GI 1 pt 1 (4.15) Flashcards
List some key components of a patient’s Hx with GI
1) Age
2) Time and mode of onset of the pain
3) Pain characteristics
4) Duration of Sx
5) Location of pain and radiation
6) Assoc. Sx and their relationship to the pain
7) Nausea, vomiting, anorexia
8) Diarrhea, constipation, or other changes in bowel habits
9) Menstrual Hx
List 4 common classes of signs & symptoms (cardinal features)
1) Abdominal or chest pain
2) Altered digestion of food (due to nausea, vomiting, dysphagia, odynophagia, anorexia)
3) Altered bowel movements (diarrhea, constipation, change in caliber of stools)
4) GI tract bleeding
List the “GI alarm features” (worrisome for malignancy)
1) Age ≥ 60 years (new onset dyspepsia)
2) Evidence of GI bleeding (hematemesis, melena, hematochezia, occult blood in stool)
3) Unexplained iron deficiency anemia
4) Early satiety
5) Anorexia
6) Unexplained weight loss
7) Dysphagia
8) Odynophagia
9) Recurrent vomiting
10) GI cancer in a first-degree relative
11) Previous esophagogastric malignancy
What are you looking for with a CBC?
1) Anemia (micro/macro/normo-cytic)
2) Infection
3) Pancytopenia (liver disease, cirrhosis)
4) Platelet disorders (thrombocytopenia in cirrhosis)
GI lab eval: What is the basic panel?
CBC, BMP or CMP, troponin, type & cross, lipase, amylase, iron panel, HCG, UA
GI lab eval:
1) What labs help eval for diarrhea?
2) Besides CBC, what labs help eval for liver disease and cirrhosis?
3) What help eval for MAFLD/pancreatitis?
1) O&P x 3, fecal leukocytes, FOBT, stool culture
2) Hepatic panel, PT/PTT, PT/INR
3) TSH (constipation, diarrhea), lipids/TG
GI lab eval:
1) What labs help eval for IBD?
2) What help eval for cancers?
3) What are other liver specific tests could you do for GI pts?
1) ESR, CRP, lactoferrin, calprotectin
2) AFP (HCC), CA19-9 (pancreatic CA), CEA (colon +)
3) Hepatitis screen, ANA, A1AT, hereditary hemochromatosis genetic markers
Liver biopsy: What kinds of diagnostic eval can it be used for? (3 things)
1) Focal or diffuse abnormalities on imaging studies
2) Parenchymal liver disease
3) Chronically (ie, > 6 months) abnormal liver tests (elevated LFTs) of unknown etiology after a thorough, noninvasive evaluation
Liver biopsy: Besides diagnostic eval, what are 2 other indications for liver biopsy according to the AASLD guideline?
1) Development of treatment plans based on histologic analysis
2) Staging of known parenchymal liver disease
Endoscopy (EGD/ esophagogastroduodenoscopy):
1) What is it?
2) What does it evaluate?
3) What are some indications?
1) Flexible fiberoptic tube (aka endoscope) with camera, able to take tissue samples/biopsies
2) Upper GI (esophagus, stomach, duodenum)
3) Ulcers, upper GI bleeding, biopsy lesions, dysphagia, odynophagia, reflux, FB removal, abdominal pain of unknown etiology, H. pylori
Endoscopy (EGD/ esophagogastroduodenoscopy):
What is it the diagnostic test of choice for? (2 things)
1) PUD (peptic ulcer disease)
2) Mallory-Weiss tears: tear in lining of the esophagus commonly at the GE junction from persistent vomiting that causes UGIB
ERCP (EndoscopicRetrogradeCholangioPancreatography):
What is it?
Endoscopy into pancreatic/ bile ducts; contrast injected into pancreatic and bile ducts
Colonoscopy:
1) What is it?
2) What is it used for?
3) What is an alternative?
1) Fiber-optic tube via anus for evaluation of entire colon
2) Ability to biopsy tissue/lesions (like CA and polyps)
3) Flexible sigmoidoscopy (aka, “flex-sig” - limited to distal descending colon-sigmoid area)
What are some indications for colonoscopy?
Lower GI bleed, colorectal cancer screening, biopsy lesions, evaluate IBD, polypectomy, TI (especially for Crohn’s (usually at terminal ilium))
Describe the risk-benefit analysis for colonoscopy
1) Process of determining if the benefits of performing the endoscopic procedure outweigh the risks involved
2) Requires careful consideration of all known benefits/indications, risks of procedure, contraindications, and patient risk factors
3) Process should involve all providers caring for the patient, incl. PCP, gastroenterologist, cardiologist, anesthesiologist, intensivist
4) Timing of procedure and management of antiplatelet/anticoagulation therapy + Setting
List some info abt the following OTCs:
1) Antacids
2) H2 blockers
3) PPIs
1) Rapid onset, short duration, caution in renal patients
2) Indications- indigestion, heartburn
Cons - slower onset, tachyphylaxis
2) PPIs: indications- heartburn, GERD
Cons - higher cost, risk for C. diff in hospitalized patients & low magnesium absorption
List some indications and cons for the following OTCs:
1) Laxatives
2) Stool softeners
1) Low cost, ease of use, effective,
cons - : gas, bloating, cramping, diarrhea
2) Stool softeners: indications - good first line for constipation.
-minimal adverse reactions, variable effectiveness,
List some info abt the following OTCs:
1) Antidiarrheals
2) Anti-flatulence drugs
1) Antidiarrheals: effective, constipation, cramping, not to be used in infectious diarrhea
2) Anti-flatulence: readily available, inconsistent data
List some info abt the following OTCs:
1) Hemorrhoidal preparations
2) Antiemetics
1) Indications: burning, itching, bleeding hemorrhoids
Cons - variable effectiveness, dermatitis, skin atrophy
2) Available, drowsiness, dizziness, flatulence
Give 3 reasons for dysbiosis
1) Abnormal host immune responses
2) Elicits the loss of naturally occurring intestinal microbiota
3) Increases numbers of yeast & bacteria and some pathogens
Is it easy to fix microbiota after excessive antibiotics?
Adverse effects on intestinal environment persists for months after discontinuing medication, very difficult to impossible to rebalance
1) What is a good Tx for C. Diff?
2) What is C. Diff?
1) Clindamycin
2) One of the most common pathogenic infections
Prevalent in continuous antibiotic use
List 4 types of GI bleeding
1) Acute upper GI bleeding (UGIB)
2) Acute lower GI bleeding (LGIB)
3) Small bowel bleeding
4) Occult GI bleeding
Acute upper GI bleeding: What is the most common presentation?
hematemesis or melena
Acute upper GI bleeding:
1) Define hematemesis
2) Define melena
3) Is acute upper GI bleeding usually serious?
1) Bright red blood or brown “coffee grounds” emesis
2) Melena (black, tarry stool) requires blood loss of only 50-100 mL
3) Self-limiting in 80% of patients
Acute upper GI bleeding: Severe UGI bleeding may cause ________________ (bloody maroon stools) in ___% of cases & requires loss of >1000 mL
hematochezia; 10%
What are the most common etiologies of acute upper GI breeding?
1) Peptic ulcers (40%)
2) Portal hypertension (10-20%) (ie, esophageal varices)
3) Lacerations of GE junction (5-10%) (ie, Mallory-Weiss tear)
4) Vascular anomalies (7%) (ie, angioectasias, telangectasias, AVMs)
5) Gastric neoplasms (1%)
6) Erosive gastritis (< 5%)
7) Severe erosive esophagitis
8) Aortoenteric fistula (rare)
Acute upper GI bleed: How do you assess hemodynamic status?
1) Systolic BP < 100 mm Hg (severe)
2) HR > 100 BPM with systolic BP > 100 mm Hg (moderate)
3) Normal BP & HR (minor)
4) Hematocrit NOT reliable indicator of acute bleeding
5) Elevated BUN-to-creatinine ratio (BUN/Cr > 36:1)
What should you establish for acute upper GI bleeding stabilization?
IV lines (two 18-gauge catheters)
Initial triage for acute upper GI bleeding: Describe factors that would make someone a high-risk patient
-Active bleeding (ie, hematemesis)
-Bright red blood on nasogastric aspirate
-Shock
-Persistent hemodynamic derangement after fluid resuscitation
-Serious comorbid medical illness/on blood thinner
-Evidence of advanced liver disease
Initial triage for acute upper GI bleeding: List 2 factors that would make someone a low-risk patient
1) No active bleeding
2) Absence of high-risk features
Acute upper GI bleeding:
1) What is the initial Tx plan for high risk pts?
2) What abt low-moderate risk?
1) ICU, stabilization, endoscopy within 12-24 hours
2) Step-down or medical unit (after stable), non-emergent endoscopy 12-24 hours (if no active bleeding)
Acute upper GI bleeding:
1) Most every patient with UGI bleeding should have upper endoscopy within ______ hours
2) Ongoing bleeding? Consider discontinuation of ___________ agents for up to 5 days & __________ agents for 7 days.
1) 24
2) antiplatelet; anticoagulant
List the benefits for endoscopy for acute upper GI bleeds
1) Identify source of bleeding
2) Determine risk of rebleeding & guide triage
3) Render endoscopic therapy (cautery, injection, endoclips)
Acute lower GI bleeding:
1) Where do they originate?
2) Where do up to 95% of cases originate?
3) What does severity range from?
4) Who are is serious low GI bleeding more common in?
1) Originating from below ligament of Treitz (duodenojejunal junction)
2) In colon
3) From mild anorectal to massive, large-volume hematochezia
4) In older men
Describe a mild acute lower GI bleed
Drips after BM or mixed with solid brown stool; usually anorectosigmoid source (outpatient)
Acute lower GI bleeds:
1) What is common?
2) Affects at least ____% of general public at least once
3) Is it usually serious?
1) Passage of small amounts of blood is common
2) 20%
3) Usually trivial, but can reflect serious disease
Give some locations acute lower GI bleeds can be found
1) On toilet paper
2) Streaks on stool
3) Dripping into toilet bowl
4) On underwear
Acute lower GI bleed
1) Usual etiologies are dependent on what?
2) Besides age-based causes, what are some other causes?
3) What meds increase risk? Give examples
1) Age & severity of bleeding
2) Benign polyps, radiation-induced changes
3) ASA, non-ASA antiplatelet agents, NSAIDs
-aspirin (ASA), warfarin (coumadin), plavix (clopidogrel), eliquis (apixaban), pradaxa (dabigatran etexilate), xarelto (rivaroxaban), lovenox (enoxaparin), heparin
Acute lower GI bleed: Symptoms & Signs:
1) What are some main Sx?
2) What suggests IBD, infectious colitis, or ischemic colitis?
1) Brown stool mixed or streaked with blood (BRBPR) predict rectosigmoid or anus origin
2) Bloody diarrhea with cramping abdominal pain, urgency, or tenesmus
Acute lower GI bleed: Symptoms & Signs:
1) What does large volume suggest?
2) What abt maroon blood?
3) What abt melena (not sure if this last one is on test)
1) Large volume bright red blood predicts colon origin
2) Maroon suggests right colon or small intestine origin
3) Melena suggests origin proximal to ligament of Treitz
Acute lower GI bleeding: What are your diagnostic options?
Anoscopy, sigmoidoscopy, colonoscopy, CT angiography, angiography, small intestine push enteroscopy, & capsule imaging (video capsule endoscopy)
Acute lower GI bleeding: What 3 things does choice of study/ test depend on?
1) Severity of bleeding at presentation
2) Hemodynamic instability with suspected ongoing/active bleeding
3) Suspected source of bleeding
Acute lower GI bleeding:
1) What should you consider if pt is unstable?
2) How can you exclude an upper GI source via testing?
1) Consider NG tube
2) Upper endoscopy for most unstable patients
-What is BUN/Cr ratio (?>36:1)
Acute lower GI bleeding:
1) Desc. initial stabilization
2) What should you consider if ongoing bleeding?
1) Initial stabilization, blood replacement, & triage same as with UGI bleeding
2) Discontinuation of antiplatelet agents for up to 5 days & anticoagulant agents for 7 days.
Acute lower GI bleeding:
1) What should you do if able?
2) What is a good Tx?
3) What is rarely needed?
1) Therapeutic colonoscopy if able
2) Angiography with selective intra-arterial embolization
3) Emergency surgery rarely needed
Suspected small bowel bleeding:
1) Is it always overt?
2) What does overt bleeding look like?
1) Can be overt or occult
2) Overt: melena or maroon stools
Suspected small bowel bleeding: List the most common causes based on age
1) Age < 40: neoplasms, Crohn’s disease
2) Age > 40: angiodysplasias (AVM’S,) NSAID-induced ulcers
Suspected small bowel bleeding assessment:
1) What does it depend on?
2) What should you repeat?
3) What is a testing option for stable pts?
4) What are 2 CT test options?
5) What blood related option is there?
1) Depends on age, health status, symptoms, & severity
2) Repeat upper endoscopy & colonoscopy
3) Capsule endoscopy (stable patients)
4) CT enterography
+ CT angiography (unstable acute bleeding) followed by urgent angiography with embolization
5) Tagged RBC scan
Occult GI bleeding:
1) Define it
2) What are 2 ways to ID it?
3) Where may it occur?
1) Bleeding that is not apparent to the patient
2) By positive FOBT or iron deficiency anemia (or both) in absence of visible blood loss
3) Anywhere in GI tract
Occult GI bleeding: What are the most common causes of it with iron-deficiency anemia?
Neoplasms, vascular abnormalities (angiodysplasias,) PUD, infections, medications, IBD
Occult GI bleeding:
1) When is colonoscopy done?
2) When are upper endoscopy & colonoscopy done?
3) Who should you eval for celiac disease?
1) Colonoscopy for asymptomatic patients with positive FOBT done for CRC screening
2) For symptomatic pts with positive FOBT or iron deficiency anemia
3) Patients with iron deficiency anemia
Lab patterns of liver disease:
1) What 2 groups may these patterns suggest?
2) Magnitude & what ratio may assist in Dx? What is a more specific marker of hepatic injury?
3) What are 3 categories of liver disease?
4) What may both groups have in common?
1)Pattern may suggest hepatocellular disease or cholestasis
2) AST:ALT ratio; ALT more specific marker of hepatic injury
3) Acute (< 6 wks), subacute (6 wks-6 mos), or chronic (> 6 mos)
4) Possible elevated Sr bilirubin & abnormal synthetic function in both patterns
Markers of liver disease:
1) What does low albumin suggest?
2) What does normal albumin suggest?
1) A chronic process (eg, cirrhosis or cancer)
2) More acute process (eg, viral hepatitis or choledocholithiasis)
Markers of liver disease:
1) What does low albumin suggest?
2) What does normal albumin suggest?
3) What does GGT (gamma-glutamyl transpeptidase) indicate?
1) A chronic process (eg, cirrhosis or cancer)
2) A more acute process (eg, viral hepatitis or choledocholithiasis)
3) Damaged liver or pancreas tissue. More specifically related to alcohol use or bile ducts
Markers of liver disease:
1) Prolonged prothrombin time (PT)/elevated INR indicates what?
2) Most hepatocellular injury results in which to be lower, AST or ALT?
1) Vitamin K deficiency due to malnutrition, malabsorption or significant hepatocellular dysfunction
2) AST lower than ALT
1) What ratio suggests alcoholic liver disease?
2) What does AST & ALT >25xULN suggest?
1) AST:ALT > 2:1
2) Acute viral hepatitis or toxin-related hepatitis with jaundice
1) What suggests Ischemic hepatitis (ischemic hepatopathy, shock liver, hypoxic hepatitis)?
2) What suggests Acute hepatic failure?
1) AST & ALT > 50xULN (LDH also often markedly elevated)
2) AST & ALT > 10xULN + prolonged PT (INR >1.5)
1) Define jaundice
2) What is it secondary to?
3) What lab level does it usually present with?
1) Yellow/orange skin, mucous membranes & sclera due to accumulation of bilirubin in tissues
2) Unconjugated (indirect) or conjugated (direct) hyperbilirubinemia.
3) Bilirubin > 3 mg/dL
Jaundice:
1) Where is it best seen?
2) What should you do with these pts?
3) When do you admit these pts?
1) Best seen in sclera/conjunctiva, under tongue, and hard palate
2) Refer for diagnostic procedures
3) Admit patients with hepatic failure
Bilirubin (hyperbilirubinemia):
1) What is bilirubin?
2) What does it provide?
3) What must the body do with it?
4) What is it mostly derived from?
1) Metabolite of heme
2) Color to bile, stool, & urine
3) Excrete it as it is potentially toxic
4) Heme from senescent RBCs
Describe the flow of bile from production to excretion
Bili production > hepatocyte uptake > conjugation > excretion into bile ducts > excretion into intestines
Hyperbilirubinemia:
Unconjugated hyperbilirubinemia (indirect) indicates what 3 things?
1) Increased bilirubin production
2) Decreased hepatic uptake
3) Impaired conjugation
Hyperbilirubinemia:
Conjugated hyperbilirubinemia (direct) indicates what 3 things ?
1) Biliary obstruction (extra-hepatic)
2) Intra-hepatic cholestasis
3) Hepatocellular injury
Give some historical clues for hyperbilirubinemia
1) Use of medications or recreational drugs
2) Use of dietary supplements or herbal medications
3) Use of alcohol
4) Hepatitis risk factors
5) H/o abdominal operations (including gallbladder surgery)
6) H/o inherited disorders (including liver diseases & hemolytic disorders)
7) HIV status
8) Exposure to toxic substances
ALT, AST, and GGT may indicate what?
Alcohol issues
