Gastrointestinal System Study Guide

GASTROINTESTINAL SYSTEM Name Zollinger-Ellison Syndrome GERD Cause Gastrinoma on pancreas or stomach Gastric contents regurgitate from stomach to esophagus due to reduction in LES tone, irritation of esophageal mucosa, ± gastric secretion Irritable Bowel Syndrome (IBS) Disorder of colon (spastic colon) Erosive Gastritis (Gastric Ulcer) H. pylori; Too much stress, alcohol or NSAIDs Duodenal Ulcer H. pylori Viral Hepatitis A: Fecal/oral B: sexual; mother to child; blood transfusion C: IV drug abuse, blood transfusion Signs/Symptoms Gastrin secretion stimulating high acid production of stomach. Develops ulcers in stomach and duodenum. Epigastric to midabdominal pain; stools may be tarry colored Diagnostics Treatments Concerns Chronic GERD may result in Barrett’s esophagus ± risk of squamous cell cancer – (followed by GI – lifetime PPI with endoscopic biopsy annually – 6 months) Fasting gastrin levels Chronic heartburn over time with large/fatty meals worsening when supine. Recurrent dry cough, chronic pharyn gitis, and hoarsen ess. Selftx w/ OTC antacids and H2 blockers. May be due to chronic NSAI D use, aspirin, or alcohol ***Anyone with GE RD x 10 yrs. should be referred to GI to R/O Barrett ’ s HPI – Clinical Dx Endoscopy when dysphagia, odynophagia, unintended weight loss, hematemesis, melena, chest pain or choking First line treatment is lifestyle changes (avoid eating 3-4 hours before bedtime, dietary changes and weight loss) avoid triggers (mints, chocolate, alcohol, ASA, NSAIDs, caffeine, carbonated beverages) Stop smoking. Evaluate meds: BB, CCB, alpha agonist, estrogen, progesterone. 2 nd line : Can combin e lifestyle changes with antacids or H2 blockers (prn up to 12 hours), if no relief: PPI once a day, before the 1st meal of day (lon g term therapy associated with hip fx, pneumonia, C Diff.; wean off due to rebound) – If no relief after 4-8 weeks, refer to GI Intermittent episodes of moderate to severe cramping in lower abdomen, especially LLQ. Bloating with flatulence. Relief after defecation. Stools range from diarrhea to constipation. Exacerbations/remissions. Commonly exacerbated by stress. Abdominal exam tenderness in lower quadrants R/O bacterial infections ROME III criteria: recurrent discomfort 3 days/month in last 3 months with 2+ Disco mfort relieved by defecation, change in stool form or appearance Increase fiber, avoid gas producing foods: beans, onions, cabbage, highfructose corn syrup. Antispasmodics. If constipation based – trial fiber supplements, Miralax. If diarrhea-based take Imodium before regularly scheduled meals. Decrease life stress Intermittent epigastric pain, burning/gnawing pain. Pain worse with eating, tender at epigastrium Worrisome symptoms: dysphagia, early satiety and weight loss Episodic epigastric pain, burning/gnawing pain. Pain relieved by food or antacids with recurrent 2-3 hours after meals. Awakens at 1-2 AM with symptoms fatigue, nausea, anorexia, malaise, abd omin al pain, dark colored urine, clay stools and joint pain for several days. Skin and sclera have a yello w tinge. Tenderness over liver with percussion and deep palpation. ± ALT/AST up to 10x normal. Remove and treat cause. Avoid hepatotoxic agents such as Tylenol, alcohol and statins. Treatment is supportive Periodic monitoring for alpha-fetoprotein to look for hepatoma (hepatocellular carcinoma) May have aversion to smoking H. pylori stool antigen test or urea breath test (no serological H. pylori because will test positive if ever infected) H. pylori negative : Stop NSAI Ds, (if needs NSAIDs add PPI or misopristol). Stop alcohol. Stop smoking. Stress management. Lifestyle changes with H2 blockers the step up to PPI. H. pylori positive: triple therapy Clarithromycin + Amoxicillin + omeprazole (Flagyl if allergic to Amoxicillin) x 14 d ***CCB – blocks calcium and ³ electoral conductivity – smooth muscle relaxer which ³ LES and increases GERD More commonly affects females Sudden abruption of medication can cause rebound worsening symptoms More common H. pylori is transmitted oral/fecal and oral/oral Reportable to public health department Hep A: Asympto matic; Hep A symptoms start about 28 days after exposure; Post-exposure and not vaccinated (age 1-40, give HAV ) if >40 give IG within 2 Weeks of exposure; avoid oral contraceptives to avoid cholestasis; avoid alcohol. Avoid working in food-related job s for 1 Week after onset of infection Hep B: acute, self-limiting or chronic infection . Tx: first-line agents pegylated interferon alfa (PEG IFN-a), entecavir (ETV ), and tenofovir disoproxil fumarate (TDF ) – Offer vaccine to those born before 1986 - cannot get vaccine if anaphylaxis to baker’ s yeast. Post-exposure and vaccinated give HBV, if in the process of vaccination series, give HBIG and complete series. Unvaccinated should receive HBIG and start vaccine series within 24 hours of exposure if possible Hep C: approximately 75-85% of people who will become infected will develop chronic infection . Most common cause of liver cancer and liver transplantation. Screen adults from 1945-1965 Tx: administer antivirals such as ledipasvir-sofosbuvir (Harvoni), ribavirin, and pegylated interferon alpha 2 A/2b NERVOUS SYSTE CEREBELLAR SYSTEM ➢ Romberg Test – stand with arms/hands straight on each side and with feet together. Have eyes closed; Positive if excessive swaying or imbalance (Proprioception) ➢ Tandem test – have pt. walk straight line in normal gait. Instruct to walk in straight line with one foot in front of the other. Positive if loose balance, falling, or unable to walk straight NEUROLOGICAL MANEUVERS ➢ Kernig’s sign – flex pt. hips one at a time, attempt to straighten leg while keeping hip flexed at 90° ➢ Brudzinski’s sign – passively flex/bend patient’s neck toward chest. Positive if patient flexes hip and knee to relive pressure and pain ➢ Nuchal rigidity – tell patient to touch chest with chin. Inability to touch chest secondary to pain is positive. CEREBELLAR TESTING Coordination (Diadochokinesia) ➢ Rapid alternative movement: patient to place lower arms on top of each thigh and move them alternating between supination and pronation positions ➢ Heel-to-shin testing: patient in supine position with extended legs. Patient to place the left heel on the right knee and then move it down the shin – repeat w/ right heel on left leg Sensory ➢ Vibration, Sharp-dull touch, temperature Stereognosis – recognizes familiar object w/ sense of touch Graphesthesia – identify figures 50 or < 5 years Previous headache history - Less worrisome if have had HA before - 50 yrs. o HA associated with fever, stiff neck, papilledema, cognitive impairment or personality change ➢ ➢ ➢ ➢ Three-word recognition Clock drawing (normal or abnormal) Three-word recall Dementia if score 0-2. No dementia if >3 - - - MINI-MENTAL STATE EXAM (MMSE): Orientation Short term memory - Recite 3 unrelated words Attention and calculation Spell 50: amoxicillin + 3rd gen. cephalosporin Prophylaxis of close contacts with rifampin or ceftriaxone Concerns Fatal if not treated Refer to ophthalmologist or ED Biopsy is definitive test High-dose steroids 40-60mg daily (Add PPI to prevent ulcer and possibly bisphosphonate for bone health) Mean age dx 72 Permanent blindness ***women more likely than men Pt’s with polymyalgia rheumatica are at very high risk 30% 911 – Assess ABCs Risk factors – A fib and HTN; aneurysm, anticoagulants, stimulants, sickle cell, diabetes, oral contraception, smoking. Blacks, Hispanics and Indians have ± prevalence Sentinel headache – can occur a few up to 20 days before event. • • Gradual onset throbbing headache behind one eye gradually worsening over several hours; photophobia and phonophobia. May last 2-3 days and become bilateral if not treated Aura can be paresthesia, seeing halos, metallic taste, hyperosmia, Scotomas (blind spots in visual field) etc. Positive family history and being female increases risk factors. In children, migraines can presentas abdominal pain. Treatments • • • • • • Migraine without aura HA last 4-72 hrs.; has 2 characteristics (unilateral pulsating quality, mod to severe intensity, aggravated by routine activity) has one of the following (Nausea and/or Vomiting, photophobia or phonophobia) 5 or more attacks no other reason for HA Migraine with aura 2 attacks with aura Visual, sensory, motor reversible Develops over 5-20 min; HA w/in 60 min. Rest in dark room w/ ice; avoid triggers (MSG, chocolate, ripened cheese, fermented foods, alcohol, caffeine, sleep changes, stress, menses, skipping meals, odors, bright light, change in weather) Abortive tx: triptans, NSAIDs, antiemetics Prophylactic tx: beta-blockers, TCAs, anticonvulsants (avoid if hx of kidney stones) (Butterbur, feverfew and magnesium) Contraindications for triptans: ischemic heart disease, CVA, TIA, HTN, diabetes, obese, male > 40, HLD; ± risk of serotonin syndrome with SSRI or SNRI; Do not start within 2 W eeks of MA OI use; Do not combine with ergots ***Avoid use of combined estrogen-progestin oral contraceptive in migraine with aura due to stroke risk Name Cause Signs/Symptoms Basilar or hemiplegic migraine Focal neurological finding with stroke-like s/s. resembles TIA. Polymyalgia Rheumatica (PMR) Bilateral morning stiffness and aching of shoulders, neck, hips, and torso (difficulty putting on bra) Trigeminal Neuralgia (Tic Douloureux) Compression of CN V root by artery or tumor Unilateral facial pain following one of the branches of the trigeminal nerve. Pain usually located close to the nasal border and the cheeks triggered by chewing, eating cold foods or cold air lasting few seconds Type I : extreme, shock-like facial pain lasting 2 minutes to 2 hours Type II: constant, aching, burning facial pain of lower intensity Bell’s Palsy Dysfunction of CN VII Viral infection, autoimmune or pressure from tumor/blood vessel Cluster headache Idiopathic Tension headaches Emotional/psychic stress Rebound headache Overuse of abortive medicines, NSAIDS, aspirin, narcotics Transient Ischemic Attack (TIA) Focal ischemia – brain, spinal cord, retinal ischemia Carpal Tunnel Syndrome (CTS) median nerve compression Facial paralysis progressing rapidly within 24h, difficulty chewing and swallo wing food on same side, unable to fully close eyelids and tear production may stop Diagnostics Treatments Concerns Avoid estrogen agents ±ESR ±CRP MRI/CT to r/o tumor/artery pressing on nerve or Multiple Sclerosis HPI - R/O CVA, TIA, mastoid infection, bone fx, Lyme disease and tumor Abrupt one-sided headache marked by recurrent episodes of brief 50 High doses anticonvulsants carbamazepine (Tegretol) or phenytoin (Dilantin); muscle relaxants, gabapentin More common in women and peaks in 60’s High dose corticosteroids x 10 days (wean) Acyclovir (Zovirax) if herpes suspected Protect cornea from drying and ulceration w/ lubricant. Patch eye at night to close with eyelid. Corneal ulceration, permanent neurological sequelae or facial weakness if prolonged case High dose oxygen (100 % 12LPM for 15 minutes), su matriptan (Imitrex) May take verapamil for prophylaxis High risk for suicide More men > women NSAIDs, OTC analgesics + caffeine (Excedrin), stress reduction and avoid triggers Daily headaches w/ irritability, depression and insomnia Narcotics and butalbital are habit forming and ± rebound headaches Discontinue medicines or gradually taper off Abrupt onset difficulty speaking, unilateral hemiparesis, dizziness, vertigo, weakness and poor balance. Slurred speech (aphasia). The longer the episode, the higher the risk of damage. CT/M RI within 24 hrs. of episode Refer to ED - Consider hospitalization within 24-48 hrs.: Patient’ s first TIA – or TIA > 1 hour; ± risk cardiac emboli – A fib; Symptomatic internal carotid stenosis >50%; hypercoagulable state; crescendo TIA; High ABCD2 score Up to 20 % will have stroke within 90 days Gradual onset of numbness and tingling on thumb, index finger and middle finger affecting hand grip. Acroparethesia – awakening at night with numbness and burning pain in fingers. Problems lifting objects w/ affected hand. Hx occupation or hobby involving frequent wrist movement Tinel’s sign – tap anterior wrist briskly. + if 96 o In evolving microcytic anemia ▪ As MCV ³ RDW ± o In evolving macrocytic anemia ▪ As MCV ±RDW ± ➢ What is the RBC hemoglobin content? o MCH or MCHC (chromic = color) o Normochromic: 31-37 o Hypochromic: <31 ➢ What is RDW (RBC distribution width)? o Index of variation in RBC size o Abnormal = > 0.15 proportion (15%) ▪ New cells differ in size ▪ Early indicator of evolving microcytic or macrocytic anemia ➢ What is reticulocyte percentage? o Body attempts to correct anemia o Normal 1-2% o Response to anemia is >2% o Reticulocytopenia - Low means body cannot fix the anemia ➢ Low MCV; Low MCHC o Thalassemia o Iron-deficiency ▪ Lead poisoning o Anemia of chronic disease ➢ Low H/H; High MCV o B12 deficiency o Folic acid deficiency ▪ Impaired liver ▪ Thyroid hypo-function ▪ Reticulocytosis ➢ Drug induced Macrocytosis without anemia o (ETOH >5 drinks in men > 3 drinks in women; carbamazepine, valproic acid, phenytoin; malabsorption, zidovudine (reversible, but meds outweigh the risks – DC ETOH – heavy alcohol intake has swollen cells) Hgb, Hct, RBC, MCHC, RDW normal with ±MCV ➢ ➢ Serum iron – measure of iron in circulation Serum ferritin – < 15 (iron in storage) o Chronic smokers, COPD, high altitudes o Hct more than 48% women and 52% men o Hbg more than 16.5 women and 18.5 men ➢ Reticulocyte count – indicates ability of bone marrow to produce RBCs ➢ TIBC – total iron binding capacity o TIBC is ±when iron ³ o TIBC is ³ when iron ± ➢ High Altitude stress – low barometric pressure causes reduction in arterial PO2 HERBAL MEDICATIONS WITH INCREASED BLEEDING RISK ➢ Ginseng ➢ Gingko ➢ Fish oil HEMATOLOGICAL SYSTEM HEMOGLOBIN ➢ Hemoglobin THALASSEMIA abnormal Hgb electrophoresis ³ MCV, MCH Normal RDW Serum Fe Normal/± Normal TIBC Normal Serum ferritin Asia, Ethnic Mediterranean, ***Alpha thalassemia North Africa, (Asians) Middle East IDA Normal ³ ± ³ ± ³ any CBC, then iron studies, then Hgb electrophoresis HEMORRHAGE ➢ Blood loss of 15% or more. o Orthostatic hypotension o Signs and symptoms of shock Nobody likes my educational background ± COPD ³ Chronic kidney disease Hypertension N/A DM with A1c 13.8 ³ Aspirin use N/A ± Testosterone use Resident of Denver, CO ± ³ 84 years old Meds that worsen anemia: ARB and ACEI in patients with CKD, diabetes, CHF, HTN 14-18 (males) 12-16 (females) Hematocrit 40-50% (males) 36-45% (females) MCV (average size of RBC) < 80 microcytic 80-100 normocytic > 100 macrocytic MCHC (average color of RBC) (³ IDA, thalassemia) 31-37 normochromic MCH (indirect measure of color) (³ IDA, thalassemia) 25-35 TIBC (capacity to seat iron – Iron count ± TIBC ³) 250-410 ± IDA Normal thalassemia, vitamin B12 deficiency and folate deficiency Serum Ferritin (stored form of iron) **sensitive IDA 20-400 ³ IDA Normal to high thalassemia Serum Iron 50-175 ³ IDA RDW (variability in size) > 15% measure variability ±IDA, Thalassemia Reticulocytes (immature – RBC survive 120 days) .5-2.5% Reticulocytosis (occurs w/ bone marrow stimulation) ± supplementation with iron, folate, B12, after acute bleeding, hemolysis, leukemia, erythropoietin (EPO) Poikilocytosis (peripheral smear) (shape) IDA Anisocytosis (variable size RBCs) Serum Folate 3.1-17.5 ³ macrocytic anemia B12 250 ³ macrocytic anemia Electrophoresis gold standard o Sickle cell anemia o Thalassemia ➢ Secondary polycythemia o Chronic smokers, COPD, high altitudes o Hct more than 48% women and 52% men o Hbg more than 16.5 women and 18.5 men ➢ High Altitude stress – low barometric pressure causes reduction in arterial PO2 o CAD, CHF, sickle cell ± risk complications Normal ➢ Neutrophils ➢ Lymphocytes 5.0-10.0 x 10 55-70% (AKA poly or segs) ****bands young Neut. Bands > 6% (shift L) 20-40% (virus) 2-8% ➢ Monocytes (debris) Eosinophils 1-4% (allergens, parasites, worms, wheezes, weird diseases) Basophils .5-1% Anaphylaxis not fully understood ➢ Leukocytosis (WBC > 10) – anticipated response in bacterial infections. ➢ Neutrophilia – elevated neutrophils ➢ Lymphocytosis – elevated lymphocytes ➢ Monocytosis - elevated monocytes ➢ Eosinophilia – elevated eosinophils ➢ Basophilia – elevated basophils HEMATOLOGICAL SYST Name Cause Neutropenia Vit. B12 Deficiency Signs/Symptoms Fever, sore throat, oral thrush Deficiency in B12 Gradual onset symmetrical peripheral neuropathy numbness, ataxia, loss of vibration and position sense, impaired memory and dementia. Stocking glove neuropathy, pale conjunctiva; systolic murmur, beefy red tongue Cancer of beta lymphocytes Night sweats, fevers, and pain with ingestion of alcoholic drinks; pruritus and painless enlarged lymph nodes (neck), anorexia and weight loss; Non-Hodgkin’s Lymphoma Cancer of lymphocytes and killer cells night sweats, fever, weight loss, generalized lymphadenopathy (painless) Multiple Myeloma Cancer of plasma cells Fatigue, weakness and bone pain usually located in back or chest; proteinuria with Bence-jones proteins; hypercalcemia, normocytic anemia; Hodgkin’s Lymphoma Thrombocytopenia Iron Deficiency Anemia Anemia of Chronic Disease Diagnostics Treatments African Americans have lower ANC ANC less than 1500 MCV > 100 Peripheral smear has macroovalocytes, megaloblasts and multisegmented neutrophils Most common cause pernicious an emia Rep lace B12 Nerve damage (? Reverse if < 6 months) Advise vegans to take supplements ± incidence age 20 -40 or >60 males, white Prognosis is poor Poor prognosis Platelet count of less than 150,000 Asympto matic until platelets lo wer than 100,000; easy bruisin g, bleeding gums, spontan eous nosebleeds, hematuria Bruising on distal lower and upper extremities is usually related to physical activity. Petechiae, purpura, large hematomas not accompanied by other symptoms are suspicious. Deficiency in ironmost common cause chronic low volume blood loss Most common type of anemia in childhood, pregnancy and women during reproductive years. Asymptomatic. Weakness, headache, irritability, skin pallor, fatigue, exercise intolerance, glossitis (red beefy tongue), angular cheilitis, cravings for pica. May cause spoon shaped nails, systolic murmurs, tachycardia, CHF, exacerbation of comorbid **common in alcoholic, NSAID users, females with heavy menses, vegans ³ Hgb ³ Hct ³ Serum Fe ³Serum ferritin ³MCV (microcytic) ³MCH (hypochromic) ±TIBC ±RD W > 15% (if <15% old) Anisocytosis Poikilocytosis Most iron is obtained from recycled iron content from aged red blood cells Iron rich foods – red meat, beans, green leafy vegetables, whole grains; *Need 150-200m g elemental iron daily. Ferrous Sulfate 325mg PO TI D take with OJ on empty stomach (65mg elemental iron per tablet) – recheck in 4-6 weeks. (Rule of thumb Hct ± 3 pts. and Hgb ± 1 pt. – if not improved check reticulocyte count for possible bone marrow problem). Treat for 3-6 months to replace iron stores. Once anemia corrected = Ferritin for estimation of iron stores Most common type of anemia in elderly followed by IDA and then pernicious anemia. Hgb ³ 12 Women; ³ 13 men Normocytic, normochromic anemia, reticulocytopenia Check serum ferritin, TIBC, vitamin B12 and folate Treatment aimed at control of underlying disease or diagnosing the occult disease or illness ³ renal EPO production Concerns >65 years more common in elderly Get better management of underlying disease. Or diagnose the occult disease or illness. Red blood cell life span is shortened from 100-120 days to 60-90 days If bleeding - Check medications ASA, NSAIDs, Warfarin, SSRI, steroids. Check CBC, PT/PTT and R/O coagulation disorders Avoid iron supplement w/ antacids, dairy products, levothyroxine, quinolones or tetracyclines. Serum iron is a drug level that fluctuates SE: constipation, black colored stools, upset stomach Store iron away from children due to toxicity Angular cheilitis – fungal infection. Tx with nystatin