GIT Flashcards
Features of FB that will not pass the GIT
Irregular<br></br>Sharp<br></br>Wide objects (wider than 2.5 cm or longer than 6 cm)<br></br>
Complications of stuck FB
Airway obstruction<br></br>Stricture<br></br>Perforation<br></br>Corrosion<br></br>Erosion<br></br>Aspiration pneumonia/pneumonitis
Indications for urgent endoscopy in FB
Sharp objects<br></br>Multiple FBs<br></br>Button batteries<br></br>Perforation<br></br>Coin at the level of cricopharyngeus in children<br></br>Airway compromise<br></br>FB for > 24 hrs
Causes of Massive UGIB
PUD<br></br>Esophageal varices<br></br>Aorto-enteric fistula
Indication for massive transfusion in UGIB
Hemodynamic instability<br></br>Shock index (HR/SBP)>1<br></br>Pt presented with presyncope<br></br>Brisk bleeding<br></br>Co-morbidities (CAD, coagulopathy)
Tests to order during an MTP
CBC for plt count<br></br>INR (correct if > 1.8)<br></br>PTT<br></br>Fibrenogen (to assess the need for cryoppt)
<strong>Contraindications to tranexamic acid</strong>
<ul><li>History of coronary stent(s)</li><li>History of active hematuria (it is thought that administration of TXA in the patient with hematuria may cause a clot resulting in obstructive uropathy)</li><li>History of venous thromboembolic disease</li></ul>
“<h3><span><strong>Order of priority of IV medications in upper GI bleed emergencies</strong></span></h3>”
<ol><li><strong>Ceftriaxone</strong>1 g IV for all cirrhotics</li><li><strong>Octreotide 50</strong><strong>μ</strong><strong>g bolus + 50</strong><strong>μ</strong><strong>g/hr infusion</strong>for all UGIB patients</li><li><strong>Erythromycin250mg,</strong>30 minutes prior to endoscopy for suspected peptic ulcer</li><li><strong>PPI e.g. Pantaprazole 80 mg IV bolus</strong>(no infusion necessary) –once you’ve given everything else, if the endoscopist asks for it</li></ol>
Mx of GIT bleeding
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What historical factors that can help sorting out reasons for GIT bleeding?
Medication<br></br>Substance abuse<br></br>Constitutional symp<br></br>Stigmata of liver dis<br></br>Coagulopathy
Initial Mx of UGIB
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The patient’s vitals do not improve, what is your next steps in management
• Massive Transfusion Protocol<br></br>• Reverse coagulopathy <br></br>• Place nasogastric tube<br></br>• Consult gastroenterologist (GI) for emergent (EGD)<br></br>• If unstable consider Blakemore tube
DDX for blood in stool
• PUD<br></br>• Gastritis<br></br>• Esophageal or gastric varices<br></br>• Mallory Weiss syndrome<br></br>• Dielafoy lesions<br></br>• Avm malformations<br></br>• Malignancy<br></br>• Zollinger Ellison Syndrome: gastrin tumor
Risk Factors ofPUD
• EtOH <br></br>• H. Pylori<br></br>• NSAIDS<br></br>• Steroids<br></br>• Aortic graft
Meds in GIT bleeding
• Octeotide 50mcg/50mcg/hr<br></br>• PPI 80 mg bolus and then 40 mg IV BID<br></br>• ABX - for patients with Cirrhosis: Ceftriaxone or Cipro<br></br>• Consider Erythromycin 3mg/kg IV over 30 min, 30 min prior to scope
Ind of D/C of UGIB
If Glasgow Blachford Score=0:<br></br>No co-morbid dis<br></br>Normal VS<br></br>Normal Hb<br></br>Neg or trac FOB<br></br>Good home support<br></br>Competent/reliable pt<br></br>F/U within 24 hrs
Meat is stuck in the esophagus, what can be done before endoscopy?
ABC<br></br>Glucagon<br></br>Nitro<br></br>Carbonation (pepsi)
GERD red flags
Dysphagia<br></br>Wt loss<br></br>Anemia<br></br>Prolonged sym<br></br>Blood in stool/melena<br></br>>50<br></br>Sympt concerning other DDx(MI)<br></br>Early satiety<br></br>FHx of GI malignancy
H pylori testing:
Rapid urase test<br></br>Biopsy<br></br>Serology<br></br>Urea breath test
GERD complications:
Hge<br></br>Perforation<br></br>Stricture/obstruction<br></br>Barrett esophagus and Ca
Causes of EsophagiJs
• Infectious - Immunocompromised (primarily Candida Albans, <br></br>also viral (CMV and HSV)<br></br>• Pill esophagitis - Iron, potassium, bisphosphonates, NSAIDS, <br></br>tetracycline<br></br>• Reflux esophagitis - barrett’s<br></br>• Other: Radiation, Autoimmune, Eosinophilic Esophagitis, <br></br>• Caustic ingestion
Dysphagia (Neuro-Muscular) causes
• <b>Infectious</b>: botulism, diphtheria, polio, tetanus<br></br>• <b>Immunologic</b>: scleroderma, Multiple Slerosis, myasthenia gravis, polymyositis<br></br>• <b>Motor/nerve dysfunction: </b>Achalasia, Cranial nerve palsies
Extra-intesanal manifestaaons of IBD
arthrias (Ankylosing spondylitis)<br></br>erythema nodosum, <br></br>pyoderma gangrenous, <br></br>hepatobiliary disease (sclerosing cholangitis), <br></br>vasculitis, <br></br>uveias, <br></br>aphthous ulcers<br></br>
Possible causes of lateral anal fissure
“HIV<br></br>Crohn’s<br></br>Ca<br></br>TB<br></br>FB<br></br>Syphilis<br></br>Sexual abuse/child abuse”
Indications of ABs in pancreatitis
infected pancreatic necrosis, <br></br>pancreatic abscess, <br></br>infected peripancreatic fluid, or <br></br>infected pseudocyst
Indication for admission of any hepatitis:
INR >1.3, <br></br>elevated Bili, <br></br>dehydration, <br></br>hypoglycemia, <br></br>age over 45, <br></br>immunosuppressed, <br></br>encephalopathy
SBP
• 30% asymptomatic<br></br>• WBC >1000/mm3 or > 250 PMNs/mm3 or Bacteria on Gram Stain<br></br>• E Coli and Streptococcus<br></br>• Ceftriaxone 2g IV q24
Hepatic EncephalopathyPrecipitants
• infection<br></br>• sedative meds<br></br>• nitrogen load (protein, GI bleed)<br></br>• Hypoglycemia<br></br>• constipation<br></br>• Dehydration<br></br>• Electrolyte abnormalities.
Intussusception causes
Viral inf<br></br>HSP<br></br>CF<br></br>Meckles<br></br>Idiopathic
Complications of Meckles diverticulum
Diverticulitis (=appendicitis)<br></br>Intussusception<br></br>SBO<br></br>Bleeding<br></br>Stricture<br></br>Perforation<br></br>Volvulus
Diarrhea - Viral
• Winter and Spring season<br></br>• Sick contacts - daycare<br></br>• Rotovirus, adenovirus, enterovirus, norwalk, norovirus<br></br>• no blood or WBC’s in stool
Diarrhea - Invasive
• Blood and WBC’s<br></br>• E.Coli 0156:H7 - Uncooked hamburger, petting zoo, raw milk, <br></br>untreated water. <br></br>• Causes HUS in children (increased risk with ABX) and TTP in Adults
Diarrhea - Invasive 2
• Shigella - febrile seizure with bloody diarrhea<br></br>• Salmonella - turtles, eggs, cafeteria, osteomyelitis in Sickle Cell <br></br>disease <br></br>• Campylobacter - chicken, bad food/water, associated with Guillain-<br></br>Barre<br></br>• Vibrio Parahaemolyticus/vulnificus - shellfish <br></br>• Yersinia Enterocolitica - (mimics Appendicitis)<br></br>• TX : CIPRO
Diarrhea - Bacterial
• Staph - toxin - symp within 6 hours, N/V/D, afebrile<br></br>• E. Coli - travelers diarrhea<br></br>• Clostridium Perfringens - Toxin - 6-24 hrs to onset, ++diarrhea<br></br>• Vibrio Cholera - rice water, electrolyte abnormalities, rehydration<br></br>• Bacillus Cereus - spores - Cooked Rice, N/V/D<br></br>• Other: Scombroid poisoning (deep ocean fish) - Histamine like reaction,Ciguatera (reef fish) - muscle weakness, paresthesia, reversed temp sense, vomiting, diarrhea
Diarrhea - Protozoan
• Giardia - Water born, backpackers, fecal-oral, 1-4 wk incubation, <br></br>floating frothy foul diarrhea<br></br>• Entamoeba histolytica - contagious, bloody diarrhea, (liver abscess, <br></br>pericarditis, pulmonary and CNS) continuum asymptomatic cyst <br></br>passer to colitis to fatal cerebral amebiasis<br></br>• TX - METRONIDAZOLE
C. Diff/Pseudomembranous Enterocolitis
• Neonatal, post-op, antibiotic related<br></br>• overgrowth of toxin producing C.diff<br></br>• can begin days to weeks after Abx<br></br>• profuse foul diarrhea<br></br>• Can be present febrile and toxic<br></br>• no anti-diarrheals, stop offending Abx<br></br>• PO metronidazole/vancomycin
Imaging for acute pancreatitis
Abdominal ultrasound to rule out gallstone pancreatitis<br></br><i>Note: you do not require an imaging study to diagnose pancreatitis. The US is to rule in/out a common, contributing cause (gallstones) that would change your management.<br></br></i><br></br>-CT Abdo/Pelvis<br></br>-ERCP<br></br>-HIDA Scan
Risk factors for C.diff
Meds:<br></br> AB<br></br> Antiviral<br></br> ChemoRx<br></br> PPI<br></br>Previous C.diff inf<br></br>Close contact with pt with C.diff<br></br>Hospitalization<br></br>Nursing home/long-term care facility<br></br>Advanced age<br></br>Immunosuppression<br></br>GIT surgery<br></br>IBD
Causes of Pancreatitis
<b>Most common:</b><br></br><ul><li><i>GS</i></li><li><i>ETOH</i></li></ul><u>Other causes:</u><br></br><b>Infections:</b><br></br><ul><li><i>Bacterial (Legionella, Mycoplasma)</i></li><li><i>Viral (mumps, CMV, HBV)</i></li><li><i>Parasitic (Ascaris, Toxoplasmosis)</i></li></ul><br></br><b>Medication (Lasix)<br></br>Autoimmune (SLE)<br></br>Metabolic:</b><br></br><ul><li><i>Hypertriglyceridemia</i></li><li><i>HyperCa</i></li><li><i>Hyperparathyroidism</i></li></ul><br></br><b>Trauma<br></br>Surgical procedures:</b><br></br><ul><li><i>ERCP</i></li></ul><b>Postop compl (abd/cardiac)<br></br>Tumors (pancreatic/ampulary)<br></br>Post. penetrating PUD<br></br>Sph of Oddi dysfunction<br></br>Toxins<br></br>Idiopathic</b><br></br><br></br>
Risk Factors for GI Bleeding
<b>Advanced age<br></br>PHM:</b><br></br><ul><li><i>Malignancy</i></li><li><i>Liver dis</i></li><li><i>H.Pylori infection</i></li><li><i>Previous GI Bleeding</i></li><li><i>Hx of AAA repair</i></li></ul><br></br><b>SH:</b><br></br><ul><li><i>Smoking</i></li><li><i>ETOH</i></li><li><i>Substance abuse</i></li></ul><b>Medication:</b><br></br><ul><li><i>NSAIDs</i></li><li><i>Steroids</i></li><li><i>AntiPlt/AntiCoag</i></li></ul>
“<span>List 4 extra-abdominal causes for severe abdominal pain</span>”
-ACS/ MI<br></br>-Pericarditis, myocarditis<br></br>-Pneumonia<br></br>-PE<br></br>-Testicular torsion<br></br>-DKA<br></br>-Toxic ingestions<br></br>-Sepsis/ Bacteremia<br></br>-Sickle cell crisis
“<span>You obtain the following abdominal XR. What are 3 features of toxic megacolon that may be seen on abdo XR?<br></br></span><img></img><span><br></br></span>”
-Dilation of colon > 5.5-6 cm<br></br>-Loss of haustral pointings<br></br>-Black arrow: ‘thumbprint sign’ – bowel wall edema<br></br>-Pseudopolyps often extending into the lumen<br></br>-White arrow: pneumatosis intestinalis - intramural gas<br></br>-Pneumoperitoneum, if perforation
