GI Flashcards
Pain that is often improved with eating but worsens 2 to 5 hours after a meal is associated with what condition?
Duodenal ulcer
Abdominal pain that is worse with eating is associated with what condition?
Gastric ulcer
A 56-year-old male with recurrent upper GI bleeds has had an upper endoscopy with no signs of bleeding found. Which procedurecould be done to further investigate his source of bleeding ?
Deep small bowel enteroscopy
Deep small bowel enteroscopy and pill capsule are both options for further investigate an upper GI bleed. Although pill capsule tends to be used first due to reduced cost and risk, this can only provide diagnosis and not direct intervention compared to deep small bowel enteroscopy.
Hematochezia
Bright red blood PR
Melena
Dark, tarry stools
Zollinger–Ellison Syndrome
A gastrinoma located on the pancreas or the stomach; secretes gastrin, which stimulates high levels of acid production in the stomach. As a result, multiple and severe ulcers in the stomach and duodenum develop. Complaints of epigastric to midabdominal pain.
Pain of acute pancreatitis
Severe epigastric pain that radiates to LUQ.
Psoas/Iliopsoas Sign
With patient in supine position, have patient raise right leg while applying downward pressure on the leg. Positive finding if RLQ abdominal pain occurs with passive right hip extension.
Obturator Sign
Positive if internal rotation of the hip causes RLQ abdominal pain.
Rovsing’s Sign
Deep palpation of the LLQ of the abdomen results in referred pain to the RLQ.
Acute appendicitis
Markle Test (Heel Jar Test)
Instruct patient to raise heels and then drop them suddenly. An alternative is to ask the patient to jump in place. Positive if RLQ pain is elicited or if patient refuses to perform because of pain.
Murphy’s Maneuver
Press deeply on the RUQ under the costal border during inspiration. Mid-inspiratory arrest and pain in the RUQ is a positive finding (Murphy’s sign).
Cullen’s sign
edema and bruising of the subcutaneous tissue around the umbilicus
Suggestive of pancreatitis
Grey Turner’s sign
bruising/bluish discoloration of the flank area that may indicate retroperitoneal hemorrhage)
Acute pancreatitis, small bowel obstruction, ruptured abdominal aortic aneurysm…
IgM Anti-HAV
Acute infection; patient is contagious.
Hepatitis A virus (HAV) still present (infectious); no immunity yet.
Screening test for hepatitis A
IgG Anti-HAV
Presence means lifelong immunity.
No virus present and patient is not infectious.
Can remain detectable for decades.
History of native hepatitis A infection or vaccination with hepatitis A vaccine (Havrix)
HBsAg
Hepatitis B Surface Antigen
Screening test for hepatitis B
HBsAg is positive when the patient is infected currently or was infected in the past.
HBsAg-positive status always means an infected patient (new infection or chronic)
HBsAg & Anti-HBs
HBsAg is the serologic hallmark of hepatitis B virus (HBV) infection. HBsAg appears weeks after an acute exposure to HBV.
The disappearance of HBsAg is followed by presence of hepatitis B surface antibody (anti-HBs) conferring antibodies and long-term immunity from reinfection.
Presence may be due to either a past infection or vaccination with hepatitis B vaccine.
HBcAg & Anti-HBc
Appears at onset of symptoms in acute hepatitis B and persists for life.
Prescence of IgM anti-HBc indicates acute HBV infection (but may remain detectable up to 2 years after acute infection).
IgG anti-HBc persists along with anti-HBs in patients who recover from hepatitis B
HBeAg
Marker for actively replicating HBV; highly infectious.
AST
0-35 is normal
Present in the liver, cardiac muscle, skeletal muscle, kidney, and brain
Elevated in most liver diseases and in those that involve the liver (e.g., hepatitis, cirrhosis, nonalcoholic fatty liver disease [NAFLD], alcohol use disorder, certain drugs, myocardial infarction, mononucleosis).
ALT
Normal in males is 29 to 33 U/L; in females is 19 to 25 U/L
Primarily present in liver; more specific biomarker for hepatocellular injury compared with AST. most sensitive to liver damage.
Fluctuate with menstrual cycle
AST: ALT Ratio
A ratio of 2:1 or greater may be indicative of alcohol abuse.
GGT
Normal range is 0 to 30 IU/L.
GGT is found in many organs of the body but mainly in the liver, kidneys, and pancreas.
Elevated levels may be an indicator of alcohol abuse or alcoholic liver disease.
Can also be elevated with medications (phenytoin, barbiturates), biliary disease, liver cancer or metastases, pancreatitis.
Elevated levels in combination with ALP elevation suggest liver etiology.
***GGT is elevated in liver disease and biliary obstruction. A “lone” elevation in the GGT is a sensitive indicator of possible alcoholism.
ALP
Enzyme derived from bone, liver, gallbladder, kidneys, GI tract, and placenta
Elevated in biliary obstruction, cholestasis, bone malignancy/metastasis, healing fractures.
May be elevated in bone disorders such as vitamin D deficiency, Paget’s disease, and bone cancer. A GGT, which would be elevated with liver disease, may be drawn to differentiate between liver disease and bone disorders.
S/S diverticulitis
- LLQ abdominal pain that is constant and has been present for several days
- RLQ or suprapubic pain due to inflamed sigmoid colon or right-sided (cecal) diverticulitis.
- fever
- nausea and vomiting.
- change in bowel habits; up to 50% will have constipation, and some will have diarrhea.
Treatment for uncomplicated diverticulitis
Liquid diet and oral analgesia—reassess in 2 to 3 days and then weekly until resolution of all symptoms
Antibiotics only for those at high risk of complications (comorbidities, immunosuppressed)
If no response in 48-72 hours or if symptoms worsen, refer to ED
Chronic Therapy for Diverticulosis
- High-fiber diet with fiber supplementation such as psyllium (Metamucil) or methylcellulose (Citrucel).
- Tobacco cessation
- physical activity
- reduced meat intake.
- Probiotics
- Colonoscopy for all patients after resolution of symptoms to rule out colon cancer.
S/S Acute Hepatitis
- fever
- fatigue
- anorexia
- nausea
- malaise
- dark-colored urine
- scleral icterus
- jaundice
- clay-colored stools
- RUQ abdominal pain.
Treatment for acute hepatitis
- Remove and treat the cause
- Avoid hepatotoxic agents such as alcoholic drinks, acetaminophen, and statins
- Treatment is supportive.
Referral is often indicated for advanced liver disease.
PCR tests
Test for presence of viral RNA.
A positive result means that the virus is present. This test can be performed for diagnosing disease such as hepatitis C or HIV.
Hepatitis D
A person must have hepatitis B to become infected with hepatitis D. There is no vaccine for hepatitis D, but hepatitis B vaccination will prevent acquisition of hepatitis D.
S/S Acute Pancreatitis
- nausea and vomiting
- severe epigastric and LUQ abdominal pain (may radiate to back). - dyspnea
- pleural effusions
- acute respiratory distress syndrome. - Abdominal guarding and tenderness over the epigastric area or the upper abdomen.
- Positive Cullen’s and Grey Turner’s sign.
- ileus and signs and symptoms of shock (e.g., fever, tachypnea, hypoxemia, and hypotension).
Refer patient to ED.
Diagnostics for acute pancreatitis
Elevated pancreatic enzymes such as serum amylase, lipase, and trypsin
Elevated AST, ALT, GGT, bilirubin, leukocytosis
Abdominal ultrasound and CT
Hypocalcemia
Antibiotics most likely to cause C. Diff infection
clindamycin (Cleocin), fluoroquinolones, cephalosporins, and penicillins
Symptoms of non-severe C. diff infection
watery diarrhea (>3 loose stools in 24 hours) with lower abdominal pain and cramping, low-grade fever, and leukocytosis.
Diagnostics for C. Diff
- Nucleic acid amplification testing (NAAT) for C. difficile of a single stool sample.
- Stool assay (by enzyme-linked immunosorbent assay) for C. difficile toxins.
- CBC with leukocytosis (>15,000 cells/μL), basic metabolic panel with serum electrolytes, creatinine, and blood urea nitrogen (BUN).
Treatment for C. Diff
- Discontinue offending antibiotic
- good hand hygiene
- fidaxomicin 200 mg PO BID for 10 days
OR
vancomycin 125 mg PO QID × 10 days
S/S Viral gastroenteritis
- N/V
- non-bloody diarrhea (3xday)
- typically lasts 1-3 days
Caused by rotavirus, norovirus, enteric adenovirus, and astrovirus.
S/S/ Bacterial gastroenteritis
- acute onset high fever,
- bloody diarrhea
- severe abdominal pain
- six stools in a 24-hour period.
Incubation period ranges from 1 to 6 hours if due to contaminated food (enterotoxin) or 1 to 3 days if bacterial infection.
Symptoms usually resolve in 1 to 7 days. Antibiotics can reduce the duration of diarrhea but may lead to bacterial resistance and eradication of normal flora.
Bacterial pathogens include Escherichia coli, Salmonella, Shigella, Campylobacter, C. difficile (antibiotic use, recent hospitalization), and Listeria (pregnant patients increased risk).
S/S Protozoal Gastroenteritis
- Symptoms develop within 7 days of exposure
- last ≥7 days.
- watery diarrhea.
Travelers’ diarrhea starts within 3 to 7 days after exposure and usually resolves in 5 days. Self-limited.
Protozoal pathogens include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.
Irritable Bowel Syndrome
Chronic functional disorder of the colon (normal colonic tissue) marked by exacerbations and remissions (spontaneous).
Commonly exacerbated by excess stress.
It may be classified as diarrhea-predominant or constipation-predominant. In some cases, it may alternate between the two.
IBS s/s
- episodes of cramping
- constipation/diarrhea
- bloating
- pain better after defecation
- increased frequency of BMs
IBS treatment
- avoid gas producing foods
- antispasmodics
- Low FODMAP diet
- decrease stress
- start fiber if constipated
- immodium before meals if diarrhea
When not to give an anti-diarrheal?
If the patient has acute onset of bloody diarrhea, fever, abdominal pain, or pain that worsens with defecation because it may be caused by Escherichia coli O157:H7 (a shiga toxin–producing E. coli [STEC]), amebiasis, Salmonella, Shigella, or other pathogens.
Treatment for Nonalcoholic Fatty Liver Disease
- Lose weight, exercise, and watch diet.
- Discontinue alcohol intake permanently.
- Avoid hepatotoxic drugs (e.g., acetaminophen, isoniazid, statins).
- Recommend vaccination for hepatitis A and B and annual flu vaccine.
- Refer to GI specialist.
Epigastric pain relieved by eating may indicate..
Peptic Ulcer Disease
Usually has relief with eating and pain reoccurs shortly after meal
Gold standard for diagnosing PUD is
Upper endoscopy with biopsy - needed to rule out gastric cancer
Treatment for non-h-pylori peptic ulcers
- stop NSAIDS
- quit smoking & alcohol
- lifestyle changes
- start H2RA or PPI for 4-8 weeks
- refer to GI if no improvement after treatment
Treatment for H-pylori peptic ulcers
Triple thearpy
- Clarithromycin, amoxicillin OR flagyl + PPI
Quadruple therapy
- Bismuth subsalicylate
- Metronidazole
- Tetracycline
- Standard-dose PPI
Treatment for 14 days
Viral hepatitis A s/s
- acute onset of fever
- headache
- malaise
- anorexia
- nausea & vomiting
- diarrhea
- abdominal pain
- dark urine
- jaundice
Lab testing for Hep A
IgM anti–HAV detectable at time of symptom onset, peak of disease, and detectable for 3 to 6 months.
IgG antibodies remain detectable for decades and are associated with lifelong protective immunity.
Treatment for Hep A
Supportive care
Hepatitis C
Can be acute or chronic
Recommend one time screening for all adults 18-75
Antiviral treatment and refer to GI if chronic.
What does this person have?
HBsAg: Positive
IgM anti-HBc: Positive
Anti-HBs: Negative
Anti-HBc: Positive
Patient is acutely infected with hepatitis B infection.
Treatment for Hep B
Supportive care
Antiviral
If chronic infection rather than acute, refer to GI
What does this person have?
HBsAg: Negative
Anti-HBs: Positive
Anti-HBc: Positive
Results: Immune to hepatitis B due to natural infection.
Gastric ulcer pain
The pain is generally worsens while eating.
Duodenal ulcer pain
The pain of is often improved with eating but worsens 2 to 5 hours after a meal, when acid is secreted in the absence of a food buffer, and at night (11 p.m. to 2 a.m.) when the circadian pattern of acid secretion is highest.
HBeAg
a marker of hepatitis B replication and infectivity
