GI Flashcards
1
Q
Anal fissue etiology, RF, and sxs
A
- irritation caused by trauma to anal canal results in increased resting pressure of internal sphincter - ischemia in region of fifssure and poor healing of injury
- MC in 30-50s, M=F
- Primary: local trauma, pooping probs, anal sex, SVD
- Secondary: previous anal surgery, IBD (Crohn dz), TB, sarcoidosis, malignancy, HIV, syphilis, chlamydia
- MC site: posterior anal midline, below or distal to dentate line (where transition zone becomes squamous epithelium)
- Sxs: tearing pain with defecation, pruritis, BRB,
- signs: superficial laceration, in chronic can see external skin tags and hypertrophied anal papillae at proximal end
2
Q
Anal fissure dx and tx
A
- dx: endoscopy (if bleeding beyond 2mos tx), sigmoidoscopy if <50yo with no FH colon cancer, colonoscopy if suspician for Crohn dz
- tx: acute heals in 6wk - fiber and water, sitz baths, topical anesthetic, vasodilator (nifedipine, NTG), stool softeners or laxative
- if failed tx/chronic: botox, lateral sphincterotomy (gold standard - may cause incontinence)
- Prevention: proper hygiene - keep dry and wipe with soft cotton or moist cloth, high fiber, high water, dont strain while pooping, avoid trauma to anus, prompt tx of D
3
Q
Appendicitis
A
- lumen obstructed by hyperplasia of lymphoid tissue, fecalith, or foreign body - leads to bacterial growth and inflammation - distention leads to ischemia, infarction, and necrosis
- peak incidence = mid 20s
- sxs: abd pain (epigastric → umbilicus → RLQ), anorexia, N/V, McBurney pnt (RLQ tendernes), rebound tenderness, guarding, decreased bowel sounds, low fever, Rovsing sign (LLQ TTP →RLQ referred pain), psoas sign (LQ pain w/ hip plexed against resistance or extended while lying on L side), obturator sign (LQ pain when hip and kne flexxed and hip internally rotated)
- dx: CLINICAL DX, CBC - neutrophilia (supportive), imaging if atypical presentation (CT, US)
- tx: appendectomy (lap), IVF, abx, NPO, pain mngmt
4
Q
SBO and LBO
A
- SBO: MCC = adhesions or hernias, cancer, IBD, volvulus, intussusception
- sxs: abd pain, distention, V, obstipation
- signs: dehydration + electrolyte imbalance, high-pitched bowel sounds, come in rushes
- LBO: MCC = cancer, strictures, hernias, volvulus, fecal impaction
- sxs: distention, pain, complete strangulation of bowel tissue (infarction, necrosis, peritonitis, death)
- signs: febrile, tachycardia (can lead to shock), dehydration + electrolyte imbalance
- dx both: KUB (air fluid levels, dilated bowel loops)
- tx both: NPO, nasogastric suction, IVF, pain mngmt
- LBO: urgent surgery when mechanical obstruction expected
5
Q
Volvulus
A
- twisting of any portion of bowel on itself (commonly sigmoid or cecum); sigmoid is MC; MC in elderly with hx of chronic constip.
- sxs: cramping, distention, N/V, obstipation
- signs: abdominal tympany, tachycardia, fever, sever pain if ischemic (ischemia can lead to gangrene, peritonitis, sepsis)
- dx: Abd XR shows colonic distention (inverted U shape), loss of haustra, coffee bean sign (sigmoid) at midline corresponding to mesentaric root
- sigmoid = loop points to RUQ
- cecal = loop points to LUQ
- barium enema (bird’s beak or bird of prey sign)
- CT abd/pelvis shows whirl pattern
- tx: emergent endoscopic decompression - laparoscopic derotation
6
Q
Cholelithiasis
A
- Etiology: stones in gallbladder, pain 2ary to contraction against obstructed duct; 3 types:
- cholesterol (yellow/green dt obestiy, DM, HLD, mult gest, OCP, Crohn, ileal resection, old, native american, cirrhosis, CF)
- Pigment (black): hemolysis (SS< thalassemia, spherocytosis, artificial valve), alcoholic
- Pigment (brown): in bile ducts dt biliary tract infxn
- sxs: most asx, biliary colic (RUQ or epigastric), pain after eating and night, boas sign (R subscap pain)
- dx: RUQ US (high sens/spec if >2mm), CT scan and MRI
- tx: no tx necessary if asx, elective cholecystectomy for recurrent bouts
- complications: cholecystitis, choledocholithiasis, gallstone ileus, malig
7
Q
acute cholecystitis
A
- obstruction of cystic duct (not infxn) - leads to inflamm of GB wall
- sxs: RUQ or epigastric pain lasts a few days, may radiate to shoulder or scap, N/V, pruritis, clay-colored stools, dark urine
- signs: RUQ TTP, rebound in RUQ, Murphy sign, hypoactive bowel sounds, low fever, leukocytosis, jaundice
- dx: RUQ US, HIDA when US inconclusive, CT scan
- Labs: elevated ALK-P and GGT, elevated conjugated bili
- tx: admit, IVF, NPO, IVabx, analgesics, correct lytes, cholecystectomy (first line)
- 70% recurrence if left untreated
8
Q
Choledocholithiasis, cholangitis, primary sclerosing cholangitis, primary biliary cirrhosis
A
- Choledocho: stones in CBD
- dx: RUQ US (first line), ERCP (gold standard - dx and tx)
- tx: ERCP with sphincterotomy and stone extract with stent placement, lap choledocholithotomy
- Cholangitis: infxn biliary tract 2ary to obstruction, CHARCOT TRIAD (RUQ pain, jaundice, fever), REYNOLD PENTAD (RUQ pain, jaundice, fever, HoTN, AMS)
- dx: RUQ US (first line), CBC, bili, ERCP (definitive, but not used in acute cases)
- tx: decompress via PTC or ERCP, bust be afeb 48h for ERCP/PTC so blood cultures, IVF, abx and decompress in the mean time
- Primary sclerosing: chonic idiopathic, likely autoimmune, strong correlation with ulcerative colitis, insidius, progressive jaundice, itching, fatigue, malaise
- dx: ERCP and PTC
- tx: liver transplant, cholestyramine - sxatic relief
- Biliary cirrhosis: chronic, intrahepatic bile duct destruction, autoimmune, similar sxs to primary sclerosing
- dx: elevated alkphos, +AMA, LIVER BX CONFIRMS DX
- tx: cholestyramin, Ca, bisphos, vitD for sxs; ursodeoxycholic acid slows progress; liver transplant curative
9
Q
Cirrhosis
A
- fibrosis, widespread nodules in liver, irreversible when advanced
- distortion of liver anatomy causes: portal HTN (dec blood flow through liver - causes ascites, periph edema, splenomeg, varicose veins), hepatocellular failure (dec albumin synth and clotting factor synth)
- Child pugh scores estimates hepatic reserve (A=mild, C=most severe)
- MCC of cirrhosis: alc liver disease
- second MCC: chronic hepB and C infxn
- MCC of liver dz: nonalcoholic fatty liver dz
- chronic liver dz: ascites, varices, hemorrhoids, gynecomast, test. atrophy, palmar erythema, spider angiomas, caput medusae)
- Monitor labs q3-4mo
10
Q
Colorectal cancer
A
- most from adenomas (endoluminal adenocarcinomas), Villous > tubular adenomas
- CRC = MCC LBO in adults
- RF: >50yo, polyps, hx CRC, IBD (UC), Fhx, diet (high fat, low fiber)
- sxs: abd pain, bowel habit change, wt loss, hematochezia (asx, unexplaine iron def., mostly in advanced states)
- R sided: obstruction less common, melena, occult blood, IDA, no bowel habit changes, Triad (anemia, weak, RLQ mass)
- L sided: obstruction more common dt smaller lumen, change in bowel habits (alternating const/D, narrowing of stools, hematochezia
- dx: colonoscopy
- tx: surgery, chemo + radiation, follow w/ guaiac, annual CT of abd/pelv, CXR up to 5y, colonoscopy at 1y, then q3y, CEA levels q3-6mo
11
Q
Familial adenomatous polyposis
A
- autosomal dominant (100s polyps in colon), 20-30yo
- RF: colon CA, thyroid CA, gastric CA, meduloblastoma, duodenal ampullary carcinoma
- sxs: >100 cumulative colorectal adenomas or hx of adenomas in combo with extracolonic features (duodenal or ampullary adenomas, desmoid tumors, papillary thyroid CA, congen hypertrophy of retinal pigment epith, epidermal cysts, osteomas)
- complications: IDA
- dx: endoscopy at 25-30yo (random sampling of fundic gland polyps)
- tx: prophylactic colectomy (large or high grade dysplasia, annual endoscopy of rectum, ileostomy eval q1-3y), screen thyroid annually
- risk of CRC 100% by 30-40yo
12
Q
Hemorrhoids
A
- varicose veins of anus and rectum
- RF: const/straining, preg, portal HTN, obesity, prolonged sitting or standing, anal intercourse
- sxs: BRBPR (painless, associated with bowel mvmnt, pruritis, fecal soilage, rectal prolapse
- dx: anoscopy if BRBPR or suspected thrombosis
- tx: sitz bath, ice, bed rest, stool softeners, high fiber/fluid, topical steroids
13
Q
external hemorrhoids
A
- dilated veins arising from inferior hemorrhoidal plexus distal to dentate
- sxs: asxatic unless thrombosed (sudden, painful swelling, lasts several days, then subsides)
- tx: conservative (sitz bath, ice, stool softeners, etc.)
- rubber band ligation: if protrudes with defecation, enlargement, or bleeding - for stages 1-3 nonresponsive
- closed hemorrhoidectomy: for permanently prolapsed (stage 3-4 chronic bleeding or stage 2 acutely thrombosed; eternal dont require surg management unless thrombosed or lare and sxatic)
14
Q
Internal hemorrhoids
A
- dilated submucosal veins above dentate line
- thrombosed: increased with def and sitting; tender, swollen, bluish ovoid mass
- sxs: painless rectal bleeding, bulging perianal mass w/ straining; when prolapsed, causes mild fecal incont, mucous d/c, wetness, sensation of fullness
- signs: bulging purplish-blue
- tx: same as external hemorrhoids
15
Q
Thrombosed hemoorhoids
A
- MC with external hemorrhoids
- sxs: painful defecation, BRBPR, pruritis
- signs: palpable mass, perianal swelling, acutely tender
- dx: anoscopy
- tx: conservative unless persistent or present w/in 72h from onset of pain
- Surgery = definitive
- complications: internal hem can become prolapsed, strangulated, and develop gangrenous changes
16
Q
grades of hemorrhoids and tx
A
- Grade I: vizualised on anoscopy and may bulge into lumen, but dont prolapse below dentate
- tx: conservative or rubber band; surg for recurrent or bleeding external
- Grade II: prolapse with defecation but reduce spontaneously
- tx: conservative or rubber band; surg for recurrent or bleeding external
- Grade III: prolapse with defecation, require manual reducation
- tx: rubber band (initial), sclerotx for sxatic internal (indicated grades I-II bleeding internal or pts on anticoags), surgery recommended (definitive)
- Grade IV: irreducible and may strangulate
- tx: requires surgical tx (excision, hemorrhoidectomy)
17
Q
Colorectal cancer screening
A
- begin 50yo, continue until 75yo
- FOBT qy
- start screening 10y younger than age of dx of youngest affected relative
- Flexible sigmoidoscopy: q5y combined with FOBT q3y
- Colonoscopy: q10y (q5y for pts with single 1st degree relative dx with CRC or advanced adenoma)
- Average risk = pts with no or 1 1st deg relative dxed >/= 60yo with CRC or advanced adenoma, never had CRC or polyp, IBD, abd radiation for childhood CA
- High risk = 1 1st deg relative dxed w/ CRC <60yo, or 2 1st deg relatives w/ CRC or advanced adenomas
- for these ppl, colonoscopy q5y beginning age 40 or 10y younger than youngest dx
18
Q
PUD
A
- Causes: H. pylori, NSAIDs, Zollinger-Ellison (acid hypersecretion)
- other causes: smoking, ETOH, coffee, stress, dietary factors
- sxs: epigastric pain (aching, gnauwing, nocturnal sxs, effect of food variable), N/V, early satiety, wt loss
- dx: endoscopy (required for dx), barium swallow, H. pylori Ag (Abs to H. pylori can remain elevated for mos-yrs after infxn gone, false negs with PPI, pepto, abx), biopsy (GOLD STANDARD), urea breath test, gastrin measurement (zollinger)
- tx: supportive (dc NSAIDs, stop: smoking, alc, stress, eating before bed, coffee), acid suppression (H2, PPI (most effective), antacids, eradicate H. pylori infxn (amox + carith + PPI (or carith + flagyl), OR pepto + tetracyc + flagyl + PPI), cryoprotection (sucralfate, misoprostol), surgical (truncal vagotomy for hem, perf, obst, failure of meds)
19
Q
duodenal vs gastric ulcers
A
- Duod: MC <40yo, 70-90% H. pylori caused, NSAIDs, relieved with eating, nocturnal pain more common
- Gast: MC >40yo, 60-70% H. pylori caused, smoking, eating can make pain worse (anorexia and wt loss)
33
Q
Upper GI bleed
A
- bleeding originates proximal to lig of treitz
- ddx: peptic ulcer, esophageal varices, gastric bleeding from portal HTN, gastritis, AVM, tumor, Mallory-Weiss tear
- RF: NSAIDs, ASA, anticoag, antiplatelet, ETOH, prev GI bleed, liver dz, coagulopathy
- sxs: Hematemesis (blood or coffee ground), Melena, hematochezia (massive upper GI bleed)
- signs: orthostatic HoTN, tachycard, abdominal TTP
- dx: type and screen, Hgb, plt count, coag studes, liver enzymes, albumin, BUN/Cr, NG lavage + for blood = confirmatory
- endoscopy once stabilized (give erythromycin before exam), abx prophylactically for cirrhotics
- tx: supportive (NPO, IV access, O2, IVF, IV PPI until confirmation of cause of bleeding, consult GI and interventional radiology or surg, tx underlying cause, surg (duodenotomy or gastroduodenotomy, ligation of bleeding)
35
Q
Jaundice
A
- yellow discoleration of skin, sclera, mucous membranes from bilirubin in tissues (indicates serum bili >3mg/dL)
- if suspect scleral icterus, second site to examine is under tongue
- sxs: yellow, wt loss, fever, chills, abd pain, flulike sxs, itching
- signs: icterus, pallor, abd mass, palpable GB, oliguria, spider angioma, muscle wasting, ecchymosis, parotid enlargement, gynecomastia, HSM, +/- ascites
- dx: urinary bili, CBC< LFTs, GGT, alkphos, hep panel, abd US or CT abd, liver bx (definitive)
- tx: tx underlying cause
- Conjugated bili is water soluble and excreted in urine
