27 th Reviews in Internal Medicine for 3 rd Year Medicine Resident Approach to Common Problems in. Gastroenterology

Transcription

1 27 th Reviews in Internal Medicine for 3 rd Year Medicine Resident 2018 Approach to Common Problems in Gastroenterology

2 Symptomatology in GI & liver diseases Ascites Jaundice Acute & chronic abdominal pain Acute & chronic diarrhea Constipation & bowel habit change Nausea & vomiting GI hemorrhage Abdominal mass

3 Approach to ascites

4 Abdominal distension Ascites Ileus, gut obstruction Huge abdominal mass/ cyst Obesity Pregnancy

5 Diagnosis of ascites Ultrasound Shifting dullness Fluid thrill 100 cc 1.5 L 4-5 L

6 Causes of ascites Others 4,5% Mixed 5% TB 1% Malignancy 2,5% Heart failure 3% Cirrhosis 84% Runyon BA. Ann Intern Med 1992

7 Pathophysiology of ascites formation Thoracic duct

8 Ascites Portal HT Non-portal HT Post sinusoidal Sinusoidal Peritoneal diseases BCS SOS Right sided HF Pulmonary HT Cirrhosis Alcoholic hepatitis Fulminant hepatitis Massive liver met. TB Carcinomatosis Pancreatitis CNT diseases Nephrogenous

9 History taking Risks of cirrhosis: alcohol, HBV, HCV, NASH Symptoms of cirrhosis: pedal edema, jaundice, variceal bleeding Thrombophilia: pills, spontaneous abortion, DVT Fever, chest symptoms, closed contact TB Weight gain or weight loss Underlying diseases; cancer, autoimmune diseases, DM, CKD, thyroid Abdominal pain Surgery

10 Physical examination GA: Pedal edema, jaundice, signs of CLD Abdomen: Surgical scar, superficial vein dilatation Sister Mary Joseph nodule Hepatosplenomegaly, abdominal mass PR Lymphadenopathy Neck vein & heart

11 Superficial vein dilatation

12 Dilated abdominal vein Normal Portal HT IVC obstruction

13 IVC Obstruction

14 Sister Mary Joseph nodule Galvan VG Ann Int Med 1998; 128: 410

15 Percussion of spleen Castell s method Traube s space dullness

16 Rectal shelf

17 Leg edema, wt. gain Splenomegaly Dilated superficial v. Jaundice Ascites Weight loss, fever Lymphadenopathy Rectal shelf Sister Mary-Joseph nodule Hepatomegaly High JVP RV heaving, TR Pericardial rub Post sinusoidal Portal HT Sinusoidal Signs of CLD Risk factors Non-portal HT Peritoneal diseases BCS SOS Right sided HF Pulmonary HT Cirrhosis Alcoholic hepatitis Fulminant hepatitis Massive liver met. TB Carcinomatosis Pancreatitis CNT diseases Nephrogenous

18 Investigations in patients with ascites Abdominal paracentesis Blood chemistry Ultrasound, Doppler U/S, CT CXR Peritoneoscopy with biopsy

19 Ascitic fluid analysis Routine Cell count Cell differential Total protein Albumin Optional ADA, PCR for mycobacteria Cytology ANA, LE cell Amylase (>1000) Bilirubin (>6 mg/dl) Triglyceride (>200 mg/dl) LDH, ALP

20 Post sinusoidal Portal HT Sinusoidal Ascites Accuracy 97% > 1.1 SAAG < 1.1 Non-portal HT > 2.5 < 2.5 TP > 2.5 Peritoneal diseases BCS SOS Right sided HF Pulmonary HT Cirrhosis Alcoholic hepatitis Fulminant hepatitis Massive liver met. TB Carcinomatosis Pancreatitis CNT diseases Nephrogenous

21 Limitations of ascitic fluid analysis SAAG Different time points Borderlined value Very low serum albumin Globulin >5 g/dl (1%) Hypotension Chylous ascites Mixed ascites Total protein High TP in cirrhosis (20%) Diuretic effect: high TP Mixed ascites: low TP (30-50%)

22 Cirrhosis

23 Budd-Chiari Syndrome (BCS) Hepatomegaly Heterogenous enhancement PHT: ascites, splenomegaly

24 BCS; Flip flop phenomenon Early central enhancement Delayed peripheral enhancement

25 Constrictive pericarditis

26 Tuberculous peritonitis Common in alcoholic cirrhosis Symptoms - Fever 54% - Weight loss 44% - Chest symptoms 30-40% Subtype - Exudative (moist type) - Plastic (dry type) doughy abdomen Investigations - ADA (>39 IU/ml; sens 100%, spec 97%) - CT - Peritoneal biopsy (gold standard)

27 TB peritonitis CT Peritoneoscopy

28 Malignancy-related ascites Peritoneal carcinomatosis Mesothelioma Primary effusive lymphoma Metastasis Massive liver metastasis HCC with decompensated cirrhosis Budd-Chiari syndrome Ruptured HCC (bloody ascites) Retroperitoneal lymph node with chylous ascites Pseudomyxoma peritonei

29 Carcinomatosis peritonei Common cancers Ovarian Pancreatic Cholangiocarcinoma Gastric Colorectal Breast, lung

30 Carcinomatosis peritonei Diagnosis Cytology; positive 96.7% - 3 samples - 50 ml of fresh ascites - immediate processing CT scan Biopsy

31 Linitis plastica with carcinomatosis peritonei

32 CA ovary with carcinomatosis peritonei

33 Mesothelioma

34 Nephrogenous ascites ESRD History of dialysis-associated hypotension Diagnosis by exclusion Ascitic profile: non-specific

35 Mixed ascites 5% of patients with ascites Portal HT + secondary causes Alcoholic cirrhosis + TB peritonitis Cirrhosis with carcinomatosis peritonei Clue; wide SAAG ascites plus high ascitic lymphocyte high total protein

36 Gross appearance A B C D E

37 Ascites Hemoperitoneum Chylous ascites Pseudomyxoma Bilious ascites Portal HT Non portal HT Post sinusoidal Sinusoidal Peritoneal diseases BCS SOS Right sided HF Pulmonary HT Cirrhosis Alcoholic hepatitis Fulminant hepatitis Massive liver met. TB Carcinomatosis Pancreatitis CNT diseases Nephrogenous

38 Chylous ascites Milky and creamy ascitic fluid Triglyceride content >200 mg/dl Cardenas A et al, AJG 2002:

39 Etiology of chylous ascites Diseases Neoplasm Congenital (pediatric) Infection Inflammation Trauma Lymphoma Ovarian, breast, pancreas, colon, carcinoid Lymphangiomyomatosis Primary lymphatic hypoplasia Intestinal lymphangiectasia Filariasis, TB, MAC Radiation Pancreatitis Retroperitoneal fibrosis Post operation, abdominal injury

40 Bilious ascites Total bilirubin >6 mg/dl Cardenas A et al, AJG 2002:

41 Diseases Etiology of hemoperitoneum Trauma Gynaecologic conditions Liver Vascular Peritoneal disease Coagulopathy Abdominal injury Post operation / biopsy / abdominal paracentesis Ruptured ectopic pregnancy Ruptured ovarian cyst Ruptured liver mass: HCC, HA, metastasis Cirrhosis: ectopic varices, idiopathic Splenic artery aneurysm, hemangioma, peliosis hepatis Carcinomatosis peritonei Warfarin overdose

42 Hemoperitoneum

43 Ruptured HCC

44 Ruptured hepatic adenoma

45 Pseudomyxoma peritonei

46 Pseudomyxoma peritonei

47 Ascites Hemoperitoneum Chylous ascites Pseudomyxoma Bilious ascites Portal HT Non portal HT Post sinusoidal Sinusoidal Peritoneal diseases BCS SOS Right sided HF Pulmonary HT Cirrhosis Alcoholic hepatitis Fulminant hepatitis Massive liver met. TB Carcinomatosis Pancreatitis CNT diseases Nephrogenous

48 Approach to jaundice

49 Jaundice Elevated serum bilirubin (>2.5-3 mg/dl)

50 Jaundice 1 Hemolysis Hepatocellular Cholestasis 2 Intravascular Extravascular Acute Acute on chronic Intrahepatic Extrahepatic Anemia Dark urine Prodromal symptoms Signs of chronic liver diseases Risk factors Pruritus Acholic stool Biliary pain Palpable gallbladder Abdominal mass Weight loss

51 Color of urine Hemolysis Normal Direct hyperbilirubinemia

52 Acholic stool

53 Palmar erythema Clubbing of fingers Dupuytren s contracture Spider nevi Gynecomastia Parotid gland enlargement

54 Kayser-Fleischer ring

55 Sunflower cataract

56 Ascites & superficial vein dilatation

57 Palpable gallbladder Abdominal mass

58 Hepatocellular jaundice Acute Virus HAV, HBV, HEV EBV, CMV, HSV AIH Drugs, toxin Acute BCS, SOS Hemophagocytosis Signs of chronic liver diseases Recurrent jaundice Risk factors: IVDU, tattoo etc. Travel Vaccination; HAV, HBV Fever, abdominal pain Family history Drugs/ toxin/ Herb/ CAM Alcohol Underlying diseases Signs of CLD / PHT Hepatosplenomegaly (KF ring, Parkinsonism) Acute on chronic HBV AIH Alcohol Wilson disease Acute hepatitis (other causes) on top cirrhosis

59 Virus Risk factors Travel, vaccination Heavy drinker Signs of CLD Alcohol NASH Obese Metabolic syndrome Female, autoimmune High globulin AIH Hepatitis Wilson HH Familial history KF, Parkinsonism Drug list Temporal relationship Drugs BCS Hepatomegaly, ascites Prothrombotic states

60 AST & ALT activity Level Predominated AST Rapid decline <5x: Chronic >5-8x: Acute >40x: Ischemic Drugs, toxins Extrahepatic: rbc, heart, skeletal m. Alcohol Reye s syndrome Cirrhosis Ischemic Drug (short T1/2) Acute biliary obstruction Fulminant hepatitis

61 Acute hepatitis Prodromal symptoms ALT Bilirubin Jaundice ALP Day

62 Hepatotrophic viral hepatitis HAV HEV HBV HDV HCV Transmisssion Feco-oral Feco-oral Blood, Sexual Vertical Presentation Acute Acute Chronic* Risk factors Travel Vaccine Travel Acute Chronic IVDU, tattoo, blood Tx, unsafe sex, family Hx Vaccine HBsAgdependent Acute Chronic IVDU Blood Chronic IVDU, tattoo, blood Tx *AIDS, post organ transplantation

63 Non-hepatotrophic viral hepatitis EBV HSV CMV Presentati on Acute Acute Acute Host Adolescent Immunocompromised Pregnancy Immunocompromised Symptoms & signs Mononucleosis-like Skin lesions (50%) Retinitis, colitis, pneumonitis

64 Herbs & CAM

65 Mushroom Amanita virosa Amanita verna

66 Intrahepatic cholestasis Extrahepatic cholestasis

67 Common bile duct obstruction Periampullary cancer CBD stone

68 TB, fungus Metastatic CA Lymphoma Amyloidosis Sarcoidosis PBC Drugs GVHD Cystic fibrosis Sepsis Pregnancy Paraneoplastic TPN Intrahepatic Extrahepatic Infiltrative Intraluminal Cholangiocyte injury Cholestatic jaundice Intrinsic Miscellaneous Onset of pruritus vs jaundice Hepatomegaly Biliary pain Palpable gallbladder Abdominal mass Rate of rising of bilirubin Extrinsic compression CBD stone Parasite Cholangiocarcinoma PSC, IgG4-related AIDS cholangiopathy Injury (TACE/Surgery) Malignancy; pancreas, duodenum, ampulla Metastatic LN Lymphoma Pancreatitis

69 Investigations for viral hepatitis Viral hepatitis HAV HBV HEV EBV HSV CMV Serology Anti HAV IgM HBsAg, anti HBc IgM Anti HEV IgM, anti HEV IgG Blood smear, Anti EBV IgM Tzanck smear, HSV PCR, liver biopsy CMV viral load, histology

70 Investigations for non-viral hepatitis Diseases AIH Alcohol Wilson disease Acute BCS Drugs Serology ANA, SMA, IgG, (liver biopsy) CBC, LFT + GGT, U/S Slit lamp, ceruloplasmin, 24 hr urine copper Doppler U/S or CT BM study and Ix for hematologic diseases Diagnosis by exclusion, (liver biopsy)

71 Investigations for cholestasis Diseases PBC PSC CBD stone Cholangiocarcinoma Periampullary cancer Serology AMA, (liver biopsy) ERCP/ MRCP (U/S), CT, EUS, ERCP CT, CA19-9, +ERCP, biopsy CT, CA19-9, biopsy

72 Ultrasonography IHD dilatation

73 Cholangiocarcinoma Hypovascular mass Delayed peripheral enhancement

74 CA head of pancreas Double duct sign

75 Good Luck!