GASTRO Flashcards
Storage function, relaxes to accomodate the meal
Proximal stomach
Phasic contractions, propels food residue against the pylorus
Distal stomach
secretes intrinsic Factor for Vitamin B12 absorption
Stomach
Suited For absorption of vit B 12 and bile acids
Ileum
GI diseases with impaired digestion and Absorption
ZE, lactase deficiency, Biliary obstruction, other intestinal enzyme deficiencies
most common intestinal maldigestion syndrome involving dairy products ( lactose content)
L actase deficiency
GI diseases with altered secretion
Gastric acid hypersecretion: ZE, G-cell hyperplasia, retained antrum Syndrome, some with DU
Gastric acid hyposecretion: Atrophic gastritis, pernicious anemia
Inflammation and infection
GI diseases with altered Gut Transit
mechanical Obstruction
Disordered Gut motor Function: impaired propulsion/ rapidpropulsion disorders
GI diseases associated with immune dysregulation
Celiac disease, Eosinophilic gastritis, Ulcerative colitis and Chron’s disease
GI diseases with Impaired Gut Blood flow
Thromboembolic causes: arterial embolus or thrombosis, venous thrombosis
Hypoperfusion causes: dehydration, sepsis, hemorrhage or decreased CO
Radiation enterocolitis
Gastroparesis due to blockage of the celias and SMA
GI disease typically presenting at after age 50
Colorectal CA
may be due to chronic acid reflux or with extensive Alcohol and tobacco use
Esophageal cancer
Abdominal pain:generally midline in location and vague in character
visceraL pain
Abdominal pain that can be localized and precisely described
Parietal pain
Most common causes of abdominaL pain
IBS and Functional dyspepsia
Initial procedure to evaluate dysphagia to exclude subtle rings or strictures and assess for achalasia
Barium swallow
Performed when colonoscopy is unsuccessful or contraindicated
Contrast enema
Alternative for colonoscopy For colon cancer screening
CT and MR Colongraphy
Diagnostic modality used to exclude mesenteric ischemia and determines Spread of malignancy
Angiography
Userful in searching for Intraabdominal abscesses not visualized on CT
Radio labeled leukocyte scans
Esophageal manometry is a functional test used for patient’s suspected Of
Achalasia
GOld standard for imaging of colonic mucosa
Colonoscopy
More accurate for evaluation of diverticula and measurement of colonic strictures
Barium enema
Procedure used to visualize the rectum and a variable portion of the left colon
used for colorectal cancer screening primarily used for evaluation of diarrhea and rectal outlet bleeding
Flexible Sigmoidoscopy
Used as both diagnostic and therapeutic procedure
open sphincter of Oddi: endoscopic sphincterotomy
Retrieval of stones from the ducts
Biopsy, dilation and stenting of duct strictures, stenting of ductal leaks
Di agnosis: sphincter of Oddi dysfunction
ERCP
Most accurate pre - op local staging of Cancers
EUS
Risks of Bleeding and GI perforation
Low risk: Diagnostic Upper endoscopy, Colonoscopy, diagnostic Eus
Increased risk: Therapeutic procedures such as EMR and ESD, control of bleeding, or Stricture
Rare with flexible sigmoidoscopy
Recommended to Start Antibiotic prophylaxis For Endoscopic procedure
Bile duct obstruction (-) Cholangitis: ERCP with anticipated incomplete drainage: prevention of Cholangitis
Sterile Pancreatic fluid collection (pseudooyst, necrosis) which communicates with pancreatic duCt: ERCP: cyst infection
Sterile pancreatic Fluid collection: Transmural drainage: cyst infection
cystic lesions along GI tract: EUS- FNA: cyst infection
percutaneous Endoscopic feeding tube placement: periostomal infection
Cirrhosis with acute GI bleeding: All patients regardless of endoscopic procedure
LR endoscopic procedures for the management of Antithrombotic Drugs before Endoscopy
EGD or colonoscopy with/ without Biopsy, EUS without FNA, ERCP with stent exchange
HR endoscopic procedures for the management of Antithrombotic Drugs before Endoscopy
E G D or colonoscopy with dilation, Polypectomy or thermal ablation, PEG, Eus with FNA, ERCP with sphincterotony or psendocyst drainage
Antithrombotic drug that does not increase the risk of bleeding during endoscopic procedures
Aspirin monotherapy
Risk of developing Pancreatitis during ERCP
5% with increased risk in young anicteric patients with normal ducts
Most common complication in Percutaneous gastrostomy tube placement during EGD
Wound infection
Increases likelihood of rebleeding from endoscopy
R/R-A-C/C
Respi/Renal Failure
Age> 70 y 0.
Cirrhosis/ Coagulopathy
Indications for urgent endoscopy
Resting hypotension, repeated hematemesis, Ngt aspirate that does not clear with large volume lavage, orthostatic change in vital signs, or requirement for BT
PUD risk of rebleeding: clean- based ulcer
low risk (3-5 %)
PUD risk of rebleeding:
Flat red or purple spots in the ulcer base
Large adherent CLots covering the ulcer base
Intermediate risk
10% and 20%
PUD risk of rebleeding: sentinel clot ( platelet plug protruding from a vessel wall in the base of an ulcer) or visible vessel; often requires local endoscopic therapy to decrease the bleeding rate
High Risk: approximately 40%
Reduces Rebleeding rate and improves patient outcome
proton Pump Inhibitor
Indicated for primary prophylaxis from large esophageal varices when BBS are. contraindicated or not tolerated preferred last therapy For bleeding esophageal varices and eradication of varices
Endoscopic Variceal Ligation
Used as salvage therapy when EVL Fails as it has higher complication rates
Endoscopic variceal sclerotherapy
Persistent caliber artery
Large caliber arteriole that runs immediately beneath the GI mucosa and bleeds through a pinpoint mucosal erosion
Dieulafoy’s Lesion
Most common location Of the Dieulafoy’s lesion
Lesser curvature of the proximal stomach
Linear mucosal rent near or across the GE junction often associated with retching or vomiting
Mallory- Weiss tear
Watermelon stomach
Gastric antral Vascular Ecasias (GAVE)
Flat mucosal anomalies diagnosed by endoscopy
vascular Ectasias
Etiology of bleeding: nutrient arteries penatrating the muscular wall of the colon en route to the colonic mucosa
Characterized by painless and impressive hermatOchezia
Colonic Diverticula
Common Causes of G00
malignancy and Chronic peptic ulceration with stenosis of the by pylorus
Risk of cecal perforation
> 12 cm
More accurate disqustic modality for Bile buct imaging
Mrcp and Eus >90 % accuracy
Procedure of choice if a bile duct stone is highly likely and urgent treatment is required(jaundice and biliary sepsis)
ERCP
Procedure of choice if a bile duct stone is highly likely and urgent treatment is required(jaundice and biliary sepsis)
ERCP
Charcot ‘s triad
Jaundice, fever, RUQ pain
Reynold’s Pentad
Charcot ‘s triad+ confusion and shock
Most sensitive test for diagnosis Of GERD
24 H ambulatory pH monitoring
Indications For endoscopy in GERD
Resistant reflux symptoms
Recurrent dyspepsia
Reflux and dysphagia to look for a stricture or malignancy
Long standing (more than or equal to 10 years) Frequent heartburn due to 6x increase risk of Barrett’s esophagus(periodic endoscopy with biopsy) to detect dysplasia or early carcinoma
Most sensitive diagnostic test For Peptic ulcer
Endoscopy
Alarm symptoms for endoscopy in Peptic ulcer
Weight loss, Anemia, Bleeding
progressive dysphagia, solids then liquids
Esophageal strictures
Intermittent dysphagia For both solids and liquids
Motor disorders
Episodic dysphagia For solids, typically at the beginning of a meal
Schatzki’s ring
Difficultly initiating deglutition ( transfer dysphagia) and nasal reflux with swallowing
pharyngeal motor disorders
Nocturnal regurgitation of undigested Food
Achalasia
Best initial test if motor disorder is suspected in dysphagia
Esophageal radiography and or a video Swallow study
Procedure done For resection of early-stage malignancies limited to the superficial layers of the GI mucosa
EMR or ESD
Colorectal Cancer screening strategies:
Asymptomatic individuals more than Or equal to 50 y. 0.
FOBT annually
CT colonography/ Flexible sigmoidoscopy /Double contrast barium enema every 5 years
Colonoscopy every 10 years
Chronic diarrhea ( Duration)
4 weeks
Behavior in which recently swallowed Food is regurgitated and then re swallowed repetitively for up to an hour
Rumination
Globus sensation is attributable to What disease
GERD
Useful test for diagnosing motility disorders. achalasia, diffuse esophageal spasm
Esophageal manometery
Outpouchings Of the esophagus wall, associated with increased intraluminal pressure associated with a distal obstruction
Diverticula
Seen in natural zone of weakness in the posterior hypopharyngeal wall (Killian’s triangle) and causes halitosis and regurgitation of saliva and food that may have been consumed several days earlier
Zenker’s diverticulum
Due to traction from adjacent inflammation ( tuberculosis) or by propulsion associated with esopageal motor abnormalities
midesophageal diverticulum
Thin membranous narrowing at the squamocolumnar mucosal junction Of the esophagus, seen in 10-15% of the population usually asymptomatic
B-ring
Similar to B - ring but with a lumen diameter of 13 mm and associated with episodic solid food dysphagia
Schatzki’s ring
Steakhouse Syndrome
Schatzki’s ring
Symptomatic hypopharyngeal webs and iron- deficiency anemia in middle -aged women
plummer - Vinson syndrome
Herniation of part of the stomach into the thoracic Cavity through the esophageal hiatus in the diaphragm
Hiatal hernia
Type of hiatal hernia which is associated with GERD
Type I sliding hiatal hernia (95% cases)
Esophageal CA with predilection to the distql esophagus
Adenocarcinoma
Esophageal cancer with predilection to the proximal esophagus
SCC
Rare motor disorder of the esophageal smooth muscle in which the LES does not relax normally with swallowing and the esophageal body undergoes non-peristaltic contractions
Achalasia
Loss of ganglion cells within the esophageal myenteric plexus involving both excitatory ( Cholinergic) and inhibitory(nitric oxide) ganglionic neurons
Achalasia
ManOmeric finding of the esophageal LES in patients with Achalasia
Normal or elevated pressure
Barium swallow xray Finding of patients with Achalasia
Dilated esophagus with poor emptying, air fluid level, tapering at the LES beak like appearance
Pharmacologic therapy For patients with Achalasia
Nitrates or CCB before meals
Botulinum toxin
Manifests as episodes of dysphagia with chest pain attributable to abnormal esophageal contractions with normal deglutitive LES relaxation
Diffuse Esophageal Spasm
Corkscrew esophagus
Rosary bead esophagus
psendo diverticula or curling
DES
Treatment shown to be efficacious For DES
Anxiolytics
Exacerbating Factors for GERD
Abd obesity, pregnancy, gastric hypersecretion states, delayed gastric emptying, disruption of esophageal peristalsis and gluttonY
Accounts for 90% Of reflux in normal Subjects or GERD patients without hiatal hernia
Transient LES relaxation
Involves proximal esophagus, Ulcerations appear punctuate and diffuse
Infectious esophagitis
multiple esophageal rings, linear Furrows or white punctate exudate
Eosinophilic Esophagitis
Singular and deep at points of luminal narrowing especially near the carina, distal sparing
pill esophagitis
Most severe histologic consequence of GERD
Barrett’s metaplasia
Dominant mechanism Of Esophagogastric junction incompetence GERD
Transient LES relaxation(90% Of reflux in normal subjects or GERD patients who histal hernia)
LES hypotension
Extra - esophageal Syndromes with established association with GERD
Chronic cough, laryngitis, asthma, dental erosions
Characterised by tongues of reddish mucosa extending proximally from the GEJ with specialized columnar metaplasia
Barrett’s metaplasia
Gold standard treatment Of high - grade dysplasia in GERD in a healthy patient with minimal surgical risk
Esophagectomy
Adverse Effect of PPI
Malabsorption of vit B12 and Iron, increase susceptibility to enteric infections especially C- difficile colitis, slight increase risk of bone fracture
Diagnosis of eosinophilic esophagitis
Symptoms + esophageal mucosal biopsies showing squamous epithelial eosinophil predominant inflammation
Patient presenting with atypical chest pain heartburn that is refractory to ppi with note of peripheral eosinophilia and with history of atopy
Eosinophilic esophagitis
Infectious esophagitis in immunocompromised hosts is due to
CMV, HSV, Candida
Infectious esophagitis is more common in AIDS patients with CD4 count of
<100
Most common organisms causing infectious esophagitis in immunocompetent hosts
HSV, Candida
Risk factors for candida esophagitis
Immunocompromised state, esophageal stasis
Treatment for candida esophagitis
Oral fluconazole for 14-21 days but if refractory may give itra, vori, posaconazole
Endoscopic finding of vesicles, small punched out ulcerations with biopsy findings of ground glass nuclei with eosinophilic cowdry type A intranuclear inclusions, giant cell formation
Herpetic esophagitis
Endoscopic appearance of serpiginous ulcers that coalesce to form giant ulcers, particularly in the distal esophagus with pathognomonic large nuclear or cytoplasmic inclusion bodies on biopsy
CMV esophagitis
Treatment of choice for cmv esophagitis
Ganciclovir iv or foscarnet iv until healing occurs (3-6wks)
Usual site of injury with endoscopy or ngt placement
Hypopharynx or GEJ
Increased intraesophageal pressure associates with forceful vomiting and retching causing spontaneous esophageal rupture
Boerhaave’s syndrome
Most sensitive in detecting mediastinal air
Chest ct
confirmed with contrast swallow with gastrografin followed by thin barium
Patient presenting with vomiting retching vigorous coughing with associated UGIB with note of nontransmural tear at the GEJ
Mallory weiss syndrome
Caused by ingestion of caustic agents more commonly strong alkali
Corrosive esophagitis
Most common location for pill to lodge in patients with pill esophagitis
Mid esophagus near the crossing of the aorta or carina
Play a central role in gastric epithelial defense/repair, regulate release of mucosal HCO3 and mucus, inhibit parietal cell secretion and maintains mucosal blood flow and epithelial cell restitution
Prostaglandin
2 principal gastric secretory products capable of inducing mucosal injury
Hcl and pepsinogen
Principal contributors to acid secretion
Cholinergic via vagus
Histaminergic via local gastric sources
Breaks in the mucosal surface >5mm in size with depth to the submucosa
Ulcers
Most common location of DU
1st portion of the duodenum (>95%) with ~90% located within 3cm of the pylorus
Ulcer associated with malignancy
Gastric ulcer
Majority of DU cases are associated with
H. Pylori or nsaid induced
Incidence of h. Pylori causing ulcer
10-15% develop frank peptic ulcer
30-60% in GU
50-70% In DU
Antral predominant gastritis
DU
Corpus dominant gastritis
GU, gastric atrophy, gastric carcinoma
Ulcer caused by interuption of prostaglandin synthesis impairing mucosal defense and repair
NSAID-induced
Blood group associated with ulcer due to preferential binding of h pylori
Blood group O
Chronic disorders with strong association with ulcer
Systemic mastocytosis Chronic pulmo disease Chronic renal failure Cirrhosis Nephrolith Alpha 1 antitrypsin deficiency
Chronic disorders with possible association with ulcer
Hyperparathyroidism
CAD
PV
chronic pancreatitis
Most discriminating symptom of DU
Pain that wakes patient from sleep (md-3am)
Pain occurs 90mins to 3h after a meal, relieved by antacids or food
DU
Ulcer pain that may be precipitated by meals
GU
Succussion splash is seen in
Gastric outlet obstruction
Most frequent finding in ulcer patients
Epigastric tenderness
Most common complication in PUD
Gi bleeding
Hypercalcemia, hyperphosphatemia with renal calcinosis and progression to renal insufficiency
Milk-alkali syndrome
Inhibits basal and stimulated acid secretion
H2 receptor antagonist
Inhibits all phases of gastric acid secretion by irreversibly inhibiting H-K-ATPase
PPI
Most potent acid inhibitory agent
PPI
Due to high incidence of malignancy in GU (especially body, fundus) if biopsy negative a repeat endoscopy should be done when
8-12wks to document healing, if still with ulcer biopsy
GU that fails to heal after 12wks and a DU that does not heal after 8 wks of therapy
Refractory ulcer
Can decrease ulcer re bleeding in patients who undergone endoscopic therapy
Parenteral and orally administered PPI
Bacterial overgrowth in the afferent limb secondary to stasis causing postprandial abdominal pain, bloating, diarrhea with malabsorption of fats and vit b12
Afferent loop syndrome
Series of vasomotor and GI signs and symptoms and occurs in patients who have undergone vagotomy and drainage (billroth)
Dumping syndrome
Phase of dumping syndrome which is due to rapid emptying of hyperosmolar gastric contentd into the small intestine causing fluid shift into gut lumen with plasma volume contraction, acute intestinal distention, release of vasoactive GI hormones
Early dumping (15-30mins after meals)
Phase of dumping syndrome secondary to hypoglycemia fron excessive insulin release
Late phase (90mins to 3h)
Gastric acid hypersecretion due to a unregulated gastrin release from a non-cell endocrine tumor (gastrinoma)
Zollinger-Ellison syndrome
In ZE >60% of the tumors are
Malignant
Most common non pancreatic lesion (gastrinoma) occuring in 50-75% of patients with ZE
Duodenal tumors
Most common clinical manifestation seen in >90% of gastrinoma patients
Peptic ulcer
Ulcer features that should raise suspicion of ZES
Unusual location (2nd part of duodenum and beyond)
Refractory to standard med therapy
Recurrence after acid reducing surgery
Frank complications(bleeding, obstruction, perforation)
Absence of h pylori/nsaids ingestion
Most frequent condition that can elevate fasting gastrin level
Gastric hypochlorhydia or achlorhydria
Used to differentiate between causes of hypergastrinemia, useful in patients with indeterminate acid secretory studies
Gastrin provocative test
Most sensitive and specific provocative test for diagnosis of gastrinoma
Secretin stimulation test
Treatment of choice for ZE
PPI
Elevated gastric acid secretion after head trauma causing ulcer
Cushings ulcer
Ulcer associated with severe burns
Curlings ulcer
Treatment of choice for stress induced ulcer prophylaxis
PPI
Most common cause of acute gastritis
Infectious
More common rype of chronic gastritis
Type B
Type B chronic gastritis involves predominantly what site of the stomach and is associated with what infection
Antral predominant
H pylori
Type A gastritis predominantly involves
Fundus and body, with antral sparing
Autoimmune type of chronic gastritis, traditionally associated with PERNICIOUS ANEMIA
Type A
Rare disease characterized by large, tortuous gastric mucosal folds
Menetriers disease
Functional disorder characterized by altered bowel habits + abdominal pain with NO detectable structural abnormalities
Irritable Bowel Sundrome
Criteria for Diagnosis of IBS
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months with 2 or more of the Following
Improvement with defecation
Onset associated with a change in the frequency of stool
Onset associated with a change in the form of stool
Prerequisite Clinical feature in IBS
Abdominal pain
most consistent Clinical feature of IBS
Altered bowel habits
Constipation alternating with diarrhea with one predominating which can switch in l year is seen in
IBS
Initial therapy of choice for IBS_ D
peripherally acting opiates
Smoking reduces the risk for developing what type of IBD
Ulcerative colitis
protective effect on patients with Ulcerative Colitis
Appendectomy
OCP use increases the risk Of developing what types of IBD
Chron’s disease
Interventions that alter microbiota and can improve CD
metro, Cipro, elemental diets
Fecal diversion
Other distinguishing Feature of CD vs UC
Rectal sparing
Segmental involvement with skip areas in the midst of diseased intestine
Possible involvement of liver and the pancreas
IBD with transmural involvement
CD
Cobblestone appearance
CD
Pathognomonic Feature Of CD
nonCaseating granulomas in all layers of the bowel
IBD Often presenting with diarrhea, rectal bleeding teneSmus, passage of mucus, crampy abdOminal pain ANCA. positive
uc
most common site of inflammation in CD
Terminal ileum
Circumferential inflammation and fibrosis_ String sign is seen in what type of IBD
CD
First line test for evaluation of Suspected CD and its Complications
CT/ MR enterography
Mainstay Of therapy For mild- moderate uc
sulfasalaZine and other 5- ASA agents
Protrusion Of mucosa through the muscularis propia of the colon
False or pseudodiverticulum
common location of diverticular disease
sigmoid colon (5 %) Asian population: 70 %. in the right colon and rectum
Inflammation due to retention Of Particulate material within diverticular Sac and Formation of a fecalith
Diverticulitis
Most common cause of hematochezia in patients >60 years
Colonic diverticulum hemorrhage
Best diagnostic modality for localization Of massive bleeding from diverticular disease in an Otherwise stable patient
Angiography
Patient presenting with fever, anorexia, LLQ Abdominal pain, Obstipation
Uncomplicated diverticulitis
Diverticular disease associated with abscess or perforation or Fistula
complicated diverticular disease
Best management For diverticular disease
Diet alteration: fiber rich ( 30g/d)
Antibiotic therapy for patients with diverticulitis
co- tri or cipro + metro
addition of Ampicillin to cover for enterococci for non responders
Circumferential/ Full- thickness profusion Of the rectal wall through the anal orifice
Rectal prolapse
Most common cause of Fecal incontinence
Obstetric injury to the pelvic floor
GOLD standard for treatment OF Faecal Incontinence
Overlapping sphincteroplasty
Sclerotherapy is part of the management in what stage of hemorrhoidS
Stage I
Banding is part of the management in What stage of Hemorrhoids?
stage Ill
Operative hemorrhoidectomy
Stage III and IV
Most common site of Anorectal Abscess
Perianal (40-50 %)
AnOrectal Abscess have higher prevalence in What group of patients
Immunocompromised, Dm, hematologic disorders, IBD, HIv
Communication of an abscess cavity with an identifiable internal opening within the anal canal
Fistula in Ano
On Anal manonetry, pathognomonic for anal Fissure
Increased anal resting pressure and sawtooth deformity with paradoxical contractions of the sphincter muscles
Risk Factors For AOMI
AF, recent AMI, VHD, recent cardiac or vascular cath
Most often seen in the aging population affected by atherosclerotic disease
cardiogenic/ septic shock on high dose vasopressor infusions, cocaine overdose
most prevalent GI disease complicating cardiOvascular surgery
NOMI
Most common locations in GI ischemia
watershed areas Splenic Flexure ( Griffith's point) Descending/ sigmoid colon ( Sudeck's point)
Origin of emboli in mesenteric ischemia
> 75% From the heart
Gold standard for diagnosis or acute arterial occlusive disease
Angiography
most common and most characteristic symptom of liver disease
Fatigue
Often the presenting symptom in PBS and Sclerosing cholangitis
Itching
Most reliable marker of severity
Jaundice
Alcohol consumption associated with an increased risk of alcoholic liver disease
22-30 g/ day for women
33-45g/ daY for men
Clinically helpful approach to diagnosis of alcohol dependence and abuse
CAGE questionnaire
ANA or SMA, elevated IgG levels and compatible histology
Autoimmune hepatitis
mitochondrial antibody, elevated Igm levels, and compatible histology
Primary biliary cirrhosis
Decreased serum cerulo plasmin and increased urinary copper increased hepatic copper level
wilson’s disease
Elevated iron Saturation and serum ferritin; genetic testing for HFE gene mutations
Hemochromatosis
Elevated arterial ammonia levels have been shown to correlate with outcome in
Fulminant hepatic Failure
More specific indicator Of liver injury
ALT
Most common cause of acute liver Failure
Drug induced liver injury
