GI Flashcards
What are the causes of Esophageal Stricture?
- Chronic reflux esophagitis
- Medications
- Radiation therapy
- Eosinophilic esophagitis
Dx test of choice for diverticulitis?
CT scan w/no oral contrast
s/s of external hemorrhoids
perianal pain aggravated w/defecation + skin tags
Hepatocellular Carcinoma Tx
Transplantation if tumors are small and few
Surgical resection may be done; however, the cancer usually recurs
What is the MCC of appendicitis?
fecalith
When would you use H pylori stool antigen (HpSA) test?
If unable to perform endoscopy
Gold standard Diagnostic test for PUD
Endoscopy w/biopsy + rapid urease test
What is the best initial diagnostic tool to assist in diagnosing a pt presenting with altered bowel habits?
history and physical exam
slowly progressive solid food dysphagia, regurgitation, and episodic food impaction.
What disease?
esophageal stricture
What are considered indicators of unresectability in gastric cancer?
vascular involvement of the aorta, hepatic artery, or proximal splenic artery, distant mets
Dx of choice for acure pancreatitis
RUQ US
*if the cause of this is biliary, ERCP is choice of dx and tx**
Conditions associated with pancreatic pseudocyst
- chronic pancreatitis
- can be found with acute pancreatitis classically occur 2-3 weeks after acute pancreatitis
- trauma to chest (steering wheel trauma)
MCC of gastroparesis?
DM
MOA of “setron” antiemetics
blocks serotonin receptors (5-HT3)
Colonoscopy results UC vs Crohns
UC: pseudopolyps
Crohns: Skip lesions, _cobblestone appearance**_
Surgery in UC vs Crohns
UC: curative
Crohns: Non-curative
What is the most common abx associated with c.diff?
clindamycin
What is the cause of jaundice in a pt w/ Normal alkaline phosphatase and aminotransferases?
not due to hepatic injury or biliary tract disease
What is the gold standard method for diagnostic eval of PUD?
Histologic tissue evaluation following endoscopy
S/E of dopamine blockers (antiemetics)
QT prolongation
anticholiergic & antihistamine S/E (drowsiness)
Extrapyramidal sxs: rigidity, bradykinesia, tremor, akathisia
Dystonic Reactions (Dyskinesia) Mgmt: IV Diphenhydramine
What is the MCC of significant lower GI bleeding?
Diverticular bleeding
What causes jaundice?
bilirubin deposition in the skin as a consequence of hyperbilirubinemia
History/Exam of UC vs Crohns
UC: bloody diarrhea, LLQ colicky pain
Crohns: perianal fissures/tags/fistulas, weight loss, watery diarrhea
What diagnostic imaging can you order when pancreatic CA is suspected?
- RUQ US
- CT scan
- ERCP
s/s of internal hemorrhoids
intermittent rectal bleeding
(BRBPR)
**if there is pain w/internal, suspect complications as they should normally be non-tender**
Internal hemorrhoids tx
stool softeners
sitz baths
Bleeding internal hemorrhoids: injection sclerotherapy
Rubber band ligation for larger, prolapsing hemorrhoids or those unresponsive to conservative management.
Pain: NSAIDS
Best diagnostic test for small bowel obstruction
abdominal CT w/contrast
When would you consider surgery for a pt with diverticular dz?
Surgical management may be necessary in severe cases, including peritonitis, large abscesses, fistulae, or obstruction.
- painless jaundice
- depression
- weight loss
- hx of smoking
What dz?
Pancreatic CA
What are risk factors for small bowel carcinoma?
- Hereditary cancer syndromes: Hereditary nonpolyposis colorectal cancer (HNPCC)
- Cystic fibrosis — Patients with cystic fibrosis have an elevated risk of small bowel cancer
- Crohn’s disease predisposes to adenocarcinoma within the involved area of the small intestine
- Intake of alcohol, refined sugar, red meat, and salt-cured and smoked foods
What is the classic presentation of Acute Ascending Cholangitis?
- fever
- jaundice
- abd pain
CHARCOTS TRIAD
What is the MC presenting symptom of a small bowel tumor?
abdominal pain- typically intermittent and crampy in nature
What are the main causes of acute pancreatitis?
Cause: cholelithiasis, alcohol abuse, hypertriglyceridemia, PUD, drugs (antiretroviral)
What is the biggest RF for mallory weiss tear?
alcohol consumption
CPx of small bowel
- hx of prior abdominal/pelvic surgery
- bilious vomiting
Tx for esophageal CA
esophageal resection (chemo w/5-FU)
endoscopic screening is recommended in pts with Barrett’s esophagus every 3-5 yrs
What will axial CT scan show in pt with diverticulitus?
fat stranding, bowel wall thickening
What are possible causes of melena (black tarry stool)?
Upper GI bleed:
- peptic ulcer
- esophageal ulcer
- Mallory-Weiss tear
- Malignancy
What other sxs can be associated with acute cholecystitis?
Fever/N/V
What will labs show in acute ascending cholangitis?
- elevated WBC w/neutrophilia
- elevated alk phos, GGT, bilirubin (cholestatic pattern of elevated liver enzymes)
What is the test of choice for pancreatic pseudocyst?
CT scan
may start with US initially
Tx for C diff
Vancomycin or Metronidazole
What tumor marker may be used for liver cancer?
alpha-fetoprotein
What is obstipation?
severe or complete constipation
Which anti-diarrheals are safe in dysentery?
bismuth-subsalicylate
- pepto-B, Kaopectate
Other than Courvoisier sign, what other PE findings will you see in a patient with Pancreatic CA?
- Trousseaus Syndrome: migratory thrombophlebitis
- Sister Mary Joseph Sign: palpable nodule bulging into the umbilicus
-
Virchow’s node: Node in the L supraclavicular fossa
- Supply is from lymph vessels in the abdominal cavity
MC type of pancreatic CA
Ductal Adenocarcinoma (worst prognosis) @ head of pancreas
When are anti-motility agents recommended?
if pt is < 65 y/o w/ moderate to severe signs of volume depletion
What is the site of involvement in UC vs Crohns?
UC: rectum + proximal extension in continuous fashion
Crohns: any portion of GI tract, mainly ileocecal region in a discontinuous pattern (skip lesions). Rectum is spared. Transmural inflammation is seen, which can lead to fistulas to other organs.
What establishes the diagnosis of Pyloric Stenosis?
Abdominal US: increased pyloric muscle thickness, length and diameter “target sign”
What class do these drugs belong to?
- Prochlorperazine
- Promethazine
- Metoclopramide
Dopamine Blockers
Blocks CNS dopamine receptors D1, D2
Dx test of choice for C.diff
PCR , culture
HCC Screening
high risk patients: AFP + US q 3 mos sometimes recommended
Common screening method: US q 6-12 mos
**Many experts advise screening patients with long-standing hepatitis B even when cirrhosis is absent.**
The following are risk factos for which disease?
- straining during defecation (constipation)
hemorrhoids
What lab tests should be ordered for pt w/ GI bleeding?
- CBC
- liver tests
- anti-coag studies
Is there hematochezia in diverticulitis?
No
What are the Preferred Diagnostic Tests for Cholecystitis?
Initial: US
Gold Standard: HIDA Scan
What will labs show for chronic pancreatitis?
elevated amylase early on, but will decrease
abdominal xray/CT (calcifications)
_____________will present as → a 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, midabdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC.
Diverticulitis
S/S of small bowel intussesception
Sudden onset of significant, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting.
Affects children after viral infections or adults with cancer
Occurs during first 2 weeks post op
Currant jelly stools
sausage-like mass in abdomen
What is the MC presentation of diverticula?
LLQ pain and tenderness
What diagnostic test should be used if unable to perform endoscopy in PUD?
urea breath test:
H pylori converts Urea to CO2
What does a standard workup prior to a surgical antireflux procedure include?
Endoscopy with biopsy is the gold standard for diagnosis
manometry
24-hour ambulatory pH probe testing
barium esophagography
X-ray
Esophageal motility testing
_________ is associated with forceful retching.
Malloer Weiss Syndrome
MCC of PUD?
H. pylori and NSAIDS
S/S for internal vs external hemorrhoids
Internal (above dentate line): bleeding + no pain, bleeding after defecation
External(below dentate line): significant pain + no bleeding
What is a positive Courvoiser sign?
Presence of painless, palpable gallbladder in the RUQ
H. pylori infection tx
Triple therapy: “CAP”
- Clarithromycin
- Amoxicillin
- PPI
Esophageal is usually a complication of what?
GERD/Barrett’s esophagus
Mgmt for diverticulosis
supportive care (most bleeding stops spontaneously)
*surgery if persistent bleeding
_______________ will present as →a 63-year-old male who is being evaluated in the emergency department for an episode of painless bright red blood per rectum for two hours.
Diverticulosis
Firm olive like mass
What disease?
Pyloric Stenosis
Tx for gastroparesis
- Low-fiber and low-residue diets, restrict fat intake, smaller meals spaced 2-3 h apart
- Metoclopramide (D2 receptor antagonist) inc GI motility
GOLD STANDARD diagnostic test for acute cholecystitis
HIDA scan (assesses the patency of the cystic duct)
What is the difference between acute cholecystitis and biliary colic?
Biliary colic has temporary pain
Acute cholecystitis has pain that does not resolve, usually with elevated WBCs, fever, and signs of acute inflammation on U/S
C. Diff tx
IV metronidazole or PO vanco
What is the difference in presentation between a duodenal versus a gastric ulcer?
Gastric Ulcer: pain immediately after meals
Duodenal Ulcer: pain relieved by food (MC than gastric)
Mgmt of Reye
supportive + Mannitol (lower ICP)
S/S and PE of pancreatic pseudocyst
abdominal pain
PE: abdominal mass
Sxs of Pyloric Stenosis
- forceful nonbilious vomiting “projctile vomiting” immediately after eating
- infant appears hungry
Dx for Mallory Weis tear?
Upper endoscopy
What is a hemorrhoid?
engorgement of venous plexus
What diet is recommended for diarrhea?
BRAT diet
Banana
Rice
Applesauce
Toast
What labs will be abnormal in Pancreatic CA?
Increased Amylase (if tumor obstructs ducts)
Tumor Marker CA 19-9 (not diagnostic but can be used to follow response to therapy)
What will labs show in acute pancreatitis?
elevated lipase x 3
How does esophageal CA present?
difficulty swallowing solids that progresses to liquids and lymphadenopathy
Which drug for Crohns and UC works primarily in the colon?
Sulfasalazine (5-ASA)
Linitis plastica:“leather bottle” appearance
gastric carcinoma
MCC of acute ascending cholangitis?
choledocolithiasis leading to bacterial infection: E coli
Tx for Pyloric Stenosis
Supportive, treat electrolyte imbalances
Pyloromyotomy
MOA of bismuth subsalicylate
- pepto-bismol
- Kaopectate
- antimicrobial
- salicylate: anti-secretory + anti-inflammatory
S/E of opioid agonists
centra opiate effects
constipation
Tx for UC vs Crohns
UC and Crohns BOTH:
5-ASA agents (sulfasalazine, mesalamine)
corticosteroids
immunomodulating agents (azathioprine) for refractory disease
S/S of gastroparesis
nausea and a full feeling after little food is eaten
Extraintestinal manifestations of UC vs Crohns
UC: primary sclerosing cholangitis(inflammation and scarring of bile ducts), aphthous stomatitis, Colon CA, toxic megacolon, smoking DECREASES risk***
Crohns: erythema nodosum, + fistulas to skin, bladder, or b/w loops (perianal dz), granulomas, Fe + B12 deficiency
Why should the gallbladder specimen be opened in the operating room?
Looking for gallbladder cancer, anatomy
A pt with pancreatic CA will usually have a history of what?
smoking
Labs UC vs Crohns
UC: + P-ANCA
Crohns: + ASCA
What is the source of an external hemorrhoid vein?
inferior hemorrhoid vein distal to the dentate line
S/s for toxic megacolon
Pt will present with FEVER, markedly distended abdomen with peritonitis and shock
Toxic Megacolon Tx
- Decompression of the colon is required.
- In some cases, colostomy or even complete colonic resection may be required
- IVF, ABX, IV corticosteroids
What is the MCC of peptic strictures?
Long standing gastric reflux
A pt presenting with diverticulosis will have a PMH significant for what?
- high dietary consumption of red meat
- low dietary fiber
- sedentary lifestyle
- BMI > 25
- cigarette smoking
Cpx of Esophageal CA
difficulty swallowing solids that progresses to liquids and lymphadenopathy
What is the MCC of traveler’s diarrhea?
enterotoxigenic E. Coli (ETEC)
What test is important to establish the dx of jaundice?
fractionated bilirubin test
fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia
What disease?
Appendicitis
onset of diarrhea and vomiting during or closely following a course of antibiotics
What do you suspect?
clostridium difficile
Dx test of choice for toxic megacolon
AXR
Kidney Ureter Bladder X ray shows dilated colon >6cm
+
At least three of the following:
Fever (>101.50F)
Heart rate > 120/min
Neutrophilic leukocytosis (>10.5 x 109/L)
Anemia
What is Reynold’s pentad?
Seen in acute ascending cholangitis:
- fever
- abd pain
- jaundice
- confusion
- hypotension
What differential dx should you have in the instance of Conjugated hyperbilirubinemia?
biliary obstruction, intrahepatic cholestasis, hepatocellular injury, or an inherited condition
Toxic megacolon is usually a complication of what disease?
Ulcerative Colitis or Crohn’s disease (rarely)
Test of choice for small bowel carcinoma
CT scan
wireless capsule endoscopy
fecal occult blood
tumor marker CEA +
What is hematochezia?
passage of fresh blood through the anus
intermittent cramping abdominal pain in the upper-right quadrant
right-upper-quadrant pain, guarding, and a positive Murphy’s sign
Precipitated by fatty foods or large meals
+ Boas sign
Acute Cholecystitis
What often accompanies pts who have gastric carcinoma?
iron deficiency anemia
What is the mgmt for small bowel obstruction?
nonstrangulated: NPO (bowel rest), IV fluids
Strangulated: surgical intervention
Ileus Tx
Physiologic ileus spontaneously resolves within 2-3 d, after sigmoid motility returns to normal
Physiological ileus is a term used to portray the normal absence of motility and propulsion in the small and large intestine.
D/C opiates
What is management of a thrombosed hemorrhoid presenting within 72 hours of the onset of symptoms?
elliptical excision
Anesthetize, make an elliptical incision of skin overlying clot, remove clot.
What is a Mallory-Weiss Tear?
tear in the esophageal mucosa often following forceful vomiting
What are diverticula?
Outpouchings of the GI tract that can occur anywehre from the esophagus to the rectum
What PE sign is a specific indicator that a pt with acute cholecystitis has had a perforation?
Hypoactive bowel sounds
What is the primary cause of appendicitis?
Appendiceal obstruction.
What is a + Boas sign and in what dz do you see it?
referred pain to right subscapular area due to phrenic nerve irritation
acute cholecystitis
What are the S/S of acute pancreatitis?
epigastric pain radiating to back; better leaning forward;
N/V, fever,
peritonitis symptoms,
hypovolemia, tachycardia,
Grey Turner Sign/Cullen Sign (hemorrhagic pancreatitis)
RF for pancreatic CA
- smoking
- alcohol
- obestiy
- chronic pancreatitis
What portion of the esophagus is involved in squamous cell esophageal cancer?
Upper 1/3 of esophagus
What is the most imp first step in caring for a pt w/ GI bleeding?
obtaining IV access:
- allows blood to be drawn for a type and screen, coagulation studies, and determination of hematocrit and hemoglobin levels.
- It also allows for fluid resuscitation to maintain intravascular volume.
What is a pancreatic pseudocyst?
Cystic collection of tissue, fluid, and necrotic debris surrounding the pancreas.
What is Rosvings sign?
Pain in the RLQ w/palpation of the LLQ
Diagnostic test of choice for gastric carcinoma
upper endoscopy w/biopsy
Dx approach for hepatic lesion < 1cm
Image w/ MRI w/contrast
If negative, obtain f/u US q 3 months
What is postoperative adynamic ileus or paralytic ileus?
Ileus that persists for more than 3 days following surgery
Dx Test of choice for hematochezia?
colonoscopy
Patient will present as → a 68-year-old smoker with a 25 lb weight loss over the last three months that is associated with a burning pain deep in the epigastrium after eating, diarrhea, and jaundice. Physical exam reveals a palpable non-tender gallbladder and clay-colored stool. Labs show a total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150
What disease?
Pancreatic CA
What are the risk factors for gastric carcinoma?
*H. Pylori*
salted, cured, smoked, pickled foods containing nitrites/nitrates
What are the S/S of chronic pancreatitis?
calcification, steatorrhea, diabetes mellitus
CLASSIC TRIAD
What will Labs show for acute cholecystitis?
- Increased WBC
- elevated Alk Phos, LFTs
- elevated amylase, T bilirubin
________ is a clinical manifestation of hyperbilirubinemia.
jaundice
Complications of bismuth-salicylates in children
Reye Syndrome: hepatoencephelopathy asssociated with ASA/salicylate use after viral illness resulting in increased ICP (vomiting, stupor, coma, death), hepatomegaly, fulminant liver failure.
What class are these drugs?
Pepto-Bismol
Kaopectate
bismuth subsalicylate (anti-diarrheals)
MCC of gastric carcinoma
H.pylori
What is the most commonly affected area in diverticulitis?
sigmoid and descending colon
Dx in UC vs Crohns
UC: flex sig test of choice in acute disease _*colonoscopy CI in acute colitis–> causes perforation, barium enema CI in acute colitis*_
Crohns: Upper GI series w/small bowel follow though in acute dz
What is the source of an internal hemorrhoid?
superior hemorrhoid vein
Tx for small bowel carcinoma
Surgery — Localized adenocarcinomas of the small bowel are best managed with wide segmental surgical resection
Adjuvant chemotherapy to patients with lymph node-positive
a 52-year-old female with a history of cirrhosis secondary to long-standing alcohol abuse visits your office to discuss a 15-pound weight loss over the last 6 months. She reports early satiety, jaundice and vague abdominal discomfort. Her ascites, generally stable and small, has worsened in the last 3 weeks.
What disease?
Hepatocellular carcinoma (HCC)
a 62-year-old man with a history of alcoholism complains of difficulty swallowing solids that has progressed to difficulty swallowing liquids. He has smoked 1-2 packs of cigarettes per day for the past 38 years. In addition he reports occasional bouts of hematemesis and hoarseness, along with progressive weight loss and weakness.
What does he have?
Esophageal Cancer
What is the Ransom Criteria?
Used to determine prognosis for acute pancreatitis:
Poor prognosis if 3 or more = severe case
- leukocyte >16K
- glucose >200
- AST >250
- LDH >350
- age>55
at 48 hours
- arterial PO2 <60
- HCO3: <20
- Ca: <8
- BUN increasing by 1.8+
- Hct: decrease by >10%
- Fluid sequestration >6L
must avoid these anti-diarrheals in patients with acure dysentery
opioid agonists
What is jaundice caused by if there is Predominant alkaline phosphatase elevation?
Elevation of the serum alkaline phosphatase out of proportion to the serum aminotransferases suggests biliary obstruction or intrahepatic cholestasis
PE of ileus
absent bowel sounds
Dx test of choice for esophageal CA
upper endoscopy w/biopsy
CT scans are used for staging
intussusception tx
barium enema
NPO, IVF, NG
manual reduction
What is jaundice caused by if there is a Predominant aminotransferase elevation?
intrinsic hepatocellular disease
What is 1st line for hemorrhoids?
- conservative tx: high fiber diet, increased fluids. Warm sitz baths
- If failed above, debilitating pain, strangulation or stage IV: rubber band ligation
- Hemorrhoidectomy for all stage IV or those not responsive to above
What differential dx should you have in the instance of Unconjugated hyperbilirubinemia?
evaluation for hemolytic anemia, drugs that impair hepatic uptake of bilirubin, and Gilbert syndrome
How is an IOC performed?
- Place a clip on the cystic duct- gallbladder junction
- Cut a small hole in the distal cystic duct to cannulate
- Inject half-strength contrast and take an x-ray or fluoro
What is jaundice caused by if you have an elevated INR that corrects with vitamin K administration?
impaired intestinal absorption of fat-soluble vitamins and is compatible with obstructive jaundice
Tx for diverticulitis
metronidazole + ciprofloxacin
OR
moxifloxacin monotherapy
Side Effects of bismuth salicylates
dark stools, dark tongue
What are possible causes of hematochezia (bright red blood per rectum)?
Lower GI bleed:
- Hemorrhoids
- Anal Fissures
- Polyps
- Colorectal CA
Tx for acute cholecystitis
If asymptomatic: observe, CCY not recommended
Symptomatic: IVFs, Abx, CCY early
What class are these drugs?
- phenobarbital
- Hyoscyamine
- Atropine
- Scopolamine
Anticholinergics, antispasmodics
Dx test of choice for diverticulitis?
abdominal CT scan w/oral and IV contrast
CT can also evaluate for abscesses, perforation, fistula, obstruction, and ileus
What is the main dx test of choice for acute pancreatitis?
US
What is a contraindication of anti-motility drugs?
do not give to pts with invasive diarrhea due to toxicity
What are basis are internal hemorrhoids classified with?
Based on the degree of prolapse from the anal canal:
I. no prolapse
II. prolapses w/defecation or straining w/ spontaneous reduction
III. prolapses w/defecation or straining, requires manual reduction
IV. Irreducible & may strangulate
What is the optimal timing for cholecystectomy following an acute presentation of cholecystitis?
Depending on the stabilization of the patient, earlier surgery within 48-72 hours of diagnosis is recommended to avoid complications.
Dx test of choice for melena?
EGD
What imaging should be ordered to confirm appendicitis?
US, CT scan
Most common type of esophageal CA
squamous cell adenocarcinoma
Which drug is best for maintenance of both UC and Crohns?
Oral Mesalamine (5-ASA)
What disease processes can cause jaundice?
increased bilirubin overproduction (hemolysis)/ineffective erythropoiesis
decreased hepatic bilirubin uptake
impaired conjugation
biliary tract obstruction
viral hepatitis
physiologic jaundice of newborn
gilbert syndrome
Dubin-johnson
What diagnostics should you order for a suspected esophageal stricture?
1st: Barium Swallow
2nd: Upper endoscopy
Tx of traveler’s diarrhea
rehydration and ciprofloxacin or azithromycin (pregnant women and children)
What is the cause of acute cholangitis?
biliary tract onstruction, stasis and infection
A rise in ________ in a patient with cirrhosis or hepatitis B should raise concern that HCC has developed.
AFP
What are risk factors of Hepatocellular carcinoma?
- chronic liver disease
- cirrhosis
- Hepatitis B or C infections
What is the next step if no radiologic hallmarks of HCC are seen?
biopsy
Barium Studies UC vs Crohns
UC: “stovepipe sign”
Crohns: “string sign”
Indications for surgical tx for GERD:
Intractability (failure of medical treatment)
Respiratory problems as a result of reflux and aspiration of gastric contents (e.g., pneumonia)
Severe esophageal injury (e.g., ulcers, hemorrhage, stricture, +/- Barrett’s esophagus)
What is the most common cause of upper GI bleed?
Peptic Ulcer Disease
Dx test of choice for small bowel intussusception
abdominal x ray/US: crescent sign or bulls eye/target sign/coiled spring lesion
Complications of acute cholecystitis
- Abscess Perforation
- Choledocholithiasis
- Cholecystenteric fistula formation
- Gallstone ileus
What are the main differences in s/s between small and large bowel obstruction?
Small bowel: colicky abd pain, bilious vomiting, hyperactive bowel sounds
Large bowel: gradually inc abd pain, longer intervals between episodes of pain, less vomiting (feculent)
Definitive dx for acute ascending cholangitis
Charcots triad + biliary dilation on US
Tx for pseudocyst
If pseudocyst persists for 4 to 6 weeks or continues to enlarge:
- Percutaneous drainage
- Surgical decompression (pancreaticogastrostomy)
- Cyst fluid is drained into the stomach or bowel
- Can become infected and lead to peritonitis
What is gastroparesis?
A condition that affects the stomach muscles and prevents proper stomach emptying
Dx test of choice for gastroparesis
gastric emptying scan
What is definitive treatment of acute ascending cholangitis?
ERCP w abx (Zosyn)
_______ hemorrhoids may become thrombosed
external
What will US show in acute cholecystitis?
- Thickened gallbladder wall (3 mm)
- Pericholecystic fluid
- Distended gallbladder
- Gallstones present/cystic duct stone
- Sonographic Murphy’s sign (pain on inspiration after placement of ultrasound probe over gallbladder)
When should a patient you suspect has GERD undergo diagnostic testing?
Those with long-standing or atypical symptoms (wheezing, cough, hoarseness), recurrence of disease after the cessation of medical therapy, or unrelieved symptoms when taking maximal-dose PPIs
Tx for acute pancreatitis
supportive therapy
- NPO
- IV Fluids
- antibiotics (zosyn: pieracillin + tazobactam)
- no Alc
What class are these drugs?
Diphenoxylate, Loperamide
opioid agonists
What is the 1st line diagnostic Test for acute cholecystitis?
US: will show stones
What are large outpouchings of the mucosa in the colon called?
Diverticula
What complication can chronic cholecystitis lead to?
Porcelain GB (premalignant condition)
Dx test of choice for ileus
CT scan w/gastrografin (must excluse mechanical obstruction)
Tx for pancreatic CA
- If confined to pancreas and can be removed: Whipple Procedure (pancreaticoduodenectomy):
- If confined to pancreas and CAN NOT be removed: combination of radiation therapy + chemo
What type of cancer is MC in small bowel cancers and where are they usually located?
Adenocarcinomas represent from 25 to 40 percent of small bowel cancers - highest in the duodenum
Tx for melena/hematochezia
Endoscopic thermal probe: This involves burning the blood vessel or tissue that’s causing an ulcer.
Endoscopic clips: These can close a bleeding blood vessel or other sources of bleeding in the tissue in your GI tract.
Endoscopic injection: Injection of liquid near the source of bleeding that will stop the flow of blood.
Band ligation: This procedure involves placing small rubber bands around hemorrhoids or swollen veins (esophageal varices) to cut off their blood supply, which will make them dry up and fall off.
Esophageal varices are complications of what?
portal vein hypertension
Whats the MC risk factor for esophageal varices in adults?
cirrhosis
Dx for esophageal varices
upper endoscopy, enlarged veins
+red wale markings and cherry red spots
1st line tx of esophageal varices
- endoscopic ligation
- octreotide: pharmacologic drug of choice in acute bleeding
- surgical decompression: trans jugular intrahepatic portosystemic shunt (TIPS)
Tx for rebleeds in esophageal varices
- nonselective beta blockers: propanolol, nadolol
**do not use in acute bleeds***
2. isosorbide: long acting nitrate
Abx prophylaxis for esophageal varices
fluoroquinolone or ceftriaxone
What is the cause of gastritis?
1 cause: H. Pylori
imbalance between increased aggressive and decreased protective mechanisms of the gastric mucosa
What is the most effective drug to treat PUD?
PPIs “prazoles”
MOA of PPIs
blocks H+/K+ ATP-ase (proton pump) of parietal cell, reducing acid secretion.
What is the main side effect of PPIs?
B12 deficiency
Omemprazole causes ______, which increases levels of warfarin and other drugs
Omemprazole causes CP450 inhibition, which increases levels of warfarin and other drugs.
MOA of H2 receptor antagonists
reduces acid/pepsin secretion
SES of H2 receptor antagonists
drug interactions with cimetidine: CP450 inhibition
Anti-androgen effects of cimetidine: gynecomastia, impotence
Which medication is good for preventing NSAID-induced ulcers but not for healing already existing ulcers?
misoprostol
Misoprostol is CI in what population?
premenstrual women because it is abortifacent and causes cervical ripening
Causative factors for Duodenal vs Gastric ulcers
Duodenal: increase in damagin factors: acid, pepsin, H.pylori
Gastric: decrease in mucosal protective factors: mucus, bicarb, prostaglandins; NSAIDs
Incidence of gastric vs duodenal ulcers
gastric: 4% malignant
duodenal: 4x more common
Younger patients will have which type of peptic ulcer?
duodenal > gastric
Where are gastrinomas most commonly seen?
duodenal wall, >66% are malignant
s/s of zollinger-ellison syndrome
multiple peptic ulcers, refractory ulcers, “kissing” ulcers
diarrhea
Dx for zollinger-ellison syndrome
test of choice: increased fasting gastrin level
+secretin test: increased gastrin release with secretin seen in gastrinomas
Tx for local vs metastatic dz of zollinger-ellison syndrome
local: surgical resection
mets: PPIs, surgical resection if +liver involvement
MC sites for mets are liver and abd lymph nodes
Risk factors for gastric carcinoma
H. Pylori = main RF
salted, cured, smoked, pickled foods containing nitrites/nitrates
What is linitis plastica?
Linitis plastica: diffise thickening of the stomach wall “leather bottle” appearance
gastric carcinoma
Most likely dx when AST/ALT is >2 and AST is very high
EtOH hepatitis
Labs: ALT>AST
ALT + AST >1000
what should you be thinking?
viral/toxic/inflammatory processes regarding the liver
Increased Alk Phos + inc GGT suggests what?
biliary obstruction or intrahepatic cholestasis
ALT > 100
+ANA
+Smooth muscle Ab
responds to Corticosteroids
What is most likely dx?
autoimmune hepatitis
What are 2 complications of choledocolithiasis?
- acute pancreatitis: epigastric pain, increased amylase and lipase
- acute cholangitis: charcots triad of fever, jaundice and RUP pain.
Diagnostic test of choice for choledocolithiasis?
-
ERCP
- (diagnostic and therapeutic: allows for strone extraction)
- obtained AFTER initial transabdominal US
MC organism responsible for acute cholangitis?
E coli: gram — enteric organism
labs in acute cholangitis
increased alk phos, GGT, bilirubiin
gold standard dx for acute cholangitis
ERCP– common bile duct decompression/stone extraction: (pt must be stabilized and afebrile for 48 hrs after IV abx)
others(usually done initially):
US
CT scan
Mgmt for acute cholangitis
abx
