DSA 1: GI Clinical Correlations Flashcards
Make sure to review the medical terminology and imaging examples on the slides
Ok
What are the GI red flags?
throat issues: dysphagia, odynophagia
bleeding issues: melena, hematemesis
signs of malignancy: weight loss, severe pain, palpable mass, lymphadenopathy GI cancer hx
losing body fluids: vomiting, Iron deficiency anemia
What are the common ddx for RUQ pain?
cholecystitis pyelonephritis ureteric colic hepatitis pneumonia
What are common ddx for LUQ pain?
gastric ulcer
pyelonephritis
ureteric colic
pneumonia
What are common ddx for RLQ pain?
appy colic inguinal hernia IBD UTI testicular torsion/gyn stuff
What are common ddx for LLQ pain?
-diverticulitis colic inguinal hernia IBD UTI testicular torsion/gyn stuff
What are common ddx for epigastric pain?
peptic ulcer dz
cholecystitis
pancreatitis
MI
What are common ddx fo peri-umbilical pain?
small and large bowel obstruction
appy (early)
AAA
What is the difference between visceral and parietal pain?
Visceral: stimulation of visceral pain fibers secondary to damage to visceral organ = not localized
Somatic: stimulation of somatic pain fibers secondary to inflammation of parietal peritoneum over diseased organ = localized
What are some important questions to ask when patient complains of nausea and vomiting?
- appearance of the vomit
- how often
- projectile
What is Oropharyngeal dysphagia and what is the usual cause
- trouble initiating swallowing
- neuro issues, muscular/rheumatic, infectious, structural or motility disorders
What is esophageal dysphagia and what is the usual cause?
What questions should you ask your patient?
- difficulty swallowing, usually mechanical obstruction or motility issue
- ask if patient has difficulty with solids, liquids, and if progressive
What are the routine labs for GI complaints?
CBC CMP BMP (if no liver concern) UA Preg
What labs are useful for evaluating pancreatitis, liver function and jaundice?
Pancreatitis - lipase, also amylase
liver - PT/PTT
Jaundice - fractionated bilirubin
What does a CBC with diff tell you?
Blood cell count with breakdown of WBC components
What are the important things to look for in a BMP?
Na, Cl, K, CO2, BUN, Creatinine and glucose
What are the important things to look for in a CMP, especially for liver function?
Albumin, ALT, AST, alkaline phosphatase
Bilirubin, globulin and protein
PT/INR, GGT
What important tests should you order if ruling out Zolinger Ellison Gastrinoma?
fasting gastrin
secretin stimulation test
What is acute abdominal series good for?
What is a KUB good for?
Be sure to look at the images on slides
-initial/quick screening for free air/constipation
usually not diagnositic
-kidneys, ureters, urinary bladder evaluation
What is a barium swallow xray/esophagram good for?
Be sure to look at the images on slides
-differentiating between mechanical lesions or motility disorders (esophageal issues/narrowing)
What is an esophagogastroduodenoscopy (EGD) good for?
Be sure to look at the images on slides
- upper endoscopy, good for heartburn, dysphagia, odynophagia
- direct visualization, allows biopsy and dilation
What is a colonoscopy good for?
Be sure to look at the images on slides
-lower GI issues (colon bleeding/cancer etc)
What is an ultrasound good for?
Be sure to look at the images on slides
- good for fluid filled structures such as Gall bladder, bladder, kidneys, vessels or heart
- also good for FAST scan (checking for abdominal bleeding after trauma)
What is the ERCP (endoscopic retrograde cholangiopancreatography) good for?
How about MRCP?
- visualizing the biliary tree/pancreatic duct for evaluating gall bladder dz, both diagnostic and therapeutic
- specifically good for bile duct visualization, diagnostic only, not therapeutic
What is a HIDA scan good for?
specifically measures gallbladder function
HIDA + CCK (gallbladder ejection fraction) = biliary dyskinesia if lower than <38%
What is an abdomen/pelvis CT scan good for?
best test to order when ddx is broad, gives most info about abdominal pathology
Why should you think about GERD/Gastritis/PUD together?
similar pathophysiology, diagnostic workup and treatment
GERD cause clinical sx workup treatment
- LE sphincter gastric reflux > injury to esophageal tissue
- heartburn worse after eating, regurgitation (worse when supine)
- can dx just based on classic sx, but do upper endoscopy if associated with non-classical symptoms
- lifestyle modification, antacids, h2 blockers, surface agents, proton pump inhibitor
*Be sure to look at what GERD looks like on endoscopy
Peptic ulcer disease
Major risk factors?
- gastric or duodenal mucosa damage that acid reached the muscular mucosa and damaged it too, most common UGIB cause
- H. pylori infection and NSAIDs
Gastric vs Duodenal ulcer
Gastric: usually at lesser curvature of antrum, caused by mucosa damage leading to parietal cell loss (low H_ secretion)
Duodenal: usually at proximal duodenum, caused by enhanced H+ secretion leading to mucosa damage
How do you dx and treat gastric and duodenal ulcers?
- both dx with EGD
- both treated with H. pylori eradication and proton pump inhibitors
What is the significance of H. pylori infection?
associated with a bunch of GI diseases
- urease hydrolyses urea to NH3+ > increases pH and protects organism > able to penetrate gastric mucosa
- H. pylori also exacerbates mucosal inflammation
How do you test for H. Pylori?
Urea breath test (gold standard)
Fecal antigen
Make sure patient stops proton pump inhibitors 14 days before taking these tests
UGIB:
clinical pearls
What is the major DDX for UGIB?
bleeding above the ligament of Treitz (duodenum and up)
Pearls: hematemesis, coffee ground emesis, melena, if pt has hx of UGIB, bleeding is likely from the same site as before
-Peptic ulcer disease
What can cause UGIB?
-blood thinners, B blockers, meds with iron or bismuth
LGIB
What is the major DDX for LGIB?
-bleeding below the ligament of Treitz (jejunum and down)
Diverticulosis
Esophageal and gastric varices
- dilated veins due to portal HTN
- can also cause UGIB (esp in cirrhosis)
What are three ways cholelithiasis/cholecystitis can present?
- asymptomatic
- RUQ pain worse after greasy food
- complications of gallstone dz (e.g. pancreatitis)
Cholecystitis vs. Choledocholithiasis vs. Cholangitis
- ) obstruction at cystic duct or gallbladder neck > inflamed gall bladder, LFTs normal since liver not affected
- ) obstruction at common bile duct > liver and gallbladder can’t drain the bile, LFTs elevated
- ) obstruction at common duct > inflamed biliary tree + presence of air
Gallstone pancreatitis
Dysfunctional GB
- stone stuck in pancreatic duct > elevated LFTs and lipase/amylase
- no stones, normal LFT, but with symptoms of biliary colic
Pancreatitis
Classic sx
workup
- severe epigastric pain + n,v, elevated lipase/amylase
- routine AP labs, + lipase, UA, CMP, preg, CT (if imaging needed)
Appendicitis
Classic sx
workup
-starts visceral around umbilicus, migrates to RLQ
-routine AP labs, CT (US for kids)
tx with surgery
Diverticulosis/Diverticulitis
Classic sx
workup
-LLQ pain, +/-n,v,fever (opposite of appy)
-routine AP labs, + CMP, UA, preg, CT
tx with abx or surgery
Primary Achalasia
cause
symptoms
- LES doesn’t relax > no peristalsis
- dysphagia, regurgitation, bird beak appearance of distal esophagus
Secondary Achalasia
cause
symptoms
- can be caused by Chaga’s disease
- same symptom as primary but with systemic symptoms of Chaga’s (swollen bite site, Romana sign - swollen eyelid)
Zollinger Ellison Syndrome (ZES) Gastrinoma
When should you consider this dz?
- gastrinoma secreting gastin, elevated gastrin and + secretin test
- ulcers at weird locations
Parasympathetic innervation of GI:
Vagus N. (from esophagus to transverse colon)
S2-S4/pelvic splanchnic nerves (from descending colon downards)
Sympathetic innervations of the following: Esophagus Stomach Liver and Gall bladder Pancreas Small intestine Colon Appendix
- T2-8
- T5-9
- T6 -9
- T5-11
- T5-9, T9-12
- T9-L2
- T12
