Gastrointestinal Disorders Flashcards
1
Q
Describe the role of HCl and Pepsin and what stimulates their release
A
HCl (secreted by parietal cells in response to histamine, acetylcholine and gastrin)
- dissolving food (solvent)
- activating pepsin
- stimulates duodenal release of other digestive enzymes
- kills harmful bacteria in the food
Pepsin: (secreted as inactive pepsinogen by chief cells and becomes activated by HCl acidic environment)
1. digests proteins into smaller peptides
2
Q
____ stimulates stomach acid secretion and motility. This hormone is inhibited by ___
A
gastrin
Somatostatin via negative feedback
3
Q
What are the main functions of the large intestines
A
- absorb water from undigested food (main fxn)
- transport undigested food for fecal removal (contains Haustra)
- absorb vitamins produced by bacteria (Vit. K and biotin)
4
Q
___ is associated w/ no suppression of gastrin levels with the secretin test
A
Zollinger-Ellison Syndrome (ZES)
*gastrin producing tumor)
5
Q
What are the main functions of the duodenum?
A
- most chemical digestion (via secretin and CCK)
- regulates rate of gastric emptying
6
Q
What are the functions of Secretin and CCK
A
Secretin: (released by duodenum), inhibits parietal cell gastric acid production and causes pancrease to release bicarb (to buff acid from chyme leaving the stomach entering the duodenum)
CCK: aids in breakdown of fats and proteins by stimulating pancreatic release of digestive enzymes
- increase bicarb release (neutralize stomach acid)
- stimulates gallbladder contraction and bile release (bile salts help emulsify fats into smaller micelles
7
Q
Biliary colic is usually worse when? this is due to ___
A
after a fatty meal
-due to CCK mediated contraction of the gallbladder and release of bile
8
Q
What organ has both endocrine and exocrine functions
A
pancreas
9
Q
- ____ breaks down starches into simple sugars
- __ neutralizes gastric acid in duodenum and activates enzymes. Secretion is stimulated by secretin.
- ___ precursors to enzymes that break down proteins.
- ___ breaks down fats into fatty acids
- ___ increases blood glucose levels
- ___ decreased blood glucose levels
A
- amylase
- bicarbonate
- proteases
- lipases
- glucagon (produced by alpha cells)
- insulin (produced by beta cells)
10
Q
Octreotide (somatostatin analog) is used in medical management of:
A
- GH producing tumors (acromegaly, gigantism)
- some pituitary tumors
- flushing and diarrhea associated w/ carcinoid tumors and VIP tumors
- bleeding esophageal varices
11
Q
Diagnostic test of choice for achalasia and nutcracker esophagus
A
Esophageal manometry (motility study)
12
Q
MC causes of esophagitis and how do you diagnose
A
- GERD (MC)
- infectious in immunocompromised (Candida, CMV, HSV)
- meds
DX: Upper endoscopy
13
Q
What type of esophagitis do the following endoscopic findings suggest and how do you treat them?
- Small, deep ulcers
- Large superficial shallow ulcers
- Linear yellow-white plaques
- multiple corrugated rings
A
- HSV- acyclovir
- CMV- Ganciclovir
- Candida- PO fluconazole
- Eosinophilic- remove foods that incite allergic response or inhaled topical corticosteroid w/o spacer
14
Q
- Heartburn (pyrosis**) often retrosternal that is worse with supine position
- Regurgitation, dysphagia
- Chest pain
A
GERD (transient relaxation of LES)
DX: clinical, endoscopy, esophgeal manometry, 24 hr pH monitoring (gold standard but only if sx are persistent)
TX: 1. lifestyle modification
- OTC H2 blocker or antacids PRN
- H2 blocker, PPI (mod-severe)
- Nissen fundoplication if refractory
15
Q
What is Barrett’s Esophagus?
A
esophageal squamous epithelium replaced by precancerous metaplastic columnar cells
*risk of developing adenocarcinoma
16
Q
What are ALARM sx of GERD
A
- Dysphagia
- Odynophagia
- Weight loss
- Bleeding
17
Q
-Dysphagia w/ both solids and liquids
vs
-stabbing CP worse w/ hot or cold liquids/foods
A
achalasia
- DX: esophageal manometry (GS)-increased LES pressure >40
- double contrast esophagram- “Birds beak” appearance of LES
Diffuse esophageal spasm
-DX: esophagram- “corkscrew”
18
Q
dysphagia, sense of lump in the neck, neck mass, regurgitation of food, cough, halitosis (old, trapped food pouch)
A
Zenker’s Diverticulum (pharyngoesophageal pouch)
*diverticulum only involves mucosal pouch
19
Q
Full thickness rupture of the distal esophagus
- associated w/ repeated forceful vomiting
- retrosternal chest pain worse w/ deep breathing and swallowing
- hematemesis
- PE: creptius on chest auscultation due
A
Boerhaave Syndrome
DX: Chest CT/CXR: pneumomediastinum Contrast esophagram (GS)
20
Q
What is Mallory Weiss Syndrome/Tears?
A
superficial longitudinal mucosal erosions following persistent retching/vomiting typically after ETOH
DX: upper endoscopy
TX: supportive - acid suppression to help promote healing
21
Q
Dysphagia + esophageal webs + iron def. anemia= ___
A
Plummer-Vinson Syndrome
*often has atrophic glossitits
DX: barium esophagram
22
Q
esophageal varices are dilation of the gastroesophageal collateral submucosal veins mostly likely due to ___
A
portal HTN and cirrhosis
23
Q
TX of acute active esophageal varices bleeds, and prevention of rebleeds
A
Acute tx:
- endoscopic ligation**
- Octreotide: vasoconstricts portal venous blood flow
- Vasopressin
- Baloon tamponade
- Trans jugular intrahepatic portosystemic shunt (TIPS)*
Prevention:
- nonselective BB: Propranolol, nadolol
- Isosorbide: long acting nitrate
Abx Prophylaxis: fluoroquinolones or ceftriaxone
24
Q
MC cause of esophageal CA worldwide:___ (MC in ___ esophagus)
MC cause of esophageal CA in US: ___ (MC in ___ esophagus)
MC cause of gastric CA worldwide: ___
A
squamous cell- in upper 1/3rd of esophagus
adenocarcinoma- in lower 1/3rd of esophagus
adenocarcinoma
25
MC causes of gastritis
1. H. pylori (MC)
2. NSAID/ASA (2nd MC)
3. Acute Stress
4. alcohol, reflux
\*\*1 and 2 are also most common causes of PUD
DX: endoscopy (GS)
26
MC cause of upper GI bleed
PUD
27
Compare and contrast gastric ulcers and duodenal ulcers
Gastric:
- decreased mucosal protective factors (mucus, bicarb, prostaglandins, NSAIDS)
- 4% malignant
- Worse w/ meals
Duodenal:
- increased damaging factors (acid, pepsin, H.pylori)
- MC- almost always benign
- Better w/ food
28
How do you diagnose H. pylori
1. endoscopy w/ biopsy is GS
2. rapid urease test
3. Urea breath test
4. Stool antigen
5. Serology Abs (CANT USE for eradication test)
\*must stop PPI 2-4 weeks prior to recheck urea breath test
29
TX of H. pylori eradication
TX of H. pylori neg. PUD
H. pylori: tripe therapy (CAP)
1. Clarithromycin
2. Amoxicillin (metronidazole if PCN allergy)
3. PPI
HP neg: acid suppression: PPI or H2 blocker, sucralfate
30
Side effects of PPIs
- B12 def.
- CP450 inhibition--\> increases levels of theophylline, warfarin and phenytoin (H2 blockers are also CP450 inhibitors)
31
multiple "kissing ulcers"
- increased fasting gastrin level
- Positive secretin test: increased gastrin release w/ secretin
Zollinger-Ellison Syndrome (ZES)
TX: surgical resection of the tumor
32
What is Dubin-Johnson Syndrome?
hereditary direct hyperbilirubinemia
TX: none needed
Think: D's "Dubin, Direct hyperbili, Dark liver on biopsy
33
What is Crigler Najjar Syndrome
Hereditary unconjugated (INDIRECT) hyperbili with normal LFTs
Type I: NO UGT activity
tx: phototherapy
Type II: Very little UGT activity
tx: usually not needed- could us phenobarbital to increase UGT activity
34
Transient episodes of jaundice during periods of stress, fasting, ETOH, or illness
Gilberts Syndrome
\*reduced UGT activity- indirect hyperbili
\*normal LFTs
No tx needed
35
What labs are used to measure:
1. hepatocellular damage
2. cholestasis
3. liver "synthetic" function
1. hepatocellular damage: ALT\*, AST
2. cholestasis: alkaline phosphate, GGT, bili
3. liver "synthetic" function: PT, albumin
36
What do the following labs suggest?
1. ALT \>1,000, + ANA, +smooth muscle Ab\*, increased IgG and response to corticosteroids
2. Increased ALP (alkaline phosphatase) and GGT
3. AST and ALT \>1,000, ALT\>AST
4. AST: ALT \>2
1. autoimmune hepatitis
2. biliary obstruction or intrahepatic cholestasis
3. viral/toxic hepatitis
4. ETOH hepatitis (think S =scotch)
37
What are the 5 F's of cholelithiasis and how do you dx and tx
Fat, fair, female, forty, fertile
DX: US
TX: elective cholecystectomy
38
What is choledocholithiasis? complications? Dx? TX?
gallstone in the common bile duct
Complications: acute pancreatitis or acute cholangitis
DX: abdominal US or ERCP (diagnostic and therapeutic)
TX: ERCP
39
What is acute cholangitis? Dx?
biliary tract infection secondary to obstruction
\*MC to gram neg organism (E. coli MC then Klebsiella and enterococci)
DX:
1. leukocytosis, increased ALP w/ GGT, increase bili\> ALT and AST
2. US or CT
3. Cholangiography via ERCP (GS)
40
What is Charcots triad and Reynolds pentad
Charcots: fever/chills, RUQ pain, jaundice
Reynolds: Charcots + shock + AMS
\*\*acute cholangitis
41
how do you treat acute cholangitis
1. Abx
2. Common bile duct decompression/stone extraction via ERCP
42
What is Boas sign
What is Kerr's sign
Boas: referred pain to R shoulder/subscapular area (phrenic nerve irritation) (seen in acute cholecystitis)
Kerrs: referred pain to L subscapular area (phrenic nerve irritation) (seen in splenic rupture)
43
How do you dx and tx acute cholecystitis
DX: US is initial test
2. HIDA is gold standard
TX: NPO, IV fluids, Abx (Ceftriaxone + Metronidazole)
-cholecystectomy
44
- Rapid liver failure (w/in 8 weeks) + hepatic encephalopathy
- Vomiting, coma, asterixis (flapping tremor of the hand w/ wrist extension)
- Coagulopathy
- Hepatomegaly, jaundice
Fulminant hepatitis
DX: Increase ammonia, PT/INR, LFTs and hypoglycemia
TX:
1. Lactulose: neutralizes ammonia
2. Rifaximin, neomycin: decrease ammonia producing bacteria in GI
3. protein restriction
4. Liver transplant (definitive)
45
Etologies of Fulminant hepatitis
1. Acetaminophen (MC)
2. Drug reaction (isoniazid)
3. viral hepatitis
4. Reye Syndrome
46
Rash (hands and feet) in children, intractable vomiting, liver damage, encephalopathy, dilated pupils with minimal response to light and multi-organ failure
s/p ASA use
Reye Syndrome
47
What viral hepatitis's are asociated w/ chronicity and may lead to \_\_\_\_
HepB
HepC (80% have chronic)
HepD
\*increase ALT\>AST
lead to ESLD or hepatocellular carcinoma
48
How are the following hepatitis transmitted? and what is their hallmark/distinguishing feature?
Hep A
Hep B
Hep C
Hep D
Hep E
A: fecal-oral: Only one associated w/ spiking high fever (self limiting)
B: Parental-sexual (tx w/ alpha-interferon 2b)
C: parenteral-IVDU (tx w/ pegylated interferon alpha-2b and ribavirin)
D: requires HepB to cause coinfection
E: fecal-oral (self limiting)
49
How do you screen for hepatocellular carcinoma with viral hepatitis
serum AFP\* and US
\*needle biopsy usually avoided to prevent seeding
50
When do you give HepB vaccine and when is it contraindicated
0, 1, 6 months
CI: allergy to bakers yeast
51
Classic triad: Ascites, hepatomegaly, RUQ abdominal pain
-idiopathic or hypercoaguable state
Hepatic vein obstruction (Budd-Chiari syndrome)
DX: US- screening test
Venography (GS)
TX:
1. Shunts (TIPS)
2. Balloon angioplasty w/ stent
3. anticoagulation
4. Management of ascites: diuretics
52
-Ascites, gynecomastia, pruritis, spider angioma, caput medusa, muscle wasting, hepatosplenomegaly, palmer erythema, jaundice, Dupuytren's contracture
Cirrhosis
DX: US, liver biopsy
Tx:
1. Encephalopathy: lactulose or rifaximin
2. Ascites: Na+ restriction, diuretics
3. Pruritis: Cholestyramine\*
4. Liver transplant- definitive
53
Etiologies of Cirrhosis
\*irreversible liver fibrosis w/ nodular regeneration secondary to chronic liver disease
1. ETOH (MC cause in US)
2. chronic viral hepatitis (HepC\*, HepB, HepD)
3. nonalcoholic fatty liver
4. hemochromatosis
54
- Fatigue--\> pruritus, RUQ discomfort, hepatomegaly, jaundice
- MC middle aged women
- Labs: elevated ALP and GGT, + Anti-mitochondrial Ab
Primary biliary cirrhosis (PBC)
\*idiopathic autoimmune disorder of INTRAhepatic small bile ducts
DX: labs and biopsy
TX:
1. Ursodeoxycholic acid 1st line to reduce progression
2. Cholestyramine (bile acid sequestrant) and UV lights for pruritus
55
- Jaundice, pruritus, fatigue, RUQ pain, hepatomegaly, splenomegaly\*,
- associated w. IBD, UC
- MC in men 20-40
- Labs: increase ALP and GGT, + P-ANCA
Primary sclerosing cholangitis (PSC)
\*autoimmune progressive cholestasis, diffuse fibrosis of INTRAhepatic and EXTRAhepatic ducts
DX: labs and ERCP (gold standard)
TX: liver transplant (meds not helpful)
56
- Parkinson-like symptoms (bradykinesia, rigidity) dementia.
- Arthralgia
- Hepatosplenomegaly, cirrhosis, hemolytic anemia
- Brown or green pigment in the cornea\*
Wilson's disease (Hepatolenticular degeneration)
\*cornea pigmentation= Kayser-Fleischer rings
\*free copper accumulation in liver, brain, kidey, cornea
57
How do you dx and treat wilson's disease
DX: decreased ceruloplasmin (serum carrier molecule for copper)
-increased urinary copper excretion
TX:
1. D-Pencillamine (chelates copper)
2. Zinc: enhances fecal copper excretion and blocks copper absorption
58
Etiologies of acute pancreatitis and common manifestations
Etiologies:
1. gallstones\*
2. alcohol\*
3. scorpion bite
4. Mumps in children\*
S/S:
- epigastric pain that is boring and constant w/ radiating to the back and relieved w/ leaning forward or in fetal position
- N/V,
- Cullen's sign (periumbilical ecchymosis)\*
- Turner sign (flank ecchymosis)\*
59
how do you dx and tx acute pancreatitis
DX: abdominal CT\*
XRAY: sentinel loop = localized ileus, colon cut off
Labs: increased TG, lipase (more specific than amylase), amylase, ALT, hypocalcemia
TX: supportive/pancreatic rest
- NPO, IV fluids, analgesia w/ Meperidine (Demerol)
- Abx NOT routinely used- if necrotizing--\> broad spectrum
60
What is Ranson's criteria?
\*used to determine prognosis of acute pancreatitis
GET ON ADMISSION:
Glucose
Age
LDH
AST
WBC
GET W/N 48 HRS:
Calcium, hematocrit fall, Oxygen, BUN, Base deficit, Sequestration of fluids
61
What are the manifestations, dx, and tx of chronic pancreatitis
s/s triad: 1. calcifications, 2. steatorrhea, 3. DM
DX: XRAY: calcified pancrease\*
-amylase/lipase usually NOT elevated
TX: oral pancreatic enzyme replacement
62
- Abdominal/back pain +/- relieved w/ sitting up and forward
- Painless jaundice\*
- Weight loss
- Pruritis
- Palpable NONTENDER, distended gallbladder\*
Pancreatic carcinoma (MC- adenocarcinoma ductal (70% found in pancreas head))
\*Courvoisier's sigb = Palpable NONTENDER, distended gallbladder\*
DX: CT\*
-increased CEA, CA 19-9 markers
TX: Whipple procedure\*\*
-ERCP w/ stent placement as palliative tx for intractable itching
63
- Persistent portion of embryonic vitteline duct (yolk stalk)\*
- Rule of 2's: 2x in males, 2y/o, 2 feet from ileocecal valve, 2 inches in length
- often found incidentally during surgery for other cause
- Painless rectal bleeding or ulceration\*
Meckel's (ileal) diverticulum
TX: surgical excision if symptomatic
64
- Abdominal cramping, abdominal distention, vomiting, obstipation (absence of stool/flatus)
- \*\*high pitched tinkles on auscultation and visible peristalsis --\>hypoactive bowel sounds later
small bowel obstruction
MC cause: post-surgical adhesions\*\*\* then incarcerated hernia
DX: XR: air fluid levels in step ladder pattern, dilated bowel loops
TX: nonstrangulated: NPO (bowel rest), IV fluids, bowel decompression
strangulated--\> surgery
65
decreased peristalsis w/o structural obstruction
- MC post-operative state, w/ opiates, metabolic hypokalemia, hypothyroidism
- Decreased to no bowel sounds
Paralytic (adynamic) ileus
66
How do you dx celiac disease
\*small bowel autoimmune inflammation 2/2 to alpha-gliadin in gluten--\> loss of villi and absorption area--\> impaired fat absorption
DX: + endomysial IgA Ab and + transglutaminase Ab
SB biopsy- definitive dx
\*May get dermatitis herpetiformis
67
How do you dx and tx lactose intolerance?
DX: hydrogen breath tests\*
TX: lactase enzyme preparations, lactose free diet
68
Diverticula most commonly occurs where?
How do you dx and tx
sigmoid colon
associated w/ low fiber diet, constipation, obesity
DX: CT, increased WBC
TX:
- itis: clear liquid diet, Abx (Cipro or Bactrim + Metronidazole)
- osis: high fiber diet, fiber supplement
69
MC cause of acute lower GI bleeding
diverticulitis
70
MC site of volvulus
\*sigmoid
71
1. RLQ pain w/ LLQ palpation= __
2. RLQ pain w/ internal and external hip rotation w/ flexed knee = __
3. RLQ pain w/ right hip flexion/extension (raise leg against resistance) =\_\_
4. point 1/3 from the distance from the anterior sup. iliac spine and navel= \_\_
1. rovsing sign
2. Obturator sign
3. Psoas sign
4. McBurneys point tenderness
72
How do you dx IBS
Recurrent abdominal pain on average at least 1 day a week in the last 3 months associated w/ at least 2 of the following:
1. releated to defecation
2. onset associated w/ change in stool FREQUENCY
3. onset associated w/ change in stool FORM/APPEARANCE
73
How do you tx IBS
1. life style modification- quit smoking, low fat/unprocessed food diet
2. tx diarrhea w/ anticholinergics/spasms (Dicyclomine) or Loperamide
3. tx constipation w/ bulk-forming laxatives
4. TCAs or serotonin for intractable pain
74
- chronic dull abdominal pain worse AFTER meals "intestinal angina"
- weight loss/anorexia
- Dx w/ angiogram and Colonoscopy: muscle atrophy w/ loss of villi
Chronic mesenteric ischemia
\*mesenteric atherosclerosis of the GI tract
75
"severe" abdominal pain out of proportion to PE findings\*\*
- poorly localized pain, N/V
- Hx of Afib, MI or atherosclerosis
Acute mesenteric ischemia
Dx: angiogram
TX: surgical revascularization w/ stent
76
abdominal pain, fever, N/V, diarrhea, electrolyte disorder
-XR: dilated colon \>6cm\*
Toxic megacolon
TX: bowel decompression, bowel rest, NG tub
\*surgery if severe or refractory
77
Compare and contrast ulcerative colitis and crohns disease
UC: -limited to colon (begins in rectum and spreads proximally), CONTINUOUS, mucosa or submucosa only
-LLQ pain, colicky,
-bowel urgency w/ bloody diarrhea
-Pseudopolyps on colonscopy
-Stovepipe sign on barium study (loss of haustral)
\*surgery is curative
CD: - any segment of GI tract (anus to mouth, MC in TERMINAL ILEUM), SKIPPED lesions, transmural
-RLQ pain, crampy
-NONbloody diarrhea
-skipped lesions w/ cobblestone appearance on colonoscopy
-String sign on barium study
\*surgery is not curative
78
Complications of UC and CD
UC: PSC, colonn CA, toxic megacolon,
\*smoking decreases risk for UC
\*MUCOSA/SUBMUCOSA only
CD: perianal dz: fistulas, strictures, abscess, granulomas\*, B12 def
\*TRANSMURAL
79
How do you dx UC and CD
UC
Colonoscopy: uniform inflammation, pseudopolyps
Barium study: "stovepipe sign"
Lab: + P-ANCA
CD:
Colonoscopy: skipped lesions, cobblestone appearance
Barium study: string sign
Lab: + ASCA
80
How do you tx IBD (UC and CD)
Aminosalicylates --\> corticosteroids--\> immune modifying agents
1. 5-ASA (sulfasalazine-works primarily in colon, mesalamine- oral best for maintenance)
2. Corticosteroids- used for flares
3. immune modifying agents
81
colorectal CA is typically caused from progression of __ polyps into malignancy
\*MC site of metastatic spread= \_\_
adenomatous polyps (10% of polyps w/in 10-20 yrs)
Liver
82
How do you dx CRC
1. Colonoscopy w/ biopsy\*
2. barium enema: apple core lesion
3. CEA level monitoring
83
When should ppl be screened for colorectal CA
1. FOB: annually at 50 or colonsocpy q10y or flex sig q5y up to 75y/o
2. + 1st degree relative 60y/o or older: annually at 40 or colonscopy q10y
3. + 1st degree relative less than 60y/o : annually at 40 or 10 yrs prior to diagnosed age or colonscopy q5y
84
What type of hernia?
1. through pelvic floor in which abdominal/pelvic contents protrude through obturator foramen
2. through abdominal wall weakness
3. through abdominal cavity through femoral canal below inguinal ligament
4. protrude at the internal inguinal ring LATERAL to inferior epigastric artery
5. protrude MEDIAL to inferior epigastric vessels WITHIN hesselbachs triangel (rectus abdominis, inferior epigastric vessels, Pouparts ligament (RIP)
1. Obturator hernia
2. Incisional (ventral) hernia
3. Umbilical hernia
4. femoral hernia (MC seen in women)
5. Indirect inguinal (MC overall in M and F and kids)
6. Direct inguinal (does not reach the scrotum)
85
How to differentiate internal and external hemorrhoids
Internal: intermittent rectal bleeding (bright red blood per rectum)
-uncomplicated internal are usually non-tender and nonpalpable
External: perianal pain\* aggravated w/ defecation + tender palpable mass
86
anorectal abscess and fistulas are treated by:
MC on posterior rectal wall
TX: I&D followed by WASH (warm water cleansing, Analgesics, sitz baths, High fiber diet)
87
- severe painful rectal pain and bowel movements causing patient to refrain from having BM leading to constipation, bright red blood per rectum
- skin tags seen w/ chronic (MC at posterior midline)
anal fissures
\>80% resolve spontaneously with supportive measures
88
what is PKU and how do you tx?
AR disorder
\*enzyme cannot metabolize--\> accumulation--\> phenylketone neurotoxicity
\*s/s- vomiting, mental delays, convulsions--\>blonde, blue-eyed w/ fair skin MC
TX: restrict phenylalanin (milk, cheese, nuts, fish, chicken, meats, eggs, legumes, aspartame)
89
Risk factors and sx of Vit. A deficiency
Risk factors: liver dz, ETOH, fat free diets
S/S:
1. visual changes (esp. at night\*\*/nighttime blindness\*) and dry eyes (xerophthalmia)
2. squamous metaplasia (conjunctiva, respiratory epithelium, urinary tract)-- Bitot's spots\*: white spots on conjunctiva due to metaplasia of cornea
3. impaired immunity and poor healing
90
Risk factors and sx of Vit. C deficiency
Risk factors: smoking, alcohol, malnourished/poor diet
S/s: (3 H's)
1. Hyperkeratosis: hyperkeratotic follicular papules (often surrounded by hemorrhage)
2. Hemorrhage: vascular fragility w/ recurrent hemorrhages in gums, skin, joints, and impaired wound healing
3. Hematologic: anemia, glossitis, weakness, increased bleeding time
91
Vit. D deficiencies in adults and in kids?
TX?
Kids: Ricketts- bone softening/ bowing
adults: Ostomalacia- looser lines on xray
TX: ergocalciferol (Vit. D)\*
92
1. nervous system changes: paresthesia, demyelination, neuropathy, muscle cramps or wasting
2. High output HF, dilated cardiomypathy
Beriberi Vit. B1 (thiamine) def.
1. Dry
2. wet
\*\*ETOH MC CAUSE!!
93
1. Ataxia
2. global confusion
3. ophthalmoplegia
Wernicke's Encephalopathy (Triad of sx)
\*Mc cause is ETOH
94
- Memory loss (esp. short term)
- Confabulation (mis interpreation/recall of memory)
```
Korsakoff Dementia (vit. B1 (thiamine) def
\*\*IRREVERSIBLE
```
95
- Oral lesions, magenta colored tongue, angular cheilitis, pharyngitis
- Photophobia, corneal lesions
- Scrotal dermatitis
Riboflavin (B2) Def.
\*Oral-Ocular-Genital syndrome
96
- diet high in corn or lack tryptophan
- Pellagra
- Diarrhea
- Dementia
- Dermatitis
Niacin/Nicotinic Acid (B3) def.
\*Pellagra-- 3 D's (diarrhea, dementia, dermatitis)
97
Common etiologies and sx of Pyridoxine (B6) def.
Etiologies: chronic alcoholism, Isoniazid\*\*\*, OCP
S/s: peripheral neuropathy, seizures, HA, stomatitis
98
\_\_\_ is the primary natural source of vitamin B12. Stomach acid releases B12 from food and binds it to ____ for later absorption in the \_\_\_
Animal foods
Intrinsic factor
terminal ileum
99
Etiologies of B12 (Cobalamin) def.
1. Pernicious anemia: autoimmune destruction/loss of gastric parietal cells\*\* (they secret intrinsic factor)
2. Strict vegans
3. Malabsorption (ETOHism, Celiac, Crohns)
4. decreased intrinsic factor production (bypass surgery, PPIs and H2RA blockers)
100
How do you dx pernicious anemia
- Ab testing
- Schilling test
(Vit. B12 (Cobalamin) def)
101
- Paresthesia, gait abnormalities, memory loss, dementia
- GI upset, anorexia, diarrhea, glossitis
- Macrocytic anemia w/ hypersegmented neutrophils\*\*\*\*
B12 (Cobalamin) def.
TX: IM or oral B12
\*pernicious anemia needs IM B12
102
Management of Diarrhea
1. IV fluid repletion (mainstay tx of gastroenteritis)-- PO preferred
2. Diet: bland low-residue die (BRAT)
3. Anti-motility agents: if pt \<65y w/ mod-severe signs of volume depletion (DONT give for invasive diarrhea)
4. Antiemetics
103
Types of anti-motility agents
1. Bismuth subsalicylate (pepto-bismol, kaopectate)--\> SE: Reyes in kids, dark stools and tongue
2. Opioid agonists (Diphenoxylate (lomotil), loperamide (immodium)
3. Anticholinergics (Phenobarbital/Hyoscyamine/Atropine/ Scopolamine)
104
What antimotility agent is best to used for dysentery (bloody diarrhea w. fever) and what what is CI w/ dysentery
Use: Bismuth Subsalicylate (pepto or Kaopectate)
CI: Loperamide (immodium)
105
Types of anti-emetics
1. 5-HT3 Blocker (serotonin receptor blocker) (Ondansetron, Granisetron, Dolasetron)
2. CNS dopamine receptor blockers (Prochlorperazine (compazine), Promethazine (phenergan), Metoclopramide (reglan))
106
SE of Dopamine blockers
\*anti-emetic drugs (prochlorperazine, promethazine, metoclopramide)
1. QT prolongation
2. Anticholinergic
3. Antihistamine SE (drowsy)
4. EPS sx (rigidity, bradykinesia, tremor, akathisia, Dystonic rxns/dyskinesia, Parkinsonism sx)
107
MC overall cause of gastroenteritis in adults in N. America
-associated w. outbreaks ex. cruise ships, hospitals, restaurants
Norovirus
108
MC cause of diarrhea in children
Rotavirus
109
How can you differentiate non-invasive vs invasive types of diarrhea
non-invasive: vomiting, watery, voluminous (involves SI), no fecal WBCs or blood
invasive: high fever, + blood and fecal leukocytes, not as voluminous (LI) mucus
110
- prominent vomiting, abdominal cramps, HA, noninvasive diarrhea
- h/o eating dairy products, mayonnaise, meats, or eggs w/in last 6 hrs (short incubation period)
Staphylocccus aures
111
- vomiting\*, cramps, noninvasive diarrhea
- h/o eating fried riced w/in last 1-6 hrs
Bacillus cereus
112
- Copious watery diarrhea "rice water stools" (grey, no fecal odor, blood or pus) that rapidly produces severe dehydration--\> hypovolemia
- h/o contaminated food and water- outbreaks may occur during poor sanitation and overcrowding conditions
Vibrio Cholera and parahemolyticus
TX: supportive- fluid replacement\*\*, Abx if severely ill or w/ high fever (tetracyclines)
Vibrio parahemolyticus- associated w/ eating raw shellfish esp. in Gulf of Mexico
113
MC cause of travelers diarrhea
s/s: abrupt onset of watery diarrhea, abdominal cramps, vomiting (IP 24-72 hrs)
enterotoxigenic E. coli
\*risks: unsanitary drinking water/ice
TX: Fluids +/- Bismuth--\> if severe use fluoroquinolone
114
s/s of C. difficile
1. abdominal cramps, diarrhea, fever, tenderness
2. Strikingly increased lymphocytosis\*
3. Psudomembranous colitis
4. Toxic mega colon
5. H/o Abx use (Clindamycin or chemo)
115
tx of C. difficile
1. Metronidazole 1st line for mild
2. Vancomycin 2nd line (but 1st line if severe)
116
Causes of bloody diarrhea
1. Campylobacter
2. Shigella
3. Salmonella
4. Yersinia
5. Enterohemorrhagic E. coli
6. Campylobacter
117
\_\_\_ MC cause of bacterial enteritis in US.
Campylobacter jejuni
118
\_\_\_ MC antecedent event in post-infectious Guillain-Barre Syndrome
Campylobacter jejuni
119
- fever, HA, abdominal pain (mimics acute appendicitis)
- Diarrhea initially watery then bloody
- h/o undercooked poultry\*, raw milk, water, diary cattle
Campylobacter jejuni
DX: stool, gram neg "S, COMMA, or SEAGULL shaped" organism
TX: fluids
-if severe, Erythromycin
120
- lower abdominal pain, high fever\*, tenemus
- Explosive watery diarrhea then mucoid, bloody (may cause toxic megacolon)
- Febrile seizures in young children\*
Shigella
\*fecal/oral transmission- HIGHLY VIRULENT
DX: stool cultures CBC +/- Leukemoid reaction WBC \>50,000
2. sigmoidoscopy: punctate areas of ulcerations
TX: fluids
-if severe: trimethoprim-sulfamethoxazole
121
- abdominal pain, fever, cramping, vomiting
- Mucus + bloody diarrhea
- h/o eating poultry products (dairy, meat, eggs) w/in last 6-48 hrs exotic pets (reptiles ex. TURTLES)
- MC in summer months
Salmonella gastroenteritis (S. typhimurium)
TX: fluids
-if severe, Fluoroquinolones
122
- HA, constipation, pharyngitis, cough --\> crampy abominal pain, diarrhea "pea soup stools\*\*\*
- intractable fever, relative bradycardia\*
- Hepatosplenomegaly, blanching "Rose Spots" appears in 2 weeks
Typhoid (enteric) Fever (S. typhi)
TX:fluids
-if severe, Fluoroquinolones
123
- Watery diarrhea early--\> bloody crampy diarrhea w/ abdominal pain, vomiting, low grade or absent fever
- h/o ingestion of undercooked ground beef, unpasteurized milk/apple cider, day care centers, contaminated water
Enterohemorrhagic E. Coli H0157:H7
\*produces cytotoxin
TX: fluids
-Abx use is controversial (increased risk of HUS in kids)
124
- fever, abdominal pain mimic acute appendicitis (can cause mesenteric adentits\*
- producing abdominal tenderness, guarding
Yersinia enterococlitica
tx: fluids
if sever fluoroquinolones
125
- Frothy, greasy, foul diarrhea (no blood or pus) and malabsorption w/ cramping, bloating
- h/o ingestion of contaminated water from remote streams or well
Giardia lamblia
DX: stools- protozoan
TX: fluids
-Metronidazole
-Furazolidone in children\*
\*Boil water x 1 minute to kill cysts
126
- GI colitis, dysentery, liver abscesses\*
- MC seen in travelers to developing nations or immigrant population
Amebiasis
DX: stool ova and parasites
TX: fluid
1. colitis and abscess metronidazole
127
MC cause of chronic diarrhea in patients with AIDS
cryptosporidium
128
Causes of osmotic diarrhea
\*malabsorption of nonabsorbable substances in the intestinal lumen
\*Decreased diarrhea w/ fasting, increased osmotic gap, and increased fecal fat
1. Rapid transit of GI contents (meds- lactulose, sorbitol, antacids)
2. Bacterial overgrowth (Whipples diase, Tropical Sprue)
3. Malabsorption (Celiac, lactose intolerance)
129
Cause os secretory diarrhea
\*normal osmotic gamp, large volume, no change in diarrhea w/ fasting
1. Hormonal: serotonin (carcinoid), ZES)
2. Laxative abuse
130
- Weight loss, steatorrhea, nutritional def, fever, lymphadenopahty
- nondeforming arthritis, neuro sx
- rhythmic motion of eye muscles while chewing\*\*
- H/o farmer around contaminated soil
Whipples Disease (Tropheryma whippelii)
DX: duodenal biopsy- Periodic aci Schiff (PAS)- positive macrophages and dilation of lacteals
TX: PCN
131
Types of meds to help w/ constipation
1. fiber
2. Bulk forming laxatives (psyllium, methylcellulose, polycarbophil, Wheat dextran)
3. Osmotic laxatives (polyethylene glycol (PEG), miralax, lactulose, sorbitol, milk of magnesia, or magnesium citrate)
4. Stimulant laxative- bisacodyl (Dulcolax), Senna
132
- Vitamins ___ are absorbed in the jejunum and ileum.
- Vitamins ___ are absorbed throughout the small intestine.
- \_\_ absorbed in the proximal jejunum.
- \_\_\_ absorbed in the distal small intestine.
- \_\_ is absorbed primarily in the proximal intestine.
- \_\_\_ is absorbed mainly in the ileum.
B1, B5, B6= jejunum and ileum
B2, and B3= throughout SI
Folic Acid= prox. jejunum
Vitamin C= distal SI
Iron= prox. intestine
Zinc= ileum
133
What are the fat soluble vitamins?
Fat: A,D,E,K
134
\_\_\_\_ is due to a combination of insufficient secretion of zymogens from the pancreas leading to incomplete protein digestion and an immature, leaky gut in the infant. The poorly digested proteins irritate the lining of the intestinal tract causing pain when the infant eats.
Milk protein intolerance
TX:
1. educating the family that this is a self-limiting condition. As the child grows and matures, the pancreas will reach adult secretory levels by a year of age and the tight junctions between the cells will work more effectively.
\*Parents typically start to see improvement around 4-6 months of age but some kids can take up to 10 months for improvement in their
2. maternal elimination diet can help. Start with a two week trial of eliminating one food at a time—dairy first, then soy and finally peanuts. If no improvement is seen after eliminating those three foods, you can do a trial of a soy formula for 2 weeks.
\*Unfortunately 50% of kids that react to breast milk or regular formula will also react to soy.
3. If soy formula does not change the condition, you can do a 2 week trial of a semi-elemental formula like Nutramigen or Alimentum where the proteins are more hydrolyzed.
4. If the child is still highly fussy, you can try a two week trial of elemental formula such as EleCare and Neocate.
135
What is the definition of chronic constipation and when are the 3 peak times of occurence
delay or difficulty in defecation present for 2 or more weeks
1. 6 months w/ introduction of solids
2. 1-2 y/o w/ introduction of cows milk
3. 3-5 y/o w/ kids not wanting to go at school
136
tx regimen for kids \<1y/o w/ constipation
1. educate on process
2. diet: introduce 2-4oz of sorbitol containing fruit juice into diet or feed pureed prunes
3. meds: trial of osmotic laxative- ex. lactulose or karosyrups 1-2x daily
137
tx regimen for kids \>1y/o w/ constipation
1. Educate
2. diet: decrease milk intake increase fiber, increase clear fluids
3. behavioral changes: toilet time 15-20 min after meals
4. meds: lactulose or miralax
138
as involuntary passage of fecal material in the underwear; typically the child has anywhere from 3-8 bowel movements in their underwear that they can’t control
encopresis (fecal incontinence due to long standing diarrhea
\*tx aggressively w/ education, diet, behavioral changes, disimpaction and meds
139
Intussusception most commonly occurs in the \_\_\_\_
terminal ileum near the ileocecal junction
140
- undernourished infant with hypochloremic metabolic alkalosis
- Vomiting is immediately post-prandial and infant will feed following emesis (“hungry vomiter”)
Pyloric stenosis
DX: abdominal us
Tx: correct electrolytes and pyloromyotomy
141
4 factors that predict level of dehydration
1. cap refill \>2 sec
2. absence of tears
3. dry mucous membranes
4. ill general appearance
142
What lab values can help assess dehydration
BUN
Creatinine
BUN/creatinine
urine specific gravity
143
Volume resuscitation formula for kids
start w/ LR or NS at 20ml/kg IV over 1 hr
144
Rehydration formula (if electrolytes are normal) for kids
\*do after volume resucitation
1. administer ORT at 100ml/kg over 3-4 hrs if tolerated OR
2. D5 1/4 NS IVF w/ 20mEq/L K+ over 3-4 hrs
3. D5 1/2 NS with 20mEq/L K\_ to replace losses on top of maintance levels
145
formula for calculating maintenance fluid
Holliday-Segar Method
1. determine the total ml per day and then calculate ml per hour to determine the rate of IV flow
Simplifed for home ORT:
infant \<1y/o: 1oz/hr
Toddler 1-3y/o: 2oz/hr
Older kids 3-5y/o: 3oz/hr
