GI / Nutritional Flashcards
1
Q
Third most common cause of cancer related death in US
A
Colorectal carcinoma
2
Q
Most common site of metastatic spread from colorectal CA
A
Liver
Lungs
Lymph nodes
3
Q
Risk factors for colorectal cancer
A
- APC gene
- Lynch syndrome
- Peutz Jeghers
- Age > 50 y/o
- Ulcerative colitis
- Diet
- Smoking, EtOH
4
Q
Signs/symptoms of colorectal cancer
A
Iron deficiency anemia
Rectal bleeding
Abdominal pain
5
Q
Most common cause of large bowel obstruction in adults
A
Colorectal cancer
6
Q
Right-sided (proximal) colorectal CA presents with _______ and ________
A
Bleeding
Diarrhea
7
Q
Left-sided (distal) colorectal CA presents with ________ and ___________
A
Bowel obstruction
Changes in stool diameter
8
Q
Diagnosis for colorectal cancer
A
- Colonoscopy with biopsy
- Barium enema - apple core lesion
- Increased CEA
- CBC (iron deficiency anemia)
9
Q
Management of colorectal cancer
A
Localized (Stages I-III): surgical resection
Stage III and metastatic: chemotherapy is mainstay (fluorouracil)
10
Q
Guidelines for colorectal CA screening
A
- Occult blood test annually
- Colonoscopy every 10 years ages 50-75 y/o
- Flex sig every 5 years with occult every 3 years
11
Q
Causes of anal fissures
A
Low-fiber diets
Passage of large, hard stools
Other anal trauma
12
Q
Signs/Symptoms of anal fissures
A
Severe rectal pain
Painful bowel movements causing patient to refrain from having BM
Leads to constipation
BRBPR
13
Q
Where is the most common location of anal fissures
A
90% posterior midline
14
Q
Treatment of anal fissures
A
80% resolve spontaneously Supportive measures: warm sitz baths High fiber diet Analgesics Increased water intake Stool softeners
15
Q
Second line treatment for anal fissures
A
Topical vasodilators: nitroglycerin
16
Q
Surgical procedure for anal fissures
A
Lateral internal sphincterotomy
17
Q
What two causes predispose a patient to peptic ulcers?
A
H. pylori
NSAIDs
18
Q
Symptoms of peptic ulcers
A
Duodenal ulcers: improve with meals
Gastric ulcers: worsen with meals
19
Q
Diagnostic modality for peptic ulcers
A
Endoscopy
Upper GI series if unwilling to do endoscopy
20
Q
Treatment for peptic ulcers
A
Treat underlying cause and start PPI
21
Q
H. pylori testing
A
Endoscopy with biopsy gold standard + rapid urease test
+ Urea breath test
+ H. pylori stool antigen
+ serologic antibodies
22
Q
Treatment for H. pylori
A
Two weeks of:
BID PPI
BID Clarithromycin
BID Metronidazole or amoxicillin
23
Q
Second line treatment for H. pylori
A
BID PPI
QID Bismuth
BID Metronidazole
BID Tetracycline
24
Q
Most common causes of gastritis
A
H. pylori infection Autoimmune causes (pernicious anemia)
25
Most common causes of gastropathy
NSAIDs
Alcohol
Bile reflux
26
Treatment for gastritis
Treat underlying cause and give PPI
27
Symptoms of gastritis
Most commonly asymptomatic
| Epigastric pain, nausea, vomiting, anorexia
28
Diagnosis of gastritis
Endoscopy gold standard, H. pylori testing
29
Most common etiologies for acute pancreatitis (5)
```
Gallstones (MC)
EtOH abuse (MC)
Malignancy
Scorpion bite
Mumps in children
```
30
Intracellular activation of pancreatic enzymes that causes autodigestion of the pancreas
Acute pancreatitis
31
Pain exacerbated if supine, eating, or walking. Relieved if leaning forward or sitting.
Acute pancreatitis
32
Signs/symptoms of acute pancreatitis
1. Epigastric pain (radiates to back)
2. N/V and fever
3. Epigastric tenderness and tachycardia
33
Cullen's Sign and Grey Turner Sign
Acute Pancreatitis if necrotizing / hemorrhagic
Cullen's periumbilical ecchymosis
Grey Turner: flank ecchymosis
34
Diagnostic studies for pancreatitis
1. Leukocytosis, lipase, amylase, high glucose
2. CT: diagnostic test of choice
3. Ultrasound
4. XRay - colon cutoff sign
35
Colon cutoff sign
Abrupt collapse of the colon near the pancreas
| Acute pancreatitis
36
Management of pancreatitis
90% recover without complications in 3-7 days
1. Supportive - NPO, IV fluid resuscitation, analgesia with meperidine/demerol
2. ABX not used routinely
3. If necrotizing pancreatitis - imipenem
4. ERCP - only effective for obstructive jaundice
37
Ranson's Criteria
Used to determine prognosis for pancreatitis
Glucose, Age, LDH, AST, WBC
Calcium, Hematocrit fall, Oxygen, BUN, Base deficit, Sequestration of fluid
38
Increased risk of CA in both where there is colonic involvement
Inflammatory Bowel Disease
| UC and Crohn's
39
Signs/Symptoms of inflammatory bowel disease
1. abdominal pain
2. weight loss
3. bloody diarrhea
4. fever
40
Extraintestinal manifestations of inflammatory bowel disease (5)
1. Erythema nodosum
2. Arthritis
3. Uveitis
4. Primary sclerosing cholangitis
5. Pyoderma gangrenosum
41
Characteristics of ulcerative colitis
Involves colon
| Continuous involvement pANCA positive
42
Characteristics of crohn's disease
```
Skip lesions
Entire GI tract involvement (mouth to anus)
Transmural inflammation
Cobblestone appearance
Fistulas may be seen
ASCA positive
```
43
Treatment for inflammatory bowel disease
1. Steroids for acute exacerbation
2. Sulfasalazine or mesalamine
3. If no response to sulfa or mesalamine, ABX are used for Crohn's only
4. Colectomy or proctocolectomy is offered to those with extensive dz refractory to medication
44
Most common causes of appendicitis
Fecalith (MC)
Inflammation
Malignancy
Foreign Body
45
Vomiting usually occurs _______ pain in appendicitis
After
46
RLQ with LLQ palpation
Rovsing Sign
| Appendicitis
47
RLQ pain with internal and external hip rotation with flexed knee
Obturator Sign
| Appendicitis
48
RLQ pain with right hip flexion/extension (raise leg against resistance)
Psoas Sign
| Appendicitis
49
Diagnosis for appendicitis
1. CT scan
2. Ultrasound
3. Leukocytosis
50
Internal hemorrhoids result from engorgement of which venous plexus
Superior hemorrhoidal vein
51
External hemorrhoids result from engorgement of which venous plexus
Internal hemorrhoidal vein
52
Risk factors for hemorrhoids
```
Increased venous pressure
Straining during defecation (constipation)
Pregnancy
Obesity
Prolonged sitting
Cirrhosis with portal hypertension
```
53
Symptoms of internal hemorrhoids
```
Rectal bleeding (intermittent)
Hematochezia
Rectal itching and fullness
Mucous discharge
Rectal pain suggests complications
```
54
Symptoms of external hemorrhoids
Perianal pain - aggravated with defecation
| +/- tender palpable mass
55
Diagnosis of hemorrhoids
```
Visual inspection
Digital rectal exam
Fecal occult blood testing
Proctosigmoidoscopy
Colonoscopy in pts with hematochezia to r/o proximal sigmoid disease
```
56
Management of hemorrhoids
Conservative tx - high fiber diet, increased fluids, warm sitz bath, topical rectal corticosteroids for pruritus and discomfort
If failed conservative therapy or debilitating pain:
Rubber band ligation
Sclerotherapy
Infrared coagulation
Hemorrhoidectomy (for all stage IV)
57
Most common causes of small bowel obstruction
1. Adhesions
2. Incarcerated hernia
3. Crohn's dz
4. Malignancy
58
Signs/Symptoms of small bowel obstruction
CAVO
1. Cramping abdominal pain
2. Abdominal distention
3. Vomiting - may be bilious if proximal
4. Obstipation - usually late finding (diarrhea early)
59
Physical exam for small bowel obstruction
Abdominal distention
Hyperactive bowel sounds in early obstruction
Hypoactive bowel sounds in late obstruction
60
Diagnosis of small bowel obstruction
1. AXR - air fluid levels in step ladder pattern, dilated bowel loops
61
Management of small bowel obstruction
Nonstrangulated: NPO, IV fluids, NG tube
Strangulated: surgical intervention
62
Most common bacterial etiologies of acute cholecystitis
E. coli
| Klebsiella
63
Diagnosis of cholecystitis
1. Ultrasound
2. CT scan
3. Labs: leukocytosis w/ left shift, high bilirubin, high LFTs
4. HIDA scan: gold standard
64
Management of cholecystitis
1. NPO, IV fluids, abx
2. Cholecystectomy
3. Pain control with NSAIDs or narcotics
65
Risk factors for cholelithiasis
Female
Fat
Forty
Fertile
66
Most common types of gallbladder stones
75% cholesterol
| 25% pigment (calcium bilirubinate, associated with biliary tract infection)
67
Boas sign
Referred right subscapular pain from cholelithiasis
68
Diagnostic modality of cholelithiasis
Ultrasound
69
Major complications of cholelithiasis (5)
1. Acute cholecystitis
2. Choledocholithiasis
3. Gallstone pancreatitis
4. Gallstone ileus
5. Cholangitis
70
Most common type of hiatal hernia
Sliding hernia
| GE junction and stomach slide into mediastinum
71
Predominant symptom of hiatal hernia
Reflux
72
Management of hiatal hernia
Similar to GERD treatment
| If a rolling hernia, must surgically repair - can lead to strangulation
73
Hernia that occurs lateral to the inferior epigastric artery
Indirect inguinal hernia
74
Indirect hernias are often congenital and occur due to a __________ _________ _________ __________
Persistent patent process vaginalis
75
Most common overall type of hernias in women and men
Indirect inguinal hernia
76
Hernia that occurs medial to the inferior epigastric arteries within Hesselbach's triangle
Direct inguinal hernia
77
Borders of Hesselbach's Triangle
RIP
Rectus abdominis
Inferior epigastric artery
Poupart's Ligament
78
Signs/symptoms of a strangulated hernia
Incarcerated hernia with systemic toxicity
Compromised blood supply - ischemic
Severe painful bowel movement
79
Management of inguinal hernias
Often require surgical repair
| Strangulated are surgical emergencies
80
Hernia that is most commonly seen in women
Femoral hernia
81
Often become incarcerated or strangulated compared to an inguinal hernia so surgical repair is often done
Femoral hernia
82
Management of umbilical hernias
Observation, will usually resolve by 2 years old
| Surgical repair if still persistent in children > 5 y/o
83
Incision hernias occur most commonly with __________ and in ____________
Vertical incisions
| Obese patients
84
Acute diarrhea is defined as being less than __________ in duration
2 weeks
85
C. diff is most commonly associated with _____________, however, any abx can lead to c. diff
Clindamycin
86
C. diff diarrhea will present _______ to _______ following abx therapy, and will present as excessive (__________)
days to weeks
| over 10x daily
87
Signs/symptoms of c. diff infxn
Watery diarrhea
Abdominal pain
Fever
Leukocytosis
88
Treatment for c. diff
Metronidazole is best initial therapy
| If no response, follow with vancomycin
89
Infectious diarrhea can be divided into ___________ and ___________
Inflammatory (blood or WBC in stool)
| Non-inflammatory
90
Most accurate test for identifying bacteria
Stool culture
91
Most common organism isolated in inflammatory diarrhea
Campylobacter
92
Inflammatory diarrhea is treated with:
Fluoroquinolone
(Ciprofloxacin, Ofloxacin, Moxifloxacin)
Azithromycin is an appropriate alternative
93
Non-inflammatory diarrhea is treated with:
Supportive therapy
| Oral rehydration
94
Diagnosis for giardiasis diarrhea
ELISA for giardia antigen
95
Treatment for giardiasis diarrhea
Metronidazole
96
Diarrhea and symptoms that begin within 6 hours suggest ___________ or ______________
Staphylococcus
| Bacillus cerus
97
Diarrhea and symptoms that begin within minutes is:
Scombroid
98
Diarrhea associations: chicken and eggs
Salmonella
99
Diarrhea associations: shellfish
Vibrio
100
Diarrhea associations: rice water stools
Cholera
101
Diarrhea associations: camping and freshwater
Giardia
102
Diarrhea associations: canned foods
Clostridium
103
Diarrhea associations: poultry and raw milk
Campylobacter
| Associated with reactive arthritis and Guillain-Barre syndrome
104
Diarrhea associations: daycare centers
Shigella
105
Diarrhea associations: spoiled fish, wheezing, flushing, vomiting, diarrhea
Scombroid
106
Dyssynergic defecation, slow transit, and IBS-constipation type
Primary causes of constipation
107
DM, hypothyroid, hypercalcemia, intestinal mass, Parkinson's disease, anal stricture, and medications
Secondary causes of constipation
108
Alarm symptoms of constipation
1. Hematochezia
2. Weight loss
3. Fam hx of colon CA
4. Anemia
5. Heme positive stool
6. Severe persistent constipation
109
Diagnosis of constipation
1. Rectal exam - r/o masses, fissures, sphincter tone
| 2. Colonoscopy if alarm sx
110
Treatment of constipation
1. Increase fluids, exercise, develop bowel pattern
2. Fiber of 25 g daily
3. Bulk/osmotic laxatives
4. Prunes are an alternative
111
Chronic GI bleeding presents as:
Hemoccult + stools
Iron deficiency anemia
Both
112
An acute upper GI bleed is _____________ than lower GI bleed
3x more common
113
Acute Upper GI bleed presents as:
Hematemesis (MC)
Melena
Hematochezia
114
Most common causes of upper GI bleeds
Peptic Ulcers
| Esophageal varices
115
Most common causes of lower GI bleeding
Diverticular dz
| Vascular malformation
116
Inflammation of the liver caused by 5 different viruses
Viral hepatitis
117
Hepatitis __, ____, and ____ are transmitted through bodily fluids, while ____ and ____ are transmitted through the fecal-oral route.
B, C, D
| A, E
118
Hepatitis ____ requires co-infection with hepatitis ___
D
| B
119
Currently, the CDC suggests that all pts born between _______ and _______ have a one-time Hepatitis C screening
1945-1965
120
Signs/Symptoms of viral hepatitis
1. Fever, fatigue
2. Nausea, vomiting
3. Abdominal pain
4. Dark colored urine (secondary to conjugated hyperbilirubinemia)
5. Jaundice
121
Hepatitis ____ and ____ will usually be asymptomatic
B and C
122
Diagnosis of Hepatitis
1. Elevated LFTs
2. Elevated PT (if developed cirrhosis)
3. Antibody testing (IgM and IgG)
123
In hepatitis testing, _____ is for acute infection, and ____ is for chronic infection
IgM
IgG
This does not apply to Hepatitis B and C
124
Test to check for active Hepatitis C infection
Hep C virus RNA
125
If there is positive Hep C antibody, but negative RNA
Pt has cleared Hep C infection
126
if there is positive Hep C antibody and positive Hep C RNA
Pt has active Hep C infection
127
Hepatitis B Screening:
HBsAg negative
anti-HBc negative
anti-HBs negative
Hepatitis B susceptible
128
Hepatitis B Screening:
HBsAg negative
anti-HBc positive
anti-HBs positive
Immune due to natural infxn
129
Hepatitis B Screening
HBsAg negative
anti-HBc negative
anti-HBs positive
Immune to due to vaccination
130
```
Hepatitis B screening:
HbsAg positive
anti-HBc positive
IgM anti-HBc positive
anti-HBs negative
```
Acutely infected
131
```
Hepatitis B screening:
HbsAg positive
anti-HBc positive
IgM anti-HBc negative
anti-HBs negative
```
Chronically infected
132
Treatment for Hepatitis A & E
Self-resolve, are not associated with chronic liver disease
133
Treatment for acute Hepatitis B
Supportive care
134
Treatment for chronic Hepatitis B or positive e-antigen
Interferon or Nucleoside analogs (entecavir, tenofovir, lamivudine, adefovir, telvibudine)
135
Treatment for hepatitis pts with cirrhosis
Require transplant
136
Treatment for hepatitis C
Ledipasvir-sofosbuvir OR
| Sofosbuvir and velpatasvir
137
Cause of jaundice
Tissue bilirubin deposition as a consequence of hyperbilirubinemia
138
Jaundice occurs when bilirubin levels exceed:
2.5 mg/dL
139
Mostly irreversible liver fibrosis with nodular regeneration secondary to chronic liver disease
Cirrhosis
140
The nodules of cirrhosis cause:
increased portal pressure
141
Macronodules seen in cirrhosis are associated with a high risk of:
hepatocellular carcinoma
142
Most common cause of cirrhosis in US
EtOH
143
Other causes of cirrhosis besides EtOH (4)
1. Chronic viral hepatitis
2. Nonalcoholic fatty liver disease (obesity, DM, hypertriglyceridemia)
3. Hemochromatosis
4. Primary biliary cirrhosis, primary sclerosing cholangitis, drug toxicity
144
Signs/Symptoms of cirrhosis
1. Fatigue, weakness
2. Weight loss
3. Muscle cramps
4. Anorexia
145
Physical exam with cirrhosis
1. Ascites
2. Hepatosplenomegaly
3. Spider angiomas
4. Caput medusa
5. Palmar erythema
6. Gynecomastia
7. Dupuytren's contractures
8. Jaundice
9. Esophageal varices
146
Diagnosis of cirrhosis
Ultrasound - determines liver size and evaluates for HCC
| Liver biopsy
147
Treatment of cirrhosis
1. Lactulose, Rifaximin - abx
2. Sodium restriction - diuretics, paracentesis
3. Cholestyramine to help with itching
148
Definitive treatment of cirrhosis
liver transplant
149
Screening for HCC
Ultrasound + alpha-fetoprotein
150
Transient relaxation of LES leading to esophageal mucosal injury
GERD
151
Complications of GERD (4)
1. Esophagitis
2. Stricture
3. Barrett's esophagus
4. Esophageal adenocarcinoma
152
Esophageal squamous epithelium replaced by precancerous metaplastic columnar cells from the cardia of the stomach
Barrett's Esophagus
153
Signs/Symptoms of GERD
1. Heartburn (hallmark) - sometimes retrosternal and postprandial
2. Regurgitation (acidic taste)
3. Dysphagia, cough at night
154
Alarm symptoms of GERD
1. Dysphagia
2. Odynophagia
3. Weight loss
4. Bleeding (suspect malignancy)
155
Diagnosis of GERD
Clinical diagnosis
1. Endoscopy often first
2. Esophageal Manometry - decreased LES pressure - may be used if endoscopy normal
3. 24 hour ambulatory pH monitoring (gold standard)
156
Lifestyle Modifications of GERD
```
Elevation of head of bed by six inches
Avoid recumbency for three hours after eating
Eat small meals
Avoid certain foods
Decrease fat and EtOH intake
Weight loss
Smoking cessation
```
157
Pharmacological Therapy for GERD
1. Antacids and OTC H2 receptor antagonists
2. PPI and prokinetic agents (Cisapride)
3. Nissen fundoplication if refractory
158
Abdominal pain associated with altered defecation/bowel habits (diarrhea, constipation)
Irritable bowel syndrome
159
Rome IV Criteria
Irritable bowel syndrome
160
Recurrent abdominal pain on average at least 1 day/week in the last 3 months with at least 2 of the following 3:
related to defecation
onset associated with change in stool frequency
onset associated with change in stool form (apperance)
Rome IV Criteria
| Irritable bowel syndrome
161
Alarm symptoms in IBS
1. Evidence of GI bleeding: occult in stool, rectal bleeding, anemia
2. Anorexia or weight loss, fever, nocturnal symptoms, family history of GI cancer
3. Persistent diarrhea causing dehydration, severe constipation or fecal impaction, onset > 45 y/o
162
Management of IBS
Smoking cessation, low fat/unprocessed food diet
Sleep, exercise, hydrate
Diarrhea - anticholinergics, antidiarrheal
Constipation - prokinetics, laxatives, fiber
163
Most common cause of esophagitis
GERD
164
Risk factors for esophagitis
```
Pregnancy
Smoking
obesity
EtOH use
Chocolate
Spicy foods
Medications
```
165
Signs/Symptoms of esophagitis
1. Odynophagia
2. Dysphagia
3. Retrosternal chest pain
166
Diagnosis of esophagitis
Endoscopy
| Double-contrast esophagram
167
Management of esophagitis
Treat underlying cause
168
Most common causes of infectious esophagitis
Candida
HSV - small, deep ulcers
CMV - large superficial shallow ulcers
169
Allergic, inflammatory infiltration fo the esophageaal epithelium
Eosinophilic esophagitis
170
Eosinophilic esophagitis is most commonly associated with:
Atopic disease - food/non-food allergies, asthma, eczema
171
Endoscopy of eosinophilic esophagitis will show:
Multiple corrugated rings on esophagus, +/- white exudates
172
How might eosinophilic esophagitis present in children?
Difficulty feeding or reflux
173
Most commonly due to prolonged pill contact with the esophagus, prolonged supination after pill ingestion
Pill-induced esophagitis
174
Pill-induced esophagitis is most commonly seen with:;
1. NSAIDs
2. Bisphosphonates (-dronate)
3. Potassium chloride
4. Iron pills
5. Vitamin C
6. Beta blockers
7. Calcium channel blockers
175
Management of pill-induced esophagitis
Take pills with at least 4 ounces of water, avoid recumbency for at least 30-60 minutes after pill ingestion
