GI

Question 1

Acute appendicitis

Answer 1

S&S: low-grade fever, guarding/rebound tenderness. Pains steadily gets worse, localizes to McBurney’s point (RLQ). Anorexia
Psoas and Obturator signs positive

Refer to ED

Question 2

Acute cholecystitis

Answer 2

S&S: severe pain in RUQ or epigastric, within 1 hr of eating fatty meal
Anorexia and N/V

Risk factors: female, obese

Question 3

Acute Diverticulitis

Answer 3

Patho: diverticula are small outpouches in external colon due to lack of fiber in diet. More likely in Western countries. More likely to affect left colon. Outpounches can get infected and burst.

S&S: Acute onset high fever, anorexia, N/V, pain in LLQ. Positive Rovsing sign (pain in RLQ when LLQ palpated) & pos rebound. H/o of bowel changes (50% will have constipation). If ruptured - board-like abdomen.
Diverticulosis: asymptomatic, will only be seen w/ colonoscopy

Risk factors: advanced age, constipation, low fiber, obesity, NSAIDs

Tx: mild cases can be treated outpatient with liquid diet + Augmentin or cipro + flagyl
If no improvement in 48-72h send to ED
Ovoid opiates, will encourage ileus

Question 4

Acute Pancreatitis

Answer 4

Inflammation of pancreas 2/2 gallstones, alcohol, elevated triglycerides. Causes autodigestion

S&S: Acute onset fever, N/V, pain that radiates from and to mid back. Positive Cullen (blue discoloration around umbilicus) and grey Turner sign (blue discoloration around flank)

Dx: elevated amylase, lipase

Refer to ED

Question 5

C. Diff colitis

Answer 5

S&S: severe watery stool, 10-15 stools per day. Lower abd pain, cramping, fever. Sx start within 5-10 days of abx initiation (CLindamycin, fluoroquinolones, cephalosporins, penicillins). Oral-fecal transmission

Dx: NAAT & stool assay

Tx: Vanco first line, high rate of reoccurrence
Consider fecal transplant w/ recurrence
inc fluids
Encourage reg diet

Refer to ED

Question 6

Chrohn’s Dz

Answer 6

IBD
Can occur anywhere in GI tract, fistula and anal involvement only with CD
If ileum involvement - watery diarrhea w/o mucus
If colon - watery diarrhea w/ mucus

W/ flair: fever, anorexia, weight loss, dehydration, fatigue

Risk: ashkenazi jew

Question 7

Ulcerative colitis

Answer 7

IBD
Affects colon/rectum
More likely to have bloody diarrhea w/ mucus than CD
Severe squeezing, “cramping” pain on L side of abd, w/ bloating and gas, exacerbated by food
May have IDA or anemia of chronic dz
During relapse: fever, anorexia, weight loss, arthralgias

Question 8

Zollinger–Ellison Syndrome

Answer 8

Gastrinoma on pancreas or stomach that secretes gastrin, causes high levels of acid in stomach
LEads to ulcers in stomach and duodenum
S&S: Pain in epigastric and mid abd, tarry colored stool

Dx: fasting gastrin level

Refer to GI

Question 9

Abdomen organs by quadrant

Answer 9

RUQ: Liver, gallbladder, ascending colon, kidney (right), pancreas (small portion); right kidney is lower than the left because of displacement by the liver

Left upper quadrant (LUQ): Stomach, pancreas, descending colon, kidney (left)

RLQ: Appendix, ileum, cecum, ovary (right)

LLQ: Sigmoid colon, ovary (left)

Suprapubic area: Bladder, uterus, rectum

Question 10

Psoas/Iliopsoas sign

Answer 10

Positive if elicits RLQ pain

With patient in supine position, have patient raise right leg against the pressure of the professional’s hand resistance. With patient on left side, extend the right leg from the hip.

Question 11

Obturator Sign

Answer 11

Positive if inward rotation of the hip causes RLQ abdominal pain. Rotate right hip through full range of motion. Positive sign is pain with movement or flexion of the hip.

Question 12

Rovsing’s Sign

Answer 12

Deep palpation of the LLQ of the abdomen results in referred pain to the RLQ, which is positive. A sign of peritonitis

Question 13

Markle Test (Heel Jar)

Answer 13

Instruct patient to raise heels and then drop them suddenly. An alternative is to ask the patient to jump in place. Positive if pain is elicited or if patient refuses to perform because of pain.

Question 14

Murphy’s manuever

Answer 14

Press deeply on the RUQ under the costal border during inspiration. Midinspiratory arrest is a positive finding (Murphy’s sign). Positive with cholecystitis or gallbladder disease

Question 15

Carnett’s Test

Answer 15

Used to determine if abdominal pain is from inside the abdomen or if it is located on the abdominal wall.

Patient is supine with arms crossed over their chest. Instruct patient to lift up shoulders from the table so that the abdominal muscles (rectus abdominus) tighten. If source of pain is the abdominal wall, it will increase the pain; if the source is inside the abdomen, the pain will improve.

Question 16

GERD

Answer 16

Patho: acid is regurgitated from stomach to esophagus d/t relaxed sphincter

S&S: chronic heart burn, worse after large fatty meals, worse supine. Can have chronic cough, chronic red throat, reduced enamel on molars, acidic breath.

Risk factors: chronic use NSAIDs, aspirin, alcohol

Tx: lifestyle changes (dont eat 3-4hr before bed, avoid acid foods, weight reduction, smoke cessation)
H2 (-tidine) first line, take at bedtime
PPI (-prazole): for esophagus erosion, do not dc suddenly, can have rebound effects. Long term use can inc risk of osteoporosis
Antacids for mild sx

Complications: Barretts esophagus (inc risk of squamous cell carcinoma)

Refer: if uncontrolled on meds (4-8 wk after initiation) or long (10 years) history of reflux. May need a biopsy (gold standard)

Question 17

Acute Gastroenteritis

Answer 17

Main symptoms of diarrhea
Acute diarrhea lasts 1 to 2 days; persistent diarrhea lasts 2 to 4 weeks; chronic diarrhea lasts ≥4 weeks.
The most common pathogens that cause acute gastroenteritis are viruses (50%–70%), bacteria (15%–20%), and protozoans (10%–15%).

Question 18

Viral Gastroenteritis

Answer 18

Acute onset N/V w/ watery diarrhea
Self-limited, short duration
Most common from rotavirus and norovirus

Question 19

Bacterial Gastroenteritis

Answer 19

Acute onset high fever, N/V, bloody diarrhea
Can be food or bacterial infection
Lasts 1-7 days
Antibiotics will make sx worse

Pathogens: Escherichia coli, Salmonella, Shigella, Campylobacter, C. difficile (antibiotic use, recent hospitalization), and Listeria (pregnant women 12-fold risk).

Question 20

Protozoal Gastroenteritis

Answer 20

Watery diarrhea
Symptoms usually start 7 days after exposure, last for 7 days
Includes traveler’s diarrhea

Pathogens: Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.

Risks: traveling to other countries, recent abx, immunocompromised

Question 21

IBS

Answer 21

Chronic colon disorder
Exacerbated w/ stress
Can be diarrhea or constipation dominant, or both

S&S: mod-severe cramping, pain in LLQ. Bloating w/ flatulence. Relieves with defecation. Tenderness w/ exacerbations. Stool w/o blood or mucus.

Tx:
Increase dietary fiber or meds: Psyllium (Metamucil or Konsyl), Methylcellulose (Citrucel), wheat dextrin (Benefiber). Start at low dose (causes gas).

Avoid gas-producing foods: Beans, onions, cabbage, high-fructose corn syrup. If poor response, use a trial diet of lactose avoidance or gluten avoidance.

Antispasmodics for abdominal pain: Administer dicyclomine (Bentyl) or hyoscyamine as needed.

IBS with constipation: fiber supplements, polyethylene glycol (osmotic laxative).
If severe constipation: Lubiprostone or linaclotide (contraindicated in pediatric patients <6 years, has caused death from dehydration).

IBS with diarrhea: Take loperamide (Imodium) before regularly scheduled meals.
Severe diarrhea–predominant IBS: Administer alosetron (warning: ischemic colitis, which can be fatal).

Question 22

PUD

Answer 22

More likely to be duodenal vs gastric ulcer
Duodenal more likely to be benign

Risk factors: Chronic NSAID/aspirin use. Smoking/alcohol

S&S: Most are asymptomatic. C/o “burning/gnawing pain” epigastric area. Pain relieved by food, recurs shortly after meal (gastric) or 2-4 h after (duodenal).Pain when hungry or stomach is empty. May have signs of GI bleed. Can have pain on palpation to epigastric area.

Dx: breath test or stool test for H pulori. Serm/titer unable to identify active disease. Breath/stool used to re-test post-treatment
Gold standard: Upper endoscopy and biopsy of gastric and/or duodenal tissue.

Tx:
If not H. Pylori - stop NSAID use, start on H2 or PPI (faster)

If H. Pylori:
Triple therapy:
Clarithromycin (Biaxin) 500 mg twice a day plus amoxicillin 1 g twice a day or metronidazole (Flagyl) 500 mg twice a day if allergic to amoxicillin × 14 days plus
Standard-dose PPI orally twice a day × 14 days

Quadruple therapy:
Bismuth subsalicylate tab 600 mg four times a day plus
Metronidazole tab 250 mg four times a day plus
Tetracycline cap 500 mg four times a day × 2 weeks plus
Standard-dose PPI orally twice a day × 14 days

(BTS are Men, no CAP)

Question 23

Hepatitis Serology

Answer 23

IgM Anti-HAV - M = maybe you have it?
Acute infection; patient is contagious.
Hepatitis A virus still present

IgG Anti-HAV - green means go
Presence means lifelong immunity
History of native hepatitis A infection or vaccination with hepatitis A vaccine (Havrix)

HBsAg
Screening test for hepatitis B
If positive, patient has the virus and is infectious

Anti-HBs
Antibodies present and patient is immune from Hep B bc past infection or vaccine.

HBeAg
Marker for actively replicating hepatitis B virus; highly infectious.

Anti-HBc
Appears at onset of symptoms in acute hepatitis B and persists for life.

Anti-HCV
Screening test for hepatitis C
If test is positive:
Order HCV RNA to rule out chronic infection

HDV RNA
Hepatitis D tests by antibody hepatitis D virus (anti-HDV) or hepatitis D virus RNA test
Requires the presence of hepatitis B to get the infection

Question 24

Hep A

Answer 24

No chronic or carrier state
Vaccine available, reportable dz
Transmission: oral-fecal

S&S: fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, abdominal pain, jaundice, dark urine

Dx: Bili > >3 mg/dL, ALT levels >200 IU/L.

Tx: self-limiting, symptomatic treatment
avoid drugs and foods that can damage the liver, such as acetaminophen, alcohol/ethanol, statins, isoniazid, and herbal teas.

Question 25

Hep B

Answer 25

Can be acute & self-limiting or chronic
Vaccine available: 3x as child (birth, 1m, 6m) or 3x as adult
Transmission: horizonal = sexually or vertical=mother/baby

Treatment:
Acute hepatitis B, administer injection of hepatitis B immune globulin (HBIG) and give first dose of hepatitis B vaccine as soon as possible (if no previous history of vaccination × three doses).
Refer chronic hepatitis B patients to gastroenterologist. First-line agents for treatment of chronic hepatitis B include antiviral agents and pegylated interferon alfa (PEG-IFN-a).

Question 26

Hep C

Answer 26

Most cases turn into chronic
No vaccine, reportable dz
Transmission: blood borne (IV drug use, blood transfusions before 1992, mother/baby, work place needle sticks)

Tx:
Refer to GI
Most can be cured with antivirals

Complications: most common cause of liver cancer

Screening: one-time HCV screening for all adults ages 18 to 79 years.