GI PEARLS Flashcards by Dylan Plocki

mechanical or functional abnormality of the LES

Reflux esophagitis

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Medication induced esophagitis:

think NSAIDS or bisphosphonates

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Pt with Asthma symptoms and GERD not responsive to antacids. Allergic, eosinophilic infiltration of the esophageal

Eosinophilic

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Fungal Esophagitis:

Candida:
Tx: fluconazole

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Viral Esophagitis:

HSV: shallow ulcers noted on EGD, treat with acyclovir
CMV: deep ulcers on EGD, treat with ganciclovir

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Decreased peristalsis, increased sphincter tone
Presentation: slowly progressive dysphagia, episodic regurgitation
Barium swallow: “parrot-beak” - dilated esophagus tapered to distal obstruction
Definitive diagnosis: esophageal manometry

Achalasia

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Corkscrew appearance on barium swallow

Diffuse Esophageal Spasm

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Dysphagia to liquids and solids caused by injury at brainstem or cranial nerves

Neurogenic dysphagia

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Outpouching of posterior hypopharynx

Presentation: Men over 60. Regurgitant symptoms several hours after eating, halitosis
Treatment: Excision, myotomy of cricopharyngeus muscle and upper 3 cm of posterior esophageal wall

Zenker diverticulum

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Dysphagia to both solids and liquids

Scleroderma esophagus

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Dysphagia to solids but not liquids

Esophageal stenosis

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Presentation: History of alcohol intake and an episode of vomiting with blood
Caused by forceful vomiting. Associated with alcohol use, upper endoscopy showing superficial longitudinal mucosal erosions
Treatment: Supportive. May cauterize or inject Epinephrine if needed

Mallory Weiss Esophageal mucosal tear

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Progressive dysphagia to solid foods along with weight loss, reflux and hematemesis

Esophageal Neoplasms

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most common worldwide espogapheal neoplasm?

squamous cell

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Most common US esophageal neoplasm?

adenocarcinoma

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Complication of Barrett’s esophagus (screen barrett’s patients every 3-5 years with endoscopy), affects distal (lower) 1/3rd of esophagus

Adenocarcinoma

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Associated with smoking and alcohol use
Affects proximal (upper) 2/3rds of esophagus
Progressive dysphagia, weight loss, hoarseness
Diagnostic studies: Endoscopy + biopsy
Treatment: Resection
-Esophageal neoplasm

squamous cell

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Solid food dysphagia in a patient with a history of GERD, Plummer-Vinson, Dx with barium swallow, TX with endoscopic dilation

Esophageal strictures

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Plummer-Vinson (3 things)

esophageal webs + dysphagia + iron deficiency anemia

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Often asymptomatic until hematemesis
Etiology: Portal hypertension (from cirrhosis), Budd-Chiari syndrome (from occlusion of hepatic veins)
Treatment: Therapeutic endoscopy – endoscopic banding and IV octreotide, prevent with nonselective beta blockers

Esophageal Varices

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Gold Standard GERD Dx?

PH Probe

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Most common gastritis cause?

H. Pylori

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3 gastritis causes?

Autoimmune (pernicious anemia)

Location: Body of fundus.
2. H. pylori infection (most common)

Location: Antrum and body
Studies: Urea breath test or fecal antigen.
Treatment: PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole
3. NSAIDs and alcohol

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Stomach Neoplasms

Adenocarcinoma, Virchow’s node (Supraclavicular), Sister Mary Joseph’s node (Umbilical)

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Most common PUD cause?

H. Pylori

PUD causes?

Etiology: H. pylori (most common), NSAID use, Zollinger-Ellison syndrome (refractory PUD) - gastrin secreting tumor

PUD symptoms, pain improves with food:

Duodenal Ulcer

PUD symptoms pain worsens with food:

Gastric ulcer

PUD gold standard diagnostic test?

Endoscopy with biopsy

PUD Tx:

H. pylori infection: Triple therapy PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole NSAIDs use: discontinue use Zollinger-Ellison syndrome: PPI and resect tumor

Projectile vomiting occurs shortly after feeding in an infant < 3 mo old, palpable "olive-like" mass Barium swallow: string sign Treatment: surgical correction

Pyloric stenosis

Presentation: 5 Fs: Female, Fat, Forty, Fertile, Fair (+) Murphy's sign (RUQ pain with GB palpation on inspiration) RUQ pain after high fat meal

Acute and Chronic Cholecystitis

Acute and chronic cholecystitis Dx:

Ultrasound is the preferred initial imaging Gallbladder wall >3 mm, pericholecystic fluid, gallstones HIDA is the best test porcelain gallbladder = chronic cholecystitis Treatment: Cholecystectomy

Presentation: Charcot’s triad: RUQ tenderness, jaundice, fever Reynold’s pentad: Charcot’s triad + altered mental status and hypotension

Cholangitis

Cholangitis Organisms:

E. coli, Enterococcus, Klebsiella, Enterobacter

Cholangitis Dx studies:

Initial imaging: Ultrasound | Best: ERCP

Cholangitis Tx:

Aggressive care and emergent removal of stones, cipro + metronidazole Antibiotics, fluids and analgesia. ERCP to remove stones, insert stent, repair sphincter Cholecystectomy (performed post-acute)

Primary sclerosing cholangitis

Jaundice and pruritus | Associated with IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer

Precursor to cholecystitis, cholesterol stones account for > 85% of gallstones in the Western world

Cholelithiasis

Symptoms: Tea colored urine, vague abdominal discomfort, nausea, pruritus, pale stool

Acute/Chronic Hepatitis

Hepatitis A

Acute | Transmission: Fecal-oral

Hepatitis B

``` Acute and Chronic Transmission: Sexual or sanguineous Serology: HBeAg – highly infectious HBsAg – ongoing infection Anti-HBc – had/have infection IgM – acute IgG – not acute Anti-HBs – immune Risk of hepatocellular carcinoma ```

Hepatitis C

Chronic Asymptomatic Transmission: IV drug use is most common. Also sexual or sanguineous Risk of cirrhosis and hepatocellular carcinoma

Hepatitis D

Only occurs when coinfected with Hepatitis B* | Risk of hepatocellular carcinoma

Hepatitis E

Pregnant woman, 3rd world countries Hepatitis E + mother = high infant mortality Treatment: Supportive. Vaccinate against other viral hepatitis. HIV treatment PRN. Hepatitis C- Pegylated interferon and ribavirin

Hepatitis Tx:

Supportive. Vaccinate against other viral hepatitis. HIV treatment PRN. Hepatitis C- Pegylated interferon and ribavirin

Alcoholic Hepatitis:

Liver enzymes: AST:ALT ratio > 2:1

Toxic Hepatitis:

Acetaminophen toxicity: Treatment with N-Acetylcysteine within 8-10 hrs

Fatty Liver Disease:

Risk factors: Obesity, hyperlipidemia, insulin resistance Liver enzymes: ALT > AST Liver biopsy: Large fat droplets (macrovesicular fatty infiltrates)

Labs: typically AST > ALT, ↑ risk for hepatocellular carcinoma: monitor AFP, Hepatic vein thrombosis: Budd Chiari: triad of abdominal pain, ascites and hepatomegaly Presentation: Ascites, pulmonary edema/effusion, esophageal varices, Terry’s nails (white nail beds) Skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation

Cirrhosis

Most common cause of cirrhosis:

Chronic hepatitis

Hepatic encephalopathy:

Asterixis (flapping tremor), dysarthria, delirium, coma | Treatment: Avoid alcohol, restrict salt, transplant

Abdominal pain, weight loss, right upper quadrant mass Etiology: Cirrhosis, Hepatitis B, Hepatitis C, Hepatitis D, Aflatoxin from aspergillus Tumor Marker: ↑ alpha-fetoprotein and abnormal liver imaging Treatment: Resect, Transplant Poor prognosis

Liver Neoplasms

epigastric abdominal pain with radiation to the back and elevated lipase Etiology: Cholelithiasis or alcohol abuse Diagnosis: Clinical + elevated lipase and amylase. CT required to differentiate from necrotic pancreatitis Signs: Grey turner's sign (flank bruising), Cullen’s sign (bruising near umbilicus)

Acute pancreatitis

Ranson’s criteria for poor prognosis of pancreatitis::

Ranson’s criteria for poor prognosis: At admit: ``` Age > 55 Leukocyte: >16,000 Glucose: >200 LDH: >350 AST: >250 At 48 hrs: ``` ``` Arterial PO2: <60 HCO3: <20 Calcium: <8.0 BUN: Increase by 1.8+ Hematocrit: decrease by >10% Fluid sequestration >6L ```

Pancreatitis Tx and complications:

Treatment: IV fluids (best), analgesics, bowel rest Complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)

Chronic Pancreatitis:

classic triad of pancreatic calcification (plain abdominal x-ray), steatorrhea (high fecal fat), and diabetes mellitus Alcohol abuse Treatment: No alcohol, low fat diet

Pancreatic Neoplasms:

Painless jaundice is pathognomonic likely ductal adenocarcinoma at head of pancreas, Courvoisier's sign - non tender, palpable gallbladder, Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle) that is associated with pancreatic cancer. Most commonly located at pancreatic head Jaundice and palpable non-tender gallbladder (Courvoisier’s sign) Trousseau sign of malignancy - migratory phlebitis Imaging: CT with contrast Whipple procedure: remove antrum of stomach, part of duodenum, head of pancreas, gall bladder Tumor Marker: CA 19-9

Umbilical pain → then pain over McBurney’s point (RLQ) Most common etiology: Fecalith Signs: Rovsing – RLQ pain with palpation of LLQ Obturator sign – RLQ pain with internal rotation of hip Psoas sign - RLQ pn with hip flexion Treatment: Appendectomy

Appendicitis

Small bowel inflammation from allergy to gluten Symptoms usually occur following ingestion of gluten containing food. Also has extraintestinal manifestations. Diagnosis: IgA antiendomysial and antitissue transglutaminase antibodies Small bowel biopsy Treatment: Lifelong gluten free diet

Celiac disease

Defined as less than 2 bowel movements per week

Constipation

LLQ pain, tenderness, abdominal distention, fever and leukocytosis in older patients Most common location: Sigmoid colon CT: Fat stranding and bowel wall thickening Treatment: Metronidazole and Ciprofloxacin + bowel rest

Diverticular disease

Isolated to the colon starts at rectum and moves proximal Continuous lesions Mucosal surface only Barium enema: Lead pipe appearance (loss of haustral markings) Treatment: - Colectomy is curative - Medications: Prednisone and mesalamine

Ulcerative Colitis

From mouth to anus, transmural, skip lesions and cobblestoning! ``` Mouth to anus Skip lesions Transmural Fistulas common Barium enema: Cobblestone appearance ``` Treatment: Flares: Prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin Maintenance: Mesalamine Surgery is not curative. Adjacent portion of bowel is affected post-op

Crohns Disease

Sudden onset of acute pain, affects children after viral infections or adults with cancer Currant jelly stools Sausage like mass in the abdomen Barium enema - Diagnostic and therapeutic in children

Intussusception

Frequent bouts of constipation alternating with diarrhea, pain relieved with defecation Diagnosis of exclusion Often associated with psychological pathology

IBS

50 years old with history of coronary artery disease experiencing recurrent cramping with postprandial abdominal pain Most common artery: Superior mesenteric artery Acute: Abdominal pain out of proportion to findings Chronic: pain 10-30 mins after eating, relieved by lying or squatting

Ischemic Bowel Disease

Gold standard Dx for Ischemic bowel disease:

Mesenteric angiography

other ischemic bowel diseases imaging tests:

Plain films/CT: Bowel edema, pneumatosis intestinalis, portal venous gas Mesenteric angiography is the gold standard

Gold standard Tx for Ischemic Bowel Disease:

Revascularization

Other Tx for Ischemic Bowel Disease:

Supportive: Bowel rest, fluids, antibiotics Laparotomy with bowel resection for bowel infarction Revascularization is the gold standard

Gold standard Dx for Lactose intolerance:

Hydrogen breath test

Apple core lesion on barium enema, adenoma most common type, treat with resection and 5FU Screening with colonoscopy begins at 50 then every 10 years until 85 Fecal occult blood testing - annually after age 50 Flexible sigmoidoscopy - every 5 years with FOB testing Colonoscopy - every 10 Sometimes CT colonography Tumor Marker: CEA More likely to be malignant: sessile, >1 cm, villous Less likely to be malignant: Pedunculated, <1 cm, tubular Treatment: Resect tumors

Colon cancer

Look for vomiting of partially digested food, severe abdominal distensions and high pitched hyperactive bowel sounds progressing to silent bowel sounds. KUB shows dilated loops of bowel with air fluid levels with little or no gas in the colon Etiology: Adhesion, hernia, fecal impact, volvulus, neoplasm Treatment: Bowel rest, NG tube placement, surgery as directed by underlying cause

Small bowel obstruction

Familial Adenomatous polyposis:

100-1,000s of adenoma polyps by age 30 Risk of adenocarcinoma and desmoid tumors Follow up screening in 3-5 years after removal

Peutz-Jeghers syndrome:

Hamartomatous polyps

``` Complication of Ulcerative colitis (most common), Crohn’s, Hirschsprung’s, pseudomembranous colitis, enteritis KUB shows dilated colon > 6 cm Presentation: Rigid abdomen Plain film: Colonic distention Treatment: ``` Decompression of colon, fluids, antibiotics If no improvement in 24 hours, colectomy is indicated

Toxic Megacolon

Tearing rectal pain and bleeding which occurs with or shortly after defecation, bright red blood on toilet paper Pain lasts for several hours, and subsides until the next bowel movement Treatment: Sitz baths

Anal fissure

Painful; perianal swelling, redness, and tenderness Location: most often perirectal/perianal Treatment: Warm water cleanse, high fiber diet and I&D/surgical drainage

Rectal Abscess and Fistula

Belly cramping and bloating, small amount of stool leakage and rectal discomfort in an elderly bed-bound patient

Fecal impaction

proximal impaction:

May be neoplasm | Break up with colonoscopy/sigmoidoscopy

Distal impaction

Rock-hard stool on rectal exam | Treatment: treat with manual disimpaction digitally, followed by a saline or tepid water enema

Hemorrhoids:

External- lower 1/3 of anus (below dentate line) External: significant pain, and pruritus but no bleeding, treat with excision for thrombosed external hemorrhoids Internal- upper 1/3 of anus bright red blood per rectum, pruritus and rectal discomfort Treatment: Fiber, sitz bath, reduction if needed

Rectal bleeding + tenesmus (a feeling of incomplete emptying after a bowel movement),

Anorectal Cancer Whenever rectal bleeding occurs, even in patients with obvious hemorrhoids or known diverticular disease, coexisting cancer must be ruled out

Most common anorectal cancer:

adenocarcinoma

Involves protrusion of the stomach through the diaphragm via the esophageal hiatus. It can cause symptoms of GERD; acid reduction may suffice, although surgical repair can be used for more serious cases.

Hiatal (diaphragmatic) hernia

Very common, generally is congenital and appears at birth. Many umbilical hernias resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life

Umbilical hernia

Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one. Remember: Indirect goes through the Internal Inguinal Ring (an “I” for an “I”)

Indirect Inguinal Hernia (Most Common)

Passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum Hernia often presents on standing and disappears and/or is reducible when patient is supine.

Direct inguinal hernia

Hernia where blood supply of its contents is seriously impaired

Strangulated hernia

This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel.

obstructed hernia

A hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.

incarcerated hernia

inadequate intake of ALL energy forms (including protein)

Marasmus

inadequate intake of protein energy and may lead to edema

Kwashiorkor

night blindness - is an important component in retinal rods and cones and is essential for normal vision, deficiency causes night blindness

Vit A

rickets, osteomalacia

Vit D

neuropathy, ataxia - an antioxidant and free radical scavenger, deficiency results in neuronal degeneration with manifests as areflexia and gait disturbances

Vit E

bleeding (makes clotting factors causes increase in PT/INR)

Vit K

an autosomal recessive disorder and inborn error of metabolism involving impaired metabolism of phenylalanine, one of the amino acids. caused by absent or virtually absent phenylalanine hydroxylase (PAH) enzyme activity.

Phenylketonuria (PKU)

GI PEARLS Flashcards

(99 cards)