gi Flashcards
diverticulosis vs itis
- 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!!
-osis pres
most asx and found incidentally
-may have vague LLQ pain, bloating, constipation / diarrhea
test of choice for diverticulosis
BARIUM ENEMA or found INCIDENTALLY ON CT!
diverticulosis treatment
high fiber diet, psyllium
diverticulosis complications
bleeding: PAINLESS BLEEDING (ID site w/ tech 99 scan + angiography if pos or colonoscopy)
diverticulitis
diverticulitis pres
LLQ pain, low fever, n/v, constipation / diarrhea, dysuria, leuocytosis
diverticulitis test of choice
CT scan w/ oral and IV contrast
could use AXR to r/o other path
BARIUM ENEMA AND COLONOSCOPY CONTRAINDICATED!
diverticulitis tx
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
diverticulitis complications
-abscess, fistula, obstruction, free colonic perforation (rate, catastrophic)
indications for emergent surgery w/ diverticulitis
-generalized peritonitis, large undrainable abscess, clinical deterioration despite med management / drainage
f/u tx required for diverticulitis
after 1st episode ALWAYS GET F/U CT after first episode to r/o cancer!!!!
causes of ulcers….
2 major causes:
- 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
- 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)
- more common w/ gastric ulcers
ulcer patho
H pylori: increased acid causing metaplastic islands, colonization of islands
NSAID: reduced PG
ulcer presentation
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
differences b/n duodenal and gastric ulcers
-duodenal: often 40 y/o, less relationship w/ food, more in SMOKERS, HIGHER RISK OF MALIGNANCY - MUST BIOPSY TO DOC HEALING / R/O CA!!!
ulcer work up
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
h pylori testing
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
uncomplicated ulcer treatment -1st line
- 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
- take PPI 30 min before breakfast QD, lasts 24 hrs, longterm use may increase risk of c diff or GI infxn
- sucralfate, misoprostol, bismuth - adjunct to promote healing
- d/c NSAIDS if nsaid induced
h pylori tx
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)
maintenance tx
needed for pt w/ reccurernt ulcers or pt w/ h pylori and failed eradication tx - need maintenance PPI qd
tx for nsaid ulcers
- discontinue nsaids!
- test for h pylori
- 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
nsaid / ASA - tips to protect stomach
- 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!
nonhealing ulcers…causes
#1 noncompliance w/ meds -malignancy, zollinger ellison, hernia, chron, h pylori
workup for nonhealing ulcers
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
complications of PUD
- GI hemorrhage
- perforation
- GOO
PUD –> GI hemorrhage
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
GI hem 2 PUD workup -
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!
gi hem 2 pud treatment
- 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
- 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 - w/ recurrent rebleed / not controlled by endsocopy - refer to surgeon
ulcer perf
- popping sensation then generalized severe abdominal pain d/t peritonitis
- appear toxic w/ rigid quiet stopmach w/ rebound tenderness
- hypotensive w/ bacterial peritonitis
PUD perf worup
abdominal CT to detect free abdominal air
PUD perf treatment
EMERGENT SURGERY TO PREVENT SEPSIS AND DEATH
GOO 2 PUD
-n/v of poorly digested food, abd fullness, weight loss, early satiety
GOO 2 PUD work up
-foul smelling fluid on NG confirms
GOO 2 PUD tx
- NG suction
- replace fluids IVF and K (often dehydrated and hypokalemic and met alk)
- IV PPI
- supplement nutrition
5 endoscopy 24-72 hours later ,may need surgery
zollinger ellison syndrome
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
ZE syndome pres
- 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
ZE syndrome workup
- 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
ZE tx
- PPI to get acid <10 meq/h
- all attempt curative resection w/ local disease
- w/ mets - debulk and chemo
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….
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!
rome II criteria for IBS….
12+ weeks in last 12 months w/ abdominal pain w/ 2 out of 3:
- pain relieved w/ defecation
- w/ change in appearance of stool
- change in frequency of stool
- may also have incomplete evac, bloating / abd distension
red flag w/ changing bowel habits…
- 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
positive hydrogen breath test indicates…
lactose intolerance!
treatment for IBS
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
type of dysphagia typically w/ GERD…
w/ solids! if w/ both solids and liquids consider another cause…think about CANCER!
GERD dx
- 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!
- 24 hr PH probe - gold std, rarely done!
- upper /GI (barium contrast) - good to detect anatomic changes / complications of GERD
- esophageal manometry: check for motility disorder
treatment for GERD:
- lifestyle mod- avoid irritants (caffeine, chocolate, citrus, peppermint, large meals / fatty foods), dont sleep after eating - can add antacid
- PPI given qd
- H2 - renally dosed
- 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! - nissen - for patient w/ normal motility
- partial fundoplication w/ impaired motility
complications of GERD
- erosive esophagitis- tx w/ PPI x 8 weeks b/c at increased risk of ulcer / stricture / barretts
- peptic stricture - dx w/ EGD, tx w/ dilation
- esophageal ulcer
- 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!
- recurrent PNA d/t aspiration -
- lipid-laden macrophages on bronchoscopy!
- pitted dental enamel
- laryngitis, pharyngitis
treatment for ulcer post endoscopy..
- 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
hospitilization for ulcer..
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
long-term prevention post ulcer…
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
esophageal varices…
- 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
management - initial
-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!
E. varice tx after meds…
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)
esophageal varice prevention…
- nonselective BB: propranolol or nadolol, best if combined w/ banding treatment!
- 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!
