GI Block Flashcards
1
Q
The largest membrane in the body is what… and what kind of cells is it made up off
A
The peritoneum
And a layer of simple squamous cells
2
Q
What organs are retroperitoneal
A
Kidneys, ascending and descending colon
Duodenum
And Head/ Body of pancreas ( not the tail)
3
Q
What are the layers of the esophagus
A
Adventitia, Muscualris and mucosa
Muscularis is 1/3 skeletal muscle, 1/3 mixed, and 1/3 smooth muscle for superior to interior
Mucosa: smooth muscle, lamina propia, and Nonkeratinized Stratified squamous
4
Q
Note the difference between the UES and the LES
A
UES: upper esophageal sphincter is skeletal muscle
LES: lower sphincter is smooth muscle
5
Q
What is the 1st part of the small intestine
A
Duodenum
6
Q
What are the 4 main regions of the stomach
A
Cardia, Fundus, Body, Pylorus
7
Q
What are the cells in the gastric pit
A
Surface mucous cell, Mucous neck cells, Parietal cells (HCL and IF) , Chief cells (Pepsinogen, Gastric lipase) , G cells (Gastrin)
8
Q
In the presence of histamine how do ACh and Gastrin react
A
They are secreted more, making histamine a synergistic component (hence H2 blockers)
9
Q
What are the ducts of the pancreas
A
Pancreatic duct ( Duct of Wirsung): connects to the common bile duct and enters the duodenum and the “AMPULA of VATER” controlled by the sphincter of oddi
Duct of Santorini (accessory duct): connects to the duodenum superior to the ampulla of Vater
10
Q
What are the cell types of the pancreas
A
Clusters of glandular Epithelial cells call acini
And pancreatic islets (langerhaans)
11
Q
Start at the left hepatic duct and trace your way to the duodenum
A
Left hepatic combines with right hepatic to form the common hepatic which joins with the cystic duct to make the common bile duct with connects to the duct of Wirsung (pancreatic duct) to make the ampulla of Vater, that passes through the sphincter of oddi into the duodenum
12
Q
Ph of pancreatic juices
A
7-8
13
Q
What stops the action of Pepsid from the stomach
A
Pancreatic juices (pH)
14
Q
What enzyme digests starch
A
Pancreatic amylase
15
Q
What enzyme breaks down proteins
A
Trypsin, Chymotrypsin, Carboxypeptidase, Elastase
16
Q
What is the principle enzyme that breaks down triglycerides
A
Pancreatic lipase
17
Q
What divides the two lobes of the liver
A
Falciform ligament
18
Q
What connects the falciform ligament to the umbilicus
A
Ligamentum teres
19
Q
Where does the liver receive blood from
A
Hepatic artery 25% (O2)
Portal Vein 75%
20
Q
What is the blood flow through the liver
A
Hepatic artery+portal vein Hepatic sinusoids Central vein Hepatic vein I. VC Right atrium
21
Q
Where does bile come from
A
Hepatic lobules to bile canaliculi to bile ducts
22
Q
What makes up the portal tríad
A
Bile duct, portal venue, portal artriole
23
Q
What are the general functions of the liver
A
Carb and lipid and protein metabolism, synthesis of bile salts, activation of vitamin D, Metz of drugs and hormones, excretion of bilirubin
Storage of glycogen and fat vitamins, as well as copper and iron,
Phagocytosis
24
Q
PH of Bile
A
7.6-8.6
25
What is the longest and shortest portion of the small intestine
Longest: ileum (6 ft)
Shortest: duodenum ( 10 inches)
26
What vitamins are produced in the large intestine
Vitamin K and biotin
27
What are the 4 regions of the large intestine
Cecum, colon, rectum, and anal canal
28
What is the pectinate line of the anal canal
Inferior most portion of the anal columns
Above this line is visceral innervation (sensitive to only stretch)
Below this line somatic innervation, sens. To pai, temp and touch
Important to hemorrhoid location
29
What is the definition of dyspepsia
Acute, chronic, or recurrent pain located in the upper abdomen
Clinically relevant > 1 month
30
What are the associated s/s of dyspepsia
```
Postprandial fullness
Early satiation
Anorexia
Belching
Nausea/vomiting
Bloating
Heartburn
Regurgitation
```
31
Does dyspepsia= heartburn
No
32
What are the 2 types of dyspepsia
Organic: GI tract dysfunction, mediations, Pancreatic/biliary DOs, systemic conditions, PUD and GERD
Functional
33
What is the most common cause of chronic dyspepsia
Functional dyspepsia
34
What is the DO criteria for functional dyspepsia
Postprandial fullnes, early fullness, Epi gastric pain or burning
With no evidence of structural dz
35
What are the alarm features of dyspepsia
```
Unintentional weight loss
New-onset dyspepsia after age 55 years
Dysphagia
Persistent vomiting
Any overt gastrointestinal bleeding, hematemesis, or melena
Family history of esophageal or gastric cancer
Iron deficiency anemia
Palpable abdominal mass or lymph node
```
36
What labs should be ordered in dyspepsia
H pylori
CBC
CMP
Thyroid panel
Others:
Celiac disease test
Stool for ova and parasites, guardia, fecal fat, or elastase
Ultrasound or CT ( pancreatic, biliary, Volvulus, or vascular dz)
Gastric emptying studies
37
What is the investigation of choice for dyspepsia
Upper endoscopy
38
What patients get an upper endoscopy
All patients over 60 with new onset of dyspepsia
| All pts with alarm features
39
What is the most important risk factor for gastric cancer
H pylori
40
What are the 4 tests for H pylori
Invasive: Gastric mucosal biopsies
Non invasive: Fecal Antigen, Urea breath test, serology
41
What test is the initial DO for H pylori and to confirm eradication
Fecal antigen test
42
What is the Tx for H pylori
high resistance: PPI, Bismuth, Tetra, and metro
Low resistance: PPI, Clarytho, Amoxicilin, metro
43
What is the managment of function dyspepisa
Lifestyle changes ( smaller meals, food diary, quit smoking)
Antisecratory Tx x 4 weeks
Antidepressants
Metocloprimide
44
What is the brain stem vomiting center
Área póstrema, nucleus tractus solitarios, and central pattern generator
All within the medulla
45
Acute onset of nausea without Ab pain what is the DDx
Food poisoning, acute gastroenteritis, systemic illness
46
Acute onset of N/V with Ab pain, DDx?
Peritoneal irritation, acute gastric or intestinal obstruction, or pancreaticobiliary disease
47
Persistent N/V, DDx ?
Pregnancy, gastric outlet obstruction, gastroparesis, intestinal dysmotility, psychogenic disorders, and central nervous system or systemic disorders.
48
Vomitting immediately after meals, DDx?
Bulimia or psychogenic
49
What is the criteria for orthostatic HOTN
Orthostatic hypotension - the presence of at least one of the following within 3 min of standing:
Decrease in systolic blood pressure by ≥20 mm Hg
or
Decrease in diastolic blood pressure by ≥10 mm Hg
A HR increase of ≥30 bpm may suggest hypovolemia, independent of whether the patient meets criteria for orthostatic hypotension
50
What is Ondansetron
Seretonin 5-HT3 antagonists
ANTIEMETIC
51
What are promethazine and prochloperazine
Dopamine antagonists
ANITEMETICS
52
What are meclizine, dimenhydrinate, scopalamine, and diphenhydramine
Antihistamines
ANTIEMETICS
53
What is singultus
Hiccups
54
Causes of hiccups
```
Sudden excitement, emotion
Gastric distention
Esophageal obstruction
Alcohol ingestion
Sudden change in temperature
```
55
Persistent hiccups are a clue to
Persistent hiccups may be a sign of serious underlying pathology.
CNS – neoplasm, infection, trauma
Metabolic – uremia, hypocapnia
Chronic irritation of the vagus or phrenic nerve
Postoperative
Psychogenic
56
What is the managment of hiccups
```
Physical maneuvers:
Teaspoon of dry sugar
Holding breath/Valsalva
Rebreathing
Scaring
```
Consider medications if persistent >48 hrs
- PPI if GERD is present
- Baclofen, gabapentin, or metoclopramide
Surgical referral for ablation/stimulation of the phrenic nerve for refractory
57
What is eructation
Belching, burping
58
What is FODMAPs
Causes of flatus
```
Fermentable
Oligosacharides
Disaccharides
Monosaccharides
Polyps
```
59
What are the drugs to tx flatus
Alpha-d-galactosidase enzyme (Beano®)
Simethicone (Gas-X®)
Lactase enzyme (Lactaid®)
60
What is the definition of constipation
Decreased stool frequency
(fewer than three bowel movements [BM] per week)
with complaints of excessive straining, lower abdominal fullness, hard stools, feeling of incomplete evacuation, commonly associated with hardened feces or another underlying disorder.
61
Common causes of constipation
Dehydration, poor diet, poor habits, DM, hypothyroid, Cancer, Drugs, IBS
62
What is the constipation W-Up
Dullness to percussion in the lower quadrants (left)
DRE- obstruction and hard stool in rectal vault
CBC
CMP
Thyroid Panel
FOBT
```
Radiographs
Endoscopy (colonoscopy or sigmoidoscopy)
```
63
What is the pharm managment of constipation
Pharmacotherapy:
Osmotic Laxative:
- Magnesium hydroxide (Milk of Magnesia, Epsom Salts)
- Polyethelyne glycol 3350 (Miralax)
* *Polyethelyne glycol (GoLYTELY)
* *Magnesium citrate
```
Stimulant Laxative:
-Bisacodyl (Dulcolax)
-Senna (ExLax)
Stool Surfactants:
-Docusate Sodium (Colace)
```
Enema:
Tap water
Saline (Fleet)
64
What is the managment to fecal Impaction
Initial treatment is directed at relieving the impaction with enemas (saline, mineral oil, or diatrizoate) or digital disruption of the impacted fecal material.
65
When should pts get referrals for constipation
```
Symptoms are refractory to treatments
Patient has structural abnormality
Evidence of obstruction
Over age 50 or Alarm symptoms
Referral for scope
```
66
What is the definition of diarrhea
Increased stool frequency (>3 BMs/day)
and/or
Loose/liquid stools
67
What is often the cause of non inflammatory diarrhea
Virus, sometime bacteria and rarely parasites
68
What is the time frame for acute vs chronic diarrhea
Acute is less than 2 weeks
| Chronic is longer than 4 weeks
69
What is the criteria for persistent diarrhea
Lasting 2-4 weeks
70
What is the essential DO for acute non inflammatory diarrhea
Less than 2 weeks
Non bloody
Mild and self limited
Caused by a virus or non invasive bacteria
71
When should evaluation for Diarhea be performed
For severe cases or lasting longer than 7 days
72
What are the agents that can cause non inflammatory acute diarrhea
Viral (most common):
- Norovirus (50%)
- Rotavirus (children, older adults)
- Cytomegalovirus (AIDS)
Bacterial (less common):
- Clostridum perfringens, Bacillus cereus, Staphylococcus aureus
- Shiga toxin–producing Escherichia coli
- Vibrio cholerae toxin (causes the small intestinal cells to secrete, rather than absorb, fluid and electrolytes)
Parasites:
-Giardia, Cryptosporidium, Cyclospora, Cystoisospora belli
73
What is essential to DO acute inflamatory diarrhea
Less than 2 weeks
Bloody
Pus
Fever
74
What is the evaluation W-up for acute inflammatory diarrhea
Routine stool cultures ( e.coli 0h157)
C. Diff testing, ova and parasites
75
What is tenesmus
Rectal cramping seen in acute inflammatory diarrhea
76
What are the agents that curse acute inflammatory diarrhea
```
Salmonella (most common)
Campylobacter
Shigella
Shiga toxin–producing Escherichia coli
Enteroinvasive Escherichia coli
Clostridium difficile (recent antibiotics)
Nosocomial origin
Yersinia
Entamoeba histolytica
(bloody diarrhea in patients who recently traveled to a developing country)
```
77
When is prompt eval of diarrhea warranted
Signs of inflammatory diarrhea:
- Fever
- WBC 15,000/mcL or more
- Bloody diarrhea
- Severe abdominal pain
- Profuse watery diarrhea and dehydration
- Frail older patients or nursing home residents
- Immunocompromised patients
- Exposure to antibiotics
- Hospital-acquired diarrhea (onset following at least 3 days of hospitalization)
- Systemic illness
78
How will fecal leukocytes be in non inflamatory diarrhea
Negative
79
How many samples are needed in ova and parasite testing
3
80
What is the test that is a marker of intestinal inflammation
Fecal lactoferrin
81
What are the anti motility agents used to tx acute diarrhea
Loperamide
| Bismuth (good for travelers diarrhea)
82
When should ABX be used in the Tx of diarrhea
Patients with fever, abdominal pain, bloody diarrhea, or dysentery presumed due to Shigella
Patients who have recently traveled internationally with body temperatures 38.5 °C or higher and/or signs of sepsis
Immunocompromised patients with severe illness and bloody diarrhea
Patients with severe diarrhea in the context of hospitalization or antibiotic therapy (C dif)
83
What are the DOC for empiric diarrhea ABX Tx
Fluoroquinolones – drugs of choice:
- Ciprofloxacin 500 mg BID for 5-7 days
- Ofloxacin 400 mg BID for 5-7 days
- Levofloxacin 500 mg QD for 5-7 days
84
What are the drugs that are used to Tx travelers Diarhhea
Fluoroquinolones – 3 day courses
Not useful for travel to Southeast Asia
Azithromycin – 1000mg single dose
Rifaximin 200 mg TID x 3 days
85
ABX in diarrhea should only be used to Tx which agents
```
Shigellosis
Cholera
Extraintestinal salmonellosis
Listeriosis
Traveler’s diarrhea
C difficile
Giardiasis
Amebiasis
```
86
When should a pt be admitted with diarrhea
Severe dehydration for intravenous fluids
Bloody diarrhea that is severe or worsening
Severe abdominal pain, worrisome for toxic colitis, inflammatory bowel disease, intestinal ischemia, or surgical abdomen.
Signs of severe infection or sepsis (temperature higher than 39.5°C, leukocytosis, rash).
Severe or worsening diarrhea in patients who are older than 70 years or immunocompromised.
Signs of hemolytic-uremic syndrome (acute kidney injury, thrombocytopenia, hemolytic anemia).
87
What is the first step in evaluating a pt with chronic diarrhea
Review their med list
88
What should be considered in all pts with chronic postprandial diarrhea
Carb malabsorption
89
How will fasting effect osmotic diarrhea?
| Secretory diarrhea?
Osmotic : Stool volume decreases with fasting
Increased stool osmotic gap
Secretory: Increased intestinal secretion or decreased absorption
High volume, watery stool
Little to no change with fasting
Normal stool osmotic gap
90
What can cause secretory chronic diarrhea
Laxative abuse
Endocrine tumors
Bile salt malabsorption
91
What are the causes of chronic inflammatory diarrhea
Inflammatory Bowel Disease
- Crohn Disease
- Ulcerative Colitis
Microscopic Colitis
Malignancy
Radiation
92
A young adult with lower Ab pain and altered bowel habits, with out wt loss, nocural diarrhea, anemia or GI bleeding think?
IBS
93
What are the causes of chronic infectious diarrhea
Parasitic infections
Giardia, E histolytica, and Cyclospora
Intestinal nematodes
94
What is the W-up to chronic diarrhea
First exclude most common causes:
Medications, IBS, lactose intolerance
Evaluation directed at most likely etiology based on symptoms and history
Lab Tests:
CBC, Chem 17, LFT, Thyroid studies, ESR, CRP
Stool studies
Culture, Leukocytes, Lactoferrin, Occult blood, O&P, electrolytes
Colonoscopy ( r/o IBD and neoplasm)
24 hr stool collection
Referral to gastro
95
What is the anatomic landmark that separates upper and lower GI
Ligament of trietz
96
What defines Acute upper GI bleeding
Essentials of Diagnosis
-Hematemesis
-Varying degrees of hypovolemia
+/- Melena (may be hematochezia in massive bleed)
-Bleeding proximal to the Ligament of Treitz
97
What are the general causes of acute upper GI bleeding
```
PUD
Portal Hypertension (esophageal varices)
Mallory Weiss tears (alcohol abuse)
Angioectasis
Telangiectasis
Neoplasms
Erosive gastritis/ esophagitits
```
Boerhaave syndrome (rupture of esophagus)
98
What is the 1st and most important step in the managment of an acute upper GU bleed
Stable or unstable?
Unstable: SBP< 100
HR>100
99
What is the managment of unstable upper GI bleed
Start IV
- CBC, PT/INR, CMP, type and screen
- Fluid or Blood Replacement
- Start isotonic fluids
- 2-4 units PRBC
- NG Tube
May be helpful in initial assessment, aspiration of blood or coffee grounds confirmatory
Consider octreotide if patient has liver disease or portal hypertension
Reduces splanchnic blood flow and portal BP
100
What are the high risk factors for rebleeding in acute upper GI bleeds
Age > 60
Comorbid illnesses
SBP < 100 mmHg
Pulse > 100 bpm
Bright red blood in NG aspirate or upon rectal examination
101
Where do high risk pts with upper GI bleeds get sent to
ICU
102
What do all pts with acute upper GI bleeds get
EGD (endoscopy)
103
What is the pharm approach to acute upper GI bleed
PPI
Octreotide ( reduces portal BP and lowers rebleed RSK)
D/c NSAIDS
ABX if H. Pylori
104
What are the causes of lower GI bleeding
```
Anorectal Disease (MC mild)
-Hemorrhoids, fissures, ulcers
```
Diverticulosis (MC severe)
-Painless, bright red blood, “large” volume
Inflammatory Bowel Disease
-Ulcerative Colitis, Crohn Disease
Infectious Colitis
Neoplasm
Angioectasias
-Commonly in older patients (> 70 yrs)
Ischemic Colitis
105
What is the causes of lower GI bleeds in pts less than 50
Anorectal Disease
Inflammatory Bowel Disease
Infectious Colitis
106
What are the likely causes of lower GI bleed in pts over 50
Diverticulosis
Malignancy
Angioectasias
Ischemic Colitis
107
What is the DDI with painful defecation
External hemorrhoids or anal fissures
108
What is the DDx with abdominal pain/ .cramps
IBD or colitis
109
What is the DDx with pts with lower GI bleeds yet painless
Internal hemorrhoids or diverticular bleeding
110
If the lower GI bleeding is a large volume thing
Diverticular bleeding
111
If the lower GI bleeding is low volume think
IBD, or hemorrhoids
112
What is an ominous sign in LGIB
Anemia- particularly If suspecting a neoplasm
113
What is the W- up/ .testing of LGIB
Exclude upper source ( NGT, EGD)
Colonoscopy- if large volume or older than 45
(Within 24 hrs if active bleed)
Anoscopy or sigmoidoscopy - if small volume or younger than 45
Technetium scal and angiography- if continued unstable or hematochezia
Capsule endoscopy
114
What is the Tx approach to Large volume LGIB
Therapeutic colonoscopy
-Vasoconstrictive injection, cautery, clips/bands
Intra-arterial embolization
Surgery
- Last resort
- Indicated if patient requires > 6 units of PRBC in 24 hrs or more than 10 units total
115
Where is obscure bleeding in the GI tract usually from
Small intestine
116
What is occult blood in the GI tract from
(positive result of fecal occult blood testing, usually in the setting of iron deficiency anemia)
117
What type of bleeding does a fecal immuniochemical test detect
Only LGIB
118
The presence of unexplained anemia or abnormal CBC think
Occult bleeding
119
If there is an occult GIB, you must investigate for a..
Neoplasm
120
Asymptomatic pt with incidental FOBT w/out anemia, gets what test
Colonoscopy
121
Symptomatic pt with +FOBT and or unexaplined anemia should get..
Upper Endoscopy AND Colonoscopy
122
IF the GI bleeding is bright red, what is the likely source
Left colon
123
If the GI bleeding is brown with streaks of red, what is the likely source
Rectosigmoid or anus
124
If the GI bleeding is maroon, what is the likely source
Small intestine ro right colon
125
If the GI bleeding is Black what is the likely source? N
Upper GI
126
What is the definition of ascites
The pathologic accumulation of fluid in the peritoneal cavity
127
What is the normal amount of fluid in the peritoneum
Men: none
Women -/+ 20 ml ( menestral dependent)
128
What is the most common cause of ascites
Portal hypertension
- hepatic congestion (CHF)
- liver dz (80%)
- hepatitis
Others: Hypoalbunima and Nephrotic syndrome
Chylous, pancreatic DO, bile ascites
Infections or Cancer
129
What two veins lead to the hepatic portal vein
Splenic and Superior Mesenteric
130
What is portal HTN
Pressure gradient between the portal vein and the IVC > 10 mmHg
131
What is the pt hz relevant to ascites
Alcohol, hepatic, and cancer
132
Fever with ascites suggests
Bacterial peritonitis
133
What are the prominent physical exam findings in Ascites
Hepatic enlargement, elevated JVP, and large adominal wall veins
W/ liver dz: muscle wasting and malnourishment
134
What is the physical exam test for ascites
Shifting Dulles test
135
What are the lab tests / W-up for ascites
Abdominal paracentesis
White cell count
Albumin and Total Protein
Culture and Gram stain
136
What does a cloud paracentisis of the abdomin tell you
Infection
137
What does a milky paracentises of the abdomin tell you
Chyle
138
What is the ranges for a serum-ascites albumin gradient (SAAG)
Serum albumin - ascetic fluid albumin
>1.1 = portal HTN
< 1.1= non portal HTN causes
139
What are the common pathogens in Spontaneous bacterial peritonitis
E. coli
Klebsiella pneumonia
Streptococcus pneumonia
viridans streptococci
Enterococcus species
140
What is the definition of spontaneous Bacterial peritonitis
Infection of ascitic fluid in the absence of an intra-abdominal source of infection
*Must be distinguished from secondary bacterial peritonitis (ie, intra-abdominal infection)
141
What is spontaneous bacterial peritonitis typically caused from
Ascites as a result of chronic liver dz
142
What are the S/s of spont. Bacterial peritonitis
Ascites
FEver
Abdominal pain without focal TTP
143
What is the most important lab test in the evaluation of ascetic fluid
Grain stain and culture with Cell count + differential
| Paracentesis
144
If a secondary bacterial peritonitis is suspected what should you order
get abdominal CT to discover source of infection.
145
What is the Tx approach for Spont. Bacterial Peritonitis
ADMIT
Empiric: 3rd gen cephalosporin ( cefotaxime or Ceftriaxone)
Comb9ined with a betalactam agent ( ampicillin/ Sulbactam)
146
What is the prophylactic Tx for patients with spontaneous Bacterial peritonitis
~70% of patients who survive an episode of spontaneous bacterial peritonitis will have another episode within 1 year
Once-daily oral antibiotic (ciprofloxacin or TMP-SMX DS)
Reduces rate of recurrence to < 20%
147
What is chylous ascites
Accumulation of lipid-rich lymph (chyle) in the peritoneal cavity
Milky white in appearance
Due to lymphatic obstruction (lymphoma)
148
What is pancreatic ascites
intraperitoneal accumulation of massive amounts of pancreatic secretions
Due to disruption of pancreatic duct
Seen in chronic pancreatitis
149
What is the cause of bile ascites
Due to complications from biliary tract surgery, or percutaneous liver biopsy, or abdominal trauma
150
What is the cause of Heart burn ( pyrosis )
Reflux of material into the esophagus
151
What is the cause of dysphasia
Aka Difficulty swallowing
Mechanical obstruction or motility DO
152
What is odynophagia
Painful swallowing
Usually erosive DO
Or can be infectious from Candida, HSV, or CMV
Or caustic ingestion of pill induced ulcers
153
What is the study of choice for Esophageal DO
EGD ( Upper Endoscopy)
154
How are barium esophagographys used in esophageal DO/ managment
Performed first to differentiate b/w structural and motility abnormalities
More sensitive for detecting subtle esophageal narrowing due to rings, achalasia, and proximal esophageal lesions.
155
What is a test that determines the function of the LES
Esophageal manometry
156
What are the 4 causes of GERD
Dysfunction of the LES
Hiatal Hernia
Abnormal esophageal clearance
Delayed gastric emptying
157
What is the clinical presentation of GERD
Heartburn
Regurgitation
Dyspepsia
158
What is the DDx for GERD
```
Esophageal motility DO
Peptic Ulcer
Angina Pectoris
Functional DO
Eosinophil esophagits
```
159
What are the alarm features of GERD
```
Troublesome dysphagia
Odynophagia
Weight loss
Iron deficiency anemia
Fever, chills, night sweats
```
160
PTs that continue to show S/s despite anti acid TX with GERD require..
EGD (upper Endoscopy)
161
What is the Test of Choice for GERD pts
EGD ( upper endoscopy)
162
What effect does smoking/ nicotine have on the LES
Relaxes it, increases RSK for GERD
163
What is the managment approach for mild GERD with intermittent S/s
PRN OTC antacids or H2 blockers
164
What is the Tx approach to patients with GERD and have troublesome S/s
Once daily PPI
165
What is the Tx approach to managing a pt with S/s of GERD that persist beyond 4 weeks
BID PPI
166
What are Cimetidine, Ranitidine, and Famotidine
H2 blockers
Onset w/in 30 min and duration 8 hours
167
What are omeprazole, Rabeprazole, Lasoprazole, Esomeprazole, Pantoprazole
PPI
Take 30 minutes borre 1st meal
168
Any pt with alarm S/s should get l
Immediate referral for EGD ( upper endoscopy)
169
When can pts D/c PPI use
Patients may discontinue PPI after 8-12 weeks if symptomatic relief has been achieved
Most will relapse and require continuous therapy with lowest dose that controls symptoms
170
What is the surgical option for GERD
Nissen Fundoplication
fundus of the stomach is wrapped around the esophagus and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle
Acts as a reinforcement for the LES
For patients who are refractory to medical treatment or have severe disease
171
What is Barrett’s esophagus
Squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium containing goblet and columnar cells
Result of prolonged exposure to caustic gastric contents
Development may actually reduce the symptoms of GERD
11-fold increased risk of esophageal adenocarcinoma
172
What is the Tx for Barrett’s esophagus
PPI therapy
| Endoscopy w/ biospsies q 3-5 years
173
What is a peptic stricture
Narrowing of the esophageal lumen at the GEJ
Progressive solid food dysphagia
Treated with endoscopic dilation
174
What are the agents of infections esophagitis
Candida
CMV
HSV
175
Infectious Esophagitis occurs most commonly in what pts
```
AIDS
Transplants
Immuno comp
Cancer pts
Chronic immuno suppressive drugs ( Steriods, RA, IBD)
```
176
How do immuno comp pts present with Infectious esophagus and what is the emperic Tx
Immunosuppressed patient presents with dysphagia and odynophagia, +/- chest pain
Diagnosis and specific etiology determined via EGD with biopsy
Treatment directed at specific etiology
May try empiric anti-fungal
Fluconazole (Diflucan), if no response in 5 days= EGD
177
What are the common offfending agents for Pill induced esophatitis
```
NSAIDs
potassium chloride pills
Quinidine
Zalcitabine
Zidovudine
Alendronate
Risedronate
emepronium bromide
Iron
vitamin C
antibiotics (doxycycline, tetracycline, clindamycin, trimethoprim-sulfamethoxazole)
```
Injury is most likely to occur if pills are swallowed without water or while supine
178
What is eosinophilic esophagitis
Inflammatory response of the esophagus to allergen
(food or environmental)
Infiltration of eosinophils
Inflammation leads to progressive dysphagia
Narrowing of the esophageal lumen
179
What is the W- up for eosinophilic esophagitis
Ask about history of asthma, allergies, atopic dermatitis (eczema).
Clinical Findings:
Dysphagia to solid foods
Heartburn
EGD with mucosal biopsy required for diagnosis
Specimens show eosinophilic infiltrates
180
What is the Tx approach for eosinophilic esophagus
Empiric trial of PPI first
BID dosing for 2 months
Referral to allergist
Topical corticosteroids
-Swallowed fluticasone (from inhaler)
181
What are esophageal webs
Esophageal Webs – thin membranes of squamous epithelium
Mid to upper esophagus
Most are asymptomatic
May cause intermittent dysphagia or GERD like symptoms
182
What are esophageal rings
(“Schatzki Rings”)
Circumferential mucosal structure in the distal esophagus
Similar symptoms as webs
Strong association with hiatal hernia
183
What are schatzki rings strongly associated with
Hiatal hernias
184
What is the DO test for Webs and RIngs of the esophagus and what is the Tx if symptomatic
Diagnostic test-
Barium swallow
Treatment-
Endoscopic dilation if symptomatic
185
What is sender diverticulum
Pharyngoesophageal diverticulum
-‘pharyngeal pouch’
Symptoms
- Progressive dysphagia
- Sensation of food ‘sticking’ in the throat
- Halitosis
- Regurgitation of undigested food, pills
Use - Barium Swallow to diagnose
186
What is achalasia
Esophageal motility disorder
Loss of normal peristalsis in the distal 2/3 of the esophagus
Impaired relaxation of the LES
ETIOLOGY-
Idiopathic
(autoimmune, viral, or primary neurodegenerative processes suspected)
187
What are the S/s of achalasia
Progressive dysphagia to solids and liquids
Regurgitation of undigested food
Substernal discomfort after eating
Adoption of ‘maneuvers’ to enhance emptying
Weight loss
188
What are the DO and presentation of Achalasia
Barium Swallow - “Bird’s Beak Deformity”
Tapering of the distal portion of the esophagus
EGD and esophageal manometry to confirm
189
What is the DDx of achalasia
Chagas Dz from T. Cruzi (Mexico and Central/ South America)
But has a more rapid onset
190
What is the Tx f or achalasia
Refer patients to GI for evaluation and management
- Botulinum Toxin into the LES – 85% effective, 50% relapse, preferred for poor surgical candidates
- Pneumatic dilation – preferred, 90% effective
- Surgery - 95% effective
191
What is the perferred Tx for achalasia
Pneumatic dilation
192
What is the cause of esophageal Varices
Dilated submucosal veins due to portal hypertension
Can cause severe upper GI bleeds with a high mortality rate
193
What is the Tx approach to esophageal Varicies
Emergent Treatment:
- Hemostasis
- Stabilization of the patient
Follow-on Treatment:
- Reduction of portal hypertension
- Beta blockade (propranolol)
- Variceal band ligation
194
What is Mallory Weiss syndrome
Mucosal tear at the GEJ
- Sudden increase in abdominal pressure
- Retching or vomiting
- Strong association with alcoholism
Causes acute upper GI bleed
Patient presents with hematemesis
195
What is the Tx approach to a Mallory Weiss tear
Stabilize the pt
Then upper endoscopy
Epinephrine
Cautery or endoclip
196
What is Boerhaave syndrome
Complete rupture of the esophagus
Shock, pneumomediastinum, general badness
197
What are the S/s of Esophageal Carcinoma
Progressive solid food dysphagia
Odynophagia
Significant, unexplained weight loss
May be body aches or pains associated with metastasis
198
What is a type I hiatal hernia
Sliding hernia
Displacement of the gastroesophageal junction above the diaphragm.
The stomach remains in its usual longitudinal alignment and the fundus remains below the GE junction
199
What are Type II, III, and IV hiatal hernias
True hernia with a hernia sac
Upward dislocation of the gastric fundus through a defect in the phrenoesophageal membrane
200
What is the DO test for hiatal hernia
Barium swallow study
201
What is the Tx approach to hiatal hernia
Small hernias =GERD management
| Larger hernias = surgical repair
202
What is the dif between gastropathy and gastritis
Gastropathy – mucosal damage without inflammation
Gastritis – mucosal damage WITH inflammation
203
What is gastritis commonly secondary to
infectious or autoimmune etiologies
204
What is gastropathy commonly secondary to
endogenous or exogenous irritants
- Alcohol
- NSAIDS
- Physical stress
205
How does a pt with gastropathy typically present
Anorexia and Epigastic pain
Most common clinical manifesting is UGIB
206
What is a prostaglandin
Lipids derived from arachidonic acid
Generated by the action of cyclooxygenase (COX) isoenzymes
207
What do prostaglandins do
Play a key role in the generation of the inflammatory response
Inflammation is the immune system’s response to infection and injury
Stimulate epithelial cells to release more bicarbonate and mucus
Reduces the permeability of gastric epithelium
Reduces acid back-diffusion
Act as potent vasodilators
Increase gastric mucosal blood flow
Increases resistance to injury
Prostaglandins that contribute to gastroprotection are derived principally from COX-1
208
What are Asprin, Ibuprofen, Naproxen, Indomethacin, Piroxicam, Diclofenac
COX-1 inhibitors
Can causes NSAD Gastropathy
209
What is the most common complaint of NSAID gastropathy
Dyspepsia
210
What is the Tx approach to Gastropathy
Discontinuation of NSAID
Reduction to lowest effective dose
Switch to COX-2
211
What is the Tx approach to Alcoholic gastropathy
Dyspepsia, nausea, vomiting with minor hematemesis
Treatment with discontinuation of alcohol
H2 or PPI for 2-4 weeks.
212
Stress-related mucosal erosions and subepithelial hemorrhages may develop within ___ hours in critically ill (bedridden) patients.
How is this prevented
72 hours
Prophylactic H2-receptor antagonists (intravenous) or proton pump inhibitors (oral or intravenous )
213
Pts with stress gastropathy and __________ are at the highest risk for significant bleeding
Coagulopathy
Or
Respiratory failure w/ mechanical ventilation
214
What is the Tx approach to portal HTN gastropathy
Beta blockers to lower portal pressure
215
Prior to testing for H pylori what must pts do
Patients should discontinue anti-secretory therapy for 2 weeks prior to testing
216
When can tests of cure be done for H pylori
4 weeks after completion of Tx
217
What is standard triple therapy, and when is it used
PPI< Clarithromycin and amoxicillin
Used with clarithromycin resistnence is less tha 15 percent
218
What is the cause of pernicious anemia gastritis
V b12 def.
219
What are the S/s of eosinophilic gastritis
Abdominal pain, rarely fullness and postprandial Vomitting
220
What is the presentation of Menetrier Dz
Idiopathic hypertrophic gastropathy
| Nausea, epigastric pain, weight loss, diarrhea
221
What is the age difference of a duodenal vs gastric ulcer
Duodenal ulcers
More common in younger patients (30-55)
Gastric Ulcer
More common in older patients (55-70)
222
What are the causes of PUD
NSAIDS
H pylori infection
```
All others:
Hypersecretory conditions
CMV (transplant patients)
Chronic disease states
Crohn Disease
Lymphoma
```
223
What is the most common S/s of PUD
Dyspepsia ( epigastric pain)
224
How do pts present with gastric vs duodenal ulcers
Shortly after eating with gastric ulcers
| 2-4 hours after eating for duodenal ulcers
225
What is the W-up for PUD
EGD establishes the diagnosis
Refer suspected PUD patients for endoscopy
Labs:
CBC – check for anemia
FOBT – eval for occult bleeding
H pylori
If PUD is found on endoscopy, biopsy will be taken
226
What is the 1st line Tx for PUD
PPIs
227
How is sucralfate used in PUD
Sucralfate (Carafate) – forms viscous protective coating at sites of ulceration
Mucosal defense
228
How is misoprostol used in PUD
Misoprostol (Cytotec) – prostaglandin analog
Often given as prophylaxis for long term NSAID patients
Downside – administered 4x/day and causes diarrhea in 10-20%
229
A pt presents with sudden severe abdominal pain, and rigid abdomen, and reduced bowel sounds, and rebound TTP
On radiographs there is air under the Diaphram
Ulcer perforation
230
What is the Tx approach for a ulcer perforation
Fluids
NG suction
IV PPI
ABX
Surgical repair
231
What is Zollinger Ellison Syndrome
Gastrin-secreting neuroendocrine tumor
Results in hypergastrinemia and gastric acid hypersecretion
80% within the “gastrinoma triangle”
Porta hepatis -pancreatic neck - 3rd portion of duodenum
232
What are the three most common gastrónoma locations
Pancreas
Duodenal wall
Lymph nodes
Common in pts with MEN-1
233
When should pts be screened for ZES
Screen with fasting gastrin levels
In patients with refractory ulcers or in patients with PUD and family history of MEN1
In patients with PUD who are not taking NSAIDS and are H pylori negative
234
What is gastroparesis
Delayed gastric emptying in the absence of a mechanical obstruction
235
What is the most common associated systemic dz with gastroparesis
DM
236
What are the S/s of gastroparesis
```
Nausea
Vomiting
Early satiety
Bloating and/or upper abdominal pain
Weight loss in severe cases
```
237
What must be ruled out with gastroparesis
Mechanical obstruction
238
What is the Tx approach for Gastroparesis
Acute exacerbations require NG decompression and IV fluid & electrolyte replacement
```
General treatment measures:
Dietary modification
Small frequent meals
Avoid high fat foods
Avoid carbonated beverages, alcohol, smoking
```
Optimize glycemic control in diabetics
Prokinetic medications:
Metoclopramide (Reglan)
Domperidone
Erythromycin
239
What are the clincal signs of metastatic disease
Sister Mary Joseph nodule
| Virchow nodes
240
What is teh W- up for gastric Adenocarcinoma
Labs:
- CBC often shows anemia
- LFTs may be elevated
Endoscopy:
-Confirms diagnosis
Other radiographs:
CT, PET once cancer is confirmed to find mets.
241
Primary Lymphomas arise from
| Secondary lymphomas arise from
Secondary tumors from spread of non-Hodgkin lymphoma
Primary tumors arise from MALT:
Mucosa-associated Lymphoid Tissue
Associated with chronic H pylori infection
242
What is a carcinoid tumor and carcinoid syndrome
Carcinoid tumor - neuroendocrine tumors originating in the digestive tract or lungs
Carcinoid Syndrome - constellation of symptoms mediated by various humoral factors that are elaborated by some carcinoid tumors
243
Describe carcinoid syndrome
Cutaneous flushing
Begins suddenly
Lasts up to 30 min
Involves face, neck, upper chest
Associated with mild burning sensation
Venous telangiectasias
Diarrhea
Watery, non-bloody, with abdominal cramping
244
What is the classical presentation for Infantile Hypertrophic Pyloric Stenosis
3-6 week old child
Immediate postprandial projectile vomiting
Fussy and hungry immediately after meals
Constipation, dehydration
245
How does a hypertrophic pylorus present in neonates on physical exam
“Olive” like mass in the RUQ
246
What is a pyloromytomy
Surgical correction of the pyloric sphincter
247
What does the duodenum absorb
IRON, calcium, phosphorus, magnesium, copper, thiamin, riboflavin
248
What does the jejunum absorb
Vitamins A, D, E, K, FOLATE
249
What does the ileum absorb
Vitamin B12, Bile salts/acids
250
How do malabsorption pts present
Steatorrhea (fecal fat), Anemia’s, Diary intolerant
251
What is celiac dz
Celiac Sprue; Gluten sensitive enteropathy
Immunologic response to gluten:
diffuse damage to the proximal small intestinal mucosa
252
What are the S/s of celiacs
```
Dyspepsia
Diarrhea
Steatorrhea
Weight loss
Flatulence
Abdominal distension/bloating
Borborygmi
Weakness, muscle wasting only if severely malnourished
```
```
Extraintestinal manifestations
Fatigue
Depression
Iron deficiency anemia
Amenorrhea
Transaminitis
Dermatitis herpetiformis
```
253
What is the cutaneous manifestation of Celiac
Dermatitis herpetiformis
Pruritic papules and vesicles (herpes-like)
Extensor surfaces of extremities
Trunk, scalp, neck
254
What is the test of choice in celiac Dz
IgA tissue transglutaminase (IgA tTG) antibody
-Test of choice
-if negative, but there is still a strong clinical suspicion for Celiac then draw serum IgA levels
Uncovers potentially undiagnosed IgA deficiency
IgG-deamidated gliadin peptides (DGPs)
For patients with identified IgA deficiency
255
What is the test in celiacs that is for pts with ID’d IgA deficiency
IgG deamidated gliadin peptides
256
What is the most abundant Ig in the body
IgA
257
What is the confirmatory test in celiacs dz
Mucosal biopsy in pts with postive serology
Histology examination reveals blunting and/or atrophy of the intestinal villi
258
What dz is villous atrophy seen in
Celiacs dz
259
What is the DO approach to celiacs
```
HPE
Serologic testing
Trial of gluten free diet
Mucosal biopsy
For those with positive serology or those with high clinical suspicion
```
260
What is Whipple Dz
Rare multisystem illness caused by infection with the bacillus Tropheryma whippelii
Most common in white males, ages 30-50
No human-human spread
Seen mostly in farm or sewage workers
Contact with sewage/waste water
Fatal if untreated
261
Classic presentation of Whipple Dz
Migratory Arthralgias (first symptom)
Large joint involvement
Diarrhea
With flatulence, steatorrhea
Abdominal Pain
Weight Loss
Fever of unknown origin
262
How is the DO of Whipple Dz established
Mucosal biopsies
| “Foamy Macrophages”
263
What is the Tx for Whipple Dz
IV ceftriaxone x 2 weeks
| TMP-SMX DS – 1 tab po BID x 12 months
264
What is Tropical sprue
Chronic diarrheal disease, possibly of infectious origin
Often seen following acute diarrheal disease
Involves the entire small intestine
Characterized by malabsorption of nutrients
especially folic acid and vitamin B12
265
What are the S/s of Tropical sprue
```
Chronic diarrhea
Steatorrhea
Weight loss
Anorexia
Malaise
B12 and Folate deficiency
Glossitis & chelitis
```
Inflamed mouth
266
How does tropical sprue present on CBC
Megaloblastic anemia
267
How does tropical sprue present of Endoscopy
Gross findings
flattening of duodenal folds
Microscopic findings
shortened, blunted villi and elongated crypts with increased inflammatory cells
268
What is the Tx and prevention of Tropical Sprue
Prevention
Boil/bottled water
Peel fruits before eating
Treatment
TMP-SMX x 6 months
Folate, B12 supplementation
269
What is lactase
Lactase - brush border enzyme that hydrolyzes lactose into glucose and galactose
270
What is the Tx and approach to lactose intolerance
Presumptive diagnosis : try 2-3 weeks of lactose free diet
Observe for symptomatic improvement
```
Diagnostic test (for confirmation)
Hydrogen breath test
```
Treatment with reduced lactose diet
Titrate to patient symptoms
Also consider dietary consultation
271
What patients are at risk for GI bacterial overgrowth
Consider in patients who:
Are on chronic PPI therapy
Due to gastric achlorhydria
Have an anatomic abnormality of the small intestine
Suffer from a small intestine motility disorder
May have a gastrocolic or coloenteric fistula
Crohn disease, malignancy, surgical resection
272
What are the S/s of Bacterial GI overgrowth
```
Flatulence
Weight loss
Abdominal pain
Diarrhea
Steatorrhea
Macrocytic anemia
```
273
What is the empiric TX for bacterial GI overgrowth
Ciprofloxacin
Amoxicillin-clavulanate
Rifaximin
274
What is short bowel syndrome
Due to the removal of significant segments of the small intestine
Type and degree of malabsorption depend on:
Length of the resection
Site of the resection
Degree of adaptation of the remaining bowel
275
Acute paralytic ileus in most often seen in what pts
Most commonly observed in hospitalized patients due to:
Abdominal surgery
Severe illness
Respiratory failure, sepsis, uremia
Medications that affect intestinal motility
Opioids, anticholinergics
276
What are the S/s of acute paralytic ileus
```
Diffuse, constant abdominal pain
Nausea and vomiting
Abdominal distension
Lack of abdominal TTP
No signs of peritoneal irritation
Diminished or absent bowel sounds
```
277
What does paralytic ileus look like of radiographs
Plain abdominal x-ray shows distended gas-filled loops of small and large bowel
278
What is the Tx approach to ileus
Generally supportive in nature
Treatment of underlying illness
Pain management
Fluid maintenance & electrolyte replacement
Bowel rest
Nasogastric decompression
For patients with significant distension or severe vomiting
279
What is chronic intestinal psuedo obstruction
Intermittent signs of obstruction in the absence of a physical obstruction
Small bowel involvement results in:
- Abdominal distension
- Vomiting
- Diarrhea
- Varying degrees of malnutrition
280
What is the Tx for acute exacerbations of intestinal psuedo obstruction
Acute exacerbations require NG decompression and IV fluid & electrolyte replacement
281
What is the most common cause of small bowel obstruction
Post op adhesions or hernias
282
List of things that can cause small bowel obstruction
```
Neoplasms
Strictures
Foreign body
Intussusception
Gallstones (Gallstone ileus)
Post op
Hernias
```
283
What are the prominent risk factors for small bowel obstruction
```
Prior abdominal or pelvic surgery
Abdominal wall or groin hernia
Intestinal inflammation
History of, or increased risk for neoplasm
Prior irradiation
History of foreign body ingestion
```
284
Clinical presentation, physical exam and lab tests for small bowel obstruction
```
Clinical Presentation:
Abrupt onset of:
Colicky abdominal pain
Nausea
Profuse vomiting
Obstipation
Inability to pass flatus or stool
```
```
Physical exam:
Abdominal distension
Tympany on percussion
Hyperactive bowel sounds early
Hypoactive later on
Signs of dehydration
```
```
Lab Tests
CBC
CMP
Urinalysis
Type and crossmatch
If surgery may be indicated
```
285
What are the signs of strangulated small bowel obstruction and what is the Tx
fever, tachycardia, localized abdominal pain, and/or leukocytosis
CT scan To diagnose strangulated obstruction
286
What is string of pearls sign
Air fluid levels on x ray in the small bowel that high light obstruction
287
Acute Tx for SBO
```
Fluid resuscitation
Bowel decompression (NG)
Pain control
Anti-emetic medications
Early surgical consultation
Admission
```
288
What is the cause of gallstone ileus
Complication of cholelithiasis.
Due to impaction of a ≥2cm gallstone in the ileum after being passed through a biliary-enteric fistula
Much more common in female patients and older patients
289
What pts is intussesception most common in
Children less than 1 yr old
290
A child presenting with vomiting abdominal pain, AMS, abdominal mass, and rectal bleeding
Intussusception
291
What is the 1st line Tx of intussusception in children and adults
Pneumatic reduction with air under fluoroscopic guidance or hydrostatic reduction with saline under ultrasonographic or fluoroscopic guidance preferred first line therapeutic intervention for uncomplicated children.
Surgery if complicated or adult.
292
Neoplasm of the small bowel often causes
Intussusception or obstruction
293
Where is the most common place for adenocarcinomas in the bowel
Most commonly in duodenum or proximal jejunum
Present with symptoms of obstruction, chronic GI bleed or weight loss
294
What pts are at increased RSK of lymphomas
Increased incidence with AIDS, chronic immunosuppressive therapy, Crohn disease
295
What is protein losing enteropathy and what is the approach to tx
Condition that results in excessive loss of serum protein into the GI tract
Results in hypoalbuminemia
Treatment aimed at underlying disorder
Low fat and high-protein diet
Surgical resection of affected bowel
296
What is the presentation and approach to Mesenteric ischemia
Physical exam:
Classically- “pain out of proportion with physical exam”
Diagnostic test:
CT angiography
```
Treatment:
Admission
Papaverine – smooth muscle relaxant
Thrombolytics
Surgical referral
```
297
What is the most common congenital abnormality of the GI tract
Meckels Diverticulum
Typically less than 10 yo
Ave age 2.5 years
298
What is the rule of 2s for Meckels Diverticulum
Occurs in 2% of the population
2:1 Male-Female ratio
Located within 2 feet of ileocecal valve
2 cm in length
2 types of mucosa:
-Native intestinal mucosa and heterotopic mucosa (most commonly gastric or pancreatic)
Symptoms commonly occur before age 2
299
A child less than 10 yo with painless lower GI bleeding without S/s of gastroenteritis or IBD
Meckels
300
A 40 yo with GI bleeding with no source ID’d of standard endo
Meckels
301
How do you DO and Tx meckels
Capsule endoscopy and meckels scan ( 99 technetium)
```
Tx: Surgical referral
Asymptomatic patient - no treatment is typically needed
Symptomatic Patient:
Stabilize if GI bleed present
Surgical removal of diverticulum
Correct intussusception, etc if present
```
302
What are the 5 normal positions of the appendix
```
Retrocecal
Subcecal
Preileal
Postielal
Pelvic
```
303
What is the presentation of appendicitis
Early - Vague, colicky periumbilical pain
Later (within 12 hrs) – pain migrates to RLQ
McBurney’s Point
Pain is sharp and increased with peritoneal irritation
Coughing, jumping, “bumpy ride”
Patient will be lying still
Low grade fever
304
What are the 5 PE test to locate appendicitis
```
TTP at McBurney’s point
Heel Tap
Psoas Sign
Obturator sign
Rovsings Sign
```
305
What is the Lab Tests results and Tx for appendicitis
CBC will show moderate leukocytosis with nuetrophillia
TX:
Surgical appendectomy
-Consult early
Antibiotics:
- Pre-op
- Conservative (non-surgical) management (20-35% recurrence w/in 1 yr)
Broad spectrum with gram-negative and anaerobic coverage
Cefoxitin or cefotetan
Ampicillin-Sulbactam
Ertapenem
306
where are internal hemorrhoids located
Internal hemorrhoids are located proximal to the dentate line
Arise from the superior hemorrhoidal veins
307
Internal hemorrhoids come from what vein
Superior hemorrhoidal veins
308
Where are external hemorrhoids located
External hemorrhoids are located distal to the dentate line
Arise from the inferior hemorrhoidal veins
Covered with squamous epithelium of the anal canal or perianal region
contains numerous somatic pain receptors
309
S/s of hemorrhoids
Most often presenting complaint is bright red rectal bleeding
Streaks on the stool or on the paper
bright red blood dripping into the toilet
Other symptoms
- Perianal itching
- Mucoid discharge with stool
- Pain w/ external hemorrhoids
310
What is the cause of internal hemorrhoids pruritus
They are Covered with columnar epithelium leading to mucous deposition on the perianal skin that can cause pruritus
Prolapse may permit leakage of rectal contents
Patients with leakage may clean aggressively, irritating the perineum and also allowing contact of fecal material with denuded skin
311
What is a grade I hemorrhoid
Bleeding only, no prolapse
312
What is a grade II hemorrhoid
Prolapse with defecation,
| Spontaneously reduces
313
What is a grade III hemorrhoid
Prolapse with defecation, must be manually reduced
314
What is a grade IV hemorrhoid
Prolapsed, Incarcerated, cannot be manually reduced
315
Thrombosis of an extrenal hemorrhoid plexus results in…
Perianal hematoma,
Acute onset, exquisitely painful
Tense and bluish perianal nodule covered with skin
Symptoms last 2-3 days, relieved w/warm sitz bath, analgesics, and ointments
Clot excision (clinic) may provide relief if performed w/in 48 hrs
316
What is the medical treatment for hemorrhoids
Topical Astringents
-Witch hazel pads (Tucks)
Topical Hydrocortisone
-Cream or foam (Proctofoam)
Topical anesthetics
-Pramoxine or dibucaine
Hydrocortisone suppositories (Preparation H)
Further Treatment (internal hemorrhoids)
- Rubber band ligation
- Sclerotherapy
- Electrocoagulation
Surgical Treatment
-Surgical excision (hemorrhoidectomy) when conservative measures fail (Stage I, II, or III) or Stage IV
Acute thrombosed Stage IV
Complications of hemorrhoidectomy include postoperative pain (which may persist for 2–4 weeks) and impaired continence
317
What are the complications associated with hemorrhoidectomy
Complications of hemorrhoidectomy include postoperative pain (which may persist for 2–4 weeks) and impaired continence
318
What is an anal fissure
Anal fissure - a tear in the anoderm distal to the dentate line
319
What causes chronic anal fissures
Chronic fissure develops due to spasm of the internal sphincter
impaired healing
320
What is a primary anal fissure
Posterior (90%) or anterior midline location (25% postpartum women)
Usually single fissure
Rarely located off midline
321
What is a secondary anal fissure
Lateral or atypical position off midline location (<1%)
Multiple fissures may be present
Associated with chronic IBD, HIV, syphilis, malignancy, granulomatous disease, psoriasis, previous surgery
322
What is the Tx for anal fissures
Sitz Baths
Increase fiber and fluid intake
Stool softeners – docusate sodium
Topical anesthetic – lidocaine jelly
Chronic fissures:
Topical vasodilators
-Nifedipine, nitroglycerin, or diltiazem
Botulinum toxin injection
Surgical treatment:
Fissurectomy
Lateral internal sphincerotomy
323
What do anorectal abscesses usually arise from
Obstructed or infected anal crypt gland
324
What are the three locations for perianal abscess formations
Supralevator space
Intersphincteric space
Ischioanal space
325
Clinical presentation of perianal abscess
Severe pain in the anorectal region
Constant and not directly associated with defecation
Fever and malaise are common
326
TX for perianal abscess
Simple (perianal)
I&D in clinic
Complex (perirectal)
I&D in OR
Oral antibiotics - may reduce the rate of fistula formation
Sitz bath
Pain management
327
What is the complication of a perianal abscess
Fistula formation (fistula in ano)
An epithelialized track can form connecting the abscess in the anus or rectum with the perirectal skin
Leads to chronic purulent drainage, pruritus, pain
Requires surgical excision
328
What is the etiology and S/s of infectious proctitis
Etiology usually STI
- Gonorrhea
- Syphilis
- Chlamydia
- Herpes
Symptoms include:
- Anorectal discomfort
- Tenesmus
- Constipation
- Mucus or bloody discharge
329
How does anal syphillis present
Chancre
330
Presentation of anal herpes
Grouped vesicles
331
Presentation of anal gonorrhea
Mucopurulent DC
332
Presentation anal chlamydia
Slight DC may be asymptomatic
333
What must you R/o with condylomata acuminata
| anal warts
Must r/o cancer
334
What are the majority of cancer types of the anus
Squamous cell cancers are the majority
335
Who is at high RSK of anal cancer
People who have anal sex or who have anal warts
336
What are carcinoma of the anus often confused with
Hemorrhoids,
Have similar S/s
Bleeding, pain, local mass,
Use a CT or MRI to DO
