Gastroenterology Flashcards
Acetaminophen toxicity causes ____. What are 2 antidotes?
Hepatic necrosis, N-acetylcysteine and activated charcoal
Salicylate (aspirin, pepto bismol) toxicity causes what? What are the antidotes?
Respiratory alkalosis, metabolic acidosis, renal failure, hypokalemia
-Activated charcoal, gastric lavage, iv fluid, sodium bicarb
Base toxicity (drain cleaner, bleach) workup and treatment?
EGD to assess for damage, supportive care and emesis prevention
Anticholinergic toxicity (antihistamines, atropine, TCA’s) effects, antidote
- Hyperthermia with no sweating, hot flushed, dry mucus membranes, mydraisis, tachycardia
- Physostigmine (acetycholinesterase inhibitor)
Cholinergic toxicity (organophosphates such as pesticides) effects, antidote
- Salivation, lacrimation, urination, increased GI function, miosis
- Atropine and pralidoxime
Iron toxicity effects, antidote
- Nausea, vomiting, metabolic acidosis, pain, shock, can be visible on x ray
- Whole bowel irrigation and deferoxamine
Amphetamines overdose treatment
Ammonium chloride
Opioid overdose treatment
Naloxone (narcan)
Benzodiazepine overdose treatment
Flumazenil
Digitalis overdose treatment
Digibind
Methemoglobin overdose treatment
Methylene blue
Cyanide overdose treatment
Hydroxocobalamin
Warfarin overdose treatment
-Vit K and fresh frozen plasma, cryoprecipitate if continued bleeding
Heparin overdose treatment
Protamine sulfate
Ethylene glycol overdose treatment (antifreeze)
IV ethanol infusion
Acute cholecystitis clinical manifestation and most common causative agent
- Continuous RUQ pain, may be precipitated by fatty foods or large meals, may have nausea, remember its obstruction of cystic duct by gallstones
- E coli
Initial imaging study of choice for acute cholecystitis, what is the most accurate test?
Ultrasound, HIDA scan
Acute cholecystitis management
-NPO, IV fluids, antibiotics, cholecystectomy within 72 hrs
Reynold’s pentad is charcots triad plus 2 things (acute ascending cholangitis
- Hypotension, altered mental status
- fever chills, RUQ pain, jaundice
Initial imaging test of choice for acute ascending cholangitis
Ultrasound
Most accurate imaging test for acute ascending cholangitis
MCRP
Gold standard imaging/therapy for acute ascending cholangitis
ERCP with stone removal after antibiotics (eventually, the patient should undergo elective cholecystectomy)
Cholelithisais risk factors
-Fat fair female forty fertile
Biliary colic is a sign of what condition?
Cholelithiasis, if prolonged and accompanied by RUQ pain and jaundice could be choledocholithiasis
When does physiologic jaundice present?
Days 3-5 of life (not in first 24 hours and not >10-14 days)
Kernicterus
Cerebral dysfunction and encephalopathy due to bilirubin deposition in brain tissue, associated with bilirubin levels >20 mg/dL, can manifest as seizures, lethargy, irritability, hearing loss, and developmental delays
Pathologic neonatal jaundice work up (3)
- Bilirubin level
- Coombs test
- LFTs, alk phos
Treatment of all pathologic neonatal jaundice types
-Phototherapy is initial management
Dubin Johnson syndrome definition
Hereditary conjugated or (DDDDDirect) hyperbilirubinemia, has a DDDDark liver on biopsy and may present with no symptoms or mild icterus, no treatment is needed
Crigler Najjar syndrome definition
Hereditary unconjugated or indirect hyperbilirubinemia, often presents week 2 of birth as neonatal jaundice with progression to kernicterus, treated with phototherapy
Gilbert’s syndrome definition
Relatively common mostly asymptomatic hereditary unconjugated hyperbilirubinemia, may develop transient episodes of jaundice during periods of stress, fasting, alcohol, or illness, diagnosed via isolated indirect bilirubini with otherwise normal LFT, no treatment needed
Is ALT or AST more sensitive for liver disease?
ALT (L for liver, AST is found in skeletal muscle as well)
What is the earliest marker of severe liver injury?
PT/INR (Note not aPTT)
AST:ALT >2 indicates what?
Alcoholic hepatitis (S for scotch)
ALT and AST >1000 think of what?
Acute viral hepatitis
ALT alone >1000 think of what?
Autoimmune hepatitis
Name 2 drugs that can contribute to constipation
- verapamil
- opioids
1 recommended bulk forming laxative most often first line for simple constipation or IBS is….
psyllium
Hepatic encephalopathy treatment
Lactulose
Most common location of an anorectal abscess formation?
Posterior rectal wall
Most common site of an anal fissure formation? What about in UC/crohn’s patients?
Posterior midline, lateral in IBD patients
Internal hemorrhoids tend to ___, while external tend to ___
bleed, be painful
Treatment of hemorrhoids (3)
- Conservative, high fiber diet, sitz baths, increased fluids
- Rubber band ligation most common if failed conservative management/debilitating pain/strangulation
- Excision of thrombosed external hemorrhoids
Most common area for diverticulosis formation vs diverticulitis
Right colon vs sigmoid colon
Most common cause of acute lower GI bleeding that is painless in adults
Diverticulosis
Diagnostic study of choice for diverticulosis
Colonoscopy
Imaging test of choice for suspected diverticulitis (LLQ tenderness, low grade fever, nausea, vomiting)
CT scan (do NOT do colonosocpy as perforation risk)
Management of uncomplicated diverticulitis vs complicated
Uncomplicated can be treated outpatient with oral antibiotics and diet as tolerated
Complicated may require CT guided percutaneous drainage
Toxic megacolon is often a complication of what form of IBD?
Ulcerative colitis
Signs of toxic megacolon
- profound bloody diarrhea and signs of toxicity (tachy, hypotension etc)
- radiologic imaging of colon >6cm
Toxic megacolon treatment
-bowel rest, bowel decompression with NG tube, broad spectrum antibiotics, fluid support
Smoking is associated with increased incidence of ___, but is protective against ____
crohns, UC
Can you cure any type of IBD?
UC via surgery, not crohns because it impacts any segment of GI tract
What part of the bowel is most commonly affected in crohn’s?
Termminal ileum
String sign
Seen in upper GI series which is initial test of choice in diagnosing crohn’s disease
Treatment of mild to moderate distal (UC) or limited ileocolonic (Crohn’s) disease
5-ASA such as mesalamine (type of NSAID)
Chronic dull abdominal pain worse after meals could indicate these 2 pathologies
- Gastric ulcer
- Chronic mesenteric ischemia
What artery is most often occluded in acute mesenteric ischemia?
Superior mesenteric artery
What type of colon polyp is most commonly neoplastic? What subtype of this tends to be highest risk of becoming cancerous?
Adenomatous, villous adenoma
Familial adenomatous polyposis (FAP) definition
Genetic mutation that causes adenomas to begin in childhood and nearly all who have will develop colon cancer by age 45, prophylactic colectomy is best for survival, requires screening at age 10-12 with flexible sigmoidoscopy yearly
Lynch syndrome (Hereditary nonpolyposis colorectal cancer) definition
Autosomal dominant genetic mutation that has high risk of colon cancer and extra-colonic cancers such as endometrial, ovarian, small intestine, etc. often by age 40 see cancer, require screening with colonoscopy every 1-2 years at age 20-25
Peutz Jehgers syndrome definition
Autosomal dominant condition that is associated with hamartomatous polyps (rarely cancerous) and mucocutaneous hyperpigmentation on the lips, mucosa, and hands
Most common cause of large bowel obstruction in adults
Colorectal cancer
Apple core lesion on barium enema
Significant for possible colorectal cancer requiring follow up colonoscopy
Dicyclomine
Anticholinergic, antispasmodic to treat diarrhea symptoms
How is pill induced esophagitis diagnosed
Endoscopy demonstrating small well defined ulcers of varying depths due to prolonged pill contact with esophagus, treated with lifestyle changes
Treatment of hiatal hernias
- For simple sliding types, PPI’s and weight loss
- for paraesophageal (stomach protrudges the GE junction) surgical repair in complications
How is esophageal atresia diagnosed?
Presents immediately after birth with excessive oral secretions, inability to pass NG tube into stomach
Gold standard diagnosis of GERD and most common diagnosis, as well as first line diagnositc if persistent or cmoplications suspected
24 hr ambulatory pH monitoring, most common clinical diagnosis, Endoscopy
Major risk factors of adenocarcinoma of the esophagus
-Barrett’s, smoking
Major risk factors of squamous cell carcinoma of the esophagus
-smoking, alcohol
Bird’s beak appearance of the LES on barium esophagram is indicatie of what condition
Achalasia
What are 2 ways to treat achalasia
- botulinum toxin injection
- pneumatic dilation of LES
Distal esophageal spasm and hypercontractile esophagus
esophageal motility disorders that see stabbing chest pain worse with liquids or food, “object stuck in throat”, diagnosed via manometry definitively to determine if distal esophageal spasm or hypercontractile esophagus
Boerhaave syndrome diagnostic test of choice
Contrast esophagram with gastrografin demonstrating leakage (gastrografin not caustic unlike barium)
Boerhaave syndrome management if small vs large and severe
Small - iv fluids, npo, antibiotics, h2 receptor blockers
Large - surgical
Diagnostic ttest of choice for esophageal webs or shatzki rings
-barium esophagram
First line medical management of an acute variceal bleed
-Octreotide (pharmacologic vasoconstrictor)
Although celiac is often a clinical diagnosis, what screening option is there? What about definitive and confirmatory testing
- Transglutaminase IgA test of choice, endomysial IgA antibodies 2nd choice
- small bowel biiopsy demonstrating atrophy of villi
Test of choice (other than clinical diagnosis which is often used) for lactose intolerance
-hydrogen breath test
Most common cause of gastritis
H pylori infection
Zollinger ellison syndrome definition
Gastrin producing tumor that causes 1% of all peptic ulcer diseases, screened with elevated gastrin level
Most common cause of upper GI bleed
PUD
Gold standard in diagnosing h pylori infection, what is a non invasive alternative? What about confirming eradication after therapy
Endoscopy with biopsy, urea breath test, h pylori stool antigen testing
Quadruple therapy for h pylori
Pepto (bismuth subsalicylate), tetracycline, metronidazole, ppi
Carcinoid tumors occur most often in the ___, what doees carcinoid syndrome present like?
GI tract (lungs are second most common), carcinoid syndrome presents with periodic episodes of diarrhea, flushing, tachycardia, bronchoconstriction, and hypotension
Biggest risk factor for gastric carcinoma
H pylori infection
Initial test of choice for pyloric stenosis
abdominal ultrasound
ALT and AST elevations in acute viral hepatitis
> 500
What percent of hep C infections become chronic?
80%!!!
Hepatitis A transmission route, treatment
Predominantly fecal oral contaminated food and water especially international travel, self limiting and prevention during international travel
Post exposure prophylaxis of hepA
-HAV vaccine preferred over immunoglobin in individuals 1-40 years old, if chronic liver disease or immunocompromised or older can be both HAV vaccine and HAV immunoglobin
Coagulopathy of liver disease treatment
-Cryoprecipitate, fresh frozen plasma if no response
Hepatitis C transmission route
Parenteral with IV drug use most common
Hepatitis B transmission route
Sexual, needle transmission, blood exposure all possibile
Management of acute hep B vs chronic
Acute is supportive, most do not become chronic, chronic may need antiviral therapy
Hepatitis B vaccination schedule
3 dose at Birth, 1-2 months, and 6-18 months
Spontaneous bacterial peritonitis (infection without perforation of bowel) is a complication of what condition?
Cirrhosis
Primary schlerosing cholangitis 2 diagnostic hallmarks
- Positive P-ANCA
- MCRP/ERCP demonstrating beaded appearance of biliary ducts
Wilson’s disease characteristic physical exam finding, common diagnosis, definitive diagnosis, and management
- Kayser fleischer rings
- 24 hour urinary copper excretion
- Liver biopsy
- Copper chelating agents like Trientine
Most common type of inguinal hernia
Indirect
Diagnosis of an inguinal hernia
- Clinical
- Groin ultrasound
Diphenyloxylate/atropine drug class and use
Opioid agonist used as an anti-diarrheal, similar to loperamide
List 4 antiemetic agents
- Odansetron
- Prochlorperazine
- Promethazine
- Metoclopramide
Rotavirus vaccine schedule
2 dose rotarix 2 month and 4 month or 3 dose rotateq 2 month 4 month and 6 month
Sources of staph aureus gastroenteritis
-Dairy, mayonnaise, meats, eggs, salads, left at room temp
Baccilus cereus gastroenteritis
Similar to S aureus, short incubatoin period within 6 hours, enterotoxin can survive reheating so souces are contaminated food like fried rice classically, predominantly vomiting and nausea, treated with fluid replacement
Enterotoxigenic E coli is the most common cause of what?
Most common cause of travelers diarrhea
Cholera antibiotic of choice
Tetracyclines first line
C-Diff risk factor
Recent antibiotic use such as clindamycin, can be healthcare associated
Diagnosis of c-diff (2)
- c diff toxin in stool
- sigmoidoscopy demonstrating pseudomembranes
C-diff treatment
-oral vancomycin
Most common cause of bacterial enteritis in US
Campylobacter jejuni
Most common antecedent event in post infecitous guillain barre syndrome
Campylobacter jejuni infection
Why should antibiotics be avoided in children in the management of enterohemorrhagic e coli?
Can precipitate hemolytic uremic syndrome because of increase release of shiga-like toxins
Whipple’s disease definition
Transmitted via contaminated soil causing chronic diarrhea and malabsorption most often in farmers, requires duodenal biopsy to diagnose and 1-2 years of antibiotic treatment
Heinz bodies and schistocytes (bite or fragmented cells) are associated with…
….g6pd deficiency
Things that trigger hemolytic anemia in g6pd deficienc
infection, fava beans
Paget disease of the bone definition
Abnormal bone remodeling seen in aging bones that leads to larger weaker bones, can see high alkaline phosphatase on testing, bone pain is most common symptom, bisphosphonates are first ine management
Vit D deficiency results in these 2 diseases
- osteomalacia
- rickets
Vit A excess and deficiency
- Hyperkaratosis, idiopathic intracranial hypertension
- Night blindness vision changes, bitot’s spots
Riboflavin (B2) deficiency manifestations
-Glossitis, angular cheilitis, stomatitis, pharyngitis
Thiamine (B1) deficiency manifestations
- Wet beriberi (high output heart failure and dilated cardiomyopathy)
- Dry beriberi (symmetric peripheral neuropathy)
- Wernicke encephalopathy (ataxia, confusion, common in chronic alcoholics)
- Korsakoff dementia (memory loss short term, irreversible, consequence of untreated wernicke)
Niacin (B3) deficiency manifestations
-Pellagra (dermatitis, diarrhea, dementia, death)
Pyridoxine (B6) deficiency unique cause
-isoniazid!
Pyridoxine (B6) deficiency manifestations
-peripheral neuropathy
Cobalamin (B12) deficiency manifestations
- Vegans are at risk due to no meat consumption
- Requires intrinsic factor for absorption
- Pernicious anemia most common source
- anemia similar to folate but WITH NEUROLOGIC ABNORMALITIES such as symmetric paresthesias
Most common and second most common causes of acute pancreatitis
- Gallstones
- Alcohol abuse
Classic descriptor of acute pancreatitis
Coonstant epigastric pain that bores and radiates to the back, relieved with leaning forward or in fetal position, nausea, vomiting, fever, cullen or grey turner sign
Best intial tests for acute pancreatitis
-Amylase and lipase
Diagnostic imaging of choice for acute pancreatitis
-Abdominal CT
Acute pancreatitis treatment
-NPO, high volume iv fluid resuscitation, analgesia, 90% recover without complications and require supportive measures only
Most common cause of chronic pancreatitis, diagnosis is usually made by?
Alcohol abuse, CT scan demonstrating calcification of pancreas (amylase and lipase usually normal)
Pancreatic carcinoma most common type, risk factors (2), classic presentation (2), 2 physical exam findings, treatment (1)
- adenocarcinoma
- Smoking and age
- Painless jaundice and pruritis
- Trousseaus malignancy sign (migratory phlebitis), courvoisier’s sign (palpable nontender gallbladder)
- Whipple proecudre (pancreaticduodenectomy)
Rule of 2’s and what it applies to?
2% of population, 2 feet of ileocecal valve, 2% symptomatic, 2 inches in length, 2 years presentation, meckel’s diverticulum (can cause painless or painful periumbilical rectal bleeding) composed of ectpic gastric mucosa
Double bubble sign on abdominal radiograph indicates
Duodenal atresia
Coffee bean sign on abomdinal radiograph indicates
Volvulus
Multiple air fluid levels on abdominal radiograph indicates
SBO
Sausage shaped mass on physical exam plus currant jelly stool is indicative of what condition? How is it diagnosed (best initial test) and treated (diagnostic and therapeutic)?
Intussusception, ultrasound demonstrating target sign, air or contrast enema diagnostic and therapeutic
