GI Block 1: Esophageal Dz - Flashcards
1
Q
What are the general S/Sx of esophageal dzs?
A
Pyrosis from reflux
Dysphagia- difficulty
Odynophagia- painful
2
Q
Define Oropharyngeal dysphagia
A
Difficulty with oral/pharyngeal phase of swelling
Pharyngeal dysphagia= immediate sense of bolus catching in neck
3
Q
Define Esophageal Dysphagia
A
Due to mechanical obstruction/motility disorder
4
Q
What is the difference between mechanical obstruction and motility?
A
Mechanical- solids
Motility- solids and liquids
5
Q
What is the study of choice for esophageal diseases?
A
EGD- study of choice for eval persistent heartburn, dysphagia, odynophagia and strucutre abnormalities and allows for direct visualization and biopsy
6
Q
What are the diagnostic studies than can be performed for esophageal diseases?
A
EGD
Barium esophagography
Esophageal manometry
Esophageal pH testing- most accurate studies for reflux, provides info on amount of acid reflux, eval PTs with persistent Sx after PPI use to find hypersenitivity, functional Sx and non-acid reflux
7
Q
What is the function of barium esophagography and esophageal manometry?
A
Barium- motility
E Manometry- tests LES function
Manometry indications- determine LES location, etiology of dysphagia, preop assessment of antireflux surgery
8
Q
Most PTs experience mild GERD but what can happen if left untreated to small PT population?
A
Esophageal cancer
9
Q
What are the GERD etiologies?
A
DADs Hernia Dysfunction of LES- norm=10-35, reflux=less than 10 Hiatal hernia Abdominal esophageal clearance Delayed emptying
10
Q
How does GERD damage the esophagus?
A
4.0 pH acidity of refluxate which is caustic which can lead to mucosal dysplasia (reqs 2 Dx from pathologist)
11
Q
What are the clinical presentations of GERD?
A
1- heartburn less than 1min after eating/when reclining and relieved by antacids
Waterbrash
Chronic cough
Others- dysphagia, laryngitis, sore throat, chest pain, sleep difficulty
12
Q
What is waterbrash?
A
Regurgitation of sour fluid/tasteless saliva in mouth
13
Q
GERD is one the three most common causes of __
A
Chronic cough
14
Q
What will be found on exam of a GERD PT?
A
Unremarkable
15
Q
What are the DDxs for GERD?
A
Functional/Motility disorder Peptic ulcer Angina pectoris Eosiniophilic esophagitis Dyspepsia
16
Q
What is included in the GERD work up?
A
No studies initially unless alarm signs are present: Dysphagia Odynophagia Weight loss F/C/Ns Do NOT do barium swallow
17
Q
What is the next step for GERD PTs if Sx are not relieved by empiric anti-acid treatment?
A
EGD- test of choice for GERD PTs
Esophageal pH/LES manometry can be ordered by specialist
18
Q
What are the treatment steps for GERD PTs?
A
Typical Sx of heartburn and regurgitation- empirically w/ BID H2 antagonist or 1/day PPI x 4-8wks
Persistent Sx= further investigation
Alarms for automatic referral= dysphagia, odynophagia, weight loss, Fe deficient anemia
19
Q
What are the pharmacotherapies for GERT treatment?
A
OTC antacids- tums, rolaids
H2 receptor antagonists- Climetidine, Ranitidine, Famotidine
PPIs
20
Q
When are H2 antagonists taken by GERD PTs?
A
Prior to meals
Onset in 30min
Duration x 8hrs
21
Q
What are the PPIs for pharmacotherapy of GERD?
A
Omeprazole Rabeprazole Lansoprazole Esomeprazole Pantoprazole- doesn't req eating after taking All others, take 30m prior
22
Q
What class medications have higher efficacy for GERD?
A
PPIs
23
Q
What are the lifestyle modification steps for GERD PTs?
A
Mild/intermittent Sx- PRN OTC antacid or H2
Troublesome: PPI daily
24
Q
What is the next step for PTs that have persistent GERD Sx despite 4wks of once daily PPIs?
What is the next step if this is still ineffective?
A
Switch to BID dose
EGD referral
25
Any/all GERD PTs w/ alarm signs have ? happen to them?
Immediate referral for EGD
26
How are GERD PTs who wish to d/c PPI handles?
If after 8-12wks and Sx relief, use H2 inhibitor during weening process
Most will relapse
27
When is surgery an option for GERD PTs?
Refractory to treatment
| Severe dz
28
What is the Niseen Funcoplication procedure
Fundus wrapped around esophagus and sewn in place to reinforce LES
29
Characteristics of Barrett Esophagus?
Squamous epithelium replaced by metaplastic columnar cells w/ goblet and columnar cells (specialized intestinal metaplasia)
Looks like orange, gastric type epitherlium from stomach to esophagus
30
Development of Barrett's has what dark benefit?
| What does the benefit come with an adverse of?
GERD Sx reduced
Inc risk of esophageal adenocarcinoma
31
What are the GERD complications?
Barretts- 3 types of columnar epithelium may be identified: gastric cardiac/fundic, and specialized intestinal metaplasia.
Stricture
32
Characteristics of peptic stricture?
Narrowing of esophageal lumen at GEJ w/ progressive solid food dysphagia that require endoscopy and biopsy to differentiate
33
How are peptic strictures treated?
Endoscopic dilation
| Refractory- injection of tramcinolone
34
What are the 3 causes of esophagitis?
Infectious- Candida, CMV, herpes
Pill induced- NSAIDs or Bisphosphonates, hospitalized/bed bound at higher risk- take w/ 4oz water and upright x 30min
Eosinophilic- asthma Sx and GERD non-responsive to antacids
These 3 are most commonly associated w/ odynophagia
35
Infectious esophagitis occurs mostly in ? PTs
Immunocompromised
| AIDS, transplant, leukemia/lymphoma, chronic immunosuppresive drugs (corticosteroids, biologics for RA, IBD)
36
How will immunosuppressed PTs present with infectious esophagitis?
Dysphagia
Odynophagia
Possible chest pain
37
How is infectious esophagitiss diagnosed and have the specific etiology determined?
EGD with biopsy
38
What is the sequence of treatment for immunosuppressed PTs with infectious esophagitis?
Treatment for specific etiology
Empiric anti-fungal (Fluconazole)
If not responsive in 5 days= EGD
39
What are the common offending agents that can cause pill-induced esophagitis?
```
CANKER A QZIZ
Vit C
Alendronate
NSAIDs
K/Cl pills
Emepronium bromide
Risedronate
ABX- doxy, tetra, clinda, trimetho
Quinidine
Zalcitabine
Fe
Zidovudine
```
40
Characteristics of eosinophilic esophagitis
Inflammatory response of esophagus to food/environmental allergen from infiltration of eosinophils
41
What is the end results of eosinophilic esophagitis
Inflammation leads to progressive dysphagia and narrowing of the lumen
42
What questions need to be asked for TP with eosinophilic esophagitis?
Hx of asthma
Allergies
Eczema
43
What will the clinical findings be for a PT with eosinophilic esophagitis?
Dysphagia to solids
| Heartburn
44
How is eosinophilic esophagitis diagnosed?
Barium swallow shows multiple corrugated rings "trachealization", edema and exudates
EGD with mucosal biopsy (4-8) and histology from prox and distal, will show eosinophilic infiltrates
45
How is eosinophilic esophagitis treated?
Empiric trial of PPIs first @ BID x 2mon
Refer to allergist
Topical corticosteroids- powdered fluticasone from inhaler, Budesonide in Sucralose suspension
46
Define esophageal webs/rings
Webs- thin membrane of squamous epithelium in mid/upper esophagus and most are axymptomatic
47
What S/Sx can be caused by esophageal webs?
Intermittent dysphagia or GERD like Sx
48
Define Esophageal Ring
Schatzki Rings
Circumferential mucosal structure in distal esophagus w/ similar Sx as webs
STRONG association to hiatal hernia
49
What is the diagnostic tests for esophageal webs/rings?
| How are they treated?
Barium swallow
Endoscopic dilation if Sx
PT with heartburn or repeat dilations should have PPI therapy
50
Define Zenker Diverticulum
Pharyngoesophageal diverticulum- "pouch"
51
What are the Sx of a Zenker Diverticulum
Progressive dysphagia
Sensation of food sticking in throat
Halitosis
Regurge of undigested foods
52
How is Zenker Diverticulum diagnosed?
How is it treated?
Viedosophagography/Barium swallow
| Sx PT may req myotomy
53
Define Achalasia
Idiopathic esophageal motility disorder with loss of normal peristalsis in distal 2/3 of esophagus causing impaired relaxation of LES
54
What are the S/Sx of Achalasia
Progressive dysphagia to solids AND liquids
Regurg of undigested food
Substernal discomfort after eating
Adoption of maneuvers to enhance emptying
Weight loss
55
How will achalasia present on PE?
| What are the diagnostic studies?
PE- unremarkable
Dx- Barium swallow showing Bird's Beak Deformity- tapering of distal portion of esophagus w/ EGD and Manometry to confirm
56
What is the DDX for Achalasia
Chagas Dz from T Cruzi if travel to Mexico/S America
| Mimics Sx of achalasia but more rapid onset
57
What are the treatment methods of achalasia
Botulinum toxin to LES
Pneumatic dilation
Surgery
58
Define Esophageal Varices
Dilated submucosal veins due to portal HTN, more than 50% will have cirrhosis, that cause severe UGI Bleeds/high mortality rates
NG tube then Dx w/ endoscopy
59
What are the Emergent, Acute and Follow-On treatments for esophageal varices
Emergent: hemostasis, stabilization
Acute: Octerotide, Vasopressin, Sengstaken-Blakemore tube (Somatostatin not used in US)
Chronic: reduce portal HTN, BB (propranolol) and variceal band ligation
60
What is the sequence of treatment for Mallory-Weiss Syndrome?
Stabilize
| Upper endoscopy
61
How are Mallory-Weiss Syndromes treated?
Endoscopic hemostatic agents- epi, cautery, endoclip
62
Define Boerhaave Syndrome and what are the S/Sx?
Complete esophagus rupture
| Shock, pneumomediastium, general badness
63
Who is more likely to develop esophageal carcinoma and what type?
3:1 males to F
Squamour or adenocarcinoma
Late presentation w/ adv dz
64
What are the S/Sx of esophageal carcinomas?
```
Progressive solid dysphagia
Odynophagia
Large unexplained weight loos
Body aches
Pains if metastasis
```
65
How are esophageal carcinomas diagnosed?
Non spec lab finding
Barium swallow to assess dysphagia
EGD for Dx
66
What are the treatment methods for esophageacl carcinoma?
Surgery
Chemo
Radiation
Less than 20% w/ 5yr survival
67
Heartburn, dysphagia and odynophagia almost always indicates what type of disorder?
Esophageal
68
Oropharyngeal phase of swalling involves what steps?
```
Tongue elevation
Nasopharynx closure
Relaxation of upper sphincter
Airway closure
Pharyngeal peristalsis
```
69
Problems with the oral phase of swallowing cause what issues?
Drooling
Food spillage
Inability to chew
Inability to initiate swallowing
70
How does pharyngeal dysphagia present?
Immediate sense of food stuck in neck
Need to repeatedly swallow
Couch/choke to clear food
Dysphonia, dysarthria, neurological Sx
71
PTs w/ mechanical obstruction have __ dysphagia and ones with motility disorders have ??
Dysphagia for solids- recurrent, predictable, worsens w/ lesion progression
Dysphagia for solid and liquid- episodic, unpredictable, progressive
72
What are the four causes of mechanical obstructions?
What are the four causes of motility disorders?
Schatzki ring, peptic stricture, esohpageal cancer, eosinophilic esophagitis
Achalasia, diffuse esophageal spasm, scleroderma, ineffective esophagus motility
73
Odynophagia usually is a sign of what issue?
| What is it most commonly associated with?
Severe erosive dz
Infectious esophagitis- Candida, Herpes, CMV
Candida- most common in HIV, linear yellow-white plaques, treat w/ Fluconazole, non-responsive w/ Itraconazole or Voriconazole refractory w/ Caspofungin.
HSV- shallow ulcers, treat with Acyclovir or Famciclovir, valacyclovir or Foscarnet if resistant
CMV- deep ulcers, treat with Ganciclovir, non-responsive or intolerant w/ Foscarnet
74
Dysphagia is best evaluated with what imaging modality
Rapid sequence Videoesophagography
75
PTs with esophageal dysphagia are often first evaluated with what imaging modality?
Barium swallow- more sensitive for detecting rings, achalasia and proximal esoph lesions
PT with dysphagia and suspected motility- barium
PT with mechanical lesion, endoscopic first endoscopy
76
What conditions are associated with diminished peristalsis?
Sjogren Syndrome
Anticholinergic meds
Oral radiation therapy
77
What do parietal, chief and G cells secrete?
Parietal- HCl and intrinsic
Chief- pepsinogen and gastric lipase
G- gastrin
78
Characteristics of Type 1 Hiatal Hernia
1= Sliding Hernia
Displaced GE junction above diaphargm
Stomach remain in place and fundus is below GE junction
79
Characteristics of Types 2-4 Hiatal Hernia
True hernia with hernia sac
| Upward dislocation of gastric fundus through defected phrenoesophageal membrane
80
How do hiatal hernias present?
How are they Dx?
How are they treated?
Sx of GERD
Barium swallow
Small- GERD management
Large- Surgical
81
# Define Gastropathy
Define Gastritis
Mucosal damage w/out inflammation
| Mucosal damage with inflammation
82
Gastritis is commonly secondary to ?
Gastropathy is commonly secondary to ?
Infectious or autoimmune etiology
Endengenous/exogenous irritants: ETOH, NSAID or stress
83
How are gastropathy and/or gastritis diagnosed?
Endoscopy with mucosal biopsy for dx and differentiation
84
What are the most common etiologies of erosive and hemorrhagic gastropathy?
NSAID
Alcohol
Physical stress- mechanical ventilation, coagulopathy, trauma, burns/shock, seps, CNCs injury, liver failure
Portal HTN
85
General S/Sx of erosive and hemorrhagic gastropathy?
Possible A-Sx
If Sx- anorexia, epigastric pain
Clinical manifestatio= upper GI bleed
86
Define Prostaglandin
Lipid derived from arachidonic acid generated by action of COX-1Where do isoenzymes
Generate inflammatory response
87
Prostaglandins stimulate epithelial cells to release ? and act as ?
BiCarb and mucus- reduce permeability and back-diffusion
Vasodilators- inc blood flow and injury resistance
88
Where do NSAIDs inhibit synthesis?
Prevent arachidonic acid to Cyclooxygenas to thromboxanes
89
NSAID gastropathy occurs in ? PT population
Chronic NSAID therapy, more frequently in COX-1 inhibitors
90
What are the COX-1 inhibitors that can cause NSAID Gastropathy
```
Aspirin
Ibuprofen
Naproxen
Indomethacin
Prioxicam
Oxaprozin
Diclofenac
```
91
What are the S/Sx of NSAID Gastropathy?
How is it treated?
Dyspepsia is most common presenting complaint
D/c NSAIDs, reduce to lowest effective dose, switch to COX-2, take with milk/meals and add daily PPI
92
What is the next step of treatment for NSAID Gastropathy if Sx don't improve or alarms are present?
Weight loss, severe pain, GI bleed, anemia
Send for upper endoscopy
93
How/why does alcohol catalyze gastropathy?
Impairs motility and leads to delayed gastric emptying leading to prlonged contact with gastric mucosa
94
What are the S/Sx of alcoholic gastritis?
How is it treated?
Dyspepsia, N/V, minor hematemesis
D/c ETOH. Use H2 or PPI x 2-4wks or Sucralfate
95
When/who is stress gastropathy seen in?
Critically ill PTs
| Highest risk of bleed w/ coagulopathy, respiratory failure w/ mechanical ventilation
96
Critically ill/bedridden PTs should receive ? prophylaxis?
Gastric acid suppression- IV PPIs
97
What is the treatment for stress gastropathy active bleeds?
H2 antagonists
| IV PPI
98
Define Portal HTN Gastropathy?
Gastric sub/mucosa congestion of capillaries and venules leading to inc gastric mucosal blood flow
99
What does portal HTN gastropathy treatment involve?
BB to dec portal press
100
H Pylori causes inflammation with wat two cells?
Neutrophilic and lymphocytic infiltration
101
How will H Pylori gastritis present in clinic?
Related to dyspepsia, 35% will be A-Sx
102
What class meds needs to be d/c'd prior to H Pylori testing?
What is the f/u testing?
D/C anti-secretory therapy x 2wks prior
Eradication confirmation 4wks after treatment completion
103
What are the other types of gastritis?
Pernicious anemia- B12 def
Infectious- bacteria, viral, fungi usually in immunocomp. pt
Eosinophilic- ab pain, early satiety, postprandial vomit
Menetrier Dz- idiopathic hypertrophic gastropathy
104
PUD is a break in what layer of mucosa?
Gastric or Duodenal from impaired defense mechanisms that is 5x more common in duodenum
105
Duodenal ulcers are more common in ? PT
| Gastric ulcer is more common in ?
Younger PT
Older, 55-70
106
Other than H Pylori and NSAIDs, what are the other etiologies of PUD?
```
Hypersecretory condition
CMV
Chronic Dz
Crohns
Lymphoma
```
107
S/Sx of PUD
Dyspepsia- most common, gnawing, aching hunger pain that are cyclic and relieved with food/antacids
108
UP to 70% of ulcers are A-Sx so PTs present with ?
Bleeding
| Perforation
109
How is PUD diagnosed?
What labs are ordered?
EGD
CBC, FOBT, H Pylori
110
How to treat PUD ulcers
NSAID related- dc, lowest dose and COX-2 (Celecoxib, Etodolac, Meloxicam)
Pylori- 3/4 therapy
General- PPIs are first line, eat at regular intervals, stop smoking
111
What meds can be given to PUD for mucosal defenses?
Sucralfate- forms coating at site of ulceration
Misoprostol- prostaglandin analog given as prophylaxis for long term NSAID PT
112
PUD have high incidence of bleeding ulcer but low mortality, may present how?
PUD Sx
Hematemesis
Melena
113
How are acute upper GI bleeds from PUD treated?
Endoscopy
| Hemostasis
114
How do PUD ulcer's perforate?
What are the S/Sx?
Chemical peritonitis
Sudden/severe ab pain, rigid abdomen, reduced sounds, pneumoperitoneum
115
How many PUD ulcer perforations spontaneously seal?
40%, adhered omentum
116
How are perforated PUD ulcers treated?
```
Fluids
NG suction
IV PPI
ABX
Surgery if- free air, peritonitis, deterioration during admission
```
117
Define PUD Ulcer penetration?
Penetration of ulcer through bowel wall without perforation/leakage into peritoneal cavity
Penetration to pancreas, liver, biliary tree
118
What do PTs with ulcer penetration complain of?
Change in PUD Sx- frequency of dyspepsia (inc frequency, pain, radiation to back)
Lack of relief w/ food or antacids
119
# Define Gastric Outlet Obstruction
What are the S/Sx
Chronic edema of pylorus/duodenal bulb
Early satiety, postprandial vomiting, weight loss
120
What is the treatment for gastric outlet obstruction
High dose PPI: IV LIquid Pill
| Endoscopic dilation
121
Define Zollinger Ellison Syndrome
Gastrinoma; gastrin secreting neuroendocrine tumor
| causing hypergastrinemia and hypersecretion of gastric acids
122
80% of gastrinomas occur within what region?
Gastrinoma Triangle:
Porta Hepatis
Pancreatic Neck
3rd portion of duodenum
123
What are the 3 gastrinoma locations and what type of PT are they common in?
Pancreas
Duodenal wall
Lymph Nodes
MEN-1
124
90% of Zollinger PTs will present ?
PUD
125
How are Zollinger PTs tested?
```
Fasting gastrin in PTs:
W/ refractory ulcer
PUD
FamHx of MEN1
PUD w/out NSAIDs and Pylori neg
```
126
Once Zollingers is confirmed, what is the next step?
Referral to GI
127
Define Gastroparesis
Delayed emptying in absence of mechanical obstruction but is uncommon in GenPop
128
When/where is gastroparesis most commonly seen?
Idiopathic w/ strong link to Diabetes or gastric surgery complication (injury to vagus nerve)
129
What are the cardinal Sx of gastroparesis?
```
N/V
Early saitety
Bloating
Ab pain
Weight loss
```
130
What is a PE for gastroparesis going to show?
Unremarkable, suspicion based on Hx and Sx
Must r/o mechanical obstruction w/ endoscopy/CT
Refer to EGD and GI
131
What treatment do acute gastroparesis exacerbations require?
NG decompression
| IV/E+ replacement
132
What are the general treatment measures of gastroparesis
Dietary mods- small, avoid high fat, avoid carbonation/ETOH and nicotine
Optimize glycemic control in DM
133
What prokinetic meds can be used in gastroparesis?
Metoclopramide
Domperidone
Erthromycin
134
What is one of the most common cancers worldwide?
Gastric Adenocarcinoma
Highest in E Asia, Europe and S America
Men > Women
135
Why is gastric adenocarcinoma associated w/ high mortality?
What are the S/Sx?
A-Sx until advanced
Dyspepsia, Epigastric Pain, Anorexia, Early Satiety, Weight loss, Dysphagia
136
What are the two classic signs of metastatic disease?
Sister Mary Joseph Nodule
| Virchow Node
137
What are the diagnostic studies for gastric adenocarcinoma?
Labs- CBC (anemia) and LFTs (elevated)
Endoscopy- confirms Dx
CT/PET after confirmation to locate metastasis
138
What are the treatments for gastric adenocarcinoma?
Surgery
Chemo
Radiation
139
Define Gastric Lymphoma
Secondary tumors from spread of Non-Hodgkin Lymphoma
Primary tumor- MALT, associated w/ Pylori
140
Gastric lymphoma presentation, Dx and Tx is similar to what other Dz?
Adenocarcinoma
141
Define Carcinoid Tumor
Neuroendocrine tumor originating in digestive tract or lungs
142
Define Carcinoid Syndrome
Constellation of Sx from jumoral factors elaborated by some carcinoid tumors
143
S/Sx of Carcinoid Syndrome
```
Begins suddenly
Last 30min involving face, neck and upper chest
Mild burning association
Venous telangiectasias
Diarrhea- water, no blood, cramping
```
144
When does Infantile Hypertrophic Pyloric Stenosis present?
3-6wks
Immediate projectile vomit
Hungry immediately after
145
What will PE on infant with Pyloric Stenosis show?
Undernourished
Dehydrated
Palaption of "olive" in RUQ- hypertrophic pylorus
146
What imaging is done for Pyloric Stenosis?
How is it treated
Necessary when suspected regardless of "olive" finding
US
Surgical pyloromyotomy
147
What is a vestigial organ and a true diverticulum of the cecum?
Vermiform appendix
148
Appendix has constant attachment at ? and variable locations of the ?
Base of cecum
| Variable tip- retrocecal, subceccal (most common), pre/postileal, pelvic
149
What materials can block the appendix lumen?
```
Inflammation
Fecalith
Calculi
Infection
Tumor
```
150
What is the pathogenesis sequence of appendicitis?
```
Obstruct
Inc Press
Venous congestion
Infection
Necrosis
```
151
Untreated necrotic appendix can lead to ?
Perforation to sepsis in 36hrs
152
What are the clinical presentations of appendicitis?
Early vague colicky peri-umbilical pain
RLQ pain- McBurney's
Pain inc w/ peritoneal irritation- cough, bumps, jump
PT will be lying still
153
How does pregnancy complicate diagnosing appendicitis?
Migration of cecum
R flank pain
R subcostal pain
154
What are the S/Sx of appendicitis?
N/V
Anorexia
Low fever
High fever or rigor= perforation
155
What will be found on an appendicitis PE?
TTP at McBurney's to direct and rebound tenderness
| Guarding Rigidity
156
What are the special tests used for appendicitis?
```
Heel tap
Psoas
Obturator
Rovsing's Sign- LLQ palpation causes RLQ pain
McBurneys- 2/3 from umbilicus to ASIS
```
157
What are the labs/rads for appendicitis?
CBC CMP UA
| CT
158
What is the most important part of appendicitis care?
Surgery
159
What kind of ABX are given in the ED for appendicitis?
```
Broad Spect w/ Gran-neg and anaerobic coverage
Cefoxitin
Cefotetan
Ampicillin-Sulbactam
Ertapenem
```
160
Anorectal Dz includes what issues?
Hemorrhoids
Fissures
Anorectal infection- perianal abscess
Anal cancer
161
Define hemorrhoid
Normal vascular cusions in anal canal arising from vascular CT that drains to Sup/Inf hemorrhoidal veins
162
What are the functions of hemorrhoids?
Normal anal pressure
| Water-tight closure of canal
163
Location of internal hemorrhoids
Location of External Hemorrhoids
Prox to dentate line, arise from Sup Hemorrhoidal veins covered in columnar epithelium
Distal to dentate line, arise from inferior hemorrhoidal veins covered with squamous epithelium and contain somatic pain receptors
164
What are the etiologies of hemorrhoids?
```
Straining
Constipation
Prolonged sitting
Pregnancy
Obesity
Low fiber
```
165
Clinical presentation of hemorrhoids?
Red blood
Perianal itching
Mucoid discharge w/ stool
Pain= external
166
Prolapsed internal hemorrhoids can cause ?
Pruritus and leakage
167
During PE for hemorrhoids what is inspected for and what exam is necessary?
```
Skin tags
Fissures
Fistulas
Condyloma
Dermatitis
```
DRE, anoscopic exam if uncertain
168
General treatment measures for hemorrhoids?
High fiber diet
Inc fluid
Wet wipes
169
What medical treatments can be offered for hemorrhoids?
Astringents- Witch Hazel pads
Hydrocortisone
Anesthetics- Pramoxine, Dibucaine
Hydrocortisone suppositories
170
How are internal hemorrhoids treated?
Rubber band ligation
Sclerotherapy
Electrocoagulation
171
When is surgical treatment an option for hemorrhoids?
What is the risk?
Medical therapy failure or chronic, severe bleeds
Fecal incontinence
172
Define anal fissure
Tear in anoderm distal to dentate line
173
What is the most common cause of anal fissures?
How do chronic fissures develop?
Trauma during defecation
Spasm of internal sphincter causing impaired healing
174
Anal fissures that appear off midline raise suspicions of ?
```
CDT TSH C
Crohn's
HIV/AIDS
TB
Syphilis
Carcinoma
Trauma
```
175
Majority of anal fissures are where?
75% posterior
| 24% anterior
176
How do anal fissures present?
Severe/tearing pain during defecation
Chronic will have less pain
Hematochezia
Self induced constipation from defecation pain fear
177
PE of anal fissure will show ?
Epithelium tear
Painful spreading
Intolerable DRE
Sentinel pile- skin tag on edge of fissure
178
What are the treatments for anal fissures?
Sitz baths
Inc fiber/fluids
Docusate Sodium
Topical anesthetic- lidocaine
179
What are the treatment methods for chronic fissures?
Topical vasodilators- nifedipine, notroglycerin, diltiazem
| Botulinum toxin injection
180
What are the two surgical treatments for anal fissures?
Fissurectomy
| Lateral internal spincerotomy
181
Define perianal abscess
Collection of purulent material from glandular crypts in anus/rectum
182
Clinical presentation of perianal abscess?
Pain in region that's constant and not associated w/ defecation
Fever
Malaise
183
What must be done during PE for perianal abscess?
| How are they treated?
DRE
Simple- InD outpatient
Complex- (ischeorectal) inpatient, surgical
184
What are the complications of perianal abscesses?
Fistual formation- fistula in ano
Track forms connecting abscess to perirectal skin
Causes chronic drainage, pruritus, pain requiring surgical excision
185
Sx of infectious proctitis
Anorectal discomfort
Tenesmus
Constipation
Mucus/blood discharge
186
What is the etiology of infectious proctitis?
```
STI-
Gonorrhea
Syphilis
Chlamydia
Herpes
```
187
Infectious proctitis' other Sx based on the pathogen
Syphilis - chancre
Herpes - grouped vesicles
Gonorrhea - mucopurulent discharge
Chlamydia - slight discharge or A-Sx
188
Define Condylomata Acuminata
Anal warts w/ CCO itching, bleeding, or pain
189
What is a risk in immunocompromised PTs with condylomata acuminata?
Coalesce and obscure anal opening
190
Carcinomas of the anus are rare but the majority are ? cell
Who are the high risk PTs?
Squamous cell cancers
Anoreceptive intercourse
Anal warts
191
What is the clinical presentation of anus carcinoma?
Confused w/ hemorrhoids
| Bleeding, pain, mass
192
How are anus carcinomas diagnosed?
CT or MRI for Dx and find extent of spread
193
What are the 3 groups of diseases of the small bowel?
Malabsorption
Motility
Miscellaneous
194
What are the malabsorption disorders of the small bowel?
```
Celiac
Whipple
Tropical Sprue
Lactase deficiency
Bacterial over growth
Short bowel syndrome
```
195
What nutrients are absorbed in the duodenum?
Mg Ca Thiamin Riboflavin Fe PO4 Cu
| MCTRIP
196
What nutrients are absorbed in the jejunum?
Vit A D E K Folate
| FADE K
197
What nutrients are absorbed in the ileum?
Vit B12
Bile Salts and acids
BBNA
198
Malabsorption clinical manifestations can appear with ? S/Sx?
Steatorrhea
Micro/Macrocytic anemia- Fe, B12, Folate issue
Dairy intolerance
199
Define Celiac Sprue
Gluten sensitive enteropathy from immunologic response to gluten causing diffuse damage to proximal small intestine mucosa
200
Where is the protein gluten found?
Wheat Barley Rye
| Whole grains related to wheat: bulgur, farro, kamut, spelt, triticale and malt/brewer's yeast
201
What are the S/Sx of celiac dz?
```
Dyspepsia
Diarrhea
Steatorrhea
Weight Loss
Flatulence
Distension/bloat
Borborygmi
Weakness
```
202
What are the extraintestinal manifestations of celiac dz?
```
Fatigue
Depression
Fe deficient anemia
Amenorrhea
Transaminitis- high transaminase enzymes from liver
Dermatitis herpetiformis
```
203
Define Dermatitis Herpetiformis
Cutaneous manifestation
| Pruritic papules and vesicles on extensor surfaces of extremities, trunk, scalp and neck
204
What will be found during PE of Celiac Dz?
Depends on severity of malnourishment
Mild case- unremarkable
Severe- S/Sx of nutrient deficiencies
205
What labs are drawn for Celiac Dz?
CBC CMP UA
IgA test STARTs the Celiac Dz work up, no Dx value
IgA tTG -> Serum IgA -> IgG DGPs -> Mucosal biopsy
Specific Serology- IgA Transglutaminase Ab (test of choice)- if neg, but still suspicion, draw serum IgA levels to uncover undiagnosed IgA deficiency
Draw IgG deamidated gliadin peptides for PTs with identified IgA deficiency
206
Where are mucosal biopsies taken when testing for Celiac Dz?
Prox and Distal duodenum
Confirmation test in PTs w/ Pos serology
Normal biopsy= no Celiac
207
Histology exam of celiac Dz biopsy will have what appearance?
Blunting/atrophied villie
208
What are the DDx for Celiac Dz?
```
G CLIT
Gastroenteritis
Chronic Diarrhea
Lactose intolerance
IBS
Tropical Sprue
```
209
What is the diagnostic approach for Celiac Dz?
HPE
Serologic test
Gluten free diet trial
Biopsy if serology is pos or there's a high clinical suspicion
210
What is the treatment method for Celiac Dz?
Removal of all gluten from diet including oats (Sx gone in 2-3wks)
Dietician referral
211
What is the most common cause of Celiac Dz treatment failure?
What small risk remains?
How is treatment/diet compliance tested for?
Non-compliance
Slight risk of lymphoma and adenocarcinoma in GI tract
CBC
212
Define Whipple Disease
Rare multisystem illness from Bacillus Tropheryma Whippelii, most commonly in White Males 30-50y/o but is not spread human-human
Fatal if untreated
213
What population is Whipple Disease most commonly seen in?
Farm workers
Sewage workers
Contact from sewage/waste water
214
What is the clinical presentation of Whipple Disease?
```
First= migratory arthralgias (large joints)
Diarrhea w/ flatulence, steatorrhea
Ab pain
Weight loss
Fever w/ UNK origin
```
215
What are the three less common signs of Whipple Disease?
Skin hyperpigmentation
General lymphadenopathy
Ophthalmoplegia
Nystagmus
216
What are the S/Sx of Whipple's Dz?
How is Whipple Dz diagnosed?
DePALM
Encephalopathy, Lymphadenopathy, Malabsorption, Diarrhea, Arthritis, PAS stain
Tropherhyma whippli bacilli in macrophages
Bacteria filled macrophages and lipids pool in mucosa
Duodenal mucosal Biopsy w/ Periodic Acid-Schiff Positive macrophage "foamy macrophages" (characteristic bacillus)
217
How is Whipple Dz treated?
IV Ceftriaxone x 2wks
TMP-SMX DS- 1 tab PO BID x 12mon
Trimethoprime sulfamethoxanole
218
Location of Tropical Sprue
Environmental enteropathy/tropical malabsorption occurring in narrow band above and below 30* line equator
219
Define Tropical Sprue
Chronic diarrhea dz involving whole sm intestine of infectious origin often seen following acute diarrhea dz
220
How is Tropical Sprue characterized in clinic?
Malabsorption of nutrients especially Folic Acid and B12
221
What are the S/Sx of Tropical Sprue?
```
Chronic Diarrhea
Steatorrhea
Weight loss
Anorexia
Malaise
Glossitis and Chelitis from B12 and Folate deficiency
```
222
What labs will be seen in PTs with Tropical Sprue?
CBC- megaloblastic anemia
223
What will endoscopy with biopsy show in PTs with Tropical Sprue?
Gross- flattening of duodenal folds
| Micro- short blunted villi and elongated crypts
224
How can acquiring Tropical Sprue be avoided?
Boil/bottle water
| Peel fruits prior to eating
225
How is Tropical Sprue treated?
TMP-SMX x 6mon (different than Whipple, 12mon)
| Folate, B12 supplements
226
Define Sprue
Dutch word for inflammation of mouth
227
Define Lactase
| What results if malabsorbed?
Brush border enzyme that hydrolyzes lactose into glucose and galactose.
Malabsorbed= fermented by bacteria to gas and organic acids
228
What 3 population groups have the highest epidemiology prevalence for lactose intolerance?
Asian- 95-100
American indian- 80-100
Black/Ashkenazi Jew- 60-80
229
What are the S/Sx of lactase deficiency?
Dose dependent-
Small= ASx
Mod= bloat, cramp, fart
Large= osmotic diarrhea
230
What should NOT be seen when examining PTs for lactase deficiency?
No weight loss or other S/Sx of malabsorption
| If weight loss- look for alternate etiology
231
How is lactase deficiency Dx?
Presumptive- free from diet x 2-3wks w/ Sx improvement
| H Breath test- Dx test for confirmation
232
How is Lactase Deficiency treated?
Reduced lactose diet
Titrate to Sx
Consider referral to dietician
233
WhaT PT populaion should bacterial overgrowth be considered in?
Chronic PPI therapy due to gastric achlorhydria (dec HCl)
Sm Int anatomic abnormality
SmInt motility disorder
Gastro/coloenteric fistula- Crohns, malignancy, surgical resection
234
What are the S/Sx of bacterial overgrowth?
```
Fart
Weight loss
Ab pain
Steatorrhea
Macrocytic anemia
HX and Sx have to match (PPT, abnormal anatomy, motility, fistula)
```
235
What is the treatment for bacterial overgrowth?
Empiric ABX against enteric an/aerobic bacteria:
Ciprofloxacin
Amoxicillin
Rifaximin
236
Define Short Bowel Syndrome
Due to removal of significant segments of small intestine
237
The type and degree of malabsorption depend on what things?
Length/sight of resection
| Degree of adaptation of remaining bowel
238
What are the 3 intestinal motility disorders?
Acute paralytic Ileus
Chronic Intestinal Pseduo-Obst
Small Bowel Obstruction
239
Define Acute Paralytic Ileus
Adynamic/post-op ileus
| Failure/loss of peristalsis w/out obstruction
240
Acute Paralytic Ileus is most commonly observed in ? PTs?
Hospitalized PTs due to:
Surgery
Illness- resp failure, sepsis, uremia
Meds- opiods, anticholinergics
241
What are the S/Sx of acute paralytic ileus?
```
Diffuse CONSTANT ab pain
N/V
Distension
LACK of TTP
Diminished/absent bowel sounds
```
242
What is the diagnostic tests for Acute Paralytic Ileus?
What are the images?
Labs are non-specific, obtain E+
Plain abd x-ray shows distended gas-filled loops in sm/l bowel
243
How is Acute Paralytic Ileus treated?
Supportive
| Pain, fluid/E+, bowel rest, nasogastric decompress (if distension or severe vomitting)
244
Define Chronic Intestinal Pseudo-Obstruction
Similar to gastroparesis
| Intermittent signs of obstruction w/out an actual obstruction
245
What are the S/Sx of chronic intestinal pseudo-obstruction
Abd distension
Vomit
Diarrhea
Varying malnutrition
246
What does a Pseudo-Obstruction work up include?
Exclude obstruction with CT or endoscopy
247
How are acute exacerbations of pseudo obstruction treated?
NG decompression
IV fluid/E+ replacement
Refer to GI
248
What are small bowel obstructions most commonly attributed to?
Post-op adnesions
Hernias
Other: FINGS
Neoplasm, Stricture, Foreign body, intussusception, Gallstones
249
What are the risk factors of small bowel obstructions?
```
Prior abd/pelvic surgery
Abd/groin hernia
Intestinal inflammation
Hx neoplasm
Prior irradiatioin
Hx of foreign body ingestion
```
250
How does a small bowel obstruction present?
Abrupt colicky ab pain
N/Profuse vomit
Obstipation- inability to take a dump or fart
251
What will the PE of a small bowel obstruction show?
Abd distension- tympany on percussion
Hyperactive bowel sounds early then hypoactive later
Sx of dehydration
252
What lab tests are ordered for small bowel obstruction?
CBC CMP UA
| Type and Crossmatch
253
What images are ordered for a small bowel obstruction?
Plain- upright /supine to ID dilated loops of small bowel with air-fluid levels
CT- if fever, tachy, focal pain or leukocytosis to Dx strangulated obstruction
254
How are small bowel obstructions treated?
```
Fluids
NG decompression
Pain
Anti-emetic
Early surgical consult
Admit
```
255
What are the complications from a small bowl obstruction?
Dilation
Compromised intramural vessle
Ischemia
Necrosis
256
Define Gallstone Ileus
Rare, impaction of gallstone in ileum after passing through b/e fistula as a complication of cholelithiasis
More common in female and older PTs
257
Define Intussusception
Segment of intestine invaginates into adjoining lumen causing an obstruction
258
What PT is Intussusception most commonly seen in and how is it identified?
Kids w/ currant jelly stool
259
What disease is rarely seen in the small intestine?
Primary malignancy
260
Neoplasms of the small bowel can cause ?
Intussusception
261
Characteristics of Adenocarcinoma
Most commonly in duodenum or porximal jejunum
| Presents w/ Sx of obstruction, chronic GI bleed or weight loss
262
Characteristics of Lymphomas
Inc in AIDS
Chronic immunosuppressive therapy
Crohn's Dz
263
What are the 4 types of small intestine neoplasms?
Adenocarcinoma
Lymphoma
Intestinal Carcinoid
Sarcoma
264
Define Protein Losing Enteropathy
Condition results in excessive loss of serum protein resulting in hypoalbuminemia usually as a result of established GI disorder
265
How is Protein-Losing Enteropathy treated?
Result of established GI disorder, treatment aimed at disorder:
Dietary therapy
Albumin replacement
266
Define Mesenteric Ischemia
Acute arterial occlusion- embolic or thrombotic
Mesenteric venous thrombosis
Non-occlusive- vasospasm, low CO
267
How is mesenteric ischemia found on PE?
What is the diagnostic test?
Pain out of proportion to exam
CT angiography
268
How is mesenteric ischemia treatment?
Admission:
Papaverine- smooth muscle relaxant
Thrombolytics
Surgical referral
269
Define Meckels Diverticulum
Most common congenital abnormality of GI tract
270
What is the Rule Of 2s for Meckel's?
```
2% of population
2:1 m/f ratio
2ft of ileocecal valve
2 types of mucosa- gastric and pancreatic
Sx before age off 2
```
271
How does Meckel's Diverticulum present?
Gi bleed- from hetertropic gastric mucosa causing ulcers and bleeding
Ab pain- most common anatomic location similarly to appendicitis
272
What PT population is Meckel's Diverticulum suspected in?
Under 10yo presenting w/ painless lower GI bleed w/out S/Sx
| Adults less than 40 with GI bleed w/out source ID
273
How is Meckel's Diverticulum diagnosed?
Capsule endoscopy
| Meckel Scan- nuclear med scan using 99m technetium pertechnetate due to it's affinity for gastric mucosa
274
How is Meckel's treated?
Stabilize of bleed is present
| Surgical removal
275
Adenocarcinoma won't be able to absorb nutrients in what section of intestine?
Ileum
276
What is the largest serous membrane of the body?
Peritoneum- layer of simple squamous w/ underlying aerolar CT
277
What are the most common causes of ascites?
```
Portal HTN- hepatic congestions from CHF, liver Dz- cirrhosis, hepatitis
Hypoabluminemia- nephrotic syndrome
Chylous, pancreatic, bile ascites
Infection
Malignancy
```
278
Function of the hepatic portal system?
Supplies liver w/ metabolites and ensured ingested substances are filtered prior to systemic circulation
279
What structures does the hepatic portal vein receive blood from?
What structures does the liver receive from?
Spenic vein and Superior mesenteric vein
| Proper hepatic artery and hepatic portal vein
280
Pathologic increase in portal pressure is what amount of increase?
Gradient between vein and IVC >10mm
281
What is the pathologic process of ascites?
Cirrhosis, inc intrahepatic vascular resistance, inc capillary pressure, inc hepatic lymph formation, ascites
282
What are the S/Sx of ascites
Primary Sx- bloating and inc girth, possible pain
283
What Hx questions for ascites PTs?
Hx liver dz/risk factors
Alcohol abuse
Risks of hepatitis
Hx of malignancy
284
What will be found on PE for ascites?
Sx of portal HTN- hepatic enlargement, elevated JVP, large abdominal wall veins
Sx of liver dz- muscle wasting, malnourishment
Shifting Dullness Test
Fever= bacterial peritonitis
285
What labs are done on ascites work ups?
```
Inspection of paracentesis
White GCAT
WBC
Albumin/total protein
Culture
Gram stain
```
286
SAAG equation
Serum albumin - ascitic fluid albumin
1.1 or higher= portal HTN
Less= other cause
287
What are the images for ascites?
Abdominal US- fluid and guiding needle
| Abdominal CT
288
Spontaneous bacterial peritonitis is typically due to ?
Ascites as a result of chronic liver dz
289
What are the common pathogens of Spontaneous Bacterial Peritonitis
```
E Coli
Klebsiella pneumonia
Strep pneumonia
Viridans strep
Enterococcus sp.
```
290
Ascites with abdominal TTP suggests ?
Other etiology source
291
What is the most important lab test for Spontaneous Bacterial Perotonitis?
```
Eval of ascetic fluid via paracentesis
Gram stain and culture
Cell count w/ differential
Cloudy= infection
Milky= chyle
Bloody= trauma/malignancy
```
292
What is the follow up imaging modality if Secondary Bacterial Peritonitis?
Abd CT
293
How is Spontaneous Bacterial Peritonitis treated?
Admit
Empiric- IV 3rd generation cephalosporin (Ceftriaxone)
Prophylaxis- Cipro or TMP-SMX DS once daily
294
Define Malignant Ascites
Carcinoma of blocked lymphatic channel
| Functional cirrhosis develops in PTs with hepatic metastases resulting in portal HTN
295
Define Chylous Ascites
Lipid rich chyle in peritoneal cavity due to lymph obstruction
296
Define Pancreatic Ascites
Intraperitoneal accumulation of pancreatic secretions due to disruption of pancreatic duct seen in chronic pancreatitis
297
What are the miscellaneous conditions of ascites?
Bile ascites- due to biliary tract surgery, percutaneous liver biopsy or abdominal trauma
Tuberculous peritonitis- rare in US from active TB w/ peritoneal involvement
Mesothelioma- from asbestos
298
Explain the LA classification grades of reflux esophagitis?
A- one or more isolated mucosal breaks 5mm or less
D- one or more breaks that involves 75% of esophageal circumference
299
How are PTs with infrequent heartburn (less than once per week) treated?
Antacids- contain Mg, don't use in CKD
| H2 antagonists
300
What criteria increase risks from esophageal verices?
Size
Red wale marking
Severity of liver dz
Active alcohol abuse
301
What meds can be used to lower portal HTN Gastropathy?
Propranolol
Nadolol
Propran failure- portal decompressive procedures
302
What are the two functions of the Ligament of Treitz?
Suspensory ligament of duodenum that widens the angle of the duodenal jejunal flexure to allow movement of intestinal contents
Divides U/L GI system
303
What are the three essentials of diagnosis for acute upper GI bleeds?
Hematemesis
Hypovolemia
Melena, possible or hematachezia in massive bleeds
304
What are the etiologies of acute upper GI bleeds?
```
PUD
Portal HTN
Mallory Weiss
Vascular abnormality
Neoplasm
Other- gastritis, esophagitis, Booerhave Synd.
```
305
How will upper GI bleeds present?
Hematemesis
Melena
Rare hematochezia
Possible epigastric/abd pain
306
What are the two follow on care steps for acute GI bleeds?
Endoscopy- all PTs w/ active upper bleeds within 24hrs of presentation to ID, assess risk of re-bleed and intervene w/ cautery, injection and band/clips
Pharmacotherapy
307
What are the steps of care for Unstable upper GI bleeds?
Start IV
CBC, PT/INR, CMP, Type and Screen
Fluid/blood replacement w/ isotonic fluid and 2-4 units of PRBC
NG Tube to aspirate
308
What criteria makes a PT at high risk for a re-bleed in the upper GI?
```
+60
Comorbid illness
SBP under 100
HR over 100
BRB on NG aspiration or rectal exam
High risk- admit to ICU
Other- admit to step down/ward
```
309
What is the follow on care pharmacotherapies for upper GI bleeds?
IV/PO PPI- lowers risk of re-bleeds for ulcers, erosion and MW tear
IV Octreotide- reduces poral HTN and lowers re-bleeds risk from the HTN
310
Essentials of Dx for Acute Lower GI bleeds?
Hematochezia
311
What are two differences about lower bleeds than upper bleeds?
Lower bleed majority come from colon
| Lower bleeds have lower risk of serious blood loss
312
Etiologies of lower bleeds?
```
Anorectal Dz
Diverticulosis
IBDz
Infectious colitis
Neoplasm
Angioectasis
Ischemic colitis
```
313
S/Sx of diverticulosis bleeds?
Painless BRB in large volumes
314
How will lower GI bleeds present?
Hematochezia- w or w/out pain
315
What are thee common causes of lower GI bleeds in PTs under 50y/o
Anorectal Dz
IBDz
Infectious colitis
316
What are the four common causes of lower GI bleeds in PTs over 50y/o
Diverticulosis
Malignancy
Angioectasis
Ischemic colitis
317
LGI bleed that is bright red = ?
| Maroon = ? Black = ?
Bright- left colon source: hemorrhoids, fissure, diverticulitis, IBD, colitis
Maroon- small intestine, right colon source
Black- upper GI
318
PTs presenting with painful defecation means ?
External hemorrhoids
| Anal fissure
319
PTs preseting with abdominal pain/cramps and lower GI bleeds = ?
IBD
| Colitis
320
Painless lower GI bleeds mean ?
Internal hemorrhoid
| Diverticular bleed
321
Large volume of LGI bleeds mean ?
| Small volume means ?
Large- diverticular
| Small- IBD, hemorrhoids
322
What labs are drawn for acute lower GI bleeds?
CBC
| CMP- anemia= ominous sign, particularly for neoplasm
323
How are lower GI bleeds diagnosed?
First- exclude upper GI source
```
Anoscopy
Sigmoidoscopy
Colonoscopy
Technetium scan
Angiography
Capsule endoscopy
```
324
What are the treatments for acute lower GI bleeds?
Large vol= therapeutic colonoscopy- constriction injection, cautery and clip/band
Intra-arterial embolization
Surgery- last resort but indicated if +6 units of PRBCs in 24hrs or more than 10 units total
325
Define Obscure GI bleed
Unknown origin or persists after initial upper/lower endoscopic evaluation
326
How much blood can be lost in an occult GI bleed and not apparent?
100mL/day
327
How are occult bleeds identified?
FOBT
Fecal immunochemical test
Unexplained anemia on CBC
328
Occult GI bleeds must have ? investigated and ? lab test
Neoplasm
| CBC for anemia
329
+ FOBT w/out anemia= ?
| + FOBT w/ anemia= ?
Colonoscopy
| Upper endoscopy and colonoscopy
330
What are the primary etiologies of constipation?
```
More common
Structure abnormality
Systemic dz
Infrequent movement, bloating, straining
Hx of psychosocial disorder
```
331
What are the secondary etiologies of constipation?
Systemic Dz
Meds
Obstructing lesion
Sudden onset w/ prior Hx of constipation
332
What will PE of a constipated PT show?
Dullness to percusion in L quaadrants
| DRE- rule out strctural abnormalities
333
Colonoscopy should be performed in constipation PTs with what criteria?
+50y/o
Severe constipation
Sx of organic disorder
Alarms- hematochezia, weight loss, + FOBT, FamHx or IBDz
334
What lab results are pulled for constipation PTs?
Labs: CBC, CMP- Ca glucose, Thyroid panel
Rads: abd x-ray non-spec gas pattern
Endoscopy- colonoscpy or flex sigmoidscopy
335
What pharmacotherapies are used for constipation?
Osmotic
Stimulant
Surfactant
Enema
336
What are the osmotic laxatives?
Mag. Hydroxide
Polyeth. Glycol 3350
Polyeth. Glycol
Mag. Citrate
337
What are the stimulant laxatives?
| What is the stool surfactant?
Bisacodly and Senna
Ducosate Sodium
338
When are constipation PTs referred?
```
Refractory Sx to treatments
PTs with abnormal structure
Evidence of obstruction
Over 50
Alarm Sx
```
339
Common etiologies of acute non-inflammatory diarrhea?
Viral- Norovirus, Rotavirus
Protozoa- Giardia
340
Essentials for Dx of acute inflammatory diarrhea?
Less than 2wks
| Blood, pus or fever from invasive/toxin producing bacterium
341
Diagnostic evaluation of acute inflammatory diarrhea includes ? tests?
Cultures for E Coli H7
C Diff
Ova and Parasite
342
What are the acute inflammatory diarrhea etiologies?
E Coli
Shigella
Salmonella
C Diff
343
What are the lab tests for acute diarrhea evaluation?
```
Fecal leukocytes
Stool culture
OandP- reqs 3 samples
C Diff
Fecal lactoferrin- marker of intestinal inflammation
```
344
What are the anti-diarrhea meds?
Loperamide
| Bismuth subsalicylate
345
When are ABX considered for diarrhea PTs?
Non-hospital acquired w/ mod/sev fever, tenesmus or bloody stools
Presence of lactoferrin
Immunocompromised
Significant dehydration
346
ABX for diarrhea empiric treatment
Cipro 500mg BID 5-7d
Ofloxacin 400mg BID 5-7d
Levofloxacin 500mg 5-7d
Trimethoprim-Sulfamethoxazole BID
Doxycycline 100mg BID
347
What meds can be used for Traveler's Diarrhea?
Fluoroquinolones- 3 day course, not useful for SE Asia
Azithromycin- 1g
Rifaximin- 200mg TID x 3d
348
ABX for diarrhea are only recommended for which microbes?
```
GC CLASTS
Giardia
Cholera
C Diff
Listeriosis
Amebiasis
Salmonellosis
Traveler's Diarrhea
Shigellosis
```
349
Acute diarrhea PTs are admitted for what criteria?
```
Dehydration
Bloody diarrhea
Inflammatory/ischemia, toxin
Infection/sepsis
Severe/worse +70y/o
Hemolytic uremic syndrome
```
350
Define Osmotic Diarrhea
Inc stoop osmotic gap
Resolves w/ fasting
Causes: carb malabsorption, lax abuse, malabsorption syndrome
351
What needs to be considered in all PTs w/ chronic postprandial diarrhea
Carb malabsorption
352
Define Secretory Conditions
Inc intestinal secretion/dec absorption
High vol, watery stool
No/little change w/ fasting
Causes: endocrine tumor or bile salt malabsorption
353
What inflammatory conditions cause chronic diarrhea?
IBDz: Crohns, Ulcerative colitis
| Microscopic colitis
354
What chronic infections can cause chronic diarrhea?
Giardia
E Hystolytica
Cyclospora
Nematodes
355
What systemic conditions can cause chronic diarrhea?
Thyroid dz
| Diabetes
356
What is in a chronic diarrhea work up
Exclude commons: meds, IBS, lactose intolerance
| Eval etiology based on Sx
357
What labs are pulled for chronic diarrhea?
```
CBC
Chem 17
LFT
Thyroid
ESR
CRP
Stool studies: culture, leukocytes, lactoferrin, occult, OandP, E+
```
358
Why is a colonoscopy with biopsy performed?
| What other test can be ordered?
Exclude IBD and neoplasm
24 stool- total weight and fat
359
4 things that present with anorexia?
Tropical sprue
Adenocarcinoma
Gastropathy, erosive/hemorrhage
Appendicitis
360
4 things that present with steatorrhea?
```
Tropical COW
Tropical Sprue
Celiac
Over growth
Whipple
```
361
Two things that present with tenesmus and one consideration about tenesmus?
Presents- acute inflammatory diarrhea
Infectious proctitis
Consideration- empiric ABC treatment for acute diarrhea
362
If SAAG is > 1.1g and peritoneum is normal
Hepatic congestion
Liver Dz
Portal vein occlusion
363
If SAAG is < 1.1g and peritonium is normal ?
Hypoalbuminemia
| Miscellaneous: ascites, myxedema, ovarian dz
364
SAAG below 1.1g and with diseased peritoneum
Infection
Malignancy
Other- mediterranean fever, vasculitis, granulomatous peritonitis, eosinophilic peritonitis
365
What is the only -itis condition with SAAG >1.1g/dL since all others with -itis ending are below 1.1G
Constrictive pericarditis
366
Treatment for GI gas?
Investigate malabsorption
Food diary
Avoid FODMAPS
Beano, Simethicone
367
Constitutional Sx of Cancer
F/C/Ns
368
Ascites PT with focal TTP
CT to find source
369
What causes non-portal HTN ascites?
Infection
Malignancy
Inflammatory disorder of peritoneum
Ductal disruption
370
Ascetic fluid neutrophil PMN greater than 250 = ?
Bacterial peritonitis
371
How do you distinguish between spontaneous and secondary peritonitis?
Spontaneous will have lactate dehydrogenase, glucose or total protein
372
What drug is preferred over Octreotide and Somatostatin for esophageal varices management?
Terlipressin
| Contraindicated in PTs with coronary/cerebral/PVDs
