Gastrointestinal Flashcards
(83 cards)
1
Q
Achalasia
A
Esophageal motility disorder (neuromuscular)
Outflow obstruction d/t inadequate LES relaxation
2
Q
Achalasia S/S
A
Dysphagia
Heartburn
Chest pain
3
Q
Achalasia Diagnosis
A
Esophagram reveals “bird’s beak” appearance
EGD
Esophageal manometry
4
Q
Achalasia Type 1
A
Classic minimal esophageal pressure
Treatment = myotomy
5
Q
Achalasia Type 2
A
Entire esophagus pressurization
Best outcome
6
Q
Achalasia Type 3
A
Esophageal spasm w/ premature contractions
Worst outcome
7
Q
Achalasia Treatment
A
Palliative Relieve obstruction (does not correct lacking peristalsis)
8
Q
Distal Esophageal Spasm
A
Diffuse esophageal spasm
Elderly patients
ANS dysfunction
9
Q
Distal Esophageal Spasm Diagnosis
A
Esophagram reveals “corkscrew” or “rosary bead” esophagus
10
Q
Distal Esophageal Spasm Treatment
A
Pain mimics angina
Responds to Nitroglycerin
11
Q
GERD
A
Gastroesophageal reflux disease
LES incompetence
12
Q
GERD S/S
A
Heartburn
Regurgitation
Less common include dysphagia & chest pain
13
Q
GERD Complications
A
Chronic peptic esophagitis
Strictures
Ulcers
Barrett’s metaplasia associated w/ adenocarcinoma
Reflux into pharynx, larynx, & tracheobronchial tree
Aspiration → pulmonary fibrosis or chronic asthma
14
Q
GERD Treatment
A
Lifestyle modification Avoid foods that impair LES tone (fat, alcohol, peppermint, chocolate) & acidic Pharmacological - PPI ↑pH & allows esophagus to heal - H2 antagonists Surgical = Nissen fundoplication
15
Q
↑aspiration risk associated w/ ___ mL & ___ pH
A
25mL or 0.4mL/kg
pH <2.5
16
Q
Esophageal Diverticula
A
Esophageal structural disorder w/ outpouchings
Most common locations:
- Pharyngoesophageal (Zenker’s diverticulum)
- Mid-esophageal
- Epi-phrenic (supradiaphragmatic)
17
Q
Hiatal Hernia
A
Stomach herniates into thoracic cavity via diaphragm esophageal hiatus
Asymptomatic
18
Q
Esophageal Tumors
A
Progressive dysphagia to solid food & weight loss
Poor survival rate (lymph node metastasis)
Adenocarcinoma
Mortality rate about 50%
19
Q
Esophageal Tumor Treatment
A
Esophagectomy (curative or palliative)
Thoracic epidural
20
Q
Esophageal Tumors Complications
A
ARDS
Malnourished
Dehydration
RLN injury risk
21
Q
Peptic Ulcer Disease
A
Epigastric pain exacerbated by fasting & improved by eating
22
Q
H. Pylori
A
Associated w/ PUD
Induces acid secretion via pro-inflammatory cytokines
23
Q
Gastric Ulcer
A
1/3 duodenal
Benign ulcers
Most common cause = NSAID use
24
Q
Stress Gastritis
A
Associated w/ shock, sepsis, respiratory failure, burns, hemorrhage, massive transfusions, or head injury
Gastric bleeding when coagulopathy, thrombocytopenia, INR >1.5, and aPTT >2x normal
25
Zollinger-Ellison Syndrome
```
Gastroduodenal & intestinal ulceration
↑gastrin secretion
Non-beta islet cell pancreatic tumor
Primarily men 30-50yo
Associated w/ MEN1
```
26
ZES S/S
Abdominal pain
Peptic ulceration
Diarrhea
GERD
27
ZES Treatment
Obtain fasting gastrin level
↑PPIs dosages
Surgical tumor resection
28
PUD Complications
Bleeding
- Hemorrhage = leading cause of death
Perforation (risk 10%)
- Severe epigastric pain caused by highly acidic gastric contents in peritoneum
Obstruction
- Gastric outlet obstruction
- Cause = edema & inflammation in the pyloric channel & duodenum 1st portion
29
PUD Treatment
```
Antacids
H2 receptor antagonists
PPIs
Prostaglandin analogues
Cytoprotective agents
Anticholinergics
```
30
Antacids
Aluminum hydroxide
Magnesium hydroxide
Avoid in chronic renal failure patients → hypermagnesemia & neurotoxicity
TUMS = calcium carbonate (milk-alkali syndrome hypercalcemia, hyperphosphatemia, & renal calculi)
HCO3 → metabolic alkalosis
31
H2 Receptor Antagonists
Cimetidine, Ranitidine, Famotidine, & Nizatidine
Inhibit basal & stimulated gastric acid secretion
Cimetidine & Ranitidine bind to CYP450
32
PPIs
Proton pump inhibitors
Omeprazole, Pantoprazole, Esomeprazole, Lansoprazole, & Rabeprazole
Covalent, irreversible bond
Inhibit hydrogen-potassium ATPase pump
Most potent drug available
Inhibit ALL gastric acid secretion phases
Interfere w/ Ketoconazole, Ampicillin, Iron, Digoxin, & Diazepam absorption
Omeprazole & Iansoprazole inhibit CYP450
33
Prostaglandin Analogues
Misoprostol only FDA approved
Contraindicated in pregnancy
Enhance mucosal HCO3 secretion, stimulate mucosal blood flow, & ↓mucosal cell turnover
Most common side effect = diarrhea
34
Cytoprotective Agents
Sucralfate provides physiochemical barrier, enhances defense & repair
Most common side effect = diarrhea
Colloidal bismuth (Pepto) MOA unknown & neurotoxicity risk
35
Anticholinergics
Inhibit muscarinic receptors activation in parietal cells
Negative side effects
Not routinely used
36
Post-Gastrectomy
| Dumping Syndrome
Hyperosmolar gastric contents enter into proximal small bowel
Fluid shifts into small bowel lumen
Results in plasma volume contraction & acute intestinal distention
37
Early Dumping Syndrome
Symptoms 15-30min after meal (nausea, epigastric discomfort, diaphoresis, cramps, diarrhea, tachycardia, palpitations, dizziness, syncope)
38
Late Dumping Syndrome
Symptoms 1-3hrs after meal
| Vasomotor symptoms 2° to hypoglycemia d/t excessive insulin release
39
Dumping Syndrome Treatment
```
Dietary modifications (fewer simple sugars) & less fluid consumption during meals
Octreotide therapy - admin SQ before meal or depot injection monthly
- Inhibit release vasoactive peptides from gut, ↓peak plasma levels, & slow intestinal transit
```
40
Post-Gastrectomy
| Alkaline Reflux Gastritis
Clinical triad:
- Post-prandial epigastric pain associated w/ N/V
- Evidence bile reflux into stomach
- Histologic evidence gastritis
Treatment = divert intestinal contents from contact w/ gastric mucosa (diversion)
41
Inflammatory Bowel Disease
Ulcerative colitis
| Crohn's disease
42
Ulcerative Colitis
IBD
Involves rectum & extends proximally to involve part or all colon
Mucosal disease
43
UC S/S
Diarrhea, rectal bleeding, tenesmus (feeling incomplete BM), passage mucus, & cramps
Anorexia, N/V, fever, weight loss
Low serum albumin & leukocytosis when severely ill
44
UC Complications
Hemicolectomy when patient requires 6-8 units PRBCs w/in 24-48hrs
Toxic megacolon - dilated transverse colon w/ loss haustrations triggered by electrolyte abnormalities & narcotics
Perforation → peritonitis
Obstruction d/t benign stricture formation
Total proctocolectomy = curative
45
Crohn's Disease
IBD
Acute or chronic bowel inflammation
Penetrating-fistulous or obstructing pattern
Most common site = terminal ileum
46
Crohn's S/S
Ileocolitis
Recurrent episodes RLQ pain & diarrhea
Fever indicates intraabdominal abscess formation
Weight loss d/t anorexia & diarrhea
Loss digestive & absorptive surface → megaloblastic anemia & neurologic symptoms
Hypoalbuminemia, hypocalcemia, hypomagnesemia, coagulopathy, hyperoxaluria, & nephrolithiasis
Vitamin D deficiency, hypocalcemia, & glucocorticoid use
B12 malabsorption → megaloblastic anemia & neurologic symptoms
Diarrhea d/t bacterial overgrowth in obstruction areas, fistulas, bile acid malabsorption, ↓H2O reabsorption
1/3 patients at least 1 symptoms outside intestines (arthritis or renal calculi)
47
IBD Surgical Treatment
NOT curative
Severe IBD → total proctolectomy & end ileostomy
Most common surgery = small intestine resection
Removal > 2/3 small intestine → short bowel syndrome & need parenteral nutrition
48
IBD Crohn's Surgical Complications
Hemorrhage
Sepsis
Neural injury
49
IBD Medical Treatment
5-ASA (Mesalamine) to treat mild to moderate IBD
- Antibacterial & anti-inflammatory
Glucocorticoids moderate to severe Crohn's only to induce remission & then taper (not maintenance)
Antibiotics "pouchitis" (Ciprofloxacin & Metronidazole)
Azathioprine, Methotrexate, Cyclosporine, & Tacrolimus
Infliximab & Natalizumab
50
Carcinoid Tumors
Tumors originate in GI tract
< 1/4 first found in the lung
Secrete GI peptides/vasoactive substances
Often found incidentally (suspected appendicitis)
Sometimes contain GI peptides
Midgut more likely to release substances than foregut carcinoids
51
Carcinoid Syndrome
Approximately 10%
| Serotonin & vasoactive substances released into systemic circulation
52
Carcinoid Syndrome S/S
```
Sudden onset flushing & diarrhea
Flushing d/t histamine (admin H1 & H2 blockers)
Hypo or hypertension
Bronchoconstriction
Cardiac manifestations
```
53
Carcinoid Syndrome
| Precipitating Factors
Stress, alcohol, exercise, certain foods, & drugs such as catecholamines, pentagastrin, & SSRIs/SNRIs
54
Carcinoid Syndrome Diagnosis
Measure urinary or plasma serotonin
Serotonin metabolites present in urine
1° metabolite: 5-HIAA (5-hydroxyindoleacetic acid)
55
Carcinoid Crisis
```
Intense flushing
Diarrhea
Abdominal pain
Tachycardia
Hypo or hypertension
Causes include stress, chemo, or biopsy
AVOID Succinylcholine, Miva/Atracurium, Epi/NE, Dopamine, Isoproterenol, or Thiopental
```
56
Carcinoid Tumor Treatment
Avoid flushing
Serotonin receptor antagonists
5HTZ or 5HT3 antagonists
H1/H2 antagonists
Somatostatin analogues
Bronchoconstriction resistant to treatment β agonists worsen effects d/t mediator release
TACE - trans-arterial chemoembolization w/ or w/o chemotherapy
57
Acute Pancreatitis
Pancreas inflammatory disease caused by digestive enzyme
Autodigestion prevented by enzymes being packaged in precursor form, protease inhibitors synthesis, & low calcium concentrations ↓trypsin activity
58
Acute Pancreatitis
| Causes
Gallstones & ETOH abuse
Hypercalcemia (hyperparathyroidism & AIDs)
Postop pancreatitis after CABG & ERCP
59
Acute Pancreatitis
| S/S
Excruciating mid-epigastric pain that radiate to the back
Sitting/leaning forward ↓pain
Abdominal distension w/ ileus
Dyspnea indicates pleural effusion or ascites
Low grade fever
Hypotension & tachycardia
Shock d/t hypovolemia (blood & plasma exudation into retroperitoneal space, kinins release, & systemic pancreatic enzymes effects)
↑serum amylase & lipase
Diagnosis CT w/ contrast
60
Acute Pancreatitis
| Treatment
```
ERCP (when caused by gallstones)
Aggressive IVF admin
Colloid replacement
NPO to rest pancreas
- NJ tube feeding
NG tube LIS
Stent placement
Opioids
Stone extraction
Sphincterotomy
```
61
Acute Pancreatitis
| Differential Diagnoses
```
Perforated duodenal ulcer
Acute cholecystitis
Mesenteric ischemia
Bowel obstruction
Acute MI
Pneumonia
```
62
Acute Pancreatitis
| Complications
Shock, hypoxemia, ARDS, GI hemorrhage & coagulation defects, DIC, infection or abscess formation
63
Chronic Pancreatitis
Chronic inflammation leads to irreversible damage to pancreas
Loss exocrine & endocrine function
64
Chronic Pancreatitis
| Causes
Chronic ETOH abuse
Especially w/ high protein diet
Genetic defects (idiopathic chronic pancreatitis)
Occurs w/ CF & hyperparathyroidism
65
Chronic Pancreatitis
| Diagnosis
History chronic ETOH abuse + pancreatic calcifications
Thin or emaciated - maldigestion proteins & fats
Normal serum amylase
U/S reveals enlarged pancreas or pseudocyst
ERCP most sensitive imaging test
66
Chronic Pancreatitis
| S/S
Epigastric pain that radiates to back
Frequent after eating
1/3 painless
Steatorrhea when 90% exocrine function lost
Diabetes d/t impaired or lost endocrine function
67
Chronic Pancreatitis
| Treatment
Manage pain, malabsorption, & diabetes
Opioids
Celiac plexus blockade
Pancreatic jejunostomy - internal surgical drainage procedure
Endoscopic stent placement & remove stones
Enzyme supplements to help fat & protein absorption
Insulin replacement/therapy
68
Upper GI Bleed
Most common
Due to peptic ulcer disease
Mortality >30% elderly, esophageal varices, cancer, & hospitalized patients
1° cause of death MODS rather than hemorrhage
69
Upper GI Bleed
| Diagnosis
```
Upper endoscopy after hemodynamic stabilization
Cardiopulmonary concerns d/t blood & gastric content aspiration risk
Prefer ETT (secured airway)
```
70
Upper GI Bleed
| S/S
Hypotension & tachycardia
Orthostatic hypotension
Melena indicated bleeding ABOVE the cecum
↑BUN
71
Upper GI Bleed
| Treatment
Endoscopic coagulation - perforation risk
Epi injection
Endoscopic ligation (bleeding varices)
Trans-jugular intrahepatic portosystemic shunt (TIPS) esophageal varices resistance to treatment → worsen encephalopathy
Mechanical balloon tamponade via Blakemore-Sengstaken tube
Refractory GI bleeding → oversew ulcer or perform gastrectomy
72
Lower GI Bleed
Usually from diverticulosis or tumor
| Common in older patients
73
Lower GI Bleed
| Diagnosis
Sigmoidoscopy to exclude anorectal lesions
| Colonoscopy
74
Lower GI Bleed
| S/S
Bright red blood & clots via the rectum
75
Lower GI Bleed
| Treatment
Angiography embolic therapy
| Surgical intervention required about 15%
76
Lower GI Bleed
Usually from diverticulosis or tumor
| Common in older patients
77
Lower GI Bleed
| Diagnosis
Sigmoidoscopy to exclude anorectal lesions
| Colonoscopy
78
Lower GI Bleed
| S/S
Bright red blood & clots via the rectum
79
Lower GI Bleed
| Treatment
Angiography embolic therapy
| Surgical intervention required about 15%
80
Adynamic Ileus
Formerly known as acute colonic pseudo-obstruction
Massive dilation w/o mechanical obstruction
Loss effective colonic peristalsis & subsequent colon distention
81
Adynamic Ileus
| Causes
```
Seriously ill hospitalized patients
- Electrolyte disorders
- Immobile
- Narcotic/ anticholinergic medications
- Surgical patients
Excessive SNS & lack PSNS input
```
82
Adynamic Ileus
| Diagnosis
CXR proximal colon dilation & decompressed distal colon w/ air in rectosigmoid region
83
Adynamic Ileus
| Treatment
```
Correct electrolyte abnormalities
Avoid narcotics & anticholinergics
Mobilization
Tap water enemas
NG suction
Conservative treatment usually takes 2 days
```
Neostigmine IV (monitor bradycardia), repetitive colonoscopy, and/or cecostomy placement
Untreated → R colon & cecum ischemia
