SSx 1-3 Flashcards
(137 cards)
1
Q
Dyspepsia… predominant epigastric pain
Maybe associated epigastric fullness, nausea, heartburn, vomiting
When is endoscopy warranted?
A
Warranted in pts 60 or older
Pts w/ alarm features
Alarm features = wt loss, anemia, dysphagia, vomiting, recurrent GI bleeding
2
Q
Pts w/ dyspepsia under 60 w/o alarm features should be tested for?
A
H. pylori… If positive abx should be administered
3
Q
Dyspepsia… pts who are h. pylori negative or see no improvement after H. pylori eradication should receive what?
A
Empiric proton pump inhibitor therapy
4
Q
Dyspepsia… Another option for pts w/ refractory symptoms might be?
A
tricyclic antidepressants, a prokinetic agent, or psychological therapy
5
Q
Functional dyspepsia?
A
Most common cause of dyspepsia
Dyspepsia w/ no identifiable etiology (by endoscopy or other testing)
6
Q
What are two common diseases also seen in dyspepsia, referred to as luminal tract dysfunction?
A
Peptic ulcer disease (15% of patients w/ dyspepsia)
GERD (20% of patients w/ dyspepsia)
7
Q
Chronic gastric infection w/ H. pylori is an important cause of what?
And even in the absence of this, h. pylori may cause dyspepsia.
A
H. pylori is often associated w/ PUD; however, even in the absence of H. pylori, it can still cause dyspepsia.
8
Q
Pancreatic carcinoma and chronic pancreatitis may also cause chronic epigastric pain. However, the pn is different… describe it…
What else is usually associated w/ pancreatic carcinoma and chronic pancreatitis?
A
Pancreatic pn is typically more severe, sometimes radiates to the back and usually is associated anorexia, rapid wt loss, steatorrhea, or jaundice
9
Q
Dyspepsia accompanied by what warrants endoscopy?
A
wt loss, persistent vomiting, constant/severe pn, progressive dysphagia, hematemesis, melena
10
Q
Though the physical examination is rarely helpful in cases of dyspepsia, certain signs of serious organic disease should be furhter evaluated. Such as?
A
wt loss, organomegaly, abdominal mass, FOBT
11
Q
If an H. pylori breath test or fecal antigen test result is negative in a pt NOT taking NSAIDs, what can be excluded?
A
PUD is virtually excluded
12
Q
Study of choice for diagnosing gastrointestinal ulcers, erosive esophagitis, and upper gastrointestinal malignancy is?
A
upper endoscopy
13
Q
In dyspepsia, h. pylori-negative pts most likely have functional dyspepsia or atypical GERD and can be treated how?
A
W/ an anti-secretory agent (PPI) for 4 weeks (empirically)
14
Q
Patients in with persistent dyspepsia AFTER H. pylori eradication can be given a trial of what?
A
PPI therapy
15
Q
Patients w/ no significant findings on endoscopy as well as patients under 60 who don’t respond to h pylori eradication or PPI therapy are presumed to have?
A
functional dyspepsia
Consider dietary changes and/or pharmacotherapy w/ antisecretory agents, TCAs, metoclopromide
16
Q
Vomiting should be distinguished from what (which is the effortless relfux of liquid or food stomach contents)?
A
regurgitation
17
Q
Acute symptoms of nausea/vomiting w/o abd pn are typically caused by what?
A
food poisoning, infectious gastroenteritis, drugs, or systemic illness
18
Q
In severe or protracted vomiting, serum electrolytes should be obtained to look for ?
A
hypokalemia, azotemia, metabolic acidosis
19
Q
What are the complications from nausea/vomiting?
A
dehydration, hypokalemia, metabolic alkalosis, aspiration, boerhaave syndrome, mallory weiss tear
20
Q
What is the standard triple therapy tx for h pylori?
A
PPI po bid
Clarithromycin 500 mg PO BID
Amoxicillin 1g PO BID
(if pen allergy, metronidazole 500 mg PO BID)
21
Q
What is the standard quadruple therapy for h pylori?
A
PPI po bid
Bismuth subsalicylate two tabs PO qid
Tetracycline 500mg PO QID
Metronidazole 500mg TID
22
Q
Acute onset of severe pn and vomting suggests what?
A
peritoneal irritation, acute gastric/intestinal obstruction, or pancreaticobiliary dz
23
Q
Early morning vomiting is common in?
A
pregnancy, uremia, alcohol intake, increased ICP
24
Q
Physical exam observations/tests for nausea/vomiting?
A
Dry mucous membranes?
SKin turgor
Orthostatic vital signs (“tilts”)
TTP?
distension?
Organomegaly?
25
"Typical" treatment options for nausea/vomiting?
Fluids, BRAT diet, ginger
26
Pharmacotherapy options for nausea/vomiting?
Serotonin-receptor antagonists (ondansetron)
Dopamine antagonists (promethazine, procloperazine)
Antihistamines (meclizine, dimenhydrinate, scope, diphen)
27
Persistent/intractable hiccups warrant a full history/physical exam for serious underlying pathology, such as?
CNS pathology (neoplasm, infection, trauma)
Metabolic issues (uremia, hypocapnia)
Chronic irritation
Postoperative
Psychogenic
28
Intractable hiccups can be treated w/?
Chlorpromazine
29
Broadly, what are soem of the FODMAPs that might cause and therefore be avoided for pts concerned w/ flatus?
lactose
Fructose
polypols
fructans
30
Most common cause of constipation?
Inadequate fiber/fluid intake
poor bowel habits
(opioids)
31
What's meant by primary constipation?
More common form that cannot be attributed to any structural/systemic dz/abnormality
32
In a patient w/ constipation, obstructive lesions (neoplasms, strictures, etc) should be ruled in patients older than 50, patients w/ fam hx of colon CA or IBD, and pts w/ alarm features.
What are alarm features for constipation?
Hematochezia
wt loss
anemia
+FOBT/FIT
33
Osmotic laxatives used for constipation?
Magnesium hydroxide
Polyethelyne glycol 3350
Polyethelyne glycol
Magnesium citrate
**magnesium should be avoided in patients w/ chronic renal insufficiency
34
Osmotic laxatives used for constipation?
Magnesium hydroxide
Polyethelyne glycol 3350
Polyethelyne glycol
Magnesium citrate
**magnesium should be avoided in patients w/ chronic renal insufficiency
35
Stimulant laxatives used for constipation?
Bisacodyl
Senna
(avoid in obstruction)
36
Stool surfactants for constipation
Docusate Sodium
37
Fecal impaction can present w/ paradoxical diarrhea. What are the tx options?
Manual fragmentation/disimpaction
| or saline/mineral oil/diatrizoate enema
38
Fecal impaction can present w/ paradoxical diarrhea. What are the tx options?
Manual fragmentation/disimpaction
| or saline/mineral oil/diatrizoate enema
39
Constipation Patients at what age or with what symptoms should be referred for colonscopy?
Pts > 50
Pts w/ alarm ssx (wt loss, hematochezia, family hx, pos FOBT)
(also refer pts unresponsive to tx and those w/ evidence of obstruction)
40
Acute diarrhea... duration? And most common cause?
Acute < 2 weeks
Most commonly caused by pathogens
41
Acute non-inflammatory diarrhea is typically watery, nonbloody and self-limited.
WHat usually causes it and when would you perform a diagnostic eval?
Usually caused by virus/non-invasive bacteria
Diagnostic evaluations for pts w/ SEVERE diarrhea or diarrhea > 7 days
42
Acute inflammatory diarrhea will present w/ blood or pus and usually caused by an invasive/toxin-producing bacterium.
What are the diagnostic evaluation requirements?
Stool bacterial testing for (E Coli O157H5, H7) in ALL
And if clinically indicated, testing for clostridioides difficile toxin, and OandP
43
Common etiologies for acute non-inflammatory diarrhea?
| think viral or protozoal
Norovirus
Rotavirus
Giardia
44
Common etiologies for acute inflammatory diarrhea?
E Coli
Shigella
Salmonella
Clostridium difficile
(also campylo and yersinia)
45
Symptoms of acute inflammatory diarrhea?
Loose/bloody stools (lower in volume)
Fever
LLQ cramps/pn
Urgency
Tenesmus
46
Distinguish mild diarrhea from those needing prompt evaluation. What are indications for further eval?
```
1 - signs of inflammatory diarrhea (fever, WBC>15000, severe pn, bloody diarrhea)
2 - Profuse diarrhea (>6 stools/day)
3 - Frail olds
4 - immunocompromised/systemic illness
5 - Abx exposure
6 - Hospital-acquired diarrhea
```
47
Acute diarrhea may require lab tests, including fecal leukocytes, stool cultures, OandP (x3, remember?), C difficile, and fecal lactoferrin.
What's fecal lactoferrin?
a marker of intestinal inflammation
48
For the tx of acute diarrhea, what should be avoided?
High-fiber foods, fats, dairy, and caffeine
49
Loperamide and bismuth subsalicylate are antidiarrheal are the recommended agents for acute diarrheal tx. When are they contraindicated?
Pts w/ bloody diarrhea
High fever
systemic toxicity
AND they should be discontinued in pts whose diarrhea is worsening despite therapy
50
Generally, community-acquired diarrhea doesn't warrant empiric abx tx.
In centers where stool microbial testing isn't available.. When should empric tx w/ antibiotics for acute diarrhea be considered?
Non-hospital acquired diarrhea
Moderate-severe fever, tenesmus, bloody stools
No suspicion of STEC infection
Immunocompromised pts
Significant dehydration
51
Drugs of choice for empirtic tx of of acute diarrhea?
Cipro BID 500mg
Oxfloxacin BID 400mg
levofloxacin QD 500mg
(flouroquinolones, all 1-3 days)
52
Alternatives abx for empiritc tx of acute diarrhea?
Trimethoprim-sulfamethoxazole 160/800mg BID
doxy 100mg BID
53
Many bacterial cases of diarrhea do not warrant abx therapy. What are the specific species for which abx therapy IS warranted?
```
Shigellosis
Salmonellosis (extraintestinal)
Listeriosis
Cholera
C. diff
```
54
What are the non-bacterial forms of infectious diarrhea that warrant abx tx?
amebiasis, giardiasis, and traveler's diarrhea
55
When should you admit for inpatient tx?
Severe dehydration
Severe/worsening bloody diarrhea
Severe abd pn
Severe infection (elevated temp >39.5 , leukocytosis ,rash)
Severe diarrhea in pts > 70
Signs of HUS
56
Chronic diarrhea is longer than 4 weeks. What should be excluded before an extensive workup?
Common causes such as medications, chronic infections, and IBS
57
What are the major pathologic categories for chronic diarrhea
```
Chronic
Osmotic
Medications
Malabsorptive
Motility
Inflammatory
Systemic
Secretory
```
COMMMISS
58
This type of chronic diarrhea typically resolves during fasting?
Common causes include carb malabsorption, laxative abuse, malabsorption syndromes
Osmotic diarrhea
| increased osmotic gap
59
Chronic diarrhea w/ a high-volume, watery stool
Doesn't resolve w/ fasting
May result from an endocrine tumor or bile salt malabsorption
Secretory diarrhea
| increased intestinal secretion, decreased absorption
60
What are the inflammatory forms of chronic diarrhea?
IBD (Crohn's, UC)
Microscopic colitis
61
A chronic diarrhea and motility disorder that presents w/ pain and altered bowel habits w/ no evidence of organic diseas?
IBS
| the most common cause of chronic diarrhea in you adults
62
What are the characteristics of chronic diarrhea as a result of malabsorptive conditions?
wt loss, osmotic diarrhea, steatorrhea, nutritional deficiencies
63
What are the common etiologies of chronic infectious diarrhea?
Giardia, E. histolytica, Cyclospira (protozoans)
Intestinal nematodes
64
What are some systemic conditions that might result in chronic diarrhea?
Thyroid dz
Diabetes
65
Common lab tests in a chronic diarrhea workup might include?
CBC, Chem 17, LFT, thyroid studies, INR, ESR, CRP
Stool studies shoudl include cultures, leukocytes, lactoferrin, occult blood, OandP, electrolytes
66
How would we test for Celiac?
serologically, for IgA tissue transglutaminase
67
Anemia occurs in what forms of chronic diarrhea?
malabsorption syndrome
inflammatory conditions
68
Hypoalbuminemia occurs in what forms of chronic diarrhea?
malabsorption
protein-losing enteropahties
inflammatory diseases
69
In inflammatory bowel disease what might we expect to see elevated?
ESR, CRP
70
Most patients w/ chronic persistent chronic diarrhea undero colonoscopy to exclude?
IBD
neoplasm
71
24-hour stool collections can be ordered for total stool weight and total fat in stool...
1. Low stool weight means?
2. A high stool weight means?
3. High fecal fat means?
1. exludes diarrhea, suggestive of IBS
2. significatn secretory process, including a neuroendocrine tumor
3. Indicates malabsorptive syndrome
72
Small bowel bacterial overgrowth might warrant a noninvasive breath.... HOwever these have high rates of false positives....definitive diagnosis should be determined how?
Bacterial culture of small intestinal contents (aspirate)
| not available at most centers
73
Chronic diarrhea tx depends on etiology and most case warrant referral to a specialist.. Some tx options are?
Loperamide
Diphenoxylate w/ atropine
Codeine (reserved for chronic, intratbale diarrhea)
Clonidine
Octreotide
Bile salt binders
74
Hematochezia are present in massive upper GI bleeds, but most cases present w/?
melena
75
Should you use hematocrit or volume status to determine severity of blood loss?
Volume status
76
Not only diagnostic, this may also be therapeutic in acute upper GI bleeding?
endoscopy
77
Upper GI bleeding is where in regards to the ligament of treitz?
Proximal duh
78
Most common presentation of upper GI bleeds?
hematemesis or melena
| hematochezia usually suggests a lower GI bleed
79
Etiology of upper GI bleeds...
Most common?
Highest mortality rate?
1. PUD accounts for 40%
2. Portal HTN accounts for 10-20% but has a higher mortality rate
3. Mallory Weiss tears
4. Vascular anomalies (most commonly angioectasis, telangiectasis)
5. Gastric neoplams (1%)
80
What are some rare causes of acute upper GI bleeding?
Erosive gastritis (associated w/ NSAIDs, alcohol) is more likely to be chronic
Erosive esophagitis (chronic GERD)
81
Initial tx measures for acute upper GI bleed should include assessment of hemodynamic status. A SBP lower than what indiciates a high risk pt?
(stable or unstable?)
100
| Or a pulse > 100 bpm
82
In unstable pt, begin an IV and send for what tests?
Blood type/screening for possible transfusion (2-4U PRBCs)...
CBC, PT/INR, CMP,
83
Though not always rec'd, placement of an NG tube may reveal what?
Red blood/coffee ground aspirate, which confirms an upper GI bleed
(Though not all pts positive for bleeding will aspirate, especially those w/ duodenal bleeding)
84
Amount of fluid/blood products is based on pt presentation, but PRBCs should aim to maintina HGB at what level?
No lower than 7-9 g/dL
85
1. If pt is using aspirin/clopidorel, consider?
| 2. Pt is uremic, consider?
1. platelet transfusion
| 2. desmopressin
86
In initial triage, what are the risk factors for a high risk pt? And wehre do they go?
Send them to ICU
Age > 60
Comorbid illness
SBP<100>HR
BRRB, bright red blood from NG aspirate
87
WHat is warranted in all cases of upper GI bleed? And w/ how many hours?
Upper endoscopy WITHIN 24 hours
88
What are upper endoscopy's benefit?
ID source
Determine risk of rebleed/ guide triage
Endoscopic therapeutic intervention
89
What are the therapeutic endoscopic modalities?
Cautery
Injection (e.g., epi)
Endoclips
90
Acute noninflammatory diarrhea cause?
Usally viral or NONINVASIVE bacteria
91
Do we want to "stop up" a pt w/ diarrhea?
Depends... prefer not to (let the body flush it out...)
BUT if they're essential personnel or a wage-worker, consider loperamide so they can get to work
92
How do we confirm an upper GI blood?
after hx and exam, EGD
| Massive GI bleed = 1-1.5 L
93
How far does an EGD go?
To the duodenum
94
Once stabilized, initial triage is based on risk of rebleed. What puts a pt in the high risk category?
Age>60
Comorbid illness
SBP<100
Pulse>100
Bright red rectal blood in aspirate OR rectal exam
95
Where do patients go who are not high risk?
Admit to a step-down unit/ward
96
What's a pharmacological intervention a pt w/ an upper GI blood should receive?
What are its benefits?
IV PPI
lowers risk of rebleed, erosive esophagitis/gastritis, and MW tear
97
Pts w/ upper GI bleed and evidence of portal HTN should receive what?
IV octreotide
98
Where does the majority of acute lower GI bleed come from?
Colon
99
Lower or Upper GI... which has a higher risk of serious blood loss?
UPPER
100
Most common cause of major lower tract bleeding?
Diverticulosis
101
Etiologies of acute lower GI bleeding?
Anorectal dz (hemorrhoids, fissure, ulcers)
Diverticulosis
IBD (UC, Crohn's)
Infectious colitis
Neoplasm
Angioectasias
102
Most likely lower GI bleed in those under 50?
Anorectal dz
IBD
Infectious dz
103
Most likely GI bleed in patients over 50?
Diverticulosis
Malignancy
Angioectasias
Ischemic colitis
104
What is the likely source of bright red blood in stool?
Left colonic source
| hemorrhoids, fissure, diverticulitis, IBD, colitits
105
Likely source of maroon blood in stool?
Small intestine or right colonic source
106
Likely source of black blood in stool?
Upper GI
107
Painful defecation could be?
External hemorrhoids
Anal fissure
108
Abdominal cramps accompany what lower GI bleeds?
IBD
Colitis
109
Painless lower GI bleeds accompany?
internal hemorrhoids
Diverticular bleeding
110
A larg volume of blood accompanying a lower GI blled, think?
Diverticular
111
Small volumes of blood in a lower GI bleed, think?
IBD
Hemorrhoids
112
With a suspected acute lower GI bleed, you must first exclude?
Upper GI source of blood
113
Options for lower GI bleed "scopes"?
```
Anoscopy
Sigmoidoscopy
Colonoscopy
Technetium scan
Capsule endoscopy
```
114
Treatment options for acute lower GI bleeding?r
Therapeutic colonoscopy
Intra-arterial embolization
Surgery (last resort)
115
As a last resort, surgery is an opton for acute lower GI bleed, what are the indications?
If a patient requires more than 6 units of PRBCs in 24 hrs, or more than 10 units total
116
Two types of obscure GI bleeding?
Obscure overt
Obscure occult
117
Common source of obscure GI Bleeding?
small intestine
118
Obscure bleeding is bleedint that isn't apparent to the pt. How much blood/day can you lose w/o appreciable signs?
Up to 100 mL/day
119
How can we ID occult GI bleeding?
Fecal Occult Blood test
Fecal Immunochemical Test (only detects LOWER bleed)
Presence of unexplained anemia in CBC
120
Occult GI bleed... what shoudl investigate for? How so?
NEOPLASM
Get CBC for anemia
121
1. Pos FOBT w/o anemia... what would you order?
| 2. Pos FOBT w/ anemia... what would you order?
1. Colonoscopy
| 2. Upper endoscopy AND colonoscopy
122
Presents as acute, painless, large-volume maroon or bright red hematochezia in patients over 50?
Diverticulosis
123
Bright red blood dripping into the toilet bowl, think?
Hemorrhoids
124
Given that we should exlude an UPPER GI bleed when a pt presents w/ an acute lower GI bleed, how might we differentiate?
NG tube aspirate w/ blood/dark brown guiac positive material is strongly suggestive of upper GI bleeding
125
In pts under 45, lower GI bleeds can be scoped with only an anoscopy and sigmoidoscopy, however patients older than 45 shoujd have what?
A full colonoscopy to exclude a tumor
126
In MOST cases, pts w/ acute, large volume GI bleeding that requires hospitalizaiton, what is the study of choice?
COlonoscopy
127
For treatment of acute lower GI bleeding, we can treat with a therapeutic colonoscopy... such as?
Vasoconstrictive injection (epi)
Cautery
Endoclips
128
Aside from therapeutic colonoscopy, what are other tx options for acute lower GI bleeds?
And when is our last resort indicated?
Intra-arterial embolization
Surgery -- indciated when a pt requires more than 6U in 24 hrs OR more than 10U over any timespan
129
In an acute lwoer GI bleed, What are our two most likley conditions that will require surgical interventio?
a bleeding diverticulum
angiectasia
130
Most common causes of small intestinal bleedin gin patient under 40?
neoplasms
Crohn dz
Celiac
Meckel diverticulum
131
Most common casues of small intestinal bleeding in patients over 40?
Angioectasis
NSAID-induced ulcers
(though other diorders occur as well)
132
Before pursuing eval of small intestine, repeat the upper endoscopy and colonoscpoy to ensure a lesion hasn't been overlooked
k cool
133
Chronic gastrointestinal blood of less than ___ may cause no appreceaible change in stool appearance.
100 mL/day
| occult blood
134
Pts over 60 w/ obscure-occult bleeding who have a nomal initial endoscope and no other worrisome ssx, most commonly have a bleed from what? And how to treat?
(worrisome = wt loss, ab pn)
Bleed from angioectasis
Consider an iron supplemetn for empiric tx. If unresponsive to iron supplementation, pursue capsule endoscopy
135
In an occult bleed, when possible, ____ should be discontinued. Patients with occult bleeding without a bleeding source identified after upper endoscopy, colonoscopy, and capsule endoscopy have a
low risk of recurrent bleeding and usually can be managed with close observation.
```
antiplatelet agents (aspirin, NSAIDs,
clopidogrel)
```
136
Derived from two sources
– ?
– ?
• Contains numerous gases including:
– oxygen, nitrogen, hydrogen, carbon dioxide, hydrogen
sulfide, ammonia, and methane – foul smell caused by ????
and methane
Derived from two sources
– swallowed air (primarily nitrogen)
– bacterial fermentation of undigested carbohydrate
• Contains numerous gases including:
– oxygen, nitrogen, hydrogen, carbon dioxide, hydrogen
sulfide, ammonia, and methane
– foul smell caused by traces of hydrogen sulfide, ammonia,
and methane
137
• Eructation – Belching
– The involuntary or voluntary release of gas
from the stomach or esophagus
– Occurs most frequently?
• gastric distention results in ____________ relaxation
– Typically due to aerophagia ?
• Eructation – Belching
– The involuntary or voluntary release of gas
from the stomach or esophagus – Occurs most frequently after meals
• gastric distention results in transient lower
esophageal sphincter relaxation
– Typically due to aerophagia (swallowing air)
