Gastroenterology Flashcards

1
Q

GERD - risk factors, clinical features, alarm features

A

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
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2
Q

GERD - dx

A

endoscopy - dx of choice

if mild, can be clinical dx

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3
Q

GERD - tx

A

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

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4
Q

gastritis - cause, presentation, dx, tc

A

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
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5
Q

atrophic gastritis - 2 types

A

see atrophy of cells that line the stomach

  1. autoimmune
    - vague abdominal pain
    - anti-intrinsic factor antibodies attack cells of stomach
    - inhibit B12 absorption
    - monitor with EGD for cancer (at inc risk)
  2. H. pylori associated
    - bacterial infection
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6
Q

H. pylori - clinical presentation, dx

A

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)

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7
Q

H. pylori - tx, complications

A

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

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8
Q

PUD: peptic ulcer disease - risks, causes, complications

A

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)
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9
Q

PUD - clinical features, dx, tx

A

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
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10
Q

adenocarcinoma - risks, clinical features, dx, tx, survival rate

A

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%

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11
Q

gastric lymphoma

A

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

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12
Q

Zollinger-Ellison Syndrome: definition and clinical features

A

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
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13
Q

Zollinger-Ellison Syndrome: dx, tx

A

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
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14
Q

pyloric stenosis - clinical features, PE, dx, tx

A

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

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15
Q

reflux esophagitis - cause, presentation, dx, tx

A

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

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16
Q

Barrett’s esophagus - definition, risks, dx, tx

A

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

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17
Q

pill-induced esophagitis - what meds

A

tetracycline (ABX)
KCl
NSAIDS
bisphosphonates

often taking meds w/o water or supine

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18
Q

radiation esophagitis

A

dysphagia several months following radiation treatment

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19
Q

eosinophilic esophagitis - cause, presentation, dx, tx

A

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

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20
Q

achalasia - definition, clinical features, dx, tx

A

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

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21
Q

scleroderma - definition, clinical features, dx, tx

A

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

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22
Q

esophageal spasms

A

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)

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23
Q

Zenker’s diverticulum - definition, clinical features, dx, tx

A

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
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24
Q

Mallory Weiss tear

A

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)
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25
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
26
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
27
esophageal obstructive entities - 2 types and tx
1. esophageal webs - assoc. w/ plummer-vinson - proximal esophagus - presents w/ dysphagia and food impaction 2. schatzki ring - hx of GERD, hiatal hernia - distal esophagus Tx: endoscopic dilation and PPI
28
Plummer Vinson Syndrome
association b/t Fe deficiency anemia, esophageal webs, stomatitis (inflammation of mucous membranes of mouth), and glossitis (inflammation of tongue)
29
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
30
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
31
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)
32
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
33
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
34
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
35
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
36
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
37
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
38
primary sclerosing cholangitis - definition and cause
biliary system fibrosis and thickening - men age 20-50 Cause: auto-immune, assoc. w/ ulcerative colitis
39
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
40
hepatitis - acute vs. chronic
liver inflammation acute: - viral is MOST COMMON - toxins: ETOH and meds (acetaminophen, NSAIDS, ABX) chronic: - viral - ETOH - NASH - autoimmune
41
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
42
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
43
which hepatitis viruses have vaccines?
A and B
44
diagnosis of acute viral hepatitis
See cheatsheets
45
which hepatitis viruses progress to chronic state
B and C
46
Hepatitis B serology - approach to determining if there is an active infection and if it is acute or chronic
1. Look at hep B surface antigen (HBsAg): HBsAg + = active infection - Look at hep B core antibody (antiHBc) (IgM = acute, IgG = chronic) 2. 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
47
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 ```
48
acute hepatitis -prevention
``` A: vaccine (travelers, etc.) B: vaccine (0, 1, 6 mo) C: precausions D: hep B vaccine E: public hygiene ```
49
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
50
what is anecdote to acetaminophen toxicity leading to liver acute failure
acetylcysteine w/in 72 hrs
51
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
52
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)
53
chronic viral hepatitis - tx
Hep B: tenofovir/entacavir Hep C: curable! - peg-interferon, ribavirin (tx is advancing)
54
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
55
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
56
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
57
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
58
liver ability to function
can function even with 60% removed liver re-generates!!
59
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
60
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)
61
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
62
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
63
most common malignant tumor in children
hepatoblastoma
64
cholangiocarcinoma - special sign
CA originals from the duct cells | - Courvoisier's sign: palpable nontender gallbladder assoc. w/ jaundice
65
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
66
acute pancreatitis - signs of hemorrhage
grey-turner: flank ecchymosis cullen: umbilical ecchymosis
67
acute pancreatitis -labs and imaging
labs: - lipase is most sensitive - amylase (but also produced elsewhere in body) Imaging: - CT w/ contrast
68
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
69
acute pancreatitis - treatment
NPO (until pain free) Pain control: hydromorphone (Dilaudid), morphine Aggressive fluid resuscitation Treat N/V
70
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
71
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
72
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)
73
appendicitis - diagnosis, treatment
diagnosis: CT scan - U/S in kids Treatment: - laproscopic appendectomy - ABX
74
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
75
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
76
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
77
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
78
what population should avoid magnesium products (milk of magnesia or Mg citrate)
those with renal disease
79
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
80
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
81
most common cause of major lower GI tract bleeding
diverticulosis | - PAINLESS
82
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
83
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
84
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)
85
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
86
extra-intestinal manifestations of IBD
joints: - arthritis - ankylosing spondylitis eyes: uveitis
87
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
88
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)
89
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
90
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
91
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
92
IBS - dx, tx
dx: clinical (diagnosis of exclusion) - colonoscopy if alarm features tx: treat sxs (diarrhea, constipation, pain)
93
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
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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
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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``
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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
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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
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colon polyps - 2 common types and risks for malignancy
adenomatous: most common mucosal serrated risk for malignancy: - > 1cm - villous features - high grade dysplasia
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colon polyps - sxs, dx, tx
sxs: - asymptomatic - may have hematochexia or occult blood loss dx: - colonoscopy tx: polypectomy
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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!)
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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
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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
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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)
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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
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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
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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
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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
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toxic megacolon - dx and tx
Dx: - colonic dilation > 6cm Tx: - broad spectrum ABX - NG suctioning and colonic decompression - IV fluids - surgery
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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)
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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
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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
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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
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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
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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
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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
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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 ```
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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
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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)
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acute diarrhea - tx
BRAT diet rehydration antidiarrheals - AVOID if infection is concern (e.g. blood in stool)
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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)
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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
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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)
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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)
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vitamin A - function, deficiency, toxicity
fx: vision, antioxidant df: blindness tox: skin disorders, hair loss, hip fx
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vitamin D - function, deficiency, toxicity
fx: calcium and phosphate regulation df: Rickett's (kids), osteomalacia (adults) tox: hypercalcemia, renal stones
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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
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vitamin K - function, deficiency, toxicity
fx: clotting df: bleeding tox: anemia, jaundice
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vitamin B12 (Cobalamin) - function, deficiency, toxicity
fx: RBC, neural fx, DNA df: paresthesias tox: N/A
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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)
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Niacin - function, deficiency, toxicity
fx: energy/fat metabolism df: Pellagra (3 D's) - diarrhea, dermatitis, dementia tox: flushing
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iron - function, deficiency, toxicity
fx: production of RBCs df: PICA tox: lethargy, ataxia
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folate - function, deficiency, toxicity
fx: DNA synthesis df: megaloblastic anemia tox: N/A
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vitamin C (ascorbic acid) - function, deficiency, toxicity
fx: antioxidant, collagen synthesis df: Scurvy, fatigue, depression, poor wound healing tox: renal stones, diarrhea
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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