Gastrointestinal Flashcards
1
Q
Nausea and Vomiting
A
- Tx is best directed at mech behind sx
- Brain chemoreceptor trigger zone, vomiting center, and GI tract
- Tx: dopaminergic antag (prochlorperazine, chlorpromazine, metoclop), anticholinergics (scopolamine), antihistamines, serotonin antag (odansetron and granisetron)
2
Q
Constipation/Fecal Impaction
A
- W 2-3x more likely
- Dx: Rome III criteria
- Must include 2 or more:
- Hard or lumpy stool ≥25%
- Straining ≥25%
- Sensation of incomplete evac ≥25%
- Sensation of anorectal obstruction or blockage ≥25%
- Manual maneuvers to facilitate ≥25%
- <3 defecations per week
- Loose stools rarely present without use of laxatives
- Insufficient criteria for irritable bowel
- Must include 2 or more:
- Secondary causes of CC: malig, meds, endo, neuro, nutritional, rheum, psych, anatomic dysfn, dec mobility/sedentary
- Elderly predisposed d/t à changes of aging, immobility, inadequate hydration, and meds
- Diagnosis by H&P, occasionally by Abdominal plain film
- Management
- Fluids and activity
- Improving mastication
- Increasing dietary fiber
- Stool softeners, laxatives/enema
- AVOID ANTICHOLINERGIC DRUGS
- Fecal impaction
- Large mass of hard, retained stool
- Clinical features
- Abdominal pain, rectal discomfort, anorexia, n/v
- Acute confusional state
- Incontinence of small amounts of water and semiformed stool may occur as leakage passes by a large impaction à mistaken for diarrhea
- Management
- Manual disimpaction, followed by saline or tepid water enema
3
Q
Diarrhea
A
-
C. diff
- Usually nosocomial/iatrogenic
- Organism overgrowth 2ndary to alteration of the normal flora
- MC after course of abx (especially Clindamycin) or chemotherapy
- Clinical manifestations
- Abdominal cramps, diarrhea, fever, tenderness, strikingly **lymphocytosis
- Pseudomembranous colitis
- Management
- Metronidazole 1st line for mild dz
- Vancomycin PO 2nd line (but 1st line if severe dz)
4
Q
Upper and Lower GI Bleed
A
-
Acute upper GI bleeding more common than lower
- Upper GI bleeding à originates proximal to the ligament of Treitz
- Can result from PUD, erosive gastritis, esophagitis, esophageal and gastric varices, Mallory-Weiss syndrome (vomiting & retching followed by hematemesis)
- Lower GI bleeds à d/t diverticular dz, colitis, adenomatous polyps, malignancies
- Upper GI bleeding à originates proximal to the ligament of Treitz
- Clinical features
- Hematemesis, coffee ground emesis
-
Hematochezia or melena
- Hematochezia suggests a more distal colorectal lesion
- Melena suggests a source proximal to the R colon
- HoTN, tachycardia, syncope, weakness, confusion
-
Diagnosis
-
NG tube placement and aspiration may detect occult upper GIB
- (-)Aspirate does NOT exclude an UGIB
- Stool Guaiac
- Type and cross match for blood
-
Labs to order
- CBC, Electrolytes, BUN, Creatinine, Glucose, Coag studies, LFTs
- UGIB may elevate BUN
- CBC, Electrolytes, BUN, Creatinine, Glucose, Coag studies, LFTs
- Initial diagnostic procedure of choice of LGIB = angiography, scintigraphy, or endoscopy
-
NG tube placement and aspiration may detect occult upper GIB
- Management
-
ABCs
- O2, large-bore IVs
- Replace volume loss w/ isotonic crystalloids (Normal saline or Ringer lactate)
- Decision to transfuse blood is based on clinical factors (continued active bleeding and no improvement in perfusion after administration of 2 L of crystalloids) rather than initial Hct values
- Initial Hct values may not reflect the actual amount of blood loss
- Replace coag factors as needed
- Octreotide 25-50micrograms bolus followed by 25-50micrograms IV for patients w/ UGIB
-
ABCs
5
Q
Esophageal Cancer
A
-
Squamous cell
- MCC of esophageal cancer; MC in upper 1/3 esophagus
- Risk factors = Tobacco/ETOH use, African-Americans
-
Adenocarcinoma
- MC type in US
- MC in younger patients, obese, Caucasians
- MC in lower 1/3
- Clinical manifestations
- Dysphagia to solid food à fluids
- Odynophagia
- Weight loss, chest pain
- Diagnosis
- Upper endoscopy w/ biopsy TOC
- Management
- Esophageal resection, radiation, chemo depending on stage
6
Q
GERD
A
- Transient relaxation of LES à gastric acid reflux à esophageal mucosal injury
- Incompetent LES
- Clinical manifestations
- Heartburn (pyrosis) = Hallmark; often retrosternal and postprandial
- Increased w/ supine position
- ALARM symptoms = dysphagia, odynophagia, weight loss, bleeding
- Diagnosis
- Clinical
- Endoscopy à often used 1st if persistent symptoms or complications
- Esophageal Manometry à decrease LES pressure
- GOLD STANDARD = 24h ambulatory pH monitoring
- Management
- Stage 1 = Lifestyle modification (elevation of head of bed, avoid fatty/spicy, citrusy foods, decrease ETOH intake, weight loss, smoking cessation)
- Stage 2 = PRN pharm therapy: Antacids & OTC H2 blockers
- Stage 3 = Scheduled pharm therapy: H2 blockers, PPIs, Prokinetic agents
7
Q
PUD
A
- Usually related to H. pylori or NSAID use
- More likely to present w/ failure to thrive, nausea, or melena rather than w/ dyspepsia or pain
- Clinical features
-
Burning epigastric pain
- May be described as sharp, dull, ache
- May be relieved by ingestion of food, milk, or antacids
- Pain recurs as the gastric contents empty and the recurrent pain classically awakens the pt at night
- Abrupt onset of severe pain is typical of perforation w/ spillage of gastric or duodenal contents into the peritoneal cavity
-
Burning epigastric pain
-
Diagnosis
- GOLD STANDARD – Upper GI endoscopy
- Testing for H. pylori most appropriate at time of f/up w/ GI
- Management
-
PPIs à decrease acid production by blocking H+ ion secretion
- Have an inhibitory effect on H. pylori
- Should be taken about 30-60 mins prior to meal
- Omeprazole 20-40mg daily, or Esomeprazole 20-40mg daily, or Lansoprazole 15-30mg daily, pantoprazole 20-40mg daily, or Rabeprazole 20mg daily
-
H2RAs à inhibit acid secretion
- Cimetidine 200-400mg BID
- Famotidine 10-20mg BID
- Nizatidine 75-150mg BID
- Ranitidine 75-150mg BID
-
H. pylori tx is rarely initiated in the ED
- Triple therapy for 14 days = PPI + Clarithromycin + Amoxicillin or Metronidazole
- Quadruple therapy for 14 days = Bismuth + PPI + Tetracycline + Metronidazole
-
PPIs à decrease acid production by blocking H+ ion secretion
8
Q
Diverticular Dz
A
- Diverticula à outpouchings d/t herniation of mucosa into the wall of the colon along natural openings at the vasa recta of the colon
- MC area = sigmoid colon
-
Diverticulosis = uninflamed diverticula
- Low fiber diet, constipation & obesity
- MCC of acute lower GIB
- Management
- High fiber diet
-
Diverticulitis
- Inflamed diverticula 2ndary to obstruction/infection (fecaliths) à distention
- Clinical manifestations
- Fever, LLQ pain, N/V/D/C, flatulence & bloating
- CT scan = TOC
- Management
- Clear, liquid diet, Cipro or Bactrim + Metronidazole
9
Q
Colorectal Cancer
A
- Progression of adenomatous polyp into malignancy
- MC site of metastatic spread = LIVER
- Risk factors à familial adenomatous polyposis; age >50y; diet low in fiber and high in red/processed meat
- Clinical manifestations
- CRC MC cause of large bowel obstruction in adults
- R sided (proximal) = lesions tend to bleed and cause diarrhea
- L sided (distal) = bowel obstruction, present later, changes in stool diameter, hematochezia
- Diagnosis
- Colonscopy w/ biopsy: Diagnostic TOC
- Barium enema: apple core lesion classic
- CEA elevated
- CBC – IDA classic
- Management
- Localized (Stage I-III) = surgical resection
- Stage III & metastatic = chemotherapy (5FU/Fluorouracil)
- USPSTF guidelines
- Colonoscopy q10y from age 50-75
10
Q
Hemorrhoids
A
- Internal = proximal to the dentate line
- Clinical manifestations
- Intermittent Rectal bleeding MC, Hematochezia (bright red blood per rectum)
- Rectal pain w/ internal suggests complication (thrombosed)
- Clinical manifestations
- External = distal to the dentate line
- Clinical manifestations
- Perianal pain aggravated w/ defecation
- Tender, palpable mass
- Clinical manifestations
- Risk factors à straining during defecation, pregnancy, obesity, prolonged sitting
- Diagnosis
- Visual inspection, DRE, fecal occult blood testing
- Management
-
Conservative tx à high fiber diet, increased fluids
- Warm sitz baths & topical rectal corticosteroids may be used for pruritus & discomfort
- Procedures à rubber band ligation, sclerotherapy or infrared coagulation
- Hemorrhoidectomy for all stage IV (irreducible and may strangulate)
-
Conservative tx à high fiber diet, increased fluids
11
Q
Heptitis A
A
- Transmission = Fecal-oral (international travel 40%)
- Clinical manifestations
- Prodromal phase à malaise, arthralgia, fatigue, URI sx, anorexia, N/V, decreased smoking, spiking fever, abdominal pain, loss of appetite, hepatomegaly
- Icteric phase à jaundice
- Diagnosis
- (+) IgM HAV Ab
- Past exposure – (+) IgG HAV Ab
- Management
- Self-limiting
- Recover within weeks
12
Q
Heptitis B
A
- Transmission = parenteral, sexual, perinatal, percutaneous
- Acute = 70% subclinical, 30% jaundice
- Chronic = 10% adult acquired
-
Chronic asymptomatic carrier = (+) HBsAg, (+) HBe antibodies
- Although asymptomatic, they can transmit the infection to others
- Chronic infection = (+) HBsAg, w/ elevated AST & ALT, HBV DNA
-
Chronic asymptomatic carrier = (+) HBsAg, (+) HBe antibodies
- Management of HBBV
- Acute = supportive
- Chronic = Alpha-interferon 2b, Lamivudine, Adefovir
- Prevention = Vaccine
13
Q
Hepatitis C
A
- Transmission = Parenteral
- 80% of patients w/ HCV develop chronic infection
- Diagnosis
- Anti HCV (+) in 6 weeks
- Management
- Pegylated interferon alpha-2b and ribavirin
- Screen for hepatocellular carcinoma via serum AFP and ULS
14
Q
Hepatitis D
A
- Transmission = requires Hep B virus to cause coinfection
15
Q
Hepatitis E
A
- Transmission = fecal-oral; associated w/ waterborne outbreaks
- Diagnosis
- IgM anti-HEV
- Management
- Self-limiting
