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Family Medicine > GI > Flashcards

GI Flashcards

1
Q

Pill esophagitis

A

Meds: NSAIDs, KCl, quinidine, bisphosphonates, Fe, Vit C, Abx

Sxs: odynophagia, dysphagia, retrosternal chest pain

Mgmt: drink 1-2 full glasses of water after pill, sit upright for at least 1 hour after

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2
Q

Infectious esophagitis

A

Et: HSV, CMV, Candida, HIV
RF: h/o immune suppression, usually HIV, organ transplant or chemo, asthmatics using steroid inhalers

Sxs: odynophagia, dysphagia, atypical CP

Dx: EGD w/bx and cytology; HIV testing

Mgmt:

  • HSV: Acyclovir 200mg PO 5x/day x 7-10 days
  • CMV: Ganciclovir 5mg/kg IV q 12hr x 3-4wk
  • Candida: Nystatin swish/swallow; clotrimazole troches, ketoconazole, fluconazole
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3
Q

Eosinophilic Esophagitis

A

Et:
- food/environmental antigens stimulate inflammatory response

RF: chldren w/h/o allergics or atopy: allergies, asthma, eczema

Sxs:

  • long h/o dysphagia to solids
  • heartburn
  • children: abd pain, vomiting, CP, FTT

Dx:

  • CBC w/diff (eosinophilia)
  • Elevated IgE
  • Barium swallow
  • EGD w/biopsy: small-caliber esophagus w/strictures or corrugated concentric rings**; exudates, red furrows

Mgmt:

  • PPI PO BID x 2mo trial - f/u w/endoscopy and bx
  • consider allergist
  • common allergenic foods: peanuts, dairy, eggs, wheat, soy, shellfish
  • topical corticosteroids: budesonide, fluticasone
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4
Q

Oropharyngeal dysphagia

A

Difficulty initiating swallow; high aspiration risk
Et: CVA, PD, MS, ALS, deconditioning

Sxs: wet quality of speech, coughing while eating
- h/o aspiration pneumonia

Dx: speech therapy eval w/swallow study

Mgmt:

  • modify diet: thickened liquids
  • swallow training
  • alternate feed route (PEG)
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5
Q

Mechanical aphagia

A

Food impaction = GI emergency
- h/o recently ingested food lodged in esophagus

Sxs: drooling and difficulty controlling secretions

Dx: refer to GI asap for EGD w/mechanical disimpaction
- repeat EGD in 6wk for bx

Mgmt:

  • PPI or Glucagon: antisecretory
  • do NOT get esophagram
  • complications: Boerhaave’s syndrome
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6
Q

Peptic Stricture

A

MC d/t GERD, typically GEjxn

Sxs: gradual onset solid food dysphagia

Dx: barium esophagram
- EGD w/bx

Mgmt: balloon dilation; bougie dilator

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7
Q

Zenker’s diverticulum

A

Diverticulum at pharyngoesophageal junction

Sxs: dysphagia, regurgitation, halitosis, nocturnal choking

Dx: esophagram

Mgmt: upper esophageal myotomy +/- diverticulectomy if symptomatic

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8
Q

Achalasia

A

Idiopathic motility disorder characterized by loss of peristalsis in distal 2/3 and impaired relaxation of LES*

Sxs:

  • failure of esophagus to relax; gradual onset
  • regurgitation, vomiting, wt loss, fullness, angina, choking, aspiration, pneumonia
  • liquid and solid dysphagia**
  • nocturnal regurgitation**

Dx:

  • barium swallow: Bird’s beak*
  • manometry: INC LES pressure w/out reflexes

Mgmt:

  • isosorbide, nifedipine, verapamil
  • botox injection
  • balloon stretching*
  • esophageal “heller” myotomy” - open w/fundoplication, cut nerves to plexus to relax LES and then tighten area so you don’t have reflux
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9
Q

Mallory-Weiss Tear

A

Longitudinal tears in mucosal membrane, distal esophagus*
Cause: retching against closed glottis
RF: alcohol, hiatal hernia

Sxs: specks of BRB or coffee-ground emesis of mild hematemesis after forceful retching
- most have no PE findings, possibly tachycardia
+/- melena

Dx:

  • Upright CXR: if hemodynamically unstable; evaluate for free air (Boerhaave syndrome - complete esophageal rupture)
  • EGD after resuscitation*
  • UGIB = inc BUN

Mgmt:

  • assess hemodynamic stability, need for resuscitation
  • PPIs, antiemetics
  • d/c w/OP EGD f/u
  • consider RF for bleeding and consider admit
  • active bleeding = endoscopic hemostatic therapy
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10
Q

GERD general

A

Cause:

  • incompetent LES (pressure <10 mmHg)
  • transient reflux
  • hiatal hernia
  • abnormal esophageal clearance
  • delayed gastric emptying

Heartburn reproducible by meals, bending or recumbency

Partial relief w/self-treatment

Sxs:

  • heartburn, dysphagia, chest pain, cough, wheezing, hoarseness
  • nocturnal awakenings, nighttime sxs - anatomical deficits (not just dietary/lifestyle)
  • solid dysphagia: mechanical obstruction
  • liquid and solid dysphagia: spasm, scleroderma, achalasia

Atypical sxs:

  • nocturnal/chronic coughing
  • hoarseness
  • atypical CP
  • sore throat
  • asthma, reactive airway disease

PE:

  • dental erosions
  • pharyngitis
  • halitosis
  • neck masses
  • wheezing
  • abd tenderness/masses

Can progress to Barrett’s and adenocarcinoma

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11
Q

GERD dx/tx

A

Dx

  • gold standard: pH monitor
  • PPI trial
  • serial EGD w/bx to r/o mucosal changes
  • manometry, motility measures

Mgmt:

  • reduce acidic foods, caffeine, wt loss, upright position for sleeping, stress reduction
  • H2Ras
  • Trial PPI*
  • Refractory: Nissen fundoplication
  • Pt w/long-standing GERD (>5y) especially >50yo should have upper endoscopy to detect/screen for Barrett’s*

PPIs

  • dec acid secretion but don’t prevent reflux
  • AE: HA, N, abd pain, bloating
  • bone density: dec absorption of Ca d/t acid suppression = supplement Ca, Vit D
  • Anemia d/t dec iron absorption
  • SI bacterial overgrowth and B12 def
  • Inc pneumonia in elderly
  • Inc r/o C. diff
  • hypoMg
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12
Q

Gastritis

A

MC w/alcohol or critically ill pt
RF: NSAIDs, stress, H. pylori

Sxs: often asx

  • may have epigastric pain
  • NV, upper abd pain, acute UGI bleed

Dx: EGD - petechiae, erosion, hemorrhage, inflammation on biopsy

Mgmt:

  • remove alcohol
  • treat H. pylori
  • IV PPI if GI bleed is present, ulcer prophylaxis for critically ill pt
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13
Q

PUD

A

D/t acidic gastric juice corroding gastric epithelium

  • more common in males
  • duodenal 5x more than gastric
  • gastric more common in elderly

RF: NSAIDs, H. pylori, stress, tobacco, Zollinger ellison

Sxs: aching, burning pain

  • duodenal ulcer: better with food
  • gastric ulcer: worse with food

Duodenal ulcer bleed MC on posterior surface of duodenal bulb

Perfs more likely anterior d/t lack of protective viscera - free air = emergency

Dx:

  • gold standard: EGD w/urease test
  • UGIB: Inc BUN
  • if bleeding on EGD: epi injection, electrocautery, laser ablation

Mgmt:

  • heal ulcer w/acid suppression and kill h. pylori [triple or quad therapy]
  • gastric: PPI x 8wk
  • duodenal: PPI x 4wk
  • d/c NSAIDs
  • surgery for complications (bleeding, perf, obstruction)
  • perf = Graham steele closure
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14
Q

Acute cholecystitis

A

80% d/t obstruction of cystic duct by gallstone impacted in Hartmann’s pouch*
- acalculus: after trauma, critically ill, recent major surgery

Sxs: acute RUQ/epigastric pain, radiates to right scapula
+ Murphy’s sign
- palpable gallbladder
- h/o biliary colic now longer/more intense

Dx:

  • CBC: leukocytosis
  • Inc bili, ALT, alk phos
  • Abd U/S* - cholithiasis, U/S Murphy’s sign, GB wall thickening, pericholecystic fluid

Mgmt:

  • NPO, NG placement
  • IV pain mgmt
  • IV abx: Unasyn, Zosyn, Ertapenem
  • Early lap chole/surgery consult
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15
Q

Chronic cholecystitis

A

MC symptomatic gallbladder disease

Biliary colic: transient gallstone obstruction of cystic duct w/RUQ pain
- may also be epigastric or LUQ may radiate to back or scapula

Dx: U/S*

  • MRCP/ERCP, HIDA Scan
  • ALT/AST modestly elevated

Mgmt:

  • NSAIDs/opioids for acute pain relief
  • Lap Chole
  • Ursodiol to dissolve stones if not surgical candidate
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16
Q

Cholelithiasis

A

RF: fat, female, fertile, forty
- rapid wt loss, DM, hemolytic anemia, pregnancy, hypertrig
Protective: low carb, high fiber, exercise, cardio, high Mg diet, coffee

Sxs: most asx; large can cause acute cholecystitis, CA

Dx: U/S

Mgmt:

  • most require no treatment
  • possible cholecystectomy if sx persist
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17
Q

ETOH hepatitis

A

Men, highest risk = 12 drinks/day

Sxs

  • Rapid onset jaundice, liver failure
  • HE, ascites, tender hepatomegaly, dark urine/acholic stool

Dx: >2:1 elevated AST>ALT

  • Inc bili, INR
  • leukocytosis, neutrophilia
  • U/S r/o biliary obstruction*

Hepatorenal syndrome: renal failure

Mgmt:

  • addiction help, nutrition
  • Maddrey discriminant index > 32 = treat w/prednisolone or pentoxifyline
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18
Q

Acute hepatic failure

A

Rapid liver failure + Hepatic encephalopathy

  • acute: w/in 8wk after onset of liver injury
  • cause: MC APAP [other: INH, pyrazinamide, rifampin, AEDs, abx, viral hep, liver ischemia, Budd-Chiari, autoimmune hep, fatty liver]

Sxs:

  • encephalopathy: vomiting, coma, asterixis*, hyperreflexia, cerebral edema, Inc intracranial pressure
  • ammonia = neurotoxin
  • coagulopathy: dec hepatic production of coag factors
  • HPM, jaundice

Dx:
- Inc ammonia, PT/INR>1.5, LFTs, hypoglycemia

Mgmt: 
encephalopathy
- lactulose: neutralize ammonia
- rifaximin, neomycin: DEC bacteria producing ammonia in GI tract
- protein restriction

Definitive: transplant

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19
Q

Viral hepatitis

A

Prodrome:
- malaise, arthralgia, fatigue, URI, anorexia
- NV, abd pain, loss of appetite
+/- acholic stool

Icteric phase: jaundice
Fulminant:
- encephalopathy, coagulopathy
- jaundice, edema, ascites, asterixis, hyperreflexia

Dx:
- Inc ALT > Inc AST
- both > 500-1000 if acute
+/- bilirubinemia

Mgmt: clinically recover w/in 3-16wk
- 10% HBV and 80% HCV become chronic

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20
Q

Hepatitis A

A

Transmission: fecal oral
- contaminated water, food, international travel, daycare workers, MSM, shellfish

Sxs:

  • adults spiking fever
  • kids usually asx

Dx:

  • acute: +IgM HAB ab
  • past exposure: +IgG HAV ab w/neg IgM

Mgmt:

  • self-limiting, sx tx
  • HAV Ig post-exposure prophylaxis
  • vaccine
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21
Q

Hepatitis E

A

Transmission: fecal oral
- water-borne outbreak

Dx: + IgM anti-HEV

Mgmt:

  • self-limiting
  • highest morality during pregnancy (especially thrid tri) ** inc r/o fulminant hep
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22
Q

Hepatitis C

A

Transmission: parenteral
- IVDU, blood transfusion prior to 1992

Dx: 
\+ anti-HCV ab in 6wk doesn't imply recovery
acute: HCV RNA +, anti-HCV +/-
resolved: HCV RNA -, anti-HCV +/-
chronic: HCV RNA +, anti-HCV +

Mgmt: antivirals
- screen for HCC via AFP, U/S

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23
Q

Hepatitis D

A

Requires Hepatitis B co-infection*

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24
Q

Hepatitis B

A

Transmission: parenteral, sexual, perinatal, percutaneous

Sxs:

  • acute: 70% subclinical, 30% jaundice
  • chronic asx carrier: +HBsAg, +HBe ab, low HBV DNA, normal LFTs
  • chronic infection: + HBsAg, Inc ALT/AST, Inc HBV DNA and evidence of hepatocellular damage on liver biopsy

Mgmt:

  • acute: supportive
  • chronic: tx may be indicated if Inc ALT, inflammation on biopsy, or +HBeAg
  • alpha-INF 2b, lamivudine, adefovir, tenofovir, entecavir

Prophylaxis w/Hep B vaccine at 0, 1, 6 months

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25
Q

Hepatitis B labs

A

HBsAg: 1st evidence of infection before symptoms, if + >6mo = chronic infection

HBsAb: distant resolved infection OR vaccination (if alone)
- signifies immunity, pt not infectious, chronic infection if don’t establish this in 6mo

HBcAb: IgM (acute infection), IgG (chronic infection or resolved)

HBeAg: Inc viral replication, Inc infectivity
- >3mo = Inc likelihood of developing chronicity

HBeAb: waning viral replication, Dec infectivity

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26
Q

Chronic viral hepatitis

A

Disease > 6mo duration

  • only Hep B, C, D
  • may lead to ESLD or HCC

Dx: ALT, AST < 500

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27
Q

Liver cirrhosis

A

Irreversible liver fibrosis w/nodular regeneration leading to increased portal pressure

  • MC cause: EtOH
  • Other cause: HCV, NASH, hemochromatosis, autoimmune hepatitis, PBC/PSC, drug toxicity

Sxs: constitutional
- ascites, HSM, gynecomastia, spider angioma, caput medusa, muscle wasting, ,bleeding, palmar erythema, Dupuytren’s contracture

Complications:

  1. hepatic encephalopathy: confusion, lethargy, asterixis, increased ammonia levels
    tx: rifaximin, lactulose
  2. esophageal varices
  3. SBP: fever, PMNs > 250 in peritoneal fluid

Dx:

  • U/S
  • Staging w/Child-Pugh [total bili, serum albumin, PT, ascites, hepatic encephalopathy]
  • MELD for ESRD

Tx:

  • ascites: Na restriction, diuretics, paracentesis
  • pruritis: cholestyramine
  • definitive mgmt: liver transplant
  • screen for HCC w/US and AFP q 6mo
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28
Q

Constipation

A

Sxs:

  • excess straining
  • sense of incomplete evacuation
  • failed or lengthy attempts to defecate
  • hard stools
  • Dec frequency of stools

Alarm: rectal bleeding, heme + stool, wt loss, obstructive sxs, recent onset of sxs, rectal prolapse, change in caliber of stool, >50yo

Dx: clinical (DRE)

  • TSH, BMP, glucose
  • abdominal Xray, barium enema

Mgmt:

  • lifestyle: fiber, fluids, exercise
  • bulk laxatives: psyllium, methylcellulose [ADR: inc flatulence/bloating - inc water intake]
  • stool softener: docusate [ADR: bitter taste, N/D, cramping]
  • osmotic laxative: PEG, Mg
  • stimulant laxative: Senna, Bisocodyl [do NOT use for chronic constipation]
  • Lineclotide, lupiprostone - if not pregnant
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29
Q

Crohn’s disease

A

Peak: 20-40yo
Affects any portion of GI tract, mouth to anus
MC affects: terminal ileum, Right colon

Sxs:

  • diarrhea, hematochezia, recurrent abdominal pain, wt loss, malaise, anorexia, SBO
  • extraintestinal: uveitis/episcleritis, oral ulcers, skin changes, joint pain

Dx: endoscopy (upper/lower)

  • cobblestoning of bowel wall
  • rectal sparing
  • skip lesions
  • granulomatous ulcers
  • fistulas
  • “string sign”

Mgmt:

  • anti-inflammatory meds, steroids, immunosuppressants, anti-diarrheal
  • surgery to relieve obstructive sxs
  • stricturoplasty
  • goal: preserve length, remove affected area
  • lleocecal anastomosis common
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30
Q

Ulcerative colitis

A

Sxs:

  • insidious or acute presentation
  • rectal bleeding, diarrhea, constipation, abdominal pain

Complications:

  • CRC likely, unless colectomy; incidence begins 8-10y after onset of UC
  • toxic megacolon
  • acute perforation (very thin walls)

Dx: colonoscopy (only if no active disease)

  • continuous lesions
  • profound leukocytosis

Mgmt:

  • Med: supportive
  • surgical: acutely if complications; chronic if unmanaged with meds- can CURE and dec CA risk
  • emergent colectomy w/toxic megacolon
  • protocolectomy w/terminal ileostomy +/- J pouch = remove colon and rectum
  • total colectomy
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31
Q

Irritable bowel syndrome

A

Chronic condition characterized by abd pain and bowel dysfunction
2:1 F:M, unusual if onset after 50y
RF: physical or sexual abuse, previous enteric infection, stress

Sxs:

  • pain relief w/defecation
  • RLQ/LLQ tenderness to palpation

Dx: diagnosis of exclusion
- CBC, stool studies, anti-TTG, abdominal Xray, flex sig, colonoscopy, hydrogen breath test, serum CRP

ROME Criteria: recurrent abdominal pain 1d/wk x 3mo associated with 2 or more:

  1. related to defecation
  2. a/w change in stool frequency
  3. a/w change in stool form

Mgmt:

  • decrease stress, cut out trigger foods (caffeine, lactose, fructose), low FODMAP diet
  • probiotics may be helpful
  • treat sxs - constipation, diarrhea accordingly
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32
Q

Lactose intolerance

A

Lactase - enterocyte brush-border disaccharidase found in small intestine
MC genetic deficiency syndrome worldwide

Sxs: after/during ingestion of lactose-containing product = bloating, flatulence, diarrhea (w/o steatorrhea), crampy abdominal pain

Dx:

  • clinical w/history or improvement on lactose-free diet
  • Hydrogen breath test for carb malabsorption

Mgmt:

  • dec/eliminate dairy products
  • enzyme replacement supplement (lactaid)
  • supplement calcium and vitamin D
33
Q

Polyp

A

Adenoma: pre-cancerous
most CRC begins as small, benign clumps of cells called adenomatous polyps/adenoma
MC: left side of colon

Sxs: typically asx
- rectal bleeding is the most common: intermittent, variable color

Dx: colon w/bx and polypectomy

Mgmt: polypectomy, may require further resection

Screening:

  • FOBT or FIT q year
  • Stool DNA q 1-3y
  • Double contrast barium enema q 5y
  • CT colonography q 5y
  • flex sig q 5y
  • flex sig + annual Fit q 10y
  • colon q 10y
  • 1st deg relative or someone younger than 60 had CRC or adenoma - start 10y earlier than earliest diagnosis
34
Q

Colorectal Cancer

A

95% adenocarcinomas
Start screening at 45y or symptomatic
Must r/o in adult with rectal bleeding even in presence of hemorrhoids

Sxs:

  • R colon: thin wall w/large lumen, liquid feces, fatigue, weakness, wt loss, tumors erode through wall quicker
  • L colon: small lumen, semisolid feces, change in bowel habits, observation, bleeding
  • Rectal: BRBPR/hematochezia, persistent

Dx:

  • check supraclavicular LAD
  • tumor marker: CEA
  • colonoscopy w/bx
  • look for mets w/CT or PET

Mgmt: wide surgical resection including regional LN drainage +/- Radiation/chemo

  • cecal: R hemicolectomy w/ileocolic anastomosis
  • transverse: transverse colectomy w/ascending and descending colon anastomosis
  • hepatic flexure: extended R colectomy w/ileocecal anastomosis
  • splenic flexure: L hemicolectomy w/transverse and sigmoid colon anastomosis
  • sigmoid: sigmoid colectomy w/colo-colo anastomosis
35
Q

Anal fissure

A

90% occur posterior (closest to spine), if not there, then anterior position; right or left are abnormal

Et: young adult; most a/w constipation
RF:
- trauma: constipation/strain, high sphincter tone, explosive diarrhea
- immunosuppressive conditions
- others: childbirth, anal intercourse, foreign body insertion

Sxs:

  • pain out of proportion to the appearance
  • ranges from mild irritation to severe pain
  • sharp, stinging, tearing, burning a/w and after defecation
  • pain may last several min - hours; scant BRBPR on toilet paper
  • itching, perianal irritation

Dx: clinical
Mgmt:
- relieve constipation, facilitate easy BM (stool softener)
- most heal w/conservative tx in 8wk
- Inc fiber/fluid, keep anal area clean/dry
- warm sitz baths after BM to inc blood flow and promote healing
- topical anesthetic (benzocaine)

Chronic fissure: 4-6wk, appear fibrotic, failure to respond to conservative therapy suggests Inc internal anal sphincter pressure
- tx w/vasodilating ointment (diltiazem); botox injection; lateral internal sphincterotomy

36
Q

Fecal impaction

A

atypical presentation of constipation
RF: opioids, bed rest, neurogenic or spinal cord disorders
Sxs: NV, abd pain, anorexia, distension, paradoxical diarrhea
Dx: confirmed by DRE
Mgmt: digital disimpaction, enema, suppository

37
Q

Hemorrhoids

A

Engorged tissue d/t Inc intra-abdominal pressure from pregnancy, ascites, obesity

  1. bleed
  2. bleed and prolapse
  3. manual reduction
  4. cannot be reduced

Sxs: swollen, inflamed vein in anus/rectum

  • BRBPR +/- Pain**, pruritic, mucoid d/c
  • external: acute intravascular thrombosis

Dx:

  • external: below dentate line = painful
  • internal: above dentate line = painless
  • new onset hematochezia = colonoscopy to r/o other causes

Mgmt: conservative tx

  • tx constipation
  • lifestyle: avoid prolonged sitting, dec toilet time, keep anal area clean and dry, increase fluid intake, high fiber, stool softener, warm sitz bath, topical steroid less than 1 week
  • symptomatic require tx
  • internal hemorrhoid: band ligation 1-4; 3-4 = injection sclerotherapy, hemorrhoidectomy
38
Q

Thrombosed external hemorrhoid

A

Acute onset very painful, tense, bluish perianal nodule precipitated by coughing, straining, lifting

Tx: removal of clot if <48hr

  • pain eases over 2-3d
  • oral/topical analgesics
  • stool softener
  • sitz bath
39
Q

Incisional hernia

A

bulge in abdomen deep to scar
worse with cough or strain

PE: palpable

Repair w/mesh; mandatory repair if bowel involved

40
Q

Inguinal hernia

A

Most Asx lump or swelling in groin

Sxs: heavy/dull sensation when straining or lifting may radiate to scrotum
- pain = incarceration or strangulation

PE: visual, index finger to external ring and pt cough

If asx/reducible = does not need surgery

**MC hernia: indirect inguinal

Mgmt: totally intraperitoneal laparoscopic surgery w/mesh

41
Q

Umbilical hernia

A

soft protuberance at umbilical, often asx

PE: visual, palpable

Repair rarely recommended until 2+ yo

Mgmt: surgical repair if sx w/possible mesh if large (>2cm)

42
Q

Ventral hernia

A

includes incisional, umbilical, epigastric, spigelian
- all defects in wall

surgical repair if symptomatic

43
Q

Richter’s hernia

A

Takes only part of the bowel, stool can still pass through

Dx: PE
- CT w/PO contrast to see defect*

44
Q

Femoral hernia

A

bowel obstruction d/t strangulation or incarceration

Mgmt:

  • MC: totally extraperitoneal repair
  • TAPP: transabdominal pre-peritoneal patch - keep mesh away from bowels

IPOM: intra-abdominal preperitoneal onlay put over defect

45
Q

Diarrhea: inflammatory vs. noninflammatory

A

Inflammatory:

  • blood/mucus more present
  • less output
  • sicker pt; often febrile

e. g.
- cholera
- v. vulnificus
- salmonellosis
- campylobacteriosis
- shigellosis
- e. coli
- c. diff
- traveler’s diarrhea

Noninflammatory:
- more vomiting and more output

e. g.
- norovirus
- staph aureus
- Bacillus cereus
- giardiasis
- cryptosporidiosis

46
Q

Norovirus

A

MC infectious GE in kids/adults in the U.S.
Et: person to person transmission: fecal-oral; vomitus aerosol
- small infecting dose
- contaminated food, H2o, fomites

Sxs:

  • year-round outbreaks in colder months
  • “stomach flu” - no ENT sxs
  • sudden onset vomiting (peds) or sudden onset diarrhea (adults) lasting 1-3d**
  • low grade transient fever
  • dehydration w/young or elderly

Dx: clinical
- PCR used for health dept during outbreak

Mgmt: supportive w/ORS

47
Q

Staph aureus

A

Eating food that has been sitting out or undercooked

Enterotoxin*
- ingested from contaminated food

Sxs:

  • 2-7hr after exposure*
  • NV, abdominal cramps*
  • fever, diarrhea uncommon*

Clinical dx, supportive tx

48
Q

Bacillus cereus

A

Rice
- spore former, not killed by boiling

Enterotoxin*
- ingested from contaminated food

Sxs:

  • 2-7hr after exposure*
  • NV +/- diarrhea

Clinical dx, supportive tx

49
Q

Giardiasis

A

Et: giardia intestinalis

  • MC parasitic cause of infectious diarrhea
  • streams, backpackers, beavers

Transmission: fecal-oral
- zoonotic: beavers, dogs, cattle

Sxs: incubation time 1-2wk; 60% as

  • acute: malaise, NVD, belching, gas, cramping, wt loss, steatorrhea
  • chronic: wax/wane overm months if not treated

Dx: immunoassay EIA stool sample

Mgmt: ORS
- tinidazole or nitazoxanide

50
Q

Cryptosporidiosis

A

Et: C. parvum > C. hominis

Transmission: fecal-oral

  • commonly waterborne
  • cattle - gets into streams

Sxs:

  • profuse, watery diarrhea
  • crampy abd pain (cholera-like) - hits Small intestine

Dx: immunoassay EIA stool sample

Mgmt: refer
- ORS, nitazoxanide

51
Q

Cholera

A

Et: vibrio cholera

  • GNB costal waters
  • may be epidemic w/raw, undercooked oysters*
  • poor sanitation or contaminated water

Transmission: bacterial ingestion (requires large infecting dose)
- colonizes SI, produces cholera toxin, modulates CFTR = Cl secretion = Na/H2o into SI lumen

Endemic: asx - mild noninflammatory diarrhea

Epidemic: severe, dehydrating life-threatening inflammatory diarrhea w/electrolyte abn and hypovolemic shock
** rice water stool

Severe: cholera gravis* - lose 1L an hour, likely dead w/in 12hr

Dx: dark-field microscopy* = comma shaped darting bacteria
- stool culture

Mgmt:

  • early/aggressive fluid replacement (200-350mL/kg)
  • IV: Dhaka solution, high in K/bicarb
  • start ORS concurrent to IV or w/in 3-4hr of stabilization
  • Doxy (adults) or azithro (peds)
  • supplemental zinc
52
Q

Vibrio vulnificus

A

GNB costal US waters
Seafood - only eat RAW oysters in cold months

Transmission:

  • ingestion of bacteria*
  • enters GI tract - most pt die from bacteremia/sepsis

Sxs:

  • hemorrhagic bullae: vibrio (costal water) or aeromonas (lake water)
  • fatal in advanced liver disease (cirrhosis)

Dx: recognize
Tx: refer

53
Q

Salmonellosis (nontyphoidal)

A

Et: flag facultative anaerobic GNB

RF: inc w/young or old, corticosteroids, immunosuppression, comorbidity

Transmission:
- zoonotic* - chicken, eggs, reptiles

Sxs:

  • gastroenteritis
  • inflammatory diarrhea
  • concern for infective endocarditis or aortic invasion

Dx: stool culture
- positive blood or urine culture = aortic involvement until proven otherwise

Tx: FQ or ceftriaxone

54
Q

Salmonellosis (typhoidal)

A

Anaerobic GNB

  • MC: south-central, SE Asia
  • dec incidence in US bc water treatment, dairy pasteurization

Trans: crowded, impoverished populations w/inadequate sanitation and exposed to unsafe H2o/food

Sxs:

  • enteric fever
  • constitutional sxs predominate
  • constipation
  • “pea-soup” diarrhea (actually uncommon)

Dx: blood culture; stool/urine culture

Mgmt:
- FQ* or ceftriaxone

55
Q

Campylobacteriosis

A

Et: s-shaped, gull-winged, bipolar GNBs

  • raw/poorly cooked chicken
  • MC bacterial zoonosis in U.S.
  • Unpasteurized milk, dairy

Trans: ingestion of bacteria, usually d/t cross-contamination

Sxs:

  • common: asx, mild, inflammatory diarrhea
  • rare, serious inflammatory diarrhea: GSB
  • complications: reactive arthritis, post-infectious IBS

Dx: stool culture

Mgmt:

  • supportive, usually self-limiting
  • Azithro* if preg, I/c, elderly, high fever, bloody stools, sxs > 1wk
56
Q

Shigellosis

A

Et: daycare, MSM
- as few as 10 infecting organisms can cause disease

Sxs:

  • abrupt, bloody diarrhea, abd pain, tenesmus, systemic toxicity
  • may develop HUS leading to ARF [#1 cause of AKI in peds]
  • may develop to TTP

Dx: stool cx
Mgmt:
- adults = FQ
- peds = Azithro, TMP-SMX

57
Q

E. coli 0157:H7

A

EHEC: Shiga-toxin producing E. coli
- shiga toxin gets absorbed causing injury to endothelial cells of glomerulus capillaries w/intra-vascular coagulation may lead to HUS

Trans:

  • cattle reservoir
  • MC ground beef
  • waterborne

Sxs: asx - lethal

  • initial: abd pain, watery diarrhea often bloody in 1-4 day (80%)
  • accounts for 35% of bloody diarrhea
  • afebrile
  • MC complication = HUS

Dx:

  • stool culture
  • fecal shiga toxin testing (new stool PCR)

Mgmt: supportive
- abx controversial

58
Q

C. diff background

A

Et:

  • anaerobic gram + spore-former; toxin producing bacillus
  • p-cresol odor = horse stable
  • MC HAI diarrhea

RF:

  • > 65yo, comorbidities
  • abx use (clindamycin** > FQ)
  • PPIs, H2Ras
  • > 1wk in hospital

PP:

  • enterotoxin A and cytotoxin B result in colonic inflammation
  • colonic inflammation destroys mucosal wall leading to massive swelling, wall disintegrates and leakage

Greatest RF:

  1. Hospital exposure
  2. Abx
  3. PPI/H2Ra
59
Q

C. diff Sxs

A

HAI
- sx onset >48hr after admission or <4wk from d/c

Community acquired

  • sx onset community or <48hr after admission
  • inc risk: peripartum women, children

Relapse: 2nd episode occurring <8wk from index case

  • first time: repeat abx course, probiotics, combo abx
  • second time: refer to GI

Sxs Spectrum

  1. asx, colonization
  2. diarrhea w/o colitis
  3. nonpseudomembranous colitis +/- diarrhea
  4. pseudomembranous colitis
  5. toxic megacolon - r/o perf
  6. fulminant colitis - perf, septic shock
60
Q

C. diff dx/tx

A

Dx:

  • 3+ unformed stool samples w/in 24hr in pt w/RF
  • C. diff NAAT (PCR)
  • leukocytosis
  • hypoalbuminemia
  • abd series: dilated loops of bowl
  • abd CT: pericolonic fat stranding
  • colonoscopy

Mod-sev disease:

  • peripheral leukocytosis (>15)
  • AKF
  • hypotension

Tx:

  • mild: metronidazole 500mg PO
  • mod-sev: vanco 125-250mg PO
  • if ileus = IV metro
  • d/c offending abx
  • toxic megacolon = colectomy
  • fecal transplant
  • out of isolation >24hr after diarrhea ceases
61
Q

Traveler’s diarrhea

A

MC illness among travelers

RF:

  • contaminated food/water
  • eating in restaurants
  • street food

bacteria (80%)

  • ETEC: watery diarrhea
  • campy
  • salmonella, shigella

ETEC:

  • malaise, anorexia, abdominal cramps
  • sudden onset watery diarrhea, non-inflammatory
  • NV 10-25%
  • low-grade fever 30%
  • duration 1-5 day

Prophylaxis

  • important trip
  • comorbid disease
  • previous bouts
  • rifaximin (expensive) or bismuth subsalicylate

Mgmt:

  • non-inflam: fluids, anti-diarrhea agents, pepto
  • inflam: azithro, FQ, rifaximin
62
Q

Chronic diarrhea

A

Meds: SPAMCAN

  • SSRIs
  • PPIs
  • ARBs
  • Metformin
  • Colchicine
  • Allopurinol
  • NSAIDs

PE: signs of malabsorption, IBD, dehydration, thyroid disease, LAD

Dx: labs

  • endoscopy r/o
  • H2 breath test, FOBT
  • 24hr stool collection for weight
  • 72hr fecal fat
  • stool osmolality
  • fecal leukocytes, stool lactoferrin

Mgmt: tx underlying cause

Anti-diarrheal:

  • loperamide scheduled dose
  • diphenoxylate w/atropine
  • cholestryamine
  • codeine sulfate
  • clonidine (DM, secretory diarrhea)

GI refer: severity, endoscopy need, dx being considered, dx requires long-term mgmt

63
Q

Osmotic diarrhea

A

Excess amounts of poorly absorbed substances act as an osmotic agent by drawing free water into lumen

Cause:

  • carb malabs: lactose intolerance, sugar-free
  • malabs: SB dz, short gut, SBO
  • osmotic lax: Mg, PEG
  • factitious diarrhea: stool osm < serum osm

** Stool volume dec w/fasting

Dx:

  • electrolyte is unaffected by osmotically-active substance
  • INC stool osmotic gap > 100-125**

290 - [stool Na + stool K] x 2

64
Q

Secretory diarrhea

A

Intestinal secretion > absorption

Cause:

  • intestinal resection/diffuse mucosal disease: dec abs surface for nutrients, lytes, fluid
  • abn mediators: bacterial toxins, non-osmotic lax, bile salt malabs, neuroendocrine tumors

Sxs:

  • nocturnal sx*, freq large volume (>1L/d)
  • small/normal osmotic gap (<50)*

Dx:
- abnormal ion transport = dec absorption of electrolytes

65
Q

Microscopic colitis

A

Idiopathic inflammatory disease of colon - chronic, watery diarrhea

MC: women, 65yo

Cause: unknown

  • meds: NSAIDs, PPIs, paroxetine
  • smokers

Types:

  • collagenous colitis: presence of thickened subepithelial collagen band formed beneath surface epithelium
  • lymphocytic colitis: intraepithelial lymphocytic infiltrate

Dx: colonoscopy random bx

Mgmt: refer to GI

66
Q

Motility disorder diarrhea

A

systemic disease or prior surgery resulting in diarrhea secondary to rapid transit or stasis of contents

MC: IBS

Other:

  • scleroderma
  • post-vagotomy
  • hyperthyroidism
  • diabetic autonomic neuropathy
67
Q

Malabsorption diarrhea

A

Results in osmotic or secretory diarrhea

Wt. loss
Steatorrhea
Nutritional def

Causes:

  • celiac sprue
  • short bowel syndrome
  • SBBO
  • pancreatic insufficiency
68
Q

Bile salt malabsorption

A

Bile salts needed to digest fat

Malabsorption (terminal ileum)

  • more bile acids lost to colon
  • draw fluid/’lytes into colon causing diarrhea and deficit in bile acids

Causes:

  • pancreatic insufficiency
  • hepatobiliary disease
  • Inc acid secretion
  • disease/resection of terminal ileum

Mgmt: cholestyramine 4mg PO daily BID
- bind free bile acids so they cannot pass out of colon

69
Q

Celiac sprue

A

Immune-mediate destruction of enterocytes
- inflammatory response in small bowel to GLUTEN [BROW - barley, rye, oats, wheat]

MC: women, white, northern euro, downs syndrome
- environment, genetics (HLA-DQ2/8)

A/w enteropathy-associated T-cell lymphoma

Sxs:

  • sx w/in first 2y of life (FTT) and 2nd peak 30-40s
  • fatigue, mild IDA, unexplained increased AST/ALT
  • diarrhea*, steatorrhea, flatulence, wt loss but hungry
  • infertility, amenorrhea
    • Dermatitis herpetiformis: multiple intensely itchy macules/papules
  • symmetrical on extensor surfaces of arms, legs, butt, trunk, neck

Dx:

  • eval on regular diet
  • IgA TTG
  • Gold standard: EGD w/random small bowel bx = villous blunting/atrophy
  • path: scallops on small intestine rings

Mgmt:

  • gluten free, dietician
  • vit D and Ca supplement
  • eat CRAP: corn flour, rice flour, arrowroot, potatoes
70
Q

Small bowel bacterial overgrowth

A

Cause:

  • anatomical: diverticulosis, surgical history, strictures
  • motility: DM, scleroderma, Crohns

Bacteria damage small bowel enterocytes; intraluminal consumption of nutrients by bacteria

Sxs:

  • generalized malabsorption
  • diarrhea, abdominal bloating, dyspepsia, nausea**

Dx: exclusion

  • gold standard: proximal jejunum aspirate and culture (>10 bugs/mL) - not routinely done
  • Carb breath tests: biphasic pattern

Mgmt: tx underlying disease
- PO broad spectrum abx x 1-2wk: Flagyl, Rifaximin, Cipro
+/- cyclic abx, +/- probiotics

71
Q

Whipple’s disease

A

Multi-system disease d/t infection with Tropheryma whipplei (GPB)
MC: white men, 40-60yo

Sxs:

  • migratory arthralgias, abd pain, wt loss, diarrhea (steatorrhea)**
  • intermittent low grade fevers, chronic cough, LAD
  • cognitive dysfunction

Dx:

  • duodenal bx
  • PCR confirms RNA

Mgmt: long-term Abx (1yr)

  • Rocephin IV 2g daily x 2wk, then Bactrim PO bid x 1yr
  • repeat bx at 6 and 12 months
72
Q

Short bowel syndrome

A

Removal of large segment of small intestine = malabsorption

Sxs: depend on length/site of resection and body adaptation

Monitor for sequelae: osteoporosis, anemia, liver disease

Mgmt:

  • supportive: fluids, electrolytes, vitamins, minerals
  • anti-diarrheals: loperamide
  • cholestyramine
  • SBBO: abx prn
73
Q

B3 (Niacin) deficiency

A

Alcoholics

Pellagra* = dermatitis, dementia, diarrhea

  • symmetric rash, hyperpigmented red, blistering and painful/pruritic
  • occurs in areas of sun exposure
  • neuro sxs: insomnia, anxiety, disorientation, delusions, dementia, encephalopathy

Dx: Niacin level

Mgmt:
- 40-250 mg/day

74
Q

B1 (Thiamine) Deficiency

A

Neuropathic sxs

  • mild sensory loss +/- burning sensation in toes/feet and LE cramping
  • untreated = pt develop generalized polyneuropathy w/distal sensory loss in hand/feet

Wernicke’s encephalopathy
Berberi: alcoholics
Peripheral neuropathy and signs of cardiac involvement (edema, CHF)

Fulminant cardiac syndrome with cardiomegaly, tachycardia

cyanosis, dyspnea, vomiting

altered sensorium

hoarseness d/t laryngeal nerve paralysis (classic sign)

Dx: blood/urine assays not always reliable
- clinically suspect = treat

Tx: Thiamine IV or IM 100 mg/day

75
Q

Vitamin A deficiency

A

Developing country

Night blindness
Xerophthalmia
Bitot’s spots: build-up of keratin located superficially in conjunctiva which are oval, triangular, irregular shape

76
Q

B2 (Riboflavin) deficiency

A

Glossitis
Cheilosis
Stomatitis

77
Q

Vitamin C (Ascorbic Acid) deficiency

A

Scurvy

  • ecchymosis, bleeding gums, malaise
  • arthralgias, hyperkeratosis, impaired wound healing

Vitamin C involved in collagen synthesis

78
Q

Vitamin D deficiency

A

Osteomalacia

  • use to walk, now bone pain and require wheelchair
  • waddling gait and bone pain = refer to endocrine
  • x-ray: pseudofractures
  • increased Alk Phos, increased PTH
  • low Ca/P, 25 hydroxy D

Rickets

  • inadequate mineralization of growing bone
  • infants need supplementation at 2 months old
  • present with delayed age of standing/walking, delayed growth, delayed closing of fontanelles
  • hypocalcemic seizures in first year of life
  • refer to peds endocrine
79
Q

Vitamin D absorption and treatment

A
  • Absorbed from diet/sun
  • converted to 25-hydroxy vit D by liver
  • converted to active form, 1,25 dihydroxy vit D by kidney (when PTH is present, low blood calcium)
  • active vit D travels to intestines and causes increased reabsorption of dietary calcium, increased bone calcium mobilization, and decreased PTH release

Definition

  • severe def: 25(OH)D < 5
  • moderate: 5-10
  • insufficiency: 10-20
  • repelete goal is 20-50 maintain

> 60yo - vit D supplement 800-2000 IU/day

dark skinned babys exclusively breastfed are greater risk of rickets and should supplement 400IU/d

Family Medicine (17 decks)

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