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GI/GU II Exam 1 > DSA 2: N/V, Dyspepsia, Heartburn, Hematemesis > Flashcards

DSA 2: N/V, Dyspepsia, Heartburn, Hematemesis Flashcards

1
Q

How do you stabilize a pt w/ UGIB

A

2 large bore (>=18 gauge) IV

unstable pts (signs of shock) –> IVF 0.9% NaCl (aka normal saline) or Lactated Ringer (LR)

ABCs: airway/breathing/circulation

proceed w/ hx, PE, and work up

CBC, PTT/INR, serum creatinine (BUN/Cr ration usually atleast 30:1 in most UGIB), liver enxymes, blood typeing & screen incase transfusion is needed

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2
Q

what are possible etiologies of gastroparesis

A

endocrine: DM, hypothyroid
infxn: post viral, chagas
postsurgical: vagotomy, partial gastric resection, fundoplication, gastric bypass, whipple)
neurologic: parkinsons, MS, postpolio syndrome, porphorya

rheumatologic syndromes

amyloidosis, medications, eating disorder, paraneoplastic syndrome, or Idiopathic

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3
Q

what is the presentation of gastroparesis & how do you diagnose

A

intermittent, waxing & waning symptoms

signs of gastric obstruction in the absence of any mechanical lesion (look for obstruction if abd pain present)

chronic/intermittent postprandial fullness (early satiety)

N/V 1-3 hrs after meal

Dx: gastric scintigraphy (gastric emptying study)- use low-fat solid meal; 60% retention after 2 hours or >10% after 4 hrs = abnormal

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4
Q

what can cause perforated viscus

how does it present?

A

PUD

possible w/ any hollow organ that perforates

NPO, IV ABx, pre-op labs, surgery consult

emergency surgery

=free air under diaphragm (pneumoperitoneum) or air in mediastinum(pneumomediastium) - see in x-ray or CT

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5
Q

What is the pathophys and RFs for DU

A

anterior wall of proximal duodenum (90-95% caued by H. pylori)

= gastric acid hypersecretion bc inflam cells release cytokines that stimulate antral G cells & diminised production of somatostatin by D cells

gastrin stimulation –> increased parietal cell mass –> exaggerated acid response

mucosal defense compromised bc H. pylori effects on pathches of gastric metaplasia (result from acid hypersecretion or rapid gastic emptying)

RF: glucocorticoids, NSAIDS, zollinger-ellison syndrome, severe medical/surgical stress

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6
Q

what is the DDx for dyspepsia/heartburn/indigestion

A
  1. GERD
  2. Gastritis
  3. PUD & severe medical/surgical stress ulcers
  4. cholecystitis
  5. pancreatitis
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7
Q

what is the prevalence of H. pylori and how is it transmitted

A

immigrants from developing countries, poverty/ low SES, overcrowding, rural, limited education, increases w/ age

person-person (fecal oral) -infancy/childhood

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8
Q

What is type A chronic gastritis associated with

A

Achlorhydia- loss of acid inhibition of gastic G cells –> hypergastrinemia –> hyperplasia of gastric enterochromaggin like cells –> 5% become carcinoid tumors

pernicious anemia (gastritis) - decreased IF –> Vit B12 malabs –> megaloblastic anemia (F>M) –> 3x increase risk of gastric adenocarcinoma

DM, thryoiditis, grave’s (autoimmune disorders)

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9
Q

how do you treat zollinger ellison syndrome

A

PPI

exploratory laparotomy - resect primary tumor & soliary metastases when possible

in pt w/ MEN 1 - cant resect & usually multifocal - so 1st treat hyperparathyroid (may help with hypergastrinemia) ; for unresectable tumor - parietal vagotomy

chemo for metastatic tumor

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10
Q

What is the etiology and presentation of type A gastritis

A

=FUNDIC-type –> affect fundic glands/mucosa) –> loss of rugal folds

elderly

Autoimmune mechanism: Auto-Ab to parietal cells or anti-intrinsic factor Ab

= usually aysmp - sxs if carcinoid or vit B12 def

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11
Q

what are the characterisitics of acute gastritis

A
  • etiology:
  • erosive (superfical, deep, hemorrhagic) or non-erosive (H. pylori; acute –> chronic)
  • alc, meds, cocaine, ischemia, viral, bacterial H. pylori, stress/shock, radiation, allergy

Sxs: abd pain, N/V, anorexia, belching, bloating

Dx: EGD w/ Bx (test for H.pylori)

Tx: treat/avoid/stop underlying cause, endoscopic intervention for bleeding , PPI, sucralfate, H2 blocker, treat & eradicate H. pylori

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12
Q

When is eradication of H. pylori recommended

A

PUD

MALToma

(otherwise not routinely recommended)

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13
Q

What is the presentation and PE of Hemorrhagic (erosive) gastropathy/gastritis

A

MCC in erosive gastritis is: UGIB

  • hematemesis, “coffee ground” emesis, or bloody aspirate in nasogastric suction, or melena.
  • may be asymp
  • epigastric discomfort
  • nausea, hematemesis, or melena
  • hyperactive bowel sounds

bc its superficial –> hemodynamically significant bleeding = rare

PE depend on underlying cause: vitals normal, liver dz stigmata, acutely distressed/severely ill, etc.

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14
Q

What is the definition, etiology and diagnostic method for esophageal varices?

A

=dilated submucosal veins in the esophagus

Etiology: MC 2ndary to portal HTN (cirrhosis)

Dx upper EGD (diagnostic & therapeutic)

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15
Q

What are the 3 types of Stress related mucosal dz (SRMD) - aka stress ulcers

A

curling ulcers: peptic ulcer (duodenum) in pt w/ extensive burns

cushing’s ulcer: peptic ulcer from severe brain injury or w/ other lesions of the CNS

severe medical/surgical illness (ICU)

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16
Q

What may cause sxs that mimic UGIB

A

med w/ iron or bismuth –> mimic melena

liquids w/ red dye (kool-aid) & certain foods (beets) –> mimin hematochezia

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17
Q

How do you treat GI bleeds

A

UGIB/LGIB: identify & stabilize, CBC, chem profile, INR/PT/PTT, type & screen or cross, 2 large bore IVs, fluid bolus if signs of shock, blood transfusion if indicated

UGIB:

PPI (PUD bleed)

octerotide: pt w/ varices

Abx if variceal bleeding

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18
Q

how do you treat gastroparesis

A

no specific tx

acute exacerbation - nasogastric suction & IV fluids

advice to eat small, freq meals w/ low fiber, milk and gas-forming foods and fat

AVOID agents that decrease GI motility in DM pts - MAINTAIN glucose levels <200 mg/dl bc hyperglycemia can slow gastric emptying in absence of dabetic neuropathy

meds:

metoclopramide (risk of tardive dyskinesia) - involuntary unintentional movement, lip smaking, twitching

erythromycin

gastric electrical stimulation w/ internally implanted neuro stimulator

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19
Q

how do you diagnose and treat type A chronic gastritis

A

Dx: CBC, B12, folic acid, methylmalonic acid and homocysteine assay, IF Abs, parital cell Abs; endoscopy w/ Bx

Tx: paraentral (IM) B12 supplements if extensive atrophy & metaplasia in antrum and body

dysplasia & small carcinoids require endoscopic surveillance

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20
Q

what is the etiology and complications of type B gastritis

A

= ANTRAL** type = **H. pylori gastritis

H. pylori –> early in life or setting of malnutrition (malabs –> B12 deficiency) or low gastric acid output

complications- b12 def,** low gastric acid output_, increased risk of gastric adenocarcinoma_, atrophic gastrtis, **gastric B cell lymphoma

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21
Q

What are the clinical features associated w/ DU

A

maybe asymp

dyspepsia, burning (gnawing) epigastric pain - 1-3 hours AFTER meals

nocturnal (periods of fasting)

relieved by food or antacid & have recurrence 2-4 hrs later

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22
Q

what is the etiology, presentation and Tx for Menetrier dz

A

idiopathic; characterized by giant thick gastric folds involving predom the body of the stomach & chronic protein loss -severe hypoprotienemia & anasarca (general body swelling)

nausea, epigastic pain, wt. loss, diarrhea (GIB NOT common)

use EGD w/ Bx to Dx

Tx: severe cases = gastric resection;

increased risk for gastic adenocarinoma (monitor)

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23
Q

What is the etiology, presentation and diagnostic test for Mallory Weiss Tear

A

etiology: superficial/non-transmural tear - GE jxn; precipitated by vomiting, retching or vigourous cough (will be in Hx)

= common cause of UGIB

may be asym

nausea/hematemesis & vital sign/PE = normal!

Dx: Hx & upper EGD

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24
Q

what are PE findings of UGIB

A

signs of hypovolemia: Vital signs!

  1. mild-mod (<15% blood volume loss) : resting tachycardia
  2. volume loss of atleast 15% - orthostatic hypotension (decrease sBP by >20 &/or increase HR of 20 beat/min after moving from recumbency to standing)
  3. volume loss of atleast 40%: supine hypotension

Stool color- clue of location of bleed

acute abd: severe pain, (+) rebound, (+) involuntary guarding ==> concern for perforation - rule out BEFORE endoscopy

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25
Q

why is HCT not a relaible indicator for severe acute bleeding

A

bc takes 24-72 hrs to equilibrate

26
Q

how do you diagnose and treat acute SBO

A

Dx: plain abd radiography (KUB/Abd series x-ray) or CT scan

-see dilated loops of small bowel, air fluid levels

Tx: NGT to suction, supportive, surgery if NGT isnt helpful

27
Q

what is important Hx/presentation for UGIB

A

severe bleeding: anemia, hypovolemia, orthostatic dizziness, confusion, angina, tachycardia, angina syncope, weak, SOB, severe palpitations & cold/clammy extremeties

hematemesis, melena, hemotochezia?

  • co-morbid conditions: aortic stenosis, renal dz : AVM, telangiectasia, angiodysplasia
  • smoking- PUD, malignancy
  • liver dz: portal HTN cause varices
  • Alc abuse: varicies, erosive, esophagitis/gastritis, PUD
  • H. pylori, NSAIDs: PUD

Meds: BE THOROUGH! aspirin (salicylates), glucocorticoids, NSAIDs, anti-coags

28
Q

what are the clinical features of GU

A

maybe asymp

dyspepsia, Burning epigastric pain- worsen w/ food w/i 30 mins of eating

Nausea/anorexia/bloating

food aversion

*perfrom endoscopy w/ Bx to rule out malignancy*

29
Q

what should you consider if pt comes in w/ dyspepsia/ heartburn/ indigestion w/ severe epigastric pain

A

complicated PUD - perforation or penetration

other causes: MI/infarction, esophageal rupture, gastic volvulus, gastric/intestinal ischemia, ruptured aoritc aneurysm

30
Q

what is the etiology, presentation and diagnostic test for Boerhaave syndrome (spontaneous esophageal perforation)

A

etiology: spontaneous - Hx of forceful retching/vomiting & alc use

transmural rupture at GE jxn

can be life-threatening!

pt in distress, has pleurtic/retrosternal chest pain, hematemesis

may have pneumomediastinum or subQ emphysema

Dx: clinical suspicion, CXR for pneumomediastinum/subQ emphysema & CT w/ contrast

31
Q

what are RFs for gastric adenocarcinoma (including malignant gastric ulcers)

A

Diet: smoked fish/meat, pickled vegtables, reduced intake of fruit/veggies

meds: nitrosamines, benzpyrene
other: h. pylori, chronic gastritis, smoking, blood type A, Menetrier’s Dz

32
Q

what should your initial evaluation be if pt presents w/ acute UGIB

A

are they stable or not?

volume status (severity of bleed) *HCT is a POOR early indicator*

do they have increased risk of re-bleed & death? - >60 yo, comorbid illnesses, sBP <90, pulse > 90, bright red blood in nasogastric aspirate or rectal exam

assess hemodynamic status

admit to ICU!

33
Q

What diagnostic tests are used to diagnose various causes of N/V

A

plain radiograph- abd (intestinal obstruction); chest (pseudomediastinum, aspiration pneumonitis)

EGD

Gastric emptying scan (gastroparesis)

CT of brain

many labs

pregnancy test (beta-Hcg)

34
Q

what is the pathophys and presentation of acute paralytic ileus

A

pathophy: neurogenic failure or loss of peristalsis in the intestine in the absence of mechanical obstruction

N/V, obstipation, distention

minimal abd tenderness, decreased/absent bowel sounds

(seen in hospitalized pt due to surgery, peritonitis, electrolyte imbalance, meds, severe medical illness

35
Q

how do you detect H. pylori

A
  1. fecal Ag test: sensitive, specific, $
  2. Ab in serum: $, preferred if endoscope not required
  3. urea breath test: confirm eradication of H. pylori
  4. upper endoscopy w/ gastric Bx: histology & rapid urease testing of antrum- clofazimine
  5. Warthin-starry silver stain & immunohistochem stain
36
Q

How do you treat hemorrhagic (erosive) gastropathy/gastritis

A

remove offending agent: aspirin/NSAID/Alc

maintenance of O2 &blood volume

portal HTN gastropathy- Beta-blocker (propranolol or nadolol)

prevent of stress ulcers in critically ill pts- H2 Blocker or PPI reduce incidence (hourly PO liquid antacids, sucralfate,or IV PPI)

enteral nutrition reduces risk of stress-related bleeding

37
Q

what is the purpose of an upper endocsopy in an acute UGIB

A

all pt w/ UGIB should undergo endoscopy w/i 24 hrs of arrive in ED

=diagnostic && therapeutic

benefits:

  1. identify bleed
  2. determine risk of rebleed & guide triage
  3. render endoscopic therapy
38
Q

how do you diagnose and treat acute paralytic ileus

how do you prevent it

A

plain abd radiograph or CT scan - gas & fluid distention in small/large bowel

Tx precipitating condition

if severe/prolonged –> nasogastric suction & paraentral fluids & electrolytes

post-op ileus reduced by using pt controlled or epidural analgesia and avoidance of intravenous opiods as wel as early ambulation, gum chewing, initiation of clear liquid diet

OMM if no contraindication

restrict oral intake w/ gradual liberalization of diet as bowel fxn returns

39
Q

How do you raise Hbg in adults by 1 g/dL

A

1 unit packed RBC (PRBCs) raise Hbg in adults by 1g/dL

40
Q

What are sxs that present w/ esophageal varices

A

do not cause sxs of dyspepsia, dysphagia, or retching, per se

Acute gastrointestinal hemorrhage- melena, hematochezia, hematemesis

After retching

1/3 pts with varices –> UGIB

Can be serious/life-threatening - usually severe bleed –> hypovolemia manifested by postural vital signs/shock

41
Q

what levels should be obtained in zollinger ellison syndrome pts to exclude MEN-1

A
  • serum parathyroid hormone (PTH)- iPTH (intact PTH)
  • prolactin
  • LH-FSH
  • GH
42
Q

What are complications of H. pylori infxns

A

chronic gastritis –> atrophic gastritis & gastric CA

Adenocarcinoma

MALToma (tx by treating H.pylori infxn)

*reason why you should confirm eradication after treatment! - urea breath test, fecal-Ag test, endoscopy w/ Bx*

43
Q

how does Dieulafoy lesion present & how do you Dx?

A

fatigue, hematemesis, obscure GI bleed, Occult GI bleed –> iron def anemia (life threatening)

Dx: awareness/clinical suspicion & careful upper EGD

44
Q

14 yo F presents w/ abd pain and N/V, whats your plan?

A

Pregnancy test!!!

blood or urine

RMR child-bearing age = broad spectrum!!!

but if pt has hysterectomy, dont need test

45
Q

How do you diagnose UGIB

A

CBC

EGD- diagnosis & Tx intervention of active bleeding

nasogastric lavage - if doubt the origin is from upper gi

46
Q

What are PE/Dx findings for gastric adenocarcinoma

A

virchows nodes

Krukenberg tumors: metastasis to ovaries

signet-ring cells

linitis plastica (leather bottle stomach)

47
Q

What is the pathophys and RFs for GU

A

in lesser curve of antrum of stomach (75% H. pylori w/ increased risk if smoker)

normal/reduced gastric acid secretory rates –> gastritis bc reflus of duodenal content (including bile)

RF: glucocorticoids, chronic renal failure, renal transplant, cirrhosis, chronic lung dz, severe medical/surgical stress; chronic NSAID/Salicylate use (increased risk of bleeding/perforation)

48
Q

What are the microbiological characterisitics of H.pylori

A

spiral (curved)

gram (-)

micoaeruphilic

urease producing rod (baccili) w/ flagella

Cag-A (+) toxin - increased risk of ulcer and gastric cancer

49
Q

what is the etiology of hemorrhagic (erosive) gastropathy/gastritis

how do you Dx

A
  1. aspirin and NSAIDs
  2. alcoholic (Portal HTN gastropathy)
  3. severe stress/critically ill

Dx: upper EGD w/ Bx - no significant inflam on histology; CBC, chemistry (liver/kidney fxn), INR/PT/PTT

50
Q

how do you diagnose and treat GAVE syndrome

A

upper EGD: watermelon stripes - red tortuous ectatic vessel columns along longitudinal fold of antrum) *dont confuse w/ portal HTN gastropathy has changes in fundus*

Tx: transfusion if needed, endoluminal therapies

51
Q

what are complications of N/V

A
  1. rupture esophagus- Boerhaave syndrome
  2. hematemesis from mucosal tear (mallory-weiss tear)
  3. dehydration, malnutrtion, dental caries and eriosins
  4. metablic alkalosis & hypokalemia
  5. aspiration pneumonitis
52
Q

what are important Hx components when pt presents w/ N/V

A

timing - morning? - pregnancy, uremia, alc gastritis ; during or after meal?

character- feculent = distal intestinal obstruction or gastrocolic fistula; or projectile = maybe increased intracranial pressure

medication

Associated sxs: vertigo/tinnitus -Meniere’s dz; relief of abd pain after vomiting = peptic ulcer ; early satiety = gastroparesis

53
Q

what is the DDx for UGIB

A
  1. PUD/Stress ulcer
  2. esophageal varcies (pt w/ portal hypertension/cirrhosis)
  3. hemorrhagic gastropathy/gastritis (alc, aspirin, NSAIDs, critically-ill, Zollinger ellison syndrome)
  4. mallory-weiss tear/borhaave syndrome
  5. dieulafoy lesion - submucosal vessels
  6. GAVE syndrome- watermelon stomach
54
Q

What is the etiology of Zolinger ellison syndrome

A

Primary Gastrinoma = non-beta islet cell –> gastrin secreting tumor

  • Pancreas (25%)
  • Proximal duodenum (45%)
  • Lymph nodes (5-15%)

2/3 = malignant &(1/3 metastasized to liver at presentation)

=Slow growing

25% associated w/ auto. dom. familial syndrome MEN 1 (multiple endocrine neoplasia type 1) = pancreatic gastrinoma (insulinoma), hyperparathyroidism (increased Ca2+), pituitary neoplasm (gigantism)

55
Q

Compare and Contrast chronic gastritis caused by H.pylori vs. autoimmune cause

A
56
Q

what are classic sxs of UGIB

A

hematemesis (bright red/coffee grou)

melena (after 50-100 mL blood loss)

hematochezia (bright red blood per rectum - in massive bleed)

*rmr upper GI = proximal to L. of Treitz*

57
Q

what is the etiology of Dieulafoy lesion

A
  • elderly, male
  • Already hospitalized/ taking NSAIDs, aspirin, warfarin/ no Hx of GI pathology
  • MC: proximal stomach –> recurrent, intermittent bleeding

= rare, aberrant large- caliber submucosal A

=obscure GI bleeding that may result in treacherous & life-threatening GI hemorrhage

Obscure Gl bleeding = overt/occult bleeding –> difficult to locate bc pathology is anatomically inaccessible, small, or subtle

=histologically normal vessel w/ abnormally large diameter (1–3 mm); tortuous course w/i submucosa & typically, the lesion protrudes thru a small mucosal defect (2–5 mm) -> fibrinoid necrosis at base

58
Q

What is the etiology and presentation of GAVE syndrome

A

= rare, multiple superficial telangiectasia in gastric antrum “watermelon stomach”

seen in diffuse scleroderma & cirrhosis

MC: elderly (70s)

= fatigue, nondescript abd pain, occult GI bleed –> iron def anemia

59
Q

when should you consider Zollinger ellison syndrome to your DDx

A

PUD that wont respond to tx or is severe, atypical, recurrent

if ulcer is severe, refractory to therapy, associated w/ ulcer in atypical location, associated w/ diarrhea (NGT suction suposed to stop diarrhea), steatorrhea, wt. loss,

Primary gastrinoma ==> duodenum (45%) –> then pancreatic (25%); 5-15% LN; or in submucosal or in multiple

60
Q

what are risk factors for esophageal varices

how can you prevent rebleeding

A

RF

  1. size (> 5 mm)
  2. EGD show red wale markings (longitudinal dilated venules on the varix surface)
  3. severity of liver disease (assessed by Child scoring C >B >A)
  4. active alcohol abuse—pts w/ cirrhosis who continue to drink have an extremely risk of bleed

Prevent rebleed: Nonselective beta-adrenergic blockers (propranolol, nadolol) reduce the risk (SE = fatigue & hypotension)

Long-term treatment with band ligation reduces the incidence of rebleeding to 30%

61
Q

How do you diagnose Zolinger Ellison syndrome

A

EGD: large mucosal folds (hypertrophic gastric mucosa)

Serum (fasting) gastrin: draw when fasting & no acid suppression meds –> >1000 ng/L (or >150pg/mL) = confirm!

(+) secretin stimulation test: if (-) think other reasons for hypergastrinemia (chronic fundic (type A ) gastritis

Endoscopic ultrasonography (EUS), CT and MRI scans: large hepatic metastases & primary lesions (low sensitivity for small lesions)

62
Q

What is the etiology and presentation of acute small bowel obstruction (SBO)

A

commonly bc adhesions - multiple abd surgery, diverticulits, crohns dz

N/V (maybe feculent), obstipation (no BM or flatus), abd pain & distention, minimal abd tenderness, deceased/absent bowel sounds & high pitch tinkling bowel sounds (rain on tin roof)

GI/GU II Exam 1 (16 decks)

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