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CCFP EM > GI > Flashcards

GI Flashcards

1
Q

causes of esophagitis

A

GERD (most common), infection, pill, caustic ingestion, radiation, autoimmune, eosinophilic esophagitis

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2
Q

causes of infectious esophagitis

A

usually in immunocomp (aids, transplant): candida, HSV, CMV,

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3
Q

typical and atypical GERD symptoms

A

typical:

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4
Q

GERD causes

A

lower eso sphincter incompetence, hiatal hernia, meds, increased intra-abdo pressure (obesity, pregnancy), incomplete emptying of stomach

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5
Q

alarm symptoms, that require f/u or endoscopy in GERD

A

weight loss, progressive dysphagia, blood in stools, anemia, age >50

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6
Q

caustic ingestion: why are alkalis worse than acids

A

acids produce coagulation necrosis which limits tissue injury (bc is causes an escahar), alkalis produce tissie liquefaction necrosis which allows for continued damage.

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7
Q

mgmt of caustic ingestion:

A

airway assessment, NPO, pain mgmt, PPI, abx if perf suspected.
DO NOT: place NGT, give anything by mouth, avoid charcoal
dispo: likely as per poison control

note: household bleach ingestion <100 mL unlikely to do any damage

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8
Q

mgmt of mallory weiss

A

supportive and symptomatic usually adequate

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9
Q

what to rule out with mallory weiss (2 things)

A

peritonitis and esophageal perf

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10
Q

pathophys of eso perf

A

rupture of all layers of eso and surrounding pleura –> non sterile contents into mediastinum or thorax

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11
Q

causes of eso perf

A

iatrogenic, Boerhave’s (rethching after etoh or large meal), trauma

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12
Q

s/s of eso perf

A

variable… most commonly epigastric pain that radiates to neck,

pleuritis pain made worse by neck flexion and swallowing

Mackler triad: vomiting, chest pain subcutaneous emphysema

+/- fever/hypotension/shock

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13
Q

dx of eso perf

A

cxr: can reveal pneumomediastinum, ptx, pleural effusion, widened mediastinum, but is not sensitive (esp early on)

esophgram using water siluable ocntrast (NOT BARIUM) or EGD can make diagnosis

can consider CT chest if above studies not available.

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14
Q

mgmt of eso perf

A

NPO, broad spectrum abx, surgical consult

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15
Q

why are button batteries bad, what is the timeline

A

alkali –> liquefaction necrosis

burns esophagus within 2 hours and perfs within 4-6 hrs

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16
Q

where do most eso fbs lodge in adults and childern

A

areas on anatomic narrowing

children: cricocopharyngeus muscle -> C6

adults: lower eso sphincter –> T10

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17
Q

imaging for eso fb

A

usually not necessary if food bolus
start with cxr, then CT if not identifiable

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18
Q

coins in trachea vs eso on xr

A

trachea they will appear sideways and then and in eso will appear head on

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19
Q

button battery vs coin on xray

A

BB with have double density or “stack of coins sign”

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20
Q

mgmt of eso fb

A

Look at highlights

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21
Q

distinguishing UGIB from LGIB

A

hemetemsis/coffee ground emesis = UGIB

BRBPR with CLOTS = LGIB

melena or hematochezia (w/o clots) can be either). up to 70% UGIB will have these

NG aspirte: specific but not sensitive for UGIB (only picks up 23% in pt w/o hemetemesis

BUN/Cr ratio > 30 ; 93% sp for UGIB

age < 50 more likely UGIB

if hemodynamic instability assume UGIB

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22
Q

cause of UGIB

A

gastritis/esophagitis
ulcers
mallory weiss
malignancy
varices
dieulafoy lesion
aorto-enteric fistula (think of this is aortic graft)
idopathic

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23
Q

cause of LGIB

A

CHAND

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24
Q

NG in GIB

A

specific, but no sensitive for UGIB (will miss over 75% if no hemetesmsis). not generally indicated.

can consider if going to intubate and needing to empty the stomach first.

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25
Q

mgmt of GIB

A

octreotide is moderate priority, 2008 cochrane review –> prevents re-bleeds in variceal and non varicel ugib, decrease splanchnic blood flow, although not lifesaving can be considered.

also need to reverse anticoagulation: if no DOAC or warfarin –> octaplex 2000 units and vitamin IV if on warfarin

TXA –> nope

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26
Q

walk through balloon tamponade in UGIB

A

go

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27
Q

walk through SALAD intubation in UGIB

A

go

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28
Q

Score for outpt mgmt of UGIB

A

Glasgow-Blathchford score , score <3 can consider dc

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29
Q

diagnostic tests for LGIB

A

-colonscopy is best, but usually not possible if active/brisk bleeding
-angiopgraphy
-tagged RBC scan

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30
Q

endoscopic therapies for UGIB

A

epi injection, banding, cautery, sclerotherapy

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31
Q

upper vs lower GIB: location and icnidenc

A

proximal to ligament of Treitz = upper

2/3rds are UGIB, 1/3 are LGIB

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32
Q

what is shock index? how to use in GIB

A

HR/SBP, if > 1 consider MTP (?seems like low threshold), in practice should use this as trigger to have PRBCs down and transfuse, if needing > 4/hr or no response to 4 then trigger MTP

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33
Q

how to diagnose and when to consider aortoenteric fistula

A

known AAA (esp if grafted) and GIB is AEF until proven otherwise, get CT abdo or angiography in stable pts, if unstable resuscitate and STAT OR

note present like upper or lower GIB

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34
Q

causes and complications of gastritis

A

NSAIDS, EtOH, H pylori, autoimmune, corrosive agents, also shock/hypovolemia!

comp: ulcers, GIB, perf,

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35
Q

zollinger-ellison syndrome

A

gastrin secreting endocrine tumour, accounts for 1% of all PUD

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36
Q

Treatment regimen for h pylori

A
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37
Q

mgmt of gastritis

A

PPI, d/c nsaids, etoh and outpt tx for h pylori.

note gastrits/PUD w/o cause, should Ix for h pylori, or at leats send test for it first, if GERD trial PPI first

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38
Q

Ix options for H pylori

A

serology –> only tests for past exposure

urea breath, stool Ag and endoscopy can confirm active infection or eradiction

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39
Q

4 entities of stomach disease

A

gastritis, PUD (gastric and duodenal ulcers), gastrinoma, gastric adenoca

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40
Q

PUD pain symptoms

A

epigastric pain, worse at night (can wake from sleep), belching, early satiety, nausea, abdo distention

most common sign: epigastric pain to palp

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41
Q

invasive vs non-invasive gastroenteritis

A

non-invasive = mild systemic symptoms, n/v, diffuse abdo tenderness,
dehydration

invasive = more severe systemic symptoms, bloody diarrhea, FEVER, tender abdomen

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42
Q

mgmt of gastro

A

supportive, usually resolves by 14 days

get GPMP/O&P if longer than 14 days, severe, recent travel, recent abx, outbreaks, etc

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43
Q

Bugs that cause bloody diarrhea

A
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44
Q

most common cau of gastric/duodenal perf

A

eroded ulcer

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45
Q

causes of small bowel perf

A

infection (typhoid/TB), tumours, strangulated hernia, IBD, ischemic colitis, FB, meds, blunt or penetrating trauma, SBO

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45
Q

Large bowel perf causes

A

LBO, colon cancer, diverticulitis, iatrogenic

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46
Q

mgmt of bowel perf

A

surgical consult, NPO, IVF, broad spectrum abx

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47
Q

bloody diarrhea more common in chrons or UC

A

UC!

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48
Q

Chrome vs UC: distinguishing features

A
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49
Q

dx of toxic megalcolon

A

colon >6 cm on radiograph with signs of systemic toxicity = high risk for perf

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50
Q

complications of UC

A

GIB, colorectal CA, toxic megacolon

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51
Q

complications of chrons

A

SBO, fistula, abscess, stricture, toxic megacolon, colorectal CA

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52
Q

extraintestinal manifestations of IBD

A
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53
Q

simple SBO vs strangulation

A

simple = impairs lumen only

strnagulation, results in loss of blood flow and can lead to necrosis/perf etc, often results from “closed loop” obstruction

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54
Q

causes of SBO

A

adhesions, neoplasm, hernias, chrons, volvulus, intussusception (<2 y/o), gallstone ileus.

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55
Q

stool and flatus in SBO

A

can pass fro up to 24 hrs after complete SBO

56
Q

AXR findings and sensitivity for SBO

A

sensitivity: 70-80%, findings= dialted loops of small bowel with air fluid levels and decompressed colon, can see string of pearls sign,

57
Q

causes of ileus

A

post-op
acute abdo process eg peritonitis
hypokalemia
meds
severe medical illness (eg sepsis)

58
Q

lactate and bowel ischemia, sensitivity and specificity

A

sensitive but not specific, although can still have necrotic bowel with normal lactate

59
Q

mgmt of SBO

A

note gastrografin and NGT for pts with significant vomiting and distention

60
Q

meckel diverticulum rule of 2’s

A

2% of population, 2% symptomatic, 2:1 male, 2 feet proximal to TI, most commonly present in pts <2yrs of age

61
Q

how does meckel diverticulum present

A

can mimic appy or present with acute onset, massive “brick-red” painless rectal bleeding

62
Q

radiation proctocolitis 2 types

A

acute: rectal bleeding, abdo pain and tenesumus during course of radiation

chronic: months to years after tx, slow onset of diarrhea, tenesums, fistulas and strictures.

** note chronic is a diagnosis of exclusion, need ot r/o other shit first

63
Q

why can bowel obstruction, esp LBO lead to sepsis

A

bacterial translocation

64
Q

NGT in LBO?

A

if distention or vomiting

65
Q

3 top causes of LBO in order

A

colorectal ca
diverticulitis
sigmoid volvulus
cecal volvulus

66
Q

why does LBO lead to dehydration

A

bowle edema and transudative fluid losses

67
Q

pathophys and tx of LBO from:
colorectal ca
diverticulitis
sigmoid and cecal volvulus

A
68
Q

most common age of appy

A

10-19

69
Q

most common cause of atraumatic abdo pain in children >1 year old?

A

appy

70
Q

appendix symptoms

A

quite vague:
-can cause nausea/vom
-diarrhea, constipation or normal.
-periumbilical pain that migrates to RLQ is most common
-retrocecal app will cause flank pain
-can cause dysuria or hematuria
-in pregnanayc can present with RUQ pain, but still RLQ is most common

71
Q

most common non-obsterical surgical emergency in pregnancy

A

appy

72
Q

what does rovsing’s sign indicate

A

right sided peritoneal irritation

73
Q

Alvarado score, sensitivity in appy

A

72%, clinical judgment is better.

no one sign, use them all in combo

74
Q

if question is appy, yes or no, what two normal tests make the diagnosis very unlikely

A

normal WBC AND CRP, make dx unlikely if pre test prob is low, cannot use them in isolation

75
Q

Ddx of appendicitis

A
76
Q

size of appendix on u/s and CT that confirms appy?

A

> 6mm

77
Q

what is accepted standard of care in acute appy?

A

appendectomy

78
Q

%age of 80 yr olds with diverticulosis

A

> 80%

79
Q

when is rt sided diverticular disease more common

A

asian or african descent

80
Q

uncomplicated vs complicated diverticulitis, pathophys

A

uncomp: obstruction of diverticula with stool, leading to inflammation into pericolonic fate

complicated: inflammation extending beyond peri-colonic fat with abcess formation +/- microperf

81
Q

diverticular bleeds: %age of LGIB and mechanism

A

40%, result from erosion of diverticula into mucosal wall, painless and are not occurring when ppl diverticulitis

82
Q

symptoms of diverticulitis

A

fever, anorexia, focla abdo pain, n/v.
if complicated will get more abdo pain, +/- peritonitis, can be systemically unwell if bigger perf

83
Q

2 classification of anorectal abcess
and their pathophys

A
  1. peri anal (simple anorectal)
  2. peri-rectal (complex anorectal)

obstructed anal gland, with subsequent polymicrobial infection. either stays superficial or spreads higher up.

84
Q

peri anal vs peri rectal abscess symptoms and dx

A

ANAL: easily palpable mass, close to anal verge, rectal pain often wirse with defaction or valsalva
dx= clinical, can get CT to exclude peri-rectal abcess

RECTAL: can be few outward signs, need DRE to feel for fluctuance.
CT if oftne first diagnositc test, but often need MRI or u/s for small fistulas etc.

85
Q

peri anal vs peri rectal abscess mgmt

A

ANAL: drain in ED with cruciate incision, clavulin or cipro/flagyl, if systemically unwell surgical consult and CT to exclude peri-rectal. + sitz-baths!!! 50% recurrence rate, if recurring referral to gen sx

RECTAL:
should be managed by gen surg, likely taken t OR

86
Q

causes of anal fistula

A

peri-rectal abcess
chrons
UC
radiation
HS

87
Q

causes of proctitis
what is proctitis

A

inflmmation of rectum
causes = STIs (most commonly: HPV, G+C, syphillis, herpes, chancroid), UC, radiation, enteric pathogens

88
Q

what is a pilonidal abcess

A

chornic, acquired infection of hair follicles in gluteal cleft, from being obese and sitting on them. NO anorectal involvement

these are a painful palpable fluctuant mass at top of gluteal cleft, posterior and midline!

89
Q

what is Goodsall’s rule for fistulas?

A
90
Q

most common location for fistulas

A

midline and posterior, less commonly midline anterior, if off midline suspect systemic disease (IBD, TB, Syphillis, HIV etc)

91
Q

most common cause of rectal bleeding in infants and children

A

anal fistula

92
Q

what test to consider after rectal fb removal?

A

sigmoidoscopy to check for bowel injury

93
Q

which rectal fb should be removed by surgeon?

A

sharp, large, proximal, etc

94
Q

degrees of hemmroids?

A

1st = not prolapse
2nd= temporary prolapse, but spont reduce
3rd+ require manual reduction
4th = irreducible

95
Q

internal vs external hemmroids

A

internal = above dentate line, painless
external= below dentate line and may painful, but very painful when thrombosed

96
Q

what is an uncomplicated hemorrhoid? what is the tx?

A

non thrombosed external and non-prolapsed internal –> conservative
ie sitz baths, high fibre diet,

97
Q

incomplete bs complete rectal prolapse

A

incomplete = only mucosa (children)
complete = all bowel layers

98
Q

causes of unconjugated (indirect) hyperbilirubinemia

A

hemolysis, crigler-nijjar, gilberts, hemtoma resorption

99
Q

causes of conjugated (direct) hyperbilirubinemia

A

long list –> anything that can cause hepatitis, obstructive HOB dz, shock liver

100
Q

viral Hepatitis

A

LOOK at presentation

101
Q

Hep B serologies

A
102
Q

HCV transimission

A

IVDU, blood products before 1992, rarely sexual

103
Q

what is cirrhosis

A

final common pathway of many liver disease, defined by hepatocellular injury leading to fibrosis

104
Q

confirmatory and screening test for HCV

A

confirm: HCV RNA = active dz
screen = anti HCV

105
Q

stigmata of chronic liver disease?

A
106
Q

3 most common organisms in SBP

A

e coli, strep, enterococcus

107
Q

diagnostic criteria for SBP

A

PMN > 250 from diagnostic para

108
Q

treatment for hepatic encephalopathy?

A

lactulose, titrated to stools

109
Q

pathophys of hepatorenal syndrome, prognosis?

A

poorly understood. ?severe portal HTN leads to splanchin vasodilatin which leads to renal artery vasocontriction –> 10 days median survival, 90% 2 months mortality

110
Q

most common causes of liver abcess in North america?

A

secondary to cholangitis or biliary obstruction

111
Q

organism for amebic liver abcess?

A

entamoeba histolytica

112
Q

empiric treatment for liver abcess?

A

cover both bacterial and amebic causes with ceftriaxone and flagyl

113
Q

risk factors for gallstones

A

fat, female, fertile, first nations, >forty years old

114
Q

lab and u/s findings of choledocolithiasis

A

elevated ALP/GGT/bili
dilated CBD of hepatic ducts on u/s

115
Q

who gets alcalculous cholecystitis

A

chronically debilitated, on TPN or in ICU

116
Q

cutoff of gallbladder wall thickening for cholecytitis

A

> = 3 mm

117
Q

what test to order if u/s unequivocal for cholecytitis

A

HIDA scan (textbook), although CT would work too?

118
Q

complications of cholecytitis

A

gangrene gallbladder, empyema, perforation, gallstone ileus, sepsis, abscess, fistula

119
Q

charcot triad for cholangitis

A

RUQ pain, fever, jaundice (present 70% of time)

120
Q

rayndauds pentad for cholangitis

A

charcot triad + AMS + hypotension = suggests sepsis

121
Q

causes of cholangitis

A

gallstones, ampullary lesion, bile duct stricture, pancreatic cyst

122
Q

what is porcelain gallbladder?

A

linear/punctate calcifications within GB, 3% of time related to malignancy so refer for elective chole

123
Q

causes of pancreastitis

A

Gallstones and etoh are 80%

then: hyperlipidemia, scorpion bites, trauma, steroids, ERCP, drugs, mumps, autoimmune

124
Q

diagnosis of pancreatitis, do you need imaging, if so when?

A

-lipase 3X ULN is diagnostic
- CT only if diagnostic uncertainty or concern for nectrotizing pancreatitis
-can consider u/s for gallstones
- imaging not usually required for dx

125
Q

mgmt of pancreatitis

A

admit, pain control, anti-emetics, IVF (250 mL/hr), NPO, surgical consult if stones for ERCP +/- chole, abx only if septic or nectrotizing pancreatitis

126
Q

pancreatitis mortality score

A

Ranson score

127
Q

necrotizing pancreatitis?

A

elevated wbc, fever (although mild fever present in 50% of non-nec panc), SHOCK

128
Q

Mesenteric ischemia vs ischemic colitis

A

MI: can be occlusive or non-occlusive dz, most commonly from embolism to SMA

IC: low flow state through IMA leading colonic ischemia

129
Q

What is chronic mesenteric ischemia

A

Recurrent abdo pain, usually post prandial, think intestinal angina

130
Q

Lactate in mesenteric ischemia

A

Sensitive but not specific

131
Q

Symptoms of acute mesenteric ischemia

A

Pain out of proportion, colicky/poorly localized,
Elevated lactate
May have vomiting or diarrhea

132
Q

Cause of occlusive and non occlusive mesenteric ischemia

A
133
Q

Imaging of mesenteric ischemia

A

CTA is best test
CT can have indirect signs, ie bowel wall edema or intramural gas
Axr: pneumotosis intestinalis

134
Q

Initial mgmt of mesenteric ischemia

A

Early surgical consult
Aggressive IVF rehydration
Broad spectrum abx
Consider heparin if embolic source, non-urgent OR etc

135
Q

Rectal bleeding in mesenteric ischemia/ischemic colitis

A

Common in ischemic colitis
Can happen, but defs not always in mesenteric ischemia

136
Q

reducible, vs incarcerated vs strangulated hernia?

A

you should just know this

137
Q

when do hernias need emergency surgical consult?

A

strangulation, obstruction, systemic s/s

also need abx and IVF

138
Q

which organisms are apslenic pts at risk of?

A

encapsulated: Haemophilus influenza, neisseria menigitidis, strep penumo)

also gram neg: eg e coli, psuedomonas,

CCFP EM (20 decks)

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