Essentials of Diagnosis Flashcards
Dyspepsia:
Predominant epigastric pain.
May be associated epigastric fullness, nausea, heartburn, or vomiting.
Endoscopy is warranted in all patients age 60 years or older and selected younger patients with alarm features.
In all other patients, what testing is recommended?
Testing for Helicobacter pylori is recommended; if positive, antibacterial treatment is given.
Dyspepsia:
Patients who are H pylori negative or do not improve after H pylori eradication should be prescribed a trial of?
Patients with refractory symptoms should be offered a trial of tricyclic antidepressant, a prokinetic agent, or psychological therapy.
empiric proton pump inhibitor therapy
Acute noninflammatory diarrhea…
Watery, nonbloody
Usually mild, self-limited
Caused by a virus or noninvasive bacteria.
Diagnostic evaluation is limited to whom?
patients with diarrhea that is severe or persists
beyond 7 days
Acute inflammatory diarrhea…
Blood or pus, fever.
Usually caused by an invasive or toxin-producing bacterium.
Diagnostic evaluation requires testing as clinically indicated for Clostridioides difficile toxin, and ova and parasites and what else?
routine stool bacterial testing (including E coli O157:H5 and O157:H7)
Chronic diarrhea…
Diarrhea present for longer than 4 weeks.
Before embarking on extensive workup, common causes should be excluded, such as?
medications, chronic infections, and irritable bowel syndrome.
Acute upper GI bleeding…
Hematemesis (bright red blood or “coffee grounds”).
- Most cases are melena. What might you see in massie upper GI bleeds?
- Volume status to determine severity of blood loss. Don’t rely on _____ because it’s a poor early indicator of blood loss.
- hematochezia
2. Hematocrit
For the diagnosis of acute upper GI bleedings, what is potentially also therapeutic?
endoscopy
Acute Lower Gastrointestinal Bleeding (essentials of diagnosis)…
- What is usually present?
- Evaluation with what in stable patients?
Massive active bleeding calls for evaluation with sigmoidoscopy, upper endoscopy, angiography, or nuclear bleeding scan.
- Hematochezia
2. Colonoscopy
Hx of chronic liver dz and ascites…
FEVER and abd pn…
Uncommon peritoneal signs (i.e., pn w/o TTP)
ascitec PMN > 250
Spontaneous bacterial peritonitis
GERD…
- Heartburn; may be exacerbated by meals, ____, or recumbency.
- Typical uncomplicated cases do not require ____ studies.
- Endoscopy demonstrates abnormalities in one-third of patients. So?
- bending
- diagnostic
- Most patients don’t have abnormalities
Infectious esophagitis…
Immunosuppresed patient
Odynophagia, dysphagia, chest pn
How do we establish diagnosis?
(May consider empiric tx w/ fluconazole… then…)
Endoscopy WITH biopsy
Gradual, progressive dysphagia for solids and liquids.
Regurgitation of undigested food.
Barium esophagogram with “bird’s beak” distal esophagus.
Esophageal manometry confirms diagnosis.
achalasia
Develop secondary to portal hypertension.
Found in 50% of patients with cirrhosis.
One-third of patients with _____develop upper gastrointestinal bleeding.
Diagnosis established by upper endoscopy.
esohpageal varices
Dilated submucosal veins that can cause severe upper GI bleeding w/ a high mortality rate
Esophageal varices
Most common cause of portal HTN (and thus esophageal varices)
cirrhosis
Increased risk for bleeding for esophageal varices…
(1) the ___ of the varices
(2) the presence at endoscopy of ____ (longitudinal dilated venules on the varix surface)
(3) the severity of liver disease (as assessed by Child scoring)
(4) active alcohol abuse
- size
2. red wale markings
Ssx of esophageal varices?
REVIEW SSX OF UPPER GI BLEEDING!
seriously review that
Tx for esophageal varices?
Hemostasis/stablization of the pt
Hematemesis; usually self-limited.
Prior history of vomiting, retching in 50%.
Endoscopy establishes diagnosis.
MWT
Most commonly seen in alcoholic or critically ill patients, or patients taking NSAIDs.
Often asymptomatic; may cause epigastric pain, nausea, and vomiting.
May cause hematemesis; usually insignificant bleeding.
Erosive & Hemorrhagic “Gastritis” (Gastropathy)
Hx of dyspepsia in 80-90% in pts
Ulcer symptoms characterized by rhythmicity and periodocity
ulcer complications present w/ out antecedent ssx in 10-20% of patients
Most NSAID induced ulcers are asymptomatic
Upper endoscopy w/ gastric biopsy for H pylori is the diagnostic procedure of choice in most patients
Gastric ulcer bipsy/documentation of complete healing necessary to exclude malignancy
PUD
“Coffee grounds” emesis, hematemesis, melena, or hematochezia.
Emergent upper endoscopy is diagnostic and therapeutic.
Upper GI bleed from PUD
Peptic ulcer disease; may be severe and atypical
.
Gastric acid hypersecretion.
Diarrhea common, relieved by nasogastric suction.
Most cases are sporadic; 25% with multiple endocrine neoplasia type 1 (MEN 1).
zollinger ellsion syndrome
Typical symptoms: weight loss, chronic diarrhea, abdominal distention, growth
retardation.
Atypical symptoms: dermatitis herpetiformis, iron deficiency anemia, osteoporosis.
Abnormal serologic test results.
Abnormal small bowel biopsy.
Celiac disease
Multisystem disease.
Fever, lymphadenopathy, arthralgias.
Weight loss, malabsorption, chronic diarrhea.
Duodenal biopsy with periodic acid-Schiff (PAS)-positive macrophages with
characteristic bacillus.
Whipple dz
Diarrhea, bloating, flatulence, and abdominal pain after ingestion of milkcontaining products.
Diagnosis supported by symptomatic improvement on lactose-free diet.
Diagnosis confirmed by hydrogen breath test
lactase defiency
Symptoms of distention, flatulence, diarrhea, and weight loss.
Increased qualitative or quantitative fecal fat.
Advanced cases associated with deficiencies of iron or vitamins A, D, and B12.
Diagnosis suggested by breath tests using glucose, lactulose, or 14C-xylose as substrates.
Diagnosis confirmed by jejunal aspiration with quantitative bacterial cultures
Bacterial overgrowth
Precipitating factors: surgery, peritonitis, electrolyte abnormalities, medications, severe medical illness.
Nausea, vomiting, obstipation, distention.
Minimal abdominal tenderness; decreased bowel sounds.
Plain abdominal radiography with gas and fluid distention in small and large bowel.
acute paralytic ilues
Severe abdominal distention.
Arises in postoperative state or with severe medical illness.
May be precipitated by electrolyte imbalances, medications.
Absent to mild abdominal pain; minimal tenderness.
Massive dilation of cecum or right colon.
acute colonic pseudo obstruction (ogilvie syndrome)
Early: periumbilical pain; later: right lower quadrant pain and tenderness.
Anorexia, nausea and vomiting, obstipation.
Tenderness or localized rigidity at McBurney point
Low-grade fever and leukocytosis.
Appendicitis
Bright red blood per rectum.
Protrusion, discomfort.
Characteristic findings on external anal inspection and anoscopic examination.
hemorrhoids
