Gastrointestional

Gastrointestinal (GI) #

Stool Scales #

Stool Scale 1 Stool Scale 2

Constipation #

  • Mirilax + Senna plus
  • Bisdocyl suppository
  • Soap-suds enema
  • Mag citrate (aka “The Nuclear Option”)

Diarrhea #

  • loperamide 4mg, then 2mg q2h
  • loperamide-simethicone (2mg-125mg)
    • Some evidence it works faster than loperamide alone
  • octreotide

Nausea/Vomiting #

  • Zofran 4-8mg
    • inhibits serotonin at 5-HT3 receptors in small bowel, vagus nerve, and chemoreceptor trigger zone
    • Qt prolonger
  • Compazine (Prochlorperazine) 5-10mg q6-8hrs
    • extrapyramidal side effects: restlessness, agitation, akathisia, dystonia, dyskinesia
    • Not really a Qt prolonger
  • Reglan (metoclopramide) 10mg IV
    • Antidopaminergic
    • Not really a Qt prolonger
  • Zyprexa-ODT 5mg, then 2.5mg q6h prn
    • Great for refractory nausea as basically hits all the nausea receptors
  • Ativan
    • Safe in long Qt
  • Benadryl 50mg IV
    • Safe in long Qt
  • Steroids
    • Safe in long Qt
  • Haldol?

Abdominal Pain (IBS) #

  • Dicyclomine 20mg QID prn

Spontaneous Bacterial Peritonitis (SBP) #

Intrabdominal infection w/o real source
Happens frequently in ESLD patients due to impaired opsonization of bacteria from failing liver

  • Paracentesis to dx
    • Cell counts and diff
    • Cultures (anaerobid and aerobic)
    • glucose, total protein, albumin, LDH, amylase
  • >250PMNs[^1] in para fluid = SBP
    • Correction for hemorrhagic ascites (> 10,000 RBC/mm3) subtract 1 PMN per 250 red
    • SBP due to gram-positive cocci frequently reported to have PMN < 250 cell/mm3
  • Bugs (most common)
    • E. Coli, Klebsiella, pneumococci, Strep viridans, Staph aureus
  • Procal can be helpful (small study)
    • cutoff of < 0.61 ng/mL
      • sensitivity 100%, specificity 92% for SBP

Treatment #

  • IV ceftriaxone 1g IV q12h
  • Albumin (1.5g/kg IV/6hrs immediately and 1g/kg IV/6hrs on day 3)
    • Consider in pts with SCr >1, BUN >20 or total bili >4mg/dL
  • Consider stopping non-selective BBs
  • Start on norfloxacin 400mg/day PO indefinitely for secondary prophylaxis

Secondary Bacterial Peritonitis (the other SBP) #

Intrabdominal infection w/ real source. Think about this if you think it’s SBP but doesn’t really shake out to be.

  • Paracentesis
    • <250 PMNs
    • Glucose <50mg/dL
    • Protein >1g/dL
    • Above values limited in sensitivity (<68%)
  • Sources
    • Gastric perf somewhere
      • PUD, Diverticuli, Gallbladder, Appendix, Meckels, post-op anastomosis leak
    • Bowel inflammation (generally transmural)
      • IBD, Appy, Ischemic bowel

Ascites #

Accumulation of intraparateneal fluid.
Causes:

  • cirrhosis (#1, ≈60% incidence in pts with cirrhosis)
  • malignancy, nephrotic syndrome, heart failure, malnutrition, and infections (peritoneal TB, coccidioidomycosis, chlamydia), Budd-Chiari

SAAG helps differentiate:

  • SAAG ≥ 1.1 g/dL → portal hypertension (cirrhosis) (+LR 4.6)
    • Protein < 1 g/dL: Chronic liver disease, massive hepatic mets
    • Protein > 2 g/dL: cardiac disease, Budd-Chiari syndrome, veno-occlusive disease, myxedema
  • SAAG < 1.1 g/dL → other: peritoneal carcinomatosis, chronic peritoneal infection, nephrotic syndrome, pancreatic ascites, and protein-losing enteropathy

Treatment #

  • Antiboitics
    • Ceftriaxone
      • NNT &qpprox;5
  • Sodium/water restrict
    • Avoid NSAIDS
      • Decreases renal sodium excretion
    • Hold home ACE/ARB, A1-blockers
  • Diurese
    • spironolactone 100 mg/day (max 400 mg/day)
    • furosemide 40 mg/day (max 160 mg/day)
  • Therapeutic para
    • Can shorten hospital stay
    • First choice for tense ascites
  • Albumin
    • May not effect mortality
    • reduces after para hypona,
  • Surgery
    • TIPS
    • Transplant
    • Peritoneovenous shunting (Denver shunt)

Cirrhosis #

Fibrosis and regenerative nodules w/ liver dysfunction.

Causes:

  • EtOH (most common)
  • NAFLD
  • Viral hepatitis
    • HCV most common in US
    • HBV most common worldwide

Diagnosis #

  • Workup:
    • hepatitis B and C serology
    • AST:ALT ratio
    • alpha-1 antitrypsin levels with phenotyping
    • antinuclear antibody, antismooth muscle titer, antimitochondrial antibodies
    • serum ferritin and transferrin saturation levels
    • hemochromatosis gene (HFE) testing (if iron saturation is greater than 45%)
    • serum copper and ceruloplasmin, and 24-hour urine copper (Wilson’s)
  • Lok index (>90% sensitive)
    • LogOddsLok = (1.26 * AST / ALT) + (5.27 * INR) - (0.0089 * Platelets) - 5.56
    • LokIndex = e(LogOddsLok) / (1 + e(LogOddsLok))
      • <0.2: Cirrhosis less likely
      • 0.2-0.5: Indeterminate
      • >0.5: Cirrhosis likely
  • Bonacini cirrhosis discriminant score (>90% specific)
    • CDS = PlateletScore + ALTASTRatioScore + INRScore
    • <7 => cirrhosis less likely
    • ≥8 => cirrhosis more likely
  • US
  • CT Abdomen

Treatment #

  • Transplant ultimately…
  • Vaccinate for HepA, HepB and Pneumo23
  • Stop drinking!

Acute Pancreatitis #

Diagnosis (2 of):

  • Epigastric pain
  • Elevated lipase
    • Urinary trypsinogen-2 (very specific)
  • Imflammation on imaging

Causes:

  • Gallstones (≈40%)
    • LFTs normal in 15-20% of patients
  • EtOH (35%)
  • meds (2%)
    • analgesics and anti-inflammatory agents
    • angiotensin-converting enzyme (ACE) inhibitors
    • antivirals (HIV)
    • atypical antipsychotics
    • corticosteroids
    • diuretics
    • hypoglycemic agents (antidiabetics)
    • macrolides and other antibiotics
    • oral contraceptive or hormone replacement therapy, especially estrogens
    • proton pump inhibitors
    • statins
    • thiopurines, including azathioprine and 6-mercaptopurine
    • Valproic acid
  • hypertryglycerides (1-4%)
    • >1000
  • trauma (1.5%)
    • Most common in kids
  • Post ERCP (5-10% of ERCPs)
  • Idiopathic (≈10%)

Heartburn #

  • No data to support BID PPI as better than Qday
  • Theoretical “max” acid supression
    • PPI in AM
    • H2RA in PM (overnight acid production more histamine driven)

Peds #

Giadariasis #

  • Classic Triad: Nausea, diarrhea, stomoch pains/cramps
    • Episodic
    • Smelly farts
  • 20-25 day incubation period
  • Usually presents in the fall and paitent have usually dealt with it for a few months
  • Tx
    • Nitazoxamide 500mg BID pc x3 days

Radiology #

Abdominal CT #

How to read:

  1. In lung window, scroll down through abdomen looking for free air
  2. Switch to bone window, scroll back up looking for any bony abnormalities
  3. Switch to soft tissue window, start with liver/gallbladder, follow ducts down to pancreas
  4. From pancreas, follow splenic artery/vein to spleen (through pancreas)
  5. Next find adrenals, kidneys, follow ureters down to bladder
  6. Trace colon up from rectum

Pearls #

  • If pt with C. Diff treated with antidiarrheals, can cause mega colon.
  • GGT not specific for hepatobiliary disease (elevated with meds: barbituates, phenytoin, EtOH)
  • MELD score to predict mortality in patients with cirhosis.
  • homemade recipe for rehydration
    • 1 L clean water
    • ouncese-half teaspoon salt (3.5 g)
    • one-half teaspoon baking soda (2.5 g NaHCO3)
    • 8 teaspoons sugar (40 g)
    • 8 ounces orange juice (1.5 g KCl)

[^1] PMNs = Neutrophils, Eos, basophils, masts