Gastrointestinal (50%) Flashcards
1
Q
Most common causes of gastritis
A
H. pylori infection Autoimmune causes (pernicious anemia)
2
Q
Most common causes of gastropathy
A
NSAIDs
Alcohol
Bile reflux
3
Q
Treatment for gastritis
A
Treat underlying cause and give PPI
4
Q
What two causes predispose a patient to peptic ulcers?
A
H. pylori
NSAIDs
5
Q
Symptoms of peptic ulcers
A
Duodenal Ulcers: improve with meals
Gastric Ulcers: worsen with meals
Coffee ground emesis
6
Q
Diagnostic modality for peptic ulcers
A
Endoscopy
7
Q
Treatment for peptic ulcers
A
Treat underlying cause and give PPI
8
Q
Most common form of gastric cancer
A
Adenocarcinoma
9
Q
Risk factors for gastric cancer
A
> 50 y/o
H pylori
Smoking
Alcohol consumption
10
Q
Treatment for H pylori
A
Two weeks of:
BID PPI
BID Clarithromycin
BID Metronidazole or amoxicillin
11
Q
Second line treatment for H pylori
A
BID PPI
QID Bismuth
BID Metronidazole
BID Tetracycline
12
Q
Preferred antiemetics for postoperative N/V
A
Ondansetron
Metoclopramide
Scopolamine
13
Q
Symptoms of esophageal cancer
A
Dysphagia to solids progressing to dysphagia to liquids
Weight loss
Anorexia
GI bleed
14
Q
Risk factors for esophageal cancer
A
Alcohol use
Tobacco use
Prolonged untreated GERD
15
Q
Diagnostic modality for esophageal cancer
A
Endoscopy
16
Q
Most common type of hiatal hernia
A
Sliding hernia
GE junction and stomach slide into the mediastinum
17
Q
Predominant symptom of hiatal hernia
A
Reflux
18
Q
Management of hiatal hernia
A
Similar to GERD treatment
If a rolling hernia, must surgically repair - can lead to strangulation
19
Q
Most common cause of intestinal obstruction in infancy
A
Pyloric Stenosis
20
Q
Pyloric stenosis has an increased incidence with __________ use
A
Erythromycin
21
Q
Erythromycin leads to an increased incidence of ______ _________
A
Pyloric Stenosis
22
Q
Electrolyte abnormality seen in pyloric stenosis
A
Hypochloremic metabolic alkalosis
23
Q
Diagnostic modalities for pyloric stenosis
A
- Ultrasound
2. Upper GI Contrast - string sign
24
Q
Management of pyloric stenosis
A
Initially: IV fluids, potassium repletion if hypokalemic from vomiting
Pyloromyotomy is definitive management
25
Most common bacterial etiologies of acute cholecystitis
E. coli
| Klebsiella
26
Diagnosis of cholecystitis
1. Ultrasound
2. CT Scan
3. Labs: leukocytosis w/ left shift, high bilirubin, high LFTs
4. HIDA scan: gold standard
27
Management of cholecystitis
1. NPO, IV fluids, abx
2. Cholecystectomy
3. Pain control with NSAIDs or narcotics
28
Premalignant condition of the gallbladder
Porcelain gallbladder
29
Acute cholecystitis without evidence of stones
Acalculous Cholecystitis
30
Acalculous cholecystitis may result from an absence of ___________ stimulation
Cholecystokinin
| Contracts the gallbladder
31
Risk factors for acalculous cholecystitis
Prolonged fasting
TPN
Trauma
Prolonged postoperative or ICU setting
32
Diagnostic modalities for acalculous cholecystitis
1. Ultrasound: sludge and inflammation
| 2. HIDA scan
33
Risk factors for cholelithiasis
Female
Fat
Forty
Fertile
34
Most common types of gallbladder stones
75% Cholesterol
| 25% Pigment (calcium bilirubinate, assoc. with biliary tract infxn)
35
Boas Sign
Referred right subscapular pain from cholelithaisis
36
Diagnostic modality of cholelithiasis
1. Ultrasound
37
Major Complications of cholelithiasis (5)
1. Acute cholecystitis
2. Choledocholithiasis
3. Gallstone pancreatitis
4. Gallstone ileus
5. Cholangitis
38
Complications of choledocholithiasis (2)
1. Acute pancreatitis
| 2. Cholangitis
39
Diagnostic modalities for choledocholithasis:
1. Ultrasound: often comes back negative
| 2. ERCP: both diagnostic and therapeutic
40
Bacterial infection of the biliary tract from obstruction
Cholangitis
41
Most common causes of cholangitis
Choledocholithiasis (MC)
Neoplasm
Stricture
42
Most common organisms in cholangitis
E. Coli (MC)
| Klebsiella
43
Charcot's Triad
Seen in cholangitis
1. RUQ pain
2. Fever
3. Jaundice
44
Reynold's Pentad
Seen in cholangitis
1,2,3. Charcot's Triad
4. Shock / Sepsis
5. AMS
45
Diagnostic modalities for cholangitis:
1. Labs: leukocytosis, high bilirubin, high ALT, AST
2. Ultrasound, CT Scan
3. Cholangiography: gold standard via ERCP
46
Management of cholangitis
```
ABX:
1. Ampicillin/sulbactam or Piperacillin/tazobactam
OR
2. Ceftriaxone + metronidazole
OR
3. flouroquinnolone + metronidazole
```
Stone extraction via ERCP
47
Risk factors for hepatic carcinoma
Chronic viral hepatitis (B, C, & D)
| Cirrhosis
48
Signs/symptoms of hepatic carcinoma
1. Malaise
2. Weight loss
3. Jaundice
4. Abd pain
5. Hepatosplenomegaly
49
Diagnostic modalities of hepatic carcinoma
1. Ultrasound, CT, MRI, hepatic angiogram
| 2. High alpha-fetoprotein
50
Treatment for hepatic carcinoma
Surgical resection if:
1. Confined to a lobe
2. Not associated with cirrhosis
51
2 most common etiologies for acute pancreatitis
```
Gallstones
EtOH abuse
Malignancy
Scorpion bite
Mumps in children
```
52
Intracellular activation of pancreatic enzymes that causes autodigestion of the pancreas
Acute pancreatitis
53
Pain exacerbated if supine, eating, or walking. Relieved with leaning forward or sitting.
Acute pancreatitis
54
Signs/symptoms of acute pancreatitis
1. Epigastric pain (radiates to back)
2. N/V and Fever
3. Epigastric tenderness and tachycardia
55
Cullen's Sign and Grey Turner Sign
Acute Pancreatitis if necrotizing / hemorrhagic
Cullen's: periumbilical ecchymosis
Grey Turner: flank ecchymosis
56
Diagnostic studies for pancreatitis
1. Labs: leukocytosis, lipase, amylase, high glucose
2. CT: diagnostic test of choice
3. Ultrasound
4. XRay - colon cutoff sign
57
Colon cutoff sign
Abrupt collapse of the colon near the pancreas
| Acute pancreatitis
58
Management of pancreatitis
90% recover without complications in 3-7 days
1. Supportive - NPO, IV fluid resuscitation, analgesia with meperidine/demerol
2. ABX not used routinely
3. If necrotizing pancreatitis - imipenem
4. ERCP - only effective for obstructive jaundice
59
Ranson's Criteria
Used to determine prognosis for pancreatitis
Glucose, Age, LDH, AST, WBC
Calcium, Hematocrit fall, Oxygen, BUN, Base deficit, Sequestration of fluid
60
Chronic inflammation that results is loss of exocrine and sometimes endocrine function
Chronic Pancreatitis
61
Most common cause of chronic pancreatitis
Alcohol abuse
62
Most common cause of chronic pancreatitis in children
Cystic fibrosis
63
Triad of chronic pancreatitis
1. Calcifications
2. Steatorrhea
3. Diabetes mellitus
64
Diagnosis for chronic pancreatitis
1. AXR: calcified pancreas
| 2. Endoscopic US
65
Management of chronic pancreatitis
Oral pancreatic enzyme replacement
EtOH abstinence
Pain control
66
Encapsulated, mature fluid collections occurring outside the pancreas - have a well-defined wall with minimal or no necrosis
Pancreatic Pseudocyst
67
Risk factors for pancreatic pseudocysts
Chronic pancreatitis
| Blunt or penetrating pancreatic trauma
68
Diagnostic for pancreatic pseudocysts
1. Ultrasound
| 2. CT or MRI - differentiate walled-of necrosis of pancreas
69
Management of pseudocysts
Clinical observation w/ f/u imaging for pts with minimal or no sx
70
Risk factors for pancreatic carcinoma
```
Smoking
> 60 y/o
Chronic pancreatitis
EtOH
DM
Male
Obesity
```
71
Most common type of pancreatis carcinoma
Adenocarcinoma: ductal
| 70% found in the head
72
Signs/symptoms of pancreatic carcinoma
```
Abdominal pain radiating to back
New onset DM
Painless jaundice (classic)
Weight loss
Pruritus, acholic stools, dark urine
```
73
Trousseau's Malignancy Sign
Seen in pancreatic carcinoma
| Migratory phlebitis associated with malignancy
74
Courvoisier's Sign
Palpable, nontender, distended gallbladder, associated with jaundice
Seen in pancreatic carcinoma
75
Diagnosis of pancreatic carcinoma
1. CT scan - test of choice
2. ERCP
3. Labs: increased tumor markers, CEA, CA 19-9
76
Treatment for pancreatic carcinoma
Whipple Procedure: radical pancreaticoduodenal resection
| Advanced/Inoperative: ERCP w/ stent placement to tx intractable itching
77
Most common causes of appendicitis
Fecalith (MC)
Inflammation
Malignancy
Foreign body
78
Vomiting usually occurs _____ pain in appendicitis
After
79
RLQ pain with LLQ palpation
Rovsing Sign
| Appendicitis
80
RLQ pain with internal and external hip rotation with flexed knee
Obturator Sign
| Appendicitis
81
RLQ pain with right hip flexion/extension (raise leg against resistance)
Psoas Sign
| Appendicitis
82
Diagnosis for appendicitis
1. CT scan
2. Ultrasound
3. Leukocytosis
83
Increased risk of CA in both when there is colonic involvement
Inflammatory Bowel Disease - UC and Crohn's
84
Signs/Symptoms of inflammatory bowel disease
1. abdominal pain
2. weight loss
3. bloody diarrhea
4. fever
85
Extraintestinal manifestations of inflammatory bowel disease (5)
1. Erythema nodosum
2. Arthritis
3. Uveitis
4. Primary sclerosing cholangitis
5. Pyoderma gangrenosum
86
Characteristics of ulcerative colitis
Involves colon
Continuous involvement
pANCA positive
87
Characteristics of crohn's disease
```
Skip lesions
Entire GI tract involvement (mouth to anus)
Transmural inflammation
Cobblestone appearance
Fistulas may be seen
ASCA positive
```
88
Treatment for inflammatory bowel disease
1. Steroids for acute exacerbations
2. Sulfasalazine or mesalamine
3. If no response to sulfa or mesalamine, ABX are used for Crohn's only
4. Colectomy or proctocolectomy is offered to those with extensive dz refractory to medication
89
Most common malignant neoplasma of the small intestine
1. Adenocarcinomas
2. Carcinoid Tumors
3. Lymphoma
4. GI stromal tumors (GIST)
90
Diagnosis of small bowel carcinoma
1. Contrast examination is test of choice
2. Enteroclysis
3. CT
4. Endoscopy
91
Treatment for tumors found in the periampullary region of the small intestine
Pancreaticoduodenectomy
92
Treatment for tumors found in remainder of small intestine (after ampullary region)
Poorer prognosis
| Rarely amenable to curative resection
93
Manifestations of carcinoid syndrome
Type of small intestine cancer
Diarrhea, flushing, hypotension, tachycardia
Fibrosis of the endocardium and valves of right heart
Treat with octreotide
94
Etiologies of toxic megacolon
UC
Crohn's
Pseudomembranous colitis
Infectious
95
Signs/Symptoms of toxic megacolon
```
Fever
Abdominal pain
N/V/D
Rectal bleeding
Tenesmus (cramping rectal pain)
Electrolyte disorders
```
96
Physical exam findings for toxic megacolon
```
Abdominal tenderness
Rigidity
Tachycardia
Dehydration
Hypotension
AMS
```
97
Diagnosis of toxic megacolon
1. AXR: large dilated colon > 6 cm
98
Management of toxic megacolon
```
Bowel decompression
Bowel rest
NG tube
Broad-spectrum abx
Electrolyte repletion
```
99
3rd most common cause of cancer related death in US
Colorectal carcinoma
100
Most common site of metastatic spread from colorectal CA
Liver
Lungs
Lymph nodes
101
Risk factors for colorectal cancer
1. APC gene
2. Lynch syndrome
3. Peutz Jeghers
4. Age > 50 y/o
5. Ulcerative colitis
6. diet
7. Smoking, EtOH
102
Signs/Symptoms of colorectal cancer
Iron deficiency anemia
Rectal bleeding
Abdominal pain
103
Most common cause of large bowel obstruction in adults
Colorectal cancer
104
Right-sided (proximal) colorectal CA presents with ________ and ________
Bleeding
| Diarrhea
105
Left-sided (distal) colorectal CA presents with __________ and _______
Bowel obstruction
| Changes in stool diameter
106
Diagnosis for colorectal cancer
1. Colonoscopy with biopsy
2. Barium enema - apple core lesion
3. Increased CEA
4. CBC (iron deficiency anemia)
107
Management of colorectal cancer
Localized (Stages I-III): surgical resection
| Stage III & metastatic: chemotherapy is mainstay (fluorouracil)
108
Guidelines for colorectal CA screening
1. Occult blood test annually
2. colonoscopy every 10 years ages 50-75 y/o
3. flex sig every 5 years with occult every 3 years
109
Meckel's Diverticulum is a persistent portion of embryonic _________ ______ (_____ ____)
Vitelline duct (yolk sac)
110
Meckel's Diverticulum rule of two's:
```
2% of population
2% asymptomatic
2 feet from ileocecal valve
2 inches in length
2x more common in boys
2 years most common age of presentation
```
111
Signs/Symptoms of meckel's diverticulum
Usually asymptomatic
Painless rectal bleeding (periumbilical pain that may radiate to RLQ)
May cause intussusception, volvulus or obstruction
112
Diagnosis of Meckel's diverticulum
Meckel's scan - looks for ectopic gastric tissue in ileal area
113
Treatment of meckel's diverticulum
Surgical excision if symptomatic
114
Most common area of diverticular disease due to intraluminal pressure
Sigmoid colon
115
Diverticulosis is associated with: (3)
Low fiber diet
Constipation
Obesity
116
Most common cause of acute lower GI bleeding
Diverticulosis
117
Signs/Symptoms of diverticulitis
Fever
LLQ abdominal pain
N/V/D/C
118
Diagnosis of diverticulitis
CT is test of choice
| Labs: WBCs increased, + guiac
119
Management of diverticulitis
Clear liquid diet
| ABX (ciprofloxacin or bactrim + metronidazole)
120
Most common causes of small bowel obstruction
1. Adhesions
2. Incarcerated hernia
3. Crohn's dz
4. Malignancy
121
Signs/Symptoms of small bowel obstruction
```
CAVO
Cramping abdominal pain
Abdominal distention
Vomiting - may be bilious if proximal
Obstipation - usually late finding (diarrhea early)
```
122
Physical exam for small bowel obstruction
Abdominal distention
Hyperactive bowel sounds in early obstruction
Hypoactive bowel sounds in late obstruction
123
Diagnosis of small bowel obstruction
1. AXR - air fluid levels in step ladder pattern, dilated bowel loops
124
Management of small bowel obstruction
Nonstrangulated: NPO, IV fluids, NG tube
Strangulated: surgical intervention
125
Decreased peristalsis without structural obstruction
Paralytic (Adynamic) Ileus
126
Etiologies of paralytic ileus
Postoperative state (abdominal surgery)
Medications (opiates)
Metabolic (hypokalemia)
Metabolic (hypothyroidism, diabetes)
127
Signs/Symptoms of paralytic ileus
N/V, abdominal pain, obstipation, abdominal distention
| Decreased/absent bowel sounds
128
Diagnosis of paralytic ileus
1. AXR: first line - uniformly distended loops of small and large bowel (due to air)
2. CT or Upper GI series if high suspicion after negative AXR
129
Treatment for paralytic ileus
1. NPO or dietary restriction
2. NG suction if moderate vomiting
3. Electrolyte and fluid replacement
4. Treat underlying cause
130
Acute colon dilation with severe inflammation
| Acute colon dilation without no inflammation
Toxic Megacolon
| Ogilvie's Syndrome
131
Acute dilation of the colon in the absence of any mechanical obstruction
Ogilvie's Syndrome
132
Most common location for Ogilvie's Syndrome to occur
Cecum and right hemicolon
133
Ogilvie's syndrome is more common in ______ (men/women)
Men > 60 y/o
134
Causes of Ogilvie's Syndrome
```
Post-surgical
Elderly
Severely ill pts
Non-operative trauma
Medications
```
135
Signs/Symptoms of Ogilvie's Syndrome
```
Abdominal distention (hallmark)
Abdominal pain
N/V
Constipation
Will have positive tympany with normal bowel sounds
```
136
Diagnosis of Ogilvie's Syndrome
1. AXR - dilated right colon w/ cutoff at splenic flexure
| 2. CT or contrast enema
137
Management of Ogilvie's Syndrome if colon dilation < 12 cm and absence of severe sx
IV fluid and electrolyte repletion
138
Management of Ogilvie's Syndrome if colon dilation > 12 cm or if failed conservative therapy after 48 hours
Neostigmine
139
Management of Ogilvie's Syndrome if fail conservative and medical treatment
```
Decompression initially with NG suction of enemas
Surgical decompression (colostomy) used if all other therapies fail
```
140
Twisting of any part of the bowel at its mesenteric attachment site
Volvulus
141
Most common areas for volvulus' to occur
Sigmoid colon and cecum
142
Signs/Symptoms of volvulus
```
Obstructive symptoms
Abdominal pain
Distention
N/V
Fever
Tachycardia
```
143
Management of volvulus
Endoscopic decompression
| Surgical correction is 2nd line
144
Causes of anal fissures
Low-fiber diets
Passage of large, hard stools
Other anal trauma
145
Signs/Symptoms of anal fissures
Severe rectal pain
Painful bowel movements causing patient to refrain from having BM
Leads to constipation
BRBPR
146
Where is the most common location of anal fissures
90% posterior midline
147
Treatment of anal fissures
```
80% resolve spontaneously
Supportive measures: warm sitz baths
High fiber diet
Analgesic
Increased water intake
Stool softeners
```
148
Second line treatment for anal fissures
Topical vasodilators: nitroglycerin
149
Most common bacterial etiologies of anorectal abscesses
Staph aureus
| E. coli
150
Most common location of anorectal abscesses
Posterior rectal wall
151
Open tract between two epithelial-lined areas
Fistula
| Seen commonly with anorectal abscesses
152
Symptoms of anorectal abscess
Swelling
Rectal pain that is worse with sitting, coughing, and defecation
May have anal discharge if fistula present
153
Management of anorectal abscesses
```
I&D followed by WASH
Warm water cleaning
Analgesics
Sitz baths
High-fiber diets
```
154
Internal hemorrhoids result from engorgement of which venous plexus
Superior hemorrhoidal vein
155
External hemorrhoids result from engorgement of which venous plexus
Internal hemorrhoidal vein
156
Risk factors for hemorrhoids
```
Increased venous pressure
Straining during defecation (constipation)
Pregnancy
Obesity
Prolonged sitting
Cirrhosis with portal hypertension
```
157
Symptoms of internal hemorrhoids
```
Rectal bleeding (intermittent)
Hematochezia
Rectal itching and fullness
Mucous discharge
Rectal pain suggests complications
```
158
Symptoms of external hemorrhoids
Perianal pain - aggravated with defecation
| +/- tender palpable mass
159
Diagnosis of hemorrhoids
```
Visual inspection
Digital rectal exam
Fecal occult blood testing
Proctosigmoidoscopy
Colonoscopy in pts with hematochezia to r/o proximal sigmoid disease
```
160
Management of hemorrhoids
Conservative tx - high fiber diet, increased fluids, warm sitz bath, topical rectal corticosteroids for pruritus and discomfort
If failed conservative therapy or debilitating pain:
Rubber band ligation
Sclerotherapy
Infrared coagulation
Hemorrhoidectomy (for all stage IV)
161
Hernia that occurs lateral to the inferior epigastric artery
Indirect inguinal hernia
162
Indirect hernias are often congenital and occur due to a __________ __________ __________
Persistent patent process vaginalis
163
Most common overall type of hernias in men and women
Indirect inguinal hernia
164
Hernia that occurs medial to the inferior epigastric arteries within Hesselbach's triangle
Direct inguinal hernia
165
Borders of Hesselbach's Triangle
RIP
Rectus abdominis
Inferior epigastric arteries
Poupart's Ligament
166
Signs/symptoms of a strangulated hernia
Incarcerated hernia with systemic toxicity
Compromised blood supply - ischemic
Severe painful bowel movement
167
Management of inguinal hernias
Often require surgical repair
| Strangulated are surgical emergencies
168
Hernia that is most commonly seen in women
Femoral hernia
169
Often become incarcerated or strangulated compared to an inguinal hernia so surgical repair is often done
Femoral hernia
170
Management of umbilical hernias
Observation, will usually resolve by 2 years old
| Surgical repair if still persistent in children > 5 y/o
171
Incision hernias occur most commonly with _____________ and in ___________
Vertical incisions
| Obese patients
172
Indications for bariatric surgery
Pt between 21-55 y/o with BMI of 40
BMI > 35 w/ life-threatening comorbidities
Pts for whom supervised weight-reducing programs have failed
173
Two most common bariatric urgeries
Roux-En-Y gastric bypass (RYGB)
| AGB (Adjustable gastric banding)
174
RYGB creates a gastric pouch of approximately _____ mL capacity, and attaches a limb of proximal _______ to this gastric pouch
30 mL
| Jejunum
175
Dumping Syndrome
Seen in post Roux-En-Y surgeries
Occurs due to intestines being bypassed in surgery
Abdominal cramps, nausea, vomiting, flushing
Occurs especially with consumption of highly concentrated sweets
176
Roux-En-Y surgeries are associated with resolution of:
DM
HTN
Obstructive sleep apnea
177
Important nutritional complications of post-bariatric surgical patients
```
Anemia (iron and B12 based)
Calcium deficiency
Electrolyte deficiencies
Dehydration
Protein malnutrition
```
