DSA 2: Stomach Pain, Heartburn, Indigestion Flashcards
what are the treatments for nausea and vomiting?
- antihistamines (meclizine) help with inner ear dysfunction
- anticholinergics (scopolamine) are effective for nausea associated with motion sickness
- metoclopramide and erythomycin may be useful in treatment of gastroparesis
what are the DDX to be aware of for nausea, vomiting and indigestion
- pregnancy** (always!)
- uremia
- ketoacidosis
- thyroid, parathyroid
- psychiatric illness/depression
- intermittent waxing/waning symptoms
- signs of gastric obstruction in absence of any mechanical lesions to account for the findings
- postprandial fullness
gastroparesis
what is the dx and tx of gastroparesis?
- dx: gastric scintigraphy (eat low fat solid meal like eggs - gastric retention of 60% after 2+ hours or more than 10% after 4+ hours is abnormal)
- tx: no specific therapy, metoclopramide, erythromycin, domperidone
what should be avoided in pt with gastroparesis?
agents that reduce gastrointestinal motility (opioids and anticholinergics)
- N/V, obstipation (cant pass stool or gas), distention
- minimal abdominal tenderness, decreased or absent bowel sounds
- commonly seen as result of surgery, peritonitis, electrolyte abnormalities, medications, severe medical illness
acute paralytic ileus
what is the dx and tx of acute paralytic ileus?
- dx: plain abd radiography or CT
- tx: treat the precipitating condition, restriction of oral intake
- N/V (can be feculent)
- minimal abdominal tenderness, decreased/absent bowel sounds
- high pitched tinkling bowel sounds
acute small bowel obstruction (SBO)
what is the tx and dx of SBO?
- dx: pain abd xray (KUB/abdominal series) or CT scan
- tx: NG tube to suction, supportive, sometimes surgery if NGT didn’t help
what are the alarm features of GERD/heartburn/indigestion?
- unexplained weight loss
- persistent vomiting
- dysphagia/odynophagia
- palpable mass
- hematemesis
- melena
- anemia
what further evaluation is needed if alarm symptoms of GERD/heartburn/indigestion present?
- endoscopy
- radiographic ABD imaging
- surgical evaluation
what is a possible complication of GERD -> Barrett’s esophagus?
adenocarcinoma
what causes Type B gastritis?
H. pylori
- antral-predominant disease
- infection early in life, or in setting of malnutrition, or low gastric acid output
- atrophic gastritis and gastric B cell lymphomas may occur
H. pylori gastritis
what is the dx and tx of H. pylori gastritis?
- dx: detection of H.pylori via fecal antigen test, urea breast test, upper endoscopy with gastric biopsy, warthrin-starry’s silver stain
- tx: eraditation of H.pylori not routinely recommended unless -> peptic ulcer disease, MALT lymphoma, or gastric adenocarcinoma
what causes type A gastritis?
autoimmune, Ab to parietal cells and intrinsic factor
- body-predominant -> loss of rugal folds*
- Ab to pareital cells in >90%
- anti-intrinsic factor Ab in 70%
- assoc with achlorhydria (loss of acid inhibition of gastrin G cells heads to hypergastrinemia)
- pernicious anemia (gastritis) -> cobalamin (B12) malabsorption
- increased risk of gastric adenocarcinoma
type A gastritis (FUNDIC type)
what is the dx and tx of type A gastritis?
- dx: CBC, serum cobalamin, folic acid, endoscopy with biopsy
- tx: parenteral B12 supplementation
- occur most commonly at the duodenal bulb or in the stomach
- signs of gastrointestinal bleeding (GIB) -> “coffe ground” emesis, hematemesis, melena or hematochezia
peptic ulcer disease (PUD)
what is the dx and tx of PUD?
- dx: EGD with biopsy must exclude malignancy, detection of H.pylori
NOTE: must stop PPI 14 days before fecal and breath tests d/t risk of false negative - tx: pain relief, healing, prevention of complications, EGD with repeat biopsy of ulcer to exclude malignancy
- 90-95% caused by H.pylori
- gastric acid hyper-secretion
- risk factors: glucocorticoids, NSAIDS
- can be asymptomatic
- dyspepsia, gnawing epigastric pain 1-3hrs after meals
- relieved by food
duodenal ulcer (DU)
- primarily in lesser curvature of antrum of stomach
- risk factors: chronic NSAID/salicylate use
- H.pylori + smoking = higher risk of ulcer
- gastric acid secretory rates are usually normal or reduced
- worse with food w/in 30 mins of eating
gastric ulcer (GU)
NOTE: need to perform endoscopy with biopsy to rule out malignancy
pneumoperitoneum
perforated viscus below diaphragm
- emergency surgery
- can happen in PUD, or with any hollow organ
pneumomediastinum
perforated viscus above diaphragm
- emergency surgery
- can happen in PUD, or with any hollow organ
a peptic ulcer (in particular of the duadenum) in a patient with extensive burns
curling’s ulcer
a peptic ulcer occurring from severe head (brain) injury or with other lesions of the CNS
cushing’s ulcer
spiral (curved), gram-negative, microaerophilic, urease-producing rods (baccili) with flagella
H. pylori
what is the associated McGowan wants us to know with H. pylori?
MALToma!
- tx: treat the H.pylori infection
what is the 3 drug regimen that McGowan uses for PUD?
- omeprazole
- clarithromycin
- metronidazole or amoxicillin
q14 days
what are the risk factors of gastric adenocarcinoma?
- smoked fish/meats
- pickled vegetables
- nitrosamines
- benzpyrene
- H. pylori
- smoking
- blood type A
- Menetrier’s disease
what are the two major types of gallstones?
- cholesterol (80%) -> cholesterol monohydrate
2. pigment stones (20%) -> calcium bilirubinate
- can be asymptomatic, OR
- biliary colic (severe steady ache in RUQ or epigastrium)
- nausea, vomiting
- the 6 F’s! female, fair, fat, female, fertile, forty
cholelithiasis
what is the dx of cholelithiasis?
ultrasound is best! (RUQ/hepatobiliary US)
- stones seen as well as an acoustic shadow
- steady, severe pain
- tenderness in RUQ
- N/V, fever/leukocytosis
- gallstones impacted in the cystic duct, inflammation develops behind the obstruction
acute cholecystitis
what is the dx of acute cholecystitis?
CBC & CMP
- elevated AST
- elevated ALP and GGT
- elevated serum amylase
RUB abdominal ultrasound
what is the preferred dx for chronic cholecystitis?
US, usually shows gallstones within a contracted gallbladder
what are the complications associated with chronic cholecystitis?
procelain gallbladder - most likely seen on plain x-ray
- shows incidental calcified lesion (calcified gallbladder) -> at risk of gallbladder cancer
- gallstones
- heavy alcohol use
- epigastric abdominal pain (boring pain straight thru back)
- RUQ pain/dyspepsia
- cullen or grey turner sign
acute pancreatitis
what is the dx of acute pancreatitis?
at least 2 of the 3:
- epigastric pain
- lipase 3 times normal limit
- CT changed consistent with pancreatitis (rapid-bolus IV contrast CT)
NOTE: US not helpful for pancreatitis
what is the tx of acute pancreatitis?
treat the cause
- fluid resuscitation (1/3 of total 72 hour fluid volume administered within 24 hrs = LOTS!)
what are the complications of acute pancreatitis?
- intravascular volume depletion (3rd spacing-> prerenal azotemia)
- fluid collections (pleural effusion)
- infection
- pseudocysts
- ARDS
- pancreatic ascites
what is the dx of acute upper gastrointestinal bleed (UGIB)?
EGD
what is the distinction point between upper/lower GI bleeds?
ligament of Treitz
what is the initial steps for UGIB?
- assessment of the hemodynamic status (stable or unstable?)
- then stabilization with two large bore (18g or larger) IV lines
- unstable pt: give 0.9% NaCl (NS normal saline) or LR
NOTE: all pt with UGIB should undergo endoscopy within 24 hours arriving in the ER
how much does 1 unit of pack red blood cells (PRBC) raise the HGB in adults?
by 1 g/dL
- portal hypertension/ or cirrhosis
- acute gastrointestinal hemorrhage
- recent retching or dyspepsia, or UGIB
esophageal varices
what is the tx of esophageal varices?
acute resuscitation with fluids or blood products
- emergent upper endoscopy with variceal banding
what is the prevention of rebleed for esophageal varices?
nonselective B-adrenergic blockers
- long-term treatment with band ligation reduces the incidence of rebleed
- UGIB- alcoholic (portal HTN gastropathy)
- “coffee ground” emesis
- epigastric discomfort (or asymptomatic)
- hyperactive bowel sounds
hemorrhagic (erosive) gastropathy/gastritis
what is the dx and tx of hemorrhagic gastropathy
- dx: upper EGD with biopsy, usually no significant inflammation on histo
- tx: remove offending agent (NSAID/aspirin/alcohol)
B-blocker for portal HTN
- 30-60 year old
- hypertrophic body of stomach (thickened gastric folds)
- chronic protein loss -> anasarca
- mucous cell type predominant
- limited lymphocytes
- hypoproteinemia, wt loss, diarrhea
- association with adenocarcinoma
Menetrier disease
- 50 year old
- hypertrophic fundus
- parietal>mucous, endocrine cell types predominant
- neutrophils present
- peptic ulcers
- MEN is risk factor
Zollinger-Ellison syndrome (ZES)
- PUD that isn’t responding to tx, is severe, atypical, recurrent
- most commonly a gastrinoma found in duodenum (45%)
- 25% associated with AD familial MEN 1 (pituitary, parathyriod, pancreatic)
ZES
what is the dx and tx of ZES?
- dx: serum fasting gastrin (confirmatory >1000 ng/L)
- tx: PPI**
NOTE: in pt with MEN1, tumor is often multifocal and unresectable
superficial/non-transmural tear
- precipitated by vomiting, retching, vigorous coughing
mallory weiss tear
NOTE: bleeding usually abates spontaneously
- recent history of forceful retching/vomiting (or trauma)
- history of alcohol use
- transmural rupture at GEJ
- Hamman’s sign (crunching, rasping sound, synchronous with heartbeat)
- dyspnea
Boerhaave syndrome (spontaneous esophageal perforation)
what is the dx and tx for Boerhaave synd
- dx: CXR with air in mediastinum, CT chest with gastrografin contrast
- tx: NPO, parenteral antibiotics, surgery, endoscopic stenting
