Gastrointestinal Disorders

Question 1

What is cause of peptic ulcer disease?

Answer 1

90% of the time H. pylori is detected if duodenal ulcers, 75% it is detected with gastric ulcers

Question 2

what are risk factors for peptic ulcer disease?

Answer 2

chronic use of NSAIDs, aspirin, glucocorticoids
smokers > 1/2 PPD
high stress

Question 3

what are signs of acute abdomen? (perforation from various causes such as ulcer perforation)

Answer 3

severe pain, board like abdomen, quiet bowel sounds, rigidity

Question 4

what is standard outpatient management of peptic ulcer disease?

Answer 4

H2 receptor blockers/ antagonists- famotidine daily
or
PPI- pantoprazole, omeprazole, lansoprazole- 30 minutes before meals

Question 5

what is black box warning for PPIs?

Answer 5

increase osteoporosis with long term PPI use- not recommended

Question 6

what is standard outpatient treatment for H. pylori erradication?

Answer 6

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

Question 7

What is effect of bismuth subsalicylate (pepto-bismol) on H. pylori?

Answer 7

direct antibacterial action against H. pylori

promotes prostaglandin production/ stimulates gastric bicarbonate

Question 8

What are anti-ulcer pharmacotherapeutic recommendations? mucusal protective therapy?

Answer 8

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

Question 9

how to detect GI ulcers bleeding/ perforated? what is treatment?

Answer 9

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)

Question 10

Hepatitis A

Answer 10

oral-fecal transmission
Outbreaks: contaminated water and food, sexual contact
infectious blood/ stool for 2-6 week incubation period
acute illness, low mortality rate

Question 11

hepatitis B

Answer 11

blood borne DNA virus- serum, saliva, semen and vaginal secretion transmission-
blood transfusions, sexual activity, mother-fetus

Question 12

hepatitis C

Answer 12

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.

Question 13

hepatitis C diagnostics

Answer 13

ua: proteinuria, bilirubinuria
elevated LFTs: AST/ ALT
slightly elevated: LDH, bilirubin, alk phos, PT

Question 14

Hepatitis A serology

Answer 14

** 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,

Question 15

hepatitis B serology

Answer 15

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)

Question 16

Hepatitis C serology

Answer 16

Acute: Anti-HCV, HCV RNA
Chronic: Anti HCV, HCV RNA

PCR needed to differentiate prior exposure to current acute viral infection

Question 17

management of Hep C

Answer 17

increase fluids
avoid liver toxic substances
no/ low protein diet
lactulose for elevated ammonia levels
antiviral drugs

Question 18

LLQ pain…. think…

Answer 18

diverticulitis- inflamation or localized performation of diverticula with abscess formation - extraluminal inflammation- seen on CT, not colonoscopy

Question 19

Labs/ diagnostics for diverticulitis

Answer 19

elevated ESR- inflammation
signmoidoscopy- inflammed mucosa
CT- evaluate abscess
abd film- evaluate free air- pneumoperitoneum= peritonitis- perf bowl- needs ex lap

Question 20

cholecystitis causes

Answer 20

most frequently caused by gallstones

post-prandial epigastric pain

Question 21

Murphy’s sign

Answer 21

indicates colecystitis
deep pain on inspiration while fingers placed under right rib cage
RUQ tenderness to palpation

Question 22

cholecystitis labs

Answer 22

High - serum bilirubin, serum ALT, AST, LDH, alk phos

Question 23

cholecystitis imaging

Answer 23

ultrasound- gold standard
plain films can show radiopaque gallstones
HIDA scan- can show gall bladder functioning

Question 24

what is ERCP?

Answer 24

ERCP: used to diagnose disease of gallbladder- bile system, pancreas and liver (endoscopic retrograde cholangiopancreatography

Question 25

pancreatitis

Answer 25

pain is worse when lying down, improved when sitting and leaning forward tender to palpation, no guarding, rigidity absent bowel sounds (paralytic ileus)

Question 26

Grey Turner's sign

Answer 26

hemorrhagic pancreatitis-flank discoloration

Question 27

Cullen's sign

Answer 27

"U"mbillical discoloration - hemorrhagic pancreatitis

Question 28

pancreatitis labs

Answer 28

serum amylase lipase- elevated in 90% of cases- higher specificity for pancreatitis elevated C-reactive protein- suggests pancreatic necrosis **CT scan abdomen preferred imaging

Question 29

Ranson's criteria

Answer 29

``` 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 ```

Question 30

pancreatitis management

Answer 30

bed rest, NPO, IV fluids, NG suction, pain control, clear diet if pain free and bowel sounds present

Question 31

proximal vs distal bowel obstruction

Answer 31

proximal: vomiting closely timed with pain, minimal abdominal distention distal: vomiting delayed response to pain (hours later), pronounced abdominal distension

Question 32

ulcerative colitis vs. Crohn's disease

Answer 32

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

Question 33

Psoas sign (Iliopsoas Test0

Answer 33

pain with R thigh extension... appendicitis | RLQ pain

Question 34

Obturator sign

Answer 34

pain with internal rotation of flexed right thigh | appendicitis test

Question 35

Positive Rovsing's sign

Answer 35

RLQ pain when pressure applied to LLQ (referred pain)

Question 36

what to consider if elderly patient is constipated ?

Answer 36

this is abnormal: lack of fiber, decreased exercise, poor dentition, hx of laxative abuse, impaired mental status common among parkinson's patients