Gastrointestinal Flashcards
Normal resting pressures of the LES, intra-thoracic cavity, and intra-abdominal cavity:
LES: 15 - 25 mmHg
Intra-thoracic: -5 mmHg
Intra-abdominal: 5 mmHg
Which is MC mechanisms with severe esophagitis: weak LES or transient relaxation?
Transient relaxation
Typical characteristics of GERD:
Heartburn, post-prandial, worse when horizontal, relieved by antacids, regurgitation, dysphagia, globus sensation
Atypical characteristics of GERD:
Chest pain, pulmonary sx (asthma/cough/bronchitis/aspiration pneumonia), ENT (laryngitis, hoarseness, sore throat)
GERD alarm symptoms:
Dysphagia/odynophagia, anemia, weight loss, blood in stool
Possible complications of GERD:
Ulceration, stricture, hemorrhage, Barrett’s esophagus
Test used to evaluate GERD that observes mucosal damage
Endoscopy
Test used to evaluate GERD that focuses on dysphagia
Barium esophagram
Test used to evaluate GERD where reflux is documented and correlated with symptoms
24 hour pH monitoring
Test used to evaluate GERD that focuses on LES pressure and peristalsis
Esophageal manometry
Differential diagnosis when patient with GERD comes in with CP:
CAD, biliary, peptic, esophageal motor disorders, esophagitis, pancreatic dz, malignancy, functional
Lifestyle modifications when treating GERD:
Elevate head while sleeping, weight management, eliminate tobacco/alcohol/late night eating/fatty foods/chocolate/peppermint
For GERD considerations, some drugs that decrease LES pressure:
Progesterone, theophylline, anticholinergics, B-agonists, a-agonists, diazepam, meperidine, Ca channel blockers
For GERD considerations, some drugs that may cause pill-induced esophageal injury:
Tetracycline/doxycycline, quinidine, KCl, Iron salts, NSAIDs
When does a patient with GERD become a surgical candidate?
When they don’t respond to medical therapy well, if they don’t want to be on long-term tx, they’re non-compliant with meds, they have high grade esophagitis, or a large hiatal hernia
Three etiologies of esophageal related chest pain:
GERD
Motility disorder
Hypersensitive esophagus
Five types of esophageal motility disorders in decreasing prevalence:
Nutcracker esophagus Non-specific motility disorder Diffuse spasm Hypertensive LES Achalasia
Difference between oropharyngeal dysphagia and esophageal dysphagia:
Oropharyngeal is the inability to initiate a swallow whereas esophageal dysphagia is sensation of food getting stuck
Alarm symptoms with dysphagia include:
Weight loss
Nausea, vomiting, hematemesis
Tobacco and alcohol use
Family hx of GI malignancy
Some neurogenic or myogenic etiologies for dysphagia:
ALS CVA Mysasthenia gravis Parkinson Muscular dystrophy
Some structural disorders as etiologies for dysphagia:
Cervical ostophytes, cricoid web, zenker’s diverticulum, thyromegaly
Risk factors for esophageal cancer:
Alcohol/tobacco Nitrosamine Vitamin deficiencies Achalasia HPV GERD/Barrett's Obesity
Dysphagia as a result of an esophageal web or shatzki ring in association with iron deficiency is criteria for what syndrome?
Plummer Vinson
Painful dysphagia that is a result of uncoordinated esophageal contractions is termed _____ _____ ______ and is diagnosed with manometry
Diffuse esophageal spasm
Dysphagia in patients with atopy
Eosinophilic esophagitis (15 eos per hpf)
Odynophagia reflects an inflammatory process in the esophageal mucosa. MC etiologies: (4)
Infectious
Pill-induced
Post-radiation
Motility
Medications that commonly cause pill-induced esophageal mucosal inflammation (odynophagia):
Tetracyclines Iron Bisphosphonates Potassium NSAIDs
The emetic reflex has multiple receptors:
5-HT3 serotonin receptor
Histamine H1/muscarininc M1 receptors
Neurokinin-1 receptor
Where are 5-HT3 receptors located? What is the action of activating them?
Throughout the CNS. Release of dopamine stimulates D2 receptors in the emetic center
Where are H1/M1 receptors located? What is their effect?
Throughout the CNS. Results in vertigo.
Where are neurokinin-1 receptors located? What is their effect?
Solitary nucleus where they bind substance P. Nausea, vomiting.
Gastroparesis can cause vomiting that occurs when?
Outside the immediate postprandial period
Acute vomiting that occurs in the morning in an adult female patient is grounds for what test?
Urine hCG (pregnancy test)
What tests, other than a urine hCG, should be administered in a patient with acute vomiting?
CBC, BMP, TSH
Glucose
Amylase and lipase
What are the anti-emetics in each of the following categories? 5-HT3 antagonists Corticosteroids Prokinetic agents Benzos
5-HT3 antagonists: Ondansetron (Zofran)
Corticosteroids: Dexamethasone
Prokinetic agents: Metoproclamide
Benzos: Lorazepam
Patient with CHF c/o abdominal pain and labs show low K. PE no bowel sounds. Diagnosis?
Ileus/Gastroparesis
The delineation between an upper GI bleed and a lower GI bleed is this anatomical structure
Ligament of trietz
How much of a change in pulse and SBP does one expect with a loss of 1L blood? (>20% total blood volume)
Pulse increase 20bpm, SBP decrease 10 - 15 mmHg
A patient that comes in with a GI bleed should be subjected to the following tests:
H/H
Platelets
Coag factors
Type, screen, cross
Some criteria for transferring GI bleed patients to ICU if hemodynamically unstable:
Shock Orthostatic Decrease in Hct by 6% Requiring >2 units PRBCs Actively bleeding
Transfusions involved in the resuscitation of a GI bleed patient might include:
PRBCs
Iron
Platelets
FFP + Vit K
An upper GI bleed results in hematemesis with:
BRB or coffee grounds
Black, tarry, foul smelling stool caused by at least 50cc of blood in GI tract =
Melena
Maroon or BRB per rectum indicates rapid bleed, is called
hematochezia
With a GI bleed, BUN:Cr will show
> 36
Once a GI bleed patient is stable, the next procedure is:
Esophagogastroduodenoscopy
In patients with esophageal varices, bleeding stops spontaneously in __% of cases but has a __% mortality rate if bleeding continues
50% stops
70% mortality
In patients with esophageal varices, this somatostatin analogue may be given to decrease portal flow via a vasoconstrictive effect and by inhibiting glucagon
Octreotide
Abnormally large, tortuous artery that approaches upper gastric mucosa and is subject to bleed when eroded.. Good prognosis.
Dieulafoy’s lesion
Ectatic vessels that run along the rugal folds that bleed and run down between the folds, has the appearance of a watermelon pattern upon endoscopy
Gastric Antral Vascular Ectasia
A stool weight grater than ____g/d can be considered diarrheal.
200 g/d
Diarrhea is considered acute when duration is:
Persistent duration:
Chronic duration:
Acute: 4 wks
The following are key features in which type of diarrhea?
High output
Persists during fasting
Minimal osmotic gap
Secretory`diarrhea
E. coli enterotoxin, laxatives, intestinal resection, and neuroendocrine tumors such as gastrinomas, carcinoid tumors, medullary thyroid carcinoma, and pancreatic cholera syndrome all cause which type of diarrhea?
Secretory diarrhea
The following are key features of which type of diarrhea?
Moderate volume of stool Improves when oral intake stops Watery/soft stool Associated with flatus if carb malabsorption No WBCs or RBCs in stool
Osmotic diarrhea
Magnesium salts, certain sugars (lactulose, sorbitol, mannitol, fructose, lactose), malabsorption of certain carbs, and generalized malabsorption all might cause which type of diarrhea?
Osmotic diarrhea
Multiple mechanisms for inflammatory diarrhea:
Inhibited absorption
Stimulation of enteric nerves
Mucosal destruction
Malabsorption
The following are key features of which type of diarrhea?
Small to moderate volume Blood WBC/RBC Abdominal pain Tenesmus
Inflammatory diarrhea
Three common causes of infectious inflammatory diarrhea:
Salmonella
Shigella
Campylobacter
Two classifications of inflammatory bowel disease (that can result in an inflammatory diarrhea)
Crohn’s
Ulcerative colitis
Post-vagotomy, post-gastrectomy, carcinoid syndrome, hyperthyroidism, diabetes, and IBS all may cause which type of diarrhea?
Motility disorder-related diarrhea
What is a normal stool osmotic gap?
Between 50 and 100 mOsm/kg
A high osmotic gap is reflective of what type of diarrhea?
Osmotic diarrhea
A low osmotic gap is reflective of what type of diarrhea?
Secretory
What types of things should one ask about with regard to diarrhea?
Duration Color Odor Travel Meds Food intake
What is the most common type of gallstone? Who is most at risk for these?
Cholesterol
Women, >40, obese, pregnant
Cirrhosis, chronic hemolysis, and alcohol may all result in what type of gallstone?
Black pigment stones (calcium bilirubinate)
What type of gallstone is most common with infection?
Brown pigment stones (calcium salts of fatty acids and unconjugated bilirubin)
Poorly localized RUQ/epigastric pain radiating to right scapula that is steady, precipitated by food, associated with dyspeptic complaints, and does not last more than 6 hours is indicative of:
Biliary colic
RUQ pain radiating to scapula accompanied by nausea and vomiting and lasts longer than 6 hours.
Acute cholecystitis
Pain and inspiratory arrest with palpation of right subcostal region is called
A positive Murphy’s sign
What will be seen in labs for choledocholithiasis?
Hyperbilirubinemia
Elevated alk phos
Transaminitis
Hyperamylasemia/hyperlipasemia
What imaging studies are useful in the diagnosis of choledocholithiasis?
Ultrasound (stone, duct dilitation) Endoscopic Ultrasound MRCP ERCP PTC
An imaging study that is the gold standard for diagnosing CBD stones and is therapeutic as well as diagnostic.
Endoscopic Retrograde Cholangeopancreatography
When ERCP is unavailable, what imaging study can be used in place of it?
Percutaneous Transhepatic Cholangiography
Cholangitis typically presents with Charcot’s triad of symptoms:
Pain, jaundice, fever
The set of symptoms of cholangitis that is accompanied by septicemia includes charcot’s triad with altered mentation and hypotension and as a whole are called
Reynold’s pentad
Three major characteristics of cholangiocarcinoma
Elderly patient
Painless jaundice
Weight loss
Primary sclerosing cholangitis is commonly associated with what two conditions?
Inflammatory Bowel Disease (specifically ulcerative colitis)
and colon cancer
What percentage of people develop necrotizing disease with pancreatitis?
10 - 20%
MC symptoms of pancreatitis:
Upper abdominal pain that radiates to back and improves with leaning forward and is tender to palpation, anorexia, nausea/vomiting
Indicators that may be observed at the bedside in pancreatitis:
Tachycardia/hypotension, tachypnea/hypoxemia, oliguria, hemoconcentration, Gray Turner/cullen signs
48 hour criteria for pancreatitis (Ranson’s Criteria):
Ca, Hct decrease, O2, BUN increase, base deficit, sequestration
Ca++ 10% decrease, O2 5mg/dL, Base deficit > 4mEq/L, Sequestration > 6L
BISAP score for pancreatitis:
BUN >25 Impaired mental status SIRS > 2 Age > 60 Pleural effusion
Common drug-induced causes for pancreatitis:
Azathioprine, 6-MP (Crohn's) Didanosine Valproate Pentamidine Asparaginase Acetaminophin
Drug induced pancreatitis mnemonic SALTER
Sulfa/salicylates Azathioprine Lasix Thiazides/tetracyclines Epileptic meds Rifampin
Management for pacreatitis focuses on:
Fluid levels, pain, nutritive supplementation
What frequency of bowel movement is considered constipation?
The presence of diverticula is termed
Diverticulosis
The presence of a microperforation in a diverticulum is termed
Diverticulitis
Most diverticula are found in the
sigmoid colon (90%)
In a patient with diverticulosis, the presence of LLQ pain that is worse with eating and better with BM, with no blood in stool, the disease is:
Symptomatic and uncomplicated
The difference between symptomatic uncomplicated diverticular disease (SUDD) and acute diverticulitis:
Diarrhea or constipation with FEVER and elevated WBC count (stool still negative for blood)
What imaging modality is used to make the diagnosis of diverticulitis?
CT with oral and IV contrast
How are patients with acute uncomplicated diverticulitis managed?
NPO 24 - 28 hours IVF Abx (cipro, metro, ampicillin, sulbactam) F/U colonoscopy 6 - 8 wks Consult surgery after 2 episodes
What sorts of complications may form with diverticulitis?
Abscess formation
Peritonitis
Fistula
Obstruction
Diverticular bleeding presents with hematochezia/BRB per rectum that is
painless, self-limiting
What should be a differential diagnosis if a patient comes in with diverticular bleeding?
Angiodysplasia
The ROME criteria for IBS requires symptom onset 6 months prior to diagnosis as well as the presence of recurrent abdominal pain/discomfort for at least _ days/months over the course of _ months and associated with:
3, 3
Improvement with defecation
Onset associated with change in freq of stool
Onset associated with change in appearance of stool
The C, D, and M classifications of IBS stand for
Constipation
Diarrhea
Mixed
The Bristol Stool Scale ranges from 1: ________ to 7: _______
1: hard pellets
7: liquid
Red flags for IBS include:
Anemia, fever, persistent diarrhea, rectal bleeding, severe constipation, weight loss, nocturnal pain, family hx of GI cancer/IBD/celiac, new onset at old age
What are some differential diagnoses for IBS?
Malabsorption Dietary factors Infection IBD Metabolic issues
Examples of anti-diarrheals that may be used in IBS-D and their side effects
Loperamide, diphenxylate-atropine; constipation
For IBS-D, ______ has been shown to be more effective than no treatment for a 2 week course but it is not cost effective
Rifaximin
For IBS-D, this serotonin receptor antagonist has moderate evidence of being effective over no treatment, but is only FDA approved in women
Alosteron
For IBS-D, this FDA-approved mu and K-opioid receptor agonist/d-receptor antagonist has evidence of efficacy over no treatment and improves both abdominal pain and diarrhea
Eluxadoline
A homeopathic approach to IBS that has shown to be more effective than placecbo:
Peppermint oil
Which IBD shows pattern of “skip lesions” and apthous ulcers that progress to a cobblestone appearance?
Crohn’s disease
In which IBD is the inflammation TRANSMURAL?
Crohn’s disease
Perianal disease is MC in which IBD?
Crohn’s disease
Smoking is protective with which IBD?
Ulcerative colitis
Test of choice for diagnosing Crohn’s?
Colonoscopy
Crohn’s tends to occur more often where in the gut that helps distinguish it from ulcerative colitis?
Terminal ileum
Strictures caused by an IBD are best visualized with which type of study?
Barium esophogram
What type of malnutrition does Crohn’s lead to and why?
Both a low caloric intake in attempts to decrease sx as well as bile salt depletion and B12 deficiency because of the terminal ileal disease (»ADEK deficiencies)
What type of kidney stones are a concern with Crohn’s?
Calcium oxalate stones (fatty acids compete for calcium)
A resection of the terminal ileum results in dairrhea for what reason?
Excess bile acids pass into colon and are osmotically active
With Crohn’s colitis, how often is it recommended to have a colonoscopy?
Every 1 - 2 years
A medication for the treatment of Crohn’s that works at the ileocecum and colon but has use-limiting side fx
Sulfasalazine
What medication might be used in short term treatment of IBD?
Corticosteroids
What other drugs might be used to treat IBD?
Abx, immunosuppressants, biologic agents (TNF-a)
Tenesmus and being located at rectum and extending proximally is reflective of what IBD?
Ulcerative colitis
A complication of UC where patient presents with T >101 degrees, tachycardia, abdominal distention, peritonitis, WBC elevation, and dilated colon on x-ray requires surgical consult for
Toxic megacolon
Dubin-Johnson syndrome, upon liver biopsy, will show:
Dark pigmented liver
Do not do a HIDA scan when bilirubin is
> 5 or 6 mg/dL
Abnormal LFTs, dilated bile ducts, procedure of choice is:
MRCP
