GI Precision & Pearls #3 Flashcards
What is the best diagnostic test for lactose intolerance?
Hydrogen breath test: hydrogen from bacteria fermenting undigested lactose
Hemorrhoids are engorgement of venous plexuses. Explain where an internal hemorrhoid occurs, symptoms, and the four grades of this type.
Proximal (above) dentate line, from superior hemorrhoid vein
Painless bleeding, rectal itching, non palpable
Grade I: does not prolapse
Grade II: prolapse with defecation, reduces spontaneously
Grade III: requires manual reduction
Grade IV: irreducible and may strangulate
On the other hand, explain where an external hemorrhoid occurs and symptoms of this type
Distal (below) dentate line, from inferior hemorrhoid vein
Perianal pain worse with defecation, but no bleeding. Tender, palpable mass
Although hemorrhoids can be visualized for diagnosis, what can also be done for internal hemorrhoids?
What is the treatment for each type of hemorrhoid?
Anoscopy for internal
Treatment:
–Conservative: high fiber diet, increase fluids, situ baths, topical rectal steroids (lidocaine)
–Rubber band ligation (MC), sclerotherapy, excision, coagulation
–Hemorrhoidectomy if failed or external
What are symptoms of an anal fissure?
-Severe rectal pain with bowel movement
-Refrain from defecation
-Bright red blood per rectum
-MC at posterior midline, skin tags
Treatment for an anal fissure
-Most resolve spontaneously, supportive treatment
-Topical nitroglycerin, Botox Injections, Sphincterotomy
An anorectal abscess is a bacterial infection at the dentate line. Where is the MC site and what is the MC bacteria that causes this?
What are some symptoms of an anorectal abscess?
Posterior rectal wall MC
Staph Aureus MC
-Swelling, pain worse with sitting, coughing, defecation
-Fluctuance on exam
On the other hand, a fistula is what?
What are some symptoms?
An open tract between 2 epithelium-lined areas
Anal discharge and pain
Treatment for an anorectal abscess and fistula are similar. What is it?
Incision and drainage and then WASH (Warm water, analgesics, sitz baths, high fiber diet)
Risk factors for rectal cancer (there is one that is a significant risk factor).
HPV infection (multiple partners, MSM, anal sex)
age >50, smoking, immunosuppression
A hernia is when tissue goes where it shouldn’t. A hiatal hernia is when the stomach goes through the esophageal hiatus. Name the two types of hiatal hernias and differentiate them.
-Sliding (Type I) MC: GEJ slides into mediastinum
-Paraesophageal (Type II): fundus of stomach goes through diaphragm. GEJ remains in anatomical position
What are symptoms of a hiatal hernia?
Postprandial fullness, GERD, n/v
Management for each type of hiatal hernia
-Type I: PPI + weight loss
-Type II: surgery if complications
An incisional hernia occurs due to what type of incision MC, and can it occur at any surgical site?
Vertical incisions
Yes, it can occur at any surgical site.
Femoral hernias, when the contents of the abdominal cavity go through femoral canal (below inguinal ligament), occur MC in who, why?
Women, due to wider pelvis
They are often strangulated or incarcerated
On the other hand, inguinal hernias, come in two types as well. Which type is MC? Explain this type and symptoms of it.
Indirect inguinal hernia (MC type)
-bowel protrusion at internal inguinal ring. Lateral to inferior epigastric artery.
Symptoms: scrotal swelling, fullness at the site
Why is an indirect inguinal hernia commonly congenital?
Due to persistent patent process vaginalis (increase in abdominal pressure causes the hernia to happen)
What are symptoms if the inguinal hernia is incarcerated? How about strangulated?
Incarcerated: painful, irreducible, n/v
Strangulated: ischemia with systemic toxicity, painful bowel movement
What diagnostic can be done for an inguinal hernia, other than a clinical exam?
Scrotal US
Explain a direct inguinal hernia (where it occurs for the most part).
-Bowel protrusion medial to inferior epigastric artery in Hesselbach’s Triangle
Name the components of Hesselbach’s Triangle
RIP
-Rectus Abdominus (Medial)
-Inferior Epigastric Vessels (Lateral)
-Poupart’s Ligament (Inferior)
If the inguinal hernia is strangulated what do you do?
This is an emergency! Surgical intervention immediately!
Acute cholecystitis is inflammation and infection of the gallbladder due to…..
What is the MCC?
Symptoms of acute cholecystitis include… (there are two specific findings with names)
Obstruction of cystic duct by gallstones
E.Coli
-RUQ or epigastric pain worse with fatty foods or large meals
-N/v, guarding, anorexia
-Fever, enlarged/palpable gallbladder
-Boas Sign: referred right shoulder pain
-Murphy Sign: RUQ pain with inspiration
Why does Boas Sign occur in cholecystitis?
Phrenic Nerve irritation
Initial diagnostic done for cholecystitis
What do labs show?
Most accurate diagnostic for cholecystitis
-US
-Leukocytosis (high WBC), High bilirubin, high Alk Phos
-HIDA scan/cholescintigraphy
What is the treatment for acute cholecystitis?
-NPO, IVF, ABX (Ceftriaxone + Metronidazole) THEN cholecystectomy within 72 hours
Chronic cholecystitis is fibrosis and thickening of the gallbladder due to chronic inflammatory cell infiltration. This almost always occurs due to….
What is the treatment?
Gallstones
Laparoscopic cholecystectomy
What is acute acalculous cholecystitis?
What are some risk factors (who should you expect to get this?)
Inflammation not due to gallstones. Gallbladder stasis and ischemia –> inflammation
Current hospitalization, critically ill. Look for a very sick person (that is likely who will have it on the test)
On US, the diagnostic done for the gallbladder, what is seen with acute acalculous cholecystitis?
Distended gallbladder without calcifications
Treatment for acute acalculous cholecystitis?
Supportive: IVF, bowel rest, pain control
What is cholelithiasis?
What is the MC type?
Name the risk factors for this condition (think F).
Gallstones in biliary tract without inflammation
Cholesterol is the MC type
-Female, forty, fat, fair, fertile (estrogen, OCPs)
-Native American, IBD, high triglycerides
Even though a patient with cholelithiasis can be asymptomatic, what symptoms CAN they have?
What diagnostic should be done?
-Biliary colic: episodic RUQ pain lasting 30 minutes - hours
-N/v worse with fatty foods
US is the diagnostic done for gallbladder
Treatment for cholelithiasis
Observation if asymptomatic
Ursodeoxycholic acid to dissolve the stone or cholecystectomy
On the other hand, what is choledocolithiasis?
What are the symptoms of THIS condition?
Gallstones in the common bile duct –> cholestasis
Prolonged biliary colic, RUQ pain, jaundice
What diagnostics are done for choledocolithiasis? One of them is therapeutic and diagnostic (is the treatment for this problem).
US (initial)
Labs: high Alk Phos + GGT (cholestasis causes this)
ERCP to remove stone (diagnostic and therapeutic)
What is acute ascending cholangitis?
What is the MCC?
In other words, what turns into this?
Biliary tract infection secondary to obstruction of common bile duct from gallstones
E. Coli
Choledocolithiasis turns into this
Symptoms of acute ascending cholangitis? (There is a Triad and a Pentad)
Charcot’s Triad: fever/chills + RUQ pain + jaundice
Reynaud’s Pentad: Triad above + AMS + hypotension/shock
Diagnostics for acute ascending cholangitis are similar to the other gallbladder tests. What are they? What is the most accurate? What is the gold standard?
Labs: Leukocytosis (high WBC), High Alk Phos and GGT, high bilirubin
US (initial)
MRCP most accurate
Cholangiography via ERCP (GOLD STANDARD)
Treatment for acute ascending cholangitis?
IV ABV + common bile duct decompression + stone extraction (ERCP)
-Ampicillin/Sulbactam, Piperacillin/Tazobactam
