GI ER

Here's your content in bullet points, with no changes:

Appendicitis

  • Special tests:

    • McBurney sign: (rebound)

    • Rovsing sign: LLQ palpation

    • Obturator: R hip internal rotation

    • Psoas: R hip extension, lay on left side

  • Dx:

    • US (DOC)

    • CT abdomen with contrast (target)

  • Tx:

    • Surgery

    • Antibiotics pre-op: Cefoxitin, Cefotetan

  • Other:

    • NPO

    • IVF

    • Pain control

    • Emetics

Obstruction (Small/Large Intestine, Volvulus)

  • About: Obstruction causing hypovolemia

  • Causes:

    • Adhesions

    • Tumor

    • Hernia

    • Volvulus

  • MCC:

    • SBO: Adhesion/Hernia

    • AC LBO: AC, diverticulitis, volvulus

  • Volvulus: MCC sigmoid

  • Sx:

    • Nausea

    • Vomiting

    • Abdominal pain

    • Constipation

  • Remember: 3, 6, 9

  • Dx:

    • X-ray: Coffee bean sign (no haustrae)

    • CT: Whirl sign

  • Tx:

    • NPO

    • IVF

    • NGT (< N/V)

Cholecystitis

  • Bacteria: E. coli (most common)

  • Chronic cholecystitis: Fibrosis + thickening

  • Sx:

    • Continuous RUQ pain after fatty or large meals

    • Nausea

    • Fever

    • Palpable gallbladder

  • Dx:

    • Murphy's sign

    • Boa sign

    • US (TOC)

    • CT (Alternative)

    • HIDA scan (Most accurate)

  • Tx:

    • NPO

    • IVF

    • Ceftriaxone + Metronidazole

    • Cholecystectomy (within 72 hrs)

    • Cholecystostomy (if unable to operate)

Cholesterolosis (Strawberry GB)

  • About: Fat in the gallbladder (remove)

Cholelithiasis / Choledocholithiasis

  • Sx: Biliary colic pain

  • Dx:

    • US (1st)

  • Tx:

    • Ursodeoxycholic acid, or wait if < 4mm

Choledocholithiasis

  • About: Blocked bile duct

  • Sx:

    • Prolonged biliary colic

    • Jaundice

  • Dx:

    • AST/ALT, Alk phos, GGT

    • US (1st)

    • ERCP (TOC/Tx)

  • Tx:

    • ERCP stone extraction

    • 2nd: Laparoscopic cholecystectomy

Gastroenteritis

  • Viral:

    • Rotavirus (<5)

    • Norovirus (food)

    • Adenovirus (<4)

  • Bacterial:

    • Campylobacter

    • E. coli

    • Salmonella

    • Vibrio

    • C. difficile: Metronidazole/Vanco, Azithromycin, Ceftriaxone

  • Parasites:

    • Giardia

    • Entamoeba histolytica

    • Treatment: Metronidazole, Tinidazole

Mesenteric Ischemia

  • Acute:

    • MC: SMA (Superior Mesenteric Artery)

    • Inferior Mesenteric Artery (IMA)

  • Chronic: Atherosclerosis, high-fat meals

  • RF:

    • A-fib

    • MI

    • Valvular heart disease (embolism > thrombosis)

  • Location: Splenic flexure (MC)

  • Sx:

    • Severe pain (no focal tenderness)

    • Avoid food

  • Dx:

    • CT angiography (CTA) abdomen/pelvis

    • Follow-up colonoscopy

  • Tx:

    • NPO

    • IVF

    • Anticoagulation: Unfractionated heparin (UFH)

    • Antibiotics

    • Revascularization: Open embolectomy, stent

Toxic Megacolon

  • About: Life-threatening acute colonic dilation (infection vs inflammation)

  • Infection: C. difficile

  • Inflammation: Ulcerative Colitis (UC)

  • Sx:

    • Bloody diarrhea

    • Vomiting

    • Abdominal pain

    • Sepsis

  • Dx:

    • High neutrophil count

    • Leukocytosis

    • ESR

    • Low potassium

    • Anemia

    • Criteria: AXR: > 6 cm, Fever, HR: 120, Leukocytes, AMS, Hypotension

  • Tx:

    • Admission

    • NPO

    • Bowel decompression with NG tube

    • Antibiotics: Ampicillin, Gentamicin, Metronidazole

    • IV steroids (for IBD, not infection)

    • Surgery: Colectomy, ileostomy if no response in 24-72 hrs

Diverticulosis

  • About: Outpouching of colon wall

  • MC location: Left colon

  • MCC of bleed: Right colon

  • Sx: MCC for lower GI bleed

Diverticulitis

  • About: Microscopic perforation leads to inflammation and necrosis

  • Location: Sigmoid (MC)

  • Dx: CT scan, leukocytosis

  • Tx: Metronidazole + Ciprofloxacin/Levofloxacin

Acute Pancreatitis

  • About: Acinar cell injury due to gallstones, alcohol

  • Sx:

    • Abdominal pain radiating to the back

    • Worse when lying back

    • Better when leaning forward

  • Necrotizing/hemorrhagic: Cullen's sign, Turner’s sign

  • Dx:

    • Acute pain + elevated Lipase/Amylase (x3)

    • US

    • CT

    • X-ray: Sentinel loop, colon cutoff sign

  • Tx:

    • NPO

    • IVF (Lactated Ringer's)

    • Meperidine

Esophageal Spasm / Esophagitis

  1. Infectious: Candida (IC)

  2. Eosinophilic: Allergies (asthma, eczema)

  3. Pill-induced: NSAID, Bisphosphonates

  4. Caustic (corrosive): Corrosive substance

  • Sx:

    • Odynophagia (painful swallowing)

    • Dysphagia

    • Retrosternal chest pain

  • Dx: Upper endoscopy

  • Tx:

    • Spasm: CCB, antidepressants, Botox

Esophageal Varices

  • About: Upper GI bleeding (UGIB)

  • Sx:

    • Hematemesis

    • Melena

  • Dx: Upper endoscopy

  • Tx:

    • Prophylaxis: Beta-blockers + band ligation

    • Antibiotics: Ceftriaxone x 7 days

    • Hemorrhage:

      • Packed RBC (Hgb < 7)

      • Octreotide or vasopressin

      • 1st Line: Variceal band ligation

      • Alternative: TIPS

Mallory-Weiss Syndrome

  • About: MCC: Persistent retching/vomiting post-EtoH

  • Sx:

    • UGI bleed post-vomiting

    • Melena

    • Syncope

    • Abdominal pain

  • Dx: Upper endoscopy: Mucosal erosion

  • Tx:

    • PPI

    • Thermal coagulation

    • Endoscopic band ligation

Upper GI Bleeding

  • Separate UGIB from LGIB: Ligament of Treitz (actual lig)

  • Sx:

    • Proximal: Hematemesis (coffee ground), Melena

    • Distal: Hematochezia

  • Dz:

    • PUD

    • Esophageal Ulcer

    • Mallory-Weiss tear

    • Variceal bleeding

    • Malignancy

  • Dx: Upper endoscopy

    • Lab: BUN to Creatinine ratio (+30:1)

  • Tx:

    • IVF

    • Transfusion

    • PPI

    • Octreotide (for varices)

**Lower GI

Bleeding**

  • Sx: Hematochezia (maroon/red blood with clots)

  • Dz:

    • Hemorrhoid (painless bleeding)

    • Anal fissure (bleeding, rectal pain with bowel movement)

    • Proctitis (rectal bleeding and abdominal pain)

    • Polyps (painless bleeding)

    • Colorectal Cancer (painless rectal bleeding with bowel changes)

  • Dx:

    • Lab: BUN/Creatinine ratio (normal)

    • Stool guaiac

    • Colonoscopy, CTA

Ulcerative Colitis

  • RF: Non-smokers

  • 3 types:

    • E1: Rectum

    • E2: Left-sided

    • E3: Extensive (right)

  • Sx:

    • Bloody diarrhea

    • Abdominal pain/cramping

    • Urgency

  • Dx:

    • Sigmoidoscopy: Edema, erosion, uniform inflammation

    • Labs: P-ANCA, ESR/CRP

    • Colonoscopy, Barium (Stovepipe sign)

  • Complication: Toxic megacolon

Crohn's Disease

  • RF: Smoker

  • Sx:

    • Abdominal pain (RLQ, terminal ileum)

    • Diarrhea

    • Weight loss

  • Dx:

    • Colonoscopy

    • CT (for small bowel)

    • Barium (no CT)

  • Findings:

    • Fistulas, stricture, granulomas, abscess, perianal disease

    • Skip lesions, cobblestone appearance, string sign

  • Labs: ASCA

IBD Treatment

  • UC:

    • Proctitis: Topical mesalamine

    • Left side/extensive: Oral 5ASA + Mesalamine

    • No improvement in 2-4 weeks: Steroids

    • Moderate/severe: Anti-TNF + steroids

  • CD:

    • Entocort (for Ileum/R colon)

    • Steroid taper

    • Scope every 6 months

    • Sulfasalazine

Hemorrhoids (Thrombosed)

  • Internal: Above dentate line (no pain)

  • External: Below dentate line (painful)

  • Dx:

    • Visual

    • DRE

    • Anoscopy

  • Tx:

    • Conservative: Diet, topical corticosteroids

    • Rubber band ligation (MC) or hemorrhoidectomy

Hernia

  • Inguinal: Indirect (lateral) | Direct (medial to inferior epigastric artery)

  • Femoral: Below inguinal ligament (MC in women)

  • Sx:

    • Incarcerated: Painful, cannot reduce, enlarged

    • Strangulated: Painful, ischemia, necrosis

  • Tx: Surgical repair (Strangulated is an emergency)

Splenic Rupture / Bowel Perforation / Perforated Peptic Ulcer

  • Dx: Clinical + imaging (e.g., CT, X-ray)