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PANCE Review > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

GERD - risk factors, clinical features, alarm features

A

risks:
- ETOH, caffeine, obesity, smoking, specific foods, hiatal hernia

clinical features:

  • heartburn 30-60 min after meals
  • improves w/ antacids
  • chest pain, halitosis, cough

alarm features:

  • refractory sxs
  • dysphagia (difficult swallow), odynophagia (painful swallow)
  • unintentional wt loss
  • GI bleed, Fe deficiency anemia
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2
Q

GERD - dx

A

endoscopy - dx of choice

if mild, can be clinical dx

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3
Q

GERD - tx

A

mild:

  • lifestyle modifications
  • OTC antacids: TUMS, Maalox, Mylanta
  • OTC H2 blockers: Cimetidine, ranitidine, famotidine

persistent:
- once daily PPI (omeprazole): TX OF CHOICE, tx 8-12 weeks or longer if needed

refractory sxs:
- nissen fundoplication for large hiatal hernia

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4
Q

gastritis - cause, presentation, dx, tc

A

inflammation of lining of stomach
- epigastric pain, N/V, UGI bleed of erosive

cause: meds, ETOH, severe stress, portal HTN
dx: upper EGD

tx:

  • stop offending agent or tx underlying dz (portal HTN
  • PPI
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5
Q

atrophic gastritis - 2 types

A

see atrophy of cells that line the stomach

  1. autoimmune
    - vague abdominal pain
    - anti-intrinsic factor antibodies attack cells of stomach
    - inhibit B12 absorption
    - monitor with EGD for cancer (at inc risk)
  2. H. pylori associated
    - bacterial infection
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6
Q

H. pylori - clinical presentation, dx

A

nausea, vague abdominal pain, bloating/dyspepsia
- can be associated w/ travel

dx: urea breath test
- if taken PPI in last 4 wks, cannot do urea breath test (EGD)

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7
Q

H. pylori - tx, complications

A

tx:
1st line: triple therapy
- PPI + amoxicillin + clarithromycin
- metronidazole instead of AMOX for PEN allergy

If fail: quadruple therapy
- PPI, bismuth (pepto), tetracycline, metronidazole

MUST CONFIRM ERADICATION: repeat urea breath test

complications: PUD, gastric cancer, gastric MALT lymphoma

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8
Q

PUD: peptic ulcer disease - risks, causes, complications

A

break in mucosa of stomach or intestine

risks: smoking, long-term NSAID use
- chronic NSAID use: most gastric ulcers
- H pylori: most duodenal ulcers
- other: Zollinger-Ellison syndrome

complications:

  • perforation
  • GI bleed (MOST COMMON cause of UGI bleed)
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9
Q

PUD - clinical features, dx, tx

A

hallmark: epigastric pain (dull, aching)
- coffee ground emesis or melena
- duodenal: improves w/ food
- gastric: worsens w/ food

PE: epigastric tenderness w/ deep palpation

dx: upper EGD w/ biopsy
- r/o malignancy and H. pylori

tx:

  • avoid irritating factors
  • PPI 4-8 weeks (PREFERRED TX)
  • treat H. pylori if present
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10
Q

adenocarcinoma - risks, clinical features, dx, tx, survival rate

A

most common GI cancer

risks: 50-70, male, tobacco, chronic gastritis

clinical: epigastric pain, anorexia, dyspepsia, wt loss, GI bleed
- virchow’s node (superclavicular node)

dx: endoscopy
- mass, irregular ulcer

tx: resection +/- chemo/radiation

5 yr survival < 20%

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11
Q

gastric lymphoma

A

most are non-Hodgkin B cell lymphoma

Risk factors: H. pylori

Clinical: epigastric pain, anorexia, dyspepsia, wt loss, GI bleed
- same as adenocarcinoma

dx: endoscopic biopsy
tx: combo chemo w/ or w/o radiation

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12
Q

Zollinger-Ellison Syndrome: definition and clinical features

A

gastrin-secreting gut neuroendocrine tumor

  • located in gastrinoma triangle (duodenum, pancreas, lymph nodes)
  • 25% associated with MEN-1 (genetic)

Clinical

  • PUD refractor to tx (MULTIPLE, large ulcers)
  • abdominal pain (80%)
  • secretory diarrhea
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13
Q

Zollinger-Ellison Syndrome: dx, tx

A

dx:

  • fasting serum gastrin level (increases w/ these tumors)
  • pH < 2 (acidic)
  • imaging

tx:

  • PPIs initial DRUG OF CHOICE
  • Resection b/f METS of liver
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14
Q

pyloric stenosis - clinical features, PE, dx, tx

A

hypertrophy of pylorus
- most common cause of gastric outlet obstruction in infants

clinical: non-bilious projectile vomiting (4-8 wks of age)

PE: olive shaped mass palpated

Dx: U/S of pylori shows thickening

tx: surgical repair

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15
Q

reflux esophagitis - cause, presentation, dx, tx

A

mucosal damage 2/2 recurrent GERD (cells of esophagus do not like acid)
- heartburn, postprandial

cause:
- mechanical: poor LES tone, hiatal hernia
- functional: chronic reflex, prolonged vomiting

dx: endoscopy w/ biopsy
- graded A-D (mild to severe)

tx: PPI twice a day for 6-8 wks

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16
Q

Barrett’s esophagus - definition, risks, dx, tx

A

consequence of long-tern reflux esophagitis

  • risk for MALIGNANCY (esophageal adenocarcinoma)
  • normal squamous epithelium w/ metaplastic columnar epithelium

risks: male, hiatal hernia, smoker, ETOH

dx: endoscopy w/ biopsy
- “irregular z-line”
- “salmon-colored mucosa”
- “intestinal metaplasia”

tx: long-tern PPI tx BID
- EGD every 3-5 yrs

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17
Q

pill-induced esophagitis - what meds

A

tetracycline (ABX)
KCl
NSAIDS
bisphosphonates

often taking meds w/o water or supine

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18
Q

radiation esophagitis

A

dysphagia several months following radiation treatment

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19
Q

eosinophilic esophagitis - cause, presentation, dx, tx

A

cause: food or environmental allergen

clinical:
- atopic hx
- dysphagia w/ solid food
- food impaction

dx: endoscopy w/ biopsy
- white exudates, red furrows, concentric rings
- presence of eosinophils in mucosa

tx: budesonide, fluticasone (steroids)
- avoid offending allergen
- send for allergy testing

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20
Q

achalasia - definition, clinical features, dx, tx

A

lower esophageal sphincter tone increased

  • peristalsis is decreased
  • common in 30-60 y/o

clinical:

  • slow, progressive dysphagia (solids and liquids)
  • episodic regurg, chest pain, cough, coking

dx:

  • barium swallow (BIRD’S BEAK)
  • endoscopy w/ biopsy (r/o malignancy)
  • manometry: confirms dx

tx:
Meds (relax LES): Ca++ channel blockers, isosorbide, LES botox injections
Surgery: pneumatic dilation

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21
Q

scleroderma - definition, clinical features, dx, tx

A

hardening of skin (rheumatologic condition) - 90% have esophageal involvement (part of CREST)
- hardening lining of esophagus

clinical: GERD, dysphagia to solids and liquids

Dx:

  • barium swallow: aperistalsis
  • manometry: decreased tone

Tx: PPI for GI sxs
- omeprazole

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22
Q

esophageal spasms

A

etiology: not understood
clinical: acute chest pain; intermittent dysphagia to solids and liquids that DOES NOT change

dx:
- corkscrew esophagus on barium
- nutcracker esophagus on manometry

tx:
- Ca+ channel blocker (relax)

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23
Q

Zenker’s diverticulum - definition, clinical features, dx, tx

A

outputting of posterior hypo pharynx

  • food gets caught
  • occurs in older people

clinic: dysphagia, coughing, regurgitation, halitosis
complicaitons: aspiration (key to prevent in old people)

Dx: barium swallow

Tx:

  • None: asymptomatic
  • surgery to remove: symptomatic
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24
Q

Mallory Weiss tear

A

tear in gastro-esophageal junction; transient

clinical: 1-2 episodes of hematemesis after forceful vomiting/retching
- possibly hx of ETOH use

Dx:
- clinical or EDG

Tx:

  • most heal in 48 hrs
  • PPI (to dec. acid)
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25
Q

esophageal neoplasms - 2 types and risk factors for each

A

squamous cell

  • most common world-wide
  • risk: tabacco, ETOH

adenocarcinoma

  • most common in US
  • risk: Barrett’s, obesity
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26
Q

peptic stricture

A

complication of chronic GERD/esophagitis
- progresses to dysphagia to solid foods over months to years

dx:
- biopsy (r/o malignancy)

tx:

  • endoscopic dilation
  • long-term PPI
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27
Q

esophageal obstructive entities - 2 types and tx

A
  1. esophageal webs
    - assoc. w/ plummer-vinson
    - proximal esophagus
    - presents w/ dysphagia and food impaction
  2. schatzki ring
    - hx of GERD, hiatal hernia
    - distal esophagus

Tx: endoscopic dilation and PPI

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28
Q

Plummer Vinson Syndrome

A

association b/t Fe deficiency anemia, esophageal webs, stomatitis (inflammation of mucous membranes of mouth), and glossitis (inflammation of tongue)

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29
Q

esophageal dysphagia (trouble swallowing)

A

solids>liquids = mechanical obstruction

  • schatzki ring, webs
  • peptic stricture
  • esophageal neoplasm
  • eosinophilic esophagitis

solids and liquids = motility disorders

  • achalasia
  • esophageal spasm
  • scleroderma

liquids>solids = neurogenic dysphagia
- hx of stroke, ALS

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30
Q

esophageal varices - definition, risks, presentation, mortality

A

dilated veins at base of esophagus

  • results from portal HTN
  • if they bleed, they bleed ALOT

risk for inc. bleeding: size, red wale markings, liver dz, ETOH use

presentation:

  • high grade: hematemesis/hypovolemia
  • low grade: melena + Fe-deficiency anemia

mortality:

  • 30% during 1st bleed
  • 50% w/in 6 mo
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31
Q

esophageal varices - management

A

first: fluids and blood products for hemodynamic stability

ENDOSCOPIC BAND LIGATION
- preferred therapy for acute bleed

Meds:
- octreotide: dec. splenic flow to these veins

Prevention:

  • band ligation
  • beta-blockers (non-selective, such as propranolol)
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32
Q

cholelithiasis

A

gallbladder stones
- mostly cholesterol stones

Risk: forty, fat, female, fertile

  • rapid wt loss
  • family hx

Clinical:
- intermittent colicky RUQ abd pain (often after fatty meal)

Dx: RUQ U/S

Tx: laparoscopic cholecystectomy (remove gallbladder)
- ONLY if symptomatic

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33
Q

acute cholecystitis - cause, clinical presentation, dx

A

impacted gallstone in cystic duct

clinical:

  • persistent RUQ or epigastric pain (esp after fatty meal)
  • N/V, fever
  • MURPHY’S SIGN: pain during inspiration

dx:

  • inc. WBC, inc. LFTs, amylase, lipase
  • RUQ U/S: gallstones + GB wall thickening
  • ERCP: indicates biliary obstruction
  • HIDA: no filling on cholecystitis - MOST SPECIFIC TEST
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34
Q

acute cholecystitis - tx, complications

A

initial: medical management
- IV fluids
- bowel rest
- IV ABX
- pain meds (morphine)

Laparoscopic cholecystectomy w/in 24 hours of admit

complications:

  • gangrene/perforation
  • chronic cholecystitis
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35
Q

chronic cholecystitis - definition, clinical, dx, tx

A

results from repeated bouts of cholecystitis or gallstones

chronic, constant RUQ pain, nausea

Dx: U/S than HIDA

Tx: Laparoscopic cholecystectomy

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36
Q

choledocholithiasis - definition, risk, dx

A

common bile duct stones

  • intermittent RUQ pain
  • ASSOCIATED W/ JAUNDICE

risk: infection, biliary stasis, s/p cholecystectomy, cholangitis

Dx: U/S then ERCP

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37
Q

cholangitis - definition, risk, dx

A

infection of common bile duct due to impacted stone

  • CHARCOT’s triad: RUQ pain, fever, jaundice
  • Reynold’s pentad: chariot’s triad + AMS + hypotension
  • emergency since indicates sepsis

MOST COMMON CAUSE: acute bacterial infection

Dx: U/S then ERCP

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38
Q

primary sclerosing cholangitis - definition and cause

A

biliary system fibrosis and thickening
- men age 20-50

Cause: auto-immune, assoc. w/ ulcerative colitis

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39
Q

primary sclerosing cholangitis - clinical dx, tx, complications

A

clinical:

  • progressive jaundice
  • pruritus
  • anorexia, fatigue

Dx:

  • elevated alk phos
  • MRCP or ERCP - liver biopsy

Tx:

  • acute: ciprofloxacin
  • liver transplant

complications:
- cholangiocarcinoma

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40
Q

hepatitis - acute vs. chronic

A

liver inflammation

acute:

  • viral is MOST COMMON
  • toxins: ETOH and meds (acetaminophen, NSAIDS, ABX)

chronic:

  • viral
  • ETOH
  • NASH
  • autoimmune
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41
Q

acute viral hepatitis - 5 viruses, risk factors

A

5 viruses: A, B, C, D, E

Risk:

  • A&E: endemic areas, poor sanitation, food and waterborne
  • B&C: IV drug use, unprotected intercourse, healthcare, childbirth
  • D: co-infection w/ Hep B
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42
Q

acute viral hepatitis - clinical features, labs

A

clinical:

  • fatigue, malaise, anorexia, RUQ pain
  • aversion to smoking,
  • PE: fever, jaundice, RUQ tenderness, enlarged liver

Labs:

  • VERY elevated AST, ALT, Alk Phos, bilirubin
  • specific serologic markers for each virus
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43
Q

which hepatitis viruses have vaccines?

A

A and B

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44
Q

diagnosis of acute viral hepatitis

A

See cheatsheets

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45
Q

which hepatitis viruses progress to chronic state

A

B and C

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46
Q

Hepatitis B serology - approach to determining if there is an active infection and if it is acute or chronic

A
  1. Look at hep B surface antigen (HBsAg): HBsAg + = active infection
    - Look at hep B core antibody (antiHBc) (IgM = acute, IgG = chronic)
  2. If HBsAg - = no active infection, but do they have immunity and, if so, is it from a vaccine or previous infection
    - anti HBs + = immunity
    - anti HBc IgG - = vaccine
    - anti HBc IgG + = previous infection
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47
Q

acute hepatitis -treatment

A 
A: self limited, supportive care
B: only tx if in severe liver failure
C: peg-interferon
D: N/A
E: self limited, supportive care
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48
Q

acute hepatitis -prevention

A 
A: vaccine (travelers, etc.)
B: vaccine (0, 1, 6 mo)
C: precausions
D: hep B vaccine
E: public hygiene
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49
Q

acute liver failure - cause, clinical, treatment, prognosis

A

cause: acetaminophen toxicity, drug reactions
clinical: encephalopathy, systemic inflammation, hemorrhage, shock, sepsis

tx:

  • metabolic and hemodynamic stability
  • acetylcysteine if acetaminophen toxicity
  • liver transplant

Prognosis: poor

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50
Q

what is anecdote to acetaminophen toxicity leading to liver acute failure

A

acetylcysteine w/in 72 hrs

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51
Q

chronic viral hepatitis - cause, clinical, complications

A

cause: viral infection (most common)
- Hep B, C, D (>3-6 mo)

Clinical:

  • fatigue, nausea, jaundice, RUQ pain
  • advanced sxs: dark urine, itching, wt loss

complications:
- HBV/HCV = leading cause of cirrhosis and hepatocellular CA

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52
Q

chronic viral hepatitis - dx

A

detection of viral DNA on serology

ALT/AST: initially very high and then remains slightly high (ALT>AST)
- alk phos minimal high unless + cirrhosis

Liver biopsy to determine dz severity (stage of fibrosis)

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53
Q

chronic viral hepatitis - tx

A

Hep B: tenofovir/entacavir

Hep C: curable!
- peg-interferon, ribavirin (tx is advancing)

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54
Q

ETOH hepatitis - clinical, dx, tx, complications

A

clinical: anorexia, nausea, hepatomegaly, jaundice, RUQ pain

Dx:

  • mildly elevated AST and ALT (AST>ALT)
  • elevated alk phos and bili
  • anemia (epo produced in kidney and liver)

Tx: reversible!!

  • avoid ETOH
  • nutritional support (thiamine, folic acid, zinc)
  • liver TXP

Complications:

  • infection
  • Wernicke-Korsakoff syndrome (neurologic)
  • cirrhosis
  • hepatocellular CA
55
Q

Nonalcoholic Fatty Liver Disease (NAFLD) - clinical, dx, tx, complications

A

deposition of fat in liver

risks: obesity, DM, PCOS
clinical: vague RUQ pain, hepatomegaly

dx:

  • mild elevation of AST, ALT, alk phos
  • LIVER BIOPSY = diagnostic

tx:
- wt loss, lifestyle change

complications:

  • NASH (non alcoholic steatohepatitis)
  • cirrhosis
  • hepatocellular CA
56
Q

autoimmune hepatitis - population, clinical, dx, tx, complications

A

population: young-middle age women w. autoimmune dz

clinical:
- acute hepatitis, ammenorrhea

dx:

  • elevated AST/ALT, bili/GGT
    • ANA, + smooth muscle antibody (SMA)
  • liver biopsy (definitive)

tx:
- prednisone +/- azathioprine

Complications:

  • cirrhosis
  • hepatocellular CA
57
Q

cirrhosis - definition, causes, stages, complications

A

irreversible fibrosis of liver

causes:

  • chronic Hep C
  • ETOH liver dz (most common in US)

stages:

  • compensated
  • compensated w/ varices
  • decompensated (varices, ascites, encephalopathy, jaundice)

complications:

  • portal HTN
  • infection, bacterial peritonitis
  • hepatic encephalopathy (elevated ammonia)
  • coagulopathy
  • hepatocellular CA
  • liver failure
58
Q

liver ability to function

A

can function even with 60% removed

liver re-generates!!

59
Q

cirrhosis - clinical features, PE, dx

A

clinical:
- weakness, fatigue, wt loss
- N/V, anorexia, abdominal pain

PE:

  • hepatomegaly
  • jaundice
  • spider angioma
  • ascites
  • esophageal varices (portal HTN)

Dx:
- liver biopsy = diagnostic

MELD score: higher the score = worse cirrhosis

Tx:

  • remove aggravating agents
  • treat sxs
  • lactulose/rifaximin - stool 2-3 times per day to remove ammonia
  • liver TXP
60
Q

Primary Biliary Cirrhosis - definiton, population, clinical, dx

A

autoimmune destruction of intrahepatic ducts

  • biliary tree becomes fibrotic
  • leads to cholestasis

population:
- women (40-60) w/ autoimmune dz

clinical:

  • fatigue, pruritus
  • late: portal HTN\

dx:

  • elevated bili, alk phos, cholesterol
    • antimitochondrial antibodies
  • liver biopsy (stage fibrosis)
61
Q

liver neoplasms - benign, malignant (primary or metastatic)

A

benign:

  • cavernous hemangioma: most common
  • focal nodular hyperplasia
  • hepatocellular adenoma: women, OCPs

malignant:

  • primary: hepatocellular CA
  • METS: from lung and breast
62
Q

primary hepatocellular CA - risk factors, tumor marker, imaging, screening

A

Hepatitis B and C

Cirrhosis
- MOST COMMON CAUSE

Aflatoxin B1 exposure (Aspergillus) - alcoholics at risk for fungal infection

Tumor marker:
- serum AFP elevated indicated primary CA

Imaging:
- CT/MRI w/ contrast

Screening: for those at risk
- AFP and abd U/S q 6 mo

63
Q

most common malignant tumor in children

A

hepatoblastoma

64
Q

cholangiocarcinoma - special sign

A

CA originals from the duct cells

- Courvoisier’s sign: palpable nontender gallbladder assoc. w/ jaundice

65
Q

acute pancreatitis - cause, clinical

A

cause:
- gallstones, ETOH abuse, elevated serum triglycerides

clinical:

  • severe epigastric pain, N/V
  • worse w/ lying down, better w/ leaning forward
66
Q

acute pancreatitis - signs of hemorrhage

A

grey-turner: flank ecchymosis

cullen: umbilical ecchymosis

67
Q

acute pancreatitis -labs and imaging

A

labs:

  • lipase is most sensitive
  • amylase (but also produced elsewhere in body)

Imaging:
- CT w/ contrast

68
Q

acute pancreatitis - severity ranking (Ranson Criteria)

A 
age > 55
WBC>16,000
Glucose>200
LDH>350
AST>250

3 or more = severe w/ potential for pancreatic necrosis

69
Q

acute pancreatitis - treatment

A

NPO (until pain free)

Pain control: hydromorphone (Dilaudid), morphine

Aggressive fluid resuscitation

Treat N/V

70
Q

chronic pancreatitis - cause, clinical features, dx, tx

A

result of several episodes of acute pancreatitis
- usually due to ETOH use

Clinical:

  • chronic abd pain
  • recurrent attacks of acute pancreatitis
  • steatorrhea (fat in stool)
  • anorexia / wt loss
  • N/V

Dx:
- ERCP

Tx:

  • Tx underlying cause
  • Tx sxs
71
Q

pancreatic neoplasms - most common type, risk factor, location, tumor marker

A

4th most common cause of CA death in US

adenocarcinoma = most common

risk factor: genetic predisposition

location: pancreatic head (75%)

tumor marker: CA 19-9

72
Q

appendicitis - cause, clinical features

A

most common acute surgical emergency
- fecalith is most likely cause

Clinical:

  • peri-umbilical, RLQ pain
  • b/t 10-30 y/o
  • pain at McBurney’s point
  • peritoneal signs: + rebound tenderness
  • fever, N/V, anorexia

PE: psoas sign (hip flexion against resistence), obturator sign (knee flexed and hip internally rotated), rovsing’s sign (palpate in LLQ and pain is in RLQ)

73
Q

appendicitis - diagnosis, treatment

A

diagnosis: CT scan
- U/S in kids

Treatment:

  • laproscopic appendectomy
  • ABX
74
Q

celiac disease - definition, high risk groups, gene involved, clinical features

A

immunological / inflammatory response to gluten (wheat, rye, barley)
- inflammation of small intestine

high risk groups:
- genetic (1st degree relatives), type I DM, other autoimmune dz

gene = HLA-DQ2/DQ8(+)

clinical: fatigue, wt loss, diarrhea, steatorrhea, abd distention, vit deficiency

75
Q

celiac disease - diagnosis, treatment, complications

A

initial: serum IgA tTg antibody
confirm: endoscopy w/ small intestine biopsy (loss of intestinal villi)

treatment:

  • gluten-free diet (villi can re-generate)
  • supplement vitamins and minerals

complications:

  • osteopenia/osteoporosis
  • malignancy: lymphoma, carcinoma
76
Q

constipation - definition, causes

A

change in bowel habits of an individual
- very common, F>M

causes:
- inadequate fluid and fiber intake
- poor bowel habits

Primary cause: slow transit time

Secondary cause: medication (opioids, anti-cholinergic), systemic disorders, neoplasm/stricture

77
Q

constipation - labs, studies, alarm features, treatment

A

Labs: CBC (r/o anemia), BMP, thyroid panel (r/o hypothyroid)

Studies: colonoscopy/sigmoidoscopy, anorectal manometry, colon transit times

Alarm features: age > 50, severe sxs not responding to therapy, blood in stool, wt loss, early satiety, FH cancer or IBD

Treatment:

  • dietary and lifestyle: fiber, fluids, d/c meds, exercise
  • osmotic laxatives: Mg hydroxide, lactulose, polyethylene glycol
  • simulant laxatives (rescue-only): basically, senna
  • opioid receptos antagonists in setting of opiate-induced constipation
78
Q

what population should avoid magnesium products (milk of magnesia or Mg citrate)

A

those with renal disease

79
Q

fecal impaction

A

constipation leads to hard, impacted feces

risks: meds, prolonged bed rest, neurogenic d/o

clinical: dec. appetiti, N/V, abd pain and distention, paradoxical/overflow diarrhea
- PE: firm feces on DRE

Tx:

  • saline/mineral oil enema
  • digital disimpaction
  • long-term goal: maintain soft stool and regular BMs
80
Q

diverticulosis - definition, clinical, complications, tx

A

uncomplicated mucosa herniations

  • mainly elderly (>80 y/o)
  • benign condition

most common site: sigmoid colon

clinical: asymptomatic, constipation

Complications:

  • diverticulitis
  • painLESS large vol. hematochezia (resolves spontaneously)

Tx:

  • high fiber diet/avoid constipation
  • bleeding: endoscopic tx vs. surgery
81
Q

most common cause of major lower GI tract bleeding

A

diverticulosis

- PAINLESS

82
Q

diverticulitis - definition, clinical, complications, dx

A

perforation of colonic diverticulum
- stool leaks into sterile abdomen

clinical:
- LLQ pain, fever, nausea, anorexia, constipation, bleeding (5%)

dx:

  • leukocytosis
  • CT scan

NOTE: barium study and colonoscopy are contraindicated in acute setting
- risk of perforation

83
Q

diverticulitis - tx and indications for surgery

A

uncomplicated (afebrile, tolerate PO): PO ABX
- clear liquid diet

complicated:
- admit and IV ABX

Indications for surgery:
- perforation, failure to respond to tx, recurrent attacks, abscess formation

84
Q

Inflammatory bowel disease - definition, two types, population

A

inflammation of intestinal tract, including ulcers

itwo types:

  • ulcerative colitis
  • Crohn’s disease

bi-modal distribution: age 15-30, 7th decade

autoimmune disease - genetic component

NOTE cigarette smoking is good for UC (bad for Crohn’s)

85
Q

Crohn’s vs. Ulcerative Colitis - location, symptoms, features, dx

A

Crohn’s:

  • mouth to anus (but spares rectum)
  • transmural
  • diarrhea, RLQ pain, wt loss
  • dx: colonoscopy shows “skip lesions” and granulomas
  • smoking worsens

Ulcerative colitis:

  • rectum, colon
  • BLOODY diarrhea, urgency, anemia
  • dx: colonoscopy shows continual lesions
  • smoking helps

NOTE: avoid colonoscopy during acute flare for risk of perforation

86
Q

extra-intestinal manifestations of IBD

A

joints:

  • arthritis
  • ankylosing spondylitis

eyes: uveitis

87
Q

IBD - tx and screening

A

Acute Attacks:

corticosteroids:
- budesonide (mild)
- prednisone (severe)

Maintenance Therapy:
aminosalicylate (5-ASA)
 - sulfasalazine
immunomodulators
 - methotrexate
biologics (suppress immune system)
 - infliximab

Note:
- surgery can be curative for UC; only used to tx complications for Crohn’s

Screening:
- for colon cancer every 1-2 yrs beginning 8 yrs after dx

88
Q

microscopic colitis: definition, sxs, dx, tx

A

chronic, intermittent, watery diarrhea w/ abd pain, fatigue and wt loss if severe
- idiopathic

Dx: colonoscopy (everything looks normal); biopsy (shows inflammation w/ inc. intraepithelial lymphocytes)

Tx:

  • 1st line: loperamide (Imodium - dec frequency of diarrhea)
  • 2nd line: budesonide (dec. inflammation)
89
Q

intussusception - definition, sxs,

A

invagination of proximal into distal segment of intestine
- most common in kids

Risk factors:

  • kids: viral enteritis, CF, Meckel’s
  • adults: neoplasm

sxs:

  • kids: CURRANT JELLY stool, palpable mass (“sausage-s (shaped”)
  • adults: abd pain, N/V/D

dx:

  • Kids: barium enema
  • Adults: CT since possible neoplasm

tx:

  • Kids: barium enema
  • Adults: surgery
90
Q

irritable bowel syndrome (IBS) - definition

A

chronic/recurrent abd pain (> 6 months)

must have at least two sxs:

  • relieved by defecation
  • onset assoc. w/ change in stool frequency
  • onset assoc. w/ change in form of stool

Note: may be exacerbated w/ stress, menses, depression

91
Q

IBS - sxs and alarm features, PE results

A

symptoms vary: can be diarrhea or constipation or mixed

alarm (require further W/U):
- acute onset, fever, anemia, wt loss, FH of colon CA, IBD, celiac dz, rectal bleeding, sxs awaking from sleep

PE: usually normal

92
Q

IBS - dx, tx

A

dx: clinical (diagnosis of exclusion)
- colonoscopy if alarm features

tx: treat sxs (diarrhea, constipation, pain)

93
Q

intestinal ischemia - definition, predisposing features

A

poor or no blood supply to portion of small intestine due to occlusion or clot
- most common vessel affected: SMA (superior mesenteric artery)

predisposing conditions:

  • older age
  • arterial embolus conditions (arrhythmias, HF, valve dz)
  • hyper coagulation states
  • vasculitis
  • low flow states: sepsis, dialysis
  • extensive surgery of GI tract
94
Q

intestinal ischemia - acute vs. chronic sxs and dx

A

acute:
- steady epigastric and periumbilical abd pain OUT OF PROPORTION to exam
- also fever, N/V, dec. bowel sounds

chronic:

  • post-prandial epigastric and periumbilical abd pain lasting 1-3 hrs
  • develop fear of eating

dx:

  • plain film: air fluid levels, thumb-print sign
  • CT ANGIOGRAPHY = image of choice
  • “pruned tree” of distal vascular bed
95
Q

intestinal ischemia - acute vs. chronic tx

A

acute:

  • volume replacement
  • immediate surgical exploration (bowel bypass if viable, resection of gangrene)

chronic:
- angioplasty and stunting or bypass``

96
Q

ischemic colitis - definition, sxs, risks, dx, tx

A

poor or no blood supply to portion of colon due to occlusion or clot

  • most common vessel affected: IMA (inferior mesenteric artery)
  • PAINFUL BLEEDING (vs. painless bleeding w/ diverticulosis)

risk factors:

  • same as intestinal ischemia
  • also LONG DISTANCE RUNNING (colon is last place to get blood when stressed)

clinical:
- acute LLQ abd pain w/ hematochezia

dx:
- CT: initial
- colonscopy w/ biopsy: definitive

tx:
- tx underlying cause
- supportive: fluids
- gangrene = requires surgery

Outcome: unless severe, resolves o 24-48 hrs

97
Q

lactose intolerance

A

lactase deficiency

diarrhea, bloating, abdominal pain w/ ingestion of lactose

dx:
- elimination diet
- confirmation: hydrogen breath test

tx:

  • lactose-free diet
  • lactase enzyme replacement
98
Q

colon polyps - 2 common types and risks for malignancy

A

adenomatous: most common
mucosal serrated

risk for malignancy:

  • > 1cm
  • villous features
  • high grade dysplasia
99
Q

colon polyps - sxs, dx, tx

A

sxs:

  • asymptomatic
  • may have hematochexia or occult blood loss

dx:
- colonoscopy

tx: polypectomy

100
Q

colorectal cancer - prevalence, most common type, risk factors

A

2nd leading cause of cancer death in US
- 85% are adenocarcinoma (arising from adenomas / polyps)

Risk factors:
- older age, +FH, hx IBD, polyposis syndromes (FAP: familial adeno-polyposis, Lynch syndrome - 1000 polyps in colon!)

101
Q

colorectal cancer - clinical, PE, Labs, dx, imaging

A

clinical:

  • slow-growing: no sxs for yrs
  • asymptomatic: detected by FOBT
  • fatigue/weakness (iron-deficiency anemia)
  • change in bowle habits

PE:

  • palpable mass
  • palpate liver (hepatomegaly - METS)
  • DRE (blood)

Labs: CBC, iron studies, FOBT

Dx: colonoscopy

Imaging:
- full body CT for preoperative staging and METS

102
Q

colorectal cancer - screening, tx

A

colonoscopy every 10 yrs (start age 50)
- screening intervals vary based on size and type of polyp

if +FH:

  • begin screen at age 40 or 10 yrs prior to age of dx of youngest affected relative
  • colonoscopy q 5 yrs or sooner if needed

tx:

  • surgery (primary)
  • may need chemo/radiation
103
Q

small bowel obstruction - causes and clinical features

A

causes:

  • adhesions (prior surgeries)
  • hernias, neoplasms, IBD, volvulus
  • acute presentation

clinical:

  • early: diffuse, crampy abd pain, hyperactive bowel sounds
  • late: steady abd pain, localized, absent bowel sounds (bad sign - perforation)
104
Q

small bowel obstruction - dx, tx

A

Dx:

  • abd x-ray (dilated bowel loops, air-fluid levels)
  • CT: definitive (determines cause)

Tx:

  • NGT, IV fluids, pain meds, anti-emetics
  • surgery: for strangulation or evidence of gangrene
105
Q

large bowel obstruction - causes and clinical features

A

slower, less acute presentation
- usually result of neoplasm

clinical:

  • distention, anorexia, N/V
  • late: vomiting, absence of bowel sounds
106
Q

large bowel obstruction - dx and tx

A

Dx:

  • abd x-ray (free air, bird’s beak = sigmoid colon)
  • CT: definitive (determines cause)

Tx:

  • depends on cause
  • decompress: NG tube
  • surgery: neoplasm, other obstruction
107
Q

toxic megacolon - definition, clinical

A

true emergency!!

extreme dilation and immobility of colon

  • high risk of perforation
  • due to complications of UC, Crohn’s or pseudomembranous colitis (from C. Diff)

clinical:
- fever, abd cramps, distention, rigid abd, rebound tenderness, shock

108
Q

toxic megacolon - dx and tx

A

Dx:
- colonic dilation > 6cm

Tx:

  • broad spectrum ABX
  • NG suctioning and colonic decompression
  • IV fluids
  • surgery
109
Q

anal fissure - definition, dx, tx

A

tear most commonly occurring at posterior midline

  • caused by trauma during defecation (strain, constipation)
  • off midline = red flag

Dx: visual inspection (linear ulcer)

Tx: fiber, sitz bath, topical lidocaine, nitroglycerin (inc. flow to area for healing)

110
Q

perianal abscess / fistula - abscess can cause a fistula

A

perianal abscess:

  • infection of anal glands
  • throbbing perianal pain
  • dx: external exam: erythema, fluctuant, swelling
  • tx: I&D

perianal fistula:

  • complication of abscess
  • clinical: purulent d/c, itching, pain
  • tx: surgical excision
111
Q

pilonidal cyst

A

abscess of sacrococcygeal cleft

  • assoc. w/ sinus development
  • inc. w/ prolonged sitting
  • pain and fluctuant area

tx:
- surgical drainage
- ABX
- unroof and drain

112
Q

hemorrhoids - definition, causes, clinical, dx

A

varicies of hemorrhoidal plexus
- caused by constipation, diarrhea, pregnancy, prolonged sitting

Internal: above dentate line

Clinical:

  • internal = painless BRBPR
  • external = pain and swelling when thrombosed

Dx:

  • DRE
  • Anoscopy
113
Q

hemorrhoids - treatment

A

depends on grades (I-IV) which depends on if prolapsed or protruding

conservative:

  • fiber, water (avoid constipation)
  • analgesics
  • sitz baths

medical:

  • rubber band ligation
  • injection sclerotherapy
  • cautery

surgical excision

114
Q

anal cancer - most common type of CA, clinical, dx, tx

A

80% associated with HPV
- most common: squamous cell CA

clinical

  • rectal bleeding
  • pain
  • palpable mass

Dx: biopsy
- CT/MRI look for METS

Tx:

  • <3cm: wide local excision
  • surgery + chemo/radiation
115
Q

hernias - definition and classification

A

protrusion of intra-abdominal tissue through a fascial defect in abdominal wall

Classification:

  • reducible: able to return contents
  • incarcerated: contents cannot be returned
  • strangulated: incarcerated w/ compromised blood supply
  • richter: only part of the bowel becomes incarcerated or strangulated
116
Q

hernias - types

A 
umbilical
hiatal: causes GERD
incisional: old incisions
inguinal:
 - direct: through Hesselbach triangle (most common acquired)
 - indirect: through inguinal canal into scrotum (most common congenital)
femoral: inc. strangulation rate
 - most common in females
117
Q

hernias - clinical, dx, tx

A

Clinical:

  • lump or swelling
  • if strangulated, local sharp, intense pain, +/- anorexia/vomiting

Dx:

  • most on PE
  • CT to confirm
  • leukocytosis is strangulated

Tx:
- surgery

118
Q

diarrhea (acute) - definition, clinical, dx

A

acute: < 2 wks

inflammatory: fever, blood or pus in stool, severe abd pain, high WBC count
- thinking invasive bacteria
- DX: need stool studies

non-inflammatory: afebrile, watery stool, abd cramping

  • thinking virus, diet, medication (ABX)
  • DX: clinical dx or stool studies if concerned (e.g. persists, dehydrated, c. diff)
119
Q

acute diarrhea - tx

A

BRAT diet
rehydration

antidiarrheals
- AVOID if infection is concern (e.g. blood in stool)

120
Q

infectious diarrhea - key organisms, sx, and tx

A

campylobacter jejuni

  • raw poultry, milk
  • fever, bloody stool
  • azith, fluoroquinolone

salmonella

  • eggs, poultry, milk
  • no ABX

shigella

  • food/water w/ feces
  • fever, pain, bloody stool
  • fluoroquinolone, Bactrim

E. coli

  • beef, milk
  • self limited

giardia

  • recreational water, wilderness
  • watery, profuse stool
  • greasy, malodorous stool
  • metronidazole

vibrio cholerae

  • water, selfish, food
  • rice water stool
  • hydration, azith, tetracycline shorten duration

C. difficile

  • ABX assoc. and hospital acquired
  • green, foul smelling
  • metronidazole, PO vancomycin (IV does not penetrate gut)
121
Q

chronic diarrhea - two types

A

osmotic:

  • caused by malabsorption, laxatives
  • inc. osmotic gap
  • resolves w/ fasting

secretary:

  • caused by endocrine tumors, bile salt malabsorption
  • normal osmotic gap
  • voluminous, water
122
Q

chronic diarrhea - general causes

A

motility disorders
- IBS, systemic dz, post-surgery

chronic infections:
- parasite (giardia), HIV/AIDS

Inflammatory:
- UC, Crohn’s, malignancy

Medications:
- SSRI’s, ARB’s, PPI’s, NSAIDS, Metformin

Malabsorption

  • dietary: lactose, Celiac dz
  • anatomic: bowel resection
  • see wt. loss, nutritional deficiencies, STEATORRHEA (fat in stool)
123
Q

chronic diarrhea - diagnostic tests and tx

A

good history and PE
- both dx and tx aimed at suspected underlying cause

Dx: labs, stool studies, hydrogen breath test (malabsorption), FOBT, CT, MRI
- endoscopic eval: upper GI (Celiac, malabsorption); colonoscopy (IBD, micro colitis, malignancy)

Tx:

  • avoid triggers
  • replete nutrients
  • antidiarrheals (avoid if infective since can lead to toxic megacolon)
124
Q

vitamin A - function, deficiency, toxicity

A

fx: vision, antioxidant
df: blindness
tox: skin disorders, hair loss, hip fx

125
Q

vitamin D - function, deficiency, toxicity

A

fx: calcium and phosphate regulation
df: Rickett’s (kids), osteomalacia (adults)
tox: hypercalcemia, renal stones

126
Q

vitamin E - function, deficiency, toxicity

A

fx: cellular aging and vascular integrity
df: areflexia, gait disturbance
tox: least toxic, inhibits K so may result in bleeding

127
Q

vitamin K - function, deficiency, toxicity

A

fx: clotting
df: bleeding
tox: anemia, jaundice

128
Q

vitamin B12 (Cobalamin) - function, deficiency, toxicity

A

fx: RBC, neural fx, DNA
df: paresthesias
tox: N/A

129
Q

vitamin B1 (thiamine) - function, deficiency, toxicity

A

fx: CHO metabolism
df: neuropathy and poor coordination, Wernicke’s encephalopathy (ETOH)
tox: lethargy, ataxia

Note: we treat alcoholics (w. liver dz)

130
Q

Niacin - function, deficiency, toxicity

A

fx: energy/fat metabolism
df: Pellagra (3 D’s) - diarrhea, dermatitis, dementia
tox: flushing

131
Q

iron - function, deficiency, toxicity

A

fx: production of RBCs
df: PICA
tox: lethargy, ataxia

132
Q

folate - function, deficiency, toxicity

A

fx: DNA synthesis
df: megaloblastic anemia
tox: N/A

133
Q

vitamin C (ascorbic acid) - function, deficiency, toxicity

A

fx: antioxidant, collagen synthesis
df: Scurvy, fatigue, depression, poor wound healing
tox: renal stones, diarrhea

134
Q

phenylketonuria (PKU)

A

unable to metabolize phenylalanine and convert it to tyrosine

  • rare, autosomal recessive dz
  • diagnosed at birth (newborn screen)

management: low phenylalanine diet (low protein)

If not treated:

  • developmental delay (brain damage)
  • movement disorder

PANCE Review (16 decks)

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