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Primary care > GI > Flashcards

GI Flashcards

1
Q

Gall bladder

Pancreas

A

referred to right shoulder

referred to back

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2
Q 
Appendicitis 
Typical age:
Presentation:
-
-
-
-
A

10-19 years
Presentation:
-Initial: Vague symptoms (indigestion, anorexia)
-Initially localized (periumbilical, epigastric) MILD CONSTANT
-4-6 hours: localizes RLQ severe constant aggravated with movement
-N/V/D preceded by pain
-FEVER

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3
Q

Appendicitis

PE

A

-pain with cough
-points to location
-tenderness at McBurneys point (umbilicus and anterior superior iliac spine)
-pain with rectal exam
pelvic- women
-Iiopsoas
-Obturator
-Rovsings: palpate LLQ

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4
Q

Appendicitis

Diagnostics

A

CBC (30% will not have, KIDS *** do)
U/A- UTI, STD, HCG
US/CT (U/S kids)

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5
Q

Ruptured Aortic Aneurysm

Symptoms

A

Symptoms:

  • Throbbing, aching back
  • Sudden onset severe pain (abdomen, flank, low back pain, groin)
  • Pain worse with recumbent
  • Syncope/shock
  • Chest pain
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6
Q

Ruptured Aortic Aneurysm

PE:

A
  • Pulsatile abdominal mass between xiphoid/umbilicus
  • Aortic bruit
  • Diminished/unequal peripheral pulses
  • Rupture: shock/arrest
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7
Q

Diverticulitis
What comes first?

Symptoms:
Elder?

A

Diverticulosis (prevent: high fiber diet) stagnation of fecal material in diverticulum–>infection–>perforation, peritonitis

Aching abd pain LLQ 
Colicky or steady 
Fever 
\+/- constipation, diarrhea 
N/V

Elder: maybe no symptoms–> septic

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8
Q

Ruptured Aortic Aneurysm

at risk

A

males, older
CAD, HTN, PVD, smoking

1 time screening 65-75 smoker or previous smoker

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9
Q

Diverticulitis

PE

A

Tenderness suprapubic area LLQ
Maybe peritoneal signs: guarding/rebound
Rectal: pain, +/- hemoccult or blood
Pelvic (women)

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10
Q

Diverticulitis

Diagnostics

A

CBC
U/A: HCG, STD
Stool OB

CT (U/S doesn’t show intestine)

Referral to GI for colonoscopy

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11
Q

Diverticulitis
Treatment

Follow up

Diet

A

Outpatient (low frade fever, mild leukocytosis)
Cipro 500 mg BID +
Metronidazole 500 mg BI 10-14 days

F/U within 24-48 hours
GI for colonscopy R/O cancer

Diet: low residue diet, once asymptomatic slowly introduce high fiber

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12
Q

Diverticulitis treatment severe

A

Fever over 101
peritoneal signs
marked leukocytosis

Hospitalize *

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13
Q

Cholelithiasis/cystitis

Highest risk

A 
Female 
Obese 
Rapid weight loss 
Pregnant 
40+

Comorbid conditions: DM, IBD, ETOH

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14
Q

Colelithiasis

Presentation

A 
colelithiasis: 
Biliary colic: intermittent or steady RUQ/epigastric pain 
Radiates to right shoulder 
Occurs after eating fatty foods 
N/V lasts 1-6 hours
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15
Q

Cholecystitis

Presentation

A

cholecystitis: biliary colic DOES NOT GO AWAY + CHILLS, FEVER
common bile duct stone: charcot’s triad, RUQ pain, fever, jaundice
acalculous cholestystitis: critically ill

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16
Q

Cholecystitis

PE

A

+ Murphys signs: can’t take a deep breath on palpation of right costal margin

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17
Q

Cholelithiasis/cholecystitis

Diagnosis

A

CBC
LFT’s *ALK PHOS
U/A: HCG, STI, UTI

Imaging:
U/S- gall stones *FASTING
after can get HIDA scan (most specific, hepatoiminodiacetic acid scan) - GI usually orders

Refer to GI

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18
Q

Gall stones (cholelethiasis/cholecystitis)

pain for months, shows gall stones what do you do?

A

Refer to general surgery

Chronic doesn’t bother them (general surgery eval but don’t need surgery)

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19
Q

Gall stones teaching

dumping syndrome

A

Avoid fatty foods go to ER if acutely ill

questran (cholestyramine powder)- also used for triglycerides

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20
Q

Pancreatitis
Presentation

Risks

A

Variable

  • Constant knifelike pain LUQ (periumbilical)
  • Increasing intensity
  • Radiation to chest, back, LEFT shoulder, flank, LLQ
  • Pain worse supine, better with legs in
  • Rocking, N/V

ETOH, gallstones/obstruction, hypertriglyceridemia, pregnancy, HIV, trauma

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21
Q

Pancreatitis

PE

A
  • Epigastric, LUQ tenderness
  • Fever
  • Hypotension, tachycardia, hemodyanmic instability, CV collapse
  • bluish hue around umbilicus (CULLEN’s sign*)
  • decreased/absent bowel sounds
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22
Q

Pancreatitis

Diagnostics

A

CBC
U/A: HCG
Serum chemisty profile LFT’s and Blood sugar COMPREHENSIVE METABOLIC PANEL
Amylase (raises first; not always elevated in drinkers and may return to normal after 2-3 days)
Lipase (raises after several days: elevated in drinkers and non-drinkers)

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23
Q

Pancreatitis

mortality

A

May be mild presentation and then deteriorate rapidly
Ranson’s criteria estimates mortality: esp age >55
WBC >16,000 glucose>200 AST>250 LDH >350 on admission
within 48 hours of admission: HCT drop >10%, BUN increase >5, CA 4 F;uid needs > 6L in 48 hours

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24
Q

Irritable bowel syndrome
Define/diagnosis:

Criteria

A

Functional bowel disorder
No structural or biochemical etiology
Diagnosis of exclusion

ROME III Criteria:
recurrent abd pain or discomfort at least 3 days a month in last 3 months
-relief with defecation
-onset associated with change in stool freq
-onset associated with change in form of stool

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25
Q

IBS presentation

A 
80% women 
Depression/anixety 
Nonradiating ache/cramp lower abd pain 
Worse with meals 
Associated with stress 
Alternating pattern 
C/O mucus in stool? 
NO BLOOD, NO WEIGHT LOSS, NO FEVER, NO NOCTURNAL 
FH, meds, diet, stress
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26
Q

IBS PE

A

Careful abd exam
Pelvic
Rectal

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27
Q

IBS Diagnostics

A

-CBC
-ESR
-BS (r/o diabetic gastroenteropathy)
-TSH
-Stool OB
+/- breath test (or 3 week trial lactose free diet)
+/- giardia
+/- IgA antitissue transglutaminase (TTG) celiac
-Pelvic U/S if concern
refer GI if needed

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28
Q

IBS management

A

Elimination of food
Increase fiber (cirtucel)
decrease stress, exercise

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29
Q 
IBS diarrhea treatment 
-
-
-
-
A
  • Antispasmotic: Hycoscyamine (Levsin) if postprandial symptoms
  • Loperamide (immodium) .123-.25 before meals (best short term)
  • Lotronex (alosetron) GI uses was taken off market for a while for ischemic colitis/perf
  • Bile acid sequestrant like cholestyramine (questran) for bile acid malabsorption
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30
Q

IBS constipation treatment

A
  • Osmotic laxative (miralax/polyethylene)
  • Stool softener
  • Fiber supplement (citrucel)
  • Lubiprostone (Amitiza) for women chronic
  • Linaclotide (linzess) stimulates intestinal fluid secretion chronic

Treat depression: TCA’s have analgesic property, careful with constipation

31
Q

Dyspepsia
Presentation

Differential

A

chronic or recurrent pain in center of abdomen

GERD, PUD, Biliary pain, IBS, drug induced (NSAIDS, biophosphanates- boniva, fosamax, orilistat, emycin) gastric cancer, cardiac pain

32
Q

Dyspepsia alarm

A 
> 55 new onset 
family hx upper gastro cancer 
unintentional weight loss 
progressive dysphagia odynophagia 
bleeding
anemia 
vomiting 
palpable mass or lymphadenopathy
jaundice
33
Q

Dyspepsia management
>55:
Alarm sx:

A

> 55: endo

Alarm: endo

34
Q

Peptic Ulcer Disease
Two associated factors

Duodenal:
incidence

Gastric:
incidence

A

NSAID use or H. pylori

Duodenal: MOST COMMON
45-54 as much as 90% H.pylori***

Gastric:
55-64 (OLDER PATIENTS)
***NSAID use, corticosteroids, smoking, ETOH

35
Q

PUD presentation
Both:

Duodenal:

Gastric:

A

Both: n/v, belching, bloating, HB, melena, anemia, GI bleed may be 1st sx

Gastric: worse with food, prolonged sx free period, may relief with antacid, may radiate to back

Duodenal: wake at night, relief with food, occurs 2-3 hours after meal

36
Q

PUD PE

A 
May be no findings*
Weight 
Rectal: occult 
May have epigastric tenderness 
Perforation: rigid abdomen, rebound
37
Q

PUD differentials

A 
Functional dyspepsia 
Cancer 
Drug induced 
Chrons 
Infections (giardia) 
Cholelithiasis
38
Q

PUD Diagnostics

A

Serologic: does not differentiate past or present

Breath: (c-urea)

Stool: definitive

Endoscopy with biopsy/staining

39
Q

PUD diagnostics continued

Breath test/stool + with no red flags what do you do? What about after you treat?

A

Treat if no red flags and under 55
RUN CONFIRMATORY testing (stool) no

> 55 or alarming symptoms + H pylori need follow up with endoscopy*****

40
Q

H. pylori treatment

A

PPI BID+ Clarithromycin/biaxin + Amox x 10d

if allergic
PPI+ Biaxin+ Flagyl

All other options are QID (bismuth, tetra, flagyl)

Biaxin-metallic taste, come to office if have the runs—> c. diff
Flagyl- no ETOH even after 48 hours

41
Q

H. pylori treatment continued

Education

A

Avoid ASA NSAIDS, alcohol, smoking, coffee, corticosteroids, finish treatment
If on PPI don’t take in addition to other PPI
Follow up breath test or endoscopy 4-6 weeks after treatment

42
Q

H. pylori negative ulcers treatment

A

Acid suppressant 6-12 weeks
H2 blockers PPI preferred
Follow up endoscopy to document healing

43
Q

GERD

Symptoms

A
  • HB worse after eating, lying, down, bending forward, night time
  • Regurgitation (sour taste, metallic, sore throat)
  • Dysphagia/odynophagia (ALARM SYMPTOM- neuro/mass/cancer)
  • Dental erosion (gingivitis)
  • Nausea
  • Water brash (hypersalivation)
44
Q

GERD aggravating factors

A 
Coffee, tea, peppermint, fatty foods, citrus, spice, concentrated sweets, tomato based, meds, ETOH, soda 
Overweight 
Tight clothing 
Lying down after eating 
Smoking
45
Q

GERD PE

A 
NEGATIVE FINDINGS usually 
Wgt 
Pharynx 
Abd 
Rectal/stool OB 
Respiratory if symptoms (cough)
46
Q

GERD diagnostics

A

Classic/nonconcerning symptoms can diagnose

CBC
+/- upper GI if diagnosis uncertain
Cardiac workup if indicated

Endoscopy: 45-55, unsuccessful tx
red flags: anemia, dysphagia, odynophagia, weight loss, long standing sx

SEVERITY OF SYMPTOMS DOES NOT CORRELATE WITH SEVERITY OF DAMAGE

47
Q

GERD diagnostics

Endoscopy:

A

for metaplasia

Barret’s esophagus (premalignant condition requiring ongoing surveillance)

48
Q

GERD differentials

A 
PUD 
Angina 
Motility d/o 
Tumor 
Infection esophagus 
Medication
49
Q

GERD meds

How long?

If fail?

A

H2 antagonist (preferred for pregnancy)

PPI (first line) b12 malabsorption, increased risk hip fx, enteric infections

6-8 weeks
Poor respones- endoscopy
Good…d/c meds…symptoms reoccur within 3 months: endoscopy

> 3 months: retrial…recurrecne

50
Q

Pediatric GI

Functional constipation

A 
Functional: poor bowel habits
2 of 6 criteria: 
-stool frequency 
-hardness
-size
-fecal incontinence (leads to encorpresis) 
-volitional stool retention 
present for one month in infants/toddlers 
2 months older children
51
Q

Pediatric GI

consipation peak prevalence

A

Pre-school

52
Q

Pediatric GI

breast fed constipation

A

rarely if bf, iron in formula ^ constipation

53
Q

Pediatric GI

3 periods prone to constipation:

A
  • intro of cereals and solid food
  • toilet training (issue with control)
  • start of school
54
Q

Pediatric GI

Abdominal pain without temp

A

constipation: can palpate LLQ

55
Q 
Pediatric GI 
Toilet training 
Age
must develop \_\_\_\_ 
leads to \_\_\_\_
Developmental readiness
A

Age: 2-3 years old start after nap
Must develop: interest in retaining bowel movement
leads to less frequent defecation–>hard painful stools
Readiness: ambulate, stability, remain dry for several hours, pull clothes, language (2 step command), expressive language (communicate need)

56
Q

Pediatric GI
Painful defecation with solids
avoidance of defecation leads to

Encopresis??

A

stool accumulation, hard stools, blood is common (streaked)

anal canal shortens, anal sphincter dilates, external sphincter relaxes–>semisolid stool leaks into perianal skin ENCOPRESIS

57
Q 
Pediatric GI 
Functional constipation treatment
Nonpharmacologic 
Goal 
Pharmacologic
A 
Fiber and fluids + Balanced diet 
Goal: one or more soft stool per day
Pharm: 
miralax 
MOM (magnesium hydroxide) 
Lactulose
58
Q

Pediatric GI
Diarrhea
WHO defines
Caused by

A

WHO: 3 or more loose per day

Acute infections viral GI (majority)

59
Q

Pediatric GI
Febrile with non-bloody diarrhea:
Febrile with blood diarrhea/mucus:

A

non-bloody: viral

blood/mucus: bacterial or parasitic

60
Q

Pediatric GI
Diarrhea
Immunization - when is it given, peaks in what month

A

rotavirus: ( more than half hospitalizations for nonbacterial gastroenteritis due to rotavirus )
not required
given at 2,4 and 6 months (not given after that)
peaks in winter months

61
Q

Pediatric GI: Diarrhea
transmission of viral

S/S viral

A

fecal-oral

s/s: d/v, low grade, fever, anorexia, HA, abdominal cramps, myalgia

62
Q

Pediatric GI: Diarrhea treatment
IV?

Abx?

A

majority will not require IV hydration: tbsp every 15 mins oral rehydration

Abx not used with acute bloody diarrhea unless pathogen isolated

63
Q

Pediatric GI: Dehydration S/S

A
  • decreased urination
  • decreased tears
  • high fever
  • dry mouth
  • weight loss
  • thirst
  • listlessness/lack of energy
  • sunken eyes, fontanelles
64
Q

Pediatric GI: Hydration
Breastfeeding?
Milk?
Foods?

A

BF through diarrhea/vomitting
Whole milk usually toleration (dilution/lactose free not necessary)
Foods high in fat and simple sugars not as good as complex carbs, lean meats, yogurt, fruits, vegetables

65
Q

Pediatric GI: Diarrhea
Diet:
Nonpharm:

A

BRAT have been recommended (unnecessarily restrictive, suboptimal nutrition)
Latest recommendation: Feed through diarrhea!! (prevent weight loss keep nutrition, add yogurt)
Lactobacillus

66
Q

Pediatric GI: GERD
Infancy:
Types:

A

Infancy: most common GI problem
Types: physiologic (weak sphincter, air bottle) or pathologic (no weight gain, blood in vomit, irritable, cranky, hungry)

67
Q

Pediatric GI: GERD diagnosis gold standard

A

24 hour intraesophageal PH for pathologic GERD

68
Q

Pediatric GI: GERD nonpharm tx

A

Thickened formula, prone position, hypoallergenic, small frequent feedings

69
Q

Pediatric GI: Tx GERD

A

H2 ie ranitidine
>one month-16 years (most common in infants 4-6 weeks)

PPI: inhibit parietal cell enzyme ATPase or PP
Omeprazole (prilosec)
Lanzoprazole (prevacid)- strawberry flavor
Admin before meals

70
Q

Pediatric GI: Colick
Rule:

Symptoms:

Less likely with:

A

Rule of 3:

  • 3 hours
  • 3 days a week
  • 3 weeks
  • first 3 months of life

Symptoms: irritable, fussing, without failure to thrive HEALTHY eating normally
later in afternoon 4-6 pm
Less likely in calm/comfortable mother

71
Q

Pediatric GI: Colic treatment

A 
Hypoallergenic formula 
Continue bf 
Mother (eliminate caffeine) 
SWADDLING** 
White noise 
Avoid overstimulation
72
Q

Pediatric GI: Functional abdominal pain

Criteria

A

Experience following symptoms once a week for 2 months:

  • periumbilical pain 1-3 hours
  • n/v, fatigue, HA, pallor
  • fetal position, grimace, cry
  • school absence
  • NO FEVER VOMITING WEIGHT LOSS OR WAKING UP FROM SLEEP

*internalized/psychosocial

73
Q

Pediatric GI: Functional what does it mean?

A

Psychosocial/internalized/nothing is really wrong physiologically

74
Q

Pediatric GI: Functional abdominal pain diagnostics

Plan follow up

A
  • no definitive diagnostic test
  • U/A
  • CBC
  • ESR (low grade infectious process)
  • metabolic panel
  • stool for occult blood parasite giardia
  • lactose breath hydrogen test

plan/f/u: counseling, symptom diary, f.u in month

Primary care (16 decks)

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