Themes Flashcards
Peptic stricture (complication of GERD)
Eosinophilic esophagitis
Achalasia
Zenker Divericulum
Esophageal carcinoma
All present w/ progressive dysphagia
(achalasia is SOLID and LIQUID)
(w/ achalasia, consider Chagas Dz if the progression is RAPIDO)
Esophageal webs/rings
Zenker Diverticulum
Achalasia
Esophageal carcinoma
Hiatal hernia
Barium swallow
Note that for achalasia, you’d confirm w/ an EGD and esophageal manometry
(note that to establish diagnosis for esophageal carcinoma, you would do an EGD; however, barium swallow initial w/ dysphagia as pt’s presenting complaint)
Nausea/vomiting WITH pain?
Gastroparesis
Acute Obstruction
Peritoneal irritation
N/V WITHOUT pain?
Food poisoning
Acute gastroenteritis
Systemic illness
NG tube relieves…?
The diarrhea of ZES
The bloating/nausea/vomiting of gastroparesis
Distension of acute hemolytic ileus
Tx with TMP-SMX?
Whipple x 12 months
Tropic Sprue x 6 months
PROPHYLAXIS - ascites x not sure if permanent or not?
DO we have weight loss in lactase deficiency?
Name all the weight loss etiologies from this block:
lactase deficiency does NOT cause weight loss
FILL THIS IN**
causes of achlorydia?
Bacterial overgrowth (small intestines leading to malabsorption of B vitamins i.e. B1 thiamine)
OR
Pernicious Anemia gastritis (B12 deficiency leads to less stomach acid)
OR
maybe H pylori or atrophic gastritis
Which diseases do NOT have TTP or it is uncommonly found (add percentages if uncommon):
Acute paralytic Ileus - No TTP, but diffuse, constant pain, N/V, distension, Diminished/absent bowel sounds
spontaneous bacterial peritonitis - NO TTP (according to lecture, but may be mild)
FILL IN OTHERS HERE***
Time frame for symptoms that are odd:
- Which disease possibly has chronic diarrhea following an acute diarrhea that may have already been treated and seemingly resolved?
1-2 years symptoms post operatively?
pain after vomiting it’s not what?
ADD MORE***
Tropical Sprue - following acute diarrhea
1-2 years post op - small bowel obstruction (SBO)
pain after vomiting it’s not appendicitis (Pain before N/V = appendicitis)
ADD MORE***
Pain out of proportion?
Dx test?
Tx?
Mesenteric Ischemia
Dx - CT angiography
Treatment = admission, papverine (relaxes smooth muscle), thrombolytics, SURGICAL EMERGENCY!
How would atypical appendicitis present and which locations of the appendix?
- Pain is less intense and poorly localized; abdominal tenderness is minimal and may be elicited in the right flank (psoas may be +)
- For pelvic appendicitis - pain in lower abdomen often on the L w/ urge to urinate or defecate w/o abdominal tenderness unless you do a pelvic or rectal exam
- retrocecal (doesn’t touch abdomen wall) or retroileal appendicitis (often associated with pyuria or hematuria) may be confused with uteretral colic or pyelonephritis
Blunting of the intestinal villi?
Celiac
Tropical sprue
(use hx to steer your dx)
Who gets TMP-SMX?
Tropical Sprue (x 6 mos)
Whipple Dz (1 tab BID x12 mos)
Spontaneous Bacterial Peritonitis (option for prophylaxis)
Acute diarrhea (option for empiric tx, 160/800mg)
Who gets Amoxicllin?
Bacterial Overgrowth (option)
H. Pylori (part of triple therapy)
Who gets Cipro?
Bacterial overgrowth (option)
Spontaneous Bacterial Peritonitis (option)
Acute diarrhea (Cipro 500mg BID 5-7, option for empiric treatment)
(traveler’s diarrhea [fluoroquinolones but not useful for SE Asia])
When might a CT scan be warratned?
- Appendicitis (DON’T DELAY SURGERY, though)
- Small Bowel Obstruction (if fever, tachycardia, abd pain, leakocytosis to differentiate from strangled obstruction)
- Gastroparesis (or endoscopy to r/o mechanical obstruction)
- Spontaneous Bacterial Peritonits (to discover source of infection if 2* peritonitis is suspected)
- Chronic Intestinal Pseudo-obstruciton (CT/endoscopy)
- Anal carcinoma (can also use MRI)
- Mesenteric ischemia (CT angiography)
What characteristically presents w/ a lack of TTP?
Acute paralytic ileus
Spontaneous Bacterial Peritonitis
progressive dysphagia
Peptic stricture (complication of GERD)
Eosinophilic esophagitis
Achalasia
Zenker Divericulum
Esophageal carcinoma
Macrocytic anemia?
Vitamin B12 deficiency…
Tropical Sprue
Bacterial overgrowth
which prazole or PPI can you take at anytime?
pantoprazole
rebound tenderness?
Appendicitis
PUD
when will fecal leukocytes be positive or in what type of diarrhea?
marker of intestinal inflammation?
inflammatory
lactoferrin
Therapeutic colonoscopy (injection / cautery / clips / bands ) When would you do it for large volume acute upper GI bleed? When would you not?
Ok with diverticulosis or neoplasms etc
Not ok with diverticulitis! No Likis the Litis for therapeutic colonoscopy!
Which test would you do that is ONLY for lower GI bleeds?
Fecal Immunochemical Test
• Only detects lower GI bleed
Chlorpromazine for?
Singultus
systemic disease causes of constipation?
hypothyroid and DM
Also IBS specifically IBS-C !!!
FIT ?
Fecal Immunochemical Test - Lower GI bleed only detection!
fever, tachycardia, localized abdominal pain and or leuckocytosis
SBO… possibly others too, but at least this
he prompt evaluation indicated for acute diarrhea:
- signs of inflammatory diarrhea (fever, WBC’s over 15,000, bloody, severe pain)
- profuse watery diarrhea and dehydration
- Frail older patients or nursing home residents
- Immunocompromised patients
- Exposure to antibiotics
- Hospital-acquired diarrhea (onset following at least 3 days of hospitalization)
- Systemic illness
What are the osmotic laxatives? Which clean you out?
Magnesium hydroxide
Polyethelyne glycol 3350
Polyethelyne glycol (cleans out)
magnesium citrate (cleans out)
What might present w/ leukocytosis?
Appendicitis (moderate)
SBO (leukocytosis, IF present, warrants a CT scan)
Severe acute diarrhea (which warrants admission)
When might Rifaximin might be a tx option?
Traveler’s diarrhea (rifaxmin 200 mg TID x 3 days)
Bacterial overgrowth
When might steatorrhea be present?
Celiac
Whipple Dz
Tropical sprue
Bacterial overgrowth
NOT LACTOSE!!!!
INtermittent dysphagia?
Esophageal web/rings
what is the grading criteria for hemorrhoids and which type?
what can we do on PE?
internal hemorrhoids only based off degree of prolapse
ask them to valsalva
thrombosed hemorrhoids?
PAINFUL due to clots… must remove clots and can be done in clinic
How would you decipher between chronic diarrhea that has come back normal (No IBD or Cancer) on all exclusion criteria, fecal luekocytes, FOBT, Colonoscopy w/ biopsy, small bowel imagin (barium, CT, or MR enterography)….
AKA what is done first after all of the above have been completed? (1)
What do we test for second (2)?
(1) test the osmotic gap (electrolytes, osmolality, weight/24 h, quantitative fat)
(2) if the osmotic gap increased we look at the FECAL FAT… if the osmotic gap is NORMAL we look at the stool weight
Make sure you know which are increased fecal fat vs normal fecal fat!! Also know normal stool weight vs increased stool weight!!
which tx of hemorrhoids is a last resort? what can it result in?
surgical treatment AKA surgical hemorrhoidectomy (after failure of all other tx options), because MAY resul t in fecal incontinence
The other “hemorrhoidectomy” done in the clinic is not eh admitted Surgical hemorroidectomy!!
braod spectrum w/ gram negative coverage for appendicitis?
CCASE of appendicitis requires these!
C - Cefoxitin
C - Cefotetan
A - Ampicillin,
S - Sulbactam
E - Ertapenem
Prokinetic meds for gastroparesis?
Metoclopramide
Domperidone
Erythromycin (less desirable)
Meds for bacterial overgrowth?
Ciprofloxacin
Amoxicillin-clavulanate
Rifaximin
Intermittent ssx of obstruction?
pseudo-obstruction
acutely requires NG decompression/IV fluid/electrolyre replacement
what do you from your PE in order for it to be secondary ascites instead of spontaneous?
FOCAL TTP = secondary = CT before US with abdominal pericentesis
remember that we do what before an EGD normally… he finally said it in the review
NG
gastropathy vs gastritis main causes
gastropathy: NSAID Alcohol Stress (mechanical ventilation and coagulopathy) Portal Hypertension
Gastritis:
H. pylori
Miscellanous: pernicous anemia, infectious (immunocompromised), eosinophils, menetrier’s disease
Ascites Markers findings in the following:
TB?
Malignancy?
Pancreatic?
To know whether or not bacterial overgrowth presumptive vs definitive dx?
TB - adenosine deaminase
Malignancy - lymphocytes
Pancreatic - amylase
presumptive - breath test,
Definitive dx = culture
how to avoid stress gastritis induced ulcers?
sucralfate BID, H2, or PPI
stress gastropathy =
coagulopathy (INR greater than 1.5 and platelets under 50k or 50,000) or respiratory failure with mechanical ventilation
spontaneous we do what first?
secondary we do what first?
spontaneous US with abdominal pericentesis (No TPP)
secondary we do CT and look for SECONDARY CAUSE (Focal TTP)
pill induced esophagitis… offenders?
who would you NOT give these pills too if you can help it…
most commonly NSAIDS, iron, vitamin C and Abx
MOST COMMON ABX: Doxy, Tetra, Clinda, TMS-SMX
Doxycycline
Tetracycline
Clindamycin
Trimethoprim-sulfamethoxazole
MITIGATE RISK: take pills with water and remain upright for 30 minutes post ingestions and the offending agents should not be given in patients with ESOPHAGEAL DYSMOTILITY, DYSPHAGIA, or STRICTURES!!!!
pill induced esophagitis… offenders? (ABX ONLY)
who would you NOT give these pills too if you can help it…
MOST COMMON ABX: Doxy, Tetra, Clinda, TMS-SMX
Doxycycline
Tetracycline
Clindamycin
Trimethoprim-sulfamethoxazole
Z-line moves above the GEJ?
Barrett Esophagus
NSAID gastropathy alarm ssx?
Severe pn
Wt loss
Anemia
GI Bleed
(or if ssx do not improve)
Send for upper endoscopy
Aside from h pylori control measures, what are the tx measures for PUD?
First line = anti secretory agents (PPIs)
And… mucosal defense w/ sucralfate and/or misoprostol
(misoprostol is often given as prophylaxis for long term NSAID use…. so… POTENTIALLY very useful in pts who have NSAID related ulcers THAT can’t get off their COX1 inhibitors)
