GI CIS/DSA Flashcards
Definitions: Acholic Anorexia Acute abdomen Borborygmi Cachexia
Acholic: acholic stools are white clay colored stools, which result from absence of secretion of bile into the GI tract
Anorexia: lack of appetite
Acute abdomen: any serious acute intraabdominal condition attended by pain, tenderness, and muscular rigidity and for which emergency surgery must be considered
Borborygmi: a rumbling noise caused by propulsion of gas through the intestines
Cachexia: a profound and marked state of constitutional disorder; general ill health and malnutrition
Definitions: Cholestasis Coffee ground emesis Colic Courvoisiers Sign Cullen sign
Cholestasis: stoppage or suppression of bile flow, due to factors within (intrahepatic cholestasis) or outside the liver (extrahepatic cholestasis)
Coffee ground emesis: denotes blood congealed and separated within gastric contents that takes the form of coffee grounds when in contact with acidic environment
Colic: acute paroxysmal abdominal pain
Courvoisiers sign: Enlarged non-tender gallbladder secondary to pancreatic disease or cancer
Cullen sign: Ecchymosis around the umbillicus secondary to hemorrhage
Definitions: Curling ulcer Cushing ulcer Dyspepsia Dysphagia Dysplasia
Curling ulcer: stress ulcer is a peptic ulcer of the duodenum in a patient with extensive superficial burns
Cushing ulcer: stress ulcer is a peptic ulcer occuring from severe head injury or with other lesions of the central nervous system
Dyspepsia: postprandial epigastric discomfort
Dysphagia: difficulty swallowing
Dysplasia: abnormal tissue development, alteration in size, shape, and organization of cells
Definitions: Edentulous Esophagitis ERCP Eructation EUS
Edentulous: having no teeth
Esophagitis: inflammation of the esophagus
ERCP: Endoscopic retrograde cholangiopancreatography
Eructation: expulsion of swallowed air, aka buroing
EUS: Endoscopic ultrasound
Definitions: Flatus Gastritis Gastropathy GGT Grey turner sign Globus pharyngeus Gaurding Heel strike
Flatus: gas or air in the GI tract expelled through the anus
Gastritis: inflammation of the stomach with distinctive histologic and endoscopic features
Gastropathy: gastric conditions where there is epithelial or endothelial damage without inflammation
GGT: gamma glutamyl transferase, used to determine the cause of elevated alkaline phosphatase (ALP)
- both elevated = liver disease
- ALP elevated but not GGT = other (usually bone)
Grey turner sign: Flank ecchymosis secondary to hemorrhage
Globus pharyndeus: also known as globus hystericus which is a foreign body sensation lovalized in the neck that does not interfere with swallowing and sometimes is relieved by swallowing
-often occurs in the setting of anxiety or OCD, often attributed to GERD
Gaurding: protective response in muscle resulting from pain or fear of movement, voluntary versus involuntary
Heel strike: Patient supine, Doc strikes patients heel. pain upon striking could indicate appendicitis
Definitions: Hematemesis Hematochezia Icterus/jaundice Iliopsoas Muscle test KUB Xray
Hematemesis: Vomiting blood
Hematochezia: passage of bright red blood or marron stools
icterus/jaundice: yellowish staining of the integument, sclera, and deeper tissues
Iliopsoas muscle test: have the patient flex their hip against your resistance - increased abdominal pain is a positive test
-suggests irritation of the psoas muscle from inflammation of the appendix
KUB Xray: plain abdominal x-ray of the kidney Ureters and bladder
Definitions: LGIB Llyods punch/CVA tenderness McBurneys Point Melena Mittleschmerz
LGIB: Lower gastrointestinal bleeding
Llyods punch/CVA tenderness: gently tapping the area of the back overlying the kidney produces pain
-suggests an infecttion around the kidney or a renal stone
McBurneys Point: Rebound tenderness or pain 1/3 of the distance from the ASIS to the umbilicus that may suggest appendicitis or peritoneal irritation
Melena: dark colored stool consistent with broken down hemosiderin in bowel, typically malodorous sticky and thick like paste (Tarry)
Mittleschmerz: lower abdominal pain in the middle of the mestrual cycle, doesnt cause rebound tenderness
Definitions: MRCP Murphy sign Nausea Obstipation Obturator muscle test Odynophagia
MRCP: Magnetic resonance cholangiopancreatography
Murphy sign: Palpate deeply under right costal margin during inspiration and observe for pain and or sudden stop in inspiratory effort
-test for cholecystitis or cholelithiasis
Nausea: subjective sensation of impending urge to vomit
Obstipation: severe intractable constipation caused by intestinal obstruction
Obturatior muscle test: Flex the patients right thigh at the hip, with the knee bent and rotate the leg internally at the hip. Right hypogastric pain is a positive test
-this suggests irriation of the obturator muscle from an inflamed appendix
Odynophagia: painful swallowing
Definitions: Pneumobilia Pneumomediastinum Pneumoperitoneum Psoas sign Pyrosis
Pneumobilia: abnormal presence of gas in the biliary system/bile ducts
Pneumomediastinum: abnormal presence of air or gas in the mediastinum, may interfere with respiration and circulation, may lead to pneumothorax or pneumopericardium, occur spontaneously or as a result of trauma or pathology or after diagnostic procedure
Pneumoperitoneum: abnormal presence of air in the peritoneal cavity
Psoas sign: associated with retrocecal appendix. Maifested by RLQ pain with passive right hip extension
Pyrosis: substernal burning sensation aka heartburn
Definitions: Rebound tenderness Regurgitation Reetching Rovsings sign Steatorrhea Tenesmus UGIB Ulcer Ureterolithiasis Virchows node Vomiting/emesis
Rebound tenderness: pain upon removal of pressure, rather than the application of pressure in the abdome. Tests for peritoneal inflammation/acute abdomen
Regurgitation: effortless reflux of liquid or gastric or esophageal food contents in the absence of N/V
Retching: peristalsis of stomach and esophagus conducted with a closed glottis
Rigidity: like it sounds, abdomen is hard, involuntary reflex contraction of abdominal wall
Rovsings sign: Pain in the RLQ during left-sided pressure- referred rebound tenderness seen in appendicitis
Steatorrhea: fatty greasy stools
Tenesmus ineffectual and painful straining at stool (or urination)
UGIB: upper gastrointestinal bleeding
Ulcer: local defect or excavation of the surface of an organ or tissue that is produced by the sloughing (shedding) of inflammed necrotic tissue
Ureterolithiasis: stone from kidney making its way through ureter to bladder, urine analysis will show hematuria
Virchows Node: Palpable mass, lymph node, in the left supraclavicular/sternoclavicular fossa
Vomiting emesis: Queasiness to retching, forceful ejection of upper gut contents from the mouth
what is a list of Red Flag symptoms and signs?
Dysphagia Odynophagia Hematemesis Melena Unintentional weight loss Persistent vomiting Constant/severe pain Unexplained iron deficiency anemia palpable mass Lymphadenopathy Family history of upper gastrointestinal cancer
Common disease found in the RUQ?
Cholecystitis Pyelonephritis Ureteric colic Hepatitis Pneumonia
Gall bladder!
Common diseases found in RLQ?
Appendicitis Ureteric colic Inguinal hernia IBD UTI Gynaecological Testicular torsion
Common diseases found in the LUQ
Gastric ulcer Pyelonephritis Ureteric colic Pneumonia PUD (peptic ulcer disease) Gastritis
common disease found in the LLQ
Diverticulitis Ureteric colic Inguinial hernia Gynaecological Testicular torsion
common diseases found in the epigastric region?
Peptic ulcer disease cholecystitis Pancreatitis Mycocardial infarction food poisoning Biliary tract disease
common diseases found in the Peri umbilical region
Small bowel obstruction
Large bowel obstruction
Appendicitis
Abdominal aortic aneursym
what is a differential diagnosis for a Upper GI bleed?
Peptic ulcer disease Erosice gastritis Arteriovenous malformations/angioectasias Mallory-weiss tear Esophageal varices
difference between visceral pain and parietal pain
Visceral pain:
- visceral pain fibers
- secondary to distention, stretching or contraction of hollow organs
- felt in midline at the level of the structure involved
- not localized
Parietal pain:
- somatic nerve fibers
- secondary to inflammation in the parietal peritoneum
- constant more severe
- localized
- aggrevated by movement or coughing
- alleviated by remaining still
what are important historical elements for Nausea and vomiting and what are the main big triggers for these?
Important historical findings:
- apperance
- blood
- coffee grounds
- food
- feculent
- how often
- projectile
main causes:
- visceral afferent stimulation
- vestibular disorders
- CNS disorders
- irritation of chemoreceptor trigger zone
Main causes of oropharyngeal dysphagia
Trouble initiating swallowing:
- Neurological disorders
- Muscular and rheumatologic disorders
- metabolic disorders
- infectious disease
- structural disorders
Main causes of esophageal dysphagia
Mechaincal obstruction:
- schatzu ring
- peptic structure
- esophageal cancer
- eosinophilic esophagitis
Motillity disorder:
- achalasia
- diffuse esophageal spasm
- scleroderma
- ineffective esophageal motillity
What is CBC and what is it if it has Diff?
CBC would contain:
- white blood count (WBC)
- Hemoglobin
- hematocrit
- Mean corpuscular volume (MCV)
- Mean corpuscular hemoglobin (MCH)
- Mean corpuscular hemoglobin concentration (MCHC)
- Red cell distribution width (RDW)
- Platelet count (RBC)
- Red cell count
with diff: includs all above and
- Percentage and absolute differential counts of
- PMN
- Lymph
- Baso
- Eos
- Mono
- Neut
what is in a BMP and what is added in a CMP
Basic metabolic panel:
- Sodium
- Potassium
- Chloride
- Carbon dioxide (bicarb)
- BUN
- Creatine
- Glucose
- calcium
- eGFR calculation
- BUN:creatine ratio
Comprehensive metabolic panel is everything in a BMP plus:
- Albumin:globulin (A:G) ratio
- Albumin
- Alkaline phosphatase
- Aspartate aminotransferase (AST/SGOT)
- Alanine aminotransferase (ALT/SGPT)
- Bilirubin total
- Globulin total
- Protein total
What GI labs to consider when looking at the pancreas?
Lipase
Amylase (better one)
what GI labs to consider when looking at the liver?
- Gamma-glutamyl transferase (GGT)
- Fractionate bilirubin
- PT/INR (helpful to know bleeding risk prior to procedure)
what GI labs to consider when looking for zolinger ellison gastrinoma?
Fasting Gastrin
-secretion stimulation test (will be elevated)
What are the two types of Plain films for the abdomen and what are they good at screening for?
Acute abdominal series:
- consists of a single view chest x-ray and a flat and upright x-ray of the abdomen
- good for inital screening
- not diagonstic in most cases
- great to check quickly for free air, bowel obstruction, and or constipation
KUB:
- single flat plate (supine) x-ray of the abdomen
- limited diagnostic benefit
what is Barium Esophagography and what is it used for
aka Barium swallow x-ray
Differentiate between mechanical lesions and motillity disorders
Barium study is more sensitive for detecting subtle esophageal narrowing due to rings, achalasia, and proximal esophageal lesions
what is Esophagogastroduodenoscopy and what is it used for?
Studty of choice: upper endoscopy
- persistent heart burn
- dysphagia
- odynophagia
- structural abnormalities detected on barium esophagography
Diagnostic and therapeutic:
- direct visualization
- allows biopsy of mucosal abnormalities and of normal apperaing mucosa
- allows for dilation of strictures
wha is colonoscopy used for?
Screening tests
Lower GI bleeds
Undifferentiated LAP
What is Ultrasound used for?
Good for imaging fluid filled structures
- gall bladder
- fast scan for trauma
- bladder
- kidneys
- aorta and vessels
- heart
Limited by air and fat
How do we visualize the biliary tree?
ERCP: endoscopic retrograde cholangiopancreatography
-diagnostic and therapeutic technique
MRCP: magnetic resonance cholangiopancreatography
HIDA: hepatobilary iminodiacetic acid scan
-useful in determing the amount of bile in biliary tree
What is CT scan used for
Gives the most information about abdominal pathology
order as ABD/pelvis
- with or without contrast
- IV or oral contrast
Epidemiology, Pathophysiology, and classical symptoms of GERD
Gastroesophageal reflux disease
-10 to 20 percent of western world
Reflux of gastric contents through the lower esophageal sphincter (LES) into the esophagus or oropharynx to cause symptoms, injury to esophageal tissue
Classic symptoms: -heartburn (pyrosis) -regurgitation/refux Alarming symptoms: -new onset of dyspepsia -gastrointestinal bleeding -persistent vomiting -dysphagia -odynophagia -unexplained weightloss -iron deficiency
What is the treatment of GERD?
Lifestyle modification:
-weight loss if obese, elevated head of bed, elimination of dietary triggers, avoid alcohol and smoking
Antacids:
-calcium carbonate, aluminum hydroxide
Surface agents:
-sucrafate
H2 Blockers:
- decreases the secretion of acid by inhibiting the histamine 2 receptor on the gastric parietal cell
- zantac
Proton pump inhibitors:
- most potent inhibitors of gastric acid secretion by irreversibly inhibiting hydrogen potassium (H-K) ATPase pump
- ex. omperazole
Peptic Ulcer disease PUD
Peptic ulcers are defects in the gstric or duodenal mucosa that extend through the muscularis mucosa
Risk factors:
- Helicobacter pylori infection
- NSAID
- smoking and alcohol consumption
Symptoms:
- can be asymptomatic
- upper abd pain, primarily epigastric but can be in RUQ and LUG
Most common cause of UGI bleeding (50% of all UGIB)
Gastric ulcer
location is typically in the lesser curvature of the antrum of the stomach
Loss of protective mucosal barrier due to decrease acid secretion
Sharp burning epigastric pain
worsens right after eating
treatment:
-H2 blocker, proton pump inhibitor, eradicate H. Pylori
Duodenal ulcer
More common than gastric ulcer
location is the anterior wall lining of proximal duodenum
-multiple ulcers or ulcers distal to 2nd portion of duodenum
increase gastric acid secretion
gnawing episgastric pain
-worsens 3-5 hours after eating
may be relieved by eating food
Treatment:
-H2 blocker, proton pump inhibitor, eradicate the H. pylori
what are the disease associate with helicobacter pylori
Most prevalent chronic bacterial disease known
causes:
-peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, gastric mucosa, associated lymphoid tissue (MALT) lymphoma, and duodenal ulcers
Pathophysiology behind Helicobacter pylori and how do we test for it?
Bacterial urease hydrolyzes gastric luminal urea to form ammonia that helps neutralize gastric acid and form a protective cloud around the organsim that enables it to penetrate the gastric mucus layer
affects the:
- Increased gastric acid secretion
- gastric metaplasia
- immune response
- mucosal defense mechanisms
How to test for H. pylori
Urea breath test Fecal antigen test detection of antibodies in serum Upper endoscopy with gastric biopsy -warthin starrys silver stain and immunohistochemistry stain
Remeber to have patient stop proton pump inhibitor medication for 14 days before fecal and breath tests otherwise have high chance for false negative tests
what are the three different types of blood appearances for the GI tract and what do they tell us?
Hematemesis: vomiting of blood or coffee ground like material
Melena:
black tarry stools
-90% of the time is secondary to an UGIB
Hematochezia:
- red or maroon blood in stool
- usually due to lower GI bleed
- can occur with massive upper GI bleeding
where is the line between the UGIB and LGIB?
UGIB:
- ANy GI bleed orginating proximal to the ligament of treitz
- esophagus, stomach, duodenum
LGIB:
- any GI bleed originating distal to the ligament of Treitz
- Jejunum, ileum, colon, and rectum
Causes of UGIB:
- peptic ulcer disease
- erosive gastritis and esophagitis
- esophageal and gastric varices (from portal hypertension)
- vasuclar anomalities
- malignancy
- mallory-weiss tear
- aorto-enteric fistula
causes of LGIB:
- Diverticulosis
- vascular anomalies
- malignancy
- IBD
- crohns, ulcerative colitis
- anorectal disease
- anal fissures
- hemmorhoids
- colitis (ischemic or infectious)
what are Esophageal and gastric varices
Dilated suubmucosal veins resulting from portal hypertension
often result of alcoholic liver disease
prone to re-bleeding
high mortality rate
Variceal bleeding is the cause of UGI bleeding in cihotics 59% of the time followed by peptic ulcer disease in 16% of cases
what are the three presentations of gallstones
- asymptomatic
- classic presentation of biliary colic (pai in RUQ and worse after eating greasy foods)
- Complications of gallstone disease
Cholelithiasis:
Cholecystitis
Choledocholithiasis:
Cholelithiasis: gall stones
Cholecystitis: inflammation of the gallbladder second to stone or obstruction in neck of GB or cystic duct
- gall bladder cant drain bile but liver can
- LFT normal
CHoledocholithiasis:
- stone stuck in the common bile duct
- neither the GB nor the Liver can drain bile
- LFT elevated
Ascending cholangits:
Gallstone pancreatitis:
Dysfunctional GB:
Ascending cholengitis:
- biliary tree gets inflamed and infected
- many times from stone in the common duct
- air in biliary tree
Gallstone pancreatitis:
-gallstone get stuck in pancreatic duct causing elevated LFTs and Pancreatic enzymes (lipase and amylase)
Dysfunctional GB:
- no stones but GB does not empty well
- symptoms of biliary colic
- diagnosed with HIDA scan
Pancreatitis:
Pathophysiology:
-acute panceatitis is an inflammatory condition of the pancreas characterized by abdominal pain and elevated levels of pancreatic enzymes in the blood
Risk factors: Gallstones, alcohol abuse, hypertriglyceridemia
Presentation:
-acute onsent of persistent severe epigastric pain (often radiating to back) nausea vomiting and epigastric tenderness on palpation
Diagnostic workup:
- CBC, CMP, LIpase, UA, preg test,
- imaging on case by case, CT scan or US
Treatment:
- IV fluids, pain and nasuea medication
- NO or clear liquids
Appendicitis
Pathophysiology:
-inflammation of the appendiceal wall followed by localized ischemia, perforation and the development of a contained abscess or generalized peritonitis
Presentation:
- RLQ abdominal pain, anorexia, nausea/vomiting. may have fever
- positive mcBurneys point and sharp somatic pain
Workup:
- CBC,CMC, UA, preg test
- CT scan or US
treatment:
- surgery
- NPO, IV fluids, pain and nausea medication
DIverticulitis/ Diverticulosis:
Pathophysiology: Diverticulitis
-erosion of the diverticular wall by increased intraluminal pressure or impacted food particles. inflammation and focal nercosis ensue, leading to perforation
Pathophysiology: Diverticulosis
-presence of diverticulum (sac like protrusions of the colonic wall)
Classic presentation:
- abdominal pain in LLQ
- nausea vomiting maybe a fever
- LLQ tenderness
Workup:
- CBC,CMC, UA, preg test
- CT scan
Treatment:
- antibiotcs
- maybe surgery
Achalasia
Pathophysiology:
- progressive degeneration of ganglion cells in myenteric plexus in the esophageal wall leading to failure of relaxation of the lower esophageal sphincter
- also loss of peristalsis in the distal esophagus
Symptoms: -progressive dysphagia -regurgitation weight loss -substernal discomfort
Diagnosis:
- Barium esophagus to get birds beak appearance
- esophageal manometry confirms
treatment:
- BoTox
- dilation
- surgery
Chagas Disease
Secondary achalasia
- esophageal dysfunction
- found in mexico, central and south america
- caused by the parsite: trypanosoma cruzi
- protozoan disease
Zollinger Ellison Syndrome gastrinoma
Pathophysiology:
- caused by secretion of gastrin by duodenal or pancreatic neuroendocrine tumor
- gastric acid hypersecretion results in severe acid related peptic disease and diarrhea
Consider when:
- intractable ulcer
- ulcers in atypical locations
- ulcer associated with diarrhea, steatorrhea, weight loss, nausea/vomitting
Significantly elevated fasting gastrin and positive secretin stimulation test
Viscerosomatics: Paraympathetics
Upper portion: esophagus thru transverse colon
-OA, AA (vagus n)
Lower portion: Descending colon, sigmoid, rectum
-S2-S4 (pelvic splanchnic n)
Viscerosomatic sympathetic levels:
T12 - appendix T2-8- esophagus T5-9- stomach T6-9- liver T6-9- gall bladder 5-T9, T9-T12- small intestine T9-L2- Colon T5-T11- Pancreas
