GI Flashcards
Hep A transmission, sx, dx, tx
transmission: Fecal-oral
Prodromal sxs:
*anorexia, N/V
*fatigue, malaise, arthralgias, myalgias
*HA, photophobia
*pharyngitis, cough, coryza
1-2wks later 🡪 jaundice, +/- RUQ pain
Dark urine, clay-colored stools – may appear 1-5d before onset of jaundice
dx
Acute: IgM anti-HAV
Past exposure: IgG anti-HAV
LFTs: ↑ AST/ALT & bilirubin
tx
No treatment needed (self-limiting)
Hep B transmission, sx, dx, tx
transmission: Sex & blood
Prodromal sxs:
*anorexia, N/V
*fatigue, malaise, arthralgias, myalgias
*HA, photophobia
*pharyngitis, cough, coryza
1-2wks later 🡪 jaundice, +/- RUQ pain
Dark urine, clay-colored stools – may appear 1-5d before onset of jaundice
dx
HBsAg (surface antigen): (+) in acute & chronic
Anti-HBs (surface antibody): (+) if recovered/immunized
Anti-HBc (core antibody):
*acute: IgM
*chronic/recovered: IgG
HbeAg (envelope antigen): replicative (chronic)
Anti-Hbe (envelope antibody): non-replicative (chronic)
LFTs: ↑ bilirubin
*acute: AST/ALT in the thousands
*chronic: AST/ALT in the hundreds
HBV DNA: best way to assess viral replications activity
Liver bx
tx
Supportive – majority will not become chronic
Hep C transmission, sx, dx, tx
transmission: Blood (IVDU MC
Prodromal sxs:
*anorexia, N/V
*fatigue, malaise, arthralgias, myalgias
*HA, photophobia
*pharyngitis, cough, coryza
1-2wks later 🡪 jaundice, +/- RUQ pain
Dark urine, clay-colored stools – may appear 1-5d before onset of jaundice
dx
Screening test: HCV antibodies
Confirmatory: HCV RNA
Acute: (+) HCV RNA, (+/-) anti-HCV
Resolved: (-) HCV RNA, (+/-) anti-HCV
Chronic: (+) HCV RNA, (+) anti-HCV
tx
w/o cirrhosis:
*sofosbuvir + (velpatasvir or daclatasvir) x12wks or
*glecaprevir + pibrentasvir x8wks
w/ compensated cirrhosis:
*sofosbuvir + velpatasvir x12wks or
*glecaprevir + pibrentasvir x12wks or
*sofosbuvir + daclatasvir x24wks
w/ decompensated cirrhosis:
*sofosbuvir + velpatasvir x24wks or
*sofosbuvir + daclatasvir x12wks
Hep D transmission, sx, dx, tx
transmission: Blood
Prodromal sxs:
*anorexia, N/V
*fatigue, malaise, arthralgias, myalgias
*HA, photophobia
*pharyngitis, cough, coryza
1-2wks later 🡪 jaundice, +/- RUQ pain
Dark urine, clay-colored stools – may appear 1-5d before onset of jaundice
dx
Screening: total anti-HDV – confirmed by immunochemical staining of liver bx for HDAg or RT; PCR assays for HDV RNA in serum (HBV serologies also performed)
tx
No FDA approved management
Hep E transmission, sx, dx, tx
transmission: Fecal-oral
Prodromal sxs:
*anorexia, N/V
*fatigue, malaise, arthralgias, myalgias
*HA, photophobia
*pharyngitis, cough, coryza
1-2wks later 🡪 jaundice, +/- RUQ pain
Dark urine, clay-colored stools – may appear 1-5d before onset of jaundice
dx
LFTs: ↑ AST/ALT, bilirubin
IgM anti-HEV: (+) = infected
tx
No treatment needed (self-limited) – not associated w/ a chronic state
Highest mortality due to fulminant hepatitis during pregnancy
Acute Pancreatitis definition, sx, dx, tx
*acinar cell injury 🡪 intracellular activation of pancreatic enzymes 🡪 autodigestion of pancreas
Etiologies:
*gallstones (MC), ETOH abuse (2nd MC)
sx
Epigastric pain
*radiates to back
*exacerbated if supine, relieved leaning forward
*N/V, fever
PE:
*epigastric tenderness
*tachycardia
*adynamic ileus 🡪 decreased bowel sounds
*severe 🡪 dehydration, shock
Necrotizing, hemorrhagic:
*Cullen’s sign (periumbilical)
*Grey Turner sign (flank)
dx
Criteria: 2/3
(1) acute onset epigastric pain radiating to back
(2) ↑ lipase/amylase ≥3xULN
(3) CT, MRI, or U/S findings of acute pancreatitis
*no imaging required if pt meets first 2 criteria
Labs:
*↑ lipase/amylase (lipase more specific)
*ALT 3-fold ↑ 🡪 gallstone pancreatitis
*hypocalcemia: necrotic fat binds calcium
*leukocytosis
*↑ glucose, bilirubin, triglycerides
Abdominal CT: dx imaging of choice
*also perform in pts who fail to improve/worsen after 48hrs
Transabdominal U/S:
*assess for gallstones & bile duct dilation
Abdominal x-ray:
*“sentinel loop” = localized ileus of small bowel segment in LUQ
*colon cutoff sign: abrupt collapse of colon near pancreas
*calcification 🡪 chronic pancreatitis
tx
“rest the pancreas”
Supportive:
*NPO
*high-volume IVF (LR preferred)
*analgesia (Meperidine)
Chronic Pancreatitis definition, sx, dx, tx
Progressive inflammatory changes to the pancreas that lead to loss of pancreatic endocrine & exocrine function
Etiologies: ETOH abuse MC, idiopathic
sx
Triad: calcification + steatorrhea + DM (seen only in 1/3 of pts)
*weight loss; epigastric &/or back pain may be atypical or completely absent
dx
Amylase & lipase usually normal
CT scan: calcification of the pancreas – often done in pts w/ acute pain to r/o other causes of abdominal pain
Abdominal x-ray: calcified pancreas
Pancreatic function testing: fecal elastase most sensitive & specific; pancreatic stimulation w/ secretin & CCK (not usually done)
tx: supportive
Anal Fissure definition, sx, dx, tx
Painful linear tear/crack in the distal anal canal
sx
Severe painful rectal pain & bowel movements causing the pt to refrain from defecating, bright red blood per rectum
PE:
*longitudinal tear in the anoderm that usually extends no more proximally than the dentate line – MC at the posterior midline (99% M, 90% W)
*skin tags seen in chronic
dx: clinical
tx
>80% resolve spontaneously
Supportive measures: first line management – warm sitz baths, analgesics, high fiber diet, increased water intake, stool softeners, laxatives, mineral oil
Second line tx: topical vasodilators: NTG (ADRs: HA, dizziness) nifedipine ointment
Botox injections: to reduce spasm of the internal sphincter (may be more effective that topical dilators)
Surgery: lateral internal sphincterotomy reserved for refractory cases
Complications: fecal incontinence
Perianal Abscess and Fistula defintion, sx, dx, tx
½ perianal abscesses are caused by fistulas
MC in posterior rectal wall
Abscess: infection MC from an obstructed anal crypt gland, w/ resultant pus collecting in the subcutaneous tissue, intersphincteric plane, or beyond
Fistula: epithelialized tract that connects an abscess w/ skin or adjacent organs
sx
Abscess: severe pain in anal or rectal area
*fever, malaise
Fistula:
*“non-healing” anorectal abscess
*chronic purulent drainage
*pain w/ defecation, sitting, & activity
*malodorous perianal drainage & pruritis
dx
Clinical rectal exam, DRE
Fistula DX: MRI & endosonography
tx
Perianal Abscess: I&D, Antibiotics; sitz baths, high fiber
*Augmentin, cipro + metronidazole
Fistula: surgical
Colorectal Cancer MCC, RF, genetics
Most arise from adenomatous polyps
MC cause of large bowel obstruction in adults
Risk Factors:
*age >50yrs (peak 65yrs), AA, family hx of CRC
*IBD: UC > Crohn
*diet (low fiber, high in red or processed meat, animal fat)
*obesity, smoking, ETOH
Protective Factors: physical activity, regular use of ASA, NSAIDs
Genetics:
Familial Adenomatous Polyposis: genetic mutation of APC gene; adenomas begin in childhood – almost all will develop colon cancer by age 45yrs; prophylactic colectomy best for survival
Turcot Syndrome: FAP-like syndrome + CNS tumors (medulloblastoma, glial tumors)
Lynch Syndrome (Hereditary Nonpolyposis CRC): autosomal dominant; d/t loss of function in DNA mismatch repair genes (MLH1, MSH2/6, PMS3); 40% risk of colon cancer – mean age late 40s
*type I: esp. seen on right side
*type II: ↑ risk of extra-colonic cancers (esp. endometrial)
Puetz-Jegher’s Syndrome: autosomal dominant; associated w/ hamartomatous polyps, mucocutaneous hyperpigmentation (lips, oral mucosa, hands) – risk of breast/pancreatic cancer
Colorectal cancer sx
Iron deficiency anemia (fatigue, weakness), rectal bleeding, abdominal pain, change in bowel habits
Advanced disease: ascites, abdominal masses, hepatomegaly
Right-Sided (Proximal): chronic occult bleeding (iron deficiency anemia, + guaiac), diarrhea
Left-Sided (Distal): bowel obstruction; present later & cause changes in stool diameter – may develop Streptococcus bovis endocarditis
↓ risk:
*pedunculated
*tubular
*<1cm
↑ risk:
*sessile
*villous
*>1cm
Colorectal cancer dx
Colonoscopy w/ bx: diagnostic TOC
Barium enema: apple core lesion
Labs: iron deficiency anemia, (CRC is MC cause of occult GI bleeding in adults)
Tumor markers: CEA is MC monitored
Screening: any of the 3 approaches
*fecal occult blood test annually starting at 50yrs
*colonoscopy q10yrs for ages 50-75
*flexible sigmoidoscopy q5yrs + fecal occult blood testing q3yrs
Lynch Syndrome: colonoscopy q1-2yrs beginning at 20-25yrs
FAP: flexible sigmoidoscopy annually beginning 10-12yrs
Colonoscopy Screening:
*no risk: q10yrs
*low risk: q5-10yrs
1-2 polyps, <1cm, tubular, low grade
*high risk: q1-3yrs
≥3 polyps, ≥1cm, sessile/villous, high grade
*mega risk: q2-6mo
≥10 polyps
Colorectal cancer tx
Localized: surgical resection (radical vs. endoscopic) + post-op chemo to destroy residual cells & micrometastases
Metastatic: palliative chemo
Chemotherapy:
*FOLFOX
-folinic acid (leucovorin calcium)
-fluorouracil
-oxaliplatin
*FOLFIRI
-folinic acid (leucovorin calcium)
-fluorouracil
-irinotecan
*VGEF inhibitor: bevacizumab
Esophageal Neoplasms definition, sx, dx, tx
Adenocarcinoma
*MC in the US
*MC in distal esophagus, esophagogastric junction
*Risks: Barret’s esophagus (complication of GERD), smoking, high BMI
Squamous Cell
*MC worldwide – increased incidence in AA
*MC in mid to upper third of the esophagus
*Risks: smoking, alcohol
sx
*progressive dysphagia – solid food dysphagia progressing to include fluids
*odynophagia
*weight loss
dx: Upper endoscopy w/ bx
tx
*esophageal resection combined w/ chemo
*radiation, chemo (5-FU)
*palliative stenting (advanced)
Esophageal Strictures defintion, sx, dx, tx
Esophageal Web: noncircumferential thin membrane in the mid-upper esophagus
Shatzki Ring: circumferential diaphragm of tissue that protrudes into the esophageal lumen
*MC at the lower esophagus (at the squamocolumnar junction)
*Risks: hiatal hernia
sx
Dysphagia (esp. to solids)
Plummer-Vinson Syndrome:
*dysphagia + webs + iron deficiency anemia
*may be associated w/ atrophic glossitis
*increased risk for esophageal SCC
dx: Barium esophagram (swallow)
tx: Symptomatic: dilation
Gastric Carcinoma definition, sx, dx, tx
Types:
*adenocarcinoma MC (90%)
*lymphoma, carcinoid tumors, stromal, sarcomas
Risk Factors:
*H. pylori biggest risk factor
*preserved foods (salted, cured, smoked, pickled, nitrites, nitrates)
sx
*weight loss & persistent abdominal pain MC
*early satiety
PE:
*supraclavicular lymph nodes (Virchow’s node)
*umbilical LN (Sister Mary Joseph’s node)
*left axillary LN (Irish sign)
*palpable nodule on rectal exam (Blumer’s shelf)
dx: Upper endoscopy w/ bx
tx
Early local disease: endoscopic resection
*gastrectomy, chemo, radiation
*poor prognosis – usually presents late in the disease
Celiac Disease definition, sx, dx, tx
Autoimmune-mediated inflammation of the small bowel due to reaction w/ alpha-gliadin in gluten-containing foods
sx
Malabsorption: diarrhea, abdominal pain/distention, bloating, steatorrhea; growth delays in children
Dermatitis herpetiformis: pruritic, papulovesicular rash MC on extensor surfaces, neck, trunk, & scalp
dx
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 villi
tx
GLUTEN-FREE DIET
*avoid wheat, rye, barley
*limit oat consumption
*vitamin supplementation
Cholelithiasis definition, sx, dx, tx
Gallstones in the biliary tract (usually in the gallbladder) w/o inflammation
Types of Gallstones:
*cholesterol (MC)
*black stones: hemolysis or ETOH-related cirrhosis
*brown stones: ↑ in Asian population, parasitic, bacterial infections
Risk Factors: 5Fs (fat, fair, female, forty, fertile)
*OCPs (increased estrogen), Native Americans, bile stasis, chronic hemolysis, cirrhosis, infection, rapid weight loss, IBD, TPN, fibrates, increased triglycerides
sx
Most are asymptomatic – may be an incidental finding
Biliary colic: episodic, abrupt RUQ or epigastric pain, resolves slowly, lasting 30min-hrs; may be associated w/ nausea & precipitated by fatty foods or large meals
dx
U/S – initial TOC: stone in GB or cystic duct
tx
Observation if asymptomatic
Symptomatic: ursodeoxycholic acid may be used to dissolve the gallstones (takes 6-9mo); elective cholecystectomy
Acute Cholecystitis definition, sx, dx, tx
Inflammation & infection of the gallbladder due to obstruction of the cystic duct by gallstones
Etiologies: E. coli MC, klebsiella, other gram-neg enteric organisms
Chronic Cholecystitis:
*fibrosis & thickening of the gallbladder due to chronic inflammatory cell infiltration of the gallbladder evident on histopathology – almost always associated w/ gallstones
sx
Continuous RUQ or epigastric pain – may be precipitated by fatty foods or large meals
*may be associated w/ nausea, guarding, anorexia
PE:
*fever (often low-grade); enlarged, palpable gallbladder
*MURPHY’S SIGN: RUQ pain or inspiratory arrest w/ palpation of the gallbladder
*Boas sign: referred pain to the right shoulder or subscapular area (phrenic nerve irritation)
dx
U/S – initial TOC: thickened or distended gallbladder, pericholecystic fluid, sonographic Murphy’s sign
CT scan: alternative to U/S; can detect complications
Labs: ↑ WBCs (leukocytosis w/ left shift), ↑ bilirubin, alk phos, & LFTs
HIDA scan: most accurate test – cholecystitis present if there is no visualization of the gallbladder
tx
NPO, IV fluids, abx (ceftriaxone + metronidazole) followed by cholecystectomy (usually within 72hrs; laparoscopic preferred)
Cholecystostomy (percutaneous drainage) if nonoperative
Cholesterolosis: fat deposits on GB 🡪 “strawberry GB”; tx is cholecystectomy
Choledocholithiasis definition, sx, dx, tx
Gallstones in the common bile duct (can lead to cholestasis due to blockage)
sx
Prolonged biliary colic: RUQ or epigastric pain, N/V – pain usually more prolonged due to the presence of the stone blocking the bile duct
PE: RUQ or epigastric tenderness, jaundice
dx
Labs: ↑ AST/ALT, alk phos, & GGT (cholestasis)
U/S – initial
ERCP: dx TOC – diagnostic + therapeutic
tx
ERCP stone extraction preferred over laparoscopic choledocholithotomy
Acute Ascending Cholangitis definition, sx, dx, tx
*biliary tract infection secondary to obstruction of the common bile duct – e.g., gallstones, malignancy
Etiologies: E. coli MC
sx
Charcot’s Triad: fever + RUQ pain + jaundice
Reynold’s Pentad: + shock or AMS
dx
Labs:
*leukocytosis
*cholestasis: ↑ alk phos & GGT
*↑ bilirubin > increased ALT/AST
U/S – initial
MRCP
Cholangiography via ERCP: gold standard
tx
*IV abx
*piperacillin/tazobactam
*metronidazole + cephalosporin
*metronidazole + cipro/levofloxacin
*CBD decompression & stone extraction (ERCP)
Eventually 🡪 elective cholecystectomy
Primary Sclerosing Cholangitis definition, sx, dx, tx
Autoimmune, progressive cholestasis leading to diffuse fibrosis of intra/extrahepatic biliary ducts
Risk Factors:
*MC associated w/ IBD – UC (90%)
*men 20-40yrs
Complications: cirrhosis, liver failure, cholangiocarcinoma
sx
Jaundice, pruritis, fatigue, RUQ pain, hepatomegaly, splenomegaly
dx
Cholestatic pattern: ↑ alk phos & GGT, ↑ AST/ALT, bilirubin, IgM
+ P-ANCA hallmark
MRCP, ERCP – most accurate test: beaded appearance of biliary ducts (narrowing, strictures)
Liver bx – rarely used
tx
Stricture dilation for symptomatic relief
Cholestyramine for pruritis
Liver transplant definitive
Cirrhosis sx, dx, tx
*result of chronic hepatic injury w/ inflammation that leads to hepatic fibrosis & regenerative nodules, HCC PRECURSOR**
MCC ⇢ ▪︎chronic viral hepatitis (HBV, HCV**)
sx
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
dx
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
tx
▪︎alcohol abstinence most important
▪︎treatment of underlying conditions
▪︎avoid hepatotoxic drugs: NSAIDs, opiates,
BDZs (HE)
Definitive ⇢ liver transplant
▪︎indications: index complication (e.g., ascites, HE, variceal hemorrhage) &/or MELD score ≥15
UC definition, sx, dx, tx
chronic recurrent disease involving only the colon characterized by diffuse mucosal inflammation that results in friability erosions and ulcers with bleeding. rectum is always involved!!
Hallmark: bloody diarrhea**
S/SXS: fecal urgency, abdominal pain & cramps, tenesmus
dx
Sigmoidoscopy: mucosa – edema, friability, mucopus, erosions; UNIFORM inflammation
*NO COLONOSCOPY W/ FULMINANT DZ (r/o perforation)
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/Moderate UC:
Induction TX: ▪︎proctitis/proctosigmoiditis: topical (rectal) mesalamine
▪︎left-sided/extensive: PO 5-ASA + rectal mesalamine
▪︎topical/PO steroids if no improvement after 2-4wks
Maintenance TX:
▪︎continue w/ same agent that induced remission except for steroids
Moderate/Severe UC:
Induction TX: TNF inhibitors
▪︎steroids for symptom control short-term
Maintenance TX:
▪︎continue w/ same agent that induced remission except for steroids
Crohns Disease definition, sx, dx, tx
Transmural process involving any segment of GI tract, resulting in mucosal inflammation/ulceration, structuring, fistula formation, and abscess formation.
MC: terminal illeus
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
▪︎watery diarrhea, steatorrhea
dx
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)
⇣ albumin
*⇡ ESR/CRP during active inflammation
*⇡ fecal calprotectin correlates w/ active inflammation
*POSITIVE ASCA
Moderate-Severe: CRP >5mg/dL, anemia, ⇣ albumin, fecal calprotectin >150-200mcg/g
tx
Induction TX (acute flares): agents w/ rapid onset ⇢ steroids, biologics
Maintenance TX: biologics & immunomodulators
Diverticulosis definition, sx, dx, tx
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
sx
Asymptomatic – incidental finding
Lower GI bleeding: diverticulosis MCC of acute lower GI bleed
*painless hematochezia
dx: colonoscopy
tx: High fiber diet, Bran, psyllium
Diverticulitis definition, sx, dx, tx
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
dx:
CT scan
Labs:
*leukocytosis
tx
Uncomplicated:
*metronidazole + (ciprofloxacin or levofloxacin)
x7-10d
*clear liquid diet
Esophagitis definition, sx, dx, tx
Etiologies:
*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
sx
3 classic sxs: odynophagia + dysphagia + retrosternal chest pain
dx
Upper endoscopy – allows for direct visualization
Double contrast esophagram
tx: underlying cause
Infectious Esophagitis definition, sx, dx, tx
Risk Factors:
*immunocompromised states (HIV, post-transplant, malignancy, chemo) but can occur in healthy pts
*candida is MCC – 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
Eosinophilic Esophagitis definition, sx, dx, tx
*allergic inflammatory eosinophilic infiltration of the esophageal epithelium
*MC seen in children & associated w/ atopic disease (asthma, eczema)
sx
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)
Pull-Induced Esophagitis definition, sx, dx, tx
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
Caustic (Corrosive) Esophagitis definition, sx, dx, tx
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
Gastritis definition, sx, dx, tx
Gastritis: superficial inflammation or irritation of the stomach mucosa w/ mucosal injury
Gastropathy: mucosal injury w/o evidence of inflammation
PATHO: imbalance between aggressive & protective mechanisms of the gastric mucosa
Etiologies: Helicobacter pylori MCC
*NSAIDs & aspirin: second MC cause
*acute stress in critically ill pts
*other: heavy ETOH consumption, bile salt reflux, medications, radiation, trauma, corrosive ischemia, pernicious anemia, portal HTN
sx
MC asymptomatic
If symptomatic, sxs are similar to PUD (e.g., dyspepsia, N/V, epigastric pain)
Gastroenteritis: V/D, dehydration
*viral (MC): rotavirus
*bacterial: salmonella, shigella, campylobacter
*parasitic: giardia, E. histolytica
Tx: fluids, fix electrolytes, BRAT diet
dx
Upper endoscopy w/ biopsy: dx TOC – thick, edematous erosion <0.5cm
H. pylori testing
tx
Similar to PUD (e.g., H. pylori eradication, acid suppression therapy w/ H2 receptor antagonists or PPIs (omeprazole), stop offending agents)
Pharmacologic prophylaxis for pts at high risk for developing stress-related gastritis w/ IV proton pump inhibitors or H2 blockers
H. pylori eradication: “CAP” – clarithromycin + amoxicillin + PPI
Rotavirus sx, dx, tx
S/SXS: generally begins w/ vomiting followed by watery diarrhea; high fevers in 1/3 of cases
DX: antigen detection via EIA, PCR
X: supportive; prevention – rotavirus vaccine
Norovirus sx, dx, tx
Norovirus – outbreaks in care centers, cruise ships
*MCC of foodborne disease outbreaks
S/SXS: sudden onset vomiting, watery diarrhea, abdominal pain, fever
DX: PCR; stool antigen tests have lower s/s
tx: supportive
Adenovirus sx, dx, tx
S/SXS: milder than rota/nora; watery diarrhea (vomiting/fever less common)
DX: sapovirus/astrovirus: PCR; adenovirus: EIA
tx: supportive
Campylobacter jejuni sx, dx, tx
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
DX: culture using selective media (preferred), EIA, PCR
tx: usually supportive; azithromycin x3d or erythromycin x5d can shorten duration when given early in illness
C. diff sx, dx, tx
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
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
E. coli, Shiga-toxin-producing (STEC) sx, dx, tx
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
DX: culture on sorbitol containing selective media, EIA for Shiga toxin – monitor: CBC/BUN/Cr for HUS
TX: supportive; abx not recommended d/t HUS risk
E. coli, Enterotoxigenic sx, dx, tx
E. coli, Enterotoxigenic – “Traveler’s diarrhea” (resource-limited settings)
S/SXS: watery diarrhea, abdominal cramping
DX: clinic; PCR; *culture cannot distinguish from normal flora
TX: azithromycin or cipro x3d may ↓ duration
Nontyphoid Salmonella sx, dx, tx
Nontyphoid Salmonella – poultry/beef, dairy, contaminated water, reptiles/amphibians, MC <4yo
S/SXS: diarrhea, abdominal cramps, fever
*Complications – bacteremia, osteomyelitis, brain abscess, meningitis
DX: stool culture
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
Salmonella typhi sx, dx, tx
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
DX: blood culture, bile culture, bone marrow aspirate *stool cultures often negative
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)
Shigella sx, dx, tx
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
DX: stool culture
TX: azithromycin, ceftriaxone, or FQ
Vibrio cholerae sx, dx, tx
Vibrio cholerae – shellfish; “rice water diarrhea”
S/SXS: painless, watery diarrhea w/ significant electrolyte imbalances
DX: stool culture (must request selective media)
TX: single dose doxy or azithromycin; erythromycin, cipro, or tetracycline x3d
Yersinia enterocolitica sx, dx, tx
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
DX: stool culture (must request selective media)
TX: parenteral 3rd gen ceph, Bactrim, aminoglycosides, FQs, tetracycline, doxy, chloramphenicol – only for neonates/IC
Giardia lamblia sx, dx, tx
Giardia lamblia – daycare, camping trips, contaminated water; “backpacker’s diarrhea”
S/SXS: acute – watery diarrhea, foul-smell, flatulence, anorexia; can 🡪 FTT
DX: stool EIA or DFA
TX: tinidazole x1, metronidazole x5-10d, nitazoxanide x3d
Entamoeba histolytica
Entamoeba histolytica – resource-limited
S/SXS: intestinal amebiasis MC – gradual onset bloody diarrhea, lower abd. pain, tenesmus, wt loss; complications: toxic megacolon, fulm. colitis
DX: stool O&P, serologic testing
TX: metronidazole or tinidazole then iodoquinol or paromomycin
Bismuth Subsalicylate meds and their MOA
Pepto-Bismol
Kaopectate
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)
Loperamide MOA
MOA: binds gut wall opioid receptors, inhibiting peristalsis; ↑ anal sphincter tone
Indications: noninvasive diarrhea
*avoid in pts w/ acute dysentery or colitis
Ondansetron, Granisetron, Dolasetron MOA
MOA: blocks serotonin receptors
*neuro: HA, fatigue, sedation
*cardiac: QT prolongation, arrhythmias
*GI: bloating, diarrhea, constipation
Dopamine Blockers MOA
Prochlorperazine
Promethazine
Metoclopramide
MOA: blocks CNS dopamine receptors; mild antihistaminic/antimuscarinic
*QT prolongation, anticholinergic, drowsiness, hypotension, hyperprolactinemia
*EPS: rigidity, bradykinesia, tremor, akathisia
Dystonic Reactions (Dyskinesia): tx – IV diphenhydramine
Parkinsonism: rigidity, tremor
GERD definition, cx, sx, dx, tx
*reflux of gastric contents into the esophagus due to an incompetent LES
*transient relaxation of the LES (incompetency) 🡪 gastric acid reflux 🡪 esophageal mucosal injury
Complications:
Esophagitis: inflammation from acid
Stricture: narrow from acidic damage
Barrett’s esophagus: esophageal squamous epithelium replaced by precancerous metaplastic columnar cells from the cardia of the stomach
Esophageal adenocarcinoma: as a result of Barrett’s
sx
Heartburn (pyrosis) hallmark
*retrosternal & postprandial
*increased w/ supine position
*may be relieved w/ antacids
Regurgitation:
*water brash, sour taste in the mouth
*cough, sore throat
Atypical sxs: hoarseness, aspiration pneumonia, wheezing, chest pain
ALARM SXS:
*dysphagia
*odynophagia
*weight loss
*bleeding
dx
Clinical dx based on hx if presenting w/ classic, simple sxs
24hr ambulatory pH monitoring: gold standard if confirmation is needed
Esophageal manometry: ↓ LES pressure
Dx if persistent or alarm sxs:
Endoscopy: first line diagnostic test if persistent sxs or complication of GERD is suspected (e.g., alarm sxs, malignancy, sxs >5-10yrs)
tx
Lifestyle modification: elevate the head of the bed 6-8in, avoid recumbency for 3hrs after eating, smoking cessation, decreased alcohol intake, weight loss
Stage 2: intermittent or mild (<2episodes/wk) – “as needed” pharmacologic therapy: antacids & H2 receptor antagonists
Stage 3: PPIs in moderate to severe disease (≥2episdoes/wk)
Hemorrhoids internal vs external definition, sx, dx, tx
Internal Hemorrhoids:
*originate from superior hemorrhoid vein; above dentate line
*tend to bleed, usually painless
stages
I: Does not prolapse (confined to anal canal); may bleed w/ defecation
II: Prolapses w/ defecation or straining but spontaneously reduce
III: Prolapses w/ defecation or straining, requires manual reduction
IV: Irreducible & may strangulate
External Hemorrhoids:
*originate from inferior hemorrhoid vein; below dentate line
*do not tend to bleed, usually painful
sx
Internal Hemorrhoids:
*intermittent rectal bleeding MC – painless bright red blood (hematochezia) – seen on toilet paper, coating the stool, or dispersed in toilet water
*may have rectal itching & fullness or mucus discharge
*uncomplicated internal are usually not tender & not palpable (unless they are thrombosed) – rectal pain w/ internal suggests a complication
External Hemorrhoids:
*perianal pain aggravated w/ defecation
*may have tender palpable mass; +/- skin tags
dx
Visual inspection, DRE, fecal occult blood testing
Anoscopy for internal allows for direct visualization & diagnosis
Proctosigmoidoscopy or colonoscopy may be indicated in pts w/ hematochezia to r/o proximal sigmoid disease
tx
conservative tx: high fiber diet, increased fluids; warm sitz baths
Procedures: if failed conservative, debilitating pain, strangulation
*rubber band ligation (MC), sclerotherapy, infrared coagulation; excision of thrombosed external hemorrhoids may be performed
Hemorrhoidectomy: for stage IV or those not responsive to other therapies; surgical management used for external hemorrhoids
Hepatocellular Carcinoma definition, MCC, sx, dx, tx
*5th MC malignancy worldwide, M > F
*MC primary liver malignancy in adults, peak 70-75yo
Etiology: cirrhosis MCC (80%)
*chronic HBV, HCV
sx
*usually asymptomatic early on
▪︎sxs from underlying cirrhosis/hepatitis
Advanced disease:
▪︎weight loss, anorexia
▪︎hepatomegaly & RUQ tenderness
▪︎jaundice, ascites
dx
LABS: ⇡ alk phos, ⇡ AST/ALT, ⇡ GGT, ⇡ α-fetoprotein (AFP)
*AFP ≥20ng/mL w/ liver lesions of any size ⇢ CT/MRI
CT w/ contrast: 1+ lesions w/ irregular borders
*arterial phase hyperenhancement
*nonperipheral washout: hypointense compared to
surrounding in portal venous or delayed phase
*enhancing capsule
Liver biopsy ⇢ definitive
tx
Early stage: surgical resection
Intermediate: locoregional therapy
*transarterial chemoembolization (TACE)
*transarterial radioembolization (TARE)
Advanced: systemic chemotherapy
*atezolizumab/bevacizumab
*liver transplant
Hiatal Hernia definition, sx, dx, tx
Herniation of structures from the abdominal cavity through the esophageal hiatus of the diaphragm
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
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
Irritable Bowel Syndrome definition and patho
*chronic, functional idiopathic pain disorder w/ NO organic cause
*onset MC in late teens, early 20s; MC in W
PATHO:
*abnormal motility: chemical imbalance in the intestine (including serotonin & acetylcholine) causing abnormal motility spasm 🡪 abdominal pain; altered gut microbiota
*visceral hypersensitivity: pts have lowered pain thresholds to intestinal distention
*psychosocial interactions & altered CNS processing
IBS sx
Hallmark: abdominal pain associated w/ altered defecation/bowel habits (diarrhea, constipation, or alternation between the two); pain often relieved w/ defecation
Alarm Sxs:
*evidence of GI bleed: occult blood in stool, rectal bleeding, anemia
*anorexia or weight loss, fever, nocturnal sxs, family hx of GI cancer, IBD, or celiac sprue
*persistent diarrhea causing dehydration; severe constipation or fecal impaction; onset >45yrs
IBS dx
Dx of exclusion (after workup e.g., colonoscopy & abdominal CT to r/o other etiologies)
Rome IV Criteria: recurrent abdominal pain on average at least 1d/wk in the last 3mo associated w/ at least 2 of the following:
Related to defecation
Onset associated w/ change in stool frequency
Onset associated w/ change in stool form (appearance)
IBS tx
Lifestyle & dietary changes first line – low fat, high fiber, unprocessed food
*avoid beverages containing sorbitol or fructose (apples, raisins), avoid gas-producing foods (beans, cruciferous vegetables); sleep, smoking cessation, exercise
Constipation Sxs:
*prokinetics: fiber, psyllium – polyethylene glycol may be added after fiber; bulk forming or saline laxatives
*lubiprostone & linaclotide are usually reserved for pts w/ no response to above
Diarrhea Sxs:
*loperamide, eluxadoline, rifaximin; bile acid sequestrants, alosetron
*anticholinergics/antispasmodics (dicyclomine, hyoscyamine)
Mallory-Weiss Syndrome (Tears) definition, sx, dx, tx
*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
Peptic Ulcer Disease definition and causes
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)
PUD sx
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)
Duodenal ulcer: better with meals, worse 2-5 hours after
gastric ulcer: worse with meals
PUD dx and tx
dx
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 = +)
tx
H. pylori positive:
*bismuth quadruple therapy: bismuth subsalicylate + tetracycline + metronidazole + PPI x14d
H. pylori negative:
*PPI; H2 blocker, misoprostol, antacids, etc.
PPI MOA
MOA: block H/K ATPase (proton pump) of parietal cell, reducing acid secretion
*associated w/ faster sxs relief & healing
*taken 30min before meals in AM
Indications: most effective drug to treat PUD; gastritis, ZES
*90% healing of duodenal ulcers after 4wks & gastric ulcers after 6wks
ADRs: diarrhea, HA, hypomagnesemia, B12 deficiency, hypocalcemia
*Omeprazole: associated w/ C. diff infections & hip fractures
DI: omeprazole causes P450 inhibition 🡪 increases levels of theophylline, warfarin, phenytoin
H2 Blockers MOA
MOA: histamine 2 receptor blocker (indirectly inhibits proton pump) reducing acid/pepsin secretion
*90% healing of duodenal ulcers after 6wks & gastric ulcers after 8wks
ADRs: B12 deficiency, ↑ LFTs
*Famotidine, Nizatidine: blood dyscrasias; Famotidine can prolong QT
-CNS: confusion, dizziness, HA
Antacids MOA
MOA: neutralize acid, prevents conversion of pepsinogen to pepsin (active form)
Systemic: calcium carbonate (Tums)
*ADRs: acid rebound, milk alkali syndrome
