Exam 5 GI OH.pdf

Exam 5 GI + Final OH ● ● ● Case Study Final: Case from each module (no GI) ○ Defining features, how do we know what it is, diagnostic features, 1st line tx, pt education ■ Foot/ankle: how to use/interpret Ottawa rules ■ Back pain: low back pain packet-Clerkship guide (red/yellow flags, radiculopa...

Exam 5 GI + Final OH ● ● ● Case Study Final: Case from each module (no GI) ○ Defining features, how do we know what it is, diagnostic features, 1st line tx, pt education ■ Foot/ankle: how to use/interpret Ottawa rules ■ Back pain: low back pain packet-Clerkship guide (red/yellow flags, radiculopathy vs mechanical LBP) and 1st line tx, when imaging has a role Module 5 Exam: 42 questions – 1 or 2 short answers (1 for sure on epigastric pain) ○ Q: Differentials for acute epigastric pain – UGI bleed, bleed, pancreatitis, biliary tract or gallbladder disease (exact ones she named in OH) Pink = things she stressed in class and/or OH IBD (Ulcerative Colitis & Crohn’s Disease) & IBS ● Ulcerative Colitis vs Crohn’s Disease ○ Both: immune-mediated, relapsing & remitting episodes of inflammation ○ Ulcerative Colitis: involves the colon only, always involves rectum, can involve the colon more proximally (prostatitis vs left sided vs extensive-beyond splenic flexure) ■ Colon wall involvement: Inflammation of mucosa layer only ■ Pop: Bimodal peak: 20s-30s and 50s-60s ■ S&Sx: bloody diarrhea (frequency/urgency/tenesmus/nocturnal BM), abd pain, fatigue/anorexia/WL/fever, anemia, biochemical inflammation (WBC/platelets/ESR), low albumin ■ EIMs: swelling of eyes (Episcleritis-inflam of episclera or Uveitis), skin (Erythema nodosum-painful shin bumps or Pyoderma gangrenosum-painless ulcers), joints ■ Etiology: gut microbes, immune response, genetic susceptibility, envt triggers ■ Dx: colonoscopy & biopsy ■ ■ ○ Tx: 5-ASA, Immunomodulators, Steroids, Biologics/JAK (just know it varies) ● Last-line: surgery! Total colectomy w/ end ileostomy vs J-pouch Crohn’s Disease: can affect ANY portion of GI tract from mouth to anus (M→L: ileocolonic (55%)→small bowel only→colonic only→upper GI→anal only) “Skip lesions” ■ Colon wall involvement: entire thickness “transmural inflammation” ■ Consequences: abscess, fistula, stricture (from scar tissue) ■ S&Sx: ● Colonic: like UC–diarrhea, bloody stool, abd pain, WL/weakness/anorexia ● Small bowel: non-bloody diarrhea, abd pain, fever/WL/anorexia, malabsorption/malnutrition, stricturing (n/v, bloat, food aversion), perforating (fever, sepsis) ■ Dx: colonoscopy & biopsy ■ ● ● ○ IBS (not mentioned in OH but quick recap) ■ IBS-C = constipation (↓ serotonin levels) ■ IBS-D = diarrhea (↑ serotonin levels) ■ IBS-M = mixed or alternating and IBS-U = unable to classify ○ Dx criteria: recurrent abd pain w/o other cause + either related to defecation, a/w change in stool frequency or a/w change in form/appearance of stool ■ Presence of ^ w/ absence of alarm sx/red flags, other GI dz causing these sx ○ Tx: only really vigorous exercise 3-5x/wk (diet changes not helpful) IBD vs IBS ○ Basic immunology ■ IBD: immune-mediated, relapsing & remitting episodes of inflammation ■ IBS: LOTS–altered GI motility, visceral hypersensitivity, post-inf reactivity, brain-gut interactions, alteration in fecal microflora, bacterial overgrowth, food sensitivity, carb malabsorption, intestinal inflam, genetics, altered intestinal permeability ○ Typical presentation ■ IBD: bloody diarrhea (frequency/urgency/tenesmus/nocturnal BM), abd pain, fatigue/anorexia/WL/fever, anemia, bloating, food aversion ■ IBS: episodic abdominal pain, altered bowel habits, sensation of incomplete evacuation (tenesmus), gas/bloating–precipitated by emotional stress, eating ● Often w/ anxiety/depression/PTSD/prior physical/sexual abuse, sx improve w/ tx of the distress ○ Red flags: Blood in stool/anemia, weight loss/anorexia, nocturnal sx, large volume of stool, progressive pain, malnutrition/absorption, symptoms develop after age 50, family hx Liver Function Tests ● Tests that tell us about liver function vs liver injury ○ Main Liver Function Tests – ALT, AST, Alk phos, GGT ○ Acute Hepatocellular damage (INJURY) ■ ↑ AST & ALT (rule of thumb–3x normal=bad) ■ ↑ Alk phos, ↑ bilirubin, ↑ PT (1st thing to happen) ○ Biliary obstruction/cholestasis ● ■ ↑ alk phos w/ ↑ GGT → cholestasis ■ ↑ AST/ALT (mildly), ↑ bilirubin ○ Gilbert’s Syndrome – jaundiced, stressed out PA student (benign) ■ ↑ bilirubin (mildly), all else normal ○ Cirrhosis ■ ↑ PT, ↓ albumin, all else normal Main tests – how we use them, what they tell us, where to look for the problem ○ ALT – specific to Liver ○ AST – elevated w/ liver, cardiac and skeletal muscle injury ○ Alk phos – elevated in cholestasis, bile duct obstruction, neoplastic, infiltrative and granulomatous liver disease ○ GGT – elevated w/ biliary tract obstruction or alcohol consumption ■ Needed for cholestasis diagnosis ○ Lactate dehydrogenase (LDH) – 5 different isoenzymes based on location ■ LDH 2 should be higher than LDH 1 (heart) – if not, “flipped LDH” ■ ↑ LDH 5 – hepatocellular injury // ↑ LDH 2&3 – pulmonary injury or disease ○ Bilirubin ■ Conj/Direct: ↑ = cholestasis, obstruction (stone, tumor, trauma), liver metastasis ■ Unconj/Indirect: ↑ = breaking down too many RBC or hepatocellular injury ● Gilbert Syndrome: back up of bilirubin (stressed jaundiced PA student) ○ PT & INR – a/w liver function bc clotting determined by factors II & VII & vitamin K(diet) Biliary Tract/Chole/Pancreatitis/Liver ● Acute Pancreatitis ○ Pt pres: SICK pt in ED in intense epigastric pain radiating to back, diaphoretic ○ MCC: etoh use, gallstones (stuck in ampulla of vater) ○ Dx 2/3: Lipase or amylase > 3 x normal, abd pain c/w pancreatitis, abd imaging c/w pancreatitis (US or CT) ■ Other hints: ↑ TGL or hypercalcemia ○ Tx: early, aggressive fluid resuscitation (NG tube to get acid out!) & tx cause → cholecystectomy, stone removal by ERCP, apheresis or insulin drip for ↑TGL ○ Complications: inflammation, multi-organ failure, necrosis (infection/sepsis), pancreatic pseudocyst (chronic inflammation/pancreatitis 4+ weeks) ● Chronic pancreatitis: hospitalized alcoholic patient (not really mentioned in OH) ○ Sx: steatorrhea, digestive discomfort, flatulence, GI bleeding and pancreatic hemorrhage ○ Sequelae: malabsorption (fat soluble vitamin deficiencies), DM, biliary cirrhosis, cholangitis, hepatic abscess, ascites, PE ● Cholestasis ○ Digestive problems d/t lack of bile secretion/flow → ↓vit ADEK absorption ○ Urobilinogen not produced by microbes in gut from bile → light colored stool ○ Sx: jaundice(skin/scleral icterus), itching(worse throughout day), fatigue, dark cola urine ○ Intrahepatic–problem with bile formation ■ Hepatocellular–fatty/alcoholic liver disease (↑carb diet), cirrhosis, hepatitis ■ Cholangiocyte–primary biliary cholangitis, primary sclerosing cholangitis, cholestasis of pregnancy, cystic fibrosis ○ Extrahepatic–physical obstruction along biliary tract preventing bile flow ■ Choledocolthiasis (stone in common bile or pancreatic duct), tumor, parasite, primary sclerosing cholangitis ■ Dx: 1st test–US // definitive dx–ERCP ● ● ● ● ○ Caput medusae: indicative of portal HTN Cholecystitis vs Cholelithiasis ○ Cholecystitis: gallbladder inflammation, usually from obstructing stone ■ Pt pres: severe, constant abd pain-epigastric/RUQ, radiate to back/R shoulder, fever, n/v, + Murphys sign, worse 1-2hr after meal ■ Tx: admission, IV abx, NPO/NG tube → requires emergent cholecystectomy ○ Cholelithiasis: stones in gallbladder (normally cholesterol) – seen on US ■ Pt pres: postprandial RUQ colicky pain, radiates to back/R shoulder, +/- Murphys ■ RF: 5Fs–Fat, Forty, Fertile, Female, Fair ■ Tx: elective cholecystectomy, oral bile salts, lithotripsy, ERCP Acute Cholangitis vs Suppurative Cholangitis ○ Acute Cholangitis → Charcot’s Triad: Jaundice, RUQ pain, fever ○ Acute Suppurative Cholangitis → Reynold’s Pentad: ^ + hypotension & confusion Primary Sclerosing Cholangitis vs Primary Biliary Cholangitis ○ Sclerosing: rare, progressive, fatal dz–destruction/fibrosis of intra/extrahepatic ducts ■ Pt pres: M>F, 30-60yo, often associated w/ UC, +/- itching/jaundice ■ Tx: liver transplant, meds for itching – otherwise fatal ○ Biliary: chronic, progressive autoimmune destruction of intrahepatic bile ducts ■ Pt pres: F>M, indolent onset–fatigue, itching, dry eyes (Lupus, Sjogrens), ↓BD ■ Tx: manage itching, UCDA to improve sx/slow progression Alcoholic liver disease vs Non-alcoholic steatohepatitis vs Fatty liver disease vs Hepatitis ○ Alcoholic liver disease: spectrum of diseases (fatty liver, steatohepatitis, cirrhosis) ■ Dx: AST/ALT > 2:1 (so AST>ALT), elevated GGT ○ Non-alcoholic steatohepatitis: inflammation + fat, asymptomatic ■ a/w metabolic syndrome, obesity, insulin resistance, inflammatory cytokines ■ Dx: ALT elevation (<3x nml), elevated Alk phos & GGT ○ Fatty liver disease: can be alcoholic or non-alcoholic (same damage either way) ■ Alch: binge drinking or in chronic intake, often asymptomatic ● Tx: reversible w/ abstinence ■ Non-alch (NAFLD): diet too high in carbohydrates, fat in liver cells ● Dx: dx of exclusion. imaging/biopsy. AST/ALT 2-5x normal ● Tx: weight loss, avoid hepatotoxins, manage comorbidities, vitE dependent ○ Hepatitis: more details in EC lecture ■ Dx: AST/ALT <1 (so ALT>AST) ALT ~20x normal (HIGH), ↑GGT, unconj bilirubin ○ Cirrhosis: irreversible damage ■ MCC: #1 NAFLD, HBV/HCV/alcoholic liver dz in other countries ■ Pt pres: jaundice/scleral icterus, ascites, varices (risk for GI bleeding) Diverticulitis, C. diff, H. Pylori ● Diverticulitis vs Diverticulosis ○ Diverticulosis: bulging pockets of intestines → called diverticula ■ Pt pres: common w/ age (50+% of people) ■ Prevent progression: vigorous physical activity, high fiber diet, avoid NSAIDs ○ Diverticulitis: inflammation/infection of diverticula d/t obstruction of diverticulum from stool ■ Sx: LLQ abd pain + fever ■ Pt pres: <50: M>F // >50: F>M ■ RF: ↓physical activity, NSAID use, genetics, ↓fiber diet, ↑BMI, tobacco use ■ ● ● ● Management: antibiotics-selectively (immunocompromised, complicated, severe) or, surgery-sigmoidectomy (after ~3 episodes) H. pylori ○ Acquired mainly in childhood-chronic if not cleared, ⅓ of US population, person→person ○ RF: infected family members, # of siblings, crowded living, poor sanitation & hygiene ○ Dx: serology–EVER had it, urea breath test or stool antigen test–active infection, scope ■ All pts who test positive must be treated, so don’t test everyone! ■ Alarm sx: dysphagia, weight loss, bleeding, family hx ○ Tx: Bismuth Quadruple Therapy (PPI or H2RA + bismuth + metronidazole + tetracycline x10-14d) vs Clarithromycin-based Triple therapy (more resistance so used less now) ○ Sequela: PUD, gastric adenocarcinoma, gastric MALT lymphoma, gastritis, dyspepsia ○ w/ GERD: ??? C. diff ○ Leading cause of nosocomial diarrhea (>10% mortality in elderly) ○ Infection requires: alteration of the microbiome AND exposure to the organism (fecal→oral) ○ Spores survive months and are extremely resistant. Germinate in bowels→inflammation ○ Dx: Toxin A&B EIA and C. diff PCR-(NAAT) ○ Tx: ■ Initial: non-severe: Vanco vs Fidaxo vs Flagyl // severe: vanco vs fidaxomicin ■ Recurrent: Fidaxomicin (tx, withdraw, repeat–to awaken sores then kill them) Microbiome questions – basic Diarrhea & Constipation & Celiac ● Constipation ○ Def: 3 or less BM/wk w/ symptoms (abd discomfort, distension/bloating) ○ Pt pres: straining, hard to pass stools, infrequent stools, abd discomfort ○ RF: older, female, inactivity, poor oral intake, low fiber diet, 5+ meds, med conditions (MS, parkinsons, dementia), low SES, rural location, cold weather ○ Primary constipation (functional) – 3 categories ■ Normal transit (24-72hr) – perception of constipation, abd pain/bloat, often w/ stress, responds to fiber/lax/lifestyle changes ■ Slow transit (120hrs/5d) – no ↑peristalsis after meals, colonic dysmotility (not coordinated), infrequent urge to defecate/bloating/discomfort, poor response to lax ● Common cause in young women, long dx of constipation not related to diet ● Tx: fiber, lax, colchicine, misoprostol, erythro, 5HT4 receptor agonists, etc ■ Outlet – pelvic floor dysfunction, incoordination of pelvic floor muscles during attempt (dyssynergia, anal sphincter/pelvic floor m dont relax w/ valsalva), stool isn’t expelled when reaching recturm, not caused by muscle/neuro ● Sx: prolonged /excess straining, difficult to pass soft stool, rectal discomfort, manual extraction of stool ○ Medications ■ Bulk forming – Fiber supplements: Methylcellulose (Citrucel), Psyllium (Metamucil) ■ Lubricating – Mineral oil ■ ● ● Osmotic – Lactulose, Magnesium hydroxide (MOM), Polyethylene glycol (Miralax) ■ Stimulant – Bisacodyl (Dulcolax), Senna (Senakot) ■ Stool softener – docusate sodium (Colace) “basically soap” ○ Lifestyle: adequate hydration, movement/exercise, high fiber foods, high inulin foods ○ Consequences: anal pain, fissures, rectal tears, hemorrhoids, diverticula, abd pain, urinary incontinence, pelvic floor dysfunction, stool leakage, poor QOL ○ Secondary constipation – secondary to medical problem, medication, lifestyle ○ Red Flags: rectal bleeding, rectal prolapse, change in stool caliber(↓size-think cancer), anemia, blood in stool, obstructive symptoms, recent onset w/o cause, weight loss Diarrhea ○ Causes (SOLAMIE “salami” gives you diarrhea) ■ Secretory – disordered electrolyte transport, decreased absorption ● inf.(e. coli, cholera), bile salts (s/p chole), IBD, laxatives(docusate sodium) ■ Osmotic – water not transporting across gut mucosa, excess water in gut ● lactose intolerance, osmotic laxatives, excess fructose, artificial sweeteners ■ Lifestyle induced ■ Abnormal motility – ↑transport time → ↓absorption of h2o/electrolytes ● Erythromycin, IBS ■ Medication induced ■ Inflammatory/Infectious/Infiltrative – exudative, secretory and osmotic components ■ Exudative – damage to mucosa, release of mucus/blood/plasma → ↑fluid in feces ● UC, CD, radiation enteritis ○ Types – not much on specifics bc tested in micro ■ Acute – stool w/ ↑ water content, volume, frequency <14 days (MCC is viral inf.) ● Infectious: inflam/invasive-bloody (travel, food poisoning, salmonella, campylobacter, shigella, shiga toxin e coli) or non-inflam-watery ● Non-infectious: meds(abx, cholinergics), acute abd process, GI disease-IgA deficiency, endocrine disease (hyperthyroidism) ■ Chronic – decreased stool consistency for 4+ weeks. Refer to GI ● Lots of causes, ID triggers/timing/appearance, keep colon ca on ddx ○ Treatment ■ Supportive: rehydration–IV or oral (salt, glucose, h2o, K+) ■ Early refeeding: avoid dairy, maybe BRAT (not proven) ■ Antidiarrheals: Loperamide (Imodium), Loperamide/simethicone, Bismuth subsalicylate (Pepto) ■ Abx: travelers-Azithro, Cipro, other FQ vs organism specific from culture Celiac Disease ○ Pt pres: most common--malabsorption (diarrhea, gas/bloat, WL/anorexia, abd pain), iron deficiency anemia, osteopenia → infertility, abnormal LFT,s neuro dz, chronic fatigue ■ F>M, ~40s, alleles for HLA-DQ2 or DQ8→activated somehow ■ vitamin/mineral deficiencies – commonly a/w iron deficiency anemia ○ Dx: Total IgA AND IgA anti tTG – pt must be eating a gluten-containing diet ■ Duodenal biopsy to confirm dx + determine severity ○ Tx: gluten free (wheat, barley, rye) diet for life :( & assess/tx vitamin deficiencies ● Colon cancer ○ Risk factors: UC, CD, primary sclerosing cholangitis ○ Screening: Fit Test (Cologuard) and colonoscopy (gold standard) GI Bleeds ● Upper GI Bleeds (UGIB) – Melena ○ MCC: #1 peptic ulcer dz (NSAID use!) ○ Tx: endoscopy +/- hemostasis → evaluate risk for rebleed→if high risk/active bleed/visible vessel→prevent recurrent bleed–ICU/surgical consult, PPIs (some benefit), stop NSAIDs ○ Fatality factors: shock, red blood, cause-varices or cancer, comorbid disease, older age, onset in hospital, recurrent bleeding ● ○ Lower GI Bleeds (LGIB) – Bright red blood in stool ○ MCC: #1 diverticulosis ○ Management: Supportive care initially, urgent colonoscopy after prep→define cause, rule out cancer, potentially treat w/ surgery, no pharm rx treatment for LGIB ○ Dx: FIT test, used for outpatient colon ca screening, + requires colonoscopy ○ Occult GI bleed (pt does not see it, not aware): less common, often morbid (slow), capsule endoscopy, enteroscopy options Alcoholic Liver Disease – Extra Credit (apparently lots of EC Qs-woohoo) ● Hepatitis A – acute disease only, vax available ○ Transmission: orally via contaminated food/water, prevent w/ sanitary water & handwash ○ Pt pres: flu-like symptoms, jaundice (develop weeks after exposure) ○ Dx: +Hep A antibody + IgM ● Hepatitis B – pts clear the virus (lasting immunity) vs develop a chronic infection, vax available ○ Transmission: sexual contact, IVDU, blood products, vertical transmission ○ Pt pres: depends on viral stage–flu-like sx, jaundice, RUQ pain (develop months after inf) ○ Dx: HBcAb (previous) & HBsAg (active or vax) – both pos=infection (otherwise just vax) ○ ○ ● Tx: Acute-supportive care(v contagious) // Chronic-refer GI, ongoing care(prevent cirrhosis) Hepatitis C – major worldwide health problem, no vax available ○ ● Transmission: IVDU, blood products (before 1992), tattoos (unsterilized needles), sexual contact, maternal-infant route (<5%) ○ Pt pres: flu-like sx, jaundice, abdominal pain. Mostly silent ■ Acute – nml self resolve // Chronic → disease and risk for cirrhosis/HCC ○ Dx: +HCV Ab, +HCV RNA Hepatocellular carcinoma – primary cancer of the liver ○ RF: cirrhosis