Gastroenterology Flashcards
INITIAL TEST- WEIGHT LOSS BLOOD IN STOOL ANEMIA, ODYNOPHAGIA, DYSPHAGIA
ENDOSCOPY
DIAGNOSIS- <50YRS, PROGRESSIVE DYSPHAGIA (SOLIDS TO LIQ), NO TOXOMANIA
INITIAL TEST-
ACC. TEST-
INITIAL TREAT-
ACHALASIA
BARIUM ESOPHAGRAM(BIRD BEAK), MANOMETRY(NO LES RELAX-BAD PLEXUS), CXR, ENDOSCOPY
MANOMETRY
PNEUMATIC DILATION(3%PERFORATION),BOTOX(EVERY3-6MO),SURGICAL SECTIONING/MYOTOMY
DIAGNOSIS->=50YRS, PROGRESSIVE DYSPHAGIA, ALCOHOL AND TABACCO USE, 5-10YRS WITH GERD
INITIAL TEST-
ACC. TEST-
INITIAL TEST-
ESOPHAGEAL CANCER
BARIUM THEN ENDOSCOPY+BIOPSY; CT/MRI(FOR SPREAD); PET(DETERMINES CONTENTS/ANATOMIC LOCALITY OF LESION: TO SEE IF RESECTABLE)
ENDOSCOPY+BIOPSY
RESECTION+CHEMOTHERAPY+RADIATION; STENT PLACEMENT(IF NOT SURGICALY POSSIBLE/PALLIATION)
DIAGNOSIS- SUDDEN ONSET OF CHEST PAIN, NORMAL EKG, PRECIPITATED BY DRINKING COLD LIQUIDS
INITIAL TEST-
ACC. TEST-
INITIAL TREAT-
DIFFUSE ESOPHAGEAL SPASM (DES) OR NUT CRACKER ESOPHAGUS
BARIUM (WHILE SPASM=CORKSCREW); MANOMETRY
MANOMETRY
CCB AND NITRATES (LIKE ANGINA)
DIAGNOSIS- PROGRESSIVE ODYNOPHAGIA, AID’S CD4+=43MM^3
INITIAL TEST-
INITIAL TEST-
INFECCTIOUS ESOPHAGITIS: ESOPHAGEAL CANDIDIASIS 90% OF TIME, 10% CMV AND HSV
INFECCTIOUS ESOPHAGITIS= ORAL FLUCONAZOLE; IF NOT BETTER-ENDOSCOPY
FLUCONAZOLE RESITANT CANDIDIASIS CONFIRMED BY ENDOSCOPY= AMPHOTERICIN
TIP- NYSTATIN IS ONLY FOR ORAL CANDIDIASIS
TIP- ESOPHAGITIS DRUG INDUCED: DOXYCYCLINE, ALENDRONAT, KCL
TRUE
TRUE
DIAGNOSIS- INTERMITTENT DYPHAGIA, ACID FELUX, HIATAL HERNIA
INITIAL TEST-
INITIAL TREAT-
SCHATZKI RING/STEAKHOUSE SYNDROME(SOLID FOOD DYSPHAGIA)
BARIUM STUDY THEN ENDOSCOPY (SHOWS
FIBROSIS/SCARRING)
PNEUMATIC DILATION
DIAGNOSIS- DYSPHAGIA, IRON DEFICIENCY ANEMIA, GLOSSITIS
INITIAL TEST-
INITIAL TREAT-
PLUMMER-VINSON SYNDROME
BARIUM STUDY THEN ENDOSCOPY; IRON PANNEL
IRON REPLACEMENT (MAY RESOLVE LESION/WEB)
DIAGNOSIS- DYSPHAGIA, HALITOSIS AND REGURGITATION OF FOOD PARTICLES; HX. ASPIRATION PNEUMONIA
INTIAL TEST-
INITIAL TREAT-
ZENKER DIVERTICULUM
BARIUM STUDY
SURGERY
TIP- NASOGASTRIC TUBE AND ENDOSCOPY ARE DANGEROUS IN ZENKER DIVERTICULUM
DIAGNOSIS- DYSPHAGIA, REFLUX, SYSTEMIC AUTO-ANTIBODIES
INITIAL TEST-
INITIAL TREAT-
SCLERODERMA
MANOMETRY= DECREASED LES PRESSURE
PPI’S
TIP- MANOMETRY FOR A.S.S.?
ACHALASIA, SPASM, SCLERODERMA
DIAGNOSIS- UPPER GI BLEED( HEMATEMESIS BRIGHT RED OR MELENA) AFTER VOMITING OR RETCHING
INTIAL TEST-
INITIAL TREAT-
MALLORY-WEISS TEAR
HX./ ENDOSCOPY
SELFLIMITED; PERSISTENT BLEEDING: INJECT EPINEPHRINE OR ELECTROCAUTERY
TIP- MALLORY-WEISS VS BOERHAAVE SYNDROME?
MUCOSAL VS FULL PENETRATION OF ESOPHAGUS
DIAGNOSIS- EPIGASTRIC PAIN + WORSE WITH FOOD
DIAGNOSIS- EPIGASTRIC PAIN + WEIGHT LOSS
DIAGNOSIS- EPIGASTRIC PAIN + TENDERNESS
TIP-TENDERNESS IS?
DIAGNOSIS- EPIGASTRIC PAIN + DIABETIC, BLOATING
DIAGNOSIS- EPIGASTRIC PAIN + BAD TAST, COUGH, HOARSE+ RADIATES TO CHEST
DIAGNOSIS- EPIGASTRIC PAIN + NOTHING
GASTRIC ULCER GASTRIC ULCER OR CANCER PANCREATITIS OR BILIARY DISEASE INCREASED PAIN TO PALPATION OR PRESSURE GASTROPARESIS GERD NON-ULCER DYSPEPSIA
INITIAL TEST- EPIGASTRIC PAIN + SOMETHING
TIP- BARIUM STUDIES IS A GOOD TEST START ONLY IN THE?
INTIAL TREAT- EPIGASTRIC PAIN
ENDOSCOPY
ESOPHAGUS
PPI’S, H2 BLOCKERS: RANITIDINE, NIZATIDINE, CIMETIDINE, FAMOTIDINE (WORKS IN 70%), ANTIACIDS( WORKS 70%), MISOPROSTOL=OBSOLETE
TIP- RELAXED LES (GERD) WORSE WITH? INTIAL TEST- GERD INITIAL TREAT- GERD MILD/INTERMITTENT INITIAL TREAT- GERD EROSIVE INITIAL TREAT- GERD NON RESPONSIVE (5%)
NICOTINE, ALCOHOL, CAFFEINE, CHOCOLATE, PEPPERMINT, LATE-NIGHT MEALS, OBESITY
HX. THEN IF DYSPHAGIA, ODYNOPHAGIA, WEIGHT LOSS, ANEMIA OR 5-10YRS EVOLUTION= ENDOSCOPY
LOSE WEIGHT IF OBESE, AVOID TRIGGERS, EAT 3 HOURS BEFORE BEDTIME, ELEVATE BED 6-8IN. + ANTIACID OR H2
LOSE WEIGHT IF OBESE, AVOID TRIGGERS, EAT 3 HOURS BEFORE BEDTIME, ELEVATE BED 6-8IN. + PPI’S
SURGICAL: NISSEN FUNDOPLICATION(WRAP STOMACH TO LES), ENDOCINCH: SUTURE AROUND LES, HEAT/RADIATION OF LES (SCARRING)
DIAGNOSIS- 5YRS WITH NON TREATED GERD
INITIAL TEST-
INITIAL TREAT- 1/3
INITIAL TREAT- 2/3
INITIAL TREAT- 3/3
BARRET ESOPHAGUS
ENDOSCOPY/ BIOPSY=COLUMNAR METAPLASIA
BARRET ALONE= PPI’S AND RESCOPE EVERY 2-3 YEARS
BARRETT + LOW GRADE DYSPLASIA= PPI’S AND RESCOPE EVERY 6-12 MONTHS
BARRETT+ HIGH GRADE DYSPLASIA=ABLATION WITH ENDOSCOPY: PHOTODYNAMIC THERAPY, RADIOFREQUENCY ABLATION, ENDOSCOPIC MUCOSAL RESECTION
DIAGNOSIS- EPIGASTRIC PAIN+BLEEDING OR PAINLESS BLEEDING IF NOT + HX. ALCOHOL, NSAID, H. PYLORI, PORTAL HYPERTENSION, TRAUMA/STRESS/INF; B12DEF./UREMIA
INITIAL TEST-
INITIAL TREAT-
GASTRITIS
ENDOSCOPY (BEST AND ACC.); SEROLOGY(H. PYLORI LACKS SPECIFICITY);UREA C13/14 BREATH (ONLY ACTIVE); STOOL ANTIGEN(ONLY ACTIVE)
PPI’S OR H2 BLOCK, SUCRALFATE (COMMENLY WRONG), ANTIACIDS (NOT AS EFFECTIVE)
TIP- VOLUME TO MANIFESTATION:COFFEE-GOUND EMESIS(5-10ML), HEME(GUAIAC) STOOL(5-10ML), MELENA (50-100ML)
TIP- PORPHYLASIS GASTRITIS?
MECHANICAL VENTILATION, BURNS, HEAD TRAUMA, COAGULOPATHY
DIAGNOSIS- GASTRITIS EROSIVE/ WITH EPIGASTRIC PAIN
INITIAL TEST-
INITIAL TREAT-
PEPTIC ULCER DISEASE (PUD)
ENDOSCOPY; GI SERIES (CANNOT DETECT CANCER; OR INFECTION THOUGH)
PPI’S, CLARITHROMYCIN, AMOX;THEN PPI’S, METRONIDAZOLE AND TETRACYCLINE + BISMUTH; THEN BREATH TEST (IN GU: ENDOSCOPY LOOK FOR CANCER)
TIP- CAUSE OF PUD
TIP- ALCOHOL AND TOBACCO DO NOT CAUSE ULCERS BUT DELAY HEALING
TIP- DU-PUD VS GU-PUD
TIP- PUD TREAT FAILURE IS FROM?
H.PYLORI THEN NSAIDS; RARE: STRESS, TUMOR, GRANULOMAS: CROHN
TRUE
IMPROVED WITH EATING VS WORSE BY EATING; 0% CANCER VS 4% CANCER; H.PYLORI 80-90% VS 50-70%
NONADHERENCE TO MEDICATIONS, ALCOHOL, TOBACCO, NSAID’S
DIAGNOSIS-EPIGASTRIC PAIN NO ULCER?
INITIAL TREAT-
NON-ULCER DYSPEPSIA (NUD)
PPI’S
TIP- SCOP NUD IF?= 45 TO 55 YRS OLD, “ALARM” DYSPHAGIA, WEIGHT LOSS, ANEMIA
DIAGNOSIS- LARGE ULCER (OVER 1-2CM), RECURRENT AFTER H.PYLORI, DISTAL(DUODENUM), MULTIPLE, DIARRHEA(ACID INACT. LIPASE)
INITIAL TEST- GASTRINOMA 1/2
INITIAL TEST- GASTRINOMA 2/2
INITIAL TREAT- GASTRINOMA
P.ASS.
GASTRINOMA
ENDOSCOPY, HIGH GASTRIN LEVELS AND HIGH ACID LEVELS WITH PPI’S, H2 OR SECRETIN
IMAGE: CT/MRI OF ABDOMEN (FOR METS); THEN SOMATOSTATIN RECEPTOR SCINTIGRAPHY(OCTREOTIDE SCAN)+ENDOSCOPIC ULTRASOUND
LOCAL=SURGERY; METS=PPI’S TO BLOCK ACID PRODUCTION
INCREASED SOMATOSTATIN RECEPTORS AND MEN(MULTIPLE ENDOCRINE NEOPLASIA)
DIAGNOSIS- DM, ABDOMINAL DISCOMFORT, “BLOATING” CONSTIPATION, ANOREXIA, NAUSEA AND VOMITING, SATIETY
INITIAL TEST-
INTIAL TREAT-
DIABETIC GASTROPARESIS
NUCLEAR GASTRIC MOTILITY TEST
ERYTHROMYCIN AND METOCLOPROMIDE
TIP- DIABETIC GASTROPARESIS IS DUE TO?
NEUROPATHY=CANNOT SENSE STRETCH AND PRODUCE REFLEX MOTILITY
DIAGNOSIS- BRIGHT RED BLOOD ON STOOL, ORTHOSTASIS(10 RISE ON PULSE ON STANDING), TACHYCARD, DROP BP 1/2
TIP- % BLOOD LOSS: ORTHOSTASIS; PULSE >100 PER MIN; SYS BP
LOWER GI BLEED: DIVERTICULOSIS, ANGIODYSPLASIA (AVM), POLYPS/CANCER, IBD, HEMORROIDS, UPPER GI HIGH VOLUME/SPEED TRANS
BLOOD LOSS: 15-20%; 30%; 30%
UPPER GI BLEED: HIGH VOLUME FROM CANCER, GASTRITIS, ESOPHAGITIS, DUODENITIS, VARICES
VICEREAL BLEED: LIVER, SPLEEN
INITIAL TEST- GI BLEED 1/3 TIP-10% OF RECTAL BLEED IS? INITIAL TREAT- GI BLEED 1/4 INITIAL TEST- GI BLEED 2/3 INITIAL TEST- GI BLEED 3/3
SEVERITY TREATMENT-FLUIDS; THEN LAB: Hct, Plt, PT, PTT/INR BLEEDING TIME; NG TUBE; ENDOSCOPY AFTER
UPPER GI BLEED: RAPID TRANSIT
SEVERITY TREATMENT; VERY OFFTEN RESOLVES ALONE JUST STABILIZE PATIENT
NUCLEAR BLEEDING SCAN-UNCLEAR ENDOSCOPY; ANGIOGRAPHY-SPECIFIC VESSEL FOR SURGERY;
CAPSULE ENDOSCOPY-UPPER/LOWER ENDO NO SHOW; EKG/LACTATE LEVEL-ISCHEMIA
TIP- NEVER CT/MRI IN? INITIAL TREAT- GI BLEED 2/4 INITIAL TREAT- GI BLEED 3/4 INITIAL TREAT- GI BLEED 4/4 TIP- WHEN TO USE Plt's? TIP- SCLEROTHERAPY IS?
GI BLEED
SEVERITY TREATMENT: FLUID 1-2L PER HR, PACKED RED BLOOD CELLS(Hct<10000-20000 SPONTANEOUS BLEED
NEVER THE ANSWER
DIAGNOSIS- ANTIBIOTIC USE+ DIARRHEA
INITIAL TEST-
INITIAL TREAT-
AAD MOST COMMON CLOSTRIDIUM DIFFICILE
STOOL C.DIFF TOXIN TEST OR PCR, BLOOD/WBC IN STOOL
METRONIDAZOLE; THEN VANCOMYCIN OR FIDAXOMICIN (IF NEVER RESPOND TO METRO)
TIP- RETREAT WITH METRONIDAZOLE IF RECURRENT RESPONDENT C.DIFF
DIAGNOSIS- GLUTEN STEATORRHEA, DEFICIENCY IN ADEK VIT.:HYPOCALCEMIA, OSTEOPOROSIS, BLEEDING, EASY BRUISING, ANEMIA, NEUROPATHY (B12)
INITIAL TEST-
INITIAL TREAT-
CELIAC DISEASE
SMALL BOWEL BIOPSY: FLAT VILLI=CELIAC DISEASE; ORGANISM=WHIPPLE AND TROPIC SPRUE;ANTI-TRANSGLUTAMINASE,ENDOMYSIAL,IGA GLIADIN; ABDOMINAL. XRAY
AVOID GLUTEN
DIAGNOSIS- ARTHRALGIAS, OCULAR FINDINGS, NEUROLOGIC ABNORMALITIES (DEMENTIA, SEIZURES) FEVER, LYMPHADENOPATHY, STEATORRHEA
INITIAL TEST-
INITIAL TREAT-
WHIPPLE DISEASE
SMALL BOWEL BIOPSY: FLAT VILLI=CELIAC DISEASE; ORGANISM=WHIPPLE AND TROPIC SPRUE;ANTI-TRANSGLUTAMINASE,ENDOMYSIAL,IGA GLIADIN; ABDOMINAL. XRAY
CETRIAXONE, TRIMETHOPRIM/SULFAMETHOXAZOLE
DIAGNOSIS- EPIGASTRIC PAIN, STEATORRHEA
INITIAL TEST-
ACC. TEST-
INITIAL TREAT-
CHRONIC PANCREATITIS
ABDOMINAL XRAY, CT SCAN, SECRETIN STIMULATION TESTING
SECRETIN STIMULATION TESTING: IV SECRETIN+ NG TUBE-NORMAL=LARGE VOL. BICARB FLUID
ENZYME REPLACEMENT
TIP- D-XYLOSE TEST IS OLD METHODE TO DEF. WALL VS PANCREATIC AFFECTION (NORMAL IN PANCREAS)
TIP- 10% CELIAC DISEASE GET?
TIP- MALABSORPTION DIFERENTIALS?
DERMATITIS HERPETIFORMIS
CELIAC, WHIPPLE, TROPIC SPRUE, PANCREATITIS
INITIAL TEST- MALABSORPTION
INITIAL TREAT- TROPICAL SPRUE
SMALL BOWEL BIOPSY: FLAT VILLI=CELIAC DISEASE; ORGANISM=WHIPPLE AND TROPIC SPRUE;ANTI-TRANSGLUTAMINASE,ENDOMYSIAL,IGA GLIADIN; ABDOMINAL. XRAY
TMP/SMX, TETRACYCLINE
DIAGNOSIS- FLUSHING, WHEEZING, CARDIAC ABNORMALITIES (RIGHT SIDE)
INITIAL TEST-
INITIAL TREAT-
CARCINOID SYNDROME
URINE 5-HYDROXYINDOLEACETIC ACID (5-HIAA) TEST
OCTREOTIDE (SOMATOSTATIN)
DIAGNOSIS- NAUSEA, VOMMITING AFTER MILK, DIARRHEA
INITIAL TEST-
INITIAL TREAT-
LACTOSE INTOLERANCE
REMOVE MILK, WAIT AND SEE
REMOVE LACTOSE PRODUCT OR ADD LACTASE PILLS
DIAGNOSIS- PAIN+ DIARRHEA, CONSTIPATION: RELIEVED WITH BOWEL MOVEMENT, LESS AT NIGHT
INITIAL TEST-
INITIAL TREAT-
IBS
EXCLUDE ALL OTHER
FIBER IN DIET, ANTISPASMODIC AGENTS-HYOSCYAMINE, DICYCLOMINE; TCA’S OR SSRI’S, ANTIMOTILITY ANGENTS, LUBIPROSTONE; LUBIPROSTONE
DIAGNOSIS- DIARRHEA, BLOOD IN STOOL, WIGHT LOSS, AND FEVER
P.ASS.-ARTHRALGIAS, UVEITIS, IRITIS, SKIN: ERYTHEMA NODOSUM, PYODERMA GANGRENOSUM, SCLEROSING CHOLANGITIS(UC)
IBD
IBD
DIAGNOSIS- SKIP LESIONS, TRANSMURAL GRANULOMAS, FISTULAS AND ABSCESSES, MASSES AND OBSTRUCTION, PERIANAL DISEASE
INITIAL TEST- IBD INTIAL TREAT- IBD 1/3 TIP- IBD STEROIDS? INITIAL TREAT- IBD 2/3 INITIAL TREAT- IBD 3/3
CROHNS
ENDOSCOPY (ACC. TEST) WHEN REACHED, BARIUM STUDIES(CD), SEROLOGIC: ANCA(UC), ANTISACCHAROMYCES CEREVESIAE ANTIBODY(ASCA) (CD)&ANEMIA
ACUTE: STEROIDS CHRONIC: 5-ASA DERIV.-ASACOL(MESALAMINE)IN UC AND PENTASA(MESALAMINE) CD ROWASA(MESA.) RECTUM UC
AZATHIOPRINE AND 6-MERCAPTOPURINE-TO TAKE OFF STEROIDS+CALCIUM&VITD, PERIANAL CD: CIPROFLOXACIN/METRONIDAZOLE
FISTULAE: ANTI-TNF (INFLIXIMAB), SURGERY: CD-PALIATIVE FOR OBSTRUCTION; UC-CURED BUT WITH COLECTOMY
DIAGNOSIS- CURABLE BY SURGERY, ENTIRELY MUCOSAL, NO FISTULAS, NO ABSCESSES, NO OBSTRUCTION, NO PERIANAL DISEASE
INITIAL TEST- IBD
INTIAL TREAT- IBD 1/3
INITIAL TREAT- IBD 2/3
INITIAL TREAT- IBD 3/3
ULCERATIVE COLITIS
ENDOSCOPY (ACC. TEST) WHEN REACHED, BARIUM STUDIES(CD), SEROLOGIC: ANCA(UC), ANTISACCHAROMYCES CEREVESIAE ANTIBODY(ASCA) (CD)&ANEMIA
ACUTE: STEROIDS CHRONIC: 5-ASA DERIV.-ASACOL(MESALAMINE)IN UC AND PENTASA(MESALAMINE) CD ROWASA(MESA.) RECTUM UC
AZATHIOPRINE AND 6-MERCAPTOPURINE-TO TAKE OFF STEROIDS+CALCIUM&VITD, PERIANAL CD: CIPROFLOXACIN/METRONIDAZOLE
FISTULAE: ANTI-TNF (INFLIXIMAB), SURGERY: CD-PALIATIVE FOR OBSTRUCTION; UC-CURED BUT WITH COLECTOMY
TIP- WHEN SHOULD SCREENING OCCUR IN IBD?
AFTER 8 TO 10 YRS OF COLONIC INVOLVEMENT, WITH COLONOSCOPY EVERY 1 TO 2 YRS
TIP- IBD STEROIDS?
PREDNISONE OR BUDESONIDE
DIAGNOSIS- LEFT LOWER QUADRANT ABDOMINAL PAIN, CONSTIPATION, BLEEDING
INTIAL TEST-
INTIAL TREAT-
DIVERTICULOSIS
COLONOSCOPY, BARIUM STUDIES
BRAN, PSYLLIUM, METHYLCELLULOSE, INCREASE FIBER
DIAGNOSIS- OLDER PT. LEFT LOWER QUAD PAIN AND TENDERNESS, FEVER, LEUKOCYTOSIS, PALPABLE MASS, BLEEDING
INITIAL TEST- DIVERTICULITIS
INITIAL TREAT- DIVERTICULTIS 1/3
INITIAL TREAT- DIVERTICULTIS 2/3
INITIAL TREAT- DIVERTICULTIS 3/3
DIVERTICULITIS
CT SCAN; NEVER-COLONOSCOPY/BARIUM ENEMA- WEAK WALL
COVER: E.COLI AND ANAEROBES- CIPROFLOXACIN
COMBINED WITH METRONIDAZOLE OR AMOXICILLIN/CLAV,
TICARCILLIN/CLAVULANATE OR PIPER/TAZ,ERTAPENEM; DO NOT FEED; SURGERY: NO RESPONSE, FREQUENT RECURRENCES, PERFORATION,
FISTULA FORMATION, ABSCESS, STRICTURES OR OBSTRUCTION ESPECIALY YOUNG PT.
DIAGNOSIS- PT >50YRS OR PT FM OR 40YRS WITH 1 FAMILY MEMBER WITH COLON CANCER OR 10 YRS BEFORE FAMILY EVENT, HEREDITARY
DIAGNOSIS- THREE FAMILY MEMBERS 2 GEN, 1 PREMATURE
COLON CANCER SCREEN COLON CANCER SCREEN COLON CANCER SCREEN COLON CANCER SCREEN COLON CANCER SCREEN
DIAGNOSIS- MELANOTIC SPOTS ON LIPS AND SKIN; INCREASED FREQUENCY OF BREAST CANCER, INCREASED GONADAL AND PANCREATIC CANCER + COLON CANCER
PEUTZ JEGHERS SYNDROME
DIAGNOSIS- OSTEOMAS, DESMOID TUMOR, OTHER SOFT TISSUE TUMOR+ COLON CANCER
GARDNER SYNDROME
DIAGNOSIS- CNS MALIGNANCY + COLON CANCER
TURCOT SYNDROME
DIAGNOSIS- MULTIPLE HAMARTOMATOUS POLYPS + COLON CANCER
JUVENILE POLYPOSIS
TIP- COLON CANCER SYNDROMES SCREENING FREQUENCY IS?
THE SAME AS COLON CANCER
DIAGNOSIS- ACUTE EPIGASTRIC PAIN + TENDERNESS + NAUSEA/VOMITING; IN SEVERE CASE: HYPOTENSION, FEVER
P.ASS.- ALCOHOLISM/ CHOLELITHIASIS; OR TRAUMA, HYPERTRIGLYCERIDEMIA; HYPERCALCEMIA; INFECTION; DRUG TOX;DRUG ALLERGY; DUCTAL OBSTRUCTION, ERCP, CYSTIC FIBROSIS; SCORPION STING
INITIAL TEST- ACUTE PANCREATITIS 1/2 INITIAL TEST- ACUTE PANCREATITIS 2/2 TIP- ULTRASOUND IS GOOD? INITITAL TREAT- ACUTE PANCREATITIS INITITAL TREAT- ACUTE PANCREATITIS
ACUTE PANCREATITIS
ACUTE PANCREATITIS
AMYLASE AND LIPASE; CT SCAN-CONTRAST (MOST SPECIFIC); NEEDLE BIOPSY IF 30% NECROSIS “EXTENSIVE”; LAB: CBC-LEUKOCYTOSIS, DROP IN Htc OVER TIME WITH REHYDRATION, INC. LDH,AST
,
HYPOXIA, HYPOCALEMIA, ELEVATED URINARY TRYPSINOGEN ACT. PEP; IMAGE: CT OR MRI SCAN(PSEUDOCYST), MRCP (FOR STONES, STRICURE, TUMOR)-ERCP (FOR THERAPY), PLAIN XRAY=SENTINEL LOOP OF BOWEL(LUQ),
NO NOT FOR PANCREATITIS
NPO, IV HYDRATION (HIGH VOLUME), ANALGESIA, PPI’S DECREASE PANCREATIC STIMULATION TO ACID ENTERING DOUDENMUM
EXTENSIVE NECROSIS: ADD ANTIBIOTICS-IMIPENEM OR MEROPENEM, DRAIN PSEUDOCYSTS AND SURGICAL DEBRIDEMENT( PREVENT ARDS); OBSTRUCTIVE PANCREAS: ERCP + STENTS
TIP- PENTAMIDINE, DIDANOSINE, AZATHIOPRINE, ESTROGENS SIDE EFFECT
TIP- A STONE, A STRICTURE, TUMOR, AND OBSTRUCTION
TIP- PAIN STRAIGHT THROUGH BACK “LIKE SPEAR” VS GOES AROUND SIDE TO BACK
TIP- SEVERITY IS DETERMINED BY?
ACUTE PANCREATITIS
ACUTE PANCREATITIS
ACUTE PANCREATITIS VS CHOLECYSTITIS
CALCIUM LEVELS
DIAGNOSIS- ASCITES, COAGULOPATHY(ALL FACTORS BUT VIII), ASTERIXIS, ENCEPHALOPATHY, SPIDER ANGIOMATA AND PALMAR ERYTHEMA, PORTAL HYPERTENSION-VARICES, THROMBOCYTOPENIA-SPLENIC SEQUESTRATION, RENAL INSUFFICIENCY (HEPATORENAL SYNDROME), HEPATOPULMONARY SYNDROME
CHRONIC LIVER DISEASE/CIRRHOSIS
TIP- HEPATOPULMONARY SYNDROME IS?
TIP- PARACENTESIS SHOULD BE PERFORMED IF?
TIP- SAAG 1.1g/Dl ?
ORTHODEOXIA- HYPOXIA UPON SITTING UPRIGHT
NEW ONSET ASCITES, ABDOMINAL PAIN AND TENDERNESS, FEVER (SHOWS SERUM ASCITES ALBUMIN GRADIENT)
INFECTIONS(EXCEPT SBP), CANCER, NEPHROTIC SX.; OR PORTAL HYPERTENSION(CAUSED BY LOW ALBUMIN), CHF, HEPATIC VEIN THROMBOSIS, CONSTRICTIVE PERICARDITIS
INITIAL TEST- CHRONIC LIVER DISEASE/CIRRHOSIS
LFT; BIOPSY
DIAGNOSIS- ASCITES, FEVER, NO PERFORATION OF BOWEL
INITIAL TEST-
INITIAL TREAT-
SPONTANEOUS BACTERIAL PERITONITIS (E.COLI OR PNEUMOCOCCUS) = SBP
CELL COUNT > 250 NEUTROPHILS, GRAM STAIN: IS NEGATIVE; FLUID CULTURE (ACC. TEST)
CEFOTAXIME OR CEFTRIAXONE; IF RECURS AND LOW ALBUMIN: PROPHYLAX WITH NORFLOXACIN OR TMP/SMX
DIAGNOSIS- ALCOHOLIC; LIVER DISEASE WITH
EXCLUSION OF ALL OTHER CAUSES
INITIAL TEST- ?
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 1/8
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 2/8
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 3
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 4
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 5
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 6
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 7
INITIAL TREAT- CHRONIC LIVER DISEASE/CIRRHOSIS 8
ALCOHOLIC LIVER DISEASE
LAB: AST»>ALT, GGTP IF BINGE DRINKING; PE: LIVER DISEASE; BIOPSY
ASCITIES AND EDEMA: SPIRONOLACTONE AND OTHER DIURETICS, SERIAL PARACENTESES FOR LARGE VOLUME ASCITES
COAGULOPATHY AND THROMBOCYTOPENIA: RRP AND PLATELETS ONLY IF BLEEDING OCCURS
ENCEPHALOPATHY: LACTULOSE, RIFAXIMIN
HYPALBUMINEMIA: NO SPECIFIC THERAPY
SPIDER ANGIOMATA AND PALMAR ERYTHEMA: NO SPECIFIC THERAPY
VARICES: PROPRANOLOL AND BANDING VIA ENDOSCOPY
HEPATORENAL SYNDROM: SOMATOSTATIN (OCTREOTIDE), MIDODRINE
HEPATOPULMONARY SYNDROME: NO SPECIFIC THERAPY
DIAGNOSIS- WOMAN 40-50’S, FATIGUE AND ITCHING, NORMAL BILIRUBIN AND ELEVATED ALKALINE PHOSPHATASE; LIVER DISEASE
P.ASS.-
INITIAL TEST-
INTIAL TREAT-
PRIMARY BILIARY CIRRHOSIS (PBC)
XANTHELASMA/XANTHOMA, OSTEOPOROSIS
LIVER BIOPSY (ACC. TEST); LAB: ANTIMITOCHONDRIAL ANTIBODY, IGM AND BILIRUBIN HIGH WHEN DISEASE ADVANCED; NOTE: TX FOR 8 LIVER SYMPTOMS
URSODEOXYCHOLIC ACID
DIAGNOSIS- IBD-UC+ PRURITIS, ELEVATED ALKALINE PHOSPHATSE AND GGTP, BILIRUBIN LOOKS LIKE PBC
ACC. TEST-
INITIAL TEST-
INITIAL TREAT-
PRIMARY SCLEROSING CHOLANGITIS
ERCP- BEADING, NARROWING OR STRICTURES IN BILIARY SYSTEM
ERCP; BIOPSY
CHOLESTYRAMINE OR URSODEOXYCHOLIC ACID; NOTE: TX FOR 8 LIVER SYMPTOMS
TIP- IS DISEASE CURED WITH IBD-UC COLECTOMY?
NO- PSC PROGRESSES
DIAGNOSIS- LIVER DISEASE+ EMPHYSEMA (COPD); YOUNG PT (<40) NONSMOKER; FAMILY HX.
INITIAL TEST-
INITIAL TREAT-
ALPHA 1-ANTITRYPSIN DEFICIENCY CIRRHOSIS
A1-ANTITRYPSIN
REPLACE TRYPSIN
DIAGNOSIS- PT 50’S, MILD INCREASES IN AST AND ALKALINE PHOSPHATASE: FATIGUE; JOINT PAIN(PSEUDOGOUT); ED; AMENORRHEA IN WOMEN(PIT IVOLVED); SKIN DARKEN; DIABETES; CARDIOMYOPATHY
INITIAL TEST-
ACC. TEST-
INITIAL TREAT-
HEMOCHROMATOSIS CIRRHOSIS OR JUST FIBROSIS (NOTE REVERSABLE)
IRON STUDIES: INC. IRON AND FERRITIN; DECR. TIBC/ TRANSFERRIN SAT. IMAGE: MRI (SHOWS IRON DEPOSITS ON LIVER); GENETIC TEST
LIVER BIOPSY
PHLEBOTOMY; IF NOT POSSIBLE OR ANEMIC OVERTRANSFUSED CAUSE=CHELATION:DEFEROXAMINE(IM), DEFERASIROX,DEFERIPRONE(ORAL)
TIP- C282Y?
TIP- VIBRIO VULNIFICUS, YERSINA AND LISTERIA INFECTIONS OCCUR BECAUSE?
TIP- ALSO IN SIDEROBLASTIC ANEMIA?
GENE MUTATION= OVERABSORPTION OF IRON IN THE DUODENUM
THEY FEED ON IRON
PRUSSIAN BLUE STAIN OF RBC’S
DIAGNOSIS- CHRONIC HEPATITIS B OR C + LIVER DISEASE
INITIAL TEST- B
INITIAL TEST- C
INITIAL TREAT- CHRONIC B
INITIAL TREAT- CHRONIC C
HEPATITIS CIRRHOSIS
HEPATITIS B CIRRHOSIS= HEP B DNA LEVEL BY PCR (VIRAL REPLICATION ACTIVITY); BIOPSY(DEGREE OF IFLAMMATION AND FIBROSIS= URGENCY TO TREAT)
HEPATITIS C CIRRHOSIS(80% CHRONIC) =HEP C PCR RNA VIRAL LOAD (VIRAL ACTIVITY)
CHRONIC HEP B CIRRHOSIS=ONE OF: ADEFOVIR, LAMIVUDINE, TELBIVUDINE, ENTECAVIR,TENOFOVIR, INTERFERON
CHRONIC HEP C CIRRHOSIS=COMBO: INF, RIBAVIRIN + ONE OF: TELAPREVIR OR BOCEPREVIR (SAME FOR ACUTE)
TIP- LIVER CANCER AND CIRRHOISIS AND POLYARTERITIS NODOSA ARE CAUSED BY?
BOTH HEP B AND C
TIP- ARTHRALGIAS, THROMBOCYTOPENIA, DEPRESSION, LEUKOPENIA
TIP- ANEMIA
TIP-TENAL DYSFUNTION
TIP-NONE
INF
RIBAVIRIN
ADEFOVIR
LAMIVUDINE
DIAGNOSIS- LIVER DISEASE+ NEUROLOGICAL SYMPTOMS: PSYCHOSIS, TREMOR,DYSARTHRIA, ATAXIA OR SEIZURES, COOMBS NEGATIVE HEMOLYTIC ANEMIA, RTA OR NEPHROLITHIASIS
TIP- PSYCHOSIS AND DELUSIONS OCCUR BECAUSE?
INITIAL TEST-
INITIAL TREAT-
WILSON DISEASE CIRRHOSIS
THE COPPER ACCUMULATES NOT TO CONFUSE: ENCEPHALOPATHIC FEATURES OF DELIRIUM
SLIT-LAMP=KAYSER-FLEISCHER RINGS; CERULOPASMIN-LOW(NOT ALWAYS OR ALL PROTEINS LOW); LIVER BIOPSY(INC. COPPER)
CHELATE: PENICILLAMINE OR TRIENTINE; ZINC(INTERFERES WITH INTESTINAL COPPER ABSORPTION)
DIAGNOSIS- YOUNG WOMAN; LIVER INFLAMMATION; POSITIVE ANA
INITIAL TEST- AUTOIMMUNE HEPATITIS
INITIAL TREAT- AUTOIMMUNE HEPATITIS
AUTOIMMUNE HEPATITIS
LIVER-KIDNEY MICROSOMAL ANTIBODIES, HIGH: GAMMA GLOBULIN(IgG), AND ANTI-SMOOTH MUSCLE ANTIBODIES; LIVER BIOPSY
PREDNISONE AND OR AZATHIOPRINE
DIAGNOSIS- NONALCOHOLIC, STEATORRHEA + RUQ DISCOMFORT
INITIAL TEST-
INITIAL TREAT-
NONALCOHOLIC STEATOHEPATITIS (NASH) OR NONALCOHOLIC FATTY LIVER DISEASE
LFT= MILDLY ABNORMAL; TEST FOR: OBESITY, DIABETES, HYPERLIPIDEMIA CORTICOSTEROID USE; LIVER BIOPSY (ACC. TEST)-EXCLUDE SERIOUS LIVER DISEASE
CORRECT UNDERLYING CAUSE
