2018 Gastroenterology 9% Flashcards
Chest pain intermittent unrelated to exertion no reflux symptoms retrosternal pain seconds to minutes corkscrew on x-ray dysphasia to both liquids and solids
Diffuse esophageal spasm treat with calcium channel blockers/ppi - multiple simultaneous contractions on manometry
Many month history of dyspepsia looking like Gerd no alarm symptoms no physical exam abnormality what is treatment
Proton pump inhibitor
Treatment of new onset severely active Crohn’s disease
Antitumor necrosis factor therapy like infliximab is best and better than immunomodulators such as mesalamine because Crohn’s disease is transmural
Treatment of severe alcoholic hepatitis
Mandry discriminant function score of greater than 32 benefit from pentoxifylline if corticosteroids are contraindicated - like with kidney failure G.I. bleed active infections
How long to keep patient in hospital after high-risk peptic ulcer and a scopic treatment
72 hours - takes this long for high-risk peptic ulcer to become peptic ulcer
Patient with G.I. bleed due to angioectasias and aortic stenosis
replace aortic valve - heyde syndrome e - mechanical destruction of von Willebrand multimers during non-laminar flow through narrow aortic valve
- Young patient w/ hx of food impaction, happened several times before. EGD: #1 stacked concentric rings OR #2 crepe paper sign OR #3 mucosal fragility OR #4 mucosal fragility. history of allergies. Eosinophils on bx. Empiric PPI started and no response after 8 wks, repeat bx reveals eosinophils. dx? next step?
Eosinophilic esophagitis (???common in young pt w/ hx allergies???)
next step in management = SFED (Six food elimination diet)
milk, wheat, eggs, nuts, soy, seafood
still symptoms –> budesonide
- Pt p/w dysphagia, EGD is normal (#1), barium swallow reveals diffuse dilation (#2), and narrowing of the lower esophagus. Most likely dx?
Achalasia
- Pt p/w complaints of regurgitating food eaten several days ago. occasional dysphagia. halitosis +. dx? test?
dx: Zenkers diverticulum (pouch in hypopharynx)
test = barium swallow
- pt p/w pain on swallowing (odynophasia) for more than 10 days. wtd? … etio?
EGD o rule out esophagitis
consider pills (Doxy., alendronate, ASA)
radiation therapy
infections ( Candida CMV herpes)
8./9. HIV + patient with oral thrush complaining of odynophasia. wtd?
empiric tx w/ fluconazole/itraconazole. No need for EGD.
No response to empiric, wtd? EGD to r/o CMV (one large ulcer), Herpes (several ulcers), Candida
- Pt w/ hx of long standing heartburn for several years now, p/w progressive dysphasia to solids . most likely dx?
Peptic stricture
- 70yo M dx w/ stroke. hemiparesis + on left side. cranial nerves intact. Pt has coughing and choking sensation, w/ regurgitation of fluids through nose. best diagnostic test
Video fluoroscopic swallowing study ( modified barium swallow)
12./13. Pt w/ heartburn OR nocturnal cough and wake up with water brash. not relieved by antacids. Best initial dx step ..
empiric PPI challenge. NO EGD. NO barrium swallow.
if pt feels better 3months later on PPI wtd?
continue PPI at lowest dose or switch to H2 blocker
If pt does not get better on PPI, wtd?
EGD while pt taking PPI
if EGD reveals no esophagitis, wtd?
ambulatory pH monitoring
if ambulatory pH monitoring shows approx 2 min of reflux in 24 hrs, wtd?
citalopram
14./15./16. Pt w/ heartburn OR nocturnal cough and wake up with water brash. not relieved by antacids.
If patient doesn’t get better with PPI…
- EGD while pt taking PPI
EGD - if no esophagitis then ambulatory pH monitoring
- if approx. 2 minutes of reflux on 24hrs then likely psychiatric give citalopram
- Pt w/ heartburn not responding to antacids and w/ weight loss. wtd?
EGD
- Can tx w/ PPIs or fundoplication sx reverse epithelial changes of Barrett’s??
No
- Pt p/w severe retrosternal chest pain. worse with swallowing and breathing - chest x-ray with left pleural effusion subcutaneous emphysema. amylase level increased. dx?
dx: Esophageal rupture
diagnosed with Gastrografin swallow study
H.pylori testing…
Nonendoscopic
- Antibody test. for dx. no value for f/u
- Urea breath test. dx and f/u
- Fecal antigen test (Most sen***). dx and f/u
[????urea breath test and fecal antigen test. false negative on PPI or GI bleed.???]
Endoscopic.
- To culture for resistance pattern histology.
- Urease testing.
- Gold standard but expensive af.
H.Pylori treatment regimens…
PAC for 14 days.
- P –> PPI ( Omeprazole, Lansoprazole, Rabeprazole)
- A –> Amoxicillin
- C –> Clarithromycin
MOC for 14 days
- M –> Metronidazole
- O –> Omeprazole
- C –> Clarithromycin
- for recurrance of sx, wtd? –> order urea breath test, if positive, then …
tetracycline
metronidazole
bismuth salicylate
and PPI
- Who would u test for h.pylori
45 yo w/ abdom pain and PUD
- Pt w/ PUD and takes ibuprofen for OA. Hpylori test is +. wtd?
treat h.pylori, then change the nsaid
ZE syndrome
- Duodenal bulb/stomach ulcer –>multiple ulcers
- Gastrinomas in mid duodenum, pancreas, porta hepatis. Assoc w/ MEN1
- can present w/ PUD or diarrhea /steatorrhea (inactivated pancreatic lipase)
- fasting gastrin level elevated. if non diagnostic then do
- IV secretin –> increases gastrin to > 1000
- CT scan or somatostatin receptor scan localized tumor
- tx w/ PPI and resection of Tumor
others that increase gastrin level: pernicious anemia/chronic gastritis renal failure hyperthyroidism PPI
life expectancy is normal if curative sx is done , otherwise 2 yrs
recurrent duodenal ulcers or poor response to treatment is suggestive of ZE
Upper GI bleed
- PUD .. (???nonexanguinating???) <7g
- Varices .. <8g
- Mallory Weiss
- Splenic vein thrombosis **
Pt p/w coffee ground vomitus and dizziness. NGT reveals blood tinged fluid . HR 120/min. BP 90/60. wtd next.
vigorous volume resuscitation. NO EGD
Pt with cirrhosis with spider angiomata . wtd next?
–> screening endoscopy; reveals varices
wtd. –> Ppx non-selective beta blockers (propranolol carvedilol nadolol)
- if asthma then no BB, do band ligation to prevent 1st variceal bleed and also for rebleeds
Post gastrectomy w/ abdominal bloating and pain 15-60min postprandial. symptoms relieved by vomiting bilious liquid
Afferent loop syndrome
Post gastrectomy fat and vitamin B12 malabsorption
Blinds loop syndrome w/ bacterial overgrowth (B12 decreased, folate increased)–> deconjugation of bile salts –> steatorrhea
decr. B12, folate incr.
Prognostic factor in acute pancreatitis
BUN - despite temperature elevated lactate white count no antibiotics
Pancreatitis with muscle spasm in weakness
Hypocalcemia
18 Year old w/ pancreatitis, of unknown etiology. what tests will you do?
Sweat chloride test
????rule out cystic fibrosis - can be associated with pancreatitis????
Lab values suggesting biliary ideology of pancreatitis
ALT greater than two times normal then increased alk phos later
Mild pancreatitis ultrasound gallstones no CBD dilation
Elective cholecystectomy
Complications of pancreatitis
Page 415
-2 days–>fluid collections, pleural effusions
-<2 wks, pancreatic necrosis–>
spiral CT or CT w/ c
comps: multiple organ failure: renal failure, hypotension, encephalopathy, metabolic–>
aggressive fluid management first 12-24 hrs; signs of infection–> abx CT guided aspiration
- 1-4 wks, Pseudocyst–>
>4cms may not resolve
comps: pseudoaneurysm, hemorrhage, rupture, fistula
—>drainage for symptoms** - 4-6wks, abscess
- -> soap bubble sign, gram stain of aspirate
- ->abx, drain tube, if persistent fever 72hrs later–> open drainage*
-anytime, splenic vein thrombosis–> CT abd
Ulcerative colitis
on endoscopy …what do you see?
chart pg 417
Rectal ulcer + spreads proximately
erythema w/ friable mucosa
Crohn’s disease
On endoscopy, what do you see?
chart on pg 417
Rectal sparing
perirectal fistulas
anywhere G.I. tract but mainly in the terminal ileum
skip lesions
Best treatment for stricture
Surgery
Ulcerative colitis with extraintestinal symptoms pain in joints of hands with early morning stiffness
Rheum neg arthritis - sulfasalazine
Diarrhea right lower quadrant mass temperature ulcer in mouth
Crohn’s disease
Bloody diarrhea last 2 years, wks ago went to mexco, colonoscopy with erythematous friable mucosa
UC
Pt h/o UC with diarrhea/leukocytosis
r/o c diff colitis
Young woman with chronic diarrhea wakes up at night for bathroom
Inflamm bowel dz
irritable bowel syndrome- during the day, not at night
inflammatory bowel dx- wakes up at night
UC in remission - p/w LFTs bili, US shows focal dilations
ERCP/MRCP dx primary sclerosing cholangitis (beaded appearance) - brush bx prodominant stricture, need annual US gallbladder for polyps - if pos - cholecystectomy - if enzymes worsen then refer for liver tx
24 y/o M with UC p/w abd pain, distension of colon to 7cm, bleeding and diarrhea. Tx w/ steorids and sulfasalzine, iv hydration, and antibiotics. A day later condition remains the sam. Abdominal xray –> distension large bowel w/ thumb printing. best tx?
subtotal colectomy
Pt with proctocolectomy and ileal anal anastamosis pouch presents a year later w/ increased bowel movements >6/day w/ blood. low grade temp.stool c/s negative. Lower endoscopy with diffuse superficial ulceration in pouch.
dx and tx>
Pouchitis -> tx with metronidazole (flagyl)
Pt with Crohns rectovaginal fistula not responding to 6MP and flagyl
anti-TNF alpha (infliximab) - watch out for TB reactiv, PNA, crypto, histo
24 yo UC 4 years with jaundic and fever, hepatomegaly, elev bili, elev alk phos, AST, ALT p-ANCA +
Primary Sclerosing Cholangitis - beading/focal dilation biliary tree - P-ANCA +, a/w UC - if LFT/bili worsens - refer for liver tx
Review Chart GI page 453
Green book - GI
20 yo rectal bleed tenesmus - anal fissue - 6x6cm ulcer on back of leg
r/o UC with sigmoidoscopy/anoscopy - tx with 5asa suppostory
pt w/ rectal bleed and. pain. W/ External hemorrhoid
topical nitroglycerin
Stool osmotic gap equation
290-2(stool Na+K)
Secretory diarrhea
> 1L/day, doesn’t stop with fasting, stool osm=290, [Na + K} x2 : [100+40} x 2; stool osm: 290, stool osmotic gap: 290-280=10, <50
Osmotic diarrhea
<1L/day, stops with fasting, stool osm=290,[Na + K} x2 : [60+40} x 2; stool osm: 290,
stool osmotic gap: 290-200=90 . [lactase def (leading cause), lactulose, sorbitol (in sugar free foods), Mg antaids, malabsorption)],
>50
- longstanding diarrhea x years
- associated w/ bloating sensation and crampy abdominal pain
- stool osm 290, stool Na=50, K=25
- bowel movements about 3 / day
- no weight loss, fever nor blood
lactose intolerance (????stool gap >50????)
diarrhea while vacation mexico - no blood, no fever
entertoxogenic e coli
tx with loperamide +- azithro x 3 days
Diarrhea +-fever +-blood with abd pain 2 days after undercooked poultry, drinking mountain stream water, contact with dogs/cats . +fecal WBCs
C.Jejunum (can cause Guillion barre)
tx w/ IVIG alone *
Diarrhea with abd cramping +/- fever , had chicken, raw eggs or ice cream
salmonella
other carrying salmonella: turtles, iguanas, frogs.
bloody diarrhea, ate hamburgers at fair 36hrs ago or unpasteurized milk or apple juice. dec platelets
O157:H7 E.Coli
culture MacConkey sorbitol agar –> Must ask lab to add sorbitol to MacConkey
tx: symptomatic, NO antibiotics. Causes HUS> IF renal failure–> Hemodialysis prn –> Eculizumab **
ANY bloody diarrhea or diarrhea w/ fever, don’t use anti motility agents. **
[??- SX treatment only DO NOT GIVE ABX - will cause HUS - if RF then HD (TTP)??]
Bloody diarrhea
Shigella, C.jejuni, salmonella, c.diff
Diarrhea 3-20 days after camping, skiing, or visiting South Africa. Associated with bloating sensation, cramping,, flatus, frothy stool, and weight loss.
dx? and tx?
Giardiasis
stool ELISA for Giardia antigen +
Tx: metronidazole
post tx ELISA test for Giardia antigen become negative
church group goes on picnic. Eat Precooked foods; beef/turkey. 8- 12 hrs later diarrhea/vomitting. no blood
dx and tx?
C.perfringens
tx? supportive tx
Diarrhea 4 hours after asian restaurant - fried rice - vomiting, no blood
Bacilius cereus - supportive tx
Diarrhea after sea food dinner - g neg comma shaped bug
vibrio parhemolyticus
tx ?cipro
Diarrhea, nausea vomiting, abd pain after eating fish (2hrs) with perioral paresthesias - reversal hot/cold sensation
ciguatera toxin from large reef fish
fish that eat other fish; amberjacks, barracuda, red snapper, etc.
Flushing, utricaria, paresthesias minutes after eating fish
scombroid poisoning
due to built up histamine in fish.
eats fish and minutes later parestehesias, weakness, ascending paralysis and SOB
tetrodotoxin from puffer fish
hx Chronic diarrhea, hx travel to mexico or other 3rd world country last year - OR presentation with acute dysentery - colonscopy with flask shaped ulcers
amoebic colitis
RUQ pain, fever, elev wbc, increased LFTs after third world country -hx of bloody diarrhea recently
amoebic liver cyst
check stool for ova/cyts
serum ELISA tst
if CT abd + then aspirate and tx with metronidazole
HIV CD4<200 chronic diarrhea/wt loss no fever no blood
cryptosporidium - stool afb small round organisms - if stable just hydration, if not imporoving nitazoxanide
woman chronic diarrhea of several years, frequent small stools with mucus, alternates w/ constipation.
abdominal pain relieved with BM, no night waking no fever, no wt loss, no anemia, stool studies neg for ova, cysts, and parasties. hx of emotional stress, ex: work place stress & anxiety or caring for an elderly adult, etc. - flex sigmoidoscopy neg
dx: irritable bowel syndrome by exclusion (???rome III criteria????)
tx: reassurance - don’t use alosetron, as it can cause ischemic colitis.
before labeling as IBS, wtd?
–> Ttg Abs to R/O celiac sprue
[??????rifaxinin, antispasmotics, anticholinergics - TCA, fiber???????]
chronic diarrhea , stool osm 300, stool Na 40, K 30 on adding naOH turns red
laxative abuse
measure phosphate and sulfate in stool
[???stool gap 160 (>50)???]
diarrhea, RLQ pain, fever, rash fecal leukocytes +, no h/o diarrhea. most likely cause?
yersinia enterocolitica
pt w/ diarrhea, C. diff +, WBC <15,000, age <60
wtd?
Metronidazole
recurred (x1) 2 wks later cdiff + diarrhea WBC 13,000
wtd?
restart metronidazole
Not a resistance problem, left over C. diff course are now maturing
recurred (x2) 3 wks later cdiff+ diarrhea , wtd?
vancomycin pulse therapy -
125mg orally 4x daily x 7-14 days, then twice daily for 7 days, then once daily for 7 days, then every other day for 7 days, then every 3 days for 14 days.
diarrhea, cdiff + WBC >15,000 or age >60, wtd?
po vanc (???>15k don't use flagyl???)
which abx induces B1/NAP1 strain cdiff which causes colitis w/ toxic megacolon
cephalosporin or quinalones
77yo M a/w PONA started on abx - what do prevent cdiff
probiotics (lactobacillus)
******* 78yo known diabetic p/w diarrhea with c.diff+, WBC 12,000, better with metronidazole PO. A week later returns to hospital w/ diarrhea, abdominal distension, tenderness.
BP: 90/64, HR 116, T 101.8, WBC 24, 000. Lactate 30 (normal is 0.6-1.8). C. diff has been ordered. Xray shows ileus. What is the best management?
start po vanc, rectal vanc, iv metronidazole, fecal transplant, and surgical consult .
better way to prevent spread of cdiff
wash hands with soap and water (no etoh sanitizer)
c. diff—> contact isolation
65yo M fatigue, chronic diarrhea, itching with pallor, bullous skin lesions, Hg low, MCV low, TIBC inc, ferritin low, hemooccult neg - blood smear howel jowell body, colonscopy neg for bleed or lesions- no change in Hb with oral ferrous sulfate, wtd?
transglutaminase IgA abs to rule out celiac sprue
If antibodies + wtd?
small bowel biopsy
If celiac sprue neg tx?
gluten free diet - can have dermatitis herpetiformis
Dermatitis herpetiformis tx
dapsone
itchy skin lesions
asx brother of pt with celiac sprue - what to check
HLA DQ2 or 8 (not TTG)
pt can also have dermatitis herpetiformis
vitamin supplement needed in celiac sprue
Vit D
Diarrheal dz a/w celiac sprue
microscopic collagenous colitis
Pt with celiac sprue confirmed with TTG abs put on gluten free diet. improves initially, then 3 months later continues to lose wt and has diarrhea. dx?
dietary non-adherence
Pt with celiac sprue responds well to gluten free diet for 10 years. now with diarrhea/abd pain/wt loss
r/o lymphoma
pt returns from 3rd world with diarrhea, foul oily** stools, +steatorrhea, Hg low, MCV high**. D-xylose test abn, folic acid decreased. wtd next?
Small bowel bx -> flattened villi with lymphocytic and plasma cell infiltrate in lamina propria
dx: tropical sprue
etiology: klebsiella or ecoli
tx: tetracycline and folic acid
25yo diarrhea, bloating, flatulance, wt loss of ~10lb in past couple months. She is from dominican republic (caribbean or is latin american or visitor to the area…must be there for >1 month). She eats in fast food restaurants.
Hb 11.2, MCV 110, WBC 3,500.
Serum alb 3.1, folate 7.8 (normal 1.8-9), B12 (normal 200-800)
stool cx for 2 fresh specimens are negative for pathogens (therefore not parasites).
stool for sudan stain + for fat globules
most likey dx?
tropical sprue
Caribbean –> folate N, B12 low,
Asia –>folate low , B12 N
Bact overgrowth–> folate high, b12 low
Pt with diarrhea few months with greasy stools or oily stools. fecal fat 15g/day, d-xylose serum level of 5 (nl>20 @ 1 hr) and urinary excretion of 500mg @ 5 hrs (nl>3500mg). What is most likely to establish dx?
check small bowel bx
pt with h/o arthritis>2yrs, diarrhea >3/day, oily stools, foul smelling, wt loss, adenopathy, SKIN PIGMENTATION, posterior uveitis with blurry vision
small bowel bx: foamy macorphages and PAS+
Whipple’s dz
etio: tropheryma whipplei
tx: bactrim or tetracycline for a year
other features: Neuro: dementia or visual disturbances.
55yo with recurrent pain/swelling shoulders and knee for years with wt loss of 15lbs, LAD and asp of knee with WBC 13K, wtd?
PCR of synovial fluid for trophyrema whipplei
NAAT
diarrhea w/ hx of food intolerance, n/v/abd pain, steatorreha +, ova/cysts/parasites neg, peripheral eosinophilia +
eosinophillic gastroenteritis - r/o parasitic infestation b/4 starting steroids
35yo n/v epigastric pain for months - n/v in morning better with hot shower - wt loss but no dysphagia. most likely diagnosis?
marijuana (cannabis) induced
30yo F early satiety and vom even with tiny amoutn of food for months . A scintiscan is done and shows normal emptying. wtd?
buspirone
chronic diarreha, fecal fat 14g/day, dxylose normal - B12 190, folate 18 (nl 1.8-9), small bowel shows diverticula, wtd next?
Bacterial overgrowth
check hydrogen breath test or xylose 14C breath test -
tx with cipro+metronidazole
Pt steatorrhea 40g/day, dxylose 8g/5hrs - colonoscopy normal, h/o lactose intolerance
xray abd check for Calcification of pancrease - chronic pancreatitis
Short bowel syndrome
calcium oxalate stones, replace ADEK, B12, Ca, Mg, Zn - replace long chain with med chain Fatty acids
Intestinal lymphangietctasia - dilated lymphatic vessels
tx?
replace long chain FA with med Chain triglycerides
Abetalipoproteinemia
normal villi - impaired B globulin synthesis**->impaired chylomicron formation **
pt s/p extensive small bowel resection with lots of diarrhea 3 days post op
PPI - acid induced diarrhea
small bowel resection after gun shot wound. presents diarrhea.
mechanism of diarrhea is?
mechanism is bile acids malabsorption
tx w/ cholestyramine
diarrhea = watery
GSW with extensive bowel resection - couple months later with greasy foul stools and wt loss of ~8lbs - fecal fat 20g/day PT INR 1.2, D-xylose excretio is nl, betacarotene is low.
Etio of diarrhea?
etiology=decreased bile acids
tx w/ medium chain triglycerides
severe ischemic colitis s/p extensive small bowel resection - now bulky, greasy stools 3-4/ day. wt loss post sx, stool fat 20g/day, alb 2.6, calcium 7.0.
most appropriate tx?
tx with med chain TG
52yo F chronic watery diarrhea 5-6x daily, wakes up pt in the middle of night to move bowels. no hx no constip, no blood, fever or weight loss - neg stool studies, neg giardia, neg EGD and colonoscopy.
best way to establish diagnosis?
flexible sigmoidoscopy with bx - (
collagenous/ microscopic coliits–> collagen vs lymphocytic colitis–>lymphocytes
biopsy will show inflammation of lamina propria
offending agens: NSAIDs, PPI, setraline, DM
Management: D/C offending agent otherwise for mild–> bismuth salicylate
if no response or severe disease–> oral budenoside
antiboides to check: tissue transglutaminase IgA antibodies
Causes of osteomalacia
post gastrectomy 43%, celiac sprue 26%, biliary cirrhosis, pancreatic insufficiency, crohn’s dz
60yo pt with fever, inc WBC, abd pain in LLQ
r/o diverticultis
appropriate diagnostic test:
–> CT scan
–> avoid colonoscopy/barium enema, cipro +flagyl
symptoms are resolving on 4th day, what diet do you reccomend?
clear fluids diet untl symptoms resolve then advance to fiber diet
4 weeks later after diverticulitis resolved, do colonoscopy to r/o cancer or other disease like crohns etc
treated diverticulitis w/ cipro and metronidazole 3 months ago, since then 3 episodes LLQ pain with no fever or WBC - left segmental diverticulosis on colonoscopy - DX?
uncomplicated symptomatic diverticular disease
tx with mesalamine or rifampin
Pt with divertiulitis with >4cm abscess
CT guided drainage first that allows for elective surgery
pt with acute diverticulits and 9cm dilation with 5cm abscess
surgical intervention
what medication can cause divertiulitis with perforation
Tocilizumab (Actemra) - IL-6 inhibitor (also causes OCP failure and hyperlipidemia)
discontinue if presets for diverticulitis
75yo M with ER c/o painless brbpr, no pmhx - BP 130/80, HR 92, BRB in rectal vault
dx - diverticulosis (painless)
55yo F with long rheum arthritis controled with ASA and naproxen x 14 years with abd pain for last 4 months - EGD/colonsocpy neg - small bowel barium enema with multiple concentric constricting lesions - dx?
small bowel diaphragm disease
Chronic mesenteric ischemic
- post prandial, abd pain, fear of eating, wt loss -
- etiology: dec blood flow and atherosclerosis
- dx: with doppler US or angiogram
- tx: angioplastry or surgica revascularization
Acute mesenteric ischemic
sudden onset sev abd pain, n/v/elev WBC, ileus +
-etio: embolism in celiac, Sup mesenteric artery:
_valvular heart dz
_afib, most likey
_low flow state in hypercoag state
-dx: give heparin 1st, then angiograpy 2nd, then TPA 3rd
- tx: with thrombolysis or surgery
Ischemic colitis
hematochezia, diarrhea, abd pain
- etio: low flow state (CHF, hypercoag state, hypotension)
- dx: with thumbprinting colon–>, pausity of vessels, aphthoid ulcerations
- tx: rehydration and antibiotics
Angiodysplasia
AVM - cause lower GIB - common in elderly - osler weber rendu syndrome -> tx with laser photocaog, sclerotherapy or cautery
65yo M pmhx severe AS with recurrent melena - colonscopy with angiodysplasia
best management?
Aortic valve replacement
Post radiation tx in pelvis, presents 1.5 years later with rectal bleeds - colonscopy with friable mucosa, atrophy and fibrosis - dx?
radiation prococolitis
70yo M with severe abd pain x 1 day, last BM normal several hours ago. mild tender abdomen w/ no guarding, h/o DM, CHF, HTN, JVD+, S3+ rectal normal , FOBT neg, amylase level elevated - abd xray normal, CT abd with small bowel wall thickenss and intestinal pneumoatosis
how do you establish a diagnosis?
check mesenteric angiography
MCC GIB in kids
meckels divertiulum (with gastric mucosa)
Constipation
BM<3x/wk
-most common metabolic disorders:
hyperCa+, hypothyroid
- idiopathic:
slow transit
pelvic floor dysfxn–> biofeedback
-Most commond rugs:
calcium/CCB, HCTZ/diruetics, anticholing, antipsych, opiates(should give senna)
Tx for constipation
tx underlying cause and inc fiber in diet
Opioid induced constipation
mangement?
start stimulant laxative as a routine with opioids
Senna
elderly pt with chronic constip not responding to fiber
polyethylene glycol
Pt with stage IV lung Ca not responding to stimulant laxative, polyethylene glycol
methylnaltrexone
NO naloxone
elderly woman with constipation and diarrhea - hard stool in LQ
enema
65yo M s/p ortho surgery on abx and morphine - next day with abd pain adn distension - abd xray with 6cm distenstion of cecum up to splenic flexure (could also be up to the rectum) with no WBC, hypokalemia
diagnsois?
dx: acute pseduo colonic obstruction (ogilvie’s syndorme) -
dx: CT scan or gentle hypaque (water soluble) enema to dx
managemnt: remove precip causes: correct electrolyties, d/c opiates, d/c aticholinergics, rectal tube, neostigmine
75yo F with LLQ pain x 2 days, last BM 1 wk ago, BS+, xray with colonic dilation, CT with partial obst of signmoid
Dx Sigmoid volvulus - flex sig (analgesia for pain won’t affect dx accuracy)
Woman sharp RUQ pain x 1 year - severe - US/CT normla - pain with raising legs
Functional abd wall pain**
No CT Scan**
Hepatitis A
- RNA virus,
- incubation15-50 dyas, p/w jaundice,
- feco-oral/sexual transmission,
- no carrier state or chronic state,
- can exacerbate underlying liver dz, so vacc HCV pts for HAV
- vaccinate high risk groups (travellors, gays, liver dz)
- IVIG for high risk exposure
- Anti- HAV IgM–> acute hepatitis A
- Anti- HAB IgG–> past infection
no exposre, IgG+–> FP–> give vaccine
Anti HAV IgM
Acute hep A -> treat!!
anti-HAV igG
post infection - Do not treat
Preg woman - how to determine past infection HAV
HAV IgG+, IgM-
Pt going to mexico for 2 weeks, sheduled to depart in 2 wks, wtd?
hep A vaccine
Hep A vaccine in….
Hep C, chronic liver dz, high risk country travelor (Asia, Africa, S. America), gay men (NOT PT WITH PNA)
Pt returns from Indonesia/belize*** with contact with commerical sex worker - now with n/v/malaise, anorexia - HBV ab+, HBV cAb+ ->dx?
Hep A - check hep A serology in 2 weeks
Hepatitis B
-only DNA virus in hepatitis ***
-transmission: sexual or parental
- 30% chance after needle stick
- >90% pts clear infxn - lose HBsAg and have anti HBs Ab - ~5% with chronic hepatitis, 1% fulminant hepatitis
Causes cirrhosis –> hepatoma 2-4%/year
-carrier status highest in infants–> children–>adults
-HBe Ag denotes viral replication. in some pts. have pre- core mutation of e-antigen & e-antigen can be negative in the presence of active replication. So check for HBV DNA
-Check for HBV DNA after acute Hepatitis to find out if pt has cleared infection or has gone to chronic hepatits
-Hepatitis B vaccine for high risk groups
-Hepatitis B immune globulin [HBIG] for high risk exposure
Heb B -> HBe Ag
denotes viral replication, active infxn
HBV Vacc
high risk groups
HBV IVIV (HBIG)
high risk exposure
HBV tx
interferon, tenofovir, entecavir, adefovir, lamivudine can suppress
HB S Ag
acute hep B, chronic hep B, Carrier Hep B
anti-HB cIgM
acute hep B
anti-HB c IgG
chronic, carrier, past infection
HB e Ag
active replication
Anti-HBs antibodies
post vaccination, cleared infection
anti Hbc IgG Ab +, HBsAg neg Anti HBsAb neg
what are the possibliites?
- chrnoic hepatitis OR past infection
- false positive (if from low prevalant area)
pt low endemic area, no risk factors for Hep B has anti-HBc Ab only - wtd?
Hep B vacc
Nurse with HBV vacc with needle stick pt with HBV
check anti HBs Ab titer - if >10 - reassure, if <10 HBIG+booster HBV vacc
Pt with Hep B vacc series
what will most likely be psotive?
+anti-HBs Ab
HBV DNA >20K, ALT normal - treatment?
none
HBV DNA >20K, ALT 1-2x normal - treatment?
Bx
HBV DNA >20K, ALT >2x normal - treatment?
Yes
HBV DNA >10IU - cirrhosis compensated (no ascities), treatment?
treat HBV
HBV DNA >10IU - cirrhosis decompensated (+ ascites), treatment?
tx and transplant
HBV treatment, what medication would you start
tenofovir, entecavir, or alpha interferon
you will continue treatment:
- until loss of HBeAG or presence of Anti HBe Abs
- if eAg neg, then until loss of sAg
HIV/HBV pt coinfected
if treating HIV also - tenofovir, otherwise peg interferon
prior to starting rituximab or chemo with steroids or anti-TNF what to check
HBc IgG and HBsAg
If any one positive then treat up to 1 year after stopping immunesuppresives
Asian american woman with HBV in 3rd trimester - how prevent HBV in child?
tenofovire for mother and hep B vaccine and HBIG in newbrn baby
Hepatitis C
- SSRNA
- MCC liver transplantation in US**
- MC presentation with fatigue and elevated LFTs
- Risk groups: IVDUs/ prisoners, blood transfusion associated before 1992, MSM**, tattoos/snorting cocaine
- no vaccine yet **
- No immune globulin yet **
Hep C high risk groups
IVDU/prisoners, blood tx before 1992, tattoos, snorting cocaine, most patients DO NOT CLEAR - NO VACCINE, NO IGG, no post exposure PPX available
Woman with hep C - precautions with husband
DO NOT SHARE TOOTHBRUSH
60yo pt born 1945 to 1965 - what to check
hep C abs
Risk factors progression to cirrohisis from HCV
age>40, etoh, man, coinfection with Hep B or HIV (higest risk)
Treatment HCV
Boceprevir, interferon, ribavirin, d/c therapy if VLsuppressed
53yo M received multple blood tx in 1990 after MVA p/w fatigue, elev LFTs AST/ALT 200/120, Hep C Ab + and liver bx with mild to mod bridging fibrosis - hep C viral load 250K - 2 months later AST/ALT lower AST/ALT 120/90 - VL 210K. wtd?
sofosbuvir + IFN + ribavirin for 12 wks
pt get depressed 2/2 interferon, wtd? Add SSRI (paroxetine)
Nurse gets stuck with needle HCV patient - Hep C ab neg
repeat HC Ab/RNA in 4 weeks
Nurse stuck with HCV 4 weeks ago with HCC VL 45K - wtd?
reassess HCV RNA at q 8 weeks for 6-12 months. if cleared, do nothing if still high begin treatment.
Pt with IV exp to HCV 6 weeks later with malaise and fatigue - all Hep Ab (HBsAg, HBc IgM, HACV IgM, HCV) neg , you still suspect hep c- wtd?
check HCV RNA
55yo pt with fatigue, no history - ALT 2x, AST 1.5x, takes tylenol occasionally for. arthralgias ( increase by tens of thousands) what is mst likely diagnosis.
Dx HCV (tylenol would be AST in 1000s)
- if HCV Ab + .HCV was done. wtd next?
HCV genotype
wtd next?
assess for fibrosis: non invasive; platelets, AST/ ALT or US OR invasive; liver bx
Naive w/ no cirrhosis--> sofosbuvir/velpatasvir 12 wks OR ledipasvir/sofusbuvir 12 wks OR elbasvir/grazoprevir 12 wks OR simeprevir/sofusbuvir12 wks OR paritaprevir/ritonavir/ombitasvir OR daclatasvir (6-mg*) plus sofosbuvir
sofosbuvir + amiodarone= brady cardia
naiive w/ cirrhosis–>
sofosbuvir/velpatasvir 12 wks OR
ledipasvir/sofusbuvir 12 wks OR
elbasvir/grazoprevir 12 wks OR
treatment failure on interferon w/o cirrhosis--> sofosbuir/ velpatasvir 12 wks OR ledipasvir/sofusbuvir 12 wks OR elbasvir/grazoprevir 12 wks OR simeprevir + sofusbuvir 12 wks
treament faioure on interferon w/ cirrhosis–>
sofubuvir. velpatasvir 12 wks OR
ledipasvir/sofusbuvir 12 wks OR
elbasvir/grazoprevir 23 wks
Pt with hep C, genotype 1 on IFN, ribavirin p/w fatigue
check Hg (ribavirin causes hemolytic anemia) - if retic + then start erythropoietin, d/c ribavirin
If pt on IFN get depressed
start SSRI (Paroxetine)
Pt with HCV with briding fibrosis and inc’d HCV RNA started on sofosbuvir/velpatasvir - advice for pt
NO ETOH, if seroneg for HAV, HBV give vaccines for HAV/HBV
Extrahepatic manifestations of HCV (indications for tx of Hep C)
small vessel vasculitis, glomerulonephritis, neruopathy, mixed cryoglobulinemia dec C4>dec C3, porphyria cutanea tarda
Pt w/ Hep B on inerferon, has to monitored for
hypothyroidism, hyperthyroidism
TSH
HDV
incomplete RNA virus needs HBV to survive
HBcIgM + HDV==> acute coinfection, doesnt make hepatits worse
HBc IgG + HDV==> acute superinfection, can cause fulminant hepatitis***
HBc IgM + HDV
Acute co-infection - doesn’t make hepatitis worse
HBc IgG + HDV
Acute superinfection - can cause fulminant hepatitis
HEV
fecooral transmission like HAV, Fulminant hepatitis in 3rd trimester of preg with increased mortality, ALL hepatitis seriology NEGATIVE,
Tylenol liver damage
> 7g tylenol can cause liver damage, in etoh 4gm tylenol causes liver damage - N-acetylcystein antidote
20yo took 30 gm pain pill - ER denies sx - tylenol level Pending - wtd
give oral n-acetylcysteine without waiting for labs
????? - if within 1hr then gastric lavage, activae charcoal and syrup of ipepac???
heavy etoh chronic drinker with myalgias and hanow with n/v/abd discomfort AST 11,000, ALT 9000 INR 3 - dx?
acetaminophen toxicity
N acetylcysteine still helps
Drug induced Hepatitis
-Dose related, age related toxicity, with inc AST/ALT,
ANA+–>INH
Hepatitis with cholestasis
amox-clavu***, bactrim, erythromycin, chlorpromazine
Hepatitis with macrovascular fatty change
etoh hepatitis, amiodarone, steroids
Hepatitis with microvasicular fatty change
mitochondrial damage
tetracycline, reye’s syndorme with ASA+flu
Chronic drug hepatitis
methyldopa, trazadone, nitrofurantoin, phenytoin
Direct liver toxicity
acetaminophen
Dysphagia
Solids -> pogressive Age>50 -> carcinoma
Solids -> progressive -> heart burn -> peptic stricture -> EGD/bx r/o CA ->dilation/PPI
Solids-> intermittent -> esosinophilic esophagitis -> esoph rings (steakhouse syndrome)
Solids or liquids ->progressive->cough/regurg ->achalasia->dx with barium swallow (autoimmune)
Solids or liquids->progressive->heart burn->scleroderma (scl70)
Solids or liquids->intermittent->chest pain -> diffuse esophageal spasm -> corkscrew esophagus->PPI trial->confirm with manometry
- Pt with intermittent dyphagia to solids and liquds assoc. w/ CP
Diffuse esophageal spasm
dx: barium swallow (cordscrew esophagus)
-> confirm with manometric studies showing non peristaltic contractons
next step-> PPI if no response-> CCB such as diltiazem
- Young pt with steak dysphagia. happened a couple times before. occurs w/ first bite, then regurgitates (or not), then swallows the rest of the meal w/o issues…. dx? tx?
dx: lower esophageal rings = schatzky ring or steak house syndrome
tx = pneumatic dilation
- Hispanic man complains of food regurg several hours after eating, no heartburn, dyphagia to solids and liquids wtd. next?
- -> barium swallow –> dilated esophagus with tapering gastro-esophageal junction (bird beak)
- -> manometry –> decreased peristalsis and increased Lower esoph pressure.
dx? tx?
dx: Achalasia
tx: surgical myotomy
wtd. prior to surgical myotomy or pneumatic dilation?? –> EGD to r/o secondary achalasia due to lymphoma or cancer before doing pneumatic dilation
GERD (Gastro Esophageal Reflux Disease)
Recently ingested fatty foods –> relax lower esophageal sphincter acid reflux –>symptoms : [?????CP, heartburn, nocturnal cough, asthma, dental erosion?????].
MCC of non-cardiac chest pain
GERD–> Barrett’s esophagus–> Adenocarcinoma
Barrett’s esophagus= replacement of epithelium with columnar cells (metaplasia)–> dysplasia–> adenocarcinoma
GERD complications
GERD–>Barrett’s esophagus-> AdenoCA
GERD Tx
- wt loss
- head elevation of bed at night
- stop smoking
- dinner at least 3 hours before bed time
- PPI much better than H2 blockers
- fundoplication sx
Indications for endoscopy in GERD:
- heart burn not relieved with PPI BID x 4- 8 wks***
- heartburn >5years
- heartburn w/ wt loss
- heartburn w/ melena
- heartburn w/ anemia
- heartburn w/ dysphagia or odynophagia
pt w/ Heartburn partial response to PPI. EGD reveals severe GERD. wtd?
lap fundoplication is planned.
prior to procedure wtd?
manometry studies to confirm esophageal motility, otherwise iatrogenic achalasia will result.
elderly pt with GERD not responsing to H2 - EGD shows stricture. Stricture is dilated - bx is neg. There is proximal gastritis - best way to manage this pt?
lifelong PPI
Barrett’s esophagus
normal Gastro-esoph junction squamous epithelium –> changes to columnar epithelium with chronic reflux disease –> Barrett’s esophagus
In older pts w/ > 10yrs of sx.
PUD causes
H. pylori, NSAIDS, Zollinger Ellison syndrome
H. Pylori
- gram neg, urease producing**
- PUD (duodenal ulcers)
- type b gastritis
- gastric cancers
- mucosa assoc lymphoma (MALT)
Treatment of H.pylori in low grade MALT results in tumor shrinkage or disappearance 50-80% of the time. Up to 30% of the time, t(8;11) poor response to h.pylori therapy. local RT required then. await biopsy report before pronouncing cure.**
45yo Fp/w itching esp at night +xanthomas, alk phos 1400, +AMA (anti mitochondrial antibody), -ANA, liver bx granulomas/lymphocytic destruction of bile ducts
???(dec ADEK, osteomalacia, HLD with high HDL)???
Primary biliary cholangitis
other features: decreased fat solube vitamine, DAKE w/ ostemalacia, hypercholesterolemia w/ high HDL
- tx :
early: ursodeoxycholate (delays progression, doesn’t prevent it
late: liver transplant
Autoimmune hepatitis
lupus against liver
young woman with fatigue, wt loss, arthralgia, acneform rash, amenorrhea,
on examz: +icterus, AST/ALT inc 5-10x, inc globulins, (a/w thyroititis, ITP, anemia, Coombs+)
autoantibodies commonly present-> +ANA, +ANCA, +Anti DSDNA, +SMA (most specific), anti-actin +, AMA + in low titer
Bx - piece meal necrosis of hepatocytes **
Tx - rapid reversal of symptoms and increased survival w/ prednisone +/- azathioprine, interferon is CONTRAINDICATED as it makes autoimmune hepatitis worse.
26yo F juandice, ALT 350, alkphos 115, +ANA, +ASMA, -AMA, IgG elev -> liver bx piecemeal necrosis of hepatocytes
Autoimmune hepatitis
26yo F jaundice, ALT 40, alk phos 290, -ANA, -ASMA -AMA, IgM/G normal - Liver bx mild inflamm with concentric fibrosis around bile ducts
Primary Sclerosing cholangitis
????(extrahep duct fibrosis) - urosdiol doesn’t help???
26yo F jaundice, ALT 100, alk phos 550, ANA neg, ASMA neg, AMA pos, IgM elev, IgG normal, liver bx - lymphocytic destruction of bile ducts
Primary Biliary cirrhosis
????(intrahep bile duct destruction, elev alk phos) - ursodiol helps????
Etoh Liver dz
Fatty liver-> etoh hepatits-> micronodular cirrhosis -
????hepatomeg, fat vaculoles on liver bx (reversible with stopping etoh)????
Etoh hepatitis
aorexia, n/v/abd pain/wt loss , hepatomegaly +, AST:ALT 2>1, AST/ALT increased but not more than 350,, Hepatomegaly, liver bx - necrosis of hepatocytes with inflamm cells,
inc WBC, encephalopahty, elev PT in severe cases (this is the most important prognostic factor***)
35yo F jaundice, confusion, malaise, RUQ pain - icterus, mild ascities, hepatomegaly, AST 205/alt 90, INR 1.5, WBC 18k bili 15, hg 12, platelets 155k, paracentesis reveals 200 WBCs
acute etoh hepatitis -> steroids if no bleed or SBP
If acute etoh hepatitis with bleed or SBP
pentoxyfyline
Obese pt weighing 275, BMI 35 . w/ DM, HLD - non-etoh - mild elev of ALT/AST 2:1, Fasting suger 160, chol 280 - liver bx fatty changes with some fibrosis
NASH (non alcoholic steatohepatits)
- dx wit liver bx NOT US
- tx underinglying risk factors….decrease weight, control DM, vit E, statin for HLD
Causes of cirrhosis
Viral (B,C,D), Autoimmune hepatitis, etoh, PBC, PSC, Hemochormatosis, wilsons, CHF/Budd chiari (stasis)
CA screening with cirrhosis
periodic liver US/ NOT alpha feto protein
best prognositc tests in cirrhotic according to MELD (model for end stage liver disease) score?
PT, INR, Ser Cr, Ser Bili
MELD <18 –>TIPS
MELD >18–> translpalnt
elective major sx in cirrhotic pts depends on MELD score
<10–> cleared fo sx
10-15 –> clear w/ CAUTION
>15–> elective sx CONTRAINDICATED
Indication for liver tx
viral hep, autoimmune hep, PBC, PSC, hepatoma, wilsons, Alpha 1 AT def, fulmianent hep failure
Contraindications
untreated HIV, extrahep CA, active etoh/drug use, unresolved sepsis/fungemia, Hep B with eAg +
When to refer for liver tx
cirrhotics with clinical or biochemical decompensation
Pt with cirrhosis p/w hep enceph - quit drinking 2 years ago, ascitic fluid WBC 70 - wtd
refer for liver tx
SAAG
figure this out
Least likely to cause chylous ascites
cirrhosis/CHF
management of cirrohsis with ascites
Na restriction to 1g/day, fluid restriction to 2 Its/day
diuresis begin with spironolactone 100mg + lasix 20 mg po –> titrate based on urine Cl or urine Na
–>refractory ascites may be treated w/ large volume paracentesis or transjugular intrahepatic portosystemic shunt (TIPS)
Cirrhotic p/w elev WBC, fever, ascities
paracentesis
Pt with long cirrhosis brought in with lethargy, asterixis and asciteis - PT INR 3, plt 40k - WTF
abdominal paracentesis ***
if PMNs > 250 / cmm in ascitic fluid or SBP is present wtd?
treat w/ a 3rd gen cephalosporin like cefotaxime**
SBP
PMN >25 in asciteis or WBC >500 with >50%pmn
SBP tx
cefotaxime (3rd gen cephalo) - usually single organism (ecoli, kleb, s pneumo) - 10-20% pts w/ cirrhosis and ascities develop SBP-give albumin- so tap new onset ascities or ascites w/ any complication such as fever, leukocytosis, or asterixix or lethargy
Post surgery NPO OR pt on abx for bronchitis get icterus - AST/ALT normla, alk phos nromla - indirect bili elev 4.2, direct bili 0.3 - 2 days later total bili 2.5
Gibert’s syndrome - no tx
Wilson’s dz
-autosom recessive
presentation at a young age/ adolescents w/
-chronic hepatitis (50%): with elev LFTs or
-neuro (30%)* (tremors, rigidity, and bradykinesia)
-psych dysfunction* (personality/behavor)
-hemolytic anemia***
- impaired excretion of copper–> copper accumulation in liver/body tissues
- urine copper high
- KAYSER-FLEISCHER RING pathognomonic
- liver bx –> copper deposition confirms dx
treatment:
- chelate w/ penicillamine** + pyridoxine or trientine
- in severe disease–> liver transplant
how i remember the treatment: “copper PENnies for PENicillamine “
Tx wilson’s dz
chelation penicillamine/pyridoxine -> severe dz - liver tx
UGIB causes
PUD, varices, mallory weiss tear, splenic vein thrombosis
Pt with coffee ground emesis and dizzinesss - NGT with blodo tinged fluid - BP 90/60 HR 120
fluid resucitation
Acute UGIB, continues bleeding confused, hypotensive/tachy
intubate then scope after volume resusitation
Point to transfuse UGIB
<7gm Hg
Tx of UGIB
bleeeding ulcer - electrocautery, visible vessel monitor/electrocautery, bleeding varices - octreotide infusion with banding -> monitor for 72hrs
Clean based ulcer no bleed
early feeding
PPI use
rel to cdiff, HAP, osteoporissis, low Mg, microscopic colitis
prevent rebleed in PUD
PPI
Pt w/ heartburn w/ partial response to PPI. endoscopy reveals severe GERD. wtd?
–> Laparoscopic fundoplication planned. prior to procedure. wtd?
manometry studies* to confirm good motility of esophagus, otherwise iatrogenic achalasia will result.
An elderly pt w/ GERD, not responding to H2-r blockers undergoes EGD and found to have stricture. Pt undergoes dilation of stricture and biopsy which is negative. There is proximal gastritis. Best way to manage pt is ?
PPI life long.
How often to endoscope Pts w/ Barrett’s esophagus.
- Pt has EGD showing metaplasia *columnar epit.)..
EGD 3-5 yrs
How often to endoscope Pts w/ Barrett’s esophagus.
- If EGD shows indefinite for dysplasia –> PPI + ….
EGD 2-6 months.
–> still indefinite? refer to esophageal pathologist –> indefinite confirmed –> repeat EGD in 1 yr
How often to endoscope Pts w/ Barrett’s esophagus.
- If EGD shows dysplasia –> refer to ….
esophageal pathologist for confirmation.
if dysplasia confirmed –> endoscopic radiofrequency ablation.
Pt on empiric PPI for 8 wks after discharge. What is most likely, when the PPI is discontinued?
new-onset heartburn
erosive gastritis..
NSAIDS, EtOH, Stress (major surgery, burns, MICU, ventilator**)
tx: IV H2 blocker, PO PPI
Chronic gastritis…
Type A: - fundus and body less common - atrophic gastritis: loss of rugae in fundus - pernicious anemia --> increased gastrin --> adenocarcinoma x 3x. No need for surveillance endoscopy.
Type B:
- antrum more common
- caused by H.pylori
- treat H.pylori only with sx
A pt w/ hx of PUD on PPI or GI bleed should undergo what test for h.pylori?
antibody testing
urea breath test and fecal antigen = increased false neg., sensitivity decreases.
(Hold PPIs 2 wks and abx 4 wks before doing urea breath or fecal antigen tests)
what will regress following treatment of h.pylori?
MALT
after treating pt..await histology report
best test for a patient w/ gastric ulcer
EGD w/ bx
NSAIDs w/ decreased incidence of PUD>
COX2 inhib
non acetylated NSAIDs (salsalate = disalcid)
non acidic prodrugs (nabumetone = relafen)
if nsaids have to be used, then co administer with COX-1 (misoprostol) or PPI
Treatment of PUD
H2 receptor blockers –> ranitidine, famotidine. use in PM
(ranitidine, famotidine …. also use in chronic urticaria)
Sucralfate –> covers ulcer
PPI –> blocks H+-K+ ATPase pump. Use 30min before breakfast**
Pt w/ acute UGI bleed, cont to bleed, HR 120, BP 90/60. confused. wtd next?
intubate.
Pt w/ acute UGI bleed, cont to bleed, HR 120, BP 90/60. confused. intubated. receives 2L NS. becomes hemodynamically stable. wtd next?
endoscopy asap
Pt w/ acute UGI bleed, cont to bleed, HR 120, BP 90/60. confused. intubated. receives 2L NS. becomes hemodynamically stable. At what Hb would you transfuse above pt. (nonexsanguinating, no comorbid factors)
7 g
Pt w/ acute UGI. EGD: bleeding ulcer…
electrocautery. mnitor for 72 hrs
Pt w/ acute UGI. EGD: visible vessel..
monitor, electrocautery . monitor for 72hrs
Pt w/ acute UGI. bleeding varices..
octreotide infusion followed by banding. banding better than sclerotherapy for varices.
monitor 72hrs
Pt w/ acute UGI. EGD: ulcer w/ a clean base (=no bleed) and < 2cm…
early feeding, PPI and send home or medical floor.
Pt w/ sudden onset of vomitting presents w onset of red blood or coffee fround comitus. pt alcoholic or a bulimic or w a hiatal hernia. c/o epigastric pain or pain in the back. wtd
EGD to r/o mallory weiss tear: longitudinal lacerations in distal esophagus and prox stomach
–> begin PPI . for persistant nausea/emesis –> anti-emetics
PPI use related to c.diff colitis
true
PPI use related to HAP
true
PPI use related to osteoporosis (vit D def)
true
PPI use can cause hypomagnesemia
true
PPI use related to microscopic colitis
true
PPI use related to B12 deficiency
true. absorbed in the terminal ileum. metformin as well
How to prevent rebleed in pt with PUD
PPI
Pt w cirrhosis w/ varices develops variceal bleed. octreotide given banding done. started on BB to prevent rebleed. Ascites tap: 150 WBCs 40% PMNs. wtd.?
IV cefriaxone (?????.... for 1 wk. switch to rifax at time of dc to complete 1 wk?????)
Pt w cirrhosis w/ varices returns a few weeks post admission with recurrent GI bleeds. MELD < 18.. wtd
transjug intrahepatic portosystem shunts (TIPS)
TIPS also with budd-chiari syndrome
pt w cirrhosis and spider angiomata has UGI bleed w ulcer. wtd
ceftriaxone
45 yo M p/w coffee ground emesis. 2 glasses wine/d. afebrile. HR 100, BP 120/80. EGD = no ulcer but gastric varices. wtd ? dx?
CT scan abdomen
dx: splenic v. thrombosis
only gastric varices= splenic vein thrombosis
esophageal + gastric varicies= cirrhosis
pt taking naproxen for arthralgia x weeks.. p/w fatigue, BRBPR (1000cc). started prev as black tarry stool. Hb 9. Gastric lavage neg. wtd?
EGD. overt obscure gi bleed
neg? repeat EGD.–> then colonscopy
if repeat EGD and colonoscopy neg then RBC scan
pt taking naproxen for arthralgia x past couple months.. p/w fatigue, Hb 10.5. fecal hemoccult positive. EGD neg. wtd?
colonoscopy
(????FOBT = <200cc blood loss. slow bleed???)
colonoscopy neg? capsule endoscopy or push enteroscopy
dyspepsia
- pain centered in the upper abdomen
- no heartburn
- no regurgitation
- if it occurs in pts over age 50, consider it pathological
- if after extensive workup including upper endoscopy no etiology is found it is called ‘non ulcer dyspepsia’
43 yo M p/w complaints of upper abdominal pain. He denies any weight loss or diarrhea. PE norm. upper endoscopy and biopsy is negative for h.pylori, no ulcer seen. this represents..
non ulcer dyspepsia
dyspepsia > 50yo or alarming sx (wt loss, bleed, odynophagia, etc) …. wtd
endoscopy
dyspepsia < 50yo and no alarming sx , wtd
check for h.pylori
- positive = tx
- neg = tx w/ antiacid** 4-8 wks
sx persist? endoscopy
Dumping syndromes.
Post prandial 15 min. later w palpitations, sweating, low BP…
rapid emptying (dumping syndrome)
dumping syndromes.
post prandial >90 min later w palpitations, tachycardia, confusion. ..
hypoglycemia
dumping syndromes tx?
freq small meals
complex sugars
35 yo F w/ abdom fullness and discomfort and occasional emesis for past 2 years. She has not lost weight. PE is normal. Labs are normal. EGD and US of abdom is norm. dx?
post-prandial distress syndrome.
Acute pancreatitis.. causes
- gall stones (USA)
- alcohol (leading in men 2nd)
- **microlithiasis (leading in women 2nd)
- hypertriglyceridemia > 1000mg/dl (lipase will look normal in 30%, amylase normal in 70%. microfiltration first)
- sphincter of Oddi dysfunction
- pancreatic divisum
- ERCP
- hypercalcemia
- pancreatic carcinoma, autoimmune
- drugs: thiazides, L-asparginase, pentamidine, bactrim, azathioprine, DPP-4 inhib**
acute pancreatitis diagnosis
clinical w abdomin pain, nausea, emesis
labs: amylase, lipase elevated
XR: sentinel loop (sign of ileus, not SBO) (???ileus at duodenum near pancrease???)
CT scan w contrast or spiral CT
pt w pmhx familial adenomatous polyposis w colectomy 4 yrs ago p/w icterus… wtd
EUS, to r/o ampulla of vater cancer
pt p/w epigastric pain, RUQ pain and leukocytosis. what is the appropriate diagnostic step?
US gallbladder
- shows stones w/ wall edema = calculous cholecystitis** (???surgery???)
- shows stones w/o edema –> HIDA can –> non-visualization of gall bladder (i.e. cystic duct obstruction)–> calculous cholecystitis **
next–> sx (lap chole)
pt p/w epigastric pain, RUQ pain and fever. ALT/AST and Alk Phos elevated. US = gallstones + hepatic duct dilation. dx? and wtd?
Mirizzi syndrome
- wtd? surgery (lap chole)
(???external compression of hepatic duct???)
55 yo p/w fever, RUQ pain and jaundice. AST 220, ALT 330, AP 450. Total Bili 10.5. Indir Bili 2.2, Amylase 355. US neg. wtd?
Piperacillin-tazobactam
if pt becomes hypotensive, after IVF, do ERCP*
pt w/ pancreatitis, w incr ALT,AST, AP. what is the approp dx step.?
US gallbladder to check for gall stones or dilated CBD
Pt w/ severe pancreatitis. Incr AST, ALT, dilated CBD on IV abx in MICU. wtd next?
ERCP and remove stone.
after inflammation subsides and enzymes decrease, do cholecystectomy
Pt w/ pancreastitis from stone, s/p laparoscopic cholecystectomy, 3days later p/w RUQ pain, icterus, and fever. AST/ALT/alk phos elevated . wtd next?
- ->US to r/o impacted gallstone
- ->dilated duct–> ERCP and remove the stone
Pt w/ pancreastitis from stone, s/p cholecystectomy. 3days later p/w RUQ pain, icterus, and fever. AST/ALT/AP elevated . went for ERCP. 3months later w/ epigastric pain and icterus. ALT/AST/Alk phos elevated. US showing dilated bile duct. wtd?
ERCP and manometric studies to r/o sphincter of oddi dysfunction
tx: endoscopic sphincterotomy
- if liver enzymes and US normal –> analgesia
pt w/ intermittent dysphagia to solids and liquids. Associated w/ CP
diffuse esophageal spasm
pt w/ intermittent dysphagia to solids and liquids. Associated w/ CP. What is it? Wtd next?
diffuse esophageal spasm
barium swallow will show corck screw esophagus
–> manometric studies showing non peristaltic contractions
now what is the next step in management
–> PPI
no response , treat w/ CCB such as diltiazem
Zenkers diverticulum
herniated pouch in hypo pharynx
barium swallow
40 y/o M w/ epigastric pain, weakness, anorexia, weight loss, labs reveal serum albumin of 2, calcium of 8. urine protein is negative. hypochlorhydria present. wtd?
EGD reveals striking enlargement of gastric folds or rugae.
dx–> Menetriers disease
peptic ulcer disease
H. pylori –> leading casue
NSAIDs
Zollinger Ellison Syndrome
H. pylori
- gram negative, urease producing**
- PUD (duodenal ulcers)
- type B gastritis
- gastric cancers
- mucosa associated lymphoma (MALT)
- treatment of H. pylori in low grade MALT results in tumors shrinkage or disappearance 50-80% of the time. Up to 30% of time, t (8;11) poor response to H. pylori therapy. Local RT required them. Await biopsy report before pronouncing cure. ***
zollinger-ellison syndrome
-duodenal bulb/ stomach ulcer–> multiple ulcers
-gastrinomas in. med duodenum, pancreas, porta hepatis. Associated w/ MEN I
-can present w/ PUD or diarrhea/steatorrhea (inactivates pancreatic lipase)
-fasting gastrin level elevated. IF non diagnostic then do,
-I.V secretin–> increase gastrin to >1000
-CT scan or somatostatin receptor scintigraphy localize tumor
-treat w/ PPI or resection of tumor
-others that increase gastrin level:
_pernicious anemia/chronic gastritis
_ renal failure
_hyperthyroidism
_PPI
All of the following are true about Zollinger Ellison
- MC earliest radiographic finding is a single duodenal ulcer
- ZE tumors are usually located on pancreas or duodenum
- 2/3rd of ZE are malignant and a quarter of them associated w/ MEN 1
- serum fasting of >1000mpg/ml w/ low pH is virtually diagnositc
- life expectancy is normal if curative surgery is done, otherwise life expectancy is 2 yrs
- recurrent duodenal ulcers or poor response to treatment is suggestive of ZE
45 y/o asymptomatic man…wtd?
nothing
40 y/o F asymptomatic w/ Family hx of gastric CA
nothing
42 y/o M w/ dyspepsia and heartburn
H. pylori testing
62 y/o w/ GERD w/o alarm symptoms
EGD
62 y/o w/ GERD w/ weight loss
EGD
43 y/o w/ peptic ulcer disease
H. pylori testing
In a pt w/ severe pancreatitis. Pt w/ recurrent pancreatitis twice in the past 2 yrs. US reveals biliary sludge in gallbladder. wtd?
ERCP for biliary sampling to R/O microlithiasis
Look for pancreatic divisum and sphincterotomy if present.
tx–> cholecystectomy
75 y/o post hip replacement, is recovering well, 6 days later, onset of pain in the upper abdomen w/ anorexia and fever of 103F. AST/ALT 40/52, total bili 1.1, amylase 90. US (NOT CT scan) reveals thickened wall of ball bladder (>3.5mm***), HIDA w/ non visualization of gallbladder but common bile duct visualized. iv abx begun. dx and tx?
dx: acalculous cholecystitits
tx: cholecystostomy
- -> put needle and drain fluid–> afterwards cholecystectomy
Pt w/ hx of UC w/ jaundice. wtd next?
- ->MRCP to r/o –> primary sclerosing cholangitis
- ->Brush bx to r/o–> cholangiocarcinoma
- ->US gallbladder to r/o–> polyp
- ->cholecystectomy otherwise–> adenocarcinoma of GB
Pt w/ epigastric pain and jaundice for a week. hx of vitiligo (clue of another autoimmune disorder). Alk phos 367 U/L, ALT 76 U/L, AST 114 U/L, amylase 260. US reveals enlarged pancreas w/ sausage shaped mass, bx negative for cytology. IgG4 elevated ** ERCP w/ dilated common bile duct w/ constriction in the pancreatic part of duct***. What is the best management?
Dx? autoimmune pancreatitis
tx: steroids***
Pt w/ hx of pancreatitis twice in the past year w/ abdominal pain radiating to the back. TGAs are 350. He drink socially. Amylase and lipase are elevated. AST/ALT appear normal. US normal. ERCP is done which reveals ventral duct contents are flowing normally to the major papilla. Dorsal duct is dilated* and content flowing thru the minor papilla sluggishly*. Most likely reason for pancreatitis?
pancreas divisium
Pt found to have incidental finding of calcification of gall bladder on US of abdm. wtd?
surgery
porcelain GB
Pt presents w/ severe pancreatitis.
T: 102F, WBC 15400 w/ 85% PMNs.
Lipase 920 U/L. Blood lactate level is 2.4 (normal 0.6-1.8).
CT shows undifferentiated mass. what is best management?
NO antibiotics
The most important prognostic factor in acute pancreatitis is INCREASED BUN
Pt w/ severe acute pancreatitis. Best way to provide nutrition is?
NG tube
Pt w/ pancreatitis. Amylase day 1 is 13,000, day 2 is 11,000, day 3 is 7,000. how long do you wanna check amylase?
stop checking
Pt w/ severe epigastric pain, vom, serum lipemic w/ triglycerides >1000. Amylase appears normal. (Normal amylase 70%, normal lipase 30%). dx? wtd to establish dx?
pancreatitis
wtd to establish dx?
-> **ultra filter TGAs and repeat amylase or
-> **dilute serum and remeasure amylase
Pt post sx w/ icterus. AST/ALT normal. Direct [conjugated] bili elevated. alkaline phosphatase elevated.
(PT /INR can increase, PTT can increase)
dx?
benign post operative cholestasis
the best diagnostic test for gallstones?
US
f/u Pt has pancreatitis and was discharged 2 wks ago, mass in abdomen is palpable, non-tender, bowel sounds heard. Amylase level 435. Dx?
pseudocyst
Pt w/ pancreatitis. Common bile duct dilated. wtd?
ERCP
Pt w/ severe pancreatitis. US neg for gall stones. Triclycerides normal. wtd?
ERCP
Pt w/ pancreatitis. increased AST + Alk phos. wtd?
US gallbladder
Pt w/ biliary pancreatitis. Week later w/ normalizing enzymes and clinically imprved. wtd?
laparoscopic cholecystectomy
chronic pancreatitis….
- MC cause is alcoholism**
- pancreatic calcifciation + in 50%, DM +
- malabsoption w/ steatorrhea (>40g/day virtually diagnostic)
- Treat steatorrhea + abdominal pain w/ high dose pancreatic lipase enzymes empirically for 6 wks–> pregabalin
Pt w/ abdominal discomfort. Abd xray: calcification in med abdm area. What complication will this pt develop?
what is the dx?
complication: DM
dx: chronic pancreatitis
asymptomatic pancreatic cysts workup:
worrisome features on CT:
- solid component**
- size >3 cms **
- dilated duct> 10mm **
- thickening of cyst**
asymptomatic pancreatic cyst …
if at least worrisome feature on CT scan (ex: solid component + >3 cms)…wtd?
EUS FNA
asymptomatic pancreatic cyst …
w/ at least worrisome feature on CT scan (ex: solid component + >3 cms).
EUS FNA confirms at least 2 worrisome features, wtd?
resect
asymptomatic pancreatic cyst …
w/ at least worrisome feature on CT scan (ex: solid component + >3 cms).
IF EUS FNA negative for worrisome features. wtd?
MRI in 1 yr, then Q2yrs
asymptomatic pancreatic cyst …
w/ at least worrisome feature on CT scan (ex: solid component + >3 cms).
If EUS FNA confirms solid component and dilated duct, but FNA neg. wtd?
resect
asymptomatic pancreatic cyst …
CT scan shows <3 cms lesion, no solid component, no dilated duct.
wtd?
MRI in 1 yr, then Q2yrs –> for total for 5 yrs surveillance.
asymptomatic pancreatic cyst …
2 cms lesion on CT , F/u MRI in 1 yr shows size change, then?
–> EUS FNA
asymptomatic pancreatic cyst …
EUS -FNA shows **inflmmatory cells and RBCs **. wtd?
resect
cyst resected for malignant lesions. wtd?
repeat MRI q 2 yrs
large cyst resected but no evidence of malignancy. wtd?
no need for f/u after resection .
Ulcerative colitis
CI ft:
pg 417 chart
Hematochezia
abdominal pain
diarrhea
tenesmus
Crohn’s disease
CI ft:
pg 417 chart
Rt lower quadrant mass
diarrhea
Ulcerative colitis
Path?
pg 417 chart
superficial ulcer w/ crypt abscess!
Crohn’s Disease
path?
pg 417 chart
deep ulcers w granulomas!
Ulcerative Colitis
Xray?
pg 417 chart
toxic megacolon
Crohn’s disease
xray?
pg 417 chart
toxic megacolon (more common) string sign
Ulcerative colitis
extra- intestinal manifestations?
Pg 417 chart
E nodosum Rh. neg arthritis pyoderma ganrenosum ankylosing spondylitis sclerosing cholangitis
mirror colitis: e. nodosum, Rh.neg arthritis, pyoderma gangrenosum
Crohn’s disease
extra-intestinal manifestations?
Pg. 417 chart
Rare
Ulcerative colitis
CA?
Pg 417 chart
+++
Crohn’s
CA?
pg 417 chart
+
Ulcerative colitis
Colonoscopy?
Pg 417 chart
after 8 years, then every q 1-2 yrs ***
Crohn’s disease
colonoscopy?
pg 417 chart
after 8 years, then every q 1-2 yrs ***
Ulcerative colitis
Labs?
Pg 417 chart
p-ANCA +
myeloperoxidase abs
Crohn’s disease
Labs?
Pg 417 chart
ASCA +
Anti-saccharomyces Cerevisiae antibodies
best way to screen for inflammatory bowel disease?
fecal calprotectin ( most sensitive)
Mirror colitis ?
E. nodosum
peripheral arthritis
pyoderma gangrenosum
DON’T mirror colitis?
sacroiliitis
primary sclerosing cholanitis
string sign?
narrowing of distal ileum
A 34 y/o woman w/ UC now complains of pain in the small joints of the hand w/ 30 min of early morning stiffness. treatment?
sulfasalazine
Pt w/ diarrhea and RLQ mass. T 101 F and has an ulcer on the tongue. Dx?
Crohn’s disease
Pt w/ bloody diarrhea for last 2 yrs. 3 wks ago, went to mexico. Colonoscopy revealed erythematous appearance w/ friable mucosa in distal colon.
Ulcerative colitis
Ulcerative colitis Toxic megacolon (6+cm), management?
steroids, broad spec abx–> surgery
(reassess in 24 hrs if and no change, perform surgery)
(if bp decreases–> sx)
Ulcerative colitis maintenance?
NO STEROIDS
hydrocortisone enema
5ASA supp, qHS to q3hrs
Ulcerative colitis flare?
sulfasalzine
mesalamine (Asacol + pentasa)
+/- prednisone or ACTH–> resistance–> 6MP + Azathioprine
5-ASA enema, hydrocoritsone enema
5-ASA supp or mesalamine supp h.s to tid –> cortisone foam
treatment for UC/ Crohn’s?
- 5-ASA (mesalamine) is the active compound
- sulfasalazine= 5-ASA + sulfapyridine in the colon by bacterial action. Hence sulfasalazine would not be of much help in disease of small bowel, where there is not much bacteria.
- 5 ASA is the active component whereas sulfapyridine contributes to reversible infertility (esp in males) and leukpenia
- Olsalazine = 5-ASA + 5-ASA which is split in the colon
- Balsalazide = 5-ASA + inert product which split in colon
- Mesalamine compounds (Asacol & Pentasa) release dependent on Ph of colon .
- perianal abscess and fistula in CD, treat w/ anti TNF alpha, metronidazole with no efficacy.
- 6 Mercaptopurine + Azathriprine are steroid sparing!!!!
What diseases wake pt up at night?
inflammatory bowel dx
bacterial overgrowth syndrome
microscopic colitis
If ulcerative colitis gets better, PSC continues!
If LFTs and bilirubin worsen..wtd?
refer for transplantation
Which medication would you use for manitenance treatment in UC or Crohn’s dx?
5-ASA (mesalamine) +/- metronidazole
What medication do you NOT use in maintenance in UC or Crohn’s dx?
steroids
A 26 y/o F c/o passing fecal material thru vagina. Recto-vaginal fistual diagnosed. colonoscopy revelas skip ulceration int he large bowel. You would start?
Anti TNF alpha.
Adverse effect? reactivation of TB, histo.
Stop if going for major sx, can cause wound dehiscence.
Think pt demographics and fungal infection from that area.
A 24 y/o w/ hx of UC for past 4 yrs. p/w jaundice, fever. Hepatomegaly +, bilirubin is 3.5, alk phos 950, AST 240, ALT 258, ANA neg, ASMA neg, AMA neg, P-ANCA +. Most appropriate diagnositc test?
ERCP/MRCP will reveal beading and focal dilation of biliary tree.
if pt continues to have worsening of jaundice and increase bilirubin and LFTs. The most appropriate step is???
refer for liver transplantation.
string sign in what dx?
crohn’s disease
shallow ulcer extending frm the recturm
dx?
UC
toxic megacolol
what dx?
UC and CD
more common in UC
cancer
what dx?
UC and CD
sclerosing cholangitis
what dx?
UC and CD
infliximab
what dx?
UC and CD
Azathioprine
what dx?
UC and CD
P-ANCA (MPO)
What dx?
UC
ASCA
what dx?
Crohn’s disease
Colonoscopy after 8 yrs w/ the d
in what dx?
UC and CD
Tenesmus
what dx?
UC
diarrhea, RLQ mass w/ pain
what dx?
CD
crypt abscess
what dx?
UC
granulomas
dx?
CD
calcium oxalate stones
increase oxalate absorption, decrease citrate + decrease B12 absorption
CD
perianal fistula
what dx?
CD
fecal soiling on urination
what dx?
CD
smoking makes it better
what dx>
UC
Acute diarrhea
Enterotoxigenic?
E. coli
Vibrio cholarae
Clostridium perfingens
bacillus cereus
Acute diarrhea
invasive?
C. jejuni (leading cause in US) salmonella (leading enterocolitis) shigella 0157: H7 (don't give abx or can cause TSS) c. difficile
Acute diarrhea
parasitic?
giardiasis
amebiasis
Chronic diarrhea?
- cryptosporidium (T cells <100)
- isospora
- MAC
- CMV (T cells low)
- DM
- IBS
- IBD
- carcinoids (osmotic gap <50)
- laxative abuse (osmotic gap >50)
Giardia and cryptosporidium are resistant to chlorination of water
Elderly Pt w/ diarrhea, fever, and confusion after eating soft cheeses. dx?
listeriasis
pt camping on river stream presents w/ diarrhea for a wk.
dx? management?
Giardiasis
management: metronidazole
Pt attends a party eats rice (B. Cereus), chicken (salmonella), and salad (staph aureus toxin). Upon reaching home about 4 hrs later, has diarrhea w/ no blood.
most likely organism?
staph. aureus (toxin)
HIV pt w/ T cell <50 presents w/ chronic diarrhea, small frequent stools, occasionally explosive diarrhea w/ lower abdominal cramps. Feels like moving bowel frequently. Hematochezia +. Dx, Tx?
Dx: biposy (CMV)
tx: Gancyclovir followed by ART 2 wks later
HIV pt w/ T cells <50 presents w/ chronic diarrhea, large volume w/ bloating, gas, low grade fevers. Alk increased
Dx. and Tx?
Dx: blood culture (MAC)
Tx: ethambutol + macrolide w/ ART
HIV pt w/ T cells <100 presents w/ severe chronic diarrhea, large volume rsulting in dehydration and electrolyte dsturbances. Dx and Tx?
Dx: microscopy, ELISA
TX: ART w/ supportive care.
cdiff + WBC >15,000 or age >60, with diarrhea after 2 wks, wtd?
vancomycin pulse therapy OR fidaxomicin OR fecal transplant
diarrhea, cdiff + WBC >15,000 or age >60, treated w/ vancomycin pulse therapy w/ diarrhea again. wtd?
fecal transplant
most likely right choice
Pt tx w/ fidaxomicin w/ c diff diarrhea a month later, wtd?
fecal transplant.
Pt w diarrhea, C. diff positive. WBC 18,000 and w/ ileus, wtd?
PO vancomycin + IV metronidazole
Absorption of Nutrients
Causes of Malabsorption
- pancreatitis
- bile salts
- mucosal
- lymphatic
- others
pancreatitis:
- chronic pancreatitis
- pancreatic CA
- CF
Bile salts:
- cholestasis
- illeal resection/ Crohn’s disease
- bacterial overgrowth
- zollinger Ellison syndrome
Mucosal: D- xylose test abnormal
- Celiac sprue
- tropical sprue
- whipple’s disease
- eosinophilic gastroenteritis
- small bowel syndrome
- amyloidosis
Lymphatic:
- intestinal lymphangiectasia
- intestinal lymphoma
Others:
-ZE, carcinoid
Malabsorption
table 428
For pancreatitis, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?
fecal fat:very increased!
D-xylose: N
bile acid: N
breath test: N
Malabsorption
table 428
For biliary disease, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?
fecal fat: increased
D-xylose: N
bile acid: decreased
breath test: N
Malabsorption
table 428
For bacterial overgrowth, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?
fecal fat: increased
D-xylose: N/ decreased
bile acid: decreased
breath test: abnormal
Malabsorption
table 428
For mucosal, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?
fecal fat: increased
D-xylose: abnormal
bile acid: N
breath test: N
Malabsorption
table 428
For lymphatic, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?
fecal fat: increased
D-xylose: abnormal
bile acid: N
breath test: N
pt on self gluten free diet, if antibodies are neg, then do?
HLA DQ 2 or 8
young woman w/ diarrhea, bloating, fatigue, fogginess**, and H/A. She went on gluten free w/ fever symptoms. When she started gluten again, she had recurrence of symptoms. wtd?
anti gliadin abs
non- celiac gluten senitivity
14C xylose test and measure exhaled 14 CO2
bacterial overgrowth
impaired chylomicron production due to dec globulins
abetalipoproteinemia
dilated lymphatic vessels
intestinal lymphangiectesia
fecal fat 50 g/ day
pancreatic insufficiency
chronic pancreatitis
klebsiella/ e. coli
tropical sprue
tropheryma whipplei
whipples disease
transglutaminase abs
celiac sprue
tetracycline + folic acid
tropical sprue
bactrim or tetracycline
whippl’es disease
gluten free diet
celiac sprue
intestinal lymphoma
celiac sprue
arthritis, weight loss, neurological symptoms, hyperpigmentation
whipples disease
bullous skin diases, dermatitis herpetiformis, howell jolly bodies
celiac sprue
megaloblastic anemia
tropical sprue
iron def aneia
celiac sprue
AVMs (arterio-venus malformations) in all organs
Osler- Weber- Rendu syndrome
angiogram
acute mesentric ischemia
chronic mesentric ischemia
colonscopy
ischemic colitis
hydration and abx
ischemic cholitis
angioplasty
chronic mesentric ischemia
thrombolytics or sx
acute mesentric ischemia
Acute Hep B
HBsAG +
Anti -HBs -
Anti-HBc: IgM
chronic Hep B
pg 440
HBsAG +
Anti -HBs -
Anti-HBc: IgG (ALT/ inc)
carrier Hep B
pg 440
HBsAG +
Anti -HBs -
Anti-HBc: IgG (N)
past infection
HBsAG -
Anti -HBs +
Anti-HBc: IgG
post vaccination
HBsAG -
Anti -HBs + (titer >10)
Anti-HBc: -
chronic/ past hepatit B/ false +
HBsAG -
Anti -HBs -
Anti-HBc: IgG
Pt received 1st dose of Hep B vaccine last year, presents for regular follow up. Can you give second dose now?
yes
no specific time frame b/w 1st and 2nd dose
for any level HBV DNA , on immune suppressives, treatment?
yes for up to 1 year after
Hep c abs are neg, but you still suspect hep C b/cpt has fatigue and liver enzymes elevation, wtd next?
Do HCV RNA
in this pt, HepC abs positive (can be false +) and Hep C RNA (NAAT) neg. wtd next?
tell pateint does not have HCV
Pt w/ hep C w/ high viral load and compensated cirrhossi is depressed. what is best management for hep c?
sofusbuvir/ ledipasvir
pt w/ cirrhosis and ascites w/ RUQ pain. US shows hepatic veing thrombosis . wtd?
triple phase CT scan to R/O hepatocellular carcinoma**
indications of liver transplant
cirrhotics w/ clinical decompensation:
ascites, variceal bleed, hepatic encephalopathy, or biochemical decompensatiosn; increase in Cr, bilirubin and PT INR
CI for liver transplant
active alcohol abuse or illict drug use
extrahepatic CA
unresolved sepsis or fungemia
relative CI to liver translplant
- active HIV disease and H. ep C
- Hep B w/ e Ag postitive–> treat for Hep b b/4 transplant or if urgent –> transplant and give HBIG
cirrhosis portal
asciitc fluid protein 1.8 (low ), albumin 3g, ascitic fluid albumin 1.5 (lo) SAAG 1.5
liver failure
asciitc fluid protein 1.8 (low ), albumin 3g, ascitic fluid albumin 1.5 (lo) SAAG 1.5
liver failure portal
asciitc fluid protein 1.8 (low ), albumin 3g, ascitic fluid albumin 1.5 (lo) SAAG 1.5
R heart failure portal
asciitc fluid protein 2.5 (high ), albumin 3g, ascitic fluid albumin 1.6 (low) SAAG 1.4
budd-chiari syndrome
asciitc fluid protein 2.5 (high ), albumin 3g, ascitic fluid albumin 1.6 (low) SAAG 1.4
nephrotic syndeome nonportal
asciitc fluid protein 2 (low ), albumin 2.8g, ascitic fluid albumin 1.8 (high) SAAG 1.0
pancreatits
asciitc fluid protein 2.5 (high ), albumin 3g, ascitic fluid albumin 2.2 (high) SAAG 0.8
all of following is ture of bacterial peritonitis
-usually a single organism is involved
-10-20% cirrhotics develop SBP
-start 3rd gen cephalo along w/ albumin iv
treat for PMN of >250
protein restriction does not prevent hepatic encephalopathy
all of following is true of bacterial peritonitis
-usually a single organism is involved
-10-20% cirrhotics develop SBP
-start 3rd gen cephalo along w/ albumin iv
treat for PMN of >250
protein restriction does not prevent hepatic encephalopathy
pt w/ hepatic encephaloppathy started on lactulose w/ little impovement and cannot tolerate higher doses b/c of diarrha. has ongoing encephalopaty on lactulose and rifximin. wtd?
add probiotics
pt s/p sx NPO or pts taking abx for bronchitis develops icterus
AST/ALT normal, alk phos normal, Hb 13,retic 1.5%
indirect bili elevated ex: 4.2
direct bili 0.3. couple days later the total bili is 2.5
dx?
gilbert’s syndrome
due to decreased glucoronyl transferase
wtd?nothhhiiinnggg bro
love you baby
you got this!
keep going!
:)
