Gastrointestinal Part 2 Flashcards
Define gastritis and gastropathy.
Gastritis: superficial inflammation/irritation of stomach mucosa with mucosal injury
Gastropathy: mucosal injury without evidence of inflammation
List factors that protect against injury to the layers of the GI tract wall.
mucus, bicarb, mucosal blood flow, prostaglandins, alkaline state, hydrophobic layer, epithelial renewal
What is the most common cause of gastritis?
H Pylori
What are the most common sequelae of H Pylori infection?
peptic ulcer, gastric adenocarcinoma,
gastric lymphoma
Other than the most common, list other causes of gastritis.
NSAIDs (PG inhibition), acute stress in critically ill patients, ETOH.
What is the role of prostaglandins in protecting the GI tract lining?
PGs inhibit acid secretion and stimulate mucus and bicarb secretion.
What S/S are associated with gastritis?
Most patients are asymptomatic. If S/S –> upper GI bleed, epigastric pain, N/V, anorexia, dyspepsia, abdominal pain
What is the gold standard for diagnosing gastritis and related issues?
Endoscopy
What non-invasive test is commonly used to evaluate for H Pylori?
Urea breath test
Describe the treatment for gastritis.
H. Pylori: clarithromycin + amoxycillin + PPI –> metronidazole if PCN allergy
Not H Pylori: PPIs, H2RAs, Sucralfate
What is the most common cause of gastroenteritis?
Salmonella –> 8-48 hours after ingestion
State the S/S of gastroenteritis.
N/V, fever, abdominal cramping, bloody diarrhea
What is used to diagnose gastroenteritis?
Stool culture
What is the treatment of gastroenteritis?
Supportive care in most –> self-limiting
Bactrom, ampicillin, Cipro options in severely ill or patients with SCD, or are malnourished.
Differentiate gastritis from gastroenteritis.
Gastritis: inflammation of the stomach lining specifically, and not always caused by infection.
Gastroenteritis: inflammation of the stomach and bowel, caused by an infection.
Define GERD
transient relaxation of LES –> gastric acid reflux –> esophageal mucosal injury
Define pyrosis and regurgitation as typical symptoms of GERD.
Pyr: heartburn –> usually 30-60 min post-prandial
Reg: water brash or sour taste in mouth
What complaints associated with GERD are cause for alarm?
dysphagia, odynophagia, weight loss, bleeding
What are potential complications of GERD?
esophagitis, esophagus stricture, barrett’s esophagus, esophageal adenocarcinoma, Barrett’s esophagus.
Define Barrett’s esophagus.
Esophageal squamous epithelium replaced by precancerous metaplastic columnar cells from the
cardia of the stomach.
When is endoscopy indicated in the evaluation of GERD?
New onset in patient > age 45, recuurent symptoms, failure to respond to therapy, indication of more serious condition –> anemia, dysphagia, recurrent vomiting.
What are the indications for esophageal manometry of 24 hour pH monitoring in the evaluation of GERD?
Manometry –> done if normal endoscopy
pH monitoring –> gold standard test but not usually done
Describe the hierarchy of therapeutics for GERD from mild to severe.
Lifestyle changes + OTC antacids and H2RAs –> Px PPIs –> Px PPI at night + Px H2RA during the day for severe overnight symptoms –> Nissen fundoplication if refractory.
What are risk factors for GERD?
obesity, pregnancy, diabetes, hiatal hernia, connective tissue disorders
What lifestyle modifications are recommended for treatment of GERD?
Elevated HOB at night, avoid laying down after meals, eat small meals, smoke cessation, weight loss, diet –> avoid fat, spicy, citrus, chocolate, caffeine, ETOH
What anatomical landmark differentiates upper GI bleeding from lower GI bleeding?
ligament of Treitz
Other than visible blood in stool or emesis, describe S/S that can present secondary to blood loss.
Syncope, fatigue, weakness
State the most common cause of upper GI bleed and list other causes.
Most common = peptic ulcer disease
Other: erosive esophagitis, duodenitis, varices, Mallory Weiss tear, vascular malformations
Patients on what medications are at 2-3 x higher risk of GI bleed?
ASA, PGY12 inhibitors, Vitamin K antagonists
What is the gold standard for evaluation of a suspected acute upper GI bleed?
Endoscopy
Differentiate pharmacologic therapy for an upper GI bleed when the suspected cause is esophageal varices vs not esophageal varices.
Varices: PPI –> 80 bolus follwed by 72 hour infusion
No varices: Ocreotide –> 25-50 mcg followed by infusion
What is used to reduce the risk of upper GI bleeding in a patient that must be on an NSAID or anti-coagulant medication?
PPI plus their NSAID/anti-coagulant
Define hemorrhoids.
enlarged venous plexus that increases with increased venous pressure
Define the 4 stages of internal hemorrhoids.
1: confined to anal canal, may bleed with defecation
2: protrude from anus but reduce spontaneously
3: require manual reduction after bowel movement
4: chronically protrude and risk strangulation
What are the most common S/S of external and internal hemorrhoids?
Ext: perianal pain
Int: intermittent rectal bleeding
Describe treatment of hemorrhoids.
Stage 1 and 2: high fiber diet, inc fluids, sitz bath, suppositories, hydrocortisone for itching/pain.
Stage 3 and 4: after failing conservative therapy –> injection, band ligation, sclerotherapy
Define hiatal hernia.
Protrusion of the stomach through the diaphragm via the esophageal hiatus
Differentiate between sliding (type 1) and rolling (tyoe 2) hiatal hernias.
1: GE junction and stomach slide into mediastinum –> treat like GERD.
2: fundus of stomach protrudes through diaphragm with GE junction remaining in place –> surgical repair.
Differentiate between ulcerative colitis and Crohn’s in terms of the areas affected and the depth of the lesions.
UC: Affects only colon with rectum always involved and lesions limited to mucosal & submucosal layers.
Crohn’s: Can affect any part of GI tract and lesions are transmural.
What part of the GI tract is most commonly affected by Crohn’s?
Terminal ileum –> LRQ pain.
Differentiate the common S/S of UC from Crohn’s.
UC: Colicky LLQ pain with bloody diarrhea.
Crohn’s: Colicky LRQ pain with weight loss and non-bloody diarrhea.
Differentiate Crohn’s from UC in terms of complications from each disease.
UC: colon cancer, toxic megacolon, primary sclerosing cholangitis.
Crohn’s: perianal disease (fistulas, abscesses, etc.), plus iron and B12 deficiency.
T/F: Smoking increases risk of complications from Crohn’s and Ulcerative Colitis.
False: Smoking worsens Crohn’s but actually improves UC.
Differentiate Crohn’s from UC in terms of findings on colonoscopy.
UC: uniform inflammation in rectum and colon –> “sandpaper appearance”.
Crohn’s: Skip lesions –> “cobblestone appearance”
Differentiate Crohn’s from UC in terms of findings on barium studies.
UC: Stove pipe appearance (loss of haustra in colon)
Crohn’s: String sign (inflamed area narrows)
Describe the serum lab findings used to help diagnose Crohn’s and UC.
p-ANCA and ASCA are not, by themselves, diagnostic of either disease. But they are used to differentiate between the two when IBD is suspected.
UC: more likely when p-ANCA is positive
Crohn’s: more likely when ASCA is positive
T/F: The definitive cure for Crohn’s and UC is surgery.
False: Surgery is curative in UC but not curative in Crohn’s
What findings are common to both Crohn’s andf UC?
Ankylising spondylitis, episclerirtis (reddening of eyes), fever, weight loss, fatigue, erythema nodosum, pyoderma gangreosum.
What are the tests of choice in the diagnosis of acute disease in UC and Crohn’s?
UC: sigmoidoscopy
Crohn’s: Upper GI series with small bowel follow through
T/F: Colonoscopy and barium enema are useful tests in definitive diagnosis of UC and Crohn’s.
False: Colonoscopy (perforation risk) and barium enema (toxic megacolon risk) are contraindicated in UC.
What diet recommendations are indicated for management of Crohn’s disease?
Smoke cessation, B12, folate, and vitamin D supplementation.
Describe the class and MOA of mesalamine and sulfasaline.
5-aminosalicylates –> ASA that gets to the intestines
Mesalamine: most active in terminal SI and colon –> best used for maintenance.
Sulfasaline: works primarily in colon but has a much higher AE profile.
Describe the use of corticosteroids in UC and Crohn’s.
Used PO or topical for acute flares only.
What is the most common cause of chronic abdominal pain in the US?
Irritable Bowel Syndrome (IBS)
Define irritable bowel syndrome (IBS).
Combination of altered motility and hypersensitivity to intestinal distention often with psychological distress.
What are common S/S associated with IBS?
Pain with altered bowel habits, post-prandial urgency and pain, relief after defecation.
What S/S associated with IBS are cause for alarm?
Evidence of bleeding, anorexia, weight loss, fever, celiac sprue, dehydration, onset > age 45
Describe the diagnostic process for IBS and important diseases in the differential.
Dx of exclusion –> r/o lactose intolerance, cholecystitis, chronic pancreatitis, bowel obstruction, celiac, carcinoma of pancreas/stomach
What is the Rome IV criteria for diagnosing IBS?
Recurrent abdominal pain at least 1 day per week plus at least 2 of …
- improvement with defecation
- change in stool frequency
- change in stool form/appearance
What lifestyle changes are recommended to patients with IBS?
Smoking cessation, low fat and unprocessed foods, avoid beverages with sorbitol and fructose, avoid cruciferous vegetables, sleep, exercise
What anti-depressant medication may be used to manage pain associated with IBS?
amitriptyline (TCA)
Describe broadly the causes of jaundice.
Increased bilirubin (hemolysis), decreased hepatic bilirubin uptake, impaired conjugation, biliary obstruction, hepatitis
Differentiate lab findings associated with pre-hepatic (hemolytic), post-hepatic (obstructive), and intra-hepatic (hepatocellular) causes of jaundice.
Pre: inc unconjugated bilirubin
Post: inc conjugated bilirubin, inc GGT and ALP
Intra: inc conjugated and unconjugated bilirubin, markedly increase AST and ALT
Differentiate between ETOH hepatitis, acute hepatitis, and chronic hepatitis by AST and ALT findings.
ETOH: AST > ALT by more than 2:1 ratio
Acute: ALT > AST –> both levels > 1,000
Chronic: ALT > AST –> both levels < 500
What bilirubin level is diagnostic and what does it mean if bilirubin is elevated with no rise in LFTs?
Bilirubin > 2.5 = diagnostic. If no rise in LFTs, suspect familial disorders or hemolysis.
What are the most common causes of pancreatitis?
Acute: cholelithiasis
Chronic: ETOH
Other causes: hypertriglyceridemia, trauma, drugs, hypercalcemia, penetrating PUD
What is the typical description of pain associated with pancreatitis?
Boring epigastric pain radiating to back that is relieved when leaning forward.
What is the classic triad of chronic pancreatitis?
Calcifications, steatorrhea, DM
What lab findings are indicative of pancreatitis?
Elevated amylase and lipase –> lipase more sensitive than amylase. Amylase increase is transient and will likely resolve in 48-72 hours.
What is the imaging test of choice in the diagnosis of pancreatitis?
Abdominal CT
What x-ray and US findings are consistent with pancreatitis?
x-ray: sentinel loop, colon cut-off sign
US: calcifications on pancreas
What are the cornerstones of the management of pancreatitis?
NPO, IV fluids –> 90% resolve without further intervention.
Describe the management of chronic pancreatitis.
PO pancreatic enzyme replacement, pain management, surgical removal of affected part of pancreas, ETOH cessation.
What are the causes of peptic ulcer disease?
H/ Pylori (MC), NSAIDs, Zollinger-Ellison syndrome
Differentiate S/S of duodenal ulcer from gastric ulcer.
Duodenal: pain improves with food intake
Gastric: pain worsens with food intake
What is the gold-standard test for suspected PUD?
Endoscopy
What testing is used to determine presence of H. Pylori?
Urea breath test - initial and confirm eradication
Stool antigen test - initial and confirm eradication
Serologic antibodies - initial but cannot confirm eradication
What medications are used in the management of H. Pylori?
clarithromycin + amoxicillin + PPI
What is the drug of choice for H. Pylori negative PUD?
PPI –> take 30 minutes before meals.
Describe the best use of misoprostil for treating PUD.
Used to prevent NSAID related ulcers but does not treat an existing ulcer.
What is the contraindication for use of misoprostil?
Pre-menopausal women –> abortifacent
Describe use of magnesium containing and aluminum containing compounds for GI disorders.
Mg: used to treat constipation –> Mg is a laxative
AL: used to treat diarrhea
Describe the prodromal and icteric phases of viral hepatitis.
Pro: malaise, arthralgia, fatigue, URI sx, anorexia, spiking fevers in Hep A
Ict: jaundice
Describe fulminant hepatitis.
encephalopathy, coagulopathy, jaundice, edema, ascites, asterixis, hyperreflexia
T/F: Hep A is the only viral hepatitis associated with spiking fevers.
True
What is used for post-exposure prohylaxis against Hep A?
HAV immune globulin
What are the most common causes of each type of viral hepatitis?
A: fecal-oral B: STI C: IVDU D: requires Hep B E: fecal-oral associated with water-borne transmission
Describe the relevance of HBsAG, HBsAb, and HBcAb testing for the diagnosis of Hep B.
HBsAG: 1st evidence of infection before symptoms –> positive for 6 months = chronic Hep B
HBsAb: Evidence of resolved infection or vaccination –> if not present after 6 months = chronic Hep B
HBcAb: IgM = acute infection and IgG = chronic or resolved infection
What is the vaccine schedule for Heo B and when is it contraindicated?
Three doses at 0, 1, and 6 months
CI in allergy to baker’s yeast
