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gi Flashcards

1
Q

diverticulosis vs itis

A
  • osis: outpouching of mucosa, most in sigmoid, most found incidentally on colonoscopy - test of choice is barium enema
  • itis: inflam / infection of diverticula d/t fecal impaction - BARIUM ENEMA AND COLONOSCOPY CONTRAINDICATED (risk of PERF) - find on CT SCAN W/ ORAL AND IV CONTRAST!!
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2
Q

-osis pres

A

most asx and found incidentally

-may have vague LLQ pain, bloating, constipation / diarrhea

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3
Q

test of choice for diverticulosis

A

BARIUM ENEMA or found INCIDENTALLY ON CT!

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4
Q

diverticulosis treatment

A

high fiber diet, psyllium

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5
Q

diverticulosis complications

A

bleeding: PAINLESS BLEEDING (ID site w/ tech 99 scan + angiography if pos or colonoscopy)
diverticulitis

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6
Q

diverticulitis pres

A

LLQ pain, low fever, n/v, constipation / diarrhea, dysuria, leuocytosis

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7
Q

diverticulitis test of choice

A

CT scan w/ oral and IV contrast
could use AXR to r/o other path
BARIUM ENEMA AND COLONOSCOPY CONTRAINDICATED!

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8
Q

diverticulitis tx

A

if mild and no comorbidities, tx outpatient
more severe inpatient:
uncomplicated: augmentin; IV cipro or bactrim + flagyl x 7-10 days or until afebrile x 3-4 (cover anaerobes), if sx persist past 3-4 may need surgery
complicated: keep on fluid diet and abx to cover anaerobe and gram negative, iv x 5-7 d and then change to oral
-get repeat CT and surgery consult w/o improvement in 72 hrs

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9
Q

diverticulitis complications

A

-abscess, fistula, obstruction, free colonic perforation (rate, catastrophic)

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10
Q

indications for emergent surgery w/ diverticulitis

A

-generalized peritonitis, large undrainable abscess, clinical deterioration despite med management / drainage

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11
Q

f/u tx required for diverticulitis

A

after 1st episode ALWAYS GET F/U CT after first episode to r/o cancer!!!!

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12
Q

causes of ulcers….

A

2 major causes:

  1. H PYLORI - ulcers in 10% affected, always look for h pylori if nsaid not the cause, more common in duodenal ulcers
    • w/o tx, 85% recurrence at 1 year - only 5-20% w/ tx
  2. NSAIDS: greatest risk w/in first 3 mo of therapy, i f >60 y/o or if using in combination w/ ASA, steroids, anticoags
    • more common w/ gastric ulcers
      3rd: rare - zolinger-ellison syndrome (acid hypersecretion)
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13
Q

ulcer patho

A

H pylori: increased acid causing metaplastic islands, colonization of islands
NSAID: reduced PG

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14
Q

ulcer presentation

A

cannot distinguish duodenal vs gastric by history!

hallmark: epigastric pain - dull, knawing, aching, often relieved w/ food (duodenal - gastric has less correlation w/ food) that returns 2-4 hours later, worse at night
- N/V, anorexia (esp w/ gastric) w/ sig weight loss / vomiting expect complication
- PE often normal - may have epigastric tenderness

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15
Q

differences b/n duodenal and gastric ulcers

A

-duodenal: often 40 y/o, less relationship w/ food, more in SMOKERS, HIGHER RISK OF MALIGNANCY - MUST BIOPSY TO DOC HEALING / R/O CA!!!

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16
Q

ulcer work up

A

Labs: normal in uncomplicated
-anemia w/ acute blood loss
-leukocytosis: suggests perforation
-elevated amylase w/ severe persistent pain - penetrated pancreas
-measure gastrin for zollinger ellison!
ENDOSCOPY IS TEST OF CHOICE!!!!!
-not needed for uncomplicated - do trial of PPI
-always biopsy gastric ulcer! (suspect malignancy w/ nonhealing ulcers!)
***do f/u endoscopy in 12 weeks post tx to document healing of gastric ulcer!
-get CT if suspect complications

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17
Q

h pylori testing

A

once dx by endoscopy -
get biopsy for rapid urease test (can detect BOTH ACTIVE INFECTION and RESOLUTION post abx)
-gold std: histologic eval of biposy
-w/ hx of ulcer / no endoscopy - test w/ urea breath test
*can get FALSE NEG w/: PPI - w/hold 7-14 d prior - bismuth, abx

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18
Q

uncomplicated ulcer treatment -1st line

A
  1. PPI > H2 blockers - reduced acid secretion by inactivating H-K atpase pump. PPI more effective and faster pain relief than H2!
    • take PPI 30 min before breakfast QD, lasts 24 hrs, longterm use may increase risk of c diff or GI infxn
      - H2 - take at night, less effective and dont use cimetidine d/t interactions, gynecomastia and ED
  2. sucralfate, misoprostol, bismuth - adjunct to promote healing
    - d/c NSAIDS if nsaid induced
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19
Q

h pylori tx

A

1st time: triple therapy - PPI + 2 abx
PPI bid + clarithromycin + amoxicilin or use flagyl w/ PCN allergy x 14 days
OR
quadruple therapy:
PPI bid + bismuth + tetracyline QID + flagyl TID/QID x 14 days
-use quadruple in areas of high clarithro resistance or w/ recent marolide use or 2nd line if triple fails
-w/ large / complicated, continue PPI 2-4 weeks (duodenal) and 4-6 weeks (gastric) after ulcer heals
then confirm eradication >4 weeks of completed abx and >2 weeks once PPI d/c w/ noninvasive (urea breath or fecal antigen tests)

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20
Q

maintenance tx

A

needed for pt w/ reccurernt ulcers or pt w/ h pylori and failed eradication tx - need maintenance PPI qd

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21
Q

tx for nsaid ulcers

A
  1. discontinue nsaids!
  2. test for h pylori
  3. PPI or H2
    * if cannot stop nsaids, do daily PPI
    - w/ RF give PPI when prescribed nsaid to prevent ulcer (w/ cv risk, give naproxen) and coxib if gi risk >cv
    * if taking combo nsaid + asa give PPI or misoprostol for protection
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22
Q

nsaid / ASA - tips to protect stomach

A
  • if <60-70 w/o gi RF give ASA alone
  • everyone else needs PPI qd for prophylaxis
  • avoid omeprazole and esomeprazole w/ plavix! inhibit cyp 450 which activates plavix!!
  • *use H2 with plavix users if need gi prophylaxis! avoid cimetidine!
23
Q

nonhealing ulcers…causes

A 
#1 noncompliance w/ meds
-malignancy, zollinger ellison, hernia, chron, h pylori
24
Q

workup for nonhealing ulcers

A

get repeat biopsy if nonhealing after 2-3 mo to r/o malignancy / infection
-refer for surgery w/ persistent nonhealing once r/o nsaid use and h pylori infection

25
Q

complications of PUD

A
  1. GI hemorrhage
  2. perforation
  3. GOO
26
Q

PUD –> GI hemorrhage

A

50% of UGIB, 80% stop spon - higher mortality w/ elderly, hypotensive, bright red blood, comorbidities, coagulopathy
-signs of bleeding - coffee grounds emesis, hematemesis, melena, hematochezia, anemia sx

27
Q

GI hem 2 PUD workup -

A

ENDOSCOPY!!!! best test - can id risk of bleed and tx bleed w/ hyeater probe / clip

  • NG tube, FOBT
  • *TEST ALL W/ BLEEDING ULCERS FOR H PYLORI!
28
Q

gi hem 2 pud treatment

A
  1. IV PPI x 3 days w/ high risk of rebleeding (highest risk is w/in first 72 hours!!!) on endoscopy 80 mg bolus then 8 mg/h infusion x 72 hours
  2. tx h pylori then f/u urea breath test 4-8 weeks after done w/ tx
    - long term acid supp w/ PPI w/ persistent h pylori / not d/t Nsaid
  3. w/ recurrent rebleed / not controlled by endsocopy - refer to surgeon
29
Q

ulcer perf

A
  • popping sensation then generalized severe abdominal pain d/t peritonitis
  • appear toxic w/ rigid quiet stopmach w/ rebound tenderness
  • hypotensive w/ bacterial peritonitis
30
Q

PUD perf worup

A

abdominal CT to detect free abdominal air

31
Q

PUD perf treatment

A

EMERGENT SURGERY TO PREVENT SEPSIS AND DEATH

32
Q

GOO 2 PUD

A

-n/v of poorly digested food, abd fullness, weight loss, early satiety

33
Q

GOO 2 PUD work up

A

-foul smelling fluid on NG confirms

34
Q

GOO 2 PUD tx

A
  1. NG suction
  2. replace fluids IVF and K (often dehydrated and hypokalemic and met alk)
  3. IV PPI
  4. supplement nutrition
    5 endoscopy 24-72 hours later ,may need surgery
35
Q

zollinger ellison syndrome

A

pancreatic islet gastrin-secreting neuroendocrine tumor (gastrinoma)
criteria;
1. gastric acid hypersecretion
2. severe PUD
3. non beta islet cell tumor of pancreas
-2/3 malignant and 80% located in gastrinoma triangle: cystic duct superiorly, junction of 2nd and 3rd part of duodenum inf and neck of pancreas medially

36
Q

ZE syndome pres

A
  • severe / atypical PUD (MULTPLE ULCERS), diarrhea (relieved by NG tube), weight loss, abd pain, steatorrhea
  • suspect w/ ulcers refractory to std tx, large or in duodenl bulb, multiple ulcers / frequent - test w/ fasting gastrin leves
37
Q

ZE syndrome workup

A
  • increased fasting gastrin >150 pg/ml -w/draw H2 24 hrs before or PPI 6 days before and check pH
    • w/ increased acid secretion (>15 meq/L) and serum gastrin >1000 pg/ml confirms ZE
  • w/ lower gastin leves, do secretin test

**secretin injection = test of choice!! (normally secretin will inhibit gastrin secretion - w/ ZE syndrome gastrin INCREASES after secretin given!)
+ w/ rise >200 in 2-30 min
-test for PTH, prolactin, LH-FSH and GH to r/o MEN
-CT / MRI to look for mets ESPECIALLY LIVER! #1 SITE
-w/ negative do somatostatin receptor scintography (SRS) w/ SPECT

38
Q

ZE tx

A
  1. PPI to get acid <10 meq/h
  2. all attempt curative resection w/ local disease
  3. w/ mets - debulk and chemo
39
Q

53 y/o Asian w/ increased stress at work w/ irregular bowel movements x past 3-4 months - sometimes has 3/d, loose watery w/ some mucous, none bloody and some abdominal pain relieved w/ BM. no changes in appetite or weight. nl PE and labs….

A

IBS!!!!!

  • functional GI disorder, nonprogressive w/o specific lab/PE diagnostics
  • gold std for dx: rome II criteria
  • dx of exclusion! r/o red flags first!
40
Q

rome II criteria for IBS….

A

12+ weeks in last 12 months w/ abdominal pain w/ 2 out of 3:

  1. pain relieved w/ defecation
  2. w/ change in appearance of stool
  3. change in frequency of stool
    - may also have incomplete evac, bloating / abd distension
41
Q

red flag w/ changing bowel habits…

A
  • bloody stools, weight loss, fever
  • recent overseas travel
  • recent med / antibiotic use
  • fam hx IBD
  • *if over 50 y/o or has red flag - must eval w/ colonoscopy / sigmoidoscopy before dx of IBS made
  • can r/o celiac w/ biopsies, check stool studies w/ concern of infection
42
Q

positive hydrogen breath test indicates…

A

lactose intolerance!

43
Q

treatment for IBS

A

mild: most respond to diet modification - add fiber - and stress relief
mod-severe: meds
1. antispasmodics - anticholinergics: hyoscyamine, dicyclomine, methscopolamine for acute pain / bloating
se: urinary retention, constipation, tachycardia, dry mouth
2. antidiarrheal agents loperamid 2 mg TID - QID, choestyramine
3. anticonstipation: osmotic laxatives (milk of mag, polyethylene glycol), linaclotide, lubiprostone
4. predominant pain / bloating: TCAs - nortriptyline, desipramine, imipramine
-severe diarrhea: alosetron

44
Q

type of dysphagia typically w/ GERD…

A

w/ solids! if w/ both solids and liquids consider another cause…think about CANCER!

45
Q

GERD dx

A
  • clinical if uncomplicated and no red flag symptoms - can do trial of PPI
  • with red flags -
    1. EGD - best test for dyspepsia! w/ biopsy!
    • do w/ red flags / refractory to medical treatment
    • **all patients w/ symptomatic gerd for 5+ years must be screened for BARRETTS!
      1. 24 hr PH probe - gold std, rarely done!
      2. upper /GI (barium contrast) - good to detect anatomic changes / complications of GERD
      3. esophageal manometry: check for motility disorder
46
Q

treatment for GERD:

A
  1. lifestyle mod- avoid irritants (caffeine, chocolate, citrus, peppermint, large meals / fatty foods), dont sleep after eating - can add antacid
  2. PPI given qd
  3. H2 - renally dosed
  4. w/o relief can add GI motility agent: metoclopromide (reglan) - dopamine antagonist w/ risk of TD, dystonia or bethanechol - cholinergic agonist
    - monitor b12, calcium, iron w/ PPI and H2 - interacts w/ phenytoin, antifungals, warfarin!
    refractory: surgery = good outcomes!
  5. nissen - for patient w/ normal motility
  6. partial fundoplication w/ impaired motility
47
Q

complications of GERD

A
  1. erosive esophagitis- tx w/ PPI x 8 weeks b/c at increased risk of ulcer / stricture / barretts
  2. peptic stricture - dx w/ EGD, tx w/ dilation
  3. esophageal ulcer
  4. barretts:
    • metaplasia of squamous cells to columnar - increased risk of ADENOCARCINOMA! 0.5% change/ yr
    • screen pt w/ symptomatic GERD for 5+ years!
    • w/ doc barretts, monitory w/ EGD q 2 years! and tx cancer w/ endoscopic radiofrequency ablation!
  5. recurrent PNA d/t aspiration -
    • lipid-laden macrophages on bronchoscopy!
  6. pitted dental enamel
  7. laryngitis, pharyngitis
48
Q

treatment for ulcer post endoscopy..

A
  • IV PPI 80 mg bolus then 8mg/hr infusion x 72 hours for bleeding ulcer, ulcer w/ visible vessel or adherent clot then switch to 40 mg BID oral PPI x 6 weeks and may do repeat scope to document healing
  • w/ flat pigmented spots or clean base do std oral PPI therapy QD
  • clear liquid diet then advance as tolerated
49
Q

hospitilization for ulcer..

A 
high risk (active bleed, visible vessel or clot): hosp x 3 days if no complications, clear liquids and slowly advance diet
-clean ulcer: regular diet and d/c if hemodynamically stable soon after
50
Q

long-term prevention post ulcer…

A

If H pylori: get std txt - dont need long-term tx unless need antiplt / NSAID tx
If NSAID induced and must resume NSAID with lowest dose PPI
If need ASA for secondary prevention w/ estab CAD / cardiovasc risk resume w/ low dose PPI
*START W/IN 1-3 DAYS IDEALLY, DEF W/IN 7!
-if taking ASA only for primary prevention - rec not taking
If idiopathic - rec longterm antiulcer therapy

51
Q

esophageal varices…

A
  • d/t portal HTN, which is most commonly d/t cirrhosis!

- #1 cause of significant UGIB and 30% lifetime bleed risk w/ 60% recurrent bleed w/in 6 weeks of bleed

52
Q

management - initial

A

-IVF and blood!!
-give FFP if INR >1.8-2 and plt if <50,000
-may need vit K later w/ abnormal protime
-ABX prophylaxis: ceftriaxone (rocephin) x 5-7 to prevent spontaneous bacterial peritonitis!!! preferred over FQ d/t resistance
-vasoactive meds: good for acute control, no reduction in mortality!
A. octreotide - dec hepatic and splanchnic blood flow
B. somatostatin
-once confirmed on EGD, continue x 3-5 days w/ adv liver disease
-lactulose and rifaximin for encephalopathy
-titrate lactulose to 2-3 BM/d
**rifaximin very expensive - wont go home on this! just lactulose!

53
Q

E. varice tx after meds…

A

ENDOSCOPY FOR ALL W/IN 2-12 HRS!!!

  • tx of choice: banding - done q 2-4 weeks for 2-6 treatments
  • if unable to band, do sclerosing then f/u with banding
  • if above fails, can do mech / balloon tamponade or TIPS (40% mortality)
54
Q

esophageal varice prevention…

A
  1. nonselective BB: propranolol or nadolol, best if combined w/ banding treatment!
  2. in pt w/ cirrhosis, do EGD to monitor and if negative for varices, repeat in 3 years!
    TIPS / portosystemic shunt if above fails / noncompliant pt!

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