GI/GU complaints Flashcards
What is the next diagnostic step in the case of acute gastroenteritis (acute diarrhea)?
- Order stool for fecal leukocytes
What are the potential complications of acute gastroenteritis?
- Dehydration and electrolyte abnormalities
Bloody diarrhea is generally caused by which organisms?
- EHEC
- Yersinia
- Shigella
- Entamoeba histolytica
What are common bacterial etiologies of traveler’s diarrhea?
- E. coli (especially ETEC)
- Salmonella
- Shigella
- Vibrio (non cholera)
- Campylobacter
What are common viral etiologies of traveler’s diarrhea?
- Rotavirus
- Norovirus
What are common parasitic etiologies of traveler’s diarrhea?
- Giardia lamblia
- Entamoeba histolytica
- Cryptosporidium parvum
How might the timing of infection from eating contaminated mayonnaise containing food influence diagnosis?
- Within 6 hours => S. aureus
- 8-12 hours => C. perfringens
- 12-14 hours => E. coli
What organisms are often seen in daycare settings of diarrhea?
- Rota virus
- Shigella
- Giardia
What infectious agent is associated with abx induced diarrhea?
- C. difficile colitis
Though most acute diarrhea does not require work up, which cases of acute diarrhea DO require work up?
- Profuse diarrhea
- Dehydration
- Fever >100.4F
- Bloody diarrhea
- Severe abdominal pain
- Duration >2 days
- Children and elderly
- Immunocompromised
What pair of symptoms are more prone to causing hospital admissions?
- Vomiting and diarrhea leading to severe dehydration requiring IV hydration
If a patient is losing fluid from vomiting or dehydration, what physical exam sign indicates the volume status?
- Mucous membranes => moist or dry
- Skin turgor
- Capillary refill
What are the primary concerns with microscopic hematuria that should be ruled out?
- renal cell carcinoma
- transitional cell carcinoma
How is the upper urinary tract imaged?
- Intravenous pyelogram OR CT
How is the lower urinary tract imaged?
- Cytoscopy (an endoscopic procedure)
What are the various types of hematuria?
- glomerular
- renal
- urologic
What is seen on urinalysis in glomerular hematuria?
- proteinuria
- erythrocyte casts
- dysmorphic RBCs
What is renal hematuria associated with?
- tubulointerstitial disorder
- renovascular disorder
- metabolic disorder
- significant hematuria
What are the urologic causes of hematuria?
- tumors
- calculi
- infections
- trauma
- BPH
What is seen on UA in cases of urologic hematuria?
- nothing: no proteinuria, dysmorphic RBCs, or erythrocyte
What are risk factors for hematuria?
- Smoking
- Occupational exposure to chemicals or dyes (benzenes or aromatic amines- think hair dressers)
- History of gross hematuria
- > 40 years old
- History of urologic disorder/disease
- History of voiding symptoms
- History of urinary tract infection
- Analgesic abuse
- History of pelvic irradiation
What abnormalities on a urinalysis should prompt evaluation for renal parenchymal disease (i.e. referral to nephrology)?
- Proteinuria
- Red cell casts
- Renal insufficiency
- Predominance of RBCs
What test will help differentiate between glomerular disease and interstitial disease?
- Urinary sediment
- Renal glomerular disease => dysmorphic red cells
- Interstitial disease (analgesic/med use) => eosinophils in the urine
What are the next diagnostic steps in working up chronic kidney disease?
- Serum electrolytes
- blood urea nitrogen
- creatinine
- imaging of the kidneys
What is the next step in therapy in initial presentation of chronic kidney disease?
- Stop any offending agents like NSAIDs
- Control BP
- Control other chronic illnesses (like DM)
- Possible dialysis in the case of: pulmonary edema, severe hyperkalemia, or anuria.
Significant reduction in urine output warrants what types of diagnostic testing?
- Creatinine
- Volume status ( skin turgor, mucous membranes, specific gravity in the UA, orthostatic blood pressure, heart rate lying down and standing)
What conditions increase risk of kidney disease?
- hypertension
- diabetes mellitus
- NSAID use
What metabolic imbalances commonly occur in chronic kidney disease?
- hyper/hyponatremia
- hyperkalemia
- elevated uric acid levels
- metabolic acidosis
- hyperparathyroidism (increased Ca2+; failing kidneys do not absorb/convert enough active Vit D, which therefore causes more PTH to be secreted)
How is hyperkalemia treated?
- sodium polystyrene sulfonate
- insulin with glucose
- retention enemas
When would a patient with chronic kidney disease also have symptoms of pulmonary edema?
- When they can no longer compensate for failing kidneys
What are the symptoms of pulmonary edema?
- shortness of breath
- lower extremity edema
- jugular venous distension
- abnormal lung sounds (rales)
What are signs of hypoalbuminemia?
Nephrotic syndrome may manifest as:
- frothy urine
- lower extremity edema (from loss of protein)
Why might a patient with chronic kidney disease suffer from occasional emesis?
- Emesis is due to high levels of urea and other toxins not excreted due to failing kidneys
Why would normocytic anemia occur in the context of chronic kidney disease?
- Chronic kidney disease decreases the amount of erythropoietin formed, leading to normocytic anemia
What types of agents treat blood pressure and improve kidney function?
- ACE-I
- ARbs (angiotensin receptor blockers)
What are the most common causes of chronic kidney disease?
- Diabetes
- Hypertension
- Glomerulonephritis
Shrinkage of kidneys in the setting of chronic kidney disease is representative of?
- Irreversible damage
Asymmetrical kidneys in chronic kidney disease represents?
- renovascular disease
What drugs can affect kidney function?
- Aminoglycosides
- NSAIDs
- Radiographic contrast
If ARB and ACE- I are combined in refractory hypertension, what should be monitored 3-5 days after initiation?
- potassium and creatinine should be monitored
Patients with chronic kidney disease may have what dietary restrictions?
- Reduced protein
- Treat hyperlipidemia
- Sodium restriction plus loop diuretics
- Low potassium diet
- Decrease calcium intake in severe stages of kidney disease (stages 3-5)
How should chronic kidney patients with anemia be treated?
- Treat with erythropoietin
A 25 yo woman presents with foul smelling vaginal discharge. She has greenish, frothy discharge and a “strawberry cervix” noted on examination. What is the most likely organism causing this infection?
Trichomonas vaginalis
- motile flagellated trichomonads and many WBCs
What is the recommended treatment of trichomonas vaginalis?
- metronidazole po for BOTH the patient and her partner
- screen for other STIs
What are common causes of vaginitis?
- Candida albicans (thicker discharge)
- Trichomonas vaginalis (frothy discharge and red cervix)
- Gardnerella vaginalis (thin and fishy discharge)
Women with recent abx use are most likely to develop what type of infection?
- Candida albicans
Women with diabetes are most likely to develop what type of vaginitis?
- Yeast infection
What risk factors are associated with trichomonas infection?
- STI ( multiple sex partners)
- pregnancy
- menopause
What would be visualized on wet mount if Gardnerella vaginalis was suspected?
- Clue cells
How is gardnerella vaginalis treated?
- metronidazole or clindamycin
What percentage of gonococcal infections and chlamydial infections are asymptomatic in women?
- 50% of gonococcus is asymptomatic in women
- 70% of chlamydia is asymptomatic in women
How is gonorrhea and chlamydia treated?
- Gonorrhea => ceftriaxone
- Chlamydia => 1 week of doxycycline or 1 dose azithromycin
What are the key features of pelvic inflammatory disease?
- lower abdominal tenderness with both adnexal and cervical motion tenderness
- Temperature >101F
- Vaginal discharge
- Elevated ESR
- Elevated CRP
- Cervical infection of gonorrhea or chlamydia
What test should be done on all patients with PID?
- Patients with suspected PID should have a pregnancy test administered because of the clinical similarity with ectopic pregnancy
What are the most common causes of lower GI bleed in the elderly?
- Tumors
- Diverticulitis
- Hemorrhoids
- Ulcerative colitis
What are symptoms of anemia?
- weakness
- fatigability
- pallor of the conjunctivae or skin
- chest pain
- dizziness
- tachycardia
- hypotension
- orthostasis
What are major causes of mortality/morbidity in GI bleeding?
- blood aspiration
- shock
What is the test of choice to determine the source of a lower GI bleed?
- Colonoscopy
What is an alternative to colonoscopy in the determination of a lower GI bleed?
- Sigmoidoscopy with air contrast barium enema xrays
What are risk factors for hemorrhoids?
- chronic constipation
- straining for bowel movements
- pregnancy
- prolonged sitting
What is the conservative treatment for hemorrhoids?
- High fiber diet
- stool softeners
- precautions against prolonged straining
- surgical intervention when necessary
What is the typical presentation of diverticulitis?
- left lower quadrant abdominal pain
- fever, nausea, diarrhea, and constipation
What is the treatment of diverticulitis?
- bowel rest
- treatment with abx against bowel flora (quinolone + metronidazole)
*surgery in severe cases
Define ulcerative colitis.
- continuous inflammation of the large bowel from the rectum extending proximally
Define Crohn’s disease.
- causes areas of focal inflammation, but can occur anywhere in the gastrointestinal tract
What are extraintestinal manifestations of IBD?
- arthritis
- sclerosing cholangitis
- cirrhosis
- fatty liver
- pyoderma gangrenosum
- erythema nodosum
What malignancy is related to ulcerative colitis?
- colon cancer
List the types of adenomatous polyps in order of malignant potential.
- Tubular adenomas (least likely)
- Tubulovillous adenomas
- Villous adenomas ( most likely)
What would UA show in the case of a UTI?
- bacteriuria
- pyuria
- nitrites
- leukocyte esterase
What is the most appropriate work up for suspected irritable bowel syndrome?
- CBC
- stool hemoccult test (guaiac)
What is the best initial trial for IBS/constipation?
- fiber supplementation
What is lubiprostone/amitiza?
Pharmacologic agent that selectively activates intestinal chloride channels and increases fluid secretion. It is approved for IBS in WOMEN with constipation, but as a side effect of nausea in many patients
What is the gender prevalence of IBS?
- Affects women 3 times more than men
- Tends to affect young women 20-30
What cluster of illnesses also tend to coexist with IBS?
- fibromyalgia
- low back pain
- chronic headahces
What are the chief complaints of someone with IBS?
- constipation
- diarrhea
- alternating constipation and diarrhea
- often left lower quadrant abdominal pain which tends to improve with defecation
- in severe cases: nighttime awakenings
What other GI symptoms might a person with IBS complain of?
- up to 50% of patients with IBS also have symptoms of dyspepsia, nausea, GERD
What are GI alarm features?
- fever
- anemia
- involuntary weight loss greater than 10lbs
- hematochezia
- melena
- refractory or bloody diarrhea
- family history of colon cancer
- family history of IBD
What workup should be done in patients with IBS symptoms who are over 50?
- CBC
- hemoccult test
- AND colonoscopy
What agents are used for IBS related abdominal pain?
- dicyclomine and hyoscyamine (antispasmodics on prn basis)
- low dose TCA when pain is frequent and severe
- If comorbid depression/anxiety, use SSRI
What agents are used for IBS related constipation?
- increasing fiber intake
What agents are used for IBS related diarrhea?
- loperamide/imodium
How is a diagnosis of Hep A infection confirmed?
- Anti-hep A immunoglobulin (Ig) M
- Remember that IgM indicates acute infection, whereas IgG indicates past infection
- Elevated conjugated bilirubin and elevated hepatic transaminases also help
What is the treatment for Hep A infection?
- supportive care and symptomatic treatment for the patient
- report infection to local health department
- consider Ig prophylaxis to household/sexual contacts
What is the most common cause of prehepatic jaundice?
- Hemolysis of RBCs => overwhelms the liver’s ability to conjugate and clear the bilirubin through its normal pathways
- Produces primarily unconjugated bilirubin
What are common causes of hepatic jaundice?
- Viruses
- Alcohol induced
- Conjugated or unconjugated
What are common causes of posthepatic jaundice?
- Usually caused by obstruction to the flow of bile through the bile ducts
- Can be caused by bile duct stones, strictures, or tumors that narrow or block the ducts
- Conjugated hyperbilirubinemia
What is a common symptom of jaundice that may actually precede the onset of yellow color?
- pruritis
What OTC pain killer when used in large amounts can cause hepatotoxicity?
- Acetominophen
Right upper quadrant pain can indicate what organ issues?
- Liver (hepatitis)
- Gallbladder (gallstones)
Splenomegaly in the context of jaundice is indicative of?
- portal hypertension from cirrhosis
- malignancy
- splenic sequestration of damaged RBCs
When measuring bilirubin, direct bilirubin is equivalent to?
Direct bilirubin = conjugated bilirubin
* conjugated is also excreted in the urine
What is Gilbert’s syndrome?
- Often an incidental finding of increased unconjugated bilirubin that is caused by a congenital reduction of conjugation of bilirubin in the liver
- It is of NO health consequence and affects approximately 5% of the population
What percentage of Hep B infections become symptomatic?
- 50%
- only 1% of these result in hepatic failure and death
What infected age group is most likely to develop chronic hep B?
- Children, particularly infants (90%) and children
What antibody is seen in resolved Hep B infection as well as vaccination?
- Antibody to the surface antigen (anti-HBs) is seen in resolved infection and is the serologic marker produced after hepatitis B vaccination
What is the most common cause of chronic liver disease in the U.S.?
- Hep C
What percentage of infected individuals will develop chronic Hep C?
- 60-85%
What is Hep D?
- Hep D is a rare cause of viral hepatitis that uses the viral envelop of Hep B to infect its host and therefore requires coinfection of Hep B AND D
- It is endemic in the Mediterranean, Middle East, and S. America
- Can be prevented with a Hep B vaccine
What type of hepatitis is most dangerous to pregnant women?
Hep E is a fecal-orally transmitted viral hepatitis that has a very high mortality rate in 2nd and 3rd trimester pregnant women
What is the evaluation of a bleeding peptic ulcer?
- CBC => eval for blood transfusion depending on blood loss
- Stop NSAIDs
- Upper GI endoscopy + test for H. pylori
- Eval for colonoscopy
What is the treatment for peptic ulcer secondary to H.pylori?
- PPI and ABX
What are alarm symptoms for which early upper GI endoscopy is recommended?
- weight loss
- progressive dysphagia
- recurrent vomiting
- GI bleeding
- Family history of cancer
How can H. pylori be tested without endoscopy?
- Urea breath test
- Stool antigen test
What is peptic ulcer disease?
- PUD is a term that describes both duodenal and gastric ulcers
- Duodenal ulcers are more prevalent overall, whereas gastric ulcers are more common in NSAID users
What are risk factors of PUD?
- H. pylori infection
- Use of an NSAID
- Smoking
- Family/personal history of PUD
- Black and Latino heritage
What are symptoms of PUD?
- epigastric abdominal pain that is improved with the ingestion of food
- Pain that develops a few hours after eating
- Nocturnal symptoms
Epigastric pain that radiates to the back and is associated with nausea and vomiting are symptoms of?
- Pancreatitis
How can an active H. pylori infection be confirmed?
- urea breath test
What is the gold standard for H. pylori testing?
- Endoscopy with biopsy
What are possible complications of PUD?
- Hemorrhage
- perforation
- gastric outlet obstruction
When should a patient with PUD symptoms be referred for upper GI endoscopy?
- > 55yo or with alarm symptoms
What is triple therapy for H. pylori treatment?
- Bismuth subsalicylate + metronidazole + tetracycline
- Ranitidine bismuth citrate + tetracycline + clarithromycin/metronidzazole
or - Omeprazole + clarithromycin + metronidazole/amoxicillin
