OMED GI Flashcards by Andrew Pruett

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

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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)

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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

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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

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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)

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Esophagitis diseases mnemonic

PIECE

Pill induced 
Infectious 
Eosinophilic 
Caustic 
Everything else (GERD, cancer)

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Diagnosing esophagitis, generally

EGD with biopsy

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Infectious esophagitis: pathogens and tx

Candida- oral thrush - fluconazole
HSV- oral lesions - val-acyclovir
CMV - linear lesions - val-agancyclovir
HIV- HAART therapy

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Esophageal Disorders listed

Achalasia 
Scleroderma 
Esophageal spasm 
Schatzi Ring 
Esophageal webs 
Zenker's diverticulum 
Stricture - (GERD type IV)
Cancer (GERD)

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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

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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

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“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

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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

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female with dysphagia, iron deficiency anemia, webs….and eventually esophageal cancer

dx and tx

Esophageal webs and plummer-vinson syndrome

barium - webs
↓
EGD screen for cancer

tx: EGD screen for cancer
warning: do NOT do an esophagectomy

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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)

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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

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↑ Pain with food

dx and tx

PUD: gastric location

EGD with bx, rule out h pylori and malignancy

Tx: PPI, stop EtOh, NSAIDs, smoking

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↓ Pain with food

PUD: duodenal location

EGD with bx, rule out h pylori and malignancy

tx: PPI, stop EtOH, NSAIDs, smoking

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Etiologies of PUD

H pylori: single ulcers 
NSAIDs: multiple ulcers 
Malignancy: heaped, necrotic 
Curling's: burns
Cushings: steroids 
Gastrinoma

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↑ 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

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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

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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

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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

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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.

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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