28. Clinical Approach to Diagnosing Gastrointestinal Diseases Flashcards
common presentation of a patient with oral disease
mouth pain
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
mouth pain history
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
apthous ulcers
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
herpes simplex virus oral lesion
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
oral candidiasis
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
dental infections
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
dental caries
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
suppurative odontogenic infections
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
gingivitis
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
gingivitis
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
periodontitis
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
dysphagia
odynophagia (painful swallowing), dysphagia (subjective sensation of difficulty or abnormality of swallowing, retrosternal chest pain, bleeding, oral lesions, fever in <1/3 of patients
common presentations of esophageal infections
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
data gathering HPI
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
common etiologies
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
approach to a patient with esophageal dysphagia
white, non-ulcerative plaque, pseudohyphae with budding years, treatment with oral fluconazole, IV voriconazole or posaconazole
candida esophageal infection endoscopy diagnosis
large shallow ulcerations with nuclear inclusions, treatment with oral valganciclovir/IV ganciclovir
cytomegalovirus endoscopy diagnosis
small deep ulcerations with nuclear inclusions, treatment with oral/IV acyclovir
herpes simplex esophageal endoscopy diagnosis
symptoms consistent with infection in an HIV infected patient, treat with systemic anti fungal agents and scope in 3-4 days if no improvement
clinical diagnosis of candida esophagitis
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
dyspepsia
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
data gathering for dyspepsia
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
gastritis
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
peptic ulcer disease
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
diarrhea
acute diarrheal disease, rapid onset lasts less than two weeks, accompanied by nausea, vomiting, fever, or abdominal pain
definition of acute gastroenteritis
infectious mainly related to medication side effects, intrinsic GI diseases, or endocrine disorders, also noninfectious but infectious is more important
differential diagnosis of diarrhea
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
diarrhea history clues
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
nausea, vomiting, diarrhea history
inflammatory or noninflammatory
acute infectious diarrhea causes
spreads by food, contaminated water, or from person to person
gastroenteritis
norovirus, non-typhoidal salmonella species, clostridium perfringens, campylobacter, highest incidence is norovirus, salmonella causes the most hospitalization and death
food borne GI infections
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
travelers diarrhea
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
diarrhea diagnostic approach
if positive can move onto confirmatory culture
GI filmarray NAAT/PCR
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
acute diarrhea treamtnet
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
c diff
