Gastro Flashcards
Secreted by parietal cells
Hydrochloric acid
Digests proteins secreted by chief cells
Pepsin
Stimulates stomach acid secretion and motility.
secreted by G cells
Gastrin
directly stimulates parietal cells to secrete Hydrochloric acid
Acetylcholine
Inhibits parietal cell gastric secretion and buffers acid chime leaving the stomach
Secretin
Stimulates bile release and amylase/lipase for fat and protein breakdown
Cholecystokinin
Suppresses the release of GI hormones: inhibits secretion of gastrin
Somatostatin
Produced by pancreatic Alpha cells
Beta cells
Glucagon
Insulin
Water soluble contrast used in upper GI study when perforation is suspected
Gastrografin (Replacing Barium)
Caused MC by GERD: common in immunocompromised with candida, CMV or HSV. Radiation therapy
Painful swallowing. RF- Prego, ETOH, SMoke, Chocolate, spicy food, Meds. Dx- Multiple corrugated rings
Esophagitis
Linear white plaques esophagitis and Tx?
Candida
Tx- PO Fluconazole
small deep ulcers esophagitis and Tx?
HSV
Tx- Acyclovir
Large superficial shallow ulcers esophagitis?
CMV
Tx- Ganciclovir
Pill induced esophagitis MCC
NSAIDS, Bisphosphonates, Potassium chloride, Iron pills, BBs, CCBs.
Incompetent or transient LES relaxation MCC. Heartburn is hallmark. cough at night, dysphagia, water brash.
Dx- and Tx
GERD
DX- 24 hr pH GS: Endscopy 1st.
Tx- Lifestyle mods, H2 Antagonist, PPI, Fundoplication
GERD: _____ cells replaced by _______ cells can lead to what kind of carcinoma?
Squamous to Columnar cells (Barret’s Esophagus)
Adenocarcinoma
Increased LES tone 2T loss of Aurbach’s Plexus. dysphagia to both solids and liquids. –> weightloss.
Dx- GS is ______ and esophagram shows (CXR)
Tx-?
Achalasia
Dx- GS is Manometry: Bird’s Beak
Tx- Botulinum Inj. 6-12 mos, nitrates, CCBs, Sx
Excessive contraction during peristalsis. Normal Esophagram and EGD
Dx-
Tx-
Nutcracker Esophagus
Dx- Manometry
Tx- CCBs, Nitrates, Botox, sildenafil
Dysphagia, regurgitation of undigested food, choking sensation, halitosis.
Dx-
Tx-
Zenker’s Dicerticulum
Dx- Barium Esophagram
Tx- Diverticulectomy Sx
Full thickness rupture of the distal esophagus. 2T repeated forceful vomiting.
Retrosternal pain worse with deep breath/swallowing.
Dx- and Tx ?
Boerhave Syndrome
Dx- Ct scan/CXR
Tx- stable= Iv, Fluids, NPO, Abx, H2-a Severe= Sx
UGI bleeding from longitudinal mucosal laceration @ GE junction. 2T persistent retching. vomiting etoh/bulimia
Hematemesis after ETOH binge. Hydrophobia.
DX- and Tx?
Mallory-Weis tear
Dx- Upper endoscopy TOC
Tx- Supportive (Severe- Epi inj., Ligation, balloon)
lower esophageal constrictions/webs @ squamo-columnar jx. MC associated with Hiatal hernias
SCHATZKI Ring (Esophageal Web/Ring)
Caused by portal vein hypertension. MC RF is _______.
Upper GI bleed, hematemesis, melena, hematochezia
TX- 1. TOC? 2. Pharmaco DOC 3. Prevention
Esophageal Varices (Cirrhosis MC RF)
Tx- 1. Endoscopic ligation: 2. Octreotide 3. BBs (Prop-Nad)
MC type of hiatal Hernia
Sliding Type 95% (GE Junction + stomach slide)
(Rolling- (paraesophageal) Fundus of stomach protrudes through diaphragm.
MC Esophageal Neoplasm @ ____ 1/3?
Usually complication of GERD–> Barret’s DX-?
Adenocarcinoma: Upper 1/3
EGD with Bx
MCC of gastritis: 2nd MCC and 3rd?
Epigastric pain, NV, anorexia, hematemesis, melena.
DX- ?
#1 H. Pylori #2 NSAIDS #3 Acute stress
Dx- Endoscopy GS
H. Pylori positive Triple therapy
(CAP)
Clarithromycin
Amoxicillin
PPI
Burning, gnawing, hunger like epigastric pain, worse at night: worse/ food provoked 1-2 hours after meal
Gastric Ulcer Peptic Ulcer disease
Burning, gnawing, hunger like epigastric pain, worse at night: relieved with food, antacids.
Duodenal Ulcer Peptic Ulcer disease
H. Pylori Testing gold standard?
MC used? and which confirms eradication
Endoscopy with Biopsy
MC used= Urea Breath test Eradication= Stool Ag
Sudden onset severe diffuse abdominal pain. Rigid abdomen with rebound tenderness think______
MC?
Duodenal Ulcer perforation
Quadruple H. Pylori therapy?
BTM-P
Bismuth Subsalicylate, Tetracycline, Metronidazole, PPI
Medication forms viscous adhesive coat that protects and promotes healing of mucosa
Sucralfate
Medication used in Esophageal varices that is a somatostatin analog–> vasoconstriction of portal vein
Decreases Gastrin/ Reduces bleeding
Octreotide
Gastrin secreting neuroendocrine tumors–> gastric acid hypersecretion–> PUD Kissing Ulcers” both sides lumen
Dx and Tx
Zollinger-Ellison Syndrome
Dx- Increased Fasting Gastrin Levels + pH<2
Tx- Sx
MC Gastric carcinoma WW?
Most important RF is _____
Adenocarcinoma
H. Pylori
A sign of adenocarcinoma metastasis supraclavicular Lymph node is known as ?
Virchow’s Node
Type of bilirubin not soluble in water therefore sent to liver for excretion
Unconjugated Bilirubin (Indirect)
Water soluble Bilirubin that can be excreted through bile
When in excess gets cleared through urine as Urobilin.
(Urine- 1st needs conversion to urobilinogen in GI)
Conjugated Bilirubin (Direct)
Bilirubin without increased LFTs =
Familia Bilirubin D/O
Hereditary unconjugated (indirect) hyperbilirubinemia
Neonatal jaundice with progress to Kernicterus
Absent UGT= Type I
Crigler-Najjar Syndrome
Hereditary unconjugated (indirect) hyperbilirubinemia
Transient in periods of stress: “ Reduced UGT”=Mild
Gilbert’s Syndrome
Hereditary conjugated (direct) hyperbilirubinemia
Black liver on Biopsy
Dubin-Johnson syndrome
LFT Pattern of liver injury (Hepatocellular damage)
Increased ALT and AST
Which liver enzyme is more sensitive for liver disease
ALT
LFT Pattern for Cholestasis
Increased ALP and GGT (Bilirubin higher than both).
synthesis coagulation factors dependent on vitamin K
PT
LFT Pattern for ETOH hepatitis
AST:ALT 2:1 Ratio “Scotch” (AST <500)
ALT>AST (>1,000) you think?
Acute viral hepatitis (Chronic <500)
Abrupt RUQ/epigastric pain. Resolves slowly lasting 30-hours. Nausea precipitated by fatty foods or large meals
Dx? TX?
Cholelithiasis
Dx- US Tx- Elective cholecystectomy
Gallstones in the common bile duct assoc. w duct dilation.
Dx- DOC Tx-
Choledocholithiasis
Dx- ERCP TX-ERCP stone extraction
Obstruction of the Biliary tract –> to biliary tract infection. MC 2T E. Coli or Klebsiella. Charcot’s/Reynold
Labs: Increased ALP, GGT, and Bilirubin
Dx- Tx-?
Acute Cholangitis
Dx- CT (GS-ERCP) Tx- ABX + ERCP
Primary Choledocholithiasis pathophysiology cause
Stones originating @ CBD 2T Cystic Fibrosis
Secondary Choledocholithiasis pathophysiology cause
Passage of stones from GB into CBD (MC)
Inflammation/infection 2T gall bladder obstruction @ cystic duct. E.coli/Klebsiella MC.
(+) Murphy’s sign RUQ pain, precipitated by fatty/large meals. DX- Initial and GS Tx-
Cholecystitis
Dx- Initial=US “GS=HIDA scan” Tx- NPO, IV, ABX,Sx
Chronic cholecystitis Associated with gallstones–> ?
Strawberry GB –> Porcelain GB (Premalignant condition)
What is Boa’s sign?
Referred pain to right shoulder from irritation of the phrenic nerve in Cholecystitis
Rapid liver failure with encephalopathy + coagulopathy? MCC?
Fulminant Hepatitis (Acute Hepatic Failure)
MCC=Acetaminophen then Reye’s syndrome
Encephalopathy Treatment
Lactulose- Neutralizes ammonia
ABX- decrease bacteria producing ammonia
Protein Restriction
Hepatitis with highest mortality during pregnancy especially during 3rd trimester?
Hepatitis E
Hepatitis MCC parenterally (Not common Sex/perinatal)
Hepatitis C
Hepatitis MCC parenterally, sexually, perinatally.
Hepatitis B
MC Hepatitis in the United states
Hepatitis C
Hepatitis Surface Antibody means
- Distant resolved infection or 2. Vaccination
Hepatitis Core Antibody means? (IgM or IgG)
IgM- Acute infection IgG-Chronic infection
Hepatitis Surface Antigen means?
Establishes evidence of infection. (>6 months=Chronic)
Hepatic venous outflow obstruction (thrombosis/ occlusion). Cause- Polycythemia, OBC, prego, malignant
Dx- Tx?
Hepatic Vein Obstruction (Budd-Chiari Syndrome)
Dx- US (SOC) Tx- Shunt, B Angioplasty, diuretics
More commonly caused by 2ry metastasis (lung/breast)
Primary is _______
Dx- Tx-
Hepatocellular carcinoma
Primary- hepatocellular carcinoma
Dx- US and AFP Tx- Sx
Irreversible fibrosis with nodular regeneration MCC by alcohol. S/Sx- Pruritus Ascites, gynecomastia, HSM,
Caput medusa, palmar, erythema, “hepatic encephalopathy”, Esophagus varices. Dx Tx-
Cirrhosis
Dx- US Tx- Ascites- no Na+ Pruritus-Cholestyramine
Hepatic encephalopathy Pathophysiology and S/Sx?
Ammonia accumulation (protein breakdown)-
Asterixis: flapping tremor (Extended wrist–> flap)
Fetor Hepaticus: Breath rotten eggs and garlic
Idiopathic autoimmune d/o of intrahepatic small bile ducts. Fatigue and pruritus, RUQ pain, jaundice, HSM
“Positive Antimitochondrial Antibody” Tx-
Primary Biliary cirrhosis
Tx-Ursudeoxycolic acid reduces progression
Diffuse fibrosis on intrahepatic ducts. Assoc. with IBD or Ulcerative colitis 2/3 patients:
”(+) P-ANCA” pruritus, RUQ pain, jaundice, HSM Tx-
Primary sclerosing cholangitis Tx ERCP
Free copper accumulation in liver, brain , cornea, kidney
inadequate copper excretion Tx-
Wilson’s disease
Tx- D-pencillamine + Zinc
epigastric constant pain that radiates to the back or other quadrants. Pain worse supine, walking or eating
MCC gallstones 2nd- ETOH. scorpion bite or mumps
Dx- SOC Tx-
Acute Pancreatitis
Dx- Ct scan Tx- NPO, IV fluids, mepiridine
Laboratories consistent with Acute pancreatitis
Lipase: More specific
Amylase: 3X ULN
ALT: 3X fold
Hypocalcemia
Parenchymal destruction and fibrosis of exocrine/endocrine function–> cancer
MCC ETOH “Lipase and Amylase not usually incr. “
Dx- Tx
Chronic Pancreatitis
Dx- AXR calcified pancreas Tx- DC ETOH
Pancreatic enzymes
Cramping abdominal pain, vomiting (bilious), Obstipation or high pitched BS/ visible peristalsis MCC?
Dx- Tx-
Small bowel Obstruction (MCC Post-Surgical adhesions)
Dx- AXR (dilated bowel loops)
Tx-non -strang. IV, NPO, NG decompress
Strangulated- Sx
Persistent portion of embryonic vitteline duct: 2 YOA
2% population, 2 feet from ICV, 2” in length, 2 tissues,
Meckel’s Diverticulum Tx- Sx
Abdominal pain, NV (bilious), Obstipation “ decreased- no BS”, post-operative MCC: DX- Tx-
Paralytic Ileus (No structural obstruction)
Dx- AXR Tx- NPO, IV fluids, NG decompress for V
Colonic pseudo obstruction MC at cecum or right hemi colon. Abdominal distention = hallmark men > 60 yo
Ogilvie’s Syndrome
small bowel autoimmune inflammation –> villi loss and impaired absorption.
Celiac Disease
SOC for Celiac Diagnosis?
Treatment
Small Bowel Biopsy (+) Endomysial IgA
(+) Transglutaminase Ab
Tx- Gluten Free diet ( no Rye, wheat Barley)
Loose stools, abdominal pain, flatulence, borborygmic after ingestion.
Dx- SOC Tx-
Lactose intolerance
Dx- Hydrogen Breath Test Tx- Lactase Enzyme preps
Abdominal pain 1 day /week for past 3 mos with altered defecation/ bowel habits. Diarrhea/constipation/both.
pain often relieved by defecation. Tx-
Irritable Bowel Syndrome
Tx- stop smoking, low fat diets, no fructose Amitriptyline
Inflammatory bowel disease includes?
Ulcerative colitis
Chron’s disease
From Mouth to Anus: MC in terminal ileum. Transmural; Skip lesions: cobblestone appearance. “String sign” Ba
(+)ASCA: S/Sx- Non Bloody diarrhea, RLQ pain MC, weight loss Tx
Crohn’s Disease
Dx- AXR Tx- Non-curative
Limited to colon, rectum always involved: Uniform inflammation rectum/colon: –> toxic megacolon
Smoking Decreases risk: S/Sx- bloody/mucus/pus diarrhea, hematochezia, tenesmus, (+) PANCA Tx-
Ulcerative Colitis
Dx- Flex sigmoidoscopy Tx- Curative
AXR- Stove pipe (loss of haustra)
Inflammatory Bowel Disease pharmacotherapy Tx
Tx- 5 ASA (Mesalamine or Sulfasalazine)
Corticosteroids (PO PR)
Methotrexate
Anti-TNF (-mabs)
Colon Polyps that tend to be malignant
#1: >1cm #2: Sessile and Villous #3: due to IBD (Familial Adenomatous Polyposis)
Colorectal Diagnostic of choice (DOC)
1. Colonoscopy with biopsy
Colorectal screening recommendations?
Annually Occult Fecal (Flex q 5 years)
FOB @ 50 : Colonoscopy @ 50 then q 10 years
FOB @ 40 (1st relative >60) colonoscopy q 10 years
FOB @ 40 (1st relative < 60) Colonoscopy q 5 years
Hernia that protrudes at the internal inguinal ring: the origin of the sac is lateral to inferior epigastric artery.
MC overall: MC in men (children and young adults)
2T persistent patent process vaginalis
Indirect Inguinal Hernia
Protrusion of contents through the abdominal cavity through the femoral canal below the inguinal ligament.
MC in women. often incarcerate or strangulate.
Femoral Hernias
due to failure of umbilical ring: Observation, usually resolves by ____ age?
Surgical repair if persistent past ____ of age
Umbilical Hernia
Resolves: by age 2 yoa Surgical repair if > 5 yoa
Protrudes medial to inferior epigastric vessels w/I Hasselbach’s triangle. 2T weakness of inguinal canal
Does not reach scrotum
Direct Inguinal Hernia
MC occurs in vertical incisions and obese patients
Incisional (Ventral) Hernias
Rare where abdominal pelvic contents protrude through the obturator foramen
Obturator Hernia
Classification of Hemorrhoids
Class I- no prolapse
Class II- Prolapse but spontaneously reduces
Class III- Prolapse only reduced manually
Class IV- Non-reducible
Hemorrhoid Treat conservative?
Within 72 hrs or failed conservative?
Conservative- high-fiber, topical CS, sitz baths
Ligation or sclerotherapy (Injection)
Within 72 hours- Hemorrhoidectomy
Tunnel that forms in skin at anus/rectum?
Anorectal Fistula
anorectal swelling with pain that is worse with sitting, coughing, or defecation.
Anorectal Abscess
Painful linear tear/crack in the anal canal involving only epithelium without mucosa. 3 or 9’0clock= ______?
Severe rectal and BM pain–> refrain BM–>constipation with bright red blood per rectum. MC__?
Anal Fissure
MC posteriorly (3 0r 9’oclock = Malignancy or Crohn’s)
Gluteal Cleft tender abscess with drainage
Pilonidal Cyst/Abscess/ Sacrococcygeal fistula
accumulation of a byproduct of proteins–> accumulation. “Urine with musty odor (Mousy-brownish)”
Phenylketonuria
Avoid Phenylalanine or Tyrosine
Deficiency leads to 3 Hs- Hemorrhage (gums, skin joints), hyperkeratosis, hematologic issues (anemia, Incr. bleed time)
Vitamin C deficiency (Scurvy)
Deficiency leads to night blindness, poor wound healing, taste loss, dry skin. needed 4 embryo develop.
Vitamin A deficiency
Deficiency can lead to rickets in children and _______ in adults? Tx?
Vitamin D Deficiency (Osteomalacia)
Tx- Ergocalciferol
MCC of deficiency is ETOH abuse.
Vitamin B1 Deficiency (Thiamine)
Vitamin B1 Deficiency (Thiamine) –> what 3 D/O
Beri-Beri
Wernicke’s
Korsakoff’s dementia
Wet vs. Dry Beri-Beri
Wet- High output HF (Dilated cardiomyopathy
Dry- Neuro Paresthesia’s and demyelination
Wernicke’s Triad
Ataxia, global confusion, ophthalmoplegia (ocular paralysis)
Korsakoff’s pathophisiology
irreversible memory loss (Tio Guero)
Deficiency leads to oral-ocular-genital syndrome.
Magenta tongue/cheilitis, photophobia/cornea lesion, scrotal dermatitis
Vitamin B2 (Riboflavin)
deficiency often due to diet high in corn. –> pellagra
3D’s Dementia, dermatitis, diarrhea
Vitamin B3 (Niacin/nicotinic acid)
Deficiency leads to peripheral neuropathy:
isoniazid, OBC, chronic ETOH
Vitamin B6 (Pyridoxine)
Deficiency leads to neuro- dementia, gait, paresthesias: 2T pernicious anemia, vegans, ETOH abuse,
Celiac/crohn’s and Gastric bypass malabsorption.
Vitamin B12 (Cobalamin)
MCC pathogen overall gastroenteritis in adults in N. America (Cruise ships, hospitals, restaurants)
Norovirus
MCC pathogen of non-entero toxin non- bloody diarrhea in children 70%
Rotavirus
Short incubation periods < 6hours–> voluminous non-bloody diarrhea dairy, mayonnaise, meat, eggs
S. Aureus
Similar to staph A. IP 4-6 hours MC in contaminated fried rice
Bacillus Cereus
Gram negative rod–> hypersecretion of water/Cl- ions–> severe dehydration. Poor sanitation and crowding
Copious “Rice Water” grey no fecal odor/blood/pus
Lose 15L /Day of fluid. Tx-
Vibrio Cholera
Fluid replacement Abx-fluroquinolones
Associated with Raw Shellfish in Gulf of Mexico
Vibrio Vulnificus
MCC of traveler’s diarrhea. Unsanitary drinking of water/ice. Tx-
Enterotoxigenic E. Coli
Tx- Severe= Fluoroquinolone (non= Bismuth/Fluids)
Organism growth secondary to alteration of normal Flora 2T ABX use. Fever, diarrhea, tenderness, Tx?
ABX MCC is ______
Clostridium Difficile
Tx-Vancomycin 1st if severe (Metronidazole)
MCC Abx= Clindamycin
MCC of bacterial enteritis in U.S. Antecedent to Guillian- Barre syndrome. S, comma, seagull shaped.
TX- TOC Abx?
Campylobacter Enteritis
Tx- Erythromycin
Highly virulent explosive watery diarrhea–> mucoid/bloody. May lead to toxic megacolon
Febrile seizures in children. Dx- CBC > 50K: Sigmoid w punctate areas of ulceration. Tx
Shigella Toxin
Tx- Septra
Greatest in the summer: MC poultry, reptiles, dairy, meat eggs. Feco-oral
Salmonella
presents with headache, constipation, pharyngitis, cough, abdominal pain, “pea soup Diarrhea”
intractable Fever, bradycardia, “Blanching rose spots”
Typhoid Enteric Fever (Salmonella Typhus)
Tx Cipro, ceftriaxone
High risk in immuno-comp patients. In sickle cell patients it leads to ________?
Salmonella
–> Osteomyelitis
Source- from undercooked ground beef, unpasteurized milk/cider, daycare contaminated water. Bloody diarrhea
Tx- if severe
Enterohemorrhagic E. Coli 0157:H7
Tx- Abx–> HUS in children
contaminated pork, milk, water, Tofu: Appendicitis mimic
produces abdominal tenderness and guarding
Yersinia Enterolitica
Contaminated water from remote streams. Backpacker/Beaver fever. Frothy greasy foul diarrhea
Tx-
Giardia Lamblia
Tx- Boil water x1 minute Metronidazole
“Furizoladine (Children)”
Fecal oral transmitted: Traveler’s in developing nations.
–> liver abcesses
Amebiasis
Tx-Metronidazole
MCC of chronic diarrhea in patients with AIDS. Fecal Oral
Cryptosporidium
MC in homosexual men fecal oral
Isospora Belli
MC in farmers around contaminated soil. –> malabsorption, weigh loss, steatorrhea,
Rhythmic motion of eye muscles while chewing
Whipple’s Disease
Bulk forming laxatives
Psyllium, Methylcellulose, wheat Dextran
Osmotic Laxatives- Side effects= Bloating and Flatulence
Polyethylene Glycol (Miralax)
Milk Magnesia
Magnesium citrate
Stimulant Laxatives
Bisacodyl/Senna
Stool softener laxatives
Docusate