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SSx 1-3 Flashcards

1
Q

Dyspepsia… predominant epigastric pain

Maybe associated epigastric fullness, nausea, heartburn, vomiting

When is endoscopy warranted?

A

Warranted in pts 60 or older

Pts w/ alarm features

Alarm features = wt loss, anemia, dysphagia, vomiting, recurrent GI bleeding

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2
Q

Pts w/ dyspepsia under 60 w/o alarm features should be tested for?

A

H. pylori… If positive abx should be administered

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3
Q

Dyspepsia… pts who are h. pylori negative or see no improvement after H. pylori eradication should receive what?

A

Empiric proton pump inhibitor therapy

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4
Q

Dyspepsia… Another option for pts w/ refractory symptoms might be?

A

tricyclic antidepressants, a prokinetic agent, or psychological therapy

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5
Q

Functional dyspepsia?

A

Most common cause of dyspepsia

Dyspepsia w/ no identifiable etiology (by endoscopy or other testing)

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6
Q

What are two common diseases also seen in dyspepsia, referred to as luminal tract dysfunction?

A

Peptic ulcer disease (15% of patients w/ dyspepsia)

GERD (20% of patients w/ dyspepsia)

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7
Q

Chronic gastric infection w/ H. pylori is an important cause of what?

And even in the absence of this, h. pylori may cause dyspepsia.

A

H. pylori is often associated w/ PUD; however, even in the absence of H. pylori, it can still cause dyspepsia.

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8
Q

Pancreatic carcinoma and chronic pancreatitis may also cause chronic epigastric pain. However, the pn is different… describe it…

What else is usually associated w/ pancreatic carcinoma and chronic pancreatitis?

A

Pancreatic pn is typically more severe, sometimes radiates to the back and usually is associated anorexia, rapid wt loss, steatorrhea, or jaundice

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9
Q

Dyspepsia accompanied by what warrants endoscopy?

A

wt loss, persistent vomiting, constant/severe pn, progressive dysphagia, hematemesis, melena

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10
Q

Though the physical examination is rarely helpful in cases of dyspepsia, certain signs of serious organic disease should be furhter evaluated. Such as?

A

wt loss, organomegaly, abdominal mass, FOBT

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11
Q

If an H. pylori breath test or fecal antigen test result is negative in a pt NOT taking NSAIDs, what can be excluded?

A

PUD is virtually excluded

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12
Q

Study of choice for diagnosing gastrointestinal ulcers, erosive esophagitis, and upper gastrointestinal malignancy is?

A

upper endoscopy

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13
Q

In dyspepsia, h. pylori-negative pts most likely have functional dyspepsia or atypical GERD and can be treated how?

A

W/ an anti-secretory agent (PPI) for 4 weeks (empirically)

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14
Q

Patients in with persistent dyspepsia AFTER H. pylori eradication can be given a trial of what?

A

PPI therapy

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15
Q

Patients w/ no significant findings on endoscopy as well as patients under 60 who don’t respond to h pylori eradication or PPI therapy are presumed to have?

A

functional dyspepsia

Consider dietary changes and/or pharmacotherapy w/ antisecretory agents, TCAs, metoclopromide

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16
Q

Vomiting should be distinguished from what (which is the effortless relfux of liquid or food stomach contents)?

A

regurgitation

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17
Q

Acute symptoms of nausea/vomiting w/o abd pn are typically caused by what?

A

food poisoning, infectious gastroenteritis, drugs, or systemic illness

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18
Q

In severe or protracted vomiting, serum electrolytes should be obtained to look for ?

A

hypokalemia, azotemia, metabolic acidosis

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19
Q

What are the complications from nausea/vomiting?

A

dehydration, hypokalemia, metabolic alkalosis, aspiration, boerhaave syndrome, mallory weiss tear

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20
Q

What is the standard triple therapy tx for h pylori?

A

PPI po bid
Clarithromycin 500 mg PO BID
Amoxicillin 1g PO BID

(if pen allergy, metronidazole 500 mg PO BID)

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21
Q

What is the standard quadruple therapy for h pylori?

A

PPI po bid
Bismuth subsalicylate two tabs PO qid
Tetracycline 500mg PO QID
Metronidazole 500mg TID

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22
Q

Acute onset of severe pn and vomting suggests what?

A

peritoneal irritation, acute gastric/intestinal obstruction, or pancreaticobiliary dz

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23
Q

Early morning vomiting is common in?

A

pregnancy, uremia, alcohol intake, increased ICP

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24
Q

Physical exam observations/tests for nausea/vomiting?

A

Dry mucous membranes?
SKin turgor
Orthostatic vital signs (“tilts”)

TTP?
distension?
Organomegaly?

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25
Q

“Typical” treatment options for nausea/vomiting?

A

Fluids, BRAT diet, ginger

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26
Q

Pharmacotherapy options for nausea/vomiting?

A

Serotonin-receptor antagonists (ondansetron)

Dopamine antagonists (promethazine, procloperazine)

Antihistamines (meclizine, dimenhydrinate, scope, diphen)

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27
Q

Persistent/intractable hiccups warrant a full history/physical exam for serious underlying pathology, such as?

A

CNS pathology (neoplasm, infection, trauma)

Metabolic issues (uremia, hypocapnia)

Chronic irritation

Postoperative

Psychogenic

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28
Q

Intractable hiccups can be treated w/?

A

Chlorpromazine

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29
Q

Broadly, what are soem of the FODMAPs that might cause and therefore be avoided for pts concerned w/ flatus?

A

lactose

Fructose

polypols

fructans

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30
Q

Most common cause of constipation?

A

Inadequate fiber/fluid intake

poor bowel habits

(opioids)

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31
Q

What’s meant by primary constipation?

A

More common form that cannot be attributed to any structural/systemic dz/abnormality

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32
Q

In a patient w/ constipation, obstructive lesions (neoplasms, strictures, etc) should be ruled in patients older than 50, patients w/ fam hx of colon CA or IBD, and pts w/ alarm features.

What are alarm features for constipation?

A

Hematochezia

wt loss

anemia

+FOBT/FIT

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33
Q

Osmotic laxatives used for constipation?

A

Magnesium hydroxide

Polyethelyne glycol 3350

Polyethelyne glycol

Magnesium citrate

**magnesium should be avoided in patients w/ chronic renal insufficiency

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34
Q

Osmotic laxatives used for constipation?

A

Magnesium hydroxide

Polyethelyne glycol 3350

Polyethelyne glycol

Magnesium citrate

**magnesium should be avoided in patients w/ chronic renal insufficiency

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35
Q

Stimulant laxatives used for constipation?

A

Bisacodyl

Senna

(avoid in obstruction)

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36
Q

Stool surfactants for constipation

A

Docusate Sodium

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37
Q

Fecal impaction can present w/ paradoxical diarrhea. What are the tx options?

A

Manual fragmentation/disimpaction

or saline/mineral oil/diatrizoate enema

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38
Q

Fecal impaction can present w/ paradoxical diarrhea. What are the tx options?

A

Manual fragmentation/disimpaction

or saline/mineral oil/diatrizoate enema

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39
Q

Constipation Patients at what age or with what symptoms should be referred for colonscopy?

A

Pts > 50

Pts w/ alarm ssx (wt loss, hematochezia, family hx, pos FOBT)

(also refer pts unresponsive to tx and those w/ evidence of obstruction)

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40
Q

Acute diarrhea… duration? And most common cause?

A

Acute < 2 weeks

Most commonly caused by pathogens

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41
Q

Acute non-inflammatory diarrhea is typically watery, nonbloody and self-limited.

WHat usually causes it and when would you perform a diagnostic eval?

A

Usually caused by virus/non-invasive bacteria

Diagnostic evaluations for pts w/ SEVERE diarrhea or diarrhea > 7 days

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42
Q

Acute inflammatory diarrhea will present w/ blood or pus and usually caused by an invasive/toxin-producing bacterium.

What are the diagnostic evaluation requirements?

A

Stool bacterial testing for (E Coli O157H5, H7) in ALL

And if clinically indicated, testing for clostridioides difficile toxin, and OandP

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43
Q

Common etiologies for acute non-inflammatory diarrhea?

think viral or protozoal

A

Norovirus

Rotavirus

Giardia

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44
Q

Common etiologies for acute inflammatory diarrhea?

A

E Coli

Shigella

Salmonella

Clostridium difficile

(also campylo and yersinia)

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45
Q

Symptoms of acute inflammatory diarrhea?

A

Loose/bloody stools (lower in volume)

Fever

LLQ cramps/pn

Urgency

Tenesmus

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46
Q

Distinguish mild diarrhea from those needing prompt evaluation. What are indications for further eval?

A 
1 - signs of inflammatory diarrhea (fever, WBC>15000, severe pn, bloody diarrhea)
2 - Profuse diarrhea (>6 stools/day)
3 - Frail olds
4 - immunocompromised/systemic illness 
5 - Abx exposure
6 - Hospital-acquired diarrhea
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47
Q

Acute diarrhea may require lab tests, including fecal leukocytes, stool cultures, OandP (x3, remember?), C difficile, and fecal lactoferrin.

What’s fecal lactoferrin?

A

a marker of intestinal inflammation

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48
Q

For the tx of acute diarrhea, what should be avoided?

A

High-fiber foods, fats, dairy, and caffeine

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49
Q

Loperamide and bismuth subsalicylate are antidiarrheal are the recommended agents for acute diarrheal tx. When are they contraindicated?

A

Pts w/ bloody diarrhea

High fever

systemic toxicity

AND they should be discontinued in pts whose diarrhea is worsening despite therapy

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50
Q

Generally, community-acquired diarrhea doesn’t warrant empiric abx tx.

In centers where stool microbial testing isn’t available.. When should empric tx w/ antibiotics for acute diarrhea be considered?

A

Non-hospital acquired diarrhea

Moderate-severe fever, tenesmus, bloody stools

No suspicion of STEC infection

Immunocompromised pts

Significant dehydration

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51
Q

Drugs of choice for empirtic tx of of acute diarrhea?

A

Cipro BID 500mg
Oxfloxacin BID 400mg
levofloxacin QD 500mg

(flouroquinolones, all 1-3 days)

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52
Q

Alternatives abx for empiritc tx of acute diarrhea?

A

Trimethoprim-sulfamethoxazole 160/800mg BID

doxy 100mg BID

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53
Q

Many bacterial cases of diarrhea do not warrant abx therapy. What are the specific species for which abx therapy IS warranted?

A 
Shigellosis
Salmonellosis (extraintestinal)
Listeriosis
Cholera
C. diff
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54
Q

What are the non-bacterial forms of infectious diarrhea that warrant abx tx?

A

amebiasis, giardiasis, and traveler’s diarrhea

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55
Q

When should you admit for inpatient tx?

A

Severe dehydration

Severe/worsening bloody diarrhea

Severe abd pn

Severe infection (elevated temp >39.5 , leukocytosis ,rash)

Severe diarrhea in pts > 70

Signs of HUS

56
Q

Chronic diarrhea is longer than 4 weeks. What should be excluded before an extensive workup?

A

Common causes such as medications, chronic infections, and IBS

57
Q

What are the major pathologic categories for chronic diarrhea

A 
Chronic
Osmotic
Medications
Malabsorptive
Motility
Inflammatory
Systemic
Secretory

COMMMISS

58
Q

This type of chronic diarrhea typically resolves during fasting?

Common causes include carb malabsorption, laxative abuse, malabsorption syndromes

A

Osmotic diarrhea

increased osmotic gap

59
Q

Chronic diarrhea w/ a high-volume, watery stool

Doesn’t resolve w/ fasting

May result from an endocrine tumor or bile salt malabsorption

A

Secretory diarrhea

increased intestinal secretion, decreased absorption

60
Q

What are the inflammatory forms of chronic diarrhea?

A

IBD (Crohn’s, UC)

Microscopic colitis

61
Q

A chronic diarrhea and motility disorder that presents w/ pain and altered bowel habits w/ no evidence of organic diseas?

A

IBS

the most common cause of chronic diarrhea in you adults

62
Q

What are the characteristics of chronic diarrhea as a result of malabsorptive conditions?

A

wt loss, osmotic diarrhea, steatorrhea, nutritional deficiencies

63
Q

What are the common etiologies of chronic infectious diarrhea?

A

Giardia, E. histolytica, Cyclospira (protozoans)

Intestinal nematodes

64
Q

What are some systemic conditions that might result in chronic diarrhea?

A

Thyroid dz

Diabetes

65
Q

Common lab tests in a chronic diarrhea workup might include?

A

CBC, Chem 17, LFT, thyroid studies, INR, ESR, CRP

Stool studies shoudl include cultures, leukocytes, lactoferrin, occult blood, OandP, electrolytes

66
Q

How would we test for Celiac?

A

serologically, for IgA tissue transglutaminase

67
Q

Anemia occurs in what forms of chronic diarrhea?

A

malabsorption syndrome

inflammatory conditions

68
Q

Hypoalbuminemia occurs in what forms of chronic diarrhea?

A

malabsorption

protein-losing enteropahties

inflammatory diseases

69
Q

In inflammatory bowel disease what might we expect to see elevated?

A

ESR, CRP

70
Q

Most patients w/ chronic persistent chronic diarrhea undero colonoscopy to exclude?

A

IBD

neoplasm

71
Q

24-hour stool collections can be ordered for total stool weight and total fat in stool…

  1. Low stool weight means?
  2. A high stool weight means?
  3. High fecal fat means?
A
  1. exludes diarrhea, suggestive of IBS
  2. significatn secretory process, including a neuroendocrine tumor
  3. Indicates malabsorptive syndrome
72
Q

Small bowel bacterial overgrowth might warrant a noninvasive breath…. HOwever these have high rates of false positives….definitive diagnosis should be determined how?

A

Bacterial culture of small intestinal contents (aspirate)

not available at most centers

73
Q

Chronic diarrhea tx depends on etiology and most case warrant referral to a specialist.. Some tx options are?

A

Loperamide

Diphenoxylate w/ atropine

Codeine (reserved for chronic, intratbale diarrhea)

Clonidine

Octreotide

Bile salt binders

74
Q

Hematochezia are present in massive upper GI bleeds, but most cases present w/?

A

melena

75
Q

Should you use hematocrit or volume status to determine severity of blood loss?

A

Volume status

76
Q

Not only diagnostic, this may also be therapeutic in acute upper GI bleeding?

A

endoscopy

77
Q

Upper GI bleeding is where in regards to the ligament of treitz?

A

Proximal duh

78
Q

Most common presentation of upper GI bleeds?

A

hematemesis or melena

hematochezia usually suggests a lower GI bleed

79
Q

Etiology of upper GI bleeds…

Most common?

Highest mortality rate?

A
  1. PUD accounts for 40%
  2. Portal HTN accounts for 10-20% but has a higher mortality rate
  3. Mallory Weiss tears
  4. Vascular anomalies (most commonly angioectasis, telangiectasis)
  5. Gastric neoplams (1%)
80
Q

What are some rare causes of acute upper GI bleeding?

A

Erosive gastritis (associated w/ NSAIDs, alcohol) is more likely to be chronic

Erosive esophagitis (chronic GERD)

81
Q

Initial tx measures for acute upper GI bleed should include assessment of hemodynamic status. A SBP lower than what indiciates a high risk pt?

(stable or unstable?)

A

100

Or a pulse > 100 bpm

82
Q

In unstable pt, begin an IV and send for what tests?

A

Blood type/screening for possible transfusion (2-4U PRBCs)…

CBC, PT/INR, CMP,

83
Q

Though not always rec’d, placement of an NG tube may reveal what?

A

Red blood/coffee ground aspirate, which confirms an upper GI bleed

(Though not all pts positive for bleeding will aspirate, especially those w/ duodenal bleeding)

84
Q

Amount of fluid/blood products is based on pt presentation, but PRBCs should aim to maintina HGB at what level?

A

No lower than 7-9 g/dL

85
Q
  1. If pt is using aspirin/clopidorel, consider?

2. Pt is uremic, consider?

A
  1. platelet transfusion

2. desmopressin

86
Q

In initial triage, what are the risk factors for a high risk pt? And wehre do they go?

A

Send them to ICU

Age > 60

Comorbid illness

SBP<100>HR

BRRB, bright red blood from NG aspirate

87
Q

WHat is warranted in all cases of upper GI bleed? And w/ how many hours?

A

Upper endoscopy WITHIN 24 hours

88
Q

What are upper endoscopy’s benefit?

A

ID source

Determine risk of rebleed/ guide triage

Endoscopic therapeutic intervention

89
Q

What are the therapeutic endoscopic modalities?

A

Cautery

Injection (e.g., epi)

Endoclips

90
Q

Acute noninflammatory diarrhea cause?

A

Usally viral or NONINVASIVE bacteria

91
Q

Do we want to “stop up” a pt w/ diarrhea?

A

Depends… prefer not to (let the body flush it out…)

BUT if they’re essential personnel or a wage-worker, consider loperamide so they can get to work

92
Q

How do we confirm an upper GI blood?

A

after hx and exam, EGD

Massive GI bleed = 1-1.5 L

93
Q

How far does an EGD go?

A

To the duodenum

94
Q

Once stabilized, initial triage is based on risk of rebleed. What puts a pt in the high risk category?

A

Age>60

Comorbid illness

SBP<100

Pulse>100

Bright red rectal blood in aspirate OR rectal exam

95
Q

Where do patients go who are not high risk?

A

Admit to a step-down unit/ward

96
Q

What’s a pharmacological intervention a pt w/ an upper GI blood should receive?

What are its benefits?

A

IV PPI

lowers risk of rebleed, erosive esophagitis/gastritis, and MW tear

97
Q

Pts w/ upper GI bleed and evidence of portal HTN should receive what?

A

IV octreotide

98
Q

Where does the majority of acute lower GI bleed come from?

A

Colon

99
Q

Lower or Upper GI… which has a higher risk of serious blood loss?

A

UPPER

100
Q

Most common cause of major lower tract bleeding?

A

Diverticulosis

101
Q

Etiologies of acute lower GI bleeding?

A

Anorectal dz (hemorrhoids, fissure, ulcers)

Diverticulosis

IBD (UC, Crohn’s)

Infectious colitis

Neoplasm

Angioectasias

102
Q

Most likely lower GI bleed in those under 50?

A

Anorectal dz

IBD

Infectious dz

103
Q

Most likely GI bleed in patients over 50?

A

Diverticulosis

Malignancy

Angioectasias

Ischemic colitis

104
Q

What is the likely source of bright red blood in stool?

A

Left colonic source

hemorrhoids, fissure, diverticulitis, IBD, colitits

105
Q

Likely source of maroon blood in stool?

A

Small intestine or right colonic source

106
Q

Likely source of black blood in stool?

A

Upper GI

107
Q

Painful defecation could be?

A

External hemorrhoids

Anal fissure

108
Q

Abdominal cramps accompany what lower GI bleeds?

A

IBD

Colitis

109
Q

Painless lower GI bleeds accompany?

A

internal hemorrhoids

Diverticular bleeding

110
Q

A larg volume of blood accompanying a lower GI blled, think?

A

Diverticular

111
Q

Small volumes of blood in a lower GI bleed, think?

A

IBD

Hemorrhoids

112
Q

With a suspected acute lower GI bleed, you must first exclude?

A

Upper GI source of blood

113
Q

Options for lower GI bleed “scopes”?

A 
Anoscopy
Sigmoidoscopy
Colonoscopy
Technetium scan
Capsule endoscopy
114
Q

Treatment options for acute lower GI bleeding?r

A

Therapeutic colonoscopy

Intra-arterial embolization

Surgery (last resort)

115
Q

As a last resort, surgery is an opton for acute lower GI bleed, what are the indications?

A

If a patient requires more than 6 units of PRBCs in 24 hrs, or more than 10 units total

116
Q

Two types of obscure GI bleeding?

A

Obscure overt

Obscure occult

117
Q

Common source of obscure GI Bleeding?

A

small intestine

118
Q

Obscure bleeding is bleedint that isn’t apparent to the pt. How much blood/day can you lose w/o appreciable signs?

A

Up to 100 mL/day

119
Q

How can we ID occult GI bleeding?

A

Fecal Occult Blood test

Fecal Immunochemical Test (only detects LOWER bleed)

Presence of unexplained anemia in CBC

120
Q

Occult GI bleed… what shoudl investigate for? How so?

A

NEOPLASM

Get CBC for anemia

121
Q
  1. Pos FOBT w/o anemia… what would you order?

2. Pos FOBT w/ anemia… what would you order?

A
  1. Colonoscopy

2. Upper endoscopy AND colonoscopy

122
Q

Presents as acute, painless, large-volume maroon or bright red hematochezia in patients over 50?

A

Diverticulosis

123
Q

Bright red blood dripping into the toilet bowl, think?

A

Hemorrhoids

124
Q

Given that we should exlude an UPPER GI bleed when a pt presents w/ an acute lower GI bleed, how might we differentiate?

A

NG tube aspirate w/ blood/dark brown guiac positive material is strongly suggestive of upper GI bleeding

125
Q

In pts under 45, lower GI bleeds can be scoped with only an anoscopy and sigmoidoscopy, however patients older than 45 shoujd have what?

A

A full colonoscopy to exclude a tumor

126
Q

In MOST cases, pts w/ acute, large volume GI bleeding that requires hospitalizaiton, what is the study of choice?

A

COlonoscopy

127
Q

For treatment of acute lower GI bleeding, we can treat with a therapeutic colonoscopy… such as?

A

Vasoconstrictive injection (epi)

Cautery

Endoclips

128
Q

Aside from therapeutic colonoscopy, what are other tx options for acute lower GI bleeds?

And when is our last resort indicated?

A

Intra-arterial embolization

Surgery – indciated when a pt requires more than 6U in 24 hrs OR more than 10U over any timespan

129
Q

In an acute lwoer GI bleed, What are our two most likley conditions that will require surgical interventio?

A

a bleeding diverticulum

angiectasia

130
Q

Most common causes of small intestinal bleedin gin patient under 40?

A

neoplasms

Crohn dz

Celiac

Meckel diverticulum

131
Q

Most common casues of small intestinal bleeding in patients over 40?

A

Angioectasis

NSAID-induced ulcers

(though other diorders occur as well)

132
Q

Before pursuing eval of small intestine, repeat the upper endoscopy and colonoscpoy to ensure a lesion hasn’t been overlooked

A

k cool

133
Q

Chronic gastrointestinal blood of less than ___ may cause no appreceaible change in stool appearance.

A

100 mL/day

occult blood

134
Q

Pts over 60 w/ obscure-occult bleeding who have a nomal initial endoscope and no other worrisome ssx, most commonly have a bleed from what? And how to treat?

(worrisome = wt loss, ab pn)

A

Bleed from angioectasis

Consider an iron supplemetn for empiric tx. If unresponsive to iron supplementation, pursue capsule endoscopy

135
Q

In an occult bleed, when possible, ____ should be discontinued. Patients with occult bleeding without a bleeding source identified after upper endoscopy, colonoscopy, and capsule endoscopy have a
low risk of recurrent bleeding and usually can be managed with close observation.

A 
antiplatelet agents (aspirin, NSAIDs,
clopidogrel)
136
Q

Derived from two sources
– ?
– ?
• Contains numerous gases including:
– oxygen, nitrogen, hydrogen, carbon dioxide, hydrogen
sulfide, ammonia, and methane – foul smell caused by ????
and methane

A

Derived from two sources
– swallowed air (primarily nitrogen)
– bacterial fermentation of undigested carbohydrate

• Contains numerous gases including:
– oxygen, nitrogen, hydrogen, carbon dioxide, hydrogen
sulfide, ammonia, and methane
– foul smell caused by traces of hydrogen sulfide, ammonia,
and methane

137
Q

• Eructation – Belching
– The involuntary or voluntary release of gas
from the stomach or esophagus
– Occurs most frequently?
• gastric distention results in ____________ relaxation
– Typically due to aerophagia ?

A

• Eructation – Belching
– The involuntary or voluntary release of gas
from the stomach or esophagus – Occurs most frequently after meals
• gastric distention results in transient lower
esophageal sphincter relaxation
– Typically due to aerophagia (swallowing air)

GI (9 decks)

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