GI Board Review with Questions (Part One): GERD, Dysphagia, Eosinophilic Esophagitis (EOE), Viral hepatitis, Drug-Induced Liver Injury (DILI), Alcoholic Liver Disease, Gl disorders of pregnancy

GERD

A condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications 

The Montreal Definition 2006

• 20% of adults have heartburn 21 time/week
• Presentation: Most commonly "Heartburn” substernal chest burning, often accompanied by regurgitation, belching or dysphagia.
• Risk factors: Obesity, Pregnancy, Smoking, Collagen Vasc Dz, EtOH use, Hiatal Hernia

Atypical manifestations of GERD

Reflux into esophagus

• Chest pain 

Reflux into oropharynx

• Globus 
• Sore throat 
• Burning tongue 
• Dental erosions
• Sinusitis 

Reflux into airway

• Laryngitis 
• Chronic cough
• Asthma

Complications of GERD

• Erosive Esophagitis
• Stricture Formation
• Barrett's Esophagus
• Loss of Dental Enamel 
• Laryngeal Cancer 
• Aspiration Pneumonia 
• Pulmonary Fibrosis 
• Chronic Asthma 
• Vocal Cord Granulomas 
• Chronic Sinusitis
• Bronchiectasis

Diagnosis of GERD

Empiric Therapy as a diagnostic test
EGD - good for looking at complications but not as diagnostic tool of reflux
pH study:

• 24 hour pH probe
• Bravo wireless pH monitoring system 

Barium study
good for dysphagia, not so for reflux

Esophagitis

Dysphagia - Structural vs dysmotility

Structural 

Progressive 

Solids 1st then liquids 

Differentials

• Schatzki's Ring 
• Stricture from injury - GERD, caustic, radiation 
• Malignancy
• Eosinophilic esophagitis (EOE) 

Work-up

• Barium Swallow 
• Upper Endoscopy

Achalasia

Characterized by: 

• Incomplete relaxation of the LES 
• Lack of peristalsis in the esophageal body
• Often also seen a hypertensive LES 
• Pathologically see ganglionic drop-out at LES
• Classic presentation is increasing dysphagia to both liquids and solids with regurgitation (Often with wt loss, chest pain)
• Some risk for esophageal cancer - Squamous ca

Diagnosis

Treatment of Achalasia

Low Risk Patient 

• Heller myotomy
• Pneumatic dilation 
• POEM ( Per Oral Endoscopic Myotomy)

High Risk Patient 

• Botulinum toxin injection into LES

Barrett's esophagus

• A condition in which metaplastic columnar epithelium that predisposes to cancer development replaces stratified squamous epithelium that normally lines the distal esophagus 
• Affects 5.6% of adult Americans 
• Cancer risk in non-dysplastic Barrett's: estimate: 0.25% per year (1 in 400 patients per year)

Barrett's esophagus - risk factors

• Chronic GERD, Heartburn, hiatal hernia 
• Age >50 years 
• Male sex 
• White race 
• Central Obesity-Intra-abdominal fat distribution 
• Smoking 
• Family history

Eosinophilic Esophagitis (EOE)

Eosinophilic esophagitis is a chronic, immune-mediated esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.

Eosinophils infiltrate esophageal squamous epithelium, releasing secretory products that mediate:

• Tissue damage - linear furrows, edema, exudates
• Tissue remodeling - strictures, rings
• Symptoms - dysphagia

Diagnosis

15 eosinophils/HPF on esophageal biopsy

Eosinophilic Esophagitis (EoE) endoscopic findings

Symptoms - Non-specific

Children 

• Vomiting 
• Feeding intolerance 
• Feeding aversion 
• Failure to thrive

Adults 

• Dysphagia: Food Impaction 
• Chest Pain 
• Heartburn 
• Upper abdominal pain

Treatment of eosinophilic Esophagitis (EOE)

• PPI BID 8 weeks, re-scope - If clinical ,endoscopic and histologic response - PPI responsive esophageal eosinophilia (PREE) 
• Steroid - Fluticasone or budesonide slurry 
• SFED ( Six food elimination diet ) - wheat, dairy, eggs, soy, sea food, nut 
• Endoscopic dilation

Question

70-year-old woman presents to your office complaining of dysphagia and a 20-16 weight loss during the preceding 6 months. She has a 40 pack-year smoking history, drinks 1 shot of bourbon daily, and has had a longstanding history of GERD but has not complied with PPI therapy. She is obese and has tried to lose weight in the past, but her current weight loss is unintentional Upon review of her chart, you discover that she also has a history of achalasia. You suspect that she may have esophageal cancer. In addition to her cigarette smoking and alcohol use, which of her risk factors suggests that she has a squamous-cell carcinoma rather than an adenocarcinoma?

A. Obesity 

B. GERD symptoms 

C. Noncompliance with PPI therapy

D. History of Achalasia

E. Older age

Answer

D. History of Achalasia

Question

A 42-year-old woman complains of hoarseness for the past 6 months, Two weeks ago, she was evaluated by an ENT physician who diagnosed laryngopharyngeal reflux (LPR) and prescribed omeprazole 20 mg QD. She has taken the medication every day since, but she is no better. A physical examination and routine blood tests are normal. Which of the following is the best management strategy at this time:

A. Add ranitidine 300 mg HS 

B. Continue omeprazole 20 mg QD

C. Add metoclopramide 10 mg QID

D. Increase omeprazole to 20 mg BID. re-evaluate in 3 months

Answer:

D. Increase omeprazole to 20 mg BID. re-evaluate in 3 months

Question

A 52-year-old white man who has had heartburn for 7 years requests you to refer him to gastroenterologist because he recently read a magazine article saying that people with chronic heartburn should have an endoscopy to prevent esophageal cancer. He has been treating himself with antacids, which usually provide good relief of his heartburn. He is otherwise in good health, and he denies dysphagia, weight loss and anorexia. Family history is unremarkable. Endoscopy in this patient is most likely to show which of the following:

A. Vertical furrows in the esophagus 

B. Erosive esophagitis 

C. Barrett's esophagus

D. Normal esophagus 

E. Esophageal rings

Answer:

D. Normal esophagus 

Question

A 26 yo man presents to the emergency room because of a meat impaction. Three hours earlier he was eating a steak and he experienced acute onset of dysphagia followed by chest pain. He is now unable to swallow anything, including his saliva. He has a history of dysphagia for solid foods for the past 7 years, but has not had a prior medical evaluation for this. He has history asthma. He denied history of heartburn or caustic ingestions. In addition to the impacted meat bolus, endoscopy revealed vertical furrows and circular rings. What is the most likely diagnosis

A. Severe reflux esophagitis 

B. Candida esophagitis 

C. Eosinophilic esophagitis 

D. Peptic esophageal stricture 

E. Esophageal adenocarcinoma

Answer:

C. Eosinophilic esophagitis

Viral hepatitis

Most common cause of acute and chronic hepatitis

Hepatitis viruses

• A and E - resolve spontaneously
• B, C & D - can develop chronicity 

Incubation period 

• A: 2-6 weeks, B: 2-6 months, C: 2-3 months
• Asymptomatic 
• Unaware of infection 
• Infectious
• Serum ALT: Normal or Elevated
• Serologic markers of viral infection: Present or Absent

Viral hepatitis Prodrome 

• Lasts for 3-5 days
• Flu-like symptoms: Myalgias , Arthralgias, Fatigue, Nausea/vomiting, Loss of appetite, Fever may occur 
• Mild tenderness over the liver
• Elevation in serum ALT 
• Serologic studies typically positive

Icteric Hepatitis 

• is uncommon 
• Only 20-25% of patients develop jaundice following acute infection

Acute hepatitis not recognized

years later patients may be found to have: 

• Chronic hepatitis 
• Abnormal liver chemistries 
• Physical findings of cirrhosis
• Serologic evidence of prior hepatitis Viral hepatitis 

Viral hepatitis - Acute liver failure

Marked elevation is serum ALT > 10,000 IU/ 

Profound jaundice - Bilirubin > 10 mg/dl 

Loss of hepatic function:

• Prolongation in pro-thrombin time
• Hepatic encephalopathy

Mortality approaches 80% without liver transplantation

Atypical vital hepatitis causes

• Epstein Barr virus (mononucleosis), Cytomegaloviru, Herpes simplex virus, Varicella zoster, Measle, Rubella, Coxsackie, Influenza 
• Causes hepatitis as part of systemic infection 
• Most commonly seen in: Children, Immune suppressed (eg HIV, Transplant recipients ) 
• Can cause severe acute liver injury 
• Do not lead to chronic liver disease

Drug-Induced Liver Injury (DILI)

• One of the most frequent causes of abnormal liver chemistries 
• Occurs in -1:5,000 persons taking prescription medications 
• Eg - Acetamenophen, Augmentin, methotrexate, INH 
• Accounts for 3-10% of all AEs reported to the FDA 
• Accounts for nearly 60% of cases of acute liver failure

Alcoholic Liver Disease

Natural History 

Alcoholic hepatitis 

Women more likely to develop cirrhosis 

Those with clinically severe hepatitis more likely to progress to cirrhosis 

Acute mortality

• 10-20% (related to severity, complications and renal failure) 
• 50-80% if DF > 32

Both AST and ALT are elevated but rarely exceed 300 IU/L (never above 500) 

If > 300, think acetaminophen 

AST / ALT ratio > 2:1 

• Both AST and ALT are cytoplasmic enzymes but mitochondrial isoenzyme is only AST. EtoH is mitochondrial toxin 
• ALT requires pyridoxal phosphate (vit-B6), which is consumed for the metabolism of alcohol

Treatment for alcoholic hepatitis

Indications for steroids +/- NAC or PTX

• DF > 32 or MELD > 18
• Encephalopathy 

Contraindications for steroids 

• Sepsis, GI bleeding
• If contraindications, treat and reassess 

Consider Pentoxifylline (400 mg tid)

• Seems to be a safe alternative, especially if steroids contraindicated (infection, bleeding)
• Not helpful if steroids fail 

Calculate Lille score after 7 days (if <0.45, continue) 

Liver transplantation not an option

Question

A 46 year old man is admitted to the hospital after being found unconscious by his family. He is known to consume more than a fifth of vodka a day for at least two decades. Physical examination reveals no fever. Tender hepatomegaly and splenomegaly are present. Laboratory tests reveal a serum bilirubin of 3 mg/dl, albumin 3 gm/dl. AST 1,550 IU/L, ALT 1210 IU/L, Alk phos 155 IU/L, INR 1.2 and serum creatinine 2.1 mg/dl. There is no leukocytosis. The next appropriate test for this patient is:

A. Doppler ultrasound of the liver 

B. ERCP 

C. Acetaminophen level 

D. CPK level 

E. Blood cultures

Answer:

C. Acetaminophen level

Question

A 45 year old man is admitted with nausea and jaundice. There is no history of fever. He admits to be a heavy daily drinker for over 15 years. Physical examination reveals tender hepatomegaly and asterixis. Laboratory tests reveal WBC of 12,000, serum bilirubin of 6 mg/dl, albumin 3 gm/dl, AST 250 IU/L, ALT 110 IU/L, Alk phos 155 IU/L, PT 20/INR 2.3 and serum creatinine 1.5 mg/dl. The most appropriate for this patient is: 

A. ERCP 

B. Prednisolone 32 mg/day

C. Broad spectrum antibiotic 

D. Referral to a liver transplant center 

Answer:

B. Prednisolone 32 mg/day

Question

A 40 yo obese male (BMI 45) is found to have NASH. He has tried weight loss and exercise but his liver enzymes remain elevated and he has only lost 10 lbs. His fasting blood sugar is 112. Which of the following do you recommend? 

A. Start pioglitazone 

B. Start metformin 

C. Bariatric surgery 

D. Vitamin E 

Answer:

C. Bariatric surgery

Question

You're seeing a 22 yo female medical student who developed flu-like symptoms and then became jaundiced 1-2 weeks after returning from a medical mission in Honduras. The AST 798, ALT 821, ALP 450 and TBILI 8 mg/dl. HAV-IgM was positive, and HB surface antigen, anti-HB core IgM and anti-HCV were all negative. INR was 1.1. A liver ultrasound was normal. Which of following would you recommend?

A. ERCP 

B. Recommend that household contacts receive HAV vaccine 

C. Quarantine the patient 

D. Prescribe URSO 300 mg BID

Answer:

B. Recommend that household contacts receive HAV vaccine

Question

A 25 year old male is referred for a persistent elevation in ALP. He has no itching, weight loss, fevers, diarrhea or hematochezia. His physical examination is normal. Laboratory studies demonstrate AST 55, ALT 68, ALP 790 IU/L, TBILI 1.5 mg, ALB 4.1 gm, Hgb 15.5 gm, PLT 267. Serologic studies are positive for ANA and ANCA and negative for AMA. MRCP demonstrates diffuse strictures of the intrahepatic bile ducts bilaterally and dilation of the left sided intrahepatic ducts. Which of the following should be done next? 

A. Colonoscopy 

B. ERCP with stenting of the left sided bile ducts 

C. URSO at a dose of 15 mg/kg

D. Liver biopsy

Answer:

A. Colonoscopy

Question

A 45-year old Cambodian male is referred for hepatitis B by his primary care physician. He is healthy and has a normal physical exam, and has the following laboratory evaluation: 

ALT: 26 

HB s Ag: positive 

HB e Ag: negative 

HB e Ab: positive 

HBV DNA: 1000 IU/mL 

You recommend the following to the patient: 

A. Follow-up US, ALT, HBV DNA every 6 months 

B. Treatment with a nucleos(t)ide analogue 

C. Liver biopsy, then treatment according to histology 

D. HCC surveillance is not necessary because he has inactive disease

Answer:

A. Follow-up US, ALT, HBV DNA every 6 months 

Gl disorders of pregnancy

• Nausea and vomiting 
• Hyperemesis Gravidarum 
• Cholelithiasis 
• Intrahepatic Cholestasis of Pregnancy (ICP) 
• HELLP syndrome 
• Acute Fatty Liver of pregnancy (AFLP)

Liver diseases unique to pregnancy

First Trimester

• Hyperemesis gravidarum 

Second or third trimester

• Cholestasis of pregnancy 

Third trimester 

• Pre-eclamptic liver disease: Pre-eclampsia, HELLP, Infarction/rupture 
• Acute fatty liver of pregnancy

Question

A 25 year old female at 12 weeks gestation presents with intractable nausea and vomiting. This is her first pregnancy. Her symptoms started about two weeks ago and have not improved. She has no prior history of liver disease and no family history of liver disease. Her physical exam is unremarkable. Laboratory tests show mild increases in AST, ALT and alkaline phosphatase. Serum bilirubin and INR are normal. The most likely diagnosis is:

A. HELLP syndrome 

B. Hyperemesis gravidarum 

C. Acute fatty liver of pregnancy 

D. Cholestasis of pregnancy

Answer:

B. Hyperemesis gravidarum