alarm symptoms

difficulty swallowing (dysphagia)

pain with swallowing (odyophagia)

recurrent vomiting

GI bleeding

weight loss

anemia

risk factors for GI cancer

persistence of hiccups may indicate.....

serious underlying disease

CNS (neoplasm, infxn, CVA, trauma)

metabolic (uremia, hypocapnia)

vagal/phrenic (FB in ear, goiter, PNA, empyema, MI, reflux, hep)

what is the first line rx for dyspepsia?

H2RAs (-tidine) after lifestyle mods

when should an EGD be performed in a pt with dyspepsia?

ALL pts >60 or <60+alarm sx

what are common causes of fecal impaction?

- meds (opioids)

- severe psych dz

- prolonged bed rest

- neurogenic disease

dx and tx with DRE

which type of ulcer causes pain when eating?

gastic ulcer

duodenal pain is relieved with eating

what are complications of non-inflammatory diarrhea?

hypokalemia

metabolic acidosis

which type of diarrhea decreases with fasting?

osmotic diarrhea → d/t antacids, lactose intolerance, laxatives

what dx study should be performed for GERD that is not responding to treatment?

esophageal pH monitoring

what is the best treatment for GERD?

PPIs

what are complications of GERD?

Barrett's esophagus

strictures

if a pt complains of heartburn in the epigastrium that radiates to the chest 30 minutes after eating, what dx should you suspect?

GERD → relief with antacids

if on endoscopy you see squamous epithelium replaced by metaplastic columnar epithelium at the distal esophagus, what dx do you suspect?

barrett's esophagus

dysplasia seen on EG increases risk of adenocarinoma

what is the only drug to heal ulcers/erosions?

PPIs

what is a common cause for infectious esophagitis in immunocompromised pts?

candida albicans → tx w/ fluconazole

in HIV pt → CMV is the cause → tx with ganciclovir

a 19 year old pt presents with hematemesis. they report they were binge drinking the night prior to the first episode. where did the tear in their esophagus likely occur?

Mallory weiss tear → GE junction

what is the MC type of esophageal cancer? what are s/sx?

adenocarcinoma → dysphagia, odynophagia, anorexia, hoarse/change in voice, anemia

mets → supraclavicular or cervical LAD, hepatomegaly, weight loss

how is esophageal cancer diagnosed?

upper EGD with bx

if a pt presents with severe retrosternal chest pain following large meals/rapid eating and intermittent dysphagia, what would you expect to see on barium esophagram? What is the first line tx?

diffuse esophageal spasm → "corkscrew" on barium study

tx with PPIs

(sublingual nitro/CCB for spasms but may increase GERD sx)

why are esophageal spasms often confused with angina?

bc nitroglycerin relieves the pain

what noninvasive study is used to dx H. pylori? what is the tx?

urea breath test or fecal antigen immunoassay → MUST dc PPI 7-14 before and abx 28 days before

tx → triple therapy (prevpac = PPI+clarithro+amox)

what dx shows free air under the diaphragm on XR?

perforation → AVOID ENDOSCOPY

which dx commonly presents with currant jelly stools and sausage-like abdominal mass?

intussusception

where are the MC sites of volvulus?

cecum and sigmoid

volvulus = sudden twisting of the bowel on itself

if a pt has "tinkling" sounds on PE, what would you expect to see on XR?

small bowel obstruction → dilated loops of small bowel and air fluid levels

also paralytic ileus has tinkling

what is the MC presenting sx of toxic megacolon?

severe bloody diarrhea

toxic megacolon = extreme dilation and immobility of the colon

associated with UC

what is the cause of ZE?

gastrinomas (gastrin-secreting tumors) primarily in the pancreas and duodenum

causes gastric acid hypersecretion, maldigestion, malabsorption

how is celiac disease confirmed?

positive serology and positive bx

what is seen on histology in celiac disease?

- villous atrophy and flattening of small intestine mucosal villi

- crypt elongation

- lymphoid proliferation in lamina propria

what triad of sx is assoc. with ZE?

unresolved GERD sx

diarrhea

weight loss

what differentiates PUD from ZE?

fasting serum gastrin is high in ZE

what are the 3 MC causes of gastroparesis?

- idiopathic

- diabetic neuropathy

- post surgical

what is the best dx study for gastroparesis?

gastric emptying scintigraphy

what is the tx for gastroparesis?

erythromycin and reglan → accelerate gastric emptying

5HT serotonin agents (zofran)

what leads to malabsorption in celiac disease?

diffuse damage to the proximal SI

14 year old pt presents with flatulence, steatorrhea, chronic diarrhea and weight loss. also has delayed growth. what test should you order?

sus celiac → IgA tissue transglutaminase

what is the Hydrogen breath test used to dx?

SIBO and lactase deficiency

pt presents with bloating, cramping, and flatulence with mild nausea about 1 hour after eating (typically yogurt). what test can dx?

lactase deficiency → hydrogen breath test

pt presents with weight loss, diarrhea, flatulence, bloating and fatigue. you performed a hydrogen breath test to confirm dx. what is the treatment?

SIBO → Rifaximin

what is a risk factor for dumping syndrome?

gastric surgery

tx by eating smaller, frequent meals

what is the tx for strictures?

dilation and long term PPIs

what is the procedure of choice for evaluating and getting biopsy of ulcers?

EGD → all gastric ulcers need to be biopsied

If you suspect a perforated ulcer, but free air is not seen on XR, what should you order?

UGI or CT (with gastrografin contrast)

what sx are assoc. with carcinoid syndrome?

diarrhea

abd pain

wheezing

flushing

may develop into carcinoid crisis

what is the MC neuroendocrine tumor? where is it often found?

carcinoid tumor → MC in SI

can be benign or malignant

what is a congenital absence of autonomic smooth muscle ganglia causing stasis of stool?

Hirschsprung's disease

which population is commonly affected by Hirschsprung's disease?

infants and males

down syndrome!

13 year old pt presents with n/v, diarrhea and periumbilical pain. On physical exam they had a positive McBurney's sign. what would you order to confirm dx?

appendicitis → CT abd

what is the MC structural abnormality of the colon?

diverticulosis → acquired saccular outpouchings of colon

also MC lower GI bleed cause

pt presents with persistent LLQ pain and fever. You order a CT which shows stranding and fatty infiltration along with mural thickening of the colon. what is your treatment?

diverticulitis → cipro and flagyl

NO COLONOSCOPY during acute phase d/t risk of perforation

pt presents with abdominal pain out of proportion that is sudden onset. what is the gold standard dx? What risk factor could be present?

acute mesenteric ischemia → mesenteric angiography gold standard

RF → afib/MI, recent cardiac cath

what are risk factors for PUD?

H. pylori

NSAIDs

if a pt complains of altered bowel habits, abd discomfort relieved by defecation that is not present at night or in the morning, what do you suspect?

IBS

tx with low FODMAP diet

you are treating a 66 y/o patient in a nursing home s/p TKA. they have had multiple episodes of watery, foul-smelling diarrhea. what should you treat with? what is a serious complication?

c. diff → tx with oral vanco or fidaxomicin

toxic megacolon is complication

33 y/o female presents with reports of bowel habit changes including intermittent abdominal pain. her mother had colon cancer diagnosed at age 53. when should this pt be screened for colon cancer?

40 b/c +FHx

if her mom was 43 then pt would need screening at 33

(age 40 or 10 years before FHx dx, whichever comes first)

(but this pt should prob have colonoscopy bc of sx!)

changes in bowel habits may indicate ___ sided colon cancer

Left

iron deficiency anemia may indicate ____ sided colon cancer

right

if a pt has no risks or FHx of colon cancer, when should they start screening?

45

what is the MC sx of colon cancer?

changes in bowel habits

+blood in stool

what is the recommended tx for pts with hemorrhoids/fissures?

lifestyle mod:

- fiber diet

- increase fluids

- exercise

tx:

- stool softener

- cream/spray

- sitz bath

- witch hazel pads

which type of hemorrhoid is above the dentate line? is it painful?

internal hemorrhoids are NOT painful

which type of hemorrhoid is located below the dentate line?

external hemorrhoids → painful

pt presents with complaints of a rectal lump. on physical exam, there is a tender, bluish mass covered with skin located on their anus. what is the dx and tx?

thrombosed external hemorrhoid → clot evac or excision

don't evac after 48 hr onset

pt presents with complaints of piercing pain during and after bowel movements with bright red blood on the toilet paper. they have been avoiding defecating and as a result, they are constipated. on PE, there is a linear tear in the anus with associated skin tag. what does the skin tag indicate?

chronic anal fissure causing ulceration that healed as a skin tag

an anal fissure that is not located midline should be suspicious for what?

crohn's, HIV/AIDS, cancer

fibrous tissue production & collagen deposition in esophagus is the cause of what?

esophageal stricture

17 year old male presents with complaints of pain and swelling on his sacral region. what do you expect to see on PE? what is the tx?

pilonidal cyst → small midline pit/abscess near midline sacrum/coccyx with chronic draining sinuses.

surgical I&D tx

also you would expect him to be suuuuuper hairy :|

what abnormal fluid-filled cavity results from an infection from an occluded crypt?

anal abscess → I&D

a 67 year old male presents to the ER with complaints of diarrhea, abdominal cramps, and fever for 2 days since he got off his cruise in mexico. What is the treatment?

Norovirus → supportive tx

24 year old female presents with pale, explosive diarrhea. Onset was shortly after she went hiking in Colorado. How should you diagnose her? what is the treatment?

Giardia → stool sample shows cysts/trophozoites

treatment → tinidazole or metronidazole

all close contacts should be treated too

what treatment should you avoid in infectious diarrhea?

avoid antidiarrheals and high fiber diet → want to get that sh*t out

17 year old patient presents with low grade fever and GI upset shortly after consuming a pound of raw cookie dough. what is the likely etiology?

salmonella → need to eat large numbers to produce illness

what can occur if you prescribe abx for a pt with E. coli 0157:H7?

Hemolytic uremic syndrome (HUS) especially in kids <5

undercooked ground beef, unpasteurized apple juice or milk, and raw fruits/veg are all linked to which toxin?

E. coli 0157:H7

you are treating a 65 year old male s/p TKA in a skilled nursing facility. He develops bloody, foul-smelling diarrhea abruptly. what is the etiology and treatment?

c. diff → oral vanco

fecal transplant if no response to vanco

22 year old female presents with abrupt onset severe N/V x24 hrs. you determine the cause to be B. cereus pathogen. which food likely caused her symptoms?

reheated rice

which pathogen is linked to rewarmed meat and poultry dishes?

C. perfringens

which pathogens are assoc. with recent foreign travel?

salmonella

shigella

campylobacter

E. coli

V. cholerae

AST/ALT elevation from alcohol alone is <_____?

<300

if >300, it is not just alcohol

which conditions cause AST/ALT ratio to be >10x normal?

viral hepatitis

acetaminophen

shocked liver

HELLP

autoimmune dz

which conditions cause AST/ALT ratio to be 5-10x normal?

Alcohol

drugs

biliary dz

what are the risk factors for cholelithiasis?

Female, fat, forty, fertile

48 year old diabetic female presents with complaints of RUQ abdominal pain that radiates to her right shoulder shortly after eating McDonald's. What study should you order to diagnose?

cholelithiasis → abdominal US

shows GB wall thickening and cystic duct dilation

what is the triad of sx assoc. with acute cholecystitis?

RUQ pain

fever

leukocytosis

dx by abdominal US

what is the treatment for acute cholangitis?

emergent ERCP

which dx causes the complication of suppurative cholangitis? What pentad of sx is associated?

suppurative cholangitis causes by acute cholangitis

Reynold's pentad = Charcot's triad PLUS hypotension and mental confusion

46 year old male presents with RUQ pain, fever, chills, and slight yellowing of his skin. on PE, he appears to be confused as to why he is in the ER despite him presenting himself a few hours earlier. what is the likely dx?

suppurative cholangitis

what is choledocholithiasis? How is it diagnosed?

stone in the common bile duct → asymptomatic unless obstruction is present!

dx by US and ERCP

which dx is defined by autoimmune destruction of the intrahepatic bile ducts and cholestasis?

primary biliary cholangitis

in which dx are calcium salts deposited within the GB wall of a chronically inflamed GB?

porcelain GB → complication of chronic cholecystitis

if a pt has hx of porcelain GB, what are you concerned about them developing?

carcinoma of the GB → treat porcelain GB with cholecystectomy

what is the only proven therapy to treat PBC?

URSO

if a pt has ALP 3-4x normal, positive AMA, and positive ANA, which dx should you suspect?

PBC