Approach in GI & HB

Te & Chin
Contents 1. Chronic Hepatitis 2. Acute liver failure 3. Metabolic causes of abdominal pain 4. Dysphagia 5. Vomiting 6. Jaundice 7. GIB 8. PHT 9. Hepatomegaly 10. Hepatosplenomegaly 11. Huge splenomegaly 12. Chronic diarrhea 13. Huge Kidney 14. Abdominal distension 15. Ascites 16. Constipation 1. Chronic hepatitis (8) Viral : HBV / HCV Alcoholic liver disease / Drugs and toxins NASH Wilsons disease Hemochromatosis 1-antitrpsin deficiency Autoimmune hepatitis 2. Acute liver failure (4) Drugs and toxins Viral Wilsons disease Autoimmune Hepatitis + Acute Buddchiari 3. Metabolic causes Abdominal pain (7+2) Lead poisoning Acute Intermittent porphyria DKA / HypoTH / HyperTH + Dyslipidemia Acute pancreatitis / Addison disease Hypercalcemia / Hyperparathyroidism Abdominal epilepsy / Uremia

4. Dysphagia Deglutition Peristalsis Esophagus LES relax Oropharyngeal / Esophageal Mechanical / Functional OP Neuro UMN disease MS / ALS / PK LMN PN : GBS / dM NMJ : MG / LEM / Botulism M : cong / metabolic(TH) / IM Effector Cleft lip-palate Infection in oral cavity + Peritonsilar abscess Inflammation Oral pemphigus Caustic injury Plummer vilson E M (solid or solid + liquid) Intra-L FB / web / ring / Tumor Intramural Infiltrative Etis : infection / CD Corrosive TE fistula Extra-L Post med mass LAE / AA / Rt. sided Inv. : EGD + BSw F (liquid + solid) Achalasia most common 1 2 CA / Chagar / Pseudoint obs Postvagotomy surgery Amyloidosis / Sarcoidosis MEN 2b Diffuse Es spasm Myotonic dystrophy Neuromyopathy DM / SSC / Alc / Amyloid Sm m. relaxant Inv. : EGD + BSw + Motility

5. Vomiting Neuro F O Migraine ICP / Floor 4th v / Posterior fossa / Brainstem Vestibular neuritis

GI Metabolic Electrolyte Uremia DKA Adrenal insufficiency Inferior wall MI 6. Jaundice Isolated IDB : Hemolysis / Ineffective Erythropoiesis(TB<5) Impair conjugate : Crigler Najar II / Gilbert DB : Rotors / Dubin-Johnson Abnormal LFT Hepatitis (hepatocellular) Viral Alcohol NASH Toxin / AIH / Wilsons / 1antitrypsin def. Hemochromatosis Cholestasis (pruritus / pale stool / dyslipid / dark skin) LFT + U/S PE GB+ EHD IL CHCA / IPMN etc. Stone IM typical PSC / RT / fibrosis EL LN / Periampullary IHD Hepatocyte dysfunction / Congestion Inflam PBC / PSC Sepsis / TPN / Drugs / Toxin Infiltrative : Infection / Malignancy / Amyloidosis / Sarcoidosis

7. GIB (malena / hematochezia / hematemesis) UGIB / LGIB UGIB ( EGD in 24 hr. If HD stable and exclude EV) PHT related (S++ / ascites / S++ / superficial v. dilate) EV Moderate to severe ebleeding Painless Other Painless or painful Signs of chronic liver disease Cirrhotic PHT 90% HD change GV : isolated / GOV(EV+GV) PHG BB + Octreotide + TIPS No endoscopic tx. Gastric vascular ectasia Antrum (GAVE) Watermelon stomach Argon plasma coagulation Treatment EV : Control bleeding : Endoscopic treatment Prevent bleeding : Terip / Oc BB / Nt Non : depend on scope finding Non PHT related PUD most common Gastritis Dulafloy Malory-Weiss Boohaave LGIB Bleeding diverticulosis Angiodysplasia Ischemic colitis Hemorrhoid Painful : Infection / Inflammation / Malignancy Treatment (4) General ABC + Fluid resuscitation Correct Coagulopathy when INR < 1.5 NG irrigation R/O UGIB

Scope within 12 hr. after admit all cases Intervention Active bleed / Adherance clot Lt. side diverticulum Adrenaline injection Radionuclide imaging (bleeding rate 0.1ml/min) Angiogram (bleeding rate 0.5 ml/min) Plain film Surgery Massive bleeding with HD instability Need Blood transfusion > 6 U 8. PHT : S++ / Thrombocytopenia / Collateral / Ascites Cirrhotic / Non cirrhotic Pre hepatic Portal v. thrombosis PV / ET / APS / Protein C-S AT def. / PNH Malignancy / pill GI (3) Pancreatitis / Diverticulitis / IBD Hepatoma Hepatic Pre-sinusoid Schistosomiasis eggs granulomatous inflame fibrosis Sinusoid Cirrhosis Alcohol : perivenular area AIH / Hemochromatosis PBC / PSC Post-sinusoid Veno-occlusive disease Post hepatic Buddchiari DDX Lt. Side PHT S++ / no carput no ascites / Isolated GV bleeding Splenic vein thrombosis

9. Hepatomegaly Confirm liver span Congestion Biliary obstruction ex. PBC Space occupying lesion Tumor Benign Hemangioma / FNH / NRH Hepatic adenoma Malignant Primary : HCC / CHCA Metastasis Cyst ex. ADPKD Abscess : Pyogenic (Melioid) / Amoebic (Fasciola) Infiltrative disease Infection : TB / Meliod Malignancy : Lymphoma Other substance NAFLD / Glycogen-stroage disease Hemochromatosis Amylodosis / Sarcoidosis 10. Hepatosplenomegaly Immune : Systemic or disseminated infection RE : EVH-extramedullary hematopoiesis Congestion Infiltrative disease as above 11. Splenomegaly Congestive PHT Rt. Sided heart failure Budd Chiari PHT most common cirrhosis Portal vein thrombosis Splenic vein thrombosis / obstruction

Non congestive Increase function RE hyperfunction : Chronic EVH Immune mediated Infection : Meliod AIR : RA BE Extramedullary hematopoiesis Space occupying lesion Tumor Benign Malignant Splenic marginal lymphoma Metastasis : Melanoma Cyst Abscess : Pyogenic(+Melioid) Infiltrative disease Infection : TB / Meliod Malignancy : Lymphoma Other substance Glycogen-stroage disease Hemochromatosis Amylodosis / Sarcoidosis Huge Splenomegaly (8) MPD especially AMM Hairy cell leukemia / CLL CMMoL Splenic marginal lymphoma ass. HCV Chronic malaria Thalassemia Splenic vein thrombosis

12. Chronic diarrhea Definition Stool weight > 200 g/d duration > 4 wk. Fluidity stool or > 3 times/day DDX incontinence and soiling Functional or Organic Predominant nocturnal diarrhea Sudden onset Continuous > Intermittent Stool weight > 400 g/d Weight loss > 5 kg Anemia / Malnutrition / High ESR Signs of systemic disease HIV or Non HIV HIV Infection : Bacteria / Virus / Fungus / Protozoa Drugs : PIs Tumor : Lymphoma / Kaposis AIDs Enteropathy Non HIV Watery Inflammatory : fever / abd. pain / mucous bloody Malabsorption Watery Osmotic Stool Volume Stool Osmolality Stool Osmotic gap Stool Sodium Stool pH Stool Reducing substance Effect of Fasting <300 ml/day >[Na+K]x2 >100 mOsm < 60 mmol/L <5 Positive Improve Secretory > 1000 ml/day <[Na+K]x2 <50 mOsm > 90 mmol/L >6 Negative Not improve

Osmotic : OG > 100 / decrease by fasting Non absorp solute CHO malabsorp ( D-Xylose test ) lactase def. Drugs : Antacid / Colchicine / Cholestyramine Neomycin Laxatives Secretory Endocrine : TH+ Motility : DM (autonomic neuropathy) Infection Inflammation Tumor : VIPoma / Carcinoid / Pheo / ZE Villous adenoma / Medullary CA Bile acid diarrhea Laxative Idiopathic Inflammatory IBD : UC / CD Infection : TB / Amebic / Aero-Plesiomonas / PMC Balantidium / Trichuris / Trichinella / Schistos Malignancy : CA colon CNT disease Ischemic colitis Radiative colitis Other : Microscopic colitis Malabsorption Steatorrhea 2 method for detection Quantitative : 72 hr. stool fat collection > 7 g/d with fat intake > 100 g/24 hr. X 3d. Quanlitative : Fat globule > 10/LP Intraluminal maldigestion Pancreatic enz. Pancreatitis Pancreatic duct obstruction Inadequate luminal Bile Synthesis : Cirrhosis Biliary obstruction Inappropriate pH : ZE syndrome Deconjugate : Bacteria overgrowth Malabsorpt bile : ileum dz. Drugs : Cholestyramine Intragastric pH : Bacterial overgrowth

Mucosal malabsorption Diffuse Drugs : Alcohol / Neomycin / Colchicine Mefenamic acid-NSAIDs / MTX / Local Parasite (3) : Cappillaria / Giardia / Strongyloid Post mucosal lymphatic obstruction Infection / Trauma / Tumor SI or LI LI High frequency small volume Urgency and tenesmus Large mucous bloody LIF pain No WL or malnutrition Infection or Non infection Hint for diagnosis Flushing / Tachycardia / Peripheral neuropathy / PU Proteinuria / Postural hypotension / Ataxia Dermatitis herpetiformis WL Clubbing finger Hypokalemia Eosinophilia Chronic (yr.) DM / Laxative / Lactose intolerance Pure protein long enteropathy SLE / Minetrier / Lymphangiectasia 13. Huge Kidney Hydronephrosis : Obstructive uropathy Pyonephrosis ADPKD Tumor Wilm / Hypernephroma-RCC TS : Angiomyolipoma / Lymphangioleiomyoma Adrenal mass Functioning Benign Malignant Non functioning

14. Abdominal distension Fat / Flatus / Fluid / Fetus / Feces Bowel dilatation Mechanical alarms feature of GO (obstruction : IL / IM / EL ) Air in rectum Out proportion bowel dilate Proximal dilate and distal collapse SI : Hernia / Adhesion LI : CA / Volvulus Non Mechanical-ileus Ischemia Hypercalcemia Hypothyroidism Hypokalemia Intra-abdominal infection Systemic sclerosis Pseudointestinal obstruction Drugs : Opiod / CCB etc. 15. Ascites always R/O Hemoperitoneum / Chylous ascites PHT / Non PHT Previous or known EV bleeding Splenomegaly Superficial v. dilatation-Carput medusae Thrombocytopenia Signs of chronic liver disease + Sister Marie Joseph node Large vein in the back ( IVC obstruction) Neck vein (Cardiac ascites) Peripheral edema Confirm by SAAG PHT approach line PHT + Myxedema / Cardiac(TP>2.5 / Neck vein) Non PHT (Peritoneal disease) + NS Infection Spontaneous or secondary bacterial peritonitis Infected CAPD TB peritonitis Inflammation : AI disease-SLE / Pancreatic ascites Tumor Primary : Mesothelioma Metastasis : GI and GU malignancy

16. Constipation o Straining o Hard stool 44% o Inability to have bowel movement 34% Traditional medical constipation 95% lower confidence limit for healthy adults in North americca & UK o 3 bowel movement per wk o inaccurate & complaints of constipation o Rome II criteria (1999) chief complaint 52%

Risk factors o Female gender unk reasons, may be hor o Advanced age esp hospitalized elderly pt excessive straining & hard stool Factor : . , muscle weak at abd wall & pelvic wall, chr illness, psychological factors, esp o Low socioeconomic status o Nonwhite ethnicity o Low education o Low physical activity & diet High fiber dec CTT & inc stool wt & freq Dehydration potential risk acvice study o Use of certain medicine Opioid Diuretics

Antihistamines Antispasmodics Anticonvulsants Antidepressants Aluminium antacids ASA or NSAIDs in the elderly

Causes of Secondary constipation Mechanical obs o Intraluminal: CA o Luminal: stricture, anal stenosis, Rectocele or sigmoidocele o Extraluminal: compression Metabolic & endocrine disorders o DM CTT non-DM (50%) cardiovas autonomic neuropathy mean CTT Neostigmine inc colonic motor activity pathology Neural > muscular o Thyroid: hypo- & hyper Hypothyroid: intes motor fn & +/- myxedematous infiltration at muscle layers o Elyte: hypoK, hyperCa hyperCa hyperPTH present constipation ( : sarcoid, CA) o Pheo o Panhypopit o Porphyria o Heavy metal: lead, mercury, arsenic o Pregnancy Medications: as above Neurologic & muscle disorders o Neuro: MS, PD, SC injury, Autonomic neuropathy, Chagas dz, intes pseudo-obs, CVA, Shy-Drager o Muscle: SSc, DM o Infiltration: Amyloid

Classification of constipation

Secondary constipation as above need early exclusion Functional constipation o Normal transit 59% ( Mayo clinic) o Slow transit 13% o Defecatory or rectal evacuation disorder 5%

Clinical assessment History What do the patients mean? Duration of symptoms o Long duration of symp not resp to conservative Rx = Functional disorder o New onset of constipation = structural dz Frequency of bowel movement Associated symptoms: abd discomfort & distention Stool consistency, size Degree of straining Warning symptoms: Wt loss, rectal bleed, FH of CA colon, Change caliber of stool, severe abd pain Dietary history: fiber and fluid intake o Skip breakfast? loss of postprandial inc in colonic motility Caffeine 150mg Obstetrical and surgical history Neurologic disorders Use of laxative, herb Why pt sought for help? o Occult sexual abuse Manifestation of depression

Physical examination

GA/voice that point to hypothyroid, depression Parkinsonism Major CNS disorder o esp. cord lesion Loss of sensation of sacral dermatome Ant Abdominal o Distension ( exclude Postural bloating; ant arching of lumbar spine) o Hard feces in palpable colon o Inflammatory or neoplastic mass Rectal exam o Exclude painful perianal conditions o Defecatory fn o Perineum at rest & staining Perineum descend 1-4 cm during straining >4cm or ischial tuberosities Descending perineal synd Inability to relax pelvic floor muscle Descending perineal syndrome o Excessive straining incomplete evacuation ( lack of straightening of anorectal angle) o Rectal prolapse o Sacral n. injury stretching Reduce rectal sensation incontinence Rectal scar, fistulas, fissures, ext hemorrhoid Digital exam o Fecal impaction o Anal stricture o Rectal mass Patulous anal sphincter: o Prior trauma to sphincter o Neurologic disorder impaired sphincter fn Inability to insert finger elevated sphincter pressure Tenderness on palpation of pelvic floor posterior rectum pelvic floor spasm

Clinical Clues to an Evacuation Disorder History Prolonged straining to expel stool Assumption of unusual postures on the toilet to facilitate stool expulsion Support of the perineum, digitation of the rectum, or application of pressure to the posterior vaginal wall to facilitate rectal emptying Inability to expel enema fluid Constipation after subtotal colectomy for constipation Rectal Examination (with patient in left lateral position) Inspection Anus is pulled forward during attempts to simulate strain during defecation. Anal verge descends < 1 cm or > 4 cm (or beyond the ischial tuberosities) during attempts to simulate straining at defecation. Perineum balloons down during straining, and rectal mucosa partially prolapses through anal canal.

Palpation High anal sphincter tone at rest precludes easy entry of examining finger (in absence of a painful perianal condition such as an anal fissure). Anal sphincter pressure during voluntary squeeze is minimally higher than anal tone at rest. Perineum and examining finger descend <1 cm or > 4 cm during simulated straining at defecation. Puborectalis muscle is tender to palpation through the rectal wall posteriorly, or palpation reproduces pain. Palpable mucosal prolapse during straining. Defect in anterior wall of the rectum, suggestive of rectocele.

Anorectal Manometry and Balloon Expulsion (with patient in left lateral position) Average resting anal sphincter tone >80 cm water (>59 mm Hg) Average anal sphincter squeeze pressure >240 cm water (>177 mm Hg) Failure of balloon expulsion from rectum despite addition of 200 g weight to the balloon Diagnostic tests Investigation only for o Exclude systemic illness or structural disorder o U/D pathophysiologic process Test to exclude systemic disease Hb, ESR, Biochem TFT, Ca, Glucose Test to exclude structural disease of the gut BE limited enema w/ water-soluble contrast constipation ( fecal impaction ) UGI study small bowel Pseudoobstruction or small bowel obstruction Colonoscopy or Flexible sigmoiloscopy + BE o Alarm feature: Bowel habit change Bleeding Wt loss Fever o >50yr w/ constipation <50 yr Flexible sigmoid only alarm symptom Physiologic measurements Refractory symptoms secondary causes & try high-fiber diet/ laxatives American Gastroenterological Association Technical review on Anorectal testing techhique o Symptom diaries (for Dx & monitor Rx)

o Colonic transit study (to confirm complaint & assess motility for slow transit & regional delay) o Anorectal manometry (Exclude Hirschsprungs dz, to complement other test of pelvic floor dysfn) o Surface EMG ( anal sphincter fn & facilitate biofeedback training) Other test of possible value o Defecation proctography ( o Balloon expulsion test o Rectal sensory testing ( disorder) ) functional Neurologic

Measurement of Whole-Gut and Colonic Transit rate o Normal CTT < 72 hrs o Slow transit Surgery o X-ray abdomen 120 hrs after ingest markers = Sitz-Markers o Avoid laxative, enema, med. affect bowel motility High-fiber diet o Prolonged CTT: retained > 20% of markers after 120 hrs o Retained most in sigmoid/rectum defecatory disorder o Retained throughout colon not exclude defecatory disorder Slow transit o Megarectum: all markers move rapidly to rectum & retained there Defecography o Instill thickened Ba into rectum o Fluoroscopy : resting, deferring defecation, straining o Evaluate rate and completeness of rectal emptying Anorectal angle Perineal descent Structural abnormality: rectocele (ant to Vg wall), internal mucosal prolapse, intussusception Paradoxical sphincter contraction common in rectocele o Limitation of study Variability among Radiologists interpretation Inh of normal rectal emptying pt embarrassment Ba & stool texture o More sensitive: Defecography with simulated stool (FECOM)

 Not widely available Balloon expulsion test o Fail to evacuate 50-60 ml balloon in rectum while sitting on toilet for 2 minutes with 200 gm of weight to the end of balloon defecatory disorder o Useful to screen defecatory disorder without pelvic floor dyssynergia o Pelvic floor dyssynergia confirmed by Manometric & defecographic finding Rome II criteria Anorectal Manometry o Assess Resting and maximal squeeze pressure of anal sphincter Relaxation of anal sphincter during balloon distension (rectoanal inhibitory reflex) Rectal sensation Neuro dz Ability of anal sphincter to relax during straining o defecatory disorder inappropriate contraction of sphincter o Loss of Rectoanal inh reflex Hirchprungs dz o High Resting anal pr anal fissure or anismus (paradoxical contraction ext sphincter straining Elcetromyographic testing of striated muscle o Study external anal sphincter and puborectalis muscle o Only in suspected cord of cauda equina lesions unilat dysfn of Ext sphincter Rectal sensitivity and sensation testing o air into rectal balloon o Record volume volume o Not of value research

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