Abdominal & GI Disorders Flashcards
Risk factors for cholangiocarcinoma
- Biliary disease (primary biliary sclerosis, primary sclerosing cholangitis)
- Cholelithiasis, choledocholithiasis
- Cirrhosis
- Alcoholic liver disease
- T2DM
- Chronic pancreatitis
- Thyrotoxicosis
- Obesity
- Smoking
- Hep C
- Infection from liver fluke Clonorchis sinensis
Information on Clonorchis sinensis, liver fluke (transmission, cause, treatment)
- Transmitted by ingesting undercooked fish
- Causes pigmented gallstone formation and biliary tract infection
- Tx = praziquantel
Tx for cholangiocarcinoma
Surgical resection - though only for early stages
If cannot be managed surgically, prognosis is about 4 months and patients are treated with chemo and radiation to extend survival 1 year
What chemotoxicities does cisplatin commonly cause?
Nephrotoxicity and ototoxicity
What is the most common cause of acquired tracheoesophageal fistula formation in adults?
Esophageal or lung malignancy
Other causes of acquired tracheoesophageal fistula
- Less common malignancies - laryngeal, thyroid CA, lymphoma, thymic CA
- Prolonged ETT or tracheostomy
- Endoscopic intervention (e.g. endobronchial laser or cryotherapy)
- Infectious Disease: TB, actinomycosis, bacterial abscess
- Inflammatory Disease (e.g. rheumatoid arthritis)
- Trauma
- Caustic ingestion
- Esophageal stent
- Surgery (thoracic laryngectomy, esophagectomy, cardiac, mediastinal)
- Radiotherapy
- Chemo
Clinical presentation of tracheoesophageal fistula
- Coughing fits following food intake
- Recurrent purulent pneumonia
- Recurrent aspiration
- Unexplained malnutrition
Diagnostic tool for tracheoesophageal fistula
Esophagram or endoscopy
First imaging of choice in jaundice patient with concern for pancreatic cancer
Transabdominal US accurately detects biliary ductal dilation and greater than 95% sensitivity for pancreatic masses
Positive imaging can be followed with CT scan or MRI
What is Trousseau syndrome?
Recurrent, migratory, and superficial thrombophlebitis of multiple vessels in different locations over time. Strongly associated with pancreatic, gastric, and lung cancers
What is Courvoisier sign?
Palpable nontender gallbladder
Virchows node
Palpable left supraclavicular node (pancreatic and gastric cancers)
Sister Mary Joseph sign
Palpable nodule bulging into umbilicus (pancreatic and gastric cancers
Preferred triple therapy for H. pylori?
PPI, clarithromycin, amoxicillin
Predisposing conditions for rectal prolapse in children
- Increased intra-abdominal pressure (e.g. toilet training, prolonged coughing, significant vomiting, straining with stooling or urinating)
- Diarrheal disease
- Malnutrition
- Pelvic floor weakness
- Cystic fibrosis
Also consider: Ehlers-Danlos, Williams, congenital hypothyroidism, trauma (sexual abuse)
Management of rectal prolapse in children
Manual reduction and conservative tx (often resolves by 5 years of age)
Surgical repair only for frequent recurrences
Clinical symptoms of Vitamin B12 Deficiency
Common in vegan patients
Psychologic: Depression, irritability, psychosis
Hematologic: Anemia, pallor
Neurologic: Sensory and motor deficits (absent reflexes, paresthesias), dementia
GI symptoms: n/v/d, glossitis
Courvoisier sign
Enlarged, palpable, nontender gallbladder in presence of painless jaundice
- classically associated with biliary obstruction not caused by gallstones such as underlying GB or pancreatic malignancy
Main risk factor for cholangiocarcinoma
Primary sclerosing cholangitis
Boas sign
Scapular hyperesthesia
- most commonly associated with acute cholecystitis
Cullen sign/Grey Turner Sign
Superficial umbilical bruising and edema/Flank ecchymosis
- acute pancreatitis
Kehr sign
pain in shoulder caused by irritation of peritoneal cavity
Which perforation related to PUD classically will not show on x-ray?
posterior duodenal
Extraintestinal manifestations of Crohn’s
- Pyoderma gangrenosum
- Erythema nodosum
- Ankylosing spondylitis or sacroiliitis
- Arthritis, especially of large joints (MOST COMMON)
- Uveitis
- Liver disease
- Renal stones
Clinical features of Meckel Diverticulum
- True diverticula of all 3 layers of the small intestines
- Painless, can be large-volume, bleeding due to ulcer caused by heterotopic gastric tissue
- Obstruction caused by intussusception, volvulus, hernia
Tx of Meckel Diverticulum
Surgery
Most common predisposing factor for PUD in adults?
H. Pylori colonization
Clinical associations with primary anal fissures
- Posterior midline
- Local trauma
- Constipation or diarrhea
- Vaginal delivery
- Anal intercourse
Clinical association with secondary anal fissures
- Lateral
- Crohn disease
- Other granulomatous diseases
- Malignancy (leukemia)
- Communicable disease (HIV, TB, syphilis)
Management of anal fissures
- Topical nifedipine or nitroglycerin or lidocaine
- Stool softener
- Sitz bath
- Fiber
Risk factors to worsen hepatic encephalopathy
- Infection
- GI bleeding
- TIPS
- Constipation
- High-protein diet
- Zinc deficiency
- Benzodiazepines
- Diuretics
What technique is likely to increase success in reducing a hernia?
- Provide pain medication prior to attempted reduction; also applying ice for 20-30 minutes reduces intestinal swelling
- Gentle and steady pressure should be applied at the proximal end of the hernia sac nearest to the defect
- Trendelenburg positioning is optimal
Difference between indirect and direct hernia
Direct: protrudes directly through Hesselbach’s triangle and medial to inferior epigastric artery (IEA)
Indirect: (most common) protrudes through internal ring, lateral to IEA
Tx for carcinoid syndrome
Octreotide - majority of carcinoid tumors have somatostatin receptors which, when blocked, will inhibit the release of hormone
What newer medication has been approved for treatment of carcinoid syndrome associated diarrhea?
Telotristat - oral tryptophan hydroxylase inhibitor (this converts tryptophan to serotonin, so decreases serotonin levels)
Most common cause of pruritus ani in the pediatric patient and adult patient
Pediatric: Pinworms (enterobius vermicularis)
Adult: presence of feces on perianal skin
Tx for pinworms
Albendazole or mebendazole or pyrantel pamoate and repeated dose in 2 weeks
All family members need to be treated if one person is diagnosed
What is the most common cause of delayed aortoenteric fistula after graft repair?
Graft infection (manifested by low-grade fever and abdominal and back pain) commonly precedes aortoenteric fistula
Ranson criteria
At admission
- age >55 yrs
- WBCs > 16,000
- Glucose >200
- LDH >350
- AST >250
48 hours after admission
- HCT fall >10%
- BUN rise >5
- Ca <8
- PO2 <60
- Base deficit >4
- Fluid sequestration >6L
What are two common causes of viral pancreatitis?
Mumps and coxsackie B
Dx of SBP due to peritoneal dialysis
Two of the following:
- Abdominal pain or cloudy dialysate
- Peritoneal fluid >/= 100 WBCs/mm3 with 50% PMNs
- Positive culture
Tx of SBP due to peritoneal dialysis
Vanc and cefepime
Which medication may reduce renal failure and hospital mortality in patients with SBP?
Albumin
What is the pathophysiology of ibuprofen induced PUD?
Prostaglandins enhance mucosal blood flow to assist in secretion of mucus and bicarb in the gut - NSAIDs inhibit prostaglandin -> decreased mucosal blood flow
Gold standard to diagnose peptic ulcer disease
Visualization with upper GI endoscopy
What are balanitis and balanoposithitis?
Balanitis: Inflammation of glans penis
Balanoposithitis: Inflammation of distal foreskin (only in uncircumcised)
Most common cause of balanitis/balanoposthitis and other causes
Most common: Candida infection
Others: poor hygiene, bacterial infection, STI, dermatological condition
What is circinate balanitis?
Small, shallow, painless, ulcerative lesions on the glans penis associated with reactive arthritis
What liver disease is irreversible?
Laennec cirrhosis - diffuse process involving entire lobule of the liver usually related to chronic alcohol consumption
Is hepatic steatosis reversible?
Yes. It is the first phase of alcoholic liver disease and resolves after 4-6 weeks with abstinence from alcohol
Foreign body management table
Q818831
Most common site of obstruction in esophageal foreign bodies
C6>T4>T11
What type of necrosis can button batteries lead to?
Liquefaction necrosis
What is the blue dot sign?
Blue dot seen through scrotal skin -> pathognomonic for torsion of appendix testis or epididymis
Nontraumatic intramural duodenal hematomas are most commonly attributed to what condition?
Coagulation abnormalities
Mechanism of ischemic colitis? What areas of colon does it affect?
Caused by a global low-flow state such as heart failure, myocardial infarction, sepsis, hemorrhage (unlike embolic phenomenon in mesenteric ischemia)
Superior and inferior mesenteric artery watershed area (splenic flexure)
Inferior mesenteric and hypogastric artery watershed area (rectosigmoid junction)
Tx of amebiasis
Metronidazole followed by paromomycin
Tx for pinworms
Mebendazole, albendazole or pyrantel with two doses 2 weeks apart. Treat all household members
What is Courvoisier sign?
Nontender but palpable distended gallbladder
What is Trousseau syndrome?
Migratory thrombophlebitis; strong association with adenocarcinoma of pancreas and lung
What is Virchows node?
Palpable left supraclavicular lymph node; could be associated with pancreatic cancer
What is Sister Mary Joseph sign?
Palpable nodule bulging into umbilicus; could be associated with pancreatic cancer
Causes of SBO
- Extramural: adhesion (most common), Hernia, Neoplasm, Abscess/phlegmon
- Mural: volvulus, neoplasm, crohn disease, radiation enteritis
What are borborygmi?
Noises made by fluid and gas moving through the intestines
Tx for giardiasis
Metronidazole 250mg TID for seven days
Most common cause of splenic infarction (and other causes)
Cardiogenic emboli
- Hematologic malignancy
- Autoimmune diseases (antiphospholipid syndrome)
- Vasospasm from stimulant drug use
- Sickle cell anemia
- Infective endocarditis
Tx for splenic infarct
- Mild or uncomplicated -> analgesia
- Some with anticoagulation -> heparin
- Complete infarction or complications (e.g. abscess, sepsis) -> splenectomy
Splenic artery is a branch of which vessel?
Celiac artery
Disease processes that can precipitate toxic megacolon?
- IBD (most common)
- Pseudomembranous colitis
- CMV colitis
- Bacterial colitis
Tx for toxic megacolon
- IVF
- Abx
- IV steroids (if IBD related)
- Emergent surgical consult
What is Boas sign?
Hyperaesthesia (increased or altered sensitivity) below right scapula
Seen in acute cholecystitis
Stepwise management of GIB (hematemesis)
- Hemodynamic resuscitation
- Medical management with octreotide, ceftriaxone
- Balloon tamponade device
- Endoscopy with banding, sclerotherapy
- IR-guided left gastric vein embolization or TIPS procedure
Perforation of what GI structure is associated with the highest mortality?
Esophagus
Where in the esophagus do most iatrogenic injuries occur?
Pharyngoesophageal junction because the wall is the thinnest in this area
Classic triad of HUS
- Hemolytic anemia
- Thrombocytopenia
- AKI
Mechanism for hepatorenal syndrome
Arterial vasodilation in the splanchnic circulation through local nitric oxide release in reaction to shear stress caused by portal hypertension
Vasodilation leads to decreased systemic vascular resistance and hypotension and activates renin-angiotensin-aldosterone system
Leads to intense renal vasoconstriction and increased sympathetic tone
Decreased MAP and renal vasoconstriction leads to decreased GFR and kidney injury
Lab values of hepatorenal syndrome
Progressive rise in Cr Often normal urine sediment No or minimal proteinuria Very low rate of sodium excretion (Urine Na < 10) Oliguria (late)
What pressure is considered intra-abdominal hypertension and what pressure is abdominal compartment syndrome?
HTN: Sustained or repeated pressure >12 mm Hg
Compartment Syndrome: Sustained > 20 mm Hg associated with new organ dysfunction or failure
Actions that can help reduce falsely elevated abdominal pressures (especially when measured indirectly by bladder pressure using foley catheter)
- Keeping patient supine (reverse T where head is up places extra pressure on bladder)
- Sedating and paralyzing patient
- Avoiding instilling excessively large volumes into foley balloon
Etiology and risk factors for abdominal compartment syndrome
- Large volume resuscitation 2/2 trauma, medical illness, post-surgicas
- Burns
- Liver transplantation
- Abdominal conditions (massive ascites, hemorrhage)
- Retroperitoneal conditions (AAA rupture, pelvic fx, pancreatitis)
Management of abdominal compartment syndrome
- Ultimately - laparotomy
- In the meantime, diuresis, pharmaceutical paralysis and sedation, stomach and bowel decompression, dialysis
What causes secondary abdominal compartment syndrome?
Visceral, abdominal wall, and retroperitoneal edema and ascites induced by resuscitation of shock
What is the most common endocrine complication in chronic pancreatitis?
Glucose intolerance
Indirect or direct inguinal hernias have higher risk of strangulation?
Indirect
Plain film findings in necrotizing enterocolitis
Signs of an ileus or obstruction early on
Pneumatosis intestinalis and portal venous gas developing later
Management of NEC
- NPO
- Place NG tube for gastric decompression
- Aggressive IV hydration
- Broad spectrum abx
- Surgical consultation
Therapy for H. Pylori
Quadruple (recent macrolide use or living in areas with local clarithromycin resistance rates >15% or triple therapy eradication rates <85%)
- Bismuth
- Metronidazole
- Tetracycline
- Omeprazole
Triple Therapy
- Omeprazole
- Clarithromycin
- Amoxicillin (or metronidazole if pcn allergy)
Patients with TE fistula are at higher risk for which type of cancer?
Esophageal cancer due to Barrett esophagitis
Most common type of hernia in women?
Indirect inguinal hernias
