GI Flashcards
Dysphagia
solid only tends to be
solids and liquids tends to be
oropharyngeal dysphagia tends to be
Solid: mechanical
solid and liquid: motility disorder
oropharyngeal: neuromuscular disorder
Dysphagia, underlined cause
infectious
immunologic
motor/nerve dysfunction (2)
infectious: botulism
immunologic: myasthenia gravis
motor/nerve dysfunction (2): achalasia and cranial nerve palsy’s
Esophageal rupture
most common cause
Mallory Weiss tear
most common location
Most esophageal ruptures are iatrogenic
Mallory Weiss: GE junction
Boerhaave’s syndrome
age, sex
physical finding with eponym
chest x-ray findings(4)
age, sex: male, 40 to 60
physical finding with eponym: mediastinal air with Hamman’s crunch
chest x-ray findings: mediastinal air, left pleural effusion, pneumothorax, widened mediastinum
Pneumomediastinum with subcutaneous emphysema
Esophageal foreign body
levels of narrowing (4)
coin x-rays, AP versus transverse orientation
–Cricopharyngeus muscle (C6)
–Aortic arch (T4)
–Tracheal bifurcation (T6)
Gastroesophageal junction (T11)
Coin xrays: AP-coin in trachea, transverse-coin in esophagus (eg round aspect facing you on AP xray)
Esophageal foreign body
Swallowed battery, management when located in
esophagus (2)
stomach
pylorus
esophagus: immediate removal. Antibiotics
stomach and pylorus: only removed when not passing spontaneously within 72 hours
Esophageal food impaction
medical management (3)
avoid
medical management (3): glucagon, nifedipine, carbonated beverage
avoid: meet tenderizer-papain
Caustic ingestions
best diagnostic method
indication for dilution
indication for neutralization
best diagnostic method: endoscopy
indication for dilution: only solid alkali ingestion
indication for neutralization: only hydrofluoric acid (milk of Mag Citrate)
Peptic ulcer disease
rare risk factor
less known medical treatment option
Zollinger Ellison syndrome
surface protectant: sucralfate
UGIB
predictors of need for severe intervention (3)
Red blood on lavage
tachycardia
hemoglobin < 8
UGIB
most common cause
because more common in pregnancy
most common cause: PUD, usually duodenal
because more common in pregnancy: esophagitis
UGIB
therapy for variceal hemorrhage (3) (non-endoscopy)
Linton tube?
Octreotide, vasopressin, Blakemore tube
Linton tube - for gastric varices
Bilirubin
increased unconjugated (2) increased conjugated (3)
increased unconjugated: hemolysis or Gilbert’s syndrome
increased conjugated: hepatocellular disease, obstruction, CHF
Hepatitis A
mitigation options (2)
Prophylaxis with vaccine, immunoglobulin within two weeks of exposure
Hepatitis B marker significance
HBsAg
HBsAb
HBeAg
HBcAb
HBsAg: positive early, active infection
HBsAb: positive after clearance of HBsAg, best marker for immunity to HBV
HBeAg: implies high infectivity
HBcAb: best indicator of history of hepatitis B infection
Hepatitis B, postexposure prophylaxis for
previously unvaccinated
vaccinated, incomplete
vaccinated
previously unvaccinated: hepatitis B immunoglobulin, vaccination
vaccinated, incomplete: booster
vaccinated: test for HBsAb - if adequate titers, no treatment, otherwise HBIG and booster
Hepatitis C
cirrhosis/cancer risk
seroconversion risk after needlestick
cirrhosis/cancer risk: 50% versus 10% for hepatitis B
seroconversion risk after needlestick: 2%
Hepatitis-other types, description/transmission mechanism
Delta
E
G
Delta: blood-borne,IVDU, homosexual higher risk
E: fecal oral, found in Asia, Africa, Russia
G: blood-borne and STD
Hepatitis - indications for hospitalization (7)
Encephalopathy,
PT/INR significantly increased,
dehydration,
hypoglycemia,
bilirubin over 20,
age over 45,
immunosuppression
Hepatic encephalopathy treatment
avoid
precipitants
neomycin, lactulose, decrease dietary protein,
avoid sedatives, avoid bicarbonate
precipitants: LIVER = Librium [sedatives], Infection, Volume loss, Electrolytes disorders, Red blood cells in the gut
AND dietary protein access, worsening liver function
SBP
common agents (2)
diagnosis
common agents (2): E. coli, enterococcus
diagnosis: PMN greater than 250
Acute liver failure
most common cause worldwide and US
most common etiology of death
most common cause worldwide and US: hepatitis A and E; Tylenol overdose
most common etiology of death: intracranial hypertension, cerebral edema -> treat with mannitol and indomethacin
Most common cause of surgical abdominal pain in the elderly and the agents (2)
Gallstone ileus-what
Cholecystitis, E. coli, Klebsiella
gallstone obstructing the ileocecal valve
Acalculus cholecystitis
common etiology
Ascending cholangitis
what
Triad
Acalculus cholecystitis
common etiology: complication of another process-trauma, burn, postpartum, postoperative, narcotics
Ascending cholangitis
what: infection spreading throughout the biliary tree
Triad - Charcot’s: jaundice, fever, right upper quadrant pain
Pancreatitis, causes
drugs
metabolic
viral
bacterial
- Drugs: thiazides, estrogens, salicylates, acetaminophen, antibiotics
- Metabolic disorders: hyperlipidemias, hypercalcemia DKA, uremia
- Viral infections: mumps, Coxsackie B, hepatitis, adenovirus, EBV
- Bacterial infections: Salmonella, Streptococcus, Mycoplasma, Legionella
Pancreatitis
significance of calcifications
Can indicate chronic pancreatitis
Sentinel loop- air in small bowel loop overlying the pancreas
Ranson’s criteria
on ED admission (5)
severe disease = ?
–Age > 55
–Glucose > 200 mg/dL
–WBC > 16,000
–SGOT(AST) > 250
–LDH > 350
severe disease if three or more positives
Pancreatitis -complications
localized (3)
electrolyte (2)
metabolic (2)
systemic (3)
–Pseudocyst, necrosis, GI bleed
–Hyperglycemia, hypocalcemia
–Volume loss, acidosis
–ARDS, DIC, renal failure
Ileus: air throughout intestines, fluid levels not as prominent
Large bowel obstruction
etiology (3) and most common
Cancer number one, volvulus, diverticulitis
Volvulus, sigmoid versus cecal
age/setting
x-ray
treatment
sigmoid age/setting: elderly, debilitated, insidious
sigmoid x-ray: inverted view, loops project obliquely to right upper quadrant
sigmoid treatment: sigmoidoscopy
cecal age/setting: young (20-40), acute onset, can be a/w pregnancy
cecal x-ray: kidney shaped loop in left upper quadrant, bird beak
cecal treatment: surgical
Sigmoid volvulus
Cecal volvulus
Hernias
incarcerated versus strangulated; more common in *** hernia
direct versus indirect
Incarcerated-irreducible; strangulated-irreducible with vascular compromise; m
ore common in femoral hernias
indirect goes through the inguinal canal to scrotum, more common in boys
direct goes for the abdominal wall, middle-aged men
Hernias, rarer types, description
Spigelian
Obturator and sx pearl
Richter
- Spigelian: lateral edge of rectus abdominis. Difficult to diagnose (CT, ultrasound)
- Obturator (rare): through obturator foramen. More common in woman. Presents as obstruction, pain in medial thigh (obturator nerve)
- Richter: only a portion of the bowel herniates. Even if the hernia is incarcerated or strangulated, the bowel may not be obstructed
Most common cause of this finding
Free air from bowel perforation Peptic ulcer disease
Bowel perforation
Constipation
less known medication causes (3)
endocrine causes (3)
less known medication causes: calcium channel blockers, psych medications, antacids, iron
endocrine causes: hypothyroid, hypoparathyroid
Inflammatory bowel disease
associated worst complication
extra intestinal manifestations (4)
Colon cancer with disease greater than 10 years duration
•arthritis, dermatologic (erythema nodosum, pyoderma gangrenosum), hepatobiliary disease, vasculitis, uveitis
Inflammatory bowel disease
medical management (4)
sulfasalazine, mesalamine, prednisone, abx (metronidazole, ciprofloxacin)
Crohn’s disease
Distribution
characteristic features (4)
Throughout entire G.I. tract and involves entire intestinal wall; gross blood RARE compared to ulcerative colitis
SBO, enteric fistula, perforation
Anorectal pathology: perianal fissures, fistulas and abscesses, rectal prolapse,
toxic megacolon
calcium oxalate kidney stones from increased oxalate absorption
Ulcerative colitis
major finding
major complications (2)
Buddy diarrhea
complications toxic megacolon (transfers: greater than 6 cm) with systemic toxicity
30 fold increase in the rate of colon cancer
Mesenteric ischemia
the main causes
characteristic laboratory abnormalities (2)
avoid these medications (3)
he main causes: embolic, thrombotic
characteristic laboratory abnormalities: leukocytosis, lactic acidosis
avoid these medications: beta-blockers, laser pressers, digoxin (decrease splanchnic blood flow)
Thumb printing from mesenteric ischemia
thump printing from mesenteric ischemia
Seen in setting of mesenteric ischemia
Appendicitis
Most common age groups for perforation
children and elderly
Diverticular disease
Diverticulitis
Most common location
–Steady, deep, LLQ location (Western world)
–RLQ Japan-Hawaii
Rectal prolapse
Differentiation from internal hemorrhoids and intussusception
–Intussusception: can place finger between protruding rectum and anus
–Internal hemorrhoids: fold of mucosa radiates out like spoke on a wheel
–Rectal prolapse: folds of mucosa are circular
Rectal prolapse - note circular ring like appearance
Anal fissure
appearance caveat
Tx (5)
Non-midline fissures suggest more serious conditions (IBD, CA, sexual abuse)
Tx: WASH regimen*, NTG ointment, anal dilatation, surgical intervention, BOTOX
*Warm water, analgesics, stool softeners, high fiber diet
