Gastrointestinal diseases

Question 1

What is the definition of dyspepsia

Answer 1

SPECTRUM of epigastric symptoms: heartburn, indigestion, bloating, epigastric pain

INCLUDES PUD, GERD, nonulcer dyspepsia, gastritis, and many others (the cystitises too)

Question 2

What is the algorithm for Dyspepsia

Answer 2

1. ) Lifestyle changes: Advise patient to stop alcohol, caffeine, smoking, raise head of the bed when sleeping, and avoid eating before sleep
2. ) Now use antacids: H2 blockers, sucralfate, or PPI
3. ) Endoscopy indicated now and test of choice

On the side: Also do H. Pylori testing via breath test, if negative, PUD highly unlikely

Question 3

What is the mechanism of GERD

Answer 3

Decreased LES tone causing retrograde flow of stomach contents into esophagus

Question 4

What are the clinical features of GERD

Answer 4

1. ) Heartburn + dyspepsia shortly after eating, made worse by lying down after meals
2. ) Regurgitation
3. ) Waterbrash - reflex salivary hypersecretion
4. ) Cough

Question 5

What happens if you have GERD + dysphagia

Answer 5

Think about development of peptic stricture

Question 6

Diagnostic testing for GERD is not needed for uncomplicated, only if it is refractory to treatment, accompanied by dysphagia, odynophagia, or GI bleeding

Answer 6

1. ) Endoscopy - test of choice

2. ) 24 hour pH monitoring - most sensitive and most specific test for GERD - gold standard

Question 7

What are the complications of GERD

Answer 7

1. ) Erosive esophagitis - requires long term PPI therapy
2. ) Peptic stricture - Need EGD if this is suspected, treatment with dilation
3. ) Esophageal ulcer - GI bleeding
4. ) Barrett’s esophagus - 10% of patients
5. ) Recurrent pneumonia: Look for lipid laden macrophages on aspirate cytologic analysis
6. ) Laryngitis, pharyngitis, gingivitis

Question 8

What is the surveillance for barrett’s esophagus based on GERD years, and how much surveillance is it if GERD is found

Answer 8

5 years after GERD diagnosis should you screen for barrett’s

Every 3 years after barrett’s is found

Question 9

What is the treatment algorithm for GERD - important

Answer 9

1. ) Behavior modification (listed above) + antacids after each meal and bedtime
2. ) Add histamine blocker to above
3. ) Switch (1) and (2) with PPI
4. ) Add a promotility agent to PPI (such as metoclopramide or bethanechol)
5. ) Combo therapy of either H2 blocker or PPI with a promotility agent
6. ) Antireflux surgery - especially if aspiration pneumonia, severe esophageal injury: Includes nissen fundoplication and partial fundoplication

Question 10

What is the criteria for acute diarrhea vs. chronic diarrhea

Answer 10

Acute 4 weeks

Question 11

What are the viral, bacterial, and protozoa causes of bacteria

Answer 11

Viral: Norwalk, Rotavirus

Bacterial: Shigella, E. Coli, Salmonella, Campylobacter, C. perfringens, C. difficile

Protozoa: Giardia, Entamoeba histolytica, and cryptosporidium

For acute bacteria, frequency viral > bacterial > protozoa

Question 12

What are the types of diarrhea you should be worried about when someone has acute diarrhea

Answer 12

Differential

1. ) Infection
2. ) Medications: Abx, laxatives, antacids, etc
3. ) Malabsorption - lactose intolerance
4. ) Ischemic bowel disease

Question 13

What is the differential for chronic diarrhea

Answer 13

1. ) IBS - most common
2. ) IBD and its treatment can cause it too
3. ) Medications
4. ) Infection - think more bacterial this time
5. ) Colon Cancer
6. ) Malabsorption: Pancreatitc insufficiency, celiac disease, short bowel syndrome, bacterial overgrowth
7. ) Endocrine: Hyperthyroidism, addisons, diabetes, gastrinoma, VIPoma
8. ) Laxative abuse

Question 14

What is the diagnosis algorithm of diarrhea - part 1

Answer 14

If no complications i.e. blood, fever, abdominal pain, chronic - Just offer rehydration and consider loperamide (imodium)

If complications present, do CBC and WBC, check stool for WBC first and wait for results, if positive, then culture or C difficile toxin

Question 15

What are fecal leukocytes not present in

Answer 15

Staph, clostridial, and viral gastroenteritis (all the gastroenteritis)

Question 16

When do you do an ova and parasite test (3 samples)

Answer 16

Only if parasites are suspected

Giardia: If drinking well water (requires special assay test)

Question 17

What is a clinical pearl of C-difficile

Answer 17

Only suspect if recent abx therapy but has 10% failure rate so must treat emperically before results even return

Question 18

What are some clinical pearls to consider for different infectious bugs

Answer 18

Entameoba histolytica: Bloody diarrhea

Salmonella, campylobacter, shigella, enteroinvasive E. Coli: Bloody diarrhea

Carcinoid syndrome: Get urine 5-HIAA or whole blood serotonin

Question 19

What is microscopic cholangitis

Answer 19

Microscopic cholangitis

1. ) Collagenous: Lymphocyte infiltrates enterocytes - watery diarrhea
2. ) Lymphangitis

Both of these are associated with SSRI’s and PPI’s

Must always rule out celiac disease in these patients

Question 20

What are good history questions to ask the patient with diarrhea

Answer 20

1. ) Is the stool bloody or melanotic
2. ) Are there any other symptoms such as fever, abdominal pain, or vomiting
3. ) Anyone with similar illness around you
4. ) Any rececnt travel outside of US
5. ) Is ingestion linked to specific foods
6. ) Any hx of AIDS or hyperthyroidism
7. ) Have there been recent changes in medications (i.e. abx recently)

Question 21

What is the treatment for acute diarrhea

Answer 21

Try NPO 24hr challenge to see if it stops

Ciprofloxacin 5 days - only if high fever, bloody stools, severe diarrhea, stool cultures positive, traveler’s diarrhea present – In this case do not give imodium (only helps with mild to moderate diarrhea)

Question 22

What are the causes of constipation

Answer 22

1. ) Diet - lack of fiber
2. ) Medications - think of anticholinergics, narcotic analgesics
3. ) IBS
4. ) Obstruction from colorectal cancer, anal stricture, hemorrhoids, and anal fissure

And many more causes

Question 23

What must you do when someone presents with constipation

Answer 23

Rule out obstruction, do rectal examination and if really unsure then do abdominal films and flexible sigmoidoscopy

Specialized studies if no cause is found: Radiopaque marker transit study, anorectal motility study

Question 24

What is the treatment for constipation

Answer 24

1. ) Start off with behavior modification: Increase physical activity, eat high fiber foods, increase fluid intake
2. ) Fleet enema for temporary relief
3. ) If obstruction, refer to surgery

Question 25

How long do symptoms of IBS have to be present for in order to make a diagnosis

Answer 25

3 months - symptoms are exacerbated by stress and irritants in the intestinal lumen

Question 26

What is the general treatment for IBS

Answer 26

Diarrhea - diphenoxylate, loperamide Constipation - Colace, psyillium, cisapride Abdominal pain - antispasmodics

Question 27

What are the most common causes of nausea and vomiting

Answer 27

Viral gastroenteritis and food poisoning

Question 28

What questions must you ask someone with nausea and vomiting

Answer 28

1. ) Recent unusual foods? 2. ) Time of onset in relation to food? 3. ) Did anyone else eat that food? 4. ) Recent medication changes? 5. ) Recent surger?

Question 29

What are the five ways to describe the vomiting

Answer 29

1. ) Billious - obstruction distal 2. ) Feculent: Obstruction really distal 3. ) Projectile vomiting - Pyloric stenosis or increased ICP 4. ) Coffee ground material - GI bleed

Question 30

What is the treatment for the nausea/vomiting

Answer 30

1. ) Fluid replacement 2. ) Medication based on cause - If pregnant, order promethazine for hyperemesis gravidarum - If chemotherapy, give zofran

Question 31

What are risk factors for developing hemorrhoids

Answer 31

Dilated vein structures (varicose veins) of anus and rectum 1. ) Constipation/straining 2. ) Portal HTN 3. ) Prolonged sitting (truck drivers) 4. ) Anal intercourse

Question 32

What are the clinical features of hemorrhoids

Answer 32

1.) Bleeding and rectal prolapse: Bright red blood that is painless

Question 33

What is the treatment for hemorrhoids

Answer 33

Symptoms management: Sitz bath, application of ice packs, stool softeners, high fiber and fluid diet Permenant: Rubber band ligation for internal hemorrhoids Surgery as last resort which can be done in ambulatory setting