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Question 1

constipation

causes
tx

Answer 1

• Persistent, difficult, infrequent or seemingly incomplete defecation
• Causes: IBS, medications, endocrine disorders, psych disorders, MS, neuro
disorders, malignancy, hemorrhoids, stricture, ischemia, inflammatory

Question 2

diarrhea

causes

Answer 2

Causes: can be acute or chronic
• Acute (< 2 weeks): infection, medications
• Chronic (>4 weeks): medications, toxins, malabsorption, hormones, cancer,
dysmotility disorders, eating disorders, bariatric surgery, cholecystectomy

Question 3

ileus

definition
causes
dx
tx

Answer 3

• Functional obstruction, dysmotility prevents intestinal contents from
being propelled distally, not a mechanical blockage
• Causes: surgery, electrolyte abnormalities (low K, low mag, low Na),
medications, intestinal ischemia, GI bleed, sepsis,
hyperparathyroidism, LL pneumonias, Ogilvie’s Syndrome, collagen
vascular disease (SLE or scleroderma)
• S/S: abdominal pain, distention, emesis, obstipation
• Diagnostics: CBC, CMP, x-ray first

Question 4

SBO

causes
S/S
DX
TX

Answer 4

Mechanical obstruction
• Causes: adhesions, malignancy,
hernia, inflammation,
intussception, volvulus
• S/S: same as ileus
• Exam: oliguric, hypotension,
tachycardic, fever, decreased
bowel sounds
• Diagnostics: same as ileus
• Treatment: supportive care, NGT,
IVF fluids, foley, admit to ICU,
resection if conservative efforts
unsuccessful

S/S: abdominal pain, distention, emesis, obstipation
• Diagnostics: CBC, CMP, x-ray first then CT scan

Question 5

large bowel Obstruction

definition 
s/s 
exam
dx 
tx

Answer 5

Blockage in the large bowel
• Causes: malignancy, diverticulosis,
volvulus
• S/S: abdominal pain, n/v
• Exam: Abdominal swelling and pain
• Diagnostics: abdominal x-ray or CT scan
• Treatment: surgical emergency

Question 6

gastroparesis

definition
causes
s/s

Answer 6

Delayed gastric emptying in the absence of mechanical obstruction,
due to vagus nerve damage, food is unable to move through the
digestive system appropriately
• Causes: diabetes, gastric surgery, medication
• S/S: n/v, delayed gastric emptying, signs of malabsorption

Question 7

gastroparesis

exam
dx
tx

Answer 7

Upper GI Series – excludes mechanical obstruction, retention of
barium without obstruction is diagnostic
• Endoscopy – highly suggestive
• Gastric emptying study – solids more sensitive than liquids

• Treatment: Reglan, erythromycin, botox, surgery

Question 8

appenndicitis

Answer 8

Inflammation of the appendix leading to infection
• Older adult at risk for perforation, pain > 48 hours
increases risk
• Etiology not completely understood
• Symptoms: RLQ pain, anorexia, constipation, diarrhea,
fever, nausea, vomiting, radiates to right flank or RUQ, pain
progressively worsens, urinary symptoms
• Exam: RLQ tenderness, rebound tenderness, rectal pain,
rigidity, psoas sign, obturator sign, Rovsing’s sign, palpable mass (less common)
• Diagnostics: CBC, UA, amylase, lipase, pregnancy test, CT
scan (but may not always show inflammation)
• Treatment: appendectomy

Question 9

acute cholecystitis

definition
causes

s/s
dx
tx

Answer 9

Acute inflammation of the gallbladder
• Causes: obstructed gallstone
• Inflammatory response
• 1. mechanical inflammation – increased intraluminal pressure and distention resulting in ischemia
• 2. chemical inflammation – lysolecithin release
• 3. bacterial inflammation – E. coli, Klebsiella, Strep, Clostridium
• S/S: fever, chills, rigors, RUQ pain , n/v, palpable mass, rebound tenderness,
distention, hypoactive bowel sounds if ileus,
• Diagnostics: CBC, LFTs, US to identify gallstones, HIDA scan to confirm, H
and P (fever, leukocytosis, RUQ pain)
• Treatment: cholecystectomy, cholecystomy

Question 10

cirrhosis /chronic liver disease

definiton
causes
exam
dx
tx

Answer 10

Liver fibrosis causes distortion decreasing hepatocellular mass
resulting in decreased function and blood flow
• Causes: alcoholism, hepatitis, congenital, nonalcoholic
steatohepatitis
• S/S: nonspecific symptoms, to RUQ pain, fever, nausea, vomiting,
diarrhea, anorexia, malaise, ascites, edema, UGI bleed, palmer
erythema
• Exam: hepatosplenomegaly
• Diagnostics: LFTs, CMP, liver biopsy (no ETOH x 6 months)
• Treatment: abstinence, supportive care, treat underlying cause

Question 11

acute hepatic failure

Answer 11

• Rapid liver failure, usually with no history of liver disease
• Causes: acetaminophen overdose, medications, herbals, hepatitis,
toxins, autoimmune, vascular abnormalities, cancer, sepsis
• S/S: jaundice, RUQ pain, abd swelling, n/v, malaise, AMS, lethargy
• Complications: bleeding (not making clotting factors), cerebral
edema, infections, renal failure
• Treatment: stop cause, liver transplant

Question 12

acute viral hepatitis

Answer 12

• Systemic infection
affecting the liver
• Causes: Hep A, Hep B,
Hep C, Hep D, or Hep E (All
RNA viruses except Hep B)
• Diagnostics: LFTs, CMP,
CBC, see next slide

Question 13

Hep A/E

S/S

transmission is

Answer 13

vowel comes from the bowel

A va E no vax

S/S RUQ pain
NV anorexia
weight loss
fever, chills jaundice dark urine history of exposure

transmission is fecal oral

Question 14

hep C transmission and vax

Answer 14

blood / Semen no vax

Question 15

hepatitis all type tx and dx

Answer 15

rest, activity as tolerated, nutrition and hydration

dx is presence of specific antibody/antigen in the serum

Question 16

hep B Vax and transmission

Answer 16

blood, semen, saliva, yes vax

Question 17

hep D is what, vax ?

Answer 17

Hepatitis superinfection on top of HBV, transmission is blood.

Question 18

hep testing first antibody to appear in response to atigen

Answer 18

Reminder: IgM is first antibody to appear in response to an antigen

Question 19

acute hep b testing

Answer 19

• Acute hep B: + HBsAg, + IgM Anti-HBc

Question 20

chronic hep B antigen

Answer 20

Chronic hep B: + HBsAg

Question 21

Acute hep A on chronic hep B

Answer 21

Acute hep A on chronic hep B: +HBsAg, +IgM Anti-HAV

Question 22

Acute hep A and hep B

Answer 22

+HBsAg, +IgM Anti-HAV, IgM Anti-HBc

Question 23

Acute hep C

Answer 23

+Anti-HCV

Question 24

Hep A

acute onset
causes
prophylazis
tx

Answer 24

Acute onset with 15-45 days incubation
• Causes: fecal oral transmission (eating or drinking), sexual activity
• Prophylaxis: inactivated vaccine
• Treatment: rehydration, rest, avoid alcohol, time

Question 25

Hep B incubation period causes prophylaxis tx

Answer 25

Insidious or acute onset with a 1-6 month incubation • Causes: percutaneous, perinatal, sexual • Prophylaxis: HBIG vaccine, screen high risk populations • Treatment: interferon, lamivudine, adefovir, pegylated interferon, entecavir, telbivudine, tenofovir

Question 26

Hep C onset causes vax tx

Answer 26

Insidious onset with 15 days to 4 months incubation • Causes: percutaneous, sexual • No vaccine, screen high risk individuals • Treatment: Pegylated interferon plus ribavirin, telaprevir, boceprevir

Question 27

Hep D ``` where is it found incubation period causes prophylaxis tx ```

Answer 27

Usually found in Mediterranean countries, in US found in those with frequent blood transfusions • Insidious or acute with 1 – 6 month incubation period • Causes: percutaneous, perinatal, sexual • Prophylaxis: HBV vaccine • Treatment: Pegylated interferon

Question 28

Hep E where found transmitted acute onset/incubation prophylaxis tx

Answer 28

Found in India, Asia, Africa, Middle East, Central America. • Transmitted through water contamination • Acute onset with 2 week to 2 months incubation • Prophylaxis: vaccine only in China • No treatment

Question 29

Acute Pancreatitis ``` definition causes S/S Exam Dx ```

Answer 29

Pancreatic inflammation • Causes: Gallstones, ETOH, hypertriglycideremia (> 1000 mg/dl), ERCP, medications, trauma, post-op abd surgery, connective tissue disorders, Ca, inc calcium, cystic fibrosis, autoimmune, idiopathic • S/S: abdominal pain, n/v, abdominal distention • Exam: fever, tachy, hypotension, shock • Diagnostics: amylase (elevated for 3-7 days), lipase (elevated for 7-14 days), CBC (inc WBC), hyperglycemia, hypocalcemia, inc LFTs, abd US in ED

Question 30

early acute phase of pancreatitis

Answer 30

Early acute phase – less than 2 weeks, most patients have SIRS and will become septic if not recognized early, older, obese and multiple comorbid conditions put patient at greater risk

Question 31

Late acute phase of acute pancreatitis

Answer 31

• Late acute phase – greater than 2 weeks, complications arise from early acute phase and now need to be treated

Question 32

Severity of acute pancreatitis

Answer 32

Severity of acute pancreatitis • Mild – no local complications or organ failure, resolves 3-7 days with treatment • Moderate – transient organ failure resolving in less than 48 hours • Severe – persistent organ failure, > 48 hours, local complications noted

Question 33

Tyes of pancreatitis by ct Interstitial

Answer 33

``` Diffuse gland enlargement • Homogenous contrast enhancement • Mild inflammatory changes • Peripancreatic stranding ```

Question 34

types of pancreatitis by CT necrotizing

Answer 34

``` Necrotizing • Takes several days to evolve • Lack of pancreatic parenchymal enhancement with IV contrast on CT • Peripancreatic necrosis ```

Question 35

treatment of acute pancreatitis

Answer 35

Mild severity – full liquid diet once nausea and vomiting subside, low fat diet • Aggressive IV fluids in the ED – LR or NS 15-20cc/kg bolused then 3mg/kg and hour afterwards, expect a drop in hct to determine if fluids are working • Maintain UO at 0.5 c/kg/hour • NPO • IV pain meds • Oxygen via NC • ICU admission • Treat underlying cause – gallstones > ERCP, inc trig > insulin, heparin or plasmapheresis

Question 36

complications of acute pancreatitis Local

Answer 36

``` Local • Necrosis • Fluid collections • Pseudocyst • Ascites • Splenic vein or portal vein thrombosis • Bowel infarction • Obstructive jaundice ```

Question 37

complications of acute pancreatitis systemic

Answer 37

``` Systemic • Pulmonary • CV • DIC • GI bleed • Renal – ATN, oliguria, thrombosis • AMS • Metabolic - encephalopathy ```

Question 38

chronic pancreatitis definition causes TIGAR-O

Answer 38

``` Irreversible damage to the pancreas from reversible changes in acute pancreatitis • Causes: TIGAR-O classification • T = toxic-metabolic • I = idiopathic • G = genetic • A = autoimmune • R = recurrent pancreatitis • 0 = obstructive ```

Question 39

chronic pancreatits s/s D/x TX Complications

Answer 39

``` S/S: see acute slide • Diagnostics: see acute slide in addition, CT then MRI, secretin test has best sens/spec • Treatment: Pancreatic enzymes • Complications: chronic pain, narcotic addiction, DM, gastroparesis, malabsorption, jaundice, retinopathy, pancreatic CA, cirrhosis, metabolic bone ds ```

Question 40

chrons disease ``` can effect.... s/s dx exam tx complications ```

Answer 40

Can affect any part of the GI tract, rectum is spared, transmural process, aphthoid ulcerations and focal crypt abscesses with loose aggregations of macrophages • S/S: acute or chronic bowel inflammation, RLQ pain, diarrhea, colicky, low grade fever, weight loss, fear of eating, anorexia • Exam: inflammatory mass palpated, urinary obstruction • Diagnostics: CBC, CRP, CMP, ESR, endoscopy (capsule is best), • Treatment: IV fluids and bowel rest, replace electrolytes • Complications: fistulas, adhesions, perforation

Question 41

UC mucosa is... s/s dx complications

Answer 41

Mucosal disease involving the rectum and all parts of the colon • Mucosa is erythematous and resembles sandpaper, severe cases hemorrhage is present, edematous and ulcerated • S/S: rectal bleeding, tenesmus, passage of mucus, crampy abd pain, proctitis • Diagnostics: similar to Crohn’s, barium enema, sigmoidoscopy during flare, colonoscopy if in remission • Complications: toxic colitis, megacolon, perforation

Question 42

diverticulitis or osis .....herniation complicacated uncomplicated tx surgical management

Answer 42

Saclike herniation in the bowel wall, generally left and sigmoid colon, causing inflammation • Determine if complicated or uncomplicated • Uncomplicated: abdominal pain, fever, leukocytosis, anorexia • Complicated: abscess, perforation, stricture, fistula • Treatment: diet alterations and increase fiber for uncomplicated, bowel rest and Bactrim or Cipro and Flagyl for complicated • Surgical management: Diverting colostomy, Hartman’s procedure, patients who are not responding medically

Question 43

GIB ``` causes s/s exam dx tx ```

Answer 43

Hematemesis or hematochezia • Causes: • UGI: PUD, gastritis, varices, Mallory-Weiss Tear (retching), AV malformation, malignancy, liver disease • LGI: hemorrhoids, diverticulosis, AV malformation, colitis • S/S: bright red blood, coffee ground, clots, retching, melena, blood in toilet, black stool • Exam: orthostatic, fatigue, exertional dyspnea, cool, clammy skin, pallor • Diagnostics: fecal occult blood test, CBC, CMP, coags, Type and cross, LFTs, EGD, colonoscopy*, bleeding scan • Treatment: stop bleeding, NGT unless contraindicated, blood transfusion, large bore IV for fluids, foley • Varices: octreotide, banding, TIPS (shunt), balloon tamponade, IV PPI, empiric abx

Question 44

GERD ``` defnition causes s/s dx tx complications ```

Answer 44

• Refluxed gastric acid and pepsin cause necrosis of the esophageal mucosa causing erosions and ulcers. • Causes: eosinophilia, infectious, herpetic, CMV • S/S: heartburn, dysphagia, chest pain • Diagnostics: endoscopy • Treatment: lifestyle modifications, PPI, H2 blocker • Complications: chronic esophagitis, adenocarcinoma, Barrett’s esophagus

Question 45

mesenteric ischemia ``` definition causes s/s exam dx tx ```

Answer 45

• Perfusion fails to meet the metabolic demands of the intestines resulting in ischemia • Causes: heart disease, shock, cocaine overdose • S/S: abdominal pain, n/v, diarrhea, anorexia, bloody stools • Exam: decreased bowel sounds, abdominal distention • Diagnostics: CBC, CMP, coags, ABG, amylase, lipase, lactate, LFTs, cardiac enzymes, CT angio*, colonoscopy, spiral CT • Treatment: ICU management, laparotomy*, hydration, antibiotics, oxygen • Chronic: reduce risk factors

Question 46

PUD ``` definitions causes s/s dx tx complicatons ```

Answer 46

Burning epigastric pain, worsened by fasting, relieved with eating • Causes: H. Pylori, NSAIDs, COPD, CRI, tobacco use, older age, ETOH use • S/S: abdominal pain, bleeding, n/v, dyspepsia • Exam: orthostatic, tachycardia, epigastric tenderness, rigid abdomen • Diagnostics: barium swallow, endoscopy, H. pylori testing, biopsy • Treatment: antacids, H2 blockers, PPI, sucralfate, bismuth, prostaglandin analogue • Complications: bleeding, perforation, obstruction

Question 47

H Pylori tx

Answer 47

Bismuth, metronidazole, tetracycline • Ranitidine bismuth citrate, tetracycline, clarithromycin or metronidazole • Omeprazole, clarithromycin, metronidazole or amoxicillin • Omeprazole, bismuth, metronidazole, tetracycline

Question 48

AKI ``` definition causes s/s dx tx complications ```

Answer 48

Sudden impairment of kidney function, retention of waste products • Causes: Prerenal, Intrinsic, Post-renal (see next slide) • S/S: related to cause • Diagnostics: serum Cr, rise of at least 50% than baseline 1 week prior, 0.3 mg/dl in 48 hours, or UO less than 0.5 ml/kg/hr in 6 hours • Treatment: IV fluids, remove nephrotoxic agent, optimize hemodynamics, treat underlying causes • Complications: ARF

Question 49

pre-renal AKI

Answer 49

``` Prerenal • Hypovolemia • Decreased CO • CHF • Liver failure • NSAIDs • ACE • Cyclosporine ```

Question 50

Intrinsic causes of AKI

Answer 50

``` Intrinsic • Sepsis • Ischemia • Nephrotoxins esp contrast • Acute glomerulonephritis, • Vasculitis • Malignant HTN • Post operative ```

Question 51

post renal aki is

Answer 51

obstruction

Question 52

CKD causes dx tx complications

Answer 52

Progressive decline in GFR • Causes: small for gest weight, obesity, HTN, DM, autoimmune, older adults, African ancestry, family history, AKI in the past, inherited • Diagnostics: GFR needed to stage CKD • Treatment: depending on stage, treat underlying cause, adjust medications, dialysis for ESRD • Complications: electrolyte imbalances, metabolic acidosis, anemia

Question 53

CKD stake I

Answer 53

gfr >90

Question 54

CKD II

Answer 54

GFR 60-90

Question 55

CKD IIIa

Answer 55

GFR 45-59

Question 56

CKD 3B

Answer 56

GFR 30-44

Question 57

CKD 4

Answer 57

gfr 15-29

Question 58

CKD stage 5

Answer 58

gfr <15

Question 59

UTI causes

Answer 59

``` Can be symptomatic or asymptomatic • Asymptomatic bacteriuria • Cystitis • Prostatitis • Pyelonephritis • Uncomplicated vs complicated • CAUTI • Causes: sexual intercourse, DM, incontinence, catheter, diaphragm with spermicide, pregnancy, functional or anatomic abnormalities ```

Question 60

UTI bacteria

Answer 60

Bacteria: E. coli is predominant, Pseudomonas, Klebsiella, Proteus, Citrobacter, Acinetobacter, Morganella

Question 61

UTI s/s dx tx

Answer 61

S/S: dysuria, urinary frequency, urgency, nocturia, hesitancy, pain, hematuria, fever, CVA pain • Diagnostics: urine culture and urinalysis, CBC, blood culture • Treatment: antibiotic based on cultures