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Internal Medicine > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Discuss the definition and differential for an Upper GI Bleed

A 
- bleed anywhere from mouth to ligament of Treitz
Differential
- Peptic ulcer
- Esophageal varices
- Mallory Weiss tear
- arterial venous malformation
- tumour
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2
Q

Discuss the presentation and investigation for an Upper GI Bleed

A 
Presentation
- hematemesis (bright red or coffee ground emesis)
- melena
- increased bowel movements
- hematochezia
- anemia (dyspnea, pre-syncope, orthostatic dizziness, CP)
- abdominal pain
- DRE
Investigation
- Blood type and crossmatch
- CBC, electrolytes, BUN, creatinine, AST, ALT, GGT, ALP, albumin, bilirubin, INR
- BUNx10:Creatinine ratio >1.5
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3
Q

Discuss an approach to Upper GI Bleed

A

ABC
- two large bore IV
- foley catheter
- NG tube
Transfusion
- indication for pRBC
- hemastatic instability despite fluid rescusitation
- moderate anemia in high risk patients (elderly, CAD), <90
- severe anemia (<70)
- platelets or FFP if indicated
Empiric Treatment
- IV PPI to stabilize ulcer and promote clotting
- Esomeprazole 50mg IV or Panteprazole 40mg IV
- IV Somatostatin (Octreotide) for variceal as it constricts splanchic arteries decreasing portal hypertension
- Octreotide 50mcg bolus or 50mch/hr infusion
- Prophylactic antibiotic for cirrhosis
- Ciprofloxacin 400-1000mg IV for 7 days
- Ceftriaxone 1g IV daily for 7 days
- Prokinetic (metoclopramide) for EGD

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4
Q

Discuss the indications for EGD with Upper GI bleed

A 
Urgent EGD if any of the following
- Hemodynamically unstable
- Hematochezia
- Suspected varices
- serious comorbidity
Lower GI Bleed
- wait for bleeding to stop and then do colonoscopy
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5
Q

Discuss therapy of EGD with upper GI bleed

A 
Injection
- injection of vasoconstrictor (epinephrine, saline, scleorsants)
Thermal Therapy
- electrocoagulation
- laser photocoagulation
Mechanical Therapy
- hemoclips, rubber bands
- closure of vessel
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6
Q

Discuss preventative treatments for peptic ulcer disease

A 
H-Pylori Therapy
- Clarithromycin 500mg PO BID for 10-14d
- Amoxicillin 1g PO BID (or flagyl if allergy)
- PPI
Proton Pump Therapy
- Lansoprazole 30mg PO BID
- Pantoprazole 40mg PO BID
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7
Q

Discuss preventative treatments for varices

A

Treat Varices
- Esophageal varices: injection with sclerosants
- Gastric varices: injfection with glue (cyanoacrylate)
- successful then beta blocker to decrease risk of re-bleed
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- for recurrent variceal bleed
- catheter is introduced through jugular vein into hepatic vein where a permanent stent is placed connecting main branch of portal vein to hepatic vein
- can worsen hepatic encephalopathy
Treat Underlying Cause
- liver transplant

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8
Q

List the stigmata of chronic liver disease

A
  • Jaundice, scleral icterus
  • Temporal muscle wasting
  • parotid gland enlargement
  • spider nevi
  • caput medusa
  • ascites
  • gynecomastic
  • testicular atrophy
  • asterixis
  • clupping
  • Dupuytren’s contrature
  • palmar erythema
  • thenar and hypothenar wasting
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9
Q

Discuss the differential for jaundice

A 
Primarily Conjugated/Direct Bilirubin
- Hepatic Cellular/High AST/ALT
       - alcoholic hepatitis
       - non-alcoholic hepatitis
       - Hepatitis A,B,C,D,E
       - Tylenol
       - Hemachromatosis
       - Wilson's disease
       - Alpha-1 anti-trypsin
       - Autoimmune chronic active hepatitis
       - portal vein thrombosis, budd-chiari syndrome
- Cholestasis/High ALP/GGT
       - extra-hepatic 
            - gallstone disease
            - malignancy (pancreatic, cholangiocarcinoma)
            - stricture (primary sclerosing, cholangitis)
       - intra-hepatic
            - medication (amox-clav)
            - sepsis
            - TPN
            - pregnancy
            - primary biliary cirrhosis
            - primary sclerosing cholangitis
Primary Unconjugated/Indirect Bilirubin
- hemolysis
- Gilbert's syndrome
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10
Q

Discuss further investigation for unconjugated hyperbilirubinemia

A 
Hemolysis
- CBC
- reticulocyte count
- Blood film
- LDH
- haptoglobin
- bilirubin
Gilbert's Syndrome
- increased bilirubin after fasting
- UGT1A1
- DNA mutation
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11
Q

Discuss further investigation for hepatic cellular causes

A 
Alcohol Hepatitis
- chronic alcohol abuse
- AST:ALT >2
NASH
- metabolic syndrome
Hepatitis A
- positive anti-hepatitis A virus IgM antibodies
Hepatitis B
- HBsAg for screening of active or cleared infection
- HBV DNA PCR for active infection
- Anti-HBs Ab for clearance or immunity
- Anti-HBc Ab for past infection
Hepatitis C
- positive HCV RNA
Hemachromatosis
- high ferritin >1000
- high transferrin
- high % iron saturation (>50%)
- genetic testing
Wilson's Disease
- low ceruloplasmin
- high 24hr urinary copper
Autoimmune Chronic Active Hepatitis
- positive ANA
- positive anti-smooth muscle antibody
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12
Q

Discuss further investigation for cholestasis jaundice

A
  • differentiate intra and extra hepatic through ultrasound and dilation of bile duct
    Extra-Hepatic
  • gallstone
  • mass
  • Primary Sclerosing Cholangitis: positive ANA, positive smooth muscle antibody, positive peri-nuclear anti-neutrophil cystoplasmic antibody
    Intra-Hepatic
  • Primary biliary cirrhosis: positive anti-mitochondrial antibody, positive ANA
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13
Q

Discuss the complications of liver cirrhosis

A 
Decreased Liver Function
- increased INR and coagulopathy
- decreased albumin leading to ascites, spontaneous bacterial peritonitis and hepatic renal syndrome
- hyperbilirubinemia
- increased ammonia leading to hepatic encephalopathy
Portal Hypertension
- varices
- portal hypertensive gastropathy
- gastric antral vascular ectasia
Hepato-Cellular Carcinoma
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14
Q

Discuss diagnotics paracentesis and interpretation

A

Paracentesis
- cell count and differential
- biochemistry including albumin, bilirubin, protein, amylase, lipase T protein, triglyceride
- gram stain, culture
- cytology
Serum Ascites Albumin Gradient (SAAG)
- albumin concentration in serum - albumin concentration in ascites fluid
- SAAG >11 with low protein (<2.5) then portal hypertension due to cirrhosis
- SAAG >11 with high protein (>2.5) then portal hypertnesion due to heart failure
- SAAG <11 then ascites not due to portal hypertension (TB, pancreatitis, renal failure)

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15
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for ascites

A 
Pathophysiology
- cirrhosis have decreased albumin leading to decreased oncotic pressure resulting in extravasation of fluid into peritoneum
Presentation
- distended abdomen
- ankle swelling
- bulging flanks
- positive shifting dullness 
- positive fluid wave test
Investigation
- paracentesis
- abdominal ultrasound or CT
Management
- discontinue NSAID, ACEi, ARB, BB
- salt restriction <2g/day
- Diuretics spironolactone 100mg PO daily + Furosemide 40mg PO OD
- therapeutic paracentesis
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16
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for spontaneous bacterial peritonitis

A 
Pathophysiology
- bacterial infection of peritoneum
- e coli, streptococcus, kliebsella
Presentation
- abdominal pain
- confusion
- fever, hypotension
- jaundice
Diagnosis
- paracentesis with neutrophil >250
Treatment
- fluid resuscitation with albumin
- antibiotics for 5 days
      - Cefotaxime 2g IV Q8H or Ceftriaxone 2g IV Q8H
      - Ciprofloxacin 200mg Q12H
17
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for hepatorenal syndrome

A 
Pathophysiology
- low albumin lead to extravasation of fluid, decreased effective circulating volume -> increase RAS and sympathetic activity -> renal vasoconstriction and failure
Types
- 1: rapidly progressive renal failure over 2 weeks (doubling creatinine >250 in 2 weeks or halfing creatinine clearance <20mL/min)
 - 2: slowly progressive renal failure
Management
- reverse precipitant
- octreotide 100-200mcg SC TID
- Midodrine 7.5-12.5mg PO OD
18
Q

Discuss the pathophysiology, presentation, investigations, diagnosis and management for hepatic encephalopathy

A 
Pathophysiology
- inability to detoxify ammonia into urea with poor liver function and encephalopathy
Presentation
- day night reversal, confusion
- lethargy, personality change
- worsened confusion
- coma
- asterixis
- fail to connect number test or clock drawing
Management
- discontinue sedatives and diuretics
- Lactulose 30-45mL BID
- Rifaximin 550mg PO BID to change gut flora and remove ammonia
19
Q

Discuss liver transplan criteria

A

Model of End-Stage Liver Disease

  • accounts for serum bilirubin, serum creatinine and INR
  • 7 normal
  • > 15 require liver transplant
  • > 25 require full liver transplant
20
Q

List the differential for acute pancreatitis

A

I GET SMASHED

  • Idiopathic
  • Gallstone
  • Ethanol
  • Trauma
  • Steroids, surgery, sphincter of Oddi dysfunction
  • Mumps
  • Autoimmune
  • Scorpian Bite
  • High calcium, triglycerides, hypotherma
  • ERCP
  • Drugs (NSAID, diuretic, immunosuppression)
21
Q

Discuss the Ranson Criteria for acute pancreatitis

A 
On Admission
- Age >55
- WBC >16
- Glucose >200
- LDH >350
- AST >250
First 2 Days of Admission
- HCT fall by 10%
- Ca <8
- PO2 <60
- Base deficit (24-HCO3) >4
- Fluid Sequestration >6L
Severity
- Mild <=3
- Severe >=4
22
Q

Discuss the presentation and management of chronic pancreatitis

A 
Presentation
- epigastric pain radiating to back
- steatorrhea
- diabetes
- weight loss
- vitamin deficiency
- pancreatic cancer
Management
- stop alcohol, smoking
- small, frequent low fat meals
- analgesic
- suppression of pancreatic enzymes
23
Q

Differentiate Chrons and Ulcerative Colitis

A 
Location
- any part of GI tract with Chron's
- Rectum and progress proximally with Ulcerative
Rectal bleeding
- common in ulcerative
Diarrhea
- frequent in ulcerative
Abdominal Pain
- post-prandial in Chron's
- pre-defecatory urgency in Ulcerative
Fever
- common in Chron's
Palpable Mass
- common in Chron's
Endoscopic
- Apthous ulcers, patchy lesions and pseudopolyps in Chron's
- continuous diffuse inflammation, friability, loss of normal vascular patter in ulcerative
Histologic
- transmural with skip lesions, noncaseating granuloma, deep fissuring and strictures in Chron;s
- mucosal distribution with continuous disease, crypt abscess in Ulcerative
Radiological
- Cobblestone mucosa with frequent strictures or fistula in Chron's
- Lack of haustra in Ulcerative
Colon Cancer Risk
- Chron's increased
- Ulcerative only for proctitis
24
Q

Discuss common extra-intestinal manifestations of IBD

A 
Dermatologic
- Erythema nodosum
- Pyoderma Gangrenosum
- Perianal skin tags
- Oral mucosa lesions
Rheumatologic
- Peripheral arthritis
- AK
- Sacroilitis
Ocular
- Uveitis
- Episcleritis
Hepatobiliary
- Cholelithiasis
- Primary sclerosing cholangitis
Urologic
- Calculi
- uteric obstruction
Other
- thromboembolism
- osteoporosis
25
Q

Discuss the management for Chron’s disease

A

Mild
- antibiotics (Flagyl or Cipro) and 5-Asa
Moderate
- Steroid and immune modulator azathioprine, methotrexate
Severe
- surgery for stricture, obstruction, fistula, performation, bleeding
- biologics infliximab or Adalimumab

26
Q

Discuss the classification and management for ulcerative colitis

A

Classification
-Mild <4 stools/day
-Moderate >4 stools/day with minimal signs of toxicity (fever, tachy, high ESR)
- Severe >6 stools/day and signs of systemic toxicity
- Fulminant: >10 stools/day with continuous bleeding, systemic toxicity, abdominal tenderness and colonic dilatation
Management
- mild 5-ASA
- moderate 5-ASA and prednisone
- severe surgery and cyclosporine
- immunomodulator or biologic

27
Q

Define diarrhea and chronic diarrhea

A
  • loss of >500mL per day of fluid and solutes from GI tract or >200g of stool daily
  • chronic if >14d
28
Q

Discuss findings for stool analysis

A 
Stool Osmotic Gap
- 290-2*(Stool Na+K) where normal <50
- osmotic diarrhea >125
Inflammatory Bowel Disease
- High fecal leukocyte
- Calprotectin
Carbohydrate Malabsorption
- low stool pH
Stool C&amp;S
- for bacteria and fungi
Stool O&amp;P
- for parasite
29
Q

Discuss the differential for chronic diarrhea

A 
Inflammatory (blood or pus with fever, leukocytosis)
- inflammatory bowel disease
- infection: C diff, ysernia, campylobacter
- ischemic bowel
- radiation colitis
- neoplastic
Steatorrhea
- infection: giardia
- inflammatory: pancreatitis
- celiac
Watery Diarrhea
- functional
- secretory (osmotic gap <50, diarrhea despite fasting)
      - cholera
      - laxatinve, post-ileal resection, cholecystectomy
      - hyperthyroidism
      - CRC
- osmotic
      - celiac
      - carbohydrate malabsorption
30
Q

Discuss the presentation, investigation and management of malabsorption

A

Presentation
- fatigue, weakness, weight loss
- steatorrhea, diarrhea
- deficiencies (carb, protein, fat, iron, calcium, vitamin)
Investigations
- 72hrs stool collection for weight, fat content and pH
- pH <5.5 then carbohydrate malabsorption
- >6g of fat over 24hr then fat malabsorption
- low urine D-xylose following ingestion then carbohydrate malabsorption
Management
- underlying cuase
- correct deficiency

31
Q

Discuss the presentation, investigation and management for Celiac

A
  • associated with DLA-DQ2, HLA-DQ8
  • associated with other autoimmune disease
    Presentation
  • mouth ulcer, abdominal pain, steatorrhea
  • isolated iron deficiency
  • early osteoporosis
    Diagnosis
  • tTG IgA >20 and EMA IgA on small bowel biopsy
    Management
  • gluten free diet
  • supplementation

Internal Medicine (12 decks)

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