Crohn’s Disease Presentations

Crohn’s Disease Presentations
University of Maryland Inflammatory Bowel Disease Symposium 2006

Management Dilemmas in Ulcerative Colitis
By:Stephen Bickston, M.D.
Assistant Professor of Medicine, University of Virginia

http://www.umm.edu/ibd/ppt/dilemmas_uc_bickston.ppt
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Management Dilemmas in Crohn's Disease
By:Raymond Cross, M.D.
Assistant Professor of Medicine
Director, IBD Program
Division of Gastroenterology and Hepatology, University of Maryland

http://www.umm.edu/ibd/ppt/dilemmas_cd_cross.ppt
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Perioperative Management of the Patient with Crohn’s Disease
By:David Binion, M.D.
Director, IBD Center
Associate Professor of Medicine
Division of Gastroenterology & Hepatology, Medical College of Wisconsin

http://www.umm.edu/ibd/ppt/perioperative_manage_binion.ppt
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Perianal Crohn’s Disease: "A review and exploration on how to improve outcomes through the use of imaging"
By:David A. Schwartz, M.D.
Director, Inflammatory Bowel Disease Center
Vanderbilt University Medical Center

http://www.umm.edu/ibd/ppt/perianal_cd_schwartz.PPT
Source:University of Maryland Medical Center

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Inflammatory Bowel Disease Symposium 2007 Presentations

University of Maryland Inflammatory Bowel Disease (IBD)Symposium 2007 Presentations

Colorectal Dysplasia/Cancer in IBD
by:David Rubin, M.D.
Associate Professor of Medicine
Co-Director, Inflammatory Bowel Disease Center, University of Chicago Medical Center

http://www.umm.edu/ibd/ppt/prevent_colorectal_cancer_ibd.ppt
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Issues in the Care of Pediatric and Adolescent IBD
By:Marla Dubinsky, M.D.
Assistant Professor of Medicine and Director of the Pediatric Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, California

http://www.umm.edu/ibd/ppt/care_teens_ibd.ppt
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Hepatic Complications in IBD
By:Preeti Reshamwala, M.D.
Assistant Professor of Medicine
Medical Director, Transplant Hepatology
University of Maryland Medical Center

http://www.umm.edu/ibd/ppt/care_teens_ibd.ppt
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Use of Psychotropic Agents in the Treatment of IBS
By:Arnold Wald, M.D.
Associate Professor of Medicine Section of Gastroenterology and Hepatology
University of Wisconsin School of Medicine and Public Health Madison, Wisconsin

http://www.umm.edu/ibd/ppt/diagnostic_approach_ibs.ppt
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Utility of Capsule Endoscopy in IBD and IBS
By:Eric Goldberg, M.D.
Assistant Professor of Medicine
Division of Gastroenterology & Hepatology
University of Maryland Medical Cente

http://www.umm.edu/ibd/ppt/wireless_capsule_endoscopy_ibd_ibs.ppt
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Prebiotics, Probiotics, and Antibiotics; Controversies in the Treatment of IBS
By:Brian E. Lacy, Ph.D., M.D.
Associate Professor of Medicine, Dartmouth Medical School
Director, GI Motility Laboratory, Dartmouth-Hitchcock Medical Center

http://www.umm.edu/ibd/ppt/biotics_treat_ibs.ppt
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Novel Diagnostic Techniques in IBD
By:Mark Flasar, M.D.
Assistant Professor of Medicine
Division of Gastroenterology and Hepatology
University of Maryland Medical Center

http://www.umm.edu/ibd/ppt/novel_diag_strat.ppt
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Emergence of New Biologic Agents in IBD; Top Down vs. Step Up Approach
By:David G. Binion, M.D.
Director, IBD Center, Division of Gastroenterology & Hepatology
Professor of Medicine, Medical College of Wisconsin

http://www.umm.edu/ibd/ppt/biologic_agents_ibd.ppt
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Safety Concerns with IBD Therapy
By:James D. Lewis, M.D., M.S.C.E.
University of Pennsylvania, Division of Gastroenterology Center for Clinical Epidemiology & Biostatistics

http://www.umm.edu/ibd/ppt/safety_ibd_therapies.ppt
Source:University of Maryland Medical Center

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The Digestive System

The Digestive System
Very detailed lecture Presentation by:Patricia Zuk, Santa Monica College

The Digestive System
* Mouth---bite, chew, swallow
* Pharynx and esophagus----transport
* Stomach----mechanical disruption; absorption of water & alcohol
* Small intestine--chemical & mechanical digestion & absorption
* Large intestine----absorb electrolytes & vitamins (B and K)
* Rectum and anus---defecation

Layers of the GI Tract
1. Mucosal layer
2. Submucosal layer
3. Muscularis layer
4. Serosa layer

Mucosa
* Epithelium
* Lamina propria
* Muscularis mucosae---thin layer of smooth muscle

Submucosa
* Loose connective tissue
* Meissner’s plexus

Muscularis
* Skeletal muscle = voluntary control
* Smooth muscle = involuntary control
* Auerbach’s plexus (myenteric)

Serosa
* An example of a serous membrane
* Covers all organs and walls of cavities not open to the outside of the body
* Secretes a serous fluid
* Consists of connective tissue covered with simple squamous epithelium

Peritoneum
* Peritoneum
* Peritoneal cavity
* Mesentery – small intestines
* Mesocolon – large intestine
* Lesser omentum
* Greater omentum
* Peritonitis = inflammation

Greater Omentum, Mesentery & Mesocolon
Lesser Omentum
The path of food:
oral cavity/teeth/salivary glands
oropharynx/epiglottis
esophagus
stomach
small intestine: duodenum
small intestine: ileum
small intestine: jejunum
large intestine: ascending colon
large intestine: transverse colon
large intestine: descending colon
sigmoid colon
rectum
anus

Mouth
* Oral cavity proper---the roof = hard, soft palate and uvula
* Lined with an oral mucosa (stratified squamous epithelium & lamina propria)
* Landmarks: lingual frenulum, labial frenulum, uvula

Pharyngeal Arches
* Two arches skeletal muscles that elevate the soft palate when we swallow
* Palatoglossal muscle
* Palatopharyngeal muscle

Structure and Function of the Tongue
* Muscular structure covered with an oral mucosa
* Muscle of tongue is attached to hyoid, mandible, hard palate and styloid process
* Two groups of muscles
* 1. Intrinsic muscless
* 2. Extrinsic muscles

Salivary Glands
* Parotid below your ear and over the masseter
* Submandibular is under lower edge of mandible
* Sublingual is deep to the tongue in floor of mouth
* All have ducts that empty into the oral cavity (exocrine glands)
* Wet food for easier swallowing
* Dissolves food for tasting
* Bicarbonate ions buffer acidic foods
* Helps build stronger enamel
* Chemical digestion begins with enzyme salivary

amylase & lingual lipase
* Also contains lysozyme ---helps destroy bacteria
* Protects mouth from infection with its rinsing action---1 to 1 and 1/2qts/day
* Cells in acini (clusters)
* Serous glands - cells secrete a watery fluid - parotid
* Mucous glands - cells (pale staining) secrete a slimy, mucus secretion
* Mixed glands secrete both mucus and serous fluids – submandibular & sublingual

Salivation
* Increase salivation
* Stop salivation

Primary and Secondary Dentition

Teeth:

-grinding, tearing and shearing of food
-two main divisions: crown and root
-crown: above gumline/gingiva
-root: entry of nerves and blood vessels via the apical foramen
-neck – where crown and root meet
-gingiva forms a seal at this area
-innermost layer - pulp (nerves/blood vessels)
-nerves and BVs enter the root and travel
through root canals to enter the pulp cavity

-outer covering of calcified connective tissue – dentin
-outermost layer - enamel
-dentin and enamel – made of calcium phosphate (similar to bone)

Pharynx
* Funnel-shaped tube extending from internal nares to the esophagus (posteriorly) and larynx (anteriorly)
* Skeletal muscle lined by mucous membrane
* Deglutition or swallowing is facilitated by saliva and mucus

Esophagus
* Collapsed muscular tube
* In front of vertebrae
* Posterior to trachea
* Posterior to the heart
* Pierces the diaphragm at hiatus
* Mucosa = stratified squamous
* Submucosa = large mucous glands
* Muscularis = upper 1/3 is skeletal, middle is mixed, lower 1/3 is smooth

Physiology of the Esophagus - Swallowing
* Voluntary phase---tongue pushes food to back of oral cavity
* Involuntary phase----pharyngeal stage
* Peristalsis pushes food down
* Travel time is 4-8 seconds for solids and 1 sec for liquids
* Lower sphincter relaxes as food approaches

Anatomy of Stomach
* Size when empty
* Muscularis – three layers of smooth muscle
* Parts of stomach
* Empties as small squirts of chyme leave the stomach through the pyloric valve

Histology of the Stomach - Mucosa
* simple columnar epithelium with embedded surface mucus cells
* lamina propria layer under the epithelium (areolar connective tissue) + muscularis mucosae (smooth muscle)
* along the mucosa – will find columns of secretory cells = gastric glands that open into the stomach lumen through gastric pits
* Hydrochloric acid (parietal cells) converts pepsinogen (from chief cells) to the enzyme pepsin = protein digestion
* Intrinsic factor (parietal cells)
* Gastrin hormone (G cell)

Anatomy of the Small Intestine
Small Intestine

* Structures that increase surface area

Small intestine - Mucosa
* Absorptive cells
* epithelial cells at the bottom of the villus form a gland = Intestinal gland
* Goblet cells – mucus production
* Enteroendocrine cells
* Paneth cells
* Submucosal layer has duodenal glands


Anatomy of Large Intestine
* 5 feet long by 2½ inches in diameter
* Ascending & descending colon are retroperitoneal
* Cecum & appendix
* Rectum = last 8 inches of GI tract anterior to the sacrum & coccyx
* Anal canal = last 1 inch of GI tract

Histology of Large Intestine
* Muscular layer
* Serosa = visceral peritoneum
* Appendix

Histology of Large Intestine
* Mucosa
* Submucosal & mucosa contain lymphatic nodules

Defecation
* Gastrocolic reflex moves feces into rectum
* Stretch receptors signal sacral spinal cord
* Parasympathetic nerves contract muscles of rectum & relax internal anal sphincter
* External sphincter is voluntarily controlled

Anatomy of the Pancreas
* 5" long by 1" thick
* Head close to curve in C-shaped duodenum
* pancreatic duct joins common bile duct from liver
* Opens 4" below pyloric sphincter

Histology of the Pancreas
* Acini- dark clusters
* Islets of Langerhans

Composition and Functions of Pancreatic Juice
* 1 + 1/2 Quarts/day at pH of 7.1 to 8.2
* Contains water, enzymes & sodium bicarbonate
* Digestive enzymes
o pancreatic amylase, pancreatic lipase, proteases
# trypsinogen---activated by enterokinase (a brush border enzyme)
# chymotrypsinogen----activated by trypsin
# procarboxypeptidase---activated by trypsin
# proelastase---activated by trypsin
# trypsin inhibitor---combines with any trypsin produced inside pancreas
o ribonuclease----to digest nucleic acids
o deoxyribonuclease

Anatomy of the Liver and Gallbladder

* Liver
* Gallbladder

Blood Supply to the Liver
* Hepatic portal vein
* Hepatic artery from branch off the aorta (Common hepatic artery from the celiac trunk)

Histology of the Liver
* Hepatocytes arranged in lobules
* Sinusoids in between hepatocytes are blood-filled spaces
* Kupffer cells phagocytize microbes & foreign matter

Gallbladder
* Simple columnar epithelium
* No submucosa
* Three layers of smooth muscle
* Serosa or visceral peritoneum

Bile Production
* One quart of bile/day is secreted by the liver
* Components

Flow of Bile
* Bile capillaries
* Hepatic ducts connect to form common hepatic duct
* Cystic duct from gallbladder & common hepatic duct join to form common bile duct
* Common bile duct & pancreatic duct empty into duodenum

Liver Functions--Carbohydrate Metabolism
* Turn proteins into glucose
* Turn triglycerides into glucose
* Turn excess glucose into glycogen & store in the liver
* Turn glycogen back into glucose as needed

Liver Functions --Lipid Metabolism
* Synthesize cholesterol
* Synthesize lipoproteins----HDL and LDL (used to transport fatty acids in bloodstream)
* Stores some fat
* Breaks down some fatty acids

Liver Functions--Protein Metabolism
* Deamination = removes NH2 (amine group) from amino acids
* Converts resulting toxic ammonia (NH3) into urea for excretion by the kidney
* Synthesizes plasma proteins utilized in the clotting mechanism and immune system
* Convert one amino acid into another

Other Liver Functions
* Detoxifies the blood by removing or altering drugs & hormones (thyroid & estrogen)
* Releases bile salts help digestion by emulsification
* Stores fat soluble vitamins-----A, B12, D, E, K
* Stores iron and copper
* Phagocytizes worn out blood cells & bacteria
* Activates vitamin D (the skin can also do this with 1 hr of sunlight a week)

Types of Digestion
* Mechanical – mouth, stomach, LI
* Chemical – mouth, stomach, SI

Chemical Digestion in GI tract
Digestion of Carbohydrates
* Mouth---salivary amylase
* Esophagus & stomach---nothing happens
* Duodenum----pancreatic amylase
* Brush border enzymes (maltase, sucrase & lactase) act on disaccharides

Digestion of Proteins
* Stomach
* Pancreas
* Intestines

Digestion of Lipids
* Mouth----lingual lipase
* Small intestine

Digestion of Nucleic Acids
* Pancreatic juice contains 2 nucleases
* Nucleotides produced are further digested by brush border enzymes (nucleosidease and phosphatase)

Digestion in the Mouth
* Mechanical digestion (mastication or chewing)
* Chemical digestion

Stomach--Mechanical Digestion
* Gentle mixing waves
* More vigorous waves
* Intense waves near the pylorus

Stomach--Chemical Digestion
* Protein digestion begins
* Fat digestion continues
* HCl kills microbes in food
* Mucous cells protect stomach walls from being digested with 1-3mm thick layer of mucous

Absorption of Nutrients by the Stomach
* Water especially if it is cold
* Electrolytes
* Some drugs (especially aspirin) & alcohol
* Fat content in the stomach slows the passage of alcohol to the intestine where absorption is more rapid
* Gastric mucosal cells contain alcohol dehydrogenase that converts some alcohol to acetaldehyde-----more of this enzyme found in males than females
* Females have less total body fluid that same size male so end up with higher blood alcohol levels with same intake of alcohol

Mechanical Digestion in the Small Intestine
* 1. Weak peristalsis in comparison to the stomach---chyme remains for 3 to 5 hours
* 2. Segmentation---local mixing of chyme with digestive juices in the SI

Small Intestine-Chemical Digestion
Digestive Hormones
* Gastrin
* Gastric inhibitory peptide--GIP
* Secretin
* Cholecystokinin--CCK

Mechanical Digestion in Large Intestine
* Smooth muscle = mechanical digestion
* Peristaltic waves (3 to 12 contractions/minute)

Chemical Digestion in Large Intestine
* No enzymes are secreted only mucous – the goblet cells in the intestinal glands
* chyme is prepared by the action of bacteria
* Bacteria ferment
* Bacteria produce vitamin K and B in colon

Absorption & Feces Formation in the Large Intestine
* food has now been in the GI tract for 3 to 10 hours
* solid or semisolid due to water reaborption = feces
* feces – water, salts, sloughed-off epithelial cells, bacteria, products of bacterial decomposition, unabsorbed and undigested materials
* 90% of all water absorption takes place in the SI – 10% in the LI
* but the LI is very important in maintaining water balance
* also absorbs some electrolytes---Na+ and Cl- and vitamins
* dietary fiber = indigestible plant carbohydrates (cellulose, lignin and pectin)
* soluble fiber – dissolves in water (beans, barley, broccoli, prunes, apples and citrus)
* insoluble fiber – woody or structural parts of the plant (skins of fruits and vegetables, coatings around bran and corn)

Where will the absorbed nutrients go?
Absorption of Water
* 9 liters of fluid dumped into GI tract each day
* Small intestine reabsorbs 8 liters
* Large intestine reabsorbs 90% of that last liter
* Absorption is by osmosis through cell walls into vascular capillaries inside villi


The Digestive System.ppt

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Digestive System

Digestive System
Presentation lecture from:deltacollege.edu

Components
* Gastrointestinal (GI) tract
o Oral cavity
o Pharynx
o Esophagus
o Stomach
o Small intestine
o Large intestine
* Accessory digestive organs
o Teeth
o Tongue
o Salivary glands
o Liver
o Gallbladder
o Pancreas

Digestive system functions
* Digestion
o Breakdown of food
* Propulsion – movement along the GI tract
* Secretion – acid, bile, digestive enzymes, mucus
* Absorption of nutrients
* Elimination

Oral cavity
* Lined by stratified squamous epithelium
* Gingivae – gums
* Salivary glands

Teeth
* Crown
* Neck
* Root(s)
* Anchored in alveoli in maxilla and mandible

Peritoneum
* Serous membrane lining the abdominopelvic cavity
* Intraperitonealt
* Retroperitoneal

Peritoneal folds
* Falciform ligament
* Lesser omentum
* Mesentery
* Greater omentum
* Mesocolon

General microscopic plan of the GI tract
* Mucosa
* Submucosa
* Muscularis
* Adventitia or serosa

Esophagus
Stomach
Stomach - microscopy
* Mucosa
* Submucosa
* Muscularis
* Serosa (visceral peritoneum)

Small intestine
Small intestine microscopy
* Increased surface area
* Mucosa
* Submucosa
* Muscularis
* Serosa (mesentery)

Large intestine
* Cecum
* Ascending colon
* Transverse colon
* Descending colon
* Sigmoid colon
* Rectum
* Anus

Liver
* Location: upper right abdomen, below diaphragm
* Intraperitoneal (covered by visceral peritoneum)
* Falciform ligament – fold of peritoneum anchored to anterior abdominal wall
* Gall bladder on inferior surface
* Lesser omentum between liver and stomach

Liver – microscopy
* Liver lobules – structural and function units
* Central vein
* Portal triads – branches of bile duct, hepatic portal vein, hepatic artery
* Cords (sheets) of hepatocytes
* Hepatic sinusoids
* Kupffer cells (macrophages)

Exocrine pancreas
* Located posterior to greater curvature of stomach
* Retroperitoneal
* Pancreatic acini – groups of secretory cells – secrete digestive enzymes
* Pancreatic duct – empties into duodenum

Exocrine pancreas
Digestive system

* Components
* Functions
* Oral cavity
* Peritoneum
* Microscopic plan
* Esophagus
* Stomach
* Small intestine
* Large intestine
* Liver
* Pancreas

Digestive system.ppt

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Gastroenterology video presentations

Gastroenterology video presentations
from University of Wisconsin

Date		Presentation
04/15/2009		Cholangiocarcinoma: A Tour with Bile Duct Bob G. Gores
03/25/2009		Screening for Pancreatic Cancer: Is There Anything on the Horizon? T. Dennie
		Quality Indicators in Curative Surgery for Colon Cancer In Vulnerable Older Adults T. Leal
03/04/2009		'It Just Keeps Getting Stuck:' A Review of Achalasia C. Dholakia
01/20/2009		Medical Student Presentations 2009 - Session II R. Baxter, R. Berg, A. Getzin, J. Tackett View description Hear the following presentations from the 2009 Medical Student Research Forum: "Discerning the Causes and Consequences of Iron-Deficiency in Infancy-Barriers to Minority Participation in Clinical Research Sub-Project" Ryan J. Baxter, Mentor: Pamela Kling, MD "Effect of Vasoactive Intestinal Peptide (VIP) on an In Vitro Chondrosarcoma Model" Ryan Berg, Mentor: John Heiner, MD "Wisconsin Medical Society 2008 Health Care Reform Survey" Anne Getzin, Mentor: Richard Rieselbach, MD "Wisconsin Medical Society Magnetic Resonance Arthrographic Study of Glenohumeral Relationships Between Genders" John Tackett, Mentor: Robert Ablove, MD, MA
12/03/2008		Intestinal Atresias: Developing a New Hypothesis from Clinical Observations in the Molecular Age of Developmental Biology P. Nichol
11/19/2008		Mesenteric Ischemia C. Zastrow
11/12/2008		'The Ileal Pouch’ 30 Years in Evolution B. Harms
		New Research in Liver Transplantation H. Lee View description H.T. Lee, MD, PhD gives an overview of problems in liver transplantation, describes hypothermic machine perfusion and shares some of his research in acute kidney injury due to liver failure.
10/29/2008		The Post Gastrectomy Syndromes A. Ibele
10/01/2008		The Ostomy: Both Friend and Foe E. Johnson
09/25/2008		Pediatric Intestinal Transplantation A. D'Alessandro
09/24/2008		Live Donor Liver Transplantation: Risk vs. Reward W. Dar
09/10/2008		Contemporary Management of Rectal Cancer E. Foley
05/21/2008		Laparoendoscopic Treatment of GI Stromal Tumors C. Dholakia
04/16/2008		Benign Biliary Stricture: Operate or Stent? A Multidisciplinary Approach S. Weber, P. Pfau
03/26/2008		Controversy in the Treatment of Gastric Cancer F. Ito
02/28/2008		Genomic Advances and Clinical Application in Pediatric Inflammatory Bowel Disease (IBD) S. Kugathasan
02/27/2008		Gastroparesis: From Emesis Basin to Enterra Therapy J. Gould
01/09/2008		Liver Flukes and Cholangiocarcinoma T. Sauerhammer
11/07/2007		Paraesophageal Hernias: Current State of Surgical Therapy J. Orr
10/22/2007		Medically Unexplained Symptoms: Medicine's Dirty Little Secret R. Moss-Morris View description Rona Moss Morris, PhD, describes her program of research to enhance coping with symptoms for individuals with chronic fatigue syndrome and irritable bowel syndrome using a model of self-regulation and cognitive behavioral therapy.
10/17/2007		Optimizing the Future Liver Remnant C. Contreras
05/16/2007		Chronic Pancreatitis: Recent Advances and Ongoing Challenges J. Matthews View description Jeffery B. Matthews, MD, professor and chair of the Department of Surgery at the University of Chicago, speaks on "Chronic Pancreatitis: Recent Advances and Ongoing Challenges" at the Health Sciences Learning Center on May 16, 2007.
05/09/2007		Endoluminal Therapies for Gastroesophageal Reflux Disease D. McKenna View description Daniel McKenna, MD, speaks on "Endoluminal Therapies for Gastroesophageal Reflux Disease" at the Health Sciences Learning Center on May 9, 2007.
04/18/2007		Hilar Cholangiocarcinoma, Klatskin Tumor F. Ito View description Fumito Ito, MD, PhD, a resident in the Division of General Surgery at the University of Wisconsin-Madison speaks on "Hilar Cholangiocarcinoma" at the Health Sciences Learning Center on April 18, 2007.
04/11/2007		Complications of Acute Pancreatitis: Management and Outcomes M. Malangoni View description

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Management Of Acute Lower Gastrointestinal Bleeding

Management Of Acute Lower Gastrointestinal Bleeding
Standard of Care Rounds
Presentation by:Mark J. Russo, MD
Advisor: Tracey D. Arnell, MD


OUTLINE

* Resuscitation
* Clinical Presentation
* Diagnostic Evaluation and Non-Surgical Treatment
* Surgical Management

RESUSCITATION

* Indications for transfusion
o Profuse bleeding
o Persistent hemodynamic instability despite crystalloid resuscitation
o Symptomatic anemia (CP, SOB, orthostasis with Hgb < 10)
o AMI or unstable angina with Hgb < 10
o transfused group
+ rebleeding 9 pts
+ longer clotting times in the transfused group.
o control group
+ rebleeding 1 pt
o significantly (P<0.001) more bleeding in the transfusion group
o no difference in mortality (2 vs 1)
o 300 severely anemic, postop pts who refused blood transfusion
* Canadian Critical Care Trials Group
o restrictive strategy (Hgb 7.0-9.0)
+ age < 55yo
+ less critically ill (APACHE scores < 20)
o liberal strategy (Hgb 10.0-12.0)
+ ischemic cardiac disease

Clinical presentation
Localization
Bleeding scan
Tagged rbc scan
Advantages
Disadvantages
Colonoscopy
Angiography
Vasopressin infusion
Embolization
Superselective embolization
Capsule endoscopy
Provocative bleeding study
Indications for surgery
Surgical management
Conclusions

Management Of Acute Lower Gastrointestinal Bleeding.ppt

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UGI Bleed

UGI Bleed
125 slides Presentation by:
Obie M. Powell, M.D.
Joseph A. Iocono, M.D.
Department of Surgery
University of Kentucky

Case study:
History
Characterization of Symptoms
Temporal Sequence
Alleviating / Exacerbating Factors
PMH
Family/Social History
What is your Differential Diagnosis?

Differential Diagnosis

* Esophageal varices
* Gastric varices
* Erosive gastritis
* Mallory Weiss tear
* Reflux esophagitis
* Gastric malignancy
* Vascular malformations
* Nose bleed
* Aorto-enteric fistula
* Gastric ulcer
* Duodenal ulcer

Physical Exam
Laboratory studies:
What is necessary?

* Type and Cross
* CBC: Do you expect anemia?
* CMP: evaluate for hepatic dysfunction and renal compromise
* Coags: active hemorrhage can cause coagulopathy and requires aggressive replacement
* ABG: probe for acidosis

Laboratory Values Discussion
Endoscopy
Surgery for Bleeding Ulcers
Operative Indications
Operative Technique
Gastrointestinal Bleeding
Discussion
Upper Gastrointestinal Bleeding
Lower Gastrointestinal Bleeding
Rectal and Anal Bleeding


Upper GastroIntestinal Bleed.ppt

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Gastro Intestinal Bleeding

Gastro Intestinal Bleeding
Presentation by:David A. Gremse, MD, FAAP, FACG
Professor and Chair of Pediatrics
University of Nevada School of Medicine

Gastrointestinal Bleeding

* Hematemesis- Vomiting of bright red blood
o usually represents bleeding proximal to the ligament of Treitz
* Hematochezia- bright red blood per rectum
o indicates a lower GI source of bleeding
* Blood has a laxative effect so with massive bleeding the stool may be bright red
* Blood streaks on the stool indicates anal outlet bleeding
* Blood mixed with stool indicates bleeding source higher than the rectum
* Blood with mucus indicates an infectious or inflammatory disease
* Currant jelly-like material indicates vascular congestion and hyperemia (intussusception or midgut volvulus)
* Maroon-colored stools indicate voluminous bleeding proximal to the rectosigmoid area
* Melena, passage of black, sticky (tarry) stools suggests upper GI tract bleeding, but can be as distal as the right colon
* Hematemesis suggests a large bleed with possible recurrence, melena alone indicates less voluminous bleeding

Causes of Upper GI Bleeding

* Common
* Nasopharyngeal bleeding
* Erosive Esophagitis
* Peptic ulcer
* Gastritis (H. pylori)
* Mallory-Weiss tear
* Prolapse gastropathy

* Less Common
* Bleeding disorders
* Duplication cyst
* Foreign body
* Tube trauma
* Vascular malformation
* Esophageal varices


Causes of Lower GI Bleeding

* Common
* Anal fissure
* Infectious colitis Salmonella, Shigella, Campylobacter, C.diff
* Inflammatory bowel disease
* Intussusception
* Upper GI source

* Less Common
* Meckel’s diverticulum
* Duplication cyst
* Hirschsprung’s enterocolitis
* Gangrenous intestine
* Vascular malformation

Clinical Findings in PUD Neonatal Period
Clinical Findings in PUD Infants and Toddlers
Clinical Findings in PUD Pre-Schoolers
Clinical Findings in PUD School Age
Pathophysiology of GI Bleeding
Causes and Effects of H+ Ion Backdiffusion
Lowflow states Drugs, EtOH Stress H. pylori Bile Reflux
Mucosal Barrier Break
Parietal Cells
Release of histamine + Vasodilatation
Increased HCl and Pepsin Secretion
Peptic Ulcer Disease Diagnostic Evaluation
Indications for EGD
Case #1 – UGI Bleeding
Esophageal varices
Case #2 – UGI Bleeding
Prolapse Gastropathy
Meckel’s Scan
99mTc- Labeled Red Cell Scan
GI Bleeding - Treatment
Drug Efficacy in Healing Ulcers
ATLS Classification of Shock
Management - Octreotide
GI Bleeding – Summary
Questions

Gastro Intestinal Bleeding.ppt

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Gastrointestinal Imaging

Gastrointestinal Imaging
Presentation by:Rajneesh Mathur D.O.

Basic Imaging Techniques

* Plain Film Radiography
o Quick, Easy, Inexpensive
o “Snapshot” of a dynamic system
o Technique
+ Bones
+ Upper quadrants
+ Flanks
+ Mid-Abdomen
+ Lower Abdomen

Plain Film Radiography Continued

* Acute Abdominal Series
o Supine
+ Detects fluid/blood in peritonuem
+ Detects gas in bowel
o Upright
+ Air Fluid Levels
o Left Lateral Decubitus
o Upright CXR
+ Best for free air

Contrast Radiography

* Barium Sulfate
o Standard for contrast GI studies
o Insoluble, High viscosity
o Not absorbed by the GI tract
* Gastrograffin
o Soluble, Low viscosity
o Not absorbed by the GI tract
o Laxative Effect
+ Not recommended in Peds

Computed Tomography

* Imaging of SOLID organs
* View of RETROPERITONEUM
* Oral Contrast
o Identify bowel
* IV Contrast
o Blood Vessels
* 2 Phases


Radionuclide Scanning

* Replaced by Ultrasound in ED secondary to time

Ultrasonography

* Inexpensive
* Non-Invasive
* Air is a poor conductor
* Solid structures conduct well

Specific Gastrointestinal Conditions

* Plain Film Radiography
* Abdominal CT
* Ultrasound
* Air Contrast or Barium Enema
* Angiography
* Radionuclide Scanning
* MRI

Plain Film Radiography

* In past, every belly pain got plain films
o 10 to 40% of the time it does not change clinical management
o Get it for
+ SBO
+ Free Air
+ Ileus
+ Bowel Ischemia
+ Foreign Bodies

Abdominal Computed Tomography

* Diagnostic Tool of Choice for:
o Diverticulitis
o Pancreatitis
o Pancreatic Pseudocysts
o Aortic Aneurysm
o Blunt Trauma
o Appendicitis
* Can pinpoint a diagnosis in 95% of cases where clinical judgment fails to narrow a wide range of potential diagnoses

Ultrasonography

* Initial study for patients with
o RUQ pain
o Pelvic Pain
o Acute Appendicitis



Air Contrast or Barium Enema

* Used for
o Intussusception
o Has been replaced by CT for suspected abdominal aortic aneurysm
o May be helpful in evaluation of patients with lower GI bleed

Angiography
Radionuclide Scanning

* Can be useful as an adjunct to Ultrasound when suspicion of
o Cholecystitis
o Cystic Duct obstruction
o No Role in the imaging of the GI tract in the ED

MRI
Gastrointestinal Imaging.ppt

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The Changing Face of Viral Hepatitis

The Changing Face of Viral Hepatitis
Presentation by:D. Robert Dufour, MD, FACB, FCAP
Consultant Pathologist
Attending, Liver Clinic
VAMC, Washington DC
Emeritus Professor of Pathology


SIGNIFICANCE
HEPATITIS A
HEPATITIS E
HEV DIAGNOSIS
HEPATITIS B
HBV BIOLOGY
HBV Replication
Circulating HBV
Infection
Reservoir
Replication
HBV
mRNA
Reverse
Transcriptase
RNA-DNA Hybrid
Partially ds-DNA
Pre-S
Free HBsAg
DNA Polymerase
Partially ds-DNA
HBV BIOLOGY
OUTCOME
Loss of HBsAg
HBV SEROLOGIC TESTS
HBsAg
ISOLATED ANTI-HBc
HBeAg
ANTI-HBe
HBV DNA
HBV OUTCOMES & SEROLOGY
Immune control
Immune active
Immune tolerance
Acute hepatitis
HBV REACTIVATION
Anti-HBc pos
HBsAg neg
HEPATITIS C
HCV BIOLOGY
ANTI-HCV
RIBA for anti-HCV
Screening test for Anti-HCV
HCV RIBA
TREATMENT OF CHRONIC HBV AND HCV
ACUTE HEPATITIS
CHRONIC HEPATITIS B
TREATMENT INDICATIONS
TREATMENT BENEFITS
MONITORING Rx

* In HBeAg + with loss HBV DNA, serial monitoring of HBeAg status prognostic; if HBeAg lost (and anti-HBe develops), treatment can be D/C after 6-12 mo with 80% success
* In HBeAg – (or HBeAg + who do not convert), D/C treatment leads to rapid reactivation of HBV replication; treatment usually long-term in these patients

CHRONIC HEPATITIS C
RECENT ARTICLES

The Changing Face of Viral Hepatitis.ppt

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Hepatitis C Update Video

Hepatitis C Update

Dr. Lorenzo Rossaro, UC Davis Chief of Gastroenterology and Hepatology presents an update on the treatment of Hepatitis C. Series: UC Grand Rounds. App. 51 minutes video

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Diagnosis of alimentary canal / gastrointestinal tract

Examination of The alimentary canal / gastrointestinal tract

Diagnosis of GIT disorders
History & Physical Exam
Investigations of GIT disease
X-Rays & barium studies
Ultrasound, CT & MRI
Endoscopy
Colonoscopy
Manometry
Gastric analysis
Laparoscopy
Bacterial cultures (stool) & serology

Manifestations of GIT disease
Dyspepsia & Differential Diagnoses
History Taking
Investigatations
Diarrhoea
Aetiology & Pathophysiology
Constipation
Gastro-Intestinal Bleeding
Causes of Weight Loss
Abdominal Pain
Areas of Pain & Differentials
Malabsorption Syndromes
Pruitis Ani - anal and perianal itching
Causes of Oral Ulcerations
Recurrent Aphthous Stomatitis
Herpes Simplex Virus
Oral Candidiasis
Salivary Gland Disorders
Suppurative Parotitis - bacterial infection of parotid glands
Mumps
Ulcerative Gingivitis
Oesophagitis
Hiatus Hernia
Mallory-Weiss Syndrome

This is 222 slides presentation. Extensively covered many topics.

The alimentary canal / gastrointestinal tract.ppt

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Drug Induced Liver Injury

Drug Induced Liver Injury
Presentation by:Robert J. Fontana, MD
University of Michigan Medical Center

Drug Induced Liver Injury
Hepatic Adverse Event Nomenclature
Liver Injury Classification
DILI Population based study
DILI Diagnosis
Clinicopathologic forms of DILI
DILI: A Diagnosis of exclusion
Acute Hepatocellular: Differential Dx
Ultrasound/ CT
DILI: Causality Assessment
RUCAM
RUCAM limitations
Prognosis in DILI with jaundice
Spectrum of DILI
ALT monitoring and DILI
DILI pathogenesis
DILIN: Sphere of Influence
Idiosyncratic Liver Injury Associated with Drugs (ILIAD)
New agent signals
Drug
Human genome
DILIN Genotyping Initiative
Acetaminophen: Friend or foe ?
Glucuronyl transferases sulfotransferases
Acetaminophen
ACM-cysteine adducts
Biomarker for ACM hepatotoxicity
Implications of ACM related ALF
Acetaminophen advice
Acetaminophen toxicity in severe acute HAV/ HBV
Prospective Study Design
DILI Causality Instrument
Prognosis in DILI with jaundice

Drug Induced Liver Injury.ppt

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Viral Hepatitis Medicine Student Lecture

Viral Hepatitis Medicine Student Lecture
Presentation by:David R Nelson, M.D.

Associate Professor of Medicine
Director, Hepatology and Liver Transplantation
University of Florida

Causes of Acute Hepatitis

Acute Hepatitis
Viral Hepatitis
A, B/D, C, E
EBV
CMV & HSV
Drugs
Ethanol
Tylenol
Halothane
Toxins
Jamaica Bush Tea
Mushrooms
Vascular
Hypotension
Budd-Chiari
Autoimmune
Hepatitis
Metabolic
Wilson's Disease
A1AT

Causes of Chronic Hepatitis
Chronic Hepatitis
Viral Hepatitis
Drugs
MTX
INH
Amiodarone
Alcohol
NAFLD
Autoimmune
AIH
PBC
PSC
Metabolic
A1AT
HHC

Hepatitis A Virus
Nucleic Acid: 7.5 kb ssRNA
HAV Prevalence
Global Prevalence of Hepatitis A Infection
Hepatitis A Prevention - Immune Globulin

ACIP Recommendations MMWR 1999; 48(RR12):1
Hepatitis A: Pre-exposure Vaccination
Persons at increased risk or danger of infection
Hepatitis E

Clinical Characteristics
Hepatitis B Virus
HBsAg
HBV DNA
HBcAg
HBV Sources of Infection
Signs and Symptoms of Acute Hepatitis B

Hepatitis B - Clinical Features
Progression to Chronic Hepatitis B Virus Infection
Typical Serologic Course
Recovery from acute hepatitis B
Chronic HBeAg + disease
Chronic HBeAG – disease
Successful Vaccination
Resistance to antiviral agents
Hepatitis B: Disease Progression
Acute Infection
Chronic HBV is the 6th leading cause of liver transplantation in the US
Higher in HIV, immune suppressed
Targeted Surveillance for HCC
Hepatitis B Carriers
Non-hepatitis B Cirrhosis
Prevention of Transmission of Hepatitis B

and much more are discussed in this presentation.
Viral Hepatitis Medicine Student Lecture.ppt

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Treatment for Chronic Hepatitis B

Treatment for Chronic Hepatitis B
Screening for Hepatocellular Carcinoma
Presentation by: Mindie H. Nguyen, MD, MAS

Assistant Professor of Medicine
Division of Gastroenterology & Hepatology
Liver Transplant Program
Stanford University Medical Center

Chronic Hepatitis B
HBV Disease Burden in Asian-Americans
Hepatitis B Prevalence
Etiology of HCC in Asians
Impact of HBV DNA and ALT Levels on Disease Outcomes
HBV DNA Levels,
Disease Progression and HCC Risk
Impact of Viral Load
HBV DNA Associated with Increased Risk of HCC
HBV DNA levels and Risk of Cirrhosis and HCC REVEAL-HBV Study
HBV DNA Levels Predict Risk of Developing Cirrhosis
HBV DNA Levels Predict Risk of Developing HCC
Dose-Response Relationship:
HBV DNA and HCC
REVEAL-HBV Study: HCC Analysis Conclusions
Impact of Treatment on Disease Progression
Primary Goal of Treatment
Rapid and sustained suppression of HBV to the lowest possible level1,2
Rapid and Profound HBV Suppression: an Important Therapeutic Goal
Lamivudine and Disease Progression and HCC incidence in Advanced HBV (stage III/IV)
HBV DNA Suppression Reduces HCC Incidence Rate
Screening for Hepatocellular Carcinoma
HCC: Screening Tests
HCC: Screening Strategies and Frequency
WHO Principles of Screening
Screening improves survival
HCC Screening: clinical studies
RCT for HCC Screening

Treatment for Chronic Hepatitis B

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Hepatitis C

Hepatitis C
Presentation by
Bruce Luxon, MD, PhD
James A. Clifton Chair in Gastroenterology
Professor of Internal Medicine
Director, Division of Gastroenterology and Hepatology
University of Iowa


The Silent Epidemic
DIAGNOSTIC APPROACH TO CHRONIC HEPATITIS
RISK FACTORS FOR HCV OR ELEVATED ALT LEVELS
ANTI-HCV (EIA) TESTING
REFER TO SPECIALIST FOR EVALUATION AND TREATMENT
NEGATIVE
POSITIVE
EIA=enzyme immunoassay.
Check HCV RNA (viral load) and HCV genotype

* Basic facts on diagnosing hepatitis C
o Who is at risk?
o How do I screen?
o Why should I screen?
* Basic facts on treating hepatitis C
o What are treatment options?
o What are the success rates?
* Mention new trials and treatment options
o What should I do if initial treatment fails?

Cure
Consensus Interferon (CIFN)
DIRECT Trial
Maintenance Therapy?
HALT-C Trial
Summary
What to Take Away from Today

Hepatitis C.ppt

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Natural Supplements in Gastroenterology

Natural Supplements in Gastroenterology—An overview
Presentation by: Victor S. Sierpina, MD

W.D. and Laura Nell Nicholson Professor of Integrative Medicine
Family Medicine Department
University of Texas Medical Branch

Learning Objectives

* Describe common categories and examples of natural products for gastroenterology
* Describe indications and rationale for use of probiotics in clinical care
* Outline integrative approaches to irritable bowel syndrome, inflammatory bowel syndrome, chronic hepatitis
* List reliable references for evidence in the use of natural supplements in gastroenterology

Categories of GI herbals with examples
Some popular Hispanic herbs for GI complaints

* Basil/Albahaca
* Chamomile/Manzanilla
* Cumin/Comino
* Rue/Ruda
* Sage/Chia
* Spearmint/Yerba buena



Probiotics/Prebiotics
* Lactobacillus GG
* Lactobacillus casei
* Lactobacillus acidophilus
* Lactobacillus planatarum
* Lactobacillus reuteri
* Bifidobacterium bifidum/longum
* Saccharomyces boulardii
* Streptococcus therpophlus

Mechanisms of Action of Probiotics
* Colonization resistance
* Production of antibacterial substances
* Competition for nutrients
* Competitive inhibition at bacterial adhesion sites
* Enhancement of the immune defense system

Roles and indications of probiotics

* Dysbiosis
* Diarrhea (anitbx, e.g. H. Pylori tx, viral, traveler’s, infantile, AIDS related)
* Lactose intolerance
* Immunomodulatory effects
* Altered gut permeability (leaky gut)
* Inflammatory disorders
* Colon cancer prevention
* Atopy/food allergy

How to prescribe probiotics

* Occur naturally in many foods: yogurt, milk, miso, tempeh, kefir, sauerkraut, some cheeses
* Even non-viable organisms may have benefit (block bacterial adherence)
* Take on an empty stomach
* Space 3-4 hrs after antibx (2 weeks post tx)
* At least 1 billion organisms per dose
* Length of intake uncertain for many conditions


Peppermint
Herbal approach to IBS--carminatives

* Enteric coated peppermint (Mentha piperita):1-2 capsules (0.2ml) tid between meals
* Ginger (Zingiber officinale): 0.25-1 g tid
* Fennel (Foeniculum vulgare): ½-1 tsp seeds pp, 0.03-0.2 ml oil qd, alcoholic extract 0.5-2 ml/d
* Chamomile (Matricaria recutita): tea/infusion with 2-3 g of flowers; 1-4 ml tincture (1:5) tid
* Caraway:1-2 tsp seeds in tea/infusion, or alcoholic extract

Fennel
Herbal approach to IBS—stool agents

Other options
Inflammatory bowel disease

Hepatitis

Anti-viral, anti-inflammatory, anti-fibrotic
Selected References—Hispanic Herbs


Natural Supplements in Gastroenterology

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