GI part 1 Flashcards
What are the 2 main types of esophagitis?
Non-infectious (medications, eosinophilic)
Infectious (HSV, CMV, Candidiasis)
What medications can cause non-infectious esophagitis in Elderly patients?
*Bisphosphonates (alendronate) Tetracyclines NSAID KCl teenagers - doxycycline
Patients that have asthma or allergies have a higher possibility of having what type of esophagitis?
eosinophilic (check with biopsy)
Treatment for eosinophilic esophagitis?
diet modification (based on allergy screening), PPI, glucocorticoids, budesonide (topical steroids to reduce inflammation)
What are the 2 common viral etiologies of infectious esophagitis?
HSV
CMV
Fungal esophagitis?
Candidiasis
seen in immunocompromised patients - HIV, Cancer, Bone marrow transplant
What type of esophagitis has small shallow volcano like vesicles and treatment?
HSV
Acyclovir
What type of esophagitis is common in HIV patients and the ulcer is deeper and wide and treatment?
CMV
ganciclovir IV
What type of esophagitis presents with white mucosal plaque-like lesions with odynophagia (painful swallowing) and whats the treatment?
candidiasis
(stain on KOH will show yeast)
fluconazole or ketoconazole
What are the 8 types of dysphagia?
Achalasia Esophageal Spasm Scleroderma Neurologic Disease Strictures Schatzki Ring Cancer Esophageal Web
What dysphagia is sensitive to solids and liquids…..degeneration of Auerbach’s plexus…. bird/parrot beak on barium swallow?
Treatment?
achalasia
Tx: muscle relaxants, nifedipine (CCB), botox, myotomy
confirm by manometry
What dysphagia is sensitive to solids and liquids… cork screw on barium swallow?
Treatment?
Esophageal Spasm
Tx: muscle relaxants, nifedipine, botox, myotomy
What dysphagia is sensitive to solids and liquids… may manifest in GI tract due to decreased esophageal sphincter tone…
scleroderma
What dysphagia is sensitive to solids and liquids… suspect if pt had CVA or parkinson’s or alzheimers?
Neurologic disease
What dysphagia is sensitive to solids…and from the healing process of ulcerative esophagitis (scarring)?
Diagnosis and treatment?
Strictures
Get endoscopy with dilatation (treatment)
What dysphagia is sensitive to solids and is caused by a muscular band near LES?
Schatzki ring
What cancerous dysphagia is from a smoker and etoh?
squamous cell carcinoma
world wide most common
What cancerous dysphagia is from Barrett’s?
columnar or adenocarcinoma
US most common
What dysphagia is sensitive to solids and iron deficiency anemia and esophageal webs?
plummer-vinson
What are the most common symptoms for esophageal neoplasm… diagnosis and treatment?
progressive dysphagia to solids
wt loss
Endoscopy w/cytology
CT for staging
chemo + surgical resection
linear mucosal tear in the esophagus after forceful vomiting or retching… causing hematemesis?
Mallory Weiss Tear
How do you diagnose and treat a Mallory Weiss Tear?
endoscopy
Tx: self limiting
-can use endoscopy with injection and thermal coagulation if bleeding does not resolve on own.
What is caused by severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain… odynophagia (pain), fever, shock?
Boerhaave’s = surgical emergency!!
what esophageal disease is caused by dilations of veins due to portal hypertension caused by cirrhosis?
Esophageal Varices
Patient presents with painless upper GI bleed, and signs of liver disease (jaundice, palmar erythema)
Esophageal varices
Treatment of esophageal varices?
Prevention = BB (nadolol or propranolol)
Endoscopic hematostasis with injection sclerotherapy and variceal band ligation
Correct coagulopathy and transfuse PRN
Symptoms = heartburn, hoarseness, regurgitation of food, atypical chest pain, cough, Barrett’s esophagitis?
GERD
What is the diagnosis for GERD?
pH monitoring = gold standard
Decrease LES pressure
Biopsy for H. Pylori
Treatment for GERD
Lifestyle modifications - smoking, avoid large meals. laying down
Antacids
H2 blockers (cimetidine, famotidine) PPI (omeprazole) Nissen Fundoplication
What medications can worsen GERD?
antibiotics (tetracycline) bisphosphonates iron NSAID anticholinergic CCB narcotics Benzo
Dyspepsia and abdominal pain…H Pylori/NSAID…may present with GI bleed?
PUD (peptic ulcer disease)
What is diagnosis for PUD?
Upper GI endoscopy
Biopsy for H. pylori (breath test)
What disease is pain with food?
peptic ulcer
What disease is pain after food?
duodenal ulcer
Treatment for H. Pylori PUD?
PPI, amoxicillin, clarithromycin x 7-14 days
or
PPI, clarithromycin + metronidazole
or
PPI, bismuth subsalicylate + tetracycline, metronidazole
What are causes of gastritis?
NSAID
Alcohol
H. pylori
What is delayed gastric emptying?
Gastroparesis
What are the causes of gastroparesis?
Myopathic diseases of smooth muscles and neurological dysfunction
-diabetes
Treatment for gastroparesis? (Delayed gastric emptying)
Pro kinetic meds = cisapride and metoclopramide
What are the 4 gastric neoplasms?
Zollinger-Ellison syndrome
Gastric adenocarcinoma
Carcinoid tumor
Gastric lymphoma
What happens in Zollinger-Ellison syndrome?
A gastrin secreting tumor (gastrinoma) causes hypergastrinemia = which results in refractory PUD
What test do you order for suspecting Zollinger-Ellison syndrome?
Fasting gastrin >150
Secretin test
Endoscopy/CT/MRI localize tumor
Treatment for gastrinoma?
PPI
Surgical resection
What gastric cancer is associated with h pylori and cigarette smoking?
Gastric adenocarcinoma
Patient is >40, dyspepsia, wt loss, iron deficiency anemia, occult GI bleeding
Order endoscopy with cytology (anyone over 40 with dyspepsia), then CT to see extent of disease
Gastric adenocarcinoma
Treatment for gastric adenocarcinoma?
Curative or palliative resection
Chemo or radiation
What is Virchow node vs sister Mary Joseph nodule?
Virchow = left supra ventricular lymphadenopathy
Sister Mary Joseph = umbilical nodule
The risk of gastric lymphoma is greater by 6 fold if ______ is present?
H pylori
S/S of gastroparesis?
post prandial hypoglycemia despite eating, post prandial n/v
Which gastric cancer is the most common site of extra-nodal site of non-Hodgkin’s lymphoma?
gastric lymphoma, <2% of gastric cancers
Tx: same as adenocarcinoma = surgery
What are the primary sites of gastric cancer metastasis?
liver
peritoneum
lung
what are the 4 diseases of the biliary tract (gallbladder)?
Cholelithiasis
acute cholecystitis
cholangitis
cancer
What are some risk factors for cholelithiasis?
- increasing age, pregnancy, estrogen, obesity
- cirrhosis
- clofibrate
- ceftriaxone
- sickle cell disease, Crohn’s
- hereditary spherocytosis
Pain is episodic, after fatty meals in RUQ, may have some n/v, normal exam between episodes?
cholelithiasis
What are the 5 F’s for cholelithiasis?
female, fat, forty, fertile, flatulent
What is Murphy’s sign?
acute cholecystitis
-severe pain when breathing in and palpating RUQ
Patient has Murphy’s sign, n/v, fever, chills, anorexia, elevated WBC and LFT?
acute cholecystitis
First step in diagnosing acute cholecystitis?
Ultrasound = stones/sludge; wall thickening +/- pericholecystic fluid
Biliary Scan
Treatment for acute cholecystitis?
ERCP = biliary obstruction/choledocholithiasis
Surgery = ABX therapy (laparoscopy vs open cholecystectomy)
What is a HIDA scan?
nuclear scan of gall bladder
What is Fitz-Hugh-Curtis?
gonococcal infection causing perihepatitis that looks like cholecystitis
What is Charcot Triad?
Cholangitis
-fever, jaundice, RUQ pain
What is Reynold’s pentad?
Cholangitis
-fever, jaundice RUQ pain
+ confusion and hypotension (acute obstructive)
What is cholangitis?
obstruction of common bile duct with ascending infection (typically e coli)
How do you diagnose cholangitis?
RUQ US = biliary dilation or stones
leukocytosis with left shift, increases transaminase levels
ERCP = diagnosis and treatment
Treatment for cholangitis?
- ABX
- fluoroquinolone (cipro)
- cephalosporin
- ampicillin
- gentamicin + metronidazole - ERCP and remove stone
- cholecystectomy when acute syndrome is resolved
primary sclerosing cholangitis is associated with what?
cholangiocarcinoma
What do you think of with wt loss +/- non-painful RUQ palpable mass, jaundice and pruritus?
Gallbladder cancer
Diagnosis for gallbladder cancer?
porcelain gallbladder = radiopaque from calcification
Treatment for gallbladder cancer?
surgery
What is the only Viral Hepatitis that is DNA?
Hepatitis B
-all others are RNA
Which 2 viral hepatitis occur together?
Hepatitis B and D
Hepatitis + _____ = _____
hepatitis + pregnancy = fetal demise
What is the most common cause of Hepatitis?
VIRAL (A-E)
toxins (alcohol) = 2nd
Which 2 viral hepatitis are transmitted by fecal-oral contamination?
hepatitis A and E
What 3 viral hepatitis are transmitted parenterally or by mucous membrane contact?
hepatitis B,C,D
Which viral hepatitis is most likely to progress to serious liver disease?
hepatitis C
What is Hepatitis A screening assay and antibody?
Screening assay = anti-HAV IgM (indicates resolved hepatitis A = gold standard for diagnosis)
Antibody = ANTI-HAV
What is Hepatitis B screening assay and antibody?
Screen assay = HBsAg (ongoing infection), Anti-HBc Ig
Antibody = HBeAg (active infection), Anti-Hbe
What are symptoms of viral hepatitis?
fatigue, malaise, anorexia, nausea, tea-colored urine, vague abdominal discomfort….jaundice
elevated LFT (AST/ALT)
Hepatitis A
fecal-oral
anti-HAV IgM
hepatomegaly + jaundice
GIVE VACCINE
Hepatits B
DNA
Blood borne: needles, sex, mom to child, close contact
Flu symptoms + jaundice
can lead to cirrhosis and liver failure
associated with hep D
Hepatitis C
needles, blood contact
almost always converts to chronic (cirrhosis/liver failure)
Hepatitis D
clotting factors and drug users
only occurs with hep B
Hepatitis E
fecal oral
self limiting
high infant mortality rate in pregnant women
Causes of Toxic Hepatitis?
ALCOHOL
acetaminophen, carbon tetrachloride, isoniazid,halthane, phenytoin
What do you use for acetaminophen toxicity?
acetylcysteine
What does chronic hepatitis result in?
cirrhosis and end-stage liver disease
caused by hep B,C,D, autoimmune/drug induced, hemochromatosis and Wilson’s disease
Treatment for viral causes of chronic hepatitis?
pegylated interferon-alpha
Hep B = HBsAg
Hep C = Anti-HCV
Hep D = Anti-HDV
treatment for autoimmune causes of chronic hepatitis?
corticosteroids
screening test = ANA
treatment for drug-induced chronic hepatitis?
remove offending agent
screening test = get history
Wilson’s Disease?
Tx: copper chelation (penicillamine)
screening = decreased ceruloplasmin
Diagnosis = kayser-fleischer ring on corneal-scleral junction, altered mental status
Treatment for hemochromatosis for chronic hepatitis?
phlebotomy and deferoxamine chelation
3 Benign Liver Neoplasm?
- cavernous hemangioma
- hepatocellular adenoma
- infantile hemangio-endothelioma
What are 3 symptoms concerning for liver cancer?
- abdominal pain
- palpable abdominal mass (hepatomegaly/splenomegaly)
- weight loss
- jaundice
- hepatic bruit
- ascites
(have increased alpha-fetoprotein)
Liver Cancer Risk factors?
- Hep B/C
- cirrhosis
- diabetes
- NAFLD
- ETOH
- aflatoxin exposure
What is cirrhosis?
irreversible fibrosis and nodular regeneration throughout the liver
-liver is unable to regenerate due to large amounts of scar tissue
Common cause of cirrhosis?
ETOH
hep B/C
Describe exam for cirrhosis?
skin telangiectasias
spider hemangioma
ruddy face/nose
caput medusae (big belly veins)
What are cirrhosis complications?
- ascites
- variceal bleeding (itchy/brusing)
- gynecomastia
- obstructive jaundice
- spontaneous bacterial peritonitis (fever/ab pain = give ABX)
- hepatic encephalopathy) - give lactulose
- hepatocellular carcinoma (monitor AFP)
- hepatic vein thrombosis (Budd Chiaria = abdominal pain, ascites, hepatomegaly)
Treatment for Cirrhosis?
- avoid NSAID
- reduce salt intake
- spironolactone and furosemide
- paracentesis
- liver transplant
Primary Sclerosing Cholangitis?
symptoms: pruritus, steatorrhea, fat soluble vitamin deficiency (ADEK), metabolic bone disease
- associated with ulcerative colitis
- order contrast cholangiography = beaded bile duct
Primary Biliary Cirrhosis?
Symptoms = fatigue, pruritus, kon-jaundic skin hyperpigment “slate colored”, hepatomegaly
diagnosis = elevated alk phos, cholesterol, bilirubin
get liver biopsy (+ anti-mitochondrial antibodies)
Non-alcoholic Steatohepatitis?
fat builds up in the liver and causes scar tissue
risk factor = DM, metabolic syndrome, obesity, CAD, steroid use
US = infiltration suggestive, biopsy
Hereditary Hemochromatosis?
FHx of cirrhosis, skin hyper pigmentation, DM, pseudo gout
transferrin and ferritin = elevated
genetics = HFE mutation
TX = phlebotomy, deferoxamine chelation therapy
Most common cause of acute pancreatitis?
alcohol
gallstones
Other causes of acute pancreatitis?
- hyperlipidemia (hypertriglyceridemia),
- trauma (blunt)
- drugs (thiazides, furosemide, tetracycline, metronidazole, sulphasalazine, salicylate, valproic acid, estrogen, calcium)
- hypercalcemia,
- penetrating PUD
Patient presents with epigastric pain that radiates to the back, n/v, pain is relieved when patient leans forward (boring pain)
acute pancreatitis
Grey Turner Sign?
acute pancreatitis
-hemorrhagic pancreatitis may cause bleeding into the flanks
Cullen Sign?
hemorrhagic pancreatitis bleeding into umbilical area
What Criteria is used for acute pancreatitis?
RANSON CRITERIA
on admission = >55, elevated WBC, serum glucose, LDH, AST, lactate dehydrogenase
within 48 hours = drop in hematocrit, increased BUN, low calcium, low O2, base deficit increased
What would labs look like for acute pancreatitis?
increased = WBC, LFT, amylase/lipase, glucose. decreased = calcium
Xray findings for acute pancreatitis?
sentinel loop
US (may help to look for gallstones)
Acute Pancreatitis Treatment?
- NPO (bowel rest)
- maintain fluid balance
- ABX
- Pain control = opioid
- monitor for complications
Causes of CHRONIC pancreatitis?
alcohol abuse (90%)
other causes = cholelithiasis, PUD< hyperparathyroidism, hyperlipidemia
Classic triad for chronic pancreatitis?
- pancreatic calcification
- steatorrhea
- DM
Diagnosis for Chronic pancreatitis?
- amylase/lipase
- 72 hr fecal analysis
- cholecystokinin
- xray pancreatic calcification
- US
- ERCP = most sensitive
Treatment for Chronic Pancreatitis?
- same as acute
- low-fat diet
- treat underlying cause = which is usually alcohol
What and where is the most common for pancreatic cancer?
ductal adenocarcinoma
-at head of pancreas
Risk factors for pancreatic cancer?
smoking, age, obesity, chronic pancreatitis, FHx
painless jaundice, non-tender palpable gallbladder, epigastric abdominal pain, wt loss?
pancreatic cancer
What is Courvoisier’s sign?
non-tender palpable gallbladder (pancreatic cancer)
What is Virchow’s node?
left supraclavicular “sentinel node” (pancreatic and GI cancers)
Diagnosis for pancreatic cancer?
CT scan = look for metastases
CA 19-9
Treatment for pancreatic cancer?
Surgical = whipple procedure
chemo/radiation
poor prognosis
What is the most common cause of appendicitis?
fecalith
other causes = infection, collagen vascular disease,e inflammatory bowel disease
patient presents with periumbilical/epigastric pain with localization to RLQ, n/v, fever, chills, anorexia
leukocytosis
Appendicitis
Describe McBurney sign?
appendicitis
+pain upon palpation in RLQ
Describe Rovsing sign?
appendicitis
+RLQ pain upon palpation of LLQ
Describe Obturator sign?
appendicitis
+RLQ pain upon flexion and internal rotation of Right LE
Describe Iliopsoas sign?
appendicitis
RLQ pain with R hip extension
Test of choice for appendicitis?
CT
Treatment for appendicitis?
- empiric ABX = piperacillin-tazobactam
- SURGERY
What is a hernia?
protrusion of an organ or structure through the wall that normally contains it
What are several types of hernias? (5)
- umbilical
- diaphragmatic or hiatal
- incisional
- inguinal (indirect - most common)
- ventral
What are the two types of hiatal hernia and Tx?
-sliding: due to decreased resting pressures of LES
(reflux)
Tx: medical (antacids), surgical if no improvement (Nissen)
-paraesophageal: stomach herniates into thorax
(asymptomatic)
Tx: surgical repair
Describe ventral hernia?
occurs when there is a weakening in the anterior abdominal wall (incisional or umbilical)
Risk factors for ventral hernia?
previous abdominal surgery, obesity, age, wound infection, previous placement of drain
(notice abdominal mass at site of previous incision)
Treatment for ventral hernia?
observation - if no pain or sign of strangulation
-surgical - if strangulation or at risk of strangulation
Risk factors for umbilical hernia?
multiple pregnancy, obesity, intra-abdominal tumor
notice mass at umbilicus
Treatment for umbilical hernia?
- surgical to avoid incarceration and strangulation
- if <12 months = will resolve on own
Describe Indirect inguinal Hernia…
-congenital and present before age 1
-patent tunical vaginalis
-exam: hernia descends into scrotum and is not easily reducible
(tip of finger)
-pass through internal inguinal ring
Describe direct inguinal hernia…
- weakness of the transversalis fascia in Hesselbach’s triangle
- present when pt stands and disappears/reducible when supine
- side of finger
What is Hesselbach’s triangle?
medial border: rectus abdominus
Superior border: inferior epigastric artery
Lateral border: inguinal ligament
(direct inguinal hernia- pass through)
urine has mouse like odor.
mental retardation. seizures. movement disorders
phenylketonuria
(autosomal recessive disorder with decreased activity of phenylalanine hydroxylase - increases in brain and causes damage)
How do you diagnose phenylketonuria?
through infancy screening between 24 hours and 3 weeks
Treatment for phenylketonuria?
limit diet intake of phenylalanine
(breast milk is low in phenylalanine, special formulas)
may need strict control of protein intake for life
projectile vomiting, immediate postprandial, non-bilious
olive like mass
between 4-6 weeks old
pyloric stenosis
How do you diagnose pyloric stenosis?
US - double tract
Barium studies - string sign/shoulder sign (delayed emptying)
Treat pyloric stenosis?
surgery
xray: double bubble sign
first day of life - bilious vomiting w/o abdominal distension
duodenal atresia
often in down syndrome and polyhydramnios
treatment for duodenal atresia?
- decompression and IVF rehydration
- surgery
newborn with excessive saliva and choking/coughing with feeding attempts.
inability to pass nasogastric tube
esophageal atresia
(associated with tracheoesophageal fistula)
Tx: surgical
immediate respiratory distress in newborn because lung is compromised by abdominal contents?
diaphragmatic hernia
Treatment for diaphragmatic hernia?
immediate intubation and ventilation
Diagnosis for diaphragmatic hernia?
- bowel sounds in chest
- radiography - loops of bowel in involved hemithorax, heart and mediastinal structures displaced
Tx: surgery
congenital megacolon
hirschsprung disease
congenital absence of Meissner and Auerbach autonomic plexus
symptoms of hirschsprung disease and treatment?
constipation, obstipation, vomiting, Failure to thrive
Tx: surgical resection of affected bowel
