GI part 2 Flashcards
What are the fat soluble vitamins?
ADEK
Deficiency in Vitamin A?
night blind
bitot’s spot
keratomalacia
(dry skin)
Sources of Vitamin A?
liver, fish oil, fortified milk, eggs
those at risk for vitamin A deficiency?
elderly, alcoholics, liver disease
Toxicity: skin disorder, hair loss, teratogenicity
Deficiency in Vitamin D?
rickets
osteomalacia
Sources of vitamin D?
fortified milk
Toxicity of vitamin D?
hypercalcmeia
kidney stone
soft-tissue deposits
At risk for vitamin D deficiency?
elderly
low sun exposure
Deficiency of Vitamin E?
hemolytic anemia
degenerative nerve changes = neuropathy, ataxia
Sources of vitamin E?
plant oils, wheat gem, asparagus, peanuts, margarine
Deficiency of vitamin K?
bleeding (increased PT/INR)
Why is vitamin K needed?
makes clotting factors: 2,7,9,10
Sources of vitamin K?
liver, green leafy veggies, broccoli, peas, green beans
Beriberi
decreased thiamine (B1)
CHF, peripheral neuropathy, Wernicke’s
decreased thiamine (B1)
glossitis, seborrheic dermatitis
decreased riboflavin (B2)
pellagra, diarrhea, psychosis, flushing
decreased niacin
AKA The 4 “Ds”
decreased niacin
-diarrhea, dementia, dermatitis, death
anemia, weakness, insomnia, HA, seizure, sore tongue
decreased pyridoxine (B6)
decreased B12?
- megaloblastic anemia
- poor nerve function
decreased folate
-megaloblastic anemia
-sore tongue
-diarrhea
-mental disorder
(at risk = pregnancy and alcohol)
SCURVY, fatigue, petechiae, bleeding gums, impaired wound healing
perifollicular petechiae
decreased vitamin C
Define constipation?
<2 BM per week
-decrease in stool volume and increase in stool firmness
if patient >50 with new onset constipation… what do you do?
evaluate for colon cancer!
Treatment of constipation?
lifestyle/diet modification = increase fiber and fluid intake
-regular exercise
List some causes of constipation?
endocrine: hypothyroid, DM, hypercalcemia, renal insufficiency, panhypopituitary
Neuro: MS, parkinson, hirschsprung
organic: mass, bowel ischemia
rectal: proctitis, anal fissure, ibs
Meds: opiates, anticholinergic, TCA
smooth muscle: scleroderma, amyloidosis
Drug treatment for constipation?
Osmotic laxatives = lactulose, sorbitol
emollient laxatives = magnesium, hydroxide
stimulant laxatives = docusate sodium, mineral oil
Diverticulosis vs Diverticulitis?
diverticulosis = outputting of mucosa of colon (painless rectal bleeding)
diverticulitis = inflammation of diverticula caused by obstructing matter (LLQ pain, fever, high WBC)
Diagnosis of diverticular disease?
endoscopy
treatment of diverticular disease?
NPO if inpatient; clear liquids outpatient
IV/PO ABX (quinolone with metronidazole; amoxicillin-clavulanate; bactrim + metronidazole)
surgery (peritonitis, large abscess, fistula, obstruction)
Prevent diverticular disease?
high fiber diet
avoid nuts, seeds, popcorn
What is the rule of 2s?
meckel’s diverticulum:
2% of population 2 feet of proximal to ileocecal valve 2 inches long 2 years old 2:1 Male 2 tissues : gastric and pancreatic
IBD examples? (2)
Crohn
Ulcerative Colitis
this IBD:
inflammation of colon, mucosa/submucosa
Bloody diarrhea
continuous
Ulcerative Colitis
Characteristics of Ulcerative Colitis? (7)
sudden onset continuous start at colon bloody diarrhea, tenesmus complication: primary sclerosing cholangitis, toxic megacolon, malignancy HLA-B27 smoking is protective
Treatment of Ulcerative Colitis?
Supportive care: antidiarrheals
oral or topical corticosteroids
aminosalicylates: sulfasalazine
immunomodulator: azathioprine
curative: colectomy
What tests do you avoid when diagnosing ulcerative colitis?
colonoscopy and barium enema = risk of perforation and toxic megacolon
this IBD:
mucosa to serosa (transmural)
cobblestone/skip lesions
terminal ileum
diarrhea and cramps
Crohn disease
complications of crohn disease?
fistula, abscess, aphthous ulcer, renal stone, colon cancer
Treatment of Crohn’s Disease?
acute attack = oral corticosteroid (prednisone) +/- aminosalicylates (sulfasalazine)
corticosteroids
maintenance = mesalamine
surgery = not curative
Define irritable bowel syndrome (IBS)?
functional disorder without a known pathology (diagnosis of exclusion)
- altered motility
- hypersensitivity to intestinal distention
- psychological distress
What are the 4 types of IBS?
- IBS with constipation
- IBS with diarrhea
- mixed IBS
- unsubtyped IBS
What is the clinical manifestation for IBS?
chronic post-prandial abdominal pain/cramp
-bloating
n/v
pain relieved by defecation
BM are irregular (constipation and diarrhea)
What is the ROME criteria?
IBS
3 months:
abdominal pain relieved by defecation and associated with change in frequency/consistency of stool
- disturbed defecation based on stool frequency and form
- altered stool passage
- passage of mucus
What do you need to rule out for IBS?
lactose intolerance cholecystitis chronic pancreatitis intestinal obstruction chronic peritonitis celiac disease carcinoma of pancreas or stomach
Treatment for IBS?
- avoid triggers
- high fiber diet, decrease fat
- bulking agents (psyllium hydrophilic mucilloid)
antispasmodics, antidiarrheal, prokinetics, antidepressants
What is ischemic bowel disease?
acute or chronic
mesenteric ischemia
sudden onset of severe abdominal pain out of proportion to exam
abdominal xray: thumb-printing sign
acute mesenteric ischemia
associated with fib, MI, CHF
gold standard for acute mesenteric ischemia?
mesenteric angiogram
all should have a duplex US of mesenteric arteries
what is the most common artery in acute mesenteric ischemia?
superior mesenteric artery
Treatment for acute mesenteric ischemia?
- pressure support: dobutamine
- vasodilation (until in OR) - papaverine
- surgery: laparatomy to restore blood flow and resect ischemic bowel
abdominal pain that occurs 10-30 minutes after eating, relieved by squatting or laying down
pt is a smoker, has PVC or CAD
chronic mesenteric ischemia
Treatment for chronic mesenteric ischemia?
- surgical resection
- PTA +/- stent
What is malabsorption?
due to impaired transport across the bowel mucosa from mucosal dysfunction, and impaired removal of nutrients
(problem with digestion, absorption, impaired blood flow, and lymph flow)
Steatorrhea, abdominal distention, increased flats, vitamin/mineral deficiency?
malabsorption
Test for malabsorption?
72 hour fecal fat test d-xylose test (maldigestion) vitamin b12 (pernicious anemia) calcium deficiency albumin deficiency bacterial growth biopsy = definitive
Treatment for malabsorption (4)?
lactose deficiency = lactose-free diet
celiac disease = gluten free
pancreatic insufficiency = pancreatic enzyme replacement
bacterial infection = ABX
what disease is characterized by inflammation of the small bowel secondary to ingestion of gluten containing foods (wheat, rye, barley) and leads to malabsorption
Celiac Sprue
Diagnostic studies for Celiac Sprue (4)?
- IgA antiendomysial
- antitissue transglutaminase antibodies
- antigliadin
- biopsy = confirm (villi atrophy)
How is lactose digested?
lactose is digested by lactase (which is produced in small intestine)
after ingesting dairy - abdominal pain, bloating, flatulence, diarrhea
lactase deficiency
Diagnose lactase deficiency?
lactose breath hydrogen test
-endoscopy
Treatment of lactase deficiency/intolerance?
- avoid dairy
- enzyme substitue
- maintenance of calcium and vitamin D intake
What are some general types of diarrhea?
- infectious - bacterial
- non-inflammatory - secretory/ostmotic/malabsorption
- inflammatory - exudative
what are clinical features of secretory diarrhea?
(large volume without inflammation)
- indicated pancreatic insufficiency
- ingestion of preformed bacterial toxins
- laxative use
What are clinical features of inflammatory diarrhea?
(bloody diarrhea with fever, dysentery)
-indicates invasive organism or inflammatory bowel disease
Anti-biotic associated diarrhea?
Clostridium difficile colitis, most severe cases causes the classic pseudomembranous colitis
should you treat diarrhea from e.coli with antibiotics?
NO - there is an increased risk of hemolytic-uremic syndrome
suspect in pt with bloody diarrhea, abdominal pain/tenderness, but no fever
should you treat diarrhea from e.coli with antibiotics?
NO - there is an increased risk of hemolytic-uremic syndrome
suspect in pt with bloody diarrhea, abdominal pain/tenderness, but no fever
What could be the cause of a diarrhea + systemic illness, deli meats, meningitis in neonates and immunocompromised?
listeria
Treatment for diarrhea?
- supportive care
- oral/IV rehydration
- replace electrolytes
Which bacteria should you treat with antibiotics (for diarrhea)?
shigella, campylobactera,
severe c diff = metronidazole, vancomyicn, fidaxomicin
What is the most common cause of secretory diarrhea?
cholera
What should you treat Giardia with? How would you get this?
from mountain stream waters, swimming pools, traveling
tx. metronidazole
Examples of causes of traveler diarrhea?
e coli
campylobacter
shigella
salmonella
have tenesmus and cramping
Patient presents with watery diarrhea and just had a course of antibiotics… what do you do?
- stool culture = + cdiff, fecal leukocytes
- supportive care
- rehydration and electrolyte replacement
- empiric ABX = metronidazole, PO vanco (2nd line)
- avoid anti-motility drugs
most common type of colon cancer?
adenocarcinoma
patient presents with recent weight loss, rectal bleeding, pain, change in bowel habits…what do you do? suspect?
colon cancer
- colonoscopy with biopsy
- barium study = apple core lesion
When should you start screening for colon cancer?
age 50
or 10 years before the earliest diagnosis of colon cancer in 1st degree relative
What is a marker you can test to monitor colon cancer, but it not used to detect?
carcinoembryonic antigen (CEA)
What is a marker you can test to monitor colon cancer, but it not used to detect?
carcinoembryonic antigen (CEA)
patient presents with vomiting, severe abdominal distention, lack of bowel sounds…what do you do? suspect?
suspect obstruction
KUB = dilated loops of bowel with air fluid levels, no gas in colon
bowel decompression with NGT
What are small bowel obstructions due to?
adhesions or hernia
other = neoplasm, IBD, volvulus
What are large bowel obstructions due to?
neoplasm
other = stricter, hernia, volvulus, intussusception, fecal impaction
What can complete strangulation of bowel lead to?
infarction
necrosis
peritonitis
death
Most common cause of obstruction in adults? kids?
adult = adhesions kid = intussusception
There is intestinal pseudo obstruction without evidence of mechanical cause?
ogilvie syndrome
urgent decompression
Where is the most common location for large bowel obstruction?
sigmoid
Where is the most common location for large bowel obstruction?
sigmoid
Patient presents with fever, severe cramps, abdominal distention with peritonitis, shock?
toxic megacolon = life threatening!
What is a complication of UC, Crohn, cdiff?
toxic megacolon
What is the criteria for a clinical diagnosis of toxic megacolon?
xray = thumbprinting due to presence of submucosal edema
+ (at least 3)
fever, HR >120, leukocytosisi >10.5; anemia
+
dehydration, altered sensorium, electrolyte disturbance, hypotension
patient presents with a tender palpable mass near the gluteal cleft coccyx area?
pilonidal cyst/abscess
- surgical drainage
- often sinus tract developed
What is a complication of surgical drainage of a pilonidal cyst?
fistula
What is a complication of surgical drainage of a pilonidal cyst?
fistula
bright red blood per rectum, pruritus, rectal discomfort?
hemorrhoid (varies of hemorrhoidal plexus)
Internal vs external hemorrhoid?
Internal: no pain, bright red blood per rectum
external: pain, no bleeding
hemorrhoid confined to anal canal and may bleed with defecation?
stage 1 hemorrhoid
hemorrhoid protrude form anal opening but reduce spontaneously. bleeding and mucoid discharge may occur
stage 2 hemorrhoid
bleeding and prolapse that require manual reduction after bowel movement. pain and discomfort
stage 3 hemorrhoid
surgery
chronically protruding and risk strangulation, bleeding with incarceration?
stage 4 hemorrhoids
surgery
Treatment for hemorrhoids?
diet = fiber and fluids
stool softeners
sitz bath
Treatment for hemorrhoids?
diet = fiber and fluids
stool softeners
sitz bath
cause of perianal cyst (4)?
- poor hygiene
- dermoid (hair) - + acid-schiff stain
- teratoma (can be cancer) - painless
- epidermoid - superficial yellow/white multiple nodules
crampy abdominal pain, distention, n/v, obstipation, abdominal tympany
xray = colonic distention and twisting of sigmoid or cecal area?
volvulus
decompression = to avoid ischemic injury (gangrene, peritonitis, sepsis)
kid with severe colicky pain, stool mucous and currant jelly.
abdominal exam = sausage like mass
abdominal xray = crescent sign, bull’s eye or coiled spring
suspect? what do you do?
suspect intussusception
barium or air enema = diagnostic and therapeutic
hospitalized
adults = may require surgery
kid with severe colicky pain, stool mucous and currant jelly.
abdominal exam = sausage like mass
abdominal xray = crescent sign, bull’s eye or coiled spring
suspect? what do you do?
suspect intussusception
barium or air enema = diagnostic and therapeutic
hospitalized
adults = may require surgery
list some extra-intestinal manifestations of crohn’s
arthritis, cholelithiasis, clubbing, Vitamin B12 deficiency, uveitits, erythema nodosum
why are bilirubin gallstones common in Cron’s disease
malabsorption of bile salts from the terminal ileum.
when can you see a elevated serum alpha-fetoprotein
males with a germ cell tumor the testis
hepatocellular carcinoma
a pregnent women who fetus has a neural tube defect
first line treatment for hematemesis from esophageal varices
IV administration of octreotide
drug class used in the prevention of variceal bleeding?
beta blockers
