Week 11 - Dyspepsia Loose Stools Disordered Eating (PDF)

dyspepsia, progressive loose stools and disordered eating CMS 150 objectives 1. Differentiate between gastrointestinal and other causes of chest pain 2. Understand the epidemiology, timing, signs and symptoms of conditions presenting with dypepsia, loose stools, or disordered eating 3. Define di...

dyspepsia, progressive loose stools and disordered eating CMS 150 objectives 1. Differentiate between gastrointestinal and other causes of chest pain 2. Understand the epidemiology, timing, signs and symptoms of conditions presenting with dypepsia, loose stools, or disordered eating 3. Define diarrhea and its subtypes 4. Compare and contrast medical tests used in the evaluation of a patient with dypepsia, loose stools, and disordered eating based on evidence of accuracy 5. Develop and refine a differential diagnosis based on new information related to dypepsia, loose stools, and disordered eating 6. Apply diagnostic evidence to clinical reasoning in the presence of dypepsia, loose stools, and disordered eating 7. Prioritize issues to be addressed in a patient encounter where there is dypepsia, loose stools, or disordered eating 8. Understand when referral is warranted in the context of a patient with dypepsia, loose stools, or disordered eating mid-sternal chest pain cardiac: angina, MI, pericarditis, heart failure pulmonary: pneumonia, pulmonary embolism vascular: dissecting aortic aneurysm MSK: costochondritis, muscular strain/tear, nerve entrapment (thoracic, iliohypogastric), painful rib syndrome GI: esophagitis, GERD, gastritis, hiatal hernia, peptic ulcer disease, pancreatitis biliary: cholelithiasis, cholecystitis, cholangitis psychiatric: anxiety disorder (panic attack) dermatologic: herpes zoster INTERCHEST Rule - predict coronary artery disease as cause of chest pain clinical predictor points risk group odds pain reproduced by palpating chest wall - 1 low 2.1% men ≥ 55 yrs, women ≥ 65 yrs + 1 (-1 to 1) physician initially suspected a serious condition + 1 not low 43% chest discomfort feels like pressure + 1 (2-5) chest pain related to effort + 1 online calculator: history of CAD + 1 mdcalc.com alternative CAD predictive tool: Marburg Heart Score (MHS) dyspepsia (aka. indigestion) - persistent or recurrent pain or discomfort in the upper abdomen approx. 30% of US + Canadians ROME IV criteria: at least 1 of the following symptoms present for the past 3 months: postprandial fullness (3 days / week) early satiety (3 days / week) epigastric pain (1 day / week) epigastric burning (1 day / week) AND no evidence of structural disease functional dyspepsia caused by structural or biochemical disease gastroesophageal reflux 50% irritable bowel syndrome 35% full algorithm: AAFP, 2020 gastro-esophageal reflux disease (GERD) - retrograde flow of stomach acid and enzymes into the esophagus, causing inflammation and pain up to 35% of general population obesity, smoking, alcohol, chocolate, peppermint, spicy food, citrus, caffeine, fatty food, tomato-based products, carbonated beverages retro-sternal or epigastric burning pain following meals (pyrosis, aka. “heartburn” or “acid reflux”), sour taste, possibly dysphagia - chronic cough/ wheeze, nausea, sore throat, hoarseness, globus sensation diagnosis is based on symptoms; endoscopy, Bx, esophageal pH testing - PPI trial (therapeutic challenge) management: potential referral (PPI), dietary and lifestyle changes prognosis: up to 23% develop into esophageal strictures 10-15% develop into Barrett’s Esophagus after 5-10 years inflammation GERD video - osmosis.org PPI trial one-week trial of a high-dose proton pump inhibitor leading to a 50% reduction in reflux symptoms Finding Sensitivity LR + LR - Protein Pump Inhibitor (PPI) trial 79% 5.5 0.24 barrett’s esophagus - metaplastic changes of esophageal squamous epithelium into columnar epithelium 2-7% of Canadian population long-standing GERD (> 5-10 yrs), smoking, male, age > 50 yrs, fHx, obesity chronic reflux symptoms including postprandial retro-sternal or epigastric pain diagnosis is based on endoscopy and Bx (histology report) management: referral to MD, endoscopic surveillance q3yr prognosis: < 1% develop into esophageal adenocarcinoma (progressive dysphagia, constitutional symptoms) gastritis - diffuse inflammation of the stomach lining due to excess gastric acid coming in contact with mucosa erosive (acute or chronic) - more severe non-erosive - atrophic or metaplastic changes H. pylori, long term NSAID use, EtOH, stress may be asymptomatic or coexist with GERD epigastric pain (with food), dyspepsia, N/V, loss of appetite, melena diagnosis by upper endoscopy management: potential referral to MD (antibiotics, antacids (H2 blocker, PPI)) prognosis: most resolve, potential to develop ulceration or carcinoma peptic ulcer disease (PUD) - localized erosion of the mucosal layer of the stomach (St) or small intestine (SmI) 15-25% of patients presenting with dyspepsia; H. pylori + NSAIDs increase risk (6X) H. pylori (SmI 90%, St 60%), NSAIDs (SmI 7%, St 35%), stress, Zollinger-Ellison syndrome (rare, 25% loose stools, 25% loose stools, >25% hard stools carbohydrate malabsorption / intolerance (e.g. lactose, fructose) - the inability to digest and/or absorb certain carbohydrates due to a lack of one or more intestinal enzymes leading to the occurence of symptoms increased age, consumption of food high in specific carbohydrate (e.g. dairy, fruit) abdominal pain, bloating, watery stool, excessive flatus diagnosis: history, may be confirmed with hydrogen breath test - a rise in breath hydrogen concentration greater than 20 ppm over baseline after carbohydrate ingestion suggests malabsorption management: patient education (diet modification) prognosis: congenital enzyme deficiencies tends to be progressive with age  short-chain fatty acids (SCFAs) diarrhea water lactose intolerance video - osmosis.org hydrogen breath test - carbohydrate malabsorption serial breath sampling following consumption of specific carbohydrate - a rise in breath hydrogen concentration greater than 20 ppm over baseline after carbohydrate ingestion suggests malabsorption Finding Sensitivity LR + LR - lactose (25g) - 0-60-120 min sampling 95% 118.7 0.05 fructose (50g) - q30min for 3-4hr 98% 7 0.02 small intestine bacterial overgrowth (SIBO) - the presence of excessive bacteria in the small intestine (exceeding 105–106 organisms/mL) approx. 15% prevalence in public; approx. 40% in patients with IBS Hx traveller’s diarrhea, food poisoning or viral gastroenteritis; Hx TBI, frequent ABx use, longterm PPI use, Hx of cholecystectomy; probiotics aggravate or do not help, high FODMAP foods cause flare abdominal pain, bloating, diarrhea (hydrogen) or constipation (methane) may also have other GI symptoms such as: nausea, belching, flatus breath test (possibly other testing depending on symptoms) management: may treat or refer to MD (antibiotics) prognosis: severe, chronic SIBO can result in weight loss, malnutrition, if left untreated, can lead to intestinal failure; recurrence may be as high as 44% hydrogen breath testing for SIBO serial breath sampling following consumption of specific carbohydrate - a rise in breath hydrogen concentration greater than 20 ppm over baseline after carbohydrate ingestion suggests small intestine bacterial overgrowth Finding Sensitivity LR + LR - glucose 62% 3.65 0.46 lactulose 31-68% 2.21 - 4.86 0.37 - 0.80 IBS video - osmosis.org crohn disease - a chronic inflammatory condition affecting the gastrointestinal tract that often causes extraintestinal complications 0.35% of Canadian population (increasing), typical age at diagnosis 20-40 homozygous for NOD2/ CARD15 (20-40X risk), smoking, OCP, ABx use, NSAIDs diarrhea, abdominal pain (cramping), rectal bleeding, fever, weight loss, fatigue anemia (9-74%), inflammatory arthropathies, osteoporosis, anterior uveitis, episcleritis, aphthous stomatitis, cholelithiasis, venous thromboembolism diagnosis: (ileo)colonoscopy with Bx, cross-sectional imaging (CT enterography) - abdominal tenderness, perianal findings (fistulas, abscesses) - fecal calprotectin, stool lactoferrin management: referral / comanagement with gastroenterologist prognosis: increased risk of cancer (cervical, CRC, skin, upper GI, bladder), osteoporosis, anemia, nutritional deficiencies, depression, infection, thrombotic events laboratory testing for crohn disease Finding Sensitivity LR + LR - fecal calprotectin 83 - 100% 2.07 - 2.50 0 - 0.28 stool lactoferrin 75% 75+ 0.25 ileocolonoscopy 75% 67 0.33 endoscopy 87% 7.91 0.15 MRI 80% 4.44 0.24 computerized tomography (CT) 81% 6.75 0.22 abdominal ultrasound 85% 9.44 0.16 bile acid malabsorption (aka. bile acid diarrhea) - diarrhea caused from either hepatic overproduction of bile acids or their malabsorption in the terminal ileum idiopathic, post-cholecystectomy, IBS-D, pancreatic insufficiency chron disease, trauma/surgery to intestines,microscopic colitis, SIBO persistent or intermittent diarrhea, increased stool frequency, urgency, nocturnal defecation, excessive flatulence, abdominal pain, possibly fecal incontinence diagnosis: selenium homocholic acid taurine (SeHCAT; nuclear medicine) or serum 7α-hydroxy-4-cholesten-3-one (C4) assay management: co-manage with gastroenterologist (bile acid sequestrant) prognosis: depending on cause and ability to tolerate treatment laboratory testing for bile acid malabsorption Finding Sensitivity LR + LR - SeHCAT (48.4 ng/mL) 90% 4.29 0.13 Clostridioides difficile - associated diarrhea - diarrhea and colitis (in up to 3%) due to a toxin-producing bacterial infection, a common cause of antibiotic-associated diarrhea hospitalization/nursing home, antibiotic therapy (2.28X), advanced age, multiple underlying diseases, immunosuppression, antacid use asymptomatic (+/- carrier); mild to severe diarrhea (watery, up to 10-15x/day) and abdominal cramps; nausea, tachycardia, fever, loss of appetite, fecal blood/pus diagnosis: history (e.g. antibiotic use within the past 3 months), limited EIA - severe cases: fever, CBC (↑ WBC), flexible sigmoidoscopy (pseudomembranes) management: support hydration, discontinue precipitating antibiotic (if possible) prognosis: resolves with conservative therapy in 15-23%, 13-50% have recurrent infections, mortality 1-2.5% diagnostic testing for c. difficile Serologic test Sensitivity LR + LR - enzyme immunoassay (EIA) for 94% 9.4 0.07 glutamate dehydrogenase enzyme immunoassay (EIA) toxin A + B 83% 83 0.17 nucleic acid amplification test 96% 16 0.04  image from: AAFP, 2005 C. difficile video - osmosis.org celiac disease - an autoimmune disorder of the gastrointestinal tract, triggered by exposure to dietary gluten in genetically susceptible individuals. 1% of Canadians, female (2-3X), family history (esp. first-degree relatives) fatigue, weakness, diarrhea, bloating, flatulence; but typically asymptomatic may have signs of malnutrition or nutritional deficiencies (e.g. iron deficiency anemia) diagnosis: serologic antibody testing, small bowel biopsy, dietary modification - IgA tTG (tissue transglutaminase) + total IgA - dermatitis herpetiformis management: patient education, avoidance of gluten; referral for endoscopy + Bx prognosis: elevated risk of lymphomas (6-8%), hepatobiliary and intestinal cancers increased risk of depression (1.8X) and nutrient deficiencies if untreated clinical presentation of celiac disease symptom sensitivity (%) LR + LR - symptoms since childhood 35 3.18 0.73 flatulence / gas 76 1.33 0.56 weight loss 49 1.14 0.89 loss of appetite 20 1.05 0.99 diarrhea 71 0.90 1.38 nausea 20 0.77 1.08 abdominal pain 37 0.53 2.10 diagnostic testing for celiac disease Serologic test Sensitivity LR + LR - IgG deaminated gliadin peptide 80% 40 0.20 IgA endomysial antibody > 90% > 18 < 0.11 IgA deaminated gliadin peptide 88% 17.6 0.13 IgA tissue transglutaminase 95 - 98% 17.5 0.04 IgA antigliadin antibody 80 - 90% 8.5 0.17 IgG tissue transglutaminase 40% 8 0.63 IgG antigliadin antibody 80% 4 0.25 dermatitis herpetiformis symmetric vesicles, crusts and erosions distributed over the extensor areas of the elbows, knees, buttocks, shoulders and scalp tendency to group individual lesions celiac video - osmosis.org at diagnosis after 5 months of gluten-free diet images from: www.endoscopy- campus.com non-celiac gluten sensitivity - the presence of intestinal and extra-intestinal symptoms related to the ingestion of gluten-containing foods in the absence of celiac disease and wheat allergy possibly 0.5-13% of general population bloating, abdominal pain (or constipation, or alternating bowel habits), dairrhea, nausea, aphthous stomatitis brain fog (inability to concentrate, reduced information processing), fatigue, headache, anxiety, joint pain, skin rash diagnosis: gluten-challenge management: patient education (gluten restriction/avoidance) prognosis: unknown disordered eating anorexia nervousa bulimia nervosa binge-eating disorder avoidant / restrictive food intake disorder orthorexia nervosa helpful resource - National Eating Disorder Information Centre (NEDIC): https://nedic.ca/ anorexia nervosa - an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. adolescent females (12-25yrs) with comorbid psychiatric disorder(s) (esp. depression) thin appearance/ marked weight loss, amenorrhea, arrhythmia, bradycardia, brittle hair/nails, edema, hyperkeratosis, hypotension, lanugo, osteoporosis (at young age) diagnosis: history (DSM-5 criteria), BMI - UA (specific gravity, pH, ketones +/- protein - hydration status, kidney function) - body temperature (low), hypotension (incl. orthostatic) - ECG, CBC, electrolytes (Na, K, Cl), P, Mg, amylase, lipase, TSH, free T3, free T4 - bone density management: collaborative care team (family, psychotherapy, psychiatry/MD) prognosis: 50% achieve full remission, 30% partial remission, 20% chronically ill 5.9X increased mortality risk anorexia - DSM-5 Diagnostic Criteria (APA, 2013) A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health. B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. anorexia - DSM-5 Diagnostic Criteria (APA, 2013) continued Specify whether: - Restricting type: during the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behaviour (weight loss is primarily accomplished through dieting, fasting and/or excessive exercise) - Bing-eating/purging type: during the last 3 months, the individual has engaged in recurrent episodes of binge-eatinig or purging behaviour (i.e., self- induced vomiting or the misuse of laxatives, diuretics or enemas) anorexia - DSM-5 Diagnostic Criteria (APA, 2013) continued Specify if: - In partial remission: after criteria were previously, Criterion A (low body weight) has not been met for a sustained period of time, but either Criterion B (intense fear of gaining weight or becoming fat or behaviour that interferes with weight gain) or Criterion C (disturbance in self-perception of weight and shape) is still met. - In full remission: after criteria were previously met, none of the criteria have been me for a sustained period of time. anorexia - DSM-5 Diagnostic Criteria (APA, 2013) continued Specify current severity: The minimum level of severity is based, for adults, on current body mass index (BMI). - mild: BMI ≥ 17 kg/m2 - moderate: BMI 16 - 16.99 kg/m2 - severe: BMI 15 - 15.99 kg/m2 - extreme: BMI < 15 kg/m2 bulimia nervosa - an eating disorder characterized by uncontrolled episodes of overeating (bingeing), followed by purging adolescent females (12-25yrs) with comorbid psychiatric disorder(s) (esp. depression) weight fluctuations, dental erosions/gum disease, edema, parotid gland enlargement, scars or calluses on fingers or hands diagnosis: history (DSM-5 criteria - eating disorder not otherwise specified) - UA (specific gravity, pH, ketones +/- protein - hydration status, kidney function) - body temperature (low), hypotension (incl. orthostatic) - ECG, CBC, electrolytes (Na, K, Cl), P, Mg, amylase, lipase, TSH, free T3, free T4 - bone density management: collaborative care team (family, psychotherapy, psychiatry/MD) prognosis: 50-70% improve/recover 4-7X increased risk suicide, 40% increased risk of all-cause mortality bulimia - DSM-5 Diagnostic Criteria (APA, 2013) A. Recurrent episodes of binge eating, characterized by both of the following: 1. Eating, in a discrete period of time (e.g. within any 2hr period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behaviours in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives/diuretics/other medications, fasting or excessive exercise. C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia. bulimia - DSM-5 Diagnostic Criteria (APA, 2013) continued Specify if: - In partial remission: after criteria were previously, some, but not all, of the criteria have been met for a sustained period of time. - In full remission: after criteria were previously met, none of the criteria have been me for a sustained period of time. bulimia - DSM-5 Diagnostic Criteria (APA, 2013) continued Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviours. The level of severity may be increased to reflect other symptoms and the degree of functional disability - mild: an average of 1-3 episodes per week - moderate: an average of 4-7 episodes per week - severe: an average of 8-13 episodes per week - extreme: an average of 14 or more episodes per week image from: cleveland clinic journal of medicine binge-eating disorder - an eating disorder characterized by recurrent episodes of eating unusually large portions in a discrete period (two hours or less), at least once a week for three months. 1-3% of general population; often females, adolescents, and obese individuals weight gain, overweight/obese diagnosis: history (DSM-5 criteria) - severity: number of binge-eating episodes per week management: collaborative care team (psychotherapy, psychiatry/MD) prognosis: 90% resolution within 5yrs, 18% ongoing clinical eating disorder high risk of obesity binge-eating - DSM-5 Diagnostic Criteria (APA, 2013) A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both: 1. Eating in a discrete period of time (e.g. within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances; AND 2. A sense of lack of control over eating during the episodes (e.g. a feeling that one cannot stop eating or control what or how much one is eating). B. Binge eating episodes are associated with three or more of the following: 1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large amounts of food when not feeling physically hungry. 4. Eating alone because of feeling embarrassed by how much one eats. 5. Feeling disgusted with oneself, depressed, or very guilty afterwards. binge-eating - DSM-5 Diagnostic Criteria (APA, 2013) cont. C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. Specify current severity: based on the frequency of binge eating. - mild: an average of 1-3 episodes per week - moderate: an average of 4-7 episodes per week - severe: an average of 8-13 episodes per week - extreme: an average of 14 or more episodes per week avoidant / restrictive food intake disorder (ARFID) - an eating disorder characterized by restriction of food intake typically begins in childhood, “picky eaters” underweight, signs of nutritional deficiency (e.g. pallor, brittle hair/nails, hairloss, weak, cold), slow growth/ developmental delays (failure to thrive) diagnosis: history (DSM-5 diagnostic criteria) - CBC, electrolyes, Mg, P, TSH, ESR, CRP - urinalysis (UA) management: collaborative care team (maybe in-patient or out-patient treatment) prognosis: malnourishment (anemia, osteoporosis) - electrolyte imbalances or cardiac arrest can cause mortality (rate unknown) ARFID - DSM-5 Diagnostic Criteria (APA, 2013) A. A feeding or eating disturbance (e.g. lack of apparent interest in eating food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). 2. Significant nutritional deficiency. 3. Dependence on enteral feeding or oral nutritional supplements. 4. Marked interference with psychosocial functioning. B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. ARFID - DSM-5 Diagnostic Criteria (APA, 2013) continued C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. orthorexia nervosa - an obsessive and unsafe focus on eating foods perceived as healthy health-conscious individuals following a specific diet for “digestive issues” or “food intolerances”; history of/concurrent eating disorder, chronic disease (e.g. diabetes) fixation on food quality, rigid food “rules” (distress if broken), elimination of entire food groups diagnosis: history (no specific criteria in DSM-5) - may or may not be associated with weight loss management: patient education prognosis: risk of malnutrition/ nutrient deficiencies ORTO-15 (doi 10.1007/BF03327537) - a validated 15-question tool for the diagnosis of orthorexia, has limitations Finding Sensitivity LR + LR - ORTO-15 score