GI Part 1 Flashcards

Question

GERD Non-Pharm Tx Nonpharm therapy is the first step 1. If obese, even __ lb weight __ will help 2. ______ Cessation 3. (2) during sleep 4. (1) meal sizes, and do not eat at what time of day? 5. Reduce foods that? 6. Use (1) PRN

Answer 1

1. If obese, even 10 lb weight will loss help 2. Smoking Cessation 3. Elevate head or sleep on wedge 4. Smaller meal sizes, and do not 2-3 hrs before bedtime 5. Reduce foods that produce symptoms 6. Use antacids PRN

Answer 2

**H2 Receptor Antagonist** Pepcid **Proton Pump Inhibitor** (Omeprazole (prilosec), Lansoprazole (prevacid), Esomeprazole (nexium))

Answer 3

Suppress acid by reversibly binding to histamine receptors located on gastric parietal cells (blocking endogenous histamine) QD or BID

Answer 4

blocks proton pump from secreting acid so should be taken 30-60 min before you eat (usually when wakin gup in morning), QD Reserved for failure of H2 blocker or erosive esophagitis

Answer 5

1. PPI associated PNA pneumonia (aerobic bacteria grow in the stomach with increasing pH and micro-aspiration and lung colonization may occur) 2. C.diff (stomach acid suppresses C.diff) 3. Hypomagnesemia 4. Decrease in Calcium absorption 5. Interference with Vit B12 absorption *Avoid cimetidine: a lot of cytochrome P450 interactions*

Answer 6

* Re-evaluate pt after 2 weeks, if controlled, complete therapy for 8-12 weeks *(2-3m treatment period then try to get them off)* * After 8-12 weeks, discontinue or lower med to lowest possible dose that provides relief * Some pts require low-dose maintenance therapy indefinitely: recurrent nature * If symptoms unresolved in 8-12 weeks of therapy, **refer to a gastroenterologist** *(to r/o ulcer, barrett’s)*

Answer 7

1. **Weight gain** 2. Dysphagia 3. Odynophagia (painful swallowing) 4. Iron deficiency anemia

Answer 8

1. It improves motility 2. It coats the distal potion of the esophagus 3. It increases the gastric pH 4. **It decreases the secretion of gastric acid** *Answer is 4) Famotidine is a histamine-2 receptor antagonist and reduces the secretion of gastric acid (option 4). This class of drugs does not have a direct effect on reflux or GI motility. Metoclopramide or Reglan improves GI motility (option 1). Sucralfate or Carafate coasts the ulcer (option 2). Antacids neutralize the hydrochloric acid in the stomach (option 3).*

Answer 9

**Premalignant condition of the esophagus considered a complication of GERD** Tissue injury dt chronic exposure to gastric acid, pepsin, and bile Squamous → Columnar epithelium White males \>50 yo

Answer 10

* Presentation is usually heartburn or dysphagia * This is a strong correlation with LT acid exposure and risk of adenocarcinoma * *Dose-related:refers to risk of development of adenocarinoma with Barrett’s esophagus is \<1% annually, 5 and 10-fold in persons with low grade and high grade dysplasia* * *Will need frequent endoscopy's depending on molecular changes of their cells*

Answer 11

1. H. pylori testing 2. CT scan 3. **Upper GI endoscopy with biopsy** 4. Barium swallow

Answer 12

**Impaired gastric emptying** *“I only took 3 bites of toast and im so full”* Usually a complication of uncontrolled DM * Motility problem as a result of autonomic neuropathy (impacts both sympathetic and parasympathetic fibers). * Affects food absorption, affecting glycemic control. Also causes nausea and vomiting. * Symptoms may improve with control of hyperglycemia.

Answer 13

1. Endoscopy 2. Gastric emptying study 3. Radiolabeled CO 2 breath test *(less common)*

Answer 14

Light meal consumption with radioactive contents measures emptying of stomach (\>60% at 2 hours or \>10% at 4 hours is a positive diagnosis

Answer 15

**Metoclopramide (Reglan) -** as motility agent (*may have neurocognitive SE, usually given for short periods of time)* * Dietary modifications * Tighter control for DM

Answer 16

Swallowing disorder that involves dysfunction of one or more stages in the normal sequence of swallowing 1. **Esophageal dysphagia (structural causes)** 2. **Oropharyngeal dysphagia (functional causes)** * May be mild or severe, resulting in malnutrition, dehydration, choking, aspiration, pneumonia and even death

Answer 17

* Onset * Gradual onset, slow progression and chronic course suggest motor disorder * Rapid onset and progressive- obstruction * Swallowing difficulty: liquids (cold), solids * Choking, reflux or pain (odynophagia) * Weight loss * PMH: neuro disease *(MG, parkinson’s)*, chronic reflux, esophagitis – (*chronic inflammation → thickening of lining → narrow space → dysphagia)*

Answer 18

* *History can lead to a tentative diagnosis* * *most important is duration and progression of symptoms* * *relation of symptoms to ingestion to liquids and solids* * *effects of cold on swallowing* * *response to swallowing a bolus (repeated swallowing and Valsava maneuver can assist in swallowing in motor disorder). Obstruction-swallowing a bolus will cause regurg*

Answer 19

* intermittent dysphagia: suggests lower esophageal. * associated with swallowing - mucosal inflammation * difficulty swallowing solids associated with chronic heartburn think stricture * accompanied by diplopia think myasthenia * associated with tremor or difficulty initiating movement Parkinson’s disease

Answer 20

May present with malnutrition, weight loss, dehydration, or pneumonia * **Problems with oral stage:** poor bolus control, spillage from lips or into pharynx, dry oral membranes, pocketing or oral residue, difficulty with chewing * **Pharyngeal dysplasia:** results from poor coordination of muscles and may cause delayed swallowing, nasal or oral regurgitation, manifested as coughing, choking, or gurgling

Answer 21

1. **Oral exam** 1. Includes oral health, hygiene, dentition, oral sensation, tongue strength, mobility, coordination 2. Altered speech, voice, gag reflex 2. **Neuro exam** 1. Attention to CN function (V trigeminal, VII facial, IX glossopharyngeal, X vagus, XII hypoglossal), assessment of muscle strength, atrophy, tremors, gait disturbance. Mental status 3. **Body =** head, neck, trunk, extremities deformities 4. **Skin** 1. Pallor, sclerodacytly, telangiectasia, CREST _variant of scleroderma_ 2. Lymph nodes and thyroid for enlargement

Answer 22

* **Oropharyngeal:** Iatrogenic, Infectious. Metabolic, Myopathic , Neurologic, Psychiatric, Environmental * **Esophageal:** Trauma, Surgery, Tumor, Webs, Strictures or Stenoses, Diverticuli, Infection, Cervical osteophytes *Anterior cervical osteophytes are common and usually asymptomatic in elderly people. Due to mechanical compressions, inflammations, and tissues swelling of osteophytes, patients may be presented with multiple complications, such as dysphagia, dysphonia, dyspnea, and pulmonary*

Answer 23

* **Transfer Dysphagia (oropharyngeal)** * **Achalasia** * **Scleroderma** * **Mechanical Obstruction**

Answer 24

* *Transfer dysphagia also called oropharyngeal dysphagias* * *common in elderly* * *caused by stroke, tumor, degenerative diseases* * *medications may effect (benzodiazepines, L-dopa\_* * *these pts have difficulty with liquids; more regurgitation, choking, and aspiration as opposed to mechanical obstruction-difficulty with swallowing* * *Achalasia* * *loss of peristalsis in distal esophagus and lower esophageal sphincter fails to relax properly, causing obstruction* * *substernal chest pain present in 80% of pts* * *difficulty swallowing both liquid and solids; cold liquids precipitate sx* * *Scleroderma* * *approximately 75% of these pts have esophageal involvement of some type* * *reflux is more common than dysphagia*

Answer 25

Modified barium swallow or esophagram * If globus present or reflux sx’s try H2 blocker or PPI before referring to GI. * If PND (post nasal drip) present try nasal spray (ie Flonase) before referring to ENT. GI and/or ENT will most likely coordinate testing * Refer for endoscopy and biopsy for suspected obstruction, suspected malignancy, lesion identification, reflux, infection (candida infection), Schatzki ring. * Globus sensation is the term used when a person has the feeling of a lump in their throat even though there is no lump present when the throat is examined. The sensation can come and go. It does not interfere with eating and drinking.*

Answer 26

*Pt ed: barium makes you poop*

Answer 27

* Barium esophagram with **esophageal dilation with classic “bird’s beak” appearance distally** * Esophageal manometry shows **lack of relaxation of the LES** with swallowing and aperistalsis of the esophageal body

Answer 28

* Structural causes of dysphagia are usually treated with surgery of dilation * Advise an adequate caloric intake that can be swallowed with minimum of difficulty: * liquid or soft diets for mechanical obstruction * small amts, eaten slowly for motor dysfunction * Follow-up should be done by a specialist

Answer 29

**Peptic ulcer disease is a problem of the gastrointestinal tract characterized by _deep mucosal damage secondary to pepsin and gastric acid secretion_**_._

Answer 30

**Stomach and Proximal Duodenum** - duodenal more common and rarely harbor malignancy, gastric ulcers 2-4% harbor malignancy **H.Pylori** 95% **NSAID/ASA use**

Answer 31

**Gnawing or burning epigastric pain** **2-5 hours after meals** (*later than GERD)* **Empty stomach** *(so eating can relieve the pain vs. worsening the pain in GERD)* * _Nocturnal pain_ relieved by food intake, antacids, or anti-secretory agents. A history of episodic or epi-gastric pain, relief of pain after food intake, and nighttime awakening because of pain with relief following food intake * _Abdominal pain_ is absent in at least 30% of older patients with peptic ulcers * _Postprandial epigastric pain_ is more likely to be relieved by food or antacids in patients with duodenal ulcers than in those with gastric ulcers. * Weight loss precipitated by fear of food intake is characteristic of gastric ulcers.

Answer 32

* PMH: cirrhosis, pancreatitis, arthritis, COPD, hyperparathyroidism, Zollinger-Ellison syndrome (hypersecretory state) * Social history: smoking, alcohol, stress * Meds: NSAIDs, oral corticosteroids * PUD in first degree relatives

Answer 33

1. ***Start a PPI once daily.*** *+ stop ibuprofen, if not better in 2w then send to GI - if not anemic, if guiac -* 2. *Perform serology test for H. pylori infection and treat if positive.* 3. ***Refer to GI for upper endoscopy******.** Could also be an option* 4. *Abdominal X ray.*

Answer 34

Occult blood, Hgb/Hct Endoscopy

Answer 35

**\*Endoscopic biopsy\*** Serum enzyme-linked immunosorbent assay (ELISA) Urea breath test (UBT) Stool antigen test XXX Serology for IgG NOT USEFUL! nonspecific *If suspecting H. pylori do not start antacid, bc must be off for dx tests*

Answer 36

* Anemia, Hematemesis, Melena, or FOBT suggests bleeding * Vomiting suggests obstruction * Anorexia or weight loss suggests cancer * Persisting abdominal pain radiating to back suggests penetration * Severe, spreading upper abdominal pain suggests perforation

Answer 37

**2 abx + 1 acid reducing agent** Clarithromycin, Amoxicillin, Metronidazole + Omeprazole for 10-14 days 1. If on NSAIDs, discontinue 2. Empiric treatment with anti-secretory drugs: H₂ antagonist, or PPI; try for 2 weeks, if works, continue for 8 weeks

Answer 38

1. Stool Gram stain, looking for the offending organism 2. Serologic testing for antigen related to the infection 3. **Organism-specific stool antigen testing** 4. Fecal DNA testing

Answer 39

15th of all cancers 1. Helicobacter pylori gastric infection. 2. Advanced age. 3. Male gender. 4. Diet low in fruits and vegetables. 5. **Diet high in salted, smoked, or preserved foods.** 6. Chronic atrophic gastritis. 7. Intestinal metaplasia. 8. Pernicious anemia. 9. Gastric adenomatous polyps. 10. Family history of gastric cancer. 11. Cigarette smoking. 12. Menetrier disease (giant hypertrophic gastritis). 13. Familial adenomatous polyposis.

Answer 40

**Insidious onset** of abdominal pain that ranges in intensity from a **vague sense of post-prandial fullness to severe, steady pain** *-* *usually diagnosed late and very high morbidity* * Wt loss, abdominal pain, anorexia, vomiting * Other symptoms include a change in bowel habits, dysphagia, melena, anemic symptoms and hemorrhage

Answer 41

* CBC with diff, electrolytes and LFT’s * Stool occult for occult blood * CT radiograph/scan of abdomen * Endoscopy and biopsy

Answer 42

Complete resection of carcinoma and adjacent lymph nodes * Palliative resection (advanced lesions) * Use of laser coagulation for obstruction and dysphagia * Require doses of radiation that exceed tolerance of surrounding structures * Chemotherapy offers no advantage

Answer 43

Celiac Disease * Traditionally **a malabsorption syndrome** but currently more of a multisystem disease * We see a flattening of cilia in duodenum which leads to the malabsorption -\> anemia etc*

Answer 44

* In North America, the prevalence is approximately 1% * Those diagnosed with celiac disease between 2-4 years had a 10.5% chance of developing an autoimmune disease. This chance increases with the age of diagnosis *Age of diagnosis of celiac disease and chance of developing autoimmune condition: Age 4-12 have 16.7% of AI disease, Age 12-20 have 27% , Age \> 20 have 34%*

Answer 45

Diarrhea, constipation or symptoms of malabsorption such as bloating, flatus or belching but only 35% of newly diagnosed patients had chronic diarrhea.

Answer 46

**Anemia** **Osteopenia** **Short stature or no weight gain** (look at growth chart, short height is more concerning) **Delayed puberty and menarche** **Transaminitis** **Recurrent abdominal pain**

Answer 47

1. First or second degree relatives of patients with celiac disease 2. Turner, Williams, **Down syndrome** 3. Diabetes type 1 4. IgA deficiency 5. Autoimmune thyroiditis

Answer 48

**IgA Tissue Transglutaminase (TtG)\*** or endomysial antibody (EMA) titers with quantitative IgA testing * Genetic testing for HLA gene * **Blood test abnormalities**: Abnormal LFT’s, low ferritin, hypocholesterolemia, Hyperamylasemia, Hypoalbuminemia, Elevated ESR, prolonged PT, vitamin deficiency, Hypocalcemia, secondary hyperparathryoidism * **EGD and bx** in pts w/ selective IgA deficiency (immune disorder)- pt should remain on normal diet before endoscopy

Answer 49

**Gluten Free Diet for Life** ## Footnote To avoid the risks of untreated celiac disease which include the development of other autoimmune conditions such as *type 1 diabetes, psoriasis, thyroid disease, neurologic problems, autoimmune liver disease and autoimmune cardiomyopathy, as well as the development of malignancies such as intestinal lymphoma, adenocarcinoma of the small intestine, esophageal carcinoma and melanoma**.*

Answer 50

**Non-celiac gluten sensitivity has been coined to describe those individuals who cannot tolerate gluten and experience symptoms similar to those with celiac disease but yet who lack the same antibodies and intestinal damage as seen in celiac disease.**

Answer 51

innate immune response as opposed to adaptive immune response (such as autoimmune) or allergic reaction Greater extra-intestinal or non-GI symptoms such as HA “foggy mind”, joint pain, numbness in legs, arms, or fingers and sx appear hours or days after eating gluten Avoid gluten

Answer 52

**Inflammation of the gallbladder** Gallstones (cholelithiasis) *Formed when bile sits in gallbladder too long and gets thicker forming **sludge into stone***; cholesterol gallstones are the most common type

Answer 53

**Female, Fat, Forty,** frequently occur during pregnancy Cholecystokinin (satiety hormone secreted after meals) causes gallbladder to contract → stone is released and gets lodged, pain develops from mechanical obstruction, local inflammation, or both

Answer 54

**Colicky RUQ pain that radiates to right shoulder** * Occurs within 1 hour after eating a large meal, lasts for hours, and residual for days * Anorexia, nausea, fever * prior episode * minimal sx in elderly *Colicky = comes and goes, not the worst, but is disturbing, , radiating, rhythmic pain*

Answer 55

**Murphy's Sign =** pain when palpating liver and gallbladder during deep inspiration * Temp * RUQ tenderness, involuntarily guarding * Gallbladder may be palpable

Answer 56

**Gallbladder Ultrasound** Distended gallbladder with mural thickening (arrowhead), and a stone in the gallbladder neck * CBC, **LFT's, GGT** * **HIDA scan** (hepatobiliary iminodiacetic acid) *The GGT test is sometimes used to help detect liver disease and _bile duct obstructions_. It is usually ordered in conjunction with other liver tests such as ALT, AST, ALP and bilirubin. In general, an increased GGT level indicates that a person's liver is being damaged but does not specifically point to a condition that may be causing the injury.*

Answer 57

**Cholecystectomy\*** **Urso Forte or Ursodiol** (oral dissolution therapy using bile acids) dissolves gallstones Cholecystectomy is safe, lowest risk of recurrence, 92% complete relief, laparoscopic \> open, 25% medically managed develop recurrent gallstones

Answer 58

Complete obstruction of cystic duct Gangrenous cholecystitis, Gallbladder perforation, Biliary peritonitis - *sepsis*

Answer 59

**Gallstones in common bile duct** * Gallstones can migrate from their primary site of origin in the gallbladder through the cystic duct and into the common bile duct. * Up to 15 percent of patients have common bile duct stones in combination with gallbladder stones, but the majority (73 percent) of these stones will pass spontaneously into the duodenum

Answer 60

1. Recovery phase of acute pancreatitis 2. Chronic relapsing *(usually in alcohol abuse)* 3. Pancreatic insufficiency (steatorrhea/ wt loss) * Gallstones * Alcohol abuse * Autoimmune (rare) and genetic diseases such as cystic fibrosis

Answer 61

**Alcohol, Gallstones, Hypertriglyceridemia** 1. Trauma/surgery 2. Abrupt discontinuation of meds (DM, Hyperlipidemia) 3. Medications (ACE, ARB, thiazide diuretics, furosemide, antimetabolites, corticosteroids, statins- list not exhaustive) 4. Hypercalcemia/hyper-parathyroidism, ARF, SLE, polyarteritis, Cystic fibrosis 5. Infectious causes (mumps, coxsackie, cryptosporidiosis-list not exhaustive) 6. Tumors 7. Sphincter of Oddi dysfunction *(morphine can cause spasm of this sphincter)* 8. Pancreatic divisum 9. Vascular disease 10. Acute fatty liver of pregnancy 11. Idiopathic

Answer 62

* Mild-severe epigastric pain with radiation to the flank, back, or both * Character: **dull,** **boring; worse when supine** * Alleviated by sitting, *leaning over the sink*, or fetal position * Triggers: heavy meal or alcohol binge * Associated sx: nausea and non-feculent vomiting

Answer 63

* **VS:** Temperature * **CV**: rate (may be tachycardic) * **Abdomen**: distension; muscle spasms; epigastric or LUQ pain on palpation * **Skin**: signs of **jaundice** *(bilirubin only needs to be about 4-5 to be visibly jaundiced)*

Answer 64

**Amylase, Lipase** (pancreatic enzymes that rise when pancreas is inflamed) * **Amylase**: starts to rise 2-12 hours after onset of symptoms; peaks 12-72 hours * may rise in biliary tract disease, renal disease, intestinal obstruction, perforated ulcer * **Lipase**: rise within 4-8hrs, peak at 24 hours; more specific and sensitive in detection *Use these values in conjunction with each other not individually*

Answer 65

**CT with Contrast\*** * _Plain radiographs_: may show gas-filled duodenum, but not specific - not a good test * _US_: may detect biliary causes * _ERCP_ (Endoscopic Retrograde Cholangiopancreatography): indicated for biliary obstruction, can remove impacted stones

Answer 66

Medical management of mild acute pancreatitis includes **IV fluid** **hydration**, keeping **pt NPO** and administration of **analgesics**; in absence of ileus, N/V, oral feeding can be initiated early if and as tolerated (low residue, **low fat**, soft diet) Patients with severe acute pancreatitis require intensive care * Antibiotics are generally not indicated but up to 20% of pts can develop extra-pancreatic infections and need abx (assoc inc mortality) * Within hours to days, a number of complications (eg, shock, pulmonary failure, renal failure, gastrointestinal [GI] bleeding, or multi-organ system failure) may develop

Answer 67

* Low fat * Check/treat alcoholism, hypertriglyceridemia, hypercalcemia * Eliminate meds which trigger * HIV+ : CMV or toxoplasmosis infection * Ultrasound: refer if stones are found

Answer 68

* Treat underlying cause * Readmit if acute pancreatitis recurs * Begin with mild analgesics (acetaminophen); may need morphine or methadone * Limit fat during flare-ups * Rule out carcinoma (U/S or CT) * Psychiatric or pain consult for refractory pain

Answer 69

Exocrine Pancreatic Insufficiency (EPI) Cystic fibrosis, Shwachman-Diamond Syndrome

Answer 70

Pancreatic Enzyme Products (PEPs) **pancrelipase**, used to break down fats, proteins and carbohydrates (2-8 tabs) with full meals and less (2 tabs) with snacks * High-calorie diet rich in carbs and protein * Supplements: medium-chain triglyceride prep * Restrict fat in symptomatic steatorrhea (excess fat in stool; oily appearance and foul smelling) * Monitor glucose tolerance and treat clinical diabetes