GI and Nutritional Flashcards
Describe the most common clinical presentation of appendicitis.
Umbilical pain migrating to the RLQ. Fever, nausea, vomiting, anorexia.
Describe three PE tests used to evaluate for appendicitis.
Rovsing’s: RLQ pain elicited by palp of LLQ
Obturator: hip internally rotated with knee and hip in flexion
Psoas: Pt supine –> flex right hip with leg straight. Pt on left side –> extend right hip with leg straight
What imaging is most useful in the diagnosis of appendicitis?
US initial, CT with contrast more sensitive.
What antibiotic is best in the management of appendicitis?
3rd generation cephalosporin
Define cholecystitis.
Inflammation and/or infection of gallbladder s/p cystic duct obstruction.
What is the most common causative agent in infective cholecystitis?
E. Coli
What clinical findings are most associated with cholecystitis?
Colicky RUQ pain worse after fatty meal, fever, nausea, vomiting, hypoactive bowel sounds (indicates perforation).
What imaging tests are used in the diagnosis of cholecystitis?
US initial
HIDA scan gold standard
ERCP diagnostic and therapeutic
What pharmacologic agent is most commonly used to manage pain in cholecystitis?
Meperidine (Demerol)
Differentiate cholelithiasis from choledocholithiasis.
Cholelithiasis: gallstones
Choledocholithiasis: obstruction of biliary tree s/p stone
What is the treatment of choledocholithiasis?
Stone removal via ERCP
Define primary sclerosing cholangitis.
Autoimmune, progressive cholestasis with diffuse fibrosis of intrahepatic and extrahepatic ducts. Usually associated with inflammatory bowel disease.
What clinical findings are associated with primary sclerosing cholangitis?
progressive jaundice, pruritus, RUQ pain, hepatosplenomegaly, inc ALP (very high), GGT, ALT, AST, and total bilirubin.
Define ascending cholangitis.
Biliary tract infection s/p obstruction by gallstone
Describe Charcot’s triad.
Fever, RUQ pain, jaundice - indicate ascending cholangitis. Add shock and AMS for Reynold’s pentad.
What is the treatment of ascending cholangitis?
Abx: PCN (Zosyn) and aminoglycoside (gentamicin)
ERCP for stone removal
Differentiate between the types of hepatitis.
A: fecal-oral transmission B: IVDU, STI (most common) C: STI, IVDU (most common) D: Requires co-infection with HBV E: fecal-oral transmission, waterborne outbreaks --> high infant mortality if mom has HEV
Describe the findings of antigen and antibody testing for HBV.
A
What are the most common causes of acute and chronic pancreatitis?
Acute: cholelithiasis –> hypertriglyceridemia
Chronic: alcohol use disorder
Describe the clinical findings most commonly associated with pancreatitis.
Epigastric pain radiating to back - improves when patient leans forward, N/V, fever, leukocytosis
Describe the triad of chronic pancreatitis.
Calcifications, steatorrhea, diabetes mellitus
Which lab finding is most sensitive in diagnosis of pancreatitis?
lipase
What is the treatment of pancreatitis?
- Fluid resus and stop PO intake –> 90% resolve
- ERCP if biliary sepsis/obstruction suspected
- Alcohol use cessation
What is the most common location of an anal fissure.
Posterior midline
What clinical S/S are most commonly associated with anal fissure?
Hematochezia, tearing pain on defecation, constipation s/p BM being too painful, skin tags in chronic
What is the treatment of anal fissure?
80% resolve spontaneously,
1st line: Sitz bath, increased fluid and bulking agents to reduce straining
2nd line: topical NTG, topical nifedipine, topical silver nitrate
Maintenance/Prevention: high fiber diet
What are the most common causative agents of anorectal abscess and what is the treatment?
Cause: Staph aureus or E. Coli
Tx: I&D –> no antibiotics
Define obstipation.
Severe or complete constipation
What are the most common causes of bowel obstruction?
Post-op adhesions or ischemia
What clinical S/S are most commonly associated with bowel obstruction?
Cramping, abdominal distention, tenderness, hyperactive high pitched bowel sounds, visible peristalsis
What x-ray finding is consistent with bowel obstruction?
Air-fluid levels and dilated loops of bowel
Differentiate common clinical presentation of small bowel obstruction from large bowel obstruction.
SBO: colicky pain, bilious vomiting, hyperactive bowel sounds (early), hypoactive (late)
LBO: gradually increasing pain with longer intervals between episodes, less vomiting, more common in elderly
What is the common clinical presentation of small bowel intussusception?
Sudden onset significant, colicky abdominal pain that recurs every 15-20 min, often after vomiting.
What patients are most often affected by small bowel intussusception?
Kids after viral infection
Adults with cancer
What are the 2 most common PE findings associated with small bowel intussusception?
Currant jelly stool and sausage-like mass on palpation
What role does barium enema play in the management of small bowel intussusception?
Both diagnostic and therapeutic.
Define ileus.
Hypomotility of GI tract in absence of mechanical bowel obstruction
What is the treatment for an ileus?
Spontaneously resolves in 2-3 days
Discontinue opiates
Describe gastroporesis.
Slowed gut motility causing delayed gastric emptying
Describe S/S of gastroparesis.
Nausea, early satiety, palpitations, heartburn, bloating, decreased appetite, GERD
State the treatment for gastroparesis.
low fiber diet, restrict fat intake, smaller meals spaced 2-3 hours apart; Reglan (metoclopramide) to increase contractility
Describe common S/S associated with C Diff.
Mild, watery foul-smelling diarrhea, fever, abdominal pain, constitutional S/S
How is C Diff commonly diagnosed?
Stool sample culture more common than PCR
What is the common treatment for C Diff?
Stop antibiotics if possible
IV metronidazole or PO vancomycin
What is the most common concerning complication of C Diff?
Toxic megacolon
What are the two most common causes of liver cirrhosis?
Most common: chronic hepatitis
2nd: alcohol
Describe clinical findings associated with hepatic encephalopathy.
asterixis (liver flaps), dysarthria, delirium, coma
For a patient with cirrhosis and acute fever and abdominal pain, what is at the top of the differential?
Spontaneous bacterial peritonitis
Describe ongoing evaluation for hepatocellular carcinoma in a patient with cirrhosis.
Monitor alpha fetoprotein (AFP) –> MRI if elevated
Abdominal US q 6-12 months
Describe common lab findings associated with cirrhosis.
AST > ALT, inc ALP, GGT, total and direct bilirubin, hemolytic anemia, folate deficiency, dec platelets and albumin, prolonged PT, PTT, INR
What pharmacologic agents are used to treat hepatic encephalopathy?
lactulose and neomycin
How is salmonella diarrhea usually transmitted?
fecal-oral from undercooked food
What is the presentation of salmonella diarrhea and what is the treatment?
Diarrhea: pea-soup and rose spots
Tx: ceftriaxone, sometimes fluoroquinolone or azithromycin
Describe diarrhea associated with shigella and state the treatment.
Watery diarrhea with blood, pus, or mucus. Often presents with lower abdominal cramping/
Tx: Bactrim, anti-diarrheals contraindicated
How is shigella diarrhea usually transmitted?
Crowded areas –> day care
Describe the diarrhea associated with cholera.
Rice water diarrhea –> life threatening illness
Differentiate diverticulosis from diverticulitis.
- osis: non-inflamed outpouchings of LI mucosa - usually in sigmoid colon. MC cause of GI bleeding
- itis: inflamed diverticula s/p obstruction or infection
How is the diagnosis of diverticular disease typically made?
CT is test of choice, WBCs elevated and Guaiac positive
Describe the treatment of diverticulosis and diverticulitis.
- osis: high fiber diet, vasopressin if bleeding doesn’t stop spontaneously (only ~ 10%)
- itis: clear liquid diet, metronidazole + cipro or Bactrim
What is the most common cause of esophagitis?
GERD
Define odynophagia and dysphagia.
Odyno: painful swallowing
Dys: difficulty swallowing
What is the most common cause of gastritis?
H. Pylori, NSAIDs/ASA 2nd most common
How is H. Pylori treated?
Clarithromycin, Amoxicillin, PPI –< metronidazole if PCN allergy
What is the greatest risk factor for gastric carcinoma? List others.
Main risk factor: H/ Pylori
Others: salted, cured, smoked, pickled foods containing nitrites
In general, when are anit-diarrheal agents contraindicated?
Undifferentiated bloody diarrhea or know C. Diff or known E. Coli (produces shiga toxin)
Define GERD.
transient relaxation of LES –> gastric acid reflux –> esophageal mucosal injury
What symptoms associated with GERD are considered alarm symptoms?
dysphagia, odynophagia, weight loss, bleeding
Define Barrett’s esophagus.
Esophageal squamous epithelium replaced by precancerous metaplastic columnar cells from the stomach.
When is endoscopy indicated to evaluate GERD?
Patient older than 45 with new onset, frequently recurring symptoms, failure to respond to therapy, or alarm symptoms
Describe pharmacological therapy indicated for GERD.
1st: OTC antacids or H2RAs
2nd: PPI if prescription therapy needed
Night Sx: H2RA at night + PPI daytime
Nissen fundoplication if refractory to meds
What drugs should be avoided by patients with GERD?
beta agonist, alpha antagonist, nitrates, CCBs, anticholinergics, theophylline, morphine, meperidine, diazepam, barbiturates
List some lifestyle modifications recommended for patients with GERD.
Elevate HoB, avoid recumbency for 3 hours after eating, eat small meals, avoid fatty/spicy, citrus, chocolate, caffeinated products, peppermint; decrease alcohol, weight loss, smoke cessation
List risk factors for GERD.
Obesity, pregnancy, diabetes, hiatal hernia, connective tissue disorders.
Resume on page 25 with hemorrhoids.
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