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

9.1 GI Flashcards by Marcus Wong

GI Bleed pt initial workup

2 large bore IVs
CBC, Coags, T+C
IVF
PPI
EKG
NG tube

If cirrhotic:
Ceftriaxone
Octreotide

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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

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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

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suspect Boerhaave

-what tests

gastrographin swallow. if neg then Barium. If neg then EGD

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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.

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Esophagitis DDx causes, categories?

“PIECE” of the esophagus. Dx requires piece to bx.

Pill-induced
Infxn
Eosinophilic
Caustic
Everything else.

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Esophagitis, pill induced.

Which are notorious (3)
tx

NSAIDs, Abx, NRTIs

-EGD to remove, time to heal. PPIs comfort

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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

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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

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GI bleeder with sytolic murmur, think what?

assoc: Aortic stenosis and AVMs

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Esophageal cancers:
which are located where.
causes?

Squamous: upper 1/3. smoking/ETOH
Adenocarcinoma: lower 1/3. GERD

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Achalasia tx

Heller myotomy 1st, unless poor surg candidate

then balloon dilation (risk perf)

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Esophageal involvement of Scleroderma

-tx

This is relentless GERD! b/c LES can’t contract.

High dose PPIs to prevent esophageal CA

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Esophageal spasm

-tx

CCB, Nitroglycerin

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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)

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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.

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Weird/rare peptic ulcers:

Curling–burns
Stress–ICU
Cushing’s–high ICP
ZE syndrome–refractory ulcers with diarrhea

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PUD triple tx:

what if pen allergic?

amoxicillin (flagyl if pen allergy), clarithromycin, PPI

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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.’

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H Pylori tests (3)

1st dx: urea breath
confirm dx: EGD with bx
test eradication: stool Ag

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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

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Gastroparesis

-tx, what to be careful

prokinetics (metoclopramide/erythromycin)

- do EGD to make sure no physical blockage before Rx

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Virchow’s node

supraclavicular node, first mets of gastric CA (signet ring CA)

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gastric MALToma

-tx

just tx H Pylori. Lymphoma goes away

GERD sxs go away, you do EGD. You see: - metaplasia - dysplasia Do what

1. Barrett's. high dose PPI to prevent progression to dysplasia 2. 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? 1. multiple shallow ulcers 2. single deep ulcer, no heaped margins 3. single deep ulcer, heaped margins 4. multiple, large, refractory ulcers

1. NSAIDs 2. H pylori 3. cancer 4. gastrinoma

Hernia types to know: (4) - what pass through - what pop

1. indirect--pas through inguinal ring, babies 2. direct--pass through transversalis fascia, adults 3. femoral--under ligament, women 4. 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:

1. 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

1. can pt absorb fat? eat fat, measure fecal fat 2. 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