GI

Question 1

Management of gastroenteritis

Answer 1

Treatment is largely supportive
Give NS for nausea and LR for diarrhea
Replete electrolytes
Order Zofran for nausea
PO Challenge with bland drinks and foods
—BRAT diet: bananas, rice, apple sauce, toast

Don’t miss appendicitis or mesenteric ischemia in the elderly patient
Sugary drinks (gatorade) can worsen diarrhea
Do not give anti-diarrheal medications in patients whose diarrhea has lasted <72 hours

Question 2

What is Zollinger-Eillison syndrome

Answer 2

Neuroendocrine tumor in the stomach that secretes gastrin
Small - can occur anywhere along the GI tract
Can cause coffee ground emesis, diarrhea, steatorrhea, severe esophageal pain and acachexia

Treatment includes PPI, H2 blocker or surgical excision

Question 3

What causes hematemesis bright red blood, copious amounts?

Answer 3

variceal bleed or a Dieulafoy lesion

Question 4

How do you get varices? What conditions are associated

Answer 4

A varix is an engorged blood vessel anywhere in the GI tract, although usually in the esophagus, which is caused by portal vein HTN.

Can be torn or irritated and then start bleeding briskly

Associated with cirrhosis (the cause of the portal vein HTN) - also platelets are low because of poor liver function.

Question 5

Treatment of variceal bleeding

Answer 5

Need two large bore IVs and start with IVF and then switch to colloid to replace blood lost

Tamponade the bleeding if possible with a Minnesota or Blakemore tube tethered to a football helmet

Intubate and mechanically ventilate if needed

Start protonix ggt, sandostatin (reduces portal HTN) and vasopressin (moves blood from GI tract)

Could consider TIPS procedure (Transjugular intra-hepatic portal shunt)
—reduces portal venous pressure and shunts it to the IVC

Question 6

How do Octreotide and vasopressin work for GI bleeds?

Answer 6

Octreotide inhibits gastrin secretion which causes vasoconstriction and therefore reduces portal venous pressure - only used for variceal bleeding

Vasopressin constricts blood vessels and reduces blood flow to the GI tract - splanchic blood flow

Question 7

How to tell which type of hepatitis the patient has just by looking at the LFTs?

Answer 7

HAV: Elevated ALT (>1000), much higher than AST, elevated alk phos and bili

HBV: ALT:AST are 1:1, elevated bili

HCV: LFTs are not outrageously elevated, normal bili

Question 8

In acute hepatic failure, how does coagulopathy happen?

Answer 8

Portal hypertension interferes with the transport of Vitamin K to the liver after it is synthesized by the gut flora.

The liver is also damaged and therefore not making thrombopoietin and therefore a decrease in platelets occurs. Hepatic vascular congestion also speeds platelet destruction in the spleen.

Disseminated Intravascular Coagulation develops when the liver stops producing enough clotting inhibitors.
–This triggers spontaneous clotting and the clotting cascade starts a chain reaction throughout the body.
—Clotting starts to interfere with organ function.
—Soon all the clotting factors are exhausted and then spontaneous bleeding begins.

Question 9

Spontaneous Bacterial Peritonitis: Causes, Presentation and Treatment

Answer 9

Infection related to massive ascites
Ascitic fluid is a perfect bacterial media
Usually caused by translocation of gut flora into the peritoneal cavity due to low level mesenteric ischemia.

Presents just like septic shock but without a pathogen

Diagnostic paracentesis is performed to look for WBC in the fluid

Empirically treated with cetriaxone 2g IV every 24 hours or cefotaxime 2gm IV every 8 hours

Question 10

What is choledocholithiasis?

Answer 10

gallstone pancreatitis when the gallstone becomes obstructed at the ampulla of Vater or at least distal to the common bile duct

Lipase will be elevated

Question 11

Diagnostic testing and treatment of choledocholithiasis

Answer 11

Confirm diagnosis with RUQUS
Once stone gets into the common bile duct, it is a medical problem, no longer surgical. Needs ERCP.
If still in gall bladder, it is a surgical problem but often is asymptomatic - cholelithiasis

Question 12

What is cholangitis

Answer 12

Infection of the gallbladder
This is an emergency!
Charcot’s Triad: Fever, RUQ pain and jaundice

Question 13

Ranson’s Criteria

Answer 13

Helpful in determining the severity of pancreatitis
What do you draw initially and then what is assessed 48 hours later

On Admission:
George Washington Got Lazy After
–Greater than 55 years old
–WBC >16
–Glucose >200
–Lactate >3.5
–AST> 250

Initial 48 hours:
He Broke C-A-B-E
–HCT decrease >10%
–BUN increase >5
–Calcium <8
–Arterial O2 <60
–Base deficit >4
–Estimated Fluid Sequestration >6L

Less than 3, not serious
More than 6, 100% mortality

Question 14

Treatment of pancreatitis

Answer 14

Aggressive IVF, often >12L in first 24 hours
Antiemetics, keep NPO
Vasopressors as needed
Generous IV pain medications
Consult GI for consideration of ERCP/MRCP
Antibiotic coverage with Zosyn, Flagyl

Question 15

If you are worried about appendicitis, what test would you order?

Answer 15

CT A/P is the gold standard

Question 16

Treatment of Infectious Colitis

Answer 16

-Check signs of clinical dehydration then check a careful hx to give a clue about exposure and the possible pathogen involved.
-Treat dehydration and correct lytes
-Check non-bloody stool for occult blood
-Stool culture only in the most at-risk pts
-Ova and parasite analysis is only needed in patient with strong clinical suspicion
-In general antibx are not indicated
— Treatment is hydration and BRAT diet
–If antibx are needed (fever, signs of systemic illness), fluoroquinolones (Cipro, levo) for 3-5 days

Question 17

Treatment of C. Diff

Answer 17

Flagyl 500mg PO TID
Vancomycin 125mg PO QID

ALWAYS orally treated

Never give anti-motility agents because it will only help retain bacteria

Question 18

Differences between Crohn’s and UC - Presentation

Answer 18

Crohn’s:
–Loose, non-bloody stools
–fevers are common during flares
–Weight loss and fistulae are common
–Can occur anywhere in the GI tract

Ulcerative Colitis:
–Mucoid, bloody stools
–Increased urgency
–Less likely fevers
–Rare weight loss or fistulae
–Only involves the colon

Question 19

Differences between Crohn’s and UC - Pathophysiology and treatment

Answer 19

Crohn’s:
–Usually evident early in life and caused by T-cells that attack the colonic mucosa
–Can occur anywhere along the GI tract
–Mild cases often don’t need daily medicines, only need low dose steroids during flares.
–More severe cases can require chronic steroids

Ulcerative Colitis:
–Involves the rectum and colon only
–During remission, no sxs at all
–During flares, bloody, mucoid stools that are painful
–Flares treated with steroids - suppositories
–Hallmark is bloody diarrhea
–Complication is toxic megacolon

Question 20

Risk factors for ischemic colitis and mesenteric ischemia

Answer 20

Ischemic colitis is usually caused by a low flow state caused by severe heart failure, shock or iatrogenic

Mesenteric ischemia is often caused by a superior mesenteric artery thrombus caused by A-fib or atherosclerosis.

Question 21

Presentation and treatment of Ischemic colitis

Answer 21

Most common in the elderly with known atherosclerotic disease
Frequently pt’s present with severe and colicky abd pain and bloody diarrhea (dark blood)
Abd is diffusely tender
CT shows inflammation of descending colon and/or sigmoid

Treatment is to hydrate, consult GI and likely will require surgical intervention
Questionable utility of antibx

Question 22

Diverticulitis Treatment

Answer 22

Uncomplicated:
-Bowel rest with strict liquid diet for 24-72 hours
-Cipro 500mg PO BID and Flagyl 500mg PO TID

Complicated:
-Zosyn 3.375gm IV every 6 hours or
- Cipro 400mg IV every 12 hours AND Flagyl 500mg IV every 8 hours
-Strict NPO, IV hydration and IV analgesics

Perforation will need surgical repair to avoid peritonitis (although if perf’ed they likely already have it)

Question 23

Causes of small bowel obstruction

Answer 23

Adhesions from previous surgeries
Hernias containing bowel
Crohn’s disease causing adhesions or inflammatory strictures
Tumors
Volvulus - twisting of the intestine
Ischemia
Foreign body

Question 24

Management of small bowel obstruction

Answer 24

Decompress the abdomen
NGT to continuous low suction
Foley catheter
NPO
IV hydration at higher than usual rates
Pain control but be careful because opiates decrease motility
Anti-emetics

If obstruction does not resolve in 48 hours then should consider surgery

Question 25

What bacteria is most common cause of duodenal ulcers and gastric ulcers?

Answer 25

H. pylori
Present in >90% of duodenal ulcers and >75% of gastric ulcers

Question 26

A younger patient (30-55) would most likely have which type of peptic ulcer, duodenal or gastric?

Answer 26

Duodenal

Duodenal ulcers occur between the ages of 30-55
Gastric ulcers occur between the ages of 55-65

Question 27

As far as symptomatology, what is the difference between a duodenal and gastric ulcer? What are they relieved by?

Answer 27

Both have gnawing epigastric pain
Relief of pain with eating - duodenal
Pain worsens with eating - gastric

Question 28

Treatment of H. pylori

Answer 28

Two antibiotics + PPI with or without bismuth for 10-14 days

For patients not allergic to PCN:
ECA: Esomeprazole BID, Clarithromycin BID, Amoxicillin BID
EBMT: Esomeprazole BID, Bismuth QID, Metronidazole QID, Doxycycline QID
ECAM: Esomeprazole BID, Clarithromycin BID, Amoxicillin BID, Metronidazole BID

For patients who are allergic to PCN:
ECM: Esomeprazole BID, Clarithromycin BID, Metronidazole TID

Then continue PPI for up to 3 months after

Question 29

Symptoms and Physical findings of diverticulitis

Answer 29

Mild to moderate aching abd pain in LLQ
Constipation or loose stools
N/V

Physical findings:
Low grade fever
LLQ tenderness with palpation

Question 30

What diagnostics would you order for diverticulitis?

Answer 30

CBC - mild to moderate leukocytosis
ESR - will be mildly elevated
Likely hem+ stool
**Plan abd films are obtained on all patients to look for evidence of free air (pneumoperitoneum - air under the diaphragm)

Question 31

What is Murphy’s Sign and what does it suggest?

Answer 31

Deep pain on inspiration while fingers are placed under the right rib cage

Suggests Cholecystitis

Question 32

Presentation of cholecystitis: Symptoms and diagnostics

Answer 32

Steady, severe pain in the epigastrium or RUQ - usually after a large, fatty meal

Physical findings: Positive Murphy’s Sign
RUQ tenderness to palpation
Muscle guarding and rebound pain
Fever

Diagnostics:
CBC - Leukocytosis
LFTs - Serum bilirubin elevated, AST, ALT, Alk phos all elevated
Amylase - elevated
RUQUS - GOLD STANDARD**
Endoscopic retrograde cholangiopancreatography (ERCP) - but ERCP can cause pancreatitis

Question 33

ERCP: When is it used and what are the complications

Answer 33

Endoscopic retrograde cholangiopancreatography

Used to diagnose diseases of the gallbladder, bile system, pancreas and liver

Complications - Most common is pancreatitis
Perforation
Hemorrhage

Question 34

Classic presentation of pancreatitis

Answer 34

Abrupt onset of steady, severe, epigastric pain worsened by walking and lying supine
Pain is improved by sitting and leaning forward
Pain usually radiates to the back
Nausea/vomiting
Weakness, sweating

Physical findings:
Upper abd tender to palpation, usually without guarding, rigidity or rebound
Distended abdomen
Absent or decreased bowel sounds
Fever
Tachycardia
Pallor, cool skin
Mild jaundice can be present

Question 35

What are the two signs associated with hemorrhagic acute pancreatitis

Answer 35

Grey Turner’s Sign: Flank Discoloration
Cullen’s Sign: Umbilical discoloration

Question 36

Gold standard for diagnosing acute pancreatitis

Answer 36

CT A/P

Question 37

Symptoms or mesenteric infarct

Answer 37

Sudden onset of cramping, colicky abd pain
Pain out of proportion to physical exam findings
Nausea/vomiting
Fever
Abd guarding and tenderness
Peritoneal findings increase as state progresses
Can have shock

Question 38

Physical findings with acute appendicitis

Answer 38

RLQ guarding with rebound tenderness
McBurney’s Point tenderness: One-third the distance from the anterior superior iliac spine to the umbilicus
Psoas Sign: Pain with right thigh extension
Obturator Sign: Pain with internal rotation of the flexed right thigh
Rovsing’s Sign: RLQ pain when pressure is applied to the LLQ
Low grade fever