GI Flashcards
1
Q
LLQ pain most likely DX
A
diverticulitis
2
Q
PUD men vs women
A
3 to one in favor of men
3
Q
PUD hpylori
A
90% of duodenal ulcers and >75% of gastric ulcers
4
Q
PUD caused by meds
A
NSAIDS, ASA and glucocorticoids
5
Q
Duodonal ulcer main age range
A
30-55
6
Q
gastric ulcers main age range
A
55-65
7
Q
PUD alcohol and diet
A
not really associated, role of stress is uncertain, more commin in greater than 1/2 ppd smokers
8
Q
PUD S and S
A
GNAWING epigastric pain
releife when eating- duodenal
pain worse when eating - gastric
9
Q
PUD physical findings
A
often unremarkable, maybe some mild epigastric tenderness
gi bleed in 20%
5-10%perf
10
Q
PUD lab
A
maybe anemia, consider endoscopy after 8-12 weeks of treatment
consider H pylori testing
11
Q
PUD H2 receptor antagonists
A
ines- cimetidine 800mg, rinatidine300mg, famatidine40mg, nizanidine300mg, before bed
QD
then BID
then PPI in am
12
Q
PPI 30 minutes before meals
A
azoles- 30 min before meals
lansoprazole
reberprazole etc
13
Q
Mucosal protective agents when to give
A
2 hours apart from other agents
14
Q
sucralfate 1g qid (carafate) dosing pearl
A
requies an acidic environment, avoid antacids and H@ blockers they are associated with a DECREASE IN nosocomial pneumonia
15
Q
bismuth sulfate (pepto)
A
has direct antibacterial action against HPylori
promotes prostaglandin productiona and natural bicarb
16
Q
Misoprostol (Cytotec) four times daily with meals
A
profolaxyis against NSAID ulcers
stims mucus and bicarb produciton
MAY STIM UTERINE CONTRACTION AND INDUCE ABORTION
discontinue offending agent first if possible
this is the PPI in pts who cannot stop NSAIDS
17
Q
NSAIDS and h2 blockers (zoles) caraate adn antacids
A
do not prevent nsaid induced ulcers,
18
Q
antacids (mylanta, maalox, MOM etc)
A
do not reduce the amount of gastric acidity or secretions-
19
Q
H. Pylori Eradication therapy pearls
resistant quickly to
A
Must be combo
quickly resistant to - Metonidaole (flagyl) and clarithromycin- (biaxin)
20
Q
H.Pyori eradication therapy no quick resistance to
A
amoxicillin or tetracycline
21
Q
Hpylori combo therapy
A
2 abx + a ppi (zole) or bismuth QID (has direct anti H pylori action)
22
Q
H pylori combo therapy MOC
A
MOC
Metro-flagyl 500 bid
prilosec (zole) 20mg bid premeal
clarithromycin (Biaxin) 500mg BID with meals for 7 days
23
Q
H Pylori combo therapy AOC
A
AOC
ammox- 1g bid with meals
prilosec (zole) 20mg BID beofre mieals
clarithromycin(biaxin) 500 bid before meals for 7 days
24
Q
Hpylori combo therapy MOA
A
metrinodizole -flagyl, 500bid with mealls
prilosec 20mg and amoxicillin 1g bid with meals for 7 dyas
25
Hpylori has bismuth regimin but has more side effects
bsmuth sunsalicylate 2 tabs fur times a day
flagyl 250 four times a day
tetracyn 500mg foru times a day
all with meals and then at bedtime
can add prilosec to this as well am and qhs for 7 days
26
antiulcer regimine is reccomended post h pylori eradication for 3-7weeks to ensure ulcer healing
for duodonal- omeprazole priolsec PPI 40mg qday or lansoprazle prevacid 30mg per day for 7 weeks
27
antiulcer regimine post H pylori H2 (dines)
H2 like famantodine Pepcid of sucarafate for 6-8 weeks
28
PUD in hospital management
```
IV access and fluids
cbc,ptt,BMP
02
endoscopy, gi angioagraphy (sx consult)
urinary cath
NPO with ng tube for lavage - bleeding stops sopontaneously in 80 percent of cases
```
29
PUD in hospital upright films
```
show free air in 70% of the cases
monitor ab
IV H2 blockers- the dines famtadine
ffp for coagulopathy
transfuse with plat if below 50K
H2 or sucarlfate fro 6-8 weeks
```
30
perf bowl sounds
quiet
31
normal plt
150-400k
32
HEP ABC
viral
33
HEP A
fecal oral,
| common from food or water (huricane busted pipes)
34
Hep A blood and stool
infectious during the 2-6 week incubation period
35
HEP A mortality
rate is low, fulmination hep A is rare
36
Hep B where is it
blood born DNA virus present in the serum, saliva, senem and vag secretions
37
Hep B transmission
via blood to blood, sex, mother fetus
38
Hep C what is it
blood born RNA virus where source is often uncertain
39
Hep C transmission
associated with blood, think drug needles (50%)
40
Hep C signs and symptoms pre icteric
per-icteric- fatigue, malaise, NV HA, aversion to smoking and ETOH
41
Hep C icteric
weight loss, jaundice, pruritius , RUQ pain, CLAY COLORED STOOL, dark urine
may have low grade fever or hepatosplenomegaly
42
Hep C labs
WBC low to normal
UA- protein and bili
Elevted AST and ALT (500-2000IU/L
LDH, Bili,Alk phos, and PT are normal to slightly elevated
43
Serology testing for Hep A-
look for antibody (anti-HAV) and IGM-which would imply recent infection
these peak during first 6 weeks then disappear in 3-6 months these are diagnostic of acute hep A
44
diagnostic of acute hep A
ANTI-HAV AND IGM ANTIBODY
IGG antibody to hep A implies previous exposure and on its own is not diagnostic of acute HAV infection -could be previous exposure, noninfectivity or immunity to recurring HAV infeciton
45
serology of active HEP A
anti-hav and IGM
46
serology of recovered hep A
anti HAV and IGG
47
Hep B serology first
first is HBSAG- will remain positive in asymptomatc carriers and chronic hep B patients
48
Hep B serology second
second is antibody to HBcAG or ANTI-HBC and IGM shortly after HBSAG goes away but before anti HB (antibody to HB appears)
49
Hep B serology third
HBeAG - protein derived from HBV core and indicates circulating HBV and HIGHLY INFECTIOUS SERA only in HBsAG+ sera presence indicates infectivity
50
anti hep B
often apears when HBeAG dissapers and signals diminished viral replication and infectivity
51
serology summary
| active hep B
HBSAG, HBEGA, ANTI-HBC, IGM ie the hep B surface antigen, the protine derived from the core and the antibody plus IGM
52
serology
| chronic Hep B
hep B surface antigen, anti Hep B, anti, HBE, IGM and IGG
53
serology
| recovered Hep B
anti HBc, Anti HBsAG
54
hep B actute vs chronic
acute has HBeAG and anti HBC plus only IGM
chronic has anti HBE, and IGG
55
Hep c how to find
enzyme immunoassay detects presence of antibodies to Hep C
sens and specificity are low- when suspected RIBA assy detects antibodies to HCV antigens
PCR used to differentiate between prior exposure and current viremia
56
Hep C acute
Anti HCV-HCV, RNA
57
Hep management
```
supportive, rest during the acute phase
increase fluids 3-4L per day
avoid alcohol, detox the liver
no or low protein diet
serax if sedation is necessary
vitamin K for prolonged PT (>15sec)
Lactulose 30ml oray or rectally for elevated ammonia. or hepatic encephalopathy
```
58
BS with obstruction
high pitched tinkling
59
normal ast alt
less than 35-40
60
IgM vs IGG for hep A
IGM immediate
| IGG gone
61
HBS AG is the tip off for B
HBE-AG is high virl load
anti HBE-ag is diminished load
IGM is immediate
IGM and IGG equals chronic
62
recoverd hep B
just anti anti
63
hep C needs PCR to tell
acute vs chronic
64
Diverticulitis
LLQ disease more common in women
| low fiber diet
65
diverticulitis
infammation or localized perf of one or more diverticula with abcess formation
66
diverticulitis causes and incidence
more common in women, low fiber diet
67
diverticulitis s and s
mild to moderate aching LLQ pain
constipation vs loose stool vs both
nausea and emisis
68
physical findings diverticulitis
low grade fever
LLQ tenderness and pain on palpation
free perf features more dramatic presentaiton
69
Diverticulitis labs and diagnostics
```
mild to moderateleukocytosis,
elevated esr
stool and heme + in 25% of cases
sigmoidoscopy shows inflamed mucosa
may consider CT to evaluate for abcess
plain ab films are OBTAINED ON ALL PATIENTS TO LOOK FOR EVIDENCE OF FREE AIR - pneumoperitenouwm
```
70
diverticulitis inpatient management
npo
IV fluids
IVABX (flagyl, cpro, ceftaidime clinda, ampicillin
if significan gi bleed present treat like PUD
20--30% of patients require sx
71
cholycystitis what
associated with gall stones in 90% of cases
72
cholycystitis when s and s
often after a large fatty meal
SUDDEN STEADY SEVER EPIGASTRIC PAIN, RO RIGHT HYPOCHNDRIUM
vomiting leads to relief
73
cholysystitis exam
murphys sign: deep pain on inspiration, while fingers are placed under the R rib cage
RUQ tender to palpation, canfeel gallblader in 15% of cases
musclegaurding
fever
74
cholecystitis exam
```
WBC's 12-15K
serum Bili may be up
serum ALT,AST,LDH,and alk phos levels are all up
amylase ma be up
plain films show radioopaque gallstones
HIDA sccan
```
75
cholecystitis gold standard exam
ULTRASOUND
76
Cholysystitis management
```
pain managemnt
ngt for decompression
npo
crystoloid syloutions
Broad spectrum ABX like Piperacillin
surgical consult for lap choley
```
77
Acute pancreatitis (autodigestion of pancreas by enzymes) causes
gallbladder disease, etoh, High calcium, High lipids, trauma, meds-sulfonamides, thiazides, lasix, estrogen, azathioprie (imuran)
78
acute pancreatitis S and S
abrupt onset of steady sever pain EPIGASTRIC, WORSE BY WALKING AND LYING SUPINE, IMPROVED BY SITTING AND LEANING FORWARD, RADIATES TO THE BACK MOST COMMONLY BUT CAN GO ELSEWHER
nausea and emisis usually present, weakness sweating and anxiety in severe attacks
E
79
acute pancreatitis exam
upper ab pain WITHOUT GAURGIND RIGIDITY OR REBOUND
distended ab
absentbowel sounds if associated with paralytic illius
fever
tacchycardia
pallor,cool skin
mild jaundice
80
aacute pancreatitis with hemmorage
grey turner- flank discoloration
| cullens sign- umbilical
81
acute pancreatitis labs and diags
wbc elevation depends on degree
hyperglycemia
serum LDH and AST elevation
Serum Amylase 50-180 and ipase 14-289 elevated in 90% of cases BUN and coag my be up as well
82
acute pancreatitis and calcium
levels below 7mg/dl associated with tetany , chvoseks sign or treseaus
83
acute pancreatits elevated CRP
suggestive of pancreatic necrosis
84
acute pancreatitis imaging
CT is better than ultrasound
85
acute pancreatitis Ransons criteria- 5-6 risk factors +40% mortality, >7 risk factors +100% mortality
george washington go lazy after taken on admisisonn
```
Greatr than 55years of age or 70 with gall stones
Wbc over 16K
Glucose over 200
LDH over 350
AST over 250
```
86
ransons at 48 hours for acute pancreatitis
he broke CABE
```
Hct drop of >10
BUN increase >5
Calcium <8
Arterial 02 <60
Base deficit >4
Estimated fluid sequestration >6000ml
```
87
Acute pancreatitis tx.
```
bed rest
npo
aggressive iv volume repletion
ng suction
pain control
pain free with bowel sounds can start clear liq diet
```
88
bowel obstruction causes
adhesion, hernia, tumor, fecal impaction, illeus, volvuls
89
bowel obstruction S and S
```
cramping and periumblical pain
later pain is constant and diffuse
vomiting within minutes of pain (proximal obstruction)
within two hours of pain is distal
minimal or no fever
```
90
bowel obstruction physical findings
```
minimal distention is proximal
ornounced distention is distal
mild tender but no peritoeal findings
high pitched, tinkling bowel sounds
cant pass stool or flatus
```
91
bowel obstruction labs
normal labs initially
later may see dehydration level rise in wbc's
plain films show DIALATED LOOPS OF BOWEL AND AR FLUID LEVELS
92
air fluid level pattern in small bowel obstruction
HORIZONTAL IN SMALL BALL
| FRAME PATTERN IN LARGE BOWEL
93
bowel obstruction management
```
fluid recuss
ngt suction
broad spectrum abx
surgery in ALL CASES OF COMPLETE OBSTRUCTION
partial obstruction may med manage
```
94
UC definition
an idopathic inflammatory condition characterized bu diffuse mucosal inflammation of the colon, unlike chrons disease, UC invariably involves the rectum and may extend upward involving the whole colon. The diseae is characterized by symptomatic episodes and remissions
95
UC signs and sx
BLOODY DIARRHEA IS THE HALLMARK SYMPTOM
96
UC labs and diagnosis
stool studies are negative
| sigmoidoscopy establishes the diagnosis
97
UC management
mesalamie (canasa) suppositories or enemas for 3-12 weeks
| hydrocortisone suppositories and enemas
98
Mesenteric infarct-
a syndrom as a result of inadequate blood flow inthe mesinteric cir leading to ischemia and gangreen of the bowel
99
UC appearance
cobblestone
100
UC is inflammatory and starts from
bottom up
101
Messinteric infarct causes
```
arterial or venous embolus or thrombus
atherosclerosis
smoking
usually occurs in older adults
coagulopathy such as that from recent surgery (cardiac, AAA, increases the risk
```
102
messinteric infarct S and S
```
sudden onset cramp and colickly ab pain potentially after eating
pain out of proportion to exam findings
NV, Fever, ab gaurding and tenderness
hyperactive to absent BS,
+ perotoneal findings
shock
```
103
messinteric infarct lab
elevated amylase, leukocytosis, ab films, CT
104
messinteric infarct tx
emergent surgery
105
appendicitis
inflamaiton of the appendix, precipitated by obstruction of the lumen, if untreated gangrene and perf can develop in 3 hours, most common presentationis men 18-30 years, affects 10% of the population.
106
appy causes
fecalith, foreign body, inflammation, neoplasm
107
appy signs and symptoms
vague colicky umbilical pain
pain shhifts to RLQ after several hours,
nausea with 1-2 episodes of vomiting LOTS OF EMISIS SUGGESTS ANOTHER DIAGNOSIS
pain is worse and is localized with coughing
108
appy labs and diagnosis
RLQ gaurding WITH REBOUND TENDERNESS
local ab tenderness
pain worse with cough
109
appy psoas sign (illiopsoas test
pain with R thigh extension
110
appy obturator sign
pain with internal rotation of the flexed right thigh
111
appy positive Rovsings sign
RLQ pain when pressure is applied to the LLQ
112
appy fever
is low high fever suggest perf and another diagnosis
113
appy and WBCs'
10k to 20k
114
appy diagnosis
CT or ultrasound
115
appy management
surgery
iv abx
iv fluids
pain managemnt
116
gero considerations for GI
```
decreased- jaw strength
thirst and taste perception
gastric motility and delayed emptying
increased transit time
impaired defication signal
decreased liver size and liver blood flow
```
117
gi gero risk of
poor nutirition
altered metabolism of drugs
gerd
nsaid induced ulcers
118
gi gero constipation
not a normal finding, most common causes include lack of fiber, deceased exercise, poor dentition, history of lax abuse, and impaired mental status
119
gerd causes
dleayed emptying or incompetent lower esophegal sphincter
120
gerd s and s
```
retrosternal burning
bitter taste in mouth
delching hicciups excessive salivation
frequently at night or recumbant
may be releived by sitting up water or food
```
exam is worthless
121
gerd diagnostics
conside refferral for EGD, rule out cancer, barretts or PUD
122
gernd non pharma
elevated HOB, avoid ETOH and caffine spices peppermint etc, stop smoking weight reduction
123
gerd pharma
antacids prn
H2 blockers the tdines in high dose at night or bid
ppi zoles if h2 blockers are inneffective
gi surgical consult prn
