Gastroenterology Flashcards
Colonoscopy screening for ulcerative colitis
Every one to two years beginning 10 years after diagnosis for patients with disease extending beyond rectum
Irritable bowel syndrome workup with history of autoimmune disease
Check TTG rule out celiac disease - especially with type one diabetes and autoimmune thyroid disease
Acute fatty liver of pregnancy
Liver failure and coagulopathy
HELLP HEMOLYSIS, elevated liver enzymes, low plateletS
Microangiopathic hemolytic anemia
Resolved acute diverticulitis next step
After appropriate antibiotic therapy will require full colonoscopy to rule out other causes mimicking diverticulitis
Chest pain intermittent unrelated to exertion no reflux symptoms retrosternal pain seconds to minutes corkscrew on x-ray dysphasia to both liquids and solids
Diffuse esophageal spasm treat with calcium channel blockers/ppi - multiple simultaneous contractions on manometry
Many month history of dyspepsia looking like Gerd no alarm symptoms no physical exam abnormality what is treatment
Proton pump inhibitor
Hematochezia hypotension syncopal symptoms use of NSAIDs anemia what is next test to perform
Suspect upper G.I. source of bleeding needs upper endoscopy first - absence of blood or coffee ground material in NG tube does not rule out upper G.I. bleed - if negative then do colonoscopy
Treatment of new onset severely active Crohn’s disease
Antitumor necrosis factor therapy like infliximab is best and better than immunomodulators such as mesalamine because Crohn’s disease is transmural
Treatment of severe alcoholic hepatitis
Mandry discriminant function score of greater than 32 benefit from pentoxifylline if corticosteroids are contraindicated - like with kidney failure G.I. bleed active infections
How long to keep patient in hospital after high-risk peptic ulcer and a scopic treatment
72 hours - takes this long for high-risk peptic ulcer to become peptic ulcer
Patient with G.I. bleed due to angioectasias and aortic stenosis
replace aortic valve - heyde syndrome e - mechanical destruction of von Willebrand multimers during non-laminar flow through narrow aortic valve
Young patient history of several food impaction’s history of allergies and asthma egd with concentric rings
Eosinophilic esophagitis treat with PPI or budesonide
Food regurgitation barium swallow dilated esophagus tapering gastroesophageal junction manometry decreased peristalsis increased lower esophageal pressure
Achalasia then do a EGD to rule out lymphoma cancer then a surgical myotomy
Regurgitating food eaten several days ago with halitosis
Zenkers diverticulum pouch in hypopharynx
odynophasia for more than 10 days
Egd to rule out esophagitis consider pill induced, radiation, infections like Candida CMV herpes
HIV patient with oral thrush complaining of odynophasia
No need for EGD right away treat empirically then if no improvement EGD to rule out CMV and herpes
Progressive dysphasia two solids heartburn several years
Peptic stricture
Patient with CVA hemiparesis with coughing and choking sensation was regurgitation of fluids to knows best diagnostic test
Video fluoroscopic swallowing study or modified barium swallow
Heartburn not remove by antacid initial diagnostic step is
Ppi challenge - step down to H2 if better in 3 months
If patient doesn’t get better with PPI
EGD - if no esophagitis then ambulatory pH monitoring if little reflux than likely psychiatric give citalopram
Heartburn not respond – since with weight loss
Directly to EGD
Treatment of GERD with PPI’s or fundoplication surgery effect on existing Barrett’s
No effect
Barrett’s esophagus EGD guidelines
After diagnosis the EGD one year later
NO Dysplasia ON REPEAT EGD NEXT ONE THREE-YEARs
Low-grade dysplasia repeat Egdsix months if still low-grade repeat yearly
If changes back to metaplasia continually EGD every three years
HIGH-GRADE DYSPLASIA ENDOSCOPIC HIGH FREQUENCY ABLATION
Severe retrosternal chest pain worse with swallowing and breathing - chest x-ray with left plural effusion subcutaneous emphysema
Esophageal rupture diagnosed with Gastrografin study
Best H. pylori test if taking PPI
Antibody ie serology test - only for diagnosis
Best H pylori test if not taking PPI
Fecal antigen test used for diagnosis and follow up
Urease breath test for H. pylori
Diagnosis and follow up
H pylori treatment failure with triple therapy
Quadruple therapy tetracycline Flagyl bismuth ppi
NSAID induced PUD
Gastric ulcers higher with old age higher dose steroids with NSAIDs give worse risk bleeding
ZE syndrome
Duodenal bulb, Gastrinoma’s, present with PUD or diarrhea steatorrhea - inactivated pancreatic lipase
Diagnosis IV secretin increase gastric greater than 1000
CT scan or somatostatin receptor scan localized tumor
PPI and resection of Tumor
MEN1
G.I. bleeding monitor period
72 hours
Ppi related issues
C diff colitis, hospital acquired pneumonia, osteoporosis, hypomagnesemia, microscopic colitis
Esophageal varices
Not selective beta blockers such as propranolol carvedilol nadolol - if asthma then band ligation
Patient with cirrhosis and variceal bleed and spider angiomata
Nonselective beta blocker and antibiotics
Gastric malignancies
Adenocarcinoma 80% caused by h pylori
MALToma
Treat for H. pylori will regress
Post gastrectomy abdominal bloating postprandial symptoms relieved by vomiting
Afferent loop syndrome
Post gastrectomy fat and vitamin B12 malabsorption
Blinds loop syndrome bacterial overgrowth the conjugation of bike salts
Prognostic factor in acute pancreatitis
BUN - despite temperature elevated lactate white count no antibiotics
Congenital failure to fuse pancreatic ducts resulting in frequent pancreatitis
Pancreas divisum
Way to feed severe acute pancreatitis
Enterojejunal tube
Pancreatitis with muscle spasm in weakness
Hypocalcemia
18 Year old pancreatitis of unknown etiology
Sweat chloride test rule out cystic fibrosis - can be associated with pancreatitis
Lab values suggesting biliary ideology of pancreatitis
ALT greater than two times normal then increased alk phos
Severe pancreatitis elevated AST and LFT dilated common bile duct next
ERCP, remove stone, eventual cholecystectomy
Mild pancreatitis ultrasound gallstones no CBD dilation
Elective cholecystectomy
Post cholecystectomy patient with nausea vomiting pain chills with elevated bilirubin liver enzyme tests amylase
Retain common bile duct stone
Post hip replacements pain fever elevated liver enzymes elevated amylase ultrasound but thinking gallbladder wall
Acalculus cholecystitis requires cholecystectomy
Complications of pancreatitis
- fluid collections pleural effusion’s two days
- Pancreatic necrosis less than two weeks
- Pseudocyst wonder four weeks can hemorrhage rupture fistula
- Abscess 4-6 weeks soap bubble sign Gram stain
- Splenic vein thrombosis can occur anytime digastric CT abd
Ulcerative colitis
Rectal ulcer spreads proximately erythema friable mucosa very superficial ulcer crypto just toxic like a cool with erythema nodosum Rh negative arthritis pyoderma gangrenosum ankylosing spondylitis sclerosing cholangitis associated with cancer colonoscopy every after 8 years then q1-3
Crohn’s disease
Rectal sparing perirectal fistulas anyone G.I. tract mainly in the terminal ileum skip lesions
Diarrhea deep ulcers with granulomas toxic Megacolon
String sign
Best treatment for stricture
Surgery
Ulcerative colitis with extraintestinal symptoms pain in joints of hands with early morning stiffness
Rheum neg arthritis - sulfasalazine
Diarrhea right lower quadrant mass temperature ulcer in mouth
Crohn’s disease
Bloody diarrhea last 2 years, wks ago went to mexco, colonoscopy with erythematous friable mucosa
UC
Pt h/o UC with diarrhea/leukocytosis
r/o c diff
Young woman with chronic diarrhea wakes up at night for bathroom
Inflamm bowel dz
UC in remission - p/w LFTs bili, US shows focal dilations
ERCP/MRCP dx primary sclerosing cholangitis (beaded appearance) - brush bx prodominant stricture, need annual US gallbladder for polyps - if pos - cholecystectomy - if enzymes worsen then refer for liver tx
UC/Crohns maintenance medication
5ASA (Mesalamine +- flagyl, antiTNF alpha - DO NOT USE STEROIDS
Young man UC p/w abd pain, distension of colon to 7cm not improving with thumb printing on xray
subtotal colectomy
Pt with proctocolectomy and ileal anal anastamosis pouch p/w diarrhea with blood, temp -> endoscopy with diffuse superficial ulceration in pouch
Pouchitis -> tx with flagyl
Pt with Crohns rectovaginal fistula not responding to 6MP and flagyl
anti-TNF alpha (infliximab) - watch out for TB reactiv, PNA, crypto, histo
24 yo UC 4 years with jaundic and fever, hepatomegaly, elev bili, elev alk phos, AST, ALT p-ANCA +
Primary Sclerosing Cholangitis - beading/focal dilation biliary tree - P-ANCA +, a/w UC - if LFT/bili worsens - refer for liver tx
Review Chart GI page 453
Green book - GI
20 yo rectal bleed tenesmus - anal fissue - 6x6cm ulcer on leg
r/o UC with sigmoidoscopy/anoscopy - tx with 5asa suppostory
External hemorrhoid
topical NTG
Stool osmotic gap equation
290-2(stool Na+K)
Secretory diarrhea
> 1L/day, doesn’t stop with fasting, stool osm=290, osm gap <50
Osmotic diarrhea
50
longstanding diarrhea x years, stool osm 290, stool Na=50, K=25
lactose intolerance (stool gap >50)
diarrhea while vacation mexico - no blood, no fever
entertoxogenic e coli - tx with loperamide +- azithro x 3 days
Diarrhea +-fever +-blood with abd pain 2 days after undercooked poultry, mountain stream water, contact with dogs/cats - +fecal WBCs
C.Jejunum (can cause Guillion barre)
Diarrhea with abd cramping +- fever - had chicken, raw eggs or ice cream
salmonella
bloody diarrhea - hamburgers at fair 36hrs ago or unpasteurized mild - dec platelets
O157:H7 E.Coli - Mcorrey sorbitol agar - SX treatment only DO NOT GIVE ABX - will cause HUS - if RF then HD (TTP)
Bloody diarrhea
Shigella, C.jejuni, salmonella, c.diff
Diarrhea after camping, skiing with bloating, flatus, frothy stool
Giardiasis - check elisa for Giardia ag -> flagyl - post tx elisa should be negative
Canned Precooked foods beef/turkey - 12 hrs later diarrhea/vomitting no blood
C.perfringen - supportive tx
Diarrhea 4 hours after asian restaurant - fried rice - vomiting no blood
Bacilius cereus - supportive tx
Diarrhea after sea food dinner - g neg comma shaped bug
vibrio parhemolyticus -> cipro
Diarrhea, nausea vomiting, abd pain after eating fish (2hrs) with perioral paresthesias - reversal hot/cold sensation
ciguatera toxin from large reef fish (fish that eat other fish)
Flushing, utricaria, paresthesias minutes after eating fish
scromboid - histamine in fish
eats fish and minutes later parestehesias, weakness, ascendign paralysis and SOB
tetrodotoxin from puffer fish
Chronic diarrhea, hx travel to mexico last year - or presentation with acute dysntery - colonscopy with flask shaped ulcers
amoebic colitis
RUQ pain, fever, elev wbc after third world country - bloody diarrhea inc LFTs
amobic liver cyst - check stool for ova/cyts - elisa - if CT abd + then aspirate and tx with flagyl
HIV CD4<200 chronic diarrhea/wt loss no fever no blood
cryptosporidium - stool afb small round organisms - if stable just hydration, if not imporoving nitazoxanide
woman chronic diarrhea years, frequent small stools with mucous and constipation pain relieved with BM, no night waking no fever, wt loss anemia, stool studies neg, emotional stress - flex sig neg
irritable bowel syndrome (rome III criteria) - reassurance - rifaxinin, antispasmotics, anticholinergics - TCA, fiber
chronic diarrhea stool osm 300, stool Na 40, K 30 on adding naOH turns red
laxative abuse - stool gap 160 (>50)
diarrhea, RLQ pain, fever, rash fecal WBC no h/o diarrhea
yersinia enterocolitica
diarrhea WBC 12K Cdiff +
flagyl PO
recurred (x1) cdiff + diarrhea WBC 13
restart flagyl (leftover cdiff spores now matured)
recurred (x2) cdiff
vanco PO pulse therapy - 125mg 4x daily x 7 days, then taper
diarrhea, cdiff + WBC 18
po vanc (>15k don’t use flagyl)
which abx induced B1/NAP1 cdiff which causes toxic megacolon
cephalosporin or quinalones
77yo M a/w PONA started on abx - what do prevent cdiff
probiotics (lactobacillus)
74yo known diabetic p/w diarrhea with c.diff WBC 12 better with flagyl returns with WBC 24 with hypotension, fever, tachycardia ele lacatate
po vanc, recta vanc, iv flagyl and surgery c/s
prevent spread of cdiff
wash hands with soap and water (no etoh sanitizer)
65yo M fatigue, chronic diarrhea, itching with pallor, bullous skin lesions, Hg low, MCV low, TIBC inc, ferritin low, occult neg - blood smear howel jowell body, colonscopy neg for bleed - no change with iron therapy
TTG ab r/o celiac sprue
If celiac sprue neg tx?
gluten free diet - can have dermatitis herpetiformis
Dermatitis herpetiformis tx
gluten free diet and dapsone
asx brother of pt with celiac sprue - what to check
HLA DQ2 or 8 (not TTG)
vitamin supplement needed in celiac sprue
Vit D
Diarrheal dz a/w celiac sprue
microscopic colitis
Pt with celiac sprue confirmed with TTG put on gluten free diet improves then worsens after few months
likely non-adherance
Pt with celiac sprue responds well to gluten free diet for 10 year now with diarrhea/abd pain/wt loss
r/o lymphoma
pt returns from 3rd world with diarrhea, foul oily stools, +steatorrhea, Hg low, MCV high D-xylose test abn, folic acid decreased
Small bowel bx - falttened villi with lymphotcitis and plasma cell infilitration - tropical sprue from klebsiella or ecoli -> treat with tetracycline and folic acid
25yo diarrhea, bloating, flatulance wt loss from dominican republic - low hg, high mcv low normal b12 +steatorrhea
tropical sprue - carribean folate N, B12 low, Asia folate low B12 N, Bact overgrowth folate high b12 low
Pt with diarrhea few months with greasy stools, fecal fat 15g/day, low d-xylose
check small bowel bx
pt with h/o arthritis>2yrs, diarrhea >3/day, oily stools, foul smelling, wt loss, adenopathy, SKIN PIGMENTATION, posterior uveitis with blurry vision - foamy macorphages and PAS+ on small bowel bx
Whipple’s dz, t.whilli -> bactrim tetracycline
55yo with recurrent pain/swelling shoulers for years with wt loss, LAD and asp of knee with WBC 13K
PCR synovial fluid for t. whipplei (whipple’s dz)
diarrhea with food intolerance, n/v/abd pain, steatorreha, ova/cysts/parasites neg -> peripheral eosinophilia
eosinophillic gastroenteritis - r/o parasitic infection then start steroids
35yo n/v epigastric pain for months - n/v in morning better with shower - wt loss but no dysphagia
marijuana induced
30yo F early satiety even with tiny amoutn of food for months - gastric emptying normal
tx with buspiron
chronic diarreha, fecal fat 14g/day, dxylose normal - B12 190, folate 18, small bowel shows diverticula
Bacterial overgrowth - check hydrogen breath test or xylose 14C breath test - tx with cipro+flagyl
Pt steatorrhea 40g/day, dxylose 8g/5hrs - colonoscopy normal, h/o lactose intolerance
xray abd check for Calcification of pancrease - chronic pancreatitis
Short bowel syndrome
calcium oxalate stones, replace ADEK, B12, Ca, Mg, Zn - replace long chain with med chain Fatty acids
Intestinal lymphangietctasia - dilated lymphatic vessels
replace long chain FA with med Chain FA
Abetalipoproteinemia
normal villi - impaired B globulin synthesis->imopaired chylomicron formation
pt s/p extensive small bowel resection with lots of diarrhea 3 days post op
PPI - acid induced diarrhea
small bowel resection of 50cm after GSW - diarrhea
mechanism is bile acid malabsorption
GSW with bowel resection - couple months later with greasy stools and wt loss - fecal fat 20g/day INR 1.2 dxylose nl,
etiology=decreased bile acids
severe ischemic colitis s/p small bowel resection - greasy stools wt loss, stool fat 20g/day, low alb/calcium
tx with med chain TG/FA
52yo F chronic watery diarrhea 5x daily no constip, blood, fever - neg stool studies, neg giardia, neg scopes
flex sig with bx - r/o microscopic colitis (collagenous) vs lymphcytic colitis (lymphocytes) - inflammation of laina propria (NSAIDs, PPI, setraline, DM can cause) - D/C offending agent - start budesonide - check TTG
Causes of osteomalacia
post gastrectomy, celiac sprue, biliary cirrhosis, pancreatic insufficiency, crohn’s dz
60yo pt with fever, inc WBC, abd pain in LLQ
r/o diverticultis - CT scan - avoid colonoscopy/barium enema, cipro +flagyl - clear fluids then high fiber
4 weeks later do colonoscopy r/o cancer, crohns etc
treated diverticulitis 3 months later still wtih LLQ pain with no fever or WBC - left segmental diverticulosis - DX?
uncomplicated symptomatic diverticular disease - tx with mealamine, rifampin
Pt with divertiulitis with >4cm abscess
CT guided drainage first then elective surgery
pt with acute diverticulits and 9cm dilation with 5cm abscess
surgical intervention
what medication can cause divertiulitis with perforation
Tocilizumab - IL-6 inhibitor (also causes OCP failure)
75yo M with ER c/o painless brbpr, no pmhx - BP ok HR ok, BRB in rectal vault
dx - diverticulosis (painless)
55yo F with long rheum arthritis controled with ASA and naproxen x 14 years with abd pain for last 4 months - EGD/colonsocpy neg - small bowel barium enema with multiple concentric constricting lesions - dx?
small bowel diaphragm disease
Chronic mesenteric ischemic
post prandial, abd pain, fear of eating, wt loss - dec blodo from from PAD - dx with doppler us/angio, - tx with revascularization
Acute mesenteric ischemic
sudden onset sev abd pain, n/v/elev WBC, ileus - emboism in celiac, S mesenteric with valvular heart dz, afib, low flow state - dx with angio, tx with thrombolysis or surgery
Ischemic colitis
hematochezia, diarrhea, abd pain - low flow state (CHF, hypercoag state, hypotension) - dx with thumbprinting colon on xray, pausity of vessesl - rehydration and antibiotics
Angiodysplasia
AVM - cause lower GIB - common in elderly - osler weber rendu syndrome -> tx with laser photocaog, sclerotherapy or cautery
65yo M pmhx severe AS with recurrent melena - colonscopy with angiodysplasia
Aortic valve replacement
Post radiation tx in pelivs 2 years later with rectal bleeds - colonscopy with friable mucosa, atrophy and fibrosis - dx?
radiation prococolitis
70yo M with severe abd pain x 1 day, last BM normal - tender abdomen, h/o DM, CHF, HTN, JVD+, S3+ rectal normal , FOBT neg, amylase elevated - abd xray normal, CT abd with small bowel wall thickenss and intestinal pneumoatosis
check mesenteric angiography
MCC GIB in kids
meckels divertiulum
Constipation
BM<3x/wk, hyperCa+, hypothyroid, slow transic - pelvic floor dysfxn, CCB, HCTZ, anticholing, antipsych, opiates+stim laxative
Tx for constipation
tx underlying cuase and inc fiber
Opioid induced constipation
start laxative with opioid rx
elderly pt with chronic constip not responding to fiber
polyethylene glycol
Pt with stage IV lung Ca not responding to stimulant laxative, polyethylene glycol
SQ methylnaltrexone
elderly woman with constipation and diarrhea - hard stool in LQ
enema
65yo M s/p ortho surgery on abx and morphine - with abd pain adn distension - abd xray with 6cm distenstion of cecum with no WBC, hypokalemia
dx: acute pseduo colonic obstruction (ogilvie’s syndorme) - CT scan or gentle hypaque (water soluble) enema to dx -> remove precip cause, correct electrolyties, d/c opiates, d/c aticholinergics, rectal tube, neostigmine
75yo F with LLQ pain x 2 days, last BM 1 wk ago, BS+, xray with colonic dilation, CT with partial obst of signmoid
Dx Sigmoid volvulus - flex sig (analgesia for pain won’t affect dx accuracy)
Woman sharp RUQ pain x 1 year - severe - US/CT normla - pain with raising legs
FXN abd wall pain
Hepatitis A
RNA virus, incubation15-50 dyas, p/w jaundice, feco-oral/sexual, no carrier state, can worssen underlying liver dz (vacc HCV pts for HAV) - vaccinate high risk groups (travellors, gays, liver dz) - IVIG for high risk exposure -
Anti HAV IgM
Acute hep A -> treat!!
anti-HAV igG
post infection - Do not treat
Preg woman - how to determine past infection HAV
HAV IgG+, IgM-
Pt going to mexico for 2 weeks
hep A vaccine
Hep A vaccine in….
Hep C, chronic liver dz, high risk country travelor, gay men (NOT PT WITH PNA)
Pt returns from beize with contact with prostitutes - now with n/v/malaise, anorexia - HBV ab+, HBV cAb+ ->dx?
Hep A - check hep A serology in 2 weeks
Hepatitis B
only DNA virus in hepatitis - sexual or IVDA, 30% chance after needle stick - most pt clear infxn - lose HBsAg and get HBV Ab - 5% with chronic - 1% fulminant hepatitis
Causes cirrhosis - hepatoma 2-4%/year -> carrier status highest in infants
Heb B -> HBe Ag
denotes viral replication, active infxn
HBV Vacc
high risk groups
HBV IVIV (HBIG)
high risk exposure
HBV tx
interferon, tenofovir, entecavir, adefovir, lamivudine can suppress
HB S Ag
acute hep B, chronic hep B, Carrier Hep B
anti-HB cIgM
acute hep B
anti-HB c IgG
chronic, carrier, past infection
HB e Ag
active replication
Anti-HB IgG
post vacc, cleared infection
anti Hbc IgG Ab +, HBsAg neg Anti HBsAb neg
chrnoic hepatitis or past infection - HBsAg or Anti-HBs could be below threshold
pt low endemic area, no risk factors for Hep B has anti-HBc Ab only - wtd?
Hep B vacc
Nurse with HBV vacc with needle stick pt with HBV
check anti HBs Ab titer - if >10 - reassure, if <10 HBIG+booster HBV vacc
Pt with Hep B vacc series
+anti-HBs Ab
HBV DNA >20K, ALT normal - treatment?
none
HBV DNA >20K, ALT 1-2x normal - treatment?
Bx
HBV DNA >20K, ALT >2x normal - treatment?
Yes
HBV DNA >10IU - cirrhosis compensated
treat HBV
HBV DNA >10IU - cirrhosis decompensated
liver tx
HBV treatment
tenofovir, entecavir, telbivudine, adefovir, lamiudine or alpha interferon
HIV/HBV pt coinfected
if treating HIV also - tenofovir, otherwise alpha interferon
prior to starting rituximab or chemo with steroids or anti-TNF what to check
Hep B cIgG and HBsAg
Asian american woman with HBV in 3rd trimester - prevent HBV in child
telbivudine for mother and hep B vaccine/HBIG in baby
Hepatitis C
SSRNA - 90% tranfusion associated before 1992 - MCC of liver transplant in US, presentation with fatigue and elevated LFTs
Hep C high risk groups
IVDU/prisoners, blood tx before 1992, tattoos, snorting cocaine, most patients DO NOT CLEAR - NO VACCINE, NO IGG, no post exposure PPX available
Woman with hep C - precautions with husband
sex ok - DO NOT SHARE TOOTHBRUSH
60yo pt born 1945 to 1965 - what to check
hep C abs
Risk factors progression to cirrohisis from HCV
age>40, etoh, man, coinfection with Hep B or HIV
Treatment HCV
Boceprevir, interferon, ribavirin, d/c therapy if VLsuppressed
53yo M received multple blood tx in 1990 after MVA p/w fatigue, elev LFTs, Hep C Ab + and liver bx with mod bridging fibrosis - hep C viral load 250K - 2 months alater AST/ALT lower - VL 210K
Start IFN/ribavirin
Nurse gets stuck with needle HCV patient - Hep C ab neg
repeat HC Ab/RNA in 4 weeks (no ribavirin/IFN)
Nurse stuck with HCV 4 weeks ago with VL 45K - wtd?
reassess HCV RNA at 12 weeks if + start PI, ribavirin and IFN
Pt with IV exp to HCV 6 weeks later with malaise and fatigue - all Hep Ab neg - wtd?
check HCV RNA
55yo pt with fatigue, no history - ALT 2x, AST 1.5x, takes tylenol
Dx HCV (tylenol would be AST in 1000s) - if HCV Ab + check HCV RNA - if viral load high liver bx - if +fibrosis treat HCV (ribavirin+IFN)
Pt with hep C, genotype 1 on IFN, ribavirin p/w fatigue
check Hg (ribavirin causes hemolytic anemia) - if retic + then start erythropoietin, d/c ribavirin
If pt on IFN get depressed
start SSRI (Paroxetine)
Pt with HCV with briding fibrosis and inc’d HCV RNA started on Ribavirin and IFN - advice for pt
NO ETOH, if seroneg for HAV, HBV give vaccines for HAV/HBV
Extrahepatic manifestations of HCV
small vessel vasculitis, glomerulonephritis, neruopathy, mixed cryoglobulinemia dec C4>dec C3, porphyria cutanea tarda
HCV pt on ribavirin/IFN - what to monitor
hypothyroid, hyperthyroid
HDV
incomplete RNA virus needs HBV to survive
HBc IgM + HDV
Acute co-infection - doesn’t make hepatitis worse
HBc IgG + HDV
Acute superinfection - can cause fulminant hepatitis
HEV
fecooral transmission like HAV, Fulminant hepatitis in 3rd trimester of preg, ALL hepatitis seriology NEGATIVE,
Tylenol liver damage
> 7g tylenol can cause liver damage, in etoh 4gm tylenol causes liver damage - N-acetylcystein antidote
20yo took 30 gm pain pill - ER denies sx - tylenol level Pending - wtd
give oral n-acetylcysteine without waiting for labs - if within 1hr then gastric lavage, activae charcoal and syrup of ipepac
heavy etoh with myalgias and ha took tylenol q4h for past couple days now with n/v/abd pain AST 11,000, ALT 9000 INR 3 - dx?
acetaminophen toxicity
INH Hepatitis
Dose related, age related tox with inc AST/ALT, ANA+
Hepatitis with cholestasis
amox-clavu, bactrim, erythromycin
Hepatitis with macrovascular fatty change
etoh hepatitis, amiodarone, steroids
Hepatitis with microvasicular fatty change
tetracycline, reye’s syndorme with ASA+flu
Chronic drug hepatitis
methyldopa, trazadone, nitrofurantoin, phenytoin
Direct liver toxicity
tylenol
Dysphagia
Solids -> pogressive Age>50 -> carcinoma
Solids -> progressive -> heart burn -> peptic stricture -> EGD/bx r/o CA ->dilation/PPI
Solids-> intermittent -> esosinophilic esophagitis -> esoph rings (steakhouse syndrome)
Solids or liquids ->progressive->cough/regurg ->achalasia->dx with barium swallow (autoimmune)
Solids or liquids->progressive->heart burn->scleroderma (scl70)
Solids or liquids->intermittent->chest pain -> diffuse esophageal spasm -> corkscrew esophagus->PPI trial->confirm with manometry
Pt with intermittent syphagia to solids and liquds w/ CP
DES -> barium swallow (cordscrew esophagus)-> confirm with manometry-> PPI if no response-> CCB
Young pt with steak dysphagia -> first bite ->
esophageal rings/schatzky ring-> pneumatic dilation
food regurg several hours after eating, no heartburn, dyphagia to solids and liquids - dilated esophagus with tapering (bird beak) - manometyr decreased peristallsis increased Lower esoph pressure
Achalasia -> surgical myotomy (EGD r/o lymphoma or cancer
GERD
Acid reflux sx - CP, heartburn, nocturnal cough, asthma, dental erosion
GERD complications
Barrett’s-> AdenoCA
GERD Tx
wt lossw, head elevation, tob cessation, early dinner, PPI>H2, fundoplication
GERD EGD indication
heart burn not relieved with PPI x 8 wks, heartburn >5years, heartburn with wt loss, melena, anemia, dysphagia/odynophagia
Hearburn partial response to PPI but EGD with severe GERD
lap fundoplication - prior to procedure manometry to confirm esophageal motility - (otherwise iatrogenic achalasia cuased)
elderly pt with GERD not responsing to H2 - EGD with stricture dilated - bx neg, prox gastritis - further managment
lifelong PPI
Barretts
normal Gastro-esoph jnc squamous epithelium - changes to columnar epithelium (like stomach) -> strictures/adenoCA
gastritis
Erosive - NSAIDS, etoh, burns, surgery, vent, - tx with H2, PPI
Chronic type A - fundus/body less common - atrophic gastritis - inc gastrin
Chronic type B - antrum more common - cause by h pylori, tx H pylori only with sx
PUD causes
H. pylori, NSAIDS, ZE
H. Pylori
gram neg urease producing, inc’d in 3rd world, PUD, type B gastritis, gastic CA, maltoma,
45yo Fp/w itching esp at night +xanthomas, alk phos 1400, +AMA, -ANA, liver bx granulomas/lymphocytic destruction of bile ducts (dec ADEK, osteomalacia, HLD with high HDL)
Primary biliary cirrhosis (PBC) - tx ursodeoxycholate (delays progression, doesn’t prevent –> liver transplant
Autoimmune hepatitis
young woman with fatigue, wt loss, arthralgia, acneform rash, amenorrhea, +icterus, AST/ALT inc 5-10x, inc globulins, (a/w thyroititis, ITP, anemia, Coombs+) -> +ANA, +ANCA, +Anti DSDNA, +SMA (most specific)
Bx - piece meal necrosis of hepatocytes,
Tx - prednisone/azathioprine - NO IFN (makes worse)
25yo F juandice, ALT 350, alkphos 115, +ANA, +ASMA, -AMA, IgG elev -> liver bx piecemeal necrosis of hepatocytes
Autoimmune hepatitis
26yo F jaundice, ALT 40, alk phos 290, -ANA, -ASMA -AMA, IgM/G normal - Liver bx mild inflamm with concentric fibrosis around bile ducts
Primary Sclerosing cholangitis (extrahep duct fibrosis) - urosdiol doesn’t help
26yo F jaundice, ALT 100, alk phos 550, ANA neg, ASMA neg, AMA pos, IgM elev, IgG normal, liver bx - lymphocytic destruction of bile ducts
Primary Biliary cirrhosis (intrahep bile duct destruction, elev alk phos) - ursodiol helps
Etoh Liver dz
Fatty liver-> etoh hepatits-> micronodular cirrhosis - hepatomeg, fat vaculoles on liver bx (reversible with stopping etoh)
Etoh hepatitis
aorexia, n/v/abd pain/wt loss - AST:ALT 2>1, AST ALT up to 300, Hepatomegaly, liver bx - necrosis of hepatocytes with inflamm cells, inc WBC, enceph, elev PT
35yo F jaundice, confusion, malaise, RUQ pain - icterus, mild ascities, hepatomegaly, AST 200/alt 100, INR 1.5, WBC 18, bili 15
acute etoh hepatitis -> steroids if no bleed
If acute etoh hepatitis with bleed
pentoxyfyline
Obese pt DM, HLD - non-etoh - mild elev of ALT/AST 2:1, Fasting suger 160, chol 280 - liver bx fatty changes with some fibrosis
NASH - dx wit liver bx - tx underinglying weight, DM, vit E, statin
Causes of cirrhosis
Viral (B,C,D), Autoimmune hepatitis, etoh, PBC, PSC, Hemochormatosis, wilsons, CHF/Budd chiari (stasis)
CA screening with cirrhosis
liver US/ alpha feto protein
MELD
PT, INR, Ser Cr, Ser Bili
MELD24 - liver tx
Indication for liver tx
viral hep, autoimmune hep, PBC, PSC, hepatoma, wilsons, Alpha 1 AT def, fulmianent hep failure
Contraindications
untreated HIV, extrahep CA, active etoh/drug use, unresolved sepsis/fungemia, Hep B with eAg +
When to refer for liver tx
cirrhotics with clinical or biochemical decompensation
Pt with cirrhosis p/w hep enceph - quit drinking 2 years ago, ascitic fluid WBC 70 - wtd
refer for liver tx
SAAG
figure this out
Least likely to cause chylous ascites
cirrhosis/CHF
management of cirrohsis with ascites
Na restriction to 1g/day, fluid restriction, diuresis witih aldactone/diurteics - large volume paracentesis or TIPS
Cirrhotic p/w elev WBC, fever, ascities
paracentesis
Pt with long cirrhosis brought in with lethargy, asterixis and asciteis - PT INR 3, plt 40 - WTF
paracentesis (plt>30 - ok)
SBP
PMN >25 in asciteis or WBC >500 with >50%pmn
SBP tx
cefotaxime (3rd gen cephalo) - usually single organism (ecoli, kleb, s pneumo) - give albumin if Ser Cr elev or bili >4
Post surgery NPO OR pt on abx for bronchitis get icterus - AST/ALT normla, alk phos nromla - indirect bili elev 4.2, direct bili 0.3 - 2 days later total bili 2.5
Gibert’s syndrome - no tx
Wilson’s dz
autosom recessive - chronic hepatitis with elev LFTs, nuero sx (tremors, rigidity, psych (personality/behavor), heolytic anemia - copper accumulation in liver/body tissues - urine copper high - KAYSER-FLEISCHER RING - liver bx with copper
Tx wilson’s dz
chelation penicillamine/pyridoxine -> severe dz - liver tx
UGIB causes
PUD, varices, mallory weiss tear, splenic vein thrombosis
Pt with coffee ground emesis and dizzinesss - NGT with blodo tinged fluid - BP 90/60 HR 120
fluid resucitation
Acute UGIB, continues bleeding confused, hypotensive/tachy
intubate then scope after volume resusitation
Point to transfuse UGIB
<7gm Hg
Tx of UGIB
bleeeding ulcer - electrocautery, visible vessel monitor/electrocautery, bleeding varices - octreotide infusion with banding -> monitor for 72hrs
Clean based ulcer no bleed
early feeding
PPI use
rel to cdiff, HAP, osteoporissis, low Mg, microscopic colitis
prevent rebleed in PUD
PPI
