GI and Hepatic Disorders Flashcards
GERD Presentation and alarm findings
- dyspepsia, chest pain at rest, postprandial fullness
- chronic horseness, sore throat, nocturnal cough
- Alarm symptoms warrant further work up
- Anemia
- Loss of weight
- Anorexia
- Recent onset of progressive symptoms in absence of increasing risk and with previous helpful symptoms
- Melena, or hematemesis
- Swallowing difficulty/painful swallowing
Gerd Dx
- with classic symptoms and no “alarms” findings diagnosis is made clinically.
- Upper endoscopy reccomended if
1. inadequate response to 8 week trial of PPI
2. Pts with chest pain after excluding heart disease
3. patients presenting with “alarms” findings or at risk for barrett’s esophagus - H. Pylori testing not indicated with classic presentation
GERD Tx
- lifestyle changes: weight loss if overweight, avoid trigger foods or eating 3 hours before sleep, avoid tabacco, elevate HOB
- Acid suppression: PPI taken once daily 30-60 min prior to meal for 8 weeks
- loger use of PPI = micronutrient malabsorption (b12, ca, mag, iron), increased fracture risk, pneumonia, c. diff risk.
- H2 receptor agonist (famotidine) PRN at bedtime with nocternal symptoms or added to PPI for continued nocternal symptoms
- Once symptoms resolve, attempt to DC PPI or switch to PRN, if maintanance therapy needed use the lowest possible dose
- Upper endocsopy reccomended if PPI ineffective
Acute pancreatitis
- alcohol use disorder
- 12 hour acute onset
- epigatric pain radiating to the back with bloating, nausea and vomiting
- epigastric tenderness, hypoactive bowel sounds, abdomen distended and hypertympanic
- Elevated lipase and amylayse
- transfer to inpatinet care for fluid, pain and alcohol withdraw management
Diverticulitis
- Intermittent hx of LLQ pain with fever, cramping, nausea, and 4-5 loose stools per day
- soft abd, +bowel sounds, tenderness to LLQ, negative rebound tenderness (Blumberg’s sign). Lab: elevated leukocytosis with neutrophillia (bacterial)
Tx:
* abdominal ct if indicated
* gut rest : liquid to low fiber diet
* PO abx an option
Duodenal Ulcer
Risk factors
* H. pylori infection
* NSAID use, systemic corticosteroid use
S/S
* epigastric burning, gnawing pain about 2-3 hours after meals
* relief with food or antacid
* clusters of symptoms with periods of feeling well
* awakening at 1-2 am with symptoms, morning pain rare
* tender at epigastrum, LUQ, slightly hyperactive bowel sounds
DX testing
* stool antigen testing for H. pylori
Gastric ulcer
risk factors:
* NSAID and Corticosteroid use (chronic)
* smoking
* peak onset 50-60 yrs
S/S
* pain with or immediately after meals
* N/V, weight loss common
Dx
* upper endoscopy with Bx needed to r/o malignancy
* rule ou/in h.pylori
Cholecystitis
- 24 hx of epigastric and RUQ pain that is constant 2-3 of increased pain (colic) with N/V and intermittent fever
- tenderness in epigastrum, and RUQ, positve murphy’s sign, moderatley eleveated ast/alt and ALP
Dx
* RUQ abdominal US
Tx
* gut rest, progressing to low fat diet
* referral to surgery
HBsAg
measure of hep B surface antigen
if positive
* evidence of HBV on board
* s=stays in people with HBV
* Ag= always growing
noted in acute or chronic hep B
* in acute: hepatic enzymes 5or more x ULN, symptomatic w/fatigue, malaise, RUQ discomfort, jaundice
* in chronic: hepatic enzymes modestly elevated asymptomatic
* ALT>AST
Anti - HAV
Includes HAV IgG (hep A virus G= gone)
Positive
* evidence of previous exposure, person is immune either by disease or vaccine
Negative
* no immunity, no evidence of prior infection or vaccination
HCV RNA
hep c virus
positive= evidence of current infection
Anti -HBs/HBSab
if positive evidence of HBV immunity
HBSab=b=bye
Anti -HBs/HBSab
if positive evidence of HBV immunity
HBSab=b=bye
Hep A virus
- fecal oral transmission
- vaccine available
- post exposure prophylaxis and imunization for close contacts
- if positive: get live function tests, notify public health dept
- Tx: supportive care
- Acute markers: HAV IgM, elevated hepatic enzymes >10x ULN
- no chronic disease
- Past infection: Anti-HAV positive, normal hepatic enzymens
- Susceptible to HAV: Anti- HAV negative
Hep B
- blood and body fluids (sexual contact)
- Vaccine available, post exposure prophylaxis, IZ for blood, body fluid contacts
- Liver function tests: screen for coinfection of HEP A/C, HIV, STI. Immunize against HAV if required. Referal for antivaral therapy
- possible sequale: chronic hep B, hepatocellular carcinoma, hepatic failure, in absence of successful tx
Acute Disease markers
* HBV IgM = acute infection
* HBsAg = always growing
* HBeAg = e=extra growing, extra contagious
* elevated ast/alt 10 x ULN
chronic disease markers
* pt without symptoms
* NL or slightly elevated AST/ALT
* HBsAg positive
Hep b in past or IZ
* HBsAb = b = bye, A =protective antibody = immune
* normal alt/ast
susceptible to HBV
* HBsAg negative
* Anti- HBc negative
* HBsAb negative
Hep C
- blood body fluids (needles)
- no IZ available
- if positive: liver function tests, screen for coinfection, referal for antiviral tx.
- possible sequale: Chronic Hep c, hepatocellular carcinoma, hepatic failure
Acute disease markers
* Anti-HCV present
* HCV viral RNA
* Elevated AST/ALT
Chronic disease markers
* same as above but normal to slightly elevated hepatic enzymes
Past disease
* Anti - HCV present (not protective, still susseptible)
* HCV - RNA absent
* normal hepatic enzymes
Hepatitis acute symptoms
- fever, fatigue, loss of appetite, N/V, abdominal pain, joint pain
- Dark urine
- Jaundice
- clay-colored stool
- diarhhea in HAV only
Hep ABC testing
Hep A
* not applicable as there is no chronic infection
Hep B
* all pregnant women
* infants born to woomen with infection
* endimic regions
* people not vaccinated as infants
* high risk behaior
* elevated liver enzymed without known cause
* end stage renal disease
* immunosuppresive therapy/suppressed immune system
* blood or body fluid donors
Hep C
* all adults 18 or older at least once
* every pregnancy
* IV drug user or hx of
* hymodyalisis currently or hx
* organ tansplant pt
* HIV
* needle stick injury
* children born to pos mother
* anyone who asks to be tested
IBS Vs IBD
IBS
* Altered GI mobility and visceral hyperalgesia
* microscopic inflammation, altered gut microflora possible contributor
* absence of rectal bleeding, fever, weightloss, elevater CRP or ESR
* Interventions: lifestyle mods, diet mods fiber fluids, exercise. Medications indicated by symptoms (antidiarrheals, motility agents, select antimicrobials, probiotics.
IBD
* intestinal ulceration, inflammation, detectable microscopically and macroscopically
* rectal bleeding, diarhea, fever, weightloss, elevated CRP or ESR; leukocytosis, especially during flares
* Interventions: lifestyle mods, antiinflammatory meds (aminosalicylates, systemic or local corticosteroids), biologics if no response to antiinflammatory meds, Surgical intervention often needed. Ongoing monitoring for GI malignancy
Diverticulitis Treatment
- Outpatient therapy for mild diverticulitis with intact GI function, able to take and keep down oral meds and fluids
- Provide coverage for gram neg anaerobic and aerobic organisms
- Causitive organisms: Enterobacteriaceae, P. aeruginosa, Bacteroides species, enterococci.
- Amoxiclillin-clavulante (augmintin)
- If beta lactam allergy/augmintin intolerant: TMP-smx-DS (bactrim); or ciprofloxacin, or levofloxacin + metronidazole
- tx for 7-10 days
