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CMS150 final (wk 9-14) > week 11 > Flashcards

week 11 Flashcards

1
Q

what is the INTERCHEST rule for

A

predict coronary artery disease as cause of chest pain

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2
Q

criteria for INTERCHEST rule

A

pain reproduced by palpating chest wall
-1
men ≥ 55 yrs, women ≥ 65 yrs
+1
physician initially suspected a serious condition
+1
chest discomfort feels like pressure
+1
chest pain related to effort
+1
history of CAD
+1

low (-1 to 1)
2.1%
not low (2-5)
43%

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3
Q

dyspepsia is AKA

A

indigestion

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4
Q

dyspepsia definition

A

persistent or recurrent pain or discomfort in the upper abdomen

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5
Q

ROME IV criteria for dyspepsia

A

at least 1 of the following symptoms present for the past 3 months: postprandial fullness (3 days / week)
early satiety (3 days / week)
epigastric pain (1 day / week)
epigastric burning (1 day / week)
AND
no evidence of structural disease

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6
Q

what structural or biochemical diseases can cause functional dyspepsia

A

gastroesophageal reflux
50%
irritable bowel syndrome
35%

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7
Q

GERD

A
  • retrograde flow of stomach acid and enzymes into the esophagus, causing inflammation and pain
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8
Q

what makes GERD worse

A

obesity, smoking, alcohol, chocolate, peppermint, spicy food, citrus, caffeine, fatty food, tomato-based products, carbonated beverages

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9
Q

symptoms of GERD

A

retro-sternal or epigastric burning pain following meals (pyrosis, aka. “heartburn” or “acid reflux”), sour taste, possibly dysphagia
- chronic cough/ wheeze, nausea, sore throat, hoarseness, globus sensation

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10
Q

first line treatment/ therapeutic challenge for GERD

A

PPI trial

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11
Q

diagnosis of GERD

A

endoscopy, Bx, esophageal pH testing
- PPI trial (therapeutic challenge)

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12
Q

what can GERD develop into

A

up to 23% develop into esophageal strictures
10-15% develop into Barrett’s Esophagus after 5-10 years

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13
Q

barretts esophagus definition

A
  • metaplastic changes of esophageal squamous epithelium into columnar epithelium
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14
Q

what are the changes to epithelium in Barretts esophagus

A

squamous into columnar

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15
Q

risks of Barretts esophagus

A

long-standing GERD (> 5-10 yrs), smoking, male, age > 50 yrs, fHx, obesity

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16
Q

symptoms of Barretts esopahgus

A

chronic reflux symptoms including postprandial retro-sternal or epigastric pain

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17
Q

barrewtxs esophagus diagnosis

A

endoscopy and biopsy

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18
Q

what can Barretts esophagus develop into

A

1% develop into esophageal adenocarincoma

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19
Q

gastritis

A
  • diffuse inflammation of the stomach lining due to excess gastric acid coming in contact with mucosa

erosive (acute or chronic) - more severe
non-erosive - atrophic or metaplastic changes

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20
Q

causes of gastritis

A

H. pylori, long term NSAID use, EtOH, stress

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21
Q

gastritis symptoms

A

may be asymptomatic or coexist with GERD
epigastric pain (with food), dyspepsia, N/V, loss of appetite, melena

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22
Q

gastritis diagnosis

A

upper endoscopy

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23
Q

gastritis management

A

potential referral to MD (antibiotics, antacids (H2 blocker, PPI))

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24
Q

gastritis prognosis/ development

A

most resolve, potential to develop ulceration or carcinoma

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25
Q

what is peptic ulcer disease

A
  • localized erosion of the mucosal layer of the stomach (St) or small intestine (SmI)
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26
Q

what increases risk of peptic ulcer disease

A

h pylori, NSAID, stress, Zollinger Ellison syndrome

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27
Q

symptoms of peptic ulcer disease

A

burning epigastric pain (after meals), dyspepsia, mild nausea, belching, hunger 1-3 hrs after eating

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28
Q

labs for peptic ulcer disease

A

H.pylori testing (urea breath test, serum), gastrin (rarely); endoscopy

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29
Q

what are the 3 tests for h pylori

A
  1. urea breath test (LR+ 12-22.3)
  2. serum antibody titres (LR+ 2.1)
  3. fecal antigen (LR+ 10.8)

serum testing is inexpensive but doesnt tell if active or previous infection

30
Q

diarrhea

A
  • loose, watery stools 3 or more times a day.

bristol stool of type 5, 6, 7

31
Q

acute vs persistent vs chronic diarrhea

A

● acute - 1 or 2 days (typically self-resolving)
● persistent - lasts longer than 2 weeks and less than 4 weeks.
● chronic - lasts at least 4 weeks (may be continuous or intermittent)

32
Q

3 types of chronic diarrhea

A
  1. watery
    -secretory
    -osmotic
    -functional
  2. fatty
    -maldigestive
    -malabsorptive
  3. inflammatory
33
Q

watery diarrhea

secretory
osmtotic
functional

A

watery - loose stool consistency, possibly testing fecal osmotic gap
- secretory - the secretion of electrolytes into the intestine, increasing the
amount of water in the stool.
- osmotic - the presence of osmotically active, poorly absorbed solutes in the
bowel lumen that inhibit normal water and electrolyte absorption.
- functional - increased transit time, without any clear cause

34
Q

fatty diarrhea

maldigestive
malabsoprtive

A

fatty - bloating and steatorrhea in many, but not all cases
- maldigestive - the inability to break down large molecules of food in the
intestinal lumen into their smaller components.
- malabsorptive - nutrients from food are not absorbed properly in the small
intestine.

35
Q

inflammatory diarrhoea

A

inflammatory (or exudative) - elevated WBCs, occult or frank blood or pus

36
Q

watery- secretory diarrhea exmaples

A

bile acid malabsorption
crohns disease

37
Q

watery- osmotic diarrhea exambples

A

-celiac disease
-carbohydrate malabsorption syndrome

38
Q

watery- functional diarrhea examples

A

IBS

39
Q

fatty- malabsorptive diarrhea examples

A

-carbohydrate malabsorption syndromes (i.e. lactose, fructose, acarbose)
-celiac disease
-SIB)

40
Q

type of inflammatory or exucdative diarrhea

A

clostridium difficile (pseudomembranous) colitis

41
Q

alarm symptoms of diarrhea

A
  • blood in stools (either as hematochezia or melena)
  • more than 10% unintentional weight loss
  • disease that wakes the patient up during the night
  • fever
  • new onset of signs and symptoms after 50 yrs of age
  • fHx of colorectal cancer, inflammatory bowel disease (IBD) or celiac disease
  • unexplained anemia
  • elevated white blood cell count (WBCs)
  • abdominal mass
42
Q

IBS-D rome IV criteria

A
  • recurrent abdominal pain at least 1 day per week in the last 3 months, and is associated with at least two of the following: defecation, change in stool frequency, and/or change in stool appearance (form). [ROME IV criteria]
43
Q

risk factors for IBS-D

A

psychologic distress, Hx of gastroenteritis (e.g. norovirus, rotavirus), ingestion of food high in fermentable carbohydrates, visceral hyperalgesia

44
Q

symptoms of IBS-D

A

altered motility (constipation or diarrhea), cramping (often lower quadrants, relieved with BM), abdominal distention, sensation of incomplete evacuation, mucous with stool, urgency; fatigue, chronic HAs, disturbed sleep, anxiety and/or depressed mood

45
Q

diagnosis of IBS-D

A

history and physical exam, using ROME IV criteria
- CBC, BMP (FBG, Ca, Electrolytes (Na, K, CO2, Cl), BUN, Creatinine), CRP;
consider anti-tTG IgA, total IgA, O&P, fecal calprotectin, TSH, LFTs

46
Q

ROME IV for IBS vs ROME III

A

recurrent abdominal pain at least 1 day per week in the last 3 months, and is associated with at least two of the following:
- defecation
- change in stool frequency, and/or - change in stool appearance (form)

LR+ is 21 vs rome 3 which has LR+ of 10

47
Q

IBS-D vs IBS-C vs IBS-M

A

> 25% loose stools, <25% hard stools <25% loose stools, >25% hard stools
25% loose stools, >25% hard stools

48
Q

carbohydrate malaboortiption/ intolerance (i.e. lactose, fructose)

A

the inability to digest and/or absorb certain carbohydrates due to a lack of one or
more intestinal enzymes leading to the occurence of symptom

increased age, consumption of food high in specific carbohydrate (e.g. dairy, fruit)

49
Q

carbohydrate malaboortiption/ intolerance symptoms

A

abdominal pain, bloating, watery stool, excessive flatus

50
Q

diagnosis of carbohydrate malabsortiption/ intolerance

A

history, may be confirmed with hydrogen breath test
- a rise in breath hydrogen concentration greater than 20 ppm over baseline after
carbohydrate ingestion suggests malabsorption

51
Q

in carbohydrate malabsortiption/ intolerance what does the hydrogen breath test have a higher LR+ for ; lactose or fructose

A

lactose LR+ = 118
fructose LR+= 7

52
Q

SIBO

A
  • the presence of excessive bacteria in the small intestine (exceeding 105–106 organisms/mL)
53
Q

risk factors of SIBO

A

antibiotics, approx. 40% in patients with IBS
Hx traveller’s diarrhea, food poisoning or viral gastroenteritis; Hx TBI, frequent ABx use, longterm PPI use, Hx of cholecystectomy; probiotics aggravate or do not help, high FODMAP foods cause flare

54
Q

symptoms of SIBO

A

abdominal pain, bloating, diarrhea (hydrogen) or constipation (methane) may also have other GI symptoms such as: nausea, belching, flatus

55
Q

sibo testing

A

hydrogen breath test– glucose and lactulose

56
Q

for sibo which hydrogen breath test is better glucose or lactulose

A

glucose (absorbed in SI) LR+=3.65
lactulose (not absorbed in SI) LR+= 2.21-4.96

57
Q

IBS vs IBD

A

IBD= IBS+ inflammation, ulcers, other damage

IBS = functional disorder of ab pain and abnormal BM (constipation or diarrhea)

58
Q

where is crohns vs ulcerative colitis

A

anywhere in GI tract, immune related

UC is large intestine, autoimmune

59
Q

crohns disease

A
  • a chronic inflammatory condition affecting the gastrointestinal tract that often causes extraintestinal complications
60
Q

risk factors for crohns

A

typical age at diagnosis 20-40 homozygous for NOD2/ CARD15 (20-40X risk), smoking, OCP, ABx use, NSAIDs

61
Q

symptoms of crohns

A

diarrhea, abdominal pain (cramping), rectal bleeding, fever, weight loss, fatigue anemia (9-74%), inflammatory arthropathies, osteoporosis, anterior uveitis, episcleritis, aphthous stomatitis, cholelithiasis, venous thromboembolism

62
Q

crohns disease diagnosis

A

(ileo)colonoscopy with Bx, cross-sectional imaging (CT enterography) - abdominal tenderness, perianal findings (fistulas, abscesses)
- fecal calprotectin, stool lactoferrin

63
Q

what does crohns disease increase risk of

A

ncreased risk of cancer (cervical, CRC, skin, upper GI, bladder), osteoporosis, anemia, nutritional deficiencies, depression, infection, thrombotic events

64
Q

what has a higher LR+ for crohnsl stool lactoferrin or fecal calprotectin

A

fecal calportectin
LR+ =2
LR- = 0.0-.28

stool lactoferrin
LR+= 75+
LR- = 0.25

65
Q

ileocolonoscopy for crohns LR+

A

LR+=67
LR- = 0.33

66
Q

bile acid malabsorption definition

A
  • diarrhea caused from either hepatic overproduction of bile acids or their malabsorption in the terminal ileum
67
Q

bile acid malabsorption risk

A

idiopathic, post-cholecystectomy, IBS-D, pancreatic insufficiency chron disease, trauma/surgery to intestines,microscopic colitis, SIBO

68
Q

bile acid malabsorption symptoms

A

persistent or intermittent diarrhea, increased stool frequency, urgency, nocturnal defecation, excessive flatulence, abdominal pain, possibly fecal incontinence

69
Q

bile acid malabsorption diagnosis

A

selenium homocholic acid taurine (SeHCAT; nuclear medicine) or serum 7α-hydroxy-4-cholesten-3-one (C4) assay

70
Q

LRs for 2 lab tests for bile acid malabsorption

A

SeHCAT, LR+ = 96+
C4, LR+ = 4.29

71
Q
A

CMS150 final (wk 9-14) (8 decks)

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