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547 > Week 2 GI > Flashcards

Week 2 GI Flashcards

1
Q

What are some some age-related changes seen in the liver?

A
  • decreased hepatic regeneration
  • decrease in size and weight
  • decreased ability to detoxify meds
  • decreased blood flow
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2
Q

what are some age-related changes seen in the biliary tract?

A
  • increased prevalence of gallstones
  • greater percentage of pigmented stone
  • increase in common bile duct diameter
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3
Q

what is the most common indication for surgery in older adults with abdo pain?

s/s?

A

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
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4
Q

what are some complications seen in acute cholecystitis?

what is Charcot’s triad?

A
  • acute ascending cholangitis
  • gallbladder perforation
  • emphysematous cholecystitis
  • bile peritonitis, and gallstone ileus

Charcot’s triad: fever, jaundice, RUQ pain

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5
Q

Risk factors for acute pancreatitis

A

**ETOH
**OBESITY
biliary tract disease, infections, hypertriglyceridemia, medications, hypercalcemia, hypothermia, and carbon monoxide exposure
**SMOKING

***GALLSTONES account for 65-75% of acute pancreatitis

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6
Q

Signs and symptoms of acute pancreatitis in older adults

classic symptoms?

labwork?
imaging?

A

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)

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7
Q

Signs and symptoms of diverticular disease

A

LLQ pain (sigmoid colon most commonly affected (90%)

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8
Q

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?

A

large bowel - malignancy

small bowel - adhesions from previous surgery (50-70%)

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9
Q

signs and symptoms of acute mesenteric ischemia

A

severe poorly localized pain out of proportion to physical findings

1/3: nausea/vomiting, diarrhea (looks like gastro)

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10
Q

signs and symptoms of AAA in older adults

A
  • 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

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11
Q

what is the most common presenting symptom of peptic ulcer disease?

A

melena

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12
Q

what investigation should be done for all elderly patients with epigastric pain?

A

ECG to r/o MI or pericarditis

not thinking of cardiac causes is a frequent pitfall

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13
Q

Liver enzyme abnormalities

hepatocellular injury is measured by _______

cholestasis is measured by _______

A

hepatocellular: ALT and AST
cholestasis: ALP and GGT

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14
Q

systemic illnesses that are risk factors for liver disease?

A
  • diabetes
  • obesity
  • hyperlipidemia
  • iron overload
  • autoimmune diseases
  • metastatic cancer
  • inflammatory bowel disease
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15
Q

chronic generalized pruritis can be a symptom or sign of _______

A

cholestasis (eg primary biliary cirrhosis)

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16
Q

For initial investigation into liver disease, what two tests would you order to determine if hepatocellular or cholestatic?

A

ALT and ALP

ALT is more sensitive and specific for hepatic origin than AST

ALP is more indicative of liver disease than GGT

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17
Q

If ALP is elevated, what should you order next?

A

GGT to confirm hepatobiliary cause

if GGT elevated, order abdo ultrasound

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18
Q

if ALP is elevated but GGT is not elevated, what would you consider for cause of ALP elevation?

A

bone or placenta origin

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19
Q

what should be considered as primary cause of newly elevated liver enzymes until proven otherwise?

A

any medication change (new rx or dose change)

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20
Q

if isolated liver enzyme test abnormality (eg >1.5 ULN), what is the follow up?

A

retest in 1-3 months

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21
Q

what tests would determine liver function?

A

albumin

INR

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22
Q

Dysphagia

what is a precursor to dysphagia?

A

sarcopenia

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23
Q

Dysphagia

what is a biomarker to predict risk for dysphagia?

A

hand grip strength

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24
Q

What is a predictor of outcome for dysphagia?

A

Functional status

-decreased ability to do ADLs independently is risk factor for aspiration pneumonia

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25
Q

what are some preventative strategies for dysphagia?

A

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.

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26
Q

Rome IV criteria for constipation

A

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(!)

27
Q

Red flag alarms for constipation in older adults

A
  • 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
28
Q

Definition of IBS-Constipation

A

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

29
Q

non-pharm recommendations for constipation

A

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

30
Q

what are the 3 primary types of fecal incontinence?

A

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

31
Q

DDx for dysphagia for solids progressing to liquids:

A

mechanical obstruction

*think malignancy, Barrett esophagus

32
Q

DDx for dysphagia with odynophagia (painful swallowing)

A

infectious etiology - think candida

33
Q

Red flag signs for GERD

A 
cardiac sx
rapid onset
dysphagia
odynophagia
unintentional weight loss
melena or hematemesis
unexplained iron deficiency anemia
34
Q

When is endoscopy warranted in GERD?

A

• 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

35
Q

Diet and lifestyle advice for GERD?

A 
• 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
36
Q

What are some concerns about long term use of PPI for GERD?

A

osteoporosis *suggest calcium supp
infection (Cdiff, pneumonia)
hypomagnesemia
reduced iron absorption

37
Q

Peptic ulcer disease is strongly correlated with which two risk factors?

A

NSAID use

H pylori

38
Q

Quad therapy for PPI consists of?

A

bismuth
flagyl
tetracycline
PPI

39
Q

Red flags signs for PUD?

A

○ Weight loss, anorexia, vomiting, dysphagia, odynophagia, family hx GI cancers
○ BLEEDING
○ Perforation: severe abdo pain, fever, distention

40
Q

what type of diet puts people at risk for diverticular disease?

A

diet that is high in red meat and total fat content

41
Q

signs and symptoms suggestive of sigmoid diverticulitis?

A

LLQ pain
constipation
painless rectal bleeding (hematochezia)

LLQ tenderness with or without peritoneal findings
fever
leukocytosis

42
Q

workup for diverticulitis

imaging?
lab?

A

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

43
Q

Rx for acute diverticulitis?

what meds to avoid?

A

Cipro 500 mg BID
Flagyl 500 mg TID x 14 days
Psyllium 1-3 tsp daily

AVOID laxatives
AVOID NSAIDs (mod increased risk diverticulitis)
44
Q

IBS

ABCD definition?

at least ____ per week over ____ months

A

recurrent ABDO pain
BLOATING
CONSTIPATION or DIARRHEA
DISTENTION

at least 1x/week over 3 months

45
Q

IBS

what is the pathophysiology behind pain associated with IBS?

A

Bowel motility disturbance and/or visceral hypersensitivity

46
Q

IBS

red flags that would suggest another sinister cause?

A
  • new onset >age 50
  • significant weight loss
  • GI bleeding
  • fever
  • nocturnal bowel movements (IBS does not appear at night)
47
Q

Cholecystitis

Risk factors

A
  • 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
48
Q

History suggestive of cholecystitis

A
  • 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
49
Q

Labwork in cholecystitis

A 
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

50
Q

Risk factors for PUD

A
  • 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
51
Q

GERD vs PUD

patho difference?

A

GERD: relaxation/incompetence of esophageal sphincter –> allows reflux of acid into esophagus

PUD: excess acid causing injury to GI mucosa

52
Q

GERD vs PUD

symptom difference?

A

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
53
Q

GERD

pharm treatment

A

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

54
Q

H pylori treatment

PAMC
vs
PBMT

A 
PAMC:
PPI
Amoxil
Metronidazole
Clarithromycin
PBMT
PPI
Bismuth
Metronidazole
Tetracycline
55
Q

GERD nonpharm

A 
smoking cessation
weight loss
sleep with HOB elevated
food triggers
avoid meals 3 hours before bedtime
56
Q

predominant symptoms in DYSPEPSIA

A

postprandial fullness
epigastric pain
upper abdominal bloating
early satiety

57
Q

RED FLAG differential for dyspepsia with weight loss?

A

pancreatic cancer

*esp if jaundice present

58
Q

RED FLAG alarm features in PUD?

A 
family hx esophageal cancer
age over 60 with new symptoms (and lasting 3 months)
dysphagia
persistent vomiting
black stool
iron deficiency anemia
59
Q

H pylori infection puts people at risk of developing…….

A

duodenal or gastric ulcers

gastric adenocarcinoma and MALT lymphoma

60
Q

H pylori follow up after first round of treatment?

A

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)

61
Q

Ulcerative colitis vs Crohn’s

PATHO

A

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
62
Q

Ulcerative colitis

Signs and symptoms

A
  • LLQ pain
  • frequent diarrhea
  • often with mucous and blood
  • nocturnal BMs
  • weight loss is less than Crohn’s
63
Q

Crohn’s

signs and symptoms

A
  • RLQ pain
  • may or may not be bloody
  • can be nocturnal
  • weight loss (more than UC)
64
Q

what is the most common complication of Crohn’s?

A

arthritis

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