GI Part 1 Flashcards
(98 cards)
1
Q
Regions of Abdominal Area
A
2
Q
Gastrointestinal Disorders
- Abdominal ____: Acute and Chronic
- P______
- Gastritis/G_ _ _
- Gastrop____
- Gastric C_____
- D_____
- P _ _
- C_____ Disease
- Ch___cystitis
- P____titis
- Nausea/Vomiting
- GI bl____
- A____icitis
- I _ _
- I _ _
- Constipation
- Diarrhea
- Di_____ Disease
- Hem_____
- C_____ Cancer
- B_____ Surgery and O
- Pediatrics
A
- Abdominal pain: Acute and Chronic
- Peritonitis
- Gastritis/GERD
- Gastroparesis
- Gastric Cancer
- Dysphagia
- PUD
- Celiac Disease
- Cholecystitis
- Pancreatitis
- Nausea/Vomiting
- GI bleeding
- Appendicitis
- IBD
- IBS
- Constipation
- Diarrhea
- Diverticular Disease
- Hemorrhoids
- Colon Cancer
- Bariatric Surgery and Obesity
- Pediatrics
3
Q
Abdominal Pain
Abdominal pain is common and often inconsequential.
When is abdominal pain concerning?
- May be sole indicator of the need for (1) and must be attended to quickly
- Particular concern in patients who are very ___ or very _____ and those who have ____ infection or taking Rx (1)
A
Abdominal pain is common and often inconsequential.
ACUTE AND SEVERE almost always a symptom of intra-abdominal disease sign of pathology)
- May be sole indicator of the need for surgery and must be attended to quickly.
- Particular concern in patients who are very old or very young and those who have HIV infection or taking immunosuppressants.
4
Q
The Peritoneum
A thin serous membrane
Parietal Peritoneum =
Visceral Peritoneum =
Peritoneal cavity =
A
Lines the walls of the abdominal and pelvic cavities
Lines the organs
Space between the two layers
5
Q
It is the most common form of abdominal pain and can be described as vague, dull and nauseating. It is poorly localized.
- Responds mainly to (2) motions, not to cutting or tearing
A
Visceral Pain
- Responds mainly to distension and muscular contraction
6
Q
Origins of Abdominal Pain
- (1) structures (stomach, duodenum, liver, and pancreas) cause pain where?
- (1) structures (small bowel, proximal colon, and appendix) cause pain where?
- (1) structures (distal colon and GU tract) cause pain where?
- (1): indigestion, cholecystitis
- (1): intestinal obstruction, early appendicitis
- (1): small or large intestine, urinary tract infection, inflammatory bowel disease
A
- Foregut structures (stomach, duodenum, liver, and pancreas) cause upper abdominal pain.
- Midgut structures (small bowel, proximal colon, and appendix) cause periumbilical pain.
- Hindgut structures (distal colon and GU tract) cause lower abdominal pain.
- Epigastric: indigestion, cholecystitis
- Periumbilical: intestinal obstruction, early appendicitis
- Suprapubic: small or large intestine, urinary tract infection, inflammatory bowel disease
7
Q
Type of abdominal pain perceived distant from its source. This is due to the lack of a dedicated sensory pathways in the brain for information concerning internal organs.
Examples (3)
A
Referred Pain
- Scapular pain dt biliary colic (right shoulder blade pain from gallbladder inflammation irritating phrenic nerve)
- Groin pain dt renal colic
- Shoulder pain from diaphragm irritation (can be rt biliary colic)
8
Q
Pain coming from lining of the abdominal wall and pelvic cavities, characterized as _____, ____ localized
- It is often mediated by (3) I’s.
- This may include acute (2) rather than biliary colic which started as visceral pain.
A
Parietal or Somatic Pain
sharp, well localized
- It is often mediated by acute inflammation, ischemia or infectious processes.
- This may include acute appendicitis or acute cholecystitis rather than biliary colic which started as visceral pain.
9
Q
CHRONIC abdominal pain associated with history of multiple body complaints, chronic non-progressive course, somatic symptoms of depression. (ie. IBD)
Examination maneuver =
A
Psychogenic pain
Examine using deep palpation while pt is distracting using stethoscope for “auscultating”
10
Q
HPI for Abdominal Pain
- L___ization vs. referred
- C_____zation
- Area of r_____
- Time course of o_____ and r_____
- Pr____ and A____ factors
- Ass_____ symptoms (P,Q,R,S,T= position, quality, radiation, severity/pain scale, timing or triggers)
A
- Localization vs. referred
- Characterization
- area of referral
- time course of onset and resolution
- precipitating and alleviating factors
- associated symptoms (P,Q,R,S,T= position, quality, radiation, severity/pain scale, timing or triggers)
- Diagnosis is heavily reliant on this part of the work-up*
- Localization: show chart*
- Characterization:: ex: duodenal ulcer (burning/gnawing), intestinal obstruction (crampy,) acute appendicitis (aching)*
- More serious associated symptoms are: weight loss, blood in stool, jaundice, nausea and vomiting, and fever*
11
Q
Past Medical History GI
- Current M_____
- D___
- S____ Pattern
- F____ History
- P___/S_____ History
- T_____ history/E___ intake/C_____/Mar____/Il______
- ____style, h____ situation, sig_____ others
- Sc____/j___/fi____/recreation
A
- Current Medications
- Diet
- Sleep Pattern
- Family History
- Psych/Social History
- Tobacco history/ETOH intake/Caffeine/Marijuana/Illicits
- Lifestyle, home situation, significant others
- School/job/financial/recreation
12
Q
ROS GI
A
Trouble swallowing, heartburn, appetite, nausea, vomiting, hematemesis, indigestion, frequency of BM’s, last BM, change in habit, rectal bleeding, melena, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or flatus, hemorrhoids, jaundice, cholecystitis, hepatitis, weight loss, noctural symptoms
13
Q
Physical Exam GI
- G____, Te_____, Co____, V _
- Look for chest signs of (1)
- Include check for (1) tenderness, her___, and pul__
- If pt having acute pain, do a complete abdominal and ____ exam, consider ____ exam if applicable
A
See image
14
Q
Assessment: Is this an Acute Surgical Abdomen?
Pain is acute, persistent lasting > __
- Symptoms are pro____
- Pain is well-_____, often re___ tenderness, g____ and ri____
- (3) associated sx
- ______ bowel sounds
A
Pain is acute, persistent lasting > 6 hours
- Symptoms are progressive
- Pain is well-localized, often rebound tenderness, guarding and rigidity
- Nausea, vomiting, and anorexia associated
- Absent bowel sounds
- Look at most serious differentials for age-appropriate concerns*
- Nausea/vomiting: worse if vomitus smells like feces or is bilious, worse if pain occurs before vomiting, pain during or after vomiting suggests gastroenteritis*
- Bowel sounds: must listen for 3 continuous minutes*
15
Q
Is this an Acute Surgical Abdomen?
Check (2)
- Extremities co___, cl____
- HR =
- Impaired men_____
- ___uria
- F_____
A
Check orthostatic blood pressure and pulse
- Cold, clammy extremities
- Tachycardia
- Impaired mentation
- Oliguria
- Fever
If the patient is orthostatic, this indicates hemorrhage or third spacing
16
Q
Peritoneal Signs
- Severe pain worsened by (2)
- Observe posture: patients with peritonitis =
- Suspect when irritable infants lie very ___, have _____ hips, and are quiet
A
- Severe pain worsened by movement or cough.
- Observe posture: patients with peritonitis LIE STILL with knees drawn up to the chest; complain when asked to move.
- Suspect when irritable infants lie very still, have flexed hips, and are quiet
Peritonitis is inflammation of the peritoneal cavity. This may result from any abdominal condition that causes marked inflammation
17
Q
Peritonitis Causes
- (3) itis’s, str_____ intestinal obstruction , P____ ID, mesenteric is______
- Intraperitoneal blood from?
- B____! – can be problematic for some patients
- Peritoneo-systemic sh___, dr___, ____ catheters (PD), as_____
A
- Appendicitis, diverticulitis, strangulating intestinal obstruction, pancreatitis, PID, mesenteric ischemia
- Intraperitoneal blood from ruptured aneurysm, trauma, surgery, ectopic pregnancy
- Barium! – can be problematic for some patients
- Peritoneo-systemic shunts, drains, dialysis catheters (PD), ascites
18
Q
Physical Findings in the Elderly
A
Vascular compromise may be indicated when reported pain outweighs pain on palpation
19
Q
Non-GI Sources of RUQ/LUQ Pain
(4)*
A
- Herpes Zoster
- Lower Lobe Pneumonia *
- MI *
- Radiculitis (nerve pain that starts in the spine)*
*Think about your patient population
20
Q
Gastro-Esophageal Reflux Disease (GERD)
=
Causes (4)
A
Reflux of gastric contents into esophagus resulting in a symptomatic condition
- Relaxation of LES
- Irritants (gastric acid and digestive enzymes)
- Decreased secondary peristalsis
- Decreased resistance to caustic liquids
21
Q
GERD
Contributing factors (4)
Triggers (5)
A
Tobacco, ETOH, exercise, hiatal hernia
SPICY, FRIED, FATTY, CITRUS, CAFFEINE
22
Q
GERD Clinical Features
Classic presentation*
- Heartburn within __-__ minutes of eating
- Symptoms worse in (2) positions
- May also have re____, nocturnal ____, ulcers, hem____, dental er____, l___gitis, as___ symptoms, or _____* esophagus
A
Burning substernal pain that radiates upward*
- Heartburn within 30 to 60 minutes of eating
- Symptoms worse lying down/ bending over
- May also have regurgitation, nocturnal aspiration, ulcers, hemorrhage, dental erosions, laryngitis, asthma symptoms, or Barrett’s esophagus
May have chest pain-mimics cardiac angina: chest pain may be heaviness or pressure that radiates to the neck, jaw or shoulders
23
Q
GERD History
Onset, duration, and progression of heartburn
- Ask if aggravated by (1)/ relieved by _____ up or (1)
- Sm_____
- Rx (2) use
- Diagnosis can be made by ____ alone is pt age
A
- Ask if aggravated by meals/ relieved by sitting up or antacids
- Smoker
- NSAID/ ASA use (GI irritants)
- Diagnosis can be made by history alone is pt age<45; history of heartburn; no dysphagia, weight loss, or blood loss – get FOBT for new GI complaints
24
Q
GERD PE
- VS (2)
- Abdominal exam for (2)
- Check for (1) in stool
- Usually no diagnostic tests indicated unless atypical presentation of concern: dysphagia, weight loss, melena, nocturnal symptoms-refer for (1)
A
- Height/Weight
- Abdominal exam: masses, tenderness
- Check for occult blood in stool
- Usually no diagnostic tests indicated unless atypical presentation of concern: dysphagia, weight loss, melena, nocturnal symptoms-refer for endoscopy
25
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
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
26
GERD Pharm Tx
(2) (1),(3) drug classes
**H2 Receptor Antagonist**
Pepcid
**Proton Pump Inhibitor**
(Omeprazole (prilosec), Lansoprazole (prevacid), Esomeprazole (nexium))
27
H2 Receptor Antagonist
(Pepcid)
MOA
Dosing frequency
Suppress acid by reversibly binding to histamine receptors located on gastric parietal cells (blocking endogenous histamine)
QD or BID
28
Proton Pump Inhibitor
(-prazoles)
MOA
Dosing frequency
Indication
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
29
PPI LT concerns
(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*
30
Tx for GERD follow up
* Re-evaluate pt after 2 weeks, if controlled, complete therapy for \_-\_ weeks
* After 8-12 weeks =
* If pts GERD is recurrent in nature =
* If symptoms unresolved in 8-12 weeks of therapy =
* 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)*
31
Which of the following is not an “alarm” finding in the person with GERD symptoms?
1. Weight gain
2. Dysphagia
3. Odynophagia (painful swallowing)
4. Iron deficiency anemia
1. **Weight gain**
2. Dysphagia
3. Odynophagia (painful swallowing)
4. Iron deficiency anemia
32
A client with gastro-esophageal reflux disease (GERD) is prescribed famotidine (Pepcid). In order to provide effective teaching, the NP must include which information about the action of the drug?
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
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).*
33
Barrett's Esophagus
=
Tissue injury dt ____ exposure to gastric a\_\_\_, p\_\_\_\_, and b\_\_\_\_
Low or high grade dysplasia (1) change into (1) epithelium
Typically affects (1) \>\_\_ yo
**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
34
Barrett's Esophagus
* Presentation is usually (1) or (1)
* This is a strong correlation with LT ____ exposure and risk of \_\_\_\_\_\_
* *Dose-related:refers to risk of development of adenocarinoma with Barrett’s esophagus is \<1% annually, 5 and 10-fold in persons with (1) and (1)*
* *Will need frequent (1) depending on molecular changes of their cells*
* 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*
35
A 57 year old male is in need of evaluation for Barrett esophagus. You recommend:
1. H. pylori testing
2. CT scan
3. Upper GI endoscopy with biopsy
4. Barium swallow
1. H. pylori testing
2. CT scan
3. **Upper GI endoscopy with biopsy**
4. Barium swallow
36
Gastroparesis
=
Usually a complication of uncontrolled \_\_\_
* Motility problem as a result of ____ neuropathy (impacts both sympathetic and parasympathetic fibers).
* Affects food \_\_\_\_, affecting ____ control. Also causes n\_\_\_\_ and v\_\_\_\_.
* Symptoms may improve with control of \_\_\_\_\_
**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.
37
Gastroparesis Diagnostics
(3)
1. Endoscopy
2. Gastric emptying study
3. Radiolabeled CO 2 breath test *(less common)*
38
Gastric Emptying Study
Light meal consumption with _____ contents measures emptying of stomach
\>\_\_\_% at 2 hours or \>\_\_% at 4 hours is a positive diagnosis
Light meal consumption with radioactive contents
measures emptying of stomach (\>60% at 2 hours or \>10% at 4 hours is a positive diagnosis
39
Gastroparesis Treatment
**Mainstay Rx (1)**
* _____ modifications
* _____ control for \_\_\_
**Metoclopramide (Reglan) -** as motility agent
(*may have neurocognitive SE, usually given for short periods of time)*
* Dietary modifications
* Tighter control for DM
40
Dysphagia
=
2 Types
1. **\_\_\_\_\_ dysphagia** more likely dt **structural causes**
2. **\_\_\_\_\_ dysphagia** more likely dt **functional causes**
* May be mild or severe, resulting in mal\_\_\_\_\_, de\_\_\_\_\_, ch\_\_\_\_, as\_\_\_\_\_, pn\_\_\_\_ and even death
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
41
Dysphagia History
* Onset
* Gradual onset, slow progression and chronic course suggest (1)
* Rapid onset and progressive suggest (1)
* Swallowing difficulty: liquids (cold), solids
* Choking, reflux or pain aka (1)
* Weight \_\_\_\_\_
* PMH: _____ disease , ____ reflux, esoph\_\_\_\_
* 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)*
42
Dysphagia Notes
* *History can lead to a tentative diagnosis*
* *Most important is d\_\_\_\_\_ and pr\_\_\_\_\_ of symptoms*
* *Relation of symptoms to ______ to liquids and solids*
* *Effects of c\_\_\_\_ on swallowing*
* *Response to swallowing a bolus (repeated swallowing and _____ maneuver can assist in swallowing in motor disorder). Obstruction-swallowing a bolus will cause regurg*
* *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*
43
Dysphagia Location of Discomfort and Symptoms
* Intermittent dysphagia: suggests (1) location
* Associated with swallowing - mucosal\_\_\_\_\_\_
* Difficulty swallowing solids associated with chronic heartburn think (1)
* Accompanied by diplopia think (1)
* Associated with tremor or difficulty initiating movement think (1)
* 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
44
Dysphagia Clinical Presentation
May present with mal\_\_\_\_\_, weight \_\_\_\_\_, de\_\_\_\_\_, or pn\_\_\_\_\_\_
* **Problems with oral stage**: poor ____ control, sp\_\_\_\_ from lips or into pharynx, ____ oral membranes, p\_\_\_\_ or oral residue, difficulty with ch\_\_\_\_\_
* **Pharyngeal dysplasia:** results from poor coordination of _____ and may cause de\_\_\_\_ swallowing, nasal or oral re\_\_\_\_\_\_\_, manifested as c\_\_\_\_\_, ch\_\_\_\_, or gu\_\_\_\_\_
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
45
Dysphagia PE
1. **Oral exam**
1. Includes =
2. Altered sp\_\_\_\_, v\_\_\_\_, g\_\_ reflex
2. **Neuro exam**
1. Attention to CN function (5), assessment of m\_\_\_\_ strength, atrophy, tr\_\_\_\_, g\_\_\_ disturbance. M\_\_\_\_ status
3. **Body =** (4) deformities
4. **Skin**
1. P\_\_\_\_, sclero\_\_\_\_, tel\_\_\_\_\_, _____ _variant of scleroderma_
2. _____ nodes and th\_\_\_\_\_ for enlargement
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
46
CREST Acronym
47
Causes of Dysphagia
* **(1) Type:** Iatrogenic, Infectious. Metabolic, Myopathic , Neurologic, Psychiatric, Environmental
* **(1) Type:** Trauma, Surgery, Tumor, Webs, Strictures or Stenoses, Diverticuli, Infection, Cervical osteophytes
* **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*
48
Dysphagia
* **(1)** usually is neurological, with difficulty initiating swallowing
* **(1)** is the most common motor dysphagia: slow progressive loss of peristalsis
* **(1)** can cause loss of tone and propulsive activity in esophagus
* **(1)**: difficulty w/solids, duration of symptoms \<1yr for malignancy
* **Transfer Dysphagia (oropharyngeal)**
* **Achalasia**
* **Scleroderma**
* **Mechanical Obstruction**
49
Dysphagia Notes
* *(1) 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*
* *(1)*
* *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*
* *(1)*
* *approximately 75% of these pts have esophageal involvement of some type*
* *reflux is more common than dysphagia*
* *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*
50
Dysphagia Diagnostic Tests
(2)
* If globus present or reflux sx’s try Rx (2) before referring to \_\_\_
* If PND (post nasal drip) present Rx (1) before referring to \_\_\_\_
GI and/or ENT will most likely coordinate testing
* Refer for (1) + (1) for suspected obstruction, suspected malignancy, lesion identification, reflux, infection (candida infection), Schatzki ring.
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.*
51
MBS vs. Esophagram
*Pt ed: barium makes you poop*
52
Rare disorder of the esophagus, characterized by impaired peristalsis**, failure of the lower esophageal sphincter (LES), to relax**.
Failure of LES to relax with swallowing
Achalasia
53
Achalasia Imaging
Progressive dysphagia for solids and liquids and regurgitation
* Barium esophagram will show **esophageal _____ with classic “\_\_\_ \_\_\_\_” appearance distally**
* Esophageal manometry shows **lack of _____ of the \_\_\_\_** with swallowing and aperistalsis of the esophageal body
* 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
54
Management of Dysphagia
* Structural causes of dysphagia are usually treated with (1)
* Advise an adequate _____ intake that can be swallowed with minimum of difficulty:
* _____ or _____ diets for mechanical obstruction
* _____ amts, eaten s\_\_\_\_\_ for motor dysfunction
* Follow-up should be done by a \_\_\_\_\_\_
* 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
55
Peptic Ulcer Disease
=
**Peptic ulcer disease is a problem of the gastrointestinal tract characterized by _deep mucosal damage secondary to pepsin and gastric acid secretion_**_._
56
Peptic Ulcer Disease Characteristics
Usually occurs in **(2)** locations of the GI tract, which one is more common, and what is the prevalence of malignancy of both locations?
Most common cause 95% **(1)**
2nd most common cause **(1)**
**Stomach and Proximal Duodenum** - duodenal more common and rarely harbor malignancy, gastric ulcers 2-4% harbor malignancy
**H.Pylori** 95%
**NSAID/ASA use**
57
PUD History
Classic symptom presentation described as an episodic **(1) or (1) _____ pain**
**Pain occurs when in association to meals?**
**Pain also occurs on an _____ stomach**
* Nocturnal pain is relieved by ____ intake, ant\_\_\_\_, or anti-\_\_\_\_\_ agents
* Abdominal pain is ____ in at least 30% of older pts with peptic ulcers
* Postprandial epigastric pain more likely to be relieved by food or antacids with _____ ulcers
* Weight loss precipitated by fear of food intake is characteristic of ____ ulcers
**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.
58
PUD History
* PMH: \_\_\_\_hosis, \_\_\_\_titis, arthritis, COPD, hyper\_\_\_\_\_ism, Z\_\_\_\_-E\_\_\_\_ syndrome (hypersecretory state)
* Social history (3)
* Meds: (1)
* PUD in (1) fam hx
* 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
59
PUD Physical =
Rectal Exam =
60
A 33 yo male presents with persistent complaints of epi-gastric pain which occurs after eating and sometimes awakens him at night. His symptoms have been infrequent for “years” but worsening for the past 6 months. He has recently begun to notice some associated nausea & vomiting. He denies weight loss or bleeding but his stool seems darker in color. His mother has a history of “ulcers”. He works in construction and takes OTC ibuprofen for “aches and pains” several times per week. BMI is 27, PE is otherwise normal. ***What would you do?***
1. *Start a PPI once daily.*
2. *Perform serology test for H. pylori infection and treat if positive.*
3. *Refer to GI for upper endoscopy*
4. *Abdominal X ray.*
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.*
61
PUD Diagnostics
All patients perform an ____ blood, and (1)
(1) for alarm symptoms, tx failure, or to obtain definitive diagnosis
Occult blood, Hgb/Hct
Endoscopy
62
H.Pylori Testing
Gold standard =
(3) others
Never do (1)
**\*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*
63
PUD Evaluation
Evaluate for alarm symptoms
* An\_\_\_\_\_, \_\_\_\_emesis, Mel\_\_\_\_\_, or FOBT suggests bl\_\_\_\_\_\_
* Vomiting suggests \_\_\_\_\_\_\_
* Anorexia or weight loss suggests \_\_\_\_\_\_\_
* Persisting abdominal pain radiating to back suggests \_\_\_\_\_\_\_
* Severe, spreading upper abdominal pain suggests \_\_\_\_\_\_
* 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
64
H. Pylori Treatment
**Combination of?\***
Duration
1. If on NSAIDS?
2. If not on NSAIDS?
**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
65
The most sensitive and specific test for H pylori infection from the following list is:
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
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
66
Gastric Cancer
Ranks \_\_th of all cancers
Precise etiology unknown but acknowledged risk factors include
1. H\_\_\_\_ _____ gastric infection.
2. Advanced a\_\_\_
3. (1) gender
4. Diet low in (2).
5. **Diet high in (3) foods**
6. Chronic atrophic gastritis.
7. Intestinal metaplasia.
8. Pernicious a\_\_\_\_\_.
9. Gastric adenomatous p\_\_\_\_\_.
10. F\_\_\_\_ history of gastric cancer.
11. Sm\_\_\_\_\_.
12. Menetrier disease (giant hypertrophic gastritis).
13. Familial adenomatous polyposis.
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.
67
Gastric Cancer Clinical Presentation
**\_\_\_\_\_\_ onset** of abdominal pain that ranges in intensity from a **v\_\_\_\_\_ sense of post-\_\_\_\_\_ \_\_\_ness to s\_\_\_\_\_, st\_\_\_\_\_ pain**
* Wt \_\_\_\_, abdominal \_\_\_\_, an\_\_\_\_, v\_\_\_\_
* Other symptoms include a change in b\_\_\_\_ habits, dy\_\_\_\_, m\_\_\_\_\_, an\_\_\_\_ symptoms and hem\_\_\_\_\_
**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
68
Gastric CA Diagnostics
* ____ with diff, el\_\_\_\_\_ and \_\_FT’s
* Stool for (1)
* ___ radiograph/scan of abdomen
* E\_\_\_\_\_ and b\_\_\_\_
* CBC with diff, electrolytes and LFT’s
* Stool occult for occult blood
* CT radiograph/scan of abdomen
* Endoscopy and biopsy
69
Gastric CA Treatment
=
* P\_\_\_\_\_ resection (advanced lesions)
* Use of l\_\_\_\_\_ coagulation for obstruction and dysphagia
* Require doses of r\_\_\_\_\_ that exceed tolerance of surrounding structures
* Chemotherapy?
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
70
**Chronic, autoimmune inflammatory disease of the small intestine triggered by gluten proteins found in wheat, barley and rye**
* Traditionally **a mal\_\_\_\_\_\_ syndrome** but currently more of a \_\_\_\_system disease
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*
71
Celiac Disease and Autoimmune Disease
* In North America, the prevalence is approximately \_\_%
* Those diagnosed with celiac disease between 2-4 years had a 10.5% chance of developing an **\_\_\_\_\_\_ disease.** This chance increases with the ___ of diagnosis
* 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%*
72
Celiac Disease Symptoms
=
Diarrhea, constipation or symptoms of malabsorption such as bloating, flatus or belching but only 35% of newly diagnosed patients had chronic diarrhea.
73
Celiac Disease Manifestations of Malabsorption
(6)
**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**
74
High Risk Groups for Celiac Disease
1. First or second degree relatives of patients with celiac disease
2. (3) syndromes
3. Diabetes type \_\_
4. Ig\_ deficiency
5. Autoimmune \_\_\_\_itis
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
75
Celiac Disease Diagnostics
**Gold Standard (1)**
or (1)
* Genetic testing for (1) gene
* Blood test abnormalities: Abnormal \_FT's, low f\_\_\_\_\_, ___ cholesterolemia, ___ amylasemia, ___ albuminemia, ESR is \_\_\_\_\_, PT is \_\_\_\_\_, vitamin \_\_\_\_, \_\_\_calcemia, secondary \_\_\_parathyroidism
* **(1) + (1)** if IgA deficient
**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
76
Celiac Disease Long Term Management
=
To avoid what?
**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**.*
77
Non-Celiac Gluten Sensitivity
=
**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.**
78
Non-Celiac Gluten Sensitivity
Arises from (1) as opposed to (1)
Compared to actual celiac disease, what is the difference in manifestations?
Treatment =
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
79
Cholecystitis
=
Most common cause (1)
How are they formed? What is the most common type?
**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
80
Cholecystitis
More commonly occurs in what population (FFF), and also during (1)
Pathology of pain symptoms =
**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
81
Risk Factors Associated with Occurrence of Gallstones
1. _Body_ _habitus_: **o\_\_\_\_\_,\* ____ weight loss**, cyclic weight loss
2. _Childbearing,_ how?
3. _Drugs_: _____ (Rocephin), postmenopausal e\_\_\_\_\_, total parenteral \_\_\_\_\_
4. _Ethnicity_: (2)
5. _____ gender
6. Heredity: first-degree relatives
7. Il\_\_\_\_ disease, resection, or bypass
8. Increasing \_\_\_
82
Cholecystitis Presentation
Describe the pain of cholecystitis
* Timing with meals?
* Associated symptoms of an\_\_\_\_, n\_\_\_\_, f\_\_\_\_
* Most patients report a ____ episode
* Symptoms may be ____ in the elderly
**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*
83
Cholecystitis PE
**(1) Sign**
* Check (1) VS
* Abdomen will have (1) quadrant tenderness, may be involuntarily g\_\_\_\_\_ (early peritoneal irritation)
* Gallbladder may be \_\_\_\_\_\_\_
**Murphy's Sign =** pain when palpating liver and gallbladder during deep inspiration
* Temp
* RUQ tenderness, involuntarily guarding
* Gallbladder may be palpable
84
Cholecystitis Diagnostics
**(1)\*** 95% sensitivity and specificity
What will it show?
* Labs: CBC with diff, (2)
* **(1) scan** helps evaluate the function (*contractility)* of gallbladder and bile ducts
**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.*
85
Cholecystitis Management
**Primary Procedure (1)\***
Reserved for pts unfit or unwilling to undergo surgery (1)
Which one is superior, why?
**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
86
Acute Cholecystitis
Develops in 10% of pts with symptomatic gallstones and is caused by (1)
Delayed diagnosis of acute cholecystitis can lead to (3)
Complete obstruction of cystic duct
Gangrenous cholecystitis, Gallbladder perforation, Biliary peritonitis - *sepsis*
87
Choledocholithiasis
=
* Gallstones can migrate from their primary site of origin in the gallbladder through the ____ duct into the ____ 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 ?
**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
88
Pancreatitis
(3) forms treated in primary care
* Most common cause of acute pancreatitis (1)
* Most common cause of chronic pancreatitis (1)
* Other causes (2)
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
89
Risk Factors for Acute Pancreatitis
**(3)**
1. Tr\_\_\_\_/su\_\_\_\_
2. Abrupt discontinuation of ___ (DM, Hyperlipidemia)
3. Medications such as?
4. Hyper\_\_\_\_\_/hyper-parathyroidism, A\_F, S\_ *,* polyarteritis, Cystic \_\_\_\_
5. Infectious causes =
6. Tu\_\_\_\_\_
7. Sphincter of ____ dysfunction *(morphine can cause spasm of this sphincter)*
8. Pancreatic divisum
9. Vascular disease
10. Acute fatty liver of pr\_\_\_\_\_\_
11. Idiopathic
**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
90
Pancreatitis History
* Mild-severe e\_\_\_\_\_ pain with radiation to the fl\_\_\_, b\_\_\_, or both
* Character: **d\_\_\_,** **bor\_\_\_; worse in what position (1)**
* Alleviated by what positions?
* Triggers: heavy (1) or (1) binge
* Associated sx (2)
* 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
91
Pancreatitis Physical
* **VS**: T\_\_\_\_\_\_
* **CV**: rate (may be \_\_\_\_cardic)
* **Abdomen**: dis\_\_\_\_\_; muscle spasms; \_\_\_gastric or \_\_Q pain on palpation
* **Skin**: signs of **(1)**
* **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)*
92
Pancreatitis Labs
(2)
**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*
93
Pancreatitis Radiology
**Test of Choice (1)\***
(especially if fever, leukocytosis, severe sx)
* (1) may show gas-filled duodenum, but not specific - not a good test
* (1) may detect biliary causes
* (1) indicated for biliary obstruction, can remove impacted stones
**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
94
Acute Pancreatitis Management
Mild =
Severe =
* Antibiotic use?
* Complications?
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
95
Pancreatitis Recovery Phase Management
* Low ___ diet
* Check/treat \_\_\_\_\_ism, hyper (2)
* Eliminate m\_\_\_ which trigger
* \_\_\_+ : CMV or toxoplasmosis infection
* Ultrasound: refer if s\_\_\_\_\_ are found
* Low fat
* Check/treat alcoholism, hypertriglyceridemia, hypercalcemia
* Eliminate meds which trigger
* HIV+ : CMV or toxoplasmosis infection
* Ultrasound: refer if stones are found
96
Chronic Pancreatitis Management
* Treat _____ cause
* Re\_\_\_\_\_ if acute pancreatitis recurs
* Begin with (1) (acetaminophen); may need morphine or methadone
* Limit ___ ingestion during flare-ups
* Rule out car\_\_\_\_\_ (U/S or CT)
* Psychiatric or pain consult for re\_\_\_\_\_ pain
* 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
97
**Inability to properly digest food due to a lack of digestive enzymes made by pancreas**
Also found in (2) populations
Exocrine Pancreatic Insufficiency (EPI)
Cystic fibrosis, Shwachman-Diamond Syndrome
98
Exocrine Pancreatic Insufficiency (EPI)
Requires taking (1) with meals
* ___ calorie diet rich in (2)
* Supplement (1)
* Restrict ___ in symptomatic steatorrhea
* Monitor _____ tolerance and treat clinical d\_\_\_\_\_
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
