Gastroenterology Ambulatory Medicine Clerkship

GastroenterologyAmbulatory Medicine Clerkship

Scott Grisolano, MD

Division of Gastroenterolgy and Hepatology

KUMC

Outline

• Physical exam

• History taking

• Evaluation of abdominal pain– Common Clinical Scenarios– Differential diagnosis

Physical Exam - Abdomen• Inspection

– Skin– Hernia– Contour– Pulsations, peristalsis

• Auscultation– Bowel sounds– Bruits

• Percussion, Palpation– Liver, spleen, masses, aneurysm– Peritoneal irritation

• Rigid abdomen, guarding, rebound tenderness• How was the ride to the ER?• blunted: elderly, severely ill

• HEENT– Scleral icterus– Conjunctival pallor

• Skin– Jaundice– Spider angiomata– Gynecomastia– Petechiae, bruising– Caput medusae

• Extremities– Palmer erythema

• Abdomen– HSM– Ascites

• Neurological – mentation– Asterixis

• Anorectal– Perianal exam– DRE– Stool

Painful History

• Location • Onset, frequency, duration, severity• Quality • Radiation • Factors that exacerbate or improve symptoms such as

food, antacids, exertion, defecation • Associated symptoms: fevers, chills, weight, N, V,

diarrhea, constipation, hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool

• Family history of bowel disorders • Medications: OTC (acetaminophen, aspirin, and NSAIDs) • Menstrual history in women

Embryology - Pain - Artery - Organ

• Foregut – Epigastrium – Celiac – S, D

• Midgut – Periumbilical – SMA – J, I, TC

• Hindgut – Hypogastrium – IMA – TC, R

Pain

• Visceral pain (viscus)

– diffuse, poorly localized– gnawing, burning, cramping

• Somatic pain (abdominal wall, parietal peritoneum)

– more intense, better localized

• Referred pain– same dermatome– sharp, well localized; resembles somatic

Abdominal Pain - Triage

• Acute – Sick patient?– High level of suspicion in immunosuppressed,

elderly– Abdominal examination

• Chronic

Abdominal Pain - Triage• History

– differential diagnosis

• Examination– vital signs

• Labs– CBC– CMP– Liver biochemistries– Amylase, lipase– UA– Pregnancy test

• Abdominal x-ray

Ruptured or Perforated Viscus

- PUD, ectopic pregnancy, dissecting aneurysm

Obstruction of Viscus

- adhesions, hernia, volvulus, intussusception

Ischemia

- mesenteric, PE, MI

Inflammation

- pancreatitis, cholecystitis, appendicitis, diverticulitis

Peritonitis

Abdominal Pain - Triage• History

– differential diagnosis

• Examination– vital signs

• Labs– CBC– CMP– Liver biochemistries– Amylase, lipase– UA– Pregnancy test

• Abdominal x-ray

RUQ Pain

• Liver, biliary tree– May radiate to back, epigastrium

• Pancreatitis

• Cardiac

• Pleural/pulmonary

• Nephrolithiasis

Epigastric Pain

• Acute pancreatitis

• PUD

• GER

• Cardiac

• Pleural/pulmonary

Lower Abdominal Pain

• Distal intestinal tract

• Urinary tract

• Pelvic structures

– Colonic, SB source = diarrhea, hematochezia– Rectal source = urgency, tenesmus

Lower Abdominal Pain

• LLQ– Diverticulitis– Colitis

• Infectious, ischemic, IBD

• RLQ– Appendicitis– ileocolitis

Lower Abdominal Pain

• Females– Menses, dysmenorrhea, dyspareunia– Possibility of pregnancy– Vaginal discharge, bleeding

– Adnexal cysts– Ovarian torsion– Ectopic pregnancy– PID

Specific Conditions

• PUD

• Gallbladder disease

• Acute pancreatitis

• Small bowel obstruction

• GI bleeding

Specific Conditions

• PUD

• Gallbladder disease

• Acute pancreatitis

• Small bowel obstruction

• GI bleeding

PUD

• Duodenal ulcer– symptoms of occur when acid is secreted in the

absence of a food buffer– symptoms occur 2-5 hours after meals or on

empty stomach

• Gastric ulcer– more severe pain occurring soon after meals,

with less frequent relief by antacids or food

PUD

• Epigastric pain in 2/3 symptomatic patients– may localize to the RUQ, LUQ – burning, gnawing, or hunger-like in quality, may be

vague

• Sudden development severe, diffuse abdominal pain may indicate perforation

• Vomiting is the cardinal feature in pyloric outlet obstruction

• Hemorrhage may be heralded by nausea, hematemesis, melena, or dizziness

PUD - Etiology

• Helicobacter pylori

• NSAIDs

< 5%

30-50%

Alarm Symptoms / Red Flags

• Age > 50• Weight loss• Dysphagia• Persistent vomiting• Palpable abdominal mass• Occult gastrointestinal bleeding• Otherwise unexplained anemia• Family history UGI malignancy• Previous gastric surgery

Specific Conditions

• PUD

• Gallbladder disease

• Acute pancreatitis

• Small bowel obstruction

• GI bleeding

Gallbladder

• Biliary colic– Pain reaches crescendo then resolves completely– Pain is visceral in origin (no true gallbladder wall

inflammation) – Pain resolves when the gallbladder relaxes, permitting

stones to fall back from the cystic duct

• Acute cholecystitis– RUQ pain lasting > 4-6 hours should raise suspicion

for acute cholecystitis– Symptoms of malaise, fever more likely

Cholecystitis – Clinical Presentation

• Abdominal pain– RUQ, epigastrium– may radiate to the right shoulder or back

• Pain is steady and severe– nausea, vomiting, and anorexia

• Prolonged RUQ pain (> 4-6 hours), especially if associated with fever, should arouse suspicion for acute cholecystitis as opposed to an attack of simple biliary colic

Differential Diagnosis

• Acute pancreatitis • Appendicitis • Acute hepatitis • Peptic ulcer disease • Diseases of the right kidney • Right-sided pneumonia • Fitz-Hugh-Curtis syndrome

– perihepatitis caused by gonococcal infection

• Sub-hepatic, intra-abdominal abscess • Perforated viscus • Cardiac ischemia

Cholecystitis – Labs

• Bilirubin, AP generally normal in uncomplicated cholecystitis– biliary obstruction is limited to the gallbladder

• If bilirubin, AP elevated this should raise concerns about complicating conditions such as cholangitis, choledocholithiasis– mild elevation in serum aminotransferases and amylase,

and hyperbilirubinemia with jaundice have been reported even in the absence of these complications

• These abnormalities may be due to the passage of small stones, sludge, or pus

Cholecystitis – Physical Exam

• Ill appearing, febrile, and tachycardic• Lie still on exam table because cholecystitis is

associated with local parietal peritoneal inflammation that is aggravated by movement

• Abdominal examination usually demonstrates voluntary and involuntary guarding

• "Murphy's sign" may be a useful diagnostic maneuver

Acute Calculous Cholecystitis

Specific Conditions

• PUD

• Gallbladder disease

• Acute pancreatitis

• Small bowel obstruction

• GI bleeding

Acute Pancreatitis - Etiology

• Gallstones (45%)• Alcohol abuse (35%)• Post-ERCP, medications, metabolic, hereditary,

infectious, connective tissue disease, trauma, congenital anatomic abnormalities, tumors (10%)

• Idiopathic (10%)

• Overall mortality 10 -15%– severe disease as high as 30%

• Males (alcohol) > Females (choledocholithiasis)

80%80%

Acute Pancreatitis – Clinical Presentation

• Mid-epigastric abdominal pain– Steady, boring pain– Radiation to the left upper back

• Anorexia, nausea vomiting diarrhea• Low grade fever• Presentations associated with complications

– Shock– Multi-system failure

• Abdominal tenderness• Fever (76%)• Abdominal guarding (68%)• Abdominal distension (65%)• Tachycardia (65%)• Hypoactive bowel sounds

• Jaundice (28%)• Dyspnea (10%)• Hemodynamic changes (10%)• Melena or hematemesis (5%)• Cullen’s sign• The Grey-Turner sign• Left pleural effusion

Acute Pancreatitis – Physical Exam

• Serum amylase

– Not specific for pancreatitis• intestinal ischemia, renal insufficiency, small bowel obstruction,

macroamylasemia, parotitis– Short half-life: elevates early, returns to normal early (within 2-3 days)

• Serum lipase– More specific to pancreas– Long half-life: levels rise later, stay elevated for longer (7-14 days)

• Liver enzymes– ALT, AST, alkaline phosphatase, total bilirubin– ALT > 150 in patient with cholelithiasis suggests gallstone

pancreatitis

Acute Pancreatitis - Diagnosis

• Ultrasound– Most useful initial test for common bile duct dilation

and gallstones

• Contrast CT Scan– Not necessary for diagnosis of acute pancreatitis– May help identify etiology in rare instances (tumor)– Useful to assess complications - fluid collections or

pancreatic necrosis

Acute Pancreatitis - Diagnosis

Pseudocyst

- - takes > 4 weeks to takes > 4 weeks to develop pseudocystdevelop pseudocyst

Acute Pancreatitis - Severity Staging

Ranson Criteria - > 3 indicates severe AP

• At Admission– Age > 55; WBC > 16K; Glucose > 200; LDH >350; AST > 250

• During first 48 hours– Hct decrease by > 10% with hydration– BUN increase > 5 mg/dL– Calcium < 8 mg/dL– pO2 < 60 mm Hg– Evidence of fluid sequestration (> 6L replacement

needed)

Specific Conditions

• PUD

• Gallbladder disease

• Acute pancreatitis

• Small bowel obstruction

• GI bleeding

Small Bowel Obstruction

• Post-operative adhesions

• Hernia

• Tumors

SBO - Symptoms• Abdominal distention, vomiting, crampy pain

• Abdominal pain– Periumbilical, crampy– paroxysms of pain every 4-5 minutes– presence of constant abdominal pain or change of pain

from colicky to constant suspect strangulation

• Patients may or may not complain of obstipation and inability to pass flatus since colon requires 12-24 hours to empty after the onset of bowel obstruction

SBO – Physical Exam• Fever, tachycardia: associated with strangulation• Inspection

– surgical scars, degree of distention

• Auscultation– may reveal high-pitched or hypoactive bowel sounds

• Percussion, Palpitation– Tenderness to percussion, rebound, guarding, and localized

tenderness suggests peritonitis– Tympany usually present due to air-filled loops of bowel or stomach– abdominal mass may indicate an abscess, volvulus, or tumor– Search for inguinal, femoral, and incisional hernias

• Rectal examination– gross or occult blood can be found with neoplasm, ischemia, and

intussusception.

SBO – Labs

• Leukocytosis: may indicate presence of strangulation

• Metabolic alkalosis: seen with frequent emesis

• Metabolic (lactic) acidosis: ischemic bowel

SBO – X-rays• Upright chest film to rule out the presence of free air

• Supine and upright abdominal films– Multiple air-fluid levels with distended loops of small bowel are seen

in small bowel obstruction, although occasionally can be seen in setting of paralytic ileus

• Presence of air in the colon or rectum makes the diagnosis of complete obstruction less likely, particularly if symptoms have been present for more than 24 hours

• Plain films:– equivocal in 20-30% of patients– normal, nonspecific in 10-20%

SBO – CT scan

• Presence, level (transition point), severity, and cause may be identified

• Other abdominal pathology can be detected• Absence of air, fluid in distal small bowel or colon

denotes complete obstruction• Intestinal pneumatosis and hemorrhagic mesenteric

changes can be seen in advanced strangulation • In most cases of SBO, no obvious source of

obstruction is seen, since adhesions cannot be detected by CT scan

SBO - Management

• "never let the sun rise or set on a small bowel obstruction"

Specific Conditions

• PUD

• Gallbladder disease

• Acute pancreatitis

• Small bowel obstruction

• GI bleeding

All bleeding is not the same…

• Where is it coming from?

• Pace of bleeding?

• Volume of bleeding?

• Associated symptoms?

• Color of blood?

What color blood?

• Melena

• Hematochezia

• Occult blood positive

Acute GI Bleeding

UPPER > LOWER

75-80% vs. 20-25%

Acute GI Bleeding

• Assessment, stabilization, resuscitation

• Medication review– Anticoagulants (Coumadin)– Antiplatelet agents (Plavix)– Aspirin, NSAIDs

Clinical Prognostic Factors

Older age (>60)Severe comorbidityAltered hemodynamics

- Tachycardia > 100 bpm- Orthostasis > 20 mg Hg systolic

> 10 mg Hg diastolicTransfusion

- 4 - 6 units/resuscitation eventSevere coagulopathyInpatient status at time of bleed

UGI Bleeding

• EGD– Diagnosis

• identifies bleeding site (90-95%)• prognostic value

– Endoscopic Therapy

• Medical Therapy– IV Proton Pump Inhibitors (PPIs)– octreotide

Active Bleeding - Dieulafoy Lesion

90%

Esophageal Varices

LGI Bleeding

• LGIH accounts for 20-25% of all GI bleeds

• Definition: distal to the ligament of Treitz

• Colonic lesions account for vast majority

• Majority cease without intervention

• 15-20% require intervention

LGIB - Etiology

* post-polypectomy bleeds

LGI Bleeding

• Urgent Colonoscopy– After rapid oral purge

– Diagnosis• identifies bleeding site 54-80%

– Treatment• epinephrine, heater probe, bipolar, hemoclips

Diverticular Bleed

Post-polypectomy - NBVV

Ischemic Colitis