1. Gastrointestinal Disease
Case
A 38 year old woman presents to the office with complaints of upper abdominal pain. She describes
pain as intermittent gnawing discomfort, often worse after meals. She denies any change in bowel
habits, dark stool or blood in the stool. She has not had any weight loss.
• What is your differential diagnosis?
• What other features of the history and physical exam would you focus on?
The patient reports none of the “alarm” symptoms on history. On exam she has some mild
midepigastric tenderness, no palpable masses. Rectal exam is normal, stool is negative for occult
blood.
• How would you proceed with your work-up?
• Should she have an endoscopy?
• Should she be tested for H. Pylori?
Her H. Pylori serology is positive. You opt to treat empirically.
• What regimen would you use?
The patient completes her treatment and 1 month later reports that her symptoms have completely
resolved. The following year she comes in for her annual exam and mentions that she is having
frequent “heartburn”
• What lifestyle modifications would you recommend?
• How would you treat her?
• Does she need an endoscopy?
America’s OB/GYN Board Review Course™ Miller
April 2013 97

2. Gastrointestinal Disease
Dyspepsia
Definitions
• Dyspepsia refers to pain or discomfort centered in the upper abdomen (mainly in
or around the midline as opposed to the right or left hypochondrium).
• Functional dyspepsia (normal dyspepsia)- normal endoscopy
• Structural dyspepsia – abnormal endoscopy
 Peptic ulcer disease (duodenal and peptic ulcer)
 Gastritis
 Esophagitis
 Gastric carcinoma
Functional dyspepsia (60%)
• Defined as 3 month h/o dyspepsia with no structural or biochemical explanation
• Etiology unclear
• Associated with GI dysmotility, altered visceral sensation, psychiatric d/o
• Most common form of dyspepsia
• Treatment controversial
• A number of medications have been tried (H2 blockers, prokinetic agents, PPI)
• Patient education, validation important
Peptic Ulcer Disease (15-25%)
• Pain occurs 2-5 hours after eating
• Pain described as gnawing, burning
• Most often localized to the epigastrum, may radiate to back
• Usually episodic
• Frequently nocturnal
• Relieved by food
• 95% duodenal ulcers, 70% of gastric ulcers caused by H. Pylori
• 70% of gastric ulcer caused by H. Pylori
Gastritis
• The term gastritis is used to denote inflammation associated with mucosal injury
• Most often caused by drugs (NSAIDs, alcohol) or Helicobacter pylori
Alarm symptoms: (Don’t want to miss gastric carcinoma!)
• Age > 55 with new-onset dyspepsia
• Unintended weight loss
• GI Bleeding
• Progressive dysphagia
• Odynophagia
• Unexplained iron deficiency anemia
• Persistent vomiting
• Palpable mass or lymphadenopathy
America’s OB/GYN Board Review Course™ Miller
April 2013 98

3. • Family h/o UGI carcinoma
• Jaundice
H. Pylori
• In U.S. H. Pylori present in 10% of 18-30 yo, 50% in > 60 yo
• More common in black and Hispanic population and lower socioeconomic groups
• Transmission is oral-oral or fecal-oral
• Disrupts protective mucosal layer resulting in cell injury
• Diagnosis
o Blood test for specific antibodies
o Urea breath test
o Stool tests
o Endoscopy with tissue examination/culture
Treatment Regimens for H.Pylori
America’s OB/GYN Board Review Course™ Miller
April 2013 99

4. Gastoresophageal reflux disease (GERD)
 Clinical symptoms include heartburn, regurgitation and dysphagia
 May mimic angina pectoris
 Can lead to esophagitis
 Complications may include reflux-induced asthma, laryngitis, cough
 Less commonly may lead to Barrett’s esophagus, stricture, cancer
 Treatment
o Lifestyle modification
• Small frequent meals
• Elevate head of bed
• Avoid alcohol, caffeine, smoking, caffeine
• Avoid citrus, tomato foods, chocolate, mints, fatty foods
• Weight management
o Medications
• Over-the-counter antacids
• H2 Blockers (Ranitidine 150 mg BID)
• Proton pump inhibitors
Indications for endoscopy for GERD
• Failure of empiric therapy
• Alarm symptoms
o Over 50 yo with new onset sxs
o GI Bleeding
America’s OB/GYN Board Review Course™ Miller
April 2013 100
REGIMEN SIDE EFFECT CURE RATE
2- Drug Regimens
Amoxicillin + PPI Low-medium <70-80%
Clarithromycin +PPI Low-medium >70-90%
3-Drug Regimens
Clarithromycin + metronidazole + PPI Medium >80-90%
Clarithromycin + Amoxicillin + PPI Low-medium >80-90%
Amoxicillin + Metronidazole + PPI Medium >80-90%
Tetracycline + Metronidazole + Sulcrafate Medium >80-90%
4-Drug Regimens
Bismuth + Metronidazole + Tetracycline+ H2 Blocker Medium-high >80-90%
Bismuth + Metronidazole + Amoxicillin + PPI Medium-high >70-90%
Bismuth + Metronidazole + Tetracycline +PPI Medium-high >80-90%
Bismuth + Metronidazole + Clarithromycin + PPI Medium-high >80-90%
Combination Products
Helidac (Bismuth, metronidazole, tetracycline) + H2
blocker
Medium-high Up to 82%
Prevpac (Amoxiciliin, Clarithromycin,PPI) Low-medium 81-92%
Pylera (Bismuth, metronidazole, tetracyline Low-medium 84-94%

5. o Unintended Weight loss
o Anemia
o Dysphagia/odynophagia
o Long duration of frequent symptoms
Diarrhea
Acute < 14 days Most due to infectious and are self-
limited
Persistent >14 days
Chronic >30 days IBS, IBD, malabsorption, secretory
America’s OB/GYN Board Review Course™ Miller
April 2013 101
Evaluation of Acute Diarrhea

6. Irritable Bowel Syndrome
• Female to male ratio of 2-3 :1
• Most common between ages of 20-40
Clinical Manifestations
• Crampy abdominal pain for > 3 months, usually lower quadrants, often on the left
America’s OB/GYN Board Review Course™ Miller
April 2013 102
Specific Therapy for Diarrhea

7. • Altered bowel habits – diarrhea and/or constipation
• May have bloating, nausea, dyspepsia, early satiety, increased flatulence or
belching
• Patients with IBS often complain of a broad range of non-gastrointestinal
symptoms including impaired sexual function, dysmenorrhea, dyspareunia, and
increased urinary frequency and urgency.
Work-up for IBS
1. Careful history and physical (exam should be normal)
2. Rule out dietary causes and/or medications (lactose , mg –containing antacids
cause diarrhea, anticholinergics, ca-channel blockers can cause constipation)
3. Look for other underlying etiologies such as depression, anxiety, physical, sexual
or substance abuse
4. Look for alarm symptoms
a. > 50 yo with new sxs
b. GI bleeding
c. Unintended weight loss
d. Family history of colon cancer
e. Recurring fever
f. Anemia
g. Chronic severe diarrhea.
5. Lab evaluation should include CBC, chemistries, and stool for WBC, Cx, O&P, c.
diff (to r/o infectious etiology)
6. Recommend flex sig/colonoscopy for patients with any alarm symptoms or for
persistent symptoms
Treatment of IBS
• Cure is not expected, but symptoms can be modified
• Most important element is reassuring, therapeutic patient-physician relationship
• Therapy should include
o Avoidance of foods the increase symptoms
o High fiber diet (25-35 gm fiber/day)
o Medication efficacy has not been established in RCTs
o Trial of medications may be warranted
• Antidiarrheal agents (loperamide, diphenoxylate)
• Anticholinergics (belladonna, dicylomine, hycosamine) for
pain/gas/bloating
• Tricyclic antidepressants may be helpful in pain-dominant
IBS
• Tegaserod (Zelnorm)
America’s OB/GYN Board Review Course™ Miller
April 2013 103

8. o Removed from market
o Was for constipation-dominant IBS in women
Inflammatory Bowel Disease
• Incidence peaks in 2nd
and 3rd
decade
• Usually present with recurrent diarrhea and abdominal pain, fever
• Often anemic, may have leukocytosis, thrombocytosis
• May have electrolyte abnormalities and elevated ESR
• Diagnostic test = colonoscopy
• Extraintestinal manifestations of IBD include iritis, episcleritis, arthritis, and skin
involvement, as well as pericholangitis and sclerosing cholangitis.
Crohns disease Ulcerative Colitis
Involves all layers of the bowel
Can occur anywhere in GI tract
Lesions discontinuous with skip areas
Most commonly present with nonbloody
diarrhea
May recur after surgery
Involves only mucosa and submucosa
Only involves rectum and lg bowel
Lesions continuous with abrupt
demarcation
Most commonly present with bloody
diarrhea
Surgery usually curative
Medications for IBD
• Aminosalicylates (sulfasalazine, mesalamine) – used for maintenance therapy
• Steroids – used for acute attacks
• Immunosuppressants (Azathioprine) – useful for patients unable to tolerate
steroids
• Tumor Necrosis Inhibitors (Inflixamab) – used to induce remission in patients
unresponsive to other treatments
Complications of IBD
• Perforation, toxic megacolon (UC > Crohns)
• Strictures
• Fistulas and Abcesses (Crohns > UC)
• Colon cancer – risk increases with extent and duration of disease
Screening for Colon Cancer
Risk factor Age to initiate screening Interval of screening
Average risk 50 years
45 years for African American
FOBT yearly
Sigmoidoscopy q 5 yrs
Colonoscopy q 10 yrs
Family history Screen as average risk Interval as in average risk
America’s OB/GYN Board Review Course™ Miller
April 2013 104

9. 1 second degree or third degree
relative
Family history
1 first degree or 2 second degree
relatives > 60 yrs
40 years Colonoscopy q 5-10 years
Family history
1 first degree or 2 second degree
relatives < 60 yrs
40 years or 10 years prior to the
index case, whichever comes first
Colonoscopy q 5-10 years
Familial adenomatous polyposis
(FAP)
10-12 years Yearly sigmoidoscopy. If genetic
test positive, colectomy
recommended
Hereditary nonpolyposis
colorectal cancer (HNPCC)
20-25 years or 10 years prior to
the youngest dx of colon cancer
in the family
Colonoscopy q 1-2 years
Inflammatory bowel disease Begin screening after 8-10 years
of disease
Yearly colonoscopy
Oral Defense Tips
 I refer patients with dyspepsia for endoscopy if they have any “alarm symptoms”
(weight loss, blood in stool, unexplained anemia) or they are using chronic
NSAIDs
 My initial treatment for dyspepsia is to do blood testing for H. Pylori and treat if
positive (Prevpac as directed)
 I would counsel a woman with GERD symptoms to have small frequent meals,
elevate the head of the bed, avoid alcohol, caffeine, smoking, caffeine, avoid
citrus, tomato foods, chocolate, mints, fatty foods, and control weight.
 My initial approach to the assessment of diarrhea is to determine duration of
symptoms, and look for signs of dehydration or inflammation (blood, fever). If
the sxs are less than 48 hours, there is no fever or blood in the stool and no signs
of dehydration, I recommend fluid, rest and bland diet.
 My initial approach to the treatment of IBS is to recommend a high fiber diet (25-
35 gm/day) and I ask the patient to keep a food diary.
 I recommend colon cancer screening to ALL women starting at 50 years old and
to African American women starting at 45 years old.
STUDY QUESTIONS
Yearly screening colonoscopy should be recommended for patients with:
A. Irritable bowel syndrome
America’s OB/GYN Board Review Course™ Miller
April 2013 105

10. B. Occult blood on rectal exam
C. Familial adenomatous polyposis
D. A first degree family member diagnosed with colon cancer under
the age of 60.
A 32 year old woman returns from a camping trip and develops acute diarrhea.
The most likely organism is:
A. E. Coli
B. V.cholera
C. Campylobacter
D. Giardia
Updated 02/13
America’s OB/GYN Board Review Course™ Miller
April 2013 106