GI Block 1: Esophageal Dz - Flashcards
What are the general S/Sx of esophageal dzs?
Pyrosis from reflux
Dysphagia- difficulty
Odynophagia- painful
Define Oropharyngeal dysphagia
Difficulty with oral/pharyngeal phase of swelling
Pharyngeal dysphagia= immediate sense of bolus catching in neck
Define Esophageal Dysphagia
Due to mechanical obstruction/motility disorder
What is the difference between mechanical obstruction and motility?
Mechanical- solids
Motility- solids and liquids
What is the study of choice for esophageal diseases?
EGD- study of choice for eval persistent heartburn, dysphagia, odynophagia and strucutre abnormalities and allows for direct visualization and biopsy
What are the diagnostic studies than can be performed for esophageal diseases?
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
What is the function of barium esophagography and esophageal manometry?
Barium- motility
E Manometry- tests LES function
Manometry indications- determine LES location, etiology of dysphagia, preop assessment of antireflux surgery
Most PTs experience mild GERD but what can happen if left untreated to small PT population?
Esophageal cancer
What are the GERD etiologies?
DADs Hernia Dysfunction of LES- norm=10-35, reflux=less than 10 Hiatal hernia Abdominal esophageal clearance Delayed emptying
How does GERD damage the esophagus?
4.0 pH acidity of refluxate which is caustic which can lead to mucosal dysplasia (reqs 2 Dx from pathologist)
What are the clinical presentations of GERD?
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
What is waterbrash?
Regurgitation of sour fluid/tasteless saliva in mouth
GERD is one the three most common causes of __
Chronic cough
What will be found on exam of a GERD PT?
Unremarkable
What are the DDxs for GERD?
Functional/Motility disorder Peptic ulcer Angina pectoris Eosiniophilic esophagitis Dyspepsia
What is included in the GERD work up?
No studies initially unless alarm signs are present: Dysphagia Odynophagia Weight loss F/C/Ns Do NOT do barium swallow
What is the next step for GERD PTs if Sx are not relieved by empiric anti-acid treatment?
EGD- test of choice for GERD PTs
Esophageal pH/LES manometry can be ordered by specialist
What are the treatment steps for GERD PTs?
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
What are the pharmacotherapies for GERT treatment?
OTC antacids- tums, rolaids
H2 receptor antagonists- Climetidine, Ranitidine, Famotidine
PPIs
When are H2 antagonists taken by GERD PTs?
Prior to meals
Onset in 30min
Duration x 8hrs
What are the PPIs for pharmacotherapy of GERD?
Omeprazole Rabeprazole Lansoprazole Esomeprazole Pantoprazole- doesn't req eating after taking All others, take 30m prior
What class medications have higher efficacy for GERD?
PPIs
What are the lifestyle modification steps for GERD PTs?
Mild/intermittent Sx- PRN OTC antacid or H2
Troublesome: PPI daily
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?
Switch to BID dose
EGD referral
Any/all GERD PTs w/ alarm signs have ? happen to them?
Immediate referral for EGD
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
When is surgery an option for GERD PTs?
Refractory to treatment
Severe dz
What is the Niseen Funcoplication procedure
Fundus wrapped around esophagus and sewn in place to reinforce LES
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
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
What are the GERD complications?
Barretts- 3 types of columnar epithelium may be identified: gastric cardiac/fundic, and specialized intestinal metaplasia.
Stricture
Characteristics of peptic stricture?
Narrowing of esophageal lumen at GEJ w/ progressive solid food dysphagia that require endoscopy and biopsy to differentiate
How are peptic strictures treated?
Endoscopic dilation
Refractory- injection of tramcinolone
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
Infectious esophagitis occurs mostly in ? PTs
Immunocompromised
AIDS, transplant, leukemia/lymphoma, chronic immunosuppresive drugs (corticosteroids, biologics for RA, IBD)
How will immunosuppressed PTs present with infectious esophagitis?
Dysphagia
Odynophagia
Possible chest pain
How is infectious esophagitiss diagnosed and have the specific etiology determined?
EGD with biopsy
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
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
Characteristics of eosinophilic esophagitis
Inflammatory response of esophagus to food/environmental allergen from infiltration of eosinophils
What is the end results of eosinophilic esophagitis
Inflammation leads to progressive dysphagia and narrowing of the lumen
What questions need to be asked for TP with eosinophilic esophagitis?
Hx of asthma
Allergies
Eczema
What will the clinical findings be for a PT with eosinophilic esophagitis?
Dysphagia to solids
Heartburn
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
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
Define esophageal webs/rings
Webs- thin membrane of squamous epithelium in mid/upper esophagus and most are axymptomatic
What S/Sx can be caused by esophageal webs?
Intermittent dysphagia or GERD like Sx
Define Esophageal Ring
Schatzki Rings
Circumferential mucosal structure in distal esophagus w/ similar Sx as webs
STRONG association to hiatal hernia
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
Define Zenker Diverticulum
Pharyngoesophageal diverticulum- “pouch”
What are the Sx of a Zenker Diverticulum
Progressive dysphagia
Sensation of food sticking in throat
Halitosis
Regurge of undigested foods
How is Zenker Diverticulum diagnosed?
How is it treated?
Viedosophagography/Barium swallow
Sx PT may req myotomy
Define Achalasia
Idiopathic esophageal motility disorder with loss of normal peristalsis in distal 2/3 of esophagus causing impaired relaxation of LES
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
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
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
What are the treatment methods of achalasia
Botulinum toxin to LES
Pneumatic dilation
Surgery
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
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
What is the sequence of treatment for Mallory-Weiss Syndrome?
Stabilize
Upper endoscopy
How are Mallory-Weiss Syndromes treated?
Endoscopic hemostatic agents- epi, cautery, endoclip
Define Boerhaave Syndrome and what are the S/Sx?
Complete esophagus rupture
Shock, pneumomediastium, general badness
Who is more likely to develop esophageal carcinoma and what type?
3:1 males to F
Squamour or adenocarcinoma
Late presentation w/ adv dz
What are the S/Sx of esophageal carcinomas?
Progressive solid dysphagia Odynophagia Large unexplained weight loos Body aches Pains if metastasis
How are esophageal carcinomas diagnosed?
Non spec lab finding
Barium swallow to assess dysphagia
EGD for Dx
What are the treatment methods for esophageacl carcinoma?
Surgery
Chemo
Radiation
Less than 20% w/ 5yr survival
Heartburn, dysphagia and odynophagia almost always indicates what type of disorder?
Esophageal
Oropharyngeal phase of swalling involves what steps?
Tongue elevation Nasopharynx closure Relaxation of upper sphincter Airway closure Pharyngeal peristalsis
Problems with the oral phase of swallowing cause what issues?
Drooling
Food spillage
Inability to chew
Inability to initiate swallowing
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
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
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
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
Dysphagia is best evaluated with what imaging modality
Rapid sequence Videoesophagography
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
What conditions are associated with diminished peristalsis?
Sjogren Syndrome
Anticholinergic meds
Oral radiation therapy
What do parietal, chief and G cells secrete?
Parietal- HCl and intrinsic
Chief- pepsinogen and gastric lipase
G- gastrin
Characteristics of Type 1 Hiatal Hernia
1= Sliding Hernia
Displaced GE junction above diaphargm
Stomach remain in place and fundus is below GE junction
Characteristics of Types 2-4 Hiatal Hernia
True hernia with hernia sac
Upward dislocation of gastric fundus through defected phrenoesophageal membrane
How do hiatal hernias present?
How are they Dx?
How are they treated?
Sx of GERD
Barium swallow
Small- GERD management
Large- Surgical
Define Gastropathy
Define Gastritis
Mucosal damage w/out inflammation
Mucosal damage with inflammation
Gastritis is commonly secondary to ?
Gastropathy is commonly secondary to ?
Infectious or autoimmune etiology
Endengenous/exogenous irritants: ETOH, NSAID or stress
How are gastropathy and/or gastritis diagnosed?
Endoscopy with mucosal biopsy for dx and differentiation
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
General S/Sx of erosive and hemorrhagic gastropathy?
Possible A-Sx
If Sx- anorexia, epigastric pain
Clinical manifestatio= upper GI bleed
Define Prostaglandin
Lipid derived from arachidonic acid generated by action of COX-1Where do isoenzymes
Generate inflammatory response
Prostaglandins stimulate epithelial cells to release ? and act as ?
BiCarb and mucus- reduce permeability and back-diffusion
Vasodilators- inc blood flow and injury resistance
Where do NSAIDs inhibit synthesis?
Prevent arachidonic acid to Cyclooxygenas to thromboxanes
NSAID gastropathy occurs in ? PT population
Chronic NSAID therapy, more frequently in COX-1 inhibitors
What are the COX-1 inhibitors that can cause NSAID Gastropathy
Aspirin Ibuprofen Naproxen Indomethacin Prioxicam Oxaprozin Diclofenac
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
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
How/why does alcohol catalyze gastropathy?
Impairs motility and leads to delayed gastric emptying leading to prlonged contact with gastric mucosa
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
When/who is stress gastropathy seen in?
Critically ill PTs
Highest risk of bleed w/ coagulopathy, respiratory failure w/ mechanical ventilation
Critically ill/bedridden PTs should receive ? prophylaxis?
Gastric acid suppression- IV PPIs
What is the treatment for stress gastropathy active bleeds?
H2 antagonists
IV PPI
Define Portal HTN Gastropathy?
Gastric sub/mucosa congestion of capillaries and venules leading to inc gastric mucosal blood flow
What does portal HTN gastropathy treatment involve?
BB to dec portal press
H Pylori causes inflammation with wat two cells?
Neutrophilic and lymphocytic infiltration
How will H Pylori gastritis present in clinic?
Related to dyspepsia, 35% will be A-Sx
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
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
PUD is a break in what layer of mucosa?
Gastric or Duodenal from impaired defense mechanisms that is 5x more common in duodenum
Duodenal ulcers are more common in ? PT
Gastric ulcer is more common in ?
Younger PT
Older, 55-70
Other than H Pylori and NSAIDs, what are the other etiologies of PUD?
Hypersecretory condition CMV Chronic Dz Crohns Lymphoma
S/Sx of PUD
Dyspepsia- most common, gnawing, aching hunger pain that are cyclic and relieved with food/antacids
UP to 70% of ulcers are A-Sx so PTs present with ?
Bleeding
Perforation
How is PUD diagnosed?
What labs are ordered?
EGD
CBC, FOBT, H Pylori
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
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
PUD have high incidence of bleeding ulcer but low mortality, may present how?
PUD Sx
Hematemesis
Melena
How are acute upper GI bleeds from PUD treated?
Endoscopy
Hemostasis
How do PUD ulcer’s perforate?
What are the S/Sx?
Chemical peritonitis
Sudden/severe ab pain, rigid abdomen, reduced sounds, pneumoperitoneum
How many PUD ulcer perforations spontaneously seal?
40%, adhered omentum
How are perforated PUD ulcers treated?
Fluids NG suction IV PPI ABX Surgery if- free air, peritonitis, deterioration during admission
Define PUD Ulcer penetration?
Penetration of ulcer through bowel wall without perforation/leakage into peritoneal cavity
Penetration to pancreas, liver, biliary tree
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
Define Gastric Outlet Obstruction
What are the S/Sx
Chronic edema of pylorus/duodenal bulb
Early satiety, postprandial vomiting, weight loss
What is the treatment for gastric outlet obstruction
High dose PPI: IV LIquid Pill
Endoscopic dilation
Define Zollinger Ellison Syndrome
Gastrinoma; gastrin secreting neuroendocrine tumor
causing hypergastrinemia and hypersecretion of gastric acids
80% of gastrinomas occur within what region?
Gastrinoma Triangle:
Porta Hepatis
Pancreatic Neck
3rd portion of duodenum
What are the 3 gastrinoma locations and what type of PT are they common in?
Pancreas
Duodenal wall
Lymph Nodes
MEN-1
90% of Zollinger PTs will present ?
PUD
How are Zollinger PTs tested?
Fasting gastrin in PTs: W/ refractory ulcer PUD FamHx of MEN1 PUD w/out NSAIDs and Pylori neg
Once Zollingers is confirmed, what is the next step?
Referral to GI
Define Gastroparesis
Delayed emptying in absence of mechanical obstruction but is uncommon in GenPop
When/where is gastroparesis most commonly seen?
Idiopathic w/ strong link to Diabetes or gastric surgery complication (injury to vagus nerve)
What are the cardinal Sx of gastroparesis?
N/V Early saitety Bloating Ab pain Weight loss
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
What treatment do acute gastroparesis exacerbations require?
NG decompression
IV/E+ replacement
What are the general treatment measures of gastroparesis
Dietary mods- small, avoid high fat, avoid carbonation/ETOH and nicotine
Optimize glycemic control in DM
What prokinetic meds can be used in gastroparesis?
Metoclopramide
Domperidone
Erthromycin
What is one of the most common cancers worldwide?
Gastric Adenocarcinoma
Highest in E Asia, Europe and S America
Men > Women
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
What are the two classic signs of metastatic disease?
Sister Mary Joseph Nodule
Virchow Node
What are the diagnostic studies for gastric adenocarcinoma?
Labs- CBC (anemia) and LFTs (elevated)
Endoscopy- confirms Dx
CT/PET after confirmation to locate metastasis
What are the treatments for gastric adenocarcinoma?
Surgery
Chemo
Radiation
Define Gastric Lymphoma
Secondary tumors from spread of Non-Hodgkin Lymphoma
Primary tumor- MALT, associated w/ Pylori
Gastric lymphoma presentation, Dx and Tx is similar to what other Dz?
Adenocarcinoma
Define Carcinoid Tumor
Neuroendocrine tumor originating in digestive tract or lungs
Define Carcinoid Syndrome
Constellation of Sx from jumoral factors elaborated by some carcinoid tumors
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
When does Infantile Hypertrophic Pyloric Stenosis present?
3-6wks
Immediate projectile vomit
Hungry immediately after
What will PE on infant with Pyloric Stenosis show?
Undernourished
Dehydrated
Palaption of “olive” in RUQ- hypertrophic pylorus
What imaging is done for Pyloric Stenosis?
How is it treated
Necessary when suspected regardless of “olive” finding
US
Surgical pyloromyotomy
What is a vestigial organ and a true diverticulum of the cecum?
Vermiform appendix
Appendix has constant attachment at ? and variable locations of the ?
Base of cecum
Variable tip- retrocecal, subceccal (most common), pre/postileal, pelvic
What materials can block the appendix lumen?
Inflammation Fecalith Calculi Infection Tumor
What is the pathogenesis sequence of appendicitis?
Obstruct Inc Press Venous congestion Infection Necrosis
Untreated necrotic appendix can lead to ?
Perforation to sepsis in 36hrs
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
How does pregnancy complicate diagnosing appendicitis?
Migration of cecum
R flank pain
R subcostal pain
What are the S/Sx of appendicitis?
N/V
Anorexia
Low fever
High fever or rigor= perforation
What will be found on an appendicitis PE?
TTP at McBurney’s to direct and rebound tenderness
Guarding Rigidity
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
What are the labs/rads for appendicitis?
CBC CMP UA
CT
What is the most important part of appendicitis care?
Surgery
What kind of ABX are given in the ED for appendicitis?
Broad Spect w/ Gran-neg and anaerobic coverage Cefoxitin Cefotetan Ampicillin-Sulbactam Ertapenem
Anorectal Dz includes what issues?
Hemorrhoids
Fissures
Anorectal infection- perianal abscess
Anal cancer
Define hemorrhoid
Normal vascular cusions in anal canal arising from vascular CT that drains to Sup/Inf hemorrhoidal veins
What are the functions of hemorrhoids?
Normal anal pressure
Water-tight closure of canal
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
What are the etiologies of hemorrhoids?
Straining Constipation Prolonged sitting Pregnancy Obesity Low fiber
Clinical presentation of hemorrhoids?
Red blood
Perianal itching
Mucoid discharge w/ stool
Pain= external
Prolapsed internal hemorrhoids can cause ?
Pruritus and leakage
During PE for hemorrhoids what is inspected for and what exam is necessary?
Skin tags Fissures Fistulas Condyloma Dermatitis
DRE, anoscopic exam if uncertain
General treatment measures for hemorrhoids?
High fiber diet
Inc fluid
Wet wipes
What medical treatments can be offered for hemorrhoids?
Astringents- Witch Hazel pads
Hydrocortisone
Anesthetics- Pramoxine, Dibucaine
Hydrocortisone suppositories
How are internal hemorrhoids treated?
Rubber band ligation
Sclerotherapy
Electrocoagulation
When is surgical treatment an option for hemorrhoids?
What is the risk?
Medical therapy failure or chronic, severe bleeds
Fecal incontinence
Define anal fissure
Tear in anoderm distal to dentate line
What is the most common cause of anal fissures?
How do chronic fissures develop?
Trauma during defecation
Spasm of internal sphincter causing impaired healing
Anal fissures that appear off midline raise suspicions of ?
CDT TSH C Crohn's HIV/AIDS TB Syphilis Carcinoma Trauma
Majority of anal fissures are where?
75% posterior
24% anterior
How do anal fissures present?
Severe/tearing pain during defecation
Chronic will have less pain
Hematochezia
Self induced constipation from defecation pain fear
PE of anal fissure will show ?
Epithelium tear
Painful spreading
Intolerable DRE
Sentinel pile- skin tag on edge of fissure
What are the treatments for anal fissures?
Sitz baths
Inc fiber/fluids
Docusate Sodium
Topical anesthetic- lidocaine
What are the treatment methods for chronic fissures?
Topical vasodilators- nifedipine, notroglycerin, diltiazem
Botulinum toxin injection
What are the two surgical treatments for anal fissures?
Fissurectomy
Lateral internal spincerotomy
Define perianal abscess
Collection of purulent material from glandular crypts in anus/rectum
Clinical presentation of perianal abscess?
Pain in region that’s constant and not associated w/ defecation
Fever
Malaise
What must be done during PE for perianal abscess?
How are they treated?
DRE
Simple- InD outpatient
Complex- (ischeorectal) inpatient, surgical
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
Sx of infectious proctitis
Anorectal discomfort
Tenesmus
Constipation
Mucus/blood discharge
What is the etiology of infectious proctitis?
STI- Gonorrhea Syphilis Chlamydia Herpes
Infectious proctitis’ other Sx based on the pathogen
Syphilis - chancre
Herpes - grouped vesicles
Gonorrhea - mucopurulent discharge
Chlamydia - slight discharge or A-Sx
Define Condylomata Acuminata
Anal warts w/ CCO itching, bleeding, or pain
What is a risk in immunocompromised PTs with condylomata acuminata?
Coalesce and obscure anal opening
Carcinomas of the anus are rare but the majority are ? cell
Who are the high risk PTs?
Squamous cell cancers
Anoreceptive intercourse
Anal warts
What is the clinical presentation of anus carcinoma?
Confused w/ hemorrhoids
Bleeding, pain, mass
How are anus carcinomas diagnosed?
CT or MRI for Dx and find extent of spread
What are the 3 groups of diseases of the small bowel?
Malabsorption
Motility
Miscellaneous
What are the malabsorption disorders of the small bowel?
Celiac Whipple Tropical Sprue Lactase deficiency Bacterial over growth Short bowel syndrome
What nutrients are absorbed in the duodenum?
Mg Ca Thiamin Riboflavin Fe PO4 Cu
MCTRIP
What nutrients are absorbed in the jejunum?
Vit A D E K Folate
FADE K
What nutrients are absorbed in the ileum?
Vit B12
Bile Salts and acids
BBNA
Malabsorption clinical manifestations can appear with ? S/Sx?
Steatorrhea
Micro/Macrocytic anemia- Fe, B12, Folate issue
Dairy intolerance
Define Celiac Sprue
Gluten sensitive enteropathy from immunologic response to gluten causing diffuse damage to proximal small intestine mucosa
Where is the protein gluten found?
Wheat Barley Rye
Whole grains related to wheat: bulgur, farro, kamut, spelt, triticale and malt/brewer’s yeast
What are the S/Sx of celiac dz?
Dyspepsia Diarrhea Steatorrhea Weight Loss Flatulence Distension/bloat Borborygmi Weakness
What are the extraintestinal manifestations of celiac dz?
Fatigue Depression Fe deficient anemia Amenorrhea Transaminitis- high transaminase enzymes from liver Dermatitis herpetiformis
Define Dermatitis Herpetiformis
Cutaneous manifestation
Pruritic papules and vesicles on extensor surfaces of extremities, trunk, scalp and neck
What will be found during PE of Celiac Dz?
Depends on severity of malnourishment
Mild case- unremarkable
Severe- S/Sx of nutrient deficiencies
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
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
Histology exam of celiac Dz biopsy will have what appearance?
Blunting/atrophied villie
What are the DDx for Celiac Dz?
G CLIT Gastroenteritis Chronic Diarrhea Lactose intolerance IBS Tropical Sprue
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
What is the treatment method for Celiac Dz?
Removal of all gluten from diet including oats (Sx gone in 2-3wks)
Dietician referral
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
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
What population is Whipple Disease most commonly seen in?
Farm workers
Sewage workers
Contact from sewage/waste water
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
What are the three less common signs of Whipple Disease?
Skin hyperpigmentation
General lymphadenopathy
Ophthalmoplegia
Nystagmus
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)
How is Whipple Dz treated?
IV Ceftriaxone x 2wks
TMP-SMX DS- 1 tab PO BID x 12mon
Trimethoprime sulfamethoxanole
Location of Tropical Sprue
Environmental enteropathy/tropical malabsorption occurring in narrow band above and below 30* line equator
Define Tropical Sprue
Chronic diarrhea dz involving whole sm intestine of infectious origin often seen following acute diarrhea dz
How is Tropical Sprue characterized in clinic?
Malabsorption of nutrients especially Folic Acid and B12
What are the S/Sx of Tropical Sprue?
Chronic Diarrhea Steatorrhea Weight loss Anorexia Malaise Glossitis and Chelitis from B12 and Folate deficiency
What labs will be seen in PTs with Tropical Sprue?
CBC- megaloblastic anemia
What will endoscopy with biopsy show in PTs with Tropical Sprue?
Gross- flattening of duodenal folds
Micro- short blunted villi and elongated crypts
How can acquiring Tropical Sprue be avoided?
Boil/bottle water
Peel fruits prior to eating
How is Tropical Sprue treated?
TMP-SMX x 6mon (different than Whipple, 12mon)
Folate, B12 supplements
Define Sprue
Dutch word for inflammation of mouth
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
What 3 population groups have the highest epidemiology prevalence for lactose intolerance?
Asian- 95-100
American indian- 80-100
Black/Ashkenazi Jew- 60-80
What are the S/Sx of lactase deficiency?
Dose dependent-
Small= ASx
Mod= bloat, cramp, fart
Large= osmotic diarrhea
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
How is lactase deficiency Dx?
Presumptive- free from diet x 2-3wks w/ Sx improvement
H Breath test- Dx test for confirmation
How is Lactase Deficiency treated?
Reduced lactose diet
Titrate to Sx
Consider referral to dietician
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
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)
What is the treatment for bacterial overgrowth?
Empiric ABX against enteric an/aerobic bacteria:
Ciprofloxacin
Amoxicillin
Rifaximin
Define Short Bowel Syndrome
Due to removal of significant segments of small intestine
The type and degree of malabsorption depend on what things?
Length/sight of resection
Degree of adaptation of remaining bowel
What are the 3 intestinal motility disorders?
Acute paralytic Ileus
Chronic Intestinal Pseduo-Obst
Small Bowel Obstruction
Define Acute Paralytic Ileus
Adynamic/post-op ileus
Failure/loss of peristalsis w/out obstruction
Acute Paralytic Ileus is most commonly observed in ? PTs?
Hospitalized PTs due to:
Surgery
Illness- resp failure, sepsis, uremia
Meds- opiods, anticholinergics
What are the S/Sx of acute paralytic ileus?
Diffuse CONSTANT ab pain N/V Distension LACK of TTP Diminished/absent bowel sounds
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
How is Acute Paralytic Ileus treated?
Supportive
Pain, fluid/E+, bowel rest, nasogastric decompress (if distension or severe vomitting)
Define Chronic Intestinal Pseudo-Obstruction
Similar to gastroparesis
Intermittent signs of obstruction w/out an actual obstruction
What are the S/Sx of chronic intestinal pseudo-obstruction
Abd distension
Vomit
Diarrhea
Varying malnutrition
What does a Pseudo-Obstruction work up include?
Exclude obstruction with CT or endoscopy
How are acute exacerbations of pseudo obstruction treated?
NG decompression
IV fluid/E+ replacement
Refer to GI
What are small bowel obstructions most commonly attributed to?
Post-op adnesions
Hernias
Other: FINGS
Neoplasm, Stricture, Foreign body, intussusception, Gallstones
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
How does a small bowel obstruction present?
Abrupt colicky ab pain
N/Profuse vomit
Obstipation- inability to take a dump or fart
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
What lab tests are ordered for small bowel obstruction?
CBC CMP UA
Type and Crossmatch
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
How are small bowel obstructions treated?
Fluids NG decompression Pain Anti-emetic Early surgical consult Admit
What are the complications from a small bowl obstruction?
Dilation
Compromised intramural vessle
Ischemia
Necrosis
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
Define Intussusception
Segment of intestine invaginates into adjoining lumen causing an obstruction
What PT is Intussusception most commonly seen in and how is it identified?
Kids w/ currant jelly stool
What disease is rarely seen in the small intestine?
Primary malignancy
Neoplasms of the small bowel can cause ?
Intussusception
Characteristics of Adenocarcinoma
Most commonly in duodenum or porximal jejunum
Presents w/ Sx of obstruction, chronic GI bleed or weight loss
Characteristics of Lymphomas
Inc in AIDS
Chronic immunosuppressive therapy
Crohn’s Dz
What are the 4 types of small intestine neoplasms?
Adenocarcinoma
Lymphoma
Intestinal Carcinoid
Sarcoma
Define Protein Losing Enteropathy
Condition results in excessive loss of serum protein resulting in hypoalbuminemia usually as a result of established GI disorder
How is Protein-Losing Enteropathy treated?
Result of established GI disorder, treatment aimed at disorder:
Dietary therapy
Albumin replacement
Define Mesenteric Ischemia
Acute arterial occlusion- embolic or thrombotic
Mesenteric venous thrombosis
Non-occlusive- vasospasm, low CO
How is mesenteric ischemia found on PE?
What is the diagnostic test?
Pain out of proportion to exam
CT angiography
How is mesenteric ischemia treatment?
Admission:
Papaverine- smooth muscle relaxant
Thrombolytics
Surgical referral
Define Meckels Diverticulum
Most common congenital abnormality of GI tract
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
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
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
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
How is Meckel’s treated?
Stabilize of bleed is present
Surgical removal
Adenocarcinoma won’t be able to absorb nutrients in what section of intestine?
Ileum
What is the largest serous membrane of the body?
Peritoneum- layer of simple squamous w/ underlying aerolar CT
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
Function of the hepatic portal system?
Supplies liver w/ metabolites and ensured ingested substances are filtered prior to systemic circulation
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
Pathologic increase in portal pressure is what amount of increase?
Gradient between vein and IVC >10mm
What is the pathologic process of ascites?
Cirrhosis, inc intrahepatic vascular resistance, inc capillary pressure, inc hepatic lymph formation, ascites
What are the S/Sx of ascites
Primary Sx- bloating and inc girth, possible pain
What Hx questions for ascites PTs?
Hx liver dz/risk factors
Alcohol abuse
Risks of hepatitis
Hx of malignancy
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
What labs are done on ascites work ups?
Inspection of paracentesis White GCAT WBC Albumin/total protein Culture Gram stain
SAAG equation
Serum albumin - ascitic fluid albumin
1.1 or higher= portal HTN
Less= other cause
What are the images for ascites?
Abdominal US- fluid and guiding needle
Abdominal CT
Spontaneous bacterial peritonitis is typically due to ?
Ascites as a result of chronic liver dz
What are the common pathogens of Spontaneous Bacterial Peritonitis
E Coli Klebsiella pneumonia Strep pneumonia Viridans strep Enterococcus sp.
Ascites with abdominal TTP suggests ?
Other etiology source
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
What is the follow up imaging modality if Secondary Bacterial Peritonitis?
Abd CT
How is Spontaneous Bacterial Peritonitis treated?
Admit
Empiric- IV 3rd generation cephalosporin (Ceftriaxone)
Prophylaxis- Cipro or TMP-SMX DS once daily
Define Malignant Ascites
Carcinoma of blocked lymphatic channel
Functional cirrhosis develops in PTs with hepatic metastases resulting in portal HTN
Define Chylous Ascites
Lipid rich chyle in peritoneal cavity due to lymph obstruction
Define Pancreatic Ascites
Intraperitoneal accumulation of pancreatic secretions due to disruption of pancreatic duct seen in chronic pancreatitis
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
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
How are PTs with infrequent heartburn (less than once per week) treated?
Antacids- contain Mg, don’t use in CKD
H2 antagonists
What criteria increase risks from esophageal verices?
Size
Red wale marking
Severity of liver dz
Active alcohol abuse
What meds can be used to lower portal HTN Gastropathy?
Propranolol
Nadolol
Propran failure- portal decompressive procedures
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
What are the three essentials of diagnosis for acute upper GI bleeds?
Hematemesis
Hypovolemia
Melena, possible or hematachezia in massive bleeds
What are the etiologies of acute upper GI bleeds?
PUD Portal HTN Mallory Weiss Vascular abnormality Neoplasm Other- gastritis, esophagitis, Booerhave Synd.
How will upper GI bleeds present?
Hematemesis
Melena
Rare hematochezia
Possible epigastric/abd pain
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
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
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
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
Essentials of Dx for Acute Lower GI bleeds?
Hematochezia
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
Etiologies of lower bleeds?
Anorectal Dz Diverticulosis IBDz Infectious colitis Neoplasm Angioectasis Ischemic colitis
S/Sx of diverticulosis bleeds?
Painless BRB in large volumes
How will lower GI bleeds present?
Hematochezia- w or w/out pain
What are thee common causes of lower GI bleeds in PTs under 50y/o
Anorectal Dz
IBDz
Infectious colitis
What are the four common causes of lower GI bleeds in PTs over 50y/o
Diverticulosis
Malignancy
Angioectasis
Ischemic colitis
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
PTs presenting with painful defecation means ?
External hemorrhoids
Anal fissure
PTs preseting with abdominal pain/cramps and lower GI bleeds = ?
IBD
Colitis
Painless lower GI bleeds mean ?
Internal hemorrhoid
Diverticular bleed
Large volume of LGI bleeds mean ?
Small volume means ?
Large- diverticular
Small- IBD, hemorrhoids
What labs are drawn for acute lower GI bleeds?
CBC
CMP- anemia= ominous sign, particularly for neoplasm
How are lower GI bleeds diagnosed?
First- exclude upper GI source
Anoscopy Sigmoidoscopy Colonoscopy Technetium scan Angiography Capsule endoscopy
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
Define Obscure GI bleed
Unknown origin or persists after initial upper/lower endoscopic evaluation
How much blood can be lost in an occult GI bleed and not apparent?
100mL/day
How are occult bleeds identified?
FOBT
Fecal immunochemical test
Unexplained anemia on CBC
Occult GI bleeds must have ? investigated and ? lab test
Neoplasm
CBC for anemia
+ FOBT w/out anemia= ?
+ FOBT w/ anemia= ?
Colonoscopy
Upper endoscopy and colonoscopy
What are the primary etiologies of constipation?
More common Structure abnormality Systemic dz Infrequent movement, bloating, straining Hx of psychosocial disorder
What are the secondary etiologies of constipation?
Systemic Dz
Meds
Obstructing lesion
Sudden onset w/ prior Hx of constipation
What will PE of a constipated PT show?
Dullness to percusion in L quaadrants
DRE- rule out strctural abnormalities
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
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
What pharmacotherapies are used for constipation?
Osmotic
Stimulant
Surfactant
Enema
What are the osmotic laxatives?
Mag. Hydroxide
Polyeth. Glycol 3350
Polyeth. Glycol
Mag. Citrate
What are the stimulant laxatives?
What is the stool surfactant?
Bisacodly and Senna
Ducosate Sodium
When are constipation PTs referred?
Refractory Sx to treatments PTs with abnormal structure Evidence of obstruction Over 50 Alarm Sx
Common etiologies of acute non-inflammatory diarrhea?
Viral- Norovirus, Rotavirus
Protozoa- Giardia
Essentials for Dx of acute inflammatory diarrhea?
Less than 2wks
Blood, pus or fever from invasive/toxin producing bacterium
Diagnostic evaluation of acute inflammatory diarrhea includes ? tests?
Cultures for E Coli H7
C Diff
Ova and Parasite
What are the acute inflammatory diarrhea etiologies?
E Coli
Shigella
Salmonella
C Diff
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
What are the anti-diarrhea meds?
Loperamide
Bismuth subsalicylate
When are ABX considered for diarrhea PTs?
Non-hospital acquired w/ mod/sev fever, tenesmus or bloody stools
Presence of lactoferrin
Immunocompromised
Significant dehydration
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
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
ABX for diarrhea are only recommended for which microbes?
GC CLASTS Giardia Cholera C Diff Listeriosis Amebiasis Salmonellosis Traveler's Diarrhea Shigellosis
Acute diarrhea PTs are admitted for what criteria?
Dehydration Bloody diarrhea Inflammatory/ischemia, toxin Infection/sepsis Severe/worse +70y/o Hemolytic uremic syndrome
Define Osmotic Diarrhea
Inc stoop osmotic gap
Resolves w/ fasting
Causes: carb malabsorption, lax abuse, malabsorption syndrome
What needs to be considered in all PTs w/ chronic postprandial diarrhea
Carb malabsorption
Define Secretory Conditions
Inc intestinal secretion/dec absorption
High vol, watery stool
No/little change w/ fasting
Causes: endocrine tumor or bile salt malabsorption
What inflammatory conditions cause chronic diarrhea?
IBDz: Crohns, Ulcerative colitis
Microscopic colitis
What chronic infections can cause chronic diarrhea?
Giardia
E Hystolytica
Cyclospora
Nematodes
What systemic conditions can cause chronic diarrhea?
Thyroid dz
Diabetes
What is in a chronic diarrhea work up
Exclude commons: meds, IBS, lactose intolerance
Eval etiology based on Sx
What labs are pulled for chronic diarrhea?
CBC Chem 17 LFT Thyroid ESR CRP Stool studies: culture, leukocytes, lactoferrin, occult, OandP, E+
Why is a colonoscopy with biopsy performed?
What other test can be ordered?
Exclude IBD and neoplasm
24 stool- total weight and fat
4 things that present with anorexia?
Tropical sprue
Adenocarcinoma
Gastropathy, erosive/hemorrhage
Appendicitis
4 things that present with steatorrhea?
Tropical COW Tropical Sprue Celiac Over growth Whipple
Two things that present with tenesmus and one consideration about tenesmus?
Presents- acute inflammatory diarrhea
Infectious proctitis
Consideration- empiric ABC treatment for acute diarrhea
If SAAG is > 1.1g and peritoneum is normal
Hepatic congestion
Liver Dz
Portal vein occlusion
If SAAG is < 1.1g and peritonium is normal ?
Hypoalbuminemia
Miscellaneous: ascites, myxedema, ovarian dz
SAAG below 1.1g and with diseased peritoneum
Infection
Malignancy
Other- mediterranean fever, vasculitis, granulomatous peritonitis, eosinophilic peritonitis
What is the only -itis condition with SAAG >1.1g/dL since all others with -itis ending are below 1.1G
Constrictive pericarditis
Treatment for GI gas?
Investigate malabsorption
Food diary
Avoid FODMAPS
Beano, Simethicone
Constitutional Sx of Cancer
F/C/Ns
Ascites PT with focal TTP
CT to find source
What causes non-portal HTN ascites?
Infection
Malignancy
Inflammatory disorder of peritoneum
Ductal disruption
Ascetic fluid neutrophil PMN greater than 250 = ?
Bacterial peritonitis
How do you distinguish between spontaneous and secondary peritonitis?
Spontaneous will have lactate dehydrogenase, glucose or total protein
What drug is preferred over Octreotide and Somatostatin for esophageal varices management?
Terlipressin
Contraindicated in PTs with coronary/cerebral/PVDs