KC GI Flashcards
*3 places where a button battery could get stuck in esophagus (peds)
- Upper esophageal sphincter (cricopharyngeus muscle)*
- Aortic arch
- Left mainsteam bronchus
- Lower esophageal sphincter (diaphragmatic hiatus)
*3 mechanical ways to get button battery out of the esophagus
- If in upper esophagus, Kelly clamps or McGill forceps under direct visualization
- Pass Foley catheter beyond foreign body, inflate balloon
- Esophageal dilator to push foreign body into stomach
- Endoscopy
*4 mechanisms of injury of a button battery in esophagus
Pressure necrosis
Current generation
Chemical alkali liquidfacation
Heavy metal poisoning
*Interpret peds CXR with coin FB and where do things get stuck
- Cricopharyngeus muscle (UES)
- Left mainstem bronchus
- Diaphragmatic hiatus (LES)
- Aortic arch
*Regarding acute esophageal obstruction: 5 indications for endoscopy
Coins in proximal esophagus
Inability to handle secretions
Sharp objects
Esophageal button battery
Impactions that fail to pass in 24h
High grade esophageal obstruction
*5 causes of esophageal obstruction
Strictures
Mucosal rings
Eosinophilic esophagitis
Large FB
Impared motility
*3 medications that could be used to relieve esophageal obstruction
New rosen’s half-heartedly recommends benzos only (previously: CCB, nitrates, glucagon)
*4 classic cxr findings that are supportive of esophageal rupture
Pneumomediastinum
Pleural effusions
Subcutaneous emphysema
Mediastinal widening
Pulmonary infiltrates
*2 diagnostic tests (best and alternate) for esophageal rupture
Contrast radiographic studies (water soluble then barium)
CT chest
*4 steps in the immediate management of esophageal rupture
IV abx (tazo + vanco)
NPO
Surgical consult
Close monitoring
*5 conditions or disorders that may predispose a patient to esophageal obstruction by foreign body
Strictures
Mucosal rings
Eosinophilic esophagitis
Mediastinal mass
Thyroid enlargement
Impared motility (MS, MG, scleroderma) …
*4 reasons for urgent endoscopy in esophageal FB
Coins in proximal esophagus
Inability to handle secretions
Sharp objects
Esophageal button battery
Impactions that fail to pass in 24h
High grade esophageal obstruction
*3 complications of esophageal FB
Perforation
Aortoenteric fustula
Tracheoesophageal fistula
Abscess
*Start with perforation and think 3 places it can go - nowhere and cause in infectino, fistula into trachea or aorta
*3 reasons for urgent gastric endoscopy
Longer than 5cm
Wider than 2.5cm
Sharp/pointed objects
*4 CXR findings of Boerhaave syndrome
see above
*Diagnostic test for Boerhaave syndrome
see above
*List 5 causes of acute liver failure
Alcoholic hepatitis
Viral hepatitis
HCC
Acute fatty liver pregnancy
Tylenol OD
Ischemia
Autoimmune
Wilson’s
Drug induced
Sepsis
Trauma
*5 findings of acute liver failure on exam or history
Think of a tylenol overdose:
Malaise
N/V
Abdo pain
Bleeding (coagulopathy)
Hypotension
Altered mental status (hepatic encephalopathy)
Seizures
*Three most common viral causes of acute liver failure and route of transmission
However the most significant and potentially severe cases of viral hepatitis are caused by type A (fecal-oral), type B (serum), type C (posttransfusion), and delta viruses. The Epstein-Barr virus, the causative agent of mononucleosis, is also a common cause of hepatitis, although it is more important clinically for its nonhepatic effects.
*What is HEP B prophylaxis in the ED for an unimmunized patient
• HBIG
• Hep B immunization x3
*Most likely lab test to be elevated in hepatic encephalopathy, and outline Tx
Ammonia
• IV fluids (hydration)
• Low protein diet
• Neomycin (reduces colonic bacteria that make ammonia)
• Lactulose (traps ammonia in feces)
• Zinc replacement (metabolism of ammonia dependant on zinc)
• Rifampicin if refractory to lactulose
LOLA, BCAA, correct hypokalemia
*Percentage risk of HEP C transmission in needlestick from HEP C positive patient
1.80%
*5 risk factors for cholesterol gall stones
- Fat
- Fertile
- Female
- Forty (over)
- Fibrosis (CF)
- Family History
- Drugs (progesterone, estrogen –>slows motility; ceftriaxone)
- recent Weight Loss
*4 complications of cholecystitis if untreated
- Gangrene of GB
- Perforation
- Sepsis
- Ascending cholangitis
- Liver failure
Porcelain GB
*2 imaging modalities (other than US) for acute cholecystitis
- MRCP
- CT scan
*3 findings of acute cholecystitis on US
- Presence of stones in gallbladder
- Thickened gallbladder wall (>3mm)
- Pericholecystic fluid
- Distended gallbladder >4cm
- Sonographic murphy’s
*2 other complications of gallstones not related to pancreatitis
- Fistula
- Gallstone ileus
*Table differentiating SBP vs secondary BP
Total protein > 1g/dL
Glucose >50 mg/dL
LDH > upper limit of normal for serum
Need 2 or more to be present in analysis of serum
*3 tests for ascitic fluid when concerned for SBP
Total protein
cell count (PMNs)
Glucose
Gram stain
Culture
pH
LDH
Carcinoembryonic antigen (CEA)
Alkaline phosphatase
*8 complications of paracentesis
Ascitic fluid leak
Abdominal wall hematoma
Perforation of viscera
Perforation of blood vessel
Local infection
Peritonitis
Hyponatremia
Rapid re-accumulation
*Underlying Causes of Hepatic Encephalopathy in Patients With Known Liver Disease
Gastrointestinal bleeding
Electrolyte abnormalities including hypokalemia and alkalosis
Venous thrombosis
Ileus and constipation
Sedative medications
Dehydration and hypovolemia
Acute or chronic kidney injury
Infection
*5 causes of cirrhosis
Not in new Rosen’s
vTreatment of hepatic encephalopathy
Assess airway
Lactulose
Aminoglycoside abx (neomycin/vanco) or rifaximin
Glycerol phenylbutyrate
Treat H. pylori
Zinc replacement
Ensure adequate PO intake of protein
Hold sedating medications
Correct electrolyte abnormalities
*Differential for hepatic encephalopathy (list 5)
- Sepsis from perforated viscus
- SBP
- ETOH withdrawal
- Meningitis
- ICH
- Post-ictal state
- Complex UTI
- Appendicitis
- Diverticulitis
- Pancreatitis
*3 causes of hepatic encephalopathy
- Non-adherent to medication regime (e.g. stopped lactulose)
- GI bleed
- Fulminant liver failure
- ETOH/new drug intoxication
- Alkalosis and hypoK (lead to increased ammonia production)
- SBP
*Ascites WBC count is 500, describe your management in one line
Abx (ceftriaxone) and admission
- Paracentesis with fluid PMN count < 250 cells/mm 3 and infectious signs and symptoms requires parenteral cefotaxime, 2 g tid
- Paracentesis with fluid PMN count > 250 cells/mm 3 requires parenteral ceftriaxone, 2 g tid
*What are 5 MOST COMMON causes of Pancreatitis in North America
In order:
EtOH
Gallstones
ERCP
Drugs (Sulphasalazine, azathioprine, NSAIDS, diuretics + metronidazole, ranitidine, valproate, erythromycin, tetracyclines)
Trauma
*According to the 2 Atlanta classification (2012) of pancreatitis, what are the two classifications of pancreatitis?
Interstitial edematous pancreatitis
Necrotizing pancreatitis
*What are 4 local complications of acute pancreatitis according to Atlanta guidelines?
Acute hemorrhage (intraluminal GI bleeding or intraabdominal)
Ileus → bowel obstruction
Peripancreatic fluid collection (homogenous) – adjacent to pancreas – seen in I.E. pancreatitis
Acute necrotic collection (heterogeneous) – intra/extrapancreatic. – seen in necrotic pancreatitis
*What are 9 systemic complications of acute pancreatitis?
ARDS
Atelectasis
Pleureal effusion
Renal failure
Sepsis
Shock
Organ failure
Coagulopathy
Hyperglycemia
*4 other causes of pancreatitis
GET SMASHED
Gall stones
EtOH
Trauma
Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidemia
ERCP
Drugs
*Ranson Criteria at admission
Ranson Gets Lucky When Attempting Acrobatics
Age > 55 years
Glucose > 10mmol/L
AST > 250 IU/L
LDH > 350 IU/L
WBC > 16
*4 principles of pancreatitis management
Fluid resuscitation
Electrolyte abnormality correction
Normoglycemia
Pain control
Oral or enteral nutrition
Consider ERCP
Possible delayed surgery
*Causes for obstructive pancreatitis
Biliary stones
Congenital—pancreas divisum, annular pancreas
Tumors—ampullary, neuroendocrine, pancreatic carcinoma
Post-ERCP
Ampullary dysfunction or stenosis
Duodenal diverticulum
Trauma
*Causes of lipase elevation that are not pancreatitis
IBD
Renal impairment
Lupus
Multiple myeloma
HCC
Lipase is really my hardest card
*8 drugs that can cause pancreatitis
Not in new Rosen’s
*4 x-ray findings in pancreatitis
Not in new Rosen’s but:
Pleural effusion
Atelectasis
Hemidiaphragm elevation
Pulmonary edema
Localized SB ileus (sentinel loop)
Spasm descending colon (colon cut-off sign)
*4 steps of management of SBO
- Antibiotics with gram-negative and anerobic coverage
- Analgesia
- NPO/IV fluid resuscitation
- General surgery consultation
*First intervention for volvulus
IV access, IVF and call surgery?
*Patient with volvulus become febrile, hypotensive with peritoneal signs. 5 next steps in management
- OR/General surgery
- IV crystalloid resuscitation
- IV antibiotics
- NPO
- Analgesia
- Anti-emetics
- Blood cultures/sepsis panels
*4 mechanisms for mesenteric ischemia
- Non-occlusive mesenteric ischemia
- Mesenteric arterial thrombosis
- Mesenteric arterial embolus
- Mesenteric venous hrombosis
*2 risk factors for above mechanisms
- Hypoperfusion: sepsis, severe dehydration, pancreatitis, or hemorrhagic shock
++Sympathetic: CHF, vasopressors, cocaine, digoxin - Advanced age, hypertension, diabetes, tobacco use
- Age >70, Female»Male, MI, cardiomyopathies, ventricular aneurysms, endocarditis, atrial fibrillation
- Hypercoagulable states: Factor V Leiden, pregnancy etc.
Inflammatory conditions: pancreatitis, cholangitis etc.
Trauma: abdo, post splenectomy
Misc: CHF, renal failure
*RLQ pain and fever: differential of causes requiring surgery
- Intestinal perforation
- Bowel obstruction
- Testicular torsion
- Obstructive ureterolithiasis
- Appendicitis
- Ovarian torsion
*Describe the following signs:
McBurney’s
Psoas
Obturator
Rovsing’s
i) McBurney’s sign: Tenderness at McBurney’s point (one-third the distance from the anterior superior iliac spine to the umbilicus)
ii) Psoas sign: Increased abdominal pain with patient lying on left side while provider passively extends the patient’s right leg at the hip with both knees extended
iii) Obturator sign: Increased abdominal pain in the supine position as the provider internally and externally rotates the right leg as it is flexed at the hip
iv) Rovsing’s sign: Abdominal pain in the RLQ while palpating the left lower quadrant
*4 diagnostic criteria for appendicitis on ultrasound
Diameter > 6mm
Non compressible
Hyperemia on Doppler flow
Air shadowing, discontinuous mucosa.
Fat stranding (hyperechoic signals associated with periappendiceal inflammation)
Peritoneal fluid surrounding the appendix (secondary finding)
*5 management priorities for appendicitis
- NPO
- Maintenance IV fluids
- Supportive care (analgesia, anti-emetic, anti- pyretic)
- Antibiotic therapy (per Rosen’s: metronidazole and ciprofloxacin or ceftriaxone and metronidazole for non-perforated appendicitis and piperacillin- tazobactam for perforated appendicitis)
- Surgery consultation
*Discuss the role of the WBC count in the setting of possible appendicitis
Only useful as part of a score ie. PAD or Alvarado, moreso in a rule-out setting
*Bloody diarrhea, backpacking in Thailand, failure of cipro: pathogen and treatment
Campylobacter, supportive care, azithromycin
*Raw seafood in Japan, bloody diarrhea: pathogen and treatment
Vibrio, supportive care
*Parasthesias and cold allodynia: pathogen and treatment
Ciguatera/ciguatoxin, supportive care (amitrityline for itch, atropine for brady)
*5 organisms that cause bloody diarrhea
Campylobacter, Salmonella, EPEC, Shigella, Yersinia, Vibrio
*Watery diarrhea from drinking water, toxin mediated (Incubation: 24-72hrs)
E. Coli
*Overgrowth of normal flora, watery diarrhea +/- blood
C. diff
*1-3 weeks incubation, usually backpackers. Watery diarrhea
Giardia lambdia
*Mayonnaise, Potato salad, Toxin Mediated, large outbreaks (I: 1-6hrs)
Staph aureus
*Bitter peppery taste; histamine rx (I: 5-60 min)
Scomboid
*Diarrhea after eating fried rice (I:2-4hrs)
B. cereus.
*Bloody diarrhea, usually afebrile — HUS (I: 3-8 days)
E. coli O157:H7
*Associated with neuro/CN deficits
C. botulinum
*Hot/cold reversal, paresthesias/GI complaints, cholinergic, worse with EtoH (I: 2-6 hrs)
ciguatoxin
*Dysentery, may mimick appendicitis, postinfection polyarthritis (I: 12-48hrs)
Yersinia
*Metallic taste, flusing 1 hr after eating fish: pathogen and treatment
Scomboid, benadryl
*Severe vx 4 hrs after eating reheated rice: pathogen and treatment
B. cereus, supportive (vanco if severe)
*Pallor, anuria, bloody diarrhea after eating hamburger: pathogen and treatment
E. coli O157:H7, supportive
*Flushing wheezing, N/V after eating meal @ Chinese restaurant
Monosodium Glutamate, Supportive (not in new rosens)
*7 extra-abdominal manifestations of Crohn’s
Here is just a few…
Perianal - skin tags, fissures, fistulas
Skin and mouth- Erythema nodosum, pyoderma gangrenosum, aphthous
ulcers
Nutritional deficiency - Acrodermatitis enteropathica (zinc), purpura (vitamins C and
K), glossitis (vitamin B), hair loss and brittle nail (protein)
PSC
Uveitis
Thromboembolic disease risk - 60% increased (PE/DVT)
Peripheral neuropathy
*Interpret XR of (large bowel) volvulos
Sigmoid volvulus: Grossly distended loop of colon lacking haustral markings,
Cecal volulus: Markedly dilated cecum, haustral markings present, with paucity of gas in the distal colon, classically a coffee bean appearance
*First intervention (stable patient)
Sigmoid: call GI
Cecal: call gen surg
*Patient becomes febrile, hypotensive, develops peritoneal signs. 5 next steps in management
- OR/General surgery
- IV crystalloid resuscitation
- IV antibiotics
- NPO
- Analgesia
- Anti-emetics
- Blood cultures/sepsis panels
*5 extra-intestinal features of IBD
see above
*4 intestinal complications of IBD
- Fissures
- Strictures
- Abscesses
- Fulminant colitis
- Toxic megacolon
- Intestinal perforation
*What is the maximum normal diameter of the transverse colon on XR?
- Small bowel: <3 cm
- Large bowel: <6 cm
- Cecum/sigmoid: <9 cm
*List 3 non GI manifestations that occur in > 10% Crohn’s patients.
Arthritis
Uveitis
Pyoderma Gangrenosum
Erythema nodosum
*List 4 pathologic features supportive of Crohn’s over ulcerative colitis.
Crohn’s skip lesions
Crohn’s goes all the way through the GI tract, especially affects ileum, UC
colon
Crohn’s transmural
Crohn’s causes fistulas, perianal disease, and stenosis
Crohn’s forms granulomas on biopsy
*Acute side effect of azathioprine?
N/V
Hepatitis
Pancreatitis
Increased risk of infection
Leukopenia
*What diagnosis do you need to r/o in sick UC patient?
Toxic megacolon - many to exclude
*3 risk factors for fournier’s
- Diabetes
- Vascular insufficiency
- Sensory neuropathy
*Mandatory treatments for fournier’s gangrene
Wide surgical débridement, broad-spectrum antibiotics with anaerobic coverage, and tetanus prophylaxis are indicated
*Recognize classic presentations for post bariatric surgery complications:
1. Months to year post surgery (after ++weight loss)
2. R shoulder pain and RUQ pain persistently and is 2 years out from surgery
3. Colicky pain 2 years post op
4. 10 days post-Roux-en-Y
5. LUQ pain, vomiting or dry heaves
6. 1 week or 1 year post lap band surgery
- Internal hernia
- Cholelthiasis
- SMA syndrome
- Anastamotic leak
- Gastric obstruction
- Migration of lap band (can be early or delayed)
*Name 2 other long term complications of bariatric surgery
GI bleeding
Vitamin deficiency (fat-soluble) / malabsorption (B12, D, thiamine)
*Crohn’s patient with abdo pain, provide differential of pain based on the following catergories: Vascular, cardiopulmonary, metabolic, GU
i) Vascular: Sickle cell crisis, mesenteric thrombosis, dissecting or ruptured aneurysm, pulmonary embolism, lymphadenopathy, retroperitoneal hemorrhage
ii) Cardiopulmonary: Pericarditis, myocarditis, myocardial ischemia, pneumonia, pleural effusion, pulmonary embolism
iii) Metabolic: DKA, Addison’s disease, hypercalcemia, uremia, porphyria, pheochromocytoma
iv) Genitourinary: Ureteral calculi, pyelonephritis, cystitis, hydronpehrosis/post-renal obstruction
*What is the mortality in elderly patients presenting to the ED with a chief complaint of abdominal pain?
NOT IN NEW ROSESNS
6-8x higher than that of young adults
*List 5 reasons why causes of abdominal pain are difficult to diagnose in the elderly
NOT IN NEW ROSENS
Abdominal musculature decreases - less likely to show rebound or guarding
Omentum is thinner and less likely to contain intra-abdominal process
Increased rate of atherosclerotic disease - decrease in blood flow leading to increased perforation
Dementia - unable to localize pain and difficult historian
May not present with fever or a WBC - immunosenescence
General physiological changes
*Name 2 physiologic changes in the elderly that predispose to increased risk of abdominal disease
NOT IN NEW ROSENS
STOMACH: decreased epithelial perfusion (increased perforation), weakened gastric mucosal, gastric secretions are more acidic (decreased bicarb secretion)
LARGE BOWEL: slow, chronic dilatation
VASCULATURE: Atherosclerosis predisposes them to mesenteric ischemia
BILIARY TRACT: Calcification of GI biliary tracts
SMALL BOWEL: Decreased blood flow,
LIVER Altered hepatic enzymatic activity
AUTONOMICS: Impaired thermoregulation, orthostatic hypotension
IMMUNE: sucks, unable to wall off infection - will have more systemic effects with intraabdominal dysfunction;
*5 etiologies for UGIB
Peptic ulcers (gastric more than duodenal)
Gastric erosion
Esophagogastric varices
Mallory-Weiss tears
Esophagitis
Gastric cancer
Aorto-enteric fisula
Also: IVACUM): Inflammation (esophagitis, gastritis, duodenitis), varices, angiodysplasia, cancer, ulcers, mallory weiss tear, AE fistula
*5 patient features for high risk UGIB
Renal failure
Liver failure
Metatstatic cancer
CHF
Present with melena, syncope
*5 management steps in this patient (Alcoholic +Hep C with hematemesis and melena)
Resuscitation
Blood products
Reverse anticoagulation (vit K/PCC/FFP)
Blakemore tube
PPI then Octreotide then Abx
GI consultation
*6 low risk criteria that would make it safe to discharge a patient with GI bleed
Normal BUN, hgb, BP, HR, young, no comorbidities
*5 high risk factors in GI bleed
Opposite of above
*3 emergent non-infectious causes of diarrhea
- Drugs (e.g. antibiotics)
- Toxins (e.g. ciguatera, Cholinergic poisoning)
- Gastrointestinal pathology (e.g. IBS, bowel obstruction, ischemic bowel)
- Neurologic (e.g. cord compression)
- Endocrine (e.g. adrenal insufficiency)
- Systemic illnesses (e.g. alcoholism, toxic shock syndrome)
- Toxic shock syndrome, SJS/TENS
*5 organisms that cause bloody diarrhea
“Clotty sanguin excrement screws your vitals”
Campylobacter
Salmonella
E. coli
Shigella
Yersinia
Vibrio
*4 organisms that have been implicated in HUS
E.coli O157:H7
Salmonella
Shigella
Campylobacter
*5 causes of life threatening constipation
SBO
Volvulos
Hernia
Intussusception
Stercoral perforation
*5 symptoms of functional constipation
Diarrhea alternating with constipation
Poor diet
Anismus
Unwilling to defecate
Abdo pain related to defecation
*5 management strategies for functional constipation
Increase activity
Increase hydration
Increase fruit and vegetables
Bulk laxatives
Osmotic laxatives
Therapy?
List risk factors for patients at higher risk for serious underlying disorders
(Box 24.1)
Age >60, previous abdominal surgery, recent instrumentation (ex. colonoscopy), hx of IBD, hx of cancer, active chemotherapy, immunocompromised, fevers/chills/systemic symptoms, women of childbearing age, recent immigrants, language or cognitive barrier
List 6 critical causes of abdominal pain
Ruptured ectopic, ruptured or leaking AAA, mesenteric ischemia, obstruction, perforated viscus, massive GI bleeding, acute pancreatitis
List 2 each of pre-hepatic, hepatic, and post hepatic causes of jaundice
Prehepatic: increased production of bilirubin, labs show increased unconjugated bilirubin. Etiologies: hemolysis, G6PD deficiency, sickle cell disease, hematoma resorption
Hepatic: failure of conversion unconjugated bilirubin to conjugated bilirubin, labs show elevated liver enzymes and signs of synthetic dysfunction ex. INR/PTT. Etiologies: tox (Tylenol), infection (hepatitis, malaria/tropical disease), EtOH, ischemia (Budd Chiari, shock liver)
Post hepatic: decreased clearance of bilirubin due to obstruction, labs show elevated conjugated bilirubin. Etiologies: cholangitis, choledocolithiasis, pancreatic head mass, Mirizzi syndrome
List 6 critical causes of jaundice
Fulminant liver failure, massive tylenol overdose, shock liver, cholangitis, Budd Chiari, transfusion reaction, preeclampsia
List 4 classes of medications (and 1 example in each) that can be used to treat vomiting
Dopamine: metoclopramide, haloperidol
Serotonin: ondansetron
Histamine: dimenhydrinate
Anticholinergic: scopolamine
List 6 critical causes of vomiting
Boerhaave’s, raised ICP, testicular torsion, ACS, DKA, ischemic bowel, carbon monoxide toxicity, meningitis
List 6 complications of vomiting
Metabolic: Metabolic alkalosis, hypokalemia, hypovolemia
Structural: Mallory-Weiss tears, Boerhaave’s, aspiration
List 6 extra-abdominal causes of nausea
Neuro: intracerebral bleed, meningitis, tumor, migraine, central vertigo (ex. stroke), peripheral vertigo (BPPV, labyrinthitis)
Endocrine: adrenal insufficiency, DKA
Pregnancy: hyperemesis gravidarum, nausea and vomiting of pregnancy
Tox: acetaminophen toxicity, alcohol withdrawal, opioid withdrawal, carbon monoxide poisoning
GU: UTI, pyelonephritis, testicular torsion, kidney stone
Cardiac: MI
List 2 etiologies of vomiting in each of the following age categories: newborn, infant, child, adult, elderly
Newborn: obstruction, biliary atresia, inborn errors of metabolism
Infant: pyloric stenosis, intussusception
Child: DKA, gastroenteritis, appendicitis, NAI
Adult: PID, MI
Elderly: increased ICP from mass, MI, intra abdominal infection
List 5 etiologies for lower GI bleed
hemorrhoids, fissures, angiodysplasia, diverticulosis, colitis (ischemic, inflammatory, infectious), cancer
List 5 mimics for GI bleeds
Meds: bismuth medications, activated charcoal, iron
Food: beets, grapes
Other sources of bleeding: vaginal bleed, epistaxis
List 5 sources of GI bleeding seen in children
Meckel’s diverticulum congenital AV malformation, foreign body, juvenile polyps, intussusception
List 10 risk factors for GI bleeds
Medications: aspirin, NSAIDs, steroids, anticoagulants, chemotherapy agents
Hx of GI disease: Peptic ulcer disease, liver disease, cirrhosis
Alcoholism, smoking
Chronic medical conditions: CHF, diabetes, chronic renal failure, malignancy, CAD
Advance age
Explain how guaiac testing works
Pseudoperoxidase in hemoglobin reacts with hydrogen peroxide and the paper turns blue
False +ve: foods (red meats), meds (methylene blue, colchicine)
False -ve: insufficient sample, patient on iron supplements, vitamin C/citrus fruits
Patient with a history of varices and massive upper GI bleeding comes in. After resuscitating with blood products, list the next three medications you would order
Pantoprazole 80 mg bolus, then 8mg/hr infusion
Ceftriaxone 2g IV (reduces mortality from SBI in cirrhotics)
Octreotide 50 mcg IV then 50 mcg/hr (decreased portal hypertension through splenic vasoconstriction)
?+/- TXA
List prognostic factors for patient with UGIB
Table 27.3, Blatchford score
Labs: BUN level, hemoglobin level
Vitals: SBP, hypertension
HPI: Presentation with melena, presentation with syncope
PmHx: hepatic disease, heart failure
Rockall Risk Score (27.4)
Age, shock, comorbidities (CHF, IHD, major morbidity, renal failure, liver failure, metastatic cancer)
Summarize the evidence for TXA in GI bleeds
HALT-IT (Lancet 2020)
Bottom line: TXA offers no mortality benefit in GI bleeds
Population: 12,009 patients with GI bleeding in an international trial. Patients who had a ‘clinical indication’ for TXA were excluded
Intervention: 1g IV with 3g over the next 24 hours
Control: Saline placebo
Outcome: Primary death due to bleeding at 5 days: no difference. All cause mortality at 28 days: no difference. No difference in rebleeding, need for endoscopy, transfusion. Signal of increased risk of VTE events; 0.4 vs. 0.8.
List 4 types of diarrhea, and 2 examples of each
Secretory: increased secretion of fluids, often due to toxins. Ex. Vibrio, salmonella, C diff, celiac
Inflammatory: cellular mucosal damage causes decreased absorption and hypersecretion ex. norovirus, radiation therapy, IBD
Osmotic: increased osmotic load draws water in ex. laxatives, lactose
Abnormal motility: ex. IBS, short gut syndrome, drug side effects
List 10 infectious causes of diarrhea
Bacterial: campylobacter, staph aureus, salmonella, shigella, clostridium, yersinia, e coli, vibrio
Viruses: norovirus, rotavirus
Parasites: giardia, cryptosporidium
List 10 non infectious causes of diarrhea
Drugs: antibiotics, laxatives, digoxin, colchicine
Foods: lactose, sorbitol
Inflammatory: IBD, IBS
Metabolic: hyperthyroid, adrenal insufficiency, pancreatic insufficiency
GI: diverticular disease, cirrhosis, GI cancer, ischemic bowel, short gut syndrome, megacolon
List 6 risk factors for constipation
Women, elderly, low SES, high BMI, low fiber diet, sedentary lifestyle, multiple medications
List 3 primary causes of constipation, and 6 secondary causes of constipation
Primary: Hirschsprung, imperforate anus, IBS, idiopathic slow transit
Secondary:
Obstruction: tumors, strictures, hernias, adhesions, inflammatory conditions
Drugs: narcotics, anticholinergics, antipsychotics, antidepressants
Nutrition: decreased fiber, decreased fluid
Metabolic: diabetes, hypercalcemia, hypokalemia, hypothyroid
Neurologic: Parkinson’s, MS
Functional: abuse, change in diet or activity level, pregnancy
List 5 medications that can be used in the treatment of constipation
Fiber/bulk: Metamucil, figs, prunes Osmotic laxatives: magnesium salts, sodium phosphate Poorly absorbed sugars: PEG 3350, lactulose Stimulants: Bisacodyl (Dulcolax), Senna (Senokot) Stool softeners: docusate sodium (Colace), mineral oil Suppositories: glycerin tip Enemas: mineral oil, fleet, soap suds
List 10 causes of dysphagia
Neuro: stroke, dementia (Alzheimer’s), ALS, Parkinson’s, brain tumor, myasthenia gravis, Muscular: dermatomyositis
Infectious: botulism, diphtheria
Obstructive: malignancy, structure, foreign body, webs, diverticulum, post surgical, thyroid goitre,
Functional: achalasia, scleroderma/CRES, GERD, esophagitis
What are 4 areas of esophageal narrowing
Cricopharyngeus muscle (UES), LES, aortic arch, left mainstem bronchus
List 8 causes of esophageal perforation
Iatrogenic (NG, endoscopy), traumatic, boerhaave’s, foreign body, cancer, infection, caustic injury, severe esophagitis, forceful emesis
List 4 radiographic signs of esophageal perforation
Wide mediastinum, pneumomediastinum, subcut emphysema, pleural effusion, infiltrates
List 4 causes of esophagitis
Eosinophilic Infectious: Candida, HSV, CMV, mycobacterium Pill Radiation Reflux
What is Barrett’s esophagus
Metaplasia of the epithelial layer of the esophagus due to reflux
List 10 causes of GERD
Increased acid production: coffee, chocolate, fatty meals, spicy foods
Increased intra-abdominal pressure: pregnancy, obesity, gastric outlet obstruction
Increased lower esophageal sphincter tone: alcohol, delayed gastric emptying (nitrates, benzos, estrogen, anticholinergics, calcium channel blockers), food (peppermint)
Decreased motility: achalasia, diabetes, scleroderma
Increased gastric emptying time: anticholinergic drugs, diabetic gastroparesis, gastric outlet obstruction
What are 2 evidence based lifestyle modifications for the treatment of GERD
Weight loss, elevate head of bed
List 6 causes of gastritis
H Pylori, NSAIDs, alcohol, smoking, pancreatic secretions, steroids, Zollinger-Ellison
List indications for GI referral for endoscopy
> 55 + constitutional sx, persistent vomiting, dysphagia, iron deficiency anemia, GI bleeding, family hx of cancer, failure of conservative treatment
List medications that can be used to treat H pylori
Clarithromycin, Amoxicillin, Metronidazole, PPI Bismuth, Tetracycline, Metronidazole, PPI
List indications for endoscopic removal of a gastric foreign body
> 2cm wide >5 cm long, sharp, obstructing, perforating, button battery >2-3 days, >1 magnet, any 3-4 weeks
3 mechanisms by which button batteries cause damage
Leakage of alkaline components, pressure necrosis, generation of electrical current
What is the King’s College Criteria for Liver Transplant
INR greater than 6.5; or,
Three of the following five criteria:
Age <10 or >40
Bili >300
Coags INR >3.5
Duration from jaundice to the development of coma >7 days
Etiology: drug toxicity, regardless of whether it was the cause of the acute liver failure
(criteria for non acetaminophen liver failure is different than acetaminophen)
List the bacteria commonly associated with a pyogenic abscess
E Coli, Klebsiella, Pseudomonas, Enterococcus. Treated with Abx (ex. pip tazo/ CTX + flagyl) and drainage
List the bacteria commonly associated with an amebic abscess
protozoal infection; entamoeba histolytica
List 3 liver diseases associated with pregnancy and their key clinical features
Intrahepatic cholestasis of pregnancy: pruritis due to dilated canaliculi in the biliary tree. Elevated liver enzymes with normal bilirubin + GGT. Treated with bile acids ursodiol
Acute fatty liver of pregnancy: medical emergency in the third trimester with an unwell patient. Elevated liver enzymes with ALT, ALT >1000. Supportive care, including delivery
HELLP syndrome: hemolysis, elevated liver enzymes, low platelets. Presents with abdominal pain, supportive care, high risk of eclampsia
List two different types of gallstones
Cholesterol (80%) and Pigment (20%)
List five risk factors for cholecystitis in children
Sickle cell, CF, TPN, sepsis, dehydration
What is Charcot’s triad and Raynaud’s pentad
Symptoms suggesting ascending cholangitis
Triad: fever, jaundice, RUQ pain
Pentad: hypotension, altered mental status
What is emphysematous cholecystitis
Gas in the gallbladder wall due to gas producing organisms (ex. C diff, E Coli, Klebsiella). Higher mortality
What is acalculous cholecystitis
Cholecystitis without impacted stone; tends to occur in critically ill patients
Describe the lab findings in a patient acutely infected with hepatitis B
positive surface antigen HBsAg, positive core antibody anti-HBc (if subacute), positive IgM antibody
Describe the lab findings in a patient chronically infected with hepatitis B
positive surface antigen HBsAg, positive core antibody anti-HBc, negative IgM antibody
Describe the lab findings in a patient immune to hepatitis B due to vaccinated
negative surface antigen HBsAg, negative core antibody anti-HBc, positive anti surface antibody anti HBs
Describe the lab findings in a patient immune to hepatitis B due to natural infection
negative surface antigen HBsAg, positive core antibody anti-HBc, positive anti surface antibody anti HBs
Describe the post exposure prophylaxis for hepatitis B
If vaccinated with adequate titres: no treatment
If unvaccinated, or vaccinated with unknown titres, and source positive: Hep B vaccine + HepB IG (0.06ml/kg) in 2 injection sites
List 8 stigmata of liver disease
Palmar erythema, muscle wasting, dupuytren’s contracture, jaundice, spider angiomata, caput medusa, gynecomastia, ascites, splenomegaly, testicular atrophy, bruising
List 5 management therapies for ascites and 2 for refractory ascites
Cessation of alcohol, salt restriction, fluid restriction, diuretics (lasix + spironolactone), avoid NSAIDs, GI referral Serial paracentesis, midodrine, TIPS
Which populations get prophylaxis for SBP?
Cirrhosis + renal failure, cirrhosis + GI bleeding, multiple episodes of SBP
List 6 low risk criteria for safe discharge of GIB
No comorbid disease, normal vital signs, normal or trace positive guaiac testing, normal hemoglobin and hematocrit, good support system, understands reasons to return, immediate access to emergent care
List 10 etiologies of small bowel obstruction
Extrinsic to bowel wall: adhesions, hernias, tumors
Intrinsic to bowel wall: inflammatory (Crohns), infection (TB), cancer
Internal to the bowel wall: bezoars, foreign bodies, gallstones, ascaris
List 5 causes of adynamic ileus
Metabolic (hypokalemia), medications (narcotics, anticholinergic), infection, recent abdominal trauma, laparotomy
List 3 x ray findings of small bowel obstruction
Distended loops of bowel >3cm (plicae circulares can distinguish large from small bowel), air fluid levels, absence of gas in the large bowel, string of pearls sign, pneumatosis
List 6 organisms that cause invasive diarrhea
Yersinia, Shigella, E Coli (Shiga producing), Vibrio, Salmonella, Campylobacter
You Should Eat Very Smelly Cheese
List 3 organisms associated with travelers diarrhea
E Coli, Campylobacter, Salmonella, SHigella, Norovirus, Rotavirus
List 3 parasites that can cause diarrhea
Cryptosporidium, Giardia, Entamoeba histolytica
Diarrhea + daycare; likely causative agent
Rotavirus
Diarrhea + HIV
Mycobacterium, diardia, cytomegalovirus
Diarrhea + food poisoning (short incubation period)
Staph Aureus, B cereus
Diarrhea + food poisoning (long incubation period)
STEC, Shigella, Vibrio
Diarrhea + buffet tables
Clostridium perfringens
Diarrhea + pet turtle
Salmonella
Diarrhea + raw seafood
Vibrio
Diarrhea + cruise ships
Norovirus
Who should get stool cultures?
Severe illness, fever, bloody diarrhea, sx >14 days, immunocompromised, recent Abx, certain bacteria suspect (ex. Shiga)
What are 2 systemic complications of E Coli 0157
HUS + TTP
List the Rome IV Criteria for IBS
Recurrent abdominal pain for at least 1 day/week in the last 3 months associated with two or more of:
1. Related to defecation
2. Associated with a change in frequency of stool
3. Associated with a change in form (consistency) of stool
Symptoms must have started at least 6 months ago
List 5 complications of diverticulitis
Phlegmon, abscess, perforation, fistula, obstruction, stricture, lower GI bleeding
List 3 antibiotic regimes for the outpatient treatment of diverticulitis
Cipro + Flagyl, Septra + Flagyl, Amox-Clav
Ceftriaxone + Flagyl for inpatient
List 8 extraintestinal manifestations of IBD
Episcleritis, uveitis, erythema nodosum, pyoderma gangrenosum, ankylosing spondylitis, primary sclerosing cholangitis, arthritis, sacroiliitis, DVT/PE
Differentiate clinical features between Crohn’s and UC
Crohns: Patchy, spreads from oropharynx to rectum, transmural. Frequently associated with fistulas, strictures, abscesses
UC: Progresses proximally from the rectum, continuous, mucosal involvement urgency.
List 4 medications classes that can be used in IBD, an example of each, and a complication
5-ASA: Mesalamine, sulfasalazine (sulfa toxicity)
Steroids: Budesonide (immunosuppression, AVN, hyperglycemia), prednisone
Antibiotics: metronidazole, ciprofloxacin (C Diff, tendon rupture)
Immunomodulators: azathioprine, cyclosporine, infliximab (bone marrow suppression, opportunistic infections)
What is Ogilvie’s syndrome
Pseudo-obstruction of the large bowel; often due to meds, metabolic disease, trauma, or recent surgery
What is toxic megacolon
Pathologic dilation of the colon >6 cm due to inflammation and paralysis of the smooth muscle layers without a mechanical obstruction. May occur as a complication of IBD, infectious colitis, volvulus, diverticulitis, colon cancer, drugs (anticholinergics, antimotility agents). Managed supportively
Differentiate between cecal and sigmoid volvulus
Cecal: Twist at the cecum, often due to redundant anatomy, more common in younger patients, pregnant patients, and those with prior surgery. Treated surgically
Sigmoid: Twist at the sigmoid, more common in older and institutional patients, treated with endoscopic decompression
Describe the pathophysiology between acute and chronic radiation proctocolitis
Acute: during or shortly after treatment; sloughing of the intestinal epithelium occurs, leading to a loss of the normal barrier function, causing gaps and ulcerations. Presents with abdominal pain, bleeding, tenesmus. Treated with steroid, enemas, stool softeners
Chronic: progressive collagen deposition leads to decreased perfusion and a higher risk of ischemia. More insidious onset
How is ischemic colitis diagnosed
Colonoscopy. CT may show thumb printing, wall thickening, and luminal narrowing. CTA is not valuable (different than in mesenteric ischemia) as the blood flow is often repaired by the time the scan happens. Managed supportively
List 5 management therapies for hemorrhoids
Warm/sitz paths, stool softeners, topical analgesia (nifedipine 0.3% + lidocaine 1.5%), topical corticosteroids (Anusol hydrocortisone cream 1-2.5%), topical calcium channel blockers (diltiazem 2% cream)
Thrombosed external hemorrhoids can be I+D’ed in ED
List 5 types of anorectal abscesses and their management in the ED
Perianal abscess: I + D in ED
Pilonidal cyst: penetration of the skin by an ingrown hair; occurs in the midline of the anal cleft, I + D in ED
Supralevator, intersphincteric, ischiorectal, horseshoe, postanal: refer to gen surg for drainage in the OR
List 7 etiologies for pruritus ani
Infection: STI, lice, scabies, bed bugs, pinworms, candida
Topical irritants: contact dermatitis, poor hygiene
Cutaneous conditions: psoriasis, lichen sclerosis
Hypersensitivity and hygiene: diet
Also anorectal disease: abscess, fissures, hemorrhoids, fistulas
List 10 potential cases for fecal incontinence
Trauma: nerve injury, spinal cord injury, obstetrical trauma, sphincter injury
Neurologic: spinal cord lesions, dementia, autonomic neuropathy, obstetrical (pudendal nerve damage
Mass effect: carcinoma, foreign body, fecal impaction, hemorrhoids
Medical causes: inflammatory disease, diarrhea, laxative abuse
Peds: congenital, spina bifida, meningocele
Describe the 4 degrees of internal hemorrhoids
1: No prolapse, just prominent blood vessels
2: Prolapse but spontaneously reduce
3: Prolapse requiring manual reduction
4: Prolapse unable to reduce
