Post on 07-Jan-2017
Gastrointestinal and Hepatobiliary Problems in
Renal Patients
Dr.M Alaa Saleh MSC,MD,PhDConsultant Nephrologist and Renal Transplantation
King Abdul-Aziz Specialist Hospital -Taif
Glossitis can result from iron , vit B12 or folic acid deficiency anemia
Reduced taste sensation Unpleasant taste can dietary intake Dental disease Gingival hyperplasia (Calcium channel
blockers and cyclosporine)
It occurs more frequently in CKD because of GI dysmotility or delay emptying and more prevalent in peritoneal dialysis because of ↑intra abdomen pressure
It is more common in patients with scleroderma because of esophageal peristalsis
Am J kidney Dis (2009).
Peptic ulcer in CKD are often multiple than in the general population and situated in post-bulbar position. Hemorrhage occurs more often
Gastritis and duodenitis are common in patients with CKD and abdominal symptoms
Gastrin in CKD
Gastric emptying is impaired in uremia particularly if associated by DM or amyloidosis (autonomic neuropathy and retained GI peptides)
Treatment: Diabetic control Correction of electrolyte Stop drugs delay emptying Prokinetic (metoclopramide, dompridone)
Am J kidney Dis (2009).
Diverticular disease Common in polycystic kidney disease Associated with peritoneal dialysis
peritonitis due to enteric organisms Greater risk of bleeding in CKD
Laffy K et al, Pediatr Radiol (2008).
Is common in CKD predisposing factors include drugs, diet restrictions, low oral fluid, electrolytes abnormalities
Pseudo-obstruction presents with acute or more chronic clinical features of abdominal pain, vomiting, constipation or diarrhea common in dysmotility states, such as DM, amyloidosis and scleroderma
Intestinal ischemia is an important cause of an acute abdomen in older CKD patients
Etiology: Nonoclusive mesenteric ischemia Excess fluid removal by dialysis Hypertension Cardiac failure Hypoxia viscosity and constipation
Schwartez A, et al, Nephron clin pract (2005).
GI hemorrhage is an important complication of CKD
Causes: Gastritis and duodenitis Angiodysplasia Dialysis related amyloidosis Systemic vasculitis
Schwartez A, et al, Nephron clin pract (2005).
There is some evidence suggesting that acute pancreatitis is more common in CKD and incidence may be greater in peritoneal dialysis
Most cases are secondary to biliary tract disease or alcohol or are idiopathic
Rare causes in CKD patient are hypercalcemia, vasculitis and drug as: steroids, Azathioprine, ACE inhibitors and diuretics
(Nephrol dial transplant 2008)
Hemoperitoneum: blood-stained peritoneal dialysatein a peritoneal dialysis patient who has developed acutepancreatitis.
Serum amylase is the usual diagnostic measures although concentrations are normally elevated up to threefold in renal failure
Serum lipase in an alternative diagnostic marker ( in uremia)
Radiology including : ultrasound , CT scan, MRI
Van Darp W et al, Gut (2009).
Some causes of acute abdominal pain occur more commonly in or are specific to CKD patients
A high index of suspicion for ischemic bowel is important because of the frequency of vascular disease in CKD
Pain may result from complications of polycystic kidney disease
Retroperitoneal hemorrhage can arise from anticoagulation including during hemodialysis
In peritoneal dialysis abdominal pain arises from peritonitis
(Kidney Int.2008)
Chronic cholicystitis and cholelithiasis are common in dialysis patients
In one study, gallstone disease was detected in 33% of the dialysis patients when 82% asymptomatic
In polycystic kidney → dil. Common bile duct
( J kidney Dis.2009)
Renal involvement GI involvement
Proteinuria gastro paresis
Diabetic nephropathy diabetic entropathy
Chronic kidney disease constipation
Renal problem GI problem
Proliferative glomerulonephritis Intestinal ischemia Chronic kidney disease GI hemorrhage Bowel perforation Hepatobiliary Acute pancreatitis
Renal problems GI problemsHematuria ( cyst hage) diverticular disease Chronic kidney disease Hernia Abdominal pain
(hepatic cyst)
Renal problems GI problems
Nephrotic syndrome Diarrhea Chronic kidney disease
Malabsorption Splenic
rupture
Renal problems GI problems
Amyloidosis Abdominal pain
Drug induced nephritis Diarrhea IGA nephropathy GI
hemorrhage Oxalate renal calculi
Malabsorption
Renal problems GI problems
Chronic kidney disease Dysphagia Acute renal crisis Constipation
Malsbsorption
Drug
GI side effect
Calcium (phosphate binders) constipation, abdominal discomfortSevelamer (renal) constipation, dyspepsia, bowel
obstruction
Statins abd. discomfort, diarrhea, constipations
ACE inhibitors constipation diarrhea , acute pancreatitis
Iron
epigastria pain, constipation
Bisphosphonates Esophagitis, esophageal ulcers and strictures
( Nephrol dial transplant,2005)
Drug
GI side effect
Calcium resonium constipation , intestinal pseudo-obstruction
Metformin anorexia, nausea, vomiting, diarrheaProton pump inhibitors nausea, omitting, abd. Pain,
constipation
Azathioprine dyspepsia, acute pancreatitis, hepatitis
Cinacalcet anorexia, nausea, vomitingMycophenolate mofetil diarrhea, abd. Pain, vomiting
Gastrointestinal and hepatobiliary disorders are common in chronic kidney
disease even in absence of primary disorders and may be caused by uremia
also dialysis treatment itself or the specific disorders causing the renal failure
The most common disease gastroparesis, Gastroesophagal reflux, peptic ulcer, acute pancreatitis, gastritis, and doudenitis, spontaneous colonic perforation, colonic necrosis inducing by cation exchange resins fecal impaction, non occlusive mesenteric ischemia, gastrointestinal bleeding, diabetic nephropathy
Gastrointestinal renal syndrome, concurrent gut and kidney disease may also be observed in a diverse group of multisystem disorder as; polycystic kidney disease , vasculitis, DM, Amyloidosis, IBD, Scleroderma
Some drugs used on CKD patients cause GI disorders as: calcium, renagl, statin, ACE inhibitor, Iron, calcium resonium, Bisphosphonates, proton pump inhibitors