3. GI: Clinical Medicine Flashcards
1
Q
GI Disorders – General Principles
- General impact is often ____
- Frequently misdiagnosed, untreated or undertreated
- U.S.
- 70 million with GI disorders
- > 105 million physician visits annually
- Significant morbidity, mortality and decreased QoL• Are you following with your PCP for your condition?
• Population of US: 350M
○ 1 out of ____ people have a GI disorder = frequent
• Must have good reason to provide a study; insurance won’t normally pay for these procedures
• GI conditions lead to higher chance of developing ____
A
underestimated
5
cancer
2
Q
GERD – Epidemiology
- Impairment of the esophageal sphincter allows for ____ of stomach contents
- Acid, Bile, Food
- US Adults complaining of “____”
- 40% monthly
- 20% weekly
- 7% daily
- No ____ predilection; ____ > females
- US / Western Europe > Asia / Africa
- Hispanic-Americans > Caucasian-Americans > Asian-Americans• Tendency to develop as one gets older
• Lifestyle has an impact in developing GERD
○ Stress
○ Work lifestyle
• Some populations have higher chance of developing GERD
A
backflow
heartburn
age
males
3
Q
GERD - pathophysiology
• \_\_\_\_ of esophageal tube > area doesn't close off > acid/stomach contents goes back up; and \_\_\_\_ of the ES which allows it to go further into the esophageal tube
A
herniation
relaxation
4
Q
GERD – Clinical Presentation
- ____
- Burning retrosternal discomfort starting in the ____ or ____ and moving upwards toward the neck
- Acidic taste in mouth
- ____ pain
- Asymptomatic
- Extraesophageal manifestations
- ____
- Odynophagia
- ____
- Sore throat
- ____
- Cough
• Acidic taste ○ Orofacial pain conditions > LP > acidic taste in mouth, or taste is altered § Reflux or disease-related? § If have reflux disease/mucosal disease > get reflux disorder managed to minimize component to just minimize component to oral symptoms • Extraesophageal ○ These are quite common ○ Dysphagia § Problem with swallowing ○ Odynophagia § Painful swallowing ○ Globus § Lump in throat ○ Sore throat ○ Laryngitis ○ Cough
A
heartburn epigastrium lower chest gastric dysphagia globus laryngitis
5
Q
GERD
- Exacerbating factors
- ____
- Citrus fruits
- ____ / tomato-based foods • High fat foods
- ____
- Alcohol
- Eating before ____
- Risk factors
- Advancing ____
- Males
- ____
- Stress
- ____
- Cigarette smoking• Citrus and spicy/tomato foods will exacerbate any case of LP or oral lichenoid lesions as well
○ Overlap in lifestyle modifications in LP and reflux > will benefit both the oral and reflux disease
• Eating before bed
○ Need ____ hours between time you eat and lay flat for bed
• Stress = chronic disease
○ Many impacts on body
§ Not only psychologically, but also physically
□ ____ - stress, anxiety and depression is higher in this population
A
chocolate
spicy
caffeine
bed
age
obesity
pregnancy
3
TMD
6
Q
GERD – Diagnostic Evaluation
- No standard ____ for diagnosis of GERD
- Clinical symptomatology
- ____
- ____
- / - ____
- Identification of exacerbating factors
- Assessment of risk factors
- Reflux disease questionnaire
- R/O other conditions that mimic symptoms of GERD
- Role of diagnostic testing• Dysphagia may or may not be there
A
criterion
heartburn
regurgitation
dysphagia
7
Q
RDQ
• Help give \_\_\_\_ to whether a patient will have reflux disorder • Symptoms over past 7 days ○ 0 day = always there • Symptoms ○ Heartburn § For 4-7 days = 3 ○ Regurgitation § The longer it's there, the higher the score § If pain is ever present = \_\_\_\_ ○ Nausea is the same as \_\_\_\_; ever there = highest (3)
A
3
pain
8
Q
GERD - Complications
- ____
- Inflammation of esophageal lining
- Narrowing of the esophagus due to ____
- Esophageal ulcers
- Barrett esophagitis
- Pre-____ change
- ____• Long-term complications that need to be monitored
• Narrowing or stricturing of the esophagus
○ ____ has a similar phenotype
§ Immune-mediated blistering disorder > ulcers, and when heal > leave scar tissue > narrowing of the esophagus
• Barrett esophagitis
○ Pre-malignant change seen that can lead to esophageal adenocarcinoma
A
esophagitis
scarring
malignant
esophageal adenocarcinoma
9
Q
GERD - Management
Treatment Goals
• Symptom ____
• Healing of ____ esophagitis
• ____ and management of GERD-related complications
• Maintenance of ____ and symptom remission
A
relief
erosive
prevention
mucosal
10
Q
Lifestyle Modifications
• ____ reduction
• ____ the head of the bed
• Avoid spicy food, coffee and carbonated beverages • Avoid ____ and drinking alcohol
• Do not lie flat after a meal for up to ____ hours
• Avoid heavy, fatty meals
• Avoid ____-fitting garments
* Mechanical modification > elevating head of the bed * Patients with globus > increased awareness of their symptoms > don't wear tight-fitting garments
A
weight elevate smoking 3 tight
11
Q
GERD - Prognosis
• Anti-reflux ____
• Post surgical
____
• High ____ of GERD symptoms
GERD
• Symptoms typically ____ within weeks of treatment
• Considered a ____ disease
• ____ treatment
• Lifelong monitoring for Barret esophagus / cancer
A
surgery complications recurrence resolve chronic lifelong
12
Q
PUD - Epidemiology
- Erosion – ____ to the muscularis mucosae
- Ulcer – ____ the muscularis mucosae
- U.S.
- Lifetime prevalence is 10%
- 4.5 million individuals affected
- ____ ulcers > gastric ulcers (4:1)
- ____ = females
A
superficial
penetrates
duodenal
males
13
Q
PUD - Pathophysiology
• Normal ○ Gastric \_\_\_\_ ○ Peptic enzymes ○ And defensive forces • Injury > most common > \_\_\_\_infection ○ Use aspirin frequently ○ \_\_\_\_ ○ Hyperacidity of gastric secretions • Impaired defenses ○ \_\_\_\_ ○ Delayed gastric emptying • Peptic ulceration develops
A
acidity
H pylori
cigarettes
ischemia
14
Q
PUD - Clinical Presentation • \_\_\_\_ / vomiting • Abdominal pressure / fullness • \_\_\_\_ tenderness • Hematemesis • \_\_\_\_
- Diagnostic test of choice
- ____• Hematemesis
○ ____ blood
• Melena
○ ____ in stool
A
nausea epigastric melena EGD vomiting blood
15
Q
Endoscopic findings and risk for future bleeding
• Prevalence of ulcers ○ \_\_\_\_ § Most common peptic ulcer § Risk of further bleeding is minimal ○ \_\_\_\_ § Low prevalence § High risk of further bleeding § Could have BV loss, can have cardiovascular problems
LOOK AT THE SCALE!
A
clean base
active bleeding
16
Q
ACHIEVING HEMOSTASIS
ACHIEVING HEMOSTASIS
Epinephrine sclerotherapy
Bicap electrocautery
Use of hemoclips
• Cauterize lesions • Sclerotherapy ○ \_\_\_\_ is injected; BV are \_\_\_\_ and bleeding stops • Electrocaudery ○ \_\_\_\_ open vessels to coagulate • Thermocaudery ○ Heat up tip, and touch tissue and \_\_\_\_ the area ○ More \_\_\_\_ way to stop bleeding ulcer • Historic way: \_\_\_\_ ○ Titanium clips
A
saline contracted fry coagulate common clips
17
Q
PUD – Diagnostic Evaluation
Tests for H. pylori
• Invasive (EGD with biopsy)
- ____ (histology)
- ____ (culture)
• Non-invasive
- ____ (anemia)
- ____(UBT)
- ____ antigen
• H. pylori one of more common ways of developing • Outcomes of H pylori ○ Most into \_\_\_\_ ○ Intestinal \_\_\_\_ ○ Gastric/duo \_\_\_\_ ○ Gastric \_\_\_\_ or MALT lymphoma
A
biopsy
biopsy
serology
urea breath test
stool
asymptomatic
metaplasia
ulcer
cancer
18
Q
PUD - Management
- Lifestyle ____ (avoid alcohol, tobacco)
- Discontinue ASA or NSAIDs
- ____ eradication therapy
- Anti-secretory therapy
- Surgery reserved for cases refractory to ____ therapy or for complications
- Repeat ____ after 10-12 weeks to confirm healing of ulcers• Discontinue ASA/NSAIDs > impact in oral care > common drugs that people take for dental pain
○ Maybe ____ or acetaminophen
A
changes H. pylori medical EGD tylenol
19
Q
Inflammatory Bowel Disease (IBD)
- Term for two idiopathic diseases of the GI tract: • Ulcerative colitis (UC)
- mucosal disease limited to ____ and ____
- Crohn’s disease (CD)
- ____ process, may produce patchy ulcerations at any point from mouth to anus, most commonly involves the ____• Initial presentation may be in the oral cavity
• UC is more limited in its distribution
○ Oral lesions can be suggestive of both UC and CD
A
large intestine
rectum
transmural
terminal ileum
20
Q
IBD
• Clinically UC and CD are different • CD ○ \_\_\_\_ in GI tract and oral cavity ○ \_\_\_\_ wall of GI tract • UC ○ No cobblertoning > \_\_\_\_ are present ○ Mucosa form \_\_\_\_ > not true polyps
A
cobblestoning
thickening
ulcers
pseudopolyps
21
Q
IBD - Epidemiology
- U.S.
- 1.4 million individuals affected
- UC = ____ (250 cases of each / 100,000) • Highest rate in ____
- ____ = female
- ____ age distribution
- Most diagnosed between 15 – 25 years • Second peak between 55 – 65 years
A
CD
caucasians
male
bimodal
22
Q
IBD - Pathophysiology
• Unknown, but likely ____
- Genetic susceptibility genes identified
- NOD2/ ____ gene
- IL-23 receptor gene
- ____ superfamily
- TLR-4 gene
- Immunologic stimulation
- Activation of ____, B-cells, ____
- No specific enteric ____ associated with inducing the pro-inflammatory responses in IBD
A
multifactorial CARD15 TNF T-cells immunoglobulins microbe
23
Q
IBD – Clinical Presentation
Ulcerative colitis
• Mild – moderate ____
• Rectal bleeding
• ____ pain
- Advanced disease→
- Development of ____ symptoms
Crohn’s disease • Chronic \_\_\_\_ • Perianal disease (fissures/fistulae) • Abdominal \_\_\_\_ • Constitutional symptoms • \_\_\_\_ loss • Unexplained fever • \_\_\_\_
* Present similarly, but minor differences * UC has more episodic forms of diarrhea, whereas CD has chronic * Peranal disease is different from rectal bleeding * CD you see constitutional symptoms earlier than in an UC
A
diarrhea
abdominal
constitutional diarrhea pain weight fatigue
24
Q
IBD - Extra-intestinal manifestations
• \_\_\_\_ ○ Similar to other immune mediated processes • Kidneys • \_\_\_\_ ○ Stomatitis - non-specific inflammation of oral cavity • Liver • \_\_\_\_ • Biliary tract • \_\_\_\_ • If many sites > not well-controlled and needs to be treated
A
eyes
mouth
joints
skin
25
Q
Skin
Pyoderma gangrenosum
Erythema nodosum
• Pyoderma gangrenosum ○ Large skin infections that are difficult to treat in terms of \_\_\_\_ and wound-healing • Erytherma nodusom ○ Looks like EM > not \_\_\_\_ like that, but it's present on the skin
A
antibiotics
bulls-eyes
26
Q
IBD – Diagnostic Evaluation
• Clinical symptomatology
- Laboratory studies
- Complete blood count
- Abnormal ____, Hct, ____ indices - ____
- Elevated WBC - ____
- Iron / B12 deficiency – ____
- Antibody testing
- Anti-Saccharomyces cerevisiae antibodies (ASCA)
- perinuclear anti-neutrophil cytoplasmic antibody (pANCA)
- ASCA (+) and pANCA (-) = c/w ____
- ASCA (-) and pANCA (+) = c/w ____
• Colonoscopy / Sigmoidoscopy
• Higher prevalence of \_\_\_\_ in those with CD > if antibodies in blood serum > suggestive of Chron's ○ ASCA + and pANCA - = CD ○ ASCA - and pANCA + = UC
A
Hgb RBC anemia infection malabsorption
CD
UC
yeast
