Gastrointestinal Disorders

NAUSEA & VOMITING

Excessive cannabinoid use may cause nausea, vomiting, and abdominal pain (cannabinoid hyperemesis syndrome), which may be temporarily relieved with hot showers or baths.

CONSTIPATION

Prucalopride is a high-affinity 5-HT₄ agonist that is approved in the United States for the treatment of chronic constipation (2 mg once daily). It does not appear to have any cardiovascular risk.

GASTROINTESTINAL BLEEDING

In patients with large volume lower GI bleeding requiring hospitalization, the timing of colonoscopy is controversial. A meta-analysis of trials found that colonoscopy within 24 hours did not reduce length of stay, rebleeding, or mortality.

GASTROESOPHAGEAL REFLUX DISEASE

A large prospective study of over 17,000 patients taking proton pump inhibitors for a median of 3 years did not find an increased risk of some previously reported adverse events, including pneumonia, bone fractures, kidney disease (due to interstitial nephritis), dementia, or myocardial infarction.

In a 2019 randomized controlled trial of patients with refractory heartburn and confirmed reflux (acid or non-acid) despite twice daily proton pump inhibitor therapy, fundoplication resulted in 67% adequate symptom relief at 1 year compared with 12-28% with continued medical therapy.

BENIGN ESOPHAGEAL LESIONS

The INR does not provide an accurate reflection of coagulopathy in advanced liver disease. Fresh frozen plasma should not be administered routinely in stable patients with an elevated INR because it has no proven benefit but does have potential harms, including increased portal pressures and risk of portal vein or deep venous thrombosis.

Transient elastography (FibroScan) is a noninvasive method for assessing liver stiffness and fibrosis that may be used to stratify patients at high risk for varices (who may benefit from endoscopy) versus those at low risk (in whom endoscopy is not needed).

ESOPHAGEAL MOTILITY DISORDERS

Per oral endoscopic myotomy (POEM) increasingly is supplanting pneumatic dilation and surgical Heller myotomy as a preferred first-line treatment option in achalasia.

GASTRITIS & GASTROPATHY

Population-based screening for intestinal metaplasia and early gastric cancer is not endorsed by professional guidelines in regions with low gastric cancer incidence but is practiced in high-incidence regions.

INTESTINAL MOTILITY DISORDERS

In 2019, a small blinded crossover trial of 34 patients with confirmed gastroparesis, the serotonin 5-HT4 receptor agonist, prucalopride (currently FDA approved for treatment of chronic constipation) demonstrated significant improvement in gastric emptying and symptoms compared with placebo.

IRRITABLE BOWEL SYNDROME

Although overtesting in irritable bowel syndrome should be avoided, a 2019 American Gastroenterological Association practice guideline recommends selected laboratory tests in patients with chronic diarrhea to exclude other diagnoses.

INFLAMMATORY BOWEL DISEASE

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