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Toronto Notes - GI

Terms in this set (87)

Commonly forgotten causes of vomiting
Drugs, uremia, CNS disease, pregnancy
Differential of Abdominal Distention (6 F's)
Fat, Feces, Fetus, Flatus, Fluid, Fatal growth
Causes of acute upper abdominal pain
Consider chest sources including MI, pneumonia, dissecting aneurysm
Intermittent abdo pain precipitated by eating
Obstruction (gastric outlet, small bowel), pancreatitis, ischemic bowel
Obscure but treatable causes of Abdo pain
Porphyria, angioedema, Familial Mediterranean Fever, Vasculitis (polyarteritis nodosa)
Most common cause of constipation
inadequate fiber or fluid intake
Retroperitoneal structures (SAD PUCKER)
Suprarenal glands, Aorta/IVC, Duodenum (D2-4), Pancreas (tail is intra), Ureters, Colon, Kidneys, Esophagus, Rectum
Which part of the small intestine absorbs Vitamin B12 and bile acids?
ILEUM
Key questions in dysphagia
Difficulty starting swallowing, associated symptoms (regurg, voice change, weight loss), solids/liquids/both, intermittent/progressive, hx of heartburn, change in eating habits
Odynophagia
Pain on swallowing
Key questions to ask in GERD
Dysphagia, weight loss
Foods that aggravate GERD
ETOH, caffeine, tobacco, fried foods, chocolate, peppermint, spicy foods, citrus fruit juices
Treatment for Non-erosive reflux disease
Symptom relief only; PPI PRN
Treatment for Esophagitis
Heal inflammation by PPI indefinitely or surgical fundoplication
What % of patients with Barrett's esophagus do not report GERD symptoms?
25%
Gastric vs. Duodenal ulcers
Gastric = ALWAY BIOPSY; Duodenal = rarely malignant
Management of Peptic Ulcer Disease
Stop NSAIDS, Acid neutralization, H. pylori eradication, Quit smoking
Relationship of smoking with PUD
risk of ulcer, complications, death from ulcer, impairs healing
Questions to ask in Acute Diarrhea (THOSE FADS WILT)
Travel, Homosexual, Outbreak, Seafood, Extra-intestinal signs of IBD, FH, Abx, Diet, Steatorrhea, Weight loss, Immunosuppressed, Laxatives, Tumor hx
Infectious causes of Inflammatory Diarrhea (CaSaDiff Coli-EhShY)
Campy, Salmonella, C diff, EHEC, E histolytica, Shigella, Yersinia
Symptoms of Salmonella typhi
Rose spot rash on chest, prodrome of high fever, bradycardia, HA, abdo pain; diarrhea is not initial presentation
Vitamin K dependent coagulation factors
2,7,9,10, protein C & S
Gluten containing products (BROW)
Barley, Rye, Oats, Wheat
Initial presentation of ulcerative colitis
Non-bloody diarrhea
Complications of Inflammatory Bowel Disease (ULCERATIVE COLITIS)
Urinary calculi, Liver, Cholelithiasis, Epithelial, Retardation of growth/sex, Arthralgia, Thrombophlebitis, Iatrogenic, Vitamin deficiencies, Eyes, Colorectal cancer, Obstruction, Leakage (perf), Iron deficiency, Toxic megacolon, Inanition (wasting), Strictures/fistula
Causes of Constipation (DOPED)
Drugs, Obstruction, Pain, Endocrine, Depression
Risk factors for mortality from bleeding peptic ulcer
co-morbid disease, hemodynamic unstable, Age > 60, transfusion required
If varices isolated to stomach, think
splenic vein thrombosis
When suspecting Lower GI Bleed, need to rule out
Upper GI Bleed
Differential for Lower GI Bleed (CHAND)
Colitis (radiation, infectious, ischemic, IBD (UC>CD)), Hemorrhoids/fissure, Angiodysplasia, Neoplastic, Diverticulitis
Melena vs. Hematochezia with regards to tumor localization
Melena = right; Hematochezia = left
Management Approach to Crohn's
Nutrition/Symptomatic (loperamide/Tylenol) --> 5-ASA/Abx --> CS --> Immunosuppression (azathioprine, 6MP, MTX) --> Immunomodulators (TNFa) --> Experimental tx/Surgery
Meds for induced remission for Crohn's disease
5ASA, CS, Immunosuppressive, Abx, MTX, Infliximab
Meds for maintenance of remission for Crohn's disease
Immunosuppressive, MTX, Infliximab
Meds for induced remission for Ulcerative colitis
5ASA, CS, Immunosuppressive
Meds for maintenance of remission for Ulcerative colitis
5ASA, Immunosuppressive
Forrest Classification of Peptic Ulcers
I (arterial bleeding), IIa (visible vessel), IIb (sentinel clot), IIc (hematin covered flat spot), III (no stigmata of hemorrhage)
Forrest Classification risk of rebleeding
I (55-100%), IIa (43%), IIb (22%), IIc (10%), III (5%)
Colorectal Cancer screening for average risk patients > 50 years old
FOBT q 2 years, sigmoidoscopy q 5 years, FOBT + flex sig q 5 years, barium enema q 5 years, colonoscopy q 10 years
When to screen for HNPCC?
Genetic testing + colonoscopy q 2 years starting at 20 years old
When to screen for FAP?
Genetic testing + sigmoidoscopy q 1 year starting at 10-12 years old
When to screen if FH of first-degree relative?
Colonoscopy q 5 years beginning at 40 years old or 10 years earlier before diagnosis of relative
Rectal cancer vs. colon cancer
Rectal cancer has higher recurrence rate and lower 5-year survival
When to refer for genetic screening for APC
Confirm FAP (> 100 colorectal adenomas), test relatives at risk
Amsterdam Criteria for HNPCC Diagnosis
3 relatives with colorectal cancer (1 is first degree), 2 generations, 1 case before 50 years old, FAP excluded
Clotting factors not synthesized by liver
Factor 8, vWF
Differential for serum transaminase > 1000
viral hepatitis, drugs, AI hepatitis, hepatic ischemia, common bile duct stone (rare)
ALT > AST
Most hepatitis
AST > ALT
Alcoholic liver disease
Signs of alcoholic hepatitis
Hx of recent ETOH, RUQ pain, AST < 300, low grade fever, mild elevated WBC
AST/ALT > 2
Alcoholic liver disease
Differential for Hepatomegaly
Congestive, Infiltrative (malignant/benign), Proliferative (infectious/inflammatory)
Differential for Congestive Hepatomegaly
Right HF, Budd-Chiari syndrome
Differential for Malignant Infiltrative Hepatomegaly
primary, secondary, lymphoproliferative, leukemia
Differential for Benign Infiltrative Hepatomegaly
fatty liver, cysts, hemochromatosis, extramedullary hematopoiesis, amyloid
Differential for Infectious Proliferative Hepatomegaly
viral, TB, abscess, echinococcus
Differential for Inflammatory Proliferative Hepatomegaly
granulomas (sarcoid), histiocytosis X
Risk of developing HBV, HCV, HIV from needle puncture
HBV (30%), HCV (3%), HIV (0.3%)
Without treatment, what % of HBV go on to develop cirrhosis
8-20%
Clinical manifestations of Wilson's disease (ABCD)
Asterixis, Basal ganglia degen (suspect if Parkinson's in young), Ceruloplasmin decrease, Cirrhosis, Corneal deposits (KF ring), Copper, Dementia
What is penetrance of hemochromatosis?
Not 100%; not all with homozygous will have clinical iron overload
Esophageal Complications from ETOH Abuse
Mallory-Weiss tear, Esophageal varices (from portal HTN)
Stomach complications from ETOH abuse
ETOH gastritis
Pancreas complications from ETOH abuse
acute/chronic pancreatitis
Liver complications from ETOH abuse
ETOH hepatitis, fatty liver, hepatic encephalopathy; Cirrhosis --> portal HTN, ascites, HCC
Usual causes of death in cirrhosis
renal failure (hepatorenal syndrome), sepsis, GI bleed, HCC
Cirrhosis Complications (VARICES)
Varices, Anemia, Renal failure, Infection, Coagulopathy, Encephalopathy, Sepsis
Signs of Portal Hypertension
Esophageal varices, melena, splenomegaly, ascites, hemorrhoids
Management of portal hypertension
B-blockers, nitrates, transjugular intrahepatic portosystemic shunt (TIPS)
Precipitating factors for Hepatic Encephalopathy (HEPATICS)
Hemorrhage in GIT/Hypokalemia, Excess dietary protein, Alkalosis/Anemia, Trauma, Infection, Colon surgery, Sedatives
Secondary bacterial peritonitis due to
perforated viscus, surgical manipulation
Gilbert vs. Crigler Najjer in reduced glucuronyltransferase activity
Gilbert = mild decrease; Crigler Najjer = complete deficiency
PBC vs. PSC on ERCP
PBC = absence of narrowing; PSC = narrowing of intra/extrahepatic ducts
Charcot's Triad for Ascending Cholangitis
RUQ pain, Fever, Jaundice
Reynold's Pentad for Ascending Cholangitis
RUQ pain, Fever, Jaundice, Hypotension, Confusion
Pancreatic enzymes
Amylase, lipase, trypsin, chymotrypsin
If serum amylase > 5 times normal
Almost always pancreatitis or renal disease
Differential for Acute Pancreatitis (I GET SMASHED)
Idiopathic, Gallstones (45%), ETOH (35%), Tumors, Scorpion sting, Micro, AI, Surgery/trauma, Hyperlipid/Hypercalcemia/Hypothermia, Emboli/ischemia, Drugs/toxins
What is Ranson's Criteria?
Prognostic indicator or mortality in pancreatitis not due to gallstones
Ranson's Criteria at admission (BALAW)
BG > 11 mmol/L, Age > 55, LDH > 350, AST > 250, WBC > 16
Ranson's Criteria at 48 hours (CHOBBS)
Ca < 2, Hct drop > 10%, PaO2 < 60, Base deficit > 4, BUN rise > 1.8, Fluid sequestration > 6 L
Prognosis based on Ranson's Criteria
2 = difficult course; > 3 = high mortality
Symptoms of Chronic pancreatitis
Abdo pain, diabetes, steatorrhea
Etiology of chronic pancreatitis (AAA)
Almost Always Alcohol
Treatment of chronic pancreatitis
ETOH abstinence, enzyme replacement, analgesics, resection if duct blockage
What is initial sign of short bowel syndrome?
Low Magnesium
Most common indications for TPN
Pre-existing nutritional deprivation, inadequate intake by mouth, significant multiorgan system disease
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