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Clin Med III - GI > IBS, GI Bleeding, Nutrition > Flashcards

IBS, GI Bleeding, Nutrition Flashcards

1
Q

IBS is divided into what 2 categories

A

UC

Crohns

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2
Q

define UC vs Crohns

A

UC - Diffuse inflammation, friability, erosions and bleeding of mucosa that is limited to colon and rectum

Crohns - Transmural and entire GI tract (mouth to anus) w/ skip lesions

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3
Q

UC is caused by

A
  • Genetics – Ashkenazi jews
  • Smoking
  • Hx of prior GI infections – shigella, salmonella
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4
Q

crohns is caused by

A

Genetic factors - Family hx well established as one of the strongest risk factors for development for CD

Environmental factors - Lifestyle factors such as tobacco use, sedentary lifestyle, exposure to air pollution, and consumption of western diet

Infectious factors - CD often occurs after infectious gastroenteritis

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5
Q

si/sx of UC

A

Rectal bleeding

Diarrhea – hallmark is bloody diarrhea often mucoid*

Abdominal pain

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6
Q

classifications of UC

mild-mod

severe

A

Mild-mod Gradual onset diarrhea <4x/day and intermittent bloody mucoid stool

•No significant abd pain but LLQ tenderness that is relieved by a BM

Severe >6 bloody diarrhea stools per day

  • Severe anemia, hypovolemia, hypoalbuminemia and nutritional deficit
  • Abd pain
  • Fulminant colitis = subset of severe dz which is rapidly worsening sx w/ toxicity
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7
Q

define Fulminant colitis

what dz state is this seen in?

A

Fulminant colitis = subset of severe dz which is rapidly worsening sx w/ toxicity

severe UC

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8
Q

imaging modalities of UC

A

sigmoidoscopic/colonoscopic and histologic examinations (flex sig safer w/ severe pancolitis)

•Distortion of crypt architecture, crypt abscess, infiltration of lamina propria w/ plasma cells, eosinophils, lymphocytes, lymphoid aggregates and mucin depletion

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9
Q

tx of UC

A

Mild dz -Aminosalicylates (5-ASA) drugs

•Mesalazine PR suppository/enema or budesonide rectal foam preferred if mild proctitis

Moderate Dz - disease (failure of 5-ASA)

Budesonide orally – targets colon minimal systemic affect

•Prednisone

Severe disease (induction therapy)

  • Hospitalization w/ steroids (methylprednisolone
  • Steroid resistant disease = anti-biologics TNF-alpha blocker -> Infliximab (remicade), adalimumab (humira), Golimumab
  • Steroid and/or antibiologic resistant disease -> VEGF or JAK inhibitor
  • Cyclosporine

Surgical =- colectomy is curative

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10
Q

what is curative for UC

A

colectomy

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11
Q

UC or Crohns ??

•Assoc w/ abscesses, fistulae, sinus tracts, strictures and adhesions

A

crohns

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12
Q

indications for colectomy in UC

emergency

urgent

elective

A

emergency - life threatening complications related to fulminant dz such as toxic megacolon unresponsive to medical tx

urgent - severe dz admitted to hospital and not responding to tx

elective - refractory dz not responive to long term matienance

colorectal dysplasia or adenocarcinoma

long term disease 7-10 yrs

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13
Q

maintenance tx for UC

A

5-ASA if response to ASA or steroids

Budesonide

immunosupporessants - Azathioprine or 6-MP OR infiximab (TNF blocker)

JAK-inhibitor

probiotics help with maintaining remission

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14
Q

screening for colorectal cancer in UC

A

8 yrs after dz onset

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15
Q

hallmark symptom seen in UC

A

hallmark is bloody diarrhea often mucoid*

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16
Q

si/sx of crohns

A

ermittent bouts of low grade fever, diarrhea and RLQ pain (flares and remission)

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17
Q

Extraintestinal – more commonly seen in???

A

UC

  • Aphthous
  • Iritis/uveitis
  • Arthritis, ankylosing spondylitis
  • Erythema nodosum

Does not improve after colectomy – primary sclerosing cholangitis

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18
Q

si/sx of crohns

A

Abdominal pain (intermittent and often RLQ/periumbilical)

Diarrhea (watery/nonbloody typically and ?# per day)

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19
Q

gold standard for diagnosis of crohns

A

Colonoscopy and mucosal bx

  • Aphthoid, stellate, linear ulcers
  • Strictures
  • Segmental involvement w/ skip lesions
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20
Q

tx of crohns

mild

mod-severe

A

Quit smoking

Diarrhea – Loperamide

Medical management first line, surgical second

Mild disease

•Colon and small bowel disease = mesalamine

Moderate-Severe disease

  • Steroids
  • Immunosuppressants
  • TNF-alpha blockers
  • Anti-integrins
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21
Q

tx of fistula dz in crohns

A
  • Antibiotic therapy- metronidazole and ciprofloxacin
  • Immunosuppressants and TNF-alpha blockers
  • Surgery
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22
Q

T/F

colectomy is curative in crohns dz

A

false

Unlike in UC, surgery is not curative in CD

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23
Q

classification system for UC and CD

A

Montreal

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24
Q

classification for crohns

A
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25
Q

classification for UC

A
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26
Q

define celiac dz?

where does it affect?

A

Immune response (allergy) in the proximal small bowel to ingested gluten

•Affects mucosa of proximal small bowel

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27
Q

si/sx of celiac dz

A

•Steatorrhea

  • Flatulence
  • Borborygmus
  • Weight loss Weakness/fatigue

•Severe abdominal pain

•Anemia

•Dermatitis herpetiformis

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28
Q

dx of celiac dz

A
  • IgA TTG
  • IgA level - If negative IgA TTG but strong clinical suspicion
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29
Q

Gold std dx of celiac

A

Endoscopy + biopsy - + distal duodenum

•Atrophy or scalloping of duodenal folds

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30
Q

histology of celiac dz

A
  • Villi are atrophic or absent
  • Hypertrophy of crypts
  • Cellularity of the lamina propria is increased with a proliferation of plasma cells and lymphocytes
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31
Q

tx of celiac

A
  • Gluten avoidance
  • Dietician consult
  • Vitamin supplementation - Vit A, B12, D, E
  • Steroids - Prednisone or budesonide 2 or more wks
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32
Q

causes of lactose intolerance

A
  • Genetics
  • Celiac disease
  • Crohn’s
  • Giardia
  • Viral gastroenteritis
  • Malnutrition
  • Short bowel syndrome
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33
Q

si/sx of lactose intolerance

A
  • Abdominal bloating/cramping
  • Flatulence
  • N/V/D
  • Borborygmi
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34
Q

dx for lactose intolerance

A

Hydrogen breath test -

After ingestion 50g lactose a rise in breath H+ of greater than 20ppm w/in 90 min

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35
Q

tx of lactose intolerance

A

Goal of therapy is patient comfort and determining “threshold” of intake when symptoms occur

  • Spread out lactose intake <12g per day (1 cup of milk)
  • Lactase enzyme replacement (ex. Lactaid, Lactrase, dairy ease)
  • Ca+ supplements (if eliminating dairy)
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36
Q

Most cases of infectious diarrhea are viral

Most cases of viral diarrhea are??

A

novovirus

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37
Q

Most cases of severe diarrhea are ____??

and are caused by ___?

A

Most cases of severe diarrhea are bacterial

Most cases of bacterial diarrhea are Campylobacter

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38
Q

define diarrhea

A
  • Decreased absorption OR Increased secretion (or both)
  • RESULTING in > 200 grams of loose or watery stool a day
  • 75% water content
  • 3 or more Bowel Movements in a 24 hour period
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39
Q

determine b/w diarrhea

acute

subacute

chronic

A
  • Acute- 14 days or less, likely infectious causes (Bacterial and Viral)
  • Subacute- > than14 days but fewer than 30 days –
  • could be inflammatory or infectious
  • Chronic- more than 30 days
  • 3 types of chronic diarrhea are osmotic, secretory and inflammatory vs noninflammatory
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40
Q

name 4 types of fiarrhea

A

exuadtive-inflammatory

secretory

osmotic

motor

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41
Q

define diarrhea

exuadtive-inflammatory

secretory

osmotic

motor

A

exuadtive-inflammatory - damage to intestinal mucosa results in hypersecretion of water, impaired absorption of fat and electrolytes

mucus, blood, luekocytes present

secretory - secretion of water and electrolytes into intestinal lumen due to impaired enzyme activity

osmotic - poor absorption or excessive ingestion of hydrophilic substances

motor - rapid passage through intestine

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42
Q

assoc conditions w/ these types of diarrhea

exuadtive-inflammatory

secretory

osmotic

motor

A

exuadtive-inflammatory

shigellosis

enteroinvasive E. coli

C. diff

camplybacter

secretory

food borne

endocrine tumors

impaired absorption of bile acids

hx of ileal resection

osmotic

laxatives, mag citrate

lactose intolerance

motor

hyperthyroid

rx - reglan, e-mycin

carcinoid syndrome

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43
Q

si/sx of small bowel vs large bowel diarhea

A

Small bowel (enterotoxic): R_ARELY w/ feve_r, occult blood or inflammatory cells

  • Watery, non-bloody stool
  • Large volume
  • Abdominal cramping
  • Bloating/flatulence
  • Weight loss
  • VOMITING

Large bowel (ex. invasive, enteric, cytotoxic)

  • Frequent, small volumes
  • Painful BM

•Fever

  • Bloody/mucoid stool
  • WBCs/RBCs in stool
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44
Q

define entertoxic vs invasive

A

entertoxic : Infectious agent (the bug) creates a toxin floating in gut causing large amounts of watery diarrhea.

  • Often NO FEVER, NO ELEVATED WBC, NO FECAL LEUKOCYTES
  • C difficile, E coli, Staph Auerus, Cholera, Giardia

small bowel

INVASIVE: The Infectious agent breaks thru the blood/ gut barrier. (large bowel)

•FEVERS, LEUKOCYTOSIS, + FECAL LEUKOCYTES

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45
Q

common pathogens responsible for small bowel diarrhea

A

Norovirus

E. Coli (enterotoxic)

C. perfringens

S. Aureus

Vibrio cholera

Giardia

Cryptosporidium

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46
Q

common pathogens responsible for large bowel diarrhea

A

Campylobacter

Shigella

C. Diff

E. Coli (enteroinvasive)

Salmonella - S. enteritidis, S. typhimurium

CMV

Adenovirus

Entamoeba - protozoan

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47
Q

what is Fecal Lactoferrin

A

Can be a diagnostic tool used to detect bacterial infections that cause inflammatory diarrhea

Highly Sensitive and Specific

Limited use – Can help distinguish between IBD and IBS

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48
Q

dx of diarrhea

A

Stool Cultures: Used to identify bacteria/viruses, fungi. Most really only report Campylobacter, Salmonella, Shigella –If you want to look for other bacteria, be sure to specify.

•C diff TOXIN will need to be ordered separately, generally looking for the toxin and not the bacteria.

•O&P stool study – Parasites such as Giardia and Strongylodies and Entero-adherent bacteria can be difficult to detect but may be dx by intestinal bx

•Fecal Leukocytes – may also support the dx of inflammatory diarrhea. à more sensitive is Fecal Lactoferrin

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49
Q

in setting of diarrhea Consider serum and stool labs if

A
  • Diarrhea > 4 days
  • Fever > 38.5C
  • Blood in stools
  • Suspect IBS
  • Immunosuppression
    • leukocytes and lactoferrin **
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50
Q
  • Acute onset N/V w/in 12-48hrs
  • watery, non-bloody diarrhea with abdominal cramps
A

norovirus

Fecal-oral route with contaminated food – 1-3 days

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51
Q
  • non-bloody, Liquid, gray, “rice-water” diarrhea
  • No odor
A

Vibrio cholera

•Profound fluid and electrolyte loss in stool and rapid progression to hypovolemic shock within 24 hours of symptom onset

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52
Q

tx Vibrio cholera

A
  • IVF
  • Abx (ex. tetracycline, ampicillin, azithromycin, Bactrim, FQs)
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53
Q
  • Watery, yellow, foul-smelling diarrhea
  • Weight loss – more then 10% body weight

hx of camping or fresh water

tx?

A

Giardia

  • Metronidazole
  • Tinidazole
  • Nitazoxanide
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54
Q

•Most common parasitic cause of acute foodborne diarrhea in US

tx?

A

Cryptosporidium

Nitazoxanide

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55
Q

si/sx camplyobacter

pathogens?

A
  • Abrupt onset abdominal pain – similar to appendicitis
  • diarrhea (bloody or mucoid)
  • Prodrome of Fever/chills/body aches in 30%
  • C. jejuni
  • C. coli
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56
Q

tx of camplybactor

A

Supportive (ex. IVF, anti-emetics)

Immunosuppressed or severe dz – abx FQs (Levo, Cipro) or Azithro

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57
Q

dx of C. diff includes what criteria?

A

diarrhea (>3 watery stools in 24 hours) or w/ risk factors

  1. abx use or chemotherapy
  2. recent hospitalization
  3. advanced age
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58
Q

diarrhea assoc w/

  • Severe, watery diarrhea
  • Pseudomembranous colitis
  • Toxic megacolon
A

C. diff

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59
Q

tx of c. diff

A
  • Metronidazole
  • Vancomycin PO
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60
Q

e. coli diarrhea si/sx

tx??

A
  • Severe abdominal pain
  • Bloody diarrhea

NO ABX due to high risk of HUS

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61
Q

Leading cause of foodborne illness in US?

pathogens?

A

Salmonella

  • S. enteritidis
  • S. typhimurium
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62
Q

•Pea-soup diarrhea

A

Salmonella

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63
Q

tx salmonella

A

Ciprofloxacin or Levofloxacin for severe disease or immunocompromised patients

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64
Q

1 cause of acute diarrhea

A

viral

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65
Q

diarrhea assoc w/ completion of abx therapy

what abx are most frequently implicated?

A

c. diff

FQs, clinda, cephalosporin, penicillin

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66
Q

if diarrhea develops w/in

6 hrs

8-16 hrs

16 hrs

A

6 hrs - s. aureus or bacillus cereus esp if N/V

8-16 hrs - c. perfringens

16 hrs - other bacterial or viral pathogens

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67
Q

define HUS

A

HUS - Hemolytic-uremic syndrome may be greater – triad of Acute renal failure, hemolytic anemia and thrombocytopenia

•*** Same with Shigella – high risk of HUS

no e.coli

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68
Q

major presenting sx: pathogen? food source?

vomitting

watery diarrhea

inflammatory diaarhea

A

vomitting - s. aureus, B. cereus - prepared foods, salads, dairy, meat, chinese food

watery diarrhea - c. perfingens, e. coli - meat, poultry, gravy, imported berries

inflammatory diaarhea - camplyobacter, shigella - poultry

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69
Q

pathogen assoc w/ visiting petting zoos

A

salmonella

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70
Q

cardinal features of salmonella

A

invasive!!!

N/V

pea soup diarrhea not gorssly bloody

abdominla cramping

fever w/ chills

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71
Q

shigella characterized by

spread??

A

invasive

high fever

diarrhea (small volume, bloody and mucoid)

abdominal cramping

tenesmus - frequent

day care centers

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72
Q

potozoan induced diarrhea is caused by

A

entomoeba

crytosporidium

giardia

travelers diarrhea

73
Q

Entamoeba most common pathogen

assoc w/??

A

Entamoeba histolytica

poor sanitation/ daycare centers

74
Q

dx entomeoba

complications

A

stool cx and serum antigen

filminant colitis w/ bowel necrosis leading to perf and peritonitis

75
Q

tx of entomeoba

A
  • Metronidazole
  • Tinidazole
  • Ornidazole
76
Q

most common cause of parasitic foodborne diarrhea

tx?

A

crytosporidium

Nitazoxanide

77
Q

define trvaelers diarrhea

pathogen?

A
  • diarrhea that develops during or within 10 days of returning from travel
  • Most common organism is Escherichia coli- 1-5 days (NOT H157H7 strain)
  • Campylobacter most common in Southeast Asia
  • Rotavirus most common in travelers from Jamaica and in kids
78
Q

prevention and tx of travekers diarrhea

A

•Prevention includes: prudent selection of food and drinks (bottled beverages only, avoid ice) food that is thoroughly cooked pasteurized diary products

•Treatment:

•Flouroquinolones- Ciproflox, Levoflox

79
Q

define IBS

A
  • defined as recurrent abdominal pain or discomfort on average, at least 1 day per week in last three months with 2 or more of the following:
  • improvement with defecation
  • change in frequency of stool
  • change in form of stool
80
Q

most common complication of diarrhea

A

dehydration

81
Q

define

sever dehydration

some dehydration

A

Severe dehydration (at least two of the following signs):

  • lethargy/unconsciousness
  • sunken eyes
  • unable to drink Capillary refill ( ≥2 seconds )

Some dehydration (two or more of the following signs):

  • restlessness, irritability
  • sunken eyes
  • drinks eagerly, thirsty
82
Q

children w/ chronic diarrhea present as

A

failure to thrive

83
Q

name common pathogens responsible for diarrhea

viral

bacterial

protozoa

A

Viruses- #1 cause - Norovirus, Rotavirus, Adenovirus, CMV

Bacteria- Salmonella, Campylobacter, Shigella, enterotoxigenic

Escherichia coli., Clostridium difficile

Protozoa- Cryptosporidium, Giardia, Cyclospora, Entamoeba

84
Q

Endoscopy indications for IBS

A
  • More than minimal rectal bleeding
  • Weight loss
  • Unexplained iron deficiency anemia
  • Nocturnal symptoms
  • Family hx of colorectal cancer, IBD or celiac spruce
85
Q

tx of IBS

A

Dietary modification

  • low gas producing foods(beans, onions, celery, bananas, apricots, bagels, pretzels etc.)
  • ETOH, caffeine lactose avoidance
  • low FODMAP diet- fermentable foods (honey, corn syrup, apples, pears, mangoes, cherries etc.)

Physical activity

86
Q

medications used to tx IBS

A
  • Lubiprostone - chloride channel activator that enhances chloride-rich intestinal fluid secretion
  • Linaclotide - guanylayte cyclase agonist that stimulates intestinal fluid secretion and transit
87
Q

HALLMARK symptom of malabsorption

A

Steatorrhea - is excess fat in the stool

88
Q

conditions that lead to malabsorption

A
  • Celiac spruce
  • Bacterial overgrowth
  • Lactose intolerance
89
Q

dx malabsorption

A

•Quantitative stool fat test - GOLD STANDARD Ingestion high fat diet for 2 days before and during collection (100G fat) à Stool collected for 3 days

•Sudan stain (qualitative) - Determines the percentage of fat in stool

•Acid steatocrit- inexpensive and reliable – centrifugation of acidified stool in a liquid HCT capillary – solid, liquid, fatty layers

90
Q

si/sx of IBS

A
  • Chronic abdominal pain
  • Flatulence
  • Diarrhea
  • Constipation
91
Q

tx of diarrhea

A
  1. IVF +/- abx - added K+ or NaHCO3-, look at Anion Gap ON YOUR LABS
  2. Electrolyte replenishment (IV or ORS)
  3. Avoidance diet (ex. BRAT)
  4. Anti-motility meds
    1. Anti-emetics
    1. Zinc supplementation
    1. Probiotics
92
Q

Anti-motility meds for diaarhea

A

1.Loperamide (Imodium) - works by slowing down gut motility, decreases number of stools and makes diarrhea less watery

***CAUTION WITH INVASIVE BACTERIA

2.Bismuth subsalicylate

3.Lomotil

4.Eluxadoline (Viberzi) - combined opioid receptor agonist/antagonist

  1. IBS-D
  2. Schedule IV

5.Bile acid sequestrants - used in patients with persistent diarrhea despite antidiarrheal use

Cholestyramine Colestipol Colesevelum

93
Q

med used used in patients with persistent diarrhea despite antidiarrheal use

A

bile acid sequesterants

1.Cholestyramine Colestipol Colesevelum

94
Q

fluids in diarrhea should include

A
  • 3.5g sodium chloride
  • 2.5g sodium bicarbonate
  • 1.5g potassium chloride 20g glucose
  • Homemade solution: ½ teaspoon salt, ½ teaspoon of baking soda, 4 tablespoons sugar in 1 liter of water
95
Q

name the esstential nutrients

A

protein

fat

carbs

water

96
Q

define pathphys of thiamine (B1)

A

Thiamine is necessary for glucose metabolism – inability to convert pyruvate to acetyl-CoA*, so it metabolizes into lactate, resulting in neuronal injury

97
Q

thiamine deficency si/sx

complications

A

Early Symptoms: anorexia, irritability, memory issues

•Can progress to cardiac dysfunction, peripheral neuritis, peripheral edema, CNS issues

Wernicke encephalopathy –

may be iatrogenically precipitated by glucose loading in patients with unsuspected thiamine deficiency

TX ALL Alcoholics w/ thiamine

98
Q

si/sx of wernicke syndrome

A

encepaopahy

ocular motor dysfucntion

ataxia

99
Q

Riboflavin (B2_ pathophys and deficency si/sx

A

Coenzyme – acts as hydrogen acceptor and is a component of amino acid oxidases

Dermatitis

Cheilosis

Photosensitivity

blurred vision

100
Q

Coenzyme in the GI tract, nervous system and bone marrow, synthesis of DNA in bone marrow, synthesis of methionine and choline

Present in liver, meat, poultry, fish, dairy

A

B12

101
Q

si/sx of B12 deficency

who is likely to have a B12 deficency ?

A

Pernicious anemia – pallor, anorexia, dyspnea, weight loss, neurological disturbances

Macrocytic anemia – LOW H7H INC MCV

Peripheral neuropathy

Deficiency seen in

  • Vegans
  • gastrectomy patients, resection of the ileum
  • Tapeworms
  • Crohn’s disease
102
Q

pathophys of folate and si/sx of deficency

A

Coenzyme in the GI tract, nervous system and bone marrow, synthesis of DNA in bone marrow, synthesis of methionine and choline

Present in liver, meat, poultry, fish, dairy

Macrocytic anemia

GI disturbances

Increased risk of spina bifida

103
Q

folate deficency is seen in what populations

A

alcoholics, anorexia nervosa, poor diet(lack of fruits and veggies)

medications such as phenytoin, trimethoprimsulfamethoxazole, or sulfasalazine may interfere with its absorption

104
Q

etiology of iron deficency

si/sx

A

Etiology of Iron deficiency: GI bleeding, colon cancer, celiac disease, s/p gastric bypass

Iron deficiency anemia – pallor, lethargy, weakness, dyspnea

phagocyte dysfunction, paresthesias, body temperature dysregulation

105
Q

tx of iron deficency

A

PO – ferrous fumarate, sulfate or gluconate(take with Vitamin C or something rich in Vit C)

IV iron sucrose, Iron dextran(LMW ID) or ferric gluconate

106
Q

si/sx of C deficency

A

Scurvy - impaired formation of mature connective tissue and include bleeding into the skin - petechiae, ecchymoses, inflamed and bleeding gums

Fatigue

107
Q

Coenzyme for numerous cellular reaction, essential for Krebs cycle, formation of purines and non-essential AA’s

Present in liver, eggs, legumes, nuts

A

biotin

scaly rash on face

108
Q

water soluable vs fat sol vitamins

A

fat solu - ADEK

109
Q

pathophys of vit D

A
  • 7-dehydrocholesterol synthesized in skin by UVB à Vitamin D3(cholecalciferol)
  • Converted to 25-hydroxyvitamin D (calcifediol, or calcidiol) in the liver
  • 25-hydroxyvitamin D (calcifediol) undergoes a chemical modification in the kidneys to the active form, calcitriol (1,25-dihydroxyvitamin D)
110
Q

test forvit D deficency

A

serum 25-dihydroxyvitamin D (25[OH] vitamin D)

111
Q

Collective designation for stereoisomers of tocopherols, chemically related to sex hormones

•Stored in muscle and adipose tissue

A

vit E

112
Q

si/x of vit E deficency

dx??

A

Hemolysis, fragile capillaries, peripheral neuropathy

Seen in celiac disease, SB resection, bariatric surgery

alpha – tocopherol

113
Q

define vit K and name 2 types

A

Coenzyme that aids in the process of carboxylation of coagulation factors (VII, IX, X and prothrombin), making them active

Present in kale, spinach, margarine, liver, veg. oils, olive oils

Vitamin K1(Phylloquinone) – vegetable sources

Vitamin K2(Menaquinone) – synthesized by bacterial flora and found in hepatic tissue

114
Q

si/sx of vit K deficency

dx?

A

Easy bruising and bleeding(prolonged clotting)

Prolonged PT and elevated INR

115
Q

pathophys of coumadin

A

•Inhibits the activity of an enzyme (vitamin K epoxide reductase) that recycles Vitamin K into the active form of vitamin K -> prevents coagulation factors from undergoing a chemical change rendering them inactive

116
Q

vit K deficency seen in

A

Deficiency seen in

  • Celiac disease
  • Crohn’s
  • Biliary obstruction.
  • SB resection
  • broad-spectrum antibiotic tx (reducing gut bacteria)
117
Q

Muscle tetany(Chvostek sign),

carpopedal spasm(Trousseau sign)

seen in??

A

hypocalcemia

hyper - depressed neural function, lethargy, confusion, muscle pain, w

118
Q

tx of calcium

hyper

hypo

A

HYPO -

IV Calcium gluconate in 50mL of NS or D5

Tx underlying cause

•Vitamin D in D deficiency, CKD, hypoparathyroidism, and liver disease

HYPER

Mild – Mod no tx

Severe >14

  1. Isotonic saline
  2. calcitonin
  3. Administer Zoledronic Acid, or pamidronate(Bisphosphtes)
119
Q

conditions causing hyper/hypophosphatemia

A

Conditions causing hyperphosphatemia

•Advanced CKD (MCC), Tumor lysis syndrome(lymphomas, leukemias), rhabdomyolysis, hypoparathyroidism, acromegaly, bisphosphonates, vit D toxicity

•

Conditions causing HYPOphosphatemia

  • Medications – antacids, niacin, anabolic steroids, estrogen, OC
  • DKA or nonketotic hyperglycemia*
  • Refeeding syndrome,
120
Q

si/sx of hypophos

A

myopathy, dysphagia, ileus, hemolysis, anorexia, bone/muscle pain

121
Q

tx of hyper/hypo phos

A

hypo

Asymptomatic with a phosphate of <2.0 à PO phosphate

Symptomatic:

  • 1.0-1.9 - PO phosphase
  • <1.0 - IV phosphate

hyper

IV saline infusion in normal renal function

•Need to monitor calcium and provide calcium supplementation

Hemodialysis in renal failure and symptomatic hypocalcemia

122
Q

tx of hypokalemia

A

Mild to moderate hypokalemia

  • PO potassium chloride
  • Amiloride 5mg daily
  • Spironolactone 25mg

•

Severe <2.5

•PO and IV Potassium

123
Q

tx of hyperkalemic emergency

A
  • Calcium gluconate or calcium chloride
  • IV regular insulin
  • Removal of Potassium: Furosemide
  • GI Cation Exchangers u Patiromer OR Zirconium cyclosilicate
124
Q

rhabdomyolysis, meds, insulin deficiency, met acidosis

•muscle weakness or paralysis, cardiac conduction abnormalities

dx??

A

Hyper K

125
Q

Vomiting, diarrhea, sweating, abdominal cramps, convulsions

tx?

A

hypoNA

Acute <48hrs – IV saline

Chronic

  • Mild (130-134) – fluid restriction
  • Severe (<130) IV saline
126
Q

Water losses (skin, GI, urinary, etc), hyperthalamic lesions – diabetes insipidus, sodium overload

tx?

A

hyperNa

Acute <48hrs

  • IV D5W
  • Add ongoing water losses
  • Monitor sodium and glucose every 1-2 hours
  • Replace any electrolyte abnormalities

Chronic

  • IV D5W
  • Monitor sodium for 4-6 hours
  • Replace any electrolyte abnormalities
127
Q

define magnesium

A

Constituent of many coenzymes that convert ATP to ADP, neuro-muscular irritability

Altered magnesium concentration usually provokes an associated alteration of Ca2+

128
Q

dominished DTR, bradycardia, hypotension, complete heart block ->Sudden cardiac death

is seen in

Tx

A

hyperMg

Normal renal function – stop magnesium therapy, or administer a loop/thiazide diuretics

Moderate renal insufficiency - stop mag-containing medication, start isotonic IV fluids plus a loop diuretic

Severe renal insufficiency – hemodialysis with IV calcium

129
Q

common causes of hypoMg

si/sx

A

•Diarrhea and GI loss

tremors, neuromuscular issues, muscle weakness, irregular heartbeat, vasospasm, and HTN

130
Q

tx of hypoMg

A

Severe symptoms: magnesium sulfate IV

Nonemergent – magnesium sulfate IV

Mild symptoms and normal renal function –elemental magnesium in divided doses

Mild Symptoms in renal insufficiency –IV mag sulfate

131
Q

Deficient mineralization(calcium and phosphorous) at the growth plate, as well as architectural disruption of this structure

A

Rickets

132
Q

2 classifications of rickets

A
  • Calcipenic rickets - calcium deficiency, which usually is due to insufficient intake of or metabolism of vitamin D
  • Phosphopenic rickets - caused by low phosphate levels, or genetic condition causing renal phosphate wasting (rare)
133
Q

si/sx of rickets

A
  • Delayed closure of fontanelles
  • parietal and frontal bossing
  • craniotabes(soft skull bones)
  • bowing of the femurs and tibias
  • widening of the wrist and bowing of the distal radius and ulna
134
Q

dx rickets

A

Elevated alk phosphatase

  • Phosphopenic - 400 to 800 IU/L])
  • Calcipenic – up to 2000 IU/L

Low phosphorous, calcium may be normal or low, 25-(OH) vitamin D usually low

Elevated PTH in calcipenic

Normal or mildly elevated PTH in phosphopenic rickets

135
Q

tx of rickets

A

Vit D def –vitamin D + Calcium

Calcium def - calcium and RDA of Vitamin D

136
Q

meds to tx obesity

A

GI fat blockers - Orlistat

Appetite suppressants

  • Liraglutide
  • Phentermine/topiramate
  • Naltrexone SR/buproprionSR
137
Q

surgical tx of obeisity

A

Bariatric Surgery:

•Severe obesity (BMI>40) or moderate obesity (BMI >35) with serious medical comorbidities*

138
Q

nutrient supplementation w/ bariatric surgery

A

Bariatric Surgery: Roux-En-Y and Sleeve Gastrectomy

dudenum - iron, thiamine, calcium, copper

ileum - B12, vit D

jejunum - zinc

139
Q

causes of UGIB

A

Gastroduodenal Ulcers/ Peptic Ulcer Disease

H pylori

Erosive esophagitis

Gastritis/Duodenitis

Esophageal Varices

Mallory-Weiss Syndrome

Arteriovenous Malformations (AVM’s)

UGI Malignancy

140
Q

Gastroduodenal Ulcers/ Peptic Ulcer Disease

si/sx

risk factors

A

Asymptomatic 70%

May have dyspepsia

PAINLESS

Risk Factors:

H. Pylori

NSAIDs

Physiologic stress

141
Q

causes of LGIB

A

Diverticular bleeding

AVM’s

Infectious / Ischemia Colitis

IBD (Cohn’s and UC)

Colon Cancer

Hemorrhoids

Anal Fissure

Post-polypectomy bleeding

142
Q

dx modalities for H. pylori

A

Most common cause of chronic bacterial infection in humans

Invasive – endoscopy w/ biopsy

Noninvasive – urea breath test, stool antigen, serology

**stool antigen test after tx to make sure it worked

143
Q

tx of h.pylori

A

Triple Therapy (Prevpac)– PPI, amoxicillin and Clarithromycin

•(OK to substitute Flagyl if PCN allergy)

•

Quadruple therapy (Pylera) – PPI, bismuth subsalicylate, Flagyl and tetracycline

144
Q

Erosive esophagitis patients usually have a hx of..?

si/sx

tx?

A

GERD

Hematemesis, Melena

Heart burn

Reflux – classic GERD hx

Difficulty swalling

Egd diagnostic – possibly therapeutic if actively bleeding

tx: PPI

145
Q

Egd- patchy, erythema, no white ulcer bed

Does not commonly require endoscopy – tx w/ PPI and follow

A

Gastritis/Duodenitis

Acid-associated inflammation and mucosal injury to lining of stomach and duodenum

•Rarely cause significant UGIB – more common during anticoagulation therapy

146
Q

Esophageal Varices - Develop as consequence of….

A

pHTN usually in liver cirrhosis

147
Q

si/sx esophageal varicies

A

Dilated veins in distal esophagus and stomach

  • Hematemesis
  • Melena/ hematochezia
  • Hypotension
  • Pallor, tachycardic, diaphoretic
148
Q

tx of eso varices

A

dentify and stabilize – think intubation if vomiting

Abx prophylaxis: Ceftriaxone

Start IV Octreotide – reduce mortality

Emergent Egd – band ligation (first line)

Blake more (balloon tamponade only for 24-48 hrs)

Transfer to liver center for TIPS

149
Q

UGIB Associated w/ forceful retching

dx?

tx?

A

Mallory-Weiss Syndrome

Longitudinal lacerations in distal esophagus

Dx: Egd

PPI therapy

Antiemetics

150
Q

Arteriovenous Malformations (AVM’s) are usually seen in patients on …?

A

Dilated veins along GI tract - Usually in pts >60 y/o

Located throughout GI tract

Risk Factors:

•Anticoagulation

  • ESRD
  • AS
  • Von Willebrand
151
Q

si/sx of AVMs

A

Asymptomatic **

Occult bleeding

Iron deficiency anemia

Dyspnea , SOB

Weakness

Melena

152
Q

dx and tx of AVMs

A

Dx: Egd w/ hemostasis

  • Argon plasma coagulation
  • Small bowel video capsule

Tx: cauterize or clip

153
Q

UGI malignancies include

tx?

A

Adenocarcinomas, GIST, Lymphomas

Ulcerated exophytic masses in the esophagus, stomach or duodenum

Difficult to achieve endoscopic hemostasis à risk of rebleeding

Surgical resection is tx of choice **

Palliative / chemo and radiation

154
Q

mainstay tx in UGIB

A

PPIs

  • Block gastric acid secretion by irreversibly binding to parietal cells who produce acid
  • In acute GI Bleeding à raise pH in stomach to more neutral level, stabilizing blood clots and promotes healing
155
Q

bleeding that ccurs distal to ligament of Treitz, but proximal to ileo-cecal valve

si/sx

A

SB Bleeding

  • Overt such as melena or hematochezia, occult bleeding
  • sx of anemia – fatigue, SOB, weakness
  • Increased sleeping
  • Pallor
156
Q

dx and tx of small bowel bleeds

A

dx •upper and lower endoscopy

tx

•Diagnose source and tx accordingly: - Cautery, endoclips, argon plasma coagulation

•If NO source is found & patient is STABLE

  • Monitor and transfuse PRN (consider iron)
  • Consider repeat evaluation if symptoms persist or change

•If bleeding persists:

  • Small bowel enteroscopy
  • Imaging
  • CTA
  • Laparoscopic enteroscopy
157
Q

Most common cause of LGIB

si/sx

A

Diverticular bleeding

Massive bleeding that stops spontaneously

Painless hematochezia – sudden onset

Syncope, diaphoresis, weakness, lightheadedness

158
Q

dx and tx of Diverticular bleeding

A

Dx: clinical suspicion

  • Colonoscopy – test of choice
  • Nuclear scintigraphy (NM Bleeding scan)
  • Angiography and embolization
  • Surgery – last resort
159
Q

Infectious / Ischemia Colitis occurs in what area of colon

A

Temporary interruption of blood flow to an area of the colon (“watershed areas” )

•From splenic flexure to descending colon

160
Q

si/sx of Infectious / Ischemia Colitis

A

Abrupt onset fecal urgency

Lightheadedness, syncope, diaphoresis

Severe abdominal PAIN – persistent and intense

Bloody diarrhea

Vasovagal sx

161
Q

si/sx of right sided vs left sided colorectal lesion

A

BRBPR – left-sided lesion

Melena – right sided lesion

Iron deficiency anemia

162
Q

anal fissure can be described as

A

passing razorblades

163
Q

Post-polypectomy bleeding

tx:

A

Ocurs w/in 7-10 days of a colonscopy w/ polypectomy

Repeat colonoscopy

  • Hemostasis w/ endoclips
  • Epinephrine
  • Cautery
  • Tell GI doc – considered complication
164
Q

dx and treatment of anal fissure

A

Dx: rectal exam, anoscope

Tx: fiber, sitz baths, stool softener

  • Topical analgesic – lidocaine
  • Topical vasodilatory – nifedipine or nitroglycerin
  • Topical diltiazem
  • Surgical repair
165
Q

dx and tx or hemhorroids

A

Dx: anoscope, colonoscopy

Tx: conservative – rubber band ligation

Hemorrhoidectomy last resort – risk of incontinence, painful

166
Q

crohns vs UC

location

appearance

anal involvement?

fisutale/stenossi?

A

crohns

  • Location: mouth to anus (commonly involves terminal ileum)
  • Appearance – skip lesions
  • Characteristics – “cobblestoning”
  • Commonly has anal involvement
  • Fistulae and stenosis can result

UC

  • Location – colon
  • Appearance – confluent areas of inflammation w/ abrupt transition to normal mucosa
  • Rarely involved the anus
  • Mucosal depth of inflammation
  • Rarely stenosis or fistulae
167
Q

lab value that could suggest UGIB

A

elevated BMP

168
Q

GOLD STANDARD FOR DIAGNOSIS AND TREATMENT OF AN UGIB *

A

endoscopy

169
Q

nasogastric lavage indications

A
  • USED TO DIFFERENTIATE IF BLEEDING IS ACTIVE FOR UGIB
  • WOULD NOT RECOMMEND IF CONCERN FOR ESOPHAGEAL VARICES
  • MAY HELP TO DIFFERENTIATE UGIB VS LGIB
170
Q

tx of UGIB

A

ABC

trend H&H, BUN

IV PPI BID – TYPICALLY IV PANTOPRAZOLE(PROTONIX

ENDOSCOPY (HEMODYNAMICALLY STABLE)

•Abx PROPHYLAXIS FOR CIRRHOSIS W/ ANY GI BLEEDING - CEFTRIAXONE

171
Q

tx of UGIB variceal bleeding

A

IV OCTREOTIDE

172
Q

tx of LGIB

A

ABCs

reversal of anticoags

colonoscopy

173
Q

define diverticular dz and 2 types

A

CONDITION OF HAVING DIVERTICULOSIS - SAC-LIKE PROTRUSION; MUCOSA AND SUBMUCOSA HERNIATE THROUGH MUSCLE LATER

•DIVERTICULITIS: INFLAMMATION OF DIVERTICULUM

•DIVERTICULAR BLEED: PAINLESS BLEEDING OF DIVERTICULA

174
Q

si/sx of diverticular dz

A

•LOWER ABDOMINAL PAIN (LLQ TO SUPRAPUBIC)

BOWEL CHANGES (CONSTIPATION OR DIARRHEA

175
Q

diverticular dz most commonly effects

A

MOST COMMONLY AFFECT SIGMOID AND LEFT COLON, BUT CAN BE PANCOLONIC

176
Q

golad standard imaging in diverticular dz

A

ABDOMINAL/PELVIC CT – BEST MODE OF IMAGING*

177
Q

tx of diverticular dz

A

analgesics and antiemetics

abx - coverage of gram neg and b. fragilis

cipro (or levaquin) + flagyl

2nd or 3rd gen ceph + flagyl

TM/Sulf + flagyl

repeat imaging not neccessary

178
Q

diverticular colonoscopy screening guidelines

A

ALL PATIENTS SHOULD HAVE AN OUTPATIENT COLONOSCOPY IN 2-3 MONTHS TO ENSURE HEALING AND RULE OUT AN UNDERLYING MALIGNANCY**

179
Q

T/F

avoid colonscopy during acitve diverticulitis

A

true

Clin Med III - GI (3 decks)

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