Final Exam Qs Flashcards
How many stools per day is considered acute diarrhea?
> 3 large volume stools per day
Sx are present for how long with acute diarrhea?
<2 weeks
What % of acute diarrhea is due to infectious agents?
90%
What is the 2nd MC cause of acute diarrhea?
Medications
Pt has acute diarrhea with fever and/or chills. Your next question is “did you notice any have blood or mucous in the diarrhea?” And what does it mean if they say yes vs no?
No: gastroenteritis AKA stomach flu
Yes: dysentery
What is gastroenteritis?
Stomach flu
Sx of gastroenteritis?
Nausea/vomiting Large watery NON-blood stools Low grade fever Diaphoresis Abdominal cramps
What is Diaphoresis
Sweating
MC cause of gastroenteritis (GE)?
Viruses e.g. norovirus and rotavirus
How long before viral gastroenteritis sx improve?
24-48 hours
Gastroenteritis “food poisoning” is due to what?
Ingesting a toxin produced by bacteria e.g. staphylococcus aureus
How long before food poisoning gastroenteritis sx improve?
12 hours
How do you treat gastroenteritis?
Supportive care when its acute, non-bloody diarrhea
- frequent sips of liquid
- BRAT diet (banana, rice, applesauce, toast)
- avoid dairy
- anti-diarrheal are soft for pts w/o dystentery
T/F stool studies and blood tests are NOT usually necessary/useful in acute gastroenteritis
True
Sx of dysentery
Bloody diarrhea (or mucous) of any cause
- fever
- nausea/vomiting
- abdominal pain
- tenesmus
What is tenesmus
Urge to have bowel movement even when colon is empty
If dysentery is caused by infection, what is it called?
Infectious colitis
Bacterial causes of infectious dysentery include
*Salmonella
*Shigella
*Campylobacter
*Enterohemorrhagic escherichia coli (EHEC) aka shiga toxin producing e coli (STEC)
E coli = travelers’ diarrhea in Asia, Africa, Central/South America
Entamoeba histolytica = parasitic cause for travelers in India and tropical locations
How is Travelers’ diarrhea transmitted? What about in the US?
*Fecal-oral via contaminated food/water
- US: more likely from pathogens in undercooked foods
- poultry/eggs: salmonella
- hamburger: E. coli
T/F patients with dysentery need to be referred for stool studies
True
- fecal leukocytes (may be helpful in deciding which patients are more likely to have positive stool cultures)
- stool cultures
- stool O&P if parasite suspected
How do you Tx dysenery if pt is tolerating liquids? If pt is severely dehydrated (dizzy, severe fatigue, tachycardic)?
Refer to PCP urgently for stool studies and antibiotics
Refer to ED for IV fluids and antibiotics
Do you give antidiarrheal meds to patients with dysentery?
NO! Can cause prolonged fever, may lead to toxic megacolon and perforation and increases risk of hemolytic uremic syndrome (HUS) in pt with STEC: Shiga toxin producing E. coli
What is the fxn of the small intestine?
Nutrient digestion and absorption
Deliver undigested food/waste to the colon for elimination
Protect against external environment with the GALT - gut associated lymphoid tissue
What % of GALT - gut associated lymphoid tissue is in small intestine?
70%
Majority of digestion occurs where?
Duodenum - duodenal brush border has enzymes that combine with bile from the liver and the enzymes and bicarb from the pancreas to breakdown all macronutrients into simple forms
The majority of nutrient absorption happens where?
Jejunum
What happens when the small intestine goes rogue?
Malabsorption
- lactase deficiency
- celiac disease
What is the MC Sx with Malabsorption?
Diarrhea
What is the difference b/w the 2 main watery types of diarrhea?
Osmotic
- water drawn into gut lumen by nondigested particles
- stops when patient fasts
E.g. lactase def.
Secretory
- intestinal crypt cells secrete too much water
- does NOT stop when pt fasts
E.g. ibd
What is the MC maldigestion syndrome of the intestines?
Lactase deficiency (aka lactose intolerance)
It’s a deficiency in the small intestinal brush border enzyme lactase (NOT allergy to lactose)
What ethnic group gets lactase def most often?
Asians
Fxn of lactase? Lifespan of lactase?
Breaks down milk sugar (lactose) into glucose + galactose
Lactase levels are highest at birth and start to decline by 3.5-5 yo
What is the pathophysiology of lactase deficiency?
Unabsorbed lactose draws water into the small bowel causing diarrhea
Unabsorbed lactose enters colon, is metabolized by colonic bacteria = excess gas production
Sx of lactase deficiency?
- Dairy intake, then:
Bloating Flatulence Cramping abdominal pain Foul smelling stools Osmotic diarrhea
**NO weight loss
DDX list for lactase deficiency (5)?
Celiac IBS Inflammatory bowel disease (IBD) Diverticulitis Acute gastroenteritis
You suspect your patient has lactase def, what do you do to evaluate?
1 - trial of going off dairy OR
2 - lactose hydrogen breath test: pt eat lactose, measure breath hydrogen concentration 3-8 hrs later, increased hydrogen suggests lactose def
Tx for lactase def?
Avoid lactose foods
Take lactase enzyme replacement with dairy
What is an AI disorder of small intestine with an abnormal response to foods containing gluten?
Celiac disease
Epidemiology of celiac disease
W>M
Family history increases risk
Associated with other AI conditions
What is the pathophysiology of celiac disease?
1 - GALT determines that gliadin is the enem
Gliadin is a glycoproteins within gluten and is found in wealth and other grains: oats, rye, barley, millet
2 - GALT triggers an enhanced lymphocyte response to gliadin and autoantibodies are produced
3 - autoantibodies trigger inflammatory cascade which causes villous atrophy and decreased absorptive ability
Sx of celiac?
Diarrhea (85%) Fatigue (80%) Weight loss (45%) Abdominal distention (33%) Excessive flatus or eructation (28%) Large, bulky, foul smelling stools
35% are asymptomatic
Eructation?
A belch
What are signs of malabsorption? What about a pathognomonic sign for celiac disease from the PE?
Anemia 50% Vitamin malabsorption (esp fat soluble vitamins a, d, e, k)
PE sign: dermatitis herpetiformis 10-20% of cases is pathognomonic for celiac disease
How do you diagnose celiac disease? Name and describe the gold standard procedure
Antibody testing for
1 - anti-tissue transglutaminase (TTG) antibody and
2 - IgA levels (because TTG is IgA antibody)
Procedure: endoscopic biopsy of distal duodenum showing villous atrophy
How do you manage celiac disease?
Check labs for sequelae of Celiac’s
DEXA for osteoporosis
Tx is STRICT GF diet
How long after going GF does it take for clinical Sx to heal? For the gut lining to heal?
2-7 days for clinical sx
3-12 months for healing
What is inflammatory bowel disease? What are 2 subtypes of this disease
Chronic inflamm process in GI
- Crohn’s disease
- ulcerative colitis (UC)
Who gets IBD?
Caucasians Teen-30 yo and 60-80yo M=W Industrialized nations SMOKING increases risk of Crohn’s, decreases risk of UC
Pathophysiology
Inappropriate inflammatory response to normal intestinal flora
Where does IBD happen?
Crohn’s = skip lesions happen anywhere except rectum
UC = continuous lesions happen at sigmoid colon
85% of crohn’s cases involve ________; 1/2 cases involve _______ (location)
Terminal ileum; small and large intestine
Spares the rectum
What do the ulcers look like in crohn’s disease? How deep can ulcers be?
Linear ulcers: cobblestone
Crohn’s is transmural: may affect entire depth of bowel wall
Sx for chron’s
Constant abdominal pain Weight loss Chronic diarrhea (if bloody, suggests UC)
PE Signs of Crohn’s
Vitals = occasional low grade fever
RLQ abdominal tenderness
Possible abdominal mass
Perineal abnormalities common
What imaging study/studies would you chose to see the ileum for crohn’s? What labs would be abnormal?
Barium contrast xray
Abdominal ct and capsule endoscopy
Elevated ESR/CRP
CBC = anemia
How do you diagnose Crohn’s disease?
Colonoscopy ONLY done when not in acute flare-up
What, if seen on biopsy, is pathognomonic for crohn’s?
Granulomas
Tx for crohn’s
Anti inflammatory meds
Nutritional support
Surgery in refractory cases/complications BUT disease can recur after surgery
Flashcards on UC
UC
What is the classic pain radiation pattern
associated with pancreatitis?
A. Back pain that radiates to the abdominal RUQ
B. RUQ abdominal pain that radiates to the scapula
C. Epigastric abdominal pain that radiates straight through to the back
C. Epigastric abdominal pain that radiates straight through to the back
What is the classic area of referred pain for a
patient with gallstones?
A. Back pain that radiates to the abdominal RUQ
B. RUQ abdominal pain that radiates to the scapula
C. Epigastric abdominal pain that radiates straight through to the back
B. RUQ abdominal pain that radiates to the scapula
Which of the following conditions on the RUQ
abdominal pain DDx is often associated with postprandial pain?
A. nephrolithiasis
B. hepatitis
C. cholecystitis
D. all of the above
C. cholecystitis
Which of the following conditions on the RUQ
abdominal pain DDx might be associated with
nausea and vomiting?
A. nephrolithiasis
B. hepatitis
C. cholecystitis
D. all of the above
D. all of the above
Which of the following conditions on the RUQ
abdominal pain DDx is likely to present with
jaundice and itching?
A. nephrolithiasis
B. hepatitis
C. cholecystitis
D. all of the above
B. hepatitis
