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GI Flashcards

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1
Q

What is the differential for a pt with fever, ascites, anorexia, and cachexia w/ hx of alcohol and drug use all concerning for liver failure?

A

alcoholic cirrhosis

chronic or acute viral heptatis (most likely hep C)

Spont. bacterial peritonitis

peritoneal carcinomatosis secondary to ovarian cancer

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2
Q

What is the work up for concern for liver failure and ascites?

A

PT, PTT, INR

CBC, peripheral smear

BUN/Cr (look for hepatorenal syndrome)

AST, ALT, Alk phos, total bili, albumin, total protein

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3
Q

What are signs of chronic liver dz?

A

ascites

spider angiomata

asterixis

caput medusa

splenomegaly

palmar erythema

reversal of sleep-wake cycle with hepatic encephalopathy

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4
Q

What clotting factors are not made in the liver?

A

8 and von willebrand factor

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5
Q

What is the most common cause of cirrhosis in the US?

A

hep C

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6
Q

What are less common causes of cirrhosis?

A

more common: alcohol, hep C

less common: primary biliary cirrhosis

hemochromatosis

wilson dz

alpha 1-antitrypsin deficiency

drugs: isoniazid, methotrexate, acetaminophen

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7
Q

What are causes of ascites?

A

cirrhosis

malignancy (ovarian)

TB

right sided heart failure

vascular obstruction due to hepatic vein thrombosis (Budd-CHiari) or IVC thrombosis

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8
Q

How do you figure out the casue of ascites?

A

SAAG

serum - ascitic albumin

if >1.0 = portal HTN as cause (cirrhosis, CHF, hepatic/portal vein thrombosis syndromes)

If <1.1 = no portal htn (cancer, infection…etc)

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9
Q

What tests should we always get in ascites?

A

paracentesis with SAAG (tell you cause) and white cell count (for SBP)

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10
Q

How do you look for hepatoma (liver cancer)?

A

get an alpha fetoprotein

*most commonly complication of hep C

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11
Q

What are the lab tests you should get for a pt with ascites and liver dz?

A

hep B and C serologies

paracentesis (WBCs and albumin)

Iron studies

ceruloplasmin levels

alpha-1 antitrypsin level

antimitrochondrial antibodies

liver U/S

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12
Q

How do you manage cirrhosis?

A

salt restriction

diuretics (spironolactone and furosemide)

stop drinking, alcohol cessation programs

balanced diet w/ protein

if portal HTN - do upper endoscopgy to look for esophageal varices to know if need to put on a beta blocker

if hepatic encephalopathy - lactulose and rifaxamin

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13
Q

How does spironolactone work?

A

direct aldo antagonist, can lead to gynescomastia and hyperK

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14
Q

How does furosemide work?

A

loop diuretic, inhibits Na-K-2Cl symporter in thick ascending loop - leads to hypoK

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15
Q

How does lactulose work?

A

It is used to increase bowel movements - which can decr ammonia levels

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16
Q

How to monitor pts with chronic liver dz?

A

surveillance for varices every 2 years if initial endoscopy negative

if cirrhosis present - liver US every 6 months for liver cancer

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17
Q

How to treat varices in chronic liver dz pts and how to prevent them?

A

treat - band ligation

prevent - non-selective beta blocker (propranolol or nadolol)

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18
Q

What is the most concerning dx to be thinking about in a patient with a GI bleed and hx of chronic liver dz?

A

bleeding esophageal varices (highest mortality)

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19
Q

Ddx for vomiting blood?

A

bleeding esophageal varices

mallory weiss tear

erosive gastritis

peptic ulcer bleeding

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20
Q

What are the first steps in management for an unstable GI bleed?

A

stabilize the pt!

  1. 2 large bore PIVs and NS boluses until BP>90, HR<90, or UOP incr
  2. CBC (won’t see acute drops in Hgb, just baseline), electrolytes, PT/PTT (liver pts), type and cross
  3. transfuse blood as needed (symptoms - SOB, chest pain, or severe cont bleed)

*give fresh frozen plasma if coagulopathy present

  1. upper endoscopy and therapeutic intervention (GI consult)
  2. NG tube can help tell if still active bleeding, then take out
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21
Q

How can an upper GI bleed present?

A

hematemesis, melena, or bright blood per rectum (10%), dizziness

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22
Q

What must be done before sending pts home who had an upper GI bleed?

A

upper endoscopy!

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23
Q

What is management for upper GI bleed due to varices after they are stabilized?

A
  1. admit and monitor for recurrent bleeding
  2. IV somatostatin/octreotide
  3. propranolol once BP stable
  4. monitor for delirium tremens (hallucinations)
  5. FFP if incr PT and cont bleeding
  6. Norfloxacin as prophylaxis against SBP (for ascites)
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24
Q

How to dx and tx upper GI bleeding?

A

endoscopy w/ band ligation

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25
What counseling must always be given in pts admitted due to complications of alcohol comsumption?
counseling to stop drinking alcohol and suggest addication treatment
26
Which kind of ulcers are worse or better with eating?
duodenal are better with eating Gastric ulcers are worse with eating
27
How to work up peptic ulcers?
CBC LFTs (rule out cholelithiasis) US gallbladder (same as above) amylase/lipase (eval for pancreatitis)
28
What are complications of gastric/duodenal ulcers?
bleeding, perforation, gastric outlet obstruction
29
How do you tx peptic ulcer disease?
PPIs (omeprazole, lanzoprazole) for 2 months Can also use H2 blockers or sucralfate) \*if symptoms continue or pt has red flags (age \>50), consider upper endoscopy
30
What is Zollinger-Ellison syndrome and how does it present?
recurrent peptic ulcers + diarrhea get a random gastrin level it is caused by a gastrinoma
31
Do you test for H pylori with peptic ulcer dz?
yes with breath testing or stool antigen testing
32
How do you treat H pylori?
only if pt is symptomatic (has a ulcer or s/sx of ulcer) PPIs (omeprazole, lanzoprazole) 2 wks of metronidazole or amoxicillin and clarythromycin depending on resistance (usually at least 2 abx)
33
What is the most common cause of peptic ulcer dz?
H pylori duodenal (90%) gastric (70%)
34
What is diseases is H pylori associated with?
peptic ulcers gastric cancer lymphoma of gastric tract NOT GERD
35
When is surgery indicated for peptic ulcer dz?
severe bleeding not responsive to local therapy perforation obstruction
36
How to counsel pts with peptic ulcer dz?
avoid excess NSAIDs smoking and alcohol prevent healing of ulcers (do not cause them) spicy food is fine!
37
What can precipitate hepatic encephalopathy?
GI bleeding, medications (diuretics, benzos), infections
38
What lab helps confirm the dx of hepatic encephalopathy?
elevated ammonia levels (if ammonia is low doesn't really help) \*though it is a clinical dx
39
How to treat hepatic encephalopathy?
Correct precipitating causes (GI bleed, tx infection) protect airway if very somlenent minimize dietary protein eliminate sedatives or tranquilizers **lactulose** to increase ammonia excretion **Rifaxamin, neomycin, ampicillin, rifampin** to reduce nitrogenous production
40
What is the ddx for chronic diarrhea?
Inflammatory bowel dz celiac disease lactose intolerance whipple dz (malabsorption, arthritis, and neuro s/sx) irritable bowel syndrome
41
What is the rash that can present with celiac dz?
dermatitis herpitiformis (diffuse pruritic, papulovesicular rash over knees, elbows, buttocks, and back)
42
How to w/u chronic diarrhea?
CBC, serum iron, Ca, B12, folate stool culture and ova/parasites smear for fecal leukocytes stool for fat (sudan stain)
43
How do you dx celiac dz?
IgA anti-tissue transglutaminase, antigliadin and antiendomysial antibodies IgA level (control) small bowel biopsy \*GOLD STANDARD
44
What diseases will cause positive fecal leukocytes?
infections (shigella, campylobacter, E coli, C diff, salmonella) IBD
45
How do you treat celiac dz?
remove gluten from diet redo small bowel biopsy in a few months to see recovery give folate and iron supplementation as needed
46
What is the most specific and sensitive antibody for celiac dz?
anti-tissue transglutaminase antibody (IgA)
47
how do you treat dermatitis herpetiformis from celiac?
dapsone
48
What vitamins/elements may be low in celiac dz due to malabsorption in the small intestine?
iron, B12, zinc, mag, calcium
49
What are possible complications of celiac dz?
T-cell lymphoma in 10-15% of cases adenocarcinoma of intestine
50
What is the ddx for elderly person with fever and LLQ pain?
diverticulitis pyelonephritis Appendicitis colon cancer
51
How to w/u pt with concern for diverticulitis?
1st step: CBC, BMP, CXR, KUB, UA clinical \*could confirm with noncontrast CT of abd and pelvis (colonoscopy and barium emena are contraindicated!)
52
How do you tx diverticulitis inpt?
1. NPO 48-72 hours 2. IV hydration 3. IV antibiotic (e coli and klebsiella) \*Ciprofloxacin and metronidazole inpt switch to oral abx for total of 14 days 4. surgical exploration if pt worsens
53
What are complications of diverticulitis?
abscess formation colovesical fistula (recurrent UTI or pneumaturia perforation inflammatory phlegmonous mass
54
How to tx diverticulitis outpt?
for mild cases with relatively young pts Amox-clav or ciprofloxacin and metronidazole for 10-14 days
55
When to do a colonoscopy or barium enema in diverticulitis?
after the acute phase of the disease - CONTRAINDICATED in acute phase due to risk for perforation!! 2-3 weeks later to check for cancer
56
What is long term f/u and prevention for diverticulitis?
eat fiber! good hydration
57
Ddx of a pt with bloody diarrhea?
infectious enterocolitis (campylobacter, E coli, shigella, salmonella) IBD Hemorrhoidal bleeding
58
How to w/u bloody diarrhea?
stool culture, ova/parasites fecal leukocytes KUB CBC, ESR/CRP
59
How to dx inflammatory bowel disease?
colonoscopy with biopsies
60
What are the different findings of UC vs Crohns?
UC - always involves rectum (starts at rectum and goes up), mucosal, no perianal dz Crohns - can be patchy from mouth to anus, full thickness (transural granulomas), more prone to fistulas, perianal dz
61
How to treat ulcerative colitis?
Mesalamine and Corticosteroids for flares Long term: 6-MP (mercaptopurine) or azathioprine (immunomodulators) Refractory UC: may consider total colectomy
62
How to tx Crohn's dz?
Mesalamine and Corticosteroids for flares Long term: 6-MP (mercaptopurine) or azathioprine (immunomodulators) Severe cases of Crohn's (with fistulas): infliximab lifelong (TNF modifier)
63
What are pts with severe ulcerative colitis at risk for?
colon cancer after have had the disease \>10 yrs
64
What must you check before putting a pt with severe Crohn's on infliximab?
PPD and CXR for TB!!!!
65
What are extra-intestinal manifestations?
arthritis erythema nodosa episcleritis, iritis sclerosing cholagitis (UC at risk for cholanigal carcinoma) \*autoimmune obstructive dz of bile ducts
66
What follow up management and counseling shoudl you give IBD pts?
NSAIDs can cause flares \*cigarette smoking can be protective in US screen for TB (PPD, CXR) if starting infliximab incr risk colorectal cancer annual colonoscopy after have had dz for 8 yrs
67
What are common precipitants for acute pancreatitis?
1. **alcoholic binge** 2. **gall stone pancreatitis** trauma, steroids, autoimmune, scorpion, **hypertryglceridemia!**!, **ERCP, drugs**
68
How do you w/u acute pancreatitis?
stabilze the pt (IV fluids) CBC BMP (glucose may be elevated in severe dz, beta cells affected) (also look out for low Ca - multisystem failure) amylase, lipase(\*this one is more important) KUB (look for free air - perforated ulcer)
69
What imaging would you do for pancreatitis?
KUB (part of initial w/u) CT of abdomen \*if worried about right dx or complications (necrosis, bleeding)
70
How do you tx acute pancreatitis?
1. admit 2. NPO, feed gradually 3. morphine 4. IV hydration 5. observe for delirium tremens (alcohol cessation) \*CT - if necrosis, imipenem. if absecess, surgical debridement \*Gallbladder US - exclude gallstone pancreatitis, if positive get surgeons involed for removal at a later date
71
Does everyone with pancreatitis need at CT?
no! only if worried about progression or complications if pt is worsening
72
What is the cause of pancreatitis if AST/ALT, alk phos are elevated?
gall stone pancreatitis - obstruction of the bile duct
73
What are complications (and their timing) of pancreatitis?
pseudocyst formation (1-4 wks) pancreatic necrosis (2 wks) abscess formation (4-6 wks) ARDS
74
What follow up is needed for a pt with pancreatitis due to gall stones?
cholecystectomy sometime after acute episode
75
What to think about with jaundice, fever, and RUQ tenderness?
**ascending cholangitis!!!!!** choledocholithiasis cholecystitis primary sclerosing cholangitis
76
How to w/u ascending cholangitis?
1. 2 large-bore IV lines and bolus (NS) until bp\>90, hr\<90, or incr UOP \*pressors if needed 2. CBC, CMP, PT/PTT, LFTs 3. consider intubation! if obtunded/has unprotected airway 4. foley cath to monitor UOP
77
How does ascending cholangitis happen?
gallstone obstruction and then infection \*other things that can cause obstruction include occluded stents, malignancy
78
How to tx ascending cholangitis?
tx (gram neg rods - e coli, klebsiella) with **pip/tazo IV** NPO, IV hydration abdominal US to confirm gall stone/dilation once stable: **ERCP to dx and tx** GI consult
79
What is the lieklihood of getting pancreatitis after ERCP?
10%
80
What is the follow up management after ascending cholangitis?
if due to gall stone - will need a cholecystectomy at some point after the acute episode (2-3 wks)
81

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