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Clinical Medicine 4 > Lecture 6 (GI)-Exam 2 > Flashcards

Lecture 6 (GI)-Exam 2 Flashcards

1
Q

Obesity:
* Defined as what?
* Disease is multifactorial stemming from what?

A
  • Defined as abnormal accumulation of adipose tissue that may impair health (via contribution to CAD/DM/HTN/HLD).
  • Disease is multifactorial stemming from mismatch of calories intake versus expenditures and further influenced by genetic (obesity os very heritable), social and societal factors.

One-thirdof adults and about 17% of adolescents in the UnitedStates are obese

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2
Q

Obesity
* What is a genetic syndrome associated with extreme obesity?
* What is the gene implicated with obesity ?

A
  • Prader-Willi is the most common genetic syndrome associated with extreme obesity
  • FTO gene is implicated with obesity
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3
Q
  • What is leptin?
  • What is ghrelin?
A
  • Leptin – adipocyte hormone that reduces food intake via appetite suppression and therefore reduces body weight
  • Ghrelin is an appetite stimulant hormone and works as an antagonist to leptin
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4
Q

What does leptin resistance cause?

A

Leptin resistance on cellular level increases obesity and promotes free fatty acid secretion that increases inflammation and cause triglyceride levels to rise and increase insulin secretion (NIDDM basic-> T2D)

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5
Q

What happens with leptin and ghrelin levels before and after eating?

A
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6
Q
  • What is Metabolic obese normal weight (MONW) ?
  • What is Metabolically healthy obese (MHO) ?
A

Metabolic obese normal weight (MONW)
* Subjects with normal BMI suffer from metabolic complications normally found in obese individuals

Metabolically healthy obese (MHO)
* Individuals have BMI over 30 kg/m2 but do not have the characteristics of insulin resistance or dyslipidemia

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7
Q

He said low yield

What are the BMI ranges?

A
  • Underweight: less than 18.5 kg/m2
  • Normal range: 18.5kg/m2to 24.9 kg/m2
  • Overweight: 25kg/m2to 29.9 kg/m2
  • Obese, Class I: 30 kg/m2 to 34.9 kg/m2
  • Obese, Class II: 35 kg/m2 to 39.9 kg/m2
  • Obese, Class III: more than 40 kg/m2
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8
Q

What should be measured for obesity dx and what are the values for males and females?

A

Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:0.8 is considered significant.

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9
Q

Obesity Treatment: Multiprong individualized approach
* Manage what?
* Provide what supportive treatment? (4)
* Who are the medications for?

A
  • Manage contributing conditions (hypothyroidism, dietary and behavioral modifications)
  • Provide supportive treatment: physical activity, exercise, nutrition, and weight maintenance.
  • Medications: reserved for patients with BMI >30 or >27 + comorbid condition
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10
Q

What are the examples of obesity medications?

A

Orlistat, phentermine, lorcaserin, liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, phendimetrazine

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11
Q

Obesity
* What is surgery reserved for?
* What are the types of surgery?
* What are the SE of surgery?

A

Surgery: reserved for BMI >40 or 35 + severe comorbid conditions
* Adjustable gastric banding, Rou-en-Y gastric bypass, and sleeve gastrectomy
* Rapid weight loss can lead to gallbladder problems
* Chronically may lead to malabsorption refeeding or dumping syndrome.

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12
Q

What are the 5 types of GI bleeding?

A
  • Acute
  • Chronic
  • Overt – clinical signs/symptoms present
  • Occult – not clinically evident (+ FOBT and/or iron deficiency anemia)
  • Obscure – routine evaluation (upper and lower endoscopy has not revealed source)
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13
Q

Gastrointestinal Bleeding
* Upper GI vs. Lower GI location is determined by what?

A

the Ligament of Treitz

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14
Q

What are locations of UGI and LGI bleeds?Dx by?

A

UGI – proximal to Ligament of Treitz
* Esophagus
* Stomach
* Duodenum
* Dx by EGD

LGI – distal to Ligament of Treitz
* Jejunum and Ileum
* Colon
* Dx by colonoscopy

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15
Q

GI Bleed Presentation
* What can happen with vomit that is probably an UGI source?

A

Hematemesis (vomiting blood) – probably an UGI source
* Bright Red Blood with or without clots
* Coffee grounds – blood accumulates in stomach

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16
Q

Stool color, consistency, frequency:
* Wha tis melena and hematochezia? What do they indicate?

A
  • Melena (black tarry stools) – Typically suggests upper GI source, but can be seen with LGI small bowel or proximal colon bleeds.
  • Hematochezia (bright red blood per rectum) – Typically suggests a lower GI source on left side, however, but can be seen with brisk UGIB
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17
Q

Hemodynamic Changes: GI bleed
* What can happen with BP? what can be some sxs?

A
  • Orthostatic drop in BP > 10 mm Hg or HR > 20 bpm - usually indicates > 20% reduction in blood volume(+/- syncope, lightheadedness, nausea, sweating, thirst)
  • Shock, BP < 100 mm Hg systolic - usually indicates > 30 % reduction in blood volume(+/- pallor, cool skin)
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18
Q

Work-up of GI Bleeds
* What do you need to do?

A
  • Vital Signs + orthostatic BP
  • Physical Exam w/ Rectal Exam
  • Labs: CBC, PT/INR/PTT/LFTs, Electrolytes/renal function
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19
Q

Work-up of GI Bleeds
* Why do we have to get CBC?
* Why PT/INR/LFTs?
* Why electrolytes/renal function?

A

CBC
* Check and monitor hemoglobin and hematocrit
* Crossmatch 2 – 6 units PRBC depending on level of active bleeding
* Platelet count (< 50,000/mcl with active bleeding requires transfusions of platelets and FFP to replete lost clotting factors)

PT/INR/PTT/LFTs to r/o advanced liver disease (coagulopathy)
* INR must be kept less than 1.5

Electrolytes/renal function
* Prerenal changes (i.e. azotemia)

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20
Q

Early Management of GI Bleeds
* What do you need to check, place and give?

A
  • ABCs (airway, breathing, circulation)
  • Bilateral 14/16-gauge upper extremity peripheral IV (need large bore IV)
  • Resuscitation: IV Fluids, PRBCs after type and cross and Correct underlying coagulopathies
  • Foley catheter to monitor renal perfusion
  • NG Tube lavage (for UGIB)
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21
Q

NG tube/gastric lavage
* What is the aspirate if UGIB and LGIB?
* WHat is nondiagnostic?

A
  • UGIB - Fresh blood or coffee-ground aspirate
  • Probable LGIB – Non-bloody, bilious aspirate
  • Clear, non-bilious aspirate is NONDIAGNOSTIC (May miss duodenal source of bleeding)
    * Bile is aspirated in duodenum, not gastrum
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22
Q

A 28 year old patient has been passing tarry stools for two days. Blood pressure in the supine position is 110/70 mm Hg with pulse of 98 bpm. In the sitting position blood pressure is 96/72 mm Hg with pulse of 110 bpm. Nasogastric aspirate is negative for blood. The most likely location of this bleed is:
A. Esophageal
B. Duodenal
C. Rectal
D. Large Bowel
E. Posterior nasopharynx

A

Duodenal

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23
Q

Causes of Upper GI Bleeding
* What are the different types of esophagus bleeds? (4)

A
  • Esophageal varices (#3 cause) – present with Portal HTN
  • Esophagitis
  • Esophageal Ulcer
  • Mallory-Weiss tear (mucosal tear at GE junction due to retching-ETOH, Bulimia, sick) (#4 cause)
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24
Q

Causes of Upper GI Bleeding
* What are the examples of stomach bleeds? (3)

A
  • Gastric ulcer (#2 cause)
  • Gastritis
  • Gastric antral vascular ectasia – Longitudinal erythematous stripes on gastric mucosa (known as Watermelon Stomach) (rare)
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25
Q

Causes of Upper GI Bleeding
* What is a dieulafoy’s lesion?

A

Dieulafoy’s Lesion - Artery at gastric fundus erodes to surface and may bleed heavily (rare)

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26
Q

Causes of Upper GI Bleeding
* What is an duodenum cause?
* What are two other cuases of UGIBs?

A
  • Duodenum: Duodenal ulcer (#1 cause)
  • Coagulopathy (liver, drugs, bleeding disorders)
  • Arteriovenous malformations
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27
Q

Upper GI Bleed management
* _
* Keep what? Why?
* What do you need to give for meds?
* What do you need to do EARLY?

A
  • Resuscitation
  • Keep NPO – prevent aspiration
  • High dose Proton Pump Inhibitors – prevent acidity to ulcer.-> Consider loading dose and drip of Protonix
  • EARLY esophagogastroduodenoscopy (EGD) to identify the source of the bleeding & for therapeutic intervention
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28
Q

Lower GI Bleeds
* What are the small bowel causes? (4)

A
  • Neoplasm
  • IBD
  • Aortoenteric Fistula
  • Mesenteric ischemia
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29
Q

Lower GI Bleeds
* What are the colon causes? (6)

A
  • Diverticuli – most common cause
  • Angiodysplasia/AVM
  • Inflammatory Bowel Disease
  • Neoplasm
  • Infectious
  • Radiation Proctitis
30
Q

Lower GI Bleeds
* What are the perianal examples? (3)
* What is another reason?

A

Perianal
* Hemorrhoid
* Fissure
* Fistula

Coagulopathy (drugs, liver disease, etc.)

31
Q

Suspected LGIB
* What will happen 80% of the time?
* Exclude waht?
* What is the primary option?

A
  • Bleeding stops spontaneously 80% of the time
  • Exclude upper GI source 1st
  • Colonoscopy is the primary option
32
Q

If the patient has massive ongoing bleeding with hemodynamic instability, what is indicated?

A

If the patient has massive ongoing bleeding with hemodynamic instability, urgent angiography vs emergent endoscopy is indicated
* Colonoscopy Prep Emergently: Purge with 4 – 8L of polyethylene glycol solution given orally or per NG tube

33
Q

Additional Studies if Needed
* New CT scan guidelines request what?
* If both CT or colonoscopy do not reveal a source, but bleeding continues, what should be ordered?

A
  • New CT scan guidelines request oral and IV contrast when evaluating lower GI bleeding with CT abdomen and Pelvis, which can help identify site of extravasation
  • If both CT or colonoscopy do not reveal a source, but bleeding continues – tagged RBC scan should be done to localize bleeding +/- angiography if positive
34
Q

Nuclear bleeding scan
* How does it work?

A

“Red blood cells are labeled with 15 mCi of technetium-99m (in vitro) and reinfused into the patient. Images are then acquired sequentially at one minute intervals in the anterior projection. Early in the study, a focus of increased activity appears in the left lower quadrant of the abdomen. Activity then progresses in a curvilinear fashion approximating the course of the sigmoid colon. “

35
Q
  • If colonoscopy does not reveal a source, but bleeding stops do what?
  • Consider what?
A
  • If colonoscopy does not reveal a source, but bleeding stops, observe the patient
  • Consider small bowel evaluation (Capsule endoscopy)
36
Q

Surgery: GI bleeds
* Who is surgery reserved for? (2)
* Every effort should be made to do what?

A

Surgery is reserved for patients
* Who have failed medical, colonoscopic, & angiographic intervention
* Who have ongoing bleeding >4U PRBC per 24 hr

Every effort should be made to localize the source of bleeding prior to surgery (especially in diverticular disease)

37
Q

Diarrhea
* What is the criteria?

A
  • Increase in stool weight (>200 g/day)
  • Decreased stool consistency
  • Increased stool frequency, urgency, fecal incontinence
38
Q

The Intestines
* How much ingested fluid and secretions enter the intestines each day
* How much is absorbed in small and large intestines?
* What is normal fluid in normal stool day?

A
  • 10 liters of ingested fluid and secretions enter the intestines each day
  • 90% is absorbed in the small intestines
  • Of the fluid that remains, 90% is further absorbed in the large intestines
  • 80-100ml of fluid is in normal stool day
39
Q

Diarrhea
* How long is acute? What are the two types?
* How long is chronic?

A

Acute – lasting less than 4 weeks
* Infection (most common)
* Medications (Metformin)

Chronic – lasting more than 4 weeks

40
Q

What are the different pathophysiologies of diarrhea?(5)

A
  • Osmotic
  • Secretory
  • Malabsorption/Maldigestion
  • Altered Motility
  • Inflammatory
    * Inflammatory Bowel Diseases
    * Infectious Diarrhea
41
Q
  • What is the osmotic gap for serum?
  • Feces is normally in osmotic equilibrium with what?
A
  • 290 mOsm/kg - 2 ([Na]+ + [K]+) – for serum
  • Feces is normally in osmotic equilibrium with blood serum, which the human body maintains between 290–300 mOsm/kg.
42
Q

Fecal Osmotic Gap
* What is osmotic and secretory diarrhea level? Why does this happen?

A
  • Osmotic diarrhea >125 – high fecal osmotic gap (can be due to lactulose)
  • Secretory diarrhea <50- cholera – massive excretion (Na, K, HCO3, Cl) and low absorption of electrolytes. It doesn’t stop if patient fasts.
43
Q

What is functional diarrhea? Typically in who?

A

Functional Diarrhea – Normal Gap >50 but <125 – Typically IBS or Altered Motility Type Disorder

44
Q

Osmotic Diarrhea
* What is the definition?

A

Definition: Increased amounts of poorly absorbed, osmotically active solutes in gut lumen interferes with absorption of water

45
Q

Osmotic Diarrhea
* What are Solutes are ingested that are osmotic? (4)

A
  • Magnesium sulfate or citrate or magnesium containing antacids
  • Sorbitol – sugar free gum
  • Lactulose – Tx constipation
  • PEG (polyethelane glycol) – Tx constipation
46
Q

Osmotic Diarrhea
* besides the solutes, what is another cause?

A

Malabsorption of food
* Lactose intolerance

47
Q

Lactose Intolerance
* What is this?
* Lactose remains where and what does that cause?

A
  • Congenital or acquired deficiency in the brush border disaccharidase lactase that leads to malabsorption of lactose
  • Lactose remains in the intestinal lumen and acts as a strong osmotic substance leading to osmotic diarrhea, flatulence, bloating
48
Q

Lactose Intolerance
* what is the txt?

A

Treatment: Avoid lactose containing foods and/or supplement oral intake of dairy products with liquid or tablet form of the lactase enzyme

49
Q

Osmotic Diarrhea
* what is the cause?

A

Nonabsorbable molecules accumulate in the gut lumen

50
Q

Osmotic Diarrhea
* What are the clinical features?

A

Diarrhea stops with fasting

Electrolyte absorption is not affected, only water is affected

Fecal osmotic gap is high
* Test checks stool electrolytes
* Stool water is low in electrolytes

51
Q

Secretory Diarrhea
* What is it?

A

Abnormal ion transport in intestinal epithelial cells -> increased secretion &/or decreased absorption of electrolytes

52
Q

Secretory Diarrhea
* What are the clinical features?

A

Fasting does not stop diarrhea

Electrolyte absorption is affected
* Increased secretion and/or decreased absorption of Na+ and Cl-

Fecal osmotic gap is low
* Stool water is high in electrolytes

53
Q

Secretory Diarrhea
* What are the bacterial or viral enterotoxins?
* What are the causes of Intestinal resection?

A

Bacterial or viral enterotoxins: Cholera, enterotoxigenic E. coli, B. cereus, S. aureus, Rotavirus, Norwalk virus (BRENCS)

Intestinal resection
* Decreased absorptive surface for not only nutrients but also electrolytes and fluid
* Combined malabsorption and secretory component

54
Q

Secretory Diarrhea
* What type of laxatives?
* Circulating agents by what?

A

Non-osmotic laxatives (castor oil, senna)

Circulating agents by neuroendocrine tumors such as:
* Carcinoid Syndrome
* Zollinger-Ellison syndrome

55
Q

Infectious Diarrhea
* Hx of what?
* _ contacts?
* Food?
* Can be what?
* is there what use?

A
  • History of travel
  • Sick contacts and their progression
  • Food exposure history
  • Could it be Hepatitis A or B or something non infectious
  • Is there drug use or homelessness history
56
Q
A
57
Q

Infectious Diarrhea: essential of dx
* Acute:
* Chronic:
* Mild diarrhea:
* Moderate diarrhea:
* Severe diarrhea:

A
  • Acute diarrhea: < 4 weeks
  • Chronic diarrhea: > 4 weeks.
  • Mild diarrhea: </= 3 stools per day
  • Moderate diarrhea: >/= 4 stools per day w/ local symptoms (cramps, nausea, tenesmus)
  • Severe diarrhea: >/= 4 stools per day w/ systemic symptoms (fever, chills, dehydration)
58
Q

Infectious Diarrhea: ESSENTIALS OF DIAGNOSIS
* Bloody, THINK what?
* Recent hospitalization or antibiotic use (MC: Clindamycin)->
* Foreign travel->(5)

A
  • Bloody, THINK Bacteria
  • Recent hospitalization or antibiotic use (MC: Clindamycin)->C. diff
  • Foreign travel-> Salmonella, Shigella, Campylobacter, E coli or V cholerae (VECSS)
59
Q

Infectious Diarrhea: ESSENTIALS OF DIAGNOSIS
* Outbreak on cruise ship, school, LTCF->
* Recurrent C. diff =
* Undercooked hamburgers ->

A
  • Outbreak on cruise ship, school, LTCF-> Norovirus
  • Recurrent C. diff = Fecal microbiota transplantation
  • Undercooked hamburgers -> EnterohemorrhagicEscherichia coli, including Shiga-toxin–producingE colistrains (STEC)
60
Q

Infectious Diarrhea: Classification of inflammatory/bloody diarrhea
* What is involved?
* What are common sxs?
* What are common causes?
* What is often postive? What is required for definitive etiology?

A
  • Colonic involvement (bacteria, parasites, toxins)
  • Common symptoms: Frequent bloody, small-volume stools, often with fever, abdominal cramps, tenesmus and fecal urgency
  • Common Causes: Shigella, Salmonella, Campylobacter, Yersinia, invasive strains of E.coli, Entamoeba histolytica and C. difficile (CCEESSY)
  • Fecal leukocytes are often positive, stool culture required for definitive etiology
61
Q

Infectious Diarrhea: Classification of noninflammatory, non-bloody or watery
* Milder, caused by what?
* interferes with what?
* Common sxs:
* Common causes:

A
  • Milder, caused by viruses or toxins that affect small intestine
  • Interferes w/ salt & water balance resulting in large-watery diarrhea
  • Common Symptoms: Nausea, vomiting, cramps
  • Common Causes: Rotavirus, norovirus, astrovirus, enteric viruses, vibriones, enterotoxin-producing E. coli, Giardia lamblia, crystosporidia & agents that cause food-borne gastroenteritis
62
Q

Acute Gastroenteritis
* What is it?
* May include what?
* Temperature?
* Signs of what?
* What is a late sign?
* Consider waht?

A
  • Flu-like illness with GI component
  • May include Melena, or hematochezia depending on organism
  • High fever
  • Signs of dehydration
  • Altered mental status -> late sign
  • Consider hypovolemic shock (hemorrhagic and non-hemorrhagic)
63
Q

AGE work up
* What type of tests? (3)
* What are the labs? (4)
* what is the imaging?
* R/O what?

A
  • Blood cultures, stool culture, O and P specific tests
  • CBC with differential
  • CMP
  • Fecal leukocytes
  • Hemoccult vomit
  • CT (with or without contrast depending on oral tolerance and Cr) if abdomen tender or you have guarding or rebound tn
  • R/O Clostridium difficile via toxin test
64
Q
A
65
Q

Treatment AGE
* Most cases are what?
* What for fever?
* What is the diet?
* What do you give for pain?

A
  • Most cases are self-limited
  • Acetaminophen for fever
  • Clear liquids until symptoms better, BRAT diet
  • Pain: Ketorolac
66
Q

Treatment AGE
* What do you give for anti-emetics?
* Fluids?
* Avoid what?
* If abnormal labs, then do what?

A
67
Q

Treatment AGE: general measures
* Most cases of acute gastroenteritis are what?
* Txt usually consists of what?

A
  • Most cases of acute gastroenteritis are self-limited and do not require therapy other than supportive measures
  • Tx usually consists of replacement of fluids and electrolytes and, very rarely, management of hypovolemic shock and respiratory compromise
68
Q

Treatment AGE: General measures
* mild diarrhea, increase what? May increase risk for what?
* What do you need to do severe dehydration?

A

Mild diarrhea, increase juices and clear soups
* May increase risk for osmotic diarrhea

Severe dehydration (postural light-headedness, decreased urination), oral glucose-based rehydration solutions (Ceralyte, Pedialyte

69
Q

Treatment AGE: Specific Measures
* Immunocompetent adults->Empiric antimicrobial therapy for bloody diarrhea while waiting for results is recommended only with the following circumstances? (2)

A
  • (1) documented fever, abdominal pain, bloody diarrhea, and bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella
  • (2) returning travelers with a temperature of at least 38.5°C or signs of sepsis
70
Q

Treatment AGE: Specific Measures
* What is the empiric antimicrobial therapy for bloody diarrhea?
* Empiric antibacterial treatment should be considered in who?

A
  • Fluoroquinolone or azithromycin as empiric antimicrobial therapy for bloody diarrhea
  • Empiric antibacterial treatment should be considered in immunocompromised people with severe illness and bloody diarrhea
71
Q

Treatment AGE: Specific Measures
* Loperamide may be given to who? When should it be avoided?

A
  • Loperamide may be given to immunocompetent adults with acute watery diarrhea, but should be avoided with Shigella infection or in suspected or proven toxic megacolon
  • Generally avoid loperamide unless you confirm lack of infection (viral or bacterial)

Clinical Medicine 4 (15 decks)

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