Category Archives: Gastroenterology and Hepatology

ZSFG Morning Report 6/9/2017: Hematochezia, Massive Transfusion Protocols and Narcan

Thank you to Malia Honda and Brad Hunter for presenting a case from 5R of a middle aged man, who presented after PEA arrest and then had massive hematochezia requiring massive transfusion protocol.

Top Learning Pearls

  1. Narcan (naloxone), is the opioid antagonist used in opioid overdose. Rarely it can cause pulmonary edema through both cardiogenic and noncardiogenic mechanisms.
  2. BUN/Cr ratio can help determine location of GI bleed, if >20 is more likely to be upper GI source.
  3. Activate massive transfusion protocol when you need blood quickly for hemodynamically unstable patient. MTP will provide blood products in appropriate ratio (pRBC:FFP:plts). Rule of thumb to call for MTP if >4 u of prbc in one hour.

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Naloxone

-Narcan can be delivered in many routes and doses (intranasal, IV, IM, subQ, inhalation).

  • Intranasal narcan prescribed to outpatients usually contains 2 or 4 mg.
  • IV/IM/SubQ: Initial 0.4mg to 2mg, and can be repeated
  • For reversal of respiratory depression with therapeutic opioid dose, more in the realm of 0.02 to 0.2mg IV to prevent severe withdrawal

-Incidence of Naloxone-Related Pulmonary Edema is overall low, thought to be between 0.2 – 3.6% of pts who receive narcan for overdose. The mechanisms of for pulmonary edema are thought to be both cardiogenic and noncardiogenic pulmonary edema, d/t the effect on cardiovascular tone from a resultant catecholamine surge, as well as increased pulmonary capillary leak.

Check out these two sources for some more information on narcan-related pulmonary edema

http://journal.publications.chestnet.org/article.aspx?articleid=1094181

https://www.ebmconsult.com/articles/mechanism-naloxone-related-pulmonary-edema-opiate-opioid-overdose-reversal

 

GI Bleeds in patient with cirrhosis

We are familiar with esophageal variceal bleeding, but Dr. Cello reminded us there are many sites where varices/collaterals occur at splanchic-systemic junctions, which all have a theoretical risk of bleeding, including

  • gastric vein + esophageal veins –> gastric varices
  • superior rectal vein + inferior rectal veins –> rectal varices
  • duodenal varices
  • jejunoileal varices
  • colonic and rectal varices
  • Paraumbilical veins + subcutaneous veins in anterior abdominal wall –> caput medusa

LABS to pay attention to in a GI Bleed:

  • -BUN/Cr ratio: if greater than 20 suggests UGIB, as blood is readily absorbed pre-jejunum, and broken down. As opposed to Lower GI bleed where the BUN/Cr ratio is normal
  • -Hemoglobin/hematocrit: Remember that acute blood loss is not reflected in hemoglobin/hematocrit! Take a GI bleed seriously even when H/H are normal, and pay attention to vitals and the clinical picture. Hemoglobin represents a concentration, so starts going down when we give IVF or when the body increases its intravascular plasma concentration.

Dr. Cello also made the good point that in a middle aged patient with LGIB, it is critical to do an anorectal exam to investigate for any anorectal masses. Remember to include malignancy on your differential for bleeding sources!

 

VA Intern Report Pearls 6.8.17: Behcet’s and the Silk Road

Case summary

Thanks to Colin Purmal for presenting the case of a 26F presenting with diffuse abdominal pain, bloody diarrhea and oral ulcers, who was diagnosed with Behcet’s disease.


Top pearls

1. Oral ulcers have a fascinating differential, including infection, autoimmune disease, malignancy, medication-induced, and vitamin deficiencies. But the most common cause is the aphthous ulcer!

2. Consider treating severe infectious bloody diarrhea (e.g. systemically ill, immunocompromised or elderly) with ciprofloxacin. The benefits outweigh the risks except in cases with high concern for EHEC or Salmonella typhi.

3. Behcet’s disease is a key “Crohn’s disease mimicker.”


Oral ulcers

  • Pocket reference Ddx:

Infection– primary HSV, HIV,TB, CMV, EBV, coxsackie, GC/CT, syphilis, fungal

Autoimmune– Behcet’s, SLE, Crohn’s, blistering skin disease (Pemphigus)

Malignant– SCC, lymphoma

Aphthous

Meds- DIHS, SJS

Vit Deficiencies


Antibiotics in infectious bloody diarrhea

  • Most acute infectious diarrhea does not require antibiotic therapy.
  • 2001 IDSA guidelines for dysentery (to use the Oregon Trail-approved terminology) recommend obtaining stool cultures and treating empirically for 3 days in 3 cases: 1) toxic-appearing, 2) elderly, 3) immunocompromise.
  • The main benefit of antibiotic therapy is reduced duration of symptoms.
  • Ciprofloxacin is first-line, but Azithromycin can be used in pregnancy or if high suspicion for resistant Campylobacter (e.g. recent SE Asia travel).
  • Contraindications: 1) high concern for enterohemorrhagic E. coli (concern for precipitating HUS), 2) high concern for Salmonella typhi (concern for promoting carrier state and relapse)

IDSA Guidelines: http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/idsadiarrhea.pdf


Crohn’s disease mimickers

  • Thinking about Crohn’s disease?
  • Consider Behcet’s disease in…patients from eastern Asia or the Middle East (the Silk Road!) with oral ulcerations (more frequent and more severe); genital ulcerations (more specific but less sensitive); systemic symptoms, including ocular symptoms, rashes, pan-vasculitis, weird clots (Budd-Chiari or cerebral venous thrombosis), pathergy (a 20G needle prick causes a papule or pustule within 48 hours).
  • International Study Group for Behcet’s Disease Diagnostic Criteria:
Recurrent oral ulceration: Aphthous (idiopathic) ulceration, observed by physician or patient, with at least three episodes in any 12-month period
Plus any 2 of the following:  
Recurrent genital ulceration Aphthous ulceration or scarring, observed by physician or patient
Eye lesions Anterior or posterior uveitis cells in vitreous in slit-lamp examination; or retinal vasculitis documented by ophthalmologist
Skin lesions Erythema nodosum-like lesions observed by physician or patient; papulopustular skin lesions or pseudofolliculitis with characteristic acnelform nodules observed by physician
Pathergy test Interpreted at 24 to 48 hours by physician

Behcet’s review: https://www.nature.com/nrrheum/journal/v9/n2/abs/nrrheum.2012.156.html

VA Ambulatory Report 6.7.17 – WEIGHT LOSS IN OLDER ADULTS and STOOL STUDIES

Thanks to Ashley Stein-Merlob for presenting an yet to be solved case of a 63 yo female with worsening cognitive impairment, chronic diarrhea and weight loss undergoing a work-up for malabsorption.

The dirty scoop on STOOL STUDIES

  • Fecal fat
    • Sudan Ill Stain: Qualitative assessment, less sensitive, often used as a first pass test
    • Quantitative 72-96 hour collection. Gold standard. More sensitive but difficult to get.
  • Bacterial culture
    • Not necessary in chronic diarrhea
    • Indications in acute diarrhea: severe illness, inflammatory diarrhea, high risk hosts, symptoms lasting > 7d days, public health concerns
  • Osms and Electrolytes
    • Order if suspect surreptitious diarrhea from laxative abuse
  • Biofire PCR
    • Available at the VA, tests for 22 pathogens including C. dif, e. coli, shigella, giardia, and more. May be helpful for acute diarrhea but more costly than targeted testing

Approach to UNEXPLAINED WEIGHT LOSS in Older Adults

  • The differential is broad and includes almost every organ system.
    • Most common categories: malignancy, psychiatric, gastrointestinal disease, endocrine.
    • In the elderly consider the 9 D’s of weight loss: Dementia, Dentition, Depression, Diarrhea, Disease (acute and chronic), Drugs, Dysfunction, Dysgeusia, and D
  • First pass work-up
    • Basic labs: CBC, BMP, LFTs, TSH
    • CRP, ESR
      • ** Pearl from Meg Pearson – Although non-specific an elevated test result may prompt you to do a more thorough work-up.***
    • LDH, UA, CXR, FOBT
    • Consider: Abdominal ultrasound
    • A prospective study demonstrated that if this baseline work-up is normal none of the patients went on to have malignancy demonstrated on additional testing. Therefore if the baseline work-up is normal, no further testing is necessary but continue with close follow-up.
    • When to get colonoscopy?
      • Primarily to look for microscopic colitis, IBD, malignancy
      • Should be considered if there are persistent symptoms, inconclusive diagnosis, or failure to respond to therapy.
      • Probably best to refer to GI prior to colo to ensure biopsies are taken
    • Resource: AAFP Practice guidelines for Unexplained Weight Loss in Older Adults

 

 

ZSFG AM Report – 6.2.17 – HIV-Associated GI Pathology

Thank you Kenny for presenting a case of a patient with AIDS, abdominal pain, diarrhea, and fevers found to have a partial SBO and inflammation in the terminal ileum.

Top Pearls:

  1. Partial or complete small bowel obstruction in a patient without prior surgery is very unusual and should raise suspicion for tumors, complicated hernias, Crohn’s disease or other inflammatory processes, gallstones, volvulus, or intussusception.
  2. CT Abdomen/Pelvis is better than KUB for identifying the specific site and severity of obstruction (partial vs. complete), as well as potentially determining the etiology.
  3. Infections in HIV can localize to different parts of the bowel with small bowel etiologies including: HIV enteropathy, MAC, protozoan (Giardia and the spordia), and helminths (strongy)

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More Information on HIV-Associated GI Pathology by Location in GI Track:
HIV-Associated GI Pathology (By Location):
Esophageal:
                -Candidiasis
                -CMV, HSV
                -Kaposi’s Sarcoma
                -Idiopathic ulceration
Gastric:
                -CMV
                -MAC
                -Neoplasia (Kaposi’s sarcoma, lymphoma)
Small Bowel:
                -HIV enteropathy
                -MAC
                -Protozoa (Giardia, Isospora, Cryptosporidia, Microsporidia)
                -Helminths (Stronglyoides)
Colorectal:
                -Viral (CMV, HSV)
                -Bacterial (Clostridia, Salmonella, Shigella, Campylobacter)
                -Fungal (Cryptococcus, histoplasmosis)
                -Neoplastic (KS, lymphoma)

 

For more info on HIV-associated diarrhea, see this Evernote from Rachel Greenblatt:

http://www.evernote.com/l/AoMGT-TiXM9Kvr7m83VuFlGi-G5w58cJwto/

References:

Bhaijee F, Subramony C, Tang SJ, Pepper DJ. Human immunodeficiency virus-associated gastrointestinal disease: common endoscopic biopsy diagnoses. Patholog Res Int 2011;2011:247923.

Evernote Link:

http://www.evernote.com/l/Af1CP_jgWCRGc70jFbvQgEgr1GfcfPdZJ7I/

 

MOFFITT GI REPORT PEARLS 5/10/17: Ischemic Colitis!

Hey Everyone! Thanks to Meghan for presenting an interesting case from the med consult service of an elderly woman with abdominal pain, vomiting, and diarrhea, who was found to have transverse colitis on CT scan without clear signs of ischemia and a negative infectious workup. Curious! Pearls on ischemic colitis below.

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Top Pearls:

  1. CT abdomen with IV contrast is the study of choice in ischemic colitis
  2. Mainstay of treatment is fluids, with antibiotics suggested in moderate/severe cases
  3. Ischemic colitis itself is NOT an indication for anticoagulation (unless embolic) or antiplatelet therapy

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For those who want more info:

Check out this 2016 BMJ “Clinical Updates” article on ischemic colitis:

http://www.bmj.com/content/355/bmj.i6600.long

Box 1: Common causes of ischaemic colitis (from above BMJ article)

Physiological
  • Systemic—Heart failure, systemic inflammatory response syndrome (SIRS), atherosclerosis
  • Embolic—Atrial fibrillation
  • Thrombotic—Concurrent malignancy and haematological disorders
Iatrogenic
  • Pharmacological—Chemotherapy, sex hormones, interferon therapy, pseudoephedrine, cardiac glycosides, diuretics, statins, non-steroidal anti-inflammatory drugs (NSAIDS), immunosuppressive drugs, vasopressors
  • Surgical—Abdominal aortic aneurysm repair
  • Endoscopic—Colonoscopy and bowel preparation media for colonoscopy

 

Workup: Urgent CT abdomen with IV contrast! Controversial whether plain films or ultrasound are helpful. Early endoscopy confirms the diagnosis by direct visualization and helps distinguish cases that merit conservative management or emergency resection.

See these prior pearls on the ddx and management of ischemic colitis including an algorithm that risk stratifies patients into mild, moderate, and severe ischemic colitis:

https://ucsfmed.wordpress.com/2016/05/09/am-report-pearls-59-ischemic-colitis/

A little more about antibiotics for ischemic colitis:

  • There is no strong evidence for the routine use of antibiotics in colonic ischemia, but ACG suggests empiric broad spectrum antibiotics (cipro + flagyl or broader if healthcare associated risk factors) for most patients with colonic ischemia except those with mild disease. The rationale is to prevent translocation of colonic bacteria across the mucosal defense barrier. Evidence is from animal studies showing reduced inflammation and colonic damage, small heterogeneous retrospective human trials, and expert opinion.
  • Caution with empiric antibiotics if EHEC is on the differential since there is evidence that antibiotic treatment of EHEC is associated with the development of HUS!

Indications for surgical exploration:

  • Perforation
  • Generalized peritonitis
  • Severe ischemia on radiography or endoscopy (pneumatosis, portal venous gas, gangrene)
  • Ongoing hemorrhage causing instability or requiring repeated transfusions
  • Lack of improvement with conservative management
  • >3 risk factors: right-sided colitis, male sex, renal dysfunction, colonic strictures, pain without rectal bleeding, SBP<90, HR>100, WBC>15, hgb<12, Na<136, BUN>20, LDH>350

Patients requiring surgical intervention have 37-48% mortality compared to 6.2% in those treated conservatively.

*Pearl: Anticoagulation is NOT indicated unless the etiology is embolic.

*Pearl: Ischemic colitis is NOT itself an indication for antiplatelet therapy since it is not purely an atherosclerotic condition.

*Pearl: DVT prophylaxis IS recommended in ischemic colitis as long as bleeding is not severe.

 

Evernote: https://www.evernote.com/shard/s272/sh/c5f0a2d6-75ae-48a9-880a-5d3b7168b8b4/d0c1d539299715ad8db0766f37b9bd5c

 

Have a great day everyone!

SamMy

MOFFITT GI REPORT PEARLS 4/12/17: Crohn Disease and TPN!

Hey Everyone! Great GI report today. Thanks to Amanda for presenting the case of a young man with Crohn disease with acute abdominal pain who was found to have an intestinal abscess, possible fistula, and also possibly recurrent c diff! Pearls below:

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Top Pearls:

  1. Large joint arthritis without destruction is the most common extra-intestinal manifestation of Crohn disease.
  2. Early TPN is recommended in hospitalized patients with severe Crohn disease.
  3. In patients with Crohn disease who have had a bowel resection, the most common site of disease recurrence is at the site of anastomosis.

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For those who want more info:

Crohn disease can affect the entire GI tract including oral ulcers, esophageal involvement, and perianal disease.

Extra-intestinal Crohn manifestations:

  • Arthritis (most common, 20%, large joints without destruction)
  • Skin manifestations (10% of patients have EN or PG)
  • Anterior uveitis (5% of patients)
  • PSC (5% of patients)
  • Thromboembolism (venous and arterial)
  • ILD
  • Renal stones
  • B12 deficiency
  • AA Amyloid

Complications of Crohn disease:

  • Malabsorption
  • GI bleeding (gross bleeding less common than in UC)
  • Phlegmon: walled off inflammatory mass without infection
  • Abscess
  • Fistula (50% within 20 years)
  • Stricture/SBO
  • Bowel perforation/peritonitis

For severe Crohn disease, management consists of bowel rest, parenteral nutrition, and IV glucocorticoids. Remember that unlike in UC, 5-ASA formulations have not been shown to be helpful in severe Crohn disease.

*Pearl: SBO in a patient with Crohn disease may be entirely due to a Crohn flare! Don’t forget to start steroids while you’re consulting surgery for the SBO.

*Pearl: From Dr. Ostroff, early TPN should be initiated in patients with severe Crohn disease who are admitted because nutritional deficiency will impair intestinal and other healing. Patients with severe Crohn disease won’t absorb sufficient enteral nutrition. Remember to check an albumin/prealbumin level!

Unfortunately, parenteral nutrition has not been shown to help induce disease remission.

TPN complications:

  • Increased risk of bacterial/fungal bloodstream infection
  • Metabolic effects: hyperglycemia, electrolyte disturbance, nutrient excess/deficiency, refeeding syndrome, Wernicke encephalopathy, hepatic dysfunction

*Pearl: In patients with Crohn disease who have had a bowel resection, disease recurrence is most common at the site of anastomosis!

 

Evernote: https://www.evernote.com/shard/s272/sh/7f85d074-e67d-4db7-b6db-ec894b98b025/20616ffd6a980cd7df32d4e520d0674a

 

Have a great day everyone!

SamMy

MOFFITT CARDIOLOGY REPORT PEARLS 4/4/17: Ascites and Baroreflex Activation Therapy!

Hey everyone! Thanks to Muazzum for presenting an interesting mystery case of a middle-aged man with heart failure who developed volume overload but had a low SAAG ascites with a PMN-predominant WBC count of 800! Pearls below on ascites and baroreflex activation therapy (!):

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Top Pearls:

  1. Ascites etiologies can be broken down into high and low SAAG, but also high and low protein (see 2×2 table below).
  2. The differential for ascites PMN count >250 is broader than just SBP!
  3. Baroreflex stimulation devices improve outcomes in HFrEF and resistant hypertension.

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For those who want more info:

Some core topics first, followed by some newfangled craziness… 🙂

Thanks to Jess Beaman for the table below reviewing the general pattern of SAAG and total protein with various causes of ascites:

Total ascites protein

< 2.5 g/dL

Total ascites protein

> 2.5 g/dL

SAAG ≥ 1.1 g/dL Portal hypertension due to cirrhosis Portal hypertension due to hepatic venous outflow obstruction (including right heart failure)
SAAG < 1.1 g/dL Nephrotic syndrome Malignancy, tuberculosis

https://ucsfmed.wordpress.com/2016/01/06/1-6-16-va-ambulatory-report-pearls-ascites-constrictive-pericarditis/

 

Diagnostic criteria for SBP are met if ascites PMN count >250, but Harry reminded us that the differential for PMN >250 is broader than just SBP and also includes:

  • Secondary bacterial peritonitis (perforation)
  • Bloody fluid (trauma or hemorrhage), need to correct 1 PMN per 250 RBCs
  • Foreign body
  • TB (usually mononuclear)
  • Malignancy (usually mononuclear)
  • Serositis (autoimmune/drug-induced, usually mononuclear)

 

Now, onto…baroreflex stimulation devices?!?

Implantable devices that provide electrical stimulation to the carotid baroreceptors, also called “baroreflex activation therapy” (BAT). As Muazzum and Anne Thorson taught us, these devices reduce HR, BP, and afterload, which is beneficial for hypertension and heart failure.

Baroreflex activation therapy has been shown to be safe and effective in improving functional status, quality of life, exercise capacity, and HF hospitalizations in patients with NYHA III HFrEF.

Abraham et al JACC Heart Fail 2015

Zile et al Eur J Heart Fail 2015

It is also safe and effective in reducing blood pressure in patients with resistant chronic hypertension.

De Leeuw et al Hypertension 2017

The device is implanted subcutaneously in the upper chest wall, and carotid sinus leads are placed in contact with the baroreceptors. An external programmer is used to turn the system on/off and regulate the signal level.

X-ray with an implanted BAT device:

Barostim CXR

ECG demonstrating artifact seen with the device’s activity:

ECG

Crazy!! Thanks Muazzum and Anne for introducing us to a brave new world of cardiac devices. 🙂

 

Evernote: https://www.evernote.com/shard/s272/sh/6ef83563-865f-4bf3-80b3-7b5702070ef9/ba2d4f31083b59ae85f9b049f6f1349e

Have a great day everyone!

SamMy