CSI Exam 6 Flashcards
Divisions for foregut, midgut, hindgut
duodenum and 2/3 transverse colon
arteries for foregut, midgut, hindgut
celiac, sma, ima,
nervesf or foregut, midgut, hindgut
vagus, vagus, pelvic
ventral wall defect with abdominal contents spilling out to the right of the umbilicus and NOT covered by peritoneum
gastroschisis
what is the six 2s of meckels diverticulum
2 inches long 2 feet from ileocecal valve 2x more common in males presents before age 2 2 types of tissue present 2% of the population
What are the retroperitoneal organs
SAD PUCKER
Suprarenal glands
Aorta and IVC
Duodenum (parts 2-4)
Pancreas (except tail) Ureters Colon (ascending and descending) Kidneys Esophagus (Thoracic portion) Rectum
Diff between femoral triangle and femoral sheath
triangle has the nerve
sheath does not
What are the borders of hesselbachs (inguinal) triangle
- Inferior epigastric vessels
- Lateral border of
rectus abdominis - Inguinal Ligament
3 GI regulatory substances released from the SI
CCK, secretin, motilin
Symptom of tropical sprue
Megaloblastic anemia
Agent of whipple
Tropheryma whipplie
Whipples dz presentation
Foamy whipped cream in a CAN
cardiac
arthralgias
neurological
also weight loss
What is seen on Whipples lab test
PAS shows foamy macrophages containing G+ bact
whats strongly associated with smoking
Crohns
What do you check for in kid with TEF
V Vertebral Hemivertebrae A Anus imperforated C Congenital heart dz T Tracheoesophageal fistula E Esophageal atresia R Renal Horseshoe kidney L Limb Radial hypoplasia, atresia
how do gallstones usually present
asymptomatic mostly or pain to RUQ with radiation to R shoulder and ifrascapular area
what are the 2 gallstones made of
cholesterol
calcium bilirubinate
what are the tx for gallstones
NSAIDS
laprascopic cholecystectomy
Ursodoxycholic acid
when is laprascopic cholecystectomy indicated
symptomatic gallstones
or
Asymptomatic with porcelain gallbladder, stones > 3cm, or surgery/cardiac transplant
when does porcelain gallbladder occur
chronic cholecystitis
what usually causes but is not the only cause of acute cholecystitis
gallstones going to cystic duct
what are the two murphys signs and what are they for
chlecystitis
regular one with pain radiating on inspiration
sonographic murphys sign
how do you diagnose gallstones
ultrasound followed by HIDA if not convinced (hepatic iminodiacetic acid)
what does HIDA scan used for
cholecystitis
what is gangrene of the gallbladder
ischemia from vasoconstriction
what is the complication of cholecystitis
gangrene of the gallbladder
what is done if pt is not stable enough for cholecystectomy
cholestotomy drainage
what are the signs of chronic cyholecystitis
hydrops and strawberry appearance of gallbaldder
what should you suspect in progressing jaundice
gallbladder obstruction (choledocholithiasis and cholangitis) or primary sclerosing cholangitis
what presents with epigastric pain and jaundice
choledocholithiasis and cholangitis
how do you diagnose choledocholithiasis
ERCP
what is charcots triad and what is it used for
chills and fever, jaundice, frequent attacks of RUQ pain
choledocholithiasis and cholangitis
what is Reynolds pentad and what is it used for
Charcots triad of fever and chills, jaundice, and frequent RUQ pain + AMS and hypotension
choledocholithiasis and cholangitis
which is a biliary emergency
Reynolds pentad for choledocholithiasis and cholangitis
How do gallstones differ from bile duct stones
duct stones should be removed even when asymptomatic
when is cholecystectomy done during the same hospital stay
if the pt has a ductal stone with cholecystitis
what are biliary strictures associated with
surgery
what are the main complications of biliary stricture
cholangitis and biloma formation
what is the risk of ERCP
pancreatitis
what is ulcerative cholangitis associated with
primary sclerosing cholangitis
who is gallstones more common in
females
who is primary sclerosing cholangitis more common in
males
what is acute pancreatitis most commonly related to
gallstone or sever alcohol intake
which has pain to the back
acute pancreatitis
which is worse when laying flat
acute pancreatitis
what are the indicators of pancreatitis on laboratory testing
hyperglycemia, amylase lipase 3x normal, elevated WBC
what is the best enzyme to assess pancreatitis
lipase
what is ransons criteria used for
determines severity of acute alcoholic pancreatitis
what is seen on x ray of acute pancreatitis
sentinel loop and colon cutoff sign
what are sentinel loop and colon cutoff sign seen in
acute pancretitis
what imaging is used to diagnose pancreatitis
CT, ultrasound is no good b/c bowel gas
what are cullens sign and grey turners sign in and what do they indicate
pancreatitis
indicate pancreatic necrosis and higher mortality
what is used to treat mild panreatitis
rest, fluids, meperidine and maybe morphine for pain although it may cause sphincter of oddi contraction
what is used to treat severe panceatitis
IV fluids, calcium if hypocalcemic, feeding, carbapenems
what is the drug of choice for necrotizing panceatitis involving more than 30% of the pancreas
carbapenems
what are the complications of acute pancreatitis
renal insufficiency/ATN and pseudocyst formation (may progress to abscess)
what are the tx of pancreatitis complications
surgery if pseudocyst formation
necrosectomy
pseudocyst drainage alternative to surgery
what has calcifications of pancreas
chronic panccreatitis
what is characterized by steeatorrhea, weight loss, and intermittent epigastric pain in the LUQ
chronic pancreatitis
what is the main cause of chronic pancreatitis
chronic alcohol (80%)
what is the mnemonic for chronic pancreatitis and what is it used for
iGATOR for the predisposing factors
idiopathic Genetic Autoimmune Toxic metabolic Obstructive Recurrent acute pancreatitis (most common)
what is a common complication of chronic pancreatitis
diabetes
what may cause calcium deposition in the pancreas leading to chronic pancreatitis
hyperparathyroidism
what is the most sensitive test for chronic pancreatitis
ERCP
how do you treat chronic pancreatitis
avoid fatty food and alcohol
NSAIDS
steroids if autoimmune
when should surgery be considered in chronic pancreatitis
accompanying biliary condition
where is pseudocyst drainage used for
draining chronic pancreatitis into the GI
what are the red flags of constipation
hematochezia, weight loss, anemia, FOBT
what is the triad for hemolytic uremic syndrome
thrombocytopenia, hemolytic anemia, and acute kidney injury
when is HUS seen
diarrhea
what is beckds triad and when is it seen
hypotension, JVD, muffled heart sounds
Cardiac tamponade
what is pulsus paradoxus seen in and what is it
cardiac tamponade
SBP drop by 10 during inspiration
what are the more common agents that cause myocarditis
coxsackie B and trypanosome cruzii (chagas)
what is myocarditis often misdiagnosed as
CHF/ischemic heart dz
what do people with myocarditis develop
dilated cardiomyopathy
what is tachycardia out of proportion to fever and when is it seen
goes up for ever degree of fever
myocarditis
what are the biopsy indications for myocarditis
new onset CHF
failing CHF tx
monitor response of immunosuppression tx
deciding if pacemaker should be placed
what results in myocardial pallor from inflammatory cells
myocarditis
what is the only tx for myocarditis
transplant
what is fibrious thickening of the pericardium resulting in decreased diastolic filling
constrictive pericarditis
when should you do pericardiocentesis
effusion or if its purulent and you want to figure out the bacterial agent
when should biopsy a pericardial effusion
if it hasn’t improved after 3 weeks
what does a cardiac echo easily diagnose
pericardial effusion
radiates to left trapezius ridge
pericarditis
friction rub
pericarditis
which has a narrow pulse pressure from reduced stroke volume
hypovolemic shock
how do you differ hypovolemic shock and cardiogenic shock on cardiac echo
Hypovolemic: small LV due to poor filling but normal contractility
Cardiogenic: decreased LV contractility
what type of shock is cardiac tamponade
obstructive
what occurs in distributive shock
parasympathetic overflow resulting in bradycardia and vasodilation
what are the requirements for SIRS
2 of the following
temp over 100.4 or below 96.8
HR over 90
RR over 20 or PCO2 less than 32
WBC over 12 or below 4 or more than 10% bands
what is sepsis
SIRS + a source
what is septic shock
sepsis + hypotension
what trio indicates sepsis
shock + DIC + trauma
what is the pressor of chocie
NE
what are the markers for septic shock
lactate and procalcitonin
when do you use corticosteroids for shock
only when it is due to adrenal insufficiency where Na is low and K is high
what is the early goal directed therapy for and what is it
septic shock
maintain CVP of 8-12
MAP greater than 65
ScvO2 > 70
what are the tx for shock
intubation for respiratory failulre fluids pressors inotropes corticosteroidsif adrenal insufficiency abx if septic
what are the signs of CHD
tachypnea, sweating, feeding difficulty, fatigue
what CHDs are associated with what chromosomal problems
Down - AV canal and VSD
Turners - CoA
what are the two causes of differential cyanosis
PDA + pulmonary hypertension
PDA + Coarc
where does cardiac cyanosis occur
centrally
Which CHD’s cause a fixed split S2
ASD
Which CHDs cause a continuous murmur
PDA and BT shunt
What is another way of referring to L to R shunts and R to L shunts
L to R - Acyanotic HD
R to L - Cyanotic HD
what are the L to R defects
VSD, ASD, PDA, and AV canal
AV canal can be
whats an av canal
ASD and VSD
which defects result in pulmonary congestion
L to R shunts
R to L shunts that increase PBF
what are the R to L shunts
Increased PBF 1. Truncus arteriosus 2. TAPVR 3. Transposition of the great arteries Decreased PBF 1. Tetralogy of Fallot 2. Tricuspid atresia 3. Ebstein’s anomaly
what keeps PDA open
Prostaglandin E produced by the placenta
boot shaped heart
TOF
most common cyanotic congenital heart defect
transposition of the great artereis
what is required for life in TGA
2 levels of mixing
what is the most common defect associated with TGA
asd
what does pulmonary veins flowing away from the heart signify
total anomalous pulmonary venous return
snowman sign
TAPVR without obstruction
vertical vein
TAPVR
what does keeping pda open do
allows blood to go to the lungs (lower resistance path)
what defect accompanies a TAPVR
asd
what occurs in tricuspid atresia
RV doesn’t pump and LV pumps both circuits through VSD
baloon shaped heart
Ebstein’s anomaly
what occurs in ebstein’s anomaly
tricuspid valve is downwardly displaced and the pulmonary vavle is in the atria so the RV is pretty much a blind culdesac
whats more likely than a CHD in babies
sepsis
what is the steps in baby management
oxygen
dextrose for brain
echo/amp and gent/PGE
what is an obstructive lesion divided into
ductal dependent and non-ductal dependent
define a ductal dependent lesion
needs PDA or there will be 0 blood flow to a certain portion of the body
what is an interrupted aortic arch
ductal dependent obstructive lesion where right side of arch is not connected to heart. REQUIRES PGE
what is a hypoplastic left heart syndrome
ductal dependent obstructive lesion where the right side pumps into the pulmonic valve only. REQUIRES PGE
what will you find on PE in a person with a blalock taussig shunt
continuous murmur
when is the norwood procedure implemented
hypoplastic left heart syndrome
what is the 3 stages of the norwood procedure
- Blood from RV goes into AORTA then block taussig shunt lets it go into the pulmonary arteries
- Bidirectional glenn gets rid of BT shunt and SVC emptys straight into pulm artery
- Fontan circuit connects IVC to pulmonary arteries
Which stages of the norwood procedure have a murmur
1
in a newborn, what happens to systemic resistance
it increases!
which form of pericarditis is the worst
purulent
what are the three types of pericarditis
fibrinous, serous, purulent
dresslers syndrome
Pericarditis 2-10 weeks after MI
what is tx for dresslers
corticosteroids
bread and butter appearance
fibrinous pericarditis
viral infection causes what type of pericarditis
serous
how does pericarditis differ from regular chest pain
improves with position
most common bacterial agent of pericarditis
staph aureus
where do you listen for pericardial friction rub
LLSB or apex
what causes first EKG finding in pericarditis
subepicardial injury
normal pericarditis fluid amount?
acute effusion?
chronic?
15-50 mL
80 mL
1-2 L
how does borhaavs present
repeated emesis
who gets varices
alcoholics - cirrhosis - portal htn - esophageal varices
what is coffee ground emesis
vomit with partially digested blood
what are the signs of upper GI bleed
red vomit
coffee ground vomit
melena
hematochezia if it goes real fast
how does diverticulosis differ from itis
painless bleeding vs painful with no bleeding
what can an avm result in
lower gi bleed
is melena a upper or lower gi bleed
usually upper
is maroon stools upper or lower
lower
if a gi bleed stops is the pt fine
no. they don’t stop for no reason. probably just obstructed temporarily and its going to come rushin out
cutoff pt between upper and lower bleed
ligament of treitz
what labs do you do on a person with gi bleed
type and cross, cbc for H and H (should be low. may lagg), EKG for ischemic changes/stemi, BMP to see if BUN is elevated
when is BUN elevated
upper GI bleed b/c digested blood is a source of BUN
what do you give gi bleed pts on heparin? coumadin? TPA?
protamine
Vitamin K/FFP
aminocaproic acid
how do you say bleeding in stool
BRBPR
how do you order blood
P RBCs
what changes for each unit of blood
Hb up 1
Hct up 3
what is a med for upper GI bleed (PPI)
protonix
are upper gi bleeds serious
yes! they can die!
what are the invasive procedures for upper gi bleed
EGD
Radionucleotide
what are the invasived procedures for lower gi bleed
Tagged RBC scan
CT angiogram
what medication treats esophageal varices
Octreotide IV
what is the problem with diagnosing upper GI bleed with NG tube
It doesn’t reach duodenum
what are the abx for acute cholecystitis
A cephalosporin + metronidazole
Fluoroquinolone + metronidazole
Piperacillin/tazobactam
Carbapenem (imipenem, meropenem, ertapenem)
what is MRCP used for
identifying biliary strictures and primary sclerosing cholangitis
string of pearls on imaging
primary sclerosing cholangitis
who is at risk for primary sclerosing cholangitis
middle aged men
what puts you at increasd risk for cholangiocarcinoma
primary sclerosing cholangitis
what occurs in primary sclerosing cholangitis
alternating strictures and dilations
what are the tx for primmary sclerosing cholangitis
abx against gnr, balooning, ursodeoxycholic acid, stenting, transplant
what is an odd symptom of primary sclerosing cholangitis
pruritis
what can decrease prognosis in primary sclerosing cholangitis
dominant bile duct stricture
what is the acronym get smashed for
GET SMASHED is for causes of pancreatitis
GALLSTONES ETHANOL TRAUMA STEROIDS MUMPS AUTOIMMUNE SCORPION VENOM HYPOTHERMIA/HYPERLIPIDEMIA ERCP DRUGS - AZATHIOPRINE, THIAZIDES, SODIUM VALPROATE, TETRACYCLINES
How do steroids cause pancreatitis
increase blood sugar making the pancreas work more
what symptoms usually occur with acute pancreatitis aside from pain
nause and vomiting and also fever
what can precipitate an acute pancreatitis attack
heavy metal or alcohol consumption
what does elevated creatinine signify in acute pancreatitis
pancreatic necrosis
what increases mortality in acute pancreatitis
SIRS and sepsis
where is the air in sentinel loop
LUQ of SB
where is the air in colon cutoff sign
transverse colon
what is a complication of pancreatic pseudocysts
infxn and abscess formation
which has milder elevations in amylase lipase
chronic pancreatitis
why might choledocholithiasis elevate amylase lipase
secondary pacnreatitis
when do pancreatic pseudocysts occur
ACUTE pancreatitis
when do pancreatic calcifications occur
CHRONIC pancreatitis
what combines with alcohol to increase the risk of chronic pancreatitis
smoking
what will result when you remove the pancreas
diabetes and pancreatic insufficiency
what chronic pancreatitis has the best prognosis
best in patients with recurrent acute pancreatitis caused by stones or sphincter of Oddi stenosis
what does a midgut malrotation wind around
sma
what can malrotation lead to
volvulus or duodenal obstruction
ladds bands
midgut malrotation
what is volvulus
twisting intesting around mesentery
what volvulus is more common in children
midgut
which volvulus is more common in elderly
sigmoid
what has currant jelly stools
intussusception
what are the ventral wall defects
gastroschisis and omphalocele
how does gastroschisis differ from omphalocele
right of umbilicus
not covered by peritoneum
another name for the viteline duct
omphalomesenteric duct
what connects the midgut to the yolk sac
vitelline duct
what does meckels result from
persistent vitelline duct
whats the most common congenital anomaly of the GI tract
meckels
what does meckels typically present like
asymptomatic
if symptomatic, hematochezia in children is most common finding
May also cause intussusception and volvulus and pain
what is the most common finding of hirschprungs
failure to pass meconium in 48 hours
how do you treat hirschprungs
resection
what is the most common tracheoesophageal defect
fistula with atresia
how do you test for EA
NG tube failure to go down
what will a kid with trachesophageal disorder present like
during first meal choke
what are the risks to herniated tissue
incarceration - non reducible
strangulation - ischemia/necrosis
NAVEL acronym is for
femoral vasculature from outside to inward pointing to umbilicus
whats in the femoral triangle
NAV
whats in the femoral sheath
AV and femoral canal
which hernia is more likely to have strangulation or incarceration
femoral
who gets femoral hernias more
females
what forms the inguinal/hesselbachs triangle
rectus abdominus, inguinal lig, Inferior epigastric vessels
what vessels are used to distinguish direct and indirect hernias
inferior EPIGASTRICS
what does a direct hernia pass through and contain
superficial inguinal ring and is covered by external spermatic fascia
what does an indirect hernia pass through and contain
deep and superficial inguinal ring and is covered by all 3 spermatic fascia layers
who gets indirect hernias
infants
failure of processus vaginalis to close results in
indirect hernias
what cells release CCK
I cells
what cells secrete gastrin
s cells of duodenum
what does gastrin do
increases bicarb secretion from panc
what can stimulate motilin receptors
erythromycin
what is targed in celiacs
gliaden
what ffactors put you at risk for celiacs
northern european
HLA DQ2
what area is affected by celiac
distal duodenum and proximal jejunum
what does celiacs result in
malabsorption probs
what are the typical findings of celiacc
weight loss, diarrhea, muscle wasting
who does celaic present in
infants under 2
what is the atypical presentation of celiacs
dermatitis herpetiformis and iron defic anemia
what is dermatitis herpetiformis
cutaneous variant of celiacs
where is dermatitis herpetiformis found
externsor surfaces
what do peope with celiacs who refuse to stop gluten have an increased chance of getting
t cell lymphoma
what will lab findings show in celiacs
IgA anti transglutaminase
crypt hyperplasia
villous atrophy
intraepithelial lymphocytosis
where is lactase found
brush borderr
what does lactase do
lactase to glucose + galactose
hwo can you diagnose lactose intolerance
lactose hydrogen breath test
where is tropical sprue occur
carribean, india, asia
what does tropical sprue respond to
tetracyclines
what is likely the etiology of tropical sprue
infectious
what occurs in tropical sprue
malabsorption in all 3 quadrants of sb. especially of B12 and folate leading to megaloblastic anemia
what causes whipples
trophyerma whipplei
who gets whipples
middle aged white men
which dz has macrophages containin G+ bacilli
whipples
what has decreasd bowel sounds in the absence of obstruction
ileus
what precipitates ileus
hypokalemia, opiates, surgery
what shows distended gas filled loops of small and large intestine
ileus
what is the tx for ileus
bowel rest, cholinergics, electrolytes
what is the most comon cause of bowel obstructions
surgery leading to adhesions of small bowel
what does physical exam of bowel obstruction show
tympanic high pitched bowel sounds
what is the tx for bowel obstruxn
bowel rest, fluids, electrolytes
where does crohns occur
terminal ileum and colon usually but could be any portion of GI
what do a lot of pts with crohns have
perianal dz
what type of lesions occur in crohns vs ulcerative
skip vs continuous lesions
what is a unique feature of crohns that differs from ulcerative
rectal sparing
what is the most common presentation of crohns
ilitis or iliocolitis
what is strongly associated with crohns
smoking
extraintestinal manifestations of crohns vs ulcerative cholitis
episcleritis uveitis apthous stomatitis spondylitis (KIDNEY STONES and GALLSTONES in Crohns) (PRIMARY SCLEROSING CHOLANGITIS in ulcerative) erythema nodosum
string sign
crohns
cobblestone mucosa
crohns
transmural inflammation
crohns
noncaseating granulomas
crohns
what helps prevent ulcerative cholitis
smoking
appendectomy before 20 puts you at risk for
ulcerative colitis
inflammation of mucosa and submucosa
ulcerative colitis
lead pipe on x ray
ulcerative colitis
loss of haustra
ulcerative colitis
pseudopolyps
ulcerative colitis
what causes lead pipe appearance of ulcerative colitis on x ray
loss of haustra
crypt abscesses
ulcerative colitis
true diverticula vs false
contains all 3 gut layers
what is diverticulosis
lots of false diverticula in the colon
who gets diverticulosis
people over 60 who dont eat their fiber
how does diverticulosis usually present vs diverticulitis
asymptomatic
symptomatic
what has LLQ pain, fever, and leukocytosis
diverticulitis
how do you treat diverticulitis
abx
what is complications of diverticulitis
abscess and perforation
what is angiodysplasia
massive dilation of vessels in terminal ileum, cecum, and ascending colon
who is at risk for angidysplasia
peeps over 70 and pts with chronic renal failure
what are the 4 types of polyps and their characteristic features
hyperplastic
hamartomatous - peutz jeghers and juvenile polyposis
adenomatous - Neoplastic (mutations APC and KRAS)
serrated - sawtooth pattern. Neoplastic mutation BRAF
what type of polyps are in familial form
adenomatous. hence name
what is inheritance for familial adenomatous polyposis
AD mutation of APC gene
what structure is always involved in FAP
rectum
what does FAP present like
hundreds to thousands of colonic polyps and cancer
what do you have to do in pts with FAP
colectomy to prevent inevitable CRC
hamartomatous polyps throughout GI
peutz jeghers
pigmented macules on lips
peutz jeghers
genetic inheritance for peutz jeghers
AD
how does lynch syndrome differ from FAP
only a few adenomas form
what is the second leading cause of death from malignancy
CRC
what two polyps predispose to CRC
adenomatous and serrated
at what age do you get routine screening for CRC
50
what do people with CRC have
iron deficiency anemia
where doees CRC occur from most to least
rectosigmoid - ascending - descending
what causes hemorrhoids
dilation of the submucosal vascular tissue in the distal anal canal
what precipitates hemorrhoid symptoms
things that increase venous pressure
what is pectinate line
where endoderm meets ectoderm
what is the distinctions between pectinate line and hemorrhoids
above:
internal
painless
superior rectal artery (IMA)
below:
external
painful (rectal branch of pudendal N)
inferior rectal artery
what is an anal fissure
tear in anal mucosa BELOW the pectinate line
skin tags
anal fissure
what can cause anal fissure off midline
crohns
what typically indicates esophageal disorder
gerd, odynophagia, dysphagia
what type of disorders cause esophageal dysphagia
mechanical and motility
what pathogens do you ahve to consider in immunocompromised
HSV, CMV, candida, other protozoans/fungi
what kind of esophageal disorders have solids worse than liquids
mechanical
what kind of esophageal disorders have solids equally as bad as liquids
motility
what are the mechanical esophageal disorders
schatzki ring
peptic stricture
esophageal cancer
eosinophilic esophagitis
what are the motility esophageal disorders
achalasia
diffuse esophageal spasm
scleroderma
which esophageal disorders get progressively worse
peptic stricture, esophageal cancer, and achalasia
which esophageal disorder is in smokers and drinkers over 50
esophagel cancer
what often causes odynophagia
infectious causes
what does a person with an autoimmune condition mean
they are immunocompromised and susceptible to the weird pathogens
which forms row like lesions down the esophagus
candida
what diagnostic studies can you do for esophagus
EGD, barium swallow, esophageal manometry, pH recording
which esophageal diagnostic study should you do first
barium swallow unless you are sure its mechanical. then egd
what is the sphincter tone in pts with gerd
below 10
what structure is iinvolved with gerd
lower esophageal sphincter
when does gerd occur
within an hour after a meal
what is the purple pill challenge
ppi for 14 days in GERD pts
what is a complication of GERD
barrets esophagus and peptic stricture
what is a complication of barrets
cancer
what is barrets
change from squamous to columnar with goblet cells
what is the hallmark of gerd
orange, gastric type epithelium that extends from the stomach into the esophagus in a circumferential manner
where does peptic stricture occur
GE junction
what is required to reduce peptic stricture relapse
long term ppi use
what alleviates pts with peptic stritcutre
dilation from catheter
what are the tx for mild gerd
antacids, diet, H2 receptor blockers
what is the tx for troublesome and long term GERD
ppis
what is nissen fundoplication for and what happens
GERD
Wrap stomach around esophagus for external compression
who shouldn’t get nissen fundoplication
people who are doing fine on ppis
what is the most comon cause of odynophagia/dysphagia
infections
what does IgM and IgG do in pts with dysphagia
IgM - recent exposure
IgG - ever been exposed
what types of pills cause pill ulcer
NSAIDS, abx, potassium, iron, vit C
what are the problems associated with pill ulcer
esophagitis, hemorrhage, perforation
elevated transabdominal pressure can result in
mallory weiss
bulimics and young binge drinkers
mallory weiss
how do you treat mallory weiss
epineph or cautery
where does zenker diverticulum occur
pharngoesophageal jxn
what are complications of zenkers
aspiration pneumonia and lung abscesses
how do you treat zenkers
diverticulectomy
what are the symptoms of zenkers
bad breath (halitosis) and regurg of undigested food
projectile vomiting blood
esophageal varice rupture in chronic alcoholic
who has esophageal varices
chronic alcoholics - cirrhosis - portal htn
what are tx options for esophageal varices
abx prophylaxis, octreotide/somatostatin to stop splanchnic flow, Vit K, lactulose for encephalopathy, emergent endoscopy with baloon tamponade
what are the portal decompressive procedures
tips and a portosystemic shunt
which vessels are connected in tips and portosystemic shunt procedures
portal vein to hepatic vein
which portal decompressive procedure has a higher mortality
portosystemic shunt
what is achalasia
loss of peristalsis in the final 2/3 of esoph
when might pts lift their chins or throw shoulders back to get food down
achalasia
birds beak
achalasia
how do you confirm achalasia
manometry
how do you treat achalaasia and the side efx
botulinum toxin which reduces pressure on esophagus (relapses though)
myotomy (GERD though..)
when do you do myotomy + fundoplication
achalasia
dyspepsia
epigastric pain
causes of dyspepsia
indigestion, meds, anxiety, PUD
who should get EGD
ppl over 55
what should someone with dyspepsia get emirically
PPI
causes of gastritis
NSAIDS alcohol and stress
whats the problem with PPIs
favorable environment created for C DIF
benefit of enteral feeding
coats stomach lining
whats the best test for diagnosing gastritis
EGD
If gastritis is suspected but EGD is normal, what is it
H pylori beneath mucosal layer
wwhere does h pylori stay
beneath mucosal layer
what does h pylori present with
aasymptomatic mostly
PUD
what complication exists from H pylori infxn and can be treated with abx
MALT lymphoma
where does h pylori infxn occur
antrum
what are good tests for h pylori
urea breath test and fecal antigen immunoassay
what may alter urea breath test
ppis and abx
what is h pylori often resistant to
metronidazole and clarithromycin
what is the tx for h pylori
Triple: PPI Clarith Amox Metronid
Quad: PPI Bismuth subsalicyclate Tetracycline Metronid
what layers do ulcers penetrate
muscularis mucosa
what causes ulcers
hypersecretion of acid
where are ulcers mostly
antrum
who gets ulcers
smokers, drinkers, middle aged men
what are the two major causes of ulcer formation
h pylori and NSAIDS
what is a good alternative to NSAIDS to prevent ulcers
Coxib which spares Cox 1
where does h pylori most frequently cause ulcers
DUODENUM
if you don’t treat h pylori ulcers what happens
reoccur
which ulcers are never malignant
duodenal
In pt with GI pain/ulcers, if BP drops suddenly what happened
perforated
In ulcer pts, what drugs should be adminsitered
abx if they perfd or if from h pylori
PPIs or H2 blockers if they are on other meds
low pH and high gastrin =
zollinger ellison
where do neuroendocrine gastrin secreting tumors occur
gastrinoma triangle bounded by the porta hepatis, neck of the pancreas, and the third portion of the duodenum
what causes zollinger ellison
gastrin secreting neuroendocrine tumors
what is the problem with zollinger ellison tumors
high chance of malignancy 2/3
who should be sreened for zollinger ellison
peeps with ulcers refractor to tx and people with ulcers > 2cm
what is the diagnosis for zollinger ellison
elevated serum gastrin
what may alter serum gastrin levels
ppis and H2 so they must be halted
what happens in zollinger ellison when ppis are halted
gastrin spikes
elevated gastrin with elevated calcium makes you think
hyperparathyroid perhaps and MEN 1
how do you treat zollinger ellison
if mets to liver, treat hypersecretion symptoms
if not mets, try and resect
what are some findings of jaundice
odor, ascites, edema, muscle wasting, gynecomastia, spider nevi, clubbing, asterixis,
why do you get edema with jaundice often
hypoalbuminemia
what are the types of cholestasis
intrahepatic and extrahepatic
alk phosph is produed where
liver, bone, placenta
defective reuptake of bilirubin
rotors
defective hepatocyte excretion of bilirubin
dubin johnsons
when might you see hypoalbuminemia
chronic liver injury
when might you see elevated pt
acute or chronic liver injury
what is LDH used for
check if hemolysis may be occuring
what are the 3 types of jaundice causes and their findings
hepatocellular - elevated ALT AST
obstructive/cholestatic - elevated Alk phosph with GGTP
isolated - elevated bilirubin ONLY
once you determine it is obstructive/cholestatic jaundice, what do you have to determine
intrahepatic or extrahepatic
intrahepatic obstructive cholestasis may be from
cirrhosis or viruses
how do you determine intrahepatic vs extrahepatic obstructive/cholestatic jaundice
ultrasound shows extrahepatic
AST/ALT > 2 has what percent chance of being due to alcohol
90%
whats the AST ALT elevations in acute, ischemic, and chronic hepatitis
acute > 25
ischemic > 50
chronic > 2
when might hepatic encephalopathy occur and why
acute liver innjury from ammonia release
super high ALT AST indicate
acute viral hepatitis
ischemic hepatitis
toxic hepatitis (alcohol tylenol)
what does traveler info indicate for hepatitis
viral
which can be bilious or non bilious
duodenal atresia
what wil have no air in abdomen
esoph atresia
what is the development of trachea and esophagus
tracheoesophageal folds forming septum
what are causes of non bilious emesis
TEF, esoph web, scaphoid abdomen and herniation
double bubble sign
duodenal atresia from failure to recanalize
dudoenal atresia is associated with
trisomy 21
bowel sounds heard in chest
scaphoid abdomen with diaphragmatic hernia
palpable olive mass in upper abdomen
pyloric stenosis
how do you see pyoloric stenosis
US or barium
pyloric stenosis is more common in
males
string sign not crohns
pyloric stenosis
beaking not achalasia
pyloric stenosis
tx for pyloric stenosis
pyloromyotomy
Corkscrew appearance with barium
midgut malrotation with volvulus causing a partial obstruction
tx for midgut malrotation
emergency surgery
intussusception usually occurs when
within first 3 months of life
sausage shaped mass
intussusception
crescent sign
intussusception
tx/diagnosis for intussuscetion
air or baium enema
intussusception lead point
meckels
intussusception more common in
males
best diagnosis for meckels
technetium scan for acid producing gastric mucosa
meconeum ileus
cystic fibrosis
meconeum plug
hirschprung
lack of internal anal relaxation
hirschrpungs
rectal biopsy dx for lack of aganglionic cells
hirschrpungs
severe abdominal distension
hirschprungs
what presents with bilious vomiting a little later
volvulus
hirschprungs is associated with
trisomy 21
lethargy is unique in which pediatric GI condish
intussusception
why babies mroe prone to jaundice
NF not established
UDP not as active
more hemolysis
phototherapy treats
unconjugated
what is the limit for physiologic jaundice
> 15
breastfeeding causes what to occur
beta glucoronidase to unconjugate bilirubin
causes of unconjugated hyperbilirubinemia
hemolysis
G6PD
Sickle cell
blood mismatch
crigler nijjar complication
kernicterus?
what is the most common hereditary cause of hyperbilirubinemia
gilberts
what are obstructive/other causes of hyperbilirubinemia
biliary atresia, choledochal cysts, galactosemia, CMV, Wilsons, and CF
what does kernicterus result in
seizures and cerebral palsy
LFTs are usually normal until
severe dmg occurs. it has a reserv
PT is for what coag factors
2, 5, 7, 10
what do you gotta double check with high PT
Vit K
how is bilirubin levels measured
van den bergh rxn
niemann pick can cause
unconjugated hyperbilirubinemia
drugs that cause impaired bilirubin uptake
rifamping
drugs that induce intrahepatic cholestasis
Nitrofurantoin, oral contraceptives, anabolic steroids
what is the most common cause of ascites
cirrhosis
most sensitive test for ascites is
shifting dullness
overflow theory
ascites theory that portal htn causes fluid leak
underflow theory
ascites theory that too much vasodilation is causing neurohumoral retention of sodium and water
procedure of choice for ascites
paracentesis
hepatitis will show
necrosis and inflammation
acute vs chronic hepatitis
6 months
wilsons causes
hepatitis
tx for wilsons
zinc and copper chelation indefinitely
what lab test will be affected in wilsons
low serum ceruloplasmin and high urinary copper
Amanita phalloides
acute hepatitis
which hep virus is DNA
B
most common Us hepatitis cause
Hep A
most common cause of hep in the world
Hep C
Hep E is associated with
poor sanitation
how does hepatitis present
asymptomatic or with hepatomegaly
Hep B antigens/Ab are
Immunity should show anti HBsAB
Active infxn has +HbsAG and maybe HBeAG
which hep viruses are chronic
B C D
which hep virus causes cholestasis
A
which heps are self limited
A B E
which hep has no vaccine
C
Which heps have post expo prophylax
A and B
leading cause of acute liver failure in the US
acetaminophen overdose
aside from acetaminophen what other drugs are associated with toxin induced hepatitis
abx (augmentin), CNS agents, herbs
Most frequent cause of chronic hepatitis
NASH
which virus goes to chronic most often
C
methyldopa
chronoic hepatitis cause
Autoimmune hepatitis will show
antinuclear antibody (ANA) or anti-smooth muscle antibody (Anti-SMA)
Nonalcoholic fatty liver dz involves
Steatosis (fatty liver)
Nonalcoholic steatohepatitis (NASH)
Cirrhosis (secondary to NASH)
Obese
Nonalcoholic fatty liver dz
Most accurate way to diagnose nonalcoholic fatty liver dz
biopsy
tx for NASH
exercise
Alcoholic fatty liver dz leads to
Alcoholic pancreatitis
Cirrhosis
Steatosis
which liver probs are reversible? and not?
Fatty Liver and Alcoholic Hepatitis are reversible
Cirrhosis is not reversible
what is a cutaneous sign of alcoholic fatty liver dz
spider angioma
mallory bodies
alcoholic fatty liver dz
Maddrey’s discriminant function (DF)
the standard test to determine severity of liver injury
Maddreys discriminant function = TBIL + 4.6(PT prolongation)
how do you tx alcoholic fatty liver dz
stop alcohol
what occurs in cirrhosis
fibrous tissue replaces hepatocytes
Cirrhosis most often presents
asymptomatic
Cirrhosis may present with
varices and hemorrhoids and asterixis
abx may cause
nausea and vomiting
recent surgery increases risk of vomiting from
GI obstruction
4 main areas that cause vomiting
Vestibular system
Afferent vagal fibers from GI tract
Higher CNS centers/Amygdala
Chemoreceptor trigger zone
what centrally could cause vomiting
cerebellar hemorrhage
elevated BUN may suggest
dehydration
what are common anti emetics
setrons (serotonin inhibitors), corticosteroids, scopalamine, dopamine agonists
Most common cause of secondary constipation
Inadequate dietary fiber and water intake
how do opiods cause constipation
inhibit peristalsis
acute vs chronoic diarrhea
less than 2 weeks
grater than 4 weeks
smaller amts of stool
inflammatory diarrhea
enterohemorrhagic e coli may cause
inflammatory diarrhea or CMV
recently been taking abx
C dif
side effx of anticholinergics
toxic megacolon
symptoms within 1-6 hrs
preformed toxins
8-16 hours
make toxins
12-72 hours
weird stuff
undercooked meat
STEC
salmonella
eggs
fried rice
bacillus cerus
picnic
staph
cruise
noro
abx are contraindicated in what why
STEC increases risk of HUS
calculate osmotic gap of stool
290 – 2( stool NA + stool K)
gap > 125 means malabsorption (osmotic diarrhea)
clue to diagnosis of osmotic diarrhea
cures with fasting
common cause of osmotic diarrhea
malabsorption syndrome
normal osmotic gap
secretory diarrhea
steatorrhea
malabsorption from pancreatic insuffic
most common cause of chronic diarrhea in young adults
IBS
abdominal pain with diarrhea think
IBS
Which is most accurate for diagnosing cholecystitis
HIDA scan has higher accuracy than ultrasound diagnosing cholecystit
Hypocalcemia is an indication of a worse prognosis for
pancreatitis
