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Case Problems in GI

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Disclosure of commercial support

• This lecture is support by Berlin pharmaceutical
  industrial company.
• The speakers are free to present their own
  information and their personal view without any
  influence from the company.

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• ????????? ???? 40 ?? ????? ??????
• ??????? ???????? ???????? 3 ???????
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  ????
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• ?????????????????

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• Thai man, not pale, no jaundice
• No lymphadenopathy
• Lung and Heart are normal
• Abdominal soft, no distension, liver spleen
  cant be palpable
• No signs of chronic liver disease

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• ?????????????????????????????? ?
• Clue ????? diagnosis?

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??????? ???????? ????????

• What is/are causes?
• Clues for diagnosis

Normal physical examination
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Causes of dyspepsia
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Causes of dyspepsia
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Causes of dyspepsia
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Causes of dyspepsia
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Diagnosis

• A) Peptic ulcer - DU or GU
• B) Gastroduodenitis
• C) Functional dyspepsia

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Etiology of dyspepsia
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Etiology of dyspepsia (endoscopically)
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Etiology of dyspepsia in Primary care
combined
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Etiology of dyspepsia
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Clues on clinical evaluation
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Clues on clinical evaluation
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Management of dyspepsia
Dyspepsia
Investigated
Uninvestigated
Organic disease
Functional
Ulcer - like
Dysmotility - like
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Initial management strategies for uninvestigated
dyspepsia

• 1. Empirical treatment
• 2. Prompt endoscope
• 3. HP. Testing follow by eradication
• treatment or endoscope

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Empirical treatment

• Who should empirical treatment ?
• What is appropriate medication ?

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Who should empirical treatment ?

• No alarm features

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Alarm features

• 1. Age of onset gt 40 years
• 2. Awakening pain
• 3. Significant weight loss (gt 5 BW within one
• month or gt 10 within three months)
• 4. History of GI bleeding
• 5. Persistent vomiting
• 6. Dysphagia
• 7. Strong family history of GI malignancy
• 1999 Thailand Consensus SRG - GAT

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Alarm features

• 8. Anemia
• 9. Jaundice
• 10. Hepatomegaly, splenomegaly,
• lymphadenopathy
• 11. Fever
• 12. Abdominal mass
• 13. Significant abdominal distension
• 14. Bowel habit change
• 1999 Thailand Consensus SRG -
  GAT

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Prompt endoscopy Alarm features or High risk

• New onset dyspepsia over age 50 years old
• Dyspepsia associated with dysphagia and / or
  weight loss
• Evidence of GI bleeding
• Occult blood
• Anemia
• Hematemesis
• Hematochezia or melena
• 4. Using NSAID or ulcerogenic agent
• 5. Signs or Symptoms of UGI tract obstruction
• Early satiety
• Vomiting
• 6. Strong family history of GI malignancy

American Society for Gastrointestinal Endoscopy
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H.pylori Test-and-Treat Strategies

• Three direct comparative studies of early
  endoscopy and H.pylori Test-and-Treat Strategies
• Heaney A,1999
• Lassen AT,2000
• Duggan A,1998
• measured dyspeptic symptom resolution
• Finding H.pylori Test-and-Treat Strategies to
  be at least as effective as prompt endoscopy in
  patients with no alarm symptoms

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Initial management strategies for uninvestigated
dyspepsia

• a) Empirical treatment
• b) Prompt endoscope
• c) HP. Testing follow by eradication
• treatment or endoscope

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A survey of etiology of dyspepsia and prevalence
of H.pylori infection in every regions of Thailand
N 1,171 Overall H.pylori ve 52.52
Kachintorn U, et al.1999
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Pharmacological intervention for uninvestigated
dyspepsia

• Subtype of Dyspepsia (Ulcer like or dysmotility
  like or reflux-like dyspepsia)
• PPI were significant more effective than H2RA and
  antacid
• 40 improved with H2RA or antacid
• 60 improved with PPI

The Cochrane Database of Systemic Review 2005
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This patient

• Empirical treatment
• PPI for 2 4 weeks
• Advise Natural history of disease
• Life style modification
• Follow up

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Case 1

• The patient was advised to modified the life
  style.
• He was on omeprazole (20mg) 1x1
• domperidone (10 mg)1x3
• Simethicone 1x3
• At 2 week follow up his symptoms were improved
  and he was advised to continue the same treatment
  for 6 weeks.

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Case 1

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Case 1 episode 2

• ????????????? 2 - 3 ????? ?????????????????
  ?????????????? ????????????? ?????? omeprazole
  ?????????????????? 1 wk ????????????????????????
  ?????????

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Case 1 episode2

• Thai man, mild pale, no jaundice
• No lymphadenopathy
• Lung Heart normal
• Abdominal soft, not tender, liver spleen can
  t be palpable
• PR melena, no mass
• No signs of chronic liver disease

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Recurrence dyspepsia
??????
Anemia

• Biopsy
• HP. Test
• HP.
• Pathology malignancy
• Inflammatory cell

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• ???????????????? H.pylori infection
  ????????????????????????????????????????????????
  ?????????????????? positive serology test

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A survey of etiology of dyspepsia and prevalence
of H.pylori infection in every regions of Thailand
N 1,171 Overall H.pylori ve 52.52
Kachintorn U, et al.1999
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Natural history of H.pylori infection
H.pylori infection
weeks to months
Chronic superficial gastritis (Histological
gastritis)
years
Chronic gastritis ( NUD )
MALT lymphoma
Peptic ulcer disease
Chronic atrophic gastritis
Gastric cancer
GERD
NSAIDs users
Cover,T.L.,et al.ASM News, 61(1),21,1995
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H.Pylori and peptic ulcer
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Laboratory findings

• CBCHct 33, Wbc 9000 PMN 65 L 30 Mono 3
  Eos 2
• Stool examination no parasite ,no wbc no rbc
• stool occult blood positive

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• ???????????? Rapid urease test ????? negative ??
  rule out H.pylori ?????????? ?????????????????????
  ???

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False negative for rapid urease test

• High dose H2RA
• PPI
• Antibiotic
• Active UGI bleeding

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• Pathologic findings mild gastritis with
  presence of H pylori.

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HP. Eradication

• First line therapy (7-14 days)
• PPI or Amoxycillin 1 gm bid
• RBC Clarithromycin
  or
• bid 500 mg bid
  Metronidazole 500 mg bid
• or PPI/RBC Amoxycillin Metronidazole
• Second line therapy (7-14 days)
• PPI bid Bismuth subsalicylate/subcitrate 120 mg
  qid Metronidazole 500 mg tid Tetracycline 500
  mg qid

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The Maastricht 2-2000
Who to treat (strongly recommended)
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HP triple therapy is more effective than
long-term maintenance antisecretory treatment in
the prevention of recurrence of DU
N 114, prospective randomized study Gr1 C 250
qds M 300 qds for 2 wks Sucralfate 1 g qds
for 4 wk Gr2 O 20 mg daily for 1 yr
(mean FU of 4.07 yrs)
Wong BCY, Aliment Pharmacol Ther 1999
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Recurrent PU in patients followingsuccessful
H.pylori eradication

• N 4940, FU up to 4 yrs
• Crude recurrence rate 3.02

GU is more likely to relapse than DU
Recurrent ulcer tended to recur at the site of
the original ulcer and were significant in those
who smoked, consumed alcohol and used NSAID
Miwa H, et al. Helicobacter 2004
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Test-and-Scope Strategies

• It should be noted that as the prevalence of HP
  infection falls, the benefit of a test-and-treat
  strategy may also decline
• a test-and-treat strategy may miss gastric
  cancer, thus HP testing followed by endoscopy in
  positive patients may be appropriate

Talley NJ. 1998 Sung JY. 2000
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Role of H.pylori in NUD

• HP NUD vs HP- NUD
• No consistent differences in
• - symptom severity
• - frequency of symptoms
• - delayed gastric emptying
• - altered visceral gastric perception

Veldhuyzen van Zanten SJO, Aliment Pharmacol Ther
1997
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H. pylori eradication in NUD

• Large optimised clinical trials give
  inconsistent results for the long-term benefit of
  eradication on dyspeptic symptoms

3 No Blum et al., 1998 Talley et al.,
1998 Talley et al., 1999 (all multicenter trials)
1 Yes McColl et al., 1998 (single-center
trial)
versus
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Eradication of H.pylori for non - ulcer dyspepsia
(Cochrane review)

• 15 RCT, 2903 patients
• Follow up 3-12 months
• - RRR in H.pylori eradication compared
  to placebo 9 (95 CI5-14)
• - NNT to cure one case of dyspepsia
• 15 (95 CI 10-28)

If there is a benefit, it is limited to a
subgroup of patients
Moayyedi P,et al. Cochrane Database Syst Rev 2005
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Case 2

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Case 2

• A Thai woman not pale, no jaundice, No signs
  of hyperthyroidism, no signs of malnutrition
  (edema, vitamin deficiency)
• BP 120/80 torr, Pulse 75/min, BT 36.7 ?C
• Lung heart WNL
• Abdomen soft ,no distension,
• liver spleen cant be palpable
• No sign chronic liver disease
• PR normal

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Case 2

• ?????????????????????????????????
• A) IBS
• B) IBD
• C) Parasitic
• D) CA colon

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• A young lady with
• Abdominal discomfort (epigastrium),
• Chronic diarrhea ( no bloody stool).
• Normal physical examination.

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Chronic diarrhea
Functional
Organic
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Some red-flag symptoms and signs suggesting
organic gut disease

• Rectal bleeding
• Weight loss
• Continuous diarrhea
• Constant and recent distension
• Anemia
• Fever
• Occasionally IBS patients lose weight because
  they food intake to avoid meal-induced symptoms

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IBS
Abdominal discomfort
Constipation
Diarrhea
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Distribution of abdominal pain induced by
balloon inflation
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Prevalence of IBS among Thai, American and
British
Thai
American British Rural
Urban No of subjects 401 676
789 301Mean age 41 31
24 NA women 56 31 58
55Change bowel pattern due to 3.5
21.3 70.5 NA stress()Abdominal pain
due to stress 1.8 15.5
54.1 NAPainless diarrhea 0 3.6
4.9 4.7Painless constipation 9.5 7.1
17.5 10.3Spastic colon
syndrome 5.7 4.3 22.3
13.6
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Diagnoses

• Most likely diagnosis is IBS
• Differentiate diagnoses
• Giardiasis
• Strogyloidiasis
• Lactose intolerance
• IBD
• Drugs

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Some drugs commonly disturb bowel function

• Drugs causing constipation
• Opiates (e.g. codeine, morphine)
• Phenothiazines (e.g. chlorpromazine)
• Tricyclic antidepressants (e.g. amitriptyline)
• 5-HT3 antagonist (e.g. ondansetron)
• Calcium channel blockers
• Anticholinergics
• Calcium carbonate

• Drugs causing diarrhea
• Misoprostol
• Cisapride
• Antacids containing magnesium hydroxide
• Herbal teas containing senna
• Alcohol
• Caffeine

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Criteria for diagnosing irritable bowel syndrome
Rome I criteria 1. Abdominal pain or
discomfort relieved with defecation or associated
with a change in stool frequency or associated
with a change in stool consistency and 2. Two
or more of the following on at least 25 of
occasions or days Altered stool frequency
Altered stool form Altered stool passage
Passage of mucus Bloating or distension
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Criteria for diagnosing irritable bowel syndrome
Rome II criteria 12 weeks or more in the
last 12 months of abdominal discomfort or pain
that has two of the following three features
1. Relieved by defecation 2.
Associated with a change in frequency of stool
3. Associated with a change in consistency of
stool The second group of criteria included
in Rome I are now considered supportive rather
than mandatory in the diagnosis. Thom
son. 1999.
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Symptom criteria to exclude organic disease in
patients with possible IBS
Young age group Chronic recurrent symptoms Mild
to moderate symptoms No signs of organic
disease
Middle age New onset of symptoms No signs of
organic disease
Age gt 50 yr Change in symptoms or new
onset of symptoms Severe symptoms Sign of organic
disease
Minimal diagnostic work up
Limited diagnostic work up
Full diagnostic work up
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Initial work-up in patients with suspected IBS

• History
• Physical examination
• (including digital examination of rectum)
• CBC
• Erythrocyte sedimentation rate
• Occult faecal blood test
• Colonic examination (discussed on an individual
  basis)
• Abdominal ultrasound (discussed on an individual
  basis)

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Stage in the evaluation of the irritable bowel
syndrome (IBS)
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• CBC Hct 40, Wbc 8500, PMN 82 L18, Mono
  1, Plt 180000
• Stool exam no parasite, no rbc no
  wbc, occult blood ve

Sigmoidoscopy normal
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Randomized , Double-Blind, Placebo-Controlled
Treatment Trial for the Irritable Bowel Syndrome
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Randomized , Double-Blind, Placebo-Controlled
Treatment Trial for the Irritable Bowel Syndrome
Test agent Ispaghula Psyllium Ispaghul
a Loperamide
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Newly approved prescription treatment for IBS

• Treatment
• Tegaserod maleate1
• 5 HT4 receptor partial agonist
• Indicated for the short term treatment of
  women with
• IBS whose primary bowel symptom is constipation
• Alosetron hydrochloride2
• 5 HT3 receptor partial agonist
• Indicated only for women with severe diarrhea
  
• predominant IBS who have
• Chronic IBS symptoms (generally lasting 6 months
  
• or longer)
• Has anatomic or biochemical abnormalities of the
  
• GI tract excluded
• Failed to respond to conventional therapy

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• ????????????????????
• A) Imodium
• B) Buscopan
• C) Mebeverine
• D) Psyllium

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Recommendations

• Various antispasmodics can be given to
• reduce pain, those with an anticholinergic
• action appearing to be slightly more
  effective
• Tricyclic antidepressants can be beneficial for
  
• pain, initially at a low dose, but
  occasionally
• higher doses may be required. They are best
• avoided if constipation is a major feature

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Recommendations

• Patients with urgency and diarrhea can be
• successfully treated with loperamide at doses
  of
• 4 - 12 mg daily. Codeine is a reasonable
  alternative
• but more likely to cause unwanted sedation
• A small number of patients with diarrhea
• predominant IBS have bile salt malabsorption
  and
• may response to cholestyramine

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Case 2 Treatment

• ??? Mebeverine 1x3 , Imodium 1 tab prn, Buscopan
  1 tab prn ??????????? ????????????????
• 6 ????? ??????????????????????????????
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  ??????????????????????????????????? ??????? 40 ??
  ????? 1 ????????? ????????????
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Case 2 episode 2

• CBC normal
• Stool exam normal
• ???????????????????????????

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Patients in English general practice with fear of
cancer or other serious disease
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FOBT vs SIGMOIDOSCOPY (FS) vs COLONOSCOPY in
detection of colorectal cancer among Chinese

• 505 asymptomatic adults older than 50 years were
  recruited from the general public through health
  exhibitions. All enrolled subjects were offered
  FOBT and full colonoscopy under sedation.
• 476 (94.3) had a complete colonoscopy were
  recorded.
• Lesions at the distal 40 cm in the left colon and
  rectum were taken as findings of FS.
• 
  Advanced colonic lesions
  
• 
  sensitivity
  specificity
• FOBT
  14.3
  79.2
• FS
  77.8
  83.9
• Combining FOBT with FS would not significantly
  improve the results of FS alone.
• Among the 385 subjects with a normal distal
  colon, 14 (3.6) had advanced lesions in the
  proximal colon that would be missed by FS alone.
  
• Advanced colonic lesions adenoma gt or 10
  mm, villous adenoma, adenoma with moderate or
  severe dysplasia, or invasive cancer

Sung JJ et al Gastroenterology. 2003
Mar124(3)608-14
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Management guideline for IBS

• Listen to the patient
• Explanation and reassurance
• Healthy lifestyle advice
• Dietary advice
• Psychological considerations
• Psychological treatment
• Pharmacological approach

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Dietary advice for IBS

• Simple dietary advice will benefit some
  patients with
• diarrhea who have excessively large intakes of
• indigestible carbohydrate, fruits or caffeine.
  
• Those with diarrhea , whose intake of lactose is
  
• substantial (gt 0.5 pint 280 ml)milk/day may
  benefit from
• a trial of lactose exclusion and/or a lactose
  tolerance test.
• Constipated patients with low fiber intake
  should be given
• a trial of a high fiber diet.

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Phrases to introduce a patient to the possible
role of psychological factors

• We may not know what causes IBS but we do know it
  gets worse when people are under stress or are
  upset
• This is especially likely to happen in people who
  have strong feelings
• Its especially likely to happen when people
  dont share their feelings but bottle them up
  inside
• Some of us express our feelings through our guts,
  so people talk about gut reactions and
  gut-wrenching experiences
• Having gut symptoms is stress in itself,
  especially if you dont tell anyone about them
• Getting upset can make symptoms worse, so its
  easy to get into a vicious circle

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Dos and donts of IBS management

• Dos
• Approach the patient empathically
• Explore any hidden agenda
• Explain nature of the disorder thoroughly

• Donts
• Discourage the patient from seeing you again
• Punish the patient
• Assume psychogenic origin of the symptoms
  without proper assessment
• Feel forced into repeated or needless
  investigations

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Thank you for your attention

• This presentation is placed on the website of
  Department of Medicine, KKU.
• http//www.med.mykku.net