GI Flashcards
GI “Alarm symptoms”: (4)
- rectal bleeding
- nocturnal or progressive abdominal pain
- weight loss
- laboratory abnormalities such as anemia, elevated inflammatory markers or electrolyte disturbances
GERD alarm symptoms: (6)
- dysphagia
- odynophagia
- weight loss
- spontaneous resolution of GERD symptoms
- iron deficiency anemia
- GI bleeding
AST and ALT are commonly elevated with :
alcohol related dx ( AST > ALT) steatohepatitis hepatitis ( A -E) hemochromatosis alpha 1 antitrypsin autoimmune hepatitis wilson's dx celiac dx cirrhosis
best imagine test for gastric motility:
gastric emptying test scintigraphy
Elevated transferases, plus pos IgA and TTG indicates:
celiac dx
Alkaline phosphate is commonly elevated with
cholestatic or infiltrative dx
biliary obstruction
bone dx
adolescence and pregnancy
elevated indirect (unconjugated) bilirubin indicates;
pre-liver disorder such as
gilbert’s
hemolytic process ( large hematoma/hemolytic anemia)
elevated conjugated ( direct) bilirubin indicates:
obstruction: unable to excrete bile
cirrhosis: loss of functioning hepatocytes
hepatitis.
minimum lab tests to work up acute pain in and:
CBC, CMP, amylase, EKG and abd/chest xray
amylase and lipase limits 3x the upper limit of normal = likely dx of :
pancreatitis
amylase > 330
lipase > 180
best initial diagnostic test for pancreatitis:
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
test of choice for evaluate pancreatic ducts:
MRCP - can identify pancreatic necrosis
ERCP is still most accurate but requires radiation and contrast can cause nephrotoxitiy
Pancreatitis causes -
GET SMASHED
G - gallstones
Ethanol - excessive alcohol
Trauma
Steroids Mumps Autoimmune Scorpion genome Hypercalcemia, hyperlipidemia ERCP Drugs
topical nifedipine OR topical nitroglycerin topical anelgesic stool softener sitz bath fiber/stool bulking agents are all first line tx for:
anal fissure
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
fat soluble vitamins A, D, E and K
essential fatty acids
second line therapy for anal fissures includes:
alternating the topical vasodilator the pt was using ( nitro/nifedipine)
topical diltiazem
topical bethanechol
oral nifedipine/diltiazem
botulinum toxin injected into anal sphincter
surgical options for anal fissures include:
sphincterotomy
anal advancement flap
injection of botulinum toxin
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
PID
TX for severe PID(inpt):
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
tx for mild to moderate outpt PID:
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
These clinical findings indicate:
smooth mobile adnexal mass
percussive dullness on affected side
diffuse pain/pressure(if ruptured).
Ovarian cyst
Tx for ovarian cyst:
oral contraceptives may hasten cyst resolution
cysts > 6 cm require evaluation via laparoscopy and possible surgical removal
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)
ectopic pregnancy
tx: surgery
These clinical findings indicate: dysmenorrhea dyspareunia pain on defecation infertility
endometriosis
tx: oral contraceptives if birth control needed, otherwise NSAIDs, poss. laparoscopy to rule out pathology
These clinical findings indicate:
flank pain, suprapubic pain, dysuria, frequency, fever, N/V
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
These clinical findings indicate:
acute, progressively severe pain
mass/tenderness on affected side upon palpation
s/s more impressive than exam
adnexal torsion
tx: hospitalization/surgery
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
appendicitis
hospitalization and surgery
These clinical findings indicate: palpable mass on uterus back pain/pressure dysmenorrhea/menorrhagia anemia frequency/constipation
uterine fibroid
tx: hysterectomy
uterine artery embolectomy
The most common symptoms of ________ are heartburn, regurgitation, and dysphagia
GERD
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 ________________
troublesome dysphagia
twice - daily PPI therapy
in pts with mild and intermittent GERD s/s who are naive to tx, tx with:
low dose H2RAs
(Famotidine 10 mg BID, ranitidine 75 mg BID)
concomitant antacids are appropriate if symptoms occur less than once a week.
If s/s of mild/mod GERD persist with low dose H2RAs:
increase dose of H2RAs to standard dose, twice daily for a minimum of two weeks
(Famotidine 20 mg BID, Ranitidine 150mg BID)
If s/s of mild/mod GERD persist on standard dose H2RAs twice daily:
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.
In pts with frequent GERD s/s ( two or more episodes per week) and severe s/s that impair quality of life, tx with:
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.
Upper endoscopy is indicated if the dx of GERD is unclear and in the following pts:
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. )
indefinite maintenance therapy is suggested for pts with:
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.
trial off medications in all pts with GERD who:
whose symptoms resolve completely with acid suppression
heartburn is usually precipitated by _______ and occurs within ___ of eating, particularly after _________
food intake
1 hr
large, fatty meals.
what causes gastritis:
an infection in the stomach ( H. pylori)
NSAIDs
drinking alcohol
auto immune
a serious or life- theatening illness
s/s gastritis ( from ulcers secondary to gastritis):
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)
diagnostics for gastritis:
upper endoscopy( poss biopsy)
H. pylori inaction ( blood tests, breath tests, fecal)
barium swallow
CBC for anemia
symptomatic peptic ulcers most commonly present with:
epigastric pain
food provoked epigastric discomfort and fullness
early satiety
nausea
complications of peptic ulcers:
bleeding,
gastric outlet obstruction
penetration into a solid organ or fistulization into a hollow viscus
free perforation
Causes of diffuse abdominal pain:
acute pancreatitis diabetic ketoacidosis early appendicitis gastroenteritis intestinal obstruction mesenteric ischemia peritonitis sickle cell crisis spontaneous peritonitis typhoid fever
Causes of R or L UQ pain:
acute pancreatitis herpes zoster lower lobe pneumonia myocardial ischemia raditulitis
Causes of RUQ pain:
cholecystitis and biliary colic congestive hepatomegaly hepatitis or hepatic abscess perforated duodenal ulcer retrocecal appendcitis
Causes of RLQ pain:
appendicitis
cecal/meckel’s diverticulitis
mesenteric adenitis
Causes of LUQ pain:
gastritis
splenic disorders
(abscesses, rupture)
Causes of LLQ pain:
sigmoid diverticulitis
Causes of R or L LQ pain:
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
Tx of gastritis:
cause dependent:
Stop NSAIDs, alcohol
tx for H.pylori
antacids, surface agents, histamine blockersH2RAs, PPIs
tx of H. Pylori infection
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
how do PPIs work
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.
Medications and dietary supplements that can increase acid reflux and worsen GERD include:
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)
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:
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.
recommendations for monitoring surveillance testing for pt’s dx with Barrett esophagus:
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.
esophageal adenocarcinoma is usually located:
at the junction of the esophagus and stomach
most common form of esophageal cancer in US is:
adenocarcinoma
esophageal squamous cell cancer is usually located:
in the upper esophagus
s/s of esophageal cancer:
dysphagia, weight loss, epigastric or retrosternal pain, persistent hoarseness and cough.
iron deficient anemia often develops from chronic low volume bleeding from esophageal tumor.
Yes or no: screening for H. pylori infection is recommended in GERD pts?
NO
drug for use in prevention of NSAID - induced gastric ulcers
misoprostol
the most specific and sensitive test for H. pylori is :
organism specific stool antigen testing
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:
esophagitis
hematochezia:
passage of maroon or bright red blood or blood clots per rectum
blood originating from the left colon tends to be ___ ____ in color
bright red
blood from the right colon usually appears ____ or ____ colored and may be _______
dark or maroon
mixed with stool
if pt with hematochezia is hemodynamically stable, initial examination choice is:
colonoscopy
pts with acute upper GI bleeding commonly present with _________ and/or ______
hematemesis
melena (black, tarry stools)
Major causes of upper GI bleeding:
peptic ulcer, esophagogastric varices, AV malformation, tumor, esophageal tear
diagnostic testing for upper GI bleed:
type and screen/crossmatch
CBC, Pt/INR, AST/ALT, albumin, BUN and creatinine
upper GI bleeding accompanied by dysphagia, early satiety, involuntary weight loss and cachexia indicates:
malignancy
diagnostic study of choice for acute upper GI bleeding:
upper endoscopy
for pts with upper GI bleeding, a negative upper endoscopy and hematochezia, a _________is required
colonoscopy
initial diagnostic step with upper GI bleeding:
NG tube lavage
cardinal s/s of gastroparesis:
N/V, early satiety, bloating, and /or upper abdominal pain
syndrome of objectively delayed gastric emptying in the absence of mechanical obstruction
initial management of gastroparesis:
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.
_________ should be suspected in a pt with RUQ or gastric pain, fever and a leukocytosis
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.
