GI Disorders in Women: GI Disorders in Women: Clinical Pearls Clinical Pearls Amy S. Oxentenko, MD, FACP, Amy S. Oxentenko, MD, FACP, FACG FACG Division of Gastroenterology and Hepatology Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, MN Mayo Clinic, Rochester, MN March, 2012 March, 2012
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GI Disorders in Women: GI Disorders in Women: Clinical PearlsClinical Pearls
Amy S. Oxentenko, MD, FACP, FACGAmy S. Oxentenko, MD, FACP, FACGDivision of Gastroenterology and HepatologyDivision of Gastroenterology and Hepatology
Mayo Clinic, Rochester, MNMayo Clinic, Rochester, MNMarch, 2012March, 2012
Disclosure of Financial RelationshipsDisclosure of Financial Relationships
Amy S. Oxentenko, MD, FACP, FACGAmy S. Oxentenko, MD, FACP, FACG
Has no relationships with any entity Has no relationships with any entity producing, marketing, re-selling, or producing, marketing, re-selling, or
distributing health care goods or services distributing health care goods or services consumed by, or used on, patients.consumed by, or used on, patients.
Case #1Case #1
A 32 y/o female presents for evaluation of “diarrhea” and A 32 y/o female presents for evaluation of “diarrhea” and abdominal pain that she has had for 5 years. She gets lower abdominal pain that she has had for 5 years. She gets lower abdominal pain and bloating 1-2 times per week. On those abdominal pain and bloating 1-2 times per week. On those days, she reports 3-5 loose stools, predominantly in the days, she reports 3-5 loose stools, predominantly in the morning or after meals. Stools are non-bloody, non-greasy morning or after meals. Stools are non-bloody, non-greasy and never nocturnal. Stooling brings relief of her pain. She and never nocturnal. Stooling brings relief of her pain. She denies weight loss. PMH is unremarkable. She takes no denies weight loss. PMH is unremarkable. She takes no meds. She has no family hx of GI problems. Exam is normal.meds. She has no family hx of GI problems. Exam is normal.
Which of the following is the next best step?Which of the following is the next best step?
A.A. No further tests; reassuranceNo further tests; reassuranceB.B. CBC & IgA tissue transglutaminaseCBC & IgA tissue transglutaminaseC.C. Stool culturesStool culturesD.D. EGD w/ small bowel biopsiesEGD w/ small bowel biopsiesE.E. Colonoscopy w/ random biopsiesColonoscopy w/ random biopsies
A 32 y/o female presents for evaluation of A 32 y/o female presents for evaluation of “diarrhea”“diarrhea” and and abdominal painabdominal pain that she has had for that she has had for 5 years5 years. She gets lower . She gets lower abdominal pain and bloating 1-2 times per week. On those abdominal pain and bloating 1-2 times per week. On those days, she reports 3-5 loose stools, predominantly in the days, she reports 3-5 loose stools, predominantly in the morning or after mealsmorning or after meals. Stools are . Stools are non-bloody, non-greasynon-bloody, non-greasy and and never nocturnalnever nocturnal. . Stooling brings reliefStooling brings relief of her pain. She of her pain. She denies weight lossdenies weight loss. PMH is unremarkable. She takes no . PMH is unremarkable. She takes no meds. She has no family hx of GI problems. Exam is normal.meds. She has no family hx of GI problems. Exam is normal.
Which of the following is the next best step?Which of the following is the next best step?
A.A. No further tests; reassuranceNo further tests; reassuranceB.B. CBC & IgA tissue transglutaminaseCBC & IgA tissue transglutaminaseC.C. Stool culturesStool culturesD.D. EGD w/ small bowel biopsiesEGD w/ small bowel biopsiesE.E. Colonoscopy w/ random biopsiesColonoscopy w/ random biopsies
Be Comfortable Diagnosing IBSBe Comfortable Diagnosing IBS
Spiller RC, et al. Am J Gastroenterol 2010:105;775-75.Brandt LJ, et al. Am J Gastroenterol 2009;104:S1-35.
Hard and lumpyHard and lumpy
Loose or wateryLoose or watery
Irritable Bowel SyndromeIrritable Bowel Syndrome
Clinical PearlClinical PearlDiarrhea-predominant irritable bowel Diarrhea-predominant irritable bowel syndrome is a diagnosis that can be syndrome is a diagnosis that can be made with little exclusionary testing made with little exclusionary testing
required, other than a CBC and IgA tTG, required, other than a CBC and IgA tTG, in the absence of alarm symptoms.in the absence of alarm symptoms.
Case #2Case #2
A 38 y/o female presents to the ER with recurrent abdominal pain, A 38 y/o female presents to the ER with recurrent abdominal pain, nausea and bilious vomiting. Six months ago, she had a Roux-en-Y nausea and bilious vomiting. Six months ago, she had a Roux-en-Y gastric bypass for obesity. She has had 3 episodes in 1 month. gastric bypass for obesity. She has had 3 episodes in 1 month. Pain is crampy, periumbilical, and crescendos over 1-2 hours and Pain is crampy, periumbilical, and crescendos over 1-2 hours and is relieved after vomiting undigested food and bilious fluid. During is relieved after vomiting undigested food and bilious fluid. During the last 2 episodes, ER eval with labs (CBC, liver biochemistries), the last 2 episodes, ER eval with labs (CBC, liver biochemistries), abdominal radiographs and RUQ ultrasounds were normal. She abdominal radiographs and RUQ ultrasounds were normal. She takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no other meds. No other PMH. Her gallbladder was not removed w/ other meds. No other PMH. Her gallbladder was not removed w/ the laparoscopic bypass. the laparoscopic bypass.
Which of the following is the most likely cause of symptoms?Which of the following is the most likely cause of symptoms?
A.A. OvereatingOvereatingB.B. Biliary colic Biliary colic C.C. Internal herniaInternal herniaD.D. Stenosis of the gastric pouchStenosis of the gastric pouchE.E. Medication side effectMedication side effect
A 38 y/o female presents to the ER with recurrent A 38 y/o female presents to the ER with recurrent abdominal pain, abdominal pain, nausea and bilious vomitingnausea and bilious vomiting. Six months ago, she had a . Six months ago, she had a Roux-en-YRoux-en-Y gastric bypass for obesity. She has had 3 episodes in 1 month. gastric bypass for obesity. She has had 3 episodes in 1 month. Pain is crampy, Pain is crampy, periumbilical, and crescendosperiumbilical, and crescendos over 1-2 hours and over 1-2 hours and is is relieved after vomitingrelieved after vomiting undigested food and bilious fluid. During undigested food and bilious fluid. During the last 2 episodes, ER eval with labs (CBC, liver biochemistries), the last 2 episodes, ER eval with labs (CBC, liver biochemistries), abdominal radiographs and RUQ ultrasounds were normal. She abdominal radiographs and RUQ ultrasounds were normal. She takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no takes a MVI w/ iron, thiamine, calcium, vitamin D and B12, but no other meds. No other PMH. Her gallbladder was not removed w/ other meds. No other PMH. Her gallbladder was not removed w/ the the laparoscopic bypasslaparoscopic bypass. .
Which of the following is the most likely cause of symptoms?Which of the following is the most likely cause of symptoms?
A.A. OvereatingOvereatingB.B. Biliary colic Biliary colic C.C. Internal herniaInternal herniaD.D. Stenosis of the gastric pouchStenosis of the gastric pouchE.E. Medication side effectMedication side effect
Roux limbBilio-pancreatic
limb
Commonchannel
Gastric remnant
Gastric pouch
Roux-en-YBypass
Short Roux limbLong common channel
Long Roux limbShort common channel
***Greater malabsorption
***Lesser malabsorption
Early Emergent ComplicationsEarly Emergent Complications• Anastomotic leaksAnastomotic leaks
– Early complicationEarly complication– Only feature may be Only feature may be
unexplained tachycardiaunexplained tachycardia
Early Emergent ComplicationsEarly Emergent Complications• Anastomotic leaksAnastomotic leaks
– Early complicationEarly complication– Only feature may be unexplained Only feature may be unexplained
– Occurs early or lateOccurs early or late– Nausea, vomiting (? bilious)Nausea, vomiting (? bilious)– Increased w/ laparoscopy; only Increased w/ laparoscopy; only
occurs with bypassoccurs with bypass• Both need surgery!!!Both need surgery!!!
Klein S, et al. Gastroenterology 2002;123:882-932.
Other Common ComplicationsOther Common Complications• Marginal ulcerationMarginal ulceration
– May cause bleeding or stricture at May cause bleeding or stricture at G-J siteG-J site
There are many potential structural, There are many potential structural, absorptive and nutritional absorptive and nutritional
complications of bariatric surgery; complications of bariatric surgery; knowledge of the post-bariatric knowledge of the post-bariatric
anatomy is essential in being able anatomy is essential in being able to effectively manage these to effectively manage these
patients.patients.
Case #3Case #3
34 y/o female referred for “IBS” who is 16 weeks 34 y/o female referred for “IBS” who is 16 weeks pregnant. She had diarrhea in teens which resolved in pregnant. She had diarrhea in teens which resolved in her 20’s and recurred early in pregnancy. Has 4-6 BM her 20’s and recurred early in pregnancy. Has 4-6 BM daily with nocturnal stools. No abdominal pain. Takes daily with nocturnal stools. No abdominal pain. Takes a prenatal MVI, iron and levo-thyroxine. Her pre-a prenatal MVI, iron and levo-thyroxine. Her pre-pregnancy BMI = 17, with 5 lb weight gain thus far. pregnancy BMI = 17, with 5 lb weight gain thus far. Conceived her baby with IVF. Her TSH is normal.Conceived her baby with IVF. Her TSH is normal.
Which of the following is the next best step?Which of the following is the next best step?
A.A. Tissue transglutaminase IgATissue transglutaminase IgAB.B. ColonoscopyColonoscopyC.C. Begin scheduled loperamideBegin scheduled loperamideD.D. Stool bacterial culturesStool bacterial culturesE.E. Begin nortriptylineBegin nortriptyline
34 y/o female referred for “IBS” who is 16 weeks 34 y/o female referred for “IBS” who is 16 weeks pregnant. She had pregnant. She had diarrhea in teensdiarrhea in teens which resolved in which resolved in her 20’s and her 20’s and recurred early in pregnancyrecurred early in pregnancy. Has . Has 4-6 BM 4-6 BM dailydaily with with nocturnal stoolsnocturnal stools. . No abdominal painNo abdominal pain. Takes . Takes a prenatal MVI, a prenatal MVI, iron and levo-thyroxineiron and levo-thyroxine. Her pre-. Her pre-pregnancy pregnancy BMI = 17BMI = 17, with , with 5 lb weight gain5 lb weight gain thus far. thus far. Conceived her baby with Conceived her baby with IVFIVF. Her TSH is normal.. Her TSH is normal.
Which of the following is the next best step?Which of the following is the next best step?
A.A. Tissue transglutaminase IgATissue transglutaminase IgAB.B. ColonoscopyColonoscopyC.C. Begin scheduled loperamideBegin scheduled loperamideD.D. Stool bacterial culturesStool bacterial culturesE.E. Begin nortriptylineBegin nortriptyline
General GastrointestinalShort statureShort stature Diarrhea, steatorrheaDiarrhea, steatorrhea
deficient states, cardiomyopathy, depression/mooddeficient states, cardiomyopathy, depression/mood•*Prevalence of CD in pts with IDA:*Prevalence of CD in pts with IDA:
•3-9% (no GI sxs) 3-9% (no GI sxs) •10-15% (GI sxs)10-15% (GI sxs)
Rubio-Tapia A, Murray JA. Curr Opin Gastroenterol 2010; 26:116-22.Rubio-Tapia A, Murray JA. Curr Opin Gastroenterol 2010; 26:116-22.
How to Diagnose Celiac DiseaseHow to Diagnose Celiac Disease• TTG IgATTG IgA single best screening test single best screening test
– IgA levels not warranted for allIgA levels not warranted for all• Small bowel biopsiesSmall bowel biopsies in: in:
– All with positive serologiesAll with positive serologies– Negative serology but clinical suspicionNegative serology but clinical suspicion– Iron deficiency anemiaIron deficiency anemia– Other unexplained extraintestinal featuresOther unexplained extraintestinal features
• Annual visits thereafter:Annual visits thereafter:– Assess clinical sxs, serologies, dieticianAssess clinical sxs, serologies, dietician– Follow-up abnormal labs; DEXA if first abnormalFollow-up abnormal labs; DEXA if first abnormal
• Repeat biopsies ONLY for those:Repeat biopsies ONLY for those:– Asymptomatic presentationsAsymptomatic presentations– Persistent or recurrent sxsPersistent or recurrent sxs
Leffler D. JAMA 2011;306:1582-92.
Clinical PearlClinical PearlCeliac disease now commonly Celiac disease now commonly
presents with “atypical” or presents with “atypical” or extraintestinal features; heightened extraintestinal features; heightened
awareness of these features is key to awareness of these features is key to thinking of the diagnosis.thinking of the diagnosis.
Case #4Case #4
28 y/o female presents with constipation for 5 years. 28 y/o female presents with constipation for 5 years. Reports one BM every 5-7 days. She has to strain and Reports one BM every 5-7 days. She has to strain and has a sense of incomplete evacuation. She has had to has a sense of incomplete evacuation. She has had to digitalize on occasion to evacuate a stool. No blood. digitalize on occasion to evacuate a stool. No blood. Had a significant tear with her vaginal delivery 6 years Had a significant tear with her vaginal delivery 6 years ago, requiring forceps delivery. No FHx colon cancer. ago, requiring forceps delivery. No FHx colon cancer. Weight stable. Exam normal with the exception of Weight stable. Exam normal with the exception of paradoxical contraction of the external anal sphincter.paradoxical contraction of the external anal sphincter.
What is the most likely diagnosis?What is the most likely diagnosis?A.A. Irritable bowel syndromeIrritable bowel syndromeB.B. Slow-transit constipationSlow-transit constipationC.C. Rectal prolapseRectal prolapseD.D. Hirschsprung’sHirschsprung’sE.E. Pelvic floor dysfunctionPelvic floor dysfunction
28 y/o female presents with 28 y/o female presents with constipation for 5 yearsconstipation for 5 years. . Reports one BM every 5-7 days. She has to Reports one BM every 5-7 days. She has to strainstrain and and has a sense of has a sense of incomplete evacuationincomplete evacuation. She has had to . She has had to digitalizedigitalize on occasion to evacuate a stool. No blood. on occasion to evacuate a stool. No blood. Had a Had a significant tearsignificant tear with her vaginal delivery 6 years with her vaginal delivery 6 years ago, requiring ago, requiring forceps deliveryforceps delivery. No FHx colon cancer. . No FHx colon cancer. Weight stable. Exam normal with the exception of Weight stable. Exam normal with the exception of paradoxical contractionparadoxical contraction of the external anal sphincter. of the external anal sphincter.
What is the most likely diagnosis?What is the most likely diagnosis?A.A. Irritable bowel syndromeIrritable bowel syndromeB.B. Slow-transit constipationSlow-transit constipationC.C. Rectal prolapseRectal prolapseD.D. Hirschsprung’sHirschsprung’sE.E. Pelvic floor dysfunctionPelvic floor dysfunction
How to Define Constipation?How to Define Constipation?
• In the past:In the past:– < 3 stools per week< 3 stools per week
• More recent:More recent:– Effort to defecateEffort to defecate– Consistency and formConsistency and form
• Bristol stool form scaleBristol stool form scale• Correlates w/ transit Correlates w/ transit
timestimes
Brandt LJ, et al. Am J Gastroenterol 2005;100:S5-21.Brandt LJ, et al. Am J Gastroenterol 2005;100:S5-21.
3 Subtypes of Primary 3 Subtypes of Primary ConstipationConstipation
• Slow-transit constipationSlow-transit constipation– Prolonged transit due to myopathy or neuropathyProlonged transit due to myopathy or neuropathy
• Pelvic floor dysfunctionPelvic floor dysfunction– Also referred to as dyssynergic defecationAlso referred to as dyssynergic defecation– Impaired abdominal, rectoanal and pelvic floor Impaired abdominal, rectoanal and pelvic floor
– Pain or discomfort a predominant symptom; transit Pain or discomfort a predominant symptom; transit and pelvic function normaland pelvic function normal
Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.
• Age > 50 yearsAge > 50 years• Short duration symptoms (< 6 months)Short duration symptoms (< 6 months)• Family hx colorectal cancerFamily hx colorectal cancer• Blood in stoolsBlood in stools• Weight lossWeight loss
*** These patients need an evaluation *** These patients need an evaluation which includes colonoscopy ***which includes colonoscopy ***
Alarm Features for Alarm Features for Constipation?Constipation?
Work-Up for ConstipationWork-Up for Constipation• CBC, calcium, TSH, fasting glucoseCBC, calcium, TSH, fasting glucose
• If If ≥ 50 or alarm features ≥ 50 or alarm features colonoscopy colonoscopy
• If features of pelvic floor dysfunction If features of pelvic floor dysfunction a)a) Anorectal manometry/balloon expulsionAnorectal manometry/balloon expulsionb)b) Colonic transit study Colonic transit study
Clinical Features of Clinical Features of Pelvic Floor DysfunctionPelvic Floor Dysfunction
• Risk factors: childbirth, abuse, chronic Risk factors: childbirth, abuse, chronic constipation, other pelvic traumaconstipation, other pelvic trauma
• Excessive straining, toilet rocking or Excessive straining, toilet rocking or repositioningrepositioning
• Sense of incomplete evacuationSense of incomplete evacuation• Sense of anorectal blockage* Sense of anorectal blockage* • Digitation for stool evacuation*Digitation for stool evacuation*
Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.
Examination Features of Examination Features of Pelvic Floor DysfunctionPelvic Floor Dysfunction
• Abnormal perineal descentAbnormal perineal descent• Abnormal resting and squeeze toneAbnormal resting and squeeze tone• Paradoxical contraction of Paradoxical contraction of
puborectalis or external anal puborectalis or external anal sphinctersphincter
Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.
Normal RestNormal Rest Normal defecationNormal defecation
Those with pelvic floor dysfunction have paradoxical Those with pelvic floor dysfunction have paradoxical contraction of puborectalis and external sphinctercontraction of puborectalis and external sphincter
Pelvic Floor DysfunctionPelvic Floor Dysfunction
Management of Pelvic Floor Management of Pelvic Floor DysfunctionDysfunction
• Refer for biofeedback programRefer for biofeedback program• Significantly improves (for at least 1 year):Significantly improves (for at least 1 year):
• If there is concomitant prolapse, fix pelvic If there is concomitant prolapse, fix pelvic floor dysfunction firstfloor dysfunction first
Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Bharucha AE, Wald AM. Am J Gastroenterol 2010;105;786-94.Rao SSC, et al. Am J Gastroenterol 2010;105:890-6.Rao SSC, et al. Am J Gastroenterol 2010;105:890-6.
Clinical PearlClinical Pearl
Constipation associated with a sense of Constipation associated with a sense of anorectal blockage, the need for digitation anorectal blockage, the need for digitation
to evacuate stool, and paradoxical to evacuate stool, and paradoxical contraction of the puborectalis is contraction of the puborectalis is
suggestive of pelvic floor dysfunction; suggestive of pelvic floor dysfunction; anorectal manometry is indicated.anorectal manometry is indicated.
Case #5Case #5
A 58 year old female presents for an evaluation of diarrhea that A 58 year old female presents for an evaluation of diarrhea that has been present for 4 months. She has crampy pain, bloating has been present for 4 months. She has crampy pain, bloating and weight loss of 10 pounds. She denies any blood in her and weight loss of 10 pounds. She denies any blood in her stool, but notes it to be foul smelling and greasy appearing. No stool, but notes it to be foul smelling and greasy appearing. No recent medication changes. No travel. She does have a history recent medication changes. No travel. She does have a history of prior cervical cancer 4 years ago, s/p resection, of prior cervical cancer 4 years ago, s/p resection, chemotherapy and radiation. Labs reveal a hemoglobin of 10.4 chemotherapy and radiation. Labs reveal a hemoglobin of 10.4 g/dL, MCV of 102 fL and albumin of 3.1 g/dL. She states that g/dL, MCV of 102 fL and albumin of 3.1 g/dL. She states that dairy avoidance has somewhat, but not fully, helped. TTG IgA is dairy avoidance has somewhat, but not fully, helped. TTG IgA is normal. Colonoscopy with ileal inspection is normal. normal. Colonoscopy with ileal inspection is normal.
Which of the following is the next best step?Which of the following is the next best step?
A.A. CT of the pancreasCT of the pancreasB.B. Lactose breath testLactose breath testC.C. PET scan PET scan D.D. Lactulose breath testLactulose breath testE.E. Flex sig w/ biopsiesFlex sig w/ biopsies
A 58 year old female presents for an evaluation of A 58 year old female presents for an evaluation of diarrheadiarrhea that that has been present for 4 months. She has has been present for 4 months. She has crampy pain, bloating crampy pain, bloating and weight loss of 10 poundsand weight loss of 10 pounds. She denies any blood in her . She denies any blood in her stool, but notes it to be foul smelling and stool, but notes it to be foul smelling and greasygreasy appearing. No appearing. No recent medication changes. No travel. She does have a history recent medication changes. No travel. She does have a history of prior of prior cervical cancercervical cancer 4 years ago, s/p resection, 4 years ago, s/p resection, chemotherapy and chemotherapy and radiationradiation. Labs reveal a . Labs reveal a hemoglobin of 10.4hemoglobin of 10.4 g/dL, g/dL, MCV of 102 fLMCV of 102 fL and and albumin of 3.1 g/dLalbumin of 3.1 g/dL. She states that . She states that dairy avoidance has somewhat, but not fully, helped. TTG IgA is dairy avoidance has somewhat, but not fully, helped. TTG IgA is normal. Colonoscopy with ileal inspection is normal. normal. Colonoscopy with ileal inspection is normal.
Which of the following is the next best step?Which of the following is the next best step?
A.A. CT of the pancreasCT of the pancreasB.B. Lactose breath testLactose breath testC.C. PET scan PET scan D.D. Lactulose breath testLactulose breath testE.E. Flex sig w/ biopsiesFlex sig w/ biopsies
A) Lactulose breath test without SIBOB) Lactulose breath test w/ SIBOC) Lactulose breath test w/ SIBO & double-peak pattern
From Dukowicz AC, et al. Gastroenterol Hepatol 2007;3:118-119.
A B C
Treatment of SIBOTreatment of SIBO• Modify underlying risk factorModify underlying risk factor (minority) (minority)
– Diabetes, surgery, etc.Diabetes, surgery, etc.• Nutritional supportNutritional support
– Correct deficiencies (vit B12, vit D, Ca++)Correct deficiencies (vit B12, vit D, Ca++)– Lactose malabsorption (secondary)Lactose malabsorption (secondary)
• Antibiotic therapyAntibiotic therapy– Single 7-10 days (46-90% improve for months)Single 7-10 days (46-90% improve for months)– Recurrence 44% at 9 monthsRecurrence 44% at 9 months– Some may need repeat courses (1 week/month)Some may need repeat courses (1 week/month)