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533 Cards in this Set
- Front
- Back
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What are 8 signs/symptoms of GI disease?
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dyspepsia
nausea and vomiting hiccups constipation eructation flatus diarrhea GI bleeding |
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How is dyspepsia defined?
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pain or discomfort centered in the upper abdomen
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What are 8 symptoms that may be associated with dyspepsia?
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upper abdominal fullness
early satiety burning bloating belching nausea retching vomiting |
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What are 6 etiologies of dyspepsia?
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self-limited indigestion
luminal GI tract dysfunction H. pylori infections pancreatic disease biliary tract diseae functional dyspepsia |
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What is indigestion?
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related to eating too much or too quickly, eating high-fat foods, eating under stress, alcohol, too much caffeine, etc.
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What are 3 conditions that may cause luminal GI tract dysfunction which may lead to dyspepsia?
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gastroparesis
gastric cancer lactose intolerance |
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What is the most common cause of dyspepsia?
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functional dyspepsia
-arise from complex interaction of visceral afferent activity, delayed gastric emptying, psychosocial stressors |
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For dyspepsia, history has ___ diagnostic utility and physical examination is ___ helpful.
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limited
rarely |
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What is the study of choice for dyspepsia?
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upper endoscopy
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Which patients should always have an upper endoscopy?
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patients over age 45 with new symptoms or all patiets with weight loss, dysphagia, or recurrent vomiting
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What type of testing should be done for H. pylori?
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noninvasive testing
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What type of testing should be done for pancreatic or biliary tract disease?
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abdominal imaging (CT)
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What is nausea?
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vague intensely disagreeable sensation of queasiness, not necessarily associated with vomiting
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What stimulates vomiting?
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medullary vomiting center
-afferent vagal fibers from GI -fibers of vestibular system -high CNS centers (sights, smells, emotions) -chemoreceptor trigger zone (chemotherapy) |
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What are 6 complications of vomiting?
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dehydration
hypokalemia metabolic alkalosis aspiration rupture of esophagus bleeding |
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What are 4 conditions that acute N/V without pain may be do to?
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food poisoning
infectious gastroenteritis cholecystitis drugs |
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What are 3 conditions that acute N/V with severe pain may be due to?
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peritoneal irritation
acute obstruction biliary disease |
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What are 5 conditions that may cause persistent vomiting?
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pregnancy
gastric outlet obstruction gastroparesis psychogenic disorders CNS disorders |
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What does vomiting after meals suggest?
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bulimia
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What are 2 conditions that vomiting undigested food 1-3 hours after meals suggests?
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gastroparesis
gastric outlet obstruction |
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What are 7 special examinations that can be done for N/V?
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-abdominal films (assess acute onset w/ severe pain)
-NG tube placement (symptom relief) -upper endoscopy -barium radiography -nuclear scintigraphy -abdominal CT scan -head CT/MRI (CNS causes) |
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What is singultus?
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hiccups
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What are 7 benign causes of hiccups?
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gastric distension
carbonated beverages air swallowing overeating sudden temp. changes alcohol ingestion heightened emotion |
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What are 5 causes of recurrent/serious hiccups?
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CNS
metabolic irritation of vagus/phrenic nerve surgical psychogenic idiopathic |
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What are some treatment options for benign hiccups? (5)
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irritation of nasopharynx
interruption of breath cycle vagus nerve stimulation diaphragm irriation gastric distension relief |
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What is the "normal" range of BM's per week?
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3-12
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How is constipation defined?
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2 or fewer BMs per week or excessive straining with defacation
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What are 4 common causes of constipation?
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poor diet
structural abnormalities (colonic lesions) systemic diseases medications |
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What are 2 medicines that can cause constipation?
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anticholinergics
opiods |
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How much fiber should an individual get per day?
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10-12g
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What are 3 causes of severe or refractory constipation?
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slow colonic transit
pelvic floor dysfunction irritable bowel syndrome |
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How should constipation be evaluated?
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history
physical exam occult blood in stool labs colonoscopy |
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What are 3 labs that can be done for constipation?
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CBC
chem panel serum TSH |
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What group of patients is colonoscopy indicated for involving constipation?
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patients over 50 or patients who fail a trial of fiber
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What is belching also known as?
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eructation
-usually not tied w/ a disease |
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What is eructation?
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involuntary or voluntary release of gas from the stomach or esophagus
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What are 4 common causes of eructation?
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rapid eating
gum chewing smoking ingestion of carbonated beverages |
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What is chronic excessive belching almost always caused by?
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aerophagia
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Are antacids and anti-gas medications useful for eructation?
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no
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What are the 2 sources that flatus is derived from?
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swallowed air
bacterial fermentation of undigested carbohydrates |
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What is initial recommended for increased flatus?
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lactose-free diet
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Do complaints of abdominal distension correlate with increased gas volumes?
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no
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What may help with flatus?
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beano :)
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How is diarrhea defined?
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stool weight >250g/24 hours
>2-3 BMs per day or increased liquidity of feces |
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How long does acute diarrhea usually last?
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less than 3 weeks
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What usually causes diarrhea? (3)
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infectious agent
bacterial toxin drugs |
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What are 2 types of acute diarrhea?
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noninflammatory
inflammatory |
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What is noninflammatory acute diarrhea?
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-watery, nonbloody, associated w/ periumbilical cramps, bloating, N/V
-usually a small bowel source |
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What does prominent vomiting with acute noninflammatory diarrhea suggest?
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viral enteritis or S. aureus food poisoning
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What is acute inflammatory diarrhea?
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-presence of fever and bloody diarrhea indicates colonic tissue damage
-invasion (shigellosis, salmonellosis, campylobacter, yersinia) -toxin (C difficile, E. coli) |
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What is tenesmus?
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feeling that you have to move your bowels but you don't
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What type of evaluation should be done if diarrhea is present for >7-10 days?
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stool should be sent for culture, fecal leukocytes, and ova and parasites
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What type of evaluation should be done for severe proctitis?
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sigmoidoscopy
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What are the 7 major pathophysiologic categories of chronic diarrhea?
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osmotic
secretory inflammatory malabsorption motility disorders chronic infections factitious diarrhea |
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What are the 3 most common causes of chronic osmotic diarrhea?
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lactase deficiency
laxative abuse malabsorption syndromes |
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When does chronic osmotic diarrhea resolve?
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during fasting
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How is chronic osmotic diarrhea characterized? (3)
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abdominal distension
bloating flatulence |
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What type of diarrhea may olestra cause?
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chronic osmotic diarrhea
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Does fasting help with secretory conditions of chronic diarrhea?
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no
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What are 3 causes of chronic diarrhea of secretory conditions?
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endocrine tumors
bile salt malabsorption laxative abuse |
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What is an inflammatory cause of chronic diarrhea?
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IBD
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What may also occur with inflammatory conditions of chronic diarrhea? (4)
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abdominal pain
fever weight loss mematochezia |
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What is the most common cause of motility disorders of chronic diarrhea?
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IBS
may be secondary to surgery or systemic disease |
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How can chronic diarrhea be evaluated?
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stool analysis
routine labs serologic testing for celiac sprue colonoscopy (mucosal biopsy) upper endoscopy (small intestine biopsy) abdominal CT endoscopic U/S (chronic pancreatitis barium radiography |
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What may be analyzed in a stool analysis for chronic diarrhea? (5)
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weight & fecal fat (24 hours)
osmolality laxative screen fecal leukocytosis ova and parasites |
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What are the routine labs that may be performed for chronic diarrhea? (5)
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CBC
chem panel liver function tests TSH PT |
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What is the most common presentation of upper GI bleeding?
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hematemesis (bright red or coffee grounds) or melena (black, tarry)
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What are 6 etiologies of upper GI bleeding?
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peptic ulcer disease (half of upper GI bleeds)
portal HTN Mallory-Weiss tears vascular anomalies gastric neoplasms erosive gastritis/esophagitis |
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What should be done for initial evaluation of upper GI bleeding?
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*hemodynamic stabilization
large bore IVS (type/match blood) NG tube blood/fluid replacement preliminary risk assessment |
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What is the first step in initial evaluation of upper GI bleeding?
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hemodynamic stablilization (Airway, Breathing, Circulation)
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What are 3 reasons an upper endoscopy should be done for upper GI bleeding?
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identify source
determine re-bleeding risk render therapy (cautery, injection, sclerosis/binding of varices) |
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Where does lower GI bleeding arise?
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below the ligament of Treitz
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Does upper or lower GI bleeding tend to have a more benign course?
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lower GI bleeding
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What are 6 etiologies of lower GI bleeding?
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diverticulosis
vascular ectasias neoplasms IBD anorectal disease ischemic colitis |
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Describe vascular ectasias?
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-painless bleeding
-flat, red lesions w/ ectatic peripheral vessels -most common in patients > 70 years |
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What are neoplasms?
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benign polyps and carcinoma
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What are 2 "signs" that may occur with anorectal disease?
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hemorrhoids
anal fissures |
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What is ischemic colitis?
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-bowel ischemia
-most bleeding is mild & self-limited -older patients with atherosclerotic disease |
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How is lower GI bleeding evaluated?
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asses color of blood/stool
exclude upper GI source anoscopy/sigmoidoscopy colonoscopy capsule imaging nuclear bleeding scans angiography |
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What are 2 reasons that a colonoscopy will be performed for lower GI bleeding?
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-performed urgently in patients w/ ongoing bleeding and 6-24 hours for others
-colonic lavage to clear colon |
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What are 4 esophageal symptoms?
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dysphagia
heartburn odynophagia atypical chest pain |
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What are 2 types of dyspagia associated with esophageal symptoms?
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oropharyngeal
esophageal (solids vs. everything) |
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What is GERD characterized by?
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recurrent heartburn
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Do more men or more women have GERD?
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men
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Is whites or blacks more common for GERD?
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whites
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What is the pathophysiology of GERD?
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gastric contents reflux into the esophagus and remain long enough to overcome the resistance of esophageal epithelium
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What are 2 symptoms of GERD?
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recurrent heartburn
dysphagia (red flag) |
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What may dysphagia with GERD indicate?
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peptic stricture or adenocarcinoma
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How is the damage of GERD best assessed?
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endoscopy
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What are 7 signs of GERD?
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erythema
edema friability (easily torn) erosions ulcers strictures Barrett's esophagus |
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What are 9 extraesophageal manifestations of GERD?
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pharyngitis, earache, laryngitis, globus sensation, gingivitis, eroded tooth enamel, chronic cough, asthma, aspiration pneumonia
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What determines the diagnosis of GERD?
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Hx of recurrent heartburn + positive response to acid-suppressant medication
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What is the gold standard for identifying reflux?
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esophageal pH monitoring
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What are 4 tests that can be done for reflux?
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upper GI series (barium swallow)
esophageal pH monitoring esophageal manometry upper endoscopy *reserved for "red flag" symptoms of dysphagis, weight loss, or GI bleeding |
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GERD usually remains stable for long periods of time with short periods of exacerbation and ___.
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remission (usually comes back once you stop medication)
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What are 2 major complications of GERD?
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peptic stricture (lumen is narrowing)
Barrett's esophagus |
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What is Barrett's esophagus?
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normal squamous epithelium is replaced by specialized columnar epithelium; no symptoms; increases risk of adenocarcinoma
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How is GERD treated?
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goal is to relieve symptoms and prevent complications (lifestyle modifications)
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What are lifestyle modifications that can be done to help relieve
GERD? |
elevate head of bed 6+ inches
stop smoking decrease EtOH decrease dietary fat smaller meal size avoid eating before bed weight reduction as needed avoidance of "fun foods" ;) avoidance of drugs that relax LES |
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What type of drugs relax the LES, worsening GERD?
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anticholinergics
diazepam (Valium) narcotics progesterone beta blockers CCB's |
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What type of "fun stuff" ;) should be avoided with GERD to help relieve symptoms?
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chocolate
mints coffee tea cola acidic foods |
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What type of drug therapy can be done for GERD?
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antacids (Tums, Maalox)
H2 blockers (Zantac, Pepcid) Prokinetics (Reglan) PPI (*Prilosec, Rrevacid, Nexium) |
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What is the surgical procedure of choice for GERD?
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laparascopic Nissen fundoplication (take fundus and wrap it around the esophagus)
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What are 3 indications for surgery with GERD?
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-alternative to medical maint. in young pts.
-means of controlling regurg -erosive disease not controlled by PPI's |
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What types of surgery can be performed on GERD patients?
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laparascopic Nissen fundoplication
Stretta & EndoCinch (endoscopy) dilation of strictures |
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What is the therapy plan for Barrett's esophagus?
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smoking & EtOH cessation to reduce risk of cancer
endoscopic surveillance (every 2-3 years) esophagectomy (w/ high-grade dysplasia) Tx same as for GERD |
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What are the 3 most common agents of infectious esophagitis?
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Candida albicans
HSV-1 CMV *most commonly in immunocompromised pts |
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What are 4 clinical manifestations of infectious esophagitis?
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odynophagia
dysphagia weight loss GI bleeding |
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How can infectious esophagitis be diagnosed?
|
barium swallow
viral cultures or biopsy required for definitive diagnosis |
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What are 3 "clues" that show up with barium swallow for infectious esophagitis that may point to the particular causative agent?
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candida-"shaggy" mucosa
HSV-numerous small, volcano-shaped ulcers CMV-deep linear ulcers |
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How is candidal esophagitis treated?
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non-Aids: oral nystatin or clotrimazole tablets
Aids: azole (oral/IV fluconazole or amphotericine IV) |
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How is HSV esophagitis treated?
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oral acyclovir
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How is CMV esophagitis treated?
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IV ganciclovir
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What are 5 other causes of esophagitis besides the common agents?
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alkaline reflux (uncommon)
pill-induced radiation eosinophilic (topical food allergy) caustic (accident/suicide) |
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What are 4 types of esophageal motor disorders?
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achalasia
diffuse esophageal spasm scleroderma nutcracker esophagus |
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What is the most common primary esophageal motor disorder?
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achalasia (etiology unknown)
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What is achalasia?
|
an esophageal motor disorder that has degeneration of the nerves in Auerbach's plexus
-inc. LES pressure -incomplete relaxation of LES w/out swallowing -complete aperistalsis in the esophageal body |
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What is the primary complaint of achalasia?
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dysphagia for liquids and solids
regurgitation is common |
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What does a barium swallw for achalasia show?
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dilated esophagus and tapered "bird's beak" deformity at LES
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How can achalasia be treated?
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muscle relaxant before meals may help
Tx-endoscopic injection of botox onto LES, pneumatic dilator, or surgical Heller myotomy |
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On barium swallow, what does diffuse esophageal spasm show?
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"corkscrew" esophagus
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What are the symptoms of diffuse esophageal spasm?
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chest pain and/or dyspagiea (pt may come in complaining of a heart attack)
uncommon motor disorder |
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How is diffuse esophageal spasm treated?
|
supportive
-assure pt that it is benign -smooth muscle relaxants |
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What is the most commonly involved GI organ of scleroderma?
|
esophagus
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What are the 3 symptoms of scleroderma (esophageal motor disorder)?
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dysphagia
regurgitation heartburn |
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How should esophageal scleroderma pts be treated?
|
prophylactically for GERD
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What is nutcracker esophagus?
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normal peristalsis but with contractions of very high amplitude; relatively common pattern in pts w/ noncardiac chest pain
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What do pts with nutcracker esophagus commonly exhibit signs/symptoms of?
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depression and anxiety
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How is nutcracker esophagus treated?
|
treating depression/anxiety:
Amitriptyline Imipramine Trazodone Clonazepam |
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What are some factors that increase the risk of esophageal squamous cell carcinoma? (7)
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heavy tobacco/EtOH use, papillomavirus, lye ingestion, achalasia, celiac disease, radiation exposure
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What is the clinical presentation of esophageal squamous cell carcinoma? (3)
|
rapidly progressive dysphagia, anorexia, weight loss
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How is the diagnosis of esophageal squamous cell carcinoma made?
|
barium swallow
confirmed by biopsy |
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How is esophageal squamous cell carcinoma treated?
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chemoradiation w/ or w/out surgery
low survival rate |
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What part of the esophagus is adenocarcinoma?
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usually distal esophagus
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What is the predominant risk of esophageal adenocarcinoma?
|
Barrett's esophagus
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What may improve the survival of esophageal adenocarcinoma?
|
chemo & surgery
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What are 4 symptoms that may occur with esophageal foreign bodies?
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neck pain
chest pain dysphagia odynophagia |
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What may occur with delayed removal of esophageal foreign bodies?
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ulceration
perforation stricture |
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How is esophageal foreign bodies diagnosed and removed?
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endoscopy (airway protection is essential during removal)
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What is gastritis?
|
inflammation of the gastric mucosa
|
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What are 3 types of gastritis?
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H. pylori
hemorrhagic infectious |
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What are 5 conditions of the GI that H. pylori is associated with?
|
gastritis
duodenal ulcer gastric ulcer gastric adenocarcinoma primary gastric B-cell lymphoma |
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When is H. pylori typically acquired?
|
childhood
-chronic, serious infection with long latent period -more common in less developed countries |
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What are the symptoms of H. pylori gastritis?
|
epigastric pain, N/V lasting a few weeks
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H. pylori gastritis causes progressive damage starting in the ___, then possibly explain to the entire ___ (pangastritis).
|
antrum
stomach |
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What is it called if H. pylori expands to the entire stomach?
|
pangastritis
-highest risk for gastric adenocarcinoma |
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How is H. pylori gastritis detected?
|
noninvasive modalities (serology, C-urea breath test, stool antigen testing)
endoscopy w/ biopsy |
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How is H. pylori gastritis treated?
|
cure of infection
-reduces risk of PUD and gastric cancer |
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What may H. pylori gastritis lead to?
|
atrophic gastritis
|
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What occurs with atrophic gastritis?
|
stomach becomes less acidic, leading to overgrowth of other bacteria and possible disappearance of H. pylori
|
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What are the 3 types of pts that erosive hemorrgagic gastritis is seen with?
|
-alkaline reflux after gastrectomy
-duodenogastric bile reflux -pts who take NSAIDs |
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Where is the pain with hemorrhagic gastritis and what other symptoms may be included?
|
midepigastric burning pain unresponsive to antacids
may include bilious vomiting, anemia and weight loss |
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How may hemorrhagic gastritis be partially prevented?
|
by simultaneous use of prostaglandin analogues (misoprostol) or suppression of gastric acid (like H2 blocker or PPI)
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Patients who abuse alcohol may have intramuscular hemorrhages that appear like what?
|
"blood under a plastic wrap"
|
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What has been implicated as a cause of gastric ulcers in normal hosts?
|
HSV-1
|
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What are 3 types of infectious gastritis that immunocompromised pts may have?
|
gastric TB
secondary syphilis CMV |
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What are the 2 most common causes of peptic ulcer disease?
|
NSAID use
H. pylori infection |
|
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What are gastric and duodenal ulcers associated with?
|
gastric-pangastritis
duodenal-antral predominant gastritis |
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What ages do duodenal and gastric ulcers commonly occur?
|
duodenal- 25-55 years old
gastric - 40-70 years old men>women |
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What seems to play a role in ulcerogenesis?
|
genetic factors
|
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What causes superficial mucosal damage (petechiae and erosions) in peptic ulcer disease?
|
stress
|
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What are 6 factors that increase stress ulcer risk?
|
mechanical ventilation > 5 days, coagulopathy, hepatic or renal failure, sepsis and shock
*greatly increased mortality |
|
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Is gastrinoma a common form of peptic ulcer disease?
|
no
|
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What are the symptoms of peptic ulcer disease?
|
may have no symptoms
burning epigastric abdominal pain after meals or at night and relieved with food or antacids |
|
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Is the physical exam useful for peptic ulcer disease?
|
not really
Unless: -perforated ulcer-shows signs of peritonitis (rebound tenderness/involuntary gaurding) -succession splash-retained gastric contents (pyloric stenosis) |
|
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How can peptic ulcer disease be differentiated from pancreatitis?
|
pancreatitis is more constant
|
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What is included in the differential for peptic ulcer disease?
|
nonulcer dyspepsia
GERD biliary tract disease pancreatitis intraabdominal neoplasms IBD IBS |
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What tests are used to make a definitive diagnosis for peptic ulcer disease?
|
upper endoscopy (more accurate, but costs more) or barium contrast radiography
|
|
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Duodenal ulcers are almost never ___ and gastric ulcers should be ___.
|
malignant
biopsied |
|
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How is peptic ulcer disease treated?
|
acid suppression help accelerate ulcer healing, but do not cure the cause
|
|
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What are the 3 goals of peptic ulcer disease?
|
relieve symptoms
heal the ulcer cure the disease and/or prevent recurrence |
|
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What helps with neutralizing the acid to acclerate healing of peptic ulcer disease?
|
PPIs (most effective)
H2 blockers Misoprostol |
|
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What type of antimicrobial therapy is given for H. pylori peptic ulcer disease?
|
*best results with combo. therapy
-BID: PPI + 2 of the following (amoxicilin, metroniadazole, or clarithromycin) -QID: Bismuth + tetracycline + metronidazole OR clarithromycin OR amoxicillin -Quadruple therapy: PPI BID + bismuth + tetracycline QID + metronidazole TID (yowsers!) 14 days better than 7-10 days |
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What type of medication can be used for peptic ulcer disease pts who require an anti-inflammatory?
|
prednisone
|
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What are 4 complications of peptic ulcer disease?
|
intractability (failure of an ulcer to heal despite successful Tx)-->Zollinger-Ellison
hemorrhage perforation obstruction |
|
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What is the most common cause of major UGI bleed?
|
hemorrhage from peptic ulcer disease
|
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What happens with perforation of peptic ulcer disease?
|
abrupt onset of severe abdominal pain followed rapidly by signs of peritoneal inflammation; leukocytosis appears rapidly
|
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How is perforation with peptic ulcer disease confirmed?
|
free air on upright CXR or lateral decubitus film
surgery to close the perforation |
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What are the symptoms/signs of obstruction with peptic ulcer disease?
|
inflammatory swelling and fibrosis
|
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What type of procedure needs to be done for obstruction of peptic ulcer disease?
|
endoscopic balloon dilation
surgery |
|
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What are 3 operative procedure that can be done for peptic ulcer disease to decrease acid secretion?
|
open or laparoscopic:
highly selective vagotomy truncal vagotomy pyloroplasty |
|
|
What is Zollinger-Ellison syndrome also know as?
|
gastrinoma
(rare) |
|
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What is Zollinger-Ellison syndrome caused by?
|
gastrin-secreting tumors (gastrinomas)
-hypergastrinemia -acid hypersecretion |
|
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Why is Zollinger-Ellison syndrome significant?
|
b/c ulcers don't heal
-over 2/3 are malignant |
|
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What are 4 signs/symptoms of Zollinger-Ellison syndrome?
|
peptic ulcers
GERD symptoms diarrhea weight loss |
|
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How is the diagnosis of Zollinger-Ellison syndrome made?
|
demonstration of increased fasting serum gastrin level
|
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What type of imaging can be done for Zollinger-Ellison syndrome?
|
CT and MRI (only up to 70% sensitive)
newer: somatostatin receptor scintigraphy endoscopic ultrasonography |
|
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How is metastatic disease for Zollinger-Ellison syndrome treated?
|
-most important predictor of survival is presence of hepatic matastases
-initial therapy directed at controlling hypersecretion w/ PPIs |
|
|
May may prolong survial of metastatic disease from Zollinger-Ellison syndrome?
|
surgical resection of isolated hepatic metastases
|
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What is the treatment of localized disease from Zollinger-Ellison syndrome?
|
resection of gastrinoma before hepatic spread
|
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Does lymph node metastases adversely affect the prognosis of localized disease from Zollinger-Ellison syndrome?
|
no
|
|
|
What are the 2 types of diseases for Zollinger-Ellison syndrome?
|
metastatic disease
localized disease |
|
|
How is upper GI bleeding defined?
|
bleeding that occurs proximal to the ligament of Treitz
|
|
|
What are the 2 most common causes of upper GI bleeding?
|
peptic ulcers
esophageal varices |
|
|
What is the method of choice for establishing the site of upper GI bleeding?
|
endoscopy
|
|
|
What type of equipment is useful to estimate the rapidity of upper GI bleeding?
|
NG
|
|
|
After hemodynamic stabilization with upper GI bleeding, what is indicated for nonvariceal bleeds?
|
endoscopy
|
|
|
If blood obscures with upper GI bleeding, what can be used prior to endoscopy?
|
gastric lavage
|
|
|
Why is barium radiography contraindicated in GI bleeding?
|
it interferes w/ endoscopy, angiography, and surgery
|
|
|
What are 3 conditions that increase the risk of upper GI bleeding?
|
age
shock comorbidity |
|
|
Endoscopy can identify patients at low risk for upper GI rebleeding and morbidity, allowing them to be treated as __ and ___ costs.
|
OP
decreasing |
|
|
What is the least expensive method of endoscopy for upper GI bleeding?
|
injection
-may not be as effective for long-term hemostasis |
|
|
What can reduce upper GI rebleeding in high-risk patients?
|
profound acid suppression
-PPP better than H2 blockers |
|
|
What is the most common presenting symptom of lower GI bleeding?
|
hematochezia
-bloody diarrhea -blood & clots per rectum -maroon colored stool |
|
|
Lower GI bleeding is commonly a disorder of the ___.
|
elderly
-increasing prevalence w/ age |
|
|
What are the 3 most common causes of lower GI bleeding?
|
diverticula
vascular ectasis tumors |
|
|
What are 3 ways that vascular lower GI lesions may be treated?
|
injection
thermal methods endoscopic laser therapy |
|
|
If colonoscopy is not effective w/ lower GI bleeding, then what 2 tests may help?
|
angiography
scintigraphy |
|
|
How is occult GI bleeding defined?
|
detection of asymptomatic GI bleeding
-routine FOBT -iron deficiency anemia |
|
|
What is the initial approach to occult bleeding?
|
endoscopy
-upper endoscopy & colonoscopy |
|
|
What are potential causative agents of occult GI bleeding?
|
NSAIDs & aspirin
|
|
|
What type of testing can be done for occult GI bleeding to exclude a hepatic or pancreatic source of bleeding?
|
abdominal CT
|
|
|
What are the 4 functions of intestinal epithelium?
|
-nutrient digestion & absorption
-barrier & immune defense -fluid & electrolyte balance -production of proteins, amines, and peptides |
|
|
What are the 3 phases of digestion?
|
intraluminal phase
mucosal phase absorptive phase |
|
|
What occurs in the intraluminal phase of digestion?
|
dietary fats, proteins, and carbohydrates are hydrolyzed and solubilized
|
|
|
Where does the mucosal phase occur and happens during the mucosal phase?
|
small intestine
-nutrient balance & absorption |
|
|
What can dysfunction during the absorptive phase lead to?
|
significant protein losses
|
|
|
What is malabsorption?
|
disruption of digestion and nutrient absorption
|
|
|
What are 11 signs/symtpoms of malabsorption?
|
steatorrhea
diarrhea weight loss, malnutrition iron deficiency/megaloblastic anemia bone pain/fractures paresthesia/tetany bleeding problems edema milk intolerance nocturia abdominal distension |
|
|
What defines acute diarrhea?
|
lasts less than 2 weeks
|
|
|
What are 3 common causes of acute diarrhea?
|
infectious agents
bacterial toxin drugs |
|
|
What are 2 types of acute diarrhea?
|
noninflammatory
inflammatory |
|
|
How is noninflammatory diarrhea defined?
|
-watery, nonbloody
-associated w/ periumbilical cramps, bloating, N/V -usually a small bowel source |
|
|
How is inflammatory diarrhea defined?
|
-presence of fever & bloody diarrhea
-associated w/ LLQ pain, urgency, tenesmus |
|
|
What does inflammatroy diarrhea need to be distinguished from?
|
acute ulcerative colitis
|
|
|
What does the presence of fever and bloody diarrhea indicate?
|
inflammatory diarrhea
-colonic tissue damage caused by invasion or a toxin |
|
|
What are 4 situations that prompt medical evaluation is required for acute diarrhea?
|
IBD signs
*profuse diarrhea w/ dehydration frail eldery & infants immunocompromised pts |
|
|
What is the treatment plan for acute diarrhea?
|
bowel rest
rehydration antidiarrheal agents (Loperamide, Pepto-Bismol) empiric antibiotics (not all pts) |
|
|
When should antidiarrheal agents not be given for acute diarrhea?
|
not w/ high fever or bloody diarrhea (sometimes need to get rid of it)
|
|
|
What are the 7 major pathophysiological categories of chronic diarrhea?
|
osmotic diarrhea
secretory conditions inflammatory conditions malabsorptive conditions motility disorders chronic infections factitious diarrhea |
|
|
What are 2 ways that chronic diarrhea can be evaluated?
|
stool analysis
colonoscopy w/ mucosal biopsy |
|
|
What are 6 medications that can be used to treat chronic diarrhea?
|
Loperamide
Diphenoxylate w/ atropine Codeine (dec. peristalisis) Clonidine Octreotide Cholestyramine |
|
|
What are 4 signs/symptoms of celiac disease?
|
weight loss
chronic diarrhea abdominal distention growth retardation usually seent in infancy, but can occur in adults |
|
|
What are 3 atypical symtpoms of celiac disease?
|
dermatitis herpetiformis (10%)
iron deficiency anemia osteoporosis |
|
|
What can improve celiac disease?
|
gluten-free diet
|
|
|
What is celiac disese also known as?
|
celiac sprue
|
|
|
What shows up on labs for celiac disease?
|
microcytic/megaloblastic anemia
low calcium or high alk phos increased prothrombin time |
|
|
What are 2 specific tests that can be done for celiac disease?
|
stool for fecal fat (24hr collection)
serologic tests (should be confirmed w/ biopsy) |
|
|
What are 3 differentials for celiac disease?
|
IBS
bacterial overgrowth lactose intolerance |
|
|
What is Whipple's disese caused by?
|
infection w/ bacillus Tropheryma whippelii
-unknown source of infection -will not spread human-to-human |
|
|
Who does Whipple's disease commonly affect?
|
whit men 30-50 years old
|
|
|
What are the signs/symptoms of Whipple's disease?
|
arthalgias/migratory arthritis, abdominal pain, chronic diarrhea, malabsorption, flatulence, steatorrhea, weight loss, fever, lymphadenopathy, uveitis/retinitis, CHF or valvular regurg, enteric protein loss w/ edema/hypoalbuminemia
|
|
|
How is the diagnosis for Whipple's disease made?
|
endoscopic biopsy of the duodenum showing the Whipple bacillus
-PAS-positive macrophages |
|
|
How is Whipple's disease treated?
|
antibiotic therapy at least 1 year
-IV Rocephin -TMP-SMX -Cepahlosporins (if allergic to sulfa) |
|
|
What is the prognosis for Whipple's disease?
|
fatal if untreated
pts must be followed closedly for recurrence |
|
|
What does bacterial overgrowth due to the GI system?
|
damages mucosa of small intenstine & interfers w/ absorption
|
|
|
What are 6 causes of bacterial overgrowth in the GI?
|
gastric achlorhydria
anatomic abnormalities w/ stagnation motility disorders gastrocolic/coloenteric fistula AIDS chronic pancreatitis |
|
|
What are the S/S of bacterial overgrowth in the GI?
|
most pts asymptomatic
S/S of malabsorption |
|
|
How can bacterial overgrowth be tested?
|
aspiration & culture of proximal jejunum secretions
14C xylose breath test |
|
|
How is bacterial overgrowth in the GI treated?
|
-correction of anatomic defect if needed
-broad spectrum antibiotics 1-2 weeks (Cipro, Amoxicillin) -may need cyclic antibiotic therapy |
|
|
What is short bowel syndrome due to? (4)
|
removal of significant segments of small intestine
-Crohn's disease -mesenteric infarction -trauma -radiation enteritis |
|
|
What happens with terminal ileum resection?
|
malabsorption of bile salts/B12
|
|
|
What is the Tx for short bowel syndrome from terminal ileum resection?
|
low-fat diet
cholestyramine vitamins |
|
|
What happens with extensive bowel resection?
|
weight loss
diarrhea |
|
|
What is the Tx for short bowel syndrome form extensive small bowel resection?
|
vitamin/mineral supplements
TPN (total parenteral nutrition) in severe cases |
|
|
What are the signs/symptoms of lactase deficinecy?
|
bloating
abdominal cramps flatulence diarrhea no weight loss *after lactose ingestion |
|
|
What type of lab can be done for lactase deficiency?
|
hydrogen breath test
|
|
|
What are 3 differentials for lactase deficiency?
|
IBD
malabsorptive disorders IBS |
|
|
What is the Tx plan for lactase deiciency?
|
patient comfort
limit lactose foods lactase enzyme replacement |
|
|
What are 2 types of IBD?
|
ulcerative colitis
Crohn's disease |
|
|
Can ulcerative colitis or Crohn's disease go through the entire wall of bowel?
|
Crohn's
|
|
|
Which type of IBD has diffuse mucosal inflammation of the colon?
|
ulcerative colitis
|
|
|
Which type of IBD has patchy transmural inflammation of the GI tract?
|
Crohn's disease
|
|
|
Which type of IBD always involves the rectum?
|
ulcerative colitis
|
|
|
Which type of IBD may involve any part from the mouth to the anus?
|
Crohn's disease
|
|
|
Which type of IBD may smoking decrease the severity of the disease?
|
ulcerative colitis
|
|
|
Which type of IBD does smoking worsen the severity of the disease?
|
Crohn's disease
|
|
|
Which type of IBD is p-ANCA>ASCA?
|
ulcerative colitis
|
|
|
Which type of IBD is ASCA>p-ANCA?
|
Crohn's disease
|
|
|
What are 7 extraintestinal symtpoms of IBD?
|
arthritis
erythema nodosum pyoderma gangrenosum ocular problems (uveitis/retinitis) cholestatic liver disease oral aphthous lesions nephrolithiasis |
|
|
Which type of test is the key to diagnosis for ulcerative colitis?
|
sigmoidoscopy
|
|
|
What are the signs/symptoms of mild/moderate ulcerative colitis?
|
gradual onset of diarrhea
diarrhea fecal urgency/tenesmus LLQ cramps |
|
|
What are the signs/symptoms of severe ulcerative colitis?
|
6+ bloody stools per day (severe anemia, hypovolemia, impaired nutrition)
abdominal pain |
|
|
What do the labs for ulcerative colitis show? (3)
|
low H/H
increased sed. rate low serum albumin |
|
|
What are the general measures of Tx of ulcerative colitis?
|
limit caffeine
limit gas-producing veggies fiber supplements anti-diarrheals |
|
|
How should distal ulcerative colitis be treated?
|
topical mesalamine
topical corticosteroids oral 5-ASA |
|
|
How should mild/moderate ulcerative colitis be treated?
|
oral agents (5-ASA, corticosteroids)
|
|
|
How should severe colitis be treated?
|
NPO 24-48 hrs
D/C opiods/anticholinergics restore fluids/elctrolytes corticosteroids 7-10 days IV cyclosporine (if steroids don't work) surgery (if no improvement) oral fluids can be restarted once symptoms improve |
|
|
What is fulminant colitis?
|
rapid progression of ulcerative colitis; very severe; small subset of pts
|
|
|
What are the signs/symptoms of fulminant colitis?
|
fever
prominent hypovolemia hemorrhage requiring transfusion abdominal distension tenderness |
|
|
What are 2 conditions that fulminant colitis is at high risk for?
|
perforation
development of toxic megacolon |
|
|
How is fulminant colitis treated?
|
same as severe colitis + broad spectrum antibiotics
|
|
|
How is toxic megacolon defined?
|
colonic dilation of more than 6cm on plain films
|
|
|
How is toxic megacolon treated?
|
-same as severe fulminant colitis + NG tube
-decompression of distended colon -maintenance of remission w/ 5-ASA daily -surgery to prevent perforation if no improvement w/ 48-72 hrs |
|
|
What type of treatment can be done for refractory ulcerative colitis?
|
-surgical resection
-immunosuppressive therapy (azathioprine or 6-MP) -transdermal nicotine -Infliximab/anti-TNF drug |
|
|
What can be done to help with the risk of cancer w/ ulcerative colitis proximal to the sigmoid colon?
|
folic acic
colonoscopies q 1-2 years starting 8-10 years after diagnosis |
|
|
What are 6 indications for surgery w/ ulcerative colitis?
|
severe hemorrhage
perforation carcinoma dysplasia on colonoscopy refractory disease no improvement w/ fulminant colitis/toxic megacolon |
|
|
What are 3 things the can ge done with complete colectomy?
|
standard ileostomy w/ external appliance
continent ileostomy internal ileal pouch anastomosed to anal canal |
|
|
What is the prognosis for ulcerative colitis?
|
lifelong disease w/ exacerbations/remissions
surgery provides complete cure |
|
|
What are the essential of diagnosis for Crohn's disease?
|
-insidious onset
-intermittent bouts of low-grade fever, diarrhea, and RLQ pain -RLQ mass/tenderness -perianal disease -radiographic evidence of ulceration/stricturing/fistulas of small intestine/colon |
|
|
What is the most common place in the GI tract for Crohn's disease?
|
ileo-cecal valve
|
|
|
What are the signs/symptoms of chronic inflammatory disease (most common presentation) associated w/ Crohn's disease?
|
low-grade fever
malaise weight loss decreased energy nonbloody diarrhea crampy steady RLQ/periumbilical pain focal RLQ tenderenss |
|
|
What are the sign/symptoms of intestinal obstruction associated w/ Crohn's disease?
|
posprandial bloatin
cramping pains loud borborygmi |
|
|
What are the signs/symptoms of fistulization +/- infection associated with Crohn's disease?
|
development of sinus tracts
may lead to intra-abdominal abscesses |
|
|
What are the signs/symptoms of perianal disease associated w/ Crohn's disease?
|
anal fissures
perianal abscesses fistulas |
|
|
What are 5 sign/symptoms of Crohn's disease?
|
chronic inflammatory disease
intestinal obstruction fistulization +/- infection perianal disease extraintestinal manifestations |
|
|
What special diagnostic studies can be done for Crohn's disease?
|
upper GI series w/ small bowel follow through
capsule imaging barium enema colonoscopy |
|
|
What are 7 complications of Crohn's disease?
|
abscess
obstruction fistulas perianal disease carcinoma hemorrhage malabsorption |
|
|
What happens w/ abscess w/ Crohn's disease?
|
-presence of tender abdominal mass w/ fever & leukocytosis
-emergent CT required -broad spectrum antibiotics -percutaneous drainage or surgery is usually required |
|
|
What happens w/ obstruction w/ Crohn's disease?
|
secondary to active inflammation or chronic fibrotic stricturing
-IV fluids & NG tube -corticosteroids if inflammation acitve |
|
|
What happens w/ fistulas w/ Crohn's disease?
|
majority are asymptomatic
6-MP or azathioprine Infliximab surgical therapy if no improvement |
|
|
What happens w/ perianal disease w/ Crohn's disease?
|
severe perianal pain suggests an abscess --> I&D
Flagyl or Cipro |
|
|
Is severe bleeding usual with Crohn's disease?
|
no it is rare
|
|
|
Patients w/ extensive colonic involvement w/ Crohn's disease are at increased risk for ___ cancer; screening colonoscopy ___ years after diagnosis.
|
colon
8 |
|
|
What is the Tx plan for Crohn's disease?
|
not curative
directed at improving symptoms nutrition symptomatic meds. surgery |
|
|
How can nutrition be maintained in Crohn's disease?
|
well-balanced diet
fiber supplement if no obstruction TPN supplemental enteral therapy via NG tube if poor growth |
|
|
What is the specific drug therapy for Crohn's disease?
|
5-ASA
antibiotics (Flagyl or Cipro) corticosteroids (Entocort) immunomodulating drugs (Azathiprine, 6-MP) Infliximab (anti-TNF) |
|
|
What are 5 indications of surgery w/ Crohn's disease?
|
intractability to medical therapy
intra-abdominal abscess massive bleeding refractory fistulas intestinal obstruction |
|
|
What are 4 essentials of diagnosis for IBS?
|
chronic functional disorder
abdominal pain alterations in bowel habits symptoms start in late teens/early 20s organic causes must be excluded |
|
|
To be considered IBS, it must last more than ___ months.
|
3
|
|
|
What is the consensus defintion for IBS?
|
abdominal pain that 2 of the following 3 features:
-relieved w/ defecation -onset of pain assocaited w/ change in freq. of stool -onset of pain associated w/ change in stool form |
|
|
What are 3 psychosocial abnormalities that can be associated with IBS?
|
depression
anxiety somatization -consider Hx of childhood sexual/physical abuse |
|
|
What are the signs/symptoms of IBS?
|
lower abdominal pain that is usually intermittent and crampy
mucus is commonly seen |
|
|
What are the 3 predominant types of IBS?
|
mostly diarrhea
mostly constipation alternating |
|
|
What are 7 "red flags" that may indicate organic disease associated w/ IBS?
|
acute onset of symptoms
nocturnal diarrhea severe diarrhea/constipation hematochezia weight loss fever family Hx (cancer, IBD, celiac disease) |
|
|
Is physical exam helpful for IBS?
|
no
|
|
|
What labs can be performed for IBS?
|
CBC
serum albumin sed rate thryroid function tests serology for celiac disease stool studies *over age 45 --> colonoscopy |
|
|
What are 6 differentials for IBS?
|
colon cancer
IBD hyperthyroidism hypothyroidism celiac disease endometriosis |
|
|
What is the most important treatment plan for IBS?
|
reassurance
education support |
|
|
What type of dietary therapy can be done for IBS patients?
|
avoidance of fatty foods, caffeine, flatulogenic foods
|
|
|
Are high-fiber diets a good idea for IBS?
|
of little value and may increase gas & distension
|
|
|
What type of drugs can be given for IBS?
|
antispasmodics (anticholinergics)
antidiarrheal agents (Loperamide) anticonstipation agents (osmotic laxatives) TCAs/SSRIs (for pain/bloating) partial serotonin agonist (Tegaserod) Seotonin antagonist (Aloestron) |
|
|
What is Tegaserod (partial serotonin agonist) with IBS?
|
constipation
-efficacy not proven in men |
|
|
What is Aloestron (serotonin antagonist) used for with IBS?
|
diarrhea
-reduces pain, cramps, urgency, & diarrhea -efficacy not proven in men -*potential side effect of severe constipation and ischemic colitis |
|
|
What are 3 types of psychological therapy that can be done for IBS pts?
|
cognitive behavioral therapy (CBT)
relaxation techniques hypnotherapy |
|
|
What is the prognosis for IBS?
|
not curable
most pts learn to cope |
|
|
What structure of the anal canal distinguishes between external and internal hemorrhoids?
|
pectinate/dentate line
|
|
|
What are internal hemorrhoids?
|
-normal antatomic structures
-subepithelial vascular cushions made of CT, smooth muscle fibers and arteriovenous communications b/t terminal branches of the superior rectal artery and rectal veins |
|
|
Are internal or external hemorrhoids painful?
|
external (innervated by cutaneous nerves)
|
|
|
What are external hemorrhoids covered with?
|
squamous epithelium of the anal canal or perianal region
|
|
|
What are 6 activities that increase venous pressure, causing distension and engorgement of hemorrhoids?
|
straining at stool
constipation prolonged sitting pregnancy obesity low fiber diets |
|
|
What are the signs/symptoms of internal hemorrhoids?
|
bleeding
prolapse mucoid discharge bright red blood per rectum (BRBPR) protrusion discomfort typically painless |
|
|
What type of hemorrhoids have protuberant purple nodules covered by mucosa?
|
prolapse internal hemorrhoids
|
|
|
On digital rectal exam, uncomplicated ___ hemorroids are not painful and cannot be ___.
|
internal
palpated |
|
|
What are the 4 degrees of prolapse for internal hemorrhoids?
|
I-confined to anal canal
II-prolapsed during straining & spontaneously reduce III-require manual reduction after bowel movements IV-remain chronically protruding |
|
|
How are stage I and II internal hemorrhoids treated?
|
high fiber diet
increase fluids w/ meals psyllium bulk laxatives (Metamucil) |
|
|
How are edematous, prolapse internal hemorrhoids treated?
|
manual reduction
suppositories Tucks pads sitz baths |
|
|
How are stage I, II, and III w/ recurrent bleeding internal hemorrhoids treated?
|
rubber band ligation (easiest)
electrocoagulation injections sclerotherapy |
|
|
When is surgery needed for hemorrhoids?
|
chronic severe bleeding w/ stage III-IV or acute thrombosed stage IV
|
|
|
What are anal fissures?
|
linear or rocket-shaped ulcers; usually <5mm in length
|
|
|
What is the cause of anal fissures?
|
trauma to anal canal during defecation (straining, constipation, high internal sphincter tone)
|
|
|
Where are most anal fissures located?
|
posterior midline
|
|
|
What are the signs/symptoms of anal fissures?
|
-severe, tearing pain during defecation followed by throbbing discomfort
-pain may lead to constipation due to fear of recurrent pain (catch 22) |
|
|
How are anal fissures treated? (5)
|
Goal: effortless, painless BM's! (usually heal on their own)
-fiber supplements -sitz baths -topical nitroglycerin (for chronic cases) -injection of botox into internal anal sphincter -lateral internal sphincterotomy (chronic/recurrent problems) |
|
|
What is the cause of an anorectal abscess?
|
anal glands at base of anal crypts at dentate line become infected and form an abscess
Other causes: anal fissure Crohn's |
|
|
What are the signs/symptoms of an anorectal abscess?
|
-throbbing, continuous perianal pain
-erythema, fluctuance, & swelling in perianal region on external exam or in the ischiorectal fossa on digital rectal exam |
|
|
How are anorectal abscesses treated?
|
perianal - local I&D
ischiorectal - drainage in the OR |
|
|
What is the etiology of anorectal fistulas?
|
arises in the anal crypt; usually preceded by anal abscess
|
|
|
What 4 conditions should be considered if an anorectal fistula connects to the rectum?
|
Crohn's
lymphogranuloma venereum rectal tuberculosis cancer |
|
|
What are the signs/symptoms of an anorectal fistula?
|
purulent discharge
+/- itching tenderness pain |
|
|
How are anorectal fistulas treated?
|
idiopathic fistula in ano: surgical incision or excision under anesthesia
Crohn's related: different managment (going to treat disease over fistula) |
|
|
What are the signs/symptoms of pruritus ani?
|
perianal itching/discomfort
on exam: erythema, excoriations, lichenified, eczematous skin |
|
|
What are the causes of pruritus ani?
|
too dirty or too clean
|
|
|
What needs to be ruled out with pruritus ani?
|
skin infecitons/conditions
|
|
|
How is pruritus ani treated?
|
education:
-avoid spicy food, coffee, chocolate, tomatoes -clean perianal area after BM's -tuck cotton ball next to anal opening (absorb perspiration/fecal seepage) +/- topical corticosteroids or diluted capsaicin cream |
|
|
What are 5 things that bowel continence requires?
|
1. solid/semisolid stool
2. distensible rectal reservoir 3. sensation of rectal fullness 4. intact pelvis nerves/muscles 5. ability to reach a toilet in a timely fashion :) *if those aren't met-->pt has incontinence |
|
|
What are the signs/symptoms of minor fecal incontinence?
|
inability to control flatus
slight soilage of undergarments after BM's/straining/coughing |
|
|
How is minor fecal incontinence treated?
|
fiber supplements
D/C caffeine cleanse perianal skin cotton ball near opening Loperamide |
|
|
What are elderly considerations/treatment for minor fecal incontinence?
|
scheduled toileting
bedside commode |
|
|
What are the signs/symptoms of major fecal incontinence?
|
complete uncontrolled loss of stool
severe sphincteric injury intact anocutaneous reflex |
|
|
What is the etiology of major fecal incontinence?
|
problem w/ central perception or neuromuscular function
|
|
|
What diagnostic techniques can be used to exam major fecal incontinence?
|
anoscopy
proctosigmoidoscopy anal U/S pelvic MRI anal manometry |
|
|
What is the Tx plan for major fecal incontinence?
|
-bulking agents, antidiarrheal drugs
-scheduled toileting after glycerin suppositories or tap water enemas -biofeedback training -surgery (rare) |
|
|
What is rectal prolapse?
|
protrusion through the anus of some or all of the layers of the rectum; most common in elderly
|
|
|
What are the causes of rectal prolapse?
|
-chronic, excessive straining at stool in conjunction w/ weakening of pelvic support structures
-surgical/traumatic injury |
|
|
What are the signs/symptoms of rectal prolapse?
|
intially-reduces spontaneously after defecation
eventually-chronic prolapse caused mucous discharge, bleeding, incontinence, sphincter damage |
|
|
What type of Tx should be done for rectal prolapse?
|
surgical correction of complete prolapse
|
|
|
What are 3 risk factors of adenocarcinoma of the stomach?
|
chronic H. pylori gastritis (inc. risk of distal stomach cancer)
pernicious anemia Hx of partial gastric resection <15 yrs |
|
|
What is the 2nd most common cancer worldwide?
|
adenocarcinoma of the stomach (skin is 1st)
|
|
|
What are the signs/symptoms of adenocarcinoma of the stomach?
|
asymptomatic until advanced
depends on tumor location dyspepsia vague epigastric pain anorexia early satiety weight loss GI bleeding (w/ ulcers) postprandial vomiting (w/ pyloric obstruction) -progressive dysphagia |
|
|
Why is adenocarcinoma of the stomach delayed?
|
pts get initial symptomatic relief from OTC meds
physical exam is rarely helpful |
|
|
Are are 4 signs of metastatic spread of adenocarcinoma of the stomach?
|
-Virchow's node (L supraclavicular)
-Sister May Josephy nodule (umbilical) -Blumer's shelf (rigid rectal shelf) -Krukenberg tumor (ovarian metastases) |
|
|
What may be lab findings for adenocarcinoma of the stomach show?
|
iron deficiency anemia
anemia of chronic disease elevated LFT's if liver metastases +/- guaiac positive stool |
|
|
When should endoscopy be done in suspection of adenocarcinoma of the stomach?
|
all pts >50yr w/ new onset epigastric sxs or persistent dyspepsia
|
|
|
What type of diagnostic test is highly sensitive for gastric carcinoma?
|
endoscopy w/ cytologic brushings & biopsy of suspicious lesions
|
|
|
What type of imaging can be done for adenocarcinoma of the stomach?
|
barium upper GI series (not as good as endoscopy)
|
|
|
After Dx of adenocarcinoma of the stomach, what is preop evaluation done with?
|
abdominal CT and esophageal U/S shows local extent of the primary tumor and nodal or distant metastases
|
|
|
What is the staging for adenocarcinoma of the stomach?
|
T-tumor
N-node M-metastasis 4 stages higher the stage, the worse the prognosis and the more difficult to treat |
|
|
What stage of adenocarcinoma of the stomach has metastases?
|
stage IV
|
|
|
What is the treatment for adenocarcinoma of the stomach?
|
surgical resection (effective if localized)
lymph node dissection chemo/radiation?? |
|
|
What are palliative measures that can be done for adenocarcinoma of the stomach?
|
resection of the tumor
gastrojejunostomy chemo |
|
|
What is the prognosis for adenocarcinoma of the stomach?
|
not very good
-proximal tumore have worse prognosis than distal tumors) |
|
|
What reduces the mortality form colorectal cancer?
|
screening (CAN BE PREVENTED!)
-all pts >50yrs should be screened -high-risk individuals should begin screening earlier |
|
|
What are the colorectal cancer risk factors?
|
age > 45 yrs
family Hx IBD race (>in blacks) |
|
|
Where does the vast majority of colorectal cancers arise from?
|
benign adenomas that progress over many years to cancer
-removal of adenomas prevents the majority of cancers |
|
|
What is familial adenomatous polyposis (FAP)?
|
autosomal dominant development of 100s-1000s of colonic polyps
polyps average age 15 cancer average age 40 |
|
|
Unless prophylactic ____ for FAP, cancer is inevitable by age ___.
|
colectomy
50 |
|
|
What are the possible extraintestinal manifestations of FAP?
|
skin
thyroid liver CNS tumors |
|
|
What is the Tx/prevention plan for FAP?
|
genetic counseling
complete proctocolectomy/colectomy w/ ileoanal/rectal anastomosis upper endoscopy q 1-3 years thereafter |
|
|
What are 2 inheritable factors/syndromes for colorectal cancer?
|
familial adenomatous polyposis (FAP)
juvenile polyposis (rare) |
|
|
What are 5 techniques to screen for colorectal cancer?
|
average risk >/= 50yrs
annual FOBT flexible sigmoidoscopy q 5yrs annual FOBT & flex sig *colonscopy q 10yrs barium enema 1 5yrs |
|
|
If the pt has a family Hx of 1st degree relative w/ colorectal cancer then when should screening be done?
|
1 relative dx'ed >/=60yrs:
-begin at 40yrs then q 10 yrs 1 relative dx'ed <60yrs OR > 1 relative: -begin at 40yrs or 10 yrs younger than age at dx of youngest affected relative -colonscopy q 5yrs |
|
|
What happens w/ FOBT?
|
-get 2 samples from 3 consecutive stools
-should be done annually |
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|
What are the negatives of FOBT?
|
often misses polyps, may miss cancers
pos. results need colonoscopy high false pos. rate = many unnecesary colonoscopies |
|
|
What is the downfall of flexible sigmoidoscopy?
|
only goes up to splenic flexure (still missing 2/3 of colon)
|
|
|
What are the advantages of colonoscopy over other screening techniques for colorectal cancer?
|
evaluates entire colon
diagnostic AND therapeutic -polyp detection & removal |
|
|
When are 2 techniques for colorectal cancer screening that can be done if pt unwilling/unable to undergo colonoscopy?
|
double contrast barium enema
CT colonscopy (still need colonoscopy if abnormalities) |
|
|
What suggestion can be made if the liver is enlarged with colorectal cancer?
|
metastatic spread
|
|
|
What type of S/S occur with right-sided colorectal cancer?
|
-iron deficiency anemia (fatigue, weakness)
-obstruction rare b/c of lg. diameter of R colon & liquid consistency of fecal material |
|
|
What type of S/S occur with left-sided colorectal cancer?
|
-often involves the bowel cirumferentially
-smaller diameter of the colon -solid fecal matter=obstructive s/s |
|
|
What type of S/S occur with rectal colorectal cancer?
|
tenesmus
urgency recurrent hematochezia |
|
|
What type of labs can be done for colorectal cancer?
|
CBC (anemia)
carcinoembryonic antigen (CEA) |
|
|
After complete surgical resection of the colon due to colorectal cancer, ___ levels should normalize.
|
CEA
|
|
|
What are the S/S of small bowel tumors?
|
rare
often no S/S acute GI bleeding chronic GI bleeding obstruction |
|
|
What type of imaging techniques can be done for small bowel tumors?
|
barium radiograph
upper endoscopy (visualization/biopsy) |
|
|
What is the most common benign mucosal tumor?
|
adenomatous polyps
|
|
|
Why is resection warranted with adenomatous polyps?
|
b/c malignant transformations DO occur
|
|
|
What are benign stromal tumors?
|
leiomyomas
|
|
|
Where are leiomyomas found?
|
all levels of the intestine; intraluminal, intramural, or extraluminal
|
|
|
Leiomyomas require ___ to distinguish b/t benign and malignant stromal tumors.
|
excision
|
|
|
What are carcinoid tumors?
|
slow-growing neuroendocrine tumors; anywhere in the GI tract
|
|
|
What are 2 complications of carcinoid tumors?
|
metastasis to heart
carcinoid syndrome (tumor secrets hormonal mediators that cause cramps, flushing, diarrhea, cyanosis, or bronchospasm) |
|
|
Zollinger-Ellison syndrome are a type of ___ tumors.
|
carcinoid
|
|
|
What are 6 types of hepatic disease?
|
HAV
HBV HCV HDV HEV HGV |
|
|
What is fulminant hepatic disease?
|
severe development of hepatic encephalopathy w/in 8 weeks
|
|
|
What is sub-fulminant hepatic disease?
|
severe development of hepatic encephalopathy at 8 weeks-2 months
|
|
|
What does the liver do? (4)
|
energy metabolism, protein synthetic functions, solubilization/transport/storage, protective/clearance functions
|
|
|
What are 7 causes of hepatic disease? (7)
|
cholelithiasis
excessive alcohol intake inherited disorders viruses/bacterial infection medications cirrhosis cancer |
|
|
What are 4 causes of jaundice?
|
diminished hepatocyte function
inability to conjugate transfer/excretion problems biliary obstruction |
|
|
How is HAV transmitted?
|
fecal/oral
|
|
|
Does HAV have a high or low mortality?
|
low
|
|
|
Is HAV chronic?
|
no-never
|
|
|
What is the Tx for HAV?
|
supportive care
|
|
|
What are the symptoms for the prodromal phase of viral hepatitis? (4)
|
malaise
mayalgia arthralgia fatigue anorexia N/V malaise aversion to smoking fever (low-grade) mild RUQ pain serum sickness in HBV |
|
|
How is HBV transmitted?
|
blood/blood products
sexual maternal-fetal homosexuals IV drug users |
|
|
What is the incubation period for HBV?
|
6 weeks to 6 months
|
|
|
Is HBV chronic?
|
in 1-2% of cases
|
|
|
Is there a vaccination for HBV?
|
yes
|
|
|
How is acute HBV treated?
|
supportive care
|
|
|
What do pts w/ chronic HBV have substantial risk of? (2)
|
cirrhoiss
hepatocellular carcinoma |
|
|
What measure shows the first evidence of HBV infection?
|
HBsAG
|
|
|
What measure signals recovery from HBV infection and immunity?
|
anti-HBs
|
|
|
How is HCV transmitted? (4)
|
*IV drug use
intranasal cocaine body piercings blood transfusion |
|
|
Is there vaccination for HCV?
|
no
|
|
|
What are 2 low risks of transmission for HCV?
|
sexual
maternal/fetal |
|
|
Is HCV a chronic infection?
|
80% will become chronic
|
|
|
What is the incubation period for HCV?
|
6-7 weeks
|
|
|
What is HDV?
|
delta agent
-defective RNA virus that causes hepatitis ONLY in association w/ HBV |
|
|
HDV is usually ___ exposure, occurs mainly in IV ___ users, has __x risk of hepatocellular disease, and may cuase ___ hepatitis or severe chronic hepatitis.
|
percutaneous
drug 3 fulminant |
|
|
Is HEV common in the US?
|
no it is rare
|
|
|
How is HEV transmitted?
|
waterborne
|
|
|
Is HEV chronic?
|
no
-illness is self-limited |
|
|
How is HGV transmitted?
|
percutaneously (blood borne)
|
|
|
HGV does not cause important ___ disease and HGV coinfection may improve survival in pts w/ ___.
|
liver
HIV |
|
|
What are the 3 phases of viral hepatitis?
|
prodromal
icteric convalescent |
|
|
What are 3 signs of viral hepatitis?
|
hepatomegaly
liver tenderness splenomegaly in 15% of cases (these signs go away in convalescent phase) |
|
|
How can viral hepatitis be prevented?
|
handwashing
universal precautions blood supply screening vaccination (HAV, HBV) |
|
|
How is chronic hepatitis defined?
|
chronic inflammatory rxn of the liver of more than 3-6 months
|
|
|
What are 4 types of chronic hepatitis?
|
HBV +/- HDV
HCV autoimmune hepatitis Wilson's disease |
|
|
Chronic HBV coninfection w/ HIV is associated w/ increased frequency of ___.
|
cirrhosis
|
|
|
How is chronic HBV treated?
|
Interferon (4 months)
Lamivudine (better tolerated) |
|
|
How is chronic HCV detected?
|
HCV RNA in the blood
|
|
|
What increases the risk of cirrhosis with chronic HCV?
|
EtOH use more than 50g/day
|
|
|
How is chronic HCV treated?
|
pegylated interferon and ribavirin po (48 weeks)
may reduce the risk of hepatocellular carcinoma |
|
|
What general features may pts with autoimmune hepatitis have besides signs of liver disease?
|
multiple spider nevi, striae, acne, hirsutism, hepatomegaly
usually a disease of young women |
|
|
How is autoimmune hepatitis treated?
|
prednisone +/- azathiprine
|
|
|
What direct hepatic toxins can cause hepatic injury? (8)
|
acetominophen
EtOH carbon tetrachloride chloroform heavy metals mercaptopurine (6-MP) tetracycline vitamin A |
|
|
What are 2 types of hepatic injury?
|
hepatic toxins
drug induced syncratic rxns |
|
|
What drug induced syncratic rxns can cause hepatic injury? (9)
|
Amiodarone
ASA carbamepine chloramphenicol diclofenac halothane isoniazid ketoconazole phenytoin -not dose associated; sporadic; suggest allergic rxn (fever/eosinophilia) |
|
|
What are the 3 stages of the liver w/ alcoholic hepatitis?
|
fatty liver
liver fibrosis (scar tissue remains) cirrhosis (irreversible) |
|
|
What is alcoholic hepatitis?
|
acute or chronic inflammation and parenchymal necrosis of the liver induced by EtOH
-often reversible |
|
|
What is the most common cause of cirrhosis and 4-5x more common cause of death as HCV in the US?
|
alcoholic hepatitis
|
|
|
Does alcoholic hepatitis affect more men or women?
|
women>men
|
|
|
How many drinks is 50g?
|
4 (4 oz. 100 proof whiskey, 15 oz. wine, or 48 oz. beer)
|
|
|
What are the signs/symptoms of alcoholic hepatitis?
|
anorexia
nausea hepatomegaly jaundice abdominal pain splenomegaly ascites fever encephalopathy :( |
|
|
What is the Tx plan for alcoholic hepatitis?
|
EtOH abstinence!!!
caloric supplement vitamins folic acid thaimine prednisone (1 month) pentoxifylline? (experimental-may reduce hepatorenal syndrome) liver transplant |
|
|
With alcoholic hepatitis, what needs to be conadministerd w/ glucose administration to prevent Wernicke-Korsakoffy syndrome?
|
thiamine
|
|
|
What are the absolute contraindications of liver transplant for alcholic hepatitis?
|
malignancy
advanced cardiomyopulmonary disease sepsis active substance abuse (relative?) |
|
|
What happens w/ portal HTN?
|
blood not going through as well b/c of scar tissue --> pressure increases --> get dilated veins (varicosities in abdomen)
|
|
|
What are 4 major complications of portal HTN?
|
ascites
spontaneous bacterial peritonitis hepatorenal syndrome hepatic encephalopathy |
|
|
How is ascited treated?
|
paracentesis
restriction of dietary Na & fluid diuretics (spironolactone +/- Lasix) TIPS |
|
|
What are the most common bacteria for spontaneous bacterial peritonitis associated w/ portal HTN?
|
E. coli
pneumococci |
|
|
What are the signs of spontaneous bacterial peritonitis associated w/ portal HTN?
|
abdominal pain
increasing ascited fever progressive encephalopathy |
|
|
How is spontaneous bacterial peritonitis associated w/ portal HTN treated?
|
IV cefotaxime (5 days)
|
|
|
What is hepatorenal syndrome?
|
azotemia in the absence of shock or significant proteinuria in a pt w/ end-stage liver disease
|
|
|
The mortality of hepatorenal syndrome is ___ w/out liver transplant.
|
high
|
|
|
Hepatorenal syndrome associated w/ portal HTN does not improve w/ IV ___ saline.
|
isotonic
|
|
|
What happens w/ hepatic encephalopathy?
|
disordered CNS function due to failure of teh liver to detoxify noxious agents originating in the gut
|
|
|
What is withheld during acute hepatic encephalopathy episodes?
|
dietary protein
-lactulose to acidify colon contents (want to skew equation towards NH4+) |
|
|
What should be avoided with hepatic encephalopathy?
|
opiods & sedatives that are metabolized or excreted by the liver
|
|
|
What are the essentials of diagnosis for Wilson's disease?
|
-excessive deposition of copper in the liver/brain
-rare autosomal recessive -urinary excretion of copper/hepatic copper concentration high |
|
|
What is a phlegmon?
|
inflammatory mass in and around the pancreas formed by edema and continued leakage of activated pancreatic enzymes
|
|
|
What is a pseudocyst?
|
a collection of tissue, fluid, debris, pancreatic enzymes, and blood that can develop after acute pancreatitis
|
|
|
What is a pseudoaneurysm?
|
occurs when a permanent communication occurs b/t an artery and a pancreatic pseudocyst (fistula b/t pseudocyst & artery)
|
|
|
What is acute pancreatitis?
|
discrete episode of abdominal pain and elevated serum amylase and lipase levels
|
|
|
What are the 2 distinct classifications of acute pancreatitis?
|
acute interstitial pancreatitis
acute hemorrhagic pancreatitis |
|
|
What are the causes of acute pancreatitis? (7)
|
alcoholism (35%)
biliary tract disease (35%) obstrution of pancreatic secretions drugs/toxins hypertriglyceridemia familial (autosomal dominant) trauma (blunt/penetrating) |
|
|
What are the drugs/toxins that can cause acute pancreatitis?
|
insecticides, methanol, scorpion venom
immunosuppressants (azathiprine), Lasix, ACE inhibitors |
|
|
What is the fundamental mechanism of acute pancreatitis?
|
injury causing activation of digestive enzymes leading to autodigestion; inflammation may lead to inflammatory response syndrome (SIRS)
|
|
|
What are the 2 major causes of death from acute pancreatitis?
|
SIRS
pancreatic infection |
|
|
What are the typical symptoms of acute pancreatitis? (3)
|
pain
nausea vomiting |
|
|
How is the pain of acute pancreatitis characterized?
|
constant
epigastrium may radiate to midback lasts hours to days not relieved by vomiting |
|
|
What may the abdominal exam of acute pancreatitis show?
|
rebound tenderness
guarding decreased/absent bowel sounds |
|
|
What may severe attacks of acute pancreatitis include? (4)
|
hypotension
tachypnea tachycardia fever |
|
|
What are 2 signs of acute pancreatitis?
|
Grey Turner's signs (ecchymosis of the flank)
Cullen's sign (periumbilical ecchymosis) |
|
|
What may the labs for acute pancreatitis show?
|
elevated amylase
elevate lipase (elevated longer) leukocytosis hypocalcemia elevated LFT's triglycerides >1000 may cause attacks |
|
|
What type of diagnostic imaging is used for acute pancreatitis?
|
U/S (gallstones)
CT/MRI (pancreatitis) |
|
|
Is ERCP useful for diagnosing acute pancreatitis?
|
no
|
|
|
How is acute pancreatitis treated?
|
NPO (complete bowel rest)
*pain meds. remove gallstones if needed hydration |
|
|
70-80% of chronic pancreatitis is related to ___.
|
alcoholism
|
|
|
What are the signs/symptoms of chronic pancreatitis?
|
persistent/recurren epigastric/LUQ pain
anorexia, weight loss N/V constipation/flatulence attacks last 2hrs-2wks steatorrhea (late finding) |
|
|
What may the labs for chronic pancreatitis show?
|
elevated amylase/lipase
elevated alk phos/bilirubin excess fecal fat glycosuria |
|
|
What type of imaging can be done for chronic pancreatitis?
|
plain films (calcifications)
CT ERCP (most sensitive) |
|
|
What are 5 complications of chronic pancreatitis?
|
opiod addiction
brittle diabetes pancreatic pseudocyst/abscess malnutrition pancreatic CA |
|
|
How is chronic pancreatitis treated?
|
surgery (biliary disease)
low fat diet no EtOH Creon/Pancrease/Ultrase H2 blockers/PPIs pancreatectomy (last resort) |
|
|
What are 4 indications for surgical/endoscopic treatment of chronic pancreatitis?
|
persistent pseudocysts
biliary obstruction intractible pain concern of pancreatic CA |
|
|
What is the prognosis for chronic pancreatitis?
|
-often leads to chronic disabilty
-best prognosis for pts w/ recurrent acute attacks related to biliary disease -narcotic addiction common |
|
|
What percentage of carcinomas of the pancreas are in the head of the pancreas?
|
75%
|
|
|
What are 5 risk factors of carcinoma of the pancreas?
|
age
obesity tobacco use chronic pancreatitis family Hx |
|
|
What are the signs/symptoms of carcinoma of the pancreas?
|
obstructive jaundice
enlarged gallbladder diarrhea weight loss hard, fixed mass migratory thrombophlebitis (rare) *Sister Mary Joseph's nodule vague, diffuse epigastric pain w/ radiation to the back |
|
|
What may the labs for carcinoma of the pancreas show?
|
mild anemia
glycosuria/hyperglycemia LFTs (obstructive jaundice) occult blood in stool |
|
|
What type of imaging can be used for carcinoma of the pancreas?
|
spiral CT
MRI *endoscopic U/S (more sensitive) *abd. U/S not reliable |
|
|
How is carcinoma of the pancreas treated?
|
lap resection
radical pancreaticoduodenal (Whipple) resection) palliation: radiation/chemo |
|
|
What is the prognosis of carcinoma of the pancreas?
|
not very good
-very poor prognosis if in body or tail of pancreas |
|
|
What are the 2 essentials of diagnosis for cholelithiasis?
|
classic biliary pain
stones detected on U/S |
|
|
What are the risk factors for cholelithiasis?
|
obesity
rapid weight loss glucose intolerance/hyperinsulinemia Crohn's disease DM cirrhosis pregnancy/HRT *female, fat, forty, flatulent* |
|
|
What are the 2 main types of gallstones?
|
cholesterol (most common)
calcium bilirubinate |
|
|
What are the signs/symptoms of cholelithiasis?
|
may be asymptomatic
biliary colic |
|
|
How is cholelithiasis treated?
|
lap cholecystecomy
cheno-/ursodeoxycholic acids (dissolve stones) lithotripsy no longer used |
|
|
What is acute cholecystitis associated w/ 90% of the time?
|
gallstones
|
|
|
What are the signs/symptoms of acute cholecystitis?
|
steady, severe epigastric RUQ pain
N/V fever leukocytosis Murphy's sign guarding/rebound jaundice acute attack precipitated by large fatty meals |
|
|
What may the labs for acute cholecystitis show?
|
elevated WBCs, bilirubin, alk phos
|
|
|
What type of imaging can be used for acute cholecystitis?
|
HIDA (nuclear scan)
RUQ U/S |
|
|
What are the complications of acute cholecystitis?
|
gallbladder gangrene
perforation emphysematous cholecystitis cholangitis chronic cholecysitis porcelain gallbladder (inc. risk for CA) |
|
|
How is acute cholecystitis treated?
|
NPO
analgesics IV antibiotics (ceph +/- Flagyl) Meperidine lap cholecystecomy |
|
|
With acute cholecystitis, whos is better for pain due to less spasm of the sphincter of Oddi?
|
Meperidine
|
|
|
What is the classic picture of cholangitis?
|
**Charcot's triad:
-recurring attacks of severe RUQ pain -fever/chills -associated jaundice |
|
|
What is Reynold's pentad?
|
acute suppurative cholangitis-->endoscopic emergency:
-Charcot's triad -altered sensorium -hypotension |
|
|
What are the essentials of diagnosis for choledocholithiasis & cholangitis?
|
-Hx of biliary pain/jaundice
-sudden severe RUQ pain radiating to R shoulder -N/V -fever, jaundice, leukocytosis -stones in common bile duct |
|
|
What are the signs/symptoms of choledocholithiasis & cholangitis?
|
Charcot's triad
Reynold's pentad hepatomegaly cirrhosis if obstruction >30 days |
|
|
What may the labs for choledocholithiasis & cholangitis show?
|
AST/ALT > 1000
elevated bilirubin/alk phos leukocytosis (cholangitis) |
|
|
What type of imaging should be used for choledocholithiasis & cholangitis?
|
EUS, spiral CT
*ERCP |
|
|
What is the Tx plan for choledocholithiasis & cholangitis?
|
endoscopic sphincterotomy
stone extraction lap chole antibiotics if indicated |
