Gastroenterology Flashcards
GERD refractory to daily PPI
- occurs in 10-40% of patients
- next step: switch to different PPI OR maximize therapy w/ PPI BID* (*preferred)
- consider GI referral
- IF still not responding after BID PPI, do esophageal pH monitoring and impedance testing
clinical features of serum-sickness like reaction 2/2 HBV (initial and subsequent)
initial: fever, rash, symmetric polyarthralgias/arthritis
- rash and joint symptoms resolve in 2-3 weeks
- rash is pruritic, urticarial, WITHOUT mucosal involvement
- arthritis affects small joints predominantly, includes morning stiffness
followed by: jaundice, non-specific systemic complaints
pathophys of serum-sickness like reaction 2/2 HBV
accumulation of antigen-antibody or immune complexes leading to vascular and cellular inflammation
clinical features of HSV esophagitis in HIV patients
usually oral lesions with abrupt onset
odynophagia and substernal pain
diagnosis of HSV esophagitis in HIV patients
EGD: well-circumscribed shallow ulcers
biopsy: stains positive for HSV, viral culture
treatment of HSV esophagitis in HIV patients
acyclovir
Clinical Features and Diagnostic Findings of Menetrier’s Disease
- GI symptoms: epigastric pain, nausea, vomiting, diarrhea
- edema 2/2 hypoalbuminemia
- significant weight loss
Endoscopy shows extreme enlargement of gastric folds in the fundus
What is Menetrier’s Disease
- protein-losing hypertrophic gastropathy
Diagnosis of metaplastic (chronic) atrophic gastritis
- diagnosis is confirmed by endoscopy
- serum gastrin levels may be elevated (AMAG) due to hypochlorhydria. levels should be repeated along w/ gastric pH off PPI
- serum gastrin levels >1000 pg / ML in both atrophic gastritis and Zollinger-Ellison Syndrome however gastric pH < 5.0 is diagnostic of ZE
metaplastic (chronic) atrophic gastritis: AMAG VS. EMAG
EMAG: (environmental)
- 2/2 dietary carcinogens or H pylori
- gastric mucosal changes in the antrum** > fundus
- risk of gastric ulcers + cancer increased (more than in AMAG)
AMAG (autoimmune)
- AD (autosomal dominant)
- more common in women
- more prone to pernicious anemia
- associated with other autoimmune conditions (Hashimotos, vitiligo)
- end-stage AMAG usually has metaplastic glands
- AMAG has an increased risk of gastric carcinoid tumors (benign > malignant) due to increased gastrin
- risk of gastric adenocarcinoma and esophageal SCC is also increase
Gastric pH that is diagnostic of ZE syndrome
< 5.0
Management of metaplastic (chronic) atrophic gastritis
- treat the complications! ex. pernicious anemia, H pylori
- gastric cancer screening w/ EGD in high-risk patients (family hx, asian)
Clinical features of Candida esophagitis in HIV patients
- involves entire esophagus
- pain w/ solids>liquids
- often associated with oral thrush (18% are not!)
Diagnostic findings of Candida esophagitis in HIV patients (EGD, biopsy, labs)
EGD: white exudate (cottage cheese)
Biopsy: pseudohyphae in mucosa
CD4 count < 100 or medication non-compliance
Treatment of Candida esophagitis in HIV patients
- antifungal ex. fluconazole
- empiric tx for 14-21 days
- ** must be systemic, cannot give topical to HIV patients, only to non-HIV patients
You think an HIV patient has Candida esophagitis based on clinical features. Now what?
- FIRST you do empiric treatment (PO antifungal like fluconazole) you ONLY do EGD if treatment fails in 72 hours.
Clinical features of CMV esophagitis in HIV patients
- odynophagia and substernal pain
Diagnostic findings of CMV esophagitis in HIV patients
EGD: sharply demarcated, linear ulcers in the distal 1/3 of the esophagus
biopsy: intranuclear inclusions
Treatment of CMV esophagitis in HIV patients
IV ganciclovir
Complications of gastric bypass surgery (name 3)
- Stomal stenosis / outlet obstruction
2. Dumping Syndrome
Features, diagnosis and treatment of stomal stenosis/outlet obstruction (complication of gastric bypass surgery)
- occurs at the gastro-jejunal anastamosis
- 5-20% of patients
- onset at 3-6 mos post-op
- obstructive symptoms: N/V, abdo pain, GERD, dysphagia, inability to tolerate PO intake
- diagnosis: endoscopy
- treatment: endoscopic balloon dilation (usually require serial)
Features, diagnosis and treatment of Dumping Syndrome (complication of gastric bypass surgery)
- 50% of patients
- abdo pain, nausea, hypotension (osmotic fluid shift from plasma to bowel)
- reflex tachycardia
- management: avoid by replacing simple carbs with complex carbs, increasing fiber, increasing protein
Incidence and preventative ppx of cholelithiasis as a complication of gastric bypass surgery
- 40% of patients
- decreased incidence with 6 mos of post op ppx: ursodeoxycholic acid
What is the difference in ICU GI bleeding risk on GI ppx vs. without?
1.5%-8.5% risk on GI ppx
15% without