GASTROENTEROLOGY Rectal Examination

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					GASTROENTEROLOGY

Tests for Alcoholism




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National Institute on Alcohol
Abuse and Alcoholism (NIAAA)

Reports 20%    of medical OPD consults are alcohol
related and is considered     „risky‟ levels of consumption:
Men - 5 or more drinks a day or

     15 or more a week
Women- 4 or more a day or

     8 or more a week




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ETOH: Major health risks
   Liver disease
   Heart Disease
   Cancers- Liver, Pancreas, Lymphomas, Breast
   Pancreatitis
   Women: at greater risk- miscarriages/ fetal
    malformations, alcohol syndromes in babies- 40,000
    babies a year




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?Assess
   CAGE questionnaire- Did you Feel like-
 Cut down consumption
 Annoyed by others comments

 Guilty about drinking

 Eye-Opener in the morning




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Lab Tests
 GGT-
 (Gamma-glutamyl transpeptidase, GGTP)
 Higher the  level the greater the “insult”-
 liver disease

 congestive heart failure

 alcohol consumption and use of

 drugs including- (NSAIDs), lipid-lowering drugs, antibiotics, histamine blockers,
 antifungal agents, seizure control medications, antidepressants, and      hormones
 such as testosterone.
 Oral contraceptives (birth control pills) and clofibrate can decrease GGT levels.
 Smoking increases levels

 Higher in Afro Americans




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Normal Ileum




               6
Celiac Disease:
AKA- Gluten Enteropathy
     An autoimmune disease characterized by an inappropriate immune
      response to dietary proteins found in wheat, rye, and barley
     Dietary proteins- gluten and gliadin (Incidence- 1/133)(Only 3%
      diagnosed)
     Causes symptoms associated with malnutrition and malabsorption.
     An inherited tendency that is triggered by an environmental,
      emotional, or physical event
     5 to 15% of close family members also may be affected




                                                                        7
Features of Malabsorption
   Abdominal pain and distension
   Anemia
   Bleeding tendency
   Bloody stool                    Food Allergies
   Bone and joint pain             Infertility
   Changes in dental enamel
                                    Dermatitis- itchy
   Diarrhea
                                    blisters
   Fatigue
   Greasy foul-smelling stools     Lymphomas
   Oral ulceration
   Weakness
   Weight loss



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Best tests
   anti-tissue transglutaminase antibody (anti-tTG), IgA
   Anti-Gliadin Antibodies (AGA), IgG and IgA
   Anti-Endomysial Antibodies (EMA), IgA (Very Specific)
    difficult to do test
   Anti-Reticulin Antibodies (ARA), IgA (60% positive)




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     Other Useful Tests
   CBC (complete blood count) to look for anemia
   ESR (erythrocyte sedimentation rate) to evaluate inflammation
   CRP (C-Reactive protein) to evaluate inflammation
   CMP (comprehensive metabolic panel) to determine electrolyte, protein,
    and calcium levels, and to verify the status of the kidney and liver
   Vitamin D, E, and B12 to measure vitamin deficiencies
   Stool fat, to help evaluate malabsorption




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            What do they mean?

Anti-tTG                        Anti-tTG            Anti-Gliadin
      antibodies,   Total IgA         antibodies,         antibodies   Diagnosis
      IgA                       IgG                 (AGA), IgG




       +                +                                              Presumptive celiac disease




        -               +               -                  -           Symptoms not likely due to celiac disease


                                                                       Possible celiac disease, false negative anti-tTG, IgA
        -               -               +                 +                 due to total IgA deficiency




                                                                                                                               11
Cystic Fibrosis (CF)
   Caused by mutations in a gene located on chromosome 7. (AR)
   Production of a protein called cystic fibrosis transmembrane
    regulator (CFTR).
   Caucasians and Ashkenazi Jews have the highest population carrier
    rates (about 1 in 20-25).
   Absent or defective production and function of CFTR leads to
    abnormal electrolyte and water movement in and out of the
    epithelial cells




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CF

interferes with  electrolyte and fluid balances
sweat is up to five times saltier
Chronic cough and sputum production
Persistent chest infection
Weight loss and malnutrition (failure to thrive)
Pancreatitis
Chronic diarrhea and foul-smelling, greasy stools
Diabetes related to chronic pancreatitis
Delayed growth and delayed sexual development at puberty
Enlargement or rounding (clubbing) of the       fingertips and toes
Chronic hepatic disease and biliary cirrhosis
Hypoproteinemia and edema
Male infertility (obstructive azoospermia)




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    CF Tests
   Sweat Chloride.
   Stool test for Trypsin/chymotrypsin
   Fecal fat
   Complete metabolic panel
   Basic metabolic panel
   Amylase
   Lipase
   Semen analysis
   Sputum cultures



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     Tests for malnutrition
Lipids
CBC (Complete Blood Count)
CMP (Comprehensive Metabolic Panel)
Albumin
Total protein
For nutritional status and  deficiencies:
Prealbumin (is decreased in malnutrition, rises and falls rapidly, and can
be used to detect short-term response to treatment)
Iron tests (such as Iron, TIBC, and Ferritin)
Vitamin and minerals (such as B12 and Folate, Vitamin D, Vitamin K,
Calcium, and Magnesium)




                                                                              15
   Inflammatory Bowel
   Diseases
affect about a million people in US
conditions vary in severity from patient to patient and change over time

periods of active disease may alternate with periods of remission.

ESR (erythrocyte sedimentation rate) to detect inflammation

CRP (C-reactive protein) to look for inflammation

CBC (complete blood count) to check for anemia




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Diarrhea Investigations
Parasites: Giardia lamblia (giardia), Entamoeba
histolytica (E. histolytica), and Cryptosporidium parvum
(crypto).
Viruses: Rotavirus (children) Norwalk, noroviruses (also
called Norwalk-like viruses), adenoviruses, calciviruses,
cytomegalovirus (CMV), and HIV




                                                       17
Diarrhea Investigations

Bacteria:

Salmonella, often  found in raw eggs, raw poultry and in pet reptiles
Shigella, from fecally-contaminated food and water

Campylobacter, from raw or undercooked poultry

Escherichia coli 0157:H7 (E. coli)- Spinach

Staphylococcus aureus and species of Yersinia and Vibrio

Clostridium difficile toxin




                                                                         18
Diseases associated with
Diarrhea
Inflammatory bowel conditions- IBD
Bowel dysfunction –  IBS
Malabsorption disorders –cystic fibrosis
Stomach or gallbladder surgery
Food intolerance, such as lactose intolerance     or celiac disease
Chemotherapy or abdominal or        gastrointestinal radiation
Endocrine diseases- diabetes and thyroid     disease
Self-induced with laxatives
Psychogenic causes such as stress




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     Malnutrition
   Anemia
   Weight loss, decreased muscle mass, and weakness
   Dry scaly skin
   Edema
   Hair that has lost its pigment
   Brittle and malformed (spooned) nails
   Chronic diarrhea
   Slow wound healing
   Bone and joint pain
   Growth retardation (in children)
   Mental changes such as confusion and irritability
   Goiter




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?Tests for Malnutrition
Lipids
CBC (Complete Blood Count)
CMP (Comprehensive Metabolic Panel)
Albumin
Total protein
For nutritional status and  deficiencies:
Prealbumin (is decreased in malnutrition, rises and falls rapidly, and
can be used to detect short-term response to treatment)
Iron tests (such as Iron, TIBC, and Ferritin)
Vitamin and minerals (such as B12 and Folate, Vitamin D, Vitamin K,
Calcium, and Magnesium)




                                                                      21
      Metabolic Syndrome
   20% of adults (about 47 million)
   Central/abdominal obesity as measured by waist circumference
   [Men - Greater than 40 inches (102 cm);
   Women - Greater than 35 inches (88 cm)]
   Fasting triglycerides greater than or equal to 150 mg/dL (1.69 mmol/L)
   HDL cholesterol [Men - Less than 40 mg/dL (1.04 mmol/L); Women - Less
    than 50 mg/ dL (1.29 mmol/L)]
   Blood pressure greater than or equal to 130/85 mm Hg
   Fasting glucose greater than or equal to 110 mg/dL (6.1 mmol/L)




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       Colon Related Tests
Colorectal Cancers- 11%    of cancer deaths
Colorectal cancer frequently develops without early symptoms.
Symptoms that can occur include:
Diarrhea, constipation, or other changes in bowel habits lasting 10 days or more
Blood in the stool (either bright red or dark in color)
Unexplained anemia
Abdominal pain and tenderness in the lower abdomen
Abdominal discomfort (frequent gas pains, bloating,     fullness, and cramps)
Intestinal obstruction
Weight loss with no known reason
Stools narrower than usual
Constant tiredness




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Begin colorectal cancer screening when they turn    50
First-degree relative has had colon cancer, for instance, screening
should start 10 years prior to the age that relative was diagnosed
High fat and meat diets

minimal fruit, vegetable, and fiber intake.

Lifestyle factors: cigarette smoking, obesity, and a sedentary lifestyle.




                                                                        24
    Other risk factors for colon
    cancer
   Personal or family history of colon cancer or polyps
   ulcerative colitis, and
   immunodeficiency disorders




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        Four common screening tests
        recommended
Test             Description                 Recommendation   Pros               Cons
Fecal Occult     Test to detect hidden       Annually         Inexpensive;       Misses some cases;
Blood Test       blood in stool sample                        easy to do         detects blood not
                                                                                 due to cancer

Sigmoidoscopy    Examination of the          Every 5 years    Simpler and less   Misses some cases
                 rectum and lower colon                       preparation than
                 with a rigid or flexible                     colonoscopy
                 lighted instrument

Double barium    Series of x-rays of the     Every 5 to 10    Does not require   Same preparation
contrast enema   colon and rectum; patient   years            sedation           needed as for
                 is given an enema with a                                        colonoscopy
                 white, chalky solution
                 that outlines the colon
                 and rectum on the x-rays

Colonoscopy      Examination of the          Every 10 years   Perhaps most       Preparation and
                 rectum and entire colon                      useful test        conscious sedation
                 with a lighted instrument                                       required; most
                                                                                 invasive


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     Pancreatic Cancer
   33,730 diagnosed /32,300 mortality
   4th leading cause of cancer death
   No specific test exists
   Comprehensive metabolic panel
   CA 19-9 (Cancer Antigen 19-9): a tumor marker for pancreatic cancer; it
    may be used to monitor for cancer recurrence but is not useful for
    detection or diagnosis
   CEA (Carcinoembryonic antigen): a tumor marker used as a monitoring
    tool
   Other tests, such as fecal fat, stool trypsin, trypsinogen, amylase, and
    lipase help evaluate how well the pancreas is functioning and to
    determine whether pancreatic enzyme supplementation is necessary.




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Other Pancreatic Conditions
Pancreatitis

Pancreatic insufficiency- related    to pancreatitis/ cystic
fibrosis
Tests-

Fecal fat

Trypsin (an enzyme that digests protein)




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  Pancreatitis
M>F, Alcohol related
Drugs such as valproic acid and estrogen
Viral infections such as mumps, Epstein-Barr, and hepatitis A and B
Hypertriglyceridemia, hyperparathyroidism, or hypercalcemia
Cystic fibrosis
Reye's syndrome in children
Pancreatic cancer
Surgery in the pancreas area (such as bile duct surgery) or trauma




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Tests for Pancreatitis
Amylase (responsible for digesting carbohydrates)
     2 to 12 hours after the beginning of symptoms and peaks at 12 to 72
hours. It may rise to 5 to 10 times the normal level and will usually return to
normal within a week.
Lipase (digests fats)increases in the blood within 4 to 8 hours of the
beginning of an acute attack and peaks at 24 hours.




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CANCER MARKERS

A PRIMER




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The Pathologies and their tumor markers
 Breast       CA-15-3; CEA; CYFRA 21-1
 Ovary        CEA; CA 125; CA 19-9; AFP; BHCG
 Uterine      SCC; CYFRA 21-1; CEA; CA 19-9; CA 125
 Prostate     PSA; FPSA and ratio
 Testicle     BHCG; AFP
 Colorectal   CEA; CA 19-9; CA 125
 Pancreas     CEA, CA 19-9; CA 72-4
 Liver        AFP; CEA
 Stomach      CA 72-4; CEA; CA 19-9
 Esophagus    CEA; CYFRA 21-1
 Thyroid      CEA; NSE
 Lung         NSE; CYFRA 21-1; CEA; CA 125; CA 19-9
 Bladder      TPA; CEA; CYFRA 21-1
                                                      32
 Cancer Marker Panels
The panel for women                             The panel for men
CEA                                             CEA
CA 15-3 (BREAST CANCER)                         CA 19-9
CA 19-9 (OVARY/ UTERINE/ COLORECTAL/            CA 125
PANCREAS/ STOMACH/ LUNG CANCERS)

CA 125                                          CA 72-4
CA 72-4 (STOMACH/ PANCREAS CANCERS)             PSA + FPSA with
                                                ratio
AFP (OVARY/ TESTTICLE/ LIVER CANCERS)           AFP
BHCG (germ cells, ovaries, bladder, pancreas,   BHCG
stomach, lungs and liver)
b2M                                             B2M
NSE                                             NSE
CYFRA 21-19 BLADDER CANCER:                     CYFRA 21-1
LUNG CANCER:
                                                                    33
           PROSTATE CANCER
   PSA: an inflammation or trauma of the prostate (e.g. in cases of urinary retention,
    or following rectal examination, cystoscopy, colonoscopy, transurethral biopsy,
    laser treatment or ergometry) can lead to PSA elevations of varying
   Free PSA: in patients receiving therapy, particularly hormone withdrawal therapy,
    the FPSA/PSA quotient cannot be utilized to differentiate prostate hyperplasia from
    cancer of the prostate.




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b2M:
BETA 2 MICROGLOBULIN
    acute lymphblastic leukemia
    chronic myelogenous leukemia
    acute myeloid leukemia and multiple other leukemias
    lymphoma
    mulitple myeloma
    prostate cancer
    ovarian cancer
    and renal cell carcinoma




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    IL6: Interleukin 6
   stimulates the growth and differentiation of human B-
    cells and is also a growth factor for plasmacytomas
   elevated in breast cancer
   renal cell cancer
   ovarian cancer and
   multiple myeloma




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      Interleukin-2 (IL-2)
   hormone-like substance released by stimulated T
    lymphocytes
   Used in treatment of metastatic renal cell carcinoma and
    metastatic myeloma (MM)
   Lung cancer marker
   Autism




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Neuron Specific Enolase
(NSE)
    Elevated in lung cancer; non small cell lung cancer
     (NSCLC) and small cell lung cancer (SCLC)
    It is also been associated with neuroblastomas,
     medullary thyroid carcinoma, Wilm‟s tumor and
     pheochromocytoma




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     Ferritin

   testicular cancer
   neuroblastoma
   Burkitt‟s lymphoma
   lung cancer
   leukemia and
   larynx cancer




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Human Chorionic Gonadotropin-
beta (hCG)
   a tumor-associated antigen that is in various types of cancer. Most commonly, hCG beta is
    elevated, >10 mIU/ml in
   gynecological cancers
   colorectal
   seminoma testicular
   bladder
   liver
   stomach
   pancreas
   lung
   brain and
   kidney cancers




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    Tumor Marker
   Carcinoembryonic Antigen (CEA)
   CEA results to determine the stage and extent of disease and the
    outlook in patients with cancer, especially colorectal cancer.
   CEA is also used as a marker for other forms of cancer-monitoring
    patients with cancer of the rectum, lung, breast, liver, pancreas,
    stomach, and ovary.
   CEA test is not used for screening the general population.




                                                                         41
      Carcinoembryonic antigen
      (CEA)
   Found in tumors of:
   uterus
   lung
   breast
    liver ,GI , colorectal,
    kidney and
   pancreas , and
   typically among tobacco users .
   One of the most useful applications of this marker is as a post surgical
    prognostic indicator in the treatment of neoplasms.
   Any elevation of this marker after conventional treatment of neoplasms has been
    correlated with a recurrence of cancer .




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    A2m: alpha 2 macroglobulin
   Decreasing levels of A2M have been observed in
    prostate cancer
   Prostate Specific antigen can also bind to A2M and this
    complex can be used for prostate cancer
   A2M levels lower than 500 ng/ml could be considered
    cancerous




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Description: GASTROENTEROLOGY Rectal Examination