GI Flashcards
What condition has this clinical picture?
- Overweight female
- Severe RUQ or epigastric pain, may radiate to R shoulder
- Within 1 hour of eating fatty meal
- Nausea and vomiting, anorexia
Cholecystitis
What condition has this clinical picture?
Elderly patient with acute onset high fever, anorexia, nausea/vomiting, LLQ pain
Diverticulitis
Risk factors for diverticulitis
Risk factors: age, constipation, low fibre, obesity, lack of exercise, NSAID use
Diverticulitis
CBC will show?
leukocytosis
neutrophilia
shift to left (bands - immature neutrophils)
What condition has this clinical picture?
- Acute onset fever, nausea, vomiting
- onset of pain “boring”/radiating to midback, epigastric
- Guarding and tenderness over epigastric area or upper abdomen
- Cullen’s sign (blue discoloration around umbilicus)
- Turner’s sign: blue discolouration on flanks
Acute pancreatitis
What is Cullen’s sign?
blue discoloration around umbilicus
What is Turner’s sign?
blue discolouration on flanks
Crohn’s or UC?
- mouth to anus
- may or may not have bloody/mucous in diarrhea
- Fever, anorexia, weight loss, dehydration, fatigue
- abdo pain periumbilical to RLQ
Crohn’s
Crohn’s or UC?
fistula formation and anal disease
Crohn’s
Crohn’s or UC?
increased risk of lymphoma if treated with azathioprine
Crohn’s
Crohn’s or UC?
- bloody diarrhea with mucus
- LLQ squeezing/cramping pain with bloating and gas
- fever, anorexia, weight loss, fatigue
- arthralgia and arthritis
UC
What syndrome causes multiple and severe ulcers in stomach and duodenum?
Zollinger-Ellison Syndrome
What type of pain and stool occurs with Zollinger-Ellison Syndrome?
epigastric to midabdminal pain
tarry stools
what medications increase risk of GERD?
what food increases risk of GERD?
NSAID CCB nitrates anticholinergics (TCA) diazepam alpha-adrenergic receptor agonists, iron supps, bisphosphonates
ETOH, chocolate, peppermint, caffeine, carbonated drinks, fatty foods
Risks associated with long term PPI use?
PPI carries risk of OP, bone/hip fractures, acute interstitial nephritis, hypomagnesemia, C diff, reduced calcium absorption
Alarm features for GERD
- unintentional weight loss (>5% over 6-12 months)
- progressive dysphagia
- odynophagia
- persistent vomiting
- black stool/blood in vomit
- IDA
- abdo mass
risk factors for Barrett’s esophagus?
- Caucasian
- age >50
- current or past smoking
- central obesity
- family hx barrett’s or esophageal cancer
treatment for C. diff associated diarrhea? (mild initial episode)
vancomycin 125 mg po QID x 10 days
what does reactive anti-HAV IgM indicate?
reactive anti-HAV IgG?
IgM anti-HAV REACTIVE = active infection, patient is contagious
IgG anti-HAV = lifelong immunity, not infectious
what does the following indicate?
HBsAg positive?
Anti-HBs (surface antibody)?
HBeAg?
Anti-HBc (core antibody)?
HBsAg positive = acute or chronic hep B, infectious
Anti-HBs (surface antibody): IMMUNITY from past infection or vaccination
Hep B “e” Antigen (HBeAg) = marker for actively replicating hep B –> highly infectious
Total Hep B Core Antibody (anti-HBc): appears at onset of symptoms in acute hep B –> persists for life
hepatitis D
- co-exists with…?
- risks of hep D?
- transmission?
co-infection with hep B
risk: fulminant hepatitis, cirrhosis, severe liver damage
transmission: same pattern as hep B
Anal fissures
most are located in which location?
posteriorly midline
If transverse, irregular –> consider DDx of Crohn’s anal squamous cell cancer, anal warts
Anal fissures
first line treatment
Treatment: • Avoid triggers/contributing factors • Prevent constipation ○ Increase dietary fibre • Mineral oil can lubricate stool ○ Long term use discouraged • Sitz baths, cool compresses
Why is long term use of mineral oil to treat anal fissures discouraged?
potentially impairs absorption of fat soluble vitamins (ADEK) and essential fatty acids
Anal fissure symptoms?
Patients with an acute anal fissure present with anal pain that is often present at rest but is exacerbated by defecation.
Pain that intensifies with defecation often lasts for hours following the act, which is a debilitating symptom.
Although anal pain is the cardinal symptom of a fissure, anal fissures can also be associated with anal bleeding (usually hematochezia)
Internal hemorrhoids
prolapse upon defecation, must be reduced manually
-what grade?
Grade III: prolapse upon defecation, must be reduced manually
Internal hemorrhoids
prolapse upon defecation, reduce spontaneously
-what grade?
Grade II: prolapse upon defecation, reduce spontaneously
Risk factors for hemorrhoids?
• Excess ETOH • Chronic diarrhea or constipation • Obesity • High fat/low fibre diet • Prolonged sitting • Sedentary • Receptive partner in anal sex Loss of pelvic floor muscle tone
how much fibre should be consumed to prevent hemorrhoids?
20-30 g per day
topical treatments for hemorrhoids should be limited to _______ because of _______
limit to one week
risk of contact dermatitis, atrophy and thinning of skin, worsening damage
what is Blumberg’s sign?
rebound tenderness - acute appendicitis
What is seen on CBC in acute appendicitis
left shift
- leukocytosis (> 10,000)
- neutrophilia (absolute neutrophil count > 7000)
- bandemia (absolute band count > 500 and >4% bands in circulation)
symptoms suggestive of perforated appendix?
Ruptured appendix:
• Marked leukocytosis (total WBC > 20-30K - UTD says >15K
• Fever > 103 (>39.4)
• Peritoneal findings
• Imaging shows fluid collection in RLQ
• Symptoms > 48 hours
Ill-defined RLQ abdo mass dull to percussion suggestive of abscess
what is Collins’ sign with gallstones?
pain radiating to tip of R scapula
Gallstone dissolving medication (eg ursodeoxycholic acid) can take _________ to dissolve stones
up to 2 years
Risk factors for colorectal cancer
Risk factors: • History of IBD • Hx of cancer • Age >50 • Family hx of CRC (important!) • Familial polyposis syndrome • Hereditary non-polyposis colorectal cancer ○ Early disease (70% by age 65) • Diet: high fat, high red meat, low calcium
Recommended screening for CRC?
FOBT at home x 3 specimens
*FOBT from DRE not recommended
Colonoscopy if positive
Alternative: colonoscopy at 10 year intervals starting age 50
Acute diverticulitis
What is the gold standard for imaging?
What type of diagnostic test is avoided?
CT with contrast gold standard bowel wall thickening
XR to see free air from obstruction/perforation
AVOID
- barium enema
- endoscopy (contraindicated *can cause perforation and peritonitis)
- ultrasound (not useful)
alpha fetoprotein is used as a marker of __________
High levels of AFP can be a sign of liver cancer or cancer of the ovaries or testicles, as well as noncancerous liver diseases such as cirrhosis and hepatitis.
symptoms of acute viral hepatitis?
• Nausea, anorexia, fever, malaise, abdo pain, jaundice (1 week after symptom onset)
• Clay coloured stool, dark urine, joint pain
• Often report aversion to cigarette smoke
Occasional arthritis, rash, mild fever
is rebound tenderness seen in acute hepatitis?
NO
50% will have hepatomegaly with mild RUQ without rebound tenderness
common lab findings in viral hepatitis?
- CBC?
- urine?
- LFT?
- leukopenia with lymphocytosis
- excess bili in urine
- AST and ALT >10 x ULN in acute hep A/B/C
- AST and ALT N or slightly elevated in chronic hep B and C
average incubation of hep A?
15-50 days
average 28 days
first dose of hep A is given at what age for kids?
12-23 months of age for kids
*if first dose given 6-11 months old for travel: still need 2 doses after 12 months
timing of hep A post-exposure prophylaxis?
-what category needs Hep A IG>
hep A vaccine ASAP within 2 weeks of exposure
hep A vax and IG if age 40+ and/or immunocompromised
contraindication to hep B vaccine?
anaphylaxis to baker’s yeast
how often should HBsAb be checked for immunity?
- no universal protocol
- do if high risk (eg health care workers, IVDU, sex workers, dialysis, immunosuppressed)
*HD need ANNUAL ANTI-HBs check
babies born to HBV infected mom should receive _______ within _____ of birth
hep B vaccine and hep B IG within 12 hours of birth
postexposure prophylaxis for hep B if exposed to known HBsAg positive person?
- if fully vaccinated?
- if incomplete vaccination?
- if unvaccinated?
• If person had complete hep B series: single vaccine booster
• If incomplete vaccination: HBIG and finish vaccine
• If unvaccinated: HBIG and hep B preferably within 24 hours of exposure
○ Test for all STIs (HIV, CT/GC, HCV A etc)
most common transmission method for hep C?
IVDU needl sharing
sexual and vertical transmission uncommon
NOT breastfeeding
do people with IBS have nocturnal symptoms?
NO
IBS symptoms disappear during sleep
Which IBD (UC or Crohn’s) has perianal disease eg fistulas and fissures?
Crohn’s
*fissures can be anterior, lateral, multiple recurrent
(in people who do not have Crohn’s, anal fissures are usually posterior)
which IBD (UC or Crohn’s) do you see skip lesions?
Crohn’s
toxic megacolon in UC and Crohn’s - most common organism implicated?
C diff
what type of anemia is anemia of chronic disease?
____cytic _____chromic
normocytic normochromic
what type of anemia can be seen in Crohn’s?
_____cytic _____chromic
B12 deficiency anemia
macrocytic normochromic
what are some extra-intestinal manifestations of Crohn’s?
Arthritis uveitis, iritis erythema nodosum pyoderma gangrenosum VTE (hypercoagulable) chronic bronchitis, interstitial lung disease, PE
smoking is a risk factor for which type of IBD?
Crohn’s
smoking not associated with increase risk of UC - in fact, smoking cessation may be linked with increase risk of UC
colorectal screening with IBD
patients with UC and Crohn’s affecting distal 1/3 of colon should have colonoscopy _________
every 2 years 8-10 years after diagnosis
Celiac disease
classic symptoms?
○ Diarrhea
-bulky foul smelling floating stools due to steatorrhea and flatulence
Weight loss, severe anemia, osteopenia (vit D and Ca deficiency), neuro symptoms from B12 deficiency
Celiac disease
extra-intestinal symptoms?
○ Dermatitis herpetiformis: multiple intensely pruritic papules and vesicles to elbows, forearms, knees, scalp, back, buttocks
○ Atrophic glossitis: soreness or burning to tongue ***always check mouth and ask about oral symptoms in suspected celiac
○ Metabolic bone disease: vit D deficiency, slight increase risk in fracture
○ Iron deficiency anemia
Celiac disease carries increase risk of which cancer?
lymphoma and GI cancer
*DECREASED risk of breast cancer
What are the biopsy findings seen in celiac disease?
intraepithelial lymphocytes
crypt hyperplasia
villous atrophy
In acute pancreatitis, lab findings include elevated amylase and lipase more than ____ x upper limit of normal
> 3 x ULN
imaging of choice for acute pancreatitis?
CT abdo with contrast
*ultrasound can determine gallbladder but cannot visualize pancreas fully
Ranson Criteria for Severity of Acute Pancreatitis:
what five features are used at time of presentation?
remainder of criteria are progression of development in 48 hours
- AGE >55
- WBC >16K
- Glucose >11.1 (>200)
- AST >250
- LDH >350
*presence of THREE features is predictive of severe course, increased risk pancreatic necrosis
Epigastric abdominal pain relieved with sitting up and leaning forward is characteristic of _____?
pancreatitis
Cullen’s sign or Grey Turner’s sign in presence of acute pancreatitis is suggestive of ______?
retroperitoneal bleeding ?pancreatic necrosis
Risk factors for pancreatic cancer
- Chronic pancreatitis
- Smoking
- DM
- Cystic fibrosis
- ETOH has SMALL effect, limited to heavy drinking
40%: no identifiable risk factors
L supraclavicular lymphadenopathy is also known as _____
Virchow’s node
irchow’s node is a potential seeding site for not only gastrointestinal malignancies, but also pulmonary adenocarcinoma, prostate cancer, lymphoma, and ovarian cancer
3 most common symptoms of pancreatic cancer
- abdo pain (insidious, worse with eating or lying supine, similar to pancreatitis)
- jaundice
- weight loss
