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65 Cards in this Set

  • Front
  • Back
what causes GERD?
inappropriate, intermittent lower esophageal sphincter (LES) relaxation
how does GERD classically present?
heartburn, often related to eating and lying supine. but can also manifest as CP, regurgitation, cough or asthma, sore throat, dysphagia, laryngitis or hoarseness or recurrent pneumonia
in what pt's is the incidence of GERD increased?
pts with sliding-type hiatal hernia and obesity
what is initial tx in GERD?
lose weight, elevate head of bed, AVOID coffee, alcohol, tobacco, chocolate, spicy and fatty foods, and meds with anticholinergic properties
if initial tx of GERD fails, what is next step?
antacids, H2 blockers or PPIs can be tried- these are often stated empirically at initial presentation
would you give CIPRO to elderly?
no, b/c of risk of achilles tendon rupture. instead can use bactrim (TMP-SMX)
what kind of surgery is reserved for severe or resistant cases of GERD?
nissen fundoplication
what are the sequelae of GERD?
esophagitis, esophageal stricture (can mimic esophageal CA), esophageal ulcer, hemorrhage, barrett's metaplasia, and esophageal adenocarcinoma (adenocarcinoma has become the leading type of esophageal cancer)
what is the gold standard for diagnosis of GERD?
24 hour esophageal pH monitoring
what is a sliding hiatal hernia?
the entire gastroesophageal juntion moves above the diaphragm pulling the stomach with it; commonly a/w GERD
what is a paraesophageal hiatal hernia?
the gastroesophageal junction stays below the diaphragm but the stomach herniates through the diaphragm into the thorax; is uncommon but serious as can cause strangulation; needs surgical correction
how does peptic ulcer disease (PUD) manifest?
with chronic, intermittent, epigastric pain (burning, gnawing or aching) that is localized and often relieved by antacids or milk
some other symptoms of PUD?
is it MC in male or female?
epigastric tenderness, occult blood in stool, N/V
MC in males
what are the two types of PUD?
duodenal and gastric
what are the characteristics of DUODENAL PUD?
75% of cases, normal to high acid secretion, usually d/t H. pylori, peak age is 40s, pain improves with eating food, then worsens 2-3 hrs later
what are the characteristics of GASTRIC PUD?
25% of cases, normal to low acid secretion, usually d/t NSAIDS, peak age is 50s, eating food does not relieve the pain or makes it worse
what is becoming the first line diagnostic study in PUD?
endoscopy; it's more sensitive (but more expensive) than xray which used to be first line (upper GI barium xray study)
should you biopsy gastric ulcers?
duodenal ulcers?
gastric- yes, always biopsy to exclude malignancy
duodenal- don't have to bx initially
what is the most feared complication in PUD?
perforation, look for peritoneal signs, hx of PUD, for free air on abdominal xray.
how to you treat perforation d/t PUD?
AbRx, and laparotomy with repair of the perforation
what are other complications of PUD?
can get obstruction d/t inflammation and/or stricture
what should you think of if the ulcers are severe, atypical or non-healing?
zollinger-ellison syndrome (get gastrin level) or stomach cancer
do diet changes help heal ulcers?
no, but reduced ETOH and/or tobacco probably help
what it initial treatment of PUD?
H2 blockers or PPIs and AbRx for H. pylori; triple or quadruple drug therapy (amoxicillin, clarithromycin, and a PPI like lansoprazole) for 2 weeks is generally given
what are the surgical procedures that might be performed if medical tx fails?
antrectomy, vagotomy, Billroth I and II.
what should you watch for after surgery for PUD (especially after Billroth)?
dumping syndrome (weakness, dizziness, sweating, N/V after eating); can get hypoglycemia 2-3 hours after meal (causes recurrence of dumping symptoms), afferent loop syndrome (bilious vomiting after a meal relieves abdominal pain), bacterial overgrowth, vitamin deficiencies (B12 and/or iron, causing anemia)
describe upper GI bleeding
occurs proximal to the ligament of Treitz, common causes are: gastritis, peptic ulcer dz, varices, stool is tarry and black (melena), and NG tube aspirate is + for blood
describe lower GI bleeding
occurs distal to ligament of Treitz, commonly caused by vascular ectasia, diverticulosis, colon CA, colitis or IBD, hemorrhoids, red blood seen in stool (hematochezia), NG tube aspirate is negative for blood
what is the first test usually performed in PUD?
endoscopy (upper or lower depending on symptoms)
What are lesions that are treatable endoscopically for PUD?
polyps, vascular ectasias, varices
in PUD if you can find source of slow or intermittent bleeding with endoscopy, how can you find it?
radionuclide or nuclear medicine scan; angiography can detect more rapid bleeding and can embolize the bleeding vessels with this
what is final tx for severe or resistant bleeding?
resection of affected bowel (often the colon)
what diet can partially cause diverticulosis?
low fiber, high fat
what are complications of diverticulosis?
lower GI bleeding and diverticulitis (inflammation of a diverticula)
what are symptoms of diverticulitis?
lower left quadrant pain and tenderness, fever, diarrhea, constipation and leukocytosis
how do you confirm dx of diverticulosis?
CT scan (and can rule out more serious things: abscess, perforation, malignancy)
what is definition of diverticulosis?
herniation of mucosa between two taeniae at point of weakness where the main blood vessel passes into the mucosa
what are the seven categories of diarrhea?
1. systemic causes
2. osmotic
3. secretory
4. malabsorption
5. infectious
6. exudative
7. altered intestinal transit
what are systemic causes of diarrhea?
any illness esp in children (hyperthyroidism, infection)
what are causes of osmotic diarrhea?
nonabsorbable solutes remain in bowel, where they retain H2O (lactose or other sugar intolerances), when the pt stops ingesting the substance (milk or NPO trial), the diarrhea stops
what are the causes of secretory diarrhea?
bowel secretes fluid d/t bacterial toxins (cholera, some strains of E. Coli), vasoactive intestinal peptide-secreting tumor (pancreatic islet cell tumor), or bile acids (after ileal resection) ***only one where diarrhea continues with NPO
what are causes of diarrhea caused by malabsorption?
celiac sprue (look for dermatitis herpetiformis, and stop gluten in the diet), crohn's dz, gastroenteritis, and exocrine pancreatic insufficiency, diarrhea stops with NPO
what are infectious causes of diarrhea?
look for fever, WBCs in stool (with invasive bacteria such as shigella, salmonella, yersinia, campylobacter), and travel (montezuma's revenge caused by E. coli); hiker's and stream drinkers can get giardia which manifests with steatorrhea (fatty, greasy, malodorous stools that float) from small bowel involvement and unique protozoal cysts in stool. tx with metronidazole
what are causes of exudative diarrhea?
inflammation in bowel mucosa causes seepage of fluid. d/t IBD (Crohn's or UC) or cancer
what are causes of altered intestinal transit?
after bowel resections or medications that interfere with bowel function
what should you watch for in diarrhea?
dehydration and electrolyte disturbances (metabolic acidosis, hypokalemia)
what do you look for in rectal exam in pt with diarrhea?
occult blood, ova or parasites, fat content (steatorrhea) and WBCs, and if pt has hx of AbRx test stool for C diff and if + tx with metronidazole (2nd line is oral vanc)
what is factitious diarrhea?
surreptitous laxative abuse, usually in medical personnel
what are some other causes of diarrhea?
hyperthyroidism, colorectal cancer, diabetes
describe irritable bowel syndrome?
anxious or neurotic pts, hx of diarrhea aggravated by stress; bloating, abd pain relieved by defecation and/or mucus in stool. look for psychosocial stressors with normal physical and lab findings. is a dx of exclusion. 3x MC in women than men. tx with reassurance and increased dietary fiber. NO MEDS
what should you watch for after bacterial diarrhea (esp e coli or shigella) in children?
hemolytic uremic syndrome: thrombocytopenia, hemolytic anemia (schistocytes, helmet cells, fragmented RBCs) and actue renal failure. tx supportively: pts may need dialysis and/or transfusions
why should you AVOID antidiarrheal meds in UC and Crohn's?
can lead to toxic megacolon
what are some things that UC and Crohn's both can cause?
uveitis, arthritis, ankylosing spondylitis, erythema nodosum or multiforme, primary sclerosing cholangitis, failure to thrive or grow in children, toxic megacolon, anemia of chronic dz, and fever
how do you tx both crohn's and UC?
5-ASA with or without a sulfa drug (sulfasalazine); use corticosteroids and other immunosuppressants (infliximab, azathioprine) for more severe dz and flare ups
describe toxic megacolon
classically seen with IBD, esp UC and infectious colitis (esp C diff). symptoms: high fever, leukocytosis, abd pain, rebound tenderness, markedly dilated colon on xray
how do you treat toxic megacolon?
is an emergency; d/c all antidiarrheal meds, make pt NPO, insert NG tube, IV fluids, AbRx to cover bowel flora (ampicillin or cefazolin) and steroids is the cause if IBD
what is the site of origin in
1. crohn's
2. UC
1. distal ileum
2. rectum
what is the thickness of pathology in
1. crohn's
2. UC
1. transmural
2. mucosa and submucosa only
what is the progression in
1. crohn's
2. UC
1. irregular (skip lesions)
2. proximal, continuous from rectum, no skipped areas
what is location of
1. crohns
2. UC
1. mouth to anus
2. colon and rectum only (rarely ileum)
change in bowel habits in
1. crohns
2. UC
1. obstruction, abd pain
2. bloody diarrhea
classic lesions in
1. crohn's
2. UC
1. fistulas/abscesses, cobblestoning, string sign on barium xray
2. pseudopolyps, lead-pipe colon on barium xray, toxic megacolon
what is colon cancer risk in
1. crohn's
2. UC
1. slightly increased
2. markedly increased
does surgery cure
1. crohn's
2. UC
1. no (can worsen it)
2. yes (proctocolectomy with ileoanal anastomosis)
what are the signs of acute liver dz?
elevated LFTs, jaundice, N/V, RUQ pain or tenderness and/or hepatomegaly