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174 Cards in this Set
- Front
- Back
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Heartburn
-aka -cause |
pyrosis
reflux of acid or alkali |
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What is achalasia?
cause symptoms diagnosis |
motility disorder with aperistalsis and failure of LES to relax; caused by loss of Auerbach's neural plexus; barium swallow; treat with NTG, dilation with bougie, maybe surgical myotomy
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Zenker's Diverticulum
symptoms age of onset treatment |
protrusion of the pharyngeal mucosa; worsening dysphagia and regurg over years; typically over 60; surgical resection
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4 serious complications of GERD
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stricture
Barrett's esophagus aspiration pneumonia acid laryngitis |
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Bernstein Test
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0.1M solution of HCl dripped into distal esophagus; a positive test reproduces the pt's symptoms
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Tx for GERD
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eliminate precip factors, elevate head of bed on block, antacids, histamine antagonists, PPIs
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Omeprazole, Lansoprazole, Rabeprazole, con't...
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Proton pump inhibitors
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Ranitidine, Famotidine, Cimetidine, Nizatidine
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H-2 receptor blockers
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Barrett's Esophagus
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condition where normal squamous epithelium is replaced by columnar epithelium (precursor to CA)
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Melena vs hematochezia
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melena - black tarry stools
hematochezia - bright red |
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Tx for esophageal varicies
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emergent - endoscopy, gastric lavage, banding
pharm - abx prophylaxis, somatostatin, vit K, lactulose balloon tamponade |
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Mallory-Weiss Syndrome
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mucosal laceration of the gastroesophageal junction; causes upper GI bleeding
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What surgery is considered a common cause of malabsorption
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gastric bypass (Roux-en-Y)
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What causes celiac dz?
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T-cell mediated autoimmune response in the intestinal submucosa that results in destruction of mucosal enterocytes
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Another name for celiac disease
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celiac sprue
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Clinical features of celiac disease (sprue)
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weight loss, dermatitis (rare), distention, flatulence, greasy stools, bone pain, 'rrhea
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Small bowel biopsy in celiac disease shows what
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diffuse damage to the proximal intestinal mucosa resulting in malabsorption
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Tx for celiac sprue
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gluten eliminated from diet, corticosteroids or immunosupp drugs can be employed in refractory cases
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Whipple's disease - definition
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multisystem illness caused by Tropheryma whipplei
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Whipple's dz - features
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malabsorption, many systems affected, fever, LA, arthralgias, biopsy reveals bacillus
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Diagnostic test for Whipple's Disease
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endoscopic biopsy of duodenum; presence of non-acid fast, gram positive bacilli
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Whipple's Dz - treatment
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prolonged abx that cross the BBB are warranted; TMPZ for one year
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Sxs of Bacterial Overgrowth
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many asymptomatic....distension, flatulence, wt loss, steatorrhea (fatty stools)
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Short Bowel Syndrome - definition
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malabsorptive condition that arises secondary to removal of signif segments of small bowel
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Short Bowel Syndrome - causes
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Crohn's (surgical resection), mesenteric infarction, radiation enteritis, trauma, surgical resection of cancer
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Lab diagnosis of lactase deficiency
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hydrogen breath test (ingest 50g lactose, rise in breath H is positive)
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Diarrhea - what is considered acute...persistent...chronic
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less than 14 days
more than 14 more than 30 |
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Chronic 'rrhea suggests the etiology is infectious in nature. T/F
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False
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Most important finding that can indicate infx with invasive bacteria
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FEVER
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Shellfish usually associated with what pathogen
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Vibrio cholerae
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Likely microbes that cause vomiting
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S. aureus, B. cereus, Norwalk-like viruses
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Likely microbes that cause watery 'rrhea
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C. perfringens, ETEC, enteric viruses, c. parvum
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Likely microbes that cause inflammatory 'rrhea
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Campylobacter, salmonella, shiga toxin producing e. coli, shigella, v. paraheolyticus
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Who typically gets stool cultures
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immunocompromised; pts with comorbidities; pts with more severe inflamm diarrhea; pts with underlying inflamm bowel dz; some food handlers
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How long are stool cultures incubated
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up to 72 hours bc some bacteria take longer to grow
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MacConkey agar
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inhibits gram-positive and diff bt gram negative that ferment lactose and those that don't
lactose fermentation also acts as a pH indicator |
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Hectone-Enteric agar - definition....aka...
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like MacConkey; inhibits GP, diff bt Lactose-Pos from Lactose-Neg , GN rods
Also, E. coli is suppressed, and H2S can be detected aka Salmonella-Shigella agar |
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OCP diagnostic studies
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Ova, Cyst, and Parasites
only used in serious cases (persistent 'rrhea, bloody 'rrhea with no fecal leukocytes...) requires 3 samples on 3 consecutive days |
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Clostridium difficile aka?
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Antibiotic Associated Colitis
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What abx are most frequently implicated in predisposition to C. difficile infection
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fluoroquinolones, clindamycin, cephalo, penicillins, metronidazole and vancomycin (virtually all abx)
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Tx for Clostridium difficile
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Metronidazole (ironic bc this can actually cause C diff infection)
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Brat diet
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bananas, rice, applesauce, toast
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What are 5 possible causes of IBS
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abnormal motility
visceral hypersensitivity enteric infx bacterial overgrowth psychosocial abnormalities (depression) |
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How long must symptoms be present to diagnose IBS
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3 months
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What are the 3 types of IBS
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diarrhea predominant
constipation predominant alternating |
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3 complications of diverticulosis
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bleeding, infection, perforation
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What are some clinical findings for diverticulosis
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NONE
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Tx for diverticulosis
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monitor for complications, avoid nuts/seeds, high fiber diet
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Diverticulitis - signs and symptoms
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mild achy abdominal pain that progresses over 2-3 days; tender to palpation; N/V frequent symptom; change in bowel habits
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How do you diagnose diverticulitis
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CT of abdomen and pelvis with and without contrast
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Diverticulitis - treatment
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broad spectrum abx
inpatient - clear liquids, pain management, IV abx outpatient - bland diet, ciprofloxacin + metronidazole; augmentin is also a good option |
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When is surgical intervention indicated for diverticulitis
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recurrent or refractory cases; no evidence of improvement on CT after 72 hrs
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Two other names for Ischemic Bowel Disease
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intestinal angina, visceral artery insufficiency
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4 major types of ischemic bowel dz
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occlusive dz - embolism or thrombosis of a major mesenteric artery
nonocclusive - from low perfusion (CHF, shock) demand mediated dz - post prandial pain occurs due to increased demand ischemic colitis - intestinal mucosa sloughs off |
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What types of imaging are used for ischemic bowel dz
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CTA (CT angiogram) or MRA
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Ischemic bowel dz - treatment
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identify source of occlusion and remove or bypass it
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Hemorrhoids - definition
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swollen or varicose veins in the anal-rectal area; typically painful; caused by pressure in the rectal veins from standing upright, sitting for a long time, and poor bowel habits
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Internal hemorrhoids occur above the ____ line whereas external hem are below
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dentate line
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Strangulated hemorrhoid
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vein that is caught (incarcerated) outside the rectal sphincter
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Hemorrhoids - signs/symptoms
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itching (pruritus ani), bleeding, mucus discharge, pain, soiling of clothes, difficulty pooping
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Fistula vs fissure
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fistula - abnormal connection/passageway bt two epithelium-lined organs or vessels that dont normally connect
fissure - tears in the anal mucosa |
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Fistula - signs/symptoms
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soiling, fecal incontinence, fever/chills, pneumaturia, chronic UTIs
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Fistula - treatment
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must ID fistulous tract by using dye; surgery to remove/repair; abx
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Fissures - treatment
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fiber supplements, Sitz baths, NTG ointment, botulinum toxin injection into external sphincter
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Skin Tags
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redundant tissue that can occur in the ano-rectal area; not malignant despite their often large size
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Condyloma accuminata
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warts; viral infection caused by various types of HPV
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Proctitis - definition, symptoms, transmission, organisms
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inflammation of the distal 15cm of the rectum; anorectal discomfort, tenesmus, constipation, and d/c; sexually transmitted; n. gonorr, t. pallidum, c. trachomatis, HSVII
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Minor incontinence
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inability to control farts or slight soilage of undergarments
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Major incontinence
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complete uncontrolled loss of stool; can be caused by trauma, sphincteric or neurologic damage
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3 major causes of uncomplicated rectal disorders
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constipation, passing hard dry stools, excessive straining
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What 2 diseases does IBD encompass
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ulcerative colitis and Crohn's dz
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Ulcerative colitis - definition
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chronic, recurrent dz characterized by diffuse mucosal inflammation involving only the colon
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Crohn's dz - definition
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chronic recurrent dz characterized by patchy transmural inflammation involving any segment of the GI system from the mouth to the anus
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What part of GI does Crohn's mostly affect
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terminal ileum (though can involve any part of the GI)
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Crohn's - signs/symptoms
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intermittent bouts of low grade fever (UC has no fever), N/V/malaise, wt loss, non bloody diarrhea and RLQ pain
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Ulcerative colitis - s/s
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bloody 'rrhea, lower abdominal cramps and fecal urgency, NO fever, negative stool cultures, tenesmus, LLQ cramps relieved by defecation
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Best way to diagnose Crohn's and UC
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biopsy
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With crohn's you typically see ____ deficiency, with UC you see ____ due to bleeding
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folate/vitB12 deficiency due to malabsorption
iron deficiency anemia |
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What is the cardinal feature of ulcerative colitis
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passage of gross blood or bloody 'rrhea
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Malaise, nausea, vomiting, and fever are more common in Crohn's or UC
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Crohn's
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Most common sites of GI bleeding
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cecum, descending colon, rectosigmoid colon
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Typically see ____ anemia with UC and ____ anemia with Crohn's
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microcytic, macrocytic
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Will crohn's or UC patients more likely undergo surgery
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Crohn's (60-70%), UC is around 30-40%
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What are the stages in the Adenoma-Carcinoma sequence
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small adenomatous polyp (<5mm) --- large adenomatous polyp (>1cm) --- dysplasia --- adenocarcinoma
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How long does an Adenoma-Carcinoma sequence typically take
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approx 10 years
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Which are we more concerned about, hyperplastic or adenomatous polyps
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adenomatous (can progress to cancer)
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What are the 2 types of polyps, what percentage do each account for, what are some features about them
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hyperplastic (33%) - small and distally located, rarely progress to cancer
adenomatous (65%) - more likely to progress to colon cancer |
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Clinical manifestations of colon cancer
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abdominal/pelvic pain (44%)
change in bowel habit (43%) hematochezia/melena (40%) weakness (20%) weight loss (6%) |
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Is hematochezia more often caused by rectal or colon cancer
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rectal
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Risk factors that change colon cancer screening recommendations
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prior colorectal cancer or polyp, IBD, family hx, hereditary nonpolyposis colon cancer, familial adenomatous polyposis
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What are 4 traditional screening modalities for colorectal cancer
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fecal occult blood, sigmoidoscopy, colonoscopy, double contrast barium enema
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What are some disadvantages to the fecal occult blood test for colon cancer
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only detects blood, and the majority of polyps don't bleed; high false positive rate requiring costly work ups
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What is the goal of colon cancer surgery
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complete removal of the tumor along with the major vascular pedicle feeding the affected colonic segment and the lymphatic drainage basin
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What 5 features must be present to diagnose cirrhosis
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abnormal enzyme levels, evidence of liver insufficiency, clinical evidence of portal HTN, known etiology for liver dz, chronicity
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What are some things that can cause cirrhosis
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viral infx (HBV or HCV), fatty liver, alcohol, hemochromatosis, autoimmune dz, biliary cirrhosis
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What is the definitive way to diagnose cirrhosis
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biopsy
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What is Child's-Pugh criteria used for? What parameters are used?
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to assess the prognosis for pts with cirrhosis
albumin, bilirubin, ascites, encephalopathy, PT |
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What is the MELD score?
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assesses severity of chronic liver dz; predicts 3 month mortality; (Model for Endstage Liver Disease)
<20 --- <10% mortality >30 --- >50% mortality |
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What are the 5 clinical stages of cirrhosis
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1 - no varices/ascites
2 - varices without bleeding, no ascites 3 - varices w/bleeding, no ascites 4 - ascites w/out bleeding 5 - ascites and bleeding |
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Ammonia level is a good test for hepatic encephalopathy. T/F
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FALSE
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What is the preferred analgesic for pts with advanced cirrhosis? What is the exception?
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Acetaminophen; NOT to be used in alcoholic patient!
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What infection is lethal in cirrhosis
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V. vulnificus
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What does iron do to the liver
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HEPATOTOXIC; induces formation of free radicals, promotes fibrogenesis
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What are 4 ways you should educate the patient with cirrhosis
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no alcohol, can take acetaminophen but limited amt, avoid raw seafood and exposure to salt water (v. vulnif), no iron and limited VitA intake
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What is HCC? Whats the most common cause of HCC?
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hepatocellular carcinoma
HCV |
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What is hepatic encephalopathy
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confusion associated with the presence of portal HTN
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2 types of hepatic encephalopathy
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overt - altered mental status
minimal - cognitive impairment |
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Hepatic encephalopathy is a ______ diagnosis, NOT a ______ diagnosis
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clinical; laboratory
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What does cirrhosis cause with regards to arterial constriction/dilation
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causes systemic VASODILATION, so patients who used to have HTN and took meds for it need to stop
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What is the most common cause of death in fatty liver dz
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cardiovascular
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Not giving statins to patients with liver disease ______
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kills them ???
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When should a pt with cirrhosis be referred for transplantation
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evidence of decompensation, MELD >16 (typically 22-26)
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Treatments for GERD
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lifestyle mod: stop smoking, avoid large meals, nothing 3 hrs before bedtime, avoid spicy foods, chocolate, tomato products, and other triggers; pharmacotherapy
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Whats the most common type of esophageal carcinoma
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squamous cell (95%); adenocarcinoma (arising from Barrett's Esophagus) is next
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What is the defining clinical feature of esophageal neoplasm
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progressive dysphagia (solid foods) with associated wt loss
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Classic symptom associated with peptic ulcer disease
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burning epigastric pain associated with eating, or with an empty stomach
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Most frequent causes of small bowel obstruction
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postoperative adhesions and hernias, which cause extrinsic compression of the intestine
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Treatment for small bowel obstruction
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nasogastric tube.....time.....if no resolution, surgery
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What disease are skip lesions primarily found in
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Crohn's
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What are some extraintestinal symptoms of Crohn's
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uveitis, iritis, episcleritis, erythema nodosum, peripheral arthritis (large joints), central/axial arthritis (ankylosing spondylitis, sacroiliitis)
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What enzyme is most useful in the diagnosis of acute pancreatitis
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amylase
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Single most helpful test in evaluation for malabsorption
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72-hour fecal fat test
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Treatment for celiac disease
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gluten-free diet
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What is Toxic Megacolon a complication of
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Inflammatory bowel disease
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Most common cause of chronic or recurrent abd pain in the US
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IBS
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A patient with severe pain and bright red blood on defecation in the absence of other symptoms likely has.....
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anal fissure
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Most common cause of chronic pancreatitis in the US
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alcohol abuse
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What infectious agent is the most likely cause of bloody and purulent stools
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shigella species
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What are 3 common findings of acute appendicitis
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RLQ pain, low grade fever, positive psoas sign (vomiting/diarrhea not typically seen)
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What is the psoas sign
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positive test indicates inflamed appendix is retrocecal; demonstrated by getting patient to flex thigh at the hip, if abd pain then is a positive test
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Only liver fxn test that will show the extent of the damage in acute viral hepatitis
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prothrombin time
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Which of the hepatitis viruses are chronic
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A - no
B,C,D,G - yes E - rarely |
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HAV - transmission
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fecal-oral (doesn't exclude hand to hand contact)
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99% of acute hepatitis results in.....
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recovery
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First antibody to appear in hepA
What does it indicate |
anti-HAV IgM
indicates acute dz |
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What does anti-HAV indicate
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acute disease OR past exposure
(includes both IgM and IgG) |
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Treatment for hepA
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supportive; no need for antiviral therapy; prophylaxis for recent contacts
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Transmission of HBV
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percutaneous or parenteral contact with infected blood and body fluids
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Most common form of HBV transmission
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mother to child
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What must be positive for HBV to be diagnosed
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HBsAG (HBV surface antigen)
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+ HBsAG and + HBcAb-IgM (core antigen)
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acute hepatitis B
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95% of adults with acute HBV
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resolved infection
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+ HBsAG and - HBcAB-IgM
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chronic HBV
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Relation between HBV and liver disease
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HBV does NOT cause liver disease; its caused by an immune response TO the virus
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Clinical features of active disease type of chronic hepB
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high viral load, liver inflammation, progression to cirrhosis
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What are some features of immune-tolerant phase chronic hep B
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high viral load; no liver inflammation; low likelihood of progression; common when infx is acquired at birth
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What does + HBsAB tell you
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person is immune to HBV
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What can immunosuppressive agents do to HBV
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reactivation; so any pt on high dose prednisone or chemotherapy need to be screened
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Prevalence of HCV compared to HIV
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3-4x more prevalent
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Risk factors and modes of transmission for HCV
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illicit injection, blood transfusion, HIV or HBV infx, infected mother at birth, multiple sex partners, tattoos
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What is the current treatment for HCV
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pegylated interferon, ribavarin, and direct acting antiviral
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Most common type of chronic viral hepatitis
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Hep C
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Hep D is only found in patients with _____
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Hep B
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3 clinical features to diagnose acute pancreatitis
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abdominal pain
serum amylase and/or lipase >3x ULN compatible CT scan of the abdomen |
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3 pathophysiological phases of acute pancreatitis
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1. trypsinogen to trypsin within the acinar cells
2. intrapancreatic inflamm 3. extrapancreatic inflamm |
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What are some systemic complications of acute pancreatitis
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fever, ARDS, pleural effusion, renal failure, shock, myocardial depression, metabolic complications
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SIRS
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systemic inflammatory response syndrome (seen in severe pancreatitis)
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2 main causes of acute pancreatitis
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gallstones and alcohol
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What is the BISAP score
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used to predict severity of acute pancreatitis
BUN > 25 Impaired mental status Systemic inflamm response Age > 60 Pleural effusion |
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Initial phase of treatment for acute pancreatitis
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FLUIDS; nothing by mouth; 02 supplementation; pain control
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What are some common metabolic complications of acute pancreatitis
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hyperglycemia, hypocalcemia, hypomagnesemia
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Clinical features of chronic pancreatitis
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persistent or recurrent pain; epigastric or LUQ radiation to back; wt loss; foul-smelling stools; epigastric mass; jaundice
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What labs do you evaluate for chronic pancreatitis
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amylase and/or lipase; hyperglycemia, glycosuria; AP and bilirubin; 72h fecal fat; fecal elastase
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What do calcifications in the pancreas upon xray indicate
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chronic pancreatitis
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What are some complications from chronic pancreatitis
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biliary obstruction, pseudocyst, duodenal obstruction, pancreatic fistula
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Chronic pancreatitis - treatment
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avoid alcohol and tobacco!!!
frequent, small volume, low fat meals; pancreatic enzyme supplementation (lipase); manage complications (diabetes) |
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Prognosis of chronic pancreatitis
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poor long-term survival; 50% mortality in 10 years
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Pancreatic cancer - signs/symptoms
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often asymptomatic; wt loss; epigastric pain radiating to back; new onset hyperglycemia; jaundice
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What are some diagnostic tools for early detection of pancreatic CA
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no test currently approved; tumor markers should NOT be used; U/S; MRI; ERCP
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What are some diseases H. pylori can cause
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acute, chronic, or atrophic gastritis
duodenal/gastric ulcers gastric lymphoma or adenocarcinoma |
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What are some nonclassical symptoms that can present with appendicitis
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indigestion, flatulence, bowel irregularity, general malaise
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Advantages/disadvantages of laparoscopic appendectomy
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fewer wound infx, less pain, shorter hospital stay
higher rates of readmission, intra-abd abscess, higher cost |
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What to do if a normal appearing appendix is identified during surgical exploration for right lower abd pain
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appendectomy
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What person in our class looks like a big bowl of diarrhea
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Jonathan Calvarese
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