gastroenterology.ppt

1、Gastroenterology,Swedish Family Practice Residency Didactics July 31, 2001,A quick trip through the GI track with brief stops at the esophagus, stomach, liver, colon, rectum and anus.And a little diarrhea.,The Upper GI Tract,Esophagus Stomach Pancreas Gallbladder Liver,Esophageal Disorders,Disorders

2、 of motility GERD Inflammatory and infectious disorders Tumors,Symptoms from the Esophagus,Dysphagia Odynophagia Chest pain Regurgitation,Disorders of Motility,Achalasia Cancer, Parkinsons, Chagas Disease (trypanosomiasis) Spasm Diffuse, Localized Scleroderma,Diagnostic Studies,Barium swallow Manome

3、try,Treatment,Long-acting nitrates Calcium channel blockers Dilation of LES (Achalsia) Surgery (Spasm, Scleroderma) Manage reflux (Scleroderma) Prokinetic drugs (Scleroderma),GERD,Frequent 10% of US population Occasional 30% of US population,Symptoms of GERD,Heartburn Water Brash Regurgitation Dysph

4、agia/odynophagia Chest pain, hoarseness, chronic cough, wheezing,Diagnosis of GERD,Therapeutic trial Endoscopy (if complicated) Manometry (for placement of pH probe or prior to reflux surgery) pH acid perfusion test (for diagnosis of unresponsive GERD),Treatment of GERD,Mild Symptoms Dietary modific

5、ation Lifestyle modification Trial of patient directed therapy with OTC antacids or H2 antagonists,Treatment of GERD,Non-responders, non-erosive disease H2 antagonists PPIs Promotility agents 8-12 weeks of therapy,Warning Symptoms Suggesting Complicated GERD,Dysphagia Bleeding Weight loss Choking (a

6、cid causing coughing, shortness of breath , or hoarsness) Chest pain Longstanding symptoms requiring continuous treatment,Treatment of GERD,Complicated GERD GI workup with endoscopy PPIs High-dose H2 antagonists Antireflux surgery no data on new procedures,Inflammatory Disorders of the Esophagus,Pil

7、l-induced esophagitis NSAIDs, steroids, doxycycline Infective esophagitis HIV, HSV, cytomegalovirus, candida Corrosive alkalis or acids,Diagnosis and Treatment,Endoscopy Treatment based on results of endoscopy,Esophageal Tumors,90% are malignant Most are squamous cell Most are associated with heavy

8、alcohol and tobacco use 8% of Barretts develop into adenocarcinomas 5% 5-year survival but improving,Diseases of the Stomach,Acid peptic disorders of the stomach and duodenum Infections Motor disorders Cancer,Acid Peptic Disorders,5 10% of the US population will have PUD in their lifetime, 50% will

9、recur .0001% mortality rate,Cause of PUD,Imbalance between protective and aggressive factors,Protective factors,Mucus and bicarbonate secretion of epithelial cells Surface membrane of mucosal cells PG E-1 and PG E-2,Aggressive Factors,Gastic acid NSAIDs Corticsteroids Smoking,Alcohol (?) Stress (?)

10、Diet (probably not) H-pylori,H. pylori and PUD,Almost all patients with H. pylori have antral gastritis Eradication of H. pylori eliminates gastritis Nearly all patients with DU have H. pylori gastritis 80% of patients with GU have H. pylori gastritis,H. Pylori Diagnosis,Serology ($20-$200) 90% sens

11、itive, 95% specific not good for following treatment Biopsy ($250) 98% sensitive 98% specific Urea breath test ($80-$100) 95% specific, 98% specific can be used to document eradication Stool antigen test ($100-$150) 90% sensitive, 95% specific can be used to confirm eradication,Natural History,20 50

12、% heal untreated 80% heal in 4 weeks of treatment 75% recur in 6 12 months More recur in patients with H. pylori, smokers, NSAID users Milk and tobacco slow healing,Treatment of PUD,H2 blockers - $25 a month for generics Maintenance dose same as treatment dose 20% recur on maintenance vs. 70% on no

13、treatment PPIs - $125 a month (Prilosec soon out in generic),Treatment of H. pylori,No therapy is 100% Treatment markedly decreases recurrences of DU Use of H2 blockers and PPIs increases eradication rate and hastens relief of symptoms PPIs have intrinsic in vivo activity against H. pylori,Diseases

14、of the Lower GI Tract,Constipation 2% of US population report chronic constipation Irritable bowel syndrome a diagnosis of exclusion (CBC, colonoscopy, stool O&P, lactose difficiency, endoscopy),Diseases of the Lower GI Tract, cont.,Malabsorption long differential (consider if weight loss, muscle wa

15、sting, hair loss, malnutrition) Inflammatory bowel disease UC and Crohns disease Mesenteric vascular disease,Diseases of the Lower GI Tract, cont.,Diverticulosis (90% have no symptoms) Diverticulitis (infectious) Infectious diarrhea,Diagnosis of Infectious Diarrhea - History,Work Travel Eating Ill c

16、ontacts Recent antibiotics HIV or immunocompromised,Treatment of Mild Symptoms,Maintain hydration: sports drinks, diluted fruit juices, watery soups, pedialyte, WHO formula, IV fluids Solids as tolerated but avoid milk and milk products,Diagnosis of Infectious Diarrhea,Stool C&S, O&P (x1), fecal blo

17、od and leukocytes if no improvement in 48 hours or severe disease with bloody stools, fever, dehydration Consider sigmoidoscopy,Treatment,Pathogens requiring treatment shigella, giardiasis, E. coli, pseudomembranous entercolitis, V. cholera,Treatment,Pathogens that may require treatment campylobacter, salmonella, amebiasis (5% carriage rate in the US, many are not pathogenic),Treatment,Mos