Gastroenterology Flashcards
Boerhaave’s Syndrome
Esophageal rupture/pert due to severe retching/vomiting
Hematemesis with SEVERE retrosternal “tearing” pain, SQ emphysema/crepitation
CXR= mediastinal widening
Confirmed by CT chest
Emergent surgery
Achalasia
Ineffective parastalsis or swallow-induced relaxation of LES
Regurgitation of u digested food
Esophagram with “birds beak” distal esophagus
Confirmed by esophageal manometer-measures peristalsis and strength of LES
Esophageal Varices
Dilated veins in lower esophagus
H/o portal HTN/cirrhosis
1/3 will bleed-brisk with hematemesis, melena and hematochezia
Emergent endoscopy
Long term expires= BB, no ETOH
Zenker’s Diverticulum
False outpouching
Dysphasia, choking, cough, aspiration, regurgitation of undigested food
Complications-aspiration pneumo/bronchiectasis
Esophageal Web
May be result of iron def anemia
Plummer Vinson Syndrome triad= dysphasia, webs, IDA
Treat IDA
EGD/dilation
Esophageal CA
Squamous-proximal esophagus
Smokers, ETOH
Adenocarcinoma-distal esophagus
Barrett’s
Dysphasia for solids only
EGD/biopsy
Barrett’s Esophagus
Squamous cells replaced with abnormal glandular-type epithelium= met plastic->dysphasia->anenocarcinoma
Orange/salmon colored patch on EGD
Treat with radio frequency endoscopic ablation and long term PPI
H pylori
Urea Breath test
Rx: amox+ Clarith+ PPI
Retest 1 month after completion (no PPI or bismuth until retested)
Ulcers
Gastric: pain after eating
Duodenal: relieved with food
Zollinger-Ellison Syndrome
Gastrinoma of pancreas or duodenum
Consider in recurrent PUD, PUD with hypercalcemia, severe and pain/diarrhea, elevated serum gastrin level
Gastric Carcinoma
Adenocarcinoma
H pylori is strong risk factor
Vague dyspepsia with weight loss
EGD all dyspepsia > 55 if new, persistent or fails empiric treatment
Bilirubin
Unconjugated/Indirect= pre-liver
Stool and urine normal, mild jaundice
Causes: hemolysis, Gilbert’s
Conjugated/Direct-jaundice, dark urine, light stools
Causes: biliary obstruction, hepatic ellipse dysfunction, inherited
Primary Biliary Cirrhosis
Autoimmune
Fatigue, jaundice, pruritis, mild hepatomegaly
Elevated Alk Phos
+AMA
Liver bx= gold standard to confirm
Treat with bile acid drugs, transplant
Autoimmune Hepatitis
Fatigue, anorexia, arthralgias, jaundice Younger women (30-50) Elevated transaminases \+ANA \+ ASMA Treat with prednisone/immunomodulators
Primary Sclerosing Cholangitis
Mostly young men (20-40) Often associated with IBD/ulcerative colitis ERCP-thick/narrowed bile duct Elevated total bili, Alk Phos Leads to end stage liver disease
Cholangiocarcinoma
Non-tender palpable GB with hx of weight loss
Klatskin tumor- hilar cholangiocarcinoma. Junction of right and left hepatic ducts.
Pancreatitis
Etiology: gallstones, ETOH
Severe epigastric pain radiating to back
Dx: CT
Ransom’s criteria= necrotizing pancreatitis (elevated age, WBC, glucose, LDH, AST. Low Ca++)
Rx-IV hydration, NPO, pain meds, pancreatic enzyme replacement.
CA 19-9=helpful tumor marker for CA
Hemochromatosis
Fe overload
Sxs: arthralgias, hepatomegaly, gray skin, cardiomegaly, DM, ED
Hallmark=increased %transferrin sat
Rx=weekly phlebotomy
Wilson’s Disease
Copper overload
Kay-Fleischer ring on eye exam
Rx= Penicillamine (copper chelation agent)
Hepatitis A
Fecal-oral transmission
Mild disease
No chronic carrier
No Rx necessary, avoid ETOH
Hepatitis B
Chronic carrier 5-10%
Major risk factor for liver CA if carrier
Hepatitis C
Leading cause of chronic liver failure Most common indication for transplant Most asymptomatic Screen with EIA, RIBA to confirm HCV RNA establish chronicity and follow RX
Test Genotype (most type 1)
Rx: interferon+Ribaviron.
Not in psych pts, autoimmune disease, CA patients
Contraindication=Ongoing ETOH/drugs
Alcoholic Hepatitis
AST > ALT (>2x) Prolonged PT/low Albumin=poor prognosis Vit deficiency (folate/ B's)
Nonalcoholic fatty liver:NASH
Mildly elevated AST/ALT and alk phos
Dx: US
RX: weight loss/exercise
Cirrhosis
Complications-portal htn, esophageal varices, ascites, peritonitis, encephalopathy (Wernicke’s)
Hepatocellular Carcinoma
Tumor marker= AFPo
Crohn’s
75% terminal ileum/cecum, 25% colon
Typically spares rectum
“Skip” lesions
Full thickness ulcer, anywhere
Sxs: Colicky RLQ pain, diarrhea, low grade fever, weight loss
Complications: SBO, fistula
Gold standard= colonoscopy
Findings: string sign, skip lesions, cobblestoning
100x increase risk small bowel CA
Mesenteric Ischemia
Abd pain sudden/severe/out of proportion, post-prandial
H/o vascular disease
CT angiography
Celiac Sprue
Loss of absorptive surface results in malabsorption Abnormal response to gluten No villi at duodenum on EGD Sx: weight loss, diarrhea, FTT in kids Gold standard= biopsy (abnormal villi)
Can’t eat: BROW
Can eat: CRAP
Dermatologic clue to Sprue
Dermatitis herpetiformis
Puritic papulovesicles extensor surfaces of trunk and neck
Happens in
Ulcerative Colitis
Superficial ulcerations, friable mucosa Crampy pain (often LLQ), bloody diarrhea
Begins distal rectum and spreads proximally
Continuous lesion, rectum always involved
Complications: toxic megacolon, perforation, cancer
Need yearly colonoscopy after 7-8yrs
Hepatitis A
Fecal-oral transmission
Mild disease
No chronic carrier
No Rx necessary, avoid ETOH
Hepatitis B
Chronic carrier 5-10%
Major risk factor for liver CA if carrier
Hepatitis C
Leading cause of chronic liver failure Most common indication for transplant Most asymptomatic Screen with EIA, RIBA to confirm HCV RNA establish chronicity and follow RX
Test Genotype (most type 1)
Rx: interferon+Ribaviron.
Not in psych pts, autoimmune disease, CA patients
Contraindication=Ongoing ETOH/drugs
Alcoholic Hepatitis
AST > ALT (>2x) Prolonged PT/low Albumin=poor prognosis Vit deficiency (folate/ B's)
Nonalcoholic fatty liver:NASH
Mildly elevated AST/ALT and alk phos
Dx: US
RX: weight loss/exercise
Cirrhosis
Complications-portal htn, esophageal varices, ascites, peritonitis, encephalopathy (Wernicke’s)
Hepatocellular Carcinoma
Tumor marker= AFPo
Crohn’s
75% terminal ileum/cecum, 25% colon
Typically spares rectum
“Skip” lesions
Full thickness ulcer, anywhere
Sxs: Colicky RLQ pain, diarrhea, low grade fever, weight loss
Complications: SBO, fistula
Gold standard= colonoscopy
Findings: string sign, skip lesions, cobblestoning
100x increase risk small bowel CA
Mesenteric Ischemia
Abd pain sudden/severe/out of proportion, post-prandial
H/o vascular disease
CT angiography
Celiac Sprue
Loss of absorptive surface results in malabsorption Abnormal response to gluten No villi at duodenum on EGD Sx: weight loss, diarrhea, FTT in kids Gold standard= biopsy (abnormal villi)
Can’t eat: BROW
Can eat: CRAP
Dermatologic clue to Sprue
Dermatitis herpetiformis
Puritic papulovesicles extensor surfaces of trunk and neck
Happens in
Ulcerative Colitis
Superficial ulcerations, friable mucosa Crampy pain (often LLQ), bloody diarrhea
Begins distal rectum and spreads proximally
Continuous lesion, rectum always involved
Complications: toxic megacolon, perforation, cancer
Need yearly colonoscopy after 7-8yrs
Diverticular hemorrhage
Most common Lower GI bleed (50%)
Most self limiting
Acute, painless, large volume maroon/mahogany or bright red bloody stools
Diverticulitis
LLQ pain and mass, fever, leukocytosis Plain films to look for free air/obstruct CT if no improvement 2-4 days **No BE or scope acutely Surgical resection if 3 attacks
Nutritional Deficiencies:
Vit A, C, D, K
Thiamine
Niacin
Pyridoxine (B6)
A-night blindness, poor wound healing C-scurvy D-osteomalacia K-blood dyscrasias Thiamin (B1)-ETOH/Beri-beri Niacin (B3)-Pellagra (3 D's)-diarrhea, dementia, dermatitis Pyridoxine (B6)-INH/ocp's
Lower GI bleed
Below Ligament of Treitz
Most common cause>50= diverticulosis
Mallory-Weiss Tear
Mucosal tear of GE junction from vomiting Self-limited (usually) Painless hematemesis Dx-EGD Rx-supportive
Eosinophilic Esophagitis
Eosinophil-predominant inflammation
Concentric esophageal rings
PPI, topical glucocorticoids (swallowed fluticasone)
?food allergy eval
