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Herkimer 2021 > Gastro > Flashcards

Gastro Flashcards

1
Q

Etiology of pancreatitis

A

I GET SMASHWED

Idiopathic
Gallstones (45%) *especially if in common bile duct
Ethanol (35%)
Tumor
Scorpion stings
Microbiology (TB, mumps, rubella, varicella, hepatitis..)
Autoimmune (SLE, polyarthritis nodosa, Crohn’s)
Surgery/Trauma
Hyperlipidemia, hypercalcemia, hypotherma
Emboli or ischemia
Drugs (Furosemide, Estrogen, H2 blocker, valproate, abx, ASA)

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2
Q

complication of pancreatitis

A

abscess
lung-pleural effusion, pneumonia, ARDS
acute renal failure secondary to hypovolemic shock
CVS: pericardial effusion, pericarditis

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3
Q

Risk factors of Celiac disease

A
  • 1st degree relative celiac disease (7-18%)
  • T2DM (4-8%)
  • autoimmune thyroiditis (2-5%)/ autoimmune liver disease
  • down syndrome /trisomy 21
  • Turner syndrome
  • IgA deficiency (1-4%)
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4
Q

Classic and non-classic GI symptoms of Celiac disease

A

Classic:

  • abdominal distension/ bloating
  • chronic diarrhea, steatorrhea
  • anorexia
  • weight loss/FTT, muscle wasting, delayed puberty/short stature

Non-classic:

  • persistent vomiting
  • chronic constipation
  • IBS
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5
Q

Pediatric SSx of Celiac disease

A
  • anorexia
  • chronic constipation
  • delayed puberty, growth failure/FTT
  • irritability
  • recurrent vomiting
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6
Q

What are the non-GI symptoms of Celiac disease?

A

Classic non-GI:
- Dermatitis herpetiform
(often have no GI symptoms)

Non-classic
- Hema:
&raquo_space; iron/folate deficiency anemia
&raquo_space; Vitamin B12 deficiency

- Neuro: 
  >> peripheral neuropathy 
  >> ataxia 
  >>epilepsy +/- cerebral calcification 
  >> migraine 
  >> depression
  • Hepatic:
    » elevated transaminases (40-54%)
  • Gynecologic :
    » infertility, early menopause, recurrent miscarriage
  • MSK:
    » arthritis
  • Oral and dental:
    » aphthous stomatitis, dental enamel defect
  • Other:
    » osteoporosis, hyposplenism (20-70% of adults)
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7
Q

how to assess bone health in adult after diagnosed with Celiac disease

A

blood test:

  • serum calcium
  • Vitamin D
  • PTH
  • calcitonin

For CD with malabsorption
- BMD

For CD without malabsorption
- do BMD if high risk (perimenopause, menopause, male > 50 y/o, smoking, low BMD, fragility #, high tTG antibody titer)

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8
Q

What serology tests are used to diagnose Celiac disease?

A

Anti-tTG IgA & serum IgA
(tissue transglutaminase)

IF IgA deficiency, check Anti-DGP IgG
(deamidated gliadin peptide)

IF < 2 y/o, Anti-DGP IgA & IgG AND Anti-tTG IgA
and serum IgA

IF gluten free diet prior to testing, consider HLA-DQ2/DQ8

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9
Q

When to consider intestinal biopsy to diagnose Celiac disease before gluten free diet?

A

1) + serology test
2) all symptomatic pts even if serology is negative

** can also confirm with biopsy of dermatitis herpetiformis lesion

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10
Q

How to confirm Celiac disease?

A

1) Serology and histology both ++ : confirmed

2) Serology + , histology -
&raquo_space; repeat serology, consider repeat histology
consider HLA-DQ2/DQ8 testing

3) serology - , histology +
&raquo_space; consider alternative diagnosis
&raquo_space; IF no alternative dx, trial treatment of celiac diet AND consider HLA-DQ2/DQ8 testing

4) serology and history both neg: CD excluded

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11
Q

What are the food containing gluten ?

A

wheat
rye
barley
oat (?)

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12
Q

What is the management after diagnosed with Celiac disease?

A
  • Diet: gluten free diet for life
  • test and treat specific deficiency
  • BMD if suspected OP
  • referred to dietician
  • monitor for symptoms solution + repeat serology in 6 month
  • screen 1st degree relatives
  • monitoring
    » annual Anti-tTG, if increased, possible dietary contamination
    » q2yr TSH (risk of autoimmune thyroid)
    » q1yr if previously abnormal ALT, AST (risk of autoimmune hepatitis)
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13
Q

What type of malignancy do pts with refractory celiac disease have increased risk of?

A

T-cell lymphoma

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14
Q

Surgical indications of diverticulitis

A
  • unstable patients with peritonitis
  • abscess/ fistula / ruptured abscess
  • immunosuppressed
  • > = 2 attacks
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15
Q

Risk factors of Crohn’s disease

A
  • smoking

- Ashkenazi Jews

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16
Q

exacerbating factors of Crohn’s disease

A

infection
cigarette smoking
NSAIDs

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17
Q

What are the common symptoms of Crohn’s disease?

A
  • abdominal cramps
  • chronic/ nocturnal diarrhea
  • weight loss
  • postprandial cramps
  • RLQ pain
  • fistulae (w/ bladder, skin, vagina)
  • fissures
  • peri-anal abscesses
  • fatigue (from inflammation, anemia, nutritional deficiency)
  • fever
  • growth failure
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18
Q

What are the extra-intestinal symptoms of Crohn’s disease?

A

Skin:

- erythema nodosum (2-20%)
- pyoderma gangrenosum (0.5-2%) 
- perianal skin tags 
- oral mucosa lesion 
- psoriasis

Joints

- inflammatory arthopathy: both axial and peripheral 
- ankylosing spondylitis 
- sacroiliitis

Eyes:

- uveitis (17%) 
- episcleritis (29%)

Liver

- primary sclerosing cholangitis/ cholelithiasis (13-34%) 
- fatty liver

Kidney/ Bladder

- calculi 
- ureteral obstruction 
- fistula 
- nephrolithiasis

Bone: OP

Others:

- VTE/hypercoagulability (10-30%) 
- Vasculitis 
- Vitamin ADEK deficiency    
- other autoimmune conditions: pericarditis, RA, MS, celiac disease, psoriasis
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19
Q

What test can help distinguish between IBS and IBD?

A

Fecal calprotectin

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20
Q

Red flags of GERD

A
  • vomiting
  • evidence of GI bleeding
  • anemia
  • involuntary weight loss
  • dysphagia
  • chest pain
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21
Q

Lifestyle modification for GERD

A
  • weight loss if overweight
  • elevated head of bed
  • avoid meal 2-3 hours before bedtime if nocturnal GERD
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22
Q

Risks of longer term use of PPI

A
  • Hip fracture
  • C. diff
  • pneumonia
  • decreased vitamin B12, magnesium, iron, hypo-parathyroid
  • polypharmacy (nonadherence), prescribing cascade, adverse reaction, medication errors, drug interaction, ER visits and hospitalization
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23
Q

Rome IV criteria `

A

Recurrent abdominal pain on average at least 1 day / week in the last 3 months associated with 2 of the following

1) related to defecation
2) associated with a change in frequency of stool
3) associated with a change in form of stool

24
Q

Alarming symptoms of IBS

A
  • vomiting
  • GI bleeding
  • unexplained weight loss
  • abdominal mass
  • dysphagia
  • anemia
25
Q

Important history of IBS when diagnosing?

A
  • Family hx of GI cancer, IBD, celiac
  • nocturnal defecation
  • new symptoms in a patient > 45 years old
26
Q

Aggravating factors of IBS

A
  • EtOH
  • Caffeine
  • Fat
  • Fiber
  • Sorbitol
  • Stress
  • Menstruation
27
Q

Management of IBS

A
  • reassurance, education (lifestyle more effective than medications)

Diet:
» FODMAP diet short term (4 wks) w/ dietician guidance
» Increase Fiber > 25 mg /day
» probiotics
» assess aggravating factors
» DO NOT offer gluten-free diet or wheat bran supplementation

> > Exercise

> > Offer CBT (NOT self-directed) or hypnotherapy to improve IBS symptoms

> > NO acupuncture

28
Q

Management of IBS bloating/ pain feature

A
  • peppermint oil 0.2-04ml TID (NNT=3)
  • antispasmodic
    » Benyl 20-40mg TID-QID
    » Bascopan 10-20mg TID
    » Dicetel 50-100mg TID
29
Q

Management of Diarrhea predominant IBS

A

1st line: TCA (amitriptyline 10-100mg QHS)

2nd line: Eluxadoline 100mg (refer as many GI contraindication)

DO NOT offer cholestyramine
DO NOT continuously use loperamide 2-4mg TID-QID (2-12mg/d)

30
Q

Management of constipation predominant IBS

A

1st line: Linaclotide 290 mcg QD
2nd : SSRI (fluoxetine, paroxetine, citalopram)
2nd also: Lubiprostone 8-25ug BID

DO NOT offer osmotic laxatives (only as adjunct)
DO NOT offer stimulants (senna, bisacodyl)
DO NOT offer prucalopride

31
Q

Common comorbidity of IBS

A

Fibromyalgia

32
Q

cancers associated with H. Pylori infection

A

1) gastric adenocarcinoma

2) MALT lymphoma

33
Q

Red flag symptoms of peptic ulcer

A

VBAD

  • vomiting
  • bleeding / anemia
  • abdominal mass (lymphadenopathy), unexplained weight loss
  • dysphagia

Family hx of GI cancer
previous documented peptic ulcer

34
Q

DDx of dyspepsia

A

cardiac, hepatobiliary, colonic, MSK

  • GERD
  • gastric cancer
  • pancreas
  • gallstones
35
Q

risk/precipitating factors of peptic ulcer

A
  • diet indiscretion: caffeine, high fat, excessive alcohol, smoking
  • NSAID/ ASA
  • prescription meds (calcium channel blockers, bisphosphonates)
36
Q

Peptic ulcer/ dyspepsia investigation & indication

A

> > Anemia - FOBT

> > Urea breath test/ H. Pylori serology test
- < 50 y/o, no alarm symptoms, no NSAID/ASA
not GERD (retrosternal heartburn + regurgitation)

> > Endoscopy ONLY IF

  • > 50 y/o (ACG recommends > 55 y/o) AND new symptoms
  • alarm features (VBAD, fm hx of cancer, previous ulcer)
  • fail repeated trial of therapy
    • choosing wisely incidate NO endoscopy without alarm symptoms
    • avoid upper GI series to investigate dyspepsia
37
Q

How to prevent peptic ulcers in pt taking long term NSAIDs

A
  • H2 blockers
  • PPIs
  • H. pylori eradication before staring NSAIDs

** antacid DO NOT show prevention against developing a peptic ulcer

38
Q

Lifestyle modification to manage peptic ulcer

A
  • eat small frequent meals
  • stop smoking
  • reduce alcohol/ caffeine, avoid irritating food stuff
  • maintain an ideal weight
39
Q

Treatment for H. Pylori positive

A

> > CLAMET for 14 days

  • PPI BID (rabeprazole 20mg)
  • clarithromycin 500mg BID
  • amoxicillin 1000mg BID
  • metronidazole 500mg BID

> > QUADRUPLE THERAPY if allergy to penicillin

  • PPI BID
  • Bismuth subsalicylate 2tab QID /30ml QID
  • metronidazole 500mg BID
  • tetracycline 500mg QID
40
Q

post-treatment management of H. pylori

A

> > asymptomatic and uncomplicate: no further

> > symptomatic OR asymptomatic + complicated
Urea breath test for test of cure: 30d after tx completed

41
Q

Indication of “test of cure” after treatment of H. Pylori

A
    • Urea breath test
    • 30 days after tx completion
    • off abx for 28-30d, off bismuth & PPI for 2 wks , off antacids/H2 blockers 24-48 hrs prior to test
    • Indication: symptomatic OR asymptomatic + complicated
  • Hx of gastric ulcer
  • complicated duodenal ulcer
  • MALT lymphoma
42
Q

alarm symptoms of peptic ulcer disease

A

VBAD

  • vomiting
  • bleeding/ anemia
  • abdominal mass (lymphadenopathy)/ unexplained weight loss ( > 10% weight loss)
  • dysphagia
  • Family history of gastrointestinal cancer
  • previous documented peptic ulcer
43
Q

precipitating factors of peptic ulcer disease

A
  • dietary indiscretion (caffeine, height fat), excessive alcohol, smoking
  • NSAIDs / ASA
  • medications (CCB, bisphosphonate)
44
Q

how to prevent peptic ulcers in patients taking long-term NSAIDs

A
  • H2 Blockers
  • PPIs
  • H. pylori eradiation before starting NSAIDs
    ( not antacids)
45
Q

lifestyle modification for peptic ulcer disease

A
  • eat small frequent meals
  • stop smoking
  • reduce alcohol/ caffeine, avoid irritating foodstuff
  • maintain an ideal weight
46
Q

what are the indications of endoscopy for pt with peptic ulcer dsease

A
  • alarm symptoms (VBAD, FHx of cancer) - “choosing wisely”
  • > 50 y/o and new symptoms
  • fail repeated trail of therapy
47
Q

Hemochromatosis - symptoms

A

∙ Skin hyperpigmentation
∙ Weakness lethargy
∙ Erectile dysfunction

Early signs:

  • severe fatigue (74%)
  • impotence (45%)
  • arthralgia (44%)

Most common symptoms when diagnosed

  • hepatomegaly (13%), cirrhosis
  • skin bronzing or hyperpigmentation
  • arthritis or arthropathy
  • amenorrhea, impotence, hypogonadism
  • Diabetes mellitus (48%)
  • Cardiomyopathy
48
Q

Hemochromatosis - screening tests

A
  • Serum ferritin studies
  • Transferrin saturation levels
  • (Hepatic iron concentration)
49
Q

Hemochromatosis - diagnosis

A
  • Genetic testing: Examination of HFE mutations (C282Y, H63D) is pivotal for diagnosis of hemochromatosis
  • liver biopsy
50
Q

elderly diarrhea DDx

A
  • acute ischemic bowel
  • obstruction
  • diverticulitis
  • appendicitis
  • neoplasm
51
Q

Risk factors of C. difficile infection

A
  • healthcare-associated
  • older age
  • immunocompromised
  • previous C. difficile infection
  • recent antibiotics or 1 mo after (esp. fluoroquinolones, clindamycin, cephalosporin)
52
Q

1st-line Rx for C. difficile infection

A

1st-line:

  • Vancomycin PO even if mild (not metro) OR
  • Fidaxomicin ($$$$)

2nd line: Metronidazole

Pediatrics mild to mod: metronidazole

53
Q

Chronic diarrhea work-up

A
  • CBC (esp. serum hemoglobin)
  • Ferritin
  • TSH
  • anti-TTG antibody (tissue transglutaminase)
  • C. difficile toxin stool test
  • stool ova & parasite
  • calprotectin (r/o IBD)
  • colonoscopy
  • other specific causes:
    • Hydrogen breath (lactose intolerance)
    • MRI for chronic pancreatitis
54
Q

complications of C. difficile infection

A 
pseudomembranous colitis (PMC)
toxic megacolon
perforations of the colon
sepsis
death (rarely)
55
Q

comorbidity of IBS

A

fibromyalgia

56
Q

Initial investigation of IBS

A

CAG:

  • suggested pts have serology testing to exclude celiac disease
  • DO NOT routinely order CRP, fecal calprotectin, food allergy, lactise hydrogen breath test, glucose hydrogen breath test

Important hx

  • family hx of GI cancer, IBD, celiac
  • nocturnal defecation
  • new symptoms in a patient > 45 y/o
57
Q

Non-pharmacological management of IBS

A
  • Education and reassurance: lifestyle more effective than meds
  • Diet
    » FODMAP diet for short term (4 wks) with dietician
    » increase soluble fiber, probiotics
  • exercise
  • CBT
  • hypnotherapy

Herkimer 2021 (21 decks)

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