Gastroentero Flashcards
esophageal disorders leading to narrowing will result in
dysphagia and weight loss
name the causes of dysphagia (7)
- achalasia
- cancer
- rings/webs
- Zenker’s diverticulum
- spastic d/o’s
- scleroderma
- eosinophilic esophagitis
- YOUNG nonsmoker
- dysphagia to solids AND liquids at the same time
- REGURGITATION of food
- ASPIRATION of previously eaten food
achalasia
best INITIAL test for achalasia
barium swallow
MOST ACCURATE test for achalasia
esophageal manometry
endoscopy in achalasia is done for what purpose?
to EXCLUDE cancer
best INITIAL treatment for achalasia
pneumatic dilation, or surgical myotomy
pneumatic dilation for achalasia is done when?
surgical myotomy is UNSUCCESSFUL
treatment for achalasia if pt refuses pneumatic dilation/surgical myotomy
botulinum toxin injection
- dysphagia to solids THEN liquids
- +/- heme-positive stool, or ANEMIA
- often pts > 50 yoa
- smoker/drink alcohol
esophageal cancer
best INITIAL test for esophageal cancer
endoscopy
barium swallow if endoscopy isn’t a choice
best INITIAL treatment for esophageal cancer
RESECTION
surgical resection of esophageal cancer should be followed by
5-fluorouracil (5-FU)
name the causes of rings/webs causing dysphagia (3)
- Plummer-Vinson syndrome
- Schatzki’s ring
- peptic stricture
best INITIAL test for rings/webs
barium swallow
- PROXIMAL stricture
- IDA
- middle-aged females
Plummer-Vinson syndrome
best INITIAL treatment for Plummer-Vinson syndrome
iron
- DISTAL ring
- INTERMITTENT symptoms of dysphagia
Schatzki’s ring
best INITIAL treatment for Schatzki’s ring
pneumatic dilation
- dysphagia
- longstanding acid reflux
peptic stricture
treatment for peptic stricture
pneumatic dilation
- horrible bad breath from rotting food in back of esophagus
- dilation of posterior pharyngeal constrictor muscles
Zenker’s diverticulum
best INITIAL test for Zenker’s diverticulum
barium swallow
best INITIAL treatment for Zenker’s diverticulum
surgical resection
- dysphagia
- h/o allergies
- mean of 5 years before diagnosis is made
eosinophilic esophagitis
test for eosinophilic esophagitis
endoscopy w/ biopsy
treatment for eosinophilic esophagitis
PPT and budesonide
- severe chest pain w/o risk factors for ischemic heart disease
- pain after drinking cold beverage
- normal EKG/stress test/coronary angiography
diffuse esophageal spasm
MOST ACCURATE test for diffuse esophageal spasm
manometry
barium swallow may show what during an episode of spasm in diffuse esophageal spasm
corkscrew pattern
treatment for diffuse esophageal spasm
- CCB
- nitrate
difference between diffuse esophageal spasm and Prinzmetal’s variant angina
ST segment elevation
- diffuse disease
- reflux symptoms
scleroderma
- odynophagia
- HIV-NEGATIVE
what is the next step in management?
endoscopy
- odynophagia
- HIV-POSITIVE w/ CD4 count
fluconazole
- odynophagia
- HIV-POSITIVE w/ CD4 count
endoscopy
> 90% of esophagitis in HIV-positive pts are caused by?
Candida
treatment for pill esophagitis
- sit up
- drink a lot of water
- remain upright for 30 minutes after
- SUDDEN UGIB
- violent retching/vomiting
- there may be hematemesis or melena
Mallory-Weiss tear
test for Mallory-Weiss tear
endoscopy
treatment for Mallory-Weiss tear
most spontaneously resolve
treatment for Mallory-Weiss tear if bleeding does NOT resolve
endoscopic epinephrine injection
- epigastric pain/substernal chest pain
- sore throat
- metallic or bitter taste
- hoarseness
- chronic cough
- wheezing
- nausea
GERD!!
diagnosis and treatment for GERD
PPI
if no response to PPI for GERD symptoms, next step in management
endoscopy
if GERD symptoms persist and EGD is normal, next step in management
24-hour pH monitoring
alarm symptoms in pt w/ GERD indicating endoscopy
- weight loss
- anemia
- blood in stool
- dysphagia
- reflux for more than 5-10 years
- PREcancerous lesion of lower esophagus
- 0.5%/year transform into cancer
Barrett esophagus
test for Barrett esophagus
endoscopy
endoscopic finding: Barrett esophagus (metaplasia)
next step in management
PPI and repeat EGD every 2-3 years
endoscopic finding: low-grade dysplasia
next step in management
PPI and repeat EGD in 3-6 months
endoscopic finding: high-grade dysplasia
next step in management
- endoscopic mucosal resection
- endoscopic ablation
- distal esophagectomy
MCC of epigastric discomfort
non-ulcer dyspepsia (diagnosis of exclusion)
test for non-ulcer dyspepsia
endoscopy
treatment for non-ulcer dyspepsia
- H2 blocker
- liquid antacid
- PPI
treatment for REFRACTORY non-ulcer dyspepsia
treat for Helicobacter pylori
MCC of peptic ulcer disease (duodenal/gastric)
H. pylori
after H. pylori, MCC of PUD
- NSAIDs
- head trauma
- burns
- intubation
- Crohn’s disease
- Zollinger-Ellison syndrome
what % of GU pts develop gastric cancer?
4%
gastritis can be associated w/
H. pylori
treatment for H. pylori
- omeprazole
- clarithromycin
- amoxicillin
MOST ACCURATE test for gastritis
endoscopy w/ biopsy
treatment if initial H. pylori treatment fails
repeat triple therapy w/ 2 new abx
- PPI
- metronidazole
- tetracycline
if H. pylori treatment fails twice
evaluate for ZES (gastrinoma)
stress ulcer prophylaxis should be given to the following:
- head trauma
- intubation and mechanical ventilation
- burns
- coagulopathy AND steroid use in combination
- epigastric pain
- H. pylori positive
- NO ulcer or gastritis
non-ulcer dyspepsia
EVERYONE on an H2 blocker or PPI has an
ELEVATED GASTRIN LEVEL
diagnostic test ZES
gastrin level and gastric acid output
test the gastrin level and gastric acid output for ZES when the following is present:
- large ulcer (> 1cm)
- multiple ulcers
- ulcer distal to ligament of Treitz
- recurrent/persistent ulcer despite H. pylori treatment
if gastrin level and acid output are elevated in ZES, next step
localize the gastrinoma
MOST ACCURATE test for ZES
secretin suppression test
treatment of ZES for LOCAL disease
surgical resection
treatment of ZES for metastatic disease
lifelong PPI
clue about the presence of a parathyroid problem w/ ZES, and multiple endocrine neoplasia (MEN) syndrome
hypERcalcemia
both CD and UC can present w/
- fever
- abdominal pain
- diarrhea
- bloody stools
- weight loss
extraintestinal manifestations of IBD
- joint pain
- iritis/uveitis
- pyoderma gangrenosum/erythema nodosum
- sclerosing cholangitis
features more common to CD
- masses
- skip lesion
- upper GI tract
- perianal disease
- transmural granulomas
- fistulae
- hypocalcemia from fat malabsorption
- obstruction
- calcium oxalate kidney stones
- cholesterol gallstones
- vitamin B12 malabsorption from terminal ileum involvement
diagnosis for CD and UC
barium swallow or endoscopy
when diagnosis of CD or UC, what can be helpful
blood tests
ASCA and ANCA in CD
ASCA POSITIVE
ASCA and ANCA in UC
ANCA POSITIVE
best INITIAL treatment for both CD and UC
mesalamine
adverse effects of sulfasalazine
- rash
- hemolytic anemia
- interstitial nephritis
treatment for acute exacerbation of CD and UC
budesonide
treatment for severe CD and UC w/ recurrent symptoms when steroids are STOPPED
azathioprine, or 6-mercaptopurine
most useful treatment for CD associated w/ FISTULA formation
infliximab
treatment for perianal involvement in CD
metronidazole and ciprofloxacin
curative treatment for UC
surgical resection of colon
most important feature of infectious diarrhea
presence of blood indicating invasive bacterial pathogen
infectious diarrhea +/- blood may be d/t which pathogens?
- Campylobacter
- Salmonella
- Vibrio parahaemolyticus
- Vibrio vulnificus
- E. coli (including E. coli O157:H7)
- Shigella
- Yersinia
- amoeba
- diarrhea
- MCC of food poisoning
Campylobacter
Campylobacter can be associated w/
- Guillain-Barre syndrome
- reactive arthritis
- diarrhea
- transmitted by chickens and eggs
Salmonella
- diarrhea
- associated w/ seafood
Vibrio parahaemolyticus
- diarrhea
- most commonly associated w/ HUS (effects of verotoxin)
- h/o undercooked beef
E. coli O157:H7
which treatments should be AVOIDED in HUS
platelet transfusion and antibiotics
- diarrhea
- associated w/ shellfish
- septicemia is MUCH more likely in pt w/ liver disease - - necrotizing wound infections can occur in skin lesions
Vibrio vulnificus
- diarrhea
- secretes Shiga toxin
- also, associated w/ reactive arthritis
- 2nd MCC of HUS
Shigella
- diarrhea
- rodents are natural reservoir
- transmission is through food contaminated w/ infected urine/feces
Yersinia
diarrhea, which may be associated w/ liver abscesses
amoeba
best INITIAL test for infectious diarrhea
fecal leukocytes
MOST ACCURATE test for infectious diarrhea
stool culture
treatment for infectious diarrhea: mild disease
none; will resolve on its own
best INITIAL treatment for infectious diarrhea: severe disease
fluoroquinolones
severe infectious diarrhea is defined as having the following
- blood
- fever
- abdominal pain
- hypotension and tachycardia
infectious diarrhea (which NEVER presents w/ blood) may be d/t which pathogens?
- viruses
- Giardia
- Staphylococcus aureus
- Bacillus cereus
- Cryptosporidium
- Scombroid
- diarrhea
- camping/hiking
- men who have sex w/ men
- bloating, flatus, signs of steatorrhea
Giardia
more accurate test for Giardia
stool ELISA Ag
treatment for Giardia
metronidazole or tinidazole
- diarrhea
- associated with mayonnaise and vomiting
Staphylococcus aureus
- diarrhea
- associated w/ refried Chinese rice and vomiting
Bacillus cereus
- diarrhea
- HIV-positive pt w/ CD4 cells
Cryptosporidium
test for Cryptosporidium
modified acid-fast stain
treatment for Cryptosporidium
HAART and nitazoxanide
- diarrhea
- histamine fish poisoning
- FASTEST onset diarrhea, w/i 10 MINUTES
- vomiting, wheezing, flushing
Scombroid
treatment for Scombroid
diphenhydramine
- antibiotic-associated diarrhea
- develops several days to weeks after abx use
Clostridium difficile
best INITIAL test Clostridium difficile diarrhea
stool toxin assay
initial treatment for mild/moderate CDI
PO metronidazole or PO vancomycin
treatment for severe CDI
PO vancomycin +/- IV metronidazole
definition of severe CDI
- WBCs > 15,000
- serum albumin
treatment for complicated CDI
- PO vancomycin and IV metronidazole
- surgery consult
definition of complicated CDI
- toxic megacolon
- peritonitis
- respiratory distress
- hemodynamic instability
alternate treatment for severe and recurrent CDI
fidaxomicin
chronic diarrhea (> 4 weeks) causes
- lactose intolerance
- carcinoid syndrome
- IBD
MCC of chronic diarrhea and flatulence
lactose intolerance
chronic diarrhea associated w/ flushing and episodes of hypotension
carcinoid syndrome
test for carcinoid syndrome
urinary 5-HIAA level
treatment for carcinoid syndrome
octreotide (somatostatin analog)
chronic diarrhea w/ blood in stools, fever, and weight loss
IBD
- chronic diarrhea ALWAYS associated w/ weight loss
malabsorption
name the causes of malabsorption (4)
- celiac disease (gluten sensitive enteropathy)
- tropical sprue
- chronic pancreatitis
- Whipple’s disease
ALL forms of fat malabsorption are associated w/
- hypocalcemia (vitamin D deficiency)
- oxalate kidney stones
- easy bruising and elevated PT/INR (vitamin K malabsorption)
- vitamin B12 malabsorption
best INITIAL test for malabsorption
Sudan black stain for stool
MOST SENSITIVE test for malabsorption
72-hour fecal fat
- iron malabsorption and microcytic anemia
- folate malabsorption
- dermatitis herpetiformis
celiac disease
best INITIAL tests for celiac disease
- anti-gliadin Ab
- anti-endomysial Ab
- anti-tissue transglutaminase Ab
MOST ACCURATE test for celiac disease
small bowel biopsy
D-xylose test result in celiac disease, Whipple’s disease, and tropical sprue
ABNORMAL (villous lining is destroyed)
what test should be done even if diagnosis of celiac disease has been confirmed?
small bowel biopsy to EXCLUDE bowel wall lymphoma
treatment for celiac disease
gluten free diet
MOST ACCURATE test for tropical sprue
small bowel biopsy showing microorganisms
treatment for tropical sprue
doxycycline, or TMP/SMX for 3-6 MONTHS
- malabsorption
- arthralgia (MCC presenting symptom)
- neurological abnormalities
- ocular findings
Whipple’s disease
MOST ACCURATE test for Whipple’s disease
small bowel biopsy showing PAS POSITIVE organisms
treatment for Whipple’s disease
tetracycline, or TMP/SMX for 12 MONTHS
- malabsorption
- h/o alcoholism
- h/o multiple episodes of pancreatitis
- amylase/lipase will most likely be normal
chronic pancreatitis
best INITIAL tests for chronic pancreatitis
- abdominal XR (pancreatic calcifications)
- CT scan of abdomen
MOST ACCURATE test for chronic pancreatitis
secretin stimulation testing
D-xylose test in chronic pancreatitis will be
NORMAL
treatment for chronic pancreatitis
pancreatic enzymes
- abdominal pain relieved by BM
- abdominal pain that’s less at night
- abdominal pain w/ diarrhea alternating w/ constipation
irritable bowel syndrome (IBS)
all diagnostic tests for IBS will be?
normal
best INITIAL treatment for IBS
fiber
if fiber does not relieve pain in IBS, next treatment
- dicyclomine
- hyoscyamine
if fiber, and dicyclomine don’t work for IBS, last resort treatment
TCA
colonoscopy screening: general population
- begin at 50 yoa
- repeat every 10 years
colonoscopy screening: 1 family member w/ colon cancer
- begin at 40 yoa, OR 10 years before age of family member who had cancer
colonoscopy screening: 3 family members, 2 generations, or 1 premature (
- begin at 25 yoa
- repeat every 1-2 years
colonoscopy screening: FAP
- begin sigmoidoscopies at 12 yoa
- COLECTOMY once polyps are found
- colon polyps
- osteomas (benign bone tumors)
Gardner’s syndrome
- hamartomatous polyps throughout small bowel and colon
- melanotic spots on lips
Peutz-Jeghers syndrome
- multiple extra hamartomas in bowel
- no significant increase in cancer risk
juvenile polyposis
colonoscopy screening: DYSplastic polyp found
repeat colonoscopy every 3-5 years after polyp was found
- LLQ abdominal pain
- LGIB
diverticulosis
MOST ACCURATE test for diverticulosis
barium enema
- complication of diverticulosis
- LLQ abdominal pain
- TENDERNESS
- FEVER
- ELEVATED WBC COUNT
diverticulitis
best test for diverticulitis
CT scan of abd/pelvis
is CI in diverticulitis d/t increased risk of perforation
colonoscopy
treatment for diverticulosis
high-fiber diet
treatment for diverticulitis
antibiotics against GNR and anaerobes
metronidazole and ciprofloxacin
GI bleed: red blood
LGIB
GI bleed: black stool
UGIB (when proximal to ligament of Treitz (duodenum/jejunum))
MOST important step in managing an acute GI bleed
determine if pt is hemodynamically unstable
GI bleed management:
when do I transfuse PRBCs?
- Hct
GI bleed management:
when do I transfuse FFP?
elevated PT/INR and vitamin K is too slow
GI bleed management:
when do I transfuse platelets?
- if pt is bleeding/undergo surgery w/ platelets
MCC of death in GI bleeding
myocardial ischemia
what should be ordered on an older pt w/ GI bleeding?
EKG to r/o ischemia
most important treatment for acute GI bleeding
fluid resuscitation
most important measure of severity of GI bleeding
pulse and BP
what if pulse is still elevated, or BP is still low in pt w/ GI bleeding and is becoming hypotensive?
oxygenate (intubate if needed) and c/w IVF
more important in GI bleed than endoscopy
correcting anemia, thrombocytopenia, or coagulopathy
with adequate fluid resuscitation, even w/o endoscopy 80% of GI bleeds
stop bleeding
should be added to initial fluid resuscitation if GI bleed is d/t ulcer disease
PPI
unnecessary stress ulcer ppx w/ PPIs increases risk of
pneumonia and Clostridium difficile colitis
- alcoholic and/or cirrhosis w/ hematemesis
- splenomegaly
- thrombocytopenia
- spider angiomata
- gynecomastia
variceal bleeding
should be added to initial fluid resuscitation if GI bleed is d/t variceal bleeding
octreotide (somatostatin analog)
decreases portal hypertension
treatment for variceal bleeding aside from fluid resuscitation and octreotide
EGD to do banding
if variceal bleeding PERSISTS, next step in management
transjugular intrahepatic portosystemic shunt (TIPS)
shunt between PORTAL vein and HEPATIC vein
MC complication of transjugular intrahepatic portosystemic shunt (TIPS) procedure
hepatic encephalopathy
prevents future episodes of variceal bleeding
propranolol
temporary measure to stop variceal bleeding to allow time for a shunt to be placed
Blakemore gastric tamponade balloon
UPPER GIB can have the following causes: (6)
- PUD
- esophagitis
- gastritis
- duodenitis
- varices
- cancer
LOWER GIB can have the following causes: (6)
- angiodysplasia
- diverticular disease
- polyps
- ischemic colitis
- inflammatory bowel disease
- cancer
- test performed to detect site of bleeding IF endoscopy cannot
- gives you location, but not exact cause
tagged red cell scan
technetium bleeding scan
- tells you precise vessel that is bleeding
- may be done PREOPERATIVELY in massive GI bleeding to let you know which part of the colon to resect
angiography
can detect location of GIB from SMALL BOWEL, IF upper and lower endoscopies cannot
capsule endoscopy
- embolus from heart resulting in infarction of bowel
- SUDDEN onset of extremely severe abdominal pain
- +/- bleeding
- PE is relatively benign
- older pt w/ h/o valvular heart disease
acute mesenteric ischemia
look for what on blood tests of acute mesenteric ischemia
- metabolic acidosis (elevated lactic acid d/t ischemia)
- elevated amylase level
MOST ACCURATE test for acute mesenteric ischemia
angiography
treatment for acute mesenteric ischemia
surgical resection of bowel
surgical emergency
treatment in mesenteric ischemia NOT caused by emboli
treat underlying flow state
management of constipation
correct underlying cause
possible causes of constipation: (7)
- dehydration (decreased skin turgor in elderly pt w/ BUN:Cr ratio > 20:1)
- CCB
- opioids
- hypothyroidism
- DM (loss of sensation in bowels)
- ferrous sulfate iron replacement
- anticholinergics (including TCAs)
differentiating between UGIB and black stool d/t ferrous sulfate iron replacement
blood is cathartic causing RAPID BM
treatment of constipation
hydration and increased fiber
- prior gastric surgery
- SHAKING, SWEATING, WEAKNESS
- +/- hypotension
dumping syndrome
mechanism of hypotension in dumping syndrome (2 possible mechanisms)
- rapid release of gastric contents in duodenum –> osmotic draw into bowel
- rapid rise in blood glucose –> reactive hypoglycemia
management of dumping syndrome
frequent small meals
- longstanding diabetes
- bloating
- constipation
- diarrhea
gastroparesis
mechanism of gastroparesis
- main stimulant to gastric motility is DISTENSION
- DM damages sensory nerves
treatment for gastroparesis
- erythromycin
- metoclopramide
mechanism of erythromycin in gastroparesis
increases motilin in gut (hormone that stimulates gastric motility)
- severe midepigastric abdominal pain and tenderness
- MCC are alcohol and gallstones
- vomiting w/o blood
- anorexia
acute pancreatitis
other causes of acute pancreatitis
- hypertriglyceridemia
- trauma
- infection
- ERCP
- medications (thiazides, didanosine, stavudine, azathioprine)
severe acute pancreatitis signs and lab findings
- hypotension
- metabolic acidosis
- leukocytosis
- hemoconcentration
- hyperglycemia
- hypocalcemia
- hypoxia
best INITIAL test for acute pancreatitis
amylase and lipase
MOST ACCURATE test for acute pancreatitis
CT scan of abdomen
detects causes of biliary and pancreatic duct obstruction not found on CT scan
MRCP
- consider if there is dilation of CBD WITHOUT pancreatic head mass
- detects presence of stones/strictures
- can REMOVE stones and DILATE strictures
ERCP
urinary test used to determine severity of pancreatitis
trypsinogen activation peptide
treatment for acute pancreatitis
- no feeding (bowel rest)
- hydration
- pain medications
most precise method of determining pancreatitis severity
CT scan
Ranson’s criteria and CT scan are methods to determine which patients require
pancreatic debridement
when the CT scan shows > 30% NECROSIS of pancreas, the pt should:
- receive abx such as imipenem, and
- undergo CT-guided biopsy
if biopsy shows INFECTED, NECROTIC pancreatitis, pt should undergo
surgical debridement
hepatitis B is associated w/ what in 30% of cases
polyarteritis nodosa (PAN)
hepatitis C is associated w/
cryoglobulinemia
- jaundice
- fatigue
- weight loss
- dark urine (bilirubin)
acute hepatitis
- jaundice
- fatigue
- weight loss
- dark urine (bilirubin)
- present w/ serum sickness-phenomena (joint pain, urticaria, and fever)
hepatitis B and C
hepatitis E is most severe in
pregnant females (can be fatal)
ALL patients w/ acute hepatitis will have an ELEVATED?
conjugated (direct) bilirubin
viraL hepatitis gives an ELEVATED
aLt
hepatitis from drugS gives and ELEVATED
aSt
MOST ACCURATE tests for hepatitis A, C, D, and E
serology
MOST ACCURATE tests for hepatitis B
- surface Ag
- core Ab
- e-Ag
- surface Ab
FIRST test to become abnormal in ACUTE hepatitis B infection
SURFACE Ag
ALT elevation, e-Ag, and symptoms all occur AFTER
SURFACE Ag
CHRONIC hepatitis B gives same serologic pattern as acute hepatitis B, but has
PERSISTENCE OF SURFACE AG > 6 MONTHS
ONLY acute hepatitis that CAN be treated
hepatitis C
best INITIAL test for acute hepatitis C
hepatitis C Ab
MOST ACCURATE tests for acute hepatitis C
- hepatitis C PCR
- liver biopsy
MOST ACCURATE way of determining response to treatment for acute hepatitis C, which is based on GENOTYPE
hepatitis C PCR
MOST ACCURATE way to determine extent of liver damage in acute hepatitis C
liver biopsy
treatment for acute hepatitis C
interferon, ribavirin, and PI (ledipasvir, simeprevir, or sofosbuvir)
treatment for chronic hepatitis B
single agent!
- lamivudine
- adefovir
- entecavir
- telbivudine
- tenofovir
- interferon
MC adverse effect of ribavirin
anemia
treatment of chronic hepatitis C genotype 1
ledipasvir and sofosbuvir
treatment of chronic hepatitis C all other genotypes
- simeprevir
- boceprevir
MC reason to need liver transplantation in USA
chronic hepatitis C
strongest indications for hepatitis A and B vaccination in ADULTS
- chronic liver disease
- household contacts w/ hepatitis A or B
- men who have sex w/ men
- chronic blood product recipients
- IVDA
specific indication for hepatitis A vaccination
travelers
specific indications for hepatitis B vaccination
- health care workers
- dialysis pts
- DM pts
- edema from low oncotic pressure
- gynecomastia
- palmar erythema
- splenomegaly
- thrombocytopenia from splenic sequestration
- encephalopathy
- ascites
- esophageal varices
cirrhosis
treatment for edema from low oncotic pressure in cirrhosis pts
spironolactone and diuretics
treatment for encephalopathy in cirrhosis pts
lactulose
treatment for ascites in cirrhosis pts
spironolactone
treatment for esophageal varices in cirrhosis pts
- propranolol to prevent bleeding
- banding to stop acute bleeding
what should be done in the following?
- new ascites
- pt w/ ascites develops pain, fever, or tenderness
paracentesis
if serum-to-ascites albumin GRADIENT (SAAG) is > 1.1
- portal hypertension from cirrhosis
- CHF
neutrophils > 250 on paracentesis
spontaneous bacterial peritonitis (SBP)
treatment for spontaneous bacterial peritonitis (SBP)
cefotaxime
causes of chronic liver disease (cirrhosis): (7)
- alcoholic cirrhosis
- primary biliary cholangitis
- primary sclerosing cholangitis
- Wilson’s disease
- hemochromatosis
- autoimmune hepatitis
- nonalcoholic steatohepatitis (NASH)
- diagnosis of exclusion
- longstanding h/o alcohol abuse
alcoholic cirrhosis
- middle-aged FEMALE c/o itching
- +/- xanthelasma (cholesterol deposit)
- may have h/o AI d/o’s
primary biliary cholangitis
best INITIAL test for primary biliary cholangitis
elevated alkaline phosphatase w/ a NORMAL bilirubin level
MOST ACCURATE tests for primary biliary cholangitis
- anti-mitochondrial Ab (AMA)
- liver biopsy
treatment for primary biliary cholangitis
ursodeoxycholic acid
- associated w/ 80% of IBD cases
- also presents w/ itching
- elevated alkaline phosphatase
- ELEVATED BILIRUBIN level
primary sclerosing cholangitis
MOST ACCURATE tests for primary sclerosing cholangitis
- ERCP (shows “beading” of biliary system)
- anti-smooth muscle Ab (ASMA)
- ANCA positive
treatment for primary sclerosing cholangitis
ursodeoxycholic acid
- liver disease
- choreiform movement d/o
- neuropsychiatric abnormalities
- hemolysis
Wilson’s disease
best INITIAL test for Wilson’s disease
slit lamp looking for Kayser Fleischer rings
on CCS check for low ceruloplasmin level as well
MOST ACCURATE test for Wilson’s disease
liver biopsy
treatment for Wilson’s disease
penicillamine, or trientine
most often caused by a genetic d/o causing overabsorption of iron
hemochromatosis
aside from liver disease, other manifestations of hemochromatosis:
- restrictive cardiomyopathy
- skin darkening
- join pain
- damage to pancreas (leads to DM)
- pituitary accumulation w/ panhypopituitarism
- infertility
- hepatoma
best INITIAL test for hemochromatosis
- ELEVATED SERUM IRON
- ELEVATED FERRITIN
- LOW TIBC
- EXTREMELY ELEVATED IRON SATURATION (> 45%)
MOST ACCURATE test for hemochromatosis
liver biopsy
what, in combination, are sufficient for diagnosis of hemochromatosis?
MRI of liver, AND HFe gene mutation
treatment for hemochromatosis
phlebotomy
- young female w/ other AI diseases
- liver disease
autoimmune hepatitis
best INITIAL tests for autoimmune hepatitis
- ANA
- anti-smooth muscle Ab (ASMA)
- SPEP
MOST ACCURATE test for autoimmune hepatitis
liver biopsy
treatment for autoimmune hepatitis
- prednisone
- azathioprine for steroid-sparing medication
- strongly associated w/ obesity, DM, hyperlipidemia
- hepatomegaly
nonalcoholic steatohepatitis (NASH)
best INITIAL test for nonalcoholic steatohepatitis (NASH)
ALT > AST
MOST ACCURATE test for nonalcoholic steatohepatitis (NASH)
liver biopsy showing fatty infiltration
looks just like alcoholic liver disease
treatment for nonalcoholic steatohepatitis (NASH)
control underlying causes (weight loss, DM control, DLD management)
