GI/Nutritional Flashcards
Esophagitis
odynophagia (painful swallow), dysphagia, retrosternal CP.
dx: EGD
MCC is GERD…. unless immunocompromised (infectious - Candida, CMV, HSV).
tx: treat underlying cause
incompetent LES
GERD
Heartburn (pyrosis) hallmark**, increases when supine, regurgitation and dysphagia.
GERD - Dx and Tx
dx:
- clinical if typical symptoms
- EGD usually 1st
- if EGD normal –> Esophageal Manometry (shows decreased LES pressure)
- GOLD STANDARD - 24 HR AMBULATORY pH MONITORING
Tx:
- stage 1 = lifestyle modifications
- stage 2 = prn meds = H2 blockers
- stage 3 = scheduled meds = PPI. Nissen fundoplication if refractory.
Dysphagia to both solids and foods + over competent LES
Achalasia
Dx:
- Esophageal Manometry ** GOLD STANDARD
- Double-contrast esophagram = Birds beak
tx = decrease LES pressure = botox injections, nitrates, CCBs
stabbing CP worse with hot or cold liquids/foods - pain similar to angina
diffuse esophageal spasm
dx = Esophagram - shows CORKSCREW esophagus.
tx = Nitrates, CCB
pharyngoesophageal diverticulum
zenker’s diverticulum
dysphagia, sense of lump in throat, regurgitation of foods, cough, halitosis
dx = barium esophagram
retrosternal CP worse with deep breathing and swallowing, hematemesis
Boerhaave syndrome
full thickness rupture of distal esophagus 2/2 repeat forceful vomiting.
dx
- CT chest/CXR : pneumomediastinum
- Contrast esophagram = definitive dx showing + leakage.
tx:
- small/stable = IV fluids, NPO, Abx, H2b
- large/severe = surgery
Physical exam findings of boerhaave syndrome
crepitus on chest auscultation 2/2 pneumomediastinum
esophageal webs
thin membranes in mid-upper esophagus.
Plummer-vinson syndrome
dysphagia + esophageal webs + iron deficiency anemia
- Atrophic glossitis, angular cheilitis, splenomegaly. MC in white women, 30-60y.
esophageal rings
Schatzki ring - lower esophageal webs/constrictions
MC associated with sliding hiatal hernia* (type 1).
Esophageal webs/rings presentation, dx, tx
sxs = dysphagia especially to solids
dx = Barium Swallow
tx =
- if no reflux = endoscopic dilation
- if + reflux = antireflux surgery
protrusion of the upper portion of the stomach into the chest cavity 2/2 a diaphragm tear or weakness
hiatal hernia
type 1 = sliding
- associated with increase in reflux.
- tx similar to GERD
type 2 = rolling (paraesophageal)
- may lead to strangulation
- tx is surgical repair to avoid complications
MCC of esophageal cancer worldwide*
SQUAMOUS cell
- MC in upper 1/3 of esophagus.
- alcohol, smoking, hot beverages, exposure to noxious stimuli, men, nitrates all increase risk.
- increased risk in African Americans.
- Decreased incidence with NSAIDs and coffee consumption.
MC type of esophageal cancer in the US**
Adenocarcinoma
- younger patients, obese, whites.
- MC in lower 1/3
- usually complication of GERD. leads to Barretts esophagus.
- dysphagia of solid foods – progressing to dysphagia of liquids; odynopahagia
- weight loss, CP, hoarseness
esophageal cancer
dx = EGD with biopsy.
tx =
- esophageal resection, XT, CTX (pends on stage)
MCC of upper GIB
peptic ulcer dz
H. pylori MCC
NSAIDs 2nd MCC
dyspepsia, epigastric pain - worse at night.
Dx: EGD with biopsy
PUD treatment if H. pylori +
CAP
Clarithromycin + Amoxicillin + PPI
Dyspepsia, Weight loss, Early satiety, Iron deficiency anemia
Gastric Carcinoma
- Adenocarcinoma MC worldwide
- H. pylori most important risk factor. other risks = salted, cured, smoked, pickled foods containing nitrites/nitrates
additional symptoms = signs of metastasis
- supraclavicular LN (Virchow’s node)
- palpable nodule on DRE (bloomer’s shelf)
- Umbilical LN (Sister Mary Joseph’s node)
- left axillary LN (Irish sign)
- Ovarian mets (Krukenburg tumors)
Dx = EGD with biopsy
tx = gastrectomy + XT + CTX. poor prognosis
your patient develops jaundice during times of stress, ETOH, or illness (transient jaundice)
Gilbert’s syndrome
hereditary unconjugated (indirect) hyperbilirubinemia.
dx: Increased isolated indirect bilirubin with NORMAL LFTs.
no treatment necessary
ALT > AST
usually present with viral, toxic, or inflammatory liver disease.
AST and ALT > 1000
usually ACUTE viral hepatitis (A and B, rarely C)
chronic viral hepatitis (B/C/D) ALT and AST levels
mildly elevated ALT and AST (usually <400)
term for gallstones in the gallbladder, NO inflammation
cholelithiasis
CHOLELITHIASIS
- risk factors
- sxs
- dx
- tx
- complications (3)
- RF: 5f’s = female, forty, fertile, fat, fair
- ASX vs biliary colic (RUQ/epigastric pain lasting 30 min to hours. may have Nausea. Precipitated by Fatty foods and large meals)
- Dx = Ultrasound
- Tx =
asymptomatic patients = observation
symptomatic = elective cholecystectomy - complications
1. choledocholithiasis
2. acute cholangitis
3. acute cholecystitis
choledocholithiasis
gallstones in CBD
secondary MCC (stones from gallbladder get stuck in CBD)
major concerns: PANCREATITIS and CHOLANGITIS
dx:
- transabdominal ultrasound
- ERCP*** diagnostic and therapeutic
patient with FEVER/CHILLS, RUQ PAIN, JAUNDICE
Charcot’s triad = acute cholangitis = biliary infection 2/2 obstruction
alk phos + bilirubin levels > ALT/AST
dx/tx = ERCP and antibiotics (Unasyn, Pip/tazo)
Reynold’s pentad
Charcot’s triad + AMS + Shock
seen in acute cholangitis
MC bacteria seen in both Cholangitis and Cholecystitis
E.coli > Klebsiella > Enterococci
Biliary colic with RUQ pain
- pain lasting continuously
- pain lasting 30 min to few hours
- pain associated with jaundice?
A = continuous pain = think cholecystitis
B = episodic pain = think cholelithiasis
C = if jaundice present = think choledocholithiasis
patient with RUQ/epigastric pain that is continuous. they also complain of nausea.
on exam the patient is FEBRILE (low grade), with ENLARGED, PALPABLE GALLBLADDER (+ Murphy’s) and REFERRED PAIN TO RIGHT SHOULDER (+ Boas).
what is suspected Dx?
Acute cholecystitis
- order Ultrasound 1st.
- labs: Leukocytosis with left shift.
- GOLD STANDARD = HIDA = + test if non visualization of the gallbladder.
Acute Cholecystitis treatment
NPO, IV fluids, Antibiotics (Rocephin + Flagyl) – continue until Cholecystectomy (w/in 72 hours)
chronic cholecystitis
- associated with GALLSTONES - may be 2/2 repeated bouts of acute/subacute cholecystitis.
- STRAWBERRY GB ==> PORCELAIN GB (premalignant condition)
Patient presents complaining of Malaise, Weight loss, Jaundice, Abdominal pain and Hepatosplenomegaly.
Hepatocellular Carcinoma (HCC)
- Ultrasound
- Increased Alpha-Fetoprotein
needle biopsy avoided to prevent seeding.
tx = Surgical resection if confined to a lobe and not associated with cirrhosis.
how do we screen for HCC?
Ultrasound + Alpha-Fetoprotein
Fatigue is 1st symptom, Itching, RUQ discomfort, Hepatomegaly, Jaundice
Primary Biliary Cirrhosis
- idiopathic autoimmune disorder of INTRAhepatic small bile ducts
- MC middle aged women
Dx:
- HIGH ALK PHOS > AST/ALT, Bili
- Anti-Mitochondrial Antibody * Hallmark
tx:
- Ursodeoxycholic acid - decreases progression
- Cholestryamine and UV light for itching
MC in men 20-40y with Inflammatory bowel disease (UC*)
- present with Jaundice, Itching, Hepatomegaly, Splenomegaly
- labs show High Alk Phos and + P-ANCA
Primary Sclerosis Cholangitis (PSC)
ERCP - gold standard diagnostic test
Tx:
- Stricture dilation to relieve symptoms
- Liver Transplant DEFINITIVE tx
MEDS NOT BENEFICIAL
Gallstones, Alcohol, Scorpion bites, Mumps (kids) - all cause what?
Acute Pancreatitis
Constant, boring epigastric pain - radiates to back, better by leaning forward or sit in fetal position.
worsened by supine, eating, walking.
Acute Pancreatitis
Dx: Labs, Abdominal CT
Tx:
- NPO + IV fluids + Analgesia
ABX NOT routinely used*.
Classic Triad:
- Calcifications
- Steatorrhea
- Diabetes Mellitus
Chronic Pancreatitis
MCC = Alcohol abuse.
2nd MCC = idiopathic
MCC in kids = Cystic fibrosis
Dx: AXR = Calcified Pancreas ***
- Amylase/Lipase levels NORMAL
Tx: PO Pancreatic enzyme replacement*, stop drinking, pain control.
Abdominal pain radiating to back, PAINLESS jaundice, weight loss, itching, migratory phlebitis (Trosseau’s sign)
Pancreatic carcinoma
- pts usually w/ METS at time of presentation. MC mets to regional LN and Liver
Pancreatic Carcinoma
- Risk factors
- Histology
RF: SMOKING, >60y, chronic pancreatitis, African Americans, etc.
Histology: Adenocarcinoma** - DUCTAL MC
- majority occur in HEAD of pancreas.
Courvoisier’s sign
palpable, NONtender, distended gallbladder associated with jaundice (CBD obstruction).
–Associated with PANCREATIC CANCER**
Pancreatic Cancer diagnosis (3)
CT initial test
ERCP most sensitive
Labs: increased tumor markers: CEA, CA 19-9
Pancreatic Cancer treatment
- WHIPPLE - if confined to head or duodenal; radical pancreaticoduodenal resection
- Tail - distal resection
- Advanced or inoperative = ERCP with stent placement as palliative tx for intractable itching.
Cramping Abdominal Pain + Distention + Vomiting + Obstipation
Small Bowel Obstruction
- adhesions MCC
- PE: Hyperactive BS - High pitched TINKLES.
- Dx: AXR = Air fluid levels, dilated bowel loops.
Tx:
- non strangulated = NPO + IV Fluids +/- NG tube
- Strangulated = surgery
twisting of any part of the bowel at its mesenteric attachment site.
Volvulus
- MC sigmoid colon and cecum
Sxs: obstructive symptoms = abd pain, distention, N/V, Fever, tachycardia.
Tx: Endoscopic decompression (1st), sx (2nd)
MCC of acute lower GIB
diverticulosis
- MCC to low fiber diet, constipation, obesity.
- usually Asymptomatic (besides the bleeding)
- Dx with CT scan
- Tx with fiber supplements
Anorexia and periumbilical/epigastric pain –> followed by RLQ pain, N/V
Appendicitis
- PE: rebound Tenderness, rigidity, guarding.
Rovsing, Obturator, Psoas, McBurney’s point
DX - CT, Leukocytosis
Tx - Appendectomy
chronic dull abdominal pain worse after meals + anorexia
chronic mesenteric ischemia (atherosclerosis of GI tract)
- Angiogram confirms dx.
- colonoscopy - muscle atrophy with loss of villi
- tx = bowel rest. surgical revascularization
severe abdominal pain out of proportion to exam finings. poorly localized abdominal pain.
acute mesenteric ischemia
- MC 2/2 occlusion (embolus, thrombus)
- Angiogram definitive dx.
- tx = surgical revascularization. resect if not salvageable.
LLQ pain with Tenderness, Bloody Diarrhea
Ischemic colitis
- Dx = Colonoscopy
- Tx = restore perfusion
non obstructive, extreme colon dilation > 6 cm + signs of systemic toxicity
toxic megacolon
- fever, and pain, N/V/D, rectal bleeding, tenesmus, electrolyte disorders
- AXR: dilated colon >6cm
- Tx: Bowel decompression: Bowel rest, NG tube, Broad-spec ABX.
- correct lytes
- colostomy if refractory.
MCC of Large Bowel Obstruction in adults
Colorectal Cancer (CRC)
Iron Deficiency Anemia + Rectal Bleeding + Abdominal Pain + Change in Bowel Habits
Colorectal Cancer
Dx:
- Colonoscopy with Biopsy**.
- Barium enema - apple core lesion classic.
- Increased CEA levels.
- labs = iron deficiency anemia
tx:
stage 1-3 = surgical resection
stage 3 and mets = CTX
Colorectal Cancer MC site of metastatic spread
Liver
patient stable with chronic hepatitis who experiences sudden deterioration and worsening of symptoms
HCC
- Lateral to inferior epigastric vessels.
- 2/2 persistent patent process vaginalis
- MC in young kids and young adults.
- MC type overall in men and women
INDIRECT inguinal hernia
protrusion of abdominal cavity contents thru femoral canal below inguinal ligament
femoral hernia
- MC seen in women
- surgical repair
Incisional (Ventral) Hernia
MC with vertical incisions and in obese patients
Intermittent rectal bleeding*, hematochezia (BRB per rectum)
internal hemorrhoids
- proximal to dentate line
management of diarrhea (4)
- IV fluids**
- Diet - bland foods = “BRAT” diet - Bananas, Rice, Applesauce, Toast
- Anti-motility agents (only for noninvasive diarrhea)
- Antiemetics
MCC of gastroenteritis in adults
Norovirus
- outbreaks on cruises, hospitals, restaurants
Vomiting, watery diarrhea, voluminous (involves small intestine), NO fecal WBCs or blood
noninvasive (enterotoxin) infectious diarrhea
copious watery diarrhea, “rice water stools”
vibrio cholera and parahemolyticus
MCC of traveler’s diarrhea
E. coli
MC antibiotic associated with C. diff
clindamycin
treatment for C. diff
mild = flagyl 1st or PO vancomycin (2nd) severe = PO vancomycin 1st line
high fever, + blood and fecal leukocytosis, not as voluminous (large intestine), mucus
Invasive infectious diarrhea
MCC of bacterial enteritis in US
C. jejuni
- symptoms that mimic appendicitis + diarrhea that’s initially watery -> becomes bloody
- cultures show “S, comma, or seagull shaped” organisms**
- tx = fluids. if severe = Erythromycin
lower abdominal pain with explosive watery diarrhea that is mucoid and bloody
Shigella
- stool cultures = WBC/RBC. labs may show WBC > 50,000.
- sigmoidoscopy = punctate areas of ulceration
tx = fluids. if severe = Bactrim
population of increased risk of osteomyelitis with salmonella infection
sickle cell patients
predominant symptoms of non-invasive diarrheas
vomiting*
Backpackers diarrhea
- Frothy, greasy, foul diarrhea
Giardia Lamblia
- tx = Fluids + Flagyl
treatment modalities for constipation (4)
- fiber
- bulk forming laxatives
- osmotic laxatives
- stimulant laxatives
