GI Flashcards
What is the differential for a pt with fever, ascites, anorexia, and cachexia w/ hx of alcohol and drug use all concerning for liver failure?
alcoholic cirrhosis
chronic or acute viral heptatis (most likely hep C)
Spont. bacterial peritonitis
peritoneal carcinomatosis secondary to ovarian cancer
What is the work up for concern for liver failure and ascites?
PT, PTT, INR
CBC, peripheral smear
BUN/Cr (look for hepatorenal syndrome)
AST, ALT, Alk phos, total bili, albumin, total protein
What are signs of chronic liver dz?
ascites
spider angiomata
asterixis
caput medusa
splenomegaly
palmar erythema
reversal of sleep-wake cycle with hepatic encephalopathy
What clotting factors are not made in the liver?
8 and von willebrand factor
What is the most common cause of cirrhosis in the US?
hep C
What are less common causes of cirrhosis?
more common: alcohol, hep C
less common: primary biliary cirrhosis
hemochromatosis
wilson dz
alpha 1-antitrypsin deficiency
drugs: isoniazid, methotrexate, acetaminophen
What are causes of ascites?
cirrhosis
malignancy (ovarian)
TB
right sided heart failure
vascular obstruction due to hepatic vein thrombosis (Budd-CHiari) or IVC thrombosis
How do you figure out the casue of ascites?
SAAG
serum - ascitic albumin
if >1.0 = portal HTN as cause (cirrhosis, CHF, hepatic/portal vein thrombosis syndromes)
If <1.1 = no portal htn (cancer, infection…etc)
What tests should we always get in ascites?
paracentesis with SAAG (tell you cause) and white cell count (for SBP)
How do you look for hepatoma (liver cancer)?
get an alpha fetoprotein
*most commonly complication of hep C
What are the lab tests you should get for a pt with ascites and liver dz?
hep B and C serologies
paracentesis (WBCs and albumin)
Iron studies
ceruloplasmin levels
alpha-1 antitrypsin level
antimitrochondrial antibodies
liver U/S
How do you manage cirrhosis?
salt restriction
diuretics (spironolactone and furosemide)
stop drinking, alcohol cessation programs
balanced diet w/ protein
if portal HTN - do upper endoscopgy to look for esophageal varices to know if need to put on a beta blocker
if hepatic encephalopathy - lactulose and rifaxamin
How does spironolactone work?
direct aldo antagonist, can lead to gynescomastia and hyperK
How does furosemide work?
loop diuretic, inhibits Na-K-2Cl symporter in thick ascending loop - leads to hypoK
How does lactulose work?
It is used to increase bowel movements - which can decr ammonia levels
How to monitor pts with chronic liver dz?
surveillance for varices every 2 years if initial endoscopy negative
if cirrhosis present - liver US every 6 months for liver cancer
How to treat varices in chronic liver dz pts and how to prevent them?
treat - band ligation
prevent - non-selective beta blocker (propranolol or nadolol)
What is the most concerning dx to be thinking about in a patient with a GI bleed and hx of chronic liver dz?
bleeding esophageal varices (highest mortality)
Ddx for vomiting blood?
bleeding esophageal varices
mallory weiss tear
erosive gastritis
peptic ulcer bleeding
What are the first steps in management for an unstable GI bleed?
stabilize the pt!
- 2 large bore PIVs and NS boluses until BP>90, HR<90, or UOP incr
- CBC (won’t see acute drops in Hgb, just baseline), electrolytes, PT/PTT (liver pts), type and cross
- transfuse blood as needed (symptoms - SOB, chest pain, or severe cont bleed)
*give fresh frozen plasma if coagulopathy present
- upper endoscopy and therapeutic intervention (GI consult)
- NG tube can help tell if still active bleeding, then take out
How can an upper GI bleed present?
hematemesis, melena, or bright blood per rectum (10%), dizziness
What must be done before sending pts home who had an upper GI bleed?
upper endoscopy!
What is management for upper GI bleed due to varices after they are stabilized?
- admit and monitor for recurrent bleeding
- IV somatostatin/octreotide
- propranolol once BP stable
- monitor for delirium tremens (hallucinations)
- FFP if incr PT and cont bleeding
- Norfloxacin as prophylaxis against SBP (for ascites)
How to dx and tx upper GI bleeding?
endoscopy w/ band ligation
What counseling must always be given in pts admitted due to complications of alcohol comsumption?
counseling to stop drinking alcohol and suggest addication treatment
Which kind of ulcers are worse or better with eating?
duodenal are better with eating
Gastric ulcers are worse with eating
How to work up peptic ulcers?
CBC
LFTs (rule out cholelithiasis)
US gallbladder (same as above)
amylase/lipase (eval for pancreatitis)
What are complications of gastric/duodenal ulcers?
bleeding, perforation, gastric outlet obstruction
How do you tx peptic ulcer disease?
PPIs (omeprazole, lanzoprazole) for 2 months
Can also use H2 blockers or sucralfate)
*if symptoms continue or pt has red flags (age >50), consider upper endoscopy
What is Zollinger-Ellison syndrome and how does it present?
recurrent peptic ulcers + diarrhea
get a random gastrin level
it is caused by a gastrinoma
Do you test for H pylori with peptic ulcer dz?
yes with breath testing or stool antigen testing
How do you treat H pylori?
only if pt is symptomatic (has a ulcer or s/sx of ulcer)
PPIs (omeprazole, lanzoprazole)
2 wks of metronidazole or amoxicillin and clarythromycin depending on resistance (usually at least 2 abx)
What is the most common cause of peptic ulcer dz?
H pylori
duodenal (90%)
gastric (70%)
What is diseases is H pylori associated with?
peptic ulcers
gastric cancer
lymphoma of gastric tract
NOT GERD
When is surgery indicated for peptic ulcer dz?
severe bleeding not responsive to local therapy
perforation
obstruction
How to counsel pts with peptic ulcer dz?
avoid excess NSAIDs
smoking and alcohol prevent healing of ulcers (do not cause them)
spicy food is fine!
What can precipitate hepatic encephalopathy?
GI bleeding, medications (diuretics, benzos), infections
What lab helps confirm the dx of hepatic encephalopathy?
elevated ammonia levels
(if ammonia is low doesn’t really help)
*though it is a clinical dx
How to treat hepatic encephalopathy?
Correct precipitating causes (GI bleed, tx infection)
protect airway if very somlenent
minimize dietary protein
eliminate sedatives or tranquilizers
lactulose to increase ammonia excretion
Rifaxamin, neomycin, ampicillin, rifampin to reduce nitrogenous production
What is the ddx for chronic diarrhea?
Inflammatory bowel dz
celiac disease
lactose intolerance
whipple dz (malabsorption, arthritis, and neuro s/sx)
irritable bowel syndrome
What is the rash that can present with celiac dz?
dermatitis herpitiformis (diffuse pruritic, papulovesicular rash over knees, elbows, buttocks, and back)
How to w/u chronic diarrhea?
CBC, serum iron, Ca, B12, folate
stool culture and ova/parasites
smear for fecal leukocytes
stool for fat (sudan stain)
How do you dx celiac dz?
IgA anti-tissue transglutaminase, antigliadin and antiendomysial antibodies
IgA level (control)
small bowel biopsy *GOLD STANDARD
What diseases will cause positive fecal leukocytes?
infections (shigella, campylobacter, E coli, C diff, salmonella)
IBD
How do you treat celiac dz?
remove gluten from diet
redo small bowel biopsy in a few months to see recovery
give folate and iron supplementation as needed
What is the most specific and sensitive antibody for celiac dz?
anti-tissue transglutaminase antibody (IgA)
how do you treat dermatitis herpetiformis from celiac?
dapsone
What vitamins/elements may be low in celiac dz due to malabsorption in the small intestine?
iron, B12, zinc, mag, calcium
What are possible complications of celiac dz?
T-cell lymphoma in 10-15% of cases
adenocarcinoma of intestine
What is the ddx for elderly person with fever and LLQ pain?
diverticulitis
pyelonephritis
Appendicitis
colon cancer
How to w/u pt with concern for diverticulitis?
1st step: CBC, BMP, CXR, KUB, UA
clinical
*could confirm with noncontrast CT of abd and pelvis
(colonoscopy and barium emena are contraindicated!)
How do you tx diverticulitis inpt?
- NPO 48-72 hours
- IV hydration
- IV antibiotic (e coli and klebsiella)
*Ciprofloxacin and metronidazole inpt
switch to oral abx for total of 14 days
- surgical exploration if pt worsens
What are complications of diverticulitis?
abscess formation
colovesical fistula (recurrent UTI or pneumaturia
perforation
inflammatory phlegmonous mass
How to tx diverticulitis outpt?
for mild cases with relatively young pts
Amox-clav or ciprofloxacin and metronidazole for 10-14 days
When to do a colonoscopy or barium enema in diverticulitis?
after the acute phase of the disease - CONTRAINDICATED in acute phase due to risk for perforation!!
2-3 weeks later to check for cancer
What is long term f/u and prevention for diverticulitis?
eat fiber!
good hydration
Ddx of a pt with bloody diarrhea?
infectious enterocolitis (campylobacter, E coli, shigella, salmonella)
IBD
Hemorrhoidal bleeding
How to w/u bloody diarrhea?
stool culture, ova/parasites
fecal leukocytes
KUB
CBC, ESR/CRP
How to dx inflammatory bowel disease?
colonoscopy with biopsies
What are the different findings of UC vs Crohns?
UC - always involves rectum (starts at rectum and goes up), mucosal, no perianal dz
Crohns - can be patchy from mouth to anus, full thickness (transural granulomas), more prone to fistulas, perianal dz
How to treat ulcerative colitis?
Mesalamine and Corticosteroids for flares
Long term: 6-MP (mercaptopurine) or azathioprine (immunomodulators)
Refractory UC: may consider total colectomy
How to tx Crohn’s dz?
Mesalamine and Corticosteroids for flares
Long term: 6-MP (mercaptopurine) or azathioprine (immunomodulators)
Severe cases of Crohn’s (with fistulas): infliximab lifelong (TNF modifier)
What are pts with severe ulcerative colitis at risk for?
colon cancer after have had the disease >10 yrs
What must you check before putting a pt with severe Crohn’s on infliximab?
PPD and CXR for TB!!!!
What are extra-intestinal manifestations?
arthritis
erythema nodosa
episcleritis, iritis
sclerosing cholagitis (UC at risk for cholanigal carcinoma)
*autoimmune obstructive dz of bile ducts
What follow up management and counseling shoudl you give IBD pts?
NSAIDs can cause flares
*cigarette smoking can be protective in US
screen for TB (PPD, CXR) if starting infliximab
incr risk colorectal cancer
annual colonoscopy after have had dz for 8 yrs
What are common precipitants for acute pancreatitis?
- alcoholic binge
- gall stone pancreatitis
trauma, steroids, autoimmune, scorpion, hypertryglceridemia!!, ERCP, drugs
How do you w/u acute pancreatitis?
stabilze the pt (IV fluids)
CBC
BMP
(glucose may be elevated in severe dz, beta cells affected)
(also look out for low Ca - multisystem failure)
amylase, lipase(*this one is more important)
KUB (look for free air - perforated ulcer)
What imaging would you do for pancreatitis?
KUB (part of initial w/u)
CT of abdomen
*if worried about right dx or complications (necrosis, bleeding)
How do you tx acute pancreatitis?
- admit
- NPO, feed gradually
- morphine
- IV hydration
- observe for delirium tremens (alcohol cessation)
*CT - if necrosis, imipenem. if absecess, surgical debridement
*Gallbladder US - exclude gallstone pancreatitis, if positive get surgeons involed for removal at a later date
Does everyone with pancreatitis need at CT?
no!
only if worried about progression or complications if pt is worsening
What is the cause of pancreatitis if AST/ALT, alk phos are elevated?
gall stone pancreatitis - obstruction of the bile duct
What are complications (and their timing) of pancreatitis?
pseudocyst formation (1-4 wks)
pancreatic necrosis (2 wks)
abscess formation (4-6 wks)
ARDS
What follow up is needed for a pt with pancreatitis due to gall stones?
cholecystectomy sometime after acute episode
What to think about with jaundice, fever, and RUQ tenderness?
ascending cholangitis!!!!!
choledocholithiasis
cholecystitis
primary sclerosing cholangitis
How to w/u ascending cholangitis?
- 2 large-bore IV lines and bolus (NS) until bp>90, hr<90, or incr UOP
*pressors if needed
- CBC, CMP, PT/PTT, LFTs
- consider intubation! if obtunded/has unprotected airway
- foley cath to monitor UOP
How does ascending cholangitis happen?
gallstone obstruction and then infection
*other things that can cause obstruction include occluded stents, malignancy
How to tx ascending cholangitis?
tx (gram neg rods - e coli, klebsiella) with pip/tazo IV
NPO, IV hydration
abdominal US to confirm gall stone/dilation
once stable: ERCP to dx and tx
GI consult
What is the lieklihood of getting pancreatitis after ERCP?
10%
What is the follow up management after ascending cholangitis?
if due to gall stone - will need a cholecystectomy at some point after the acute episode (2-3 wks)
