Gastro Flashcards
Etiology of pancreatitis
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)
complication of pancreatitis
abscess
lung-pleural effusion, pneumonia, ARDS
acute renal failure secondary to hypovolemic shock
CVS: pericardial effusion, pericarditis
Risk factors of Celiac disease
- 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%)
Classic and non-classic GI symptoms of Celiac disease
Classic:
- abdominal distension/ bloating
- chronic diarrhea, steatorrhea
- anorexia
- weight loss/FTT, muscle wasting, delayed puberty/short stature
Non-classic:
- persistent vomiting
- chronic constipation
- IBS
Pediatric SSx of Celiac disease
- anorexia
- chronic constipation
- delayed puberty, growth failure/FTT
- irritability
- recurrent vomiting
What are the non-GI symptoms of Celiac disease?
Classic non-GI:
- Dermatitis herpetiform
(often have no GI symptoms)
Non-classic
- Hema:
»_space; iron/folate deficiency anemia
»_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)
how to assess bone health in adult after diagnosed with Celiac disease
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)
What serology tests are used to diagnose Celiac disease?
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
When to consider intestinal biopsy to diagnose Celiac disease before gluten free diet?
1) + serology test
2) all symptomatic pts even if serology is negative
** can also confirm with biopsy of dermatitis herpetiformis lesion
How to confirm Celiac disease?
1) Serology and histology both ++ : confirmed
2) Serology + , histology -
»_space; repeat serology, consider repeat histology
consider HLA-DQ2/DQ8 testing
3) serology - , histology +
»_space; consider alternative diagnosis
»_space; IF no alternative dx, trial treatment of celiac diet AND consider HLA-DQ2/DQ8 testing
4) serology and history both neg: CD excluded
What are the food containing gluten ?
wheat
rye
barley
oat (?)
What is the management after diagnosed with Celiac disease?
- 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)
What type of malignancy do pts with refractory celiac disease have increased risk of?
T-cell lymphoma
Surgical indications of diverticulitis
- unstable patients with peritonitis
- abscess/ fistula / ruptured abscess
- immunosuppressed
- > = 2 attacks
Risk factors of Crohn’s disease
- smoking
- Ashkenazi Jews
exacerbating factors of Crohn’s disease
infection
cigarette smoking
NSAIDs
What are the common symptoms of Crohn’s disease?
- 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
What are the extra-intestinal symptoms of Crohn’s disease?
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
What test can help distinguish between IBS and IBD?
Fecal calprotectin
Red flags of GERD
- vomiting
- evidence of GI bleeding
- anemia
- involuntary weight loss
- dysphagia
- chest pain
Lifestyle modification for GERD
- weight loss if overweight
- elevated head of bed
- avoid meal 2-3 hours before bedtime if nocturnal GERD
Risks of longer term use of PPI
- 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
Rome IV criteria `
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
Alarming symptoms of IBS
- vomiting
- GI bleeding
- unexplained weight loss
- abdominal mass
- dysphagia
- anemia
Important history of IBS when diagnosing?
- Family hx of GI cancer, IBD, celiac
- nocturnal defecation
- new symptoms in a patient > 45 years old
Aggravating factors of IBS
- EtOH
- Caffeine
- Fat
- Fiber
- Sorbitol
- Stress
- Menstruation
Management of IBS
- 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
Management of IBS bloating/ pain feature
- peppermint oil 0.2-04ml TID (NNT=3)
- antispasmodic
» Benyl 20-40mg TID-QID
» Bascopan 10-20mg TID
» Dicetel 50-100mg TID
Management of Diarrhea predominant IBS
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)
Management of constipation predominant IBS
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
Common comorbidity of IBS
Fibromyalgia
cancers associated with H. Pylori infection
1) gastric adenocarcinoma
2) MALT lymphoma
Red flag symptoms of peptic ulcer
VBAD
- vomiting
- bleeding / anemia
- abdominal mass (lymphadenopathy), unexplained weight loss
- dysphagia
Family hx of GI cancer
previous documented peptic ulcer
DDx of dyspepsia
cardiac, hepatobiliary, colonic, MSK
- GERD
- gastric cancer
- pancreas
- gallstones
risk/precipitating factors of peptic ulcer
- diet indiscretion: caffeine, high fat, excessive alcohol, smoking
- NSAID/ ASA
- prescription meds (calcium channel blockers, bisphosphonates)
Peptic ulcer/ dyspepsia investigation & indication
> > 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
How to prevent peptic ulcers in pt taking long term NSAIDs
- H2 blockers
- PPIs
- H. pylori eradication before staring NSAIDs
** antacid DO NOT show prevention against developing a peptic ulcer
Lifestyle modification to manage peptic ulcer
- eat small frequent meals
- stop smoking
- reduce alcohol/ caffeine, avoid irritating food stuff
- maintain an ideal weight
Treatment for H. Pylori positive
> > 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
post-treatment management of H. pylori
> > asymptomatic and uncomplicate: no further
> > symptomatic OR asymptomatic + complicated
Urea breath test for test of cure: 30d after tx completed
Indication of “test of cure” after treatment of H. Pylori
- 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
alarm symptoms of peptic ulcer disease
VBAD
- vomiting
- bleeding/ anemia
- abdominal mass (lymphadenopathy)/ unexplained weight loss ( > 10% weight loss)
- dysphagia
- Family history of gastrointestinal cancer
- previous documented peptic ulcer
precipitating factors of peptic ulcer disease
- dietary indiscretion (caffeine, height fat), excessive alcohol, smoking
- NSAIDs / ASA
- medications (CCB, bisphosphonate)
how to prevent peptic ulcers in patients taking long-term NSAIDs
- H2 Blockers
- PPIs
- H. pylori eradiation before starting NSAIDs
( not antacids)
lifestyle modification for peptic ulcer disease
- eat small frequent meals
- stop smoking
- reduce alcohol/ caffeine, avoid irritating foodstuff
- maintain an ideal weight
what are the indications of endoscopy for pt with peptic ulcer dsease
- alarm symptoms (VBAD, FHx of cancer) - “choosing wisely”
- > 50 y/o and new symptoms
- fail repeated trail of therapy
Hemochromatosis - symptoms
∙ 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
Hemochromatosis - screening tests
- Serum ferritin studies
- Transferrin saturation levels
- (Hepatic iron concentration)
Hemochromatosis - diagnosis
- Genetic testing: Examination of HFE mutations (C282Y, H63D) is pivotal for diagnosis of hemochromatosis
- liver biopsy
elderly diarrhea DDx
- acute ischemic bowel
- obstruction
- diverticulitis
- appendicitis
- neoplasm
Risk factors of C. difficile infection
- healthcare-associated
- older age
- immunocompromised
- previous C. difficile infection
- recent antibiotics or 1 mo after (esp. fluoroquinolones, clindamycin, cephalosporin)
1st-line Rx for C. difficile infection
1st-line:
- Vancomycin PO even if mild (not metro) OR
- Fidaxomicin ($$$$)
2nd line: Metronidazole
Pediatrics mild to mod: metronidazole
Chronic diarrhea work-up
- 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
complications of C. difficile infection
pseudomembranous colitis (PMC) toxic megacolon perforations of the colon sepsis death (rarely)
comorbidity of IBS
fibromyalgia
Initial investigation of IBS
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
Non-pharmacological management of IBS
- 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
