GI conditions

Question 1

osmotic diarrhea

Answer 1

malabsorption or maldigestion
lactase deficiency or disaccharidase def.
responds to fasting
ingestion of poorly absorbed solutes-sorbitol, mag sulfate, laxatives

Question 2

secretory diarrhea

Answer 2

voluminous, watery stools
unresponsive to fasting
result of bacterial endotoxins or laxative abuse
cholera and E. coli, or

Question 3

morphologic changes that cause diarrhea

Answer 3

inflammation in CD or UC

Question 4

diarrhea caused by altered intestinal motility

Answer 4

diabetic neuropathy, dumping syndrome, IBS

pathogenic bacteria

Question 5

common causes of diarhea

Answer 5

recent travel (dysentary)
untreated water (dysentary)
IBS, IBD
ingestion of mag-containing antacid
lactose intolerance
abx therapy (C. diff)
bacterial or viral gastroenteritis (less than 1 week)
laxative abuse
AIDS
celiac sprue

Question 6

causes of drug-induced diarrhea

Answer 6

iron or mag, high dose of aspirin
quinidine
anti-inflammatory agents
beta-blockers, colchicine,
digitalis,
phenothiazides

Question 7

meds that cause dyspepsia

Answer 7

etoh, salicylates, corticosteroids, NSAID, erythromycin, theophylline

Question 8

history components of diarrhea

Answer 8

freq, amount, color and characteristics
diet history
recent travel
source of water
meds
sexual practice
living conditions
fam hx of IBD, colon CA
associated sx - abd pain, fever, vomitting, neuro sx, HA, malaise, muscle weakness, 
exacerbating or alleviating factors

Question 9

normal serum bilirubin level

Answer 9

0.3 to 1.0

Question 10

elevated transaminases AST and ALT

Answer 10

do not necessarily correlate with overall severity of liver dx
some extreme elevations can be diagnostic

Question 11

ALT

Answer 11

found in hepatocyte cytoplasm

more specific marker for hepatocyte damage

Question 12

alk phos

Answer 12

helpful in assessing cholestasis

GGT is usually also elevated (also found in bone) a

Question 13

elevations of ALT and AST greater than 1000

Answer 13

acute viral hepatitis
toxin or drug induced hepatitis
ischemic liver injury

Question 14

symptoms associated with jaundice

Answer 14

pruritis, anorexia, n/v
fever, light-colored stools
weight loss and fatigue
RUQ pain and tenderness
abd distension, dark urine

Question 15

symptoms indicative of cholestasis

Answer 15

light-colored stools
pruritis, dark urine
jaundice
can be caused by cholelithiasis, cirrhosis, 
other biliary obstruction

Question 16

lab filnding in cholecystitis

Answer 16

mildly elevated WBC (15,000), serum transaminases up to 4x their norm,
ALT up to 300
alk phos upt to 2 to 4x norm
bilirubin as high as 4

Question 17

suspicious signs for perforated chole

Answer 17

shaking chills, inc. fever, rebound tenderness

Question 18

cholecycstitis physical exam findings

Answer 18

RUQ pain, positive Murphy’s sign, transient inspiratory arrest, involuntary guarding on right side, low grade fever

Question 19

acute pancreatitis physical exam findints

Answer 19

severe abd tenderness, esp epigastric area
may be guarding, but NO rigidity or reboundprese
may be milder pain in lower abd
20% abd distention
hypoactive or absent bowel sound (if paralytic ileus)
tachycardia, shallow rapid breaths
stool negative for blood
insptiratory effore poor
HTN initially, hypotensive if shock imminent

Question 20

subjective findings of acute pancreatitis

Answer 20

sudden onset of deep epigastric pain, hours to days
may radiate to the back
refractory to large amounts of parenteral analgesia
aggrivated by activity, coughing, lying supine
alleviated by leaning forward
intractible n/v
acutely ill apprearing
if severe-sweating, weakness, anxiety
preceded by big meal, biliary colic or etoh

Question 21

diagnostic tests for acute pancreatitis

Answer 21

gold standard-serum amylase (up to 3x normal)
concurrent elevation of serum lipase
levels of elevation no indicative of severity
WBC 12-20
Hct 50-55, hemoconcentration, third spacing
dec serum CA
elevated liver enzymes, maybe
CT of abdomen

Question 22

Rovsing’s sign

Answer 22

deep palpation ove the LLQ with sudden, unexpected release of pressure.
if RLQ tenderness occurres, positive finding

Question 23

Psoas sign

Answer 23

patient raises right leg against resistance, or extend right leg in left lateral decub.
pain is a positive finding

Question 24

obturator sign

Answer 24

right knee and hip flexed, examiner slowly rotates the right leg internally
positive indicates irriatation of the muscle by inflamed appendix

Question 25

McBurney's sign

Answer 25

pressure is applied halfway between umbilicus and anterior spine of ilium postivie is pain with pressure

Question 26

Three systems to assess with RUQ

Answer 26

pulmonary - PNA, PE, CXR, D-dimer, helical CT urinary - UTI, nephrolithiasis - UA, US colic - hepatobiliary or nephrolithiasis (UA), US US if colic, fever, steatorrhea, +murphy's sign

Question 27

RLQ pain

Answer 27

w/u appendix/perotinits first, signs and hx if suggestive of appi, CT and urgent surg consult otherwise colon, urine and pelvic exam

Question 28

LLQ pain eval

Answer 28

diverticulitis w/u first fever, diverticular dx hx, tenderness, distention, rectal blood --->emprirc therapy or CT If these normal, urinary or gyn pathology

Question 29

conditions to always consider in the elderly

Answer 29

``` inc incidence, morbidity and mortality, commonly missed occult UTI perforated viscus ischemic bowel disease cholecystitis (classic sx often absent) ```

Question 30

findings in elderly associated with mortality

Answer 30

free air on radiograph leukocytosis (w/ high neutrophil band #) older than 84 need for surgery? assoc with hypotension, abnormal BS, dilated bowel loops, free air, air-fluid levels, leukocytosis

Question 31

when to consider SBO in elderly

Answer 31

hx of surgery, hernia. diffuse colicky pain, n/v, altered BS distention, deydration diffuse tenderness possible ill-defined mass

Question 32

when to consider AAA in older patient

Answer 32

back or abd pain male hx of tobacco use

Question 33

when to think acute mesenteric ischemia in elderly

Answer 33

severe, poorly localized pain out of proportion to physical findings

Question 34

Charcot's triad

Answer 34

fever, jaundice, RUQ pain Reynold's pentad, add MS change and shock acute ascending cholangitis

Question 35

PUD in the elderly, s/sx

Answer 35

no pain, or poorly localized/vague may present with perforation (absent BS, abd rigidity, serum amylase and leukocytosis dev. quickly) associated with NSAID and H pylori

Question 36

SBO s/sx

Answer 36

diffuse, colicky pain, n/v. PE; altered BS, distension, dehydration, diffuse tenderness, possible ill-defined mass peritoneal signs if perforation plain radiograph will show distended SB loops, air fluid levels and a paucity of large bowel air gallstaone ileus is rare, but 20% ov older 65 had this as a cause

Question 37

AAA

Answer 37

screen men 65 to 76 with hx of smoking (USPSTF) highest ricsk - HTN, PVD, fam hx of AAA may be asymptomatic or non specific sx - abd pain, back ache, claudication triad for rupture - severe abd pain, back/flank pain, hypotension, pulsatile mass palpable mass and flank echymosis may resemble cholecystitis, perforate ulcer, renal colic US

Question 38

acute mesenteric ischmia

Answer 38

uncommon but fatal

Question 39

peds - volvulus

Answer 39

``` intestinal malrotation green emesis birth defect can predispose surgical emergency necrotic intestine must be removed bloody stools, n/v, bloating, abd distention rare ```

Question 40

untussusception

Answer 40

``` caused by part of intesting being pulled into itself dehydration rand shock emergent age 6 mo - 24 mo boys 4x than girls bloody/mucous stool (currant jelly) abd x-ray, KUB, US sometimes child screams loudly, barium or air enema 90% successful for ID and tx if perf, dont use barium 20%recurrence ```

Question 41

lactose intolerance

Answer 41

babies pre 34 weeks sx n/dairrhea, abd pain, bloating, flatulence, no lactose for 2 weeks, if imp. then diagnose also hydrogen breath test warn about hidden sources of lactose Ca supplement needed

Question 42

s/sx of GERD in infants and instructions, meds

Answer 42

``` coughing, wheezing, gagging, difficulty breathing irritable after feeds back arching poor feeding, poor weight gain, poor growth colic instructions: burp freq after food, prop up for 30 min, avoid over feeding, add rice cereal to 2 oz formula, not great with breast milk H2 zantac, pepcid, tagamed ppi pepcid, prilosec, nexium ```

Question 43

pyloric stenosis, symptoms, tx, diagnostics

Answer 43

narrowing between stomach and small intestine presents before 6 months males>female projectile vomitting after each feed starts around 3 weeks, between 1w and 5 mo infant hunger after vomit appears dehydrated swollen abd sometimes palpable (olive shaped mass) tests: US or x-ray, electrolyte imb., monitor for growth and feeding surgery is curative

Question 44

FTT

Answer 44

``` not on growth chart, or less than 5th 5 REDO measurements redflags-cardiac finding, congenital heart dx, dev delay, dysmorphic features, failure to gain dispite adequate calories, organomegaly, lymadenopathy, recurent vomitting, diarrhea or dehydration, severe respiratory, uro or mucocutaneous condition often needs inpatient, multidisc rare ```

Question 45

peds constipation, s/sx, causes, w/u

Answer 45

``` fewer than 2 BM/week hard, dry stools, diff to pass common, bloated or abd pain causes, low fiber diets, ignore urge W/u abd exam, rectal, hemocult, abd x-ray ```

Question 46

peds constipation meds and therapy

Answer 46

dietary, behavioral change, meds, dietary fiber, prune juice, f/v, fluids, enemas initially MEDS; toddler glycerine suppository 0.5-1.5 g/kg miralax, mag 17g/day, OTC 1 capful (17 g) with 8 oz of water or juice takes time, up to one year for resolution goal; daily, soft stool

Question 47

acute viral gastroenteritis

Answer 47

inflammation of stomach and SI and LI common causes are norovirus, adenovirus, rotovirus watery diarrhea, vomitting, differentiate from bacterial cause or parasites Symptoms; HA, fevers, abd cramsp, diarrhea 1-10 days infants and young kids at r/f dehydration may need IV fluids/hospitalization contagious through close contact oral rehydration protocols rotavirus (october-april, oral vaccine, 2,4,6 months)

Question 48

mesenteric lymphadenitis

Answer 48

``` presents like appi, doesn't need surgery inflammation of lymp glands and mesentary, terrible pain send for US not much you can to to treat ```

Question 49

celiac disease

Answer 49

immune response to rye, wheat and barley over time damages SI, hereditary, leads to malabsorption, weight loss, bloating, diarrhea, abd pain, malabsorption, probs with growth and dev, reflux, joint pain, HA, fatigue, anemia 75% of kids are overweight or obese. non-adherence can cause infertility, low calcium, some cancers, malnutrition, lactose intolerance 1 in 133 americans have this

Question 50

erythema nodosum (peds)

Answer 50

with Chrons and UC, cutaneous manifestations | tender/hard bumps under the skin, most common on shin, arthritis and arthralgia also. more raised than bruises.

Question 51

herschprungs disease

Answer 51

``` not common abd distension, inability to pass meconium after 48 hours assoc with down's rectum biopsy definitive surgery and special diet definitive ```

Question 52

increased amyalase indicates?

Answer 52

pancreatitis, intestinal obsturction, biliary tract disease | lipase will r/o pancreatitis

Question 53

diagnostic studies to w/u abd pain

Answer 53

flat plate x-ray contrast studies - barium (upper and lower GI) US CT endoscopy sigmoidoscopy, colonoscopy ERCP endoscopic retrograde cholangeopancreatography

Question 54

labs to w/u abd pain

Answer 54

``` UA CBC with Diff amylase lipase (to r/u pancreatitis) LFT pregnancy test ```

Question 55

acute (surgical abdomen)

Answer 55

``` acute, longer than >6 h progressive symptoms well-localized, rebound tenderness, guarding and rigidity n/v/anorexia absent bowel sounds (listen for one minute/quad) orthos cold, clammy extremities tachycardia impaired mentation oliguria fever ```

Question 56

peritoneal signs

Answer 56

``` severe pain worse with movement or cough LIES still, with knees drawn up to dec pain infants who lie still, flexed hips inflammation of peritoneal cavity ```

Question 57

acute abdomen syndromes

Answer 57

``` appendicitis diverticulitis cholecystitis pancreatitis perf of ulcer intestinal obstruction; barium ruptured AAA pelvic d/o ```

Question 58

GERD alarm symptoms

Answer 58

dysphagia, bleeding, anemia, weight loss, recurrent vomitting

Question 59

when is upper endoscopy is indicated? GERD

Answer 59

heartburn and alarm symptoms typical sx persist despite trial of 4 to 8 weeks BID PPI severe erosive esophaghitis after 2 mo of ppi, to assess healing and r/o barretts hx of esophageal stricture and recurren sx men

Question 60

PUD alarm symptoms

Answer 60

bleeding (upper or lower), anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomitting + PMH esophagogastric malignancy +FH of GI CA severe, spreading upper abd pain, consider perf, emergent referral -->hematemesis, hypotension/gachy, guarding abd x-ray-free air under diaphragm

Question 61

Duodenal PUD

Answer 61

``` 2/3 of PUD sx relieved with food sx 2-5 h after eating, 11 -2 at night 95% H. pylori gnawing or burning ```

Question 62

Gastric PUD

Answer 62

``` 1/3 of cases 70% associated with H. pylori 2-4% assoc with malignancy gnawing or burning, increased by food LUQ radiating to back bloating, belching, n/v food EXACERBATES sx--> weight loss ```

Question 63

PUD w/u, assesment

Answer 63

``` PE-unremarkable some have abd tenderness, epigastric rectal - melena and or +FOB Hgb/Hct Weight gain in DU, loss in GU H. pylori ```

Question 64

red flag symptoms of PUD

Answer 64

dysphagia, early satiety, protracted vomiting, anorexia, loss of 10% of body weight, melena, rectal bleeding, abd mass, previous peptic ulcer disease, jaundice, fam hx of gastric CA

Question 65

who to w/u for diarrhea,

Answer 65

``` if severly ill and have the following bloody diarrhea hypovolemia temp >38.5 (101.3) duration >48 h more than 6 unformed stools/24h severe abd pain hospitalized or recent abx >70 yo or immunocompromised systemic illness, esp pregnant (think listeriosis) ```

Question 66

diarrhea, if your gonna w/u, what tests? what tests not helpful

Answer 66

gram's stain for leukocytes, occult blood c&S, routine Salmonella, campylobacter, shigella (most common in US) C. diff NOT helpful - cbc, electrolytes, stool O&P, endoscopy

Question 67

oral rehydration solution

Answer 67

1/2 tsp salt, 1/2 tsp baking soda, 4 TBS sugar/liter of water

Question 68

enterocyte renewal in acute diarrhea mgt, eat what?

Answer 68

``` boiled starches (potatoes, rice, noodles) with salt, banana, soup. AVOID lactose and high fat foods ```

Question 69

when can i use loperamide/immodium for acute diarrhea

Answer 69

no fever, dysentary, stools are non-bloody | this is an antimotility

Question 70

when to use empiric antibiotics for diarrhea

Answer 70

``` CIPRO >8 stools/day volume depletion sx>one week if hospitalization is considered immunocompromised hosts moderate to severe traveler's diarrhea, >4 unformed stools/day, fever, blood, pus, or mucus in stool ```

Question 71

when not to use empiric abx

Answer 71

presumes viaral or most self-limiting bacterial diarrhea C diff EHEC/ enterohemorrhagic Ecoli suspted - bloody diarrhea, abd pain and tenderness, no/low fever