Gastrointestinal System Flashcards
This deck covers Chapters 79-86 in Rosens, compromising all of gastroenterology.
What are the 4 narrowings in the esophagus?
- Upper esophageal sphincter
- Aortic arch
- Left mainstem bronchus
- LES
Differentiate between direct and indirect inguinal hernias.
Direct
- Medial to epigastrics
- Usually from the weakened abdominal wall
Indirect
- Lateral to epigastrics
- Usually from patent processus vaginalis
- 5x more common than direct
What are 5 indications for endoscopic removal of an ESOPHAGEAL foreign body?
- Airway compromise
- Button battery
- >24h
- Sharp
- Distress
- Failure of other measures
What is Charcot’s triad? Reynold’s pentad?
Charcot
- Fever
- Jaundice
- RUQ pain
Reynold
- Fever
- Jaundice
- RUQ pain
- Hypotension
- Confusion
Which 2 bacteria mimic appendicitis?
- Yersinia
- Campylobacter
List 5 causes of elevated amylase
- Pancreatitis
- Ectopic pregnancy
- Parotitis
- Renal failure
- Mesenteric ischemia
- Bowel obstruction
- PUD
- Peritonitis
List 8 physical exam findings of cirrhosis
- Palmar erythema
- Caput medusa
- Ascites
- Hepatomegaly
- Spider nevi
- Testicular atrophy
- Gynecomastia
- Jaundice
- Dupuytren’s contractures
- Thin skin
- Easy bruising
List 6 causes of traveler’s diarrhea
Bacteria
- E. coli (ETEC)
- Shigella
- Campylobacter
- Salmonella
Viruses
- Norovirus
- Rotavirus
Parasites
- Giardia
- Cryptosporidium
- Entamoeba histolytica
Differentiate sigmoid from cecal volvulus
Triad (more common in Sigmoid)
- Pain
- Distention
- Constipation
Cecal Volvulus
- No gas in the distal colon
- Usually pregnant patients (1: 1,000,000 pregnancies)
- Surgery to fix
- Only one air-fluid level seen
Sigmoid Volvulus
- Coffee bean sign
- Usually older people with constipation
- Endoscopy to fix unless ischemia/gangrene
List and interpret the following hepatitis serologic markers:
- HBsAb
- HBsAg
- HBcAb
- HBcAg
- HBeAb
- HBeAg
- HBsAb - Acute/Past Infection or Immunity
- HBsAg - Active infection
- HBcAb - Acute/Past Infection
- HBcAg - Acute Infection
- HBeAb - Resolving infection + Infective!
- HBeAg - Acute Infection + Infective!
What are the indications for empiric treatment of SBP with a pending culture?
- ANC >250 (>100 if on PD)
- Granulocyte count >500
- Ascitic fluid: Leuk +, pH low
Treatment
- Ceftriaxone 2 g IV (note dose)
- Ciprofloxacin 400 mg IV if PCN allergic
- Intraperitoneal is preferred for patients on PD
List 5 causes of appendiceal lumen obstruction
- Fecolith
- Appendicolith
- Lymphadenopathy
- FB
- Tumour
- Parasite (Ascaris)
List 6 complications from esophageal button batteries
- Ulceration
- Perforation
- Migration
- Obstruction
- UGIB
- Stricture
- Fistula
Name 3 findings of SBO on x-ray
- Air-fluid levels
- Dilated loops >3cm
- Plicae circularis
- “String of beads” sign
List 6 substances or conditions that damage the gastric mucosal barrier
- NSAIDs
- Alcohol
- Prednisone
- Smoking
- Bile
- Pancreatic secretions
- H. pylori
- Stress
- Shock state
List 5 sonographic findings of cholecystitis
- Impacted stone
- Thickened wall >3 mm
- Pericholecystic fluid
- Sonographic Murphys’s
- Distended lumen >4 cm
What are the Rome III criteria for IBS?
Abdo pain 3 days/month x3 months with 2 of:
- Change in bowel frequency
- Change in bowel consistency
- Pain relieved with BMs
List 8 drugs that cause pancreatitis
- Steroids
- Tylenol
- Alcohol
- Ranitidine
- ASA
- Lasix
- Flagyl
- Macrobid
- Septra
- Tetracycline
- Valproate
What is the BEST TEST to rule out esophageal perforation?
- Upper GI series w/ gastrograffin
- Endoscopy may miss small perforations
- CT chest can pick up mediastinal air, abscesses
What percentage of patients with a needlestick injury will get HepB? HepC? HIV?
- HIV = 0.3%
- Hep C = 3% (really like 1.8% according to CDC)
- Hep B = 30%
These ‘classic numbers’ are dated…
List 6 causes of chronic pancreatitis
- EtOH
- Trauma
- Autoimmune
- Hyperlipidemia
- Hyperparathyroidism (High Ca)
- Pancreatic cancer/obstruction
- Cystic fibrosis
- Alpha-1 Anti-trypsin deficiency
List 5 types of anorectal abscess. Which can be treated with I&D in the ED?
- Perianal
- Ischiorectal
- Intersphincteric
- Supralevator
- Postanal
I&D = ischiorectal and perianal
What is the management of acute mesenteric ischemia?
- IVF +/- low-dose pressors
- ABx
- Surgery consult
- Papaverine (PDE inhibitor)
- Heparin
Name 2 other scoring systems (other than Ranson) for predicting mortality from pancreatitis
Atlanta
- Ranson 3+ or
- APACHE II 8+ or
- Organ failure
APACHE II
- Components are basic vitals and investigations
- MAP, HR, RR, Temp, GCS
- Na, K, Cr, HCT, pH
Who should receive PEP for Hep A? Hep B? Hep C?
Hepatitis A - ISG 0.02 mL/kg IM
- Food handlers
- Daycare
- Close personal contacts
- Within 2 weeks of exposure
- Given Hep A vaccine only unless:
- >50 years old
- Immunocompromised
- Liver disease
Hepatitis B - HBIg +/- Hep B vaccine series
- If an unvaccinated person exposed
- Source HBV+ or unknown = HBIg + Vaccine
- Source HBV- = Vaccine
- If a vaccinated person exposed
- Source HBV- = Do nothing
- Any other situation = test anti-HBsAb
- If adequate, do nothing
- If inadequate, HBIg + Vaccine booster
Hepatitis C
- Unknown benefit
What is scromboid?
High levels of histidine (usually in spoiled tuna) are metabolized into histamine and cause flushing, rash, headache, tingling
What is acute fatty liver of pregnancy? Symptoms? Lab findings? Management?
Malignant liver disease in late pregnancy
Symptoms
- N/V, Abdo pain, mild jaundice
Labs
- AST/ALT >x5 normal
- Elevated bilirubin
- Hypoglycemia
- DIC
Treatment
- Supportive
- Glucose
- Immediate delivery
What is ciguatera poisoning?
- Predatory coral reef fish toxin
- Na channel poison w/ cholinergic/anticholinergic
- GI + Neuro symptoms
- Worse with alcohol
How do you make the diagnosis of Hepatitis B?
HBsAg + Anti-HBcAb (IgM)
Usually not symptomatic for 3 months
HBsAg usually starts at 1 month
List 4 treatments for anal fissures
- WASH regimen
- CCB gel
- Nitro ointment
- Botox
- Surgery
What is the classification system for internal hemorrhoids?
1st Degree
- No prolapse
2nd Degree
- Prolapse on defecation
3rd Degree
- Spontaneous prolapse
4th Degree
- Irreducible
- Surgical fix
What is the treatment for benign cholestasis of pregnancy?
- Urosfalk
- Vitamin K SC if abnormal clotting times
- Malabsorption
- Prevent fetal ICH
- Induced after 37 weeks –> resolves
List 12 causes of pancreatitis
I GET SMASHED
- Idiopathic
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion sting
- Hypertriglyceridemia, Hypercalcemia
- ERCP
- Drugs (steroids)
List 8 causes of fecal incontinence
Trauma
- Spinal cord injury
- Obstetrical trauma
- Sphincter injury
Neurologic
- Dementia
- Diabetes
- Obstetrical
Mass
- Anal cancer
- Rectal cancer
- FB
- Fecaloma
- Hemorrhoids
Medical
- Diarrhea
- Laxatives
- IBD
What are 8 precipitants of hepatic encephalopathy?
C-BEDRAIL
- Constipation
- Bleed (UGIB)
- Electrolyte abnormalities
- Drugs (Opiates, Sedatives)
- Renal failure
- Alcohol withdrawal
- Infection
- Large protein meals
How does Salmonella typhi present?
Typhoid Fever
Enter GI and replicate in Peyer patches then liver/spleen
Symptoms
- High fever
- N/V/D (bloody)
- Abdo pain
- Headache
- Rash (rose spots)
Treatment
- Ceftriaxone 1g IV
- Azithromycin 1g x1, then 500 mg daily x6d
What constitutes severe disease for 1) UC and 2) Crohn’s?
UC
Mild
- 0-3 stools/day
- No systemic toxicity
Moderate
- 4+ stools/day
- Minimal systemic toxicity
Severe
- 6+ bloody stools/day
- Systemically toxic
Crohn’s
Mild
- Able to eat
- No systemic toxicity
Moderate
- Mild disease not responding to treatment
- Weight loss
- Fever, Abdo pain, N/V
Severe
- Persistent symptoms on biologics/steroids
- Systemically unwell
- Obstruction/Abscess
Differentiate SBP from secondary bacterial peritonitis
Runyon’s Criteria
Spontaneous Peritonitis
- Protein <10 g/L
- Glucose >2.8
- LDH
Secondary Peritonitis
- Protein >10 g/L
- Glucose <2.8
- LDH >⅔ ULN of serum
Differentiate UC from Crohn’s by:
- Location
- Endoscopy
- Histology
- Radiology
- Complications
- Location
- Crohn’s = any
- UC = colon
- Endoscopy
- Crohn’s = skip lesions
- UC = continuous
- Histology
- Crohn’s = granulomas, transmural
- UC = ulceration, crypt abscesses
- Radiology
- Crohn’s = cobblestoning
- UC = lack of haustra
- Complications
- Crohn’s = perianal disease, strictures
- UC = cancer, biliary disease, toxic megacolon
List 8 factors associated with mesenteric venous thrombosis
Hypercoagulable States
- Polycythemia
- Sickle cell
- Protein C/S
- Factor V
- Pregnancy
- OCP
- Cancer
Inflammatory Conditions
- Pancreatitis
- Cholangitis
- Diverticulitis
- Appendicitis
Trauma
- Post-splenectomy
- Blunt abdominal trauma
- Operative injury
Miscellaneous
- CHF
- Renal failure
- Portal hypertension
- DCS
How can you differentiate large from small bowel on x-ray? What is the 3-6-9 rule?
Small Bowel
- Central
- Smaller diameter
- Plicae circularis
Large Bowel
- Peripheral
- Larger diameter
- Haustra
3-6-9 Rule
- Small = 3 cm max
- Large = 6 cm max
- Cecum = 9 cm max
Differentiate between the different types of E. coli
-
Uropathogenic E. coli
* UTIs -
ETEC (Enterotoxigenic)
* Traveler’s diarrhea
* Treat if severe -
EIEC (Enteroinvasive)
* Severe Dysentry
* Treat -
EPEC (Enteropathogenic)
* Moderate Dysentry
* Treat if severe -
EHEC (Enterohemorrhagic)
* HUS
* Don’t treat
Name 3 types of gallstones
-
Cholesterol
* Classic F’s of biliary disease -
Brown Pigmented
* Infections -
Black Pigmented
* Lots of heme (Sickle/Hemolysis)
List 5 causes of pruritis ani
Dermatitis
- Poor hygiene
- Fissure
- Fistula
- Hemorrhoids
Systemic
- Psoriasis
- Lichen sclerosis
- Diabetes
Infection
- Syphilis
- HSV
- HPV
- Pinworms!
- Scabies
List 2 criteria for safe removal of a rectal FB in the ED
- Low-lying (within 10 cm)
- Soft (not sharp, not fragile)
Helps if patient is awake to assist with Valsalva
List 6 indications for endoscopy in GERD
- Dysphagia to solids
- Weight loss
- Iron deficiency (GI bleeding)
- Elderly with new-onset
- White male >40 y/o
- Surveillance of Barrett’s esophagus
- Severe symptoms despite PPI
- Extra-esophageal manifestations of GERD (cough, hoarse)
List 3 treatments used to treat C. diff. List 3 complications.
Treatments
- Vancomycin
- Flagyl
- Fecal transplant
Complications
- Dehydration
- Toxic megacolon
- Perforation
- Bloody stool
What are the 4 categories for acute mesenteric ischemia? Name 2 risk factors for each.
- Arterial embolism
- Afib
- Valvular heart disease
- Arterial thrombus
- Big 5 cardiac RFs (HTN, DM, DLD, FHx, Smoke)
- Venous thrombus
- Hypercoag RFs (Factor 5, Protein C/S, APLS…)
- Low flow state
- Shock
- Sympathomimetic overload (pressors)
List the Ranson Criteria and associated mortality
Ranson’s Criteria
GA-LAW - At admission
- Glucose >11.1
- Age >55
- LDH >350
- AST >250
- WBC >16
C&HOBBS - 48h after admission
- Calcium <2.0
- Hct drop >10%
- Oxygen <60 mmHg
- BUN increase >5
- Base deficit >4
- Sequestered >6L fluid
Interpret
- Score 0-2 = 1%
- Score 3-4 = 15%
- Score 5-6 = 40%
- Score 7+ = 100%
List 8 drugs that cause hepatic injury
- Alcohol
- Tylenol
- OCP
- Steroids (anabolic)
- Tetracycline
- Amphotericin B
- Amiodarone
- Methotrexate
- Phenytoin
- Carbamazepine
- Valproate
List 8 complications of chronic pancreatitis
- Pseudocyst
- Cancer
- Pancreatic fistula
- Splenic vein thrombosis
- Hemorrhage
- Infection
- Bowel obstruction
- Exocrine dysfunction
- Malabsorption
- Diarrhea
- Endocrine dysfunction
- Diabetes
List 8 extra-intestinal manifestations of IBD
Eye
- Uveitis
- Episcleritis
Skin
- Erythema nodosa
- Pyoderma gangrenosum
Hepatobiliary
- Primary sclerosing cholangitis
- Cholelithiasis
- Fatty liver
- Cholangiocarcinoma
- Pancreatitis
- Functional asplenia
Vascular
- Thromboembolic diseases
List 5 causes of protozoal gastroenteritis
- Giardia
- Entamoeba
- Cyclospora
- Cryptosporidium
- Strongyloides
- Entermonas
List 4 enteric toxins that are pre-formed
- Scromboid (histamine)
- Ciguatera (cold allodynia, EtOH bad)
- Staphylococcus (mayo)
- Bacillus cereus (fried rice)
List 5 drugs that may be used to treat IBD
- 5-ASA
- MTX
- Azathioprine
- 6-Mercaptopurine
- Steroids
- Infliximab (Humira)
- Cyclosporine
- Antibiotics
List 8 reportable foodborne DISEASES
Bacterial
- E. coli (STEC)
- Salmonella
- Shigella
- Vibrio species
- Cholera (separate from above for some reason)
- Botulism
- HUS
Viral
- Hep A
Parasites
- Cryptosporidium
- Cyclospora
- Trichinosis
Name 5 conditions associated with hepatocellular carcinoma
- HBV
- HCV
- Alcoholism
- Primary biliary cirrhosis
- Hemochromatosis
- Schistosomiasis
What is CREST syndrome? What is it associated with?
- Calcinosis cutis
- Raynauds
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
CREST and Scleroderma are associated with primary biliary cirrhosis
List 6 causes of large bowel obstruction
- Cancer
- Volvulus
- Fecaloma
- Diverticulitis
- Ileus
- Hernia
- Adhesions
- Strictures
Describe two treatment regimens for H. pylori, including doses
Triple Therapy (10-14 days)
- Amoxicillin 1000 mg PO BID
- Metronidazole 500 mg PO BID if PCN allergic
- Clarithromycin 500 mg PO BID
- Pantoprazole 40 mg PO BID
**Note everything is BID**
Quadruple Therapy
- Tetracycline 500 mg PO QID
- Metronidazole 250 mg PO QID
- Pepto Bismol 525 mg PO QID
- Pantoprazole 40 mg PO BID
**ABx are QID**
What are the current recommendations for the prevention and/or treatment of traveler’s diarrhea?
- Wash your hands
- Don’t eat sketchy stuff
- Prophylaxis in patients with severe illnesses or immunocompromise –> Cipro
- Pepto-Bismol is effective
- Treat with Cipro 750 mg x1 if non-bloody or x3d if bloody
What are the anatomic boundaries of Hesselbach’s triangle?
- Inguinal ligament
- Epigastric veins
- Lateral to rectus abdominus belly
How do you manage hepatic encephalopathy?
- Treat underlying cause
- Low protein diet
- Lactulose 15 mL PO TID
- Flagyl 500 mg PO TID
- Rifaxamin 400 mg PO TID
*Note meds TID*
How do you treat pinworms?
Mebendazole 100 mg PO
List 5 causes of diarrhea in patients with AIDS
- Cryptosporidium (Azithro)
- CMV (Ganciclovir)
- Giardia (Flagyl)
- Entamoeba (Paramomycin)
- MAC (Levaquin)
- Salmonella (Cipro)
- Aeromonas (Cipro)
- C. diff (Vanco)
- Campylobacter (Azithro)
List 10 causes of dysphagia
Obstructive
- Esophageal ring
- Esophageal web
- Esophageal stricture
- Esophageal FB
- Esophagitis
- Zenker’s diverticulum
Immune
- MS
- Myasthenia gravis
- Scleroderma
Neuromuscular
- Stroke
- Diabetes
Infectious
- Botulism
- Tetanus
- Polio
List 5 red flags for diarrhea that would make you reconsider a diagnosis of IBS
- Fever
- Rectal bleeding
- Nocturnal symptoms
- Age of onset >50
- Anorexia
- Severe abdominal pain
- Progressive pain
List 6 causes of elevated lipase
- Pancreatitis
- Pancreatic cancer
- Bowel obstruction
- Mesenteric ischemia
- Cholecystitis
- Celiac disease
- Post-ERCP
- PUD
- DKA
- HIV
What are 4 indications for endoscopic removal of a foreign body in the STOMACH?
- Sharp
- >5cm long
- >2.5 cm wide
- In stomach >4 weeks
List the 7 components of the Alvarado score for appendicitis
- Migratory RLQ pain
- Anorexia
- N/V
- Temp >37.5 degrees
- RLQ tenderness (2)
- Rebound tenderness
- Elevated WBCs (2)
Interpret
- <4 low
- >6 high
- But just don’t use this.
List 5 causes of adynamic ileus
- Surgery
- Peritonitis
- Opiates
- Trauma
- Metabolic disease (Hypokalemia)
List 8 causes of esophageal obstruction
- FB
- Cancer
- Stricture
- Webs
- Schatzki ring
- Achalasia
- Thyroid mass
- Zenker’s diverticulum
- Lung cancer
- Aortic aneurysm
- Congenital abnormality with the aorta
List 5 causes of small bowel obstruction
HANG IV
- Hernia
- Adhesions (MCC)
- Neoplasm
- Gallstone ileus
- Intussusception
- Volvulus
List 6 causes of invasive enteritis
- Campylobacter
- Shigella
- Salmonella
- E. coli (STEC)
- Yersinia
- Vibrio parahemolyticus
- Anthrax
- Plesiomonas
List 5 drugs that may result in pill esophagitis
- NSAIDs
- ASA
- Tetracyclines
- Antivirals
- Potassium supplements
- Iron supplements
- Bisphosphonates
- Quinidine
What is Ogilvie’s syndrome?
Pseudo-obstruction of the large bowel
Usually from:
- Trauma
- Electrolyte abnormalities
- Opiates
What hepatitis viruses are transmitted fecal-oral?
Hepatitis A
Hepatitis E
The rest are parenteral
List 8 agents or conditions linked to GERD
LES Tone Lower
- Alcohol
- Caffeine
- Smoking
- Chocolate
- Fatty Foods
- Peppermint
- Nitrates
- Pregnancy
Esophageal Motility Issues
- Scleroderma
- Diabetes
- Achalasia
- Hiatal Hernia
What antibiotics would you give for invasive enteritis?
- Cipro or Septra x3d works for most
- Use Azithro for Campylobacter and Salmonella
- Don’t treat E. coli or V. parahemolyticus
What is the WASH regimen for hemorrhoid management?
WASH
- Warm water
- Analgesia
- Stool softener
- High-fiber diet