GI Flashcards

Question

Gastroenteritis bacterial causes

Answer 1

BACTERIAL (10-20%): 1) Campylobacter jejuni – poultry, unpasteurized milk, untreated water, new pets, dairy farms -- S/SXS: bloody diarrhea w/ severe abdominal pain, fever, occasional bacteremia *Immune-Mediated Manifestations: Guillain-Barre, Miller-Fisher, reactive arthritis 2) C. diff – spectrum: mild diarrhea – pseudomembranous colitis – toxic megacolon -- S/SXS: fever, crampy abdominal pain, foul-smelling, watery stools *Pseudo Colitis: diarrhea w/ blood/mucus, abdominal pain, fever, systemic toxicity 3) E. coli, Shiga-toxin-producing (STEC) – beef, greens, unpasteurized milk, petting zoos, person-person -- S/SXS: hemorrhagic colitis w/ bloody diarrhea appearing 3-4d after sxs onset; *may cause HUS 3) E. coli, Enterotoxigenic – “Traveler’s diarrhea” (resource-limited settings) -- S/SXS: watery diarrhea, abdominal cramping 4) Nontyphoid Salmonella – poultry/beef, dairy, contaminated water, reptiles/amphibians, MC <4yo -- S/SXS: diarrhea, abdominal cramps, fever *Complications – bacteremia, osteomyelitis, brain abscess, meningitis 4) Salmonella typhi – humans are only hosts; resource-limited settings -- S/SXS: initially – fever, malaise, myalgias, abdominal pain, constipation or bloody diarrhea; then – HSM & rose spots by wk2 *Associated w/ bacteremia & meningitis 5) Shigella – infection requires low inoculum; childcare outbreaks -- S/SXS: varies; watery stools w/o other sxs – bloody stools + high fever, abdominal pain, tenesmus *S. dysenteriae – HUS; seizures, reactive arthritis 7) Vibrio cholerae – shellfish; “rice water diarrhea” -- S/SXS: painless, watery diarrhea w/ significant electrolyte imbalances 8) Yersinia enterocolitica – SWINE; pork, milk, well water, chitterlings, tofu; uncommon in US -- S/SXS: fever, abdominal pain, bloody diarrhea in young children *Pseudo-Appendicitis: mesenteric lymphadenitis w/ fever, abdominal pain/tenderness, leukocytosis – older children

Answer 2

PARASITES (up to 5%): 1) Giardia lamblia – daycare, camping trips, contaminated water; “backpacker’s diarrhea” -- S/SXS: acute – watery diarrhea, foul-smell, flatulence, anorexia; can 🡪 FTT 2) Entamoeba histolytica – resource-limited -- S/SXS: intestinal amebiasis MC – gradual onset bloody diarrhea, lower abd. pain, tenesmus, wt loss; complications: toxic megacolon, fulm. colitis

Answer 3

DX: two-step: enzyme immunoassay for glutamine dehydrogenase w/ confirmatory toxin testing by NAAT or toxin immunoassay *CBC: leukocytosis; anemia possible if bloody TX: metronidazole 30mg/kg/d divided 4x daily x10d; vancomycin 40mg/kg/d divided 4x daily x10d if severe; *fidaxomicin for continuous relapse

Answer 4

non: TX: initial dose of ceftriaxone followed by PO (azithromycin or amoxicillin or Bactrim) * only in pts @ high risk of invasive disease – <3mo, chronic GI dz, HIV/immunocompromised TX: empiric – ceftriaxone or azithromycin; then definitive therapy based on cultures x7-14d *steroids may be beneficial in children w/ enteric fever (delirium, coma, shock)

Answer 5

azithromycin, ceftriaxone, or FQ

Answer 6

TX: tinidazole x1, metronidazole x5-10d, nitazoxanide x3d

Answer 7

TX: metronidazole or tinidazole then iodoquinol or paromomycin

Answer 8

peptobismol: MOA: antimicrobial properties; salicylate: anti-secretory & anti-inflammatory properties Indications: safe in pts w/ dysentery = significant fever, bloody diarrhea *dark colored stools, darkening of tongue Contraindications: children w/ viral illness (↑ risk of Reye syndrome) Diphenoxylate: MOA: binds to gut wall opioid receptors, inhibiting peristalsis. *CNS (central opiate effects), anticholinergic, N/V, abd. pain, constipation Loperamide: MOA: binds gut wall opioid receptors, inhibiting peristalsis; ⇡ anal sphincter tone Indications: noninvasive diarrhea *avoid in pts w/ acute dysentery or colitis

Answer 9

Zofran MOA: blocks serotonin receptors CI: *neuro: HA, fatigue, sedation *cardiac: QT prolongation, arrhythmias *GI: bloating, diarrhea, constipation dopamin blockers MOA: blocks CNS dopamine receptors; mild antihistaminic/antimuscarinic CI: *QT prolongation, anticholinergic, drowsiness, hypotension, hyperprolactinemia *EPS: rigidity, bradykinesia, tremor, akathisia, dystonic reactions, parkinsonism

Answer 10

Etiologies: *disordered movement of stool through colon/anus/rectum (usually proximal GI tract intact) *slow colonic transport: idiopathic, motor disorders (CRC, DM, hypothyroid), adverse effects of drugs (verapamil, opioids); outlet delay: Hirschsprung’s disease Gastroparesis: condition that affects the stomach muscles & prevents proper stomach emptying *MCC: diabetes; others: anorexia, bulimia, scleroderma, Ehlers-Danlos, adnominal surgery *S/SX: nausea, full feeling after little food is eaten; palpitations, heartburn, bloating, decreased appetite, GERD S/SX: absent bowel sounds *DX: CT scan w/ gastrografin – must exclude mechanical obstruction *DX: KUB, manometry, gastric emptying scan *TX: laxatives, low fiber & low residue diets, restrict fat intake, smaller meals spaced 2-3hrs apart; metoclopramide Ileus: ileus that persists >3d following surgery is termed postoperative adynamic ileus or paralytic ileus

Answer 11

retains water & improves GI transit

Answer 12

MOA: causes water retention in stool (osmotic effect pulls water into gut) ADRs: flatulence, bloating *saline laxatives 🡪 hypomagnesemia (esp. w/ chronic renal disease)

Answer 13

MOA: increases acetylcholine-regulated GI motility (peristalsis) & alters electrolyte transport in the mucosa ADRs: diarrhea, abdominal pain

Answer 14

Autoimmune-mediated inflammation of the small bowel due to reaction w/ alpha-gliadin in gluten-containing foods PATHO: *autoimmune damage leads to loss of villi w/ subsequent malabsorption *increased incidence in females, European descent (Irish & Finnish)

Answer 15

Malabsorption: diarrhea, abdominal pain/distention, bloating, steatorrhea; growth delays in children Dermatitis herpetiformis: pruritic, papulovesicular rash MC on extensor surfaces, neck, trunk, & scalp Clinical: sxs improvement w/ trial of gluten-free diet Screening: transglutaminase IgA antibodies; endomysial IgA antibodies Definitive & confirmatory: small bowel bx (duodenum) – atrophy of the vill GLUTEN-FREE DIET *avoid wheat, rye, barley *limit oat consumption *vitamin supplementation

Answer 16

*result of chronic hepatic injury w/ inflammation that leads to hepatic fibrosis & regenerative nodules, HCC PRECURSOR** *prevalence rate 0.27%, ♂ > ♀︎ (2:1) MCC ⇢ ▪︎chronic viral hepatitis (HBV, HCV**)

Answer 17

Clinical Manifestations: ▪︎muscle cramps (can be severe), easy bruising, LE edema ▪︎anovulation (♀︎): amenorrhea, menstrual irregularities ▪︎fever, diarrhea, pruritis, muscle wasting ▪︎hypogonadism (♂): gynecomastia, ⇣ libido, testicular atrophy ▪︎⇣ MAP (contributes to hepatorenal syndrome) ▪︎Skin: jaundice, dark urine, spider angiomata (telangiectasia) ▪︎hepatosplenomegaly, ascites ⇡⇡ bilirubin: jaundice usually not detectable until >2-3mg/dL ▪︎caput medusae ⇢ dilated abdominal veins ▪︎Fetor hepaticus (sweet, pungent smelling breath): dimethyl ▪︎palmar erythema, clubbing (MC in 1° biliary cirrhosis) sulfide accumulation, suggests severe portal-systemic shunting

Answer 18

Hepatic Encephalopathy ⇢ ammonia accumulation in brain ▪︎cognitive deficits + impaired neuromuscular function ▪︎asterixis: flapping tremor Portal Vein Thrombosis (PVT) ⇢ thrombus in the portal vein ▪︎contributes to development of portal HTN

Answer 19

LABS: ▪︎hepatic studies: Modest ⇡ AST & alk phos ⇡ bilirubin, ⇣ albumin, ⇡ GGT ▪︎coagulation studies ⇡ PT, ⇡ INR ▪︎CBC: thrombocytopenia (MC), anemia, leukopenia ▪︎hyponatremia (common in cirrhosis + ascites) IMAGING: ▪︎U/S: surface nodularity, ⇡ echogenicity, small liver ▪︎Caudate/left lobes: hypertrophy ▪︎Right lobe: atrophy LIVER BX ⇢ confirmatory Hemochromatosis: ▪︎transferrin sat ≥45%, ⇡ ferritin >200-300ng/mL ▪︎BX: ⇡ hemosiderin Wilson: ⇣ ceruloplasmin, ⇡ urinary copper excretion ▪︎slit lamp (Kayser-Fleischer rings) ▪︎BX: ⇡ copper content

Answer 20

▪︎alcohol abstinence most important ▪︎treatment of underlying conditions ▪︎avoid hepatotoxic drugs: NSAIDs, opiates, BDZs (HE) ▪︎vaccinations: PPSV23, HAV/HBV, influenza ▪︎adequate nutritional intake Definitive ⇢ liver transplant ▪︎indications: index complication (e.g., ascites, HE, variceal hemorrhage) &/or MELD score ≥15 Hemochromatosis: phlebotomy, Deferoxamine (iron-chelation) Wilson: Penicillamine, avoid seafood & other high-copper foods Hepatic Encephalopathy: ▪︎lactulose + rifaximin, liver transplant PVT: anticoagulation (enoxaparin)

Answer 21

S/SXS: hematemesis &/or melena DX: EGD – prediction of variceal hemorrhage: location, size, appearance, clinical features, variceal pressure ▪︎⊕red signs associated w/ ⇡ bleeding risk TX: bleeding prophylaxis ⇢ beta blockers (e.g., propranolol or nadolol), endoscopic variceal band ligation TX: variceal hemorrhage ⇢ PRBCs to maintain Hgb ≥7g/dL, octreotide (preferred) or vasopressin ▪︎ABX prophylaxis: IV ceftriaxone x7d ▪︎endoscopic variceal band ligation** (1st line), sclerotherapy, balloon tamponade, TIPS (alternatives)

Answer 22

Ascites ⇢ accumulation of fluid within the peritoneal cavity S/SXS: abdominal distention/pain, early satiety DX: paracentesis ▪︎diuretics (spironolactone, furosemide) TX: therapeutic paracentesis, ▪︎salt restriction ≤2g/d, +/- fluid restriction

Answer 23

infection of ascitic fluid w/o an intraabdominal secondary source

Answer 24

▪︎common pathogens: E. coli, strep, Klebsiella S/SXS: fever, abdominal pain/tenderness, AMS DX: paracentesis ⇢ PMN (neutrophil) count ≥250 cells/mm3 TX: IV cefotaxime 2g q8h x5d, IV albumin

Answer 25

development of renal failure in a patient who has advanced liver disease d/t cirrhosis, severe alcoholic liver disease, acute liver failure, etc. DX: ⇡ creatinine, normal urine sediment, no/minimal proteinuria (<500mg/d), urine Na <10mEq/L TX: improve hepatic function, liver transplant

Answer 26

pulmonary HTN + portal HTN

Answer 27

S/SXS: fatigue, dyspnea, peripheral edema, CP, syncope & a dysfunctional or blunted response to stress DX: initial ⇢ TTE, confirmatory ⇢ right heart catheterization TX: liver transplant definitive

Answer 28

pleural effusion in a patient w/ cirrhosis & no evidence of underlying cardiopulmonary disease resulting from movement of ascitic fluid into the pleural space through defects in the diaphragm ▪most commonly right-sided

Answer 29

S/SXS: dyspnea, nonproductive cough, pleuritic CP DX: thoracentesis ⇢ transudative TX: diuretics, sodium restriction, therapeutic thoracentesis, TIPS, NO CHEST TUBE*

Answer 30

triad of abnormal arterial oxygenation + intrapulmonary vascular dilatations (IPVDs) + liver disease

Answer 31

S/SXS: dyspnea, platypnea (⇡ dyspnea when upright vs supine), orthodeoxia (⇣ arterial O2 saturation when going from supine to upright), SpO2 <96% DX: ABG (⇡ A-a gradient ≥15mmHg), TTE (⊕IPVDs) TX: medical therapies not effective, liver transplant*

Answer 32

Diverticula: outpouchings due to herniation of the mucosa into the wall of the colon along natural openings at the vasa recta of the colon L colon MC in incidence, R colon MC for bleeding Risk Factors: low fiber diet, constipation, obesity Asymptomatic – incidental finding Lower GI bleeding: diverticulosis MCC of acute lower GI bleed *painless hematochezia dx: Colonoscopy tx: Bleeding usually stops spontaneously

Answer 33

Microscopic perforation of a diverticulum leads to inflammation & focal necrosis Complicated: bowel perforation, abscess, fistula, bowel obstruction Sigmoid colon MC area; onset usually >40yrs sx *LLQ pain, LLQ tenderness *low grade fever +/- N/V/D/C, flatulence, bloating, changes in bowel habits PE: +/- tender mass d/t inflammation or abscess CT scan Labs: *leukocytosis Uncomplicated: *metronidazole + (ciprofloxacin or levofloxacin) x7-10d *clear liquid diet

Answer 34

*GERD MC cause *infectious: candida, CMV, HSV; MC associated w/ immunocompromised states *eosinophilic: due to allergic reaction *pill-induced: bisphosphonates, BBs, CCBs, NSAIDs *caustic (corrosive): due to acidic or basic substances

Answer 35

*immunocompromised states (HIV, post-transplant, malignancy, chemo) but can occur in healthy pts candida is MC cause – in pts w/ classic sxs, empiric tx w/ fluconazole can be initiated w/ upper endoscopy reserved if no response to initial therapy sx: Odynophagia + dysphagia + retrosternal chest pain dx: Endoscopic findings: *candida: linear yellow-white plaques *CMV: large superficial shallow ulcers *HSV: small, deep ulcers tx Candida: PO fluconazole CMV: ganciclovir HSV: acyclovir

Answer 36

*allergic inflammatory eosinophilic infiltration of the esophageal epithelium *MC seen in children & associated w/ atopic disease (asthma, eczema) Dysphagia (esp. solids), odynophagia; reflux or feeding difficulties in children dx: Endoscopy: normal or multiple corrugated rings, white exudates Bx: presence of abundance of eosinophils tx: Remove foods that incite allergic response; PPIs may be needed in some Inhaled topical corticosteroids (w/o using a spacer to allow for penetration)

Answer 37

Esophagitis due to prolonged pill contact w/ the esophagus Medications: NSAIDs, bisphosphonates, BBs, CCBs, potassium chloride, iron pills, vitamin B sx: Odynophagia, dysphagia dx: Endoscopy: small, well-defined ulcers of varying depths tx: Take pills w/ at least 4 ounces of water, avoid recumbency at least 30-60min after pill ingestion

Answer 38

Ingestion of corrosive substances: alkali (drain cleaner, lye, bleach) or acids sx: Odynophagia, dysphagia, hematemesis, dyspnea dx: Endoscopy – used to determine the extent of damage & look for complications (esophageal perforation, structure, fistula) tx: Supportive, pain meds, IV fluids

Answer 39

Gastritis: superficial inflammation/irritation of stomach mucosa w/ mucosal injury Gastropathy: mucosal injury without inflammation PATHO: imbalance between aggressive & protective mechanisms of the gastric mucosa MCC: H. pylori, NSAIDs/ASA 2nd MCC S/SXS: most commonly asymptomatic; when symptoms present, similar to PUD (e.g., dyspepsia, N/V, epigastric pain) DX: upper endoscopy w/ biopsy ▪︎thick, edematous erosion <0.5cm H. pylori testing TX: similar to PUD (e.g., H. pylori eradication, H2 antagonists/PPIs, stop offending agents) ▪︎H. pylori ⇢ “CAP” » clarithromycin + amoxicillin + PPI Prophylaxis: for patients w/ high risk of stress-related gastritis ⇢ PPI

Answer 40

Ligament of Treitz

Answer 41

*PUD *esophagitis *portal HTN *Mallory-Weiss tear *angiodysplasia

Answer 42

Hematemesis – vomiting blood, “coffee-ground” *bloody: suggests moderate-severe bleeding *coffee ground: suggests more limited bleeding Melena – black, tarry stools *hematochezia usually indicates LGIB but can occur in massive UGIB Symptom assessment: *PUD – upper abdominal pain *esophageal ulcer – odynophagia, reflux, dysphagia *mallory-weiss tear – emesis, retching, or cough prior to bleeding *variceal hemorrhage or portal HTN gastropathy – jaundice, abdominal distention (ascites) *malignancy – early satiety, dysphagia, weight loss, cachexia Medication hx *aspirin/NSAIDs predispose to PUD *anticoagulants/antiplatelets ↑ bleed risk *SSRIs/CCBs/aldosterone antagonists have been associated w/ GI bleeding Labs: CBC, CMP, electrolytes, lipids, liver enzymes, albumin, creatinine, BUN, thyroid, coagulation studies *monitor Hgb every 2-8hrs *typically have ↑ BUN-to-creatinine ratio - >30:1 suggest UGIB UPPER ENDOSCOPY (within 24hrs) Tx: PPI Octreotide for esophageal varices or cirrhosis

Answer 43

*diverticulosis *angiodysplasia *colitis (infectious, ischemic, IBD) *colon cancer

Answer 44

Hematochezia – maroon/bright red blood, blood clots *L colon origin: bright red *R colon origin: dark/maroon colored Symptom assessment: *hemorrhoids: painless bleeding w/ wiping *anal fissures: severe rectal pain w/ defecation *proctitis: rectal bleeding & abdominal pain *polyps: painless rectal bleeding, no red flag signs *colorectal cancer: painless rectal bleeding & a change in bowel habits in a pt 50-80yrs Labs: CBC, CMP, electrolytes, lipids, liver enzymes, albumin, creatinine, BUN, thyroid, coagulation studies *typically have normal BUN-to-creatinine ratio - <20:1 +/- upper endoscopy to r/o UGIB COLONOSCOPY, CT angiography, radionucleotide scanning tx: treat underlying cause

Answer 45

sx: epigastric pain & vomiting, anorexia, & nausea dx: HX/PE, EGD w/ multiple bx (looking for gastric cancer)

Answer 46

sx: epigastric pain – burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain) *bleeding, back pain N/V, anorexia, ↓ appetite dx: HX/PE, EGD, UGI series (if the pt is not actively bleeding)

Answer 47

sx: weight loss, emesis, anorexia, pain/epigastric discomfort, obstruction, nausea dx: EGD w/ bx, endoscopic U/S to evaluate the level of invasion, CT of abdomen/pelvis for metastasis, CXR, labs

Answer 48

sx: biliary colic, weight loss, anorexia *many pts are symptomatic until late; may present as acute cholecystitis dx: U/S, abdominal CT, ERCP

Answer 49

sx: *painless jaundice from obstruction of the common biliary duct *weight loss, abdominal pain, back pain, weakness *pruritis from bile salts in the skin; anorexia *Courvoisier’s sign *acholic stools *dark urine, diabetes dx: abdominal CT, U/S, cholangiography (ERCP to r/o choledocholithiasis & cell brushings), endoscopic U/S w/ bx

Answer 50

dilated submucosal vascular cushions within the anal canal ▪︎excessive straining (chronic constipation, BPH), older age, extended periods of sitting, pregnancy (mainly 3rd TM) dx: DRE, anoscopy, colonoscopy (high risk) or flexible sigmoidoscopy (low risk) if concern for malignancy tx: Lifestyle modifications (all patients): high fiber diet (20-30g/d), ⇡ fluid intake, avoid fatty foods, regular physical activity, avoidance of excessive straining & limiting amount of time spent on toilet » constipation: short-term (1wk max) use of stool softeners (docusate) or laxatives (PEG) Symptom relief (pain, pruritis): sitz baths, topical anesthetics (lidocaine), steroids (hydrocortisone), &/or vasoconstrictors (phenylephrine)

Answer 51

Internal hemorrhoids: originate from superior hemorrhoid vein above dentate line; ⊖cutaneous innervation = ⊖pain ▪︎S/SXS: painless, BRBPR at end of defecation; perianal mass if prolapsed, pruritis, anal discharge (mucus, fecal matter) tx: » Internal, grades I-III unresponsive to conservative: rubber band ligation, sclerotherapy » Internal, grade IV: surgery (hemorrhoidectomy) External hemorrhoids: originate from inferior hemorrhoid vein below dentate line; ⊕cutaneous innervation = ⊕pain ▪︎S/SXS: similar to internal (e.g., BRBPR, pruritis), thrombosed external manifests w/ severe perianal pain & tender mass tx: » Symptomatic external hemorrhoids refractory to conservative therapy: refer for surgery » Thrombosed external hemorrhoids: surgical excision if duration <3-4d ▪︎duration >3-4d: antispasmodics (topical NTG or nifedipine), lidocaine, hydrocortisone, docusate

Answer 52

GERD: reflux of gastric contents into esophagus d/t an incompetent LES Mechanism: transient relaxation of LES RF: smoking, caffeine, & ETOH (⇣ LES tone); stress, obesity, pregnancy, scleroderma, sliding hiatal hernia Complication ⇢ Barrett’s esophagus: intestinal metaplasia of esophageal mucosa induced by chronic reflux (columnar epithelium instead of normal squamous epithelium) ▪︎RF: ♂︎, European descent, age ≥50yo, obesity, SXS ≥5y ▪︎Barrett’s predisposes esophageal adenocarcinoma

Answer 53

*acute, chronic, or recurrent pain/discomfort centered in the upper abdomen (epigastric) *may be associated w/ heartburn, nausea, postprandial fullness, or vomiting Heartburn: retrosternal burning – should be distinguished from dyspepsia *when heartburn is predominant complaint ⇢ gastroesophageal reflux nearly always present FOOD/DRUG INTOLERANCE: acute, self-limited *overeating, eating too quickly, eating high-fat foods by endoscopy/other testing *eating during stressful situations, alcohol/coffee *MCC of chronic dyspepsia, often difficult to treat *MEDS: ASA, NSAIDs, metronidazole, macrolides, *PATHO: ⇡ visceral afferent sensitivity, delayed metformin, GLP-1 antagonists, ACEI/ARBS, SSRIs, gastric emptying or impaired accommodation to SNRIs, Parkinson RX (DA agonists, MAO-B), steroids, food/psychosocial stressors estrogens, iron, opioids, digoxin H. PYLORI INFECTION: chronic gastric infection w/ LUMINAL GI TRACT DYSFUNCTION: H. pylori important cause of PUD but may cause *PUD present in 5-15% of patients w/ dyspepsia dyspepsia in a subset of patients in absence of PUD *GERD present in up to 20%, even w/o significant HB *gastric/esophageal cancer <1%, rare if <60yo pancreatic carcinoma & chronic *gastroparesis (diabetics) pancreatitis may cause chronic epigastric pain, but usually *parasitic infections (Giardia, Strongyloids, Anisakis) more severe, radiates to back, & associated w/ anorexia, weight loss, jaundice.

Answer 54

Typical SXS: retrosternal burning (heartburn), regurgitation, water brash (i.e., excessive salivation triggered by reflux of acid; bad/sour taste) ▪︎worsened by lying flat, foods (e.g., chocolate, spicy food) Atypical SXS: persistent cough, asthma, hoarseness, dental erosion, halitosis (bad breath), N/V, belching, epigastric pain, bloating ALARM SXS: ▪︎dysphagia, odynophagia ▪︎anemia ▪︎unintentional weight loss ▪︎GI bleeding (hematemesis, hematochezia) EGD indications: ⊕alarm symptoms, risk factors for Barrett’s, no symptom improvement after PPI trial » Findings (typically in lower 1/3 of esophagus): ▪︎erythema, edema, friability ▪︎erosions, mucosal breaks, ulcers ▪︎peptic strictures/rings ▪︎salmon pink mucosa (suggestive of Barrett’s) Esophageal pH monitoring: indicated for patients w/ normal EGD & typical symptoms despite PPI TX ▪︎normal esophageal pH ~7 Lifestyle changes (all patients): ▪︎elevate head of bed 6-8in, weight loss if indicated ▪︎AVOID: eating 3h before bedtime, smoking, triggering foods (coffee, ETOH, OJ, chocolate) TX: PPIs (8wk trial for patients w/ typical SXS) ▪︎good response ⇢ discontinue PPI ▪︎no response or relapse after DC ⇢ GI for EGD *controversy regarding long-term PPI therapy d/t conflicting evidence about potential risks H2 antagonists (famotidine, ranitidine): alternative maintenance for non-erosive reflux Maintenance TX: lowest effective dose Refractory: Nissen fundoplication

Answer 55

abrupt onset epigastric/RUQ pain d/t cholelithiasis or choledocholithiasis ischemia, intra-abdominal malignancy, gastric volvulus or paraoesophageal hernia, chronic gastric or intestinal

Answer 56

UPPER ENDOSCOPY: *mainly indicated to look for upper gastric or esophageal malignancy in ALL patients >60yo w/ new-onset dyspepsia (if ⇡ malignancy risk) *guidelines recommended against routine endoscopy for pts <60yo (risk of cancer <1%) unless alarm features TX: ⊕H. pylori: bismuth quadruple therapy x14d *PPI + Bismuth subsalicylate 262mg + tetracycline + metronidazole *alternative ⇢ ▪︎omeprazole + rifabutin + amoxicillin *standard triple therapy w/ clarithromycin no longer recommended ⊖endoscopy, <60yo w/o response to PPI: ⇢ presumed to have functional dyspepsia *reassurance, lifestyle/dietary changes *herbal therapies: peppermint, caraway *low-dose TCAs (desipramine or nortriptyline)

Answer 57

Indirect: (MC!!) *bowel protrusion @ internal inguinal ring *LATERAL to inferior epigastric artery Direct: *MEDIAL to the inferior epigastric artery *Hesselbach’s triangle: “RIP” rectus abdominis, inferior epigastric, oupart’s (inguinal) ligament *MC found on the right side

Answer 58

Asymptomatic: swelling or fullness at the hernia site; enlarges w/ increased intraabdominal pressure &/or standing; may develop scrotal swelling Incarcerated: painful, enlargement of an irreducible hernia Strangulated: ischemic incarcerated hernias w/ systemic toxicity tx for strangulated p emergent surgery

Answer 59

Protrusion of the contents of the abdominal cavity through the femoral canal (below the inguinal ligament) MC seen in women Often become incarcerated or strangulated because femoral ring is smaller in women

Answer 60

Hernia through the umbilical fibromuscular ring Congenital (failure of umbilical ring closure) - usually due to loosening of the tissue around in the ring in adults Observation: usually resolves by 2yrs of age Surgical repair

Answer 61

Herniation through weakness in the abdominal wall Mostly occur w/ vertical incisions & in obese pts

Answer 62

Rare hernia through the pelvic floor in which abdominal/pelvic contents protrude through the obturator foramen MC in women (esp. multiparous) or women w/ significant weight loss

Answer 63

Herniation of structures from the abdominal cavity through the esophageal hiatus of the diaphragm sx: Usually an asymptomatic incidental finding *may develop intermittent epigastric or substernal pain, postprandial fullness, retching, or nausea tx: Sliding: management of GERD *PPIs + weight loss Paraoesophageal: surgical repair for complications *volvulus, obstruction, strangulation, bleeding, perforation

Answer 64

Type I: Sliding (95%) *GE junction “slides” into the mediastinum (increases reflux) Type II: Paraoesophageal (“rolling hernia”) *fundus of stomach protrudes through diaphragm w/ the GE junction remaining its anatomic location

Answer 65

pathogen: Enterobius vermicularis sx: perianal pruritis that is worst at night dx: *scotch tape test: done in early AM Can see eggs under microscope tx: *mebendazole *pyrantel pamoate

Answer 66

causes: Transmission: raw or undercooked meat *associated w/ B12 deficiency sx: GI sxs, weight loss dx: *tape test for D. latum *stool sample: eggs tx: *praziquantel

Answer 67

Larvae invade the skin, travel to lung, cough, & swallow, reside in intestine *eosinophilia & anemia *recent travel sx: *cough *weight loss *anemia dx: *stool sample: adult worms tx: *mebendazole *pyrantel

Answer 68

MC intestinal helminth worldwide; found in contaminated soil sx: Small worm load: asymptomatic Larger load: vague abdominal sxs High load: pancreatic duct, common bile duct, & bowel obstruction dx: *stool sample: eggs or adult worms tx: *albendazole *mebendazole *pyrantel pamoate

Answer 69

Also known as “Snail Fever” & “Bilharzia” Etiology: parasitic flatworms called schistosomes PATHO: penetrating of skin (contaminated freshwater) 🡪 enter the bloodstream & migrate to liver, intestines, etc. sx: *rash *abdominal pain, diarrhea *bloody stool *blood in urine dx: *eggs in urine or feces tx: *praziquantel

Answer 70

Rheumatologic: MSK pain, arthritis, ankylosing spondylitis, osteoporosis Dermatologic: erythema nodosum, pyoderma gangrenosum Ocular: conjunctivitis, anterior uveitis/iritis (ocular pain, HA, blurred vision), episcleritis (mild ocular burning) Hepatobiliary: fatty liver, primary sclerosing cholangitis Hematologic: B12/iron deficiency (esp. w/ CD), ↑ r/o thromboembolism Workup: CBC, ESR/CRP, albumin, electrolytes, AST/ALT, creatinine, urea nitrogen, fecal calprotectin, stool microscopy, stool cultures, testing for C. diff

Answer 71

ULCERATIVE COLITIS (UC): chronic, recurrent disease involving only the colon characterized by diffuse mucosal inflammation that results in friability, erosions, & ulcers w/ bleeding; mucosa + submucosa Bimodal: 15-25, 55-65, slightly more common in males *MC in nonsmokers & previous smokers *RECTUM ALWAYS INVOLVED Complications: *Primary Sclerosing Cholangitis *Colon Cancer *Toxic Megacolon S/SXS: fecal urgency, abdominal pain & cramps, tenesmus dx: Sigmoidoscopy: mucosa – edema, friability, mucopus, erosions; UNIFORM inflammation Abdominal radiograph, CT: pts w/ severe colitis to look for significant colonic dilation Barium studies: “stovepipe sign,” loss of haustral markings *little use, can precipitate toxic megacolon in pts w/ severe disease Labs: Hct, albumin (⇣), ESR/CRP, fecal calprotectin *POSITIVE P-ANCA tx mild: mesalamine, steroids severe: immunomodulators

Answer 72

Cardinal SXS: ▪︎abdominal pain (crampy), RLQ pain if limited to terminal ileum (MC location) ▪︎diarrhea (+/- bleeding) ▪︎systemic symptoms ⇢ fatigue, weight loss (d/t ⇣ intake, malabsorption) Transmural Inflammation *associated w/ sinus tracts that may lead to fistulas & phlegmon formation ▪︎fistulas: enterovesical (bladder), enterocutaneous, enterovaginal ▪︎phlegmon: walled-off inflammatory mass w/o bacterial infection ▪︎abscess: acute ⇢ localized peritonitis + fever, abdominal pain, tenderness ▪︎perianal disease: perianal fistula, perianal abscess Malabsorption: small bowel CD ⇢ bile salt malabsorption Initial DX: compatible clinical picture + supporting endoscopic, pathologic, & radiographic findings Colonoscopy: aphthoid, linear, or stellate ulcers; strictures; segmental involvement w/ areas of normal-appearing mucosa adjacent to inflamed mucosa (“skip lesions”); cobblestone appearance BX: granulomas (seen in <25%) CT/MR enterography: for suspected small bowel involvement *ulcerations, strictures, fistulas *bowel wall thickening & vascularity, mucosal enhancement, fat stranding Barium studies: “string sign,” barium flow through narrowed inflamed/scarred area d/t transmural strictures *only performed when CT/MR enterography unavailable Labs: inflammatory markers – albumin, CRP, fecal calprotectin; CBC (anemia), C. diff testing *⇣ albumin *⇡ ESR/CRP during active inflammation Induction TX (acute flares): agents w/ rapid onset ⇢ steroids, biologics Maintenance TX: biologics & immunomodulators

Answer 73

▪︎life-threatening acute colonic dilation + systemic toxicity » infectious colitis: C. difficile (pseudomembranous colitis) » inflammatory colitis: ulcerative colitis S/SXS: bloody diarrhea, vomiting, abdominal distention & pain, signs of sepsis (e.g., fever, tachycardia, hypotension), dehydration, peritonitis ▪︎LABS: neutrophilic leukocytosis, ⇡ ESR/CRP, hypokalemia, anemia ▪︎abdominal XR: transverse colon >6cm, loss of haustration ▪︎colonoscopy/endoscopy contraindicated d/t high-risk of perforation TX: ICU admission, complete bowel rest (NPO), bowel decompression w/ NG tube, broad-spectrum IV ABX (ampicillin, gentamicin, & metronidazole) ▪︎rotation techniques: frequent position changes to facilitate evacuation of bowel gas (prone or knee-elbow position) ▪︎AVOID anticholinergics & narcotics ▪︎IV steroids (hydrocortisone, dexamethasone) for IBD *contraindicated in infective colitis Surgery: no response within 24-72h, development of complications ▪︎subtotal colectomy & end ileostomy

Answer 74

ACUTE (AMI): acute reduction in arterial or venous blood flow to small intestine, may ⇢ bowel ischemia or infarct *SMA MC (~90%), SMV LC (<10%), IMA & celiac uncommon S/SXS: pain out of proportion to exam** *severe, steady, diffuse abdominal pain +/- N/V/D *no focal tenderness or distention CHRONIC (CMI) ⇢ “Intestinal Angina” *atherosclerosis ⇢ ischemia (i.e., hypoperfusion) MCC *⇣ supply during ⇡ demand (eating) sx: S/SXS: epigastric/periumbilical postprandial pain

Answer 75

DX: CTA abdomen & pelvis *mesenteric stenosis & thromboembolism *bowel-wall thickening, hypoperfusion *bowel dilation, mesenteric fat stranding *pneumatosis intestinalis (gas within walls) CT abdomen: *bowel wall thickening, bowel edema *thumbprint sign: edematous mucosal thickening causing indentation in large bowel colonoscopy ⇢ confirms *clearly defined segmental ischemia in areas of low perfusion (e.g., splenic fixture) *edematous, friable mucosa w/ erosions AMI – initial Measures: *IV fluids, NPO, NG decompression *anticoagulation ⇢ UFH *empiric broad-spectrum antibiotics *PPI, O2 PRN

Answer 76

Yellowing of the skin, nail beds, & sclera by bilirubin deposition as a consequence of hyperbilirubinemia FIRST SIGN 🡪 scleral icterus Serum bilirubin >2.5mg/dL – not a disease but a sign of disease Occurs w/ increased bilirubin overproductions (hemolysis)/ineffective erythropoiesis, decreased hepatic bilirubin uptake, impaired conjugation, biliary tract obstruction, viral hepatitis, physiologic jaundice of newborn, Gilbert syndrome, Dubin-Johnson syndrome Causes: Extravascular hemolysis/ineffective erythropoiesis *increases the level of UCB which overwhelms the liver’s ability to conjugate UCB *dark urine & increased risk for pigmented bilirubin gallstones results Physiologic jaundice of the newborn *newborn has transient low UGT which increases UCB *it can present w/ kernicterus leading to neuro deficits & death *tx w/ phototherapy

Answer 77

*the absence of UGT (enzyme) which increases UCB causing kernicterus which is usually fatal

Answer 78

*mildly low UGT activity which increases UCB *jaundice occurs during stress like a severe infection; otherwise, pts are asymptomatic

Answer 79

*deficiency of bilirubin canaliculi transport protein which increases CB *the liver is pitch-dark *Rotor syndrome – liver is not dark

Answer 80

*associated w/ gallstones, pancreatic carcinoma, liver fluke, & cholangiocarcinoma *this also increases the CB, & alkaline phosphatase & decrease urine urobilinogen *dark urine, pale stool, pruritis due to increased bile acids, steatorrhea

Answer 81

Initial lab tests: *serum total & unconjugated bilirubin *alk phos *AST/ALT *PT/INR *albumin Interpretation: Normal alk phos & aminotransferases *jaundice likely not due to hepatic injury or biliary tract disease Predominant alk phos elevation *suggests biliary obstruction or intrahepatic cholestasis Predominant aminotransferase elevation *suggests jaundice is caused by intrinsic hepatocellular disease Elevated INR *an elevated INR that corrects w/ vitamin K admin suggests impaired intestinal absorption of fat-soluble vitamins & is compatible w/ obstructive jaundice Unconjugated hyperbilirubinemia *typically involves evaluation for hemolytic anemia, drugs that impair hepatic uptake of bilirubin, & Gilbert syndrome Conjugated hyperbilirubinemia *evaluation will be based on whether the abnormalities are likely due to biliary obstruction, intrahepatic cholestasis, hepatocellular injury, or an inherited condition

Answer 82

full thickness rupture, MC affecting the left posterolateral wall of the lower esophagus Etiologies: *iatrogenic perforation during endoscopy (MC) *repeated, forceful retching or vomiting (Bulimia, alcoholism) sx: *retrosternal chest pain worse w/ deep breathing & swallowing *vomiting, hematemesis PE: *crepitus on chest auscultation (subcutaneous emphysema) *Hamman’s sign: mediastinal “crackling” accompanying every heartbeat in the left lateral decubitus position dx: Contrast esophagram: leakage Chest CT, CXR *left-sided hydropneumothorax (MC) *pneumomediastinum *esophageal thickening tx: Small & stable: *IV fluids, NPO, broad-spectrum abx, H2 receptor blockers Large or severe: surgical repair

Answer 83

PATHO: *sudden rise in intraabdominal pressure or gastric prolapse into the esophagus (persistent retching or vomiting after ETOH binge) *may also be associated w/ hiatal hernias sx: *upper GI bleeding preceded by retching or vomiting *hematemesis, melena, syncope *may develop abdominal pain, back pain, or hydrophobia dx: Upper endoscopy – superficial longitudinal mucosal erosions tx: Not actively bleeding: supportive *PPIs promotes healing Severe bleeding: *thermal coagulation, hemoclips, endoscopic band ligation, balloon tamponade

Answer 84

temporary functional impairment of peristalsis, ⊘physical barrier *postoperative, peritonitis, meds (e.g., opioids, anticholinergics) *electrolyte abnormalities (e.g., hypokalemia) *hemoperitoneum/retroperitoneal hematoma

Answer 85

SBO MCC: adhesions from prior abdominal surgery (75%) > hernia > neoplasms LBO MCC: adenocarcinoma > scarring secondary to diverticulitis > volvulus

Answer 86

torsion of bowel on its axis ⇢ closed loop obstruction; sigmoid MC (75%), cecal (25%) *torsion of mesenteric vascular pedicle ⇢ occlusion/thrombosis of mesenteric vessels ⇢ bowel

Answer 87

Both: *N/V, colicky abdominal pain, obstipation *peristalsis (bowel sounds) ⇡⇡ in early phases of mechanical obstruction d/t intense intestinal muscular contraction (“peristaltic rush”) ▪︎progressively ⇣ & eventually disappears in late obstruction *strangulation: fever, crampy abdominal pain ⇢ peritonitis *vitals: initially normal ⇢ tachycardia & hypotension d/t dehydration SBO: Proximal SBO: profuse emesis containing undigested food, upper abdominal discomfort, epigastric distention Distal SBO: diffuse, poorly localized crampy abdominal pain LBO: *emesis is late finding, may be absent if ileocecal valve prevents reflux *deep, visceral, cramping pain from colonic obstruction usually referred to hypogastrium *cancer ⇢ gradually progressive pain/symptoms, volvulus ⇢ acute

Answer 88

DX: plain abdominal x-rays (supine/standing), CT w/w/o contrast *dilated bowel loops w/ air-fluid levels in ladder-like appearance ▪︎3-6-9 rule: small bowel >3cm, large bowel >6cm, cecum >9cm ▪︎SBO dilated loops ⇢ central, LBO dilated loops ⇢ peripheral *little/no air distal to obstruction *pneumoperitoneum ⇢ perforation

Answer 89

SIGMOID Volvulus: coffee bean sign (bent inner tube, kidney bean) *dilated loop w/ absent haustrae, arises in LLQ & extends ⇢ RUQ *proximal colonic/small bowel dilation w/ air-fluid levels, ⊘distally CECAL Volvulus: *dilated loop w/ maintained haustrae, arises in RLQ & extends ⇢ LUQ

Answer 90

SMALL BOWEL: *NPO, IV fluids, foley to monitor urine output *NGT for gastric decompression (⇣ N/V, distention) *monitor electrolytes for hypokalemia, metabolic acidosis (signs of ischemia) *pts w/ suspected strangulation need fluid resuscitation prior to surgery 24h w/o improvement, deterioration: *laparotomy, procedure depends on cause ▪︎adhesions: lysis of adhesions (LOA) ▪︎hernias: reduced/repaired ▪︎Crohn’s: resection or stricturoplasty *entire small bowel should be examined *resect nonviable intestine *primary anastomosis of resected segments LARGE BOWEL: *surgery almost always required *goals ⇢ resection of necrotic bowel & decompression of obstructed segment Options: *resection + primary anastomosis *resection + diversion, diversion alone *endoscopic stent placement

Answer 91

Gastric erosions >0.5cm on imaging Duodenal Ulcers: 4x more common, usually benign Gastric Ulcers: 4% associated w/ gastric adenocarcinoma PATHO: imbalance between - ↑ aggressive factors in DU (hydrochloric acid, H. pylori) - ↓ protective mechanisms w/ GU (mucus, bicarb, PGs) Etiologies: *H. pylori MC cause of gastritis *NSAIDs/ASA – 2nd MC cause (GU – PG inhibition)

Answer 92

Dyspepsia (burning, gnawing, epigastric pain) hallmark; N/V DU: dyspepsia classically relieved w/ food GU: sxs worsened w/ food Bleeding ulcer: hematemesis, melena, hematochezia – PUD is MC cause of upper GI bleed Perforated ulcer: sudden onset of severe abdominal pain (may radiate to shoulder); peritonitis (rebound tenderness, guarding, rigidity) Upper endoscopy w/ bx – all GU need repeat endoscopy to document healing H. pylori testing: *endoscopy w/ bx – gold standard *urea breath test (H. pylori converts labeled urea 🡪 labeled CO2; breathing out labeled urea = +) H. pylori positive: *bismuth quadruple therapy: bismuth subsalicylate + tetracycline + metronidazole + PPI x14d H. pylori negative: *PPI; H2 blocker, misoprostol, antacids, etc.