Clinical Correlations

Question 1

Which sx are red flags that will require further elucidation and work up?

Answer 1

Dysphagia, odynophagia, hematemesis, melena, unintentional weight loss, persistent vomiting, constant/severe pain, unexplained iron deficiency anemia, palpable mass, lymphadenopathy, FHx of upper GI cancer

Question 2

What can cause abdominal pain the RUQ?

Answer 2

Cholecystitis, hepatitis, pneumonia, kidney stones

Gallbladder*

Question 3

Which conditions can cause pain in the epigastric region?

Answer 3

Pancreatitis, PUD/GERD

Question 4

What can cause pain in the LUQ?

Answer 4

Gastritis, PUD

Question 5

What can cause pain the RLQ?

Answer 5

Appendicitis

Question 6

What can cause pain in the LLQ?

Answer 6

Diverticulitis

Question 7

What is visceral pain?

Answer 7

Caused by stimulation of the visceral pain fibers
Secondary to distention, stretching or contracting of hollow organs, stretching the capsule of solid organs or organ ischemia
Not localized

Question 8

What is parietal (somatic) pain?

Answer 8

Caused by stimulation of the somatic pain fibers
Secondary to inflammation in the parietal peritoneum
Localized
Aggravated by movement/coughing and alleviated by remaining still

Question 9

What to ask when someone has nausea and vomiting?

Answer 9

Appearance? Blood? Coffee grounds? Food? Feculent?

How often? Projectile?

Question 10

What is oropharyngeal dysphagia?

Answer 10

Trouble initiating swallowing

Associated with neurological, metabolic, structural disorders or infections

Question 11

What are the two types of esophageal dysphagia?

Answer 11

Due to mechanical obstruction or motility disorder

Question 12

What questions are important to ask with esophageal dysphagia?

Answer 12

Solids, liquids or both?
Progressive or not?
Constant vs intermittent?

Question 13

Which labs are used for GI/abdominal work up?

Answer 13

CBC, comprehensive metabolic panel (chem 12), basic metabolic panel (chem 7), urinalysis, pregnancy test
Others: lipase/amylase, Pt/Ptt (liver failure), fractionated bilirubin

Question 14

What is in a CBC with diff?

Answer 14

Percentage and absolute differential counts of specific cell types (PMN, lymph, basophils, eosinophils, monocytes)
Diff = percentages
Regular = counts

Question 15

What is tested in a basic metabolic panel?

Answer 15

Na, K, Cl, CO2 (bicarb), BUN, creatinine, glucose

Question 16

What is tested in a comprehensive metabolic panel?

Answer 16

Albumin:globulin ratio (A:G), albumin, alkaline phosphatase, AST, ALT, total bilirubin, total globulin, total protein

Question 17

What are examples of plain films of the abdomen?

Answer 17

Acute abdominal series and KUB

Question 18

What is an acute abdominal series?

Answer 18

Single view chest XR and a flat upright XR of the abdomen

Good for initial screening but not good for diagnostic

Question 19

What is a KUB?

Answer 19

Single flat plate (supine) XR of the abdomen

Limited diagnostic benefit

Question 20

What is a barium esophpgraphy (barium swallow)?

Answer 20

Differentiate b/w mechanical lesions and motility disorders

More sensitive for detecting subtle esophageal narrowing due to rings, achalasia, and proximal esophageal lesions

Question 21

What is an upper endoscopy (EGD)>

Answer 21

Study of choice for imaging of upper GI tract like heartburn, dysphagia, structural abnormalities
Diagnostic and therapeutic - direct visualization, allows biopsy of mucosal abnormalities or normal appearing mucosa, and allows for dilation of strictures

Question 22

What are colonoscopies used for?

Answer 22

Screening test, lower GI bleeds, undifferentiated LAP

Question 23

What are ultrasounds used for?

Answer 23

Good for imaging fluid filled structures like gallbladder, fast scan for trauma, bladder, kidneys, aorta and vessels, heart
Limited by air and fat

Question 24

What is an endoscopic retrograde cholangiopancreatography (ERCP)?

Answer 24

Invasive way to visualize the hepatobiliary and pancreatic ducts
Can provide intervention: diagnostic and therapeutic techniques

Question 25

What is MRCP used for?

Answer 25

Diagnosing gall stones

Question 26

What is HIDA (hepatobiliary iminodiacetic acid scan)?

Answer 26

Nuclear scan that tests for dysfunctional gall bladder | HIDA + CCK -> check gall bladder ejection fraction, if low then biliary dyskinesia

Question 27

Which imagining technique will give you the most information about abdominal pathology?

Answer 27

CT scan

Question 28

How are GERD, gastritis and PUD similar?

Answer 28

Similar pathophysiology, diagnostic work up and tx

Question 29

Describe GERD

Answer 29

Very common in the western world Classic sx: heartburn (pyrosis) and regurgitation/reflux Diagnosis can often be based on clinical sx alone in pts with classical sx such as heartburn and regurgitation Can perform an upper endoscopy

Question 30

How is GERD treated?

Answer 30

``` Lifestyle modification (weight loss if obese, elevate head of bed, eliminate triggers, avoid alcohol and smoking) Antacids, surface agents, H2 blockers, proton pump inhibitors ```

Question 31

Describe peptic ulcer disease

Answer 31

Very common Two major risk factors: H pylori and NSAIDs Sx: upper abdominal pain, primarily epigastric but can also be in RUQ and LUQ, may be present initially as GI bleed or perforation Most common cause of UGI bleed

Question 32

Describe a gastric ulcer

Answer 32

Located typically in the lesser curvature of the antrum of the stomach Sx: sharp and burning epigastric pain, worsens wihtin 30mins-1.5hour after eating Tx: proton pump inhibitor, eradicate H pylori

Question 33

Describe duodenal ulcers

Answer 33

Located in the proximal duodenum; multiple ulcers or ulcers distal to 2nd portion of duodenum Sx: gnawing epigastric pain; worsens 3-5 hours after eating; may be temporarily relieved by food/eating Tx: proton pump inhibitor, eradicate H pylori

Question 34

Describe H pylori

Answer 34

Most prevalent chronic bacterial disease known Associated with many types of GI pathology including PUD, chronic gastritis, gastric adenocarcinoma, gastric mucosa, associated lymphoid tissue (MALT) lymphoma, and duodenal ulcers*

Question 35

Describe the pathophysiology of H pylori

Answer 35

Bacterial urease hydrolyzes gastric luminal area to form ammonia that helps neutralize gastric acid and form a protective cloud around the organism enabling it to penetrate the gastric mucous layer

Question 36

What are some diagnostic tests for H pylori?

Answer 36

Urea breath test (great first line and generally used to confirm eradication of H pylori) Fecal antigen test (first line; confirms eradication) Have pt stop proton pump inhibitor medication 14 days before fecal and breath tests or high chance of a false negative test

Question 37

What is 90% of the time secondary to UGIB?

Answer 37

Melena (black tarry stools)

Question 38

Hematochezia is usually due to what?

Answer 38

Lower GI bleed | Red blood in stool

Question 39

What is an UGIB?

Answer 39

Any GI bleed originating proximal to ligament of Treitz Esophagus, stomach or duodenum (Can be caused by PUD)

Question 40

What is a LGIB?

Answer 40

Any GI bleed originating distal to the ligament of Treitz | Jejunum, ileum, colon, rectum

Question 41

What is strongly associated with a number of causes of GI bleeding?

Answer 41

Alcohol abuse

Question 42

What are the 3 options for presentation of gall stones (cholelithiasis/cholecystitis)?

Answer 42

Asymptomatic (most often) Classic presentation = biliary colic (episodic to constant RUQ pain, worse after eating greasy foods) Complications of gallstone disease (ex. pancreatitis)

Question 43

Describe pancreatitis

Answer 43

Pathophysiology: inflammatory condition of the pancreas | Risk factors include gallstones, alcohol abuse, hypertriglyceridema, multiple others

Question 44

What is the classic presentation for appendicitis?

Answer 44

RLQ abdominal pain, anorexia, nausea/vomiting, +/- fever Usually starts with visceral pain (vague nonspecific) The pain migrates and becomes localized in the RLQ and ends with somatic pain (sharp and localized) in the RLQ

Question 45

What is the diagnostic work up for appendicitis?

Answer 45

CBC, comprehensive metabolic panel, UA, pregnancy test | Imaging on case by case basis

Question 46

Describe diverticulitis/diverticulosis

Answer 46

Diverticulosis: prevalence is age dependent (age 60) (presence of diverticulum) Diverticulitis: develops after diverticulosis (erosion of diverticular wall) Abdominal pain which Localizes to the LLQ, nausea/vomiting, +/- fever

Question 47

Describe achalasia (BP)*

Answer 47

Uncommon Results from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall, leads to failure of relaxation of the lower esophageal sphincter accompanied by a loss of peristalsis in the distal esophagus Primary or secondary achalasia

Question 48

Describe primary achalasia

Answer 48

Loss of NO producing inhibitory neurons in the myenteric plexus Progressive dysphagia for solids and foods; regurgitation of undigested food Birds beak with barium swallow study Esophageal manometry confirms diagnosis (complete absence of normal peristalsis and incomplete lower esophageal sphincter (ES) relaxation (and LES stays closed) with swallowing)

Question 49

What is Chagas’ disease (secondary achalasia)?*

Answer 49

Esophageal dysfunction indistinguishable from primary achalasia Caused by the parasite Trypansoma Cruzi (protozoan disease) Causes other systemic sx (causes swelling of the site/chagoma and a romana sign)

Question 50

Describe Zollinger-Ellison syndrome (ZES)**

Answer 50

Very uncommon Caused by secretion of gastrin by duodenal or pancreatic NE tumors (gastrinomas) Consider when intractable ulcer/recurrent ulcer disease/severe ulcer disease, ulcers in atypical locations, ulcer associated with diarrhea, steatorrhea, weight loss, nausea/vomiting Elevated fasting gastrin level and positive secretin stimulation test

Question 51

Describe the parasympathetic levels of viscerosomatics

Answer 51

Upper portion: esophagus through transverse colon (OA, AA, vagus N) Lower portion: descending colon, sigmoid rectum (S2-4 (pelvic Splanchnic N))

Question 52

Describe the sympathetic levels of viscerosomatics

Answer 52

``` Appendix T12 Esophagus T2-8 Stomach T5-9 Liver T6-9 Gallbladder T6-9 SI T5-9; T9-12 Colon T9-L2 Pancreas T5-11 ```