Smart Phrases And Workups – GI
ALCOHOLIC HEPATITIS #Alcoholic Hepatitis -Acute inflammatory syndrome i/s/o chronic liver inflammation -pt @ risk: >7-14 drinks/week (women) or >14-27 drinks/week (men) -P/w jaundice, ascites, encephalopathy, fever often weeks after alcohol cessation Plan -CBC, BMP, LFTs, GGT, PT/INR, ammonia, iron panel, triglycerides -RUQ US with doppler -PPI -thiamine, folate, glucose, multivitamin ##MELD >/= 20 -prednisolone 40mg/d for 4 weeks to inc short term survival (NEJM2015;372:1619) -Prednisolone chosen as no need for hepatic metabolism **Contraindications: active infection, chronic HBV/HCV, GIB, pancreatitis, renal failure (exclusion criteria in steroid trials) -SW consult for cessation resources ##consider MAT w/ -acamprosate 666 mg TID -naltrexone 50mg QD (?dose in cirrhosis) -baclofen 5-10mg TID -gabapentin 600mg TID (JAMA 2014;174:70) Complication: portal HTN CHOLANGITIS #Acute Cholangitis -Pt P/w Charcot's triad (RUQ pain, fever, jaundice) -Pt p/w Reynold's pentad (RUQ pain, fever, jaundice, AMS, shock) Plan -f/u RUQ US -Zosyn x7-10 days -GI consult ERCP biliary drainage <48h -Surg consult urgent cholecystectomy <7d CHOLECYSTITIS #Cholecystitis -Pt P/w RUQ pain, fever, Murphy's sign -Ddx calculous (stone in cystic duct) vs acalculous (10% cases, sterile inflammation of gallbladder) Plan -f/u CBC, BMP, LFTs -f/u RUQ US >> if negative consider HIDA scan -start Zosyn -Surg consult urgent cholecystectomy <7d (Br J Surg 2015;102:1302) ##Acalculous cholecystitis unexplained fever leukocytosis ab pain RUQ mass Rf: trauma, burns, TPN, ICU, fasting, sepsis (Clin Gastro Hep 2010;8:15) CHOLEDOCOLITHIASIS #Choledocolithiasis Gallstone in CBD -pt P/w RUQ pain, N/V, jaundice Plan - f/u CBC, LFTs - f/u RUQ US for CBD dilation >6 mm - GI consult for ERCP *Complications: acute pancreatitis, cholangitis CIRRHOSIS #Cirrhosis -MELD @@@ -Seen on imaging *** Plan -f/u hepatitis panel -f/u iron studies -f/u ANA -f/u ASMA -f/u AMA -f/u total IgG -f/u A1AT -f/u ceruloplasmin -f/u SPEP -f/u RUQ US -lactulose 20g TID -spironolactone/lasix 5:2 ratio -Na restriction <2g/d -fluid restriction 1.5L/d ##anticpate d/c w/ -HAV -HBV -influenza -pneumovax -prevnar -HCC screening q6m (Hepatology 2018;68:723) -f/u w/ liver clinic ##new diagnosis for varices -EGD COLONOSCOPY #Colonoscopy Prep -anticipated date: *** Plan -CLD noon day prior -2L Golytely 6 pm night prior -additional 2L at midnight -dulcolax 10 mg CONSTIPATION #Constipation -DRE w/o e/o fissures/hemorrhoids/abnml tone -CBC (anemia) *** Plan -f/u TSH -f/u Ca -f/u BG -f/u FOBT -high fiber diet -senna 2 tab BID >> miralax 17g daily >> lactulsoe >> mag citrate >> MOM >> bisacodyl >> enemas >> Golytely >> disimpaction ##+FOBT, fevers, IBD -Colonoscopy DIARRHEA #Acute Diarrhea ##Ddx secretory, osmotic, functional, malabsorptive, inflammatory @@@<2 weeks duration @@@>/= 3 loose stools/day Plan -f/u BMP -f/u BCx -mIVF -replete electrolytes PRN @@@##>6 stools/day @@@-Stool Cx @@@##age >70 @@@-Stool Cx @@@##IBD @@@-Stool Cx @@@##>2 weeks @@@-Stool Cx @@@-stool O&P @@@##immunocompromised @@@-Stool Cx @@@-stool O&P @@@MSM @@@-stool O&P @@@febrile/septic @@@-fluoroquinolone or azithromyocin @@@avoid in EHEC due to risk of HUS @@@=no fever or bloody stool @@@-loperimide @@@=post-abx diarrhea @@@-probiotics #Chronic Diarrhea @@@>4 weeks duration ##Ddx secretory, osmotic, functional, malabsorptive, inflammatory Plan -f/u CBC -f/u BMP -f/u LFTs -f/u ESR -f/u CRP -f/u TSH -f/u BCx -f/u stool Na, K, pH -f/u fecal WBC -f/u calprotectin -f/u fecal fat -f/u FOBT DIVERTICULITIS #Diverticulitis -LLQ pain, fever, leukocytosis, diarrhea -CT scan *** Plan - NPO - NGT - norco for pain - cipro/flagyl, Bactrim/flagyl, or augmentin GASTROPARESIS #Gastroparesis -QTc Plan -EKG -if wnl -> ondansetron - consider benadryl, reglan HE #Hepatic Encephalopathy -A&Ox*** Plan - lactulose 20g TID - consider rifaximin LOWER GI BLEED #Acute Lower GI Bleed -HR:tachy ***, BP:hypotensive *** -Hgb *** -most likely 2/2 Diverticulosis (30-65%) -less likely but also on ddx: Ischemic colitis (5-20%), Hemorrhoids (5-20%), brisk UGIB (13%), polyps/neoplasm (2-15%), vascular lesions (5-10%, IBD (3-5%), infectious colitis (2-5%) Plan -2 large bore IVs -type and screen -CBC q6h ##transfusion goal -Hgb >7 (8 in CAD) -plt >50k -INR <2.5 -GI consult: colonoscopy @@@HDS @@@-prep for colonoscopy @@@HD Unstable @@@-EGD to r/o UGIB @@@-IR consult @@@-surgical consult N/V #Nausea/Vomiting ##Triggers: time of day, meds, food, sick contacts, HA, trauma, last BM, melena/hematemesis? ##Ddx: SBO, cardiac ischemia, pancreatitis, pyelonephritis, cholecystitis, pregnancy, adrenal insufficiency, DNA, elevated ICP, gastroenteritis, gastroparesis Plan - f/u CBC, CMP, lipase, hCG, UA, UTox, ABG, lactate, troponin, cortisol stimulation - f/u EKG - f/u KUB, CT A/P, EGD, gastric emptying study - f/u CT head - ondansetron 4-8 mg PO/IV q8h - consider metoclopramide 10-20 mg PO/IV q6-8h #SBO Management - NPO, NGT x48h - gastrografin 100 cc by NGT decreases surgical intervention by 74% (BJS 2010;97:470) Chemo PPX: dexamethasone / lorazepam / ondansetron / aprepitant / olanzapine (NEJM 2016;375:134) PANCREATITIS #Acute Pancreatitis ##Ddx: alcohol (30%), gallstones (40-75%, ALT >3x ULN), tryglycerides (>1000), idiopathic (10-25%), post-ERCP (3-5%) -Lipase *** -CT abdomen/pelvis w/contrast *** Plan -f/u labs: CBC, CMP, lipid panel, lactate, lipase -RUQ US if first episode >> urgent ERCP if choledocolithiasis -start LR @150-250/h x48h -encourage PO intake when pain/N/V resolved | tube feeds if unresolved by 96h -norco for pain SIRS on admission = 8% mortality, persistent SIRS = 25% mortality ##Complications: <4 weeks: SIRS, thromboses, electrolyte abnormalities, ARDS, necrosis >4 weeks: pseudocyst, abscess, walled-off necrosis, pseudoaneurysm ##Long-term: pancreatic dysfunction (20-30%), chronic pancreatitis (33-50%) SBO #Small Bowel Obstruction ##Ddx includes: adhesions, hernia, cancer Plan - f/u KUB, CT A/P + gastrografin for evidence of dilated bowel proximal and decompressed bowel distal to obstruction - NPO, large bore NGT to continuous low suction - surgery consulted, appreciate recs SBP #Spontaneous Bacterial Peritonitis (SBP) -Dx: >250 PMN/L -S/p paracentesis *** with ***PMNs Plan - CTX 1g IV qdaily x5 days OR cipro 400 mg IV q12h - albumin 25% (1.5g/kg day 1 then 1g/kg day 3) - Discontinue BB - consider repeat para if no improvement in 48h - ppx on discharge with CTX 1g IV daily x7 days if GIB OR cipro 500 mg PO q12h OR Bactrim DS PO TRANSAMINITIS #Transaminitis Admission ALT *** and ALT *** Plan -f/u RUQ US -daily LFTs UPPER GI BLEED #Upper GI Bleed -Ddx: ulcers (50%), esophagitis/gastritis (30%), vascular lesions (5-10%) varices (5%), traumatic (5%), neoplastic (5%) -HR ***, BP *** -Hgb *** Plan - 2 large bore IVs - type and screen - CBC q6h - correct coagulopathy (vit K, FFP, Plt, PCC) - f/u H. pylori - transfusion goals: Hgb >7, plt >50, INR <2, Fib >100 - IV pantoprazole 40 mg IV BID x72h then PPI PO BID x3 months (Cochrane Syst Rev 2010;7:7) - GI consult for EGD, appreciate recs ##Cirrhotics: -octreotide IV 50 mcg x1 >> 50 mcg/h x3-5 days -CTX 1g IV daily x7 days (Aliment Pharmacol Ther 2011;34:509). -Can be switched to cipro 500 mg PO q12h - Recommend outpatient f/u w/ with GI and liver clinic -treat H. Pylori if positive VARICEAL BLEED #Variceal Bleed - 2 large bore IVs - IVF - pRBC +/- FFP, transfuse for Hgb >7 - IV PPI BID and octreotide - GI consulted for EGD - consider carvedilol 6.25 BID for primary ppx | nadolol 20-40 mg QD or propranolol 20-40 mg BID for secondary ppx - goal HR 55-60 with SBP >90 #SAAG >1.1 pHTN Cirrhosis (ascites fluid total protein [AFTP] 2.5 g/dL) Acute hepatitis (including EtOH) Massive liver metastases Hepatocellular carcinoma Budd-Chiari syndrome Portal vein thrombosis #SAAG <1.1 other Secondary bacterial peritonitis TB peritonitis Peritoneal carcinomatosis (+cytology) Chylous ascites (triglycerides >200) Hypoalbuminemia (malnutrition, nephrotic syndrome) Serositis (e.g. SLE) Pancreaticobiliary
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