OMED GI Flashcards
Colicky RUQ pain radiating to the shoulder, worse with fatty foods:
DX and TX
Cholelithiasis
Dx: RUQ US = gallstones in gallbladder
Tx: Ursodeoxycholic acid (non-surgical) or elective cholecystectomy
Constant RUQ pain
+Murphy’s sign
+ fever
+ ↑ WBC
Dx and tx
Cholecystitis
Dx: RUQ U/S then HIDA if scan is equivocal
Tx: NPO, IVF, cholecystectomy (urgent)
Constant RUQ pain painful jaundice murphy's sign (+) fever ↑ WBC
Dx and Tx
Choledocolithiasis plus/minus pancreatitis, hepatitis
Dx: RUQ US showing dilated CBD
MRCP if uncertain
Tx: NPO, IVF
ERCP urgently or cholecystectomy with intraoperative choleangiogram
RUQ pain Jaundice Fever Hypotension AMS
Dx and Tx
Cholangitis
Dx RUQ US dilated bilary duct
Tx: NPO, IVF + IV Abx (cipro or metronidazole), ERCP emergently
Biliary diseases and Locations
Cholelithiasis - gallstones in gallbladder
Cholecystitis - gallstone impaction in cystic duct
Choledocheolithiasis - gallstones in CBD
Cholangitis - gallstones in CBD with alarm symptoms (Charcot’s Triad or Reynold’s pentad)
Esophagitis diseases mnemonic
PIECE
Pill induced Infectious Eosinophilic Caustic Everything else (GERD, cancer)
Diagnosing esophagitis, generally
EGD with biopsy
Infectious esophagitis: pathogens and tx
Candida- oral thrush - fluconazole
HSV- oral lesions - val-acyclovir
CMV - linear lesions - val-agancyclovir
HIV- HAART therapy
Esophageal Disorders listed
Achalasia Scleroderma Esophageal spasm Schatzi Ring Esophageal webs Zenker's diverticulum Stricture - (GERD type IV) Cancer (GERD)
dysphagia with “knot” or ball of food stuck at GE junction
dx and tx
achalasia
1. barium swallow - bird's beak ↓ 2. Manometry - LES high tone ↓ EGD w/biopsy to rule out cancer (pseudoachalasia)
Tx: Myotomy - best but balloon dilation is the standard. botulinum if they’re a poor surgical candidate
Patient with relentless GERD, calcinosis, Raynaud’s phenomenon, dysphagia, sclerodactyly, and telangiectasia
Dx and tx
Scleroderma: CREST syndrome or systemic sclerosis
dx: barium swallow - normal ↓ Manometru - LOW tone LES ↓ EGD with bx - collagen deposition
Tx: PPI, FU with serology
“heart attack” symptoms exacerbated by cold liquids and improved with nitro
dx and tx
ACS (assume HA) ↓ barium swallow - corkscrew esophagus ↓ manometry - random contractions ↓ NO EGD
Tx: CCB, nitro
Infrequent, large caliber pieces of food get stuck in throat
dx and tx
“steak house dysphagia” - Schatzki Ring
dx
barium swallow - normal lumen with ring
↓
EGD with Bx = ring
tx lysis during EGD
female with dysphagia, iron deficiency anemia, webs….and eventually esophageal cancer
dx and tx
Esophageal webs and plummer-vinson syndrome
dx
barium - webs
↓
EGD screen for cancer
tx: EGD screen for cancer
warning: do NOT do an esophagectomy
Old man with halitosis, chokes while eating…regurgitates undigested food
Zenker’s diverticulum
dx
barium swallow - pouch
↓
EGD with Bx = visualization
tx surgical resection (endoscopic or open)
GERD, dysphagia, weight loss
stricture or cancer
barium swallow – symmetric for stricture, asymmetric for cancer (i.e. fungating mass)
EGD with bx – no cancer = stricture, cancer = cancer.
stricture = type IV GERD
↑ Pain with food
dx and tx
PUD: gastric location
EGD with bx, rule out h pylori and malignancy
Tx: PPI, stop EtOh, NSAIDs, smoking
↓ Pain with food
PUD: duodenal location
EGD with bx, rule out h pylori and malignancy
tx: PPI, stop EtOH, NSAIDs, smoking
Etiologies of PUD
H pylori: single ulcers NSAIDs: multiple ulcers Malignancy: heaped, necrotic Curling's: burns Cushings: steroids Gastrinoma
↑ or ↓ pain with food + other symptoms of indigestion
Dx and Tx
H. Pylori infection
Pt:
PUD + dyspepsia: 15%
Maltoma = 1%
Asx = 85%
dx: Urea breath test: initial Serology = test and treat (once) Stool antigen = for eradication EGD with bx = best (histology)
tx:
- clarithromycin
- amoxicillin
- PPI
Diarrhea, epigastric/abdominal pain. EGD with bx: big virulent ulcers refractory to treatment
dx and tx
Zollinger Ellison - gastrin secreting tumor
dx:
- Gastrin < 250 = normal
- Gastrin > 1600 = Gastrinoma
- (250–1600) = increased secretion stimulation
- CT scan
tx: resection
Burning CP, worse with recumbency and/or spicy food. Improved by sitting up and antacids
dx and tx
GERD
dx:
PPI + lifestyle modifications
If alarm symptoms –> EGD with bx
24 hr pH monitoring
tx: GERD: PPI Metaplasia: PPI Dysplasia: local ablation Adeno: resection
Hoarseness, coughing, stridor, nocturnal asthma
GERD, atypical
dx:
PPI + lifestyle modifications
If alarm symptoms –> EGD with bx
24 hr pH monitoring
tx: GERD: PPI Metaplasia: PPI Dysplasia: local ablation Adeno: resection
Chronic N/V, abdominal pain, peripheral neuropathy
dx and tx
Gastroparesis, idiopathic/diabetic
dx:
- nuclear emptying study
- above 60% @ 24 hrs
- below 10% @ 4 hrs
tx:
- avoid opiates
- blood sugar control
- prokinetic agents
- metoclopromide, erythromycin, domperidone. Low fiber diet.
Habitual marijuana smoker with cyclic N/V they treat with marijuana
tx
Cyclic vomiting syndrome
tx: stop THC
What are the alarm symptoms of acute diarrhea
fever > 104, blood/pus, electrolyte disturbances, ABx use, duration > 3 days
Steps 1 - 5 diagnosing acute diarrhea
In order of elimination…
step 1: c diff step 2: stool WBC and RBC step 3: if WBC/RBC (+) --> colonoscopy step 4: if WBC/RBC (-) ---> ova, parasites step 5: c. diff positive --> treat
smelly, watery acute diarrhea in hospital
dx and tx
dx: c diff NAAT
tx: vancomycin (PO) or fidaxomicin (po)
tx refractory: fecal transplant
Diarrhea: infectious etiologies (3 main headers)
entero, toxic, invasive
Diarrhea: entero
c diff–> vanco
Diarrhea: toxic causes
ETEC: travelers, Central America Vibrio cholera: 3rd world, boil your water!! S. aureus: proteinaceous foods B cereus: reheated rice Giardia: camping, fresh water
Diarrhea: invasive causes
Salmonella: raw eggs, pulty Shigella: hus EHEC (0157:H7): HUS, raw meat campylobacter: most common e histolytica: HIV/AIDs
HIS/TTP causes by
dx and tx
EHEC 0157:H7
Dx:
- Bloody diarrhea after meat consumption
- increased BUN/Cr
- Anemia
Tx: supportive care with plasma exchange transfusion
virulent and refractory PUD + diarrhea
dx and tx
ZE (gastrinoma)
dx:
gastrin < 250 (ruled out)
gastrin 250–1600 (ruled in)
SRS vs CT
tx resection
diarrhea, bloating, weight loss, rash
dx and tx
Celiac disease
Dx
1st: antibodies: TTG best, emdomysial less so, dont pick gliadin.
2nd: EGD with bx: blunted villi
tx: avoid gluten 3-4 months
flatulence, osmotic diarrhea
dx and tx
lactose intolerance
dx: avoid dairy
tx: lactose enzyme
malabsorption, diarrhea, LAD, joint pain, neurological symptoms/brain fog
dx and tx
Whipple disease
dx: EGD with Bx–Pas (+), organisms
Tx: TMP-SMX or doxycycline
K
A
D
E
symptoms of malabsorption if pancreas isnt working
K- bleeding
A- night blindness
D- osteoporosis
E- nystagmus
If absorption in duodenum is obstructed
Folate
Iron
Calcium
Carbs
50 yo+, painless hematochezia
dx and tx
diverticular hemorrhage
dx colonoscopy + angiogram for embolization
tx: embolize if severe, self-limiting (often)
“left sided appendicitis”- constant LLQ pain, fever, leukocytosis, local peritoneal signs
dx and tx
diverticulitis
dx:
KUB to r/o frank perforation
CT with IV and PO contrast
tx: mild--> liquid diet and po abx severe NPO and IV abx abscess NPO and IV abx + drainage perforation: exploratory laparotomy with IV abx, refractory: hemicolectomy
Fe deficiency anemia in 50+ yo male
dx and tx
colon cancer until disproven
dx
colonoscopy with biopsy
age 50q10 yrs
tx
polyp: polypectomy
stage I/II colectomy
stage III/IV chemo (FOLFOX, FOLFIRI)
Changed caliber stool with alternating bowel habits
colon cancer
dx
colonoscopy with biopsy
age 50q10 yrs
tx
polyp: polypectomy
stage I/II colectomy
stage III/IV chemo (FOLFOX, FOLFIRI)
colonoscopy revealing asymptomatic cancer
tx
polyp: polypectomy
stage I/II colectomy
stage III/IV chemo (FOLFOX, FOLFIRI)
APC gene predictions + dx and tx
100s polyps by 20, cancer by 40, dead by 50
dx colonoscopy before 20
tx prophylactic colectomy
three family members, two generations, one premature cancer diagnosis
dx and tx
HNPCC/Lynch
DNA mismatch repair
dx: patient biopsy
tx: resection
brain tumors and colon cancer
turcot
jaw tumors and colon cancer
gardener
spots on the mouth, small intestinal tumors, colonic hamartomas
Peutz Jeghers
hematemesis, melana, hematochezia
UGIB
Melana, hematochezia
LGIB
GI bleed: tx
2 large bore IVs IVF bolus type and cross transfuse as necessaru IV PPI Call GI for EGD
GI bleed: dx
UGIB: EGD first
LGIB: colonoscopy (no bleeding), arteriogram (fast bleeder), tagged RBCs (slow bleeders), Pill-Cam (last resort)
cirrhotic with GI bleed:
path
dx
tx
portal HTN
DX: EGD tx: stabilize 1st octreotide 2nd: balloon 3rd: EGD with banding refractory- TIPS Transplant
dyspepsia with GI bleed
dx and tx
PUD
EGD with bx
PPI
weekend warriors vomiting up blood
superficial mucosa tears
dx: EGD
tx: supportive
Air in mediastinum Dyspnea Fever Wretching Bulimic/Alcoholic
dx and tx
Boerhaave’s
dx:
1st gastrograffin
2nd: barium
best: EGD
tx:
surgery
painless abrupt bleeding
dieulafoy’s lesion
dc: EGD
tx: “subtotal gastrectomy”
hemorrhoids
dx and tx
dx Clx
tx: Sitz bath –> banding
Diverticular hemorrhage
dx and tx
dx: colonoscopy
tx: hemicolectomy
pain out of proportion
afib
vasculopath
weight loss (chronic)
dx and tx
mesenteric ischemia
dx: angiogram, colonoscopy
tx: revascularization, resection
hypotension –> GI bleed –> painful BRBBR (bright red blood per rectum)
dx and tx
ischemic colitis
dx: colonoscopy
tx: supportive
weight loss, clay colored stools, painless jaundice
dx
tx
cancer causing obstruction
dx: increased direct bilirubin, RUQ US shows dilation, MRCP shows lesion, EUS pancreas, ERCP biliary
RUQ pain, tenderness, + murphy’s, worse on eating, jaundice
dx and tx
gallstones
dx: RUQ US gallstones, dilated ducts, MRCP diagnosis, ERCP intervention
tx: ERCP or intraop cholangiogram
