GI (Gastrointestinal)

Links

CA Colon

Diarrhea

Bloody diarrhea

Mucositis and Aphthae

Obesity

Ulcer

CA Colon

Screening

to really make this kind of risk-adjusted screening work you really need clinical automation ...
risk assessment: tobacco, alcohol, saturated fat diet, obesity, low serum folate, genetics
screening (briefly)
- average risk: FOBT yearly and flex sig q5y
- medium to higher risk: colonoscopy, interval varies with risk factors and polyp size, start from age 40 or lower, repeat q3-5 years
- high risk: refer
very small polyps (<.5 cm) may not be relevant
reduce risk: celebrex approved, low dose aspirin may work?

Population	test	interval	age to begin
general	occult blood	annual	50
general	sigmoidoscopy	q3-5y	50
1st degree relative with colorectal cancer (CRC) or adenomas > age 60	colonoscopy	q5y	50 or 10 years younger than index case
Two 1st degree relative with CRC/adenomas aged > 60 or 1 relative age < 60	colonoscopy	q5y	40 or 10 years younger than index case
chronic ulcerative colitis	colonoscopy	q1-2y	10 yrs after onset, 15 yrs after onset if left sided colitis only
Crohn's disease	colonoscopy	q1-2y	10-15 yrs after onset
Risk of familial adenomatous polyposis risk (FAP)	sigmoidoscopy	q1-2y	age 10-12
Risk of hereditary non-polyposis risk CRC	colonoscopy	q2y	25 yrs or 10 yrs younger than index case

Diarrhea

Timing and Etiology

1-6h: pre-formed toxin, food poisoning (Staph, Bacillus)
8-16h: infection with toxin (Clostridium)
>16h: invasive infection

Bloody diarrhea

see Food Poisoning
bacterial: Salmonella, Shigella, Campylobacter, Yersinia, enteroinvasive E. Coli (usually with fever, vomiting, tenesmus)
fecal leukocytes more typical of Shigella or bad E Coli
culture: E Coli 0157:H7, Shigella if high fever. Can do serologic test for 0157.
no antimotility therapy
U/A, peripheral smear, CBC, Cr at presentation and repeat in 1 weeek if fear hemolytic-uremic syndrome

Cryptosporidia

Cecil's, Cryptosporidiosis $
protista, related to toxoplasma and cyclospora
usually benign, except HIV. In large WI outbreak, 1/100 hospitalized.
quite infectious, unaffected by swimming pool chlorine
if true Cryptosporidiosis: incubation 2-14 days, explosive onset, lasts 10-14 days, infectious for weeks. Probably adults are asymptomatic.
ELISA test most often used to diagnose. Cyclospora and Cryptosporidia look same on acid fast.

Traveler’s Diarrhea management (enterotoxic E. Coli)

AFP July 1999 review
ciprofloxacin 750 mg once
imodium 2 mg: 4 mg initially then 2 mg after each unformed stool, 16 mg/day max.

Diverticulitis

right sided more in Asian ethnicity
CT for diagnsosis; false neg 2-21%
outpt rx: liquid diet, 7-10 days ab Rx
prevention: high fiber diet (Citrucil, metamucil)
20% require surgery

Food Poisoning

Table sorted by time of onset.

Organism/Toxin	Onset	Duration	Characteristic Findings	Other Findings	Source	Misc	Treat
Scombrotoxin (histamine)	< 30 min	< 30 min	wheezing, flushing, mouth burning, N/V/D		tuna, sardines, mahi mahi, etc	infrequent	antihistamine
Ciguatera	?	days!	oral numbness, tingling then N/V/D then paresthesias, twiching, vertigo, temp sensitivity, temperature sensory reversal		large predator fish: barracuda, grouper, red snapper	infrequent	supportive
Bacillus cereus	30 min to 6 h	24 h	N/V (like staph)		fried rice left out overnight		supportive
Bacillus cereus	6-15 h	24 h	abd cramps, watery diarrhea		fish, meat, vegetables		supportive
Botulin toxin (C. difficile)	variable	variable	descending paralysis	Mild cases have blurry vision, dysarthria	flavored oils, honey in infants, home canning	Like Guillain-Barre, but inverted. Facial paralysis, then resp failure	CDC has botulin antitoxin. ICU.
Staph	1-6 h	<24h	nausea & vomiting	diarrhea 68%	ham, poultry, pastries, egg salads		supportive
C perfringes	6-24h	<24h	abdominal cramps, diarrhea	vomiting & fever < 10%	beef, poultry, gravy, Mexican food		supportive
Norwalk Virus	16-72h	1-2d	watery diarrhea, vomiting	abd cramping & nausea, then myalgias with diarrhea/vomiting. Malaise, headache, low-grade fever.	shellfish, salads, secondary contacts		Pepto-bismol
Enterotoxic E Coli (ETEC)	16-72h	3-4d	watery diarrhea	rare fever & vomiting	travel	"Traveler’s Diarrhea", can cause severe dehydration	Cipro
Salmonella (S. enteritidis)	10-72h	3-5d	fever, tenesmus, bloody or watery diarrhea	vomiting 35-80%	eggs, poultry, beef, dairy	positive leukocytes	Cipro, but may prolong shedding. Many recommend no Rx unless at risk for dissemination.
Enteroinvasive E Coli (EIEC)	16-72h	3-5d	fever, tenesmus, dyseneteric diarrhea	vomiting 35-80%	eggs, vegetables, dairy	positive leukocytes	none
Shigella	16-72h	3-5d	fever, tenesmus, bloody diarrhea	vomiting 35-80%	eggs, vegetables, dairy, direct contact	positive leukocytes, very contagious	Cipro
Yersinia (rare in US)	16-72h	1d-4w	fever, abdominal pain	vomiting 25-40%	milk, tofu, pork	pos/neg leukocytes	none?
Campylobacter jejuni	2-5d	3-9d	fever, tenesmus, dyseneteric diarrhea	vomiting 15-25%	poultry, unpasteurized milk, pets, beef	positive leukocytes. 40% of all cases of Guillaine-Barre syndrome follow campylobacter infection.	Cipro
Enterohemorrhagic E Coli (EHEC) aka Shiga toxin-producing E. Coli (STEC) and E. coli O157:H7	2-5d	1-12d	bloody diarrhea	serum leuk.	beef, dairy, cider, water	risk of HUS 2-14d post onset, 30% pos leuk. Can do serologic test for 0157 infections.	Avoid antibiotics and antidarrheal agents.
Listeriosis (food borne)	??		encephalitis/ meningitis	Listeriosis	Brie cheese, milk, hot dogs etc.	risk for pregnant women (abortion) and immunocompromised	Antibiotics. See Listeriosis.
Toxoplasmosis	??		none usually, sometimes flu-like, adenopathy		Under cooked venison, lamb, pork	risk for pregnant women and immunocompromised	50% disease food borne, 50% from cat feces

Notes

can't clinically distinguish EIEC, Shigella, Samonellae, Campylobacter and Yersinia. Of these Salmonella & Campylobacter are the most common by far.
very bloody diarrhea is more likely Shigella (pos leuk) or EHEC (neg leuk, usually)
antibiotic use in mo prior to sx increases risk of Salmonella.
antibiotics don't clearly help with much other than Enterotoxic E Coli (ETEC), Bactrim may precipitate HUS. For bloody diarrhea, treat Campylobacter or Shigella after a culture is positive.
EHEC has more bloody diarrhea, with less abdominal pain and fever. Risk of HUS.
control N/V with Compazine 25mg PR q12. Tigan can be given in children > 2 yo. See anti-emetics.
Campylobacter jejuni has a significant relationship to Guillain-Barre syndrome. Unsure if treatment reduces risk, which is thought to be small.

GERD (gastroesophageal reflux)

Prilosec (omeprazole) 10-20 mg qD until symptom free, then PRN symptoms. Some people will get good results with prn H2 blockers for maintenance.

Laxatives

bulking, form stool

metamucil: 1-3 biscuit or powder daily

soften stool/lubricant

Colace 100 mg PO BID
lactulose 7.5 ml qD (good for elderly if well hydrated)
glycerine suppositories (rectal, need liner because will leak)
mineral oil 30 ml PO BID (pediatric)

peristaltic agents, including combo

Peri-Colace: 1-2 tab HS
Dulcolax: 5 mg PO BID or hs, 10 mg PR. acts in 15-60 minutes
MOM 30 ml PO hs
Senakot 1 tab PO hs

Mucositis and Aphthous ulcers

Recurrent and Complex Recurrent

consider B12 deficiency, Celiac Disease, Crohn's, Nicorandil, other meds, Behcet's (however simultaneous oral and genital may not mean Behcet's), HIV, sprue
associated sometimes with: anemia, B vitamin deficiencies, folate, iron, zinc, Feverfew
consider referral to interested dermatologist - Rx colchicine, pentoxifylline, dapsone, thalidomide, TNF alpha-blockers?

Single Large Aphthae

triamcinolone in orobase paste (check pharmacy carries)
Tenovate ointment .05% (15g tube) on gauze, apply to ulcer for 15-20 minutes BID
Debacterol is a cauterizing agent being studied.
Aphthasol (amlexanox) may accelerate healing (NSAID)

Chronic non-microbial mucositis (Aphthous ulcers, apthae, canker sores)

Aphthasol (amlexanox) may accelerate healing (NSAID). Based on some early work in cold sores, consider low-dose aspirin 1 qD from onset symptoms.
Dental recipe
Triamcinolone acetonide 0.1% aqueous suspension. Disp 200 ml. 5 ml rinse for 10-15 seconds and spit, 1/2 hour after meals and hs.
To prepare triamcinolone: 5 ml of 70% ethanol to a 5 ml vial of triamcinolone acetonide 40 mg/ml injectable, QS to 200 ml with sterile water.
"Faughnan’s" Mouthwash, swish and spit q4h prn. Don't swallow. Best 1/2 to 1 hour before meals. May omit triamcinolone and use dental recipe for severe cases.
- 30 ml viscous lidocaine
- 30 ml benadryl elixir
- 40 ml maalox
- triamcinolone 40mg/ml 1 ml

Obesity

Body Mass Index (BMI)

Adult Examples (CDC BMI Calculator)

Height	Weight Range	BMI (kg/m2)	Weight Status
5’ 9”	124 lbs or less	Below 18.5	Underweight
	125 lbs to 168 lbs	18.5 to 24.9	Normal
	169 lbs to 202 lbs	25.0 to 29.9	Overweight
	203 lbs to 273 lbs	30 to 40	Obese
	273 lbs or more	40 or higher	Bariatric surgery candidate

The categories for children are based on percentiles on CDC growth charts. This makes no sense to me, so I'll just ignore it for now.

Bariatric Surgery

> 40 kg/m2: indication for bariatric surgery
> 35 kg/m2: indic for bariatric if other comorbid factor - diabetes, sleep apnea, coronary artery

Ulcer

H Pylori and Duodenal Ulcer

relationship is changing, as H Pylori infection decreases in US popn more duodenal ulcer is H Pylori negative
currently assume pt with duodenal ulcer is H Pylori positive if never treated for HP and no major risk factors
Current recommendations for screening and monitoring:
- pt never treated before: can use serology -- cheap and convenient (but remains positive post Rx)
- pt previously treated: Urea breath tests. 13C has no radiation but is expensive, 14C minimal radiation
- stool test for H pylori antigen: may replace other tests for all settings
one approach to non-reflux dyspepsia in low-risk patient not taking NSAID and never treated for H Pylori (esp. if past hx of duodenal ulcer)
- if serology positive: empiric treatment followed by 4-6 weeks proton pump inhibitor
- if symptoms recur do endoscopy with biopsy, look for reflux

Author: John G. Faughnan. The views and opinions expressed in this page are strictly those of the page author. Pages are updated on an irregular schedule; suggestions/fixes are welcome but they may take weeks to years to be incorporated. Anyone may freely link to anything on this site and print any page; no permission is needed for citing, linking, printing, or distributing printed copies.