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