Herkimer 2021 > Gastro > Flashcards

Gastro Flashcards

(57 cards)

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1
Q

Etiology of pancreatitis

A

I GET SMASHWED

Idiopathic
Gallstones (45%) *especially if in common bile duct
Ethanol (35%)
Tumor
Scorpion stings
Microbiology (TB, mumps, rubella, varicella, hepatitis..)
Autoimmune (SLE, polyarthritis nodosa, Crohn’s)
Surgery/Trauma
Hyperlipidemia, hypercalcemia, hypotherma
Emboli or ischemia
Drugs (Furosemide, Estrogen, H2 blocker, valproate, abx, ASA)

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2
Q

complication of pancreatitis

A

abscess
lung-pleural effusion, pneumonia, ARDS
acute renal failure secondary to hypovolemic shock
CVS: pericardial effusion, pericarditis

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3
Q

Risk factors of Celiac disease

A
  • 1st degree relative celiac disease (7-18%)
  • T2DM (4-8%)
  • autoimmune thyroiditis (2-5%)/ autoimmune liver disease
  • down syndrome /trisomy 21
  • Turner syndrome
  • IgA deficiency (1-4%)
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4
Q

Classic and non-classic GI symptoms of Celiac disease

A

Classic:

  • abdominal distension/ bloating
  • chronic diarrhea, steatorrhea
  • anorexia
  • weight loss/FTT, muscle wasting, delayed puberty/short stature

Non-classic:

  • persistent vomiting
  • chronic constipation
  • IBS
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5
Q

Pediatric SSx of Celiac disease

A
  • anorexia
  • chronic constipation
  • delayed puberty, growth failure/FTT
  • irritability
  • recurrent vomiting
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6
Q

What are the non-GI symptoms of Celiac disease?

A

Classic non-GI:
- Dermatitis herpetiform
(often have no GI symptoms)

Non-classic
- Hema:
»_space; iron/folate deficiency anemia
»_space; Vitamin B12 deficiency

- Neuro: 
  >> peripheral neuropathy 
  >> ataxia 
  >>epilepsy +/- cerebral calcification 
  >> migraine 
  >> depression
  • Hepatic:
    » elevated transaminases (40-54%)
  • Gynecologic :
    » infertility, early menopause, recurrent miscarriage
  • MSK:
    » arthritis
  • Oral and dental:
    » aphthous stomatitis, dental enamel defect
  • Other:
    » osteoporosis, hyposplenism (20-70% of adults)
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7
Q

how to assess bone health in adult after diagnosed with Celiac disease

A

blood test:

  • serum calcium
  • Vitamin D
  • PTH
  • calcitonin

For CD with malabsorption
- BMD

For CD without malabsorption
- do BMD if high risk (perimenopause, menopause, male > 50 y/o, smoking, low BMD, fragility #, high tTG antibody titer)

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8
Q

What serology tests are used to diagnose Celiac disease?

A

Anti-tTG IgA & serum IgA
(tissue transglutaminase)

IF IgA deficiency, check Anti-DGP IgG
(deamidated gliadin peptide)

IF < 2 y/o, Anti-DGP IgA & IgG AND Anti-tTG IgA
and serum IgA

IF gluten free diet prior to testing, consider HLA-DQ2/DQ8

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9
Q

When to consider intestinal biopsy to diagnose Celiac disease before gluten free diet?

A

1) + serology test
2) all symptomatic pts even if serology is negative

** can also confirm with biopsy of dermatitis herpetiformis lesion

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10
Q

How to confirm Celiac disease?

A

1) Serology and histology both ++ : confirmed

2) Serology + , histology -
»_space; repeat serology, consider repeat histology
consider HLA-DQ2/DQ8 testing

3) serology - , histology +
»_space; consider alternative diagnosis
»_space; IF no alternative dx, trial treatment of celiac diet AND consider HLA-DQ2/DQ8 testing

4) serology and history both neg: CD excluded

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11
Q

What are the food containing gluten ?

A

wheat
rye
barley
oat (?)

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12
Q

What is the management after diagnosed with Celiac disease?

A
  • Diet: gluten free diet for life
  • test and treat specific deficiency
  • BMD if suspected OP
  • referred to dietician
  • monitor for symptoms solution + repeat serology in 6 month
  • screen 1st degree relatives
  • monitoring
    » annual Anti-tTG, if increased, possible dietary contamination
    » q2yr TSH (risk of autoimmune thyroid)
    » q1yr if previously abnormal ALT, AST (risk of autoimmune hepatitis)
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13
Q

What type of malignancy do pts with refractory celiac disease have increased risk of?

A

T-cell lymphoma

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14
Q

Surgical indications of diverticulitis

A
  • unstable patients with peritonitis
  • abscess/ fistula / ruptured abscess
  • immunosuppressed
  • > = 2 attacks
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15
Q

Risk factors of Crohn’s disease

A
  • smoking

- Ashkenazi Jews

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16
Q

exacerbating factors of Crohn’s disease

A

infection
cigarette smoking
NSAIDs

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17
Q

What are the common symptoms of Crohn’s disease?

A
  • abdominal cramps
  • chronic/ nocturnal diarrhea
  • weight loss
  • postprandial cramps
  • RLQ pain
  • fistulae (w/ bladder, skin, vagina)
  • fissures
  • peri-anal abscesses
  • fatigue (from inflammation, anemia, nutritional deficiency)
  • fever
  • growth failure
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18
Q

What are the extra-intestinal symptoms of Crohn’s disease?

A

Skin:

- erythema nodosum (2-20%)
- pyoderma gangrenosum (0.5-2%) 
- perianal skin tags 
- oral mucosa lesion 
- psoriasis

Joints

- inflammatory arthopathy: both axial and peripheral 
- ankylosing spondylitis 
- sacroiliitis

Eyes:

- uveitis (17%) 
- episcleritis (29%)

Liver

- primary sclerosing cholangitis/ cholelithiasis (13-34%) 
- fatty liver

Kidney/ Bladder

- calculi 
- ureteral obstruction 
- fistula 
- nephrolithiasis

Bone: OP

Others:

- VTE/hypercoagulability (10-30%) 
- Vasculitis 
- Vitamin ADEK deficiency    
- other autoimmune conditions: pericarditis, RA, MS, celiac disease, psoriasis
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19
Q

What test can help distinguish between IBS and IBD?

A

Fecal calprotectin

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20
Q

Red flags of GERD

A
  • vomiting
  • evidence of GI bleeding
  • anemia
  • involuntary weight loss
  • dysphagia
  • chest pain
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21
Q

Lifestyle modification for GERD

A
  • weight loss if overweight
  • elevated head of bed
  • avoid meal 2-3 hours before bedtime if nocturnal GERD
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22
Q

Risks of longer term use of PPI

A
  • Hip fracture
  • C. diff
  • pneumonia
  • decreased vitamin B12, magnesium, iron, hypo-parathyroid
  • polypharmacy (nonadherence), prescribing cascade, adverse reaction, medication errors, drug interaction, ER visits and hospitalization
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23
Q

Rome IV criteria `

Study These Flashcards
A

Recurrent abdominal pain on average at least 1 day / week in the last 3 months associated with 2 of the following

1) related to defecation
2) associated with a change in frequency of stool
3) associated with a change in form of stool

24
Q

Alarming symptoms of IBS

Study These Flashcards
A
  • vomiting
  • GI bleeding
  • unexplained weight loss
  • abdominal mass
  • dysphagia
  • anemia
25
Important history of IBS when diagnosing?
- Family hx of GI cancer, IBD, celiac - nocturnal defecation - new symptoms in a patient > 45 years old
26
Aggravating factors of IBS
- EtOH - Caffeine - Fat - Fiber - Sorbitol - Stress - Menstruation
27
Management of IBS
- reassurance, education (lifestyle more effective than medications) Diet: >> FODMAP diet short term (4 wks) w/ dietician guidance >> Increase Fiber > 25 mg /day >> probiotics >> assess aggravating factors >> DO NOT offer gluten-free diet or wheat bran supplementation >> Exercise >> Offer CBT (NOT self-directed) or hypnotherapy to improve IBS symptoms >> NO acupuncture
28
Management of IBS bloating/ pain feature
- peppermint oil 0.2-04ml TID (NNT=3) - antispasmodic >> Benyl 20-40mg TID-QID >> Bascopan 10-20mg TID >> Dicetel 50-100mg TID
29
Management of Diarrhea predominant IBS
1st line: TCA (amitriptyline 10-100mg QHS) 2nd line: Eluxadoline 100mg (refer as many GI contraindication) DO NOT offer cholestyramine DO NOT continuously use loperamide 2-4mg TID-QID (2-12mg/d)
30
Management of constipation predominant IBS
1st line: Linaclotide 290 mcg QD 2nd : SSRI (fluoxetine, paroxetine, citalopram) 2nd also: Lubiprostone 8-25ug BID DO NOT offer osmotic laxatives (only as adjunct) DO NOT offer stimulants (senna, bisacodyl) DO NOT offer prucalopride
31
Common comorbidity of IBS
Fibromyalgia
32
cancers associated with H. Pylori infection
1) gastric adenocarcinoma | 2) MALT lymphoma
33
Red flag symptoms of peptic ulcer
VBAD - vomiting - bleeding / anemia - abdominal mass (lymphadenopathy), unexplained weight loss - dysphagia Family hx of GI cancer previous documented peptic ulcer
34
DDx of dyspepsia
cardiac, hepatobiliary, colonic, MSK - GERD - gastric cancer - pancreas - gallstones
35
risk/precipitating factors of peptic ulcer
- diet indiscretion: caffeine, high fat, excessive alcohol, smoking - NSAID/ ASA - prescription meds (calcium channel blockers, bisphosphonates)
36
Peptic ulcer/ dyspepsia investigation & indication
>> Anemia - FOBT >> Urea breath test/ H. Pylori serology test - < 50 y/o, no alarm symptoms, no NSAID/ASA not GERD (retrosternal heartburn + regurgitation) >> Endoscopy ONLY IF - > 50 y/o (ACG recommends > 55 y/o) AND new symptoms - alarm features (VBAD, fm hx of cancer, previous ulcer) - fail repeated trial of therapy * * choosing wisely incidate NO endoscopy without alarm symptoms * * avoid upper GI series to investigate dyspepsia
37
How to prevent peptic ulcers in pt taking long term NSAIDs
- H2 blockers - PPIs - H. pylori eradication before staring NSAIDs ** antacid DO NOT show prevention against developing a peptic ulcer
38
Lifestyle modification to manage peptic ulcer
- eat small frequent meals - stop smoking - reduce alcohol/ caffeine, avoid irritating food stuff - maintain an ideal weight
39
Treatment for H. Pylori positive
>> CLAMET for 14 days - PPI BID (rabeprazole 20mg) - clarithromycin 500mg BID - amoxicillin 1000mg BID - metronidazole 500mg BID >>QUADRUPLE THERAPY if allergy to penicillin - PPI BID - Bismuth subsalicylate 2tab QID /30ml QID - metronidazole 500mg BID - tetracycline 500mg QID
40
post-treatment management of H. pylori
>> asymptomatic and uncomplicate: no further >> symptomatic OR asymptomatic + complicated Urea breath test for test of cure: 30d after tx completed
41
Indication of "test of cure" after treatment of H. Pylori
* * Urea breath test * * 30 days after tx completion * * off abx for 28-30d, off bismuth & PPI for 2 wks , off antacids/H2 blockers 24-48 hrs prior to test * * Indication: symptomatic OR asymptomatic + complicated - Hx of gastric ulcer - complicated duodenal ulcer - MALT lymphoma
42
alarm symptoms of peptic ulcer disease
VBAD - vomiting - bleeding/ anemia - abdominal mass (lymphadenopathy)/ unexplained weight loss ( > 10% weight loss) - dysphagia - Family history of gastrointestinal cancer - previous documented peptic ulcer
43
precipitating factors of peptic ulcer disease
- dietary indiscretion (caffeine, height fat), excessive alcohol, smoking - NSAIDs / ASA - medications (CCB, bisphosphonate)
44
how to prevent peptic ulcers in patients taking long-term NSAIDs
- H2 Blockers - PPIs - H. pylori eradiation before starting NSAIDs ( not antacids)
45
lifestyle modification for peptic ulcer disease
- eat small frequent meals - stop smoking - reduce alcohol/ caffeine, avoid irritating foodstuff - maintain an ideal weight
46
what are the indications of endoscopy for pt with peptic ulcer dsease
- alarm symptoms (VBAD, FHx of cancer) - "choosing wisely" - > 50 y/o and new symptoms - fail repeated trail of therapy
47
Hemochromatosis - symptoms
∙ Skin hyperpigmentation ∙ Weakness lethargy ∙ Erectile dysfunction Early signs: - severe fatigue (74%) - impotence (45%) - arthralgia (44%) Most common symptoms when diagnosed - hepatomegaly (13%), cirrhosis - skin bronzing or hyperpigmentation - arthritis or arthropathy - amenorrhea, impotence, hypogonadism - Diabetes mellitus (48%) - Cardiomyopathy
48
Hemochromatosis - screening tests
- Serum ferritin studies - Transferrin saturation levels - (Hepatic iron concentration)
49
Hemochromatosis - diagnosis
- Genetic testing: Examination of HFE mutations (C282Y, H63D) is pivotal for diagnosis of hemochromatosis - liver biopsy
50
elderly diarrhea DDx
- acute ischemic bowel - obstruction - diverticulitis - appendicitis - neoplasm
51
Risk factors of C. difficile infection
- healthcare-associated - older age - immunocompromised - previous C. difficile infection - recent antibiotics or 1 mo after (esp. fluoroquinolones, clindamycin, cephalosporin)
52
1st-line Rx for C. difficile infection
1st-line: - Vancomycin PO even if mild (not metro) OR - Fidaxomicin ($$$$) 2nd line: Metronidazole Pediatrics mild to mod: metronidazole
53
Chronic diarrhea work-up
- CBC (esp. serum hemoglobin) - Ferritin - TSH - anti-TTG antibody (tissue transglutaminase) - C. difficile toxin stool test - stool ova & parasite - calprotectin (r/o IBD) - colonoscopy - other specific causes: - Hydrogen breath (lactose intolerance) - MRI for chronic pancreatitis
54
complications of C. difficile infection
``` pseudomembranous colitis (PMC) toxic megacolon perforations of the colon sepsis death (rarely) ```
55
comorbidity of IBS
fibromyalgia
56
Initial investigation of IBS
CAG: - suggested pts have serology testing to exclude celiac disease - DO NOT routinely order CRP, fecal calprotectin, food allergy, lactise hydrogen breath test, glucose hydrogen breath test Important hx - family hx of GI cancer, IBD, celiac - nocturnal defecation - new symptoms in a patient > 45 y/o
57
Non-pharmacological management of IBS
- Education and reassurance: lifestyle more effective than meds - Diet >> FODMAP diet for short term (4 wks) with dietician >> increase soluble fiber, probiotics - exercise - CBT - hypnotherapy
Herkimer 2021
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