Gastrointestinal and Nutritional Flashcards
1
Q
What is an anal fissure?
A
tearing rectal pain and bleeding which occurs with or shortly after defecation, bright red blood on toilet paper
- superficial laceration (paper cut like)
- pain lasts for several hours and subsides until the next bowel movement
2
Q
What is the tx of anal fissure?
A
sitz baths, increase dietary fiber, and water intake, stool softeners or laxatives
- usually heals in 6 weeks
- botulinum toxin A injection (if failed conservative treatment)
3
Q
What are the characteristics of an appendicitis?
A
the first symptom is crampy or “colicky” pain around the navel (periumbilical)
- there is usually a marked reduction in or total absence of appetite, often associated with nausea, and occasionally, vomiting and low-grade fever
- as the inflammation increases, the abdominal pain tends to move downward - begins in epigastrium - umbilicus - RLQ
- right lower quadrant = “McBurney’s point.” this “rebound tenderness” suggests inflammation has spread to the peritoneum
4
Q
What are the signs of appendicitis?
A
- Rovsing - RLQ pain with palpation of LLQ
- Obturator sign - RLQ pain with internal rotation of the hip
- Psoas sign - RLQ pain with hip extension
5
Q
How is appendicitis clinical diagnosis?
A
- imaging if atypical presentation - apply ultrasound or abdominal CT scan
- CBC - neutrophilia supports the diagnosis
6
Q
What is the tx of appendicitis?
A
surgical appendectomy
7
Q
What are the characteristics of small bowel obstruction?
A
- colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention
- hyperactive bowel sounds (early) or hypoactive bowel sounds (late), prior abdominal surgery
- dehydration + electrolyte imbalances
- MCC: adhesions or hernias, cancer, IBD, volvulus, and intussusception
- KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon
8
Q
What are the 4 cardinal signs of strangulated bowel?
A
fever, tachycardia, leukocytosis, and localized abdominal tenderness
9
Q
What are the characteristics of large bowel obstruction?
A
- gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly
- febrile, tachycardia - shock
- dehydration + electrolyte imbalances
- MCC: cancer, structures, hernias, volvulus, and fecal impaction
- KUB shows dilated loop of bowel with air-fluid levels with little or no gas in the colon
10
Q
What do you look for with bowel obstruction?
A
vomiting of partially digested food, severe abdominal distensions and high pitched hyperactive bowel sounds progressing to silent bowel sounds
-KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon
11
Q
What is the tx of bowel obstruction?
A
bowel rest, NG tube placement, surgery as directed by the underlying cause
12
Q
What is cholelithiasis?
A
a precursor to cholecystitis
- stones in the gallbladder, pain secondary to contraction of gall against the obstructed cystic duct
- asymptomatic (most), symptoms only last few hours
- biliary colic - RUQ pain or epigastric
- pain after eating and at night
- boas sign - referred right subscapular pain
- RUQ ultrasound - high sensitivity and specificity if >2 mm, CT scan and MRI
13
Q
What is the tx of cholelithiasis?
A
asymptomatic - no treatment necessary
-elective cholecystectomy for recurrent bouts
14
Q
What is cholecystitis?
A
inflammation of the gallbladder; usually associated with gallstones
15
Q
What is the presentation of cholecystitis?
A
5 Fs: Female, Fat, Forty, Febrile, Fair
- (+) Murphy’s sign (RUQ pain with GB palpation on inspiration)
- RUQ pain after a high-fat meal
- low-grade fever, leukocytosis, jaundice
16
Q
How is cholecystitis diagnosed?
A
- ultrasound is the preferred initial imaging - gallbladder wall >3 mm, pericholecystic fluid, gallstones
- HIDA is the best test (gold standard) - when ultrasound is inconclusive
- CT scan - alternative, more sensitive for perforation, abscess, pancreatitis
- Labs: increase All-P and increase GGT, increase conjugated bilirubin
- porcelain gallbladder = chronic cholecystitis
- choledocholithiasis = stones in common bile duct - diagnosed with ERCP (gold standard)
17
Q
What is the tx of cholecystitis?
A
cholecystectomy (first 24-48 hours)
18
Q
What is cirrhosis?
A
a chronic liver disease characterized by fibrosis, disruption of the liver architecture, and widespread nodules in the liver
19
Q
What is the most common cause of cirrhosis?
A
alcoholic liver disease
20
Q
What is the second most common cause of cirrhosis?
A
chronic hepatitis B and C infections
21
Q
What labs are needed for cirrhosis?
A
typically AST > ALT
22
Q
What are the characteristics of cirrhosis?
A
increase risk for hepatocellular carcinoma - 10-25% of patients with cirrhosis - monitor AFP
-hepatic vein thrombosis (Budd Chiari Syndrome): a triad of abdominal pain, ascites, and hepatomegaly
23
Q
What is portal hypertension?
A
decreased blood flow through the liver - hypertension in portal circulation; causes ascites, peripheral edema, splenomegaly, varicosity of veins
24
Q
What is ascites?
A
accumulation of fluid in the peritoneal cavity due to portal HTN and hypoalbuminemia
- the most common complication of cirrhosis
- abdominal distention, shifting fluid dullness, fluid wave
- abdominal ultrasound, diagnostic paracentesis - measure serum albumin gradient
- self restriction and diuretics (furosemide and spironolactone)
- paracentesis if tense ascites, SOB, or early satiety
25
What is an esophageal variceal rupture?
dilated submucosal veins, retching or dyspepsia, hypovolemia, hypotension, and tachycardia
26
What is hepatorenal syndrome?
progressive renal failure in ESLD, secondary to renal hypo perfusion from vasoconstriction - azotemia (elevated BUN), oliguria (low urine output, hypotension
27
What is hepatic encephalopathy?
ammonia accumulates and reaches the brain causing decrease mental function, confusion, poor concentration
- asterixis (flapping tremor) - have patient flex hands
- dysarthria, delirium, and coma
28
What is hepatocellular failure?
decrease albumin synthesis and clotting factor synthesis
| -prolonged PT - PTT in severe disease - tx with fresh frozen plasma
29
What is the presentation of cirrhosis?
- ascites, pulmonary edema/effusion, esophageal varices, Terry's nails (white nail beds)
- skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput Medusa, hyperpigmentation
30
What is the tx of cirrhosis?
avoid alcohol, restrict salt, transplant
- monitoring: periodic lab values every 3-4 months (CBC, renal function, electrolytes, LFT, coagulation panel), perform endoscopy for varices
- abdominal ultrasound every 6-12 months to screen for hepatoceulluar carcinoma
- CT-guided biopsy for hepatocellular carcinoma
31
What are colonic polyps?
are common; the incidence ranges from 7 to 50% of people (depending on the diagnostic method used)
32
What are the characteristics of colonic polyps?
The main concerns is malignant transformation, which occurs at different rates depending on the size and type of polyp
- polyps in the distal colon are commonly benign if seen in the proximal colon they are more likely to be cancerous
- the larger the colonic polyp, the greater the risk of malignant transformation
- villous adenomas have 30-70% risk of malignant transformation
- the greater the number of concomitant colonic polyps, the greater the risk of malignant transformation
- once identified follow-up colonoscopy in 3-5 years
33
What is the most common cause of painless rectal bleeding in the pediatric population?
colonic polyps
34
What are familial adenomatous polyposis (FAP)?
is characterized by the developmental of hundreds to thousands of colonic adenomatous polyps
35
What are the characteristics of familial adenomatous polyposis (FAP)?
- autosomal dominant
- colorectal polyps develop by a mean age of 15 years and cancer at 40 years
- first-degree relatives of patients with FAP should undergo genetic screening after age 10 years
- risk of colorectal cancer 100% by 30-40 years of age
- the family should undergo yearly sigmoidoscopy beginning at 12 years of age
- prophylactic colectomy recommended
36
What is colon cancer?
painless rectal bleeding and a change in bowel habits in patients 50-80 years of age
-apple core lesion on barium enema, adenoma most common type
37
When should screening for colon cancer begin?
screening with colonoscopy begins at 50 then every 10 years until 75
- fecal occult blood testing - annually after age 50
- flexible sigmoidoscopy - every 5 years with FOB testing
- colonoscopy - every 10 years
- CT colonography - every 5 years
38
When is the tumor marker for colon cancer?
CEA
- more likely to be malignant: sessile, >1 cm, villous
- less likely to be malignant: pedunculate, <1 cm, tubular
39
What is the tx for colon cancer?
resect tumors and adjuvant chemotherapy
40
What is constipation?
according to the Rome III criteria, functional constipation is defined as two of the following features
- straining
- lumpy hard stools
- a sensation of incomplete evacuation
- use of digital maneuvers
- a sensation of anorectal obstruction or blockage with 25 percent of bowel movements
- a decrease in stool frequency (less than three bowel movements per week)
41
How long does a pt need to have symptoms of constipation before dx?
the above criteria must be fulfilled for the last three months with symptom onset six months prior to diagnosis, loose stools should rarely be present without the use of laxatives, and there must be insufficient criteria for a diagnosis of irritable bowel syndrome
- opiate use is a classic cause of constipation, all patients on chronic opioids should be prophylaxes with stool softener
- patients who are older than 50 with new-onset constipation should be evaluated for colon cancer
- think of causes of secondary causes of constipation: DM, hypothyroidism, MS, dehydration, medications are common
42
What is the treatment of constipation?
increase fiber (20-25 grams per day), exercise and water in the diet
-the effects of fiber on bowel movements may take several weeks
Laxatives: laxative usage in older adults should be individualized based on the patient's history, comorbidities, drug interactions, and side effects
-bulk-forming laxatives first line - bulk-forming laxatives include psyllium seed (eg, Metamucil), methyl cellulose (eg, Citrucel), calcium polycarbophil (eg FiberCon), and wheat dextrin (eg Benefiber)
-osmotic laxatives can be used in patients not responding satisfactorily to bulking agents, start with low-dose polyethylene glycol (PEG) as it has been demonstrated to be efficacious and well-tolerated in older adults
-stimulant laxatives - stimulant laxatives affect electrolyte transport across the intestinal mucosa and enhance colonic transport and motility
-stool softeners, suppositories (glycerin or bisacodyl), and enemas have limited clinical efficacy and should only be used in specific clinical scenarios
-a patient with constipation lasting for more than 2 weeks that is refractory to treatments should undergo further investigation to identify the underlying cause
43
What is acute viral gastroenteritis?
- diarrhea breakout in a daycare center: Rotavirus
- diarrhea on a cruise ship: norovirus
- the most common cause of acute diarrhea
- viral cause: rotavirus, Norwalk virus, enterovirus
- duration 48-72 Horus by symptoms may linger up to one week
- myalgias, malaise, possible low-grade fever
- headache, watery diarrhea, abdominal pain, nausea, and vomiting
- supportive look for similar illness in family members
44
What are the labs for acute viral gastroenteritis?
- fecal leukocytes: none
| - hypokalemia and metabolic acidosis
45
What is traveler's diarrhea?
- e-coli
- Food and water contaminated with fecal matter
- Enterotoxigenic Escherichia coli (ETEC), campylobacter, salmonella, shigella
- occurs in the first 2 weeks of travel, lasts 4 days without treatment
46
How is traveler's diarrhea defined as?
3+ unformed stools in 24 h with at least one of the following: fever, nausea, vomiting, abdominal cramps, tenesmus, bloody stools
47
What are the complications of traveler's diarrhea?
dehyration (MC), guillain-barre, reiter syndrome
48
What is the clinical dx of traveler's diarrhea?
fecal leukocytes, clostridium difficile toxin, test 3 stool samples for ova and parasites, bacterial stool culture, FOBT
49
What is the tx of traveler's diarrhea?
empiric treatment with ciprofloxacin 500 mg BID x 1-3 d and loperamide (if older than 2 y)
-campylobacter and Shigella: treat with fluoroquinolone
-FQ-resistant, children, pregnant: azithromycin
-complications from treatment: C. difficile colitis
-Bismuth-subsalicylate is 60%
-not recommended for patients taking anticoagulants or other salicylates
-AE: black tongue, dark stools, tinnitus, Reye syndrome in children
Prophylaxis
-prophylaxis with a fluoroquinolone is 90% effective
-bismuth-subsalicylate taken daily as either 2 oz of liquid or 2 chewable tablets 4 times per day reduces the incidence of TD by approximately 50%
50
What is salmonella?
diarrhea from poultry, pork, or raw eggs
-although there are many types of salmonella, they can be divided into two broad categories: those that cause typhoid and enteric fever and those that primarily induce gastroenteritis
51
Wha are the characteristics of enteric fever (salmonella typhi)?
a flu-like bacterial infection characterized by fever GI symptoms, and headache
- transmitted via the consumption of fecally contaminated food or water
- GI symptoms may be marked constipation or "pea soup diarrhea"
- rose spots may be present (2-3 mm papule on trunk usually)
- more common in the developing world (usually immigration cases)
52
What is gastroenteritis (salmonella Typhimurium, Enteritidis and Newport)?
- results from improperly handled food that has been contaminated by animal or human fecal material
- it can also be acquired via the fecal-oral route, either from other humans or farm or pet animals
- it is estimated that 1 in 10,00 egg yolks is infected with salmonella enteritidis
- inflammatory diarrhea (small volume), nausea, and vomiting
- symptoms appear 24-48 hours after ingesting food
53
What is the dx of salmonella?
possible fever + fecal leukocytes, C. difficile toxin and culture, test 3 stool samples for ova and parasites, bacterial stool culture
-hypokalemia and metabolic acidosis
54
What is the tx of salmonella?
ceftriaxone and sometimes a fluoroquinolone or azithromycin
- no treatment expect in immunocompromised or enteric fever (S. typhi)
- without antibiotics, the mortality rate is about 12%
- with prompt therapy, the mortality rate is 1% a vaccine is available
55
What is shigella?
shigellosis predominantly affects children and is often spread in areas with crowded condition (like daycare centers)
- abdominal pain and inflammatory diarrhea (small volume), frequent, mucous and bloody stool, nausea, vomiting (less common), possible fever
- tenesmus: a feeling of constantly needing to pass stools
56
How is shigella dx?
- fecal leukocytes: (+)
- c. difficile toxin and culture test 3 stool samples for ova and parasites bacterial stool culture
- hypokalemia and metabolic acidosis
- produces the largest quantity of fecal leukocytes than any other cause of gastroenteritis
57
What is the tx of Shigella?
TMP -SMX is the antibiotic of choice, although ciprofloxacin or a fluoroquinolone may be substituted; amoxicillin is not effective
-drugs to stop diarrhea (such as diphenoxylate or loperamide) may prolong the infection and should not be used
58
What is Enterohemorrhagic E. coli (EHEC), also referred to by E.coli O157:H7 or Shiga-toxin producing E. coli (STEC)?
consumption of undercooked ground beef Shiga-like toxin
- onset 12-60 hour and symptom duration: 5-10 d
- watery, voluminous, nonbloody diarrhea with nausea and vomiting = dysentery (bloody)
- no fecal leukocytes
59
What is the tx of Enterohemorrhagic E. coli (EHEC), also referred to by E.coli O157:H7 or Shiga-toxin producing E. coli (STEC)?
antibiotics not recommended, expect in severe disease
| -complications: hemolytic uremic syndrome (AKI, thrombocytopenia, hemolytic anemia)
60
What is Enteroinvacise E. coli (EIEC)?
source: food
-onset: 5-15 d
-duration: 1-5 d
-cramping, watery diarrhea
-fecal leukocytes (+)
Pepto-Bismol, Imodium hydration
61
What is cholera?
causes a life-threatening, rice water diarrhea
- the organism is typically found in seafood - consumption of contaminated, locally harvested shellfish
- onset: 24-48 h after consumption
62
What is the treatment of cholera?
treated with both glucose and Na rich electrolyte fluids
-doxycycline, azithromycin, furazolidone, trimethoprim/sulfamethoxazole (TMP/SMX), or ciprofloxacin, depending on results of susceptibility testing
63
What is infectious esophagitis?
immunosuppressed patients with AIDS, solid organ transplants, leukemia, and lymphoma
- MC pathogens: candida albicans, herpes simplex, CMV, odynophagia, dysphagia, substernal chest pain
- candida: linear yellow-white plaques - oral thrust (75%)
- CMV: large solitary ulcers or erosions on EGD - infection at other sites (colon, retina)
- HSV: shallow punched out lesions on EGD
- oral ulcers (herpes labialis)
64
How is infectious esophagitis dx?
endoscopy with biopsy and brushings
65
What is the tx of infectious esophagitis?
candida: fluxonazole 100 mg BID x 14-21 d
-AIDS - HAART
-Herpetic: symptomatic TX unless immunocompromised
then acyclovir x 2-3 wk
-CMB - ganciclovir 3-6 wk
66
What is medication-induced esophagitis?
caused by: alendronate, clindamycin, doxycyline, iron, NSAIDs, KCl tablets, quinidine, tetracycline, bactrim, vitamin C, zidovudine
-odynophagia, dysphagia, severe retrosternal chest pain
67
How is medication-induved esophagitis dx?
endoscopy - one or several discrete; shallow or deep ulcers
68
What is the tx of medication-induced esophagitis?
take oral bisphosphonates with 4-ounce water and remain upright for 30 minutes after
69
What is eosinophilic?
patient with asthma symptoms + GERD not responsive to antacids
-allergic, dysphagia, impaction (food being stuck at the lower end of the esophagus)
70
How is eosinophilic dx?
upper endoscopy and biopsy: eosinophilic infiltration of the esophageal epithelium, stacked circular rings, stricutres, linear furrows
-a barium swallow will show a ribbed esophagus and multiple corrugated rings
71
What is the tx of eosinophilic?
treat by removing foods that incite allergic response, topical steroids via inhaler
72
What is radiation esophagitis?
radiosensitizing drugs: doxorubicin, bleomycin, cyclophosphamide, cisplatin
- dysphagia and odynophagia lasting weeks-months after therapy
- radiation exposure of 5000 cGy associated with increased risk for stricture
- supportive therapy or dilation
73
What is corrosive esophagitis?
- ingestion of alkali or acid from attempted suicide
| - tx: steroids
74
What is gastritis?
dyspepsia (bleching, bloating, distension, and heartburn) and abdominal pain are common indicators of gastritis
75
What are the causes of gastritis?
- infection - H. pylori (most common)
- Inflammation of the stomach lining (NSAIDS and alcohol)
- autoimmune or hypersensitivity reaction (eg pernicious anemia)
76
What are the characteristics of infection - H. pylori gastritis?
- location: antrum and body
| - studies: urea breath test or fecal antigen
77
What are the characteristics of inflammation of the stomach lining gastritis?
- NSAIDs: cause gastric injury by diminishing local prostaglandin production in the stomach and duodenum
- alcohol: a leading cause of gastritis
78
What are the characteristics of autoimmune of hypersensitivity reaction (eg pernicious anemia) gastritis?
- Location: body of the fundus
| - pernicious anemia: + schilling test + decrease intrinsic factor and parietal cell antibodies
79
What is the tx and dx of gastritis?
stop NSAIDs, empiric therapy with acid suppression 4-8 wk of PPI
- if no response, consider upper GI endoscopy with biopsy and ultrasoun d
- test for H. pylori infection = if H. pylori (+) treat with (CAP) - clarithromycin + amoxicillin +/- metronidazole + PPI (i.e. omeprazole)
- quadrule therapy (PPI, Pepto, and 2 antibiotics) for one week
80
What is gastroesophageal reflux disease?
retrosternal pain/buring shortly after eating worse with carbonation, greasy foods, spicy foods and laying day
81
What is the dx of gastroesophageal reflux disease?
- Endoscopy with biopsy - the test of choice but not necessary for typical uncomplicated cases
- indicated if refractory to treatment or is accompained by dysphagis, odynophagia, or GI bleeding
- Upper GI series (barium contrast study - this is only helpful in identifying complications of GERD (strictures/ulcerations)
- PH probe is gold standard for diagnosis (but usually unnecessary)
82
What is the tx of gastroesophageal reflux disease?
- H2 receptor blockers, proton pump inhibitors, diet modification (avoid fatty foods, coffee, alcohol, orange juice, chocolate; avoid large meals before bedtime); sleep with trunk of body elevated; stop smoking
- nissen fundoplication; antireflux surgery for severe or resistant cases
- Complications: Strictures or Barrett's esophagus
83
What is upper GI bleed?
bleeding that originates proximal to the ligament of Treitz
-hematemesis: vomiting of blood or coffee-ground emesis
-melena: black tarry stool
Orthostatic hypotension, tachycardia, abdominal tenderness - causes include:
-peptic ulcer: upper abdominal pain
-esophageal ulcer: odynophagia, gastroesophageal reflux, dysphagia
-Mallory-Weiss tear: emesis, retching, or coughing prior to hematemesis
-Esophagel varices with hemorrhage or portal hypertension: jaundice, abdominal distension (ascites)
-Malignancy (gastic cancer and right-sided colon cancer): dysphagia, early satiety, involuntary weight loss, cachezia
-severe erosive esophagitis: odynophagia (painful swallowing), dysphagia and retrosternal chest pain
84
What is the tx of upper GI bleed?
- supportive care: NPO, IV access, oxygen, IV fluids of isotonic crystalloid
- transfuse for hemodynamic instability despite fluids, Hgb < 9 in high-risk patients (elderly, CAD), Hgb <7 in low-risk patients
- treate with IV PPI until confirmation of the cause of bleeding - treat the underlying cause
- surgery - duodenotomy or gastroduodenostomy, ligation of bleeding
85
What is a lower GI bleed?
- Hematochezia (BRBPR): the passage of maroon or right red blood or clots per rectum
- Orthostatic hypotension or shock - causes include:
- hemorrhoids: painless bleeding with wiping
- anal fissures: severe rectal pain with defection
- proctitis: rectal bleeding and abdominal pain
- polyps: painless rectal bleeding, no red flag signs
- colorectal cancer: painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age
- diverticulosis is generally an incidental finding since diverticular bleeding is usually of greater volume
86
What are the characteristics of giardia lamblia?
protozoa
- diarrhea after a recent camping trip, drinking (not so fresh) mountain stream water
- giardia incubates for 1-3 weeks, causes foul-smelling bulky stool and may wax and wane over weeks before resolving
- acute profuse, fatty, non bloody diarrhea
87
What is the dx of giardia lamblia?
stool sample cyst or trophozoites
88
What is the tx of giardia lamblia?
with tinidazole (first line)
- flagy (metronidazole) 25-750 mg PO TID
- symptoms resolve within 5-7 days
89
What are the characteristics of pinworm?
(enterobius vemicularis): perianal pruritus that is worse at night
90
How are pinworms dx?
"scotch tape test" done in the early morning
| -can see the eggs under microscopy
91
What is the tx of pinworms?
with mebendazole or pyrantel pamoate
92
What are the characteristics of tapeworms?
GI symptoms and weight loss
- transmission from raw or undercooked meat
- associated with B12 deficiency
93
How are tapeworms dx?
tape test fo D. latum, stool sample: eggs
94
What is the tx for tapeworm?
praziquantel
95
What are the characteristics of hookworm?
cough, weight loss, anemia, recent travel
- larvae invade the skin, travel to the lung, cough, and swallow, reside in the intestine
- eosinophillia and anemia
96
How is hookworm dx?
stool sample - adult womrs
97
What is the tx of hookworm?
mebendazole or pyrantel
98
What are the characteristics of roundworm?
pancreatic duct, common bile duct, and bowel obstruction
- most common intestinal helminth worldwide found in contaminated soil
- small worm load will be asymptomatic, a larger load may cause vague abdominal symptoms
- a high load may cause pancreatic duct, common bile duct and bowel obstruction
99
How is roundworm dx?
stool sample eggs or adult worms
100
What is the tx for roundworm?
albendazole, mebendazole, pyrantel pamoate
101
What is amebiasis?
entamoeba histolytica (protozoa)
- fecal-oral, contaminated water/food, anal-oral
- bloody diarrhea, tenesmus, abdominal pain
- associated with liver abscess
102
How are amebiasis dx?
stool sample - trophozoites
103
What is the tx of amebiasis?
lodoquinol or paromoycin and flagyl for liver abscess
104
What are schistosomiasis?
also known as snail fever and bilharzia, is a disease caused by parasitic flatworms called schistosomes
- penetration of skin (contaminated freshwater) - enter the bloodstream and migrate to the liver, intestines, and other organs
- symptoms include rash, abdominal pain, diarrhea, bloody stool, or blood in the urine
105
How are schistosomiasis dx?
eggs in urine or feces
106
What is the tx of schistosomiasis?
praziquantel
107
What are hemorrhoids?
varicose veins of anus and rectum
108
What are the risk factors for hemorrhoids?
constipation/straining, pregnancy, Portal HTN, obesity, prolonged sitting or standing and intercourse
109
What is Hematochezia?
rectal bleeding (BRPPR), painless and fecal soilage
110
How are hemorrhoids dx?
anoscopy if BRBPR or suspected thrombosis
111
What are the characteristics of external hemorrhoids?
lower 1/3 of the anus (below dentate line)
- Thrombosed
- significant pain, and pruritus but no bleeding
- palpable perianal mass with a purplish hue
- treat with excision for thrombosed external hemorrhoids
112
What are the characteristics of internal hemorrhoids?
upper 1/3 of the anus
- bright red blood per rectum, pruritus and rectal discomfort
- Treatment: fiber, sitz bath, ice packs, bed rest, stool softeners, topical steroids
- rubber band ligation if protrudes with defecation, enlargement, or intermittent bleeding
- close hemorrhoidectomy iff permanently prolapsed
113
What is a hiatal hernia?
hiatal (diaphragmatic): involves protrusion of the stomach through the diaphragm via the esophageal hiatus
-it can cause symptoms of GERD
114
How is a hiatal hernia dx?
barium upper GI series, upper endoscopy
115
What is the tx of hiatal hernia?
acid reduction may suffice, although surgical repair can be used for more serious cases (15%)
116
What is ulcerative colitis?
isolated to the colon starts at the rectum and moves proximally
- continuous lesions
- mucosal surface only
- hematochezia and pus-filled diarrhea, fever, tenesmus (feeling of incomplete defecation), anorexia, weight loss
- barium enema: lead pipe appearance (loss of haustral markings)
117
What is the tx for ulcerative colitis?
- colectomy is curative
| - medications: prednisone and mesalamine
118
What is Crohn's disease?
from mouth to anus, transmural, skip lesions, and cobblestoning
- mouth to anus
- skip lesions
- transmural thickening
- fistulas common, abscess
- abdominal pain, pathos ulcers, weight loss, nonbloody diarrhea, abdominal pain, and cramping
- Barium enema: cobblestone appearance
119
What is the tx for Crohn's disease?
flares: prednisone +/- mesalamine +/- metronidazole or ciprofloxacin
- maintenance: mesalamine
- surgery is not curative, adjacent portion of the bowel is affected post-op
120
What is irritable bowel syndrome?
symptoms complex marked by abdominal pain and altered bowel function (typically constipation, diarrhea, or alternating constipation and diarrhea) for which no organic cause can be determined; also called spastic colon
121
What is the Rome IV criteria for IBS?
IBS is defined as recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria
- related to defecation
- associated with a change in stool frequency
- associated with a change in stool form (appearance)
122
What is the dx of exclusion for IBS?
- all labs normal, no mucosal lesions: CBC, renal panel, FOBT, O&P, sed rate +/- flex sig
- colonscopy, barium enema, ultrasound, or CT
- endoscopy in patients with persistent symptoms, weight loss/anorexia, bleeding or history of other GI
123
What is the tx for IBS?
- diarrhea - diphenoxylate or loperamide (Imodium)
- constipation - colic, psyllium, cisapride
- tegaserod maleate (zelnorm) is a serotonin agonist introduced for the treatment of IBS
- rifaximin (xifazan) - antibiotics approved for IBS-D
- health maintenance: avoid dairy products and excessive caffeine, high fiber diet, physical exercise, stress management, and relaxation techniques
- comorbid: depression, anxiety, somatization
124
What is jaundice?
The yellowish discoloration of the skin
- the first sign of jaundice is sclera icterus if suspected a second site is under the tongue
- indicates serum bilirubin <2 mg/dL
125
How is jaundice dx?
- serum total and unconjuated bilirubin
- urinary bilirubin indicated that conjugated hyperbilirubienmia present
- CBC, LFTs, albumin, PT/INR, GGT, alkaline-phosphates, hepatitis panel
- abdominal ultrasound (preferred) or CT abdomen liver biopsy (definitive)
126
What is unconjugated (indirect) bilirubin?
Hemolysis
-hereditary spherocytosis
-glucose 6 phosphate dehydrogenase
Hematoma
127
What is the cause of intraheptic?
Gilbert syndrome
128
What are the causes of conjugated (direct bilirubin)?
- alcohol
- infectious hepatitis
- drug reaction
- autoimmune
129
What are the causes of intrahepatic?
- hepatocellular disease: hepatitis, chronic alcohol use, autoimmune disorders
- drugs: OCPs, Tylenol, Thorazine, estrogenic or anabolic steroids
- pregnancy
- parenteral nutrition
- sarcoidosis
- primary biliary cirrhosis
- primary sclerosing cholangitis
130
What are the causes of posthepatic?
Cholelithiasis, cholecystitis, pancreatitis, malignancy
131
What are the causes of extrahepatic?
Gallstones, surgical strictures, infection (CMV), cholangiocarcinoma, malignancy
132
What is pancreatitis?
Epigastric pain radiating to back, with nausea and vomiting
133
What is acute pancreatitis?
Epigastric abdominal pain with radiation to the back and elevated lipase
-etiology: cholelithiasis or alcohol abuse
134
How is acute pancreatitis dx?
Clinical + elevated lipase and amylase
| -CT required to differentiate from necrotic pancreatitis
135
What are the signs of acute pancreatitis?
Grey Turner’s sign (flank bruising) and Cullen’s sign (bruising near umbilicus)
136
What is Ranson’s criteria for poor prognosis?
At admit
- age > 55
- leukocyte >16,00
- glucose > 200
- LDH >350
- AST >250
At 48 hrs
- Arterial PO2L <60
- HCO3<20
- Calcium <8.0
- BUN: increase by 1.8+
- Hematocrit: decrease by >10%
- Fluid sequestration > 6L
137
What is the treatment for acute pancreatitis?
IV fluids (best), analgesics, bowel rest
138
What are the complications of acute pancreatitis?
Pancreatic pseudo cyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)
139
What is chronic pancreatitis?
The classic triad of pancreatic calcification (plain abdominal x-ray), steatorrhea (high fecal fat), and diabetes mellitus
- alcohol abuse
- treatment: no alcohol, low-fat diet
140
What is peptic ulcer disease?
refers to painful sores or ulcers in the lining of the stomach or the first part of the small intestine, the duodenum
141
What are the characteristics of peptic ulcer disease?
epigastric pain, nocturnal symptoms
- duodenal ulcer (food classically relieves pain think Duodenum = decreased pain with food)
- gastric ulcer (food classically causes pain)
- endoscopy is the definitive study
142
What is the tx of peptic ulcer disease?
- D/C aspirin/NSAIDs, no alcohol, stop smoking and decrease emotional stress, avoid eating before bedtime, decrease coffee intake
- PPI (most effective), H2 blockers
- Eradicate H. pylori with "CAP" - clarithromycin, amoxicillin, and PPI
- surgery for refractory cases
143
What are the symptoms of viral hepatitis?
tea-colored urine, vague abdominal discomfort, nausea, pruritus, pale stool
144
What are the characteristics of Hepatitis A?
- acute - fatigue malaise, nausea, vomiting, anorexia, fever and right upper quadrant pain
- transmission: fecal-oral
- serum IgM anti-HAV
- Vaccine: killed (inactivated) - given in two doses, recommended for travelers
145
What are the characteristics of Hepatitis B?
- acute and chronic
- transmission: sexual or sanguineous
- serology:
- HBeAg - highly infectious
- HBsAg - ongoing infection
- Anti-HBc - had/have infection
- IgA - acute
- IgG - not acute
- Anti-HBs - immune
- risk of hepatocellular carcinoma
- the vaccine is given to all infants (birth, 1-2 mo, 6-18 mo)
146
What are the characteristics of Hepatitis C?
- chronic
- asymptomatic
- transmission: IV drug use is the most common, Also sexual or sanguineous
- screen with testing for anti-HCV antibodies
- diagnosis with HCV RNA quantitation
- risk of cirrhosis and hepatocellular carcinoma
- treatment: antiretrovirals target complex of enzymes needed for HCV RNA synthesis
147
What are the characteristics of Hepatitis D?
- only occurs when coinfected with Hepatitis B
| - risk of hepatocellular carincoma
148
What are the characteristics of Hepatitis E?
- pregnant women, 3rd world countries
| - hepatitis E + mother = high infant mortality
149
What is the tx of hepatitis?
supportive, vaccinate against other viral hepatitis, HIV treatment PRN
-hepatitis C: direct acting antiretrovirals target complex of enzymes needed for HCV RNA synthesis
150
What is alcoholic hepatitis?
liver enzymes: AST:ALT ratio >2:1
151
What is toxic hepatitis?
acetaminophen toxicity: treatment with N-acetylcysteine within 8-10 hrs
152
What is fatty liver disease?
- risk factors: obesity, hyperlipidemia, insulin resistance
- liver enzymes: ALT > AST
- liver biopsy: large fat droplets (macrovesicular fatty infiltrates)
153
What are the lab results for acute HBV?
Anti-HBc IgM +
Anti-HBc IgG -
HBsAg +
Anti-HBs -
154
What are the lab results for early acute HBV?
Anti-HBc IgM -
Anti-HBc IgG -
HBsAg +
Anti-HBs
155
What are the lab results for resolved acute HBV?
Anti-HBc IgM -
Anti-HBc IgG +
HBsAg -
Anti-HBs +
156
What are the lab results for HBV vaccine/immunity?
Anti-HBc IgM -
Anti-HBc IgG -
HBsAg -
Anti-HBs +
157
What are the lab results for no infection or immunity?
Anti-HBc IgM -
Anti-HBc IgG -
HBsAg -
Anti-HBs -
158
What are the lab results for chronic HBV?
Anti-HBc IgM -
Anti-HBc IgG +
HBsAg +
Anti-HBs -
159
What are the lab results for acute hepatitis C?
HCV RNA +
| Anti-HCV +/-
160
What are the lab results for resolved hepatitis C?
HCV RNA -
| Anti-HCV +/-
161
What are the lab results for chronic hepatitis C?
HCV RNA +
| Anti-HCV +
162
What are the lab results for acute hepatitis A?
IgM HAV Ab +
163
What are the lab results for past exposure of hepatitis A?
IgM HAV Ab -
| IgG HAV Ab +
