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Emergency Medicine > Gastrointenstinal > Flashcards

Gastrointenstinal Flashcards

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1
Q

Acute and Chronic Pancreatitis

dx

A

Dx:

  • Serum Amylase x5 ULN (non spec)
  • Serum Lipase x3 ULN specific
  • CT scan - gold standard
  • +/- jaundice
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2
Q

Acute Appendicitis

A

fecalith trapped in appendix

Sxs:

  • Periumbilical pain => pain over RLQ McBurney’s point
  • N/V/Chills, anorexia

Dx

  • PE
    • Rovsing’s sign - RLQ pain after pressing on LLQ
    • Obturator’s sign - pain with flexion and internal rotation of R LE
    • Iliopsoas’s sign - supine, raise R leg against resistance
  • Labs
    • leukocytosis, fever
  • Imaging - US first line for kids
    • CT for adults to confirm

Tx

  • Appendectomy
  • IV Ceftriaxone pre-op
  • no need for abx post op
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3
Q

Ranson’s Criteria

A

At admission:

  • Age > 55
  • Glucose > 200
  • AST > 250
  • LDH > 350
  • WBC > 16,000

48 hrs after admission

  • Hematocrit fall > 10%
  • BUN Rise > 5mg/dl
  • Ca < 8 mg/dl
  • PO2 < 60 mmHG
  • Base deficit > 4 mEq/L
  • Fluid sequestration > 6L
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4
Q

Acute Pancreatitis

eti, sxs

A

MC gallstones, 2/2 ETOH N/V

Sxs:

  • Epigastric abd pain
  • r-> back worse supine and
  • post prandial
  • hemorrhagic
    • Grey Turner - flank ecchymosis
    • Cullen - periumb ecchymosis
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5
Q

Acute Pancreatitis

tx

A

Mild

  • bowel rest
  • NPO
  • Pain control

Severe - ICU

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6
Q

Anal Abscess and Fistula

Dx, tx

A

Clinical I&D

followed by WASH

  • Warm water
  • Cleansing
  • Analgesics
  • Sitz Bath
  • High fiber diet
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7
Q

Anal Abscess

eti, sxs

A

Bacterial infx of perianal ducts/glands - MC S Aureus

MC posterior rectal wall

Sxs:

  • Painful defecation
  • Rectal pain worse with sitting, coughing
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8
Q

Anal Fissures

dx and tx

A
  • clinical
  • Sigmoidoscopy if < 50 yo to r/o FH of colon ca
  • Analgesics
  • High fiber diet
  • Stool softener, laxatives, mineral oils
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9
Q

Anal Fissures

eti, sxs

A

Painful, linear tear/crack low fiber diet

MC in posterior midline

2/2 Crohn’s and Granulomatous (TB or sarcoid)

Sxs:

  • Severe, tearing pain with defecation
  • Pt afraid of BM —> Constipation and
  • BRBPR
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10
Q

Anal Fistula

eti, sxs

A

open tract btwn two epithelial-lined areas

MC with Crohn’s

Sxs:

  • Perirectal/anal swelling
  • painful defecation
  • Malodorous drainage
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11
Q

Cholangitis

dx, tx

A

Dx:

  • ele serum bilirubin, alk phos, aminotransferases
  • 1st - RUQ US or CT
  • ERCP for cholangiography after afebrile for 48 hrs
    • ERCP for decompression
    • PTC if can’t do ERCP

Tx with Abx - Ceft + Metro - Zosyn (pip/tazo)

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12
Q

Cholangitis

eti, sxs

A

Infection of common bile ductt 2/2 to obstruction - gallstones

MC Ecoli or Kleb

Charcot’s Triad

  1. RUQ pain
  2. Jaundice
  3. Fever

Reynold’s Pentad

  1. above + AMS & Sepsis/hypotension
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13
Q

Cholecystitis eti, sxs

A

Inflammation of GB

MC gall stones

Sxs:

  • RUQ/epigastric pain
  • N/V/Anorexia
  • R-> R shoulder/scapular - Boas’s sign
  • Inspiratory halt during deep palpi = Murphy’s sign
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14
Q

Cholecystitis

dx & tx

A

Dx with RUQ US >3mm

HIDA scan (gold std)

Tx:

NPO IV fluids Abx (ceft + metron) Definitive - cholecystectomy

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15
Q

Choledocholithiasis

dx, tx

A

Trans abd US gold - ERCP extraction tx

cholecystectomy definitive

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16
Q

Choledocholithiasis

eti, sxs

A

GS in Common Bile Duct

1ry - formation of gs in CBD

2ry - passage of gs from GB to CBD

Sxs:

asymp 50%

Biliary colic w/ RUQ tenderness +/- jaundice

may lead to shock

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17
Q

Cholelithiasis

dx, tx

A

Gold - RUQ US > 2mm GB wall

3 types deps on color

  • yellow for cholesterol
  • black - hemolysis, ETOH, cirrhosis
  • brown - biliary tract infx observation if asymp

Tx - Urseodeoxycholic acid to dissolve GS

Elective cholecystectomy

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18
Q

Cholelithiasis eti, sxs

A

Gallstones + pain when GB compresses on GS

Fat Forty Fertile Female Flatulence

Sxs:

  • MC asymp Biliary colic
  • episodic RUQ/epig pain —> resolves in 30-1h
  • post prandial pain + at night
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19
Q

Chronic Pancreatitis

tx

A

Pancreaticojejunostomy -> Whipple PO

Pancreatic enzyme replacement

ETOH abstinence

Pain control

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20
Q

Colorectal Carcinoma (CRC)

dx

A

Colonoscopy with bx - gold

barium enema - apple core lesion

+ CEA - marker

CBC - anemia

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21
Q

Colorectal Carcinoma (CRC)

eti

A

3rd MC Cancer in US Genetics

Familial Adenomatous Polyposis (APC gene - develop colon cancer by 40yo —> prophylactic colectomy

RFs

  • age > 50yo -
  • UC > Crohn’s -
  • Low fiber diet -
  • smoking -
  • etoh -
  • AAs -
  • fam hx of CRC
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22
Q

Colorectal Carcinoma (CRC)

Screening

A

average risk

  • start at 50 yo
  • FOBT q 1 year
  • Colonoscopy q 10y or Flex sig q 5 y

1st degree Relative or high RFs

  • FOBT q1y
  • starting at 40y or 10 yrs younger than earliest dx age Colo - q 5y

Highest risk

  • UC or Crohn’s >8yrs,
  • FAP
  • FOBT any age
  • Colonoscopy q5y
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23
Q

Colorectal Carcinoma (CRC)

sxs

A

Painless rectal bleeding changes in bowel habits

MCC large bowel obstruction in adults

Right sided

  • proximal - lesions tend to bleed (anemia/+ FOBT) diarrhea

Left sided

  • distal bowel obstructions present later
  • hematochezia
  • +changes in stool diameters
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24
Q

Colorectal Carcinoma (CRC)

tx

Study These Flashcards
A

localized (stage 1 to 3) - resection

Stage 3 to Mets - chemotherapy with 5FU/Fluorouracil

25
Diverticulitis dx, tx
**gold - CT scan** FOBT + CBC Leuks Tx: * Abx - Cipro/Bactrim + MNZ * Clear liquid diet * colonoscopy in 6 wks to r/o cancer
26
Diverticulitis eti, sxs
Infection and inflammation of outpouchings d/t fecalith Sxs: * LLQ abd pain * Fever N/V/D * Constipation * bowel changes and bloating
27
Diverticulosis dx, tx
KUB r/o free air avoid barium enema high fiber diet psyllium
28
Diverticulosis eti, sxs
Outpouchings d/t intestinal mucosa herniation Sxs: * MCC BRBPR * Low fiber diet * LLQ discomfort * fever, chills
29
Esophageal Carcinoma - Adenocarcinoma dx, tx
Endoscopy with Bx - gold Barium esophagram CT for staging Esophageal resection chemo 5FU
30
Esophageal Carcinoma - Adenocarcinoma eti, sxs
MCC esophageal ca in US a/w Barrett's esophagus and GERD Sxs: * progressive dysphagia solids -\> fluids odynophagia * chest pain not related to eating * wt loss * reflux hoarseness
31
Esophageal Carcinoma - Squamous Cell Carcinoma
MCC Esophageal worldwide upper 1/3 of esophagus 50-70yo a/w smoking/etoh
32
Gastric Carcinoma dx, tx
Endoscopy with Biopsy Linitis plastica - thickening of gastric wall - infiltration of cancer Gastrectomy poor prognosis
33
Gastric Carcinoma signs of metastasis
Virchow's Node - Left supraclavicular LN Sister Mary Joseph's Nodule - umbilical LN
34
Gastric Carcinoma eti, sxs
MC adenocarcinoma RFs: * H pylori\*\*\* salted, cured, pickled food * Etoh * Smoking * Blood type A WEAPONS * Weight loss * Emesis * Anorexia * Pain/abd discomfort * Obstruction * Nausea
35
Hepatocellular Carcinoma eti, sxs
Primary Cancer - HCC 2/2 to mets from lungs and breast Ca (MC) RFs: * Hepatitis B, C, D * Cirrhosis * Aflatoxin B1 exposure (Aspergillus spp) * Malaise * Jaundice * Wt loss * ascites * abd pain * Hepatosplenomegaly
36
Hepatocellular Carcinoma dx, tx
Alpha fetoprotein (AFP) marker esp in pst with hep C or cirrhosis Ultrasound, MRI lesions \>/= 1cm Liver transplant for single lesion \< 5cm or = 3 lesions that are all = 3cm Surgical resection - cancer can recur
37
**Mallory Weiss Tear** Hematemesis
Mucosal tearing of gastroesophageal junction from vomiting Sxs: * Hx of vomiting/retching or alcohol intake * **PainLESS** hematemesis Dx - Esophagogastroduodenoscopy (EGD) Tx - self limited, supportive
38
**Esophageal Varices** Hematemesis
Dilated submucosal veisn in distal esophagus or proximal stomach hx of portal HTN & Cirrhosis; high mortality Sxs: * Hematemesis - coffee ground appearance * melena * VS instability * hypovolemia/tachycardia * shock Dx: * Emergent endoscopy (EGD) * **Band ligation\*\*\*\* & IV Ocreotide for vasoconstriction** * sclerotherapy * If fails - Balloon tamponade or TIPS (transjugular intrahepatitc portosystemic shunt) * Longterm - BB (propanolol), no etoh
39
Infectious Esophagitis
MC in IMC hosts Sxs: * **Odynophagia\*** (painful swallowing) - food or liquid * Dysphagia (difficult swallow) * Chest/substernal pain/fever Dx/Tx - EGD * **Candida MC** - linear yellow white plaques * Fluconazole 100 mg PO QD * HSV - shallow punched out lesions * Acyclovir * CMV - large solitary ulcers or erosions * Ganciclovir
40
Non-Infectious Esophagitis
1. Reflux Esophagitis * mechanical or functional abn from LES - refer to GERD 2. Medication induced * Usu NSAIDs or bisphosphonates - drink 4oz of water, sit upright 3. Eosinophilic - allergic eosinophilic infiltration of esophageal epithelium * dx w/ **Barium swallow = ribbed esophagus and multiple corrugated rings**
41
GERD
Relaxation of LES Sxs: * Heartburn\* w/ meals, wt gain, N, recumbency * Throat irritation and cough Tx - symptom relief w/ PPO and H2 Blockers * **PPI - sx relief + promote healing** * Tx empircally on PPI x 4 wks (failed H2blockers w/ mod-severe GERD) Dx * **Endoscopy - if failed empirical tx on PPI OR** * GI bleeding/anemia * Dysphagia/odynophagia * unintentional wt loss * H/o heavy NSAIDs * Risk of UGI cancers
42
Peptic Ulcer Disease
MCC of non hemorrhagic GI bleeds Duodenal 5x \> Gastric; MCC H pylori \> NSAIDs, ETOH, smoking Sxs: * _Gastric Ulcers_ * abd pain worse with meals - get better after eating * patient refuses to eat (losing weight) * _Duodenal Ulcers_ * Pain gets better with eating - worse after eating * Patient gaining weight Dx * plain films r/o perf * UGi * **Endoscopy\* - gold** Tx * PPI qd-BID x 8 to 12 weeks
43
**H. pylori** Peptic Ulcer Disase
Dx * **Urea Breath test \* gold** - needs to be off PPI, bismuth and abx * active infection * urea as byproduct of metabolism * Stool antigen * Endoscopy bx Tx * Clarithromycin 500 mg BID * Amoxicillin 1g BID * PPI BID * Metronidazole 500 mg if pcn allergic * Follow up with urea breath test 1 mo post tx to ensure eradication
44
**Zollinger-Ellison Syndrome** PUD ddx
Gastrinoma of pancreas\* or duodenum PUD develops in 90% of pts Consider if * Recurrent PUD * Neg H. pylori, Neg NSAID/ASA use * Severe abd pain, diarrhea Dx * **secretin test =\>** gastrin level will rise Tx * Surgical resection of gastrinoma
45
Hepatitis (acute All
Hep A and Hep E * Fecal oral route * self limited, mild * IgM Hep A is positive infx Hep B * IVDU, needles * Chronic carrier * Major risk for **hepatocellular carcinoma** * Coinfection with HIV Hep C * Sex - blood borne, tattoos, transfusion * Pts btw 1945-1965 - screened * Should be vaccinated against HAV and HBV
46
Hepatitis B serology
HBsAg = active infection HBsAby = immunity HBcAg/Aby = exposure or past infection * if + core, exposed to virus HBeAg = highly infectious BAD HBeAby = low infectious risk (closed envelope) Immunity via vaccination = only have HBsAby + Active infection = HBsAby, HBcAg/Aby, HBeAg
47
Hepatitis C
a/w cirrhosis, chronic Hep C =\> Hepatocellular carcinoma Dx * HCV RNA viral load testing * HCV Aby w/ neg viral load = resolved HCV * Liver bx = for state * most are genotype 1 Tx * Initial - with Interferon and Ribavirin + chemotherapy * Now - Direct acting viral drugs * **Telaprevir/Incivek** * **Sofosbuvir/Harvoni** - 3 mos w/o any SEs
48
Hepatitis - Alcoholic
Reversible - MCC of cirrhosis AST \>ALT (2:1) ~300 Increased bilirubin Megaloblastic anemia prolonged PT/low albumin = poor prognosis
49
Cirrhosis eti,sxs, dx
Hepatic fibrosis - scar tissue Eti: Chronic hepatitis is MCC, etoh abuse, NASH, Wilson's disease Sxs: * Hepatomegaly * Terry's nails (white nail beds) * fluid wave + shifting dullness from **ascites** * Esophageal varices * **caput medusae** * **Hepatic encephalopathy - asterixis** Dx: * AST \> ALT, incr ALP * ele GGT * Jaundice = incr unconjugated bilirubin * hypoalbuminia (ascites) * Prolonged PTT = decr clotting factors K * **Liver bx - gold** * **Child-Pugh Cirrhosis mortality****​**
50
Cirrhosis tx and management
* quit etoh * Antiviral for Hep C * BB for esophageal varices * Liver transplant - definitive * Encephalopathy * **lactulose + rifaximin** * Ascites * Fluid restriction, paracentesis * if + abd pain and fever, think **Spontaneous Bacterial Peritonitis** ​ * diagnostic tap of 50cc =\> (ANC \> 250) * tx with IV Cefotaxime/Ceftriaxoen x 5 d, PO Cipro once stable * Give with albumin 1.5mg/kg to prevent Renal failure
51
**Crohn's Disease** IBD
Genetic +environmental factors; peaks at 15-35 yo Mouth to anus - transmural, "**Skip lesions"** Sxs: * Colicky RLQ pain * Diarrhea/ malabsorption * Low grade fever * Wt loss * a/w anal fistulas, aphthous ulcers Dx: * Colonoscopy - gold * **cobblestoning** * **skip lesions** * small bowel films * **string sign - barium study** * Lab - CBC, ESR, CRP, B-12, stool culture * **+ASCA**
52
**Ulcerative Colitis** IBD
Idiopathetic, inflammatory dz Friable **mucosa and submucosa**, limited to colon = **Rectum MC** bimodal distr - 15-25yo and 55-65 Sxs: * Bloody, pus filled diarrhea * LLQ pain * fever Dx: * Barium enema - **lead pipe appearance** * **coloscopy with bx** - gold = loss of haustral markings and lumen narrowing * risk of toxic megacolon * **pANCA**
53
IBD Treatment
Medical Management _5-Aminosalicylates ASA_ * **Mesalamine** * SE - NV, HA, rash, fever * replace folic acid * **Sulfasalazine** _Immunomodulators_ * **Azothioprine/6-mercaptopurine** * maintenance therapy * takes 3-6 mos for full effect * can come off 5ASA * check LFTs and CBC q 90 ds Biologics * TNF-inhibitors (Infliximab/Remicade, Adalimumab/Humira) * SE - reactivate of Hep B and TB (check prior to initiation) * expensive _Corticosteroids_ * high dose, short course =\> acute exacerbations * Prednisone in taper 30-40mg _Abx - for fistula_ * Metronidazole * Cipro * Rifaximin
54
Mesenteric Ischemia
Hypoperfusion to bowel vasculature Sxs: * abd pain OOP to PE * h/x of afib, vascular dz Dx - CT angio, treat in surgery
55
Small Bowel Obstruction
MCC - adhesions d/t previous abd surgeries Sxs: * N, V * Abd distention, rigid or firm Dx * KUB - air fluid level on upright Tx * NG tube * Bowel rest * Surgery if unresolved
56
Large Bowel Obstruction
Causes - volvulus, adhesions, hernias, colon cancer (MCC in elderly ppl) Sxs: * Constipation * N/V * distention and pain * high pitched BS Dx: * KUB/abd Xray - distended proximal colon w/ haustra, air fluid levels, no gas in rectum Tx: * NPO * NG suction * IV fluids * monitoring pain * Surgery if mechanical obstruction
57
Giardiasis and Parasitic infections
_Giardia_ * after camping trip, mountain stream water * incubates for 1-3 wjs * foul smelling bulky stool * Acute profuse, fatty non bloody diarrhea * Dx - stool sample * Tx - **Tinidazole 1st line,** metronidazole * resolves w/in 5-7 ds _Pinworms_ * perianal swelling * scotch tape test * Tx **mebendazole** _Hookworm_ * cough, wt loss, anemia, recent travel * Eosinophilia and anemia * Tx **Mebendazole or pyrantel** _Roundworm_ * contaminated soil * pancreatic duct, common bile duct and bowel obstruction * Dx - stool sample eggs * Tx **abendazole, mebendazole, pyrantel pamoate** _Amebiasis_ * Fecal-oral, contaminated water/food, anal-oral * bloody diarrhea, tenesmus * a/w **liver abscess** * Tx **Iodoquinol or flagyl for liver abscess** _Tapeworm_ * GI sxs w/ weight loss * raw or undercooked meat * B12 deficiency * Dx - diphyllobothrium latum tape test * Tx **praziquantel** _Schistosomiasis_ * skin penetration in freshwater -\> blood stream -\> liver, intestines * rash, abd pain, diarrhea, bloody stool, hematuria * Dx - egs in urine or feces * Tx **praziquantel**
58
Hemorrhoids
varicose vein of anus and rectum RFs - constipation/straining, pregnancy, portal HTN Dx - **Anoscopy** if BRBPR or suspected thrombosis _External_ * lower 1/3 of anus * thrombosed * significant pain, pruritis, NO bleeding * palpable perianal mass w/ purplish hue * Tx - **excision** _Internal_ * upper 1/3 of anus * BRBPR, pruritis, rectal discomfort * Tx - Fiber, sitz bath, ice packs, stool softeners * Rubber band ligation - if +protrudes, enlargement and intmt bleeding * Hemorrhoidectomy if prolapse
59
Hernia (incarcerated/strangulated)
Protrusion of organ/structure through abd wall **Inguinal hernias** * MC - through internal ring down the inguinal canal (into scrotum) **Direct inguinal hernias** * passage of intestines through external inguinal ring at Hesselbach's triangle Sxs: * Reducible bulge when patient coughs or strains * Usu painless unless 1. Incarcerated - can't be reduced 2. Obstructed - irreducible hernia but no interference w/ blood flow 3. Strangulated - blood supply cut off - bowel ischemia, necrosis perforation Tx - Open repair or lap w/ mesh reinforcement

Emergency Medicine (13 decks)

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