Studied by 9 people
What are the alarm sx?
constant or severe pain, unintentional wt loss, persistent vomiting, dysphagia, odynophagia, hematemesis, melena, hematocherzia, abd mass, unexplained IDA, fhx GI cancer
What should be apart of the plan if alarm sx are present?
further evaluation via endoscopy & abd imaging
What condition is characterized by epigastric pain or burning, early satiety, or postprandial fulness?
dyspepsia (indigestion)
What is heartburn?
retrosternal burning
What kind of dyspepsia?
younger pt
variety abd & GI sx
anxiety, depression, or stress
non-ulcer dyspepsia
What kind of dyspepsia?
older pts; >55
often smokers
pain changed w/ food or meds
peptic ulcer dyspepsia
What is the study of choice for all pts ≥60 w/ dyspepsia or <60 with alarm sx? ?
EGD
What should be done for dyspepsia pts <60, no alarm sx, and negative PE?
lifestyle modifications & H. pylori testing
What should be done for pts >45 y/o born in areas with increased incidence of gastric cancer?
refer for endoscopy
What are the non-pharm tx options for dyspepsia?
lifestyle mods (food diary, avoid lying down after meals, etc)
What are pharmacological tx options for dyspepsia if no improvement with lifestyle modifications?
antacids, H2RAs, low dose antidepressants, PPIs, prokinetic agents, triple drug therapies for H. pylori
What is the MCC of constipation?
Diet- inadequate fiber, fluids, or exercise
What should be done for a patient presenting with constipation and alarm sx?
colonoscopy, flex sig, BA enema
What should be avoided in pts > 55 y/o with known kidney disease or on meds that affect kidney function?
sodium phosphate (Osmoprep, Fleets phosphor-soda)
What is the clinical presentation of a fecal impaction?
dec appetite, N, V, abd pain & distention, diarrhea from liquid stool seeping around impaction, and palpable firm feces on PE
What is the treatment for fecal impactions?
DRE, saline/mineral oil enemas, disimpaction
What alarm sx are associated with diarrhea requiring immediate workup (stool specimen)?
bloody, fever, abd pain
What classifies diarrhea as acute?
< 2 weeks
What classifies diarrhea as chronic?
> 4 weeks
How does non-inflammatory diarrhea present?
watery & non-bloody, cramps, bloating, N, V, large volumes
How does acute inflammatory diarrhea present?
bloody, fever, small volumes, LLQ cramps, urgency, tenesmus, + fecal leukocytes
What are possible complications of non-inflammatory diarrhea?
hypokalemia, metabolic acidosis
What are possible complications of acute inflammatory diarrhea?
HUS
What is the best treatment for non-bloody (noninflammatory) diarrhea?
bowel rest (BRAT diet) & rehydration
What is the treatment for acute infectious diarrhea?
anti-diarrheal agents (kaopectate, pepto-bismol, loperamide)
abx in select pts (rifaximin- traveler’s, cipro, azithro)
What is the treatment for acute inflammatory diarrhea?
oral fluids (no antidiarrheal agents or abx)
What kind of chronic diarrhea?
fecal water output inc; fecal osmotic gap
stool volume dec w/ fasting
etio: antacids, lactulose, sorbitol, lactose intolerance, magnesium/sodium sulfate laxatives, carb malabsorption
osmotic
What kind of chronic diarrhea?
no malabosrbed solute / fecal osmotic gap
large watery volumes (>1L/day),
little change w/ fasting, painless
etio: hormonal, meds, stimulant laxative abuse, alcoholism
secretory
What kind of chronic diarrhea?
wt loss, anemia, hypoalbuminemia
fecal fat > 10g/24 hrs
etio: SB mucosa dz, lymph obstruction, pancreatic dz
malabsorption
What kind of chronic diarrhea?
systemic dz or prior abdominal surgery
chronic peristalsis
motility induced
What are treatment options for chronic diarrhea?
narcotic analogues- loperamide, BSS, lamotil
narcotics (avoid), cholestyramine
What always needs to be r/o with chronic diarrhea?
cancer
What is the major goal when evaluating abdominal pain complaints?
determine if life threatening surgical dz (dissecting AA, perforated viscus, bowel obstruction)
What should be done for females presenting with abdominal pain?
rectal & gynecologic exams, UA & pregnancy tests
A sensation of a non-painful lump in the throat due to the cricopharyngeal muscle becoming too tight is ______
globus pharyngeus / hystericus
What is the study of choice for persistent heartburn, odynophagia and abnormalities on barium studies?
upper endo (EGD)
What is the gold standard for assessing motility disorders?
esophageal manometry
A substernal burning originating in epigastrium and radiating up into chest is a cardinal symptom of _____
GERD
What are clinical findings associated with GERD?
heartburn 30-60 min after meals that is relieved with antacids
What is NOT recommended to perform in GERD patients?
barium radiographs, manometry, H. pylori screening
What is the first recommended tx for GERD?
lifestyle mods
What is the pharmacological tx for GERD?
PPIs (most effective) & H2RAs (non-erosive dz)
What should be done for GERD patients unresponsive to treatment or presenting w/ alarm sx?
refer for EGD
What is seen on a bx in Barrett’s esophagus?
metaplastic columnar epithelium at distal esophagus that replaced squamous epithelium
What does the presence of dysplasia in Barrett’s esophagus increase the risk of progression to?
adenocarcinoma
What are the only agents that heal ulcers and erosions?
PPIs
What is the treatment for Barett’s esophagus?
long-term PPIs
What is the pathophysiology of esophageal strictures?
reflux induced ulceration → fibrous tissue production & collagen deposition in esophagus → gradual development of solid food dysphagia
What is the recommended evaluation & mgmt for recurrent strictures?
EGD (r/o malignancy)
dilators & long term PPIs
What infection would you suspect in an immunocompromised patient with esophagitis?
candida albicans, HSV, CMV
What is a Mallory-Weiss tear?
non penetrating mucosal tear at GE junction
What are precipitating factors to a Mallory Weiss tear?
prolonged vomiting/retching; alcoholism
What is the typical presentation of a mallory-weiss tear?
hematemesis & hx vomiting or retching
What is the treatment of mallory-weiss tear?
self limiting or endoscopic hemostatic therapy
What is Boerhaave syndrome / effort rupture?
full thickness (transmural) tear in esophagus associated w/ overindulgence & forceful vomiting
What are clinical findings associated with Boerhaave syndrome?
severe CP, sepsis, shock, pneumomediastinum (Hammans sign), pyopneumothorax
What condition is a pharyngeal mucosa protrusion at posterior hypopharyngeal wall (Killian’s triangle)?
Zenker’s diverticulum
What has the highest mortality and morbidity of any upper GI bleed?
esophageal varices
What is the treatment for esophageal varices?
fluids, FFP, platelets, emergent endo
IV octreotide, vasopressin, NTG, BBs
surgery- TIPS
What is the typical presentation of esophageal cancer?
M > F; 50-70 y/o
progressive solid dysphagia, odynophagia, anorexia, hoarseness, anemia, LAD, hepatomegaly
What diagnostic studies are done for esophageal cancer?
upper endo w/ bx, BA esophagram, CXR
The following clinical findings are seen in what disease?
aperistalsis in distal 2/3 of esophagus
progressive dysphagia; regurgitation of undigested food
cough, heartburn, wt loss, aspiration
pt attempt to enhance emptying by lifting neck, throwing shoulders back, & valsalva
achalasia
How would achalasia appear on a barium esophogram?
birds beak tapering of esophagus
late finding→ dilation
How is achalasia diagnosed?
barium esophagam, confirm w/ manometry
What is the treatment for achalasia?
pneumatic dilation of LES, surgery, CCBs, botox
What is the typical presentation of diffuse esophageal spasms?
severe retrosternal CP & intermittent dysphagia
made worse by hot/cold foods, rapid eating, large meals, emotions, carbonation
How would a diffuse esophageal spasm appear on a barium esophagram?
corkscrew appearance of esophagus
What condition is often confused with angina pectoris due to the relief of CP with NTG?
diffuse esophageal spasm
What is the treatment for diffuse esophageal spasms?
PPIs, SL NTG & CCBs, antidepressants, botox, surgery
what condition can have the following sx after gluten ingestion?
unexplained, nonspecific GI sx (diarrhea, steatorrhea, flatulence)
unexplained iron/folate/B12 deficiency
dermatitis herpetiformis
PE- loss of muscle mass/SC fat, pallor, bone pain, hyperactive bowel sounds, hyperkeratosis
Celiac disease
How is celiac disease tested for?
small bowel bx; 24hr stool for fecal fat (>7g)
serology: IgA tTG & EMA > antigliadin ab
What is needed for confirmation of celiac disease diagnosis?
positive serology & small bowel bx
What is the typical presentation of SIBO?
wt loss, diarrhea, steatorrhea (rare), flatulence, bloating, distention, fatigue
elderly→ B12 depletion that mimics pernicious anemia
What tests can be done to dx SIBO?
breath test, empiric abx trial, CBC, stool collection for steatorrhea, barium w/ SBFT or CT
What is the recommended treatment for SIBO?
abx: rifaximin > cipro, norfloxacin, augmentin, metro + bactrim combo
What is the clinical presentation of lactase deficiency?
bloating, cramps, flatulence, N or D w/in 30min-2hrs after ingestion
How is lactase deficiency diagnosed?
empirical trial of diet elimination & hydrogen breath test
What is the treatment for lactase deficiency?
restriction of dietary lactose, lactase enzyme supplement (lactaid), calcium supplement
What condition?
malabsorption after gastric surgery
pain, cramping, N, V
hypovolemia & hypoglycemia (dec BP, weak, tachy, pallor, diaphoresis, confusion)
Dumping syndrome
What is the treatment for dumping syndrome?
smaller frequent meals (6-8/day), dec fatty foods & carbs
What is the typical presentation of acute paralytic Ileus?
abd discomfort → steady severe pain w/ strangulation
N, V, distention, obstipation
hyperactive high pitched tinkling bowel sounds; peristaltic rushes
How would acute paralytic ileus appear on imaging?
diffuse gas filled loops of small & large bowel +/- air fluid levels
What is the treatment for acute paralytic ileus?
tx underlying, IV fluids, NPO, NG tube low intermittent suction, surgery
What is the typical presentation of SBO?
abd pain, N, V, bloating, obstipation
hypoactive & high pitched tinkling bowel sounds, hyper resonance, tachycardia & signs of dehydration
What is the MCC of mechanical SBOs?
adhesions from prior surgery
What indicates a perforation of SBO on imaging?
free air under diaphragm
what is the treatment for SBO?
emergent surgical consult, IV fluids, NPO, NG tube w/ suction
What is a sudden twisting of the bowel on itself leading to obstruction and ischemia, most commonly in the cecum or sigmoid colon?
volvulus
What is intussusception?
invagination of a portion of the bowel into a distal portion → constriction, edema, & hemorrhage
What is the clinical presentation of intussusception?
children: severe colicky pain, currant jelly stools, sausage like abd mass
adults: crampy abd pain
What condition?
extreme dilation and immobility of colon
MC sx→ severe bloody diarrhea
emergent treatment → decompression, IV fluids, surgical resection
toxic megacolon
What is the pathophysiology of Hirschsprung disease?
congenital abence of autonomic smooth muscle ganglia → aganglionic bowel segment contracts but relaxation does not occur → stasis of stool
What condition is MC in males and often coexists with other anomalies such as Down Syndrome?
Hirschsprung disease
What is the most common neuroendocrine tumor, most frequently in the SI, that develops from enterochromaffin cells & produces hormones?
carcinoid tumors
What can result from secreted hormones from carcinoid tumors and cause sx of diarrhea, abd pain, wheezing, and flushing?
carcinoid syndrome
What must be administered pre-op to prevent carcinoid crisis during surgery?
somatostatin
What is the most common abdominal surgical emergency?
appendicitis
What is the typical presentation of appendicitis?
generalized periumbilical pain → localized RLQ pain
N, V, anorexia, constipaiton or diarrhea, fever, rebound tenderness at mcburney’s, + psoas & obturator
What is the best study for further evaluation of appendicitis?
abdominal CT (dilated tubular structure w/ small amount of air in lumen)
What medication should be given for NSAID related injury in patients who CANNOT d/c NSAID use?
Misoprostol (Cytotec)
