GI / Nutrition Flashcards
MC mechanism for GERD ; RF
Transient LES relaxation
RF =
ETOH, caffeine , obesity, smoking , hiatal hernia
When does heartburn occur in GERD
30-60 mins after meals
Alarm features of GERD [4]
Refractory Heartburn
Dysphagia
Unintentional weight loss
GI Bleed/IDA
Refractory GERD with negative endoscopy = get what test
Amb pH monitoring ; acidity confirming test
Peristaltic abnormalities / or pre op before GERD surgery get what?
Manometry ; dysphagia ID
Mild treatment GERD
Lifestyle
Tums
H2 blockers
Persisitant sxs GERD think what TXM
PPI once daily for 4-8 weeks
Reflux esophagitis is what two etiologies
Mechanical or Functional
Dx for Reflux esophagitsi
Endoscopy w/ biopsy
TXM for reflux esophagitis
PPI x2 daily [4-8 weeks]
Barrets makes you at risk for what
Adenocarcinoma ; metaplastic columnar epithelium change
Salmon colored mucosa makes you think what
Barrett’s
Barrets get PPI when ; survelience?
For life x2 daily
EGD every 3-5 years
Infectious esophagitis effects who most
HIV DM Chemo therapy patients
Infectious esophagitis 3 diff types and what they look like ; TXM
CMV = large ulcers ; linear [TXM = IV ganciclovir/foscarnet]
HSV : multi small ulcers less 2cm [TXM = PO acyclovir]
Candidi = white plaques [TXM = PO fluconazole]
How long can pill induced esophagitis last
Hours to days after ingestion
Pill induced esophagitis study of choice
Initial double contrast esophagram
Def = upper endoscopy
Radiation esophagitis can cause what
Impaired peristalsis decreased motility due to edema inflammation
Treatment for trouble swallowing
Prokinetics
E o E usually of hx of what
Allergies or atropy as a child
E o E looks like what on endoscopy
White exudates ; red furrows ; concentric rings
Bx= + eosinophilia
E o E txm?
Budesonide or fluticasone
Swallow instead of inhaling
Peristalsis and LES tone in achalasia
Peristalsis is decreased ; LES in increased
Dx of choice most sensitive for achalasia
Dx = barium swallow
Most sensitive = manometry
CREST with Scleroderma
Caclicnosis
Raynauds
Esoph dysmotitlity = solids and liquids
Scledorodactyly
Telangiectasia
Barium vs manometry on esophageal spasms
Corkscrew = Barium swallow
Nutcracker = manometry
MI pain with dysphagia
Zenkers outpouch where?
Posterior hypopharnyx
Dysphagia coughing regurgitation halitosis
Zenkers
when do surgically treat Zenkers
If dysmotility is severe
SCC risk factors in the throat
Tobacco and ETOH
Peptic stricture is a complication of what 2 things
GERD and Esophagitis
Peptic stricture is usually more of a problem of swallowing
Solids
Esophageal webs vs schatzkis rings
EW = proximal ; solids > liquids ; barium = shelf
Schatzkis = distal ; heartburn solids > liquids ; barium = esophageal narrowing
TXM = dilation and PPI for heartburn
Plummer Vinson syndrome [4]
Cervical esophageal webs
IDA
Stomatitis
Glossitis
Solid and liquid dysphagia =
Motility disorder
Dysphagia to liquids think what
Neurogenic cause
Low grade esoph varices presentation
Melena + IDA
Pharm therapy for esophageal varices
Vit K = abnormal PT
Laculose = encephalopathy
ABX prob = IV FQ or Cef
MW tear occurs where
GE junction
Self limiting hematemesis
Heavy ETOH after forced RETCHING
Most MW tears heal when
48 hours with PPI txm
Refractory = epinephrine or coagulation
Gastritis 4 etiologies
NSAIDS
ETOH
Stress
Portal HTN
What med can coat the stomach and treat pain in gastritis
Sucralfate
AIG = auto immune gastritis
Pernicious enemies
Dec IF secretion —> B12 def. —> anemia.
TXM = B12 r2 and survellience endoscopy
H. Pylori risk factor ;; looks like?
Travel and eating different foods
Gram negative spiral shaped bacillus
Dx of H. Pylori
Urea breathe test
TXM H. Pylori
14 days of Quad Therapy : PBMT
PPI + Bismuth + Tetracycline + Metronidazole
CLARITHRO less 15% = triple therapy
PPI + amoxicillin + CLARITHROMYCIN
3 complication of H Pylori
Gastric cancer
MALT Lymphome
PUDz
NSAID // H pylori cause what ulcers
NSAIDS = gastric
H pylori = duodenal
PUD dz
Upper endoscopy bx ro r/o H pylori and malignancy
Treatment gastric ulcer vs. duodenal
Gastric = PPI x 8 weeks
Duodenal = PPI x 4 weeks
Gastric neos = MC
Adenocarcinoma
[Virchow node// Sister Mary Joseph nodule // krukenberg tumor]
Gastric Lymphoma MC in
Non Hodkin B cell lymphoma
ZES is what kind of tumor
NE tumor gastric secretin = increased acid production
[MEN-1 Syndrome]
Hella Refractory Ulcers
Gastrin can cause what kind of diarrhea
Secretory = normal stool ion gap ; high purge rate ; no response to fasting
ZES for gastrin level over
150
PH less 2.0
Pyloric stenosis Mc cause of what
Gastric outlet obstruction in infants
Succession splash think what
PS
MC gallstones are what
Cholesterol
Think the F’s
What two things can prevent gallstones
ASA and NSAIDS
Abdominal pain after fatty meal colicky RUQ pain
Cholelithiasis
Cholecystitis impacted gallstone where
Cystic duct
What chole sign inhibits inspiration
Murphys
Most definitive test of cholecystitis
HIDA scan
TXM cholecystitis
IV fluids
Bowel Rest
IV ABX : Metro and CIPRO
Pain management
4 complications of cholecystectomy
CBD stone
Bile duct stricture
Bile acid induced diarrhea
Sphincter of oddi dysfunction
Chronic Cholecystitis
Repeat irritation
RUQ pain vague dull does not go away
Nausea
Fatty meals make it worse ; but does go away
CBD stones RF
Stones
Biliary stairs s
S/p cholecystectomy
Large glass tone in the duodenum causing SBO think what
Gallstones ILEUS
Gold standard for CBD stone
ERCP
Cholangitis MC organisms
E Coli
Klebsiella
Enterococcus
Enterobacter
Charcots Cholangitis
RUQ Fever Jaundice
PENTAD = AMS + Hypotension
What do you give after ERCP to prevent post ERCP pancreatitis
Indomethacin
cholangitis ABX of choice
Piperzillan / Taxobactam
What type of Hep is common in endemic areas
AE
What type of hep is blood borne
BC
Aversion to smoking occurs think what
Hepatitis
What type of hep is fecal to oral
Hep. A
What type of Hep do we have PEP meds ?
A and B
Acute hepatitis
IgM
Previous hepatitis infection
IgG
Vaccination are usually [hepatitis]
Anti HAVE IgG
Anti -HBs
Hep B previos infection think positive what
Core antigen
Hep A B C treatment
A = self limited
B = antivirals [tecavir]
C = monitor for 3 months ; protease inhibitor [simeprevir] NS5B ;
Needles stick HEp C exposure mangement
RNA/LFTs @ 2 wk ; 4 wk ; 6 months
Heb B vaccine is when
0 , 1, 6 months
What type of hep has vaccines
A and B
MC of ALF in the US
APAP toxicity and drug rxns
N acetycystein only given in APA if when
Less than 72 hours
Chronic viral hepatitis worry about
Progression to cirrhosis or carcinoma of liver
Alcoholic Hepatitis think what LFTS
AST > ALT
GGT+
elevated ALK phos and Bilirubin
PROLONGED PT
3 nutritional deficiencies in alcoholic hepatitis
Thiamine
Folic Acid
Zinc
Improves circulation prevents hepatorenal syndrome ; treatment in alcoholic hepatitis ?
Pentoxyfilline
Reduces short term mortality in alcoholic hepatitis
Methlyprednisolone
Infection complications common in alcoholic hepatitis
Aspergillosis - fungal infection
NAFLD Dx
Mildly elevated ALK phos , AST , ALT
ALT > AST
Get : U/S ; liver bx = Dx
“Fat in the liver no inflammation”
Treatment NAFLD
10% body weight loss; lifestyle changes
Autoimmune hepatitis mc in who
Young middle aged women
Amenorrhea
Straie
Hirsituism
Telangiectasias
+ANA or + Smooth muscle antibody
Liver Bx = Dx
A hep treatment
Prednisone and Azathioprine
Cirrhosis classified as
Irreversible fibrosis and nodular regeneration
Compensated
Compensated with varices
Decompensated [ascites, encephalopathy, jaundice]
A fibrotic liver in late stage cirrhosis will be what?
Smaller and more nodular, firm
Cirrhosis dx =
Liver biopsy
Low platelets
Low albumin
Leukopenia / anemia
How can we treat ascites
Salt restriction // fluid restriction
Spironolactone + Furosemide
Paracentesis + Albumin
Primary Biliary cirrhosis is destruction where ?
Automunimme destruciton of intrahepatic ducts
-cholestasis = jaundice; pruritus
What is the positive diagnostic in primary biliary cirrhosis
+ antimitochondrial antibodies
Elevated bili, ALK phos, and cholesterol
Primary sclerosing cholangitis is what
Cholestasis with destruction of intra and extra hepatic bile ducts
Assoc with Ulcerative Colitis
MRCP and ERCP imaging // bx shows periductal fibrosis or “onion skinning”
Screen yearly for malignancy
Mc liver neoplasm [benign]
Cavernous hemangioma
What Mets most common to the liver
Lung and breast
Exposure to what can predispose someone to Hepatocellular CA
Aspergillosis
Courvesoier sign =
Palpable Nontender gallbladder associated with jaundice
Cholangeiocarcinoma
MC liver cancer in children
Hepatoblastoma
When do you treat liver neos
If risk of rupturing hepatic capsule
+ Tumor marker for Hepatocellular carcinoma =
AFP greater 200 // with U/S every 6 months
Get CT.MRI with Contrast
No needle Bx
Pancreatitis is what on exam
Steady pain boring
Worse lying down
Between leaning forward
Rads to the back
Imaging modality of choice for acute pancreatitis
CT scan
4 lab values associated with bad acute pancreatic outcomes
LDH over 350
AST over 250
Glucose over 200
WBC over 16,000K
Treatment for Acute pancreatitis
Keep NPO
With AGGRESSIVE FLUID RESCUCITATION
When can you advance diet for acute pancreatitis
Once pain free
MC chronic pancreatitis = due to what?
ETOH ; with chronic abdominal pain ; steattorhea
Chronic pancreatitis dx
ERCP = most sensitive
CT = +calcifications
75% of pancreatic cancer occurs where
The head
What is a sister Mary Joseph nodule
Hard Periumbilical nodule
Tumor marker for pancreatic neoplasm
CA 19-9
TTP where for appendicitis
McBurney’s Point
Psoas vs. OPbturator
Psoas = raise leg against resistance
Obturator = right knee bent , Flexion + internal rotation of the right hip
Foods for celiac disease [3]
Wheat rye and barley
High risk groups for celiac
1st degree relatives
Type 1 DM
Autoimmune thyroid disorder
Initial test vs. confirmatory for celiac
Initial = tTG IgA
Confirm = endoscope with small intestine bx
70% of celiac disease get what and what else can happen commonly
Osteopenia / osteoporosis = 70%
Malignancy = lymphoma or carcinoma
Whipple disease is infection of what
Trophyeryma whippelii
-affect any system in the body but GI is common.
-dementia ; opthalmoplegia ; myoclonus = TRIAD
“Can’t absorb fats or carbs”
Whipple disease picture ; TXM
Diarrhea with weight loss fever arthralgia
TXM = Ceftriaxone x 2 weeks then bacttrim for 12 months
MC site of Mesenteric ischemia
SMA
Chronic intestinal ischemia is characteristically what
Postpraindal with progressive anorexia
Imaging ofr choice for intestinal ischemia
CT Angio = pruned tree appearance of distal vascular bed
Bowel sounds are what with SBO
Hyperactive at first; with progressive absence of sounds
Plain film + in SBO + management ?
Dilated bowel loops with positive air fluid levels
Get CT to define transition points
GET NGT , IV fluids , pain control , antiemetics
Invagination of what = intussusception
Proximal bowel into distal segment
Kids vs. Adults intussusception treatment
Kids = barium enema
Adults = surgery because likely a mass is provoking it.
Constipation red flags [ 5 ]
Age over 50
IDA
Weight Loss
FH of Colon Cancer or IBD
+FOBT or +FIT test
Osmotic laxatives are indicated when? How do they work? Examples?
—> good start medication
Increase secretion of water into the lumen
Mag Hydroxide ; PEG ; Sorbitol ; Lactulose
Stimulant laxatives are indicated when? How do they work? Examples?
Short term step up from osmotics
Stimulate fluid secretion and colonic contraction
Bisacodyl ; senna ; cascara
Chloride secretory agent laxatives are indicated when? How do they work? Examples?
Longer term use without building a tolerance
Increase intestinal fluid and accelerate colonic transit
Lubiprostone ; linaclotide ; plecanatide
Serotonin 5 HT receptor agonist
Prucalopride
Opioid receptor antagonists
Block peripheral opioid receptors without affecting central anesthesia
Methlynaltrexone ; naloxegol
Mangement for fecal impaction
Saline mineral oil enema
Digital disimpaction
Maintain soft stool // regular BM
REFERAL for PFT ; Colonscopy ; Surgery
MC diverticulosis MC site
Sigmoidoscopy colon
What should you not get for diverticulitis
Barium study
Mild uncomplicated diverticulitis treatment
PO ABX x 7-10 days
Metro + Cipro or Bactrim
Augmentin
Clear liquid diet ASTolerated
Severe diverticulitis treatment
Admit + IV ABX
1st line = cefoxitin / pipe/tazo
Abscess formation can occur in diverticulitis greater than how large
4 cm
Ciggarettes help what and make what worse
Help UC . Make Crohns worse
What ethnicity is commonly effected by IBD
Jews
Crohn’s think what [4]
Mouth to anus
Transmural
NEGATIVE IN THE RECTUM
Non caseating Granulomas on Bx
+strictures ; fistula ; malabsorption*
UC [4]
Gradual onset rectum to proximal segment
Bloody diarrhea
Tenesmus
Severe Fever def ; Toxi mega ; perforation
Colon CA
MC extra intestinal IBD
Joints
Crohn’s mild mod severe/ Mx treatment
Mild / moderate = PO 5 ASA
Severe = PO or IV Steriods
Mx = 5 ASA ; Immunomodulators ; Biologics
UC distal ; above sigmoid ; severe treatment
Distal = topical 5 Asa or steriods
Above sigmoid = PO 5 ASA
Severe = PO or IV Steriods
Mx - 5 ASA ; Immunomodulators Biologics
In UC surgery =
Curative
2 types of microscopic colitis
Lymphocytic
Collagenous
How do elevated levels of estrogen // progesterone effect the gallbladder [ pregnancy ]
Estrogen = increase cholesterol excretion into the bowel
Progesterone = decrease gallbladder motility and emptying
Pregnant women are increased risk for Gallbladder Dz
* Both elevated E and P can lead to decreased LES tone*
Are pregnant women good candidates for cholecystectomy
No usually delayed until postpartum
What is the most sensitive initial test for malabsorptive conditions ?
Stool fat testing
4 risk factors for C diff
Recent ABx
Gastric acid suppression
IBD
Chem/rads / AGE
How do patients present with FOB in the esophagus vs down to the bronchus?
Esophagus = usually a witnessed swallow but patient as no sxs ; no drooling ; NML breathe sounds
Bronchus = sudden onset respiratory distress and asmx breathe sounds
3 risk factors for emphysematous cholecystitis
Immune suppression
DM
Vascular Compromise
What age size umbilical hernia gets surgical management
Age = over 5 years old
Size = over 1.5 cm
Achalasia discomfort is better in what position
Sitting up right and leaning forward
What type of IBS do you need to make sure you screen for celiac disease?
IBS-D because sxs can be similar
-loose with freq stools-
What is the treatment algorithm for pregnant patients with N/V
lifestyle changes —> B6 & H1[doxylamine] AH —> oral dopamine and serotonin antagonists —> IV Fluid and IV Antiemetics —> CC —> TPN
SBO looks like what on plain film
Multiple loops of dilated bowel
What is the typical chronic pancreatitis supplementation
Lipase , protease , amylase
What does the imaging look like in chronic pancreatitis
Pancreatic atrophy with calcifications
What are two protective factors for RF for colon cancer?
High fiber diet
NSAID / ASA use
Acalcaulous cholecystitis can lead to what complications
Cholestasis
Gallbladder ischemia
Gallbladder edema and necrosis [from secondary infection]
IBS at least 1 day per week assoc with greater than 2 what
ABD pain relieved to defecation
Change in stool frequency
Assoc with change in stool appearance
Peppermint oil can do what
Antispasmodic but caution because it relaxes the LES
IBS c med treatment
Lubiprostone linaclotide plecantide proclamation
What type of IBS benefits from TCA
IBSD
After long run LLQ + hematochezia think
Ischemic colitis
Get CT / def = Colonscopy
MC location for ischemic colitis
Inferior Mesenteric Artery
What type of colon polyp has most risk for malignancy
ADENOMATOUS
If family history what is the Colonscopy screening
Every 5 years + family history
And 10 years before onset of family cancer
Or age 40
What age should the avg adult start Colonscopy screening
Age 45
Tumor marker for colon cancer
CEA
MC cause of LBO
Neoplasm
What is a good motility activator for LBO
Neostigmine ; decompress the bowel
If volvulus = Colonscopy
What will x ray for LBO
Free Air
Coffee bean or Birds Beak
get a CT scan to confirm
2 etiologies for Toxic megacolon
C diff
Or
UC
***new onset fever; shock, hypovolemia
MC place for anal fissure
Posterior midline
Treatment for anal fissure
Fiber
Sitz bath
Topical lidocaine ; diltiazem
Perinatal abscess think what etiology
Crohn’s ; also can develop fistulas into the mucosa
Where are pilonidal cysts commonly
Sacrococcygeal cleft
How do you know internal vs external hemorrhoids
Internal = painless BRPR
External = below the dentate line ; painful
Management vs. grade hemorrhoids
1 = bleed ; no prolapse —> rubber band ligation ; sclerotherapy
2 = prolapse but Spont reduce —> rubber band ligation ; sclerotherapy
3 = prolapse but req manual reduction —> rubber band ligation ; sclerotherotherapy, surgery
4 = chronic prolapse ; STRANGULATION risk —> urgent surgery ; hemorroidectomy
MC anal cancer
80% HPV squamous cell carcinoma
Less than what size = conservative txm for anal cancer? ; what treatment for anal cancer
3cm = local excision
Larger = surgery/chemo
What is a richter hernia
Part of the bowel wall becomes incarcerated not the whole LOOP
Hiatal hernia are due to what
GERD
Direct vs Indirect Hernia location
Direct = MC Acquired ! Through the abdominal wall
Indirect = through inguinal canal
what are the components of the hesselbach triangle
Inguinal ligament ; inferior epigastric vessels ; lateral border of the rectus muscle
Acute diarrhea vs Chronic diarrhea
Acute = less than 2 weeks
Chronic = longer than 3 weeks
How do you describe febrile bloody or pus in stool diarrhea
Inflammatory
Pregnant women are at risk for what bloody diarrheal agent
Listeria
Campylobacter think what [3]
Rare poultry
Fever bloody diarrhea
FQ treatment
Entoemeba [3]
Tropical regions poor sanitation
Hepatomegaly
Metronidazole TXM
salmonella [3]
Eggs poultry unpastrerized milk
Bloody diarrhea
FQ TXM
Shigella [3]
Food water in human feces
Fever pain diarrhea + blood
FQ or Bactrim TXM
Yersenia E. [3]
Undercooked pork ; contaminated water
Bloody appendix like pain + poly arthritis in children or erythema nodosum
Tetracycline or FQ if severe TXM
With metronidazole txm avoid what
ETOH for disulfiram reaction
Greasy malodorous diarrhea ? And what TXM
Giardia ; FQ
Rice water stool ? And TXM?
Vibrio Cholerea
Tetracycline or Azithromycin TXM
What diet is good in diarrhea
BRAT
Osmotic diarrhea resolves with what
Fasting
secretory does not change with eating
Secretory diarrhea has a normal what
Osmotic gap
Vitamin A deficiency causes what
Vision changes ; at night
Dry scaly skin
Hair loss
Hip fractures
Vitamin D deficiency think what
Rickets
Hypercalcemia
Renal stones
Vitamin E deficiency think what
Cellular aging and vascular integrity changes
Areflexia gait disturbance loss of vibratory sense
GI discomfort
Vitamin K deficiency think what
Bleeding issues anemia jaundice
Vitamin B12 deficient think what
Megaloblastic anemia
Parenthesias
Confusion
Vitamin B1 deficiency thin what
Thiamine
Lethargy ataxia
Wernickes encephalopathy
Vitamin B6 deficiency think what
Dermatitis / cheilossis
Photosensitivity
Peripheral neuropathy
Vitamin B2 deficiency think what
Glossitis leukopenia anemia
Oxidation reduction function
Niacin defiency think what
Diarrhea
Dermatitis
Dementia
Vitamin C deficiency think what
Swollen gums
“Scurvy”
Atraumatic hermarthrosis
Risk factors for phentermine / topiramate
Tachycardia
Contraindicated in pregnancy
What is an injectable obesity medication
Liraglutide
FOB with cough worry about what
Aspiration
When do you barium swallow for FOB
If highly suspect but negative X-RAY
What substances a can cause hyperthermia [4]
Amphetamines
Anticholinergic
Cocaine
Salicylates
Arsenic ;; methadone ;; citalopram can cause what arrhythmia
QT prolongation
APAP toxicity affects what organ
The liver
G6PD is what type of deficiency
X lined recessive
What is the osteoid formation in Piaget disease
Affects what body area first
Disorganized
Affects long bones first
Increased hat size think what disease
Pagets
Elevated ALK phos
Treatment and complication of Paget’s disease
Bisphosphonates = TXM
Complication = osteosarcoma
‘PKU is what genetic defect
Autosomal recessive
Reduce intake of what in PKU
Dairy
Meat
Fish
Eggs
Nuts/Legumes
