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Surgery > GI/Nutritional > Flashcards

GI/Nutritional Flashcards

1
Q

Esophagitis

A

odynophagia (painful swallow), dysphagia, retrosternal CP.

dx: EGD
MCC is GERD…. unless immunocompromised (infectious - Candida, CMV, HSV).

tx: treat underlying cause

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2
Q

incompetent LES

A

GERD

Heartburn (pyrosis) hallmark**, increases when supine, regurgitation and dysphagia.

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3
Q

GERD - Dx and Tx

A

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.
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4
Q

Dysphagia to both solids and foods + over competent LES

A

Achalasia

Dx:

  • Esophageal Manometry ** GOLD STANDARD
  • Double-contrast esophagram = Birds beak

tx = decrease LES pressure = botox injections, nitrates, CCBs

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5
Q

stabbing CP worse with hot or cold liquids/foods - pain similar to angina

A

diffuse esophageal spasm

dx = Esophagram - shows CORKSCREW esophagus.

tx = Nitrates, CCB

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6
Q

pharyngoesophageal diverticulum

A

zenker’s diverticulum

dysphagia, sense of lump in throat, regurgitation of foods, cough, halitosis

dx = barium esophagram

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7
Q

retrosternal CP worse with deep breathing and swallowing, hematemesis

A

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

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8
Q

Physical exam findings of boerhaave syndrome

A

crepitus on chest auscultation 2/2 pneumomediastinum

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9
Q

esophageal webs

A

thin membranes in mid-upper esophagus.

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10
Q

Plummer-vinson syndrome

A

dysphagia + esophageal webs + iron deficiency anemia

  • Atrophic glossitis, angular cheilitis, splenomegaly. MC in white women, 30-60y.
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11
Q

esophageal rings

A

Schatzki ring - lower esophageal webs/constrictions

MC associated with sliding hiatal hernia* (type 1).

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12
Q

Esophageal webs/rings presentation, dx, tx

A

sxs = dysphagia especially to solids

dx = Barium Swallow

tx =

  • if no reflux = endoscopic dilation
  • if + reflux = antireflux surgery
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13
Q

protrusion of the upper portion of the stomach into the chest cavity 2/2 a diaphragm tear or weakness

A

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
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14
Q

MCC of esophageal cancer worldwide*

A

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.
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15
Q

MC type of esophageal cancer in the US**

A

Adenocarcinoma

    • younger patients, obese, whites.
    • MC in lower 1/3
    • usually complication of GERD. leads to Barretts esophagus.
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16
Q
  • dysphagia of solid foods – progressing to dysphagia of liquids; odynopahagia
  • weight loss, CP, hoarseness
A

esophageal cancer

dx = EGD with biopsy.

tx =
- esophageal resection, XT, CTX (pends on stage)

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17
Q

MCC of upper GIB

A

peptic ulcer dz

H. pylori MCC
NSAIDs 2nd MCC

dyspepsia, epigastric pain - worse at night.

Dx: EGD with biopsy

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18
Q

PUD treatment if H. pylori +

A

CAP

Clarithromycin + Amoxicillin + PPI

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19
Q

Dyspepsia, Weight loss, Early satiety, Iron deficiency anemia

A

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

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20
Q

your patient develops jaundice during times of stress, ETOH, or illness (transient jaundice)

A

Gilbert’s syndrome

hereditary unconjugated (indirect) hyperbilirubinemia.

dx: Increased isolated indirect bilirubin with NORMAL LFTs.

no treatment necessary

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21
Q

ALT > AST

A

usually present with viral, toxic, or inflammatory liver disease.

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22
Q

AST and ALT > 1000

A

usually ACUTE viral hepatitis (A and B, rarely C)

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23
Q

chronic viral hepatitis (B/C/D) ALT and AST levels

A

mildly elevated ALT and AST (usually <400)

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24
Q

term for gallstones in the gallbladder, NO inflammation

A

cholelithiasis

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25
Q

CHOLELITHIASIS

  • risk factors
  • sxs
  • dx
  • tx
  • complications (3)
A
  • 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
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26
Q

choledocholithiasis

A

gallstones in CBD

secondary MCC (stones from gallbladder get stuck in CBD)

major concerns: PANCREATITIS and CHOLANGITIS

dx:
- transabdominal ultrasound
- ERCP*** diagnostic and therapeutic

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27
Q

patient with FEVER/CHILLS, RUQ PAIN, JAUNDICE

A

Charcot’s triad = acute cholangitis = biliary infection 2/2 obstruction

alk phos + bilirubin levels > ALT/AST

dx/tx = ERCP and antibiotics (Unasyn, Pip/tazo)

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28
Q

Reynold’s pentad

A

Charcot’s triad + AMS + Shock

seen in acute cholangitis

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29
Q

MC bacteria seen in both Cholangitis and Cholecystitis

A

E.coli > Klebsiella > Enterococci

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30
Q

Biliary colic with RUQ pain

  • pain lasting continuously
  • pain lasting 30 min to few hours
  • pain associated with jaundice?
A

A = continuous pain = think cholecystitis

B = episodic pain = think cholelithiasis

C = if jaundice present = think choledocholithiasis

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31
Q

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?

A

Acute cholecystitis

  • order Ultrasound 1st.
  • labs: Leukocytosis with left shift.
  • GOLD STANDARD = HIDA = + test if non visualization of the gallbladder.
32
Q

Acute Cholecystitis treatment

A

NPO, IV fluids, Antibiotics (Rocephin + Flagyl) – continue until Cholecystectomy (w/in 72 hours)

33
Q

chronic cholecystitis

A
  • associated with GALLSTONES - may be 2/2 repeated bouts of acute/subacute cholecystitis.
  • STRAWBERRY GB ==> PORCELAIN GB (premalignant condition)
34
Q

Patient presents complaining of Malaise, Weight loss, Jaundice, Abdominal pain and Hepatosplenomegaly.

A

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.

35
Q

how do we screen for HCC?

A

Ultrasound + Alpha-Fetoprotein

36
Q

Fatigue is 1st symptom, Itching, RUQ discomfort, Hepatomegaly, Jaundice

A

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

37
Q

MC in men 20-40y with Inflammatory bowel disease (UC*)

  • present with Jaundice, Itching, Hepatomegaly, Splenomegaly
  • labs show High Alk Phos and + P-ANCA
A

Primary Sclerosis Cholangitis (PSC)

ERCP - gold standard diagnostic test

Tx:
- Stricture dilation to relieve symptoms
- Liver Transplant DEFINITIVE tx
MEDS NOT BENEFICIAL

38
Q

Gallstones, Alcohol, Scorpion bites, Mumps (kids) - all cause what?

A

Acute Pancreatitis

39
Q

Constant, boring epigastric pain - radiates to back, better by leaning forward or sit in fetal position.
worsened by supine, eating, walking.

A

Acute Pancreatitis

Dx: Labs, Abdominal CT

Tx:
- NPO + IV fluids + Analgesia

ABX NOT routinely used*.

40
Q

Classic Triad:

  • Calcifications
  • Steatorrhea
  • Diabetes Mellitus
A

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.

41
Q

Abdominal pain radiating to back, PAINLESS jaundice, weight loss, itching, migratory phlebitis (Trosseau’s sign)

A

Pancreatic carcinoma

  • pts usually w/ METS at time of presentation. MC mets to regional LN and Liver
42
Q

Pancreatic Carcinoma

  • Risk factors
  • Histology
A

RF: SMOKING, >60y, chronic pancreatitis, African Americans, etc.

Histology: Adenocarcinoma** - DUCTAL MC
- majority occur in HEAD of pancreas.

43
Q

Courvoisier’s sign

A

palpable, NONtender, distended gallbladder associated with jaundice (CBD obstruction).
–Associated with PANCREATIC CANCER**

44
Q

Pancreatic Cancer diagnosis (3)

A

CT initial test
ERCP most sensitive
Labs: increased tumor markers: CEA, CA 19-9

45
Q

Pancreatic Cancer treatment

A
  1. WHIPPLE - if confined to head or duodenal; radical pancreaticoduodenal resection
  2. Tail - distal resection
  3. Advanced or inoperative = ERCP with stent placement as palliative tx for intractable itching.
46
Q

Cramping Abdominal Pain + Distention + Vomiting + Obstipation

A

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
47
Q

twisting of any part of the bowel at its mesenteric attachment site.

A

Volvulus
- MC sigmoid colon and cecum

Sxs: obstructive symptoms = abd pain, distention, N/V, Fever, tachycardia.

Tx: Endoscopic decompression (1st), sx (2nd)

48
Q

MCC of acute lower GIB

A

diverticulosis

  • MCC to low fiber diet, constipation, obesity.
  • usually Asymptomatic (besides the bleeding)
  • Dx with CT scan
  • Tx with fiber supplements
49
Q

Anorexia and periumbilical/epigastric pain –> followed by RLQ pain, N/V

A

Appendicitis
- PE: rebound Tenderness, rigidity, guarding.
Rovsing, Obturator, Psoas, McBurney’s point

DX - CT, Leukocytosis
Tx - Appendectomy

50
Q

chronic dull abdominal pain worse after meals + anorexia

A

chronic mesenteric ischemia (atherosclerosis of GI tract)

  • Angiogram confirms dx.
  • colonoscopy - muscle atrophy with loss of villi
  • tx = bowel rest. surgical revascularization
51
Q

severe abdominal pain out of proportion to exam finings. poorly localized abdominal pain.

A

acute mesenteric ischemia

  • MC 2/2 occlusion (embolus, thrombus)
  • Angiogram definitive dx.
  • tx = surgical revascularization. resect if not salvageable.
52
Q

LLQ pain with Tenderness, Bloody Diarrhea

A

Ischemic colitis

  • Dx = Colonoscopy
  • Tx = restore perfusion
53
Q

non obstructive, extreme colon dilation > 6 cm + signs of systemic toxicity

A

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.
54
Q

MCC of Large Bowel Obstruction in adults

A

Colorectal Cancer (CRC)

55
Q

Iron Deficiency Anemia + Rectal Bleeding + Abdominal Pain + Change in Bowel Habits

A

Colorectal Cancer

Dx:

  1. Colonoscopy with Biopsy**.
  2. Barium enema - apple core lesion classic.
  3. Increased CEA levels.
  4. labs = iron deficiency anemia

tx:
stage 1-3 = surgical resection
stage 3 and mets = CTX

56
Q

Colorectal Cancer MC site of metastatic spread

A

Liver

57
Q

patient stable with chronic hepatitis who experiences sudden deterioration and worsening of symptoms

A

HCC

58
Q
  • 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
A

INDIRECT inguinal hernia

59
Q

protrusion of abdominal cavity contents thru femoral canal below inguinal ligament

A

femoral hernia

  • MC seen in women
  • surgical repair
60
Q

Incisional (Ventral) Hernia

A

MC with vertical incisions and in obese patients

61
Q

Intermittent rectal bleeding*, hematochezia (BRB per rectum)

A

internal hemorrhoids

- proximal to dentate line

62
Q

management of diarrhea (4)

A
  1. IV fluids**
  2. Diet - bland foods = “BRAT” diet - Bananas, Rice, Applesauce, Toast
  3. Anti-motility agents (only for noninvasive diarrhea)
  4. Antiemetics
63
Q

MCC of gastroenteritis in adults

A

Norovirus

- outbreaks on cruises, hospitals, restaurants

64
Q

Vomiting, watery diarrhea, voluminous (involves small intestine), NO fecal WBCs or blood

A

noninvasive (enterotoxin) infectious diarrhea

65
Q

copious watery diarrhea, “rice water stools”

A

vibrio cholera and parahemolyticus

66
Q

MCC of traveler’s diarrhea

A

E. coli

67
Q

MC antibiotic associated with C. diff

A

clindamycin

68
Q

treatment for C. diff

A 
mild = flagyl 1st or PO vancomycin (2nd) 
severe = PO vancomycin 1st line
69
Q

high fever, + blood and fecal leukocytosis, not as voluminous (large intestine), mucus

A

Invasive infectious diarrhea

70
Q

MCC of bacterial enteritis in US

A

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
71
Q

lower abdominal pain with explosive watery diarrhea that is mucoid and bloody

A

Shigella

  • stool cultures = WBC/RBC. labs may show WBC > 50,000.
  • sigmoidoscopy = punctate areas of ulceration

tx = fluids. if severe = Bactrim

72
Q

population of increased risk of osteomyelitis with salmonella infection

A

sickle cell patients

73
Q

predominant symptoms of non-invasive diarrheas

A

vomiting*

74
Q

Backpackers diarrhea

- Frothy, greasy, foul diarrhea

A

Giardia Lamblia

- tx = Fluids + Flagyl

75
Q

treatment modalities for constipation (4)

A
  1. fiber
  2. bulk forming laxatives
  3. osmotic laxatives
  4. stimulant laxatives

Surgery (7 decks)

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