CLINICAL CARE OF THE GASTROINTESTINAL SYSTEM Flashcards by Tim Mackey

What is known as increased stool frequency?

Diarrhea

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Diarrhea is usually defined as more than how many bowel movements a day?

3 bowel movements or more a day

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The liquidity of feces is known as what?

Diarrhea

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Diarrhea can be classified as what?

Acute or chronic

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Diarrhea that is acute in onset and persisting for less than two weeks is most commonly caused by what?

infectious agents
bacterial toxins

(either preformed or produced in the gut)

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How can infectious sources of diarrhea be transmitted and what is the usual incubation period?

Fecal-oral contact
food and water
between 12-72 hours

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What is the prime absorptive surface of the GI tract?

Small intestine

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>90% of all water absorbed in the GI tract takes place where?

Small intestine

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What part of the small intestine is the major site of water reabsorption?

Jejunum

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True or False

Disorders of the small intestine results in increased amounts of diarrheal fluid with a concomitantly greater loss of water, electrolytes, and nutrients

True

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What is the most common cause of acute gastroenteritis?

Infectious agents

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What is a common diarrheal illness seen in the operational setting?

Acute infectious gastroenteritis

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What is a diarrheal disease (three or more times per day or at least 200g of stool per day) of rapid onset that lasts less than two weeks and may be accompanied by nausea, vomiting, fever, or abdominal pain?

Acute gastroenteritis

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What involves inflammation of the stomach and portions of the small intestine; both vomiting and diarrhea are usually present; however either can occur alone?

Acute gastroenteritis

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What are some common findings on the physical examination of patients with acute viral gastroenteritis?

mild diffuse abdominal tenderness on palpation
abdomen is soft but may have voluntary guarding

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True or False

Acute viral gastroenteritis is usually self-limited and is treated with supportive measures. No specific antiviral agents are necessary.

True

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The agents that cause diarrhea work by several mechanisms such as what?

adherence
mucosal invasion
enterotoxin production and/or cytotoxin production

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The mechanisms that cause diarrhea usually result in what?

Increased fluid secretion and/or decreased absorption

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True or False

Infectious gastroenteritis can be easily confused with acute gastritis

True

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True or False

Infectious gastroenteritis can be easily confused with acute gastritis

True

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What term is often used to describe endoscopic or radiologic characteristics of abnormal-appearing gastric mucosa, a diagnosis of this is defined as and required histopathologic evidence of inflammation?

Gastritis

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True or False

Gastritis involves the same organs that gastroenteritis does

False

Gastritis ONLY involves the stomach

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What are the two most common causes of gastritis?

Chronic NSAID use
Chronic alcohol and/or large amounts of alcohol consumption

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What form of gastritis causes a decrease in prostaglandin synthesis that’s required for the maintenance of the stomach mucosal lining, making the mucosa susceptible to damage by gastric acid resulting in peptic ulcers (PUD) as well as diffuse mucosal inflammation?

Chronic NSAID use

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Chronic alcohol use results in what?

Diffuse gastric mucosal inflammation

True or False Other etiologies for gastritis can include trauma and critically ill patients that are admitted to the ICU

True (Burn patients: Curling Ulcers)

Gastritis is usually self limiting but patients may also benefit from what?

1. Proton Pump Inhibitor 2. Removal of offending agent

What should be done if a patient doesn't respond to conservative management of gastritis?

1. Referral for endoscopy 2. H. Pylori testing

Chronic Diarrheal illnesses may be classified as what?

1. Osmotic 2. Inflammatory 3. Secretory 4. Chronic infection: parasites: Giardia Lamblia 5. Malabsorption Syndromes 6. Motility disorders

What is a chronic diarrheal illness due to an increase in the osmotic load presented to the intestinal lumen, either through excessive intake or diminished absorption?

Osmotic chronic diarrheal illness

What is a chronic diarrheal illness when the mucosal lining of the intestine if inflamed?

Inflammatory chronic diarrheal illness (IBS, Malignancy)

What are some forms of malabsorption syndromes that can cause chronic diarrheal illnesses?

1. Celiac disease 2. Whipple 3. Crohn Disease 4. Lactose intolerance

True or False Irritable bowel syndrome is a motility disorder

True

What term for diarrhea suggests colonic involvement by invasive bacteria or parasites or by toxin production?

"inflammatory diarrhea"

Patients with what usually complain of frequent blood, small-volume stools, often associated with fever, abdominal cramps, tenesmus (feeling that you need to pass stools), and fecal urgency?

Inflammatory Diarrhea

These are all common causes of what? 1. Shigella 2. Salmonella 3. Escherichia coli 4. E coli O157:H7

Inflammatory Diarrhea

What is a common protozoal cause of inflammatory diarrhea?

Entamoeba histolytica

True or False Community outbreaks of inflammatory diarrhea suggests a viral etiology or a common food source

True

Similar recent inflammatory diarrheal illnesses in family members suggest what kind of origin?

Infectious origin

True or False Ingestion of improperly stored or prepared food implicates food poisoning

True

What is generally a milder form of diarrhea that is caused by viruses or toxins that affect the small intestine?

Acute Non-inflammatory diarrhea

The viruses and toxins associated with acute non-inflammatory diarrhea interfere with salt and water balance resulting in what?

Large volume watery diarrhea, often with nausea, vomiting and cramps

What are some common viral causes of acute non-inflammatory diarrhea?

1. Rotavirus 2. Norwalk virus

What are vibriones associated with acute non-inflammatory diarrhea?

1. Vibrio cholerae 2. Vibrio parahaemolyticus

Common protozoal causes of acute non-inflammatory diarrhea include what?

1. Giardia lamblia 2. Cryptosporidium 3. Cyclospora

What term usually denotes diseases caused by toxins present in consumed foods?

"food poisoning"

True or False When the incubation period for food poisoning is short (1-6 hours after consumption), the toxin is usually new

False When the incubation period for acute non-inflammatory diarrhea is short (1-6 hours after consumption), the toxin is usually preformed

In food poisoning, vomiting is usually a major complaint but what is normally absent?

Fever

True or False When the incubation period for food poisoning is longer (between 8 hours and 16 hours) the organism is present in the food and produces toxin after being ingested. Vomiting is less prominent, abdominal cramping is frequent, and fever is often absent.

True

In what percentage of patients with acute non- inflammatory diarrhea, the illness is mild and self-limited, responding within 5 days to simple rehydration therapy or antidiarrheal agents?

Over 90% Diagnostic investigation is unnecessary

If diarrhea worsens or persists for more than 7 days, stool should be sent to the lab for what?

1. fecal leukocyte 2. ovum and parasite evaluation 3. bacterial culture

What is indicated in the following situation? 1. Signs of inflammatory diarrhea manifested by any of the following: fever (\> 38.5 degree Celcius), bloody diarrhea, or abdominal pain. 2. The passage of six or more unformed stools in 24 hours. 3. Profuse watery diarrhea and signs or symptoms of dehydration.

Prompt medical evaluation

What kind of findings may be present in infection with C difficile or enterohemorrhagic E coli?

Peritoneal findings

These could be symptoms of what? 1. Sudden onset: a. nausea, vomiting and decreased appetite b. crampy abdominal pain c. loose stool d. malaise e. fatigue 2. Diffuse abdominal tenderness 3. Distention 4. Increased bowel sounds 5. Usually afebrile

Diarrhea

What are some labs you would order for diarrhea?

1. CBC Dif 2. Fecal leukocyte 3. Fecal O/P 4. Stool Culture 5. C difficile assay, if recent hospitalization or antibiotics 6. Stool examination for Giardia Lamblia if Giardiasis suspected, which is an important cause of waterborne and foodborne disease, daycare center outbreaks, and illness in international travelers

True or False Stopping diarrhea abruptly with antidiarrheal medications can prolong symptoms relief if causes are ingested bacteria, parasites, etc.

True

What is the rate of oral fluid replacement for patients with diarrhea if they have a concerning hydration status?

50-200mL/kg/24h

Should patients with diarrhea follow a strict BRAT diet and avoid irritating foods?

Yes

What antidiarrheal agents should be given to a patient with diarrhea?

1. Loperamide (Imodium) 4mg, then 2mg after each loose stool with max dose of 16mg/day 2. Bismuth Subsalicylate (Pepto-Bismol) 2 tabs or 30mL PO every 30-60 mins as needed, max 16 tabs or 240mL/24hrs

True or False Empiric antibiotic therapy is indicated in patients with acute, community acquired diarrhea

False Normally not indicated

What are the infectious bacterial diarrheas for which antibiotic treatment is recommended?

1. Shigellosis 2. Cholera 3. Salmonellosis 4. Listeriosis 5. C. Difficile

What are the diarrhea causing parasitic infections that require treatment?

1. Amebiasis 2. Giardiasis 3. Cryptosporidiosis

What is the most common digestive complaint in the United States?

Constipation

What is the most common cause of constipation?

Diminished intake of fiber associated with decreased fluid intake

Can chronic laxative abuse cause constipation?

Yes

Systemic diseases such as hypothyroidism, hyperparathyroidism, diabetes, and chronic neurologic disorders can all be causes of what?

Constipation

Medications such as CCB's, iron, narcotic analgesics, and antipsychotics can cause what?

Constipation

True or False Irritable bowel syndrome with predominant constipation (IBS-C) is characterized by abdominal pain with altered bowel habits

True

What labs would you order for someone with constipation?

1. CBC for anemia 2. Thyroid function test for suspected hypothyroidism 3. Electrolyte abnormalities (hypokalemia and hypercalcemia)

What radiology studies would you order for constipation?

1. Upright chest film and abdominal flat and erect films for the presence or absence of intestinal obstruction 2. Abdominal films to assess stool burden

What does the first line treatment of constipation include?

1. Strict diet changes 2. Exercise 3. Increased water intake 4. Fiber supplementation (increase dose gradually over 7-10 days)

What emollient laxative is used for constipation?

Docusate sodium (Colace) 100mg daily to twice daily

What stimulant laxative would be used for constipation?

Bisacodyl (Dulcolax) 5-15mg PO daily or 10mg PR TID

What saline laxatives are used for constipation?

1.Magnesium Hydroxide (Milk of Magnesia) 15-30mL daily to twice daily (not to be given to patients with impaired renal function) 2. Magnesium Citrate 100-300mL PO divided qd-bid

What hyperosmolar agents are used for constipation?

1. Sorbitol 15-30mL PO qd-bid 2. Polyethylene Glycol (MiraLAX) 1 capful PO qd-bid, with with at least 8oz of fluid and drink all at once

What does third line treatments of constipation include?

1. Glycerin suppository PR qid 2. Fleets enemas

Where should a patient with a complicated or chronic case of constipation be referred to?

Gastroenterologist

What is located above the dentate line and are sub epithelial cushions of the anorectum?

Internal hemorrhoids

What arises from the inferior hemorrhoidal veins, below the dentate line, covered with squamous epithelium, posses nervous innervation, and are very painful when thrombosed?

External hemorrhoids

What are normal anatomic structures of the anorectum and are universally present unless a previous intervention has taken place?

Hemorrhoidal venous cushions

Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, what are common causes of anal pathology?

Hemorrhoidal venous cushions

What are subepithelial vascular cushions consisting of connective tissue, smooth muscle fibers, and ateriovenous communications between terminal branches of the superior rectal artery and rectal veins?

Internal hemorrhoids

What are the common locations that internal hemorrhoids usually occur?

1. right anterior 2. right posterior 3. left lateral

True or False Internal hemorrhoids have a nerve supply so are very painful when present

False They lack a nerve supply so are not painful when present

What arises from the inferior hemorrhoidal veins located below the dentate line and are covered with squamous epithelium or the anal canal or perianal region?

External hemorrhoids

Straining with bowel movements, constipation, prolonged sitting, pregnancy, obesity, and low-fiber diets all may contribute to what?

Hemorrhoids

Thrombosis of the external hemorrhoidal plexus results in a what?

Perianal Hematoma

What condition is characterized by the relatively acute onset of an exquisitely painful, tense and bluish perianal nodule covered with skin that may be up to several centimeters in size?

Hemorrhoids

True or False Pain with hemorrhoids is most severe within the first few hours but gradually eases over 2-3 days as edema subsides

True

The principal problems attributable to internal hemorrhoids are usually what?

1. Painless bleeding 2. Prolapse 3. Mucoid discharge

True or False Bleeding associated with hemorrhoids is often severe enough to cause anemia

False Rarely is bleeding severe enough to result in anemia

True or False Pain is unusual with internal hemorrhoids, occurring only when there is extensive inflammation and thrombosis of irreducible tissue or with thrombosis of an external hemorrhoid

True

What is stage one of an internal hemorrhoid?

Confined to the anal canal

What stage of internal hemorrhoids is this? Over time the internal hemorrhoids may gradually enlarge and protrude from the anal opening. Mucosal prolapse occurs during straining and reduces spontaneously

Stage 2

Prolapsed hemorrhoids that may require manual reduction after bowel movements is what stage of hemorrhoids?

Stage 3

Prolapsed hemorrhoids that remain chronically protruding and are unresponsive to manual reduction is what stage of internal hemorrhoids?

Stage 4

True or False Chronically prolapsed hemorrhoids may result in a sense of fullness or discomfort and mucoid perianal discharge, resulting in irritation and soiling of underclothes

True

True or False Non-prolapsed internal hemorrhoids are not visible but may protrude through the anus with gentle straining

True

What are visible as protuberant purple nodules covered by mucosa?

Prolapsed hemorrhoids

True or False During a digital rectal exam, uncomplicated internal hemorrhoids are palpable and painful

False They are neither palpable nor painful

Small volume rectal bleeding not caused by hemorrhoids may be caused by what instead?

1. Anal fissure or fistula 2. Neoplasms of the distal colon or rectum 3. Ulcerative colitis or Crohn disease 4. Infectious proctitis 5. Rectal ulcers

True or False Colonoscopy should be performed in all patients with hematochezia to exclude disease in the rectum or sigmoid colon that could be misinterpreted in the presence of hemorrhoidal bleeding

True

Treatment for thrombosed external hemorrhoids includes what?

1. warm sitz bath 2. analgesics and ointments 3. if seen in the first 24-48 hours, removal of the clot may hasten symptomatic relief

Most patients with early, Stage 1 and Stage 2, disease can be managed with what?

Conservative treatment

For edematous, prolapsed hemorrhoids, gentle manual reduction may be supplemented by what?

1. suppositories 2. Topical pads containing witch hazel 3. Warm sitz baths

What is reserved for 5-10% of patients with chronic severe bleeding due to stage 3 or stage 4 hemorrhoids or patients with acute thrombosed stage 4 hemorrhoids?

Surgical Excision (hemorrhoidectomy)

What are linear or rocket shaped ulcers that are usually \<5mm in length?

Anal Fissures

Anal fissures most commonly occur in the posterior midline, but what percentage occur anteriorly?

10%

Fissure that occur off the midline could be symptomatic of what?

1. More serious disease process 2. Sexual assault

Where do most anal fissures come from?

Trauma to the anal canal during defecation

A patient with what may complain of severe, tearing pain during defecation followed by throbbing discomfort that may lead to constipation due to fear of recurrent pain?

Anal fissure

What do acute anal fissures look like?

Cracks in the epithelium

Chronic fissures result in what?

Fibrosis and the development of a skin tag at the outermost edge

What is an important portion for the management of anal fissures?

Promoting effortless, painless bowel movements

What are some additional treatments for anal fissures?

1. Fiber supplements 2. Topical anesthetics (5% viscous lidocaine; 2.5% lidocaine w/ 2.5% procaine) 3. Oral analgesics (Tylenol or NSAIDS)

With conservative management, healing of anal fissures usually occurs within 2 months in up to what percentage of patients?

45%

True or False Chronic Fissures should be referred

True

Can anal fissures be treated with topical nitroglycerin 0.2-0.4% or Diltiazem 2%?

Yes

Can anal fissures be treated with an injection of botulinum toxin into the internal anal sphincter?

Yes

The mechanism of what involves obstruction of an anal gland that opens in the base of an anal crypt which normally drains into the anal canal?

Anorectal Abscess

True or False Anorectal disorders range from simple to complex, may be varied and multiple, and at times can manifest signs and symptoms of underlying serious local or systemic disorders that may be life threatening.

True

Where are anorectal abscesses frequently encountered?

Perianal and perirectal region

What do almost all anorectal abscesses begin with involvement of?

Anal crypt and its gland

When obstruction of an anal gland occurs, the gland orifice is blocked, resulting in what?

Infection and abscess formation

What are these spaces? 1. Perianal space 2. Interphincteric space 3. Ischiorectal space 4. Deep postanal space 5. Supralevator or pelvirectal space

Spaces in which an anorectal abscess can form

What is a common sequela that can form from an anorectal abscess?

Fistula

In what group are anorectal abscesses more common?

Young middle-aged males

What would you suspect if a patient presents to you with a dull, aching, or throbbing pain that becomes worse immediately before defecation, is lessened after defecation, but persists between bowel movements?

Anorectal abscess

True or False Perianal abscesses, easily palpable, are usually accompanied by fever, leukocytosis, and sepsis in the immunocompetent patient

False Usually not accompanied by fever, leukocytosis, and sepsis in the immunocompetent patient

True or False Other anorectal abscesses (ischiorectal, intersphincteric, supralevator, etc) are painful but may express fewer outward signs upon examination. The patient often appears markedly uncomfortable and may be febrile. Leukocytosis may be present.

True

Could you perform an ultrasound for a deep anorectal abscess?

Yes

What is the treatment for an anorectal abscess?

Surgery Should be performed as soon as the diagnosis is made, before it becomes fluctuant

True or False Drainage for anorectal abscesses should be both early and extensive

True

Should all perirectal abscesses (supralevator, intersphincteric, and complicated ischiorectal) be drained in the operating room?

YES

Can isolated, simple, fluctuant perianal abscesses that are NOT associated with the presence of any deeper abscesses be drained in the ED or outpatient setting using local anesthetics?

Yes

If a simple, linear drainage incision is made for the drainage of an anorectal abscess, the abscess is more likely to recur because of the premature closing of the skin edges, what additional care should be given to this patient with this form of drainage incision?

1. Abscess cavity must be packed initially with strips of gauze for at least 24hrs 2. These patients require closer follow up care

To ensure adequate drainage, a \_\_\_or \_\_\_incision can be made over the fluctuant part of the abscess. Trimming the flaps of these incision is suggested to prevent closure

1. cruciate 2. elliptical

Is packing required in a drainage using a cruciate or elliptical incision?

No packing is not required, but if it is used it should be done lightly and removed in 24 hours

Are antibiotics necessary after an abscess have been adequately drained?

What broad-spectrum antibiotics should be used in patients with fever, leukocytosis, valvular heart disease, or those with cellulitis, in the management of a patient with an anorectal abscess?

1. Cephalexin (Keflex) 250mg four times daily (QID) 2. Doxycycline 100mg BID for 7 days 3. Clindamycin 300mg PO q 6hrs for 7 days 4. Dicloxacillin 125-500mg PO q 6 hours

What is a chronic manifestation of the acute perirectal process that forms an anal abscess; When the abscess ruptures or is drained, and epithelialized track can form that connects the abscess in the anus or rectum with the perirectal skin?

Anorectal Fistula

These are symptoms of what? 1. “non-healing” anorectal abscess following drainage 2. Chronic purulent drainage and a pustule-like lesion in the perianal or buttock area 3. Intermittent rectal pain, particularly during defecation, but also with sitting 4. intermittent and malodorous perianal drainage and pruritus

Anorectal Fistula

True or False Patients presenting with an anal fistula require higher echelons of care due to the proximity of the involved area

True

Should you MEDEVAC and unstable patient with an anorectal fistula?

PUNT PUNT PUNT

What is a malfunction which describes a spectrum of clinical presentations, ranging from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses of the sacrococcygeal region that have some tendency to recur?

Pilonidal disease

Can pilonidal abscesses occur from Staph aureus after it invades the openings caused by ingrown hairs?

Yes

Pilonidal sinuses are formed by the penetration of the skin by an ingrowing hair, which causes a what?

a foreign body granuloma reaction

When does pilonidal disease most commonly occur?

Before the 4th decade of life

True or False An abscessed pilonidal cyst is always located in the midline (there may however be secondary fistula openings on either side of the midline) and does not communicate with the anorectum.

True

What are some common complaints of patients with pilonidal cysts?

Swelling, pain, and persistent discharge

What is the most common exam finding for patients with pilonidal cysts?

A single opening from which hair is protruding

Examination of a patient with a possible pilonidal cyst generally reveals what?

an area of inflammation in the midline of the gluteal crease with one or more sinus openings

True or False IF the patient gives a history of recurrent infection at the base of the spine, this in itself may be considered diagnostic

True

True or False When concerning pilonidal disease or cysts, a patient will usually present when an abscess has formed that can no longer drain

True

Should you consider a CBC in a patient with a pilonidal cyst?

Yes, if the patient demonstrates systemic symptoms (fever, chills, etc.)

What is the treatment of choice for a pilonidal cyst?

Surgical treatment

Are recurrences of pilonidal cysts common?

Yes

True or False A simple I&D performed in the clinical setting often does not completely resolve the pilonidal disease due to reoccurrence and the presence of hair follicles within the sinus tracts that were not debrided. Thus the definitive treatment for persistent or complicated pilonidal abscesses is surgical excision performed in the operating room.

True af

What antibiotic therapy is considered for patients after I&D of a pilonidal cyst or if surrounding cellulitis is present?

1. Cephalexin(Keflex) 500mg PO three times daily (TID) 2. Doxycycline 100mg BID for 7 days

If a patient with a pilonidal cyst remains uncomplicated you may retain them onboard, but should ultimately be referred to who for a more definitive management?

General Surgery

Should you MEDEVAC complicated cases of patients with pilonidal cysts?

Yes

True or False Depending on your Physician Supervisor's preferences MEDADVICE may be required for patients with pilonidal cysts

True

The term "inflammatory bowel disease" includes what ?

1. Ulcerative Colitis 2. Crohn's Disease

True or False In several studies, genetic factors appeared to have no influence of the risk of inflammatory bowel disease (IBD)

False In several studies, genetic factors appeared to influence the risk of inflammatory bowel disease (IBD).

The immune response disrupts the intestinal mucosa and leads to a chronic inflammatory process in what?

Inflammatory bowel disease

In what disease process can you have pseudo-polyps and inflammation that is limited to the colonic mucosa?

Ulcerative Colitis (UC)

What is an island of normal colonic mucosa which only appears raised because it is surrounded by atrophic tissue?

Pseudo-polyp

What disease process can affect ANY segment of the GI tract from the mouth to the anus?

Crohn's Disease

What can also be seen in Crohn's disease?

1. "skip lesions" 2. Transmural inflammation

Crohn's disease and ulcerative colitis may be associated in what percentage of patients with a number of extra-intestinal manifestations? ESPECIALLY CROHN'S

50%

What are some extra-intestinal manifestations in Crohn's AND Ulcerative Colitis?

1. Erythema nodosum 2. Pyoderma Gangrenosum 3. Thromboembolic events

What are some extra-intestinal manifestations just from Crohn's?

1. oral ulcers 2. anorectal disease

What are some extra-intestinal manifestations for just Ulcerative Colitis?

1. Peripheral Arthritis 2. Spondylitis or Sacroiliitis 3. Episcleritis or Uveitis 4. Hepatitis 5. Sclerosing Cholangitis

What kind of inflammation only involves the mucosal layer of the bowel wall

Mucosal Inflammation

What is mucosal inflammation characteristic of?

Ulcerative Colitis

What kind of inflammation shows inflammatory changes/ulceration of all layers of the bowel wall?

Transmural Inflammation

What is transmural inflammation characteristic of?

Crohn’s Disease

What is transmural inflammation characteristic of?

Crohn’s Disease

What disease has segmental involvement of the alimentary tract (mouth to anus) by a nonspecific inflammatory process (transmural inflammation)?

Crohn’s Disease

What is the most common portion of the GI tract that Crohn’s affects?

Terminal Ilium

When Crohn’s involves the terminal ilium it can result in what?

Malabsorption of digested foods | (B12, Bile salts, Calcium)

What is a chronic and recurrent disease, which can affect any segment of the GI tract from the mouth to the anus and involves “skip lesions”?

Crohn’s Disease

True or False Because of the variable location of involvement and severity of inflammation, Crohn’s disease may present with a variety of symptoms and signs

True

What is the most common presentation of symptoms with Crohn's Disease?

Ileitis or Ileo-colitis

Can you develop a low grade fever with Crohn's?

Yes

What is a possible complication of Crohn's disease?

Small Bowel Obstruction (SBO)

Due to the transmural nature of the inflammation characteristic of Crohn's disease patients may develop what?

Possible penetrating disease and fistulae formation

One third of patients with Crohn's disease with either large or small bowel involvement develop what?

Perianal Disease | (skin tags, anal fissures, perianal abscesses, peri-anal fistulas)

What is a common oral presentation of Crohn's?

Oral aphthous lesions

True or False Patients with Crohn's have and increased prevalence of cholelithiasis (cholesterol gallstones)

True

Perianal disease with abscesses and fistulas are common following exacerbations of what?

Crohn's disease

You would see radiographic evidence of ulceration, stricturing, or fistulas of the small intestine or colon in what?

Crohn’s Disease

1/3 of cases of what disease involves the small bowel only, usually the terminal ileum (ileitis)?

Crohn’s Disease

Half of all cases of what disease involve the small bowel and colon, usually the terminal ileum and adjacent proximal ascending colon (ileocolitis)?

Crohn’s disease

What is strongly associated with the development of Crohn’s disease, resistance to medical therapy, and early disease relapse?

Cigarette smoking

True or False A CBC and Serum Albuming should be obtained in all patients with Crohn’s disease to assess immune response and nutritional status respectively

True

True or False Anemia in patients with Crohn’s Disease may reflect chronic inflammation, (anemia of chronic disease), mucosal blood loss, iron deficiency, or vitamin B12 malabsorption secondary to terminal ileum inflammation or resection

True

Are endoscopies recommended during acute Crohn’s exacerbations?

During acute exacerbations or worsening of symptoms of Crohn’s disease a what of the abdomen should be done to assess for abscess/fistula formation or even perforation?

CT Scan of the abdomen

What is a chronic lifelong illness characterized by exacerbations and periods of remission?

Crohn’s disease

What are some available therapies for Crohn’s disease?

1. 5-aminosalicylic acid derivatives (5-ASA) 2. Corticosteriods 3. Immuno-modulating and biologic agents a. monoclonal antibodies b. methotrexate

Complications of Crohn’s Disease Tender abdominal mass with fever and leukocytosis suggests a what? An emergent CT of the abdomen is needed to confirm this diagnosis.

Intra-abdominal Abscess Treatment: broad spectrum antibiotics

What may develop secondary to active inflammation or chronic structure/adhesion formation in Crohn’s Disease?

Small bowel obstruction

What is the treatment for a small bowel obstruction in Crohn’s disease?

NG tube to decompress the GI tract, MEDEVAC

Patients with Crohn’s Disease are how much more likely to develop colon cancer than the general population?

20 times more likely

True or False UC has a higher risk of development of carcinoma than that of Crohn’s Disease

True

True or False Ulcerative Colitis (UC) is limited to the stomach

False UC is limited to the colonic mucosa

What is thought to be caused by abnormal activation of the immune system resulting in diffuse inflammation of the colonic mucosa (mucosa of the large intestine)?

Ulcerative colitis manifests in the inflammation of the mucosa of the colon causing what?

1. ulceration 2. edema 3. Bleeding (more common than in Crohn’s) 4. Fluid and electrolyte loss

True or False UC may be more severe and more common in active smokers

False It is more common in non-smokers and former smokers

True or False Appendectomy before the age of 20 for acute appendicitis is associated with a reduced risk of developing ulcerative colitis

True

Can infectious colitis, such as diverticulitis, mimic signs and symptoms of UC?

YES

What is the hallmark of Ulcerative Colitis?

Bloody diarrhea

What classification of UC is this? 1. Gradual onset of infrequent diarrhea (less than five movements per day) with intermittent rectal bleeding and mucus. 2. Stools may be formed or loose in consistency 3. Because of rectal inflammation, there is fecal urgency and tenesmus 4. Left lower quadrant cramps relieved by defecation are common, but there is no significant abdominal tenderness

Mild

What classification of UC is this? 1. Have more severe diarrhea with frequent bleeding. 2. Abdominal pain and tenderness may be present but are not severe. 3. May be mild fever, anemia, and hypoalbuminemia

Moderate

What classification of UC is this? 1. Have more than six to ten bloody bowel movements per day, resulting in severe anemia, hypovolemia, and impaired nutrition with hypoalbuminemia 2. Abdominal pain and tenderness are present

Severe

These are labs that are run for what Inflammatory Bowel Disease? 1. CBC 2. ESR 3. CRP 4. Stool Bacterial Culture 5. C DIF 6. Ova and Parasites 7. Serum and Albumin 8. Electrolytes

Ulcerative colitis

True or False The degree of abnormality of the hematocrit, sedimentation rate, and serum albumin reflects disease severity for UC

True

What are the two main treatment objectives when treating patients with UC?

1. Terminate the acute attack 2. Prevent recurrence of attacks

What are some medication options of UC?

1. Mesalamine 2. Corticosteroids 3. Aminosalicylates (5-ASA) 4. Antidiarrheals for chronic mild symptoms in patient negative for C. Diff

What surgical intervention may be required for severe UC?

Total proctocolectomy

What is the treatment for mild/moderate colitis?

1. treatment as recommended by GI 2. Limit intake of caffeine and gas producing vegetables

What is the treatment for severe UC?

1. hospitalization 2. Discontinue oral intake for 24-48 hours until clinical improvement 3. Restore circulating volume with fluids 4. Serial abdominal exams

Can Crohn’s Disease or UC be definitively diagnosed in the outpatient setting?

No, patients will require a biopsy

Where should patients with Crohn’s disease or UC be referred to after MEDEVAC?

GI or General Surgery

True or False The physiology of sensation in the gut is multifaceted

True

What is involved in the perception autonomic response to visceral stimulation?

1. 5-HT (serotonin) 2. Substance P 3. Norepinephrine 4. Nitric Oxide

What is a chronic disease (**_more than 3 month_**s) that is characterized by abdominal pain or discomfort that occurs in association with altered bowel habits?

IBS

How many months of symptoms are required for a diagnosis of IBS?

3 months

True or False IBS is hypothesized to occur from a complex interaction between psychosocial abnormalities, intestinal permeability, immune system and the nervous system

True

What is believed to play a large role in the pathophysiology of IBS?

Mental Health

These are symptoms of what? 1. Usually begins in the late teens to twenties 2. Abnormal frequency, form, and passage of stool 3. **_Hallmark symptom_**: abdominal discomfort that is relieved immediately after defecation with otherwise normal physical exam

IBS

A diagnosis of IBS is defined as abdominal discomfort or pain that has **_at least two of the three_** features of what?

1. Relieved with defecation 2. Change in stool frequency 3. Change in form of stool

Patients with IBS are classified into how many major categories based on predominant bowel habits?

Three

What is IBS-C?

IBS with constipation

What is IBS-D?

IBS with diarrhea

What is IBS-U?

IBS with infrequent bowel movements

What is IBS-M?

IBS with mixed constipation with diarrhea

Alarm symptoms: IBS You should rule out alternative diagnosis if the patient has what symptoms not normally seen in patients with IBS?

1. acute symptoms onset, patients 40-50 y/o 2. nocturnal diarrhea 3. severe constipation 4. Hematochezia/Unexplained IDA 5. Weight loss 6. Fever 7. Family history of cancer, IBD, Celiac

True or False Patients with IBS should have associated fevers, rashes, blood in the stool

False, physical exam is usually completely normal. Abdominal tenderness is common but not pronounced.

True or False IBS is a diagnosis of exclusion

## Footnote True

For patients who fulfill the diagnostic criteria for IBS and have no alarm symptoms, are routine blood tests necessary?

Nope, only if alternative diagnosis is suspected

Imaging/Radiology IBS In all patients age ___ years or older who have not had a previous evaluation, colonoscopy should be obtained to exclude malignancy

What is closely associated with bettering and worsening of symptoms of IBS?

Diet

Someone with IBS should avoid what kind of foods?

Fatty food and caffeine

Patients with IBS may benefit from a diet low in what?

1. Fermentable oligo-,di-, and monosaccharides and polyols (FODMAPs) 2. Lactose 3. Gluten

What antidiarrheal agents could you use for IBS?

Loperamide (Imodium) 2mg po 3-4 times daily

What antispasmodic agents (anticholinergics) could you use for IBS?

1. Hyoscyamine (Levsin) 0.125mg orally (or sublingual) or sustained release, 0.037mg or 0.75mg orally twice daily 2. Methscopolamine (Pamine) 2.5-5mg orally before meals and at bedtime 3. Dicyclomine (Bentyl) 10-20mg PO QID

What psychotropic agents could you use for IBS?

Tricyclic Antidepressants (TCA) 1. Amitriptyline (Elavile) or Imipramine (Tofranil) 25-75mg PO qHS

## Footnote Patients with IBS who have underlying psychological abnormalities may benefit from evaluation by who?

Mental Health

Patients with IBS with severe disability should be referred to where?

Pain Treatment center

What kind of reflux episodes typically occur postprandially, are short-lived, asymptomatic, and rarely occur during sleep?

Physiologic Reflux

What kind of reflux is associated with symptoms or mucosal injury and often occurs nocturnally?

Pathologic Reflux

What is a condition that develops when the reflux of the stomach contents causes troublesome symptoms or complications?

GERD

Endoscopy demonstrates abnormalities in how many patients with GERD?

1/3 of patients

What plays a vital role on the frequency and severity of GERD?

Lower esophageal sphincter

Pain associated with GERD is secondary to the stimulation and activation of mucosal chemoreceptors by what?

Acid

What kind foods exacerbate the symptoms of GERD?

1. Spicy 2. Acidic 3. Salty 4. Alcohol may contribute to onset

Heartburn can occur how many minutes after meal and upon bending over or reclining with GERD?

30-60 minutes

What occurs in one-third of patients and may be due to erosive esophagitis, abnormal esophageal peristalsis, or the development of an esophageal stricture?

Dysphagia

“Atypical” or “Extraesophageal” manifestations of gastroesophageal disease may occur including what?

1. asthma 2. chronic cough 3. chronic laryngitis 4. sore throat 5. non-cardiac chest pain

Reflux erosive esophagitis may be confused with what?

1. pill-induced damage 2. eosinophilic esophagitis 3. infection (CMV, Herpes, Candida)

What is a condition in which the squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells (specialized intestinal metaplasia) ?

Barret Esophagus

What is present in up to 10% of patients with chronic reflux; it arises from chronic reflux-induced injury to the esophageal squamous epithelium?

Barret Esophagus

What is the most common complication of Barret Esophagus?

Esophageal Adenocarcinoma

Peptic stricture formation occurs in about what percentage of patients with esophagitis?

What is manifested by the gradual development of solid food dysphagia progressive over months to years?

Peptic stricture

Where are most peptic strictures located?

At the gastroesophageal junction

What is the treatment for GERD with Mild, intermittent symptoms?

1. lifestyle modifications a. eat smaller meals b. elimination of acidic foods c. elimination of food that cause reflux 2. weight loss

What are some food that precipitate reflux?

1. fatty foods 2. chocolate 3. peppermint 4. alcohol 5. cigarettes

Patients with nocturnal symptoms of GERD should be advised to avoid lying down with how many hours after meals?

3 hours

What medications are used for relief of mild GERD symptoms that occur less than once a week?

Antacids 1. Ranitidine (Zantac) 150mg PO bid 2. Famotidine (Pepcid) 20-40mg PO bid

What medications are used for relief of mild GERD symptoms that occur less than once a week?

Antacids 1. Ranitidine (Zantac) 150mg PO bid 2. Famotidine (Pepcid) 20-40mg PO bid

What is the treatment of choice for troublesome symptoms of GERD?

Proton Pump Inhibitors (PPI) 1. Omeprazole (Prilosec) 20mg PO daily 2. Pantoprazole (Protonix) 20mg PO daily 3. Esomeprazole (Nexium) 40mg PO daily

When taken for active heartburn PPIs have a delay in onset of at least 30 minutes, but can provide relief for up to how long?

8 Hours

True or False Patients with typical GERD whose symptoms do not resolve with maximum empiric management with three months of twice-daily proton pump inhibitor therapy should be referred out

True

What is the most common abdominal surgical emergency?

Appendicitis

What are the common ages for appendicitis?

10-35

What is the MOST COMMON age for appendicitis

20-35

Where is the appendix located?

base of the cecum

What is located one third of the distance from the right anterior superior iliac spine to the umbilicus (navel)?

McBurney’s Point

What is the function of the appendix?

The function is unknown

True or False It is believed that the appendix is involved with the development of the intestinal bacterial flora

True

True or False The prevalence of appendicitis in teenagers and young adults suggests a pathophysiologic role for lymphoid aggregates that exist in abundance in the appendix of this age group

True

Appendicitis typically manifests due to some sort of blockage of what?

The lumen of the appendix

Blockage of the lumen of the appendix causes buildup of mucous that would have otherwise sloughed off the walls of the appendix and expelled via what?

Feces

True or False The lumen of the appendix becomes full of sloughed off cells and begins to expand; eventually the appendix will expand so much it outgrows its blood supply resulting in necrosis and eventual perforation of the appendix

True

What are the majority of luminal blockages of the appendix caused by?

1. fecalith (most common) 2. Immune response/expansion of the lymph tissue 3. Neoplasms

True or False All patients who present with appendicitis present differently, however typical patients will have a gradual onset (over the course of 12-24 hours) of periumbilical abdominal pain

True

Patients who have signs or symptoms of an acute abdomen should be suspected as having what?

Perforated appendix

Most patients with appendicitis will have what?

Nausea/anorexia

True or False The presence or absence of bowel sounds has been shown to be a good indicator of presence of appendix pathology

False The presence or absence of bowel sounds has been shown to be a poor indicator of presence of appendix pathology

True or False Appendicitis may manifest in many strange ways due to the non-specific visceral nervous innervation and the many different variations of the position of appendix on the cecum

True

What are these atypical symptoms of? 1. pain in the flank area (CVA tenderness) 2. lower back pain 3. groin pain 4. especially in very thin females 5. tenesmus 6. non-specific lower abdominal pain

Appendicitis

What is the gold standard imaging used for diagnosis of appendicitis?

CT scan of the abdomen

Appendicitis Should all women with progressively worsening abdominal pain be evaluated with a beta-HCG and pelvic exam regardless of reported sexual/medical history?

YES

What will the CBC show for a patient with appendicitis?

Likely show an increased WBC count

What will a UA show for a patient with appendicitis?

May have mild pyuria or hematuria on micro

True or False All patients with suspected appendicitis need broad spectrum antibiotics

True

How many days of IV antibiotics have been shown to have success at treating uncomplicated appendicitis in 18-35 year olds?

4 days

What percentage of individuals successfully treated for appendicitis with only antibiotics will have a subsequent episode of appendicitis requiring surgery within 3 months and over what percentage will have a repeat episode of appendicitis and surgery within 12 months?

1. 29% 2. 50%

Antibiotics used for appendicitis need to cover gram negative and anaerobic bacteria, what are some examples?

1. Ampicillin-sulfabactam (Unasyn) 3g IV every 6 hours 2. Ertapenem (Invanz) 1g single dose

Bile is made in the what and stored where?

1. liver 2. Gallbladder

Bile is ejected from the gallbladder into what duct in response to fat entering the proximal small intestine?

cystic duct

Bile flows from the cystic duct into what duct?

Common bile duct

Bile flows from the common bile duct into what?

The duodenum(proximal small intestine

What works in the proximal small intestine (duodenum) to emulsify fats which aids in fatty acid digestion and is eventually reabsorbed into circulation in the terminal ilium (distal small intestine)?

Bile

What serves as a reservoir for bile and stores excess bile to be used in the digestive tract?

Gallbladder

True or False Without bile would aggregate to form large hydrophobic micelles (similar to if you put oil in water) which don't have large surface areas to allow for enzymatic digestion

True

What are the two main components of bile?

1. bile salts 2. cholesterol and bilirubin

There are how many major types of gallstones?

two

What is the most common form of gallstones?

Cholesterol gallstones

Cholesterol gallstones form when cholesterol in the circulation is increased in situations such as?

1. increased estrogen states such as pregnancy 2. increased total circulating cholesterol a. poor diet b. rapid weight loss

What kind of gallstones are not very common and are formed by the precipitation of bilirubin?

Pigmented Gallstones

If the amount of cholesterol or bilirubin present in the gallbladder exceeds the amount of bile salts needed to dissolve it, what forms?

Precipitates (stones)

Gallstones can occlude ducts within the biliary tract, producing common disease processes such as what?

1. Asymptomatic Cholelithiasis 2. Biliary Colic 3. Cholecystitis 4. Choledocholithiasis 5. Cholangitis

There are how many main conditions that result from the development of gallstones?

Five

What refers to the condition in which a patient has gallstones present, but has not had any symptoms associated with them?

Asymptomatic Cholelithiasis

In what percentage of individuals with gallstones will be asymptomatic throughout their entire life?

80%

What refers to the situation in which gallstones have formed in the patients gallbladder, and they will intermittently obstruct the lumen of the cystic duct?

Biliary Colic

How long will symptoms typically last with biliary colic?

Less than 6 hours

True or False Individuals with biliary colic have an approximately 1-3% chance of developing cholecystitis or choledocholithiasis

True

Cholecystitis is the inflammation of the what?

Inflammation of the gallbladder

True or False Typically (but not always), the situation leading to the inflammation of the gallbladder (cholecystitis) occurs when a gallstone gets permanently lodged in the cystic duct?

True

By definition patients with symptoms of cholecystitis must have the symptoms for over 6 hours?

Yes

Will you see an increased white blood cell count and possible fever in a patient with cholecystitis?

Yes

What refers to the inflammation of the gallbladder caused by obstruction of the common bile duct?

Choledocholithiasis

Will patients with Choledocholithiasis show an increase in conjugated bilirubin?

Yes

True or False Patient with Choledocholithiasis may have jaundice

True

True or False Its possible to distinguish between cholecystitis and Choledocholithiasis by physical exam alone

False

What is a bacterial infection of the biliary tract?

Cholangitis

Do patients with Cholangitis tend to be very sick?

yes

Since this disease process is almost always seen in patients that have choledocholithiasis, these patients will have all the signs and symptoms of choledocholithiasis in combination with what?

Charcot’s triad

What is Charcot's triad?

1. RUQ pain 2. Fever 3. Jaundice

A patient presents with an acute onset of intermittent, sharp, right upper quadrant (RUQ) pain that is precipitated by meals, what would you suspect?

Biliary Colic

What is the treatment for biliary colic?

No specific treatment, recommend a change in diet

Cholecystitis is associated with gallstones in over what percentage of the cases?

90%

What form of cholecystitis shows no radiologic evidence of gallstones in the gallbladder or biliary tract, yet the patient has all the other signs and symptoms consistent with cholecystitis?

Acalculous Cholecystitis

True or False Typically patients with Acalculous Cholecystitis have had a major surgery within the past 2-4 weeks or are NPO due to some sort of critical condition

True

Acute cholecystitis caused by infectious agents may occur in patients with what?

AIDS

What are the “6 F’s” for cholecystitis?

1. Fat 2. Fertile 3. Female 4. Forty 5. Flatulence 6. Fever

Will patients with cholecystitis have a positive murphy's sign?

OH YEAH

A palpable gallbladder is present in what percentage of cases of cholecystitis?

15%

What is the gold standard imaging used for the diagnosis of cholecystitis?

Right Upper Quadrant (RUQ) Ultrasound

Can you see cholesterol gallstones on x-rays or CT scans?

Nope

Continuous symptoms for \>24hrs suggests possible necrosis of the gallbladder and may occasionally develop without definite signs in what patients?

1. obese 2. diabetic 3. elderly 4. immunosuppressed

What is the mainstay of treatment for cholecystitis?

Cholecystectomy(surgical removal of the gallbladder)

What antibiotics are used in mild-moderate cholecystitis?

1. Ertapenem 1g IV qD 2. Ceftriaxone 2g IV qD

What antibiotics are used in severe cholecystitis?

Piperacillin-tazobactam 4.5 grams IV q 6hrs + Metronidazole 500mg IV q 8hrs

What NSAIDS should you give someone with cholecystitis?

Ketorolac 15-30mg IV q 6hrs PRN

What is the dosage for Morphine in patients with cholecystitis that continue to have severe pain?

Morphine 2-8mg IV q 2-4hrs PRN

True or False Patients with Choledocholithiasis typically present exactly the same as those with cholecystitis, however unlike cholecystitis patients, they may show signs of jaundice due to obstruction of the common bile duct and decreased excretion of conjugated bilirubin

True

Labs for Choledocholithiasis True or False Patients will have elevated conjugated bilirubin which is pathognomonic for this disease process

True

What is the gold standard imaging used for the diagnosis of Choledocholithiasis?

Right Upper Quadrant (RUQ) Ultrasound Will show common bile duct dilation

What is commonly a complication of Choledocholithiasis?

Cholangitis

What is the typical infectious organism in cholangitis?

E. Coli

Cholangitis patients tend to be much more ill and typically require fluid resuscitation and present with RUQ pain, Fever, and Jaundice; which is also known as what?

Charcot’s Triad

True or False Esophagitis can range from pill-induced, reflux, eosinophilic to infectious

True

What are some medications that can cause Esophagitis?

1. Antibiotics (tetracycline, doxycycline, clindamycin) 2. Anti-inflammatory 3. Bisphosphonates

True or False Reflux esophagitis describes a subset of patients with GERD who have endoscopic evidence of esophageal inflammation

True

Esophagitis and thrush often occur together in what kind of patients?

Immunosuppressed patients

Does the absence of thrush preclude the diagnosis of candida esophagitis?

Patients with medication induced esophagitis usually present with retrosternal pain or heartburn in \_\_\_%, odynophagia \_\_\_%, and dysphagia \_\_\_%.

1. 60% 2. 50% 3. 40%

True or False Patients with medication-induced esophagitis, there is often a history of swallowing a pill without water, commonly at bedtime

True

What is the hallmark of Candida Esophagitis?

Odynophagia (pain on swallowing)

What diagnosis is usually made when white mucosal plaque-like lesions are noted on endoscopy?

Candida esophagitis

Esophageal candidiasis is most common in what patients?

HIV-infected patients AIDS-defining illness

If infection is considered in esophagitis what labs would you order?

1. CBC 2. Specimen culture 3. Swab for candida

Would you consider an endoscopy for esophagitis?

Yes

What is the initial care for esophagitis?

Treat the underlying cause

True or False Most infectious manifestations of esophagitis require endoscopy with biopsy to confirm diagnosis

True

Should broad spectrum antibiotics be considered in those with esophagitis who present with fever and elevated WBC?

Yes

What is likely caused as a result to esophageal irritation from chronic GERD?

Esophageal Strictures

True or False Stricture formation happens to lower the volume of reflux in the esophagus to reduce symptoms of GERD

True

Approximately what percentage of cases of esophageal strictures are unrelated to gastroesophageal reflux and treatment in these cases may be more difficult?

25%

What is a more commonly recognized cause of esophageal strictures, particularly in young men?

Eosinophilic esophagitis

In what does an accumulation of eosinophils within the esophagus causes symptoms of dysphagia, food impaction, refractory heartburn, and mild chest pain?

Eosinophilic esophagitis `

What is a cardinal feature of an esophageal stricture?

Dysphagia

For mild symptoms of an esophageal stricture what should you do?

Treat for GERD as the causative factor

For severe symptoms of an esophageal stricture should you consider MEDEVAC for potential surgery?

Yes

True or False ## Footnote Refer all patients with an esophageal stricture to Gastroenterology for dilation and evaluation

True

What is an idiopathic motility disorder which causes loss of peristalsis in the distal two-thirds of the esophagus ad impaired relaxation of the LES and could be caused by GERD?

Esophageal Spasm

What is thought to be a consequence of impaired inhibitory innervation, leading to premature and rapidly propagated contractions in the distal esophagus?

Esophageal spasm

Can symptoms of esophageal spasms be present for months?

Yes

True or False Patients with esophageal spasms will often lift the neck or throw the shoulders back to enhance gastric emptying

True

What radiology studies would be needed for an esophageal spasm?

1. Chest X-ray 2. Barium Esophagography 3. Endoscopy

What is the goal of treatment in esophageal spasms?

Symptom reduction

Can eating smaller bites of food be an appropriate treatment for esophageal spasms?

yes

True or False In a patient with an esophageal spasm, if oral feeding becomes problematic, refer to parental IV, NPO and prepare them for MEDEVAC

True

When the balance between the aggressive factors and the defense mechanisms of the stomach and duodenum become disrupted, what can occur?

Peptic Ulcers

Peptic ulcer symptoms are characterized by what?

Rhythmicity and periodicity

What percent of patients present with ulcer complications without antecedent symptoms?

10-20%

True or False Most NSAID-induced ulcers are asymptomatic

True

What is the diagnostic procedure of choice in most patients with peptic ulcers?

Upper endoscopy with gastric biopsy for H. Pylori

What is a break in the gastric or duodenal mucosa that arises when the normal mucosal defensive factors are impaired or are overwhelmed by aggressive luminal factors such as acid and pepsin ?

Peptic Ulcers

Peptic ulcers occur five times more commonly in the what; where over 95% are in the bulb or pyloric channel?

Duodenum

True or False In the stomach, benign ulcers are located most commonly in the antrum (60%) and at the junction of the antrum and body on the lesser curvature (25%)

True

What age group do duodenal ulcers most commonly occur in?

30-55 y/o

What age group do gastric ulcers most commonly occur in?

55-70 y/o

Ulcers are more common in ____ and in patients taking ____ on a long term basis.

1. Smokers 2. NSAIDS

What are the three major causes of peptic ulcer disease?

1. NSAIDS 2. Chronic H pylori infection 3. Acid hypersecretory states

True or False ## Footnote There is a 10-20% prevalence of gastric ulcers and a 2-5% prevalence of duodenal ulcers in long-term NSAID users.

True

What is the hallmark symptom of peptic ulcer disease and is present in 80-90% of patients?

Epigastric pain (dyspepsia)

The epigastric pain associated with peptic ulcer disease is often described as what?

A gnawing, dull, aching, “hunger-like” pain

Approximately what percentage of patients with peptic ulcer disease report a relief of pain with foods or antacids (especially duodenal ulcers) and a recurrence of pain 2-4 hours later?

50%

How long is the anti-H. Pylori antibiotic regimen?

10-14 days

What is the anatomical landmark that defines the border between the upper and lower GI tract?

Ligament of Trietz

Proximal to the Ligament of Treitz is considered what portion of the GI tract?

Upper GI tract

Distal to the Ligament of Treitz is considered what portion of the GI tract?

Lower GI tract

What is microscopic blood found in GI tract secretions?

Occult blood

What is the most common source of lower GI bleeding?

Colon carcinoma

What is known as vomiting of blood?

Hematemesis

“Coffee-ground” colored hematemesis has a likely origin of where?

The bleed is either at or distal to the stomach

Bright red blood in hematemesis means the bleed it where?

likely to be at or proximal to the lower esophageal sphincter

What are the two most common presentations of an upper GI bleed?

1. Hematemesis 2. Melena

What can develop after as little as 50ml of upper GI blood loss?

Melena

What is the gold standard for the definitive diagnosis of GI bleeds?

Upper endoscopy

True or False Labs can have massive value in the diagnosis of a GI bleed?

False as hell

What should be inserted into all patient with a suspected active upper GI bleed?

NG Tube

In a patient with a potential GI bleed a systolic blood pressure \<100mmHg indicates what?

Severe blood loss (30-40% of circulating blood volume)

In a patient with a potential GI bleed, a heart rate \>100 bpm with a SBP \>100mmHg is indicative of what?

moderate blood loss (15-29% of circulating blood volume)

What is the gold standard medication of choice for severe GI bleeds?

IV Proton pump inhibitors (PPIs) Omeprazole/Pantoprazole IV 80mg bolus +8mg/h continuous infusion

Upper GI bleeding is self limited in what percentage of patients?

80%

These are common causes of what? 1. Diverticulosis/diverticulitis 2. IBD 3. Anorectal Disease 4. Hemorrhoids 5. Fissures

Lower GI bleeding

Large volumes of bright red blood in a lower GI bleed suggests what?

a colonic source

Lower GI bleeding Maroon stools may indicate what?

lesion in the right colon or small intestine

Lower GI bleeding Black tarry stools (melena) predict a source of bleeding where?

proximal to the ligament or treitz

What is the goal of therapy for a Lower GI bleed?

Treating the underlying cause

What is the gastro-esophageal junction also known as?

squamo-columnar junction

What is characterized by a non-penetrating vertical mucosal tear/laceration at the gastroesophageal junction?

Mallory-Weiss

A history of heavy alcohol use leading to vomiting has been noted in what percentage of patients with Mallory-Weiss syndrome?

40-80%

What is a more severe laceration of the anterior esophagus associated with full perforation of the esophagus into the mediastinum?

Boerhaave's Syndrome

In Boerhaave's syndrome you may see Hartman's sign, which is what?

"crunching' sound heard on auscultation of the mediastinum

Mallory-Weiss or Boerhaave's? Most patients stop bleeding spontaneously and require no therapy

Mallory-Weiss

True or False Both Mallory-Weiss and Boerhaave's require a surgical evaluation

True

True or False A hernia is defined as the protrusion of any body part through a cavity

True

What are some of the most common types of hernias?

1. Inguinal 2. Femoral 3. Hiatal 4. Umbilical

What are some of the less common hernias?

1. Obturator canal 2. Lumbar (retroperitoneal)

What is the most common type of hernia, accounting for 75-80% of all hernias?

Inguinal

What type of inguinal hernia is where abdominal contents herniate DIRECTLY through hasselbach's triangle?

Direct Hernia

What type if inguinal hernia is where abdominal contents herniate through the inguinal canal ?

Indirect hernia

What is the most common inguinal hernia?

Indirect (R\>L)

What is caused by a patent processus vaginalis, leaving an open communication between the intraperitoneal and the inguinal canal/scrotum?

Indirect inguinal hernia

Passage of contents through the patent processus vaginalis is called a what?

Indirect inguinal hernia

What is a herniation of abdominal contents through the abdominal wall musculature (Hasselbach's Triangle)?

Direct inguinal hernia

What are direct inguinal hernias due to?

Muscular weakness in the hasslebach's triangle

Is a direct inguinal hernia an acquired defect and that does not involve the passage of contents through the inguinal canal?

Yes

What is typically a congenital hernia, may be seen as an “outy belly button", and has an increased prevalence in African American children?

Umbilical hernia

Are acquired umbilical hernias more likely to incarcerate than congenital?

Yes

True or False All hernias have the ability to present with signs and symptoms of Small Bowel Obstruction

True

True or False If strangulation of a hernia occurs the patient may become toxic

True

In males, palpation of the inguinal canal is easily performed by inversion of the scrotal skin and passage of a finger through the external ring, if an indirect hernia is present the examiner should feel what?

A tapping sensation on the tip of the finger

True or False In males, palpation of the inguinal canal is easily performed by inversion of the scrotal skin and passage of a finger through the external ring, if a direct inguinal hernia is present, the hernia will bulge anteriorly, pushing against the side of the finger on examination

True

What is the treatment for an incarcerated hernia that cannot be manually reduced?

Surgical fixation

What is also necessary in the treatment of hernias if strangulation is suspected or shock is present?

Broad-spectrum antibiotics and fluids

What is the disposition for a patient with an acutely irreducible incarcerated hernia?

MEDEVAC for immediate surgical eval/repair

What is a sac-like protrusion of the colonic wall?

Diverticula/diverticulum

If a patient is diagnosed with diverticulosis, it means they have the presence of what in there large intestine?

Diverticula

True or False Diverticular disease is defined as clinically significant and symptomatic diverticulosis due to diverticular bleeding, diverticulitis, segmental colitis associated with diverticula, or symptomatic uncomplicated diverticular disease

True

What is defined as the inflammation of a diverticulum?

Diverticulitis

Most patients with diverticulitis with localized inflammation or infection report mild to moderate aching abdominal pain, usually where?

Lower left quadrant

Diverticular bleeding occurs from the right colon in what percentage of cases?

50-90%

True or False In patients with diverticulitis, stool occult blood is common, but hematochezia is rare

True

Is mild to moderate leukocytosis present in patients with diverticulitis?

Yes

Patients with mild symptoms of diverticulitis and no peritoneal signs may be managed initially as outpatients on a clear liquid diet and what else?

Broad spectrum antibiotics with anaerobic activity Amoxicillin and clavulanate potassium (Augmentin) OR Metronidazole (Flagyl) PLUS either Ciprofloxacin (Cipro) OR trimethoprim-sulfamethoxazole (Bactrim), for 7-10 days or until the patient is afebrile for 3-5 days

Patients with severe diverticulitis (high fevers, leukocytosis, or peritoneal signs) and elderly, immunosuppressed, or patients with serious comorbid disease require what?

Hospitalization

Diverticulitis recurs in what percentage of patients treated with medical management?

10-30%

What is the disposition of a patient with Diverticulitis ?

MEDEVAC

What disease may present with a low grade fever, leukocytosis, LLQ tenderness, and a possible palpable abdominal mass?

Diverticulitis

What is defined as inflammation of the localized of gneralized peritonemum, the lining of the inner wall of the abdomen and cover of the abdominal organs?

Peritonitis

In what form of peritonitis is there inflammation of the peritoneal surface without another intra-abdominal process?

Primary peritonitis

What is primary peritonitis also known as?

Spontaneous Bacterial Peritonitis (SBP)

What form of peritonitis develops as a result of inflammation of another intra-abdominal structure or in association with another intra-abdominal disease process?

Secondary peritonitis

True or False Many different disease processes may lead to the development of an acute secondary peritonitis (acute peritonitis)

True

Can peritonitis be diffuse and involve the entire peritoneum?

Yed

Can peritonitis be diffuse and involve the entire peritoneum?

Yes

Peritonitis is commonly referred to as?

“acute abdomen” or “surgical abdomen”

Peritonitis typically indicates what?

a severe intra-abdominal infection

What are the most common causes of acute peritonitis?

1. perforated appendicitis 2. perforated diverticulitis 3. pancreatitis

Are females presenting with signs of peritonitis pregnant until proven otherwise?

YES

Patients with secondary peritonitis will commonly have unstable vital signs such as what?

1. Fever 2. Tachycardia 3. Hypotension in severe cases

How will a patients abdomen appear with palpation in suspected secondary peritonitis?

board-like abdomen, this is unmistakable and indicated OBVIOUS PERITONITIS

True or False Patients with possible peritonitis DO NOT want to move at all

True

What labs would you get for possible secondary peritonitis?

1. CBC w/ Diff : leukocytosis w/ increased neutrophils 2. UA 3. Blood culture for infection 4. HCG FOR FEMALE PATIENTS

True or False Choice of imaging for peritonitis often depends on the suspected disease process?

True

True or false All patients with suspected peritonitis do not require antibiotics

False ALL patients with suspected peritonitis need antibiotics

Are broad spectrum antibiotics that have gram negative and anaerobic bacterial coverage indicated if the etiology of peritonitis not clear?

Yes

True or False All patients with diffuse peritonitis should have two large bore IVs in the event they decompensate

True

What is the dosage of Morphine you should give a patient with peritonitis?

Morphine 1-10mg IV q 4 Hrs

True or False MEDEVAC is always necessary for diffuse peritonitis or peritonitis of unknown origin

True

What consult would a patient with peritonitis need?

General surgery

What is a retroperitoneal organ that produces enzymes that are released into the duodenum via the common bile duct and produces hormones that are secreted into the vascular system?

Pancreas

The inflammation of the pancreas is defined as what?

Pancreatitis

What form of pancreatitis happens when alcohol causes auto-activation of pancreatic enzymes while still in the pancreas resulting in enzymatic destruction of the pancreas?

Alcoholic pancreatitis

## Footnote Can the passage of gallstones cause pancreatitis?

Yes, they can obstruct the ampulla of vater, causing impaired extrusion of enzymes into the duodenum leading to auto-digestion of pancreas tissue

## Footnote True or False Patients presenting with possible pancreatitis may have a history of cholelithiasis and/or cholecystitis treated with out surgery

True

This is a common presentation of what? 1. abrupt onset epigastric abdominal pain 2. severe abdominal pain made worse with walking and lying down 3. pain relief with sitting upright and leaning forward \* 4. pain typically radiates to back \* 5. mild jaundice is common 6. nausea and vomiting almost always present 7. weakness, fever, anxiety

Pancreatitis

What is the gold standard lab value in the diagnosis of pancreatitis?

Elevated serum Lipase

What can you see in a UA for a patient with possible pancreatitis?

1. Proteinuria 2. Granular casts 3. Glycosuria (10% of cases)

What is the gold standard imaging choice for showing the enlarged pancreas and will demonstrate the severity of pancreatitis?

CT scan

What is the gold standard treatment for uncomplicated pancreatitis?

NPO and aggressive fluid resuscitation

True or False Non-severe acute pancreatitis subsides spontaneously within several days

True

What is a hallmark of therapy in a patient with Pancreatitis?

Fluid resuscitation

What are some medications you can use for pain control with pancreatitis?

1. Ketorolac (Toradol) 15-30mg IV/IM/PO q 6 hrs 2. Morphine 2-8mg IV every 2 hours as needed

What kind of duty does a history of pancreatitis disqualify you from?

Submarine duty

Pancreatitis patient disposition

MEDEVAC MEDEVAC MEDEVAC

What are the two main subcategories of intestinal obstruction?

1. Mechanical obstruction 2. Adynamic Ileus (paralytic ileus)

What kind of intestinal blockage is a physical blockage of the intestinal tract lumen disabling passage of food and bowel contents?

Mechanical obstruction

What kind of intestinal obstruction is not caused by a physical blockage, but rather a dysfunction of the intestinal tracts ability to move bowel contents through its lumen?

Adynamic Ileus (paralytic ileus)

What are the two most common causes of small bowel obstructions in the US?

1. Most common: Adhesions 2. Second most common: Hernias

What are some other much less common causes of small bowel obstructions?

1. Intra-luminal polyps 2. lymphoma 3. adenocarcinoma

True or False Unlike patients with peritonitis/acute abdomen, patients with SBO will typically feel the urge to move, and typically will report a feeling of being unable to find a comfortable position

True

True or False A patient with SBO will have crampy, intermittent abdominal pain

True

An SBO caused by mechanical obstruction may produce what kind of bowel sounds?

High pitched with occasional “rushes”

True or False In patients with a possible paralytic ileus, they will have similar symptoms as a mechanical obstruction but usually will have less intense abdominal pain that is more constant

True

What is the gold standard for imaging for a patient with a small bowel obstruction?

Upright abdominal X-ray

True or False Patient presenting with a mechanical small bowel instructions need IV antibiotics

True

In patients with SBO surgery is likely needed if:

1. Gangrene or necrosis is suspected (WBC\>20,000) 2. Intrinsic mechanical cause of obstruction (carcinoma) 3. Fails conservative therapy

What percentage of patients with a completely obstructed SBO will fail conservative therapy?

60%

Disposition for all patients suspected to have a mechanical small bowel obstruction

MEDEVAC

True or False Almost all large bowel obstructions are caused intrinsically, with the large majority being from adenocarcinoma

True

Patients with a large bowel obstruction tend to present similarly to patients with what kind of small intestine obstruction?

Paralytic ileus