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Primary care > GI > Flashcards

GI Flashcards

1
Q

Gall bladder

Pancreas

A

referred to right shoulder

referred to back

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2
Q 
Appendicitis 
Typical age:
Presentation:
-
-
-
-
A

10-19 years
Presentation:
-Initial: Vague symptoms (indigestion, anorexia)
-Initially localized (periumbilical, epigastric) MILD CONSTANT
-4-6 hours: localizes RLQ severe constant aggravated with movement
-N/V/D preceded by pain
-FEVER

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3
Q

Appendicitis

PE

A

-pain with cough
-points to location
-tenderness at McBurneys point (umbilicus and anterior superior iliac spine)
-pain with rectal exam
pelvic- women
-Iiopsoas
-Obturator
-Rovsings: palpate LLQ

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4
Q

Appendicitis

Diagnostics

A

CBC (30% will not have, KIDS *** do)
U/A- UTI, STD, HCG
US/CT (U/S kids)

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5
Q

Ruptured Aortic Aneurysm

Symptoms

A

Symptoms:

  • Throbbing, aching back
  • Sudden onset severe pain (abdomen, flank, low back pain, groin)
  • Pain worse with recumbent
  • Syncope/shock
  • Chest pain
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6
Q

Ruptured Aortic Aneurysm

PE:

A
  • Pulsatile abdominal mass between xiphoid/umbilicus
  • Aortic bruit
  • Diminished/unequal peripheral pulses
  • Rupture: shock/arrest
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7
Q

Diverticulitis
What comes first?

Symptoms:
Elder?

A

Diverticulosis (prevent: high fiber diet) stagnation of fecal material in diverticulum–>infection–>perforation, peritonitis

Aching abd pain LLQ 
Colicky or steady 
Fever 
\+/- constipation, diarrhea 
N/V

Elder: maybe no symptoms–> septic

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8
Q

Ruptured Aortic Aneurysm

at risk

A

males, older
CAD, HTN, PVD, smoking

1 time screening 65-75 smoker or previous smoker

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9
Q

Diverticulitis

PE

A

Tenderness suprapubic area LLQ
Maybe peritoneal signs: guarding/rebound
Rectal: pain, +/- hemoccult or blood
Pelvic (women)

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10
Q

Diverticulitis

Diagnostics

A

CBC
U/A: HCG, STD
Stool OB

CT (U/S doesn’t show intestine)

Referral to GI for colonoscopy

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11
Q

Diverticulitis
Treatment

Follow up

Diet

A

Outpatient (low frade fever, mild leukocytosis)
Cipro 500 mg BID +
Metronidazole 500 mg BI 10-14 days

F/U within 24-48 hours
GI for colonscopy R/O cancer

Diet: low residue diet, once asymptomatic slowly introduce high fiber

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12
Q

Diverticulitis treatment severe

A

Fever over 101
peritoneal signs
marked leukocytosis

Hospitalize *

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13
Q

Cholelithiasis/cystitis

Highest risk

A 
Female 
Obese 
Rapid weight loss 
Pregnant 
40+

Comorbid conditions: DM, IBD, ETOH

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14
Q

Colelithiasis

Presentation

A 
colelithiasis: 
Biliary colic: intermittent or steady RUQ/epigastric pain 
Radiates to right shoulder 
Occurs after eating fatty foods 
N/V lasts 1-6 hours
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15
Q

Cholecystitis

Presentation

A

cholecystitis: biliary colic DOES NOT GO AWAY + CHILLS, FEVER
common bile duct stone: charcot’s triad, RUQ pain, fever, jaundice
acalculous cholestystitis: critically ill

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16
Q

Cholecystitis

PE

A

+ Murphys signs: can’t take a deep breath on palpation of right costal margin

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17
Q

Cholelithiasis/cholecystitis

Diagnosis

A

CBC
LFT’s *ALK PHOS
U/A: HCG, STI, UTI

Imaging:
U/S- gall stones *FASTING
after can get HIDA scan (most specific, hepatoiminodiacetic acid scan) - GI usually orders

Refer to GI

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18
Q

Gall stones (cholelethiasis/cholecystitis)

pain for months, shows gall stones what do you do?

A

Refer to general surgery

Chronic doesn’t bother them (general surgery eval but don’t need surgery)

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19
Q

Gall stones teaching

dumping syndrome

A

Avoid fatty foods go to ER if acutely ill

questran (cholestyramine powder)- also used for triglycerides

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20
Q

Pancreatitis
Presentation

Risks

A

Variable

  • Constant knifelike pain LUQ (periumbilical)
  • Increasing intensity
  • Radiation to chest, back, LEFT shoulder, flank, LLQ
  • Pain worse supine, better with legs in
  • Rocking, N/V

ETOH, gallstones/obstruction, hypertriglyceridemia, pregnancy, HIV, trauma

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21
Q

Pancreatitis

PE

A
  • Epigastric, LUQ tenderness
  • Fever
  • Hypotension, tachycardia, hemodyanmic instability, CV collapse
  • bluish hue around umbilicus (CULLEN’s sign*)
  • decreased/absent bowel sounds
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22
Q

Pancreatitis

Diagnostics

A

CBC
U/A: HCG
Serum chemisty profile LFT’s and Blood sugar COMPREHENSIVE METABOLIC PANEL
Amylase (raises first; not always elevated in drinkers and may return to normal after 2-3 days)
Lipase (raises after several days: elevated in drinkers and non-drinkers)

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23
Q

Pancreatitis

mortality

A

May be mild presentation and then deteriorate rapidly
Ranson’s criteria estimates mortality: esp age >55
WBC >16,000 glucose>200 AST>250 LDH >350 on admission
within 48 hours of admission: HCT drop >10%, BUN increase >5, CA 4 F;uid needs > 6L in 48 hours

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24
Q

Irritable bowel syndrome
Define/diagnosis:

Criteria

A

Functional bowel disorder
No structural or biochemical etiology
Diagnosis of exclusion

ROME III Criteria:
recurrent abd pain or discomfort at least 3 days a month in last 3 months
-relief with defecation
-onset associated with change in stool freq
-onset associated with change in form of stool

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25
IBS presentation
``` 80% women Depression/anixety Nonradiating ache/cramp lower abd pain Worse with meals Associated with stress Alternating pattern C/O mucus in stool? NO BLOOD, NO WEIGHT LOSS, NO FEVER, NO NOCTURNAL FH, meds, diet, stress ```
26
IBS PE
Careful abd exam Pelvic Rectal
27
IBS Diagnostics
-CBC -ESR -BS (r/o diabetic gastroenteropathy) -TSH -Stool OB +/- breath test (or 3 week trial lactose free diet) +/- giardia +/- IgA antitissue transglutaminase (TTG) celiac -Pelvic U/S if concern refer GI if needed
28
IBS management
Elimination of food Increase fiber (cirtucel) decrease stress, exercise
29
``` IBS diarrhea treatment - - - - ```
- Antispasmotic: Hycoscyamine (Levsin) if postprandial symptoms - Loperamide (immodium) .123-.25 before meals (best short term) - Lotronex (alosetron) GI uses was taken off market for a while for ischemic colitis/perf - Bile acid sequestrant like cholestyramine (questran) for bile acid malabsorption
30
IBS constipation treatment
- Osmotic laxative (miralax/polyethylene) - Stool softener - Fiber supplement (citrucel) - Lubiprostone (Amitiza) for women chronic - Linaclotide (linzess) stimulates intestinal fluid secretion chronic Treat depression: TCA's have analgesic property, careful with constipation
31
Dyspepsia Presentation Differential
chronic or recurrent pain in center of abdomen GERD, PUD, Biliary pain, IBS, drug induced (NSAIDS, biophosphanates- boniva, fosamax, orilistat, emycin) gastric cancer, cardiac pain
32
Dyspepsia alarm
``` > 55 new onset family hx upper gastro cancer unintentional weight loss progressive dysphagia odynophagia bleeding anemia vomiting palpable mass or lymphadenopathy jaundice ```
33
Dyspepsia management >55: Alarm sx:
>55: endo | Alarm: endo
34
Peptic Ulcer Disease Two associated factors Duodenal: incidence Gastric: incidence
NSAID use or H. pylori Duodenal: MOST COMMON 45-54 as much as 90% H.pylori*** Gastric: 55-64 (OLDER PATIENTS) ***NSAID use, corticosteroids, smoking, ETOH
35
PUD presentation Both: Duodenal: Gastric:
Both: n/v, belching, bloating, HB, melena, anemia, GI bleed may be 1st sx Gastric: worse with food, prolonged sx free period, may relief with antacid, may radiate to back Duodenal: wake at night, relief with food, occurs 2-3 hours after meal
36
PUD PE
``` May be no findings* Weight Rectal: occult May have epigastric tenderness Perforation: rigid abdomen, rebound ```
37
PUD differentials
``` Functional dyspepsia Cancer Drug induced Chrons Infections (giardia) Cholelithiasis ```
38
PUD Diagnostics
Serologic: does not differentiate past or present Breath: (c-urea) Stool: definitive Endoscopy with biopsy/staining
39
PUD diagnostics continued Breath test/stool + with no red flags what do you do? What about after you treat?
Treat if no red flags and under 55 RUN CONFIRMATORY testing (stool) no >55 or alarming symptoms + H pylori need follow up with endoscopy*****
40
H. pylori treatment
PPI BID+ Clarithromycin/biaxin + Amox x 10d if allergic PPI+ Biaxin+ Flagyl All other options are QID (bismuth, tetra, flagyl) Biaxin-metallic taste, come to office if have the runs---> c. diff Flagyl- no ETOH even after 48 hours
41
H. pylori treatment continued | Education
Avoid ASA NSAIDS, alcohol, smoking, coffee, corticosteroids, finish treatment If on PPI don't take in addition to other PPI Follow up breath test or endoscopy 4-6 weeks after treatment
42
H. pylori negative ulcers treatment
Acid suppressant 6-12 weeks H2 blockers PPI preferred Follow up endoscopy to document healing
43
GERD | Symptoms
- HB worse after eating, lying, down, bending forward, night time - Regurgitation (sour taste, metallic, sore throat) - Dysphagia/odynophagia (ALARM SYMPTOM- neuro/mass/cancer) - Dental erosion (gingivitis) - Nausea - Water brash (hypersalivation)
44
GERD aggravating factors
``` Coffee, tea, peppermint, fatty foods, citrus, spice, concentrated sweets, tomato based, meds, ETOH, soda Overweight Tight clothing Lying down after eating Smoking ```
45
GERD PE
``` NEGATIVE FINDINGS usually Wgt Pharynx Abd Rectal/stool OB Respiratory if symptoms (cough) ```
46
GERD diagnostics
Classic/nonconcerning symptoms can diagnose CBC +/- upper GI if diagnosis uncertain Cardiac workup if indicated Endoscopy: 45-55, unsuccessful tx red flags: anemia, dysphagia, odynophagia, weight loss, long standing sx SEVERITY OF SYMPTOMS DOES NOT CORRELATE WITH SEVERITY OF DAMAGE
47
GERD diagnostics | Endoscopy:
for metaplasia | Barret's esophagus (premalignant condition requiring ongoing surveillance)
48
GERD differentials
``` PUD Angina Motility d/o Tumor Infection esophagus Medication ```
49
GERD meds How long? If fail?
H2 antagonist (preferred for pregnancy) PPI (first line) b12 malabsorption, increased risk hip fx, enteric infections 6-8 weeks Poor respones- endoscopy Good...d/c meds...symptoms reoccur within 3 months: endoscopy >3 months: retrial...recurrecne
50
Pediatric GI | Functional constipation
``` Functional: poor bowel habits 2 of 6 criteria: -stool frequency -hardness -size -fecal incontinence (leads to encorpresis) -volitional stool retention present for one month in infants/toddlers 2 months older children ```
51
Pediatric GI | consipation peak prevalence
Pre-school
52
Pediatric GI | breast fed constipation
rarely if bf, iron in formula ^ constipation
53
Pediatric GI | 3 periods prone to constipation:
- intro of cereals and solid food - toilet training (issue with control) - start of school
54
Pediatric GI | Abdominal pain without temp
constipation: can palpate LLQ
55
``` Pediatric GI Toilet training Age must develop ____ leads to ____ Developmental readiness ```
Age: 2-3 years old start after nap Must develop: interest in retaining bowel movement leads to less frequent defecation-->hard painful stools Readiness: ambulate, stability, remain dry for several hours, pull clothes, language (2 step command), expressive language (communicate need)
56
Pediatric GI Painful defecation with solids avoidance of defecation leads to Encopresis??
stool accumulation, hard stools, blood is common (streaked) anal canal shortens, anal sphincter dilates, external sphincter relaxes-->semisolid stool leaks into perianal skin ENCOPRESIS
57
``` Pediatric GI Functional constipation treatment Nonpharmacologic Goal Pharmacologic ```
``` Fiber and fluids + Balanced diet Goal: one or more soft stool per day Pharm: miralax MOM (magnesium hydroxide) Lactulose ```
58
Pediatric GI Diarrhea WHO defines Caused by
WHO: 3 or more loose per day Acute infections viral GI (majority)
59
Pediatric GI Febrile with non-bloody diarrhea: Febrile with blood diarrhea/mucus:
non-bloody: viral | blood/mucus: bacterial or parasitic
60
Pediatric GI Diarrhea Immunization - when is it given, peaks in what month
rotavirus: ( more than half hospitalizations for nonbacterial gastroenteritis due to rotavirus ) not required given at 2,4 and 6 months (not given after that) peaks in winter months
61
Pediatric GI: Diarrhea transmission of viral S/S viral
fecal-oral s/s: d/v, low grade, fever, anorexia, HA, abdominal cramps, myalgia
62
Pediatric GI: Diarrhea treatment IV? Abx?
majority will not require IV hydration: tbsp every 15 mins oral rehydration Abx not used with acute bloody diarrhea unless pathogen isolated
63
Pediatric GI: Dehydration S/S
- decreased urination - decreased tears - high fever - dry mouth - weight loss - thirst - listlessness/lack of energy - sunken eyes, fontanelles
64
Pediatric GI: Hydration Breastfeeding? Milk? Foods?
BF through diarrhea/vomitting Whole milk usually toleration (dilution/lactose free not necessary) Foods high in fat and simple sugars not as good as complex carbs, lean meats, yogurt, fruits, vegetables
65
Pediatric GI: Diarrhea Diet: Nonpharm:
BRAT have been recommended (unnecessarily restrictive, suboptimal nutrition) Latest recommendation: Feed through diarrhea!! (prevent weight loss keep nutrition, add yogurt) Lactobacillus
66
Pediatric GI: GERD Infancy: Types:
Infancy: most common GI problem Types: physiologic (weak sphincter, air bottle) or pathologic (no weight gain, blood in vomit, irritable, cranky, hungry)
67
Pediatric GI: GERD diagnosis gold standard
24 hour intraesophageal PH for pathologic GERD
68
Pediatric GI: GERD nonpharm tx
Thickened formula, prone position, hypoallergenic, small frequent feedings
69
Pediatric GI: Tx GERD
H2 ie ranitidine >one month-16 years (most common in infants 4-6 weeks) PPI: inhibit parietal cell enzyme ATPase or PP Omeprazole (prilosec) Lanzoprazole (prevacid)- strawberry flavor Admin before meals
70
Pediatric GI: Colick Rule: Symptoms: Less likely with:
Rule of 3: - 3 hours - 3 days a week - 3 weeks - first 3 months of life Symptoms: irritable, fussing, without failure to thrive HEALTHY eating normally later in afternoon 4-6 pm Less likely in calm/comfortable mother
71
Pediatric GI: Colic treatment
``` Hypoallergenic formula Continue bf Mother (eliminate caffeine) SWADDLING** White noise Avoid overstimulation ```
72
Pediatric GI: Functional abdominal pain | Criteria
Experience following symptoms once a week for 2 months: - periumbilical pain 1-3 hours - n/v, fatigue, HA, pallor - fetal position, grimace, cry - school absence - NO FEVER VOMITING WEIGHT LOSS OR WAKING UP FROM SLEEP *internalized/psychosocial
73
Pediatric GI: Functional what does it mean?
Psychosocial/internalized/nothing is really wrong physiologically
74
Pediatric GI: Functional abdominal pain diagnostics Plan follow up
- no definitive diagnostic test - U/A - CBC - ESR (low grade infectious process) - metabolic panel - stool for occult blood parasite giardia - lactose breath hydrogen test plan/f/u: counseling, symptom diary, f.u in month

Primary care (16 decks)

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