GI- adults Flashcards
1
Q
Bilirubin- pathophysiology
A
Inc unconjugated bile:
- Inc production - hemolytic anemia
- Dec uptake by liver - CH, Gilbert syndrome
- Dec conjugation - Crigler-Najjar syndrome, Gilbert syndrome
Inc conjugated bile:
- Liver doesn’t secrete - damage to liver, Dubin-Johnson syndrome, Rotor syndrome
- Biliary tree is obstructed - intrahepatic (cirrhosis, Ca, granuloma), extrahepatic (stones, stricture, Ca)
2
Q
Bilirubin- cause
A
Clay-colored stools
Dark tea-colored urine
Pruritis
3
Q
Bilirubin- S/S & PE
A
Jaundice - inc of unconjugated or conjugated bilirubin
4
Q
Cholelithiasis- pathophysiology
A
Cholesterol - 90% In Gallbladder Pigment stones: - Black - formed in sterile bile - heme - Brown - bacterial metabolism in biliary infection
5
Q
Cholelithiasis- cause
A
Cholesterol stones - 4Fs
- Fat
- Forty
- Female
- Fertile
6
Q
Cholelithiasis- epidemiology
A
> 40
F>M
Western Countries
7
Q
Cholelithiasis- S/S & PE
A
Asymptomatic
- 80% stay this way
Symptomatic - intermittent blockage of cystic duct by a stone
Biliary Colic - intense, dull discomfort, RUQ radiates to back -> R shoulder blade
- N/V and diaphoresis
- Last 30min ->60min then subsides
- triggered - eating fatty meal
No positive PE signs
Incidental findings
8
Q
Cholelithiasis- diagnosis
A
U/S - echogenic foci that cast an acoustic shadow
- gravitationally dependent - will move w/ movement
- may look like sludge, but is not
9
Q
Cholelithiasis- labs & imaging
A
Labs - Nl, even during biliary colic
10
Q
Cholelithiasis- treatment
A
Asymptomatic - do NOT perform cholecystectomy
Typical biliary symptoms + gallstones
- acute pain - NSAIDs or opioids
- Cholecystectomy or medical dissolution of stones
Atypical symptoms + gallstones
- Cholecystectomy - lower relief rates then w/ typical symptoms
Typical symptoms, but no stones visualized
- May have function gallbladder disorder
11
Q
Cholelithiasis- prognosis
A
Symptom relief post-surgery
Complications - bile leak, bleeding, abscess formation, biliary injury, bowel injury
> 12% develop diarrhea - can’t digest food as well
12
Q
Acute Cholecystitis- pathophysiology
A
Acute inflammation of the gallbladder
Calculous - gallstones
- Cystic duct become obstructed by a stone -> leads to inflammation
- Bacterial inflammation? - eColi, klebsiella, streptococcus, clostridium
Acalculous - no gallstones
- unknown
- some may have biliary sludge in cystic duct, vasculitis, obstructing adenocarcinoma of the gb, unusual infection, or systemic disease - TB, sarcoidosis, TB, syphilis
- Underlying SEVERE illness - burn, postpartum, postop, TPN
13
Q
Acute Cholecystitis- epidemiology
A
Calculous:
- F>M
- 40-60y
Acalculous
- critically ill, bedridden, on TPN
- 5-10% w/ cholecystitis
- M>F
14
Q
Acute Cholecystitis- S/S & PE
A
RUQ pain, Fever, Leukocytosis
Diarrhea
N/V
Hx of fatty food
Lasts - several hours >4-6
Hx of previous spontaneous resolving attacks
Ill appearing
Fever
Tachy
Voluntary/involuntary guarding on abdominal exam
Rebound tenderness in RUQ
Tender to Palpation RUQ
Pos Murphys Sign - when pressed -> inspiratory arrest and inc discomfort
Able to palpate an enlarged, tender gallbladder?
15
Q
Acute Cholecystitis- diagnosis
A
U/S:
- cholelithiasis - supports, but doesn’t diagnosis
- Gallbladder wall thickened or edema
- sonographic Murphy’s sign
- Pericholecystic fluid & dilation of bile duct
HIDA scan - done if still not confirmed diag
- Technetium labeled HIDA injected IV -> taken by hepatocytes -> excreted into bile
- Neg = can visualize gallbladder
- Pos = can’t visualize gallbladder
16
Q
Acute Cholecystitis- labs & imaging
A
Leukocytosis - Left shift (Inc bands)
LFTs - inc
17
Q
Acute Cholecystitis- treatment
A
ADMIT!
Pain - NSAIDs or opioids
Abx - given for acute until resolution or chole
- Comm acquired acute - Cefazolin, cefuroxime, or ceftriaxone
Cholecystectomy or cholecystostomy
- Emergent for: progressive s/s - fever, hemodynamic instable, intractable pain; suspicion or gallbladder gangrene or perforation
- Low risk: chole during initial hosp - laparoscopic
- Risk>benefits, but not emergent: gallbladder drainage w/ percutaneous cholecystostomy; once acute episode resolved -> assess for risk, maybe schedule surgery
18
Q
Acute Cholecystitis- prognosis
A
If not treated:
- can get better in 7-10 days
- Gangrenous cholecystitis
- Perforation - abscess or peritonitis
- Cholecystoenteric fistula
- Gallstone ileus
- Emphysematous cholecystitis
19
Q
Chronic Cholecystitis- pathophysiology
A
Chronic inflammation of gallbladder wall
With gallstones
20
Q
Chronic Cholecystitis- cause
A
Episodes of acute/subacute cholecystitis or gallstones -> persistent irritation to gallbladder wall -> fibrosis & thickening of gallbladder
21
Q
Chronic Cholecystitis- S/S & PE
A
Multi episodes of biliary colic
22
Q
Chronic Cholecystitis- labs & imaging
A
U/S - cholelithiasis, wall thickening from scarring
23
Q
Chronic Cholecystitis- treatment
A
Cholecystectomy
24
Q
Porcelain Gallbladder- pathophysiology
A
Calcification of gallbladder wall
25
Porcelain Gallbladder- cause
Chronic cholecystitis?
26
Porcelain Gallbladder- S/S & PE
Asymptomatic
27
Porcelain Gallbladder- diagnosis
Incidentally - Xray
| - US or CT to confirm
28
Porcelain Gallbladder- treatment
Inc RISK FOR CARCINOMA
Resection
29
Choledocholithiasis- pathophysiology
Stones within the common bile duct
30
Choledocholithiasis- S/S & PE
```
RUQ /epigastric pain
- prolonged then typical biliary colic
Nausea
Vomiting
Jaundice?
```
31
Choledocholithiasis- diagnosis
U/S - 1st
32
Choledocholithiasis- labs & imaging
AST/ALT - inc early
| Bili, ALP, GGT - inc later
33
Choledocholithiasis- treatment
If high risk for CBD stone -> ERCP w/ stone removal + cholecystectomy
34
Acute Cholangitis (Ascending Cholangitis)- pathophysiology
Statis and infection in biliatry tract
Biliary obstruction + bacterial infection
Obstruction:
- calculi, stenosis, malignancy
- > inc intrabiliary pressure -> permeability of bile ductulus -> easier for bacteria to transfer from portal circulation to biliary tract
-> easier for bacteria to g from bile to circulation -> septicemia
Bacteria - Ecoli, Klebsilella, Enterobacter
35
Acute Cholangitis (Ascending Cholangitis)- S/S & PE
Charcot triad - Fever, abdominal pain (RUQ), jaundice
Reynolds Pentad - Confusion, hypotension, fever, abdominal pain, jaundice
- suppurative cholangitis
```
Fever & abdominal pain - most common
- RUQ, diffuse
Jaundice - less common
Older pts and immunosuppressed - atypical presentation
- HTN only?
```
36
Acute Cholangitis (Ascending Cholangitis)- diagnosis
Suspect: 1 from each
- fever, shaking/chills, lab evidence of inflammatory response (WBC or inc CRP)
- Jaundice, abnormal LFTs
Definite: above and also has
- Biliary dilation on imaging
- evidence of an etiology on imaging - stricture, stone, stent
37
Acute Cholangitis (Ascending Cholangitis)- labs & imaging
Leukocytosis - neutrophil predominance
LFTs - Cholestatic patter -> Inc ALP, GGT and Bili
Blood cultures - pos?
- all should have done
- if ERCP - culture bile or stent
38
Acute Cholangitis (Ascending Cholangitis)- treatment
Charcots Triad + abn LFTs:
- ERCP - diagnose and drain
NO Charcots Triad:
- Transabdominal U/S - look for CBD dilation or stone
- Sene -> ERCP w/in 24 hrs for drainage/stone removal
- nl -> MRCP - only use if not 100% sure
```
Admit to hosp
Watch for sepsis
Abx
- Ampicillin-sulbactam - Unasyn
- Piperacillin-tazobactam - Zosyn
- Ticarcillin-clavulanate
- Ceftiazone + Metronidzaole
- modify w/ culture results
- 7-10 days
Biliary drainage - ASAP
- ERCP - TOC
- Percutaneous transhepatic cholangiography or open surgical decompression
```
39
Acute Cholangitis (Ascending Cholangitis)- prognosis
11-20% mortality
At risk for recurrence - Cholecystectomy recom
Benign stenosis - surgery or endoscopic therapy
Malignant stenosis - recurrent obstruction common - stent?
40
Mirizzi Syndrome- pathophysiology
Hepatic duct obstruction from extrinsic compression
| - from impacted stone in cystic duct
41
Mirizzi Syndrome- cause
Alcohol abuse
Chronic viral Hep
Hemochromatosis
Nonalcoholic fatty liver disease
```
Autoimmune hep
Prim and sec biliary cirrhosis
Prim sclerosing cholangitis
Meds
Polycystic liver dis
RS heart failure
Wilson dis
Celiac dis
Alpha-1 antitrypsin def
```
42
Mirizzi Syndrome- S/S & PE
Jaundice
Fever
RUQ pain
43
Mirizzi Syndrome- diagnosis
U/S - 1st
| ERCP - 2nd
44
Mirizzi Syndrome- labs & imaging
ALP - inc
| Bili -inc
45
Mirizzi Syndrome- treatment
Surgery - cholecystectomy
| - poor candidate - lithotripsy
46
Mirizzi Syndrome- prognosis
High frequency of bladder Ca
47
Cirrhosis- pathophysiology
Progressive hepatic fibrosis
- fibrosis & regenerative nodes in live
Fibrosis -> Architectual distortion -> disruptt nl portal blood flow -> inc BP and impairs liver function
48
Cirrhosis- cause
```
Most Common:
Alcohol abuse
Chronic viral Hep
Hemochromatosis
Nonalcoholic fatty liver disease
```
```
Autoimmune hep
Prim and sec biliary cirrhosis
Prim sclerosing cholangitis
Meds
Polycystic liver dis
RS heart failure
Wilson dis
Celiac dis
```
49
Cirrhosis- S/S & PE
Nonspecific symptoms - fatigue, anorexia, weakness, weight loss/wasting
Specific hepatic dysfunction:
Skin
- Jaundice - yellow of skin, eyes, membranes, >2-3 mg/dl
- Spinder angioma - vascular lesions; trunk, face, upper limbs
- Palmar erythema - palm w/ central pallor
Chest/Feminization
- Gynecomastia - 2/3 of pt
- Men - loss of chest/axillary hair, inversion of normal male public hair pattern; testicular atrophy
Abdominal findings
- Ascites - distended, fluid wave, flank dull to percussion
- Liver palpation - enlarged, nl, or small; can feel - firm and nodular
- Splenomegaly
- Capute medusa
- Cruveilhier-Baumgarten murmur - venous hum heard w/ portal HTN, over epigastrium
- Umbilical hernia
Neurologic
- cognitive deficits & impaired neuromuscular fnt
- Disturbances in sleep pattern often initial changes, mood changes, inappropriate behavior, disorientation, somnolence, confusion, unconsciousness, bradykinesia
- Asterixis - flapping of outstretched, dorsiflexed hand
- Hyperactive or hypoactive, slurred speech, nystagmus, ataxia, focal neuro deficit, coma
Hepatic Encephalopathy
- Ammonia neruotoxin - don't need to be elevated
- Not specific - DO NOT use to screen
Extremity Changes
- Muehrcke nails - paired whitte horizontal bands separated by normal color
- Terry nails - proximal 2/3 of nail plate white, distal 1/3 is red, clubbing, Dupuytren's contracture
50
Cirrhosis- diagnosis
Live biopsy - gold
- not needed dif clinical, lab and radiologic data strongly support presence
U/S - liver may be small & nodular, inc echogenicity w/ irregular appearing areas
Fibroscan - noninvasive test of hepatic fibrosis
- staging of fibrosis -> helps determine treatment
Child-Pugh score - severity of liver disease
5-6 = A - well compensated -> 100-85% survival
7-9 = B - signif functional compromise -> 80-60% survival
10-15 = C = decompensated -> 45-35% survival
MELD score - used to prioritize liver transplant
- >10 - refer
- >15 - candidate for transplant
- Predicts outcomes
- Bili, Creatinine, INR, Na
- The higher the score - the worse the outcome
51
Cirrhosis- labs & imaging
```
AST/ALT - inc
ALP - inc
GGT - much higher
Bili - inc w/ progression
Albumin - dec w/ progression
PT - inc w/ progression
Hyponatremia
Serum Cr - inc
Cytopenia - thrombocytopenia, leukopenia, anemai
```
52
Cirrhosis- treatment
NO Alcohol!
Vaccinate - hep
Med adjust for hepatic impairment
Treat chronic hep
Compensated - >12y survival
Decompensated
- <6m w/ a Child-Pugh score >12 or MELD >21
- <6m - hosp w/ acute liver illness
- lower mean arterial pressure - worse the survival
```
Transplant:
Indications
- Acute liver failure - highest priority
- Cirrhosis w/ complication
- neoplasm
- liver based metabolic conditions - wilson dis, CF, hemochromatosis
Contraindications
- uncorrectable cardiopulm dis
- AIDs
- Ca outside of liver
- uncontrolled sepsis
- persistent nonadherence w/ medical care
- lack of adequate social support
Alcoholic liver dis - min of 6m none!
```
53
Cirrhosis- complications
Complications:
Variceal hemorrhage
- varices from portal HTN
- high mortality rates from bleeding episodes
- Asymptomatic -> hematemesis, melena
- everyone w/ cirrhosis needs to be screened - EGD
- if found - variceal band ligation
- Prevent - BB - low portal pressure and Dec risk of bleeding
Ascites
- Most common
- accumulation of fluid in peritoneal cavity
- Treated - diuretics, Na restriction - alcohol abstinence
- Diuretic therapy - spironolactone + furosemide 100:40 mg/day
- Paracentesis - tense ascites, need to rapidly decompress abdomen
-> remove 4-5L - anything more and albumin needs to be given
- TIPS - transjugular intrahepatic portosysttemic shunts - w/ refractory ascites
Spontaneous Bacterial Peritonitis
- infection of ascetic fluid
- Fever, abdominal pain, abdominal tenderness, AMS
- Diagnosis - fluid cultures or inc polymorphonuclear leukocyte count (>250) on eval of ascetic fluid
- High morality - start empiric abx ASAP - cefotaxime 2g IV Q8h
- if had it before - need to take daily abx forever - Norfloxacin or Bactrim
Hepatic Hydrothorax
- pleural effusion - w/ no other cause
- R sided - movement of ascites into pleural space from defects in diaphragm
- Treat - diuretics and Na restriction, thoracentesis if needed
Hepatopulmonary syndrome
- abnormal arterial O2 - intrapulmonary vascular dilatations
- Dyspnea, platypnea (better when laying down), impaired O2
- imaging - nonspecific
- PFTs - nl
- progressive
- therapy - liver transplant, O2 therapy - no meds work
Hepatorenal syndrome
- Renal failure
- Renal perfusion dec by hepatic dysfunction
- Diag - exclusion of other renal issues
Hepatic Encephalopathy
- Lactulose - dec ammonia from GI tract, titrate until having 2-3 stools a day, enema or PO
- nonabsorbable abx - rifaximin - added to lactulose or cant tolerate lactulose
- if combined - may have mortality benefit
- recurrent - need to be on forever
Hepatocellular carcinoma
- inc risk of developing
- think if - decomp in a previously stable pt
- asymptomatic - upper abdominal pain, weight loss, early satiety, palpable abdominal mass
- labs - nonspecific, maybe inc AFP
- only effective screening - U/S x 6m
- Treat - surgery, liver transplant
Portopulmonary HTN
- pulmonary htn in pts w/ portal htn
- Fatigue, dyspnea, peripheral edema, chest pain, syncope
- Diagnosis - echo - confirmed w/ R heart cath
- very hard to treat
- high mortality during liver transplant
54
Inflammatory Bowel Disease- cause
Crohn
| Ulcerative Colitis
55
Inflammatory Bowel Disease- epidemiology
15-40yo
Jewish decent
1st deg relative w/ IBD
Smoking - inc risk of Crohn's
- protective against UC
Western diet - inc risk
56
Ulcerative Colitis- pathophysiology
Idiopathic inflammatory condition
- involves mucosal surface of colon -> diffuse friable areas and erosions w/ bleeding
Starts distally -> progresses proximally
Continuous - no skip areas
57
Ulcerative Colitis- S/S & PE
Bloody diarrhea - BM frequent and small volume
Tenemesmus - straining, feeling like you have to poop all the time
Mainly distal - constipation + frequent blood and mucus discharge
Incontinence
Colicky abdominal pain
Onset of symptoms - gradual and progressive
Systemic symptoms - fever, weight loss, fatigue
Arthritis - nondestructive, peripheral large joints
- ankylosing spondylitis
Uveitis/episclertitis
Erythema nodosum
Pyoderma gangrenosum
VTE
Arterial thromboembolism
Autoimmune hemolytic anemia
Primary sclerosing cholangitis - liver and gallbladder disease
PE - usually nl
- abdominal pain w/ palpation
- fever
- hypotension
- tachy
- pallor
- blood on rectal exam
58
Ulcerative Colitis- diagnosis
Chronic diarrhea >4w
Evidence of active inflammation on endoscopy
- loss of vascular markings from swelling of mucosa -> looks erythematous
- Petechiae, exudates, edema, erosions, friability to touch, spontaneous bleeding
Chronic changes on biopsy
- Crypt abscesses
- Crypt branching
- Shortening and disarray
- Crypt atrophy
- Epithelial cell abnormalizes - mucin depletion, Paneth cell metaplasia
- Inflammatory features - inc lamina propria cellularity, basal plasmacytosis, lymphoid aggregates, lamina propria eosinophils
Exclude all other causes
Pattern:
- involves rectum
- extends proximally in continuous, circumferential
- No normal areas of mucosa
59
Ulcerative Colitis- labs & imaging
```
Anemia
ESR/CRP - inc
Electrolyte abnormalities - diarrhea/dehydration
Fecal calprotectin - inc
- differentiate b/t UC and IBS
```
Xray
- proximal constipation
- mucosal thickening - thumbprinting from edema
- colonic dilation - severe
Double contrast barium enema
- diffusely reticulated pattern w/ punctate collections of barium in microulcerations
- collar button ulcers
- shortening of colon
- loss of haustra
- polyps or pseudopolyps
- avoid in those severely ill -> can cause toxic megacolon
CT and MRI
- lower sensitivity than barium enema at detecting subtle early disease
- Thickening of bowel wall
60
Ulcerative Colitis - treatment
Ulcerative Proctitis or Proctosigmoiditis
Topical 5-aminosalicylic acid (5-ASA) - 1st line
- Suppositories - dis just distal to part of rectum
- Mesalamine 1 PR BID
- Enema + suppository - dis extends furth
- Enema BID + suppository BID
- symptomatic relief and dec bleeding - w/in few days
- complete healing >4-6w -> continue for 8 weeks - then taper
- 1st episode + proctitis -> disc, no maintenance therapy
- Proctosigmoiditis or >1relapse /year -> maintenance therapy
Alternatives - topical steroids, PO 5-ASA
Left sided colitis, extenside colitis, pancolitis
- combo therapy - PO 5-ASA, suppositories 5-ASA or steroid, and enemas 5-ASA or steroid
Refractory
- Refer
- further oral immunosuppressants
61
Ulcerative Colitis- severity
```
Severity:
Mild
- <4 stools/day
- nl ESR
- no severe abdominal pain, fever, wt loss, profuse bleeding
```
Mod
- >4 loose, bloody stools/day
- mild anemia - no trans
- mod abdominal pain
- Minimal signs of systemic toxicity - low grade fever
- No wt loss
Severe
- Frequent loose bloody stools >6/day
- Severe abdominal pain
- Systemic symptoms - fever, tachy, anemia, Inc ESR
- May have rapid weight loss
62
Ulcerative Colitis- prognosis
Prognosis:
- w/ treatment - exacerbations/flares alternating w/ long periods of symptomatic remission - some won't be able to get remission
- Dis extension
- Colectomy - 20-30% - acute complications or intractable disease
- slightly higher mortality - then rest of population
63
Chrohn Disease- pathophysiology
Transmural inflammation of GI tract - throughout whole GI tract
- ilium & R colon - most common
Skip areas - classic
Cause - Uknown
64
Chrohn Disease - epidemiology
15-35
65
Chrohn Disease - S/S & PE
```
Crampy abdominal pain
Strictures - lead to repeated obstruction
Diarrhea - fluctuating over time
- gross bleeding - less common than UC
Fistulas - entervesical, enterocutaneous, enteroenteric, enterovaginal
Malabsorption
Abscess formulation
Aphthous ulcers
```
```
Fatigue, wt loss
Arthritis
Eye - uveitis, iritis, episcleritis
Skin - erythema nodosum, pyodermo gangrenosum
Primary sclerosing cholangitis
VTE & arterial thromboembolism
Nephrolithiasis
Vit B12 def
Pulm involvement
Sec amyloidosis
```
PE - nl
- Perianal skin tags, sinus tracts, abdominal tenderness, wt loss, pallor
66
Chrohn Disease- diagnosis
Colonoscopy
- focal ulcerations next to nl areas
- polypoid mucosal changes - give cobblestone appearance
- Skip areas
- Rectal sparing
Wireless capsule Endoscopy
- no radiation
- don’t do - w/ suspected stricture
Crohn's Disease Activity Index - CDAI
- stool patterns, abdominal pain rating, general wellbeing, complications, abdominal mass, anemia, weight change
Harvey-Bradshaw Index (HBI)
- general wellbeing, abdominal pain, number of liquid stools, abdominal mass, complications
67
Chrohn Disease- labs & imaging
```
CBC
CMP
ESR/CRP - CRP higher than in UC
Serum Iron
Vit D
Vit B12
Fecal calprotection - diff b/t IBS
Antibody test - pANC and ASCA pos
- diff b/t CD and US
```
Barium Swallow - upper GI series
- narrowing o lumen w/ nodularity & ulceration
- Sring sign
- Cobblestone appearance
- Fistulas/abscess formation
- Bowel wall thickening
- Stricturing
CT - w/ ingestion of a neutral contrast agent to distend small bowel
- best study if abscess suspected
MRI
- mural thickening, high mural signal intensity (edema), layered patter of enhancement = acute small bowel inflammation
68
Chrohn Disease- treatment
Mild - Mod Disease
Ileum or proximal colon involvement
- Budesonide 9mg QD x 4-8 weeks -> taper Q2-4 w = 8-12 w total
- Corticosteroid
- AE - HA, acne, adrenal suppression, osteoporosis, immunosuppression, edema, psychiatric distrubances, exacerbation of CV dis, hyperglycemia
- Alternatives - budesonide - prednisone, oral 5-ASA - controversial
Diffuse Colitis or Left colonic involvement
- PO prednisone 40mg QD x 1w -> taper
- Atlern - Sulfasalazine
Oral lesionx
- topical meds - triamcinolone acetonide
Severe Disease
- Top Down
- Refer
- Bioloigic + immunomodulatory for induction
- TNFinhibitor - infliximab (remicade), adalimumab (Humaria), certolizumab (Cimizia)
- + azathioprine, 6-mercaptopurine, or methotrexate
- Glucocorticoid - immediate symptom relief - <8w
- Maintenance - long term w/ biologic
Relapse - begin sec course of glucocorticoid
Surgery - for complications or persistent symptoms
- perf, abscess, fistula, hemorrhage, stricture, neoplasm
69
Chrohn Disease- prognosis
Step Therapy - start w/ less potent meds - but fewer side effect
- use more potent meds if initial not effective
Top-down therapy - start w/ more potent therapies early in the course of disease before they become glucocorticoid- dependent
Goal - remission - endoscopic, histologic, clinical
- demonstrating complete mucosal healing
Intermittent exacterbat -> periods of remission
>1/2 develop structuring or penetrating disease
Will require surgery
80% require hosp
Predictors of severe course
- <40, perianal or rectal disease, smoking, low education level, initial need for glucocorticoids
70
Constipation- cause
Inadequate fiber & water consumption
Meds - opiates, anticholinergic, CCBs, antacids, Fe, Ca
Neurologic conditions - MS, Parkinson disease, dementia, stroke
Prolonged immobility - SCI, complete bed rest
Metabolic - DM, hypothyroidism, uremia, hypercalcemia, hypokalemia
Functional fecal retention - chronic stool-withholding
- common in kids
Anatomic abnormalities - neoplasms, anal fissures, lesions, proctitis, perirectal abscess, anorectal stenosis
Functional - inc rectal compliance, Pelvic floor dysfunction
71
Constipation - S/S & PE
```
Hard or lumpy stools
Feeling of incomplete voiding
Straining
Abdominal discomfort or bloating
Manual maneuvers
<3 defecation x week
Loose stools rare w/out laxative use
```
72
Constipation - treatment
Fiber - psyllium, methylcellulose, calcium polycarbophil
Hyperosmolar agent - sorbitol, lactulose, PEG (miralax)
Stimulant - glycerin suppository, bisacodyl, senna, senna/colace
Enema - mineral oil, tap water enema, Na phosphate
Opioid antagonist - methylnaltrexone, naloxegol
73
Fecal Impaction- pathophysiology
Mass of compacted feces in large intestine
Can't be evacuated spontaneously
Rectum or distal sigmoid - common
74
Fecal Impaction - epidemiology
Elderly
75
Fecal Impaction - S/S & PE
Chronic constipation
Rectal discomfort
Abdominal pain & cramping
Bloating
Overflow fecal incontinence or paradoxical diarrhea - leaking aroudn it
Inc urinary frequency, incontinence, obstruction
Detect impacted feces on rectal examination
76
Fecal Impaction - diagnosis
Xray/CT - show impaction and associated bowel obstruction
77
Fecal Impaction - treatment
Manual disimpaction
Enema administration
Osmotic laxative
Address underlying cause - adequate fiber & H2O, bulking agents, stool softeners
78
Fecal Impaction - complications
Large bowel obstruction w/ colonic perf - high mortality
79
Celiac Disease- pathophysiology
Immune disorder - triggered by environmental agent - gliaden
- people genetically predisposed
Gluten-sensitive enteropathy and nontropical sprue
Inflammation of the small bowel 2nd to ingesting gluten-containing food
80
Celiac Disease - cause
wheat, barley, rye, oats
81
Celiac Disease - epidemiology
Caucasian
Norther European ancestry
10-40
82
Celiac Disease - S/S & PE
```
Diarrhea w/ bulky, foul smelling, floating stools - steatorrhea, flatulence
Wt loss, weakness
Abdominal distension
Infant and kids - FTT
IDA
Osteopenia & osteoporosis
```
Dermatitis Herpetiformis - grouped pruritic papules and vesicles
- elbows, dorsal forearms, knees, scalp, back & butt
DM 1
Down Syndrome
Liver disease
Menstrual & reproductive issue - recent miscarriage, infertility, later menarche, early menopause, preterm delivery, low birth weight
83
Celiac Disease- diagnosis
Who Screened? - done while on gluten diet
GI S/S, extrintestinal S/S suggestive of Celiacs - serologic testing
Low probably -> serologic
- no sig s/s of malabsorption
- no FHx
- Chinese, Japanese, or sub-Saharan African descent
High probability -> serologic + small bowel biopsy
- Classic presentation
- Risk - 1st/2nd relative w/ confirmed CD, DM, autoimmune thyroiditis, down syndrome, turner syndrome
84
Celiac Disease - labs & imaging
Tissue tranglutaminase (tTga)-IgA - 1st line
Anti-endomysial (EMA-IgA) - also can be done
If serology + -> small bowel biopsy - confirm diagnosis
If neg -> doesn’t exclude celiac reason:
- IgA def
- low gluten/gluten free diet
- false neg - common mild
```
Endoscopy w/ small bowel biopsy
Seen:
- atrophic mucosa w/ loss of folds
- visible fissures
- nodularity
- scalloping
- prominent submucosal vascularity
Biopsy:
- Graded using marsh-Oberhofer classification
- 4 biop needed to confirm dx
- inc intrepithelial lymphocytes
- atrophic mucosa w/ villi loss
- epithelial apoptosis
- crypt hyperplasia
```
85
Celiac Disease - treatment
```
Gluten Free diet
Refer - RD
Replete a nutritional def
Eval bones - DEXA
Pneumococcal vaccine
Improvement of dermatitis herpetiformis - more delayed than response - 6-12m
Screen Fm members
```
86
Celiac Disease - prognosis
Inc mortality - CV and Ca
| Inc Malignancy - lymphoma and GI
87
Colorectal Cancer- pathophysiology
Leading cause of cancer in US
88
Colorectal Cancer- cause
```
Risk:
Hereditary syndromes
- Familial adenomatous polyposis (FAP)
- Lynch syndrome (HNPCC)
IBD
Abdominal Radiation
Cystic Fibrosis
```
Obesity, DM
Red/processed meat
Smoking
alcohol consumption
89
Colorectal Cancer- epidemiology
AA
M>F
Acromegaly
Renal transplant + long term immunosuppression
90
Colorectal Cancer- S/S & PE
Change in bowel habits
Unexplained IDA
Rectal bleeding + change in bowel habits
Rectal mass or abdominal mass
Abdominal pain
Asymptomatic - discovered on routine screening
Emergent admit - intestinal obstruction, peritonitis, acute GI bleeding
91
Colorectal Cancer- diagnosis
Colonoscopy
- Endoluminal masses - from mucosa and protrude into lumen
- Friable, necrotic, ulcerated lesions - may bleed
- ""Apple core""
92
Colorectal Cancer- labs & imaging
CT Colonography - virtual colonoscopy
- computer-simulated endoluminal perspective of air-filled distended colon
- Still requires bowel prep
- abnormal -> f/u w/ colonoscopy for excision & tissue diagnosis
CEA - tumor marker
- low diagnostic ability to detect primary colorectal cancer
- significant overlap w/ benign disease
- low sensitivity for early-stage disease
- Useful for - F/U of pts w/ diagnosed CRC
- >5 preop -> worse prognosis
- don't normalize after surgery -> look for persistent disease
93
Colorectal Cancer- treatment
Carcinoma in polyp - endoscopic removal alone - as long as margins are clear
Larger tumors - surgical resection -> surgery
Radiation therapy - most commonly used for rectal
- not routine for completely resected colon
94
Colonoscopy Screening Guidelines- pathophysiology
Inc risk
- personal hx of CRC or adenomatous polyp
- Fm w/ CRC 0r doc advanced polyp
- personal or fm hx of genetic syndromes that cause CRC - familial adenomatous polyposis, lynch syndrome, juvenile polyposis syndrome, peutz[jeghers syndrome, mutyh-associated polyposis
- inflammatory bowel disease
- Prior hx of abdominal radiation for child malignancy
Other risk
- HIV pos Men
- AA
95
Colonoscopy Screening Guidelines- cause
Age start screening - w/ avg risk
- 50
- 45 - AA
Discontinue screening - avg risk
- to 75 -> unless have <10y to live
- b/t 76-85 - pt preference, prior test results, comorbidities
96
Colonoscopy Screening Guidelines- S/S & PE
```
"Choices of test: average risk
Colonoscopy
- 10 yr - avg risk
- highest sensitivity - CRC and adenomatous
- lesion removal
- reduced incidence and mortality
```
Fecal immunochemical testing (FIT)
- yearly - 1 stool sample for occult blood
- measure hemoglobin in stool
- pos -> colonoscopy ASAP
CT colonography
- 5 yr
- polyps/finding of CRC -> colonoscopy ASAP
- still need bowel prep
```
Sigmoidoscopy + FIT - timing vary
Sigmoidoscopy alone
- 5-10 yr
- minimal pt prep - no sedation required
Guaiac-based FOBT - 3 sample yearly
Stool DNA testing - one stool sample, performed every 3 years
```
97
Colonoscopy Screening Guidelines- diagnosis
Choice of screening - FH of CRC or advanced poly
Colonoscopy - GOLD
- if refuse -> FIT yearly
When to start - FH of CRC or advanced polyp
1 1st deg relative diag <60
- begin screening at 40 or 10y before Fm diagnosis - whichever is earlier
- Colonoscopy - 5yr
>2 FDR diag at any age
- screen at 40 or 10y before youngest FDR diagnosis - earlier wins
- Colonoscopy - 5yr
FDR >60y
- begin screening at age 40
- Same screening options/freq as avg risk
When to stop - FH or CRC or advanced polyp
1FDR >50 - end at 79yo
>2 FDR <40 - end at 85y
- life expectancy of <10 - stop
98
Colonoscopy Screening Guidelines- labs & imaging
High Risk Syndrome
- Lynch syndrome - 20-25 yo or 2-5 yr prior to earliest age of CRC diag
- Familial adenomatous polyposis (FAP) - yearly colonoscopy - starting at age 10-12 for classic; 1-2 yr at 25yo for attenuated FAP
- Peutz-Jeghers syndrome - EGD, video capsule endoscopy, colonoscopy at 8yo
99
Anal Fissure- pathophysiology
Tear, cut or crack in the lining of distal half of anal canal
100
Anal Fissure- epidemiology
Infants
Middle aged adults
Local trauma - constipation, anal sex, diarrhea, vaginal delivery
Secondary - IBD, malignancy, STI
101
Anal Fissure- S/S & PE
Anal pain
Pain intensifies w/ defecation
- ripping/tearing
- lasts for hours after
- mild anal bleeding
Posterior midline - most common ->less purfusion - mild ischemia
Anterior midline - 2nd most cmmon
- doesn’t extend above dentate line
- not w/in midline - think other issues
Acute - looks fresh, superficial - like papercut
Chronic - raised edges, fibrotic appearance - accompanied by skin tag
102
Anal Fissure- diagnosis
H&P
Direct visualization
Reproduce pain w/ digital palpation of posterior anal verg
103
Anal Fissure- treatment
Fiber + H2O +/- stool softeners -> prevent hard BM which can be the cause
Sitz bath - anus immersed in warm water for 10-15 min BID-TID
- relaxes anal sphincter & improves blood flow to mucosa
Topical analgesics - pain control
- 2% lidocaine jelly
Topical vasodilators - promote healing -> inc local blood flow & dec anal sphincter pressure
- Nifedipine gel BID-QD
- Topical nitroglycerin BID
- SE - HA & hypotension
- DONT USE - w/in 24 hr of Viagra, cialis, levitra
Reeval after 1month
- if persist -> complete 1 more m of Smale treatment
Sx persist after 2m -> refer to endoscopy - rule out Crohn
- Crohn -> refer GI
- no Crohn -> refer to colorectal surgeon
- botox or lateral sphincterotomy recommended
104
Hemorrhoid- pathophysiology
Swollen veins in rectum and anus
- lead to discomfort, prolapse, bleeding
External - distal to dentate line
- arise from superior hemorrhoidal cushion
- Somatic innervation -> more sensitive to pain/irritation
Internal - proximal to dentate line
- arise from inferior hemorrhoidal line
- Visceral innervation -> less sensitive to pain/irritation
Mixed - both above and below dentate line
105
Hemorrhoid- cause
```
Advancing age
Chronic constipation, straining
Preo
Pelvic tumors
Diarrhea
Prolonged sitting
Anal sex
Anticoag and antiplatelet meds
Obesity
Low fiber diet
```
106
Hemorrhoid- S/S & PE
40% - asymptomatic
Bleeding
- painless
- associated with BM
- bright red and coats strool at end of defecation
Pruritis or irritation - perineal area common
Mild fecal incontinence, mucus discharge, or wet sensation
Acute onset of perianal pain - w/ palpable ""lump"" from thrombosis
Protuberant purple nodules - covered by mucosa
107
Hemorrhoid- diagnosis
Classic symptoms + visualization
Anoscopy - allows visualization of internal hemorrhoids
Grade 1 - no prolapse
Grade II - prolapse w/ defecation, spontaneously reduces
Grade III - prolapse w/ defecation or other times, needs manual reduction
Grade IV - permanently prolapsed/irreducible, visible externally, may strangulate
108
Hemorrhoid- treatment
When to Refer to surgeon
- symptomatic low grade (I-II) - refractory 6-8 w of medical treatment
- Symptomatic high grade (III-IV) hemorrhoids
- thrombosed hemorrhoids
Office-based procedure: only for internal
Rubber band ligation
- most common procedure
- rubber band rings are placed on internal hemorrhoids
- complication - bleeding & pain
Sclerotherapy
- injecting solution that causes an inflammatory reaction - destroying tissue
- Can be used for those who have an elevated bleeding risk
Infrared coag - infrared light waves -> necrosis
Surgery
External hemorrhoidectomy
- symptomatic & refractory to conservative measures
- Symptomatic and refractory to office-based procedures
- Large or severely symptomatic external hemorrhoids
- pts w/ substantial external skin tag
- Combined internal and significant external hemorrhoids
Internal hemorrhoidectomy
- prolapsed internal hemorrhoids that can be manually reduced - Grade III
- prolapsed and incarcerated internal hemorrhoids - Grade IV
- Symptomatic internal hemorrhoids refractory to conservative measures
- Symptomatic internal hemorrhoids refractory to office - based procedures
- Combine internal and external hemorrhoids
109
Diverticulosis- pathophysiology
Diverticulum - sac-like protrusion of colonic wall
- develop at points of weakness
- don’t have a disease - just an outpouching in intestine
110
Diverticulosis - cause
```
Inc age
Low fiber, high fat, red meat diet
- nut, seeds, corn -> not w/ inc risk
Lack of physcial acitivty
BMI >25
Smoking >40pk year hx
Meds - NSAIDs, opiates, steroids
```
111
Diverticulosis - S/S & PE
asymptomatic/symptomatic
Diverticular bleeding - painless hematochezia
- most common cause of brisk hematochezia
Diverticulitis - inflammation of diverticulum
Diverticular colitis - inflammation in the interdiverticular mucosa - w/out involvement of diverticular orifices
Symptomatic uncomplicated diverticular disease - persistent abdominal pain attributed to diverticular w/out over colitis
112
IBS- pathophysiology
Functional disorder of GIT w/ chronic abdominal pain and altered bowel habits
113
IBS - epidemiology
```
W>M
10-15%
Fibromyalgia
Chronic fatigue syndrome
Depression
Anxiety
```
114
IBS - S/S & PE
Chronic abdominal pain - crampy, variable intensity, location and character can vary widely, defecation often improves the pain, stress can worsen the pain
Altered bowel habits:
- Diarrhea
- Constipation
- Alternating diarrhea and constipation
- Nl bowel habits alternating w/ diarrhea or constipation
115
IBS - diagnosis
Rome IV criteria
Recurrent abdominal pain on avg at least once a week, past 3 months associated w/ >2 of the following:
- related defecation
- associated w/ a change in stool frequency
- associated w/ a change in stool appearance
116
IBS- treatment
Dietary mods - FODMAPs
- fermentable oligo di and monosaccharides and polyols, lactase and gluten avoidance
Inc fiber - w/ constipation dominant
- miralax
- lubiprostone - miralax doesn't work
Antidiarrheals - w/ diarrhea dominant
- Imodium
- Bile acid sequestrat if failed - cholestramine
Abdominal pain
Antispasmodic -inhibits gastrointestinal smooth muscle
- Dicyclomine (Bentyl)
- Hyoscyamine (Levsin)
TCAs - slow intestinal time and help w/ abdominal pain
- amytriptyline, nortipryline, imipramine
Abx - mod/severe IBS w/out constipation if failed other
- Rifaximin
117
IBS- prognosis
Refer to GI:
- more than minimal rectal bleeding
- Wt loss
- Unexplained IDA
- Nocturnal symptoms
- FH of colorectal Ca, celiac disease, inflammatory bowel disease
Education & reassurance
118
GERD- cause
Hiatal Hernia - treat like GERD
119
GERD- S/S & PE
Heart burn - postprandial or positional
Acid taste or reflux
Dysphagia
Atypical presentation
PE - NL
Symptoms DOESN’T = tissue damage
120
GERD- diagnosis
Ambulatory esophageal pH monitoring - GOLD - not 1st line -> if failing treatment
PPI trial - 1st line diagnosis
Upper endoscopy - if alarm symptoms
Barium esophagography - barium swallow
121
GERD- labs & imaging
Labs - nl
Hpylori testing - not recommended
122
GERD- treatment
```
Lifestyle changes - 1st line
- avoid supine position w/in 3 hours postprandial
- Elevation of head of bed 6in or use a wedge
- Encourage weight loss
- dec portion size
- eliminate or dec aggravating food
Antacids
Gaviscon
H2 blocker
- pepcid - famotidine - 20
- Tagament - cimetidine - DONT USE - cytocrone P450
- Axid - nizatidine
Proton Pump Inhibitors - PPI
- Omeprozole - Prilosec
- Lansoprazole - Prevacid
- Rabeprazole - Acephex
- Esomeprazole - Nexium
- Pantoprazole - Protonix
- Ddexlansoprazole - Dexilant
- Omeprazole and Na bicarbonate
- education - Take before meals - might need a holidy
Metoclopramide - Reglan
- helps w/ parastolsis -> keeps things down
- short term
Surgery:
Fundoplication - 360, partial anterior, partial posterior
Endoscopic
Link - band around that allows normal swelling
```
123
Barrett's Esophagus- pathophysiology
Chronic acid injury
| Squamous epithelium -> metaplastic columnar epithelium
124
Barrett's Esophagus- cause
Complication of GERD
125
Barrett's Esophagus- diagnosis
Endoscopic biopsy
126
Barrett's Esophagus- treatment
Screen every 3-5 yrs - if chronic GERD
Low-grade dysplasia, high-grade dysplasia, adenocarcinoma - ablation
Adenocarcinoma - esophagectomy
127
Peptic stricture- cause
Complication of GERD
128
Peptic stricture- S/S & PE
Gradual and progressive dysphagia w/ solid foods -> m - y
| Reduce heartburn - anatomical barrier to reflux
129
Peptic stricture- diagnosis
Endoscopic biopsy - exclude malignant causes of stricture
130
Peptic stricture- treatment
Dilation - single to several session
| PPIs - long term
131
Achalasia- pathophysiology
Poorly relaxing LES
132
Achalasia - S/S & PE
```
Gradual, progressive dysphagia - solids and liquids
Substernal discomfort
Postprandial fullness
Regurg of undigested food
Wt loss
```
PE - nl
133
Achalasia- diagnosis
Barium esophagography/esophagram
134
Achalasia- labs & imaging
Esophageal manometry
| Endoscopy
135
Achalasia- treatment
Pneumatic dilation
Surgery myotomy
Botulinum toxin injection - short term
CCB or long-acting nitrates
136
Esophageal Dysphagia- pathophysiology
Diffuse esophageal spasms
137
Esophageal Dysphagia - S/S & PE
Simultaneous and repetitive contractions
Nl peristalsis?
LES - nl
Present - chest pain, +/- dysphagia
138
Esophageal Dysphagia- diagnosis
Nitrates
CCB
- not great
139
Strictures- pathophysiology
Loss of diameter
20mm - nl
<15mm - dysphagia
- if less severe - can cause intermittent dysphagia to large pieces of food
140
Strictures - cause
Intrinsic - most common
- acid/peptic
Extrinsic - not from tissue itself
Complication of GERD
141
Strictures- treatment
```
Esophageal dilation
Refractory
- pill induced irritation
- uncontrolled GERD
- inadequate dilation diameter
```
142
Rings/Webs- pathophysiology
Rings - circumferential mucosa or muscle in the distal esophagus
Webs - occupy only part of the esophageal lumen, always mucosal, usually proximal
143
Rings/Webs- - risks
Risk - esophagus and pharynx cancer
144
Rings/Webs- S/S & PE
Solid food dysphagia
Aspiration
Regurg
Plummer Vinson Syndrome TRIAD
- proximal esogeal webs, IDA, Dysphagia
145
Rings/Webs- diagnosis
Endoscopy
Barium radiography - webs
- some are proximal - can get fractured before even see it
146
Rings/Webs- treatment
Mechanical disruption
147
Schatzki's Ring- pathophysiology
Near LES
148
Schatzki's Ring- cause
Complication of GERD
149
Schatzki's Ring- S/S & PE
Intermittent solid food dysphagia and food impaction
Symptoms depend on luminal diameter
- 13-20mm - variable symptoms
150
Schatzki's Ring- diagnosis
Barium swallow
151
Schatzki's Ring- treatment
PPIs
152
Esophageal Cancer- pathophysiology
SCC - aggressive, locally invasive w/ distant mets
Adenocarcinoma - not locally invasive w/ mets
153
Esophageal Cancer- epidemiology
SCC:
- Black Males
- ETOH and tobacco
- prior esophageal injury
- Associated w/ HPV
- Associated w/ achalasia
Adenocarcinoma
- white Males
- Obesity
- GERD, Barretts esophagus
- Scleroderma
154
Esophageal Cancer- S/S & PE
Rapid progressing solid food dysphagia
| Wt loss
155
Esophageal Cancer- diagnosis
CT - look for mets
| Endoscopic U/S - depth of invasion
156
Esophageal Cancer- treatment
Early - surgery
Advanced - chemo/radiation -> surgery
Late - palliative treatment - dilation, stent, gastrostomy tube
157
Zenker's Diverticula- pathophysiology
Sac protruding from esophageal wall
Incomplete relaxation of UES
158
Zenker's Diverticula- S/S & PE
```
Oropharyngeal dysphagia
Regurg of undigested food
Halitosis
Cough
Aspiration pneumonia
```
159
Zenker's Diverticula- diagnosis
Barium swallow
160
Zenker's Diverticula- treatment
Surgical resection
161
Pill-induced Dysphagia- pathophysiology
Ingestion of irritant meds
| Swallowing a pill w/out water or while supine
162
Pill-induced Dysphagia- S/S & PE
Severe retrosternal chest pain
odynophagia
Dysphagia
163
Pill-induced Dysphagia- imaging
Endoscopy - see ulceration
164
Pill-induced Dysphagia- treatment
Rapid healing w/ removal of offender
165
Infectious Esophagitis- pathophysiology
Seen in Immunocompromised pt
| - HIV
166
Infectious Esophagitis- cause
Candida albicans
Herpes Simplex
CMV
167
Infectious Esophagitis- S/S & PE
Odynophagia
| Dysphagia
168
Infectious Esophagitis- diagnosis
Endoscopy biopsy and brushings
169
Eosinophilic Esophagitis- pathophysiology
Hx of allergies or atopy
170
Eosinophilic Esophagitis- S/S & PE
Episodic dysphagia/food impaction
171
Eosinophilic Esophagitis- labs & imaging
Labs - eosinophilia or Inc IgG
Endoscopy
- white exudates or papules
- Red furrows
- Corrugated concentric rings
- Strictures
172
Eosinophilic Esophagitis- treatment
```
Allergy testing
PPI
Avoidance of allergy
ICS
Refer - allergy
```
173
Mallory-Weiss Syndrome- pathophysiology
Mucosal tear from vomiting/retching
| - in esophagus
174
Mallory-Weiss Syndrome- cause
Alcoholism
175
Mallory-Weiss Syndrome- S/S & PE
Hematemesis
| Sudden onset
176
Mallory-Weiss Syndrome- diagnosis
Upper endoscopy
177
Mallory-Weiss Syndrome- treatment
Fluid resuscitation
Blood transfusion
Endoscopic hemostatic therapy - active bleeding
Epinephrine injection, cautery, mechanical compression
178
Varices- pathophysiology
Dilated submucosal veins
Inc risk of bleed
- size
- red signs on endoscopy
- liver disease severity
- active alcohol abuse
179
Varices- cause
Portal HTN
| Cirrhosis
180
Varices- S/S & PE
Hematemesis
Melena
Sudden/insidious onset
181
Varices- treatment
```
Acute resuscitation
Emergent endoscopy
Meds
- abx
- vasoactive drugs
- Vit K
- lactulose
Ballon tube tamponade
Portal decompressive procedures
```
```
Prevent Rebleeding:
Endoscopic techniques
- band ligation
- sclerotherapy
BB
Transvenous Intrahepatic Portosystemic Shunt
Surgical portosystemic shunts
Liver transplant
```
182
Varices- prognosis
Prevent 1st Bleed
- Cirrhosis - diagnostic endoscopy
- If present - BB or prophylactic band ligation
- if none - repeat every 1-2y
