GI Flashcards
The two major causes of dysphagia and the way to distinguish them? How to best work them up?
Dysmotility – dysphagia for solids only. Work up with manometry + barium swallow
Obstruction- progressive dysphagia. Work up with barium swallow.
Both are best worked up with EGD + biopsy
Achalasia (path, dx, tx?)
Dysmotility syndrome Path: LES can't relax. DX:Barium swallow - bird beak Manometry- tonically contracted LES Biopsy: Lack of Auerbach's plexus. Tx: Botox, myotomy.
Scleroderma (path, pt, dx, tx)
Path: LES can't contract due to collagen deposition Pt: regurgitation and relentless GERD. Dx:Barium - normal Manometry-loose LES EGD- collagen deposition. TX: PPI for GERD
Esophageal spasm (Path, pt, dx, tx)
Path: Sustained contraction
Pt; Crushing substernal CP worse with food or emotional stress.
Dx: R/o cardiac causes, barium swallow shows corkscrew
Tx: CCB, nitroglycerin.
Schatzki’s Ring (Path, pt, dx)
Path: Ring at LES
Pt: Dysphagia for large foods (steakhouse)
Dx: Barium swallow, confirm with EGD+Bx.
Plummer-Vinson Syndrome (Pt, dx, tx)
Pt: Female with iron deficiency anemia due to esophageal webs. Can predyspose to cvancer
Dx: Webs seen on barium swallow
Tx: Screen for cancer, DO NOT do prophylactic esophagectomy.
Zenker Diverticulum (pt, dx, tx)
Pt: Dysphagia with halitosis.
Dx; Barium swallow, EGD.
Tx; Resection
Stricture (path, pt, dx, tx)
Path: State 4 gerd
Pt: Progressive dysphagia and weight loss
Dx: Barium, EGD and biopsy
Tx: Control GERD with PPI, surgery.
Cancer (Path, pt, dx, tx)
Path: Adenocarcinoma - GERD lower 1/3 Squamous cell - smoking, alcohol, upper 1/3. Pt: Progressive dysphagia, wt loss Dx; Barium, EGD+bx Tx: Esophagectomy
Causes of esophagitis
Pill Infectious Eosinophilic Caustic gErd
Pill-induced esophagitis (which pills, pt, dx, tx)
Pills: antibiotics, NSAIDS, NRTIs.
Pt: any age, odynophagia
Dx: EGD, remove pill
Tx: PPI until resolved.
Infectious esophagitis (organisms, tx)
Org: Candida- oral thrush, treat with po fluconazole or nystatin S+S
HSV- Lesions, val or acyclovir
CMV- linear lesions, ganciclovir
Dx; EGD+Bx.
Eosinophilic esophagitis (pt, dx, tx)
Pt: atopic
Dx: EGD+Bx, stain for Eos.
Tx: Avoid allergen, PPI
Caustic esophagitis (pt, dx, tx)
Pt: Child- drain cleaner
Adult - suicide
Patients are hoarse and drool.
Dx: EGD+BX
Tx: Low severity? NPO 1 night, liquid diet.
High severity? NPO x 3 nights, F/u EGD.
NEVER induce vomiting, do not neutralize.
GERD (Path, typical vs atypical symptoms, dx)
Path: Weakened LES, acid burning esophagus.
Typical Sxs; Burning pain, worse with lying down, better with sitting up and antacids.
Atypical Sxs: Hoarseness, cough, stridor, nocturnal asthma.
Dx: PPI and lifestyle modification (avoid chocolate, peppermint, smoking) x 6 weeks, then EGD + bx.
Best, 24h pH monitor.
Treatment for GERD, metaplasia, dysplasia, cancer
Tx: PPI if GERD
Metaplasia: High dose PPI BID
Dysplasia: Cryoablation and f/u EGD
Cancer: Resect
Three types of PUD ulcers
NSAID induced, multiple shallow ulcers. H.Pylori/cancer. Large heaped up margins.
Cushing, Curling ulcers, ZE
How do patients with PUD present?
Annoying epigastric pain either better or worse with meals. Radiates to back.
How to treat H.pylori?
Clarithromycin, PPI, amoxicillin.
How to diagnose H. Pylori?
Urea breath test, EGD and biopsy with CLO staining.
How to f/u treatment with H.Pylori?
Stool antigen to confirm eradication after triple therapy.
ZE syndrome (path, dx, tx)
Path: Gastrin secreting tumor which causes parietal cell activation of HCl.
Dx: Somatostatin receptor scintigraphy
Tx; Secretin
Gastroparesis (path, pt, dx, tx)
Path: Stomach can’t empty – either idiopathic or due to DM.
Pt; Bloated, relieved by vomiting
Dx: Gastric nuclear emptying study (>50% of material left is diagnostic)
Tx: Diabetes control, then prokinetic agents like erythromycin, metoclopramide, domperidone.
Approach to acute diarrhea?
Determine whether or not presentation is more than gastroenteritis (>3 days, hospitalized, recent travel, blood, pus, antibiotics). If so, investigate by ordering a C.diff toxin, fecal RBC and WBC. If C.diff positive, treat with po metronidazole. If very sick, treat with po vancomycin and iv metronidazole.
If RBC and WBC negative, then diarrhea is not invasive, get stool O and P.
If RBC and WBC positive, then diarrhea is invasive, so do a stool culture and a scope. If scope is positive, then disease. If culture is positive, treat bacterial infection.
Approach to chronic diarrhea
Make sure diarrhea isn’t due to laxatives, meds, lactose intolerance, c.diff.
Then get fecal fat, stool osm, WBC, RBC, and make patient NPO.
How to calculate stool osm gap? Normal stool osm gap?
Measured stool osm-expected stool osm.
Expected stool osm: 2(Na+K). Should equal ~290.
Secretory diarrhea
Normal osm gap, no rbc, no wbc, no mucous. No change with NPO. + nocturnal symptoms. Normal fecal fat. usually due to C.diff or WDHA.
Osmotic diarrhea
Increased osm gap, no rbc, no wbc, no mucous, but gets better with NPO, no nighttime symptoms. Increased fecal fat.
Inflammatory diarrhea
Has RBC, WBC, mucous.
How to work up malabsorption?
Fat challenge (100g in 72h), check fecal fat, 14g day. Do a d-xylose and a CT scan. If positive, then problem with digestion (pancreas), if negative, then problem with absorption (mucosa). If problem with absorption, do an EGD and biopsy.
Diverticulosis (pt, dx, tx)
Pt: >50, low fiber diet, asymptomatic.
Dx: Colonoscopy
Tx: None
Diverticular Hemorrhage (pt, dx, tx)
> 50, painless brisk bleed. BRBPR.
Path: Stretched arteriole at diverticulum.
Dx; Scope or arteriogram of bleeding is very brisk.
Tx: Cauterization or hemicolectomy.
Diverticular spasm (pt, dx, tx)
Postprandial LLQ pain 2/2 gastrocolic reflex. Relieved by BM
Dx: clinical (vs. IBD)
Tx: Increase fiber
Diverticulitis (path, pt, dx)
Path: Fecalith blocks lumen
Pt: LLQ constant abdominal pain +fever +leukocytosis
Dx: 1st KUB to ensure no free air, then CT scan.
Treatment of mild and severe diverticulitis, treatment of diverticular abscess.
Mild: Liquid diet PO antibiotics
Severe: NPO, IVF, IV abx
Abscess: Drain
Refractory: hemicolectomy
Which antibiotics should be used for diverticulitis?
Metronidazole, amp/gent, or fluoroquinolone.
First step in evaluating colicky LLQ pain?
KUB, followed by CT scan.
Poor prognostic sign for polyp
Sessile, villous, large
Tx for polyp, stage I/II colon cancer, stage III/IV colon cancer
Polyp: Polypectomy
Stage I/II: Colectomy
Stage III/IV: FOLFOX or FOLFIRI
How frequently to scope if polyp found, if noninvasive carcinoma found, if invasive carcinoma found?
Polyp q3-5
Noninvasive q1-3
Invasive: stage
How to evaluate a patient that comes in with a change in stool caliber?
Barium enema, if positive, then stage III. If negative,then scope and look for cancer.
FAP
Deletion in APC, thousands of polyps by age 20, cancer by age 30, dead by 40. Tx with total colectomy.
HNPCC (lynch syndrome
MSI CC which is associated with endometrial and ovarian cancer.
Turcot syndrome
Colon cancer + brain tumors
Gardner’s Syndrome
CC + jaw tumors
Peutz Jegers
Polyps, non cancerous in large intestine, but cancerous in small intestine. Plus hyperpigmented lips.
Treatment of GI bleed
2 large bore IVs Type and Cross IVF IV PPI GI Consult
How to change management of GI bleed if patient is cirrhotic?
Give octreotide and ceftriaxone
Workup of GI bleed?
Stabilize with treatment, then do NG lavage or EGD**. If EGD is positive, then GI bleed is upper. If GI bleed is lower and brisk, do an arteriogram. If not brisk, do a colonoscopy. If colonoscopy is negative, redo EGD.
Cameron lesions?
Folds in stomach where diaphragm is. Indicative of hiatal hernia.
Prophylaxis for variceal bleed?
Propranolol
How to diagnose boorhave syndrome?
Gastrographin swallow (less dangerous than barium if it enters mediastinum), then barium swallow, then EGD (but dangerous)
Dieulafoy’s Lesion
Normal anatomic variant arteriole near surface of gi tract. Causes brisk hematemesis.
Painful BRBPR indicative of?
Ischemic colitis
Causes of cirrhosis
Viral hepatitis Wilson's Disease Hemachromatosis A1AT Deficiency PBC PSC EtOH NASH Something else
PBC vs PSC
PBC is in women and associated with antimitochondrial antibodies. Treat with ursodiol
PSC is associated with ulcerative cholitis, is extrahepatic. T
Effects of cirrhosis
Increase pt/ptt, jaundice, pruritis, ammonemia, decreased albumin, decreased blood flow, increased estrogen
How to treat a patient with cirrhosis?
Vaccinate for hepatitis A and B, no drinking, transplant
How to follow up a patient with cirrhosis
RUQ ultrasounds with AFP to assess for presence of HCC every 6 months. Do EGD to visualize varices occasionally.
How to work up ascites?
SAAG
>1.1? Then patient has portal htn – cirrhosis, RHF, Budd-Chiari, Schistosomiasis
How to treat a patient with cirrhosis?
Treat underlying disease. Salt restrict
Most common organisms in SBP?
Strep, or e.coli/klebsiella
What increases the risk of SBP in a patient with ascites?
Total protein
How to treat SBP?
Third generation cephalosporin (FQ if pen allergic)
How to treat secondary SBP due to perf?
3rd gen cef + metronidazole + ex-lap
What cell count in ascites fluid is suggestive of sbp?
> 250 cells
Best way to investigate cholelithiasis?
RUQ ultrasound.
How to treat ascending cholangitis?
ERCP -> cholecystectomy and flagyl + cipro.
Cullen sign
Umbilical hematoma from pancreatitis
turner sign
Flank hematoma from pancreatitis
What lab value corresponds to prognosis in pancreatitis?
BUN
Early complications of pancreatitis, dx and tx
ARDS, dx with chest xr, intubate
Hypocalcemia, check ca, give ca
Mid complications of pancreatitis
SIRS (day 7), dx with CT, give abx
Infection, biopsy, debridement (closed > open)
Late complications of pancreatitis
Pseudocyst, ct
Abscess, ct
Drain if >6weeks and >6cm and symptomatic.
