Diseases of the GI System Flashcards
Gastroesophageal Reflux
Vague sx difficult to distinguish from other causes of epigastric pain
pH monitoring dx reflux and correlate to sx
Complain of retrosternal burning/heartburn
Brought on by bending over, tight clothes or lying flat in bed
Improved w/ OTC antacids or H2 blockers
Concern of peptic esophagitis and Barrett esophagus
Endoscope w/ biopsy to r/o Barrett
Surgery if cannot control w/ meds- Nissan fundoplication
If severe dysplasia, resection
Diffuse esophageal spasm
Crushing pain with swallowing
Uncoordinated massive contraction
Seen as corkscrew esophagus on manometry
Achalasia
More common in women
Dysphagia worse for liquids
Must sit straight up and wait for liquids to get past sphincter
Occasional regurgitation of undigested food
Xray shows megaesophagus; manometry dx
Tx- balloon dilation by endoscope
Esophageal cancer
Progressive dysphagia- meat, then other solids, then soft food, liquids, then finally saliva
Significant weight loss always seen
Squamous cell carcinoma seen in men who smoke and drink- higher incidence in blacks
Adenocarcinoma w/ hx of GERD
Dx w/ endoscopy and biopsy after barium study
CT determines surgery- usually only palliative
Mallory-Weiss Tear
Prolonged, forceful vomiting
Bright red blood
Endoscope dx and allows photocoagulation
Boerhaave syndrome
Prolonged forceful vomiting leading to esophageal perforation
Continuous severe wrenching and low sternal pain of sudden onset
Followed by fever, leukocytosis, and looks sick
Contrast swallow (gastrografin then barium if neg)
Emergency surgery
Instrument perforation of esophagus
Most common cause of perforation
Continuous severe wrenching and low sternal pain of sudden onset
Followed by fever, leukocytosis, and looks sick
May have emphysema in lower neck
Contrast studies and prompt repair
Gastric adenocarcinoma
More common in elderly Weight loss, anorexia, vague epigastric distress, and early satiety Occasional hematemasis Endoscopy and biopsy dx CT determines surgery- best tx
Gastric lymphoma
Now as common as adenocarcinoma
Weight loss, anorexia, vague epigastric distress, and early satiety
Occasional hematemasis
Endoscopy and biopsy dx
Tx: chemo or radiation, surgery if perforation
Low grade MALTOMA can be reversed by eradicating H. pylori
Mechanical intestinal obstruction
Typically caused by adhesions from prior abdominal surgery
Colicky abdominal pain, protracted vomiting, progressive distention, and no gas or poop
Early, high pitched BS coincides with pain
Xray shows distended loops w/ air-fluid levels
Tx: NPO, NG suction, IV fluids
Surgery if no response in 24h (complete) or days if partial
Strangulated obstruction
Compromised blood supply
Starts as any SBO
Eventually fever, leukocytosis, constant pain, and peritoneal irritation And ultimately sepsis
Emergency surgery required
Mechanical intestinal obstruction from incarcerated hernia
Compromised blood supply
Starts as any SBO
Eventually fever, leukocytosis, constant pain, and peritoneal irritation And ultimately sepsis
Physical exam finds irreducible hernia
Surgical repair of hernia: emergent if cannot reduce, elective if manual reduction successful
Carcinoid Syndrome
Small bowel carcinoid tumor that mets to liver
Flush face, diarrhea, wheezing and RT side valve damage (prominent JVP)
Dx: 24h urine for 5-hydroxyindoleacetic acid
Classic acute appendicitis
Anorexia, vague periumbilical pain that becomes severe, constant, in RLQ
Tenderness, guarding, rebound in RLQ and below umbilicus
Modest fever, leukocytosis, neutrophila & bands
If doubtful, CT to confirm
Emergency appendectomy
Cancer of RT colon
Typically w/ unexplained anemia in elderly
Stool 4+ occult blood
Dx: colonoscopy w/ biopsy
Right hemicolectomy to treat
Cancer of LT colon
Bloody bowel movements w/ blood coating stool
Constipation w/ change in stool caliber
Flex sig and biopsy to dx w/ full colonoscopy to rule out synchronous second primary
Pre-op chemo/radiation to shrink
Surgery to tx
Colonic polyps
May be premalignant
familial polyposis>familial multiple inflammatory polyps>villous adenoma>adenomatous polyp
Not premalignant: juvenile polyps, Peutz-Jeghers, isolated inflammatory, and hyperplastic
Chronic ulcerative colitis
Managed medically
Surgical intervention after 20yrs (cancer risk), nutritional interference, high dose steroids, or toxic megacolon
Toxic megacolon: fever, leukocytosis, epigastric tenderness, massively distended transverse colon
Surgical removal of affected colon including all rectal mucosa
Pseudomembraneous enterocolitis
Over growth of C. diff in pt on antibiotics
Clindamycin historically, cephalosporins common
Profuse watery diarrhea, crampy abdominal pain, fever, and leukcytosis
ID toxin in stool
Cultures take too long and pseudomembranes not always seen on endoscopy
Antibiotics stopped, no antidiarrheals
Tx w/ Metronidazole or Vancomycisn
Virulent form unresponsive to tx w/ WBC >50000 and serum lactate >5 req colectomy
Hemorrhoids
Internal bleed; prolapsed can hurt and itch
External hurt and can thrombose
Internal can have band ligation
External conservative, then surgery
Anal Fissure
Young women
Pain pooping w/ blood covering stools
Avoid BM and get constipated b/c fear of pain
Refuse physical exam (may need EUA)
Caused by tight internal sphincter
Tx w/ stool softeners, topical nitroglycerin, botulinum toxin, calcium channel blockers, forced dilations, or lateral internal sphincterotomy
CCBs most successful
Crohn Disease
Starts as fissure, fistula, or ulcer but fails to heal
Suspected if fails to improve with surgery
Fistula could be drained with setons
Ramicade helps healing
Ishiorectal abscess
Very common
Febrile w exquisite perirectal pain- can’t sit or shit
Red, pain, hot, swollen b/t anus and ischial tuberocity
I&D to tx
Cancer should be ruled out
Severe diabetics can get necrotizing soft tissue infection
Fistula in ano
Develops after draining ischiorectal abscess
Epithelial migration from anal crypts and perineal skin forms permanent tract.
Fecal soiling and perineal discomfort
Openings lateral to anus and cordlike tract
Discharge may be expressed
R/o necrotic and draining tumor
Tx w fistulotomy
Squamous cell carcinoma of anus
More common in HIV+ and anoreceptive sex
Fungating mass out of anus
Metastatic inguinal nodes often present
Biopsy dx
Tx: Nigro chemoradiation followed by surgery if residual tumor
Currently 5wk chemo-radiation 90% successful so surgery rarely needed
GI bleed statistics
3/4 from upper GI
1/4 rectum or colon
Very few from jejunum and ileum
Colon bleed: angiodysplasia, polyps, diverticulosis, or cancer
Young people usually upper; older can be any
Always upper if vomiting blood
Vomiting blood
Always upper GI bleed
Also if blood in NG suction
Upper GI endoscopy
Look at mouth and nose
Melena
Black, tarry stools
Indicated digested blood from upper GI
Start workup with upper GI endoscopy
Red blood per rectum
Could be from anywhere in GI
Upper if passes too fast for digestion
Put in NG tube: if bloody then upper GI;
if white fluid then may still be duodenum;
if green then upper GI is clear must be lower
Active bleeding per rectum when upper GI cleared
Exclude hemorrhoids w anoscopy
Colonoscopy not helpful if active b/c obscured
If >2ml/min angiogram
If <0.5ml/min wait for it to stop then colonoscpy
In between: tagged red cell study shows puddling and an area where angio can be done,
Tagged red cell is a slow test & may stop bleeding before done; can allow blind hemicolectomy
If bleeding not found in colon, capsule endoscopy to see small bowel
Patient w history of blood per rectum but not actively bleeding
Start workup w/ upper endoscopy if young
Both ends if old
Blood per rectum in child
Should be from Meckel diverticulum
Start workup w/ technetium scan looking for ectopic gastric mucosa
Massive upper GI bleeding in stressed multi trauma
Likely stress ulcer
Endoscopy to confirm
Angiographic embolization best therapy
Avoid by maintaining gastric pH above 4
Acute abdominal pain caused by perforation
Sudden onset constant, generalized, severe pain
Reluctant to move, protective of abdomen
Generalized peritoneal signs except in old/sick
Tenderness, guarding, rebound, silent abdomen
Free air under diaphragm in upright xray
Perforated peptic ulcer most common example
Urgent surgery needed
Acute abdomen caused by obstruction of narrow duct
Ureter, cystic duct, common duct Sudden onset colicky pain Patient moves constantly trying to get comfortable Location/radiation according to source Few physical findings
Acute abdomen caused by inflammatory process
Gradual onset/slow build up over 6-12hrs
Constant pain starting as ill defined then localizing
Often has typical radiation patterns
Physical findings of peritoneal irritation in affected area (except pancreatitis)
Systemic signs: fever & leukocytosis
Ischemic process in bowel
Only thing with sever abdominal pain and blood in the lumen of the gut
Primary peritonitis
Should be suspected in child w/ nephrosis and ascites or adult with ascites and equivocal findings
Cultures of ascitic fluid yields single organism
Treat with antibiotics no surgery
Generalized acute abdomen treatment
Exploratory laparotomy; no need for specific diagnosis
r/o myocardial ischemia w/ EKG
r/o lower lobe pneumonia w/ CXR
r/o PE in immobilized patient
r/o pancreatitis w/ amylase/lipase b/c no surgery
r/o urinary stones w/ CT b/c no surgery
Acute pancreatitis
Suspected in alcoholic w/ upper acute abdomen
Onset over several hrs
Constant epigastric pain radiating thru to back
Nausea, vomiting, retching
Dx w/ serum/urine amylase or lipase
CT if not clear
Tx: NPO, NG suction, IV fluids
Biliary tract disease
Fat female, 40s fertile w/ RUQ pain
Ureteral stones
Sudden onset flank pain radiating to inner thigh and scrotum/labia
Sometimes w/ urinary sx- urgency/frequency
CT scan best test
Acute diverticulitis
One of few inflammatory processes causing acute abdominal pain in LLQ
Middle age or older
Fever, leukocytosis, peritoneal irritation in LLQ
CT is diagnositic
Start NPO, IV fluids, antibiotics- most cool down
Emergency surgery if unimproved
Sigmoid volvulus
Seen in old people
Signs of obstruction & severe abdominal distention
Xray-air-fluid levels, distending colon, air filled loop in RUQ that tapers toward LLQ-Parrots beak
Proctosigmoidscope resolves acute problem
Rectal tube left in
Recurrent cases need elective sigmoid resection
Mesenteric ischemia
Seen in elderly, atrial fibrillation, or recent MI
Old peeps have less acute abdomen often dx late with blood in lumen, with acidosis & sepsis
If very early, arteriogram and embolectomy
Late, colectomy
Primary hepatoma/ hepatocellular carcinoma
In US, caused by cirrhosis or HBV Vague RUQ discomfort and weight loss Blood marker alpha fetoprotein CT shows location and extent Surgery if possible
Mets to liver
Outnumbers primary cancer 20:1
Found on CT or rising carcinoembryonic antigen
If primary slow growing and mets only in one lobe, can resect or radioablation
Hepatic adenoma
Complication of OCP
Risk of rupture with massive bleeding
CT diagnostic
emergency surgery
Pyogenic liver abscess
Complication of biliary tract disease Especially acute ascending cholangitis Fever, leukocytosis, tender liver U/S or CT dx Percutaneous drainage required
Amebic abscess of liver
Favors men with Mexico connection
Fever, leukocytosis, tender liver
U/S or CT dx; definitive w/ serology
Treated with metronidazoe and seldom req drainage
Hemolytic jaundice
Usually low level (bilirubin 6-8 not in 30-40)
All bilirubin is unconjugated
No bile in urine
Must determine what chewing up red cells
Hepatocellular jaundice
Elevation of both fractions of bilirubin
Very high levels transaminase
Modest elevation alk phos
Hepatitis most common example- look at serology
Obstructive jaundice
Elevation of both bilirubin fractions
Modest elevations of transaminase
Very high levels alk phos
Get U/S first
Obstruction may be stones- may not see; no gallbladder dilation
Malignant obstruction gets distended gallbladder
Obstructive jaundice caused by stones
Suspect in 40 female fertile fat
High alk phos, dilated ducts, nondilated GB w stones
ERCP to confirm and sphincterotomy
Cholecystectomy to follow
Obstructive jaundice caused by tumor
Adenocarcinoma of pancreas head Adenocarcinoma of ampulla Cholangiocarcinoma of common bile duct U/S shows distended GB- get CT Percutaneous biopsy to follow If CT negative get ERCP
Ampullary cancers
Suspect when malignant obstructive jaundice coincides w/ anemia and blood in stools
Can bleed into lumen & also obstruct
Endoscopy first dx test
Pancreatic cancer
Seldom cured even with whipple
Ampullary cancer and cancer of common duct have better prognosis 40%
Gallstones
Vast majority of biliary tract pathology
Fat female fertile 40
Also in Mexican and Native americans
Asymptomatic stones left alone
Biliary colic
Occurs when stone temporarily occludes the duct
Colicky RUQ pain radiating to shoulder & back
Often triggered by fatty food
Nausea and vomiting w/o peritoneal signs or inflammatory process
Self limited 10-30min
Easily aborted by anticholinergics
If u/s shows gallstones then elective cholecystectomy
Acute cholecystitis
Stone in duct and inflammation occurs in obstructed gallbladder
Pain is constant, low fever, leukocytosis & RUQ peritoneal irritation
LFTs usually normal
U/S dx-GB wall thickening, pericholecystic fluid, and stones
HIDA will show uptake in liver, common duct, and duodenum but NOT in the GB
NG suction, NPO, IV fluids, & abx
Cool down w/ elective cholecystectomy to follow, but usually in same admission
If not cooling down (often men w/ diabetes) then emergency cholecystectomy
Emergency percutaneous transhepatic cholecystectomy may temporize in old/very sick
Acute ascending cholangitis
Very deadly; stone blocks common duct and leads to ascending infection
Temp to 104-105, chills, very high WBC count
Hyperbilirubinemia and extremely high alk phos
IV abx and emergency decompression of common bile duct (usually ERCP or PTC but rarely surgery)
Eventually cholecystectomy to follow
Obstructive Jaundice
Without ascending cholangitis
Occurs when stones produce complete biliary obstruction rather than partial
Elevation of both bilirubin fractions
Modest elevations of transaminase
Very high levels alk phos
Get U/S first
Obstruction may be stones- may not see; no gallbladder dilation
Malignant obstruction gets distended gallbladder
Biliary Pancreatitis
Seen when stones impacted distally in ampulla temporarily obstruct both pancreatic & biliary ducts
May pass spontaneously
Produces transient cholangitis and pancreatitis (elevated amylase & lipase)
U/S shows stones in GB
NPO, NG suction, IV fluids often improves w/ later cholecystectomy
If not, ERCP w/ sphincterotomy
Acute pancreatits
Complication of gallstones, or in alcoholics
May be edematous, hemorrhagic, or suppurative
Late complications: pancreatic pseudocyst, and chronic pancreatitis
Acute edamatous pancreatits
Alcoholics or gallstones
Epigastric & midabdominal pain after heavy meal or booze
Constant pain radiating to back w/ nausea & vomiting
Tenderness & mild rebound in upper abdomen
Elevated amylase and lipase w/ elevated hematocrit
Resolution after pancreatic rest-NPO, NG suction and IV fluids
Acute hemorrhagic pancreatitis
Much more deadly
Starts as edmatous, but has lower hematocrit
Ranson criteria: elevated WBC, elevated glucos, low serum Ca2+ at presentation; Next day lower hct, low Ca2+ increased BUN & metabolic acidosis
Terrible outcome; ICU needed
Death follows multiple pancreatic abscesses; have daily CT to drain if forming
Necrosectomy
Best way to deal with necrotic pancreas
Wait for necrotic tissue to delineate
Best to wait 4wks
Pancreatic abscess (acute suppurative pancreatitis)
Persistent fever & leukocytosis about 10 days after onset of pancreatitis
CT shows collections of pus
Percutaneous drainage or necrosectomy
Pancreatic pseudocyst
Late sequela of acute pancreatitis or trauma 5wks after initial presentation
Collection of pancreatic juice outside pancreatic duct-usually lesser sac
Pressure symptoms-early satiety, vague discomfort and deep palpable mass
Dx w/ CT or U/S
6cm or >6wk more likely to rupture/bleed so req drainage- percutaneous, surgically into GI or endoscopically into stomach
Chronic pancreatitis
Repeat episodes of pancreatitis (usually alcohol)
Develop calcified burned out pancreas
Steatorrhea, diabetes, and constant epigastric pain
Diabetes & steatorrhea controlled w/ insulin & enzymes
Pain cannot be controlled
If ERCP shows specific point of obstruction & dilation, surgery to drain that duct
Abdominal hernias
All abdominal hernias should be electively repaired to prevent obstruction/strangulation
Except: umbos pt 2-5 (may close themselves) or esophageal sliding hiatal hernia (not true hernia)
Hernias that become irreducible req emergency surgery to prevent strangulation
