Gastrointestinal Disorders Flashcards
What is cause of peptic ulcer disease?
90% of the time H. pylori is detected if duodenal ulcers, 75% it is detected with gastric ulcers
what are risk factors for peptic ulcer disease?
chronic use of NSAIDs, aspirin, glucocorticoids
smokers > 1/2 PPD
high stress
what are signs of acute abdomen? (perforation from various causes such as ulcer perforation)
severe pain, board like abdomen, quiet bowel sounds, rigidity
what is standard outpatient management of peptic ulcer disease?
H2 receptor blockers/ antagonists- famotidine daily
or
PPI- pantoprazole, omeprazole, lansoprazole- 30 minutes before meals
what is black box warning for PPIs?
increase osteoporosis with long term PPI use- not recommended
what is standard outpatient treatment for H. pylori erradication?
Quadruple therapy: 2 antibiotics + PPI +/- bismuth (pepo bismol) for 10-14 days.
Antibiotic considerations:
Triple therapy (first treatment regimen, however contraindicated if PCN allergy or previous exposure to macrolide, because of antibiotic resistance) PPI + clarithromycin + amoxicillin
Latest quadruple therapy: PPI + bismuth + metronidazole and tetracycline
What is effect of bismuth subsalicylate (pepto-bismol) on H. pylori?
direct antibacterial action against H. pylori
promotes prostaglandin production/ stimulates gastric bicarbonate
What are anti-ulcer pharmacotherapeutic recommendations? mucusal protective therapy?
PPI- can be given for several weeks, but not recommended for longterm use H2 blockers 6-8 weeks Sucralfate (Carafate) - requires acidic environment, so avoid antacids and H2 blockers- associated with decreases in nosocomial pneumonia Bismuth subsalicylate (pepto bismol)- antibacterial against H. pylori, promotes prostaglandin production/ stimualtes gastric bicarbonate (antacid effect) Antacids (maalox)- do no reduce the amount of gastric acidity- neutralizes but not treating problem of too much gastric acid- that's what PPI does
how to detect GI ulcers bleeding/ perforated? what is treatment?
upright films shows free air most cases- air under diaphragm
tx: NG tube for lavage. bleeding stops spontaneously in 80% of cases
IV H2 blocker (famotidine)
Hepatitis A
oral-fecal transmission
Outbreaks: contaminated water and food, sexual contact
infectious blood/ stool for 2-6 week incubation period
acute illness, low mortality rate
hepatitis B
blood borne DNA virus- serum, saliva, semen and vaginal secretion transmission-
blood transfusions, sexual activity, mother-fetus
hepatitis C
blood borne RNA virus
blood transfusion, and 50% of cases r/t IV drug use
s/s fatigue, anorexia, n/v,
icteric involvement: weight loss, jaundice, RUQ pain, clay colored stool, dark urine, fever, hepatosplenomegaly.
hepatitis C diagnostics
ua: proteinuria, bilirubinuria
elevated LFTs: AST/ ALT
slightly elevated: LDH, bilirubin, alk phos, PT
Hepatitis A serology
** presence of antibody: Anti-HAV + immunoglobulins to indicated time frame of infection
acute illness: 1-3 months: anti-HAV (antibody) and IgM
chronic/ immunity: IgG and anti-HAV- exposed, immune,
hepatitis B serology
active Hep B: HBsAg (surface antigen), HBeAg (protein from core), Anti-HBc (antibody to core antigen), IgM
Chronic Hep B: HBsAg, Anti-HBc (antibody to core), Anti-HBe (antibody to protein), IgM, IgG (chronic)
Recovered: Anti-HBc (antibody to core), Anti-HBs (surface antibody indicates recovery)
Hepatitis C serology
Acute: Anti-HCV, HCV RNA
Chronic: Anti HCV, HCV RNA
PCR needed to differentiate prior exposure to current acute viral infection
management of Hep C
increase fluids avoid liver toxic substances no/ low protein diet lactulose for elevated ammonia levels antiviral drugs
LLQ pain…. think…
diverticulitis- inflamation or localized performation of diverticula with abscess formation - extraluminal inflammation- seen on CT, not colonoscopy
Labs/ diagnostics for diverticulitis
elevated ESR- inflammation
signmoidoscopy- inflammed mucosa
CT- evaluate abscess
abd film- evaluate free air- pneumoperitoneum= peritonitis- perf bowl- needs ex lap
cholecystitis causes
most frequently caused by gallstones
post-prandial epigastric pain
Murphy’s sign
indicates colecystitis
deep pain on inspiration while fingers placed under right rib cage
RUQ tenderness to palpation
cholecystitis labs
High - serum bilirubin, serum ALT, AST, LDH, alk phos
cholecystitis imaging
ultrasound- gold standard
plain films can show radiopaque gallstones
HIDA scan- can show gall bladder functioning
what is ERCP?
ERCP: used to diagnose disease of gallbladder- bile system, pancreas and liver (endoscopic retrograde cholangiopancreatography
pancreatitis
pain is worse when lying down, improved when sitting and leaning forward
tender to palpation, no guarding, rigidity
absent bowel sounds (paralytic ileus)
Grey Turner’s sign
hemorrhagic pancreatitis-flank discoloration
Cullen’s sign
“U”mbillical discoloration - hemorrhagic pancreatitis
pancreatitis labs
serum amylase
lipase- elevated in 90% of cases- higher specificity for pancreatitis
elevated C-reactive protein- suggests pancreatic necrosis
**CT scan abdomen preferred imaging
Ranson’s criteria
evaluate prognosis of pancreatitis- risk factors GWGLAHBCABE: George Washington Got Lazy After He Broke CABE at admission: -Greater than 55 years of age -WBC > 16000 -Glucose> 200 -LDH > 350 AST> 250 1st 48 hours Hct drop > 10 BUN > 5 increase Calcium < 8 Arterial O2 < 60 Base deficit > 4 Estimated fluid sequestration > 6L
pancreatitis management
bed rest, NPO, IV fluids, NG suction, pain control, clear diet if pain free and bowel sounds present
proximal vs distal bowel obstruction
proximal: vomiting closely timed with pain, minimal abdominal distention
distal: vomiting delayed response to pain (hours later), pronounced abdominal distension
ulcerative colitis vs. Crohn’s disease
UC: idiopathic inflammatory condition- diffuse mucosal inflammation of colon; rectum and large bowel- episodic illness, ** bloody diarrhea, toxic megacolon risk
Crohn’s- upper bowel malabsorption syndrome
Psoas sign (Iliopsoas Test0
pain with R thigh extension… appendicitis
RLQ pain
Obturator sign
pain with internal rotation of flexed right thigh
appendicitis test
Positive Rovsing’s sign
RLQ pain when pressure applied to LLQ (referred pain)
what to consider if elderly patient is constipated ?
this is abnormal:
lack of fiber, decreased exercise, poor dentition, hx of laxative abuse, impaired mental status
common among parkinson’s patients
