GI Flashcards
Odynophagia =
Dysphagia =
painful swallowing
difficulty swallowing
Causes of esophagitis
- infections related to immunocomp’d patient: Candida, Herpes, CMV
- GERD
How does endoscopy with biopsy for esophagitis patient differentiate the infectious causes?
Herpes – Multiple shallow ulcers throughout the esophagus
CMV – Large solitary deep ulcers
Candida – Raised white plaques which can be removed
How is esophagitis caused by Candida treated?
Fluconazole x 3 weeks
Diagnostic test of choice for most esophageal and gastric issues
Barium swallow
Why is there concern for doing an endoscopy with diverticula?
possible perforation
What is diverticula within the esophagus called?
Zenker’s Diverticula
Zenker’s Diverticula treatment
Hydration after meals
Thorough chewing
Surgical repair of diverticula
Decreased peristalsis of the esophagus along with increased muscle tone of the lower esophagus
Achalasia
Barium swallow of achalasia
bird’s beak (clear tapering at LES)
I came in to see my physician assistant because of…
- Regurgitating undigested food hours after a meal
- Bad breath
- Neck pain
- Odynophagia
- Dysphagia
Zenker’s Diverticula
I came in to see my physician assistant because of…
- Dysphagia with both fluids and solids and will continue to get progressively worse
- Regurgitation of undigested foods
- Non-cardiac chest pain
Achalasia
Achalasia treatment
CCBs – Nifedipine
Try to dilate LES: Nitrates, Botox injections, Pneumatic dilation
Surgical myotomy
Patient c/o forced retching vomiting and is now vomiting blood. Also has epigastric pain. Likely dx?
Mallory-Weiss tears (longitudinal lacerations of esophagus)
Mallory-Weiss tear treatment
Usually self limiting
Transfusion if high loss of blood
Endoscopy with epinephrine injection or thermal coagulation
Treatment of esophageal strictures
Treat for GERD since most likely cause
PPIs - omeprazole
H2 Blockers - Zantac
Surgical correction
DDX of hematemesis (vomiting blood)
Mallory-Weiss tears, esophageal varices, PUD, cirrhosis…
I came in to see my physician assistant because of…
- Substernal chest pain
- Pain typically postprandial
- Dysphagia
- Chronic dry cough and laryngitis
GERD
I came in to see my physician assistant because of…
Hematemesis (vomiting blood)
Black, tarry or bloody stool
Signs and symptoms of GI bleed (lightheaded etc)
Esophageal varices
Pathophysiology of esophageal varices
dilated veins of esophagus secondary to alcoholism, cirrhosis, and/or portal HTN
What is diagnostic and therapeutic for esophageal varices?
Endoscopy
- Variceal ligation or banding
- Sclerotherapy
- Balloon tamponade
Behavior modifications to relieve GERD?
Smaller portion sizes Not laying down after meals Weight reduction Avoid acidic foods Avoid things that relax the lower esophageal sphincter - fatty foods, mint, chocolate, alcohol, smoking
Medical treatment for GERD
OTC antacids - rolaids, TUMS, Pepto-Bismol, Milk of Magnesia
H2 blockers - rantidine (Zantac), famotidine (Pepcid)
PPIs - omeprazole
Possible complications of GERD
Increased risk for esophageal strictures
Barrett’s esophagus (pre-malignancy)
Peptic ulcers
I came in because of…
- Unexplained weight loss
- Abdominal discomfort
- Dysphagia
- Anorexia
- Enlarged left supraclavicular lymph node (virchow’s node)
Must not miss dx?
Gastric adenocarcinoma
Risk factors for gastric adenocarcinoma
Smoking
H. Pylori
Male (3:1)
Gastrin secreting tumor of pancreas resulting in GERD symptoms, diarrhea, and unexplained weight loss?
Zollinger Ellison Syndrome (gastrinoma)
Patient c/o achy stomach pain, nausea, hematemesis, and anorexia. Urea breath test positive for H. pylori. Likely dx?
Peptic ulcer disease
Where can peptic ulcer disease occur? Most likely spot?
mucosal lining of stomach or duodenum
ulcer 4-5x more likely to be found in duodenum
Risk factors for Peptic Ulcer Disease
H. Pylori (90% of cases)
NSAIDS
Smoking
How is H. Pylori detected?
urea breath test
Gold standard for PUD diagnosis
endoscopy with biopsy
Peptic Ulcer Disease treatment plan
1st line: triple therapy = PPI + 2 antibiotics x 2 weeks
(omeprazole + clarithromycin + amoxicillin)
Quadruple therapy = PPI + bismuth subsalicylate + 2 antibiotics x 2 weeks
PPIs long term
Surgical repair of ulcer if necessary
An 4 wk old infant comes in with projectile vomit and abd distention. Epigastric olive-like mass found on palpation. DX?
Pyloric stenosis
Barium swallow test results for Pyloric Stenosis
String sign
or railroad track sign
Treatment of Pyloric Stenosis
Fluids for dehydration
Pyloromyotomy (Ramstedt’s procedure)
Average age of Pyloric Stenosis
6 weeks old
corkscrew appearance on Barium swallow =
esophageal spasms
What is the best test to diagnose peptic ulcer disease?
endoscopy
A 65 year old male has had GERD for years. Over the past year he has noticed an increase in difficulty swallowing his food. What is the most likely diagnosis?
Esophageal strictures
achalasia and esophageal also possible, but strictures more likely with h/o GERD
________ is a direct cause of esophageal varices.
Portal HTN
________ is an infection of the gallbladder.
Cholecystitis
Explain pathophysiology behind the most common cause of Cholecystitis.
90% of cases are associated with gallstones (cholelithiasis)
Cholesterol builds up in gallbladder to form stones that can block cystic duct (choledocholithiasis)
Risk factors for Cholecystitis
Native American Females slightly higher rate Obesity Diabetes Pregnancy Crohn’s disease
What is Murphy sign? When is it positive?
Inhibited inspiration with pressure over RUQ secondary to pain
Cholecystitis
Woman comes in with pain in RUQ that worsens after fatty meals. She is jaundice and has elevated bilirubin. DDX?
Cholecystitis, Cholangitis
Cholecystitis treatment
Asymptomatic gallstones require no treatment
Initially antibiotics and NSAIDs are given to stabilize patient and bring down inflammation (2nd gen cephalosporin OR fluoroquinolone + Metronidazole)
Cholecystectomy is the definitive treatment for cholecystitis
Labs that indicate gallbladder infection
WBC
Bilirubin
Alk Phos and ATF
- all will be elevated
Charcot’s triad includes symptoms for what disease? What are sx’s?
pain, fever, jaundice = Cholangitis
What is Reynold’s pentad?
Charcot’s triad + hypotension and altered mental status = EMERGENCY!!!
DDX of RUQ pain
Cholecystitis Cholangitis Choledocholithiasis Hepatitis A, B ...
Most common cause of Cholangitis?
choledocholithiasis
Test of choice for Cholangitis
ERCP (Endoscopic retrograde cholangiopancreatography) because it can both diagnose and treat with stone extraction and sphincterotomy
infection of common bile duct is
cholangitis
Hepatits A treatment
Supportive care as illness is self limiting with full recovery in about 9 weeks
Vaccine available
How is Hepatitis A differentiated from other RUQ pains?
hepatomegaly
anti-HAV
Hepatitis A, B, and C transmission
A: fecal-oral
B, C: blood, needles, sex, across placenta
Incubation period of Hep B
6 wks - 6 months
Acute and chronic Hep B treatment
Vaccination available; given to all infants
Acute - usually self limiting with sx’s improvement in 2-3 weeks and full recovery in 16 weeks; however some become chronic
Chronic - Antiviral therapy
What do HBsAG, Anti-HBs, and Anti-HBc indicate on serum testing for Hep B?
HBsAG (surface antigen) = disease; either acute or chronic
Anti-HBs (Antibody to surface antigen) = immunity; vaccine or recovery from previous infection
Anti-HBc (Antibody to core antigen) = has infection or h/o infection
30% of ____ patients are found to also have Hep C.
HIV
How will untreated Hep B and C progress?
chronic hepatitis -> cirrhosis -> hepatoellular carcinoma or liver faliure
Hep C treatment
Self limiting and recovery is complete in 3-6 months
Meds if doesn’t resolve in 3 months and becomes chronic: Interferon alpha, Pegylated interferon, Ribavirin
Labs to help dx Hep C
screen for anti-HCV antibody
Which hepatitis most likely to become chronic?
Hep C
Patient must have _____ in order to contract Hep D.
Hep B
Risk factors for cirrhosis
Chronic hepatitis Chronic alcohol abuse Drug toxicity Age > 55 Diabetes Obesity
Symptoms associated with decreased liver function?
jaundice hepatomegaly ascites peripheral edema asterixis caput medusa spider angioma
Labs results associated with decreased liver function?
Elevated bilirubin (mostly conjugated)
Increased prothrombin time
Decreased serum albumin
Diagnostic imaging for cirrhosis
U/S to determine liver size and hepatic blood flow
CT/MRI with contrast to find hepatic nodules
How to manage/treat cirrhosis?
STOP DRINKING ALCOHOL!!!
Treat symptoms:
- restrict fluids and Na+ for edema and ascites
- daily folate, iron for anemia
- fresh frozen plasma for increased bleeding time
ultimately need liver transplant
Most cases of cirrhosis will progress to _______.
hepatocellular carcinoma
What lab value can differentiate liver cancer from cirrhosis?
hepatocellular carcinoma will have elevated WBC and cirrhosis will not
How can hepatocellular carcinoma be prevented?
Hep B vaccines
Monitor patients with cirrhosis or chronic hepatitis with alpha fetoprotein and U/S
Test of choice for dx of pancreatitis
CT
What are Cullen and Turner signs? What pathology do they suggest?
Cullen sign – ecchymosis in periumbilical region
Turner sign – ecchymosis in the flanks
Both positive in pancreatitis
What is included in liver function panel?
bilirubin, Alk phos, ALT/AST, ATF
Patient with acute epigastric pain that is alleviated by sitting or leaning forward. Bruising is seen around umbilicus. Likely dx?
acute pancreatitis
What is included in a BMP lab order?
BUN, creatinine, glucose, Na, K, Ca
Median survival for cases of pancreatic cancer?
less than 1 year
Risk factors for pancreatic cancer
Age > 60 FHX Diet - Low in fruits and veggies, high in red meat and sugar Smoking Obesity
Pancreatitis treatment
IV fluids Monitoring of vitals Pain medication NPO Treat abnormal labs -blood transfusion, calcium, albumin
What lab value is 3x normal level in pancreatitis?
serum amylase
lipase
What is the Trousseau sign?
tender nodules within veins which are small venous thrombi
Hallmark of hypercoagulable state associated with some cancers (pancreatic)
Surgical treatment for Pancreatic Cancer
Whipple procedure
major surgery involving a pancreaticoduodenectomy, a gastro-jejunostomy and a cholecystojejunostomy. A successful procedure results in 5 year survival rate of about 20%
Abdominal pain beginning periumbilical and moving toward the RLQ
appendicitis
Positive tests for appendicitis on PE
Rebound tenderness
Tenderness over McBurney’s point – located on the right side of the abdomen one third of the way from the anterior superior iliac spine to the umbilicus
Obturator sign – pain with flexion and internal rotation of the right hip
Psoas sign – pain with either passive right hip extension or active right hip flexion
What are specific managements of appendectomy pre-op?
Keep patient NPO
IV antibiotics
Pathophysiology of Celiac disease
Autoimmune disease which is an inflammatory reaction to the protein gluten
Damages villi of small intestine causing poor absorption of nutrients
Treatment of Celiac Disease
gluten free diet (avoid wheat) and intestinal villi should heal within weeks
What is clinical definition of constipation?
less than 2 bowel movements per week
Constipation treatment
Fiber supplements Mineral oil Osmotic or stimulant laxatives Digital disimpaction Enema
Diverticulosis vs Diverticulitis
Diverticulosis is out-pouching of diverticula due to weakened intestinal walls
Diverticulitis if diverticula become inflamed
What tests are contraindicated in acute diverticulitis due to risk of perforation?
endoscopy and colonoscopy
Typical location of diverticulitis pain
descending colon in LLQ
Treatment of mild/moderate and severe diverticulitis
Mild/mod treated conservatively:
Clear liquid diet
Oral antibiotics (metronidazole, cipro, Augmentin)
Severe:
NPO
IV fluids and abx
Surgery - Removal of diseased colon with temporary colostomy
DDX LLQ pain
diverticulitis
diverticulosis
Crohn’s Disease
Ulcerative Colitis
Labs to look for malnutrition
B12, folate, iron, albumin
Disease with cobblestone appearance and skip lesions on colonscopy?
Crohn’s Disease
Common effects of Crohn’s Disease on GI tract
strictures, fistulas, abscesses
B12 deficiency anemia in small intestines
Management of Crohn’s Disease
Smoking cessation Encourage fluids Treat malnutrition Anti-diarrheals ABX prn Prednisone for inflammation Surgery if abscess, stricture, or fistula
Patient with bloody diarrhea and abd pain localized to LLQ. Blood is found on DRE but stool cultures are negative. Likely dx?
Ulcerative colitis
Difference in sx’s and location of Crohn’s and Ulcerative colitis
Crohn’s: non-bloody diarrhea, can occur anywhere along GI tract (usually intestines)
UC: bloody diarrhea, restricted to colon
Ulcerative colitis treatment
NPO only in severe colitis
Topical or oral aminosalicylate agents – 5 ASA (mesalamine)
Topical or oral corticosteroids
Surgical removal of the colon
Massive dilation of the colon in acute colitis that makes patient extremely sick.
Toxic megacolon
Child laying on exam table holding his knees to chest. Palpable sausage-shaped abdominal mass
Intussusception
Pathophysiology of intussusception vs volvulus
intussusception: portion of bowel telescopes into another portion of bowel
volvulus: twisting of bowel on itself
* both cause bowel ischemia
Typical age range of intussusception
3 mon to 6 yrs
Dx and Tx of intussusception
air contrast enema
Patient comes in with diffuse acute abd pain and distention. There are signs of shock and patient has started vomiting. XR shows air fluid levels. Likely dx and tx?
Volvulus
MEDICAL EMERGENCY!
Need surgery
Risk factors for ischemia bowel disease
> 60 yo History of a-fib Vasculitis Hypercoagulable states Uses of vasoconstrictors - vasopressins, cocaine, etc.
currant jelly stool =
intussusception; secondary to bowel ischemia (later finding)
Likely dx of patient with severe abdominal pain that is out of proportion to your exam. Has sx’s of bloody diarrhea, fever, and shock.
Ischemic bowel disease
Treatment of ischemic colitis and mesenteric ischemia
Ischemic colitis
- Supportive care including NPO and IV fluids
Mesenteric Ischemia
- Surgical removal of ischemic bowel
- Patients have 50% survival rate if dx’d within 24 hrs
1 cause of small bowel obstruction
adhesions following abdominal surgery
1 cause of large bowel obstruction
carcinoma
Early and late PE findings of bowel obstruction
Early obstruction
- Peristaltic waves
- High pitched bowel sounds
Late obstruction
- Peristaltic waves stop
- Bowel sounds quiet down and stop
Abdominal XR findings of bowel obstruction
Dilated loops of bowel
Air fluid levels – step ladder appearance
Free air
Condition defined by…
- Abd pain relieved with defecation
- Change in freq, form, or appearance of stool
- Sx’s for +6 months
- Normal PE
Irritable bowel syndrome
Possible treatments of Irritable Bowel?
Modified diet - fiber, probiotics, avoiding aggravators Increase exercise Anti-spasmodics Laxatives SSRIs or TCAs
Recommendations for colorectal cancer screening - tests and how often?
Colonoscopy: every 10 years starting at age 50 (more often if h/o polyps)
Fecal occult blood test: annually starting at age 50
95% of adenocarcinoma of the colon come from _____ found on colonoscopy.
polyps
When is colon polypectomy indicated?
polyps > 2-3 cm
Air fluid levels or step ladder appearance on abdominal XR =
perforated bowel
Who is at higher risk for colorectal cancer?
H/O of colon polyps, Crohn’s disease, or ulcerative colitis
Increasing age
FHX
African Americans
Symptoms if neoplasm in rectum
tenesmus
hematochezia = bright red blood in stool
List all 5 of Ranson’s Criteria
Age > 55 years old WBC > 16,000 Glucose > 200 Lactate dehydrogenase (LDH) > 350 Aspartate aminotransferase (AST) > 250
used to assess severity of pancreatitis upon admission
mneumonic: “GA LAW”
What are the first 3 steps in managing pancreatitis?
NPO, IV fluids, pain medication
** Abx currently not recommended. A surgical consult is unnecessary for pancreatitis.
A 45 yo male presents with a low grade fever and abdominal pain. He has had non bloody diarrhea x 2 weeks. You decide to have the patient undergo a colonoscopy. On the report it mentions a cobblestone appearance. What is the most likely diagnosis?
Crohn’s Disease
What are some tests to eval Celiac Disease? What is the definitive test?
Serum antibodies
Gluten challenge
Anti tTG assay
Endoscopic biopsy (definitive)
Patient has extreme rectal pain especially during bowel movements. Ulcers are visualized on posterior midline of rectum. DX?
anal fissure
Anal fissure treatment
Increase fiber Stool softeners Sitz baths Topical nitroglycerin Botox injection into the anasl sphincter Sphincterotomy
An abscess can form if anal gland gets blocked. A ______ is the tract that forms from abscessed gland to skin.
fistula
Patient has severe rectal pain with opening of skin near anus. There is purulent discharge and area is tender, red, and swollen. Dx and tx?
anal fistula
tx: surgical drainage and/or repair
How is fecal impaction treated and prevented?
Laxatives, water or oil enema
Manual disimpaction
Prevention: reduce occurrence of constipation
Ways to prevent constipation
increase fiber increase fluids daily exercise regular bowel habits avoid opiates
What differentiates internal from external hemorrhoids?
- dentate line divides them
- internal are painless and external are painful
- both have bright red blood per stool
What diagnostic imaging is used to assess hemorrhoids?
anoscopy
How are hemorrhoids treated and when can they be manually reduced?
Grade I-III (may be manually reduced)
- Sclerotherapy
- Rubber band ligation
- Electrocoagulation
Grade IV or thrombosed (can’t be reduced)
- Surgical excision
Symptomatic - Sitz bath, increased fluids and fiber
movement of an organ through the wall which normally contains it is called a ________.
hernia
Strangulated hernia
a hernia whose blood supply has been cut off; ischemic bowel
Most common type of hernia
inguinal hernia
indirect vs direct inguinal hernias
Indirect: hernia sac enters inguinal ring through a congential defect
Direct: protrude through weakening in fascia of Hesselbach’s triangle
Boundaries of Hesselbach’s triangle
rectus abdominalis, inguinal ligament, and inferior epigastric artery
2 types of groin hernia? Which is more complicated?
Inguinal - more common
Femoral - rare but more likely to strangulate
Diagnostic imaging for hernias
U/S with doppler
CT (study of choice)
How are hernias managed?
Unincarcerated
- monitor
- reduce if possible
Incarcerated
- NPO
- Narcotics
- Reduce if possible
- Surgical repair
Strangulated
- Surgical emergency!
Clinical definition of diarrhea
3 or more watery bowel movements per day OR increase in freq
Non-infectious pathologies that cause diarrhea
Inflammatory bowel disease
Irritable bowel disease
Celiac disease
Lactose intolerance
Which part of nervous system allows for LES to relax and let food into stomach?
parasympathetic
** nerve branches damaged in achalasia
What chemicals stimulates acid release in stomach?
Histamine
Gastrin
Acetylcholine (parasympathetic)
H+ release into stomach is inhibited by what?
Somatostatin
Prostaglandins
Secretin
Why do NSAIDs cause decreased mucosal protection in the stomach? Which NSAIDs are least damaging?
inhibit prostaglandins which increase mucus secretion
COX-2 inhibitors have fewer GI side effects (Celebrex)
Function of the following cells in the stomach: G cells, parietal cells, mucus cells
G cells -> gastrin
parietal cells -> H+ and intrinsic factor
mucus cells -> mucus
When and where is secretin secreted? What is its function?
produced by small intestines when food arrives from stomach
stimulates pancreas to secrete bicarbonate to neutralize duodenal contents
inhibits gastrin secretion and thus stomach acid
MOA of H2 blockers in peptic ulcer treatment
block histamines that help stimulate parietal cell secretion of H+
When food exits stomach, the duodenum, pancreas, and gall bladder release what?
duodenum - CCK and secretin
pancreas - bicarbonate and digestive enzymes
gall bladder - bile
Typical virus that causes diarrhea
Rotavirus
Define Inflammatory Bowel Disesae (IBD)
chronic inflammation of all or part of GI tract
Crohn’s Disease and Ulcerative Colitis
Significance of “coffee grounds” vomit
indicates bleeding after the gastro-esophageal junction
blood has been digested
gastric or duodenal ulcer
What is hematochezia?
bright red blood in stool
DDX of hematochezia
hemorrhoid
colon cancer
diverticula
Where do all the absorbed nutrients from the gut go? via what?
nutrients in gut’s venous system go to the liver via the hepatic portal vein
_______ occurs due to an increase in conjugated or unconjugated bilirubin.
jaundice
Elevation in specifically conjugated bilirubin indicates what?
liver is not secreting bile OR bile cannot be released due to biliary tree obstruction
Signs of elevated bilirubin
jaundice (yellowing of skin and sclera)
clay-colored stools
tea-colored urine
itchy skin (bile salt deposits)
Elevated AST and ALT =
liver injury
Labs that measure liver function? What function specifically?
bilirubin - conjugation
albumin - protein synthesis
PT - clotting factor synthesis
Elevated _____ associated with acute liver disease, while a decrease in _____ is generally chronic liver disease.
PT
albumin
Elevated Alkaline Phosphate =
biliary obstruction
Serology result that indicates patient has new infection of Hep B? chronic infection?
IgM anti-HBcAg = new infection
IgG anti-HBcAg = old infection
Which hepatitis does not become chronic?
A and E
What does positive HBeAg indicate?
highly infectious Hep B
Autosomal recessive disease that causes bronze skin, cirrhosis, diabetes, and restrictive cardiomyopathy
Hemochromatosis - high iron in blood
Autosomal recessive disease that causes cirrhosis, Kayser-Fleischer rings in eyes, and increased urinary copper.
Wilson’s Disease
Alcoholic comes to the ER vomiting blood. Classic scenario of what condition?
esophageal or gastric varices
pathophysiology of hepatic encephalopathy
liver failure -> decreased detoxification reactions -> toxic chemicals get to brain -> delirium
Trace pathway of biliary tree from liver to gall bladder and duodenum
R and L hepatic ducts -> common hepatic duct -> common bile duct -> ampulla of Vater (converges with pancreatic duct) -> duodenum
common hepatic duct -> cystic duct -> gall bladder
_____ stimulates contraction of gall bladder and release of bile.
CCK from duodenum
_______ is inflammation and obliteration of extrahepatic biliary system in neonates. Have jaundice which leads to severe cirrhosis.
Biliary atresia
Two most common causes of pancreatitis
alcoholism and gallstone that obstructs pancreatic duct
“Female, fat, forty, and fertile” describes at-risk patient for what pathology?
cholesterol gallstones
PE findings of peritonitis
rebound abd pain
guarding
- PID, appendicitis, ruptured bowel???
Some conditions that predispose a patient to development of GERD
hiatal hernia, pregnancy, scleroderma, incompetent esophageal sphincter, obesity
