GI 5

Question 1

What is the diagnosis : Sudden onset peri-umbilical pain, N/V, pain out of proportion to PE?

What will labs show?

How do you DX?

TRX?

Answer 1

Acute Mesenteric Ischemia.

Labs = marked leukocytosis, Metabolic acidosis (lactic acid), increased amylase.

DX= CT angiogram

TRX = Re-vascularize if early, surgical resection if infected.

Question 2

Radiation Proctitis is a potential complication of chemo/radiation or pelvic region…

What is the classic presentation?
What time frame can you see this?

How do you DX?

Answer 2

Presentation:

• Blood diarrhea
• Mucus discharge from rectum
• Tennesmus ( ineffective painful straining on dedication)

Can see it acutely during radiation or even YEARS later..

DX = of exclusion - r/o infectious, IBD, ischemia, malignancy ext.

Question 3

1. What is DES (Distal Esophageal Spasm)?
2. How do you dx?
3. TRX?

Answer 3

1. Motility disorder where there is pre-mature simultaneous contractions of distal esophagus (but with normal esophageal sphincter tone)

Presents as intermittent chest pain and dysphagia for both liquid and solids.

2. Dx with Manometry –> shows multiple simultaneous contractions.
   (Esophagram with “cork screw” pattern but not diagnostic)
3. TRX = CCB (DILTIAZEM)

Question 4

ACUTE COLONIC ISCHEMIA presents with mild-mod abdominal pain with bloody diarrhea.

What is the common cause of this?

How do you DX?

Answer 4

Ischemia of watershed area of colon due to hypovolemia/hypotension.

DX = initially get CT abdomen

• Colonic wall thickening
• Fat stranding
• Air in bowel wall ***

Confirm with COLONOSCOPY:
- friable, edematous, erythematous mucosa with pale patches.

Question 5

Where is the level of the lesion for:

Cholelithiasis?
Cholecystitis?
Choledocolithiasis?
Cholangitis?

Answer 5

Cholelithiasis –> stones in gall bladder
Cholecystitis –> cystic duct
Choledocolithiasis –> common bile duct
Cholangitis –> Common bile duct

Question 6

What is the 2 main causes of Cholelithiasis?

What is the classic presentation for Cholelithiasis?

DX?

TRX?

Answer 6

1. Cholesterol stones - 4Fs “fat, forty, female, fertile”
2. Pigmented stones (2/2 hemolysis)

PRESENTS WITH colicky RUQ pain WORSENED WITH fatty meals.

DX = RUQ US

TRX:

• Elective cholecystectomy if symptomatic or punctate calcifications.
• Ursodeoxycholic Acid (if not surgical candidate)

Question 7

Describe the pathophysiology of Cholecystitis?

What is classic presentation of Cholecystitis?

DX?

TRX?

Answer 7

Pathophysiology –> gall stone in cystic duct causes inflammation of gall bladder, causing dilation/inflammation of gall bladder.

Presentation =

• CONSTANT RUQ pain and +ve Murphy’s sign
• Mild fever and leukocytosis (2/2 inflammation)

DX = RUQ US, if RUQ -ve but clinical suspicion is high do HIDA scan.

TRX = NPO, IVF, IV ABX, Urgent cholecystectomy

Question 8

Describe the pathophysiology of Choledocolithiasis?

Classic Presentation?

DX?

TRX?

Answer 8

Pathophysiology –> gall stone in common bile duct causing dilation/inflammation of biliary tree

Presentation:

• RUQ pain, + Murphy’s sign
• +/- Hepatitis, Direct Bilirubinemia
• +/- Pancreatitis (depending on if stone is distal enough)
• Mild Fever. Leukocytosis (2/2 inflammation)

DX = RUQ US, if -ve for stone but you see dilation of biliary tree do ERCP (dx and trx)

TRX: ERCP

+ (NPO, IVF, IV ABX)

Question 9

Describe the pathophysiology of Cholangitis?

It classically presents with Charcot’s triad which is?
What is Reynold’s Pentad?

DX?

TRX?

Answer 9

Pathophysiology –> gall stone in common bile duct with ascending infection of biliary tree

Charcot's triad:
- RUQ pain
- Jaundice 
- Fever
Reynold's Pentad: (when severe) 
- HYPOtn
- AMS

DX = RUQ US
TRX = ERCP asap + IV ABX

Question 10

For cholecystitis, choledocolithiasis and cholangitis, what IV ABX do you want to start once you confirm dx?

Answer 10

IV CIPROFLOXACIN + METRONIDAZOLE

OR

IV AMP-GENT + METRONIDAZOLE.

Question 11

A Patient with chronic GERD presents with dysphagia of solids that progress to liquids…

What should you be concerned about?

Answer 11

Peptic or Esophageal STRICTURES (results form the healing process of erosive gastritis/GERD).

Question 12

What are the indications of Stress ulcer PPX in the ICU?

Answer 12

if any ONE of the following:

• Coagulopathy ( plt < 50,000, INR > 1.5, PTT X2 upper limit)
• Mechanical ventilation
• GI bleed or ulcer
• Head trauma, Spinal trauma, major burn.

if any TWO of following

• Steroids
• > 1 week in ICU
• Occult GI bleed > 6 days
• Sepsis

Question 13

What is DUMPING SYNDROME?

What is the presentation?

Answer 13

Complication of Gastrectomy, due to increase transit of food into jejunum.

Presentation:
- N/V, diarrhea, abd pain
+/- dizziness, sweating, dyspnea

Question 14

What is the management of Dumping syndrome?

Answer 14

High protein + Low Carb diet

Frequent small meals.

Question 15

How does GASTROPARESIS effect BG levels in insulin dependent DM?

Answer 15

Can cause episodes of HYPOGLYCEMIA, because you get delayed absorption of food, blood sugars rise after insulin peak.