GI Flashcards
Danger Signals
Acute A_____
Acute Ch_______
Acute D________
Acute P_______
(1) Colitis
Colon _____
C____ Disease
U______ Colitis
(1) Syndrome
Acute Appendicitis
Acute Cholecystitis
Acute Diverticulitis
Acute Pancreatitis
Clostridium Difficile Colitis
Colon Cancer
Crohn’s Disease
Ulcerative Colitis
Zollinger-Ellison Syndrome
Acute Appendicitis
Patient who is a young adult complains of ____ onset of peri______ pain that is steadily getting worse. Over a period of 12 to 24 hours, the pain starts to localize at _____ point. The patient has no ______ (anorexia). Classic exam findings include low-grade ____ and right lower quadrant (RLQ) pain (McBurney’s point) with re_____ and g______. The p____ and o_____ signs are positive. When the appendix ruptures, clinical signs of acute _______ occur, such as involuntary guarding, rebound, and a b____like abdomen. Refer to ___.
Patient who is a young adult complains of acute onset of periumbilical pain that is steadily getting worse. Over a period of 12 to 24 hours, the pain starts to localize at McBurney’s point. The patient has no appetite (anorexia). Classic exam findings include low-grade fever and right lower quadrant (RLQ) pain (McBurney’s point) with rebound and guarding. The psoas and obturator signs are positive. When the appendix ruptures, clinical signs of acute abdomen occur, such as involuntary guarding, rebound, and a boardlike abdomen. Refer to ED.
Acute Cholecystitis
Overw_____ gender (1) patient complains of severe (1) quadrant or epigastric pain that occurs within 1 hour (or more) after eating a _____ meal. Pain may radiate to the right ______. Accompanied by nausea/vomiting and anorexia. If left untreated, may develop ______ of the gallbladder (20%). May require hospitalization.
Overweight female patient complains of severe right upper quadrant (RUQ) or epigastric pain that occurs within 1 hour (or more) after eating a fatty meal. Pain may radiate to the right shoulder. Accompanied by nausea/vomiting and anorexia. If left untreated, may develop gangrene of the gallbladder (20%). May require hospitalization.
Acute Diverticulitis
(1) Age patient with acute onset of high fever, anorexia, nausea/vomiting, and (1) quandrant abdominal pain. Risk factors for acute diverticulitis include increased a__, con_____, low dietary ____ intake, obesity, lack of exercise, and frequent (1)Rx use.
Signs of acute abdomen are rebound, positive ______ sign, and a _____like abdomen. Complete blood count (CBC) will show leuko_____ with neutro____ and shift to the _____. The presence of band forms signals severe bacterial _____ (bands are immature neutrophils). Complications include abscess, s____, il____, small-bowel _____, hemorrhage, per_____, fis____, and phlegmon stricture. May be life-threatening.
Elderly patient with acute onset of high fever, anorexia, nausea/vomiting, and left lower quadrant (LLQ) abdominal pain. Risk factors for acute diverticulitis include increased age, constipation, low dietary fiber intake, obesity, lack of exercise, and frequent nonsteroidal anti-inflammatory drug (NSAID) use.
Signs of acute abdomen are rebound, positive Rovsing’s sign, and a boardlike abdomen. Complete blood count (CBC) will show leukocytosis with neutrophilia and shift to the left. The presence of band forms signals severe bacterial infection (bands are immature neutrophils). Complications include abscess, sepsis, ileus, small-bowel obstruction, hemorrhage, perforation, fistula, and phlegmon stricture. May be life-threatening.
Rovsing’s sign is the finding of right lower quadrant pain during palpation of the left side of the abdomen or when left-sided rebound tenderness is elicited
Acute Pancreatitis
Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of abdominal pain that radiates to the _____ (“b____”) located in the _____ region.
Frequent causes include _____ (approximately 90% of cases of acute pancreatitis), biliary factors, and al____ abuse. Abdominal exam reveals guarding and tenderness over the _____ area or the upper abdomen, as well as positive ______ sign (blue discoloration around umbilicus) and (1) sign (blue discoloration on the flanks). The patient may have an ileus and show signs and symptoms of sh_____. Refer to ED
Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of abdominal pain that radiates to the midback (“boring”) located in the epigastric region.
Frequent causes include drugs (approximately 90% of cases of acute pancreatitis), biliary factors, and alcohol abuse. Abdominal exam reveals guarding and tenderness over the epigastric area or the upper abdomen, as well as positive Cullen’s sign (blue discoloration around umbilicus) and Grey Turner’s sign (blue discoloration on the flanks). The patient may have an ileus and show signs and symptoms of shock. Refer to ED
Clostridium Difficile Colitis
Severe w_____ diarrhea from __ to __ stools a day that is accompanied by lower abdominal pain with cr______ and f____. Symptoms usually appear within 5 to 10 days after initiation of _____ (such as _____ (Cleocin), fl______, ceph_____, and p______) have been implicated as the most likely cause of C. difficile infection. Most cases occur in patients in h_____ as well as those residing in n_____ facilities
Severe watery diarrhea from 10 to 15 stools a day that is accompanied by lower abdominal pain with cramping and fever. Symptoms usually appear within 5 to 10 days after initiation of antibiotics. (clindamycin (Cleocin), fluoroquinolones, cephalosporins, and penicillins) have been implicated as the most likely cause of C. difficile infection. Most cases occur in patients in hospitals as well as those residing in nursing facilities
Colon Cancer
Very gradual (years) with v____ gastrointestinal (GI) symptoms.
Tumor may bleed intermittently, and patient may have (1). Changes in _____ habits, stool, or bl____ stool. H____-positive stool, dark ____ stool, and mass on abdominal palpation.
(1) gender, older patients (>___ years of age), patients with history of multiple p_____ or inflammatory bowel disease (IBD) such as (2), and post_____l women with (1) should be referred to GI specialist for colonoscopy and endoscopy.
(1) race have the highest incidence of colon cancer in the United States. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colon cancer between ages of __ and __ years (Grade A recommendation).
Very gradual (years) with vague gastrointestinal (GI) symptoms.
Tumor may bleed intermittently, and patient may have iron-deficiency anemia. Changes in bowel habits, stool, or bloody stool. Heme-positive stool, dark tarry stool, and mass on abdominal palpation.
Males, older patients (>50 years of age), patients with history of multiple polyps or inflammatory bowel disease (IBD) such as Crohn’s disease (CD) or ulcerative colitis (UC), and postmenopausal women with iron-deficiency anemia should be referred to GI specialist for colonoscopy and endoscopy.
African Americans have the highest incidence of colon cancer in the United States. The U.S. Preventive Services Task Force (USPSTF) recommends screening for colon cancer between ages of 50 and 75 years (Grade A recommendation).
Crohn’s Disease
CD is an IBD that may affect what part of the GI tract?
If ____ is involved, there is watery diarrhea without blood or mucus. If ____ is involved, there is bloody diarrhea with mucus.
During relapses, fever, anorexia, weight loss, dehydration, and fatigue with periumbilical to (1) quandrant abdominal pain occur. ____ formation and ___ disease occur only with CD (not UC). May palpate tender abdominal mass. R____ and r_____ are common. Higher risk of (2) colon. Risk of development of _____ is also increased, especially for patients treated with azathioprine. More common in (1) ethnicity.
CD is an IBD that may affect any part(s) of the GI tract, from mouth (canker sores), small or large intestine, rectum, and anus.
If ileum is involved, there is watery diarrhea without blood or mucus. If colon is involved, there is bloody diarrhea with mucus.
During relapses, fever, anorexia, weight loss, dehydration, and fatigue with periumbilical to RLQ abdominal pain occur. Fistula formation and anal disease occur only with CD (not UC). May palpate tender abdominal mass. Remissions and relapses are common. Higher risk of toxic megacolon and colon cancer. Risk of development of lymphoma is also increased, especially for patients treated with azathioprine. More common in Ashkenazi Jews.
Ulcerative Colitis
IBD that affects what part?
_____ diarrhea with mucus (hematochezia) more common with UC than with CD. Severe “_____” cramping pain located on the ____ side of the abdomen with bl____ and gas that is exacerbated by food.
Relapses characterized by fever, anorexia, weight loss, and fatigue. Accompanied by (1)gia/ritis (15%–40%) that affect large joints, sacrum, and ankylosing spondylitis. May have ___-deficiency anemia or anemia of _____ disease. Disease has remissions and relapses. Increased risk of (2) colon.
IBD that affects the colon/rectum.
Bloody diarrhea with mucus (hematochezia) more common with UC than with CD. Severe “squeezing” cramping pain located on the left side of the abdomen with bloating and gas that is exacerbated by food.
Relapses characterized by fever, anorexia, weight loss, and fatigue. Accompanied by arthralgias and arthritis (15%–40%) that affect large joints, sacrum, and ankylosing spondylitis. May have iron-deficiency anemia or anemia of chronic disease. Disease has remissions and relapses. Increased risk of colon cancer. Risk of toxic megacolon.
(1)
A gastrinoma located on the pancreas or the stomach; secretes gastrin, which stimulates high levels of acid production in the stomach. The end result is the development of multiple and severe ulcers in the stomach and duodenum. Complaints of epigastric to midabdominal pain. Stools may be a tarry color. Screening by serum fasting gastrin level. Refer to gastroenterologist.
Zollinger–Ellison Syndrome
Route of Food or Drink from the Mouth
=
Esophagus → stomach (hydrochloric acid, intrinsic factor) → duodenum (bile, amylase, lipase) → jejunum → ileum → cecum → ascending colon → transverse colon → descending colon → sigmoid colon → rectum → anus
Abdominal Contents
Which quadrants/areas of the abdomen are these organs located?
(1): Liver, gallbladder, ascending colon, kidney (right), pancreas (small portion); right kidney is lower than the left because of displacement by the liver
(1): Stomach, pancreas, descending colon, kidney (left)
(1): Appendix, ileum, cecum, ovary (right)
(1): Sigmoid colon, ovary (left)
(1) area: Bladder, uterus, rectum
- RUQ:* Liver, gallbladder, ascending colon, kidney (right), pancreas (small portion); right kidney is lower than the left because of displacement by the liver
- Left upper quadrant (LUQ):* Stomach, pancreas, descending colon, kidney (left)
- RLQ:* Appendix, ileum, cecum, ovary (right)
- LLQ:* Sigmoid colon, ovary (left)
- Suprapubic area:* Bladder, uterus, rectum
Abdominal Maneuvers Indicating Acute Abdomen or Peritonitis
Psoas
Obturator
Rosving’s
Mcburney’s
Involuntary Guarding
Rebound Tenderness
Murphy’s
Carnett’s Test
Psoas/Iliopsoas Sign
How to perform the maneuver?
+ Sign
What does a + sign indicate?
With patient in supine position, have patient raise right leg against the pressure of the professional’s hand resistance.
RLQ pain = + sign
Indicates irritation of iliopsoas group of hip flexors suggesting acute appendicitis, peritoneal irritation
Obturator Sign
How to perform the maneuver?
+ Sign =
What does a + sign indicate?
Bend knee and rotate inward at hip joint
+ Sign = RLQ Pain with movement or flexion of hip
Acute Appendicitis, Acute abdomen or peritonitis
Rosving’s Sign
How to perform the maneuver?
+ Sign =
What does a positive sign indicate?
Deep palpation of LLQ
+ Sign = Deep palpation of LLQ results in referred pain to the RLQ
Sign of peritonitis/acute abdomen
McBurney’s Point
=
Palpation of RLQ illicits pain/tenderness - sign of possible acute appendicitis
(Area located between superior iliac crest and umbilicus in RLQ)
Markle Test (Heel Jar)
=
The Markle Sign, Markle Test or Heel Drop Jarring Test is elicited in patients with intraperitoneal inflammation by having a patient stand on his or her toes and suddenly dropping down onto the heels with an audible thump, or jumping in place If abdominal pain is localized as the heels strike the ground or patient refuses to perform bc of pain - Markle Sign is positive
Involuntary Guarding
=
With abdominal palpation, the abdominal muscles reflexively become tense or boardlike. Suspect acute or surgical abdomen. Refer to ED.
Rebound Tenderness
=
Patient complains of worsening abdominal pain when hand is released after palpation of abdomen compared with the pain felt during deep palpation. Suspect acute or surgical abdomen. Refer to ED
Murphy’s Maneuver
How to perform manuever?
+ Sign =
What does a + sign indicate?
Press deeply on the RUQ under the costal border during inspiration
Midinspiratory arrest is a positive finding (Murphy’s sign).
Positive with cholecystitis or gallbladder disease.
Carnett’s Test
How to perform maneuver?
What is it used to test?
Results of test?
Patient is supine with arms crossed over their chest. Instruct patient to lift up shoulders from the table so that the abdominal muscles (rectus abdominus) tighten.
An abdominal maneuver that is used to determine if abdominal pain is from inside the abdomen or if it is located on the abdominal wall.
If source of pain is the abdominal wall, it will increase the pain; if the source is inside the abdomen, the pain will improve.
Gastroesophageal Reflux Disease
=
- ___ percent of U.S. adults have gastroesophageal reflux disease (GERD).
- Diagnosis is based on h____ and clinical s______.
- Chronic GERD does what to the esophagus? (2)
Acidic gastric contents regurgitate from the stomach into the esophagus due to inappropriate relaxation of the lower esophageal sphincter.
- Forty percent of U.S. adults have gastroesophageal reflux disease (GERD).
- Diagnosis is based on history and clinical symptoms.
- Chronic GERD causes damage to squamous epithelium of the lower esophagus, and in about 10% of GERD patients may result in Barrett’s esophagus (a precancer), which increases risk of squamous cell cancer (cancer of the esophagus).
Classic Case of GERD
Middle-aged to older adult complains of chronic heart____ of many years’ duration.
Symptoms associated with l___ and/or f__ meals that worsen when in what position?
Long-term history of self-medication with over-the-counter (OTC) ant____ or __-antagonists
Risk factors may include the chronic use of N____, as____, or al____.
Middle-aged to older adult complains of chronic heartburn of many years’ duration.
Symptoms associated with large and/or fatty meals that worsen when supine.
Long-term history of self-medication with over-the-counter (OTC) antacids and H2 antagonists.
Risk factors may include the chronic use of NSAIDs, aspirin, or alcohol.
Objective Findings in GERD
Acidic or s____ odor to breath
Reflux of sour acidic stomach contents, especially with overeating
______ tooth enamel (rear molars) due to increased hydrochloric acid
Chronic ____-red throat (not associated with a cold)
Chronic c________
Acidic or sour odor to breath
Reflux of sour acidic stomach contents, especially with overeating
Thinning tooth enamel (rear molars) due to increased hydrochloric acid
Chronic sore red throat (not associated with a cold)
Chronic coughing
GERD 1st Line Treatment
First line treatment for mild/intermittent GERD =
- Avoid ___ and/or high-___meals, especially 3 to 4 hours before ___time.
- Avoid foods or medications that ____ the lower esophageal sphincter or foods or medications that irritate the esophagus
- Weight ______ if overweight (body mass index [BMI] >___) or obese.
- Cease s_____. Smoking increases stomach ___ and lowers esophageal sphincter ____.
If poor response, next step is to (1) and continue with lifestyle modifications.
Lifestyle changes for mild/intermittent GERD
- Avoid large and/or high-fat meals, especially 3 to 4 hours before bedtime.
- Avoid foods or medications that relax the lower esophageal sphincter or foods or medications that irritate the esophagus (Box 1).
- Weight reduction if overweight (body mass index [BMI] >25) or obese.
- Cease smoking. Smoking increases stomach acid and lowers esophageal sphincter pressure.
If poor response, next step is to prescribe medications and continue with lifestyle modifications.
Foods that Worsen GERD Symptoms
(1)-flavored gum or candy
Ch_____
C______
A_____ drinks
Ca______ beverages
T_____ sauce
Citrus drinks (e.g., ____ juice)
F____ foods
Peppermint- or mint-flavored gum or candy
Chocolate
Caffeine
Alcoholic drinks
Carbonated beverages
Tomato sauce
Citrus drinks (e.g., orange juice)
Fatty foods
Medications that Worsen GERD Symptoms
_____ channel blockers
N_____
Ni_____
____-adrenergic receptor agonists
Antich_____
I____ supplements
Bis_________
Quinidine
Theophylline
Calcium channel blockers
NSAIDs
Nitrates
Alpha-adrenergic receptor agonists
Anticholinergics
Iron supplements
Bisphosphonates
Quinidine
Theophylline
H2 Antagonists
(3)
First-line treatment for what type of symptoms/GERD?
When should you take this medication?
Ranitidine (Zantac) 300 mg
Nizatidine (Axid) 300 mg
Famotidine 40 mg at bedtime (Pepcid)
First-line treatment for mild-to-moderate symptoms or mild esophagitis.
Should be taken at bedtime.
Proton-pump inhibitors (PPIs)
(4)
Indicated for what type of GERD?
When should you take this medication?
Do not discontinue abruptly, why?
Omeprazole (Prilosec) 20 mg once daily
Esomeprazole (Nexium) 40 mg once daily
Lansoprazole (Prevacid) 30 mg once daily
pantoprazole (Protonix) 40 mg once daily.
For erosive esophagitis. Refer to gastroenterologist.
Take 30 to 60 minutes before meals.
Do not discontinue PPIs abruptly because can cause rebound symptoms/worsen symptoms- taper dose to wean
Proton Pump Inhibitors (PPIs) Complications of Long Term Use
(1) in postmenopausal women (interferes with calcium homeostasis)
Acute interstitial _____
hypo______
(1) infection
Reduced absorption of _____
Osteoporosis and bone/hip fractures in postmenopausal women (interferes with calcium homeostasis)
acute interstitial nephritis
hypomagnesemia
C. difficile infection
Reduced absorption of iron.
Antacids for GERD
(1) (Mylanta, Maalox)
(1) (Tums, Caltrate)
(1) (Gaviscon)
Minerals can bind with certain medications such as t_____ and lev_______
Aluminum–magnesium–simethicone (Mylanta, Maalox)
Calcium carbonate (Tums, Caltrate)
Aluminum–magnesium (Gaviscon)
Minerals can bind with certain medications such as tetracycline and levothyroxine (Synthroid).
GERD Treatment
What should you do if patient has? Gold standard procedure =
no relief after __-__ weeks of therapy
high risk for _____ esophagus (long term GERD, white male >50yo)
Experiencing worrisome symptoms
Refer to GI specialist for upper endoscopy/biopsy (GOLD STANDARD)
no relief after 4-8 weeks of therapy
high risk for Barrett’s esophagus (long term GERD, white male >50yo)
Experiencing worrisome symptoms
Complications of GERD
(3)
Barrett’s esophagus (a precancer for esophageal cancer)
Esophageal cancer
Esophageal stricture/scarring
Worrisome Symptoms of GERD
Refer to Gastroenterologist
- Odynophagia =
- Dysphagia =
- Early _____
- Weight ____
- (1) anemia
- gender (1) over (1) years old
- Odynophagia = pain with swallowing
- Dysphagia = difficulty swallowing
- Early Satiety
- Weight Loss
- Iron deficiency anemia (weight loss)
- Male >50 yo
Clinical Pearls for GERD
Any patient with at least a _____ or more history of chronic heartburn should be referred to a ______ for an ______ to rule out (1)
Patients with Barrett’s esophagus have up to ___ times higher risk of _____ of the esophagus (______ type).
Any patient with at least a decade or more history of chronic heartburn should be referred to a gastroenterologist for an endoscopy to rule out Barrett’s esophagus.
Patients with Barrett’s esophagus have up to 30 times higher risk of cancer of the esophagus (adenocarcinoma type).
Exam Tips
Barrett’s Esophagus =
How do you diagnose Barrett’s Esophagus?
Know lifestyle factors to teach patient with GERD (e.g., no m____, avoid c______).
(1) sign = edema and bruising of the subcutaneous tissue around the umbilicus indicates → (1)
(1) sign = bruising/bluish discoloration of the flank area that may indicates → (1)
Barrett’s esophagus is a precancer (esophageal cancer).
Diagnosed by upper endoscopy with biopsy.
Know lifestyle factors to teach patient (e.g., no mints, avoid caffeine).
Cullen’s sign = edema and bruising of the subcutaneous tissue around the umbilicus → haemorrhagic pancreatitis
Grey Turner’s sign = bruising/bluish discoloration of the flank area that may indicate → retroperitoneal hemorrhage/necrotizing pancreatitis
Exam Tips
Classic pain of acute pancreatitis =
How do you perform Rosving’s maneuver?
How do you perform Markle’s maneuver?
Positive Rosvings and Markle’s Maneuver tests indicate what?
How do you perform Psoas maneuver?
How do you perform Obturator sign?
Positive Psoas and Obturator signs indicate what?
Acute pancreatitis pain = severe midepigastric pain that radiates to midback (boring pain)
Rosving’s maneuver = pain in RLQ when palpating LLQ
Markle’s maneuver = having patient stand on toes and suddenly drop onto heels with an audible thump
Positive Rosving’s and Markles = acute abdomen
Psoas maneuver = having the patient lie on his or her left side while the right thigh is flexed backward
Obturator sign = internal rotation of right hip (ankle moves outward) with hip and knee flexed
Positive Psoas and Obturator signs = acute appendicitis
Exam Tips
Worrisome symptoms for esophageal cancer ____ on swallowing, early _____, and ____ loss
If patient needs treatment for GERD, start with Rx (1); if poor relief or erosive esophagitis, step up to Rx (1)
Worrisome symptoms for esophageal cancer include pain on swallowing, early satiety, and weight loss.
If patient needs treatment for GERD, start with H2 antagonists; if poor relief or erosive esophagitis, step up to PPIs.
Acute Gastroenteritis
Most common pathogens (1) (50-70%), (1) (15-20%), (1) (10-15%)
Main symptom =
Acute diarrhea =
Persistent diarrhea =
Chronic diarrhea =
Most common pathogens viruses (50-70%), bacteria (15-20%), protozoans (10-15%)
Main symptom = Loose, watery diarrhea 3x or more per day
Acute diarrhea = 1-2 days
Persistent diarrhea = 2-4 weeks
Chronic diarrhea = _>_4 weeks
(1)
Acute onset of nausea and vomiting accompanied by watery diarrhea that is not bloody. It is self-limited and of short duration, typically lasting 1 to 3 days.
Most common pathogens (2)
One of these pathogens (1) can cause outbreaks in crowded areas such as (2)
Viral Gastroenteritis
Acute onset of nausea and vomiting accompanied by watery diarrhea that is not bloody. It is self-limited and of short duration, typically lasting 1 to 3 days.
Rotavirus, Norovirus
Norovirus can cause outbreaks in crowded areas such as nursing homes, cruise ships
(1)
Acute onset of high fever, bloody diarrhea, severe abdominal pain with at least six stools in a 24-hour period.
Incubation period ranges from 1 to 6 hours if (1)
Incubation period 1 to 3 days if (1)
Bacterial Gastroenteritis
Acute onset of high fever, bloody diarrhea, severe abdominal pain with at least six stools in a 24-hour period.
Incubation period ranges from 1 to 6 hours if due to contaminated food (enterotoxin)
Incubation period 1 to 3 days if bacterial infection
Bacterial Gastroenteritis
Bacterial pathogens include E____ ____ Sa_____, Sh____, Ca_____, C. ______ (antibiotic use, recent hospitalization), and L_____ (pregnant women 12-fold risk).
Symptoms usually resolve in __ to __ days.
(1) can prolong the length and/or severity of the disease(pregnant women 12-fold risk).
Bacterial pathogens include Escherichia coli, Salmonella, Shigella, Campylobacter, C. difficile (antibiotic use, recent hospitalization), and Listeria (pregnant women 12-fold risk).
Symptoms usually resolve in 1 to 7 days.
Antibiotics can prolong the length and/or severity of the disease
(1)
Symptoms develop within 7 days of exposure and typically last ≥7 days. It is usually watery diarrhea. Travelers’ diarrhea starts within 3 to 7 days after exposure and usually resolves in 5 days. It is usually self-limited.
Pathogens (3)
Protozoal Gastroenteritis
Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.
Protozoal Gastroenteritis
Risk Factors
- Travel to (1)
- Recent _____ use
- _________ state
- ____ care or resides in a _____ setting (e.g., nursing homes, institutions)
- Travel to developing countries
- Recent antibiotic use
- Immunocompromised state
- Day care or resides in a crowded setting (e.g., nursing homes, institutions)
Protozoal Gastroenteritis
Preventive Measures
- Drink (1), avoid (1)
- Food and water precautions when traveling in ____-world countries
- _____ hands frequently
- Careful food _____, such as washing v____ and f____
- ______ vaccine (infants)
- Drink bottled water during foreign travel; avoid ice cubes
- Food and water precautions when traveling in third-world countries
- Wash hands frequently
- Careful food preparation, such as washing vegetables and fruits
- Rotavirus vaccine (infants)
(1)
A chronic functional disorder of the colon (normal colonic tissue) marked by exacerbations and remissions (spontaneous). Commonly exacerbated by excess stress. It may be classified as diarrhea-predominant or constipation-predominant. In some cases, it may alternate between the two
Irritable Bowel Syndrome
Classic Case of IBS
Young adult to middle-aged ____ complains of in______ episodes of moderate-to-severe cr_____ pain in the lower abdomen, especially in the (1) quadrant. Bl_____ with fl______. Relief obtained after _______. Stools range from _____ to ______ or both types with __creased frequency of bowel movements.
Young adult to middle-aged female complains of intermittent episodes of moderate-to-severe cramping pain in the lower abdomen, especially in the LLQ. Bloating with flatulence. Relief obtained after defecation. Stools range from diarrhea to constipation or both types with increased frequency of bowel movements.
IBS Objective Findings
A complete physical exam should be performed to exclude other causes.
Vital signs are typically _____.
- Abdominal exam*: ______ in lower quadrants during an _______. Otherwise the exam is _____.
- Rectal exam*: Stool is _____ with no blood or pus. Stools are heme ______.
A complete physical exam should be performed to exclude other causes.
Vital signs are typically normal.
- Abdominal exam*: Tenderness in lower quadrants during an exacerbation. Otherwise the exam is normal.
- Rectal exam*: Stool is normal with no blood or pus. Stools are heme negative.
- PE all normal except for tenderness in lower quadrants during exacerbation*
IBS Treatment
Diet Recommendations
Increase dietary _____ = Supplement with below, start at low dose (causes gas)
- (1) (Metamucil or Konsyl)
- (1) (Citrucel)
- (1) (Benefiber).
Avoid ___-producing foods: Beans, onions, cabbage, high-fructose corn syrup.
If poor response, use a trial diet of l_____ avoidance or g_____ avoidance.
Increase dietary fiber. Supplement fiber with, start at low dose (causes gas)
- psyllium (Metamucil or Konsyl)
- methylcellulose (Citrucel)
- wheat dextrin (Benefiber).
Avoid gas-producing foods: Beans, onions, cabbage, high-fructose corn syrup.
If poor response, use a trial diet of lactose avoidance or gluten avoidance.
IBS Pharm Treatment
(1)-(2)Rx for abdominal pain
(1)Rx for IBS with diarrhea
(1)Rx for Severe diarrhea-predominant IBS (warning _____ colitis, which can be fatal)
Antispasmodics-Dicyclomine (Bentyl) or Hyoscyamine PRN for abdominal pain
Loperamide (Immodium) before meals for IBS with diarrhea
Alosetron for Severe diarrhea-predominant IBS (warning: ischemic colitis, which can be fatal)
IBS Pharm Treatment
IBS with constipation
- Begin trial of ______ supplements, and (1)Rx (osmotic laxative)
- If severe constipation = 1(Rx) or (1)Rx (contraindicated in pediatric patients <6 years, has caused death from dehydration)
- Begin trial of fiber supplements, and polyethylene glycol (osmotic laxative)
- If severe constipation = Lubiprostone or Linaclotide (contraindicated in pediatric patients <6 years, has caused death from dehydration)
IBS Treatment
Decrease life ____/____ and offer treatment strategies.
Rule Out: Amoebic, parasitic, or bacterial _____; _______ disease of the GI tract. Check stool for ova and p______ (especially diarrheal stools) with c_____.
Decrease life anxiety/stress and offer treatment strategies.
Rule Out: Amoebic, parasitic, or bacterial infections; inflammatory disease of the GI tract. Check stool for ova and parasites (especially diarrheal stools) with culture.
IBS Clinical Pearl
When should you not give antidiarrheal medications?
Do not give antidiarrheal medications if patient has acute onset of bloody diarrhea, fever, abdominal pain, or pain that worsens with defecation because it may be caused by E. coli O157:H7, shiga toxin–producing E. coli (STEC), amebiasis, Salmonella, Shigella, or other pathogens. May need to go to ED.
Peptic Ulcer Disease (Gastric and Duodenal)
(1) common cause of both duodenal and gastric ulcers
Usually between ___-____ years of age
Which ulcer is more common?
Do these ulcers always cause symptoms?
Which ulcer has higher risk of malignancy?
Helicobacter Pylori common cause of both duodenal and gastric ulcers
Usually between 25-64 years of age
Duodenal ulcers more common
Most (70%) asymptomatic
Gastric ulcers have higher risk of malignancy (up to 10%)
PUD Causes
Most Common Cause (1) (gram-negative bacteria)
Chronic (1) and (1) use which disrupts ______ production, results in reduction of GI blood flow with reduction of protective mucus layer. It inhibits cyclooxygenase (COX 1 and COX 2) enzyme, which reduces production of prostaglandin.
(1) and (1) use
Drug-induced PUD can result from = bis______, clop____, antic______, p______supplements, cortico______, ch____therapeutic drugs, illicit drugs (crack ______).
Most Common Cause = H. Pylori (gram-negative bacteria)
Chronic NSAID and Aspirin use which disrupts prostaglandin production, results in reduction of GI blood flow with reduction of protective mucus layer. It inhibits cyclooxygenase (COX 1 and COX 2) enzyme, which reduces production of prostaglandin.
Cigarette smoking and Alcohol use
Drug-induced PUD can result from = bisphosphonates, clopidogrel, anticoagulants, potassium supplements, corticosteroids, chemotherapeutic drugs, illicit drugs (crack cocaine).
PUD Classic Case
Adult complains of recurrent _______ pain, b_____/gn____ pain, or ache (80%).
Pain _____ by food and/or antacids (50%) with recurrence shortly after meals (____ ulcer) and 2 to 4 hours after a meal (______ ulcer).
Pain also recurs when hungry or stomach is empty. Self-medicating with OTC antacid, H2 blocker, and/or PPI.
May be taking NSAIDs or aspirin for chronic pain or prophylaxis against heart disease or stroke. Black or tarry stools (melena), red/maroon blood in stool (hematochezia), coffee-ground emesis, or iron-deficiency anemia indicates GI ______.
If signs of shock (_______) are present with ____like abdomen and re_____ tenderness, call 911.
Adult complains of recurrent epigastric pain, burning/gnawing pain, or ache (80%).
Pain relieved by food and/or antacids (50%) with recurrence shortly after meals (gastric ulcer) and 2 to 4 hours after a meal (duodenal ulcer).
Pain also recurs when hungry or stomach is empty. Self-medicating with OTC antacid, H2 blocker, and/or PPI.
May be taking NSAIDs or aspirin for chronic pain or prophylaxis against heart disease or stroke. Black or tarry stools (melena), red/maroon blood in stool (hematochezia), coffee-ground emesis, or iron-deficiency anemia indicates GI bleeding.
If signs of shock (hemorrhage) are present with boardlike abdomen and rebound tenderness, call 911.
PUD Worrisome Symptoms
Early ____, an_____, an____ (bleeding), recurrent v_____, hema____, ____loss.
Early satiety, anorexia, anemia (bleeding), recurrent vomiting, hematemesis, weight loss.
PUD Objective Findings
- Abdominal exam =*
- Hemoccult =*
- Abdominal exam:* Normal or mildly tender epigastric area during flare-ups.
- Hemoccult:* Can be positive if actively bleeding.
PUD Workup
Labs (2) to check for bleeding
H.Pylori Tests (3)
Gold Standard (1)
CBC (iron-deficiency anemia), Fecal occult blood test (FOBT)
H.Pylori Tests = Urea Breath Test*, Stool antigen, Serology (titers)
Gold Standard = Upper endoscopy and biopsy of gastric and/or duodenal tissue
Urea Breath Test for H.Pylori
Indicative of ____ H. pylori infection and is commonly used to document ______ of H. pylori after treatment. Use of ____ within 2 weeks of the test can interfere with results.
Indicative of active H. pylori infection and is commonly used to document eradication of H. pylori after treatment. Use of PPIs within 2 weeks of the test can interfere with results.
Stool Antigen Test
Can be used to confirm (1) and (1)
Urea breath test and stool/fecal antigen test are _____ sensitive for active infection than serology/titers.
Serology (Titers)
immunoglobulin (Ig__) levels elevated. Do antibodies indicate active infection?
Stool Antigen Test
Can be used to confirm infection and posttreatment to document eradication.
Urea breath test and stool/fecal antigen test are more sensitive for active infection than serology/titers.
Serology (Titers)
immunoglobulin (IgG) levels elevated. Presence of antibodies does not necessarily indicate current infection. H. pylori antibodies can be elevated for months to years.
PUD
What should you test for if the patient has multiple severe ulcers or is unresponsive to treatment?
What test is needed to rule out gastric cancer and document healing of an ulcer?
Use fasting gastrin levels to rule out Zollinger–Ellison syndrome as needed.
Requires an endoscopy to rule out gastric cancer and document healing of ulcer.
Treatment for H.Pylori Negative Ulcers
Do you use antibiotics?
Stop use of (1), but if needs long-term use, use with (1) or misoprostol to decrease ulcer formation risk
_____ cessation, stop drinking _____
Combine lifestyle changes with (1) or (1) antagonists (no antibiotics).
- Duration of therapy is from __ to __ weeks.
- If recurrent ulcers, poor response after 4 to 8 weeks of therapy, or suspect bleeding ulcer, refer to ___.
NO ANTIBIOTICS NEEDED
Stop use of NSAIDs. If a patient needs long-term NSAIDs, ulcer formation risk can be decreased if combined with a PPI or misoprostol.
Encourage smoking cessation. Stop drinking alcohol.
Combine lifestyle changes with PPIs or H2 antagonists (no antibiotics).
- Duration of therapy is from 4 to 8 weeks.
- If recurrent ulcers, poor response after 4 to 8 weeks of therapy, or suspect bleeding ulcer, refer to GI.
H2 Antagonists and PPIs for PUD
H2 antagonists:
- ______ (Zantac) 150 mg twice a day or 300 mg at ____
- _____ (Axid) 150 mg twice a day or 300 mg at _____
- _____ (Pepcid) 40 mg at _____
PPIs:
- ______ (Prilosec) 20 mg daily
- _______ (Nexium) 40 mg daily
- ________ (Prevacid) 15–30 mg daily
H2 antagonists:
- Ranitidine (Zantac) 150 mg twice a day or 300 mg at bedtime
- Nizatidine (Axid) 150 mg twice a day or 300 mg at bedtime
- Famotidine (Pepcid) 40 mg at bedtime
PPIs:
- Omeprazole (Prilosec) 20 mg daily
- Esomeprazole (Nexium) 40 mg daily
- Lansoprazole (Prevacid) 15–30 mg daily
Treatment for H. pylori**–Positive Ulcers
Triple Therapy
(1) + (1) + (1) BID
for __ days
If allergic to amoxicillin?
Clarithromycin + Amoxicillin + PPI BID
for 14 days
Metronidazole (Flagyl) 500mg if allergic to amoxicillin
Clarithromycin (Biaxin) 500 mg + Amoxicillin 1 g + PPI BID x14 days
Treatment for H. pylori**–Positive Ulcers
Quadruple Therapy
(1)QID + (1)QID + (1)QID + (1)BID
For ___ days
Bismuth Subsalicylate QID + Metronidazole QID + TetracyclineQID + PPIBID
For 14 days
Bismuth subsalicylate tab 600mg QID +
Metronidazole tab 250mg QID +
Tetracycline cap 500mg QID +
Standard-dose PPI orally twice a day × 14 days
Exam Tips for PUD
Determine whether question is about H. pylori–____ ulcers or H. pylori–_____ ulcers.
H. pylori–positive ulcers require ____ for __ days plus ___ orally twice a day.
Worrisome symptoms for esophageal ____ include an____, early ____, an____, recurrent _____, h___temesis, and ____ loss.
Determine whether question is about H. pylori–negative ulcers or H. pylori–positive ulcers.
H. pylori–positive ulcers require antibiotics for 14 days plus PPI orally twice a day.
Worrisome symptoms for esophageal cancer include anorexia, early satiety, anemia, recurrent vomiting, hematemesis, and weight loss.
Clinical Pearls for PUD
______ rate for untreated PUD is about 60%.
High rates of _______ resistance (42%) in the United States. Avoid using clarithromycin therapy if there is high resistance in your area.
Eradication rates in the United States using traditional triple therapy are now?
PPIs vs. H2 antagonists for PUD?
Recurrence rate for untreated PUD is about 60%.
High rates of clarithromycin resistance (42%) in the United States. Avoid using clarithromycin therapy if there is high resistance in your area.
Eradication rates in the United States using traditional triple therapy are now <80%.
PPIs cure ulcers faster than H2 antagonists.
Acute Diverticulitis
(1) = Small pouch-like herniations on the external surface of the colon
Diverticulitis occurs when diverticula become _____; high risk of r____ and bleeding, can be life-threatening
Cause =
Higher incidence in ______ societies
Majority of cases occur in what part of the colon (2)?
Diverticula = Small pouch-like herniations on the external surface of the colon
Diverticulitis occurs when diverticula become infected; high risk of rupture and bleeding, can be life-threatening
Cause = chronic lack of dietary fiber
Higher incidence in Western societies (up to 50% of Americans age 60 years or older have diverticula in their colon)
Majority of cases occur in left colon - descending colon and sigmoid
Acute Diverticulitis Complications
- Ab_____, p______ with peritonitis and bleeding
- Il____, s_____, death
What should you do if the patient has a Moderate-to-severe cases, dehydration, elderly, signs/symptoms of acute abdomen, high fever, comorbidities, or immunocompromised?
- Abscess, perforation with peritonitis and bleeding
- Ileus, sepsis, death
Hospitalize
Classic Case of Acute Diverticulitis
____ aged adult presents with (1) quadrant abdominal pain that is (1) frequency and has been present for several days.
If bowel ______ , may have nausea and/or vomiting or ileus due to peritonitis.
Abdominal palpation reveals _____ on the LLQ. About half (50%) of patients have had one or more prior episodes of similar pain.
Reports history of change in _____ habits; up to 50% will have constipation, and some will have diarrhea.
Elderly or older adult presents with LLQ abdominal pain that is constant and has been present for several days.
If bowel obstruction, may have nausea and/or vomiting or ileus due to peritonitis.
Abdominal palpation reveals tenderness on the LLQ. About half (50%) of patients have had one or more prior episodes of similar pain.
Reports history of change in bowel habits; up to 50% will have constipation, and some will have diarrhea.
Acute Diverticulitis vs. Diverticulosis
- (1):* Physical exam is normal; no palpable mass; no tenderness. Diverticula can be visualized only by ________.
- (1):* acute abdomen, positive for rebound, positive Rovsing’s sign, and boardlike abdomen, refer to ___.
- Diverticulosis:* Physical exam is normal; no palpable mass; no tenderness. Diverticula can be visualized only by colonoscopy.
- Acute diverticulitis:* If acute abdomen, positive for rebound, positive Rovsing’s sign, and boardlike abdomen, refer to ED.
Lab Findings in Acute Diverticulitis
CBC =
FOBT =
What should you do if positive findings
CBC = reticulocytosis if acute bleeding and low Hgb/Hct, leukocytosis, neutrophilia (>70%, shift to left (band forms) - presence of band forms signals severe bacterial infection
FOBT = + if bleeding
Send to ED
Mild Acute Diverticulitis Treatment
Uncomplicated Mild Cases
- Treatment Setting =
- Diet modification =
- Pharm Therapy =
- Treatment Setting = can be treated outpatient
- Diet modification = clear liquid diet
- Pharm Therapy = antibiotics for 48-72 hours should improve
Antibiotics for Diverticulitis
(1) or (1) + (1)
Treat for __-__ days
Amoxicillin/Clavulanate or Ciprofloxacin + Metronidazole
Treat for 7-10 days
Amoxicillin–clavulanate 875/125 mg orally twice a day or ciprofloxacin 750 mg twice a day plus metronidazole (Flagyl) 500 mg every 6 hours. Duration based on clinical response. Usually treat for 7 to 10 days.
Acute Diverticulitis Treatment
Opiates?
Fiber?
Probiotics?
NO! Opiates should be avoided during the acute phase because they increase intraluminal pressure and promote an ileus.
NO! Increasing fiber intake is not recommended in the acute management of diverticulitis.
Maybe - Probiotics have been used to prevent recurrences with mixed success.
Acute Diverticulitis Treatment Follow Up
Close follow-up: If no response in 48 to 72 hours or symptoms worsen (high fever, toxic), refer to ___; moderate-to-severe cases should be _______.
Can be life-threatening if abscess ____, which will cause per_____, bacteremia, and septic _____.
Close follow-up: If no response in 48 to 72 hours or symptoms worsen (high fever, toxic), refer to ED; moderate-to-severe cases, hospitalize.
Can be life-threatening if abscess ruptures, which will cause peritonitis, bacteremia, and septic shock.
Chronic Therapy for Diverticulosis
Diet modification =
Misconception =
High-fiber diet with fiber supplementation such as psyllium (Metamucil) or methylcellulose (Citrucel)
Avoidance of nuts, seeds, and popcorn is not evidence-based.
Acute Pancreatitis
Acute inflammation of the pancreas secondary to many factors, such as _____ abuse, ____stones (cholelithiasis), elevated ______ levels, infections
- Pancreatic enzymes become activated inside pancreas, causing auto_____.
- Varies in severity from mild to life-threatening/death.
- (1) are responsible for 40% to 70% of cases; 25% to 35% are caused by (1).
- Elevated _______ (>____ mg/dL) at very high risk for acute pancreatitis.
Acute inflammation of the pancreas secondary to many factors, such as alcohol abuse, gallstones (cholelithiasis), elevated triglyceride levels, infections
- Pancreatic enzymes become activated inside pancreas, causing autodigestion.
- Varies in severity from mild to life-threatening/death.
- Gallstones (includes microlithiasis) are responsible for 40% to 70% of cases; 25% to 35% are caused by alcohol.
- Elevated triglycerides (>800 mg/dL) at very high risk for acute pancreatitis.
Classic Case of Acute Pancreatitis
Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of abdominal pain that radiates to the _____*, located in the _____ region. Abdominal exam reveals g_____ and t_____ over the epigastric area or the upper abdomen.
Positive (2) signs.
May have ileus and signs and symptoms of shock. Refer patient to ED.
Adult patient complains of acute onset of fever, nausea, and vomiting that is associated with rapid onset of abdominal pain that radiates to the midback, located in the epigastric region. Abdominal exam reveals guarding and tenderness over the epigastric area or the upper abdomen.
Positive Cullen’s and Grey Turner’s sign.
May have ileus and signs and symptoms of shock. Refer patient to ED.
Acute Pancreatitis Objective Findings
(1) sign: Bluish discoloration around umbilicus (hemorrhagic pancreatitis)
(1) sign: Bluish discoloration on the flank area (hemorrhagic pancreatitis)
______ bowel sounds (ileus), j____, g____, and _____like upper abdomen if peritonitis
Cullen’s sign: Bluish discoloration around umbilicus (hemorrhagic pancreatitis)
Grey Turner’s sign: Bluish discoloration on the flank area (hemorrhagic pancreatitis)
Hypoactive bowel sounds (ileus), jaundice, guarding, and boardlike upper abdomen if peritonitis
Pancreatitis Workup
Elevated pancreatic (1) such as serum (3)
Elevated liver/bile ducts (3), b_____, leuko_____
Abdominal (1) and (1)
Elevated pancreatic enzymes such as serum amylase, lipase, and trypsin
Elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (GGT), bilirubin, leukocytosis
Abdominal ultrasound and CT
Acute Pancreatitis Complications
Serious complications such as il___, s____, sh____, multiorgan ____, death
D_____
Serious complications such as ileus, sepsis, shock, multiorgan failure, death
Diabetes
(1)
Infection from a Gram-positive, spore-forming anaerobic bacillus that releases toxins that produce clinical disease. The classic symptom is watery diarrhea a few days after starting antibiotic treatment due to changes in intestinal flora caused by antibiotics.
Clostridium Difficile–Associated Diarrhea
Clostridium Difficile–Associated Diarrhea
Antibiotics most likely to cause C.Diff (4)
Most cases occur in ______ patients; may also occur in institutionalized patients (_____facilities).
Transmission route =
Clindamycin (Cleocin), Fluoroquinolones, Cephalosporins, Penicillins
Most cases occur in hospitalized patients; may also occur in institutionalized patients (nursing facilities).
It is spread by fecal–oral contact.
Clostridium Difficile–Associated Diarrhea Risk Factors
Prior or current systemic _____ therapy
_____ age
Hos________
Cancer _________
Prior or current systemic antibiotic therapy
Advanced age
Hospitalization
Cancer chemotherapy
C. Diff Classic Case
____ aged patient who is currently on ______ or has recently completed a course of antibiotics. History of h______. Acute onset of diarrhea with lower abdominal cr____ and p___, anorexia, nausea, and low-grade fever. C. difficile colitis has a ____ recurrence rate (25%), so ask about previous episodes.
Adult to elderly patient who is currently on antibiotics or has recently completed a course of antibiotics. History of hospitalization. Acute onset of diarrhea with lower abdominal cramping and pain, anorexia, nausea, and low-grade fever. C. difficile colitis has a high recurrence rate (25%), so ask about previous episodes.
C.Diff Diarrhea Labs
(1) Testing for C. difficile
(1) for C. difficile toxins.
CBC with _____ (>15,000 cells/μL), metabolic profile, electrolytes, serum creatinine, blood urea nitrogen (BUN).
Should you repeat stool testing to confirm cure?
Should you treat asymptomatic patients?
Nucleic acid amplification testing (NAAT) for C. difficile of a single stool sample.
Stool assay (by enzyme-linked immunosorbent assay) for C. difficile toxins.
CBC with leukocytosis (>15,000 cells/μL), metabolic profile, electrolytes, serum creatinine, blood urea nitrogen (BUN).
Not recommended to repeat stool testing for test of cure is not recommended. C. difficile toxin may persist despite clinical response to treatment.
Do not treat asymptomatic patients
C. Diff Treatment
First line =
Avoid what medication?
Anticipate _____ in 20% to 25% of patients. Consider (1) in recurrent disease.
Moderate evidence that (1) are effective for those with intact immune systems.
First line = Vancomycin 125mg PO QID x10 days
Avoid antimotility agents (loperamide) in patients with bloody diarrhea or antibiotic-associated colitis.
Anticipate relapse in 20% to 25% of patients. Consider fecal microbiota transplant in recurrent disease.
Moderate evidence that probiotics are effective for those with intact immune systems.
C. Diff Treatment
Recommendations for Fluid intake and Diet?
Do you need a specific type of diet?
Isolation precautions =
Rehydration (Naturalyte, Rehydralyte), increase fluids, eat food as tolerated.
Early oral refeeding is encouraged, regular diet. Restricted diets such as BRAT (bananas, rice, applesauce, toast) not necessary.
Contact precautions.
Clinical Pearl C.Diff
Should you use alcohol based hand wipes or soap and water to protect against C.diff?
Handwashing with soap and water is more effective against C. difficile than alcohol-based hand wipes.
Screening Test for Hepatitis A
(1) = acute infection, patient is contagious, no immunity yet
(1) = lifelong immunity, no virus present and is not infectious, can remain detectable for decades
How do receive immunity to hepatitis A? (2)
IgM Antibody Hepatitis A Virus (IgM Anti-HAV) = acute infection, patient is contagious, no immunity yet
IgG Antibody Hepatitis A Virus (IgG Anti-HAV) = lifelong immunity, no virus present and is not infectious, can remain detectable for decades
How: History of native hepatitis A infection or vaccination with hepatitis A vaccine (Havrix)
Screening for Hepatitis B
(1) = active infection and is infectious
(1) = ongoing infection, appears at onset of symptoms in acute Hep B and persists for life
(1) = immunity, due to past infection or immunization
(1) = marker of actively replicating hep B virus, highly infectious, indicates chronic hepatitis
Hepatitis B Surface Antigen (HBsAg) = active infection and is infectious
Total Hepatitis B Core Antibody (Anti-HBc) = ongoing infection, appears at onset of symptoms in acute Hep B and persists for life
Hepatitis B Surface Antibody (Anti-HBs) = immunity, due to past infection or immunization
Hepatitis B “e” Antigen (HBeAg) = marker of actively replicating hep B virus, highly infectious, indicates chronic hepatitis
Hepatitis C Screening
(1)
Up to 85% of cases become ______.
Does a positive Hep C antibody always mean immunity?
What should you if HCV antibody is positive?
Then what should you do if the HCV RNA is positive?
Hepatitis C Virus Antibody (Anti-HCV)
Up to 85% of cases become carriers.
Unlike hepatitis A and B, a positive anti–hepatitis C virus (HCV; antibody) does not always mean that the patient has recovered from the infection and developed immunity; it may instead indicate current infection because up to 85% of cases become carriers.
If HCV antibody test is positive: Order HCV RNA to rule out chronic infection.
If HCV RNA positive, then patient has hepatitis C; refer to GI specialist for liver biopsy/treatment.
Hepatitis D Screening
(1) and/or (1)
You can only have Hepatitis D when?
If you do have infection with both Hep B and D leaves the patient at increased risk for?
Transmission Route =
When should you suspect HDV infection?
Antibody Hepatitis D Virus and/or Hepatitis D Virus RNA (HDV RNA)
Requires presence of Hep B to get infection, is a coinfection
Infection with both hepatitis B and hepatitis D increases the risk of fulminant hepatitis, cirrhosis and severe liver damage; low prevalence in the United States
Transmission Route = blood and bodily fluids (Transmission by sex, sharing needles, birth to an infected mother, needle sticks, semen, saliva)
Suspect HDV infection in any person with positive hepatitis B antigen (HBsAg) who has severe symptoms of hepatitis or acute exacerbations
Hepatitis A
- Transmission Route =*
- Labs* (2)=
Hepatitis A is ______ to the public health department.
Is there a chronic carrier state?
- Transmission:* Transmitted via fecal and oral route from contaminated food or drink, households, sex.
- Labs:* IgM anti–hepatitis A virus (HAV) or NAAT/polymerase chain reaction (PCR) test for hepatitis A virus RNA.
Hepatitis A is reportable to the public health department.
No chronic or carrier state exists for hepatitis A.
Hepatitis A
- Symptoms =*
- Treatment =*
- Prevention =*
Avoid hepatotoxic foods and drugs such as = ac______, al_____/ethanol, st____, iso____, and ______ teas.
Avoid working in ____-related jobs for 1 week after onset of infection.
- Symptoms =* Acute onset of fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, abdominal pain, dark urine, jaundice. Bilirubin levels >3 mg/dL, ALT levels >200 IU/L.
- Treatment* = Self-limiting infection; treatment is symptomatic
- Prevention =* vaccine available (Havrix) and recommended for travelers to areas where hepatitis A is endemic.
Avoid hepatotoxic foods and drugs such as = acetaminophen, alcohol/ethanol, statins, isoniazid, and herbal teas.
Avoid working in food-related jobs for 1 week after onset of infection.
Hepatitis B
- Transmission =*
- Vaccination =*
Hepatitis B can either be (1) or (1), or it can be a ______ infection.
- Transmission =* Horizontal transmission via sexual activity (semen, vaginal secretions, and saliva), blood, blood products, organs. Vertical transmission occurs from mother to infant.
- Vaccination =* Three total doses given during infancy (at birth, 1 month, 6 months); adults require three doses.
Hepatitis B can either be acute and self-limiting, or it can be a chronic infection.
Acute Hepatitis B Treatment
=
Hepatitis B Immune Globulin (HBIG) + start 3 dose Hep B Vaccine series if no previous vaccine history
Chronic Hepatitis B Treatment
=
1st line treatment for Chronic Hep B
Antiviral agents + Pegylated interferone alpha (PEG-IFN-a)
Refer to gastroenterologist
Hepatitis C
- Transmission =*
- Most common cause of (1) in the US*
Approximately 75% to 85% of people who become infected with hepatitis C will develop chronic infection.
Transmission = Mostly Blood and sometimes bodily fluids - Transmitted via sharing needles, blood transfusions before 1992, mother to infant (vertical transmission), needle-stick injuries in healthcare settings. Less common, spread by sexual contact, sharing personal items (razors or toothbrushes)
Most common cause of liver cancer and liver transplantation in the United States
Approximately 75% to 85% of people who become infected with hepatitis C will develop chronic infection.
Hepatitis C
High-risk groups: (1) users, h___philiacs, anyone with history of frequent ______ , and persons born between 1945 and 19__.
The USPSTF recommends routine ___-time HCV screening for ___ adults ages __ to __ years
_____ acute cases of hepatitis C to the health department.
High-risk groups: Intravenous drug users, hemophiliacs, anyone with history of frequent transfusions, and persons born between 1945 and 1965.
The USPSTF recommends routine one-time HCV screening for all adults ages 18 to 79 years
Report acute cases of hepatitis C to the health department.
Hepatitis C Treatment
Can you treat Hep C by yourself? Why or Why not?
Advise patient to not share?
Treatment =
Refer to Gastroenterology because Hep C has the highest risk of chronic hepatitis infection and cirrhosis (30%). Cirrhosis markedly increases the risk of liver cancer or liver failure
Advise patient not to share razors, toothbrushes, and nail clippers and to cover cuts and sores.
Treatment = Refer to gastroenterologist. Highly effective oral antiviral regimens are available, and the vast majority of hepatitis C patients can be treated.
Hepatitis B Practice Question
- Hepatitis B surface antigen (HBsAg):* Negative
- Anti-HBs:* Positive
- Hepatitis B “e” antigen (HBeAg):* Negative
Immune to Hep B
Because due presence of hep B surface antibodies - due to either vaccination or recovered from native hepatitis B infection
Negative surface antigen = not an active infection
Positive hepatitis B surface antibodies = immune
Negative Hep B “e” antigen = not actively replicating or a carrier
Viral Hepatitis Practice Question
- HBsAg*: Positive
- HBeAg:* Positive
- Anti-HBs:* Negative
- Anti-HAV:* Positive
- Anti-HCV:* Negative
+ Hep B infection and Immunity to Hep A
Current Hepatits B infectio (HbsAg positive)
Chronic carrier of hepatitis B (both HBsAg and HBeAg are positive)
Presence of antibodies to hepatitis A (anti-HAV); patient either had a previous hepatitis A infection or received the hepatitis A vaccine (has immunity
This patient is a carrier of the hepatitis B virus; if the HBeAg is positive and highly reactive, it means that the patient is contagious.
Liver Function Tests
(4) biomarkers of hepatic injury
AST
ALT
Alkaline phosphatase
Bilirubin
Aspartate Aminotransferase (AST)
Normal: __ to __ U/L
Also known as (1) (SGOT)
Present in the liver, h____ muscle, sk____ muscle, k____, and br____
Elevated in h_____, cirr____, nonalcoholic ____ liver disease, _____ abuse, drugs (e.g., acetaminophen, statins), ______ infarction, _____nucleosis
Normal: 0 to 35 U/L
Also known as serum glutamic oxaloacetic transaminase (SGOT)
Present in the liver, heart muscle, skeletal muscle, kidney, and brain
Elevated in hepatitis, cirrhosis, nonalcoholic fatty liver disease, alcohol abuse, drugs (e.g., acetaminophen, statins), myocardial infarction, mononucleosis
Alanine Aminotransferase (ALT)
Normal: Males, __ to __ U/L; Females: __ to __U/L
Also known as (1) (SGPT)
Found ______ in the liver; a positive finding indicates liver _______
Compared to AST?
Rapid __creases in AST and ALT levels together with rise of serum _____ and prolongation of ___
Normal: Males, 10 to 40 U/L; Females: 8 to 35 U/L
Also known as serum glutamic pyruvic transaminase (SGPT)
Found mainly in the liver; a positive finding indicates liver inflammation
More specific for hepatocellular injury than AST
Rapid decreases in AST and ALT levels together with rise of serum bilirubin and prolongation of PT
AST/ALT Ratio
What ratio is indicative of alcohol abuse?
Ratio of 2 or higher is indicative of alcohol abuse
So AST will be 2x greater than ALT
(1)
An indicator of continuous heavy drinking for several weeks or longer (about 70 drinks/week).
Found in many organs of the body but mainly on the liver, kidneys, and pancreas.
Can become elevated with medications (phenytoin, barbiturates), biliary disease, liver cancer or metastases, pancreatitis.
During alkaline phosphatase elevation, check this, and if it is elevated, the source is the _____.
Gamma-Glutamyl Transferase (GGT)
An indicator of continuous heavy drinking for several weeks or longer (about 70 drinks/week).
GGT is found in many organs of the body but mainly on the liver, kidneys, and pancreas.
Can become elevated with medications (phenytoin, barbiturates), biliary disease, liver cancer or metastases, pancreatitis.
During alkaline phosphatase elevation, check this, and if it is elevated, the source is the liver.
(1)
Enzyme derived from bone, liver, gallbladder, kidneys, GI tract, and placenta
The highest amounts come from the bones and the liver. During the third trimester of pregnancy, elevated levels come from the placenta.
Alkaline phosphatase levels vary with age; in general, higher levels are seen during growth spurts (physiologic osteoblastic activity) in children and teens.
Elevated in biliary obstruction, cholestasis, bone malignancy/metastasis, healing fractures.
Alkaline Phosphatase (ALP)
(1)
An acute liver inflammation with multiple causes, including viral infection, hepatotoxic drugs (e.g., statins), excessive alcohol intake, medications, and toxins.
Acute Hepatitis
Classic Case of Acute Hepatitis
Adult complains of a new onset of fatigue, anorexia, nausea, malaise, and ____-colored urine for several days. Both sclerae have a ______ tinge (ic___). Skin is j_______. May have _____-colored stools. May have (1) quadrant abdominal pain
Adult complains of a new onset of fatigue, anorexia, nausea, malaise, and dark-colored urine for several days. Both sclerae have a yellowish tinge (icteric). Skin is jaundiced. May have clay-colored stools. May have RUQ abdominal pain
Acute Hepatitis Objective Findings
Skin and sclerae =
Liver =
Skin and sclerae have a yellow tinge (jaundiced or icteric).
Liver: Tenderness over the liver occurs with percussion and deep palpation.
Acute Hepatitis Labs
ALT and AST: Levels are elevated up to __× normal during the acute phase of the illness.
Other liver function tests (LFTs), such as serum (1) and (1), may be elevated.
ALT and AST: Levels are elevated up to 10× normal during the acute phase of the illness.
Other liver function tests (LFTs), such as serum bilirubin and GGT, may be elevated.
Acute Hepatitis Treatment
Remove and treat the _____ (if possible). Avoid hepatotoxic agents such as _____ drinks, rx (1), and rx (1) (e.g., pravastatin [Pravachol]). Treatment is s_______. Chronic hepatitis _ and _ are managed by gastroenterologists.
Remove and treat the cause (if possible). Avoid hepatotoxic agents such as alcoholic drinks, acetaminophen, and statins (e.g., pravastatin [Pravachol]). Treatment is supportive. Chronic hepatitis B and C are managed by gastroenterologists.
Exam Tips
- There will be a serology question. You will have to figure out what type of viral hepatitis the patient has (A, B, or C). It is usually hepatitis B. HBs___-positive status always means an infected patient (new infection or chronic).
- PCR tests are not ______ tests. They test for presence of viral ____. A positive result means that the virus is ______. This test can be performed for ______ disease such as hepatitis C or HIV.
- There will be a serology question. You will have to figure out what type of viral hepatitis the patient has (A, B, or C). It is usually hepatitis B. HBsAg-positive status always means an infected patient (new infection or chronic).
- PCR tests are not antibody tests. They test for presence of viral RNA. A positive result means that the virus is present. This test can be performed for diagnosing disease such as hepatitis C or HIV.
Exam Tips
- Hepatitis ___ has highest risk of cirrhosis and liver cancer.
- Screening test for hepatitis C virus is called the (1). If positive, next step is to order (1). If positive, patient has hepatitis C.
- GGT is elevated in liver disease and _____ obstruction. A “____” elevation in the GGT is a sensitive indicator of possible ______.
- Hepatitis C has highest risk of cirrhosis and liver cancer.
- Screening test for hepatitis C virus is called the HCV antibody (anti-HCV). If positive, next step is to order HCV RNA test. If positive, patient has hepatitis C.
- GGT is elevated in liver disease and biliary obstruction. A “lone” elevation in the GGT is a sensitive indicator of possible alcoholism.
Exam Tips
- (1)* is normally elevated during the teen years due to bone growth. The ALP may also be elevated in bone disorders such as vitamin D deficiency, Paget’s disease, and bone cancer. A ____, which would be elevated with liver disease, may be drawn to differentiate between liver disease and bone disorders.
- A person must have (1) to become infected with hepatitis D. There is no ____ for hepatitis D, but hepatitis B _____ will prevent acquisition of hepatitis D.
- Alkaline phosphatase (ALP) is normally elevated during the teen years due to bone growth. May also be elevated in bone disorders such as vitamin D deficiency, Paget’s disease, and bone cancer. A GGT, which would be elevated with liver disease, may be drawn to differentiate between liver disease and bone disorders.
- A person must have hepatitis B to become infected with hepatitis D. There is no vaccine for hepatitis D, but hepatitis B vaccination will prevent acquisition of hepatitis D.
Exam Tips
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(1) is more sensitive to liver damage than (1).
- AST is also found in other organs such as the (1) and (1) system. AST and ALT may be elevated and may reflect acute liver injury or inflammation. However, these levels may be _____ in chronic liver disease, such as cirrhosis.
- For mild cases of GERD, _____ management and (1)rx or (1)rx. For moderate-to-severe esophagitis, first line is (1)rx.
- Acute ________ symptoms: Amylase and lipase are sensitive tests
- ALT is more sensitive to liver damage than AST.
- AST is also found in other organs such as the heart and skeletal system. AST and ALT may be elevated and may reflect acute liver injury or inflammation. However, these levels may be normal in chronic liver disease, such as cirrhosis.
- For mild cases of GERD, lifestyle management and antacids or H2 antagonists. For moderate-to-severe esophagitis, first line is PPIs.
- Acute pancreatitis symptoms: Amylase and lipase are sensitive tests used for pancreatic inflammation (pancreatitis).
