clin med quick review Flashcards
1
Q
Irritable bowel SYNDROME
IBS
A
FUNCTIONAL bowel disorder
Recurrent abd pain AND altered bowel habits
2
Q
Usually affects 20-39 YO, F>M
A
IBS
3
Q
RED FLAG sx of IBS
A
Onset after 50YO Severe/ prog worsening Night sx Fever/vomiting Weight loss Blood PMHx/FMHx CA, IBD, Celiac Iron def anemia
4
Q
Abdominal pain is diffuse, lower abdomen
Variable intensity, periodic exacerbations
A
IBS
5
Q
Rome IV Criteria for IBS
A
Abd pain at least 1 day/week for the last 3 months
associated w at least two:
- related to pooping
- change in stool frequency
- change in stool form
6
Q
If pt has IBS classic sx and no alarm features
A
No X Ray or Endoscopic tests are recommended
7
Q
If pt has IBS, atypical hx, and any alarm sx or refractory to treatment
A
Lab/stool studies
Cross section/small bowel imaging
Endoscopy/Colonoscopy w biopsy
8
Q
IBS tx bolded on slide
A
Reconcile offending meds
9
Q
Low FODMAP diet
“Fermentable oligo, di, monosaccharides and polyols”
A
remove sugars and fibers that cause pain and bloating
10
Q
IBS treatment for abdominal pain
A
Antispasmodics -Dicyclomine (bentyl) -Hyocyamine (levsin) Antidepressents -TCA -SSRI
11
Q
IBS treatment for constipation
A
Polyethylene glycol (PEG) Prosecretory agents -Lubiprostone -Linaclotide -Plecanatide 5-HT4 agonist -Tegaserod
12
Q
IBS treatment for diarrhea
A
Anti-diarrheal (Loperamide) Bile acid sequestrant Rifaximin Eluxadoline 5-HT3 antagonist (Alosetron)
13
Q
How do you diagnose IBS?
A
Rome IV criteria
no definitive biomarkers
14
Q
Lubiprostone
Linaclotide
Plecanitide
A
Prosecretory agents used for constipation
15
Q
Polyethylene glycol (PEG) used for
A
constipation
16
Q
Most common digestive complaint
A
Constipation
17
Q
IBS-C
A
Constipation + pain predominant
18
Q
What to ask about with constipation history
A
Laxative use
Need for digital evacuation
Previous colonoscopy
Red flag sx
19
Q
How to evaluate constipation in REFRACTORY pts
A
Sitz marker (X rays) Defecography (fluoroscopy) Anorectal manometry (sphincter pressure/fx)
20
Q
First step of constipation treatment
A
Reconcile offending meds
21
Q
Caution with Osmotic laxatives
PEG- Miralax, Milk of Mg, Mag citrate, Lactulose
A
Mg-containing laxatives and hyperMg in pts with Kidney insufficiency
22
Q
High risk of bowel obstruction
A
Dementia
Neurologic dz
Immobile
on Hypomotility meds
23
Q
Most commonly associated with acute diarrhea
A
Norovirus
24
Q
Acute diarrhea
A
<14 days
25
Chronic diarrhea
>30 days
26
Key questions for Acute diarrhea
Previous colonoscopy
Red flag sx
Risk exposures
27
Common causes of NON-inflammatory diarrhea
Norovirus
| Giardia
28
Inflammatory diarrhea
Fever
Bloody
Severe diarrhea
29
Causes of INFLAMMATORY diarrhea
```
Salmonella
Campylobacter
Shigella
E.Coli
C.diff
```
30
```
Loperamide (imodium)
Bismuth subsalicylate (pepto-bismol)
```
Acute diarrhea tx
| SE of pepto-bismol: Black stool
31
Most cases of acute diarrhea are self limited, but if we use abx
EMPIRIC
Fluoroquinolone x3-5d
Alt: Azithro
32
Most common cause of acute diarrhea
Norovirus- cruise ship, restaurant
33
Diarrhea in 6mo-2YO
| daycare
Rotavirus
34
Rice water diarrhea
Vibrio cholerae
35
Creamy foods, egg/potato salad
| illness (diarrhea) within hours of exposure
Staph aureus
36
Inflammatory bacterial diarrhea
Salmonella
Campylobacter
Shigella
E.Coli
37
Salmonella
Poultry, livestock, reptiles
38
Campylobacter
Guillian Barre syndrome
39
"Classic dysentery"
Shigella
40
Severe afebrile bloody diarrhea
E.Coli
41
Tx for E.Coli (inflammatory, severe bloody diarrhea)
DO NOT GIVE antidiarrheal or abx
| Risk of HUS
42
Tx for C-diff
Vancomycin
Fidaxomicin
Metronidazole
43
Raw seafood/shellfish
Vibrio parahemolyticus
44
Inflammatory acute diarrhea that mimics Appendicitis
Yersinia enterocolitica
45
HCl and intrinsic factor
Parietal cells
46
Protective features of STOMACH mucosa
Bicarb rich mucus
Tight jx
Stem cells
Prostaglandins
47
Defect in GASTRIC or DUODENAL mucosa that extneds through muscularis mucosa into deeper layer
Peptic Ulcer dz
48
Two biggest causes of PUD
H. Pylori
| NSAIDs
49
If you have these factors AND use NSAIDs, bigger risk for getting PUD
```
Also have H. Pylori
>75YO
Lots of NSAID use
Also using: steroids, NSAIDs, anticoag, ASA, SSR, Alendronate
Prior hx of PUD/ulcer
```
50
PUD clinical presentation
usually no sx! but if you do:
| Upper abdominal pain
51
Pain right after meal, vomiting, anorexia, more likely to bleed
Gastric (stomach) ulcers
52
Weight gain is associated with what type of PUD?
Duodenal ulcers
53
Alarm sx for PUD
```
Bleeding
Iron def anemia
Unexp weight loss
Progressive dysphagia
Acute onset upper abd pain
Persistent vomiting
Fam hx upper GI CA
```
54
Most common complication of PUD
Hemorrhage
55
How do you diagnose hemorrhage (complication of PUD)
EGD diagnostic and therapeutic
56
Perforation complication of PUD
Severe, diffuse abdominal pain
tachycardia
"Board like abd rigidity"
57
How to dx Perforation
"board like rigidity"
severe diffuse abd pain
X RAY!
| upright chest and abd
58
If you suspect perforation, what should you AVOID?
UGI with barium
59
Vomiting, early satiety
| Dilated stomach and succussion splash
Gastric outlet obstruction
60
Gastric outlet obstruction
Sucussion splash
61
How long before testing for H.Pylori should you stop using PPI?
1-2 weeks
62
If H pylori testing is negative and likely d/t NSAIDs, stop NSAID use and
treat w 6-8 wks of PPI
63
If H pylori testing is negative and not likely d/t NSAIDs
try 4-8 wks of PPI and do EGD after initial PPI to try to find etiology
64
Where do gastrinomas from Zollinger-Ellison syndrome usually arise from?
Duodenum or
| Pancreas
65
Clinical presentation of Zollinger Ellison syndrome
Recurrent peptic ulcer dz
| often to duodenal bulb
66
Recurrent PUD
Upper abd pain
Steatorrhea
Think of what dx?
Zollinger Ellison syndrome
67
Use Fasting serum gastrin and Gastric pH to diagnose what?
Zollinger Ellison
Fasting serum gastrin: >1000
Gastric pH: <2
68
Treatment of Zollinger Ellison
PPI and Surgery
69
What is most common type of Gastric CA
Adenocarcinoma
70
Virchow's nodes
Left supraclavicular
71
Dyspepsia
abd discomfort sometimes with bloating, belching, or discomfort
72
Pt has dyspepsia
| >60 YO
Perform EGD scope in all pts over 60 with dyspepsia
73
Pt younger than 60
Has dyspepsia
Do they have these as well?
2 or more alarm features
Rapidly progressing alarm features
Weight loss
Overt GI bleeding
74
Dyspepsia alarm features
```
Weight loss
Progressive dyspepsia
Odynophagia
Iron def anemia
Persistent vomiting
Mass/lymphadeno
Fam hx UGI CA
```
75
IBD
Crohn and Ulcerative colitis
76
condition that mostly affects 15-35 YO,
| Bimodal again at 50-80YO
IBD
77
Which subcategory of IBD do women usually have
Crohns dz
78
Bimodal 15-35 and 50-80,
| Caucasion and Jewish
IBD
79
Smoking increases the risk of which branch of IBD
Crohns
80
Mouth to anus
Transmural (deeper)
Patchy, skip lesions
Crohns
81
Just colon, involving rectum
Continuous, circumferential
Mucosal layer (superficial)
Ulcerative colitis
82
RLQ pain and tenderness
| Tender palpable mass if abscess
Crohns dz
83
Arthralgias are a common extra-intestinal manifestation for what dz
Crohns and Ulcerative colitis (IBD)
84
Diagnosing Crohns
Colonoscopy with TI intubation
85
Ulcerations, cobblestoning
| Skip lesions
Crohns disease
86
Biopsy shows granulomas and chronic inflammation in what condition
Crohns dz
87
How often are colonoscopies recommended when screening for Colon CA?
every 1-2 yrs starting 8 years after disease onset
88
Classifications of Ulcerative Colitis
mild <4 stools
mod >4 stools, anemia, low grade fever
severe >6 stools, systemic
89
LLQ pain, bloody diarrhea, fecal urgency
Ulcerative colitis
90
Sclerosing cholangitis
| Check Alk phos
Ulcerative Colitis
91
Flex sigmoidoscopy or Colonoscopy
Dx Ulcerative Colitis
92
Toxic Megacolon complication of:
Ulcerative Colitis
93
Pharm therapy for IBD
```
Salicylates (ASA)
Corticosteroids
Immunomodulator
Biologics
Abx (crohns)
```
94
Abx are used for which sub of IBD
Crohns (the shittier one)
95
Mild-moderate Ulcerative Colitis
5-ASA
| Sulfasalazine or Mesalamine
96
SE of ASA drugs (Sulfasalazine and Mesalamine)
Diarrhea
| Kidney injury
97
Corticosteroids in tx of IBD
Flares
| short term, not maintenance
98
Considerations with steroids in treating UC and CD
DEXA after 3 months
Calcium
Vit D
99
Treatment for Moderate-Severe UC and CD
Immunomodulators
| Biologics
100
Immunomodulators
Thiopurines (6MP, Azathioprine)
| Methotrexate
101
Methotrexate (an immunomodulator)
need Folate supp
102
MTX
Folate supp
103
6MP, Azathioprine (Thiopurines) considerations
SE: bone marrow suppression, infection, pancreatitis, hepatotoxic,CA
Frequent monitoring: CBC and liver tests
104
Risk of infusion reaction with this Biologic
Infliximab
105
Biologics to treat Moderate-severe IBD
"mabs"
I and A treat both
G for UC
C for CD
106
Considerations prior to Anti-TNF (biologics) "mabs" therapy
CXR to screen for TB
| Hep A and B screen
107
When to use Abx for IBD
in CROHNS acute dz
When pt has Peri-anal dz:: fistulas, abscess
Cipro and Flagyl
108
SE of Cipro
Tendonitis
Photosensitive
Prolong QT
109
SE of Flagyl (Metronidazole)
Peripheral neuropathy
Metallic taste in mouth
Disulfuram rxn
110
Indications for surgery in IBD
Severe hemorrhage
Perforation
Dysplasia/CA
Not responding to meds
111
Consider starting with Immunomodulator/biologic therapy in these pts,
risk factors for aggressive dz
```
Bad locations (perianal)
Penetrating/fistula
Steroid resistance
Severe dz (weight loss, nutrient deficiency, hypoalbuminemia)
Young age
```
112
If pt has IBD and develops diarrhea (change in baseline stool)
Always check stool studies
113
NSAIDs with IBD?
NO, NEVER
| can exacerbate dz activity
114
usually infant dz but now
| 10-40 YO
Celiac
115
Villous atrophy
Celiac dz
116
Small bowel malabsorption
Celiac dz
117
Genetic pre-D (HLA)
Diabetes
Thyroid
Down syndrome
Celiac dz
118
Diarrhea, steatorrhea, flatulence, bloating, weight loss
"malabsorptive sx"
Celiac dz
119
Dermatitis Herpetiformis is an extra-intestinal manifestation of what
Celiac dz
120
Gold standard dx for Celiac
EGD with duodenal biopsy
shows villous atrophy
121
IgA tissue transglutaminase (rTG Ab) primary
Celiac
122
Identified w elevated tTG IgA and confirmed with duodenal biopsy
Celiac
