GI Flashcards
Celiac disease
Patient will be complaining of diarrhea, steatorrhea,flatulence, weight loss, weakness and abdominal distension
Labs will show IgA anti-endomysial (EMA) and anti-tissue transglutaminase (anti-tTG) antibodies
Diagnosis is made by small bowel biopsy
Treatment is gluten free diet
Comments: Associated with dermatitis herpetiformis (chronic, very itchy skin rash made up of bumps and blisters-papulovesicular)
Diverticulitis
Patient will be complaining of abdominal pain in the LLQ, fever, n/v and a change in bowel habits
Diagnosis is made by CT scan
Treatment uncomplicated is abx 7-10 days
Complicated: extensive inflammation or complications such as abscess, peritonitis or obstruction: IV abx
Cholecystitis
Patient will be an overweight (Fat),Fertile,Female in her Forties (4Fs)
Complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods
PE will show Murphy’s sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula)
Diagnosis is made by:
Initial - US: gallbladder wall thickening and pericholecystic fluid
Gold standard - HIDA: passage of contrast into the common bile duct but not into the gallbladder.
Most commonly caused by obstruction by a gallstone
Treatment is NPO, IVF, antibiotics and cholecystectomy usually within 3 days after onset of symptoms.
Complications: gallbladder gangrene, bile duct leaks, retained stones, sphincter of Oddi dysfunction and gas-forming organism infection of the gallbladder wall.
Ulcerative colitis
Patient will be 15-30-year-old
Complaining of bloody diarrhea, crampy abdominal pain, tenesmus, fecal urgency
PE will show continuous mucosal inflammation always involving the rectum
+p-ANCA, small % has +ASCA
Treatment is oral/rectal sulfasalazine or mesalamine (5-ASA) for maintenance, Oral/rectal corticosteroids for acute flares, 6-mercaptopurine, azathioprine, mtx.
surgery is curative
Complications: Toxic megacolon, ↑ colon cancer risk
“Left sided colitis”
Mesenteric ischemia
Arterial embolism > thrombus
Superior mesenteric artery MC
Patient with a history of dysrhythmias (AF), recent MI, or CAD, infective endocarditis, valvular disease, and hypercoagulability.
Complaining of abdominal pain out of proportion to exam
Labs: CBC, CMP, prothrombin time, and partial thromboplastin time. Leukocytosis, hemoconcentration, and lactic acidosis
Diagnosis is made by CTA, angiography (gold standard)
Surgery
Anal fissure
Patient will be complaining of rectal pain and bleeding which occurs with or shortly after defecation
PE will show fissure located in the posterior midline
Diagnosis is made by visual inspection
Treatment is stool softeners, protective ointments, sitz baths
Comments: If fissures are located laterally, search for pathologic etiologies: anal surgical procedures, inflammatory bowel disease, granulomatous diseases, malignancy and communicable diseases.
Traveler’s diarrhea
Patient with a history of recent travel
Complaining of abrupt onset of watery diarrhea, nausea, and abdominal cramping
Most commonly caused by enterotoxigenic Escherichia coli (ETEC)
Treatment is rehydration and ciprofloxacin or azithromycin (pregnant women and children)
Eosinophilic esophagitis
Adult with history of asthma, eczema, food allergies
Complaining of solid food dysphagia and food impactions, upper abdominal pain, GERD-like symptoms (eg, heartburn) and allergies
PE will show inflammation in esophagus due to eosinophils
Diagnosed via endoscopy /esophageal biopsies: stacked circular rings
Treatment: diet modifications (food allergens), steroids/anti-inflammatory, mechanical dilatation
Spontaneous bacterial peritonitis
Patient will have a history of chronic liver disease or cirrhosis
Complaining of fever, chills, and abdominal pain
PE will show ascites, shifting dullness
Labs will show PMNs > 250, WBC > 1,000, pH < 7.34
Diagnosis is made by analysis of the ascitic fluid
Most commonly caused by E. coli, Streptococcus spp
Treatment is immediate IV antibiotics with third-generation cephalosporin (cefotaxime) or fluoroquinolone as 2nd line.
Consider giving albumin
Crohns disease
Patient will be complaining of chronic nonbloody diarrhea, crampy abdominal pain, and weight loss
PE will show aphthous ulcers, anal fissures, perirectal abscesses, anorectal fistulas
Labs will show ASCA positive, p-ANCA negative
Diagnosis is made by colonoscopy
Colonoscopy will show skip lesions, cobblestone mucosa, transmural inflammation
Txt: metronidazole
Surgery will not be curative
Comments: Can occur anywhere on GI tract from mouth to anus
Esophageal varices
Patient with a history of chronic liver disease, alcoholism
Diagnosis is made by upper endoscopy
Upper endoscopy will show dilated submucosal gastric veins
Most commonly caused by portal hypertension
Treatment is hemodynamic support, prophylactic nonselective beta-blocker (labetalol, nadolol), octreotide, prophylactic ceftriaxone, variceal band ligation, Sengstaken-Blakemore tube
Comments: Associated with massive UGIB
Hepatic encephalopathy
Patient with a history of infection, dehydration, medications, GI bleed, hypoxia, hypoglycemia
Complaining of confusion
PE will show scleral icterus and asterixis
Most commonly caused by toxin accumulation due to liver dysfunction
Worsens with constipation, renal failure, gastrointestinal bleeding, infection, medications with central nervous system activity, and diuretic therapy leading to hypokalemia and alkalosis
Treatment is lactulose
Comments: CSF glutamine correlates with severity
Pancreatic cancer
Patient with a history of smoking
Complaining of painless jaundice, depression, and weight loss
PE will show palpable nontender gallbladder (Courvoisier sign), tender migratory thrombophlebitis (Trousseaus syndrome)
Labs will show CA 19-9 serum marker
Most common type is adenocarcinoma
Comments: Other PE signs: Palpable left supraclavicular lymph node (Virchows node), palpable nodule bulging into the umbilicus (Sister Mary Joseph sign)
Toxic megacolon
Patient with a history of ulcerative colitis or infectious colitis
PE will show systemic toxicity (shock)
Dx: Abdominal X-ray will show the colon dilated > 6 cm
Most commonly caused by IBD
Treatment is IVF, ABX, IV corticosteroids (only if IBD related), emergent surgical consultation
colonic dilatation in a patient with a known inflammatory condition of the colon who appears systemically toxic.
Mallory-Weiss tear
Patient will have a history of drinking alcohol and forceful vomiting
Complaining of hematemesis, abdominal pain
Diagnosis is made by upper endoscopy
Caused by an incomplete tear in the distal esophagus mucosa and proximal stomach
Txt: supportive, non-active bleed: acid suppression, active bleed: endoscopic therapy and epinephrine may be injected to control bleed
Samonellosis
Patient with a history of eating poultry, meat, or eggs or fresh produce
Complaining of fever, diarrhea (possibly bloody), and abdominal cramps
Labs will show fecal WBCs
Txt: supportive, ciprofloxacin if severe
Comments: common cause of osteomyelitis in children with sickle cell disease; associated with reactive arthritis
Perirectal abscess
Risk factors: Crohn’s disease, diabetes mellitus and chronic corticosteroid use.
Dull or throbbing anal pain, usually acute in onset, worsens prior to, and lessens after, a bowel movement.
May not be visible, need rectal exam
Complication: fistula
Txt: abx and surgical drainage
Shigellosis
Patient will be complaining of fever, bloody/mucoid diarrhea (dysentery) and seizures (more common in children)
extraintestinal manifestations such as reactive arthritis, seizures, and hallucinations.
Labs will show fecal RBCs and WBCs
Txt: oral rehydration. Avoid anti-diarrheal meds
Abx only if immunocompromised, bacteremic or hospitalized: azithromycin or ciprofloxacin
Pyloric stenosis
Patient will be 2–8 weeks of age
Complaining of nonbilious projectile vomiting after feeding and early satiety
PE will show RUQ olive-like mass (hypertrophied pylorus)
Labs will show hypochloremic hypokalemic metabolic alkalosis
Diagnosis is made by ultrasound or UGI series (string sign)
Treatment is surgical
Excessive loss of gastric hydrochloric acid not only leads to alkalosis, but also hypochloremia, not hyperchloremia. Excessive loss of gastric fluid causes a hypovolemic state, which triggers the adrenal glands to oversecrete aldosterone. Hyperaldosteronism triggers the kidneys to become “volume sparing”, thereby actively reabsorbing sodium and excreting potassium, hence the hypernatremia
G6PD deficiency
Patient with a history of taking antimalarials, sulfonamides, nitrofurantoin, fluoroquinolones, phenazopyridine (gu analgesic) fava beans.
Infection is also a cause for the hemolysis
Labs will show heinz bodies, presence of bite cells on the smear, negative Coombs test (nonimmune hemolytic anemia)
Consider testing patients prior to starting potential agents in at risk patients
Comments: X-linked recessive
Wernicke syndrome
Encephalopathy, ataxia, oculomotor dysfunction
Txt: thiamine, then glucose
Complication: korsakoff - irreversible amnesia
Ogilvie syndrome
Massive dilation of colon without mechanical obstruction
autonomic dysfunction
Risk factors: elderly, bedbound, comorbidities
Rx: colonic decompression, rectal tube and sigmoidoscopy, neostigmine (acetylcholinesterase inhibitor)
Potential s/e of neostigmine: asystole and bradycardia - cardiac monitor and atropine should be at the bedside
Hepatitis C
Often asymptomatic Transmission via blood Screen all adults aged 18 to 79 years (updated 2020) Screen with anti-HCV antibody testing Confirm with PCR for HCV RNA Antiviral regimen based on: HCV genotype Presence of cirrhosis History of prior antiviral tx Vaccinate against hepatitis A and B
Virchow’s node
palpable left supraclavicular lymph node common in abdominal (eg., gastric, pancreatic) cancers
Homan’s sign
popliteal pain after abrupt ankle dorsiflexion. It is associated with lower extremity deep vein thrombosis, which may occur in any cancer-related hypercoagulable state.
Ischemic colitis
Patient with a history of atherosclerotic disease
Complaining of sudden onset of mild to severe cramping, often on the left side of the abdomen, along with rectal bleeding or bloody diarrhea within 24 hours of symptom onset.
CT imaging will show thickening of bowel wall or free peritoneal fluid
Most commonly caused by inadequate blood flow through the mesenteric vessels
Colonoscopy is diagnostic
Treatment: Most cases resolve with supportive care; may require antithrombotic therapy or surgical exploration
Alcoholic hepatitis
S/s: nausea, vomiting, anorexia, and abdominal pain.
Tachycardic with a low-grade fever.
Scleral icterus or jaundice, and RUQ tenderness due to inflammation of the liver. There may be characteristic signs of cirrhosis: spider angiomata, palmar erythema, and gynecomastia.
In alcoholic hepatitis, there is a moderate elevation of AST and ALT, usually only 2–10 times normal. Values in excess of 10 times normal are unusual, even in severe cases, unlike in viral or toxin-induced hepatitis that can have a rise into the thousands. Also, the AST is commonly more elevated than the ALT (AST»ALT).
Bilirubin can also be elevated, leading to icterus and jaundice.
A leukocytosis is often present along with elevation of the PT and INR. The ultrasound is consistent with hepatic steatosis, an indication of chronic ethanol abuse.
Conjugated vs unconjugated bilirubin
Unconjugated bilirubin is unable to be excreted in the bile and rises in cases of hemolysis and liver disease.
Conjugated bilirubin is excreted into the bile and rises in cases of biliary obstruction.
Boerhaave syndrome
Spontaneous esophageal rupture
Patient will be complaining of severe chest pain
PE will show Hamman crunch (mediastinal crackling with each heartbeat)
Chest X-ray will show pneumomediastinum
Diagnosis is made by esophogram with water-soluble oral contrast
Most commonly caused by a full-thickness esophageal rupture due to iatrogenic > forceful vomiting
Most common location is left posterolateral distal esophagus
Treatment is emergent surgical consult and broad-spectrum antibiotics
Inguinal hernias
Bimodal: < 1 and > 40
Direct: elderly men; goes into a weakened part of the abdominal wall
Protrudes directly through Hesselbach’s triangle and medial to the inferior epigastric artery (IEA)
Bulge decreases upon reclining
Indirect: goes into the scrotum
Most common type
Protrudes through internal ring, lateral to IEA
Medial to IEA: Direct; Lateral to IEA: Indirect (MDs don’t LIe)
Strangulation risk: indirect > direct
Nonreducible hernia: emergent surgery consultation
Achalasia
Patient will be complaining of dysphagia to solids and liquids
PE will show absent peristalsis in the lower esophagus
Barium swallow shows “bird beak” appearance
Diagnosis is made by esophageal manometry - increased LES pressure
Esophageal stricture
Most common cause: GERD
Progressive dysphagia
Barium swallow (initial), endoscopy
Surgery, high-dose PPIs
Blood and WBCs in stool
- Salmonella
- Campylobacter (assoc with guillain-barre)
- Ecoli O157.H7 (HUS) - abx controversial
- Shigella (2nd cause of HUS) - Bactrim first line, fluoroquinolones
Best initial test: stool lactofertin or blood/fecal leukocytes
Most accurate: stool cx
Txt if severe: severe: fluids + ciprofloxacin (hypotension, tachycardic, Fever, abd pain, bloody diarrhea, metabolic acidosis)
No blood or WBCs in stool
- Viral
- Giardia: unfiltered fresh water, camping, hiking
Txt with metronidazole, tinidazole - Cryptosporidiosis: AIDS <100 CD4 cells. Do modified acid fast stain
Txt with nitazoxanide - Bacillus cereus: vomiting
- Staphylococcus: vomiting
Txt:
Mild: oral fluids
severe: fluids + ciprofloxacin (hypotension, tachycardic, Fever, abd pain, bloody diarrhea, metabolic acidosis)
Acute cholangitis
Patient will be complaining of right upper quadrant pain, jaundice, fever (Charcot triad)
Diagnosis is made by RUQ ultrasound, CT scan, or ERCP (gold standard)
Most commonly caused by choledocholithiasis leading to bacterial infection, E. coli
Treatment is antibiotics, definitive treatment is ERCP with antibiotics typically an adjunct
Comments: Charcot triad + hypotension and AMS = Reynolds pentad, acute obstruction
