Module 21: Gastrointestinal Disorders

Disorders of the Esophagus

• Common symptoms of Gastroesophageal Reflux Disease (GERD) include heartburn and regurgitation.
• Physical examination can be unremarkable in patients with GERD.
• Achalasia presents with dysphagia, regurgitation, and weight loss, distinguishing it from GERD.
• Schiatzki rings are usually asymptomatic but can cause choking (steakhouse syndrome).

Erosive Esophagitis Classification

• Grade A of the Los Angeles Classification is insufficient to confirm GERD.
• Grades B, C, and D are diagnostic for GERD according to American College of Gastroenterology guidelines.

Management of GERD Symptoms

• Patients with alarm symptoms such as age over 50 or weight loss should have an EGD (esophagogastroduodenoscopy).
• Proton pump inhibitors (PPIs) are not the first step in management when alarm signs are present.

Infectious Esophagitis

• Odynophagia is a key symptom of Candida esophagitis, which is prevalent in immunocompromised patients, such as those with HIV.
• Patients with Zenker’s diverticulum may experience halitosis, regurgitation, and neck mass although often asymptomatic.
• Eosinophilic esophagitis is immune-mediated, triggered by allergens, and often associated with other allergic conditions.

Diagnosis of Esophageal Motility Disorders

• High-Resolution Esophageal Manometry (HREM) is the most sensitive method to diagnose motility disorders, particularly achalasia.
• Barium swallow assesses dysphagia and visualizes anatomical abnormalities but is not as sensitive as HREM.

Specific Patient Cases

• A patient presenting with serpiginous ulcers and cytoplasmic inclusion bodies in the context of HIV suggests Cytomegalovirus (CMV) esophagitis, treatable with Ganciclovir.
• Mallory-Weiss syndrome occurs after severe retching, leading to mucosal lacerations causing hematemesis.

Pill-Induced Esophagitis

• The mid esophagus is the most common site for pill-induced ulcers due to anatomical narrowing by the aorta.
• Understanding the location of ulceration helps in diagnosing and preventing further complications.

Duodenal Ulcer Complications

• The Gastroduodenal artery is the most common source of bleeding in duodenal ulcers.
• Basal and stimulated acid secretion differs in gastric ulcers, tending to be decreased or normal, while duodenal ulcers are associated with increased secretion.

General Pathophysiology of Peptic Ulcers

• H. pylori infection primarily affects the gastric mucosa, while NSAIDs hurt gastric mucosa more than the duodenum.

• Gastric ulcers can be classified by their location, with Type I ulcers usually linked to reduced gastric acid production.### Gastric and Peptic Ulcer Disease

• Types of Gastric Ulcers:

  • Type II: Located in antrum; gastric acid secretion ranges from low to normal.
  • Type III: Found within 3 cm of pylorus; often linked with duodenal ulcers (DU) and exhibits normal to high acid production.
  • Type IV: Located in the cardia; associated with low gastric acid production.

• Complications of Peptic Ulcer Disease (PUD):

  • Most Common Complication: GI bleeding occurs in 19.4–57 per 100,000 individuals, particularly in those over 60.
  • Other complications include perforation, which is the second most common and has increased with NSAID use.
  • Obstruction is the least common complication (1-2%) but may occur due to inflammation and scar formation.

Clinical Scenarios

• Signs of Bleeding Peptic Ulcer:

  • Hypotension (BP = 80/60), tachycardia (HR = 110), and pale conjunctiva due to internal bleeding.
  • Melena (black, tarry stools) indicates upper GI bleeding from ulcers.

• Diagnosis for GI Bleeding:

  • Best Test: Upper Gastrointestinal Endoscopy; highly sensitive for confirming diagnoses and assessing upper GI tract.
  • Abdominal ultrasound and upper GI series are less recommended; they have limitations in detecting active bleeding.

Medication for Osteoarthritis

• Best Medicinal Approach:
  • Tramadol combined with methylprednisolone is preferred as it avoids bleeding risks associated with NSAIDs.
  • COX-2 inhibitors and conventional NSAIDs can cause gastrointestinal issues, while acetaminophen may lead to GI symptoms in high doses.

Gastric Neoplasm Indicators

• Clinical Presentation:

  • A patient with a history of ulcer bleeding presents with early satiety, weight loss, and a firm, nodular mass in the abdomen, suggestive of gastric neoplasm.
  • Physical examination reveals pale conjunctiva and a scaphoid abdomen.

• Recommended Physical Examination Maneuver:

  • Succussion Splash indicates retained fluid in the stomach, which is often associated with gastric outlet obstruction.

Treatment for Peptic Ulcer Disease

• Preferred Medication:
  • Esomeprazole is a proton pump inhibitor (PPI) that effectively inhibits acid secretion, with a treatment duration of 4-6 weeks for DU and 6-8 weeks for gastric ulcers.

Diagnostic Imaging for Abdominal Pain

• Best Initial Imaging:
  • Erect chest X-ray is recommended to check for free air under the diaphragm, indicating perforation, particularly following severe abdominal pain presentations.

Post-Angioplasty Care

• Following angioplasty, continue the anti-platelet regimen while adding a PPI to reduce the risk of bleeding, as seen with melena in the patient’s presentation.### Gastrointestinal Management and Pharmacotherapy
• Initiate EGD (esophagogastroduodenoscopy) and perform injection sclerotherapy for acute esophageal variceal bleeding.
• Use pharmacotherapy with cytoprotective agents (e.g., PPIs like omeprazole) to promote healing of the gastrointestinal bleed site while controlling bleeding.
• Though studies indicate mixed interaction results between PPIs and anti-platelet medications, the slight increase in mortality and readmission rates doesn't change expert recommendations for concurrent use.
• Anticipate taking PPIs and anti-platelets 12 hours apart to minimize competition for the CYP450 enzymes.

Diarrhea Pathobiology

• Cytotoxin is the most likely cause of rapidly worsening diarrhea, characterized by bloody stool.
• Different agents associated with diarrhea classified by mechanism (enteroadherence, preformed toxin, enterotoxin, cytotoxin) have distinct incubation periods and stool characteristics.

Diarrhea Etiology After Raw Seafood Consumption

• Norovirus is implicated when a patient presents with watery diarrhea, abdominal pain, and fever following consumption of raw mussels.
• Other pathogens commonly linked to gastroenteritis present different symptoms, often featuring bloody diarrhea and longer incubation periods.

Noninfectious Causes of Acute Diarrhea

• Antacids may lead to acute diarrhea, particularly in patients treated for peptic ulcer disease.
• Common medications associated with diarrhea include antibiotics, NSAIDs, and certain antidepressants, often linked to a temporal onset of symptoms.

Management of Mild Acute Diarrhea

• For mild dehydration due to acute diarrhea (without alarm features), manage with observation and oral rehydration salts rather than IV hydration or antibiotic therapy.
• Colonoscopy is not recommended for acute diarrhea; it is typically reserved for chronic cases.

Characteristics of Secretory Diarrhea

• Secretory diarrhea, evidenced by painless, large-volume stools, results from abnormal fluid/electrolyte transport, not contingent on food intake.
• Inflammatory diarrhea typically presents with abdominal pain and positive leukocytes in stool, indicative of underlying pathology.

Eosinophilic Gastroenteritis Diagnosis

• The presence of Charcot-Leyden crystals in stool signifies eosinophilic gastroenteritis, a condition linked to eosinophil infiltration often associated with allergic or parasitic reactions.
• Differentiate from other forms of colitis (e.g., ulcerative colitis, lymphocytic colitis) that demonstrate varying inflammatory profiles.

Diagnostic Approach for Chronic Diarrhea

• In patients with over 4 weeks of diarrhea and significant symptomatology (e.g., weight loss, fever), colonoscopy is the preferred diagnostic tool to exclude serious underlying conditions.

This quiz covers various gastrointestinal disorders focusing on the esophagus, stomach, duodenum, and small intestine. Review the key concepts and conditions associated with these areas as discussed by Dr. Santi and Dr. Sebollena. Test your knowledge to ensure a comprehensive understanding of these critical topics.