GI Flashcards
Management steps in lower GI bleed
Large Bore IVs
Fluid bolus
Blood transfusion
Monitors
Labs
Pressors if required
Differential Dx for LGIB
Diverticulitis
Ischemic Colitis
Brisk UGIB
Angiodysplasia
Malignancy
Infectious colitis
Differential for N/V and generalized abdo pain
SBO
LBO
Pancreatitis
Perforated viscous
SBP
Diverticulitis
Malignancy
Cecal vs Sigmoid Volvulus on abdo XR
Cecal: Empty RLQ
Sigmoid: Apex of volvulus in LUQ
History factors predictive of ischemic colitis
Low flow states:
IHD, CHD, Vasoactive drugs
VTE/PVD Risks
In young patients: prolonged intense exercise (marathons), IBD, collagen vasc disease (SLE), Cocaine
Complications of IBD
Fistulas
Malabsorption
Bowel Perforation
Toxic Colitis (thumb print on abdo XR) aka megacolon
Obstruction
What is Ogilvie’s Syndrome
Acute colonic pseudo-obstruction without anatomic lesion to obstruct flow.
Causes: Medications, Neurologic conditions (parkinson’s, autonomic dysfunction of DM), recent surgery or trauma
Conditions that can be dx with anuscopy
Fissures
Internal hemorrhoids
Masses
Traumatic lesions
Cancer
Anorectal abscess types and mgmt
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
Conditions associated with fissures
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
Treatment options for anal fissures
WASH
Topical nifedipine
Topical lidocaine
Topical nitro
Surgery
6 Rectal STIs and mangement
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
Extraintestinal Manifestations of IBD
Ankylosing spondylitis
Erythema Nodosum
Iritis/Uveitis
Sacroiliitis
Arthropathy
VTE (60% increase)
Apthous Stomatitis
PSC (in UC)
DDx for oropharyngeal dysphagia
Structural: diverticula, cancer, achalasia, esophageal webs
Extrinsic compression: thyromegally, osteophytes
Neuromuscular: stroke, parksinson, ALS, MS, Huntingtons, myasthenia, polymyositis, muscular dystrophies
DDx for esophageal dysphagia
Peptic stricture, shatzki ring, cancer, lymphoma, hiatal hernia
Extrinsic: Mediastinal tumors, postsurgical
Motor:
Achalasia, CREST, DM, alcoholism
Esophagitis: Caustic ingestion, GERD, infecetious, pill, radiation
Most common sites for foreign body in esophagus
Proximally at crichopharyngeal muscle, mid at the aortic arch and left mainstem bronchus, and lower at LES
Esophageal Perforation Causes and Mgmt
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,
Signs of pneumomediastinum on CXR
Mesenteric Ischemia Mgmt
MOVI
Fluid resus
Abx
Antiemetics and pain mgmt
Surgical resection
If imaging confirmed - initiate heparin in consultation with gen Surg.
4 Categories of Mesenteric Ischemic
Thromboembolic
Thrombotic (gut angina)
Low flow state - distributive shock, etc. ICU
VTE
Differential for hematemesis / brisk UGIB
Variceal Bleed
Neoplasm
Boorhaave’s
PUD
Mgmt of acute upper GI bleed
ABC
- Intubate fast
Code Bleed - Restrictive
Reverse coagulopathy
Ceftriaxone
Octreotide
Erythromycin
Size of FB that needs surgery / consult
> 20 mm wide or 50 mm long
Types of Dysphagia
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
Diagnostic testing for Dysphagia
Video esophography
Barium swallow
Manometry
CT enterography
Four area of narrowing for foreign bodies
Cricopharyngeus / UES
Aortic Arch
left main stem
LES
Therapies for a food bolus (P.S. None really work)
- Indications for removal of esophageal bodies
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)
indications for removal of gastric FB
Larger than 2.5 cm wide or 5 cm long
Sharp
Objects in for 304 weeks
Objects in same location x 1 week
Causes
of esophageal perforation
Food stuff - sharp
Button batteries
Coins
Forceful valsalva
Iatrogenic: EGD, NG tube, ETT
Caustic substances
Cancer
Esophagitis
Trauma
CXR Findings of Esophageal Perf
Pneumomediastinum
Subcutaneous air
Unilateral pleural effusion
Hydro/pneumothorax
Wide mediastinum
Mgmt of Esophageal Perf
Pip-tazo, Admit, NPO
GERD Causes
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
Causes of gastritis
EtOH
NSAIDS
Shock states
H. Pylori
Lymphoma
Adenocarcinoma
Smoking
Bile / Obstructive
Steroids
Types of gastric volvulus
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
Hepatitis Summary of Transmission / Risk Factors
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
Management of EtOH Hepatitis
Replace fluids and electrolytes (Mg in particular)
Thiamine
Waych for hypoglycemia
Stop EtOH
High calorie diet
Steroids
Mgmt of cirrhosis and complication
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
Hepatic Encephalopathy Grades
Mild Cog Dysfunction - Irritability - Confusion - Coma
West-Haven Criteria
Hepatic Abscess Types and Mgmt
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
Budd-Chiari Syndrome Features, Dx and Mgmt
Hepatic vein outflow obstruction (not portal vein)
- Clotting disorders, OCP
- Presents with hepatic failure or jaundice and ascites
- Dx with doppler US
PSC vs PBC
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
Cholelithiasis RF
Age
Female
Obesity
Rapid Weight loss
Family Hx
Pregnancy
OCP drugs
XR and US findings of cholecystitis
XR: Stones, pneumobilia, air around gall bladder, Upper quadrant sentinel loop
US: wall thickening > 4 mm, presence of stones, pericholecystic fluid, sonogrpahic Murphy
Ascending Cholangitis
Fever, jaundice, RUQ pain, shock, AMS
Mgmt: Resuscitate, Abx, decompression with ERCP / Surgery
Mgmt of needle stick
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
Pancreatitis Causes
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
ROME Criteria IBS
Recurrent abdo pain
1/7 over the last 3 months
Related to defecation
Change in stool freq
Change in appearance of stool
4 complications of diverticulitis
Abscess formation.
Peritonitis.
Intestinal obstruction.
Fistula formation
Types and causes of large bowel obstruction
Mechanical versus pseudo obstruction.
Malignancy.
Diverticulitis.
Volvulus.
Fecal impaction.
Strictures secondary to IBD.
Hernias
Pseudo obstruction a.k.a. Ogilvie syndrome
Four types of Gastro intestinal volvulus
Gastric colon Organo axial, and Mesenteroaxial
Cecal: on x-ray, empty, right lower quadrant. Coffee bean sign.
Sigmoid:
Extra intestinal manifestations of IBD
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
Four classes of medical therapy for IBD.
Oral amino salicylates.
Steroids
Immune suppressants
Antibiotics.
Causes and radiographic features of toxic megacolon
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
Conditions associated with ischaemic colitis. Four causes in adults and three causes in young adults
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
Low and high risk causes of fissures
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
WASH regimen for haemorrhoids and fissures
Warm sitz bath
Analgesia
Stool softeners
High fiber, diet
Conditions associated with abscesses and fistulas
IBD.
Trauma.
Malignancy.
Infections;
Tuberculosis, lymphogranuloma, venereum, actinomycosis.
Abscesses, usually with staff aureus, E. coli, streptococcus, Proteus, or Bacteroides.
Five sites of anal rectal abscesses in which can be drained in the emergency department
- Super elevator need surgery.
- Intersphincteric. Surgery
- Ischiorectal. Form outside the anal sphincter. Usually surgical drainage.
- Post anal: posterior to rectum. Severe coccyx pain. need surgical drainage.
- 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
Eight causes a faecal incontinence
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
Six rectal STI’s and their management
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.
