16: GIGU Clinical Correlations Flashcards
Red flags in GI complaint
- Dysphagia or odynophagia
- Hematemesis, melena
- Unintentional weight loss
- Persistent vomiting
- Constant severe pain
- Palpable mass
- Lymphadenopathy
- FHx upper GI CA
DDx for pain in RUQ (5)
- Cholecystitis
- Pyelonephritis
- Ureteric colic
- Hepatitis
- Pneumonia
DDx for LUQ (4)
- Gastric ulcer
- Pyelonephritis
- Ureteric colic
- Pneumonia
DDx for both RLQ and LLQ (5)
- Ureteric colic
- Inguinal hernia
- IBD
- UTI
- gynecological or testicular
Ddx that is different for RLQ vs LLQ
RLQ: appendicitis
LLQ: diverticulitis
What causes visceral vs parietal/somatic pain?
Visceral: distention or contracting hollow organs or organ ischemia
ParietaL: inflammation of parietal peritoneum
Location and localization of visceral vs parietal pain
Visceral: midline at level of structure, not localized
Parietal: localized at the source, is more constant and severe
How appendicitis moves from visceral pain to parietal
Starts out as a diffuse periumbilical pain -> becomes RLQ parietal tenderness in acute appendicitis
General concepts that can cause N/V
- Mechanical obstruction
- Dysmobility
- Vestibular disorders
- Increased intracranial pressure
- Migraine
- Psychogenic
- Meds and drugs
- Systemic disorders
Main causes of oropharyngeal dysphagia vs esophageal dysphagia
Oropharyngeal: neurologic disorders, metabolic disorders, infectious disease, structural disorders
Esophageal: mechanical obstruction, motility disorder
Diagnosing GERD
- Based on clinical symptoms alone
2. Can do an EGD to evaluate alarming features/red flags
GERD treatment
- Lifestyle modifications
- Antacids
- Surface agents
- H2 blockers (Zantac)
- Proton pump inhibitors (Omeprazole)
PUD: Peptic ulcer disease: risk factors
H pylori, NSAIDs, smoking, alcohol
PUD sx
Mostly asymptomatic, upper abd pain, GI bleeds sometimes
What is the most common cause of UGI bleed?
PUD
Symptoms fo gastric vs duodenal ulcer
Gastric: sharp burning epigastric pain 30-90mins after eating
Duodenal: gnawing epigastric pain 3-5 hours after eating
why does it not really matter if you can differentiate between gastric and duodenal ulcer?
Diagnosis and treatment are the same
H pylori characteristics
Gram negative rod, flagellated
The most prevalent chronic bacterial disease
H pylori
H pylori is associated with lots of GI pathology, including…
PUD, chronic gastritis, gastric adenocarcinoma, gastric MALT lymphoma, duodenal ulcers
Pathophys of how H pylori works
Secretes urease -> forms ammonia that helps neutralize gastric acid, producing a protective cloud around the organism so it can penetrate the gastric mucus layer
Four diagnostic tests for H pylori
- Urea breath test
- Fecal Ag test
- Abs in serum
- EGD with biopsy
What is melena usually caused by?
Upper GI bleed
What is hematochezia usually caused by?
Lower GI bleed
Upper vs lower GI bleed location distinction
Upper: above ligament of Trietz
Lower: below/distal to ligament of Treitz
If pts have a Hx of GI bleed, what is likely in the next GI bleed?
That theyre bleeding from the same site
Important things to ask about PMHx with upper GI bleeds
- Hx GI bleeds
- Aortic graft
- Liver disease (portal HTN)
- EtOH abuse and smoking
- NSAIDs or othe rmedications
- H pylori
Things that may cause feces to mimic a GI bleed
Mediations with iron or bismuth, red foots like Koolaid or beets
What causes gastric and esophageal varices?
Dilated submucosal veins from portal hypertension; usually from alcoholic liver disease in US
Three types of gallstone presentations
- Asymptomatic (most common)
- Classic presentation with biliary colic, RUQ pain, worse with greasy foods
- Complicated presentation with pancreatitis, etc.
Cholelithiasis
Gallstones
Cholecystitis
Inflammation of gallbladder, usually secondary to obstruction/stone
choledocholithiasis
Stone in the common bile duct -> neither liver nor gallbladder can drain
LFTs in cholecystitis vs choledocholithiasis
Cholecystitis: LFTs normal
Choledocholithiasis: LFTs elevated
Ascending cholangitis
Biliary tree inflamed or air in biliary tree
Gallstone pancreatitis + lab values
Gallstone gets stuck in pancreatic duct -> elevated LFTs and pancreatic enzymes
Dysfunctional GB
No stones, but GB doesn’t empty well -> biliary colic
Risk factors for pancreatitis
Gallstones, alcohol abuse, high triglycerides, many other
Classic presentation of pancreatitis
Acute onset persistent/severe epigastric pain and TTP, N/V
Pancreatitis treatment
Depends on severity; IV fluids, pain/nausea meds, NPO or clear liquids only
Classic presentation of appendicitis
RLQ pain, anorexia, N/V, +/- fever, starts visceral and becomes parietal, localized at McBurney’s Point
Diverticulosis risk factors
Diet of low-fiber high fat and red meat, physical inactivity, obesity
Diverticulitis
Erosion of diverticula wall by increased intraluminal pressure or impacted food particles -> inflammation
Diverticulitis presentation
Abd pain in LLQ, +/- N/V or fever
Diverticulitis treatment
Abx, some require surgery
Achalasia pathophysiology
Progressive degeneration of ganglion cells in esophagus -> failure to relax LES -> loss of peristalsis in distal esophagus
Primary achalasia diagnosis
barium esophageal shows “birds beak” distal esophagus
Chagas’ disease can cause?
Secondary achalasia
Where is Chagas’ disease most common
Mexico, central and South America
What parasite causes Chagas’ disease?
Trypanosoma cruzi
Zollinger-Ellison syndrome cause
Gastrin-secreting tumor (gastrinomas)
Sympathetic levels for appendix, esophagus, and stomach
Appendix: T12
Esophagus: T2-8
Stomach: T5-9
Sympathetic levels for liver and gallbladder
T6-9
Sympathetic levels for SI and colon
SI: T5-12
Colon: T9-12
Sympathetic levels for pancreas
T5-11
Risk factors for small bowel obstruction
Prior abdominal surgery (adhesions), hernia, intestinal inflammation
small bowel obstruction symptoms
N/V, cramping pain, distention, obstipation (constipation due to obstruction)
Schatzki’s ring
Stricture/ring in the esophagus causing difficulty swallowing
Zenker’s diverticulum
Pouch in esophagus where food goes, making it difficult to swallow, can cause aspiration
