Gastroenterology Flashcards
GERD - risk factors, clinical features, alarm features
risks:
- ETOH, caffeine, obesity, smoking, specific foods, hiatal hernia
clinical features:
- heartburn 30-60 min after meals
- improves w/ antacids
- chest pain, halitosis, cough
alarm features:
- refractory sxs
- dysphagia (difficult swallow), odynophagia (painful swallow)
- unintentional wt loss
- GI bleed, Fe deficiency anemia
GERD - dx
endoscopy - dx of choice
if mild, can be clinical dx
GERD - tx
mild:
- lifestyle modifications
- OTC antacids: TUMS, Maalox, Mylanta
- OTC H2 blockers: Cimetidine, ranitidine, famotidine
persistent:
- once daily PPI (omeprazole): TX OF CHOICE, tx 8-12 weeks or longer if needed
refractory sxs:
- nissen fundoplication for large hiatal hernia
gastritis - cause, presentation, dx, tc
inflammation of lining of stomach
- epigastric pain, N/V, UGI bleed of erosive
cause: meds, ETOH, severe stress, portal HTN
dx: upper EGD
tx:
- stop offending agent or tx underlying dz (portal HTN
- PPI
atrophic gastritis - 2 types
see atrophy of cells that line the stomach
- autoimmune
- vague abdominal pain
- anti-intrinsic factor antibodies attack cells of stomach
- inhibit B12 absorption
- monitor with EGD for cancer (at inc risk) - H. pylori associated
- bacterial infection
H. pylori - clinical presentation, dx
nausea, vague abdominal pain, bloating/dyspepsia
- can be associated w/ travel
dx: urea breath test
- if taken PPI in last 4 wks, cannot do urea breath test (EGD)
H. pylori - tx, complications
tx:
1st line: triple therapy
- PPI + amoxicillin + clarithromycin
- metronidazole instead of AMOX for PEN allergy
If fail: quadruple therapy
- PPI, bismuth (pepto), tetracycline, metronidazole
MUST CONFIRM ERADICATION: repeat urea breath test
complications: PUD, gastric cancer, gastric MALT lymphoma
PUD: peptic ulcer disease - risks, causes, complications
break in mucosa of stomach or intestine
risks: smoking, long-term NSAID use
- chronic NSAID use: most gastric ulcers
- H pylori: most duodenal ulcers
- other: Zollinger-Ellison syndrome
complications:
- perforation
- GI bleed (MOST COMMON cause of UGI bleed)
PUD - clinical features, dx, tx
hallmark: epigastric pain (dull, aching)
- coffee ground emesis or melena
- duodenal: improves w/ food
- gastric: worsens w/ food
PE: epigastric tenderness w/ deep palpation
dx: upper EGD w/ biopsy
- r/o malignancy and H. pylori
tx:
- avoid irritating factors
- PPI 4-8 weeks (PREFERRED TX)
- treat H. pylori if present
adenocarcinoma - risks, clinical features, dx, tx, survival rate
most common GI cancer
risks: 50-70, male, tobacco, chronic gastritis
clinical: epigastric pain, anorexia, dyspepsia, wt loss, GI bleed
- virchow’s node (superclavicular node)
dx: endoscopy
- mass, irregular ulcer
tx: resection +/- chemo/radiation
5 yr survival < 20%
gastric lymphoma
most are non-Hodgkin B cell lymphoma
Risk factors: H. pylori
Clinical: epigastric pain, anorexia, dyspepsia, wt loss, GI bleed
- same as adenocarcinoma
dx: endoscopic biopsy
tx: combo chemo w/ or w/o radiation
Zollinger-Ellison Syndrome: definition and clinical features
gastrin-secreting gut neuroendocrine tumor
- located in gastrinoma triangle (duodenum, pancreas, lymph nodes)
- 25% associated with MEN-1 (genetic)
Clinical
- PUD refractor to tx (MULTIPLE, large ulcers)
- abdominal pain (80%)
- secretory diarrhea
Zollinger-Ellison Syndrome: dx, tx
dx:
- fasting serum gastrin level (increases w/ these tumors)
- pH < 2 (acidic)
- imaging
tx:
- PPIs initial DRUG OF CHOICE
- Resection b/f METS of liver
pyloric stenosis - clinical features, PE, dx, tx
hypertrophy of pylorus
- most common cause of gastric outlet obstruction in infants
clinical: non-bilious projectile vomiting (4-8 wks of age)
PE: olive shaped mass palpated
Dx: U/S of pylori shows thickening
tx: surgical repair
reflux esophagitis - cause, presentation, dx, tx
mucosal damage 2/2 recurrent GERD (cells of esophagus do not like acid)
- heartburn, postprandial
cause:
- mechanical: poor LES tone, hiatal hernia
- functional: chronic reflex, prolonged vomiting
dx: endoscopy w/ biopsy
- graded A-D (mild to severe)
tx: PPI twice a day for 6-8 wks
Barrett’s esophagus - definition, risks, dx, tx
consequence of long-tern reflux esophagitis
- risk for MALIGNANCY (esophageal adenocarcinoma)
- normal squamous epithelium w/ metaplastic columnar epithelium
risks: male, hiatal hernia, smoker, ETOH
dx: endoscopy w/ biopsy
- “irregular z-line”
- “salmon-colored mucosa”
- “intestinal metaplasia”
tx: long-tern PPI tx BID
- EGD every 3-5 yrs
pill-induced esophagitis - what meds
tetracycline (ABX)
KCl
NSAIDS
bisphosphonates
often taking meds w/o water or supine
radiation esophagitis
dysphagia several months following radiation treatment
eosinophilic esophagitis - cause, presentation, dx, tx
cause: food or environmental allergen
clinical:
- atopic hx
- dysphagia w/ solid food
- food impaction
dx: endoscopy w/ biopsy
- white exudates, red furrows, concentric rings
- presence of eosinophils in mucosa
tx: budesonide, fluticasone (steroids)
- avoid offending allergen
- send for allergy testing
achalasia - definition, clinical features, dx, tx
lower esophageal sphincter tone increased
- peristalsis is decreased
- common in 30-60 y/o
clinical:
- slow, progressive dysphagia (solids and liquids)
- episodic regurg, chest pain, cough, coking
dx:
- barium swallow (BIRD’S BEAK)
- endoscopy w/ biopsy (r/o malignancy)
- manometry: confirms dx
tx:
Meds (relax LES): Ca++ channel blockers, isosorbide, LES botox injections
Surgery: pneumatic dilation
scleroderma - definition, clinical features, dx, tx
hardening of skin (rheumatologic condition) - 90% have esophageal involvement (part of CREST)
- hardening lining of esophagus
clinical: GERD, dysphagia to solids and liquids
Dx:
- barium swallow: aperistalsis
- manometry: decreased tone
Tx: PPI for GI sxs
- omeprazole
esophageal spasms
etiology: not understood
clinical: acute chest pain; intermittent dysphagia to solids and liquids that DOES NOT change
dx:
- corkscrew esophagus on barium
- nutcracker esophagus on manometry
tx:
- Ca+ channel blocker (relax)
Zenker’s diverticulum - definition, clinical features, dx, tx
outputting of posterior hypo pharynx
- food gets caught
- occurs in older people
clinic: dysphagia, coughing, regurgitation, halitosis
complicaitons: aspiration (key to prevent in old people)
Dx: barium swallow
Tx:
- None: asymptomatic
- surgery to remove: symptomatic
Mallory Weiss tear
tear in gastro-esophageal junction; transient
clinical: 1-2 episodes of hematemesis after forceful vomiting/retching
- possibly hx of ETOH use
Dx:
- clinical or EDG
Tx:
- most heal in 48 hrs
- PPI (to dec. acid)
esophageal neoplasms - 2 types and risk factors for each
squamous cell
- most common world-wide
- risk: tabacco, ETOH
adenocarcinoma
- most common in US
- risk: Barrett’s, obesity
peptic stricture
complication of chronic GERD/esophagitis
- progresses to dysphagia to solid foods over months to years
dx:
- biopsy (r/o malignancy)
tx:
- endoscopic dilation
- long-term PPI
esophageal obstructive entities - 2 types and tx
- esophageal webs
- assoc. w/ plummer-vinson
- proximal esophagus
- presents w/ dysphagia and food impaction - schatzki ring
- hx of GERD, hiatal hernia
- distal esophagus
Tx: endoscopic dilation and PPI
Plummer Vinson Syndrome
association b/t Fe deficiency anemia, esophageal webs, stomatitis (inflammation of mucous membranes of mouth), and glossitis (inflammation of tongue)
esophageal dysphagia (trouble swallowing)
solids>liquids = mechanical obstruction
- schatzki ring, webs
- peptic stricture
- esophageal neoplasm
- eosinophilic esophagitis
solids and liquids = motility disorders
- achalasia
- esophageal spasm
- scleroderma
liquids>solids = neurogenic dysphagia
- hx of stroke, ALS
esophageal varices - definition, risks, presentation, mortality
dilated veins at base of esophagus
- results from portal HTN
- if they bleed, they bleed ALOT
risk for inc. bleeding: size, red wale markings, liver dz, ETOH use
presentation:
- high grade: hematemesis/hypovolemia
- low grade: melena + Fe-deficiency anemia
mortality:
- 30% during 1st bleed
- 50% w/in 6 mo
esophageal varices - management
first: fluids and blood products for hemodynamic stability
ENDOSCOPIC BAND LIGATION
- preferred therapy for acute bleed
Meds:
- octreotide: dec. splenic flow to these veins
Prevention:
- band ligation
- beta-blockers (non-selective, such as propranolol)
cholelithiasis
gallbladder stones
- mostly cholesterol stones
Risk: forty, fat, female, fertile
- rapid wt loss
- family hx
Clinical:
- intermittent colicky RUQ abd pain (often after fatty meal)
Dx: RUQ U/S
Tx: laparoscopic cholecystectomy (remove gallbladder)
- ONLY if symptomatic
acute cholecystitis - cause, clinical presentation, dx
impacted gallstone in cystic duct
clinical:
- persistent RUQ or epigastric pain (esp after fatty meal)
- N/V, fever
- MURPHY’S SIGN: pain during inspiration
dx:
- inc. WBC, inc. LFTs, amylase, lipase
- RUQ U/S: gallstones + GB wall thickening
- ERCP: indicates biliary obstruction
- HIDA: no filling on cholecystitis - MOST SPECIFIC TEST
acute cholecystitis - tx, complications
initial: medical management
- IV fluids
- bowel rest
- IV ABX
- pain meds (morphine)
Laparoscopic cholecystectomy w/in 24 hours of admit
complications:
- gangrene/perforation
- chronic cholecystitis
chronic cholecystitis - definition, clinical, dx, tx
results from repeated bouts of cholecystitis or gallstones
chronic, constant RUQ pain, nausea
Dx: U/S than HIDA
Tx: Laparoscopic cholecystectomy
choledocholithiasis - definition, risk, dx
common bile duct stones
- intermittent RUQ pain
- ASSOCIATED W/ JAUNDICE
risk: infection, biliary stasis, s/p cholecystectomy, cholangitis
Dx: U/S then ERCP
cholangitis - definition, risk, dx
infection of common bile duct due to impacted stone
- CHARCOT’s triad: RUQ pain, fever, jaundice
- Reynold’s pentad: chariot’s triad + AMS + hypotension
- emergency since indicates sepsis
MOST COMMON CAUSE: acute bacterial infection
Dx: U/S then ERCP
primary sclerosing cholangitis - definition and cause
biliary system fibrosis and thickening
- men age 20-50
Cause: auto-immune, assoc. w/ ulcerative colitis
primary sclerosing cholangitis - clinical dx, tx, complications
clinical:
- progressive jaundice
- pruritus
- anorexia, fatigue
Dx:
- elevated alk phos
- MRCP or ERCP - liver biopsy
Tx:
- acute: ciprofloxacin
- liver transplant
complications:
- cholangiocarcinoma
hepatitis - acute vs. chronic
liver inflammation
acute:
- viral is MOST COMMON
- toxins: ETOH and meds (acetaminophen, NSAIDS, ABX)
chronic:
- viral
- ETOH
- NASH
- autoimmune
acute viral hepatitis - 5 viruses, risk factors
5 viruses: A, B, C, D, E
Risk:
- A&E: endemic areas, poor sanitation, food and waterborne
- B&C: IV drug use, unprotected intercourse, healthcare, childbirth
- D: co-infection w/ Hep B
acute viral hepatitis - clinical features, labs
clinical:
- fatigue, malaise, anorexia, RUQ pain
- aversion to smoking,
- PE: fever, jaundice, RUQ tenderness, enlarged liver
Labs:
- VERY elevated AST, ALT, Alk Phos, bilirubin
- specific serologic markers for each virus
which hepatitis viruses have vaccines?
A and B
diagnosis of acute viral hepatitis
See cheatsheets
which hepatitis viruses progress to chronic state
B and C
Hepatitis B serology - approach to determining if there is an active infection and if it is acute or chronic
- Look at hep B surface antigen (HBsAg): HBsAg + = active infection
- Look at hep B core antibody (antiHBc) (IgM = acute, IgG = chronic) - If HBsAg - = no active infection, but do they have immunity and, if so, is it from a vaccine or previous infection
- anti HBs + = immunity
- anti HBc IgG - = vaccine
- anti HBc IgG + = previous infection
acute hepatitis -treatment
A: self limited, supportive care B: only tx if in severe liver failure C: peg-interferon D: N/A E: self limited, supportive care
acute hepatitis -prevention
A: vaccine (travelers, etc.) B: vaccine (0, 1, 6 mo) C: precausions D: hep B vaccine E: public hygiene
acute liver failure - cause, clinical, treatment, prognosis
cause: acetaminophen toxicity, drug reactions
clinical: encephalopathy, systemic inflammation, hemorrhage, shock, sepsis
tx:
- metabolic and hemodynamic stability
- acetylcysteine if acetaminophen toxicity
- liver transplant
Prognosis: poor
what is anecdote to acetaminophen toxicity leading to liver acute failure
acetylcysteine w/in 72 hrs
chronic viral hepatitis - cause, clinical, complications
cause: viral infection (most common)
- Hep B, C, D (>3-6 mo)
Clinical:
- fatigue, nausea, jaundice, RUQ pain
- advanced sxs: dark urine, itching, wt loss
complications:
- HBV/HCV = leading cause of cirrhosis and hepatocellular CA
chronic viral hepatitis - dx
detection of viral DNA on serology
ALT/AST: initially very high and then remains slightly high (ALT>AST)
- alk phos minimal high unless + cirrhosis
Liver biopsy to determine dz severity (stage of fibrosis)
chronic viral hepatitis - tx
Hep B: tenofovir/entacavir
Hep C: curable!
- peg-interferon, ribavirin (tx is advancing)
ETOH hepatitis - clinical, dx, tx, complications
clinical: anorexia, nausea, hepatomegaly, jaundice, RUQ pain
Dx:
- mildly elevated AST and ALT (AST>ALT)
- elevated alk phos and bili
- anemia (epo produced in kidney and liver)
Tx: reversible!!
- avoid ETOH
- nutritional support (thiamine, folic acid, zinc)
- liver TXP
Complications:
- infection
- Wernicke-Korsakoff syndrome (neurologic)
- cirrhosis
- hepatocellular CA
Nonalcoholic Fatty Liver Disease (NAFLD) - clinical, dx, tx, complications
deposition of fat in liver
risks: obesity, DM, PCOS
clinical: vague RUQ pain, hepatomegaly
dx:
- mild elevation of AST, ALT, alk phos
- LIVER BIOPSY = diagnostic
tx:
- wt loss, lifestyle change
complications:
- NASH (non alcoholic steatohepatitis)
- cirrhosis
- hepatocellular CA
autoimmune hepatitis - population, clinical, dx, tx, complications
population: young-middle age women w. autoimmune dz
clinical:
- acute hepatitis, ammenorrhea
dx:
- elevated AST/ALT, bili/GGT
- ANA, + smooth muscle antibody (SMA)
- liver biopsy (definitive)
tx:
- prednisone +/- azathioprine
Complications:
- cirrhosis
- hepatocellular CA
cirrhosis - definition, causes, stages, complications
irreversible fibrosis of liver
causes:
- chronic Hep C
- ETOH liver dz (most common in US)
stages:
- compensated
- compensated w/ varices
- decompensated (varices, ascites, encephalopathy, jaundice)
complications:
- portal HTN
- infection, bacterial peritonitis
- hepatic encephalopathy (elevated ammonia)
- coagulopathy
- hepatocellular CA
- liver failure
liver ability to function
can function even with 60% removed
liver re-generates!!
cirrhosis - clinical features, PE, dx
clinical:
- weakness, fatigue, wt loss
- N/V, anorexia, abdominal pain
PE:
- hepatomegaly
- jaundice
- spider angioma
- ascites
- esophageal varices (portal HTN)
Dx:
- liver biopsy = diagnostic
MELD score: higher the score = worse cirrhosis
Tx:
- remove aggravating agents
- treat sxs
- lactulose/rifaximin - stool 2-3 times per day to remove ammonia
- liver TXP
Primary Biliary Cirrhosis - definiton, population, clinical, dx
autoimmune destruction of intrahepatic ducts
- biliary tree becomes fibrotic
- leads to cholestasis
population:
- women (40-60) w/ autoimmune dz
clinical:
- fatigue, pruritus
- late: portal HTN\
dx:
- elevated bili, alk phos, cholesterol
- antimitochondrial antibodies
- liver biopsy (stage fibrosis)
liver neoplasms - benign, malignant (primary or metastatic)
benign:
- cavernous hemangioma: most common
- focal nodular hyperplasia
- hepatocellular adenoma: women, OCPs
malignant:
- primary: hepatocellular CA
- METS: from lung and breast
primary hepatocellular CA - risk factors, tumor marker, imaging, screening
Hepatitis B and C
Cirrhosis
- MOST COMMON CAUSE
Aflatoxin B1 exposure (Aspergillus) - alcoholics at risk for fungal infection
Tumor marker:
- serum AFP elevated indicated primary CA
Imaging:
- CT/MRI w/ contrast
Screening: for those at risk
- AFP and abd U/S q 6 mo
most common malignant tumor in children
hepatoblastoma
cholangiocarcinoma - special sign
CA originals from the duct cells
- Courvoisier’s sign: palpable nontender gallbladder assoc. w/ jaundice
acute pancreatitis - cause, clinical
cause:
- gallstones, ETOH abuse, elevated serum triglycerides
clinical:
- severe epigastric pain, N/V
- worse w/ lying down, better w/ leaning forward
acute pancreatitis - signs of hemorrhage
grey-turner: flank ecchymosis
cullen: umbilical ecchymosis
acute pancreatitis -labs and imaging
labs:
- lipase is most sensitive
- amylase (but also produced elsewhere in body)
Imaging:
- CT w/ contrast
acute pancreatitis - severity ranking (Ranson Criteria)
age > 55 WBC>16,000 Glucose>200 LDH>350 AST>250
3 or more = severe w/ potential for pancreatic necrosis
acute pancreatitis - treatment
NPO (until pain free)
Pain control: hydromorphone (Dilaudid), morphine
Aggressive fluid resuscitation
Treat N/V
chronic pancreatitis - cause, clinical features, dx, tx
result of several episodes of acute pancreatitis
- usually due to ETOH use
Clinical:
- chronic abd pain
- recurrent attacks of acute pancreatitis
- steatorrhea (fat in stool)
- anorexia / wt loss
- N/V
Dx:
- ERCP
Tx:
- Tx underlying cause
- Tx sxs
pancreatic neoplasms - most common type, risk factor, location, tumor marker
4th most common cause of CA death in US
adenocarcinoma = most common
risk factor: genetic predisposition
location: pancreatic head (75%)
tumor marker: CA 19-9
appendicitis - cause, clinical features
most common acute surgical emergency
- fecalith is most likely cause
Clinical:
- peri-umbilical, RLQ pain
- b/t 10-30 y/o
- pain at McBurney’s point
- peritoneal signs: + rebound tenderness
- fever, N/V, anorexia
PE: psoas sign (hip flexion against resistence), obturator sign (knee flexed and hip internally rotated), rovsing’s sign (palpate in LLQ and pain is in RLQ)
appendicitis - diagnosis, treatment
diagnosis: CT scan
- U/S in kids
Treatment:
- laproscopic appendectomy
- ABX
celiac disease - definition, high risk groups, gene involved, clinical features
immunological / inflammatory response to gluten (wheat, rye, barley)
- inflammation of small intestine
high risk groups:
- genetic (1st degree relatives), type I DM, other autoimmune dz
gene = HLA-DQ2/DQ8(+)
clinical: fatigue, wt loss, diarrhea, steatorrhea, abd distention, vit deficiency
celiac disease - diagnosis, treatment, complications
initial: serum IgA tTg antibody
confirm: endoscopy w/ small intestine biopsy (loss of intestinal villi)
treatment:
- gluten-free diet (villi can re-generate)
- supplement vitamins and minerals
complications:
- osteopenia/osteoporosis
- malignancy: lymphoma, carcinoma
constipation - definition, causes
change in bowel habits of an individual
- very common, F>M
causes:
- inadequate fluid and fiber intake
- poor bowel habits
Primary cause: slow transit time
Secondary cause: medication (opioids, anti-cholinergic), systemic disorders, neoplasm/stricture
constipation - labs, studies, alarm features, treatment
Labs: CBC (r/o anemia), BMP, thyroid panel (r/o hypothyroid)
Studies: colonoscopy/sigmoidoscopy, anorectal manometry, colon transit times
Alarm features: age > 50, severe sxs not responding to therapy, blood in stool, wt loss, early satiety, FH cancer or IBD
Treatment:
- dietary and lifestyle: fiber, fluids, d/c meds, exercise
- osmotic laxatives: Mg hydroxide, lactulose, polyethylene glycol
- simulant laxatives (rescue-only): basically, senna
- opioid receptos antagonists in setting of opiate-induced constipation
what population should avoid magnesium products (milk of magnesia or Mg citrate)
those with renal disease
fecal impaction
constipation leads to hard, impacted feces
risks: meds, prolonged bed rest, neurogenic d/o
clinical: dec. appetiti, N/V, abd pain and distention, paradoxical/overflow diarrhea
- PE: firm feces on DRE
Tx:
- saline/mineral oil enema
- digital disimpaction
- long-term goal: maintain soft stool and regular BMs
diverticulosis - definition, clinical, complications, tx
uncomplicated mucosa herniations
- mainly elderly (>80 y/o)
- benign condition
most common site: sigmoid colon
clinical: asymptomatic, constipation
Complications:
- diverticulitis
- painLESS large vol. hematochezia (resolves spontaneously)
Tx:
- high fiber diet/avoid constipation
- bleeding: endoscopic tx vs. surgery
most common cause of major lower GI tract bleeding
diverticulosis
- PAINLESS
diverticulitis - definition, clinical, complications, dx
perforation of colonic diverticulum
- stool leaks into sterile abdomen
clinical:
- LLQ pain, fever, nausea, anorexia, constipation, bleeding (5%)
dx:
- leukocytosis
- CT scan
NOTE: barium study and colonoscopy are contraindicated in acute setting
- risk of perforation
diverticulitis - tx and indications for surgery
uncomplicated (afebrile, tolerate PO): PO ABX
- clear liquid diet
complicated:
- admit and IV ABX
Indications for surgery:
- perforation, failure to respond to tx, recurrent attacks, abscess formation
Inflammatory bowel disease - definition, two types, population
inflammation of intestinal tract, including ulcers
itwo types:
- ulcerative colitis
- Crohn’s disease
bi-modal distribution: age 15-30, 7th decade
autoimmune disease - genetic component
NOTE cigarette smoking is good for UC (bad for Crohn’s)
Crohn’s vs. Ulcerative Colitis - location, symptoms, features, dx
Crohn’s:
- mouth to anus (but spares rectum)
- transmural
- diarrhea, RLQ pain, wt loss
- dx: colonoscopy shows “skip lesions” and granulomas
- smoking worsens
Ulcerative colitis:
- rectum, colon
- BLOODY diarrhea, urgency, anemia
- dx: colonoscopy shows continual lesions
- smoking helps
NOTE: avoid colonoscopy during acute flare for risk of perforation
extra-intestinal manifestations of IBD
joints:
- arthritis
- ankylosing spondylitis
eyes: uveitis
IBD - tx and screening
Acute Attacks:
corticosteroids:
- budesonide (mild)
- prednisone (severe)
Maintenance Therapy: aminosalicylate (5-ASA) - sulfasalazine immunomodulators - methotrexate biologics (suppress immune system) - infliximab
Note:
- surgery can be curative for UC; only used to tx complications for Crohn’s
Screening:
- for colon cancer every 1-2 yrs beginning 8 yrs after dx
microscopic colitis: definition, sxs, dx, tx
chronic, intermittent, watery diarrhea w/ abd pain, fatigue and wt loss if severe
- idiopathic
Dx: colonoscopy (everything looks normal); biopsy (shows inflammation w/ inc. intraepithelial lymphocytes)
Tx:
- 1st line: loperamide (Imodium - dec frequency of diarrhea)
- 2nd line: budesonide (dec. inflammation)
intussusception - definition, sxs,
invagination of proximal into distal segment of intestine
- most common in kids
Risk factors:
- kids: viral enteritis, CF, Meckel’s
- adults: neoplasm
sxs:
- kids: CURRANT JELLY stool, palpable mass (“sausage-s (shaped”)
- adults: abd pain, N/V/D
dx:
- Kids: barium enema
- Adults: CT since possible neoplasm
tx:
- Kids: barium enema
- Adults: surgery
irritable bowel syndrome (IBS) - definition
chronic/recurrent abd pain (> 6 months)
must have at least two sxs:
- relieved by defecation
- onset assoc. w/ change in stool frequency
- onset assoc. w/ change in form of stool
Note: may be exacerbated w/ stress, menses, depression
IBS - sxs and alarm features, PE results
symptoms vary: can be diarrhea or constipation or mixed
alarm (require further W/U):
- acute onset, fever, anemia, wt loss, FH of colon CA, IBD, celiac dz, rectal bleeding, sxs awaking from sleep
PE: usually normal
IBS - dx, tx
dx: clinical (diagnosis of exclusion)
- colonoscopy if alarm features
tx: treat sxs (diarrhea, constipation, pain)
intestinal ischemia - definition, predisposing features
poor or no blood supply to portion of small intestine due to occlusion or clot
- most common vessel affected: SMA (superior mesenteric artery)
predisposing conditions:
- older age
- arterial embolus conditions (arrhythmias, HF, valve dz)
- hyper coagulation states
- vasculitis
- low flow states: sepsis, dialysis
- extensive surgery of GI tract
intestinal ischemia - acute vs. chronic sxs and dx
acute:
- steady epigastric and periumbilical abd pain OUT OF PROPORTION to exam
- also fever, N/V, dec. bowel sounds
chronic:
- post-prandial epigastric and periumbilical abd pain lasting 1-3 hrs
- develop fear of eating
dx:
- plain film: air fluid levels, thumb-print sign
- CT ANGIOGRAPHY = image of choice
- “pruned tree” of distal vascular bed
intestinal ischemia - acute vs. chronic tx
acute:
- volume replacement
- immediate surgical exploration (bowel bypass if viable, resection of gangrene)
chronic:
- angioplasty and stunting or bypass``
ischemic colitis - definition, sxs, risks, dx, tx
poor or no blood supply to portion of colon due to occlusion or clot
- most common vessel affected: IMA (inferior mesenteric artery)
- PAINFUL BLEEDING (vs. painless bleeding w/ diverticulosis)
risk factors:
- same as intestinal ischemia
- also LONG DISTANCE RUNNING (colon is last place to get blood when stressed)
clinical:
- acute LLQ abd pain w/ hematochezia
dx:
- CT: initial
- colonscopy w/ biopsy: definitive
tx:
- tx underlying cause
- supportive: fluids
- gangrene = requires surgery
Outcome: unless severe, resolves o 24-48 hrs
lactose intolerance
lactase deficiency
diarrhea, bloating, abdominal pain w/ ingestion of lactose
dx:
- elimination diet
- confirmation: hydrogen breath test
tx:
- lactose-free diet
- lactase enzyme replacement
colon polyps - 2 common types and risks for malignancy
adenomatous: most common
mucosal serrated
risk for malignancy:
- > 1cm
- villous features
- high grade dysplasia
colon polyps - sxs, dx, tx
sxs:
- asymptomatic
- may have hematochexia or occult blood loss
dx:
- colonoscopy
tx: polypectomy
colorectal cancer - prevalence, most common type, risk factors
2nd leading cause of cancer death in US
- 85% are adenocarcinoma (arising from adenomas / polyps)
Risk factors:
- older age, +FH, hx IBD, polyposis syndromes (FAP: familial adeno-polyposis, Lynch syndrome - 1000 polyps in colon!)
colorectal cancer - clinical, PE, Labs, dx, imaging
clinical:
- slow-growing: no sxs for yrs
- asymptomatic: detected by FOBT
- fatigue/weakness (iron-deficiency anemia)
- change in bowle habits
PE:
- palpable mass
- palpate liver (hepatomegaly - METS)
- DRE (blood)
Labs: CBC, iron studies, FOBT
Dx: colonoscopy
Imaging:
- full body CT for preoperative staging and METS
colorectal cancer - screening, tx
colonoscopy every 10 yrs (start age 50)
- screening intervals vary based on size and type of polyp
if +FH:
- begin screen at age 40 or 10 yrs prior to age of dx of youngest affected relative
- colonoscopy q 5 yrs or sooner if needed
tx:
- surgery (primary)
- may need chemo/radiation
small bowel obstruction - causes and clinical features
causes:
- adhesions (prior surgeries)
- hernias, neoplasms, IBD, volvulus
- acute presentation
clinical:
- early: diffuse, crampy abd pain, hyperactive bowel sounds
- late: steady abd pain, localized, absent bowel sounds (bad sign - perforation)
small bowel obstruction - dx, tx
Dx:
- abd x-ray (dilated bowel loops, air-fluid levels)
- CT: definitive (determines cause)
Tx:
- NGT, IV fluids, pain meds, anti-emetics
- surgery: for strangulation or evidence of gangrene
large bowel obstruction - causes and clinical features
slower, less acute presentation
- usually result of neoplasm
clinical:
- distention, anorexia, N/V
- late: vomiting, absence of bowel sounds
large bowel obstruction - dx and tx
Dx:
- abd x-ray (free air, bird’s beak = sigmoid colon)
- CT: definitive (determines cause)
Tx:
- depends on cause
- decompress: NG tube
- surgery: neoplasm, other obstruction
toxic megacolon - definition, clinical
true emergency!!
extreme dilation and immobility of colon
- high risk of perforation
- due to complications of UC, Crohn’s or pseudomembranous colitis (from C. Diff)
clinical:
- fever, abd cramps, distention, rigid abd, rebound tenderness, shock
toxic megacolon - dx and tx
Dx:
- colonic dilation > 6cm
Tx:
- broad spectrum ABX
- NG suctioning and colonic decompression
- IV fluids
- surgery
anal fissure - definition, dx, tx
tear most commonly occurring at posterior midline
- caused by trauma during defecation (strain, constipation)
- off midline = red flag
Dx: visual inspection (linear ulcer)
Tx: fiber, sitz bath, topical lidocaine, nitroglycerin (inc. flow to area for healing)
perianal abscess / fistula - abscess can cause a fistula
perianal abscess:
- infection of anal glands
- throbbing perianal pain
- dx: external exam: erythema, fluctuant, swelling
- tx: I&D
perianal fistula:
- complication of abscess
- clinical: purulent d/c, itching, pain
- tx: surgical excision
pilonidal cyst
abscess of sacrococcygeal cleft
- assoc. w/ sinus development
- inc. w/ prolonged sitting
- pain and fluctuant area
tx:
- surgical drainage
- ABX
- unroof and drain
hemorrhoids - definition, causes, clinical, dx
varicies of hemorrhoidal plexus
- caused by constipation, diarrhea, pregnancy, prolonged sitting
Internal: above dentate line
Clinical:
- internal = painless BRBPR
- external = pain and swelling when thrombosed
Dx:
- DRE
- Anoscopy
hemorrhoids - treatment
depends on grades (I-IV) which depends on if prolapsed or protruding
conservative:
- fiber, water (avoid constipation)
- analgesics
- sitz baths
medical:
- rubber band ligation
- injection sclerotherapy
- cautery
surgical excision
anal cancer - most common type of CA, clinical, dx, tx
80% associated with HPV
- most common: squamous cell CA
clinical
- rectal bleeding
- pain
- palpable mass
Dx: biopsy
- CT/MRI look for METS
Tx:
- <3cm: wide local excision
- surgery + chemo/radiation
hernias - definition and classification
protrusion of intra-abdominal tissue through a fascial defect in abdominal wall
Classification:
- reducible: able to return contents
- incarcerated: contents cannot be returned
- strangulated: incarcerated w/ compromised blood supply
- richter: only part of the bowel becomes incarcerated or strangulated
hernias - types
umbilical hiatal: causes GERD incisional: old incisions inguinal: - direct: through Hesselbach triangle (most common acquired) - indirect: through inguinal canal into scrotum (most common congenital) femoral: inc. strangulation rate - most common in females
hernias - clinical, dx, tx
Clinical:
- lump or swelling
- if strangulated, local sharp, intense pain, +/- anorexia/vomiting
Dx:
- most on PE
- CT to confirm
- leukocytosis is strangulated
Tx:
- surgery
diarrhea (acute) - definition, clinical, dx
acute: < 2 wks
inflammatory: fever, blood or pus in stool, severe abd pain, high WBC count
- thinking invasive bacteria
- DX: need stool studies
non-inflammatory: afebrile, watery stool, abd cramping
- thinking virus, diet, medication (ABX)
- DX: clinical dx or stool studies if concerned (e.g. persists, dehydrated, c. diff)
acute diarrhea - tx
BRAT diet
rehydration
antidiarrheals
- AVOID if infection is concern (e.g. blood in stool)
infectious diarrhea - key organisms, sx, and tx
campylobacter jejuni
- raw poultry, milk
- fever, bloody stool
- azith, fluoroquinolone
salmonella
- eggs, poultry, milk
- no ABX
shigella
- food/water w/ feces
- fever, pain, bloody stool
- fluoroquinolone, Bactrim
E. coli
- beef, milk
- self limited
giardia
- recreational water, wilderness
- watery, profuse stool
- greasy, malodorous stool
- metronidazole
vibrio cholerae
- water, selfish, food
- rice water stool
- hydration, azith, tetracycline shorten duration
C. difficile
- ABX assoc. and hospital acquired
- green, foul smelling
- metronidazole, PO vancomycin (IV does not penetrate gut)
chronic diarrhea - two types
osmotic:
- caused by malabsorption, laxatives
- inc. osmotic gap
- resolves w/ fasting
secretary:
- caused by endocrine tumors, bile salt malabsorption
- normal osmotic gap
- voluminous, water
chronic diarrhea - general causes
motility disorders
- IBS, systemic dz, post-surgery
chronic infections:
- parasite (giardia), HIV/AIDS
Inflammatory:
- UC, Crohn’s, malignancy
Medications:
- SSRI’s, ARB’s, PPI’s, NSAIDS, Metformin
Malabsorption
- dietary: lactose, Celiac dz
- anatomic: bowel resection
- see wt. loss, nutritional deficiencies, STEATORRHEA (fat in stool)
chronic diarrhea - diagnostic tests and tx
good history and PE
- both dx and tx aimed at suspected underlying cause
Dx: labs, stool studies, hydrogen breath test (malabsorption), FOBT, CT, MRI
- endoscopic eval: upper GI (Celiac, malabsorption); colonoscopy (IBD, micro colitis, malignancy)
Tx:
- avoid triggers
- replete nutrients
- antidiarrheals (avoid if infective since can lead to toxic megacolon)
vitamin A - function, deficiency, toxicity
fx: vision, antioxidant
df: blindness
tox: skin disorders, hair loss, hip fx
vitamin D - function, deficiency, toxicity
fx: calcium and phosphate regulation
df: Rickett’s (kids), osteomalacia (adults)
tox: hypercalcemia, renal stones
vitamin E - function, deficiency, toxicity
fx: cellular aging and vascular integrity
df: areflexia, gait disturbance
tox: least toxic, inhibits K so may result in bleeding
vitamin K - function, deficiency, toxicity
fx: clotting
df: bleeding
tox: anemia, jaundice
vitamin B12 (Cobalamin) - function, deficiency, toxicity
fx: RBC, neural fx, DNA
df: paresthesias
tox: N/A
vitamin B1 (thiamine) - function, deficiency, toxicity
fx: CHO metabolism
df: neuropathy and poor coordination, Wernicke’s encephalopathy (ETOH)
tox: lethargy, ataxia
Note: we treat alcoholics (w. liver dz)
Niacin - function, deficiency, toxicity
fx: energy/fat metabolism
df: Pellagra (3 D’s) - diarrhea, dermatitis, dementia
tox: flushing
iron - function, deficiency, toxicity
fx: production of RBCs
df: PICA
tox: lethargy, ataxia
folate - function, deficiency, toxicity
fx: DNA synthesis
df: megaloblastic anemia
tox: N/A
vitamin C (ascorbic acid) - function, deficiency, toxicity
fx: antioxidant, collagen synthesis
df: Scurvy, fatigue, depression, poor wound healing
tox: renal stones, diarrhea
phenylketonuria (PKU)
unable to metabolize phenylalanine and convert it to tyrosine
- rare, autosomal recessive dz
- diagnosed at birth (newborn screen)
management: low phenylalanine diet (low protein)
If not treated:
- developmental delay (brain damage)
- movement disorder
