GIT Flashcards
Features of FB that will not pass the GIT
Irregular<br></br>Sharp<br></br>Wide objects (wider than 2.5 cm or longer than 6 cm)<br></br>
Complications of stuck FB
Airway obstruction<br></br>Stricture<br></br>Perforation<br></br>Corrosion<br></br>Erosion<br></br>Aspiration pneumonia/pneumonitis
Indications for urgent endoscopy in FB
Sharp objects<br></br>Multiple FBs<br></br>Button batteries<br></br>Perforation<br></br>Coin at the level of cricopharyngeus in children<br></br>Airway compromise<br></br>FB for > 24 hrs
Causes of Massive UGIB
PUD<br></br>Esophageal varices<br></br>Aorto-enteric fistula
Indication for massive transfusion in UGIB
Hemodynamic instability<br></br>Shock index (HR/SBP)>1<br></br>Pt presented with presyncope<br></br>Brisk bleeding<br></br>Co-morbidities (CAD, coagulopathy)
Tests to order during an MTP
CBC for plt count<br></br>INR (correct if > 1.8)<br></br>PTT<br></br>Fibrenogen (to assess the need for cryoppt)
<strong>Contraindications to tranexamic acid</strong>
<ul><li>History of coronary stent(s)</li><li>History of active hematuria (it is thought that administration of TXA in the patient with hematuria may cause a clot resulting in obstructive uropathy)</li><li>History of venous thromboembolic disease</li></ul>
“<h3><span><strong>Order of priority of IV medications in upper GI bleed emergencies</strong></span></h3>”
<ol><li><strong>Ceftriaxone</strong>1 g IV for all cirrhotics</li><li><strong>Octreotide 50</strong><strong>μ</strong><strong>g bolus + 50</strong><strong>μ</strong><strong>g/hr infusion</strong>for all UGIB patients</li><li><strong>Erythromycin250mg,</strong>30 minutes prior to endoscopy for suspected peptic ulcer</li><li><strong>PPI e.g. Pantaprazole 80 mg IV bolus</strong>(no infusion necessary) –once you’ve given everything else, if the endoscopist asks for it</li></ol>
Mx of GIT bleeding
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What historical factors that can help sorting out reasons for GIT bleeding?
Medication<br></br>Substance abuse<br></br>Constitutional symp<br></br>Stigmata of liver dis<br></br>Coagulopathy
Initial Mx of UGIB
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The patient’s vitals do not improve, what is your next steps in management
• Massive Transfusion Protocol<br></br>• Reverse coagulopathy <br></br>• Place nasogastric tube<br></br>• Consult gastroenterologist (GI) for emergent (EGD)<br></br>• If unstable consider Blakemore tube
DDX for blood in stool
• PUD<br></br>• Gastritis<br></br>• Esophageal or gastric varices<br></br>• Mallory Weiss syndrome<br></br>• Dielafoy lesions<br></br>• Avm malformations<br></br>• Malignancy<br></br>• Zollinger Ellison Syndrome: gastrin tumor
Risk Factors ofPUD
• EtOH <br></br>• H. Pylori<br></br>• NSAIDS<br></br>• Steroids<br></br>• Aortic graft
Meds in GIT bleeding
• Octeotide 50mcg/50mcg/hr<br></br>• PPI 80 mg bolus and then 40 mg IV BID<br></br>• ABX - for patients with Cirrhosis: Ceftriaxone or Cipro<br></br>• Consider Erythromycin 3mg/kg IV over 30 min, 30 min prior to scope
Ind of D/C of UGIB
If Glasgow Blachford Score=0:<br></br>No co-morbid dis<br></br>Normal VS<br></br>Normal Hb<br></br>Neg or trac FOB<br></br>Good home support<br></br>Competent/reliable pt<br></br>F/U within 24 hrs
Meat is stuck in the esophagus, what can be done before endoscopy?
ABC<br></br>Glucagon<br></br>Nitro<br></br>Carbonation (pepsi)
GERD red flags
Dysphagia<br></br>Wt loss<br></br>Anemia<br></br>Prolonged sym<br></br>Blood in stool/melena<br></br>>50<br></br>Sympt concerning other DDx(MI)<br></br>Early satiety<br></br>FHx of GI malignancy
H pylori testing:
Rapid urase test<br></br>Biopsy<br></br>Serology<br></br>Urea breath test
GERD complications:
Hge<br></br>Perforation<br></br>Stricture/obstruction<br></br>Barrett esophagus and Ca
Causes of EsophagiJs
• Infectious - Immunocompromised (primarily Candida Albans, <br></br>also viral (CMV and HSV)<br></br>• Pill esophagitis - Iron, potassium, bisphosphonates, NSAIDS, <br></br>tetracycline<br></br>• Reflux esophagitis - barrett’s<br></br>• Other: Radiation, Autoimmune, Eosinophilic Esophagitis, <br></br>• Caustic ingestion
Dysphagia (Neuro-Muscular) causes
• <b>Infectious</b>: botulism, diphtheria, polio, tetanus<br></br>• <b>Immunologic</b>: scleroderma, Multiple Slerosis, myasthenia gravis, polymyositis<br></br>• <b>Motor/nerve dysfunction: </b>Achalasia, Cranial nerve palsies
Extra-intesanal manifestaaons of IBD
arthrias (Ankylosing spondylitis)<br></br>erythema nodosum, <br></br>pyoderma gangrenous, <br></br>hepatobiliary disease (sclerosing cholangitis), <br></br>vasculitis, <br></br>uveias, <br></br>aphthous ulcers<br></br>
Possible causes of lateral anal fissure
“HIV<br></br>Crohn’s<br></br>Ca<br></br>TB<br></br>FB<br></br>Syphilis<br></br>Sexual abuse/child abuse”
pancreatic abscess,
infected peripancreatic fluid, or
infected pseudocyst
elevated Bili,
dehydration,
hypoglycemia,
age over 45,
immunosuppressed,
encephalopathy
• WBC >1000/mm3 or > 250 PMNs/mm3 or Bacteria on Gram Stain
• E Coli and Streptococcus
• Ceftriaxone 2g IV q24
• sedative meds
• nitrogen load (protein, GI bleed)
• Hypoglycemia
• constipation
• Dehydration
• Electrolyte abnormalities.
HSP
CF
Meckles
Idiopathic
Intussusception
SBO
Bleeding
Stricture
Perforation
Volvulus
• Sick contacts - daycare
• Rotovirus, adenovirus, enterovirus, norwalk, norovirus
• no blood or WBC’s in stool
• E.Coli 0156:H7 - Uncooked hamburger, petting zoo, raw milk,
untreated water.
• Causes HUS in children (increased risk with ABX) and TTP in Adults
• Salmonella - turtles, eggs, cafeteria, osteomyelitis in Sickle Cell
disease
• Campylobacter - chicken, bad food/water, associated with Guillain-
Barre
• Vibrio Parahaemolyticus/vulnificus - shellfish
• Yersinia Enterocolitica - (mimics Appendicitis)
• TX : CIPRO
• E. Coli - travelers diarrhea
• Clostridium Perfringens - Toxin - 6-24 hrs to onset, ++diarrhea
• Vibrio Cholera - rice water, electrolyte abnormalities, rehydration
• Bacillus Cereus - spores - Cooked Rice, N/V/D
• Other: Scombroid poisoning (deep ocean fish) - Histamine like reaction, Ciguatera (reef fish) - muscle weakness, paresthesia, reversed temp sense, vomiting, diarrhea
floating frothy foul diarrhea
• Entamoeba histolytica - contagious, bloody diarrhea, (liver abscess,
pericarditis, pulmonary and CNS) continuum asymptomatic cyst
passer to colitis to fatal cerebral amebiasis
• TX - METRONIDAZOLE
• overgrowth of toxin producing C.diff
• can begin days to weeks after Abx
• profuse foul diarrhea
• Can be present febrile and toxic
• no anti-diarrheals, stop offending Abx
• PO metronidazole/vancomycin
Note: you do not require an imaging study to diagnose pancreatitis. The US is to rule in/out a common, contributing cause (gallstones) that would change your management.
-CT Abdo/Pelvis
-ERCP
-HIDA Scan
AB
Antiviral
ChemoRx
PPI
Previous C.diff inf
Close contact with pt with C.diff
Hospitalization
Nursing home/long-term care facility
Advanced age
Immunosuppression
GIT surgery
IBD
- GS
- ETOH
Infections:
- Bacterial (Legionella, Mycoplasma)
- Viral (mumps, CMV, HBV)
- Parasitic (Ascaris, Toxoplasmosis)
Medication (Lasix)
Autoimmune (SLE)
Metabolic:
- Hypertriglyceridemia
- HyperCa
- Hyperparathyroidism
Trauma
Surgical procedures:
- ERCP
Tumors (pancreatic/ampulary)
Post. penetrating PUD
Sph of Oddi dysfunction
Toxins
Idiopathic
PHM:
- Malignancy
- Liver dis
- H.Pylori infection
- Previous GI Bleeding
- Hx of AAA repair
SH:
- Smoking
- ETOH
- Substance abuse
- NSAIDs
- Steroids
- AntiPlt/AntiCoag
-Pericarditis, myocarditis
-Pneumonia
-PE
-Testicular torsion
-DKA
-Toxic ingestions
-Sepsis/ Bacteremia
-Sickle cell crisis
"
-Loss of haustral pointings
-Black arrow: ‘thumbprint sign’ – bowel wall edema
-Pseudopolyps often extending into the lumen
-White arrow: pneumatosis intestinalis - intramural gas
-Pneumoperitoneum, if perforation
