GI Flashcards
duodenal & gastric ulcers: your first thought regarding causative agent is?
that damn H. Pylori
90% duo
75% gastric
Which 3 medications cause peptic ulcer disease?
NSAIDS
ASA
Glucocorticoids
duodenal vs gastric ulcers: what age ranges for each?
duodenal: youngies - 30-55
gastric: old farts - 55-65
Your patient has hella gnawing epigastric pain. How do tell what kind of peptic ulcer disease it is?
Ask ‘em if food makes it better or worse. If it’s a duodenal ulcer, it feels better after eating. If it’s a gastric ulcer, it feels worse after eating.
peptic ulcer disease: s/s x3
both: gnawing epigastric pain
duod: pain relief w food
gastric: pain worses w food
Expected physical findings associated with PUD?
PE unremarkable
GI BLEEDING (20%): melena, hematemesis, or coffee-ground emesis (duodenum)
PERF (5-10%): severe epigastric pain, quiet BS, rigid abd
Your patient is barfing up coffee ground looking shit and you suspect an ulcer. What is the location of the ulcer in this poor soul?
DUODENUM!
You think your patient has a perforated peptic ulcer because of what findings in your physical exam?
severe epigastric pain
RIGID/board-like acute abdomen
QUIET bowel sounds
What kinda drugs (class and names) you wanna prescribe first to a patient with PUD? When should the patients take them?
Go for them H2 Receptor Antagonists, like:
famotidine (Pepcid) 40 mg
ranitidine (Zantac) 300 mg
take qHS
What’s an important educational point for PPI?
take 30 minutes before meals
PPI black box warning?
↑ RISK HIP FRACTURE
Okay you’re gonna try PPI with your PUD patient. What are two options + their doses?
pantoprazole (Protonix) 40 mg
omeprazole (Prilosec) 20 mg
QD
NAME 4 MUCOSAL PROTECTIVE AGENTS
+ an administration consideration pertinent to all of them
sucralfate (Carafate)
bismuth subsalicylate (Pepto-Bismol)
misoprostol (Cytotec)
antacids
GIVE 2 HOURS APART FROM OTHER MEDS
What medication used to treat PUD is associated with decreases in nosocomial pneumonia? What IS it? **
sucralfate (Carafate) - it’s a mucosal protective agent
What mucosal protective agent used to treat PUD has antimicrobial action against H.Pylori?
bismuth subsalicylate (Pepto-Bismol)
Which medication is used prophylactically against NSAID-induced peptic ulcers?
misoprostol (Cytotec)
What medication should be prescribed for patients who cannot d/c NSAIDs in order to protect them from developing ulcers?
PPIs
What are the three combination therapy trios indicated for H. Pylori treatment?
metronidazole + omeprazole + amoxicillin
amoxicillin
metronidazole + omeprazole + clarithromycin
amoxicillin + omeprazole + clarithromycin
BID x 7 days
Which 3 kids of mucosal protective agents do not prevent NSAID-induced ulcers?
H2 receptor antagonists
carafate (Sucralfate)
antacids
H. Pylori develops quick resistance against which 2 meds? And slower resistance against what other 2 meds?
QUICK:
metronidazole (Flagyl) & clarithromycin (Biaxin)
NOT:
amoxicillin & tetracyclin
What is the anti-ulcer therapy recommended after H. Pylori therapy is complete?
3 - 7 weeks after completion of previous regimen:
- if duodenal ulcer: omeprazole 40mg QD or lansoprazole (Prevacid) 30 mg QD for 7 more weeks
- H2 blocker or sucralfate for 6 - 8 weeks
PUD: inpt mgmt x13
- IV access: IVF, blood, H2 blockers
- baseline labs: CBC, PT/PTT, BMP
- O2
- endoscopy, GI angiography
- urinary cath
- NPO/ng for lavage
- monitor abdomen: quiet, rigid, rebound tenderness
- if coagulopathy: FFP
- if thrombocytopenia: transfuse plts
- GI surgical eval
- upright or decub films: in 75%
What should you order if the cause of a GI bleed is unexplained?
GI angiography
Why is ng tube/gastric lavage not always necessary in GI bleeds?
80% of bleeds stop spontaneously
What is the preferred secretory agent to give to in-patients with GI bleeds?
H2 blocker - ex: famotidine (Pepcid)
42 yo. M presents to your clinic with complaints of epigastric pain that increased intensity over past two weeks. He describes the pain as decreasing after he eats. This finding mostly suggests what?
Duodenal ulcer
What is GERD?
backflow of acidic gastric contents into the esophagus
What are the two main causes of GERD?
Incompetent lower esophageal sphincter
Delayed gastric emptying
A 65 yo. M complains of dysphagia and epigastric pain. He reports hx of ETOH use and smoking for 25 years. What is the most likely diagnosis?
GERD
GERD: hallmark s/s
occurs at night +/- recumbent position
retrosternal burning
bitter taste in mouth
In the elderly what is a classic sign of GERD?
dysphagia
What diagnostic should you order for suspected GERD? What is the rationale for it?
esophagogastroduodenoscopy (EGD)
to r/o esophageal cancer, Barrett’s Esophagus, PUD, and more
GERD: mgmt x5
- antacids PRN
- H2 blockers: qHS or BID
- PPI if H2 ineffective
- GI/Surgical consult PRN
- non-pharm measures (elevate HOB, don’t eat stuff that exacerbates, stop smoking, weight reduction)
What is hepatitis?
inflammation of liver with resultant dysfunction
Describe Hep A.
A is for ANAL: fecal-oral route transmission
- enteral virus
- sources: contaminated food, water, intimate sexual contact
- mortality rate super low
When and for how long does a Hep A patient’s blood and stool remain infectious?
During the 2 - 6 week incubation period.
How is Hep B transmitted?
blood/blood products
sexual activity
mother to fetus
Describe Hep B.
Blood borne DNA virus found in serum, semen, saliva, secretions (vaginal)
Describe Hep C.
Blood borne RNA virus traditionally associated with blood transfusion and IVDU, but source of infection can be uncertain.
What is the mode of transmission of Hep C?
Blood
- transfusions
- IVDU
hepatitis: pre-icteric s/s
aversion to smoking, EtOH
fever, HA, n/v, fatigue, malaise, anorexia
hepatitis: icteric s/s
clay colored stool RUQ pain jaundice, pruritis dark urine weight loss sometimes: hepatosplenomegaly and low grade fever
any hepatitis: notable findings
WBC: low - normal
UA: protein, bilirubin
LFTs: ↑ ALT, AST (500 - 2000 IU/L)
What serology is diagnostic of acute Hep A?
Anti-HAV
IgM
peak during first week, disappear in 3 - 6 mo
What serology implies previous exposure, recovery, & immunity to Hep A?
Anti-HAV
IgG
What serology indicates active Hep B infection?
HBsAg (first evidence of infection, + in carriers and chronic)
HBeAg (= circulating virus in highly infectious sera)
Anti-HBc
IgM
What serology indicates recovery from Hep B?
Anti-HBsAg
Anti-HBc
True or False: There is a chronic form of Hep. A.
False. There is NO chronic form of Hep. A.
Hep A peaks at one week and disappears in 3-6 months
What is the first evidence of Hep B infection?
Hep B surface antigens - HBsAg
What indicates cirulating HBV and highly infectious serum?
HBeAg - envelope protein
What is the serology indicating active Hep C infection?
HCV RNA (acute) Anti-HCV (seen in acute or prior)
What diagnostic test detects presence of antibodies to hepatitis viruses?
Enzyme Immunoassay (ELISA)
What diagnostic test is used to distinguish prior exposure from current infection of Hep C?
Polymerase Chain Reaction (PCR)
HCV RNA means acute
hepatitis: mgmt
SUPPORTIVE! rest fluids 3 - 4L /day NO protein diet No ETOH, drugs
Vitamin K for prolonged PT (gt 15)
Lactulose 30 mL PO/PR if elevated ammonia (hepatic encephalopathy)
Your hepatitis patient has elevated ammonia levels suggestive of hepatic encephalopathy. What pharmacological intervention would you order?
Lactulose 30 mL PO or PR
Your hepatitis patient’s labs come back with PT of 20. What intervention do you order?
Vitamin K to promote clotting
What is diverticulitis?
INFLAMMATION or localized PERFORATION of 1+ diverticula with ABSCESS
incidence higher in people who have low dietary fiber intake, and women
What type of pain is typical of diverticulitis?
mild - mod aching LLQ
45 yo. M presents to your office with complaints of colicky cramping abdominal pain in the left lower quadrant and recent history of constipation. Patient now complains of nausea and vomiting x 2 days. You suspect:
Diverticulitis - inflammation; perforation; abscess formation
What diagnostic should you order for all patients with suspected diverticulitis?
CXR: assess for pneumoperitoneum
What sigmoidoscopy findings would you expect for diverticulitis?
inflamed mucosa
diverticulitis: diagnostics
- stool heme test (+)
- sigmoidoscopy: inflamed mucosa
- CT scan: abscess evaluation
- CXR: pneumoperitoneum
diverticulitis: mgmt
NPO **** - IVF - IV abx metronidazole (Flagyl) ciprofloxacin (Cipro) clindamycin (Cleocin) ampicillin - if significant GIB, treat as w PUD - surgical consult
What is cholecystitis?
inflammation of the gallbladder, associated with gallstones 90%
What kind of pain is typical of cholecystitis?
sudden, steady, severe in epigastrum or right hypochondrium
cholecystitis: hallmark s/s
- after eating large fatty meal
- pain: sudden, steady, severe epigastric or R hypochondrium
- vomiting = relief
What sign elicited during PE suggests cholecysititis?
Murphy’s Sign: deep pain on inspiration when fingers are placed under right rib cage
cholecystitis: expected PE findings
Murphy’s Sign
RUQ tender to palpation, palpable gallbladder 15%
guarding
rebound tenderness
What is the gold standard diagnostic of cholecystitis?
US
cholecystitis: mgmt
- analgesics
- NPO
- NGT (gastric decompression)
- IVF (crystalloid)
- IV abx: broad spectrum, like piperacillin
- surgical consult (choley lap)
What are the two most important components in the mgmt of cholecystitis?
NPO
IV broad spectrum abx - piperacillin
What is pancreatitis?
acute pancreas inflammation d/t panc enzymes seeping into surrounding tissue
- autodigestion of the pancreas!
** What are the causes of pancreatitis? **
gallbladder disease heavy EtOH hypercalcemia hyperlipidemia trauma, drugs (sulfa drugs, furosemide, thiazides, estrogen, azathioprine)
What pain is typical of acute pancreatitis?
sudden, severe epigastric pain
- worsens: movement, walking, supine
- improves: sitting, leaning forward
- radiates: usually to back, can go anywhere
What 2 signs are classic for hemorrhagic acute pancreatitis?
Grey Turner’s: flank bruising
Cullen’s: umbilical bruising
acute pancreatitis: notable PE findings x4
- upper abd tender to palpation usually WITHOUT guarding, rigidity, rebound tenderness
- distension
- absent BS (if paralytic ileus)
- mild jaundice
What labs are elevated in 90% of acute pancreatitis patients?
amylase (normal: 50 - 180)
lipase (normal: 14 - 280)
What lab value is suggestive of pancreatic necrosis?
Elevated C-reactive protein
What electrolyte abnormality is commonly seen with acute pancreatitis? What are 3 manifestations you can watch for?
hypocalcemia
under 7 = tetany
watch for Chvostek & Trousseau
What is the preferred diagnostic imaging to order for acute pancreatitis?
CT (more useful than US)
acute pancreatitis: Ransom’s Criteria
“george washington got lazy after he broke C-A-B-E”: evaluates prognosis 5-6 = 40% mort, 7+ = 100%
PROGNOSTIC @ ADMIT: G reater than 55 W BCs 16+ G lucose 200+ L DH 350+ A ST 250+
PROGNOSTIC DURING FIRST 48 HOURS: H CT drop 10+ B UN increase 5+ C a under 8 A rt O2 under 60 B ase deficit 4+ E st fluid sequestration 6L+
In the management of acute pancreatitis when is it indicated to advance from NPO to clear liquid diet?
Once patient is PAIN FREE and BS RETURN
What are 6 causes of a bowel obstruction?
adhesions ** (will pick up in surgical hx) tumors (colon cancer) volvus hernias fecal impaction ileus
What signs are indicative of a proximal bowel obstruction?
Vomiting within MINUTES of pain onset
Minimal distension
(the longer to vom, the lower it is)
What signs are indicative of a distal bowel obstruction?
Vomiting within HOURS of pain onset
Basketball belly
(the longer to vom, the lower it is)
What pain is typical of bowel obstruction?
initially: cramping, periumbilical
later: constant, diffuse
- What bowel sounds are associated with a bowel obstruction *
high pitched tinkles
What is the diagnostic standard for bowel obstruction and what are the findings?
abdominal plain films, show dilated loops of bowel and air-fluid levels
Horizontal pattern: SBO
Frame pattern: LBO
bowel obstruction: mgmt x4
IVF
NGT
Broad spectrum abx
Surgical intervention if complete obstruction
What is ulcerative colitis?
idiopathic inflammation of the colon and RECTUM
- DIFFUSE mucosal inflammation
has periods of symptomatic / remission
What is Crohn’s Disease?
upper bowel malabsorption syndrome that can occur in any portion of the GI tract and in any layer of the bowel tissue
cobblestone & peyer’s patches
What is the hallmark sign of Ulcerative Colitis?
Bloody diarrhea.
What is diagnostic of ulcerative colitis?
Sigmoidoscopy
PS stool studies negative
- ulcerative colitis: mgmt *
- mesalamine (Canasa) suppositories or enemas x 3 - 12 wks
- hydrocortisone suppositories & enemas
What is a mesenteric infarct?
inadequate blood flow through the mesenteric circulation → ischemia & gangrene of bowel
poor prognosis: 60%+ die
What are 3 causes and 2 risk factors of mesenteric infarcts?
- arterial or venous thrombosis/embolism
- atherosclerosis
- smoking
increases risk:
- older adults
- coagulopathy (ex: s/p cardiac, AAA surgery)
What is the classic symptom of a mesenteric infarct?
pain out of proportion to PE findings
Sudden onset or cramping colicky abdominal pain (usually after eating)
What is the diagnostic for mesenteric infarct?
Abdominal films
CT scan
What is pancreas-related lab value is elevated in mesenteric infart?
amylase but NOT lipase
mesenteric infarct: mgmt
EMERGENCY SURGICAL INTERVENTION
What is appendicitis?
inflammation of the appendix caused by obstruction of the appendiceal lumen.
SURGICAL EMERGENCY! untreated = gangrene w/in 36 hrs
What pain is typical of appendicitis?
begins as vague colicky umbilical pain that shifts to RLQ after several hours
- worsens/localizes with coughing
What is Psoas sign?
Pain with right thigh extention
- suggests appendicitis
What is Obturator’s Sign?
Pain with internal rotation of flexed right thigh
- suggests appendicitis
What is a positive Rovsing’s Sign?
RLQ pain when pressure applied to LLQ
- suggests appendicitis
What is McBurney’s Point?
Associated with appendicitis. Pain illicited with one finger RLQ
What is diagnostic for appendicitis?
CT scan`
appendicitis: mgmt
MEDICAL EMERGENCY! STAT SURGICAL CONSULT
- IV broad spectrum abx
- IVF
- analgesics
What is the most critical assessment finding in the differential diagnosis of the acute abdomen with peritonitis such as in a patient with a bowel perforation?
rigidity =
50 yo. M presents with complaints of decreased stool caliber, constipation, and black tarry stool. You would:
a. consult general surgery for colon cancer resection
b. consult oncology
c. order more tests
d. 2 units PRBC stat
C. Order more tests
What is the classic xray finding associated with mesenteric infarct?
thumbprinting on abdominal film
What two antibiotics are associated with C. difficile?
Clindamycin
Ampicillin
What is the drug of choice for treatment of C. diff?
metrondiazole (Flagyl)
Projectile vomiting is a hallmark symptoms of what GI disease?
Acute pancreatitis
25 yo. F with PMH significant for Chron’s disease presents with abdominal pain fever and nausea. An abdominal xray reveals air under the diaphragm. What is your next plan of care?
Obtain stat surgical consult and start broad spectrum antibiotics due to suspected bowel perforation and ARF peritonitis
Pneumoperitoneum is clinically significant for what potential problem?
Bowel perforation resulting in peritonitis
35 yo. F health care worker has sustained a needle stick from a patient known to have hep B. What should the plan of care be for the health care worker?
Give HIBG immunoglobulin and hepatitis B vaccine immediately
You’re auscultating your patient’s big belly and, uh oh, you hearing high pitched tinkling sounds. Crap, what are you think?
OBSTRUCTION!
NAME THE 3 MOST COMMON GI PERFS AAAAAAND GO!!
- ruptured diverticula
- perforated ulcer
- ruptured appendix
What the hell is peptic ulcer disease?
either duodenal or gastric ulcers, yo
usually old farts get gastrics
Okay so you think your patient has peptic ulcer disease. What kinda testing ya gonna consider?
labs are usually pretty normal, MIGHT see anemia on CBC
- H. Pylori testing
- consider endoscopy after 8 - 12 weeks tx
When do you order an endoscopy for a patient with PUD?
Use it to check ‘em after they’ve been treated for 8 - 12 weeks
You have a patient with an acute abdomen, what two differentials pop into your head?
GI perf or pneumoperitoneum
Why the hell do I have to know outpatient management of PUD? Whatever, what would it be?
- Try an H2 blocker
- If it doesn’t work, up to BID
- If THAT doesn’t work, try a PPI.
- Tolerance develops so switch around within drug class.
What’s a reason you’d go for a PPI over an H2 blocker when treating PUD?
Longterm use of PPI is associated with rebound GERD.
By how much do antacids reduce gastric acidity?
SIKE THEY DON’T
What CXR finding in 75% of cases of PUD?
upright or decubitus films: free air!
How is Hep A transmitted?
fecal-oral route
contaminated food & water, sex
For which GI disorder does vomiting often bring relief?
cholecystitis
What happens if you palpate the upper abdomen of a patient with acute pancreatitis?
upper abd will be tender to palpation but usually WITHOUT guarding, rigidity, rebound tenderness
What is the difference in the response elicited by palpation between PUD, cholecystitis, and acute pancreatitis patients?
PUD: good luck palpating that because it’s an acute abdomen that is hella rigid
choley: RUQ tender to palpation plus guarding and rebound pain
acute panc: upper abd tender to palpation but usually WITHOUT guarding, rigidity, rebound
amylase normals
50 - 180
lipase normals
14 - 280
What kind of pain is typical of mesenteric infarcts?
- pain out of proportion to PE findings
- sudden onset or cramping colicky abd pain (usually after eating)
A 60 yo M patient s/p AAA surgery complains of crampy abdominal pain that began after he ate lunch. You perform a PE and it seems negative but his pain is significant. What do you suspect?
mesenteric infarct
