AG-ACNP - GI

What bacteria is associated with >90% duodenal ulcers and >75% gastric ulcers?

H. pylori

Which medications cause peptic ulcer disease?

NSAIDS

ASA

Glucocorticoids

At what age do duodenal ulcers typically present?

30-55 yo.

At what age do gastric ulcers typically present?

55-65 years old

What are the signs and symptoms associated with a duodenal ulcer?

Gnawing, epigastric pain

Relief of pain WITH eating

What are the signs and symptoms associated with a gastric ulcer?

Gnawing, epigastric pain

Pain WORSENS with eating

What are the expected physical findings associated with PUD?

Physical exam unremarkable

GI bleeding - melena, hematemesis or coffee-ground emesis (duodenum)

In a patient presenting with coffee-ground emesis, where does the ACNP suspect the ulcer is located?

In the duodenum

What are the signs and symptoms of a perforated peptic ulcer?

Severe epigastric pain

BOARD LIKE abdomen

QUIET BOWEL SOUNDS

Acute abdomen

What is the first-line treatment in PUD?

H2 Blocker - Ranitidine (Zantac) 300 mg/hr at SLEEP

Famotidine (Pepcid) 40 mg/hrs at SLEEP

When should you educate patients on administration of a Proton Pump Inhibitor?

Patient should take PPI 30 minutes before meals

What is the BBW associated with PPIs?

HIP FRACTURE

What is the dosing for PPIs in PUD?

Pantoprazole (Protonix) 40 mg/day

Omeprazole (Prilosec) 20 mg/day

What patient education is needed when prescribing Mucosal Protective Agents?

Sucralfate (Carafate) 1 gm PO QID

Requires acidic environment - avoid ANTACIDS and H2 Blockers

What medication used in treatment of PUD is also associated with decreases in nosocomial PNA?

sucralfate (Carafate) - mucosal protective agent

What medication indicated in the management of PUD has antimicrobial action against H.Pylori?

bismuth subsalicylate (Pepto-Bismol)

Which medication is used as ppx against NSAID-induced peptic ulcers?

misoprostol (Cytotec)

What are examples of antacids?

Mylanta

Maalox

Milk of Magnesia

What medications are used in combination therapy MOC indicated for H.Pylori treatment?

Metrondiazole (Flagyl)

omeprazole (Prilosec)

clarithryomycin (Biaxin)

BID x 7 days

What medications are used in combination therapy AOC for H. Pylori?

Amoxicillin

omeprazole (Prilosec)

clarithromycin (Biaxin)

What two medications does H. Pylori develop the least resistance to?

amoxicillin

tetracycline

What is the duration of antiulcer therapy?

3-7 weeks to ensure symptom relief and ulcer healing

What is the common CXR finding associated with inpatient hospital PUD/GI bleed/Perforation management?

CXR - upright, decubitus films show free air = PNEUMOPERITONEUM

What diagnostic is standard for inpatient PUD management?

Endoscopy - GI angiography

What medication is standard in in patient PUD management?

IV H2 Blockers

What medications do NOT prevent NSAID-induced ulcers?

Antacids

H2 Blockers

sucralfate (Carafate)

42 yo. M presents to your clinic with complaints of epigastric pain that increased intensity over past two weeks. He describes the pain as decreasing after he eats. This finding mostly suggests what?

Duodenal ulcer

Define GERD.

The backflow of acidic gastric contents into the esophagus

What are the two main causes of GERD?

Incompetent lower esophageal sphincter

Delayed gastric emptying

A 65 yo. M complains of dysphagia and epigastric pain. He reports hx of ETOH use and smoking for 25 years. What is the most likely diagnosis?

GERD

What is are the hallmark signs and symptoms associated with GERD?

Occurs at night and/or in recumbent position

Retrosternal burning sensation

Bitter taste in mouth

In the elderly, what is a classic sign of GERD?

Dysphagia

What diagnostic procedure is used in GERD?

EGD - r/o cancer, Barrett's esophagus, PUD

What is the medical management of GERD?

Antacids PRN

H2 blockers - at hour or sleep or BID

PPI

GI/Surgical consult PRN

What pharmacological agent was initially marketed for and used most commonly in the treatment of GERD?

omeprazole (Prilosec)

Define Hepatitis.

Inflammation of the liver, with resultant liver dysfunction.

Define Hep. A.

ANAL

Enteral virus, transmitted via ORAL-FECAL route.

How long is the blood and stool of an individual with Hep A infective?

2-6 week incubation period

What are the common sources of Hep. A?

contaminated food and water

intimate sexual body contact - body secretion exchange

What is the mode of transmission for Hep. B?

Blood

Sexual activity

mother-fetus

Define Hep. B.

Blood borne DNA virus found in serum, semen, saliva and vaginal secretions

Define Hep. C

Blood borne RNA virus.

What is the mode of transmission of Hep. C virus?

Blood

- transfusions

- IVDU

What signs and symptoms are characteristic of the pre-icteric phase of Hepatitis?

Aversion to smoking and ETOH

Fever

Nausea

HA

Malaise

Anorexia

What signs and symptoms are characteristic of the icteric phase of Hepatitis?

Clay colored stool

RUQ pain

Jaundice

Dark urine

Pruritus

Weight loss

What is hallmark lab values suggestive of Hepatitis?

Elevated AST/ALT (n: 500-2000) >35-40

What serology tests are associated with active Hep. A?

Anti-HAV

IgM

What serology marker is indicative of Hep A noninfectivity?

Anti-HAV

IgG

What is the serology tests associated with active Hep B.?

HBsAg

HBeAg

Anti-HBc

IgM

What are the serology markers characteristic of immunity to Hep B?

Anti-HBsAg, Anti-HBc

True or False: There is a chronic form of Hep. A.

False. There is NO chronic form of Hep. A.

Hep A peaks at one week and disappears in 3-6 months

What is the first evidence of Hep B infection?

Hep B surface antigens - HBsAg

What indicates cirulating HBV and highly infectious serum in Hep. B patient?

HBeAg - protein derived from HBV core

What is the serology test associated with active Hep. C?

Anti-HCV, HCV RNA

What diagnostic is used to determine the presence of antibodies in Hep C?

Enzyme immunoassay

What diagnostic test is used to distinguish prior exposure from current viremia in Hep C?

Polymerase Chain Reaction (PCR)

What is the management for Hepatitis?

Supportive, increase rest

FLUIDS 3-4L/day

NO protein diet

No ETOH

What drug is indicated for elevated ammonia levels causing hepatic encephalopathy?

Lactulose 30 mL PO or PR

What is indicated in the management of a prolonged PT interval (>15 seconds) in a hepatic patient?

Vitamin K - clotting

Define diverticulitis.

Inflammation or localized PERFORATION of one or more diverticula WITH ABSCESS formation

Inflammation

Perforation

Abscess formation

What type of pain is associated with diverticulitis?

Cramping LLQ pain

What is a significant cause of diverticulitis?

Low fiber diet

45 yo. M presents to your office with complaints of colicky, cramping abdominal pain in the left lower quadrant, and recent history of constipation. Patient now complains of nausea and vomiting x 2 days. You suspect:

Diverticulitis - inflammation, perforation, abscess formation

What diagnostic is obtained on all patients presenting with diverticulitis?

CXR - assess for free air in abdomen; pneumoperitoneum

A positive stool heme test is suggestive of what GI disorder?

Diverticulitis - positive stool heme in 25% patients

What is standard diagnostics used in diverticulitis?

Stool heme test (+)

Sigmoidoscopy - inflamed mucosa

CT scan - abscess evaluation

CXR - pneumoperitoneum

What is the inpatient management of diverticulitis?

NPO

IVF - hydration

IV Abx

metronidazole (Flagyl)

ciprofloxacin (Cipro)

clindamycin (Cleocin)

ampicillin

GI surgical consult

Define cholecystitis.

Inflammation of the gallbladder

What is the most common cause of cholecystitis?

Gallstones - >90% of cases

What are the hallmark signs and symptoms associated with cholecystitis?

Precipitated by large, fatty meal

Sudden onset steady, severe epigastric pain or R hypochondrium

Vomiting - relief

What classic physical examination finding is suggestive of cholecysititis?

Murphy's Sign - deep pain on inspiration while fingers are placed under right ribcage

Guarding

Rebound tenderness

RUQ finger placement under ribs = PAIN on inspiration

True or False: A patient will experience relief of pain with vomiting in the presence of cholecystitis.

True. Vomiting provides relief in these patients.

What is the gold standard in diagnosing cholecystitis?

Ultrasound

What is the treatment of cholecystitis?

PAIN meds

IVF

NPO - Gastric lavage

IV abx - piperacillin

Lap cholecystectomy

What are the two most important interventions in the management of cholecystitis?

NPO

IV broad spectrum abx - piperacillin

What is the pathology of pancreatitis?

Acute inflammation of the pancreas due to escape of pancreatic enzymes into the surrounding tissue, causing autodigestion of the pancreas.

What is the number one cause of acute pancreatitis?

Gallbladder disease

Others: ETOH use, Hypercalcemia, hyperlipidemia, trauma, drugs (sulfonamides, furosemide, thiazides, estrogen)

What is a classic presentation of a patient with acute pancreatitis?

SUDDEN severe epigastric pain worsened with movement/walking and supine

Pain improved with sitting and leaning forward

Grey and Turner's signs are indicative of what GI disease?

Acute hemorrhagic pancreatitis

Greys - flank ecchymosis

Turners - umbilical eccymosis

What are the classic physical findings in acute pancreatitis?

Distended abdomen

Absent bowel sounds (paralytic ileus)

What lab findings are elevated in 90% of patients with acute pancreatitis?

Amylase (50-180)

Lipase (14-280)

What lab value is suggestive of pancreatic necrosis?

Elevated C-reactive protein

What electrolyte abnormality is commonly seen with acute pancreatitis?

Hypocalcemia

What is the gold standard diagnostic for acute pancreatitis?

CT scan more useful than ultrasound

What is the medical management of acute pancreatitis?

Bed rest

NPO

NGT LWS

IVF - hydration

Pain meds

In the management of acute pancreatitis, when is it indicated to advance from NPO to clear liquid diet?

Once patient is PAIN FREE and BOWEL SOUNDS RETURN

Define bowel obstruction.

Blockage of the lumen of the bowel that impedes movement of gas and contents through bowel

What are the causes of a bowel obstruction?

Adhesions

Tumors

Volvus

Hernias

Fecal impaction

Ileus

What sign is indicative of a proximal bowel obstruction?

Vomiting within MINUTES of pain.

What sign is indicative of a distal bowel obstruction?

Vomiting within hours of pain

Pronounced abdominal distention

Cramping, periumbilical pain that become constant and diffuse is suggestive of?

Bowel obstruction

What bowel sounds are associated with a bowel obstruction?

High pitched, tinkling bowel sounds

What is the diagnostic standard for bowel obstruction and what are the findings?

Plain abdominal films - dilated loops of bowel and air-fluid levels

Horizontal pattern - SBO

Frame pattern - LBO

What is the management of a bowel obstruction?

IVF

NGT LWS

Broad spectrum abx

Define ulcerative colitis.

Idiopathic inflammation of the colon and rectum.

DIFFUSE inflammation

What is a defining characteristic of Chron's Disease?

Entire span of GI tract. Diffuse, transluminal mucosal irritation.

What is a classic characteristic of ulcerative colitis?

Symptomatic episodes and remission

What is the hallmark sign of ulcerative colitis?

Bloody diarrhea.

What establishes diagnosis of ulcerative colitis?

Sigmoidoscopy

Stool studies negative

What is the medical management of ulcerative colitis?

mesalamine (Canasa) suppositories or enemas x 3-12 weeks

Hydrocortisone suppositories and enemas