GERD and PUD CIS - Tieman Flashcards Preview

Year2 GI Exam II > GERD and PUD CIS - Tieman > Flashcards

Flashcards in GERD and PUD CIS - Tieman Deck (66):
1

Case 37yo M, waking up coughing at night, bitter liquid in mouth, after eating large meal before bed, sharp substernal chest pain, radiates to back

mild HTN
pain in knees
obesity
NSAID use

takes PPIs - it helps

returns 6 months with recurrence

scope - erosive esophagitis - no intestinal metaplasia

GERD

DDx - PUD, asthma, COPD, atypical angina

after recurrence - scope - because has alarm symptoms - difficult and painful swallowing**

increase effectiveness of PPI - take H2RA

2

GERD and obesity

with increased abdominal pressure

-pushes acid through the LES

-bending over, pregnancy, obesity

3

alcohol and GERD

relaxes the LES

4

diagnosis of GERD

trial of PPIs - if goes away

80% specific if response in 2 or 3 weeks

5

sx of GERD

heartburn - epigastric
-post prandial - after eating

water brash - salivary secretions in mouth

effortless regurg of gastric contents

**dysphagia
**odynophagia
-these are alarm symptoms

6

goal of GERD tx

relieve symptoms to prevent esophagitis and complications in cost-effective manner

lifestyle modifications - elevate head of bed, avoid spicy food, weight loss, stop smoking, avoid esophagitic drugs

7

scope with GERD

painful or difficulty swallowing
-alarm symptoms

8

barium swallow and EGD

done together

barium swallow - anatomical info and physio information (reflux)

EGD - visualize mucosa and allow biopsy

9

EGD

indicated in alarm symptoms

high specificity for esophagitis, barrets esophagus, cancer

10

barrets esophagitis

columnar epitheilum extends up into the esophagus

metaplasia and increased goblet cells**
-intestinal metaplasia

11

PPI

take 1 hour before meal

12

how to enhance PPI

combine with H2RA

take it

13

prokinetics

bethanecol
metaclopramide

side effects

14

gaviscon

antacid

15

H2RA

delayed onset but effective if used long period (12 weeks)

with PPIs - suppress nocturnal acid reflux

increased drug concentration if metabolized by cytochrome P-450 enzyme - warfarin

16

suppress nocturnal acid reflux

PPI with H2RA

17

PPI

given before meals

10-14 hours of action

esomeprazole - most effective

18

interfere with diazepam and warfarin metabolism

PPIs

19

pH monitoring

placed distal esophagus

records time and pH when patient hits button with symptoms

abnormal pH < 4 more than 5% of time

useful in establishing GERD

20

esophageal manometry

measure amplitude of peristaltic wave down esophagus

for motility disorders

21

surgery for GERD

laparoscopic nissen fundoplication

in good risk patients who respond well to medical therapy - but need a long-term maintenance**

if not cured with maintenance - no surgery**

90-95% successful - but 60% return to meds within 10-15 years

22

barrets esophagus

esophageal adenocarcinoma

23

extra-esophageal GERD manifestations

asthma

indication for GERD surgery

24

Case 45yo M - pain pit of stomach, intermittent epigastric radiates to back

-worse with eating and getting up
-pain levels vary 3-6/10
-pain worse after ethanol
-NSAID use for muscle aches
-increased stress
-stool weakly guiac positive

gastric ulcer

is urgent - check CBC
-microcytic hypochromic anemia

next - EGD

biopsy - h pylori

tx - triple threapy
-six weeks later - similar symptoms
-scope again - look for cancer

25

gastric ulcer

worse with eating

26

duodenal ulcer

better with eating

bc neutralize acid

27

stress

can increase acid production

28

peptic ulcer disease

duodenal - 2-3 hours after eating, relieved by food

gastric - right after eating, worse with food

chronic low grade bleeding - iron deficiency anemia

29

PUD diagnosis

barium swallow

EGD - higher sensitivity and specificity - allows biopsy - for h pylori

30

etiology of PUD

h pylori
acid secretory testing
NSAID

31

duodenal ulcers

virtually never malignant

but gastric ulcers can be malignant

32

agar gel test

test ammonia from biopsy
-surrounding material turn purple - ammonia present

h pylori test - because it has urease

33

h pylori

gram negative
flagellated
spiral bacteria

produces urease - splits urea to CO2 and ammonia

endemic loser SES groups

20% infected individuals develop ulcers
-80% duodenal h pylori
-60% gastric h pylori

34

gram negative, spiral, flagellated

h pylori

35

diagnose of h pylori

agar gel slide test

serology IgG Ab to h pylori - shows exposure a while ago - not necessarily now

urea breath test

stool antigen

36

high false negative with PPI

urea breath test and stool antigen

37

C13 urea breath test

for h pylori
-13C broken down to CO2 by h pylori - breathed out and results in positive test

38

triple therapy

for h pylori

PPI bid
metrondiazole
amoxicillin/clarithromycin

39

quadruple therapy

for h pylori

PPI bid
bismuth
tetracycline
metrondiazole

40

post-tx testing for PUD

repeat EGD for gastric ulcers - look for cancer

h pylori test for duodenal ulcer - 4 weeks after last PPI tx

41

choledochal cyst

type 1 - extrahepatic dilation
type 2 - diverticuli
type 3 - intrapancreatic - difficult to treat** whipple procedure
type 5 - caroli - intrahepatic

42

Case 35yo F epigastric pain after eating fat food, radiate chest and right shoulder, sometimes diarrhea

normal amylase/lipase

cholelithiasis

DDx - PUD, pancreatitis, gastritis

abdominal ultrasound - no stones - but sludge

returns 18 months later - sx never went away - pain worsened - avoids eating - 8/10

ultrasound - sludge and thickened wall

HIDA with CCK - EF 15%
-know have chronic acalculous cholecystitis

43

biliary colic

temporary pain goes away

44

acute cholecystitis

pain that stays

45

ultrasound for gallstone

95% sensitive** - stones >2mm

but 50% in common bile duct

46

HIDA scan

useful in questionable cases of acute calculous cholecystitis

contrast to liver that gives image of biliary tree and gallbladder

CCK - to make gallbladder contract

measure how much comes out - if <35% - biliary dyskinesia**

47

biliary dyskinesia

measure on HIDA scan with CCK

diagnostic of acalculous cholecystitis

48

chronic cholecystitis

acalculous and calculous

biliary colic
-visceral pain - self limmiting - fats or rich meals

few physical findings

49

acute cholecystitis

acalculous and calculous

biliary colic - becomes parietal pain - persistant and escalating, N/V

RUQ tender - murphys sign

elevated WBC

elevated liver enzyme and amylase

acalculous - patient with c-o-existing disease process

50

tx chronic cholecystitis

benefit from laparoscopic cholecystectomy

remove of gallbladder

51

Case 27yo M, RUQ pain, N/V, pain suddenly goes away 4-6 hours, sharp and crampy and unrelievable, feverish

-ulcerative colitis
-sulfasalazine

-jaundice, fever, tachycardia, dry membranes, RUQ pain, rebound

direct bilirubin

MCRP - obstruction of common bile duct

ascending suppurative cholangitis

very urgent

get ultrasound and ERCP/MRCP

ultrasound - not very specific for common duct**

52

jaundice, fever, RUQ pain

charcots triad -

53

reynolds pentad

jaundice, fever, RUQ pain - charcots

WITH hypotension, mental changes (septic shock)

54

cholangitis

infection of common bile duct

55

primary sclerosing cholangitis tx

ERCP with dilation

consider liver transplant

56

beading on ERCP

PSC

inflammation of bile ducts - maybe autoimmune

57

choledocholithiasis

stone of common bile duct

most should be removed

58

cholangitis

tx - hydration - antibiotics - ductal drainage

urgent if reynolds pentad**

59

primary sclerosing cholangitis

autoimmune
patchy inflammation, fibrosis, and destruction of intrahepatic and extrahepatic bile ducts

obstruction - cirrhosis - liver failure

young pts 25-45yo

more in men

80% have IBD

2% IBD patients develop PSC

60

anti nuclear and anti smooth m Abs

PSC

61

anti-mito Abs

PBC

62

primary biliary cirrhosis

female age 20-60
intrahepatic ductal fibrosis

63

secondary sclerosing cholangitis

post-surgical trauma

infection

toxin

cholangiosarcoma

AIDS

64

diagnosis of primary sclerosing cholangitis

MRCP or ERCP and liver biopsy

65

mild-moderate PSC

tx jaundice, pruritis, cholangitis

monitor colonic neoplasia and IBD

monitor cholangiocarcinoma

66

severe PSC

tx liver transplant