9.1 GI Flashcards
GI Bleed pt initial workup
2 large bore IVs CBC, Coags, T+C IVF PPI EKG NG tube
If cirrhotic:
Ceftriaxone
Octreotide
GI Bleed
-brisk vs slow bleeding: cc/h? and PRBC how often?
brisk: >2cc/hr, 1U PRBC q4h
slow: <0.5cc/hr, 1U PRBC qday
GI Bleed: what dx test to look for bleeding? after EGD negative
brisk bleed: angiogram (IR)
slow: tagged RBC
none: colonoscopy
bleeding stopped, colonoscopy sees nothing: pill cam
suspect Boerhaave
-what tests
gastrographin swallow. if neg then Barium. If neg then EGD
Esophagitis:
think what infections and their tx? (4)
Exam clues to each?
candida–nystatin, fluconazole. Thrush
CMV–ganciclovir/foscarnet. Immunosuppressed.
herpes–acyclovir/foscarnet. Oral ulcers.
HIV–HAART. AIDS is clue.
Esophagitis DDx causes, categories?
“PIECE” of the esophagus. Dx requires piece to bx.
Pill-induced Infxn Eosinophilic Caustic Everything else.
Esophagitis, pill induced.
- Which are notorious (3)
- tx
NSAIDs, Abx, NRTIs
-EGD to remove, time to heal. PPIs comfort
Pt in ED with drooling and odynophagia, after ingestion of battery acid or drain cleaner. What next
Caustic esophagitis.
EGD in 24h to eval severity
low severity: liquid diet, then solid in 24-48h
high severity: NPO 72h. high risk strictures, perf, fistulas, bleeding
Eosinophilic esophagitis
- classic vignette
- tx
- how to dx and to be aware of
- kid with asthma/exzema, with long hx dysphagia. Cause is food allergy!
- tx PPI, topical steroids
- EGD shows eosinophilia. However, GERD can cause this too. Must have pt on PPI for 6-8 wks, then re-bx to see eosinophils
GI bleeder with sytolic murmur, think what?
assoc: Aortic stenosis and AVMs
Esophageal cancers:
which are located where.
causes?
Squamous: upper 1/3. smoking/ETOH
Adenocarcinoma: lower 1/3. GERD
Achalasia tx
Heller myotomy 1st, unless poor surg candidate
then balloon dilation (risk perf)
Esophageal involvement of Scleroderma
-tx
This is relentless GERD! b/c LES can’t contract.
High dose PPIs to prevent esophageal CA
Esophageal spasm
-tx
CCB, Nitroglycerin
Female with dysphagia and anemia, think what?
Plummer-Vinson.
esophageal rings, webs, and Fe def anemia
-No tx, but screen for esophageal CA (higher risk)
Pt at clinic with new GERD sxs. What are alarm sxs?
what to do if alarm sxs?
odynophagia, dysphagia.
weight loss
N/V
anemia
If alarm, go straight to EGD.
Weird/rare peptic ulcers:
4
Curling–burns
Stress–ICU
Cushing’s–high ICP
ZE syndrome–refractory ulcers with diarrhea
PUD triple tx:
what if pen allergic?
amoxicillin (flagyl if pen allergy), clarithromycin, PPI
Duodenal vs gastric ulcer sxs
Duodenal ulcer pain relieved with eating. Gastric worse eating.
Duodenal ulcer pain occurs after meal.(acid released in duodenum). ‘Pain wakes from sleep.’
H Pylori tests (3)
1st dx: urea breath
confirm dx: EGD with bx
test eradication: stool Ag
ZE syndrome
-what tests (3)
suspect if refractory Ulcers+diarrhea. gastrin secreting tumor at pancreas
- Serum gastrin level (high)
- Confirm dx: Secretin stim test (gastrin increases)
- locate: SRS–somatostatin receptor scintigraphy, or CT
Gastroparesis
-tx, what to be careful
- prokinetics (metoclopramide/erythromycin)
- do EGD to make sure no physical blockage before Rx
Virchow’s node
supraclavicular node, first mets of gastric CA (signet ring CA)
gastric MALToma
-tx
just tx H Pylori. Lymphoma goes away
GERD sxs go away, you do EGD. You see:
- metaplasia
- dysplasia
Do what
- Barrett’s. high dose PPI to prevent progression to dysplasia
- Dysplasia–ablation to prevent adenoCA
Peptic ulcer: after endoscopy cautery, when to do surgery?
After 2 attempts to cauterize bleeding ulcer, do surgery to resect.
Who gets PPI ppx in hospital?
3
burn pts–curling
increased ICP–cushings ulcers
ICU–stress ulcers
Peptic ulcers, what cause?
- multiple shallow ulcers
- single deep ulcer, no heaped margins
- single deep ulcer, heaped margins
- multiple, large, refractory ulcers
- NSAIDs
- H pylori
- cancer
- gastrinoma
Hernia types to know: (4)
- what pass through
- what pop
- indirect–pas through inguinal ring, babies
- direct–pass through transversalis fascia, adults
- femoral–under ligament, women
- ventral hernia (umbilical included)–post surg, fascia dehisced
carcinoid syndrome (abdominal) heart sxs -also, test vignette to know
TIPS
tricuspid insuff, pulmonic stenosis
Post-menopausal female, says she’s getting hot flashes again! also diarrhea and heart murmur
Give what for post-op or opioid-induced ileus
Not just Colace (docusate=dulcolax–stool softener). must include motility drug
-bisacodyl, senna, lactulose
Only 2 times you do not operate on a hernia:
- when surgery is contraindicated (eg cirrhosis)
2. umbilical hernias in children <2
Colon cancer–left vs right
L side obstruct,
R side bleed
Hemorrhoids:
internal vs external, surgical tx
internal: band
external: resect
anal fissure:
tx
topical lidocaine. also try sitz baths, NTG paste, or botulism. Give docusate and senna.
if fails, do lateral internal sphincerotomy
hairy butt gets what
tx?
pilonidal cyst
-drain, then resect
anal cancer
- screening
- tx
- screen with anal Pap smears
- “nigro protocol”–chemo and rad
Elderly pt, LLQ post prandial pain, relieved with BM
-think what, do what
Think diverticular spasm. (sounds like IBS, but elderly pt).
-r/o severe dz, advise high fiber
sessile, villous, pedunculated, tubular
what is worse
pedunculated > sessile
tubular >villous
high suspicion for colon CA (pencil stools, sxs of met dz, Fe def anemia, alternating diarrhea and constipation).
Do what
barium enema (looking for obvious mass/apple core lesion)
Lynch syndrome
HNPCC
‘meryl lynch, CEO’
Colon
Endometrial
Ovarian
GI tumors and jaw tumors
Gardner syndrome
GI tumors, brain tumors
Turcot syndrome (turban, head)
Peutz-Jeghers
-what affected
- nonmalignant polyps
- hyperpig buccal mucosal
small intestine hamartomas
celiac sprue
-what tests to screen and confirm?
anti-endomysial and ati-transgulataminase Ab
(anti-gliadin not useful)
confirm with bx showng atrophic villi
celiac sprue
-how long takes to show improvement in sxs after stopping gluten
3-4mo (ab must diminish)
Whipple dz
- how test will show
- tx
- malabsorbtion pt, with electron microscope picture=whipples
- long term abx (bactrim or doxy)
celiac sprue sxs in pt, but Ab negative. think what
Caribbean farmer with Tropical sprue.
tx with abx, not gluten removal
malabsorption algorithm
2 big steps
- can pt absorb fat?
eat fat, measure fecal fat - Give D-Xylose (does not need enzymes to break down for absorption), CT scan
- if D Xylose absorbed, then it is pancreas deficiency (no enzyme)
- If D Xylose not absorbed, then do EGD. maybe sprue, whipples, IBD etc
diverticulitis, first time dx
-do what
colonoscopy to r/o CA. 2-6 weeks after first presentation
ulcerative colitis
-when/how often to get colonoscopies
q1y starting 8y after dx
celiac sprue
-what nutrient deficiencies?
FIC vitamins
Folate, iron, calcium in prox duodenum
acute diarrhea
- if admitting to hospital, what 5 tests?
- what algorithm?
- what med to be careful
- stool cx, WBC, O+P
- fecal occult blood, C Diff toxin
Invasive: WBC+, blood+
If Cx-, then do bx looking for IBD.
Enterotoxic: WBC-, blood-
If O+P -, then gastroenteritis and just needed hydration in the first place.
No Loperamide in invasive diarrhea, makes worse
acute diarrhea DDx
invasive: bloody:
shigella, salmonella, campylobacter, HUS, amoeba.
also giardia
enterotoxic:
-staph, C Diff, cholera, ETEC, bacilus
C Diff
- tx
- what to give after 3 episodes (recurrent)
- IV flagyl, PO vanc
- fidaxomycin PO
chronic diarrhea, without obvious cause like meds or C Diff
-dx approach, what tests (4)
3 causes: secretory, osmotic, inflammatory
Stool osmol gap, WBC, FOBT, fecal fat
Secretory (hormones/toxins): all -
Osmotic (malabs): Fecal fat+, osmol gap+
Inflamm (IBD): WBC+, FOBT+
UC vs Crohns
- diff in meds
- diff in tx of severe dz
5-ASA (sulfasalazine, mesalamine) works in UC, only in mild Crohn’s. (meds work best in colon)
UC: colectomy
Crohn’s: TNF-i (fistulas is severe)
UC
-abd pain assoc to know
PSC
“uSerating colitis”
Pt with severe IBD, you want to start TNF -i. do what first (4)
tests:
TB, HIV, HepA, C
-also worry about lymphoma
