Gastroenterology 💩 Flashcards
Mx for acute fatty liver disease of pregnancy
delivery
Dx this:
Patient with bowel issues, having to strain for poo, and rectal fullness. Have white mucopurulent discharge from anus, but no perianal issues. Patient is 23 years old, and has a new male partner
Neisseria G proctitis
Dx and Tx for Neisseria G proctitis
NAAT of discharge and Doxy Foxy
gastric cancer general signs
mild/vague epigastric pain/fullness. worse when eating. weight loss. can be seen with dysphagia if proximal
When do we do the prophylactic proctocolectomy in FAP
late teens, early 20’s. Or if there is CRCA or high grade dysplasia
who goes directly to an endoscopy for esoph CA check
above 50 and alarm symptoms (weight loss, occult bleeding, early satiety)
what should a young/low risk patient with esophageal symptoms have done before an endoscopy
esophagram
failure to thrive definiton on growth charts
weight deceleration crossing two or more major percentiles (50, 25, 10 etc.)
Tx for biliary atresia
Kasai (hepatoportoenterostomy)
Gold standard to Dx biliary atresia
intraoperative cholangiography
Mx of wound dehiscence and evisceration
emergency Sx to prevent strangulation
when are abdominal binders used in the setting of wound dehiscence
prior to Sx (not long term), but are CI’d in high risk wounds
mx of superficial wound dehiscence. what can we give to prevent high risk wounds from dehiscence
wound packing and saline gauze. Negative pressure dressings can prevent dehiscence
if suspect perf of viscus, and the CXR is negative… order what?
CT (can detect smaller air releases). unless patient is unstable…. go straight to surgery anyway
first invx for infected necr. pancreatitis? if that is equivocal?
CT (see the necro and gas produced), or aspirate and culture if CT equivocal
Dx of colonovesical fistula
CT with rectal or oral contrast
New onset of constipation in >50 year old woman… with early satiety and distension. must do what?
Pelvic US to rule out ovarian CA. Obviously do colonoscopy to rule out CRCA too
GI Bleed and Hb less than X, or less than Y if unstable. Then transfuse
X = 7
Y = 9
Quick neonatal bilious emesis algorithm
Hirshsprungs disease Dx steps
Would do X-ray first (see obstruction). Then an upper GI contrast series. Then our suction biopsy
Good tests to do to rule out fictitious diahrrea
Stool osm, osm gap, stool electrolytes
Best nutrition for patient with moderate to severe burns
Best give enteral within 24 hours. Due to hyper metabolic syndrome. Helps keep intestinal intergrity and reduced risk of sepsis compared to parenteral
Biliary atresia invx to diagnose (two answers to this according to UW)
Liver biopsy. But intraoperative cholangiography is diagnostic
Ascites with paracentesis yielding multiple bloody aspirates…. Highly suggest what?
HCC
If a patient <45 comes with blood on toilet paper after poo. No other symptoms. How to Mx
Do anoscopy, to check for likely hemorrhoids/fissure, and to rule our unlikely polyp/cancer. Do colonoscopy if cannot find cause. Straight o colonoscopy if >45 or has alarm symptoms
XRay differences between SBO and ileus
Ileus: no air fluid levels and generally dilation of all bowel.
SBO: air fluid levels and area of decompression
Mx of post op ileus
Fluids and bowel rest/observe
Management of neonatal umbilical hernia
Observation only…. Elective Sx at 5 years old.
Tx for umbilical granuloma
Topical silver nitrate
Dx this:
Sudden abdomen pain in adolescent. Was doing sport. Abdomen distended. Signs of shock. Free fluid in abdomen. Mild anemia.
Splenic rupture
Main risk factors for sigmoid volvulus
Chronic constipation (causes sigmoid redundancy). And neurogenic bowel conditions
Treatment for giardia (consider 1st line, best for kids and preg)
1st: tinidazole or nitazoxanide
Kids: metro
Preg: paromomycin
What is pseudoachalasia
A Halas is like symptoms, abused instead by obstruction (like CA)
In achalasia suspicion case… once done barium swallow, what other two invx should be done and why?
Manometry (confirms diagnosis), and endoscopy to rule out pseudoachalasia
Go through dyspepsia work up
> =60 or alarm symptoms, patient should have EGD. If below 60 and no alarm symptoms, patient can do H pylori test. If h pylori negative, we can do trial of PPIs.
Name causes of elevated SAAG ascites and lower SAAG ascites
High: HF, Budd chiari, cirrhosis. Low: Tb, malig, nephrotic syndrome
Indications to do liver transplantation in paracetamol overdose
If severe ALF, which looks like it’s not improving. Generally signs of hepatica enceph (grade III, IV). High Cr > 3.4, PT > 100,
Mx of ischmeic colitis
Conservative (Iv fluids, Abx, bowel rest. Resection if perf or necr
Patient with cholecystectomy signs and crepitus in RUQ/ air in GB wall on US
Emphysetmous cholecystectomy
Can we liver transplant in Colon mets to liver
No…. It’s a CI
Can we ruse radioTx in cancer proximal to the rectum
No, due to increase risk of enteritis
Should exclusively breastfeed until…?
6 mo
If you exclusively breastfeed, you are at risk of …..? Deficiency
Vit D
All infants are at risk of what deficiency, especially if drink too much cows milk
Iron
Hemochromatosis sus patient… with ferritin above 1000…. How to mx
Phlebotomy. Don’t wait for HFE mutation check.
Drugs causing pancreatitis
Furosemide, thiazide, sulfadiazine (sulfas)
Azathioprine, didanosine, metronidazole, tetracycline
Refeeding syndrome Tx
Aggressive repletion of electrolytes.
Optimal form of nutrition for critically ill patients?
Enteral, via tube. Not parenteral, due to increase infx risk and gut mucosal atrophy
What is intrahepatic cholestasis of pregnancy, and why is it risk to baby
Due to high estrogen, there is more bile stasis. Risky in older women. Bile salts cross the placenta and are toxic to baby….. so Tx with URSO, anti H, deliver at 37
Women with other AI, has lost prandial pain and fullness. Maybe some anemia signs
AI gastritis … not always abvious b12 def
Dx this
Girl with recurrent committing episodes. Has then in clusters…. 100% ok between episodes. Mum has migraines. Serious diseases excluded
Cyclical vomiting syndrome
Hard to tell!!
Why is is impossible for infants to get c diff infx
Neonates are often colonized with C difficile but do not develop symptomatic disease due
to absent intestinal receptors to the bacterial toxins.
If GB perforates, does it cause free air under diaphragm
No. GB doesn’t really have much gas in it
Mx overview on necrotising enterocolitis
To start
Discontinuation of enteral feeds
• Nasogastric decompression
interventions • Blood cultures & empiric antibiotics
Intravenous fluid repletion
Monitoring
• Serial complete blood count & electrolytes
• Serial abdominal examinations & imaging
Indications for surgery
• Bowel perforation (pneumoperitoneum)
• Clinical deterioration despite medical management (suggestive of bowel necrosis)
Name some Alarm features, that would make you want to do a further work up in IBD
Older age of onset (≥50)
Gastrointestinal bleeding
Nocturnal diarrhea
Worsening pain
• Unintended weight loss
• Iron deficiency anemia
• Elevated C-reactive protein
• Positive fecal lactoferrin or calprotectin
• Family history of early colon cancer or IBD
Drugs causing pancreatitis. Generally is this pancreatitis severe or mild
- Diuretics (furosemide, thiazides)
- Drugs for inflammatory bowel disease (sulfasalazine, 5-ASA)
- Immunosuppressive agents (azathioprine)
- HIV-related medications (didanosine, pentamidine)
- Antibiotics (metronidazole, tetracycline)
And CS
Mild
Diverticulosis on right or left… which causes more bleeding
Diverticulosis is most common in the sigmoid colon, but diverticular bleeding is more common in the right colon.
Massive lower GI bleed… in old patient. What is he most likely cause
Diverticula bleed
Burn injury nutrition
Enteral ASAP. unless hemodynamic ally unstable, since low BF to GI tract is a CI
Signs an symptoms of rectal prolapse
- Abdominal discomfort
• Straining or incomplete bowel evacuation, fecal incontinence
• Digital maneuvers possibly required for defecation - Erythematous mass extending through anus with concentric rings (full-thickness
prolapse) or radial invaginations (non-full-thickness prolapse)
Why are ACE inhibitor s CId in cirrhosis patients
Patients with cirrhosis have low mean arterial pressure due to splanchnic vasodilation and are
dependent on the renin-angiotensin-aldosterone system to help normalize blood pressure and renal
perfusion.
How long does it take usually for achalasia to present fully
patients with achalasia have symptoms for approximately 5 years before receiving a diagnosis,
Crazy right
Everyone with likely achalasia… needs what invx? And why?
Endoscopic evaluation can differentiate between achalasia and pseudoachalasia. In achalasia, this
evaluation usually shows normal-appearing esophageal mucosa and a dilated esophagus with possible residual material; in addition, it is generally possible to easily pass the endoscope through the lower esophageal sphincter. All patients need this
Diagnostic requirements of Acute liver failure
- Severe acute liver injury (ALT & AST often >1,000 U/L)
• Signs of hepatic encephalopathy (eg, confusion, asterixis) - Synthetic liver dysfunction (INR≥1.5)
Abdomen structure Tx
Sx resect
Red flags for underlying issue in intuss
Recurrent
Atypical location
Atypical age
Persistent bleed
Most common cause of intuss, not peyers patches hypertrophy
Mekels diverticulum
Mx overview for sigmoid volvulus
Flexible sigmoidoscopy (therapeutic), then elective colectomy to prevent recurrent.
Emergency surgery if perf or peritonitis.
Blunt abdominal trauma:
Why do non peritonitis/stable patients do CTAP after positive FAST
A positive FAST strongly suggests intraabdominal injury. In stable patients, there is time to pursue more definitive imaging (eg, CT scan) to visualize the site and extent of injury. In contrast, HDUS
patients with a positive FAST require immediate laparotomy.
Some not so known symptoms of Zenker
Undirected food regurgitate. This food is often regurgitated later and appears undigested because it has not been exposed to gastric enzymes. Aspiration of the regurgitated food may lead to recurrent aspiration pneumonia.
What are the causes of traction diverticula of the mid esophageal diverticula
Chronic inflammation in the mediastinum (eg, due to tuberculosis or fungal infections) can lead
to the formation of midesophageal diverticula due to the pull (traction) of adjacent scar
Pancreatic cancer and Jaundice, first invx
US, then do CT. CT straight away if no jaundice
How can baclofen help in alcoholics
Baclofen has been shown to decrease alcohol cravings in patients with alcoholic liver disease and can help with cessation.
Choledochocele triad, and why does it cause high bilirubin
Abdomen pain, palpable mass, jaundice. The main duct (unified CBD and pancreatic duct) is abnormally long and prone to plugging
Dx and Tx of food induced allergic proctocolitis
Clinical diagnosis confirmed by symptom resolution after protein elimination
• Breastfed infants: restrict dairy (‡ soy) from maternal diet
• Formula-fed infants: switch to hydrolyzed formula
Risk factors for C diff
Recent antibiotic use or
hospitalization
• Advanced age (>65)
• Gastric acid suppression (eg,
PPl, H2 blocker)
• Underlying inflammatory bowel
disease
• Chemotherapy
How and how often do we screen in cirrhosis patients
Abdominal US very 6mo to check for HCC
Risks of UC on preg? Are usually Tx safe?
preterm delivery and small for gestational age. Usual Txs are safe. UC will worsen in preg, so make sure it’s Managed well
Three ways battery can cause esoph erosion
Button batteries create an external current that can lead to tissue corrosion. In addition, leaking alkaline battery solution causes liquefaction necrosis of surrounding mucosa. As with any lodged object, pressure necrosis can also occur because of local inflammation and ischemia.
When are Balloon tamponade with the Sengstaken-Blakemore, Minnesota, or Linton-Nachlas tubes used in upper GI bleed
Balloon tamponade with the Sengstaken-Blakemore, Minnesota, or Linton-Nachlas tubes can
be used for the temporary control of bleeding when early endoscopy is unavailable or other modalities are unavailable and medical management is unsuccessful. Used until proper intervention can be done, but never first line
When to use contrast angiography for upper GI bleed
Contrast angiography should be considered in the small number of patients with UGIB who are
not able to be stabilized sufficiently to undergo upper endoscopy or in whom upper endoscopy is
unsuccessful in controlling hemorrhage.
How does focal nodular hyperplasia present on US
imaging will show evidence of increased arterial flow and sometimes a central scar.
Difference between physiological and pathological GERD in infants. How to Mx each
• Physiologic
Asymptomatic
“Happy spitter”
Reassurance
Positioning therapy
Pathologic (GERD)
o Failure to thrive
o Significant irritability
o Sandifer syndrome
Thickened feeds
Antacid therapy
If severe, esophageal
pH probe monitoring
& upper endoscopy
What is sandifier syndrome
Infants with GERD, and intermittent opisthontonic posturing
Goats milk for infants, issue?
Goat milk is deficient in folate and would result in a macrocytic anemia.
Stress ulcer Tx? And when to do prophylaxis for ICU patients
Prophylactic acid suppressive agents (eg, proton pump inhibitors
[PPls], H2 blockers) are a mainstay in the prevention of stress ulcerations. However, they are typically
reserved for high-risk patients (eg, bleeding diathesis, prolonged mechanical ventilation, recent Gl bleed) due to the potential harms associated with these agents, including pneumonia and Clostridiodes (formerly Clostridium) difficile infection. Patients who develop ulcerations should receive PPl and close monitoring; endoscopy may be required in those with clinically significant bleeding.
How to screen patients with first degree relative with CRCA. Consider if relative was above or below 60 years old
relative’s CRC was diagnosed at an early age (ie, <60), the patient’s screening colonoscopy should
be repeated every 5 years. If the relative’s CRC was diagnosed at a later age (ie, ≥60) and the patient has a normal initial colonoscopy, the patient has only a nominally increased risk for CRC and may undergo repeat screening as for an average-risk patient.
Other than colonoscopy, which other test has good sensitivity to screen for CRACA
FIT-DNA
Meconium ileus vs hirschorungs on X-ray
Meconium ileus has micro colon and hirschprungs has megacolon
What screening to cirrhosis patients need
all patients with cirrhosis should undergo screening endoscopy to exclude varices, determine risk of variceal hemorrhage, and indicate strategies for prevention of hemorrhage. And need US of liver
When is large volume paracentesis done for ascites
Large- volume therapeutic paracentesis is indicated in case of respiratory compromise or significant abdominal discomfort
When is TIPS indicated in varies/ascites
A transjugular intrahepatic portosystemic shunt is often used as salvage therapy in patients
with refractory ascites or esophageal varices who have failed endoscopic or medical management.
Hepatic hydrothroax usually on which side
Right
Why is AST so much higher than ALT in alcoholic cirrhosis
A ratio of AST to ALT >2 (thought to be due to hepatic deficiency of pyridoxal 5’-phosphate, an ALT enzyme cofactor)
Three main causes of super high ALT and AST
If marked elevations (>25 times the upper limit) of AST and ALT are present, toxin-
induced (eg, acetaminophen), ischemic, or viral hepatitis should be suspected.
Triggers for microscopic colitis
Smoking, medications (eg, NSAIDs, PPIs, SSRIs, ranitidine)
Mx of splenic rupture (consider if stable of unstable)
- Catheter-based angioembolization (stable patients)
• Emergency splenectomy (unstable patients)
Malrotation of small intestine can cause which two complications
Volvulus (intermittent or complete), Ladd band obstruction
Omphalocele and malroation linked?
Yes, they occur at the same stage, so they can be seen at high incidence together
Risk factors for incisional hernia after surgery
Obesity
Tobacco smoking
Poor wound healing (eg, immunosuppression, malnutrition)
Vertical or midline incision
Surgical site infection
Time frame for acute organ rejection
Less than 3 mo
How long after abdominal trauma does it take for duodenal hematoma to present
As the hematoma progressively expands over the subsequent 24-48 hours, partial or
complete obstruction of the duodenal lumen can develop.
Overview of RFs for c diff
Recent antibiotic use or
hospitalization
Risk factors
• Advanced age (>65)
Gastric acid suppression (eg,
PPI, H2 blocker)
• Underlying inflammatory bowel
disease
Chemotherapy
Why is barium enema contraindicated if perforation sus
Because it can leak into the abdomen and is toxic
What invx to order if sus perf, but X-ray equivocal
Order CT abd
How can diverticulitis cause urine leuk esterase positive
Bladder symptoms (eg, urgency, frequency, dysuria) or sterile pyuria (eg, positive leukocyte
esterase, negative nitrite/bacteria) due to bladder irritation from adjacent sigmoid colon inflammation
Summary of ascites total protein and SAAG can tell us
Total Protein low in nephrotic and cirrhosis, due to low protein generally. SAAG > 1.1 tells us it’s portal HTN related.
How to confirm a potential spontaneous bacterial peritonitis
The diagnosis is confirmed by an absolute polymorphonuclear cell count ≥250/mm?.
What colour is the ascitic fluid in bowel perforation
Patients typically have brown (bilious) ascites,
BUN:Cr >20 can mean what in GI.
blood urea nitrogen to creatinine ratio > 20) is consistent with upper gastrointestinal bleeding
Hb levels for transfusing GI bleed
stable patients without significant comorbid conditions should receive PRBC transfusion for
hemoglobin <7 g/dL. A higher threshold of hemoglobin <9 g/dL can be considered for patients with acute coronary syndrome. If there is big bleed, then can raise threshold a bit, since it can falsely raise the Hb
When to transfuse PLT
Less than 10, or less than 50 if bleeding
How does hitschsprungs present in children, if mild
Children/adolescents: Chronic constipation, failure to thrive
Further evaluation for IBS with diarrhea or constipation
IBS with diarrhea
o Stool cultures
• Celiac disease screening
o 24-hr stool collection
o Colonoscopy or flexible sigmoidoscopy & biopsy
IBS with constipation
• Radiography
• Flexible sigmoidoscopy & colonoscopy
Why some patients have recurrent cecal volvulus
patients with cecal volvulus tend to be younger and often report prior self-resolving episodes because many have a congenital mobile cecum (ie, mesentery failed to fuse with the parietal peritoneum).
X-rays power to Dx sigmoid vs cecal volvulus
However, plain radiographs are diagnostic less often in cecal than in sigmoid volvulus, so abdominopelvic CT scan is typically performed.
Main difference in Mx for cecal volvulus and sigmoid volvulus
Treatment is emergency laparotomy and resection of the volvulized colonic segment (eg, right colectomy). Endoscopic detorsion is not advised (success rate: <5%-20%). Whereas success rates are better for sigmoid endoscopic detorsion
Dx this
fever, right upper quadrant pain (which may be severe), leukocytosis,
and elevated liver function studies. The diagnosis is confirmed with abdominal imaging; CT scan
classically demonstrates a well-defined, hypoattenuating, rounded lesion,
Liver abscess
How can diverticulitis cause liver abcess
This patient likely developed the abscess as a result of his recent diverticulitis,
which allowed for the spread of bacteria from the inflamed intestines through the portal circulation.
Little pathophys of PAN in terms of arterial damage
PAN causes segmental, transmural inflammation in the arterial wall
and damages the internal and external elastic laminae, which results in arterial lumen narrowing and
microaneurysms.
If someone has ascites and in the Q they mention albumin in blood and paracentesiss. Do what?
Calc SAAG
Discuss mild ulcerative colitis. How it presents, how it’s Treated
Clinical features
<4 watery bowel movements per day
• Hematochezia is rare or intermittent
Laboratory findings
• No anemia
• Normal ESR & CRP
Treatment
• 5-Aminosalicylic acid agents (eg, mesalamine,
sulfasalazine) for induction and maintenance
Can pancreatic cancer cause gastric outlet obs
Yes, it can invade pylorus and stomach
Signs of Chronium deficiency
Glucose intolerance in DM , and high cholesterol
Signs of Cu deficiency
Brittle hair
Copper
• Skin depigmentation
• Neurologic dysfunction (eg,
ataxia, peripheral
neuropathy)
• Anemia
• Osteoporosis
Selenium deficiency signs
- Thyroid dysfunction
• Cardiomyopathy
• Immune dysfunction
Mg deficiency signs
Alopecia
• Pustular skin rash (perioral
region & extremities)
Crusting skin
Hypogonadism
Most common signs of pancreatic cancer
Weight loss and fatigue. Then abdomen and back pain. 80% of patients have this.
How is dumping syndrome caused. And what is the diagnosis and Mx
From bariatric or Nissan Sx. (Pyloric sphincter ducked or vagus snipped)
Clinical diagnosis
Mx
• Small, frequent meals
• Replacement of simple sugars with complex carbohydrates
• Incorporation of high-fiber & protein-rich foods
Describe the role of the C. difficile PCR toxin test for Dx
Many patients (20%) are carriers of Clostridioides difficile, and false-positive results can occur
with highly sensitive PR tests, which do not differentiate toxin-producing from non-toxin-producing
organisms; testing should be used only in the appropriate clinical context
Gamma gap above what is considered big
4
Are the Transaminases substantially increased in alcoholic hep?
No, 200-300. Not >400
Crepitus in abdominal wall adjacent to gallbladder and cholecystectomy signs…. Maybe the Dx is?
Emphysematous cholecysitis
Mx of emphysematous cholecystitis
- Emergency cholecystectomy
• Broad-spectrum antibiotics with Clostridium coverage (eg, piperacillin-
tazobactam)
Two fun facts for emphysamtous cholecystitis. About bilirubin levels and imaging issues
Bilirubin is high due to C. Perfringes causing hemolysis. US becomes less relaible since gas is in the GB
First step in patient with mildly high AST/ALT
patient’s history, to provide insight as to whether the transaminase elevation
could be caused by alcohol, medications (eg, NSAIDs, antibiotics, HMG-CoA reductase inhibitors,
antiepileptic drugs, antituberculous drugs, herbal preparations), or viral agents.
Patient with chronically mildly elevated LFTS, (AST/ALT). What tests should be considered
Testing for viral hepatitis B and C, hemochromatosis, and fatty liver should then be undertaken to further evaluate chronically elevated transaminases.
How is formula fed infants at increased risk of hypertrophic pyloric sphincter
, compared with breastfed infants, formula-fed infants have slower gastric emptying and typically consume more volume in less time. This increased gastric burden may stimulate pyloric muscle growth.
How does roux en Y cause stenosis, how would it present, how do we Dx andand Mx
(anastomotic) stenosis, caused by progressive narrowing of the GJ anastomosis that leads to obstruction of gastric pouch outflow. This complication usually occurs within the first year. Patients typically have progressive symptoms including nausea, postprandial vomiting, gastroesophageal reflux, and dysphagia, to the point of not tolerating liquids.
Diagnosis requires visualization of the G anastomosis via esophagogastroduodenoscopy (EGD), during
which balloon dilation can be performed to open the narrowing. Patients sometimes require surgical
revision if balloon dilation fails.
Red flags for Pediatric constipation
Lower extremity neurologic symptoms (eg, weakness) and sacral anomalies (eg, hair tuft) concerning for spinal dysraphism, as well as a history of poor growth. In this case, poor weight gain in the setting of constipation warrants consideration of celiac disease, cystic fibrosis, or hypothyroidism. Poor linear growth, in particular, is concerning for hypothyroidism, which can also present with lethargy, cold intolerance, and dry skin.
Mx overview for intuss
Retrograde pneumatic (ie, air enema) or hydrostatic (ie, contrast enema) pressure reduces the telescoped bowel in most cases. Laparotomy is indicated if enema reduction is ineffective, if a pathological lead point is identified, or if the patient has signs of perforation (eg, free air
on x-ray, rigid abdomen)
Dyspepsia/ulcer pain vs gall stones
Ulcer is described as burning (as opposed to dull like gall stones)
Vital signs in necr enterocolitis
Unstable
A false-positive D-xylose test (ie, low urinary D-xylose level despite normal mucosal absorption) can be
seen in the following:
• Delayed gastric emptying
• Impaired glomerular filtration
Small intestinal bacterial overgrowth (SIBO), leading to bacterial fermentation of the D-xylose
before it can be absorbed. SIBO is treated with rifaximin; so give that and do the test again
We see blood in stool of acute mesnteric ischemia. But is this occult or frank
Fecal occult blood testing may
be positive due to friability of ischemic intestinal mucosa, but frank hematochezia is rare until later in the disease course.
Symptoms of perirectal fistula
- Perirectal pain, discharge
• Inflammatory papule/pustule
• Palpable fistula tract
Some random labs findings of acute fatty liver of preg, and the Mx
Profound hypoglycemia
• 1Aminotransferases (2-3x normal)
Bilirubin
Thrombocytopenia
Disseminated intravascular coagulopathy
deliver
Neuro symptoms in b12 def
poor concentration and irritability to depression and dementia.
Riboflavin def signs
cheilosis, glossitis, and seborrheic dermatitis.
Pyridoxine deficiency signs
irritability and depression, glossitis,
peripheral neuropathy, and seborrheic dermatitis.
General idea to Tx colon cancer with hepatic mets
When metastatic spread is confined to the liver, surgical resection of both the hepatic
mass and the primary tumor can be curative,
Gastroschisis mx
The exposed bowel is covered with sterile saline dressings and plastic wrap immediately after delivery to minimize insensible heat and fluid losses (due to intestinal fluid sequestration). A nasogastric tube is placed to decompress the stomach, antibiotics are administered, and the defect is repaired surgically.
Infant dyschezia pathophysiology
• Failure to coordinate increased intraabdominal pressure with relaxation of the pelvic floor muscles
- Inadequate abdominal muscle tone to produce an effective Valsalva maneuver
Presentation of infant dychezia
Crying, turning red in the face, and straining for
greater than 10 minutes, followed by passage of a soft, nonbloody stool. Infants are otherwise well-
appearing with no abnormalities on physical examination.
Main cause of death in acute liver failure
Cerebral edema is a potential complication of ALF that may lead to coma and brain stem herniation, and is the most common cause of death.
E. And P. Effect on gallbladder
, estrogen causes an increase in cholesterol secretion and progesterone causes a reduction in
bile acid secretion, causing increased cholesterol saturation of bile. Progesterone also slows gallbladder emptying and thus facilitates the formation of cholesterol gallstones during pregnancy.
How to tell clinically if a loop of bowel is in a hernia
When a bowel loop is present within the hernia, it is often tympanitic to percussion.
Subphrenic abscesses comes from what?
Subphrenic abscess (rare) can cause fever and abdominal pain and are complications from perforation peritonitis
Neuropsych complications of celiacs
Despression, anxiety, neuropathy (peripheral)
Why does alkalosis worsen hepatic enceph
Metabolic alkalosis (elevated bicarbonate), which can also exacerbate HE as it promotes conversion
of ammonium (NH.*), which cannot enter the CNS, to NH3, which can enter the CNS
In theory protein restriction should help hepatic enceph, but it can worsen malnutriton in liver patients. When can we do protein restriction.
Protein restriction is generally limited to patients who have required transjugular intrahepatic
portosystemic shunting (TIPS).
Can old patients have anemia normally, without pathology
Yes, baseline anemia for which no etiology is apparent, the so-called “idiopathic anemia of ageing.”
Dx and Mx for SIBO
Diagnostic tests include carbohydrate breath tests (eg, lactulose, glucose) that measure the production of
hydrogen and/or methane by intestinal flora. Endoscopy with jejunal aspirate and culture showing
increased bacterial burden (>103 colony-forming units/mL) is the gold standard but invasive. Management
involves empiric antibiotics (g, rifaximin).
Presentation of post stomal stenosis
typically occurs in the first 1-2 months after gastric bypass surgery, and although it can
cause bloating, it typically presents with dysphagia and vomiting of undigested food rather than with
diarrhea.
Minimal bright red bloood per rectum cause
most often is due to benign disorders such as hemorrhoids or anal fissures. However, more serious disorders (eg, proctitis, ulcers, colorectal polyps, cancer) are possible.
Minimal bright red per rectum Mx. Consider if red flag or not
Anoscopy, or colonoscopy if red flags
Patient on warfarin. What do to before Op?
Stamp warfarin, give PCC (FFP second line), IV vit K
Giving PCC is good for how long? And how rapid does it work to correct PCC
Works in mins, but lasts hours only
Main drawback to FFP over PCC
Need more units and increase risk of overload . And needs cross match
Heaptorenal syndrome and spont bacterial perontitis (or ascites) recquire which fluids
albumin is indicated in the treatment of hepatorenal syndrome or spontaneous bacterial peritonitis.
Causes of oropharyngeal dysphagia
Underlying etiologies for oropharyngeal dysphagia can include stroke, advanced dementia, oropharyngeal malignancy, or neuromuscular disorders (eg, myasthenia gravis).
What medications can increase the risk of megacolon in UC
Risk with use of antimotility agents (eg, loperamide) or opioids
Contrast symptom timings in proximal and more distil SBO.
Complete proximal obstructions are characterized by early vomiting, abdominal discomfort, and abnormal contrast filling on x-ray. Mid or distal obstructions typically present as colicky abdominal pain, delayed vomiting, prominent abdominal distension, constipation-obstipation, hyperactive bowel sounds, and dilated loops of bowel on abdominal x-ray.
Maroon coloured stool on right or left colon usually
Right
In blunt trauma to abd, what can cause a delayed perf
• Bowel contusion (eg, thickened [edematous] proximal small bowel on initial CT scan) progressing to
full-thickness injury
• Injured mesenteric vasculature (eg, mesenteric hematoma on initial CT scan) progressing to
ischemia and necrosis
so don’t be too hasty to discharge
Secondary lactase deficiency? Last forever?
Usually after gastroent, but also after crohns etc. when mucosa heals, it goes away, so no need to H breath test
What is FODMAP diet, and where is it used
loperamide and the
low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) diet
represent initial steps in the management of irritable bowel syndrome (IBS).
Do we see high CRP in celiacs.
Rarely
Go through PANCREAS mnemonic for pancreatitis severity
Tx of chemo diarrhoea
Management includes oral hydration and antidiarrheal therapy with loperamide or diphenoxylate-
atropine.
How to diagnose chemo diarrhea and when to do more tests
Clinical Dx, so just Tx with loperamide and if resistant do further stool tests like ac diff
What is the ALT, FBC like in Gilbert
Normal
3 scenarios we do Sx in c diff
Signs of peritonitis: Diffuse abdominal tenderness, rebound tenderness (ie, tenderness with release
of palpation pressure)
• Colonic dilation: Megacolon (ie, colonic diameter >6 cm) on abdominal x-ray, with associated loss of
smooth muscular tone (eg, decreased diarrhea)
• Increased serum lactate: Possible marker of colonic ischemia
Name some red flags for Pediatric function constipation
Delayed passage of meconium
• Fever or vomiting
“Ribbon” stools
• Poor growth
Severe abdominal distension
• Abnormal examination findings (eg, displaced anus, tuft at gluteal cleft)
Tx for Pediatric functional constipation
1 Dietary fiber & water intake
• Limit cow’s milk (<24 oz/day)
• Laxatives (eg, polyethylene glycol)
• Age-appropriate toileting guidance
• ‡ Enemas/suppositories if severe and chronic
Correct amount of milk consume for kids
milk is appropriate (16-24 oz daily); my age
Risk factors for atraumatic splenic rupture
Hematologic malignancy (eg,
leukemia, lymphoma)
• Infection (eg, CMV, EBV, malaria)
• Inflammatory disease (eg, SLE,
pancreatitis)
• Splenic congestion (eg, cirrhosis,
pregnancy)
• Medications (eg, anticoagulation, G-
CSF)
What is kehr sign
Left shoulder tip referred pain from splenic rupture
Blood pressure aims in abdomen trauma and likely hemorrhage
With balanced resuscitation, blood products are administered only as needed to maintain a blood pressure (eg,
mean arterial pressure ~65 mm Hg) sufficient for tissue perfusion, until definitive hemorrhage control (eg, surgical
intervention) can be achieved.
Urea breath test less spec or sens than stool Ag
Less sensitive (bad for me!)
Sus viscus perforation but X-ray negative
Do CT
Mild gastroparesis first line
Hydration and small meals
Two diabetic drugs to avoid in gastroparesis
GLP ag and pramlinitide
Bezoar severe… mx?
Do endoscopic removal or even Sx
Splenic rupture if stable and unstable
Stable: angioemb
Unstable: splenectomy
VIPoma Ca, glucose, Cl and K levels
High calcium and glucose
Low K and Cl
How to differentiate stress ulcer from ischaemic colitis.
Ischaemic colitis we usually have a greater quantity of blood. And is usually more painful
My three causes of super high ALT/AFT
 Ischaemic hepatitis, paracetamol, acute hepatitis virus
Ophalocele is linked to which obstruction disorder
Maltaotion (occur at the same time)
Is IBD flare a risk for c diff
Yrs
Diagnose constipation clinically in a child, what do you do
As long as no red flags, just increase fluids and give a laxative. Don’t need to do x-ray
Normal amount of milk for an infant
24 oz
All new Ascites need what to be checked
PMN number. If above 250 equals SBP. Don’t always need cytology, amylase, triglyceride. Only do this if suspect
Polyarteritis nodosa can cause what GI symptom
Mesenteric ischaemia
How can pancreatic cancer cause gastric signs
If a Pancreatic cancer Invades the stomach, then it can cause gastric outlet obstruction
boerhaave causes FEVER 🥵
Gamma gap is calculated how. What is the upper limit
Total protein minus albumin. Any more than four, this is pathological. Seen an autoimmune hepatitis
Treatment of meconium ileus
Hyperosmolar enema. Potentially surgical evacuation
