Notes from a GI Doc for Residents

Chronic Constipation

Overview:

Common, often secondary, very treatable

Treatment goal: identify red flags and reversible contributing factors, manage symptoms

Diagnosis (Rome III criteria):

Symptoms for over 6 months

Absence of loose stools and insufficient criteria for IBS*

At least 2 of the following features for >25% of defecations in the last 3 months:

Straining

Lumpy/hard stools

Sensation of incomplete evacuation

Sensation of anorectal obstruction/blockade

Manual maneuvers

Less than 3 defecations per week

*Rome III Criteria for IBS

Symptoms for over 6 months

Abdominal pain/discomfort >3 days/month in last 3 months with 2 or more of the following:

Improvement with defecation, onset with change in frequency, onset with change in form

Treatment

Review medication list for contributing agents and consider alterations if possible

Analgesics, opiates, NSAIDS, anticholinergics, antacids, iron

5-HT3 receptor antagonists, TCA, antipsychotics, MAOI

Antispasmodics, antihistamines, calcium channel blockers, diuretics, beta-blockers

Encourage increased physical activity and avoidance of dehydration

Trial of laxative agents (combination therapy and chronic therapy is often required and safe)

Bulking agents (fiber, Citrucel is less bloating)

Stool softeners (surfak)

Osmotic agents (miralax, titrated every 3 days to effect, no maximum dose)

Stimulants (senna, especially if patient requires opiate medications)

When to refer to Gastroenterology:

Red flag symptoms

Change in bowel habits after 50 years old without subsequent colonoscopy

Hematochezia or iron deficiency anemia

Unexplained weight loss or family history of colorectal cancer

Abdominal/rectal mass, obstructive symptoms, rectal prolapse, or change in stool caliber

Failure to respond to combination therapy

Digital rectal exam suggestive of a defecatory disorder

What to expect from Gastroenterology Referral:

Endoscopic evaluation or other testing as necessary to make or confirm diagnosis

Consideration for need for anorectal manometry or pelvic floor physical therapy

Consideration for addition of linaclotide or lubiprostone to patient’s combination therapy

References:

AGA technical review: http://www.gastrojournal.org/article/S0016-5085(12)01544-2/fulltext

ASGE guideline:  http://www.asge.org/uploadedFiles/Publications_(public)/ Practice_guidelines/Endoscopy_in_mgnt_constipation.pdf 

Colorectal Cancer (CRC) Screening 

Overview: 

- CRC is the 3rd leading cause of cancer-related deaths in the US

- CRC is HIGHLY preventable through screening programs

- CRC often does not have symptoms until the disease is advanced

Screening:

- Who: 

- Beginning at age 50 (45 AF-AM), all men and women should undergo routine CRC screening. 

- Anyone of any age with a first degree relative (mom, dad, brother or sister) who has been diagnosed with any cancer of the colon, pancreas, uterus or stomach

- How:  Beginning at age 50 (45 AF-AM), men and women should have (in order of preference),

- a complete colonoscopy every 10 years, or

- a flexible sigmoidoscopy every 5 years, or 

- an occult blood test on spontaneously passed stool every 1 year (at a minimum)

- Colonoscopy and Flexible Sigmoidoscopy: 

- Close inspection of the colon and rectum for abnormalities is performed by inserting a flexible tube the size of a finger through the anus 

- Colonoscopy: the entire colon and rectum is inspected. Sedation is given for patient comfort

- Flexible sigmoidoscopy: the end of the colon is inspected and sedation is not used

When to refer to Gastroenterology:

-Anyone ≥ 50 years who is not up to date on CRC screening 

-Anyone < 50 years if they have a first degree relative (mom, dad, brother or sister) who has been diagnosed with any cancer of the colon, pancreas, uterus or stomach 

What to Expect From Gastroenterology Referral: 

- Appointment for history and physical and discussion of risks, benefits and alternatives of CRC screening

- Second appointment for colonoscopy examination following bowel preparation

- The patient is provided a copy of the procedural report. 

- A copy of procedure report is placed in HAIMs section of AHLTA

- Follow-up of any tissue pathology obtained during examination

- Return to PCM 

Links:

1) http://www.screenforcoloncancer.org/

2) http://www.asge.org/patients/patients.aspx?id=12830 (describes colonoscopy)

Chronic Diarrhea

Overview:

- Decrease in stool consistency for > 4 weeks, generally > 3 stools / day

- 3 basic categories: 1) Watery   2) Fatty (malabsorption)   3) Inflammatory (+/- bloody)

- Watery subdivides into:  1) Osmotic   2) Secretory   3) Functional

Diagnosis:

- History (age, duration, food, family hx, pattern, timing, travel, medications  - prescription and OTC)

- Physical exam (general, eye, skin, abdomen, anorectal)

- Labs (albumin, TSH, CBC, ESR, chem 11, LFT, celiac panel), (stool cx, fecal leukocytes, O&P, Giardia, Cryptosporidium, c diff, ? laxative screen)

- Categorize based upon stool appearance

Fatty – Fecal Fat, stool fecal elastase for pancreatic insufficiency

Inflammatory (positive fecal leuks, blood, etc.) – Consider infectious vs IBD

Watery:  Secretory = >1 liter stool / day, often nocturnal sx despite fasting

Treatment:

- Dependent on underlying etiology

- In the absence of infection or “alarm symptoms” anti-diarrheals (Imodium, Lomotil) may be initiated.

- Trial fiber supplementation, Bismuth, etc.

When to refer to Gastroenterology:

- “Alarm symptoms”: Weight loss, hypoalbuminemia, hematochezia, iron deficiency anemia, fever

What to expect from Gastroenterology:

- History and Physical

- Endoscopic evaluation or other testing to make, confirm, or exclude diagnoses

- Initial management recommendations

- Referral back to PCM for chronic management

# Evaluation of mild transaminitis

from UpToDate.com, 2019

## Step 1: Initial evaluation

[ ] Review possible links to medications, herbal therapies, or recreational drugs

[ ] Screen for alcohol abuse (history, screening instruments, AST/ALT ratio >2:1)

[ ] Obtain serology for hepatitis B and C (HBsAg, anti-HBs, anti-HBc, anti-HCV)

[ ] Screen for hemochromatosis (Fe/TIBC >45 percent)

[ ] Evaluate for fatty liver (AST/ALT usually <1, obtain RUQ ultrasonography)

## Step 2: Second-line evaluation (if initial evaluation is unrevealing)

[ ] Consider autoimmune hepatitis, particularly in women and in those with a history of other autoimmune disorders (check serum protein electrophoresis; obtain ANA and ASMA if positive)

[ ] Obtain thyroid function tests (TSH if hypothyroidism is suspected; otherwise, obtain serum TSH, free T4, and T3 concentrations)

[ ] Consider celiac disease (especially in patients with a history of diarrhea or unexplained iron deficiency: serum IgA anti-tissue transglutaminase antibodies)

## Step 3: Evaluation for uncommon causes (if second-line evaluation is unrevealing)

[ ] Consider Wilson disease, especially in those <40 years of age (check serum ceruloplasmin, evaluate for Kayser-Fleischer rings)

[ ] Consider alpha-1 antitrypsin deficiency, especially in patients with a history of emphysema out of proportion to their age or smoking history (obtain alpha-1 antitrypsin level)

[ ] Consider adrenal insufficiency (8 am serum cortisol and plasma ACTH, high-dose ACTH stimulation test)

[ ] Exclude muscle disorders (obtain creatine kinase or aldolase)

## Step 4: Obtain a liver biopsy or observe (if no source identified after steps 1 to 3)

[ ] Observe if ALT and AST are less than twofold elevated

[ ] Otherwise, consider a liver biopsy

_AST: aspartate aminotransferase; ALT: alanine aminotransferase; HBsAg: hepatitis B surface antigen; anti-HBs: antibody to hepatitis B surface antigen; anti-HBc: antibody to hepatitis B core antigen; anti-HCV: antibody to hepatitis C virus; Fe: iron; TIBC: total iron binding capacity; RUQ: right upper quadrant; ANA: antinuclear antibodies; ASMA: anti-smooth muscle antibodies; TSH: thyroid-stimulating hormone; IgA: immunoglobulin A; ACTH: corticotropin._

_Mild is defined as between 2 and 10 times the upper limit of normal; chronic is defined as more than six months._