Gastroenterology Exam IV Flashcards
bilious vomitting is suggestive of
prolonged vomitting
vomitting undigested food 4-6 hours later makes concern form
pyloric obstruction, gastroparesis, achalasia and zenker diverticulum
feculent vomitting
obstruction’ fistula, peritonitis
relief of pain when vomitting
peptic ulcer disease
early satiety with vomitting
gastroparesis, tumor, gastric outlet obstruction
projectile vomitting
increased ECP, food poisoing
early morning vomitting
alcholism and uremia
ex of anticholinergic anti emetic
scopolamine
ex of antihistamine antiemetic
promethazine, cinnarzine, cyclizine
ex of dopamine antagonist antiemetic
metoclorpamide, domperidone, haloperidol
cannabinod used for antiemic
nabliion
corticosteroid used for antiemetic
dexamethasone
histamine analogue used for antiemetic
betahistine
5HT3 antagonst
ondansetron, granisetron, tropisetron
adverse effect of metoclopramide
tardive dyskisea
adverse effect of domperidone
prolonged QT, hyperprolactinemia
types of drugs used for labyrinth caused nausea and vomitting
histamine antagonists and muscarinic antagonists (anticholinergics)
how do you diagnose gastrparesis
solid phase gastric emptying less than 50% at 4 hours is diagnostic!
action of erythromycin
increases migrating motor complexes but can cause severe cramping, prolonged QT and tachyphylaxis
gas is primarily composed of
methane, hydrogen and nitrogen
drug used to treat upper GI gas
smethicone
what patient popuation are probiotics contraindicated in
pancreatitis
rifaimin
reduces bacterial overgrowth, used to treat for intestinal gas
most common compication of cirrhosis that results from portal hypertension
ascites
the HVPG level necesssary to develop ascites is
greater than 12 mmHg
what is the most sensitive method to detect ascites
ultrasound
routine tests for ascies
protein
abumin
PMN count
Culture
if serum albumin is greater than 1.1
portal hypertension
if serum albumin is less than 1.1
non-portal hypertension
if ascites protein is less than 2.5 and serum albumin is greater than 1.1
sinusoidal hypertension
if ascites protein is greater than 2.5, SAAG is greater tahn 1.1
post sinusoidal hypertension
SAAG less than 1.1 and ascites protein greater than 2.5
peritoneal pathology, malignancy, TB
treatment of portal hypertension with no ascites
no therapy, consider salt restriction
treatment of uncomplicated ascites
salt restriction + diuretics (spironolactone based) and large volume paracentesis (LVP) in hospitalized pts with tense ascites
diuretics used in uncomplicated ascites
progressive schedule of spironolactone to furosemide
side effects of diuretic therapy
renal dysfunction, hyponatremia, hyperkalemia, encephalopathy and gynecomastia
consider ascites refractory if
spironolactone dose is 400 mgs/day + 160 furosemid mgs/day without any significant weight loss
LVP is therapy of choice in what pts
respiratory compromise, impending rupture of umbilical hernia or severe peripheral venous stasis
fluid restriction is unnecessary unless
serum sodium is less than 125
Treatment of refractory ascites
LVP + albumin
TIPS
PVS in non TIPS pts
complications of TIPS procedure
increased risk for encephalopathy, shut stenosis with recurrent portal hypertension
complications of ascites
infection, tense ascites, abdominal wall hernias/rupture, pleural effusions and peripheral venous stasis
SBP
acute bacterial infection of ascitic fluid that occurs in the absence of an infection elsewhere in the body
diagnosis of SBP
PMN’s of greater than 250 and or culture positive (ecoli, Klebsiella, strep and staph)
risk factors for SBP
bilirubin greater than 2.5 GI bleeding previos SBP low protein Ascites low platelet
treatment of SBP
cefotaxime +/- ampicillin and repeat paracentesis 48 hours to ascess PMN’s + IV albumin
albumin is indicated in SBP treatment if
BUN greater than 30
creatinine greater than 1
bilirubin greater than 4
main mechanim for SBP
bacterial translocation
indications for prophylactic antibiotics to prevent SBP
cirrhotic with GI bleed and pts. recovered from SBP (norfloxacin daily)
secondary bacterial peritonitis
total protein greater than 1, glucose less than 50 and LDH upper limit for normal for serum
type 1 hepatorenal syndrome
doubling of creatinin to greater than 2.5 or halfing clerance to less than 20
type 2 hepatorenal syndrome
creatinin reater than 1.5 or creatinine clearance less than 40 (associated with refractory ascites)
what are always present in hepatorenal synrome
ascites and hyponatremia
treatment of hepatorenal syndrome
liver transplant, vasoconstrictors + albumin, TIPS
treatment of type I hepatorenal syndrome
octretoide + midorine + albumin
most common causes of acute pancreatitis
gallstone pancreatitis, alcohol, drugs, hypertriglyceridemia, infections
most common cause of acute pancreatitis in children
trauma
genes associated with hereditary acute pancreatitis
PRSS1, SPIN1 and CFTR
microlithiasis
(cholesterol and calcium bilirubinate crystals) causing obstruction of bile duct and pancreatic duct resulting in reflux into pancreatic duct. Tx’ed with cholecystectomy, ERCP & sphincterotomy, or with oral bile salts
IgG4 increased and sausage shaped pancreas
autoimmune pancreatitis
treatment of autoimmune pancreatitis
steroids or azanthioprine or 6 mercaptopurine
trypsin is activated by
cathepsin B
most specific serological marker for acute pancreatitis
lipase
macroamylasemia
heretiary condition which macromolecules of amylase exist and urine amylase to creatinine is 0 on macroamylassemia and is INCREASED in pancreatitis, lipase is normal
diagnosis of pancreatitis
abdominal pain
CT findings-colon cutoff sign
lipase X3
gallstone pancreatitis
greater than 50 female AST greater tahn 100 Amylase greater tayn 4000 alkaline phosphatase greater than 300
ranson criteria for pancreatitis severity
age greater than 55 WBC greater tahn 16000 glucose greaer than 200 LDH greater than 350 AST greater tan 250 and at 49 hours hct decrease greatr than 10, BUN increase gareater tahn 5, CA less than 8, O2 less than 60, base deficit greater than 4, fluid greater tahn 6
abscess formaition
10-15 days after presentation of acute pancreatitis
danger signals of acute pancreatitis
encephalopathy hypoxemia tachycardia greater than 140 hypotension less than 90 hct greater than 50 oliguria less than 50 azotemia
pseudocyst
Cystic, fluid-filled structure inside or extending outside of pancreas which matures (often communicates with pancreatic duct) Takes 4-6 weeks after acute episode to form
phlegmon
edematous pancreas
type of TPN used for severe pancreatitis
nasal jejunal
ARDS
adult respiratory distress syndrome, assoc with hyperlipidemia, diagnosis-hypoxemia normal wedge pressure
most appropriate prcedureto remove stones from the bile duct
ERCP
type of fibrosis in lithogenic
irregular fibrosis
type of fibrosis that is obstructive
uniform fibrosis
type of fibrosis that is inflammatory
diffuse and atrophic
chronic obstructive pancreatitis due to
pancreatic adenocarcinoma, IPNM, post pancreatitis strictures and post traumatic strictures
clinical features of chronic pancreatitis
abdominal pain steatorrhea DM weight loss nephrolithiasis osseous abnormalities
test used for steatorrhea diagnosis
sudan staining or quantitative test
to get steatorrhea you mut lose how much of exocrin function
90%
low trypsin
chronic pancreatitis
why do you get vitamin B12 deficiency in acute pancreatitis
pancreatic enzymes digest cobalmiin binding proteins
most sensitive and specific test for early phases of pancreatic insufficiency
fecal elastase test (less than 200 indicate pancreatic insufficiency)
what is the most useful assess structure
MRCP and ERCP
non enteric coated pancreatic enzymes
used to treat pancreatic pain by being available in the duodenum. Given with antacids to increase bioavailability. High in peptidases.
enteric coated pancreatic enzymes
used to treat steatorrhea to decrease diarrhea and malabsorption. High in lipase and able to withstand acid
what are the most common places gallstones deveop
cystic duct, common bile duct and mouth of the pancreas
most important factor for gallstone formation
gallbladder stasis
Mirizzis syndrome
stone in cystic duct causing occlusion of CBD
charcots triad
Fever, RUQ pain, and jaundice indicative of suppurative cholangitis which is an emergency
papillary stenosis
The choledochal sphincter or sphincter of Oddi fibroses causing inability to relax with CCK (cholecystokinin) or glucagon
billiary dyskinesia
sphincter paradoxically spasms when it is to relax with gallbladder contraction
when is cholecystectom safe
2nd trimester
when is ERCP safe
2nd or 3rd trimester
