GASTROINTESTINAL Flashcards
Organisms that produce ENTEROTOXIN. Prominent symptoms include Vomiting and diarrhea (watery). Incubation period 8-72 hrs.
- V. cholerae
- Enterotoxigenic E.coli
- K. pneumoniae
- Aeromonas spp
There is an interval between the disappearance of HBsAg and the appearance of anti-HBsAb. This period is referred to as the ____.
WIndow period
During this interval, anti–hepatitis B core antigen (anti–HBc) is the only detectable serology
MOST common cause of LGIB
Hemorrhoids
GASTRIC OR DUODENAL ULCER?
Risk of Malignancy is common and should be biopsied
Gastric ulcer
In the ICU setting, a rising ___ may be a sign of an occult GI bleeding.
BUN
What are the two types of gallstones?
o Cholesterol stones (90%): contain >50% cholesterol monohydrate
o Pigment stones: composed primarily of Ca2+
- Black type (common in those with chronic hemolytic states)
- Brown type (due to chronic biliary infection)
Benign GUs are MOST often found
DISTAL to the junction between the antrum and the acid secretory mucosa
What is the most common non-infectious cause of acute diarrhea?
Side effect of medications
“Cork-screw” esophagus
Diffuse esophageal spasm
Now the single most common risk factor for Hepatitis C is ____
injection drug use
Best diagnostic work-up for pancreatitis
CT scan of the abdomen with IV contrast (done 3-5 days into hospitalization when patients are not responding to supportive care to look for local complications such as necrosis)
urgent endoscopy age cutoffs are:
- >55 for dyspepsia with alarm
- >40 for PUD with alarm
Common first line H. pylori treatment:
o Triple therapy: “OCA” - Omeprazole + Clarithromycin + Amoxicillin
o Quadruple therapy: “TOMB” - Tetracycline + Omeprazole + Metronidazole + Bismuth
n children and adolescents – MOST common colonic cause of significant GIB
IBD and juvenile polyps
Loperamide dose.
Loperamide 4mg/tab 1 tab as initial dose then 2mg after each loose stool is recommended. Maximum dose of Loperamide is 8mg/day.
Most severe histologic consequence of GERD
Barrett’s metaplasia with the associated risk of adenocarcinoma
How do you classify hemorrhoidal disease?
o External hemorrhoids: originate below dentate line, covered by squamous epithelium, and are painful when thrombosed
o Internal hemorrhoids (majority): originate above dentate line, covered with mucosa
aberrant blood vessels from dilatation of the terminal aspect of the blood vessel
Angioectasia
AST:ALT < 1
chronic viral hepatitis, NAFLD
What is the initial treatment of cirrhotic ascites?
Restriction of sodium intake (next line of management: Spironolactone + Furosemide)
presence of IDA, weight loss, symptoms of obstruction, abdominal pain, BM changes
Colonic mass
most frequent visceral site of metastasis of colon CA
Liver
the first serologic marker to appear after infection with Hepatitis B. This is repeated after 6 months for those who had an acute Hepatitis B infection to document chronicity
HBsAg
AST:ALT > 2
alcoholic liver disease
GOLD standard for confirmation of Barrett’s esophagus
Endoscopic biopsy
Child-Pugh classification of liver failure is still a reliable prognosticator for tolerance of hepatic surgery – only Child A should be considered for resection. Enumerate the components for scoring.
Useful INITIAL diagnostic test when mechanical obstruction is suspected
Endoscopy
Procedures of choice for visualization of biliary tree
ERCP, MRCP
Gold standard in diagnosing most liver diseases
Liver Biopsy
Differentiate Ulcerative colitis from Chron’s disease
distinguish portal HPN vs nonportal HPN
Serum-ascites-albumin-gradient (SAAG):
o SAAG ≥1.1 g/dL: presence of portal hypertension
o SAAG <1.1 g/dL: not related to portal hypertension
Charcot’s triad of cholangitis:
o Fever
o Pain
o Jaundice
What is the mainstay of treatment for hepatic encephalopathy?
Lactulose
drop in systolic pressure of > 20 mm Hg or a rise in pulse of > 10 beats per minute
Orthostasis
Two predominant causes of PUD
NSAID ingestion infection
Forrest classification of ulcers
Non-invasive H.pylori tests
Urea breath test
Serology
Stool Angtigen
liver or biliary tract disease, Dubin-Johnson, Rotor
Conjugated bilirubinemia
GASTRIC OR DUODENAL ULCER?
Precipitated by food
GASTRIC ULCER
Cervical CA screening
at age 21-65 PAP every 3 years
predominates during 1 st 6 months after acute infection. Present even at the window period
IgM Anti-HBc
MOST common esophageal symptom
Heartburn / pyrosis
Review the serology in viral Hepatitis B
an area of discoloration in the periumbilical area seen in pancreatitis
Cullen sign is a hemorrhagic discoloration of the umbilical area due to intraperitoneal hemorrhage
hallmark symptom of liver disease & most reliable marker of severity
Jaundice
Organisms that produce PREFORMED TOXINS. Prominent symptom include vomiting and watery diarrhea
- Bacillus cereus
- Staphylococcus aureus
Clostridium perfringens
Tests to document H. pylori eradication (think GI tract as the source!):
o Urea breath test (gastric) - test of choice
o Stool antigen (intestines)
o Rapid urease test (gastric)
Most common complication of peptic ulcer disease (PUD)
GI bleeding
Stigmata of Cirrhosis
o Palmar erythema o Spider angiomata o Gynecomastia o Testicular atrophy o Dupuytren’s contractures o Caput medusae
Organisms that produce CYTOTOXIN. Prominent symptom is crampy abdominal pain.
- C. difficile
- Hemorrhagic E.coli
Staging and Treatment of hemorrhoids
Mass located in this location:
§ develop obstruction and even perforation
§ X-ray often shows “apple-core or napkin-ring” deformity annular, constricting lesion
transverse and descending colon
MOST frequent finding in GU or DU
Epigastric tenderness
Level of obstruction in the portal venous system in portal hypertension due to Budd-Chiari syndrome
Posthepatic
most important treatment intervention in pancreatitis
Safe, aggressive intravenous fluid resuscitation
first line ancillary procedure if blood tests suggest cholestasis
Ultrasound
Classification of portal HTN
Procedure of choice for detection of stones?
Gallbladder UTZ
indicates presence of portal hypertension
SAAG ≥1.1 g/dL
The Bedside Index for Severity in Acute Pancreatitis (BISAP) score has been developed to identify patients at high risk for mortality or severe disease early during the course of acute pancreatitis.
The Ranson criteria form a clinical prediction rule for predicting the prognosis and mortality risk of acute pancreatitis.
Enumerate the parameters for the scoring.
GASTRIC OR DUODENAL ULCER?
- Occurs 90 min to 3 hrs after a meal
- Relieved by antacids or food
DUODENAL ULCER
Test of choice for documenting eradication of H.pylori
Urea breath test
Mainstay of treatment of nonalcoholic fatty liver disease
Weight loss and exercise
Endoscopic therapy of CHOICE for esophageal varices
Ligation
recommended as the initial test in unexplained dyspepsia >55 years old or who have alarm factors because of the purported elevated risks of malignancy and ulcer
Upper endoscopy
MOST common cause of UGIB
Peptic ulcer
CENTRAL role in gastric epithelial defense/ repair
Prostaglandin
drop in blood pressure or rise in pulse from a lying to a standing or seated position
Orthostatic hypotension
If local anal processes, which rarely require hospitalization, are excluded, the most common causes of LGIB in adults are ____________
diverticula, vascular ectasias (especially in the proximal colon of patients >70 years), neoplasms (primarily adenocarcinoma), colitis (ischemic, infectious, idiopathic inflammatory bowel disease), and post- polypectomy bleeding.
Phase of hepatitis characterized with Anorexia, nausea, vomiting, malaise, arthralgia, headache, pharyngitis, cough, coryza precede onset of jaundice by 1-2 weeks
Prodromal phase
Responsible for MAJORITY of cases of obscure GIB
Small intestinal sources of bleeding
________ is the leading cause of acute pancreatitis; followed by alcohol.
gallstone
Alkaline phosphatase > AST, ALT
cholestatic conditions
CLASSIC symptoms of GERD
Water brash and substernal heartburn
Alarming manifestations (requiring endoscopy)
o Dysphagia
o Weight loss
o Anemia
o Bleeding
Presence of scleral icterus indicates total bilirubin level of at least ___
2.5-3mg/dL
Elevation of AST/ALT >1000 U/L
o Viral hepatitis
o Ischemic liver injury
o Toxin- or drug-induced liver injury
Lung CA screening
at age 55-80 if with at least 30 pack years of smoking history, and have been smoking for the last 15 years, do a plain chest CT scan at least once
Most common organism in spontaneous bacterial peritonitis (SBP)
Escherichia coli
MOST common cause of significant lower GIB in children
Meckel’s diverticulum
MOST common cause of esophageal chest pain
Gastroesophageal reflux
MAINSTAY of treatment of PUD
Eradication of H. pylori and therapy / prevention of NSAID induced disease
treatment for chronic hepatitis B infection and is part of an antiretroviral prophylaxis if the patient was HIV positive.
Oral Lamivudine
MOST potent acid inhibitory agents available
Proton Pump inhibitors
most discriminating symptom of duodenal ulcer
Pain that awakens the patient from sleep
MOST sensitive test for diagnosis of GERD
24-h ambulatory pH monitoring
most common physical sign (50-90%) of hepatocellular CA.
Hepatomegaly
manifesting as ecchymosis or discoloration of the flanks. seen in pancreatitis
Grey Turner’s sign refers to an uncommon subcutaneous manifestation of intra-abdominal pathology manifesting as ecchymosis or discoloration of the flanks.
mass in this location become large without any obstructive symptoms or bowel habit changes. But they commonly ulcerate leading to chronic blood loss (IDA)
cecum and ascending colon
Invasive H.pylori tests
Rapid urease test
histology
culture
PCR assay
Smoking and appendectomy are protective to what type of IBD?
Ulcerative Colitis
Characteristic symptom of infectious esophagitis
Odynophagia
for diagnosis of Hepatitis C (no way of determining acute vs chronic Hep C infection via serology)
Anti-HCV
Breast CA screening
at age 50-74 mammography every 2 years
Duodenal ulcers occur MOST often in what specific location
FIRST portion of the duodenum (>95%)
Differentiate types of diarrhea according to duration :
o Acute: < 2 weeks
o Persistent: 2-4 weeks
o Chronic: > 4 weeks
most common and most characteristic symptoms of liver disease, typically occurs after activity or exercise, rarely after adequate rest (afternoon rather than morning fatigue)
Fatigue
What are the three hemorrhoidal complexes that traverse the anal canal?
Left lateral, right anterior, and right posterior
KEY enzyme that controls the rate-limiting step in prostaglandin synthesis
Cyclooxygenase (COX)
What is the next step if esophageal varices are documented?
Endoscopic ligation and IV vasoactive medications (e.g., octreotide)
Hemorrhoid stage where sclerotherapy is the treatment of choice
Stage I with enlargement and bleeding
marker for hepatitis A during the acute illness, may persist up to several months
IgM Anti-HAV
Significant alcohol intake
Alcohol intake of 30g or more (3 Pilsen cans) everyday
the most common cause of death in pancreatitis
Hypovolemic shock
BT is recommended when Hgb ____
Hgb < 7g/dL
classic history of vomiting, retching, or coughing preceding hematemesis, especially in alcoholic patient. Commonly in gastric side of GEJ.
Mallory-Weiss tear
“Ulcer definition” is ____ depth
>5mm
Prostate CA screening
start at age 50
Organisms that produce ENTEROADHERENT TOXIN. Prominent symptom is crampy abdominal pain. Incubation period 1-8 days.
- Enteropathogenic E. coli
- Enteroadherent E.coli
- Giardia
- Cryptosporidiosis
- Helminths
gold standard treatment for high-grade dysplasia
Esophagectomy
What important serologic test would you request to check for acute viral hepatitis A and B?
Anti-HAV IgM
HBsAg and Anti-HBc IgM
GASTRIC OR DUODENAL ULCER?
Pathophy: Gastric acid output normal or decreased
Gastric Ulcer
What is the characteristic bleeding of diverticular bleeding?
Abrupt in onset, painless, sometimes massive, and often from the right colon (chronic/occult bleeding is not characteristic)
MOST common cause of obscure GIB in adults
- Vascular ectasia, tumors, NSAID induced
- For <40-50 years: small bowel tumors
- For >50-60 years: vascular ectasia, NSAID-induced
Screening for colon CA schedule:
• At age 50 (10 years younger if with one first degree relative with Colon
CA and if with consideration of familial polyposis start at age 25)
o colonoscopy every 10 years
o Sigmoidoscopy every 5 years
o FOBT annually
hemolysis, Crigler-Najjar, Gilbert
Unconjugated bilirubinemia
Standard indications for testing for H. pylori
- Active PUD
- History of PUD without prior treatment
- MALT
- Uninvestigated dyspepsia (if population prevalence >20%)
Triad for cholecystitis
RUQ tenderness, fever, leukocytosis
What are the markers for chronic hepatitis?
Persistence of HBsAg or HBeAg
represents high level of viral replication and high infectivity
Hepatitis B precore antigen (HBeAg)
Defined as ≥3 months of bothersome postprandial fullness, early satiety, or epigastric pain or burning with symptom onset at least 6 months before diagnosis in the absence of organic cause
Functional dyspepsia
protruding rectal mass with occasional pain and blood streaked stools
Hemorrhoidal bleeding
Melena: indicates blood present in GIT for at least ______
14 hours and as long as 3-5 days
Most important mechanism in formation of stone-forming bile?
Increased biliary secretion of cholesterol
Test of Choice:
- UGIB: _______
- LGIB (unless with massive bleed): _____
- Massive obscure bleed: _____
- UGIB: upper endoscopy
- LGIB (unless with massive bleed): colonoscopy
- Massive obscure bleed: angiography
Complications of PUD
Most common: gastrointestinal bleeding
Second most common: perforation
Least common: gastric outlet obstruction
Portal HPN: defined as elevation of hepatic venous pressure gradient >____
>5 mmHg
GASTRIC OR DUODENAL ULCER?
Gastric acid output is increased and HCO3 secretion is decreased
Duodenal Ulcer
infectious, ischemic, drug-induced (NSAID); frequently accompanied by diarrhea
Colitis
