GI Flashcards
Primary sclerosing cholangitis
Progressive hepatic disorder in which inflammation in the liver and gallbladder causes scarring of the bile ducts
primary sclerosing cholangitis: labs, clinical findings
Labs:
-elevated alk phos
-hyperbilirubinemia
Clinical findings:
-jaundice
-pruritis
-hepatomegaly
-cirrhosis
Primary sclerosing cholangitis: increased risk for..
cholangiocarcinoma (bile duct cancer)
Hepatocellular carcinoma
gallbladder cancer
colon cancer
primary sclerosing cholangitis is strongly associated with which disorders?
IBD
ulcerative colitis
What is the only definitive treatment for primary sclerosing cholangitis:
Liver transplant
- Indicated for recurrent episodes of cholangitis, cirrhosis, complications of portal hypertension, HCC, hisar cholangiocarcinoma
Peptic ulcer disease: S/Sx
gnawing epigastric pain
Peptic ulcer disease: common causes
H. pylori – most common cause
NSAIDs
H. Pylori treatment
Two ABx:
- clarithromycin
- amoxicillin
- metronidazole
- tetracycline
PLUS
PPI: esomeprazole (20mg/day, can be given IV gtt)
+/- bismuth subsalicylate
x10-14 days
duodenal ulcers: presentation
common in ages 30-55
relief of pain with eating
Most common pathogens causing grossly bloody diarrhea
enterohermorrhagic E. coli
Also common:
- shigella
- salmonella
- campylobacter
Zollinger Ellison syndrome
Syndrome of gastric acid hypersecretion that results in severe peptic ulcer disease and diarrhea
Zollinger Ellison syndrome: cause
Excess secretion of gastrin by a gastrinoma stimulates gastric acid secretion by the parietal cells
Zollinger Ellison syndrome: S/Sx
abdominal pain and chronic diarrhea
NSAID-induced peptic ulcer disease: treatment
misoprostol
gastric ulcers: S/Sx
common in ages 55-65
pain worsens with eating
perforation: S/Sx
severe epigastric pain
rigidity, “board-like” abdomen
quiet bowel sounds
peptic ulcer disease: labs/Dx
anemia
consider endoscopy after 8-12 weeks of treatment
consider H. pylori testing
treatment for PUD, dyspepsia
acid anti-secretory agents
- PUD: start PPI first
- Dyspepsia: Start H2 reactor antagonists first
dyspepsia
recurrent indigestion or epigastric pain with no obvious cause
mucosal protective agents
Give 2 hours apart from other medications
Sucralfate
- avoid antacids and H2 blockers
Bismuth subsalicylate
- direct antibacterial action against H. pylori
Antacids
- immediate relief
- do not reduce the amount of gastric acidity
GERD: diagnostics
consider EGD
rule out:
-cancer
-Barrett’s esophagus (if GERD x5 years)
-peptic ulcer disease
GERD: management
antacids PRN
H2 blockers in high doses
PPI if H2 blockers are ineffective
hepatitis: types
Viral: A, B, C, D, E G
Autoimmune
Alcoholic
Hepatitis A: transmission
fecal-oral
-Common source outbreaks result from contaminated water and food (e.g. shellfish, hurricane-stricken areas with poor sewage)
-sexual contact
blood and stool are infectious during the 2-6 week incubation period
Hepatitis B: transmission
blood, blood products
sexual activity
perinatally mother-fetus
Hepatitis C: transmission
traditionally associated with blood transfusion
IVDU
hepatitis: S/Sx
Pre-icteric
-fatigue
-malaise
-anorexia
-N/V
-headache
-aversion to smoking and alcohol
Icteric:
-weight loss
-jaundice
-pruritis
-RUQ pain
-clay colored stool
-dark urine
-fever may be present
-hepatosplenomegaly may be present
hepatitis: labs/Dx
WBC low to normal
UA: proteinuria, bilirubinuria
AST, ALT elevated
LDH, bilirubin, alk phos, PT: normal or slightly elevated
Active Hepatitis A: serology
Anti-HAV
IgM
Recovered Hepatitis A: serology
Anti-HAV
IgG
Active Hepatitis B: serology
HBsAg
HBeAg
Anti-HBc
IgM
Chronic Hepatitis B: serology
HBsAg
Anti-HBc
Anti-HBe
IgM
IgG
Recovered Hepatitis B: serology
Anti-HBc
Anti-HBs
Acute Hepatitis C: serology
Anti-HCV
HCV RNA
Chronic Hepatitis C: serology
Anti-HCV
HCV RNA
hepatitis: management
Supportive care
Increase fluids to 3000-4000 ml/day
No/low protein diet (byproduct of protein metabolism is ammonia)
Oxazepam if sedation is necessary
Vitamin K for prolonged PT (>15 sec)
Lactulose
Antiviral drugs
diverticulitis: incidence
more common in women
higher incidence in those with low dietary fiber
diverticulitis: S/Sx
mild to moderate LLQ aching abdominal pain
constipation or loose stools may be present
N/V
low grade fever
diverticulitis: labs/Dx
leukocytosis
ESR: elevated
stool heme + in 25% of cases
sigmoidoscopy: inflamed mucosa
may consider CT to evaluate abscess
x-ray to look for evidence of free air (pneumoperitoneum)
- air under the diaphragm requires ex-lap and evacuation
mild diverticulitis: management
aspirin
high fiver diet
possible ABx therapy
diverticulitis: inpatient management
NPO for bowel rest
IV fluids
Manage GIB
Surgery if indicated
cholecystitis: S/Sx
often precipitated by a large or fatty meal
sudden appearance of steady, severe colicky pain in epigastrium or right hypochondriac (RUQ)
vomiting with relief
Can radiate to the back
Murphy’s sign
RUQ tender to palpation; gallbladder may be palpable
muscle guarding and rebound pain
fever
murphy’s sign
deep pain on inspiration while fingers are placed under the right rib cage
cholecystitis: labs/Dx/imaging
leukocytosis
bilirubin: elevated
ALT, AST, LDH, AP: elevated
amylase may be elevated
Ultrasound: gold standard
XRays may show gallstones
HIDA scan
ERCP
-complications: pancreatitis, perforation, hemorrhage, acute cholangitis
cholecystitis: management
pain management
NGT for gastric decompression
NPO
crystalloids
surgical consult for lap cholecystectomy
acute pancreatitis: causes/incidence
GETSMASHED
G: Gallstones
E: Ethanol, alcohol
T: Trauma
S: Steroids
M: Mass (pancreatic cancer), Mumps
A: Autoimmune pancreatitis
S: Scorpion sting
H: HLD, hypercalcemia
E: ERCP complications
D: Drugs (Depakote, Metformin, Trulicity, sulfonamides, thiazides, lasix, estrogen, azathioprine)
Most common causes: gallstones, ethanol
acute pancreatitis: S/Sx
Abrupt onset of steady, severe epigastric pain worsened by walking and lying supine, improved by sitting and leaning forward
Pain usually radiates to the back but may radiate elsewhere
N/V
Weakness, sweating, anxiety
Fever
Tachycardia
Exam:
-Pallor, cool skin
-Mild jaundice common
-Upper abdomen tender to palpation usually without guarding, rigidity, or rebound
-Abdominal distention
-Absent bowel sounds if paralytic ileus present
If hemorrhagic: Grey Turner’s sign, Cullen’s sign
Grey Turner’s sign
Flank discoloration
sign of hemorrhagic pancreatitis
Cullen’s sign
Umbilical discoloration
sign of hemorrhagic pancreatitis
acute pancreatitis: labs/Dx
leukocytosis
hyperglycemia
LDH, AST elevated
amylase, lipase elevated
BUN elevated
coagulation values elevated
hypocalcemia
-watch for Chvostek’s sign and/or Trousseau’s sign
-can lead to Torsades
CRP elevated suggests pancreatic necrosis
Contrast enhanced CT is the most reliable imaging - can identify the type of pancreatitis and any concurrent complications
Ultrasound & MRI also options but not as reliable
Ranson’s criteria
5-6 factors = 40% mortality
>7 factors = 100% mortality
Geroge Washington Got Lazy After He Broke C-A-B-E
Prognostic signs at admission
-Greater than 55 years of age
-WBCs >16,000
-Glucose >200
-LDH >350
-AST >250
Prognostic signs during the first 48 hours
-Hct drop of >10
-BUN increases >5
-Calcium <8
-Arterial O2 <60
-Base deficit >4
-Estimated fluid sequestration >6000 ml
acute pancreatitis: management
bed rest
NPO
aggressive IV fluids
NG suction
pain control
start clear diet once pain free and +bowel sounds
bowel obstruction: causes
adhesions
hernia
volvulus
tumors
fecal impaction
ileus
bowel obstruction: S/Sx
Cramping periumbilical pain initially; later becomes constant and diffuse
Minimal or no fever
Mild tenderness but no peritoneal findings
High pitched, tinkling bowel sounds
Late sign: Unable to pass stool/gas
Vomiting
-proximal: within minutes of pain
-distal: within 2 hours of pain
Abdominal distention:
-proximal: minimal
-distal: pronounced
bowel obstruction: labs/Dx
late: leukocytosis, dehydration
KUB: dilated loops of bowel and air fluid levels
-SBO: horizontal staircase pattern
-LBO: frame pattern
large bowel obstruction: imaging
dilated loop of bowel with air-fluid level sand a frame pattern
SBO: imaging
X-ray, 2 views: ladder/staircase-like pattern of dilated small-bowel loops with air-fluid levels
No colonic distention
bowel obstruction: management
IV fluids
NG suction
surgical intervention in all cases of complete obstruction
partial obstruction: treat medically
ulcerative colitis
idiopathic inflammatory condition characterized by diffuse mucosal inflammation of the colon
Involves the rectum and may extend upward involving the whole colon
ulcerative colitis: S/Sx
bloody diarrhea
ulcerative colitis: imaging
mural thickening
thumb printing
ulcerative colitis: Dx
sigmoidoscopy
ulcerative colitis: management
mesalamine suppositories or enemas for 3-12 weeks
hydrocortisone suppositories and enemas
mesenteric infarct
a syndrome as a result of inadequate blood flow through the mesenteric circulation, leading to ischemia and gangrene of the bowel
mesenteric infarct: causes
Arterial or venous embolus or thrombus
atherosclerosis
smoking
coagulopathy increases risk
mesenteric infarct: S/Sx
Sudden onset of cramping, colicky abdominal pain (perhaps after eating)
Pain out of proportion to physical exam findings
N/V
Fever
Guarding and tenderness
Hyperactive to absent bowel sounds
Peritoneal findings as state progresses
Shock
mesenteric infarct: labs/imaging
elevated amylase
leukocytosis
STAT CT angio of the abdomen
surgical consult
mesenteric infarct: management
immediate surgical intervention
appendicitis: S/Sx
Begins with vague, colicky umbilical pain that shifts to RLQ
Nausea with 1-2 episodes of vomiting
Pain worsened and localized with coughing
RLQ rebound tenderness
McBurney’s point tenderness
Psoas sign (iliopsoas test)
Obturator sign
+Rovsing’s sign
Local abdominal tenderness
Low grade fever
McBurney’s point tenderness
2/3 of the distance from the right anterior superior iliac spine to the umbilicus
RLQ
Common landmark suggestive of acute appendicitis
psoas sign (iliopsoas test)
pain with right thigh extension
obturator sign
pain with internal rotation of flexed right thigh
Rovsing’s sign
RLQ pain when pressure is applied to the LLQ
appendicitis: labs/Dx
leukocytosis
CT or ultrasound is diagnostic
IBD
Benign GI disorder
Diagnosis of exclusion- no pathological problems with GI system
IBD: S/Sx
No weight loss
No systemic symptoms
No blood in the stool
Alternating constipation and diarrhea with relief of abdominal pain when having a bowel movement
IBD: managmeent
management of diet
peppermint oil
antispasmodic therapy
Crohn’s disease
Inflammatory bowel disorder in which skip lesions can occur anywhere in the GI system with a patchy distribution
Crohn’s disease: S/Sx
abdominal pain
bloody stools
constipation/diarrhea
bloating
possible fever/chills
Crohn’s disease: associated findings
anemia
uveitis
arthritis
erythema nodosum
skin rashes
Crohn’s disease: management
dietary management
aspirin
steroids
infliximab
Conditions associated with AST >10x normal limit
acute viral hepatitis
toxins
acute fulminant hepatitis
tumor necrosis
gastroparesis is a complication of…
uncontrolled hyperglycemia
gastroparesis: S/Sx
abdominal pain
early satiety
postprandial fullness
nausea
hypoglycemia after meals if taking rapid-acting insulin
upper GI bleed: labs
hypernatremia d/t fluid loss through emesis
elevated BUN
elevated BUN:Cr ratio d/t digestion of blood or prerenal azotemia
mild leukocytosis
metabolic acidosis
elevated PTT
upper GI bleed: management
NPO
NG tube
serial H/H
PPI (H2 blockers ineffective)
preferred method of nutrition for patients who cannot eat
GI tract (enteral feeds) - least invasive, preserves integrity of GI tract
-parenteral nutrition is only used if enteral nutrition is contraindicated
Formula for estimating daily caloric needs
calories (kcal/day) = 25-30 x wt (kg)
giardia lamblia: presentation
Incubation period of 7-21 days
Diarrhea
Abdominal pain/cramping
Nausea
Greasy stools
guardia lamblia: who is at risk?
People who drink contaminated water
Travelers to countries where giardiasis is common
Backpackers or campers who drink untreated water from lakes or rivers
3 diagnostic criteria for acute pancreatitis
Symptoms consistent with pancreatitis (e.g. epigastric pain)
Elevation of serum amylase or lipase to 3x normal level
Radiological features consistent with pancreatitis (e.g. CT or MRI)
Diagnosis is made when 2 out of 3 criteria are met
GI perforation: imaging
free air under the diaphragm
GI perforation: presentation
abdominal pain
large amount of free air on abdominal films
GI perforation: management
OR for immediate surgical exploration
IV fluids
NPO
Broad spectrum ABx
GI perforation: most common cause
peptic ulcer disease
hepatorenal syndrome: management
albumin, midodrine, and octreotide to increase circulating volume and improve renal perfusion
Spontaneous bacterial peritonitis (SBP)
Complication of liver failure d/t translocation of enteric pathogens across the bowel mucosa and into the peritoneal fluid
Spontaneous bacterial peritonitis (SBP): diagnosis
diagnostic paracentesis
- ascitic fluid culture
Spontaneous bacterial peritonitis (SBP): management
Empiric broad-spectrum ABX for proven or suspected SBP (cefoxatime)
-narrowed when susceptibility results are available
