CMN 568 UNIT 4: GI/GU-ADULT & PEDS QUESTIONS WITH 100% CORRECT ANSWERS

dyspepsia epigastric pain/discomfort, early satiety or postprandial fullness causes of dyspepsia food/drug intolerance, stress/anxiety, peptic ulcer disease (PUD), GERD, H. pylori (assoc with PUD), pacreatic & biliary disease (rare) signs and symptoms of dyspepsia nonspecific symptoms; clarify chronicity, location & quality of discomfort, any assoc hematemesis/melena recommended testing for patients c/o dyspepsia >50yo=CBC, lytes, liver enzymes, calcium, thyroid >55yo=endoscopy with "alarm features" <50yo=noninvasive tests- H. pylori or trial PPI's GI "alarm" features weight loss, dysphagia, recurrent vomiting, bleeding, anemia endoscopy study of choice to diagnose: gastroduodenal ulcers, erosive esophagitis, upper GI malignancy, failed PPI treatment after 4-8 weeks what test should be ordered in patients with progressive weight loss or refractory symptoms? antibodies for celiac disease or stool test ova/parasites when is abdominal ultrasound/CT used? pancreatic, biliary tract, vascular disease or volvulus suspected gastric emptying ordered for reoccurring vomiting (NM study) treatment of dyspepsia - Antibiotics (H. pylori) - Acid suppression (PPI, "-azole", antidepressants) - Alter medication (e.g. aspirin/NSAIDs) - Lifestyle factors (reduce alcohol/caffeine) causes of persistent vomiting pregnancy, gastric outlet obstruction, gastroparesis, dysmotility, CNS/systemic disorders causes of acute onset vomiting without pain food poisoning, infectious gastroenteritis, drugs, systemic illness causes of acute onset vomiting with pain peritoneal irritation, acute gastric/intestinal obstruction, pancreaticobiliary disease diagnostic tests of persistent/prolonged vomiting lytes-assess loss gastric contents AXR, CT,upper endoscopy assess obstructions Treatment of Vomiting (general) most cases self-limiting clear liquids, small/dry foods treatment of vomiting (antimetics) 1. serotonin 5-HT3-receptor antagonists "-tron" 2. corticosteroids "-sone" 3. neurokinin receptor antagonists- "-tant" 4. dopamine antagonists "-zine" 5. antihistamines & anticholinergics 6. cannabinoids antiemetics: serotonin 5-HT3 receptor antagonists "-tron" ondansetron, granisetron prolonged half-life antiemetics: corticosteroids "-sone" dexamethasone enhance effects of serotonin receptor antagonists antiemetics: neurokinin receptor antagonists "-tant" aprepitant, fosaprepitant used in combo with corticosteroids & serotonin receptor antagonists antiemetics: dopamine antagonists "-zine" sedative effects high doses=extrapyramidal reactions, depression antiemetics: antihistamines & anticholinergics meclizine, dimenhydrinate, scopolomine prevent vomiting from motion sickness may cause drowsiness antiemetics: cannabinoids THC-marketed as Dronabinol appetite stimulant & antiemetic constipation causes inadequate fiber/fluid intake, decreased mobility, medications, structural abnormalities Constipation symptoms infrequent stools (<3/week), hard stools, abd strainings treatment of constipation dietary/lifestyle modifications, laxatives Osmotic laxatives draw water into the intestine to increase the mass of stool, softening and promoting defecation onset: 24 hours magesium hydroxide (not given to renal insufficiency), lactulose, polyethylene glycol Stimulant laxatives stimulate fluid and colonic contraction of bowel 6-12 hours senna, bisacodyl avoid daily use if possible fiber laxatives bran powder, psyllium, methylcellulose, distention & flatulence resides with continuous increase of fiber intake response to fiber therapy is not immediate Stool Surfactant Agents docusate sodium, mineral oil Promote H2O and lipid penetration of stool= lubrication Use: Prevent constipation in Pts who should avoid strain onset: 6-24 hours acute diarrhea <2 weeks usually caused by non/invasive pathogens & enterotoxins acute noninflammatory diarrhea watery, nonbloody mild, self-limiting caused by virus, noninvasive bacteria eval for pts with symptoms >7 days acute inflammatory diarrhea blood, pus or fever caused by invasive/toxin bacterium eval routine stool cultures:bacteria, ova, parasite symptoms & testing prompt medical evaluation of diarrhea >38.5C, abd pain, bloody diarrhea, dehydration, >6stools/24hrs, immunocomp, elderly age >70yo -send stool leukocytes, culture, C. Diff -ova/parasite symptoms >10days & recent travel acute diarrhea treatment No work-up needed (mild non-inflammatory): -Rehydration -Avoid fiber, fat, caffeine, alcohol -Loperamide or Bismuth subsalicylate Work-up needed (inflammatory): -Fluoroquinolones "-xacin" -NO antidiarrheal agents referral criteria for diarrhea severe dehydration, bloody diarrhea, severe abd pain, signs of sepsis or fever >38.5C, elderly >70yo chronic diarrhea causes >4 weeks; rule out lactose intolerance, IBS, parasitic infections, medications, prev gastric surgery Acute upper GI bleed symptoms hematemesis or coffee-ground, melena stools obtain amount estimation, patient history & refer acute lower GI bleed symptoms hematochezia (blood from anus), melena stools determine amount, frequency and refer occult blood blood that cannot be seen in the stool but is positive on a fecal occult blood test evaluation of positive occult blood test assess anemia status, endo/colonoscopy needed dysphagia difficulty swallowing oropharyngeal: drooling, spilling of food from mouth esophageal: due to mechanical obstruction of solids studies for dysphagia barium esophagography-differ b/t mechanical or motility disorder upper endoscopy-assess heartburn, dilation, strictures, biopsies gastroesophageal reflux disease (GERD) heartburn r/t backflow stomach contents exacerbated by meals, bending, lying down often resulting from abnormal function of the lower esophageal sphincter, Treatment of GERD 1. Lifestyle modifications: cessation of smoking, avoid eating at bedtime, avoid large meals, alcohol, and foods that cause irritation (tomatoes, fried foods, caffeine), and avoid lying down 3 hours after meals 2. Pharmacotherapy: A) Antacids mild/PRN symptoms B) h2 receptor antagoist (histamine blockers): cimetidine, ranitidine, famotidine, nizatidine C) PPI "-zole" first line in moderate to severe disease and those that do not respond to H2 blockers. D) Combo treatment of H2 blocker at bedtime and a PPI in the daytime are helpful in patients with significant nighttime symptoms. Infectious esophagitis common with immunocompromised pts odynophagia (painful swallowing), dysphagia, chest pain endoscopy-est diagnosis Mallory-Weiss syndrome tear in the distal esophagus from retching in alcoholism or bulimia sx's: hematemesis & history vomiting, retching eosinophilic esophagitis (EoE) allergens stimulate inflammatory esophageal response assoc with allergies, eczema, asthma eosinophilic esophagitis (EoE) symptoms heartburn, dysphagia solid foods, abd pain, vomiting, chest pain, FTT eosinophilic esophagitis (EoE) treatment PPI trial with endoscopy to diagnose & referral esophageal varices -Dilated submucosal veins that develop in patients w/ underlying portal hypertension -signs of acute upper GI bleeding Achalasia gradual, progressive dysphagia for solids/liquids -regurg of undigested food "birds beak" esophagus Erosive & Hemmorhagic Gastritis asymptomatic or epigastric pain, N/V, *hematemesis commonly see in alcoholic, NSAIDS, critically ill Gastropathy vs Gastritis Gastropathy - mucosal damage without inflammation Gastritis - mucosal damage with inflammation Nonerosive, nonspecific gastritis generally caused by H. pylori infection test stool or endoscopy biopsy Peptic Ulcer Disease (PUD) break in gastric/duodenal mucosa arising when normal mucousal barriers impaired by acid or pepsin Peptic Ulcer Disease (PUD) symptoms dyspepsia, epigastric pain "gnawing, dull, aching "hunger-like" major causes peptic ulcer disease (PUD) NSAIDS & H. Pylori Treatment of Peptic Ulcer Disease 1. Acid-Antisecretory agents: PPI's "-zole" & H2 receptor antagonists "-tidine" 2. Enhance Mucosal Defenses: bismuth sucralfate & antacids 3. eradication H. pylori=abx combo & PPI's eradication of H. pylori infection r/t PUD treat 14 days with abx combo & PPI options: Standard Bismuth Quad: PPI, bismuth, tetracycline, metronidazole Non-Standard Bismuth Quad: PPI, amoxicillin, claryithromycin, metronidazole Standard Triple Therapy: PPI, amoxicillin, clarithromycin -after completion of course continue PPI treatment daily 4-6 weeks Zollinger-Ellison Syndrome (ZES) gastrin-secreting gut neuroendocrine tumors (gastrinomas) causing acid hypersecretion -form of PUD diagose with fasting serum gastrin level & Rx PPI Celiac disease immunologic response to gluten causing damage to small bowel with malabsorption symptoms of celiac disease weight loss, chronic diarrhea, abd distention, growth retardation, stetorrhea, dermatitis herpetiformis=pruritic vesicles over extensor surfaces