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GI II Exam 1 > DSA WL and FAtigue > Flashcards

DSA WL and FAtigue Flashcards

1
Q

What nutrients are absorbed in the proximal SI?

A
  1. Iron
  2. Ca2+
  3. Folate
  4. Fats
  5. Carbs
  6. TAGS
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2
Q

What nutrients are absorbed in the distal SI?

A
  1. Vitamin B12
  2. Bile salts
  3. Water
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3
Q

What nutrients are absorbed in the colon?

A
  1. Water
  2. Electrolytes
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4
Q

______________ difficulty initiating or maintaining voluntary mental or physical activity.

A

Fatigue

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5
Q

Differential Dx Fatigue

A
  1. Occult GI Bleed
  2. Cancer
    1. Esophageal
    2. Gastric
    3. Colon
    4. Pancreas
    5. Liver (HCC and Cholangiocarcinoma)
    6. GB
  3. IBD
  4. Chronic liver disease
  5. Malnutrition/malabsoprtion
    1. Celiac
    2. Chronic Pancreatitis/ Pancreatic insufficieny/ CF
    3. Bile salt malabsorption
    4. Whipple Disease
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6
Q

Differential Dx: Unintentional WL

A
  1. Cancer
  2. Malabsorption Syndromes
  3. IBD
  4. Poor dentition
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7
Q

When diagnosing Fatigue

  • What is CRITICAL?
  • What must we distinguish, review and what is neecessary to understand the patients experience and gauge recovery and success of treatment?
  • What can raise our suspicions o_f occult infection_ or malignancy?
A
  • DETAILED HISTORY is CRITICAL
  • In ROS, we must distinguish fatgue from excessive sleepiness, dyspnea on exertion, excercise intolerance and muscle weakness.
  • Review patients meds/drugs/alcohol, life stressors, sleep habits and sleep hygeine.
  • ASK how fatigue is impacting daily functioning => understand experience and used to to compare treatments
  • Fever, chills, night sweats, WL = occult infection or malignancy.
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8
Q

How is fatigue diagnosed?

A
  • Lab testing will only diagnose chronic fatigue 5% of the time => let H&P guide labs.
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9
Q

What labs should we run, based on the H&P, for fatigue?

A
  1. CBC + differential (anemia, infection and cancer)
  2. Electrolytes (K, Na , Ca, glucose, liver and renal fx)
  3. Thyroid function
  4. HIV
  5. Adrenal function
  6. ESR (Erythrocye sedmentation rate); looks for mimics
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10
Q

__________ =not informative in isolation in patients with fatigue and is + at low titers in healthy people

_________ are not indicated in patients with fatigue because inconentient, risk, costly and show unrelated findings.

A
  • Routine screening with antinuclear antibody (ANA)
  • Whole-body image scans
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11
Q

Rapid fluctuations of weight over days = ___________, whereas long-term changes = _________

A

Rapid fluctuations of weight over days suggest loss or gain of fluid, whereas long-term changes usually involve loss of tissue mass.

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12
Q

Loss of _____ of body weight over ____ months should prompt further evaluation.

A

Loss of 5-10% of body weight over 6 months should prompt further evaluation.

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13
Q

Common causes of unintentional weight loss:

In older persons

A
  1. Cancer (lung cancer and GI cancers)
  2. Benign GI disease
  3. Depression
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14
Q

Common causes of unintentional weight loss:

In younger persons

A
  1. DM
  2. Hyperthyroidism
  3. Anorexia nervosa
  4. Infection (HIV)
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15
Q

When taking a history in unintentional weight loss, what should you ask?

A

A history of GI symptoms, including difficulty eating, dysgeusia (distorted sense of taste), dysphagia, anorexia, nausea, and change in bowel habits.

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16
Q

When taking a PE in unintentional weight loss, what should you do?

A
  1. START with weighing them
  2. All men = rectal and prostate exam
    1. cancer
  3. All women = pelvic exam
    1. cancer
  4. Both = stool for occult blood
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17
Q

Before extensive evailation is done for unintentional WL, what must be done?

A

Confirm WL HAS occured (up to 50% of claims cannot be proven); if no docutmention, changes in clothes or belt size

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18
Q

What GI disorders can cause WL?

A
  1. Malabsorption
  2. Obstriction
  3. Peptic Ulcer
  4. Celiacs
  5. IBD
  6. Pancreatitis
  7. Perncious anemia
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19
Q

Occult GI Bleed = bleeding that is not apparent to patient.

  • Symptoms
  • MCC causes occult bleeding with iron deficiency
A
  • Symptoms can be similar to signs of anemia: Fatigue, shortness of breath
  • The most common causes of occult bleeding with iron deficiency are
  • (1) neoplasms
  • (2) vascular abnormalities (angioectasias)

•(3) acid-peptic lesions (esophagitis, peptic ulcer disease, erosions in hiatal hernia)

  • (4) infections (nematodes, especially hookworm; tuberculosis)
  • (5) medications (especially NSAIDs or aspirin)
  • (6) inflammatory bowel disease (CD > UC)
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20
Q

Common causes of occult blood loss

A
  1. Nonfamilial adenomatous & serrated polyps
  2. Familial Adenomatous Polyposis (FAP)
  3. Lynch Syndrome
  4. Angioectasias (angiodysplasias)
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21
Q

You will need to remember: In premenopausal women, iron deficiency anemia is most commonly attributable to

A
  1. menstruation
  2. pregnancy-associated iron loss
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22
Q

Dx Occult GI Bleed (3)

A
  1. positive (fecal occult blood test) FOBT,
  2. (fecal immunochemical test) FIT,
  3. Iron deficiency anemia in the absence of visible blood loss.
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23
Q

Patients with iron deficiency anemia should be evaluated for possible:

A

Celiac disease with either:

  1. IgA anti-tTG
  2. Duodenal biopsy
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24
Q

In patients, younger than 60 years, with unexplained occult bleeding or iron deficiency anemia

it is recommended to pursue,

A

Further evaluation of the small intestine for a source of obscure-occult bleeding in order to exclude a small intestinal neoplasm or IBD

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25
1st thing you think of person **over 45** with **iron-def anemia** think \_\_\_\_\_\_\_\_
**Colon Cancer**
26
Patients **over age 60** with **occult bleeding** who have a **NL initial endoscopic evaluation** and **no other worrisome symptoms or signs** (eg, abdominal pain, weight loss) most commonly have \_\_\_\_\_\_\_\_\_\_\_\_.
**blood loss from angioectasias**
27
**_NONFAMILIAL_ _ADENOMATOUS_ & _SERRATED POLYPS_** ## Footnote Clinical Findings: Diagnosis:
* **Clinical Findings** * Completely Asymptomatic * **Diagnosis** * **Endoscopy = ​**Colonoscopy **=** best test to _treat and detect_ polypectomy colorectal polyps * Radiology * CT colonscopy = (okay for low risk pts) *
28
**_NONFAMILIAL ADENOMATOUS & SERRATED POLYPS_** **CT Colonoscopy** * Detection polyps larger = \_\_\_\_\_mm (diagnostic but NOT therapeutic) * Accuracy for detection of polyps _____ size is significantly lower
1. Detection polyps larger **\> 10mm** (diagnostic but NOT therapeutic) 2. Accuracy for detection of polyps **5–9 mm** in size is significantly lower
29
**_NONFAMILIAL ADENOMATOUS & SERRATED POLYPS_** ## Footnote Treatment and Management? Complication of the treatment?
1. **Colonoscopic Polypectomy** = colonoscopic removal with biopspy foreceps * Complications: perforation and BAD bleedings 2. **Postpolypectomy surveillance** for 3-10 years.
30
* **Familial Adenomatous Polyposis (FAP) =** Early development **100s to 1000s** of colonic adenomatous polyps and adenocarcinoma * What are extraintestinal manifestions you see in H&P that can be an early sign for surveillance?
* **congenital hypertrophy of the retinal pigment epithelium** (detected at birth)
31
In **FAP, 90%** of people have a _____ disorder where there is a mutation in _______ gene; **8%** have a ______ disorder where there is a mutation in ______ gene.
* In **FAP, 90%** of people have a **_AD disorder_** where there is a mutation in **_APC gene;_** * **8%** have a **_AR disorder_** where there is a mutation in **_MUTYH gene._**
32
How do you treat and manage **FAP**?
* **Complete proctocolectomy** with ileoanal anastomosis is recommended usually before age 20 years. * **Prevention of colon cancer=** Prophylactic colectomy
33
**Lynch Syndrome (HNPCC)** poses a lifetime risk of what? Who quickly do the polyps progress to cancer?
* **Colorectal** cancer (22-75%); **endometrial** cancer (30-60%); other cancers develop at a **young age.** * **Rapidly**; 1-2 years from NL =\> adenoma =\> cancer
34
Multisociety guidelines recommend that **ALL colorectal cancers** should undergo **testing** for\_\_\_\_\_\_\_\_\_\_ with either _________ or \_\_\_\_\_\_\_
* Multisociety guidelines recommend tha tall colorectal cancers should undergo testing for **Lynch syndrome** with either **immunohistochemistry** or **microsatellite instability.**
35
**_Lynch syndrome:_** mutation in ogenes that are important in the detection and repair of \_\_\_\_\_\_\_\_\_\_\_\_\_\_
Lynch syndrome =\> defect in one of several genes that are important in the detection and repair of **DNA base-pair mismatches (MLH1, MSH2)**
36
**_Lynch Syndrome;_** * Diagnosis **suspected:** * Diagnosis **confirmed:**
* Diagnosis **suspected:** * tumor tissue immunohistochemicalstaining for mismatch repair proteins * testing for microsatellite instability * Diagnosis **confirmed:** * genetic testing
37
**_Lynch Syndrome:_** * Treatment and management?
* **Subtotal colectomy** with **ileorectal anastomosis** (followed by annual surveillance of the rectal stump)
38
What screenings should be done in patients with **HNPCC**?
* Beginning at **30–35YO:** W screened for **endometrial** and **ovarian cancer** * 40 or stop having children: recommended for women to have **prophylactic hysterectomy** and **oophorectomy**. * @ 30-35YO: G**astric cancer** with **upper endoscopy** =\> every **2–3 years**
39
**Familial juvenile polyposis** increases risk \_\_\_\_\_\_
**Adenocarcinoma by 50%.**
40
**PTEN multiple hamartoma syndrome (Cowden disease**) has what findings on PE? Increases risk of what?
* **Harmatomatous polyps** and **lipomas** t/o _GI tract,_ _trichemmonas_ and _cerebellar lesions._ * _Thyroid, breast and GU tract cancers_
41
**Angioectasias (angiodysplasias)** cause what kind of bleeding? Who is it most common in?
**Painless bleeding** ranging from [melena = hematochezia = **occult blood loss]** * Melena if above ligament of trietz **Chronic renal failure** or **aortic stenosis.**
42
Esophageal cancers: **Esophageal SqCC** = Most common type of esophageal cancer in the world * Who is it found in? * RF? * Symptoms? * Dx * Located?
* **AA Males \>50** * **Smoking + alcochol** * Esopheageal disorders: achalasia, HPV, Plemmer Vinson syndrome, Tyolsis * Progressive dysphagia, WL, anorexia, bleeding, hoarsness and cough * EGD + biospy * 50% in the middle 1/3) *
43
Esophageal cancers: * **Esophageal Adenocarcinoma** * Who is it found in? * RF? * Dx * Located?
* Caucasian Males * Barrets metaplasia =\> dysplasia =\> adenocarcinoma * EGD + biopsy * Distal 1/3
44
**Gastric Adenocarcinoma** * Histology: * Signs: * RF:
* Signet ring cells * Linitis plastica, virchows node * RF * Dietary factors
45
**_Colon cancer (adenocarcinoma)_** * Age of onset: \_\_\_ * Occurs in high prevelance in people with \_\_\_\_\_\_\_\_\_\_\_. * When should we start screening?
* \>45YO * Strep bovis bacteremia * 45 YO: If 1st degree relative = starts at 40YO or 10 years earlier than 1st degree relative diagnosed.
46
In patients with **Colon Cancer**, early diagnosis is done how?
Screen asympmatic patienst with **fecal occult blood testing**
47
1. Rectal bleeding, altered bowel habits, abdominal or back pain 2. Anemia, occult blood in stool, WL; perforation, fistula, volvulus, inguinal hernia ## Footnote **What kind of colon cancers?**
1. L 2. R
48
Painless jaundice, N/V, WL, Steatorrhea. If pain, typically mid epigastric that radiates to the back, hurts most at night when laying down. Sxs of \_\_\_\_\_\_
Pancreatic cancer
49
50
Treatment and managment of patient wit**h Liver cancer: hepatocellualr caricnoma**
1. Surgical resection or liver transplant = therapeutic but rarely successful 2. Radiofrquency ablation 3. TACE (transcathetic arterial embolization)
51
**_LIVER (BILE DUCT) CANCER: CHOLANGIOCARCINOMA_** Classic risk factor is \_\_\_\_\_\_\_.
**Primary sclerosingcholangitis (PSC)**
52
* Which of the following usually has **non-bloody diarrhea?** * **Mimic appendicits?** * Treated with **corticosteroids**, **corticosteroids**, **immunomodulating agent**s, and **biologic agents, ABX** * One question we should ask in Crohns UC/Crohns?
* **Crohns; MC in TI =\>** * **RLQ =\> Acute iletis =\> mimic appendicits** * recently started to smoking?
53
\_\_\_\_\_\_\_ is associated with the cessation of smoking.
**UC**: Bloody diarrhea + fecal urgency
54
What is the **treatment** of **UC**?
1. Corticosteroids, immunomodulatingagents, and biologic agents 2. **Surgery** = curative
55
**Chronic hepatitis** * What is it? * Common symptoms? * What is seen in HBV HCV? * Diagnosis
* Chronic inflammtion of the liver for at least 6 months. * Fatigue, Malaise * **HBV** = **polyartertis nodosa** * **HCV** = **mixed cryoglobinemia** * Dx: **Biopsy for Histology**
56
\_\_\_\_\_\_\_\_\_\_\_\_\_ and/or _____________ can tell us whether or not we have f**ibrosis (cirrhosis)** in chronic hep
1. **Serum FibroSure** 2. **US elastography**
57
**SAAG \>1.1 g/dL** indicates \_\_\_\_\_\_\_
**Cirrhosis**
58
What are signs of Cirrhosis?
1. **Spider telangiectasias** (on the upper half of the body) 2. **Palmar erythema** (mottled redness of the thenar and hypothenar eminences) 3. **Dupuytren contractures** 4. Vit def (glossitis and cheilosis) 5. Jaundice 6. Caput medusa = obstruction of protal BF =\> superfical veins of abdomen and thorax = dilated
59
How can we definitively diagnose cirrhosis?
1. Biopsy =\> histological classification (grade and stage), telling us degree of fibrosis 1. Serum fibrosure 2. US elastography
60
Cirrhosis, what do we see on the following? * CBC * INR * Chemistry * Serum * US
* CBC * Microcytic anemia d/t blood loss; macrocytic due to folate def * Pancytopenia (hypersplenism) = Low platelet count * pa * Prolonged PT on INR * Chemistry * Glucose disturbances * Hypoalbuminemia * Serum * Viral etiology =\> HBsAg, anti-HBc, anti-HBs, anti-HCV, anti-HDV * •Fe, total iron-binding capacity, ferritin (Hemochromotosis) * Antimitochondrialantibody (AMA) [Primary Biliary Cirrhosis] * Smooth-muscle antibody (SMA), anti-liver/kidney microsomal (anti-LKM) Ab, ANA (Autoimmune) * Ceruloplasmin(Wilson’s Disease) * α1antitrypsin (and phenotyping) [α1antitrypsin deficiency] *
61
Abdominal US with doppler stufy for Cirrhosis will show what?
establish patency of the splenic, portal, and hepatic veins
62
Patients with **Cirrhosis** * ___________ is the most important in in tx and management of cirrhosis * Receive the following vaccines: * ______ are CI * Avoid the following drugs:
* ABSTAIN FROM ALCOHOL * HAV, HBV, pneumococcal and yearly influenza shot * NSAIDS are CI * ACE-I and Angiotensin II ANT should be avoided.
63
How do we treat ascities and edema seen in Cirrhosis?
1. BEd rest and low Na diet 2. If not =\> Sprinolacton (watch for hyperkalemia) + furosomaide
64
Surgical internvention for acites and edema in cirrhosis? Complications
**TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS/TIPSS)** * hepatic encephalopathy, infection, shunt stenosis, shunt occlusion
65
**Malabsorption** Symptoms
**1. Steatorrhea** **2. OSmotic diarrhea** **3. WL** **4. Nutritiona defiiency**
66
**Significant diarrhea** WITHOUT _________ NOT likely to be due to malabsorption
**WL**
67
Malabsorption disorders: small bowel mucosal disorders
1. Celiacs 2. Whipple 3. Bile salt malabsorption 4. Crohns Disae
68
Pancreatic disease/insufficiency caues of malabsorption
1. CF 2. Pancreatic carcinoma 3. chronic pancreatitit
69
Only 10% have a clinical diagnosis of celiac disease =\> most cases are\_\_\_\_\_\_
undiagnosed or asymptomatic
70
**Celiac Sprue** only develops in people with ________ (95%) or _____ (5%) class II molecules (40% of population)
Only develops in people with the **HLA-DQ2**(95%) or -**DQ8** (5%) class II molecules (40% of population)
71
Celiac atypical symptoms
1. **Dermatitis herpetiformis** 2. **iron deficiency anemia** 3. **osteoporosis**
72
Older children and adults are _____ likely to manifest signs of serious malabsorption in Celiacs
less
73
In **celiacs**, Many adults have minimal or no gastrointestinal symptoms but present with extraintestinal:
1. Fatigue 2. Depression 3. Iron deficiency anemia 4. Osteoporosis 5. Short stature 6. Delayed puberty 7. Amenorrhea 8. Reduced fertility
74
How do we diagnose celiacs? What can exclude diagnosis?
1. Abnormal serology 2. Small bowel biopsy Exclude: NL biopsy
75
1. In patients with IgA deficieny with **celiacs**: measure ______ antibodies to \_\_\_\_\_\_\_\_\_. 2. When do all AB become undectable?
* **IgG antibodies to deamidatedgliadin peptides (anti-DGP)** * **3-12 months after dietary withdrawal**
76
What do we see on endoscopy + biopsy in celiac disease?
* atrophy or scalloping of the duodenal folds may be observed * complete loss of intestinal villi
77
Most common reason for treatment failure in Celiacs is \_\_\_\_.
is incomplete removal of gluten.
78
\_\_\_\_\_\_\_\_\_\_\_\_ scanning is recommended for all patients with **celiac sprue** to screen for **osteoporosis**.
## Footnote **Dual-energy x-ray densitometry scanning**
79
PAncreatic Insuffiency * MC causes * leads to
* * Chronic pancreatitis, cystic fibrosis, or pancreatic cancer * Significant steatorrhea(due to malabsorption of triglycerides
80
Levels of what are DECREASED in pancreatic insufficiency?
1. Decreased fecal chymotrypsin 2. Decreased Pancreatic fecal elastase (\<100mcg/gram)
81
**Bile salts** are resorbed in the \_\_\_\_\_\_\_\_\_. This area is removed in _______ =\> \_\_\_\_\_\_
* Terminal ileum * Crohns * Insuffiencnet intraliminal bile salts
82
Sx in **Bile salt malabsorption**
* Mild steatorrhea * Watery secreteory diarrhea * WL is minimal * Cannot absorb vit ADEK * =\> bleeding, osteoporis and hypocalcemia
83
Sx of Whipple Disease
1. Chronic Diarrhea 2. Malabsorption 3. WL
84
Dx Whipples Tx?
Endoscopy with Duodenal biopsy •periodic acid Schiff (PAS)-positive macrophages with characteristic bacillus ABX that dont cross BBB
85

GI II Exam 1 (19 decks)

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