IM GI key points

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kjschult
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221509
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IM GI key points
Updated:
2013-06-10 19:28:38
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im gi
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GI and hepatology key points for internal medicine
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  1. Noncontrast helical abdominal CT scan is the imaging choice to dx nephrolithiasis (kidney stones)
    Initial screen in acute abdominal pain should include supine and upright abd plain films to look for air-fluid levels (indicates bowel obstruction) and free peritoneal air (indicates perforated viscus)
  2. Rupture of AAA is preceded by abdominal pain, back pain, and syncope
    -leukocytosis and anemia are also common
    -CT scan should be performed for dx
    • -IBS: clinical dx made when pt meets Rome II criteria and do not have alarm indicators
    • -Rome III Criteria: 2 of the following for 3 months -> pain relieved by defecation, pain onset with change in stool frequency, pain onset with change in stool consistency
    • -Alarm indicators: older age, male sex, noctural awakening from pain, rectal bleeding, weight loss, or FH colon cancer
  3. Ischemic colitis presents most commonly in elderly pt with athersclerotic vascular disease with crampy abdominal pain and bloody stool; usually self-limited
    Contrast-enhanced CT is image choice to confirm suspected diverticulitis and evaluate for extraluminal complications
  4. Chronic pancreatitis common in pt with hx alcoholism who presents with chronic upper abd pain that radiates to the back, DM, steatorrhea, and pancreatic calcifications on abd xray
    • HUS is dx based on presence of microangiopathic hemolytic anemia and thrombocytopenia
    • -See schistocytes on peripheral smear, elevated retic count, and elevated LDH level with MAHA
  5. Acute radiation proctitis can cause diarrhea and tenesmus within 6 weeks of therapy
    Pt with chronic pancreatitis can present with abd pain, malabsorption, and endocrine insufficiency
  6. Invasive workup is not necessary in IBS in the absence of alarm symptoms
    Pt with previous Abx exposure can develop C. diff and colitis, char by diarrhea 10-15 times daily, lower abd pain, cramping, fever, and leukocytosis
  7. Abx tx is generally not required for Salmonella gastroenteritis
    • Abx tx is generally not required for Salmonella gastroenteritis because it is self limited
    • Tx is recommended for
    • 1) immunocompetent <2 yr or >50 yr
    • 2) immunocompetent with severe illness that requires hospitalization
    • 3) immunocompetent with athersclerotic plaques, endovascular/bone prostheses
    • 4) immunocompromised pt
  8. Hepatocellular injury most often results in elevation of ALT and AST and is associated with direct hyperbilirubinemia
    Incidental finding of indirect (unconjugated) hyperbilirubinemia in asx pt with normal Hb level and otherwise normal LFT indicates Gilbert syndrome
  9. Cholecystectomy provides definitive therapy for pt with symptomatic gallstone disease
    Pt with acute hepatitis have marked elevation of aminotransferases

    Pt with primary sclerosing cholangitis have cholestatic pattern (primary elevation of bilirubin and alk phos levels)
  10. Classic findings of acute cholecystitis: biliary colic, murphy sign, fever, leukocytosis, mild bilirubin and aminotransferase elevation, gallstones, pericholecystic fluid, thickening of gallbladder wall on US
    Clinical dx of acute cholangitis based on presence of fever, jaundice, and RUQ abd pain with the finding of common bile duct obstruction
  11. ERCP with sphincterotomy and stone extraction is the initial tx choice for gallstone pancreatitis
    Presence of stones in the gallbladder, dilated bile duct, and elevated aminotransferase levels highly suggest gallstones as cause of acute pancreatitis
  12. Enteral feeding is preferred route for providing nutrition in pt with severe acute pancreatitis
    Endoscopy is indicated in pt with GERD who have alarm sx (dysphagia)
  13. PPI is tx of choice for erosive or severe esophagitis
    Bx of all gastric ulcers should be preformed because even small benign-appearing gastric ulcers may harbor malignancy
  14. Two most common causes of PUD are NSAIDs and H. pylori infection (>90% of cases)
    NSAIDs are potential causes of dyspepsia and should be stopped/changed in pt with dyspeptic syndrome
  15. Upper endoscopy is indicated in pt >55 with new-onset dyspepsia even without alarm features of iron def anemia, unintentional weight loss, dysphagia, odynophagia, palpable abd masses, or jaundice
    Empiric trial of PPI is indicated for ulcer-like functional dyspepsia
  16. In GI bleeding of obscure origin, repeat upper endoscopy will ID bleeding source in significant proportion of pt
    Most pt with colonic ischemia are >60 yr and present with LLQ pain, urgent defecation, and red or maroon rectal bleeding that does not require transfusion
  17. Upper endoscopy should be performed at time of upper GI bleed after appropriate volume resuscitation to provide dx of cause of bleeding, provide prognosis, and perform endoscopic guided therapy if required
    Volume restoration if primary management intervention for Gi bleeding in hemodynamically unstable pt
  18. Most likely sources of painless lower GI bleeding are diverticulosis and vascular ectasia
    Anal fissures general cause rectal outlet bleeding and pain with defecation
  19. Pt with chronic hep B infection in absence of cirrhosis may develop HCC and should undergo periodic screening via liver US
    Patients with acute hepatitis generally have fatigue, vomiting, nausea, jaundice, and aminotransferase values >1000 U/L
  20. Pt with alcoholic hepatitis have hx of recent heavy EtOH use, elevated AST and ALT with AST:ALT ratio >2:1, and elevated alk phos
    Lab findings of autoimmune hepatitis: Elevated serum aminotransferases, hypergammaglobulinemia, mild hyperbilirubinemia, mildly elevated serum alk phos, and presence of autoantibodies
  21. Positive hep B surface antigen and IgM antibody to hep B core antigen est dx of acute hep B infection
    Anti-hepatitis C virus antibody test is screening test for at risk persons; positive test in person with risk factor confirms exposure to virus
  22. NASH is associated with obesity, DMII, hyperlipidemia, and is potential cuase of cirrhosis
    Primary sclerosing cholangitis is strongly associated with ulcerative colitis and marked elevations of alk phos
  23. Ascitic fluid analysis showing serum-to-ascited albumin gradient >1.1 g/dL suggests chronic liver disease as cause (ex. cirrhosis, right sided HF, and Budd-Chiari syndrome)
    First line tx for hepatic encephalopathy is lactulose
  24. Hepatorenal syndrome is defined as development of kidney dysfunction in pt with protal htn after exclusion of prerenal azotemia, renal parenchymal disease, or obstruction
    Erythema nodosum (small, exquisitely tender nodules on anterior tibial surface) is most common cutaneous manifestion of IBD (more common in Crohn's; pyoderma gangrenosum is more common in ulcerative colitis)
  25. Ulcerative colitis typically involves rectum and extends proximally with contiguous inflammation that is generally limited to mucosa of colon and rectum
    First line tx for induction and maintenance of remission in mild to moderate UC is mesalamine o another 5-aminosalicylate agent
  26. Microscopic colitis is char by chronic water diarrhea without bleeding; dx must be made by histologic examination of colonoscopic bx specimens

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