Gastroenterology Flashcards
high fat content in stool can indicate
pancreatic/biliary function
inc / dec leukocyte in stool can indicate
inc: UC, parasitosis
dec: cholera/viral diarrhea
alkaline/acidic stool may indicate
alkaline: abx use, fungal overgrowth
acidic: CHO, fat malabsorption, disaccharide def
dec bile or urobilinogen in stool can indicate
hepatobiliary compromise/dysfunction
what is the most common stool sample IgA test for?
h pylori
GI imaging choices
US: cystic masses, aortic aneurysms, ovarian cysts
CT: go to for solid organs, masses, extraintestinal pathologies
if you need to see below ASIS, order abdominal AND pelvic u/s or CT
what is flouroscopy
motion xray in GI
diagnostically and placement guide for invasive procedures
-prazole
vs
-conazole
-prazole = PPI
-conazole = triazole antifungals
BB warning PPIs
significant magnesium def with long term use
type of drugs that would slow down the GI tract are primarily going to be from ___ receptors
alpha 1: excitatory EXCEPT in GI
(PS LYTIC, anti cholinergic)
belladonna alkaloids in GI tract
hyoscyamine
dicyclomine
scopolamine
uses: diarrhea, spasms, motion sickness
AE: CNS depression, constipation, dry mouth, HA, dizziness
docusate CI
mineral oil use
herbal cathartics for constipation
castor oil
senna
cascara
prunes
if u take away suddenly > worse than before
common referred pain patterns for the stomach
left 5th rib to mid lumbar
midline to left lateral border of dorsal and ventral epigastric area
common referred pain patterns for the liver
same as stomach but on right half
right scapula
common referred pain patterns for the gallbladder
RUQ
right scapula
murphys point
common referred pain patterns for the appendix
mcburneys, RLQ
right dorsal flank
celiac area
common referred pain patterns for the colon, small intestine
celiac
local area large intestine
common referred pain patterns for the rectum
suprapubic area, sacral area
common referred pain patterns for the kidneys
CVA
bilateral dorsal flank
bilateral dorsal iliac crests
common referred pain patterns for the ureters
left inf iliac crest
left inguinal area
left labia/testicle
achalasia
motility disorder of esophagus from loss of neurons from mesenteric plexus
LES fails to relax with swallowing > LES pressures inc
causes of esophageal spasm
cold liquids
eating ice cream
food caught in esophagus
ddx for central/celiac abdominal pain
acute/early API
small bowel obstruction
gastritis
pancreatitis (may also be epigastric)
intestinal colic
ddx LUQ/hypochondrium abdominal pain
subphrenic abscess
pancreatitis
perforated gastric ulcer
jejunal diverticulitis
spleen (pain, rupture, artery aneurysm)
signs of stomach/pancreatic pain
wants to be in fetal position
LUQ/epigastric pain
pancreatic: rise in lipase/amylase
gastric vs duodenal ulcer
gastric: h pylori, smoking, NSAIDs, burning epigastric pain, WORSE with food
duodenal: more common men, burning epigastric pain 1-3 hours post eating, BETTER eating, h pylori, MEN
most common gastric cancer
adenocarcinoma
RF gastric cancer
h pylori infxn hx
older males
cig smoker
dry, salty food in diet
presentation gastric cancer
sx of gastritis/gastric ulcers but not responding to normal therapies
pancreatitis etiology, presentation, and dx
alcohol & gallstones
epigastric sharp/boring pain, radiation to back
pain better sitting up/fetal position
worse w movement
N/V, anorexia
elevated amylase and lipase, abdominal XR
ddx for RUQ/right hypochondrium abdominal pain
pleuritic pain
acute API
cholecystitis
leaking duodenal ulcer
subphrenic abscess
cholelithiasis workup
US
next steps if a total bilirubin comes back elevated
check direct and indirect (unconjugated) bilirubin
indirect/unconjugated bilirubin is elevated in
“prehepatic”
hemolytic conditions
gibert syndrome
acute hepatitis
acetaminophen toxicity
toxic mushrooms
direct (conjugated) bilirubin is increased in
hepatocellular dz (normally with inc ALT)
biliary obstruction (often w inc amylase)
inflammation/cancer of the liver
what drug to avoid in a patient with active hepatitis because of the risk of liver toxicity that would lead to inc unconjugated bilirubin?
acetominophen
most common causes of biliary obstruction
gallstones (painful)
strictures or neoplasms (painless)
why is pancreatic cancer so deadly?
usually silent and caught very late
acute hepatitis vs chronic hepatitis
acute: self limited injury of liver <6 mo
chronic: hepatic inflammation >6 mo
signs/sx hepatitis
fever, N/V, anorexia, vague RUQ pain, jaundice, HA, myalgia/arthralgia
smokers may find tobacco tastes bad
pronounced elevation of liver enzymes in acute hepatitis and variable inc with chronic dz
hep A transmission, incubation
RNA virus
fecal oral
abrupt onset, 15-50 day incubation
low mortality, no carrier state
hep E transmission, incubation, mortality
fecal-oral
not found in US
15-60 incubation (avg 40)
more fatal in pregnancy
severity inc with age
hep B transmission, incubation, associated pathologies
DNA virus
parenteral/sexual transmission
insidious onset, incubation 10-12 weeks > fever, fatigue, nausea, jaundice, painful hepatomegaly
ass w hepatocellular carcinoma and cirrhosis
hep C transmission, incubation, associated pathologies
same profile as hep B; fever, malaise, nausea, mild hepatitis
slow, chronic course
RNA virus, parenteral transmission (tattoos, cocaine)
very high risk hepatocellular carcinoma, risk of diabetes
hep D transmission, incubation, associated pathologies
parenteral/sexual transmission
coinfection with hep b ALWAYS
deadly
serologic marker for hep a
IgM
Anti-HA
serologic marker for hep B
HbsAg
serologic marker for hep C
anti-HCV
common causes acute hepatitis
viral ifxn, toxic exposure, ischemic injury
presentation cirrhosis
weakness, anorexia, malaise, wt loss, pruritis, jaundice, palpable firm liver with blunt edge
cirrhosis dx
dec serum albulim
prolonged prothrombin
CT (ev liver size/texture)
US for organomegaly
etiology cirrhosis
hep b/c
alcoholism
ascites presentation
accumulation of serous fluid in abdomen
percussion of flanks = dullness
fluid shifts upon rotating pt in right/left lateral positions
shifting dullness indicates 1.5+ liters of ascites
etiology ascites
intraabdominal masses
liver dz
number one RF for liver cancer
hep B or C
cirrhosis
RLQ/right iliac abdominal pain etiology
API
chohns
mesenteric adenitis
leaking duodenal ulcer
ectopic preg
less common; ileocecal valve
cholecystitis
biliary peritonitis
pancreatitis
inflamed meckels diverticulum
referred pain locations appendicitis
flank
testicle
bladder
dx appendicitis
CBC with differential
UA
preg test to ro ectopic
mild to mod elevated WBC with left shift; also can be normal
LLQ/left iliac abdominal pain can be indicative of
diverticulitis
peritonitis (spreading)
pericolitis (around colon cancer(
what pathology presents like appendicitis but on the left side?
diverticulitis
diverticulum vs diverticulosis vs diverticulitis
diverticulum: outpouching of bowel wall, usu in sigmoid/desc colon
diverticulosis: multiple diverticula
diverticulitis: inflam/infxn in 1+ diverticula
diverticulos/diverticulitis workup
CT scan
colonoscopy is CI
flank and left inguinal/iliac pain in the abdomen may be indicative of
inguinal: ureteric pain (either side)
flank: kidney pain
internal vs external hemorrhoids
internal: derived from int hemorrhoid plexus above the dentate line, covered by rectal mucosa
external: derived from ext hemorrhoid plexus** below dentate line**, covered by stratified squamous epithelium
cryptitis
obstruction of anal glands > infection and abscess formation
e coli, proteus vulgaris, strep, staph
anal fistula etiologies
- drainage of perirectal abscess
- mild infxn burrowing to skin and bursting like pumple
usually begin in anal recal crypts but sometimes result from
- trauma
- diverticulitis
- neoplasm
fistulas and fissures are common in pts with
IBD: crohns/colitis
RF colon cancer
50+
hx polyps
UC, crohns
fhx colon ca or familial polyposis syndrome
diet high in fat/low in fiber
smoking
alcohol
inactive lifestyle
ddx with watery, profuse diarrhea with no fever and potential emesis
staph, clostridium, enterogenic e coli, viliaria cholerae
4-72 hour incubation
ddx with variable, watery diarrhea, mild emesis, and moderate abdominal pain
e coli
giardia
2-7 day incubation
ddx with bloody diarrhea, severe abominal pain
hemorrhagic e coli, c diff (no/mild fever)
salmonella, shigella, campylobacter, entamoeba, enteroinvasive e coli (mod to high fever, severe bleeding)
1-4 day incubation
dysentery
more fluid loss than diarrhea
> 2 -20 L
forcing fluid into colon bc of inflammation
cholera etiology and presentation
bacterial gastroenteritis; vibro cholerae
vague abd fullness > cold hands and feet, lightheadedness, rapidly progressing vomiting, painless watery purging, leg muscle cramps, urine shutdown
e coli enteritis presentation
water or fecal/oral spread
24-72 hour incubation
enterotoxin causes diarrhea
non bloody unless enterohemorrhagic strain O157:H7
rapid onset food poisoning, think
staph
longer onset food poisoning think
salmonella, vibrio
staph food poisoning presentation/diagnosis
cramps, vomiting, mild diarrhea, occasional fever
onset 1-2 hours, sx last 5-8 hours to days
meat type foods
stool microscopy for gram+ cocci
clostridium gastroenteritis presentation/dx
meat (cooked and cooled)
duration 24 hr
watery diarrhea, nausea, cramps (vomiting rare)
hx, toxin or organism in feces, serology
salmonella enteritis source and sx
eggs, poultry
diarrhea with blood, cramps
occasional sepsis
shigella enteritis source and sx
poor hygiene, person to person
N/V, diarrhea > invastive heme pos diarrhea
neuro sx, inc seizures in young pts
giardiasis enteritis source and sx
protozoal; water from animal feces
foul, greasy diarrhea, cramping, bloating, inc gas, weakness, wt loss
cryptosporidiosis enteritis source and sx
contaminated water
profuse watery diarrhea, cramping
sometimes nausea, anorexia, fever, malaise
crohn’s vs UC:
site of origin, pattern of progressiom, and thickness of inflammation
crohn’s: terminal ileum (but can be anywhere) and has “skip” lesions/irregular progression, transmural inflammation
UC: ALWAYS involves rectum, may extend proximally in continuous distrubution, submucosal/mucosal inflammation
crohn’s vs UC:
sx and complications
crohn’s: crampy abdominal pain (RLQ), fever, fatigue > fistulas, abscess, obstruction
UC: bloody diarrhea; hemorrhage, toxic megacolon
crohn’s vs UC:
radiographic findings
crohn’s: string sign on barium XR
UC: lead pipe colon on barium XR
crohn’s vs UC:
risk of colon cancer
crohns: slight inc
UC: marked increase
crohn’s vs UC:
pain onset
earlier in crohns
skin manifestations of IBD
erythema nodosum
pyoderma gangrenosum
rheumatic manifestations IBD
asymmetric polyarticular arthritis and ankylosing spondylitis (more common in crohns)
ocular manifestations IBD
uveitis (photophobia, blurred vision, headache)
urologic manifestations IBD
nephrolithiasis in crohns/after small bowel resection surgery
hepatobiliary manifestations of IBD
crohns: cholelithiasis, fatty liver
UC: fatty liver
primary sclerosing cholangitis rare in both
what is toxic megacolon?
inflammation into smooth muscle causing paralysis > dilation of colon with systemic toxicity
diarrhea, rectal bleeding, abdominal pain, tenesmus, N/V, fever
dx criteria:
-radiographic dilated colon
- 3 of : >120 bpm, >101.5 F, leukocytosis, anemia
1 of: dehydration, elec abnm, altered mental status, hypotension
dx of celiac sprue
serum IgA antiendomysial and TTG
**intestinal biopsy most senstive **
anti-gliadin levels less specific
IBS diarrhea is often worse ____
in morning
after meals
bacterial gastroenteritis etiology/presentation
blood in stool, fecal leukocytes
travel, exposure to animals, meat consumption
campylo, e coli, salmonella, shigella, staph A, yersinia
viral gastroenteritis etiology/presentation
fecal leukocytes typically absent
rotavirus, norovirus, adenovirus
parasitic gastroenteritis etiology/presentation
pinworks, ascariasis, hookworms, tapeworms, flukes
giardia, entamoeba, cyclospora, cryptosporidium, blastocystis
IBS RF and dx
RF: domestic abuse hx, hx child sexual abuse, stress, depression
Rome criteria
- at least 3 mo in past year having: relieved w defacation, change in frequency or appearance of stool
workup IBS
dx of exclusion; r/o lactose intolerance, crohns, celiac sprue, parasites
C&S, O&P, sigmoidoscopy, colonoscopy
tx IBS
fiber, water, eliminate trigger foods
dicyclomine
loperamide
laxatives
tx SIBO
rifaximin
proctitis etiologies and tx
- shigella (self lim; ampicillin, tetracycline, ciprofloxacin)
- yersinia with IV tetracycline/ceftriaxone
- campylobacter self limiting
-amaebiasis / c diff (metronidazole)
supplementation with what nutrient may dec risk of developing colon polyps?
calcium
imaging megacolon
XR: loss of haustra
CT look for perforation
meckel diverticulum presentation
remnant of omphalomesenteric duct, may be attached to umbilicus
2 inch long, 2 ft from IC valve, 2% of ppl, 2% sx
painless GI bleed, melena, intestinal obstruction, diverticulitis, TTP near umbilicus
workup/tx for meckel diverticulum
abdominal XR, techn 99 radioisotope scanning to identify ectopic gastric mucosa
tx: resection if hemorrhage, intestinal obstruction, diverticulitis, umbilico-ileal fistulas
what is ileus?
obstruction from hypomobility of GI tract
crohns vs IBD:
smoking
RF for crohns
protective for UC
presentation / workup inguinal hernia
tenderness worse at end of day, relieved supine, abdominal fullness, N/V, constipation
US, CT
direct vs indirect inguinal hernia
direct:
- intestine protrudes through hesselbachs triange to create bulge in abdominal wall (more common in elderly)
indirect:
- intestinal loop goes through internal/deep inguinal ring, external (superficial) inguinal ring, and into the scrotum (more common)
tx IBD
corticosteroids
sulfasalazine analgesics
TNF blockers
loperamide in crohns, but antidiarrheal meds CI in UC
presentation, complications, workup, and tx duodenal ulcer
epigastric pain BETTER w eating
complications: bleeding, perforation, pancreatitis
workup: endoscopy, urea breath test
tx: tx h pylori, smoking cessation, avoid triggers/etoh, H2 antagonists, PPI, antacids
diverticulitis presentation
infxn of diverticula; medical emergency
LLQ pain/mass, alternating constipation/diarrhea, low grade fever
workup diverticulitis
milk leukocytosis
CT scan with rectal contrast
sigmoidoscopy/colonoscopy 4-6 weeks after acute attack
when would a barium enema be CI?
acute attack of diverticulitis (inc risk perforation)
tx diverticulitis
refer to ED; surgery to drain ascess/resection (Hartmann)
ciprofloxacin, metronidazole, castor oil topically
diverticulosis presentation
multiple false diverticuli, esp in sigmoid colon
asx, episodia LLQ pain, bloating, flatulence, constipation, diarrhea, painless rectal bleeding
tx hep C
IFN a
antivirals
tx hep b
IFN-a (chronic)
adefovir
enecavir
vaccinate for HAV
tx hep a
HAV prophylaxis
hygiene
antismooth muscle antibodies would be present in
primary biliary cirrhosis (cholangitis)
what is zollinger ellison syndrome? how is it worked up?
overproduction of gastrin; somatostatin receptor scintography
common causes of gastritis
h pylori
NSAIDs
alcohol
stress
non-erosive: asx, requires biopsy
erosive: bleeding, melena, iron def, dx upper endoscopy
GI cancer tx
surgery, radiation, 5FU
esophageal cancer presentation
adenocarcinoma (more common): smoking, obesity, GERD
SCC: 4s (smoking, spirits, seeds, scalding liquids)
wt loss, dysphagia, bleeding, hematemesis, retrosternal pain, hoarseness
most common form of gastric and GB cancer
adenocarcinoma
acute pancreatitis
activation pancreative enzymes > autodigestion of pancreas
etoh and gallstones most common cause
knife like pain in mid epigastric area, may radiate to back, fever, N/V, jaundice, hypoxemia, hypovolemic shock, cullen sign
ALT >150, inc WBC, inc glucose, dec calcium, CT with contrast, sentinel loop
chronic pancreatitis
alcohol most common cause
steatorrhea, calcification of pancreas, DM1
CT shows pseudocyst, US shows calcification, dilated ducts, pseudocysts
benefit of PPIs in barrets esophagus in terms of complications
dec sx/cancer risk
types of esophagitis
infectious (candida)
pill induced
eosinophilic
eosinophilic esophagitis presentation, dx, tx
young m w atopy
dysphagia with solid food, GERD sx
upper endoscopy to dx
montelukast, fluticasone spray (swallowed), PPI
sign of achalasia on barium swallow study
birds beak
workup of dysphagia
barium swallow
upper endoscopy
esophageal manometry (pressure)
pH monitoring
esophageal varices
dilated submucosal L gastric veins, complication of portal HTN from cirrhosis (etoh)
rupture = massive hematemesis, most common cause of death in cirrhosis, black tarry stools, coffee ground emesis
esophageal strictures etiology, presentation, tx
due to gerd, dysfunctional LES, hiatal hernia, post surgery
sx: GERD, regurgitation, dysphagia, wt loss
H2 ant, PPI, surgery
