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27th Reviews in Internal Medicine for 3rd Year Medicine Resident 2018
Approach to Common Problems in
Gastroenterology
Symptomatology in GI & liver diseases
• Ascites
• Jaundice
• Acute & chronic abdominal pain
• Acute & chronic diarrhea
• Constipation & bowel habit change
• Nausea & vomiting
• GI hemorrhage
• Abdominal mass
Abdominal distension
• Ascites• Ileus, gut obstruction• Huge abdominal mass/ cyst• Obesity• Pregnancy
Causes of ascites
Cirrhosis 84%
Heart failure 3%Malignancy 2,5%
TB 1%Mixed 5%
Others 4,5%
Runyon BA. Ann Intern Med 1992
Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non-portal HT
History taking
• Risks of cirrhosis: alcohol, HBV, HCV, NASH• Symptoms of cirrhosis: pedal edema, jaundice,
variceal bleeding• 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
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
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
Investigations in patients with ascites
• Abdominal paracentesis• Blood chemistry• Ultrasound, Doppler U/S, CT• CXR• Peritoneoscopy with biopsy
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
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%
• 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
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)
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
Carcinomatosis peritonei
Common cancers • Ovarian • Pancreatic• Cholangiocarcinoma• Gastric• Colorectal• Breast, lung
Carcinomatosis peritonei
Diagnosis• Cytology; positive 96.7%
- 3 samples- 50 mL of fresh ascites- immediate processing
• CT scan• Biopsy
Nephrogenous ascites
• ESRD• History of dialysis-associated hypotension• Diagnosis by exclusion• Ascitic profile: non-specific
Mixed ascites
• 5% of patients with ascites
• Portal HT + secondary causes
Alcoholic cirrhosis + TB peritonitis
Cirrhosis with carcinomatosis peritonei
• Clue; wide SAAG ascites plus
– high ascitic lymphocyte
– high total protein
Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non portal HT
HemoperitoneumChylous ascitesPseudomyxomaBilious ascites
Chylous ascites
• Milky and creamy ascitic fluid
• Triglyceride content >200 mg/dLCardenas A et al, AJG 2002:1896-1900
Diseases
Neoplasm LymphomaOvarian, breast, pancreas, colon, carcinoidLymphangiomyomatosis
Congenital (pediatric) Primary lymphatic hypoplasiaIntestinal lymphangiectasia
Infection Filariasis, TB, MAC
Inflammation RadiationPancreatitisRetroperitoneal fibrosis
Trauma Post operation, abdominal injury
Etiology of chylous ascites
Diseases
Trauma Abdominal injuryPost operation / biopsy / abdominal paracentesis
Gynaecologic conditions 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
Ascites
SinusoidalPeritoneal diseases
Post sinusoidal
BCSSOSRight sided HFPulmonary HT
CirrhosisAlcoholic hepatitisFulminant hepatitisMassive liver met.
TBCarcinomatosisPancreatitisCNT diseasesNephrogenous
Portal HT Non portal HT
HemoperitoneumChylous ascitesPseudomyxomaBilious ascites
Jaundice
Hepatocellular CholestasisHemolysis1
2 Intravascular Extravascular AcuteAcute on chronic
Intrahepatic Extrahepatic
AnemiaDark urine
Prodromal symptomsSigns of chronic liver diseasesRisk factors
PruritusAcholic stoolBiliary painPalpable gallbladderAbdominal massWeight loss
Palmar erythema Dupuytren’s contractureClubbing of fingers
Gynecomastia Parotid gland enlargementSpider nevi
Hepatocellular jaundice
Acute on chronicAcute • Signs of chronic liver diseases• Recurrent jaundice
• Virus HAV, HBV, HEV EBV, CMV, HSV
• AIH• Drugs, toxin• Acute BCS, SOS• Hemophagocytosis
• HBV• AIH• Alcohol• Wilson disease• Acute hepatitis (other
causes) on top cirrhosis
• Risk factors: IVDU, tattoo etc.• Travel• Vaccination; HAV, HBV• Fever, abdominal pain• Family history• Drugs/ toxin/ Herb/ CAM• Alcohol• Underlying diseases
• Signs of CLD / PHT• Hepatosplenomegaly• (KF ring, Parkinsonism)
Virus
NASH
Wilson
HH
BCSDrugs
AIH
Alcohol
Hepatitis
Risk factorsTravel, vaccination
Drug listTemporal relationship
Familial historyKF, Parkinsonism
Hepatomegaly, ascitesProthrombotic states
Female, autoimmuneHigh globulin
ObeseMetabolic syndrome
Heavy drinkerSigns of CLD
AST & ALT activity
Predominated AST
Rapid decline
• <5x: Chronic• >5-8x: Acute• >40x:
• Ischemic• Drugs, toxins
• Extrahepatic: rbc, heart, skeletal m.• Alcohol• Reye’s syndrome• Cirrhosis
• Ischemic• Drug (short T1/2)• Acute biliaryobstruction• Fulminant hepatitis
Level
HAV HEV HBV HDV HCV
Transmisssion Feco-oral Feco-oral Blood, SexualVertical
HBsAg-dependent
Blood
Presentation Acute AcuteChronic*
AcuteChronic
AcuteChronic Chronic
Risk factors Travel
Vaccine
Travel IVDU, tattoo, blood Tx, unsafe sex, family HxVaccine
IVDU IVDU, tattoo, blood Tx
Hepatotrophic viral hepatitis
*AIDS, post organ transplantation
EBV HSV CMV
Presentation
Acute Acute Acute
Host Adolescent ImmunocompromisedPregnancy
Immunocompromised
Symptoms & signs
Mononucleosis-like Skin lesions (50%) Retinitis, colitis, pneumonitis
Non-hepatotrophic viral hepatitis
Cholestaticjaundice
IntrinsicExtrinsic
compressionIntraluminal
CBD stoneParasite
CholangiocarcinomaPSC, IgG4-relatedAIDS cholangiopathyInjury (TACE/Surgery)
Malignancy; pancreas, duodenum, ampulla
Metastatic LNLymphomaPancreatitis
Intrahepatic
Extrahepatic
Cholangiocyteinjury
MiscellaneousInfiltrative
TB, fungusMetastatic CALymphomaAmyloidosisSarcoidosis
PBCDrugsGVHDCystic fibrosis
SepsisPregnancyParaneoplasticTPN
• Onset of pruritus vs jaundice• Hepatomegaly• Biliary pain• Palpable gallbladder• Abdominal mass• Rate of rising of bilirubin
Viral hepatitis Serology
HAV Anti HAV IgM
HBV HBsAg, anti HBc IgM
HEV Anti HEV IgM, anti HEV IgG
EBV Blood smear, Anti EBV IgM
HSV Tzanck smear, HSV PCR, liver biopsy
CMV CMV viral load, histology
Investigations for viral hepatitis
Diseases Serology
AIH ANA, SMA, IgG, (liver biopsy)
Alcohol CBC, LFT + GGT, U/S
Wilson disease Slit lamp, ceruloplasmin, 24 hr urine copper
Acute BCS Doppler U/S or CT BM study and Ix for hematologic diseases
Drugs Diagnosis by exclusion, (liver biopsy)
Investigations for non-viral hepatitis
Diseases Serology
PBC AMA, (liver biopsy)
PSC ERCP/ MRCP
CBD stone (U/S), CT, EUS, ERCP
Cholangiocarcinoma CT, CA19-9, +ERCP, biopsy
Periampullary cancer CT, CA19-9, biopsy
Investigations for cholestasis
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