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Royal College: Emergency Medicine > Gastrointestinal System > Flashcards

Gastrointestinal System Flashcards

This deck covers Chapters 79-86 in Rosens, compromising all of gastroenterology.

1
Q

What are the 4 narrowings in the esophagus?

A
  1. Upper esophageal sphincter
  2. Aortic arch
  3. Left mainstem bronchus
  4. LES
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2
Q

Differentiate between direct and indirect inguinal hernias.

A

Direct

  • Medial to epigastrics
  • Usually from the weakened abdominal wall

Indirect

  • Lateral to epigastrics
  • Usually from patent processus vaginalis
  • 5x more common than direct
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3
Q

What are 5 indications for endoscopic removal of an ESOPHAGEAL foreign body?

A
  1. Airway compromise
  2. Button battery
  3. >24h
  4. Sharp
  5. Distress
  6. Failure of other measures
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4
Q

What is Charcot’s triad? Reynold’s pentad?

A

Charcot

  1. Fever
  2. Jaundice
  3. RUQ pain

Reynold

  1. Fever
  2. Jaundice
  3. RUQ pain
  4. Hypotension
  5. Confusion
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5
Q

Which 2 bacteria mimic appendicitis?

A
  1. Yersinia
  2. Campylobacter
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6
Q

List 5 causes of elevated amylase

A
  1. Pancreatitis
  2. Ectopic pregnancy
  3. Parotitis
  4. Renal failure
  5. Mesenteric ischemia
  6. Bowel obstruction
  7. PUD
  8. Peritonitis
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7
Q

List 8 physical exam findings of cirrhosis

A
  1. Palmar erythema
  2. Caput medusa
  3. Ascites
  4. Hepatomegaly
  5. Spider nevi
  6. Testicular atrophy
  7. Gynecomastia
  8. Jaundice
  9. Dupuytren’s contractures
  10. Thin skin
  11. Easy bruising
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8
Q

List 6 causes of traveler’s diarrhea

A

Bacteria

  1. E. coli (ETEC)
  2. Shigella
  3. Campylobacter
  4. Salmonella

Viruses

  1. Norovirus
  2. Rotavirus

Parasites

  1. Giardia
  2. Cryptosporidium
  3. Entamoeba histolytica
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9
Q

Differentiate sigmoid from cecal volvulus

A

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
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10
Q

List and interpret the following hepatitis serologic markers:

  • HBsAb
  • HBsAg
  • HBcAb
  • HBcAg
  • HBeAb
  • HBeAg
A
  • HBsAb - Acute/Past Infection or Immunity
  • HBsAg - Active infection
  • HBcAb - Acute/Past Infection
  • HBcAg - Acute Infection
  • HBeAb - Resolving infection + Infective!
  • HBeAg - Acute Infection + Infective!
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11
Q

What are the indications for empiric treatment of SBP with a pending culture?

A
  • 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
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12
Q

List 5 causes of appendiceal lumen obstruction

A
  1. Fecolith
  2. Appendicolith
  3. Lymphadenopathy
  4. FB
  5. Tumour
  6. Parasite (Ascaris)
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13
Q

List 6 complications from esophageal button batteries

A
  1. Ulceration
  2. Perforation
  3. Migration
  4. Obstruction
  5. UGIB
  6. Stricture
  7. Fistula
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14
Q

Name 3 findings of SBO on x-ray

A
  1. Air-fluid levels
  2. Dilated loops >3cm
  3. Plicae circularis
  4. “String of beads” sign
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15
Q

List 6 substances or conditions that damage the gastric mucosal barrier

A
  1. NSAIDs
  2. Alcohol
  3. Prednisone
  4. Smoking
  5. Bile
  6. Pancreatic secretions
  7. H. pylori
  8. Stress
  9. Shock state
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16
Q

List 5 sonographic findings of cholecystitis

A
  1. Impacted stone
  2. Thickened wall >3 mm
  3. Pericholecystic fluid
  4. Sonographic Murphys’s
  5. Distended lumen >4 cm
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17
Q

What are the Rome III criteria for IBS?

A

Abdo pain 3 days/month x3 months with 2 of:

  • Change in bowel frequency
  • Change in bowel consistency
  • Pain relieved with BMs
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18
Q

List 8 drugs that cause pancreatitis

A
  1. Steroids
  2. Tylenol
  3. Alcohol
  4. Ranitidine
  5. ASA
  6. Lasix
  7. Flagyl
  8. Macrobid
  9. Septra
  10. Tetracycline
  11. Valproate
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19
Q

What is the BEST TEST to rule out esophageal perforation?

A
  • Upper GI series w/ gastrograffin
  • Endoscopy may miss small perforations
  • CT chest can pick up mediastinal air, abscesses
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20
Q

What percentage of patients with a needlestick injury will get HepB? HepC? HIV?

A
  • HIV = 0.3%
  • Hep C = 3% (really like 1.8% according to CDC)
  • Hep B = 30%

These ‘classic numbers’ are dated…

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21
Q

List 6 causes of chronic pancreatitis

A
  1. EtOH
  2. Trauma
  3. Autoimmune
  4. Hyperlipidemia
  5. Hyperparathyroidism (High Ca)
  6. Pancreatic cancer/obstruction
  7. Cystic fibrosis
  8. Alpha-1 Anti-trypsin deficiency
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22
Q

List 5 types of anorectal abscess. Which can be treated with I&D in the ED?

A
  1. Perianal
  2. Ischiorectal
  3. Intersphincteric
  4. Supralevator
  5. Postanal

I&D = ischiorectal and perianal

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23
Q

What is the management of acute mesenteric ischemia?

A
  • IVF +/- low-dose pressors
  • ABx
  • Surgery consult
  • Papaverine (PDE inhibitor)
  • Heparin
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24
Q

Name 2 other scoring systems (other than Ranson) for predicting mortality from pancreatitis

A

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
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25
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
26
What is scromboid?
High levels of histidine (usually in spoiled tuna) are metabolized into histamine and cause flushing, rash, headache, tingling
27
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
28
What is ciguatera poisoning?
* Predatory coral reef fish toxin * Na channel poison w/ cholinergic/anticholinergic * GI + Neuro symptoms * Worse with alcohol
29
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
30
List 4 treatments for anal fissures
1. WASH regimen 2. CCB gel 3. Nitro ointment 4. Botox 5. Surgery
31
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
32
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
33
List 12 causes of pancreatitis
**I GET SMASHED** * **I**diopathic * **G**allstones * **E**thanol * **T**rauma * **S**teroids * **M**umps * **A**utoimmune * **S**corpion sting * **H**ypertriglyceridemia, Hypercalcemia * **E**RCP * **D**rugs (steroids)
34
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
35
What are 8 precipitants of hepatic encephalopathy?
**C-BEDRAIL** 1. **C**onstipation 2. **B**leed (UGIB) 3. **E**lectrolyte abnormalities 4. **D**rugs (Opiates, Sedatives) 5. **R**enal failure 6. **A**lcohol withdrawal 7. **I**nfection 8. **L**arge protein meals
36
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
37
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
38
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
39
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
40
List 8 factors associated with mesenteric venous thrombosis
**Hypercoagulable States** 1. Polycythemia 2. Sickle cell 3. Protein C/S 4. Factor V 5. Pregnancy 6. OCP 7. Cancer **Inflammatory Conditions** 1. Pancreatitis 2. Cholangitis 3. Diverticulitis 4. Appendicitis **Trauma** 1. Post-splenectomy 2. Blunt abdominal trauma 3. Operative injury **Miscellaneous** 1. CHF 2. Renal failure 3. Portal hypertension 4. DCS
41
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
42
Differentiate between the different types of E. coli
1. **Uropathogenic E. coli** * UTIs 2. **ETEC (Enterotoxigenic)** * Traveler's diarrhea * Treat if severe 3. **EIEC (Enteroinvasive)** * Severe Dysentry * Treat 4. **EPEC (Enteropathogenic)** * Moderate Dysentry * Treat if severe 5. **EHEC (Enterohemorrhagic)** * HUS * Don't treat
43
Name 3 types of gallstones
1. **Cholesterol** * Classic F's of biliary disease 2. **Brown Pigmented** * Infections 3. **Black Pigmented** * Lots of heme (Sickle/Hemolysis)
44
List 5 causes of pruritis ani
**Dermatitis** * Poor hygiene * Fissure * Fistula * Hemorrhoids **Systemic** * Psoriasis * Lichen sclerosis * Diabetes **Infection** * Syphilis * HSV * HPV * Pinworms! * Scabies
45
List 2 criteria for safe removal of a rectal FB in the ED
1. Low-lying (within 10 cm) 2. Soft (not sharp, not fragile) Helps if patient is awake to assist with Valsalva
46
List 6 indications for endoscopy in GERD
1. Dysphagia to solids 2. Weight loss 3. Iron deficiency (GI bleeding) 4. Elderly with new-onset 5. White male \>40 y/o 6. Surveillance of Barrett's esophagus 7. Severe symptoms despite PPI 8. Extra-esophageal manifestations of GERD (cough, hoarse)
47
List 3 treatments used to treat C. diff. List 3 complications.
**Treatments** 1. Vancomycin 2. Flagyl 3. Fecal transplant **Complications** 1. **​**Dehydration 2. Toxic megacolon 3. Perforation 4. Bloody stool
48
What are the 4 categories for acute mesenteric ischemia? Name 2 risk factors for each.
1. **Arterial embolism** 1. Afib 2. Valvular heart disease 2. **Arterial thrombus** 1. Big 5 cardiac RFs (HTN, DM, DLD, FHx, Smoke) 3. **Venous thrombus** 1. Hypercoag RFs (Factor 5, Protein C/S, APLS...) 4. **Low flow state** 1. Shock 2. Sympathomimetic overload (pressors)
49
List the Ranson Criteria and associated mortality
**Ranson's Criteria** **GA-LAW - At admission** * **G**lucose \>11.1 * **A**ge \>55 * **L**DH \>350 * **A**ST \>250 * **W**BC \>16 **C&HOBBS - 48h after admission** * **C**alcium \<2.0 * **H**ct drop \>10% * **O**xygen \<60 mmHg * **B**UN increase \>5 * **B**ase deficit \>4 * **S**equestered \>6L fluid **Interpret** * Score 0-2 = 1% * Score 3-4 = 15% * Score 5-6 = 40% * Score 7+ = 100%
50
List 8 drugs that cause hepatic injury
1. Alcohol 2. Tylenol 3. OCP 4. Steroids (anabolic) 5. Tetracycline 6. Amphotericin B 7. Amiodarone 8. Methotrexate 9. Phenytoin 10. Carbamazepine 11. Valproate
51
List 8 complications of chronic pancreatitis
1. Pseudocyst 2. Cancer 3. Pancreatic fistula 4. Splenic vein thrombosis 5. Hemorrhage 6. Infection 7. Bowel obstruction 8. Exocrine dysfunction 1. Malabsorption 2. Diarrhea 9. Endocrine dysfunction 1. Diabetes
52
List 8 extra-intestinal manifestations of IBD
**Eye** 1. Uveitis 2. Episcleritis **Skin** 1. Erythema nodosa 2. Pyoderma gangrenosum **Hepatobiliary** 1. Primary sclerosing cholangitis 2. Cholelithiasis 3. Fatty liver 4. Cholangiocarcinoma 5. Pancreatitis 6. Functional asplenia **Vascular** 1. Thromboembolic diseases
53
List 5 causes of protozoal gastroenteritis
1. Giardia 2. Entamoeba 3. Cyclospora 4. Cryptosporidium 5. Strongyloides 6. Entermonas
54
List 4 enteric toxins that are pre-formed
1. Scromboid (histamine) 2. Ciguatera (cold allodynia, EtOH bad) 3. Staphylococcus (mayo) 4. Bacillus cereus (fried rice)
55
List 5 drugs that may be used to treat IBD
1. 5-ASA 2. MTX 3. Azathioprine 4. 6-Mercaptopurine 5. Steroids 6. Infliximab (Humira) 7. Cyclosporine 8. Antibiotics
56
List 8 reportable foodborne DISEASES
**Bacterial** 1. E. coli (STEC) 2. Salmonella 3. Shigella 4. Vibrio species 5. Cholera (separate from above for some reason) 6. Botulism 7. HUS **Viral** 1. Hep A **Parasites** 1. Cryptosporidium 2. Cyclospora 3. Trichinosis
57
Name 5 conditions associated with hepatocellular carcinoma
1. HBV 2. HCV 3. Alcoholism 4. Primary biliary cirrhosis 5. Hemochromatosis 6. Schistosomiasis
58
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**
59
List 6 causes of large bowel obstruction
1. Cancer 2. Volvulus 3. Fecaloma 4. Diverticulitis 5. Ileus 6. Hernia 7. Adhesions 8. Strictures
60
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\*\*
61
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
62
What are the anatomic boundaries of Hesselbach's triangle?
1. Inguinal ligament 2. Epigastric veins 3. Lateral to rectus abdominus belly
63
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\*
64
How do you treat pinworms?
Mebendazole 100 mg PO
65
List 5 causes of diarrhea in patients with AIDS
1. Cryptosporidium (Azithro) 2. CMV (Ganciclovir) 3. Giardia (Flagyl) 4. Entamoeba (Paramomycin) 5. MAC (Levaquin) 6. Salmonella (Cipro) 7. Aeromonas (Cipro) 8. C. diff (Vanco) 9. Campylobacter (Azithro)
66
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
67
List 5 red flags for diarrhea that would make you reconsider a diagnosis of IBS
1. Fever 2. Rectal bleeding 3. Nocturnal symptoms 4. Age of onset \>50 5. Anorexia 6. Severe abdominal pain 7. Progressive pain
68
List 6 causes of elevated lipase
1. Pancreatitis 2. Pancreatic cancer 3. Bowel obstruction 4. Mesenteric ischemia 5. Cholecystitis 6. Celiac disease 7. Post-ERCP 8. PUD 9. DKA 10. HIV
69
What are 4 indications for endoscopic removal of a foreign body in the STOMACH?
1. Sharp 2. \>5cm long 3. \>2.5 cm wide 4. In stomach \>4 weeks
70
List the 7 components of the Alvarado score for appendicitis
1. Migratory RLQ pain 2. Anorexia 3. N/V 4. Temp \>37.5 degrees 5. RLQ tenderness (2) 6. Rebound tenderness 7. Elevated WBCs (2) **Interpret** * \<4 low * \>6 high * But just don't use this.
71
List 5 causes of adynamic ileus
1. Surgery 2. Peritonitis 3. Opiates 4. Trauma 5. Metabolic disease (Hypokalemia)
72
List 8 causes of esophageal obstruction
1. FB 2. Cancer 3. Stricture 4. Webs 5. Schatzki ring 6. Achalasia 7. Thyroid mass 8. Zenker's diverticulum 9. Lung cancer 10. Aortic aneurysm 11. Congenital abnormality with the aorta
73
List 5 causes of small bowel obstruction
**HANG IV** * **H**ernia * **A**dhesions (MCC) * **N**eoplasm * **G**allstone ileus * **I**ntussusception * **V**olvulus
74
List 6 causes of invasive enteritis
1. Campylobacter 2. Shigella 3. Salmonella 4. E. coli (STEC) 5. Yersinia 6. Vibrio parahemolyticus 7. Anthrax 8. Plesiomonas
75
List 5 drugs that may result in pill esophagitis
1. NSAIDs 2. ASA 3. Tetracyclines 4. Antivirals 5. Potassium supplements 6. Iron supplements 7. Bisphosphonates 8. Quinidine
76
What is Ogilvie's syndrome?
**Pseudo-obstruction of the large bowel** Usually from: * Trauma * Electrolyte abnormalities * Opiates
77
What hepatitis viruses are transmitted fecal-oral?
Hepatitis A Hepatitis E The rest are parenteral
78
List 8 agents or conditions linked to GERD
**LES Tone Lower** 1. Alcohol 2. Caffeine 3. Smoking 4. Chocolate 5. Fatty Foods 6. Peppermint 7. Nitrates 8. Pregnancy **Esophageal Motility Issues** 1. Scleroderma 2. Diabetes 3. Achalasia 4. Hiatal Hernia
79
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
80
What is the WASH regimen for hemorrhoid management?
**WASH** * **W**arm water * **A**nalgesia * **S**tool softener * **H**igh-fiber diet

Royal College: Emergency Medicine (25 decks)

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