Upper GI Flashcards

Question

GERD in elderly considerations

Answer 1

* Highest risk of complications * Lower threshold for endoscopy * PPIs safe, but need to be mindful of Rx interactions, (Cyto P450 path) most common) - Major: WARFARIN (BLEED RISK) - Minor: Benzos, CCBs, theophylline

Answer 2

* New onset of dyspepsia in patient ≥ 60 years * Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, occult blood in stool) * Iron deficiency anemia * Anorexia * Unexplained weight loss * Dysphagia * Odynophagia * Persistent vomiting * Gastrointestinal cancer in a first-degree relative

Answer 3

Mild/Intermittent Symptoms * Step Up Therapy * Lifestyle/diet modifications then * Fewer than 1 episode per week: PRN antacids * Fewer than 2 episodes per week * Stepwise therapy: low dose H2 blockers x 2 weeks, if no improvement → standard dose H2 blockers for 2 weeks, if no improvement → Once daily PPI Successful treatment should continue for a minimum of 8 weeks*

Answer 4

Severe/Frequent Symptoms OR Erosive Esophagitis on EGD * Step Down Therapy → start with high dose then step down * Lifestyle/diet modifications + * Standard dose PPI x 8 weeks → Low dose PPI → H2 Blocker if intermittent symptoms **Acid suppression therapy should be discontinued EXCEPT in patient with Barrett’s Esophagus or severe erosive esophagitis → Maintenance PPI therapy**

Answer 5

Overuse can change stomach medium + can facilitate growth of bacteria * C. difficile diarrhea (mechanism unclear) * ↑ risk of pneumonia, likely d/t decreased gastric acid secretion – easier colonization UGI tract * Malabsorption – Mg, Ca, Vit B12, Iron * Atrophic Gastritis, kidney disease, drug-induced lupus * Large study showed long-term use of PPI a/w osteoporosis + hip fractures, although this is now in question; however, still FDA labeling on fracture risk

Answer 6

* After at least 3 months symptom free on PPI, may taper * Cut dose by half every week * Once on lowest dose for one week, may stop * Do not reduce or discontinue if patient has Barrett’s Esophagitis * Patients receiving 4-8 wk treatment for acute duodenal or gastric ulcers do not require taper, nor do those being treated for H. pylori

Answer 7

* Erosion in either stomach or duodenum > 5mm AND penetrates into submucosa

Answer 8

* H. Pylori responsible for 60% of PUD in US - Causes increased acid secretion - Increases inflamm - Downregulates mucosal defense system * **NSAIDs** (4x inc risk) * Smoking * EtOH * Genetics

Answer 9

* 70% asymptomatic * Gnawing or burning epigastric pain * Bloating, abd fullness, nausea, early satiety, GERD * Establish relationship w/eating - Duodenal: Pain worse **2-5hrs** post eating - Gastric: Pain worse **soon** after eating * Nocturnal pain relieved w/food, antacids

Answer 10

* Hx should assess for prior Hx of H. pylori, NSAID use, RFs, alarm features * PE normal - +/- epigastric tenderness

Answer 11

* Confirmation should be performed on all pts treated for H. Pylori d/t abx resistance - Should be performed at least 4wks after completion of abs treatment - Can use either urea breath test, stool antigen test or endoscopy based testing - DO NOT use serologic testing; does not distinguish between past + present

Answer 12

**only if < 55 + no alarm sx** * Active or hx of PUD * Dyspepsia * Gastric MALT lymphoma * Consider before starting chronic NSAID therapy * ? Unexplained iron deficiency

Answer 13

* > 55 * Alarm sx: Unexplained wt loss, Progressive dysphagia * Odynophagia * Recurrent vomiting * FMHx of GI cancer * GI bleeding * Anemia * Jaundice * Abd mass ** Endoscopy is not indicated for sole purpose of determining H. Pylori status**

Answer 14

**Urea breath testing (UBT)**: * Highly sensitive and specific * Cannot be used if any PPI, bismuth or abx use in the last 2 weeks * False negatives may be seen with bleeding ulcers * Expensive **Stool antigen assay** – best in COVID setting * Less expensive vs. UBT + slightly less affected by PPI use * Still recommend avoidance of PPIs, bismuth or abx for 2 weeks * POC test not as sensitive but lab based testing equal to urea breath test * Can be used for diagnosis and confirmation of eradication **Serology** * ELISA test to detect H. Pylori IgG * Inexpensive * Not accurate (85% sensitive and 79% specific) * Does not determine between active and past infection * Not affected by PPI, bismuth, antibiotic use * Not generally recommended

Answer 15

* Clarithromycin, Metronidazole (metallic taste) * Metronidazole: Peripheral neuropathy, seizures, vomiting w/EtOH; DO NOT DRINK * Clarithromycin: N/V, abd p!, prolonged QT * Amoxicillin: diarrhea, allergic reaction – skin rash

Answer 16

* Age independent predisposing factor in GI bleeding * Risk increases significantly > 65 yrs + further > 75 yrs * UGI bleed dramatic event w/ high mortality * NSAID use highest cause followed by H. Pylori * Cox-2 inhibitors (though not as high risk, not without risk) * Low dose ASA (risk doubles)

Answer 17

* Unexplained or gradual drop in Hgb—think of GI bleeding * Gradual = usually asymptomatic * Avoid NSAID use * If must use: - Lowest dose for shortest amount of time - Prescribe gastroprotective drug concomitantly; PPI best choice * Long term considerations - Consider testing for & tx H. Pylori if NSAID tx will be > 3 mos

Answer 18

* Inflamm of gallbladder * Can be w/calculous or w/o * More serious complications may occur when gallstone passes out of cystic duct + into common bile duct

Answer 19

* Gallstones can block tube (cystic duct) leading out of gallbladder → cholecystitis * Bile buildup can → inflamm * Bile duct problems, tumors, serious illness, infection (E. coli, enterococcus, Klebsiella, Enterobacter) * More serious complications may occur when a gallstone passes → cystic duct → common bile duct Cholelithiasis * Appearance of gallstones w/in gallbladder or cystic duct * Choledocholithiasis – common bile stones * Cholangitis – inflamm of common bile duct – via bact infxn

Answer 20

* RUQ pain or epigastric area * Radiating pain to R shoulder or back * Worsens after eating * N/V

Answer 21

* **(+) Murphy’s sign **: tenderness to RUQ palpation * Distended gallbladder * Jaundice (choledocholithiasis, I.e. gallstones in the common bile duct) * Bile duct obstruction → turn yellow * ↑ fever & chills if septic

Answer 22

* CBC – Leukocytosis * LFTs – ALT, AST normal or mildly elevated - **ALKphos + bilirubin elevated w/CBD obstruction or cholangitis** * **Serum pancreatic enzymes (amylase + lipase) – mildly elevated** * Pregnancy test

Answer 23

* **1st line Abd U/S (practical) **– not contraindicated in preg - Can’t determine if stone passed out of gallbladder → bile duct - Look for **thickening of gallbladder wall** - acute * HIDA scan * CT scans: if unclear picture * MRCP: for current choledocholithiasis in pts w/acute cholecystitis; noninvasive for evaluating intrahepatic + extrahepatic bile ducts

Answer 24

* IV fluids * Pain management

Answer 25

* Hospitalization usually necessary: observation * Cholecystectomy most widely used therapy when s/s arise from gallstones - Pts do well post surgery, w/no difficulty w/digesting food, despite lacking gallbladder to help - Laparoscopic cholecystectomy preferred * Open procedure if ↑ inflamed gallbladder * Stones in bile duct can frequently be removed w/ERCP

Answer 26

Bile duct injury is most common complication of laparoscopic cholecystectomy * Can have post-surgical diarrhea * D/t ↑ bile acid entering large intestine causes laxative effect * Usually resolves but can treat w/immodium or cholestyramine

Answer 27

* **Female sex** * **Overweight** * **Adv age > 40** * Pregnancy * Hx of “crash diets” w/rapid weight loss * Meds: estrogens, thiazides, fibrates, anabolic steroids * FMHx, HiTGs * Spinal cord injury * Hx of gastric bypass surgery * DM * Crohn’s disease * Alcoholic + biliary cirrhosis * Hyperparathyroidism

Answer 28

* Be aware of ↑ likelihood of gallbladder disease during pregnancy & postpartum period * In elderly pts, sometimes difficult to DX; complications more likely; cholecystectomy mortality rate ↑

Answer 29

* Can be acute or chronic inflamm * Digestive enzymes attack pancreatic tissues → swelling * Leading cause of hospitalization among digestive system diseases

Answer 30

* Disorder of exocrine pancreas + A/w cell injury w/local + systemic inflamm responses * Inflamm range from milld edema → necrosis * Life threatening

Answer 31

* Inflamm cause chronic damage to gland – fibrosis, calcification, + ductal inflamm * Slow progression over years * Related to XS EtOH * Smoking ↑ risk * More common in AMAB pts * Lead to panc. Failure * Exocrine: stop producing enzymes → dietary fat + protein poorly digested → oily stools * Endocrine: no insulin prod → DM

Answer 32

- **Gallstones – AFAB pts** - Cause obstruction in bile duct build-up of enzymes causing tissue damage - **EtOH – AMAB pts** - **HLD TGs > 1000** - Infxns: mumps, HIV - Meds: thiazide diuretics + furosemide - ERCP procedure - Heredity - Cystic fibrosis, DM, celiac, high calcium - Idiopathic - Malignancy

Answer 33

* **A**lcohol, autoimmune disorders, arteritis * **B**iliary, blunt trauma * **C**ongenital – pancreas divisum (ducts don’t join up) * **D**rugs or meds * **E**RCP, eosinophilia * **F**ormations – primary + metastatic tumors * **G**enetic - mutations * **H**LD, hypercalcemia * **I**diopathic, infectious – HIV, IBD

Answer 34

* N/V * Acute onset of epigastric pain → back, worse w/movement

Answer 35

* ↑ HR, RR, + temp * Low skin turgor, dry mucous membranes (dehydrated) * Diaphoretic * HoTN * Tender abd w/diminished bowel sounds * Mild rigidity w/o rebound tenderness * Jaundice possible * **Cullen sign (+)** * **Grey Turner sign (+)**

Answer 36

**Amylase** - Rises w/in 6-12hrs + returns to normal w/in 3-5d - 3x value of upper limit **Lipase** - Rises w/in 4-8hrs, peaks at 24hrs, returns to normal w/in 8-14d - Rises earlier + lasts longer - Useful in pts who present later, + more sensitive vs. amylast in pts w/this d/t EtOH - Lipase 3x upper limit of normal * Am:Li > 5 = EtOH * Am:Li > 3x = gallstone * CBC w/diff = ↑ WBC * Hct ↑ = necrosis * CMP (electrolytes, BUN, HFTs) * Serum Hcg for pts w/uterus of childbearing age * Fasting lipids for TGs

Answer 37

**1st line tx: IV hydration, pain control** * Meperidine * Ketorlac * Ondansetron Early TPN

Answer 38

* Pancreatic enzyme supplements w/every meal (creon)

Answer 39

* NPO * Refer/Hospitalize! * Hospitalize for 3-7d if responsive to conservative therapy Need to address underlying cause * ERCP – address bile duct narrowing/ obstructions - ERCP: x-ray + endoscope * Cholecystectomy * Pancreatectomy (chronic) * Low-fat diet + enzyme supplements help control pain in reducing pancreas stimulation * EtOH + smoking cessation * May need to drain pseudocyst

Answer 40

* Lifestyle modifications - EtOH misuse: D/C - Control ↑ TG - Lipid lowering meds - Eat small, low-fat meals of carbs + proteins

Answer 41

- Diagnostics – don’t delay diagnosis + tx as delay can ↑ maternal = newborn morbidity + mortality - Care by obstetrician well-versed in high-risk pregnancies

Answer 42

* Protrusion of abd viscera through abnormal opening in mm wall

Answer 43

- Reducible: structure returns abd cavity - Irreducible/ incarcerated: structure does not return to abd cavity - Strangulated: interrupted blood flow to structure that has herniated

Answer 44

* Congenital/acquired * pregnancy * frequent stooping * acites * mm atrophy * trauma * dysfunctional CT r/t malnutrition * long-term steroid use * recurrent Valsalva (BPH, straining at urination, heavy lifting) * Chronic cough (COPD, asthma, GERD, smoking)

Answer 45

* Ventral - epigastric, **umbilical**, spigelian, parastomal, most incisional * Groin - direct & **indirect inguinal & femoral ** * most common; we will be spending the most time on these. 75% of hernias are inguinal. * Pelvic - sciatic, **obturato**r, perineal * Flank – protrude through weakened areas of back musculature; superior and inferior lumbar triangle hernias

Answer 46

* Indirect inguinal: **most common in both sexes**; 60% of all hernias. * More common in infants < 1 year old & in males 16-20 years old * Direct inguinal-less common; occurs most often in men > 40; rare in women. Incidence increases with age. Acquired. * Femoral-least common; 10% of all groin hernias; more common in women. Usually seen later in life. Acquired. * **Though uncommon, 40% present as emergencies**. * Umbilical-very common in newborns & infants up to 1 year; often resolves in infants up to age 2. More common in women; often missed, obscured by subcutaneous fat. F/U w/surgeon * **High risk of strangulation and mortality due to risk of colonic entrapment ** * Obturator – rare but serious; more common in elderly women; incidence increases with age. Acquired.

Answer 47

* Etiology – congenital; patent processes vaginalis * Incidence decreases with age * Location – lateral side of spermatic cord * **Protrudes through internal inguinal ring, lateral to inferior epigastric artery** * Can contain sac of peritoneum, omentum, or bowel * **Medium likelihood of strangulation** Indirect inguinal hernia passes through the inguinal canal or the groin

Answer 48

* Etiology – acquired, weakness in the posterior floor * Incidence increases with age * Location – directly forward thru posterior wall of the inguinal canal * **Protrudes through external inguinal ring, medial to inferior epigastric area** * Can contain periorbital fat, bowel, peritoneal sac * Low likelihood of strangulation A direct inguinal hernia shows a bulge from the posterior wall of the inguinal canal

Answer 49

* Incidence: more common in women, later in life * Location: femoral canal, fossa ovalis – medial to the femoral pulse * More common on the right side * Protrudes through femoral ring, medial to femoral sheath, which containes femoral artery * **Likelihood of strangulation – high**; nearly half of patients are unaware of their femoral hernia before strangulation occurs; groin pain and tenderness may be absent

Answer 50

* Rare * Women affected > men 6:1, likely due to larger, more triangular obturator canal * R side more common * BL hernias & concurrent femoral hernias are rare but documented * Greatest incidence in patients in their 70s and 80s weighing < 40 kg * Decreased muscle and fat * 1/3rd of pts have history of previous attacks * Watch for symptoms of bowel obstruction, present in greater than 80% of cases

Answer 51

Inguinal Hernia * Pain w/straining * Pt feels bulging in groin area/scrotal pain & swelling – scrotal hernia * May also describe sensation as “dragging” * Inguinal swelling w/o pain Femoral Hernia * Can have severe pain, but sometimes not Umbilical hernia * Periumbilical pain, may be severe; consider umbilical hernia for periumbilical pain Obturator hernia * Often no symptoms until acute onset of N/V * Dull, cramping, abd pain - Can be intestinal obstruction, recurrent

Answer 52

Red flags * Painful to palpation * Erythema * Ulceration * Febrile patient * Abdominal pain * Bloating * N/V DO NOT TRY TO REDUCE A STRANGULATED HERNIA

Answer 53

* Male patient stands to start - R hand = pt R side - L hand = pt L side * Invaginate loose scrotal skin w/index finger * Off note – not able to in women - Need to palpate mass or painful area

Answer 54

* Higher up * Insert finger into inguinal canal → palp for bulge → bear down * Hernia **comes down** inguinal canal + touches fingertip

Answer 55

* Insert finger through inguinal canal → bear down → palp for bulging * Hernia bulges anteriorly + **pushes side of finger forward**

Answer 56

* Hernias become strangulated (high risk) → refer to surgeon

Answer 57

* Pt lies supine → bear down → palp mass at umbilicus * Have pt sit up + watch for protrusion of umbilical or ventral mass

Answer 58

* Usually not palpable externally but sometimes tender mass w/pelvic or rectal exam * **(+) Howship-Romberg sign** - Groin pain radiating down medial thigh w/EXT, ABD, or IR d/t compressed obturator nerve; knee pain relieved w/flexion - Indicator that the obturator nerve is irritated

Answer 59

* Inguinal adenopathy-enlarged, palpable inguinal lymph nodes * Abd lesion * Incarcerated hernia - hernia that cannot be reduced * Strangulated hernia-blood supply of incarcerated contents is interrupted; gangrene may quickly ensue * Important to differentiate btwn diastasis vs. hernia

Answer 60

* Usually DX on clinical exam, often not needed **1st line: Abd U/S** 2nd line: Abd CT scan; Abd MRI; herniography (INJ contrast; subsequent x-ray imaging – invasive + rarely needed)

Answer 61

REFER, either electively or emergently

Answer 62

* For male pts: for inguinal hernias **if hernia is reducible + not affecting pt’s ADL d/t pain or ROM** * Pregnant pts: groin swelling can be caused by self-limiting round ligament varicosities

Answer 63

* For asymptomatic patients with risk factors such as female sex, femoral hernia, scrotal hernia, recurrent hernia, **surgery is advised** * For symptomatic inguinal and femoral hernias, **surgery is recommended** * For incarcerated/strangulated hernias, **surgery is recommended urgently/emergently** **AKA REFER TO SURGERY** * Surgery - Can be laparoscopic (more $$$; shorter recovery, can be open) - Open (less $$$; longer recovery) * Strangulated or necrotic hernia – bowel resection

Answer 64

* Give guidance prior to surgery, recovering time - To walking – same day for local and general - To working – 10-21d if undemanding; 2-4 wks for more physically demanding work - No effect on sexual function * Follow-up: As indicated; often patients have post-op pain; refer back to operating surgeon after a few weeks