Gastric Disorders/Small Intestine

Question 1

Gastritis

Answer 1

• Definition: inflammatory/infectious process of gastric mucosa
• Acute etiology:
  
  • Most common cause = NSAIDs; EtOH, heavy cigarette use, caffeine
• Chronic Etiology:
  
  • Most common cause = H. Pylori; physiologic stress (burns, infections),, NSAIDs, EtOH
• S/sxs:
  
  • epigastric pain
    
    • Worsened with eating
  • N/V
  • anorexia
  • GI bleed
  • ***most commonly asymptomatic +/- GI bleed (melena, hematochezia, hematemesis)
• Dx:
  
  • Endoscopy = GOLD STANDARD though clinical diagnosis is more frequent
  • H. pylori testing should be done if no other obvious causes are present
• Tx: D/c the offending agents!!
• For H. Pylori: CAP = Clarithromycin, Amoxicillin, and a PPI; BID x 2 weeks, for PPIs continue for an additional 6-10 weeks
  
  • If penicillin allergy = give metronidazole
• If not H. pylori can give a PPI for 8-12 weeks +/- an H2 blocker (famotidine/pepcid)

Question 2

Peptic Ulcer Disease: Definition, Risks, Types

Answer 2

• Definition: break in the gastric or duodenal mucosa >5mm in diameter that penetrates through the muscularis into the submucosa.Most common cause of upper GI bleed.
• Risks:
  
  • H. pylori, NSAIDs, tobacco, alcohol, age >50 yo, family hx of PUD, COPD, CKD
• types:
  
  • Gastric ulcers: more likely to become malignant, peak at the 6th decade
  • duodenal ulcers = Most common, usually benign

Question 3

S/sxs of Gastric Ulcer, Duodenal Ulcer, vs Bleeding Ulcer in Peptic Ulcer Disease

Answer 3

• Gastric Ulcer:
  
  • dyspepsia (burning, gnawing, epigastric pain) worse with food
  • n/v, weight loss
• Duodenal Ulcer:
  
  • Dyspepsia relieved with food or antacids, aggravated by hunger (usually at night, 2-5 hours after a meal)
  • no weight loss b/c no pain with eating
• Bleeding Ulcers:
  
  • hematamesis
  • melena
  • hematochezia (if enough bleeding)

Question 4

Peptic Ulcer Disease: PE, complications, dx, and tx

Answer 4

• PE:
  
  • epigastric tenderness
    
    • tachycardia and orthostasis suggest dehydration
    • severe tender, board-like abdomen suggest peritonitis due to perforation
• Dx:
  
  • Upper endoscopy with Biopsy = Gold Standard
    
    • all gastric ulcers need repeat upper endoscopy to document healing (even if asymptomatic)
  • Other H. pylori testing:
    
    • urea breath test: breathing out labeled urea
    • H. pylori stool antigen: useful for diagnosis & eradication
    • Serologic antibodies: only useful in confirming new dx
• Tx:
  
  • Quadruple therapy: bismuth subsalicylate, tetracycline, metronidazole, & PPI x 14 days
  • Triple therapy: Clarithromycin, amoxicillin, &PPIx 10-14 days (1st line)
• Complications:
  
  • GI bleeding
  • Bowel penetration
  • Perforation: GI emergency, sudden onset of severe abdominal pain, air under the diaphragm, duodenal ulcers = most common (thin wall)
  • gastric outlet obstruction: d/t edema & scarring -→ bloating, early satiety, N/V, pain just after eating
  • Gastric cancer: gastric ulcer (H.Pylori)

Question 5

Zollinger-Ellison Syndrome

Answer 5

aka Gastrinoma

• Definition: gastrin–secreting neuroendocrine tumor → parietal cells release excess HCl → Severe PUD & diarrhea. Most commonly seen in the duodenum & pancreas
• S/sxs:
  
  • severe Peptic Ulcer Disease refractory to tx
  • chronic diarrhea
  • weight loss
• Dx:
  
  • elevated serum gastrin levels
• Tx:
  
  • tumor resection if local
  • if metastatic = lifelong high-dose PPIs
  • *Liver & abdominal lymph nodes = most common sites for METS

Question 6

Pyloric Stenosis

Answer 6

• Pathophys:
  
  • overgrowth/hypertrophy of the pylorus → stomach contents are unable to pass through the gastric outlet → leads to increased pressure → forced vomiting may occur
• S/sxs:
  
  • 3-6 week old baby with non-bilious “projectile vomiting” after meals
  • -after vomiting the child cries from hunger
  • -dehydration
• PE:
  
  • Pyloric sphincter may be palpable→ described as olive shaped
• Dx:
  
  • pyloric US
  • labs to evaluation for dehydration and electrolyte status
• Tx:
  
  • Pyloromyotomy

Question 7

Gastric Carcinoma

Answer 7

• Types:
  
  • adenocarcinoma = most common
  • lymphoma, carcinoid tumors, stromal, sarcomas
• Risks:
  
  • H. Pylori (associated with 90%), males > 40 yo, preserved foods (cured meats), obesity, pernicious anemia, chronic gastritis, smoking,
  • -non-hodgkin lymphoma
• S/sxs:
  
  • * Most patients very advanced at the time of presentation
  • Unintentional weight loss
  • Persistent Abdominal pain
• PE:
  
  • palpable abdominal mass
  • Virchow’s node:
    
    • supraclavicular node
  • St. Mary Joseph’s Node
• Dx:
  
  • upper endoscopy with biopsy
• Tx:
  
  • **usually a poor prognosis**
  • early disease: endoscopy resection
  • late disease: gastrectomy, chemo
• Protective: aspirin & NSAIDs, diet high in fruits and veggies

Question 8

Celiac Disease: Definition, General Info, S/sxs

Answer 8

• Definition:
  
  • inflammation of the small bowel secondary to the ingestion of gluten-containing food
  • villous atrophy occurs as a result of this autoimmune disease trigger → decreased absorptive area → malabsorption (of fat)
• General Info:
  
  • HLA-DQ2 and/or DQ8 loci
  • Autoimmune disorder
    
    • → runs in families
  • Female > Male usually 10-40 years old
  • Most common in N European ancestry
• S/sxs:
  
  • diarrhea, steatorrhea (will have floating stools), flatulence, weight loss
  • weakness, and abd distention
  • infants and children present with FTT
• Malabsorption symptoms:
  
  • weight loss, poor growth, severe anemia, neuro disease from B12 deficiency
    *

Question 9

Celiac Disease: PE, Dx, & Tx

Answer 9

• PE:
  
  • dermatitis herpetiformis: herpes -like rash of grouped vesicles that’s intensely pruritic INTENSELY ITCHY (like poison oak, but not in streaks)
• Dx:
  
  • ALL TESTING SHOULD BE PERFORMED ON A GLUTEN RICH DIET
  • IgA antiendomysial (EMA) and Antitissue transglutaminase (anti-TTG) antibodies
  • Tissue transglutaminase antibodies (TTG-IgA): the TTG-IgA test will be positive in about 98% of patients with celiac disease who are on a gluten-containing diet
  • endoscopic intestinal mucosal biopsy = definitive diagnosis
    
    • if biopsy & serum tests disagree = DQ2 & DQ8 genotyping
• Tx:
  
  • Gluten free diet → caution with oats (no wheat, barley, rye)
  • supplementation may be needed: iron, vitamin B12, folic acid, calcium, Vitamin D

Question 10

Volvulus

Answer 10

• Definition:
  
  • twisting of any part of the bowel at its mesenteric attachment site → obstruction & impaired vascular supply. Most commonly occurs in the sigmoid colon & cecum in adults, midgut & ileum in children
• S.sxs:
  
  • crampy abd pain and distention
  • constipation
  • N/V
• PE:
  
  • tympanic abd
  • tenderness to palpation
• dx:
  
  • Adbominal CT = dilated sigmoid colon
  • Abdominal XR = bent inner tube or “coffee bean” sign
• Tx:
  
  • endoscopic decompression with rectal tube left in place to decrease acute recurrence
    
    • decompression often followed by surgery d/t high rate of recurrence

Question 11

Intussusception

Answer 11

• Definition:
  
  • the invagination of a proximal segment of the bowel into the portion just distal to it
• Risk factors:
  
  • ⅔ of cases seen in age 6-18mo of age, esp esp males, esp after viral infections
  • adults = think NEOPLASM!
• S/sxs:
  
  • Classic Triad:
    
    • 1. Vomiting
    • 2. Abd pain
    • 3. Passage of blood per rectum “currant jelly” stool (stool mixed with blood & mucus)
  • sudden onset of significant colicky abd pain that recurs Q 15-20 min often with vomiting
• PE:
  
  • sausage shaped mass in RUQ
• Dx:
  
  • For kids: barium or air enema can be both diagnostic & therapeutic
  • Best initial test = abd U/S looking for target or donut sign
  • then Abd XRay → Crescent sign or Bull’s eye target
• tx:
  
  • Children: barium or air enema
    
    • surgery if refractory
  • Adults = surgery

Question 12

Small Bowel Obstruction

Answer 12

• Definition:
  
  • partial or complete mechanical block of the small intestine
• S/sxs:
  
  • 4 hallmark sxs:
    
    • 1.Crampy abdominal pain, 2. abdominal distention, 3.vomiting (Bilious), and 4.obstipation
• PE:
  
  • High-pitched tinkling bowel sounds with visible peristalsis or ABSENT (SEVERE)
• Dx:
  
  • Abdominal KUB Xray: multiple air-fluid levels in a “step-ladder” appearance, dilated bowel loops.
• Tx:
  
  • Non-strangulated:
    
    • NPO (bowel rest), IV fluids & electrolytes. Bowel decompression if severe vomiting
  • Strangulated:
    
    • surgical intervention

Question 13

Answer 13

Small bowel obstruction

Question 14

Acute Peritonitis

Answer 14

• Definition: inflammation of the visceral and parietal peritoneum
  
  • usually infectious and often life-threatening!!
• Risk factors:
  
  • IBD, appendicitis, PUD, diverticulitis, surgery
• S/sxs:
  
  • acute, severe abdominal pain (diffuse or localized)
  • fever
  • NVD, anorexia, decreased UO, polydipsia, obstipation, fatigue
• PE:
  
  • guarding, rigidity
  • absent or hypoactive bowel sounds
  • hypotension
• Dx:
  
  • no labs needed
  • upright CXR and abdominal series will show FREE AIR under the diaphragm
    
    • → lack of free air does not rule out perforated viscus → need to do CT if you suspect
  • complications:
    
    • more susceptible to adhesions → increased risk of bowel obstruction
• Tx:
  
  • Broad spectrum Abx, ex lap

Question 15

Spontaneous Bacterial Peritonitis

Answer 15

• definition:
  
  • ascites fluid infx seen in patients with cirrhosis (E. coli, Klebsiella)
• S/sxs:
  
  • Suspect in patients with ascites & any of the following:
    
    • temp > 37.8C (100F)
    • abd pain or tenderness
    • AMS
• Dx:
  
  • Paracentesis → take fluid from abd (this will also relieve pressure and therefore pain) → ≥ 250 cells/mm3 of neutrophils
  • send for cx
• Tx:
  
  • Admit for IV abx (3rd gen cephs) cefotaxime > ceftriaxone

Question 16

Mesenteric Ischemia

Answer 16

• Definition: stroke of the gut
• most commonly obstructs the superior mesenteric artery
• full gut necrosis can occur within 6 hours
• Causes:
  
  • CAD, atherosclerosis, Afib, HF, valvular disease
• S/sxs:
  
  • severe colicky pain that is poorly located
  • normal appearing abd and exam
  • **Pain out of proportion to exam**
• Dx:
  
  • abd Xray: may show “thumb-printing”
  • CT Angio → Test of Choice
• Tx:
  
  • Acutely: will need IV fluids and IV abx
  • Immediate surgical intervention for necrotic bowel → if cause is emboli, will get embolectomy
  • if venous thrombus, will require anti-coag
  • If chronic, will require revascularization

Question 17

Appendicitis

Answer 17

• definition:
  
  • obstruction of the lumen of the appendix, results in inflammation & bacterial overgrowth
• Risks:
  
  • 10-30 yrs
• Etiology:
  
  • Fecalith & lymphoid hyperplasia = most common
  • inflammation, malignancy or foreign body
  • Lymphoid hyperplasia due to infx = most common cause in kids
• PE:
  
  • Rebound tenderness at McBurney’s Point
  • Rovsing sign: RLQ pain with palpation of LLQ
  • Obturator sign; RLQ pain with internal rotation of hip
  • Psoas sign: RLQ pain with hip extension while in Left lateral decubitus position
• Dx:
  
  • clinical diagnosis
  • In adults: CT scan of abdomen/pelvis = imaging of choice with u/s and MRI reserved for radiosensitive populations (pregnant women, children)
  • CBC - neutrophilia
• Tx:
  
  • appendectomy

Question 18

McBurney’s Point

Answer 18

⅓ between ASIS to umbilicus

RLQ

deep tenderness = appendicitis

• Also where you test for rebound tenderness
  
  • release the pressure quickly!!

Question 19

Rovsing’s Sign

Answer 19

Palpate on the LLQ and the pt will feel pain on the RLQ

suggests appendicitis

Question 20

Psoas Sign

Answer 20

Have pt lie supine and lift one, straight leg against resistance of your hand

• stretches the psoas muscle which puts pressure on the appendix
  
  • sign is Positive if pt feels more abd pain when lifting leg

Question 21

Obturator Sign

Answer 21

When the pt lies supine and you bend the pts leg moving the knee laterally

• this stretches the obturator muscle = puts more pressure on appendix
  
  • this sign is positive if abd pain increases

Question 22

Murphy’s Sign

Answer 22

Press firmly upward on the RUQ and ask pt to take a deep breath

• if gall bladder is enlarged it will push down on the hand and elicit pain.
  
  • sign is positive if pt stops breathing due to pain

Question 23

Fluid Thrill

Answer 23

Tests for Ascites

• requires 3 hands:
  
  • have one person place hand on abdomen and push down
    
    • I will have one hand on each side of abdomen and tap
      
      • if fluid is present I will be able to feel the fluid wave on the opposite side

Question 24

Castell’s Spot

Answer 24

feeling for splenomegaly

• percuss at castell’s spot and have pt inhale and exhale
  
  • if you hear dullness on percussion during this inhale/exhale = positive indication for splenomegaly