atleast two of: - pain releived with defecation - onset assoc. w/ change in stool frequency - onset assoc. w/ change in consistency of stool

supportive with fluids and monitoring of electrolytes and blood counts - packed RBC is anemia is severe - antibiotics and platelets are not recommeneded

Gastroenterology Flashcards by Magda Kazmierczak

gold standard for dx. kidney stones in someone who presents with unilateral flank pain

non-contrast helical CT scan

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acute abdomen

sudden and severe abdominal pain less than 24 hours in duration

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next best step in pt presenting with acute abdomen

chest XR

supine and upright abdominal radiographs - to exclude bowel obstruction or perforation

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what is definitive diagnostic test for acute abdominal pain?

abdominal CT scan

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elderly man presents with severe back pain with syncope followed by abdominal discomfort - dx?

ruptured aortic aneurysm

- medical emergency

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what diagnostic test should be performed in someone suspected of having ruptured aortic aneurysm

CT scan followed by surgery

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patient presents with fever, crampy abdominal pain (LLQ) and an associated change in bowel habits; labs show leukocytosis - dx?

diverticulitis

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Rome III criteria

atleast two of:

pain releived with defecation
onset assoc. w/ change in stool frequency
onset assoc. w/ change in consistency of stool

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alarm symptoms

older age
male sex
nocturnal awakening
rectal bleeding
weight loss
family history of colon cancer

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tx. of constipation-predom IBS in a pt whom fibre supplements did not work

reassurance and polyethylene glycol

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an elderly patient with known atherosclerotic disease presents with rapid onset, severe abdominal pain or tenderness; she also notes bright red rectal bleeding and diarrhea - what test should you do? what will you find? and what is diagnosis?

do CT scan abdomen

dx. ischemic colitis
- will show segmental thickening of bowel wall

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how do you establish diagnosis of ischemic colitis?

colonscopy - patchy segmental ulcerations (in pt with compatible history)

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patient presents with signs/symptoms of acute diverticulitis - what imaging/diagnostic test should you do?

contrast-enhanced CT scan of abdomen and pelvis

- confirms diagnosis as well as evaluates for any complications

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what two tests should be avoided in suspected acute diverticulitis?

colonscopy
barium enema
- both pose risk of perforation with air insufflation

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complications of diverticulitis

obstruction
perforation
abscess
fistulas

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chronic alcoholic patient presents with chronic upper abdominal pain radiating to the back, diabetes and steatorrhea - what do you consider?

chronic pancreatitis

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how do you confirm dx of chronic pancreatitis?

calcififcations on plain films or CT scan

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patient presents with pain, fever and jaundice; there is also elevation of pancreatic enzymes in the setting of biliary obstruction…

acute cholangitis

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diagnostic criteria of HUS

thrombocytopenia

microangiopathic hemolytic anemia (schistocytes, elevated reticulocytes, elevated LDH)

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tx. of HUS

supportive with fluids and monitoring of electrolytes and blood counts

packed RBC is anemia is severe
antibiotics and platelets are not recommeneded

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patient presents with diarrhea and tenesmus; she recently underwent chemotherapy and radiation for rectal cancer - dx?

radiation proctitis

- develops within 6 weeks after tx and resolves on its own usually

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how do you diagnose radiation proctitis?

flexible sigmoidoscopy

mucosal telengiectasias
submucosal fibrosis
arteriole endarteritis

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when does stool osmolality test come in handy?

when you want to distinguish osmotic diarrhea from secretory diarrhea - ie. in pts having factitious diarrhea (low stool osmolality)

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how does malabsorption present in chronic pancreatitis?

diarrhea, steatorrhea
weight loss
deficiency in fat soluble vitamins

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definitive diagnostic test for chronic pancreatitis

abdominal CT scan

tx. of severe CDI with colitis

oral vancomycin | IV metronidazole

Tx. of ischemic colitis

IV fluids and bowel rest | - symptoms resolve w/in 48 hrs

what patients with salmonella gastroenteritis should receive antibiotic therapy?

1. pts < 2y yo or > 50 yo 2. pts with severe illness - toxicity/bacteremia 3. pts with atherosclerotic plaques, endovascular or bone prosthesis - seeding 4. immunocompromised pts

what drugs should be avoided in pts with infectious diarrhea (fever, bloody stools, systemic toxicity)

bowel paralytics such as loperamide

how do you diagnose hepatocellular injury?

elevation of ALT (more specific )and AST | direct (CB) hyperbilirubinemia > 50%

how do you diagnose cholestatic injury?

elevation of ALP (minimal elevations of ALT and AST)

first step to evaluate cholestatic pattern of injury?

USG - determine if intrahepatic or extrahepatic biliary obstruction is present

how do you diagnose non-hepatic injury such as muscle injury?

striking elevations of AST (less ALT) | no assoc. elevation of CB

incidental finding of indirect (UCB) hyperbilirubinemia in an asymptomatic patient, with normal Hb and LFTs - dx?

Gilbert's syndrome

total bilirubin conc. up to 3.0 mg/dL resulting from a reduced expression of enzyme that conjugates bilirubin

lab findings in pts with hemolysis

UCB high | low Hb level, low MCV and high RDW

cholestatic dz due to OCP

CB high | elevated ALP

ERCP with sphincerterectomy is recommended for...

pts with biliary obstruction due to choledocholithiasis

definitive tx. for pts with symptomatic gallstone disease

laparoscopic cholecystectomy

chronic cholestatic disease, associated with IBD, characterized by fibrosis, inflammation and stricturing of the biliary tree

primary sclerosing cholangitis

dx. of primary sclerosing cholangitis

elevated ALP | dx. ERCP - take biopsy, place stent if needed

patient presents with history of pain that radiates to right shoulder, Murphy sign, fever, leukocytosis, mild elevation in LFTs - what diagnostic test should you do?

USG - to dx. acute cholecystitis: will reveal gallstones, pericholecystic fluid and thickened gallbladder wall

patient presents with fever, jaundice and RUQ pain; on USG there is bile duct dilation and gallstones in gallbladder - dx?

acute cholangitis

Tx. of acute cholangitis

broad spectrum empiric antibiotics | ERCP with sphincterectomy to remove impacted stones

how do you confirm diagnosis of acute pancreatitis?

serum conc. of amylase and lipase at least 3x the upper limit of normal

next steps in someone with elevated pancreatic enzymes and suspected acute pancreatitis?

abdominal USG - to detect cholelithiasis | ERCP - pts with evidence of gallstone pancreatitis and suspected biliary obstruction

preferred immediate intervention for removing obstructing stones in acute pancreatitis

ERCP w/ spincterectomy and stone extraction

preferred route for providing nutrition in patients with severe acute pancreatitis

enteral feeding w/ nasojejunal tube

tx. of pancreatic necrosis

imipenem - antibiotics should only be used in this case surgical debridement

dx. of pancreatic necrosis

contrast enhanced CT scan showing non-enhancing pancreatic tissue

pt presents with burning pain releived by antacids and worsened by lying down/bending forward

GERD

how do you diagnose and confirm GERD in pt absent of alarm symptoms?

trial of PPI

pt with GERD and alarm symptoms, ie. dysphagia - what do you do?

upper endoscopy

gold standard for dx. GERD

ambulatory 24hr pH monitoring | - for pts in whom dx is uncertain or are unresponsive to therapy

Tx of choice for erosive esophagitis

PPI

a pt is found to have a gastric ulcer on endoscopy - what should you do?

biopsy!! - even benign appearing ulcers may harbor malignancy

test of choice for dx. h.pylori

endoscopy with biopsy

triple therapy for h.pylori

PPI amoxicillin clarithromycin

2 MCC of peptic ulcer disease

NSAIDs | h.pylori

pt presents with multiple ulcers in unusual locations, severe esophagitis and fat malabsorption - dx?

Zollinger-Ellison | - measure serum gastrin to confirm

indications for upper endscopy in evaluation of dyspepsia

- pt > 55 yo w new onset dyspepsia | - alarm symptoms

functional dyspepsia

chronic or recurrent discomfort in epigastrium w. no organic cause determined

recommended tx. for functional dyspepsia

do a trial of PPI

most accurate method of confirming GERD

ambulatory pH monitoring for 24 hrs | - do if dx is uncertain or GERD therapy is unsuccessful

Cameron lesions

linear gastric ulcers or erosions in a hiatal hernia sac - usually incidental findings but may cause chronic or acute blood loss

what do you do next in someone who had a non-diagnostic Upper EGD and lower endoscopy but it still bleeding?

repeat upper EGD or wireless capsule endoscpy

indications for double balloon endoscopy

- evaluate/tx findings on capsule endoscopy - evaluation of ongoing bleeding with endoscopic hemostasis needed - nondiagnostic wireless capsule endoscopy

male, 60 yo, presents with LLQ pain, urgent defecation and red/marroon rectal bleeding; colonscopy shows segmental and hemorrhagic nodules and possible gangrene- dx?

ischemic colitis

therapy of ischemic colitis

IVF | antibiotics - to cover anaerobes and gram neg bacteria

pt presents with abdominal pain out of proportion to the P/E findings; occult (not overt) blood is present

acute mesenteric ischemia

important cause of massive painless lower GI Bleeding in older patients

diverticulosis

pt presents with LLQ pain, fever, leukocytosis; not overt rectal bleeding is seen - dx? what test should you avoid?

diverticulitis | - avoid colonscopy for risk of perforation

first management of choice for upper GI Bleeding

endoscopic intervention

what drug has been shown to reduce the risk of recurrent upper GI bleeding in peptic ulcers after endoscopic hemostasis?

IV omeprazole

when is arteriography useful in management of upper GI Bleeds?

pts with presume arterial bleed as in PUD or tumors of GI tract - can be used to identify and embolize the vessel

next step after IVF resuscitation in acute variceal bleed?

EGD with band ligation (sclerotherapy as effective)

chronic anal fissures are often accompanied by...

skin tags

recurrent or nonhealing anal fissures should raise concern for...

Crohn's disease

how do you screen for HCC in a pt with chronic hep B or C or alcoholic liver disease/

USG

how can you diagnose HCC without biopsy?

positive ultrasound results | AFP > 500

antibodies present in autoimmune hepatitis

ANA anti-sm mm ab's anti-LKM1 ab's

screening test to determine exposure to Hep C virus

anti-HCV antibody

test to determine active Hep C infection

HCV RNA test

highest risk for acquiring hep D

injection drug users with Hep B

who is non-alcoholic steatohepatitis most commonly seen in?

obesity, insulin resistance, HTN, hyperlipidemia, metabolic syndrome

how can you diagnose non-alcoholic steatohepatitis?

patients with characteristic clinical risk factors have mildly elevated serum aminotransferase concentrations; imaging confirms steatosis

a pt with UC presents with significantly elevated ALP levels; he is experiencing pruritus and fatigue - what should you consider?

primary sclerosing cholangitis | - inflammation and fibrosis of intra and extra hepatic bile ducts leading to cirrhosis

how can you tell apart PBC and PSC?

PBC is associated with presence of other autoimmune conditions and most pts have a positive antimitochondrial ab's assay

serum-to-ascites albumin gradient

subtract the ascitic fluid albumin level from the serum albumin level

SAAG > 1.1 g/dL

indicates portal hypertension -can be due to cirrhosis, RHF or Budd-Chiari syndrome

SAAG < 1.1 g/dL

no portal HTN; it is associated with other conditions such as infection, inflammation and low serum oncotic pressure

inciting events that can precipitate hepatic encepahlopathy in pts with cirrhosis

``` dehydration - diuretic therapy infection - peritonitis, UTIs diet indiscretions GI bleeding medications ```

what is the optimal dose of lactulose for tx. of hepatic encephalopathy?

titrated to achieve two-three soft stools per day with a pH < 6.0

kidney failure in pts with portal HTN and normal renal tubular function

hepatorenal syndrome | - must exclude all other causes of renal failure first

most effective tx. for hepatorenal syndrome

liver transplantation

MC cutaneous manifestation of IBD, most common in Crohns

erythema nodosum

MC cutaneous manifestation of UC

pyoderma gangrenosum

neutrophillic, ulcerative skin disease with multiple lesions on lower extremities; begin as tender papules/pustules that ulcerate leaving a purulent base and ragged, violoceaous borders

MC location of rheumatoid nodules

subcutaneous tissue just distal to elbow on extensor surface of forearm

first line therapy for induction and maintenance of remission in UC

mesalamine

tx. of microscopic colitis

loperamide, diphenoxylate, bismuth subsalicylate

Gastroenterology Flashcards

(101 cards)