deck_10249239 Flashcards
1
Q
Achalasia
A
•Esophageal motility disorder (neuromuscular)
•Outflow obstruction d/t inadequate LES relaxation
2
Q
Achalasia S/S
A
Dysphagia
Heartburn
Chest pain
3
Q
Achalasia Diagnosis
A
Esophagram reveals “bird’s beak” appearance on EGD manometry
4
Q
Achalasia Type 1
A
Classic minimal esophageal pressure| Treatment = myotomy
5
Q
Achalasia Type 2
A
Entire esophagus pressurization| Best outcome
6
Q
Achalasia Type 3
A
Esophageal spasm w/ premature contractions| Worst outcome
7
Q
Achalasia Treatment
A
Palliative Relieve obstruction (does not correct lacking peristalsis)
8
Q
Distal Esophageal Spasm
A
Diffuse esophageal spasm
Seen in elderly patients
ANS dysfunction
9
Q
Distal Esophageal Spasm Diagnosis
A
Esophagram reveals “corkscrew” or “rosary bead” esophagus
10
Q
Distal Esophageal Spasm Treatment
A
Pain mimics angina| Responds to Nitroglycerin
11
Q
GERD
A
Gastroesophageal reflux disease
LES incompetence
12
Q
GERD S/S
A
Heartburn
Regurgitation
Less common include dysphagia & chest pain
13
Q
GERD Complications
A
•Chronic peptic esophagitis
•Strictures
•Barrett’s esophagus
metaplasia associated w/ adenocarcinoma
•Reflux into pharynx, larynx, & tracheobronchial tree
•Apsiration → pulmonary fibrosis or chronic asthma•
14
Q
GERD Treatment
A
Lifestyle modification:
•avoid foods that impair LES tone (fat, alcohol, peppermint, chocolate) or are acidic
Pharmacological: PPI ↑pH & allows esophagus to heal- H2 antagonists
Surgical: Nissen fundoplication
15
Q
↑aspiration risk associated w/ ___ mL & ___ pH
A
25mL or 0.4mL/kg| pH <2.5
16
Q
Esophageal Diverticula
A
Esophageal structural disorder w/ outpouchings
Most common locations: Pharyngoesophageal (Zenker’s diverticulum)- Mid-esophageal- Epi-phrenic (supradiaphragmatic)
17
Q
Hiatal Hernia
A
Stomach herniates into thoracic cavity via diaphragm esophageal hiatus
Asymptomatic
18
Q
Esophageal Tumors
A
Progressive dysphagia to solid food & weight loss
Poor survival rate (lymph node metastasis)
Adenocarcinoma
Mortality rate about 50%
19
Q
Esophageal Tumor Treatment
A
Esophagectomy (curative or palliative)| Thoracic epidural
20
Q
Esophageal Tumors Complications
A
ARDs
Malnourishment
injury risk
21
Q
Peptic Ulcer Disease
A
Epigastric pain exacerbated by fasting & improved by eating
22
Q
H. Pylori
A
Associated w/ PUD| Induces acid secretion via pro-inflammatory cytokines
23
Q
Gastric Ulcer
A
1/3 duodenal
Benign ulcer
Most common cause = NSAID use
24
Q
Stress Gastritis
A
Associated w/ shock, sepsis, respiratory failure, burns, hemorrhage, massive transfusions, or head injury
•Gastric bleeding occurs when coagulopathy, thrombocytopenia, INR >1.5, and aPTT >2x normal
25
Zollinger-Ellison Syndrome
•Gastroduodenal & intestinal ulceration d/t increased gastrin secretion
•Non-beta islet cell pancreatic tumor
•Primarily in men 30-50yo
Associated w/ MEN1```
26
Zollinger-Ellison syndrome (ZES)
S/S
Abdominal pain
Peptic ulceration
Diarrhea
GERD
27
ZES Treatment
Obtain fasting gastrin levels
Increasing PPIs dosages
Surgical- tumor resection
28
PUD Complications
•Bleeding- Hemorrhage = leading cause of death
•Perforation(risk 10%)- Severe epigastric pain caused by highly acidic gastric contents in peritoneum
•Obstruction- Gastric outlet obstruction-
Cause = edema & inflammation in the pyloric channel & duodenum 1st portion
29
PUD Treatment
Antacids
H receptor antagonists
Proton pump inhibitors Prostaglandin analogues
Cytoprotective agents
Anticholinergics
30
Antacids
Aluminum hydroxide
Magnesium hydroxide (avoid in chronic renal failure patients → hypermagnesemia & neurotoxicity)
TUMS = calcium carbonate (milk-alkali syndrome hypercalcemia, hyperphosphatemia, & renal calculi)HCO3 → metabolic alkalosis
31
H2 Receptor Antagonists
Cimetidine, Ranitidine, Famotidine, & Nizatidin
•inhibit basal & stimulated gastric acid secretion
•Cimetidine & Ranitidine bind to CYP450
32
PPIs
Proton pump inhibitors
Omaprazole, Pantoprazole, Esomeprazole, Lansoprazole, & Rabeprazole
•They inhibit hydrogen-potassium ATPase pump
The most potent drug available
•Inhibit ALL gastric acid secretion phases
•Interfere w/ Ketoconazole, Ampicillin, Iron, Digoxin, & Diazepam absorption
•Omaprazole & Iansoprazole inhibit CYP450
33
Prostaglandin Analogues
Misoprostol
•Is the onlyFDA approved •Contraindicated in pregnancy
•Enhances mucosal HCO3 secretion, stimulate mucosal blood flow, & ↓mucosal cell turnover
•Most common side effect = diarrhea
34
Cytoprotective Agents
Sucralfate
•provides physiochemical barrier, enhances defense & repair
•Most common side effect = diarrhea
Colloidal bismuth (Pepto) MOA unknown & neurotoxicity risk
35
Anticholinergics
•Inhibit muscarinic receptors activation in parietal cells
•Negative side effects
•Not routinely used
36
Post-Gastrectomy| Dumping Syndrome
•Hyperosmolar gastric contents enter into proximal small bowel
•Fluid shifts into small bowel lumen
•Results in plasma volume contraction & acute intestinal distention
37
Early Dumping Syndrome
Symptoms 15-30min after meal (nausea, epigastric discomfort, diaphoresis, cramps, diarrhea, tachycardia, palpitations, dizziness, syncope)
38
Late Dumping Syndrome
Symptoms 1-3hrs after meal| Vasomotor symptoms 2° to hypoglycemia d/t excessive insulin release
39
Dumping Syndrome Treatment
•Dietary modifications (fewer simple sugars) & less fluid consumption during meals
•Octreotide therapy - admin SQ before meal or depot injection monthly- Inhibit release vasoactive peptides from gut, ↓peak plasma levels, & slow intestinal transit
40
Post-Gastrectomy| Alkaline Reflux Gastritis
Clinical triad:- Post-prandial epigastric pain associated w/ N/V- Evidence bile reflux into stomach- Histologic evidence gastritis
•Treatment-divert intestinal contents from contact w/ gastric mucosa (diversion)
41
Inflammatory Bowel Disease
Ulcerative colitis| Crohn's disease
42
Ulcerative Colitis
IBD involves rectum & extends proximally to involve part or all colon
Mucosal disease
43
Ulcerative Colitis s/s
•Diarrhea
•rectal bleeding
•tenesmus (feeling incomplete BM)
•passage mucus
•Cramps
•Anorexia
•N/V
•fever
•weight loss
•Low-serum albumin & leukocytosis when severely ill
44
Ulcerative Colitis (UC) Complications
•Hemicolectomy when patient requires 6-8 units PRBCs w/in 24-48hrs
•Toxic megacolon - dilated transverse colon w/ loss •hallucinations triggered by electrolyte abnormalities & narcotics
•Perforations → peritonitis
•Obstruction d/t benign stricture formation
•Total proctocolectomy = curative
45
Crohn's Disease
•IBD with acute or chronic bowel inflammation
•Can be Penetrating-fistulous or obstructing pattern
•Most common site = terminal ileum
46
Crohn's S/S
Ileocolitis
•Recurrent episodes RLQ pain & diarrhea and fever indicates intraabdominal abscess formation
•Weight loss d/t anorexia & diarrhea
•Loss of digestive & absorptive surface → megaloblastic anemia & neurologic symptoms
•Hypoalbumenia,
•hypocalcemia, •hypomagnesemia, •coagulopathy,
•hyperoxaluria
•Vit. D deficiency
•hypocalcemia
glucocorticoid use
•B12 malabsorption → megaloblastic anemia & neurologic symptoms
•Diarrhea d/t bacterial overgrowth in obstruction areas, •fistulas,
•bile acid malabsorption,
•DecreasedH2O reabsorption
•1/3 patients at least 1 symptoms outside intestines (arthritis or renal calculi)
47
IBD Surgical Treatment
•NOT curative
•Severe IBD → total proctolectomy & end ileostomy
•Most common surgery = small intestine resection
•Removal > 2/3 small intestine → short bowel syndrome & need parenteral nutrition
48
IBD Crohn's Surgical Complications
Hemorrhage
Sepsis
Neural injury
49
IBD Medical Treatment
•5-ASA (Mesalamine) to treat mild to moderate IBD-
•Antibacterial & anti-inflammatoryGlucocorticoids moderate to severe Crohn's only to induce remission & then taper (not maintenance)
•Antibiotics "pouchitis" (Ciprofloxacin & Metronidazole)Azathioprine, Methotrexate, Cyclosporine, & TacrolimusInfliximab & Natalizumab
50
Carcinoid Tumors
•Tumors originate in GI tract
1/4 first found in the lung
•Secrete GI peptides/vasoactive substances
•Often found incidentally (suspected appendicitis)
•Sometimes contain GI peptides •Midgut more likely to release substances than foregut carcinoids
51
Carcinoid Syndrome
Approximately 10%| Serotonin & vasoactive substances released into systemic circulation
52
Carcinoid Syndrome S/S
•Sudden onset flushing & diarrhea
•Flushing d/t histamine (admin H1 & H2 blockers)
•Hypo or hypertension
•Bronchoconstriction
manifestation
53
Carcinoid Syndrome| Precipitating Factors
Stress, alcohol, exercise, certain foods, & drugs such as catecholamines, pentagastrin, & SSRIs/SNRIs
54
Carcinoid Syndrome Diagnosis
Measure urinary or plasma serotonin
Serotonin metabolites present in urine1° metabolite: 5-HIAA (5-hydroxyindoleacetic acid)
55
Carcinoid Crisis
•Intense flushing
•Diarrhea
•Abdominal pain
•Tachycardia
•Hypo or hypertension
Causes include stress, chemo, or biopsy
Avoid using Succinylcholine, Miva/Atracurium, Epi/NE, Dopamine, Isoproterenol, or Thiopental```
56
Carcinoid Tumor Treatment
Avoid flushingSerotonin receptor antagonists5HTZ or 5HT3 antagonistsH1/H2 antagonistsSomatostatin analoguesBronchoconstriction resistant to treatment β agonists worsen effects d/t mediator releaseTACE - trans-arterial chemoembolization w/ or w/o chemotherapy
57
Acute Pancreatitis
•Pancreas inflammatory disease caused by digestive enzyme
•Autodigestion prevented by enzymes being packaged in precursor form, protease inhibitors synthesis, & low calcium concentrations ↓trypsin activity
58
Acute Pancreatitis| Causes
•Gallstones
•ETOH abuse
•Hypercalcemia (hyperparathyroidism & AIDs)
•Post operative pancreatitis after CABG & ERCP
59
Acute Pancreatitis| S/S
•Excruciating mid-epigastric pain that radiate to the back
Sitting/leaning forward ↓pain •Abdominal distension w/ ileus
•Dyspnea indicates pleural effusion or ascites
•Low grade fever
•Hypotension& tachycardia
•Shock d/t hypovolemia (blood & plasma exudation into retroperitoneal space, kinins release, & systemic pancreatic enzymes effects)↑serum amylase & lipase
Diagnosis: CT w/ contrast
60
Acute Pancreatitis| Treatment
•ERCP (when caused by gallstones)
•Aggressive IVF admin
•Colloid replacement
•NPO to rest pancreas- NJ tube feeding NG tube
•LISStent placement
•Opiods
•extraction
•Sphincterotomy
61
Acute Pancreatitis| Differential Diagnoses
•Perforated duodenal ulcer
•Acute cholecystitis
•Mesenteric ischemia
•Bowel obstruction
•Acute MI
•Pneumonia
62
Acute Pancreatitis| Complications
•Shock
•hypoxemia
•ARDS
•GI hemorrhage & coagulation •defects
•DIC
•infection or abscess formation
63
Chronic Pancreatitis
•Chronic inflammation leads to irreversible damage to pancreas
•Loss of exocrine & endocrine function
64
Chronic Pancreatitis| Causes
•Chronic ETOH abuse
w/ high protein diet
•Genetic defects (idiopathic chronic pancreatitis)
•Occurs with CF & hyperparathyroidism
65
Chronic Pancreatitis| Diagnosis
•History chronic ETOH abuse + pancreatic calcifications
•Thin or emaciated
•maldigestion proteins & fats
•Normal serum amylase
•U/S reveals enlarged pancreas or pseudocyst
•ERCP most sensitive imaging test
66
Chronic Pancreatitis| S/S
•Epigastric pain that radiates to back
•Frequent after eating
•painless steatorrhea
•Diabetes when 90% exocrine fx is lost
67
Chronic Pancreatitis| Treatment
•Manage pain, malabsorption, & diabetes
•Opioids
•Celiac plexus blockade
•Pancreatic jejunostomy internal surgical drainage procedure
•Endoscopic stent placement & remove stones
•Enzyme supplements to help fat & protein absorption insulin replacement/therapy
68
Upper GI Bleed
Most common
Due to peptic ulcer disease
Mortality >30% elderly, esophageal varices, cancer, & hospitalized patients
#1 cause of death MODS rather than hemorrhage
69
Upper GI Bleed| Diagnosis
•Upper endoscopy after hemodynamic stabilization
•Cardiopulmonary concerns d/t blood & gastric content aspiration risk
•Prefer ETT (secured airway
70
Upper GI Bleed| S/S
•Hypotension & tachycardia
•Orthostatic hypotension
•Melina stool indicated bleeding ABOVE the cecum
•↑BUN
71
Upper GI Bleed| Treatment
•Endoscopic coagulation - perforation risk
•Epi injection
•Endoscopic ligation (bleeding varices)
•Trans-jugular intrahepatic portosystemic shunt (TIPS) esophageal varices resistance to treatment → worsen encephalopathy
•Mechanical balloon tamponade via Blakemore-Sengstaken tube
•Refractory GI bleeding → oversew ulcer or perform gastrectomy
72
Lower GI Bleed
Usually from diverticulosis or tumor| Common in older patients
73
Lower GI Bleed| Diagnosis
Sigmoidoscopy to exclude anorectal lesions| Colonoscopy
74
Lower GI Bleed| S/S
Bright red blood & clots via the rectum
75
Lower GI Bleed| Treatment
Angiography embolic therapy| Surgical intervention required about 15%
76
Lower GI Bleed
•Usually from diverticulosis or tumor
•Common in older patients
77
Lower GI Bleed| Diagnosis
•Sigmoidoscopy to exclude anorectal lesions
•Colonoscopy
78
Lower GI Bleed| S/S
Bright red blood & clots via the rectum
79
Lower GI Bleed| Treatment
•Angiography embolic therapy
•Surgical intervention required about 15%
80
Adynamic Ileus
•Formerly known as acute colonic pseudo-obstruction
•Massive dilation w/o mechanical obstruction
•Loss of effective colonic peristalsis & subsequent colon distention
81
Adynamic Ileus| Causes
```Seriously ill hospitalized patients- Electrolyte disorders- Immobile- Narcotic/ anticholinergic medications- Surgical patientsExcessive SNS & lack PSNS input```
82
Adynamic Ileus| Diagnosis
CXR proximal colon dilation & decompressed distal colon w/ air in rectosigmoid region
83
Adynamic Ileus| Treatment
•Correct electrolyte abnormalities
•Avoid narcotics & anticholinergics
•Mobilization tap water enemas
•NG suction
Conservative treatment usually takes 2 days
•Neostigmine IV (monitor bradycardia)
•repetitive colonoscopy, and/or cecostomy placement
If untreated:→ R colon & cecum ischemia
