chronic GI Flashcards
visceral pain
dull, poorly localized
parietal pain
sharp, localized
colicky pain
comes and goes
burning pain
caused by irritation from gastric contents
gastroparesis treatment
reglan
small, low-fat meals
ondansetron MOA and AE
serotonin 5-HT3 receptor antagonist
can cause constipation and worsten nausea (bowel reg!)
antiemetics
serotonin receptor antaonists
corticosteroids
dopamine antagonists
antihistamines and anticholinergics
cannabinoids
abdominal pain red flags
duration <48 hours
pain followed by vomiting
age >65 years
hx of abdominal surgery
guarding
rebound tenderness
rigidity
dyspepsia red flags
dysphagia or odynophagia
unintentional weight loss
anemia
hematemesis
melena
recurrent vomiting
palpable mass
jaundice
GERD symptoms
epigastric or retrosternal burning or discomfort
symptoms worse when lying down
chronic cough/laryngitis/enamel erosiion/halitosis
trigger foods - ETOH, coffee, soda
biliary tract disease symptoms
RUQ or epigastric pain occurring after fatty meal
pain lasts 1-6 hours
may have associated N/V
pain is usually colicky
GI malignancy risk factors
> 60 years old
significant weight loss
dysphagia
long history of GERD
hx of smoking
family history of stomach or esophageal cancer
common meds causing dyspepsia
NSAIDs
iron
bisphosphonates
antibiotics
dyspepsia differentials
PUD
GERD
biliary tract disease
malignancy
medication induced
food intolerance
pancreatitis
IBS
gastroparesis
common food causes of dyspepsia
lactose intolerance
celiac disease
alcohol
symptoms of pancreatitis
epigastric pain radiating to back
pain of abrupt onset, severe, lasting several hours
history of heavy ETOH use
history of gallstones
symptoms of IBS
alteration of bowel habits w/wo abdominal pain and no organic cause
gastroparesis
delayed gastric emptying
gastroparesis risk factors
history of metabolic disorder - DM (A1C)
abdominal surgery w vagal nerve injury
who gets an endoscopy?
adults >60 or w dyspepsia alarm symptoms
dysphagia diagnostics
esophagram - least invasive
EGD - gold standard
PUD - repeat EGD @ 6 weeks
which ulcers are more common for each age
55-70 gastric
30-55 duodenal
causes of PUD
H. pylori
acid hypersecretion
gastric ischemia
meds (NSAIDS, ASA, K, bisphosphonates)
idiopathic
is H. pylori gram positive or negative?
negative
gastric vs duodenal ulcer symptoms
gastric - pain aggravated by food, loss of weight/appetite
duodenal - pain relieved by food, radiates to back, weight gain not uncommon
PUD s/s
burning, gnawing epigastric pain (may be nocturnal)
N/V uncommon
GI bleeding
epigastric tenderness w palpation
abd rigidity if perf
melena
weight changes?
tests for H. pylori
urea breath test
stool antigen
serum not evidence based
diagnostic for Zolling-Ellison syndrome
fasting gastrin
H. pylori treatment
triple therapy 10-14 days
PPI BID &
Amoxicillin 1g BID - flagyl if allergy
Clarithromycin 500 mg BID
check for eradication @ 4 weeks
H. pylori quadruple therapy
PPI
Bismuth
Metronidazole
Tetracycline
PUD first line management
PPIs
BID recommended
benefit - duration >24 hours
gastric ulcers - 8 weeks, then QD
duodenal ulcers - 4 weeks, then QD
use of H2RAs in PUD
mild symptoms w no complications
taken at bedtime
inhibit P-450
PUD additional meds
add onto PPI
antacids - cheap, neutralize acid
carafate - coats ulcer
bismuth - stimulate bicarb production, antimicrobial against H. pylori
when to consult GI for PUD
GI bleed
s/s of ulcer perf
s/s of gastric outlet obstruction
if no improvement after 2 weeks of treatment
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GERD risk factors
family history
age
hiatal hernia
obesity
LES tone-reducing drugs - Ca channel blockers, TCAs, anticholinergics
ETOH
smoking
aggravating foods - mint, coffee, citrus, fats
GERD important rule out
acute MI/CAD
GERD treatment
PPI QD x 8 weeks
refractory - increase to BID for 2-3 month, add H2RA noc, consider zollinger-ellision, pH testing
consult GI - EGD/ barium esophagraphy
surgery - laparoscopic fundoplication tighten LES, LINX procedure w magnet
Zollinger-Ellison syndrome
gastric tumor causing elevated levels of gastrin
->PUD, GERD
GERD complications
esophageal ulcer, hemorrhage, or perf
esophagitis leading to dysphagia
esophageal stricture
barrett’s esophagus**
adenocarcinoma of esophagus
Barrett’s esophagus
squamous mucosa esophageal lining becomes columnar epithelial
starts with GERD, metaplasia occurs w injury
precursor to esophageal adenocarcinoma
indication for surgical referral (acute abd)
fever
chills
leukocytosis
rebound tenderness
guarding
rigidity
abdominal compartment syndrome
sustained intra-abdominal pressure of >20 mm Hg
s/s of abdominal compartment syndrome
dyspnea, pain, weakness
rigid/tense abdomen, progressive oliguria, hemodynamic instability
abd compartment syndrome treatment
optimize fluid balance
NG, rectal tube
pro kinetic agents - neostigmine, erythromycin
surgical decompression
dialysis
mesenteric ischemia risk factors
advanced age
smoking
hypercoagulatable states
a fib
MI/structural heart defects, CHF, atherosclerosis, AS
vasculitis
abd surgery/IR procedure
oral contraception
hypotension/shock/pressors
s/s of mesenteric ischemia
acute abd pain out of proportion to physical findings, generalized or periumbilical
early - hypoactive BS, abd distention, but grossly normal exam
later - acute abd, hemodynamic instability & CV collapse
mesenteric ischemia management
surgical consult - laparotomy
NG decompression
chronic - angioplasty stenting, TPN
broad spectrum abx - 3rd gen cephalosporin or quinolone & flagyl
inotropes, fluids, blood products
papaverine
anticoagulation
rule out for mesenteric ischemia
abdominal aneurysm
mesenteric ischemia complications
food fear - sitophobia
stricture
short gut syndrome - TPN or small bowel transplant
broad spectrum abx
third gen cephalosporin or quinolone
ceftazidime, ceftriaxone, cefdinir
primary constipation treatment
bulk laxative w/wo stool softeners
psyllium, Metamucil
acute constipation w fecal impaction tx
enemas, suppositories, polyethylene glycol, stimulant laxatives (senna, colace)
opioid induced constipation tx
opioid receptor agonists - methylnaltrexone
CI to magnesium-containing laxatives
renal disease
diarrhea definition
> 3 loose/liquid BMs per day
risk for colonic perf
c. diff, salmonella, shigella
infections risk for intestinal obstruction
shigella & helminth
Reiter syndrome triad
conjunctivitis
urethritis
reactive arthritis
may occur following GI infection
bloody diarrhea rule out
HUS & TTP
organisms that cause bloody diarrhea
SEECSY
salmonella
E. coli ehec, etec
entamoeba (protozoa)
campylobacter
shigella
yersinia entercolitica
abx of choice for diarrhea empiric therapy
fluoroquinolone
sulfa/doxy are alternatives
chronic diarrhea
present longer than 4 weeks, >3 stools/day
microscopic colitis
10-15 wattery stools/day
confirm w colonic biopsy
budesonide therapy
meds for chronic diarrhea
loperamide, diphenoxylate with atropine, codeine, clonidine, octreotide, bile salt binders
s/s of diverticulitis
LLQ abd pain
fever
leukocytosis
N/V
diarrhea maybe w blood
perf - gen pain, peritoneal signs
main cause of diverticulitis
constipation
common gut bacteria
anaerobic & gram negative
abx for diverticulitis
augmentin OR cipro & flagyl
ceftriaxone & flagly or zosyn IV
