GI Board Review Elizabeth Paine, MD Division of Digestive Diseases The University of Mississippi Medical Center Esophagus • Proximal 1/3 esophagusstriated muscles under CNS control • Distal 2/3 esophagussmooth muscle under vagal and myenteric nervous system control • UES and LES are normally in a contracted state • Initiation of swallow relaxes both of the sphincters Question 70 year old female with PMH of Parkinson’s disease, HTN, DM presents with dysphagia and occasional choking while eating for past several weeks. She notices dysphagia as soon as she initiates a swallow. CXR is normal. Which modality is the most sensitive in the diagnosis of this patient’s dysphagia? A. B. C. D. Esophageal manometry Modified barium swallow EGD Chest CT Dysphagia • Oropharyngeal Dysphagia - Structural disorders - Neurological disorders (Stroke, ALS, myasthenia gravis, Parkinson’s, myotonic dystrophy) • Esophageal Dysphagia Esophageal Dysphagia Solids Only: Characteristic Etiology Treatment Intermittent Schatzki’s ring Dilation Progressive + heartburn Peptic stricture Dilation + PPI Progressive + weight loss Esophageal cancer Depends on stage Solids and Liquids: Characteristic Etiology Treatment Intermittent + chest pain Diffuse esophageal spasm PPI + nitrates/CCB Progressive + heartburn Scleroderma PPI Progressive + no GERD Achalasia Heller myotomy, pneumatic dilation Schatzki’s Ring • 45yo M with longstanding GERD presenting with 6 months of intermittent solid food dysphagia Odynophagia • Ulcerative Esophagitis - Due to infection or pill - Viral (HSV,CMV) - Candida - most common • Pill-Induced Esophagitis - Tetracyclines, FeSO4, Bisphosphonates, NSAIDs, Quinidine, Potassium Question • 55 y/o man presents with progressive dysphagia for both solids and liquids, intermittent regurgitation of food, and wt loss of 30 lbs over the course of 1 year. Symptoms not relieved with PPI. Barium esophagram shows a dilated esophagus with an air/fluid level and tapered narrowing of the distal esophagus. What is the most likely diagnosis? A. Esophageal cancer B. Esophageal stricture C. Achalasia D. Esophageal ring Achalasia • Failure of the LES to relax with swallowing • Progressive dysphagia for solids and liquids and regurgitation • Barium esophagram with esophageal dilation with classic “bird’s beak” appearance distally • Esophageal manometry shows lack of relaxation of the LES with swallowing and aperistalsis of the esophageal body Achalasia treatment • Laparoscopic Heller myotomy • Pneumatic dilation • Botox injection just proximal to LES • Nitrates/CCB offer temporary relief Pseudoachalasia • If obstruction at LES is caused by a malignant lesion, the disorder is designated “pseudoachalasia” • Mimics manometric findings of achalasia • EGD is recommended in all suspected cases of achalasia GERD • Most common cause of non-cardiac chest pain • Inappropriate LES relaxation • Empiric PPI - first dx/tx • Refractory GERD needs EGD, pH monitoring and/or eso manometry Indications for EGD • Failure of treatment • Age > 50 • Symptoms > 5 years • Alarm symptoms - Wt Loss - Dysphagia - Anemia GERD Treatments • • • • Life style modifications PPI H2 Blockers Fundoplication Risks of PPI • • • • Enteric infections (C. difficile) Pneumonia Hip fractures (Osteoporosis) B12 deficiency Dyspepsia • Definition • Alarm signs - Age >55 years with new-onset symptoms - Family history of gastric cancer - Unintentional wt. loss - GI bleeding - Dysphagia/Odynophagia - Gastric outlet obstruction signs/symptoms Dyspepsia Question 59 y/o white male with h/o GERD for the last 5-6 years. Symptoms have gotten worse lately. OTC tums don’t help much. Recent cardiac work up was negative. Denies N/V or weight loss. Also has HTN, DM, and Obesity. He is a smoker. Meds include HCTZ , Metformin. Other than BMI of 32 rest of PE is normal. Which of the following is the most appropriate management of this patient? A. B. C. D. Ambulatory esophageal pH monitoring Barium swallow study EGD H2 Blockers Barrett’s Esophagus • Normal squamous epithelium of the distal esophagus is replaced by columnar epithelium • Obese/white/male/smoker with GERD • Pre-malignant condition • Increased risk of esophageal adenocarcinoma • Long segment BE > 3 cm • Histologically diagnosed by detection of specialized intestinal metaplasia and goblet cells Barrett’s Esophagus Management of Barrett’s esophagus (AGA guidelines 2011) Finding Management No dysplasia Low-grade dysplasia High-grade dysplasia without eradication tx Mucosal irregularity within Barrett’s Invasive cancer EGD every 3-5 years EGD every 6-12 months EGD every 3 months Endoscopic mucosal resection Surgery Esophageal Squamous Cell Cancer • More common in men, especially black men • Risk factors: Smoking, alcohol, nitrosamine exposure, corrosive injury to esophagus, achalasia, HPV • Clinical presentation: Dysphagia, weight loss, GI bleed, anorexia • Dx: Endoscopy. Mass usually involves upper esophagus • Rx: Surgery/Chemo/Radiation Question 39y/o male with PMH of seasonal allergies for past several years presented with c/o chest discomfort after he ate pork chops for lunch 2-3 hrs ago. He can’t swallow anything and feels food stuck in his chest. He has had 2 such episodes in the past. Physical examination is unremarkable. EGD is as shown. Histologic examination of the mucosa shows intense inflammation of the lamina propria with more than 15 eosinophils per HPF. No strictures are seen. What is the diagnosis? A. B. C. D. Achalasia Severe GERD Eosinophilic esophagitis Schatzki’s ring Eosinophilic Esophagitis • Young adults with dysphagia and food impaction and with h/o other allergic disorders • Endoscopic Dx : - Mucosal longitudinal furrowing - Circumferential rings • Pathology shows > 15-20 Eos/HPF • TX : PPI and swallowed fluticasone H.Pylori Diagnosis • Stool Antigen Test • Urea Breath test • Serum antibody test • Endoscopic histology (gold standard) Treatment of H.pylori • Triple Therapy PPI BID+ Amox 1 Gm + Clarithromycin 500mg BID X 10-14 days • With PCN Allergy PPI BID + Metronidazole 500mg BID + Clarithromycin 500 mg BID X 10-14 Days • Quadruple Therapy PPI BID+ Bismuth 525 mg QID + Metronidazole 500 mg BID + Tetracycline 500 mg QID X 10-14 days Peptic Ulcer Disease Causes • • • • • • H.Pylori NSAIDS ZE Syndrome Malignancy Crohn’s disease Viral infections Peptic Ulcer Disease Complications • Bleeding (most common) (Risk factors: Age and NSAIDS) • Perforation • Gastric outlet obstruction • Anemia Management of PUD • • • • • Stop NSAIDS Eradicate HP if present PPI BID x 8 weeks Follow up EGD in 8 weeks for gastric ulcers Surgery for those refractory to medical therapy Zollinger-Ellison Syndrome • Involves gastrinoma causing ulcers and diarrhea • Gastrinomas are frequently in the duodenum or pancreas • Can be associated with MEN 1 • Initial tests are 3 fasting serum gastrin levels off PPI on different days • Additional testing includes secretin stimulation test, octreotide scan, CT/MRI to localize gastrinoma, EUS Upper GI Bleeding Causes • Non-Variceal: Gastric and DU Ulcers Mallory-Weiss tear GAVE (watermelon stomach) AVMs (Age, CRI, AV, OWR) Hemosuccus pancreaticus • Variceal Esophagitis/Gastritis Malignancy Hemobilia Dieulafoy lesion Aortoenteric fistula Question 57 year old male presents with c/o weakness and melena for 3 days. No significant abdominal pain. He is orthostatic on exam. Stool is heme positive. NG suction with coffee-grounds material. HCT 30. What is the next step in management? A. B. C. D. E. EGD UGI series Angiography Insert large-bore IV’s and T/C match for blood EGD/Colon exam Management of UGI Bleed • • • • • • Fluid resuscitation Blood transfusion 2 large bore IV’s or Central Line Placement PPI infusion initially Octreotide infusion (Variceal Bleed) EGD Epinephrine inj + Coag and/or clips • IR or Surgery if endoscopy fails Management of UGI Bleed • Evaluate severity of bleed – NGT lavage that does not clear = emergent endoscopy – Coffee ground or NGT that clears in hemodynamically stable patient can wait – Hemodynamically unstable patient should be admitted to the ICU • Remember ABCs • Elevated BUN (normal creat) = UGI bleed • Look for signs of liver disease Gastric Adenocarcinoma • Risk factors: smoking, blood type A, H.Pylori, family history of gastric cancer, environmental • Clinical Presentation: wt. loss, abd pain, early satiety, GOO, anemia • Diagnosis: Endoscopy with biopsy • EUS for depth of invasion Gastroparesis • Causes - Idiopathic - DM - Postoperative - Autoimmune disorders • Diagnosis - Rule out mechanical obstruction with EGD/UGI - 4 hr Gastric emptying test Gastroparesis Management • • • • • • • Low fat and low fiber diet Small/frequent meals Antiemetics Prokinetics GES Feeding jejunostomy tube TPN Gastric Bypass • Roux-en-Y is the most common in US • PE is the most common cause of death post-procedure • IDA • B12 deficiency • Calcium and Vit D deficiency Dumping Syndrome • Early: - within 30 minutes of eating - nausea, bloating, and diarrhea • Late: - 1-3 hrs after eating - hypoglycemia, tachycardia, sweating • Treatment: - low carb diet - small meals - more protein and fat in diet Gastric volvulus • Abnormal rotation of the stomach around its axis • Acute volvulus: pain in the upper abdomen or lower chest, inability to pass NG tube, vomiting • Radiographic findings • Acute gastric volvulus is a surgical emergency. However, if the patient is a poor surgical candidate, endoscopic methods can be tried. • Chronic volvulus usually has vague upper abdominal symptoms Images from Uptodate.com Lower GI Bleeding Etiologies • • • • • • Diverticuli Ischemic colitis AVMs Post-polypectomy bleed Meckel’s Diverticulum UGI cause in 10-15% Hemorrhoids NSAIDs/ulcers IBD Dieulafoy lesion Radiation colitis Acute Diverticular Bleeding • Painless bleeding with hypotension/syncope • Usually elderly patients • 85% of cases have spontaneous remission • Diagnosis/treatment: - Volume resuscitation with fluids/blood - Colonoscopy & endo tx - Angiography Ischemic colitis • Due to decreased mesenteric blood flow and hypoperfusion in “watershed” areas • Due to non-occlusive ischemia • Sudden LLQ pain with tenesmus, then passage of red-to-maroon stool • Virtually never embolic • Dx with colonoscopy or CT • Rx: Supportive care with IVF, pain control, risk factor modification, +/antibiotics Management of LGIB • Identify contributing factors by history (NSAIDS, antiplatelets, anticoagulants, radiation) • Volume resuscitation with blood and IVF • Colonoscopic treatment with epi/coag/clips • Tagged RBC scan • Angiography with possible embolization • Small bowel eval with push enteroscopy or Pillcam Obscure GI bleeding • • • • Dieulafoy lesion Hemobilia Missed lesions Meckel’s Meckel’s diverticulum • Outpouching of the ileum • Can have ectopic gastric mucosa • Maroon painless bleeding per rectum • Can present with intestinal obstruction or appendicitis-like symptoms • Can be diagnosed by Meckel’s scan (99mmtechnetiumpertechnetate study) Diverticulitis • Acute LLQ pain with fever and leukocytosis • Diagnosis: - CT scan with contrast - Avoid colonoscopy • Treatment: - Needs to cover Gram negatives and anaerobes - Cipro/Flagyl - Ampicillin-sulbactum Pericolonic diverticular abscess • IF < 3-4 cm: - antibiotics - supportive care • IF > 3-4 cm: - CT guided drainage - antibiotics Acute Mesenteric Ischemia • Do not confuse with ischemic colitis • Pain out of proportion to examination, acutely ill • Due to loss of blood flow to SB and/or ascending colon • Commonly embolic • Older patients with h/o CHF, recent MI, cardiac arrhythmias • Do angiography unless there are signs of perforation Chronic mesenteric ischemia • “Intestinal angina” • Postprandial abdominal pain, abdominal bruit, weight loss • Caused by atherosclerosis of intestinal arteries • Often have signs of other PVD and smoking hx • Diagnosis often based on sx although MRA or spiral CT have been used • Tx: angioplasty with stent placement in patients who can tolerate this Question 54 y/o WF with protein S deficiency presents with a 2 day history of severe epigastric abdominal pain with nausea/vomiting. She had this CT in the ER. What is the cause of her pain? A. Peptic ulcer disease B. Mesenteric venous thrombosis C. Biliary colic D. Functional abdominal pain Colon Cancer Risk factors: – Age > 50 – H/o adenomatous polyps – H/o breast, ovarian, or endometrial CA – Family History (1st degree) – Ulcerative colitis/Crohn’s colitis – Lifestyle (fat, fiber, obesity) 3rd most common cancer in males (behind prostate and lung) and female (behind breast and lung) Colon Cancer Screening Average risk: begin at 50 Above-average risk • FS q5y, FIT qy - if adenoma found – • 1 first degree relative with CRC or adenoma <60 y/o or 2 first degree relatives with CRC or adenoma: q5y - begin age 40 or 10y younger than proceed with colonoscopy • Colonoscopy q10y - if incomplete: do BE • CT colonography q5y earliest diagnosis • Personal history of polyp: q5y - Advanced polyp (>1cm, villous features, high-grade dysplasia): 3y - 3 or more polyps: 3y Familial Adenomatous Polyposis (FAP) • Classic version has >100 adenomatous polyps • Classic has 100% CA risk • Proctocolectomy by age 20 • Periampullary duodenal cancer # 1 cause of cancer death after colectomy FAP Variants • Gardner syndrome - FAP + osteomas, desmoid tumors - supernumerary teeth • Turcot’s variant - FAP + brain tumors (GBM or medulloblastoma) • Attenuated APC - 10-100 adenomatous polyps What’s wrong with this patient? Familial Hamartomatous Polyposis Syndromes Peutz-Jeghers Syndrome Juvenile Polyposis • Multiple hamartomatous polyps & lip/buccal hyperpigmentation • Hamartomas mostly in distal colon • High cancer risk (>90%) - small bowel, colon, breast, • Congenital malformation of GI,GU tract and heart ovarian, pancreaticobiliary • Common presentation= abd pain due to intussusception or obstruction by large polyp • Increased cancer risk - surveillance q1-3y Hereditary Nonpolyposis Colon Cancer (HNPCC) or Lynch Syndrome • Colon CA in 3 relatives (one first degree) over 2 generations & with one diagnosed < 50 yo – microsatellite instability (MSI) – MMR gene mutations • Lynch I: limited to colon and rectum • Lynch II: increased risk of CA in female genital tract, breast, other sites • Surveillance: q1-2 yrs beginning age 20-25 or 10 yrs before the age of youngest family member • q1 year after the age of 40 Staging of Colon Cancer Stage Involvement 5 year survival TNM I/Duke’s A TNM II/Duke’s B mucosa/ submucosa 95% muscularis or serosa 70%/85% TNM III/Duke’s C regional LN’s 35%-65% TNM IV/Duke’s D metastasis 5% Note: CEA levels are only helpful for recurrence of colon & only if elevated pre-colectomy & normal afer surgery Colon Cancer • If a distal lesion is found, the entire colon needs to be “cleared” prior to treatment due to a high risk of concomitant lesions • XRT is not used for colonic lesions – Remember this because the colon “moves around” and the XRT beam can’t localize the tumor – XRT is indicated for rectal cancer Stage C Colon Cancer • Common Board Question • Stage C = tumor penetrated into and/or through muscularis propria of bowel wall + pathologic evidence of colon cancer in lymph nodes • Treatment is with 5-Fluorouracil and leukovorin Classification of Diarrhea A cu te In fe ctio us C h ro n ic In ge stion W a te ry O sm o tic In fla m m a to ry S e cre to ry In fe ctio us F a tty IB D M a lab so rp tion Acute Diarrhea • Duration – Acute (< 3 weeks) • Infectious, drugs, ingestion of osmotic substances. • Usually self-limited (given a competent immune system) • Treatment usually only with severe dehydration/toxic Infectious Diarrheas Bacteria Key points Treatment Staph aureus Foodborne in dairy, mayo-based salad, poultry. n/v, short incubation Supportive ETEC (E.coli) Traveler’s diarrhea Supportive, can use FQ Bacillus cereus Reheated fried rice Supportive Vibrio cholera Profuse watery diarrhea Copious rehydration. Can use doxycycline Giardia Malabsorption and steatorrhea, daycare, creek water. FQ or nitazoxanide Campylobacter Bloody diarrhea. Uncooked poultry, unpasteurized milk Supportive, erythromycin if septic E.Coli 0157:H7 Can cause HUS. Poorly cooked beef Supportive, avoid abx Vibrio vulnificus Raw seafood, injury in seawater. Skin infection. Can be deadly in cirrhotics. Doxycycline Shigella Acute bloody diarrhea with tenesmus, 3rd generation cephalosporin daycare Salmonella Eggs, chicken, turtles, iguanas, other reptiles. Bloody diarrhea Supportive, avoid antibiotics unless septic, febrile Diarrhea Pearls • • • • • Guilian-Barre Campylobacter Raw eggs Salmonella HUS E.coli O157:H7 Antibiotics C. diff Bloody diarrhea followed by RUQ pain, fever +/Jaundice Amebiasis (tx flagyl + paromomycin) • Abd pain, bloating, frothy stool Giardia • Rice water stools Vibrio Clostridium difficile • Often will have a leukocytosis • Management depends on severity and recurrence • Initial episode: - Mild: metronidazole 500mg TID x 10-14 days - Severe: vancomycin 125mg po QID x 10-14 days • First relapse: repeat same treatment as initial episode • Second relapse: tapering vancomycin or fidaxomicin 200mg po BID x 10 days • Subsequent relapse: fidaxomicin if not used previously vs. fecal transplant Chronic Diarrhea • Duration – Chronic (> 3 weeks) • More complex work-up and treatment C h ro n ic W a te ry O sm o tic In fla m m a to ry S e cre to ry In fe ctio us F a tty IB D M a lab so rp tion Osmotic vs. Secretory Diarrhea O sm otic S ecretory D aily stool volum e < 1L > 1L E ffect of fasting S tops C ontinues S tool N a 30 100 S tool K 30 40 290-2(N a + K ) > 125 (> 50) < 50 pH U sually acidic U sually neutral Osmotic Diarrhea Etiologies • Bacterial overgrowth • Lactase deficiency/malabsorption • Drugs (colchicine, neomycin, magnesiumcontaining laxatives, lactulose) • Celiac disease • Tropical sprue • Pancreatic insufficiency • Whipple’s disease Laxative abuse • • • • • High volume, frequent, watery diarrhea Often associated with crampy abdominal pain Osmolar gap >50 Usually female and may be in medical field Stool magnesium often >108 mg/dL (45 mmol/L or 90 mEq/L) with magnesium-based laxatives • Testing for laxatives Secretory Diarrhea • Most common cause is infection • Enterotoxins from infections interacting with receptors causing increased anion secretion • Congenital defect in transport molecules • Exogenous agents – Drugs and poisons Etiologies: • Enterotoxins from E.coli, V. cholera, S. aureus • Villous adenomas • Gastrinomas • VIPomas with secretion of VIP • Lymphocytic colitis • Collagenous colitis • Bile acids Secretory “Structural” Diarrhea • There must be an adequate mucosal surface area for transport to occur – Compromise water absorption – Ileal resection length • >100cm: Malabsorption due to decreased bile acids • <100cm: Bile acid diarrhea Carcinoid syndrome • Clinical symptoms: flushing, diarrhea, hypotension, hyperthermia, tachycardia • Screen with urine 5-HIAA • Most tumors located in terminal ileum but can be located rarely in the bronchus • Treat symptoms with octreotide Fat Malabsorption • • • • Celiac Disease Small-Intestinal Bacterial Overgrowth Short-bowel syndrome Pancreatic Insufficiency Celiac Disease • Abd discomfort, bloating, diarrhea, weight loss, flatulence • IDA, Vit A,D,E,K, Folic acid deficiency • Steatorrhea & enteropathy • Aphthous stomatitis • Associated with dermatitis herpetiformis or other autoimmune disorders Celiac Disease • Gluten-sensitive enteropathy • Allergy to wheat, rye, barley, oats • Diagnosis – – – – Anti-tissue transglutaminase (tTG) most useful IgG/IgA antigliadin antibodies Anti-endomysial antibody less sensitive HLA –DQ2 or HLA-DQ8 • Treat with gluten free diet • Steroids for refractory disease Celiac Disease Whipple’s Disease • Tropheryma whipplei (G + Bacilli) • PAS positive material in macrophages • Dx by PCR on Biopsy or CSF Whipple’s Disease • Clinical Features - Intermittent episodes of polyarthritis - Diarrhea with wt. loss - CNS: Dementia, myoclonus, ophthalmoplegia - Psych: Depression and personality changes - Card: pericarditis, myocarditis • Treatment: IV Ceftriaxone x 2 weeks followed by oral Bactrim x 12-18 months Toxic megacolon • Acute toxic colitis with colonic dilation • Complication of ischemic colitis, infectious colitis, C.diff, IBD, etc • Signs of sepsis • Can result in perforation • Management: IVF, replete electrolytes, IV antibiotics, colonic decompression, consult surgeon • Surgery indications Colonic inertia • Severe form of slowtransit constipation • Disordered colonic motor function • Sitz marker test • Conservative measures tried first • If symptoms persist, may need surgery Question 55 y/o F presented with a 2-month history of profuse watery diarrhea up to 5 times per day without bleeding, abdominal pain or vomiting. She had lost 5lbs but there was no history of iritis, arthritis, rashes or aphthous ulcers. Exam was normal. Labs revealed a normal CBC, CMP, and CRP. There was no growth on stool culture. Colonoscopy was normal without ulceration. Her biopsies are shown. What is causing her symptoms? A. B. C. D. Crohn’s disease Ulcerative colitis Microscopic colitis Irritable bowel syndrome – diarrhea predominant Irritable bowel syndrome • Chronic crampy abdominal pain, alternating bowel habits, improves with defecation • Rome criteria • Treatment: - Reassurance - Dietary modifications including low FODMAP diet - adjunctive medical therapy Inflammatory Bowel Disease Crohn’s disease Ulcerative colitis Lesions Focal, skip, deep Shallow, continuous Clinical Course Indolent More acute Steroids Less responsive Very responsive Granuloma Pathognomonic None Rectal Involvement Rectal sparing Rectum involved Perianal disease Abscesses, fistulas None IBD Clinical Pearls • GI CA UC >>> Crohn’s • Toxic megacolon Both – BE contraindicated in acute exacerbation • Smoking & CD risk exacerbation • Smoking & UC UC symptoms can start w/tobacco cessation Crohn’s Disease: Pearls • Bimodal age distribution – Peak 20-30s – Smaller one in 70-80s – ASCA+ in 50-60% • Granulomas are pathognomonic… …but seldom seen • “String sign” in TI on SBFT • 30% colon, 40% SB, 30% both – “mouth to anus” Ulcerative Colitis: Pearls • Area of involvement – proctitis – left-sided colitis – pancolitis (“universal colitis”) • 70-80% P-ANCA + IBD Treatments • 5 ASA – Several designer drugs – “col” = colon (Asacol, Colazal…) • Steroids—avoid if possible – Budesonide (Entocort) • Azathioprine/6-MP – Immunomodulator – Steroid-sparing agent – Monitor for SEs • Methotrexate • Antibiotics • Anti-TNF therapies – Fistulizing disease – Unresponsive to conventional therapy IBD Extraintestinal Manifestations • • • • • • Usually seen in colitis therefore more common in UC Seronegative arthropathy Uveitis, Ankylosing Spondylitis (HLA-B27) Erythema nodosum Pyoderma gangrenosum Primary sclerosing cholangitis (HLA-B8) – PSC, check ALP annually 2X ULN ERCP/MRCP • Osteoporosis • HLA associated manifestations do not correlate with course of colitis UC and Cancer • Duration & extent of disease, age at dx increases risk – Ulcerative Proctitis has no risk CA – 10 years 2% – 20 years 15% • Pancolitis- begin at 8 years (AGA guidelines) • Left sided colitis- begin at 15 years (AGA guidelines) • Colonoscopies are generally performed q1-2 years after surveillance is started, depending on findings • High-grade dysplasia or cancer colectomy • Low grade dysplasia management is controversial Physical Exam Pearls • Emaciation, cheilosis, glossitis – Severe malabsorption • Associated dermatitis herpetiformis – Celiac sprue • Associated pyoderma gangrenosum -- IBD • Arthritis – IBD or Whipple’s • Pulmonic stenosis and tricuspid regurgitation – Carcinoid syndrome Physical Exam Pearls • Associated neuropsychiatric findings – Whipple’s disease • Abdominal mass – Malignancy, Crohn’s, diverticulitis • Localized abdominal tenderness – Inflammatory condition • Perianal ulcers/fistulas, reduced sphincter tone/incontinence/right sided abdominal pain -- Crohn’s • Peripheral or autonomic neuropathy – May correlate with visceral neuropathy in DM and intestinal pseudo-obstruction Questions?