GastroIntestinal Flashcards
Know G.I.
Dysphagia
Difficulty swallowing
Odynophagia
Pain with swallowing
Esophageal Webs
- Associated with Iron Deficiency Anemia
- Glossitis
(Plummer-Vinson Syndrome)
Dysphagia
Dx
Esophageal Dysphagia:
- Barium Swallow followed by
- endoscopy
If obstructive lesion shows then BIOPSY
Diffuse Esophageal Spasm
Motility disorder which normal peristalsis is periodically interrupted by high amplitude nonperistaltic contractions
Diffuse Esophageal Spasms
HX / PE
- Chest Pain
- Dysphagia
- Odynophagia
- Precipitated by ingestion of hot or cold liquids
- relieved by nitroglycerin
Diffuse Esophageal Spasms
Dx & Tx
Dx- Barium Swallow (cork screw esophagus)
Tx- Nitrates and CCB’s
- Surgery for SEVERE problems
Achalasia
Impaired relaxation of lower esophageal sphincter (LES)
Achalasia
Hx / PE
- Progressive dysphagia
- Chest pain
- Regurgitation of undigested food
- Weight loss
- Nocturnal cough
Achalasia
Dx
1st- Barium Swallow : shows dilation, “birds beak”
- Manometry shows increase resting LES pressure
Achalasia
Tx
Nitrates
CCB’s
Inject botulinum into LES
Pneumatic balloon dilation or surgical myotomy
Esophageal Cancer
- Squamous Cell Carcinoma (SCC) is most common.
- Adenocarcinoma is most prevalent in USA (Barrett’s Esophagus)
Esophageal Cancer
Hx / PE
- Progressive dysphagia (solids first then liquid)
- Weight Loss
- GERD
- GI Bleeding
Esophageal Cancer
Dx
1st- Barium Study
2nd- Biopsy confirms
- CT and Endoscopic used for staging
Esophageal Cancer
Tx
- ChemoRadiation and surgical resection if definitive tx
- Prognosis is poor
Cancer Metastasizes early because esophagus lacks a serosa
GastroEsophageal Reflux Disease (GERD)
Reflux of gastric contents into the esophagus
- from transient LES relaxtion
- due to incompetent LES, Gastroparesis or Hiatal hernia
GERD
Dx
Hx and Clinical impression
- Trial of lifestyle modification and tx attempted first
- Studies maybe a Barium Swallow to look for Hiatal hernia
- EGD with biospy should be done in pt with symptoms unresponsive to initial therapy
GERD Tx
Liftstyle Change
- Weight loss
- Head of bed elevation
- Reduce meal size
- Avoid Noctural meals
Pharm
- Antacids
- H2 antagonists (cimdetidine) or PPI (omeprazole) in chronic and frequent symptoms
- Surgical (Nissen Fundoplication) for SEVERE disease
GERD Avoid what types of food
- Caffeine
- Alcohol
- Chocolate
- Garlic
- Onions
- Mints
- Nicotine
Hiatal Hernia
Herniation of a Portion of stomach upwards into the chest through a diaphragmatic opening
- Sliding (95%)- Gastroesophageal junction and portion of stomach displaced above diaphram
- Paraesophageal (5%)- Gastroesophgeal remains below diaphram, but portion of fundus goes into mediastinum
Hiatal Hernia
Dx / PE
May be asymptomatic
Sliding may present with GERD
Hiatal Hernia
Dx a& Tx
Dx- Commonly incidental finding on CXR
- DX by Barium Swallow or EGD
Tx-
Sliding- Medical Therapy and life style mods
to decrease GERD
Paraesophageal- Surgical gastropexy (Attach stomach to rectus sheath and closure of hiatus)
Gastritis
Inflammation of the stomach lining
Gastritis
Subtypes (3)
Acute: rapid develop
- Due to NSAIDS
- Alcohol
- H. Pylori
- Stress
Chronic Type A (10%)
- Occurs in Fundus
- Due to Autoantibodies of parietal cells
- causes Pernicious anemia
Chronic Type B (90%)
- Occurs in Antrum
- Due to NSAIDS or H. Pylori
Gastritis
Hx / PE
Maybe Asymptomatic
- epigastric pain
- Nausea
- Vomiting
- Hematemesis
- Melena
Gastritis
Dx
Upper Endoscopy visulizes gastric lining
H. Pylori detect by Urease Breath Test
- IgG indicates exposure
Gastritis
Tx
- Antacids, H2 blockers, PPI
- Triple Therapy
(Amoxicillin, Clarithromycin, Omeprazole) - Prophylactic H2 or PPI for risk of stress ulcers
Gastric Cancer
Tumors generally Adenocarcinoma
2 types
- Intestinal: arises by H. pylori
- Diffuse- Signet Sing Cells seen
Gastric Cancer
Hx / PE
Early Signs
- Indigestion
- Loss Appetite
Advanced
- Ab pain
- Weight loss
- Upper GI bleed
Gastric Cancer
Dx & Tx
Early
- discovered serendipitously with endoscopic exam
Tx- successful tx rests on early detection and surgical removal
5 year survival rate <10% in advanced disease
Peptic Ulcer Disease (PUD)
Damage to gastric or duodenal mucose
caused by impaired mucosal defense and/or gastric contents
PUD
Hx / PE
Duodenal Ulcers
- Dull
- Buring epigastric pain
- Improves with means
Gastric
- Pain right after meals
- “Coffee ground emesis)
- Blood in stool
Gastric Cancer
Has Virchow’s Node
what is it located
Enlarged Left SupraClavicular Lymph Node
PUD
PE
- Exam reveal epigastric tenderness
- Stool guaiac
- Acute perforation can present with rigid abdomen
- rebound tenderness
- Guarding
- peritoneal irritation
PUD
DX
- AXR rule out perforation (free air under diaphram)
- CBC assess for GI bleed (Low hematocrit)
- Upper Endoscopy with biopsy to confirm PUD
- H. Pylori test
PUD
Tx
Acute
- rule out active bleed with Serial Hematocrits
- Rectal exam with stool guaiac
- Monitor B.P.
- Perforation- SURGICAL
Pharm
- Protect Mucosa
Mild
- Antacids
- Misoprostal for mucosal production
- Pt with H. Pylori (give triple antiobiotics)
- Dicontinue exacerbating agents
Endoscopy and Surgery
- Symptoms for > 2 months and refractory
Diarrhea
4 etiologic mechanisms?
Production of > 200 g of feces per day along with increase frequency or decrease consistency of stool
4 etiologic mechanisms
- Increase motility
- Increase Secretion
- Increase luminal osmolarity
- Increase inflammation
Diarrhea
He / PE
Acute
- < 2 weeks of symptoms
- usually infectious and self limited
Preformed Toxins
- S. Aureus
- Bacillus
Non-invasive
- E-coli
- Vibrio
- C. Difficle
Invasive - Enteroinvasive E-Coli - Salmonella - Singella Campylobacter
Parasite
- Giardia
- Entamoeba Histolitica
Peds
- Rotavirus (common during winter)
Chronic Diarrhea
Insidious onset
>4 week of symptoms
Due to increase secretion (carcinoid, vipoma)
Malabsorption/osmotic
- Bacterial overgrowth
- Pancreatic insufficiency
- lactose intolerance
Inflammatory Bowel Disease
Diarrhea
DX
Acute
- No lab required
- No investigation unless high fever, blood and > 5 days
- Consider SIGMOIDOSCOPY in patients with bloody diarrhea
Diarrhea
TX
Acute
- no bacterial infection
- treat with antidiarrheal (loperamide) and ORAL rehydration
Chronic
- Identify underlying cause
- tx symptoms
- loperamide
- opioids
Peds
- Hospitalize
- IV fluids
- repleate Electrolytes
Carcinoid Syndrome
Due to liver metastasis of Carcinoid Tumors
Arise from Ileum and Appendix
Produce vasoactive substances like serotonin and substance P.
Carcinoid Syndrome
HX / PE
- Cutaneous flushing
- Diarrhea
- Ab cramps
- Wheezing
- Right sided valvular heart lesions
Carcinoid Dx
High urine levels of
5-HIAA (serotonin Metabolite)
Carcinoid Tx
Octreotide (for symptoms)
Debulking of tumor mass
Small Bowel Obstruction (SBO)
Blocked passage of bowl contents through the small bowel.
Leading to fluid and electrolyte imbalances, ab discomfort
Obstruction can be
- Complete
- Partial
&
- Ischemic
- Necrosis
SBO
occur due to what?
- Adhesions (60%)
- Hernia (20%)
- Neoplasms (20%)
- Intussusception
- Gallstone Ileus
- Stricture
SBO
HX / PE
- Cram ab pain with crescendo-decrescendo pattern 5 - 10 min intervals
- Vomiting
- Partial (no stool but has faltulance)
- Complete (no stool or flatulance)
- Bowel sounds: high pitch tinckles
SBO
DX
CBC
- Leukocytosis (if ischemic or necrosis)
Labs
- Dehyration
- Metabolic Alkalosis (due to vomit)
- Lactic Acidosis (necrotic bowel)
AXR
- Stepladder pattern of dilated small bowel loops
- Air fluid levels
Children
- Hernia
Adults
- Adhesions
SBO
Tx
Partial
- Supportive care
- NPO
- NG suction
- IV hydration
- Correct electrolytes
- Foley Cath to monitor fluid
Surgery
- required of complete SBO
- Vascular compromise
- > 3 days without improvements
Ileus
Loss of peristalsis without structural obstruction
Ileus
Risks
- Recent surgery
- Recent GI procedure
- Severe Medical Illness
- Immobility
- Hypokalemia
- Hypothyroid
- DM
- Meds that slow GI motility
Ilieus
Hx / PE
Symptoms
- Diffuse, constant, moderate ab discomfort
- N/V, especially with eating
- Absence of flatulence or BM
Exam
- Tenderness
- Ab distention
- No peritoneal signs
- Decrease or abscent bowel sounds
Ilieus
Dx & Tx
- Distended loops of small and large bowel on supine AXR with airfluid levels on upright view
Tx
- Discontinue meds
- Temporary discontinue oral feels
- Initiate NG suction
- Replete Electrolytes
Mesenteric Ischemia
Decrease blood supply leading to insufficient perfustion to intestinal tissue and ischemic injury
Mesenteric Ischemia
HX / PE
- Severe ab pain out of proportion to the exam
- Older people
- Ab exam is unremarkable
- N/V/D
- Bloody stools
Mesenteric Ischemia
Dx / Tx
Dx
- Leukocytosis
- Metabolic Acidosis with
- increase lactate
- Increase amylast
- Increase LDH and CK
Tx
- Volume resuscitation
- Broad spectrum antibiotics
- Avoid vasoconstrictors
- Anticoagulation
Diverticular Disease
Outpouching of mucosa and submucosa that herniate through the colonic muscle layers of high intraluminal pressure.
Found in Sigmoid most common
Diverticulosis
Seen mostly in what age?
Risks?
- > 40
- Most common cause of acute lower GI bleed
Risks
- Low fiber
- high fat diet
Diverticulitis
Inflammation and potentially perforation of diverticulum secondary to fecalith impaction
Diverticular
HX / PE
Diverticulitis HX/PE?
HX
- Often asymptomatic
- Bleeding is painless and sudden
Diverticulitis
- LLQ ab pain
- Fever
- N/V/C
Diverticulum
DX & TX
Dx
CBC
- Leukocytosis
- AXR
Tx
Uncomplicated Diverticulosis
- Followed up and given high fiber diet
Diverticular Bleed
- Bleeds stop spontaneous
- Transfuse and rehydrate as needed
Diverticulitis
- Bowel Rest (NPO)
- NG tube
- Broad Spectrum Antibiotics (Metronidazole and Quinilone or 2-3 gen ceph)
AVOID Sigmoidoscopy’s
Colon Cancer
Second leading cause of cancer mortality in the USA after lung Cancer
Increase incidence with Age
Peak incidence @ 70 y/o
Colon Cancer
HX / PE
Hx Right sided lesions - Often bulky - Ulcerating masses - Weight loss - Anorexia - Diarrhea - Vague Ab Pain
Left- Sided
- Apple core
- Obstructing mass
- Change in bowel Habits
- Colicky Ab pain
Colon Cancer
Dx
- CBC
- Sigmoidscopy (Evaluate rectal bleed and left sided lesions)
- Colonoscopy (right sided lesions)
- Determine degree of invasion in Rectal Canacer with endorectal u/s
Metastatic Workup
- CXR
- LFT
- AB/Pelvic CT
Colon Cancer
Tx
- Surgical Resection
- Reginal Lymph node resection for staging
- Adjuvant Chemo
- used in colon cancer with + lymph nodes
- Follow with serial CEA
Ischemic Colitis
Lack of arterial blood supply to the colon
Severity ranges from superficial to full thickness necrosis
Ischemic Colitis
Most common affected
- Splenic Flexure (watershed area)
Ischemic Colitis
Hx / PE
- Crampy
- Lower ab pain
- Bloody Diarrhea
Ischemic Colitis
DX and Tx
Dx
CBC
- Leukocytosis
- Sigmoidoscopy or colonoscopy to assess colonic mucosa
Tx
- Bowel Rest
- IV
- Broad spectrum Antibiotics
- Surgery with resection indicated for infarction
Inguinal Hernia’s
Abdormal protrusions of Abdominal contents (usually small intestine) into the inguinal region.
- Direct
- Indirect
Based on their relationship to inguinal canal
Indirect Hernia
Herniation of abdominal contents through the internal and then external inguinal rings and into the scrotum.
MD don’t LIE
Due to congential patent processus vaginalis
- Lateral to Inferior epigastic vessel
Direct hernia
Herniation of abdominal contents through floor of Hesselback’s triangle
- Protudes MEDIAL to epigastic vessel
MD don’t LIE
Hernial sac contents do not transverse the internal inguinal ring. Stay in external oblique muscle
- Acquired defect in transversalis fascia from mechanical breakdown through age
Hernia Tx
Risk of Incarceration and Strangulation Surgical management indicated unless specific contraindications.
Hesselback’s Triangle
- Inguinal ligament
- Inferior epigastric artery
- Rectus Abdominis
Triangle of Calot
What passes through structure
- Cystic Artery
traingle made up of
- Common hepatic duct
- Cystic Duct
- Inferior border of liver
Abnormal Liver Disease
3 patterns
Hepatocellular Injury
- Increase AST and ALT
Cholestasis
- Increase Alkaline phosphatse and Bilirubin
Isolated Hyperbilirubinemia
- Increase bilirubin
Jaundice- seen in all 3, shows up when bilirubin >2.5 mg/dL
Hepatitis
Inflammation of the liver leading to liver cell injury and necrosis
Cause of Acute Hepatitis
Virus (HAV, HBV, HCV)
Drugs (alcohol, acetaminophen, INH)
Causes of Chronic Hepatitis
Virus (HBC, HCV, HDV)
Alcoholic Hepatitis
Autoimmune Hepatitis
Hereditary (Wilsons, Hemochromatosis)
HAV and HEV
Transmitted?
Fecal-Oral Route
HBV and HCV
Transmitted
Bodily Fluids
Risk of acquiring HCV sexually is very low
Hepatitis
HX / PE
Hx
- Nonspecific Symptoms
- N/V
- Joint pain
- Malaise
- Fever
- Jaundice and RUQ tenderness
Exam
- Jaundice
- Scleral Icterus
- Tender Hepatomegaly
- Lymphadenopathy
Hepatitis
DX
- Increase in AST and ALT
- Increase Bilirubin / Alkaline Phosphatase
Chronic Hep
- ALT and AST increased >6 months
Diagnosis
- Hepatitis serology
Hepatitis
TX
Alcoholic
Immunosuppressive
Steroids for Alcoholic Hepatitis
Immunosuppression and steroids for Autoimmune
- Liver transplant for end stage liver failure
- IFN, Lamivudine for chronic HBV
- Peginterferon and Ribavirin HCV
Cirrhosis
Fibrosis and nodular regeneration resulting in hepatocellular injury.
Cirrhosis
Hx / PE
Presents with:
- Jaundice
- Ascites
- Bacterial Peritonitis
- Hepatic Encephalopthy
- Gastroesophageal Varices
- Renal Dysfunction
Exam:
- Enlarged, palpable or firm liver
- Portal HTN
Cirrhosis
DX
- Decrease Albumin
- Increase PT/PTT
- Increase Bilirubin
Abdominal U/S/
- Assess liver size
- Ascites
- Patency of splenic and hepatic veins
Cirrhosis
Tx
Ascites:
- NA restriction and Diuretics
- Rule out infections and neoplastic causes
Spontaneous Bacterial Peritonitis
- Fever
- Ab pain
- Altered Mental Status
- Check Peritoneal fluid
Fluid + if >250 PMNs/Ml or >500 WBC
- Treat IV antibiotics (3rd Gen Ceph)
Hepatorenal Syndrome
- Diagnosis of exlusion
- Needs Dialysis
Hepatic Encephalopathy
- Due to decrease clearance of ammonia
- Tx with protein restriction
- Lactulose
- Rifaximin
Primary Biliary Cirrhosis
Autoimmune disorder characterized by:
- destruction of intrahepatic bile ducts
- Middle aged women with other autoimmune disorders
Primary Biliary Cirrhosis
DX / PE
Presents:
- Progressive jaundice
- Pruritis
- Malabsorption of Fat Soluable
Primary Biliary Cirrhosis
Dx and Tx
Dx
- Increase Alkaline Phosphatse
- Increase Bilirubin
- anti-Mitochondrial Antibody
- Increase Cholesterol
Tx
- Ursodeoxycholic Acid (slows diease)
- Cholestyramine (pruritis)
- Liver Transplant
Hepatocellular Carcinoma
Risk Factors
- Cirrhosis
- Chronic Hepatitis (HCV)
- Aflatoxins
- HBV inections
Hepatocellular Carcinoma
HX / PE
Presents
- RUQ Tenderness
- Ab distention
- Signs of chronic liver diesase
- Jaundice
- Easy Bruise
- Coagulopathy
PE
- Enlarged liver
Hepatocellular Carcinoma
DX & TX
Dx
- U/S or CT
- Liver Biopsy Definitive Diagnosis
Tx
- Small Tumors
- Aggressive Tumor resection
- Orthotopic liver transpantation
Chemo and Radiation NOT effective
- Monitor recurrence with serial AFP leverls
Hemochromatosis
Hyperabsorption of Iron with parenchymal hemosiderin accumulation in the liver, pancreas, heart, adrenals, testes, pituitary, and kidneys
Hemochromatosis
is what type of recessive disease
Autosomal recessive
Can be seen in Alcoholics as well, since alcohol increase iron absorption
Hemochromatosis
Hx / PE
Presents:
- Ab pain
- Symptoms of DM
- Hypogonadism
- Arthropathy of MCP joints
- Heart Failure
- Cirrhosis
Exam: - Bronze Skin - Pancreatic dysfunction - Cardiac Dysfunctoin - Hepatomegaly _ Testicular Atriphy
Hemochromatosis
DX
- Increase serum Iron
- Decrease Serum Transferrin
- TRANSFER SATURATION most SENSITIVE
- Glucose intolerence
- LIVER BIOPSY
- Hepatic MRI
Hemochromatosis
TX
- Weekly phlebotomy (ever 2-4 months)
- Deferoxamine
Wilson’s Disease
Hepatolenticular Degeneration
- Decrease Ceruloplasmin
- Excessive deposition of Copper in liver and brine
- AR on Chromosome 13
- < 30
Wilson’s Disease
Hx / PE
Hx
- present with Hemolytic Anemia
- Liver Abnormalities
- Neurologic
- Psychiatric abnormalities
PE
- Kayser-Fleischer Rings (Green to brown deposits of copper)
Wilson’s Disease
Dx & Tx
- Decrease Serum Ceruloplasmin
- Increase urinary copper excretion
- Increase hepatic copper
Tx
- Dietary Copper restriction (avoid liver, shell fish)
- Penicillamine
Wilson’s ABCCCD
Asterixis Basal Ganglia Deterioration Ceruloplasmin Decrease Cirrhosis Copper Increase Carcinoma of Liver Choreiform movements Dementia
Pancreatic Cancer
Risks
what part of the pancreas
75% are adenocarcinom of the head of the pancreas
Risks
- Smoking
- Chronic Pancreatitis
- 1st degree relative with Pancreatic cancer
- High fat diet
Pancreatic Cancer
Hx / PE
Presents
- Ab pain radiates toward back
- Obstructive jaundice
- Loss of apetite
- N/V
- Weight loss
- Indigestion
- Asymptomatic
EXAM:
- palpable nontender gallbladder (Courvoisier’s Sign)
- Migratory thrombophlebitis (Trousseau’s Sign)
Pancreatic Cancer
DX & Tx
Dx
- CT to detect Mass
- If NO mass use ERCP
- CA 19-9 elevated
Tx
- Treatment is Palliative
- 20% have no metastasis use Whipple procedure
- Chemo with 5-FU and Gemcitabine may improve short term survival (5-10% survival 5 years)
Ranson’s Criteria
On Admission
“GA LAW”
Glucose >200 mg/dL Age >55 LDH >350 AST >250 WBC >16 000
Ranson’s Criteria
After 48 hr
C HOBBS
Ca < 60 mmHg
Base excess >4
BUN increase by 5
Sequestered fluid >6L
Ranson’s Criteria
How it works
Ranson’s predicts mortality associated with acute pancreatitis.
20% with 3-4 signs
40% with 5-6 signs
100% with >7 signs
Cholelithiasis & Biliary Colic
Risks
Colic results from Tansient cystic duct blockage from impacted stones
Risks- 4 F’s
- Fat
- Female
- Fertile
- Forty
Cholelithiasis & Biliary Colic
Hx / PE
Presents
- Postprandial ab pain (RUQ) and radiates to the right subscapular area or Epigastrium
- Pain Abrupt followed by gradual relief
- N / V
- Fatty Food intolerance
- Dyspepsia
- Flatulence
PE
- 80% asymptomatic
- Exam RUQ tenderness
- Palpaple gallbladder
Cholelithiasis & Biliary Colic
Dx and Tx
Dx
- RUQ U/S
Tx
- Cholecystectomy curative
- Asymptomatic needs nothing
Patients may need
- Endoscopic Retrograde Cholangiopancrreatograpthy (ERCP) for common bile duct stone
Choledocholithiasis
Gallstone in Common Bile DUCT
Symptoms vary according to degree of obstruction
Choledocholithiasis
Hx / PE & Tx
Hx
- Presents with
- Biliary colic
- Jaundice
- Fever
- Pancreatitis
- Increase Alkaline Phosphatse
- Increase Total Bilirubin
Tx
- ERCP and Cholecystectomy
