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Conferences and Medical Updates

Diarrhea etc

TRAVELERS DIARRHEA
1.    Canada has a vaccine for TD
2.    TD is in Asia, Africa, mexico, Caribbean. Less than 5% in Europe USA
3.    Drink carbonated drinks
4.    NO ice cubes
5.    Higher altitude – boil water longer
6.    EAEC and ETEC are 50-70% of bacteria
7.    South east asia incidence is usually campylobacter.
8.    Treatment is hydration, antimotility drug.
9.    Cipro 500 mg bid for 1-3 days, Levofloxacin 500 mg once a day, same duration.  Do not use in young children and pregnant women
10.    Azithromycin 500 mg once a day for 1-3 days. Ok to use in pregnancy.  Drug of choice in South east Asia. Rest of the world Cipro.  Causes arrhythmia (azithromycin)
11.    Xifaxan can be used for TD.  More beneficial for ETEC. Campy is resistant to it. 200 mg tid for 3 days.
12.    Is it ok to use immodium with antibiotic?  Yes, it should be used.  Do not use lomotil.
13.    Lomotil causes urinary retention due to anti cholinergic effect.
14.    Use prophylaxis if you are using PPI or H2 blockers, IBD,AIDS, DM, hypertension, important business meeting.
15.    Non antibiotic prophylaxis, 2 tab qid peptobismol
16.    Probiotics are effective.  Worth trying.
17.    Prophylaxis is 500 mg of Cipro or levaquin or azithromycin 250 mg.  All once a day.
18.    Doxycycline for malaria, lepto and TD prophylaxis for all 100 mg a day
19.    Xifaxan 200 mg bid is effective for TD prophylaxis but not FDA approved

Neuroendocrine tumor
·         Neuron specific enolase
·         PNET
·         Above and other standard markers
·         Gallium 68 scan for neuroendocrine tumors

Colon Ischemia

·         From IMA occlusion by a thrombos or low flow state of IMA
·         Usually splenic to sigmoid
·         RF : aortic or cardiac bypass, vasculitis including PAN, SLE, infections like CMV, Ecoli 0157, medications like BCP, sumatriptan, alosetron,, diuretics, coagulopathies, long distance running, protein C and S, AT 3 def, APC resistance, hypotension, cocaine use, COPD, RF, DM, obstructing lesions of colon
·         More in elderly and women
·         Usually lasts 2-3 days but insevere cases can develop stricture, gangrene
·         Right colon involved then more severe, CAD,  RF,
·         Single linear ulcer, variable endoscopic appearance, colon single stripe sign,
·         Avoid mesenteric angiography, BE less likely
·         AGA recommends use of antibiotics in moderate to severe cases since it reduces severity, protects against bacterial translocation,  BUT no studies in humans to support use of antibiotics.  Needs gm neg and anaerobic coverage for ???
·         Role of steroids ?
·         Surgery with massive bleeding,peritoneal signs, toxic megacolon
·         If ischemic colitis does not resolve in 2-3 weeks or protein losing colopathy then consider surgery
·         Recurrent sepsis – consider surgery
·         Stricture or segmental ischemic colitis can consider surgery
·
Liver imaging
·         EOvist MRI for bile leak
·         If lesion washes out on MRI – MALIGNANT
·         Adenoma can have lipid or fat and some calcification
·         Neuroendocrine mets are hypervascular mets
·         Hepatocyte phase on MRI
·         Pseudotumor in left lobe of liver from SVC syndrome from abd. Wall to the liver !!
·         Hypovascular lesion less than 1 cm.  Do nothing, benign  If anxiety get mRI but nothing more than that. However if pt has liver disease or malignancy then get MRI any size
·         T2 bright, then bright lesion.  Suppression on OP  focal fat, fatty liver then focal sparing , bile dilatation then cholangioca
·         Hypervascular lesion, multiple in cancer it is mets.  Cirrhotic liver and hypervascular in Hepatic arterial phase
·         Central scar then FNH, hemangioma or HCC
·         Fibrous capsule then adenoma or HCC but NOT HCC
·         Hemangioma periherla nodule enhancement in hypervascular – typical hemangioma

Hemorrhoids
5% of population have it.
90% of pt getting colonoscopy have hemorrhoids
Treatment options are banding, sclerotherapy, IRC, sonographic ligation, surgery
Conservative involves bulk laxatives, topical steroids, sitz bath
Banding often causes pain and serious life threatening complications have occurred and causes ulceration of the mucosa that can get infected
Sclerotherapy, IRC cause less pain
HET bipolar device – Modified endoscope.
No prep or sedation needed.

Fecal incontinence
RF energy
Injections
Dietary changes
Plugs – patients do not tolerate it
Irrigation
Surgical management – anal sphincteroplasty 50% success, stimulated graciloplasty (high complication rate), rectal augmentation, fecal diversion end stage option, artificial sphincter (long term complication rate is high)

Pelvic floor dysfunction

  • Manometry and Balloon expulsion are adequate to make diagnosis.
  • Defecography to be done if only one of them is positive.  Or get MRI.
  • Biofeedback
  • If biofeedback not available – use suppositories, enemas, regular bowel habits, avoid straining.
  • Fecal incontinence : Obstetric injury is anterior wall of anal sphincter.
  • Post surgical injury is posterior defect of anal sphincter.
  • MRI is better test to identify anal sphincter abnormality.
  • Diarrhea related fecal incontinence – can use colesevelam (welchol) or cholestyramine

Short Bowel

  • Less than 200 cm of small bowel remaining
  • Three types : jejunal resection, jejunal and ileal resection or end jejunostomy where colon is also removed.
  • Complications include malabsorbption, diarrhea, fluid imbalance, oxalate nephropathy, bacterial overgrowth, metabolic bone disease, peptic ulcer dis.
  • Lactose free diet is not recommended for SBS.  However, patients should have a high CHO, low fat diet, oxalate restricted and hyperosmolar fluid restriction
  • Do not use questran in SBS