Gastroenterology

Irritable Bowel Syndrome

• Pathophysiology:
  • Normal perception of abnormal gut motility, vs abnormal perception of normal gut motility
• Use Rome III criteria for diagnosing

  • >=12 wks of abdo disomfort over 12mo and has 2/3: 1. Relieved by defecation 2.  Associated with change in frequency of stool 3. Associated with change in consistency of stool Supporting criteria: (not essential for dx) Abnormal frequency Anbormal form Abnormal passage Mucous  Bloating RED FLAGS:  (if present unlikely IBS) Wt loss Fever Nocturnal defecation Blood/Pus in stool Hematuria Abnormal Fex-sig

Esophageal Varices

• Almost always from portal hypertension (often with stomach varices)
• Risk of bleeding - 30% in first year
• Risk of re-bleeding 50-70%
• Need endoscopy
• Management.

1. ABC's - Resuscitate
2. IV Octreotide
   - Causes splanchnic vasoconstriction
   - Decreases poral collateral circulation and pressure
3. Endoscopic therapy: variceal ligation or sclerotherapy
4. Long term tx to decrease recurrence:
    - B-Blocker (i.e. non-cardiospecific such as nadolol or propranolol)
   - Repeat ligation or sclerotherapy
   - Nitrates
5. Persistent or Recurrent
   - Transjugular intrahepatic portosystemic shunt (TIPS)
   - Balloon tamponade
   - Liver transplant

• Splanchnic vasoconstriction
  • Somatostatin
  • Octreotide
  • Terlipressin
• Review Article: Improved survival with Patients with Variceal Bleeds (Int. J Hepatol 2011)
  • Resuscitation to achieve (Hb >70-80g/L, but avoid fluid overload)
  • Antibiotic prophylaxis: IV ceftriaxone or postendoscopic norfloxacin reduced infection, rebleeding rates, length of hosp., all-cause mortality
  • Band ligation superior to injection sclerotherapy.

Sclerosing Cholangitis

• Inflammation of biliary tree (intra and/or extrahepatic bile ducts) --> scarring and obliteration.
• Two types:
  • Primary/idiopathic
    • most common
    • Associated with IBD, more commonly UC in up to 70% of pts (usually male)
    • One of the most common indications for transplant.
  • Secondary -less common
    • Long-term choledocholithiasis
    • Cholangiocarcinoma
    • Surgical/traumatic injury (iatrogenic)
    • contiguous inflammatory process
    • Post-ERCP
    • Associated with HIV/AIDS ("HIV cholangiopathy")
• Symptoms:
  • Often insiduous... fatigue, pruritis
  • May have episotic bacterial cholangitis due to biliary obstruction.
• Diagnosis:
  • High ALP, less often high bili
  • Mildily increased AST (<300 U/L)
  • p-ANCA (30-80%), elevated IgM (40-50%)
  • ERCP shows narrowing and dilatations of bile ducts that may result in "beading", both intrahepatic and extrahepatic bile ducts.
    • If intrahepatic narrowing only, do Antimitochondria antibody (AMA) to r/o PBC.
• Complications:
  • Repeated bouts of cholangitis may lead to biliary 

Primary Biliary Cirrhosis (PBC)

• Chronic inflammation and fibrous obliteration of intrahepatic ductules.

• Often autoimmune (associated Sjogren's syndrome, scleroderma, CREST syndrome, RA, thyroiditis)

• Classically affects middle-aged women (9:1)

• Classic presentation:

  • Middle aged woman presents with fatigue, pruritis, and edema... Has elevated cholestatic liver enzymes.

• Symptoms:

  • Asymptomatic

  • Pruritis, fatigue.

    • Chronic: Jaundice, melanosis (darkening skin),

  • High incidence of osteoporosis.

• Labs

  • Increased ALP, GGT, bilirubin (rises at later stage)

  • Positive Anti-mitochondrial antibody (AMA) --> 95% specificity

  • Increased serum cholesterol. (mild increase LDL and larger increase HDL)

    • May have xanthelasmas, xanthomas

  • Gold standard: liver biopsy.

  • Many "overlap" symptoms with autoimmune cholangitis, autoimmune hepatitis, sclerosing cholangitis.

• Treatment:

  • Treat w. ursodiol (less frequently colchicine, methotrexate)

    • Mechanism: Ursodiol replaces endogenous bile acids that are more toxic.
         1. Increased hydrophilicity index of bile acids
         2. Stiulation of hepatocellular ductal secretion

         3. Cytoprotection against bile acid and cytokine induced injury

       

  • Pruritis:

    • cholestyramine

    • rifampin (150mg bid)

  • Calcium and Vitamin D for low bone density, bisphosphonates if osteoporisis.

  • monitor TSH

  • Liver transplant if disease severe, progressive.

Secondary Biliary Cirrhosis

• Cirrhosis from prolongued major bile duct obstruction
  • Acquired: post-op strictures, chronic pancreatitis, sclerosing cholangitis, stones in duct.
  • Congenital: cystic fibrosis, congenital biliary atresia, choledochal cysts.
• Investigations:
  • Cholangiography and liver biopsy.
• Tx:
  • Treat obstruction
  • Give Antibiotics for cholangitis prophylaxis.

Inflammatory Bowel Disease