GI Flashcards
Candidiasis
Fungal infection caused by candida albicans
Oral Candidiasis
Thrush
What is the causative agent of candidiasis?
Candida albicans
- Often part of the resident flora
- opportunistic organism
Who are Candidiasis found in?
- People receiving broad-spectrum antibiotics
- During and after cancer therapy
- Immunocompromised
- DM
Clinical Manifestations of Candidiasis
- Red swollen areas
- May be irregular patches of white curd like material on tongue
- Soreness
- Problems with swallowing
Treatment of Candidiasis
Oral antifungals
Ex: Nystatin
Dysphagia
Difficulty swallowing
What are the three types of dysphagia?
Oropharyngeal
Esophageal
Functional
Characteristics of esophageal dysphagia
Inability to swallow solid food
- Pain on swallowing
- Highly indicative of carcinoma
Characteristic of functional dysphagia
No organic cause for dysphagia that can be found
What are the two types of causes for dysphagia?
Mechanical
Neuromuscular disorders
Examples of mechanical obstruction (dysphagia)?
-Tumors, masses, trauma, lesions
Examples of Neuromuscular disorders (dysphagia)?
CVA, Parkinson’s brainstem tumors, ALS, MS, peripheral neuropathy, Myasthenia gravis, Myopathies
Signs and Symptoms of Oropharyngeal Dysphagia
- difficulty swallowing or controlling food
- coughing, choking
- frequent pneumonia
- unexplained weight loss
- gurgly or wet voice after swallowing
- nasal regurgitation
- dysphagia-patient complains of difficulty swallowing
Signs and Symptoms of Esophageal Dysphagia
- inability to swallow solid food
- described as being stuck or held up
- pain on swallowing is highly indicative of carcinoma
Diagnostic of Oropharyngeal Dysphagia
-When asked where the food is stuck, patients usually point to the neck as site of obstruction (but actual site is always at or below where it is perceived)
If undiagnosed or untreated, Dysphagia can lead to
Dehydration, malnutrition and renal failure
What is a dysphagia patient at high risk of?
Pulmonary aspiration
Subsequent aspiration pneumonia (secondary to food/liquid going the wrong way to the lungs)
Treatment for Dysphagia
- Swallowing therapy with exercises and dietary changes
- Thickening liquids or mechanically soft diet
- Surgery or medicine for problems with the esophagus
- Nasogastric or endoscopic tubes are also used to treat dysphagia
GERD
Gastroesophageal Reflux Disease
Chronic reflux of chyme from the stomach to the esophagus
Reflux esophagitis
If GERD causes inflammation of the esophagus, it can lead to Barrett’s esophagus
Barrett’s Esophagitis
Intestinal metaplasia (change of squamous to intestinal columnar epithelium of distal esophagus)
Causes of GERD
Conditions that increase abdominal pressure:
-Ascites
-Constipation
-Pregnancy
-Pancreatitis
Changes in the barrier between the stomach and esophagus
-Abnormal relaxation of the lower esophageal sphincter
Hiatal Hernias
Clinical Manifestations of GERD
Chronic symptom of mucosal damage caused by stomach acid into esophagus
- Heartburn
- Regurgitation of chyme
- Pain in upper abdominal/epigastric area after eating
- Pain relieved by food or antacids
Treatment of GERD
Lifestyle changes Medications -Proton Pump inhibitors (Nexium) -H2 receptor blockers or antacids with or without algenic acid Surgery if no improvement
Peptic Ulcer Disease
Break in the lining of the stomach, duodenum, or the lower esophagus
Duodenal Ulcers
Most common form of peptic ulcer disease, occur in the duodenum
Gastric Ulcers
Ulcers in the stomach
Most common cause of peptic ulcers
H. Pylori infection (bacterial)
Causes of Peptic Ulcers (4)
- H. Pylori
- Hypersecretion of stomach acid or pepsin
- Use of NSAIDs
- Acid production by cigarette smoking
Most common symptoms of Peptic Ulcers
- Chronic intermittent pain in the epigastric area 2-3 hours after eating
- Dull/Burning pain
- Waking up at night with abdominal pain
- Upper abdominal pain that goes away with eating
- Bleeding
If asymptomatic, what might be the first sign of peptic ulcers?
Bleeding
Other symptoms of Peptic Ulcer Disease
- Belching
- Vomiting
- Weight loss
- Poor appetite
Complications of Peptic Ulcers
- Bleeding
- Perforation
- Obstruction of the duodenum
Acute Manifestations of Peptic Ulcer Disease
- Hematemesis
- Melena
- Hematochezia
Hematemesis
Vomiting of blood
-associated with upper GI bleed
Melena
Black tarry stool caused by GI bleeding
-Hemoglobin in the blood altered by digestive chemicals and intestinal bacteria
Hematochezia
Passage of fresh blood through the anus
-associated with lower GI bleed
Chronic Manifestations of Peptic Ulcers
Occult bleeding
Occult Bleeding
Small amounts of bleeding; detected by fecal occult blood test, signifying an upper GI bleed
Diagnostic tests for Peptic Ulcer Disease
- Barium swallow
- Endoscopy
- H. Pylori Test
Goal of Management
Relieve the causes and effects of hyperacidity
- Administer antacids and protein pump inhibitors (Nexium)
- Antibiotics for H. Pylori
GI Bleed
All forms of blood loss from the GI tract (from mouth to rectum)
Causes of upper GI bleed
- Peptic ulcer disease
- Esophageal varices due to liver cirrhosis
- Cancer
Causes of lower GI bleed
- Hemorrhoids
- Cancer
- IBD
Manifestations of GI Bleed
Vomiting red, black, blood Bloody or black stool Small amounts of blood loss Anemia (from the blood loss) Fatigue or chest pain (from the anemia) Low blood volume + anemia can cause abdominal pain, pale skin, or syncope
Diagnostics for GI Bleed
- Medical history and physical exam
- CBC for hemoglobin and HCT
- Stool analysis (elimination patterns, characteristics)
- Endoscopy of upper and lower GI
- Fecal Occult Blood Test (FOBT) - if testure turns blue, blood is present
Treatment for GI Bleed
Resuscitation - IV Fluids, blood transfusions
Medications - PPIs (nexium), Octreotide, antibiotics
IBD
Group of autoimmune inflammatory conditions related to colon and small intestine
Two types of IBD
Crohn’s and Ulcerative Colitis
Chronic IBD
Relapsing IBD of unknown origin
Cause of IBD
Autoimmune
Genetics
Alterations of epithelial barrier functions
Abnormal T cell responses
IBD has periods of ____ and ______
Remissions and exacerbations
Ulcerative Colitis
Chronic inflammatory disease that causes ulcerations in the colonic mucosa in the sigmoid colon and rectum
Causes of Ulcerative Colitis
Autoimmune disease in which the T cells infiltrate the colon creating ulcers
May be related to: infection, immunologic (anti-colon antibodies), dietary, genetic
Manifestations of Ulcerative Colitis
Periods of exacerbation and remission
Diarrhea (10-20 times a day)
Bloody stools
Cramping
Long term complications of Ulcerative colitis
Increased risk for colon cancer
Anemia
GOAL of ulcerative colitis
- Induce remission with medications
- Administration of maintenance medication to prevent relapse
- Broad spectrum antibiotics and steroids
- Immunosuppressive agents
- Surgery
Crohn’s Disease
Idiopathic inflammatory bowel disease that affects both small and large intestines (mostly in terminal ileum)
-can also affect mouth, stomach and anus
Cause of Crohn’s Disease
Idiopathic
Focal infiltration of neutrophils into the epithelium causes mucosal inflammation
-Chronic mucosal damage and blunting of the intestinal villi
Manifestations of Crohn’s
- Transmural pattern of inflammation
- Skip Lesions
- Ulcerations can produce longitudinal and transverse inflammatory fissures
- Periods of exacerbation and remission (but remission may not be possible)
- Abdominal pain
- Diarrhea
- Fever
- Weight loss
- Anemia can lead to malabsorption of vitamin B12 and folic acid
Long-Term Complications of Crohn’s
- Formulation of a fistula between different areas of the GI tract, between the GI and bladder, vagina, urethra, or skin
- Intestinal obstruction
- Abscess formation
- Pyroderma Gangrenosum
- Erythem Nodosum
- Bowel obstruction
- Greater risk for bowel cancer
Pryoderma Gangrenosum
Condition that causes tissue to become necrotic, causing deep ulcers that usually occur in the legs
Erythem Nodosum
Inflammatory condition of the fat cells under the skin, resulting in tender red noodles or lumps that are usually seen on both shins
Other complications of Crohn’s
Anemia, skin rash, arthritis, inflammation of the eye
Treatment of Crohn’s
- No cure
- Relapse may be prevented with medication, lifestyle and dietary changes
Surgery is contraindicative !
Intestinal Obstruction
Obstruction of the intestines prevents normal transit of products of digestion
Causes of Intestinal Obstruction
Simple mechanical causes vs functional causes
- Tumor
- Fecal impaction
- Intussuception
Intussuception
Part of the intestine folds into another section of the intestinal wall
Manifestations of Intestinal Obstruction (general)
- Pain
- Swollen, distended abdomen
- Constipation
- Gassiness, fullness
- Diarrhea
- Nausea/vomiting
Manifestations of Small Obstructions
- Intermittent cramping/pain
- Spasms
- Vomiting BEFORE constipation
- Proximal obstruction of large bowel may present as a small obstruction
Manifestations of Large Obstructions
- Pain in lower abdomen
- Longer spasms
- Constipation before vomiting
What does Intestinal Obstruction lead to?
- Water and electrolyte imbalance (due to vomiting)
- Respiratory complications (due to pressure on the diaphragm and aspiration of vomit)
- Perforation from prolonged dissension or pressure from foreign body
- Perforation can lead to sepsis
Treatment of Intestinal Obstruction
Usually surgery/treatment of causative lesions are required
- Decompression fo abdomen with NG tube
- Correction of dehydration and electrolyte imbalances
- Opioids for severe pain
- Antiemetics for vomiting
Some cases may resolve spontaneously
Diverticular Disease
Altered structure and function of the large intestine walls with diverticulum
Diverticulum
Small sac outpouring along the wall of the colon
Causes of Diverticular Disease
Prolonged pressure on the large intestine wall alters structure and function
-Weakness leads to outpouching
Diverticulitis
Infected diverticula due to fecal matter getting stuck in the out pouches
Manifestations of Diverticular Disease
LLQ pain and tenderness
Complicated Diverticulitis
Subsequently infect the outside of the colon
Manifestations of complicated diverticulitis
- Inflamed diverticula burst open
- Infections spread to lining of abdominal cavity (peritoneum) = peritonitis
- Narrowing of bowel (from inflamed diverticula)
- Infected part of colon could adhere to bladder or other organs in pelvic cavity causing a fistula or abdominal connection
Diagnostic Tests for Diverticular Disease
- History and physical exam for abdominal tenderness/distension
- Lab analysis
- Bloody stools
- Low Hmg and Hct
- CBC for infection
- CT scan
- Inflamed and or ruptured diverticula = confident diagnostic
- Localized wall thickening
- Bariumanima and colonoscopy - but don’t do this in acute phase because of its risk of perforation
Prevention of Diverticular Disease
- Low fiber diet
- Lifestyle alterations
- Medications (bulk forming laxatives, antispasmodic)
Treatment for Diverticular Disease
Conservative therapy with bowel rest
- Control infection
- Manage symptoms
- Antibiotics for bacterial infection
- Prevent complications
- Surgical correction of perforated diverticula, peritonitis, abscess
Emergency surgery for those with ruptured intestine
Appendicitis
Blockage of hollow portion of appendix, usually by a calcified stone composed of feces
(Inflammation of the vermiform appendix)
Causes of Appendicitis
Blockage leads to tissue injury and death
- obstruction
- ischemia
- increased intraluminal pressure
- infection
- ulceration
3 factors of Appendicitis blockage
- Increases pressure in appendix
- Decreased blood flow to tissues of appendix
- Bacterial growth inside the appendix causing inflammation
Manifestations of Appendicitis
Epigastric and RLQ pain
- Rebound tenderness
- Abdominal tenderness
Rebound Tenderness
Pain upon removal of pressure rather than application of pressure
What happens if Appendicitis is not treated?
- Appendix may burst and release bacteria into the abdominal cavity (increases abdominal pain and complications)
- Perforation can lead to peritonitis and possible sepsis and shock
Diagnostic Tests for Appendicitis
- Increase in WBC
- CT scan
Treatment for Appendicitis
Pain management
Surgery (removal of appendix)
Antibiotics
Cholelithiasis
Gallstones
-Most common biliary disorder
Cholecystitis
Inflammation of the gallbladder associated with cholelithiasis
What do gallstones develop from?
Pigments and cholesterol
Risk factors for Cholelithiasis/Cholecystitis
Obesity Middle age Female Native American Diseases of the gallbladder, pancreas, or ileal disease
Causes of Cholecystitis
Due to blockage of cystic duct with gallstones
- Build up of bile in the gall bladder increases the pressure, causing RUQ pain
- Concentrated bile, pressure, and bacterial infection irritate and damage the gallbladder wall leading to ischemia / cell death
General Manifestations of Cholelithiasis
Will not necessarily develop cholecystitis
- Biliary colic (severe pain with gallstones)
- Tachycardia, diaphoresis, exhaustion
- Residual tenderness in RUQ
- Attacks 3-6 hours after heavy/fatty meal
Manifestations of Cholelithiasis if there is total obstruction
- Steatorrhea (lack of bile causes abnormal amounts of fat in feces)
- Pruritus
- Dark, amber urine (excess bilirubin in urine)
- Jaundice
- Clay colored stools
- Fever
Complications of Cholelithiasis
- Abscess
- Pancreatitis
- Gallbladder rupture
- Delayed diagnosis increases morbidity and mortality
Diagnostic tests for cholelithiasis
- RUQ pain + nausea + vomiting + fever
- Increased WBC count
- Elevated bilirubin in urine (dark amber urine, lab analysis)
- Ultrasound (visualize gallstones, changes in GB wall)
- CT scan
- Heaptobiliary scan (HIDA) - radioactive tracer
- Oral cholecystography
- ERCP
- PTC
How does HIDA diagnose cholelithiasis?
- Gallbladder visualized within 1 hr of radioactive injection = no disease
- If gallbladder is not visualized within 4 hrs of injection = cholecystitis or cystic duct obstruction
Treatment of Cholelithiasis
-Antibioditcs, analgesics, antispasmodics
-NPO until symptoms subside
-Gastric decompression with NG tube
-Avoidance of fatty/fried foods
-Laparoscopic cholecystectomy (GOLD standard)
Cholecystectomy - removal of gallbladder or opening it to remove stones, bile, pus
What is the gold standard treatment of Cholelithiasis?
Laparoscopic Cholecystectomy
What are supportive measures prior to Cholecystectomy?
Fluid resuscitation
Pain managemnt
Antibiotics to target enteric organs
Pancreatitis
Inflammation of the pancreas due to autodigestion of the tissues
Chronic Pancreatitis
Irreversible histological changes and diminished function of the pancreas
-ETOH USE = major cause
Causes of Acute Pancreatitis
Alcoholism, biliary tract disease, trauma, infection, drugs, GI surgery post op
*They cause early activation of excessive pancreatic enzymes causing massive inflammation, bleeding, and necrosis
How do trypsin, lipase, elastase, and cytokines/prostaglandis cause Pancreatitis?
Trypsin - progresses into tissues surrounding the pancreas
Lipase - causes fat necrosis, binding calcium ions
Elastase - erodes blood vessels, causing hemorrhage
Cytokines/Prostaglandis - released by tissue necrosis, inducing an inflammatory response, leading to vasodilation, hypovolemia, and circulatory collapse
Causes of Chronic Pancreatitis
Serious loss of exocrine and endocrine pancreatic function as well as deterioration of pancreatic structure
-Decreased enzyme production and decreased insulin production lead to malabsorption of fats and proteins
Manifestations of Acute Pancreatitis
- Sudden onset of severe epigastric pain after a large meal or ETOH
- Referred pain to back and left shoulder
- Jaundice if there is biliary obstruction and accumulation of bile
- Malaise, restlessness, lung involvement, respiratory distress and decreased urine output
- Decreased bowel sounds, ascites
- Abdominal tenderness with guarding
Manifestations of Chronic Pancreatitis
Periods of exacerbations and remissions
- Constant dull epigastric pain
- Steatorrhea
- Severe weight loss
- Onset of symptoms of DM because of insufficient production of insulin
Diagnostics for Pancreatitis
- History of abdominal pain, risk factors, physical exam, diagnostic findings
- Increased serum bilirubin
- Increased liver enzymes
- Increased WBC
- Increased serum glucose (lack of insulin)
- Increased pancreatic enzymes (lipase, amylase, trypsin)
- Decreased Ca and Mg
- Ultrasound, CT scan, x rays
Treatment for Acute Pancreatitis
- Opioids for pain
- Decrease pancreatic secretions by decreasing stimulation of the pancreas
- NPO and NG suctioning
- Remove irritants
- Reduce vomiting and gastric distention
- Control fluid and electrolyte imbalances
- Maintain adequate blood volume (check I/O)
- When no longer NPO, have a diet high in CHO and protein and low in fat
- Antibiotics to prevent infection
Treatment for Chronic Pancreatitis
Long-term pain management
- Oral pancreatic enzyme replacement therapy (PERT)
- Alcohol rehab
- Treat DM with insulin
- Nutritional therapy - High calorie, high CHO, high, protein, low fat
- Surgical interventions if obstruction
What are the disorders of the liver?
Hepatitis
Cirrhosis
Where is Hepatitis A found?
Feces, bile, and sera of infected individuals
What is the sequence of Acute Hepatitis?
Prodromal phase, Icteric phase, Recovery phase
Prodromal Phase
Begins 2 weeks after exposure with non specific symptoms
Icteric phase
Lasts 2-6 weeks
Recovery phase
Improvement of symptoms
Hep A (transmission, and where its found)
Usually transmitted by fecal-oral route
- Direct contact
- Food and beverage
- Cups and spoons
- Chronic
Risk Factors for Hep A
Crowded, unsanitary conditions
Food and water contamination
Hep E
Fecal-oral transmission
- Developing countries
- Similar to hep A but NOT chronic
Hep B
Contact with infected blood, body fluids, contaminated needles
- piercing/tattooing
- vertical transmission (breastfeeding)
- maternal transmission if mother is infected during 3rd trimester
- blood transfusion
Hep D
same transmission route as HBV (blood, fluids, needles)
- Dependent on HBV for replication
- Often makes HBV infection worse
What does Hep D need to manifest?
Hep B
Hep C
IV drug use through sharing needles, and high risk sexual behavior
- Maternal transmission is a rare but present case
- 50-80 % of Hep C results in chronic hepatitis
What is the primary mode of transmission of Hep C?
IV drug use through sharing needles
What is the secondary mode of transmission of Hep C?
High risk sexual behavior
Symptoms of A & B Hepatitis
Nausea, vomiting
Complications of Hep B and C
- Chronic hepatitis and cirrhosis
- End stage liver failure
- Hepatocellular carcinoma
Cirrhosis
Irreversible inflammatory disease that disrupts liver function and structure
Types of Cirrhosis
- Alcoholic
- Non-alcoholic fatty liver
- Biliary (Bile canaliculi)
- Metabolic
Cause of Cirrhosis
Inflammation leads to necrosis and fibrosis
-Nodular and fibrotic tissue synthesis leads to decreased hepatic function
Manifestations of Cirrhosis - Inflammation
Pain, fever, nausea, vomit, anorexia, fatigue
Manifestations of Cirrhosis - Necrosis
- Decreased bilirubin metabolism (causes hyperbilirubemia and jaundice)
- Decreased bile in GI tract (light colored stools)
- Decreased vitamin K absorption (bleeding)
- Increased urobilinogen (dark urine)
- Decreased hormone metabolism
- Increased androgens and estrogen
- Liver failure
- Hepatic encephalopathy
- Death
Manifestations of Cirrhosis - Fibrosis
Edema Portal HTN can cause: -hepatic necrosis -esophageal varices -splenomegaly -ascites
Other complications of Cirrhosis
Endstage liver disease
- reduced clotting
- impaired ammonia metabolism
- impaired bilirubin metabolism
- hypoglycemia
- increased aldosterone production
