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264 Cards in this Set
- Front
- Back
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What are the natural areas of narrowing in the esophagus?
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cricopharyngeus
aortic arch left mainstem bronchus lower esophageal sphincter |
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What is a cafe coronary?
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Sudden cyanosis and collapse caused by food lodged in the upper esophagus or oropharynx
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What are pathologic causes of esophageal stenosis?
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-carcinoma
-webs -extrinsic compression (neck, thyroid) -congenital anomalies of the aortic arch -aneurysm -bronchogenic carcinoma -pharyngoesophageal diverticulum |
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-What tests can be done for esophageal FB?
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-lateral neck x-ray
-contrast study (1st gastrograffin then barium) -endoscopy -CT |
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When/how should glucagon be used in esophageal obstruction?
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Only useful in lower esophageal obstruction (acts on smooth muscle)
1mg IV (up to 2mg) |
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When is urgent endoscopy indicated for esophageal FB?
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-significan distress
-children with alkaline button battery -sharp objects, disc battery or coin in the proximal esophagus |
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Which FBs in the stomach require endoscopic retrieval?
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-longer than 5cm or wider than 2.5 cm
-sharp and pointed FB |
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When is surgical removal of GI FB indicated?
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-if they remain in the stomach for 3-4 weeks
-same intestinal location for >1week |
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What are causes of esophageal perforation?
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-Boerhaave syndrome
-Valsalva -endoscopy -FB -caustic substance -esophagitis -Cancer -direct injuey (trauma) -postoperative breakdown of anastomosis |
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How should possible esophageal perforations be evaluated?
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-xray (CXR, upright abdomen) +/- neck
-contrast study (gastrograffin and then barium) -CT |
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What are characteristics of contrast agents?
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gastrograffin - water-soluble, less inflammatory to tissues however may result in pneumonitis
barium - may incite inflammatory response in tissues |
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What is the management of esophageal perforation?
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-IV antibiotics
-NPO -NG tube -Sx consult |
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What is the most common pathogen in infectious esophagitis?
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Candida species
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What is pill esophagitis?
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Inflammation and injury resulting from a pill or capsule that remains in contact with the esophagus
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What is eosinophilic esophagitis?
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Presence of eosinophils within the esophageal mucosa
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What drugs can cause gastritis?
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ASA
NSAIDs Potassium preps iron |
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What are 2 main causes of PUD?
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NSAIDs
H pylori |
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What are ways of testing for H pylori?
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Urea breath test
Urea blood test Antibody testing Stool antigen test |
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Which patients have increased risk of NSAID induced gastroduodenal toxicity?
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-those >60 years of age
-high dose NSAIDs -steroid use -anticoagulant use |
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What meds other than NSAIDs have ulcerogenic potential?
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5-fluorouracil
mycophenolate mofetil bisphosphonates |
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What are complications of PUD?
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-hemorrhage
-perforation -penetration -gastric outlet obstruction |
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What is the treatment of NSAID related PUD?
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stop NSAIDs
begin PPI |
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What is the treatment of PUD without NSAID use?
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Treat for H pylori
Triple therapy (clarithromycin, amoxil, PPI) Quadruple therapy (bismuth, flagyl, tetracycline, PPI) |
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What are causes of dysphagia?
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Neuromuscular
-vascular (CVA, dermatomyositis) -immunologic (MS, MG, scleroderma) -infectious (botulism, tetanus, diptheria) -metabolic (lead, hypomagnesemia) other (Alzheimers, tumor, depression, ALS) Obstructive aortic aneurysms esophageal motility disorders (achalasia, diffuse esophageal spasm) Esophageal rings Esophageal strictures Esophagitis |
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How can you classify dysphagia?
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Oropharyngeal
-food stuck on swallowing -mostly neuromuscular -coughing/choking -liquids>solids -usually CVA Esophageal -2-4s after swallowing -mechanical vs motility |
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What is the approximate risk of transfusion related Hep C?
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1:100,000
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What is the most common form of hepatitis?
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Viral hepatitis
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What is fulminant hepatitis?
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Acute onset hepatitis which progresses to hepatic failure and encephalopathy within a few days (usually Hep B and D)
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What are lab findings in hepatitis?
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10 to 100 fold increase in ALT and AST (ALT>AST)
Moderately increased bilirubin which may only appear post clinical symptoms |
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How can you distinguish acute Hep A from previous infection?
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Hep A IgM (acute) vs Hep A IgG
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What establishes acute Hep B?
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HBsAg and HBcAg IgM
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What is a marker of previous Hep B infection?
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Anti-HBcAg
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What is a marker of Hep B immunity?
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anti-HBsAg
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Why is the HCV antibody test not very useful?
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It does not distinguish between acute and chronic disease and there is a delay between the onset of disease and positivity
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What are features of alcoholic hepatitis?
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History of chronic or excessive EtOH
AST>ALT less marked elevation of transaminases |
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What are complications of acute hepatitis?
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Fluid and electrolyte imbalance
Severe vomiting causing UGIB Liver failure |
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What are indications for admission in hepatitis?
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Altered sensorium
Prolonged PT (>5s) INR >1.5 |
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Who requires PEP for Hep A?
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Close personal contacts
Daycare employee and attendees Foodborne source contacts |
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Is there any pre or post exposure prophylaxis for Hep C?
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No
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What is the most common variety of alcohol-induced liver disease?
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Steatosis (fatty infiltration)
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Is liver steatosis of concern?
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Beyond enlargement of the liver it is a benign process
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What are the lab features of alcoholic hepatitis?
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Moderate elevation of AST and ALT with a predominance of AST to ALT, increased wbc, increased PT and INR indicate hepatic dysfunction
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How can Mg++ be replaced?
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Mgsulfate 1g IV or as an oxide, chloride salt or amino acid conjugate for oral repalcement 200-1000mg
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What are the 2 manifestations of cirrhosis?
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Altered metabolic and synthetic function
portal hypertension |
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What finding is suggestive of biliary cirrhosis?
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ALP increased out of proportion to other liver enzymes
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What is biliary cirrhosis?
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Chronic consequence of extrahepatic biliary obstruction or primary disorder of autoimmune mediated intrahepatic duct inflammation and scarring
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What can be given to ascites patients who have outpatient follow up?
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Low dose thiazide or loop diuretic (if normal renal function)
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What should you do in a cirrhosis patient with increased Cr?
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Suspect hepatorenal syndrome and consider hospitalization for fluid and electrolyte management
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What causes ascites in cirrhosis?
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Portal hypertension
Impaired hepatic lymph flow Hypoalbuminemia Renal salt retention |
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What causes encephalopathy?
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Impaired hepatic metabolic function and portal hypertension
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What is the definition of hepatorenal syndrome?
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Renal failure in the setting of cirrhosis without obvious renal pathology. It is almost universally fatal
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Explain the role of ammonia in hepatic encephalopathy?
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Ammonia is normally absorbed and converted to urea in the liver. In severe hepatic disease it accumulates, croses the BBB and forms glutamine
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What is the management of hepatic encephalopathy?
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Lactulose
neomycin protein restriction |
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What is spontaneous bacterial peritonitis?
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Acute bacterial infection of ascitic fluid in patients with liver disease without apparent external or intra-abdominal focus of infection
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When should SBP be considered?
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Any patient with ascites who presents with abdo pain or unexplained clinical deterioration
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When should SBP treatment be initiated?
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Ascitic fluid neutrophil cound >250cells/mm3
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What are the treatment options in SBP?
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Third generation cephalosporin
Ampi-sulbactam ampi and aminoglycoside |
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What are 2 categories of hepatic abscesses?
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Pyogenic
Amebic |
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How is amebiasis transmitted?
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Fecal-oral route
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What ameba is responsible for invasive disease?
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Entamoeba histolytica
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How is amebiasis identified?
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Identification of protozoa in stool or ELISA
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What is the treatment for amebic liver abscess?
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Metronidazole 750mg PO IV TID +/- percutaneous drainage if refractory
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What is the management of incidental detection of elevated aminotransferases?
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Viral serological studies
(HBsAg, HBeAg (establishes infectivity) and anti HCV )with f/u in IM or GI |
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What hepatic disorders are associated with pregnancy?
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Benign cholestasis
Acute fatty liver |
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How does cholestasis in pregnancy present?
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Pruritus in the 3rd trimester (usually)
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What is the management fo cholestasis in pregnancy?
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Subcutaneous vit K and cholestyramine for mom and post partum for baby
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How does acute fatty liver of pregnancy present?
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Fatigue, nausea and vomiting abdo pain in the epigastrium and RUQ increased aminotransferases, bilirubin and decreased glucose and evidence of DIC. Treat with aggressive fluid, glucose and delivery
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What is Budd Chiary syndrome?
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Venous outflow obstruction above the level of the venules
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How is biliary colic diagnosed?
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Clinically in conjunction with stones in the GB
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What are common complications of biliary colic?
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M-W tear
electrolyte imbalance cholangitis |
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What is acute cholecystitis?
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A sudden inflammation of the GB
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Should antibiotics be given for cholecystitis?
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Yes, a single broad spectrum 2nd or 3rd generation cephalosporin
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When is acalculous cholecystitis most common?
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Elderly persons
Recovery from non-biliary tract surgery |
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What patient population has presented with acalculous cholecystitis recently? Why?
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AIDS (advanced) secondary to infection with CMV or Cryptosporidium
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What are causes of cholangitis?
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Common duct blockage by a gallstone
Malignancy Benign stricture |
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What are the most common organisms involved in cholangitis?
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Ecoli
Klebsiella Bacteroides Enterococcus |
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What is Charcot's triad?
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RUQ pain
fever Jaundice |
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What is Raynaud's pentad?
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AMS
Hypotension Fever RUQ pain Jaundice |
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What is the most helpful sign to distinguish cholecystitis from cholangitis?
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Jaundice
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What US finding distinguishes cholecystitis from cholangitis?
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Dilated CBD or intrahepatic ducts
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What is reasonable empiric treatment for cholangitis?
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Pip-tazo
Timentin Imipenem Extended cephalosporin + flagyl + ampicillin |
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What is the key to successful treatment of cholangitis?
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Decompression through transhepatic cholangiography, ERCP or surgery
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What is chronic pancreatitis?
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Ongoing inflammation of the pancreas interrupted by spells of acute pancreatitis
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What is the most common cause of pancreatitis in children?
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Trauma
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How long does it take for pseudocysts to develop?
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4-6 weeks
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What causes loss of intravascular fluid in pancreatitis?
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Bowel wall edema and ascites
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What are the 2 main causes of pancreatitis?
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Gallstones and alcohol
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What are etiologies of pancreatitis?
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Toxic (alcohol, scorpions, drugs)
Metaboli (Hypercalcemia and triglyceridemia) Obstructive (biliary, tumors, ERCP) Infectious (Coxsackie B and mumps) DKA, Crohns, lupus, HIV |
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What are metabolic complications of pancreatitis?
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Hypocalcemia
Hyperglycemia |
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Which patients may have false negative amylase?
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Alcoholic
Chronic Pancreatitis Hypertriglyceridemia |
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How long does it take for lipase to increase in pancreatitis?
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4-8 hours
increase lasts 8-14 days |
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Is the degree of amylase or lipase elevation a marker of disease severity in pancreatitis?
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No!
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Why does pancreatitis cause hyperglycmia?
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Glucagon and insulin abnormalities
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What lab test suggests a biliary cause of pancreatitis?
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ALT 3x normal
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When are Ranson's criteria not accurate?
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In patients with AIDS secondary to HIV changes in Ca++ and LDH
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What are components of Ranson's criteria at admission?
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Age >55
WBC >16 LDH >350IU/L AST >250 Glucose >11mmol/L LEGAL (LDH, enzyme-AST, Glucose, Age, Leukocytes) |
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What other criteria are useful for pancreatitis prognostication?
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APACHE II
>8 severe disease >13 high likelihood of death |
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When should an US be done in pancreatitis?
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Within 24 hours of admission
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Why should you CT a patients with pancreatitis?
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1- identify other causes of abdo pain
2 - complications (hemorhhage, abscess, pseudocyst) 3 - staging |
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When should CT be done in pancreatitis?
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Uncertain diagnosis
Severe disease Ransons >3 or APACHE >8 no improvement in 72 hours acute deterioration |
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What is the CT protocol for pancreatitis?
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CT with oral and IV contrast
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Should hyperglycemia be treated in pancreatitis
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Cautiously as it may resolve with resolution of the pancreas
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How do you treat hypocalcemia in pancreatitis?
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Ensure that it is true hypocalcemia (ionized)
correct K+ Ca++ gluconate |
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What radiographic finding is pathognomic of chronic pancreatitis?
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Pancreastic calcifications
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What are long term complications of chronic pancreatitis?
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Malabsorption
Diabetes |
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What is simple obstruction?
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intestinal lumen is completely or partially occluded in one or more areas without compromise of vascular compromise
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What is a closed loop obstruction?
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A segment of bowel is obstructed sequentially at 2 sites usually twisting and compromising blood flow
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What is an adynamic ileum?
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intestinal contents fails to pass because of disturbances in gut motility (aka neurogenic/functional)
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What are causes of adynamic ileum?
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Abdo trauma
medications infection laparotomy metabolic disease renal colic skeletal injury |
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What are causes of SBO?
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Intrinsic
-IBD -congenital -neoplasms -intussusception -trauma Extrinsic -hernia -adhesion -volvulus -compressive mass Intraluminal -FB -gallstones -ascaris -bezoars -barium |
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What is the cause of 90% of intusussception in adults?
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mechanical cause (tumors etc.)
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What are the features of proximal vs distal SBO?
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Proximal - colicky abdo pain with vomiting and distention
Distal - progressively worsening pain with abdo distention |
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What are radiographic findings of SBO?
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dilated loops of bowel proximally, collapsed bowel distal
step ladder arrangement of bowel loops string of pearls or string of beads |
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What is the managment of SBO?
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-fluid resuscitation
-bowel decompression -early surgical consult |
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What is pseudo-obstruction?
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Poorly understood dysfunction in intestinal motility associated with amyloidosis, collagen vascular disease, hypothyroid, DM, metabolic problem (hypokalemia, hypocalcemia)
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What are the causes of mesenteric schema?
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-arterial embolus
-arterial thrombosis -non occlusive mesenteric ischemia -mesenteric vein thrombosis |
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What vessel do most mesenteric arterial emboli involve?
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the SMA - the source of which is usually the heart
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What are RF fro mesenteric arterial embolus?
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CAD (post myocardial infarction mural thrombi or CHF)
Valvular hear disease (rheumatic MV or non-bacterial endocarditis) Arrhythmia -> chronic afib AD Aortic aneurysm Coronary angiography |
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What is the most common area for mesenteric thrombus formation?
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SMA
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What are factors associated with non occlusive mesenteric schema?
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CV disease
preceding hypotensive episodes drug induced splanchnic vasoconstriction digoxin, cocaine, vasopressors, ergot |
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What are factors associated with mesenteric venous thrombosis?
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Hypercoagulable state (PCV, SCD, antithrombin III deficiency, Protein C or S deficiency, malignancy, Myeloproliferative disorder, estrogen therapy, pregnancy)
Inflammatoy condition (pancreatitis, cholangitis, appendicitis, diverticulitis) Trauma (blunt or abdo trauma, postsplenectomy, operative venous injury) Miscellaneous (CHF, Renal Failure, decompression sickness, portal HTN) |
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What is the gold standard for mesenteric schema?
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angiography
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What is the classification of haemorrhoids?
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1st - protrudes into the lumen but no prolapse
2nd - prolapse during defecation but spontaneously reduces 3rd - prolapse spontaneously, manually reducible 4th prolapse spontaneously not manually reducible |
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What treatment can you offer patients with thrombosed haemorrhoids?
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Nifedipine 0.3% with lidocaing 1.5% topical BID for 2 weeks
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What is the most common form of anorectal abscess?
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perianal
|
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What are the 5 different types of abscess?
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perianal
ischiorectal intersphincteric supralevator post-anal |
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What is a fistula?
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Connection between two epithelial lined surfaces
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What are causes of fistulas
|
anorectal abscess
Crohn's trauma TB CA FB reaction |
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What is perianal hydradenitis suppurativa?
|
infection of the apocrine glands
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What are causes of proctalgia?
|
levator ani syndrome
proctalgia fugax |
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What is levator ani syndrome?
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Dull pain in the sacrococcygeal region post defecation or prolonged sitting
Ttx with sitz bath |
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What is proctagia fugal?
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An intensely painful spasm that begins suddenly in the rectal area and lasts for several minutes
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What is procidentia
|
rectal prolapse
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What are possible etiologies of invasive bacterial enteritis?
|
Campylobacter
Salmonella Shigella Yersinia Vibrio parahaemolyticus Ecoli 0157:H7 Plesiomonas Bacillus Anthracis Aeromonas |
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What is the source of campylobacter?
|
Contaminated food/water, chickens, backpackers diarrhea
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Which invasive entritides can mimic appendicitis?
|
campylobacter and yersinia
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What is the cause of salmonella
|
eggs, poultry, unpasteurized milk, domestic animals
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What is a sequelae of yersinia enteritis
|
There can be a post-infection arthritis. THere is a long duration of fecal excretion of the organism and the diarrhea can last up to 14 days
|
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What causes vibrio parahaemolyticus?
|
raw or inadequately cooked seafood especially shrimp
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What are untreated features of Ecoli O157:H7?
|
Blood diarrhea/hemorrhagic colitis and HUS/TTP
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What are the features of HUS and TTP
|
microangiopathic hemolytic anemia, thrombocytopenia, neurologic deficits and renal dysfunction
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What are the differences between HUS and TTP?
|
In TTP the neurologic findings predominate and the renal dysfunction is unusual and in HUS the opposite is true and it is more common in children
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What are the features of ingested bacillus antracis?
|
Oral ulcers, neck swelling, lymphadenopathy, fever, gastrointestinal hemorrhage and possible ascites
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What is used to treat gastrointestinal anthrax?
|
penicillin
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What are the possible etiologies of toxin-induced bacterial enteritis?
|
Preformed toxin
Staphylococcus Bacillus cereus (emetic and diarrheal toxin) scromboid fish poisoning Ciguatera Toxins produced after colonization Clostridium Perfringens Vibrio Ecoli enterotoxigenic (turista) Clostridium difficile aeromonas |
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How does gastroenteritis due to toxin-forming bacteria and viral agents manifest?
|
As an acute non-invasice enteritis with watery dairrhea, minimal fever, little or no abdominal crampong and absence of fecal leukocytes and erythrocytes
|
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What are typical causes of staphylococcal enteritis?
|
Food handler related, potato salad, mayonnaise confections
|
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What causes scromboid fish poisoning?
|
Mahi mahi, tuna, blue fish
|
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What are symptoms of scromboid?
|
peppery/metallic/bitter taste, symptoms are similar to histamine intoxication and can be treated with H1 and H2 blockers
|
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What are symptoms of ciguateral poisoning?
|
GI and neuro symptoms: paresthesias, dysesthesias, cold allodynia, confusion. Treated with IVF, atropine and TCAs
|
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What organism mimics the presentation of IBD?
|
Aeromonas
|
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What is the treatment of campylobacter diarrhea?
|
Erythromycin
|
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What is the treatment of salmonella diarrhea?
|
Cipro
|
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What is the treatment of Shigella diarrhea?
|
Cipro
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What is the treatment of yersinia diarrhera?
|
TMP-SMX
|
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What is the treatment of vibrio parahaemolyticus diarrhea?
|
Not recommended
|
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What is the treatment of vibrio cholerae diarrhea?
|
Ciprofloxacin
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What is the treatment of Ecoli O157H7 diarrhea?
|
NOt recommended
|
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What is the treatment of enterotoxigenic E coli?
|
Cipro 500mgPO BID x 3days
|
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What is the treatment of plesiomonas hominis diarrhea and aeromonas?
|
TMP-SMX
|
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What is the treatment of bacillus anthracis diarrhea?
|
Cipro or doxy
|
|
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What is the treatment of giardia lamblia?
|
Metronidazole
|
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What is the treatment of entamoeba histolytica (confirmed by PCR assay)
|
Paromycin
|
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What is the treatment of cryptosporidium?
|
Paromycin (14-21 days)
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What is the treatment of enterobius vermicularis?
|
Mebendazole (one dose)
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What are the most common etiologies of diarrhea in patients with AIDS?
|
Cryptosporidium and CMV
|
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What are the distinguishing features of protozoal enteritis?
|
As a group parasitic pathoges are associated with more prolonged illness than bacterial or viral pathogens. These should be considered in patient with diarrhea that persists longer than 2 weeks especially in immunocompromised persons, traveler and residents of developing countries
|
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What are causes of protozoal gastroenteritis?
|
Entamoeba histolytica
Giardia Lamblia Cryptosporidium Cyclospora cayetanensis Strongyloides Enteromonas hominis |
|
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What is the source/risk factor for stongyloides stercoralis?
|
Occupational exposure to soil in endemic areas (Kentucky, Tennessee, West Virginia)
|
|
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What is the treatment of strongyloides?
|
Ivermectin
|
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What is the etiology of diarrhea in patients with AIDS?
|
Most Common
cryptosporidium CMV Common Entamoeba histolytica Giardia Lamblia MAC Salmonella Aeromonas C difficile Campylobacter jejuni |
|
|
What is the initial evaluation of diarrhea in patients with AIDS?
|
In patients with CD4 count less than 300/mm3 they should all have
1)stool cultures for enteric bacteria 2) Stool examination for giardia, cryptosporidium, isospora, cyclospora, mycobacteria and c-difficie 3) blood cultures 4) proctosigmoidoscopy |
|
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What are the possible etiologies of traveler's diarrhea?
|
Enterotoxigenic E coli
Shigella Campylobacter Enteroinvasive Ecoli Salmonella Rotavirus Norwalk Giardia Cryptosporidium Entamoeba histolytica |
|
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What is the prevention and treatment of traveler's diarrhea?
|
Only immunocompromised patients should take preventative therapy which involves cipro 500mgPO QD and pepto-bismol. They should begin on the day before travel and continue 2 days after returning home.
Non immunocompromised patients should be instructed to take cipro 750mg PO and loperamide at the onset of diarrhea. Those with symptoms of dysentry - high fever, bloody stools or the typical bacterial or invasive picture - cipro 500mg POBID for 3 days. Those who fail to respond should be switched to azithromycin |
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What are the Rome II criteria for IBS?
|
abdo pain or discomfort for 12 weeks of longer within the past year and 2 of the following
1)relief of discomfort with defecation 2)association of dicomfort with altered stool frequency 3) association of discomfort wiht altered stool form |
|
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What are medications used to treat IBS?
|
Osmotic laxatives
antidiarrheals antispasmodics TCA Serotonin receptor antagonists prokinetic agents female hormone modulating agents tranquilizers |
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What is complicated diverticulitis?
|
The presence of more extensive disease including abscess formation, peritonitis, intestinal obstruction or fistula formation
Essentially any extension of disease beyond the pericolonic fat. |
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How should you evaluate patients with complicated diverticulitis?
|
abdominal CT
|
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What is oral antibiotic therapy for uncomplicated diverticulitis?
|
TMPSMX ds and flagyl
Cipro and flagyl Amox-clav extended release All for 7-10 days |
|
|
What is appropriate IV coverage for diverticulitis?
|
Mild to moderate disease
Timentin Ampi-sulbactam Cipro Severe Ampicillin and flagyl and genta or cipro imipenem |
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What should be done in all patients with diverticulitis?
|
All patients should undergo and evaluation for colon cancer when the acute episode has resolved.
|
|
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What is the most common cause of LBO?
|
colorectal CA
|
|
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What are causes of LBO?
|
colorectal CA
volvulus diverticular disease fecal impaction strictures adhesions hernia |
|
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What is pseudo-obstruction of the large bowel or Ogilvie's syndrome?
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LBO in which no obstructing lesion can be identified.
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What is the hallmark of LBO on plain radiography?
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a distended colon
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Which causes of LBO are dealt with surgically?
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Carcinoma
cecal volvulus strictures intussusception adhesions hernias |
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What is the first step in management of sigmoid volvulus?
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If clinical evidence of gangrenous bowel is lacking then endoscopic detorsion should be attempted
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what is the management of cecal volvulus?
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surgical detorsion
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What is the hallmark of toxic megacolon?
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Colonic dilatation in a patient with a known inflammatory condition of the colon who appears systemically toxic
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What clinical findings are more suggestive of appendicitis in females?
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-migration of pain and tenderness localized to the RLQ
-anorexia -normal or minimally abnormal findings on pelvic physical exam |
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What clinical findings are suggestive of PID?
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Several days of symptoms
hunger hx of PID diffuse lower abdominal pain bilateral adnexal tenderness CMT vaginal discharge |
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What increases the complication rate in appendicitis?
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Perforation (increased by 3- fold) it can result in local wound infection and deep abscesses
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When are diagnostic scores inaccurate in appendicitis?
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In female patients
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What is a diagnostic finding for appendicitis on US?
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Non-compressible appendix with a diameter of >6-7mm
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What is the anatomical landmark that differentiates UGIB from LGIB?
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The ligament of Treitz
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What causes the majority of UGIBs in adults?
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PUD
gastric erosions varices |
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What causes the majority of LGIB?
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Diverticulosis
Angiodysplasia |
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What causes massive LGIB in children?
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Meckel's diverticulum or intussusception
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Which GI bleeds should receive immediate consultation?
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Persistently unstable
UGIB-> GI LGIB-> surgery |
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What is the etiology of UGIB in adults?
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PUD
gastric erosions varices M-W tear Esophagitis duodenitis |
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What is the etiology of LGIB in adults?
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Diverticulosis
Angiodysplasia UGIB Cancer Rectal disease IBD |
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Can you determine if vomited blood is arterial or venous?
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No, the color does not differentiate between arterial or venous
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Does bismuth cause FOB+
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No, it just causes black stool
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What causes false + FOB?
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Cantaloupe, grapefruit, figs, radish, cauliflower, broccoli, red meat, methylene blue, chlorophyll, cupric and bromide
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What can cause a false negative FOB?
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Mg++ containing antacids
ascorbic acid bile |
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What are potential complications of NG tube placement?
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Pharyngeal perforation
Esophageal perforation Cardiac arrest ethmoid sinus # |
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HOw is gastric lavage done?
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Ewald tube (pass orally)
LLD position Irrigant (tap water) delivered and removed by gravity 200-300cc until clear |
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Which patients will benefit from anoscopy/proctosigmoidoscopy?
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mild rectal bleeding with no obvious external haemorrhoids (this will allow you to look for internal haemorrhoids)
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What is the managment of internal haemorrhoids?
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In the absence of portal hypertension discharge with appropriate hemorrhoid treatment
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When should you perform angiography for GIB?
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During active bleeding, this may facilitate arterial embolization
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What test can be done for patients with indolent/elusive bleeding?
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Nuclear isotope-tagged rbc scan
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What is the dose of octreotide in varices and it's use?
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Use it in documented esophageal varices with acute UGIB
25-50ug/hr x 24 hours (possibly also in LGIB secondary to angiodysplasia) |
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When can vasopressin be added to UGIB treatment and what is the dose?
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Exsanguinating patients with suspected variceal bleed and no endoscopy available. 20U over 20 minutes then 0.2-0.4U/min
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What are criteria for very low risk GI bleed?
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No comorbid disease
normal VS normal or trace + FOB negative gastric aspirate (if done) normal or near normal Hgb good support Proper undertanding of signs and symptoms Immediate access to urgent care f/u in 24hours |
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What are the low risk GI bleed patients as determined by the GBS system
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absence of liver failure
absence of syncope absence of cardiac disease absence of melena SBP >120mmHg pulse <100bpm ureal <6.5mmol/L Hgb >130g/L(men) and >120g/L in women |
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Is the GBC clinical prediction rule useful?
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It has bee n shown to be accurate in at least one large prospective multicenter study. No impact study has been done.
It still needsto be externaly validated. a modified BRS score (no urea or syncope data recorded) has been validatd in a Canadian population presenting during daytime hours. |
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What are the etiologies of upper GI bleeding in children?
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Esophagitis
Gastritis Ulcer Esophageal varices Mallory Weiss tear |
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What are the etiologies of lower GI bleeding in children?
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anal fissure
infectious colitis IBD Polyps Intusussception |
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Why is BUN elevated in patients with GI bleed?
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Absorption of blood from the GI tract
Hypovolemia causing prerenal azotemia |
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What serum bilirubin level causes clinical jaundice?
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~43umol/L
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What are the 3 main diagnostic categories for jaundice?
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Hematologic disorder
Liver injury or dysfunction Biliary obstructive disorders |
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What does rapid onset hepatomegaly and ascites suggest?
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Budd Chiari syndrome
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What are physical exam findings in liver disease and cirrhosis?
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Spider angiomas
Gynecomastia Testicular atrophy Caput medusae Excoriations/Jaundice Asterixis AMS Hepatomegaly Ascites |
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What is empiric antibiotic treatment for SBP?
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3rd generation cephalosporin
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What are the clinical stages of hepatic encephalopathy?
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Grade I - disordered sleep, irritability, depression, mild cognitive dysfunction
Grade II - lethargy, disorientation, confusion, personality changes Grade III - somnolence or marked disorientation, confused speech, inability to follow commands Grade IV - coma |
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What are critical causes of jaundice?
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Hepatic:
Fulminant hepatic failure Toxin Virus Alcohol Ischemic insult Reye's syndrome Biliary: cholangitis Systemic: sepsis heat stroke Cardiovascular; Obstructing AAA Budd-chiari severe CHF Hematologic-oncologic: transfusion reaction Reproductive: Preeclampsia/HELLP Acute fatty liver of pregnancy |
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What are emergent causes of jaundice?
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Hepatic:
Hepatitis Wilson's Primary biliary cirrhosis Autoimmune hepatitis liver transplant rejection Infiltrative liver disease Drug-induced (INH, phenytoin, APAP, ritonavir, inflammation, halothane) Biliary: bile duct obstruction (stone, inflammation, stricture, neoplasm) Systemic: sarcoidosis Amyloidosis GvHD CV: right sided CHF Veno-occlusive disease Hematologic: Hemolytic anemia Massive malignant infiltration inborn error of metabolism Pancreatic head tumor Pregnancy: Hyperemesis gravidarum |
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What is Reye's syndrome?
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Potentially fatal disease affecting primarily the brain and liver
Causes hypoglycemia |
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What is obstipation?
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When constipation becomes severe with constant pain; represents progression towards bowel obstruction
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What diagnoses should you consider in a patient with diarrhea?
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GI bleed
Ischemic Bowel Appendicitis Ectopic Bowel Obstruction Heavy Metal ingestion Plant/fish borne toxins Toxic exposures (cholinergics, sympathomimetics) Adrenal insufficiency Hyperthyroidism Diabetic enteropathy Hormone secretion tumors |
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What is Boerhaave's syndrome?
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Esophageal perforation as a result of forceful vomiting or straining
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Where does the tear typically occur in Boerhaave's?
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Left posterolateral aspect of the distal esophagus
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What are the xray findings of esophageal rupture?
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Subcutaneous emphysema
Pneumomediastinum Mediastinal widening Pleural effusion Pulmonary infiltrate |
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What is the pro of barium as a contrast agent?
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It is superior in identifying small perforations
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What medications commonly cause pill esophagitis?
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Antibiotics (tetracyclines)
antivirals ASA NSAID KCl Pamidronate |
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What are causes of GERD
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Anticholinergic
Caffeine Chocolate Estrogen EtOH Nicotine Fatty foods Progesterone Pregnancy |
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What are the complications of cirrhosis?
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Hepatorenal syndrome
Hepatopulmonary syndrome encephalopathy Ascites SBP Portal vein thrombosis Hepatocellular carcinoma |
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What is the management of hepatic encephalopathy?
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DC CNS depressant meds
Correct electrolyte abnormalities and hypoglycemia Neomycin Lactulose Protein restriction |
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Which patients with hepatic encephalopathy can be managed at home?
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Grade I and II
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What high risk features in patients with ascites mandate antibiotic prophylaxis for SBP?
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Prev history of SBP
Serum BT >55umol/L Platelet <98 Ascitic fluid protein levels <1g/dL |
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What bacterial are responsible for SBP? What is empiric therapy?
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Ecoli
Klebsiella Strep Staph Cefotaxime 2g IV q8 |
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What common drugs can cause hepatic injury?
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APAP
Salicylate Amiodarone BCP Haloperidol INH Ketoconazole Methotrexate Carbamazepine Phenobarbital Phenytoin |
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What are the RF for cholelithiasis?
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Age
Female Obesity Rapid weight loss Cystic fibrosis Parity Drugs History |
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What types of stones can form in the biliary tract?
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Cholesterol
Black stones (associated with intravascular hemolysis) Brown stones (associated with infection) |
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What are the complications of cholecystitis?
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Gangrene and perforation
Pericholecystic abscess Pericholecystic fistula Emphysematous cholecystitis Gallstone ileus |
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What are early complications of pancreatitis?
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Sepsis
Shock Acute renal failure Coagulopathy Pulmonary complications (ARDS) Metabolic complications (hyperglycemia and hypocalcemia) |
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What are late complications of pancreatitis?
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Abscess
Pancreatic pseudocysts Fistula formation GI bleeding from stress ulcers Splenic vein thrombosis splenic rupture |
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What are long term complications of pancreatitis?
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Chronic pancreatitis
DM Digestive and malabsorption problems |
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What are the grades of pancreatitis on CT?
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Grade A - normal pancreatitis consistent with mild pancreatitis
Grade B - focal or diffuse pancreatic enlargement without peripancreatic inflammation Grade C - Grade B + peripancreatic inflammation Grade D - Grade C + a single fluid collection Grade E - Grade C + >/=2 peripancreatic fluid collections or gas |
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What are Ransons criteria within 48 hours of admission?
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Hematocrit fall >10%
BUN rise >1.8mmol/L Calcium <2mmol/L PO2 <60mmHg Base deficit >4mEq/L Fluid sequestration >6L |
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What are the Atlanta criteria for predicting severe acute pancreatitis?
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One or more of the following:
Ranson >3 at admission or in the 1st 48 hours Apache II >8 Presence of organ failure (shock, pulmonary insufficiency, renal failure) Systemic complications (DIC or metabolic(Ca++) Presence of one or more local complications (pancreatic necrosis, pancreatic abscess, pancreatic pseudocyst) |
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What abdo organs does the celiac artery supply?
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Esophagus, stomach, proximal duodenum, liver, GB, pancreas, and spleen
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What abdo organs does the SMA supply?
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Distal duodenum, jejunum, ileum and colon to the splenic flexure
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What abdo organs does the IMA supply?
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Descending and sigmoid colon and rectum
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What are physical signs suggestive of appendicitis?
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Increased abdo pain with coughing
Tenderness over McBurney's point Rigidity Guarding Rovsing's sign (palpation of the LLQ causes pain in the RLQ) Psoas sign (pain with extension of the hip) Obturator sign (pain with hip flexion and external rotation) Rebound tenderness |
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What is the differential diagnosis of appendicitis in children?
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Henoch Schonlein
Testicular Torsion Epiploic appendigitis Mesenteric Adenitis Meckel's diverticulum |
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What is the management of pseudo-obstruction?
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Bowel rest, hydration, treat comorbidities
Consider neostigmine Surgery only for refractory cases |
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What is the appearance of sigmoid volvulus on X-ray?
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Large dilated colon lacking haustra - may be on the left or right side
Bird's beak appearance |
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What is the appearance of cecal volvulus on X-ray?
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Marked dilation of the cecum
Coffee bean sign Comma shaped cecal shadow |
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When is thumbprinting seen on X-ray?
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Colonic ischemia
IBD Colonic infections Hemorrhage |
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What is radiation protocolitis?
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a side effect of radiation
May be acute or chronic Managed supportively, steroid enemas and water absorbing stool softeners |
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What is the management of hemorrhoids?
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Warm water
Analgesics Stool softeners High-fiber diet |
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When is emergency hemorrhoidectomy required?
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thrombosed or gangrenous 4th degree internal hemorrhoids
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What should you consider if an anal fissure is not in the posterior midline?
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Leukemia
Crohns TB HIV Syphilis |
