Systemic Diseases and The GI Tract

Question 1

What is the cause of gastroparesis in diabetes, and how is it tested?

Answer 1

Autonomic neuropathy
-> Measured via gastric emptying study, where a radiolabelled meal is consumed, and time to be released from the stomach is measured via radiosignature

Question 2

What are the complications of gastroparesis in diabetes? General treatment? Why is glycemic control important?

Answer 2

Bezoars - like hairballs, concretions of vegetable matter which build up in stomach and cannot be moved

Malnutrition and poor glycemic control may result

Treatment: Prokinetics, better glycemic control (also controls ischemia to bile and overgrowth of Candidiasis in esophagus)

Question 3

What causes intestinal diarrhea in diabetes and what are the consequences?

Answer 3

Loss of sympathetic tone -> unopposed cholinergic tone leading to secretion

Stasis can lead to bacterial overgrowth -> bile salt deconjugation and fat malabsorption, further causing diarrhea

Question 4

What is the treatment for intestinal stasis with bacterial overgrowth in diabetes?

Answer 4

Antibiotics like rifaximin to clear the gut bacteria, vitamin and nutrient replacement

Question 5

How does diabetes cause fecal incontinence and how is it a real problem?

Answer 5

Sympathetic denervation of the smooth muscle in the IAS leads to required voluntary contraction by EAS striated muscle to maintain continence

-> causes problems at night where you shit yourself because you aren’t awake to think about your need to contract EAS

Question 6

How is anal sphincter tone measured? What will be the diabetes abnormality?

Answer 6

Ano-rectal manometry studies
-> inflate balloon in rectum, the IAS should relax and the EAS will contract in normal patients

Diabetics have decreased resting IAS tone

Question 7

What liver disease is seen in diabetes?

Answer 7

Steatohepatitis -> fibrosis & cirrhosis

With accumulation of Mallory-Denk hyaline like in alcoholic hepatitis

Question 8

How does thyroid disease contribute to GI symptoms?

Answer 8

Hypothyroid - slows everything down, constipation

Hyperthyroid - speeds everything up -> increased stool frequency = diarrhea

Question 9

What GI manifestations does hyperparathyroidism and its associated hypercalcemia cause?

Answer 9

Constipation or diarrhea

Calcium stimulates gastrin -> Hypergastrinemia -> peptic ulcer disease + diarrhea

Calcium stimulates pancreas -> pancreatitis

Note: ZE syndrome (gastrinoma) associated with parathyroid adenoma

Question 10

What are the GI manifestations of renal failure?

Answer 10

Angiodysplasias everywhere (unknown why) -> bleeds and subsequent iron deficiency anemia

Pancreatitis and “nephrogenic ascites” - assocatied with renal failure, reason unknown

Duodenal polyps - hypertrophy of Brunner’s glands, reasons unknown

Question 11

What symptoms do each of the following drugs cause?:

1. Calcium channel blockers (Non-DHP)
2. Magnesium
3. Aluminum (i.e. hydroxide)

Answer 11

1. Ca channel blockers i.e. verapamil - cause constipation (clogged toilet in sketchy)
2. Magnesium - near osmotic laxatives in sketchy (Must Go to bathroom)
3. Aluminimum amount of feces - constipation

Question 12

What two drugs are especially associated with esophageal ulcers?

Answer 12

Doxycycline

Bisphosphonates

Question 13

What are the manifestations of GI symptoms in scleroderma similar to? Include the ano-rectal manometry result?

Answer 13

Very similar to diabetes, with lots of stasis and dysmotility

Neuropathies in the condition -> complete loss of LES and IAS tone

-> worse fecal incontinence than diabetes with no maintenance of IAS tone, severe GERD from loss of LES tone

Question 14

What are the important manifestations of autoimmune diseases like SLE, RA, and polyarteritis nodosa in the GI tract?

Answer 14

Pancreatitis - think of the “A” in the I GET SMASHED mnemonic

Acalculous cholecystitis - inflammation and hypoperfusion leads to cholecystitis without stones

Question 15

What does amyloidosis of the GI tract cause?

Answer 15

Malabsorption, cholestatic liver disease, motility disorders, and GI blood loss due to malabsorption

Question 16

What are the GI manifestations of polymyositis and dermatomyositis? Include the ano-rectal findings?

Answer 16

Striated muscle weakness

• > loss of UES / upper esophagus function
• oropharyngeal dysphagia
• > loss of EAS
• severe fecal incontinence

Question 17

What are the biggest causers of problems in GI tract of in uncontrolled HIV?

Answer 17

Esophagus - Candidate, CMV, HSV

Stomach - CMV

Small intestine - Mycobacterium avium complex, TB (miliary), Cryptosporidium, CMV

Colon - CMV

Question 18

What GI problems does Schistosomiasis cause?

Answer 18

Colitis / Proctitis from egg deposition and granuloma formation in mucosa / submucosa

Hepatic fibrosis - eggs washed into portal flow, hepatic granulomas and fibrosis in pre-hepatic sinusoidal space. Causes portal hypertension

Question 19

What are the GI symptoms of Graft-versus-Host disease?

Answer 19

Bleeding, diarrhea, malabsorption, protein-losing enteropathy

In liver: “vanishing bile duct” syndrome -> cholestasis / jaundice

Question 20

What are the most common GI problems of pregnancy?

Answer 20

Nausea / vomiting - hyperemesis gravida

GERD / heartburn - estrogen and progesterone cause LES dysfunction, and increased intraabdominal pressure allow acid to leak thru LES

Question 21

What is the fulminant liver disease of pregnancy and what is seen on liver pathology?

Answer 21

Acute fatty liver of pregnancy -> relieved by delivering child

MICROvesicular fatty change

Question 22

What GI tract anomaly is seen more commonly in aging and is also seen in renal failure?

Answer 22

GI tract angiodysplasis

Question 23

How does stomach acid and motility change with age?

Answer 23

Acid - goes down (hypo/achlorhydria), but usually causes few problems

Motility - decreases