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Diagnosis & Mgmt 1 > GI disorders > Flashcards

GI disorders Flashcards

1
Q

Epigastric pain usually indicates…

A

liver, pancreas, biliary tree, stomach, duodenum

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2
Q

Periumbilical pain usually indicates…

A

distal end of the small intestine, cecum, appendix, ascending colon

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3
Q

Visceral pain is usually described as…

And where?

A

Described as dull, diffuse, cramping, burning or nauseating
From dissension and muscular contraction
Pain in lower abdomen: from hindgut structures (distal colon and GU tract)
Periumbilical pain: from midgut structures (small bowel, proximal colon and appendix)
Pain in upper abdomen: from foregut structures (stomach, duodenum, liver and pancreas)

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4
Q

Suprapubic pain usually indicates…

A

distal intestine, urinary tract infection, pelvic organ dysfunction

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5
Q

What history should be taken with GI distress?

A
  • feeding habits (any food intolerance?)
  • change in appetite
  • bowel habits
  • constipation/diarrhea
  • presence of pain
  • N/V
  • Thirst level
  • Heart burn, belching, flatulence
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6
Q

Define: globus

A

complaint of something stuck in their throat

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7
Q

Define: dysphagia

A

Difficulty swallowing

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8
Q

What are 4 main causes of dysphagia?

A
  • structural defect: narrowing of esophagus or extrinsic obstruction. Usually solids harder to swallow than liquids
  • neurological disorder: from cerebral palsy, or muscular dystrophy
  • motor disorder: uncommon in children
  • mucosal injury: usually from GERD or gastritis
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9
Q

What history is common for dysphagia?

A
  • progressive dysfunction
  • persistant drooling or cough
  • discomfort with swallowing (esp. solids)
  • picky eating or food refusal
  • heartburn, halitosis, chest pain
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10
Q

What physical exam areas to focus on in dysphasia?

A

In children:

  • feeding, oral motor skills, safety in swallowing
  • PE: mouth, neck, throat
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11
Q

What differential diagnosis should be considered with dysphagia?

A
  • trouble swallowing solids only: obstructive/compression lesion
  • trouble with liquids and solids: physiological dysfunction
  • trouble feeding: child/feeder dysfunctional feeding relationship
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12
Q

Vomiting vs. Regurgitation

A

Vomit: forceful expulsion
Regurg: passive reflux

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13
Q

How can vomit be described?

A
  • bilious or non-bilious

- bloody or non-bloddy

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14
Q

What are potential diagnosis of a newborn or new infant with vomiting?

A
  • infectious process
  • congenital GI anomaly
  • CNS abnormality
  • inborn errors of metabolism
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15
Q

What are the potential diagnosis of an infant or young child with vomiting?

A
  • gastroenteritis
  • GERD
  • Mild/soy allergy
  • pyloric stenosis or obstructive lesion
  • inborn errors of metabolism
  • intussusception
  • child abuse
  • intracranial mass lesion
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16
Q

What are the potential diagnosis of an older child or adolescent with vomiting?

A
  • gastroenteritis
  • systemic illness
  • CNS (cyclic vomiting syndrome, abdominal migraine, meningitis, brain tumor)
  • pregnancy
  • intussusception
  • rumination
  • superior mesenteric artery syndrome
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17
Q

What is non bilious vomit usually causes by?

A
  • infection
  • inflammation
  • metabolic/neurologic,psychological problems
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18
Q

What is bloody vomit usually caused by?

A

active bleeding in the upper GI tract (gastritis or peptic ulcer disease)

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19
Q

What is intussusception?

A
  • when part of the intestine telescopes itself
  • very rare
  • S&S: loud cry ever 15-20 minutes, vomiting and stool has blood and mucus in it, lethargic, loss of appetite
  • Treatment: enema or surgery
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20
Q

What is gastritis?

A
  • when your stomach is inflamed
  • S&S: pain, nausea, vomiting, loss of appetite, bloating, belching, indigestion, hiccups
  • Treatment: antibiotics (Amoxicillin, Clarithromycin, Metronidazole) and antacids (Pantoprazole (Protonix), Rabeprazole (AcipHex), Dexlansoprazole (Dexilant))
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21
Q

What is esophagitis?

A
  • when your esophagus is inflamed
  • S&S: chest pain with eating, epigastric pain, dysphagia, heartburn, regurgitation, vomiting
  • Treatment: Antifungal (diflucan) or Antacid (Pantoprazole)
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22
Q

What is annular pancreas?

A

When the ring of the pancreas squeezes and narrows the small intestine so food cannot pass.

  • S&S: infants take in less milk, cry often, and vomit
  • Treatment: surgery
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23
Q

What is pyloric stenosis?

A
  • When the opening between the stomach and small intestine thickens
  • S&S: projectile vomiting, baby colic, failure to thrive, insufficient urination, lump in abdomen, weight loss, dehydration, lethargy
  • Treatment: surgery
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24
Q

What is a tracheoesophageal fistula?

A
  • When the trachea and esophagus have a connection that lead to severe and fatal pulmonary complications
  • S&S: cyanotic infant, trouble feeding, rattling respiration and coughing episodes
  • Treatment: surgery
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25
Q

What is hirschsprung’s disease?

A
  • Large blockage in the large intestine which leads to trouble passing stool. No ganglia in the distal colon, so movement in slowed or doesn’t occur.
  • S&S: newborn unable to pass stool, constipation, vomiting, flatulence and failure to thrive
  • Treatment: bowel resection
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26
Q

What is Necrotizing Enterocolitis?

A
  • Occurs in formula-fed premature infants in 2-3 week of life.
  • S&S: vomiting, diarrhea, delayed gastric emptying, abdominal distension, decreased bowel sounds
  • Treatment: hospitalization with antibiotics, maybe surgery
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27
Q

What could visceral epigastric pain be?

A

indigestion, cholecystitis

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28
Q

What could visceral periumbilical pain be?

A

intestinal obstruction, early appendicitis

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29
Q

What could visceral suprapubic pain be?

A

small or large intestine, UTI, IBS

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30
Q

What is referred pain?

A

Pain received distant from its source. Due to the lack of dedicated sensory pathways in the brain for information concerning internal organs.

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31
Q

What is parietal or somatic pain? What does it feel like?

A

Parietal pain comes from the parietal peritoneum.
Feels sharp and well localized.
Due to acute ischemia, infection or inflammation
i.e. acute appendicitis or acute cholecystitis

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32
Q

What is psychogenic pain?

A
  • Chronic, non-progressive pain, may wax and wane
  • Usually multiple body complaints
  • Could be Somatic symptoms of depression
  • Perform light and deep palpation with stethoscope to assess for tenderness/rebound to validate their account
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33
Q

How does serotonin play a role in pain?

A

The neurotransmitter and a hormone that plays a role in: mood, sleep, temp, appetite, pain perception, sexual behavior and other hormones.

  • When in the gut, it increases the gut motility, allows the stomach to expand and transmits info to the CNS.
  • Use SSRIs in IBS
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34
Q

What should be included in the ROS for a GI complaint?

A

trouble swallowing, heartburn, appetite changes, nausea, vomiting, hematemesis, indigestion, BM frequency, last BM, rectal bleeding, melena, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or flatus, hemorrhoids, jaundice, cholecystitis, hepatitis, weight loss, nocturnal symptoms

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35
Q

What should the physical exam included for a GI complaint?

A

General, temp, color and VS (low BP: worried about low blood volume)
Assess respiratory, signs of pneumonia
Assess for CVAT, hernia, and pulses
With acute pain, do abdominal, pelvic, and rectal exam

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36
Q

When is it an acute (surgical) abdomen?

A
  • pain is acute (lasting > 6hrs with no relief)
  • Symptoms are progressive
  • pain is well localized (often rebound tenderness, guarding and rigidity)
  • N/V and anorexia associated
  • Absent bowel sounds
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37
Q

If you suspect an acute abdomen, what should you include in your physical exam?

A
  • check for orthostatic blood pressure and pulse
  • cold, clammy extremities
  • tachycardia
  • impaired mentation
  • oliguria (less than 500mL output per day)
  • fever
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38
Q

What are some signs of peritonitis?

A
  • worse when they move or cough. They lie very still and want to keep their knees to chest
  • infants will lie very still with flexed hips and are quiet
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39
Q

What are the potential causes of peritonitis?

A
  • appendicitis, diverticulitis, strangulating intestinal obstruction, pancreatitis, PID, mesenteric ischemia
  • intraperitoneal blood from ruptured aneurysm, trauma, sugary, ectopic pregnancy
  • Barium
  • Ascites, peritoneo-systemic shunts, drains, dialysis catheters
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40
Q

What should you look for in elderly to suspect peritoneal irritation?

A
  • usual signs of peritoneal irritation are absent in the elderly
  • instead, they may have a mild fever, tachycardia, reduced bowel sounds, vague abdominal discomfort without refund or guarding
  • May also be: cardiac, respiratory, or GU problem
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41
Q

What are some non GI sources of Upper quadrant pain?

A
  • herpes zoster
  • lower lobe pneumonia
  • MI
  • radiculitis (never pain from the spine)
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42
Q

What is GERD? What contributes to it?

A

Reflux of gastric contents into the esophagus from:

  • LES relaxation
  • Irritants
  • Decreased secondary peristalsis
  • Decreased resistance to caustic liquids
  • possibly from a large hiatus hernia

Contributors:

  • tabacco
  • alcohol
  • exercise
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43
Q

What are some triggers of GERD? How can you tell?

A

Triggers:

  • Spicy or fatty or fried or food
  • Citrus
  • Caffeine

Try: cutting out all possible triggers and re-introducing one at a time to find the triggers

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44
Q

What are the clinical features of GERD?

A
  • heartburn 30-60 minutes after eating
  • worse symptoms when laying down or wear tight clothes
  • pain radiates upward in the heart area
  • May also have regurg, nocturnal aspiration, ulcers, hemorrhage, dental erosions, laryngitis, asthma symptoms or Barrett’s esophagus
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45
Q

What should you ask about with possible GERD patient?

A
  • Onset, duration, progression of heartburn
  • what helps/ aggravates its?
  • smoker?
  • NSAID/ ASA use?
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46
Q

What is needed to make a GERD diagnosis?

A

Dx can be made on history alone if:

  • > 45 years old
  • history of heartburn
  • no dysphagia
  • no weight loss
  • no blood loss
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47
Q

What physical exam is needed in possible GERD patient?

A
  • height/weight
  • abdominal exam for masses and tenderness
  • occult blood test of stool
  • only need endoscopy if atypical presentation of GERD
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48
Q

What is the first phase of GERD therapy?

A

Nonpharmacologic therapy for 2 weeks:

  • IF obsess, lose 10 lbs.
  • smoking cessation
  • elevate the head of the bed
  • eat smaller meals and don’t eat 2-3 hours before bed
  • reduce triggering foods
  • use antacids PRN
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49
Q

What is the second phase of GERD therapy?

A

If failure of first phase or moderate sx:
- H2 receptor antagonist, BID like Zantac or Pepcid.

  • PPI, 30 minutes before meals like omeprazole or Prilosec

Use PPI if H2 doesn’t work or erosive esophagitis

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50
Q

What are the long-term side effects of PPIs?

A
  • PPI associated pneumonia
  • possible connection with C.diff infection
  • hypomagnesemia
  • decrease Ca absorption
  • interferes with Vit B 12 absorption
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51
Q

How long do therapies for GERD need to be put into place for?

A

Re-evaluate after 1-2 weeks
If controlled, keep on for 12 weeks.
Then discontinue or lower the medication as much as possible.

If unresolved: refer to gastroenterologist

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52
Q

What is Barrett’s Esophagus?

A
  • Complication of GERD
  • a pre-malignant condition, usually white men over 50 years old
  • Presents with heartburn or dysphagia
  • tissue injury due to chronic exposure to gastric acid, pepsin and bile
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53
Q

What is gastroparesis?

A

impaired gastric emptying, usually from uncontrolled hyperglycemia/ DM

  • impacts both sympathetic and parasympathetic nerve fibers
  • affects food absorption, which affects glycemic control
  • Causes nausea and vomiting
  • Symptoms improve with control of hyperglycemia
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54
Q

How is gastroparesis diagnosed?

A

endoscopy or gastric emptying study

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55
Q

How is gastroparesis treated?

A
  • Dietary modifications

- Med: reglan (metoclopramide)- increases motility but CI in elderly

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56
Q

What is dysphagia?

A

A swallowing disorder that involved one or more of the stages of swallowing (either oropharyngeal or esophageal)

  • Oropharyngeal: usually a functional cause
  • Esophageal: usually a structural cause
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57
Q

What are the risks of dysphagia?

A
  • malnutrition
  • dehydration
  • choking
  • aspiration
  • pneumonia
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58
Q

What is transfer dysphagia?

A

type of oropharyngeal

usually neurological with difficult initiating swallowing

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59
Q

What is achalasia?

A

the most common motor dysphagia

slow progressive loss of peristalsis

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60
Q

What type of dysphagia is rapid and usually affects solids?

A

A mechanical obstruction

if less than 1 year, it could be malignant

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61
Q

Describe the onset of a motor disorder dysphagia.

A

gradual onset, slow progression and chronic

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62
Q

Describe the onset of an obstructive disorder dysphagia

A

Rapid onset and progression

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63
Q

Why ask about respiratory symptoms with a dysphagic patient?

A

recurrent unexplained pneumonia may occur from tracheal aspiration of esophageal contents

  • think esophageal disease
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64
Q

What does heartburn and dysphagia suggest?

A

inflammatory stricture or disease

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65
Q

What does intermittent dysphagia suggest?

A

lower esophageal problems

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66
Q

What does dysphagia associated with swallowing suggest?

A

mucosal inflammation

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67
Q

What does dysphagia of solids and heartburn suggest?

A

stricture

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68
Q

What does dysphagia and diplopia suggest?

A

myasthenia gravis

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69
Q

What does dysphagia with reflux, skin changes and cold extremities suggest?

A

scleroderma, Raynaud’s phenomena

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70
Q

What does dysphagia associated with a tremor suggest?

A

parkinson’s disease

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71
Q

How would dysphasia that comes from the oral stage manifest?

A

poor bolus control, spillage from lips, dry oral membranes, oral residue and difficult chewing

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72
Q

How does pharyngeal dysphagia manifest?

A

delayed swallowing, nasal/oral regurgitation, coughing, choking or gurgling

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73
Q

What do you prescribe a patient with dysphagia, if bolus is present or reflux symptoms?

A
  1. H2 block or PPI

If it doesn’t help, then refer to GI

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74
Q

What do you prescribe a patient with dysphasia with post nasal drip?

A
  1. Try nasal spray, like Flonase

If it doesn’t help, then refer to ENT

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75
Q

What referrals should be made for a patient with dysphagia, suspected with an obstruction, malignancy, lesion, reflux, infection or Schatzki’s ring?

A

Refer to endoscopy and biopsy

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76
Q

What is Schatzki’s ring?

A

narrowing of the lower esophagus that can cause dysphagia. The narrowing is caused by a ring of mucosal tissue or muscular tissue.

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77
Q

What should be tested if you suspect dysphasia is caused by muscle weakness?

A

manometry- measures intraluminal pressure during swallow

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78
Q

How can calorie intake be achieved with dysphasia? In motor and mechanical obstruction.

A

Motor- eat small meals slowly

Mechanical obstruction- liquid or soft diets

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79
Q

How is structural dysphagia treated?

A

surgery of dilation

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80
Q

Which type of peptic ulcers tend not to be malignant?

A

duodenal ulcers- tend not to be malignant

gastric ulcers- malignant 2-4% of the time

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81
Q

Which type of peptic ulcers tend to be more common?

A

duodenal ulcers are more common than gastric ulcers

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82
Q

Which type of peptic ulcer tends to caused by H.pylori?

A

duodenal ulcers

83
Q

Which type of peptic ulcer tends to be caused by NSAIDS?

A

gastric ulcers

84
Q

Which type of peptic ulcer is helped with food?

A

duodenal ulcers

85
Q

Which type of peptic ulcer is worse with food?

A

gastric ulcers- pt. tend to loose weight

86
Q

What are alarm symptoms in peptic ulcer disease?

A

Signs of bleeding: Anemia, hematemeis, melena and heme positive stool

signs of obstruction: vomiting

Signs of cancer: weight loss or anorexia

Signs of penetration to deeper mucosa: persistent upper abdominal pain radiating to the back

Signs of perforation: severe, spreading upper abdominal pain (Emergency!)

87
Q

What diagnostic tests should be performed for all patients with suspected peptic ulcer disease?

A

occult blood

Hcb/Hct

88
Q

What diagnostic tests should be performed for a patient with PUD and has an alarm symptom or is not responding to the treatment?

A

Endoscopy

89
Q

What test can be given if you suspect PUD with H.pylori?

A

ELISA
UBT (urea breath test)
stool antigen test
endoscopy biopsy

90
Q

How is H.pylori treated?

A

Regimin for 10-14 days:

  1. PPI, twice a day
  2. Amoxicillin 1g or flagyl 500mg, twice a day
  3. Clarithromycin 500mg twice a day or Bismuth subsalicylate 525mg, four times a day
  4. Tetracycline 500mg, four times a day,
  5. Histamine H2 blocker BID

aka PREVpac

-should be taken OFF NSAIDs

91
Q

How can PUD be prevented? (lifestyle changes)

A

STOP: NSAIDs and smoking

Reduce stress

92
Q

When is PUD follow up?

A

Repeat endoscopy in 2-3 months to monitor ulcer healing

93
Q

Name the 3 different acid neutralization surgeries?

A

Biliroth
Vagotomy
Subtotal gastrectomy

94
Q

What is the clinical presentation of gastric cancer?

A
  • insidious (gradual) onset of abdominal pain that ranges
  • Weight loss, abdominal pain, anorexia, vomiting
  • change in bowel habit, dysphagia, melena, anemia, hemorrhage
95
Q

What diagnostic tests need to be ordered for suspected gastric cancer?

A

CBC with diff, electrolytes, LFTs

Stool occult sample

CT radiograph/scan of abdomen

Endoscopy and biopsy

96
Q

What treatments of offered for gastric cancer?

A

Surgery or resection

  • chemo does NOT work
97
Q

What is celiac disease?

A
  • chronic, autoimmune inflammatory disease of the small intestine

triggered by wheat, barley and rye gluten proteins

98
Q

What are the clinical features of celiac disease?

A

Anemia

Short stature or no weight gain

Delayed onset of puberty/menarche

osteopenia (loss of bone density)

transaminitis (elevated AST/ALT)

Recurrent abdominal pain

99
Q

What are the diagnostic tests for celiac disease?

A
  • Genetic testing for HLA gene
  • IgA-Ttg
  • IgA-EMA
  • Blood tests: CBC, LFTs, cholesterol, albumin, vitamin levels, TSH
100
Q

What are the blood test abnormalities in celiac disease?

A
  • abnormal LFTs
  • low ferritin
  • hypocholestrolemia
  • hyperamylasemia
  • hypoalbuminemia
  • elevated ESR
  • prolonged PT
  • vitamin deficiency
  • hypocalcemia
101
Q

How does non-celiac gluten sensitivity differ from celiac disease?

A

Non-celiac gluten sensitivity experience similar symptoms as celiac disease, but lack the same antibodies

It’s like having a gluten allergy

Tx: avoid gluten

102
Q

What is the treatment for celiac disease?

A

Gluten- free diet, and may need separate cook wear.

  • not avoiding gluten can lead to other autoimmune disease
103
Q

What is cholecystitis?

A

acute/chronic inflammation of the gallbladder

usually caused by gallstones that make a mechanical obstruction, local inflammation or both

Common in FFF: female, fat, fifty

104
Q

What increases your risk of developing gallstones?

A
  • rapid weight loss or cyclic weight loss
  • childbearing, due to increased estrogen
  • Drugs: TPN, estrogen, ceftriaxone- prophylactic antibiotic
  • Native american or scandinavian
  • women
  • first degree relative
  • ileal disease
  • increasing age
105
Q

What is the clinical presentation of cholecystitis?

A
  • colicky, RUQ pain radiating to flanks and right should
  • occurs 1 hour after eating a large meal and lasts for hours
  • associated with anorexia, nausea, fever
106
Q

What would you find on the physical exam for a patient with cholecystitis?

A
  • RUQ tenderness
  • involuntary guarding
  • Murphy’s sign
  • gallbladder may be palpable
107
Q

How is chronic cholecystitis diagnosed?

A
  • CBC with differential, LFTs and GGT
  • gallbladder ultrasound- pt. must fast for the test
  • HIDA (shows how well the gallbladder contracts) Done if the ultrasound is negative
108
Q

How can cholecystitis be treated?

A
  • cholecystectomy- removed the gallbladder
  • oral dissolution therapy using bile acid- dissolved the gallstones, 25% of medically managed patients will redevelop gallstones within 5 years
109
Q

What can a delayed diagnosis of cholecystitis lead to?

A

Acute cholecystitis is when cystic duct is blocked

Delayed treatment can lead to gangrenous cholecystitis, gallbladder perforation and biliary peritonitis

110
Q

What is choledocholithiasis?

A

when gallstones migrate from gallbladder to common bile duct.

Usually they pass spontaneously into duodenum

111
Q

What is pancreatitis? What 3 types are treated in primary care?

A

Pancreatitis- inflammation of the pancreas

Treated in Primary Care:
1- recovery from acute pancreatitis
2- chronic relapsing, will have chronic abd pain
3- pancreatic insufficiency- will have steatorrhea

112
Q

What is steatorrhea?

A

fatty stool with bad smell

From too much ETOH or biliary tract disease

113
Q

What is the clinical presentation of pancreatitis?

A
  • mild/severe epigastric pain with radiation to the flank or back
  • pain is: dull, boring, and worse when supine
  • Alleviated when sitting in fetal position
  • Triggers- heavy meal or alcoholic binge
  • Nausea and non-feculent (clear) vomiting
114
Q

What would you find on physical exam for a patient with pancreatitis?

A

Temp elevated

Tachycardia

Abdomen: distended, muscle spasms, LUQ pain on palpation

Skin is jaundice

115
Q

What labs are needed with suspected pancreatitis?

A

Amylase- rises within 2-72 hours

Lipases- rises within 4-24 hours

Trypsin- most accurate, but not always available

116
Q

What radiology can help identify pancreatitis?

A

Ultrasound- can show stones

CT scan- the best

ERCP- endoscopy that can also remove the stone from the common bile duct

117
Q

How to manage acute pancreatitis?

A
  • rehydrate aggressively
  • Pain meds: NO Morphine, use demerol and an antiemetic
  • withhold food to reduce pain
118
Q

How to manage pancreatitis recovery?

A
  • high card, low fat, low protein diet
  • check/treat for alcoholism
  • eliminate meds that trigger pain
119
Q

How to manage chronic pancreatitis?

A
  • treat underlying cause
  • begin with mild analgesic and may go up to methadone
  • limit fat during flare ups
  • rule out carcinoma
  • monitor blood glucose
120
Q

What should be check for in N/V exam?

A
  • Abdomen is soft
  • Mental status, gait and CNS if functional
  • Is there fecal impaction of bleeding?
121
Q

When/What labs should be ordered for N/V patient?

A

When: If persistent fo 24 hours or more
- do urine dip if worried about hydrations status

What: UA, serum electrolytes, glucose, BUN, keytones, TSH, drug levels, LFTs, Hcg, CBC w/ diff

If chronic: barium swallow, CT scan, endoscopy, head CT and ECG.

122
Q

How to manage patient (non-pharm) for N/V?

A
  • no solid food or clear liquid for 24 hours
  • sip fluids 1tbsp. every 10 minutes
  • pt. should void every 2-3 hours
  • bland diet for 1 week
123
Q

How to manage a patient with severe N/V- not responding to mgmt?

A

IV hydration

Med: dramamine, regland, Tigan, compazine, zofran if not pregnant, promethazine

Never give anti emetics to children

124
Q

When should a child with N/V be sent to the ER?

A

Emisis and colicky or fever for 24+ hours

125
Q

What are the potential causes of hematemesis?

A

esophageal (varicies, ulceration, esophagitis)

Gastritis, cancer, PUD, neoplasm

126
Q

What are the potential causes of Melena?

A

Meckel’s diverticulum

Crohn’s disease

Ulcer disease

varicies

127
Q

What are the potential causes of hematochezia?

A

hemorrhoid, fissure, polyp, carcinoma, diverticular disease, IBD

128
Q

What diagnostic tests should be run for a potential GI bleed?

A

CBC, coagulation studies, renal function and liver function

If hematochezia and 50+ y.o. do a colonoscopy

If hematemesis- do endoscopy, and biopsy for H.pylori

129
Q

What medication is prescribed to prevent a bleed in a known varicose secondary to cirrhosis?

A

Nadolol or Propanolol

130
Q

What is prescribed for a suspected ulcer/gastritis?

A

H2 blockers, omeprazole

131
Q

What are some physical exam signs of appendicitis?

A

psoas sign

obturator sign

132
Q

What labs/tests confirm acute appendicitis?

A

elevated WBC (above 10,000)

CT scan

133
Q

How is appendicitis treated?

A
  • surgical removal of the appendix
134
Q

What are the two diseases of IBD?

A

Inflammatory bowel disease:

ulcerative colitis and crohns disease

135
Q

What are the peak onset age of IBD?

A

15-25 years old

Second pear: 60’s and 70’s

136
Q

What is the biggest risk factor is IBD?

A

family history

137
Q

What is the difference between ulcerative colitis and Crohn’s disease?

A

Ulcerative colitis is a confluent inflammatory disease of the bowel mucosa

Crohn’s disease is a chronic relapsing inflammatory-autoimmune disease that is segmented anywhere from mouth to anus. Extends through all layers of the GI tract.

138
Q

How will ulcerative colitis present?

A
  • blood diarrhea, urgency, fecal incontinence, abdominal pain
  • maybe: fever, anorexia, weight loss
  • arthritis, uveitis, jaundice, skin lesions
139
Q

How is ulcerative colitis managed?

A

During flare up: reduce dietary fiber

In remission: increase fiber, iron and folic acid

Initial treatment/prophylaxis: mesalamine (anti-inflammatory) or sulfasalazine (anti-inflammatory)

Other meds: steroids, opiates, immunosuppressants

140
Q

How will Crohn’s disease present?

A

diarrhea, RLQ pain or distension,

weight loss, food avoidance,

n/v, fever, recurrent UTI,

pneumaturia,

psoas abscess

arthritis

aphthous oral ulcers

141
Q

How is crohn’s disease diagnosed?

A

Colonoscopy

EGD

Capsule EGD

Barium enema

Tissue biopsy

142
Q

How is Crohn’s disease managed?

A

Food: increased fiber for diarrhea, no milk, decrease fat

May need TPN for bowel rest

Meds: 5-ASA: Asacol, Pentsa, Apriso

Others: antibiotics, steroids, immunosuppresents, opiates, methotrexate and adalimumab (chemo drugs)

Surgery reserved for intractable disease

143
Q

What is IBS?

A

Irritable bowel syndrome is a catch all term for people with no structural or biochemical etiologies but have symptoms of: abdominal pain, bloating, and disturbed defecation

Women are more effected than men.

144
Q

What is the clinical presentation of IBS?

A

bloating, cramping and diarrhea and/or constipation

usually being late teens/ early 20’s

LLQ abdominal pain is intermittent, crampy

Worse 1-2 hours after meals

Exacerbated by stress, better after BM, doesn’t disturb sleep

145
Q

What is the Rome III criteria for IBS?

A

recurrent abd pain/discomfort for 3 days/month in the last 3 months.

2 of 3 must be true:

  • improves with BM
  • change in stool frequency
  • change in form of BM
146
Q

What is the IBS work up?

A
  • abdominal exam: LLQ tenderness, guarding, masses
  • rectal exam: tendeness, masses, blood
  • Labs
  • If severe symptoms or unsure, give colonoscopy
147
Q

What test should be run for IBS?

A

CBC, ESR (erythrocyte sedimentation rate- non specific inflammation test), TSH, glucose, electrolytes, BUN (kidney function), fecal occult, stool culture, UBT (urea breath test for H.pylori),

abdominal ultrasound

x-ray: KUB (kidney, ureter and bladder x-ray), Barium enema.

148
Q

What does IBS management entail?

A
  • treat the symptoms
  • dietary/medication modifications to relive gas
  • fiber to bulk stool in predominate diarrhea
  • Miralax for constipation (osmotic laxative)
  • Bentyl (Muscarinic antagonist) for abdominal cramping TID or Levsin (anti spams) for abdominal cramping PRN
  • reduce stress and increase exercise
149
Q

How is constipation defined?

A

A decrease in the frequency of BMs

150
Q

What are the common causes of constipation?

A

Functional: ignoring the urge, not enough fiber/fluids, sedentary life, disorders of the endocrine, neuro or colorectal

In elderly: decreased activity, chronic illness, poor diet, not enough fluids, medications

151
Q

What are the Rome III criteria of functional constipation?

A

Must have 2:

  1. straining 25% of the time
  2. lumpy/hard stool
  3. incomplete evacuation feeling
  4. sensing anorectal blockage
  5. need to help stool out
  6. fewer than 3 stools per week
152
Q

What diagnostic tests could be used with constipation?

A

CBC with diff, Chem profile, TSH, UA, stool culture

KUB (kidney, ureter, bladder x-ray), abdominal x-ray

Abdominal ultrasound

Barium enema

Colonoscopy

Anorectal manometry (measures pressure)

Colonic transport studies (motility)

Electromyelogram (assesses nerve/muscle cell health)

153
Q

How is constipation managed?

A
  • increase water, exercise, fiber and fiber supplements
  • Use Senna, Miralax if straining still present- only sporadic use
  • Refer if 50+ yo and: unresponstive to tx, positive hem occult or weight loss
154
Q

How is diarrhea defined?

A

Increase in liquidity and frequency of stools

usually abrupt, self limiting (less than 1 week), and due to infection like viral gastroenteritis

155
Q

How is chronic diarrhea defined?

A

diarrhea lasting lover than 2-3 weeks

Can be intermittent or continuous

Classified as inflammatory, osmotic, secretory, factitious or altered intestinal motility

156
Q

What is tenesmus?

A

when you feel like you have to dedicate, when you don’t.

Related to inflammation

157
Q

What are some potential associated symptoms with diarrhea?

A

N/V

abdominal pain or cramping

fever

malaise

158
Q

What diagnostic tests could be run for diarrhea over 48 hours?

A

stool culture w/ fetal leukocytes and occult blood

CBC with diff, electrolytes, glucose, BUN, SCr

159
Q

What should be looked for on physical exam for a patient with diarrhea?

A
  • Temperature, weight changes
  • CV status- do they have postural hypotension from dehydration
  • Skin- turgor, rash, joint inflammation
  • HEENT: conjunctivitis (or joint inflammation = Reiter’s)
  • Abdominal: tenderness, distension, rigidity, tympany
  • Rectal: tenderness, mass, fecal impaction, occult blood (could abuse laxatives which would lead to impacted stool with liquid stool leaking around it)
160
Q

How is diarrhea managed?

A

oral fluid replacement, IV if severe or very young/old

Educate: handwashing

If bacterial- appropriate antibiotics

If not resolved with above- start Florastor probiotic

No anti-motility (loperimide/simethicone) with bloody diarrhea

F/U in 48 hours, if unresolved, need to find underlying cause

161
Q

What is C.diff?

A

Pseudomembranous colitis from enterotoxin or cytotoxin

Can occur up to 3 months after antibiotics are taken

162
Q

How is C.diff diagnosed?

A

stool sample

163
Q

How is C.diff treated?

A

metronidazole (flagyl) (250-500mg QID in adults)

if no response: vancomycin (125-500mg in adults)

164
Q

What is diverticular disease?

A

abnormal herniations of colonic mucosa

increases risk with age

165
Q

What is the difference between diverticulosis and diverticulitis?

A

Losis- asymptomatic, but have the abnormal mucosa

Litis- plugged and inflamed mucosa leading to LLQ pain, mild fever and increased leukocytes

Risk- can perforate, create fistulas, obstructions and hemorrhage

166
Q

How is diverticulitis diagnosed?

A

CT scan with oral/IV contrast

167
Q

How is diverticulitis treated?

A

Bedrest and a clear liquid diet

non-opiate analgesic

mild fever: Broad spectrum antibiotic

Fever >101 and worse symptoms: hospitalization

168
Q

How is diverticulosis treated?

A

increase dietary fiber

avoid small seeds/popcorn

Avoid laxatives, enemas and laxatives

Anticholenergics may help, but may constipate

Educate: report fever, tenderness and bleeding

169
Q

What are hemorrhoids?

A

masses of vascular tissue that form a cushion in the submucosa of the anal canal

170
Q

What is the clinical presentation of hemorrhoids?

A

painless or some pain

rectal bleeding

anal discomfort

puritis

protrusion

171
Q

What can increase the risk of developing hemorrhoids?

A

recent pregnancy

constipation

liver disease

anorectal disease

cyclists

sedentary life

172
Q

What diagnostic tests for hemorrhoids?

A

CBC with diff

Serial fecal occult test

Flex sig or colonoscopy

173
Q

What are differentials for hemorrhoids?

A

anal fissure (painful defecation because re-tears)

crown’s disease

anal skin tags

condyloma

rectal prolapse

anorectal abscess

perianal tumors/rectal polyps

174
Q

How are mild hemorrhoids managed?

A

high fiber diet

witch hazel pas

sitz baths 1-2x per day to make mucosa soft

anusol (prepH) QID for 7 days

175
Q

How are moderate hemorrhoids managed?

A

proctoCream-HC 2.5% or Anusol-HC 2.5% ceam (has hydrocortozone and lidocaine)

Analpram-HC/ pramoxine 1%/1% (stool softener)

176
Q

How are severe hemorrhoids managed?

A

surgery

177
Q

What are risk factors of colorectal cancer?

A

prior CRC

IBD

Hereditary/genetic factors

Hx: breast or female general cancer

High fat, low bulk diet

70-90% CRC arise from adenomatous polyps

178
Q

When does colorectal cancer screening begin?

A

50 yo for general population

40 yo for family Hx

After the pt. has had hx of colon cancer/adenomatous polyps

Annually for IBD disease

179
Q

What does colorectal cancer screening entail?

A

annual digital rectal exam

fecal occult blood testing annually

OR

Flexible sigmoidoscopy every 5 years

OR

Colonoscopy every 10 years

180
Q

What are the red flags for constipation in pediatrics?

Hirschsprung’s disease?

A

Failure to thrive

Small stools

Fever

Bloody stool

Bilious vomiting

Tight anal sphinter

empty rectum with palpable fecal mass

181
Q

What are the red flags for constipation in pediatrics? (Pseudo-obstruction)

A

abdominal distension

bilious vomiting

ileus (inability to move fecal matter out)

182
Q

What are the red flags for constipation in pediatrics?

spinal cord abnormalities

A

decrease in lower extremity reflexes or muscle tone

absence of anal wink

presence of pilonidal dimple or hair tuft

183
Q

What are the red flags for constipation in pediatrics? (hypothyroidism)

A

fatigue

cold intolerance

bradycardia

poor growth

184
Q

What are the red flags for constipation in pediatrics? (diabetes insipidus)

A

polyuria

polydipsia

185
Q

What are the red flags for constipation in pediatrics? (cystic fibrosis)

A

diarrhea

rash

failure to thrive

fever

recurrent pneumonia

186
Q

What are the red flags for constipation in pediatrics? (Gluten enteropathy)

A

diarrhea after wheat was introduced into the diet

187
Q

What are the red flags for constipation in pediatrics? (congenital anorectal malformations)

A

abnormal position or appearance of the anus

188
Q

What should be included on the physical exam of a child with diarrhea?

A

digital rectal exam- use pinky!

radiography can be used if digital rectal exam not possible

189
Q

How can constipation be treated in children?

A

infant: disimpaction with glycerin supplement or enema

> 1yr old: osmotic laxative like lactulos, senns, polyethylene glycol powder, or sorbitol

190
Q

How should management change if constipation has not improved in 6 months?

A

peds gastroenterologist

Relapse rate of constipation is high

191
Q

What are the differential diagnoses for children in acute abdominal pain?

A

Meckel’s diverticulum (congenital abnormality)

Incarcerated hernia or intestinal obstruction

testicular torsion

Hirschsprung’s disease

Constipation

Appendicitis

Intussusception

192
Q

What is the clinical presentation for intussusception?

A

severe colicky pain with sudden onset

current jelly stools

193
Q

What is intussusception?

A

one portion of the bowel slides into the next

causes bowel obstruction, swelling, inflammation and decreased blood flow to the intestines

Common: RUQ mass

194
Q

How is intussusception diagnosed?

A

Ultrasound

195
Q

What is Meckel’s diverticulitis?

A

Congenital pouch about 2 inches from end of small intestine that can contain 2 types of ectopic tissue: stomach or pancreas

2x more likely in males

196
Q

How is failure to thrive defined?

A

Weight for age falls below 5th% on multiple occasions

OR

Weight declines 2 major percentile lines on growth chart

197
Q

What are the causes of failure to thrive?

A

inadequate caloric intake due to behavioral/psychosocial issues, so routine labs don’t help identify cause

Inadequate caloric intake in relation to caloric expenditure

198
Q

How is failure to thrive best treated?

A

Multi-disciplinarian team: visiting nurse and nutritional counseling

199
Q

What is NIH criteria for bariatric surgery?

A

BMI >40 OR BMI >45 with other co-morbid diseases

AND

H/o failed sustained weight loss

AND

No substance abuse, psychoses or uncontrolled depression

200
Q

What are the types of bariatric surgeries?

A

Restrictive- decreases food intake by decreasing appetite

Malabsorptive- limits digestion and absorption

201
Q

What is vertical band gastroplasty?

A

purely restrictive

Stomach stapled, or ring is put on outlet

Failure rate is high => being abandoned

202
Q

What is the LAP-BAND surgery?

A

purely restrictive

silicone band put on upper part of stomach

leads to early satiety/appetite suppression

Can adjust restriction through mediport, so it is reversible if necessary

Not used due to complications and not making desired outcome

203
Q

What is the gastric-sleeve?

A

Reduces the size of the stomach by 25% and removes the Ghrelin hormone (hunger stimulating hormone), non reversible

Limits the food eaten and reduces hunger sensation

Quicker weight loss

More common today

Diagnosis & Mgmt 1 (7 decks)

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