GI Block 1 Flashcards
Differential Dx for URQ
Gallstones
Stomach ulcer
Pancreatitis
Differential Dx for Epigastric Region
Stomach ulcer Dyspepsia Pancreatitis Gallstones Epigastric hernia
Differential Dx for ULQ
Stomach/Duodenal ulcer
Pancreatitis
Biliary colic
Differential Dx for RLR?
Kidney stones
UTI
Constipation
Lumber hernia
Differential Dx for Umbilical Region?
Pancreatitis
Early appendicitis
IBS
Umbilical hernia
Differential Dx for LLR?
Kidney stones
Diverticulitis
Constipation
Inflammatory bowel
Differential Dx for LRR?
Appendicitis Constipation Pelvic pain Groin pain Inguinal hernia
Differential Dx for Suprapubic Region?
UTI Appendicitis Diverticulitis Inflammatory bowel Pelvic Pain
Differential Dx for LLQ?
Diverticulitis
Pelvic pain
Groin pain
Inguinal hernia
Define Dyspepsia
Acute, chronic, recurrent pain centered in upper abdomen
AKA- upset stomach
Only relevant if > 1mon
How can dyspepsia be a result of food/drug interolerance?
Indigestion- too much, too soon, stress eating
High fat food
Alcohol/caffeiine
Meds- NSAIDs, ABX, DM, ACEI/ARB, SSRI, AntiLipids
What is the most common cause of chronic dyspepsia?
Functional dyspepsia, result of psychosocial stressors and encompasses 75% of PTs will have not obvious cause
What are some organic disorders that cause dyspepsia?
PUD- 5-15% GERD- 20% Neoplasm- less than 1% Lactose intolerance Gastroparesis- DM
Dyspepsia in the absence of PUD means?
H. Pylori
How is dyspepsia from pancreatic/biliary tract disease distinguished?
Sx of more serious issue
Distinguished by severe pain
What are miscellaneous comorbidities of dyspepsia?
Diabetes
Thyroid disease
CKD
MI
What are the five alarm signs of dyspepsia?
Weight loss Dysphagia Recurrent vomiting GI bleed Anemia
Physical exam of PT with dyspepsia will present how?
Unremarkable
Mild epigastric TTP
R/o of organomegaly, mass, focal/severe TTP
What lab tests are ordered for dyspepsia?
CBC
Chem 17 (CMP)
Thyroid panel
H Pylori
Additional:
Celiac Dz
Stool- ova/parasite
Fecal fat
WHen does a PT with dyspepsia go in for an EGD?
S/Sx suggest etiology other than uncomplicated dyspepsia (ulcer, esophagitis, malignancy)
Or
Failure to respond to therapy in 6 wks
PTs receive an EGD without delay or 6wk therapy period if what two conditions exist?
Over 60 w/ new onset
All PTs with alarm signs
Purpose of an EGD
Examine lining of esophagus, stomach and firs part of small intestine
What is the initial empiric treatment for dyspepsia?
Young than 60y/o
No alarms
Consists of: H pylori tests, PPI x 4wks
Characteristics of H Pylori?
Spiral Gram neg rod- resides adjacent to epithelial cells as mucosal surface and gastric pits
What are three times H pylori testing is indicated?
Dypeptic PTs
Chronic GERD
Suspected/confirmed GERD
What are the three types of H Pylori tests?
Fecal Ag
Carbone 13 urea breath
H pylori serology
What is the Standard Triple Therapy H Pylori regim?
PPI PO BID
Clarithomycin 50mg PO BID
Amoxicillin 1g PO BID
(or metronidazole 500mg PO BID if PT has pcn allergy)
What is the Standard Quadruple Therapy H Pylori regim?
PPI PO BID
Bismuth subsalicylate- 2 tab PO QID
Tetracycline 500mg PO QID
Metronidazole 500mg PO TID
Both standard triple and quadruple therapies are given for __ days?
14
Once all organic causes of functional dyspepsia have been excluded, what is next?
Lifestyle changes
Pharmacotherapy- antisecretory/depressant/metoclopromide
Psychotherapy
Define Nausea
Vague, intense disagreeable sensation of sickness or queasiness, distinguished from anorexia
What causes vomiting?
Afferent vagal fibers from GI viscera- serotonin 5-HT3 receptors
Vestibular fiber stimulation
High CNS
Chemoreceptor trigger zone
What type of senses can stimulate Serotoning 5-HT3 receptors to puke?
Biliary/GI distension
Mucosal/periotneal irritation
Infections
What type of stimulants can trigger the amygdala to puke?
Sight
Smell
Emotional experience
What type of stimulants can trigger the chemoreceptor zone to puke?
Drugs/chemo Toxins Hypoxia Uremia Acidosis Radiation therapy
What questions needs to be asked for a PT w/ N/V?
Hematemesis? Only nausea or N/V? Onset Meal relation Pain/location Meds Diet Contact w/ sicks GI/Systemic Sx
Cause of N/V without abdominal pain?
Food poisoning
Acute gastoenteritis
Systeic illness
Cause of N/V with abdominal pain?
Peritoneal irritation
Acute obstruction
Gastroparesis
How can a PT complaining of N/V be assess for dehydration?
Dry mucous membranes
Sking turgor
Orthostat VS
N/V abdominal pain is to rule out what 3 things?
TTP
Distention
Organomegaly
Slide 35
OHOTN steps
How are OHOTN measurements interpreted?
Substract values 3min after standing from lying value
>20mm SBP or .10mmg DBP after 3min of standing is OHOTN
What type of HR change is indicative of OHOTN?
Inc of 30bpm after 3min of standing mean hypovolemia
Although not always necessary, what labs can be done for N/V PTs?
CBC
BMP/CMP- E+, serum pH, Liver enzyme, amyl/lipase
What types of imaging should be performed for N/V further work ups?
Typically not indicated unless Hx/Exam suggests focal cause
Plain- flat and upright
Ab CT
Complications of vomiting?
Dehydration HypoKalemia Metabolic alkalosis Aspiration Boerhaave Synd- esophagus rupture Mallory-Weiss- bleeding secondary to mucosal tear in GE junction
What is the treatment plan for N/V PTs?
Supportive: Fluids- frequent small sips of clear fluis BRAT Ginger "Don't forget to profile or work note"
What is the consequence of giving an IV to N/V PT?
Greater expansion of circulating volume for greater period of time compared to parenteral fluids
If PT in NPO, use an IV to prevent dehydration
What is the pharmacotherapy regim for N/V PTs?
Antiemetics:
Serotonin 5HT3 antagonist- Ondansetron
Dopamine antagonist- Promethazine/Procloperazine
Antihistamines- Meclizine, Dimenhydrinate, Scopolamine, Diphenhydramine
When Rx for N/V PTs, what is a consideration to remember?
Degree of vomiting, can they be tolerated
Define Singultus
Hiccups
Usually L>R
What are some causes of Benign, self-limiting hiccups?
Gastric distention
Sudden temp changes
Alcohol ingestion
Heightened emotion
Persistent hiccups can be indicative of what types of underlying issues?
CNS- neoplasm, infection, trauma Metabolic- uremia, hypcapnia Chronic vagus/phrenic irritation Post-Op Psychogenic
What are some treatment methods for hiccups?
Tsp of dry sugar Stim of nasopharynx Valsalva Re-breathing Scare Relieve gastric distension Chlorpromazein for intractable hiccups
Define Eructation
Belching- in/voluntary release of gas from stomach/esophagus most frequently after meals (distension results in transient lower sphincter relaxation)
Eructation is usually due to ?
Aerophagia
What are the two sources of gas for flatus?
Swallowed air
Bacterial fermentation of undigested carbs
Flatus contains numerous types of gas including?
O N H CO2 H2S, ammonia, methane
Foul smell= H2S, ammonia and methane
What is the FODMAPs acronym for?
Short chain carbs that cause farts
Fermentable Oligosaccharides Disaccharides Monosaccharides And Polypol
What are four categories of food that can cause farts?
Lactose
Fructose
Polypols
Fructans
Describe a Flatus workup and treatment
Investigate for malabsorption syndromes
Avoid FODMAPs
Beano
Simethicone
Dyspepsia is predominantly ______ and may be associated with ?
Epigastric pain
Fullness, N/V, heartburn, early satiety, Postprandial fullness for more than 1mon
PTs that are H Pylori negative or don’t improve after H Pylori eradication should be given ?
PPI trial
PTs with refractory Sx of dyspepsia should be prescribed ?
TCA
Prokinetics agent or,
Psychological therapy
What is the most common cause of chronic dyspepsia?
Functional Dyspepsia- no organic cause
Functional dyspepsia Sxs may arise form interactions of what stimulus?
Inc visceral afferent sensitivity
Gastric delayed emptying
Impaired food accommodation
Psychological stressors
PUD is in ?% of PTs with dyspepsia
GERD is in ? %
5-15%
20%
What are other causes of GI tract dysfunction other than PUD and GERD?
Gastroparesis- esp DM PTs
Parasite infection- Giardia, Strongyloides, Anisakis
S/Sx of pancreatic carcinomaa and/or chronic pancreatitis
Chronic epigastric pain but more severe Radiating to back Anorexia Rapid weight loss Steatrrhea Jaundice
What two biliary tract diseases need to be distinguished from dyspepsia?
Cholelithiasis
Choledocholithiasis
What are the “other” conditions that can accompany acute/chronic epigastric pain or discomfort?
DM Thyroid Dz CKD MI Intrabdominal malignancy Gastric volvulus Paraesophageal hernia Gastric ischemia Pregnancy
Since dyspepsia has non-specific Sx, the history has limitd usefulness but can clarify what four things?
Chronicity
Location
Quality
Relationship to meals
The pain of dyspepsia can be accompanied by what other upper abdominal Sx?
Post-pranial fullness
Hearburn
N/V
What are the red flags that signal the need for endoscopy or abdominal CT?
Weight loss Persistent vomiting Constant/severe pain Progressive dysphagia Hematemesis Melena
What two irritation factors need to be identified and removed from PTs complaining of dyspepsia?
Offending medications
Excessive alcohol
What are non-medical reasons PTs may seek care for dyspepsia Sx?
Employment Marital status Abuse Anxiety/depression Fear of diseases
PTs with functional dyspepsia usually have what characteristics?
Younger
Variety of abd/GI complaints
Signs of Anx/Dep
Hx of psychotropic meds
When a dyspepsia physical exam is rarely helpful, what other signs of serious organic disease need to be evaluated?
Weight loss
Organomegaly
Abdominal mass
Fecal occult blood
PTs older than 60 and CCO dyspepsia should have initial lab work that includes what studies?
Blood count E+ Liver enzymes Ca Thyroid function test
What is the initial lab work for PTs younger than 60 and complaining of dyspepsia?
Urea breath test
Fecal Ag test
If neg and no NSAIDs, PUD is virtually excluded
Stopped on
1384 Upper Endoscopy
