GI Flashcards
common symptoms of GERD
- epigastric pain
- CP (burning)
- halitosis
- hoarseness
- cough
- wheezing
- globus sensation (lump in the throat)
- sore throat
ALARM symptoms for GERD (indications for upper endoscopy)
- dysphagia
- odynophagia (painful swallowing felt in the mouth, throat or esophagus)
- GI bleeding
- weight loss
- anemia
- recurrent vomiting
Screen for Barrett’s esophagus in patients with multiple risk factors for carcinoma:
chronic GERD age >= 50 white race intraabdominal body fat distribution hiatal hernia male gender elevated BMI
T/F routine screening for Barrett’s esophagus in patients with chronic GERD is recommended
F
it is not recommended
Things that make GERD worse are the same things that cause relaxation of the LES such as:
caffeine, tobacco, alcohol
obesity
Treatment of GERD:
sleeping with head elevated at night decreases Sx
PPI x1 daily for 2 months, if this fails then BID dose for another 2 months
people that are naive to GERD treatment, we initially recommend:
lifestyle and dietary modifications
and, as needed, Histamine 2 receptor antagonists H2RAs (famotidine 20 mg BID, ranitidine 150 mg BID)
or twice daily for a minimum of two weeks
if symptoms of GERD persists, discontinue H2RAs and initiate:
once daily PPI for 2 months (increase to BID for another 2 months if once daily doesn’t help)
(omeprazole 40 mg daily)
start low and then increase to standard dose
some lifestyle and dietary modifications for patients with GERD include:
weight loss
elevation of the head of the bed
elimination of dietary triggers (fatty foods, caffeine, chocolate, spicy foods, food with high fat content, carbonated drinks, and peppermint)
What do H2RAs do
decrease the secretion of acid by inhibiting the histamine 2 receptor on the gastric parietal cell
When should you use PPIs instead of H2RAs?
used in patients who fail BID H2RA therapy and in patients with erosive esophagitis and/or frequent (two or more episodes per week) or severe symptoms of GERD that impair QOL
What do PPIs do?
potent inhibitors of gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump
they are most effective when taken 30 minutes before the first meal of the day
What are the two most common causes of Peptic Ulcer Disease?
and then what are some other causes?
#1 H. pylori #2 NSAIDs
Zollinger-Ellison syndrome (gastrin producing tumor) EtOH smoking stress males elderly steroids malignancy
What are some symptoms of Peptic Ulcer Disease?
dyspepsia epigastric pain worse at night \+/- N/V asx GI bleed (PUD is the MC common cause of upper GI bleed)
differentiate between gastric ulcers and duodenal ulcers:
gastric ulcer–pain with food and gets better an hour or so after eating
duodenal ulcer–pain that improves with food and gets worse an hour or so after eating
Diagnostic studies for Peptic Ulcer Disease
persistent or increased symptoms after PPI = look for H. Pylori
Biopsy is the GOLD STANDARD for diagnosis of H. pylori
second most reliable is urea breath test and fecal antigen testing
Treatment for H. Pylori
PPI + Amoxicillin 1 g po BID + metronidazole or clarithromycin 500 mg po BID
think Baseball CAP = clarithromycin + amoxicillin + PPI
(metronidazole if PCN allergic)
What is the gold standard for definitive diagnosis of PUD?
upper GI endoscopy
it allows for visualization of the ulcer and taking a biopsy for histology
Treatment for PUD if (-) H. pylori?
PPI, H2RA
misoprostol, antacids, bismuth compounds, sucralfate
Risk factors for cholelithiasis: (think 5Fs)
fat fair female forty fertile
symptoms of cholelithiasis
MC asymptomatic
biliary colic (episodic, abrupt RUG epigastric pain x 30 min-hrs)
+/- N
precipitated by fatty foods/large meals
How to diagnose cholelithiasis:
ULTRASOUND***
+/- CT
MRI
Treatment of cholelithiasis”
asymptomatic: observe (or ursodeoxycholic acid to dissolve stones?)
(+) Sx: elective laparoscopic cholecystectomy
what are some complications of cholelithiasis?
choledocholithiasis
acute cholangitis
acute cholecystitis
What is the most common bacterial cause of cholecystitis (inflammation of the gallbladder usually from the obstruction of the biliary duct by gallstones)?
E. coli
What are the symptoms of cholelithiasis?
rapid onset of intermittent cramping abdominal pain in RUQ
gradually becomes worse and lasts several hours
fever, N/V may be present
physical findings in cholecystitis:
RUQ pain
guarding
positive Murphy’s sign (acute RUQ pain/inspiratory arrest with GB palpation)
(=) Boas sign = referred pain to right subscapular area due to phrenic nerve irritation
What are diagnostic studies for cholecystitis?
US is 1st line in patients with a typical history for gallstones
GOLD STANDARD: radionuclide scanning (HIDA) when clinician suspicion is high with equivocal US. assesses the patency of cystic duct
serum bilirubin and AST levels are usually normal except at the time of an attack
labs may show leukocytosis with left shift
Treatment for cholecystitis:
laparoscopic cholecystectomy is the procedure of choice for uncomplicated acute and chronic cholecystitis
- IV fluids
- parenteral Abx
- pain control
- laparoscopic cholecystectomy within 24 to 48 hours
What can gallstones be composed of?
cholesterol (most common)
pigment
mixed stones
acute diarrhea lasts how long?
< 2 weeks
What is the most common etiology of acute diarrhea?
self-limited infection
What is C. diff associated with?
clindamycin but really any Abx
will present days-weeks following Abx therapy, with excessive, watery diarrhea
Diagnosis of C. diff
stool testing for C. diff toxins
Treatment of C. diff
metronidazole
followed by vanc if no response
most common organism in inflammatory diarrhea?
and other causes?
campylobacter
other causes–salmonella, shigella, E. coli
Treatment of inflammatory diarrhea?
fluoroquinolone
ciprofloxacin
T/F: enterohemorrhagic E. coli should be given Abx as treatment
false
they should not be given Abx due to risk of hemolytic uremia syndrome
treatment for non-inflammatory diarrhea (will not have blood or WBC in stool)
supportive care
rehydration
if patient has persistent diarrhea…
stool should be sent for ova and parasites
How is giardia antigen detected?
stool ELISA
How is constipation defined?
straining
hard stools
incomplete evacuation
< 3 BM in one week
primary causes of constipation:
sys-synergic defecation
gastroparesis
IBS constipation
secondary causes of constipation
DM hypothyroid Parkinson's disease medications (opioid, antipsychotics, CCBs) intestinal mass
For constipation, a rectal exam should be performed to rule out….
masses, fissures, abnormal sphincter tone
Treatment for constipation
all patients should increase fluids and physical activity
also, fiber 25 g daily
bulk and osmotic laxatives first line
bulk laxatives
psyllium
methylcellulose
osmotic laxatives
milk of magnesia magnesium citrate sorbitol polyethylene glycol lactulose
alarm symptoms of constipation
those with alarm symptoms should have a colonoscopy done
hematochezia FHx of colon cancer weight loss anemia severe persistent constipation
What are some causes of acute pancreatitis?
- gallstones
- EtOH
- meds (thiazides, protease inhibitors, estrogen, valproic acid)
- malignancy
- trauma
- CF
- mumps in kids
symptoms of acute pancreatitis
severe epigastric pain radiating to the back
the pain lessens when the patient leans forward or lies in the fetal position
diminished bowel sounds
There are two “bruising” signs you may find on physical exam with acute pancreatitis. What are they called?
Cullen’s sign (bruising near umbilicus)
Grey Turner’s sign (flank bruising)
What is an elevated lab value that is fairly specific for acute pancreatitis?
lipase
What is Ranson’s criteria?
forms a clinical prediction rule for predicting the severity of acute pancreatitis. Three or more means more severe course.
at admit: age > 55 leukocyte > 16,000 glucose > 200 LDH > 350 AST > 250
at 48 hours: arterial PO2 < 60 HCO3 < 20 calcium < 8.0 BUN increase by 1.8+ Hct decrease by > 10% fluid sequestration > 6 L
What is the diagnostic test of choice for acute pancreatitis?
abdominal CT
What is the mainstay of treatment for acute pancreatitis?
supportive therapy
NPO, IV fluids (best), analgesics, bowel rest
What is the treatment for acute pancreatitis if biliary sepsis is suspected?
ERCP
What are the clinical features of chronic pancreatitis?
same as those of acute pancreatitis with the addition of fat malabsorption (steatorrhea)
What is the classic triad for chronic pancreatitis?
pancreatic calcification
steatorrhea
DM
What is the cause of chronic pancreatitis?
EtOH abuse
idiopathic
CF is the MC cause in kids
What is different about the lab values with chronic pancreatitis in comparison to acute pancreatitis?
lipase/amylase usually NOT elevated
What is the treatment for chronic pancreatitis?
the only definitive treatment is to address the underlying cause which is most commonly alcohol, low fat diet
What are some differential diagnoses for RUQ pain?
gallstones biliary colic acute cholecystitis acute cholangitis acute choledocholithiasis
hepatitis
liver disease/abscess
What is Charcot’s triad for cholangitis?
fever, jaundice, RUQ pain
What are some differential diagnoses for epigastric pain?
GERD PUD pancreatitis gastritis dyspepsia gastroparesis
What are some differential diagnoses for LUQ pain?
splenomegaly
splenic infarction
splenic rupture
splenic abscess
What are some differential diagnoses for right lower abdominal pain?
appendicitis renal colic/stones colitis cystitis/pyelo hernia epididymitis
What are some differential diagnoses for lower abdominal pain that would be specific for females?
pregnancy PID ovarian cyst/torsion endometriosis fibroids dysmenorrhea
What are some differential diagnoses for left lower quadrant pain?
diverticulitis renal colic/stones colitis cystitis/pyelo hernia epididymitis
What are some differential diagnoses for DIFFUSE abdominal pain?
obstruction perforation IBD (UC/Crohn's) mesenteric ischemia volvulus gastroenteritis (viral and food borne) constipation IBS AAA Celiac disease
Some reasons for abdominal pain that are “extra-abdominal” (non GI/GU)
DKA acute MI PNA, pleural effusions herpes zoster HIV sickle cell disease
Diagnosis of acute pancreatitis requires two of the following three factors:
- typical abdominal pain
- at least 3x elevation in amylase and/or lipase level
- confirmatory findings on cross-sectional abdominal imaging
What is the imaging most commonly used for acute pancreatitis?
CT
Example of a “Plan” for acute pancreatitis…
- admit to medicine
- NPO, start IV fluids
- IV morphine 4mg pen for pain
- IV ondansetron 4 mg pro for nausea
- check lipid panel
Key clinical features of mesenteric ischemia:
acute and severe onset of diffuse abd pain, often described as pain out of proportion to examination
Key clinical features of Inflammatory Bowel Disease (UC or Crohn’s):
bloody diarrhea, urgency, tenesmus, bowel incontinence, weight loss, fevers
key clinical features of celiac disease:
abd pain in addition to diarrhea with bulky, foul-smelling floating stools due to steatorrhea and flatulence
