Gastrointestinal/Nutritional Flashcards
LFTs for alcoholic liver
AST 2x> ALT
think alcohol makes an aSS out of yourself
What is the most important test to assess for liver disease
PT/INR
these maybe deranged before LFTs elevate in patients with liver disease, hepatitis, HCC
Charcot’s triad
fever
RUQ abdominal pain
jaundice
(cholangitis)
Cholelithiasis Path: Pt: Dx: Tx:
Path: Gallstones in gallbladder (NO inflammation)
Pt: Fat, fair, fertile, female, 40s (TPN another risk factor)
Biliary colic: RUQ pain lasting 30 mins- few hrs precipitated by fatty foods or large meals
Dx:
U/S
CT or MRI
Tx:
Asx-> observation
Elective cholecystectomy
Cholecystitis Path: Pt: Dx: Tx:
Path: Obstruction by a gallstone
Pt: Fat, Fertile, Female, 40s
Colicky, steadily inc RUQ/epigastric pain after eating fatty foods
PE: Fever
Murphy’s sign-> inspiratory arrest w/ palpation of gallbladder
Boas sign->referred pain R shoulder
Dx:
(GS): HIDA scan (cholescintigraphy scan)-> nonvisualization of the gallbladder
Labs-> inc WBCs, inc bilirubin, inc Alk Phos, and inc LFTs
Initial: U/S
Thickened gallbladder; distended gallbladder, sludge, gallstones, pericholecystic fluid, + sonographic Murphy’s sign
Tx:
NPO, IVF, abx-> ceftriaxone + metronidazole
Pain-> NSAIDs, narcotics
Cholecystectomy
Cholecystostomy tube (if surgery contraindicated)
Peptic ulcer disease Path: Pt: Dx: Tx:
Path: H. Pylori infection or NSAID use
Duodenal: pain alleviated by ingesting food
Gastric: pain exacerbated by ingesting food
Pt: Gnawing epigastric pain
Dx:
Endoscopy
H. Pylori infection made by H. Pylori fecal antigen or urea breath test
Tx:
H. Pylori negative: PPI, H2 blocker, misoprostol, antacids, bismuth compounds, sucralfate
H. Pylori eradication:
Triple Therapy: Clarithromycin, amoxicillin (metronidazole), PPI (think CAP)
Quadruple therapy: Tetracycline, metronidazole, PPI, bismuth subsalicylate
Acute pancreatitis Path: Pt: Dx: Tx: Complications
Path: GET SMASHED
gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion stings, HLD/hyper Ca+, ERCP, Drugs
Pt: epigastric pain radiates to back, N/V
Grey-Turner Sign
Cullen Sign
Dx: elevated lipase
RUQ U/S-> gallstone obstruction
Abd CT-> non-obstructive origin
Tx: NPO, IVF
Complications: GA-LAW >/=3 severe pancreatitis glucose >200 Age >55 LDH >350 AST >250 WBC >16k
Chronic Pancreatitis Path: Pt: Dx: Tx:
Path: ETOH most common
Pt: Glucose intolerance
Abdominal pain radiating to back
Malabsorption, steatorrhea
Dx: CT/ Abdominal XR: calcifications
Tx: small, low fat meals Pain: TCAs, narcotics NPO-> acute exacerbations Pancreatic enzymes Replace fat soluble vitamins and cyanocobalamin-> steatorrhea
Viral Hepatitis Path: Pt: Dx: acute infection recovered immunized early marker for infection, positive in window period best marker for prior Hep B high infectivity low infectivity Tx:
Path: Hep A, E: fecal oral
Hep B infectious
Hep C: IVDA, chronic, cirrhosis, carcinoma, carrier
Hep D: dependent on Hep B co-infection
Pt: N/V, RUQ abd pain
PE-> tender enlarged liver +/- jaundice
Dx: HBsAg: acute infection Anti-HBs: recovered or immunized Anti-HBc IgM: early marker of infection, positive in window period Anti-HBc IgG: best marker for prior HBV HBeAg: high infectivity Anti-HBeAb: low infectivity
Tx: Supportive
Diarrhea after ingestion of… Name the pathogen:
- proteinaceous foods
- fried rice
- water, shellfish
- recent abx use
- raw veggies, water
proteinaceous foods: -chicken: salmonella -beef or poultry: clostridium perfringens fried rice: bacillus cereus water, shellfish: vibrio cholera recent abx use: C diff raw veggies, water: Shigella
Diarrhea recently ate poultry, meat or eggs Path: Pt: Dx: Tx:
Path: Salmonella
Pt: fever, diarrhea (possibly bloody in children), abdominal cramping
Dx:
labs-> fecal WBCs
stool culture
Tx: HYDRATION!
can consider cipro, bactrim if patient toxic
Colorectal cancer Path: risk factors Pt: Dx: Tx:
Path: Progression of adenomatous polyp into malignancy (adenocarcinoma)
Risk factors-> age>50, IBD, adenomatous polyps, diet (low fiber, high red meat), ETOH, african americans, family hx CRC
-genetics: familial adenomatous polyposis (APC gene mutation), lynch syndrome, Peutz-Jehgers
Pt: Iron deficiency anemia, rectal bleeding, abd pain, change in bowel habits
Large bowel obstruction (MC cause in adults)
Dx: Colonoscopy w/ bx (GS)
Barium enema: apple core lesion classic
Inc CEA; monitored during tx
CBC-> iron deficiency anemia
Tx:
Localized (stage I-III): surgical resection
Stage III and Mets: chemo mainstay (5FU/fluorouracil)
Rovsing sign
Appendicitis
RLQ pain w/ LLQ palpation
Obturator sign
Appendicitis
RLQ pain w/ internal and external hip rotation w/ flexed knee
Psoas sign
Appendicitis
RLQ pain w/ right hip flexion/extension (raise leg against resistance)
McBurney’s point tenderness
Appendicitis
point 1/3 the distance from the anterior superior iliac spine and naval
Esophagitis- Infectious Path: Pt: Dx: Tx:
Path: Infection an inflammation of esophagus MC in immunocompromised Fungal- candida, other fungi Viral- CMV, HSV, HIV, EBV, HPV Parasitic- cryptosporidum, PCP Mycobacterium- TB, MAC Bacterial- rare
Pt: Acute onset of odynophagia, dysphagia, chest pain, B symptoms
Dx: EDG w/ biopsy- apperance depends on infection
Tx: Appropriate antimicrobial therapy
+/- steroids for inflammation
Hydration
Esophagitis- Radiation
Pt:
Dx:
Tx:
Pt:
Early/acute: dysphagia, odynophagia, snub-sternal discomfort
Late (3-6m s/p therapy): dysphagia and odynophagia due to stricture/altered motility 2/2 fibrosis/muscular/nerve damage
Dx: EGD w/ bx
Tx: Viscous lidocaine Indomethacin Dilatation \+/- feeding tube Resolves w/ cessation of radiation therapy
Esophagitis- Eosinophilic Path: Pt: Dx: Tx:
Path: Eosinophilic predominate inflammation of the esophagus 2/2 to a trigger
Pt: Teenage caucasian males w/ hx of environmental allergies, GERD sxs, dysphagia, anorexia
Dx: EDG w/ bx w/ >15 eosinophils/HPF
Tx:
PPI
Topical steroids
Dietary elimination
Esophagitis- Corrosive Path: Pt: Dx: Tx:
Path: Chemical trauma to esophagus resulting in scarring (stricture)
Pt: Dependent on corrosive agent and severity of injury
Dx: Clx
Tx:
observation/supportive care
Potential G/J tube placement
Once healded dilation/esophagectomy prn
Esophagitis- Pill Induced Path: Pt: Dx: Tx:
Path:
Abx
NSAIDs
Bisphosphonates
Pt:
Retrosternal pain/heartburn
Odynophagia
dysphagia
Dx: Clx
EDG w/ signs of injury
Tx:
Instruction to take pills upright w/ lots of water to prevent further injury
Medication changes
Gastritis Path: Pt: Dx: Tx:
Path:
Acute: NSAIDS>alcohol
Type A chronic: pernicious anemia
Type B chronic: H. Pylori
Pt: Hematemesis
Dx: Upper endoscopy (EGD)
Tx:
Triple therapy
Clarithromycin, amoxicillin (metronidazole), PPI
Quadruple therapy
Bismuth subcitrate potassium, metronidazole, tetracycline, PPI
GERD
Dx:
Tx:
Complications:
Dx: Clx
Endoscopy
Esophageal manometry-> dec LES pressure
24hr ambulatory pH monitoring: GOLD STANDARD
Tx:
Lifestyle modifications: Elevation of HOB, Avoid recumbency for 3 hours after eating, Eat small meals, Avoid certain foods-> fatty, spicy, citrus, chocolate, caffeinated products, peppermint , Decrease fat & ETOH, Weight loss, Smoking cessation
Meds:
Antacids, H2 blockers, PPIs
Nissen fundoplication if refractory
Complications: Esophagitis Stricture Barrett’s esophagus Esophageal squamous epithelium replaced by precancerous metaplastic columnar cells from the cardia of stomach Esophageal adenocarcinoma
Hemorrhoids
Classification: internal hemorrhoids
Tx:
Classification:
1st: do not protrude through the anus
2nd: prolapse but reduce spontaneously
3rd: prolapse and require manual reduction
4th: cannot be reduced, may strangulate
Tx: Lifestyle modifications, sitz baths, analgesic creams,
surgical excision (thrombosed)
External: <72 hrs elliptical excision
Internal: Infrared coagulation, Rubber band ligation
