GI Precision & Pearls #1 Flashcards
GERD is due to ___________. Name some typical symptoms of this condition.
What diagnostics are done for GERD. There are three. What is shown on the first? What is the GOLD standard? What is the first line if persistent or complicated?
Transient relaxation of the LES –> esophageal mucosal injury
Symptoms: Pyrosis, acid taste, etc.
Diagnostics: Esophageal manometry (shows decreased LES pressure); 24 hour ambulatory pH (GOLD STANDARD); Endoscopy (first line if complicated)
What are some atypical GERD symptoms?
Name some alarm symptoms of GERD.
Atypical: Hoarseness, wheezing, chest pain
Alarm: bleeding, dysphagia, odynophagia, weight loss
Treatment for GERD
-Lifestyle modifications: elevate head of bed, smoking cessation, avoid laying down after eating, low alcohol intake, weight loss
-Antacids or H2 blockers -tidines (Cimetidine, Ranitidine, Famotidine)
-PPI if > 2 episodes/week
-Nissen fundoplication if refractory
What is gastritis? Name the MC etiology, as well as other etiologies.
Symptoms of this condition
Superficial inflammation of mucosa without injury. Imbalance between aggressive and protective factors.
MC etiology: H. Pylori.
Others: NSAIDs, Aspirin, Stress, Etoh
Symptoms: Most asymptomatic, dyspepsia, n/v
What diagnostics can be done for gastritis?
How do you manage this condition?
Upper endoscopy with biopsy (GOLD)
H. Pylori testing needed as well
Treatment: like PUD (H. Pylori eradication, PPI, H2 blockers)
What are some things in a patient’s history that may lead you to believe they have erosive gastritis?
History of H. Pylori, NSAIDs/Aspirin, acute stress, heavy alcohol use, reflux, radiation, trauma, corrosives
Chronic gastritis, also known as autoimmune metaplastic atrophic gastritis, increases the risk for ______.
This usually occurs in which parts of the stomach?
What is the pathophysiology of this condition?
Gastric adenocarcinoma
Fundus and body
Auto-antibodies against intrinsic factor and parietal cells. Lack of intrinsic factor –> B12 deficiency (pernicious anemia).
With peptic ulcer disease (PUD), which type is usually benign and which type is associated with gastric adenocarcinoma?
What is the pathophysiology of each of the two types?
Duodenal (MC): Usually benign
Gastric: Associated with gastric adenocarcinoma
Patho: Imbalance between (increased aggressive factors - duodenal ulcers) and (decreased protective factors - gastric ulcers)
With peptic ulcer disease (PUD), which type is usually benign and which type is associated with gastric adenocarcinoma?
What is the pathophysiology of each of the two types?
Duodenal (MC): Usually benign
Gastric: Associated with gastric adenocarcinoma
Patho: Imbalance between (increased aggressive factors - duodenal ulcers) and (decreased protective factors - gastric ulcers)
MCC of PUD?
Name symptoms of both types of ulcers.
Because PUD is the MCC of an upper GI bleed, what are symptoms of a bleeding ulcer? How about a perforated ulcer?
H. Pylori
Dyspepsia
-Duodenal ulcer: pain relieved with food, younger patients (30-55), worse before meals
-Gastric ulcer: pain worse with food, older patients (55-70)
Bleeding: hematemesis, hematochezia
Perforated: sudden onset pain, may radiate to shoulder, rebound tenderness, rigidity, guarding, etc.
Upper endoscopy with biopsy is the diagnostic of choice for PUD; however, what else should be done (there are four ways to test for it).
H. Pylori Testing
-Upper endoscopy with biopsy is GOLD standard
-Urea Breath Test
-Stool Antigen (confirms eradication)
-Serologic antibodies (only to confirm)
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient is H. Pylori negative, what treatment should you do?
PPI, H2 blocker, Misoprostol
-Smoking, ETOH, and NSAIDs cessation. Prophylaxis with Misoprostol or PPI in patients with a history of an ulcer
What is the order of treatment (pharm therapy) in which you should give patients if they have PUD?
-OTC antacids –> H2 Blockers –> PPI’s if H. Pylori negative
If the PUD is refractory to pharm therapy, what is the last line treatment?
Bilroth II surgery
Proton Pump Inhibitors (PPI)’s, such as _____, _______, and ________, have a MOA of….
Omeprazole, Lansoprazole, Pantoprazole
Block H/K ATPase of parietal cell, decreasing acid secretion
What are some recommendations for taking PPI’s?
Adverse Effects?
Take 30 minutes before meals
-B12 deficiency, C. Diff, Hip fractures
Name some H2 Receptor blockers.
When should you take this medication?
Cimetidine, Ranitidine, Famotidine
At night
MC type of gastric carcinoma?
Adenocarcinoma
What are some risk factors for gastric carcinoma?
What are two things that apparently decrease the risk of this condition?
-H. Pylori (MC), Males, Obesity, Preserved foods, Smoking, NHL.
-Chronic NSAID and Aspirin use, eating fruits and veggies decreases risk
What are some symptoms of gastric carcinoma (think of the various specific findings).
-Weight loss, persistent abdominal pain, early satiety, dysphagia, melena
-Supraclavicular lymph node (Virchow Node)
-Umbilical LN (Sister Mary Joseph Nodule)
-Ovarian Mets (Krukenberg Tumor)
Diagnostic of choice for gastric carcinoma?
Upper endoscopy with biopsy
Treatment for gastric carcinoma
Endoscopic resection vs. gastrectomy
Pyloric stenosis occurs due to what?
When is this MC and what is one other risk factor for this?
Hypertrophy and hyperplasia of pyloric muscles that lead to an obstruction (preventing gastric emptying)
MC in the first 3-12 weeks of life. Erythromycin use in infancy.
Symptoms of pyloric stenosis
-Nonbilious, projectile vomiting
-Palpable pylorus (olive shaped mobile mass in right of epigastrium)
Initial diagnostic for pyloric stenosis?
What is seen on an Upper GI series (two findings)?
What labs are expected?
Abdominal US (initial)
String Sign: narrowed pylorus
RR track sign: excess mucosa
Hypokalemia, hypochloremia, metabolic alkalosis from vomiting
Treatment for pyloric stenosis?
Rehydration (IVF) and potassium replacement
Pyloromyotomy is definitive
What is Zollinger-Ellison Syndrome?
Where is it seen MC?
Gastrin secreting neuroendocrine tumor –> PUD
Duodenal wall
Symptoms of Zollinger-Ellison Syndrome
Severe, recurrent multiple or refractory ulcers and diarrhea
What diagnostics are done for ZES?
-Best screening test: elevated fasting gastrin levels
-Confirmatory: Positive secretin test (persistent elevations)
-Increased basal acid output; increased chromogranin A
-Somatostatin receptor scintigraphy helpful in localizing tumor
Treatment for Zollinger-Ellison Syndrome
-Resection of tumor and lifelong PPI use
Carcinoid tumors are well-differentiated neuroendocrine tumors of the GI tract that arise from transformation of enterochromaffin-like cells which secrete histamine. What are some symptoms of this tumor (carcinoid syndrome)?
-episodic diarrhea, flushing, tachycardia, and bronchoconstriction, hypotension
Even though a carcinoid tumor is MC an incidental finding on endoscopy, what other diagnostic can be done?
-24 hour urinary 5-hydroxyindolacetic acid - serotonin metabolism end product
MC etiology of appendicitis
-Lymphoid hyperplasia and fecalith
Symptoms of appendicitis
-Anorexia and epigastric pain
-RLQ pain with vomiting
-Rovsing Sign: RLQ pain with LLQ palpation
-Obturator Sign: RLQ pain with ER hip, knee flex
-Psoas Sign: RLQ pain with hip flexion
-mcBurney Point: 1/3 from navel and anterior superior iliac spine
Appendicitis is characterized by RLQ pain with vomiting. What nerve fibers are stimulated by this condition (inflamed appendix)?
T8-T10
What diagnostic should be done for appendicitis in adults?
Pregnant women/children?
CT in adults
MRI in pregnant and children
Treatment for appendicitis?
Appendectomy!
Peritonitis, the inflammation of peritoneum (lining of the stomach), is caused by numerous things. name a few of them.
What are some symptoms?
-Bacterial infection, untreated appendicitis, colonic perforation, trauma, ruptured diverticulum
Pain, distention, fever, n/v, constipation, tender abdomen, ill-appearing, decreased bowel sounds, rigidity
What diagnostic is both therapeutic and diagnostic for bacterial peritonitis?
Paracentesis: will see polymorphonuclear leukocyte (PMN) count of > 250 cells
What are some etiologies of constipation?
Hemorrhoids, impaction
Verapamil, opioids, Hirschsprung Disease
Management for fecal impaction
-Digital disimpaction followed by warm water enema with mineral oil
-Polyethylene Glycol
-Water soluble contrast enema
Pharm Treatments for constipation
-Fiber: Retains water/improves transit
-Bulk Forming Laxatives (Psyllium, Methylcellulose): absorbs water and increases fecal mass
-Osmotic Laxatives (Poly-Glycol, Lactulose, Sorbitol, Mag. Citrate): H20 retention in stool
-Stimulant Laxatives (Bisocodyl, Senna): Increased peristalsis –> diarrhea
-Linaclotide (Linzess): stimulates chloride and bicarb secretion
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
If the patient with PUD is H. Pylori positive, what two treatment regimens can be done?
Quad Therapy: Bismuth + Tetracycline + Metronidazole + PPI X 14 days
Triple Therapy: Clarithromycin + Amoxicillin + PPI X 10-14 days
–Metro if PCN allergy
With peptic ulcer disease (PUD), which type is usually benign and which type is associated with gastric adenocarcinoma?
What is the pathophysiology of each of the two types?
Duodenal (MC): Usually benign
Gastric: Associated with gastric adenocarcinoma
Patho: Imbalance between (increased aggressive factors - duodenal ulcers) and (decreased protective factors - gastric ulcers)
