GI Flashcards
The physiology of bile metabolism may be altered in three principal areas:
(1) overproduction of heme products (hemolysis)
(2) failure of the hepatocyte to take up, conjugate, and excrete bilirubin (hepatocellular dysfunction)
(3) obstruction of biliary excretion into the intestine.
Which is more dangerous, Conjugated or Unconjugated bilirubin?
Unconjugated bilirubin that is
not bound to albumin can cross the blood-brain barrier, causing
adverse neurologic effects ranging from subtle developmental
abnormalities to encephalopathy and death.
New onset painless jaundice is the classic presentation of
Neoplasm involving the head of the pancreas
Indirect > Direct bilirubin suggests what pathology(s)
Hematologic cause
Would expect normal transaminases, alk phos, PT/PTT
Direct > Indirect bilirubin suggests what pathology(s)
Hepatobiliary pathology
#Obstructive: biliary stones, benign/malignant stenosis Elevated alk phos
#Hepatocellular/Cholestatic: Transaminitis, elevated PT
Triad of Acute Hepatic Failure
Jaundice
Encephalopathy
Coagulopathy (INR >1.5)
Rapid development of ascites and hepatomegaly suggests what diagnosis
Portal Vein Thrombosis (Budd Chiari Syndrome)
Diagnosis of SBP via paracentesis
Presence of more than 250 polymorphonuclear cells
per cubic millimeter of ascitic fluid is diagnostic for SBP
(ie >250 neutrophil count)
What medication has been shown to INCREASE mortality in SBP
Beta blockers
Where is jaundice first apparent?
Jaundice is first apparent sublingually, in the conjunctiva and on the hard palate.
Treatment of SBP
Cefotaxime 2g
Idiopathic cause of jaundice in 3rd trimester of pregnancy
Intrahepatic cholestasis of pregnancy
Blood transfusion is immediately indicated in patients with GI bleed who have
hemoglobin level acutely less than 7 to 8 g/dL, are experiencing vigorous blood loss, or require further resuscitation beyond 2 L of crystalloid to maintain a systolic blood pressure in the range of 100 mm Hg
What clinical scoring systems can be used to aid disposition in upper GI bleed
Blatchford Score
Rockall Scoring system
empirical treatments for systemically
ill appearing adults with suspected traveler’s diarrhea
Ciprofloxacin 500 mg orally twice daily or levofloxacin (Levaquin) 500 mg once daily
C. difficile treatments
metronidazole 500 mg orally three
times daily for 10 to 14 days as initial treatment or vancomycin 125 mg four times daily orally for 10 to 14 days.
dysphagia differential
Dysphagia can be caused by:
# obstructive lesions (aortic aneurysm) # motility disorders (achalasia) # neuromuscular disorders that can be vascular (eg, cerebral vascular accident), immunologic (eg, multiple sclerosis [MS]), infectious (eg, botulism), or metabolic
Abx for esophageal perforation
broad-spectrum antibiotics (eg, vancomycin, 15 mg/
kg and piperacillin-tazobactam, 3.375 g)
First Line treatment for H. Pylori
PPI (eg, omeprazole, 20 mg bid), amoxicillin (1 g bid) and clarithromycin (500 mg bid) for 14 days.
Pathonomonic triad (Mackle’s triad) for upper esophageal perforation
emphysema, chest pain, and vomiting
GERD Tx
H2 blockers (mild-to-moderate GERD)
The only lifestyle recommendations that have evidence based support are weight loss and head of bed elevation
#PPI (A Cochrane systematic review has concluded that PPIs are more effective than H2 blockers in eliminating symptoms and healing mucosal damage)
Sucralfate is a mucosal protectant that binds to inflamed tissue to create a protective barrier. It blocks the diffusion
of gastric acid and pepsin across esophageal mucosa and can limit the erosive action of pepsin and bile. It has limited side effects and can be safely used in pregnant women.
Treatment regiments for pyogenic abscess
- Cefotaxime + metronidazole
- Ampicillin + gentamycin + metronidazole
- Ciprofloxacin or levofloxacin or moxifloxacin + metronidazole
- Piperacillin-tazobactam
- Impinem or meropenem, or doripenem or ertapenem
• Definitive treatment for abscesses larger than 3 cm includes image-guided percutaneous drainage.
How do you differentiate amebic from pyogenic liver abscesses
Amebic Abscess
• Although similar in many ways to pyogenic abscess, diagnosis is made via stool analysis or ELISA testing.
• Most patients will have elevation in alkaline phosphatase and aminotransferase levels.
• Ultrasound may reveal specific findings unique to an amebic abscess, including a peripherally located abscess with a well-circumscribed boarder and a homogeneous, hypoechoic center.
Treatment for amebic liver abscess
IV or oral metronidazole (750 mg tid for 7–10 days).
Abx for cholecystitis
IV piperacillin-tazobactam (3.375 g qid)
Combination therapy with a third-generation cephalosporin and metronidazole or monotherapy with a carbapenem or β-lactamase inhibitor is recommended
In actively bleeding cirrhotic patients with liver-associated coagulopathies, which is preferred - cryoprecipitate or FFP?
Cryoprecipitate, 1 unit/10 kg body weight
What medication classes should be avoided in Cirrhotic patients?
Angiotensin-converting enzyme inhibiting drugs and angiotensin receptor blocking drugs should be avoided in patients with cirrhosis. Both lower mean arterial blood pressure and may increase mortality.
Management of hepatorenal syndrome?
norepinephrine, 0.5–3 mg/h in combination with albumin 1 g/kg (maximum, 100 g).
What underlying conditions can exacerbate hepatic encephalopathy
GI bleeding, hypokalemia, infection and dehydration
What is the sensitivity and specificity of CT for cholecystitis
Sensitivity: 92%
Specificity: 99%
Abx for cholangitis
FIRST-LINE SINGLE-DRUG REGIMEN
Ampicillin-sulbactam 3 g IV qid
Piperacillin-tazobactam 3.375 g IV qid
FIRST-LINE MULTIDRUG REGIMEN
Ceftriaxone + Metronidazole 1 g IV every 24 h + 500 mg IV tid
Schatzki’s ring
Frequently found in patients with impacted food boluses.
Ring of muscular tissue in the esophagus that causes dysphagia.
Dx via upper endoscopy and frequently a/w hiatal hernia
Difference in Location of Mallory-Weiss tear vs Boerhaave’s syndrome
MW: gastro-esophageal junction
BS: unsupported left posterolateral wall of distal esophagus
** Iatrogenic esophageal rupture often occurs in proximal esophagus**
PUD: Gastric vs Duodenal
Which is associated with weight loss?
Gastric ulcer
-> pain right after eating, gets worse with food, therefore, a/w weight loss
*Duodenal: pain 2-3 hours after eating, gets better with food
PUD: Gastric vs Duodenal
Which is more likely to bleed
Duodenal ulcer
2x more likely to bleed
PUD: Gastric vs Duodenal
Which increases risk for cancer?
Gastric
Biopsy should be done during endoscopy to rule out malignancy
*Duodenal does not lead to cancer, biopsy is unnecessary
Treatment for NSAID-induced gastric ulcer
misoprostol
Osler-Weber-Rendu Syndrome
Autosomal Dominant
Epistaxis is most common presentation
A/W telangiectasis of the skin, mucous membranes, GI tract causing recurrent GI bleeding
Which Hepatitis progresses to chronic infection
Hepatitis C: 50% will develop chronic infection
Hepatitis B: small chance
Hepatitis serum marker:
Indicates acute infection
HbcAb IgM
Hepatitis serum marker:
Hallmark for diagnosis; appears 1-10 weeks after exposure and is positive even before liver enzymes start to increase
HBsAg
Hepatitis serum marker:
Indicates immunity; persists for life; signs of previous infection or vaccination
HBsAb
Most common isolated organism in SBP
E. Coli
What lab value can help identify etiology of pancreatitis
ALT
Low sensitivity but high specificity for biliary etiology
Ranson’s criteria: Prognostic indicator for inpatient mortality for acute pancreatitis.
Criteria at admission?
On admission:
Age > 55 WBC > 16 Glucose > 200 AST > 250 LDH > 350
Bowel sounds in Ileus vs SBO
Ileus: HYPOactive
SBO: HYPERactive
Treatment of Ogilvie Syndrome
Colonic decompression and Neostigmine
*Acute colon pseudo-obstruction secondary to autonomic dysfunction leading to massive dilation of colon (>10cm). No mechanical obstruction.
Treatment for Travelers diarrhea (ETEC)
Single dose of Cipro
Unless: children, pregnant, pt just returned from SE asia (where campylobacter is more common)
–> single dose of azithromycin
Differentiate Vibrio vulnificus and vibrio parahaemolyticus
both a/w raw oysters and seafood
vulnificus: characteristic skin findings and more aggressive
parahaemolyticus: no skin findings, self-limited
Test of choice for Giardia
Stool antigen
not stool for ova or parasites
Rectal prolapse in a child can be a sign of…
Cystic Fibrosis
When clinicians have a low pretest possibility for appendicitis, what lab values support the exclusion of appendicitis as a likely diagnosis
When clinicians have a low pretest possibility for appendicitis, the combination of a WBC count below 10,000/mm3 and CRP level below 8 mg/L support the exclusion of appendicitis as a likely diagnosis.
What is the most common cause of bacterial enteritis in developed countries.
Campylobacter
What is the most common cause of acute gastroenteritis in children and adults
The norovirus, previously referred to as the Norwalk-like virus, is the most common cause of acute gastroenteritis in children and adults and usually occurs in the winter months.
Risk factors for C. Diff
# recent antibiotic use (1–4 weeks) # recent hospitalization # living in a long-term care facility # use of antacids.
Diagnosis consideration?
Diarrhea lasting more than 2 weeks, with foul-smelling stools and symptoms of flatulence, abdominal bloating, cramping, and recent exposure to contaminated river water
Giardia
What is dysentery
refers to an inflammation of the intestine, particularly the colon, causing diarrheas associated with blood and mucus; it is generally associated with fever, abdominal pain, and rectal tenesmus (sense of incomplete
defecation).
Historical feature that distinguishes Crohn’s disease from IBD
Nocturnal diarrhea
