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Diagnosis & Management 2 > GI > Flashcards

GI Flashcards

1
Q

GI “Alarm symptoms”: (4)

A
  1. rectal bleeding
  2. nocturnal or progressive abdominal pain
  3. weight loss
  4. laboratory abnormalities such as anemia, elevated inflammatory markers or electrolyte disturbances
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2
Q

GERD alarm symptoms: (6)

A
  1. dysphagia
  2. odynophagia
  3. weight loss
  4. spontaneous resolution of GERD symptoms
  5. iron deficiency anemia
  6. GI bleeding
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3
Q

AST and ALT are commonly elevated with :

A 
alcohol related dx ( AST > ALT)
steatohepatitis
hepatitis ( A -E)
hemochromatosis
alpha 1 antitrypsin
autoimmune hepatitis
wilson's dx
celiac dx
cirrhosis
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4
Q

best imagine test for gastric motility:

A

gastric emptying test scintigraphy

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5
Q

Elevated transferases, plus pos IgA and TTG indicates:

A

celiac dx

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6
Q

Alkaline phosphate is commonly elevated with

A

cholestatic or infiltrative dx
biliary obstruction
bone dx
adolescence and pregnancy

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7
Q

elevated indirect (unconjugated) bilirubin indicates;

A

pre-liver disorder such as
gilbert’s
hemolytic process ( large hematoma/hemolytic anemia)

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8
Q

elevated conjugated ( direct) bilirubin indicates:

A

obstruction: unable to excrete bile
cirrhosis: loss of functioning hepatocytes
hepatitis.

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9
Q

minimum lab tests to work up acute pain in and:

A

CBC, CMP, amylase, EKG and abd/chest xray

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10
Q

amylase and lipase limits 3x the upper limit of normal = likely dx of :

A

pancreatitis
amylase > 330
lipase > 180

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11
Q

best initial diagnostic test for pancreatitis:

A 
abdominal ultrasound ( rule out presence of stones)
suspect gallstones in pt with sever abd pain, high amylase and lipase w/out presence/hx of excessive alcohol consumption
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12
Q

test of choice for evaluate pancreatic ducts:

A

MRCP - can identify pancreatic necrosis

ERCP is still most accurate but requires radiation and contrast can cause nephrotoxitiy

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13
Q

Pancreatitis causes -

GET SMASHED

A

G - gallstones
Ethanol - excessive alcohol
Trauma

Steroids
Mumps
Autoimmune
Scorpion genome
Hypercalcemia, hyperlipidemia
ERCP
Drugs
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14
Q 
topical nifedipine OR topical nitroglycerin
topical anelgesic
stool softener
sitz bath
fiber/stool bulking agents 
are all first line tx for:
A

anal fissure

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15
Q

oral mineral oil helps lubricate stool and renders defecation more comfortable and minimizes anal mucosal damage in pts with anal fissure:
long term use is discouraged due to its potential to attenuate the absorption of ___________ and ___________ when used consistently in large amounts

A

fat soluble vitamins A, D, E and K

essential fatty acids

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16
Q

second line therapy for anal fissures includes:

A

alternating the topical vasodilator the pt was using ( nitro/nifedipine)

topical diltiazem
topical bethanechol
oral nifedipine/diltiazem
botulinum toxin injected into anal sphincter

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17
Q

surgical options for anal fissures include:

A

sphincterotomy

anal advancement flap

injection of botulinum toxin

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18
Q 
These clinical findings indicate: 
lower abd tenderness
cervical motion tenderness
adnexal tenderness
oral temp above 101F
high ESR
abnormal cervical/vaginal discharge abscess or pregnancy.
Evidence of chlamydia/gonorrhoeae
high WBC
A

PID

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19
Q

TX for severe PID(inpt):

A 
antibiotics: 
Cefotetan 2 g IV Q12hrs PLUS
doxycycline 100mg orally or IV Q12hrs
OR
Cefoxitin 2 g IV Q 6hrs PLUS
Doxycycline 100mg orally or IV every 12 hrs
OR
Clindamycin 900mg IV Q8 hrs PLUS Gentamicin loading dose IV or IM 2mg/kg, followed by maintenane dose 1.5mg/kg Q 8 hrs. single daily dosing 3-5 mg/kg can be substituted.

hospitalization may be required for uncertain dx, pelvic abscess or pregnancy

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20
Q

tx for mild to moderate outpt PID:

A

ceftriaxone 250 mg IM single dose PLUS
doxycyline 100mg PO BID for 14 days
OR
cefoxitin2g IM single dose PLUS probenecid ( 1 gm IM in single dose) PLUS doxycycline 100 mg PO BID for 14 days

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21
Q

These clinical findings indicate:
smooth mobile adnexal mass
percussive dullness on affected side
diffuse pain/pressure(if ruptured).

A

Ovarian cyst

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22
Q

Tx for ovarian cyst:

A

oral contraceptives may hasten cyst resolution

cysts > 6 cm require evaluation via laparoscopy and possible surgical removal

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23
Q

These clinical findings indicate:
localized or diffuse colicky or dull pain
shoulder pain with hemoperitoneum
reobound tenderness/guarding ( if ruptured)
abnormal vaginal bleeding
amenorrhea
quant serum hCG immunoassay pos ( 1 week after conception)

A

ectopic pregnancy

tx: surgery

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24
Q 
These clinical findings indicate: 
dysmenorrhea
dyspareunia
pain on defecation
infertility
A

endometriosis

tx: oral contraceptives if birth control needed, otherwise NSAIDs, poss. laparoscopy to rule out pathology

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25
Q

These clinical findings indicate:

flank pain, suprapubic pain, dysuria, frequency, fever, N/V

A

UTI

tx: abx
nitrofurantoin 100 mg PO BID for 5 days

trimethoprim - sulfamethoxazle: one double strength tab 160/800mg BID PO for 3 days( avoid if pt has taken TMP- SMX for cystitis in past 3 months)

fosfomycin 3 gm single dose

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26
Q

These clinical findings indicate:
acute, progressively severe pain
mass/tenderness on affected side upon palpation
s/s more impressive than exam

A

adnexal torsion

tx: hospitalization/surgery

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27
Q

These clinical findings indicate:
initially - epigastric to midabdominal pain and anorexia
Later: lower quandrant to suprapubic to flank pain and vomiting
rebound tenderness/gaurding - tenderness over McBurney’s point
Psoas/obturator sign
low grad fever

A

appendicitis

hospitalization and surgery

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28
Q 
These clinical findings indicate: 
palpable mass on uterus
back pain/pressure
dysmenorrhea/menorrhagia
anemia
frequency/constipation
A

uterine fibroid

tx: hysterectomy
uterine artery embolectomy

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29
Q

The most common symptoms of ________ are heartburn, regurgitation, and dysphagia

A

GERD

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30
Q

Endoscopy with biopsy should be done at presentation for patients with an esophageal GERD syndrome with _______ _________ and to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of ________________

A

troublesome dysphagia

twice - daily PPI therapy

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31
Q

in pts with mild and intermittent GERD s/s who are naive to tx, tx with:

A

low dose H2RAs
(Famotidine 10 mg BID, ranitidine 75 mg BID)
concomitant antacids are appropriate if symptoms occur less than once a week.

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32
Q

If s/s of mild/mod GERD persist with low dose H2RAs:

A

increase dose of H2RAs to standard dose, twice daily for a minimum of two weeks
(Famotidine 20 mg BID, Ranitidine 150mg BID)

33
Q

If s/s of mild/mod GERD persist on standard dose H2RAs twice daily:

A

discontinue H2RAs and initiate once daily PPIs at a low dose, then increase to standard doses if required for symptom control.
(e.g.; Omeprazole 20 mg/day; 40 mg daily)

make gradual changes in therapy at two - four week intervals.
once symptoms are controlled, therapy should be continued for at least 8 weeks.

34
Q

In pts with frequent GERD s/s ( two or more episodes per week) and severe s/s that impair quality of life, tx with:

A

standard dose PPI daily ( omeprazole 40 mg)
its who fail to respond to once daily PPI therapy are considered to have refractory GERD and should be referred to GI specialist.

35
Q

Upper endoscopy is indicated if the dx of GERD is unclear and in the following pts:

A

pts with heartburn AND alarm s/s ( dysphagia, bleeding, anemia, weight loss, recurrent vomiting)

pts with severe erosive esophagitis after a 2 month course of PPI therapy to assess healing and rule out Barrett’s esophagus

pts with typical GERD s/s that persist despite a therapeutic trial of four to eight weeks of twice daily PPI therapy

Men older than 50 yrs with chronic GERD s/s ( more than 5 yrs) and additional risk factors( nocturnal s/s, hiatal hernia, high BMI etc. )

36
Q

indefinite maintenance therapy is suggested for pts with:

A

recurrent s/s within three months of discontinuing acid suppression

if s/s occur AFTER three or more months, repeat a course of previously effective acid suppression and then taper off when s/s resolve.

37
Q

trial off medications in all pts with GERD who:

A

whose symptoms resolve completely with acid suppression

38
Q

heartburn is usually precipitated by _______ and occurs within ___ of eating, particularly after _________

A

food intake

1 hr

large, fatty meals.

39
Q

what causes gastritis:

A

an infection in the stomach ( H. pylori)

NSAIDs

drinking alcohol

auto immune

a serious or life- theatening illness

40
Q

s/s gastritis ( from ulcers secondary to gastritis):

A

pain in the upper belly

feeling bloated, feeling full after eating a small amount of food

decreased appetite

N/V

vomiting blood or having black colored bowel movements

feeling more tired than usual ( anemia)

41
Q

diagnostics for gastritis:

A

upper endoscopy( poss biopsy)

H. pylori inaction ( blood tests, breath tests, fecal)

barium swallow

CBC for anemia

42
Q

symptomatic peptic ulcers most commonly present with:

A

epigastric pain

food provoked epigastric discomfort and fullness

early satiety

nausea

43
Q

complications of peptic ulcers:

A

bleeding,
gastric outlet obstruction
penetration into a solid organ or fistulization into a hollow viscus
free perforation

44
Q

Causes of diffuse abdominal pain:

A 
acute pancreatitis
diabetic ketoacidosis
early appendicitis
gastroenteritis
intestinal obstruction
mesenteric ischemia
peritonitis
sickle cell crisis
spontaneous peritonitis
typhoid fever
45
Q

Causes of R or L UQ pain:

A 
acute pancreatitis
herpes zoster
lower lobe pneumonia
myocardial ischemia
raditulitis
46
Q

Causes of RUQ pain:

A 
cholecystitis and biliary colic
congestive hepatomegaly
hepatitis or hepatic abscess
perforated duodenal ulcer
retrocecal appendcitis
47
Q

Causes of RLQ pain:

A

appendicitis
cecal/meckel’s diverticulitis
mesenteric adenitis

48
Q

Causes of LUQ pain:

A

gastritis
splenic disorders
(abscesses, rupture)

49
Q

Causes of LLQ pain:

A

sigmoid diverticulitis

50
Q

Causes of R or L LQ pain:

A 
abdominal or psoas abscess
abdominal wall hematoma
cystitis
endometriosis
incarcerated or strangulated hernia
IBD
Mittelschmerz
PID
Renal stone
Ruptured AAA
ruptured ectopic pregnancy
torsion of ovarian cyst or teste
51
Q

Tx of gastritis:

A

cause dependent:

Stop NSAIDs, alcohol

tx for H.pylori

antacids, surface agents, histamine blockersH2RAs, PPIs

52
Q

tx of H. Pylori infection

A

standard triple therapy:
PPI, amoxicillin 1g and clarithromycin 500mg twice daily for 7 to 10 days
OR
PPI, clarithromycin 500mg and metronidazole 500mg twice daily for 10 to 14 days
OR
sequential therapy:
PPI and amoxicillin 1g twice daily for 5 days followed by tinidazole 500mg or metronidazole 500 mg twice daily for 5 days.

second line tx: may be used if first line therapy fails.
quadruple therapy - PPI, amoxicillin 1g, clarithromycin 500mg, tinidazole 500mg or metronidazole 500mg twice daily for 10 days.

bismuth based quad therapy:
bismuth 525 mg( or substrate 300mg), metronidazole 250mg and tetracycline 500mg 4 times daily plus PPI twice daily

53
Q

how do PPIs work

A

PPIs reduce the production of stomach acid. Instead of shutting down histamine receptors in acid-producing stomach cells like H2 receptor antagonists, PPIs disable the pumps that push acid into the stomach.

This raises the stomach’s pH level, making the stomach’s contents less acidic. By reducing the acidity of the stomach, there’s less acid available to shoot into the esophagus. When you do experience reflux, your stomach’s contents will do significantly less damage to your esophagus.

54
Q

Medications and dietary supplements that can increase acid reflux and worsen GERD include:

A

Anticholinergics, such as oxybutynin (Ditropan XL), prescribed for overactive bladder and irritable bowel syndrome
Tricyclic antidepressants (amitriptyline, doxepin, others)
Calcium channel blockers and nitrates used for high blood pressure and heart disease
Narcotics (opioids), such as codeine, and those containing hydrocodone and acetaminophen (Lortab, Norco, Vicodin)
Progesterone
Quinidine
Sedatives or tranquilizers, including benzodiazepines such as diazepam (Valium) and temazepam (Restoril)
Theophylline (Elixophyllin, Theochron)

55
Q

when prescribing a fluoroquinolone abx( cipro/levaquin) to treat a UTI or respiratory infection, be aware if pt has GERD which they take antacids for b/c:

A

The oral absorption of all fluoroquinolones(ciprofloxacin, moxifloxacin) are significantly impaired when coadministered with aluminum- and magnesium-containing antacids and sucralfate, as well as with other metal cations such as calcium and iron. Concomitant use of these agents, even when dosed several hours apart, should be avoided.

56
Q

recommendations for monitoring surveillance testing for pt’s dx with Barrett esophagus:

A

When no dysplasia is detected after 2 consecutive endoscopies within 6-12 mo, the usual recommendation is to repeat the test after 3-5 years.

57
Q

esophageal adenocarcinoma is usually located:

A

at the junction of the esophagus and stomach

58
Q

most common form of esophageal cancer in US is:

A

adenocarcinoma

59
Q

esophageal squamous cell cancer is usually located:

A

in the upper esophagus

60
Q

s/s of esophageal cancer:

A

dysphagia, weight loss, epigastric or retrosternal pain, persistent hoarseness and cough.
iron deficient anemia often develops from chronic low volume bleeding from esophageal tumor.

61
Q

Yes or no: screening for H. pylori infection is recommended in GERD pts?

A

NO

62
Q

drug for use in prevention of NSAID - induced gastric ulcers

A

misoprostol

63
Q

the most specific and sensitive test for H. pylori is :

A

organism specific stool antigen testing

64
Q

difficult swallowing, painful swallowing, chest pain ( particularly behind the breastbone) that occurs with eating, food impactions, heartburn and acid regurgitation are all common s/s of:

A

esophagitis

65
Q

hematochezia:

A

passage of maroon or bright red blood or blood clots per rectum

66
Q

blood originating from the left colon tends to be ___ ____ in color

A

bright red

67
Q

blood from the right colon usually appears ____ or ____ colored and may be _______

A

dark or maroon

mixed with stool

68
Q

if pt with hematochezia is hemodynamically stable, initial examination choice is:

A

colonoscopy

69
Q

pts with acute upper GI bleeding commonly present with _________ and/or ______

A

hematemesis

melena (black, tarry stools)

70
Q

Major causes of upper GI bleeding:

A

peptic ulcer, esophagogastric varices, AV malformation, tumor, esophageal tear

71
Q

diagnostic testing for upper GI bleed:

A

type and screen/crossmatch

CBC, Pt/INR, AST/ALT, albumin, BUN and creatinine

72
Q

upper GI bleeding accompanied by dysphagia, early satiety, involuntary weight loss and cachexia indicates:

A

malignancy

73
Q

diagnostic study of choice for acute upper GI bleeding:

A

upper endoscopy

74
Q

for pts with upper GI bleeding, a negative upper endoscopy and hematochezia, a _________is required

A

colonoscopy

75
Q

initial diagnostic step with upper GI bleeding:

A

NG tube lavage

76
Q

cardinal s/s of gastroparesis:

A

N/V, early satiety, bloating, and /or upper abdominal pain

syndrome of objectively delayed gastric emptying in the absence of mechanical obstruction

77
Q

initial management of gastroparesis:

A

dietary modification, optimization of glycemic control and hydration

if symptoms continue, tx with pro kinetic and antiemetics:
e.g.;metoclopramide
10 mg up to 4 times daily 30 min before meals or food and at HS for 2 to 8 weeks. tx beyond 12 weeks not recommended.

78
Q

_________ should be suspected in a pt with RUQ or gastric pain, fever and a leukocytosis

A

acute cholecystitis

also mild elevations in ALT/AST, amylase

if same pt has elevated serum total bilirubin and alkaline phosphatase, should suspect complicating conditions to cholecystitis.

Diagnosis & Management 2 (4 decks)

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