IBS, GI Bleeding, Nutrition Flashcards
(179 cards)
1
Q
IBS is divided into what 2 categories
A
UC
Crohns
2
Q
define UC vs Crohns
A
UC - Diffuse inflammation, friability, erosions and bleeding of mucosa that is limited to colon and rectum
Crohns - Transmural and entire GI tract (mouth to anus) w/ skip lesions
3
Q
UC is caused by
A
- Genetics – Ashkenazi jews
- Smoking
- Hx of prior GI infections – shigella, salmonella
4
Q
crohns is caused by
A
Genetic factors - Family hx well established as one of the strongest risk factors for development for CD
Environmental factors - Lifestyle factors such as tobacco use, sedentary lifestyle, exposure to air pollution, and consumption of western diet
Infectious factors - CD often occurs after infectious gastroenteritis
5
Q
si/sx of UC
A
Rectal bleeding
Diarrhea – hallmark is bloody diarrhea often mucoid*
Abdominal pain
6
Q
classifications of UC
mild-mod
severe
A
Mild-mod Gradual onset diarrhea <4x/day and intermittent bloody mucoid stool
•No significant abd pain but LLQ tenderness that is relieved by a BM
Severe >6 bloody diarrhea stools per day
- Severe anemia, hypovolemia, hypoalbuminemia and nutritional deficit
- Abd pain
- Fulminant colitis = subset of severe dz which is rapidly worsening sx w/ toxicity
7
Q
define Fulminant colitis
what dz state is this seen in?
A
Fulminant colitis = subset of severe dz which is rapidly worsening sx w/ toxicity
severe UC
8
Q
imaging modalities of UC
A
sigmoidoscopic/colonoscopic and histologic examinations (flex sig safer w/ severe pancolitis)
•Distortion of crypt architecture, crypt abscess, infiltration of lamina propria w/ plasma cells, eosinophils, lymphocytes, lymphoid aggregates and mucin depletion
9
Q
tx of UC
A
Mild dz -Aminosalicylates (5-ASA) drugs
•Mesalazine PR suppository/enema or budesonide rectal foam preferred if mild proctitis
Moderate Dz - disease (failure of 5-ASA)
Budesonide orally – targets colon minimal systemic affect
•Prednisone
Severe disease (induction therapy)
- Hospitalization w/ steroids (methylprednisolone
- Steroid resistant disease = anti-biologics TNF-alpha blocker -> Infliximab (remicade), adalimumab (humira), Golimumab
- Steroid and/or antibiologic resistant disease -> VEGF or JAK inhibitor
- Cyclosporine
Surgical =- colectomy is curative
10
Q
what is curative for UC
A
colectomy
11
Q
UC or Crohns ??
•Assoc w/ abscesses, fistulae, sinus tracts, strictures and adhesions
A
crohns
12
Q
indications for colectomy in UC
emergency
urgent
elective
A
emergency - life threatening complications related to fulminant dz such as toxic megacolon unresponsive to medical tx
urgent - severe dz admitted to hospital and not responding to tx
elective - refractory dz not responive to long term matienance
colorectal dysplasia or adenocarcinoma
long term disease 7-10 yrs
13
Q
maintenance tx for UC
A
5-ASA if response to ASA or steroids
Budesonide
immunosupporessants - Azathioprine or 6-MP OR infiximab (TNF blocker)
JAK-inhibitor
probiotics help with maintaining remission
14
Q
screening for colorectal cancer in UC
A
8 yrs after dz onset
15
Q
hallmark symptom seen in UC
A
hallmark is bloody diarrhea often mucoid*
16
Q
si/sx of crohns
A
ermittent bouts of low grade fever, diarrhea and RLQ pain (flares and remission)
17
Q
Extraintestinal – more commonly seen in???
A
UC
- Aphthous
- Iritis/uveitis
- Arthritis, ankylosing spondylitis
- Erythema nodosum
Does not improve after colectomy – primary sclerosing cholangitis
18
Q
si/sx of crohns
A
Abdominal pain (intermittent and often RLQ/periumbilical)
Diarrhea (watery/nonbloody typically and ?# per day)
19
Q
gold standard for diagnosis of crohns
A
Colonoscopy and mucosal bx
- Aphthoid, stellate, linear ulcers
- Strictures
- Segmental involvement w/ skip lesions
20
Q
tx of crohns
mild
mod-severe
A
Quit smoking
Diarrhea – Loperamide
Medical management first line, surgical second
Mild disease
•Colon and small bowel disease = mesalamine
Moderate-Severe disease
- Steroids
- Immunosuppressants
- TNF-alpha blockers
- Anti-integrins
21
Q
tx of fistula dz in crohns
A
- Antibiotic therapy- metronidazole and ciprofloxacin
- Immunosuppressants and TNF-alpha blockers
- Surgery
22
Q
T/F
colectomy is curative in crohns dz
A
false
Unlike in UC, surgery is not curative in CD
23
Q
classification system for UC and CD
A
Montreal
24
Q
classification for crohns
A
25
classification for UC
26
# define celiac dz?
where does it affect?
Immune response (allergy) in the proximal small bowel to ingested gluten
•Affects mucosa of proximal small bowel
27
si/sx of celiac dz
**•Steatorrhea**
* Flatulence
* Borborygmus
* Weight loss **Weakness/fatigue**
**•Severe abdominal pain**
•Anemia
**•Dermatitis herpetiformis**
28
dx of celiac dz
* IgA TTG
* IgA level - If negative IgA TTG but strong clinical suspicion
29
Gold std dx of celiac
Endoscopy + biopsy - + distal duodenum
## Footnote
•Atrophy or scalloping of duodenal folds
30
histology of celiac dz
* Villi are atrophic or absent
* Hypertrophy of crypts
* Cellularity of the lamina propria is increased with a proliferation of plasma cells and lymphocytes
31
tx of celiac
* Gluten avoidance
* Dietician consult
* Vitamin supplementation - Vit A, B12, D, E
* Steroids - Prednisone or budesonide 2 or more wks
32
causes of lactose intolerance
* Genetics
* Celiac disease
* Crohn’s
* Giardia
* Viral gastroenteritis
* Malnutrition
* Short bowel syndrome
33
si/sx of lactose intolerance
* Abdominal bloating/cramping
* Flatulence
* N/V/D
* Borborygmi
34
dx for lactose intolerance
Hydrogen breath test -
After ingestion 50g lactose a rise in breath H+ of greater than 20ppm w/in 90 min
35
tx of lactose intolerance
Goal of therapy is patient comfort and determining “threshold” of intake when symptoms occur
* Spread out lactose intake \<12g per day (1 cup of milk)
* Lactase enzyme replacement (ex. Lactaid, Lactrase, dairy ease)
* Ca+ supplements (if eliminating dairy)
36
Most cases of infectious diarrhea are viral
Most cases of viral diarrhea are??
novovirus
37
Most cases of severe diarrhea are \_\_\_\_??
and are caused by \_\_\_?
Most cases of severe diarrhea are **bacterial**
Most cases of bacterial diarrhea are **Campylobacter**
38
define diarrhea
* Decreased absorption OR Increased secretion (or both)
* RESULTING in \> 200 grams of loose or watery stool a day
* 75% water content
* 3 or more Bowel Movements in a 24 hour period
39
determine b/w diarrhea
acute
subacute
chronic
* **Acute**- 14 days or less, likely infectious causes (Bacterial and Viral)
* **Subacute**- \> than14 days but fewer than 30 days –
* could be inflammatory or infectious
* **Chronic**- more than 30 days
* 3 types of chronic diarrhea are osmotic, secretory and inflammatory vs noninflammatory
40
name 4 types of fiarrhea
exuadtive-inflammatory
secretory
osmotic
motor
41
# define diarrhea
exuadtive-inflammatory
secretory
osmotic
motor
**exuadtive-inflammatory** - damage to intestinal mucosa results in hypersecretion of water, impaired absorption of fat and electrolytes
mucus, blood, luekocytes present
**secretory** - secretion of water and electrolytes into intestinal lumen due to impaired enzyme activity
**osmotic** - poor absorption or excessive ingestion of hydrophilic substances
**motor** - rapid passage through intestine
42
assoc conditions w/ these types of diarrhea
## Footnote
exuadtive-inflammatory
secretory
osmotic
motor
**exuadtive-inflammatory**
shigellosis
enteroinvasive E. coli
C. diff
camplybacter
**secretory**
food borne
endocrine tumors
impaired absorption of bile acids
hx of ileal resection
**osmotic**
laxatives, mag citrate
lactose intolerance
**motor**
hyperthyroid
rx - reglan, e-mycin
carcinoid syndrom**e**
43
si/sx of small bowel vs large bowel diarhea
**Small bowel (enterotoxic)**: R_ARELY w/ feve_r, occult blood or inflammatory cells
* Watery, non-bloody stool
* Large volume
* Abdominal cramping
* Bloating/flatulence
* Weight loss
* VOMITING
_Large bowel (ex. invasive, enteric, cytotoxic)_
* Frequent, small volumes
* Painful BM
**•Fever**
* Bloody/mucoid stool
* WBCs/RBCs in stool
44
define entertoxic vs invasive
**entertoxic** : Infectious agent (the bug) creates a toxin floating in gut causing large amounts of watery diarrhea.
* Often NO FEVER, NO ELEVATED WBC, NO FECAL LEUKOCYTES
* C difficile, E coli, Staph Auerus, Cholera, Giardia
small bowel
**INVASIVE**: The Infectious agent breaks thru the blood/ gut barrier. (large bowel)
•FEVERS, LEUKOCYTOSIS, + FECAL LEUKOCYTES
45
common pathogens responsible for small bowel diarrhea
Norovirus
E. Coli (enterotoxic)
C. perfringens
S. Aureus
Vibrio cholera
Giardia
Cryptosporidium
46
common pathogens responsible for large bowel diarrhea
Campylobacter
Shigella
C. Diff
E. Coli (enteroinvasive)
Salmonella - S. enteritidis, S. typhimurium
CMV
Adenovirus
Entamoeba - protozoan
47
what is Fecal Lactoferrin
Can be a diagnostic tool used to detect bacterial infections that cause inflammatory diarrhea
Highly Sensitive and Specific
Limited use – Can help distinguish between IBD and IBS
48
dx of diarrhea
_Stool Cultures_: Used to identify bacteria/viruses, fungi. Most really only report Campylobacter, Salmonella, Shigella –If you want to look for other bacteria, be sure to specify.
_•C diff TOXIN_ will need to be ordered separately, generally looking for the toxin and not the bacteria.
_•O&P stool study_ – Parasites such as Giardia and Strongylodies and Entero-adherent bacteria can be difficult to detect but may be dx by intestinal bx
_•Fecal Leukocytes_ – may also support the dx of inflammatory diarrhea. à more sensitive is Fecal Lactoferrin
49
in setting of diarrhea Consider serum and stool labs if
* Diarrhea \> 4 days
* Fever \> 38.5C
* Blood in stools
* Suspect IBS
* Immunosuppression
* + leukocytes and lactoferrin \*\*
50
* Acute onset N/V w/in 12-48hrs
* watery, non-bloody diarrhea with abdominal cramps
norovirus
Fecal-oral route with contaminated food – 1-3 days
51
* non-bloody, Liquid, gray, “rice-water” diarrhea
* No odor
Vibrio cholera
•Profound fluid and electrolyte loss in stool and rapid progression to hypovolemic shock within 24 hours of symptom onset
52
tx Vibrio cholera
* IVF
* Abx (ex. tetracycline, ampicillin, azithromycin, Bactrim, FQs)
53
* Watery, yellow, foul-smelling diarrhea
* Weight loss – more then 10% body weight
hx of camping or fresh water
tx?
Giardia
## Footnote
* Metronidazole
* Tinidazole
* Nitazoxanide
54
•Most common parasitic cause of acute foodborne diarrhea in US
tx?
Cryptosporidium
Nitazoxanide
55
si/sx camplyobacter
pathogens?
* Abrupt onset abdominal pain – similar to appendicitis
* diarrhea (bloody or mucoid)
* Prodrome of Fever/chills/body aches in 30%
* C. jejuni
* C. coli
56
tx of camplybactor
Supportive (ex. IVF, anti-emetics)
Immunosuppressed or severe dz – abx FQs (Levo, Cipro) or Azithro
57
dx of C. diff includes what criteria?
diarrhea (\>3 watery stools in 24 hours) or w/ risk factors
1. abx use or chemotherapy
2. recent hospitalization
3. advanced age
58
diarrhea assoc w/
## Footnote
* Severe, watery diarrhea
* Pseudomembranous colitis
* Toxic megacolon
C. diff
59
tx of c. diff
* Metronidazole
* Vancomycin PO
60
e. coli diarrhea si/sx
tx??
* Severe abdominal pain
* Bloody diarrhea
NO ABX due to high risk of HUS
61
Leading cause of foodborne illness in US?
pathogens?
Salmonella
* S. enteritidis
* S. typhimurium
62
•Pea-soup diarrhea
Salmonella
63
tx salmonella
Ciprofloxacin or Levofloxacin for severe disease or immunocompromised patients
64
#1 cause of acute diarrhea
viral
65
diarrhea assoc w/ completion of abx therapy
what abx are most frequently implicated?
c. diff
FQs, clinda, cephalosporin, penicillin
66
if diarrhea develops w/in
6 hrs
8-16 hrs
16 hrs
6 hrs - s. aureus or bacillus cereus esp if N/V
8-16 hrs - c. perfringens
16 hrs - other bacterial or viral pathogens
67
define HUS
HUS - Hemolytic-uremic syndrome may be greater – triad of Acute renal failure, hemolytic anemia and thrombocytopenia
•\*\*\* Same with Shigella – high risk of HUS
no e.coli
68
major presenting sx: pathogen? food source?
vomitting
watery diarrhea
inflammatory diaarhea
**vomitting** - s. aureus, B. cereus - prepared foods, salads, dairy, meat, chinese food
**watery diarrhea** - c. perfingens, e. coli - meat, poultry, gravy, imported berries
**inflammatory diaarhea** - camplyobacter, shigella - poultry
69
pathogen assoc w/ visiting petting zoos
salmonella
70
cardinal features of salmonella
invasive!!!
N/V
pea soup diarrhea not gorssly bloody
abdominla cramping
fever w/ chills
71
shigella characterized by
spread??
invasive
high fever
diarrhea (small volume, bloody and mucoid)
abdominal cramping
tenesmus - frequent
day care centers
72
potozoan induced diarrhea is caused by
entomoeba
crytosporidium
giardia
travelers diarrhea
73
Entamoeba most common pathogen
assoc w/??
Entamoeba histolytica
poor sanitation/ daycare centers
74
dx entomeoba
complications
stool cx and serum antigen
filminant colitis w/ bowel necrosis leading to perf and peritonitis
75
tx of entomeoba
* Metronidazole
* Tinidazole
* Ornidazole
76
most common cause of parasitic foodborne diarrhea
tx?
crytosporidium
Nitazoxanide
77
# define trvaelers diarrhea
pathogen?
* diarrhea that develops during or within 10 days of returning from travel
* Most common organism is Escherichia coli- 1-5 days (NOT H157H7 strain)
* Campylobacter most common in Southeast Asia
* Rotavirus most common in travelers from Jamaica and in kids
78
prevention and tx of travekers diarrhea
•Prevention includes: prudent selection of food and drinks (bottled beverages only, avoid ice) food that is thoroughly cooked pasteurized diary products
_•Treatment:_
•Flouroquinolones- Ciproflox, Levoflox
79
define IBS
* defined as recurrent abdominal pain or discomfort on average, at least 1 day per week in last three months with 2 or more of the following:
* improvement with defecation
* change in frequency of stool
* change in form of stool
80
most common complication of diarrhea
dehydration
81
# define
sever dehydration
some dehydration
**Severe dehydration (at least two of the following signs):**
* lethargy/unconsciousness
* sunken eyes
* unable to drink Capillary refill ( ≥2 seconds )
**Some dehydration (two or more of the following signs):**
* restlessness, irritability
* sunken eyes
* drinks eagerly, thirsty
82
children w/ chronic diarrhea present as
failure to thrive
83
name common pathogens responsible for diarrhea
viral
bacterial
protozoa
**Viruses-** #1 cause - Norovirus, Rotavirus, Adenovirus, CMV
**Bacteria**- Salmonella, Campylobacter, Shigella, enterotoxigenic
Escherichia coli., Clostridium difficile
**Protozoa**- Cryptosporidium, Giardia, Cyclospora, Entamoeba
84
Endoscopy indications for IBS
* More than minimal rectal bleeding
* Weight loss
* Unexplained iron deficiency anemia
* Nocturnal symptoms
* Family hx of colorectal cancer, IBD or celiac spruce
85
tx of IBS
_Dietary modification_
* low gas producing foods(beans, onions, celery, bananas, apricots, bagels, pretzels etc.)
* ETOH, caffeine lactose avoidance
* low FODMAP diet- fermentable foods (honey, corn syrup, apples, pears, mangoes, cherries etc.)
_Physical activity_
86
medications used to tx IBS
* **Lubiprostone** - chloride channel activator that enhances chloride-rich intestinal fluid secretion
* **Linaclotide** - guanylayte cyclase agonist that stimulates intestinal fluid secretion and transit
87
HALLMARK symptom of malabsorption
Steatorrhea - is excess fat in the stool
88
conditions that lead to malabsorption
* Celiac spruce
* Bacterial overgrowth
* Lactose intolerance
89
dx malabsorption
•**Quantitative stool fat test - GOLD STANDARD** Ingestion high fat diet for 2 days before and during collection (100G fat) à Stool collected for 3 days
**•Sudan stain (qualitative)** - Determines the percentage of fat in stool
•**Acid steatocrit**- inexpensive and reliable – centrifugation of acidified stool in a liquid HCT capillary – solid, liquid, fatty layers
90
si/sx of IBS
* Chronic abdominal pain
* Flatulence
* Diarrhea
* Constipation
91
tx of diarrhea
1. IVF +/- abx - added K+ or NaHCO3-, look at Anion Gap ON YOUR LABS
2. Electrolyte replenishment (IV or ORS)
3. Avoidance diet (ex. BRAT)
4. Anti-motility meds
* 5. Anti-emetics
* 6. Zinc supplementation
* 7. Probiotics
92
Anti-motility meds for diaarhea
1**.Loperamide (Imodium)** - works by slowing down gut motility, decreases number of stools and makes diarrhea less watery
\*\*\*CAUTION WITH INVASIVE BACTERIA
**2.Bismuth subsalicylate**
**3.Lomotil**
**4.Eluxadoline (Viberzi)** - combined opioid receptor agonist/antagonist
1. IBS-D
2. Schedule IV
**5.Bile acid sequestrants** - used in patients with persistent diarrhea despite antidiarrheal use
Cholestyramine Colestipol Colesevelum
93
med used used in patients with persistent diarrhea despite antidiarrheal use
bile acid sequesterants
## Footnote
1.Cholestyramine Colestipol Colesevelum
94
fluids in diarrhea should include
* 3.5g sodium chloride
* 2.5g sodium bicarbonate
* 1.5g potassium chloride 20g glucose
* Homemade solution: ½ teaspoon salt, ½ teaspoon of baking soda, 4 tablespoons sugar in 1 liter of water
95
name the esstential nutrients
protein
fat
carbs
water
96
define pathphys of thiamine (B1)
Thiamine is necessary for glucose metabolism – inability to convert pyruvate to acetyl-CoA\*, so it metabolizes into lactate, resulting in neuronal injury
97
thiamine deficency si/sx
complications
Early Symptoms: anorexia, irritability, memory issues
•Can progress to cardiac dysfunction, peripheral neuritis, peripheral edema, CNS issues
Wernicke encephalopathy –
may be iatrogenically precipitated by glucose loading in patients with unsuspected thiamine deficiency
**TX ALL Alcoholics w/ thiamine**
98
si/sx of wernicke syndrome
encepaopahy
ocular motor dysfucntion
ataxia
99
Riboflavin (B2\_ pathophys and deficency si/sx
Coenzyme – acts as hydrogen acceptor and is a component of amino acid oxidases
Dermatitis
Cheilosis
Photosensitivity
blurred vision
100
Coenzyme in the GI tract, nervous system and bone marrow, synthesis of DNA in bone marrow, synthesis of methionine and choline
Present in liver, meat, poultry, fish, dairy
B12
101
si/sx of B12 deficency
who is likely to have a B12 deficency ?
Pernicious anemia – pallor, anorexia, dyspnea, weight loss, neurological disturbances
Macrocytic anemia – LOW H7H INC MCV
Peripheral neuropathy
Deficiency seen in
* Vegans
* gastrectomy patients, resection of the ileum
* Tapeworms
* Crohn’s disease
102
pathophys of folate and si/sx of deficency
Coenzyme in the GI tract, nervous system and bone marrow, synthesis of DNA in bone marrow, synthesis of methionine and choline
Present in liver, meat, poultry, fish, dairy
Macrocytic anemia
GI disturbances
Increased risk of spina bifida
103
folate deficency is seen in what populations
alcoholics, anorexia nervosa, poor diet(lack of fruits and veggies)
medications such as phenytoin, trimethoprimsulfamethoxazole, or sulfasalazine may interfere with its absorption
104
etiology of iron deficency
si/sx
Etiology of Iron deficiency: GI bleeding, colon cancer, celiac disease, s/p gastric bypass
Iron deficiency anemia – pallor, lethargy, weakness, dyspnea
phagocyte dysfunction, paresthesias, body temperature dysregulation
105
tx of iron deficency
PO – ferrous fumarate, sulfate or gluconate(take with Vitamin C or something rich in Vit C)
IV iron sucrose, Iron dextran(LMW ID) or ferric gluconate
106
si/sx of C deficency
Scurvy - impaired formation of mature connective tissue and include bleeding into the skin - petechiae, ecchymoses, inflamed and bleeding gums
Fatigue
107
Coenzyme for numerous cellular reaction, essential for Krebs cycle, formation of purines and non-essential AA’s
Present in liver, eggs, legumes, nuts
biotin
scaly rash on face
108
water soluable vs fat sol vitamins
fat solu - ADEK
109
pathophys of vit D
* 7-dehydrocholesterol synthesized in skin by UVB à Vitamin D3(cholecalciferol)
* Converted to 25-hydroxyvitamin D (calcifediol, or calcidiol) in the liver
* 25-hydroxyvitamin D (calcifediol) undergoes a chemical modification in the kidneys to the active form, calcitriol (1,25-dihydroxyvitamin D)
110
test forvit D deficency
serum 25-dihydroxyvitamin D (25[OH] vitamin D)
111
Collective designation for stereoisomers of tocopherols, chemically related to sex hormones
•Stored in muscle and adipose tissue
vit E
112
si/x of vit E deficency
dx??
Hemolysis, fragile capillaries, peripheral neuropathy
Seen in celiac disease, SB resection, bariatric surgery
alpha – tocopherol
113
define vit K and name 2 types
Coenzyme that aids in the process of carboxylation of coagulation factors (VII, IX, X and prothrombin), making them active
Present in kale, spinach, margarine, liver, veg. oils, olive oils
Vitamin K1(Phylloquinone) – vegetable sources
Vitamin K2(Menaquinone) – synthesized by bacterial flora and found in hepatic tissue
114
si/sx of vit K deficency
dx?
Easy bruising and bleeding(prolonged clotting)
Prolonged PT and elevated INR
115
pathophys of coumadin
•Inhibits the activity of an enzyme (vitamin K epoxide reductase) that recycles Vitamin K into the active form of vitamin K -\> prevents coagulation factors from undergoing a chemical change rendering them inactive
116
vit K deficency seen in
Deficiency seen in
* Celiac disease
* Crohn’s
* Biliary obstruction.
* SB resection
* broad-spectrum antibiotic tx (reducing gut bacteria)
117
Muscle tetany(Chvostek sign),
carpopedal spasm(Trousseau sign)
seen in??
hypocalcemia
hyper - depressed neural function, lethargy, confusion, muscle pain, w
118
tx of calcium
hyper
hypo
HYPO -
IV Calcium gluconate in 50mL of NS or D5
Tx underlying cause
•Vitamin D in D deficiency, CKD, hypoparathyroidism, and liver disease
HYPER
Mild – Mod no tx
Severe \>14
1. Isotonic saline
2. calcitonin
3. Administer Zoledronic Acid, or pamidronate(Bisphosphtes)
119
conditions causing hyper/hypophosphatemia
**Conditions causing hyperphosphatemia**
•Advanced CKD (MCC), Tumor lysis syndrome(lymphomas, leukemias), rhabdomyolysis, hypoparathyroidism, acromegaly, bisphosphonates, vit D toxicity
•
**Conditions causing HYPOphosphatemia**
* Medications – antacids, niacin, anabolic steroids, estrogen, OC
* DKA or nonketotic hyperglycemia\*
* Refeeding syndrome,
120
si/sx of hypophos
myopathy, dysphagia, ileus, hemolysis, anorexia, bone/muscle pain
121
tx of hyper/hypo phos
hypo
Asymptomatic with a phosphate of \<2.0 à PO phosphate
Symptomatic:
* 1.0-1.9 - PO phosphase
* \<1.0 - IV phosphate
hyper
IV saline infusion in normal renal function
•Need to monitor calcium and provide calcium supplementation
Hemodialysis in renal failure and symptomatic hypocalcemia
122
tx of hypokalemia
Mild to moderate hypokalemia
* PO potassium chloride
* Amiloride 5mg daily
* Spironolactone 25mg
•
Severe \<2.5
•PO and IV Potassium
123
tx of hyperkalemic emergency
* Calcium gluconate or calcium chloride
* IV regular insulin
* Removal of Potassium: Furosemide
* GI Cation Exchangers u Patiromer OR Zirconium cyclosilicate
124
rhabdomyolysis, meds, insulin deficiency, met acidosis
•muscle weakness or paralysis, cardiac conduction abnormalities
dx??
Hyper K
125
Vomiting, diarrhea, sweating, abdominal cramps, convulsions
tx?
hypoNA
## Footnote
Acute \<48hrs – IV saline
Chronic
* Mild (130-134) – fluid restriction
* Severe (\<130) IV saline
126
Water losses (skin, GI, urinary, etc), hyperthalamic lesions – diabetes insipidus, sodium overload
tx?
hyperNa
## Footnote
_Acute \<48hrs_
* IV D5W
* Add ongoing water losses
* Monitor sodium and glucose every 1-2 hours
* Replace any electrolyte abnormalities
_Chronic_
* IV D5W
* Monitor sodium for 4-6 hours
* Replace any electrolyte abnormalities
127
define magnesium
Constituent of many coenzymes that convert ATP to ADP, neuro-muscular irritability
Altered magnesium concentration usually provokes an associated alteration of Ca2+
128
dominished DTR, bradycardia, hypotension, complete heart block -\>Sudden cardiac death
is seen in
Tx
hyperMg
## Footnote
**Normal renal function** – stop magnesium therapy, or administer a loop/thiazide diuretics
**Moderate renal insufficiency** - stop mag-containing medication, start isotonic IV fluids plus a loop diuretic
S**evere renal insufficiency** – hemodialysis with IV calcium
129
common causes of hypoMg
si/sx
•Diarrhea and GI loss
tremors, neuromuscular issues, muscle weakness, irregular heartbeat, vasospasm, and HTN
130
tx of hypoMg
Severe symptoms: magnesium sulfate IV
Nonemergent – magnesium sulfate IV
Mild symptoms and normal renal function –elemental magnesium in divided doses
Mild Symptoms in renal insufficiency –IV mag sulfate
131
Deficient mineralization(calcium and phosphorous) at the growth plate, as well as architectural disruption of this structure
Rickets
132
2 classifications of rickets
* Calcipenic rickets - calcium deficiency, which usually is due to insufficient intake of or metabolism of vitamin D
* Phosphopenic rickets - caused by low phosphate levels, or genetic condition causing renal phosphate wasting (rare)
133
si/sx of rickets
* Delayed closure of fontanelles
* parietal and frontal bossing
* craniotabes(soft skull bones)
* bowing of the femurs and tibias
* widening of the wrist and bowing of the distal radius and ulna
134
dx rickets
**Elevated alk phosphatase**
* Phosphopenic - 400 to 800 IU/L])
* Calcipenic – up to 2000 IU/L
Low phosphorous, calcium may be normal or low, 25-(OH) vitamin D usually low
Elevated PTH in calcipenic
Normal or mildly elevated PTH in phosphopenic rickets
135
tx of rickets
Vit D def –vitamin D + Calcium
Calcium def - calcium and RDA of Vitamin D
136
meds to tx obesity
GI fat blockers - Orlistat
Appetite suppressants
* Liraglutide
* Phentermine/topiramate
* Naltrexone SR/buproprionSR
137
surgical tx of obeisity
Bariatric Surgery:
•Severe obesity (BMI\>40) or moderate obesity (BMI \>35) with serious medical comorbidities\*
138
nutrient supplementation w/ bariatric surgery
Bariatric Surgery: Roux-En-Y and Sleeve Gastrectomy
dudenum - iron, thiamine, calcium, copper
ileum - B12, vit D
jejunum - zinc
139
causes of UGIB
Gastroduodenal Ulcers/ Peptic Ulcer Disease
H pylori
Erosive esophagitis
Gastritis/Duodenitis
Esophageal Varices
Mallory-Weiss Syndrome
Arteriovenous Malformations (AVM’s)
UGI Malignancy
140
Gastroduodenal Ulcers/ Peptic Ulcer Disease
si/sx
risk factors
Asymptomatic 70%
May have dyspepsia
PAINLESS
Risk Factors:
H. Pylori
NSAIDs
Physiologic stress
141
causes of LGIB
Diverticular bleeding
AVM’s
Infectious / Ischemia Colitis
IBD (Cohn's and UC)
Colon Cancer
Hemorrhoids
Anal Fissure
Post-polypectomy bleeding
142
dx modalities for H. pylori
Most common cause of chronic bacterial infection in humans
Invasive – endoscopy w/ biopsy
Noninvasive – urea breath test, stool antigen, serology
\*\*stool antigen test after tx to make sure it worked
143
tx of h.pylori
Triple Therapy (Prevpac)– PPI, amoxicillin and Clarithromycin
•(OK to substitute Flagyl if PCN allergy)
•
Quadruple therapy (Pylera) – PPI, bismuth subsalicylate, Flagyl and tetracycline
144
Erosive esophagitis patients usually have a hx of..?
si/sx
tx?
GERD
## Footnote
Hematemesis, Melena
Heart burn
Reflux – classic GERD hx
Difficulty swalling
**Egd diagnosti**c – possibly therapeutic if actively bleeding
tx: PPI
145
Egd- patchy, erythema, no white ulcer bed
Does not commonly require endoscopy – tx w/ PPI and follow
Gastritis/Duodenitis
Acid-associated inflammation and mucosal injury to lining of stomach and duodenum
•Rarely cause significant UGIB – more common during anticoagulation therapy
146
Esophageal Varices - Develop as consequence of....
pHTN usually in liver cirrhosis
147
si/sx esophageal varicies
Dilated veins in distal esophagus and stomach
* Hematemesis
* Melena/ hematochezia
* Hypotension
* Pallor, tachycardic, diaphoretic
148
tx of eso varices
dentify and stabilize – think intubation if vomiting
Abx prophylaxis: Ceftriaxone
Start IV Octreotide – reduce mortality
Emergent Egd – band ligation (first line)
Blake more (balloon tamponade only for 24-48 hrs)
Transfer to liver center for TIPS
149
UGIB Associated w/ forceful retching
dx?
tx?
Mallory-Weiss Syndrome
Longitudinal lacerations in distal esophagus
Dx: Egd
PPI therapy
Antiemetics
150
Arteriovenous Malformations (AVM’s) are usually seen in patients on ...?
Dilated veins along GI tract - Usually in pts \>60 y/o
Located throughout GI tract
Risk Factors:
**•Anticoagulation**
* ESRD
* AS
* Von Willebrand
151
si/sx of AVMs
Asymptomatic \*\*
Occult bleeding
Iron deficiency anemia
Dyspnea , SOB
Weakness
Melena
152
dx and tx of AVMs
Dx: Egd w/ hemostasis
* Argon plasma coagulation
* Small bowel video capsule
Tx: cauterize or clip
153
UGI malignancies include
tx?
Adenocarcinomas, GIST, Lymphomas
Ulcerated exophytic masses in the esophagus, stomach or duodenum
Difficult to achieve endoscopic hemostasis à risk of rebleeding
**Surgical resection is tx of choice \*\***
Palliative / chemo and radiation
154
mainstay tx in UGIB
PPIs
## Footnote
* Block gastric acid secretion by irreversibly binding to parietal cells who produce acid
* In acute GI Bleeding à raise pH in stomach to more neutral level, stabilizing blood clots and promotes healing
155
bleeding that ccurs distal to ligament of Treitz, but proximal to ileo-cecal valve
si/sx
SB Bleeding
## Footnote
* Overt such as melena or hematochezia, occult bleeding
* sx of anemia – fatigue, SOB, weakness
* Increased sleeping
* Pallor
156
dx and tx of small bowel bleeds
dx •upper and lower endoscopy
tx
•Diagnose source and tx accordingly: - Cautery, endoclips, argon plasma coagulation
_•If NO source is found & patient is STABLE_
* Monitor and transfuse PRN (consider iron)
* Consider repeat evaluation if symptoms persist or change
_•If bleeding persists:_
* Small bowel enteroscopy
* Imaging
* CTA
* Laparoscopic enteroscopy
157
Most common cause of LGIB
si/sx
Diverticular bleeding
Massive bleeding that stops spontaneously
Painless hematochezia – sudden onset
Syncope, diaphoresis, weakness, lightheadedness
158
dx and tx of Diverticular bleeding
Dx: clinical suspicion
* Colonoscopy – test of choice
* Nuclear scintigraphy (NM Bleeding scan)
* Angiography and embolization
* Surgery – last resort
159
Infectious / Ischemia Colitis occurs in what area of colon
Temporary interruption of blood flow to an area of the colon (“watershed areas” )
•From splenic flexure to descending colon
160
si/sx of Infectious / Ischemia Colitis
Abrupt onset fecal urgency
Lightheadedness, syncope, diaphoresis
**Severe abdominal PAIN** – persistent and intense
Bloody diarrhea
Vasovagal sx
161
si/sx of right sided vs left sided colorectal lesion
BRBPR – left-sided lesion
Melena – right sided lesion
Iron deficiency anemia
162
anal fissure can be described as
passing razorblades
163
Post-polypectomy bleeding
tx:
Ocurs w/in 7-10 days of a colonscopy w/ polypectomy
_Repeat colonoscopy_
* Hemostasis w/ endoclips
* Epinephrine
* Cautery
* Tell GI doc – considered complication
164
dx and treatment of anal fissure
Dx: rectal exam, anoscope
Tx: fiber, sitz baths, stool softener
* Topical analgesic – lidocaine
* Topical vasodilatory – nifedipine or nitroglycerin
* Topical diltiazem
* Surgical repair
165
dx and tx or hemhorroids
Dx: anoscope, colonoscopy
Tx: conservative – rubber band ligation
Hemorrhoidectomy last resort – risk of incontinence, painful
166
crohns vs UC
location
appearance
anal involvement?
fisutale/stenossi?
crohns
* Location: mouth to anus (commonly involves terminal ileum)
* Appearance – skip lesions
* Characteristics – “cobblestoning”
* Commonly has anal involvement
* Fistulae and stenosis can result
UC
* Location – colon
* Appearance – confluent areas of inflammation w/ abrupt transition to normal mucosa
* Rarely involved the anus
* Mucosal depth of inflammation
* Rarely stenosis or fistulae
167
lab value that could suggest UGIB
elevated BMP
168
GOLD STANDARD FOR DIAGNOSIS AND TREATMENT OF AN UGIB \*
endoscopy
169
nasogastric lavage indications
* USED TO DIFFERENTIATE IF BLEEDING IS ACTIVE FOR UGIB
* WOULD NOT RECOMMEND IF CONCERN FOR ESOPHAGEAL VARICES
* MAY HELP TO DIFFERENTIATE UGIB VS LGIB
170
tx of UGIB
ABC
trend H&H, BUN
IV PPI BID – TYPICALLY IV PANTOPRAZOLE(PROTONIX
ENDOSCOPY (HEMODYNAMICALLY STABLE)
•Abx PROPHYLAXIS FOR CIRRHOSIS W/ ANY GI BLEEDING - CEFTRIAXONE
171
tx of UGIB variceal bleeding
IV OCTREOTIDE
172
tx of LGIB
ABCs
reversal of anticoags
colonoscopy
173
define diverticular dz and 2 types
CONDITION OF HAVING DIVERTICULOSIS - SAC-LIKE PROTRUSION; MUCOSA AND SUBMUCOSA HERNIATE THROUGH MUSCLE LATER
**•DIVERTICULITIS:** INFLAMMATION OF DIVERTICULUM
**•DIVERTICULAR BLEED:** PAINLESS BLEEDING OF DIVERTICULA
174
si/sx of diverticular dz
•LOWER ABDOMINAL PAIN (LLQ TO SUPRAPUBIC)
BOWEL CHANGES (CONSTIPATION OR DIARRHEA
175
diverticular dz most commonly effects
MOST COMMONLY AFFECT SIGMOID AND LEFT COLON, BUT CAN BE PANCOLONIC
176
golad standard imaging in diverticular dz
ABDOMINAL/PELVIC CT – BEST MODE OF IMAGING\*
177
tx of diverticular dz
analgesics and antiemetics
abx - coverage of gram neg and b. fragilis
cipro (or levaquin) + flagyl
2nd or 3rd gen ceph + flagyl
TM/Sulf + flagyl
repeat imaging not neccessary
178
diverticular colonoscopy screening guidelines
ALL PATIENTS SHOULD HAVE AN OUTPATIENT COLONOSCOPY IN 2-3 MONTHS TO ENSURE HEALING AND RULE OUT AN UNDERLYING MALIGNANCY\*\*
179
T/F
avoid colonscopy during acitve diverticulitis
true
