GI

Question 1

Important Hx in Diarrhea

Answer 1

• Blood or melena?
• Associated sx like nausea, vomiting, fever?
• Sick contacts?
• Travel hx?
• Related to food ingestion?
• Underlying medical problems - HIV, immunocompromised, hyperthyroid
• Recent changes in meds? Abx use?

Question 2

Acute Diarrhea Work-Up

Answer 2

If no complications - no workup needed

If severe fever, blood, nausea and vomiting or severe dehydration then do work up

• CBC, WBC
• Stool leuks ?
• If leuks - stool cx, C diff cx and toxin assay, ova/parasites, stool giardia antigen assay
• If no leuks then no more work up

Question 3

What types of diarrhea are associated w/ blood and leuks in stool?

Answer 3

Campylobacter, Shigella, Salmonella

No leuks / blood - viral gastroenteritis, staph and clostridial food poisoning

Question 4

Tx of Acute Diarrhea

Answer 4

REHYDRATE (hospitalize if severely dehydrated or cannot take in PO)

Loperamide if mild NOT IF BLOODY

Cipro if Campylobacter, Shigella, Salmonella (reduces duration by 24 hrs)

Metro if C diff

If no improvement/ lasts longer than expected - flexible sigmoidoscopy w/ biopsy

Question 5

When should you get an endoscopy for dyspepsia? (6)

Answer 5

• Alarming sx - wt loss, dysphagia, obstructive sx
• > 55 yo w/ new onset dyspepsia
• Recurrent vomiting or GI bleeding
• If try empiric therapy for reflux and sx persist
• Signs of PUD complications - strictures or esophageal ulcers
• Evidence of systemic illness

Question 6

Complications of GERD

Answer 6

• Erosions / ulcers - bleed
• Peptic stricture (fibrous band that narrows lumen - dysphagia)
• Barrett (stratified squamous –> columnar)
  
  • If pt has had symptomatic GERD for 5+ yrs then screen for Barrett w/ endoscopy + biopsy
  • If detect Barrett but no dysplasia yet then redo endoscopy every 3 yrs
• Recurrent aspiration pneumonia - see lipid laden macrophages in pleural aspirate (fat phagocytosis)
• Dental enamel problems
• Laryngitis, pharyngitis

Question 7

GERD Tx

Answer 7

Advise - avoid alcohol, caffeine, chocolate, spicy foods; stop smoking; raise head when sleeping; limit meals before bed

Antacids and/or H2 blocker

If fails or severe GERD try PPI

Surgery if refractory to tx (fundoplification)