Gastroenterology Flashcards
List the differential by location for abdominal pain
Right - cholecystitis, cholangitis - hepatitis - RLL pneumonia perforated or penetrating duodenal ulcer Epigastric - GERD - peptic ulcer disease - pancreatitis - gastritis Left - spleen - LLL pnemonia - acute gastric distention Right lower - appendicitis - PID, ectopic, endometriosis - Colitis (Chron's or infectious) - inguinal hernia Suprapubic - urinary retention - cystitis - fibroid, PID, menstruation Right lower - constipation - diverticulities - ischemic colitis
List causes of diffuse and life threatening abdominal pain
Diffuse - obstruction - perforation - IBD - gastroenteritis - celiac Life threatening - acute bowel obstruction - acute mesenteric ischemia - perforation - ectopic pregnancy
List the red flag signs of abdominal pain
- acute onset
- fever
- nausea/vomiting
- hematochezia
- melena
- weight loss >10lbs
- change in bowel habits
- family history of colon cancer
- unstable vitals
- peritonitis
Discuss the Rome criteria for irritable bowel syndrome
Recurrent abdominal pain or discomfort at least 1day/week in last 3 months associated with >=2
- related to defecation
- onset associated with change in stool frequency
- onset associated with change in stool form
Discuss the investigations for IBS
Diarrhea predominat - ESR, CRP - TTG for Celiac - TSH Constipation - CBC - TSH - lytes - abdominal x-ray Abdo pain - CBC - LFT - amylase
Discuss the management for IBS
Conservative - increase fiber and fluid intake - decrease gas producing foods, caffeine, alcohol - lactose elimination Constipation prone when fail fiber - PEG (osmotic) - lubiprostone or linaclotide Diarrhea prone - Loperamide - Bile acid sequestrants (side effects of bloating, flactulence, abdominal discomfort) Abdominal Pain - antispasmodics: Hyoscine (Buscopan) - antidepressant - trial of rifaximin (abx) if treatment resistant
List the Rome criteria for dyspepsia
Dyspepsia is defined as one or more of:
- bothersome postprandial fullness
- bothersome early satiation
- epigastric pain or burning
List the red flags for dyspepsia
- Age >55 with new onset
- Family history of upper GI Cancer
- Progressive dysphagia
- Odynophagia
- Unexplained iron deficiency
- persistent vomiting
- Palpable mass or lymphadenopathy
- Jaundice
- Unintentional weight loss
Discuss the treatment algorithm for dyspepsia with NSAID or GERD
Over 55 or red flags
- EGD
Less than 55 and no red flags
- test for H pylori
- negative treat with PPI for 8 weeks
- positive treat for H pylori
- fail then treat with PPI for 8 weeks
Fail Management
- Consider EGD
- abnormal then take biopsies and treat off finding
- normal then rapid urease test and/or histology for H pylori and if detected treat
Discuss the investigations and treatment for H Pylori
Investigation
- Non-invasive: urea breath test, stool antigen assay, serology for IgG
- Invasive: Biopsy urease testing or histology
Treatment
- Triple therapy for 7-14 days
- PPI BID
- Amoxicillin 1g BID
- Clarithromycin 500mg BID
- Quadruple therapy for 10-14 days
- PPI BID
- Bismuth 525mg QID
- Tetracycline 500mg QID
- Metronidazole 250mg QIDCompare the differences between erosive esophagitis and nonerosive reflux disease
Erosive
- endoscopically visible breaks in distal esophageal mucosa with or without troublesome symptoms of GERD
Nonerosive
- endoscopic negative with presence of troublesome symptoms
Discuss the typical, extraesophageal, and alarm features of GERD
Typical - Heartburn - Acid regurgitation Extraesophageal - Bronchospasm - Laryngitis - Chronic cough - Water brash (10mL of saliva per minute) - globus secretion - Odynophagia - Nausea Alarm - Vomiting - GI blood loss - Anemia - Weight loss - Dysphagia - chest pain
Discuss when to perform a upper endoscopic evaluation
- Atypical or alarm features
- Detect Barrett’s esophagus
- Dysphagia that was not resolved within 2-4 weeks of adequate BID PPI therapy
- Determine severity of esophagitis
Discuss the therapy for mild GERD (symptoms less than 2x/week and no erosion)
- follow up every 2-4 weeks
Lifestyle Changes - Weight loss
- Head elevation at night
- Avoidance of trigger foods
- Avoid alcohol, tobacco, caffeine
- Encourage salivation through gum
Symptoms Persist - start low dose histamine 2 receptor antagonist PRN -> increase dose and begin BID for 2 weeks
- continue to persist then discontinue and begin PPI (lansoprazole 30mg) PO OD
- if symptoms controlled therapy lasts for 8 weeks
Discuss the treatment for severe GERD (two or more episodes, impact quality of life, or erosive)
- PPI OD for 4-8 weeks in addition to lifestyle and dietary changes
- if symtpoms decrease then switch to low dose PPI and then H2RA
- goal to discontinue therapy in all patients except in those with Barrett’s
