Gastrointestinal and Hepatobiliary Problems in Renal Patients Dr.M Alaa Saleh MSC,MD,PhD Consultant 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)

Glossitis

Gingeval hyperplasia

 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

Upper gastrointestinal endoscopy shows multiple duodenal ulcers

 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).

Diverticular disease

 Is common in CKD predisposing factors include drugs, diet restrictions, low oral fluid, electrolytes abnormalities

 Diverticulitis  Fecal impaction  Dialysis related amyloidosis Laffy K et al, Pediatr Radiol (2008).

 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).

Angiodysplasia

 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 dialysate in a peritoneal dialysis patient who has developed acute pancreatitis.

 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)

Disease result in both renal and GI manifestations

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 problems Hematuria ( 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

Renal problem GI problem IgA nephropathy Malabsorption Iron deficiency anemia

DrugGI side effect Calcium (phosphate binders) constipation, abdominal discomfort Sevelamer (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) DrugGI side effect Calcium resonium constipation, intestinal pseudo-obstruction Metformin anorexia, nausea, vomiting, diarrhea Proton pump inhibitors nausea, omitting, abd. Pain, constipation Azathioprine dyspepsia, acute pancreatitis, hepatitis Cinacalcet anorexia, nausea, vomiting Mycophenolate 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

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