This chapter discusses the assessment and laboratory findings, imaging, diagnosis and management of ascites. A common complication of cirrhosis is ascites, or the accumulation of fluid in the abdominal cavity. Ascites that develops from cirrhosis is associated with portal hypertension. The patient with cirrhosis and ascites may complain of increased weight gain, lower extremity edema, and abdominal bloating or distension. Physical examination findings may reveal a distended or even tense abdomen, positive fluid wave, dullness to abdominal percussion, and peripheral edema. Routine laboratory testing, such as complete blood count, complete metabolic panel, and liver function testing, should be performed with new-onset ascites and at routine return visits. Patients with cirrhosis and ascites can develop electrolyte imbalances and renal failure. Ultrasound is helpful to determine whether ascites is present if there is any uncertainty upon physical examination. Patients should abstain from alcohol consumption and avoid using nonsteroidal anti-inflammatory drugs.

Inflammatory bowel disease (IBD) is a broad diagnosis that includes two major chronic diseases: ulcerative colitis (UC) and Crohn’s disease (CD). IBD is typically diagnosed in young adulthood. Smoking has been associated with a higher risk of developing CD. UC is an inflammatory disease of the mucosa of the colon and rectum. Typical symptoms include bowel movement urgency, tenesmus and bloody diarrhea. CD is a chronic inflammatory disorder of the alimentary tract. It is associated with high levels of proinflammatory cytokines. Referral to a gastroenterologist specializing in IBD may be needed. To confirm diagnosis, a flexible sigmoidoscopy is necessary in cases of UC and a colonoscopy is necessary in cases of CD. The goal for treatment of IBD is to suppress the immune system and help heal the bowel. Initial treatment for patients with mild to moderate UC includes 5-aminosalicyclic acid compounds.

Some drugs, like aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), have been blamed for peptic ulcer formation. The most common peptic ulcers are duodenal ulcers. Risk factors for the development of peptic ulcer disease are chronic NSAID use, older age, Helicobacter pylori infection, use of anticoagulant or anti-platelet medications, history of prior ulcers, use of corticosteroids, alcohol use, and smoking. One of the goals of treatment for the patient with peptic ulcer disease is eradication of H. pylori infection. Complications that develop if peptic ulcer is untreated include gastrointestinal bleeding, gastric cancer and gastric outlet obstruction, with bleeding the most common. Most patients with peptic ulcer disease are asymptomatic. When symptoms do arise, dyspepsia is a common complaint. Sucralfate, a formula of aluminum hydroxide and sulfated sucrose, is given to patients with peptic ulcer disease to protect the gastric and duodenal mucosa.

This chapter discusses the incidence and risk factors, assessment, laboratory and image testing, diagnosis and treatment of constipation. Constipation affects 15" of adults in Western countries and 33" of patients older than 60. History is important when trying to determine the cause of constipation. The patient should be asked for a detailed description of bowel movements, including how many per day or week, how often, and how long has constipation been a problem. A complete blood count and complete metabolic panel should be obtained. Several electrolyte imbalances can cause constipation. Constipation is often caused by inadequate fiber intake or hydration, inactivity, or can be medication-related. Providers should encourage patients with acute constipation to increase hydration and fiber intake to 20 to 35 grams per day. Nutritional modification may be enough to resolve constipation and can likely prevent further episodes. In some cases of chronic constipation, nonpharmacologic treatments are helpful.

This chapter discusses the incidence and risk factors, assessment and laboratory findings, diagnosis and management of celiac disease. Celiac disease is considered an autoimmune disorder with a genetic component. If left untreated, patients with celiac disease have an increased risk of developing gastrointestinal cancers and enteropathy-associated T-cell lymphoma. Some of the disease’s symptoms are asymptomatic, whereas some have severe malabsorption issues with skin manifestations. Celiac disease is frequently found in patients who have other autoimmune disorders. A serologic test called immunoglobulin A (IgA) anti-tissue transglutaminase (tTGA) is performed to detect possible celiac disease in patients over two years old. Characteristic histological changes of celiac disease are villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis, and mucosal inflammation. The only curative treatment for celiac disease is strict adherence to a gluten-free diet (GFD). It is important to recognize other vitamin deficiencies in patients with celiac disease, including B 12, D, iron, and folate.

Diarrheal diseases are one of the top leading causes of death worldwide. Although in normal healthy people diarrhea is considered a self-limiting illness, certain individuals can be susceptible to severe dehydration that can cause serious complications. Providers should ask about the patient’s definition of diarrhea, as individuals may differ on its meaning. Correcting dehydration and preventing worsened hydration status is the top priority when treating the patient with diarrhea. Patients must be educated to eat high-carbohydrate foods like bananas, rice, baked potatoes, applesauce, and saltine crackers for a day or two prior to resuming a normal diet. Probiotics have been shown to recolonize the intestine with healthy bacterial flora, which may have been lost from episodes of diarrhea. Multiple episodes of diarrhea cause perineal irritation and tenderness, even pain. To slow down or reduce the frequency of diarrhea, loperamidine or atropine can be used.

Irritable bowel syndrome (IBS) is a common disorder. It is characterized as a functional disturbance of bowel motility with symptoms of lower abdominal pain and alternating episodes of diarrhea and constipation. Risk factors for the development of IBS include alcohol consumption and high levels of psychological stress. Diagnosis is made by history and physical examination. If bloody stools are reported, then a complete blood count is necessary to rule out anemia. Patients report mucus-like stools with IBS. The management of IBS depends mostly on symptom control, especially stress management. Dietary changes are necessary and include no alcohol or caffeine, avoidance of substances to which one is allergic, and an increase in dietary fiber intake. Adequate hydration is important. Some patients report relief from pain and abdominal distension with the use of probiotics. For any patient suffering from IBS, tricyclic antidepressants and antispasmodics can be tried to improve symptoms.

This chapter reviews liver testing and some reasons for the liver abnormalities. The liver function test (LFT) is a combination of serum testing, including alkaline phosphate, alanine aminotransferase (ALT), aspartate aminotransferase (AST) and bilirubin levels. Alkaline phosphatase is a serum level that is derived from bone and liver cells. Albumin is a protein that is produced by the liver. Low levels are seen in patients who have chronic liver disease, malnutrition, or cancer. Imaging studies that are frequently ordered for the patient with abnormal LFT results are an initial abdominal ultrasound and/or CT scan if further imaging is required. Mild elevations are seen in patients with chronic hepatitis B or C, fatty liver disease, or alcoholic cirrhosis. There are certain medications that can cause acute elevations in LFT readings. Some of those include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, antiseizure medications, antituberculosis medications, antilipid agents, sulfonylureas, herbal medications, and illicit drugs.

This chapter discusses the incidence, assessment, laboratory findings, additional studies, diagnosis and treatment options of nausea and vomiting (N/V). N/V are common complaints in primary care offices. Initial evaluation of the patient with N/V includes determining how long the patient has had symptoms. The most common complications of N/V are dehydration and conditions caused by electrolyte imbalances, mainly hypokalemia and metabolic alkalosis. Depending on the degree of dehydration, basic laboratory evaluation may be needed to evaluate specifically for anemia, infection, and electrolyte imbalances. Esophagogastroduodenoscopy (EGD) can be performed for patients with unexplained N/V. Abdominal X-rays can be performed if there is concern about a bowel obstruction. For patients who are dehydrated, intravenous fluids (IVFs) are usually needed to assist with hydration until oral intake is possible. Antiemetics are medications that works by controlling response from the central nervous system.

Abdominal pain can occur in a patient for any number of reasons. When evaluating the patient with abdominal pain, obtaining a detailed history is important in determining the proper diagnosis. Vital signs should be obtained and a detailed abdominal examination including a rectal examination, and pelvic examination, should be performed. In the patient with acute abdominal pain, laboratory testing should include complete blood count with differential, complete metabolic panel, lipase and amylase tests, liver function tests, urinalysis, and pregnancy test. Abdominal flat and upright films are useful in the patient presenting with abdominal pain. Bowel obstruction or intestinal perforation can be seen on these films. Abdominal ultrasound imaging is preferred in cases in which peritonitis is a concern and/or if the patient is pregnant or possibly pregnant. Surgical and acute abdomen are terms used to describe abdominal pain that quickly worsens and will likely continue to do so without surgery.