GastroExam1 Flashcards
What is acid reflux?
When food moves backwards into the esophagus
What is pyrosis?
Also called heartburn, described as burning retrosternal discomfort that may move up and down the chest like a wave
Pertinent positives of heartburn/pyrosis are?
Aggravation by bending forward, straining, or lying recumbent, worse after meals
Relieved by upright posture, swallowing salvia/water, or more reliably antacids
Dysphagia to what suggests a motility disorder?
Solid and liquids
Dysphagia to solids that later involves liquids suggest what?
Mechanical Esophageal Obstruction
How will a patient with achalasia typically present?
Progressive dysphagia to liquids and solids, regurgitation
Occasional chest pain
What age does achalasia typically affect?
Ages 25-60
In achalasia, the idiopathic loss of what causes failure of LES relaxation and a lack of peristalsis
Auerbach’s Plexus
What does this show/how do you describe the radiograph and what disease is associated with it?
Bird/Parrot Beak
Achalasia
For achalasia, the treatment goal and treatment options are?
Goal - Decrease LES pressure so the sphincter no longer impedes the passage of the ingested material
Treatment options:
Mechanical - Dilation or surgery
Surgery - Heller Myotomy most effective!
Pharmacological - Botulinum toxin for temporary relief, oral nitrates
Typical presentation of diffuse esophageal spasm?
Complaints of stabbing chest pain that is worse with hot or cold liquids and food
What does this show/how do you describe the radiograph and what disease is associated with it?
Corkscrew esophageal appearance which indicates diffuse esophageal spasm
What is the goal and treatment of diffuse esophageal spasm?
Goal - Provide relief of symptoms
Treatment - Antidepressants, low-dose tricyclics (imipramine)
Persistent symptoms can try CCB -diltiazem
If no relief from others, then endoscopic treatment - botulinum toxin injection and pneumatic dilation
What is neurogenic dysphagia?
Dysphagia to liquid and solids
Weakness and incoordination of the muscles in pharynx that propel food into the esophagus
Results from faulty transmission of nerve impulses to pharyngeal muscles. Generally caused by neuromuscular diseases such as myasthenia gravis, amyotrophic lateral sclerosis, or stroke
What is Zenker Diverticulum?
Sac-like outpouching of the mucosa and submucosa
How does Zenker Diverticulum typically present?
Regurgitation of undigested food and liquid several hours after eating, foul odor of breath
Should be suspected in middle age or older adults with progressive dysphagia (usually solids)
What does this show and what disease is it an indication of?
It shows a sac-like outpouching which indicates Zenker Diverticulum
What is the gold standard diagonostic procedure for Zenker Diverticulum? What is a second diagnostic that is easy to do?
Gold standard is EGD (Upper Endoscopy)
Another diagnostic is barium swallow
What is the treatment for Zenker Diverticulum?
Observation if small and asymptomatic (<1cm divertitula)
Otherwise can do diverticulectomy, cricopharyngeal myotomy if symptomatic and >2cm diverticula
Zenker Diverticulum normally emerges from this area of weakness in the muscular wall of the hypopharynx which is known as?
Killian’s Triangle
How do patients with esophageal stricture normally present?
They present with solid food dysphagia and have a history of GERD. Scarring is typically at the distal end of the esophagus due to chronic exposure from GERD
What is a thin (<2 mm) eccentric membrane that protrudes into the esophageal lumen called?
Esophageal web
What is always found in association with a hiatal hernia and recognized as a thin membrane (2 mm) that constricts the esophageal lumen and can decrease the diameter of the lumen to 13 mm or less?
Schatzki ring (AKA B ring)
A patient presents with Zenker’s diverticulum, dermatologic and immunologic disorders, and iron deficiency anemia. What diagnosis would you lean towards?
Esophageal web
What is Plummer-Vinson Syndrome?
Triad of iron deficiency anemia, dysphagia, and cervical esophageal web
Who is more affected by esophageal strictures/Plummer-Vinson Syndrome, men or women? At what age do esophageal strictures normally affect these patients?
White women in the 4th to 7th decade of life, though can occur in children and adolescents
What two main things are Schatzki rings normally associated with?
Hiatus Hernia
Esosinophilic Esophagitis
67 year old patient presents to you with intermittent, nonprogressive dysphagia for solid food. He recently went to Texas de Brazil and wolfed down enough meat to make it worth his money. What diagnosis would you lean towards?
Esophageal stricture - Schatzki ring “steakhouse syndrome”
How will a patient with esophageal varices present?
Hematemesis, melena, hematochezia, possibly hypovolemia. Typically have cirrhosis
What labs would you get for esophageal varices?
Albumin/totel serum protein PT/INR Bilirubin AST/ALT ALP GGT ANA AMA Ferritin/Iron Hep Panel A1-antitrypsin USg CT Scan
That are the treatments for esophageal varices?
Treatment of choice - Nonselective beta blockers (propranolol, nadolol)
Isosorbide
Fluoroquinolones
Endoscopic banding/IV octreotide
Transjugular intrahepatic shunts
A 21 year old college students comes to your clinic drunk out of their mind. They present with hematemesis, vomiting, and retching after alcohol intake. Patient endorses this happening before when they go out to party and drink. What would you diagnose and how would you treat it?
Mallory Weiss Tear
No treatment generally needed, depends on patient’s presentation
How will patient with esophageal neoplasm present?
Progressive dysphagia to solids along with weight loss, chest pain, hoarseness, reflux, hematemesis.
What is most common cause of esophageal neoplasms in US? What is it usually a complication of?
Adenocarcinoma is most common cause
Usually a complication of GERD/Barrett’s esophagus
What are esophageal infections normally caused by and how would you treat it?
HSV-1
Acyclovir
A patient with HIV presents with odynophagia, dysphagia, chest pain, yellow-white mucosal plaques. What would you think the culprit is and how would you treat?
Candidiasis
Flucanazole
A patient with HIV and low CD4 counts are commonly found with what esophageal infection? And how would you treat it?
Cytomegalovirus
Ganciclovir
One of the most common causes of acute abdominal pain and one of the most frequent indications for an emergency abdominal surgical procedure worldwide is called?
Appendicitis
Appendicitis is most commonly caused by ?
Fecalith
Most common organisms for gangrenous and perforated appendicitis include?
Escherichia coli, peptostrepcococcus, bacteroides fragilis, and pseudomonas species
What percentage of patients develop perforation less than 24 hours after the onset of symptoms?
20%
After 48 hours, what percentage of patients get perforations after onset of appendicities?
65%
Classic presentation of appendicitis?
- Right lower quadrant abdominal pain
- Anorexia
- Nausea and vomiting
- Low grade fever - 101.0 F (38.3 C)
What is Rovsing’s sign and what does it suggest?
Right lower quadrant pain with palpation of left lower quadrant
Right sided local peritoneal irritation
Where is obturator sign and what does it suggest?
Pelvic Appendix
Inflamed appendix may lie against right obturator internus muscle
Where is Psoas sign and what does it suggest?
Retrocecal appendix
Inflame appendix may lay on right psoas muscle (right lower quadrant pain with passive right hip extension)
Male infants and children with appendicitis also occasional present with what?
Inflamed hemiscrotum
Labs for appendencitis?
CBC, UA, CMP, Lipase
Leukocytosis >10k uL but <18k uL unless perforation occurred
Treatment for appendicitis?
Hydration, antibiotics, surgery
Antibiotics should be administered as soon as diagnosis of appendicitis is established and at least 30-60 minutes before incision is made.
Surgery should be done in a timely manner and done within 24 hours of diagnosis
What is celiac disease?
Autoimmune gluten disease
Celiac disease normally occurs at what age?
2 years of age or 20’s, 30’s, 40’s
Adults with celiac disease often present with what?
Anemia or osteoporosis without diarrhea or other gastrointestinal symptoms
Sometimes dermatitis herpetiformis
What test is used for celiac disease?
Anti-tTG IgA antibody testing
EMA (endomyesial antibodies) are virtually diagnostic of celiac disease
What age does Crohn’s and UC normally occur?
Any age but normally 2nd-4th decade with another peak at 7th decade
UC features
Continuous Disease of colon Common site is rectum Bloody pus filled diarrhea Rectal pain Urgency for defecate Toxic megacolon, colorectal cancer
Labs or procedures for UC?
CBC, ESR, albumin, stool studies
Sigmoidoscopy or colonoscopy
Uveitis can occur secondary to what inflammatory disease?
UC
What does cobblestoning and skip lesions describe?
Crohn’s disease
Is rectal involvement rare in Crohn’s or UC?
Crohn’s
P-ANCA would be positive or negative in what disease?
Positive in UC
Negative in Crohn’s
Most common presentation of Crohn’s?
Weight loss, abdominal cramps, nonbloody diarrhea, aphthous ulcers
When do you diagnose IBS?
When you exclude everything else
What age and who does IBS normally affect?
Mid age, more common in women
What is a sign for IBS?
Improvement with defecation
Treatment for IBS?
Increase fiber, anticholinergics
What age does intussusception obstruction normally occur in?
Children 95% of the time. Adult = probably neoplasm
Describe intussusception presentation.
Colicky abdominal pain with “currant jelly” stools / sausage like mass
What is shown on ultrasonography with intussusception?
“Target sign”. US is the preferred means of diagnosis.
Most common location of bowel obstruction?
Sigmoid colon
What age does bowel obstruction normally occur?
70s
How does small bowel obstruction present?
Abdominal pain, distention, vomiting of partially digested food, OBSTIPATION
What does this suggest?
Small bowel obstruction
70 year old male presents with fever, tachycardia, distention, and abdominal pain. You order an X-Ray and see this. What would you diagnose?
Large bowel obstruction
Treatment for bowel obstruction?
NPO, IV fluids, surgery if suspected mechanical obstruction, pain management
62 year old female who has been in the hospitalized for 7 days shows signs of nausea, vomiting, abdominal distention, bloody stool presents to you. On physical examination you find typanic percussion, rebound, guarding, and rigidity. The pain seems to be proportionally worse than the physical exam finding. You order an X-Ray and see this. You note a “coffee bean” appearance. What would you diagnose?
Loop of intestine twisting around itself causing an obstruction
Sigmoid volvulus
What is diverticulitis?
Inflammation of a diverticulum, due to stool getting stuck in the microperforations
Where and what kind of pain is associated with diverticulitis?
Sudden left lower quadrant pain
Treatment for diverticulitis?
Low residue diet, quinolone with metronidazole, augmentin, bactrim with metronidazole
Surgery for severe cases
Findings for peritonitis?
Shallow breathing, flexed knees, distended abdomen with tenderness to palpation
Treatment for peritonitis?
IV fluids
Broad spectrum antibiotics
Most gastric and duodenal ulcers can be attributed to what?
H. Pylori
NSAIDs
Severe physiological stress
Zollinger-Ellison
Whnat are the hallmark presentations for gastritis?
Dyspepsia and abdominal pain
Gastritis are the cause of the pain that people feel.
True or False?
False
When people have symptoms, it is due to other conditions that can happen from gastritis, like ulcers
What are alarm signs of gastritis?
Age 55+ Bleeding Anemia Unintentional weight loss >10% of body weight Dysphagia Odynophagia Early Satiety Previous malignancy Previous documented ulcer
What is the gold standard for diagnosing gastritis?
Endoscopy with four biopsies
H. Pylori testing is a cornerstone of managing dyspepsia
Treatment for Peptic Ulcer Disease?
1st line - Triple therapy (PPI, clarithryomycin, amoxicillin) - 70-85% eradication rate
Metronidazole for amoxicillin allergy
2nd line - Quadruple therapy (PPI, bismuth subcitrate, tetracycline, metronidazole)
Patient presents with fever, tachycardia, dehydration. You order an Xray and notice this. What do you see and what would you diagnose?
Free air under the diaphragm
Diagnosis - Peptic ulcer disease
Patient presents with heartburn, dysphagia, regurgitation. What should be one of your top differentials?
GERD
What are some exacerbating factors of GERD?
Obesity Fatty foods Caffeine Carbonated beverages ETOH Tobacco Drugs Peppermints Chocolate
What is Barrett’s Esophagus?
Condition that results from severe esophageal mucosal injury, normal squamous epithelium replaced by columnar epithelium
Describe what is the finding called from both pictures
Left picture - Virschows Node
Right picture - Sister Mary Joseph’s Node
A 2 month old baby comes into your clinic because of projectile vomiting. You notice an olive like mass at the lateral edge of the upper right quadrant. What would you diagnose?
Pyloric Stenosis
