Clinical questions - Gastroenterology Flashcards
Distinguishing between upper and lower GI bleeds
UGI is typically melenic stools
LGI is typically red blood or hematochezia
Ligament of Treitz is the landmark dividing upper and lower
Most important aspect of managing an acute, large volume GI bleed
IVF resuscitation
Hypotension surpasses all other findings - you have to perfuse the body
HBsAg -
HBsAb -
HBcAB +
HBeAg -
Window period
HBsAg +
HBsAb -
HBcAB +
HBeAg +
Acute disease
HBsAg -
HBsAb +
HBcAB +
HBeAg -
Recovered
HBsAg -
HBsAb +
HBcAB -
HBeAg -
Vaccinated
Ulcerative colitis (presentation, lab markers, endoscopy findings, treatment)
Presentation: intermittently bloody diarrhea with colicky abdominal pain and fatigue
Labs: pANCA positive
Scope: continuous circumferential inflammation of the rectum that may include more proximal colon
Treatment:
Mild/all patients: 5-ASA (mesalamine) can be given orally or suppositories or enemas
More severe disease:
- Steroids
- Immunosuppressants: cyclosporine, azathioprine, 6-mercaptopurine
- Anti-TNFalpha durgs: infliximab
Colectomy is curative
Cause of diarrhea in a patient with HIV and CD4 less than 100
Cryptosporidium
Cause of diarrhea in a patient with vomiting and diarrhea after eating reheated Chinese fried rice
Bacillus cereus
Cause of diarrhea in a patient with vomiting and diarrhea after eating raw oysters
Vibrio parahaemolyticus
Cause of diarrhea in a patient with diarrhea beginning after backpacking in the mounts
Giardia lamblia
Cause of diarrhea in a patient with recent treatment for UTI
C. diff
Type of hepatitis with AST 2 times as high as ALT
Alcohol hepatitis
In general, causes of direct vs indirect hyperbilirubinemia
Direct (conjugated) bilirubin is elevated in hepatobiliary disease
Indirect (unconjugated) bilirubin is elevated in hemolysis
Crohn disease (presentation, lab markers, endoscopy, treatment)
Colicky abdominal pain, occasional low grade fevers
Lab: ASCA (Anti-Saccharomyces cerevisiae antibodies) positive (ANCAs negative)
Scope: cobblestoning and skip lesions
Path: transmural inflammation, non-caseating granulomas
Treatment: 5-ASA Steroids Immunosuppressants Anti-TNF alpha drugs
Colectomy no curative in Crohn dz
Irritable bowel syndrome
Intermittent abdominal bloating and crampy lower abdominal pain without nausea or vomiting; alternating between diarrhea and constipation with defecation often relieving the abdominal pain. No blood or mucus in stools
Tx: Avoid gas producing foods Diet low in fermentable short chain saccharides (lactose, fructose) GF diet High fiber diet Exercise
Celiac disease
Chronic diarrhea - steatorrhea
Occasional nausea/vomiting and abdominal pain
Lab markers: anti-endomysial Ab and anti-tissue transglutaminase Ab positive
GF diet: “BROW” - barley, rye, oats (often contaminated), wheat
Hereditary Hemochromatosis
AR - increased Fe absorption
Presentation: pruritis, jaundice, fatigue, infertility, joint pain, fat malabsorption
Advanced disease: skin hyperpigmentation, DM, cirrhosis
-“Bronze diabetes”
Labs: elevated Fe, ferritin, transferrin, %sat; decreased TIBC
Dx: Liver biopsy
Most common - HFE gene mutation
Tx: phlebotomy
Criteria to use ppx against stress ulcers in the ICU
Coagulopathy intubation/ventillation > 48 hrs GI ulceration/bleeding within 1 yr Head trauma Spinal cord trauma burn injury
2 or more of the following: Sepsis ICU > 1 week Occult GI bleed 6 or more days Glucocorticoid tx
What infectious risk is associated with PPIs and H2 blockers
C diff risk increased
Acute pancreatitis: presentation, an Initial lab testing, an Initial lab testing, management
Presentation: epigastric pain, nausea, vomiting, anorexia
Exam: epigastric tenderness without guarding, may have ecchymosis at bilateral flanks (Grey-turner sign) or at umbilicus ( Cullen sign)
Lab: elevated serum lipase
Management: Admit +/- ICU Monitor for hemodynamic instability and organ failure Aggressive hydration NPO Pain control (morphine) Established underlying cause
If worsening, CT A/P to r/o pseudocyst
Common causes of pancreatitis
Most common - gallstone
Alcohol abuse
Medications
Elevated triglycerides
Causes of cirrhosis and portal vein hypertension
Alcohol abuse Chronic hepatitis B or C Fatty liver disease Hemachromatosis Chronic biliary obstruction Chronic cholestasis
Exam findings consistent with cirrhosis
Jaundice, spider angiomata, gynecomastia, abdominal distention with shifting dullness and a fluid wave
Lab testing to determine cause of ascitic fluid
Serum albumin compared with ascitic fluid albumin
Calculate SAAG
> or = 1.1 - cirrhosis, CHF, budd chiari (portal vein thrombosis)
less than 1.1 - pancreatitis, chronic nephrotic syndrome (losing protein)
Achalasia - presentation, diagnosis and management
Presentation:
Progressive difficulty swallowing to both liquids and solids, with a sensation of sticking in chest
Barium esophageal shows narrowing of the esophagogastric junction - “bird’s beak” appearance, with a dilation of the proximal esophagus
Confirm diagnosis with esophageal manometry - high LES pressure, lack peristaltic distally
Tx:
Esophageal dilation
Surgical myotomy
Botox to LES
Medical tx: nifedipine, nitrates
Primary sclerosing cholangitis - cause, presentation, diagnosis, tx, risk
Inflammation and stricturing of the biliary tree, leading to cholestasis, jaundice, and pruritic
- Common in young men, hx of IBD esp. UC
Lab: elevated direct bill and ALP
pANCA strongly positive (30-80:1)
ERCP with beads on a string
Tx:
No proven medical treatment
ERCP for a dominant stricture - dilate
Liver transplant for advanced liver disease and cirrhosis
Risk: cholangiocarcinoma, gallbladder cancer, hepatocellular carcinoma (2/2 cirrhosis)
gastritis management
Get EGD to r/o gastric CA with bx
Tx:
PPI
triple antibiotic tx if H. pylori cause
Limit use of NSAIDs, tobacco, etoh
alpha 1 antitrypsin deficiency
Increased elastase activity leads to lung disease - panacinar emphysema - obstructive pattern on PFTs
Mutated protein accumulates in the liver which is toxic to the cells -> liver disease - early onset cirrhosis
Tx:
- infusion of alpha 1 antitrypisn (A1AT)
- Lung transplant
- liver transplant is curative as it makes normal alpha1 antitrypsin
Treatment for c. diff
Most common initial therapy is metronidazole
If initial therapy fails or recurrent diarrhea or more severe:
- PO Vanc
- Fidoxamicin
- rifaximin
- fecal bacteriotherapy - enema
Primary biliary cirrhosis - presentation, exam findings, diagnosis, management
Presents with generalized pruritic, fatigue, RUQ pain
Associated with other autoimmune disorders, middle aged females - 90%
Exam:
mild hyperpigmentation of skin without jaundice or scleral icterus (unless advanced then + jaundice)
Liver moderately enlarged - contender
Labs: Mild elevated AST, ALT markedly elevated ALP normal t bili ANA (antinuclear) and AMA (antimitochondrial) Ab positive
Confirm dx: liver bx
Tx:
- Ursodeoxycholic acid
- cholestyramine for pruritis
- ultimately transplant
Treatment of GERD
mild - lifestyle modifications: Weight loss, elevate head of bed, stop smoking, limit alcohol, caffeine, chocolate, avoid eating 3 to 4 hours before bed
next option: H2 blocker or PPI
Wilson’s disease
Effects liver, brain, eyes
Exam:
Kayser Fleischer rings on slip lamp exam
Labs:
- slightly elevated AST, ALT
- normal t bili, ALP
- ferritin normal
- Serum ceruloplasmin low or normal -> low serum copper
- high 24 hr urine copper
Dx:
liver bx
genetic testing - multiple mutations
Tx:
Chelation - penicillamine or trientine
