1 Define gastroesophageal reflux disease (GERD). What causes it?

GERD means that stomach acid refluxes into the esophagus. It is caused by inappropriate, intermittent relaxation of the lower esophageal sphincter. The incidence is increased greatly in patients with a hiatal hernia (see question 4).

2 Describe the classic symptoms of GERD. How is it treated?

The main complaint is usually “heartburn,” often related to eating and lying supine. GERD may also cause abdominal or chest pain. Initial treatment is to elevate the head of the bed and to avoid coffee, alcohol, tobacco, spicy and fatty foods, chocolate, and medications with anticholinergic properties. If this approach fails, antacids, histamine-2 blockers, and proton-pump inhibitors may be tried. Many patients have already tried over-the-counter remedies, and many physicians begin empirical treatment at the first visit because “lifestyle modifications” usually fail. Surgery (Nissen fundoplication) is reserved for severe or resistant cases.

3 What are the sequelae of GERD?

Sequelae of GERD include esophagitis, esophageal stricture (which may mimic esophageal cancer), esophageal ulcer, hemorrhage, Barrett esophagus, and esophageal adenocarcinoma (Fig. 12-1).

4 What is a hiatal hernia? How is it different from a paraesophageal hernia?

A hiatal hernia is a sliding hernia, which means that the whole gastroesophageal junction moves above the diaphragm, pulling the stomach with it. This common and benign finding may predispose to GERD. In a paraesophageal hernia, the gastroesophageal junction stays below the diaphragm, but the stomach herniates through the diaphragm into the thorax. This type of hernia is uncommon but serious; it may become strangulated and should be repaired surgically.

5 What are the signs of peptic ulcer disease (PUD)?

The classic symptoms of PUD are chronic, intermittent, epigastric pain (burning, gnawing, or aching) that is localized and often relieved by antacids or milk. Look for epigastric tenderness. Other signs and symptoms include occult blood in the stool and nausea or vomiting. PUD is more common in men. The two types of PUD are gastric and duodenal ulcers.

6 Explain the classic differences between duodenal and gastric ulcers.

7 What is the diagnostic study of choice for PUD?

The gold standard is endoscopy (most sensitive test), but an upper gastrointestinal (GI) barium study is cheaper and less invasive. Empirical treatment with medications may be tried in the absence of diagnostic studies if the symptoms are typical. If endoscopy is done, a biopsy of any gastric ulcer is mandatory to exclude malignancy. Duodenal ulcers do not have to be biopsied initially because malignancy is rare.

8 What is the most feared complication of PUD? What should you suspect if an ulcer does not respond to treatment?

The most feared complication of PUD is perforation. Look for peritoneal signs, history of PUD, and free air on an abdominal radiograph (Fig. 12-2). Treat with antibiotics (e.g., ceftriaxone, metronidazole) and laparotomy with repair of the perforation. If ulcers are severe, atypical (e.g., located in the jejunum), or nonhealing, think about stomach cancer or Zollinger-Ellison syndrome (gastrinoma; check gastrin level). PUD is also a cause of GI bleeding, which can be severe in some cases.

9 How is PUD treated initially?

First, remember that diet changes are not thought to help heal ulcers, although reduced alcohol and tobacco use may speed healing. Stop all NSAID use. Start treatment with proton-pump inhibitors, test for Helicobacter pylori infection, and treat with antibiotics if positive. Many regimens exist, but the most commonly used is triple therapy with a proton-pump inhibitor, clarithromycin, and amoxicillin.

10 List the surgical options for ulcer treatment. What complications may occur?

Surgical options generally are considered only if medical treatment has failed or if complications are present (perforation, bleeding). Surgical procedures for PUD include antrectomy, vagotomy, and Billroth I or II procedures. After surgery (especially with Billroth procedures) watch for dumping syndrome (weakness, dizziness, sweating, and nausea or vomiting after eating). Patients also develop hypoglycemia 2 to 3 hours after a meal, which causes recurrence of the same symptoms, as well as afferent loop syndrome (bilious vomiting after a meal relieves abdominal pain), bacterial overgrowth, and vitamin deficiencies (vitamin B₁₂ and/or iron, causing anemia).

11 Define achlorhydria. What causes it?

Achlorhydria is an absence of hydrochloric acid (HCl) secretion. It is caused most commonly by pernicious anemia, in which antiparietal cell antibodies destroy acid-secreting parietal cells and thus cause achlorhydria and vitamin B₁₂ deficiency. It often is associated with other endocrine autoimmune disorders (e.g., hypothyroidism, vitiligo, diabetes, hypoadrenalism). Achlorhydria also may be caused by surgical gastric resection.

12 What are the classic differences between upper and lower GI bleeds?

13 How is a GI bleed treated?

The first step is to make sure that the patient is stable (ABCs [airways, breathing, circulation]); intravenous fluids and blood, if needed, before you try to reach a diagnosis. Next, place a nasogastric tube, and test the aspirate for blood to help determine whether the patient has an upper or lower GI bleed. Endoscopy is usually the first test performed (upper or lower, depending on symptoms and nasogastric tube aspirate). Endoscopically treatable lesions include ulcers, polyps, vascular ectasias, and varices.

14 What radiologic imaging studies can be done to localize a GI bleed? Does surgery have a role?

Radionuclide (i.e., nuclear medicine) scans can detect slow or intermittent bleeds if a source cannot be found with endoscopy. Angiography can detect more rapid bleeds, and embolization of bleeding vessels can be done during the procedure. Surgery is reserved for severe or resistant bleeds and typically involves resection of the affected bowel (usually colon).

15 Define diverticulosis. What are its complications?

Diverticulosis is characterized by saclike mucosal projections through the muscular layer of the colon and/or rectum. It is extremely common, and the incidence increases with age. It is thought to be caused in part by a low-fiber, high-fat diet. Complications include GI bleeding (common cause of painless lower GI bleeds) and diverticulitis (inflammation of a diverticulum), which can lead to abscess, fistula formation, sepsis, or large bowel obstruction.

16 How do you diagnose and treat diverticulitis? What test should a patient have after a treated episode of diverticulitis?

Signs and symptoms of diverticulitis include left lower quadrant pain or tenderness, fever, diarrhea or constipation, and increased white blood cell count. The pathophysiology is thought to be similar to appendicitis. Stool or other debris impacts within the diverticulum and causes obstruction, leading to bacterial overgrowth and inflammation. The diagnosis can be confirmed with a computed tomography (CT) scan (Fig. 12-4), if needed, which can also help rule out complications such as perforation or abscess. In the absence of complications, the treatment is antibiotics that cover bowel flora (e.g., a fluoroquinolone plus metronidazole) and bowel rest (i.e., no oral intake). Surgery is needed for perforation or abscess.

After a treated episode of diverticulitis, all patients need colon cancer screening with colonoscopy (colon carcinoma with perforation can mimic diverticulitis clinically and on CT). These studies should be avoided during active diverticulitis, however, because of an increased risk for perforation.

17 How is diarrhea categorized according to etiology?

18 Define osmotic diarrhea. How can an easy diagnosis be made?

Osmotic diarrhea is caused by nonabsorbable solutes that remain in the bowel, where they retain water (e.g., lactose or other sugar intolerance). When the patient stops ingesting the offending substance (e.g., avoidance of milk, a trial of not eating), the diarrhea stops—an easy diagnosis.

19 What causes secretory diarrhea?

Secretory diarrhea results when the bowel secretes too much fluid. It is often caused by bacterial toxins (cholera, some species of Escherichia coli), VIPoma (pancreatic islet cell tumor that secretes vasoactive intestinal peptide), or bile acids (after ileal resection). Secretory diarrhea continues when the patient stops eating.

20 What are the common causes of malabsorptive diarrhea?

Celiac disease (look for dermatitis herpetiformis, and avoid gluten in the diet; Fig. 12-5; Plate 21), Crohn disease, and postgastroenteritis (because of depletion of brush-border enzymes). Malabsorptive diarrhea improves when the patient stops eating.

21 What are the common clues to infectious diarrhea? What are the common causes?

In patients with infectious diarrhea, look for fever and white blood cells in the stool (only with invasive bacteria such as Shigella, Salmonella, Yersinia, and Campylobacter spp.; not found with toxigenic bacteria). Travel history (Montezuma’s revenge caused by E. coli) is also a tip-off. Hikers and stream-drinkers may have Giardia infection, which includes steatorrhea (fatty, greasy, malodorous stools that float) because of small bowel involvement and unique protozoal cysts in the stool. Treat with metronidazole. Also watch for Clostridium difficile diarrhea in patients with a history of antibiotic use. Test the stool for C. difficile toxin, and if the result is positive, treat with oral metronidazole (vancomycin is a second-line agent if metronidazole is not an option).

22 What causes exudative diarrhea?

Exudative diarrhea results from inflammation in the bowel mucosa that causes seepage of fluid. Mucosal inflammation is usually because of inflammatory bowel disease (Crohn disease or ulcerative colitis; see question 27) or cancer. Patients commonly have fever and white blood cells in the stool, as in infectious diarrhea, but a lack of pathogenic organisms, chronicity, and nonbowel symptoms are clues.

23 What are the common causes of diarrhea caused by altered intestinal transit?

This type of diarrhea is seen after bowel resections, in patients taking medications that interfere with bowel function, and in patients with hyperthyroidism or neuropathy (e.g., diabetic diarrhea). Watch for factitious diarrhea, which is caused by secret laxative abuse.

24 Define irritable bowel syndrome. How do you recognize it?

Irritable bowel syndrome is a common cause of GI complaints. Patients may be anxious or neurotic and have a history of diarrhea aggravated by stress; bloating; abdominal pain relieved by defecation; and/or mucus in the stool. Look for psychosocial stressors in the history and normal physical findings and test results. Irritable bowel syndrome is a diagnosis of exclusion; you must do at least basic lab tests, rectal examination, stool examination, and sigmoidoscopy. Because it is so common, however, it is the most likely diagnosis if the question gives no positive findings, especially in young adults (female-to-male ratio = 3:1).

25 What should you do if a patient has diarrhea?

In all patients with diarrhea, watch for and treat dehydration and electrolyte disturbances, especially metabolic acidosis and hypokalemia. Diarrhea is a common and preventable cause of death in underdeveloped countries. Do a rectal examination, look for occult blood in stool, and examine the stool for bacteria (Gram stain and culture), ova and parasites, fat content (steatorrhea), and white blood cells.

26 What should you watch for in children after a bout of diarrhea?

After bacterial (especially E. coli or Shigella sp.) diarrhea in children, watch for hemolytic uremic syndrome, which is characterized by thrombocytopenia, hemolytic anemia (schistocytes, helmet cells, and fragmented red blood cells on peripheral blood smear), and acute renal failure. Treatment is supportive. Patients may need dialysis and/or transfusions.

27 Specify the classic differences between Crohn disease and ulcerative colitis.

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