GI Flashcards
Gastric angiodysplasia
gastrointestinal angiodysplasia with advanced chronic kidney disease, von Willebrand disease, and aortic stenosis have been reported.
Patients with persistent symptoms of peptic ulcer disease, evidence of Helicobacter pylori-associated ulcers, or H pylori-associated malignancy should undergo an evaluation to determine bacterial eradication.
The preferred options include urea breath testing and fecal antigen testing.
Patients with Helicobacter pylori-associated peptic ulcer disease should receive treatment based on local antibiotic susceptibility.
Acceptable first-line regimens include triple drug therapy with a proton pump inhibitor, clarithromycin, and amoxicillin, or quadruple therapy with a proton pump inhibitor, bismuth, and 2 antibiotics (or a PPI and 3 antibiotics).
Porcelain gallbladder is often found incidentally on imaging and is associated with an increased risk of gallbladder cancer. x
Patients with punctate calcifications or symptoms of biliary colic are usually referred for prophylactic cholecystectomy to reduce cancer risk.
Choledocholithiasis (common bile duct stones) causes prolonged biliary colic symptoms and cholestatic liver function test abnormalities.
Endoscopic retrograde cholangiopancreatography is indicated for patients with visualized choledocholithiasis, high-risk features (eg, dilated common bile duct, elevated serum bilirubin), or evidence of acute cholangitis.
Management of gallstones is guided by the patient’s symptoms, imaging findings, and presence of complications.
Patients with typical biliary colic symptoms and confirmed gallstones should undergo elective cholecystectomy to prevent recurrent symptoms and complications.
Biliary colic presents with episodes of intense, dull, epigastric or right upper quadrant pain that can radiate to the back and right shoulder with associated nausea, vomiting, and diaphoresis.
Abdominal examination is usually benign. Ultrasonography is preferred for initial diagnostic imaging.
Hepatic encephalopathy (HE) is usually triggered by elevated ammonia levels due to an underlying precipitating event. A common trigger of HE is excessive diuresis, which reduces intravascular volume and results in hypokalemia and metabolic alkalosis.
Treatment includes volume and electrolyte repletion and using medications (eg, lactulose) to reduce ammonia levels.
Delayed gastric emptying may be due to mechanical obstruction (intrinsic or extrinsic) or impaired motility.
Obstruction should first be excluded by esophagogastroduodenoscopy, especially in those at risk for peptic ulcer disease (eg, NSAID use); sometimes CT/MR enterography is also needed if small bowel pathology is of concern. Once excluded, a scintigraphic gastric emptying study can confirm the diagnosis of gastroparesis.
In adition to improving control of hyperglycemia, dietary modification is generally the first step in management of diabetic gastroparesis.
Smaller, more frequent meals may help to improve symptoms. A diet low in fat and with only soluble fiber is important. Promotility medications such as metoclopramide can be helpful in those who fail to improve with dietary modification.
Confirmation of H. pylori eradication is recommended for patients with ulcers or ongoing dyspepsia.
Either urea breath or fecal antigen testing can be used after 4 weeks to confirm H. pylori eradication. H. pylori serology should not be used since it may remain positive a year or more after eradication.
Chronic cough is a common presenting symptom of gastroesophageal reflux disease (GERD), and in some cases may be the only presenting symptom.
The initial management of suspected cough-predominate GERD involves lifestyle modification and 8 weeks of proton-pump inhibitor therapy.
Endoscopic ultrasound with aspiration is the best test to evaluate a pancreatic cyst
to differentiate malignancy from nonmalignant causes.
Dyspepsia is characterized by epigastric pain/burning and postprandial fullness for ≥1 months. Management of dyspepsia is largely determined by malignancy risk.
Patients at low risk (eg, age <60 without alarm symptoms) should first undergo noninvasive H pylori testing.
In patients with nonalcoholic fatty liver disease, hepatic fibrosis is associated with increased risk of progression to cirrhosis.
It is the primary prognostic factor for liver-related death.
Hepatic adenoma is most commonly seen in young women on oral contraceptive therapy. Most cases are asymptomatic and are found incidentally on imaging for another condition.
CT scan of the abdomen with contrast typically reveals a well-demarcated liver lesion with peripheral enhancement (early phase). Asymptomatic lesions <5 cm are usually managed with discontinuation of oral contraception. Symptomatic patients and patients with larger lesions should undergo surgical resection.
Nonselective beta blockers (eg, nadolol, propranolol) can be used in the primary and secondary prevention of esophageal variceal hemorrhage,
particularly in combination with endoscopic surveillance and band ligation.
The typical symptoms of diabetic gastroparesis include early satiety and postprandial fullness. It is often accompanied by other autonomic symptoms and labile glucose control.
Mechanical obstruction should be excluded. A nuclear gastric emptying study is the procedure of choice to confirm the diagnosis.
(Choice B) Fresh frozen plasma (FFP) can be used to correct coagulopathies due to vitamin K deficiency and is typically administered when the INR is >2; this patient’s INR is 1.5.
FFP administration is associated with a risk of volume overload in patients with cirrhosis. In addition, variceal bleeding is due primarily to increased portal venous pressure and vascular changes rather than to coagulopathy, making FFP less beneficial.
Patients with an isolated elevation of anti-HBc should have hepatitis B serologies repeated to rule out a false positive result, followed by measurement of IgM anti-HBc and liver function tests to determine the acuity of infection.
IgM anti-HBc may be the only diagnostic marker for acute HBV infection during the “window period.”
Gastroesophageal reflux disease, characterized by substernal burning and regurgitation, is treated with proton pump inhibitor therapy in cases where symptoms are frequent (eg, >2 times per week).
Evaluation with upper gastrointestinal endoscopy is not needed in the absence of alarm symptoms. Helicobacter pylori testing is also unnecessary.
Celiac disease is a chronic malabsorptive disorder caused by immune-mediated hypersensitivity to gluten.
The most common cause of continued or recurrent symptoms is gluten intake from inadvertent ingestion or poor compliance. A detailed dietary review can help identify the source of gluten.
A serum-ascites albumin gradient value of >1.1 g/dL indicates the presence of portal hypertension, while a value of <1.1 g/dL
indicates the absence of portal hypertension.
Patients with adenomatous polyps found on screening sigmoidoscopy should undergo colonoscopy for visualization of the entire colon and
detection of synchronous adenomas and advanced neoplasia.
Although hematochezia is most commonly associated with lower gastrointestinal (GI) bleeding, large-volume, upper GI bleeding can also present with hematochezia.
Patients with hematochezia and hemodynamic instability (eg, orthostatic hypotension) should generally be assumed to have an upper GI source of bleeding. Following initial volume resuscitation, they should undergo initial evaluation with esophagogastroduodenoscopy.
Alcohol and tobacco cessation, along with dietary modifications, is the first-line treatment of chronic pancreatitis. Pancreatic enzyme replacement and analgesics should be considered if conservative measures are unsuccessful.
A variety of minimally invasive and surgical interventions is available for patients with refractory disease.
Toxic megacolon should be suspected in patients who have a history of severe colitis, particularly secondary to inflammatory bowel disease, who develop toxic signs and have a distended, tympanitic abdomen.
Abdominal plain films are helpful for making the diagnosis. CT scan is best utilized for early detection of complications.
Abdominal pain accompanied by fat malabsorption should raise suspicion of chronic pancreatitis, particularly in patients with a history of heavy alcohol intake.
The diagnosis can be confirmed with magnetic resonance cholangiopancreatography or an abdominal CT scan, which can identify pathognomonic findings (eg, pancreatic calcifications).
The first-line treatment for toxic megacolon is medical management to lessen the degree of colitis, with glucocorticoids used for patients with underlying inflammatory bowel disease and appropriate antibiotics used for patients with infectious colitis.
5-ASA compounds and opioids should be avoided in patients with toxic megacolon.
he evaluation and management of chronic diarrhea involves a comprehensive history (eg, clear description of stool characteristics, duration and timing of symptoms),
basic serum analysis, and, importantly, stool analysis.
Celiac disease (gluten-sensitive enteropathy) is characterized by large-volume, foul-smelling stools; excessive flatulence; weight loss; and microcytic anemia. Evaluation involves both serologic studies and small-bowel biopsy.
Common histologic findings include villous atrophy, loss of the normal villus architecture, intraepithelial lymphocytic infiltrates, and crypt hyperplasia.
In patients with cirrhosis in whom there is concern for variceal hemorrhage, intravenous octreotide should be initiated after stabilization and while awaiting endoscopic therapy.
Octreotide is thought to decrease the elevated portal venous pressure that causes variceal formation and may stop the hemorrhage.
Patients at average risk for colon cancer should start colon cancer screening at age 45.
For those with a first-degree relative with colon cancer or advanced adenoma, screening colonoscopy is recommended beginning at age 40 or 10 years before the relative’s age at diagnosis, whichever comes first.
