Gastrointestinal/Nutritional Flashcards
1
Q
Abdominal pain high risk features
A
- age >65, immunocompromised, alcoholics, CV dz, major comorbidities (cancer, diverticulosis, gallstones, IBD, pancreatitis, renal failure, prior surgery or recent GI instrumatation, ealry preg
- pain characteristics: sudden onset, maximal at onset, pain with subsequent vomiting, constant pain of <2 d duration
- exam findings: tense or rigid abdomen, involunatry guarding, signs of shock
- life threatening causes: bowel obstruction, mesenteric ischemia, acute pancreatitis, and myocardial infarction
2
Q
abdominal pain locations and causes: RUQ, epigastric, LUQ
A
- RUQ:
- colonic: colitis, diverticulitis
- Biliary: cholesystitis, cholelithiasis, cholangitis
- hepatic: abscess, hepatitis, mass
- pulm: PNA, embolus
- renal: nephrolithiasis, pyelonephritis
- primary test of choice: US
- epigastric:
- biliary: cholecystitis, choleltihiasis, cholangitis
- cardiac: MI, pericarditis
- vascular: aortic dissection, mesenteric ischemia
- pancreatic: mass, pancreatitis
- gastric: esophagitis, gastritis, PUD
- primary test of choice: CT
- LUQ
- cardiac: angina, MI, pericarditis
- vascular: aortic dissection, mesenteric ischemia
- pancreatic: mass, pancreatitis
- renal: nephrolithiasis, pyelonephritis
- gastric: esophagitis, gastritis, PUD
3
Q
abdominal pain locations and causes: periumbilical, RLQ, suprapubic, LLQ
A
- periumbilical
- colonic: early appy
- vascular: aortic dissection, mesenteric ischemia
- gastric: esophagitis, gastritis, PUD, small bowel mass, obstruction
- RLQ:
- colonic: appy, coliitis, diverticulitis, IBD, IBS
- renal: nephrolithiasis, pyelonephritis
- Gyn: ectopic, fibroids, ovarian mass, torsion, PID, endometriosis
- primary test of choice: CT with con
- suprapubic
- colonic: appendicitis, colitis, diverticulitis, IBD, IBS
- renal: nephrolithiasis, pyelonephritis, cystitis
- Gyn: ectopic, fibroids, ovarian mass, torsion, PID, endometriosis
- primary test of choice: US
- LLQ
- colonic: colitis, diverticulitis, IBD, IBS
- renal: nephrolithiasis, pyelonephritis
- Gyn: ectopic, fibroids, ovarian mass, torsion, PID, endometriosis
- primary test of choice: CT with oral and IV con
4
Q
acute/chronic cholecystitis
A
- obstruction of cystic duct (not infxn) - leads to inflamm of GB wall
- sxs: RUQ or epigastric pain lasts a few days, may radiate to shoulder or scap, N/V, pruritis, clay-colored stools, dark urine
- signs: RUQ TTP, rebound in RUQ, Murphy sign, hypoactive bowel sounds, low fever, leukocytosis, jaundice
- dx: RUQ US, HIDA when US inconclusive, CT scan
- Labs: elevated ALK-P and GGT, elevated conjugated bili
- tx: admit, IVF, NPO, IVabx, analgesics, correct lytes, cholecystectomy (first line)
- 70% recurrence if left untreated
5
Q
anal fissure etiology, RF, and sxs
A
- irritation caused by trauma to anal canal results in increased resting pressure of internal sphincter - ischemia in region of fifssure and poor healing of injury
- MC in 30-50s, M=F
- Primary: local trauma, pooping probs, anal sex, SVD
- Secondary: previous anal surgery, IBD (Crohn dz), TB, sarcoidosis, malignancy, HIV, syphilis, chlamydia
- MC site: posterior anal midline, below or distal to dentate line (where transition zone becomes squamous epithelium)
- Sxs: tearing pain with defecation, pruritis, BRB,
- signs: superficial laceration, in chronic can see external skin tags and hypertrophied anal papillae at proximal end
6
Q
anal fissure dx and tx
A
- dx: endoscopy (if bleeding beyond 2mos tx), sigmoidoscopy if <50yo with no FH colon cancer, colonoscopy if suspician for Crohn dz
- tx: acute heals in 6wk - fiber and water, sitz baths, topical anesthetic, vasodilator (nifedipine, NTG), stool softeners or laxative
- if failed tx/chronic: botox, lateral sphincterotomy (gold standard - may cause incontinence)
- Prevention: proper hygiene - keep dry and wipe with soft cotton or moist cloth, high fiber, high water, dont strain while pooping, avoid trauma to anus, prompt tx of D
7
Q
appendicitis
A
- lumen obstructed by hyperplasia of lymphoid tissue, fecalith, or foreign body - leads to bacterial growth and inflammation - distention leads to ischemia, infarction, and necrosis
- peak incidence = mid 20s
- sxs: abd pain (epigastric → umbilicus → RLQ), anorexia, N/V, McBurney pnt (RLQ tendernes), rebound tenderness, guarding, decreased bowel sounds, low fever, Rovsing sign (LLQ TTP →RLQ referred pain), psoas sign (LQ pain w/ hip plexed against resistance or extended while lying on L side), obturator sign (LQ pain when hip and kne flexxed and hip internally rotated)
- dx: CLINICAL DX, CBC - neutrophilia (supportive), imaging if atypical presentation (CT, US)
- tx: appendectomy (lap), IVF, abx, NPO, pain mngmt
8
Q
SBO and LBO
A
- SBO: MCC = adhesions or hernias, cancer, IBD, volvulus, intussusception
- sxs: abd pain, distention, V, obstipation
- signs: dehydration + electrolyte imbalance, high-pitched bowel sounds, come in rushes
- LBO: MCC = cancer, strictures, hernias, volvulus, fecal impaction
- sxs: distention, pain, complete strangulation of bowel tissue (infarction, necrosis, peritonitis, death)
- signs: febrile, tachycardia (can lead to shock), dehydration + electrolyte imbalance
- dx both: KUB (air fluid levels, dilated bowel loops)
- tx both: NPO, nasogastric suction, IVF, pain mngmt
- LBO: urgent surgery when mechanical obstruction expected
9
Q
volvulus
A
- twisting of any portion of bowel on itself (commonly sigmoid or cecum); sigmoid is MC; MC in elderly with hx of chronic constip.
- sxs: cramping, distention, N/V, obstipation
- signs: abdominal tympany, tachycardia, fever, sever pain if ischemic (ischemia can lead to gangrene, peritonitis, sepsis)
- dx: Abd XR shows colonic distention (inverted U shape), loss of haustra, coffee bean sign (sigmoid) at midline corresponding to mesentaric root
- sigmoid = loop points to RUQ
- cecal = loop points to LUQ
- barium enema (bird’s beak or bird of prey sign)
- CT abd/pelvis shows whirl pattern
- tx: emergent endoscopic decompression - laparoscopic derotation
10
Q
cholelithiasis
A
- Etiology: stones in gallbladder, pain 2ary to contraction against obstructed duct; 3 types:
- cholesterol (yellow/green dt obestiy, DM, HLD, mult gest, OCP, Crohn, ileal resection, old, native american, cirrhosis, CF)
- Pigment (black): hemolysis (SS< thalassemia, spherocytosis, artificial valve), alcoholic
- Pigment (brown): in bile ducts dt biliary tract infxn
- sxs: most asx, biliary colic (RUQ or epigastric), pain after eating and night, boas sign (R subscap pain)
- dx: RUQ US (high sens/spec if >2mm), CT scan and MRI
- tx: no tx necessary if asx, elective cholecystectomy for recurrent bouts
- complications: cholecystitis, choledocholithiasis, gallstone ileus, malig
11
Q
choledocholithiasis, cholangitis, primary sclerosing cholangitis, primary biliary cirrhosis
A
- Choledocho: stones in CBD
- dx: RUQ US (first line), ERCP (gold standard - dx and tx)
- tx: ERCP with sphincterotomy and stone extract with stent placement, lap choledocholithotomy
- Cholangitis: infxn biliary tract 2ary to obstruction, CHARCOT TRIAD (RUQ pain, jaundice, fever), REYNOLD PENTAD (RUQ pain, jaundice, fever, HoTN, AMS)
- dx: RUQ US (first line), CBC, bili, ERCP (definitive, but not used in acute cases)
- tx: decompress via PTC or ERCP, bust be afeb 48h for ERCP/PTC so blood cultures, IVF, abx and decompress in the mean time
- Primary sclerosing: chonic idiopathic, likely autoimmune, strong correlation with ulcerative colitis, insidius, progressive jaundice, itching, fatigue, malaise
- dx: ERCP and PTC
- tx: liver transplant, cholestyramine - sxatic relief
- Biliary cirrhosis: chronic, intrahepatic bile duct destruction, autoimmune, similar sxs to primary sclerosing
- dx: elevated alkphos, +AMA, LIVER BX CONFIRMS DX
- tx: cholestyramin, Ca, bisphos, vitD for sxs; ursodeoxycholic acid slows progress; liver transplant curative
12
Q
acute pancreatitis etiology and sxs
A
- inflamm of pancreas from prematurely activated enzymes (autodigestion)
- causes: ETOH, gallstones, post ERCP, viral infxn, drugs, scorpion stings, pancreatic CA, hyperTG, hyper Ca, uremia, blunt trauma (MCC in kids)
- sxs: abdominal pain, epigastric, radiates to back, steady, dull, and severe (worse when supine and after meals), N/V, anorexia
- signs: low fever, tachycard, hoTN, leukocytosis, epigastric tenderness, abd distention, dec/absent bowel sounds, hemorrhagic pancreatitis (Gray Turner signs (flank), cullen sign (periumbilical), fox sign (inguinal lig))
13
Q
acute pancreatitis dx and tx
A
- dx: serum amylase (MC) - nonspecific, absence doesnt r/o, 5xULN, normal 48-72h after, serum lipase = more specific (3xULN), LFTs (possible gallstone pancreatitis), hyperglycemia, hypoxemia, leukocytosis
- Ranson criteria = glucose, Ca, hematocrit, BUN, ABG, LDH, AST, WBC
- KUP to ro perf, abd US identifies cause, CT scan is confirmatory, ERCP for severe with obstruction
- tx: mild = bowel rest (NPO), IVF, replete electrolytes, pain control (fentanyl, meperidine)
- severe = high mortality; ICU admit (enteral nutrition in first 72hrs through NJ tube
- recurrence high in ETOH related
- complications: pancreatic necrosis, pancreatic pseudocyst
14
Q
chronic pancreatitis
A
- persistent, continued inflammation of pancreas - fibrosis and lateration of ducts = IRREVERSIBLE
- causes: chronic ETOH-ism
- other causes: hereditary, tropical, idiopathic
- sxs: severe epigastric pain, recurrent or persistent, N/V, aggravated by drinking or eating, radiates to back, weight loss dt malabsorption, ETOH, DM, steatorrhea dt malabsorption
- dx: CT scan first line (calcifications, normal doesnt ro), KUB, ERCP gold standard (chain of lakes), serum amylase and lipase NOT elevated, other labs not helpful, stool elastase (most sensitive and specific for pancreatic insuff)
- tx: pain meds, NPO, panc enzymes and H2 blockers, insulin, ETOH abstinence, frequent small-volume low-fat meals, pancreaticojejunostomy or pancreatic resection (whipple)
- complications: narcotic addiction (MC), DM, malabsorption, pseudocyst, CBD obstruction, B12 malabsorption, effusions, panc carcinoma
15
Q
anorectal fistulas etiology and sxs
A
- 10% associated with IBD, tuberculosis, malignancy, radiation
- communication of abscess cavity with an identifiable internal opening within anal canal, most commonly located at dentate line where anal glands enter the canal
- arise through obstruction of anal crypts or glands
- intersphincteric (70%), transsphincteric, extrasphincteric, suprashpincteric
- 40% are + for intestinal bacteria, male 2x > F, MCC = anorectal abscess
- sxs: nonhealing anorectal abscess folowing drainage or chronic purulent drainage and pustule-like firm mass in perianal or buttock area, intermittent rectal pain (worse with defecation, sitting, and activity), malodorous perianal drainage, pruritus
- signs: excoriation and inflammation of perianal skin, inflamed, tender, draining, external opening
16
Q
anorectal fistulas dx and tx
A
- dx: all require anoscopy with diluted hydrogen peroxide to look for internal opening, imaging not required, drain with Mallenkot catheter, then fistulagram to search for an occult fistula tract, parks classification system
- tx:
- simple: fistulotomy with probing (preferred) - decreased risk of incontinence and recurrence, shorter healing time; simple ligation of internal fistula tract procedure, fistulectomy (larger wound, prolonged healing time, higher risk of incontinence
- complex: seton (vessel loop r silk tie placed through fistula tract - reduces risk of incontinence in cases where poor would healing expected, can be initial temporary intervention or for complex fistulas who fail initial tx), can also do fistulotomy
17
Q
anorexia nervosa
A
- MC F 14-21yo, F:M (3:1), homosexual men, child sex abuse, OCD, childhood/parental obesity
- starvation induces protein and fat catabolism → loss of cellular volume and atrophy in kidneys, brain, heart, liver, intestines, and muscles
- restriction of energy intake, intense fear of gaining weight, distorted perception of body weight and shape, palpitations, dizziness, weakness, exertional fatigue, cold intolerance, amen, abd pain or bloating, early satiety, const, swelling of feet
- signs: bradycardia, ortho hoTN, BMI <17.5, hypotherm, hypoactive bowel sounds, brittle hair, hair loss, xerosis (dry skin), lanugo, abd distention
- dx: EKG (inc PR interval, 1st def heart block, ST-T wave abnl, QT prolong.), CBC (anem leukopen, thrombocytopen), hypoK, hypoMg, hypophosph, hypoNa, Cr low, elevated bili/alkphos/AST/ALT, low T3/T4, low FSH/LH, high cholesterol
- tx: psychotherapy, nutritional . rehab, avoid bupropion
18
Q
bulimia nervosa
A
- F:M 3:1
- RF: childhood trauma
- sxs: recurrent eps of binge eating, compensatory behavior to prevent wt gain (vomiting, laxatives, diuretics, fasting, excessive exercise)
- both of these occur at least 1x/wk for 3mo
- excessive concern about body wt and shape, lethargy, irreg menses, abd pain, bloating, const
- signs: tachycardia, hoTN, xerosis, parotid gland swelling, erosion of dental enamel, + Russel sign (scarring or calluses on knuckles or back of hands)
- dx: serum alb low, hypoK, met alkalosis, hypoCl, hypoNa, hypoMg
- tx: psychotx, nutritional rehab, pharm (SSRIs, TCAs/MAOIs)
19
Q
anorectal abscess
A
- Goodsall’s rule: all fistula tracts with external opening within 3cm of the anal verge and post to a line drawn through ischial spines travel in a curvilinear fashion to the posterior midline; all tracks with external openings anterior to this line enter anal canal in a radial fashion
- complex fistulas: extrasphincteric or high fistulas proximal to dentate line; women with ant fistulas; fistulas with multiple tracts; recurrent fistulas; fistuals related to IBD, TB, HIV, or radiation tx; hx or anal incont; rectovag fistulas
- Parks described four types that originate from cryptoglandular infxns
- type 1: intersphincteric fistula that travels along the intersphincteric plane
- type 2: transsphincteric fistula that encompasses a portion of internal and external sphincter
- type 3: suprasphincteric fistula that encompasses the entire spincter apparatus
- type 4: extrasphincteric fistula that extends from primary opening in rectum, encompasses the entire sphincter apparatus, and opens onto skin overlying the buttock
20
Q
bariatric surgery
A
- Class 1: obesity (>30-34.9)
- class 2: severe obesity (>35-39.9) = surgical intervention if severe weight related conditions (DM, HTN, osteoarth, sleep apnea)
- class 3: morbid obesity (>40) = surgical intervention with or without comorbidities
- complications of obesity = OSA, HTN, CAD, nonalc fatty liver dz, DM, pseudotumor cerebri
- unfavorable prognostic factors for surg = BMI >50, male, HTN, PE risks, age >/=45yo
- CI: pts with unstable angina, end-stage pulm dz, cirrhosis, unstable psychological dz (uncontrolled schizophrenia or bipolar, recent suicide attempt, current eating disorder, chronic steroid use, chronic NSAID use
- periop diet: fasting (2 wks before surg, high protein shakes, 1 sensible meal), phase 1 (day before to 2 wks postop full liquid diet - protein shakes and zero cal bevs), phase 2 (2-5wks postop - full liquids and 1 cup soft foods), phase 3 (4-6wks postop - solid foods)
21
Q
types of bariatric surgeries
A
- roux-en-Y gastric bypass
- restrictive and malabsorptive procedure involving bypass of most of stomach, entire duodenum, and 100-150cm of small intestine, pouch is restrictive causing fullness, roux limb inhibs amoutn of absorption
- indications: BMI >35
- adverse effects: dumping syndrome
- Mortality = 1/500
- vertical sleeve gastrectomy
- restrictive and hormonal, reduces stomach to <25% of orig volume by resection of large portion along greater curvature including fundus, ghrelin made in fundus - dec with removal)
- indications: BMI >35
- adverse effects: lack of hunger 1-2y, barium swallow
- 70% estimated wt loss at 2y, mortality 1/2000
- adjustable gastric banding, lap-band
- restrictive
- indications: BMI >30-35 w/ comorbidities but insurance doesnt cover this
- ideal: volume eaters, no sweets, no liquid calories, trains you to eat and chew slower
- adverse effects: regurg, must see annually for upper GI (barium swallow) checking for band slippage, prolapse, and dilation
- less op risk but less avcerage wt loss, must repair hiatal hernias before
22
Q
dumping syndrome
A
- late complication of post-gastrectomy pts
- sugars = rapid fluid shifts
- sxs: abd cramping, diarrhea - shortly after meals (specially meals high in sugar), N/V, palps, lightheadedness, diaphoresis
- tx: health maint (check vitD, B12, and folate annually)
23
Q
colorectal cancer
A
- most from adenomas (endoluminal adenocarcinomas), Villous > tubular adenomas
- CRC = MCC LBO in adults
- RF: >50yo, polyps, hx CRC, IBD (UC), Fhx, diet (high fat, low fiber)
- sxs: abd pain, bowel habit change, wt loss, hematochezia (asx, unexplaine iron def., mostly in advanced states)
- R sided: obstruction less common, melena, occult blood, IDA, no bowel habit changes, Triad (anemia, weak, RLQ mass)
- L sided: obstruction more common dt smaller lumen, change in bowel habits (alternating const/D, narrowing of stools, hematochezia
- dx: colonoscopy
- tx: surgery, chemo + radiation, follow w/ guaiac, annual CT of abd/pelv, CXR up to 5y, colonoscopy at 1y, then q3y, CEA levels q3-6mo
24
Q
colorectal cancer screening
A
- begin 50yo, continue until 75yo
- FOBT qy
- start screening 10y younger than age of dx of youngest affected relative
- Flexible sigmoidoscopy: q5y combined with FOBT q3y
- Colonoscopy: q10y (q5y for pts with single 1st degree relative dx with CRC or advanced adenoma)
- Average risk = pts with no or 1 1st deg relative dxed >/= 60yo with CRC or advanced adenoma, never had CRC or polyp, IBD, abd radiation for childhood CA
- High risk = 1 1st deg relative dxed w/ CRC <60yo, or 2 1st deg relatives w/ CRC or advanced adenomas
- for these ppl, colonoscopy q5y beginning age 40 or 10y younger than youngest dx
25
Q
mechanical (intestinal) obstruction
A
- postop adhesions or internal (mesenteric) ischemia
- sxs: short period of normal intestinal fn before obstructive sxs, cramping, abd distension
- signs: high-pitched hyperactive bowel sounds, visible peristalsis, minimal tenderness
- dx: XR - air fluid levels in loops of small bowel
- tx: NG suction for several days, invasive hemodynamic monitoring if cardiac, pulm, or renal dz, if no resolution in 24-48h or peritoneal signs, laparotomy (abx for surg)
26
Q
gastroparesis
A
- MCC: diabetes
- other couses: anorexia, bulemia, scleroderma, ehlers-danlos, abd surg, female
- sxs: chronic N/V, abd pain, fullness after eating small amnts
- others: palps, heartburn, bloating, dec appetite, GERD
- dx: KUB, manometry, gastric emptying scan
- tx: low fiber, low residue, restrict fat intake, smaller meals spaced 2-3h apart, metoclopramide (D2 receptor antagonist increases contractility and resting tone in GI tract)
27
Q
small bowel intussusception
A
- 10% in peds cases, occurs during first 2wk postop, most ileoileal or jejunoileal
- sxs: atypical sx complex (V, abd distension, abd pain)
- dx: abd US: target/bull’s eye/coiled spring sign, CT scan (target lesion representing layers of intussuscepted segment)
- tx: barium/air enema (dx and tx), NPO, IVF, NG, abx, manual reduction or resection w/ primary anastomosis
55
Q
upper GI bleed
A
- bleeding originates proximal to lig of treitz
- ddx: peptic ulcer, esophageal varices, gastric bleeding from portal HTN, gastritis, AVM, tumor, Mallory-Weiss tear
- RF: NSAIDs, ASA, anticoag, antiplatelet, ETOH, prev GI bleed, liver dz, coagulopathy
- sxs: Hematemesis (blood or coffee ground), Melena, hematochezia (massive upper GI bleed)
- signs: orthostatic HoTN, tachycard, abdominal TTP
- dx: type and screen, Hgb, plt count, coag studes, liver enzymes, albumin, BUN/Cr, NG lavage + for blood = confirmatory
- endoscopy once stabilized (give erythromycin before exam), abx prophylactically for cirrhotics
- tx: supportive (NPO, IV access, O2, IVF, IV PPI until confirmation of cause of bleeding, consult GI and interventional radiology or surg, tx underlying cause, surg (duodenotomy or gastroduodenotomy, ligation of bleeding)
