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CCFP-EM > GI > Flashcards

GI Flashcards

1
Q

Management steps in lower GI bleed

A

Large Bore IVs
Fluid bolus
Blood transfusion
Monitors
Labs
Pressors if required

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2
Q

Differential Dx for LGIB

A

Diverticulitis
Ischemic Colitis
Brisk UGIB
Angiodysplasia
Malignancy
Infectious colitis

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3
Q

Differential for N/V and generalized abdo pain

A

SBO
LBO
Pancreatitis
Perforated viscous
SBP
Diverticulitis
Malignancy

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4
Q

Cecal vs Sigmoid Volvulus on abdo XR

A

Cecal: Empty RLQ
Sigmoid: Apex of volvulus in LUQ

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5
Q

History factors predictive of ischemic colitis

A

Low flow states:
IHD, CHD, Vasoactive drugs
VTE/PVD Risks

In young patients: prolonged intense exercise (marathons), IBD, collagen vasc disease (SLE), Cocaine

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6
Q

Complications of IBD

A

Fistulas
Malabsorption
Bowel Perforation
Toxic Colitis (thumb print on abdo XR) aka megacolon
Obstruction

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7
Q

What is Ogilvie’s Syndrome

A

Acute colonic pseudo-obstruction without anatomic lesion to obstruct flow.
Causes: Medications, Neurologic conditions (parkinson’s, autonomic dysfunction of DM), recent surgery or trauma

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8
Q

Conditions that can be dx with anuscopy

A

Fissures
Internal hemorrhoids
Masses
Traumatic lesions
Cancer

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9
Q

Anorectal abscess types and mgmt

A

Supralevator
Intersphincteric
Ischiorectal
Postanal
Perianal
- Most common
- Painful perianal mass
- outside the anal verge
- only one that can be drained in ER
- Abx if immunocompromised, diabetes, valvular HD, cellulitis

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10
Q

Conditions associated with fissures

A

Constipation
Straining
Prolonged Diarrhea
Anal Sex
Vag delivery

If not 6:00 or 12:00 then think about associated conditions:
- Leukema, HIV, Chron’s, TB, Syphillis

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11
Q

Treatment options for anal fissures

A

WASH
Topical nifedipine
Topical lidocaine
Topical nitro
Surgery

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12
Q

6 Rectal STIs and mangement

A

syphillis - Penicillin G 2.4 Million U x 1
chlamydia - Azithromycin 1000 mg PO x 1or doxy 100 BID x 7 days
gonorrhea - Ceftriaxone 500 mg IM x 1
HSV - valacyclovir 1000 mg PO OD x 7-10 days
HPV - Test for HIV, cryotherapy
Chancroid: Ceftriaxone 500 mg IM x 1

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13
Q

Extraintestinal Manifestations of IBD

A

Ankylosing spondylitis
Erythema Nodosum
Iritis/Uveitis
Sacroiliitis
Arthropathy
VTE (60% increase)
Apthous Stomatitis
PSC (in UC)

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14
Q

DDx for oropharyngeal dysphagia

A

Structural: diverticula, cancer, achalasia, esophageal webs
Extrinsic compression: thyromegally, osteophytes
Neuromuscular: stroke, parksinson, ALS, MS, Huntingtons, myasthenia, polymyositis, muscular dystrophies

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15
Q

DDx for esophageal dysphagia

A

Peptic stricture, shatzki ring, cancer, lymphoma, hiatal hernia
Extrinsic: Mediastinal tumors, postsurgical
Motor:
Achalasia, CREST, DM, alcoholism
Esophagitis: Caustic ingestion, GERD, infecetious, pill, radiation

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16
Q

Most common sites for foreign body in esophagus

A

Proximally at crichopharyngeal muscle, mid at the aortic arch and left mainstem bronchus, and lower at LES

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17
Q

Esophageal Perforation Causes and Mgmt

A

Boerhaave from vomiting or other sudden increases in esophageal pressure
Iatrogenic
Foreign bodies
Caustic Ingestions

*can have Hamman’s Crunch on auscultation

Mgmt: XR, Endo or CT.
If unstable: IV antibiotics (gram +/- and anaerobes, fluids, pressors, airway management,

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18
Q

Signs of pneumomediastinum on CXR

A
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19
Q

Mesenteric Ischemia Mgmt

A

MOVI
Fluid resus
Abx
Antiemetics and pain mgmt
Surgical resection
If imaging confirmed - initiate heparin in consultation with gen Surg.

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20
Q

4 Categories of Mesenteric Ischemic

A

Thromboembolic
Thrombotic (gut angina)
Low flow state - distributive shock, etc. ICU
VTE

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21
Q

Differential for hematemesis / brisk UGIB

A

Variceal Bleed
Neoplasm
Boorhaave’s
PUD

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22
Q

Mgmt of acute upper GI bleed

A

ABC
- Intubate fast
Code Bleed - Restrictive
Reverse coagulopathy
Ceftriaxone
Octreotide
Erythromycin

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23
Q

Size of FB that needs surgery / consult

A

> 20 mm wide or 50 mm long

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24
Q

Types of Dysphagia

A

Oropharyngeal - Immediate
- Neuromuscular
- Degenerative aging
- MS. MG / Scleroderma . Myositis
- Infectious: Botulism, diptheria, polio,vrabies, tetanus
- Metabolic: Thyrotoxicosis, lead, Mg deficiency
Esophageal
- Mechanical: strictures, webs, rings, tumours, extrinsic compression
- Motility: Achalasia, DES, hypertensive LES, Scleroderma, CREST, nutcracker esophagus
- Extrinsic: Gastric volvulus, EtOH, DM, GERD
Hx:
1) Immediate vs Delayed
2) Solids, liquids or both
3) Intermittent or progressive
4) Associated symptoms, GI hx or family Hx

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25
Q

Diagnostic testing for Dysphagia

A

Video esophography
Barium swallow
Manometry
CT enterography

26
Q

Four area of narrowing for foreign bodies

A

Cricopharyngeus / UES
Aortic Arch
left main stem
LES

27
Q

Therapies for a food bolus (P.S. None really work)
- Indications for removal of esophageal bodies

A

Glucagon 0.5-2 mg IV (no longer recommended)
Benzos
Nitroglycerin
Nifedipine
Coca-cola (no longer favored)

Removal If:
- Button batteries
- Large objects
- Sharp objects
- Coins lodged in proximal esophagus
- Complete esophageal obstructions (within 24 hours)

28
Q

indications for removal of gastric FB

A

Larger than 2.5 cm wide or 5 cm long
Sharp
Objects in for 304 weeks
Objects in same location x 1 week

29
Q

Causes
of esophageal perforation

A

Food stuff - sharp
Button batteries
Coins
Forceful valsalva
Iatrogenic: EGD, NG tube, ETT
Caustic substances
Cancer
Esophagitis
Trauma

30
Q

CXR Findings of Esophageal Perf

A

Pneumomediastinum
Subcutaneous air
Unilateral pleural effusion
Hydro/pneumothorax
Wide mediastinum

31
Q

Mgmt of Esophageal Perf

A

Pip-tazo, Admit, NPO

32
Q

GERD Causes

A

Meds: LES tone decrease. CCB, nitrates, Ventolin, Benzos
Food: Fat, caffeine, booze, chocolate, citrus, peppermint
Females: Estrogen/progesterone, pregnany
Delayed gastric Emptying: Anticholinergic drugs, gastroparesis
Increased pressure: Cough, obesity, preggo, supine

Lifestyle changes:
- Weight loss
- No smoking
- Sleeping elevated
- No eating before bed / lying down after eating
- Exercise
- Alcohol avoidance

33
Q

Causes of gastritis

A

EtOH
NSAIDS
Shock states
H. Pylori
Lymphoma
Adenocarcinoma
Smoking
Bile / Obstructive
Steroids

34
Q

Types of gastric volvulus

A

Subdiaphragmatic - Primary
Supradiaphragmatic - Secondary
- Organoaxial
- Mesenteroaxial

Triad: Severe abdo pain and wretching and can’t pass NG tube

Mgmt: NG tube decompress, EGD vs Sx
- Phone a friend

35
Q

Hepatitis Summary of Transmission / Risk Factors

A

Hep A: Fecal-oral.
- RF: Travel, food handling / daycare
- Acute Infection - Hep A IgM. =

Hep B: Parenteral / Parent Child / initimate contact
- RF: IVDU, homosexual men, endemic areas
- Acute Infection: HBsAg, HBcAb IgM

Hep C: Parenteral, Intimate Contact
- RF: Blood transfusion pre 1992, IVDU, > 20 sexual partners
- HHCV RNA

36
Q

Management of EtOH Hepatitis

A

Replace fluids and electrolytes (Mg in particular)
Thiamine
Waych for hypoglycemia
Stop EtOH
High calorie diet
Steroids

37
Q

Mgmt of cirrhosis and complication

A

Encephalopathy: Lactulose and rifaxamin
GI Bleed: Platelets > 50k, fibrinogen > 100, Vit K, Ceftriaxone (Octeotide or Vasopressin for variceal)
SBP: Tap (PMN >250), Ceftriaxone 2g + albumin 1.5 g/ kg, hold BB
Hepatorenal Syndrome: Albumin, midodrine, octreotide, IV norepi

38
Q

Hepatic Encephalopathy Grades

A

Mild Cog Dysfunction - Irritability - Confusion - Coma

West-Haven Criteria

39
Q

Hepatic Abscess Types and Mgmt

A

Pyogenic - From biliary tract obstruction, diverticulitis, appendicitis, bacteremia, pneumonia etc.
- CT with contrast for Dx.
- Abx: Pip-Tazo or Cefotaxime + Flagyl

Amebic - Entamoeba Histolytica
- US for Dx and ELISA Protozoa
- Flagyl

40
Q

Budd-Chiari Syndrome Features, Dx and Mgmt

A

Hepatic vein outflow obstruction (not portal vein)
- Clotting disorders, OCP
- Presents with hepatic failure or jaundice and ascites
- Dx with doppler US

41
Q

PSC vs PBC

A

PSC: Fibrosis of intra/extrahepatic bile ducts
- Associated with IBD / UC

PBC: Granulomatous inflammation of intrahepatic bile ducts
- Scleroderma or CREST, more common in females

42
Q

Cholelithiasis RF

A

Age
Female
Obesity
Rapid Weight loss
Family Hx
Pregnancy
OCP drugs

43
Q

XR and US findings of cholecystitis

A

XR: Stones, pneumobilia, air around gall bladder, Upper quadrant sentinel loop
US: wall thickening > 4 mm, presence of stones, pericholecystic fluid, sonogrpahic Murphy

44
Q

Ascending Cholangitis

A

Fever, jaundice, RUQ pain, shock, AMS
Mgmt: Resuscitate, Abx, decompression with ERCP / Surgery

45
Q

Mgmt of needle stick

A

Clean wound
Baseline tests of exposed
Test source if possible
HIV: PEP - prealbs CBC, Chem, LFTs, Pregnancy
Determine Hep B status - If not immune HBIG and vaccine

46
Q

Pancreatitis Causes

A

Idiopathic
Gallstones
EtOH
Trauma
Steroids
Mumps and other viruses (EBV)
Autoimmune / Preg
Scorpions
Hypertriglyceridemia, hypothermia, hypotension
ERCP
Drugs: GLP1, NSAIDS, diuretics, ranitidine, erythro/tetra, valproate

47
Q

ROME Criteria IBS

A

Recurrent abdo pain
1/7 over the last 3 months
Related to defecation
Change in stool freq
Change in appearance of stool

48
Q
A
49
Q

4 complications of diverticulitis

A

Abscess formation.
Peritonitis.
Intestinal obstruction.
Fistula formation

50
Q

Types and causes of large bowel obstruction

A

Mechanical versus pseudo obstruction.
Malignancy.
Diverticulitis.
Volvulus.
Fecal impaction.
Strictures secondary to IBD.
Hernias
Pseudo obstruction a.k.a. Ogilvie syndrome

51
Q

Four types of Gastro intestinal volvulus

A

Gastric colon Organo axial, and Mesenteroaxial
Cecal: on x-ray, empty, right lower quadrant. Coffee bean sign.
Sigmoid:

52
Q

Extra intestinal manifestations of IBD

A

Polyarthropathy
Erythema nodosum or pyoderma gangrenosum
Aphthous stomatitis
Perianal abscess
Uveitis/iritis/scleritis
Thrombophilia leading to thromboembolic events
Ankylosing spondylitis or sacroiliitis
Personal neuropathy’s
Primary sclerosing cholangitis

53
Q

Four classes of medical therapy for IBD.

A

Oral amino salicylates.
Steroids
Immune suppressants
Antibiotics.

54
Q

Causes and radiographic features of toxic megacolon

A

Causes: infectious, including, C. difficile, inflammatory, bowel disease, ischemia, volvulus, diverticulitis or obstructive cancer.
X-ray features: dilation greater than 6 cm, thumb printing, intraluminal air, and dilation of the transverse colon

55
Q

Conditions associated with ischaemic colitis. Four causes in adults and three causes in young adults

A

CHF, vasoactive, drugs, atherosclerosis, renal failure, thrombophilia, postoperative, cardiac.
Elderly; CHF, renal failure, atherosclerosis, and postoperative/shock states.
Young; endurance sports, cocaine use, collagen, vascular disease, haematologic disorder

56
Q

Low and high risk causes of fissures

A

If posterior in males or anterior in females, usually caused by: hard stools, anal sex, vaginal delivery, prolong, diarrhea
If anywhere, other than midline think of:
Leukemia, syphilis, HIV, TB, Crohn’s disease

57
Q

WASH regimen for haemorrhoids and fissures

A

Warm sitz bath
Analgesia
Stool softeners
High fiber, diet

58
Q

Conditions associated with abscesses and fistulas

A

IBD.
Trauma.
Malignancy.
Infections;
Tuberculosis, lymphogranuloma, venereum, actinomycosis.

Abscesses, usually with staff aureus, E. coli, streptococcus, Proteus, or Bacteroides.

59
Q

Five sites of anal rectal abscesses in which can be drained in the emergency department

A
  1. Super elevator need surgery.
  2. Intersphincteric. Surgery
  3. Ischiorectal. Form outside the anal sphincter. Usually surgical drainage.
  4. Post anal: posterior to rectum. Severe coccyx pain. need surgical drainage.
  5. Perianal abscess. Most common. Located outside the anal verge. Can be drained in the ER. Need antimicrobial therapy post incision and drainage. Should do image to assess for fistulae
60
Q

Eight causes a faecal incontinence

A

Trauma with spinal cord injury
Sphincter incompetence.
Neurologic: i.e. diabetes
Mass effects, i.e. cancers or foreign bodies or faecal impaction.
Medication‘s; laxatives.
Dementia
In young children; emotional distress/abuse

61
Q

Six rectal STI’s and their management

A

HSV. Valaciclovir.
Syphilis. Penicillin.
HPV. Conservative management/vaccination should conduct HIV testing.
Gonorrhea. Treat for concomitant chlamydia. Ceftriaxone 500 mg I am plus azithromycin or doxycycline.
Chlamydia.
Chancroid. Ceftriaxone or azithromycin.
HIV.

CCFP-EM (20 decks)

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