GI E1 Review

I based this off her study guide/review powerpoint/what was bolded in her lectures; does not include everything!!

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)