Surgery > GI/Nutritional > Flashcards

GI/Nutritional Flashcards

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1
Q

Esophagitis

A

odynophagia (painful swallow), dysphagia, retrosternal CP.

dx: EGD
MCC is GERD…. unless immunocompromised (infectious - Candida, CMV, HSV).

tx: treat underlying cause

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2
Q

incompetent LES

A

GERD

Heartburn (pyrosis) hallmark**, increases when supine, regurgitation and dysphagia.

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3
Q

GERD - Dx and Tx

A

dx:
- clinical if typical symptoms
- EGD usually 1st
- if EGD normal –> Esophageal Manometry (shows decreased LES pressure)
- GOLD STANDARD - 24 HR AMBULATORY pH MONITORING

Tx:

  • stage 1 = lifestyle modifications
  • stage 2 = prn meds = H2 blockers
  • stage 3 = scheduled meds = PPI. Nissen fundoplication if refractory.
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4
Q

Dysphagia to both solids and foods + over competent LES

A

Achalasia

Dx:

  • Esophageal Manometry ** GOLD STANDARD
  • Double-contrast esophagram = Birds beak

tx = decrease LES pressure = botox injections, nitrates, CCBs

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5
Q

stabbing CP worse with hot or cold liquids/foods - pain similar to angina

A

diffuse esophageal spasm

dx = Esophagram - shows CORKSCREW esophagus.

tx = Nitrates, CCB

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6
Q

pharyngoesophageal diverticulum

A

zenker’s diverticulum

dysphagia, sense of lump in throat, regurgitation of foods, cough, halitosis

dx = barium esophagram

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7
Q

retrosternal CP worse with deep breathing and swallowing, hematemesis

A

Boerhaave syndrome

full thickness rupture of distal esophagus 2/2 repeat forceful vomiting.

dx

  • CT chest/CXR : pneumomediastinum
  • Contrast esophagram = definitive dx showing + leakage.

tx:
- small/stable = IV fluids, NPO, Abx, H2b
- large/severe = surgery

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8
Q

Physical exam findings of boerhaave syndrome

A

crepitus on chest auscultation 2/2 pneumomediastinum

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9
Q

esophageal webs

A

thin membranes in mid-upper esophagus.

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10
Q

Plummer-vinson syndrome

A

dysphagia + esophageal webs + iron deficiency anemia

  • Atrophic glossitis, angular cheilitis, splenomegaly. MC in white women, 30-60y.
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11
Q

esophageal rings

A

Schatzki ring - lower esophageal webs/constrictions

MC associated with sliding hiatal hernia* (type 1).

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12
Q

Esophageal webs/rings presentation, dx, tx

A

sxs = dysphagia especially to solids

dx = Barium Swallow

tx =

  • if no reflux = endoscopic dilation
  • if + reflux = antireflux surgery
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13
Q

protrusion of the upper portion of the stomach into the chest cavity 2/2 a diaphragm tear or weakness

A

hiatal hernia

type 1 = sliding

    • associated with increase in reflux.
    • tx similar to GERD

type 2 = rolling (paraesophageal)

    • may lead to strangulation
    • tx is surgical repair to avoid complications
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14
Q

MCC of esophageal cancer worldwide*

A

SQUAMOUS cell

  • MC in upper 1/3 of esophagus.
  • alcohol, smoking, hot beverages, exposure to noxious stimuli, men, nitrates all increase risk.
  • increased risk in African Americans.
  • Decreased incidence with NSAIDs and coffee consumption.
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15
Q

MC type of esophageal cancer in the US**

A

Adenocarcinoma

    • younger patients, obese, whites.
    • MC in lower 1/3
    • usually complication of GERD. leads to Barretts esophagus.
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16
Q
  • dysphagia of solid foods – progressing to dysphagia of liquids; odynopahagia
  • weight loss, CP, hoarseness
A

esophageal cancer

dx = EGD with biopsy.

tx =
- esophageal resection, XT, CTX (pends on stage)

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17
Q

MCC of upper GIB

A

peptic ulcer dz

H. pylori MCC
NSAIDs 2nd MCC

dyspepsia, epigastric pain - worse at night.

Dx: EGD with biopsy

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18
Q

PUD treatment if H. pylori +

A

CAP

Clarithromycin + Amoxicillin + PPI

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19
Q

Dyspepsia, Weight loss, Early satiety, Iron deficiency anemia

A

Gastric Carcinoma

    • Adenocarcinoma MC worldwide
    • H. pylori most important risk factor. other risks = salted, cured, smoked, pickled foods containing nitrites/nitrates

additional symptoms = signs of metastasis

    • supraclavicular LN (Virchow’s node)
    • palpable nodule on DRE (bloomer’s shelf)
    • Umbilical LN (Sister Mary Joseph’s node)
    • left axillary LN (Irish sign)
    • Ovarian mets (Krukenburg tumors)

Dx = EGD with biopsy

tx = gastrectomy + XT + CTX. poor prognosis

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20
Q

your patient develops jaundice during times of stress, ETOH, or illness (transient jaundice)

A

Gilbert’s syndrome

hereditary unconjugated (indirect) hyperbilirubinemia.

dx: Increased isolated indirect bilirubin with NORMAL LFTs.

no treatment necessary

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21
Q

ALT > AST

A

usually present with viral, toxic, or inflammatory liver disease.

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22
Q

AST and ALT > 1000

A

usually ACUTE viral hepatitis (A and B, rarely C)

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23
Q

chronic viral hepatitis (B/C/D) ALT and AST levels

A

mildly elevated ALT and AST (usually <400)

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24
Q

term for gallstones in the gallbladder, NO inflammation

A

cholelithiasis

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25
CHOLELITHIASIS - risk factors - sxs - dx - tx - complications (3)
- RF: 5f's = female, forty, fertile, fat, fair - ASX vs biliary colic (RUQ/epigastric pain lasting 30 min to hours. may have Nausea. Precipitated by Fatty foods and large meals) - Dx = Ultrasound - Tx = asymptomatic patients = observation symptomatic = elective cholecystectomy - complications 1. choledocholithiasis 2. acute cholangitis 3. acute cholecystitis
26
choledocholithiasis
gallstones in CBD secondary MCC (stones from gallbladder get stuck in CBD) major concerns: PANCREATITIS and CHOLANGITIS dx: - transabdominal ultrasound - ERCP*** diagnostic and therapeutic
27
patient with FEVER/CHILLS, RUQ PAIN, JAUNDICE
Charcot's triad = acute cholangitis = biliary infection 2/2 obstruction alk phos + bilirubin levels > ALT/AST dx/tx = ERCP and antibiotics (Unasyn, Pip/tazo)
28
Reynold's pentad
Charcot's triad + AMS + Shock seen in acute cholangitis
29
MC bacteria seen in both Cholangitis and Cholecystitis
E.coli > Klebsiella > Enterococci
30
Biliary colic with RUQ pain - pain lasting continuously - pain lasting 30 min to few hours - pain associated with jaundice?
A = continuous pain = think cholecystitis B = episodic pain = think cholelithiasis C = if jaundice present = think choledocholithiasis
31
patient with RUQ/epigastric pain that is continuous. they also complain of nausea. on exam the patient is FEBRILE (low grade), with ENLARGED, PALPABLE GALLBLADDER (+ Murphy's) and REFERRED PAIN TO RIGHT SHOULDER (+ Boas). what is suspected Dx?
Acute cholecystitis - order Ultrasound 1st. - labs: Leukocytosis with left shift. - GOLD STANDARD = HIDA = + test if non visualization of the gallbladder.
32
Acute Cholecystitis treatment
NPO, IV fluids, Antibiotics (Rocephin + Flagyl) -- continue until Cholecystectomy (w/in 72 hours)
33
chronic cholecystitis
- associated with GALLSTONES - may be 2/2 repeated bouts of acute/subacute cholecystitis. - STRAWBERRY GB ==> PORCELAIN GB (premalignant condition)
34
Patient presents complaining of Malaise, Weight loss, Jaundice, Abdominal pain and Hepatosplenomegaly.
Hepatocellular Carcinoma (HCC) - Ultrasound - Increased Alpha-Fetoprotein needle biopsy avoided to prevent seeding. tx = Surgical resection if confined to a lobe and not associated with cirrhosis.
35
how do we screen for HCC?
Ultrasound + Alpha-Fetoprotein
36
Fatigue is 1st symptom, Itching, RUQ discomfort, Hepatomegaly, Jaundice
Primary Biliary Cirrhosis - idiopathic autoimmune disorder of INTRAhepatic small bile ducts - MC middle aged women Dx: - HIGH ALK PHOS > AST/ALT, Bili - + Anti-Mitochondrial Antibody *** Hallmark** tx: - Ursodeoxycholic acid - decreases progression - Cholestryamine and UV light for itching
37
MC in men 20-40y with Inflammatory bowel disease (UC*) - present with Jaundice, Itching, Hepatomegaly, Splenomegaly - labs show High Alk Phos and + P-ANCA
Primary Sclerosis Cholangitis (PSC) ERCP - gold standard diagnostic test Tx: - Stricture dilation to relieve symptoms - Liver Transplant DEFINITIVE tx MEDS NOT BENEFICIAL
38
Gallstones, Alcohol, Scorpion bites, Mumps (kids) - all cause what?
Acute Pancreatitis
39
Constant, boring epigastric pain - radiates to back, better by leaning forward or sit in fetal position. worsened by supine, eating, walking.
Acute Pancreatitis Dx: Labs, Abdominal CT Tx: - NPO + IV fluids + Analgesia ABX NOT routinely used*.
40
Classic Triad: - Calcifications - Steatorrhea - Diabetes Mellitus
Chronic Pancreatitis MCC = Alcohol abuse. 2nd MCC = idiopathic MCC in kids = Cystic fibrosis Dx: AXR = Calcified Pancreas *** - Amylase/Lipase levels NORMAL Tx: PO Pancreatic enzyme replacement*, stop drinking, pain control.
41
Abdominal pain radiating to back, PAINLESS jaundice, weight loss, itching, migratory phlebitis (Trosseau's sign)
Pancreatic carcinoma - pts usually w/ METS at time of presentation. MC mets to regional LN and Liver
42
Pancreatic Carcinoma - Risk factors - Histology
RF: SMOKING, >60y, chronic pancreatitis, African Americans, etc. Histology: Adenocarcinoma** - DUCTAL MC - majority occur in HEAD of pancreas.
43
Courvoisier's sign
palpable, NONtender, distended gallbladder associated with jaundice (CBD obstruction). --**Associated with PANCREATIC CANCER****
44
Pancreatic Cancer diagnosis (3)
CT initial test ERCP most sensitive Labs: increased tumor markers: CEA, CA 19-9
45
Pancreatic Cancer treatment
1. WHIPPLE - if confined to head or duodenal; radical pancreaticoduodenal resection 2. Tail - distal resection 3. Advanced or inoperative = ERCP with stent placement as palliative tx for intractable itching.
46
Cramping Abdominal Pain + Distention + Vomiting + Obstipation
Small Bowel Obstruction - adhesions MCC - PE: Hyperactive BS - High pitched TINKLES. - Dx: AXR = Air fluid levels, dilated bowel loops. Tx: - non strangulated = NPO + IV Fluids +/- NG tube - Strangulated = surgery
47
twisting of any part of the bowel at its mesenteric attachment site.
Volvulus - MC sigmoid colon and cecum Sxs: obstructive symptoms = abd pain, distention, N/V, Fever, tachycardia. Tx: Endoscopic decompression (1st), sx (2nd)
48
MCC of acute lower GIB
diverticulosis - MCC to low fiber diet, constipation, obesity. - usually Asymptomatic (besides the bleeding) - Dx with CT scan - Tx with fiber supplements
49
Anorexia and periumbilical/epigastric pain --> followed by RLQ pain, N/V
Appendicitis - PE: rebound Tenderness, rigidity, guarding. Rovsing, Obturator, Psoas, McBurney's point DX - CT, Leukocytosis Tx - Appendectomy
50
chronic dull abdominal pain worse after meals + anorexia
chronic mesenteric ischemia (atherosclerosis of GI tract) - Angiogram confirms dx. - colonoscopy - muscle atrophy with loss of villi - tx = bowel rest. surgical revascularization
51
severe abdominal pain out of proportion to exam finings. poorly localized abdominal pain.
acute mesenteric ischemia - MC 2/2 occlusion (embolus, thrombus) - Angiogram definitive dx. - tx = surgical revascularization. resect if not salvageable.
52
LLQ pain with Tenderness, Bloody Diarrhea
Ischemic colitis - Dx = Colonoscopy - Tx = restore perfusion
53
non obstructive, extreme colon dilation > 6 cm + signs of systemic toxicity
toxic megacolon - fever, and pain, N/V/D, rectal bleeding, tenesmus, electrolyte disorders - AXR: dilated colon >6cm - Tx: Bowel decompression: Bowel rest, NG tube, Broad-spec ABX. - - correct lytes - - colostomy if refractory.
54
MCC of Large Bowel Obstruction in adults
Colorectal Cancer (CRC)
55
Iron Deficiency Anemia + Rectal Bleeding + Abdominal Pain + Change in Bowel Habits
Colorectal Cancer Dx: 1. Colonoscopy with Biopsy**. 2. Barium enema - apple core lesion classic. 3. Increased CEA levels. 4. labs = iron deficiency anemia tx: stage 1-3 = surgical resection stage 3 and mets = CTX
56
Colorectal Cancer MC site of metastatic spread
Liver
57
patient stable with chronic hepatitis who experiences sudden deterioration and worsening of symptoms
HCC
58
- Lateral to inferior epigastric vessels. - 2/2 persistent patent process vaginalis - MC in young kids and young adults. - MC type overall in men and women
INDIRECT inguinal hernia
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protrusion of abdominal cavity contents thru femoral canal below inguinal ligament
femoral hernia - MC seen in women - surgical repair
60
Incisional (Ventral) Hernia
MC with vertical incisions and in obese patients
61
Intermittent rectal bleeding*, hematochezia (BRB per rectum)
internal hemorrhoids | - proximal to dentate line
62
management of diarrhea (4)
1. IV fluids** 2. Diet - bland foods = "BRAT" diet - Bananas, Rice, Applesauce, Toast 3. Anti-motility agents (only for noninvasive diarrhea) 4. Antiemetics
63
MCC of gastroenteritis in adults
Norovirus | - outbreaks on cruises, hospitals, restaurants
64
Vomiting, watery diarrhea, voluminous (involves small intestine), NO fecal WBCs or blood
noninvasive (enterotoxin) infectious diarrhea
65
copious watery diarrhea, "rice water stools"
vibrio cholera and parahemolyticus
66
MCC of traveler's diarrhea
E. coli
67
MC antibiotic associated with C. diff
clindamycin
68
treatment for C. diff
``` mild = flagyl 1st or PO vancomycin (2nd) severe = PO vancomycin 1st line ```
69
high fever, + blood and fecal leukocytosis, not as voluminous (large intestine), mucus
Invasive infectious diarrhea
70
MCC of bacterial enteritis in US
C. jejuni - symptoms that mimic appendicitis + diarrhea that's initially watery -> becomes bloody - cultures show "S, comma, or seagull shaped" organisms** - tx = fluids. if severe = Erythromycin
71
lower abdominal pain with explosive watery diarrhea that is mucoid and bloody
Shigella - stool cultures = WBC/RBC. labs may show WBC > 50,000. - sigmoidoscopy = punctate areas of ulceration tx = fluids. if severe = Bactrim
72
population of increased risk of osteomyelitis with salmonella infection
sickle cell patients
73
predominant symptoms of non-invasive diarrheas
vomiting*
74
Backpackers diarrhea | - Frothy, greasy, foul diarrhea
Giardia Lamblia | - tx = Fluids + Flagyl
75
treatment modalities for constipation (4)
1. fiber 2. bulk forming laxatives 3. osmotic laxatives 4. stimulant laxatives
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