gastro Flashcards
hcl and pepsin
hcl: secreted by pareital cells: dissolves food, activates pepsin, stimulates release of other digetstive enzymes, , kills harmful bacteria i food
pepsin: digests proteins into small peptiedes.
Parietal cells are stimulanted by 3 hormones
gastrin: stimulates stomach acid secretion and motility
histamine: in response to gastrin- THIS STIMULATES THE PARIETAL CELLS TO SECRETE HCL
acetylcholine: stimulates parietal cells to secretes hydrochloric acid
somatastatni
inbhits secretion of gastri, insulin, glucagon, pancreatic enzymes
USED in ACROMEG, gigantism- OCREOTID- somatostatin ANALOG!
duodenum
secretin: inhibits parietal cell gastric acid production- causes pancreas to relase bicarb
cck: stimulates panc release of digestive enzymes
pancreas
exo : bicarb, protease, amylase, lipase
endocrine: insulin, glucagon, somatostatin
egd
TOC for mallory-weiss, PUD, malignancy suspection
upper GI SERIES (barium swallow, esophagram)
acute crohs disease: TOC is UGI Series with small bowel follow through
BARinUM enema (lower GI series)
not used if bowel perforation is suspected
contraindicated in acute ulcerative colitis- may cause toxic megacolon
esophageal manometry
achalasia, nutcracker esophagus
esophagitis
GERD MC cause-
infectous in immmunocomp (candida, CMV, HSV)
upper endoscopy
infectious esophagitis
odynophagia!!
candida: yellow-white plaques linear- po fluconoazole
cmv: large superficial shallow ulcers ganciclovir
HSV: SMALL DEEP ULCERS: acyclovir
pill induced esophagitis
MC seen with NSAIDS, bisphosphonates
GERD
TRANSIENT RELAXATION OF THE LES!!!
incompetent lower esophageal sphincter
heart burn, increased with supine position, dysphagia, regurg, cough at night, noncardiac chest pain
endoscopy- used FIRST, esophageal manometry,
gold standard: 24 h ambulatory ph monitorig
achalasia
LOSS OF AUERBACH’s plexus: leads to INCREASED LES pressure
FAILURE OF LES relaxxation- tone of LES is increased- obstruction and lack of persitalsis
dysphagia to BOTH SOLIDS AND LIQUIDS
esophageal manometry : shows increased les pressure
double contrast esophagram: bird’s beak appearance
management: decrease LES pressure: CCB, botulinum toxin, NITRATES, CCB
diffuse esophageal spasms
stabbling, chest pain worse with hot or cold liquids/foods
esophagram- corckscrew
zenker’s
pharygoesophageal pouch- dysphagia
boerhaave syndrome
full thickness rupture of the DISTAL esophagus
repeated, forceful vomiting causes this
chest pain worse with deep breathing and swallow
crepitus due to pneumomediastium
contrast esophagram: shows +leakage- DOC
mallory-weiss syndrome
longitutidnal mucosal lacerations @ gastroeesophageal junction- happens after vomiting a lot- hydrophobia-
upper endoscopy
supportive
esophageal webs and rings
plummer vinson syndrome: dysphagia, esophageal webs and IDA:
barium esophagram: DOC
esophageal varices
PORTAL vein htn
dilation of the gastroesophageal collateral submucosal veins
CIRRHOS MC
upper GI bleed- hematemesis, melena, hematochezia
endoscopic ligation
OCREOTIDE: vasoconstrcition of portal venous flow
balloon tamponande
surgical
PREVENTION:
BB: non selective like propranolol or nadolol - reduces the pressure
isosorbide: long acting nitrate
esophageal neoplasm
squamous: upper 1/3 due to tobacco/etoh use
adenocarcinoma: MC in US: lower 1/3 - GERD–barette’s
dysphagia to solid first and then fluids
weight loss, chest pain
upper endoscopy with biopsy
gastritis
h. pylori- mc
nsaids/aspirin: 2nd
acute stress
ostly asymptomatic
epigastric pain
endoscopy gold standard
h pylori neg: ppi, h2 blocker, antacids, sucralfate
PUD
h pylori: MC cause
nsaids: 2nd mc
suspect GI malig (ZEs, gastirc cancer) in nonhealing GU
epigastric pain- burning hunger like, worse at night
RELief with FOOD: associated with DU, worse before meals is Duodenal
1-2 hours after meal- pain is GASTRIC ULCER
pud MC cause of upper GI bleed
endoscopy
upper GI
endoscopy with biopsy: gold standard to diagnose H pylori
+rapid urease test,
+urea breath test: if endoscopy can’t be done- used to confirm erdication
stool antigen: useful for diagnosis, or confirm eradication
serological antibodies: only to confirm infection- not for eradication confirmation
complications of pud
BLEEDING
PERFORMATION- rebound tenderness, rigit abdomen
penetration: pain goes to the back
obstruction: vomiting
tX of h pyori
clarithryo, amoxi, ppi, : CAP
metro if pcn allergy
proton pump inhibitors
prazoles- blocks proton pump of parietal cells- reduces acid secretiions
se: b12 deficiency
antacids
neutralize acid, prevents conversion of pepsinogen to pepsin
bismuth
antibacterial and cytoprotective
se : darkening of tongue and stool, constipation
sucralfate
cytoprotective
zollinger-ellison syndrome
gastrin secreting neuroendorcrine tumors leads to pud
MC in duodenal wall
refractory ulcers, diarrhea
increased fasting gastrin level: bEST screen test
secretin test: increased gastrin release with secretin seen in gastrinomas- normally- gastrin release inhibited by secretin
gastric carcinoma
mc is adenocarcinoma h pylori is a huge risk factor, salted, cured, smoked , pickled foods with nitrtes also risk factors dyspepsia, weight loss, early satiety supraclavicular LN: virchow's umbilical ln: sister mary josephs' node upper endo with biopsy
jaundice
bilirubin deposition- occurs when bili is more than 2.5
dublin johnson syndrome
hereditary conjugated hyperbili
DUBIN, DIRECT, DARK LIVER- ALL D
none needed for tx
gilbert’s
hereditary unconjugated INDIRECT hyperbili-
can’t convert from indirect to direct- reduced UGT activity
transient episodes of jaundice during periods of stress, fasting, etoh
normal LFTs
none needed for tx
etoh hepatitits
AST is moe than AST
S: SCOTCH
ETOH causes direct mitochondrial injury- increases AST
viral/toxic/inflammatory
ALT is more than AST
L for liver
AST & ALT more than 1000 - acute viral hep
biliary obstruction
increased alk phos with GGT
GGT= biliary injury
autoimmune hep
ALT more than 10000, +ANA, +smooth muscle ABX, IGG increased
ultrasound is toc for
cholelithiasis
acute cholangitis
charcot traid of fRever, RUQ pain and jaundice
mc reason: E.coli!!!
ultrasound first ordered
ERCP- diag test of CHOICE
pentad: _shock and altered mental statis
icreased alk phos with increased GGT, increased bili
ABX : ceftriaxone and metro or cipro plus metro,
ERCP
choelecystitis
E.coli mc
fever, murphys sign, BOAS sing: pain to right shoulder- prhrenic nerve irritation
ultrasound
hida scan: gold standard
NPO, iv fluids, abx: (CEFtriaxone and metro), cholecystectomy
chronic chole
strawberry GB, porcelain GB (premalig condition)
acute hepatic failure
ASTERixiS: flapping tremor of hand with wrist extension
MC: ACetaminophen
increased ammonia, increased pt/INR
lactulose: treatment- neutralizes ammonia
liver transplant: def treatment
reye syndrome: MC in children with aspirin use during VIRAL infections
hep a
feco -oral, international travel spiking fever jaundice igM hav AB self limiting
hep c
hcv rna is more sensitive than hcv antibody
iv drug users
interferon or ribavirin- tx
hep B
hbsAG: evidence of hbv infection- establishes infection and infectivity
surface antibody: recovery or vacination
core antibody: igM: acute infection, IGG: chronic or resolved
envelope antigation: increased infectivity, viral replication
supportive tx, chronic: alphainterferon 2b
hep b vaccine
0,1 and 6 months
dont give if allergic to baker’s yeast
budd-chiari syndome
hepatic venous outflow obstruction- leads to portal htn and cirrhosis
hepatic vein thrombiss: MC reason, or heaptic vein or inferior vena cava occlusion
ascites, hepatomeg, ruq abd pain
screen with ultrasound
tx: management of shutns
hepatocellular carcinoma
mostly due to METS from lung or BREAST
utlrasound, increased alpha fetoprotein
cirrhosis
irreversible liver fibrosis with nodular regeneration
ascites, gynecomastia (unable to metabolize estrogen), spider angioma, palmar erythema,
hepatic enceph, esophageal varcies,
def management: liver transplant
pbc- primary biliary cirrhosis
AUTOIMMune of
INTRAHEPATIC MSALL BILE DUCTS!
RUQ discomfort, hepatomeg, jaundice, pruritis, FATIGUE (most common first)
increased ALP with increased GGT
ANTIMITOCHONDIRLA ANTIBODY!!
liver biopsy-def
tx: ursodeoxycholic acid, cholestryamine for pruritis
PSC primary sclerosing cholangitis
intrahep and extrahep ducts fibrosis INFLMAATORY bowel disease: ULCERATIVE COLITIS MEN alp with ggt increased, +P-ANCA! ERCP- gold standard liver transplant!! ef
wilson’s
copper accumulation in liver, brain, kidney , cornea
kayser-fleischer rings- brown pigment in the cornea
decreased ceruloplasmin, increased urinary copper secretion
tx: D-penicillamine, zinct
acute panc
intracellular activation of pancreatic enzymes- autodigestion of pancreas
epigastric constant boring - radiating tobank, relieved withl leaning forward
cullen- periumbilical
grey- flank ecchymosis
lipase increased, amylase, ALT, hypocalcemia!!!!
abd ct: diag test
_Sentinel loop: localized ileus
supprtove: NPO, IV, abx not used
meperidine for pain
ranson’s
gulcose, age, ldh, ast, wbc
chronic panc
etoh abuse,
calcification, steattorhea, DM!!!
calcified pancrease- amylase/lipase not elevated
tx: oral pancreatic enzymes replacement
panc carcinoma
smoking!!
adnocarcinma- mostly head of pancrease
abd pain, PAinleSS JAUNDICE!!!, weight loss, pruritis,
courvoisier’s sign/ : palpable, nontender, distended gallbladded- with juandice
CT SCAN
whipple procedure
small bowel obstruction
mostly after surgery
cramping abd distention, vomiting, obstipation
high pitched tinkles on auscultation, dilated bowel loops
non strangulated: NPO, IV fluids, bowel decom
strangulated: surgical
celiac
loss of villi- impareid fat absorption malabsoprtipon, diarrhea, dermatitis herpetiformis endomysial IGA ab and transglutaminase ABx: small bowel biopsy: msost def avoide wheat, rye barley
diverticulitis
cipo or bactrim +metronidazole
diverticulosis: MC cause of acute lower GI bleed
volvulus
mc sigmoid- twisting of bowel- endoscopic decom
appendicitis
rovsing: RLQ pain with LLQ palpation
obturator: internal and external hip rotation with flexed knee: RLQ pain
psoas: RLQ with right hip flexio and etension- rasise leg against resistance
mcburney’s: anterior superior illiac spine and navel- 1/3 distance in between them pain
IBS
abd pain at least once day/week in the last 3 months with change in stool freq, change in stool form, related to defecation
stop smoking, low fat food, loperamide for diarrhea (anticholinergics, spasm), use laxatives if needed for consti
chronic mesenteric ischemia
atheroscelerosis reason
fabd pain after meals
acute mesenteric ischemia
mc due to occlusion: EMBOLUS, thrombus
severe abd pain out of proportion to physical
angiogram def
surfical revas
Ulcerative colitis
begins in rectum- contigious spread, rectum always involved, LLAQ mc, tensesmus, bloody diarrhea with mucus, hematochezia, PSC associated, colon cancer, toxic megacolon, SMOKING DECREASES RISK
stovepipe isign- loss of huastral markings!
+p- anca
surgery is curative
croh’s
mouth to anus mc: terminal ileum- RLQ pain granulomas!! B12 deficience skip lesions- cobblestone string sign in barium flow- transmural inflammation surgery does not cure
during acute disease
corh’s: upper GI with small bowel
uc: flex sigmoidoscopy TOC
management
aminosalicylates—> corticosteroids—>immune modifying agents
5sa- aminosalycisc acid: mesalamine, sulfasalazine: best for maintenance
corticosteroids: rapid acting for acute flares only
immune modifying: azathioprine, methotrexate
anti-tnf agents: infliximab, adalimumab
adenomatous colon polyps
tubular- nonpedunculated- mc and least risk)
tubulovillous; intermediate risk
villous : highest risk of becoming cancerous
colorectal cancer
3rd mc cause of cancer-related death in us
MC site of metastatic spread is the LIVER!!
adenocarcinoma!
RISK FACTORS: genetics: familial adenomatous polyposis: 100% develop cancer- prophylactic colectomy
lynch syndrome- 40% risk - as well as endometrial, ovaria, small intestine, brain and skin-
peutz jehger’s: hyperpig of lips, oral mcusa, hands, polyps
MC CAUSE OF LARGE BOWEL OBSTRUCTION IN ADULTS!!
colonoscopy, barium enema (apple core), CEA
right side cancer: tends to bleed and cause diarrhea
left side: bowel obstruction and presents later
colonoscopy every 10 year from 50-75,
flex sigmoid: every 5 years along with fecal occult every 3 years
or…high sesntive fecal occult blood testing annually
lynch/fap
lynch: screen @ 20-25 with colonoscopy
fap: initiate at 10-12 with flex sig
indirect inguinal
prodrudes at the internal inguinal ring- lateral to inferior epigastric atery- REACHES SCROTUM
mc overall type of hernia
direct inguinal
MEDIAL to inferior epigastric vessel - DOES NOT REACH SCROTUM
internal hemorrhoids
bright red blood- not in pain, hematochezia
external hemorrhoids
perianal pain- aggravated with defecation
anorectal fistulas and abscess
mc in posterior rectal wwall- I AND D –warm water cleansing, analgesics, SITZ baths, high fiber diet
anal fissures
painful linear tear/ crack
constipation,
POSTERIOR MIDLINE- MOST COMMON
phenylketonuria
accumulation of phenylanlanine- normally screened at 24 weeks gestation
vomiting, mental delays, blonde,blue eyed with fair skin
can’t eat diet with it.: aspartame, legumes, milk, cheese, nutes, fish, chicken, metas, eggs= can’t eat that!!
vitamin A
night blindness,
vitamin C
hyperkaratotiss, hemorrhage, impaired wound healing, incresed bleeding time!
vitamin D
softening of boones- rickets in children- bowing deformities
osteomalacia: in adults
tx: vitamin D
vitamin B1 def
alcoholics
beriberi: dry:nervous system changes
beriberi: wet: high output heart fialure, dilated cardiomyopathy
WERNICKe’s enceph: ataxia, global confusion, opthalmoplegia
korsakoff’s dementia: memorry loss, confabulation
b2 deficiency
riboflavin- magenta colored tongue
niacine (b3 deficienc)- due to high corn in diet
DIARRHEA
DEMENTIA
DERMATITIS
b6 def
INH, alcoholic
peripheral neuropathy
b12 deficiency
animal food is primary source- absorbed in terminal illeum
strict vegans, pernicious anemia- schilling test, etoh
neruo symptoms, macrocytic anemia with hyperseg neutrophils
ondansetron
blocks seratonin receptors both peripherally and centrally
dopamine blockers
prochlorperazine, promethazine, metoclopramide:
BLOCKS CNS dopamine receptors!!
QT prolongation
extrapyraidal syndrome : rigitidty, bradykinesea, tremor, akathesia (restless)
norovirus
most overal cause of Gastroenteritis in US
enterotxin
non-invasive- vomiting, watery, voluminous diarrhea, no fecal WBC or blood
staph: 6 hours- dairy products, mayo, meats, eggs- self limits
bacilius ceres: fried rice- 1-6 hours, vomiting, diarrhea
cholera: poor santiation and overcrwoding- copious watery diarrhea- rice water stools- grey, rapid dehydration- supportive tx, ABX: TETRACYCLINES
enterotox e.coli
MC cause of traveler’s diarrhea
unsatintary drinking water
fluids, flouroquinolones
c.diff
due to clinda, pseudomembraneous colities,
tx: METRO for mild
VANCO po: 2nd line- but first if SEVERE
INVASIVE INFECTIOUS
high fever, blood, fecal lekocytes, not as voluminous, mucus- do not give anti motility drugs with invasive diarrhea
c. jejuni mc cause of bacterial enteritis
undercooked poultry
watery then bloody diarrhea
erythroycin 1st line
shigella
highly virulet- explosive watery then bloody, and mucoid, in young children- seizures
BACTRIM 1st line!!!
salmonella
poultry, dairy, meat, eggs, exotic pets (reptiles like trutles)- high risk of osteomyltietis with sick cell disease
moucous and bloody diarrhea
typhoid: pea soup stools, rose spots
FLOUROQUINOLONES
enterohemorrhagic e.coli
undercookied ground beef
fluid replacement
abx controversial- can cause hemolytic uremic syndrome in children
yersinia
pork, milk, tofu
mimic acute appendicitis
giardia lamblia
contaminated water from remote streams/wells
frothy,greasy foul diarrhea
METRONIDAZOLE
amebiasis
entamoeba histolytica, amebic liver abscess
METRONIDAZOLE
cryptosporidium
mc cause of chornic diarrhea in patients with aids
bulk forming laxatives
psyllium, methylcellulose, - absorbs water and increases fecal mass
osmotic laxitives
polytehlene glycole, lactulose, sorbitol, milk of mag, mag citrate: causes h20 retention in Stool- osmotic effect pulls h20 into GUT
se: hypermag
common side effect of ERCP
pancreatitis
peptic ulcer most commonly in
lesser curvature of stomach and duodenal bulb
causes of pancreatitis
hypercalcemia, alcohol, gallstones, elevated triglycerides
upper gi bleed
proximal to the ligament of trietz
