On Tuesday morning we discussed a case of a 77-year old man who presented with epigastric abdominal pain and was found to have gallstone pancreatitis. The patient went on to develop a prolonged ileus and an extended hospital stay. Two weeks later, the patient developed a new leukocytosis and tachycardia and was found to have pancreatic necrosis. We brainstormed the early and late complications of pancreatitis. We additionally discussed the standard recovery timeline from pancreatitis. The development of walled-off necrosis is a key distinction in the evaluation of post-pancreatitis complications. Our teams also came up with the antibiotic choices they would consider when treating the patient. Finally, we discussed the procedural considerations to treatment of necrotic collections. The initial approach often involves placement of percutaneous or transluminal drain (or stent). Serious cases may also need to be treated with necrosectomy – either surgical using video-assisted retroperitoneal debridement (VARD) or endoscopic. A special thank you to our discussant, Dr. Phil Fejleh, the advanced endoscopy GI fellow, for sharing all of his expertise!
Today Dr. Joe Ryan presented a case of a 30-year old man who presented to the ED with food impaction in his esophagus. We discussed the general approach to dysphagia, as well as the differential for esophageal impaction in our patient. We discussed how glucagon is often used as first-line medical therapy for food impaction but that the evidence is not robust for its efficacy. Our patient received two doses without improvement before he underwent an endoscopy that advanced the food bolus into his stomach and found linear furrows in his esophagus. His biopsy ultimately showed eosinophilia, and he was diagnosed with eosinophilic esophagitis (EoE). He was discharged home with an 8 week trial of PPI therapy. PPI therapy has an anti-inflammatory effect that is independent of its acid suppression. Maintenance therapy is achieved by viscous/swallowed inhaled corticosteroids. Our expert discussant, Dr. Rena Yadlapati, a gastroenterology expert in esophageal disorders, helped us make the diagnosis and discussed the treatment of
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Today Kim E. Barrett, Ph.D., Distinguished Professor of Medicine in the Division of Gastroenterology, gave us a fascinating talk on diarrheal diseases. Dr. Barrett started out by describing how foodbourne illnesses are a constant threat to public health, as they have a significant overall disease burden, and impedes socioeconomic development in the developing world.
The vast majority of foodbourne illnesss are caused by microorganisms via pore-forming toxins, enterotoxins, adherent pathogens and invasive pathogens, or by direct toxin forms or by contaminants. There are sequels of food-borne illnesses including post-infectous IBS, reactive arthritis, GBS, reactivation/activation of IBD, developmental/cognitive impacts, and growth stunting. In particular enteric dysfunction may lead to systemic inflammatory effects and increased nutrient need in nutrient deficient conditions for those in developing countries, leading to ultimately stunted growth.
Dr. Barrett then reviewed the role of the intestinal epithelium in regards to water and electrolyte transport and nutrient absorption during digestion, as well as a barrier for toxins and pathogens. She noted the balance between absorption and secretion across the villi vs crypts, which is important for maintaining the appropriate amount of gut flora. Dr. Barrett then demonstrated how infection with bacteria or viral pathogens can change these mechanisms and lead to excess chloride secretion and decreased nutrient absorption.
Next Dr. Barrett went on to focus on non-typhoidal Salmonella, which is the leading cause of death from diarrheal illness in vulnerable population. It is a disease that has increasing antibiotic resistance but it’s mechanism of disease is still poorly understood. She and other researchers at UCSD, particularly Drs. Josh Fierer and Don Guiney, set about trying to better understand this pathophysiology though various mouse models. They have concluded that there is a decreased capacity for electrogenic transport, decreased capacity for electroneutral NaCl absorption, epithelial proliferation and diarrhea symptoms independent of neutrophil activation.
Dr. Barrett then spoke about a current project her lab is currently working on addressing the effects of tyrosine kinase inhibitor-EGFr therapy on the intestinal tract. Physiologically, there is inhibition of chloride secretion by EGF receptor via an apical membrane effect. Therefore, these immunotherapy agents have a propensity to cause diarrhea by reversing this inhibitory effect on chloride secretion. So it appears that drugs targeting receptors and transporter on the membrane may be the key to treating these diarrheal illness, and it is an area of active investigation.
Thank you for a very thoughtful talk, Dr. Barrett!
Today one of our amazing Resident as Clinician Educator (RACE) track residents Dr. Maggie Kozman led us through a fascinating case of a young woman with HIV and priorly diagnosed disseminated MAC affecting the liver who presents with diffuse abdominal pain and fevers after restarting ARVs for 6 weeks. We learned that she had markedly elevated alkaline phosphatase and GGT levels and diffuse abdominal and pelvic lymphadenopathy.
Dr. Kozman lead us through a diagnostic schema for an HIV patient coming in with fever and abdominal pain, with the help of our expert Owen discussant, Dr. Jill Blumenthal and taught us about HIV cholangiopathy. Ultimately, we learned that the patient had likely IRIS from MAC infection in the setting of her recently restarted ARVs, as her CD4 count had a marked recovery with a corresponding significant drop in the viral load.
Thank Dr. Kozman for that interesting case and excellent teaching, and Dr. Blumenthal for your additional clinical pearls!
1) When thinking of the differential for fever and focal infectious symptoms consider the categories of 1) common infections 2) opportunistic infectious and 3) IRIS.
2) HIV/AIDs cholangiopathy is a cause of secondary biliary sclerosis in HIV patients. Patients who have had infections with cryptosporium or CMV may be more at risk. They can present with fever, RUQ pain and diarrhea and can have a markedly elevated AP and ggt, as well as biliary strictures visualized on MRCP.
3) IRIS or immune reconstitution syndrome is a diagnosis of exclusion in HIV patients presenting with fever, particularly those with an initial low CD4 count and high VL who have a significant response and immune recovery after restarting ARVs. Infectious etiologies should be ruled out prior to patients being diagnosed with IRIS and getting treated with steroids.
Today at Hillcrest, we discussed a case of a clinic patient initially presenting with heartburn, suggestive of GERD. We then followed his course over a few years to the point where he started to have nocturnal symptoms despite adequate therapy, which prompted a referral to GI for an EGD. His EGD resulted in the discovery of an esophageal adenocarcinoma, for which he ultimately underwent an esophagogastrectomy with adjuvant chemotherapy. We used this case to build a discussion about many important aspects of GERD and the potential sequelae , highlighted below!
Take Home Points:
- GERD is a clinical diagnosis and it is appropriate to treat empirically with an 8 week trial of PPI in the absence of alarm symptoms. Always address lifestyle modification as well!
- Once symptoms are controlled, efforts should be made at least annually to deescalate PPI therapy as tolerable.
- Alarm features (constitutional symptoms, dysphagia, hematemesis/melena/unexplained anemia, or recalcitrant symptoms) can develop later in the disease course, so be thoughtful in follow-up as an EGD may be warranted when initially it was not indicated.
Today at the VA, Dr. Hairan Zhu presented a fascinating case of a middle-aged patient who was admitted for uncomplicated alcohol withdrawal syndrome, but after 4 days of therapy and a plan for discharge, he spiked a fever, became tachycardic, and started to complain of abdominal pain. We walked through a basic differential for (LEID) new onset fevers in the hospital and discussed how people wanted to work-up the case. Ultimately the patient was diagnosed with acute acalculous cholecystitis complicated by gall bladder perforation, but he ultimately did well with surgical management. We finally discussed the illness script for this uncommon, but very morbid disease process (see below)!
Today at the VA, we started off a series of outpatient focused cases by discussing a patient in his 50’s who presented with 1 year history of diarrhea and 70 lbs of weight loss. The teams collectively discussed their approach to diarrhea and an overall schema for the outpatient setting. We discussed the alarm features for diarrhea and, for our patient, the need for urgent colonoscopy. With a history of alcohol use disorder, CT findings of chronic pancreatitis, and an abnormal fecal elastase, the teams astutely diagnosed our patient’s diarrhea as malabsorption secondary to exocrine pancreatic insufficiency (EPI).
Today, one of our amazing 3rd year residents and future UCSD Cardiology fellow, Ali Brann, presented a case of a 53 year old woman presenting with nonspecific GI and pulmonary symptoms with fevers. She had a history of a renal transplant due to lupus nephritis over 5 years ago. We reviewed the differential for fever in a solid organ transplant and considered the “common” and “opportunistic” agents this patients are at risk for.
Clinical Pearl: These patients may have more subacute symptoms, less impressive imaging and up to 40% have no fever despite substantial infection burden!
We reviewed the 3 immuno-suppressive agents the patient was taken: Prednisone, Tacrolimus, Mycophenolate to remind ourselves about CYP interactions, and mechanism.
Our patient had a CT scan that showed inflammation in the terminal ileum with lymphadenopathy. She underwent colonscopy which showed a large mass. Biopsy revealed many AFP positive organisms consistent with Intestinal Tuberculosis!
Clinical Pearl: Treatment for intestinal tuberculosis is the same as pulmonary TB, but this patient required Rifabutin due to interactions with her transplant medications.
Thank you to Dr. Cathy Logan for her clinical expertise!!
Dominic Picetti, one of our amazing R2s, presented a case of a young man who presented with abdominal pain, moderate increase in liver enzymes, and possible new ascites. We reviewed a systematic approach to abdominal pain by reminding ourselves to consider each quadrant, the epigastrum, the pelvis as well as referred symptoms from the thorax (CHF, ACS, pneumonia ect, esophageal conditions). Then one of our fantastic Hepatologists Dr. Yuko Kono reviewed indications for different types of imaging to examine the Right Upper Quadrant. We recommended starting with an Ultrasound with doppler for this patient and then considering CT Abdomen with contrast if the initial ultrasound is equivocal. MRI with MRCP should be considered to gather information on the biliary system and Triple Phase Abdominal CT may be helpful in patients with chronic liver disease.
This patient’s imaging revealed right hepatic vein thrombosis consistent with Budd Chiari Syndrome!