Esophageal Varices Bleed

Pt with h/o liver cirrhosis, portal hypertension, varices presents with acute onset hematemesis. Varices diagnosis previously established during q3 year screening endoscopy. Active hematemesis with bright red-blood, gynecomastia, hepatomegaly, caput medusa on exam.

• Obtain CBC, CMP, PT, PTT, INR, FOBT

• Surgery consult for urgent EGD; may require banding

• Start octreotide 50mcg IV bolus followed by 25mcg/hour IV x2 days

• Bactrim SS BID x 7 days

• H/o previous variceal bleeds; consider TIPS procedure s/p stabilization

• Discharge with prophylactic propranolol 40mg BID

• Propranolol contraindicated; start isosorbide mononitrate 20mg BID

• Yearly EGD due to established variceal diagnosis

• Pt counseled about significantly elevated risk for re-bleed during 6 weeks following discharge

• Pt advised that long-term therapy may involve liver transplant

Notes

• Rate of variceal bleeding in patients with established diagnosis is 10-30% per year

• For patient's with Bactrim allergy, use Norfloxacin

Peptic Ulcer Disease

Pt with h/o NSAID use presents with dyspepsia. Denies unexplained weight loss, dysphagia/odynophagia, recurrent vomiting, family history of gastrointestinal cancer, overt gastrointestinal bleeding. No conjunctival pallor, abdominal mass on exam.

• Obtain H. pylori fecal antigen testing

• [Pt <55 y/o with no alarm symptoms; endoscopy not indicated]

• Triple therapy x14 days: PPI 20mg BID, amoxicillin 1g BID, clarithromycin 500mg BID

• Follow-up in 1 month and repeat fecal antigen testing if symptoms persist

• Failed triple therapy; start PPI 20mg BID, metronidazole 500mg TID, tetracycline 500mg 4x daily, bismuth sbsalicylate 524mg 4x daily

Functional Dyspepsia

Pt <55 y/o with h/o GERD, IBS, anxiety/depression presents with chronic, paroxysmal epigastric pain associated with early satiety. Symptoms started 6 months ago and have been persistent during past 3 months. Abdominal pain does not radiate to chest/back/RUQ and is not relieved by flatus. Pt cannot finish normal size meals multiple times per seek due to sensation of bloating/nausea. Denies excessive alcohol use and red flags including unintended weight loss, progressive dysphagia, persistent vomiting, dark tarry stools, BRBPR. No family h/o GI malignancy. Pain with palpation of epigastric region on exam.

• Obtain CBC, BMP, H. pylori fecal antigen testing

• Treatment

  • CrCl >50 mL/min: Start ranitidine 150 mg BID

  • Positive H. pylori fecal antigen test: Triple therapy with omeprazole 20 mg BID, amoxicillin 1 g BID, and clarithromycin 500 mg BID x 14 days

  • Refractory symptoms

    • Negative H. pylori fecal antigen testing: Consider starting metoclopramide 5 mg TID; pt counseled that medication should not be taken for greater than 12 weeks due to risk for tardive dyskinesia

    • H. pylori fecal antigen testing and s/p triple therapy: Consider quadruple therapy vs. referral for EGD (see PUD)

• Pt advised to schedule follow-up appointment to address anxiety/depression

Notes

• Affects 40 percent of adults yearly

• Responsible for 70% of dyspepsia cases; differential also includes

  • Peptic ulcer disease (~20%)

  • Reflux esophagitis (~10%)

  • Esophageal/gastric CA (~2%)

• Diagnosis

  • CBC screens for anemia that may occur due to GI bleed

  • Rome III criteria separates condition into disorders of epigastric pain and postprandial fullness

• Intervention

  • Ranitidine

    • If not already documented, calculate creatinine clearance before starting BID

    • CrCl <50 mL/min: Start 150 mg qd

  • Metoclopramide (Reglan): Use with caution in older adults

  • Consider endoscopy and/or colonoscopy for patients older than 55 years and/or those with red flag symptoms

Acute (Infectious) Gastroenteritis

Non-pregnant patient with no h/o GI disease, endocrine disease, or radiation therapy presents with acute onset diarrhea. Describes increased stool frequency, volume, and water content x 2 days. Additional symptoms include thirst, lightheadedness, vomiting, and decreased urine output. Reports recent consumption of unpurified water/undercooked meat and antibiotic treatment while hospitalized in a developing nation. Sick contacts include child who attends daycare. Acute weight loss, dry mucous membranes, hyperactive bowel sounds, and mild/diffuse abdominal tenderness on exam.

• Diarrhea lasting > 7 days with h/o immunosuppression, bloody stools, or fever: Obtain fecal lactoferrin (if positive, obtain stool cultures +/- analysis for stool ova/parasites)

• Hospitalization with previous 3 days or antibiotic treatment within past 3 months: Test for C. difficile toxins A and B

• Treatment

  • Oral rehydration therapy with 1/2 teaspoon salt and 6 teaspoons sugar mixed in 1 liter of water

  • BRAT (bananas, rice, applesauce, toast) diet until symptoms improve

  • Sensation of bloating/gas pain: Start simethicone 80 mg TID PRN

  • Non-bloody diarrhea: Start loperamide 2 mg q4h PRN, maximum 16 mg/day

  • Fever and/or bloody diarrhea: Trial of Pepto-Bismol

  • Patient advised that lactobacillus 1 to 4 packets qd may shorten illness duration

  • Antibiotics

    • C. difficile: Vancomycin 125 mg PO q6h x 10 days

    • Elderly, immunocompromised, or severely ill: Empiric ciprofloxacin 500 mg BID x 3 days

    • Recent travel: Azithromycin 500 mg qd x 5 days (Asia) vs. ciprofloxacin 500 mg BID (other continents)

    • Giardia: Metronidazole 500 mg TID x7 days

• Pt counseled about importance of hand washing to prevent infection of others

• Schedule follow-up appointment is symptoms last > 14 days

Notes

• Etiology

  • Viral gastroenteritis is the most common etiology

  • C. difficile should be suspected s/p recent hospitalization

  • Advanced organizer for bacterial causes of bloody (inflammatory) diarrhea: You’re Constantly SShitting EErythrocytes

    • Yersinia

    • Campylobacter

    • Salmonella (non-Typhi), Shigella

    • Enteroinvasive E. coli, Entamoeba histolytica

  • Consider giardia in pt with recent consumption of unpurified water, e.g. while camping

  • Additional risk factors

    • Recent treatment with antibiotics

    • Exposure to high-risk individuals, e.g. children in daycare

    • Travel in underdeveloped nations

• Special populations

  • In children, presence of two or more of the following indicates > 5% fluid deficit and need for oral rehydration therapy: Capillary refill > 2 seconds, absence of tears, dry mucous membranes, generally ill appearance

  • Pregnant patients are at increased risk for listeriosis

  • Immunocompromised patients are at greater risk overall

  • GI/endocrine disease and treatment with radiation therapy may cause gastroenteritis, but are beyond the scope of this vignette

• Lactoferrin: Marker for fecal leukocytes (sensitivity 90%, specificity 70%)

Irritable Bowel Syndrome

Female pt with h/o functional abdominal pain presents with acute on chronic abdominal pain x6 months. Cramping pain has occurred ≥3 days per month during the past 2-3 months (see notes) and is associated with change in frequency/consistency of stools. Pain improves with defecation, but pt often experiences sensation of incomplete evacuation. Mucous sometimes present in stool, but no hard/bloody/tarry stools. Denies fever, unintentional weight loss, dysphagia/dysphagia, vomiting, back pain, dysuria. No family h/o Celiac disease, IBD. Afebrile and appears anxious on exam.

• Consider CBC, TSH, CRP, ESR

• Rule out Celiac disease: Consider anti-tissue transglutaminase IgA

• Rule out GI bleed/alternative diarrhea etiologies: Consider FOBT and/or fecal ova/parasite testing

• Consider abdominal x-ray

• Pain persisting for >1 year: Consider referral for EGD

Treatment for Pediatric and Adult Patients

• Recommend exercise and CBT

• Diarrhea-predominant symptoms

  • Hydrolyzed guar gum 5g qd

  • Peppermint oil capsules TID

  • Probiotics: Recommended Kefir PO

  • Refractory symptoms

    • Consider loperamide 0.25-0.5 mg/kg/day in 2 divided doses

    • Consider rifaximin 600mg

• Constipation predominant symptoms: See pediatric functional constipation

• Counseling for parents of pediatric patients

  • Parents advised to validate symptoms but avoid reinforcing symptoms with secondary gain, e.g. missing school

  • Parents counseled that symptoms generally resolve over the course of several months

Additional Treatment Options for Adults

• Diarrhea and/or constipation predominant symptoms

  • Antidepressant: Fluoxetine 20 mg qd; increased to 40 mg qd for refractory symptoms

  • Antispasmotic: Dicyclomine (Bentyl) 20 mg 4 times daily x7 days; after 1 week, increase to 40 mg 4 times daily if necessary

• Constipation predominant symptoms

  • Neomycin 4g qd

  • Lubiprostone (Amitiza): Start 8 mcg BID and increase to 24 mcg BID for severe, refractory symptoms

Notes

• Peak onset occurs between 20 and 40 years old

• 1.5 times more common in females

• Diagnosis

  • Based on Rome Criteria that include

    • Recurrent abdominal pain + two or more symptoms at least 1 day per week during the past 3 months

    • Additional symptoms include pain with defecation, change in stool frequency/form, etc.

  • Pediatric patients: Only 2 months of symptoms required vs. 3 months in adults

  • Describe stools using the Bristol Stool Scale

  • Most labs are not useful in diagnosis and should only be considered if history suggests an alternate etiology

Crohn Disease

30 y/o white F presents with history of smoking presents with abdominal pain, diarrhea and intermittent bright red blood per rectum for > 3 months. Abdominal pain is not exacerbated by meals and diarrhea sometimes occurs at night. Reports fever, unintentional weight loss, fatigue, abdominal pain, and arthralgias. Family history of first degree relative with inflammatory bowel disease. Medications include oral contraceptives and daily NSAIDs use. Weight loss > 5% over 3 months, scleral erythema, aphthous stomatitis, perirectal abscess/ulcer/fistula, intravaginal fistula, and erythema nodosum on exam.

• Labs

  • Consider fecal calprotectin to rule out disease

  • CBC shows anemia

  • Obtain CMP, ESR, CRP, urine pregnancy test

  • Obtain ferritin, TIBC, folate level, and 25-hydroxyvitamin D level

  • Obtain stool studies including clostridium toxin A and B, ova & parasites, and stool culture

  • Obtain yearly Pap smear with HPV co-testing due increased cervical cancer risk

• Imaging/Procedures

  • Initial workup

    • Toxic presentation: obtain CT abdomen and pelvis

    • Non-toxic presentation: Refer for colonoscopy with biopsy

  • Obtain colonoscopy every 1 to 3 years after diagnosis

• Treatment

  • Crohn flare: Start prednisone 40 mg daily and taper daily dose by 10 mg/weeks until 20 mg qd and then taper by 5 mg/week until finished

  • Immunomodulators and/or biologics

    • Initiate per GI instruction

    • Administer PCV13 and PPSV23 if started

  • Start iron, vitamin D, and B12 supplementations

  • Administer HPV vaccine

• Referrals

  • Refer to GI

  • Perianal involvement: Refer to colorectal surgery

• Counseling

  • Patient advised that smoking cessations reduces associated complications

  • Patient counseled that she is at higher risk for nutritional deficiencies, osteoporosis, anemia, and thromboembolic events (e.g. DVT), and malignancy

Notes

• Smoking, OCPs, and regular NSAID use increase risk for conditions

• Patients diagnosed at age < 30 years often suffer greater complications

• Increased risk for cervical, biliary tract, colorectal, and skin malignancies

• Physical exam

  • Anterior uveitis and episcleritis (scleral erythema) may be present

  • Lesions may occur at any point along the GI tract

  • Fistulas from GI tract to vagina may form

Ulcerative Colitis (UC)

Young adult with h/o recent abdominal infection presents with chronic abdominal pain. Pain associated with bloody diarrhea. ROS positive for blurred vision, arthritis. Reports diet rich in meats/fats and family h/o UC. Uveitis, aphthous stoma on exam.

• Labs

  • Obtain CBC, ESR, CRP, FOBT, bacterial stool culture

  • Recent antibiotic use: Obtain C. difficile toxin PCR

  • Recent consumption of under-cooked beef: Obtain stool cx for E. coli O157:H7

• Endoscopy/colonoscopy reveals contiguous inflammation limited to colonic mucosa; biopsy consistent with UC

• Treatment: Refer to GI

  • Mesalamine

    • Disease limited to rectum: Start mesalamine 1g rectal suppository qhs

    • Extensive disease: Start mesalamine (Asacol HD) 1.6 g TID x4 weeks; continue 800 mg TID for maintenance of remission

  • Symptoms refractory to 5-ASA: Start budesonide (Uceris) 9 mg qd x8 weeks; consider adding probiotic E. coli 1917

  • Symptoms refractory to budesonide: Consider infliximab (Remicade) 5 mg/kg IV at weeks 0, 2, and 6; continue q8 weeks thereafter

  • Consider azathioprine 2 mg/kg/day for maintenance of remission

• Counseling

  • Pt encouraged to call if experiencing fever, severe abdominal pain, 7 or more stools daily, and/or GI bleeding

  • Pt advised that cases of severe UC  (>7 stools/day and elevated ESR) will require hospital admission for treatment with IV corticosteroids and/or surgical intervention

  • Pt counseled that she is at greater risk for cervical CA and osteoporosis

  • Pt counseled that UC increases risk for colon CA and that regular colonoscopies will be started within 10 years of diagnosis

Notes

• Risk factors for UC include family history, living at higher latitudes in Western nations, diets high in meat/fat, and recent abdominal infection

• UC-associated complications include uveitis (4%), aphthous stomatitis (4%), and arthritis (21%)

• Normal ESR and CRP do not r/o UC

• Medications

  • Mesalamine suppositories are more effective than oral formulations

  • Probiotic E. coli 1917 was shown to be as effective as mesalamine for achieving symptom remission

  • Azathioprine is a mercaptopurine derivative that acts to halt DNA replication

Celiac Disease

Pt with family h/o Celiac disease presents with acute, recurrent abdominal pain. Reports weight-loss, fatigue, N/V, recurrent mouth ulcers, abdominal bloating, diarrhea. Food diary shows symptom correlation with gluten-containing foods. Herpetiform rash on exam.

• Initial diagnosis: Pt advised to keep a food diary/symptom log

• Labs

  • Obtain CBC to r/o anemia

  • Anti-tissue transglutaminase IgA >10x ULN

  • Total IgA level WNL

  • Consider HLA DQ2, HLA DQ8, endomysial antibody testing

• Elevated Anti-tissue transglutaminase IgA: Refer for endoscopy with duodenal biopsy

• Counseling

  • Pt educated about elimination of dietary gluten including wheat, rye, and barley products

  • Recommend Celiac Disease Foundation’s guide to eating gluten free

Notes

• Total IgA must be obtained to rule out IgA deficiency

• Intestinal symptoms are significantly more common extraintestinal manifestations, e.g. dermatitis herpetiformis, anemia

Acute Appendicitis

8 y/o pt presents with acute onset abdominal pain. Pain started 24 hours ago in periumbilical region with radiation to RLQ. Pain now localized in RLQ and worse with coughing, movement. Reports anorexia, N/V. Fever, decreased bowel sounds, abdominal rigidity/guarding, RLQ pain with rebound tenderness on exam; positive psoas, obturator, and Rovsing signs.

• Labs

  • CBC shows leukocytosis (WBC >10,000) with left shift (ANC >7,500)

  • Obtain CMP, CRP

  • Consider obtaining APPY1 panel, U/A, and/or beta-hCG

• Imaging

  • Obtain abdominal ultrasound

  • Equivocal abdominal ultrasound: Consider clinical re-evaluation in 12 hours vs. abdominal CT with IV contrast pending calculated appendicitis risk (see below)

• Calculate risk for appendicitis:

  • Children: Pediatric Appendicitis Score

  • Adults: Appendicitis Inflammatory Response Score

• Appendicitis suspected

  • Consult surgery

  • Morphine 0.1 mg/kg for pain control

  • Monitor for wound infection/post-surgical complications s/p procedure

• Pt counseled that even with appropriate care, perforation occurs in ~20% of patients

Notes

• Special populations

  • Appendicitis is less common in patients younger than 5 and may present differently

  • Appendix location changes during pregnancy and may alter exam findings

• Exam maneuvers

  • Psoas sign: Pain elicited when pt lies on left side and examiner straightens and extends extends the R leg

  • Obturator sign: Pain with passive internal rotation of L thigh

  • Rovsing sign: RLQ pain with palpation of LLQ

• Labs/Imaging

  • A normal WBC does not rule out appendicitis

  • Absolute neutrophil count (ANC) = [WBC * (% segmented neutrophils + % segmented bands)] * 10

  • APPY1 panel

    • Includes WBC, CRP, and myeloid reactive protein

    • Has prognostic value when combined with U/S, but may not be readily available some institutions

  • Choosing wisely: Avoid CT as first line imaging modality in pediatric patients

• Treatment

  • New evidence suggests that uncomplicated cases can be treated with antibiotics; however, 40% of patients still require surgery within 1 year of treatment

  • Morphine does not increase perforation risk, but may only provide pain relief equivalent to placebo

  • Prompt surgical consult reduces perforation risk

Diverticulitis

40 y/o F with h/o low-fiber intake and diverticulosis presents in summer with acute onset abdominal pain. Reports fever, anorexia, nausea, LLQ abdominal pain (LR 3.3), dysuria. Denies vomiting (LR 1.4), regular physical activity. Medications include NSAIDs, steroids, and chronic PO analgesics. Obese with fever (LR 1.4), abdominal distention, and LLQ pain (LR 10.4) on exam. Hypoactive bowel sounds, abdominal rigidity, and rebound tenderness concerning for peritonitis.

• Labs

  • Obtain BMP, U/A

  • CBC shows leukocytosis

  • C-reactive protein >50 mg/L

• Imaging

  • Abdominal/pelvic CT with contrast shows inflamed diverticulum, arrowhead sign, fascial thickening, and free air

    • Abscess present: Consult for CT-guided percutaneous drainage; send aspirate for culture

    • Bowel obstruction, abscess, and/or perforation: Consult surgery and calculate mortality risk using Mannheim Peritonitis Index

  • Complicated disease: F/u 4-6 weeks s/p symptom resolution for colonoscopy

• Treatment

  • Unable to tolerate PO, concern for complicated diverticulitis, and/or s/sx peritonitis: Admit  inpatient

  • NS at 125 cc/hr while NPO

  • Start metronidazole 500 mg IV q8 hours; transition to PO at discharge

  • Start ceftriaxone 2g IV qd; transition to ciprofloxacin 750 mg BID at discharge

• Counseling

  • Pt advised that 30% of patients require abdominal surgery while admitted

  • Pt counseled that dietary fiber, exercise, weight loss, and smoking cessation can help prevent future episodes

  • Pt counseled that avoiding nuts, corn, and popcorn will not reduce risk of future episodes

Notes

• Epidemiology

  • Diverticulitis admissions are more common during summer months

  • Women at 2x greater risk for complications

  • Chronic NSAIDs, corticosteroid, and/or opioid analgesics increase perforation risk

• Diagnosis

  • Localized LLQ pain is the most predictive physical exam finding (LR 10.4)

  • Arrowhead sign: Triangular colonic wall thickening pointing to diverticulitis

• Severity

  • Complicated diverticulitis

    • Associated with one of the following diagnoses: Obstruction, phlegmon, abscess, fistula, perforation

    • Indication for hospitalization and IV antibiotics

    • Refer to a local antibiogram due to increasing E. coli resistance against fluoroquinolones and some 3rd generation cephalosporins

  • Uncomplicated diverticulitis:

    • Does not meet qualifications for complicated diverticulitis (>90% of cases)

    • Can be managed outpatient with rest and fluids

    • Antibiotics do not improve outcomes

Small Bowel Obstruction

Pt with h/o abdominal hernia, irritable bowel disease, intra-abdominal malignancy, and abdominal surgery presents with acute onset, generalized abdominal pain. Reports N/V. No flatus, bowel movement since abdominal pain began. Fever, abdominal distention, hypoactive high-pitched bowel sounds, tympany with abdominal percussion on exam.

• CBC shows leukocytosis

• CMP shows hypokalemic, hypochloremic metabolic alkalosis

• Obtain serum lactate

• Abdominal CT with IV contrast shows dilated small bowel loops proximal to obstruction with air-fluid levels >2.5 cm long and located at different heights within the same bowel loop (step-ladder distribution)

  • Uncomplicated bowel obstruction: Initiate bowel rest, abdominal exams q8 hours

  • Complicated bowel obstruction with evidence of vascular compromise, perforation, and/or closed loop obstruction: Obtain immediate surgical consult

• Start normal saline at 125 cc/hr

• Replete electrolytes

• Fever and leukocytosis: Start metronidazole 500 mg IV q8 hours, ciprofloxacin 400 mg IV BID

• Significant N/V and/or abdominal distention: Initiate decompression with NG tube

• Presence of intra-abdominal malignancy: Consult hematology/oncology

• Diet: NPO

Notes

• Greatest risk factor is mechanical occlusion

  • Up to 75% of cases are due to surgical adhesions

  • Hernia, luminal masses due to IBD, and malignant may serve as nidus for obstruction

• Strangulated hernia can lead to vascular compromise

• Closed loop obstruction etiologies include intestinal volvulus

Mesenteric Ischemia

Pt >60 y/o with h/o CAD, AFib, PAD, ESRD, hypercoagulability, and smoking presents with paroxysmal abdominal pain out of proportion to physical exam. Pain worse after eating and/or snorting cocaine. Receives outpatient dialysis three times weekly and is s/p recent vascular surgery including CABG. Fever, tachycardia, tachypnea, leukocytosis, JVD, bilateral lung crackles, irregularly irregular heart rhythm, diffuse abdominal tenderness to palpation, and LE pitting edema on exam.

• Obtain CBC, CMP, lactic acid

• FOBT negative

• Obtain magnetic resonance angiography

• Treatment

  • Consider GI decompression

  • Start normal saline at 125 cc/hr

  • Start IV morphine 3 mg q4h PRN pain control; titrate as necessary

  • Etiology specific

    • Arterial occlusion identified: Consult surgery for potential laparotomy with embolectomy

    • Non-occlusive: Eliminate vasoconstricting medications and consider starting nitroglycerin 0.4 mg sublingual for acute pain

  • Start anticoagulation with apixaban (Eliquis) 5mg BID

Notes

• Risk factors

  • Conditions that reduce peripheral circulation, e.g. sepsis, HF

  • CABG → transient hypoperfusion during procedure and increased risk for thromboemboli

  • Cocaine → vasoconstriction

  • Dialysis increases risk for non-occlusive mesenteric ischemia

• Intestinal bleeding is uncommon early in the disease process

• Start vasodilating agents if needed, but avoid vasoconstricting agents that may reduce blood supply

External Hemorrhoid

Pt with h/o constipation/straining presents with rectal bleeding. Hemorrhoid visible on exam.

• Refer for colonoscopy due to [FOBT+, iron deficiency anemia on CBC]

• Age>50 and no colonoscopy within the past 10 years: refer for colonoscopy

• Age>40 and no colonoscopy within the past 10 years with one 1st degree relative diagnosed with colorectal CA prior to age 60: refer for colonoscopy

• Age>40 and no colonoscopy within the past 5 years with more than one 1st degree relative diagnosed with colorectal CA prior to age 60: refer for colonoscopy

• Topical nifedipine/lidocaine for pain relief

• Stool softener, fiber supplementation

• Discussed importance of adequate fluid intake

• Refer to surgery: Concern for thrombosis due to acute onset of severe pain

Abdominal Wall Hernia

Pt with h/o abdominal surgery presents with paroxysmal epigastric/umbilical discomfort. Pain occurs at site of protrusion extending from the abdominal wall; worse with coughing/straining. Denies fever, chills, anorexia, unintended, weight loss, change in bowel habits, diarrhea, dark/tarry stools, BRBPR. Abdominal wall protrusion reducible and resolves while pt is supine.

• CBC WNL

• Obtain ultrasound if unsure of diagnosis

• Non-incarcerated: Refer to general surgery for elective repair

• Pt counseled that smoking cessation, weight loss to achieve BMI <50 kg/m^2, and glucose control to achieve HbA1c <8% may be required prior to elective surgery

• Pt advised to contact provider if experiencing acutely increased abdominal pain associated with constipation and/or a non-reducible protrusion

Notes

• Hernias can cause pain even without palpable protrusion in exam

• Location of common hernia types

  • Associated with abdominal pain: Ventral midline

  • Sports hernias caused by twisting motion: Groin

• A CBC may be obtained if there is concern for a rectus sheath hematoma (rare)

Hepatitis B

Acute Infection

Health care professional with h/o HIV, IV drug use presents with acute onset jaundice. Reports recent needlestick at work and episode of sexual assault. ROS positive for fatigue, poor appetite, N/V, abdominal pain, and dark urine. Denies h/o hepatitis B vaccination. Low-grade fever, jaundice, RUQ tenderness, hepatosplenomegaly on exam.

• Labs

  • Positive HBsAg, anti-HBc, IgM anti-HBc

  • Negative anti-HBs

  • Obtain CBC, CMP, PT/INR

  • Obtain HBeAg, anti-HBe

  • Obtain HAV Ab, HCV Ab, hepatitis D Ab, HIV (ELISA Ag/Ab)

• Imaging: Obtain RUQ U/S

• Treatment: Refer to GI

  • Healthcare worker with needlestick exposure to HBV positive blood: Administer hepatitis B immunoglobulin and start hepatitis B vaccine series if not vaccinated

  • Newly diagnosed disease in HBeAg negative pt: Retest HBeAg in 6 months to determine if seroconversion to HbeAg positive state has occurred (see below for treatment of chronic hepatitis B)

  • Negative HAV Ab: Administer hepatitis A vaccine now and again in 6 months

  • Administer hepatitis B vaccine to other household members and any sexual contacts

• Counseling

  • Transmission

    • Pt informed that HBV can be spread via intercourse, exposure to blood of an infected individual, and sharing personal items such as a toothbrush or razor

    • Pt reassured that HBV is not spread by casual contact (e.g. sharing food, kissing) or breastfeeding

  • Pt advised to stop drinking alcohol

  • Pt counseled that monitoring will include regular liver enzyme and HBV DNA level testing

Chronic Hepatitis B Evaluation and Treatment

Evaluate for

• History of co-infection with HCV, HIV

• Personal/family h/o liver disease

• History of alcohol use

• Signs/symptoms active cirrhosis

  
  

Labs

• Obtain HbsAg, anti-HBc, IgM anti-HBc, anti-HBs

• Obtain HBeAg, anti-HBe, HBV DNA, and HBV genotype

• Obtain HAV IgG, HCV Ab, hepatitis D Ab, HIV (ELISA Ag/Ab)

• Evaluate liver function: Obtain CBC with diff, CMP, PT/INR

Referrals and Monitoring

• Refer to GI for further evaluation

  • Pt informed that further workup/treatment may include liver biopsy, anti-viral therapy, and/or liver transplant

  • Counseling: See acute hepatitis B infection (above)

• Yearly monitoring for cirrhosis: Obtain alpha-fetoprotein levels and RUQ ultrasound with liver elastography

• Refer pt to surveillance program for hepatocellular carcinoma

Treatment

• Treatment for patients without cirrhosis

  • HBeAg positive six months after initial diagnosis

    • ALT <2x ULN: Continue to monitor

    • ALT >2x ULN: Start tenofovir 300 mg qd and obtain HBeAg, anti-HBe monthly; continue for 4 months s/p conversion to anti-HBe positive state

  • HbeAg negative, HBV DNA >2,000 IU, and ALT > 2x ULN: Start tenofovir 300 mg qd and consider continuing treatment indefinitely

• Treatment for patients with cirrhosis and HBV DNA >2,000 IU: Start tenofovir 300 mg qd and continue indefinitely

• All other patients: Continue to monitor and/or defer to GI recommendations

Notes

• Acronyms: HAV, (hepatitis A virus), HBV (hepatitis B virus), HCV (hepatitis C virus), Ag (antigen), Ab (antibody)

• Screening

  • In general, all patients born in Africa and mainland Asia should be screened; see the CDC Yellow Book for all nations with a >2% infection list that qualify for screening

  • Common risk factors: Dialysis, immunosuppression, increased exposure (e.g. men who have sex with men, IV drug users)

  • Standard screening tests: HBsAg and anti-HBc

• Acute hepatitis B

  • Liver failure occurs in 1% of patients

  • Risk for progression chronic disease is greatest in infants (90%) and decreases with age; only 5% of adults progress to chronic disease

• Chronic hepatitis B

  • Considered chronic when infection persists >6 months

  • Each year, 1 in 400 HBV carriers die due to liver complications

  • Ultimate goal of treatment is to prevent initiation/progression of cirrhosis

    • Patients without cirrhosis: Initiation primarily determined by seroconversion to anti-HBe and evidence of liver damage

    • In cirrhosis patients: Initiation determined by evidence of active disease

• CDC overview of hepatitis B for health professionals

Chronic Liver Disease (Cirrhosis)

Pt with h/o alcoholism, chronic viral hepatitis, NAFLD, DM type 2, autoimmune disease presents to establish care. Reports recent anorexia, weight loss, weakness, fatigue, abdominal fullness, pruritus. Fever, confusion, gynecomastia, abdominal distention, caput medusa, flank dullness with percussion, splenomegaly, Dupuytren's contracture, jaundice, spider angiomata, palmar erythema, asterixis on exam.

• Labs

  • Liver function

    • Obtain CBC, CMP, GGT, PT, PTT, INR

    • CMP shows AST and ALT 2x ULN (consistent with values 6 months prior), elevated bilirubin

  • Hepatitis B screening

    • Obtain hepatitis B surface antigen (HBsAg)

    • If HBsAg positive: Obtain HBsAg antibodies (anti-HBs) and hepatitis B core antigen (anti-HBc)

  • Hepatitis C screening: Obtain HCV antibody test; if positive, obtain HCV RNA test

  • Concern for hepatic encephalopathy: Obtain ammonia level

• Imaging

  • Ultrasound

    • RUQ U/S shows liver nodularity, irregularity, increased echogenicity, atrophy

    • Abdominal U/S shows abdominal ascites

    • Consider Doppler U/S of portal and hepatic veins

  • Consider abdominal CT to establish baseline assessment of hepatic nodules

  • Consider EGD to assess for esophageal varices

• Treatment

  • Hepatic encephalopathy (hypersomnia, asterixis): Start lactulose 20 mg TID and titrate to 4 bowel movements daily

  • Beta blockers

    • Esophageal varices on EGD: Start nadolol 40 mg daily

    • Stop beta-blockers for MAP < 82 mmHg

  • Ascites

    • Limit sodium intake to < 2,000 mg daily

    • Start Bumex 1 mg daily

    • Paracentesis with > 5L fluid removed: Administer 6g albumin for each liter of fluid removed

  • Spontaneous bacterial peritonitis: Admit to hospital

    • Obtain ascitic fluid culture and PMN count

    • Obtain blood, urine, sputum culture

    • Start IV cefotaxime 2g q 8 hours

    • Administer IV albumin 1.5 g/kg for BUN > 30 mg/dL, Cr > 1 mg/dL, and/or bilirubin > 4 mg/dL

• Referral

  • Consider liver biopsy to definitively establish diagnosis

  • Refer to GI to establish care

  • Concern for esophageal varices: Refer for EGD

  • MELD score ≥ 15: Consider referral to transplant center

• Counseling

  • Stop drinking alcohol

  • Three month mortality rate per MELD score

  • Risk for ascites, spontaneous bacterial peritonitis, portal HTN leading to variceal bleeding and/or hepatorenal syndrome, hepatic encephalopathy

Notes

• DM type 2 is a risk factor for NAFLD

• Labs

  • Liver enzymes 2x ULN for 6 months is strongly correlated with cirrhosis on biopsy

  • If liver enzymes are normal and cirrhosis is suspected, consider ANA, anti-smooth muscle antibody

  • Anti-smooth muscle antibody is correlated with autoimmune hepatitis

  • Ammonia levels

    • Should only be obtained in the setting of altered mental status

    • Are not sufficient for the diagnosis if hepatic encephalopathy

• Protein-restricted diets do not improve encephalopathy

Abdominal Ascites

Pt with h/o liver cirrhosis, right HF, Budd-Chiari syndrome, portal vein thrombosis presents with abdominal fullness. Reports weight gain, shortness of breath, early satiety. Weight increased from baseline, decreased breath sounds, flank dullness, abdominal fullness, shifting abdominal dullness/fluid wave on exam.

• Obtain CBC, CMP, GGT, PT, PTT, INR

• Abdominal U/S shows large-volume ascites

• Obtain Doppler U/S of hepatic/portal veins

• Paracentesis

  • Perform diagnostic/therapeutic paracentesis

  • Send ascitic fluid for differential leukocyte count, total protein level, a serum-ascites albumin gradient, fluid cultures

  • SAAG >1.1/dL indicating high likelihood of portal hypertension

  • Paracentesis >5L; consider albumin 10g/L albumin infusion

• Treatment

  • Start oral spironolactone 100mg qd and titrate to 400mg/day

  • Consider adding furosemide 40mg/day and titrating to 160mg/day for refractory ascites

  • Serum sodium <125 mEq/L; fluid restrict to 1.5L/day

  • Refractory ascites and

    • May require transplant: Consider TIPS procedure

    • Not a candidate for paracentesis, TIPS, transplant: Consider peritoneovenous shunt

  • Pt advised to abstain from alcohol, restrict sodium to 2g/day

Notes

• 85% of abdominal ascites is due to portal hypertension

• SAAG = serum-ascites albumin gradient = serum albumin - ascitic fluid albumin

• For SAAG <1.1/dL; evaluate for peritoneal carcinomatosis vs. pancreatic ascites

Spontaneous Bacterial Peritonitis

Pt with h/o cirrhosis, ascites presents with abdominal fullness, malaise. Reports fever, abdominal pain, confusion. Fever, hypotension, altered mental status, gynecomastia, abdominal tenderness, hepatomegaly on exam.

• Obtain CBC, CMP, GGT, PT, PTT, INR

• Abdominal U/S performed prior to antibiotic administration shows ascites

  • Ascitic fluid sent for differential leukocyte count, total protein level, a serum-ascites albumin gradient, fluid cultures

  • Ascitic fluid neutrophil count > 250/mL: Start empiric cefotaxime 2g q8h

• Treatment after starting empiric antibiotics

  • Concern for hepatorenal syndrome: Continue to monitor

  • Administer albumin 1.5g/kg within 6 hours of diagnosis and 1g/kg on day 3

  • Discharge with prophylactic Bactrim SS (400mg SMX + 80mg TMP) daily

• Patient counseling

  • Abstain from alcohol

  • Long-term therapy may involve liver transplant

Notes

• Bactrim or norfloxacin ppx recommended for patients who survive episode of SBP

• Ascitic fluid neutrophil count > 250/mL is diagnostic of SBP and an indication for starting empiric antibiotics

Hepatic Encephalopathy

Pt with h/o liver cirrhosis, portal hypertension presents with acute onset confusion. Family reports recent changes in memory, personality, concentration. Denies recent head trauma. Normal SPO2, impaired attention, decreased decreased response time bradykinesia, hyperreflexia, rigidity, myoclonus, asterixis on exam. MMSE score <24.

• Obtain CBC, CMP, fingerstick, ammonia level, ABG, FOBT

• Head CT shows no signs of intracranial bleed or acute pathology

• Eliminate sedating medications

• Start lactulose 30mL PO TID; titrate to 3 BMs/day, max dose 300mL/day

• Confusion continues with lactulose 300mL/day; start neomycin 4g q6h; titrate to 12g q6h

• Condition refractor to lactulose, neomycin; consider starting flumazenil

• Pt advised to abstain from alcohol

• Pt counseled that long-term therapy may involve liver transplant

Notes

• Hepatic encephalopathy may be exacerbated by endogenous benzodiazepines

• Flumazenil is a benzodiazepine receptor antagonist

• Protein restricted diet does not improve symptoms

Hepatorenal Syndrome

Pt with h/o alcohol abuse, liver cirrhosis, portal HTN presents with elevated serum creatinine. Reports recent oliguria. No history suggestive of nephrotoxic drug use, shock, infection, significant recurrent fluid loss. Gynecomastia, hepatomegaly, caput medusa on exam.

• Obtain CBC, CMP, U/A, urine osmolality/sodium/protein; strict I&Os

• Serum sodium <130, creatinine >1.5, creatinine clearance <40

• U/A with <50 RBCs per HPF

• Urine osmolality > plasma osmolality, urine sodium <10

• No sustained improvement in renal function s/p discontinuation of diuretics, 1.5L isotonic saline bolus

• Renal U/S shows no evidence of obstruction/parenchymal disease

• Start midodrine 2.5mg IV and IV octreotide to achieve MAP increase of 15 mmHg or more

• Consider dopamine 2 mcg/kg/min IV to induce renal vasodilation

• Consider TIPS to reduce portal HTN

• Pt advised to abstain from alcohol

• Pt counseled that median survival is 3-6 months

• Pt counseled that long-term therapy may involve liver transplant

Notes

• Hepatorenal syndrome = functional renal failure in cirrhotic patients in the absence of intrinsic renal disease

• Cirrhosis } portal hypotension } splanchnic vasodilation } decreased systemic circulation } renal vasoconstriction } decreased renal blood flow, GFR, urine output } azotemia } sodium/water retention

• Midodrine is an alpha-1 agonist

• MAP = mean arterial pressure = 1/3(systolic BP) + 2/3(diastolic BP)

• TIPS = transjugular intrahepatic portosystemic shunt

Acute Cholecystitis and Complications

40 y/o Native American F with h/o DM, HLD, grand multiparity presents with acute on chronic abdominal pain. H/o similar relapsing/remitting pain x2 years. Now experiencing sudden onset, steady RUQ pain that started s/p consuming a fatty meal, has lasted >6 hours, and was not relieved by a bowel movement. Endorses chills and initially tried NSAIDs for pain relief with positive effect. PMH includes rapid weight cycling. Medications include OCPs. Fever, obesity, and positive Murphy’s sign on exam.

• CBC shows leukocytosis

• Obtain CMP, amylase, lipase, and total bilirubin levels

• Imaging

  • Initial U/S shows bile duct dilation

  • Equivocal U/S with suspicion for acute cholecystitis: Obtain CT with contrast to confirm diagnosis and rule out complications, e.g. perforation

  • CT contraindicated: Consider HIDA vs. magnetic resonance cholangiopancreatography (MRCP)

• Ketorolac 10 mg q4 hours as needed for pain; maximum duration of therapy = 5 days

• Surgery c/s recommends laparoscopic cholecystectomy (CCY) within 72 hours of admission

Choledocolithiasis with suspected cholangitis +/- gallstone pancreatitis:

• Development of jaundice, hypotension, and altered mental status since admission

• NS at 125 cc/hr while NPO

• Start metronidazole 500 mg IV q8 hours and ceftriaxone 2g IV qd

• Suspect pt will benefit from endoscopic retrograde cholangiopancreatography (ERCP); consult GI

Notes

• Risk factors for gall stones include ethnicity, female gender, and medical history including pregnancies (fat, female, forty, fertile and from the Americas)

• Murphy’s sign: Pain that causes pt to stop inhaling while examiner palpates RUQ

• Biliary colic

  • Pain due to intermittent impaction of gallstones against gallbladder neck; usually resolves after 1-5 hours

  • Two-thirds of patients will progress to acute cholecystitis within 2 years

  • Elective cholecystectomy should be considered after more than one occurrence

  • Antibiotic ppx is not required in low risk patients undergoing elective CCY

• Choledocolithiasis

  • Obstruction of bile duct by gallstone → bacterial infection → complications

  • Bacterial infection within bile duct (cholangitis) may present with

    • Charcot’s triad: Fever, abdominal pain, jaundice

    • Renaud’s pentad: Charcot’s triad + hypotension and altered mental status

Acute Pancreatitis

Pt >55 y/o with h/o alcoholism, biliary colic presents with sudden onset epigastric abdominal pain radiating to the back. Reports N/V, recent abdominal trauma. Current medications include estrogen HRT, furosemide, valproic acid, azathioprine, sulfonamide/tetracycline abx. Scleral icterus, decreased bowel sound, abdominal tenderness/guarding on exam. Positive Cullen and Grey-Turner sign.

• Clinical dx of pancreatitis due to abdominal pain + serum amylase and/or lipase* 3x ULN

• Suspected alcoholic pancreatitis due to Lipase/amylase >4; obtain Mg2+ and phosphorus levels

• Obtain initial CBC, CMP, LDH, lipid panel, U/A

• CBC, CMP (BUN, glucose, CA), Mg2+ q12h for 48h s/p admission

• Perform u/s exam; consider f/u with contrast CT

• Treatment

  • Initial 20mL/kg LR bolus over 1hr, then 300mL/hr x48hr; maintain UOP > 0.5mL/kg

  • IV morphine 2mg q2h; titrate per sx

  • Initial bowel rest; consider NJ nutrition if prolonged bowel rest required

  • Transition to PO fluid, low fat diet when pain controlled

  • >30% necrosis on CT: Start abx ppx with imipenem/cilastatin

• Procedures

  • Suspected gallstone; consult GI for ERCP and consider cholecystectomy

  • Infected necrosis/persistent fluid collections on CT; c/s for CT-guided aspiration vs. surgical debridement

  • Monitor for 48-72 hours; evaluation/prognosis per Atlanta, BALI, Ranson, or APACHE II criteria

Notes

• Imipenem/cilastatin (Primaxin IV) decreases pancreatic necrosis infection, but does not decrease mortality

Chronic Pancreatitis

45 y/o pt with h/o alcoholism, documented genetic disorder, autoimmune disease including IBD, previous radiation therapy to abdomen presents with acute on chronic abdominal pain. New onset midepigastric postprandial pain that radiates to the back; some relief with sitting upright/leaning forward. Reports pale, foul-smelling, bulky, and difficult to flush stools. Weight loss, jaundice on exam.

• Obtain CBC, CMP, amylase, lipase, lipid panel
  Suspected autoimmune pancreatitis; obtain IgG4 serum antibody, ANA, rheumatoid factor, ESR

• One time screen for vitamin D deficiency

• Contrast CT showing pancreatic ductal calcifications; f/u mass lesions/weight loss/jaundice suspicious for malignancy with EUS + FNAB

• Presence of complicated/symptomatic pseudocyst and biliary/pancreatic duct obstruction; perform ERCP

• Pancreatic duct >7mm (large duct disease); consider pancreaticojejunostomy

• Pancreatic head enlargement noted; consider pancreatoduodenectomy (Whipple)

• Pain control with Tylenol, NSAID, narcotics

• 40,000u lipase for steatorrhea and malabsorption

• Start PPI to reduce pancreatic enzyme deactivation by gastric acid

• .dmrx for control of DM

• Pt counseled about low fat diet, small meals for pain control

• Pt encouraged to consider alcohol, tobacco cessation

• Refer to GI

Note: Serum lipase, amylase are not specific for chronic pancreatitis

Pancreatitis Evaluation

Atlanta Criteria for Acute Pancreatitis

• Mild

  • No organ failure, no local complications (fluid collection/necrosis), no systemic complications

  • Typically resolves in first week

• Moderate if one of the following:

  • Transient organ failure (≤ 48 hours)

  • Local complications

  • Exacerbation of co-morbid disease

• Severe: Persistent organ failure

BALI Criteria

1 point for each; obtain labs within 48h of admission

• Blood urea nitrogen level ≥ 25 mg per dL (8.9 mmol per L)

• Age ≥ 65 years

• Lactate dehydrogenase level ≥ 300 U per L (5.0 μkat per L)

• Interleukin-6 level ≥ 300 pg per mL

Mortality rates

• +3 (>25%)

• +4 (>50%)

Ranson Criteria

At admission (1 point for each):

• Age >55

• Blood glucose >200

• WBC >16,000

• AST >250

• LDH >350

Within 48 hours (1 point for each):

• Serum Ca <8

• Hematocrit drop >10%

• PaO2 <60 mmHg

• BUN increase >5

• Base deficit > 4

• Fluid sequestration >6L

Mortality prognosis

• 0-2 (2%)

• 3-4 (15%)

• 5-6 (40%)

• 7-8 (100%)