Gastrointestinal and Nutritional Flashcards
1
Q
What is biliary colic?
A
intense, dull comfort located in the RUQ or epigastrium, associated with nausea, vomiting, and diaphoresis
- it generally lasts at least 30 minutes, plateauing within one hour
- benign abdominal examination
2
Q
What is acute acholecystitis?
A
prolonged (>4 to 6 hours) RUQ or epigastric pain, fever.
-patients will have abdominal guarding and Murphy’s sign
3
Q
What is acute cholangitis?
A
fever, jaundice, RUQ pain
4
Q
What is sphincter of Oddi dysfunction?
A
RUQ pain is similar to other biliary pain
5
Q
What is acute hepatitis?
A
RUQ pain with fatigue, malaise, nausea, vomiting, and anorexia
-patients may also have jaundice, dark urine, and light-colored stools
6
Q
What is perihepatitis (Fitz-Hugh-Curtis syndrome)?
A
RUQ pain with a pleuritic component, pain sometimes referred to the right shoulder
7
Q
What is a liver abscess?
A
fever and abdominal pain are the most common symptoms
8
Q
What is Budd-Chiari syndrome?
A
symptoms include fever, abdominal pain, abdominal distention (from ascites), lower extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy
9
Q
What is portal vein thrombosis?
A
symptoms include fever, abdominal pain, abdominal distention (from ascites), lower extremity edema, jaundice, gastrointestinal bleeding, and/or hepatic encephalopathy
10
Q
What is portal vein thrombosis?
A
symptoms include abdominal pain, dyspepsia, or gastrointestinal bleeding
11
Q
What are the clinical features of acute myocardial infarction?
A
may be associated with shortness of breath and exterional symptoms
12
Q
What are the clinical features of acute pancreatitis?
A
acute-onset, persistent upper abdominal pain radiating to the back
13
Q
What are the clinical features of chronic pancreatitis?
A
epigastric pain radiating to the back
14
Q
What are the clinical features of peptic ulcer disease?
A
epigastric pain or discomfort is the most prominent symptom
15
Q
What are the clinical features of gastroesophageal reflux disease?
A
associated with heartburn, regurgitation, and dysphagis
16
Q
What are the clinical features of gastritis/gastropathy?
A
abdominal discomfort/pain, heartburn, nausea, vomiting, and hematemesis
17
Q
What are the clinical features of functional dyspepsia?
A
the presence of one or more of the following: postprandial fullness, early satiation, epigastric pain, or burning
18
Q
What are the clinical features of gastroparesis?
A
nausea, vomiting, abdominal pain, early satiety, postprandial fullness, and bloating
19
Q
What are the clinical features of splenomegaly?
A
pain or discomfort in LUQ, left shoulder pain, and/or early satiety
20
Q
What are the clinical features of splenic infarct?
A
severe LUQ pain
21
Q
What are the clinical features of splenic abscess?
A
associated with fever and LUQ tenderness
22
Q
What are the clinical features of splenic rupture?
A
may complain of LUQ, left chest wall, or left shoulder pain that is worse with inspiration
23
Q
Where is the localization of appendicitis?
A
generally right lower quadrant
24
Q
What are the clinical features of appendicitis?
A
periumbilical pain initially that radiates to the right lower quadrant
-associated with anorexia, nausea, and vomiting
25
Where is the localization of diverticulitis?
generally left lower quadrant; right lower quadrant more common in Asian patients
26
What are the clinical features of diverticulitis?
the pain is usually constant and present for several days prior to presentation
-may have associated nausea and vomiting
27
Where is the localization of nephrolithiasis?
either
28
What are the clinical features of nephrolithiasis?
pain most common symptom varies from mild to severe
| -generally, flank pain, but may have back or abdominal pain
29
What are the clinical features of pyelonephritis?
associated with dysuria, frequency, urgency, hematuria, fever, chills, flank pain, and costovertebral angle tenderness
30
Where is the localization of pyelonephritis?
either
31
Where is the localization of acute urinary retention?
suprapubic
32
What are the clinical features of acute urinary retention?
present with lower abdominal pain and discomfort; inability to urinate
33
Where is the localization of cystitis?
suprapubic
34
What are the clinical features of cysitis?
associated with dysuria, frequency, urgency, and hematuria
35
Where is the localization of infectious colitis?
either
36
What are the clinical features of infectious colitis?
diarrhea is the predominant symptom, but may also have associated abdominal pain, which may be severe
37
What is an acute appendicitis?
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
38
What are the signs of acute appendicitis?
- Rovsing - RLQ pain with palpation of LLQ
- Obturator sign - RLQ pain with internal rotation of the hip
- Psoas sign - RLQ pain with hip extension
39
How is an acute appendicitis dx?
- imaging if atypical presentation - appy ultrasound or abdominal CT scan
- CBC - neutrophilia supports the diagnosis
40
What is the tx of acute appendicitis?
surgical appendectomy
41
What is cholelithiasis?
a precursor to cholecystitis
| -stones in the gallbladder, pain secondary to contraction of gall against the obstructed cystic duct
42
What are the characteristics of cholelithiasis?
- asymptomactic (most), symptoms only last few hours
- biliary colic - RUQ pain or epigastric
- pain after eating at night
- Boas sign - referred right subscapular pain
- RUQ ultrasound - high sensitivity and specificity if > 2 mm, CT scan and MRI
43
What is the tx of cholelithiasis?
asymptomatic - no treatment necessary
| -elective cholecystectomy for recurrent bouts
44
What is cholecystitis?
inflammation of the gallbladder; usually associated with gallstones
45
What is the presentation of cholecystitis?
- 5 Fs: Female, Fat, Forty, Fertile, Fair
- (+) Murphy's sign (RUQ pain with GB palpation on inspiration)
- RUQ pain after a high-fat meal
- Low-grade fever, leukocytosis, jaundice
46
How is cholecystitis dx?
- 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 sensititve for perforation, abscess, pancreatitis
- labs: increase Alk-P and increase GGT, increase conjugated bilirubin
- porcelain gallbladder = chronic cholecystitis
- choledocholithiasis = stones in common bile duct - diagnosed with ERCP (gold standard)
47
What is the tx of cholecystitis?
cholecystectomy (first 24-48 hours)
48
What is acute hepatitis?
an acute (temporary) form of hepatitis, which describes the inflammation of the liver tissue
49
What are the causes of acute hepatitis?
- viral hepatitides (HAV, HCV, and HBV)
- parasites (toxoplasmosis)
- alcohol
- drug-induced (acetaminophen)
- autoimmune hepatitis
- steatohepatitis
- metabolic disease
50
What is the presentation of acute hepatitis?
recent travel and sudden jaundice
- initial prodrome of flu-like symptoms (fatigue, nausea, vomiting, headaches) followed by jaundice (1-2 weeks after)
- right upper quadrant (RUQ) pain, jaundice, scleral icterus, hepatomegaly, splenomegaly, fever
51
How is acute hepatitis dx?
ultrasound is a good initial imaging modality for rule out of other causes of abdominal pain
-hepatomegaly (most sensitive sign) and gallbladder wall thickening
Serum analysis
-(CBC) may demonstrate elevated WBC count with atypical lymphocytosis in viral hepatitis
-hepatic panel
-mixed direct and indirect hyperbilirubinemia
-dramatically elevated aspartate aminotransferase (AST) and alanine aminotranferase (ALT)
-ALT usually higher than AST
-AST: ALT > 2, suspect alcohol hepatitis
-hepatitis viral serologies
-IgM antibodies are present during early infection
-IgG antibodies are present and remain after recovery: if patient is positive for IgG but negative for IgM, the patient is immune via either prior infection or vaccination
52
What is the serology for acute HBV?
+ Anti-HBc IgM
- Anti-HBc IgG
+ HBsAg
- Anti-HBs
53
What is the serology for early acute HBV?
- Anti-HBc IgM
- Anti-HBc IgG
+ HBsAg
- Anti-HBs
54
What is the serology for resolved acute HBV?
- Anti-HBc IgM
+ Anti-HBc IgG
- HBsAg
+ Anti-HBs
55
What is the serology for HBV vaccine/immunity?
- Anti-HBc IgM
- Anti-HBc IgG
- HBsAg
+ Anti-HBs
56
What is the serology for no infection or immunity?
- Anti-HBc IgM
- Anti-HBc IgG
- HBsAg
- Anti-HBs
57
What is the serology for chronic HBV?
- Anti-HBc IgM
+ Anti-HBc IgG
+ HBsAg
- Anti-HBs
58
What is the serology for acute hepatitis C?
+ HCV RNA
| +/- Anti-HCV
59
What is the serology for resolved hepatitis C?
- HCV RNA
| +/- Anti-HCV
60
What is the serology for chronic hepatitis C?
+ HCV RNA
| + Anti-HCV
61
What is the serology for acute hepatitis A?
+ IgM HAV Ab
62
What is the serology for past exposure of hepatitis A?
- IgM HAV Ab
| +IgG HAV Ab
63
What is the lifestyle treatment for acute hepatitis?
- supportive care
- indications
- especially for patients with acute viral hepatitis and alcoholic hepatitis
- modalities
- fluid and electrolyte management
- treatment of any encephalopathy or coagulopathy
- monitor and management for alcohol withdrawal and abstain from alcohol
- nutritional support for acute alcoholic hepatitis
- thiamine/folate
64
What is the medical treatment for acute hepatitis?
- antiviral therapy
- indications: used for the treatment of severe acute hepatitis B
- modalities: nucleoside analogs (e.g. entecavir)
- pentoxifylline and/or corticosteroids
- indications: used for severe alcoholic hepatitis
65
What is acute pancreatitis?
inflammation of the pancreas
| -it happens when digestive enzymes start digesting the pancreas itself
66
What are the characteristics of acute pancreatitis?
- pancreatitis may start suddenly and last for days, or it can occur over many years
- symptoms include upper abdominal pain radiating to the back, nausea, and vomiting
- it has many causes, including gallstones and chronic, heavy alcohol use
- the mnemonic GET SMASHED is useful in recalling the most common causes: Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune disease, Scorpion sting, Hypercalcemia, Hyperlipidemia, ERCP, and drugs
67
How is acute pancreatitis dx?
clinical + elevated lipase and amylase
- abdominal CT is the diagnostic test of choice - required to differentiate from necrotic pancreatitis
- ERCP is the most sensitive for chronic pancreatitis
68
What are the signs of acute pancreatitis?
Grey Turner's sign (flank bruising), Cullen's sign (bruising near umbilicus)
69
What is the Ranson's criteria for poor prognosis for acute pancreatitis?
At admit
- Age > 55
- Leukocyte: >16,000
- Glucose: >200
- LDH: >350
- AST: >250
At 48 hours:
- Arterial PO2: <60
- HCO3: <20
- Calcium: <8.0
- BUN: Increase by 1.8+
- Hematocrit: decrease by >10%
- Fluid sequestration > 6 L
70
What is the tx of acute pancreatitis?
```
IV fluids (best), analgesics, bowel rest
-complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood and necrotic tissue)
```
71
What is an anorectal abscess?
a result of infection, whereas fistula is a chronic complication of an abscess
- produce painful swelling at the anus as well as painful defecation
- examination reveals localized tenderness, erythema, swelling, and fluctuance; fever is uncommon
- deeper abscesses may produce buttock or coccyx pain and rectal fullness; fever is more likely
72
What is the tx of anorectal abscess?
requires surgical drainage, followed by warm-water cleansing, analgesics, stool softeners, and a high-fiber diet are prescribed for all patients
- many abscesses can be drained as an in-office procedure; deeper abscesses may require drainage in the operating room
- antibiotics are needed for high-risk patients
73
What is an anorectal fistula?
an open tract between two epithelium-lined areas and is associated with deeper anorectal abscesses
-fistulae will produce anal discharge and pain when the tract becomes occluded
74
What is the tx for anorectal fistula?
must be treated surgically
75
What is an anal fissure?
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
76
What is the tx of an anal fissure?
- 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)
77
What is the classic chronological order of an appendicitis?
- periumbilical pain (intermittent and crampy)
- nausea/vomiting
- anorexia
- pain migrates to RLQ (constant and intense pain), usually in 24 hours
78
What are the symptoms of gastric ulcers?
epigastric pain, vomiting, anorexia, and nausea
79
What are the symptoms of duodenal ulcers?
epigastric pain - burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain) bleeding back pain nausea, vomiting, and decreased appetite
80
What are the symptoms of gastric cancer?
"WEAPON": weight loss, emesis, anorexia, pain/epigastric discomfort, obstruction, nausea
81
What are the symptoms of lower GI bleed?
hematochezia (bright red blood per rectum [BRBPR]), with or without abdominal pain, melena, anorexia, fatigue, syncope, shortness of breath, shock
82
What are the symptoms of carcinoma of the gallbladder?
biliary colic, weight loss, anorexia; many patients are asymptomatic until late; may present as acute cholecystitis
83
What are the symptoms of pancreatic carcinoma?
painless jaundice from obstruction of common bile duct; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in the skin; anorexia; Courvoisier's sign; acholic stools; dark urine; diabetes
84
What are the medications that cause anorexia?
sedatives, digoxin, laxatives, thiazide diuretics, narcotics, antibiotics
85
What are the causes of constipation/obstipation (severe or complete constipation)?
- colerectal cancer: consider this in all patient over 50 with new-onset constipation
- bowel obstruction: x-ray with air-fluid levels and dilated loops of bowel
- volvulus: an obstruction due to twisting or knotting of the gastrointestinal tract, symptoms include belly pain and bloating, nausea, bloody stools, and constipation, X-ray with colonic distention
- Illeus: hypermobility of the GI tract in the absence of mechanical obstruction, absent bowel sounds
- gastroparesis: (diabetes) vomiting, abdominal pain, fullness after eating small amounts
86
What are causes of diarrhea?
may be infectious, toxic, dietary (excessive laxative use) or other GI disease, inflammatory diarrhea (bloody diarrhea with fever) indicates an invasive organism or inflammatory bowel disease
87
What is cholangitis?
an infection of biliary tract secondary to obstruction, which leads to biliary stasis and bacterial overgrowth
88
What are the characteristics of cholangitis?
- characterized by pain in the upper-right quadrant of the abdomen, fever, and jaundice
- choledocholithiasis accounts for 60% of cases
- other causes include pancreatic and biliary neoplasm, postoperative strictures, invasive procedures such as ERCP or PTC, and choledochal cysts
- organisms: E.coli, Enterococcus, Klebsiella, Enterobacter
89
What is the presentation of cholangitis?
- Charcot's triad: RUQ tenderness, jaundice, fever
| - Reynold's pentadf: Charcot's triad+ altered mental status and hypotension
90
What are the diagnostic studies for cholangitis?
- initial imaging: ultrasound
| - best: ERCP
91
What is the tx of cholangitis?
is potentially life-threatening and requires emergency treatment
- aggressive care and emergent removal of stones, Cipro + metronidazole
- antibiotics, fluids, and analgesia
- ERCP to remove stones, insert a stent, repair the sphincter
- cholecystectomy (performed post-acute)
92
What is primary sclerosing cholangitis?
- jaundice and pruritus
| - associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer
93
What is cirrhosis?
a chronic liver disease characterized by fibrosis, disruption of the liver architecture, and widespread nodules in the liver
94
What are the characteristics of cirrhosis?
- the most common cause is alcoholic liver disease
- second most common cause: chronic hepatitis B and C infections
- labs: typically AST > ALT
- 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
95
What are the distortion of live anatomy causes of cirrhosis?
- Portal HTN: decreased blood flow through the liver - hypertension in portal circulation; causes ascites, peripheral edema, splenomegaly, varicosity of veins
- ascites - accumulation of fluid in the peritoneal cavity due to portal HTN and hypoalbuminemia
- the most common complication of cirrhosis
- abdominal distension, shifting fluid dullness, fluid wave
- abdominal ultrasound, diagnostic paracentesis - measure serum albumin gradient
- salt restriction and diuretics (furosemide and spironolactone)
- paracentesis if tense ascites, SOB, or early satiety
- esophageal variceal rupture - dilated submucosal veins, retching or dyspepsia, hypovolemia, hypotension, and tachycardia
- hepatorenal syndrome: progressive renal failure in ESLD, secondary to renal hypoperfusion from vasoconstriction - azotemia (elevated BUM), oliguria (low urine output, and hypotension
- hepatic encephalopathy: ammonia accumlates and reaches the brain causing decrease mental function, confusion, poor concentration
- asterixis (flapping tremor) - have patient flex hands
- dysarthria, delirium, and coma
- hepatocellular failure - decreases albumin synthesis and clotting factor synthesis
- prolonged PT - PTT in severe disease - tx with fresh frozen plasma
96
What is the presentation of cirrhosis?
- ascites, pulmonary edema/effusion, esoophageal varices, Terry's nails (white nail beds)
- skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation
97
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 hepatocellular carcinoma
- CT-guided biopsy for hepatocellular carcinoma
98
What is constipation?
defined as less than 3 bowel movements per week
- according to the Rome III criteria, functional constipation is defined as any 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)
99
What are the characteristics of constipation?
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
- patients who are older than 50 with new-onset constipation should be evaluated for colon cancer
- bloating, abdominal pain, straining and pain with bowel movements
- opiate use is a classic cause of constipation, all patients on chronic opioids should be prophylaxed with stool softener
- think of causes of secondary causes of constipation: DM, hypothyroidism, MS, dehydration, medications are common
100
How is constipation dx?
a comprehensive physical examination should be performed that includes a rectal exam to palpate for hard stools, assess for masses, anal fissures, hemorrhoids, sphincter tone, push effort during attempted defecation, prostatic hypertrophy in males, and posterior vaginal masses in females
- there are limited date to support the role of imaging in the evaluation of constipation in the older adult
- laboratory testing: CBC, CMP, TSH to identify secondary causes
101
What is the tx of constipation?
increase fiber (20 to 25 grams per day), exercise and water in the diet
Laxatives:
-bulk-forming laxatives first line - bulk-forming laxatives include psyllium seed (eg, Meamucil), methylcellulos (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 adults
-stimulant laxatives
-stool softeners, suppositories (glycerin or bisacodyl) and enemas have limited clinical efficacy and should be used in specific clinical scenarios
- a patient with constipation lasting for more then 2 weeks that is refractory to treatments should undergo further investigation to identify the underlying cause
102
What are the causes of diarrhea?
may be infectious, toxic, dietary (excessive laxative use) or other GI diseases
-inflammatory diarrhea (bloody diarrhea with fever) indicated an invasive organism or inflammatory bowel disease
103
What are the causes of diarrhea from exposure to daycare centers?
rotavirus, cryptosporidium, giardia, shigella
104
What are the causes of diarrhea from breakout in a daycare center?
rotavirus
105
What are the causes of diarrhea from hospital admission?
C. difficile, treatment adverse effect
106
What are the causes of diarrhea from recent antibiotic use?
C. difficile
107
What are the causes of diarrhea from cruise ship?
norovirus
108
What are the causes of diarrhea from picnic and egg salad?
staphylococcus aureus
109
What are the causes of diarrhea from seafood?
especially raw or undercooked shellfish: Vibrio cholerae, Vibrio parahaemolyticus
110
What are the causes of diarrhea from raw ground beef or seed sprouts?
Shiga toxin-producing E.coli (e.g. E. coli O157:H7)
111
What are the causes of diarrhea from poultry or pork?
Salmonella
112
What are the causes of diarrhea from undercooked beef, pork, or poultry?
staphylococcus aureua, Clostridium perfringens, Salmonella, Listeria (beef, pork, poultry), Shiga toxin-producing E. coli (beef and pork), B. cereus (beef and pork), Yersinia (beef and pork), campylobacter (poultry)
113
What are the causes of diarrhea from travel to a develop country?
enterotoxigenic E. coli is most common (traveler's diarrhea)
-many other pathogens (e.g Shigella, Salmonella, E. histolytica, Giardia, Cryptosporidium, cyclospora, enteric viruses) are possible because of poorly cleaned or cooked food, or fecal contamination of food or water
114
What are the causes of diarrhea from poorly canned home foods?
C. perfringens
115
What are the causes of diarrhea from fried rice?
Bacillus cereus
116
What are the causes of diarrhea from raw milk?
salmonella, campylobacter, Shiga toxin-producing E.coli, Listeria
117
What are the causes of diarrhea from camping?
consumption of untreated water: Giardia - incubates for 1 to 3 weeks, causes foul-smelling bulky stools and may wax and wane over weeks before resolving
118
What are the causes of diarrhea from receptive anal intercourse?
with or without rectal pain or proctitis: Herpes simplex virus infection, chlamydia, gonorrhea, syphilis
119
What are the causes of diarrhea from human immunodeficiency virus infection, immunosuppression?
cryptosporidium, microsporidia, isospora, cytomegalovirus, mycobacterium avium-intracellulare complex, listeria
120
What are the causes of diarrhea from rice-water stools?
V. cholerae
121
What are the causes of diarrhea from blood stools?
salmonella, shigella, campylobacter, shiga toxin-producing E. coli, clostridium difficile, entamoeba histolytica, yersinia
122
What are the causes of diarrhea from afebrile, abdominal pain with bloody diarrhea?
shiga toxin-producing Escherichia coli
123
What is diverticular disese?
inflammation of an abnormal pouch (diverticulum) in the intestinal wall, usually found in large intestine
- the presence of the pouches themselves is called diverticulosis, when they become inflamed, the condition is known as diverticulitis
- left-sided appy
- most common location: sigmoid colon
- fevers/chills/nausea/vomiting/left-sided abdominal pain
124
How is diverticular disease dx?
abdominal/pelvic CT scan revealing fat stranding and bowel wall thickening
-the most common cause of massive lower gastrointestinal bleeding
125
What is the tx of divberticular disease?
ciprofloxacin or augmentin/ + metronidazole (Flagyl)
- recurrent attacks or the presence of perforation, fistula, or abscess require surgical removal of the involved portion of the colon
- treat by increasing the bulk in the diet with high-fiber foods and bulk additives such as Metamucil
126
What is esophagitis?
simply inflammation that may damage tissues of the esophagus
-it can be divided into two types: non-infectious and infectious
127
What are the characteristics of non-infectious esophagitis?
- reflux esophagitis: mechanical or functional abnormality of the LES
- medication-induced: think NSAIDs or bisphosphonates
- eosinophilic: pt with asthma symptoms and GERD not responsive to antacids, allergic, eosinophilic infiltration of the esophageal epithelium
- diagnosed with a biopsy
- a barium swallow will show a ribbed esophagus and multiple corrugated rings
- Radiation: radiosensitizing drugs include doxorubicin, bleomycin, cyclophosphamide, cisplatin
- dysphagia lasting weeks-months after therapy
- radiation exposure of 5000 cGy associated with increased risk for stricture
- Corrosive: ingestion of alkali or acid from attempted suicide
128
What are the characteristics of infectious esophagitis?
odynophagia (pain while swallowing food or liquids) is the hallmark sign
- this occurs mainly in patients with impaired host defenses, primary agents include Candida albicans, herpes simplex virus, and cytomegalovirus
- symptoms are odynophagia and chest pain
- fungal: infectious Candida: linear yellow-white plaques with odynophagia or pain on swelling, Tx with Fluconazole 100 mg PO daily
- Viral
- HSV: shallow punched out lesions on EGD, treat with acyclovir
- CMV: large solitary ulcers or erosions on EGD, treat with ganciclovir
- EBV, mycobacterium tuberculosis, and mycobacterium avium intracellular are additional infectious causes
129
How is esophagitis dx?
endoscopy, biopsy, double-contrast esophagram, and culture
130
How is esophagitis treated?
- Candida: treat with fluconazole 100 mg PO daily
- HSV: treat with acyclovir
- CMV: treat with ganciclovir
- Corrosive: treat with steroid
- Eosinophilic: treat by removing foods that incite allergic response, topical steriods via inhaler
- Medication-induced: to prevent bisphosphonate-related esophagitis treat by drinking pills with at least 4 ounces of water, avoid laying down for at least 30-60 minutes after ingestion
131
What is gastritis?
dyspepsia (bleching, bloating, distension, and heartburn) and abdominal pain are common indicators of gastritis
132
What are the three causes of gastritis?
- infection - H. pylori (most common)
- inflammation of the stomach lining (NSAIDs and alcohol)
- autoimmune or hypersensitivity reaction (pernicious anemia)
133
What are the characteristics of gastritis caused by infection?
- location: antrum and body
| - studies: urea breath test or fecal antigen
134
What are the characteristics of gastritis caused by inflammation?
- NSAIDs: cause gastric injury by diminishing local prostaglandin production in the stomach and duodenum
- alcohol: a leading cause of gastritis
135
What are the characteristics of gastritis caused by autoimmune or hypersensitivity reaction?
- location: body of the fundus
| - pernicious anemia: + schilling test + decreased intrinsic factor and parietal cell antiboides
136
What is the treatment and diagnosis of gastritis?
- stop NSAIDs, empiric therapy with acid suppression 4-8 wk of PPI
- if no response, consider upper GI endoscopy with biopsy and ultrasound
- test for H. pylori inection - if H. pylori (+) treat with (CAP) - clarithromycin + amoxicillin +/- metronidazole + PPI (i.e omeperzole)
- quadruple therapy (PPI, pepto, and 2 antibiotics) for one week
137
What are the characteristics of upper GI bleed?
bleeding that originates proximal to the ligament of Treitz
- hematemesis: vomiting of blood or coffee-ground emesis
- melena: black tarry stool
138
What are the causes of orthostatic hypotension, tachycardia, and abdominal tenderness?
- peptic ulcer: upper abdominal pain
- esophageal ulcer: odynophagia, gastroesophageal reflux, dysphagia
- Mallory-Weiss tear: emesis, retching, or coughing prior to hematemesis
- Esophageal varices with hemorrhage or portal hypertension: jaundice, abdominal distention (ascites)
- malignancy (gastric cancer and right-sided colon cancer): dysphagia, early satiety, involuntary weight loss, cachexia
- severe erosive esophagitis: odynophagia (painful swallowing), dysphagia and retrosternal chest pain
139
What is the tx for 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
- treat with IV PPI until confirmation of the cause of bleeding - treat the underlying cause
- srugery - duodenotomy or gastroduodenostomy, ligation of bleeding
140
What are the causes of lower GI bleed?
hematochezia (BRBPR): the passage of maroon or right red blood of clots per rectum
141
What are the causes of orthostatic hypotension or shock with lower GI bleed?
- hemorrhoids: painless bleeding with wiping
- anal fissures: severe rectal pain with defecation
- 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
142
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, nonbloody diarrhea
- Dx: stool sample cyst or trophozoites
- Tx with tinidazole (first line)
- Flagyl (Metronidazole) 250-750 mg PO TID
- symptoms resolve within 5-7 days
143
What are the characteristics of pinworm (enterobius vermicularis)?
perianal pruritus that is worse at night
- Dx: "scotch tape test" done in the early morning, can see the eggs under microscopy
- tx with mebendazole or pyrantel pamoate
144
What are the characteristics of tapeworm?
GI symptoms and weight loss
- transmission from raw or undercooked meat
- associated with B12 deficiency
- DX: tape test for diphyllobothrium latum, stool sample: eggs
- Tx: praziquantel
145
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
- eosinophilia and anemia
- DX: stool sample - adult worms
- TX: mebendazole or pyrantel
146
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
- DX: stool sample eggs or adult worms
- Tx: albendazole, mebendazole, pyrantel pamoate
147
What are the characteristics of amebiasis?
entamoeba histolytica (protozoa)
- fecal-oral, contaminated water/food, anal-oral
- bloody diarrhea, tenesmus, abdominal pain
- associated with liver abscess
- DX: stool sample - trophozoites
- TX: lodoquinol or paromomycin and flagyl for liver abscess
148
What are the characteristics of 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 urine
- DX: eggs in urine or feces
- Tx: praziquantel
149
What is heartburn?
burning pain or discomfort in the upper chest and midchest, possibly involving the neck and throat, that usually occurs after eating or at night and may worsen when lying down
150
What are the causes of heartburn?
can have causes that aren't due to underlying disease
| -examples include spicy food, alcohol, overeating, or tight clothing
151
What are the characteristics of acid reflux (GERD)?
a digestive disease in which stomach acid or bile irritates the esophagus
- acid reflux and heartburn more than twice a week may indicate GERD
- symptoms include burning pain in the chest that usually occurs after eating and worsens when lying down
152
What are the characteristics of food intolerance?
digestive problems that occur after a certain food is eaten
| -once the cause of the intolerance is identified, diet medication is the main treatment
153
What are the characteristics of esophagitis?
esophagitis often causes painful, difficulty swallowing, and chest pain with eating
- emergency symptoms include food stuck in the esophagus and chest pain that lasts more than a few minutes
- causes include GERD, infection, some medications, and allergies
154
What are the characteristics of gastritis?
any of a group of conditions in which the stomach lining is inflamed
-causes include infection (H. pylori), injury, regular use of pain pills called NSAIDs, and too much alcohol
155
What are the characteristics of a hiatal hernia?
a condition in which part of the stomach pushes up through the diaphragm muscle
-hiatal hernias can have no symptoms, in some cases, they may be associated with heartburn and abdominal discomfort
156
What are the characteristics of peptic ulcer disease (PUD)?
burning abdominal pain, nausea, vomiting, bloating, history of using a PPI or H2 blocker, pain presents post-prandially and usually resolves on its own, not likely to have significant weight loss, history or H. pylori and/or chronic NSAID use
157
How is heartburn dx?
patients with self-limiting or mild symptoms do not automatically require further workup
-those with long-standing or atypical symptoms (wheezing, cough, hoarseness), recurrence of disease after the cessation of medical therapy, or unrelieved symptoms when taking maximal-dose PPIs should undergo diagnostic testing to confirm the diagnosis and to rule out complications of GERD
158
What is the work-up for heartburn?
although not all surgeons routinely perform all four studies, a standard workup prior to a surgical antireflux procedure includes
- endoscopy with biopsy is the gold standard for diagnosis
- manometry
- 24-hour ambulatory pH probe testing
- barium esophagography
- x-ray
- esophageal motility testing
159
What is the tx for heartburn?
- empiric treatment with lifestyle modification and acid suppression therapy for classic presentations
- lifestyle modification: avoid triggering foods (fatty, caffeine, acidic, and alcohol), stop smoking, sleep in an elevated position, stop NSAIDs
- step-up therapy for mild to moderate symptoms = histamine H2 receptor antagonist - proton pump inhibitor
- step down therapy for severe or erosive symptoms for faster relief = proton pump inhibitor - histamine H2 receptor antagonist
- H. pylori infection: triple therapy PPI (ie omeprazole) + clarithromycin + amoxiccilin +/- metronidazole
- surgical - fundoplication = for failed medical management or complications
- Zollinger-Ellison syndrome: PPI and resect the tumor
160
What is hematemesis?
vomiting of stomach contents mixed with blood, or the regurgitation of blood only
161
What are the symptoms of peptic ulcer disease?
hematemesis, abdominal discomfort, dull pain
162
What are the symptoms of esophageal varicer?
hematemesis, bleeding, difficulty swallowing
163
What are the symptoms of alcohol abuse?
physical dependence, craving, vomiting
164
What are the symptoms of Mallory-Weiss syndrome?
a tear in the lining of the stomach just above the esophagus caused by violent retching or vomiting
165
What are the symptoms of coagulation disorders?
characterized by a decreased ability to form a clot
166
What are the symptoms of esophageal cancer?
progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis
167
What are the symptoms of Gastrointestinal system neoplasms?
abdominal pain and unexplained weight loss are most common symptoms along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, guaiac-positive stool
168
What is hemorrhoids?
varicose veins of anus and rectum
- risk factor: constipation/straining, pregnancy, portal HTN, obesity, prolonged sitting or standing, anal intercourse
- hematochezia - rectal bleeding (BRPPR), painless, fecal soilage
- dx: anoscopy if BRBPR or suspected thrmobosis
169
What are 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
170
What are 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
- closed hemorrhoidectomy if permanently prolapsed
171
What is a hernia?
a protrusion of an organ or structure through the wall that normally contain it
172
what is a hiatal (diaphragmatic) hernia?
involves protrustion of the stomach through the diaphragm via the esophageal hiatus, it can cause symptoms of GERD; acid reduction may suffice , although a surgical repair can be used for more serious cases
173
What is a ventral hernia?
often from previous abdominal surgery, obesity, abdominal mass noted at the site of previous infection
174
What is a umbilical hernia?
very common, generally is congenital and appears at birth, many umbilical hernias resolve on their own and rarely require intervention, refer to surgery if an umbilical hernia persists > 2 year of life
175
What is a indirect inguinal hernia?
(most common): passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum, often congenital and will present before age one
-remember: indirect goes through the internal inguinal ring (an "i" for an "i")
176
What is a direct inguinal hernia?
passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum
177
What are the types of hernias?
various types can entrap the intestines and cause an intestinal blockage - this is called an "incarcerated hernia" and is a medical emergency
- strangulated hernia: a hernia becomes strangulated when the blood supply of its contents is seriously impaired
- obstructed hernia: this is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel
- incarcerated hernia: a hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated
178
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)
179
What is the tx for ulcerative colitis?
- colectomy is curative
| - medications: prednisone and mesalamine
180
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, aphthous ulcers, weight loss, nonbloody diarrhea, abdominal pain, and cramping
- barium enema: cobblestone appearance
181
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
182
what is toxic megacolon?
- toxic patient: sepsis, febrile, abdominal pain
- megacolon: acutely and massively distended colon
- can occur with IBD (UC > Crohn's)
183
What is the tx of toxic megacolon?
decompression of the colon is required
| -in some cases, colostomy or even complete colonic resection may be required
184
What is ischemic bowel disease?
inadequate blood supply resulting in vascular compromise to bowel
- fifty-year-old with a history of coronary artery disease experiencing recurrent cramping with postprandial abdominal pain
- most common artery: superior mesenteric artery
- acute: abdominal pain out of proportion to findings
- chronic: pain 10-30 mins after eating, relieved by lying or squatting
185
What is the imaging for ischemic bowel disease?
- plain films/CT: bowel edema, pneumatosis intestinalis (gas within the bowel), portal venous gas
- mesenteric angiography is the gold standard
186
What is the tx for ischemic bowel disease?
- supportive: bowel rest, fluids, antibiotics
- laparotomy with bowel resection for bowel infarction
- revascularization is the gold standard
187
What is jaundice?
yellowing of the skin, nail beds, sclera by bilirubin deposition as a consequence of hyperbilirubinemia
- the first sing of jaundice is scleral icterus
- serum bilirubin > 2.5 mg/dl - not a disease but a sign of disease
- occurs with increased bilirubin overproduction (hemolysis)/ineffective erythropoiesis, decreased hepatic bilirubin uptake, impaired conjugation, biliary tract obstruction, viral hepatitis, physiologic jaundice of newborn, gilbert syndrome, Dubin-johnson
188
What is hemolytic jaundice?
prehepatic
- increased indirect/unconjuaged bilirubin, mild hyperbiliruinemia
- dark urine due to hemoglobinuria; dark stools
189
What is obstructive jaundice?
post hepatic
- cholestasis = bile duct blockage = increased conjugated bilirubin
- cholestasis/pancreatic CA
- increased direct/conjugated hyperbilirubinemia
- GGT and ALP elevated
- dark urine = increased direct bilirubin
- acholic stools = biliary obstruction (white)
190
What is hepatocellular (intrahepatic) jaundice?
- increased indirect and direct bilirubin; ALT and AST markedly elevated
- dark urine = increased direct bilirubin
- ETOH hepatitis: AST > ALT 2:1
- acute hepatitis: increased ALT and AST > 1000; ALT > AST usually
- chronic hepatitis: increased ALT: AST but < 500
191
How is jaundice dx?
- bilirubin > 2.5 mg/dL
- increased bilirubin without increased LFTs = suspected familial bilirubin disorders (gilbert's, Dubin-johnsons) and hemolysis
192
What is the tx of jaundice?
depends on the underlying cause
193
What is Mallory-Weiss tear?
tear that occurs in the esophageal mucosa at the junction of the esophagus and stomach caused by severe retching and vomiting and results in severe bleeding
- presentation: history of alcohol intake and an episode of vomiting with blood
- caused by forceful vomiting, associated with alcohol use, upper endoscopy showing superficial longitudinal mucosal erosions
194
What is the tx for Mallory-Weiss tear?
supportive, may cauterize or inject epinephrine if needed
195
What are the causes of melena?
black tarry stool - upper GI bleed
-gastric cancer, duodenal ulcers, right-sided colon cancer, portal hypertension with esophageal varices, severe erosive esophagitis, Mallory-Weiss syndrome
196
What are the causes of hematochezia?
bright red blood per rectum (BRBPR) - lower GI bleed
-hemorrhoids, anal fissures, polyps, proctitis, rectal ulcers, and colorectal cancer, diverticulosis is generally an incidental finding since diverticular bleeding is usually of greater volume
197
What is nausea?
can have causes that aren't due to underlying disease, examples include motion such as from a car and plane, taking pills on an empty stomach, eating too much or too little, or drinking too much alcohol
198
What are the symptoms of gastroenteritis?
nausea, vomiting, diarrhea, stomach cramps
199
What are the symptoms of migraine headache?
nausea, vomiting, headache
200
What are the symptoms of food poisoning?
nausea, vomiting, malaise
201
What are the symptoms of influenza virus?
nausea, vomiting, cough with phelgm
202
What are the symptoms of pyloric stenosis?
infant with projectile vomiting
203
What are the symptoms of peptic ulcer disease?
upper abdominal pain, may have nausea or vomiting
204
What are the symptoms of hiatal hernia?
symptoms of GERD
205
What are the symptoms of common cold?
nausea, vomiting, runny nose
206
What is the tx for nausea?
treatment includes anti-emetics - scopolamine patch, dexamethasone (4 mg), ondansetron (4 mg)
- rescue antiemetics: prochlorperazine, droperidol
- GI cocktail: maalox, viscous lidocaine, droperidol
- PO challenge in ED - eat something before going home = can be performed with GI cocktail
207
What is a small bowel obstruction?
- 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 intussuscpetion
- KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon
208
What is a large bowel obstruction?
- gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in elderly
- febrile, tachycardia - shock
- dehydration + electrolyte imbalances
- MCC: cancer, strictures, hernias, volvulus, and fecal impaction
- KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon
209
What do you look for with bowel obstruction?
look for 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 colon
210
What is the tx for a bowel obstruction?
bowel rest, NG tube placement, surgery as directed by the underlying cause
211
What is the presentation for a gastric ulcer?
patient will present with - abdominal discomfort that is worse with meals and gets better an hour or so later after eating
212
What is the presentation for duodenal ulcer?
patient with present with - abdominal discomfort that improves with meals and gets worse an hour or so after eating
213
What are the characteristics of peptic ulcer disease?
a peptic ulcer is a defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall
- etiology: H. pylori (most common), NSAID use, Zollinger-Ellison syndrome (refractory PUD) secondary to a gastrin-secreting tumor
- duodenal ulcer - pain improves with food
- gastric ulcer - pain worsens with food
214
How is peptic ulcer disease dx?
endoscopy with biopsy is the gold standard for diagnosis
215
What is the tx for peptic ulcer disease?
- H. pylori infection: treat with (CAP) - clarithromycin + amoxicillin +/- metronidazole + PI (omeprazole) or quadruple therapy
- patients with NSAID - associated ulcers should be treated with a PPI for a minimum of eight weeks
- PPI therapy for four to eight weeks in patients with H. pylori-negative ulcers that are not associated with NSAID use
- Zollinger-Ellison syndrome: PPI and resect the tumor
