Gastroenterology - Inflammatory Flashcards
List the differential for acute pancreatitis
I GET SMASHED
- Idiopathic
- Gallstone
- Ethanol
- Trauma
- Steroids, surgery, sphincter of Oddi dysfunction
- Mumps
- Autoimmune
- Scorpian Bite
- High calcium, triglycerides, hypotherma
- ERCP
- Drugs (NSAID, diuretic, immunosuppression)
Discuss the Ranson Criteria for acute pancreatitis
On Admission - Age >55 - WBC >16 - Glucose >200 - LDH >350 - AST >250 First 2 Days of Admission - HCT fall by 10% - Ca <8 - PO2 <60 - Base deficit (24-HCO3) >4 - Fluid Sequestration >6L Severity - Mild <=3 - Severe >=4
Discuss the presentation and management of chronic pancreatitis
Pathophysiology - inflammation of the pancreas - gallstone obstructing Ampulla of Vater or alcohol most common causes Presentation - Nausea/vomiting - Severe sharp epigastric pain that radiates to the back - fevery/hypotension - Cullen's sign (bruising around umbilicus) - Grey Turners (bruising around flanks) Investigations - Elevated WBC, amylase, lipase - elevated ALP, GGT if gallstone - Abdominal CT with constrast Management - NPO - hydration - Gallstone then ERCP
Differentiate Chrons and Ulcerative Colitis
Location - any part of GI tract with Chron's - Rectum and progress proximally with Ulcerative Rectal bleeding - common in ulcerative Diarrhea - frequent in ulcerative Abdominal Pain - post-prandial in Chron's - pre-defecatory urgency in Ulcerative Fever - common in Chron's Palpable Mass - common in Chron's Endoscopic - Apthous ulcers, patchy lesions and pseudopolyps in Chron's - continuous diffuse inflammation, friability, loss of normal vascular patter in ulcerative Histologic - transmural with skip lesions, noncaseating granuloma, deep fissuring and strictures in Chron;s - mucosal distribution with continuous disease, crypt abscess in Ulcerative Radiological - Cobblestone mucosa with frequent strictures or fistula in Chron's - Lack of haustra in Ulcerative Colon Cancer Risk - Chron's increased - Ulcerative 2-3x for CRC
Discuss common extra-intestinal manifestations of IBD
Dermatologic - Erythema nodosum - Pyoderma Gangrenosum - Perianal skin tags - Oral mucosa lesions Rheumatologic - Peripheral arthritis - AK - Sacroilitis Ocular - Uveitis - Episcleritis Hepatobiliary - Cholelithiasis - Primary sclerosing cholangitis Urologic - Calculi - uteric obstruction Other - thromboembolism - osteoporosis
Discuss the management for Chron’s disease
Mild
- antibiotics (Flagyl or Cipro) and 5-Asa
Moderate
- Steroid and immune modulator azathioprine, methotrexate
Severe
- surgery for stricture, obstruction, fistula, performation, bleeding
- biologics infliximab or Adalimumab
Discuss the classification and management for ulcerative colitis
Classification
-Mild <4 stools/day
-Moderate >4 stools/day with minimal signs of toxicity (fever, tachy, high ESR)
- Severe >6 stools/day and signs of systemic toxicity
- Fulminant: >10 stools/day with continuous bleeding, systemic toxicity, abdominal tenderness and colonic dilatation
Management
- mild 5-ASA
- moderate 5-ASA and prednisone
- severe surgery and cyclosporine
- immunomodulator or biologic
Define diarrhea and chronic diarrhea
- loss of >500mL per day of fluid and solutes from GI tract or >200g of stool daily
- chronic if >14d
Discuss findings for stool analysis
Stool Osmotic Gap - 290-2*(Stool Na+K) where normal <50 - osmotic diarrhea >125 Inflammatory Bowel Disease - High fecal leukocyte - Stool Calprotectin Carbohydrate Malabsorption - low stool pH Stool C&S - for bacteria and fungi Stool O&P - for parasite
Discuss the differential for chronic diarrhea
Inflammatory (blood or pus with fever, leukocytosis)
- inflammatory bowel disease
- infection: C diff, ysernia, campylobacter
- ischemic bowel
- radiation colitis
- neoplastic
Steatorrhea
- infection: giardia
- inflammatory: pancreatitis
- celiac
Watery Diarrhea
- functional
- secretory (osmotic gap <50, diarrhea despite fasting)
- cholera
- laxatinve, post-ileal resection, cholecystectomy
- hyperthyroidism
- CRC
- osmotic
- celiac
- carbohydrate malabsorptionDiscuss the presentation, investigation and management of malabsorption
Presentation
- fatigue, weakness, weight loss
- steatorrhea, diarrhea
- deficiencies (carb, protein, fat, iron, calcium, vitamin)
Investigations
- 72hrs stool collection for weight, fat content and pH
- pH <5.5 then carbohydrate malabsorption
- >6g of fat over 24hr then fat malabsorption
- low urine D-xylose following ingestion then carbohydrate malabsorption
Management
- underlying cuase
- correct deficiency
Discuss the presentation, investigation and management for Celiac
- associated with HLA-DQ2, HLA-DQ8
- associated with other autoimmune disease
Presentation - mouth ulcer, abdominal pain, steatorrhea
- isolated iron deficiency
- early osteoporosis
Diagnosis - tTG IgA >20 with baseline serum IgA level done at same time
- Biopsy show crypt hyperplasia and villous atrophy
Management - gluten free diet
- supplementation
Discuss the Rome criteria for irritable bowel syndrome
Recurrent abdominal pain or discomfort at least 1day/week in last 3 months associated with >=2
- related to defecation
- onset associated with change in stool frequency
- onset associated with change in stool form
Discuss the investigations for IBS
Diarrhea predominat - ESR, CRP - TTG for Celiac - TSH - Fecal calprotectin Constipation - CBC - TSH - lytes - abdominal x-ray Abdo pain - CBC - LFT - amylase
Discuss the management for IBS
Conservative - increase fiber and fluid intake - decrease gas producing foods, caffeine, alcohol - lactose elimination Constipation prone when fail fiber - PEG (osmotic) - lubiprostone or linaclotide Diarrhea prone - Loperamide - Bile acid sequestrants (side effects of bloating, flactulence, abdominal discomfort) Abdominal Pain - antispasmodics: Hyoscine (Buscopan) - antidepressant - trial of rifaximin (abx) if treatment resistant
