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IPAP > GI Block 1: Esophageal Dz - > Flashcards

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

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2
Q

Define Oropharyngeal dysphagia

A

Difficulty with oral/pharyngeal phase of swelling

Pharyngeal dysphagia= immediate sense of bolus catching in neck

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3
Q

Define Esophageal Dysphagia

A

Due to mechanical obstruction/motility disorder

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4
Q

What is the difference between mechanical obstruction and motility?

A

Mechanical- solids

Motility- solids and liquids

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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

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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

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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

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8
Q

Most PTs experience mild GERD but what can happen if left untreated to small PT population?

A

Esophageal cancer

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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
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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)

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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

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12
Q

What is waterbrash?

A

Regurgitation of sour fluid/tasteless saliva in mouth

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13
Q

GERD is one the three most common causes of __

A

Chronic cough

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14
Q

What will be found on exam of a GERD PT?

A

Unremarkable

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15
Q

What are the DDxs for GERD?

A 
Functional/Motility disorder
Peptic ulcer
Angina pectoris
Eosiniophilic esophagitis
Dyspepsia
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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
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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

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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

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19
Q

What are the pharmacotherapies for GERT treatment?

A

OTC antacids- tums, rolaids
H2 receptor antagonists- Climetidine, Ranitidine, Famotidine
PPIs

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20
Q

When are H2 antagonists taken by GERD PTs?

A

Prior to meals
Onset in 30min
Duration x 8hrs

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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
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22
Q

What class medications have higher efficacy for GERD?

A

PPIs

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23
Q

What are the lifestyle modification steps for GERD PTs?

A

Mild/intermittent Sx- PRN OTC antacid or H2

Troublesome: PPI daily

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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

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25
Q

Any/all GERD PTs w/ alarm signs have ? happen to them?

A

Immediate referral for EGD

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26
Q

How are GERD PTs who wish to d/c PPI handles?

A

If after 8-12wks and Sx relief, use H2 inhibitor during weening process
Most will relapse

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27
Q

When is surgery an option for GERD PTs?

A

Refractory to treatment

Severe dz

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28
Q

What is the Niseen Funcoplication procedure

A

Fundus wrapped around esophagus and sewn in place to reinforce LES

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29
Q

Characteristics of Barrett Esophagus?

A

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

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30
Q

Development of Barrett’s has what dark benefit?

What does the benefit come with an adverse of?

A

GERD Sx reduced

Inc risk of esophageal adenocarcinoma

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31
Q

What are the GERD complications?

A

Barretts- 3 types ​of columnar epithelium may be identified: ​gastric cardiac/fundic, and ​specialized intestinal metaplasia.
Stricture

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32
Q

Characteristics of peptic stricture?

A

Narrowing of esophageal lumen at GEJ w/ progressive solid food dysphagia that require endoscopy and biopsy to differentiate

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33
Q

How are peptic strictures treated?

A

Endoscopic dilation

Refractory- injection of tramcinolone

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34
Q

What are the 3 causes of esophagitis?

A

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

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35
Q

Infectious esophagitis occurs mostly in ? PTs

A

Immunocompromised

AIDS, transplant, leukemia/lymphoma, chronic immunosuppresive drugs (corticosteroids, biologics for RA, IBD)

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36
Q

How will immunosuppressed PTs present with infectious esophagitis?

A

Dysphagia
Odynophagia
Possible chest pain

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37
Q

How is infectious esophagitiss diagnosed and have the specific etiology determined?

A

EGD with biopsy

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38
Q

What is the sequence of treatment for immunosuppressed PTs with infectious esophagitis?

A

Treatment for specific etiology
Empiric anti-fungal (Fluconazole)
If not responsive in 5 days= EGD

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39
Q

What are the common offending agents that can cause pill-induced esophagitis?

A 
CANKER A QZIZ
Vit C
Alendronate
NSAIDs
K/Cl pills
Emepronium bromide
Risedronate
ABX- doxy, tetra, clinda, trimetho
Quinidine
Zalcitabine
Fe
Zidovudine
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40
Q

Characteristics of eosinophilic esophagitis

A

Inflammatory response of esophagus to food/environmental allergen from infiltration of eosinophils

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41
Q

What is the end results of eosinophilic esophagitis

A

Inflammation leads to progressive dysphagia and narrowing of the lumen

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42
Q

What questions need to be asked for TP with eosinophilic esophagitis?

A

Hx of asthma
Allergies
Eczema

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43
Q

What will the clinical findings be for a PT with eosinophilic esophagitis?

A

Dysphagia to solids

Heartburn

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44
Q

How is eosinophilic esophagitis diagnosed?

A

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

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45
Q

How is eosinophilic esophagitis treated?

A

Empiric trial of PPIs first @ BID x 2mon
Refer to allergist
Topical corticosteroids- powdered fluticasone from inhaler, Budesonide in Sucralose suspension

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46
Q

Define esophageal webs/rings

A

Webs- thin membrane of squamous epithelium in mid/upper esophagus and most are axymptomatic

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47
Q

What S/Sx can be caused by esophageal webs?

A

Intermittent dysphagia or GERD like Sx

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48
Q

Define Esophageal Ring

A

Schatzki Rings
Circumferential mucosal structure in distal esophagus w/ similar Sx as webs
STRONG association to hiatal hernia

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49
Q

What is the diagnostic tests for esophageal webs/rings?

How are they treated?

A

Barium swallow

Endoscopic dilation if Sx
PT with heartburn or repeat dilations should have PPI therapy

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50
Q

Define Zenker Diverticulum

A

Pharyngoesophageal diverticulum- “pouch”

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51
Q

What are the Sx of a Zenker Diverticulum

A

Progressive dysphagia
Sensation of food sticking in throat
Halitosis
Regurge of undigested foods

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52
Q

How is Zenker Diverticulum diagnosed?

How is it treated?

A

Viedosophagography/Barium swallow

Sx PT may req myotomy

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53
Q

Define Achalasia

A

Idiopathic esophageal motility disorder with loss of normal peristalsis in distal 2/3 of esophagus causing impaired relaxation of LES

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54
Q

What are the S/Sx of Achalasia

A

Progressive dysphagia to solids AND liquids
Regurg of undigested food
Substernal discomfort after eating
Adoption of maneuvers to enhance emptying
Weight loss

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55
Q

How will achalasia present on PE?

What are the diagnostic studies?

A

PE- unremarkable
Dx- Barium swallow showing Bird’s Beak Deformity- tapering of distal portion of esophagus w/ EGD and Manometry to confirm

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56
Q

What is the DDX for Achalasia

A

Chagas Dz from T Cruzi if travel to Mexico/S America

Mimics Sx of achalasia but more rapid onset

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57
Q

What are the treatment methods of achalasia

A

Botulinum toxin to LES
Pneumatic dilation
Surgery

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58
Q

Define Esophageal Varices

A

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

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59
Q

What are the Emergent, Acute and Follow-On treatments for esophageal varices

A

Emergent: hemostasis, stabilization
Acute: Octerotide, Vasopressin, Sengstaken-Blakemore tube (Somatostatin not used in US)
Chronic: reduce portal HTN, BB (propranolol) and variceal band ligation

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60
Q

What is the sequence of treatment for Mallory-Weiss Syndrome?

A

Stabilize

Upper endoscopy

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61
Q

How are Mallory-Weiss Syndromes treated?

A

Endoscopic hemostatic agents- epi, cautery, endoclip

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62
Q

Define Boerhaave Syndrome and what are the S/Sx?

A

Complete esophagus rupture

Shock, pneumomediastium, general badness

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63
Q

Who is more likely to develop esophageal carcinoma and what type?

A

3:1 males to F
Squamour or adenocarcinoma
Late presentation w/ adv dz

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64
Q

What are the S/Sx of esophageal carcinomas?

A 
Progressive solid dysphagia
Odynophagia
Large unexplained weight loos
Body aches
Pains if metastasis
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65
Q

How are esophageal carcinomas diagnosed?

A

Non spec lab finding
Barium swallow to assess dysphagia
EGD for Dx

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66
Q

What are the treatment methods for esophageacl carcinoma?

A

Surgery
Chemo
Radiation
Less than 20% w/ 5yr survival

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67
Q

Heartburn, dysphagia and odynophagia almost always indicates what type of disorder?

A

Esophageal

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68
Q

Oropharyngeal phase of swalling involves what steps?

A 
Tongue elevation
Nasopharynx closure
Relaxation of upper sphincter
Airway closure
Pharyngeal peristalsis
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69
Q

Problems with the oral phase of swallowing cause what issues?

A

Drooling
Food spillage
Inability to chew
Inability to initiate swallowing

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70
Q

How does pharyngeal dysphagia present?

A

Immediate sense of food stuck in neck
Need to repeatedly swallow
Couch/choke to clear food
Dysphonia, dysarthria, neurological Sx

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71
Q

PTs w/ mechanical obstruction have __ dysphagia and ones with motility disorders have ??

A

Dysphagia for solids- recurrent, predictable, worsens w/ lesion progression
Dysphagia for solid and liquid- episodic, unpredictable, progressive

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72
Q

What are the four causes of mechanical obstructions?

What are the four causes of motility disorders?

A

Schatzki ring, peptic stricture, esohpageal cancer, eosinophilic esophagitis

Achalasia, diffuse esophageal spasm, scleroderma, ineffective esophagus motility

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73
Q

Odynophagia usually is a sign of what issue?

What is it most commonly associated with?

A

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

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74
Q

Dysphagia is best evaluated with what imaging modality

A

Rapid sequence Videoesophagography

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75
Q

PTs with esophageal dysphagia are often first evaluated with what imaging modality?

A

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

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76
Q

What conditions are associated with diminished peristalsis?

A

Sjogren Syndrome
Anticholinergic meds
Oral radiation therapy

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77
Q

What do parietal, chief and G cells secrete?

A

Parietal- HCl and intrinsic
Chief- pepsinogen and gastric lipase
G- gastrin

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78
Q

Characteristics of Type 1 Hiatal Hernia

A

1= Sliding Hernia
Displaced GE junction above diaphargm
Stomach remain in place and fundus is below GE junction

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79
Q

Characteristics of Types 2-4 Hiatal Hernia

A

True hernia with hernia sac

Upward dislocation of gastric fundus through defected phrenoesophageal membrane

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80
Q

How do hiatal hernias present?

How are they Dx?

How are they treated?

A

Sx of GERD

Barium swallow

Small- GERD management
Large- Surgical

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81
Q

Define Gastropathy

Define Gastritis

A

Mucosal damage w/out inflammation

Mucosal damage with inflammation

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82
Q

Gastritis is commonly secondary to ?

Gastropathy is commonly secondary to ?

A

Infectious or autoimmune etiology

Endengenous/exogenous irritants: ETOH, NSAID or stress

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83
Q

How are gastropathy and/or gastritis diagnosed?

A

Endoscopy with mucosal biopsy for dx and differentiation

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84
Q

What are the most common etiologies of erosive and hemorrhagic gastropathy?

A

NSAID
Alcohol
Physical stress- mechanical ventilation, coagulopathy, trauma, burns/shock, seps, CNCs injury, liver failure
Portal HTN

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85
Q

General S/Sx of erosive and hemorrhagic gastropathy?

A

Possible A-Sx
If Sx- anorexia, epigastric pain
Clinical manifestatio= upper GI bleed

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86
Q

Define Prostaglandin

A

Lipid derived from arachidonic acid generated by action of COX-1Where do isoenzymes
Generate inflammatory response

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87
Q

Prostaglandins stimulate epithelial cells to release ? and act as ?

A

BiCarb and mucus- reduce permeability and back-diffusion

Vasodilators- inc blood flow and injury resistance

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88
Q

Where do NSAIDs inhibit synthesis?

A

Prevent arachidonic acid to Cyclooxygenas to thromboxanes

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89
Q

NSAID gastropathy occurs in ? PT population

A

Chronic NSAID therapy, more frequently in COX-1 inhibitors

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90
Q

What are the COX-1 inhibitors that can cause NSAID Gastropathy

A 
Aspirin
Ibuprofen
Naproxen
Indomethacin
Prioxicam
Oxaprozin
Diclofenac
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91
Q

What are the S/Sx of NSAID Gastropathy?

How is it treated?

A

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

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92
Q

What is the next step of treatment for NSAID Gastropathy if Sx don’t improve or alarms are present?

A

Weight loss, severe pain, GI bleed, anemia

Send for upper endoscopy

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93
Q

How/why does alcohol catalyze gastropathy?

A

Impairs motility and leads to delayed gastric emptying leading to prlonged contact with gastric mucosa

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94
Q

What are the S/Sx of alcoholic gastritis?

How is it treated?

A

Dyspepsia, N/V, minor hematemesis

D/c ETOH. Use H2 or PPI x 2-4wks or Sucralfate

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95
Q

When/who is stress gastropathy seen in?

A

Critically ill PTs

Highest risk of bleed w/ coagulopathy, respiratory failure w/ mechanical ventilation

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96
Q

Critically ill/bedridden PTs should receive ? prophylaxis?

A

Gastric acid suppression- IV PPIs

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97
Q

What is the treatment for stress gastropathy active bleeds?

A

H2 antagonists

IV PPI

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98
Q

Define Portal HTN Gastropathy?

A

Gastric sub/mucosa congestion of capillaries and venules leading to inc gastric mucosal blood flow

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99
Q

What does portal HTN gastropathy treatment involve?

A

BB to dec portal press

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100
Q

H Pylori causes inflammation with wat two cells?

A

Neutrophilic and lymphocytic infiltration

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101
Q

How will H Pylori gastritis present in clinic?

A

Related to dyspepsia, 35% will be A-Sx

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102
Q

What class meds needs to be d/c’d prior to H Pylori testing?

What is the f/u testing?

A

D/C anti-secretory therapy x 2wks prior

Eradication confirmation 4wks after treatment completion

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103
Q

What are the other types of gastritis?

A

Pernicious anemia- B12 def
Infectious- bacteria, viral, fungi usually in immunocomp. pt
Eosinophilic- ab pain, early satiety, postprandial vomit
Menetrier Dz- idiopathic hypertrophic gastropathy

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104
Q

PUD is a break in what layer of mucosa?

A

Gastric or Duodenal from impaired defense mechanisms that is 5x more common in duodenum

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105
Q

Duodenal ulcers are more common in ? PT

Gastric ulcer is more common in ?

A

Younger PT

Older, 55-70

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106
Q

Other than H Pylori and NSAIDs, what are the other etiologies of PUD?

A 
Hypersecretory condition
CMV
Chronic Dz
Crohns
Lymphoma
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107
Q

S/Sx of PUD

A

Dyspepsia- most common, gnawing, aching hunger pain that are cyclic and relieved with food/antacids

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108
Q

UP to 70% of ulcers are A-Sx so PTs present with ?

A

Bleeding

Perforation

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109
Q

How is PUD diagnosed?

What labs are ordered?

A

EGD

CBC, FOBT, H Pylori

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110
Q

How to treat PUD ulcers

A

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

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111
Q

What meds can be given to PUD for mucosal defenses?

A

Sucralfate- forms coating at site of ulceration

Misoprostol- prostaglandin analog given as prophylaxis for long term NSAID PT

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112
Q

PUD have high incidence of bleeding ulcer but low mortality, may present how?

A

PUD Sx
Hematemesis
Melena

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113
Q

How are acute upper GI bleeds from PUD treated?

A

Endoscopy

Hemostasis

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114
Q

How do PUD ulcer’s perforate?

What are the S/Sx?

A

Chemical peritonitis

Sudden/severe ab pain, rigid abdomen, reduced sounds, pneumoperitoneum

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115
Q

How many PUD ulcer perforations spontaneously seal?

A

40%, adhered omentum

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116
Q

How are perforated PUD ulcers treated?

A 
Fluids
NG suction
IV PPI
ABX
Surgery if- free air, peritonitis, deterioration during admission
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117
Q

Define PUD Ulcer penetration?

A

Penetration of ulcer through bowel wall without perforation/leakage into peritoneal cavity
Penetration to pancreas, liver, biliary tree

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118
Q

What do PTs with ulcer penetration complain of?

A

Change in PUD Sx- frequency of dyspepsia (inc frequency, pain, radiation to back)
Lack of relief w/ food or antacids

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119
Q

Define Gastric Outlet Obstruction

What are the S/Sx

A

Chronic edema of pylorus/duodenal bulb

Early satiety, postprandial vomiting, weight loss

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120
Q

What is the treatment for gastric outlet obstruction

A

High dose PPI: IV LIquid Pill

Endoscopic dilation

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121
Q

Define Zollinger Ellison Syndrome

A

Gastrinoma; gastrin secreting neuroendocrine tumor

causing hypergastrinemia and hypersecretion of gastric acids

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122
Q

80% of gastrinomas occur within what region?

A

Gastrinoma Triangle:
Porta Hepatis
Pancreatic Neck
3rd portion of duodenum

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123
Q

What are the 3 gastrinoma locations and what type of PT are they common in?

A

Pancreas
Duodenal wall
Lymph Nodes

MEN-1

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124
Q

90% of Zollinger PTs will present ?

A

PUD

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125
Q

How are Zollinger PTs tested?

A 
Fasting gastrin in PTs:
W/ refractory ulcer 
PUD  
FamHx of MEN1
PUD w/out NSAIDs and Pylori neg
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126
Q

Once Zollingers is confirmed, what is the next step?

A

Referral to GI

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127
Q

Define Gastroparesis

A

Delayed emptying in absence of mechanical obstruction but is uncommon in GenPop

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128
Q

When/where is gastroparesis most commonly seen?

A

Idiopathic w/ strong link to Diabetes or gastric surgery complication (injury to vagus nerve)

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129
Q

What are the cardinal Sx of gastroparesis?

A 
N/V
Early saitety
Bloating
Ab pain
Weight loss
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130
Q

What is a PE for gastroparesis going to show?

A

Unremarkable, suspicion based on Hx and Sx
Must r/o mechanical obstruction w/ endoscopy/CT
Refer to EGD and GI

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131
Q

What treatment do acute gastroparesis exacerbations require?

A

NG decompression

IV/E+ replacement

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132
Q

What are the general treatment measures of gastroparesis

A

Dietary mods- small, avoid high fat, avoid carbonation/ETOH and nicotine
Optimize glycemic control in DM

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133
Q

What prokinetic meds can be used in gastroparesis?

A

Metoclopramide
Domperidone
Erthromycin

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134
Q

What is one of the most common cancers worldwide?

A

Gastric Adenocarcinoma
Highest in E Asia, Europe and S America
Men > Women

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135
Q

Why is gastric adenocarcinoma associated w/ high mortality?

What are the S/Sx?

A

A-Sx until advanced

Dyspepsia, Epigastric Pain, Anorexia, Early Satiety, Weight loss, Dysphagia

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136
Q

What are the two classic signs of metastatic disease?

A

Sister Mary Joseph Nodule

Virchow Node

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137
Q

What are the diagnostic studies for gastric adenocarcinoma?

A

Labs- CBC (anemia) and LFTs (elevated)
Endoscopy- confirms Dx
CT/PET after confirmation to locate metastasis

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138
Q

What are the treatments for gastric adenocarcinoma?

A

Surgery
Chemo
Radiation

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139
Q

Define Gastric Lymphoma

A

Secondary tumors from spread of Non-Hodgkin Lymphoma

Primary tumor- MALT, associated w/ Pylori

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140
Q

Gastric lymphoma presentation, Dx and Tx is similar to what other Dz?

A

Adenocarcinoma

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141
Q

Define Carcinoid Tumor

A

Neuroendocrine tumor originating in digestive tract or lungs

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142
Q

Define Carcinoid Syndrome

A

Constellation of Sx from jumoral factors elaborated by some carcinoid tumors

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143
Q

S/Sx of Carcinoid Syndrome

A 
Begins suddenly
Last 30min involving face, neck and upper chest
Mild burning association
Venous telangiectasias
Diarrhea- water, no blood, cramping
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144
Q

When does Infantile Hypertrophic Pyloric Stenosis present?

A

3-6wks
Immediate projectile vomit
Hungry immediately after

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145
Q

What will PE on infant with Pyloric Stenosis show?

A

Undernourished
Dehydrated
Palaption of “olive” in RUQ- hypertrophic pylorus

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146
Q

What imaging is done for Pyloric Stenosis?

How is it treated

A

Necessary when suspected regardless of “olive” finding
US

Surgical pyloromyotomy

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147
Q

What is a vestigial organ and a true diverticulum of the cecum?

A

Vermiform appendix

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148
Q

Appendix has constant attachment at ? and variable locations of the ?

A

Base of cecum

Variable tip- retrocecal, subceccal (most common), pre/postileal, pelvic

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149
Q

What materials can block the appendix lumen?

A 
Inflammation
Fecalith
Calculi
Infection
Tumor
150
Q

What is the pathogenesis sequence of appendicitis?

A 
Obstruct
Inc Press
Venous congestion
Infection
Necrosis
151
Q

Untreated necrotic appendix can lead to ?

A

Perforation to sepsis in 36hrs

152
Q

What are the clinical presentations of appendicitis?

A

Early vague colicky peri-umbilical pain
RLQ pain- McBurney’s
Pain inc w/ peritoneal irritation- cough, bumps, jump
PT will be lying still

153
Q

How does pregnancy complicate diagnosing appendicitis?

A

Migration of cecum
R flank pain
R subcostal pain

154
Q

What are the S/Sx of appendicitis?

A

N/V
Anorexia
Low fever
High fever or rigor= perforation

155
Q

What will be found on an appendicitis PE?

A

TTP at McBurney’s to direct and rebound tenderness

Guarding Rigidity

156
Q

What are the special tests used for appendicitis?

A 
Heel tap
Psoas
Obturator
Rovsing's Sign- LLQ palpation causes RLQ pain
McBurneys- 2/3 from umbilicus to ASIS
157
Q

What are the labs/rads for appendicitis?

A

CBC CMP UA

CT

158
Q

What is the most important part of appendicitis care?

A

Surgery

159
Q

What kind of ABX are given in the ED for appendicitis?

A 
Broad Spect w/ Gran-neg and anaerobic coverage 
Cefoxitin
Cefotetan
Ampicillin-Sulbactam
Ertapenem
160
Q

Anorectal Dz includes what issues?

A

Hemorrhoids
Fissures
Anorectal infection- perianal abscess
Anal cancer

161
Q

Define hemorrhoid

A

Normal vascular cusions in anal canal arising from vascular CT that drains to Sup/Inf hemorrhoidal veins

162
Q

What are the functions of hemorrhoids?

A

Normal anal pressure

Water-tight closure of canal

163
Q

Location of internal hemorrhoids

Location of External Hemorrhoids

A

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
Q

What are the etiologies of hemorrhoids?

A 
Straining
Constipation
Prolonged sitting
Pregnancy
Obesity
Low fiber
165
Q

Clinical presentation of hemorrhoids?

A

Red blood
Perianal itching
Mucoid discharge w/ stool
Pain= external

166
Q

Prolapsed internal hemorrhoids can cause ?

A

Pruritus and leakage

167
Q

During PE for hemorrhoids what is inspected for and what exam is necessary?

A 
Skin tags
Fissures
Fistulas
Condyloma
Dermatitis

DRE, anoscopic exam if uncertain

168
Q

General treatment measures for hemorrhoids?

A

High fiber diet
Inc fluid
Wet wipes

169
Q

What medical treatments can be offered for hemorrhoids?

A

Astringents- Witch Hazel pads
Hydrocortisone
Anesthetics- Pramoxine, Dibucaine
Hydrocortisone suppositories

170
Q

How are internal hemorrhoids treated?

A

Rubber band ligation
Sclerotherapy
Electrocoagulation

171
Q

When is surgical treatment an option for hemorrhoids?

What is the risk?

A

Medical therapy failure or chronic, severe bleeds

Fecal incontinence

172
Q

Define anal fissure

A

Tear in anoderm distal to dentate line

173
Q

What is the most common cause of anal fissures?

How do chronic fissures develop?

A

Trauma during defecation

Spasm of internal sphincter causing impaired healing

174
Q

Anal fissures that appear off midline raise suspicions of ?

A 
CDT TSH C
Crohn's
HIV/AIDS
TB
Syphilis
Carcinoma
Trauma
175
Q

Majority of anal fissures are where?

A

75% posterior

24% anterior

176
Q

How do anal fissures present?

A

Severe/tearing pain during defecation
Chronic will have less pain
Hematochezia
Self induced constipation from defecation pain fear

177
Q

PE of anal fissure will show ?

A

Epithelium tear
Painful spreading
Intolerable DRE
Sentinel pile- skin tag on edge of fissure

178
Q

What are the treatments for anal fissures?

A

Sitz baths
Inc fiber/fluids
Docusate Sodium
Topical anesthetic- lidocaine

179
Q

What are the treatment methods for chronic fissures?

A

Topical vasodilators- nifedipine, notroglycerin, diltiazem

Botulinum toxin injection

180
Q

What are the two surgical treatments for anal fissures?

A

Fissurectomy

Lateral internal spincerotomy

181
Q

Define perianal abscess

A

Collection of purulent material from glandular crypts in anus/rectum

182
Q

Clinical presentation of perianal abscess?

A

Pain in region that’s constant and not associated w/ defecation
Fever
Malaise

183
Q

What must be done during PE for perianal abscess?

How are they treated?

A

DRE

Simple- InD outpatient
Complex- (ischeorectal) inpatient, surgical

184
Q

What are the complications of perianal abscesses?

A

Fistual formation- fistula in ano
Track forms connecting abscess to perirectal skin
Causes chronic drainage, pruritus, pain requiring surgical excision

185
Q

Sx of infectious proctitis

A

Anorectal discomfort
Tenesmus
Constipation
Mucus/blood discharge

186
Q

What is the etiology of infectious proctitis?

A 
STI-
Gonorrhea
Syphilis
Chlamydia
Herpes
187
Q

Infectious proctitis’ other Sx based on the pathogen

A

Syphilis - chancre
Herpes - grouped vesicles
Gonorrhea - mucopurulent discharge
Chlamydia - slight discharge or A-Sx

188
Q

Define Condylomata Acuminata

A

Anal warts w/ CCO itching, bleeding, or pain

189
Q

What is a risk in immunocompromised PTs with condylomata acuminata?

A

Coalesce and obscure anal opening

190
Q

Carcinomas of the anus are rare but the majority are ? cell

Who are the high risk PTs?

A

Squamous cell cancers

Anoreceptive intercourse
Anal warts

191
Q

What is the clinical presentation of anus carcinoma?

A

Confused w/ hemorrhoids

Bleeding, pain, mass

192
Q

How are anus carcinomas diagnosed?

A

CT or MRI for Dx and find extent of spread

193
Q

What are the 3 groups of diseases of the small bowel?

A

Malabsorption
Motility
Miscellaneous

194
Q

What are the malabsorption disorders of the small bowel?

A 
Celiac
Whipple
Tropical Sprue
Lactase deficiency
Bacterial over growth
Short bowel syndrome
195
Q

What nutrients are absorbed in the duodenum?

A

Mg Ca Thiamin Riboflavin Fe PO4 Cu

MCTRIP

196
Q

What nutrients are absorbed in the jejunum?

A

Vit A D E K Folate

FADE K

197
Q

What nutrients are absorbed in the ileum?

A

Vit B12
Bile Salts and acids
BBNA

198
Q

Malabsorption clinical manifestations can appear with ? S/Sx?

A

Steatorrhea
Micro/Macrocytic anemia- Fe, B12, Folate issue
Dairy intolerance

199
Q

Define Celiac Sprue

A

Gluten sensitive enteropathy from immunologic response to gluten causing diffuse damage to proximal small intestine mucosa

200
Q

Where is the protein gluten found?

A

Wheat Barley Rye

Whole grains related to wheat: bulgur, farro, kamut, spelt, triticale and malt/brewer’s yeast

201
Q

What are the S/Sx of celiac dz?

A 
Dyspepsia
Diarrhea
Steatorrhea
Weight Loss
Flatulence
Distension/bloat
Borborygmi
Weakness
202
Q

What are the extraintestinal manifestations of celiac dz?

A 
Fatigue
Depression
Fe deficient anemia
Amenorrhea
Transaminitis- high transaminase enzymes from liver
Dermatitis herpetiformis
203
Q

Define Dermatitis Herpetiformis

A

Cutaneous manifestation

Pruritic papules and vesicles on extensor surfaces of extremities, trunk, scalp and neck

204
Q

What will be found during PE of Celiac Dz?

A

Depends on severity of malnourishment
Mild case- unremarkable
Severe- S/Sx of nutrient deficiencies

205
Q

What labs are drawn for Celiac Dz?

A

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
Q

Where are mucosal biopsies taken when testing for Celiac Dz?

A

Prox and Distal duodenum
Confirmation test in PTs w/ Pos serology
Normal biopsy= no Celiac

207
Q

Histology exam of celiac Dz biopsy will have what appearance?

A

Blunting/atrophied villie

208
Q

What are the DDx for Celiac Dz?

A 
G CLIT
Gastroenteritis
Chronic Diarrhea
Lactose intolerance
IBS
Tropical Sprue
209
Q

What is the diagnostic approach for Celiac Dz?

A

HPE
Serologic test
Gluten free diet trial
Biopsy if serology is pos or there’s a high clinical suspicion

210
Q

What is the treatment method for Celiac Dz?

A

Removal of all gluten from diet including oats (Sx gone in 2-3wks)
Dietician referral

211
Q

What is the most common cause of Celiac Dz treatment failure?
What small risk remains?
How is treatment/diet compliance tested for?

A

Non-compliance
Slight risk of lymphoma and adenocarcinoma in GI tract
CBC

212
Q

Define Whipple Disease

A

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
Q

What population is Whipple Disease most commonly seen in?

A

Farm workers
Sewage workers
Contact from sewage/waste water

214
Q

What is the clinical presentation of Whipple Disease?

A 
First= migratory arthralgias (large joints)
Diarrhea w/ flatulence, steatorrhea
Ab pain
Weight loss
Fever w/ UNK origin
215
Q

What are the three less common signs of Whipple Disease?

A

Skin hyperpigmentation
General lymphadenopathy
Ophthalmoplegia
Nystagmus

216
Q

What are the S/Sx of Whipple’s Dz?

How is Whipple Dz diagnosed?

A

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
Q

How is Whipple Dz treated?

A

IV Ceftriaxone x 2wks
TMP-SMX DS- 1 tab PO BID x 12mon
Trimethoprime sulfamethoxanole

218
Q

Location of Tropical Sprue

A

Environmental enteropathy/tropical malabsorption occurring in narrow band above and below 30* line equator

219
Q

Define Tropical Sprue

A

Chronic diarrhea dz involving whole sm intestine of infectious origin often seen following acute diarrhea dz

220
Q

How is Tropical Sprue characterized in clinic?

A

Malabsorption of nutrients especially Folic Acid and B12

221
Q

What are the S/Sx of Tropical Sprue?

A 
Chronic Diarrhea
Steatorrhea
Weight loss
Anorexia
Malaise
Glossitis and Chelitis from B12 and Folate deficiency
222
Q

What labs will be seen in PTs with Tropical Sprue?

A

CBC- megaloblastic anemia

223
Q

What will endoscopy with biopsy show in PTs with Tropical Sprue?

A

Gross- flattening of duodenal folds

Micro- short blunted villi and elongated crypts

224
Q

How can acquiring Tropical Sprue be avoided?

A

Boil/bottle water

Peel fruits prior to eating

225
Q

How is Tropical Sprue treated?

A

TMP-SMX x 6mon (different than Whipple, 12mon)

Folate, B12 supplements

226
Q

Define Sprue

A

Dutch word for inflammation of mouth

227
Q

Define Lactase

What results if malabsorbed?

A

Brush border enzyme that hydrolyzes lactose into glucose and galactose.
Malabsorbed= fermented by bacteria to gas and organic acids

228
Q

What 3 population groups have the highest epidemiology prevalence for lactose intolerance?

A

Asian- 95-100
American indian- 80-100
Black/Ashkenazi Jew- 60-80

229
Q

What are the S/Sx of lactase deficiency?

A

Dose dependent-
Small= ASx
Mod= bloat, cramp, fart
Large= osmotic diarrhea

230
Q

What should NOT be seen when examining PTs for lactase deficiency?

A

No weight loss or other S/Sx of malabsorption

If weight loss- look for alternate etiology

231
Q

How is lactase deficiency Dx?

A

Presumptive- free from diet x 2-3wks w/ Sx improvement

H Breath test- Dx test for confirmation

232
Q

How is Lactase Deficiency treated?

A

Reduced lactose diet
Titrate to Sx
Consider referral to dietician

233
Q

WhaT PT populaion should bacterial overgrowth be considered in?

A

Chronic PPI therapy due to gastric achlorhydria (dec HCl)
Sm Int anatomic abnormality
SmInt motility disorder
Gastro/coloenteric fistula- Crohns, malignancy, surgical resection

234
Q

What are the S/Sx of bacterial overgrowth?

A 
Fart
Weight loss
Ab pain
Steatorrhea
Macrocytic anemia
HX and Sx have to match (PPT, abnormal anatomy, motility, fistula)
235
Q

What is the treatment for bacterial overgrowth?

A

Empiric ABX against enteric an/aerobic bacteria:
Ciprofloxacin
Amoxicillin
Rifaximin

236
Q

Define Short Bowel Syndrome

A

Due to removal of significant segments of small intestine

237
Q

The type and degree of malabsorption depend on what things?

A

Length/sight of resection

Degree of adaptation of remaining bowel

238
Q

What are the 3 intestinal motility disorders?

A

Acute paralytic Ileus
Chronic Intestinal Pseduo-Obst
Small Bowel Obstruction

239
Q

Define Acute Paralytic Ileus

A

Adynamic/post-op ileus

Failure/loss of peristalsis w/out obstruction

240
Q

Acute Paralytic Ileus is most commonly observed in ? PTs?

A

Hospitalized PTs due to:
Surgery
Illness- resp failure, sepsis, uremia
Meds- opiods, anticholinergics

241
Q

What are the S/Sx of acute paralytic ileus?

A 
Diffuse CONSTANT ab pain
N/V
Distension
LACK of TTP
Diminished/absent bowel sounds
242
Q

What is the diagnostic tests for Acute Paralytic Ileus?

What are the images?

A

Labs are non-specific, obtain E+

Plain abd x-ray shows distended gas-filled loops in sm/l bowel

243
Q

How is Acute Paralytic Ileus treated?

A

Supportive

Pain, fluid/E+, bowel rest, nasogastric decompress (if distension or severe vomitting)

244
Q

Define Chronic Intestinal Pseudo-Obstruction

A

Similar to gastroparesis

Intermittent signs of obstruction w/out an actual obstruction

245
Q

What are the S/Sx of chronic intestinal pseudo-obstruction

A

Abd distension
Vomit
Diarrhea
Varying malnutrition

246
Q

What does a Pseudo-Obstruction work up include?

A

Exclude obstruction with CT or endoscopy

247
Q

How are acute exacerbations of pseudo obstruction treated?

A

NG decompression
IV fluid/E+ replacement
Refer to GI

248
Q

What are small bowel obstructions most commonly attributed to?

A

Post-op adnesions
Hernias

Other: FINGS
Neoplasm, Stricture, Foreign body, intussusception, Gallstones

249
Q

What are the risk factors of small bowel obstructions?

A 
Prior abd/pelvic surgery
Abd/groin hernia
Intestinal inflammation
Hx neoplasm
Prior irradiatioin
Hx of foreign body ingestion
250
Q

How does a small bowel obstruction present?

A

Abrupt colicky ab pain
N/Profuse vomit
Obstipation- inability to take a dump or fart

251
Q

What will the PE of a small bowel obstruction show?

A

Abd distension- tympany on percussion
Hyperactive bowel sounds early then hypoactive later
Sx of dehydration

252
Q

What lab tests are ordered for small bowel obstruction?

A

CBC CMP UA

Type and Crossmatch

253
Q

What images are ordered for a small bowel obstruction?

A

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
Q

How are small bowel obstructions treated?

A 
Fluids
NG decompression
Pain
Anti-emetic
Early surgical consult
Admit
255
Q

What are the complications from a small bowl obstruction?

A

Dilation
Compromised intramural vessle
Ischemia
Necrosis

256
Q

Define Gallstone Ileus

A

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
Q

Define Intussusception

A

Segment of intestine invaginates into adjoining lumen causing an obstruction

258
Q

What PT is Intussusception most commonly seen in and how is it identified?

A

Kids w/ currant jelly stool

259
Q

What disease is rarely seen in the small intestine?

A

Primary malignancy

260
Q

Neoplasms of the small bowel can cause ?

A

Intussusception

261
Q

Characteristics of Adenocarcinoma

A

Most commonly in duodenum or porximal jejunum

Presents w/ Sx of obstruction, chronic GI bleed or weight loss

262
Q

Characteristics of Lymphomas

A

Inc in AIDS
Chronic immunosuppressive therapy
Crohn’s Dz

263
Q

What are the 4 types of small intestine neoplasms?

A

Adenocarcinoma
Lymphoma
Intestinal Carcinoid
Sarcoma

264
Q

Define Protein Losing Enteropathy

A

Condition results in excessive loss of serum protein resulting in hypoalbuminemia usually as a result of established GI disorder

265
Q

How is Protein-Losing Enteropathy treated?

A

Result of established GI disorder, treatment aimed at disorder:
Dietary therapy
Albumin replacement

266
Q

Define Mesenteric Ischemia

A

Acute arterial occlusion- embolic or thrombotic
Mesenteric venous thrombosis
Non-occlusive- vasospasm, low CO

267
Q

How is mesenteric ischemia found on PE?

What is the diagnostic test?

A

Pain out of proportion to exam

CT angiography

268
Q

How is mesenteric ischemia treatment?

A

Admission:
Papaverine- smooth muscle relaxant
Thrombolytics
Surgical referral

269
Q

Define Meckels Diverticulum

A

Most common congenital abnormality of GI tract

270
Q

What is the Rule Of 2s for Meckel’s?

A 
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
Q

How does Meckel’s Diverticulum present?

A

Gi bleed- from hetertropic gastric mucosa causing ulcers and bleeding

Ab pain- most common anatomic location similarly to appendicitis

272
Q

What PT population is Meckel’s Diverticulum suspected in?

A

Under 10yo presenting w/ painless lower GI bleed w/out S/Sx

Adults less than 40 with GI bleed w/out source ID

273
Q

How is Meckel’s Diverticulum diagnosed?

A

Capsule endoscopy

Meckel Scan- nuclear med scan using 99m technetium pertechnetate due to it’s affinity for gastric mucosa

274
Q

How is Meckel’s treated?

A

Stabilize of bleed is present

Surgical removal

275
Q

Adenocarcinoma won’t be able to absorb nutrients in what section of intestine?

A

Ileum

276
Q

What is the largest serous membrane of the body?

A

Peritoneum- layer of simple squamous w/ underlying aerolar CT

277
Q

What are the most common causes of ascites?

A 
Portal HTN- hepatic congestions from CHF, liver Dz- cirrhosis, hepatitis
Hypoabluminemia- nephrotic syndrome
Chylous, pancreatic, bile ascites
Infection
Malignancy
278
Q

Function of the hepatic portal system?

A

Supplies liver w/ metabolites and ensured ingested substances are filtered prior to systemic circulation

279
Q

What structures does the hepatic portal vein receive blood from?
What structures does the liver receive from?

A

Spenic vein and Superior mesenteric vein

Proper hepatic artery and hepatic portal vein

280
Q

Pathologic increase in portal pressure is what amount of increase?

A

Gradient between vein and IVC >10mm

281
Q

What is the pathologic process of ascites?

A

Cirrhosis, inc intrahepatic vascular resistance, inc capillary pressure, inc hepatic lymph formation, ascites

282
Q

What are the S/Sx of ascites

A

Primary Sx- bloating and inc girth, possible pain

283
Q

What Hx questions for ascites PTs?

A

Hx liver dz/risk factors
Alcohol abuse
Risks of hepatitis
Hx of malignancy

284
Q

What will be found on PE for ascites?

A

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
Q

What labs are done on ascites work ups?

A 
Inspection of paracentesis
White GCAT
WBC
Albumin/total protein
Culture
Gram stain
286
Q

SAAG equation

A

Serum albumin - ascitic fluid albumin
1.1 or higher= portal HTN
Less= other cause

287
Q

What are the images for ascites?

A

Abdominal US- fluid and guiding needle

Abdominal CT

288
Q

Spontaneous bacterial peritonitis is typically due to ?

A

Ascites as a result of chronic liver dz

289
Q

What are the common pathogens of Spontaneous Bacterial Peritonitis

A 
E Coli
Klebsiella pneumonia
Strep pneumonia
Viridans strep
Enterococcus sp.
290
Q

Ascites with abdominal TTP suggests ?

A

Other etiology source

291
Q

What is the most important lab test for Spontaneous Bacterial Perotonitis?

A 
Eval of ascetic fluid via paracentesis
Gram stain and culture
Cell count w/ differential
Cloudy= infection
Milky= chyle
Bloody= trauma/malignancy
292
Q

What is the follow up imaging modality if Secondary Bacterial Peritonitis?

A

Abd CT

293
Q

How is Spontaneous Bacterial Peritonitis treated?

A

Admit
Empiric- IV 3rd generation cephalosporin (Ceftriaxone)
Prophylaxis- Cipro or TMP-SMX DS once daily

294
Q

Define Malignant Ascites

A

Carcinoma of blocked lymphatic channel

Functional cirrhosis develops in PTs with hepatic metastases resulting in portal HTN

295
Q

Define Chylous Ascites

A

Lipid rich chyle in peritoneal cavity due to lymph obstruction

296
Q

Define Pancreatic Ascites

A

Intraperitoneal accumulation of pancreatic secretions due to disruption of pancreatic duct seen in chronic pancreatitis

297
Q

What are the miscellaneous conditions of ascites?

A

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
Q

Explain the LA classification grades of reflux esophagitis?

A

A- one or more isolated mucosal breaks 5mm or less

D- one or more breaks that involves 75% of esophageal circumference

299
Q

How are PTs with infrequent heartburn (less than once per week) treated?

A

Antacids- contain Mg, don’t use in CKD

H2 antagonists

300
Q

What criteria increase risks from esophageal verices?

A

Size
Red wale marking
Severity of liver dz
Active alcohol abuse

301
Q

What meds can be used to lower portal HTN Gastropathy?

A

Propranolol
Nadolol
Propran failure- portal decompressive procedures

302
Q

What are the two functions of the Ligament of Treitz?

A

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
Q

What are the three essentials of diagnosis for acute upper GI bleeds?

A

Hematemesis
Hypovolemia
Melena, possible or hematachezia in massive bleeds

304
Q

What are the etiologies of acute upper GI bleeds?

A 
PUD
Portal HTN
Mallory Weiss
Vascular abnormality
Neoplasm
Other- gastritis, esophagitis, Booerhave Synd.
305
Q

How will upper GI bleeds present?

A

Hematemesis
Melena
Rare hematochezia
Possible epigastric/abd pain

306
Q

What are the two follow on care steps for acute GI bleeds?

A

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
Q

What are the steps of care for Unstable upper GI bleeds?

A

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
Q

What criteria makes a PT at high risk for a re-bleed in the upper GI?

A 
\+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
Q

What is the follow on care pharmacotherapies for upper GI bleeds?

A

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
Q

Essentials of Dx for Acute Lower GI bleeds?

A

Hematochezia

311
Q

What are two differences about lower bleeds than upper bleeds?

A

Lower bleed majority come from colon

Lower bleeds have lower risk of serious blood loss

312
Q

Etiologies of lower bleeds?

A 
Anorectal Dz
Diverticulosis
IBDz
Infectious colitis
Neoplasm
Angioectasis
Ischemic colitis
313
Q

S/Sx of diverticulosis bleeds?

A

Painless BRB in large volumes

314
Q

How will lower GI bleeds present?

A

Hematochezia- w or w/out pain

315
Q

What are thee common causes of lower GI bleeds in PTs under 50y/o

A

Anorectal Dz
IBDz
Infectious colitis

316
Q

What are the four common causes of lower GI bleeds in PTs over 50y/o

A

Diverticulosis
Malignancy
Angioectasis
Ischemic colitis

317
Q

LGI bleed that is bright red = ?

Maroon = ? Black = ?

A

Bright- left colon source: hemorrhoids, fissure, diverticulitis, IBD, colitis
Maroon- small intestine, right colon source
Black- upper GI

318
Q

PTs presenting with painful defecation means ?

A

External hemorrhoids

Anal fissure

319
Q

PTs preseting with abdominal pain/cramps and lower GI bleeds = ?

A

IBD

Colitis

320
Q

Painless lower GI bleeds mean ?

A

Internal hemorrhoid

Diverticular bleed

321
Q

Large volume of LGI bleeds mean ?

Small volume means ?

A

Large- diverticular

Small- IBD, hemorrhoids

322
Q

What labs are drawn for acute lower GI bleeds?

A

CBC

CMP- anemia= ominous sign, particularly for neoplasm

323
Q

How are lower GI bleeds diagnosed?

A

First- exclude upper GI source

Anoscopy
Sigmoidoscopy
Colonoscopy
Technetium scan
Angiography
Capsule endoscopy
324
Q

What are the treatments for acute lower GI bleeds?

A

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
Q

Define Obscure GI bleed

A

Unknown origin or persists after initial upper/lower endoscopic evaluation

326
Q

How much blood can be lost in an occult GI bleed and not apparent?

A

100mL/day

327
Q

How are occult bleeds identified?

A

FOBT
Fecal immunochemical test
Unexplained anemia on CBC

328
Q

Occult GI bleeds must have ? investigated and ? lab test

A

Neoplasm

CBC for anemia

329
Q

+ FOBT w/out anemia= ?

+ FOBT w/ anemia= ?

A

Colonoscopy

Upper endoscopy and colonoscopy

330
Q

What are the primary etiologies of constipation?

A 
More common
Structure abnormality
Systemic dz
Infrequent movement, bloating, straining
Hx of psychosocial disorder
331
Q

What are the secondary etiologies of constipation?

A

Systemic Dz
Meds
Obstructing lesion
Sudden onset w/ prior Hx of constipation

332
Q

What will PE of a constipated PT show?

A

Dullness to percusion in L quaadrants

DRE- rule out strctural abnormalities

333
Q

Colonoscopy should be performed in constipation PTs with what criteria?

A

+50y/o
Severe constipation
Sx of organic disorder
Alarms- hematochezia, weight loss, + FOBT, FamHx or IBDz

334
Q

What lab results are pulled for constipation PTs?

A

Labs: CBC, CMP- Ca glucose, Thyroid panel

Rads: abd x-ray non-spec gas pattern

Endoscopy- colonoscpy or flex sigmoidscopy

335
Q

What pharmacotherapies are used for constipation?

A

Osmotic
Stimulant
Surfactant
Enema

336
Q

What are the osmotic laxatives?

A

Mag. Hydroxide
Polyeth. Glycol 3350
Polyeth. Glycol
Mag. Citrate

337
Q

What are the stimulant laxatives?

What is the stool surfactant?

A

Bisacodly and Senna

Ducosate Sodium

338
Q

When are constipation PTs referred?

A 
Refractory Sx to treatments
PTs with abnormal structure
Evidence of obstruction
Over 50
Alarm Sx
339
Q

Common etiologies of acute non-inflammatory diarrhea?

A

Viral- Norovirus, Rotavirus

Protozoa- Giardia

340
Q

Essentials for Dx of acute inflammatory diarrhea?

A

Less than 2wks

Blood, pus or fever from invasive/toxin producing bacterium

341
Q

Diagnostic evaluation of acute inflammatory diarrhea includes ? tests?

A

Cultures for E Coli H7
C Diff
Ova and Parasite

342
Q

What are the acute inflammatory diarrhea etiologies?

A

E Coli
Shigella
Salmonella
C Diff

343
Q

What are the lab tests for acute diarrhea evaluation?

A 
Fecal leukocytes
Stool culture
OandP- reqs 3 samples
C Diff
Fecal lactoferrin- marker of intestinal inflammation
344
Q

What are the anti-diarrhea meds?

A

Loperamide

Bismuth subsalicylate

345
Q

When are ABX considered for diarrhea PTs?

A

Non-hospital acquired w/ mod/sev fever, tenesmus or bloody stools
Presence of lactoferrin
Immunocompromised
Significant dehydration

346
Q

ABX for diarrhea empiric treatment

A

Cipro 500mg BID 5-7d
Ofloxacin 400mg BID 5-7d
Levofloxacin 500mg 5-7d

Trimethoprim-Sulfamethoxazole BID
Doxycycline 100mg BID

347
Q

What meds can be used for Traveler’s Diarrhea?

A

Fluoroquinolones- 3 day course, not useful for SE Asia
Azithromycin- 1g
Rifaximin- 200mg TID x 3d

348
Q

ABX for diarrhea are only recommended for which microbes?

A 
GC CLASTS
Giardia
Cholera
C Diff
Listeriosis
Amebiasis
Salmonellosis
Traveler's Diarrhea
Shigellosis
349
Q

Acute diarrhea PTs are admitted for what criteria?

A 
Dehydration
Bloody diarrhea
Inflammatory/ischemia, toxin
Infection/sepsis
Severe/worse +70y/o
Hemolytic uremic syndrome
350
Q

Define Osmotic Diarrhea

A

Inc stoop osmotic gap
Resolves w/ fasting
Causes: carb malabsorption, lax abuse, malabsorption syndrome

351
Q

What needs to be considered in all PTs w/ chronic postprandial diarrhea

A

Carb malabsorption

352
Q

Define Secretory Conditions

A

Inc intestinal secretion/dec absorption
High vol, watery stool
No/little change w/ fasting
Causes: endocrine tumor or bile salt malabsorption

353
Q

What inflammatory conditions cause chronic diarrhea?

A

IBDz: Crohns, Ulcerative colitis

Microscopic colitis

354
Q

What chronic infections can cause chronic diarrhea?

A

Giardia
E Hystolytica
Cyclospora
Nematodes

355
Q

What systemic conditions can cause chronic diarrhea?

A

Thyroid dz

Diabetes

356
Q

What is in a chronic diarrhea work up

A

Exclude commons: meds, IBS, lactose intolerance

Eval etiology based on Sx

357
Q

What labs are pulled for chronic diarrhea?

A 
CBC
Chem 17
LFT
Thyroid
ESR
CRP
Stool studies: culture, leukocytes, lactoferrin, occult, OandP, E+
358
Q

Why is a colonoscopy with biopsy performed?

What other test can be ordered?

A

Exclude IBD and neoplasm

24 stool- total weight and fat

359
Q

4 things that present with anorexia?

A

Tropical sprue
Adenocarcinoma
Gastropathy, erosive/hemorrhage
Appendicitis

360
Q

4 things that present with steatorrhea?

A 
Tropical COW
Tropical Sprue
Celiac
Over growth
Whipple
361
Q

Two things that present with tenesmus and one consideration about tenesmus?

A

Presents- acute inflammatory diarrhea
Infectious proctitis
Consideration- empiric ABC treatment for acute diarrhea

362
Q

If SAAG is > 1.1g and peritoneum is normal

A

Hepatic congestion
Liver Dz
Portal vein occlusion

363
Q

If SAAG is < 1.1g and peritonium is normal ?

A

Hypoalbuminemia

Miscellaneous: ascites, myxedema, ovarian dz

364
Q

SAAG below 1.1g and with diseased peritoneum

A

Infection
Malignancy
Other- mediterranean fever, vasculitis, granulomatous peritonitis, eosinophilic peritonitis

365
Q

What is the only -itis condition with SAAG >1.1g/dL since all others with -itis ending are below 1.1G

A

Constrictive pericarditis

366
Q

Treatment for GI gas?

A

Investigate malabsorption
Food diary
Avoid FODMAPS
Beano, Simethicone

367
Q

Constitutional Sx of Cancer

A

F/C/Ns

368
Q

Ascites PT with focal TTP

A

CT to find source

369
Q

What causes non-portal HTN ascites?

A

Infection
Malignancy
Inflammatory disorder of peritoneum
Ductal disruption

370
Q

Ascetic fluid neutrophil PMN greater than 250 = ?

A

Bacterial peritonitis

371
Q

How do you distinguish between spontaneous and secondary peritonitis?

A

Spontaneous will have lactate dehydrogenase, glucose or total protein

372
Q

What drug is preferred over Octreotide and Somatostatin for esophageal varices management?

A

Terlipressin

Contraindicated in PTs with coronary/cerebral/PVDs

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