GI Flashcards
Adenocarcinoma of the esophagus
Caused from GERD progressing to Barrett metaplasia occurring at the lower half of the distal esophagus
Squamous cell carcinoma of the esophagus
Can occur at any part of the esophagus
- Other risk factors include smoking and alcohol use
- Esophageal cancer is the seventh most common cause of cancer death in males with a 5-yr survival rate of 19%
Hx/PE of esophageal cancer
Dysphagia Wt loss Bleeding Chest pain Hoarseness Persistent cough PE findings are typically nl LAD in supraclavicular area occasionally or hepatomegaly for advanced cases
Work up of esophageal cancer
EGD CMP to assess liver enzymes and albumin CBC to assess for anemia CT scan to assess for metastasis Barium swallow rarely used now- EGD preferred
Tx of esophageal cancer
Staging- TNM classification
Stage 1 (T1aN0)- endoscopic -removal
T1b and any N- surgery plus multimodality therapy
-15-30% of those given neoadjuvant chemoradiation have the tumor completely disappear with a 3-yr survival of 50%
Stage IV dz usually given palliative care to try and keep esophagus patent and improve pain
Gastric neoplasm
Difficult to cur because most pts present with advanced disease
Early gastric cancer typically has no sx
5-yr survival rate is 30-50% with stage II
And 10-25% for pts with stage III
Hx- gastric neoplasm
Early stage- no sx Most sx reflect advanced dz: Severe indigestion Nausea with vomiting Dysphagia Postprandial fullness Loss of appetite Very late complications- pleural effusion, obstruction, bleeding into stomach
Exam of gastric neoplasm
All PE signs are late events. By the time they develop, the cancer is too far advanced to cure Enlarged stomach Hepatosplenomegaly Virchow nodes (L supraclavicular) Wt loss in some Melena Pallor from anemia
RFs of gastric cancer
Diet Obesity Smoking 5% of those with H. pylori Pernicious anemia Chronic atrophic gastritis Radiation exposure
Workup for gastric cancer
CBC to assess for anemia
CMP to check for liver enzymes
CEA is increased in 45-50% of cases
EGD with bx has a diagnostic accuracy of 95%
-CT scan of chest, abd, and pelvis to assess mets
Tx of gastric cancer
Surgery- subtotal or total gastrectomy
-Any nodal involvement indicates a poor prognosis
Most pts who undergo a surgical resection will have a recurrance
Cholecystitis causes
90% of cause is from stones (cholelithiasis)
10% is acalculous
-Biliary stasis- possibly from debilitation, severe trauma, or prolonged fasting
Diabetes is a RF, salmonella infections, CMV
Cholelithiasis
Gallstones can be present and remain asymptomatic for decades
Migration of a gallstone into the opening of the cystic duct may block the outflow of bile during gallbladder contraction, causing biliary colic
Ascending cholangitis
Gallstone in the common bile duct may impact distally in the ampulla of Vater, this leads to abdominal pain and jaundice.
Then, stagnant bile above the obstructing stone often becomes infected, and bacteria can spread rapidly backing up the dutctal system into the liver to produce a life-threatening infection
What is the common cause of cholangitis?
Choledocholithiasis
Sx of cholangitis
Charcot triad of fever, jaundice, and RUQ pain
Workup for cholangitis
CBC CMP Blood cultures Amylase Lipase -Blood cultures positive- 50% with E. coli or Enterococcus
Tx of cholangitis
Broad-spectrum abx-Piperacillin or ceftazidime and IV fluids
For severe cases- endoscopic drainage
Cirrhosis
The diffuse hepatic process characterized by fibrosis and the conversion of nl liver tissue into structurally abnormal nodules
Causes of cirrhosis
Alcoholism Hep B and C Biliary cirrhosis Non-alcoholic steatohepatitis Drugs, toxins R heart failure can lead to liver failure
Pancreatitis
An inflammatory process in which pancreatic enzymes autodigest the gland. The pancreas will sometimes heal without any impairment of function. Recurrent attacks are referred to as chronic pancreatitis
Common causes of pancreatitis
MCC is gallstones passing into the bile duct and lodging at the sphincter of Oddi
Alcohol use is also a major cause (35%)
Triglycerides >1000 mg/dL and can be more severe
Work up for pancreatitis
CBC CMP Amylase Lipase Abdominal u/s to look for gallstones CT abdomen for severe cases only Consider MRCP to detect Biliary and pancreatic duct obstruction
DDx of pancreatitis
Acute mesenteric ischemia Cholangitis Cholecystitis Colon adenocarcinoma Bowel obstruction Duodenal ulcers Myocardial infarction Pancreatic cancer
Tx of pancreatitis
NPO
IV fluid hydration
Analgesics (antibiotics are generally not indicated)
Cholecystectomy if needed
Enteral feedings
ICU for severe acute pancreatitis
Pt is discharged when pain is well controlled and they are able to tolerate an oral diet and all complications have been addressed
Appendicitis
An inflammation of the inner lining of the vermiform appendix that spreads and can cause significant morbidity
What occurs in only 50% of cases of appendicitis?
Classic presentation: hx of loss of appetite, periumbilical pain followed by nausea, then RLQ pain and vomiting
Appendicitis workup
CBC- WBC > 10.5K in 80-85% of adults
CMP- to r/o other problems
UA to r/o other causes of pain
Urine hCG level: all women of childbearing age that have not had sterilization: no matter what
CT scan with PO contrast- important imaging study
Tx for appendicitis- criteria for referral
Refer to general surgeon if clinical hx and exam plus labs are highly suspicious for appendicitis
If CBC and CT scan is inconclusive- consult with you physician and search for another cause of abd pain
Irritable bowel syndrome
Alternating bowel habits from constipation and diarrhea
Abd cramping relieved by bowel movements
Stress makes it worse and cramping usually occurs right after eating
Red flags to look for other causes than IBS
Nocturnal diarrhea Wt loss Fever Blood in stool Steatorrhea Gluten intolerance
Tx for inguinal hernia
Symptomatic pts should be repaired surgically
Tx of umbilical hernia
Children under 5 do not usually need surgery. Surgery in kids or adults only if incarceration
Acute diarrhea
In developed countries is almost always a benign, self-limited condition that subsides in a few days
Giardia is rare but could be indicated if extremely foul smelling stool that floats
Viruses include rotavirus, adenovirus, norovirus
Bacteria- rare
-E. coli, Klebsiella, C. diff, cholera, Campylobacter, salmonella
Mexico- Entamoeba or Yersinia
Chronic diarrhea
R/o IBD
R/o celiac dz
R/o pancreatic d/o
IBS is dx of exclusion
Diarrhea tx- Campylobacter
Erythromycin
Diarrhea tx- C. difficile
Metronidazole
Life-threatening: Vancomycin by mouth
Diarrhea tx- E. coli
TMP/SMX
Diarrhea tx- salmonella
Only infants and severely immune compromised: TMP/SMX
Diarrhea tx- shigella
TMP/SMX
Diarrhea tx- Yersinia
TMP/SMX
Diarrhea tx- Entamoeba
Flagyl then iodoquinol
Diarrhea tx- Giardia
Flagyl
Diarrhea tx- Cryptosporidium
paromomycin
