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Five red flags in Chronic Abd. Pain
- weight loss
- fever
- electrolyte abnormalities
- signs of GI blood loss
- anemia
- (also listed: malnutrition, chronic diarrhea, dysphagia, vomiting)
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Some causes of chronic abdominal pain
- -Intermittent SBO
- -Chronic pancreatitis
- -mesenteric ischemia
- -PUD
- -abdominal wall pain
- -biliary disease
- -GERD
- -IBS
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What are the Rome III criterion for IBS?
- 1) Need to have had symptoms for the past three months with them starting at least 6 months ago
- 2) abd pain and discomfort for 3 days/month with 2 of the following:
- -improvement with defecation
- -associated with a change in stool freq
- -associated with a change in stool appearance
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Rare causes of chronic abd. pain
- -Celiac artery compression syndrome: usually associated with epigastric bruit and weight loss
- -Narcotic bowel syndrome: happens when using narcotics
- -Painful rib syndrome: tenderness over the costal margins
- - Eosinophlic Gastroenteritis: due to eosinophlic infiltration
- - sickle cell anemia can cause abdominal pain because of vaso-occlusive crises
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Symptoms of esophageal disease
- -dysphagia
- -odynophagia
- -esophageal colic
- -heartburn
- -regurgitation/aspiration
- -hematemesis
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4 questions for esophageal dysphagia
- progressive vs non-progressive
- painful vs painless
- intermittent vs continuous
- solid vs liquid
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agents that reduce LES tone
Dietary: Caffiene, fatty meal, chocolate, peppermint, smoking, alcohol
Meds: morphine, Ca++ channel blocker, nitrates, anticholinergics
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Red flags of GERD
- Dysphagia
- Odynophagia
- Hematemesis
- Melena (black stool)
- Anemia
- Weight loss
- Refractory to therapy
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What are some of the complications of GERD
- esophagitis/ulceration
- aspiration
- stricture
- bleeding
- Barrett's
- adenocarcenoma
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Tx for GERD
- 1) Lifestyle mods: diet, don't eat just before bed, physchosocial stress?
- 2) Prokinetics
- 3) acid reduction: PPIs, H2
- 4) surgery: fundoplication
- 5) endoscopic
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top 3 UGI/ top 3 LGI causes of bleeding
UGI: duodenal/gastric ulcer, gastritis/esophagitis, esophageal varices, (also Mallory-Weis tear)
LGI: angiodysplasia, diverticulosis, cancer
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UGI bleeding DDX (8)
- -duodenal ulcer
- -gastric ulcer
- -gastric erosions
- -ulcerative esophagitis
- -eso. varices
- -M-W tear
- -Carcinoma/lymphoma
- -angiodysplasia
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LGI bleeding DDX (8)
- -hemorrhoids/anal fissures
- -carcinoma
- -angiodysplasia
- -Crohn's
- -diverticular disease
- -ischemic colitis
- -bacterial infections
- -Meckel's diverticulum
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Signs and Symptoms of acute and chronic bleeds
acute: fatigue (weakness), shock, MI, renal failure
chronic: anemia, weakness, fatigue
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Recall the 4 grades of hemorrhoids
- 1) bleeding
- 2) prolapse, but retract by themselves
- 3) prolapse, but need manipulation to reduce
- 4) incarcerated
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describe 4 common clinical manifestations of congenital intestinal obstruction
- 1) bilious emesis
- 2) abdominal distention
- 3) failure to pass meconium (should happen in 1st 48 hours)
- 4) maternal h/o polyhydroamnios
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What is the most common EA/TEF presentation?
EA with distal TEF
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What is on the DDx for "double bubble"
- duodenal atresia
- annular pancreas
- intestinal malrotation
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How to initially manage peds bowel obstruction
- 1) Hx and PE
- 2) NG tube
- 3) correct fluids/lytes
- 4) Abs
- 5) AXR
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What anomalies to think of if you see one on a newborn?
- VACTERL
- -vertebrae
- -anal
- -cardiac
- -trachea
- -esophagus
- -renal
- -limb
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What is the electrolyte balance you expect to see in pyloric stenosis
- -vomiting a ton! so....
- -hypocholeremia (low Cl-)
- -metabolic alkalosis (losing stomach acid)
- -hypokalemia (low K+ as it is exchanged in the kidneys to try and overcome the alkalosis)
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What is the rule of 2's for Meckel's diverticulum?
- 2% of population affected->2% become symptomatic
- 2 feet from terminal ileum
- 2" long
- usually present by age 2
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5 things to ask when dealing with uninvestigated dyspepsia
- 1) upper GI: cardiac, dietary related
- 2) alarm bells: VBAD (vomiting, bleeding, abdominal pain and weight loss, dysphagia)
- 3) NSAIDS
- 4) H. pylori
- 5) reflux
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Name 5 symptoms that support IBS Dx
- abnormal stool freq
- abnormal stool form
- abnormal stool passage (e.g. tenesmus)
- passage of mucus
- bloating or abdominal distension
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What red flags to watch out for in IBS diagnosis
- weight loss
- rectal bleeding
- arthritis, skin rash
- nighttime symptoms
- family Hx
- age greater than 50
- abnormal PE or lab findings
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list 8 common GI-associated Hx symptoms
- pain
- onset: gradual to acute
- nausea/vomiting
- anorexia
- bloating
- change in BM
- diarrhea
- recent travel
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list 8 common GI associated PE signs
- fever
- tachycardia
- hypotension
- abd. tenderness
- guarding/rebound
- absent bowel signs
- jaundice
- ascites
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What is Barrett's esophagus?
normal squamous epithelium replaced by metastatic, columnar, or glandular epithelium due to GERD usually
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When do we offer a scope to someone with GERD
- -severe GERD
- -patients with red flags
- -PPIs for more than ten years
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Gastric Ca S&S
- late
- non-specific
- GI bleeding
- early satiety
- wt loss
- epigastric/back pain
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Recurrent abdominal pain criteria
- greater than 3 yo
- at least 3 attacks of pain
- recur over a 3 month period
- severe enough to affect activity
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red flags in kids for abdominal pain (8)
- persistent RUQ or RLQ pain
- dysphagia
- persistent vomiting
- GI blood loss
- nocturnal diarrhea
- family Hx of IBD, celiac, or PUD
- pain that wakes them up at night
- arthritis
- (others)
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What is the Tx for H. Pylori
- 3-2-1 Tx
- 3 drugs (PPI+1000mg amoxicillin+500 mg clarithromycin)
- 2 times a day for
- 1 week
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Red flags when looking at functional constipation in kids
- Weight loss/failure to thrive
- Bilious vomiting
- fever
- bloody stool
- large thyroid
- abnormal neuro exam
Basically ruling out the organic causes: neuro, endocrine, intestinal obstruction
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What are the red flags that make you think about gastric cancer?
- weight loss
- anemia
- bleeding
- dysphagia
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What is the diagnostic criteria for functional constipation?
- History longer than 8 weeks PLUS any 2 of the following:
- -stool freq < 3x/week
- -large stool in rectum or palpable on abdo exam
- -fecal incontinence 1x per week or more
- -toilet obstruction
- -retentive posturing
- -painful defecation
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What does it mean if the rectum to colon ratio is less than 1 (i.e. colon diameter is bigger than rectum diameter)
Hirschsprung's disease. #1 cause of intestinal obstruction in newborn
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Most common cause of intestinal obstruction in kids < 2yo
intussusseption
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Red flags for people with intestinal symptoms (6)
- -new onset
- -weight loss
- -nocturnal symptoms
- -fever
- -anemia
- -vomiting
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4 categories of diarrhea
- malabsorption/osmotic
- secretory
- inflammatory/infectious
- increased motility
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Iron deficiency anemia is WHAT until proven otherwise?
CRC
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What are the 4 F's in biliary colic?
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How is the inflammation pattern different in Crohn's and UC?
UC: continuous from rectum, only in colon, only mucosa and submucosa
CD: skip lesions, gum to bum, transmural (fistulas)
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What is a common extra-intestinal manifestation of UC?
primary sclerosing cholangitis
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What is first line tmt in IBD?
5-ASA agents
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What is Charcot's triad? What does it suggest?
RUQ pain, fever/chills, jaundice
suggests ascending cholangitis
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If you have intermittent abdo pain precipitated by eating food. What 3 things should you be thinking of?
- 1) obstruction (SBO, gastric outlet)
- 2) Pancreatitis
- 3) ischemic bowel
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What are some foods that aggravate GERD?
- Fried/fatty foods
- Spicy foods
- Citrus
- Caffeine
- chocolate
- peppermint
- tobacco
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What is the 6F's that can cause abdominal distention?
- Fat
- Fluid (ascites)
- Fecal matter
- Fetus
- Flatus
- Fatal growth
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Go through the approach to esophageal dysphagia (solid vs solid and liquid, progressive vs intermittent, etc)
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Describe the effects of histamines, gastrin, ACh, and prostaglandins on H+ secretion in the stomach
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What must you ALWAYS do with a gastric ulcer that you dont need to do with a duodenal ulcer
Biopsy it!! (duodenal ones are rarely malignant)
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When looking at bleeding in CRC, what side would you expect to see melena, hematochezia
- melena -> right sided
- hema-> left sided
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