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)

Glossitis

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

Diverticular disease

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

DiverticulitisFecal impactionDialysis 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

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 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)

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 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

Renal problem GI problem IgA nephropathy Malabsorption Iron deficiency

anemia

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

Thank You

Thank You