Gastrointestinal Flashcards
symptoms which indicate need for endoscopy?
weight loss + anemia + heme-positive stool
achalasia px
- worsening dysphagia to BOTH solids & liquids
- “birds beak” on barium study
achalasia dx
-manometry = most accurate
- incomplete LES relaxation in response to swallowing
- increased resting LES pressure
- absent esophageal peristalsis
achalasia tx
- direct dilation of LES (not permanent)
- botulinum toxin injection –> relax LES (lasts 3-6 months)
- myotomy (remove muscle)
esophageal cancer px
- > 50YO
- dysphagia with solids THEN liquids
- associated with prolonged alcohol & tobacco use
- > 5 years of GERD symptoms
esophageal cancer dx & tx
- px: endoscopy
- tx: surgery, chemo, radiation
esophageal spasm px & dx
- px: sudden chest pain (nonexertional)
- dx: must rule out cardiac causes first (EKG, stress test)
- esophagram = best initial (corkscrew pattern)
- manometry = most accurate (abnormal contractions)
esophageal tx
- nitrates (relax smooth muscle)
- CCB (inhibits smooth muscle contraction)
dysphagia + CD4<100.. next step?
- tx with oral fluconazole (candida)
- continue HAART therapy
-no response to fluconazole –> endoscopy –> CMV or HSV (tx with ganciclovir vs acyclovir)
Plummer-Vinson syndrome px, dx & tx
- dysphagia due to esophageal webs
- Fe deficiency anemia
- glossitis
- dx: barium esophagram
- tx: iron replacement
Zenker’s diverticulum px, dx, tx
=outpocketing of posterior pharyngeal constrictor muscles
- px: dysphagia, halitosis, RUL PNA from chronic aspiration
- dx: barium esophagram
- tx: surgery
Mallory-Weiss tear is limited to ____
mucosa
Boerhaave’s syndrome px & tx
=esophageal rupture due to prolonged retching (alcoholics)
=full-thickness tear
- Hammen’s sign = crepitus
- tx: surgery (emergency)
epigastric pain + \_\_\_\_ =? worse with food better with food weight loss tenderness bad taste/cough/hoarse DB/bloating nothing
- gastric ulcer
- duodenal ulcer
- cancer, gastric ulcer
- pancreatitis
- GERD
- gastroparesis
- non-ulcer dyspepsia
epigastric pain dx
endoscopy
-direct visualization to differentiate ulcer from gastritis
epigastric pain tx
-PPIs = first line, empiric, 4 weeks (-prazole)
- H2 blockers (not as effective as PPIs) (-tidine)
- liquid antacids
- misoprostol = prostaglandin analogue (not as good as PPIs)
GERD symptoms =
heartburn + metallic taste + cough
GERD dx
- history
- 24 hour pH monitoring
GERD tx
- all: lifestyle changes (weight loss, avoid alcohol/nicotine, avoid spices, elevate head at bedtime)
- mild intermittent: liquid antacids, H2 blockers
- persistent: PPI 4-6weeks
- surgery: Nissen fundoplication = stomach wrapped around LES
- heat/radiation = last resort
columnar metaplasia in esophagus =
Barret’s esophagus
- can progress to cancer
- dx: biopsy via endoscopy
- tx: PPI
gastritis types, causes
- hemorrhagic vs non-hemorrhagic
- alcohol, NSAIDS, H pylori, portal HTN, stress (burns, trauma, sepsis), atrophic (vit B12 deficiency)
gastritis dx
EGD = esophoduodenoscopy
H pylori dx
- endoscopic biopsy = most accurate
- serology (lacks specificity)
- urea C13 or C14 breath testing (active infection; expensive)
- H pylori stool antigen (active infection)
PUD px and changes with eating?
- recurrent episodes of epigastric pain
- improved with eating: duodenal
- worse with eating: gastric
PUD dx & tx
dx:
-upper endoscopy
+biopsy
tx:
- H pylori –> PPI + clarithromycin/tetracycline + amoxicillin/metronidazole
- bleeding ulcer –> clip or epinephrine injection
- PPI
gastric ulcer associated with _____
cancer (4% of people)
-not associated with duodenal ulcer
non-ulcer dyspepsia tx
- PPI
- endoscopy: >45YO
Zollinger-Ellison Syndrome (gastrinoma) px
- large ulcers
- multiple
- past 3rd portion of duodenum
- diarrhea, abdominal pain, anemia, heme+ stools
-high gastrin despite secretin injection, high gastric output, PPI/H2
ZE syndrome tx
-exclude metastatic disease (somatostatin-R scintigraphy +endoscopic ultrasound)
- local removal
- metastasis –lifelong PPI
gastroparesis px
- px: n/v, early satiety, constipation
- dysmotility from an inability to sense stretch in GI tract
- “splash” over stomach
- cause: autonomic neuropathy from high glycemic index
- tx: erythromycin
variceal bleeding tx
- octreotide (somatostatin)
- urgent endoscopy + banding to control bleed
- TIPS: dec portal pressure if above 2 don’t work
-propranolol = prophylaxis against further bleeds
GI bleeding tx
- endoscopy: dx and tx with bands, cauterize, inject epi
- IV PPIs
- surgery –if fluids/blood/FFP do not control bleed
types of diarrhea
- lactose intolerance
- antibiotics
- malabsorption
- chronic pancreatitis
- carcinoid syndrome
antibiotic associated diarrhea dx
- dx: stool C. diff toxin = best initial
- C. diff PCR = most accurate
- tx: metronidazole
- vancomycin (oral) or fidaxomicin
oral vanc in antibiotic-associated diarrhea used when…?
2 failed tx with metronidazole
steatorrhea px & causes?
- oily, greasy, floating, foul smelling stools
- causes: Celiac’s, Whipple’s, chronic pancreatitis
vitamin B12 deficiency when…?
bowel wall is NOT intact
Celiac’s disease dx
- anti-tissue tranglutaminase = best initial
- small bowel biopsy = most accurate (flattening of villi)
- IgA antigliadin Ab, antiendomysial Ab
- dermatitis herpetiformis (10%)
-tx: avoid gluten
Whipple’s disease
- bacteria invade villi in small bowel
- px: malabsorption, arthralgias, ocular findings, neurologic, fever, lymphadenopathy
- dx: bowel biopsy = most accurate (PAS+ non-acid fast macrophage inclusion)
- tx: ceftriaxone or TMP-SMX
chronic pancreatitis dx
- abdominal CT, xray
- show calcifications
-secretin stimulation = most accurate
D-xylose
-tx: enzyme replacement
carcinoid syndrome px, dx, tx
-px: flushing, wheezing, tricuspid regurg, diarrhea
- dx: urinary 5-HIAA test (serotonin breakdown product)
- tx: octreotide (somatostatin stops bowel hormones)
IBS
irritable bowel syndrome
-diarrhea, constipation, both
- pain relieved by bowel movement, less at night
- dx of EXCLUSION
- no weight loss, blood/WBCs in stool
IBS tx
- fiber in diet
- antispamodic agents
- TCAs
- antimotility agents (loperamide for diarrhea, lubiprostone for constipation)
sclerosing cholangitis more common in UC or CD?
ulcerative cholitis
IBD dx
endoscopy
ANCA
(+)ulcerative colitis
(-)Crohn’s disease
ASCA
(-)ulcerative colitis
(+)Crohn’s disease
IBD acute tx for exacerbations
- steroids
- azathioprine & 6MP used to wean pts off steroids
diverticulitis px & dx
- occur where arteries meet mucosa (weak point)
- asymptotic until bleeding or infected
- dx: colonoscopy = most accurate
- CT of abdomen = best initial
diverticulitis tx
- antibiotics against E coli & anaerobes
- cipro + metronidazole, amox/clavulanate, ticracillin/clavulanate, pipercillin/tazobactam
-surgery for those who do not respond to medical tx
colon cancer screening
-50YO and every 10 years
- FHx: 10 years before family member’s onset OR 40YO
- every 10 years if fam >60YO; every 6 years if fam <60YO
hereditary nonpolyposis colon cancer px & screening
- px: 3 fam members, 2 generations, 1 premature (<50YO)
- screen: 25YO and every 1-2 years
familial adenomatous polyposis px & screening
- px: 1000s of polyps + APC gene mutation
- screen: 12YP and every year
acute pancreatitis px, dx, tx
- px: epigastric pain + n/v
- hypoCa, elevated LDH & AST
- dx: amylase & lipase = best initial
- CT scan = most specific
- tx: IV hydration, NPO, analgesia, PPIs
- add antibiotics if necrosis present >30%
SAAG score
serum ascites albumin gradient
1.1 = CHF, hepatic vein thrombosis, constrictive pericarditis
SBP
spontaneous bacterial peritonitis
- infection without bowel perforation
- E coli, Pneumococcus, anaerobes, gram(-) bacilli
- dx: fluid culture = most accurate
- tx: ceftriaxone or cefotaxime
cirrhosis-induced encephalopathy tx
lactulose, neomycin, or rifaximin
cirrhosis-induced varices tx
- propranolol
- banding via endoscopy
binge drinking causes a rise in _____
GGTP (sudden)
primary biliary cirrhosis
“fat, forty, female”
- px: fatigue, normal bilirubin, elevated alk phosphate
- xanthelasma/xanthoma, osteoporosis
- dx: liver biopsy OR antimitochondrial Ab = most accurate
- tx: ursodeoxycholic acid
primary sclerosing cholangitis
- px: pruritis, elevated alk phosphate/GGTP/bilirubin
- dx: ERCP
- tx: cholestyramine, ursodeoxycholic acid
alpha 1-antitrypsin deficiency
liver disease + emphysema
- young, nonsmoker
- tx: replace enzyme
hemochromatosis px
amenorrhea erectile dysfunction fatigue joint pain (pseudogout) DB cardiomegaly skin darkening
“bronze DB”
-dec TIBC, inc ferritin
Wilson’s disease px
- dec ceruloplasmin
- px: psychosis, tremor, dysarthria, ataxia, seizures
- Coombs negative hemolytic anemia
- RTA, nephrolithiasis
- Kayser-Fleischer rings
Wilson’s disease tx
- penicillamine –chelates copper and removes it
- zinc: interferes with Cu absorption
autoimmune hepatitis
- microsomal antibodies
- anti-smooth muscle antibodies
-tx: prednisone, azathioprine
