GI System Flashcards
Gastroesophageal Reflux
overweight pt with burning retrosternal pain and heartburn from bending over, wearing tight clothes, lying flat in bed at night.
Relieved by antacids or OTC H2 blockers.
Dx: pH monitoring
May get Barrett esophagus or peptic esophagitis.
Dx: endoscopy and biopsies.
Tx: PPI, H2 blockers, antacids, surgery if meds can’t control it or get ulcers (radioablation or Nissen).
Motility Problems of Esophagus
crushing pain with swallowing = uncoordinated massive contraction
solids swallowed with less difficulty than liquids = achalasia.
Achalasia
usually women
Features: dysphagia worse with liquids, sit straight and wait to allow liquids past sphincter, regurgitation of undigested food.
Dx: x-ray shows megaesophagus, manometry
Tx: balloon dilation via endoscopy
Esophageal Cancer
squamous cell in men who smoke and drink.
adenocarcinoma in long-standing GERD.
Features: progression of dysphagia from meat to solids to soft food to liquids to saliva, significant weight loss.
Dx: endoscopy and biopsy, barium swallow to prevent inadvertent perforation, CT scan
Tx: surgery
Mallory-Weiss tear
Cause: prolonged forceful vomiting.
Features: hematemesis.
Dx: endoscopy
Tx: photocoagulation
Boerhaave Syndrome
Cause: prolonged forceful vomiting with esophageal perforation.
Features: sudden, continuous, severe, wrenching epigastric and low sternal pain followed by fever, leukocytosis, sick patient.
Dx: contrast swallow
Tx: surgery
Esophageal perforation
mostly from instrumental perforation.
Features: after endoscopy symptoms suddenly develop. Emphysema in lower neck.
Dx: contrast studies
Tx: surgery
Gastric adenocarcinoma
elderly
Features: anorexia, weight loss, vague epigastric distress or early satiety, hematemesis.
Dx: endoscopy and biopsy, CT scan
Tx: surgery
Gastric lymphoma
Features: anorexia, weight loss, vague epigastric distress or early satiety, hematemesis
Dx: endoscopy and biopsy
Tx: chemotherapy or radiotherapy, surgery if perforated.
Maltoma reversed if eradicate H pylori
Mechanical Intestinal Obstruction
cause: adhesions in those with prior laparotomy
Features: colicky abd pain, protracted vomiting, progressive abd distention, no passage of gas or feces. Early on have high pitched bowel sounds with colicky pain, then silence.
Dx: x-ray shows distended loops ofbowel with air-fluid levels
Tx: NPO, NG suction, IV fluids, watch for strangulation, surgery if necessary
Strangulated Obstruction
cause: compromised blood supply
Features: pt with mechanical intestinal obstruction symptoms develops fever, leukocytosis, constant pain, signs of peritoneal irritation, full-blown peritonitis and sepsis.
Tx: surgery
Mechanical Intestinal Obstruction from Incarcerated Hernia
Features: pt with mechanical intestinal obstruction symptoms and potential strangulation but on exam have irreducible hernia that was reducible before.
Tx: surgery (emergent if strangulated, elective if viable bowel and reducible).
Carcinoid Syndrome
cause: small bowel carcinoid tumor with liver metastases.
Features: diarrhea, facial flushing, wheezing, right sided heart valvular damage (increased JVD)
Dx: 24 hour urinary collection for 5-hydroxyindoleacetic acid
Acute Appendicitis
Features: anorexia, then vague periumbilical pain that becomes sharp, severe, constant, and moves to RLQ, tenderness, guarding, rebound in RLQ, fever, leukocytosis in 10,000-15,000, neutrophilia and immature forms.
Dx: CT
Tx: appendectomy
Right Colon Cancer
Features: anemia (hypochromic, iron deficiency) in elderly.
Dx: 4+ occult blood in stool, colonoscopy and biopsy
Tx: right hemicolectomy
Left Colon Cancer
Features: bloody bowel movements, constipation, narrow stools.
Dx: flexible proctosigmoidoscopic exam and biopsy, colonoscopy, CT
Tx: chemotherapy and radiation, surgery
Colonic Polyps
can be premalignant range: most to least likely for malignancy 1. familial polyposis 2. familial multiple inflammatory polyps 3. villous adenoma 4. adenomatous polyp non malignant: juvenile, Peutz-Jeghers, isolated inflammatory, hyperplastic
Chronic Ulcerative Colitis
surgical indications:
disease >20yr
severe interference with nutritional status
multiple hospitalizations
need for high dose steroids or immunosuppressants
develop toxic megacolon
Tx: remove affected colon and rectal mucosa
Toxic Megacolon
Features: abd pain, fever, leukocytosis, epigastric tenderness, distended transverse colon on x-ray with gas in colon wall
Pseudomembranous Enterocolitis
cause: overgrowth of C. difficile in pt on antibiotics (historically clindamycin and cephalosporins)
Features: profuse watery diarrhea, crampy abd pain, fever, leukocytosis
Dx: toxin in stool
Tx: discontinue antibiotic, start metronidazole or vancomycin. colectomy if unresponsive to tx, WBC >50,000, and serum lactate over 5.
Hemorrhoids
Internal: bleed
when prolapsed can be painful and itch.
Tx: rubber band ligation
External: hurt
Tx: conservative tx, surgery if fails
Anal Fissure
young women
fissure usually posterior and midline.
cause: tight sphincter
Features: pain with defecation, blood streaked stool, avoid bowel movements, constipated, refuse anal exam
Tx: stool softeners, topical nitroglycerin, local botox injection, forceful dilation, lateral internal sphincterotomy.
CCB such as diltiazem ointment 2% TID topically 6 weeks
Crohn Disease
affects anal area frequently
Features: fissures, fistulas, small ulceration, suspect when fail to heal or worse with surgery.
Tx: treat fistula with setons and remicade
Ischiorectal Abscess
aka perirectal abscess
Features: febrile, perirectal pain where can’t sit or have BM, signs of abscess lateral to anus btw rectum and ischila tuberosity.
Tx: I & D, r/o cancer, if diabetic then watch for necrotizing soft tissue infection
Fistula-In-Ano
in patient with previous ischiorectal abscess
cause: epithelial migration from anal crypts and perineal skin form permanent tract.
Features: fecal soiling, perineal dicsomfort, opening lateral to anus, cordlike tract felt, discharge.
Rule out necrotic and draining tumor
Tx: fistulotomy
Squamous Cell Carcinoma of Anus
in HIV and homosexuals who receive.
Features: fungating mass grows from anus, metastatic inguinal nodes.
Dx: biopsy
Tx: Nigro chemoradiation then surgery if still there
Hematemesis
usually upper GI source.
Dx: upper GI endoscopy
Melena
shows digested blood
Dx: upper GI endoscopy
Hematochezia
- pass NG tube to aspirate gastric contents
- blood shows upper GI source, do upper GI endoscopy
- no blood and fluid is white means source is duodenum or below, do upper GI endoscopy
- no blood and fluid is green excludes all upper GI
Hematochezia, no upper GI bleeding
- anoscopy - rule out hemorrhoids
- rate of bleeding > 2mL/min => angiogram
- rate of bleeding < 0.5mL/min => wait for bleeding to stop, colonoscopy
- rates between 0.5-2mL/min => tagged red-cell study
Hematochezia in kid
work up for Meckel diverticulum
Dx: technetium scan
Massive upper GI bleed
In stressed, multiple trauma, complicated post-op patient is usually stress ulcer
Dx: endoscopy
Tx: angiographic embolization, maintain gastric pH above 4
