GI Pearls and Diagnostic Errors

Similar documents
Treatment of Helicobacter pylori Infection

9/18/2018. Clostridium Difficile: Updates on Diagnosis and Treatment. Clostridium difficile Infection (CDI) Clostridium difficile Infection (CDI)

I. Kalfus MD, D. Riff MD, R. Fathi PhD, D. Graham MD

CHAPTER 18. PEPTIC ULCER DISEASE, SELF-ASSESSMENT QUESTIONS. 1. Which of the following is not a common cause of peptic ulcer disease (PUD)?

Treating H. pylori in 2016

Case 1. Which of the following would be next appropriate investigation/s regarding the pts diarrhoea?

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) MANAGEMENT OF DYSPEPSIA

Proton Pump Inhibitors Drug Class Prior Authorization Protocol

Helicobacter 2008;13:1-6. Am J Gastroent 2007;102: Am J of Med 2004;117:31-35.

GASTROENTEROLOGY ESSENTIALS

University Medical Center at Brackenridge. Gastroenterology Clinic Worksheet

Peptic Ulcer Disease Update

Clostridium difficile Infection: Diagnosis and Management

Clostridium difficile Infection (CDI) Management Guideline

What is the status of Sequential Therapy Versus Standard Triple- Drug Therapy in peptic ulcer disease in eradicating H pylori?

PEPTIC ULCER DISEASE JOHN R SALTZMAN, MD. Director of Endoscopy Brigham and Women s Hospital Professor of Medicine Harvard Medical School

Helicobacter Pylori Testing HELICOBACTER PYLORI TESTING HS-131. Policy Number: HS-131. Original Effective Date: 9/17/2009

A Trip Through the GI Tract: Common GI Diseases and Complaints. Jennifer Curtis, MD

Dr David Rowbotham. The Leeds Teaching Hospitals NHS Trust NHS

Management of Dyspepsia

ACG Clinical Guideline: Treatment of Helicobacter pylori Infection

MANAGEMENT OF DYSPEPSIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

Clostridium DifficileInfection & Readmissions: An ounce of prevention is worth a pound of cure

ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Management of dyspepsia and of Helicobacter pylori infection

Stony Brook Adult Clostridium difficile Management Guidelines. Discontinue all unnecessary antibiotics

Clostridium Difficile Infection: Applying New Treatment Guidelines and Strategies to Reduce Recurrence Rate

Objectives. Definitions. Colorectal Cancer Screening 5/8/2018. Payam Afshar, MS, MD Kaiser Permanente, San Diego. Colorectal cancer background

Chapter 14: Training in Radiology. DDSEP Chapter 1: Question 12

Updates in Evaluation and Management of Dyspepsia and H. Pylori Infection

6/25/ % 20% 50% 19% Functional Dyspepsia Peptic Ulcer GERD Cancer Other

! MQ is a 44 year old woman that I first saw in Sept ! In MVA in Jan 2003 requiring spinal surgery

Outline. GI-Bleeding. Initial intervention

GASTROINTESTINAL AND ANTIEMETIC DRUGS. Submitted by: Shaema M. Ali

The incubation period is unknown. However; the onset of clinical disease is typically 5-10 days after initiation of antimicrobial treatment.

ACP Aaron Fieker, D.O

Updates in Colorectal Cancer Screening & Prevention

Gut Microbiota Transplant Pro Position. Christina Surawicz, MD, MACG Professor of Medicine University of Washington Seattle WA

Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer

Modern approach to Clostridium Difficile Infection

Colon Cancer Screening Past, Present & Future

Peptic ulcer disease Disorders of the esophagus

What Is Peptic Ulcer Disease?

Disclosures. Co-founder and Chief Science Officer, TechLab

Fecal Microbiota Transplantation in C. diff. colitis Benefits and Limitations

Colorectal Cancer Screening: Cost-Effectiveness and Adverse events October, 2005

Helicobacter pylori: Diagnosis, treatment and risks of untreated infection

When to Refer for OGD and the Work Up of Upper GI Malignancies

Fecoprevalence and determinants of Helicobacter pylor infection among asymptomatic children in Myanmar

The New Grade A: USPSTF Updated Colorectal Cancer Screening Guidelines, What does it all mean?

Diagnosis, Management, and Prevention of Clostridium difficile infection in Long-Term Care Facilities: A Review

-2002: Rectal blood loss, UC? (no definite diagnosis) rectal mesalazine. -June 2008: Recurrence of rectal blood loss and urgency

The PPI Doesn t Work, Now What? PPI Non-responsive Dyspepsia. Disclosures

Zinplava. (bezlotoxumab) New Product Slideshow

C. difficile: When to Do Fecal Microbiota Transplant (FMT)

Improving Outcomes in Colorectal Cancer: The Science of Screening. Colorectal Cancer (CRC)

Clostridium difficile: Can you smell the new updates?

Drug Class Monograph

CLOSTRIDIUM DIFICILE. Negin N Blattman Infectious Diseases Phoenix VA Healthcare System

Primary Sclerosing Cholangitis and Cholestatic liver diseases. Ahsan M Bhatti MD, FACP Bhatti Gastroenterology Consultants

concerned about his health and does not want to end up on medication, like his siblings

GI update. Common conditions and concerns my patients frequently asked about

Epidemiology and Treatment of Colonic Angiodysplasia; a Population-Based Study. Naomi G. Diggs, MD Lisa L. Strate, MD MPH March 2, 2010

DISCLOSURE Relevant relationships with commercial entities Wyeth (received advisory board & speaker honoraria) Potential for conflicts of interest wit

Colorectal Cancer Screening. Daniel C. Chung, MD GI Unit and GI Cancer Genetics Service Massachusetts General Hospital

HELICOBACTER PYLORI UPDATE

Division of GIM Lecture Series Case Presentation David A. Erickson, M.D October 9th, 2013

HEALTHCARE- ASSOCIATED INFECTIONS: A FOCUS ON Clostridium difficile

Patient presentation

Managing Upper GI Tract Disease. Michael Herzlinger, MD Pediatric Gastroenterology 7/2018

Urea Breath Test for Diagnosis of Helicobactor pylori. Original Policy Date 12:2013

C. Difficile Testing Protocol

Sphincter of Oddi dysfunction: SOD after EPISOD, Now what do we do?

Updated Clostridium difficile Treatment Guidelines

QUICK QUERIES. Topical Questions, Sound Answers

Bezlotoxumab (Zinplava) as Adjunct Treatment for Clostridium difficile. Janel Liane Cala, RPh Medical Center Hospital

GASTROINTESTINAL SYSTEM MANAGEMENT OF DYSPEPSIA

Pediatric Gastroenterology Referral Guidelines

Sequioa Education Systems, Inc. 1

The significance of Helicobacter pylori in the approach of dyspepsia in primary care Arents, Nicolaas Lodevikus Augustinus

11/9/2015 OUTLINE. Quality Indicators for the Doctor Performing Screening Colonoscopy: What you should expect from your Endoscopist

Corporate Medical Policy

Clostridium Difficile Infection in Adults Treatment and Prevention

KK College of Nursing Peptic Ulcer Badil D ass Dass, Lecturer 25th July, 2011

2. Describe pros/cons of screening interventions (including colonoscopy, CT colography, fecal tests)

Clostridium difficile

2017 NEEDS ASSESSMENT SURVEY

Common Gastrointestinal Problems in the Elderly

Bloating, Flatulence, and

When to Scope in Lower GI Bleeding: It Must Be Done Now. Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA

Acid-Peptic Diseases of the Stomach and Duodenum Including Helicobacter pylori and NSAIDs Prof. Sheila Crowe

Clostridium difficile Asymptomatic Carriers The Hidden Part of the Iceberg?

Clostridium difficile Infection (CDI) Guideline Update:

EDUCATION PRACTICE. Persistent Helicobacter pylori Infection After a Course of Antimicrobial Therapy What s Next? Clinical Scenario.

Bleeding in the Digestive Tract

Efficacy of standard triple therapy versus bismuth-based quadruple therapy for eradication of Helicobacter Pylori infection

Managing Clostridium Difficile: An Old Bug With

Peptic ulcer disease. Nomin-Erdene. D SOM-531

American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection

Transcription:

GI Pearls and Diagnostic Errors David A. Johnson MD MACG FASGE FACP Professor of Medicine Chief of Gastroenterology Eastern VA Medical School Norfolk VA

Disclosures Editor: NEJM J Watch Gastro (esophageal) : WebMD/MedScape (Gastro) Consultant: Pfizer, Aries, CRH Medical

Helicobacter pylori testing 34 year old Hispanic epigastric pain 2 weeks -worse with eating -melena for the last 24 hrs Emergent upper endoscopy: 1 cm prepyloric ulcer -active bleed which is controlled by endoscopic therapy -antral biopsies: Helicobacter pylori PPI, clarithromycin, amoxicillin, metronidazole x 14 d - 8 week PPI Seen back in the office 10 weeks off all meds You recommend:

Next Test A H pylori serology (IgG) B H pylori serology (IgA) C Repeat endoscopy with biopsy D Stool for HP antigen E No further test- observation for recurrence

H.Pylori testing Appropriate testing document eradication - stool antigen for H.pylori - urea breath test - biopsy (only if endoscopy to be repeated) Repeat testing >4 weeks post completion Rx PPIs may affect sensitivity/specificity of nonserologic testing - hold PPI at least 1 week Am J Gastroenterol 2017; 112 (2), 212-239

H pylori Treatment Most patients will be better served first line Tx: -bismuth quadruple therapy or -concomitant therapy consisting of PPI, clarithromycin, amoxicillin, metronidazole

Next Test A H pylori serology (IgG) B H pylori serology (IgA) C Repeat endoscopy with biopsy D Stool for HP antigen E No further test- observation for recurrence

H. Pylori - Pearls 14 day treatment duration New treatments-quadruple based tx All treated patients- document eradication Serology testing not for eradication f/u

CRC Screening Fecal Blood Testing 52 yr old Caucasian male seen annual physical exam Initial screening colonoscopy (age 50) -mild diverticulosis and hemorrhoids -GI colonoscopist recommended repeat 10 yrs He reports his father recently diagnosed CRC age 86 What test would you recommend for CRC screening?

Next Test A Hemoccult testing x 3 (FOBT) B Fecal immunohistochemical test x1 (FIT) C Fecal DNA (Cologuard) D No test at present - repeat colonoscopy 10 yrs after first exam E EpiproColon (Septin 9 serum assay)

CRC Screening After high quality screening colonoscopy -no alternative screening if colonoscopy to be repeated FOBT no longer recommended (replaced by FIT) - Improves sensitivity/specificity - Any + FIT warrants colonoscopy Am J Gastroenterol 2017; Jul;112(7):1016-1030

Next Test A Hemoccult testing x 3 (FOBT) B Fecal immunohistochemical test x1 (FIT) C Fecal DNA (Cologuard) D No test at present - repeat colonoscopy 10 yrs after first exam E EpiproColon (Septin 9 serum assay)

CRC Screening Pearls FIT replaces FOBT No interval sceen testing if 10 yr colonoscopy Family hx CRC >60 -First degree relative begin at 40 then q 10 Age to stop -USPTF 85 yr -MSTF- consider comorbidities (life <10 yrs)

Abdominal Pain Evaluation 24-year-old Caucasian woman RUQ pain - dull ache with intermittent stabbing severe pains - improved with recumbence - intermittent nocturnal awakening (rolled her right side) - no change with meals/ associated relief with BM - no radicular pain

Abdominal Pain Evaluation Onset: - backpacking hiking vacation trip to Europe - swinging backpack/carrying infant extended hiking Return home month ago but since - experienced it on two separate occasions - severe enough that she went to the emergency room - normal CAT/labs x2 PE: point tender RUQ over gallbladder area - more tender flexes abdominal muscles/raises off bed - no rebound/normal BS/no rashes

Next Test A CCK Hida (evaluation ejection fraction) B MRCP C ERCP D Referral for upper endoscopy E Local heat/analgesics

Abdominal Pain Evaluation Good history/classic physical finding -abdominal wall pain Carnett s sign -patient supine/ find exact point maximally tender -fold arms flex up -examiner kept fingers point of max tenderness Carnett s hypothesis Savings average $900 per case /avoidance testing Clin Translat Gastro 2016; 7: e136

Next Test A CCK Hida (evaluation ejection fraction) B MRCP C ERCP D Referral for upper endoscopy E Local heat/analgesics

Abdominal Pain Carnett s Pearls Local heat/nsaids/topical analgesics Look for causes - habitus/posture - take good history - look at back/posture/shoulders/pelvis tilt

Clostridium difficile Testing 75 yr old female acute diarrheal illness Recent tx amoxacillin for URI No prior history of diarrheal disease C difficele + glutamate dehydrogenase (GDH) - Rx flagyl 500 mg tid for 10 days Seen your office 2 weeks post treatment -resolution diarrhea now normal BM What is best recommendation for next test?

Next Test A C. difficile glutamate dehydrogenase (GDH) B CDI Nucleic Acid Amplification Gene Testing C EIA detection toxin A+B toxin D No CDI test at present E Immune deficiency evaluation

Clostridium difficile Testing 50% responded to treatment -asymptomatically can shed C difficile spores 6 weeks After successful treatment -stool assays often remain + for months -indicating ongoing colonization w/o clinical disease JAMA Intern Med 2015 ;175(11): 1746-1747 Am J Gastroenterol 2013; 108:478 498; Clin Infect Dis. 2018; doi: 10.1093/cid/cix1085

Clostridium difficile Testing Repeated demonstration stool + by laboratory assays - repeated stool test of cure not recommended - even more so patients not have ongoing diarrhea JAMA Intern Med 2015 ;175(11): 1746-1747 Am J Gastroenterol 2013; 108:478 498; Clin Infect Dis. 2018; doi: 10.1093/cid/cix1085

Next Test A C. difficile glutamate dehydrogenase (GDH) B CDI Nucleic Acid Amplification Gene Testing C EIA detection toxin A+B toxin D No CDI test at present E Immune deficiency evaluation

C diff. Pearls No test if not diarrhea Toilet hygiene discussion Prophylaxis for high risk patients FMT treatment option - high risk - recurrence

BELL RINGERS

Be Thoughtful and.. Careful with Change

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback