Gastrointestinal and Hepatobiliary Disorders

ABNORMAL LIVER CHEMISTRIES

Management

Adults

Recommendations from

►ACG 2017, ACR 2023

–Elevations in liver function tests are encountered frequently in clinical practice and indicate hepatobiliary insult or obstruction.
–Albumin and prothrombin time serve as markers of hepatocellular synthetic function.
–Patterns of LFT elevation are characterized as “hepatocellular” and “cholestatic.”
–See Figs. 5–1, 5–2, and 5–3 for a recommended approach to abnormal liver chemistries.

Fig. 5–1

Algorithm for Evaluation of Aspartate Aminotransferase (AST) and/or Alanine Aminotransferase (ALT) Level.

“Two types of elevations are considered. One. Borderline elevation less than two times ULN. Two. Mild elevation two to five times ULN. The following are the processes to be followed for Borderline elevation less than two times ULN. One. History and physical exam; Discontinue hepatotoxic meds; Discontinue alcohol consumption; Assess for risk factors for fatty liver and viral hepatitis. Two. CBC count or platelet count, AST or ALT, ALK Phos, TB, albumin, PT or INRHBs Ag, HBc Ab, HBs Ab, HCV Ab with PCR confirmation if positive, iron panel, abdominal ultrasound. Three. If negative, consider observation for three to six months with repeat AST or ALT, Alk Phos, TB. Four. If persistently elevated, continue investigation: ANA, ASMA, gamma-globulin, ceruloplasmin, alpha-1 antitrypsin phenotype, and may consider additional tests based on history (Example, celiac sprue, tick-borne disease, thyroid disease, and muscle disorders). Five. If normal, further testing at the discretion of clinical refers to a hepatologist for consideration of liver biopsy. Mild elevation between two to five times ULN: The following are the processes to be followed: One. History and physical exam; Discontinue hepatotoxic meds; Discontinue alcohol consumption; Assess for risk factors for fatty liver and viral hepatitis. Two. CBC/platelet count, AST/ALT, ALK Phos, TB, albumin, PT/INR, H Bs Ag, H Bc Ab, H Bs Ab, HCV Ab with PCR confirmation if positive, iron panel, Abdominal ultrasound. Three. If negative, consider observation for three months with repeat AST/ALT, Alk Phos, TB or continue investigation. Four. f persistently elevated, continue investigation: ANA, ASMA, gamma-globulin, ceruloplasmin, alpha-1 antitrypsin phenotype and may consider additional tests based on history (Example, celiac sprue, tick-borne disease, thyroid disease, and muscle disorders). If no diagnosis, consider a diagnostic liver biopsy.”

View Full Size||Download Slide (.ppt)

Fig. 5–2

Algorithm for Evaluation of Elevated Serum Alkaline Phosphatase.

“The top left of the chart begins with Normal total bilirubin and serum transaminases, which leads to four steps. The first step reads: History and physical exam confirm with serum GGT. The second step reads: If GGT is normal, evaluate for non-hepatobiliary etiologies; if GGT is abnormal, obtain right upper quadrant ultrasound, evaluate for potential hepatotoxic medications, and check AMA, ANA, and SMA. The third step reads: If evaluation negative and alkaline phosphatase is 2x ULN, it leads to consider liver biopsy; if evaluation negative and alkaline phosphatase is 1 to 2x ULN, it leads to observation; If ductal dilatation identified leads to ERCP or MRCP. If AMA is positive, it leads to evaluate for primary biliary cirrhosis/cholangitis. The fourth step reads: If the persistent elevation of serum alkaline phosphatase after six months of observation leads to consider liver biopsy. The top right of the chart begins with elevated serum transaminases plus or minus elevated bilirubin, which leads to four steps. The first step reads: History and physical exam, Check right upper quadrant ultrasound. The second step reads: If ductal dilatation leads to ERCP, MRCP; If no ductal dilatation leads to check AMA, ANA, SMA. The third step reads: If AMA is positive, it leads to evaluate for primary biliary cirrhosis/cholangitis. If AMA negative and alkaline phosphatase leads to 2x ULN leads to consider liver biopsy or MRCP. If AMA is negative and alkaline phosphatase 1 to 2x ULN, it leads to consider observation. The fourth step reads: If persistent elevation of serum alkaline phosphatase after six months of observation, then consider liver biopsy or MRCP.”

View Full Size||Download Slide (.ppt)

Fig. 5–3

Algorithm for Evaluation of Elevated Serum Total Bilirubin.

“Top left of the chart begins with Elevated total bilirubin (predominant unconjugated), which leads to four steps. The first step reads: History and physical exam, Assess liver transaminases and serum alkaline phosphatase. The second step reads: Review medications, Evaluate for hemolysis, Evaluate for Gilbert’s syndrome. The third step reads: If the persistent elevation is otherwise unexplained, may consider diagnostic testing for Gilbert’s syndrome (UGT1A1 genotype) and evaluate for uncommon etiologies in Table 6. The fourth step reads: If the persistent elevation is otherwise unexplained, is symptomatic, is worsening over time, and/or associated with abnormal transaminases, leads to consider liver biopsy.”

View Full Size||Download Slide (.ppt)

Sources

–J Am Coll Radiol. 2023;20(11S):S302–S314.
–Am J Gastroenterol. 2017;112(1):18–35.

ANAL FISSURES

Management

Adults

Recommendations from

American Society of Colon and Rectal Surgeons (ASCRS) 2022

–Begin with nonoperative first-line treatments including:
- Sitz baths and fiber supplementation.
- Topical steroids or analgesics as needed for pain relief.
- Topical nitrates, with the understanding of increased risk for headaches.
- Topical calcium channel blockers.
- Botulinum toxin injections may be considered for chronic anal fissures.
–Consider operative treatment with lateral internal sphincterotomy unless the following contraindications are present:
- Women with prior obstetrical injuries.
- Patients with IBD.
- History of anorectal operations.
- History of anal sphincter injury.
–Other operative treatment approaches are available for those with a high risk for fecal incontinence.

Source

–ASCRS. Dis Colon Rectum. 2022;66:190–199.

BARRETT ESOPHAGUS (BE)

Screening

Adults

Recommendations from

►ASGE 2019

–Do not screen for BE in patients with gastroesophageal reflux disease (GERD) who are otherwise low risk.
–Screen moderate- to high-risk individuals using upper endoscopy (EGD) and biopsy.
- Moderate risk: GERD and ≥1 other risk factor: age > 50 y, male sex, White, obesity (BMI ≥ 30), central adiposity, tobacco use.
- High risk: family history of esophageal adenocarcinoma or BE.

Practice Pearls

Forty percent of persons with BE and esophageal cancer have no preceding GERD symptoms.
Treat all persons with biopsy-proven BE with proton pump inhibitor (PPI) therapy, including asymptomatic individuals.

Sources

–Gastrointest Endosc. 2019;90(3):335–359.
–Am J Gastroenterol. 2016;111(1):30–50.
–Barrett’s Oesophagus and Stage 1 Oesophageal Adenocarcinoma: Monitoring and Management. London: National Institute for Health and Care Excellence (NICE); 2023.

Management

...

Get Free Access Through Your Institution

Learn how to see if your library subscribes to McGraw Hill Medical products.

Subscribe: Institutional or Individual

Sign In

Username

Password

Forgot Password? Forgot Username?

Download the Access App: iOS | Android

Chapter 5: Gastrointestinal and Hepatobiliary Disorders

Citation

Jump to a Section

ABNORMAL LIVER CHEMISTRIES

Management

Recommendations from

Fig. 5–1

Fig. 5–2

Fig. 5–3

Sources

ANAL FISSURES

Management

Recommendations from

Source

BARRETT ESOPHAGUS (BE)

Screening

Recommendations from

Sources

Management

Pop-up div Successfully Displayed