Gastrointestinal Flashcards
Cullen Sign
Bruising at the periumbilicus (often because of retroperitoneal bleeding)
Grey Turner Sign
Bruising on the flank (suggest hemorrhage or trauma)
Hematochezia
Blood seen in stool (may be seen with inflammatory bowel disease, hemorrhoids)
Hepatomegaly
A normal adult liver spans <16cm in the midclavicular line
Markle sign
The patient forcefully drops the heel down to the ground causing abdominal pain (may indicate peritonitis, appendicitis)
Murphy’s sign
Pain with palpation to the RUQ while the patient inhales (may indicate cholecystitis)
Psoas/Obturator test
Pain while extending the psoas muscle/ pain on passive internal rotation of the right thigh (May indicate appendicitis)
Rovsing’s sign
Deep palpation at the LLQ causes pain in the RLQ (may indicate peritonitis or appendicitis)
Splenomegaly
Spleen is not normally palpable (Spleen >20cm is enlarged)
Streatorrhea
Fatty/oily appearing stool, foul smelling stool (may indicate celiac disease)
Tenesmus
Sensation that the patient needs to have a bowel movement
Tympanic Abdomen
Hollow/Drum like abdominal sounds (may indicate bowel obstruction)
Gastroesophageal Reflux Disease (GERD)
Reflux of tomach contents into the esophagus due to the reaction of the lower esophageal sphincter causing uncomfortable symptoms
- Stomach pH is 1 to 3 compared to esophagus pH 3 to 5.
Presentation:
- Classic symptoms of GERD: Heartburn in the retrosternal area, regurgitation after a meal.
Diagnosis:
- Clinical diagnosis is made in the patient with classic symptoms of GERD
- Endoscopy is used if red flag symptoms are present
- RED FLAGS: New onset of symptoms in patients 60 years and older, evidence of GI bleeding, presence of IDA, anorexia or unexplained weight loss, difficult with swallowing, persistent vomiting and GI cancer in a first degree relative.
Treatment:
- Non-Pharmacological Treatment:
- Avoid triggers: Carbonated beverages, spicy foods, fatty or friend foods, excess coffee, peppermint, weight gain, restrictive clothing, tobacco, stress.
- Pharmacological treatment:
- Mild/Intermittent symptoms:
- Histmaine 2 receptor antagonist (Famotidine, Nizatidine, Cimetidine)
- Frequent/Severe symptoms:
- Proton pump inhibitors (Omeprazole, Lansoprazole, Pantoprazole)
- Typically tapered after 8 weeks.
REMEMBER: H comes before P
Barrett’s Esophagus
Pre-malignant condition and is the result of repeated exposure to stomach acid
Risk factors;
- Hx of GERD for a minimum of 5 years, age 50 years and older, male gender, Caucasian, hiatal hernia, central obesity, reflux symptoms during sleep, hx or current use of tobacco, and a first degree relative with Barrett’s esophagus.
Presentation:
- Most typical symptoms: Heartburn, Regurgitation
- Other possible symptoms: Dysphagia (difficult swallowing), or Odynophagia (pain with swallowing)
Diagnosis:
- Upper endoscopy and biopsy
Treatment:
- Daily PPI Indefinitely
- Examples: Omeprazole, lansoprazole, pantoprazole
Peptic Ulcer Disease
Disruption of the mucosal lining of the stomach or duodenum that results in an ulcer
Risk factors:
- Smoking, alcohol use, advanced age
Presentation:
- Approximately 70% of peptic ulcers are asymptomatic
- If symptoms are present: Epigastic pain (often worse after eating), the sensation of fullness, or early satiety and nausea
Diagnosis:
- Suspected in patients with indigestion or dyspepsia, especially in those who frequently use NSAIDs, or those who have a history of Helicobacter Pylori infection
- Diagnosis confirmed with upper endoscopy or on abdominal CT
- CT Findings: Focal discontinuity of the mucosal hyper-enhancement and luminal out pouching
Treatment:
- Daily proton pump inhibitor
- Test for H. Pylori infection and treat if present
- Avoid NSAIDs, tobacco alcohol, spicy foods.
Helicobacter Pylori Induced Gastritis
Most common chronic inflammatory bacterial infection of the stomach
Presentation:
- Often symptomatic, however may develop dyspepsia, abdominal pain and bloating
Diagnosis:
- Endoscopy, urea breath testing and stool antigen testing
Treatment:
- Risk for Macrolide resistance
- Bismuth quadruple therapy:
- Bismuth, Metronidazole, Tetracycline, PPI
- Without risk for macrolide resistance
- Clarithromycin triple therapy
- Clarithromycin, amoxicillin and PPI
- Clarithromycin, Metronidazole, PPI (if amoxicillin allergy)
- Clarithromycin triple therapy
- Levofloxacin based therapy
- Levofloxacin, amoxicillin, PPI
- Concern for resistance (do not use unless resistance rates <15%)
- Levofloxacin, amoxicillin, PPI
- Test of cure should be performed at least four weeks after completion of antibiotic treatment
Diarrhea
3 or more episodes in a 24-hour period
- Common viral pathogens: Novovirus, Rotavirus and Adenociruses
- Common bacterial pathogens: Salmonella, Campylobacter, Shigella, Enterotoxigenic E. Coli, C. Diff.
- Common protozoan pathogens: Cryptosporidium, Giardia, Cyclospora, and Entamoeba
Treatment:
- Symptomatic treatment
- Loperamide (Imodium)
- Do not use if fever or bloody stool present, UNLESS being co-treated with antibiotics
- Bismuth salicylate (Pepto-Bismol) is alternative for symptom relief
- Empiric Antibiotics
- Indications: Severe illness, inflammatory diarrhea, high risk patients
- Options: Azithromycin or a Fluoroquinolone
- Specific indications:
- C. Diff
- Oral Vancomycin or Fidaxomicin
- Pregnant women with listeria
- IV Ampicillin
Stool studies indicated
- Severe illness
- Fever >38.5
- > 6 unformed stools per 24 hours
- Severe abdominal pain
- Hospitalization
- Inflammatory diarrhea
- Bloody diarrheas
- Small Volume with mucus
-High-risk patient
- >70 years
- Cardiac disease
- Inflammatory bowel disease
- Pregnant
-Public health concern
- Food handler
- health care worker
- Day care worker
- Symptoms lasting > 1 week
Constipation
< 3 bowel movements/week plus any 2 of the following features:
- straining, lumpy hard stools, sensation of incomplete evacuation, use of digital maneuvers, sensation of rectal obstruction, blockage with 25% of bowel movements.
- Criteria must be fulfilled for the last 3 months with symptom onset 6 months prior to diagnosis
- Rarely loose stools without the use of axatives
- Insufficient diagnostic criteria for IBS
Red flags:
- Hematochezia, weight loss of > 10 pounds, a family history of colon cancer or inflammatory bowel disease, anemia, a positive fecal occult blood tests or the recent onset of constipation without an obvious explanation
Diagnosis:
- History and physical exam
- Rectal exam: hard stool or masses, anal fissure, hemorrhoids, sphincter tone, prostatic hypertrophy in males, posterior vaginal masses in females
- Lab work
- Thyroid function tests
- Calcium
- Colonoscopy if red flags present
Treatment:
- Daily fiber intake of 20 to 25 g/day
- Bulk laxatives: Psyllium
- Osmotic laxatives: low dose/high dose polyethylene glycol, lactulose
- Stool softeners: Docusate
- Suppositories: Glycerin, Bisacodyl
- Enema: Tap water, soap suds
Inflammatory bowel disease - Crohn’s Disease
- Comprised of two major disorders: Ulcerative colitis and Crohn’s disease
Crohn’s:
- Transmural inflammation and may involve any portion of the gastrointestinal tract
Presentation:
- Cramping abdominal pain, intermittent diarrhea with or without blood, fatigue and weight loss
Diagnosis:
- Radiologic or Endoscopic findings:
- Segmental and transmural inflammation of the GI tract
Treatment:
- Refer to Gastroenterology
Inflammatory bowel disease - Ulcerative Colitis
- Recurring episodes of inflammation, limited to the mucosal layer of the colon
Presentation:
- Diarrhea (blood frequently seen), colicky abdominal pain, urgency, tenesmus
Diagnosis:
- Diarrhea for > 4 weeks and evidence of chronic colitis on endoscopy and biopsy.
- Endoscopic findings: Loss of markings d/t engorgement of the mucosa, petechiae, exudates, edema, erosions, touch friability, spontaneous bleeding
- Biopsy findings: Crypt abscesses, crypto branching, shortening and disarray, crypt atrophy
Treatment:
- Refer to gastroenterology
Hepatitis A Virus
- Self limiting, viral illness
- Incubation period of approximately 28 days (ranges 15 to 50 days)
- Transmission is fecal-oral route
- Among the most common preventable infections acquired with traveling
Presentation:
- Most are symptomatic with sudden onset of low grade fever, fatigue nausea and vomiting
- a few days later clay colored stools, tea-colored urine and jaundice skin may be seen
Diagnosis:
- Hepatitis panel: ALT > AST
- Anti-HAV IgM and IgG
Treatment:
- Symptomatic treatment
- Prevent with Vaccine
IgM = Infected that moment
IgG = Infection GONE
Hepatitis B Virus
- Viral illness with both acute infection with resolution and chronic infection with exacerbations
- Transmission route is through blood, semen, wound exudates
- Incubation period is 60 to 150 days.
Presentation:
- Abdominal pain, fatigue, anorexia, nausea, vomiting, jaundice of the skin, tea-colored urine
Diagnosis:
- Acute Hepatitis B:
- Presence of HBsAG and IgM anti-HBc
- Previous HBV infection:
- Presence of anti-HBs and IgG anti-HBc
- Immunity from vaccine
- Presence of anti-HBs ONLY
Treatment:
- Refer to hematology or gastroenterologist who specializes in liver disease
Serologic Testing
- HBsAG (hepatitis b surface antigen)
- Appears in serum 1 to 10 weeks after exposure and typically resolves by 6 months (> 6 months implies chronic infection)
- anti-HBs (hepatitis B surface antibody)
- Generally present for life, implies long-term immunity (over time may disappear)
- HBcAG (hepatitis B core antigen)
- Can be detected through out the course of infection
- anti-HBc (hepatitis B core antibody)
- Appears at the onset of symptoms and persists for life
