Gastroenterology Flashcards
Short gut syndrome refers to ___________________.
patients who have anatomically or functionally decreased small intestinal length; anatomically this is typically less than 1/4 over the intestines and children and less than 1/6 of the intestines in adults
Patients with short gut syndrome will require what?
TPN
Common causes of short gut syndrome include ___________________.
NEC, volvulus, and trauma
___________ is characterized by a paucity of bile ducts on liver biopsy.
Alagille syndrome
Alagille syndrome has what inheritance pattern?
Autosomal dominant w/ variable penetrance
What are the diagnostic criteria of pancreatitis?
Two of the following:
- Elevated lipase
- Imaging findings
- Epigastric pain
Start feeding on ___________ days of no appetite in acute pancreatitis.
3
Colitis comes in three categories: __________.
infectious, ischemic, and inflammatory
Ischemic colitis typically affects what area of the colon?
The watershed area between the IMA and SMA, which is the splenic flexure
What are advantages and disadvantages to G-tubes and GJ-tubes?
G-tubes have the benefit of being easy to replace (can be done at bedside) and the ability to bolus feeds, but they carry a risk of aspiration. GJ-tubes have a decreased aspiration risk and have two ports, but they require fluoroscopy and must be continuous feeds through the J.
What kinds of abdominal pain present with abrupt, sudden-onset pain?
- Torsion (both ovarian and testicular)
- Aortic dissection
- Nephrolithiasis
- Ruptured ovarian cyst
To help get the best abdominal tenderness exam, _______________.
don’t tell them you’re going to press on their abdomen; instead, tell them you’re going to listen with your stethoscope and then slowly progress to palpation
When should you get a lactate in assessing abdominal pain?
Mesenteric ischemia
True or false: for suspected pancreatic cancer (e.g., painless jaundice) the first test to order is an abdominal CT with contrast.
False
For all suspected biliary disorders, an ultrasound is still the right first test. The other reason this might be helpful is that if it shows a pancreatic head mass then the next test may be an MRCP.
What medical things can help with achalasia if someone is obstructed?
- Glucagon
- NO
GI bleed in a person who’s had a AAA repair could be _____________.
aorto-enteric fistula, usually through the duodenum which is closest to the aorta
____________ is the most common complaint in acute diverticulitis.
Constipation
Review the four categories of causes of ascites.
Portal HTN:
- Cirrhosis
- Thrombosis
Hypoalbuminemia (loss of intravascular oncotic pressure):
- Protein-losing enteropathy
- Malnutrition
Volume overload:
- ESRD
- CHF
Malignancy:
- Peritoneal metastasis
- Hepatic metastasis
- Lymph blockage
What two criteria are diagnostic of SBP?
- WBC > 1,000 cells/mL
- PNMs > 250 cells/mL
Low glucose and high protein are suggestive of infection (and should be sent with cell count and culture) but not diagnostic.
_____________ is first line for SBP.
Cefotaxime
Review the causes of constipation and bowel obstruction.
Pharmacologic:
- Anticholinergics
- Antihistamines
- Opiates
- Antipsychotics
Neurologic:
- Neuropathies
- Parkinson’s
Endocrine:
- Hypothyroidism
- Diabetes
- Hyperparathyroidism (hypercalcemia)
Metabolic:
- Hypokalemia
- Hypomagnesemia
- Hypercalcemia
Toxicologic:
- Iron
- Lead
Malignant:
- GI cancers
Functional:
- Anal fissures
- Ileus
- Ogilvie
Review the three groups of causes of acute diarrhea.
Infectious:
- Bacterial
- Viral
- Protozoal (e.g., E. histolytica, Giardia, Cryptosporidium)
Ischemic:
- Mesenteric ischemia
- Ischemic colitis
Intoxication:
- Meds (e.g., metformin, NSAIDs)
- Alcohol
True or false: never treat ETEC.
False
EHEC should not be treated with abx because of the increased likelihood of HUS. ETEC should be treated with ciprofloxacin.
What are the two antibiotics of choice for most traveler’s diarrhea (like ETEC, Campylobacter)?
Ciprofloxacin or Bactrim
What three viruses are some of the most common causes of diarrhea?
Enterovirus, Norovirus, and Rotavirus
The most common cause of hematemesis in adults is ____________.
PUD
Dieulafoy lesions typically cause what type of GI bleeding?
Brisk bright red blood
Dieulafoy are arterial lesions so they will have sudden forceful, painless bleeds of bright red blood.
What study should you order to rule out esophageal perforation?
Chest CT
CXR can show it, but it is not sensitive so if you are concerned enough that you want to rule it out then get a CT.
Which kind of IBD has transmural inflammation?
Crohn’s
UC usually just affects the mucosa and submucosa.
What are the emergency conditions that can be caused by IBD?
Toxic megacolon
Small bowel obstruction
Abscess
Perforation
C difficile
On KUB, what diagnostic criteria meets toxic megacolon?
Colon greater than 6 cm
What is your suspected workup for Mallory Weiss tears?
Maybe nothing if the patient is stable and the exam/HPI is clear, but if concerned then the following:
- CXR (r/o pneumomediastinum)
- CBC
Also, observation in the ED for f/u bleeding.
The CTA GI bleed is for _________ GI bleeding.
lower
What is the Glasgow-Blatchford score?
A score used in ED patients with suspected upper GI bleed to determine who is low risk and can be discharged. The scores range from 0-23. Any score greater than 6 warrants admission.
- It’s not often used because it has a low threshold for positivity.
In patients with cirrhosis who have GI bleeding, ___________ has been shown to reduce mortality.
ceftriaxone
When would you diagnose SBP with a lower peritoneal PMN count?
In a patient receiving peritoneal dialysis the cutoff is > 100 WBC/uL w/ 50% or more PMNs or > 100 PMNs/uL
When you see a abscess near the anus, you need to decide what?
Is this a simple perianal abscess or is this a perirectal abscess. The main way you do this is by digital rectal examination. If the abscess feels like it abuts the anus or goes deep along on the rectum then you ought to get a CT pelvis w/ IV contrast. If it is a perirectal abscess then they must see surgery for more complex I&D w/ anoscopy. If it is a simple perianal abscess then ED I&D is acceptable.
True or false: perianal abscesses should not be treated with antibiotics.
False
All abscesses should be treated with either Augmentin or ciprofloxacin/Flagyl for 4-5 days.
Why is ammonia not a helpful lab in hepatic encephalopathy?
People can have hyperammonemia without hepatic encephalopathy and can have normal ammonia while having hepatic encephalopathy.
What percent of patients with SBP will have no symptoms or signs of infection?
10-20%
The most important treatment of hepatic encephalopathy is _____________.
poop
______________ is one of the earliest signs of HE.
Mental status changes
Ask “how much money do you have if you have three nickels and a dime.”
Intussusception typically occurs in what age group?
3-36 months
If it happens in older kids there is usually a lead point.
What is the classic triad of intussusception?
Currant jelly stools
Sudden colicky abdominal pain
Sausage-shaped mass in the right side of the abdomen
How good is ultrasound at diagnosing intussusception?
Nearly 100% sensitive and specific, but it is operator dependent
Intussusception less than _______ cm in length will often reduce on its own and may not require intervention.
2.3
Review the management steps of intussusception.
If the child looks sick or has a peritoneal exam, contact surgery early.
If the intussusception is less than 2.3 cm and the child looks well, then they may be suitable for non-operative management.
If the intussusception is larger than 2.3 cm
By history, how can you differentiate acute mesenteric ischemia and acute colonic ischemia?
Colonic ischemia usually presents with bloody diarrhea, whereas mesenteric ischemic doesn’t.
Because colonic ischemia presents in the watershed areas, it will typically be lateralized whereas mesenteric ischemia is periumbilical.
When should inguinal hernias in babies be repaired?
Within two weeks
In young children with hernias (classically premature boys), inguinal hernias have a relatively high rate of incarceration (up to 13% in some studies). Because of this, prompt correction is warranted.
A patient with an occult GI bleed is found to have cherry-red spots on his right hemicolon. What comorbidity does he likely have?
ESRD
Angiodysplasias are vascular malformations that appear in the colon as cherry-red spots. They are seen frequently in those with ESRD, aortic stenosis, and von Willebrand disease.
True or false: focal nodular hyperplasia presents with a peripherally enhancing liver lesion.
False
FNH is uniformly enhancing. Hepatic adenomas are peripherally enhancing.
______________ are common liver tumors seen in women on OCPs.
Hepatic adenomas
What treatment course should you offer to someone with ulcerative colitis who presents with toxic megacolon but has no evidence of pneumoperitoneum or necrosis on CT?
High-dose steroids and surgical consultation
Although people with toxic megacolon often need colostomies of some kind, they can frequently avoid surgery with medical treatment first.
Those with mild HCV should take what preventive precautions?
- Avoid alcohol
- Avoid non-essential hepatotoxic medicines
- Receive vaccines for HAV and HCV
- Improve any potential NAFLD by diet and exercise
True or false: meconium ileus presents with dilation of the transverse and ascending colon on contrast enema.
False
Meconium ileus presents with microcolon because meconium is usually stuck at the ileocecal valve and the colon does not get used.
The transition zone from a normal-caliber rectosigmoid colon to a dilated descending colon suggests _____________.
Hirschprung’s disease
True or false: diverticular bleeding occurs because of microperforations in the diverticular wall.
False
It happens from erosion of the mucosa, not from a perforation.
Dyspepsia is defined by postprandial fullness and epigastric pain. When should you refer for EGD?
- Age less than 60 with alarm features: weight loss, iron-deficiency anemia, difficulty swallowing, palpable mass,or family history of GI cancer
- Age greater than 60
Because the Ranson criteria and APACHEII criteria are cumbersome, researchers have evaluated single-factor risk assessments for severe pancreatitis. What four single factors have had the best evidence for predicting severe pancreatitis?
Age
Hct greater than 44%
BUN 20 or greater
CRP greater than 150 mg/dL
Hydration is best with ______-osmolar beverages.
hypo
Hyperosmolar solutions pull fluid from the body to the GI tract. This is the mechanism behind fructose- and sorbitol-induced diarrhea.
How do you make the diagnosis of hepatorenal syndrome?
HRS is a diagnosis of exclusion. You must eliminate Pre- and post-renal causes of AKI (w/ a renal US and trial of fluids). Intrinsic causes are harder to eliminate because you likely won’t be doing a biopsy given how sick the person is, but you should get a UA to look for casts and any other serum workup if they have findings concerning for new GN.
What antibodies test for celiac disease?
Anti gliadin
Tissue transglutaminase A
What things do you need to screen for in those with celiac?
Osteoporosis (get a DEXA)
Micronutrient deficiencies (ADEK, Cu, B12, Fe)
Treatment of ______________ involves placement of a rectal tube to decompress the sigmoid.
sigmoid volvulus
Sigmoidoscopy can also be done to reduce the volvulus
Ischemic colitis usually affects which areas?
The splenic flexure (which is the watershed area of the SMA and IMA) and the rectosigmoid junction (the watershed areas between the IMA and hypogastric artery)
Which medication can treat symptoms of pyloric stenosis?
Atropine
It’s important to remember that patients with Hirschprungs can still have _______________ after surgical correction.
enterocolitis
In patients older than 3 years, there is usually _______________ that causes intussusception.
a lead point
Kids with catastrophic guts can develop what lab abnormality?
DIC
What is the recipe for ORS (oral rehydration solution)?
1 L clean water
6 teaspoons (or 24 g) granulated sugar
1/2 teaspoon (or 3 g) salt
Most cases (3/4) of malrotation obstruction occur by age _____.
5
It can happen at any time.
SBP is diagnosed by ______________.
PMNs greater than 250 or WBCs greater than 1000
Secondary bacterial peritonitis from peritoneal dialysis is diagnosed by ______________.
WBCs greater than 100
Radiation of the pelvis can cause what syndrome that presents with tenesmus and mucous diarrhea?
Radiation proctocolitis (can present anywhere from weeks to decades after radiation)
Dieulafoy lesions are found _________.
in the stomach
Which patient population is younger, cecal volvulus or sigmoid volvulus?
Cecal
Risk factors are pregnancy, IBD, and extreme athletes.
Why do you always need to look for history of AAA (w/ or w/o repair) in someone with a GI bleed?
Aortoenteric fistula is a rare but catastrophic form of GI bleed that presents in those with aortic pathology. It can often have a “herald bleed” that happens before a catastrophic bleed.
What are the four causes of decompensated liver failure?
Gi bleed
Hepatorenal syndrome
Hepatic encephalopathy
Spontaneous bacterial peritonitis
Which beta-blocker is specific to those with esophageal varices?
Nadolol
The HALT-IT trial (2020) showed ______________.
no mortality benefit from TXA in GI bleed
How does octreotide work?
It causes splanchnic vasoconstriction that diverts blood from varices.
What is the dosing of octreotide in varices?
50 mcg bolus followed by 50 mcg/hr infusion
How long is octreotide continued in variceal bleeding?
3-5 days after EGD
True or false: octreotide has not been shown to reduce mortality.
False
It has been shown to reduce mortality.
Why does ceftriaxone help mortality in variceal bleeding?
Endotoxin is a splanchnic vasodilator. Any bacterial infection will thus lead to worsening of variceal bleeding.
Why does beta-blockade help variceal bleeding?
B2 receptor blockade causes splanchnic vasoconstriction.
What is the dose of ceftriaxone for SBP?
2 g IV Q24H x 5 days
Administration of ____________ on day 1 and 3 of SBP treatment has been shown to reduce mortality.
albumin
How do you treat HRS?
Stop diuretics
Administer albumin and splanchnic vasoconstrictor trial (octreotide of midodrine)
What are the treatments for alcoholic hepatitis?
Supportive measures (e.g., electrolyte correction, glucose supplementation, pain control, abstinence from alcohol) and steroids if they meet severe criteria
Three RCTs have shown that inhaled __________ is effective in treating nausea.
isopropyl alcohol
At what bilirubin level is jaundice of the face evident?
Greater than 5 mg/dl
True or false: kids who are suspected to have Hirschprung’s associated enterocolitis should not undergo enema.
True
The bowel is stressed if they have HAEC.
True or false: recent ingestion of sharp objects should managed by supportive care.
False
Sharp objects are at high risk of perforation. Endoscopy should be discussed.
What two lab tests are diagnostic of SBP (not related to PD)?
PMNs > 250
WBBCs > 1000
The ________ cells release pancreatic exocrine hormones.
acinar
What are the grades of internal hemorrhoids?
I: they never protrude
II: protrude with bowel movements but retract spontaneously
III: protrude with BMs but require manual reduction
IV: unable to be reduced
Which side of the battery causes damage?
Negative (anode)
“Negative Necrosis.”
The negative pole generates hydroxide anions.
What is the WBC count for peritonitis in patients getting PD?
> 100 WBCs
50% PMNs
This is different than SBP which is > 250 PMNs.
What is the recommendation by the American Pancreatic Association for initial fluid management in pancreatitis?
5-10 ml/kg/hr
Does supplemental iron cause a false-positive FOBT?
No
In patients who have greater than 5 L of fluid removed by paracentesis, what amount of albumin should they be given?
5 g of 25% per L of ascites removed
Which kind of dysphagia gets better with positional changes (like straightening the back or elevating the arms)?
Achalasia
Other than biliary obstruction, GGT is also upregulated in which disorder?
Alcoholic cirrhosis
What is the most common cause of cirrhosis in the U.S.?
HCV
What is the recommended time frame for food bolus removal when patients can control their secretions?
24 hours
