Gastrointestinal Flashcards
A 15 year old presents with umbilical pain that is worsening over the past 12 hours, now localized in the RLQ. He admits to loss of appetite and nausea. What tests should be performed as part of the physical exam?
Rosving’s, Psoas, Bloomberg, Markle and Obturator
In the 15 year old with peri-umbilical and RLQ abdominal pain, what exam findings would be suggestive for acute appendicitis? (Describe tests performed and findings)
Pain at McBurney’s point (between umbillicus and RLQ)
+ Bloomberg (rebound tenderness)
+ Rovsing’s Sign (palpation LLQ produces pain in RLQ)
+ Psoas sign (pain with resisted extension of RLE)
+ Obturator sing (pain in RLQ with inward rotation R. Hip)
Abdominal pain localized in the LLQ, described as cramping and fullness with associated anorexia and nausea/vomiting is suggestive of what condition?
Diverticulitis
When examining someone you suspect to have diverticulitis, would you expect a positive or negative Rovsing’s sign?
Positive, although negative does not exclude diverticulitis
Sudden onset of severe epigastric abdominal pain that radiates into the back that is often accompanied by tachypnea, tachycardia, fever, nausea and vomiting is suspicious for what disorder?
Acute pancreatitis
What sign may be found with acute pancreatitis?
+ Cullen sign (peri-umbilical ecchymosis)
+ Grey Turner’s sign (flank ecchymosis)
A sudden or gradual change in bowel habits in patient over the age of 55, presence of occult or visible blood in stool, vague abdominal pressure or discomfort without acute findings is suspicious for what disorder?
Colon cancer
What are the recommendation ages for colon cancer screenings?
Males and females between the ages of 50-70 years, 40-45 for those with first degree relatives w/ hx of colon cancer
What patients are at higher risk for colon cancer?
First degree relatives w/ hx of colon cancer Hx of crown’s disease Smokers Heavy red meat eaters Diets low in fiber
T/F Crohn’s disease may affect any part of the GI?
True
Patient with history of Crohn’s disease presents with abdominal pain and watery non-bloody diarrhea, what part of the GI tract do you suspect is involved?
Ileum
Patient with history of Crohn’s disease, colonic involvement would be suspected if the stools appear as?
Bloody diarrhea w/ mucous
Unlike ulcerative colitis, what complication can occur with Crohn’s disease?
Fistula and anal diseases
What associated findings are common with Crohn’s relapse?
Fever, anorexia, weight loss, dehydration, fatigue and peri-umbilical to RLQ abdominal pain.
Hematochezia is what?
Bloody diarrhea w/ mucous
Younger patient who experiences recurring episodes LLQ abdominal pain that described as of squeezing or cramping, which is accompanied by bloody/mucous diarrhea, as well as bloating and gas which is exacerbated by eating is suspicious for what chronic disorder?
Ulcerative colitis
Toxic megacolon is a concerning risk for patients with which disorders?
UC and Crohn’s
What causes Zollinger-Ellison Syndrome and how is it manifested?
A gastinoma in the pancreas or stomach that stimulates gastric producing excessive acids in the stomach which causes multiple and severe ulcers to form.
What lab test screens for Zollinger-Ellison syndrome?
Serum fasting gastrin
A Carnett’s test performed who and indicates what?
While supine, have pt lift shoulders off the exam table. If positive, the pain is worse when pt lifts shoulders. If negative, pain is reduced indicating source within the abdominal cavity.
What is a long-term GI complication of untreated GERD?
Barrett’s esophagus, esophageal cancer and stricture
What is Barrett’s esophagus?
Precancerous condition found on UGI biopsy
What are some signs of esophageal cancer?
Significant early satiety, odynophagia (painful swallowing), dysphasia, and weight loss.
When should someone be referred to gastroenterologist for GERD?
Any red flags, advanced age, after failure of PPI, or anyone with 10 or greater hx of GERD.
What are the most common viral pathogens in gastroenteritis?
Rotavirus and norovirus
T/F bloody diarrhea is usually associated with viral gastroenteritis?
False
Patient without other risk factors experiencing acute onset of fever, severe abdominal pain and bloody diarrhea with at least 6 stools in the past 24 hours, what is the likely diagnosis?
Bacterial gastroenteritis
What are the most common bacterial pathogens in gastroenteritis?
E. Coli, salmonella, shigella, campylobacter, c diff (recent hospitalization/abx use), and listeria
What is the typical duration of viral gastroenteritis?
1-3 days
Patients with bacterial gastroenteritis can generally expect symptoms to last how long?
1-7 days for most pathogens, although many can have longer courses such as c. Diff
T/F patients with pathogenic gastroenteritis should routinely be recommended to use anti-diarrhea medications?
False, can cause severe complications with many of the bacterial pathogens
Functional bowel disorder such as IBS produce what symptoms?
Intermittent unpredictable bowel patterns ranging between diarrhea and constipation with gas and bloating. Moderate to severe diffuse lower abdominal pain (often worse in LLQ).
What is a classic symptom in IBS?
Abdominal discomfort that is relieved w/ defecation.
Before confirming diagnosis of IBS, it is important to do what?
Rule out other causes such as pathogenic gastroenteritis (parasitic, amoebic and bacterial) and inflammatory bowel diseases.
What are the treatment and management recommendations/ therapies a NP should prescribe to a patient with IBS?
Increase dietary fiber (supplements may be used as well)
Avoid gas’s-producing foods
Limit/avoid dairy and gluten (if worsens symptoms)
Pharmacological
Constipation: miralax or fiber supplements
Diarrhea: Imodium prior to meals
Antispasmotics: dicyclomine (Bently) as needed
What are some risk factors for protozoal gastroenteritis?
Travel to developing countries
Recent abx use
Immune compromised states
Crowded living facilities (day cares, nursing homes, institutions)
What is the most common cause of peptic ulcer disease?
H. Pylori
Aside from H. Pylori, what are other risks for PUD?
Smoking
Chronic alcohol use
Drugs: NSAIDs, bisphosphonates, anticoagulants/anti-thrombotic, glucocorticoids, and chemo drugs
What tests can be done to diagnose H. Pylori?
Urea breath test, stool antigen, and UGI (gold standard)
T/F acute diverticulitis is most common in adults 35-40 years old?
False, it is more common in older adults
What is the recommended treatment for diverticulitis?
Augmentin 875mg PO bid x 7-10 days
OR
Cipro 500mg PO BID WITH Flagyl 500mg Q 6 Hours x 7-10 days
T/F Opiates can be helpful and recommended for an acute attack of diverticulitis?
False- it is best to avoid if possible as they promote ileus
When managing an acute diverticulitis flare as an outpatient, it is recommended to follow up with patient how often?
Every 2-3 days or sooner if sx worsen
T/F management of diverticulosis in the non-acute phase includes high-fiber diet and supplementation?
True
T/F according to evidence, avoidance of seeds/nuts, and popcorn has been found to reduce incidence of diverticular flare ups?
False- not supported by evidence, but may be anectodal in patient’s experience
What are the most common causes of acute pancreatitis?
Chronic alcohol use, gallbladder disease w/ stone obstructing common bile duct, and hypertriglyceridemia.
What labs are elevated with acute pancreatitis?
Lipase and amylase
Liver enzymes: AST, ALT, GGT, bilirubin
CBC: Leykocytosis
Which antibiotics are most likely to cause c. Diff?
clindamycin, Fluoroquinolones, cephalosporins, and PCNS
What are the recommended treatment options for mild-moderate c. Diff?
vancomycin 125mg PO QID x 10 days
OR
Flagyl 500mg PO tid x 10 days
T/F ALT is more specific for liver inflammation than AST?
True
AST:ALT ratio greater than ___ indicates alcohol abuse?
2.0
What liver enzyme test is an indicator of heavy and continuous alcohol consumption for several weeks or longer?
GGT
In the presence of elevated alkaline phosphatase (ALP), what additional finding is suggestive of liver pathology?
GGT
T/F elevated ALP (alkaline phosphatase) is always indicative of underlying pathology?
False, levels can fluctuate at many stages in life. Must be taken in context of other findigns
Aside from liver, alkaline phosphatase (ASP) is found predominately in what other tissue?
Bone- elevations can be related to biliary pathology, healing fractures, bone malignancy or metastasis.
T/F treatment of acute Hepatitis B included administration of hep B immune globulin (HBIG) and administration of the first of three doses of the Hep B immunization?
True
What is the treatment for chronic Hep B infections?
Antiviral agents and pegylated interferon alfa (PEF-IFN-a)
A patient presents with acute onset fever, headache, malaise, anorexia, nausea, vomiting and diarrhea with abdominal pain. Urine is dark and patient appears mildly jaundiced. What is the likely condition and what lab findings would support the diagnosis?
Bilirubin >3, ALT >200
Hepatitis A antibodies: IgM + or +NAAT for Hep A
Patient with diagnosis of Hep A should be advised what to permanent liver damage?
Avoid use of liver toxic substances such as alcohol, Tylenol and many herbal teas. Statins and INH should be avoided as well.
T/F Sexual contact with Hep C carrier is the most common cause of Hep C infection?
False, needle sharing and blood product transfusion before 1992 are the most common causes.
Sexual transmission is rare
HBsAg (antigen) is positive when?
Patient actively has the virus, they are considered infectious
Anti- HB c (core antibody) indicates what?
Infection- previous or current. Is positive soon after symptoms and remains so for life
Anti-HBs (surface antibody) indicates what?
Protection- either from past recovered infection or successful immunization
Positive IgM anti Anti-HBc indicates what?
Acute infection, w/in 6 months
Interpret the following:
HBsAG (surface antigen)- negative
Anti-HBc (Core antibody)- negative
Anti-HBs (Surface antibody)-negative
No past infection or current protection from immunization, they are susceptible
HBsAB (surface antigen)- negative
Anti-HBc (Core antibody)- negative
Anti-HBs (Surface antibody)-positive
Immune due to immunization
HBsAB (surface antigen)- negative
Anti-HBc (Core antibody)- positive
Anti-HBs (Surface antibody)-positive
Previous infection with immunity
HBsAG (surface antigen)- positive
Anti-HBc (Core antibody)- positive
Anti-HBs (Surface antibody)-negative
IgM antiHBc- positive
Acute infection
HBsAB (surface antigen)- positive
Anti-HBc (Core antibody)- positive
Anti-HBs (Surface antibody)-negative
IgM anti-HBc- negative
Chronic infection (>6mos)
T/F for mild to moderate GERD, PPIs are the first line treatment?
False, lifestyle modification and H2 blockers are indicated for mild/moderate symptoms
With RUQ pain, what maneuver is done to elicit possible biliary cause?
Murphy’s maneuver, palpate under the costal border during inspiration produces severe RUQ pain.
If ALT > than AST, what is the likely cause?
Hepatitis
If AST > ALT, what is the likely cause
Substances, alcohol, statin drugs and acetaminophen
“AST- Acetaminophen, Statins, Tequilla)”
This appearance on endoscopy is classic with Crohn’s Disease?
Cobblestone
What year did newborn HepB vaccination become standard?
1986
What is achalasia?
Neurogenic functional dysphasia caused by loss of esophageal innervation or relation of LES
