SSx 1-3 Flashcards
Dyspepsia… predominant epigastric pain
Maybe associated epigastric fullness, nausea, heartburn, vomiting
When is endoscopy warranted?
Warranted in pts 60 or older
Pts w/ alarm features
Alarm features = wt loss, anemia, dysphagia, vomiting, recurrent GI bleeding
Pts w/ dyspepsia under 60 w/o alarm features should be tested for?
H. pylori… If positive abx should be administered
Dyspepsia… pts who are h. pylori negative or see no improvement after H. pylori eradication should receive what?
Empiric proton pump inhibitor therapy
Dyspepsia… Another option for pts w/ refractory symptoms might be?
tricyclic antidepressants, a prokinetic agent, or psychological therapy
Functional dyspepsia?
Most common cause of dyspepsia
Dyspepsia w/ no identifiable etiology (by endoscopy or other testing)
What are two common diseases also seen in dyspepsia, referred to as luminal tract dysfunction?
Peptic ulcer disease (15% of patients w/ dyspepsia)
GERD (20% of patients w/ dyspepsia)
Chronic gastric infection w/ H. pylori is an important cause of what?
And even in the absence of this, h. pylori may cause dyspepsia.
H. pylori is often associated w/ PUD; however, even in the absence of H. pylori, it can still cause dyspepsia.
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?
Pancreatic pn is typically more severe, sometimes radiates to the back and usually is associated anorexia, rapid wt loss, steatorrhea, or jaundice
Dyspepsia accompanied by what warrants endoscopy?
wt loss, persistent vomiting, constant/severe pn, progressive dysphagia, hematemesis, melena
Though the physical examination is rarely helpful in cases of dyspepsia, certain signs of serious organic disease should be furhter evaluated. Such as?
wt loss, organomegaly, abdominal mass, FOBT
If an H. pylori breath test or fecal antigen test result is negative in a pt NOT taking NSAIDs, what can be excluded?
PUD is virtually excluded
Study of choice for diagnosing gastrointestinal ulcers, erosive esophagitis, and upper gastrointestinal malignancy is?
upper endoscopy
In dyspepsia, h. pylori-negative pts most likely have functional dyspepsia or atypical GERD and can be treated how?
W/ an anti-secretory agent (PPI) for 4 weeks (empirically)
Patients in with persistent dyspepsia AFTER H. pylori eradication can be given a trial of what?
PPI therapy
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?
functional dyspepsia
Consider dietary changes and/or pharmacotherapy w/ antisecretory agents, TCAs, metoclopromide
Vomiting should be distinguished from what (which is the effortless relfux of liquid or food stomach contents)?
regurgitation
Acute symptoms of nausea/vomiting w/o abd pn are typically caused by what?
food poisoning, infectious gastroenteritis, drugs, or systemic illness
In severe or protracted vomiting, serum electrolytes should be obtained to look for ?
hypokalemia, azotemia, metabolic acidosis
What are the complications from nausea/vomiting?
dehydration, hypokalemia, metabolic alkalosis, aspiration, boerhaave syndrome, mallory weiss tear
What is the standard triple therapy tx for h pylori?
PPI po bid
Clarithromycin 500 mg PO BID
Amoxicillin 1g PO BID
(if pen allergy, metronidazole 500 mg PO BID)
What is the standard quadruple therapy for h pylori?
PPI po bid
Bismuth subsalicylate two tabs PO qid
Tetracycline 500mg PO QID
Metronidazole 500mg TID
Acute onset of severe pn and vomting suggests what?
peritoneal irritation, acute gastric/intestinal obstruction, or pancreaticobiliary dz
Early morning vomiting is common in?
pregnancy, uremia, alcohol intake, increased ICP
Physical exam observations/tests for nausea/vomiting?
Dry mucous membranes?
SKin turgor
Orthostatic vital signs (“tilts”)
TTP?
distension?
Organomegaly?
“Typical” treatment options for nausea/vomiting?
Fluids, BRAT diet, ginger
Pharmacotherapy options for nausea/vomiting?
Serotonin-receptor antagonists (ondansetron)
Dopamine antagonists (promethazine, procloperazine)
Antihistamines (meclizine, dimenhydrinate, scope, diphen)
Persistent/intractable hiccups warrant a full history/physical exam for serious underlying pathology, such as?
CNS pathology (neoplasm, infection, trauma)
Metabolic issues (uremia, hypocapnia)
Chronic irritation
Postoperative
Psychogenic
Intractable hiccups can be treated w/?
Chlorpromazine
Broadly, what are soem of the FODMAPs that might cause and therefore be avoided for pts concerned w/ flatus?
lactose
Fructose
polypols
fructans
Most common cause of constipation?
Inadequate fiber/fluid intake
poor bowel habits
(opioids)
What’s meant by primary constipation?
More common form that cannot be attributed to any structural/systemic dz/abnormality
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?
Hematochezia
wt loss
anemia
+FOBT/FIT
Osmotic laxatives used for constipation?
Magnesium hydroxide
Polyethelyne glycol 3350
Polyethelyne glycol
Magnesium citrate
**magnesium should be avoided in patients w/ chronic renal insufficiency
Osmotic laxatives used for constipation?
Magnesium hydroxide
Polyethelyne glycol 3350
Polyethelyne glycol
Magnesium citrate
**magnesium should be avoided in patients w/ chronic renal insufficiency
Stimulant laxatives used for constipation?
Bisacodyl
Senna
(avoid in obstruction)
Stool surfactants for constipation
Docusate Sodium
Fecal impaction can present w/ paradoxical diarrhea. What are the tx options?
Manual fragmentation/disimpaction
or saline/mineral oil/diatrizoate enema
Fecal impaction can present w/ paradoxical diarrhea. What are the tx options?
Manual fragmentation/disimpaction
or saline/mineral oil/diatrizoate enema
Constipation Patients at what age or with what symptoms should be referred for colonscopy?
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)
Acute diarrhea… duration? And most common cause?
Acute < 2 weeks
Most commonly caused by pathogens
Acute non-inflammatory diarrhea is typically watery, nonbloody and self-limited.
WHat usually causes it and when would you perform a diagnostic eval?
Usually caused by virus/non-invasive bacteria
Diagnostic evaluations for pts w/ SEVERE diarrhea or diarrhea > 7 days
Acute inflammatory diarrhea will present w/ blood or pus and usually caused by an invasive/toxin-producing bacterium.
What are the diagnostic evaluation requirements?
Stool bacterial testing for (E Coli O157H5, H7) in ALL
And if clinically indicated, testing for clostridioides difficile toxin, and OandP
Common etiologies for acute non-inflammatory diarrhea?
think viral or protozoal
Norovirus
Rotavirus
Giardia
Common etiologies for acute inflammatory diarrhea?
E Coli
Shigella
Salmonella
Clostridium difficile
(also campylo and yersinia)
Symptoms of acute inflammatory diarrhea?
Loose/bloody stools (lower in volume)
Fever
LLQ cramps/pn
Urgency
Tenesmus
Distinguish mild diarrhea from those needing prompt evaluation. What are indications for further eval?
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
Acute diarrhea may require lab tests, including fecal leukocytes, stool cultures, OandP (x3, remember?), C difficile, and fecal lactoferrin.
What’s fecal lactoferrin?
a marker of intestinal inflammation
For the tx of acute diarrhea, what should be avoided?
High-fiber foods, fats, dairy, and caffeine
Loperamide and bismuth subsalicylate are antidiarrheal are the recommended agents for acute diarrheal tx. When are they contraindicated?
Pts w/ bloody diarrhea
High fever
systemic toxicity
AND they should be discontinued in pts whose diarrhea is worsening despite therapy
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?
Non-hospital acquired diarrhea
Moderate-severe fever, tenesmus, bloody stools
No suspicion of STEC infection
Immunocompromised pts
Significant dehydration
Drugs of choice for empirtic tx of of acute diarrhea?
Cipro BID 500mg
Oxfloxacin BID 400mg
levofloxacin QD 500mg
(flouroquinolones, all 1-3 days)
Alternatives abx for empiritc tx of acute diarrhea?
Trimethoprim-sulfamethoxazole 160/800mg BID
doxy 100mg BID
Many bacterial cases of diarrhea do not warrant abx therapy. What are the specific species for which abx therapy IS warranted?
Shigellosis Salmonellosis (extraintestinal) Listeriosis Cholera C. diff
What are the non-bacterial forms of infectious diarrhea that warrant abx tx?
amebiasis, giardiasis, and traveler’s diarrhea
When should you admit for inpatient tx?
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
Chronic diarrhea is longer than 4 weeks. What should be excluded before an extensive workup?
Common causes such as medications, chronic infections, and IBS
What are the major pathologic categories for chronic diarrhea
Chronic Osmotic Medications Malabsorptive Motility Inflammatory Systemic Secretory
COMMMISS
This type of chronic diarrhea typically resolves during fasting?
Common causes include carb malabsorption, laxative abuse, malabsorption syndromes
Osmotic diarrhea
increased osmotic gap
Chronic diarrhea w/ a high-volume, watery stool
Doesn’t resolve w/ fasting
May result from an endocrine tumor or bile salt malabsorption
Secretory diarrhea
increased intestinal secretion, decreased absorption
What are the inflammatory forms of chronic diarrhea?
IBD (Crohn’s, UC)
Microscopic colitis
A chronic diarrhea and motility disorder that presents w/ pain and altered bowel habits w/ no evidence of organic diseas?
IBS
the most common cause of chronic diarrhea in you adults
What are the characteristics of chronic diarrhea as a result of malabsorptive conditions?
wt loss, osmotic diarrhea, steatorrhea, nutritional deficiencies
What are the common etiologies of chronic infectious diarrhea?
Giardia, E. histolytica, Cyclospira (protozoans)
Intestinal nematodes
What are some systemic conditions that might result in chronic diarrhea?
Thyroid dz
Diabetes
Common lab tests in a chronic diarrhea workup might include?
CBC, Chem 17, LFT, thyroid studies, INR, ESR, CRP
Stool studies shoudl include cultures, leukocytes, lactoferrin, occult blood, OandP, electrolytes
How would we test for Celiac?
serologically, for IgA tissue transglutaminase
Anemia occurs in what forms of chronic diarrhea?
malabsorption syndrome
inflammatory conditions
Hypoalbuminemia occurs in what forms of chronic diarrhea?
malabsorption
protein-losing enteropahties
inflammatory diseases
In inflammatory bowel disease what might we expect to see elevated?
ESR, CRP
Most patients w/ chronic persistent chronic diarrhea undero colonoscopy to exclude?
IBD
neoplasm
24-hour stool collections can be ordered for total stool weight and total fat in stool…
- Low stool weight means?
- A high stool weight means?
- High fecal fat means?
- exludes diarrhea, suggestive of IBS
- significatn secretory process, including a neuroendocrine tumor
- Indicates malabsorptive syndrome
Small bowel bacterial overgrowth might warrant a noninvasive breath…. HOwever these have high rates of false positives….definitive diagnosis should be determined how?
Bacterial culture of small intestinal contents (aspirate)
not available at most centers
Chronic diarrhea tx depends on etiology and most case warrant referral to a specialist.. Some tx options are?
Loperamide
Diphenoxylate w/ atropine
Codeine (reserved for chronic, intratbale diarrhea)
Clonidine
Octreotide
Bile salt binders
Hematochezia are present in massive upper GI bleeds, but most cases present w/?
melena
Should you use hematocrit or volume status to determine severity of blood loss?
Volume status
Not only diagnostic, this may also be therapeutic in acute upper GI bleeding?
endoscopy
Upper GI bleeding is where in regards to the ligament of treitz?
Proximal duh
Most common presentation of upper GI bleeds?
hematemesis or melena
hematochezia usually suggests a lower GI bleed
Etiology of upper GI bleeds…
Most common?
Highest mortality rate?
- PUD accounts for 40%
- Portal HTN accounts for 10-20% but has a higher mortality rate
- Mallory Weiss tears
- Vascular anomalies (most commonly angioectasis, telangiectasis)
- Gastric neoplams (1%)
What are some rare causes of acute upper GI bleeding?
Erosive gastritis (associated w/ NSAIDs, alcohol) is more likely to be chronic
Erosive esophagitis (chronic GERD)
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?)
100
Or a pulse > 100 bpm
In unstable pt, begin an IV and send for what tests?
Blood type/screening for possible transfusion (2-4U PRBCs)…
CBC, PT/INR, CMP,
Though not always rec’d, placement of an NG tube may reveal what?
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)
Amount of fluid/blood products is based on pt presentation, but PRBCs should aim to maintina HGB at what level?
No lower than 7-9 g/dL
- If pt is using aspirin/clopidorel, consider?
2. Pt is uremic, consider?
- platelet transfusion
2. desmopressin
In initial triage, what are the risk factors for a high risk pt? And wehre do they go?
Send them to ICU
Age > 60
Comorbid illness
SBP<100>HR
BRRB, bright red blood from NG aspirate
WHat is warranted in all cases of upper GI bleed? And w/ how many hours?
Upper endoscopy WITHIN 24 hours
What are upper endoscopy’s benefit?
ID source
Determine risk of rebleed/ guide triage
Endoscopic therapeutic intervention
What are the therapeutic endoscopic modalities?
Cautery
Injection (e.g., epi)
Endoclips
Acute noninflammatory diarrhea cause?
Usally viral or NONINVASIVE bacteria
Do we want to “stop up” a pt w/ diarrhea?
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
How do we confirm an upper GI blood?
after hx and exam, EGD
Massive GI bleed = 1-1.5 L
How far does an EGD go?
To the duodenum
Once stabilized, initial triage is based on risk of rebleed. What puts a pt in the high risk category?
Age>60
Comorbid illness
SBP<100
Pulse>100
Bright red rectal blood in aspirate OR rectal exam
Where do patients go who are not high risk?
Admit to a step-down unit/ward
What’s a pharmacological intervention a pt w/ an upper GI blood should receive?
What are its benefits?
IV PPI
lowers risk of rebleed, erosive esophagitis/gastritis, and MW tear
Pts w/ upper GI bleed and evidence of portal HTN should receive what?
IV octreotide
Where does the majority of acute lower GI bleed come from?
Colon
Lower or Upper GI… which has a higher risk of serious blood loss?
UPPER
Most common cause of major lower tract bleeding?
Diverticulosis
Etiologies of acute lower GI bleeding?
Anorectal dz (hemorrhoids, fissure, ulcers)
Diverticulosis
IBD (UC, Crohn’s)
Infectious colitis
Neoplasm
Angioectasias
Most likely lower GI bleed in those under 50?
Anorectal dz
IBD
Infectious dz
Most likely GI bleed in patients over 50?
Diverticulosis
Malignancy
Angioectasias
Ischemic colitis
What is the likely source of bright red blood in stool?
Left colonic source
hemorrhoids, fissure, diverticulitis, IBD, colitits
Likely source of maroon blood in stool?
Small intestine or right colonic source
Likely source of black blood in stool?
Upper GI
Painful defecation could be?
External hemorrhoids
Anal fissure
Abdominal cramps accompany what lower GI bleeds?
IBD
Colitis
Painless lower GI bleeds accompany?
internal hemorrhoids
Diverticular bleeding
A larg volume of blood accompanying a lower GI blled, think?
Diverticular
Small volumes of blood in a lower GI bleed, think?
IBD
Hemorrhoids
With a suspected acute lower GI bleed, you must first exclude?
Upper GI source of blood
Options for lower GI bleed “scopes”?
Anoscopy Sigmoidoscopy Colonoscopy Technetium scan Capsule endoscopy
Treatment options for acute lower GI bleeding?r
Therapeutic colonoscopy
Intra-arterial embolization
Surgery (last resort)
As a last resort, surgery is an opton for acute lower GI bleed, what are the indications?
If a patient requires more than 6 units of PRBCs in 24 hrs, or more than 10 units total
Two types of obscure GI bleeding?
Obscure overt
Obscure occult
Common source of obscure GI Bleeding?
small intestine
Obscure bleeding is bleedint that isn’t apparent to the pt. How much blood/day can you lose w/o appreciable signs?
Up to 100 mL/day
How can we ID occult GI bleeding?
Fecal Occult Blood test
Fecal Immunochemical Test (only detects LOWER bleed)
Presence of unexplained anemia in CBC
Occult GI bleed… what shoudl investigate for? How so?
NEOPLASM
Get CBC for anemia
- Pos FOBT w/o anemia… what would you order?
2. Pos FOBT w/ anemia… what would you order?
- Colonoscopy
2. Upper endoscopy AND colonoscopy
Presents as acute, painless, large-volume maroon or bright red hematochezia in patients over 50?
Diverticulosis
Bright red blood dripping into the toilet bowl, think?
Hemorrhoids
Given that we should exlude an UPPER GI bleed when a pt presents w/ an acute lower GI bleed, how might we differentiate?
NG tube aspirate w/ blood/dark brown guiac positive material is strongly suggestive of upper GI bleeding
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 full colonoscopy to exclude a tumor
In MOST cases, pts w/ acute, large volume GI bleeding that requires hospitalizaiton, what is the study of choice?
COlonoscopy
For treatment of acute lower GI bleeding, we can treat with a therapeutic colonoscopy… such as?
Vasoconstrictive injection (epi)
Cautery
Endoclips
Aside from therapeutic colonoscopy, what are other tx options for acute lower GI bleeds?
And when is our last resort indicated?
Intra-arterial embolization
Surgery – indciated when a pt requires more than 6U in 24 hrs OR more than 10U over any timespan
In an acute lwoer GI bleed, What are our two most likley conditions that will require surgical interventio?
a bleeding diverticulum
angiectasia
Most common causes of small intestinal bleedin gin patient under 40?
neoplasms
Crohn dz
Celiac
Meckel diverticulum
Most common casues of small intestinal bleeding in patients over 40?
Angioectasis
NSAID-induced ulcers
(though other diorders occur as well)
Before pursuing eval of small intestine, repeat the upper endoscopy and colonoscpoy to ensure a lesion hasn’t been overlooked
k cool
Chronic gastrointestinal blood of less than ___ may cause no appreceaible change in stool appearance.
100 mL/day
occult blood
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)
Bleed from angioectasis
Consider an iron supplemetn for empiric tx. If unresponsive to iron supplementation, pursue capsule endoscopy
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.
antiplatelet agents (aspirin, NSAIDs, clopidogrel)
Derived from two sources
– ?
– ?
• Contains numerous gases including:
– oxygen, nitrogen, hydrogen, carbon dioxide, hydrogen
sulfide, ammonia, and methane – foul smell caused by ????
and methane
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
• 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 ?
• 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)
