Lankenau Pearls
Gastroenterology
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What are common extra-esophageal manifestations of GERD?
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Cough, chest pain, wheezing
Without alarm features, what is standard treatment?
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PPI once daily, if no response then increase to twice daily for 4-8 weeks, ensure taking correctly (30-60 minutes before first meal of day)
Who should be screened for Barrett’s?
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Men aged >50 with 5+ years of GERD and an additional risk factor like smoking/alcohol, obesity
What would you see on EGD for Barrett’s?
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Salmon-colored mucosa
Indications for testing of H. Pylori?
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Active PUD, Hx of PUD without documented cure, gastric MALT lymphoma, hx of early gastric cancer
What is the best test to diagnose H. Pylori?
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Urea breath test, stool antigen both have >95% sensitivity and specificity and are non-invasive
What is the treatment for H. Pylori?
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Triple therapy: PPI bid + clarithromycin 500 bid + amoxicillin 1 g bid for 14 days
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Quadruple therapy: PPI + Bismuth + Doxycycline + Metronidazole for 14 days
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Quadruple therapy preferred in our area due to resistance patterns
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How do you confirm treatment has worked?
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Must perform fecal antigen test around 1 month after completion of eradication therapy (to reduce false-negatives) to confirm eradication
What do you do if H. Pylori is not eradicated after treatment?
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Must treat with salvage therapy - ex. PPI + bismuth + tetracycline + metronidazole
What are the most common reasons for failure to respond to H. Pylori treatment?
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Lack of adherence to treatment or resistance to H. Pylori strain
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How does solid vs liquid dysphagia change your differential?
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Solid food dysphagia suggests structural abnormality
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Solid and liquid or liquid alone suggests dysmotility
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Solids progressing to solids and liquids suggests malignancy
What are red flag signs in a patient with dysphagia?
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Odynophagia, onset in older patients, association with weight loss, or acute symptom timeline → these would all warrant urgent EGD
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What are common culprits for pill esophagitis?
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Potassium, bisphosphonates, doxycycline, NSAIDs, iron
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How do you manage uncomplicated diverticulitis?
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Watch and wait. For 95% of patients, it will resolve on its own. You only need abx for complicated - abscess, fistula, obstruction, peritonitis, stricture or immunocompromised
Why is a colonoscopy recommended 6-8 weeks later?
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What are the most common causes?
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PUD, Mallory-Weiss tear, gastritis, varices
Most common underlying cause?
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NSAID use and H. pylori
Initial management for all UGIBs?
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2 large bore IVs (remember large bore and peripheral causes less resistance to flow than central lines or other long catheters), PPI, type and screen, blood consent, typically NPO, fluid resuscitation, blood product resuscitation, reversal agents if indicated for anticoagulation
How do you manage a variceal bleed?
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As above plus STAT page to GI for urgent endoscopy plus airway protection if needed
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In settings where urgent EGD not available can place Blakemore tube to tamponade
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May need Reglan or erythromycin prior to EGD to clear gastric contents
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Start antibiotics for SBP ppx with CTX 1g/day typically for 5-7 days
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Octreotide; typical 50 mcg bolus followed by 50 mcg/hr gtt (lowers portal pressure)
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TIPS may be required for refractory bleeding
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Transfusion goal Hgb >7 as worse outcomes with overtransfusion in cirrhotics
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Varices may require serial banding
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Nonselective BB once stabilized
What is a Mallory-Weiss tear?
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Longitudinal mucosal laceration usually in distal esophagus; associated with forceful retching
Ideal timeline to EGD in hospitalized UGIB?
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Within 24 hours of admission, within 12 hours for rapid or variceal bleed
Dangerous etiology to consider in those with prior aortic surgery?
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Aortoenteric fistula
PPI therapy in UGI bleed?
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IV BID or continuous gtt; continuous gtt not felt to improve outcomes compared to BID dosing except in the case of high risk ulcers found on endoscopy
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Most common cause?
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Diverticulosis
Imaging, if unstable and actively bleeding?
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CTA; if active bleed seen can get IR to embolize
Potential treatment options for chronic small bowel AVMs?
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Octreotide
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Angiogenesis inhibitors - thalidomide, bevacizumab
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Presentation of chronic mesenteric ischemia?
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Post-prandial pain, weight loss, fear of eating
Presentation of acute mesenteric ischemia?
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Pain out of proportion to exam -> diarrhea -> bleeding
Imaging?
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CTA or MRA
Management of AMI?
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Surgical consult, antibiotics (because of potential compromise in mucosal integrity), and hemodynamic support
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What are the two most common causes of pancreatitis?
What are common medications known to cause pancreatitis?
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Thiazides, GLP-1s, valproic acid, sulfas, didanosine
What are the criteria to diagnose pancreatitis?
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2 out of the 3 following
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Typical abdominal pain associated with pancreatitis (acute upper)
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Lipase or amylase >3x the ULN
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Imaging findings suggestive of pancreatitis
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What specific lab markers portend a poor outcome?
All patients with pancreatitis require what imaging?
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RUQ US to evaluate the biliary tract for obstruction
What would be the indication to start antibx?
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If infected necrosis is a concern -> lack of improvement after 7-10 days or deterioration or extrapancreatic infection
What is the treatment for chronic pancreatitis?
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Mainly symptomatic - tramadol, SNRI, gabapentin, avoidance of tobacco and alcohol; can give pancreatic enzymes if steatorrhea is present
What are common associations with autoimmune pancreatitis?
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Sclerosing cholangitis, sclerosing sialadenitis, or retroperitoneal fibrosis
What is the treatment for autoimmune pancreatitis?
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High-dose oral prednisone over 2-3 months (90% of patients achieve remission)
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What is first line?
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Fiber (bloating), miralax, magnesium oxide (caution with renal disease), enemas (no fleets in renal disease), exercise, avoidance of offending agents
What is second line?
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Stimulant laxatives -> dulcolax, senna
What is third line?
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Secretagogues (linaclotide, plecanatide, lubiprostone, etc.)
What is narcotic bowel syndrome and how do you treat it?
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Paradoxical worsening of abdominal pain with narcotic dose escalation
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Stop narcotic use
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Criteria for diagnosis?
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Abdominal pain at least once weekly for 3 months and 2 of the 3 following
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Pain relieved by defecation
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Change in stool frequency
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Change in stool consistency
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Things to rule out with IBS-D
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Celiac disease, giardia, and calprotectin (to differentiate from IBD)
What differentiates IBS from functional constipation/diarrhea?
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How does it present?
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Nausea, vomiting, upper abdominal pain, early satiety; often in diabetic pts
How do you evaluate suspected gastroparesis?
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First, must do EGD to exclude gastric outlet obstruction, H. pylori. After ruling out, complete gastric emptying test
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Try to avoid medications that affect gastric motility for 48 hours prior to gastric emptying study eg opiates, anti-cholinergics, metoclopramide
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Treatment of gastroparesis?
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Small, frequent meals, tight glycemic control, low-dose metoclopramide (erythromycin can help sxs but should be limited to short-term use given risk of tachyphylaxis)
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Metoclopramide should be given for acute treatment but not chronic due to extrapyramidal side effects
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What are standard therapies for ulcerative colitis?
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Mild or moderate = aminosalicylates (sulfasalazine, olsalazine, balsalazide, mesalamine) and can be combined - oral and rectal.
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Flares = steroids (should never be used for maintenance therapy)
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Severe (pts who keep requiring steroids for flares) = combination azathioprine + 6-MP which are thiopurines or immunomodulators that have 2-3 month onset of action OR biologics - TNF-a inhibitors most commonly used is infliximab which should be used in combination with immunomodulator agents
What biliary disease is associated with ulcerative colitis?
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Primary sclerosing cholangitis (PSC) - associated with IBD in 85% cases
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All pts with PSC should have a colonoscopy at the time of diagnosis
What do you need to screen for before starting a TNF-a?
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Latent TB and Hep B
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How do you determine which patients with Alcoholic Hepatitis benefit from steroids?
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A Maddrey Discriminant Function ≥ 32 is associated with possible mortality benefit with steroids (https://pubmed.ncbi.nlm.nih.gov/20940288/), though the recent evidence is a bit mixed
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Treatment is with Prednisolone (or Prednisone) 40 mg daily for 28 days; active infection is contraindication
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Pentoxifylline is an alternative to steroids for those who have contraindications to steroids or who are at risk for infection, though evidence is also mixed (use is falling out of favor) Pentoxifylline for alcoholic hepatitis - PubMed (nih.gov)
How do you monitor response to treatment with steroids?
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A Lille score of > 0.45 at day 7 after initiation of steroids suggests that a patient is not responding to steroids
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Alternatively, can consider stopping steroids if no improvement in bilirubin or discriminant function (DF)
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What work-up should you order in a new cirrhotic?
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CBC, CMP, coags, US with elastography, hepatitis panel, A1A, HSV, CMV, EBV, ANA, HIV, anti-LKM, ASMA
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Liver biopsy gold standard but often not required
What score is used to predict survival and prioritize transplant?
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MELD-Na score
What should every patient with new ascites have done?
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Diagnostic paracentesis (include cytology), ultrasound with doppler to look for PVT, AFP to assess likelihood of HCC
What SAAG and protein values are suggestive of cirrhosis?
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High SAAG and low protein
What conditions are associated with low SAAG ascites?
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Malignancy, TB, nephrotic syndrome, trauma, pancreatitis
How do you volume resuscitate after large volume paracentesis?
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Albumin 6-8g/L when >5 L removed (there is an EPIC order set at Lankenau)
Common physical exam findings of cirrhosis?
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Jaundice, spider angiomas, telangiectasias, distended abdomen with possible fluid wave, gynecomastia, small testicles, asterixis, Milkmaid’s grip
How is volume overload/ascites typically managed in cirrhotics?
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Lasix and spironolactone; typically administered in 2:5 ratio respectively
How do you treat hepatic encephalopathy?
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Lactulose and rifaximin
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Lactulose: helps with ammonia excretion; titrate to 2 bowel movements/day outpatient and 3 bowel movements/day inpatient
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Rifaximin: alters bacterial production of ammonia
What are common precipitants of hepatic encephalopathy?
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Infection, GI bleed, hypovolemia/AKI
What is hepatorenal syndrome and how do you “test” for it?
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Dx of exclusion: r/o usual causes of AKI - get lytes, bladder scans, stop b-blocker and diuretics; Albumin challenge: 1 g/kg, up to 100, x 2 days - if the Cr worsens, then think HRS
How do you treat hepatorenal syndrome?
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Octreoride + albumin + midodrine / levophed / vasopressin + terlipressin if not in USA
How do you diagnose and treat SBP?
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Para with >250 PMNs; for every 250 RBCs subtract one PMN
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Treat with CTX 1g q12; fluoroquinolones also option where resistance rates are low
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Albumin should be given on day 1 and day 3 of therapy if Cr > 1, BUN > 30, or TBili > 4 for mortality benefit
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Repeat para on day 3 to ensure PMNs improving
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Common type of cholecystitis seen in critically ill/ICU patients?
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Acaculous cholecystitis
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Typically managed with perc chole
Timing of cholecystectomy in acute cholecystitis?
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Before hospital discharge
Procedural management of acute cholangitis?
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ERCP for CBD stone removal and drainage
Antibiotic treatment for patients with suspected GB Infection?
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Ceftriaxone + Metronidazole OR Zosyn