Gastroenterology Flashcards

Question

Investigations for oropharyngeal dysphagia?

Answer 1

Neurological exam + Cine swallow

Answer 2

Mechanical and motor

Answer 3

Lower esophageal rings/webs - Schatski's ring

Answer 4

SOLIDS worse than liquids. Not temp sensitive, regurg of boluses

Answer 5

If age >50 and associated weight loss - cancer. If heartburn associated peptic stricture

Answer 6

Barium swallow, endoscopy (+/- biopsy)

Answer 7

Gradual onset, liquids and solids both affected, temp sensitive

Answer 8

Diffuse esophageal spasm

Answer 9

Spontaneous chest pain that radiates to the back + GER

Answer 10

Weight loss, regurg undigested food and dysphagia

Answer 11

Achalasia, scleroderma (reflex symptoms)

Answer 12

Barium swallow, esophageal manometry

Answer 13

ALT and AST

Answer 14

ALP and GGT

Answer 15

Fatty liver

Answer 16

Liver damage, kidney, brain, RBC and muscle (rhabdomyolysis, MI, extensive surgery, PE)

Answer 17

DINA-MAVO Drugs - anabolic steroids, tylenol, amox/clav Infection - viral hep Non-alcoholic fatty liver - associated with features of metabolic syndrome Alcohol - AST>ALT, increased MCV, increased GGT, increased IgA Metabolic liver disease - Wilsons, A-1 antitrypsin deficiency, hemochromatosis Autoimmune Vascular liver disease - ischemic hepatitis, budd chiari Other - Neoplastic (HCC, mets)

Answer 18

Viral or autoimmune hepatitis (chronic liver disease)

Answer 19

EtOH liver disease or biliary obstruction

Answer 20

Wilson’s Disease

Answer 21

Serum bilirubin, serum albumin, ALP, GGT

Answer 22

Pale, bulky and more difficult to flush.

Answer 23

Haemolysis (e.g. haemolytic anaemia) Impaired hepatic uptake (e.g. drugs, congestive cardiac failure) Impaired conjugation (e.g. Gilbert's syndrome)

Answer 24

Hepatocellular injury | Cholestasis

Answer 25

Cholestasis, bone growth (Paget’s disease, osteoblastic cancers – breast) placenta , anabolic steroids

Answer 26

- Bony metastases or primary bone tumours (e.g. sarcoma) - Vitamin D deficiency - Recent bone fractures - Renal osteodystrophy

Answer 27

PT and serum blood glucose

Answer 28

- Benign (stricture, stones, primary sclerosing cholangitis (MOST COMMON)), - Malignant (GB ca, ampullary ca, pancreatic ca)

Answer 29

- Granulatomous - DINA (drugs, infection (TB or schistosomiasis), neoplasm (lymphoma), autoimmune (sarcoid, primary biliary cirrhosis or cholangitis). - Drugs (protease inhibitors, hormones, antibiotics, steroids) - Other (fibrosing or alcohol hepatitis, rare disorders, amyloid, paraneoplastic)

Answer 30

Inflammation of the salivary glands

Answer 31

Presentation: acute onset of pain and edema of parotid or submandibular gland that may lead to marked swelling ± fever, ±leukocytosis, ± suppurative drainage from punctum of the gland

Answer 32

Lab features: high serum amylase

Answer 33

Cause: usually bilateral (sometimes unilateral) inflammation of the salivary glands caused by mumps virus (usually Paramyxovirus) OR bacteria (often staph aureus).

Answer 34

Treatment: supportive if viral. Complications can affect postpubertal male testicles causing epididymitis → sterility. If bacterial – treat with cloxacillin ± abscess drainage, sialogogues

Answer 35

Presence of calculi/stones in salivary glands or ducts

Answer 36

Most (80 to 90 percent) salivary gland stones occur in the submandibular glands, 6 to 20 percent occur in the parotid glands, and 1 to 2 percent occur in the sublingual or minor salivary glands

Answer 37

Pain in gland region especially when eating ± swelling near submandibular region. About 33% present with painless swelling. Usually unilateral.

Answer 38

Can show up on X-ray, but up to 20% not detected on X-ray. Can try sialogram (inject dye and film duct system).

Answer 39

- Mainstay is conservative management - Patients should be instructed to keep well hydrated, apply moist heat to the involved area, massage the gland, and "milk" the duct - Nonpharmacologic agents that promote salivary flow (eg, tart, hard candies such as lemon drops) - Discontinue medications with anticholinergic effects that reduce salivary flow, such as diphenhydramine and amitriptyline. - NSAIDS - Surgical intervention — If minimally invasive interventions are not successful, the salivary stone can be removed surgically.

Answer 40

Risk factors for this includes age and medication use

Answer 41

Mouth dryness or mucinous quality saliva

Answer 42

Causes: anticholinergic action of systemic medications, radiation for head/neck cancer, Sjogren’s syndrome

Answer 43

Presentation: messed up taste, dry mouth or mucous mouth, infection, dental caries (saliva acts as a buffer)

Answer 44

Management: review meds, dental measures, substitute or stimulate saliva with ACh analogues (e.g. Pilocarpine).

Answer 45

Autoimmune injury to salivary + lacrimal glands (incurable)

Answer 46

The most common diseases associated with SS are rheumatoid arthritis and systemic lupus erythematosus.

Answer 47

Presentation: dry eyes and mouth, possible swelling of glands usually bilaterally.

Answer 48

Malignant lymphoma developing in salivary glands

Answer 49

In individuals with persistent symptoms of dry eyes and/or mouth, parotid gland enlargement, an unexplained increase in dental caries, or abnormal results of specific serologic tests (eg, anti-Ro/SSA antibodies with or without anti-La/SSB antibodies, rheumatoid factor, and hyperglobulinemia).

Answer 50

Incurable, maybe monoclonal antibodies, saliva substitutes or stimulants (Salagen)

Answer 51

They are cavities filled in with mucus and lined by epithelium or covered by granulation tissue, resulting from damage of a salivary gland duct and extravasation of mucus into the surrounding tissue.

Answer 52

Presentation: Hx: minor trauma, esp. lower lip usually in young children and adults

Answer 53

Remove associated minor gland. Surgical removal of the entire lesion and histologic confirmation of clinical diagnosis is the standard management of mucocele

Answer 54

No Tx with lancing

Answer 55

Excess sun exposure. It can also be a sign of iron deficiency.

Answer 56

Cheilitis is an acute or chronic inflammation of the lips characterized by dryness, scaling, erythema, and fissuring of the lips.

Answer 57

Exclude other mucosal diseases, including xerostomia and allergic contact stomatitis.

Answer 58

Burning mouth syndrome is a disorder affecting predominantly postmenopausal women characterized by a persistent intraoral burning sensation, without clinical signs, and for which no medical or dental cause can be found.

Answer 59

Treatments for burning mouth syndrome include tricyclic antidepressants, benzodiazepines, and gabapentin.

Answer 60

Cause: esp. parotid gland (80-85%) but majority benign

Answer 61

>50% minor salivary gland tumors are malignant

Answer 62

Tx: wide excision

Answer 63

Recurrent aphthous stomatitis

Answer 64

Aphthae are painful oral lesions that appear as localized, shallow, round to oval ulcers with a yellowish adherent exudate centrally.

Answer 65

Causes: Many patients with RAS experience an exacerbation of their disease following trauma to the oral mucosa, such as biting the inside of the cheek or undergoing a dental procedure.

Answer 66

In most individuals, they resolve in 10 to 14 days

Answer 67

Celiac + crohn’s, behcet’s syndrome (Triad of oral, genital, and eye ulcers)

Answer 68

Triad of oral, genital, and eye ulcers

Answer 69

Behçet syndrome are believed to be due to vasculitis. Among the systemic vasculitides, Behçet syndrome is remarkable for its ability to involve blood vessels of all sizes (small, medium, and large) on both the arterial and venous sides of the circulation.

Answer 70

Genital ulceration, the most specific lesion for Behçet syndrome, occurs in 75 percent or more of patients with Behçet syndrome

Answer 71

HIV/AIDS can be associated with canker sores – other manifestations include candidiasis, hairy leukoplakia, squamous cell carcinoma, Kaposi’s, or major ulcers.

Answer 72

Tx: General measures aimed at maintaining good oral hygiene (soft toothbrush, waxed tape-style dental floss, and a soft-tipped gum stimulator to gently remove plaque are generally well tolerated.), avoiding exacerbating factors (reduce traumatic factors inside the mouth (eg, sharp/rough dental restorations, braces). Avoid habits that cause trauma (eg, biting cheeks or lips) and foods that seem to exacerbate the process), and reducing pain (viscous lidocaine) are appropriate for essentially all patients with RAS

Answer 73

Early childhood caries are an infectious disease caused by strep mutans

Answer 74

Affects low income/Aboriginals more

Answer 75

Prevention: early identification of disease or risk (enamel is thinner near the gingiva), stop transmission (improve mum’s oral health), lower bacterial levels (screening, brushing, fluoride), reduce enviro factors like diet and bottle feeding at night, apply fluoride to strengthen teeth.

Answer 76

- Extracted are by expanding the socket, severing the periodontal ligament - Stainless steel crowns

Answer 77

Risk factors: sun exposure, smoking, alcohol

Answer 78

Pre-malignant lesions (i.e. leukoplakia or erythroplakia)

Answer 79

Cancers are often indurated and firm with a rolled border.

Answer 80

The oral mucosa is involved in about 50% of cases

Answer 81

Reticulated, lacy, bluish white, linear lesions (Wickham striae) are a hallmark of oral lichen planus, especially on the buccal mucosae.

Answer 82

2 groups: - Syndromic (30%) - oral clefts are those present in patients with recognized congenital syndromes or with multiple congenital anomalie. Chromosome abnormalities and defined monogenic syndromes. - Nonsyndromic (70%) - oral clefts are those present in patients without associated anomalies or developmental delays.

Answer 83

Tx: surgical repair

Answer 84

- Labs: CBC (anemia, infection), LFTs, amylase + lipase (pancreatic CA), CEA (colon CA), α-Fetoprotein (HCC), CA-125 (ovarian CA) - Endoscopy - ERCP - US (biliary tree + liver) - CT (neoplasms + infection) - MRI (delineate liver masses) - Leukocyte scans may define the extent and locations of intra-abdominal abscesses

Answer 85

- Pain related to meals or defecation suggests a lumenal origin, whereas gross or occult fecal bleeding or alterations in bowel function suggest either a primary source within or invasion of a lumenal site. - Nausea and vomiting with abdominal distension raise concern for an obstructive process within the proximal gut. - Dysuria or hematuria may indicate involvement of the urinary tract either by primary disease or by local irritation, as with Crohn’s disease. - Jaundice suggests benign or malignant obstruction at the level of the pancreas or bile ducts. - Impingement of a large mass on surrounding vasculature may present with lower extremity edema or intestinal ischemia. - Ascites may indicate peritoneal metastases from an intra-abdominal malignancy or a worsening of liver function in a cirrhotic patient with hepatocellular carcinoma. - High fever points toward an intra-abdominal abscess, whereas unexpected loss of more than 5% of body weight raises suspicion of malignancy - HTN - Menstrual irregularities

Answer 86

- Scleral icterus or jaundice suggests liver infiltration versus biliary obstruction from a bile duct or pancreatic tumor. - Temperature higher than 38°C is consistent with an infectious or inflammatory process such as an intra-abdominal abscess. - If the mass is tender, as with Crohn’s disease, this suggests that the mass is inflammatory. - Lymphadenopathy raises concern for metastatic malignancy. Palpable supraclavicular (Virchow) or periumbilical (Sister Mary Joseph) nodes are found with gastric cancer. - Rectal examination detects approximately half of all rectal neoplasms

Answer 87

Organomegaly - Hepatomegaly - Splenomegaly - Enlarged kidneys (e.g., cysts, hydronephrosis) Neoplasms (benign/malignant) - Lymphoma/Sarcoma 0 Gastrointestinal tumors (e.g., gastric, colon, pancreas, hepatoma, gastrointestinal stromal tumor) - Gynecologic tumors (e.g., ovarian, uterine) - Renal/adrenal - Neuroblastoma Gynecologic - Ovary (e.g., benign or malignant) - Tube (e.g., ectopic pregnancy) - Uterus (e.g., leiomyoma, pregnancy) Bladder/prostate (e.g., urinary retention, cancer) Other - Pancreatic pseudocyst - Vascular (abdominal aortic aneurysm) - Abdominal wall masses

Answer 88

Infrequent passage of stools, passage of hard/small stool, excess straining during defecation or sense of incomplete bowel evacuation

Answer 89

1. Functional | 2. Organic

Answer 90

Slow-transit constipation (Chronic constipation with modest abdominal discomfort in a patient who has used laxatives for a long time), irritable bowel syndrome, pelvic floor dysfunction (functional defecatory disorders)

Answer 91

- Medication side effects (narcotics, antidepressants/, Ca channel blockers) are the most common - Intestinal obstruction, left sided colon cancer (consider in older patients), and fecal impaction - Metabolic – DM, hypothyroidism, hypercalcemia, hypokalemia, uremia - Neurological - spinal cord compression/injury, intestinal pseudo-obstruction, Parkinson’s disease, MS - Collagen vascular disease (e.g. scleroderma) - Painful anal conditions (e.g. fissures) - Diet: Low-fiber diet, sugar-restricted diet, chronic laxative abuse

Answer 92

Stool firm, difficult to expel, passed with straining, abdominal pain relieved by defecation, flatulence

Answer 93

Certain findings raise suspicion of a more serious etiology of chronic constipation: Distended, tympanitic abdomen, Vomiting, Blood in stool, Weight loss, Severe constipation of recent onset/worsening in older patients

Answer 94

Based on a flat AXR, divide into four quadrants (ascending, transverse, descending, and rectosigmoid colon) – rate the amount of stool in each quadrant 0-3 and a total score of >6/12 suggests constipation

Answer 95

1: like rabbit droppings 2: grapes 3: corn on cob 4: sausage 5: nugs 6: porridge 7: gravy

Answer 96

Colon visualization (colonoscopy, CT colonography)

Answer 97

RECTAL EXAM (anal wink reflex, observe perineal descent on bearing down, resting tone, squeeze pressure).

Answer 98

- Underlying disease rarely found if constipation is the only presenting symptom – thus treat symptomatically - Only test indicated in this situation is a CBC (2013 recommendation of American Gastroenterology Association), but also consider TSH, calcium, and glucose, X-ray of abdomen

Answer 99

Send for colonic transit or anorectal manometry if normal, or barium/MR defecography in unsure. NO COLONOSCOPY unless >50 or alarm features.

Answer 100

Stool softeners such as docusate sodium 100-240mg PO QID (eg, Colace) are intended to lower the surface tension of stool, thereby allowing water to more easily enter the stool. Although these agents have few side effects, they are less effective than other laxatives

Answer 101

o Patient education: exercise, hydration of 8-10 glasses per day) + stop offending meds + treat underlying cause o Dietary changes and bulk-forming laxatives: Dietary fiber (wheat bran/high fibre cereals) and bulk-forming laxatives such as psyllium or methylcellulose 2-3 teaspoon/day

Answer 102

 PEG – PEG 3350 250ml-4L PO PRN and powdered preparations (eg, MiraLAX) that do not contain electrolytes are available for the treatment of chronic constipation  Synthetic disaccharides – Lactulose 15-60ml PO daily (eg, Enulose) is a synthetic disaccharide. It is not metabolized by intestinal enzymes; thus, water and electrolytes remain within the intestinal lumen due to the osmotic effect of the undigested sugar. Lactulose requires some time (24 to 48 hours) to achieve its effect. Another example is Sorbitol 15-30ml PO BID  Saline – Saline laxatives such as milk of magnesia 15-30ml PO BID, magnesium citrate 150-300ml PO daily, or water containing high amounts of magnesium sulfate are poorly absorbed and act as hyperosmolar solutions

Answer 103

Stimulant laxatives such as bisacodyl (eg, some forms of Dulcolax), senna (eg, Senokot), and sodium picosulfate (eg, Dulcolax drops) primarily exert their effects via alteration of electrolyte transport by the intestinal mucosa. They also increase intestinal motor activity.

Answer 104

- Initial trial of suppositories (glycerin or bisacodyl) since suppositories can be effective in liquifying stool and thereby overcoming obstructive defecation. - Disimpaction — Patients with a fecal impaction (a solid immobile bulk of stool in the rectum) should initially be disimpacted starting with manual fragmentation if necessary. After this is accomplished, an enema with mineral oil will help to soften the stool and provide lubrication.

Answer 105

Increased stool liquidity + weight (more than 300 g/day), increased stool frequency (>3/day)

Answer 106

Associated with urgency, abdominal cramps, and incontinence

Answer 107

(<2 wks) is usually infectious (90%), a drug side effect, or a toxin. Usually self-limiting + resolve within 7d.

Answer 108

Raw or undercooked meat/seafood, unpasteurized dairy products, antibiotics/laxatives, high risk sexual activity, infectious outbreaks, family history (IBD), occupational exposures

Answer 109

- Non-inflammatory (Watery) | - Inflammatory

Answer 110

Viral (Rotovirus, Adenovirus, Norovirus), E Coli, Giardia, Cryptosporidiosis (Every virus gets caught), drugs (colchicine, antibiotics): • Rotavirus (MOST COMMON for kids) – oral-fecal transmission, contagious, diagnose by stool antigen test. NEW VACCINE AVAILABLE (LIVE). • Adenovirus is similar but can be transmitted by the respiratory route. • Norovirus – oral-fecal also, from shellfish, often associated with vomiting. ON CRUISES! Cooking kills it

Answer 111

Bloody (not always), Small volume, high frequency, Often lower abdominal cramping with urgency ± tenesmus. May have fever ± shock

Answer 112

Fecal WBC and RBC positive

Answer 113

* Organisms and cytotoxins invade mucosa, killing mucosal cells, and further perpetuating the diarrhea * Usually colon

Answer 114

Salmonella, Shigella, Campylobacter – most common, E Coli 0157H:7, Yersinia. (SECSY). Others: NSAIDs, IBD, ischemic

Answer 115

>4wks, rarely infectious/parasitic (exceptions are Giardiasis, C. Difficile)

Answer 116

1. Osmotic 2. Secretory 3. Inflammatory 4. Abnormal motility

Answer 117

Caused by ingestion of non-absorbable, osmotically active substance. Usually lactase would cleave lactose into component sugars, but if deficient, then lactose continues into colon where bacteria will digest and cause CO2/H2 production (fermentation) + short-chain-fatty-acids = liquidy stool

Answer 118

Congenital vs. acquired due to viral gastroenteritis, small bowel disease – celiac or Crohn’s, aging. Lactose, fructose, mannitol/sorbitol, lactulose, divalent ions Mg2+ ingestion – antacids or Epsom salts.

Answer 119

Diarrhea stops with fasting, Hx of ingestion of offending substance, minimal cramps and pain - no RBC’s or mucus in stool; stool pH<6 if carbohydrate malabsorption

Answer 120

Loss of fluids + electrolytes from intestine

Answer 121

Cholera, meds (Mg antacids, Abx, NSAIDs, colchicine, beta blockers, PPI, antineoplastic agents, prostaglandins), bacterial toxins, bile salt wasting (prev. cholecystectomy), toxins (EtOH, arsenic), secretagogues, laxatives

Answer 122

Diarrhea persists despite fasting, minimal cramps and pain, large volume watery stools, absence of mucus, blood, or excess fat in the stool

Answer 123

Some kind of damage to gut villi = breakdown of cells = activated inflammatory mediators

Answer 124

Invasive infections (Salmonella, Shigella, E.coli 0157H:7, Campylobacter, Yersinia), radiation therapy, IBD (UC or Crohn’s)

Answer 125

Systemic symptoms like fever, fatigue, night sweats, weight loss; visible blood in stools, significant cramps and pain, PMN’s on stool microscopy

Answer 126

Reduced transit time leads to decreased water absorption.

Answer 127

IBS, hyperthyroidism, post-surgical diarrhea (vagotomy, resection of ileocecal valve)

Answer 128

Stools tend to be soft, porridge-like

Answer 129

o Organic: systemic features, blood, pus, weight loss, nocturnal diarrhea, recent onset, age >50. o IBS/functional: no systemic features, no blood or pus, stable weight, never at night, longstanding, age <50.

Answer 130

Can be due to bacteria (E coli – most common, salmonella, C jejuni), virus (rotavirus), or parasite (giardia from Nepal, St Petersburg, Rocky Mountains). Prevent through normal measures and prophylaxis (Dukoral for E coli and Cholera – only 40% effective for 3 mnths).

Answer 131

C Difficile (get pseudomembranous colitis)!

Answer 132

Opportunistic infections (Cryptosporidia, CMV)or lymphoma

Answer 133

Travel, homosexual contacts, outbreaks, seafood, extraintestinal signs of IBD, FHx, antibiotics, diet, steatorrhea, weight loss, immunosuppressed, laxatives, tumor history , sexual history

Answer 134

Stool culture/microscopy (C&S/O&P) required for inflammatory/severe/epidemiological purpose - C&S: only tests Salmonella, Shigella, E.coli 0157H:7, Campylobacter; must order other organism - C. Difficile Toxin: if recent/remote abx use, hospitalization, nursing home, recent chemo - Flexible Sigmoidoscopy: if not perforation, if inflammatory; biopsies help dx IBD vs. infectious colitis

Answer 135

- Stool Analysis for: C. Difficile, C&S/O&P +/- fecal fat, WBC, stool osmolality (secretory vs. osmotic diarrhea) - Hematology: CBC + lytes + CRP + TSH + celiac serology (IgA, anti-tTG, + IgA = rule out IgA deficiency - ^frequency w/ celiac disease) - FIT - Colonoscopy/Ileoscopy/Gastroscopy: If chronic - for biopsy - Trial: of lactose free diet – however, may delay dx of IBD and celiac disease

Answer 136

Fever or hematochezia

Answer 137

Generally not required unless pt high risk or has severe Sx (>6 episodes/day, hematochezia, febrile > 1wk) Most cases are self limiting

Answer 138

Hydration PO Rehydration Solutions: fluid/lyte replacement PO, IV if severe extremes of age/coma Pedialyte, Apple Juice, i.e. bring ^Na+ in via Na+ channels + glucose coupled receptors

Answer 139

Fidaxomicin or vancomycin. 2nd line - Metronidazole - Vancomycin is always given IV with C.diff being the one EXCEPTION to it being given orally. - Duration = 10 days

Answer 140

Metronidazole

Answer 141

Activation of δ receptors = reduced secretory activity + mew receptors = enhanced NaCl + water absorption = net effect of reduction of fluid entering the large intestines

Answer 142

Act by absorbing intestinal toxins/micro-organisms or by coating intestinal mucosa

Answer 143

Bismuth subsalicylate (Pepto-Bismol)

Answer 144

Methylnatrexone or alvimopan. If you constipate someone with too much opioid, reverse with these.

Answer 145

- Food and water choices (boiled or bottled water only, no ice, purify your own water – filter/drops. Avoid: fruit salads, lettuce, chicken salads, guacamole, street vendors. Eat fruit that can be peeled, well cooked, boiled; prophylaxis usually not recommended – but, dukoral PO vaccine (E. Coli, Cholera) - Empiric Antibiotics for Traveler’s Diarrhea of Moderate/Severe Quality: ciprofloxacin or azithromycin or rifaximin; however, there is increasing fluoroquinolone resistance in causative agents, especially in South America and Southeast Asia

Answer 146

Kaolin/pectin (Kaopectate), methylcellulose, activated attapulgite

Answer 147

Side Effects: abdo cramps, toxic megacolon

Answer 148

Diphenoxylate, loperamide (Imodium)

Answer 149

Not in mucosal inflammation or hematochezia because of concerns that antimotility agents can prolong disease in such infections or lead to more severe illness. In such patients, bismuth salicylate (Pepto-Bismol, 30 mL or two tablets every 30 minutes for eight doses) is an acceptable alternative

Answer 150

- Anti-Motility Agents - Absorbants - Modifiers of Fluid Transport - Opioids

Answer 151

Involuntary reflux of gastric contents into esophagus. The esophagus mucosa has stratified squamous epithelium and is more susceptible to acid damage. The lower esophageal sphincter (LES) blocks acid from coming up into the esophagus. When pressure decreases, gastric acid can reach esophagus and decrease the esophagus pH.

Answer 152

Obesity (increased abdo pressure), lower esophageal sphincter pressure, decreased esophageal peristalsis, gastric acid hypersecretion (Zollinger-Ellison syndrome), delayed gastric emptying, and overeating

Answer 153

EtOH, nicotine, obesity, dietary fat, peppermint, meds (narcotics, Ca2+ channel blockers, aspirin and NSAIDS), hormones (estrogen, glucagon)

Answer 154

- Typical Heartburn - sensation of discomfort or burning behind sternum and radiating toward neck, throat, and occasionally the back; typically occurs postprandially. - Regurgitation - perception of flow of refluxed gastric contents into mouth or hypopharynx - Less common/atypical symptoms: chest or epigastric pain and/or discomfort, water brash (excessive saliva mixing with stomach acid in throat and mouth), chronic cough, wheezing, burping or hiccups, bloating, hoarseness, sore throat, dysphagia or odynophagia, either of which indicates upper endoscopy

Answer 155

* Effect of symptoms on quality of life including missed work * Nocturnal symptoms * Sleep disturbance * Alcohol use * Consumption of various foods reported to possibly provoke GERD symptoms such as coffee, chocolate, fatty or fried foods, or spicy foods (based on limited and conflicting evidence)

Answer 156

Medications reported to potentially exacerbate or cause symptoms of GERD include: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers, nitroglycerin, nitrate, anticholinergic agents, alpha-adrenergic antagonists, prostaglandins, theophylline, sedatives, antidepressants, sildenafil, albuterol, glucagon, bisphosphonates

Answer 157

o Physical exam typically unremarkable o Atypical signs of GERD may include: Dental erosion, wheezing, sinus or pulmonary problems such as recurrent otitis media or laryngitis

Answer 158

- GERD is usually a presumptive clinical diagnosis based on bothersome presence of heartburn and/or acid regurgitation, and patient response to empiric trial of proton pump inhibitors (PPIs) - Proton pump inhibitor (PPI) trial consists of administration of any available PPI at appropriate dose once or twice daily for 1-2 weeks to assess treatment response

Answer 159

Indications include alarm symptoms, high risk for Barrett’s (male, age >50, obese, white, tobacco use), inadequate response to PPI trial (4-8wks) Options include upper endoscopy (might not show anything) and 24hr pH monitoring • Can determine relationship between reflux and sx

Answer 160

* Dysphagia * Odynophagia * Hematemesis, anemia (symptoms may include fatigue, pallor, or dyspnea on exertion), or other signs of upper gastrointestinal bleeding * Weight loss * Epigastric mass * Vomiting

Answer 161

Esophageal manometry

Answer 162

Nonmalignant esophageal disorders: Motility disorders such as achalasia or diffuse esophageal spasm, Eosinophilic esophagitis (in adults or children), Other causes of esophagitis, such as pills, infection, radiation, or caustic agents, Rumination syndrome, Esophageal strictures, webs, or rings, Zenker diverticulum Other nonmalignant gastrointestinal disorders: Functional dyspepsia, Peptic ulcer disease, Gastroparesis, Biliary tract disease or colic, Supragastric belching Malignancies: Esophageal and esophagogastric junction cancer, Gastric cancer Coronary artery disease Chest wall pain Oropharyngeal and laryngeal disorders Food allergy Functional esophageal disorders

Answer 163

Functional esophageal disorders

Answer 164

Reflux hypersensitivity, characterized by normal esophageal acid exposure but a positive (> 95%) symptom association probability (SAP) for acid reflux or nonacid reflux.

Answer 165

Esophageal complications include esophagitis, esophageal ulcer, esophageal stricture, and Barrett’s syndrome. Extra esophageal complications include asthma, aspiration, chronic cough, hoarseness, chronic laryngitis, and dental erosions.

Answer 166

Dietary (avoid fat, caffeine), avoid eating 4h before bed, smoking, elevate head of bed (6-9 in), weight loss, avoid tight fitting clothes.

Answer 167

 PPI (pantoprazole) for 4-8 weeks is first line treatment – if inadequate: optimize dose, consider twice daily, consider endoscopy  Histamine receptor antagonist - H2RAs (ranitidine - Zantac) may improve GERD symptoms but may be less effective than PPIs  OTC Antacids PRN may provide short-term relief from heartburn but may not provide prolonged symptom relief nor prevent GERD complications

Answer 168

Surgery: Nissen fundoplication – gastric fundus is wrapped around the LES strengthening junction

Answer 169

Metaplasia of normal squamous esophageal epithelium to intestinal columnar epithelium containing- type intestinal mucosa (intestinal metaplasia)

Answer 170

Thought to be acquired via long-standing GERD and consequent damage to squamous epithelium

Answer 171

More common in males, age >50, Caucasians, smokers, overweight, hiatus hernia, and long history of reflux symptoms

Answer 172

o Endoscopy shows erythematous epithelium in distal esophagus; diagnosis of BE relies on biopsy demonstrating the presence of specialized intestinal epithelium of any length within the esophagus o BE predisposes first to premalignant changes characterized a slow or high-grade dysplasia, which then progresses to adenocarcinoma

Answer 173

o Acid suppressive therapy with high-dose PPI indefinitely (or surgical fundoplication) o Surveillance gastroscopy every 3yr if no dysplasia

Answer 174

Regular and frequent surveillance with intensive biopsy, endoscopic ablation/ resection, or esophagectomy produce similar outcomes; however, evidence increasingly favouring endoscopic ablation with mucosal resection or radiofrequency ablation

Answer 175

If low grade dysplasia, both surveillance (every 6mo for 1yr then annually) and endoscopic ablation/resection are satisfactory options

Answer 176

Blood in stool, passage of dark blood/clots, recent changes in bowel habits, tenesmus, changes in weight/appetite/energy, personal medical history of polyps, FHx of colon cancer or hereditary polyposis

Answer 177

1. Abdo exam 2. EDAP (External, digital, anoscopy, proctoscopy) - External – skin tags, hemorrhoids, fissure, prolapse, skin tags, pruritis, inflammation - Digital – tone (circumferential), masses, irregularities and tenderness. DON’T DO THIS IF FISSURE - Anoscopy – best tool for hemorrhoids - Proctoscopy – looks at the rectum at length

Answer 178

- If BRBPR and hemodynamic instability > r/o upper GI bleed, diverticular (60% from R colon), meckel’s diverticulum - Vascular: angiodysplasia, hemorrhoids, fissures - Neoplasm: CA, polyps - Inflammation: colitis (UC, infectious, radiation, ischemic) - Post-Polypectomy - Trauma - Coccygeal pain

Answer 179

- Anoscopy / Rigid Sigmoidoscopy > allow you to see hemorrhoids/rectal mucosa/polyps/CA - FIT Test > good for occult blood, NOT overt bleeding (screening test) - To exclude CA: - >50yo + bleeding > colonoscopy (if with red flags urgently) - <50yo + bleeding > rigid or flexible sigmoidoscopy/barium enema

Answer 180

Purulent discharge, Pain in the rectum (sometimes) and/or abdomen (often), Sometimes draining fistula, Sometimes diarrhea

Answer 181

^intra-abdominal pressure (chronic constipation, pregnancy, obesity, portal HTN, heavy lifting)

Answer 182

- Vascular and connective tissue complexes form a plexus of dilated veins (cushion) - Internal: superior hemorrhoidal veins, above dentate line, portal circulation - External: inferior hemorrhoidal veins, below dentate line, systemic circulation

Answer 183

Engorged vascular cushions usually at 3, 7, 11 o’clock positions (patient in lithotomy position). Painless rectal bleeding, anemia, prolapse, mucus discharge, pruritus, burning pain, and rectal fullness

Answer 184

1st Degree: bleed but do not prolapse through anus

Answer 185

High fibre/bulk diet, sitz bath, steroid cream, pramoxine (Anusol, hydrocortisone, preparation H), rubber bad ligation, sclerotherapy, photocoagulation

Answer 186

2nd Degree: bleed, prolapse with straining, spontaneous reduction

Answer 187

Treatment: rubber band ligation, photocoagulation

Answer 188

3rd Degree: bleed, prolapse, requires manual reduction

Answer 189

Treatment: rubber band ligation (doesn’t work as well), or hemorrhoidectomy

Answer 190

4th Degree: bleed, permanently prolapsed and cannot be manually reduced

Answer 191

Closed hemorrhoidectomy – closes the mucosa with sutures after hemorrhoid tissue removal vs open which leaves the mucosa open. Crohn’s disease is a contraindication to hemorrhoidectomy

Answer 192

Usually present as a bulge or a mass in the anoderm below the dentate line. Often very painful as it is in an area of somatic sensory innervations

Answer 193

Mildly symptomatic, pain after bowel movement, associated with poor hygiene, bleeding

Answer 194

Dietary fibre, stool softeners, steroid cream (short course), pramoxine (Anusol), avoid prolonged straining

Answer 195

Very painful, more likely to bleed, resolve w/n 2wks, may leave perianal skin tag

Answer 196

Treatment: thrombectomy: patient with acute thrombosis and present within 24 hours. After 24 hours is usually not effective – better managed by treating the pain with ice

Answer 197

Tear of anal canal below dentate line (very sensitive squamous epithelium) usually due to constipation, 90% posterior midline, 10% anterior midline because the posterior midline is in the watershed area of blood supply; if off midline = consider other possible causes such as IBD/STI/TB/leukemia/anal carcinoma

Answer 198

Repetitive Injury after 1st Tear: sphincter spasm occurs preventing edges from healing and leads to further tearing, ischemia may ensure and contribute to chronicity

Answer 199

- Local trauma: constipation, irritation, diarrhea, vaginal delivery, anal intercourse - Secondary to: Crohn's disease, granulomatous diseases, malignancy, communicable diseases

Answer 200

Acute: very painful BRBPR especially after bowel movement, sphincter spasm on limited DRE. Pain can last for hours after defecation Heals in 1-2 weeks with treatment

Answer 201

Chronic: fissure, sentinel skin tags (Thickened mucosa/skin at the distal end of an anal fissure that is often confused with a small hemorrhoid), hypertrophied anal papillae; anal ulcer

Answer 202

Acute: conservative – stool softeners, bulking agents, sitz bath, analgesia

Answer 203

- Conservative - Topical Nitroglycerin or Nifedipine: ^local blood flow, promote healing/relieves sphincter spasm - Botox: In the intersphincteric groove inhibits release of Ach, reducing sphincter spasm - Lateral Internal Anal Sphincterotomy: (most effective, 90% heal successfully) cut the internal sphincter to release it from spasm, not often done, used in chronic fissure refractory to conservative treatment

Answer 204

At the dentate line, there are crypts and anal glands. These glands extend through the internal sphincter into the intersphincteric space. When obstructed, this can lead to abscess in a number of potential spaces.

Answer 205

Perianal | Ischiorectal

Answer 206

Cryptoglandular abscess accounts for 90% of anorectal abscess/fistula disease. The remaining 10% are due to IBD, atypical infections such as TB or actinomycosis, trauma (both community acquired such as foreign body or impalement and hospital acquired such as episiotomy or prostatectomy), and malignancy

Answer 207

E. coli, proteus, streptococci, staphylococci, bacteriodes, anaerobes

Answer 208

Throbbing pain that may worsen with straining/ambulation, abscess can spread vertically downward (perianal), vertically upward (supralevator), or horizontally (ischiorectal), tender perianal/rectal mass on exam

Answer 209

Irrigation and debridement (curative in 50% of cases, 50% develop anorectal fistulas), may require antibiotics if DM/heart murmur/cellulitis, sitz bath, anal hygiene and stool softeners

Answer 210

Fistula from anal canal to perianal skin; inflammatory tract w/ internal os at dentate line (almost always) + external os on anal skin. Most are cryptoglandular origin and go to the intersphincteric space.

Answer 211

1. Intersphincteric 40% 2. Trans-sphincteric 30% (through the external sphincter muscle). 3. Suprasphincteric 20% very rare 4. Extrasphincteric 10% - don’t start at the dentate line

Answer 212

Same processes that lead to the formation of an anal abscess, others (post op, trauma, anal fissure, malignancy, radiation proctitis). **THINK ABOUT CROHN’S

Answer 213

Intermittent or constant purulent d/c from perianal opening, pain, redness, tender, swelling, palpable cord-like tract, recurrent perirectal abscess

Answer 214

Fistulas originating anterior to a transverse line through the anus will have a straight course and exit anterior, whereas those originating posterior to the transverse line will begin in the midline and have a curved tract.

Answer 215

Goodsall’s rule does not apply to patients with Crohn’s disease

Answer 216

- Goodsall’s Rule | - Fibrous Tract: probing or fistulography under anesthesia

Answer 217

A simple anal fistula are low and include superficial, intersphincteric, or low transsphincteric fistulas. They also involve only one communicating tract and are not associated with inflammatory bowel disease (IBD) or other organs (bladder or vagina).

Answer 218

Complex fistulas are higher along the gastrointestinal (GI) tract, have multiple tracts, involve other organs, are recurrent, or are associated with IBD or radiation.

Answer 219

Usually more aggressive cutting out muscle when posterior anal canal (especially in men), and less aggressive when anterior anal canal (especially in women)

Answer 220

Fistulotomy: unroof tract from external to internal opening, allow drainage, heals by secondary intention (occurs when the sides of the wound are not opposed, therefore healing must occur from the bottom of the wound upwards)

Answer 221

Low lying fistula (does NOT involve external sphincter) > primary fistulotomy

Answer 222

High lying fistula (involves external sphincter) > staged fistulotomy with Seton suture placed through tract - Thick suture placed through fistula tract to allow slow transection of sphincter muscle; scar tissue formed will hold the sphincter muscle in place and allow for continence after transection (promotes drainage and fibrosis, decreases incidence of incontinence, delineates anatomy, usually done to spare muscle)

Answer 223

- For complex fistulas there is usually a primary track which is connected to the internal opening and secondary tracks arise from this. You want to control that primary track first with a seaton suture - Tissue glue and fistula plug aim to fill the primary track with fibrosis and the external opening left open - Ligation of Intersphincteric Fistula Tract (LIFT): alternative for high lying fistula – access fistula between sphincter muscles and ligate them, sparing them

Answer 224

Sitz bath, irrigation and packing to ensure healing from inside to outside (fistulas heal from the bottom up).

Answer 225

Cyst/abscess near or on the intergluteal cleft of the sacrococcygeal area containing hair/skin debris

Answer 226

Surgery - Fistulotomy

Answer 227

Epi: usually young men age 15-35yr, rare in >50

Answer 228

Obstruction of hair follicles > formation of cysts, sinuses, or abscesses, associated with occupations that require prolonged sitting, obesity, and high amounts of body hair. Friction and pressure — skin rubbing against skin, tight clothing, bicycling, long periods of sitting or similar factors — force the hair down into skin

Answer 229

Asymptomatic or chronically itchy until acutely infected, then pain/tenderness, purulent discharge and increased moisture near the coccyx

Answer 230

- Acute Abscess: irrigation and debridement, wound packed open, 40% develop chronic pilonidal sinuses - Surgery: pilonidal cystotomy (excision of sinus tract and cyst, wound closed by secondary intention, primary closure with tissue flap or marsupialization

Answer 231

- Severe, episodic pain in the regions of the rectum and anus. It can be caused by cramping of the levator ani muscle, particularly in the pubococcygeal part - It most often occurs in the middle of the night and lasts from seconds to minutes; pain and aching lasting twenty minutes or longer would likely be diagnosed instead as levator ani syndrome - During an episode, the patient feels spasm-like, sometimes excruciating, pain in the rectum and/or anus, often misinterpreted as a need to defecate. To be diagnosed as proctalgia fugax, the pain must arise de novo (meaning the absence of clear cause).

Answer 232

Failure of healing after irrigation/debride, recurrent disease, or complex disease

Answer 233

SSC of the anal canal

Answer 234

Anal bleeding, pain, mass, ulceration, pruritus, 25% asymptomatic

Answer 235

Chemotherapy ± radiation ± surgery

Answer 236

- SSC of the Anal Canal - Malignant Melanoma of Anal Canal - Anal Margin CA

Answer 237

Wide excision or abdominal perineal resection ± chemoradiation

Answer 238

Cigarette smokers, men who have sex with men, individuals with a history of immunosuppression (such as in HIV infection) and women with a history of cervical, vaginal and vulval cancer are at increased risk of getting anal cancer

Answer 239

Pain that persists for more than 3 months either continuously or intermittently. Intermittent pain may be referred to as recurrent abdominal pain (RAP)

Answer 240

1. Gastrointestinal Disorders - Celiac Disease - Chronic cholecystitis - Chronic hepatitis - Upper abdominal discomfort, malaise, anorexia, Jaundice uncommon, In about one third of patients, a history of acute hepatitis - Chronic pancreatitis - Episodes of severe epigastric pain, Sometimes malabsorption (eg, diarrhea, fatty stool), Usually a history of acute pancreatitis - Colon cancer - Discomfort uncommon but possibly colicky discomfort if left colon is partially obstructed, Often occult or visible blood in stool - Crohn Disease - Gastric Cancer - Inflammatory bowel disease - Diverticular disease - Irritable bowel syndrome - Ulcer and non-ulcer dyspepsia (e.g., heartburn) - Referred cardiothoracic pain 2. Genitourinary disease - Endometriosis - Discomfort before or during menses GOOD - Benign or malignant tumors - Vague lower abdominal discomfort, bloating. Sometimes a palpable pelvic mass - Urinary tract disease - Pelvic inflammatory disease

Answer 241

- OPQRST - Diet history - Milk products cause cramping/distension - Concomitant GI symptoms such as gastroesophageal reflux, anorexia, bloating or “gas,” nausea, vomiting, jaundice, melena, hematuria, hematemesis, weight loss, and mucus or blood in the stool. - Bowel symptoms, such as diarrhea, constipation, and changes in stool consistency, color, or elimination pattern - PMHx - Past surgical Hx - Medications

Answer 242

- Vitals - General exam - jaundice, skin rash, and peripheral edema. - Abdominal exam - areas of tenderness, presence of peritoneal findings (eg, guarding, rigidity, rebound), and any masses or organomegaly

Answer 243

Fever, Anorexia, weight loss, Pain that awakens patient, Blood in stool or urine, Jaundice, Edema, Abdominal mass or organomegaly

Answer 244

- Urinalysis, complete blood count, liver tests, blood urea nitrogen, glucose, and lipase - Other tests: ultrasonography for ovarian cancer in women > 50 years, CT of the abdomen and pelvis with contrast, upper GI endoscopy (particularly in patients > 60 years old) or colonoscopy, and perhaps small-bowel imaging or stool testing.

Answer 245

- NON GASTRIC CAUSES cardiac (myocardial infarction), pulmonary (pneumonia), hepatobiliary (biliary colic), pancreatic (pancreatitis), colonic (irritable bowel disease), musculoskeletal, dietary indiscretion - PEPTIC ULCER DISEASE (PUD, 10 20%) H. pylori, ASA, NSAIDs (COX 2 inhibitors slightly decreased risk), cancer, Zollinger Ellison, smoking - MEDICATION SIDE EFFECTS NSAIDs, ASA, theophylline, calcium channel blockers, erythromycin, metronidazole, bisphosphonates, orlistat, acarbose, iron, potassium supplements - GASTROESOPHAGEAL REFLUX DISEASE (GERD, 20%) - NON ULCER DYSPEPSIA (50%) cause unclear. Diagnosis of exclusion (rule out organic cause and irritable bowel disease)

Answer 246

* ACIDS* - Acid hypersecretion Zollinger Ellison disease (gastrinomas, secrete large amounts of the hormone gastrin, which causes your stomach to produce too much acid) - Alcohol abuse - Connective tissue disease scleroderma - Infections of esophagus CMV, HSV, candidiasis - Diabetic gastroparesis - Drug therapy - Smoking

Answer 247

Chronic or recurrent epigastric pain, often with regurgitation, heartburn, bloating, nausea, and post prandial fullness (indigestion)

Answer 248

Retrosternal burning sensation secondary to lower esophageal sphincter relaxation = more specific for GERD

Answer 249

- Consider non gastric causes of dyspepsia (cardiac, pulmonary, hepatobiliary, colonic, musculoskeletal, medications, and dietary indiscretion) and investigate those causes if likely. Otherwise proceed to step 2 - If age >50 or alarm symptoms *Very BAD* (Vomiting, Bleed/anemia, Abdominal mass/ weight loss, Dysphagia), refer for gastroscopy to check for gastric cancer. Otherwise proceed to step 3 - If ASA or NSAIDs use, stop medications if possible. If not, consider proton pump inhibitor/H2 blocker trial and proceed to step 4 - If GERD predominant symptoms (heartburn, regurgitation), treat as GERD. Otherwise, proceed to step 5 - If H. pylori urea breath test positive, treat with triple therapy. Otherwise, proceed to step 6 - If none of the above, diagnosis of non-ulcer dyspepsia

Answer 250

- Labs - CBCD, lytes, glucose, AST, ALT, ALP, bilirubin, lipase, Ca, albumin, fecal occult blood - Imaging - upper GI series, U/S abd, CT abd - Special tests – Urea beath test, H. Pyloria Serology, 24h Esophageal pH study, Endoscopy w/ biopsy and Culture, PPI inhibitor trial

Answer 251

Consider using Manning Criteria: 3 or more of the following with no red flags: - Pain relief with bowel movement, more frequent stools with onset of pain, loose stools with onset of pain, passage of mucus, sensation of incomplete evacuation, abdominal distention - Red Flags: Age >50 years, weight loss, blood in stools, anemia, fever

Answer 252

- Many patients with peptic ulcers remain asymptomatic, particularly older patients - Common presentations of peptic ulcers are nonspecific, and symptoms are often intermittent/episodic due to spontaneous healing and relapse - Gastric ulcer presentations include epigastric pain, often postprandial, dyspepsia, bloating and/or abdominal fullness, early satiety, nausea, vomiting, weight loss

Answer 253

- Peptic ulcer disease definitively diagnosed with endoscopy, but a Helicobacter pylori test-and-treat strategy (without endoscopy) may be used in some younger patients without alarm features - Patients not receiving endoscopy, consider urea breath test (13C or 14C) or stool antigen tests (serologic antibody testing may also be used, but may have lower sensitivity and specificity than other noninvasive testing options)

Answer 254

Uncomplicated peptic ulcer in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin: stop NSAID or aspirin use + PPI therapy (lansoprazole, omeprazole, pantoprazole for 4-6 weeks for duodenal ulcer, 6-8 weeks for gastric ulcer)

Answer 255

- Classic triple therapy CLAMET: 1. PPI (omeprazole) 20mg BID for 14 days 2. clarithromycin 500mg BID 3. Amoxicillin 1g BID and metronidazole

Answer 256

Both present with chronic diarrhea, possibly bloody, abdo cramping, urgency.

Answer 257

Age 15-40 y, jews, FHx of IBD, smoking (before for Crohn’s, after smoking cessation UC), western diet, NSAIDS

Answer 258

Distribution gum to bum, discrete skip lesions, usually rectal sparing, transmural disease, granulomas, Cobblestoning and creeping fat, strictures, and fistulas, more extraintestinal complications/Sx (arthritis, liver, blood, eyes/mouth, skin - erythema nodosum, kidney – calcium oxalate stones), perianal disease often

Answer 259

Stricture, fistula, arthritis, irtis, episcleritis, erythema nodosum, pyoderma gangrenosum

Answer 260

- Colonoscopy + intubation of ileum* - Biopsy & histology confirm diagnosis - Gastroscopy to assess UGI - Small Bowel Assessment – MR/CT enterography – thickened colonic wall, wireless capsule endoscopy

Answer 261

Abdominal pain (esp. RLQ), diarrhea, Fe deficiency +/- anemia, fever, weight loss, growth failure, fatigue, pallor, malnutrition; gross bleeding uncommon, mucosal cobblestoning, gallstones, malabsorption, renal stones, hydronephrosis, amyloidosis

Answer 262

Biopsy shows inflamm confined to mucosa, distorted and branched crypts, abscesses crypts and plasma cells at base of crypt! Infectious colitis would have straight crypts

Answer 263

Usually chronic bloody diarrhea, abdominal cramping, urgency, tenesmus, incontinence, mild fever, tachycardia, dehydration, anemia

Answer 264

- Lower endoscopy* (colitis begins in rectum + ascends) - Always exclude infectious colitis → send stool for C + S, C.diff, O + P - AXR leadpipe colon, thumbprinting CT – inflammation.

Answer 265

Toxic megacolon (colonic distension >6cm + fever, anemia, HR >120, neutrophils >10.5, dehydration, hypotension, altered sensorium, electrolyte disturbance), perforation, stricture, colon cancer

Answer 266

Insidious onset, >4wks, chronic changes to mucosa→ mixed infiltrate, branched crypts, contiguous, mucosal disease, no granulomas.

Answer 267

Management of the 2 diseases are similar; however, in Colitis you can do a total colectomy to solve the problem. Surgery only used in Crohn’s to treat complications MED THERAPY IS THE MAINSTAY: start with mesalamine → antibio/probio → corticosteroids → immunosuppression → biologics (anti-TNF, anti-integrin therapy)→ surgery (mostly for UC).

Answer 268

Sigmoid colon

Answer 269

Lifestyle (low fiber diet [predispose to motility abnormalities and higher intraluminal pressure], in activity, obesity), muscle wall weakness from aging and illness (E.g. Ehler-Danlos, Marfan’s)

Answer 270

Asymptomatic if uncomplicated (70-80%), painless massive bleeding, episodic abdo pain (often LLQ), bloating, flatulence, constipation, diarrhea, NO fever/leukocytosis, NO physical exam findings/poorly localized LLQ pain (most commonly in the sigmoid colon)

Answer 271

- Uncomplicated: high fiber diet, education, mesalamine (5-ASA) - Diverticular Bleed: initially work up and treat as any LGIB, if hemorrhage does not stop > resection - Colonoscopy: Due to risk of perforation, this is performed 6 weeks after inflammation resolves to rule out colon cancer

Answer 272

Diverticulitis (15-25%), diverticulitis complicated with abscess/obstruction/perforation/fistula, bleeding (5-15% PAINLESS from rectum), diverticular colitis (rare: diarrhea, hematochezia, tenesmus, abdo pain)

Answer 273

High intraluminal pressures cause outpouching that occur at point of greatest weakness, most commonly where vasa recta penetrate the circular muscle layer, therefore increased risk of hemorrhage

Answer 274

Virus infects hepatocytes creating MHC I proteins that are then attacked by CD8 T-cells for apoptosis leading to liver damage

Answer 275

- Most are subclinical - Flu-like prodrome may precede jaundice by 1-2wk - Nausea/vomiting, anorexia, headaches, fatigue, myalgia, low-grade fever, arthralgia, and urticaria (especially HBV) - Only some progress to icteric (clinical jaundice) phase, lasting days to weeks: - pale stools and dark urine 1-5 d prior to icteric phase - Hepatomegaly and RUQ pain - Splenomegaly and cervical lymphadenopathy (10-20% of cases)

Answer 276

- AST and ALT (> 10-20x normal in hepatocellular necrosis) - ALP minimally elevated - Viral serology: - IgM antibody to HAV (IgM anti-HAV) - Hepatitis B surface antigen (HBsAg) - IgM antibody to hepatitis B core (IgM anti-HBc) - Antibody to hepatitis C virus (anti-HCV) and hepatitis C RNA (HCV-RNA) PCR - Increased urobilinogen (bile is broken down in UBG which is then transferred to the liver to convert back to bilirubin, but this isn’t happening

Answer 277

- Supportive (hydration, diet) - Usually resolves spontaneously, but if severe HBV infection, treatment with entecavir should be considered; in anicteric hepatitis C, anti-viral treatment should be considered - Indications for hospitalization: encephalopathy, coagulopathy, severe vomiting, hypoglycemia

Answer 278

Hepatitis D

Answer 279

Infectious

Answer 280

The presence of anti-HBs is generally interpreted as indicating recovery and immunity from hepatitis B virus infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B.

Answer 281

Antibody to HBcAg (anti-HBc, or HBcAb) usually appears at the onset of clinical illness; thereafter, titers gradually diminish, usually over years or life. Its presence with anti-HBs indicates recovery from previous HBV infection. Anti-HBc is also present in chronic HBsAg carriers, who do not mount an anti-HBs response.

Answer 282

HBeAg | anti-HBe

Answer 283

Oral interferon-free regimens

Answer 284

Mechanism: high acetaminophen dose saturates glucuronidation and sulfation elimination pathways - reactive metabolite is formed - covalently binds to hepatocyte membrane

Answer 285

- First 24 h: nausea and vomiting (usually within 4-12 h of overdose) - 24-48 h: asymptomatic, but ongoing hepatic necrosis resulting in increased transaminases - >48 h: continued hepatic necrosis possibly complicated with acute liver failure or resolution

Answer 286

- gastric lavage/emesis (if <2 h after ingestion) - oral activated charcoal - N-acetylcysteine (NAC) can be given PO or IV (most effective within 8-10 h of ingestion, but should be given no matter when time of ingestion) - promotes hepatic glutathione regeneration

Answer 287

Copper builds up due to lack of ceruloplasmin (which normally binds it in liver). Affects other organs (esp brain). Mutation of copper transporting ATPase results in excess copper, autosomal recessive

Answer 288

- Asterixis - Basal ganglia degeneration: suspect if parkinsonian features in the young Ceruloplasmin decreases - Cirrhosis/hepatitis - Corneal deposits (Kayser-Fleischer ring) - Copper - Dementia - CNS: basal ganglia (wing flapping tremor, Parkinsonism), cerebellum (dysarthria, dysphagia, incoordination, ataxia), cerebrum (psychosis, affective disorder) - Fanconi syndrome (malabsorption proximal tubule of kidney - Blood: intravascular hemolysis; may be initial presentation in fulminant hepatitis - Joints: arthritis, bone demineralization, calcifications

Answer 289

1. reduced serum ceruloplasmin (<50% of normal) 2. Kayser-Fleischer rings (usually require slit-lamp examination) 3. increased urinary copper excretion (measure 24-hour urine copper)

Answer 290

1. increased copper on liver biopsy by quantitative assay | 2. genetic analysis imperfect as many mutations in ATP7B are possible

Answer 291

1. penicillamine chelates copper, poorly tolerated 2. trientine chelates copper 3. zinc impairs copper excretion in stool and decreases copper absorption from gut 4. tetrathiomolybdate preferred if neurological involvement

Answer 292

Iron overload syndrome, autosomal recessive, common in Caucasians. Excessive iron storage causing multiorgan system dysfunction (liver, in particular) with total body stores of iron increased to 20-40 g (normal 1 g)

Answer 293

Hepcidin deficiency results in ongoing gut absorption of iron despite adequate iron stores

Answer 294

- Parenteral iron overload (e.g. transfusions) - Chronic hemolytic anemia: thalassemia, pyruvate kinase deficiency - Excessive iron intake

Answer 295

- Usually presents with trivial elevation in serum transaminases - Liver: cirrhosis (less common nowadays due to earlier detection), HCC (200x increased risk) - Pancreas: DM, chronic pancreatitis - Skin: bronze or grey (due to melanin, not iron) - Heart: dilated cardiomyopathy - Pituitary: hypogonadotropic hypogonadism (impotence, decreased libido, amenorrhea) - Joints: arthralgia (any joint, but especially MCP joints), chondrocalcinosis

Answer 296

Screening for individuals with clinical features and/or family history (1/4 chance of sibling having the disease) - Transferrin saturation (free Fe2+/TIBC) >45% - Serum ferritin >400ng/mL - HFE gene analysis: 90% of primary hemochromatosis involves C282Y allele, while H63D and S65C alleles also commonly involved and screened

Answer 297

- Phlebotomy: weekly or q2wk then lifelong maintenance phlebotomies q2-6mo - Deferoxamine if phlebotomy contraindicated (e.g. cardiomyopathy, anemia) - Primary hemochromatosis responds well to phlebotomy - Secondary hemochromatosis usually requires chelation therapy (administration of agents that bind and sequester iron, and then excreted)

Answer 298

Alcoholic liver disease

Answer 299

- Metabolic condition (fatty liver) - Inflammatory condition (alcohol hepatitis) - Fibrotic condition (cirrhosis)

Answer 300

Mildly tender hepatomegaly; jaundice rare, mildly increased transaminases <5x normal

Answer 301

Mild: stops drinking because feels unwell, resumes when feeling better (if assessed, findings of hepatitis, potentially mild jaundice, and mildly elevated INR)

Answer 302

Severe: stops drinking but feels unwell, low grade fever, RUQ discomfort, increased white blood cell count - mimics RLL pneumonia and cholecystitis

Answer 303

- AST:ALT >2:1 (both usually <300) - CBC: increased MCV, increased WBC often seen with alcoholic hepatitis but not necessarily in other alcohol-related liver injury - Increased GGT

Answer 304

- Alcohol cessation - Alcoholics Anonymous, disulfiram, naltrexone, acamprosate - Multivitamin supplements (especially thiamine) - Caution with drugs metabolized by the liver - Prednisolone if severe alcoholic hepatitis based on Maddrey's discriminant function or MELD score

Answer 305

DM, Male, hyperlipidemia, obesity

Answer 306

- Non-alcoholic fatty liver (NAFL): The term used when there is simple steatosis in the liver not accompanied by inflammation, cell injury or fibrosis. 25% of N. Americans - NASH: The term used when steatosis is accompanied by inflammation and cell injury/ballooning degeneration with or without fibrosis (resembles alcoholic liver disease).

Answer 307

- Often asymptomatic - May present with fatigue, malaise, and vague RUQ discomfort - Elevated serum triglyceride/cholesterol levels and insulin resistance

Answer 308

- Elevated serum AST, ALT ± ALP; AST/ALT <1 | - Presents as echogenic liver texture on ultrasound

Answer 309

- Mainstay is gradual weight loss (0.5-1kg/wk) as rapid weight loss can worsen liver disease. Ideally, aim to lose at least 7-10% of body weight - Some evidence for vitamin E (800 U daily) if there is hepatic inflammation - Some evidence for benefits of coffee drinking (3cups/d) and vitaminD

Answer 310

A1AT inactivates elastase. Thus a deficiency results in elastase breaking down too much elastin. Thus, neutrophil elastase will go unchecked, breaking down elastin in the lungs. The acinus turns into one big cavity -this is emphysema. Can also lead to chronic bronchitis and COPD

Answer 311

- Insufficient A1AT (unopposed elastase in lung – null or heterozygote allele WORST) - Accumulation of A1AT (leading to cell dysfunction – ZZ allele is the WORST for this).

Answer 312

Early emphysema, neonatal hepatitis syndrome, or cirrhosis carcinoma, elevated liver enzymes

Answer 313

Serum A1AT level, Pi phenotype abnormal

Answer 314

NONE for liver type – just treat complications, screen for carcinoma. If lung type, then can give A1AT infusion! Screen family.

Answer 315

Liver damage characterized by diffuse distortionofthebasicarchitecturewithfibrosisandformationof regenerative nodules

Answer 316

- Fatty liver (alcoholic or non-alcoholic fatty liver disease) - Chronic viral hepatitis (B,B+D,C; not A or E) - Autoimmune hepatitis - Drugs (e.g. chronic methotrexate or amiodarone use) - Hemochromatosis - Primary biliary cholangitis - Chronic hepatic congestion: cardiac cirrhosis (chronic right heart failure, constrictive pericarditis), hepatic vein thrombosis (Budd-Chiari)

Answer 317

- Definitive diagnosis is histologic (liver biopsy) - Blood work: fall in platelet count <150 is the earliest finding, followed many years later with rise in INR, fall in albumin, rise in bilirubin, fall in glucose level (pre-terminal event) - Imaging • U/S is the primary imaging modality but only finds advanced cirrhosis • CT to look for varices, nodular liver texture, splenomegaly, ascites • Transient Ultrasound Elastograhy: non-invasive tool using elastography (variable availability) for measuring liver compliance - Gastroscopy: varices or portal hypertensive gastropathy

Answer 318

- Decrease insults (e.g. alcohol cessation, hepatotoxic drugs, immunize for Hep A and B if non-immune) - Follow patient for complications (esophageal varices, ascites, HCC defines stage 2 cirrhosis) - Liver transplantation for end-stage disease if no alcohol for >6mo; use MELD score

Answer 319

- Pancytopenia from hypersplenism: platelets first, then WBC, then hemoglobin - decreased clotting factors resulting in elevated INR

Answer 320

Hepatic venous pressure gradient (HVPG) >10 mmHg

Answer 321

Resuscitation, antibiotic prophylaxis, vasoactive drugs (e.g. octreotide IV) combined with endoscopic band ligation or sclerotherapy, Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Answer 322

- pre-renal (usually due to over-diuresis) - acute tubular necrosis - Hepatorenal Syndrome (HRS)

Answer 323

Type I: sudden and acute renal failure (rapid doubling of creatinine over 2 wk)

Answer 324

Type II: gradual increase in creatinine with worsening liver function (creatinine doubling over years)

Answer 325

- Overdiuresis or dehydration, such as diarrhea, vomiting, etc. - GI bleed - Sepsis

Answer 326

- For type I HRS: octreotide + midodrine + albumin (increases renal blood flow by increasing systemic vascular resistance) - Definitive treatment is liver transplant

Answer 327

Thought to arise from ventilation-perfusion mismatch, intrapulmonary shunting and limitation of oxygen diffusion, failure of damaged liver to clear circulating pulmonary vasodilators vs. production of a vasodilating substance by the liver

Answer 328

- hyperdynamic circulation with cardiac output >7 L/min at rest and decreased pulmonary + systemic resistance (intrapulmonary shunting) - dyspnea, platypnea (increase in dyspnea in upright position, improved by recumbency), and orthodeoxia (desaturation in the upright position, improved by recumbency)

Answer 329

Only proven treatment is liver transplantation

Answer 330

Diagnosis via contrast-enhanced echocardiography: inject air bubbles into peripheral vein; air bubbles appear in left ventricle after third heartbeat (normal = no air bubbles; in ventricular septal defect, air bubbles seen <3 heart beats)

Answer 331

Pressure gradient between hepatic vein pressure and wedged hepatic vein pressure (corrected sinusoidal pressure) >5 mmHg

Answer 332

- pre-sinusoidal (e.g. portal vein thrombosis, schistosomiasis, sarcoidosis) - sinusoidal (e.g. cirrhosis, alcoholic hepatitis) - post-sinusoidal (e.g. right-sided heart failure, hepatic vein thrombosis, veno-occlusive disease, constrictive pericarditis)

Answer 333

Esophageal varices, Melena, Splenomegaly, Ascites, Hemorrhoids

Answer 334

- GI bleeding from varices in esophagus, less commonly in stomach, even less frequently from portal hypertensive gastropathy - ascites - hepatic encephalopathy - thrombocytopenia - renal dysfunction - sepsis - arterial hypoxemia

Answer 335

- Non-selective B-blockers (propanolol, nadolol, carvedilol) decrease risk of bleeding from varices - TIPS: to decrease portal venous pressure

Answer 336

Jaundice, asterixis, palmar erythema, dupuytren's contracture(contraction of the tendons in the hand), leukonychia, ecchymosis, fetor hepaticus (a sign that your liver is having trouble doing its job of filtering out toxic substances), parotid hypertrophy, spider angiomas (often on neck or above), gynecomastia, caput medusae (appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen), ascites, scleral icterus, umbilical hernia, esophageal varices, malnourished

Answer 337

Spectrum of potentially reversible neuropsychiatric syndromes secondary to liver disease diagnosed after ruling out other causes for symptoms (e.g. structural/metabolic)

Answer 338

Portosystemic shunt around hepatocytes and decreased hepatocellular function increase level of systemic toxins (believed to be ammonia from gut, mercaptans, fatty acids, amino acids) which go to the brain

Answer 339

- Nitrogen load (GI bleed, protein load from food intake, renal failure, constipation) - Drugs (narcotics, CNS depressants) - Electrolyte disturbance (hypokalemia, alkalosis, hypoxia, hypovolemia) - Infection (spontaneous bacterial peritonitis) - Deterioration in hepatic function or superimposed liver disease

Answer 340

I: apathy, restlessness, reversal of sleep-wake cycle, slowed intellect, impaired computational abilities, impaired handwriting II: asterixis, lethargy, drowsiness, disorientation III: stupor (rousable), hyperactive reflexes, extensor plantar response (upgoing Babinski) IV: coma (response to painful stimuli only)

Answer 341

- Non-liver-related neuropsychiatric disease in a patient with liver problems (e.g. alcohol withdrawal or intoxication, sedatives, subdural hematoma, metabolic encephalopathy) - Causes of metabolic encephalopathy (e.g. renal failure, respiratory failure, severe hyponatremia, hypoglycemia)

Answer 342

- Lactulose: titrated to achieve 2-3 soft stools/d | - Oral rifaximin for both acute treatment and maintenance therapy has high level evidence for efficacy

Answer 343

- Prevents diffusion of NH3 (ammonia) from the colon into blood by lowering pH and forming non-diffusible NH4 (ammonium) - Serves as a substrate for incorporation of ammonia by bacteria, promotes growth in bowel lumen of bacteria which produce minimal ammonia - Also acts as a laxative to eliminate nitrogen-producing bacteria from colon

Answer 344

Accumulation of excess fluid in the peritoneal cavity

Answer 345

Serum [Alb] – Ascitic [Alb]

Answer 346

- Cirrhosis/severe hepatitis - Chronic hepatic congestion - Massive liver metastases - Myxedema

Answer 347

- Peritoneal carcinomatosis - TB - Pancreatic disease - Serositis - Nephrotic syndrome

Answer 348

- Abdominal ultrasound - Physical exam (clinically detectable when >500mL): bulging flanks, shifting dullness, fluid-wave test positive. Most sensitive symptom: ankle swelling

Answer 349

- Na+ restriction (daily sodium intake <2 g) - diuretics: spironolactone, furosemide - aim for weight loss 0.5-1 kg/d, more if concomitant peripheral edema (which is mobilized quicker than ascitic fluid); overly rapid weight loss increases risk of renal failure - if target weight loss is not achieved and there are no complications, increase dose to achieve target while monitoring for complications

Answer 350

- Therapeutic paracentesis with intravenous albumin - TIPS in anappropriate patient (no contraindications) with potential ltransplant-free survival advantage - Liver transplantation

Answer 351

- Cirrhosis or GI bleed: ceftriaxone IV daily or norfloxacin bid x7d - Previous episode of SBP: long-term prophylaxis with daily norfloxacin or TMP-SMX

Answer 352

- 1/3 of patients are asymptomatic, thus do not hesitate to do a diagnostic paracentesis in ascites even if no clinical indication of infection - Fever, chills, abdominal pain, ileus, hypotension, worsening encephalopathy, acute kidney injury

Answer 353

- Culture, count and Albumin (also get serum albumin content) - Absolute neutrophil count in peritoneal fluid >0.25 x109 cells/L (250 cells/mm3) - Gram stain positive in only 10-50% of patients

Answer 354

- IV antibiotics (cefotaxime 2g IV q8h or ceftriaxone 2g IV daily is the treatment of choice for 5d; modify if response inadequate or culture shows resistant organisms) - IV albumin (1.5g/kg at time of diagnosis and 1g/kg on day 3) decreases mortality by lowering risk of acute renal failure

Answer 355

- Infectious – Gastroenteritis (viral and bacterial) - Gastrointestinal system - Drugs - chemotherapeutic agents, opioids, cannabis - CNS - Endocrinologic and metabolic: Pregnancy, Other endocrine and metabolic – Uremia, Diabetic ketoacidosis, Hyperparathyroidism, Hypoparathyroidism, Hyperthyroidism, Addison's disease, Acute intermittent porphyria - Others: Postoperative nausea and vomiting, Cyclic vomiting syndrome, Cardiac disease - Myocardial infarction, Heart failure, Starvation, Radiation therapy to the upper abdomen and lower chest

Answer 356

- Mechanical obstruction - Gastric outlet obstruction, Small bowel obstruction - Functional gastrointestinal disorders - Gastroparesis - Chronic intestinal pseudo-obstruction - Nonulcer dyspepsia - Irritable bowel syndrome - Organic gastrointestinal disorders - Pancreatic adenocarcinoma, Inflammatory intraperitoneal disease, Peptic ulcer disease, Cholecystitis, Pancreatitis, Hepatitis, Crohn disease, Mesenteric ischemia, Retroperitoneal fibrosis, Mucosal metastases

Answer 357

- Migraine - Increased intracranial pressure – Malignancy, Hemorrhage, Infarction, Abscess, Meningitis, Congenital malformation, Hydrocephalus, Pseudotumor cerebri - Seizure disorders - Emotional responses - Psychiatric disease - Psychogenic vomiting, Anxiety disorders, Depression, Pain, Anorexia nervosa, Bulimia nervosa - Labyrinthine disorders – Labyrinthitis, Ménière's disease, Motion sickness

Answer 358

- Onset of symptoms – abrupt or insidious - Timing of symptoms - Nature of matter - Abdominal pain - Associated symptoms/findings

Answer 359

- Before breakfast - Ethyl alcohol, increased intracranial pressure, pregnancy, uremia - During or directly after eating - Psychiatric causes - One to four hours after a meal - Gastric outlet obstructions (e.g., from peptic ulcer disease, neoplasms), gastroparesis - Continuous - Conversion disorder, depression

Answer 360

- Undigested food - Achalasia, esophageal disorders (e.g., diverticulum, strictures) - Partially digested food - Gastric outlet obstruction, gastroparesis - Bile - Proximal small bowel obstruction - Feculent or odorous - Fistula, obstruction with bacterial degradation of contents - Large volume (> 1,500 mL per 24 hours) - Suggests organic rather than psychiatric causes

Answer 361

- Right upper quadrant - Biliary tract disease, cholecystitis - Epigastric - Pancreatic disease, peptic ulcer disease - Severe pain - Biliary disease, pancreatic disease, peritoneal irritation, small bowel obstruction - Severe pain that precedes vomiting - Small bowel obstruction

Answer 362

- Weight loss - Malignancy (significant weight loss may also occur secondary to sitophobia in gastric outlet obstructions and peptic ulcer disease) - Diarrhea, myalgias, malaise, headache, contact with ill persons - Viral etiologies - Headache, stiff neck, vertigo, focal neurologic deficits - Central neurologic causes (e.g., encephalitis/meningitis, head injury, mass lesion or other cause of increased intracranial pressure, migraine) - Early satiety, postprandial bloating, abdominal discomfort - Gastroparesis - Repetitive migraine headaches or symptoms of irritable bowel syndrome – cyclic vomiting syndrome

Answer 363

- Signs of dehydration - General: jaundice, lymphadenopathy, and signs of thyrotoxicosis - Signs of bulimia: dental enamel erosion, parotid gland enlargement, lanugo-like hair, and calluses on the dorsal surface of the hand - Abdo exam: tenderness, distension, hernias - Neuro

Answer 364

- CBC, lytes, CRP, Cr, Ca, glucose - bHCG, lipase, liver enzymes, protein/albumin, TSH - Abdo Xray, possible CT - Endoscopy - Small bowel follow-through - Enteroclysis - Gastric motility studies (e.g., gastric emptying scintigraphy, cutaneous electrogastrography, antroduodenal manometry) may be considered.

Answer 365

Dopamine receptor blockers are metoclopramide and haloperidol. Hits GI/CRTZ causes. Useful for chemical causes (meds). Don’t give these two together because it can induce extrapyramidal symptoms (EPS)

Answer 366

- Prokinetic agents (to remove constip) are metoclopramide and domperidone (Motilium). For stasis and ileus. Motilium doesn't work on the brain, only on the gut but also can cause cardiac abnormalities. Maxeran can rarely cause extrapyramidal symptoms and delirium - Agents with mainly prokinetic properties include erythromycin (motilin receptor agonist) and bethanechol (muscarinic receptor agonist).

Answer 367

Prochlorperazine is an antiemetic that often partially alleviates acute nausea and vomiting (eg, acute gastroenteritis), but is associated with risks of hypotension and extrapyramidal side effects

Answer 368

Serotonin receptor blockers are Ondansetron (Zofran) and granisetron. Target 5HT receptors in CRTZ and vomiting centers. Doesn’t impact dopamine receptors so good when risk of EPS is high. They've become standard in chemo pre-treatment. No impact on motion sickness.

Answer 369

- Dark urine, pale stools: suggests that bilirubin elevation is from direct fraction - Pruritus: suggests chronic disease, cholestasis - Abdominal pain: suggests biliary tract obstruction from stone or pancreatic tumour (obstructive jaundice) - Painless jaundice in the elderly: think of pancreatic cancer, although most patients with pancreatic cancer have pain - Kernicterus: rarely seen in adults due to maturation of blood brain barrier

Answer 370

- Overproduction (hemolysis, reabsorption of hematoma) - Decreased hepatic uptake (congestive heart failure) - Decreased bilirubin conjugation (Gilbert syndrome, neonatal jaundice)

Answer 371

- Blood work: CBC, bilirubin (direct and total), liver enzymes (AST, ALT, ALP, GGT), liver function tests (INR/PT, PTT, albumin), amylase - Hepatitis viral and autoimmune serologic tests, blood smear - U/S or CT for evidence of bile duct obstruction (e.g. bile duct dilation) - MRCP: non-invasive - EUS: sensitive for stones and pancreatic tumours - ERCP: invasive,most accurate,allows for therapeutic intervention - Percutaneous transhepatic cholangiography (PTC): if ERCP fails (endoscopic access not possible)

Answer 372

1. Intrahepatic cholestasis - Common: Alcohol-related liver disease, drugs, toxins, viral hepatitis - Less common: Infiltrative disorders (eg, amyloidosis, lymphoma, sarcoidosis, tuberculosis), pregnancy, primary biliary cholangitis, steatohepatitis 2. Extrahepatic cholestasis - Common: Common bile duct stone, pancreatic cancer - Less common: Acute cholangitis, pancreatic pseudocyst, primary sclerosing cholangitis, common duct strictures caused by previous surgery, other tumors 3. Hepatocellular injury - Common: Drugs, toxins, viral hepatitis - Less common: Alcohol-related liver disease, hemochromatosis, primary biliary cholangitis, primary sclerosing cholangitis, steatohepatitis, Wilson disease 4. Other (e.g., infiltrative states, fatty liver)

Answer 373

Chronic inflammation and fibrous obliteration of intrahepatic bile ductules

Answer 374

Likely autoimmune (associated with Sjogren's syndrome, scleroderma, CREST syndrome, rheumatoid arthritis (RA), thyroiditis)

Answer 375

Affects mainly middle-aged women (M:F=1:9)

Answer 376

- Often asymptomatic - Initial symptoms: pruritus, fatigue - Chronic: jaundice and melanosis (darkening skin) and other signs of cholestasis - End-stage: hepatocellular failure, portal HTN, ascites - High incidence of osteoporosis

Answer 377

- Increased ALP, GGT; bilirubin rises in later stage - Positive anti-mitochondrial antibodies (AMA; 95% specificity and sensitivity) - elevated IgM - increased serum cholesterol (mild increase in LDL, larger increase in HDL). may have: xanthelasmas, xanthomas - liver biopsy confirms diagnosis and stages severity → mononuclear infiltrate centered on bile ducts + granulomas - Normal bile duct on MRCP rules out bile duct obstruction which can mimic PBC

Answer 378

- ursodiol (usual first line treatment) - obeticholic acid (particularly if inadequate response to urosiol) - cholestyramine (for pruritus and hypercholesterolemia) - Calcium and vitamin D for low bone density; bisphosphonates if osteoporosis severe - Monitor for thyroid disease - Liver transplant if disease severe

Answer 379

Infection of the biliary tree

Answer 380

- Stasis in the biliary tract due to obstruction or stricture (usually from previous cholecystectomy) - Infection originates in the duodenum or spreads hematogenously from the portal vein

Answer 381

- Charcot's triad: fever, RUQ pain, jaundice (50-70%) - Reynolds' pentad in patients with suppurative cholangitis: fever, RUQ pain, jaundice, hypotension, altered mental status

Answer 382

- Increased WBC - Usually increased ALP and bilirubin, ALT variably elevated - Blood culture - Abdominal U/S: CBD dilation, stones

Answer 383

- Most important is drainage, ideally via ERCP; perform by percutaneous biliary or by surgical routes (least often) if ERCP not possible - Antibiotic therapy: broad spectrum to cover Gram-negatives, Enterococcus, and anaerobes (especially if CBD manipulation)

Answer 384

Chronic inflammation + fibrosis of bile ducts in response to portal bacteria in genetically predisposed, progresses to liver failure over 12 years

Answer 385

Primary/idiopathic (most common) - associated with IBD, more commonly UC, in up to 70-80% of patients (usually male) with PSC

Answer 386

- long-termcholedocholithiasis - cholangiocarcinoma - surgical/traumatic injury (iatrogenic) - contiguous inflammatory process - post-ERCP - associated with HIV/AIDS ("HIV cholangiopathy") - IgG4-related disease

Answer 387

- Often insidious, may present with fatigue and pruritus | - May present with signs of episodic bacterial cholangitis secondary to biliary obstruction

Answer 388

- Increased ALP (hallmark), less often increased bilirubin - Mildly increased AST, usually <300U/L - p-ANCA (30-80%), elevated IgM (40-50%) - MRCP and ERCP shows narrowing and dilatations of bile ducts that may result in "beading", both intrahepatic and extrahepatic bile ducts - if intrahepatic narrowing only, do anti-mitochondrial antibody to rule out PBC

Answer 389

- Image bile duct (MRCP) at least annually for early detection of cholangiocarcinoma - Endoscopic sphincterotomy, biliary stent in selected cases of dominant common bile duct stricture - Antibiotics for cholangitis - Suppurative cholangitis requires emergency drainage of pus in common bile duct - Liver transplant

Answer 390

- Metabolic defect- failure of bilirubin conjugation (UDP transferase). Normal Hb, Normal liver enzymes. Benign, non-progressive, COMMON - Isolated unconjugated hyperbilirubinemia

Answer 391

- Obesity, chronic cough, asthma, COPD, pregnancy, constipation, bladder outlet obstruction, ascites, and heavy lifting - Congenital abnormality (e.g. patent processus vaginalis, and indirect inguinal hernia) - Previous hernia repair, especially if complicated by wound infection - Loss of tissue strength and elasticity (e.g. hiatus hernia, aging, and repetitive stress)

Answer 392

- Mass of variable size  Tenderness worse at end of day, relieved with supine position or with reduction  Abdominal fullness, vomiting, constipation - Transmits palpable impulse with coughing or straining

Answer 393

- Physical examination usually sufficient - U/S ¬ ± CT (CT required for obturator hernias, internal abdominal hernias, and Spigelian and/or femoral hernias in obese patients)

Answer 394

When the contents can be replaced through the hernia defect. Repair is either deferred or done electively

Answer 395

Vascular supply of protruded viscus is compromised (ischemia). Requires emergency repair

Answer 396

Incarcerated hernia contents are unable to be replaced through the defect. Is indication for emergency surgery if contains small bowel, are otherwise repaired electively, Not necessarily strangulated

Answer 397

Develop due to developmental deficiencies, congenital umbilical hernia, or may occur due to weakness in the linea alba in the area of the umbilicus (acquired umbilical hernia)

Answer 398

10x more common in women, also common in children but usually closes by age 2 – ideally fix them at age 5 if not (fewer than 5% persist into later childhood/adulthood)

Answer 399

Results from poor wound healing in a previous surgical incision (infection, tension, malnutrition, intra-abdominal pressure, etc.) – occurs in 5-10% of abdo incisions

Answer 400

Hernia involving a Meckel’s diverticulum (Think alphabetically: Littre’s Meckel’s = LM)

Answer 401

Hernia through the linea semilunaris (or spigelian fascia); also known as spontaneous lateral ventral hernia (Think: Spigelian = Semilunaris)

Answer 402

Hernia sac exists as both a direct and indirect hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring (two sacs separated by the inferior epigastric vessels [the pant crotch] like a pair of pantaloon pants)

Answer 403

Only part of bowel circumference (usually anti-mesenteric border) is incarcerated or strangulated so may not be obstructed

Answer 404

Part of wall of hernia sac formed by retroperitoneal structure (usually colon)

Answer 405

Diastasis of the rectus abdominis muscles (DRAM) is characterised by thinning and widening of the linea alba

Answer 406

Femoral >> indirect inguinal > direct inguinal

Answer 407

1. Bilateral inguinal hernias 2. Recurring hernia 3. Need to resume full activity as soon as possible

Answer 408

- Surgical treatment (herniorrhaphy) is only to prevent strangulation and evisceration, for symptomatic relief, for cosmesis; if asymptomatic can delay surgery - Observation is acceptable for small asymptomatic inguinal hernias

Answer 409

- Repair may be done open or laparoscopic and may use mesh for tension-free closure - Avoid mesh for emergent cases with bowel compromise given risk of infection - Most repairs are now done using tension free techniques (Lichtenstein) -a plug in the hernial defect and a patch over it or patch alone

Answer 410

Vas deferens, Testicular artery, Artery of the ductus deferens, Cremasteric artery, Pampiniform plexus, Genital branch of the genitofemoral nerve (sensation to lateral scrotum), Parasympathetic and sympathetic nerves. **Remember the ilioinguinal nerve runs outside of the spermatic cord** The gubernaculum attaches the testicle to the scrotum

Answer 411

Inferior epigastric vessels, Inguinal ligament (Poupart’s), Lateral border of the rectus sheath. Floor consists of internal oblique and the transversus abdominis muscle

Answer 412

Acquired weakness of transversalis fascia “Wear and tear”. Increased intra-abdominal pressure

Answer 413

Through Hesselbach’s triangle Medial to inferior epigastric artery Usually does not descend into scrotal sac

Answer 414

Congenital persistence of processus vaginalis in 20% of adults

Answer 415

Indirect inguinal

Answer 416

Generally symptoms include an intermittent bulge in the inguinal region to vague pain or discomfort and occasionally paresthesia (compression of inguinal nerves – ilioinguinal nerve (pain in groin) and/or genital branch of the genitofemoral nerve). Ask about pain/bulge at night (there shouldn’t be any pain at night)

Answer 417

- All babies with inguinal hernias need repair ASAP - All with incarcerated or strangulated hernia need repair urgently, have higher rates of strangulation compared to direct hernias - Elective herniorrhaphy is indicated to prevent the chance of incarceration/strangulation

Answer 418

Originates in deep inguinal ring Lateral to inferior epigastric artery Often descends into scrotal sac (or labia majora)

Answer 419

Affects mostly females

Answer 420

Pregnancy – weakness of pelvic floor musculature. Increased intra-abdominal pressure

Answer 421

- Into femoral canal, below inguinal ligament but may override it. Medial to femoral vein within femoral canal - Femoral Canal: femoral nerve > artery > vein > empty space (CANAL) > lymph nodes/lacunar ligament

Answer 422

SHOULD ALWAYS BE REPAIRED - McVay (Cooper’s ligament repair), mesh plug repair

Answer 423

- Blunt: usually causes solid organ injury | - Penetrating: usually causes hollow organ injury or liver injury (most common)

Answer 424

CARDIAC VIEW + LUQ VIEW + RUQ VIEW + PELVIC VIEW + ANTERIOR LUNG FIELD

Answer 425

SPLEEN* > LIVER > MESENTARY > UROLOGIC > PANCREAS

Answer 426

Intra-abdominal and retroperitoneal

Answer 427

1. Abdomen - inspect: contusions, abrasions, seat-belt sign, distention - auscultate: bruits, bowel sounds - palpate: tenderness, rebound tenderness, rigidity, guarding - DRE: rectal tone, blood, bone fragments, prostate location - placement of NG, Foley catheter should be considered part of the abdominal exam 2. Other systems to assess: cardiovascular, respiratory (possibility of diaphragm rupture), genitourinary, pelvis, back/neurological

Answer 428

Labs: CBC, electrolytes, coagulation, cross and type, glucose, Cr, CK, lipase, amylase, liver enzymes, ABG, blood EtOH, B-hCG, U/A, toxicology screen

Answer 429

- Equivocal abdominal examination, altered sensorium, or distracting injuries (e.g. head trauma, spinal cord injury resulting in abdominal anesthesia) - unexplained shock/hypotension - patients have multiple traumas and must undergo general anesthesia for orthopedic, neurosurgical, or other injuries - fractures of lower ribs, pelvis, spine - positive FAST

Answer 430

- General: ABCs, fluid resuscitation, and stabilization - Surgical: watchful waiting vs. laparotomy - Solid organ injuries: decision based on hemodynamic stability, not the specific injuries - Hemodynamically unstable or persistently high transfusion requirements: laparotomy - Hollow organ injuries: laparotomy

Answer 431

- Hemodynamically unstable from abdominal trauma - Peritonitis - Evisceration - Free air - Certain injuries (confirmed or suspicious): Hollow viscious injuries, Diaphragmatic injury, Intraperitoneal bladder injury, ureteric injury, Pancreatic injury, Transaxial GSW - Failure of nonoperative management

Answer 432

Foley catheter: unconscious or patient with multiple injuries who cannot void spontaneously or is unconscious

Answer 433

NG tube: used to decompress the stomach and proximal small bowel. Contraindicated if suspected facial or basal skull fractures

Answer 434

SMALL BOWEL > LIVER > COLON > STOMACH > DIAPHGRAM

Answer 435

- General: ABCs, fluid resuscitation, and stabilization | - Gunshot wounds always require laparotomy

Answer 436

- GI Disorders - Hepatobiliary - Genital - Urinary: Pyelonephritis, Renal colic, cystitis - CVS: MI, aortic dissection, AAA, Pericarditis - Resp: PE, empyema, pneumonia - Metabolic: DKA, sickle cell crisis, toxin, Addisonian crisis, Lead poisoning, porphyria - Other: Abdominal wall injury, herpes zoster, psychiatric, abscess, hernia, mesenteric adenitis

Answer 437

- Perforated viscus, bowel obstruction, ischemic bowel, appendicitis, strangulated hernia, IBD flare, esophageal rupture, peptic ulcer disease - Diverticulitis, gastroenteritis, GERD, esophagitis, gastritis, IBS

Answer 438

- Hepatic/splenic injury, pancreatitis, cholangitis, spontaneous bacterial peritonitis, Biliary colic, cholecystitis, hepatitis

Answer 439

Female: Ovarian torsion, PID, ectopic pregnancy, tubo-ovarian abscess, ovarian cyst, salpingitis, endometriosis Male: Testicular torsion, epididymitis, prostatitis

Answer 440

Severe pain + signs of shock + peritoneal signs + abdominal distention + pain out of proportion to clinical findings + new onset pain/change in pain/altered bowel habits in elderly + weight loss + BRBPR/melena + anemia + supraclavicular nodes + FHx of serious bowel disease

Answer 441

- AXR: look for calcifications, free air, gas pattern, air fluid levels - CXR upright: look for pneumoperitoneum (free air under diaphragm), lung disease - U/S: biliary tract, ectopic pregnancy, AAA, free fluid - CT: trauma, AAA, pancreatitis, nephro-/urolithiasis, appendicitis, and diverticulitis

Answer 442

CBC, electrolytes, glucose, BUN/Cr, U/A ± liver enzymes, LFTs, amylase + lipase, B-hCG, ECG, troponins, VBG/lactate , INR/PTT, tox screen

Answer 443

1. acute abdominal or back pain 2. hypotension 3. pulsatile abdominal mass

Answer 444

Indications for surgery >6cm diameter, painful/tender on palpation, enlarging, distal emboli, thrombosis, obstruction/compression of adjacent viscera, rupture

Answer 445

- Often incidental - Confirmation by ultrasonography or abdominal CT - Sometimes CT angiography or magnetic resonance angiography - Most abdominal aortic aneurysms are diagnosed incidentally when they are detected during physical examination or when abdominal ultrasonography, CT, or MRI is done for other reasons. An AAA should be considered in older patients who present with acute abdominal or back pain whether a palpable pulsatile mass is present or not.

Answer 446

Control of atherosclerotic risk factors, especially smoking cessation and use of antihypertensive drugs as appropriate, is important. If a small or moderate-sized aneurysm becomes > 5.0 to 5.5 cm and if risk of perioperative complications is lower than estimated risk of rupture, AAA repair is indicated. Risk of rupture vs that of perioperative complications should be discussed frankly with the patient.

Answer 447

Any pregnancy that is implanted outside of the endometrial lining in the uterine cavity. Most happen in the fallopian tubes

Answer 448

- Prior ectopic pregnancy - PID – usually chlamydia or gonorrhea (recurrence rate if PID flare - 1 prior flare (13%), 2 (35%), 3 (75%)) - Tubal surgery, tubal ligation failure - Smoking - IUD failure (decreases pregnancy rate, but if fails then 50% likelihood)! - Infertility/IVF - Age <18 or >35

Answer 449

Classic triad of amenorrhea, bleeding, and abdominal pain usually at 6-8wks.

Answer 450

Abdominal pain/tenderness acute onset and then constant(epigastric, band-link, radiates to the back, sharp, worse when supine) + postprandial pain, constant N/V + guarding upper abdo + fever + tachycardia (SIRS or infection), orthostatic hypotension

Answer 451

- Idiopathic - Gallstones (or other obstructive lesions) - EtOH - Trauma - Steroids - Mumps (& Other Viruses – CMV, EBV) - Autoimmune (SLE, polyarteritis nodosa) - Scorpion sting - Hyper Ca2+, High Triglycerides - ERCP (5-10% of patients undergoing the procedure) - Drugs (thiazides, sulfonamides, ACE-I, NSAIDS, azathioprine)

Answer 452

CBC + Lytes + Urea + Creatinine + ALT/ALP + Total/Direct Bilirubin + Lipase (specific) + amylase

Answer 453

Abdo RUQ U/S (used to r/o cholelithiasis and to assess for choledocholithiasis) + CT Scan (key study) – comment of extent of inflammation, presence of fluid collection and extent of necrosis + AXR - Sentinel loop, colon cutoff, possibly gallstones (only 10% visible on x-ray)

Answer 454

WORSENING OF CO-MORBIDITIES. Fluid sequestration, dehydration, acute sequelae (peripancreatic fluid collection, phlegmon, pancreatic necrosis (infection), SIRS), chronic sequelae including pseudocyst (sterile/infected), obstruction (gastric/duodenal/biliary), pseudoaneurysms (splenic/gastric/hepatic/aortic), Hemosuccus Pancreaticus (erosion of pseudoaneurysm into PD causing an UGB), erosion/perforation (colon/duodenum), pancreatic ascites, pancreatic fistula, pleural effusions, splenic/portal/SMV thrombosis, diabetes

Answer 455

Fluid-filled cyst in the lesser sac filled with digestive enzymes (amylase/lipase) – no epithelial lining, formed of inflammatory fibrosis; these are under high pressure and can erode into vital structures, they can become infected, and can get massive, blocking outflow of the stomach or crush/occlude the splenic or portal vein. 50% resolve spontaneously

Answer 456

Percutaneous aspiration/drain, Operative drainage, Transpapillary stent via ERCP (pseudocyst must communicate with pancreatic duct). If infected – add IV antibiotics. Must bx the cyst wall to rule out a cystic carcinoma (e.g., cystadenocarcinoma)

Answer 457

Cholecystectomy after inflammation has resolved but before discharge

Answer 458

- Determine Etiology: hx of EtOH/gallstones (most common)/trauma/drugs, U/S to look for cholelithiasis, and workup (^Ca/TG?) - Resuscitation + Supportive Care: IV fluids/foley + early feeding (within 24-48 hrs, if can’t tolerate oral try NGT or NJT) + pain management (not morphine), correction of coags/electrolytes - Adjuncts: CT Scan to look for complications (abscess, necrosis, sterile acute fluid collections, pseudocyst, infection, bleeding or ERCP for persistent non-resolving biliary obstruction in gallstone pancreatitis - Surgery

Answer 459

Step up approach of Percutaneous drain -> endoscopic transgastric drainage -> minimally invasive retroperitoneal necrosectomy

Answer 460

Antibiotics and percutaneous drain placement or operative debridement and placement of drains

Answer 461

Lymphoid hyperplasia is thought to be common cause in younger patients

Answer 462

Blockage by solid particles of stool fecaliths is more common etiology in adults

Answer 463

Obstruction of appendiceal lumen (lymph node hyperplasia, fecalith, etc.) > continued mucus secretion and bacterial overgrowth > increased intraluminal pressure/inflammation/edema > venous congestion and impaired arterial flow = appendiceal ischemia > gangrene, necrosis, perforation, with irritation of parietal peritoneum

Answer 464

- Vague pain, initially epigastric or periumbilical - Anorexia, nausea (comes after the pain), rarely vomiting - Over course of 24 hours or less, pain intensifies and localizes to RLQ (visceral pain – somatic pain caused from parietal peritoneum) - McBurney’s Point: maximal tenderness 2/3 of the distance from umbilicus to the right ASIS - If patient complains of high fever, chills and describes pain that briefly subsided before getting worse, suspect a perforated appendix

Answer 465

- Gastroenteritis, Meckel’s diverticulitis, UTI and Crohn’s - Women who are sexually active and of childbearing age - include ectopic pregnancy, pelvic inflammatory disease, ruptured ovarian cyst, tubo-ovarian abscess and ovarian torsion - Older patients - include diverticulitis and malignancy - Young children - include mesenteric adenitis and intussusception

Answer 466

Appendiceal wall necrosis and translocation (gangrenous appendicitis) > Perforation and spillage of appendiceal contents > Peritonitis > Hemodynamic instability, sepsis, abdominal/appendiceal abscess

Answer 467

When a patient does not seek care within 24h after developing appendicitis-like symptoms, a diagnosis of ‘missed appendicitis’ is provided

Answer 468

Omentum covers the area of inflammation and walls it off in the right iliac fossa. The infection will carry on and create an abscess or phlegmon

Answer 469

A few days of pain, sometimes 7-10 days. Some days may be worse than others

Answer 470

- If sick, toxic, febrile, high WBC than surgery will probably be considered - Most don’t require immediate surgery, usually admit for antibiotics, analgesia and sometimes PERC drain - Recurrence is about ¼ if the appendix is not removed - May want to get a barium enema or colonoscopy to ensure no Crohn’s disease - Interval day surgery will be booked if the patient wants an appendectomy

Answer 471

Perforated and/or complicated appendicitis +/- hemodynamic instability, sepsis, free perforation, persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis – especially if leukocytosis is present; for acute nonperforated appendicitis, immediate appendectomy should be performed within 12 hours of diagnosis – moreover, those with appendiceal abscess (especially if not amenable to percutaneous drainage)

Answer 472

Ideally, at least 60 minutes before surgery – ceftriaxone 2g daily, flagyl 500mg BID

Answer 473

CBC (neutrophil shift) + Lytes + BUN (vomiting) + Creatinine + ALT (should be normal, r/o acute hepatitis) + Bilirubin + Lipase (r.o pancreatitis) + Urinalysis (r/o kidney stones)+ b-HCG (urine dip +/- serum r/o ectopic pregnancy)) + ECG + Abdominal Series X-rays

Answer 474

U/S (for appendicitis – useful to r/o gyne pathology in women; assess if there was periappendiceal fluid, surrounding inflammation + fat stranding, is there is dilation >6mm? – can do a dynamic study to see if compressible or if there is an echogenic fecalith present) + CT Scan w/contrast (can help diagnose an atypical presentation – all patients >50 should receive one unless unstable) The appendix is located just above the psoas muscle

Answer 475

Ileus – impaired bowel motility. Common causes: opiates, electrolytes abnormalities (hypokalemia) or intra-abdominal infections

Answer 476

1. Intraluminal: intussusception, gallstones, Bezoars 2. Intramural: Crohn’s disease, radiation stricture, adenocarcinoma 3. Extramural: previous surgery adhesions (75% of SBO), incarcerated hernia, peritoneal carcinomatosis

Answer 477

- Colicky pain (at first) > abdominal pain huge, ^HR, localized tender, leukocytosis, lactate acidosis (if strangulated) - Diarrhea - Early nausea, vomiting (more proximal > distal) – if feculent, then more established BO b/c of bacterial overgrowth - Constipation, obstipation (no passage of stool or gas) – WHEN WAS THE LAST TIME THEY PASSED GAS - Abdominal distention - Tympany to percussion in central abdomen - Hyperactive bowel sounds precedes absent bowel sounds

Answer 478

Proximal dilated SB (>3cm in diameter), air fluid levels on upright film (LADDER APPEARANCE) – if its just 2 lines, then probably an ileus, no colonic gas. If there is fluid-filled loops – string of beads

Answer 479

Prior abdominal surgery or presence of abdominal wall hernias

Answer 480

- Creatinine + HCT: assess degree of hydration. Hemoconcentration indicated by elevated hemoglobin and hemocrit - Electrolyte Abnormalities: may see this and metabolic hypochloremic alkalosis due to frequent emesis - Amylase: elevated. You should not see an elevation of lipase. Amylase and lipase-done to rule out pancreatitis. Should be normal in a patient with bowel obstruction or only have a mild elevation of amylase - CBC: leukocytosis + ^lactate (late sign) – both of these if strangulation

Answer 481

Peritonitis, high fever or high concern of ischemia, elevated white blood count, primary SBO (tumor) – all those that shouldn’t have adhesions

Answer 482

If no improvement or worsening sx after trial of conservative management then surgery is indicated. Complete obstruction, closed loop obstruction, perforation or dead gut

Answer 483

NPO, NG tube, resuscitation (IV isotonic fluids, foley catheter and serial abdominal exams), gastrografin. 50% resolve their sx - Overall: IV isotonic fluid resuscitation + urine output monitoring with catheter + 10mg buscopan (relaxes the bowels), and gravol - NG Tube for Gastric Decompression: decreases nausea, distention, risk of aspiration from vomiting

Answer 484

Ischemia, perforation, toxic megacolon (septic patient with exceedingly dilated colon – 12cm: IBD, c.dif, pseudo-obstruction, mechanical obstruction, volvulus), closed loop obstruction (both ends of the obstructed segment are blocked)

Answer 485

- Intraluminal: constipation, foreign bodies - Intramural: adenocarcinoma, diverticulitis, IBD stricture, radiation stricture - Extramural: volvulus, adhesions, hernias (sigmoid colon in inguinal groin hernia)

Answer 486

Nausea/vomiting, colicky abdo pain, distention, constipation, bowel sounds normal/increased/absent if ileus

Answer 487

Incompetent ileocecal valve allows relief of colon pressure as contents reflex INTO the ileum > clinical features are similar to SBO

Answer 488

Competent ileocecal valve results in proximal/distal occlusions and massive colonic distention then pressure in the cecum > bowel wall ischemia > necrosis > perforation

Answer 489

Distention of colon without actual obstruction in distal end – exact mechanism unknown; ends up leading to abdominal distention (acute/gradual over 3-7d), abdominal pain, nausea, vomiting, constipation, diarrhea, fever, leukocytosis, peritoneal signs

Answer 490

Dilated LB, primarily cecum (>9cm in diameter), more than 12cm is a risk for perforation, air fluid levels (PICTURE FRAME APPEARANCE) + proximal distention/distal decompression, no small bowel air if competent ileocecal valve – Coffee Bean Sign (i.e. sigmoid volvulus)

Answer 491

Surgical correction of obstruction, usually resection and diverting colostomy – volvulus requires sigmoidoscopic/endoscopic decompression first, then if not, operative resection

Answer 492

Treat underlying cause, NPO, nasogastric tube decompression (or rectal tube decompression, colonoscopy, neostigmine), or surgical decompression (ostomy/resection) uncommon

Answer 493

Temporary, reversible impairment of intestinal motility, most frequently caused by = abdominal operations, infections/inflammation, medications (opiates, anesthetics, psychotropics), electrolyte abnormalities

Answer 494

Same as mechanical obstruction but without actual obstruction – however, bowel sounds are diminished/absent, not hyperactive; post-op gastric/SB motility returns by 24-48hrs, colonic motility by 3-5d

Answer 495

Routine post-op ileus is expected, so no investigations required; if persists or without abdominal surgery, then review patient medications (opiates), monitor serum electrolytes (+ magnesium, calcium, phosphate), CT scan to r/o abscess/peritoneal sepsis or exclude complete mechanical obstruction

Answer 496

NPO + fluid resuscitation + nasogastric decompression + correct causative abnormalities (e.g. sepsis, meds, electrolytes), consider TPN for prolonged ileus

Answer 497

Arterio-occlusive mesenteric ischemia (thrombotic, embolic, extrinsic compression [strangulating hernia]), non-occlusive mesenteric ischemia (mesenteric vasoconstriction 2˚ to systemic hypoperfusion [preserves supply to vital organs]), mesenteric venous thrombosis (consider hypercoagulable state, DVT)

Answer 498

Acute – severe abdo pain out of proportion to physical, vomiting, bloody diarrhea, bloating, minimal peritoneal signs, hypotension, shock, sepsis; chronic – postprandial pain, fear of eating, weight loss

Answer 499

Leukocytosis (nonspecific) + lactic acidosis (late finding) + get amylase/lactate/CK/ALP (observe progress) + hypercoagulability workup if suspect venous thrombosis

Answer 500

- ABDO XR: portal venous gas, intestinal pneumatosis, free air if perforation - CONTRAST CT: thickened bowel wall, luminal distention, SMA or SMV thrombus, mesenteric or portal venous gas and pneumatosis - CT ANGIO: GOLD STD for acute arterial ischemia

Answer 501

- Fluid resuscitation – correct the metabolic acidosis, NPO, nasogastric decompression of the stomach + prophylactic broad-spectrum ABX - Surgery: exploratory laparotomy +/- angiogram, embolectomy/thrombectomy, bypass/graft, mesenteric endarterectomy, anticoagulation therapy, percutaneous transluminal angioplasty ± stent + segmental resection of necrotic intestine

Answer 502

1. Ascites - Portal HTN – Cirrhosis, Cardiac failure, Hepatic vein thrombosis - Normal Portal HTN - Cancer (especially ovarian), Pancreatitis, TB 2. Flatulence - Functional bowel disease (e.g. IBS) - Fibre - Lactose intolerance - Chewing gum (e.g. sorbitol, mannitol) 3. Feces - Constipation - Colonic obstruction - Dysmotility 4. Other - Pregnancy (fetus) - Obesity (fat) - Blood - Large tumours (fatal growth)

Answer 503

6Fs: Fat, Feces, Fetus, Flatus, Fluid, Fetal Growth

Answer 504

- Psychiatric/Neurologic disease – depression, dementia, stroke, Parkinson’s disease, eating disorder - Endocrine/Metabolic – hyperthyroidism, DM, hyperparathyroidism - GI – malabsorption (celiac disease, CF), PUD, IBD - Cardiac – CHF - Respiratory – COPD, and other respiratory diseases - Renal – end stage renal failure - Infections – HIV, TB, chronic HCV, fungal - Rheumatologic disease – lupus, RA, GCA - Malignancy – GI, lung, lymphoma, prostate

Answer 505

- Blood work: CBC, lytes, liver enzymes, CRP, Cr, urea, albumin, INR, total protein, TSH, fasting blood glucose, HIV serology, hep B/C serology, anti-TTG + IgA level, vit B12, iron studies - Imaging: CXR, abdominal US - Cancer screening: mammography, FIT/colonoscopy, pap smear, PSA - MMSE - Geriatric Depression Scale