GI

Question 1

Visceral abdominal pain

= comes from the _____
Responds mainly to sensations of ____ and _____ _____ not to cutting or tearing.
- It is the most ____ form of pain and can be described as ___, ___ and ___. It is ___ ___.
- Foregut structures (____, ____, ____, and ____) cause upper abdominal pain.
- Midgut structures (____, ____, and ____) cause periumbilical pain.
- Hindgut structures (____ and ____) cause lower abdominal pain.
- Epigastric: (2)
- Periumbilical: (2)
- Suprapubic: (3)

Answer 1

Visceral pain comes from the abdominal viscera. Responds mainly to sensations of distention and muscular contraction, not to cutting or tearing.

• It is the most common form of pain and can be described as vague, dull and nauseating. It is poorly localized.
• Foregut structures (stomach, duodenum, liver, and pancreas) cause upper abdominal pain.
• Midgut structures (small bowel, proximal colon, and appendix) cause periumbilical pain.
• Hindgut structures (distal colon and GU tract) cause lower abdominal pain.
• Epigastric: indigestion, cholecystitis
• Periumbilical: intestinal obstruction, early appendicitis
• Suprapubic: small or large intestine, urinary tract infection, inflammatory bowel disease

Question 2

Referred pain:

• Referred pain is pain perceived ____ from its source. This is due to the lack of a _______ in the brain for information _____.
• Common examples include (3)

Answer 2

Referred pain:

• Referred pain is pain perceived distant from its source. This is due to the lack of a dedicated sensory pathways in the brain for information concerning internal organs.
• Common examples include scapular pain due to biliary colic, groin pain due to renal colic, and shoulder pain due to blood or infection irritating the diaphragm

Question 3

Parietal/ Somatic Pain:

• Parietal or somatic pain comes from the _____. It is characterized as ___ and well ___.
• It is often mediated by (3)
• This may include (2) rather than ____ which started as visceral pain.

Answer 3

• Parietal or somatic pain comes from the parietal peritoneum. It is characterized as sharp and well localized.
• It is often mediated by acute inflammation, ischemia or infectious processes.
• This may include acute appendicitis or acute cholecystitis rather than biliary colic which started as visceral pain.

Question 4

Psychogenic Pain:

• History may include multiple ____, ____, ____.
• Examine patient by _____ while pt is distracted; can use stethoscope to press down while “auscultating.”
• _____

Answer 4

• History may include multiple body complaints, chronic non-progressive course, somatic symptoms of depression.
• Examine patient by deep palpation while pt is distracted; can use stethoscope to press down while “auscultating.”
• CHRONIC

Question 5

Peritoneal signs:

• ____ pain worsened by ____ or ___.
• Observe ____ : patients with peritonitis _______; ____ when asked to ____.
• Suspect when irritable infants lie ___, ____, and are ___
• Peritonitis is ____. This may result from any ____ that causes ____.

Answer 5

• Severe pain worsened by movement or cough.
• Observe posture: patients with peritonitis LIE STILL with knees drawn up to the chest; complain when asked to move.
• Suspect when irritable infants lie very still, have flexed hips, and are quiet
• Peritonitis is inflammation of the peritoneal cavity. This may result from any abdominal condition that causes marked inflammation.

Question 6

Peritonitis causes: (4+)

Answer 6

• Appendicitis, diverticulitis, strangulating intestinal obstruction, pancreatitis, PID, mesenteric ischemia
• Intraperitoneal blood from ruptured aneurysm, trauma, surgery, ectopic pregnancy
• Barium!
• Peritoneo-systemic shunts, drains, dialysis catheters (PD), ascites

Question 7

Right/ Left Quadrant pain:

GI sources: (7)

Answer 7

• GI Sources
• GERD
• Gastroparesis
• Dysphagia
• PUD
• Gastric Cancer
• Cholecystitis
• Pancreatitis

Question 8

Right/ Left Quadrant pain:

Non-GI sources: (4)

Answer 8

• Herpes Zoster
• Lower Lobe Pneumonia *
• MI *
• Radiculitis (nerve pain that starts in the spine)*

Question 9

GERD:
Reflux of ____ into ____ resulting in a ____

Relaxation of the ____, irritants (2), decreased ____, and decreased ____ GERD

• ____ may contribute

Contributing: (3)
Triggers: (5)

Clinical features:

• _____ within __ to __ minutes of eating
• Symptoms worse _____
• Classic presentation is _____
• May also have (9)
• May have chest pain- mimics ___

History:

• __, __, and __ of heartburn
• Ask if aggravated by ___ / ___ by ___
• ___
• ___ use
• Diagnosis can be made by history alone is pt age

Answer 9

Reflux of gastric contents into esophagus resulting in a symptomatic condition

Relaxation of the LES, irritants (gastric acid & digestive enzymes), decreased secondary peristalsis, and decreased resistance to caustic liquids cause GERD

• Hiatus hernia may contribute

Contributing: tobacco, Etoh, exercise
Triggers: SPICY, FRIED, FATTY, CITRUS, CAFFEINE

Clinical features:

• Heartburn within 30 to 60 minutes of eating
• Symptoms worse lying down/ bending over
• Classic presentation is burning substernal pain that radiates upward
• May also have regurgitation, nocturnal aspiration, ulcers, hemorrhage, dental erosions, laryngitis, asthma symptoms, or Barrett’s esophagus
• May have chest pain-mimics cardiac angina: chest pain may be heaviness or pressure that radiates to the neck, jaw or shoulders

History:

• Onset, duration, and progression of heartburn
• Ask if aggravated by meals/ relieved by sitting up or antacids
• Smoker
• NSAID/ ASA use
• Diagnosis can be made by history alone is pt age<45; history of heartburn; no dysphagia, weight loss, or blood loss

Physical:

• Height/Weight
• Abdominal exam: masses, tenderness
• Check for occult blood in stool
• Usually no diagnostic tests indicated unless atypical presentation of concern: dysphagia, weight loss, melena, nocturnal symptoms-refer for endoscopy

Question 10

GERD non-pharmacologic methods:

• If ___, even ____ may help
• ____ cessation
• Elevate ____
• Eat ___ meals; do not eat ___ hrs before ___
• Reduce ___ that may produce symptoms
• Use ___ prn

Answer 10

• If obese, even 10 lb. weight loss may help
• Smoking cessation
• Elevate head of bed or sleep on wedge
• Eat smaller meals; do not eat 2-3 hrs before bedtime
• Reduce foods that may produce symptoms
• Use antacids prn

Question 11

GERD pharmacologic methods:

• _____: QD or BID dosing to suppress acids (Pepcid10-40mg)
• _____: (Prilosec 20mg or Omeprazole, Prevacid 15-30mg or Lansoprazole, Nexium 20-40 mg or Esomeprazole) reserved for ____
• __ minutes before ___

Long-term side effects of PPI:

1. ____ (aerobic bacteria grow in the stomach with increasing pH and micro-aspiration and lung colonization may occur)
2. Possible connection to ____
3. ____
4. Decrease in ____
5. Interference with _____
   - Avoid ____ : a lot of cytochrome P450 interactions

Answer 11

• H2 receptor antagonist: QD or BID dosing to suppress acids (Pepcid10-40mg)
• Proton pump inhibitor (Prilosec 20mg or Omeprazole, Prevacid 15-30mg or Lansoprazole, Nexium 20-40 mg or Esomeprazole) reserved for failure of above or erosive esophagitis
• 30 minutes before eating

Long-term side effects of PPI

1. PPI associated pneumonia (aerobic bacteria grow in the stomach with increasing pH and micro-aspiration and lung colonization may occur)
2. Possible connection to C Diff infection (stomach acid suppresses C Diff)
3. Hypomagnesemia
4. Decrease in calcium absorption
5. Interference with Vit B 12 absorption
   - Avoid cimetidine: a lot of cytochrome P450 interactions

Question 12

GERD eval:

• Re-evaluate pt after ___, if controlled, complete therapy for ___
• After ____, ____ to lowest possible dose that provides relief
• Some pts require ____ maintenance therapy indefinitely: recurrent nature
• If symptoms unresolved in ____ of therapy, refer to a gastroenterologist

Answer 12

• Re-evaluate pt after 2 weeks, if controlled, complete therapy for 8-12 weeks
• After 8-12 weeks, discontinue or lower med to lowest possible dose that provides relief
• Some pts require low-dose maintenance therapy indefinitely: recurrent nature
• If symptoms unresolved in 8-12 weeks of therapy, refer to a gastroenterologist

Question 13

Barrett’s Esophagus:

• Considered a ____ of __
• ___ condition of the ____ that typically affects ___ over ___
• Presentation is usually ___ or ___
• This is a strong correlation with ___ and ____ of the esophagus
• Premalignant stage: ____ (squamous cells have changed to columnar epithelium)
• Tissue injury is due to _____
• Dose-related: refers to risk of development of adenocarinoma with Barrett’s esophagus is <1% annually, but rises fivefold with the onset of low-grade dysphasia and 10-fold in persons with high-grade dysphasia

Answer 13

• Considered a complication of GERD
• Premalignant condition of the esophagus that typically affects white males over 50 years
• Presentation is usually heartburn or dysphagia
• This is a strong correlation with LT acid exposure and risk of adenocarcinoma of the esophagus
• Premalignant stage: low or high grade dysplasia (squamous cells have changed to columnar epithelium)
• Tissue injury is due to chronic exposure to gastric acid, pepsin, and bile
• Dose-related: refers to risk of development of adenocarinoma with Barrett’s esophagus is <1% annually, but rises fivefold with the onset of low-grade dysphasia and 10-fold in persons with high-grade dysphasia

Question 14

Gastroparesis:

• Impaired ____ , usually a ____ of ____
• ____ problem as a result of _____ (impacts both ____).
• Affects ____, affecting ____. Also causes ____.
• Symptoms may improve with control of ____.

Diagnostics:

• _____
• _____ (light meal consumption with radioactive contents, measures emptying of stomach (>60% at 2 hours or >10% at 4 hours to diagnose delayed gastric emptying
• ____

Treatment:

• ____
• ____
• ____ in tighter control

Answer 14

• Impaired gastric emptying, usually a complication of uncontrolled DM
• Motility problem as a result of autonomic neuropathy (impacts both sympathetic and parasympathetic fibers).
• Affects food absorption, affecting glycemic control. Also causes nausea and vomiting.
• Symptoms may improve with control of hyperglycemia.

Diagnostics:

• Endoscopy
• Gastric emptying study (light meal consumption with radioactive contents, measures emptying of stomach (>60% at 2 hours or >10% at 4 hours to diagnose delayed gastric emptying
• Radiolabeled CO 2 breath test

Treatment:

• Dietary modifications
• Use of metoclopramide (Reglan)
• DM in tighter control

Question 15

Dysphagia:

• ____ disorder that involves ___ of one or more stages in the normal sequence of ____
• Dysphagia may be either ___ or ____
• ____ causes are more common with ____ and ____ causes are more likely with ____
• May be ___ , resulting in (6)

Dysphagia History:

• ____
• Swallowing difficulty: (2)
• ___, ___ or ___ (odynophagia)
• ____
• PMH: ____
• *most important is ___ and ___ of symptoms
• relation of symptoms to ____ to liquids and solids
• effects of ___ on swallowing
• response to swallowing a ___ (repeated swallowing and Valsava maneuver can assist in swallowing in motor disorder). Obstruction-swallowing a bolus will cause regurg

Location of discomfort and the presence or absence of associated symptoms:

• intermittent dysphagia: suggests ___
• associated with swallowing: ____
• difficulty swallowing solids associated with _____
• accompanied by diplopia: think ____
• associated with tremor or difficulty initiating movement: _____

Answer 15

• Swallowing disorder that involves dysfunction of one or more stages in the normal sequence of swallowing
• Dysphagia may be either oropharyngeal or esophageal
• Structural causes are more common with esophageal dysphagia and functional causes are more likely with oropharyngeal dysphagia
• May be mild or severe, resulting in malnutrition, dehydration, choking, aspiration, pneumonia and even death

Dysphagia History:

• Onset: Gradual onset, slow progression and chronic course suggest motor disorder; rapid onset and progressive- obstruction
• Swallowing difficulty: liquids (cold), solids
• Choking, reflux or pain (odynophagia)
• Weight loss
• PMH: neuro disease, chronic reflux, esophagitis
• *most important is duration and progression of symptoms
• relation of symptoms to ingestion to liquids and solids
• effects of cold on swallowing
• response to swallowing a bolus (repeated swallowing and Valsava maneuver can assist in swallowing in motor disorder). Obstruction-swallowing a bolus will cause regurg

Location of discomfort and the presence or absence of associated symptoms:

• intermittent dysphagia: suggests lower esophageal.
• associated with swallowing - mucosal inflammation
• difficulty swallowing solids associated with chronic heartburn think stricture
• accompanied by diplopia think myasthenia
• associated with tremor or difficulty initiating movement Parkinson’s disease

Question 16

Dysphagia Presentation:

• May present with ___, ___, ___ or ___
• Problems with oral stage: (5)
• Pharyngeal dysphagia results from poor ____ and may cause ____, ____, manifested as ____

PE:

• Thorough PE including complete ___
• ___
• Altered ___
• Neuro exam, attention to CN function, assessment of (4). Mental status
• Head, neck, trunk or extremity deformities
• Skin: (3): CREST variant of scleroderma (CREST is an acronym that stands for calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.)
• Lymph nodes and thyroid for ____

Answer 16

• May present with malnutrition, wt loss, dehydration or pneumonia
• Problems with oral stage: poor bolus control, spillage from lips or into pharynx, dry oral membranes, pocketing or oral residue, difficulty with chewing
• Pharyngeal dysphagia results from poor coordination of muscles and may cause delayed swallowing, nasal or oral regurgitation, manifested as coughing, choking or gurgling

PE:

• Thorough PE including complete oral exam
• Oral health, hygiene, dentition, oral sensation, tongue strength, mobility, coordination.
• Altered speech, voice, gag reflex
• Neuro exam, attention to CN function (V,VII, IX, X, XII), assessment of muscle strength, atrophy, tremors, gait disturbance. Mental status
• Head, neck, trunk or extremity deformities
• Skin: pallor, sclerodactyly, telangiectasia CREST variant of scleroderma (CREST is an acronym that stands for calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.)
• Lymph nodes and thyroid for enlargement

Question 17

Scleroderma:
(CREST)

C___- ___ deposits in the skin

R__ ___- ___ of ____ in response to __ or __

E___ ___- ___ reflux and decrease in motility of ___

S____ - ___ and ___ of skin on the fingers and hands

T_____- ___ of capillaries causing red marks on surface of skin

Answer 17

Calcinosis- calcium deposits in the skin

Raynaud’s phenomenon- spasm of blood vessels in response to cold or stress

Esophageal dysfunction- acid reflux and decrease in motility of esophagus

Sclerodactyly- thickening and tightening of skin on the fingers and hands

Telangiectasias- dilation of capillaries causing red marks on surface of skin

Question 18

Causes of Dysphagia:

Oropharyngeal: (7)

Esophageal: (9)

= Transfer dysphagia (oropharyngeal) usually is ____, with difficulty ____

• common in ___
• caused by (3)
• medications may effect (2)
• these pts have difficulty with ___; more ___, ___, and ___ as opposed to mechanical obstruction- difficulty with swallowing

= Achalasia is the most common ____ : slow progressive loss ___

• loss of ___ in ___ and ___ fails to relax properly, causing obstruction
• ____ chest pain present in 80% of pts
• difficulty swallowing both ___; ____ precipitate symptoms

= Scleroderma can cause ___ and ____ activity in esophagus

• approximately 75% of these pts have esophageal involvement of some type
• ___ is more common than dysphagia

= Mechanical obstruction: ____, duration of symptoms <1yr for malignancy

= Difficult swallowing due to neuromuscular or anatomic pathology involving esophagus

Answer 18

Causes of Dysphagia:

Oropharyngeal:

• Iatrogenic
• Infectious
• Metabolic
• Myopathic
• Neurologic
• Psychiatric
• Environmental

Esophageal:

• Trauma
• Surgery
• Tumor
• Webs
• Strictures or Stenoses
• Diverticuli
• Infection
• Cervical osteophytes
• Anterior cervical osteophytes are common and usually asymptomatic in elderly people. Due to mechanical compressions, inflammations, and tissues swelling of osteophytes, patients may be presented with multiple complications, such as dysphagia, dysphonia, dyspnea, and pulmonary aspiration.

= Transfer dysphagia (oropharyngeal) usually is neurological, with difficulty initiating swallowing

• common in elderly
• caused by stroke, tumor, degenerative diseases
• medications may effect (benzodiazepines, L-dopa)
• these pts have difficulty with liquids; more regurgitation, choking, and aspiration as opposed to mechanical obstruction-difficulty with swallowing

= Achalasia is the most common motor dysphagia: slow progressive loss peristalsis

• loss of peristalsis in distal esophagus and lower esophageal sphincter fails to relax properly, causing obstruction
• substernal chest pain present in 80% of pts
• difficulty swallowing both liquid and solids; cold liquids precipitate sx

= Scleroderma can cause loss of tone and propulsive activity in esophagus

• approximately 75% of these pts have esophageal involvement of some type
• reflux is more common than dysphagia

= Mechanical obstruction: difficulty w/solids, duration of symptoms <1yr for malignancy
= Difficult swallowing due to neuromuscular or anatomic pathology involving esophagus

Question 19

Achalasia:

= rare disorder of the ___,
= characterized by (2) to relax.
- Failure of ___ to ___ with ___
- ___ dysphagia for solids and liquids and regurgitation
- ____ with ____ with classic “bird’s beak” appearance distally
- ____ shows lack of relaxation of the LES with swallowing and aperistalsis of the esophageal body

Answer 19

= rare disorder of the esophagus,
= characterized by impaired peristalsis, failure of the lower esophageal sphincter (LES), to relax.
- Failure of LES to relax with swallowing
- Progressive dysphagia for solids and liquids and regurgitation
- Barium esophagram with esophageal dilation with classic “bird’s beak” appearance distally
- Esophageal manometry shows lack of relaxation of the LES with swallowing and aperistalsis of the esophageal body

Question 20

Peptic Ulcer Disease:

= burning ___ pain
- Pain occurring __ to __ hours after ___ or on an ____
- Nocturnal pain relieved by (3).
A history of ___-, relief of pain after ___, and ____ because of pain with relief following ____

• Abdominal pain is ___ in at least 30 percent of older patients with peptic ulcers
• Postprandial epigastric pain is more likely to be ____ or ____ in patients with ____ than in those with gastric ulcers.
• _______ precipitated by _____ is characteristic of gastric ulcers.

PE: Usually unremarkable although some patients may have abdominal tenderness or pain with deep palpation of the (4)
Rectal exam: (3)

Eval:

• Evaluate for alarm symptoms: (4)
• Vomiting suggests ___
• Anorexia or weight loss suggests ___
• Persisting upper abdominal pain radiating to the back suggests ___
• Severe, spreading upper abdominal pain suggests ___

Diagnostic Tests:

• All patients: (2)
• ___ for alarm symptoms, treatment failure, definitive diagnosis
• ___
• serum enzyme-linked immunosorbent assay (ELISA)
• ___
• stool antigen test
• endoscopic biopsy

Answer 20

= burning epi-gastric pain
- Pain occurring two to five hours after meals or on an empty stomach
- Nocturnal pain relieved by food intake, antacids, or anti-secretory agents.
A history of episodic or epi-gastric pain, relief of pain after food intake, and nighttime awakening because of pain with relief following food intake

• Abdominal pain is absent in at least 30 percent of older patients with peptic ulcers
• Postprandial epigastric pain is more likely to be relieved by food or antacids in patients with duodenal ulcers than in those with gastric ulcers.
• Weight loss precipitated by fear of food intake is characteristic of gastric ulcers.
• PMH: cirrhosis, pancreatitis, arthritis, COPD, hyperparathyroidism, Zollinger-Ellison syndrome (hypersecretory state)
• Social history: smoking, alcohol, stress
• Meds: NSAIDs, oral corticosteroids
• PUD in first degree relatives

PE: Usually unremarkable although some patients may have abdominal tenderness or pain with deep palpation of the epi-gastric region, rigidity, masses, liver/spleen enlargement
Rectal exam: tenderness, masses; occult blood in stool

Eval:

• Evaluate for alarm symptoms:
• Anemia, hematemesis, melena, or FOBT suggests bleeding
• Vomiting suggests obstruction
• Anorexia or weight loss suggests cancer
• Persisting upper abdominal pain radiating to the back suggests penetration
• Severe, spreading upper abdominal pain suggests perforation

Diagnostic Tests:

• All patients: perform occult blood, Hgb/Hct
• Endoscopy for alarm symptoms, treatment failure, definitive diagnosis
• H.pylori testing:
• serum enzyme-linked immunosorbent assay (ELISA)
• urea breath test (UBT)
• stool antigen test
• endoscopic biopsy

Question 21

H pylori test management:

• H pylori positive requires combination treatment for __ to __ days: ___ two times daily plus ___ 1 g two times daily or ___ 500 mg two times daily*
• Eradication rates 80 to 90 percent
• If on NSAIDs, ___
• If not on NSAIDs, 3 options: Empiric treatment with anti-secretory drugs: ___, or ___; try for 2 weeks, if works, continue for 8 weeks
• If allergic to penicillin: Rx ___ (Biaxin) 500 mg two times daily instead of ___ OR ____ (Pepto-Bismol), 525 mg four times daily, plus ____ (Flagyl), 250 mg four times daily, plus ___, 500 mg four times daily, plus ____ QD-BID or ____ daily

Answer 21

• H pylori positive requires combination treatment for 10 to 14 days: PPI two times daily plus Amoxicillin 1 g two times daily or metronidazole (Flagyl) 500 mg two times daily*
• Eradication rates 80 to 90 percent
• If on NSAIDs, discontinue
• If not on NSAIDs, 3 options

Empiric treatment with anti-secretory drugs: H2 antagonist, or PPI; try for 2 weeks, if works, continue for 8 weeks

• If allergic to penicillin: Rx clarithromycin (Biaxin) 500 mg two times daily instead of Amoxicillin OR Bismuth subsalicylate (Pepto-Bismol), 525 mg four times daily, plus metronidazole (Flagyl), 250 mg four times daily, plus tetracycline, 500 mg four times daily, plus histamine H2 blocker QD-BID or PPI daily

Question 22

Gastric Cancer:

Risk factors- (13)

Clinical Presentation:

• ___ onset of ___ that ranges in intensity from a vague sense of ___ to ___ pain
• (4)
• Other symptoms include a change in ___, ___, ___, ___ symptoms and ___

Diagnostics: (5)

Treatment:

• Complete ___
• Palliative ___ (advanced lesions)
• Use of ___
• Require doses of ___ that exceed tolerance of surrounding structures
• ____ offers no advantage

Answer 22

Risk factors- 
o	Helicobacter pylori gastric infection.
o	Advanced age.
o	Male gender.
o	Diet low in fruits and vegetables.
o	Diet high in salted, smoked, or preserved foods.
o	Chronic atrophic gastritis.
o	Intestinal metaplasia.
o	Pernicious anemia.
o	Gastric adenomatous polyps.
o	Family history of gastric cancer.
o	Cigarette smoking.
o	Menetrier disease (giant hypertrophic gastritis).
o	Familial adenomatous polyposis.

Clinical Presentation:

• Insidious onset of abdominal pain that ranges in intensity from a vague sense of post-prandial fullness to severe, steady pain
• Wt loss, abdominal pain, anorexia, vomiting
• Other symptoms include a change in bowel habits, dysphagia, melena, anemic symptoms and hemorrhage

Diagnostics:

• CBC with diff, electrolytes and LFT’s
• Stool occult for occult blood
• CT radiograph
• CT scan of abdomen
• Endoscopy and biopsy

Treatment:

• Complete resection of carcinoma and adjacent lymph nodes
• Palliative resection (advanced lesions)
• Use of laser coagulation for obstruction and dysphagia
• Require doses of radiation that exceed tolerance of surrounding structures
• Chemotherapy offers no advantage

Question 23

Celiac disease:

• ____, ____ inflammatory disease of the ____ triggered by ___ proteins found in ___ (3)
• GI sx’s may manifest as (4)
• Those diagnosed with celiac disease between 2-4 years had a __ chance of developing an ____. This chance increases with the age of diagnosis.

Clinical Manifestation:

• ____
• ___ or no ___ (look at growth chart)
• Delayed onset of ___ and ___
• ____
• ____ (Elevated LFT’s)
• Recurrent ____

Celiac Disease Laboratory Tests:

• Genetic testing for __ gene; disease is not gender sensitive or specific
• Serologic tests can identify many patients
• ORDER these tests: _____ or _____ with ____
• Blood test abnormalities: (11)
• EGD and bx in pts w/ selective IgA deficiency (immune disorder)- pt should remain on normal diet before endoscopy

Long term:

• Patients with confirmed celiac disease should be on a ___ diet for life to avoid the risks of untreated celiac disease.
• These risks mainly include the development of other autoimmune conditions such as (10+)

Non-celiac gluten sensitivity:

• Non-celiac gluten sensitivity has been coined to describe those individuals who ____
• Early research suggests that non-celiac gluten sensitivity is an ____
• Individuals with non-celiac gluten sensitivity have a prevalence of ____
• Treatment: avoid ___.

Answer 23

Celiac disease:

• Chronic, autoimmune inflammatory disease of the small intestine triggered by gluten proteins found in wheat, barley and rye
• GI sx’s may manifest as diarrhea, constipation or symptoms of malabsorption such as bloating, flatus or belching but only 35% of newly diagnosed patients had chronic diarrhea.
• Those diagnosed with celiac disease between 2-4 years had a 10.5% chance of developing an autoimmune disease. This chance increases with the age of diagnosis.

Clinical Manifestation:

• Anemia: Iron deficiency anemia
• Short stature or no weight gain (look at growth chart)
• Delayed onset of puberty and menarche
• Osteopenia
• Transaminitis (Elevated LFT’s)
• Recurrent abdominal pain

Celiac Disease Laboratory Tests:

• Genetic testing for HLA gene; disease is not gender sensitive or specific
• Serologic tests can identify many patients
• ORDER these tests: IgA tissue transglutaminase (TtG) or endomysial antibody (EMA) titers with quantitative IgA testing
• IgA-TtG sensitivity 92-100% and specificity 91-100%
• IgA EMA sensitivity 88-100% and specificity 91-100%
• Blood test abnormalities: Abnormal LFT’s, low ferritin, hypocholesterolemia, Hyperamylasemia, Hypoalbuminemia, Elevated ESR, prolonged PT, vitamin deficiency, Hypocalcemia, secondary hyperparathryoidism
• EGD and bx in pts w/ selective IgA deficiency (immune disorder)- pt should remain on normal diet before endoscopy

Long term:

• Patients with confirmed celiac disease should be on a gluten-free diet for life to avoid the risks of untreated celiac disease.
• These risks mainly include the development of other autoimmune conditions such as type 1 diabetes, psoriasis, thyroid disease, neurologic problems, autoimmune liver disease and autoimmune cardiomyopathy, as well as the development of malignancies such as intestinal lymphoma, adenocarcinoma of the small intestine, esophageal carcinoma and melanoma.

Non-celiac gluten sensitivity:

• Non-celiac gluten sensitivity has been coined to describe those individuals who cannot tolerate gluten and experience symptoms similar to those with celiac disease but yet who lack the same antibodies and intestinal damage as seen in celiac disease.
• Early research suggests that non-celiac gluten sensitivity is an innate immune response, as opposed to an adaptive immune response (such as autoimmune) or allergic reaction.
• Individuals with non-celiac gluten sensitivity have a prevalence of extra-intestinal or non-GI symptoms, such as headache, “foggy mind,” joint pain, and numbness in the legs, arms or fingers. Symptoms typically appear hours or days after gluten has been ingested.
• Treatment: avoid gluten.

Question 24

Cholecystitis

• ___ inflammation of ___
• Symptoms develop from ___, ___
• Pain occurs when ___ causes ____ to contract
• More common in ___ and ___; frequently occur during ___

Risk Factors Associated with occurrence of Gallstones:

• Body habitus: (3)
• Childbearing : ___
• Drugs: (3)
• Ethnicity: Native American (Pima Indian), Scandinavian
• __- gender
• Heredity: first-degree relatives
• Ileal disease, resection, or bypass
• Increasing ___
• —Obesity defined as body mass index greater than 30 kg per m2

Clinical Presentation:

• ____ with radiation to the ___ and ___
• Occurs within __ hour after eating ___, lasts for ___, and ___ for days
• Associated with ___, ___, and ___
• Most pts report a prior ___
• Symptoms may be ___ in the elderly

Physical Exam:

• ___
• Abdomen: ___
• ___ sign- painful ___ w/ deep ___ & ___
• May palpate ___ in ___

Diagnostics:

• ____
• Gallbladder ____ to confirm gallstones: 95% sensitivity and specificity
• ____ scan helps evaluate the function of the ___ and the ___
• The ___ test is sometimes used to help detect ____ and ____. It is usually ordered in conjunction with other liver tests such as (4). In general, an increased ___ level indicates that a person’s liver is being ___ but does not specifically point to a ____

Management:

• ____ remains the primary procedure for the management of symptomatic gallstone disease.
• Oral dissolution therapy using bile acids (___ or ___) has successfully dissolved gallstones in an extremely limited patient population (reserved for patients ___ or ___ to undergo surgery)
• 25% of medically managed patients develop ___ gallstones within five years

Acute cholecystitis develops in up to 10 percent of patients with symptomatic gallstones and is caused by the complete obstruction of the ___

Delayed diagnosis of acute cholecystitis can lead to ___ (3)

Answer 24

Cholecystitis

• Acute/chronic inflammation of gallbladder
• Symptoms develop from mechanical obstruction, local inflammation, or both
• Pain occurs when hormone cholecystokinin causes gallbladder to contract
• More common in obese and women; frequently occur during pregnancy (FFF)

Risk Factors Associated with occurrence of Gallstones:

• Body habitus: obesity,* rapid weight loss, cyclic weight loss
• Childbearing : high levels of estrogen can cause cholesterol levels in bile to spike which can lead to development of gallstones
• Drugs: ceftriaxone (Rocephin), postmenopausal estrogens, total parenteral nutrition
• Ethnicity: Native American (Pima Indian), Scandinavian
• Female gender
• Heredity: first-degree relatives
• Ileal disease, resection, or bypass
• Increasing age
• —Obesity defined as body mass index greater than 30 kg per m2

Clinical Presentation:

• RUQ pain with radiation to the flanks and right shoulder
• Occurs within one hour after eating a large meal, lasts for hours, and residual for days
• Associated with anorexia, nausea, and fever
• Most pts report a prior episode
• Symptoms may be minimal in the elderly

Physical Exam:

• Temperature
• Abdomen: RUQ tenderness, involuntary guarding (early peritoneal irritation)
• Murphy’s sign- painful splinting w/ deep inspiration and RUQ palpation
• May palpate gallbladder in RUQ

Diagnostics:

• CBC with differential,LFTs, GGT (gamma-glutamyltranspeptidase)
• Gallbladder ultrasound to confirm gallstones: 95% sensitivity and specificity
• A hepatobiliary iminodiacetic acid (HIDA) scan helps evaluate the function of the gallbladder and the bile ducts.
• The GGT test is sometimes used to help detect liver disease and bile duct obstructions. It is usually ordered in conjunction with other liver tests such as ALT, AST, ALP and bilirubin. In general, an increased GGT level indicates that a person’s liver is being damaged but does not specifically point to a condition that may be causing the injury.

Management:

• Cholecystectomy remains the primary procedure for the management of symptomatic gallstone disease. It is safe, has the lowest risk of recurrence, and provides 92 percent of patients with complete relief of their biliary pain
• Laparoscopic cholecystectomy continues to have numerous advantages compared with the open technique
• Oral dissolution therapy using bile acids (Urso Forte or Ursodiol) has successfully dissolved gallstones in an extremely limited patient population (reserved for patients unfit or unwilling to undergo surgery)
• 25% of medically managed patients develop recurrent gallstones within five years

Acute cholecystitis develops in up to 10 percent of patients with symptomatic gallstones and is caused by the complete obstruction of the cystic duct
Delayed diagnosis of acute cholecystitis can lead to gangrenous cholecystitis, gallbladder perforation, and biliary peritonitis

Question 25

Pancreatitis:

Three forms treated in primary care:

• ___ phase of acute ___
• ____ relapsing
• pancreatic ____ (___/ ___)
• ____ are the most common cause of acute pancreatitis.
• ____ ____ is the most common cause of ___ pancreatitis in adults.
• ____ (rare) and ___ diseases, such as ___ ___, can also cause chronic pancreatitis in some patients.
• Mortality secondary to pancreatitis ranges from 2 to 9 percent.

Risk factors for acute pancreatitis (10)

Pancreatitis: History

• ___ ___ pain with radiation to the ___, __, or ___
• Character: (3)
• Alleviated by __ or __ position
• Triggers: ___ or ___
• Associated sx: ___ and ____

Pancreatitis: Physical

• Temperature
• ____ (may be ___)
• Abdomen: ____
• Skin: signs of ___

Pancreatitis: Laboratory
- ____: starts to rise 2-12 hours after onset of symptoms; peaks 12-72 hours
o may rise in biliary tract disease, renal disease, intestinal obstruction, perforated ulcer
- _____: rise within 4-8hrs, peak at 24 hours; more specific and sensitive in detection

Pancreatitis: Radiology
- ____ may show gas-filled duodenum, but not specific

• ____: can detect biliary causes
• ______
  o best imaging of the pancreas and surrounds
  o study of choice: fever, leukocytosis, severe sx
• ______ : Indicated for biliary obstruction; can remove impacted stones

Answer 25

Three forms treated in primary care:

• recovery phase of acute pancreatitis
• chronic relapsing
• pancreatic insufficiency (steatorrhea/ wt loss)
• Gallstones are the most common cause of acute pancreatitis.
• Alcohol abuse is the most common cause of chronic pancreatitis in adults.
• Autoimmune (rare) and genetic diseases, such as cystic fibrosis, can also cause chronic pancreatitis in some patients.
• Mortality secondary to pancreatitis ranges from 2 to 9 percent.

Risk factors for acute pancreatitis

• Alcohol
• Gallstones
• Trauma/surgery
• Abrupt discontinuation of meds (DM, Hyperlipidemia)
• Medications (ACE, ARB, thiazide diuretics, furosemide, antimetabolites, corticosteroids, statins- list not exhaustive)
• Hypertriglyceridemia, hypercalcemia/hyper-parathyroidism, ARF, SLE, polyarteritis, Cystic fibrosis
• Infectious causes (mumps, coxsackie, cryptosporidiosis-list not exhaustive)
• Tumors
• Sphincter of Oddi dysfunction
• Pancreatic divisum
• Vascular disease
• Acute fatty liver of pregnancy
• Idiopathic

Pancreatitis: History

• Mild-severe epigastric pain with radiation to the flank, back, or both
• Character: dull, boring; worse when supine
• Alleviated by sitting or fetal position
• Triggers: heavy meal or alcohol binge
• Associated sx: nausea and non-feculent vomiting

Pancreatitis: Physical

• Temperature
• CV: rate (may be tachycardic)
• Abdomen: distension; muscle spasms; epigastric or LUQ pain on palpation
• Skin: signs of jaundice

Pancreatitis: Laboratory
- Amylase: starts to rise 2-12 hours after onset of symptoms; peaks 12-72 hours
o may rise in biliary tract disease, renal disease, intestinal obstruction, perforated ulcer
- Lipase: rise within 4-8hrs, peak at 24 hours; more specific and sensitive in detection

Pancreatitis: Radiology
- Plain radiographs may show gas-filled duodenum, but not specific

• Ultrasonography: can detect biliary causes
• CT w/contrast
  o best imaging of the pancreas and surrounds
  o study of choice: fever, leukocytosis, severe sx
• ERCP (Endoscopic Retrograde Cholangiopancreatography): Indicated for biliary obstruction; can remove impacted stones

Question 26

Pancreatitis Management:

= Recovery Phase
o	Low \_\_\_
o	Check/treat \_\_\_ (3)
o	Eliminate \_\_\_ which trigger
o	HIV+ : CMV or toxoplasmosis infection
o	\_\_\_\_: refer if stones are found

= Chronic Pancreatitis
o Treat ____ cause
o Readmit if acute pancreatitis recurs
o Begin with mild ____ (_); may need ____
o Limit ___ during ___
o Rule out ___ (U/S or CT)
o Psychiatric or pain consult for refractory pain

Exocrine Pancreatic Insufficiency (EPI)

• Inability to properly ___ food due to a lack of _____ made by pancreas
• EPI is also found in humans afflicted with ___ ___ and ____

o Need to take Pancreatic Enzyme Products (PEPs), such as pancrelipase, that are used to break down ____ with full meals and less (2 tabs) with ___
o High-calorie diet rich in carbs and protein
o Supplements: medium-chain triglyceride prep
o Restrict ___ in symptomatic ____ (excess fat in stool; oily appearance and foul smelling)
o Monitor ___ ___and treat clinical diabetes

• Shwachman–Diamond syndrome (SDS) or Shwachman–Bodian–Diamond syndrome is a rare congenital disorder characterized by ___ (4)

Answer 26

= Recovery Phase
o	Low fat
o	Check/treat alcoholism, hypertriglyceridemia, hypercalcemia
o	Eliminate meds which trigger
o	HIV+ : CMV or toxoplasmosis infection
o	Ultrasound: refer if stones are found

= Chronic Pancreatitis
o Treat underlying cause
o Readmit if acute pancreatitis recurs
o Begin with mild analgesics (acetaminophen); may need morphine or methadone
o Limit fat during flare-ups
o Rule out carcinoma (U/S or CT)
o Psychiatric or pain consult for refractory pain

• Exocrine Pancreatic Insufficiency (EPI)
• Inability to properly digest food due to a lack of digestive enzymes made by pancreas
• EPI is also found in humans afflicted with cystic fibrosis and Shwachman-Diamond syndrome.

o Need to take Pancreatic Enzyme Products (PEPs), such as pancrelipase, that are used to break down fats, proteins and carbohydrates (2-8 tabs) with full meals and less (2 tabs) with snacks
o High-calorie diet rich in carbs and protein
o Supplements: medium-chain triglyceride prep
o Restrict fat in symptomatic steatorrhea (excess fat in stool; oily appearance and foul smelling)
o Monitor glucose tolerance and treat clinical diabetes

• Shwachman–Diamond syndrome (SDS) or Shwachman–Bodian–Diamond syndrome is a rare congenital disorder characterized by exocrine pancreatic insufficiency, bone marrow dysfunction, skeletal abnormalities, and short stature.

Question 27

Nausea & Vomiting:

= Varies from ___ onset noted with (7)
= Relationship of N/V to ___, force of ___, quality of ___

Associated symptoms: (10)

= Abdominal pain this may be indicative of serious illness, especially if they have neuro symptoms
- Neuro symptoms: (4)

***Acute emergencies: (6)

Chronic or recurrent N/V: (6)

= Physical

• Weight, temperature; orthostatic VS; pulse rate
• Skin exam to assess turgor, color, moisture, rash
• CV exam
• Abdominal exam to assess for distention, peristalsis, tenderness, rigidity, rebound, masses
• Mental status, gait, CN function
• Additional exam in children to include:
  1. Presence of tears
  2. Urination or # wet diapers

Abdominal exam includes:

• check for ____, visible ___
• abnormal __
• ___ signs
• ___ tenderness; ___ tenderness
• ____

Neuro exam: (4)

Diagnostic

• If N/V is <24 hours, __ labs are generally needed; ____
• Lab tests may include: (12)
• ___ and ___ if obstruction suspected
• Diagnostics depend on differential
• Abdominal pain:
• amylase: r/o ____
• LFT’s: alk phos and AST-r/o ____, ____
• abdominal x-ray: plain and upright-r/o ____ and ____

Answer 27

Nausea & Vomiting:

= Varies from gradual onset noted with med SE, gastric retention, early pregnancy to the acute episodes caused by viral gastroenteritis, food poisoning, increased ICP, or acute abdominal emergency

= Relationship of N/V to food, force of vomiting and quality of emesis (undigested food?)

Associated symptoms:

• Abdominal pain
• Headache
• Dizziness
• Tinnitus
• Diarrhea
• Fever
• Mental status changes
• Pregnancy
• Anxiety
• Abdominal pain
• If a patient has NO symptoms of abdominal pain this may be indicative of serious illness, especially if they have neuro symptoms
• Neuro symptoms:
• Headache, visual disturbances, ataxia, vertigo
• **Acute emergencies:
• Acute pancreatitis
• Appendicitis
• Bowel obstruction (SBO or Ileus)
• Peritonitis
• Cholecystitis
• *Usually accompanied by fever or pain

Chronic or recurrent N/V

• May be psychogenic
• Result of radiation or chemotherapy
• Gastric disorders
• Migraine headaches (aura)
• Diabetic gastroparesis
• Metabolic or endocrine abnormality

= Physical

• Weight, temperature; orthostatic VS; pulse rate
• Skin exam to assess turgor, color, moisture, rash
• CV exam
• Abdominal exam to assess for distention, peristalsis, tenderness, rigidity, rebound, masses
• Mental status, gait, CN function
• Additional exam in children to include:
  1. Presence of tears
  2. Urination or # wet diapers

Abdominal exam includes:

• check for distension, visible peristalsis
• abnormal BS
• peritoneal signs
• focal tenderness; flank tenderness
• masses

Neuro exam:

• retinopathy and papilledema
• nystagmus
• stiff neck
• ataxia of gait

Diagnostic

• If N/V is <24 hours, no labs are generally needed; Presentation, history and diff dx will guide testing
• Lab tests may include: UA or urine dipstick (SG), serum electrolytes, glucose, BUN, Scr, serum ketones, amylase, LFT’s, drug levels, Hcg, CBC with diff, TSH
• Abd X-ray and plain x-ray if obstruction suspected
• Diagnostics depend on differential
• Abdominal pain:
• amylase: r/o pancreatitis
• LFT’s: alk phos and AST-r/o acute cholecystitis, choledocholithiasis
• abdominal x-ray: plain and upright-r/o obstruction and peritonitis

Question 28

Non-Pharmacologic Management of Nausea/ Vomiting:

• No ___ for at least ____ and ____ for __ hours; start with 1 tbsp. (15mLs) every 10 minutes
• ____ status should be assessed by pt’s ability to void every ___
• Followed by ___ diet for __ hours
• Bland diet approx___
• Most n/v is self-limited and supportive therapy is all that is indicated; although must look at cause to dictate therapy
• -No solids for ___ hours in children
• Advance diet as tolerated:
• if vomiting does not occur, __ fluids every __
• if vomiting occurs, allow stomach to rest briefly and then start again
• May use ____ for infants and small children
• Regular diet may resume as tolerated: usually _ hours after vomiting stops
• For children, advance to BRAT diet

Pharmacologic Management:

• If pt is too nauseated or does not respond to po intake IV hydration should be started
• ____: motion sickness
• ____: Gastroparesis, GERD, Chemotherapy SE
• ___: for cancer, RT, surgery (Preg class B)
• ___ (Phenergan): Preg class C (migraine induced vomiting)
• Do not routinely give anti-emetics to children

Answer 28

Non-Pharmacologic Management of Nausea/ Vomiting:

• No solids for at least 24 hours and clear liquids for 24 hours; start with 1 tbsp. (15mLs) every 10 minutes
• Hydration status should be assessed by pt’s ability to void every 2-3 hours
• Followed by BRAT diet for 24 hours
• Bland diet approx 1 week
• Most n/v is self-limited and supportive therapy is all that is indicated; although must look at cause to dictate therapy
• -No solids for 8-12 hours in children
• Advance diet as tolerated:
• if vomiting does not occur, double fluids every hour
• if vomiting occurs, allow stomach to rest briefly and then start again
• May use glucose-electrolyte solutions for infants and small children such as Pedialyte or Rehydralyte
• Regular diet may resume as tolerated: usually 4 hours after vomiting stops
• For children, advance to BRAT diet

Pharmacologic Management:

• If pt is too nauseated or does not respond to po intake IV hydration should be started
• Dramamine: motion sickness
• Reglan: Gastroparesis, GERD, Chemotherapy SE
• Zofran: for cancer, RT, surgery (Preg class B)
• Promethazine (Phenergan): Preg class C (migraine induced vomiting)
• Do not routinely give anti-emetics to children

Question 29

GI bleeding:

Hematemesis: (2)

Melena: (4)

Hematochezia: (6)

Physical Examination:

• Vital signs: ____
• C____
• Skin: (5)
• Nose/Pharynx:
• Lymph nodes: enlarged in ___
• Abdomen: ___, ___
• Rectal exam

Diagnostics:
- CBC (Hgb may not reflect acute loss), coagulation studies, renal
(elevated BUN) and liver function
- Hematochezia: if >___ years old, colonoscopy is warranted
- Hematemesis: ___; biopsy- H.pylori
- Melena: Decide location first; likely ___
- Occult bleeding: ___

Diagnosis:
o Hematemesis: (5)
o IBD sx: (3)
o Frank rectal bleeding: (3)

Management:
o Ulcer/gastritis: (2)
o ___ replacement
o ___ bleeding: cause- ____ (if secondary to constipation-tx: ___ supplements or ____)
o ___ or ___ to prevent bleed in known varices (goal pulse < 70) secondary to cirrhosis
o Refer for acute ___, those who need ___, unclear etiology of bleed

Answer 29

Hematemesis:
o Esophageal (varices, ulceration, esophagitis)
o Gastritis, cancer, PUD, neoplasm

Melena: 
o	Meckel’s diverticulum
o	Crohn’s disease
o	Ulcer disease
o	Varices

Hematochezia:
o hemorrhoid, fissure, polyp, carcinoma, diverticular disease, IBD

Physical Examination:

• Vital signs: postural hypotension
• Cardiovascular exam
• Skin: pallor, ecchymoses, petechiae, telangiectases, stigmata of chronic liver dx
• Nose/Pharynx: source of bleeding
• Lymph nodes: enlarged in malignancy
• Abdomen: masses, HSM
• Rectal exam

Diagnostics:
- CBC (Hgb may not reflect acute loss), coagulation studies, renal
(elevated BUN) and liver function
- Hematochezia: if >45 years old, colonoscopy is warranted
- Hematemesis: Endoscopy; biopsy-H.pylori
Melena: Decide location first; likely upper
Occult bleeding: colonoscopy

Diagnosis:
o Hematemesis: cirrhosis, chronic liver disease, alcoholism, meds, epigastric pain
o IBD sx: diarrhea, urgency, cramping
o Frank rectal bleeding: diverticular, ulcerative colitis, rectosigmoid disease

Management:
o Ulcer/gastritis: H2 blockers, omeprazole
o Iron replacement
o Anal bleeding: cause- hemorrhoids (if secondary to constipation-tx: fiber supplements or stool softener)
o Nadolol or Propanolol to prevent bleed in known varices (goal pulse < 70) secondary to cirrhosis
o Refer for acute bleed, those who need endoscopy, unclear etiology of bleed

Question 30

Appendicitis:

• Appendicitis is defined as an ____ of the inner lining of the _____ that spreads to its other parts
• Appendicitis may occur for several reasons, such as an ___ of the appendix, but the most important factor is the obstruction of the ____
• Left untreated, appendicitis has the potential for severe complications, including (3)

Symptoms: ___ (2)

Labs: elevated ___

Physical Exam:
-____ Sign:
o Pain on ____ extension of the ___ ___. Patient lies on ___ side. Examiner extends patient’s ___ ___ while applying counter resistance to the right ___.
o Place your hand above the patient’s right knee. Ask the patient to flex the right ___ against ____.
o Increased ____ indicates a positive ___ sign.

-____ Sign
o Raise the patient’s ___ leg with the ___ flexed. Rotate the leg internally at the hip.
o Increased ___ pain indicates a positive obturator sign.

Diagnosis:

• Diagnosis of acute appendicitis is suggested by the ___
• __ and ___ (WBC that ranges 10,000-16,000 cells/ul support diagnosis)
• ___
• ___
• ___ or ___ if indicated

Management:

• All cases of appendicitis require ____
• Non-operative management with _____ has been studied as an alternative for uncomplicated appendicitis
• Carries a recurrent appendicitis rates of 14-20% in 1st year
• Patients who present late (>4-5 days after symptom onset may be treated initially with ____, ____ rest and ___ if any abscess. Later (4- 10wks) appendectomy can then be performed in this subgroup only

Answer 30

Appendicitis:

• Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts
• Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the obstruction of the appendiceal lumen
• Left untreated, appendicitis has the potential for severe complications, including perforation or sepsis, and may even cause death

Symptoms:

• vague abdominal pain
• hx of anorexia and periumbilical pain followed by nausea, right lower quadrant plan, vomiting

Labs: elevated WBC

Physical Exam:
-Psoas Sign:
o Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient’s right thigh while applying counter resistance to the right hip.
o Place your hand above the patient’s right knee. Ask the patient to flex the right hip against resistance.
o Increased abdominal pain indicates a positive psoas sign.

-Obturator Sign
o Raise the patient’s right leg with the knee flexed. Rotate the leg internally at the hip.
o Increased abdominal pain indicates a positive obturator sign.

Diagnosis:

• Diagnosis of acute appendicitis is suggested by the H &P
• CBC and diff (WBC that ranges 10,000-16,000 cells/ul support diagnosis)
• UA
• Beta Hcg, QN
• CT scan or U/S if indicated

Management:

• All cases of appendicitis require emergent surgical consultation
• Appendectomy: standard of care for acute uncomplicated appendicitis
• Laparoscopic appendectomy favored unless perforation; give pre-op broad spectrum antibiotics with gram negative and anaerobic coverage
• Non-operative management with antibiotics has been studied as an alternative for uncomplicated appendicitis
• Carries a recurrent appendicitis rates of 14-20% in 1st year
• Patients who present late (>4-5 days after symptom onset may be treated initially with antibiotics, bowel rest and drainage if any abscess. Later (4- 10wks) appendectomy can then be performed in this subgroup only

Question 31

Ulcerative colitis:
= diffuse ____ disease of the bowel ___

Presentation: 
- \_\_\_\_ (4) 
- May have (3) 
- Extracolonic manifestations include: (4) 
- Frequently involves \_\_ colon and \_\_\_
- Diagnosis may be done by \_\_\_\_
90% go into remission after first attack

Ulcerative Colitis: Management

• Reduction in ____ during ___
• Inactive disease: 1-2 tsp. of Metamucil/day
• May need supplements: (2)
• Initial treatment/prophylaxis: ____
• ____ agents for control/prophylaxis: Asacol, Pentasa, Lialda
• Others: steroids, immunosuppression (6-MP, AZA, CsA), biologics, opiates, psychological support, surger

Biologics used in ulcerative colitis
- The FDA has approved these biologics to treat Ulcerative Colitis (10)

Answer 31

Ulcerative colitis:
= diffuse inflammatory disease of the bowel mucosa

Presentation:
- Bloody diarrhea, urgency, fecal incontinence (decreased fecal tone due to frequent diarrhea), abdominal pain
- May have fever, anorexia, weight loss
- Extracolonic manifestations include: arthritis, uveitis, jaundice, skin lesions
- Frequently involves distal colon and rectum
- Diagnosis may be done by sigmoidoscopy
90% go into remission after first attack

Ulcerative Colitis: Management

• Reduction in dietary fiber during flare-up
• Inactive disease: 1-2 tsp. of Metamucil/day
• May need supplements: iron, folic acid
• Initial treatment/prophylaxis: mesalamine (5-ASA)
• 5-ASA agents for control/prophylaxis: Asacol, Pentasa, Lialda
• Others: steroids, immunosuppression (6-MP, AZA, CsA), biologics, opiates, psychological support, surger

Biologics used in ulcerative colitis

• The FDA has approved these biologics to treat Ulcerative Colitis:
• Adalimumab (Humira)
• Infliximab (Remicade)
• Vedolizumab (Entyvio)
• Golimumab (Simponi)
• adalimumab-atto (Amjevita)
• adalimumab-adbm (Cyltezo)
• certolizumab pegol (Cimzia)
• Infliximab-abda (Renflexis)
• infliximab-dyyb (Inflectra)
• tofacitinib (Xeljanz

Question 32

Crohn’s disease:
= affects all ___ of bowel wall, along the entire ____
- most commonly at the ____
- chronic relapsing _____

Systemic Complications: (10)

• Involves mostly ___, ____
• s/s: (11)
• Extraintestinal: ___ (5)
• May have discreet ___ mass
• Diagnostics: (5)

Management:

• Adequate __ and ___; ___ for those with diarrhea, decreased __; no __
• Elemental diet preparations; vitamins
• May need ___ rest or __
• Meds: 5-ASA agents for control/prophylaxis: Asacol, Pentasa, Apriso
• Others: antibiotics, steroids, immunosuppression (6-MP, AZA), biologics, opiates, psychological support
• Surgery reserved for intractable disease; most pts have to get at some time

Biologics used in crohn’s disease
- The FDA has approved these biologics to treat Crohn’s disease: (10)

Answer 32

Crohn’s disease:
= affects all layers of bowel wall, along the entire GI tract
- most commonly at the ileocecal junction
- chronic relapsing inflammation-autoimmune

Systemic Complications: Eye inflammation, lower bone density, liver and bile duct inflammation, gallstones, skin lesions, growth failure in children, kidney stones, subfertility (more so in females), arthritis, joint pain

• Involves mostly small intestine, terminal ileum
• Diarrhea, abdominal pain (RLQ) or distention, weight loss, food avoidance, nausea, vomiting, fever, perianal pain /drainage, recurrent UTI’s, pneumaturia, psoas abscess
• Extraintestinal: arthritis, ankylosing spondylitis, uveitis, aphthous oral ulcers, sclerosing cholangitis
• May have discreet RLQ mass
• Diagnostics: Colonoscopy, EGD, Capsule EGD, Barium enema, tissue biopsy

Management:

• Adequate protein and calories; fiber for those with diarrhea, decreased fat; no milk
• Elemental diet preparations; vitamins
• May need bowel rest or TPN
• Meds: 5-ASA agents for control/prophylaxis: Asacol, Pentasa, Apriso
• Others: antibiotics, steroids, immunosuppression (6-MP, AZA), biologics, opiates, psychological support
• Surgery reserved for intractable disease; most pts have to get at some time

Biologics used in crohn’s disease

• The FDA has approved these biologics to treat Crohn’s disease:
• Adalimumab (Humira)
• Adalimumab-adbm (Cyltezo), a biosimilar to Humira
• Adalimumab-atto (Amjevita), also a biosimilar to Humira
• Certolizumab (Cimzia)
• Infliximab (Remicade)
• Infliximab-abda (Renflexis), a biosimilar to Remicade
• Infliximab-dyyb (Inflectra), also a biosimilar to Remicade
• Natalizumab (Tysabri)
• Ustekinumab (Stelara)
• Vedolizumab (Entyvio)

Question 33

Irritable Bowel Syndrome:

• GI condition that is classified as ____ because there are no identifiable ____ etiologies to explain its development
• Chronic benign disorder: s/s ___ (3)
• ____ affected more than ___ (2:1)
• Most common presentation: ____ (3)
• Rome criteria can help make diagnosis

Rome IV Criteria:

• Functional GI disorders have a new definition. Rome IV defines them as follows: “Functional GI disorders are disorders of ___ interaction.
• It is a group of disorders classified by GI symptoms related to any combination of the following: m_____, v_____, a_____, a_____, and a_____.
• A person may experience problems with:
  1. _____ (“motility disturbance”)
  2. _____ (“visceral hypersensitivity”)
  3. _____(“altered mucosal and immune function”)
  4. ______ (“altered gut microbiota”)
  5. ______ (“altered central nervous system processing”)

Rome Criteria for IBS:
Rome IV Criteria
- Recurrent ___, on average, at least _day/week in the last _ months, associated with two or more of the following criteria:
- Related to ____
- Associated with a ___ in ___ of stool
- Associated with a ___ in form (___) of stool.
- *Criteria fulfilled for the last _ months with symptom onset at least _ months before diagnosis.

Presentation:

• Weight -usually ___
• Abdominal exam: ___ (usually LLQ) guarding, bowel sounds, masses, HSM
• Rectal exam: tenderness, masses, blood
• Diagnostics: (8)
• May have imaging: Abd u/s and x-ray, KUB, BE
• If severe symptoms or unsure-proceed w/ colonoscopy

Management

• Treatment is purely ___ and includes ___ modifications, medications, behavioral therapy, education and reassurance
• Establish effective relationship with pt: education and reassurance is key
• Symptom ___ (timing, associated sx, feelings)
• Predominate diarrhea: ___ to bulk stool; loperamide 2-4 mg QID (45 min before meals) can be helpful
• Constipation: dietary ___; laxative- ___ preferred
• Gas/Bloating: diet
• Abdominal cramping: ___ 10-20mg TID, ___ sl TID prn or ___
• Stress reduction, biofeedback, exercise
• Moderate to severe IBS, consider SSRI
• Follow-up in ___ weeks then every ___ mos

Answer 33

Irritable Bowel Syndrome:

• GI condition that is classified as functional because there are no identifiable structural or biochemical etiologies to explain its development
• Chronic benign disorder: abdominal pain, bloating and disturbed defecation in absence of structural/biochemical abnormalities
• Women affected more than men (2:1)
• Most common presentation: abdominal pain and bloating; diarrhea &/or constipation
• Rome criteria can help make diagnosis

Rome IV Criteria:

• Functional GI disorders have a new definition. Rome IV defines them as follows: “Functional GI disorders are disorders of gut-brain interaction.
• It is a group of disorders classified by GI symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing.
• A person may experience problems with:
  1. The movement of food and waste through the GI tract (“motility disturbance”)
  2. Heightened experience of pain in the internal organs (“visceral hypersensitivity”)
  3. Changes in the gut’s immune defenses (“altered mucosal and immune function”)
  4. Changes in the community of bacteria in the gut (“altered gut microbiota”)
  5. Changes in how the brain sends and receives from the gut (“altered central nervous system processing”)

Rome Criteria for IBS:
Rome IV Criteria
- Recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following criteria:
- Related to defecation
- Associated with a change in frequency of stool
- Associated with a change in form (appearance) of stool.
- *Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.

Presentation:

• Weight -usually stable
• Abdominal exam: tenderness (usually LLQ) guarding, bowel sounds, masses, HSM
• Rectal exam: tenderness, masses, blood
• Diagnostics: CBC, ESR, TSH, glucose, lytes, BUN/Scr Fecal occult ; stool for O&P x 3; stool culture, Urea breath test
• May have imaging: Abd u/s and x-ray, KUB, BE
• If severe symptoms or unsure-proceed w/ colonoscopy

Management

• Treatment is purely symptomatic and includes dietary modifications, medications, behavioral therapy, education and reassurance
• Establish effective relationship with pt: education and reassurance is key
• Symptom diary (timing, associated sx, feelings)
• Predominate diarrhea: fiber to bulk stool; loperamide 2-4 mg QID (45 min before meals) can be helpful
• Constipation: dietary fiber; laxative- Miralax preferred
• Gas/Bloating: diet
• Abdominal cramping: Bentyl 10-20mg TID, Levsin sl TID prn or Levbid
• Stress reduction, biofeedback, exercise
• Moderate to severe IBS, consider SSRI
• Follow-up in 3-6 weeks then every 3-6 mos

Question 34

Constipation:

• Defined as a ____ in the frequency of bowel movements
• Most commonly occurring gastrointestinal complaint
• This disorder does affect the pediatric population but is a common complaint among older adults and more prevalent in women

Common causes (mostly functional): (3)
Elderly patients:
- _____ (5)

Constipation: Evaluation
- History: pt definition of constipation; ___ pattern and recent ___, ___, ___, ___ and ___ use, PMH, PSH
Meds associated with constipation: (10)
- Rectal exam: (3)
- check for ____ –esp in elderly or those with chronic constipation

Physical Exam

• Not uncommon to have normal findings
• Orthostatic hypotension and/or tachycardia implies dehydration
• Wt loss suggests ___ or ___
• Oral exam
• GI, GYN, Rectal exam
• Neuro exam

Diagnostics (10)

Management

• Keep stool diary
• Increase ___ intake
• Increase ___ fiber and supplements: Metamucil, Fiberall or Fibercon, stool softeners, or osmotic agents;
• Is straining still present a laxative is indicated
• ____ (3)
• Refer> 50 years old: unresponsive to tx, positive hemoccult, or weight loss

Fda approved Medications for constipation

1. ___ (lubiprostone) softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food.
2. ___ (linaclotide) is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bm’s occur more often. It is not approved for use in those age 17 years and younger.
3. ____, a prescription laxative with a variety of brand names, draws water into the bowel to soften and loosen the stool.
4. ___ (polyethylene glycol)is an osmotic laxative and causes water to remain in the stool, which results in softer stools.
5. ___, taken orally once daily, works locally in the upper GI tract to stimulate secretion of intestinal fluid and support regular bowel function. Trulance was approved by the FDA January 2017.
6. ___ (Zelnorm) reduces abdominal pain and improves constipation C/I: history of ischemic colitis, bowel obstruction, gallbladder disease
7. ___ (Ibsrela) ADULTS only

Answer 34

Constipation:

• Defined as a decrease in the frequency of bowel movements
• Most commonly occurring gastrointestinal complaint
• This disorder does affect the pediatric population but is a common complaint among older adults and more prevalent in women
• Results in approx 2.5 million visits annually

Common causes (mostly functional)
- ignoring urge to defecate (most common)
- inadequate fiber and fluids in diet; sedentary
- metabolic, endocrine, neuro, colorectal disorder
Elderly patients:
- Diminished vitality, decreased activity, consequence of chronic illness and medications, poor dietary habits, and decreased fluid intake

Rome criteria:

• Functional constipation categorized under new Rome criteria IV
• IBS subtypes (constipation and diarrhea) are now based on abnormal stool type occurring at least 25% of days
• New diagnoses added to this edition include reflux hypersensitivity syndrome, cannabinoid hyperemesis syndrome (CHS), opiod-induced constipation (OIC), and narcotic bowel syndrome (NBS). **
• **“Many purists would say [these] are not really functional because [they have] a cause, but we have to rethink … this in the 21st century,” Drossman said. “What we’re really saying is that these are conditions that will mimic other so-called functional GI conditions, which … may have specific etiologies, and [they are] also consistent with our [new] definition [for functional GI disorders].”

Constipation: Evaluation
- History: pt definition of constipation; stool pattern and recent changes, diet, activity, medication and laxative use, PMH, PSH
Meds associated with constipation:
- Opioids and related narcotics, Nonsteroidal anti-inflammatory drugs, Atropine, dicyclomine, hyoscyamine, clidinium, Tricyclic antidepressants, Antipyschotic and neuroleptic , Anti-parkinsonian drugs, Calcium channel antagonists, Central alpha adrenergic agonists, Hydralazine , MAO inhibitors, Methyl-DOPA, Aluminum (antacids, sucralfate), Iron supplements, Calcium supplements, Barium sulfate, Heavy metal intoxication (lead, mercury, arsenic), Vinca alkaloid, Cholestyramine, Sodium polystyrene sulfate
- Rectal exam: fissures, hemorrhoids, irritation, guiac disease
- check for impaction–esp in elderly or those with chronic constipation

Physical Exam

• Not uncommon to have normal findings
• Orthostatic hypotension and/or tachycardia implies dehydration
• Wt loss suggests anorexia or carcinoma
• Oral exam
• GI, GYN, Rectal exam
• Neuro exam

Diagnostics

• CBC with diff
• Chemistry profile
• TSH
• UA
• Stool for occult blood/Stool culture
• AXR/ KUB
• Abdominal u/s
• BE
• Colonoscopy or Flex Sig
• Anorectal manometry (measures pressure of anal sphincter muscles)
• Colonic transport studies
• Electromyelogram (assess health of muscles and nerve cells that control them)

Management

• Keep stool diary
• Increase fluid intake
• Increase dietary fiber and supplements: Metamucil, Fiberall or Fibercon, stool softeners, or osmotic agents;
• Is straining still present a laxative is indicated
• Senna, Bisacodyl, Miralax
• Refer> 50 years old: unresponsive to tx, positive hemoccult, or weight loss

Fda approved Medications for constipation

1. Amitiza (lubiprostone) softens the stool by increasing its water content, so the stool can pass easily. This medication is taken twice daily with food.
2. Linzess (linaclotide) is a capsule taken once daily on an empty stomach, at least 30 minutes before the first meal of the day. Linzess helps relieve constipation by helping bm’s occur more often. It is not approved for use in those age 17 years and younger.
3. Lactulose, a prescription laxative with a variety of brand names, draws water into the bowel to soften and loosen the stool.
4. Miralax (polyethylene glycol)is an osmotic laxative and causes water to remain in the stool, which results in softer stools.
5. Trulance, taken orally once daily, works locally in the upper GI tract to stimulate secretion of intestinal fluid and support regular bowel function. Trulance was approved by the FDA January 2017.
6. Tegaserod (Zelnorm) reduces abdominal pain and improves constipation C/I: history of ischemic colitis, bowel obstruction, gallbladder disease
7. Tenapanor (Ibsrela) ADULTS only

Question 35

Diverticular Disease:

• Abnormal ___ of colonic ___
• Increase with ___
  1. Prevalence 101F despite antibiotics, pain worsens, peritoneal signs develop or WBCs rise: ____
• Once symptoms subside, ___ may be warranted to rule out cancer

Answer 35

Diverticular Disease:

• Abnormal herniations of colonic mucosa
• Increase with age
  1. Prevalence <5% for age < 40 years
  2. Peak incidence of occurrence in 6th, 7th and 8th decades of life
• May cause diverticulitis if plugged and inflamed: 10-30% with disease will present with diverticulitis
• Diverticulosis usually asymptomatic
• Diverticulitis: LLQ pain, fever, and leukocytosis (Asian patients usually have Rt sided disease)
• Complications: perforation, fistulas, obstruction, hemorrhage
• Diverticulitis: Mild (fever <101oF, WBC 13,000-15,000)
  o bedrest and clear liquid diet
  o nonopiate analgesics for pain
  o May have abd pain, n/v/d
  o if febrile, broad spectrum antibiotic
  o CT is diagnostic tool of choice using oral, IV and rectal contrast (although oral and IV most commonly done)
  o Barium enema NEVER performed
• If temperature > 101F despite antibiotics, pain worsens, peritoneal signs develop or WBCs rise: hospitalize
• Once symptoms subside, lower GI endoscopy may be warranted to rule out cancer

Question 36

Diverticulosis Management:

• low ___, high ___ and ___ assoc with inc risk of symptomatic ____ disease
• avoid ___, ___, and ___
• ____ may help but constipate
• Pt Ed: report ___, ____, ___ ASAP
• Conflicting research on avoiding seeds, nuts, popcorn, cucumbers, tomatoes, figs, corns, strawberries, caraway seeds to prevent diverticular complications
• JAMA 2008 large prospective study: no associations were seen between ___

Answer 36

Diverticulosis Management:

• low fiber, high fat and red meat assoc with inc risk of symptomatic diverticular disease
• avoid laxatives, enemas, and opiates
• anticholinergics may help but constipate
• Pt Ed: report fever, tenderness, bleeding ASAP
• Conflicting research on avoiding seeds, nuts, popcorn, cucumbers, tomatoes, figs, corns, strawberries, caraway seeds to prevent diverticular complications
• JAMA 2008 large prospective study: no associations were seen between nut, corn, popcorn consumption

Question 37

Diverticulitis Management:

Mild (fever <101F, WBC 13,000-15,000)-

• ___ and ___ diet
• ____ for pain
• monitor ____
• if febrile, ___

= ____ _mg q 12h + ____ _mg q 8h OR Levofloxacin 750mg daily + Flagyl 500mg q 8 h OR Bactrim DS q 12h + Flagyl 500mg q 8h OR Augmentin q 8 h OR Moxifloxacin 400mg daily

• If temperature > 101F despite ___, symptoms worsens, intolerance to __, _____ develop or WBCs rise: hospitalize
• If treating as outpatient re assess 2-3 days after initiation of abx and weekly thereafter until resolution of all symptoms

Answer 37

Diverticulitis Management:

Mild (fever <101F, WBC 13,000-15,000)-

• bedrest and clear liquid diet
• Non opiate analgesics for pain
• monitor temp, abd, WBCs
• if febrile, broad spectrum antibiotic

= Cipro 500mg q 12h + Flagyl 500mg q 8h OR Levofloxacin 750mg daily + Flagyl 500mg q 8 h OR Bactrim DS q 12h + Flagyl 500mg q 8h OR Augmentin q 8 h OR Moxifloxacin 400mg daily

• If temperature > 101F despite antibiotics, symptoms worsens, intolerance to oral fluids, peritoneal signs develop or WBCs rise: hospitalize
• If treating as outpatient re assess 2-3 days after initiation of abx and weekly thereafter until resolution of all symptoms

Question 38

Hemorrhoids:

= Masses of ____ tissue that, along with ___ and ____ tissue, form a cushion in the ____ layer of the __ canal
= One of their functions is to help maintain ___ of the anus
= They are part of normal human anatomy and therefore symptomatic hemorrhoids can potentially develop in all adults

= Clinical presentation: Usually painless ___ ___, Anal ___, ___, protrusion or pain may be present.

• History: onset, duration of symptoms
• PMH: recent pregnancy, constipation, liver disease, anorectal surgery
• Physical: Inspect entire perineum and perianal area and perform DRE
• Diagnostics: CBC

Mild:

• high ___ diet, bulk-forming agents
• ____ pads (Tucks) or ___
• __ baths 1-2x/day
• ___ or PrepH QID x7days

Moderate:

• ___-HC 2.5% cream or Anusol-HC 2.5% cream
• ___-HC/ pramoxine 1%/1% or 2.5%/1% supp

Answer 38

Hemorrhoids:

= Masses of vascular tissue that, along with connective and muscular tissue, form a cushion in the submucosal layer of the anal canal
= One of their functions is to help maintain closure of the anus
= They are part of normal human anatomy and therefore symptomatic hemorrhoids can potentially develop in all adults

= Clinical presentation: Usually painless rectal bleeding, Anal discomfort, pruritis, protrusion or pain may be present.

• History: onset, duration of symptoms
• PMH: recent pregnancy, constipation, liver disease, anorectal surgery
• Physical: Inspect entire perineum and perianal area and perform DRE
• Diagnostics: CBC

Mild:

• high fiber diet, bulk-forming agents
• witch hazel pads (Tucks) or baby wipes
• sitz baths 1-2x/day
• Anusol or PrepH QID x7days

Moderate:

• ProctoCream-HC 2.5% cream or Anusol-HC 2.5% cream
• Analpram-HC/ pramoxine 1%/1% or 2.5%/1% supp

Question 39

Intussusception:

= when one portion of the ___ slides into the next. when this occurs, it creates an ____ in the bowel, with the walls of the intestines pressing against one another
= leading to ___, ___, decreased ____ to the intestines involved

• Common cause of pain & obstruction in infancy and childhood-up to age 6, 80% occur before a child is 24 months old
• 3 to 4 times more common in ___ than ___
• Severe ___ pain; ___ onset
• Pain is manifested by ____ alternating with ____
• ___ ___ stools: classic sx of ___ and ___ in the stool
• ____ enema may be successful if done within 24 hours of onset
• ____, this can lead to loss of bowel due to ischemia

Answer 39

= when one portion of the bowel slides into the next. when this occurs, it creates an obstruction in the bowel, with the walls of the intestines pressing against one another
= leading to swelling, inflammation, decreased blood flow to the intestines involved

• Common cause of pain & obstruction in infancy and childhood-up to age 6, 80% occur before a child is 24 months old
• 3 to 4 times more common in boys than girls
• Severe colicky pain; sudden onset
• Pain is manifested by screaming alternating with quiet periods
• currant jelly stools: classic sx of blood and mucous in the stool
• Barium enema may be successful if done within 24 hours of onset
• Untreated, this can lead to loss of bowel due to ischemia