Rosen's 10th > GI > Flashcards

GI Flashcards

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1
Q

List 1 main ABX treatment for traveller’s diarrhea

A

Azithromycin 1000mg PO x1

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2
Q

Outline 4 ABX txs for C. difficile

A
  1. Vancomycin 125mg PO QID x 10 days
  2. Fidaxomicin 200mg PO x 10 days
  3. Metronidazole 500mg PO TID x 10 days *for non-severe disease
  4. Consider fecal transplant
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3
Q

Define acute diarrheal illness

A

3+ liquid or watery stools in 24h, up to 14 days

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4
Q

Outline Bristol Stool Scale

A

Type 1 - Hard separate “lumps”, hard to pass

Type 2 - Sausage shaped, formed but hard and lumpy

Type 3 - Sausage shaped with fissured surface

Type 4 - Sausage shaped with smooth, soft texture

Type 5 - Soft separate “lumps” passed easily

Type 6 - Unformed, “mushy” stool

Type 7 - Entirely liquid, watery, with no solid pieces

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5
Q

Outline 5 types of diarrhea

A
  • Osmotic diarrhea - due to the presence of poorly absorbed solutes within the gut
  • Secretory diarrhea - due to toxin-producing infectious agents
  • Exudative diarrhea - due to infectious or inflammatory conditions
  • Motility-related diarrhea - associated with diabetes mellitus or scleroderma as well as prokinetic medications
  • Malabsorptive diarrhea - related to infectious agents, lactose intolerance, celiac disease, or pancreatic insufficiency.
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6
Q

Define dysentery

A

Infectious diarrhea in which enteropathogens and their toxic metabolites have invaded the intestinal mucosa, resulting in fever, abdominal pain, and visible blood mixed with stools.

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7
Q

List 15 Common Causative Agents of Acute Infectious Diarrhea

A

Viral:
- CMV
- enteric adenovirus
- HIV enteropathy
- norovirus
- rotavirus

Bacterial:
1) Invasive
- Salmonella
- Shigella
- Enteroinvasive E. coli
- Camplyobacter sp.
- C. difficile
- Yersinia enterocolitica
- Vibrio vulnificus

2) Toxigenic
-> Pre-formed toxins
- B. cereus
- S. aureus
- Clostridium botulinum
-> Toxin formed after colonization
- EHEC (Shiga-toxin producing E. coli O157:H7)
- ETEC
- Shigella
- Vibrio cholerae

Protozoa:
- Cryptosporidium
- Cyclospora
- Entamoeba histolytica
- Giardia

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8
Q

List 20 Causes of Noninfectious Diarrhea

A

Pharmaceuticals
- Antacids (magnesium)
- Antimicrobials
- Antiretrovirals
- Chemotherapeutic agents
- Cholinergic agents
- Cholinesterase inhibitors
- Colchicine
- Lactulose
- Laxatives
- Prostaglandins

Dietetic supplements
- Caffeine
- Sorbitol
- Xylitol

Seafood-Associated Toxins
- Ciguatera
- Paralytic shellfish poisoning
- Scombroid

Plant and herbal preparations
- Aloe vera juice
- Senna
- Pokeweed
- Turmeric

Miscellaneous
- Pesticides (organophosphates)
- Opiate withdrawal

Gastrointestinal Pathology
- Celiac disease
- IBD
- IBS-D
- Lactose intolerance
- Malabsorption syndromes
- Post vagotomy
- Radiation enteritis
- Short gut syndrome

Endocrine-Related Conditions
- Carcinoid syndrome
- Adrenal insufficiency
- Diabetic enteropathy
- Pancreatic insufficiency

Systemic Illness and Other Causes
- Alcoholism
- Connective tissue disease/scleroderma
- Cystic fibrosis
- Runners diarrhea

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9
Q

List 6 indications to test for C. diff

A

Immunocompromised

ABX use in last 3mo

Recent hospitalization

Nursing home residence

HCW

Significant diarrhea >5/d for several days w/out vomiting

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10
Q

List 4 ABXs that cause C. diff

A
  1. Cephalosporins
  2. Penicillins
  3. Fluoroquinolones
  4. Clindamycin
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11
Q

List 4 features common with ova and parasites in stool

A
  • Chronic diarrhea
  • Ingestion of stream or spring water
  • Hx travel or recent immigration from developing countries
  • HIV or other immunocompromised

(Cryptosporidium, Giardia, Cyclospora, E. histolytica)

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12
Q

Outline The WHO Oral rehydration solution

A

Dissolving the following in 1 L of clean water:
- 3.5 g of NaCl
- 2.5 g of NaHCO3
- 1.5 g of KCl
- 20 g of glucose or 40 g of sucrose.

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13
Q

List 6 indications to give empiric ABX in diarrhea, and include 5 ABX options with dosing

A

Consider for:
- immunocompromised
- signs of sepsis/toxic appearing
- fever
- dysentery
- severe traveller’s diarrhea
- suspected C. diff colitis

Choose one of below:
- Ciprofloxacin 500 mg PO BID x 3-5 days
- Azithromycin 500 mg PO OD x 3 days
- Levofloxacin 500 mg PO OD x 3-5 days
- Ciprofloxacin 400mg IV BID
- CTX 1-2g IV q24h

*Above cover the majority of enteric pathogens

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14
Q

List 3 anti-motility agents

A
  1. Loperamide
  2. Simethicone *synergistic with loperamide
  3. Bismuth subsalicylate
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15
Q

List 9 causes of hepatitis

A
  • Viral
  • Toxic alcohol
  • Chemical exposure
  • Medication
  • Bacterial
  • Fungal
  • Parasitic
  • Genetic d/o
  • Immune mediated
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16
Q

Outline Features of Hepatitis A/B/C/D/E/G Virsues

A

Hep A
- fecal-oral, or contaminated water/food
- rare in blood
- most common risk factor is travel to endemic area in ages >15yr
- incubation 30 days, symptoms 2-6 weeks after exposure
- not chronic carriership

Hep B
- parenteral or bodily fluids
- clinical onset of symptoms 120 days
- Acute HepB is (+) HBsAg and HBcAb-IgM
- Chronic Hep B is (+) HB surface Ag in serum >6 mo

Hep C
- Hep C leading cause of cirrhosis in USA
- parenteral or bodily fluids
- incubation 50 days, acute phase 12 weeks
- progress to chronic hepatitis infection in 90%
- can take ART to cure

Hep D
- needs HBV to replicate
- worsens HBV disease

Hep E
- fecal-oral

Hep G
- likely co-infection with other hep virus

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17
Q

List 3 prodromal symptoms of Hep B illness

A

Arthralgia
Polyarthritis (small joints in hands and wrists)
Urticarial dermatitis

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18
Q

List 4 characteristics of Fulminant Hepatitis

A

Acute onset of illness
Hepatic failure
Encephalopathy/altered mentation
Spontaneous mucosal bleeding

*most often in association with HBV + HDV

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19
Q

List 15 DDx of Viral Hepatopathy & Elevated Transaminases

A
  • Alcohol
  • Hep ABCDEG viruses
  • EBV
  • CMV
  • Acetaminophen
  • Amox-Clav
  • Isoniazid
  • Macrobid
  • Dapsone
  • Phenytoin
  • Carbamazepine
  • Statins
  • Weight-loss drugs
  • Anabolic steroids
  • Ayurvedic herbal meds
  • Green tea
  • Toluene
  • Carbon tetrachloride
  • Chloroform
  • Polycyclic aromatic hydrocarbons
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20
Q

Describe situations for HAV and HBV PrEP and PEP

A

HAV PrEP:
- HAV Vaccine
OR
- HAV IG for nonimmune individuals who are at high risk of exposure to hepatitis A, immunocompromised patients, >6 months of age, have chronic liver disease, allergy to HAV vaccination

HAV PEP:
- ISG 0.1mL/kg IM to close personal contacts, daycare workers and kids
- ISG 0.2mL/kg IM to food-borne exposures within 2 weeks of exposure

HBV PrEP:
- HBV Vaccine (3 inj series)

HBV PEP:
- Tx w/in 1-2 weeks to prevent seroconversion
- HBIG 0.06mL/kg IM ASAP

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21
Q

Outline tx for chronic HCV infxn

A

Nucleoside polymerase inhibitors
- Goal endpoint is a sustained virologic response (SVR), defined as absence of HCV RNA by PCR testing at 3 to 6 months following treatment

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22
Q

List 8 risk factors for progression of EtOH-related hepatic steatosis

A
  • Female
  • Obesity
  • Dietary factors
  • Polymorphisms
  • Drinking pattern (>80g/day in males, >20g/day in females)
  • Smoking
  • Viral hepatitis
  • HIV
  • Hemachromatosis
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23
Q

Outline mgmt of EtOH Hepatitis

A
  • Thiamine
  • Dextrose/Glucose replacement
  • Mg replacement
  • tx any UGIB

If Maddrey >32 and no GIB, HRS or sepsis, give steroids:
- PredNISolone 40 mg PO daily
- Methylprednisolone 32 mg IV daily

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24
Q

List 8 co-morbidities associated with Autoimmune Hepatitis

A
  • Female
  • Primary sclerosing cholangitis
  • Primary biliary cirrhosis
  • AI Thyroiditis
  • T1DM
  • RA
  • IBD
  • SLE
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25
List 5 serologic tests to order for w/u of Autoimmune Hepatitis
- ANA - ASMA - Anti-LKM1 - Gamma globulin - IgG levels
26
Outline tx of Autoimmune Hepatitis
- Corticosteroids - Azathioprine (alongside or in lieu of steroids) - Mycophenolate mofetil (2nd line) - Transplantation for life-threatening cases
27
Outline 2 pathologic changes in cirrhosis, and an example of clinical manifestation
1. Loss of Hepatocytes - metabolic and synthetic dysfnc - gluconeogenesis and glycogenolysis, coagulation factors 2. Fibrosis & Altered Hepatic Architecture - impaired portal vein blood flow - portal HTN
28
Outline associated dzs with Primary Biliary Cirrhosis, and s/s of PBC
Associated w/ other AI D/O or Scleroderma CREST syndrome - Calcinosis cutis - Raynaud phenomenon - Esophageal motility disorder - Sclerodactyly - Telangiectasia ALP elevated out of proportion to other LEs
29
List 4 complications of cirrhosis
- Ascites (+/- infection) - GIB - HRS - Hepatic encephalopathy
30
Describe MELD Score
- Predicts 3-month mortality with end-stage liver disease - Calculated using Cr, T bili, INR, and Na. - Used in determining liver transplantation priority and predicting survival rate after TIPS procedure
31
List 8 Common Underlying Causes of Hepatic Encephalopathy in Patients With Known Liver Disease
- GIB - HypoK - Alkalosis - Venous thrombosis - Ileus & Constipation - Sedatives - Dehydration & Hypovolemia - AKI or CKD - Infection
32
List 5 drug toxicities enhanced by Hypoalbuminemia
Due to low protein available for binding medications Higher circulating levels (especially in extracell compartment) - Phenytoin - Morphine - B-lactams - Vancomycin - Daptomycin
33
List 4 Treatments for Hepatic Encephalopathy
- Lactulose 30-60g/day - Rifaximin 400mg PO q8h - Neomycin - Vancomycin - Metronidazole Less commonly - L-ornithine – L-aspartate - Probiotics - Eradication of H. pylori - Zinc replacement - Low protein diet - Multiple small meals with complex carbohydrates
34
List 2 diagnostic criteria of SBP
1. ANC in ascites >250cells/mm3 (or >100 in peritoneal dialysis) 2. Positive culture growth
35
List 2 common bacteria involved in SBP
Gram negative enterics - E. coli - Klebsiella Gram positives - in outpts, now seen with improved care *Polymicrobial and anaerobics are uncommon
36
Outline Runyon Criteria for differentiating SPONTANEOUS bacterial peritonitis from SECONDARY bacterial peritonitis
Need 2/3 to be more likely Secondary BP: 1. Total Protein >10g/L 2. Glucose < 2.8 3. LDH > ULN for serum THIS IS POOR SENSITIVITY
37
List 2 ABX treatments for SBP
- Cefotaxime 2g IV q8h x 5d - CTX 2g IV q24h x 5d
38
Outline ABX treatments for peritonitis in PD pts
Most commonly S. aureus and S. epidermidis - Ceftazidime OR Cefepime OR - Aminoglycosides (Gent, Tobra, Amikacin) - PLUS Vancomycin
39
List 7 risk factors for development of SBP
- Any ascites - Hx of SBP - Ascitic fluid protein >10 - Serum bili >54 - PLT <98 - PPI use - Beta blockers
40
List 4 ABX options for SBP ppx
- Ciprofloxacin 500 mg PO daily - Norfloxacin 400 mg PO daily - TMP-SMX DS 800/160 mg PO daily - CTX 1g IV daily (in cirrhosis and UGIB)
41
List 8 Etiologies of Hepatic Abscesses
Microbial pathogens: - Gram neg bacilli - Gram pos cocci - Anaerobes - Amebic infxn - Fungal infxn Hematogenous: > thru Portal Vein - intra-abdo infxn - abdo abscess - amebiasis > thru Arterial - ENT - oral cavity Biliary: - gallstones - obstructed biliary duct - ascending cholangitis - bile duct ischemia Underlying lesions or anomalies: - biliary cysts - hyatid cyst - necrosis of primary tumour - superinfection of metastases - biliary stricture - sclerosing cholangitis Particular cases: - pancreatoduodenectomy - liver transplant - hepatic trauma +/- arterial embolization - radiation or chemoembolization in presence of infected bile
42
List 6 common organisms causing pyogenic hepatic abscess
- E. coli - Klebsiella - Pseudomonas - Enterococcus sp - Anaerobic streptococci - Bacteroides sp
43
Outline mgmt & ABX tx of Pyogenic Hepatic Abscesses
Size <5cm - abx alone >5cm - abx + drainage - Cefotaxime 2 g IV q8h OR - CTX 2 g IV daily + Metronidazole 500 mg IV q8h OR - Ampicillin 2 g IV q6h + Gentamycin 1.7 mg/kg IV q8h + Metronidazole 500 mg IV/PO q8h OR - PipTazo 3.375g IV q6h OR Meropenem 1g q8h + Metronidazole 500 mg IV/PO q8h Add Vancomycin for acutely ill or unstable patient, gram-positive cocci on staining, or high suspicion for enterococcal or staphylococcal organisms
44
Name most likely cause of Amebic Hepatic Abscess
Entamoeba histolytica - symptoms 12 weeks post exposure
45
Outline tx of amebic hepatic abscess
*Both tissue and luminal agents are required Tissue Tx - Metronidazole 750 mg PO q8h x10d Luminal Tx (after tissue clearance) - Paromomycin 10 mg/kg PO q8h x7d
46
Outline benign cholestasis of pregnancy, its dangers, and tx
2/2 higher circulating estrogens - Onset in 2nd-3rd trimester - Higher risk w/ multiple gestations IN MOM: - ALP, GGT, T & D bilis may be up, may be jaundiced - Pruritic palms & soles IN FETUS: - Bile acids cross placenta into amniotic fluid - Cause prematurity, stillbirth, fetal distress TREATMENT - Ursodeoxycholic acid (UDCA) 300 mg PO q8h until delivery - Resolution only w/ delivery
47
Outline Acute Fatty Liver of Pregnancy, and Swan Criteria for dx
OB EMERGENCY - Onset in 3rd trimester, >30wks - Rapidly progress to maternal or fetal demise - is diff than HELLP S/S: - Fatigue, Anorexia, N/V - Mild jaundice, RUQ to epigastric tenderness - Resp & Renal complications MGMT: - Supportive maternal care - Prompt delivery of fetus Swansea Criteria (Need 6/15) - Abdo pain - Ascites - Vomiting - Polydipsia or Polyuria - Encephalopathy - Bilirubin >14 - Hypoglycemia <4 - Elevated uric acid > 340 - Leukocytosis >11 - ALT >42 U/L - Ammonia >66 μmol - Cr >150 - Coagulopathy or PT >14s or aPTT >34s - Bright liver on U/S - Microvesicular steatosis on Liver Bx
48
Outline 2 types of Budd-Chiari syndrome (BCS)
Caused by hepatic venous outflow obstruction located anywhere above level of hepatic venules 1) Primary BCS is caused by thrombosis or phlebitis - associated with hypercoagulable states: - OCP use - factor V Leiden - protein S or C deficiency - thrombophilia - antithrombin III deficiency - myeloproliferative disorder - Behçet disease - paroxysmal nocturnal hemoglobinuria 2) Secondary BCS is external compression of the venous outflow tract (hepatic vein or IVC)
49
List 4 Mgmt Options in Budd-Chiari Syndrome
- TIPS procedure - Thrombolytic therapy - Percutaneous angioplasty - Portacaval surgical shunting - Liver Transplant
50
List 4 early and 4 delayed complications of liver transplantation
EARLY (immed post-op period) - bleeding - acute rejection - vascular or biliary tract issues - infection DELAYED (>1yr later) - recurrence of underlying disease - malignancy - infection - chronic rejection - medication toxicity - biliary complications - renal failure
51
List 8 risk factors for formation of cholesterol gallstones
*elevated levels of cholesterol in makeup of bile - Increased age - Female - Obesity - Rapid weight loss - Cystic Fibrosis - Parity - OCP use - Familial tendency
52
Name differences between black and brown pigmented gallstones
BLACK - occur exclusively in gallbladder - older adults - pts with intravasc hemolytic dz: sickle cell disease or hereditary spherocytosis BROWN - can form in gallbladder, intrahepatic or extrahepatic bile ducts - associated with infection
53
List 5 causes of cystic duct obstruction unrelated to stone disease
Tumour LNA Fibrosis Parasitic illness Kinking of duct
54
Describe acalculous cholecystitis
- More common in older adults & pts recovering from non-biliary tract surgery - GB wall inflammation from stasis & ischemia - Complication of AIDS 2/2 CMV or Cryptosporidium - More acute & malignant course, higher mortality than calculous form
55
Describe emphysematous cholecystitis, 3 bacterial causes, 2 risk factors, and ABX tx
- Presence of gas in GB wall, from invasion of mucosa - E. coli, Klebsiella, Clostridium perfringens - Common in Males, DM - 50/50 acalculous - Tx CTX + flagyl, or carbapenem
56
List 4 most common bacteria in cholangitis
E. coli Klebsiella Enterococcus Bacteroides
57
Outline Primary Sclerosing Cholangitis
Autoimmune disorder (chronic idiopathic) Progressive, diffuse fibrosis & narrowing of intrahepatic & extrahepatic bile ducts & biliary tree - associated w/ IBD (Ulcerative Colitis) - Presents as weight loss, lethargy, jaundice, pruritis - Can still get infectious cholangitis - AMA (-) in PSC, (+) in PBC - Tx w/ Cholestyramine, bile acid sequestrant
58
Outline 3 examples of AIDS Cholangiopathy, and list 3 common bacterial causes
CD4 < 200 - Bile duct stricture - Papillary stenosis - Sclerosing cholangitis - Cryptosporidium parvum is most common - CMV - Microsporidia - (MAC) Mycobacterium avium complex Mgmt: Ursodiol (8–10 mg/kg/day PO q8-12h) for patients w/ intrahepatic ductal disease
59
List 2 top causes of bacterial enteritis & 1 top viral cause
1. Campylobacter 2. Salmonella 1. Norovirus
60
List 5 risk factors for C. diff
Recent ABX use Recent hospitalization Living in long-term care Solid organ transplant Use of antacids
61
Outline 4 time periods of diarrheal illnesses
1. Acute <7 days 2. Prolonged 7-13 days - above usually viral or bacterial 3. Persistent 14-29 days 4. Chronic >30 days - above usually protozoans, parasites, noninfectious
62
List 10 Gastroenteritis Common Causes
Foreign travel: - Traveler’s diarrhea = ETEC - Southeast Asia = Vibrio, Campylobacter species - South America, Asia, Africa = Rotavirus Recent camping: - Giardia - Aeromonas - Cryptosporidium Recent antibiotics: - Clostridium difficile Daycare exposure: - Rotavirus - Norovirus Exposure to raw seafood: - Noncholera Vibrio MSM: - Shigella - Salmonella - Entamoeba - Campylobacter HIV: - Mycobacterium avium-intracellulare complex - microsporidia - CMV - Giardia - Salmonella - C. difficile - Shigella Public Health Outbreaks: - Cruise ships = norovirus - Contaminated local water, food, products, restaurants = Campylobacter, Salmonella, E. coli, Bacillis
63
Outline Bacterial Gastroenteritis ABX txs
Shigella --> Ciprofloxacin 500mg PO BID x 3d OR --> Azithromycin 500mg PO OD x3d Salmonella enteritidis *Nontyphoid - Tx only SEVERE --> Levofloxacin 500mg PO/IV OD x7d Salmonella typhi *Typhoid --> Ciprofloxacin 500mg PO BID x7d OR --> Azithromycin 500mg PO OD x7d OR --> CTX 1–2g IV q24h x7d Campylobacter jejuni --> Azithromycin 500mg PO OD x3d OR --> Erythromycin 500mg PO BID x5d Vibrio cholerae --> Doxycycline 4-6 mg/kg, max 300mg, PO OD x3d Vibrio (noncholera) --> Ciprofloxacin 750mg PO x1 OR --> Ciprofloxacin 500mg PO BID x3d OR --> Rifaximin 200mg PO TID x3d OR --> Azithromycin 1g PO x1 ETEC & EAEC - Mild --> Ciprofloxacin 750mg PO x1 - Severe --> Ciprofloxacin 500mg PO BID x 3 days OR --> TMP-SMX DS 1 Tab PO BID x 3 days Shiga toxin–producing E. coli; E. coli O157:H7 --> NO ABX TX, can get HUS or TTP Yersinia enterocolitica - No treatment in nonsevere - Tx SEVERE only --> TMP-SMX DS 1 Tab PO BID x3d OR --> Ciprofloxacin 500mg PO BID x3d Bacillus cereus - Tx SEVERE only --> Vancomycin 125mg PO QID x7-10d OR --> Clindamycin 500mg PO TID x7–10d S. aureus & Clostridium perfrigens - SUPPORTIVE
64
Outline parasitic gastroenteritis tx
Giardia lamblia --> Nitazoxanide 500 mg PO BID x 3 days --> Tinidazole 2g PO x1 --> Metronidazole 500mg PO BID x 5–7 days Entamoeba histolytica --> Nitazoxanide 500 mg PO BID x 3 days OR --> Metronidazole 500–750mg PO TID x 7–10 days THEN --> Paromomycin 25–35 mg/kg PO divided TID x 7 days Cryptosporidium --> Nitazoxanide 500 mg PO BID x 3 days Cyclospora cayetanensis --> TMP-SMX DS 1 tab PO BID x 7–10 days
65
Outline difference between invasive and noninvasive gastroenteritis, and give 4 examples of each
INVASIVE: - clinical diagnosis made in presence of intestinal mucosal invasion - fever, gross or occult blood in stool - tenesmus (feeling of constantly needing to pass stool) - severe abdominal pain ex) Salmonella (typhoid and non-typhoid), Shigella, E. coli O157:H7 (shiga toxin producing), Campylobacter, Yersinia, Vibrio parahemolyticus NON-INVASIVE - suggests presence of a viral pathogen or toxin-producing bacteria - brief and self-limited illness - no fever - no bloody stools - no significant abdominal pain ex) S. aureus, Clostridium, B. cereus, Vibrio cholerae, Vibrio vulnificus, Scromboid, Ciguatera, ETEC, C. diff
66
List 5 complications of C. diff infection
- Severe diarrhea - Pseudomembranous colitis - Toxic megacolon - Intestinal perforation - Death
66
Outline likely pathogens by the timing of food poisoning onset
1) 1-6 hours = Preformed toxins - S. aureus - B. cereus - scrombroid - ciguatera 2) 8-16 hours = Toxin-forming - C. perfrigens - B. cereus (long incubation form) 3) >16 hours - ETEC - STEC - Shigella - Vibrio sp.
67
Outline Scombroid fish poisoning: - Fish types - S/S - Tx
Mahi mahi, Tuna, Bluefish - high levels of histidine Symptoms resemble Histamine Intoxication - metallic, bitter, peppery taste in mouth - dry mouth - conjunctivitis - urticaria - severe HA - facial flushing - palpitations - N/V/D - abdominal cramps - Tx w/ Diphenhydramine 25-50mg IM/IV OR - Cimetidine 300mg IM/IV
68
Outline Ciguatera fish poisoning: - Fish types - S/S - Tx
Barracuda, Grouper, Sea bass, Sturgeon - Anti-Cholinesterase & Cholinergic properties *Neurotoxicity from open Na channels & constant firing - n/v/profuse watery diarrhea - bradycardia, hypotension - dysesthesias and paresthesias to mouth and throat - sensation of burning feet, painful teeth - ataxia, weakness, vertigo, hallucinations, coma - cold allodynia *WORSENED BY ETOH INGESTION Supportive tx w/ Diphenhydramine 25mg PO QID OR Cetirizine 10mg PO OD Atropine 0.5mg IV for HR effects Amitriptyline 25mg PO BID for neuro effects
69
Outline 8 Traveller's Diarrhea organisms and their treatments
ETEC --> Ciprofloxacin 500 mg PO bid or 750 mg PO once daily for 1–3 days EAEC --> Ciprofloxacin 500 mg PO bid or 750 mg PO once daily for 1–3 days Campylobacter --> Azithromycin 500 mg PO daily for 3 days Salmonella --> Levaquin 500 mg PO daily for 7 days Shigella --> Ciprofloxacin 750 mg PO daily for 3 days Norovirus --> Supportive care Rotavirus --> Supportive care Giardia --> Metronidazole 500 mg PO bid for 5–7 days
70
3 severities of traveller's diarrhea?
Mild: Diarrhea that is tolerable, not distressing, and does not interfere with planned activities. - Antibiotics are not recommended. Moderate: Diarrhea that is distressing or interferes with planned activities. - Antibiotics may be indicated (e.g., immunosuppressed, solid organ transplant, elderly) Severe: Diarrhea that is incapacitating or prevents planned activities; Dysentery. - Antibiotics are indicated
71
Empiric Preventative and Treatment Meds for Traveller's Diarrhea?
72
Empiric abx to start in HIV/AIDS patients with gastroenteritis?
Ciprofloxacin 500mg PO BID OR CTX 1-2g IV daily
73
Causes of Dysphagia?
Obstructive: - esophageal neoplasm - aortic aneurysm - aberrant subclavian artery - enlarged aorta - esophageal rings - esophageal stricture - esophageal webs - esophagitis - foreign bodies - hypertrophic cervical spurs - inflammatory lesions - left atrial enlargement - mediastinal mass - bronchogenic carcinoma - enlarged lymph nodes - thyroid enlargement - Zenker diverticulum Motility: - achalasia - diffuse esophageal spasm - nutcracker esophagus - hypertensive lower esophageal sphincter - CREST syndrome - Chagas disease - paraneoplastic syndrome Neuromuscular: --> Vascular - CVA (stroke) --> Immunologic - Dermatomyositis - Polymyositis - Scleroderma - Myasthenia gravis - Multiple sclerosis --> Infectious - botulism - diptheria - poliomyelitis - rabies - Sydenham chorea - tetanus --> Metabolic - lead poisoning - magnesium deficiency Other: - alcoholism - Sjogren syndrome - post-radiation - diabetes - functional - GERD - post-operative
74
Name indications for Immediate and Urgent intervention in Upper GI Foreign Bodies?
Immediate (up to 2-6hr) - button batteries - magnets - food boluses causing high-grade obstruction - patients in significant distress (vomiting, gagging, choking, stridor, or inability to tolerate oral intake) Urgent (<12-24h) - low-grade obstructions: - sharp objects - coins lodged in the proximal esophagus - food boluses - gastric FBs wider than 2.5cm and longer than 5cm Flexible Endoscopy with sedation to remove
75
Causes of Esophageal Perforation?
*** Iatrogenic: - complication of endoscopy - NG placement - ETT --> Rapid increase in IntraEsophageal Pressure against closed LES: - forceful vomiting - Valsalva-like maneuvers - childbirth - coughing - heavy lifting --> FB Ingestion --> Caustic substance ingestion --> Severe esophagitis --> Carcinoma --> Direct blunt or penetrating trauma
76
List 5 medications associated with pill esophagitis
ASA NSAIDs Penicillins Antivirals Tetracyclines Quinidine KCl Ferrous sulfate Bisphosphonates VPA
77
Treatments for H. pylori
Triple Therapy x 14 days 1) Clarithromycin 500mg PO BID 2) Amoxicillin 1g PO BID OR Metronidazole 500mg PO BID (for pen allergy) 3) any PPI Quadruple Therapy x 14 days 1) Bismuth subsalicylate 525mg PO QID 2) Metronidazole 250mg PO QID 3) Tetracycline 500mg PO QID 4) any PPI
78
3 phases of swallowing?
oral pharyngeal esophageal
79
2 types of dysphagia?
1. Oropharyngeal dysphagia - transfer dysphagia - difficulty transferring a food bolus from the oropharynx to proximal esophagus 2. Esophageal dysphagia - difficulty in transporting material down the esophagus
80
Describe Plummer-Vinson syndrome
- women 30-50 years old - dysphagia - anterior webs - iron deficiency anemia - cheilosis - spooning of the nails - glossitis - thin friable mucosa in the mouth, pharynx, and upper esophagus - intermittent symptoms - worse with solids - if untx, can become constant
81
Features along with Zenker diverticulum?
- noisy swallowing - dysphagia - halitosis - palpable compressible neck mass - laryngotracheal aspiration when supine
82
Treatment for Achalasia?
- nitrates - CCBs * decrease tone of LES - anticholinergic drugs: hyoscyamine sulfate or dicyclomine * decrease amplitude of esophageal peristalsis and LES pressure - peroral endoscopic myotomy (POEM) - endoscopic botox
83
4 major groups of pts with esophageal foreign bodies?
(1) pediatric patients (2) psychiatric patients or prisoners (typically intentional ingestion) (3) patients with underlying esophageal disease (4) edentulous adults
84
4 narrowings of the esophagus?
1. cricopharyngeus muscle (component of UES) - most common place for peds FBs 2. aortic arch 3. left mainstem bronchus 4. LES at the diaphragmatic hiatus - most common place for adults FBs
85
Types of muscle along the esophagus?
Upper 1/3: striated muscle Middle 1/3: skeletal and smooth muscle Distal 1/3: smooth muscle
86
What are 'Cafe Coronary' and 'Steakhouse Syndrome'?
Café Coronary: - proximal esophageal obstruction of food (usually an incompletely chewed piece of meat) - sudden cyanosis and collapse as a result of airway obstruction Steakhouse Syndrome: - improperly chewed large piece of food - distal esophageal obstruction
87
How can you distinguish a button battery from a coin on XR?
Button battery has radiographic double density sign
88
Complications of objects in Esophagus >24hr?
- perforation - aorto-enteric fistula - tracheoesophageal fistula - abscess
89
2 ways to remove upper esophageal foreign bodies other than EGD?
- foley catheter removal - bougienage
90
What FB objects should be removed from the stomach?
- longer than 5cm - wider than 2.5cm - all sharp and pointed objects - in place longer than 3-4 weeks
91
What is the Mackler Triad?
Subcut emphysema Chest pain Vomiting * pathognomonic for spontaneous esophageal rupture
92
What is Hamman sign?
Crunching sound during auscultation * pathognomonic for mediastinal/cervical emphysema from lower esophageal rupture
93
Difference between Upper and Lower esophageal rupture on XR?
Upper: pneumomediastinum +/- Rt pleural effusion Lower: pneumomediastinum +/- Lt pleural effusion
94
Empiric abx for Esophageal perforation?
- PipTazo 3.375 g IV q6h - Vancomycin 15 mg/kg IV q8h to q12h - Consider antifungal coverage (fluconazole 400 mg IV daily) if patient has significant risk factors for fungal colonization
95
Causes of Esophagitis?
- GERD - Eosinophiliic infiltration - Infection - Foreign body - Toxic ingestion - Radiation
96
Causes of GERD?
- nitrates - CCBs - anti-cholinergics - salbutamol - benzos - estrogen - progesterone - nicotine - caffeine - fatty meals - chocolate - ethanol - peppermint - achalasia - diabetes mellitus - scleroderma - obesity - pregnancy - acid hypersecretion - gastric outlet obstruction - gastroparesis - neuromuscular disease
97
Criteria for diagnosis of Eosinophilic Esophagitis?
- Clinical symptoms of esophageal dysfnc - >15 Eos/hpf on esophag bx - lack of responsiveness to PPI
98
Risk factors for EoE?
- food allergen hx - asthma - eczema *atopy
99
Risk factors for Infectious Esophagitis?
- immunocompromised - inhaled steroid use - general corticosteroid use - immunosuppressive agents - chemotherapy - use of broad-spectrum abx - diabetes mellitus - alcoholism - underlying malignancy - advanced age - HIV
100
Bugs common to cause Infectious Esophagitis?
- Candida albicans - HSV-1 - CMV - HPV - T. cruzi - Cryptosporidium - Pneumocystis
101
Treatments for GERD?
H2 histamine resceptor antagonists: - cimetidine - famotidine Proton pump inhibitors: - esomeprazole - pantoprazole - lansoprazole - rabeprazole - omeprazole Mucosal protectant: - sucralfate 1g PO q6h * safe in pregnancy Gastric motility agent: - metoclopromide Procedures/Surgery: - laparoscopic fundoplication - thermal ablation at LES - sutured plication at LES
102
Treatment for EoE?
- oral viscous budesonide - topical swallowed steroids - leukotriene receptor antagonists - mast cell stabilizers - azathioprine - 6-mercaptopurine - biologic immunemodulators
103
Top 2 and other causes of Gastritis?
1) H. pylori 2) NSAIDs and ASA - bile - ethanol - glucocorticoids - pancreatic secretions - shock state - stress - 5-fluorouracil - MMF - bisphosphonates - iron supplements - radiation - Crohn's - sarcoidosis - autoimmune
104
NSAIDs with highest risks of GI complications?
Most to Least: Indomethacin Naproxen Diclofenac Piroxicam Tenoxicam Ibuprofen Meloxicam
105
What is Zollinger-Ellison syndrome?
ZES is an acid hypersecretion syndrome - increased levels of circulating gastrin from gastrin-secreting tumors - gastrin stimulates parietal cells of stomach to secrete more acid = parietal cell hyperplasia - leads to ulcer formation
106
Causes of PUD in Infants and Children?
Stress ulcers associated with systemic illnesses: - sepsis - head trauma - burns - sickle cell disease
107
Complications of PUD?
Hemorrhage Perforation - of duodenal, antral, and gastric body ulcers Penetration - to liver or pancreas Gastric outlet obstruction
108
What is milk alkali syndrome? Common cause?
Hypercalcemia Alkalosis Renal insufficiency From excess consumption of calcium antacids
109
Pros and Cons of H2 receptor blockers and PPIs?
H2 Receptor Blockers - fast onset - can take 'prn' - good for duodenal ulcers, less so for gastric - hepatic and renal metabolism - can affect cardiac conduction - gynecomastia (cimetidine) PPIs - need to take regularly - best for all ulcer types - hepatic metabolism - avoid in pts high risk for hip fractures
110
When to refer to GI specialist?
- age 55 years+ with new-onset dyspepsia - dysphagia - progressive unintentional weight loss - persistent vomiting - iron deficiency anemia - epigastric mass
111
Describe difference btwn Primary and Secondary Gastric Volvulus?
1' = Subdiaphragmatic - stabilizing ligaments too lax or congenitally abnormal 2' = Supradiaphragmatic - occurs in pts with diaphragmatic defects ex) paraesophageal hiatal hernia, elevated diaphragm, gastric ulcer or carcinoma, diaphragmatic paralysis, extrinsic pressure on the stomach from other organs, or abdominal adhesions.
112
Describe difference btwn Organoaxial and Mesenteroaxial Gastric Volvulus?
Organoaxial - stomach twists on long axis (2/3 cases) Mesenteroaxial - stomach folds on its short axis from its lesser to greater curvature (1/3) cases
113
What is Borchardt triad?, and what condition does it insinuate?
1. severe epigastric pain and distention 2. vomiting then violent nonproductive retching 3. inability to pass NG tube * Gastric Volvulus
114
Complications of Gastric Volvulus?
- gastric ischemia - perforation - death - ulceration - hemorrhage - pancreatic necrosis - omental avulsion
115
What condition is this?
Gastric volvulus
116
How can you reduce a gastric volvulus?
- immediate passage of NG - endoscopic reduction (if no infarction signs) - surgery and fixation of stomach (plus repair of diaphragm defects)
117
First line anti-emetic for hyperemesis gravidarum and vomiting associated with headache?
Metoclopromide
118
First line antiemetic for chemo-induced vomiting?
Ondansetron
119
3 phases of vomiting?
Nausea Retching Vomiting
120
Describe acute, chronic, and cyclic vomiting
Acute - begins abruptly - lasts < 1 week - associated with acute conditions Chronic - > 1 month - motility disorders - effects of systemic treatments (chemo) - neuropsychiatric conditions (bulimia) - neurologic conditions Cyclic - discrete episodes - asymptomatic periods
121
Disorders associated with Vomiting
- Nausea & vomiting of pregnancy - Hyperemesis gravidarum - Gastroenteritis - Gastritis - Peptic ulcer disease - Biliary disease - Myocardial infarction - DKA - Pancreatitis - Appendicitis - Bowel obstruction - CO Poisoning - Boerhaave syndrome - Cannabinoid hyperemesis syndrome
122
Causes of Acute N&V
- Ischemic bowel - Ruptured viscus - Chollithiasis - Cholcystitis - Cholangitis - Bowel obstruction - Appendicitis Peritonitis - Acute pancreatitis PUD - Gastroenteritis - Hepatitis - Food poisoning - Intracerebral bleed - Meningitis - Cerebellar infarct - Drug toxicity - Drug withdrawal - Renal colic - Gonadal torsion - Pyelonephritis - MI - Sepsis - CO - Alcohol intoxication - Alcohol withdrawal
123
Causes of Chronic N&V
- Gastroparesis - Chronic pancreatitis - PUD - Gastritis - Gastric outlet obstruction - CNS tumour - Raised ICP - Migraine - Drug toxicity - Bulimia - CO - Pregnancy
124
Causes of Episodic N&V
- Cholelithiasis - IBD - IBS - Gastritis - BPPV - Motion sickness - Chemotherapy - DKA - Uremia - Pregnancy
125
Causes of cyclical N&V
- Cyclical vomiting syndrome - Cannabinoid hyperemesis syndrome
126
Critical Diagnoses with N&V
- Boerhaave syndrome - Ischemic bowel - GI bleeding - Ruptured viscus - Cholangitis - Peritonitis - Intracerebral bleed - Cerebellar infarct - DKA - ASA - Acetaminophen - Gonadal torsion - MI - Sepsis - Organophosphate poisoning
127
DDx for vomiting of bright red blood
Peptic ulcer Gastritis Esophageal varices Aortoenteric fistula Esophageal rupture Duodenal or gastric tumors Mallory-Weiss syndrome Dieulafoy lesion Foreign body
128
DDx for vomiting undigested food
Gastric outlet obstruction Achalasia Esophageal stricture Foreign body
129
List Rome IV Criteria for Cannabinoid Hyperemesis Syndrome
Must include ALL of the following: 1) Stereotypical episodic vomiting resembling cyclical vomiting syndrome in terms of onset, duration, and frequency 2) Presentation after prolonged, excessive cannabis use 3) Relief of vomiting episodes by sustained cessation of cannabis use *Criteria fulfilled for the last 3 months, with symptom onset at least 6 months before diagnosis Supportive remarks: *May be associated with pathologic bathing behaviours (prolonged hot baths or showers)
130
Name 4 diagnoses associated with N&V and Nystagmus
Labyrinthitis Vertebrobasilar insufficiency Cerebellar infarct or bleed Cerebellopontine angle tumor
131
What electrolyte abnormalities come with prolonged/severe vomiting?
Hypo- or hypernatremia Hypokalemia Hypochloremia Contraction alkalosis Azotemia
132
Name side effects/risks with ondansetron use
- HA - dizziness - MSK pain - teratogenic effects - QT prolongation, TdP - Serotonin toxicity
133
List 5 Anti-emetics
Ondansetron Metoclopromide Dimenhydrinate Prochlorperazine Promethazine Haldol Methylprednisolone Dexamethasone Propofol Olanzapine
134
List anti-emetic options in pregnancy
Ginger Vitamin B6 Metoclopromide Prochlorperazine Dimenhydrinate Ondansetron Methylprednisolone
135
Complications of IBD
Fistulae Strictures Abscesses Fulminant colitis Toxic megacolon Intestinal perforation
136
List Rome IV Criteria for IBS
1) Patient has recurrent abdominal pain (>1 day/week in the previous 3 months), with an onset >6 months before diagnosis. 2) Abdominal pain is associated with at least TWO of the following three symptoms: - Pain related to defecation - Change in frequency of stool - Change in form of stool 3) Patient has none of the following warning signs: - Age >50 years, no previous colon cancer screening, and presence of symptoms - Recent change in bowel habits - Evidence of overt gastrointestinal bleeding - Nocturnal pain or passage of stools - Unintentional weight loss - Family history of colorectal cancer or inflammatory bowel disease - Palpable abdominal mass or lymphadenopathy - Evidence of iron-deficiency anemia on blood testing - Positive test for fecal occult blood
137
DDx for IBS-constipation
- Bowel obstruction - Malignancy - Adult-onset Hirschsprung disease - Rectocele - Paradoxical closure of the anus during defecation
138
DDx for IBS-diarrhea
- Bacterial or parasitic intestinal infection - IBD - Lactose intolerance - Malabsorption - Radiation proctocolitis - Celiac disease
139
DDx for IBS-mixed
- IBD - Ureteral colic - Bowel obstruction - Diverticular disease - Gastroesophageal reflux of ulcer - Liver or pancreatic disease - Lead toxicity - Porphyria
140
Risk Factors for Diverticular Dz
- Weak bowel wall - Colonic stasis - Chronic constipation - Low fiber intake - Seasonal variation (summer months) - Smoking - Increased Age - Obesity - Alcohol use - Immunocompromised state - Composition of intestinal flora - Noncircumferential muscular layers - Insertion of the vasa recta - Localized ischemia - Connective tissue disorders - Ehlers-Danlos syndrome - High Intraluminal Pressure - Increased collagen crosslinking with age more distensible, more contractile bowel segmentation - Obstruction of diverticula
141
Complications of diverticulitis
Abscess Fistula Strictures Perforation Peritonitis
142
Standard of care for dx'ing diverticulitis?
CT abdomen with IV and enteric contrast
143
List CT findings of diverticulitis
- colonic wall thickening - pericolonic fat stranding - localized/micro perforation abscesses, free air or fluid
144
Hinchey Classification of Diverticulitis
1a. Pericolonic phlegmon and inflammation without fluid collection 1b. Pericolonic abscess <4 cm 2. Pelvic abscess or abscess >4 cm 3. Purulent peritonitis 4. Feculent peritonitis
145
Oral ABX for Uncomplicated Diverticulitis
- Ciprofloxacin 500mg PO BID PLUS - Metronidazole 500mg PIO q8h OR - Amox-clav 875/125mg PO BID *7-10 day course
146
IV ABX to cover bowel flora?
MILD to MODERATE INFXN Peds: --> CTX 50mg/kg IV q24h PLUS Metronidazole 7.5mg/kg IV q6h OR --> Gentamicin 2.5mg/kg IV q8h PLUS Metronidazole 7.5mg/kg IV q6h Adults: --> Metronidazole 500mg IV q8h PLUS - CTX 1g IV q24h OR - Ciprofloxacin 400mg IV q12h OR - Levofloxacin 750mg IV q24h SEVERE or COMPLICATED INFXN --> PipTazo 3.375g IV q6h (or 4.5g IV q8h) OR --> Cefepime 2g IV q12h PLUS Metronidazole 500mg IV q8h OR --> Meropenem 1g IV q8h
147
Causes of LBO?
Intrinsic: - Colorectal malignancy - Diverticular disease - Volvulus - IBD - Ischemia - Adhesions - Endometriosis - Radiation - Fecal impaction Extrinsic: - Ovarian Ca - Hernias
148
Describe Acute Colonic Pseudo-Obstruction (ACPO)
- aka Ogilvie Syndrome - acute colonic dilation w/out mechanical obstruction - usually affects cecum and Rt hemicolon - elderly - chronic opioid users - post-op pts - severe electrolyte abnormalities - fnc'l obstruction from increased sympathetic tone or decreased parasympathetic tone - conditions that affect autonomic intestinal innervation - Treat reversible factors - If >3 days, give Neostigmine 2mg IV (inc ACh to promote colon motility) - or colonic endoscopic decompression
149
What is the finding of LBO on AXR?
- Distended colon > 6cm - if >12cm, high risk of perforation
150
Differences btwn cecal and sigmoid volvuli?
Cecal - younger pts - mostly women - chronic constipation - high fiber use - Frequent laxative use - hx of laparotomy pregnancy pelvic sx - colonoscopy - long distance running - must be surgical mgmt Sigmoid - older pts (60-70) - long-term care residents - neurologic or psychiatric d/os - higher mortality rates - can try flex sigmoid endoscopy decompression before sx
151
Where does a colonic volvulus usually occur?
In a redundant colonic segment with an elongated mesentery along a narrow base.
152
Complications of colonic volvulus?
Ischemia Gangrene Perforation Death
153
What is hallmark triad of sigmoid volvulus
Crampy lower abdo pain Distention Constipation
154
Findings on AXR of sigmoid volvulus?
- large dilated loop of colon - absence of rectal gas - coffee bean sign - may have free air - bird's beak sign with contrast enema *CT shows whirl sign (twisting of the mesentery and mesenteric vessels) and can have bird's beak with contrast
155
Findings on AXR of cecal volvulus?
- Cecum dilated - air-fluid level - distended SB as well - distal colon absense of gas - may have free air
156
Compare and contrast Pediatric and Adult Intussusception
Peds: - peak 4-10mos, but any infant to toddler - idiopathic - small inc risk after rotavirus vax - acute onset, intermittent, colicky pain - may feel abdominal mass - vomiting, rectal bleeding (currant jelly stools) - lethargy, pallor - pulls knees up - US dx - pneumatic or hydrostatic reduction Adult: - >50yrs - neoplasm/malignancy - acute onset abdo pain, vomiting, rectal bleeding - may have constipation - CT dx - surgical reduction
157
Reasons for elevated lipase?
Acute pancreatitis Chronic pancreatitis Renal failure Acute cholecystitis Bowel obstruction or infarction Duodenal ulceration Pancreatic calculus Pancreatic tumors Type 2 diabetes mellitus Diabetic ketoacidosis HIV disease HCV infection Post-ERCP/trauma Sarcoidosis Celiac disease Inflammatory bowel disease Idiopathic Drugs
158
Where does intussusception usually occur in infants?
Ileum invaginates through the ileocecal valve into the cecum - can be related to Peyers patches in the small bowel, hyperplasia of same 2/2 viral infxns
159
Causes of Adult intussusception, small vs large bowel
Small Bowel: - benign lesions - metastatic tumours - idiopathic Large Bowel: - mostly malignancy
160
Ultrasound findings with intussusception
1. Target/donut shape with multiple concentric rings in transverse 2. Pseudo-kidney sign in longitudinal
161
What criteria must be met for peds intussusception pts to be d/c'd from the ED?
1) No signs of peritonitis on exam 2) Able to tolerate PO fluids 2 hours post-reduction without nausea, vomiting, or abdominal pain 3) Symptom-free for 2 hours following the PO trial
162
Inflammation type and location in Crohn's vs UC
CD: - Transmural inflammation - Skip lesions anywhere from mouth to anus UC: - Superficial inflammation - Continuous involvement of colon or rectum
163
Most common Extra-Intestinal Symptoms in Crohn's vs UC
CD: - Ankylosing spondylitis - Arthritis - Aphthous stomatitis - Uveitis - Erythema nodosum UC: - Primary sclerosing cholangitis - Inflammatory arthropathies
164
Clues of possible IBD in children with abdominal pain?
- Diarrhea - Growth or pubertal delay - Weight loss - Rectal bleeding - Anemia - Pallor - Fatigue - Perianal skin tags - Fistulae or abscesses - Erythema nodusum or pyoderma gangrenosum - Seronegative rheumatic joint pain - FamHx of IBD
165
Complications of IBD
- Fistulae - Strictures - Abscesses - Fulminant colitis - Toxic megacolon - Intestinal perforation
166
What can trigger Toxic Megacolon?
Recent ingestion of: - anticholinergics - anti-motility agents - narcotics - anti-depressants
167
General extra-intestinal manifestations of IBD?
- Ankylosing spondylitis - Primary sclerosing cholangitis - Uveitis - Scleritis - Episcleritis - Erythema nodosum - Pyoderma gangrenosum - Inflammatory arthritis - Sacroiliitis - Osteoporosis - DVT - PE - Cerebral sinus thrombosis - Ischemic heart disease - Mesenteric ischemia - Peripheral neuropathy
168
Criteria for disease severity in Crohns
--> Mild to Moderate Disease: - Patient ambulatory and able to eat - No dehydration - No toxicity - No significant abdominal pain or mass - Weight loss of 10% --> Moderate to Severe Disease (Any of the Following): - Mild disease that has failed to respond to treatment - Patient may have some systemic toxicity, significant weight loss, anemia - Fever, some abdominal pain or tenderness, intermittent nausea or vomiting --> Severe Disease - Persistence of symptoms during corticosteroid or biologic (e.g., infliximab) therapy - High fever, persistent vomiting - Intestinal obstruction - Rebound tenderness - Cachexia - Abscess
169
Criteria for disease severity in UC?
--> Mild Disease - <4 stools/day - Stools may contain some blood - No systemic signs of toxicity (e.g., fever, tachycardia, anemia, elevated erythrocyte sedimentation rate) --> Moderate Disease - >4 stools/day - Minimal signs of toxicity --> Severe Disease - >6 bloody stools/day - Signs of systemic toxicity
170
Mgmt of Crohns?
- PO budesonide, prednisone or IV steroids - immune modulators (azathioprine or methotrexate) - anti-TNF biologics (infliximab) - PPIs - Cipro 500mg PO BID and Metro 500mg PO TID x7-10 days
171
Mgmt of UC?
- 5-ASA PO or PR - budesonide - systemic steroids - tacrolimus - azathioprine - infliximab
172
Risks of IBD with Pregnancy
- spontaneous abortions - low birth weight - premature birth - ischemic placental disease - stillbirth - C/S delivery
173
Where does nonocclusive ischemic colitis usually occur?
*hypoperfusion and reperfusion injury in watershed areas --> splenic flexure --> rectosigmoid junction
174
List 15 Causes of Colonic Ischemia?
*Any low flow state - arrhythmias - heart failure - shock - atherosclerosis - embolic - thrombotic - vasculitis - E. coli O157:H7 - Hepatitis B - CMV - surgical interventions on the aorta - long-distance running - cocaine - methamphetamine - COPD - CKD - collagen vascular disease - hematologic disorders - anti-hypertensives - vasoconstrictors - anti-psychotics - OCP - anti-diarrheals - pseudoephedrine - immunosupressive agents - distal colonic obstructions
175
List 4 AXR findings of ischemic colon
1) Intraluminal prominences = thumbprinting (submucosal hemorrhage & swelling) 2) Wall thickening & ahaustral segments 3) Air in portal venous system 4) Air in bowel wall
176
List CT findings of colonic ischemia?
- mesenteric fat stranding - abnormal colon wall enhancement - thumbprinting - wall thickening - luminal narrowing - inner wall hypoperfusion = double halo sign - pneumatosis linearis - bowel dilation - peri-colonic free fluid
177
List 5 complications of prolonged/severe colonic ischemia
Transmural ischemia Gangrene Intestinal perforation Scarring Stricture formation Bacterial translocation + Sepsis
178
List clinical features of colonic ischemia
Mild crampy abdo pain LLQ (or RLQ) pain Abdo distention Bloody stool N/V Peritonitis Elevated WBC Toxic megacolon as complication
179
What vessel is implicated in isolated right colonic ischemia?
SMA
180
Outline mgmt of colonic ischemia
IVF hydration Analgesia Antiemetics Empiric IV ABX Surgical consult
181
List 6 risk factors for Stercoral Colitis
- Elderly - Bedbound - Neurologic disorder w/ poor physical activity - Comorbid neuro + psych d/o's - Metabolic d/o - Colonic fnc d/o - Narcotic therapy - Inappropriate diet + fluid intake
182
List 3 common locations for Stercoral Colitis
Anterior rectum Rectosigmoid junction Apex of sigmoid colon
183
List 4 complications of Stercoral Colitis
Increased intraluminal pressure wall necrosis Ischemic colitis Stercoral ulcer formation Colonic perforation
184
List 5 CT findings of Stercoral Colitis
- fecal impaction w/ hard calcified fecal mass (fecaloma) - colon dilation - colon wall thickening - mucosal discontinuity - pericolonic fat stranding - extraluminal free air
185
Outline mgmt of Stercoral Colitis
Bowel regimen Enema Manual fecal disimpaction Endoscopic guided disimpaction +/- IV ABX + GenSx if perforation
186
List parts of colon at greatest risk of receiving high doses of radiation
Fixed portions of colon, cecum, rectum
187
List clinical features of acute radiation proctocolitis
Abdo + rectal pain Diarrhea Hematochezia Tenesmus Anal sphincter dysfnc Onset during radiation tx
188
List clinical features of chronic radiation proctocolitis
Insidious onset after finishing radiation tx Ulcerative disease Strictures Obstructions Fistulae Bowel perforations LGIB Anal sphincter dysfnc
189
Outline mgmt of Acute Radiation Proctocolitis
Supportive care Discuss w/ Rad Onc Improve nutritional status Hydrocortisone enema 100mg PR BID Sucralfate enema 2g of 10% suspension in water PR BID Butyrate enema Docusate
190
Outline mgmt of Chronic Radiation Proctocolitis
Supportive care Stool softeners Analgesics Sulfasalazine or Mesalazine HBOT
191
List 8 illnesses associated with Neutropenic Enterocolitis (Typhlitis)
Leukemia Lymphoma Multiple myeloma Aplastic anemia Myelodysplastic syndrome AIDS Receiving tx for solid tumours Organ transplant pts
192
List 5 chemotherapeutic agents associated with the development of Neutropenic Enterocolitis
cytarabine gemcitabine vincristine doxorubicin cyclophosphamide
193
List U/S finding of Neutropenic Enterocolitis
Bowel wall thickening >0.5cm
194
List 6 CT findings of Neutropenic Enterocolitis
Bowel wall thickening Cecum dilation Pericolonic inflammation Pericecal fluid Pneumatosis intestinalis Perforation
195
Outline mgmt of Neutropenic Enterocolitis
IVF resuscitation Correction of electrolyters Bowel rest PipTazo 3.375g IV q6h in adults - 100 mg Piperacillin/12.5 mg Tazobactam /kg IV q8h in peds OR Cefepime 1g IV q8h (50mg/kg IV in peds) + Metronidazole 1g IV q6h (30mg/kg/day IV divided q6h in peds) +/- Fluconazole 800mg IV on D1, then 400mg IV until 2wk after neutropenia resolves Consider G-CSF if ANC <0.1
196
List 2 most common causes of acute pancreatitis
Gallstones Chronic EtOH use
197
List dx criteria for acute pancreatitis
Need 2/3 1. Characteristic abdo pain 2. Serum lipase or amylase >3x ULN 3. Characteristic findings on abdominal imaging
198
List 2 indications for ERCP
Cholangitis Biliary obstruction
199
List 20 Causes of Acute Pancreatitis
TOXIC & METABOLIC - EtOH - Drugs - Hyperlipidemia - HyperCa - Uremia - Scorpion venom MECHANICAL & OBSTRUCTIVE - Biliary stones - Congenital pancreas divisum - Congential annular pancreas - Ampullary tumour - Neuroendocrine tumour - Pancreatic carcinoma - Post-ERCP - Ampullary dysfunction or stenosis - Duodenal diverticulum - Trauma INFECTIOUS - Mumps - Coxsackie virus - HIV - CMV - EBV - Varicella - TB - Salmonella - Campylobacter - Legionella - Mycoplasma - Ascaris parasite VASCULAR - Vasculitis - Embolism - Hypoperfusion & Ischemia - Hypercoagulability OTHER - Idiopathic - Hereditary - Diabetes mellitus - DKA - Autoimmune
200
List Local Complications of Acute Pancreatitis
Interstitial Edematous Pancreatitis: 1) Acute peripancreatic fluid collection - homogeneous fluid collection adjacent to pancreas - seen <4wk of symptom onset 2) Pancreatic pseudocyst - homogeneous fluid collection w/ well-defined wall - seen >4wk of symptom onset Necrotizing Pancreatitis: 1) Acute necrotic collection - heterogeneous collection of fluid + necrosis - intrapancreatic and/or extrapancreatic 2) Walled-off necrosis - heterogeneous collection of fluid + necrosis w/ well-defined wall - intrapancreatic and/or extrapancreatic - seen >4wk of symptom onset
201
List 2 classic but rare findings of pancreatitis
Cullen sign - bluish periumbilical discoloration 2/2 hemoperitoneum Grey Turner sign - reddish-brown discoloration around flanks 2/2 retroperitoneal bleeding
202
List extra-pancreatic complications of acute pancreatitis
Ileus Bowel necrosis Splenic vein thrombosis Portal vein thrombosis GIB GOO Sepsis Shock Multiorgan failure ARDS Pleural effusion Thrombocytopenia DIC Hyperglycemia HypoCa
203
List 15 DDx for Acute Pancreatitis
Abdominal Disorders - PUD - Gastritis - Gastroenteritis - Cholelithiasis - Cholecystitis - Choledocholithiasis - Cholangitis - Nephrolithiasis - Bowel obstruction - Perforated viscus - Mesenteric ischemia - AAA - Ectopic pregnancy Cardiopulmonary Disorders - MI - PNA - Pericarditis - Pleural effusion Systemic Disorders - Sickle cell crisis - DKA
204
List 10 DDx for elevated amylase
Macroamylasemia Renal failure Parotitis Liver dz PUD Cholecystitis Pancreatitis Post-ERCP Trauma Appendicitis Intestinal obstruction Intestinal ischemia PID Ruptured ectopic AIDS ASA Semaglutide VPA Sulfa drugs
205
List 10 DDx for elevated lipase
Pancreatitis Pancreatic calculus Pancreatic tumors Renal failure Acute cholecystitis Bowel obstruction or infarction Duodenal ulceration T2DM DKA HIV disease HCV infection Macrolipasemia Post-ERCP Trauma Sarcoidosis Celiac disease IBD Idiopathic Furosemide Methylprednisolone OCP VPA
206
List 3 recommendations for CT in pancreatitis w/u
1) Dx uncertainty in setting of high clinical suspicion - atypical abdominal pain - normal pancreatic enzyme levels 2) R/o other suspected intra-abdominal pathology - bowel obstruction - AAA 3) Assess for complications in failure to respond to appropriate tx @48-72 hrs
207
List CT findings of pancreatitis
- parenchymal enlargement w/ lack of enhancement - loss of typical texture & borders - surrounding retroperitoneal fat stranding
208
List IV ABX regimen for infected pancreatic necrosis
Meropenem or PipTazo or Cefepime + Metronidazole or Ciprofloxacin + Metronidazole
209
List 10 Causes of Chronic Pancreatitis (TIGAR-O)
TOXIC & METABOLIC - Alcohol - Tobacco - HyperCa - Hypertriglyceridemia - CKD - Medications IDIOPATHIC - Tropical chronic pancreatitis - Early onset - Late onset GENETIC - Hereditary pancreatitis - PRSS1 mutations - CFTR mutations - SPINK1 mutations AUTOIMMUNE - Type 1 (IgG4 related) and Type 2 RECURRENT & SEVERE ACUTE PANCREATITIS - Post-necrotic - Vascular disease/ischemia OBSTRUCTIVE - Pancreas divisum - Sphincter of Oddi disorders - Malignant pancreatic duct obstruction - Post-traumatic pancreatic duct scars & strictures
210
List examples of Exocrine & Endocrine pancreatic insufficiency
Exocrine: - weight loss - steatorrhea - malnutrition/malabsorption Endocrine: - DM - Hypoglycemia
211
List 7 common complications of chronic pancreatitis
- pseudocysts - pancreatic ascites - ductal strictures - duodenal stenosis - pleural effusions - pseudoaneurysms (splenic, hepatic, gastroduodenal, pancreaticoduodenal arteries) - portal & splenic vein thromboses
212
List 6 CT findings of chronic pancreatitis
Intraductal pancreatic calcifications Pancreatic enlargement Dilated pancreatic ducts Pancreatic calcifications Atrophy Biliary duct dilatation Fluid collections Changes in panpancreatic fat
213
List diagnostic imaging modalities for evaluating chronic pancreatitis
CT MRCP EUS US
214
Outline mgmt for chronic pancreatitis
IVF Acetaminophen NSAIDs Tramadol TCAs SNRIs Gabapentins Enzyme replacement Octreotide Celiac plexus block
215
List 6 risk factors for pancreatic cancer
Tobacco use Alcohol abuse Obesity T2DM Chronic pancreatitis FamHx pancreatic Ca
216
List 3 most common causes of SBO
1. Adhesions from prior sx 2. Tumours 3. Abdominal hernias
217
List 4 most common presenting signs of SBO
Colicky abdominal pain Abdominal distention Nausea Vomiting
218
List 10 Lesions Causing Small Bowel Obstruction (Relative to Intestinal Wall)
External to Intestinal Wall: - Postop adhesions - Hernias - Volvulus - Compressing masses (Tumours, Abscesses, Hematomas) Intrinsic to Intestinal Wall: - Primary neoplasms - Inflammatory (Crohn disease, Radiation enteritis) - Infectious causes (Intestinal tuberculosis) - Intussusception - Traumatic (intestinal wall hematoma) Intraluminal: - Bezoars - Foreign bodies - Gallstone ileus - Ascaris infestation
219
Define Simple & Closed Loop Obstructions
Simple = obstruction occurs at a single point Closed = obstruction at two locations - creates a segment of bowel w/ compromised blood flow proximally & distally
220
List 5 Causes of Adynamic Ileus
Metabolic disease (HypoK) Medications (Narcotics) Infection (Retroperitoneal, Pelvic, Intrathoracic) Abdominal trauma Laparotomy
221
List 4 causes of Pseudo-SBO
Degenerative neuropathies Autoimmune dz - SLE - Scleroderma Paraneoplastic disease Hereditary conditions
222
List 7 types of small intestinal hernia
Ventral Inguinal Femoral Parastomal Lateral ventral Internal Obturator
223
List 7 common tumours that cause SBO
Adenocarcinomas Carcinoid tumours Lymphomas Sarcomas Adenomas Leiomyomas Lipomas
224
List 4 causes of ADULT intussusception
Tumour AIDS Lymphoma Atypical mycobacterial infxns
225
List XR findings of SBO
Distended loops of bowel >3cm diameter - can see plicae circulares around whole lumen Air-fluid levels when upright Likely no gas in large bowel
226
List gold standard imaging test for SBO
CT abdo pelvis w/ IV contrast - NOT oral contrast
227
List U/S findings of SBO
Fluid-filled bowel Dilated loops >2.5 cm in diameter Decreased or absent peristalsis w/ distally collapsed bowel Abdo FF btwn loops = Tanga sign - suggestive of high grade obstruction
228
Outline mgmt for SBO
IVF +/- NG - can inc risk of PNA Try to reduce a hernia if cause IV ABX for pre-op or suspected perf - PipTazo - Meropenem - CTX or Cipro, plus Metronidazole Octreotide 100mcg IV TID or IV inf to reduce GI secretions - if non-op or palliative
229
List 4 distinct clinical entities w/in Acute Mesenteric Ischemia
1. Mesenteric arterial embolism 2. Mesenteric arterial thrombosis 3. Nonocclusive mesenteric ischemia 4. Mesenteric venous thrombosis
230
List gold standard test for investigation/dx of acute mesenteric ischemia
CT angiogram
231
Describe intestinal angina
= Chronic mesenteric ischemia recurrent episodes of post-prandial abdominal pain resulting from insufficient intestinal blood flow during periods of increased metabolic demand, leading to food aversion and weight loss
232
What is most common cause of acute mesenteric ischemia?
Arterial emboli - usually related to cardiac dz
233
List 4 risk factors for mesenteric arterial thrombosis
2/2 progression of atherosclerotic disease - Advanced age - HTN - DM - Smoking
234
List 8 causes of nonocclusive mesenteric ischemia
2/2 Mesenteric vasospasm 1) Hypoperfusion - Sepsis - Severe dehydration - Pancreatitis - Hemorrhagic shock 2) Excessive sympathetic activity - CHF - Vasopressor use - Cocaine - Digoxin
235
List 15 factors associated w/ mesenteric venous thrombosis
- Usually affects SMA and branches Hypercoagulable States: - Polycythemia vera - Sickle cell disease - Antithrombin III deficiency - Protein C or S deficiency - Malignancy - Myeloproliferative disorders - Estrogen therapy, OCP - Pregnancy Inflammatory Conditions: - Pancreatitis - Diverticulitis - Appendicitis - Cholangitis - IBD Trauma: - Operative venous injury - Postsplenectomy - Blunt or abdominal trauma Miscellaneous: - CHF - Renal failure - Decompression sickness - Portal HTN
236
Outline triad of s/s of acute mesenteric ischemia
1) Sudden onset of poorly localized abdominal pain (pain out of proportion) 2) Vomiting or Diarrhea 3) Pt w/ cardiac disease
237
Outline mgmt of acute mesenteric ischemia
IVF resus Hemodynamic stabilization Heparin infusion (80u/kg IV bolus, then 18u/kg/h IV inf) Dobutamine, or Milirinone, or Dopamine low dose IV ABX for infarction, perforation, or peritonitis - PipTazo 3.375g IV q6h - Meropenem 1g IV q8h - CTX 2g IV q24h or Cipro 400mg IV q12h, plus Metronidazole 500mg IV q8h General Sx, Vascular Sx, IR Consults
238
Outline progression of appendicitis
- appendiceal luminal distention - appendiceal wall ischemia - transmural inflammation - perforation - resulting peritonitis
239
List 3 important anatomic features that determine the site of pain and tenderness in appendicitis
1) location of origin of appendix 2) course the appendix takes from its origin 3) length of appendix
240
List 5 possible locations of the appendix
Retrocecal Pelvic Subcecal Pre-ileal Post-ileal
241
List 7 causes of obstruction in appendicitis
Fecalith Appendicolith Lymphoid hyperplasia Fecal stasis Foreign bodies Tumours Intestional parasites
242
List highest positive LRs and negative LRs in predicting appedicitis in ADULTS
LR+ RLQ pain Rebound tenderness Rigidity Migration/Periumbilical pain Psoas sign LR- Absence of RUQ pain
243
List highest positive LRs in predicting appedicitis in PEDS
LR+ Obturator sign Psoas sign Rebound tenderness Guarding
244
List 4 physical exam maneuvers associated with appendicitis
Specificities are better that Sensitivities
245
List 10 DDx for Appendicitis
- Nonspecific abdominal pain - Gastroenteritis - Epiploic appendicitis - Omental infarction - Ureterolithiasis - Nephrolithiasis - IBD - Ileus or bowel obstruction - Intestinal perforation - Testicular torsion (males)
246
List 4 Gynecologic DDx for Appendicitis in Females
Ectopic pregnancy Ovarian torsion PID Ovarian cyst
247
List 3 DDx for Appendicitis in Pediatrics
HSP Mesenteric lymphadenitis Meckel diverticulum
248
Outline Alvarado Score for Appendicitis
RUQ tenderness = 2 WBC >10 = 2 Migration of pain = 1 Anorexia = 1 N/V = 1 Rebound pain = 1 Temp >37.7 = 1 PMN >75% = 1 Total /10 * High risk score =/>7
249
Outline of Pediatric Appendicits Score
Cough/Percussion/Hopping tenderness in RLQ = 2 Tenderness to Rt iliac fossa = 2 Migration of pain = 1 Anorexia = 1 N/V = 1 Pyrexia = 1 WBC >10 = 1 ANC >7500 = 1 Total /10 * Low risk <4 = No imaging * Equivocal 4-6 = U/S or MRI * High risk >6 = Surgery consult + U/S
250
List graded compression U/S findings diagnostic of appendicitis
MUST HAVE: - Diameter >6-7mm - Non-compressible appendix MAY HAVE: - Fat stranding (hyperechoic signals) - Peritoneal fluid surrounding appendix
251
List CT findings of appendicitis
- Diameter >6mm w/ surrounding inflammation OR - Diameter >8mm w/out inflammation changes - Circumferential wall thickening >2mm w/ mural enhancement - Calcified appendicolith - Signs of periappendiceal inflammation (fat stranding, clouding of adjacent mesentery)
252
List MRI findings of appendicitis
- Diameter >7mm - Circumferential wall thickening >2mm - Signs of inflammation adjacent to appendix (fat stranding or phlegmon formation) - Abscess or Fluid filled appendix
253
List 5 limiting factors for appendix U/S
Operator experience Pt body habitus Pt cooperation Superimposed bowel gas Atypically located appendix
254
List ABX tx regimens for appendicitis
Ertapenem 1g IV q24h - 15 mg/kg IV BID in peds (max 1g/d) or PipTazo 3.375g IV q6h - 75 mg/kg of piperacillin in peds (max 3g) or CTX 2g IV q24h + Metronidazole 500mg IV q8h - 50mg/kg + 10mg/kg in peds or Cefepime + Flagyl if significant systemic illness, immunosuppression, or advanced age
255
Name best risk factor for tx failure in non-op mgmt of appendicitis
Presence of a fecalith/appendicolith
256
List 1 long term risk in pts w/ non-op mgmt of appendicitis
1-2% cases of appendicitis associated w/ malignancy Will req colonoscopy f/u for age >40 in tx'd non-op
257
List 4 criteria for outpt mgmt of appendicitis
1) Prefers outpt mgmt 2) Benign exam 3) No fecalith or appendicolith on imaging 4) Planned f/u w/in 24hr - get rx for PO ABX and strict return instructions
Rosen's 10th
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