Week 2 GI Flashcards
What are some some age-related changes seen in the liver?
- decreased hepatic regeneration
- decrease in size and weight
- decreased ability to detoxify meds
- decreased blood flow
what are some age-related changes seen in the biliary tract?
- increased prevalence of gallstones
- greater percentage of pigmented stone
- increase in common bile duct diameter
what is the most common indication for surgery in older adults with abdo pain?
s/s?
cholecystitis
-RUQ pain - unremitting and intense
-fever and vomiting
○
Significant number of older patients do not have classic symptoms of cholecystitis.
- No back or flank pain
- No nausea
- Normal WBC
- No abnormal liver enzymes
- No fever
what are some complications seen in acute cholecystitis?
what is Charcot’s triad?
- acute ascending cholangitis
- gallbladder perforation
- emphysematous cholecystitis
- bile peritonitis, and gallstone ileus
Charcot’s triad: fever, jaundice, RUQ pain
Risk factors for acute pancreatitis
**ETOH
**OBESITY
biliary tract disease, infections, hypertriglyceridemia, medications, hypercalcemia, hypothermia, and carbon monoxide exposure
**SMOKING
***GALLSTONES account for 65-75% of acute pancreatitis
Signs and symptoms of acute pancreatitis in older adults
classic symptoms?
labwork?
imaging?
N+V
dehydration
midepigastric pain that may radiate to back
classic:ANA
ACUTE epigastric abdo pain
NAUSEA and vomiting
ANOREXIA
serum AMYLASE and LIPASE 5x ULN
lipase is equally sensitive and more specific
Abdo US (acute) or CT (chronic)
Signs and symptoms of diverticular disease
LLQ pain (sigmoid colon most commonly affected (90%)
what is the most common cause of large bowel obstruction in older adults?
what is the most common cause of small bowel obstruction in older adults?
large bowel - malignancy
small bowel - adhesions from previous surgery (50-70%)
signs and symptoms of acute mesenteric ischemia
severe poorly localized pain out of proportion to physical findings
1/3: nausea/vomiting, diarrhea (looks like gastro)
signs and symptoms of AAA in older adults
- hypotension
- abdo pain *can have isolated back pain
- pulsatile mass (<50% of people)
**extreme caution with diagnosing elderly with renal colic, MSK back pain or syncope without ruling out AAA because presentation can be vague
what is the most common presenting symptom of peptic ulcer disease?
melena
what investigation should be done for all elderly patients with epigastric pain?
ECG to r/o MI or pericarditis
not thinking of cardiac causes is a frequent pitfall
Liver enzyme abnormalities
hepatocellular injury is measured by _______
cholestasis is measured by _______
hepatocellular: ALT and AST
cholestasis: ALP and GGT
systemic illnesses that are risk factors for liver disease?
- diabetes
- obesity
- hyperlipidemia
- iron overload
- autoimmune diseases
- metastatic cancer
- inflammatory bowel disease
chronic generalized pruritis can be a symptom or sign of _______
cholestasis (eg primary biliary cirrhosis)
For initial investigation into liver disease, what two tests would you order to determine if hepatocellular or cholestatic?
ALT and ALP
ALT is more sensitive and specific for hepatic origin than AST
ALP is more indicative of liver disease than GGT
If ALP is elevated, what should you order next?
GGT to confirm hepatobiliary cause
if GGT elevated, order abdo ultrasound
if ALP is elevated but GGT is not elevated, what would you consider for cause of ALP elevation?
bone or placenta origin
what should be considered as primary cause of newly elevated liver enzymes until proven otherwise?
any medication change (new rx or dose change)
if isolated liver enzyme test abnormality (eg >1.5 ULN), what is the follow up?
retest in 1-3 months
what tests would determine liver function?
albumin
INR
Dysphagia
what is a precursor to dysphagia?
sarcopenia
Dysphagia
what is a biomarker to predict risk for dysphagia?
hand grip strength
What is a predictor of outcome for dysphagia?
Functional status
-decreased ability to do ADLs independently is risk factor for aspiration pneumonia
what are some preventative strategies for dysphagia?
Regular oral care!!!
Feed slowly and safely!
Increase physical activity and time spent out of bed.
Training caregivers to use safe feeding strategies
Remain upright during and after feeding as well as a slightly head up position during day and night.
Rome IV criteria for constipation
Functional constipation: 2 or more of the following:
- straining
- lumpy hard stools
- sensation of incomplete evacuation
- use of digital maneuvers to relieve symptoms
- sensational of anorectal obstruction or blockage with 25% of bowel movements
- decrease in stool frequency (<3 BM per week)
2+ symptoms must be present for last 3 consecutive months
Onset of any symptom for 6 months before making diagnosis of constipation(!)
Red flag alarms for constipation in older adults
- ACUTE ONSET of constipation in elderly is a red flag
- anemia or abnormal bloodwork
- unintentional weight loss >10 lbs
- family hx of colon cancer or IBD
Definition of IBS-Constipation
IBS-C definition:
-recurrent abdo pain or discomfort for at least 3 days per month in the last 3 months
-onset of symptoms 6+ months before diagnosis
Associated with at least 2 of the following:
-improvement of pain or discomfort upon defecation
-onset of symptoms associated with changes in frequency of stool
-onset of symptoms associated with change in stool form or appearance
non-pharm recommendations for constipation
Fluid intake esp if on bulking agents, apple/pear/prune juice
Fibre: soluble preferred, increase by 5 g/week with goal 20-30 g/day
Toilet in AM and PM
Mild activity within 1 hour of waking, hot drink, fibre cereal
what are the 3 primary types of fecal incontinence?
urgency FI: unable to hold stool in rectal avult
passive FI: does not have sensation of need to defecate (ie can’t tell difference between gas or BM)
overflow FI: esp in impaired mobility and functional impairment
-associated with CONSTIPATION
DDx for dysphagia for solids progressing to liquids:
mechanical obstruction
*think malignancy, Barrett esophagus
DDx for dysphagia with odynophagia (painful swallowing)
infectious etiology - think candida
Red flag signs for GERD
cardiac sx rapid onset dysphagia odynophagia unintentional weight loss melena or hematemesis unexplained iron deficiency anemia
When is endoscopy warranted in GERD?
• Endoscopy if
○ Not responding to PPIs after 4-8 weeks
○ Alarm symptoms
○ Longstanding reflux
Lower threshold in older adults : AGE alone is risk factor for esophageal malignancy
Diet and lifestyle advice for GERD?
• Dietary and lifestyle mods ○ Hob to 30 degrees ○ Fasting for 2 hours before bed ○ Left lateral sleeping position ○ Avoid smoking and ETOH Weight loss, smaller meals avoid triggers
What are some concerns about long term use of PPI for GERD?
osteoporosis *suggest calcium supp
infection (Cdiff, pneumonia)
hypomagnesemia
reduced iron absorption
Peptic ulcer disease is strongly correlated with which two risk factors?
NSAID use
H pylori
Quad therapy for PPI consists of?
bismuth
flagyl
tetracycline
PPI
Red flags signs for PUD?
○ Weight loss, anorexia, vomiting, dysphagia, odynophagia, family hx GI cancers
○ BLEEDING
○ Perforation: severe abdo pain, fever, distention
what type of diet puts people at risk for diverticular disease?
diet that is high in red meat and total fat content
signs and symptoms suggestive of sigmoid diverticulitis?
LLQ pain
constipation
painless rectal bleeding (hematochezia)
LLQ tenderness with or without peritoneal findings
fever
leukocytosis
workup for diverticulitis
imaging?
lab?
CT scan
- endoscopy is not done until after acute flare settles (risk of perforation)
- colonoscopy done in 6-8 weeks to determine extent of inflammation
Lab:
CBC: leukocytosis, may have mild anemia
CRP: elevated
Rx for acute diverticulitis?
what meds to avoid?
Cipro 500 mg BID
Flagyl 500 mg TID x 14 days
Psyllium 1-3 tsp daily
AVOID laxatives AVOID NSAIDs (mod increased risk diverticulitis)
IBS
ABCD definition?
at least ____ per week over ____ months
recurrent ABDO pain
BLOATING
CONSTIPATION or DIARRHEA
DISTENTION
at least 1x/week over 3 months
IBS
what is the pathophysiology behind pain associated with IBS?
Bowel motility disturbance and/or visceral hypersensitivity
IBS
red flags that would suggest another sinister cause?
- new onset >age 50
- significant weight loss
- GI bleeding
- fever
- nocturnal bowel movements (IBS does not appear at night)
Cholecystitis
Risk factors
- female
- ethnicity: northern European, Hispanic, Indigenous, Asian (Chinese/Japanese)
- prolonged fasting, sudden starvation
- meds: cholesterol-lowering rx, estrogen (OCP, HRT), furosemide, cefriaxone, cyclosporine, opiates
- obesity
- pregnancy
- diabetes
- dyslipidemia (high TG, low HDL)
- cirrhosis, celiac, gallbladder stasis
- sickle cell disease
History suggestive of cholecystitis
- duration of pain (typically 4-6 hours)
- radiation to R shoulder/back
- associated symptoms: fever, N+V, anorexia, pain aggravated by movement
- ingestion of fatty food 1+ hr prior to pain onset
Labwork in cholecystitis
CBC (leukocytosis) LFTs amylase (normal) CRP u/a (r/o pyelo and renal calculi) preg test
LFTs in classic cholecystitis generally normal: normal alk phos, normal to mildly elevated bili, AST, ALT
Risk factors for PUD
- hx previous ulcers
- smoking
- ETOH (stimulates acid secretion and loosens sphincters)
- Medications: Corticosteroids potentiate effects of NSAIDS, anticoagulants, SSRI, spironolactone
- NSAIDS cause 16-31% of ulcers
- stress
- medical: cirrhosis, COPD, renal failure, celiac disease, CD
- H pylori
GERD vs PUD
patho difference?
GERD: relaxation/incompetence of esophageal sphincter –> allows reflux of acid into esophagus
PUD: excess acid causing injury to GI mucosa
GERD vs PUD
symptom difference?
GERD
- heartburn/retrosternal pain 30-60 min after eating, or with lying down
- chronic cough at bedtime
- harsh voice
PUD
- burning pain
- 1-3 hours after meal and on empty stomach - can wake people up at night
- RELIEVED WITH FOOD
GERD
pharm treatment
H2RA: can get good effect in mild infrequent forms but tolerance can occur
PPI is gold standard, if having symptoms 2+ times/week
- PPI trial once daily x 4-8 weeks
- take 30-60 before first meal of the day
- must titrate down prolonged therapy
- avoid long term use in people w/osteoporosis with high risk of hip #
- PPI is risk for c.diff and community acquired pneumonia
Antacids:
Relief of mild GERD
H pylori treatment
PAMC
vs
PBMT
PAMC: PPI Amoxil Metronidazole Clarithromycin
PBMT PPI Bismuth Metronidazole Tetracycline
GERD nonpharm
smoking cessation weight loss sleep with HOB elevated food triggers avoid meals 3 hours before bedtime
predominant symptoms in DYSPEPSIA
postprandial fullness
epigastric pain
upper abdominal bloating
early satiety
RED FLAG differential for dyspepsia with weight loss?
pancreatic cancer
*esp if jaundice present
RED FLAG alarm features in PUD?
family hx esophageal cancer age over 60 with new symptoms (and lasting 3 months) dysphagia persistent vomiting black stool iron deficiency anemia
H pylori infection puts people at risk of developing…….
duodenal or gastric ulcers
gastric adenocarcinoma and MALT lymphoma
H pylori follow up after first round of treatment?
retest no sooner than 4 weeks after completion
-must be off antibiotics for 4 weeks, PPI for 3 weeks (preferable 2 weeks)
if first line fails, try alternative (do not repeat same treatment)
Ulcerative colitis vs Crohn’s
PATHO
UC:
- autoimmune
- mucosal and submucosal layers
- crypt abscesses
- circumferential
- continuous
Crohn’s
- inflammatory response to pathogen
- transmural (all layers)
- skip lesions
- throughout GI tract, most common to small bowel
- thickening, fissures, strictures
Ulcerative colitis
Signs and symptoms
- LLQ pain
- frequent diarrhea
- often with mucous and blood
- nocturnal BMs
- weight loss is less than Crohn’s
Crohn’s
signs and symptoms
- RLQ pain
- may or may not be bloody
- can be nocturnal
- weight loss (more than UC)
what is the most common complication of Crohn’s?
arthritis
