Smart Phrases And Workups – GI

ALCOHOLIC HEPATITIS	"Alcoholic Hepatitis Acute inflammatory syndrome in the setting of chronic liver inflammation Increased risk with >7-14 drinks/week (women) or >14-27 drinks/week (men) P/w jaundice, ascites, encephalopathy, fever often weeks after alcohol cessation - CBC, BMP, LFTs, GGT, PT/INR, ammonia, iron panel, triglycerides - RUQ US with doppler  - PPI - thiamine, folate, glucose, multivitamin - prednisolone 40mg/d for 4 weeks ↑short term survival w/ MELD ≥ 20 (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 medication assisted therapy with 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 P/w Charcot's triad (RUQ pain, fever, jaundice) | Reynold's pentad (RUQ pain, fever, jaundice, AMS, shock) - f/u RUQ US - GI consult for ERCP  biliary drainage within 48h - Zosyn x7-10 days - EGS consult for urgent cholecystectomy within 7 days"
CHOLECYSTITIS	"Cholecystitis Ddx: calculous (stone in cystic duct) vs acalculous (10% cases, sterile inflammation of gallbladder) P/w RUQ pain, fever, Murphy's sign - f/u CBC, BMP, LFTs - f/u RUQ US >> if negative consider HIDA scan - start Zosyn - EGS consult for urgent cholecystectomy (<7 days) (Br J Surg 2015;102:1302)  Acalculous cholecystitis: unexplained fever, leukocytosis, ab pain, RUQ mass  Risk factors: trauma, burns, TPN, ICU, fasting, sepsis (Clin Gastro Hep 2010;8:15)"
CHOLEDOCOLITHIASIS	"Choledocolithiasis Gallstone in CBD P/w RUQ pain, N/V, jaundice - f/u CBC, LFTs - f/u RUQ US for CBD dilation >6 mm - GI consult for ERCP  Complications: acute pancreatitis, cholangitis"
CIRRHOSIS	"Cirrhosis MELD Score *** Seen on imaging *** - f/u hepatitis panel, iron studies, ANA, ASMA, AMA, total IgG, A1AT, ceruloplasmin, SPEP - f/u RUQ US - lactulose 20g TID - spironolactone/lasix 5:2 ratio, Na restriction <2g/d, fluid restriction 1.5L/d - on discharge will need vaccines (HAV, HBV, influenza, pneumovax, prevnar) and HCC screening q6m (Hepatology 2018;68:723) - on discharge schedule follow-up with liver clinic - EGD if new diagnosis for varices"
COLONOSCOPY	"Colonoscopy Prep Plan for colonoscopy *** - CLD noon day prior - 2L Golytely 6 pm night prior, additional 2L at midnight - dulcolax 10 mg"
CONSTIPATION	"Constipation DRE (fissures/hemorrhoids/tone) CBC (anemia) *** - f/u TSH, Ca, glucose  Colonoscopy if +FOBT, fevers, IBD  Treatment - high fiber diet - senna 2 tab BID >> miralax 17g daily >> lactulsoe >> mag citrate >> MOM >> bisacodyl >> enemas >> Golytely >> disimpaction"
DIARRHEA	"Diarrhea Acute Diarrhea <2 weeks duration >/= 3 loose stools/day - f/u BMP, BCx - stool Cx if (>6 stools/day, age >70, immunocompromised, IBD, >2 weeks - stool O&P if (>2 weeks, immunocompromised, MSM) - mIVF - replete electrolytes PRN - if febrile/septic >> fluoroquinolone or azithromyocin | avoid in EHEC due to risk of HUS - loperimide if no fever or bloody stool - probiotics only if post-abx diarrhea  Chronic Diarrhea >4 weeks duration Ddx: secretory, osmotic, functional, malabsorptive, inflammatory - f/u CBC, BMP, LFTs, ESR, CRP, TSH - f/u stool Na, K, pH, fecal WBC, calprotectin, fecal fat, FOBT"
DIVERTICULITIS	"Diverticulitis LLQ pain, fever, leukocytosis, diarrhea CT scan *** - NPO - NGT - norco for pain - cipro/flagyl, Bactrim/flagyl, or augmentin"
GASTROPARESIS	"Gastroparesis - EKG: QTc - ondansetron - consider benadryl, reglan"
HE	"Hepatic Encephalopathy A&Ox*** - lactulose 20g TID - consider rifaximin"
LOWER GI BLEED	"Acute Lower GI Bleed Etiology: Diverticulosis (30-65%), 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%) HR ***, BP *** Hgb *** - 2 large bore IVs - type and screen - CBC q6h - transfusion goal Hgb >7 (8 in CAD), plt >50k, INR <2.5) - GI consult for colonoscopy  HDS >> prep for colonoscopy HD Unstable >> EGD to r/o UGIB, IR and 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 - 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 *** - 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 
- 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 - 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    includes: ulcers (50%), esophagitis/gastritis (30%), vascular lesions (5-10%0, varices (5%), traumatic (5%), neoplastic (5%) 
-    HR ***, BP *** Hgb *** 
Plan
w/u
- 2 large bore IVs 
- type and screen 
- CBC q6h 
tx
- 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
- GI consult 
-    EGD
-    appreciate recs  
-Cirrhotics: 
-    octreotide IV 50 mcg x1 >> 50 mcg/h x3-5 days 
-    CTX 1g IV daily x7 days. 
-    Can be switched to cipro 500 mg PO q12h 
-    outpatient follow-up 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"