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● Cholecystitis ○ Inflammation of the gallbladder, usually associated with gallstone disease, can be acute or chronic ■ Gallstones obstruct the gallbladder-cystic duct junction, resulting in inflammation and acute pain ■ In some cases, calculous cholecystitis, or gallbladder inflammation without stones, is more common than obstruction of the common bile duct. ■ Increases with age and BMI, most common in ages 50-70 years ● Females > males (2:1) ● 4 F’s (Female, Fair, Fat, Forty-Fifty) ■ Increased incidence in Native Americans ○ ○ Types ■ Classic obstruction - cystic duct or junction obstruction - mild WBC elevation, bilirubin normal, amylase/lipase normal, LFT’s slight elevation ■ Bile duct obstruction - WBC elevation, bilirubin elevated, amylase/lipase elevated, LFT’s normal ■ Pancreatic duct obstruction - WBC elevation, bilirubin elevated, amylase/lipase elevated, LFT’s elevated ■ ○ Risk Factors ■ Pregnancy ■ Rapid weight loss (e.g., bariatric surgery) ■ Obesity ■ Gallstones ■ Surgery or trauma
■ Sickle cell anemia ■ Parental feeding over a prolonged period ■ Family history of gallstones ○ Clinical Presentation ■ typically present with RUQ pain, nausea, and vomiting ■ Pain may radiate from the shoulder to the scapula ■ Fever may or may not be present ○ Assessment ■ Subjective ● RUQ pain that is steady and severe, whose onset may have been gradual or sudden with radiation to the right shoulder or back, and has lasted at least 4-6 hours ● May report fever ● c/o nausea/vomiting ● c/o anorexia ● May report that pain started after a meal, particularly a fatty meal, one or more hours before the onset of pain ■ Objective ● Appears ill ● May be febrile ● May be tachycardic ● Abdominal guarding ● + Murphy’s sign (to perform, have the patient take a deep breath while palpating the area of gallbladder/ With acute choley, the patient will respond to pain by catching their breath) is considered highly sensitive ● May have a palpable RUQ mass ○ Differentials Diagnosis ■ Biliary colic-mild intermittent complaints ■ Peptic ulcer disease ■ Cardiac disease ■ Pancreatitis ■ Hepatitis ■ Bowel obstruction ■ Appendicitis ■ Right-sided pneumonia ○ Diagnostics ■ Labs ● CBC - leukocytosis ● CMP ● Bilirubin ● Liver Function Tests (LFT) - ALT/AST & ALP ● Amylase ● Lipase
○ Incidence ■ Acute diverticulitis is the third most common inpatient GI diagnosis in the US ■ The most frequently listed GI diagnosis in Outpatient clinics and ERs ■ Annual Cost $2.1 Billion ○ Prevalence ■ The prevalence of diverticulosis increases with age ■ 60% by age 60 years ■ The prevalence has been rising over the past few years ■ 180/100,000 people per year ■ Men > women ■ More complications in people who smoke ■ More common where there are low-fiber dietary habits ○ Clinical Presentation ■ Abdominal Pain Most Common ( LLQ ) 70% of patients ■ Nausea and vomiting ■ Anorexia ■ Constipation, obstipation, or diarrhea ■ Fever, Leukocytosis, and chills ■ Flatulence, bloating, gas abdominal distention ■ Board-like rigidity and rebound tenderness ■ Presence of fistulas ■ Unremarkable findings on PE ■ Urinary complaints - *urinary retention or dysuria ■ Signs of peritoneal infection/requires hospitalization ○ Common Differential Diagnosis ■ Inflammatory bowel disease ■ Appendicitis ■ Infectious Colitis ■ Ischemic Colitis ■ Colorectal cancer ■ Irritable Bowel Syndrome (IBS) ■ Gynecological disorders ■ Urological disorders ■ Lactose intolerance ○ Diagnostic Studies ■ Abdominal CT with or without contrast ■ Barium Enema - used to diagnose diverticulosis ■ CBC : leukocytosis ■ Electrolytes *deficiency from diarrhea or vomiting ■ Urinalysis *may show blood or, eventually, a UTI ■ Pregnancy test, if clinically indicated ■ SED rate elevated ■ Colonoscopy/flexible sigmoidoscopy
■ Colonoscopy recommended 4-6 weeks after resolution of symptoms ○ Management ■ Management depends on the severity, presence of complications, and comorbidity ■ There is no standard management in the treatment of diverticular diseases, including diverticulitis ■ Use of antibiotics selectively rather than routinely ■ A colonoscopy should be performed after resolution of acute diverticulitis ■ Advise patients to avoid routine use of aspirin and NSAIDs ○ Pharmacological Treatment ■ Ciprofloxacin 500 mg q 12 hours & Metronidazole 500 mg q 8 hours x 7-10 days OR ■ Bactrim 800/160 mg 1 DS q 12 hours & Metronidazole 500 mg q 8 hours x 7-10 days OR ■ Augmentin 875/125 mg q 8 hours for 7-10 days ■ *Take with food ■ For patients intolerant of both Metronidazole and beta-lactam agents ● Moxifloxacin 400 mg daily for 7-10 days ○ Nonpharmacological Management ■ Bowel Rest; Clear liquids 2-3 days ■ Advance to a soft or regular diet as tolerated ■ Restricting seeds, nuts, corn, and popcorn is controversial ■ Recommend high-fiber diet ■ Regular exercise or activity ■ Avoid NSAIDs in flares ■ Follow up 2-3 days after initiating treatment ■ GI referral colonoscopy 6-8 weeks after resolution of symptoms ■ Surgery may be indicated if there are frequent recurrences ○ Refer for inpatient treatment ■ Severe abdominal pain and or fever persists despite 2 days of oral antibiotics ■ Inability to tolerate PO fluids ■ Inpatient treatment consists of ● NPO or clear liquids ● IVF ● IV broad-spectrum antibiotics ● Pain control ● CT to exclude abscess or perforation ● Surgical Resection ○ Geriatric Considerations ■ Prevalence increases to 50-70% in those aged over 80 years ■ Diagnosis and treatment for the elderly are more complicated due to more comorbid conditions.
● Exposure to sunlight. ○ Etiology ■ The primary cause is unknown ■ Secondary multifactorial causes: ● Genetic predisposition- (hereditary) ● Epithelial barrier defects- When irritation and swelling lead to ulcers and open sores in the lining. ● Dysregulated immune responses. When the body mistakenly attacks itself, causing inflammation in the inner lining of your colon. ● Environmental factors: Bacteria, viruses, and antigens may trigger your immune system. ○ UC ■ Frequent diarrhea, with or without blood ■ Ranging from mild abdominal to severe abdominal pain and cramping ■ Intermittent constipation ■ Fatigue ■ Low to high fever ■ Tachycardia ■ Weight loss ○ Crohn’s ■ cramping sensation/intermittent or constant ■ Fatigue ■ Weight loss ■ Fever ■ Prolonged diarrhea ■ Occasional blood on stools ■ Ulcers of the intestines or mouth ■ Fistulas ■ Joint swelling ○ Assessment ■ Abdominal tenderness with distention and tympany on percussion. ■ Bleeding on rectal exam. ■ Anal fissures or skin tags may be present due to irritation from diarrhea. ■ Other symptoms due to inflammation: ● Pain/swelling of large joints: hips and knees. ● Itchy eyes or red spots on the skin. ○ Differentials ■ Infectious colitis or enteritis ■ Irritable bowel syndrome ■ Appendicitis ■ Peptic ulcer disease ■ Renal colic ■ Diverticulitis
■ Hyperthyroidism ■ Malabsorption disorders ■ Lactose intolerance ■ NSAID adverse effects ○ Diagnostics ■ CBC with differential ■ CMP, including LFTs, creatinine, glucose, Vitamin B12, and folate ■ C-reaction protein ■ Genetic testing ■ Stool test ● Culture and sensitivity ● Fecal leukocytes and calprotectin = inflammation in the bowels ■ Upper endoscopy with biopsy ■ Flexible sigmoidoscopy/ colonoscopy ■ CT scan of abdomen/ enterography ■ MRI of abdomen/ enterography ■ Barium xrays ■ Capsule endoscopy ○ Management ■ Pharmacological ● Corticosteroids – for inflammation ● Immunomodulators ● Biologics – to induce and maintain remission ● antibiotics – to treat infection ■ Non-pharmacological ● Maintain nutrition and weight: avoid food triggers, a low-fat diet, lactose, and low-fiber diet if strictures are present, and avoid caffeine, alcohol, nuts, and seeds. ● Stop smoking ● Exercise regularly and practice stress management ● Surgery when indicated: intestinal obstruction, bowel perforation, GI bleeding, enteric fistula refractory to medical therapy, small bowel or colon cancer ○ *People with Crohn’s disease are more likely to develop colon cancer. ○ Most cases are referred to GI for treatment and management ● Hepatitis ○ What is Hepatitis? ■ Acute or Chronic Inflammation of the liver caused by ● Viruses, alcohol, medications, autoimmune disease, metabolic defects ■ Inflammation >6 months is considered chronic liver disease (CLD) ■ Hepatitis has a high incidence of progression to Cirrhosis and ■ Liver failure and the need for transplantation may occur
■ Vomiting ■ Abdominal pain ■ Weight loss ■ ■ ○ Physical Exam ■ Jaundice ■ Dark Urine ■ Cutaneous angiomas ■ Ascites ■ Prominent dilated veins, especially to the abdomen if ascites present ■ Tender or enlarged liver, normal 6-12cm ● *Mean liver span is 10.5cm for males and 7 cm for females; the liver palpated more than 1-2cm below the right coastal margin is enlarged ■ Mild to moderate dull pain in RUQ or epigastrium ■ Anorexia, nausea, malaise, and low-grade fever ■ Needle tracks- hands, arms, and antecubital fossae
○ Acute Hepatitis Diagnostics ■ CBC – leukocytosis, anemia (especially if it is alcoholic hepatitis) ■ CMP - elevated ALT and AST, bilirubin and alkaline phosphatase may be elevated, low albumin, abnormal glucose, electrolyte imbalances ■ ESR, CRP – elevated ■ PT, PTT, INR - Abnormal ■ Elevated ammonia - neurologic symptoms (*hepatic encephalopathy - it is a big indicator of hepatic failure) ○ Diagnostic Testing ■ Ultrasonography- the most cost-effective. ■ Computed tomography- shows the presence of tumor, fatty tissue, and liver size ■ Magnetic resonance cholangiopancreatography ■ Liver Biopsy if diagnosis is inconclusive (ultrasound or CT guided) ■ A CT scan of the upper abdomen shows a fatty liver ○ Laboratory Testing ■ Serologic tests for acute infections: ● Hepatitis A: IgM anti-HAV ● Hepatitis B: HBsAg, plus IgM anti-HBc ● Hepatitis C: No serologic marker for acute infection ■ Serologic tests for chronic infections: ● Hepatitis A: Not applicable—no chronic infection ● Hepatitis B: Tests for chronic infection should include three HBV seromarkers: HBsAg, anti-HBs, and Total anti-HBc
■ Wilson's disease ■ Cystic fibrosis ■ Other viral infections (EBV, CMV, coxsackievirus herpes) ■ Acute cholangitis (infection of the bile duct) ■ Drug toxicity and poisoning ■ Hepatic malignancy ■ Autoimmune, alcoholic, or ischemic hepatitis ■ Acute cholecystitis ■ Disseminated sepsis ○ HCV Screening ■ The USPSTF recently expanded screening recommendations to all adults aged 18 to 79 years ■ There needs to be a focus on low-income, uninsured, and underserved populations where screening has remained low ■ Stigmatization, anxiety, and patient labeling discourage people from getting screening for HCV ○ Prevention and Pharmacological Interventions ■
○ Pharmacological Symptom Management ■ Cholestyramine (Questran) for pruritus associated with Jaundice- 1 packet/ scoop (5 mg) mixed with food or fluids BID ■ Acetaminophen overdose, N-Acetylcysteine- oral regimen (Mucomyst) or IV formulation (Acetadone) ■ Rifaximin 550 mg PO every 12 hours, along with a large dose of lactulose for hepatic encephalopathy ■ No pharmacological treatment for NAFLD, prevention, and control of metabolic disorders is imperative ○ Evidenced-Based Treatment Approach: Non-Pharmacological ■ Education ■ Vaccinate against other viral hepatitis infections ■ Abstain from alcohol ■ Avoid large doses of hepatotoxic drugs (acetaminophen, iron, etc.) ■ Refrain from starting new medications ■ Acute hepatitis ● High-calorie diet (best tolerated in the morning), maintain fluid balance ● Monitoring of clotting factors, liver function, and metabolic disease ■ Chronic hepatitis ● Serology, radiology, or pathology testing ● Screening/monitoring for HHC: liver ultrasound/biopsy ● Vaccination against pneumococcal infections ○ Geriatric Considerations ■ Liver size decreases by 25% between the ages of 20 and 70 years. ■ Drug metabolism by the liver is impaired. ■ Prolonged liver metabolism causes increased side effects. ■ Polypharmacy has a high risk of drug-drug interaction with antiviral drugs. ○ Follow up ■ HAV 6 to 12 months after acute illness; measure LFTs
■ Overweight/obesity ■ Lifestyle: ● Alcohol, caffeine, smoking, carbonated beverages, eating before sleeping, fatty/fried foods, spicy foods, overly processed foods ■ Medication (i.e.: Calcium channel blockers, NSAID’s) ■ Hormones ■ Aging ■ Increased acid secretion ■ Pregnancy ■ DM - diabetic gastroparesis ■ Disease process – gastritis, H.Pylori, Cancer ○ Clinical Presentation ■ Typical ● Heartburn ● Regurgitation Bad taste ■ Atypical ● Dysphagia ● Non-cardiac chest pain ● hypersalivation ● Globus sensation ● Odynophagia (Painful swallowing) ● Epigastric fullness/pain ● Dyspepsia ● Nausea ● Bloating ■ Extraesophageal ● Dental erosions ● Sore throat ● Laryngitis ● Hoarseness ● Chronic cough ● Wheezing ● Asthma ● Bronchospasm ○ Physical Exam ■ Careful history is likely to be more important than the physical findings in GERD ● dental erosions, loss of enamel and exposed dentin, Halitosis ● Cutaneous evidence of smoking, scleroderma, evidenced as thickened, tight, shiny skin or sclerodactyly as well as facial telangiectasia ● Weight loss is a concern - particularly with dysphagia
● Respiratory wheezes and coughs may be seen if there is associated asthma ● Epigastric tenderness or Hemoccult-positive stool may be the result of esophageal erosions, ulcerations, or even severe inflammation ● Any abdominal mass is suggestive of malignant neoplasia ○ Diagnosis ■ Patient with classic symptoms and no red flags can be diagnosed with presumptive GERD ■ Patient’s with not enough information, atypical symptoms or red flags need further evaluation to rule out other diagnosis before diagnosing GERD ■ Referral to GI for endoscopy or further testing may be warranted. ■ Primary Care ● CBC ● CMP ● H. pylori (breath or blood) ● Stool testing ■ Specialty ● Endoscopy ● Barium Esophagram (swallow) ● HRM ● 24 or 48 hr. PH scan by transnasal catheter or radiotelemetry capsule ● EndoFLIP ● Gastric scintigraphy ● Gastric emptying scan ○ Differential Diagnosis ■ Infectious esophagitis ■ Pill esophagitis ■ Eosinophilic esophagitis ■ Esophageal CA ■ Esophageal motility disorder ■ Esophageal rings w/ webs ○ Treatment Goals ■ Symptom control ■ Esophageal mucosal healing ■ Prevention of complications (eg strictures, Barrett's esophagus, CA) ○ Complications ■ Esophageal ● Barrett's esophagus ● Esophageal stricture ● Esophageal carcinoma ■ Extra-esophageal
■ Individuals who fail to respond to once-daily PPI therapy OR ■ Can’t tolerate long-term PPIs OR ■ Want to discontinue therapy ○ Endoscopic Correction (considered experimental) ■ Linx ● A small expandable ring of magnetically linked beads is placed in the distal esophagus to hold the les CLOSED WHEN NOT SWALLOWING ● ■ Stretta ● A catheter is positioned and needles are inserted into the muscles at the gastroesophageal junction. Radiofrequency is used to create thermal lesions thought to thicken the sphincter ○ Surgical Intervention ■ Nissen Fundoplication ● The laparoscopic procedure was developed in 1991 and is considered the standard – fewer complications than an open procedure ● ● Hemorrhoids ○ Used to be called "piles.” ○ Patients will often not disclose - ask! ○ There are management techniques ○ Literally causes “pain in the ___.” ○ Hemorrhoidal veins are normal anatomic structures located in the submucosal layer in the lower rectum ○ There are internal, external, and mixed hemorrhoids ○ Equal in both sexes, peak ages 45 to 65 ○ Cardinal features are bleeding, anal pruritus, prolapse, and pain ○ External ■ Located in the skin around the anus ● Itching or irritation in your anal region
● Pain or discomfort ● Swelling around your anus ● Bleeding ○ Internal ■ lie inside the rectum. Patient may not be able to see or feel them ● Rarely cause discomfort. But straining or irritation can cause symptoms ● Painless bleeding during bowel ● A hemorrhoid to push through the anal opening (prolapsed or protruding hemorrhoid) ○ resulting in pain and irritation. ○ Thrombosed ■ blood pools in an external hemorrhoid and forms a clot (thrombus). ● Severe pain ● Swelling ● Inflammation ● A hard lump near the anus ○ ○ ○ Risk Factors ■ Pregnancy ■ Hypertension, heart failure ■ Prolonged sitting ■ Obesity ■ Low-fiber diets ■ Lifting heavy weights ■ Aging ■ Straining with defecation
