Gastrointestinal Flashcards
Acute appendicitis pain can start and radiate to
periumbilical to McBurney’s point
Rupture of appendix symptoms
- acute abdomen
- involuntary guarding
- rebound tenderness
- board-like abdomen
Another term for rebound tenderness
Blumberg’s sign
Typical presentation of acute cholecystitis
- overweight female
- ate a fatty meal within 1 hour or more
- Severe RUQ or epigastric pain
Where can acute cholecystitis pain radiate to
right shoulder
Acute diverticulitis presentation
- acute onset of high fever
- anorexia
- N/V
- LLQ pain
Positive Rovsing’s sign
Pain in RLQ with palpation of LLQ
Acute pancreatitis presentation
- acute onset fever
- N/V
- rapid abdominal pain
- radiates to midback
- located in epigastric region
Common causes of acute pancreatitis
- drugs
- biliary factors
- alcohol abuse
Positive Cullen’s sign
- blue discoloration around umbilicus
- indicative of acute pancreatitis
Positive Grey-Turner’s Sign
- blue discoloration on the flanks
- indicative of acute pancreatitis
C.diff presentation
- severe watery diarrhea
- 10-15 stools a day
- lower abdominal pain
- cramping
- fever
Antibiotics implicated with C.diff
- Clindamycin
- fluroquinolones
- cephalosporins
- PCNs
When to suspect colon cancer
- older patient with vague GI symptoms
- bloody stools
- history of multiple polyps or IBD
Crohn’s disease pathology
-inflammation of any part of the GI tract
Crohn’s disease relapse
- fever
- anorexia
- weight loss
- dehydration
- fatigue with periumbilical to RLQ abdominal pain
Crohn’s disease is at higher risk for
toxic megacolon
colon CA
lymphoma (especially if treated with azathioprine)
Ulcerative colitis pathology
-inflammation of colon/rectum
Ulcerative colitis presentation
- bloody diarrhea with mucus (hematochezia)
- squeezing cramping pain in LLQ
- bloating and gas with food
- arthralgias and arthritis
Ulcerative colitis is at higher risk for
toxic megacolon
colon CA
Zollinger-Ellison syndrome
- gastrinoma (tumor) on pancreas or stomach
- secretes gastrin to produce high levels of acid in stomach
- results in multiple and severe ulcers in stomach and duodenum
- epigastric to midabdominal pain
- tarry stools
Zollinger-Ellison syndrome screening
serum fasting gastrin level
Possible causes of acute abdomen
- appendicitis
- cholecystitis
- pancreatitis
- diverticulitis
Preferred imaging for appendicitis
CT
US in peds
Preferred imaging for cholecystitis
- US
- HIDA if US inconclusive
Preferred imaging for diverticulitis
CT
Preferred imaging for pancreatitis
CT
abdominal US
Organs in RUQ
- liver
- gallbladder
- ascending colon
- right kidney
Organs in LUQ
- stomach
- pancreas
- descending colon
- left kidney
Organs in RLQ
- appendix
- ileum
- cecum
- right ovary
Organs in LLQ
- sigmoid colon
- left ovary
Organs in suprapubic area
- bladder
- uterus
- rectum
Psoas/iliopsoas sign maneuver
- (+): RLQ abdominal pain
- supine, raise right leg against pressure of hand resistance
- patient on left side, extend right leg from hip
Obturator sign maneuver
- (+) if inward rotation of hip causes RLQ pain
- rotate right hip through full ROM
- pain with movement or flexion of hip
McBurney’s point
-between superior iliac crest and umbilicus in RLQ
Markle test
- aka heel jar
- raise heels and drop suddenly
- or ask to jump in place
- positive if pain elicited or patient refuses to perform due to pain
Involuntary guarding
-with palpation, abdominal muscles reflexively become tense or board-like
Murphy’s sign
- deep palpation of RUQ under costal margin during inspiration
- (+) midinspiratory arrest
Positive Murphy’s sign is indicative for
Cholecystitis
Complication of GERD
Barrett’s esophagitis (precancer)
increased risk of SCC
GERD objective findigns
- acidic or sour odor to breath
- reflux of sour acidic stomach contents
- thinning tooth enamel
- chronic sore red throat
- chronic coughing
First line treatment for GERD
- lifestyle modifications
- avoid large and/or high fat meals
- avoid eating 3-4 hours before bedtime
- avoid ASA
- avoid mints, chocolate, alcohol, caffiene, NSAIDs, carbonated beverages, other aggravating foods
- smoking cessation
Medications with GERD side effects
- BB
- CCB
- alpha 1 or alpha 2 adrenergic receptor agonists
3 mechanisms of GERD
- reduction in LES tone
- irritation of esophageal mucosa
- increased gastric acid secretion
Examples of antacids
- Maalox
- Mylanta
- Rolaids
- Tums
Antacids mechanism
- increase pH for about 20-30 minutes
- fastest relief
H2 receptor antagonist examples
- Cimetidine (Tagamet)
- Famotidine (Pepcid) ***
- Nizatidine (Axid)
H2 receptor antagonist mechanism
- decrease acid production for 6-12 hours
- relief in 60 minutes
PPI examples
- omeprazole (Prilosec)
- Lansoprazole (Prevacid)
- Esomeprazole (Nexium)
- Pantoprazole (Protonix)
PPI mechanism
- reduce gastric acid secretion
- relief in 1-3 days
- Rx for 4-8 weeks
Gold standard treatment for GERD
PPI
GERD diagnosis
- presumptive: heartburn, dysphagia, regurgitation
- empiric treatment with PPI
PPI long-term therapy associated with
- hip fractures
- PNA
- C.diff
PPI discontinuation
- needs taper
- can cause rebound symptoms
Patient with GERD not responding to therapy in 4-8 weeks
- high risk for Barrett’s
- refer to GI for upper endoscopy/biopsy
Worrisome symptoms of GERD
- progressive dysphagia
- iron-deficiency anemia
- weight loss
- Hemoccult positive
What do Cullen’s sign and Grey-Turner’s sign indicate
-retroperitoneal bleeding
How does smoking effect GERD
increases stomach acid
-lowers esophageal sphincter pressure
IBS pathology
- chronic functional disorder of colon
- exacerbations and spontaneous remissions
- common exacerbation by stress
- diarrhea or constipation, can be both
IBS treatment plan
- increase dietary fiber
- supplement with psyllium (Metamucil)
- avoid gassy foods: beans, onion, cabbage, high-fructose corn syrup
- decrease stress
IBS with constipation treatment
-fiber supplement
IBS with diarrhea treatment
-loperamide (Imodium) before meals
Infectious causes of diarrhea
- usually viral
- Salmonella, Shigella, Campylobacter
- Giardia, etc.
Diarrhea red flags
- rectal bleeding
- nocturnal or progressive abdominal pain
- weight loss
- anemia
- elevated inflammatory markers
- electrolyte disturbance
Hematochezia
blood in stool
Which ulcer has a higher risk of malignancy
Gastric ulcers
Which ulcers are mostly benign
Duodenal
Most common cause of both duodenal and gastric ulcers
H.pylori
Etiology of PUD
- H.pylori
- Chronic NSAID use –> reduction of GI blood flow and reduction of protective mucosal layer
- Tobacoo
- alcohol
- stress after acute illness
- bisphosphonates
PUD labs
- CBC
- FOBT
- H.pylori testing
- If (+) for H.pylori –> gastroenterology referral
Gold standard for diagnosing PUD
-upper endoscopy and biopsy
Testing for H.pylori
- Serology (titers): IgG elevated, not used to document eradication
- Urea breath test: active H.pylori, can be used to document eradication
- Stool antigen: screening and eradication documentation.
H.pylori negative PUD treatment
- Stop NSID use
- H2 blockers at bedtime
- PPI for 4-8 weeks daily
H.pylori triple therapy
- Clarithromycin (Biaxin)
- Amoxicillin or metronidazole (PCN allergy)
- PPI 4-8 weeks
H.pylori quad therapy
- Bismuth subsalicylate tab
- Metronidazole tab
- Tetracycline
- PPI 4-8 weeks
Treatment duration for H.pylor ulcers
14 days
Colorectal cancer screening starts at
age 50
Gold standard for colon CA screening
colonoscopy q10 years
Cause of diverticula
- pouch-like herniations due to poor diet and lack of fiber
- higher incidence in Western societies
Diverticulitis presentation
- older adult
- acute fever
- LLQ pain
- anorexia
- N/V
- hematochezia
Diverticulitis treatment plan
- uncomplicated cases can be treated outpatient
- routine antibiotic treatment controversial
- Ciprofloxacin and Flagyl x 19-14 days
- probiotics
- increased fiber intake not recommended until resolved
- follow up in 2-3 days, go to ED if no improvement
Chronic therapy for diverticulosis
-high fiber diet with supplementation
Causes of acute pancreatitis
- alcohol abuse
- gallstones
- elevated TG
- infections
Pathology of pancreatitis
-pancreatic enzymes activate and autodigest
TG levels for pancreatitis risk
->800
Where can acute pancreatitis pain refer to
midback
Complications of acute pancreatitis
- ileus
- sepsis, shock, multiorgan failure
- diabetes
C.diff labs
- PCR
- CBC with leukocytosis
- stool assay
- testing and treating asymptomatic patients not recommended
C.diff treatment
-Oral Vancomycin most effective Flagyl 10-14 days used if Vancomycin not available for some reason -avoid antimotility agents -probiotic use controversial -increase fluid intake
IgG anti-HAV positive
- Immune
- previous HAV infection or immunized
IgM anti-HAV positve
- acute infection
- still contagious
HBsAg
- screening for HBV
- (+) acute infection or chronic infection
Anti-HBs
- (+) immune
- from past infection or immunization
HbeAg
- active viral replication
- persistent e: chronic HBV
alk phos is found in
liver bone GI kidneys placenta
causes of elevated alk phos
- age (growth spurt)
- pregnancy
- recent healing fracture
- hyperthryoidism
- bone metastasis
- overdose with acetaminophen
Anti-HBc
current or previous infection
Anti-HCV indication
screening for hep C
does not always mean patient recovered from infection
-may indicated current infection
-carrier
Next step with + anti-HCV
- HCV RNA or HCV PCR to r/o chronic infection
- if positive, refer to GI for biopsy
what does hepatitis D require for infection
-current hepatitis B infection
Risk of concurrent hep B and hep D infection
- increases risk of
- fulminant hepatitis
- cirrhosis
- severe liver damage
- low prevalence in US
HBsAg (-)
Anti-HBc (-)
Anti-HBs (-)
not immune
no current infection
need vaccination
HBsAg (-)
anti-HBc (+)
anti-HBs (+)
immune from previous infection
HBsAg (-)
anti-HBc (-)
anti-HBs (+)
immune from immunization
HBsAg (+)
anti-HBc (+)
IgM anti-HBc (+)
anti-HBs (-)
acute infection
HBsAg (+)
anti-HBc (+)
IgM anti-HBc (-)
anti-HBs (-)
chronically infected
HBsAg (-)
anti-HBc (+)
anti-HBs (-)
unclear
Normal AST
0-45
Where is AST found
liver heart skeletal muscle kidney lung
Normal ALT
0-40
Where is ALT found
primarily in liver
Can hepatitis A be chronic
no
Hepatitis A transmission
fecal oral
Food workers with active hepatitis A
avoid work for 1 week after onset of infection
Hepatitis B transmission
-sexual activity
blood
vertical transmission
Hepatitis B treatment
- pegylated interferon alfa
- entecavir
- tenofovir disoproxil fumarate
Hepatitis C transmission
- needle sharing
- blood transfusions before 1992
- vertical transmission
- needle stick injuries
- sexual contact
Most common cause for liver cancer and transplant in US
hepatitis C
Hepatitis C management
refer to GI
-biopsy to stage
acute hepatitis presentation
- fatigue
- nausea
- dark colored urine for several days
- new sexual partner
- jaundice
- liver tenderness
acute hepatitis labs
-AST/ALT: elevated 10x during acute phase
Which lab value is usually elevated during growth spurts
alk phos
LFT’s may be normal in chronic liver disease
true
Labs for acute pancreatitis
amylase and lipase
HIDA scan is used for…
rule out cholecystitis
Bloody traveler’s diarrhea may be caused by
Campylobacter jejuni
Watery traveler’s diarrhea may be caused by
salmonella or e.coli
Best antibiotic to treat traveler’s diarrhea
Cipro
Foods that contain gluten
- wheat
- barley
- rye
- Rice is OKAY
How to differentiate between intra and extra abdominal mass
- instruct patient to lift head off table while tensing her ab muscles to visualize any mass and palpate the abdominal wall.
- if intra: will be pressed down by muscles and be less obvious
Statin plus high dose B complex can cause what
drug induced hepatitis
What is high dose B complex
Niacin
First line treatment for mild C.diff
-Flagyl 500 mg PO TID x 10-14 days
Treatment for severe C.diff
-Vancomycin
