammatory (UC) Bloody BM’s – Inflammatory (UC) Weight loss – Fatty, Inflammatory Weight loss – Fatty, Inflammatory RLQ pain – think Crohn’s RLQ pain – think Crohn’s Iron Deficiency – think Celiac sprue Iron Deficiency – think Celiac sprue Wakes up at night with symptoms – not IBS Wakes up at night with symptoms – not IBS Ask about medications or surgeries (cholecystectomy or IC valve resection, etc) Ask about medications or surgeries (cholecystectomy or IC valve resection, etc)

70. Irritable Bowel Syndrome Rome III Criteria Rome III Criteria Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following Improvement with defecation Improvement with defecation Onset associated with a change in frequency of stool Onset associated with a change in frequency of stool Onset associated with change in form of stool Onset associated with change in form of stool Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

71. Irritable Bowel Syndrome Pain poorly localized and inconsistent and often in BLQ Pain poorly localized and inconsistent and often in BLQ Need to have bowel movement soon after meals (gastro-colic reflex) Need to have bowel movement soon after meals (gastro-colic reflex) Symptoms do NOT wake the person from sleep Symptoms do NOT wake the person from sleep Symptoms worsened with stress Symptoms worsened with stress Less than age 40 at start of symptoms Less than age 40 at start of symptoms Depression or Anxiety Depression or Anxiety Often overlap with other functional syndromes (Dyspepsia, FMS, etc) Often overlap with other functional syndromes (Dyspepsia, FMS, etc)

72. Evaluation for IBS If meet Rome III Criteria then testing has not been shown to be helpful (except for sprue in diarrhea predominant) If meet Rome III Criteria then testing has not been shown to be helpful (except for sprue in diarrhea predominant) Celiac Sprue serology has been positive in 5% Celiac Sprue serology has been positive in 5% Sigmoidoscopy/Colonoscopy no benefit Sigmoidoscopy/Colonoscopy no benefit ESR, FOBT, Stool Culture, O&P etc. no benefit ESR, FOBT, Stool Culture, O&P etc. no benefit If they don’t meet the criteria or fit the usual description then testing is indicated If they don’t meet the criteria or fit the usual description then testing is indicated For testing purposes, avoid performing diagnostic tests (CT) on patients who meet Rome III criteria For testing purposes, avoid performing diagnostic tests (CT) on patients who meet Rome III criteria

73. Treatment Treat symptoms Treat symptoms Most medications have unproven benefit Most medications have unproven benefit Fiber : Metamucil, Citrucel, Benefiber Fiber : Metamucil, Citrucel, Benefiber Antispasmodics: Bentyl, Levsin, Donnatol Antispasmodics: Bentyl, Levsin, Donnatol Tricyclic Antidepressants, SSRI’s Tricyclic Antidepressants, SSRI’s Imodium (diarrhea), Miralax (constipation) Imodium (diarrhea), Miralax (constipation) Stress Reduction Stress Reduction Avoid fatty foods, Avoid Dairy Avoid fatty foods, Avoid Dairy

74. Celiac Sprue 40 year old Irish immigrant with history of DM 1 and hypothyroidism with steatorrhea, microcytic anemia and mild elevation of ALT (80). 40 year old Irish immigrant with history of DM 1 and hypothyroidism with steatorrhea, microcytic anemia and mild elevation of ALT (80). Chronic malabsorption of small intestine secondary to exposure to dietary gluten (gliadin portion) Chronic malabsorption of small intestine secondary to exposure to dietary gluten (gliadin portion) 1:250 in US 1:250 in US Symptoms include: Symptoms include: Diarrhea or steatorrhea Diarrhea or steatorrhea Weight loss Weight loss Transaminase elevations Transaminase elevations Anemia (iron deficiency) Anemia (iron deficiency) Vitamin deficiency Vitamin deficiency Asymptomatic Asymptomatic

75. Celiac Disease Associated with HLA DQ2 and DQ8 Associated with HLA DQ2 and DQ8 Associated diseases: Associated diseases: IBS IBS Osteoporosis Osteoporosis IgA nephropathy IgA nephropathy Dermatitis Herpetiformis - Elbows, knees, buttocks Dermatitis Herpetiformis - Elbows, knees, buttocks Increased risk of lymphoma (NHL) and GI malignancies Increased risk of lymphoma (NHL) and GI malignancies DM 1 DM 1 IgA deficiency IgA deficiency Thyroid disease Thyroid disease

76. Celiac Sprue Diagnose with endomysial Ab or tissue transglutaminase Ab (both IgA). Confirm diagnosis with small bowel biopsy. Diagnose with endomysial Ab or tissue transglutaminase Ab (both IgA). Confirm diagnosis with small bowel biopsy. Activated T-cells damage villous architecture with inflammatory response (blunted villi, epithelial lymphocytic infiltrate, crypt hyperplasia). Activated T-cells damage villous architecture with inflammatory response (blunted villi, epithelial lymphocytic infiltrate, crypt hyperplasia). All testing improves with treatment All testing improves with treatment Gluten-free diet Gluten-free diet No wheat, rye or barley No wheat, rye or barley Not in oats, though they are often contaminated with gluten Not in oats, though they are often contaminated with gluten Nonresponsive or relapse likely due to dietary indiscretion Nonresponsive or relapse likely due to dietary indiscretion

77. Lower GI Bleed Diverticular (Painless) Diverticular (Painless) Ischemic Colitis (painful) Ischemic Colitis (painful) Angiodysplasia Angiodysplasia Cancer / Polyps Cancer / Polyps Ulcerative Colitis / Crohn’s Hemorrhoids 10% LGIB is from upper source Diagnose etiology with colonoscopy If unable to find source of bleeding or if unable to tolerate a colonoscopy then: Tagged RBC Scan (Technetium 99m) - Requires.1-.4ml/min of active bleeding Angiography - Requires.5-1ml/min of active bleeding Allows directed therapy with gelfoam etc.

78. Inflammatory Bowel Disease String sign – seen with Crohn’s

79. Ulcerative Colitis Recurring episodes of inflammation limited to the mucosal layer of the colon. Invariably involving the rectum and extends proximally in a continuous fashion. Recurring episodes of inflammation limited to the mucosal layer of the colon. Invariably involving the rectum and extends proximally in a continuous fashion. Bloody diarrhea Bloody diarrhea Rectal urgency Rectal urgency Abdominal cramps Abdominal cramps Fever, weight loss, anorexia, N/V Fever, weight loss, anorexia, N/V

80. UC - Complications Massive hemorrhage Massive hemorrhage Toxic megacolon Toxic megacolon Colonic perforation (5%) Colonic perforation (5%) Extraintestinal Manifestations Extraintestinal Manifestations Lead pipe – chronic UC

81. UC - treatment Inducing remission Inducing remission Mild = 5-ASA (mesalamine, sulfasalazine) Mild = 5-ASA (mesalamine, sulfasalazine) Moderate = Steroid taper Moderate = Steroid taper Severe = IV steroids, Cyclosporine, colectomy, TNF alpha antagonists (i.e. Remicade or Humira) Severe = IV steroids, Cyclosporine, colectomy, TNF alpha antagonists (i.e. Remicade or Humira) Maintenance Maintenance 5-ASA 5-ASA Azathioprine/6-MP Azathioprine/6-MP TNF alpha antagonists TNF alpha antagonists

82. Crohn’s Disease Chronic recurring transmural inflammation associated with fibrosis and sinus tracts that penetrate serosa giving rise to microperforations and fistulae presenting as skip lesions in any area of the GI tract Chronic recurring transmural inflammation associated with fibrosis and sinus tracts that penetrate serosa giving rise to microperforations and fistulae presenting as skip lesions in any area of the GI tract Mucosal Mucosal Stricturing Stricturing Penetrating Penetrating Based upon location Based upon location 50% ileocolitis, 30% ileitis, 5% Gastroduodenal 50% ileocolitis, 30% ileitis, 5% Gastroduodenal

83. Crohn’s complications 74% require surgery 74% require surgery Right lower quadrant pain Right lower quadrant pain Diarrhea Diarrhea Weight loss/Anorexia Weight loss/Anorexia Small Bowel Obstruction Small Bowel Obstruction Fistulas Fistulas Perirectal Abscess/Intraabdominal abscesses Perirectal Abscess/Intraabdominal abscesses Osteoporosis Osteoporosis Extraintestinal Manifestations Extraintestinal Manifestations Entero- colonic fistula and string sign

84. Crohn’s - Treatment Induction of Remission Induction of Remission ?5-ASA = target to area of disease ?5-ASA = target to area of disease Ciprofloxacin / Flagyl Ciprofloxacin / Flagyl Steroids (Prednisone or Budesonide) Steroids (Prednisone or Budesonide) TNF alpha antagonists TNF alpha antagonists Maintenance Maintenance 5-ASA 5-ASA 6-MP/Azathioprine/MTX 6-MP/Azathioprine/MTX TNF alpha antagonists TNF alpha antagonists

85. Extraintestinal Manifestations Arthropathy (20%) Arthropathy (20%) Large joint – follows disease activity Large joint – follows disease activity Small joint – independent of disease Small joint – independent of disease Ankylosing Spondylitis (10%) Ankylosing Spondylitis (10%) Not associated with disease activity Not associated with disease activity Erythema Nodosum (10%) Erythema Nodosum (10%) Associated with disease Associated with disease Pyoderma Gangrenosum (10%) Pyoderma Gangrenosum (10%) Not associated with disease activity Not associated with disease activity

86. Extraintestinal Manifestations Episcleritis / Uveitis – 5% Episcleritis / Uveitis – 5% Nephrolithiasis Nephrolithiasis Calcium oxalate stones with ileal Crohn's Calcium oxalate stones with ileal Crohn's Primary Sclerosing Cholangitis Primary Sclerosing Cholangitis 5% of UC, 75% of PSC have UC 5% of UC, 75% of PSC have UC 25% cancer at 10 years after PSC diagnosis 25% cancer at 10 years after PSC diagnosis Colon Cancer Colon Cancer 1% per year after 15 years 1% per year after 15 years Start surveillance at 8-10 year after diagnosis in pancolitis and after 15 years in left sided colitis Start surveillance at 8-10 year after diagnosis in pancolitis and after 15 years in left sided colitis

87. IBD = Indication for surgery UC UC Toxic megacolon/Perforation Toxic megacolon/Perforation Failure to control symptoms Failure to control symptoms Dysplasia on surveillance Dysplasia on surveillance Crohn’s Crohn’s Strictures with obstruction Strictures with obstruction Complicated fistula Complicated fistula Unresponsive inflammatory mass Unresponsive inflammatory mass

88. Dermatologic and GI Associations

89. Dermatitis Herpetiformis Chronic, symmetric, intensely pruritic eruption including vesicles, papules and urticarial wheals

90. Celiac Disease

91. Acanthosis Nigricans Diffuse, velvety thickening and hyperpigmentation of skin in axilla and other body folds

92. Gastric Cancer

93. Tricholemmomas

94. Cowden’s Syndrome Cowden’s syndrome more associated with thyroid and breast cancer as well as GI hamartomas

95. Necrolytic Migratory Erythema Superficial migratory necrolytic erythema with central blisters or erosions that crust and heal with hyperpigmentation, a beefy red tongue, and angular cheilitis

96. Glucagonoma

97. Peutz Jeghers Syndrome

98. Intussusceptions and Malignancies

99. Pancreatic Neuroendocrine tumors

100. Neurofibromatosis-1 Tuberous Sclerosis MEN1, And…

101. Von Hippel-Lindau Hemagioblastomas and retinal angiomas Clear cell RCC Pheochromocytoma Endolymphatic sac tumors of middle ear Pancreatic serous cystadenoma or neuroendocrine tumors Papillary cystadenomas of epididymis and broad ligament

102. Questions? Good luck on Boards