28. Clinical Approach to Diagnosing Gastrointestinal Diseases

Question 1

common presentation of a patient with oral disease

Answer 1

mouth pain

Question 2

HPI, fever, weight loss, odynophagia, bleeding, rashes, pain with chewing, trauma, dental history, immunocompromised history, medications like prescription and over the counter, recent antibiotics, immune compromising meds, tobacco, alcohol, drug use, visual inspection with a good light source of the lips, tongue, teeth, gums, mucosa, posterior pharynx

Answer 2

mouth pain history

Question 3

apthous stomatitis or canker sores, most common lesion of the oral mucosa, 1mm to 2cm, round to oval, mucosal, yellowing adherent exudate centrally, does not overlie bone, infetcious etiololgies include viral as cocksackie A, herpes simplex, herpes sozer, cytomegalovirus, epstein-barr, HIV, bacterial infections like tuberculosis and syphilis, fungal infections like coccidiodes immitis, cryptococcus neoformans, blastomyces dermatidis, also recurrent apthous stomatitis, diagnosis is visual, treatment is supported with chlorhedixine 12% of rinse

Answer 3

apthous ulcers

Question 4

gingivestomatitis as a painful small ulcer on the gums, palate, tongue, lips, mucosal membranes, can overlay the bone, labialis as clusters of vesicles on the lips or cold sores, prodrome of pain, burning, or tingling, diagnosis by PCR, DFA, and serologic testing, Tzank smear, treatment of primary infection is acyclovir within 72 hours, treatment of recurrent with prodrome is famiciclovir or valacylovir for 1 day

Answer 4

herpes simplex virus oral lesion

Question 5

pseudomembranous thrush most common with candida albicans, hyperplasic plaque like lesions, or hyperplastic nodular lesions, or denture stomatitis, risk factors include infant population, denture wearers, antibioti use, chemotherapy, radiation therapy, cellular immune deficiency, chronic dry mouth, inhaled glucocorticoids, diabetics, visual diagnosis can be adequate but definitive is KOH prep of scraping showing pseudohyphae or budding yeast, treatment is with nystatin suspesion/troche, miconazole, or clotrimazole troche, check for HIV, diagnosis is visual, definitive testing is KOH prep, use nystatin suspension, miconazole, or clotrimazole troche

Answer 5

oral candidiasis

Question 6

infections arising from the teeth or supporting structures, important because cna extend beyond the mouth to deep fascial spaces of the head and neck, associated with fever of unknown origin, bacteremic seeding of heart valves and prosthetic devices, preterm birth, increased risk for CAD and stroke

Answer 6

dental infections

Question 7

typically asymptomatic but can lead to pulpitis which can cause pain and is treated with fillings, pupitis is an inflammation of the dental pulp that is reversible if mildly inflammated but irreversible if acute intense pain from pressure building up in the pulp chamber, one of the most frequent reasons for people to seek emergency dental care, frequently treated with antibiotics but no proof there is benefit, treated by drilling to relieve pressure (root canal) or removal of the tooth, which can lead to dental abscess

Answer 7

dental caries

Question 8

painful tooth, peridental swelling and pain, treat with surgical drainage or antibiotics if fever and regional lymphadenopathy, oral antibiotics like amoxicillin clavulanate for oral with mild inflammation with no sepsis or comorbidities use amoxicillin clavulanate, use parenteral antibiotics if septic, severely immunocompromised, perforated bony cortex use ampicillin sulbactam, if bone is osteomyelitis

Answer 8

suppurative odontogenic infections

Question 9

inflammation of the gingiva around the tooth, diagnosis is visual, for acute with mild pain give chlorhexidine 0.12% oral rinses, rapidly advancing disease or severe pain or immunocompromised treat with penicillin plus metronidazole, amoxicillin-clavulanate, or clindamycin, patients should see the dentist, rapidly

Answer 9

gingivitis

Question 10

inflammation of the gingiva around the tooth, diagnosis is visual, for acute with mild pain give chlorhexidine 0.12% oral rinses, rapidily advancing disease or severe pain or immunocompromised treat with penicillin plus metronidazole, amoxicillin-clavulanate, or clindamycin, patients should see the dentist

Answer 10

gingivitis

Question 11

inflammation of the supporting structures of the teeth, especially the periodontal membrane, diagnosis is visual and cultures if complicated, nonsecure treatment with minocycline, doxycycline or metronidazole topically, severe with amoxicillin clavulanate or amoxicillin plus metronidazole

Answer 11

periodontitis

Question 12

subjective sensation of difficulty or abnormality of wallowing, common presentation of a patient with esophageal infection, commonly presents with other problems, obstruction including tumor, ring, web, stricture, erosive esophagitis, eosinophilic esophagitis, motility disorders, and diverticulum

Answer 12

dysphagia

Question 13

odynophagia (painful swallowing), dysphagia (subjective sensation of difficulty or abnormality of swallowing, retrosternal chest pain, bleeding, oral lesions, fever in <1/3 of patients

Answer 13

common presentations of esophageal infections

Question 14

HPI including onset, ROS including fever, weight loss, abdominal pain, nausea, vomiting especially undigested food, hematemesis, GERD, chest pain, history of cancer, anemia, previous structures requiring dilatation, past surgical history of chest, throat, esophageal, or stomach surgery, smoking history, visual inspection of the mouth with a good light source, visual inspection of the face, beck, and thorax for scaring from previous treatments/surgery, palpation of the neck, thyroid, and supraclavicular area, auscultation of the heart and lungs, abdominal exam

Answer 14

data gathering HPI

Question 15

infectious causes include candida, herpes simplex virus, cytomegalovirus, histoplasmosis, and tuberculosis, risk factors include immunosuppression with medications like corticosteroids treatment, immunosuppressants after transplant, chemotherapy, HIV/AIDS, age, history of blood transfusion

Answer 15

common etiologies

Question 16

esophageal dysphagia suspicion, history of prior radiation, caustic injury, surgery for laryngeal or esophageal cancer, complex stricture, if yes, barium swallow, upper endoscope +/- esophageal biopsies, structural abnormality or normal

Answer 16

approach to a patient with esophageal dysphagia

Question 17

white, non-ulcerative plaque, pseudohyphae with budding years, treatment with oral fluconazole, IV voriconazole or posaconazole

Answer 17

candida esophageal infection endoscopy diagnosis

Question 18

large shallow ulcerations with nuclear inclusions, treatment with oral valganciclovir/IV ganciclovir

Answer 18

cytomegalovirus endoscopy diagnosis

Question 19

small deep ulcerations with nuclear inclusions, treatment with oral/IV acyclovir

Answer 19

herpes simplex esophageal endoscopy diagnosis

Question 20

symptoms consistent with infection in an HIV infected patient, treat with systemic anti fungal agents and scope in 3-4 days if no improvement

Answer 20

clinical diagnosis of candida esophagitis

Question 21

epigastric pain or burning, postprandial fullness, early satiety, can be acute or chronic, a common presentation of a patient with infectious diseases, other causes include functional medications like NSAIDs, antibiotics, corticosteroids, excessive consumption of food and/or alcohol, biliary disease, excessive gas, ulcerative and non-ulcerative disease, gastritis, gastroparesis

Answer 21

dyspepsia

Question 22

HPI, ROS including fever, weight loss, nausea, vomiting, jaundice, change in stool color, hematochezia, melena, history of previous h pylori infection, systemic illnesses like autoimmune diseases, radiation therapy, NSAIDSs, corticosteroids, alcohol, tobacco, and drug use, also family history, physical exam includes oral exam with a good light source, neck palpation, heart and lung auscultation, abdominal exam, structural exam, rectal exam with stool testing for blood

Answer 22

data gathering for dyspepsia

Question 23

inflammation of the lining of the stomach, etiologies are typically infectious agents or immune mediated, infectious includes h pylori, most common cause of gastritis worldwide, mycobacterial syphilitic, viral including herpes simplex or CMV, parasitic including cryptosporidium, Strongyloides stercoralis, anisakiasis, gunnel, no typical clinical manifestations, sudden onset of epigastric pain, nausea, and vomiting have been described to accompany acute gastritis, many people are asymptomatic or develop minimal dyspeptic symptoms, diagnosis by biopsy specimen from patients undergoing upper endoscopy for evaluation, non-invasive testing is best if PPIs are stopped 2 weeks before testing, urea breath test is for initial diagnosis and eradication, stool antigen for initial diagnosis and eradication, serology for concerns over accuracy, treatment for h pylori associated gastritis includes, triple therapy of clarithromycin/proton pump inhibitors, amoxicillin for 14 to 21 days, or quadruple therapy adding bismuth

Answer 23

gastritis

Question 24

etiologies include h pylori, SNAIDS< risk factors including smoking, alcohol, genetic factors like predisposition, diagnosis with endoscopy and h pylori testing, treatment is to discontinue NSAIDS and treat h pylori

Answer 24

peptic ulcer disease

Question 25

3 or more loose/water stools in 24 hours, acute is less than 7 days , prolonged is 7-13 ays, persistent is 14-29 days, and chronic is greater than 30 days, the most common manifestation of GI infections, the most common travel related symptom

Answer 25

diarrhea

Question 26

acute diarrheal disease, rapid onset lasts less than two weeks, accompanied by nausea, vomiting, fever, or abdominal pain

Answer 26

definition of acute gastroenteritis

Question 27

infectious mainly related to medication side effects, intrinsic GI diseases, or endocrine disorders, also noninfectious but infectious is more important

Answer 27

differential diagnosis of diarrhea

Question 28

invasive bacterial pathogens cause fever and blood in the stool, small bowel pathogens cause a large volume of diarrhea, bloating, gas, and cramping, large bowel pathogens include frequent small volume or painful bowel movements

Answer 28

diarrhea history clues

Question 29

HPI includes onset, duration, severity, frequency, stool volume, character including watery, bloody, or mucous, ROS includes fever, tenesmus which are painful rectal spasms with a strong urge to defecate but little passage of stool, history of immunocompromised, radiation exposure, or recent antibiotic use, past surgical history of previous abdominal surgeries, sick contacts, food exposures, travel history, physical exam includes orthostasis, skin exam includes turgor, oral exam, neck palpation, auscultation of the heart and lungs, abdominal exam, rectal exam for stool testing of blood

Answer 29

nausea, vomiting, diarrhea history

Question 30

inflammatory or noninflammatory

Answer 30

acute infectious diarrhea causes

Question 31

spreads by food, contaminated water, or from person to person

Answer 31

gastroenteritis

Question 32

norovirus, non-typhoidal salmonella species, clostridium perfringens, campylobacter, highest incidence is norovirus, salmonella causes the most hospitalization and death

Answer 32

food borne GI infections

Question 33

most commonly bacterial including shiva toxin producing e coli, other coli types, salmonella, campylobacter, shigella, aeromonas, vibrio, areas of highest risk are Africa, South Asia, Latin America, Middle East, persistent symptoms are to think protozoa including Giardia lambia, cryptosporidium Cyclospora, or e hystolycia

Answer 33

travelers diarrhea

Question 34

most patients no testing is necessary if presentation is consistent with viral cause and of mild to moderate severity, severe diarrhea, fever, blood stools, mucoid stools, severe abdominal pain or cramping, duration greater than 14 days or signs of sepsis, obtain stool testing with GI film array, fecal leukocytes, lactoferrin, and/or cultures, blood cultures include fever, immunocompromised, infants less than 3 months old or fever of unknown origin

Answer 34

diarrhea diagnostic approach

Question 35

if positive can move onto confirmatory culture

Answer 35

GI filmarray NAAT/PCR

Question 36

mainly supportive, rehydration preferably oral including solutions containing water, salt, and sugar, diluted fruit juices with saltine crackers and broths or soups, oral rehydration solutions includes rehydralyte and ceralyte, for severe dehydration IV fluids, empiric antibiotics, consider for those with complications, severe disease including fever >6 stools a day, dehydration requiring hospitalization, blood or mucoid stools with fever

Answer 36

acute diarrhea treamtnet

Question 37

diarrhea, abdominal pain, nausea, vomiting, history of recent antibiotic use, may occur up to weeks after discontinuation of antibiotics, pay attention to the history of antibiotic use, symptoms may occur 4-9 days of antibiotic treatment, when testing you need fresh liquid stool, do it on people with more than 3 stools in a 24 hour period, can do PCR testing but can’t differentiate between, can do toxin gene testing, can do EIA which is less sensitive but can do rapid results, GDH testing but cannot distinguish between toxin and non-toxin producing strains, cultures are rarely performed, treatment is to stop the antibiotic, nonsecure disease is oral vancoymycin or fidoxamycin which are both more effective than metronidazole, severe use oral vancomycin or fidaxomicin, fulminant oral vancomycin and IV metronidazole, surgery may be required, 5-50% of treated patients ave recurrence and most respond to a second course of treatment but some are offered fecal microbiota transplantation, to prevent infection, minimize the frequency, duration, and number of antibiotics, consider restricted use of flouroquinolones, clindamycin, and cephalosporins

Answer 37

c diff