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76 Cards in this Set
- Front
- Back
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Incidence of H. phylori in PUD?
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H. pylori present in >90% of duodenal ulcers and >75% of gastric ulcers
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Causes of PUD?
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NSAIDS, ASA, and glucocorticoids
more common in men 3:1 duodenal between ages 30-55 gastric between ages 55-65 more common in > 1/2 pack day smokers alcohol and dietary factors do NOT appear to cauise them role of stress uncertain |
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S/S of PUD?
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Gnawing epigastric pain
relief of pain with eating (duodenal) pain worsens with eating (gastric) |
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Physical Findings PUD?
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unremarkable usually; maybe mild epigastric tenderness
GI bleed in 20%: melena, hematemesis, or coffee-ground emesis (so yoiu know its at least at the level of the duodenum) Perforation (5-10%): severe epigastric pain, "board like" abdomen, quiet bowel sounds, rigidity and other signs of an acute abdomen. |
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What 3 things can cause a perforation?
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ruptured ulcer, diverticuli, and appendicitis+peritonitis=quiet bowel sounds, should be no free air
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What bowel sounds would you hear with: obstruction? Perforation?
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obstruction: high pitched tinkling
Perforation: quiet, ominous |
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Lab/Diagnosis with PUD?
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normal, may have anemia on CBC
Consider endoscopy after 8-12 wks of treatment consider H.pylori testing |
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Out-Pt PUD pharmacological mgmt:
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H2receptor antagonists 1st (cemetidine, ranitidine, famotidine, nizatidine)
PPIs (30 min before meals)--(lansoprazole, rabeprazole, pantoprazole, omeprazole, dexlansoprazole) |
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for PUD: what are the mucosal protective agents used and when are they given?
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give them 2 hrs apart from other meds!!
Sucralfate 1mg/qid (Carafate): requires an acidic environment (avoid antacids and H2 blockers--assoc w/ decreases in nosocomial pneumonia Bismuth subsalicylate (Pepto)--has antibacterial action against H.pylori promotes prostaglandin production/stimulates gastric bicarb Misoprostol (Cytotec) 4 x a day with food--used as prophylaxis against NSAID induced ulcers, stim mucus and bicarb production, may stim uterine contraction and induce abortion |
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Your pt has known PUD, what meds would you start out with?
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give PPIs in known cases of PUD, if only suspected you start out with the H2Blocker BID, then add the PPI
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Your pt who has PUD but states that he cannot stop his NSAIDS. What would you prescribe?
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PPI
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Do antacids (mylanta, maalox, MOM etc) reduce the amount of gastric acidity?
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No
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Do H2blockers, sucralfate, and antacids prevent NSAID-Induced ulcers?
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NO
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What 2 antibiotics does H.phlori develop early resistance to?
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metronidazole-(nitroimidazole) (flagyl) and clarithromycin (macrolide) (Biaxin)
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What antibiotic does H.phlori not develop early resistance to?
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amoxicillin (pcn) (Amoxil) or tetracycline (tetracycline)
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What are the 3 main options for pharmacological treatment of H.phlori?
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MOC: Metronidazole (Flagyl) 500mg BID w/meals, Omeprazole (Prilosec) 20mg BID before meals, and Clarithromycin (Biaxin) 500mg BID w/ meals for 7 days.
AOC: Amoxicillin (Amoxil) 1g BID w/ meals, Omeprazole (Prilosec) 20 mg BID before meals, and Clarithromycin (Biaxin) 500 mg BID w/ meals for 7 days MOA: Metronidazole (Flagyl) 500 mg BID w/ meals, Omeprazole (Prilosec) 20 mg BID before meals, and Amoxicillin (Amoxil) 1 gm BID w/ meals for 7-14 days MOA MOC AOC |
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What is an alternative treatment for H.pylori besides MOC, AOC, and MOA?
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Bismuth regiments but require more frequent dosing-4x daily and have more side effects. can give BMT: Bismuth subsalicylate 2 tabs 4x day, metronidazole (flagyl) 250 mg 4 x a day, and tetracycline (Tetracyn) 500 mg 4x a day (all w/ meals and at bedtime).
OR MBT + Omeprazole (Prilosec) The above regimen + Omeprazole (Prilosec) 20 mg twice a day before meals for 7 days |
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What regimen is recommended following PUD pharmacological treatment?
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antiulcer therapy is recommended following PUD treatment for 3 to 7 weeks to ensure symptom relief and ulcer healing--for duodenal ulcer: Omeprazole (Prilosec) 40mg q day or Lansoprazole (Prevacid) 30 mg per day continued for 7 additional weeks--OR
H2B or sucralfate can be given for 6-8 weeks. |
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What would you do for in-hospital mgmt of PUD/bleeding ulcer/potential perforation?
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get IV access, begin fluid or blood, get CBC, PT/PTT, BMP, give 02, endoscopy; GI angiography, foley cath, NPO/NG tube for lavage (bleeding stops spontaneously in 80% of cases), get KUB to check for free air, monitor abdomen for rigidity, tenderness. If coagulopathic give FFP. If thrombocytopenic <50,000 give platelets. get possible surgical evaluation
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What are the causes/incidence of GERD?
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back flow (reflux) of acidic gastric contents into the esophagus--incompetent lower esophageal sphincter (LES), and delayed gastric emptying
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What are S/S of GERD?
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retrosternal "burning", bitter taste in mouth, belching, hiccoughs, dysphagia, excessive salivation, frequently occurs at night and/or in recumbent position, may be relieved by sitting up, antacids, water or food
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What do you find on physical exam for GERD?
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non-contributory
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What diagnostics do you order for GERD?
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esophagogastroduodenoscopy (EGD) to r/o CA, Barrett's esophagus, PUD, etc.
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Whats the mgmt for GERD?
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elevate HOB
avoid alcohol, caffeine, spices, peppermint, etc Antacids PRN H2 Blockers ("-tidines")in high doses at night or divided twice a day dosing PPI ("zoles") if H2 blockers ineffective GI/surgical consult PRN Stop smoking weight reduction if obese |
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What is hepatitis?
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inflammation of the liver with resultant liver dysfunction
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What are the types of hepatitis?
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viral: subtypes A, B, C, (non-A, non-B), D, E, G
Alcoholic |
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What kind of virus is Hep A, how is it transmitted?
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enteral virus that is transmitted thru fecal-oral route
blood and stool infectious for 2-6wk incubation period low mortality rate |
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What kind of virus is Hep B, how is it transmitted?
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a blood borne DNA virus that is in all body fluids. transmitted via blood and blood products, sexual activity, and mother-fetus
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What kind of virus is Hep C, how is it transmitted?
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a blood borne RNA virus, source of infection often uncertain
associated with blood transfusion 50% r/t IVDU |
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what are S/S of Hepatitis?
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Pre-icteric-fatigue, malaise, anorexia, n/v, HA, aversion to smoking and alcohol
Icteric: wt loss, jaundice, pruritus, RUQ pain, clay colored stool, dark urine--may have low grade fever, may have hepatosplenomegaly |
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What lab tests do you run if you suspect hepatitis and what would you expect to see?
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WBC will be low to normal
UA: proteinuria, bilirubinuria Elevated AST/ALT (500-2000 IU/L) LDH, t-bili, alk phos, and PT normal or slightly elevated |
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What serology tests would you use to diagnose Hep A?
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anti-HAV is the antibody
IgM (antibody to HAV which implies recent infection) **these are diagnostic of acute Hep A*** IgG (antibody to HAV) implies previous exposure and confers immunity; presence of IgG alone is not diagnostic of acute HAV infection; it indicates previous exposure, noninfectivity and immunity to recurring HAV infection Summary: Active hep A: Anti-HAV, IgM Recovered hep A: Anti-HAV, IgG |
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What serology tests would you use to diagnose Hep B?
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1. HBsAg-first evidence of HBV infection--will stay positive in asymptomatic carriers and chronic hep B pts
2. Anti-HBc (antibody to HBcAg) and IgM appear shortly after HBsAg disappears and before anti-HBc (antibody specific to HBsAg) appears 3. HBeAg is only found in HBsAg serum and indicates circulating HBV and highly infectious sera ****its presence indicates viral replication and infectivity**** 4. Anti-HBe often appears after HBeAg disappears. It signifies diminished viral replication and decreased infectivity. Summary: Active Hep B: HBsAg, HBe,Ag, Anti-HBc, and IgM Chronic Hep B: HBsAg, Anti-HBc, Anti-HBe, IgM, IgG (both igm and igg mean chronic) Recovered Hep B: Anti-HBc, Anti-HBsAg Note: Anti-HBc is in active, chronic and recovered! think c=co-exists in all of them HBsAg is only in active and chronic HBeAg: think elevated viral load=e in the recovered, i know there will be an anti-HBc, and the only other one is the Anti-HBsAg--both antibodies |
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How are antibodies in Hep C detected?
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PCR (polymerase chain reaction (PCR) --used to differentiate prior exposure from current viremia
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What serology tests would you use to diagnose Hep C?
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Acute Hep C: Anti-HCV, HCV RNA
Chronic Hep C: Anti-HCV, HCV RNA Have to do the PCR to find out if its acute or chronic |
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What is out-patient management for Hep C?
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supportive care, rest during active phase
increase fluids to 3000 or 4000cc/day avoid alcohol or other drugs detoxified by the liver No/low protein diet Oxazepam (Serax) if you must sedate Vitamin K for prolonged PT (>15 sec) Lactulose 30cc orally or rectally for elevated ammonia levels: hepatic encephalopathy |
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What is diverticulitis?
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inflammation or localized perf of one or more diverticula with abscess formation
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what are the causees/incidence of diverticulitis?
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more common in women than men
higher incidence in those with low dietary fiber |
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what are S/S of diverticulitis?
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mild to moderate aching abd pain in LLQ
constipation or loose stools (can look like IBS) Nausea and vomiting |
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what are the physical findings of diverticulitis?
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low grade fever
LLQ tenderness to palpation Pts w/ perf present w/ a more dramatic pic and peritoneal signs |
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What labs/diagnostics would you do and see if you suspect diverticulitis?
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mild to moderate leukocytosis
elevated ESR (indicates inflammation) stool heme + in 25% of cases Sigmoidoscopy shows inflamed mucosa May consider CT scan to eval abscess Plain abd films are obtained on ALL pts. to look for evidence of free air |
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What is in-patient mgmt for diverticulitis?
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NPO dependent on condition
IV fluids for hydration IV antibiotics: Metronidazole (Flagyl), Ciprofloxacin (Cipro-fluroquinolone 2), Ceftazidime (Fortaz-Cephalosporin 3), Clindamycin (Cleocin-macrolide), Ampicillin (Ampicin-PCN), and others If significant bleeding, treat like PUD 20-30% of pts will require surgical mgmt |
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What are the S/S of cholecystitis?
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often precipitated by a large or fatty meal
sudden appearance of steady, severe pain in epigastrum or R hypochondrium vomiting in many clients affords relief Remember: FAIR FAT FEMALE FORTY |
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What are the physical findings with cholecystitis?
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Murphys Sign: deep pain on inspiration while fingers are placed under the R rib cage
RUQ tenderness to palpation; palpable gallbladder in 15% of cases Muscle guarding and rebound pain Fever |
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What labs do you expect to see in a patient with cholecystitis?
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WBC 12-15000
bili may be elevated Serum ALT, AST, LDH, and alk phos levels increased amylase may be elevated plain films may show radiopaque gallstones HIDA scan ****Ultrasound is the gold standard**** |
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How do you manage a pt with cholycystitis?
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pain mgmt
NGT for gastric decompression maintain NPO Crystalloid solutions IV antibiotics, broad spectrum such as Pipercillin (Pipracil) Surgical consult for lap choley |
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what is pancreatitis?
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inflammation of the pancreas due to escape of pancreatic enzymes into surrounding tissue, resulting in an autodigeestive state of the pancreas
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what causes pancreatitis?
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gallbladder disease
heavy ETOH Hypercalcemia Hyperlipidemia Trauma Meds, i.e sulfonamides, thiazides, lasix, estrogen or imuran (azathioprine) |
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what are the physical findings in pancreatitis?
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***NOT AN ACUTE ABDOMEN***
Upper abd tender to palpation no guarding, rigidity or rebound distended abdomen absent bowel sounds (if paralytic ileus present) fever tachycardia pallor, cool skin mild jaundice common |
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what are the 2 signs associated with pancreatitis?
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grey turner sign: flank discoloration
Cullen's Sign: umbilical discoloration |
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what are the symptoms of pancreatitis:
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abrupt onset of steady, severe epigastric pain worsened by walking and laying supine
pain improved by sitting and leaning forward pain usually radiates to the back but may radiate elsewhere N/V weakness, sweating, anxiety in severe attacks |
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what labs and diagnostics would you expect to see with pancreatitis?
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WBC elevation
hyperglycemia LDH and AST elevation **amylase (50-180 U/dL) and lipase (14-280 U/L) elevated in 90% of cases Bun and Creat elevated Hypocalcemia < 7mg/dL associated with tetany; watch for Chvostek's sign and/or Trousseau's sign Elevated C-reactive protein suggests pancreatic necrosis CT scan more useful than ultrasound |
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What is used to evaluate prognosis in pancreatitis?
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Ranson's criteria
5-6 risk factors = 40% mortality >7 risk factors = approx 100% mortality |
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Name the Ranson's Criteria.
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Prognostic signs at admission:
George Washington Got Lazy After, i.e. Greater than 55yo, WBC >16,000, Glucose > 200, LDH>350, AST>250 Prognostic signs during the first 48H. He Broke C-A-B-E Hct drop of >1 BUN incr > 5 Calcium < 8 Arterial 02 < 60 Base deficit > 4 Estimated fluid sequestration > 6000 |
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What is the management for pancreatitis?
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bed rest
NPO agressive IV volume repletion NG suction Pain control once pt is pain free and has BS he can start a clear diet |
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What is a bowel obstruction?
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it is blockage of the lumen of the intestine that impedes passage of gas and contents through the bowel.
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what are the causes/incidence of bowel obstructions?
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Adhesions
Hernia Volvulus Tumors fecal impaction ileus (functional obstruction) |
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What are the S/S of bowel obstructions?
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cramping perumbilical pain initially; later becomes constant and diffuse
vomiting within minutes of pain (proximal); within two hours of pain (distal) minimal or no fever |
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What are the physical findings in a bowel obstruction?
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1. minimal abd distention (proximal)
2. pronounced abd distention (distal) 3. Mild tenderness but no peritoneal findings 4. High pitched, tinkling bowel sounds 5. unable to pass stool/gas |
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What labs/diagnostics would you do if you suspect a bowel obstruction?
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1. lab findings normal in initial stages
2. later may see elevated WBCs and values consistent with dehydration 3. plain films show dilated loops of bowel and air-fluid levels -Horizontal pattern in SBO - Frame pattern in LBO |
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What is the management for a bowel obstruction?
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Fluid resuscitation
NGT suction Broad spectrum antibiotics surgical intervention in all cases of complete obstruction in partial obstruction, may treat medically |
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What is Ulcerative Colitis?
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An idiopathic inflammatory condition characterized by diffuse mucosal inflammation of the colon. Unlike Crohn's disease (upper bowel malabsorption syndrome), UC invariably involves the rectum and may extend upward involving the whole colon. The disease is characterized by symptomatic episodes and remissions.
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What is the Hallmark Symptom for UD?
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Bloody diarrhea
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What labs/diagnostics do you do for UC?
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stool studies are negative
sigmoidoscopy establishes the diagnosis |
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How do you pharmacologically manage pts with UC?
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Mesalamine (Canasa) suppositories or enemas for 3-12 wks.
Hydrocortisone suppositories and enemas |
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What is a mesenteric Infarct?
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A syndrome as a result of inadequate blood flow through the mexenteric circulation leading to ischemia and gangrene of the bowel.
mesenteric infarct vs. pancreatitis fewer that 40% live, tend to have a big cardiac history |
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What are the causes of a Mesenteric Infarct?
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1. arterial or venous (embolus or thrombosis)
2. Atherosclerosis 3. smoking 4. usually occurs in older adults 5. coagulopathy such as that following recent surgery (cardiac, AAA, etc.) increase risk |
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What are the S/S of mesenteric infarction?
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1. sudden onset of cramping, colicky abd pain (perhaps after eating)
2. PAIN OUT OF PROPORTION TO PE findings 3. N/V 4. Fever 5. Adb guarding and tenderness 6. BS: Hyperactive to absent 7. Peritoneal findings increase as state progresses 8. Shock |
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What lab/diagnostics would you see with mesenteric infarction?
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1. elevated amylase
2. leukocytosis 3. abdominal films 4. CT |
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what is the mgmt for Mesenteric infarct?
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emergent surgical intervention
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What is appendicitis?
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inflammation of the appendix, precipitated by obstruction of the appendiceal lumen. If untreated, gangrene and perf may develop w/in 36 hours. most common presentation is among men 18-30 yo. affects approx 10% of the population
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What causes appendicitis?
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fecalith (undigested food)
foreign body inflammation neoplasms |
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What are the S/S of appendicitis?
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begins with vague, colicky umbilical pain
after several hours, pain shifts to RLQ Nausea with 1-2 episodes of vomiting (more vomiting suggests another diagnosis)*** Pain worsened and localized with coughing |
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What are the Physical Findings in appendicitis?
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RLQ guarding with rebound tenderness
Psoas Sign (Iliopsoas Test): pain with R thigh extension Obturator sign: pain with internal rotation of flexed R thigh Positive Rovsing's sign: RLQ pain when pressure is applied to the LLQ Local abd tenderness low grade fever (high fever suggewsts performation or another diagnosis |
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What are the lab/diagnostics in appendicitis?
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WBCs 10,000 to 20,000
CT or ultrasound is diagnostic |
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What is the management for appendicitis?
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Surgical treatment
IV broad spectrum antibiotics IV fluids Pain mgmt |
