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Gastrointestinal Disorders – Evaluation and Differential

DiagnosisTed D. Williams

PharmD Candidate

OSU/OHSU College of Pharmacy

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Learning Objectives

1. Demonstrate the ability to associate laboratory values, physical findings, and diagnostic test results with specific disorders

2. Rule out unlikely disorders based on laboratory values, physical findings, and diagnostic test results

3. Synthesize information from multiple courses to identify possible causes for physical findings

4. Synthesize information from multiple courses to determine potential therapies

5. Distinguish etiology and pathophysiology of discussed bowel disorders

6. Distinguish etiology and pathophysiology of discussed hepatic disorders

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Overview

• Present previous material within the context of physical assessments– Procedural vs. disease state organization

• Laboratory Tests• Physical Exam• Diagnostic Procedures• Specific Disorders

– Bowel Disorders– Hepatitis

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What this lecture is and is not

• It is NOT a– Systematic Review of the Literature– Exhaustive Reference– Evidence Based Medicine

• It is– Practical for pharmacists– From personal clinical experience– Highlights to keep in mind while practicing– Q&A

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What’s on the exam

• I’m not sure…

• If you’re really worried about it, do the reading, it’s pretty much all there

• If you want some “clinical pearls” then come to lecture

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INs and OUTs

• If INs and OUTs are good, the patient is good

• If the INs and OUTs are not good, the patient is not good

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Take a history

• Without a history, you are shooting in the dark…(and burning cash and time)– Do you often have “belly” pain?– Where does it hurt?– What did you eat today (or the last day you felt like eating)?– When was the last time you were in the hospital? Why did you

go?– What medications are you taking?– How are things going in the bathroom?

• From these questions, I can make a pretty accurate guess of what’s wrong.

• Labs, Ultrasound, CT Scan, etc, just confirm what I guessed from the history or identify insidious disease processes

• When you hear hoof beats, think horses, not zebras

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Patient Case

• ER note indicates blood in the stools

• Patient admitted to the floor

• Where can the blood be coming from?– Larynx through the rectum– What are the different characteristics of the

observed blood?

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Laboratory Findings• Signs of Blood Loss

• Signs of Liver Damage

• Signs of Pancreas Damage

• Signs of Infection

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Blood in stools (OUTs)• Rectal

• Colon

• Small intestine

• Gastric

• Esophageal

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Other findings

• Pain– Location– Quality– Severity

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Legs of the stools

• It’s Bloody, but what else?

• Constipation

• Diarrhea

• Upper GI (gastric and esophageal) may not have additional stool findings other than tarry stools

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The other end

• Nausea

• Vomiting– Coffee Ground Emesis

– Bright red blood

• Chronic vs. acute

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Abdominal Exam

• Stop and think– What are you expecting?– What would be abnormal?

• Inspection– Peristalsis suggests….

• Auscultation– Absent bowel sounds in….– Continuous bowel sounds in…

• Percussion– Tympany in what regions….

• Palpation– When/Where would firmness be expected?– When/Where would pain be expected

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Abdominal Findings• Ask about “belly pain” before touching the

patient…do no harm• Inspection

– Ascites• 80% of cases are from hepatitis

– Hernia– Hematoma– Jaundice– Pallor– Kaput Medusa

• A fairly infrequent, if distinct finding– Spider Angiomas– Ostomies

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Jaundice• Hepatic Injury

• Bile Duct Obstruction

• Pancreatitis

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http://bhtimes.blogspot.com/2007/03/lukashenka-makes-business-decree.html

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Ascites

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Ascites vs. Obesity

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Hernia

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Ostomies

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Spider angiomas

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Abdominal Findings• Auscultation

– Hyperactive or absent– Bruits

• Percussion– Dullness over enlarged organs and fluid– Tympany over air pockets

• Palpation– Confirm quadrant pain verbally– Palpate areas where the patient doesn’t think there is

much pain, working your way closer to the painful areas without hurting them

– Deep palpation only for non-painful areas/patients– Fluid wave indicates…..

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Abdominal Exam Summary

• History tells you what you should find on exam

• Confirm the history on examination (horses)

• Rule out other (zebras)

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Diagnostic Testing• “-scopy”

– Fiber optic camera• Colonoscopy

– One or two bend– Looking for polys, ulceration, and inflammation

• Endoscopy– Esophageal– Gastric– Duodenal

• Supposed to be pretty uncomfortable

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Ulcerative Colitis vs. Crohn’s Disease

• Ulcerative Colitis– Isolated to the colon

• Crohn’s Disease– Can appear anywhere (or everywhere) in the small

and large intestines– Often has perianal fistula

• I’ll spare you from that picture

• Additional reading has a very good, comparision of pathophysiology and treatment for those who are interested

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Clostridium difficile (C. diff)• Bacterial overgrowth in the

digestive tract• Foul, frequent diarrhea• Often associated with broad

spectrum antibiotics – e.g. fluoroquinolones

• Often associated with contamination in hospitals – remember to wash those hands

• Treatment– Metronidazole

• East coast hospitals are seeing metronidazole-resistant C. difficile

– Oral Vancomycin

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Hepatitis

• Alcoholic

• Viral/Infectious

• Toxins

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Hepatocyte Organization

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Liver morphology

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Portal Hypertension Pathophysiology

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Portal Hypertension Complications

• Esophageal Varices

• Gastric Varices

• Ascites

• Hepatorenal syndrome– For now, just know they are interrelated

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Esophageal Varices

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Bleeding Varices

• Bleeding varices

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Damaged Hepatocytes

• AST/ALT leaks out

• Bilirubin can’t be processed– Jaundice

• Clotting factors are not manufactured– Increased bleeding– Add to this occult bleeding…

• Ammonia processing decreased

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Hepatic Encephalopathy

• Build up of Ammonia in the blood• Signs

– Asterixis– AMS (altered mental status)

• MMSE (mini-mental status exam)• Can vary from apparent developmental delay to profound

confusion and disorientation

• Family and friends can monitor for these signs– Counseling, counseling, counseling

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Liver Disease Party Pack

• Lactulose– Reduce blood ammonia by converting to ammonium in the GI

Tract and rapid excretion– Titrate to effect (i.e. Q 1-2hr, 4-5 BM per day)– Low compliance (taste and efficacy)

• Diuresis– Reduce fluid build up– Furosemide– Spironolactone– 2:5 ratio, e.g. 20mg furosemide, 50mg spironolactone

• Propranolol– Reduce portal pressure

• Block Beta-2 mediated mesenteric arteriole smooth muscle dilation• Reduced cardiac output

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Viral Hepatitis

• Type A,B,C,D,E– F?,G?,H?– Onset is weeks to months (vs alcoholic with onset of years)

• Acute Forms of Hepatitis (Fecal Oral transmission)– A, E– Restaurant-acquired hepatitis

• Chronic Forms of Hepatitis (Blood Borne)– B,C,D– People get this from blood transfusions in the 80’s and from a

BF/GF who was a IV drug user– Surprisingly few patients get this from using IV drugs themselves

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Liver Transplant

• MELD Criteria– Model for End Stage Liver Disease– Rates Severity an prognosis of the patient– Patient compliance to medication protocols is

key!

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Fatty Liver

• Dr Leid will talk about this one…

• Diet and exercise…damn!

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Liver Disease Summary

• Very, very common in hospitals

• Know the party pack– make sure everyone is on it unless

contraindicated

• Acute life threatening side effects

• Simply a matter of time, unless they get on the transplant list

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Final Summary

• You practice will depend on how you use this material– Community

• Identify chronic GI disorders and refer for better treatment options

• Counsel on side effects of non-compliance• Talk through Physical exam and assess likely problems

– Ambulatory care• Monitor disease progression• Monitor therapy efficacy

– Inpatient• Speak knowledgeably with physicians about patients• Ensure proper labs are being ordered• Make sure everyone is on appropriate medications (e.g.

party pack)

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Additional Resources

• http://oregonstate.edu/~williate/p1wiki– Search for key words like ascites

• Harrison’s Online (via Access Medicine at OHSU)

• Mosby’s Guide to Physical Examination 6th edition