GI 1 pt 1 (4.15)

Question 1

List some key components of a patient’s Hx with GI

Answer 1

1) Age
2) Time and mode of onset of the pain
3) Pain characteristics
4) Duration of Sx
5) Location of pain and radiation
6) Assoc. Sx and their relationship to the pain
7) Nausea, vomiting, anorexia
8) Diarrhea, constipation, or other changes in bowel habits
9) Menstrual Hx

Question 2

List 4 common classes of signs & symptoms (cardinal features)

Answer 2

1) Abdominal or chest pain
2) Altered digestion of food (due to nausea, vomiting, dysphagia, odynophagia, anorexia)
3) Altered bowel movements (diarrhea, constipation, change in caliber of stools)
4) GI tract bleeding

Question 3

List the “GI alarm features” (worrisome for malignancy)

Answer 3

1) Age ≥ 60 years (new onset dyspepsia)
2) Evidence of GI bleeding (hematemesis, melena, hematochezia, occult blood in stool)
3) Unexplained iron deficiency anemia
4) Early satiety
5) Anorexia
6) Unexplained weight loss
7) Dysphagia
8) Odynophagia
9) Recurrent vomiting
10) GI cancer in a first-degree relative
11) Previous esophagogastric malignancy

Question 4

What are you looking for with a CBC?

Answer 4

1) Anemia (micro/macro/normo-cytic)
2) Infection
3) Pancytopenia (liver disease, cirrhosis)
4) Platelet disorders (thrombocytopenia in cirrhosis)

Question 5

GI lab eval: What is the basic panel?

Answer 5

CBC, BMP or CMP, troponin, type & cross, lipase, amylase, iron panel, HCG, UA

Question 6

GI lab eval:
1) What labs help eval for diarrhea?
2) Besides CBC, what labs help eval for liver disease and cirrhosis?
3) What help eval for MAFLD/pancreatitis?

Answer 6

1) O&P x 3, fecal leukocytes, FOBT, stool culture
2) Hepatic panel, PT/PTT, PT/INR
3) TSH (constipation, diarrhea), lipids/TG

Question 7

GI lab eval:
1) What labs help eval for IBD?
2) What help eval for cancers?
3) What are other liver specific tests could you do for GI pts?

Answer 7

1) ESR, CRP, lactoferrin, calprotectin
2) AFP (HCC), CA19-9 (pancreatic CA), CEA (colon +)
3) Hepatitis screen, ANA, A1AT, hereditary hemochromatosis genetic markers

Question 8

Liver biopsy: What kinds of diagnostic eval can it be used for? (3 things)

Answer 8

1) Focal or diffuse abnormalities on imaging studies
2) Parenchymal liver disease
3) Chronically (ie, > 6 months) abnormal liver tests (elevated LFTs) of unknown etiology after a thorough, noninvasive evaluation

Question 9

Liver biopsy: Besides diagnostic eval, what are 2 other indications for liver biopsy according to the AASLD guideline?

Answer 9

1) Development of treatment plans based on histologic analysis
2) Staging of known parenchymal liver disease

Question 10

Endoscopy (EGD/ esophagogastroduodenoscopy):
1) What is it?
2) What does it evaluate?
3) What are some indications?

Answer 10

1) Flexible fiberoptic tube (aka endoscope) with camera, able to take tissue samples/biopsies
2) Upper GI (esophagus, stomach, duodenum)
3) Ulcers, upper GI bleeding, biopsy lesions, dysphagia, odynophagia, reflux, FB removal, abdominal pain of unknown etiology, H. pylori

Question 11

Endoscopy (EGD/ esophagogastroduodenoscopy):
What is it the diagnostic test of choice for? (2 things)

Answer 11

1) PUD (peptic ulcer disease)
2) Mallory-Weiss tears: tear in lining of the esophagus commonly at the GE junction from persistent vomiting that causes UGIB

Question 12

ERCP (EndoscopicRetrogradeCholangioPancreatography):
What is it?

Answer 12

Endoscopy into pancreatic/ bile ducts; contrast injected into pancreatic and bile ducts

Question 13

Colonoscopy:
1) What is it?
2) What is it used for?
3) What is an alternative?

Answer 13

1) Fiber-optic tube via anus for evaluation of entire colon
2) Ability to biopsy tissue/lesions (like CA and polyps)
3) Flexible sigmoidoscopy (aka, “flex-sig” - limited to distal descending colon-sigmoid area)

Question 14

What are some indications for colonoscopy?

Answer 14

Lower GI bleed, colorectal cancer screening, biopsy lesions, evaluate IBD, polypectomy, TI (especially for Crohn’s (usually at terminal ilium))

Question 15

Describe the risk-benefit analysis for colonoscopy

Answer 15

1) Process of determining if the benefits of performing the endoscopic procedure outweigh the risks involved
2) Requires careful consideration of all known benefits/indications, risks of procedure, contraindications, and patient risk factors
3) Process should involve all providers caring for the patient, incl. PCP, gastroenterologist, cardiologist, anesthesiologist, intensivist
4) Timing of procedure and management of antiplatelet/anticoagulation therapy + Setting

Question 16

List some info abt the following OTCs:
1) Antacids
2) H2 blockers
3) PPIs

Answer 16

1) Rapid onset, short duration, caution in renal patients
2) Indications- indigestion, heartburn
Cons - slower onset, tachyphylaxis
2) PPIs: indications- heartburn, GERD
Cons - higher cost, risk for C. diff in hospitalized patients & low magnesium absorption

Question 17

List some indications and cons for the following OTCs:
1) Laxatives
2) Stool softeners

Answer 17

1) Low cost, ease of use, effective,
cons - : gas, bloating, cramping, diarrhea
2) Stool softeners: indications - good first line for constipation.
-minimal adverse reactions, variable effectiveness,

Question 18

List some info abt the following OTCs:
1) Antidiarrheals
2) Anti-flatulence drugs

Answer 18

1) Antidiarrheals: effective, constipation, cramping, not to be used in infectious diarrhea
2) Anti-flatulence: readily available, inconsistent data

Question 19

List some info abt the following OTCs:
1) Hemorrhoidal preparations
2) Antiemetics

Answer 19

1) Indications: burning, itching, bleeding hemorrhoids
Cons - variable effectiveness, dermatitis, skin atrophy
2) Available, drowsiness, dizziness, flatulence

Question 20

Give 3 reasons for dysbiosis

Answer 20

1) Abnormal host immune responses
2) Elicits the loss of naturally occurring intestinal microbiota
3) Increases numbers of yeast & bacteria and some pathogens

Question 21

Is it easy to fix microbiota after excessive antibiotics?

Answer 21

Adverse effects on intestinal environment persists for months after discontinuing medication, very difficult to impossible to rebalance

Question 22

1) What is a good Tx for C. Diff?
2) What is C. Diff?

Answer 22

1) Clindamycin
2) One of the most common pathogenic infections
Prevalent in continuous antibiotic use

Question 23

List 4 types of GI bleeding

Answer 23

1) Acute upper GI bleeding (UGIB)
2) Acute lower GI bleeding (LGIB)
3) Small bowel bleeding
4) Occult GI bleeding

Question 24

Acute upper GI bleeding: What is the most common presentation?

Answer 24

hematemesis or melena

Question 25

Acute upper GI bleeding: 1) Define hematemesis 2) Define melena 3) Is acute upper GI bleeding usually serious?

Answer 25

1) Bright red blood or brown “coffee grounds” emesis 2) Melena (black, tarry stool) requires blood loss of only 50-100 mL 3) Self-limiting in 80% of patients

Question 26

Acute upper GI bleeding: Severe UGI bleeding may cause ________________ (bloody maroon stools) in ___% of cases & requires loss of >1000 mL

Answer 26

hematochezia; 10%

Question 27

What are the most common etiologies of acute upper GI breeding?

Answer 27

1) Peptic ulcers (40%) 2) Portal hypertension (10-20%) (ie, esophageal varices) 3) Lacerations of GE junction (5-10%) (ie, Mallory-Weiss tear) 4) Vascular anomalies (7%) (ie, angioectasias, telangectasias, AVMs) 5) Gastric neoplasms (1%) 6) Erosive gastritis (< 5%) 7) Severe erosive esophagitis 8) Aortoenteric fistula (rare)

Question 28

Acute upper GI bleed: How do you assess hemodynamic status?

Answer 28

1) Systolic BP < 100 mm Hg (severe) 2) HR > 100 BPM with systolic BP > 100 mm Hg (moderate) 3) Normal BP & HR (minor) 4) Hematocrit NOT reliable indicator of acute bleeding 5) Elevated BUN-to-creatinine ratio (BUN/Cr > 36:1)

Question 29

What should you establish for acute upper GI bleeding stabilization?

Answer 29

IV lines (two 18-gauge catheters)

Question 30

Initial triage for acute upper GI bleeding: Describe factors that would make someone a high-risk patient

Answer 30

-Active bleeding (ie, hematemesis) -Bright red blood on nasogastric aspirate -Shock -Persistent hemodynamic derangement after fluid resuscitation -Serious comorbid medical illness/on blood thinner -Evidence of advanced liver disease

Question 31

Initial triage for acute upper GI bleeding: List 2 factors that would make someone a low-risk patient

Answer 31

1) No active bleeding 2) Absence of high-risk features

Question 32

Acute upper GI bleeding: 1) What is the initial Tx plan for high risk pts? 2) What abt low-moderate risk?

Answer 32

1) ICU, stabilization, endoscopy within 12-24 hours 2) Step-down or medical unit (after stable), non-emergent endoscopy 12-24 hours (if no active bleeding)

Question 33

Acute upper GI bleeding: 1) Most every patient with UGI bleeding should have upper endoscopy within ______ hours 2) Ongoing bleeding? Consider discontinuation of ___________ agents for up to 5 days & __________ agents for 7 days.

Answer 33

1) 24 2) antiplatelet; anticoagulant

Question 34

List the benefits for endoscopy for acute upper GI bleeds

Answer 34

1) Identify source of bleeding 2) Determine risk of rebleeding & guide triage 3) Render endoscopic therapy (cautery, injection, endoclips)

Question 35

Acute lower GI bleeding: 1) Where do they originate? 2) Where do up to 95% of cases originate? 3) What does severity range from? 4) Who are is serious low GI bleeding more common in?

Answer 35

1) Originating from below ligament of Treitz (duodenojejunal junction) 2) In colon 3) From mild anorectal to massive, large-volume hematochezia 4) In older men

Question 36

Describe a mild acute lower GI bleed

Answer 36

Drips after BM or mixed with solid brown stool; usually anorectosigmoid source (outpatient)

Question 37

Acute lower GI bleeds: 1) What is common? 2) Affects at least ____% of general public at least once 3) Is it usually serious?

Answer 37

1) Passage of small amounts of blood is common 2) 20% 3) Usually trivial, but can reflect serious disease

Question 38

Give some locations acute lower GI bleeds can be found

Answer 38

1) On toilet paper 2) Streaks on stool 3) Dripping into toilet bowl 4) On underwear

Question 39

Acute lower GI bleed 1) Usual etiologies are dependent on what? 2) Besides age-based causes, what are some other causes? 3) What meds increase risk? Give examples

Answer 39

1) Age & severity of bleeding 2) Benign polyps, radiation-induced changes 3) ASA, non-ASA antiplatelet agents, NSAIDs -aspirin (ASA), warfarin (coumadin), plavix (clopidogrel), eliquis (apixaban), pradaxa (dabigatran etexilate), xarelto (rivaroxaban), lovenox (enoxaparin), heparin

Question 40

Acute lower GI bleed: Symptoms & Signs: 1) What are some main Sx? 2) What suggests IBD, infectious colitis, or ischemic colitis?

Answer 40

1) Brown stool mixed or streaked with blood (BRBPR) predict rectosigmoid or anus origin 2) Bloody diarrhea with cramping abdominal pain, urgency, or tenesmus

Question 41

Acute lower GI bleed: Symptoms & Signs: 1) What does large volume suggest? 2) What abt maroon blood? 3) What abt melena (not sure if this last one is on test)

Answer 41

1) Large volume bright red blood predicts colon origin 2) Maroon suggests right colon or small intestine origin 3) Melena suggests origin proximal to ligament of Treitz

Question 42

Acute lower GI bleeding: What are your diagnostic options?

Answer 42

Anoscopy, sigmoidoscopy, colonoscopy, CT angiography, angiography, small intestine push enteroscopy, & capsule imaging (video capsule endoscopy)

Question 43

Acute lower GI bleeding: What 3 things does choice of study/ test depend on?

Answer 43

1) Severity of bleeding at presentation 2) Hemodynamic instability with suspected ongoing/active bleeding 3) Suspected source of bleeding

Question 44

Acute lower GI bleeding: 1) What should you consider if pt is unstable? 2) How can you exclude an upper GI source via testing?

Answer 44

1) Consider NG tube 2) Upper endoscopy for most unstable patients -What is BUN/Cr ratio (?>36:1)

Question 45

Acute lower GI bleeding: 1) Desc. initial stabilization 2) What should you consider if ongoing bleeding?

Answer 45

1) Initial stabilization, blood replacement, & triage same as with UGI bleeding 2) Discontinuation of antiplatelet agents for up to 5 days & anticoagulant agents for 7 days.

Question 46

Acute lower GI bleeding: 1) What should you do if able? 2) What is a good Tx? 3) What is rarely needed?

Answer 46

1) Therapeutic colonoscopy if able 2) Angiography with selective intra-arterial embolization 3) Emergency surgery rarely needed

Question 47

Suspected small bowel bleeding: 1) Is it always overt? 2) What does overt bleeding look like?

Answer 47

1) Can be overt or occult 2) Overt: melena or maroon stools

Question 48

Suspected small bowel bleeding: List the most common causes based on age

Answer 48

1) Age < 40: neoplasms, Crohn's disease 2) Age > 40: angiodysplasias (AVM'S,) NSAID-induced ulcers

Question 49

Suspected small bowel bleeding assessment: 1) What does it depend on? 2) What should you repeat? 3) What is a testing option for stable pts? 4) What are 2 CT test options? 5) What blood related option is there?

Answer 49

1) Depends on age, health status, symptoms, & severity 2) Repeat upper endoscopy & colonoscopy 3) Capsule endoscopy (stable patients) 4) CT enterography + CT angiography (unstable acute bleeding) followed by urgent angiography with embolization 5) Tagged RBC scan

Question 50

Occult GI bleeding: 1) Define it 2) What are 2 ways to ID it? 3) Where may it occur?

Answer 50

1) Bleeding that is not apparent to the patient 2) By positive FOBT or iron deficiency anemia (or both) in absence of visible blood loss 3) Anywhere in GI tract

Question 51

Occult GI bleeding: What are the most common causes of it **with iron-deficiency anemia**?

Answer 51

Neoplasms, vascular abnormalities (angiodysplasias,) PUD, infections, medications, IBD

Question 52

Occult GI bleeding: 1) When is colonoscopy done? 2) When are upper endoscopy & colonoscopy done? 3) Who should you eval for celiac disease?

Answer 52

1) Colonoscopy for asymptomatic patients with positive FOBT done for CRC screening 2) For symptomatic pts with positive FOBT or iron deficiency anemia 3) Patients with iron deficiency anemia

Question 53

Lab patterns of liver disease: 1) What 2 groups may these patterns suggest? 2) Magnitude & what ratio may assist in Dx? What is a more specific marker of hepatic injury? 3) What are 3 categories of liver disease? 4) What may both groups have in common?

Answer 53

1)Pattern may suggest hepatocellular disease or cholestasis 2) AST:ALT ratio; ALT more specific marker of hepatic injury 3) Acute (< 6 wks), subacute (6 wks-6 mos), or chronic (> 6 mos) 4) Possible elevated Sr bilirubin & abnormal synthetic function in both patterns

Question 54

Markers of liver disease: 1) What does low albumin suggest? 2) What does normal albumin suggest?

Answer 54

1) A chronic process (eg, cirrhosis or cancer) 2) More acute process (eg, viral hepatitis or choledocholithiasis)

Question 55

Markers of liver disease: 1) What does low albumin suggest? 2) What does normal albumin suggest? 3) What does GGT (gamma-glutamyl transpeptidase) indicate?

Answer 55

1) A chronic process (eg, cirrhosis or cancer) 2) A more acute process (eg, viral hepatitis or choledocholithiasis) 3) Damaged liver or pancreas tissue. More specifically related to alcohol use or bile ducts

Question 56

Markers of liver disease: 1) Prolonged prothrombin time (PT)/elevated INR indicates what? 2) Most hepatocellular injury results in which to be lower, AST or ALT?

Answer 56

1) Vitamin K deficiency due to malnutrition, malabsorption or significant hepatocellular dysfunction 2) AST lower than ALT

Question 57

1) What ratio suggests alcoholic liver disease? 2) What does AST & ALT >25xULN suggest?

Answer 57

1) AST:ALT > 2:1 2) Acute viral hepatitis or toxin-related hepatitis with jaundice

Question 58

1) What suggests Ischemic hepatitis (ischemic hepatopathy, shock liver, hypoxic hepatitis)? 2) What suggests Acute hepatic failure?

Answer 58

1) AST & ALT > 50xULN (LDH also often markedly elevated) 2) AST & ALT > 10xULN + prolonged PT (INR >1.5)

Question 59

1) Define jaundice 2) What is it secondary to? 3) What lab level does it usually present with?

Answer 59

1) Yellow/orange skin, mucous membranes & sclera due to accumulation of bilirubin in tissues 2) Unconjugated (indirect) or conjugated (direct) hyperbilirubinemia. 3) Bilirubin > 3 mg/dL

Question 60

Jaundice: 1) Where is it best seen? 2) What should you do with these pts? 3) When do you admit these pts?

Answer 60

1) Best seen in sclera/conjunctiva, under tongue, and hard palate 2) Refer for diagnostic procedures 3) Admit patients with hepatic failure

Question 61

Bilirubin (hyperbilirubinemia): 1) What is bilirubin? 2) What does it provide? 3) What must the body do with it? 4) What is it mostly derived from?

Answer 61

1) Metabolite of heme 2) Color to bile, stool, & urine 3) Excrete it as it is potentially toxic 4) Heme from senescent RBCs

Question 62

Describe the flow of bile from production to excretion

Answer 62

Bili production > hepatocyte uptake > conjugation > excretion into bile ducts > excretion into intestines

Question 63

Hyperbilirubinemia: Unconjugated hyperbilirubinemia (indirect) indicates what 3 things?

Answer 63

1) Increased bilirubin production 2) Decreased hepatic uptake 3) Impaired conjugation

Question 64

Hyperbilirubinemia: Conjugated hyperbilirubinemia (direct) indicates what 3 things ?

Answer 64

1) Biliary obstruction (extra-hepatic) 2) Intra-hepatic cholestasis 3) Hepatocellular injury

Question 65

Give some historical clues for hyperbilirubinemia

Answer 65

1) Use of medications or recreational drugs 2) Use of dietary supplements or herbal medications 3) Use of alcohol 4) Hepatitis risk factors 5) H/o abdominal operations (including gallbladder surgery) 6) H/o inherited disorders (including liver diseases & hemolytic disorders) 7) HIV status 8) Exposure to toxic substances

Question 66

ALT, AST, and GGT may indicate what?

Answer 66

Alcohol issues