week 11 Flashcards
what is the INTERCHEST rule for
predict coronary artery disease as cause of chest pain
criteria for INTERCHEST rule
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%
dyspepsia is AKA
indigestion
dyspepsia definition
persistent or recurrent pain or discomfort in the upper abdomen
ROME IV criteria for dyspepsia
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
what structural or biochemical diseases can cause functional dyspepsia
gastroesophageal reflux
50%
irritable bowel syndrome
35%
GERD
- retrograde flow of stomach acid and enzymes into the esophagus, causing inflammation and pain
what makes GERD worse
obesity, smoking, alcohol, chocolate, peppermint, spicy food, citrus, caffeine, fatty food, tomato-based products, carbonated beverages
symptoms of GERD
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
first line treatment/ therapeutic challenge for GERD
PPI trial
diagnosis of GERD
endoscopy, Bx, esophageal pH testing
- PPI trial (therapeutic challenge)
what can GERD develop into
up to 23% develop into esophageal strictures
10-15% develop into Barrett’s Esophagus after 5-10 years
barretts esophagus definition
- metaplastic changes of esophageal squamous epithelium into columnar epithelium
what are the changes to epithelium in Barretts esophagus
squamous into columnar
risks of Barretts esophagus
long-standing GERD (> 5-10 yrs), smoking, male, age > 50 yrs, fHx, obesity
symptoms of Barretts esopahgus
chronic reflux symptoms including postprandial retro-sternal or epigastric pain
barrewtxs esophagus diagnosis
endoscopy and biopsy
what can Barretts esophagus develop into
1% develop into esophageal adenocarincoma
gastritis
- 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
causes of gastritis
H. pylori, long term NSAID use, EtOH, stress
gastritis symptoms
may be asymptomatic or coexist with GERD
epigastric pain (with food), dyspepsia, N/V, loss of appetite, melena
gastritis diagnosis
upper endoscopy
gastritis management
potential referral to MD (antibiotics, antacids (H2 blocker, PPI))
gastritis prognosis/ development
most resolve, potential to develop ulceration or carcinoma
what is peptic ulcer disease
- localized erosion of the mucosal layer of the stomach (St) or small intestine (SmI)
what increases risk of peptic ulcer disease
h pylori, NSAID, stress, Zollinger Ellison syndrome
symptoms of peptic ulcer disease
burning epigastric pain (after meals), dyspepsia, mild nausea, belching, hunger 1-3 hrs after eating
labs for peptic ulcer disease
H.pylori testing (urea breath test, serum), gastrin (rarely); endoscopy
what are the 3 tests for h pylori
- urea breath test (LR+ 12-22.3)
- serum antibody titres (LR+ 2.1)
- fecal antigen (LR+ 10.8)
serum testing is inexpensive but doesnt tell if active or previous infection
diarrhea
- loose, watery stools 3 or more times a day.
bristol stool of type 5, 6, 7
acute vs persistent vs chronic diarrhea
● 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)
3 types of chronic diarrhea
- watery
-secretory
-osmotic
-functional - fatty
-maldigestive
-malabsorptive - inflammatory
watery diarrhea
secretory
osmtotic
functional
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
fatty diarrhea
maldigestive
malabsoprtive
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.
inflammatory diarrhoea
inflammatory (or exudative) - elevated WBCs, occult or frank blood or pus
watery- secretory diarrhea exmaples
bile acid malabsorption
crohns disease
watery- osmotic diarrhea exambples
-celiac disease
-carbohydrate malabsorption syndrome
watery- functional diarrhea examples
IBS
fatty- malabsorptive diarrhea examples
-carbohydrate malabsorption syndromes (i.e. lactose, fructose, acarbose)
-celiac disease
-SIB)
type of inflammatory or exucdative diarrhea
clostridium difficile (pseudomembranous) colitis
alarm symptoms of diarrhea
- 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
IBS-D rome IV criteria
- 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]
risk factors for IBS-D
psychologic distress, Hx of gastroenteritis (e.g. norovirus, rotavirus), ingestion of food high in fermentable carbohydrates, visceral hyperalgesia
symptoms of IBS-D
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
diagnosis of IBS-D
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
ROME IV for IBS vs ROME III
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
IBS-D vs IBS-C vs IBS-M
> 25% loose stools, <25% hard stools <25% loose stools, >25% hard stools
25% loose stools, >25% hard stools
carbohydrate malaboortiption/ intolerance (i.e. lactose, fructose)
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)
carbohydrate malaboortiption/ intolerance symptoms
abdominal pain, bloating, watery stool, excessive flatus
diagnosis of carbohydrate malabsortiption/ intolerance
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
in carbohydrate malabsortiption/ intolerance what does the hydrogen breath test have a higher LR+ for ; lactose or fructose
lactose LR+ = 118
fructose LR+= 7
SIBO
- the presence of excessive bacteria in the small intestine (exceeding 105–106 organisms/mL)
risk factors of SIBO
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
symptoms of SIBO
abdominal pain, bloating, diarrhea (hydrogen) or constipation (methane) may also have other GI symptoms such as: nausea, belching, flatus
sibo testing
hydrogen breath test– glucose and lactulose
for sibo which hydrogen breath test is better glucose or lactulose
glucose (absorbed in SI) LR+=3.65
lactulose (not absorbed in SI) LR+= 2.21-4.96
IBS vs IBD
IBD= IBS+ inflammation, ulcers, other damage
IBS = functional disorder of ab pain and abnormal BM (constipation or diarrhea)
where is crohns vs ulcerative colitis
anywhere in GI tract, immune related
UC is large intestine, autoimmune
crohns disease
- a chronic inflammatory condition affecting the gastrointestinal tract that often causes extraintestinal complications
risk factors for crohns
typical age at diagnosis 20-40 homozygous for NOD2/ CARD15 (20-40X risk), smoking, OCP, ABx use, NSAIDs
symptoms of crohns
diarrhea, abdominal pain (cramping), rectal bleeding, fever, weight loss, fatigue anemia (9-74%), inflammatory arthropathies, osteoporosis, anterior uveitis, episcleritis, aphthous stomatitis, cholelithiasis, venous thromboembolism
crohns disease diagnosis
(ileo)colonoscopy with Bx, cross-sectional imaging (CT enterography) - abdominal tenderness, perianal findings (fistulas, abscesses)
- fecal calprotectin, stool lactoferrin
what does crohns disease increase risk of
ncreased risk of cancer (cervical, CRC, skin, upper GI, bladder), osteoporosis, anemia, nutritional deficiencies, depression, infection, thrombotic events
what has a higher LR+ for crohnsl stool lactoferrin or fecal calprotectin
fecal calportectin
LR+ =2
LR- = 0.0-.28
stool lactoferrin
LR+= 75+
LR- = 0.25
ileocolonoscopy for crohns LR+
LR+=67
LR- = 0.33
bile acid malabsorption definition
- diarrhea caused from either hepatic overproduction of bile acids or their malabsorption in the terminal ileum
bile acid malabsorption risk
idiopathic, post-cholecystectomy, IBS-D, pancreatic insufficiency chron disease, trauma/surgery to intestines,microscopic colitis, SIBO
bile acid malabsorption symptoms
persistent or intermittent diarrhea, increased stool frequency, urgency, nocturnal defecation, excessive flatulence, abdominal pain, possibly fecal incontinence
bile acid malabsorption diagnosis
selenium homocholic acid taurine (SeHCAT; nuclear medicine) or serum 7α-hydroxy-4-cholesten-3-one (C4) assay
LRs for 2 lab tests for bile acid malabsorption
SeHCAT, LR+ = 96+
C4, LR+ = 4.29
