3. GI Flashcards
GI hormone pathway
G cell -> gastrin -> parietal cell -> hydrochloric acid
Cholelithiasis vs Acute Cholecyctitis vs choledocholithiasis vs Acute Cholangitis
Cause/Sx/Dx/Tx
Risk factor for gallstone?
Cholelithiasis (billary colic)
- Cause: gallstone in gallbladder but not inflammed
- Sx: after fatty food, then pain
- Dx: US
- Tx: Observe or elective
Acute cholecyctitis
- Cause: gall bladder duct blocked by stone which cause inflammed
- Sx: RUQ pain, Fever,
- Murphy sign (deep breath push pain)
- Psoas sign (shoulder pain)
- Dx: US first, HIDA (best)
- Tx: Fluid, Ceftx + Metro (CM)
Choledocholithiasis
- Cause: Stone in common bile duct but No inflammed
- Sx: RUQ pain, Jaundice
- Dx: US (first), ERCP (best)
- Tx: ERCP
Acute Cholangitis
- Cause: infection due to obstruction MC E coli
- Sx: Fever, RUQ pain, Jaundice
- Dx: US (first), ERCP (best)
- Tx: ERCP + ABX (Ceftx + Metro)
Female, forty age, fertile (pregnancy), fat
Charcot vs Raynoid pentad
Explain
which group of peplpe has high risk of gallbladder stone?
- Charcot - fever, RUQ pain, Jaundaice
- Raynoid pentad - Fever RUQ pain, Jaundice
Native american
Primary Sclerosing Cholangitis vs Primary billary cirrhosis
Cause/Sx/Dx/Tx
PSC
- Cause: Sclerosing of bile duct to strictures (autoimmune)
- Sx: Pruritus, jaundice
- Hx: UC
- Dx: ERCP (best)
- Lab: ALP GGT evelvated, P ANCA +
- Tx: Liver transplant
PBC
- Cause: T cell attack bile duct and destruction
- Sx: Pruritus, Jaundice
- Dx: AMA (antimitochondrial antibody), Bx (definitive)
- ALP, GGT elevated
- Tx: Ursodeoxycholic acid
Pilonidal
Cause/Sx/PE/Tx
- Cause: abscess sacroccygeal cleft
- Sx: Tender
- PE: Tender, Fluctuant
- Tx: I & D, Surgical excision (definitive)
Anal fissure
Sx/PE/Tx
- Cause: hard stool, constipation
- Sx: Rectal pain, may bleed
- PE: Posterior of midline tear, Lateral tear - Crohn, malignacy
- Tx: Supportive (sitz bath, fiber, topical analgesic, Nitroglycerin)
- Lateral internal sphincterotomy for chronic
Fecal impaction
Cause/medication cause/Sx/Tx
- Cause: infrequent bowel movement
- Medication: verapamil
- Sx: abd distension and pain
- Tx: Stool softener (psyllium, PEG)
- if failed conservative, Fecal disimpact by hand and Enema washout
Diverticulosis vs Diverticulitis
Cause/Sx/Dx/Tx
Diverticulosis
- Cause: Outpouching of colon But not inflammed (low fiber)
- Sx: painless Bleeding
- Dx: CT
- Tx: high fiber diet, supportive
Diverticulitis
- Cause: Outpouching of colon scarred and inflammed
- Sx: Painful NO bleeding, fever
- Dx: CT, NO colonoscopy
- Tx: clear liquid diet (low fiber) + Cipro + Metro
Hemorrhoids
Internal vs External
Sx/Tx/Special comment
Internal
- Sx: Painless bright bleed above dentate line
- Tx: Sitz Bath, high fiber diet, if large, Rubber band ligation
External
- Sx: Painful perianal pain with defecation
- Tx: Excision, topical hydrocortisone helpful
Special comment: MC cause rectal bleed
UC (ulcerative colitis) vs Crohn
Site/Depth/Sx/Dx/Tx/Special risk
Ulcerative colitis
- Site: Always involve rectum
- Depth: Not muscle involve
- Sx: bloody, Tenesmus
- Dx: Flex sigmoidoscopy, CI: colonoscopy acute colitis
- Uniform inflammation
- Tx: Sulfasalazine, surgery is curative
- Special risk: colon cancer, toxic megacolon
Crohn
- Site: Keep legion can be any GI tract
- Depth: Transural
- Sx: No blood, pain RLQ
- Dx: Colonoscopy
- Skip lesion, cobblestone appearance
- Tx: Mesalamine, surgery not curative
IBS
Patient/Sx/Dx/Tx
- Patient: Women
- Sx: Constipation and diarrhea alternating
- Dx: Rome criteria 1d/week for 3month, CBC fo anemia
- Sx related with defecation
- Frequency of stool
- Form of stool
- Tx: low fat diet, supportive care
- Constipation - bulk laxatative (psyllium)
- Diarrhea - loperamide
Ischemic colitis
Cause/Hx/Sx/Dx/Tx
- Cause: Blood flow interfere (superior mesenteric artery involve)
- Hx: Atherosclerosis
- Sx: Sudden abd pain
- Dx: CT
- Tx: supportive care
Mesenteric ischemia
Cause/Hx/Sx/Dx/Tx
- Cause: emboli ostruction mesenteric artery
- Hx: a fib, MI, CAD
- Sx: out of proportion pain
- Dx: Angiogram
- Tx: surgical revascularization
Toxic megacolon
Hx/Sx/Dx/Tx
- Hx: UC, Crohn
- Sx: abd pain
- Dx: X-ray abd dilated more than 6cm
- Tx: bowel decompress, IV fluid, bowel rest, NG tube
Large bowel obstruction
MC site/Cause/Sx/PE/Dx/Tx
- MC site: Sigmoid
- Cause: MC colorectal cancer
- Sx: Distended bowel
- PE: hyperresonance
- Dx: X-ray (haustra present)
- Tx: NG tube
Polyps in intestine
Cancerous Site/Main concern/MC population w/ painless bleeding/follow up
- Cancerous site: Proximal
- Main concer: Malignant transform
- MC population w/ painless bleeding: pediatric
- Follow up: Once identified colonoscopy Q3-5y
Familial adenomatous polyposis (FAP)
Cause/Patient/Screening
- Cause: multiple polyps (hundreds)
- Patient: polyps development average 15yo and cancer at 40 yo
- Screening
- if first degree relative - genetic screening at 10 yo
- Sigmoidoscopy start at 12 yo
Esophagitis
Cause/Dx finding/Tx
Infection
- 3 Type cause
- Candida - white plaque
- CMV - deep
- HSV - Shallow
- Dx: Endoscopy
- Tx
- Candida - fluconazole
- CMV - ganciclovir
- HSV - acyclovir
Eosinophillic
- Cause: allergic MC in children
- Dx: Endoscopy - multiple corrugated rings
- Tx: remove
pill-induced - bisphosphonates
GERD
Cause/Increase GERD/Sx/Dx/Tx
- Cause: weak muscle in LES, acid leaks out
- Increase GERD: Caffeine
- Sx: Heartburn laydown painful after food
- Dx: Trial of H2 and PPI (initial) Endoscopy (dysphagia, odynophagia, weight loss, persistent vomiting, palpable mass or adenopathy or positive FOBT), 24hr Ph monitoring (Gold)
- Tx
- 1st: Life modification
- 2nd: OTC antacid, H2 blocker
- 3rd: PPI
Barrett’s esophagus
Hx/Dx/Tx/Special risk
- Hx: Chronic GERD
- Dx: endoscopy, Bx (squamous to columnar)
- Tx: PPI
- Special risk: adenocarcinoma
Achalasia
Cause/Sx/Dx/Tx
- Cause: loss of auerbach’s plexus
- Sx: dysphagia to both solids & liquids
- Dx: Manometry (gold), Barium (bird beak)
- Tx: botulinum injection
Mallory-weiss syndrome
Cause/Hx/Sx/Dx/Tx
- Cause: tear
- Hx: Forceful vomitting
- Sx: bleeding
- Dx: Endoscopy
- Tx: Supportive care
Esophageal spasm
Cause/Sx/Dx/Tx
- Cause: strong contraction of esophagus
- Sx: Dysphagia of solid and liquid
- Dx: Manometry (Corkscrew look)
- Tx: CCB, botox
Esophageal Stricture
Type 3/Sx/Dx/Tx
- Type
- Web - mid upper
- Ring - lower
- Plummer - dysphagia + web + Iron deficiency
- Sx: Can’t swallow solid
- Dx: Barium
- Tx: Dilation + PPI
Esophageal varices
Cause/Hx/Dx/Tx/Prevention
- Cause: Portal HTN
- Hx: Alcholism, liver dz
- Dx: Endoscopy
- Tx: Octreotide
- Prevention: CCB, BB
Boerhaave syndrome
Cause/Sx/Hx/Dx/Tx
- Cause: Iatrogenic perforation of esophagus
- Sx: breathing or swallowing retrosternal chest pain
- Hx: Endoscopy was done
- Dx: Barium
- Tx: IV fluid + NPO, if large surgical repair
Celiac disease
Cause/Sx/Dx/Tx/Related Dz
- Cause: gluten cause loss of villi
- Sx: diarrhea, dermatitis herpetiforms, weight loss
- Dx: Iga antidomysial (EMA), bx (definitive)
- Tx: Gluten free diet
- Related Dz: Type 1 DM
- Avoid: Barely, Rye, Wheat
Lactose intolenrance
Cause/Sx/Dx/Tx
- Cause: lack of lactase enzyme
- Sx: bloating flatulence, No weight loss
- Dx: hydrogen breath test
- Tx: Avoid dairy product, lactose free diet, Calcium supplement
Nut allergy
Cause/MC type/Tx/Special comment
- Cause: IgE mediated reaction
- MC type: Dermatologic
- Tx: avoidance, if severe epinephrine
- MC food type related anaphylaxis
Gastritis
Cause/Sx/Dx
- Cause: H pylori MC, NSAID, Stress
- Sx: Epigastric pain
- Dx: Endoscopy
- Tx
- Positive H pylori - CAP (clarithromycin + AMOX + PPI)
- Negative H pylori - PPI, H2 blocker
Peptic ulcer disease
Cause/Sx/Dx/Tx
- Cause: H pylori MC, NSAID, Zollinger ellison syndrome
- Sx
- epigatric pain worse at night
- Food in pain gets better - duodenal
- Food in pain gets worse - gastric
- Dx: Endoscopy (best)
- Urea breath test
- H pylory stool test
- Tx
- H pylori positive: CAP (clarithromycin + AMOX + PPI)
- 4 meds: bismuth + PPI + tetra + Metro
- H pylori negative: H2 blocker or PPI
- H pylori positive: CAP (clarithromycin + AMOX + PPI)
- Special comment: MC cause of upper GI bleed
Pyloric stenosis
Cause/Patient/Sx/PE/Dx/Tx
- Cause: autosomal dominant
- Risk: Macrolide, first baby
- Patient: infant (2 week- 2month)
- Sx: Non-bilious projectile vomitting
- PE: RUQ Olive shape mass
- Dx: US (target)
- Lab: Hypokalemic, Hypochloremic (Malka)
- Tx: surgical
Hepatitis
Type/Route/Dx/Tx
Hep A
- Route - oral fecal (Only A has Spike fever)
- Dx: Hep A IgM - actue, IgG - recovery
- Tx: supportive
Hep B
- Route - sex or needle
- Dx
- HBsAg - any active infection (Acute or chronic)
- Anti-HBs - recovery or immune
- Anti IgM - Acute
- Anti IgG - chronic or recovery
- Tx: Supportive
Hep C
- Route - Blood - borne
- Dx: HCV, Screening for HCC via serum alpha feto
- Tx: interferon
Hep D
- Route: blood borne, requires Hep C
Hep E
- Route: Oral fecal
- Dx: IgM
- Tx: none (highest mortality during pregnancy 3rd)
Lab for liver injury
Explain
- AST/ALT 2:1 ratio - ETOH
- ALT> AST 1000 difference - Acute hepatitis
- ALP, GGT elevated - hepatic, billiary (PBC, PSC)
Fulminant Hepatitis
Cause/Sx/Dx/Tx
- Cause: Acetaminophen MC
- Sx: Encephalopathy (AMS, asterixis)
- Dx: Ammonia elevated, PT/INR >1.5
- Tx
- Encephalopathy - lactulose
- protein stop + abx (neomycin)
- Liver transplant definitive
Cirrhosis
Cause/PE/Dx/Tx
- Cause: ETOH
- PE: acities, encephalopathy, esophageal varices
- Dx: US
- Tx
- Encephalopathy - lactulose
- Ascities - Na stop
- Pruritis - Cholestyramine
- Fluid remove - Spironolactone
Peritonitis
Cause/Sx/Dx/Tx
- Cause: Portal HTN -> edema -> bacterial infiltrate (E coli)
- Sx: Fever
- Hx: Cirrhosis
- PE: Acities, fluid wave
- Dx
- PMNs > 250, WBC > 1,000
- Analysis fluid
- Tx: IV abx
Hernia
Direct vs indirect
location/patient/Tx
- Location
- Indirect - pass into scrotum
- Direct - Do not extend into scrotum
- Hasselbach’s triangle (inferior epigastric vessel,inguinal ligament, Rectus abdominus muscle)
- Patient: less than 1 yo or more than 40 yo
- Tx
- Stage 1 - soft and able to reduce
- Stage 2 - firm and painful
- Stage 3 - strangulated (painful and impaired blood flow)
Noninvasive diarrhea vs invasive diarrhea
Pathgen/sx difference
- Noninvasive - Staph A, Cholera, E coli, C Diff, bacillus
- Invasive - Salmonella, Campylobacter, shigella, salmonella, yarsinia, E coli 0157
- Sx:
- Noninvasive - watery, No WBC
- Invasive - bloody, WBC high
Noninvasive
Pathogen/Source/Sx/Tx
- Bacillus - fried rice in 6 hrs
- Sx: N/V/D
- Tx: Fluid
- Staph A - mayo, custard in 6hrs
- Sx: N/V/D
- Tx: Fluid
- Cholera - contaminated food or water (3rd world country)
- Sx: Severe water loss (Rice water stool)
- Tx: Fluid, Cipro (tetracycline)
- E coli (traveler) - other underdevelop country
- Sx: N/V/D
- Tx: Fluid, Cipro (pregnancy - AZA)
- C Diff - Normal flora, clindamycin
- Sx: high lymphocytosis
- Tx: Vancomycine Oral, Severe IV Vanco
Invasive
Pathogen/Source/Sx/Dx/Tx
- Campylobacter - undercooked poultry (chicken) 3day incubation
- Sx: initially water -> become bloody diarrhea
- Dx: stool culture (seaful shape)
- Tx: Erythromycin
- Shigella - oral fecal contamination
- Sx: Explosive initially water -> become bloody diarrhea
- Dx: Stool culture (1st), sigmoid (punctate ulcer)
- Tx: Fluid, Bactram
- Salmonella - poultry product 6-48 hrs
- 2type
- Gastro(typhim) vs thyphid (typhi)
- Sx
- Gastro - bloody diarrhea
- Thyphoid - bradycardia, pea soup stool
- Tx: Fluid, Cipro (Sickle cell must get abx - osteomyelitis)
- 2type
- E Coli 0157 - ground beef
- Sx: bloody diarrhea
- Tx: Fluid
- Abx may cause HUS in children
- Yersinia - undercook pork
- Sx: mimic acute appendicitis (right lower quadrant tenderness)
- Tx: Fluid
Giardia
Source/Sx/Dx/Tx
- Which diarrhea has amebic liver abscess? Tx?
- AIDs related diarrhea?
- Osmotic gap high vs osmotic gap low?
- Most common diarrhea in children?
- MC gastro virus in cruise ships?
- Giardia
- Source - water stream and well
- Sx: frothy, greasy foul diarrhea
- Dx: stool culture
- Tx: Metronidazole
- Amebiasis, Tx: Metronadazole
- Cryptosporidium
- Gap high - Osmotic, Gap normal - secretory (motility)
- Rotavirus
- Novovirus
Ingesting toxic
- Acetaminophen
- Anticoagulants
- Benzodiazepine
- BB
- ASA
- Opioids
- TCA (amitriptyline)
- N-acetylecysteine
- FFP, Vit K
- Flumazenil
- Insulin, glucagon
- Sodium bicarbonate
- Naolxone
- Sodium bicarbonate
G6PD deficiency
Cause/Patient/Sx/Hx/Dx/Tx
- Cause: X linked recessive
- Patient: AA male
- Sx: Anemia, splenomegaly
- Hx: taking Sulfa, antimalarial, nitrofurantoin
- Dx: Heinz body
- Tx: self-limited
Paget vs osteomalcia vs Ricket
Cause/Sx/Dx/Tx
Paget
- Cause: Osteoclast work a lot become larger but weaker
- Sx: Asymptomatic
- Dx: high ALP, X-ray (blade of glass)
- Tx: Bisphosphonates (slow osteoclast)
Osteomalacia (adult), Ricket (children)
- Cause: Vit D deficiency (soft bone)
- Sx: Bowing of long bone, Ricket - Fontanell closer slow, Growth retardation
- Dx: Low Vit D, X-ray (loose line)
- Tx: Vit D
Phenylketonuria
Cause/Sx/Dx/Tx
- Cause: autosomal recessive (deficiency of Phenylalanine hydroxylase)
- Dx: musty urine and oder
- Tx: life time phenylalanine diet (milk, egg, meat, chicken, aspartame (diet soda))
Colorectal cancer
Cause/Sx/Dx/Tx/Screening
- Cause: FAP (familial adenomatous polyposis)
- Sx: Bleeding, bowel obstruction (constipation)
- Dx: Colonoscopy
- Barium - apple core lesion
- CEA test high
- Tx: Surgical
- Screen: 50yo start Q10y, flex Q5y
- 1st degree relative >60y - 40y Q10y check
- 1st degree relative <60y - 40y Q5y
Pancreatic carcinoma
Cause/MC type/Sx/PE/Dx/Tx
- Cause: Smoking + >60y
- MC type: Adenocarcinoma ductal
- Sx: painless jaundice + weight loss
- PE
- Palpable nontender gallbladder (courvoisier sign)
- Trousseau’s syndrome - migratory thrombophlebitis
- Palpable left supraclavicular lymph node (Virchows node)
- Palpable nodule bulging into the umbilicus (Sister Mary Joseph sign)
- Dx: CT(1st), CA19-9
- Tx: whipple procedure
Hepatocellular carcinoma
Cause/Dx/Tx
- Cause: Chronic Hep B,C,D
- Dx: US, alpha fetoprotein
- Tx: Surgical remove
Gastric carcinoma
Cause/MC type/Sx/Dx/Tx
- Cause: H pylori
- MC type: Adenocarcinoma
- Sx: Weight loss, pain, bleeding
- PE
- Left supraclavicular (virchow)
- Left axillary (Irish)
- Periumbilical node (sister mary joseph’s node)
- Dx: Endoscopy w/ bx
- Tx: Surgical remove, chemo
Esophageal cancer
Cause/Sx/Dx/Tx
- Cause: continue GERD sx
- MC type: Adenocarcinoma (upper 1/3 part)
- Risk: Smoking, alcohol
- Sx: Weight loss, pain with solid food
- Dx: Endoscopy w/ bx
- Tx: Surgical remove, chemo
Vitamin deficiency
Vit A/B/C/D/K
Medication blocks vitamine absorption?
- Vit A
- Night vision blindness, bitot spot (keratin (rough) conjunctiva)
- Hypervit A - tetragenicity, papilledema, alopecia, HA
- Vit B
- B1 (thiamine) - MC ETOH
- Wernicke AGO - ataxia (gait blance broke), global confusion, opthalmoplegia (abnormal eye muscle)
- Korsakoff’s dementia - short term memory loss
- B2 (riboflavin)
- Oral (angular cheilitis), ocular, genital syndrome
- B3 (niacin)
- 3D (pellegra) - diarrhea, dementia, and dermatitis
- B6 (pyridoxine)
- Peripheral Neruopathy - INH
- B12 (cobalamin)
- Patient: Vegan, hx of gastrectomy (parietal cell), ETOH
- PE: pallor and glossitis
- Dx: MCV > 100, hypersegmented neutrophils, elevated homocysteine, elevated methylmalonic acid
- Tx: IM or oral Vit B12
- B1 (thiamine) - MC ETOH
- Vit C (ascorbic acid) - lack of citrus fruits and green vegetable
- Scurvy 3 H - hemorrage, hyperkeratosis, hematologic
- Vit D - lack of sun exposure
- Rickets, osteomalacia
- Vit K
- low coagulation factor leads to increased bleeding and PTT
PPI blocks vitamine absorption should separated each other
Refeeding syndrom
Cause/Lab/Tx
- Cause: Starvation lead hypophosphatemia and refeeding demand more phosphate -> severe hypophosphatemia
- Lab: HypoK, HypoMg
- Complication: HF or dysrhythmias
- Tx: slowly replenish
Acute Pancreatitis
Cause/Sx/Dx/Tx/Ranson’s criteria
- Cause: Gallstone (1st), ETOH (2nd)
- Sx: epigastric pain radiate to the back
- PE: Gery turner sign (left flank eccymosis), Cullen (umbilical eccymosis)
- Dx
- If billirubin is high - gallstone cause US (1st choice)
- If billirubin is not high - CT (initial)
- Lipase (best), amylase elevated
- Tx: IV fluid
- Ranson’s criteria
- Age 55<
- WBC 16000<
- LDH 350<
- AST 250<
- Glucose 200<
Chronic Pancreatitis
Cause/Triad/Dx/Tx
- Cause: ETOH
- Triad: Calcification, steatorrhea, DM
- Dx: X-ray (Calcification), Lipase and amylase NOT elevated
- Tx: Pancreatic enzyme replacement
Appendicitis
Cause/Sx/PE/Dx/Tx
- Cause: Fecalith
- Sx: pain start with periumbilically then moved to RLQ
- PE
- Rsoas sign - hip extension pain
- Obturator - knee flex and rotate pain
- Rovsing - LLQ push, pain RLQ
- Mcburney - RLQ pain
- Dx: US (1st), CT
- Tx: appendectomy
- Post op lab: Hypokalemia
Intussusception
Cause/Patient/Sx/Dx/Tx
- Cause: tumor, mechel’s diverticulum
- Patient: Children
- Sx: colicky abd pain (currant jelly like blood stool)
- Dx: US (target)
- Tx: Air contrast enema
Small bowel obstuction
Cause/Hx/Sx/Dx/Tx/
- Cause: adhesion
- Hx: surgery
- Sx: vomitting
- Dx: CT (best) X-ray (dilated bowel, air fluid level in step ladder pattern)
- Tx
- Nonstrangulated: NGT, bowel rest, IV fluid
- Strangulated: surgery
Meckel’s diverticulum
Rules of 2/Sx/Dx/Tx
- Rules of 2: 2 feet from ilocecal valve, 2 yo, 2 inch long, 2% population
- Sx: Painless rectal bleeding
- Dx: Meckel’s scan
- Tx: surgical if sx
Ogilvie syndrome
Cause/Dx/Tx
- Cause: Massive dilation w/o mechanical obstruction
- Dx: CT
- Tx: neostigmine