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28th Reviews in Internal Medicine for 3rd Year Medicine Resident 2019
Approach to Common Problems in
Gastroenterology
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Symptomatology in GI & liver diseases
• Ascites
• Jaundice
• Acute & chronic diarrhea
• Acute & chronic abdominal pain
• Constipation & bowel habit change
• Nausea & vomiting
• GI hemorrhage
• Abdominal mass
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Approach to ascites
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Abdominal distension
• Ascites• Ileus, gut obstruction• Huge abdominal mass/ cyst• Obesity• Pregnancy
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1.5 L 4-5 L100 cc
Diagnosis of ascites
Ultrasound Shifting dullness Fluid thrill
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Causes of ascites
Cirrhosis 84%
Heart failure 3%Malignancy 2,5%
TB 1%Mixed 5%
Others 4,5%
Runyon BA. Ann Intern Med 1992
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Pathophysiology of ascites formationThoracic duct
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Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight-sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non-portal HT
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History taking
• Risks of cirrhosis: alcohol, HBV, HCV, NASH• Symptoms of cirrhosis: pedal edema, jaundice,
massive UGIH• Thrombophilia: pills, spontaneous abortion, DVT• Fever, chest symptoms, closed contact TB• Weight gain or weight loss• Underlying diseases; cancer, autoimmune diseases,
DM, CKD, thyroid• Abdominal pain• Surgery
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Physical examination
• GA: pedal edema, jaundice, signs of CLD
• Abdomen:
Surgical scar, superficial vein dilatation
Sister Mary Joseph nodule
Hepatosplenomegaly, abdominal mass
PR
• Lymphadenopathy
• Neck vein & heart
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Superficial vein dilatation
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Dilated abdominal vein & flow direction
Normal Portal HT IVC obstruction
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IVC Obstruction
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Sister Mary Joseph nodule
Galvan VG Ann Int Med 1998; 128: 410
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Percussion of spleen
Castell’ s method Traube’s space dullness
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Rectal shelf
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Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non-portal HT
Leg edema, wt. gainSplenomegaly
Dilated superficial v.Jaundice
Signs of CLDRisk factors
HepatomegalyHigh JVP
RV heaving, TRPericardial rub
Weight loss, feverLymphadenopathy
Rectal shelfSister Mary-Joseph nodule
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Investigations in patients with ascites
• Abdominal paracentesis• Blood chemistry• Ultrasound, Doppler U/S, CT• CXR• Peritoneoscopy with biopsy
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Ascitic fluid analysis
Routine• Cell count• Cell differential• Total protein• Albumin
Optional• ADA, PCR for mycobacteria• Cytology• ANA, LE cell• Amylase (>1000)• Bilirubin (>6 mg/dl)• Triglyceride (>200 mg/dl)• LDH, ALP
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Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non-portal HT
SAAG>1.1 <1.1
>2.5 >2.5 <2.5 TP
Accuracy97%
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• Different time points• Borderlined value• Very low serum albumin• Globulin >5 g/dL (1%)• Hypotension • Chylous ascites• Mixed ascites
• High TP in cirrhosis (20%)• Diuretic effect: high TP• Mixed ascites: low TP (30-
50%)
Limitations of ascitic fluid analysis
SAAG Total protein
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Cirrhosis
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Budd-Chiari Syndrome (BCS)
• Hepatomegaly
• Heterogeneous enhancement
• PHT: ascites, splenomegaly
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Early central enhancement
Delayed peripheral enhancement
BCS; Flip flop phenomenon
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BCS with IVC involvement
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Constrictive pericarditis
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Tuberculous peritonitis
• Common in alcoholic cirrhosis• Symptoms
- Fever 54%- Weight loss 44%- Chest symptoms 30-40%
• Subtype- Exudative (moist type)- Plastic (dry type) “doughy abdomen”
• Investigations- ADA (>39 IU/ml; sens 100%, spec 97%)- CT- Peritoneal biopsy (gold standard)
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TB peritonitis
CT Peritoneoscopy
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Malignancy-related ascites
• Peritoneal carcinomatosis Mesothelioma
Primary effusive lymphoma
Metastasis
• Massive liver metastasis
• HCC with decompensated cirrhosis
• Budd-Chiari syndrome
• Ruptured HCC (bloody ascites)
• Retroperitoneal lymph node with chylous ascites
• Pseudomyxoma peritonei
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Carcinomatosis peritonei
Common cancers • Ovarian • Pancreatic• Cholangiocarcinoma• Gastric• Colorectal• Breast, lung
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Carcinomatosis peritonei
Diagnosis• Cytology
- 3 samples- 50 mL of fresh ascites- immediate processing
• CT scan• Biopsy
Sensitivity96.7%
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Linitis plastica with carcinomatosis peritonei
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CA ovary with carcinomatosis peritonei
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Mesothelioma
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Nephrogenous ascites
• ESRD• History of dialysis-associated hypotension• Diagnosis by exclusion• Ascitic profile: non-specific
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Mixed ascites
• 5% of patients with ascites
• Portal HT + secondary causes
Alcoholic cirrhosis + TB peritonitis
Cirrhosis with carcinomatosis peritonei
• Clues; wide SAAG ascites plus
– high ascitic lymphocyte
– high total protein
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Gross appearance
A B C D E
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Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non portal HT
HemoperitoneumChylous ascitesPseudomyxomaBilious ascites
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Chylous ascites
• Milky and creamy ascitic fluid
• Triglyceride content >200 mg/dLCardenas A et al, AJG 2002:1896-1900
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Diseases
Neoplasm LymphomaOvarian, breast, pancreas, colon, carcinoidLymphangiomyomatosis
Congenital Primary lymphatic hypoplasiaIntestinal lymphangiectasia
Infection Filariasis, TB, MAC
Inflammation RadiationPancreatitisRetroperitoneal fibrosis
Trauma Post operation, abdominal injury
Etiology of chylous ascites
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Bilious ascites
Total bilirubin >6 mg/dL
Cardenas A et al, AJG 2002:1896-1900
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Diseases
Trauma Abdominal injuryPost operation / biopsy / paracentesis
Gynaecologicconditions
Ruptured ectopic pregnancyRuptured ovarian cyst
Liver Ruptured liver mass: HCC, HA, metastasisCirrhosis: ectopic varices, idiopathic
Vascular Splenic artery aneurysm, hemangioma, peliosishepatis
Peritoneal disease Carcinomatosis peritonei
Coagulopathy Warfarin overdose
Etiology of hemoperitoneum
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Hemoperitoneum; hematocrit sign
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Ruptured HCC
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Ruptured hepatic adenoma
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Pseudomyxoma peritonei
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Pseudomyxoma peritonei
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Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non portal HT
HemoperitoneumChylous ascitesPseudomyxomaBilious ascites
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Approach to chronic diarrhea
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Etiologies of chronic diarrhea1. INFECTIOUS CAUSES e.g. bacteria, viruses, parasites, fungus
- include TB, Syphilis, Gonorrhoea, Lymphogranuloma venerium, Malaria, Psittacosis, Leptospirosis, Measles
2. DRUGS e.g. Cathartics & Laxatives, Antibiotics, Antacids (MgSO4, CaCO3), Antimalarials, Neomycin, Colchicine, Digitalis, Thyroid extracts, Iron, Biguanides, PAS, Mercury, CCl4, Misoprostol, Theophylline, Herbal medicine
3. GI TRACT DISEASES e.g. Ulcerative colitis, Crohn's disease, Coeliac diseases, Tropical sprue, Whipple's diseases, Necrotizing enteritis, Eosinophilic gastroenteritis, IPSID, Microscopic colitis, Giant hypertrophic gastritis, Hypertrophic hypersecretory gastropathy, Allergic enteropathy, Cronhite-Canada syndrome, Ischemic bowel diseases, Radiation enteritis, Diverticulitis, GI tumor/malignancy, GI lymphoma, GI fistula, Short bowel syndrome, GI obstruction, intestinal lymphangiectasia, Constrictive pericarditis
4. PANCREATIC DISEASES e.g. Chronic pancreatitis, Ca pancrease, Cystic fibrosis, Z-E syndrome
5. OTHER INTRA-ABDOMINAL CONDITIONS e.g. Appendiceal abcess, Pelvic inflammatory diseases, Pyelonephritis/perinephric abcess, Ectopic pregnancy, Endometriosis, Cholycystitis acute/chronic, Neural crest tumor
6. ENDOCRINE DISEASES e.g. Hyperthyroid, Addison's diseases, Diabetic diarrhea, Cushing' syndrome, Hypoparathyroidism, Carcinoid syndrome, Z-E syndrome, Medullary Ca thyroid, Pheochromocytoma, VIPoma, Gastrinoma, Somatostatinoma
7. METABOLIC DISEASES e.g Uremic colitis, Hypervitaminosis D, Pellegra, Pernicious anemia, Folate deficiency, alcoholism, Congenital chloridorrhoea, Enteric hyperoxaluria, Amyloidosis, Abetalipoproteinemia
8. CONNECTIVE TISSUE DISEASES e.g. SLE, Progressive systemic sclerosis, Polyarteritis nodosa, Dermatitis herpetiformis
9. BLOOD DISEASES e.g. Hodgekin's lymphoma, Non-hodgekin's lymphoma, Acute lymphoblastic leukemia, Chronic myeloid leukemia, IPSID, Mastocytosis, Hypogammaglobulinemia
10. OTHER CONDITIONS e.g. Factitious diarrhea, Idiopathic secretory diarrhea, Epidemic secretory diarrhea (Brainerd)
>200 etiologies !!!
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Battery of tests!!!
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History taking
• General: onset and duration, stool character, frequency, amount & volume of stool, relationship with meals
• Associated symptoms: nausea, vomiting, tenesmus, abdominal pain, constipation, etc.
• Malnutrition: anemia, edema, bruise
• Social history: diet (lactose, food allergy), occupation, environment, traveling, contact with diarrhea
• Past history & underlying illness: DM, PU, thyrotoxicosis, autoimmune disease, surgery, radiation, pancreatitis, etc.
• Family history: IBD, polyposis syndrome, MEN
• Systemic enquiry: fever, weight loss, amenorrhea, impotence, change of voice, polyuria, polydipsia, arthralgia/arthritis, rash, eye symptoms, paresthesia, difficult walking, sweating, tremor, proteinuria, bone pain, etc.
• Drugs: antibiotics, laxatives, etc.
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Important history
• Co-morbid
• Drugs
• Food & beverages
• Surgery & radiation
• Immunosuppression & HIV
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Important history
• Co-morbid
• Drugs
• Food & beverages
• Surgery & radiation
• Immunosuppression & HIV
DM
• Drug-induced; metformin
• SIBO
• Diabetic diarrhea
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Common drug-induced diarrhea
• Laxatives
• Colchicine
• Antibiotics; clindamycin, amoxicillin, ampicillin, cephalosporins, erythromycin etc.
• Chemotherapeutic agents; 5-flurouracil, methotrexate, irinotecan, cisplatin, doxorubicin etc.
• Metformin
• Alpha glucosidase inhibitors; acarbose, miglitol
• Mg antacids (Mg hydroxide), phosphates
• Enteral feeds
• Cholinesterase inhibitors
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Important history
• Co-morbid
• Drugs
• Food & beverages
• Surgery & radiation
• Immunosuppression & HIV
Food & beverages
Chronic diarrhea
ปลาดิบ Capillariasis
FODMAPSs Osmotic diarrhea
Milk Lactose intolerance
Alcohol Chronic pancreatitis
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Steatorrhea
SIBO
Bile acid diarrhea
Short bowel syndrome
Bowel Surgery
Anastomotic strictureAdhesionBlind loopIC valve resectionVagotomy
Ileal resection 60-100 cm
Ileal resection >100 cm
SB <200 cm
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Physical examination
• Signs of malnutrition
• Clues for diagnosis
– Dermatitis herpetiformis -> Coeliac disease
– Vasculitis -> Autoimmune disease
– Oral/genital ulcer -> Behcet’s disease
– Uveitis, episcleritis -> Ulcerative colitis
– Exophthalmos -> thyrotoxicosis
– Peripheral neuropathy -> amyloidosis, DM
– Oral hairy leucoplakia -> AIDS
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Bitot spot
Koilonychia
Glossitis
Angular stomatitis
Pellagra Edema
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Patients with diarrhea >4 weeks
1
R/O functional diarrhea2
Duration
Exclude conditions mimic chronic diarrhea
5
SB vs LB Character HIV
3
Find clinical clues4
Categorization
Investigations & empirical treatment
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Patients with diarrhea >4 weeks
1
R/O functional diarrhea2
Duration
Exclude conditions mimic chronic diarrhea
5
SB vs LB Character HIV
3
Find clinical clues4
Categorization
Investigations & empirical treatment
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Step 1: Exclude conditions mimic chronic diarrhea
• Post-infectious IBS• Protozoa; giardiasis• Clostridium difficile• IBD, aggravated by
infection
Protracted acute diarrhea
Abrupt onset
Pseudo-diarrhea Incontinence
PRStool <200 g/d
Bristol stool scale 1-4
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Patients with diarrhea >4 weeks
1
R/O functional diarrhea2
Duration
Exclude conditions mimic chronic diarrhea
5
SB vs LB Character HIV
3
Find clinical clues4
Categorization
Investigations & empirical treatment
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Step 2: R/O functional diarrhea
• Young female
• Mild, intermittent
• No nocturnal symptoms
• Mucous diarrhea +, tenesmus +
• Cramping pain relieved by defecation
• Precipitated by stress, spicy food
• Onset >50 yr.
• Severe, progressive
• Nocturnal diarrhea
• Bloody diarrhea or IDA from chronic blood loss
• Fever, weight loss
• Familial Hx of IBD, CRC
Functional diarrhea Organic diarrhea
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Patients with diarrhea >4 weeks
1
R/O functional diarrhea2
Duration
Exclude conditions mimic chronic diarrhea
5
SB vs LB Character HIV
3
Find clinical clues4
Categorization
Investigations & empirical treatment
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Duration of diarrhea
<6 months 6 months-2 years >2 years
Any causes
Exclude bacteria & virus IBS-D
Laxative-inducedDiabetic diarrhea
Lactose intoleranceMicroscopic diarrhea
Factitious diarrhea
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• Large volume
• Moderate frequency
• No urgency
• No tenesmus
• No/ minimal mucus
• Periumbilical pain
• Weight loss
• Signs of malnutrition
• Small volume
• High frequency
• Urgency
• Tenesmus
• Mucus & blood
• LLQ pain
• No weight loss
• No signs of malnutrition
Small bowel diarrhea Large bowel diarrhea
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Secretory Osmotic
Steatorrhea Inflammatory
Stool characteristics
Stool pHStool osmolalityStool volumeFasting
Sudan stainStool fat >6 g/d Stool wbc & rbc
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Secretory Osmotic
Stool volume >1000 ml/d <300 ml/d
Stool osmolality
Stool osmotic gap
<[Na+K]x2
<50 mOsm
>[Na+K]x2
>100 mOsm
Stool Na >90 mmol/L <60 mmol/L
Stool pH >6 <5
Effect of fasting Not improved Improved
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Secretory diarrhea
• Drugs; non-osmotic laxatives, antibiotics
• VIPoma, carcinoid tumor
• Villous adenoma
• Congenital defect
– Cl-/HCO3 exchange
– Na+/H+ exchange
• Intestinal resection
• Diffuse mucosal diseases
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Osmotic diarrhea
• Laxatives induced
• Diet-induced; candy, sorbitol, mannitol, xylitol
• Drugs-induced; colchicine, cholestyramine, neomycin, lactulose, PAS
• Disaccharidase deficiency; fructose, lactose
• All prolonged malabsorption diarrhea
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Steatorrhea
• Chronic pancreatitis, CA pancreas, IPMN
• Oristat
• Diseases of terminal ileum; TB, CD, ileal resection >100 cm
• Obstructive jaundice, PBC, cirrhosis
Lipase
Bile salts
• SIBO
• ZE syndrome
• Lymphangiectasia
• TB, lymphoma, carcinomatosis
pH
Lymph
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Inflammatory diarrhea
Infections
• Bacteria; Aeromonas, Plesiomonas, C. difficile, TB
• Viruses; CMV
• Parasites; Amoeba histolytica, Balantidium coli, Trichinella spiralis, Trichuris trichiura, Schistosoma mansoni/mekongi
Non-infection
• IBD, Behcet’s disease, eosinophilic gastroenteritis
• Ischemic colitis, radiation
• Malignancy; colon cancer, lymphoma
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HIV
Virus
Bacteria
Mycobact.
FungusParasite
Protozoa
Lymphoma
CMV, HIV
CampylobacterShigella
SalmonellaC. difficile
TB, MAC
CryptococcosisHistoplasmosis
CryptosporidiumIsospora
MicrosporidiumCyclosporaGiardiasis
CD4, OI, environmentMultiple organisms !!!
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Patients with diarrhea >4 weeks
1
R/O functional diarrhea2
Duration
Exclude conditions mimic chronic diarrhea
5
SB vs LB Character HIV
3
Find clinical clues4
Categorization
Investigations & empirical treatment
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Remarkable weight loss
• Malabsorption syndrome
• Thyrotoxicosis
• Malignancy
• TB
• Parasite; Capillariasis
• IBD
• IPSID, lymphoma
• AIDS-related diarrhea
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Prolonged fever
• AIDS-related diarrhea
• Infectious diarrhea; Amoebiasis, TB, CMV, C. difficile, Actinomycosis, Histoplasmosis
• IBD
• Autoimmune disease: SLE
• Lymphoma
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RLQ pain
Infections
• Salmonella
• Campylobacter
• Yersinia
• TB enteritis
• Histoplasmosis
• Actinomycosis
• Amoeboma
Non-Infection
• Lymphoma
• Crohn’s disease
• Ischemic colitis
• Carcinoid tumor
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Peptic ulcer
• Antacid-induced diarrhea
• Zollinger-Ellison syndrome
• Gastro-colic fistula
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Generalized lymphadenopathy
• IPSID
• Lymphoma
• Leukemia
• AIDS-related diarrhea
• Disseminated tuberculosis
• Whipple’s disease
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Clubbing of fingers
• IBD
• IPSID
• Coeliac disease
• Cystic fibrosis
• Whipple’s disease
• Malignancy (paraneoplastic)
• Grave’s disease
• Cronkhite-Canada syndrome
• Sarcoidosis
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Eosinophilia
• Parasites: Strongyloidiasis, Gnathostomiasis, Giardiasis, Capillariasis
• Eosinophillic enterocolitis
• Lymphoma
• Autoimmune disease: SLE, vasculitis
• Drugs-induced: sulphonamide, aspirin, cephalosporins
• Food allergy
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Hypokalemia
• VIPoma
• Laxative abuse
• Conn’s syndrome
• Thyrotoxicosis
• Villous adenoma
• Prolonged watery diarrhea
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Megaloblastic anemia
• SIBO
• Diseases of terminal ileum
• Diphyllobothrium latum
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Other hints
• Flushing; carcinoid syndrome, mastocytosis
• Tachycardia; thyrotoxicosis, carcinoid syndrome
• Peripheral neuropathy; DM, amyloidosis
• Proteinuria; amyloidosis, SLE
• Vasculitis; autoimmune diseases
• Postural hypotension; DM, Addison’s disease
• Dermatitis herpetiformis; coeliac disease
• Ataxia; abetalipoproteinemia
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Dermatitis herpetiformis; coeliac disease
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Pyoderma gangrenosum; IBD
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Papular pruritic eruption; HIV
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Patients with diarrhea >4 weeks
1
R/O functional diarrhea2
Duration
Exclude conditions mimic chronic diarrhea
5
SB vs LB Character HIV
3
Find clinical clues4
Categorization
Investigations & empirical treatment
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• CBC, ESR, MCV, MCH, MCHC, UA
• Stool exam(conc.), culture, stool weight, stool fat
• Stool C. difficile toxin assay
• Blood chemistry, FBS, BUN, Creatinine, chol, trig, alb, glob etc.
• Serum electrolytes, Ca, PO4, Mg, Zn
• PT, ferritin, B12 level, folate level, serum carotene
• Thyroid function test
Battery of tests in chronic diarrhea• Anti-HIV
• Tissue tranglutaminase (tTG)
• Urine 5-HIAA, calcitonin
• Tumors markers eg. CEA, CA19-9
• Autoimmune: ANA, p-ANCA, ASCA, anti-DNA, etc.
• VIP, gastrin, glucagon levels
• Radiologic & endoscopic examinations
• etc.
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Empirical treatment
• Metronidazole; C. difficile, giardiasis, SIBO
• Albendazole; capillariasis
• Cholestyramine; bile acid diarrhea
• Pancreatic enzyme; chronic pancreatitis
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Good Luck!