Gastroenterology Flashcards
[Diagnosis]
cervical CA, post brachytherapy, with tenesmus
radiation proctitis
___ term which refers to complete constipation with no passage of either feces or gas
Obstipation
___ difficulty emptying the bowels, usually associated with hardened feces
Constipation
[Diagnosis]
> / 3 months of bothersome postprandial fullness, early satiety, epigastric pain, or burning with symptom onset at least 6 months in the absence of organic cause
functional dyspepsia
what are the most common causes of indigestion
- GERD
2. Functional dyspepsia
[Diagnosis]
very severe abdomina pain but abdominal PE is relatively benign
Acute Mesentery Ischemia
[Diagnose]
25F, chest pain by burning sensation associated with unpleasant taste, sore throat, cough
Dx: GERD
Next step: start PPI
[Diagnose]
25F, chest pain by burning sensation associated with unpleasant taste, sore throat, cough with associated dysphagia
Dx: GERD
Next step: start PPE
Test: Upper endoscopy
Factors that exacerbate GERD
- Obesity
- Pregnancy
- Gastric hypersecretory states
- Delayed gastric emptyiing
- Disruption of esophageal peristalsis
- Gluttony
What is the most severe histologic consequence of GERD
Barrett’s metaplasia associated risk of adenoCA
The bitter taste receptors are controlled by what nerve?
Bitter = back of tongue = CN IX
[GERD]
in patients with drug-refractory symptoms, what will you suggest as workup?
Esophageal pH
[GERD]
When surgery is considered for GERD, what workup will you request?
esophageal manometry
What are the alarming manifestations of GERD that requires endoscopy?
- Dysphagia
- Weight loss
- Anemia
- Bleeding
Upper endoscopy is recommended as the initial test in unexplained dyspepsia of patients age?
> 55 years old
What is the surgical technique for chronic GERD?
Nissen Fundoplocation
[GERD]
What us the gold standard treatment for high grade dysplasia
Esophagectomy
What is the urgent endoscopy age cutoff for dyspepsia with alarm?
> 55 years old
What is the urgent endoscopy age cutoff for PUD with alarm?
> 40 years old
What is the most sensitive test of GERD
24hr ambulatory pH monitoring
What is the gold standard for confirming barrett’s esophagus?
Endoscopic biopsy
What is the useful initial diagnostic test when mechanical obstruction is suspected in GERD?
Endoscopy
What is the most common esophageal symptom of GED?
Heartburn/Pyrosis
What is the most common symptom of infectious esophagitis?
Odynophagia
[Diagnosis]
30M recurrent upper abdominal pain, burning, awakening him at night.
pain is more noted when meals are delayed, relieved after food intake, no weight loss
Dx: PUD, prob duodenal ulcer
Next Step: H. pylori testing
Next step if anemia is present: upper endoscopy
[GU vs DU]
Gastric acid output is normal or decreased
burning or gnawing abdominal pain
precipitated by food
GU
Biopsy GU lesions.
Usually, distal to the junction between antrum and acid secretory mucosa
[GU vs DU]
gastric output is increased
bicarb output is decreased
burning or gnawing abdominal pain that awakens the patient at night
relieved by antacids or food
DU
Rare risk of malignancy
What are the risk factors of H. pylori?
- Poor SES
- Crowded or unsanitary conditions
- Low educational attainment
What are the indications for testing for H. pylori?
- Active PUD
- History of PUD without prior treatment
- MALT
- Uninvestigated dyspepsia
How will you confirm the eradication of H. pylori?
Do a urea breath test 4 weeks after therapy
What test will you need to assess the susceptibility of H. pylori to clarithromycin?
PCR assay
What is the gold standard in diagnosing H. pylori?
Histologic evaluation of endoscopic biopsy
Cite examples of cytoprotective agents used in PUD
- Sucralfate
- Rebamipide
- Prostaglanding analogues (misoprostol)
What are the drugs involved in triple therapy for H. pylori eradication?
- Omeprazole
- Clarithromycin
- Amoxicillin
What are the drugs involved in quadruple therapy for H. pylori eradication?
- Tetracycline
- Omeprazole
- Metronidazole
- Bismuth
What are the 3 pathways that govern acid secretion?
- Acetylcholine via the parasympathetic NS
- Histamine release produced locally by enterochromaffin cells
- Gastrin released by the G cells
What eicosanoid plays a central role in gastric epithelial defense?
prostaglandin
Most common location of duodenal ulcers
first portion of duodenum
benign GU are usually founf
Distal to the junction between the antrum and the acid secretory mucosa
What are the two predominant causes of PUD?
- NSAID ingestion
2. H. pylori
Most discriminating symptom of DU?
pain that awakens the patient from sleep between midnight and 3am
What is the most frequent finding in both GU and DU?
epigastric tenderness
[Diagnose]
58/M boring epigastric pain, progressively worsening, radiating to the back
(+) malaise, nausea, vomiting.
HPN, dyslipidemia, heavy alcoholic beverage drinker. Soft distended abdomen, direct tenderness, no rebound tenderness
Dx: Acute pancreatitis
Next step: serum lipase
Best diagnostic workup: CT Scan with IV contrast
Patient with acute pancreatitis. Noted discoloration in the periumbilical area. What do you call this sign?
Cullen Sign
Patient with acute pancreatitis. Noted discoloration in the flank area. What do you call this sign?
Grey Turner Sign
What is the most common cause of acute pancreatitis?
Gallstone
What is the second most common cause of acute pancreatitis?
alcohol
What value of tricglyceride can cause acute pancreatitis?
> 1000 mg/dL
What is the most important clinical finding in regard to severity of the acute pancreatitis?
persistent organ failure (>48hr)
___ classification which defines the phases of acute pancreatitis, defines severity, clarifies imaging definition
Revised atlanta classification
What is the preferred pain medication for acute pancreatitis?
meperidine
What is the most common cause of death in patients with acute pancreatitis?
Hypovolemic shock
What are the components of charcot’s triad of cholangitis?
- Fever
- Pain
- Jaundice
When do we start feeding patients with acute pancreatitis?
Early enteral feeding using nasojejunal tube within 48hrs confers lower morbidity and mortality
What are the components of BISAP Score?
BUN >25 Impaired mental status SIRS >/2 of 4 Age >60 Pleural effusion
What are the markers of severity during hospitalization for Acute Pancreatitis
- Persistent organ failure
2. Pancreatic necrosis
What are the markers of severity at admission for Acute Pancreatitis?
- SIRS
- APACHE II
- Hct >44
- BUN >22, crea 2
- BISAP Score
- Organ failure
- SBP <90
- HR >130
- PaO2 <60
[diagnose]
45/Female RUQ pain after a large fatty meal
Dx: Cholelithiasis
What are the two types of gallstones
- Cholesterol
2. Pigment stones
Brown pigment stone is due to?
Chronic biliary infection
Black type pigment stone is due to?
chronic hemolytic state
what is the most important mechanism in formation of stone forming bile?
increased biliary secretion of cholesterol
Procedure of choice for detection of gallstone
Gallbladder UTZ
Type of stones amendable for dissolution
radiolucent stone
Cut off size of gallstone amenable for dissolution
<10mm
What is the recommended dose of UDCA for dissolution
10-15 mg/kg/day
for 2 years to dissolve stones
What are the triad for cholecystitis?
- RUQ tenderness
- Fever
- Leukocytosis
What is the ultrasound criteria suggesting GB stone?
Acoustic shadowing of opacities within the GB lumen that changes with the patients position
[diagnose]
45F burning epigastric pain 2 hours after meal
DU
[diagnose]
40M with epigastric pain after a meal (+) Nausea (+) weight loss
GU
[diagnose]
35M RUQ pain after a fatty meal
Acute cholecystitis
[diagnose]
30/M obese, severe, dull epigastric pain radiating to the back
acute pancreatitis
[diagnose]
30F fever, abdominal pain, jaundice
ascending cholangitis
[diagnose]
21/F burning sensation behind sternum, bad metallic taste in the morning with cough
GERD
[Guess the toxin producer]
1-8 hours, vomiting, watery diarrhea
preformed toxin since mabilis,
B. cereus
S. aureus
[Guess the toxin producer]
8-24 hours, vomiting, watery diarrhea
preformed toxin
C. perfringes
[Guess the toxin producer]
8-72 hours, vomiting, watery diarrhea
enterotoxin na to since 3 days-ish na
Remember: VEKA
V. cholerae
ETEC
K. pneumoniae
Aeromonas spp
[Guess the toxin producer]
1-8 days, abdominal pain, fever, watery mushy diarrhea
Days na, so adherent
Crytosporidiosis Helminths EAEC Giardia EPEC
[Guess the toxin producer]
12 to 72 hours, abdominal pain, fever, watery first then bloody diarrhea
cytotoxin na to
EHEC
[Guess the toxin producer]
1-3 days, abdominal pain, fever, watery and occasional bloody
C. difficile
[Guess the Invasive organism]
1-3 days, abdominal pain, fever, watery diarrhea
Viral
Rotavirus
Norovirus
[Guess the Invasive organism]
12 hours to 11 days, abdominal pain, fever, watery or bloody diarrhea
Remember: SCARY
Salmonella Campylobacter Aeromonas paRahaemolyticus Yersinia
[Guess the Invasive organism]
12 hours to 8 days, abdominal pain, fever, bloody diarrhea
Remember: SEE
Shigella
ETEC
Entamoeba histolytica
What are the indications for evaluation of diarrhea?
- Profuse diarrhea with dehydration
- Grossly bloody stools
- Fever >/ 38.5
- > 48 hours without improvement
- Recent antibiotic use
- New community outbreaks
- Severe abdominal pain in px >50 years old
- Elderly >/ 70 or ICC
Most common cause of persistent diarrhea
Giardia
___ type of diarrhea
abrupt-onset, persists at least 1 months lasting 1-3 years, associated with subtle inflammation of the distal small intestine or proximal colon
Brainerd diarrhea
Can lead to hemolytic uremic syndrome
- EHEC 0157:H7
2. Shigella
Loperamide is avoided in what type of diarrhea
Febrile dysentery
Loperamide can be used in this case of diarrhea
Initial dose: 4mg/tab 1 tab as initial dose the 2mg after each stool
moderate/severe nonfebrile, non-bloody
Which patients suffering with diarrhea will you give antibiotic?
- Immunocompromised
- Elderly
- Mechanical heart valves or recent vascular grafts
Melena indicates that blood is present in GIT for at least ___ hours
At least 14 hours.
and as long as 3-5 days
Orthostasis is when_____
- SBP drops >20mmHg OR
2. rise in pulse of >10bpm
[Diagnose]
65M alcoholic, massive hematemesis
110/70 11 bpm
jaundice, ascites, edema
Dx: BEV
Next step: urgent endoscopy within 12hours
If (+) BEV seen: Endoscopic ligation and IV vasocactive medications
What is the most common cause of UGIB?
peptic ulcer
[Diagnosis]
vomiting, retching, coughing, before hematemesis who binges alcohol
Mallory-Weiss
What is the cut-off depth to say that it is an ulcer
mucosa depth > 5mm
[How will you manage this UGIB findings]
ulcer, Active bleeding, or visible bleeding
- IV PPI + endoscopic therapy
- ICU 1 day
- Ward 2 days
[How will you manage this UGIB findings]
ulcer, adherent clot
- IV PPI with or without endoscopic therapy
2. Ward 3 days
[How will you manage this UGIB findings]
ulcer that is flat, pigmented
- NO IV PPI or endoscopic therapy
2. Ward for 2 to 3 days
[How will you manage this UGIB findings]
ulcer, clean base
Discharge
[How will you manage this UGIB findings]
BEV
- Ligation
- IV vasoactive drug (octreotide)
- ICU 1-2 days
- Ward for 2 to 3 days
[How will you manage this UGIB findings]
mallory-weiss tear, actively bleeding
- Endoscopic therapy
2. Ward 1-2 days
[diagnose]
68/M no comorbids
passage of fresh blood per rectum
80/50 120bom,
abdomen is soft, nontender, normoactive bowel sounds, no stigmata of cirrhosis
DRE: fresh blood per examining finger, no mass no tenderness
After IVF and transfusion
next step: upper GI endoscopy to rule out UGIB before evaluating Lower GIT
[diagnose]
68/M no comorbids
passage of fresh blood per rectum
80/50 120bom,
abdomen is soft, nontender, normoactive bowel sounds, no stigmata of cirrhosis
DRE: fresh blood per examining finger, no mass no tenderness
EGD is normal
Dx: diverticular disease
Most common cause of LGIB
Diverticular disease
[diagnose]
blood streaked stools, protruding rectal mass with occasional pain
hemorrhoidal disease
[diagnose]
IDA, weight loss, tenesmos, abdomnal pain, BM changes
colonic mass
pseudodiverticula is an outpouching composed of what layers
mucosa and submucosa only
A right sided mass commonly present with?
anemia
A mass is located on the left/right when it presents an obstructive sign prior to bleeding
left sided
[Management of LGIB]
No hemodynamic instability, age <40, minimal bleeding
Flexible sigmoidoscopy
[Management of LGIB]
No hemodynamic instability, age <40, more copious bleeding
Colonoscopy
[Management of LGIB]
No hemodynamic instability, age >40, minimal bleeding
Colonoscopy
Most common cause of UGIB?
peptic ulcer
Most common cause of LGIB
hemorrhoids
Endoscopic therapy of choice for BEV
ligation
most common cause of obscure GIB in adults <50 years old
small bowel tumors
most common cause of obscure GIB in adults >50 years old
vascular ectasia, NSAID-induced
most common cause of significant LGIB in children
meckel’s diverticulum
In children and adolescents, most common colonic cause of significant GIB
IBD, juvenile polyps
[Test of choice]
UGIB
upper endoscopy
[Test of choice]
LGIB, bleeding not massive
colonoscopy
[Test of choice]
LGIB, bleeding massive
upper endoscopy
[Test of choice]
massive obscure bleed
angiography
what are the three hemorrhoidal complexes that traverse the anal canal
Left lateral
Right anterior
Right posterior
[Diagnosis]
painless, bright red blood seen in toilet or upon wiping
Hemorrhoidal bleeding,
if with anemia, rule out colonic neoplasm
[management of bleeding hemorrhoids]
Young, without history of colon CA
- Treat hemorrhoids firs
2. Colonoscopy if bleeding persists
[management of bleeding hemorrhoids]
old, with bleeding
- Colonoscopy or flexible sigmoidoscopy
[Management of hemorrhoids]
enlargement with bleeding
This is stage I
- Cortisone suppository, short course
- Sclerotherapy
- infrared coagulation
[Management of hemorrhoids]
protrusion with spontaneous reduction
This is stage II
- Cortisone suppository, short course
- Sclerotherapy
- infrared coagulation
[Management of hemorrhoids]
protrusion requiring minimal reduction
This is stage III
- Cortisone suppository, short course
- Rubberband ligation
- Operative hemorrhoidectomy
[Management of hemorrhoids]
irreducible protrusion
This is stage IV
- Cortisone suppository
- Operative hemorrhoidectomy
[location of colon CA]
IDA, large, large without obstructive symptoms, commonly ulcerates
cecum or ascending colon (right)
[location of colon CA]
apple-core or napking ring deformity
obstruction + perforation
transverse and descending colon
[location of colon CA]
hematochezia, tenesmus, narrowing of stool caliber
rectosigmoid
How does NSAIDs and aspiring prevent the risk of colon CA?
suppress prostaglandin synthesis
Colon CA frequently metastasize to
liver
What is the best predictor of long-term prognosis?
pathologic stage at diagnosis
What is the backbone of treatment of colon CA
5FU systemic therapy
[When will you screen]
patient with one first degree relative with colon CA
10 years younger
[When will you screen]
generally, you screen all patients for colon CA
at age 50
[When will you screen]
patient with one first degree relative with colon CA and if with consideration of FAP at age 25
10 years younger
[When will you screen]
colonoscopy is done every?
10 years
[When will you screen]
sigmoidoscopy is done every?
5 years
[When will you screen]
FOBT is done every?
every year
[When will you screen]
for cervical CA
at age 21 to 65
PAP every 3 years
HPV co testing every 5 years
[When will you screen]
for breast CA
at age 50 to 74
every 2 years
[When will you screen]
for lung CA, do a plain chest CT
At age 55 to 80 if with at least 30 pack years of smoking, and have been smoking for the last 15 years
[UC vs CD]
smoking prevents the disease
UC
Smoking is causative in CD
[UC vs CD]
OCP increases the risk of?
CD
[UC vs CD]
appendectomy is protective
UC
[UC vs CD]
Gross blood in stool, mucus present, continuous disease, stricture
UC
ulcers, pseudopolyp, continuous, begins in rectum
[UC vs CD]
systemic symptoms, pain, abdominal mass, fistylas, intestinal obstruction, colonic obstruction, recurrence
rectal sparing, cobblestoning
CD
Skip lesion, transmural, linear fissures
[UC vs CD]
inflammation of the colon without skip lesion
UC
[UC vs CD]
inflammation of the colon with skip lesions, chronic, more toxic patient with fistula
CD
