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
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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