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Emergency Medicine > Gastrointenstinal > Flashcards

Gastrointenstinal Flashcards

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1
Q

Acute and Chronic Pancreatitis

dx

A

Dx:

  • Serum Amylase x5 ULN (non spec)
  • Serum Lipase x3 ULN specific
  • CT scan - gold standard
  • +/- jaundice
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2
Q

Acute Appendicitis

A

fecalith trapped in appendix

Sxs:

  • Periumbilical pain => pain over RLQ McBurney’s point
  • N/V/Chills, anorexia

Dx

  • PE
    • Rovsing’s sign - RLQ pain after pressing on LLQ
    • Obturator’s sign - pain with flexion and internal rotation of R LE
    • Iliopsoas’s sign - supine, raise R leg against resistance
  • Labs
    • leukocytosis, fever
  • Imaging - US first line for kids
    • CT for adults to confirm

Tx

  • Appendectomy
  • IV Ceftriaxone pre-op
  • no need for abx post op
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3
Q

Ranson’s Criteria

A

At admission:

  • Age > 55
  • Glucose > 200
  • AST > 250
  • LDH > 350
  • WBC > 16,000

48 hrs after admission

  • Hematocrit fall > 10%
  • BUN Rise > 5mg/dl
  • Ca < 8 mg/dl
  • PO2 < 60 mmHG
  • Base deficit > 4 mEq/L
  • Fluid sequestration > 6L
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4
Q

Acute Pancreatitis

eti, sxs

A

MC gallstones, 2/2 ETOH N/V

Sxs:

  • Epigastric abd pain
  • r-> back worse supine and
  • post prandial
  • hemorrhagic
    • Grey Turner - flank ecchymosis
    • Cullen - periumb ecchymosis
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5
Q

Acute Pancreatitis

tx

A

Mild

  • bowel rest
  • NPO
  • Pain control

Severe - ICU

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6
Q

Anal Abscess and Fistula

Dx, tx

A

Clinical I&D

followed by WASH

  • Warm water
  • Cleansing
  • Analgesics
  • Sitz Bath
  • High fiber diet
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7
Q

Anal Abscess

eti, sxs

A

Bacterial infx of perianal ducts/glands - MC S Aureus

MC posterior rectal wall

Sxs:

  • Painful defecation
  • Rectal pain worse with sitting, coughing
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8
Q

Anal Fissures

dx and tx

A
  • clinical
  • Sigmoidoscopy if < 50 yo to r/o FH of colon ca
  • Analgesics
  • High fiber diet
  • Stool softener, laxatives, mineral oils
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9
Q

Anal Fissures

eti, sxs

A

Painful, linear tear/crack low fiber diet

MC in posterior midline

2/2 Crohn’s and Granulomatous (TB or sarcoid)

Sxs:

  • Severe, tearing pain with defecation
  • Pt afraid of BM —> Constipation and
  • BRBPR
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10
Q

Anal Fistula

eti, sxs

A

open tract btwn two epithelial-lined areas

MC with Crohn’s

Sxs:

  • Perirectal/anal swelling
  • painful defecation
  • Malodorous drainage
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11
Q

Cholangitis

dx, tx

A

Dx:

  • ele serum bilirubin, alk phos, aminotransferases
  • 1st - RUQ US or CT
  • ERCP for cholangiography after afebrile for 48 hrs
    • ERCP for decompression
    • PTC if can’t do ERCP

Tx with Abx - Ceft + Metro - Zosyn (pip/tazo)

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12
Q

Cholangitis

eti, sxs

A

Infection of common bile ductt 2/2 to obstruction - gallstones

MC Ecoli or Kleb

Charcot’s Triad

  1. RUQ pain
  2. Jaundice
  3. Fever

Reynold’s Pentad

  1. above + AMS & Sepsis/hypotension
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13
Q

Cholecystitis eti, sxs

A

Inflammation of GB

MC gall stones

Sxs:

  • RUQ/epigastric pain
  • N/V/Anorexia
  • R-> R shoulder/scapular - Boas’s sign
  • Inspiratory halt during deep palpi = Murphy’s sign
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14
Q

Cholecystitis

dx & tx

A

Dx with RUQ US >3mm

HIDA scan (gold std)

Tx:

NPO IV fluids Abx (ceft + metron) Definitive - cholecystectomy

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15
Q

Choledocholithiasis

dx, tx

A

Trans abd US gold - ERCP extraction tx

cholecystectomy definitive

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16
Q

Choledocholithiasis

eti, sxs

A

GS in Common Bile Duct

1ry - formation of gs in CBD

2ry - passage of gs from GB to CBD

Sxs:

asymp 50%

Biliary colic w/ RUQ tenderness +/- jaundice

may lead to shock

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17
Q

Cholelithiasis

dx, tx

A

Gold - RUQ US > 2mm GB wall

3 types deps on color

  • yellow for cholesterol
  • black - hemolysis, ETOH, cirrhosis
  • brown - biliary tract infx observation if asymp

Tx - Urseodeoxycholic acid to dissolve GS

Elective cholecystectomy

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18
Q

Cholelithiasis eti, sxs

A

Gallstones + pain when GB compresses on GS

Fat Forty Fertile Female Flatulence

Sxs:

  • MC asymp Biliary colic
  • episodic RUQ/epig pain —> resolves in 30-1h
  • post prandial pain + at night
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19
Q

Chronic Pancreatitis

tx

A

Pancreaticojejunostomy -> Whipple PO

Pancreatic enzyme replacement

ETOH abstinence

Pain control

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20
Q

Colorectal Carcinoma (CRC)

dx

A

Colonoscopy with bx - gold

barium enema - apple core lesion

+ CEA - marker

CBC - anemia

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21
Q

Colorectal Carcinoma (CRC)

eti

A

3rd MC Cancer in US Genetics

Familial Adenomatous Polyposis (APC gene - develop colon cancer by 40yo —> prophylactic colectomy

RFs

  • age > 50yo -
  • UC > Crohn’s -
  • Low fiber diet -
  • smoking -
  • etoh -
  • AAs -
  • fam hx of CRC
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22
Q

Colorectal Carcinoma (CRC)

Screening

A

average risk

  • start at 50 yo
  • FOBT q 1 year
  • Colonoscopy q 10y or Flex sig q 5 y

1st degree Relative or high RFs

  • FOBT q1y
  • starting at 40y or 10 yrs younger than earliest dx age Colo - q 5y

Highest risk

  • UC or Crohn’s >8yrs,
  • FAP
  • FOBT any age
  • Colonoscopy q5y
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23
Q

Colorectal Carcinoma (CRC)

sxs

A

Painless rectal bleeding changes in bowel habits

MCC large bowel obstruction in adults

Right sided

  • proximal - lesions tend to bleed (anemia/+ FOBT) diarrhea

Left sided

  • distal bowel obstructions present later
  • hematochezia
  • +changes in stool diameters
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24
Q

Colorectal Carcinoma (CRC)

tx

A

localized (stage 1 to 3) - resection

Stage 3 to Mets - chemotherapy with 5FU/Fluorouracil

25
Q

Diverticulitis

dx, tx

A

gold - CT scan

FOBT + CBC Leuks

Tx:

  • Abx - Cipro/Bactrim + MNZ
  • Clear liquid diet
  • colonoscopy in 6 wks to r/o cancer
26
Q

Diverticulitis

eti, sxs

A

Infection and inflammation of outpouchings d/t fecalith

Sxs:

  • LLQ abd pain
  • Fever N/V/D
  • Constipation
  • bowel changes and bloating
27
Q

Diverticulosis

dx, tx

A

KUB r/o free air

avoid barium enema

high fiber diet

psyllium

28
Q

Diverticulosis

eti, sxs

A

Outpouchings d/t intestinal mucosa herniation

Sxs:

  • MCC BRBPR
  • Low fiber diet
  • LLQ discomfort
  • fever, chills
29
Q

Esophageal Carcinoma - Adenocarcinoma dx, tx

A

Endoscopy with Bx - gold Barium

esophagram CT for staging

Esophageal resection chemo 5FU

30
Q

Esophageal Carcinoma - Adenocarcinoma

eti, sxs

A

MCC esophageal ca in US

a/w Barrett’s esophagus and GERD

Sxs:

  • progressive dysphagia solids -> fluids odynophagia
  • chest pain not related to eating
  • wt loss
  • reflux hoarseness
31
Q

Esophageal Carcinoma - Squamous Cell Carcinoma

A

MCC Esophageal worldwide

upper 1/3 of esophagus

50-70yo

a/w smoking/etoh

32
Q

Gastric Carcinoma

dx, tx

A

Endoscopy with Biopsy

Linitis plastica - thickening of gastric wall -

infiltration of cancer Gastrectomy

poor prognosis

33
Q

Gastric Carcinoma

signs of metastasis

A

Virchow’s Node - Left supraclavicular LN

Sister Mary Joseph’s Nodule - umbilical LN

34
Q

Gastric Carcinoma

eti, sxs

A

MC adenocarcinoma RFs:

  • H pylori*** salted, cured, pickled food
  • Etoh
  • Smoking
  • Blood type A

WEAPONS

  • Weight loss
  • Emesis
  • Anorexia
  • Pain/abd discomfort
  • Obstruction
  • Nausea
35
Q

Hepatocellular Carcinoma

eti, sxs

A

Primary Cancer - HCC

2/2 to mets from lungs and breast Ca (MC)

RFs:

  • Hepatitis B, C, D
  • Cirrhosis
  • Aflatoxin B1 exposure (Aspergillus spp)
  • Malaise
  • Jaundice
  • Wt loss
  • ascites
  • abd pain
  • Hepatosplenomegaly
36
Q

Hepatocellular Carcinoma

dx, tx

A

Alpha fetoprotein (AFP) marker esp in pst with hep C or cirrhosis

Ultrasound, MRI lesions >/= 1cm

Liver transplant for single lesion < 5cm or

= 3 lesions that are all = 3cm

Surgical resection - cancer can recur

37
Q

Mallory Weiss Tear

Hematemesis

A

Mucosal tearing of gastroesophageal junction from vomiting

Sxs:

  • Hx of vomiting/retching or alcohol intake
  • PainLESS hematemesis

Dx - Esophagogastroduodenoscopy (EGD)

Tx - self limited, supportive

38
Q

Esophageal Varices

Hematemesis

A

Dilated submucosal veisn in distal esophagus or proximal stomach

hx of portal HTN & Cirrhosis; high mortality

Sxs:

  • Hematemesis - coffee ground appearance
  • melena
  • VS instability
    • hypovolemia/tachycardia
    • shock

Dx:

  • Emergent endoscopy (EGD)
  • Band ligation**** & IV Ocreotide for vasoconstriction
  • sclerotherapy
  • If fails - Balloon tamponade or TIPS (transjugular intrahepatitc portosystemic shunt)
  • Longterm - BB (propanolol), no etoh
39
Q

Infectious Esophagitis

A

MC in IMC hosts

Sxs:

  • Odynophagia* (painful swallowing) - food or liquid
  • Dysphagia (difficult swallow)
  • Chest/substernal pain/fever

Dx/Tx - EGD

  • Candida MC - linear yellow white plaques
    • Fluconazole 100 mg PO QD
  • HSV - shallow punched out lesions
    • Acyclovir
  • CMV - large solitary ulcers or erosions
    • Ganciclovir
40
Q

Non-Infectious Esophagitis

A
  1. Reflux Esophagitis
    • mechanical or functional abn from LES - refer to GERD
  2. Medication induced
    • Usu NSAIDs or bisphosphonates - drink 4oz of water, sit upright
  3. Eosinophilic - allergic eosinophilic infiltration of esophageal epithelium
    • dx w/ Barium swallow = ribbed esophagus and multiple corrugated rings
41
Q

GERD

A

Relaxation of LES

Sxs:

  • Heartburn* w/ meals, wt gain, N, recumbency
  • Throat irritation and cough

Tx - symptom relief w/ PPO and H2 Blockers

  • PPI - sx relief + promote healing
  • Tx empircally on PPI x 4 wks (failed H2blockers w/ mod-severe GERD)

Dx

  • Endoscopy - if failed empirical tx on PPI OR
    • GI bleeding/anemia
    • Dysphagia/odynophagia
    • unintentional wt loss
    • H/o heavy NSAIDs
    • Risk of UGI cancers
42
Q

Peptic Ulcer Disease

A

MCC of non hemorrhagic GI bleeds

Duodenal 5x > Gastric; MCC H pylori > NSAIDs, ETOH, smoking

Sxs:

  • Gastric Ulcers
    • abd pain worse with meals - get better after eating
    • patient refuses to eat (losing weight)
  • Duodenal Ulcers
    • Pain gets better with eating - worse after eating
    • Patient gaining weight

Dx

  • plain films r/o perf
  • UGi
  • Endoscopy* - gold

Tx

  • PPI qd-BID x 8 to 12 weeks
43
Q

H. pylori

Peptic Ulcer Disase

A

Dx

  • Urea Breath test * gold - needs to be off PPI, bismuth and abx
    • active infection
    • urea as byproduct of metabolism
  • Stool antigen
  • Endoscopy bx

Tx

  • Clarithromycin 500 mg BID
  • Amoxicillin 1g BID
  • PPI BID
    • Metronidazole 500 mg if pcn allergic
  • Follow up with urea breath test 1 mo post tx to ensure eradication
44
Q

Zollinger-Ellison Syndrome

PUD ddx

A

Gastrinoma of pancreas* or duodenum

PUD develops in 90% of pts

Consider if

  • Recurrent PUD
  • Neg H. pylori, Neg NSAID/ASA use
  • Severe abd pain, diarrhea

Dx

  • secretin test => gastrin level will rise

Tx

  • Surgical resection of gastrinoma
45
Q

Hepatitis (acute

All

A

Hep A and Hep E

  • Fecal oral route
  • self limited, mild
  • IgM Hep A is positive infx

Hep B

  • IVDU, needles
  • Chronic carrier
  • Major risk for hepatocellular carcinoma
  • Coinfection with HIV

Hep C

  • Sex - blood borne, tattoos, transfusion
  • Pts btw 1945-1965 - screened
  • Should be vaccinated against HAV and HBV
46
Q

Hepatitis B

serology

A

HBsAg = active infection

HBsAby = immunity

HBcAg/Aby = exposure or past infection

  • if + core, exposed to virus

HBeAg = highly infectious BAD

HBeAby = low infectious risk (closed envelope)

Immunity via vaccination = only have HBsAby +

Active infection = HBsAby, HBcAg/Aby, HBeAg

47
Q

Hepatitis C

A

a/w cirrhosis, chronic Hep C => Hepatocellular carcinoma

Dx

  • HCV RNA viral load testing
  • HCV Aby w/ neg viral load = resolved HCV
  • Liver bx = for state
  • most are genotype 1

Tx

  • Initial - with Interferon and Ribavirin + chemotherapy
  • Now - Direct acting viral drugs
    • Telaprevir/Incivek
    • Sofosbuvir/Harvoni - 3 mos w/o any SEs
48
Q

Hepatitis - Alcoholic

A

Reversible - MCC of cirrhosis

AST >ALT (2:1) ~300

Increased bilirubin

Megaloblastic anemia

prolonged PT/low albumin = poor prognosis

49
Q

Cirrhosis

eti,sxs, dx

A

Hepatic fibrosis - scar tissue

Eti: Chronic hepatitis is MCC, etoh abuse, NASH, Wilson’s disease

Sxs:

  • Hepatomegaly
  • Terry’s nails (white nail beds)
  • fluid wave + shifting dullness from ascites
  • Esophageal varices
  • caput medusae
  • Hepatic encephalopathy - asterixis

Dx:

  • AST > ALT, incr ALP
  • ele GGT
  • Jaundice = incr unconjugated bilirubin
  • hypoalbuminia (ascites)
  • Prolonged PTT = decr clotting factors K
  • Liver bx - gold
  • Child-Pugh Cirrhosis mortality​
50
Q

Cirrhosis

tx and management

A
  • quit etoh
  • Antiviral for Hep C
  • BB for esophageal varices
  • Liver transplant - definitive
  • Encephalopathy
    • lactulose + rifaximin
  • Ascites
    • Fluid restriction, paracentesis
    • if + abd pain and fever, think Spontaneous Bacterial Peritonitis ​
      • diagnostic tap of 50cc => (ANC > 250)
      • tx with IV Cefotaxime/Ceftriaxoen x 5 d, PO Cipro once stable
      • Give with albumin 1.5mg/kg to prevent Renal failure
51
Q

Crohn’s Disease

IBD

A

Genetic +environmental factors; peaks at 15-35 yo

Mouth to anus - transmural, “Skip lesions”

Sxs:

  • Colicky RLQ pain
  • Diarrhea/ malabsorption
  • Low grade fever
  • Wt loss
  • a/w anal fistulas, aphthous ulcers

Dx:

  • Colonoscopy - gold
    • cobblestoning
    • skip lesions
  • small bowel films
    • string sign - barium study
  • Lab - CBC, ESR, CRP, B-12, stool culture
  • +ASCA
52
Q

Ulcerative Colitis

IBD

A

Idiopathetic, inflammatory dz

Friable mucosa and submucosa, limited to colon = Rectum MC

bimodal distr - 15-25yo and 55-65

Sxs:

  • Bloody, pus filled diarrhea
  • LLQ pain
  • fever

Dx:

  • Barium enema - lead pipe appearance
  • coloscopy with bx - gold = loss of haustral markings and lumen narrowing
    • risk of toxic megacolon
  • pANCA
53
Q

IBD Treatment

A

Medical Management

5-Aminosalicylates ASA

  • Mesalamine
    • SE - NV, HA, rash, fever
    • replace folic acid
  • Sulfasalazine

Immunomodulators

  • Azothioprine/6-mercaptopurine
    • maintenance therapy
    • takes 3-6 mos for full effect
    • can come off 5ASA
    • check LFTs and CBC q 90 ds

Biologics

  • TNF-inhibitors (Infliximab/Remicade, Adalimumab/Humira)
    • SE - reactivate of Hep B and TB (check prior to initiation)
    • expensive

Corticosteroids

  • high dose, short course => acute exacerbations
  • Prednisone in taper 30-40mg

Abx - for fistula

  • Metronidazole
  • Cipro
  • Rifaximin
54
Q

Mesenteric Ischemia

A

Hypoperfusion to bowel vasculature

Sxs:

  • abd pain OOP to PE
  • h/x of afib, vascular dz

Dx - CT angio, treat in surgery

55
Q

Small Bowel Obstruction

A

MCC - adhesions d/t previous abd surgeries

Sxs:

  • N, V
  • Abd distention, rigid or firm

Dx

  • KUB - air fluid level on upright

Tx

  • NG tube
  • Bowel rest
  • Surgery if unresolved
56
Q

Large Bowel Obstruction

A

Causes - volvulus, adhesions, hernias, colon cancer (MCC in elderly ppl)

Sxs:

  • Constipation
  • N/V
  • distention and pain
  • high pitched BS

Dx:

  • KUB/abd Xray - distended proximal colon w/ haustra, air fluid levels, no gas in rectum

Tx:

  • NPO
  • NG suction
  • IV fluids
  • monitoring pain
  • Surgery if mechanical obstruction
57
Q

Giardiasis and Parasitic infections

A

Giardia

  • after camping trip, mountain stream water
  • incubates for 1-3 wjs
  • foul smelling bulky stool
  • Acute profuse, fatty non bloody diarrhea
  • Dx - stool sample
  • Tx - Tinidazole 1st line, metronidazole
    • resolves w/in 5-7 ds

Pinworms

  • perianal swelling
  • scotch tape test
  • Tx mebendazole

Hookworm

  • cough, wt loss, anemia, recent travel
  • Eosinophilia and anemia
  • Tx Mebendazole or pyrantel

Roundworm

  • contaminated soil
  • pancreatic duct, common bile duct and bowel obstruction
  • Dx - stool sample eggs
  • Tx abendazole, mebendazole, pyrantel pamoate

Amebiasis

  • Fecal-oral, contaminated water/food, anal-oral
  • bloody diarrhea, tenesmus
  • a/w liver abscess
  • Tx Iodoquinol or flagyl for liver abscess

Tapeworm

  • GI sxs w/ weight loss
  • raw or undercooked meat
  • B12 deficiency
  • Dx - diphyllobothrium latum tape test
  • Tx praziquantel

Schistosomiasis

  • skin penetration in freshwater -> blood stream -> liver, intestines
  • rash, abd pain, diarrhea, bloody stool, hematuria
  • Dx - egs in urine or feces
  • Tx praziquantel
58
Q

Hemorrhoids

A

varicose vein of anus and rectum

RFs - constipation/straining, pregnancy, portal HTN

Dx - Anoscopy if BRBPR or suspected thrombosis

External

  • lower 1/3 of anus
  • thrombosed
    • significant pain, pruritis, NO bleeding
    • palpable perianal mass w/ purplish hue
  • Tx - excision

Internal

  • upper 1/3 of anus
  • BRBPR, pruritis, rectal discomfort
  • Tx - Fiber, sitz bath, ice packs, stool softeners
    • Rubber band ligation - if +protrudes, enlargement and intmt bleeding
    • Hemorrhoidectomy if prolapse
59
Q

Hernia (incarcerated/strangulated)

A

Protrusion of organ/structure through abd wall

Inguinal hernias

  • MC - through internal ring down the inguinal canal (into scrotum)

Direct inguinal hernias

  • passage of intestines through external inguinal ring at Hesselbach’s triangle

Sxs:

  • Reducible bulge when patient coughs or strains
  • Usu painless unless
  1. Incarcerated - can’t be reduced
  2. Obstructed - irreducible hernia but no interference w/ blood flow
  3. Strangulated - blood supply cut off - bowel ischemia, necrosis perforation

Tx - Open repair or lap w/ mesh reinforcement

Emergency Medicine (13 decks)

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