Dr. DeMonseserte Flashcards
what TE fistula is the most common?
type C
-esophageal atresia w/ a DISTAL TE fistula
-distal fistula -> abdomen distends (air in GI tract from lungs)
what do you do for child born with fistula or esophageal atresia?
get ECHO & renal US
esophageal atresia in infant
polyhydramnios in mother
hypertrophic pyloric stenosis
- thicken pyloric musculature -> outlet obstruction
- projectile NON-billous vomit
- palpable olive
- DOUBLE BUBBLE sign
Meckel’s Diverticulum
- contains gastric mucosa
- current jelly bleeding
- rule of 2’s -> 2% of population, 2 feet from ileocecal valve, 2 inches or younger, 2 years or younger, 2 different mucosae
Gastroschisis
- paraumbilical defect
- bowel protrudes NOT in sac
- elevated MSAFP
Omphalocele
- midline defect
- bowel contents contained within membrane
Hirschsprung disease
- aganglionic colon
- aut. dominant -> RET mutations
- empty rectal vault
- associated w/ Waardenburg and Downs
- Dx: rectal SUCTION biopsy
achalasia
- failure of LES to relax
- bird beak appearance
- nocturnal regurg and weight loss
- treat with Heller myotomy or per oral endoscopic myotomy
Ogilvie’s syndrome
-if cecal diameter >9cm -> emergency
what can bacteria do to folate & vit. B 12?
bacteria metabolized B12 and produce folate
how is glucose absorbed at brush border?
with Na+ via SGLT1
most common carbohydrate malabsorption disorder
lactose intolerance
-deficiency in lactase enzyme
medium chain TGs
-absorbed directly into portal bloodstream w/o the need for micelles
what do you see with fat malabsorption?
steatorrhea and fat soluble vit. deficiencies
what do you see with protein malabsorption?
edema, ascites, muscle atrophy
small intestinal bacterial overgrowth (SIBO)
- see bloating and diarrhea
- draw vit. B12 and folate levels -> bacteria eat B12 and produce folate
what happens if you resect terminal ileum?
won’t absorb bile salts
-cholestyramine only works up to 100cm of recection
Crohns disease (IBD)
- creeping fat
- terminal ileum most affected - can be ANY portion of GI tract
- transmural involvement
- cobblestoning mucosa
- ASCA Abs or C-bir1
- diagnosed with CTE + colonoscopy
- smoking makes worse
- granulomas
Ulcerative Colitis (IBD)
- ONLY involves colon
- PSC
- p-ANCA
- bloody diarrhea
- smoking helps
- crypt abscesses
type 1 peripheral arthritis from IBD
- paucyarticular
- associated w/ IBD activity
- LARGE joints
- other extra intestinal manifestations
- self limited
type 2 peripheral arthritis
- polyarticular
- independent of IBD
- SMALL joints
- no association w/ other extra intestinal manifestations
- chronic
ankylosing spondylitis
- HLA-B27 +
- bamboo spine
- Tx: anti-TNF
Primary Sclerosing Cholangitis
- inflammation/strictures of INTRA and EXTRAhepatic bile ducts
- associated with UC
- p-ANCA +
- associated with cholangiocarcinoma and colorectal carcinoma
- yearly colonoscopy after Dx
Celiac Disease
- immune response to gliadin
- Dermatitis Herpetiformis
- Dx: small bowel biopsies -> distal duodenum
- Tx: gluten free diet
- Anti-gliadin, anti-endomysial, anti-TTG
- HLA-DQ2, HLA-DQ8
- crypt hyperplasia, flattened villi
PUD
-due to H. pylori and NSAIDs
gastric ulcers
-post-prandial pain and weight loss
duodenal ulcers
- eating and antacids help with pain
- weight gain
1st line Treatment for H. pylori
-Clarithromycin (or Macrolide if already taken macrolide)
what do you do for ALL H. pylori gastric ulcers?
follow up EGD
what are you at risk for with H. pylori?
MALT lymphoma
infectious gastritis
- H. pylori most common bacteria
- CMV most common virus
stool osmotic gap
- GAP <50 -> SECRETORY diarrhea w/ more volume
- GAP >100 -> OSMOTIC diarrhea w/ less volume
290 - 2(stool [Na+] + [K+])
cholestryamine
- works up to 100cm resection of terminal ileum
- change to MCT diet w/ >100cm resection
extra intestinal manifestations of IBD
- peripheral arthritis
- axial arthritis
- AS
- sacroilitis
- Erythema nodosum
- pyoderma gangrenous
- sweet syndrome
most common causes of acute pancreatitis?
- GALLSTONES
2. EtOH
hypertriglyceridemia causing pancreatitis
- # 3 most common cause
- if fasting for >12 hours -> REPEAT TGs levels
drug induced pancreatitis
- 4th most common cause
- Azathioprine
Dx of acute pancreatitis
- epigastric pain radiating to back
- amylase/lipase (>3x ULN) - LIPASE MORE SPECIFIC
- imaging consistent w/ acute pancreatitis
neither lipase or amylase correlates w/ severity or outcomes
severe AP management
- aggressive fluids (>250-300 cc)
- ENTERAL NUTRITION 1ST -> TPN if intolerant
- EN prevents infection
Antibiotic coverage pancreatitis
- NOT recommended regardless of type or severity
- exception: infected necrosis -> start quinolones, carbapenems, metronidazole
walled off pancreatic necrosis (WON) - aka pancreatic pseudocyst
- fluid collection + necrosis
- Dx w/ MRI or CT
infected pancreatic necrosis (IPN) - aka abscess
- gas bubbles -> AIR in fluid collection on CT
- due to anaerobes (E. coli)
- Dx: +GM stain and FNA culture**
Pseudoaneurysm
- due to AP
- gastroduodenal or splenic artery -> GI bleed
Splanchnic venous thrombosis (splenic, SMV, portal)
- due to AP
- leads to gastric VARICES and GI BLEED
type I autoimmune pancreatitis (AIP)
- High IgG4
- histo: lymphoplasmacystic sclerosing pancreatitis (LPSP)
- older males
- systemic
type 2 autoimmune pancreatitis (AIP)
- idiopathic duct centric pancreatitis (IDCP)
- histo: GRANULOCYTE EPITH. LESION (GEL)
- younger males
- not systemic
Tx for autoimmune pancreatitis
-steroids (prednisone) -> Rituximab if steroid intolerant
chronic pancreatitis
- atrophy and fibrosis
- calcifications
- pancreatic insufficiency
- pseudocyst
- amylase and lipase may or may not be elevated
most common causes of chronic pancreatitis
- EtOH*** (Most common)
- SMOKING***
- strongest risk factor for progression from AP to CP - cystic fibrosis??
does recurrent AP mean you have CP???
NO
-but structural changes do
what mutation is seen in both hereditary pancreatitis and pancreatic cancer?
PRSS1
preferred initial test for chronic pancreatitis
CT -> look for calcifications
-contract enhanced CT (CECT)
indirect tests for CP/pancreatic insufficiency
- fecal fat quantification (72 hr.) -> best for steatorrhea
- FECAL ELASTASE (or chymotrypsin)
genes associated w/ chronic pancreatitis
-PRSS1 (most common), CFTR, SPINK1
therapy for CP
-PERT -> helps with pain and insufficiency
complications of CP
- pseudocyst - due to EtOH
- bile duct stricture
- venous thrombosis -> gastric varices
- pseudo aneurysms
- OSTEOPOROSIS -> vit. D malabsorption
- DM
surgery vs. endoscopy for CP
-surgery is SUPERIOR to endoscopy for PAIN relief
most common cause of pancreatic cancer?
DUCTAL ANDENOCARCINOMA
-poor prognosis
marker for pancreatic adenocarcinoma
CA 19-9
symptoms of pancreatic andenocarcinoma
- PAINLESS JAUNDICE (Courvoisier’s sign) w/ palpable GB
- tumor usually in HEAD of pancreas
Dx of pancreatic cancer
-multi-detector CT (MDCT) w/ contrast -> can’t detect tumors <1cm
Tx of pancreatic cancer
- WHIPPLE (pancreatico-duodenectomy)
- adjuvant chemo (5-FU, Gemcytabine, Folfirinox) + radiotherapy
genetic factors increasing pancreatic adenocarcinoma risk
- STK11 mut. (from Peutz-Jegher) has HIGHEST risk
- PRSS1 mut. (from hereditary pancreatitis) is MOST COMMON
what is used to measure whether pancreatic cancer is resectable or not?
EUS
look at tumors in DeMontesertes Chronic Pancreatitis/Cancer lecture
- serous cyst adenoma
- mucinous cystic neoplasm (MCN)
- branch duct IPMN
- main duct IPMN
serous cystadeoma
- benign, 60 y/o females
- body/tail, microcytic
- HONEYCOMB and CENTRAL SCAR
- CEA <5
- glycogen rich -> PAS+
Mucinous cystic neoplasm (MCN)
- malignant, females
- head/tail, macrocytic
- CEA >200
- produce mucin
- solitary
branch duct IPMN
- malignant
- most common**
- most frequent incidental pancreatic cyst**
- dilated branch duct
- CEA >200
- produce mucin
- multiple
- cysts >1 cm (10mm) communicating w/ pancreatic duct
- GNAS MUTATIONS
main duct IPMN
- malignant
- dilated main duct
- high risk of cancer if >10mm
what is very worrisome of pancreatic malignancy?
-PANCREATITIS
only resect if branch duct is >3cm in diameter or main duct is >1cm in diameter
cholelithiasis
-GB stone
choledolithiasis
-common bile duct stone
cholesterol stones
- MOST COMMON
- brown/yellow
- Lucent
pigment stones
- BLACK (opaque) -> Ca2+ bilirubinate due to hemolysis
- BROWN (Lucent) -> due to bacterial infection (B-glucoronidase) or parasites
- brown stones ONLY found in bile ducts and most common after cholecystectomy
acalculous cholecystitis
- ICU
- ischemia and GB stasis
Biliary colic
- GB contracts against stone in cystic duct
- RUQ pain
acute cholecystitis
- cystic duct obstruction
- Murphys sign
- US 1st (HIDA more sensitive)
- Tx: DRAINAGE or cholecystectomy
- start Abx for gram neg
what are the most common GB polyps?
cholesterol polyps - benign
choledocholelithiasis
- COMMON BILE DUCT stones
- imaging: EUS best -> detects small stones
- Tx: TAKE STONE AND GB OUT (even if asymptomatic)
- ERCP + sphincterotomy standard of care
acute cholangitis
- CBD stone + infection
- E. coli, Klebsiella, Enterococcus, Enterobacter, Pseudomonas, Clostridium
- CHARCOT TRIAD: fever, RUQ pain, jaundice
- Tx: Abx, URGENT DRAINAGE via ERCP
gallstone ileus/cholecystoenteric fistula
-GB forms fistula with bowel -> gallstone enters -> duodenal or gastric outlet obstruction obstruction (Bouvaret’s syndrome)
Mirizzi’s syndrome
- suspect GB CANCER and biliary fistulas*** (type 2-4 has fistulas)
- Tx: cholecystectomy or ERCP
Primary biliary cholangitis/cirrhosis (PBC)
- autoimmune -> T cell destruction of intralobular bile ducts
- risk of Sicca syndrome, CREST, Celiac, Scleroderma
- Sx: PRURITIS and XANTHOMAS
- anti-mitochondrial Abs + (AMA)
- for AMA neg PBC -> do liver biopsy to Dx
- Tx: ursodeoxycholic acid (UDCA)…Obeticholic acid or Fibrates if needed
- cholestyramine for pruritus
Primary sclerosing cholangitis (PSC)
- inflammation/stricturing of intra and extra hepatic ducts -> beads on string
- ULCERATIVE COLITIS
- p-ANCA +
- periductal fibrosis - “onion skin”
- high risk of colorectal cancer (yearly colonoscopy) and cholangiocarcinoma
- Dx: MRCP >ERCP
- Tx: liver transplant only
