GI geriatrics Flashcards
sx esophagitis (any type)
odynophagia (hallmark) - painful swallow
dysphagia
retrosternal chest discomfort
dx esophagitis
upper endoscopy
biopsy
tx candidiasis esophagitis
systemic fluconazole
tx HSV esophagitis
acyclovir
tx CMV esophagitis
gancyclovir
tx eosinophilic esophagitis
PPI
what is frequently associated w GERD
hiatal hernia
what is a significant RF for GERD
obesity
what is GERD
incompetent LES –> too much relaxation
sx GERD
heartburn (pyrosis) and regurgitation
what to do if ALARM features of GERD
upper endoscopy
dx GERD
clinical
24 hour ambulatory pH monitoring - standard;
tx GERD
< 2/week - lifestyle –> H2RA
> /= 2/week - PPI x 8 weeks
MC esophageal CA in US
adenocarinocma
MC esophageal CA in the world
SCC
where is adenocarcinoma of the esophagus commonly found
distal esophagus and esophagogastric junction
where is SCC of the esophagus commonly found
mid to upper third of the esophagus
sx esophageal CA
progressive dysphagia – first fluids then solids
dx esophageal CA
upper endoscopy w biopsy
what is achalasia
impaired relaxation of the lower esophageal sphincter
loss of peristalsis in the distal 2/3 (smooth muscle) of the esophagus
pathopphys of achalasia
loss of ganglion cells in the myenteric (Auerbach’s) plexus
sx achalasia
dysphagia to solids and liquids and regurgitation of undigested food or saliva
dx achalasia
barium esophagagram - initial
manometry - most accurate
endoscopy - standard
what will barium esophagram show for achalasia
dilation of the proximal esophagus
smoother tapering of the distal esophagus (bird-beak!!!)
lack of peristalsis distally
what will manometry show for achalasia
increased LES pressure
lack of peristalsis + lack of LES relaxation
tx achalasia
pneumatic dilation or myotomy
where is zenker’s diverticulum
weakness in the junction of Killian’s triangle - between the fibers of the cricopharyngeal muscle and lower inferior pharyngeal constrictor muscle
sx zenker’s
dysphagia
halitosis
dx zenker’s
barium esophagram with video fluoroscopy
tx zenkers
asx + < 1 cm - observe
otherwise - diverticulectomy
tx H pylori + PUD
bismuth subsalicylate
tetracycline
metronidazole
PPI
x 14 days!!
tx h pylori - PUD
PPI or H2RA
which type of PUD should be surveilled with endoscopy
gastric ulcers - after 8-12 weeks of therapy
sx of carcinoid syndrome
flushing
tachycardia
diarrhea
bronchoconstriction
what is ischemic colitis
ischemic injury to the colon usually as a consequence of a sudden and transient reduction in blood flow resulting in a low flow state
where does ischemic colitis typically occur
watershed areas (limited collateral blood supply) :
Griffith’s point = splenic flexure
Suder’s point = rectosigmoid junction
causes of ischemic colitis
Nonocclusive colonic ischemic MC due to low flow state leading to hypo perfusion
Embolic and thrombotic arterial occlusion
RF ischemic colitis
elderly == > 90% are > 60
sx ischemic colitis
abdominal pain - rapid onset of mild crampy abdominal pain over the affected bowel + urgent desire to defecate
bloody diarrhea or Hematochezia within 24H onset of abdominal pain
dx ischemic colitis
CT abdomen - thump printing - wall edema and segmental bowel wall thickening and edema in a non segmental pattern
sigmoidoscopy or colonoscopy confirms
Increased serum lactate, LDH, CK, amylase when advanced tissue damage
tx ischemic colitis
supportive - bowel rest, IV fluids
surgical exploration if colon infarction and necrosis suspected (ongoing pain that is out of proportion)
what is acute mesenteric ischemia
abrupt reduction of small intestinal blood flow from :
acute arterial occlusion - embolism or thrombus from Afib (MC) or atherosclerosis
nonexclusive mesenteric arterial ischemia - low flow state
venous thrombosis - hypercoagulable states MC
sx acute mesenteric ischemia
severe abdominal (periumbilical) pain out of proportion to physical findings
minimal PE findings
dx acute mesenteric ischemia
CT angiography without contrast
Catheter-based arteriography - definitive - can also be therapeutic
labs - leukocytosis, lactic acidosis, increased LDH, increased amylase
tx acute mesenteric ischemia
revascularization - laparotomy with embolectomy vs aortomesenteric bypass grafting vs anticoagulation (if due to hypercoagulability)
excision of necrotic bowel
3 MCC of SBO
adhesions
hernias
neoplasms
sx SBO
CAVO
crampy abdominal pain
abdominal distention
vomiting
obstipation (no flatus or stool)
PE SBO
abdominal distention
high pitched tinkles on auscultation and visible peristalsis (early)
hypoactive bowel sounds late
dx SBO
abdominal radiography - upright - air fluid levels in a step ladder appearance
CT scan - more accurate - dilation proximal to the site of obstruction; transition zone from dilated loops of bowel
tx SBO
supportive - bowel rest, volume resuscitation, nasogastric tube placement
can do adhesiolysis or bowel resection if refractory
where do internal hemorrhoids originate from
superior hemorrhoid vein
proximal (above) to the dentate line
grading of INTERNAL hemorrhoids
- does not prolapse
- prolapses w defecation or straining but reduces spontaneously
- prolapses with defecation or straining and require manual reduction
- irreducible and may strangulate
where do external hemorrhoids originate from
inferior hemorrhoid vien
distal (below) the dentate line
sx hemorrhoids
intermittent rectal bleeding
perianal pain aggravated w defecation
may have skin tags
internal hemorrhoids tend to bleed and are usually painless
external hemorrhoids tend to be painful and don’t usually bleed
dx hemorrhoids
visual inspection
anoscopy for internal
may need to do colonoscopy to R/O hematochezia causes
tx hemorrhoids
increase fiber and fluids. sitz bath. topical rectal corticosteroids!! or analgesics (lidocaine)
internal hemorrhoids - band ligation
external hemorrhoids - excision
what is diverticulosis
outpouchings due to herniation of the mucosa and submucosa into the wall of the colon
MC location for diverticulosis
left colon
sx diverticulosis
usually asx
MCC of acute lower GI bleeding (painless hematochezia)
dx diverticulosis
colonoscopy
tx diverticulosis
bleeding usually stops spontaneously
MC location for diverticulitis
sigmoid colon (LLQ)
sx diverticulitis
LLQ abdominal pain
low grade fever
PE often normal
dx diverticulitis
CT with contrast - localized bowel wall thickening
Labs: leukocytosis
colonoscopy is contraindicated
tx diverticulitis
metronidazole + either ciprofloxacin or levofloxacin for 7-10 days and clear liquid diet
abscess - can do CT guided percutaneous drainage
characteristics of Crohn dz
transmural inflammation that affects any part of the GI tract
skip areas of involvement
what location is MC for Crohn dz
terminal ileum (RLQ)
sx Crohn dz
crampy abdominal pain
chronic persistent but intermittent diarrhea often without gross blood
fatigue
weight loss
may develop abscesses and fistulas
dx Crohn dz
ileocolonoscopy w biopsy - segmental skip areas
biopsy - transmural inflammation, focal lesions with or without noncaseating granulomas. creeping fat.
upper GI series - string sign
+ ASCA
iron and B12 deficiency
Increased ESR and CRP
tx Crohn dz
mesalamine or oral steroids
azathioprine, 6-mercaptoprine, methotrexate, adalimumab, infliximab
characteristics of ulcerative colitis
chronic, intermittent inflammation of the colon limited to the mucosal and submucosal layers
usually involves the rectum
continuous, circumferential pattern
who are generally protected from ulcerative colitis
smokers
people who had appendectomy
sx ulcerative colitis
Hematochezia, diarrhea with blood/mucus
abdominal pain LLQ
dx ulcerative colitis
flexible sigmoidoscopy or colonoscopy - uniform mucosal erythema, granularity, ulceration
endoscopic bx - confirms
double-contrast barium enema - stovepipe or lead pipe sign - cylindrical bowel with loss of haustral markings
+ P-ANCA
tx ulcerative colitis
mesalamine or oral steroids
azathioprine, 6-mercaptoprine, methotrexate, adalimumab, infliximab
what is IBS
chronic > 3 mos functional disorder characterized by abdominal pain with alterations in bowel habits with NO organic cause
sx IBS
abdominal pain associated w altered defecation/bowel habits
pain often relieved with defecation
what criteria is used to dx IBS
Rome IV criteria
dx IBS
recurrent abdominal pain on average at least 1 day/week win the last 3 mos associated with at least 2 of the 3
related to defecation
onset associated with change in stool frequency
onset associated with change in stool form (appearance)
tx IBS
lifestyle and diet - low fat, high fiber, unprocessed food
constipation - fiber, psyllium, polyethylene glycol. Lubiprostone and Linaclotide if unresponsive
diarrhea - loperamide first line
dicyclomine, hyoscyamine, methscopolamine
Anorexia
BMI 17.5 or less or body weight < 85% of ideal weight
is anorexia nervosa ego syntonic or ego dystonic
ego syntonic - their behaviors are acceptable to them
which psychiatric condition has the highest mortality rate
anorexia
sx anorexia
amenorrhea
cold intolerance
constipation
extremity edema
fatigue
irritability
bradycardia and hypotension -> dizziness if severe
preoccupation w weight - exercise compulsively
subtypes of anorexia
restrictive - strict, reduced calorie intake, excessive exercise, diet pills
binge eating/purging - self-induced vomiting, diuretic, laxative, enema abuse
sign for self-induced vomiting
russe’s sign - callouses on the dorsum of the hand
labs for anorexia
hypokalemia
elevated BUN and creatinine
hypochloremic metabolic alkalosis
tx anorexia
weight gain through positive and negative reinforcement
sx C diff
water diarrhea (3 or more loose stools in 24H)
low grade fever
abdominal pain/cramping
decreased appetite
anorexia
malaise
should you screen asx people for C diff
NO
two step algorithm vs one step for c diff
two step = enzyme immunoassays for glutamate dehydrogenase (GDH) and stool toxins A and B –> NAAT of tcdB gene if initial results are indeterminate
one step == NAAT
imaging c diff
CT abdomen and pelvis
lower GI endoscopy
tx C diff
d/c offending abx
contact precautions
hand hygiene - soap and water!!!
fidaxomicin or vancomycin
Traveler’s diarrhea
E coli
Diarrhea after a picnic and egg salad:
staph aureus
Diarrhea from shellfish
Vibrio cholerae
Diarrhea from poultry or pork
salmonella
Diarrhea in a patient post antibiotics
C diff
Diarrhea in poorly canned home foods
C. perfringens
Diarrhea breakout in a daycare center
Rotavirus
Diarrhea from cruise ship
norovirus
Diarrhea after drinking (not so) fresh mountain stream water
Giardia lamblia - incubates for 1-3 weeks, causes foul-smelling bulky stool, and may wax and wane over weeks before resolving
what is hepatocellular carcinoma
primary neoplasm of the liver arising from parenchyma cells
RF hepatocellular carcinoma
cirrhosis
chronic liver damage (HBV, HCV, HDV)
sx hepatocellular carcinoma
asx
weight loss
fatigue, etc
dx hepatocellular carcinoma
multiphase helical CT and MRI + contrast
increased serum AFP
liver bx definitive
tx hepatocellular carcinoma
surgical resection if confined to lobe
advanced - Atezolizumab and Bevacizumab
primary prevention of hepatocellular carcinoma
vax against HBV and effective tx of HBV and HCV infection
surveillance for hepatocellular carcinoma
US q 6 months with or without serum AFP
