GI Flashcards
bowel obstruction definition
Blockage of the lumen of small bowel; can perforate if necrosis present
bowel obstruction causes and risk factors
-Adhesions from prior surgery
-Strictures from Crohns, XRT or ischemia
-Hernia
-Hematoma
-Volvus/intussusception
-LBO
-Tumor, foreign body
bowel obstruction presentation and workup
Leukocytosis, dehydration
KUB: ladder-like pattern w/ air fluid levels on upright. Thickening of abd wall (thumbprinting)
CT w/ oral contrast w/ follow through
bowel obstruction treatment
Surgical consult
NGT to LIWS
IV fluids
Pain control
ABX IF: strangulation/necrosis suspected
cholecystitis definition
Inflammation of gallbladder
Cholelithiasis= stones in gallbladder
Choledocholithiasis = stones in CBD
cholecystitis causes and risk factors
-Cholelithiasis, Acalculous cholecystitis
-Bacteria
-Neoplasm
-Ischemia, torsion, strictures
-Obesity, pregnancy
4 Fs = female, fat, 40, fertile
-Female, advanced age, rapid wt loss, fad diets, high cholesterol
cholecystitis presentation
NV, bloating, gas, belching, previous episodes, RUQ pain, radiating pain to shoulder and scapula, Fever, jaundice
(+) Murphy’s sign
Mild leukocytosis, mild bili elevation, LFTs elevated (ALK PHOS)
Amylase > 500 consider pancreatitis also
cholecystitis diagnostic imaging
RUQ US = visualize stones
EKG = r/o cards issues
HIDA/PIPIDA scan = how well gallbladder is squeezing
ERCP: invasive but can place stent/remove stones and look at bili and pancr ducts
MRCP = non-invasive but non interventional
cholecystitis surgical and medical treatment
-NPO/NGT if severe NV
IV fluids
-Pain control including antispasmodics (Robinul)
-antiemetics
-ABX if infection suspected
-Sx or GI consult
Medical Tx if Sx not an option
-ursodiol for 12-24 months
-chenodeoxycholic acid
-dissolve stones w/ an ether placed directly into the gallbladder via percutaneous route
Crohns definition
Chronic inflammatory disease of bowel and digestive system that can effect any level of digestive systems
-transmural process (all layers) r/I ABD pain, perforations, abscess and strictures
Crohns presentation and workup
Labs: anemia d/t micro blood loss, B12 deficiency, inflammatory markers high, poor nutritional markers
(-) stool studies
Biopsy
Crohns management
-STOP SMOKING
-Nutritional support: maybe TPN
-Surgical consult
-ABX: flagyl, cipro, rifaximin
Steroids: IV initial then PO
-Entocort (for 1 yr)
-Pred is better but want to avoid systemic
Immunomodulating drugs: azathioprine, mercaptopurine, MTX
-Anti TNF
UC definition
Unknown etiology but characterized by intermittent bouts of inflammation of the mucosa in part of or the entire colon
UC presentation
S/s: bloody diarrhea, fever, ABD pain, wt loss, cramping
Extra colon s/s: arthralgias, ocular complications, skin disorders, liver disorders
UC workup
Labs: leukocytosis, anemia, lytes d/t diarrhea, elevated LFTs, stool Cx (-)
KUB: r/o or confirm megacolon; can help w/ disease severity by looking for feces in colon
Sigmoidoscopy/ colonoscopy w/ Bx for Dx
Can do barium enema but not as good and can’t be done during a flair
UC treatment
5-ASA: sulfasalazine, mesalamine, balsalazide
-sulfasalazine: wean on for acute flair up to 4-6 gm/day and then wean down to 2 gm/day for maintenance dosing
-supplement w/ folate
Step up to hydrocortisone
-foam enemas first
-step up to oral steroids Pred 20-30 BID taper slowly over 4-8 weeks
UC: when to hospitalize and hospital management
-NPO
-NGT if obstruction or toxic megacolon
-IV fluids
-Lytes
-TPN if wasting
-Stool sample for infection, leukocytes, occult blood
-KUB for toxic megacolon, free air and stool in colon
-SM 48-60 md/day
-ACTH 120 unit/day if not responding to SM
-cyclosporine is no response
-Surgery for removal and to cure disease
Celiacs defintion
Malabsorptive disease 2nd to intolerance of gluten that affects the small intestinal mucosa
1:100 people
Celiacs presentation and workup
s/s: stunted growth and s/s of malnutrition
IgA endomysial antibody
IgA tTG antibody tests
>90% sens and 95% specific screening
EGD w/ Bx for official Dx
Celiacs management
Remove all wheat, rye and barley products from diet
Can be refractory = very poor prognosis
PUD definition
Chronic disorder w/ lifelong tendency
Loss of enteric surface epithelium that extends deeply enough to penetrate muscularis mucosa (common duodenum and stomach)
Natural defense: mucosal barrier, good blood supply, competent sphincters
PUD risk factors
Gastric acid, pepsin, bile acids, decreased blood flow, incompetent sphincters, NSAIDS, ASA, steroids, smoking, tumors, stress, alcohol, low bicarb, H. pylori
PUD labs and results
-CBC: anemia, macrocytosis, leukocytosis if perf
-CMP: looking for liver disease, hypercalcemia, elevated BUN, dehydration
-Lipase and amylase
-Serum gastrin levels
PUD diagnostic tests
-H pylori testing: biopsy from EGD, serum test can show acute or past infection, breath test is better but cannot have ABX/antacids/pepto for 4 weeks AND no PPI for 2 weeks before test. Can do fecal test to check for cure
-CXR check for: asp PNA, effusions, eso or vicus perforation, ileus
-CT abd check for: fistula, inflammatory changes, cholecystitis, free air, liver disease
-EGD is best since it’s most accurate and can do interventions to fix condition
-UGI barium: if positive will likely still need EGD
PUD medical management
Medical Management
-IV PPI and wean to oral PPI
-can do antacids and antimetics
-H2
-carafate if not using H2 blockers
-eradicate h. pylori
H pylori regimens
-3 ABX: Clarithromycin, Amoxicillin, Metronidazole
-PPI: omeprazole
-Regimens: MOC, MOA, COA
Regimen w/ Bismuth
-QID dosing
-Bismuth, metronidazole, omeprazole, tetracycline
-Regimen: BMT or TOMB
PUD follow up care
Follow up Care
-duodenal ulcer no f/u if asymptomatic after 8 weeks of therapy
-gastric ulcer: repeat EGD in 4-6 weeks.
-Partially healed and no evidence of cancer = 6 more weeks therapy then rescope
-Partially healed and CA = surgery
-Partially healed < 50% = surgery consult
PUD complications (3) and the management
Complications
UGI bleed
-stabilize fluids, RBC, PLT, fibrinogen, PPI gtt 80 mg bolus then 8mg/hr for 48-72 hrs, NGT to empty stomach and protect airway
-sandostatin can be used until EGD is done and varicies are r/o
-vasopressin for vasoconstriction. Do not use in coronary or PAD
Perforation
-pain, rigid abd, shock, leukocytosis, amylase elevated maybe, KUB w/ free air
-UGI w/ water soluble contrast only
-Sx and GI consult
-Abx:
Gastric outlet obstruction
-d/t edema or narrowing of pylorus or duodenal bulb
-NV, anorexia, early satiety, wt loss
-UGI barium, gastric emptying study
-NGT to allow edema to improve (this may be all you need to do)
-possible EGD for Dx and dilation
-TPN if NPO for a while, or can do DH tube
Peritonitis definition and types
Acute inflammation of visceral and parietal peritoneum
Primary = SBP. Complication of cirrhosis, ascites, PD. Causes: e.coli, kleb, pneumococcus, entero
Secondary = trauma (abd sx, ruptured appy, PUD, panc rupture ) or perforation
Ascites = cirrhosis, portal HTN, renal failure, low albumin, PD, panc cyst rupture, CHF
peritonitis risk factors
Cirrhosis, trauma involving abd cavity
PD
Bowel perforation
TB
Familial Mediterranean fever
peritonitis s/s and labs
s/s: gen abd pain, rigid abd, distention, low bowel sounds, hyperresonance, NV, fever
Labs: leukocytosis
-Check: CBC, CMP, CRP
-May do: UA, BNP
peritonitis imaging and diagnostics. SBP vs 2ndBP
Imaging
-KUB: free air, dilation
-CXR: elevated diaphragm
-CT/US: ascites, intra abd mass
Peritoneal fluid = order protein, cell count, stain, C&S, lactic acid, glucose, LDH
SBP lab results
-polys cell count > 500
-Grm stain = bacteria
-C&S GN usually
-Lactic acid > 32
-glucose > 50 (opp in 2ndary peritonitis)
-LDH < 225 (opposite)
-protein > 1 (opposite)
Sec. SBP results
-leukocytosis > 10k
-LDH > 225
-Protein < 1
-Glucose < 1
peritonitis management
Infectious workup and management
-IV fluids, ABX, pan culture
-ABX: cefotaxime, ceftriaxone, ampicillin or Unasyn. Possible aminoglycosides + metronidazole for anaerobic coverage. Ceftazidime for pseudomonas
Surgical consult
hepatitis defintion and types
Inflammation of the liver caused by viral, bacterial, fungal, parasitic infections or alcohol, drugs, autoimmune disease or metabolic diseases
Viral ABCDEG
hepatitis presentation and workup
s/s: fatigue, fever, low appetite, NV, clay stools, dark urine, joint pain, jaundice
-surface antigen: current infection and able to infect.
-surface antibody: immune to hep infection and cannot pass on to other
-total antibody to core antigen: has or has had Hep infection now or sometime in the past. Includes IgM and IgG
-IgM: current or recent acute infection. “miserable”
-IgG: has had hep but “gone”
hepatitis general management
Bed rest until jaundice is gone
No heavy lifting or strenuous activity
High calorie, high carb, low protein, low fat
NO ALCOHOL
Antiemetics
Review and dose meds
HOSPITALIZE IF: encephalopathy or dehydration
Diverticulitis definition
Inflammation or localized perforation of diverticulum w/ abscess formation
Can rupture and cause peritonitis. Can bleed w/o rupture
diverticulitis risk factors
Weakness in bowel wall, constipation, low fiber diet, change in diet
diverticulitis presentation and workup
s/s: LLQ pain, fever, constipation, NV, cramping, hypoactive BS, rectal bleeding
Labs
-CBC: leukocytosis, anemia
-CMP: lyte issues d/t NV
-sepsis/inflamm: ESR, CRP, procal, lactate
-UA to r/o pyelo or UTI
-Beta hCg for all females
Dx
-CT: free air = rupture
-flexsig: usually outpt
-colonoscopy/BE: usually outpt also
-angiography to locate bleeding vessel
diverticulitis management
Can be managed outpatient
Mild: home w/ bowel rest; low residue or CL diet 24-48 hours, no laxatives/enemas
Hospital management
-NPO
-ABX (sometimes): Zosyn, ertapenem, impipenem, merrem, ticarcillin clavulanate
-pain control: No ASA or NSAIDS
-Sx consult if no improvement w/in 72 hours or decompensation, free air, abscess on CT, peritonitis
-Possible reversible colostomy
appendicitis definition
Acute inflammation 2nd to occlusion of the lumen from fecaliths, inflammation, foreign bodes, worms, strictures, tumors
appendicitis presentation and workup
s/s: RLQ pain, + Psoas sign, + obtutator sign, + Rovsings sign, + McBurneys point, periumbilical pain, fever, constipation, diarrhea, NV
Labs
-UA: looking hematuria, pyuria, albuminuria
-leukocytosis
Dx
-US: can Dx but painful
-CT: BEST
appendicitis management
Sx is still mainstay
IV fluids/ABX (GN, anaerobic)
-Cefoxitin if not ruptured
-rupture/gangrenous: Unasyn, gentamycin, clindamycin, flagyl, imipenem/cilastatin
-Pain control
Rupture: leave wound open, pack it and let close by secondary intention
pancreatitis definition
Acute, inflammatory autodigestive process of the pancreas
pancreatitis risk factors
Alcoholism, biliary tract disease, hyperlipidemia, cancer, hypercalcemia, ABD trauma/surgery, ERCP, viral infections, ischemia, PUD, pregnancy
Congenital: pancrease divisum
Drugs: Monjaro, Victoza
pancreatitis presentation and staging
2 of the following: amylase/lipase 3 x normal, radiographic evidence, characteristic abd pain
Staging
-Mild (80%): interstitial edema pancreas w/o organ failure
-Moderately severe = w/ transient organ failure (failure last < 48 hrs & pancreatitis resolves w/in 1 week)
-Severe = organ failure > 48 hrs
s/s: NV, fever, sweating, anxiety, low bowel sounds, jaundice, steatorrhea, ascites, pl. eff, tachypnea, sharp shooting to back pain in epigastric area
pancreatitis labs and imaging
Labs
-CBC: WBC > 10, Hct elevated d/t dehydration
-CMP: hypocalcemia, high or low K, low albumin
-Lipase/amylase: lipase more specific. P-amylase is more specific than amylase
-Lactate, LDH, CRP, procal
-Trigs
-High glucose d/t islet cell damage
-AST/LDH elevated if tissue necrosis
-Bili and Alk phos = CBD obstruction
Imaging
-KUB: gallstones, calcif of pancreas, ileus, free air
-US: gallstones, panc pseudocyst
-CT w/ contrast: better than US but c/f renal damage in severe ill pts
-MRCP
pancreatitis management
Treat the cause
May need lap/choley to prevent recurrence
Pain control
Fluids: NS or LR (better)
NGT if uncontrolled NV.
Resume diet slowly; enteral feeds preferred over parenteral
Glucose management: get A1c on admit
Trend labs for improvement
ERCP is not routinely recommended
ABX if severe: GN and anaerobic coverage (zosyn, merrem)
CT guided aspiration for fluid to get C&S if not getting any better
Prognostic indicators
-Atlanta revised criteria is preferred
Mesenteric ischemia definition
Failure of blood supply to mesentery to carry enough oxygen to meet intestinal needs
1/3: arterial embolism (moving)
1/3: arterial thrombus (stationary)
1/3: low flow states (shock, pressors etc)
mesenteric ischemia risk factors
PAD
surgical accidents
ABD trauma
Tumor
TTP, DIC
SLE
polyarteritis nodosa
mesenteric presentation and workup
s/s: cramping, abd pain, possible rectal bleed
-HOTN and abd distention signals infarct
Labs
-leukocytosis
-lactic acidosis
Imaging
-US w/ doppler
-mesenteric arteriography
-BE: thumbprinting or xray
-MRA w contrast
-CT w contrast
mesenteric ischemia management
Vascular or general Sx consult: stent, bypass. May need colon resection
Increase blood flow, increase oxygenation
Declot: surgery or drugs
GIB risk factors for UGI and LGI bleed
UGI: esophagus, stomach or duodenum
-varices, Mallory Weiss tear or PUD
LGI: diverticulitis, hemorrhoids, cancer, ischemic colitis, inflammatory colitis, post XRT injuries
GIB presentation and workup
Labs
-CBC w/ serial H&H
-PT/INR
-CMP
-EKG
INR/PT/PTT: if INR 1.5-2 can consider endoscopy. INR > 2.5 and on anticoag then reversal agents
GIB general management
General Treatment
-IV fluids
-Consider O2
-GI consult
-Hgb > 9 if massive bleeding, significant comorbities, delay in treatment. Otherwise Hgb > 7
-PLT and plasma transfusion consider in pts getting massive RBC
-4 factor prothrombin complex concentrate > FFP
Consider reversal agent and hold anticoagulants initially
-Vit K and FFP for coumadin
-idarucizumab = dabigatran
-andexanet alfa = apixaban/rivaroxaban
ASA for high-risk CV pts should be restarted ASAP or w/in 7 days.
PTs w/ ACS in last 90 days, or stent in last 30 days should not DC anticoag
No NSAIDS
Basics of Hepatitis A
A = acute
fecal/oral transmission from food/water, restaurants, shellfish.
VERY CONTAGIOUS.
IG shot for temporary immunity for 2-3 mo
Vaccine (Havrix, VAQTA) for high risk travel and after exposure. Combo w/ hep B. 2 shots.
Hep B basics
B = BAD
-percutaneous/mucosal contact w/ virus through blood, semen or vaginal secretions.
-90 day incubation
-Vaccine: recombivax, engerix for 3 does.
-No cure just remission. Can cause cirrhosis and liver Ca
-Worse if combo infxn w HDV
-Tx: interferon, lamivudine, adefovir, tenofovir, entecavir, telbivudine
Hep C basics
C = cure
-blood or tissue contact
Worse if also have HBV or HIV
-20-30 yrs for serious damange
-70% cure w/ protease inhibitors, interferon, ribavirin
Hep D basics
need Hep B to replicate
Can be prevented w/ vaccine
Hep E basics
fecal/oral route
not common in US, check if recent travel
