GI Study Guide Flashcards
How do diagnose hepatitis based on presenting symptoms
A- mild flu like illness, or acute hepatitis with jaundice.
Fatigue, Malaise, HA, RUQ pain, Nausea, Loss of appetitie, Weight loss, Jaundice dark urine, clay stools. High fevers more common in HAV
B- anorexia, fatigue, N/V, jaundice, malaise, Diarrhea, Low grade temp, Tender hepatomegaly. Aversion to smoking, skin rashes, arthritis, more common in early HBV
C- Asymptomatic in acute illness, Chronic- liver failure, cirrhosis, fatigue
What tests should be ordered to confirm hepatitis?
A- anti HAV-IgM
B- HBsAg in acute infection, first to show
C- Anti HCV suggests infection until proven otherwise, RIBA-2, 2/4 present confirms infection
D- Anti-HDV
What are the serological tests for severity of hepatitis?
HBV-DNA - if you have either acute or chronic this is a quantitative test that will let you know the extent of the viral load
HCV-RNA- quantitative, tests level of actual virus
What is the appropriate intervention for a patient with a mallory-weirs tear who fails endoscopic therapy?
Angiographic arterial embolization
What is the most specific and sensitive test for diagnosis of GERD?
24 hour ambulatory pH monitoring
What are the genotypes for hepatitis?
Six different genotypes in hepatitis C
type 1 is the most common and most difficult to treat
Type 2 and 3 are more sensitive to treatment.
Types 1, 4, 5, 6- 48 weeks treatment
Types 2, 3- 24 weeks treatment
What is the treatment for hepatitis?
Acute HAV:
No specific treatment for
rest the body and assist the liver with regeneration
Nutrition and rest
Avoid alcohol and drugs detoxified in liver
Chronic:
B- Interferon, nucleoside and nucleotide analogs if severe (Intron A for 5 months or Epivir for 1 year)
C- Pegylated interferon (best within 12-24 weeks of infection to prevent chronic), protease inhibitors, ribavarin
Intron for 24-48 weeks
Ribavirin for 24 weeks
How do you determine if the hepatitis is acute or chronic?
IgM AntiHBc- is for acute infections
IgG AntiHBc- shows chronicity
HBeAg- if this is detectable after 3 months probably chronic
Pseudomembraneous colitis
C. Diff is responsible for virtually all cases Clindamycin Ampicillin, amoxicillin, Cephalosporins Risk factors: Severe illness > 2 days in hospital GI surgery PPI Enteral tube feedings
What is the most specific and sensitive test for diagnosis of GERD?
24 hour ambulatory pH monitoring
Type of Pseudomembraneous Colitis
Type 1- mild Inflammatory changes, lesions present Type 2- More severe disruption of glands Marked mucin secretion intense inflammation Type 3- Severe, intense necrosis of the fully thickness
symptoms of PMC
Profuse diarrhea
Nausea/anorexia
dehydration
Abdominal tenderness and distention
Findings of Ulcerative colitis
Affects only the large intestine extending form the rectum upwards
Inflammation is limited to the mucous membrane
Pyoderma gangrenosum occurs frequently with UC
Liver disease
Treatment of Ulcerative colitis
Can give 5-aminocalicyclic acid derivatives (salazopyrin, asacol, pentasa, salofalk, dipentum, colazide)- if disease is confined to rectum
Corticosteroids for severe attacks
Immunosuppressive agents sometimes to reduce the use of steroids
can use antidiarrheal and antispasmodic medications
Know PUD presentation
Duodenal ulcers are the most common
More common in men
Presentation:
Epigastric tenderness 1 inch or more to the right of midline
Know GERD presentation
heart burn- described as substernal sensation of warmth, or burning that may radiate to the neck, throat and or back regurgitation dysphagia odynophagia belching
Know ulcers presentation
DU: epigastric pain, gnawing, aching 1-3 hours after eating nocturnal pain Relieved by antacid of food ingestion GU: Epigastric pain, not relieved by food Food may precipitate symptoms nausea and anorexia
How long would you continue omeprazole therapy?
DU 4 weeks
GU 8 weeks
Gastric ulcers most common cause…
NSAIDs
Duodenal ulcers most common cause…
H. Pylori
PUD risk factors…
NSAIDS Smoking Zollinger-Ellison syndrome Stress Corticosteroid use
Findings with Chronic lower GI bleed
anemia
orthostatic hypotension
Diagnostics for H. Pylori
Biopsy from endoscopy is the gold standard
Urea breath test- PPI gives false negative, withhold PPI 7-14 days before
Serum antibody test- not current infection, past infection
Fecal antigen- active infection, PPI false negative
Would you obtain a barium study to confirm perforated ulcer?
No this is contraindicated
PUD treatment
PPI (suppresses acid secretion)- administered at least 30 minutes before meals
4 weeks for DU
8 weeks for GU
Serum gastrin level checked after 6 months of therapy- terminated or decreased if rise > 500 pg/ml
H2 Blocker- decreases acid secretion
8 weeks of therapy for both
Sucralfate- enhance mucosal defense
Bismuth- (promotes healing through stimulation of mucosal Bicarb and prostaglandin production. Has direct antibacterial action against H. Pylori)
Follow up endoscopy
PUD complications
GI bleed (Elevated BUN, not creatinine) Perforations (Severe epigastric pain radiates to the back, hypoactive, very ill, board like abdomen, rebound tenderness) Leukocytosis Gastric outlet obstruction
GERD complications
Reflux related pulmonary disease
Persistent ulcerative esophagitis
Recurrent esophageal strictures
Large hiatal hernia
GERD Treatment
phase 1: lifestyle modification elevate bed avoid exercise and large meals before bed avoid aggravating foods Weight reducation Stop smoking Antacids PRN- Mylanta, maalox Over the counter H2 blockers Phase 3: PPI Phase 4: surgical intervention
Antibiotic therapy for H. Pylori eradication…
- Metrondiazole, clarithromycin, Amoxicillin
- PPI
- Bismuth
Radiographic findings for mesenteric ischemia
Digital subtraction angiography (DSA) is the gold standard to diagnose
Upright abdominal films will be normal in AMI- rules out other causes of pain
Pneumatosis may be seen which is a late sign
CT with contrast- may reveal “thumb printing, pneumatosis”
Ultrasound can be used
MRI/MRA- similar to CT but expensive
Radiography findings for perforated bowel
Free air under the diaphragm on an upright chest film suggests the presence of a bowel perforation
S/S of mesenteric ischemia
Abdominal pain- severe, diffuse, non localized, constant N/V Distention Hypotension Hematochezia
Causes of mesenteric ischemia
Arterial Clot
Embolism: Most commonly from cardiac source: MI, mitral stenosis, Afib, Endocarditis, Septic emboli
Thrombotic: Atherosclerotic disease, aortic aneurysm, dissection, spontaneous thrombus
TTP, DIC, SLE
Low flow conditions: Hypotension, Arrhythmias, Shock, Vasoconstricting drugs
Venous: Tumors, hypercoagulubility, infection, congestion
How to diagnose mesenteric ischemia
Gold standard for diagnosis is the Digital subtraction angiography (DSA)
Treatment of occlusive mesenteric ischemia
Embolectomy Bowel resection Stent placement Thrombolytics during an angiogram TPN- if large portion of bowel removed
Treatment of non occlusive mesenteric ischemia
Correct problem
Hypovolemia
Heart failure
Dig toxicity
Treatment of chronic MI
Nitrate therapy
Anticoagulation- coumadin
Stent placement
Labs to monitor for hepatic failure
Bilirubin- elevated Albumin- decreased PT, ptt- prolonged ALT- elevated (greater specificity for liver disease) AST- elevated Ammonia- elevated CMP with albumin
Findings of diverticulitis
LLQ pain
Fever
Alternating constipation/diarrhea
Elevated ESR, CRP, Procal
Treatment of diverticulitis
IV antibiotics
bowel rest
NGT for ileum
Surgery for free air or abscess
Interventions to decrease complications of hepatic dysfunction
Acetaminophen is the most common cause of acute liver failure in the US
Administration of N-Acetylcysteine promptly helps to decreases mortality.
Causes of pancreatitis
ETOH Gallstones Hypertriglyceridemia Hypercalcemia ERCP post
Tests to screen for hepatocellular carcinoma
US every 6 months for high risk patients (patients with cirrhosis or chronic hepatitis B)
What HD parameters to maintain with esophageal varices
SBP < 110
CVP < 10
PAWP < 8
GERD presentation
Heartburn regurgitation hyper salivation dysphagia odynophagia hemorrhage belching
Most likely cause of acute liver failure…
Acetaminophen
Risk factors for gall stones
Female Fourty Fertile Fat Rapid weight loss high cholesterol diet Certain meds: thiazide diuretics, birth control pills, lipid lowering agents
Murphys sign and what it indicates
Deep pain on inspiration while fingers are placed under the right rib cage
Cholecystitis
Labs to order for suspected gallstones
Elevated bilirubin, ALT, AST, LDH, Alk phos
Elevated Amylase
US of gall bladder
S/S of pancreatitis
Epigastric abdominal pain Abrupt onset steady and severe N/V Hypoactive BS Tachycardia Fever Tachypnea
What is greys turner sign
flank discoloration
Can be seen with hemorrhagic pancreatitis
What is cullens sign
Periumbilical discoloration
Can be seen in hemorrhagic pancreatitis
Lab findings in pancreatitis
Elevated amylase and lipase Lipase elevates higher and remains elevated longer Elevated trypsin level Leukocytosis elevated H/H Hyperglycemia AST and LDH Hypocalcemia Low albumin
Treatment for pancreatitis
IV hydration Pain control Antibiotics- not used prophylactically NPO NGT Monitor calcium Monitor pulmonary function Insulin Surgery if indicated
Ransons Criteria mortality risk
0-3 risk factors- < 1% mortality
3-4 risk factors- 16% mortality
5-6 risk factors- 40% mortality
more than 7 risk factors- close to 100% mortality
Ranson criteria risk factors
on admission: older than 55 WBC > 16000 Glucose > 200 LDH > 350 AST > 250 In initial 48 hours; H/H drop > 10% BUN increases > 5 Calcium below 8 SaO2 below 60 Base deficit > 4 fluid sequestration > 6000
IV antibiotics for diverticulitis
Inpatient: (7-10 days of IV ABX but can switch to oral if improved after 5 days).
- Ciprofloxacin or levofloxacin (Flouroquinolone) and metronidazole
- Cefotaxime or ceftriaxone or cefepime (3-4 gen. cephalosporin) and metronidazole
- Zosyn
- Timentin
- Imipenem- immunocompromised patients
McBurneys point
RLQ pain
indicative of appendicitis
Rovsings sign
RLQ pain with palpation of LLQ
indicative of appendicitis
Psoas sign
pain with active extension of the right hip
indicative of appendicitis
Obturators sign
pain with internal rotation of the right hip
Findings in appendicitis
RLQ pain Nausea with or without vomiting Constipation fever guarding UA with elevated specific gravity, hematuria, pyuria, albuminuria US to diagnose
Causes of SBO
Adhesions are most common Hernias Volvulus Strictures (Crohns, Radiation, Ischemia) Hematomas Intussusception Feces Tumors Foreign bodies
PE findings of SBO
Cramping periumbilical pain- sporadic
Proximal: profuse vomiting, upper abdominal pain
Distal: periumbilical pain, distention, episodic vomitting
the more distal the more NGT output, more feculent emesis
Obstipation
water diarrhea for incomplete
high pitched tinkling bowel sounds
s/s dehydration
Labs of SBO
Possibly leukocytosis Hemoconcentration Electrolyte imbalances Hypokalemia BUN/Cr elevated
Treatment of SBO
NPO IV fluids NGT Labs ABX if suspect perforation Surgical consult for complete obstruction
Facts about esophageal varices
EGD is gold standard for diagnosis Stabilize patient Blood products Octreotide Propranolol to prevent rebleed Needs emergent banding TIPS with stent Can cause hepatic encephalopathy due to digestion of blood- give lactulose
Facts about hematochezia
Indicates a lower GI bleed or a massive upper GI bleed of more than a liter
Information regarding balloon tamponade
Can be used short term to control bleeding
sengstaken-blakemore (3) or minnesota (4)
Inflate to 20-45 mmHg
Monitor continuously
Deflate every 8-12 hours
Scissors at bedside
always deflate esophageal balloon first
Complications include airway occlusion, esophageal rupture, ulceration
VS findings r/t severity of blood loss
40% blood loss- signs of hypovolemic shock (hypotension, tachycardia, pallor)
20% blood loss- orthostatic changes
ABX for mild diverticulitis
Acute uncomplicated: oral ABX for 7-10 days. Cipro, Bactrim or Levo plus flagyl or Amoxicillin and clavulanate
Treatments for upper GI bleed
T/C for 4 units resuscitation blood transfusions to keep hat > 20 in young patient, >30 in everyone else FFP NGT Endoscopy PPI Surgery Arteriography
Interventions to decrease complications of hepatic dysfunction in hepatitis include:
Supportive care
Symptom management
Treatment of Lower GI bleed
place NGT to rule out UGI bleed IV PPI T/C Colonoscopy Angiography Surgery
Courvoisers sign
enlarged gallbladder that is palpable but not tender
Charcots triad
Jaundice, fever, RUQ pain
C-reactive peptide elevated
Over 50
LLQ pain
No vomitting think
Diverticulitis
ABX for appendicitis
Prior to surgery- cefoxitin, cefotan
Gangrenous or perforation- single or combination therapy with flagyl
Immunocompromised or elderly- carbapenem plus flagyl
ABX for cholecystitis
Third generation cephalosporins (Cefazolin, cefuroxime, ceftriaxone) and metronidazole
For severe cases:
Fluoroquinolones (ciprofloxacin) plus metronidazole
ABX will be necessary for pancreatitis in
Septicemia
Abscess
Pseudocyst
ABX for pancreatitis
Imipenem
Cefuroxime
Treatment of Peritonitis
IVF
ABX- 10 day therapy
ABX for peritonitis
3rd generation cephalosporin
Ampicillin for enterococcus
Colonic obstruction Meds
Broad spectrum ABX early; Clindamycin, flagyl
Labs for UGI bleed
T/C for 4 units PRBC H/H pt, ptt, plt, electrolyte, BUN/Cr, Liver enzymes EKG (ischemia related to blood loss) Endoscopy
Labs for LGI bleed
R/O UGIB with NGT
CBC
Iron, TIBC, Ferritin
Fecal Occult blood
The main cause of inflammation of liver cells and liver damage in hepatitis is because of…
Cell apoptosis
Which liver test will be higher and stay elevated longer in viral hepatitis?
ALT
True of false, the resolution of jaundice in hepatitis means resolution of infection?
false
