GI Re-Up #1 Flashcards
What is cholelithiasis? What is the MC type?
Name 5 risk factors for this condition (think F’s)
-Gallstones in the biliary tract WITHOUT inflammation
-Cholesterol is the MC type
-Female, Fat, Forty, Fertile, Fair: OCPs, IBD, rapid weight loss, Native American, increased TG’s
Although most patients with cholelithiasis are asymptomatic, what are some symptoms they CAN have?
-Biliary colic: episodic, abrupt RUQ pain, resolves slowly, lasting 30 minutes to hours.
-Nausea
-Precipitated by fatty foods or large meals
Initial test of choice for cholelithiasis
What is the treatment? Observation can be used if asymptomatic, but there is a medication that can dissolve the stones.
US
Ursodeoxycholic acid used to dissolve the stones (takes about 6-9 months)
Cholelithiasis can progress to _______ which is inflammation and infection of the gallbladder due to obstruction of the cystic duct by gallstones.
What is the MCC of this infection?
Acute cholecystitis
E. Coli
What are symptoms and physical exam findings of a patient with acute cholecystitis?
-Continuous RUQ or epigastric pain, precipitated by fatty foods or large meals
-N/v, Anorexia, Guarding
-Fever, Enlarged Palpable Gallbladder
-Murphy’s Sign: RUQ pain or inspiratory arrest with palpation of gallbladder
-Boas Sign: referred pain to right shoulder or sub scapular area
Back to Boas Sign; Explain why this occurs
-Phrenic Nerve Irritation
-Initial test of choice for cholecystitis
-What do labs show?
-Most accurate test for this.
-US initial
-Labs: Increased WBC’s (Leukocytosis)
-Accurate: HIDA (Cholescintigraphy)
Treatment for acute cholecystitis
-NPO, IVF, ABX (Ceftriaxone + Metronidazole) followed by cholecystectomy
On the same note, what is acute acalculous cholecystitis?
Explain why this occurs
-Acute inflammatory disease of gallbladder NOT due to gallstones
-Gallbladder stasis and ischemia leads to concentration of bile salts, distention, infection, perforation, or necrosis of gallbladder tissue
Who is at increased risk for acute acalculous cholecystitis specifically?
What is the treatment, because imaging studies are the same as cholecystitis.
-Current hospitalization, critically ill patients
-Treatment: Supportive care (IVF, bowel rest, pain control, lytes correction, ABX)
What is choledocolithiasis?
What are symptoms of this condition?
-Gallstones in the common bile duct (leads to cholestasis due to blockage)
-Prolonged biliary colic (longer than cholecystitis), RUQ pain, jaundice
Initial imaging study for choledocolithiasis?
What do labs show (there is a specific one for cholestasis)
Diagnostic test of choice (because it can be therapeutic as well)
-US initially
-Labs: elevated AST and ALT. Increased Alkaline phosphatase and GGT (cholestasis)
-ERCP can allow for extraction of the stone as well
Choledocolithiasis can progress to ________, which is a biliary tract infection secondary to obstruction of the common bile duct from gallstones or malignancy.
What is the MCC of this condition?
Name symptoms (think of the triad and pentad)
-Acute ascending cholangitis
-E. Coli
-Charcot’s Triad: fever + RUQ pain + jaundice
-Reynold’s Pentad: add hypotension/shock + AMS
Initial imaging study of choice for cholangitis
What do labs show (think of cholestasis again)
Most accurate imaging study?
Gold standard imaging study
-US initially
-Labs: Leukocytosis, Increased alkaline phosphatase and GGT (cholestasis), increased bilirubin
-Accurate: MRCP
-Gold: Cholangiography via ERCP or PTC (percutaneous transhepatic cholangiography) once stable for 48 hours after IV ABX
Initial management for acute cholangitis
-IV ABX followed by CBD decompression and stone extraction via ERCP
-ABX used: Ampicillin/Sulbactam, Piperacillin/Tazobactam, Ceftriaxone + Metronidazole
The ERCP for cholangitis is done when the patient has been _______ for ______ hours and after IV ABX.
Stable/Afebrile for 48 hours
Appendicitis is obstruction of the lumen of the appendix resulting in inflammation and bacterial overgrowth. What is the MCC of this condition?
True or False: Appendicitis is the MCC of acute abdomen in children 12-18 years old?
Fecalith and lymphoid hyperplasia
True
Symptoms of appendicitis
There are also 4 specific exam tests that can be done for this. Name and explain them.
-Anorexia and periumbilical of epigastric pain followed by RLQ pain, nausea, and vomiting
-Rovsing Sign: RLQ pain with LLQ palpation
-Obturator Sign: RLQ pain with hip rotation w/ flexed knee
-Psoas Sign: RLQ pain with right hip flexion/extension (raise leg against resistance)
-McBurney’s Point Tenderness: 1/3 distance from anterior superior iliac spine and navel
Appendiceal inflammation stimulates nerve fibers around ___- _____, causing vague periumbilical pain.
T8-T10
What is the preferred imaging study of choice for appendicitis in adults?
What is preferred if the patient is pregnant or a child?
-CT scan
-US and MRI for radiosensitive populations
Treatment for appendicitis
-Appendectomy (Laparoscopic preferred)
Hirschsprung Disease is what?
Where is it MC?
What are some risk factors?
-Congenital megacolon due to absence of ganglion cells (Auerbach and Meissner plexuses)
-MC in distal colon and rectum
-Males, Down Syndrome, MEN II
Symptoms of Hirschsprung Disease
-Neonatal meconium ileus (failure to pass > 48 hours)
-Bilious vomiting
-Abdominal distention
-Failure to thrive
What is seen on contrast enema in Hirschsprung Disease?
What is the definitive diagnostic?
Treatment?
-Enema: Transition zone between normal and affected bowel
-Definitive: Rectal biopsy
Treatment: Resection of affected bowel segment
What is the pathophysiology of pyloric stenosis?
What are two risk factors for this condition?
Hypertrophy and hyperplasia of pyloric muscles, causing functional gastric outlet obstruction
-MC in first 3-12 weeks of life
-Erythromycin use (within the first two weeks of life)
Symptoms of pyloric stenosis
What is the initial diagnostic of choice?
-Nonbilious projectile vomiting (after feeding)
-Palpable pylorus (olive shaped, nontender, mobile hard mass to right of epigastrium)
Abdominal US: elongated, thickened pylorus
What is seen on upper GI series for pyloric stenosis?
How about labs?
-Upper GI series: String sign (thin column of barium through narrowed pyloric channel), delayed gastric emptying. Railroad track sign (excess mucosa in pylorus resulting in 2 columns of barium)
Labs: Hypokalemia and hypochloremic metabolic alkalosis from vomiting
Treatment for pyloric stenosis
-Rehydration (IVF) and Potassium Replacement
-Definitive: Pyloromyotomy
What is intussusception?
True or False: This is the MCC of bowel obstruction in children 6 months - 4 years of age.
Telescoping (invagination) of an intestinal segment into adjoining distal intestinal lumen, leading to bowel obstruction.
True
Where does intussusception MC occur?
What is the MCC?
Ileocolic junction
Idiopathic MCC; others: hyperplasia of Peyer’s Patches, tumors, foreign body
Symptoms of intussusception (triad)
Physical exam findings
-Vomiting + abdominal pain + passage of blood per rectum (currant jelly stools - stool mixed with blood and mucus). Abdominal pain colicky in nature, pulls knees to chest due to pain
-Sausage-shaped mass in RUQ or emptiness in the RLQ (Dance’s Sign) due to telescoping of bowel
Best initial diagnostic for intussusception and what is seen?
What is the diagnostic that can also be therapeutic?
US initial: Donut or Target Sign
Air or contrast enema
Management for intussusception
-Fluid and electrolyte replacement (initial steps)
-Then, NG decompression with pneumatic (air) or hydrostatic (saline or contrast)
-Admit for observation (10% recurrence rate within 24 hours)
What is dumping syndrome and what is it often a complication of?
-Symptoms due to rapid gastric emptying and rapid fluid shifts when large amounts of carbs are ingested
Often a complication of bariatric surgery
Symptoms of dumping syndrome
What tests can be done to confirm rapid gastric emptying?
-Bloating, flatus, diarrhea, abdominal pain, nausea, dizziness, tachycardia, flushing (within 15 minutes)
-Barium fluoroscopy and radionuclide scintigraphy
Treatment for dumping syndrome
-Decreased carbohydrate intake
-Eat more frequently with smaller meals
-Separating solids from liquid intake by 30 minutes
Celiac Disease is autoimmune-mediated inflammation of the small bowel due to reaction with _______ in gluten-containing foods. What are some foods that have gluten in it?
Explain the pathophysiology behind this condition
What are some common symptoms of this (think of the skin as well)
-Alpha-Gliadin
-Foods: wheat, rye, barley
-Patho: Autoimmune damage leads to loss of villi with subsequent malabsorption
-Symptoms: Malabsorption (diarrhea, distention, bloating, steatorrhea). Growth delays.
–Dermatitis herpetiformis: pruritic, papulovesicular rash on extensor surfaces, neck, trunk, and scalp.
Screening test for celiac disease
Definitive and confirmatory diagnostic for celiac disease
-Screening: Transglutaminase IgA antibodies (Endomysial IgA antibodies)
-Confirmatory: small bowel biopsy –atrophy of the villi
Management for Celiac Disease
-Gluten Free Diet: avoid wheat, rye, barley.
-Vitamin Supplementation
Diagnostic test of choice for lactose intolerance
-Hydrogen breath test: hydrogen produced when colonic bacteria ferment the undigested lactose.
Peanut and Tree Nut Allergies are mostly IgE mediated. What are some risk factors for this condition?
What is the management of an acute attack?
-Risks: Genetics, Family History. Delayed introduction of nuts until > 3 years of age.
Antihistamines if mild, Epinephrine if severe
What exactly are diverticula?
Where do they MC occur? Where do they MC bleed?
Risk Factors for diverticulosis?
-Outpouchings due to herniation of mucosa into the wall of the colon
-MC occur in left colon, right colon MC site for bleeding
-RF: low fiber diet, constipation, obesity
Symptoms of diverticulosis
Remember, diverticulosis is the MCC of acute lower GI bleeding
-Usually asymptomatic, incidental finding
-Lower GI Bleeding (painless hematochezia) in adults
Test of choice for diverticulosis
If bleeding not visualized on this diagnostic, what can be done?
-Colonoscopy
-radionuclide imaging (technetium-99 tagged RBC scan)
In most cases, the bleeding with diverticulosis stops spontaneously. However, what can be done to stop the bleeding if needed?
Resuscitation (2 large bore IVs, correction of coagulopathies)
Epinephrine injection, tamponade
What recommendation do you have for a patient with asymptomatic diverticulosis?
-High fiber diet, use of Bran, or psyllium
On the other hand, diverticulitis is ….
Where is the MC area for this?
Microscopic perforation of a diverticulum that leads to inflammation and focal necrosis.
Sigmoid colon
Symptoms of diverticulitis
-LLQ pain
-Low grade fever
-N/v, Constipation, diarrhea, bloating, flatulence, change in bowel habits
Initial imaging study of choice for diverticulitis (why should you NOT use colonoscopy?)
What do labs show?
CT scan. Do not use colonoscopy due to perforation risk.
Labs: leukocytosis
Management for uncomplicated diverticulitis
-Outpatient treatment with oral ABX (Metronidazole + Ciprofloxacin or Levofloxacin) for 7-10 days and clear liquid diet
-Surgery: if refractory, recurrent, perforation, or stricture
When should you admit a patient with diverticulitis?
-Perforation, abscess, stricture, obstruction, fistula.
-High risk: High fever > 102, sepsis, immunosuppression, increased age, unable to tolerate oral intake, etc.
