Gastrointestinal Flashcards
Dysphagia / Odynophagia (PE)
Oropharyngeal dysph: prob w/ initiation of swallowing
! aspiration of food, cough, choke, drool
Etiologies: neuro (stroke, Parkins), muscul (myast gr), prol intubat, Zenker divert.
Prob w/ liquids > solids
Esophageal dysph: prob w/ obstruction (strictures, webs, carcinoma) or w/ mobility (achala, scleroderm, spasm)
Obstruction: solids > liquids; Mobility: both
Dysphagia / Odynophagia (dg, ttt)
- Oroph: barium swallow #1; rarely EGD
- Esoph: EGD #1; barium before if Hx of esoph radiation/stricture (! perforation)
- Odynophagia: EGD
ttt: cause
Infectious esophagitis
Immcomprom
- Candida alb: oral thrush; fluconazole PO
- HSV: oral ulcers; acyclovir IV
- CMV: retinitis, colitis; gancyclovir IV
Diffuse esophageal spasm
Peristalsis periodic interrupted by high-amplit nonperistal contractions
Heartburn, chest pain, dysph, odynoph
↑ w/ hot/cold liquids; ↓ w/ nitroglyc
Dg: EGD (r/o structural abNl); barium swal (corkscrew esoph); manometry (definitive test)
ttt: CCB/TCA/nitrates (↓ sympt); if severe, surgery (myotomy)
Achalasia (PE)
Impaired relaxation of lower esoph sphincter + loss of peristal in dist 2/3 of esoph (smooth M)
By degeneration of inhib neurons in Auerbach plex
Progress dysph, chest pain, regurg undigest food, ↓weight, noctur cough
Achalasia (dg, ttt)
Dg: EGD (r/o structural abNl) (cancer causes pseudoachal) Barium swal (dilation w/ bird's beak); manometry (definitive test)
ttt: short-term (nitrates, CCB, endosc inject botulinum toxin in LES); long-term (balloon dilation or surg myotomy)
Esophageal diverticula
Zenker: false divert; cervical outpouch in cricopharyng muscle; post
Chest pain, dysph, halitosis, regurg undigest food
Dg: barium swal
ttt: surg excision if sympt; myotomy of cricoph for Zenker
Esophageal cancer
#1 world: squamous cell carcinoma (RF: alcohol, tobacco, nitrosamines); up 2/3 #1 (US/EU/AUS): adenocarcinoma (RF: Barrett esoph); down 1/3
Progr dysph, ↓weight, odynoph, GERD, GI bld, vomit
Dg: barium (narrow, irreg border); EGD+biopsy (confirm dg); CT+echoendo (stage)
ttt: chemoradiation + surgical resec
Early metast: poor pg
Gastroesophageal reflux disease (PE, dg)
Transient LES relaxation; incompet LES; gastroparesis; hiatal hernia
Heartburn 30-90min after meal, ↑reclining, ↓antacids/sit; globus sensat; morning hoars, chest pain (!CAD)
Dg: clinical (+ empiric ttt)
EGD+biopsy if refract, long-stand (r/o Barrett, adenoK), alarm sympt (bld, ↓weight, dysph/odynoph)
24h pH monitor (definitive if uncertain)
Other (barium, manometry)
Gastroesophageal reflux disease (complic, ttt)
Complic: erosive esoph, esoph peptic stricture, aspir pneum, up GI bld, Barrett esoph
ttt: lifestyle (↓weight, head elev, small meals, no noct meals, avoid alcoh/choc/coff)
Mild/intermitt: antacids
Chronic/fqt: H2 recept antag, PPI
Severe/erosive: PPI; if refract, surgery (fundoplication)
Hiatal hernia
- Sliding HH: 95%; GEjunct+part of stom abov diaph; asympt or GERD
- Paraesoph HH: 5%; GEjunct below diaph; fundus above; strangulation
- Mixed HH: rare
Dg: incident on CXR; barium swal or EGD
ttt: sliding (lifestyle+drug to ↓GERD); paraesoph (surg gastropexy)
Gastritis (etiologies)
Acute: rapid, superf; by NSAID, alcoh, H pylori, stress (burns/CNS injury)
Chronic: A(10%) in fundus, autoAb to parietal cells, pernic anem, ↑R of adenoK+carcinoid tum
B(90%) in antrum, by NSAIDs or H pylori, ↑R peptic ulcer ds and gastric cancer
Gastritis (PE, ttt)
Asympt or epig pain, N/V, hematem, melena
ttt: stop exacerb agent; antacids/sucralfate/H2 recept block/PPI
H pylori: amoxic+clarithrom+omepraz (metronid if All to amoxi)
PPI prophyl if R stress ulcers
H pylori (dg)
! H pylori does not always cause gastritis
Serology: IgG (screen); ⊕ if cured or active
Urea breath T: ammonia (urease=urea to CO2+NH3); PPI may false⊖; to see if cured
Stool Ag T: initial T + to see if cured
Endoscopic biopsy: histo/culture + detect intest metapl, MALT, widespr gastritis; Gold stand but invasive
Gastric cancer (RF)
Esp adenocarcinoma
Common in Korea, Japan
RF: diet w/ ↑nitrites+salt and ↓fresh vegetables; H pylori coloniz; chronic gastritis; pernicious An
Gastric cancer (PE, dg, ttt)
Early: asympt; ass w/ indigest, ↓appetite
Late: abdo pain, ↓weight, upper GI bld; Virchow node
Dg: upper endosc + biopsy
ttt: if early, surg resect; if late, incurable
Poor pg: <10% surv in 5y if adv
Only malignancy cured w/ antibiotics
MALT lymphoma
Ass w/ chronic H pylori inf
ttt: triple therapy
Peptic ulcer disease (RF; PE)
Damage to gastric or duod mucosa
↓ mucosal defense or ↑ acid
RF: H pylori (>90% duod; 70% gastric), NSAIDs, Alcoh, tobacco; CS+NSAIDs; male>fem
Chron/period dull, burn, epig pain; nausea; hematem; hematochez
Pain ↑w/ meal if gastr ulc and ↓w/ meal if duod ulc
Peptic ulcer disease (dg, complications)
Dg: Upright KUB or CT (if perfor suspect); upper endosc w/ biop; H pylori test; gastrin level (Zol-Ell sd)
Complic: hge (post ulcer erode gastroduodenal art); gastr outlet obstruct; perforation; intract pain
All gastric ulc biopsied to r/o cancer
Peptic ulcer disease (ttt)
Acute: surg if perfor confirmed (AXR/CT)
R/o activ bld (Ht, DRE, NG lavage), monit BP + give IV fluids/bld transf/IV PPI, urgent EGD
Long-term: antacids, PPI, H2 blockers (mild ds)
Triple therapy (H pylori)
Stop exacerb agents
If refractory, EGD w/ biopsy (r/o adenoK) or surgery
Zollinger-Ellison syndrome (PE)
Gastrin-prod tumor; ass w/ MEN1 (20%)
In duodenum and/or pancreas
↑ gastr acid; recurrent intract ulcers
Unresp, recurr, burn abdo pain; diarrhea; N/V; fatigue; ↓weight; GI bld
Zollinger-Ellison syndrome (dg, ttt)
Dg: ↑fasting serum gastrin + ↑gastrin w/ secretin admin
CT for staging
ttt: moder/high-dose PPI; surg resect
Diarrhea (etiologies)
> 200g feces/day w/ ↑fqcy or ↑liquidity
Etiologies: malabsorption, maldigestive/osmotic, secretory, inflammatory/infectious, ↑motility
Acute D: < 2wks; inf and self-limit; pediat (rotaV, norwalk V, enteroV)
Chronic D: > 4wks; secretory (carcinoid T, VIPoma); malabs/maldig (bact overgrowth, pancr insuff, mucos dam, lacto intol, celiac ds, laxativ abuse, postsurg short bow sd); infl/inf (IBD); ↑motility (IBS)
Diarrhea (dg)
Acute: no tests unless high fever/bloody D/ >4-5d
Chronic: stool analysis (WBCs, culture, C diff toxin, ova, parasite); sigmoidoscopy (bld D w/o dg)
ttt: acute (hydration; AB just if Cdiff or epidemy; antidiarrheal only if No high fever + No bloody D)
Chronic: ttt etiology
Diarrhea caused by Campylobacter
#1 bacterial cause of D Contaminated food/water Bloody D R/o appendicitis; IBD ttt: supportive #1, then fluoroqu or azithrom
Diarrhea caused by Clostridium difficile
Ass w/ AB (penic, quinol, clindamyc)
AXR (toxic megacolon)
Toxin in stool; pseudomembr on sigmoidosc
ttt: Stop the cause; PO metronid (mild); PO vancom (mod-sev); IV metronid (ileus)
Diarrhea caused by Entamoeba histolytica
Contaminated foor/water (develop country) Incubation ≤ 3mo Flask shaped ulcers (colono) R/o IBD ttt: metronid
Diarrhea caused by E coli O157:H7
Contaminated raw meat
R/o GI bld, ischem colitis
Complic: HUS
ttt: Nothing; avoid AB or antidiarrheal bcz ↑R of HUS
Diarrhea caused by Salmonella
Contaminated poultry/eggs
! sepsis; ! osteomyel in SCD
ttt: fluids; if high risk PO quinolone or TMP-SMX
Diarrhea caused by Shigella
! Contagious; fecal-oral route
Complic: severe dehydr; febrile seizures
ttt: TMP-SMX
Malabsorption / maldigestion (etiologies, PE)
Inability to absorb macro/micronutrients
- Mucosal abNl: celiac ds, Whipple ds, tropical sprue
- Bile salt def: ileal ds, bacterial overgrowth
Carb malabs: frequent, loose, watery stools
Fat maldigest: pale, foul-smell, bulky stools
+ abdo pain, flatus, bloat, ↓weight, nutritional def, fatigue
Malabsorption / maldigestion (dg, ttt)
Dg: lab tests
Biopsy is definitive
ttt: etiology
If severe: TPN, immunosuppressants, anti-inflam
Lactose intolerance
Lactase def
African/Asian/Native Amer; after acute gastroenteritis
After milk: abdo bloat; flatus, cramp, watery D
Dg: empiric ttt lactose-free diet; Hydrogen breath test
ttt: avoid dairy prod; oral lactase enz
Carcinoid syndrome
Before meta, firt-pass metab of serotonin (no sympt)
Sd: when weta of carcinoid tumors in ileum, appendix
Flushing, diarrhea, abdo cramp, wheezing, right valvular lesion; +niacin def (pellagra)
Dg: ↑5-HIAA in urine; CT and octreotide scan
ttt: octreotide; surg resect
Irritable bowel syndrome
Chron, interm, abdo pain + changes bowel habits; ↓by bowel mvt; mucous stools; ↑by stress
No alarm sympt
Dg: ≥3d in 3mo of ≥2 (↓w/ defec; change stool fqcy/consist; change stool appear)
R/o organic ds; !↑ incid of celiac ds in IBS so r/o
ttt: psychological (offer reassur); fiber suppl; exclude gas-food; antispasm; +/-TCA/SSRI
Small bowel obstruction (etiologies, PE, #dg)
Partial (yes flatus) or complete (no flatus/stool)
Adhesions from surg; hernia; neopl; intuss; gallst ileus; stricture (IBD); volvulus
Cramp abdo pain; vomit after pain Distention, tender, scar, hernia, hyperactive perist #dg: LBO, paralytic ileus, gastroenteritis
Small bowel obstruction (complications, dg, ttt)
Complic: ischem necrosis; rupture if prolong; peritonitis
Dg: AXR (no gas); CT (defin); ↑WBCs if isch/necrosis; dehydr/metab alk
ttt: fluids; partial (NPO, NG suct, IV hydr, correct e-, Foley to monitor fluid, ↓pain (No opioids/anticholin)
Laparotomy (complete obs, isch, necros, refract)
Ileus (RF, PE)
Loss of perist w/o obstruction
RF: recent surg/proced; severe medic ds, immobil; hypoK; e- imbal; hypothyr; DM; drugs (opiod; anticholin)
Diffuse, constant discomf, N/V, No flatus/feces
Diffuse tender, distension, ↓/No sounds; DRE to r/o fecal impaction
Ileus (dg, ttt)
Dg: AXR (w/ air); CT (defin)
ttt: stop cause; ↓oral intake; NG suction; parenteral feeds; correct e-; IV hydration
Mesenteric ischemia (etiologies, PE)
Insuff bld to small intest → isch → necrosis
- Emboli: from heart (AFib; stasis from ↓EF)
- Thrombi: esp in prox SMA (#1 atheroscl)
- Other: nonocclus arterial ds (atheroscl, vasospasm), venous thromb (hypercoag), shock
Severe abdo pain out of prop to PE; N/V; diarr; bld stools; intest angina (after meals)
Mesenteric ischemia (dg, ttt)
Dg: AXR and CT (bowel wall edema + air)
Mesenteric/CT angiography (defin): dg +/- intervention
Complic: septic shock, multiorg failure, death
ttt: volume resuscit; broad-sp AB
Art embol/thromb: anticoag + laparotomy or angioplasty
Venous thromb: anticoag
Surg: infarcted bowel
Diverticular disease (RF)
Outpouch mucosa + submucosa through muscularis
Esp sigmoid; ↑intraluminal pressure
Diverticulosis: many; #1 cause lower GI bld in >40yo
Diverticulitis: infl + microperf 2* to fecalith
RF: ↓fiber, ↑fat; adv age; connect T disorder
Diverticular disease (PE, dg)
D.osis: asympt until painless bld (anemia if severe)
D.itis: LLQ abdo pain, fever, N/V; peritonitis (if perf)
Dg: ↑WBCs, anemia; CT; colono (def)
No colono if acute D.itis
Diverticular disease (ttt)
Uncompl: follow-up, ↑fiber
D. bleeding: stops spont, transfuse, hydrate
If not stopped: hemostasis (colono), emboliz (angiography), surg
D.itis: NPO, +/-NG tube, broad AB (metronid + fluoroq or C2G or C3G), colono after acute
Perfor: immediate surg resect of bowel part + colostomy
Large bowel obstruction (PE, etiologies, #dg)
Constip/Obstip; deep cram abdo pain; feculent N/V
↑distention, tender, high-pitch sounds then no sounds
Perfor/peritonitis or isch/necr: fever, shock
Colon cancer (until proven otherw/), D.itis, volvulus, fecal impact, benign tumor #dg: SBO, paral ileus, appendic, IBD, pseudo-obstr
Large bowel obstruction (dg, ttt)
Dg: e-, lactic acid, AXR, CT, water contrast enema; sigmoid/colono if stable
ttt: gastrografin enema, colono, rectal tube; surg usually requ.; ttt cause
If ischem, partial colectomy w/ colostomy
Colorectal cancer (PE, RF)
2 cancer morta in USA
Right-side: bulky, ulcerat mass; anemia; ↓weight,…
Left-side: apple-core obstruct mass; change bowel habits, bld in stool
Rectal: red bld, tenesmus, rect pain
RF: ↑w/ age; FAP (100% by 40yo); HNPCC; fam Hx; UC>Crohn; villous>tubular, sessile>pedunc adeno
Colorectal cancer (dg, ttt)
Dg: colono + biopsy (def); check meta (CXR/LFTs/CT)
Stage (TNM)
ttt: surg resect (#1); adjuv chemoth (if ⊕LN)
Follow w/ serial CEA/colono/LFTs/CXR/abdo CT
Ischemic colitis (RF, PE)
Insuff bld → isch → necrosis; usual w/ atheroscl
Esp left colon; esp watershed area (splenic flexure)
Crampy lower abdo pain then bld diarrhea; after meals/heat/exertion
Necros: fever, periton signs
Ischemic colitis (dg, ttt)
Dg: CT w/ contrast; colono
ttt: bowel rest (NPO), IV fluids, broad AB
If infarct, fulmin colitis, obstruc: surg resect
Screening recommendations for colorectal cancer
No Hx: start 50yo; annual DRE+FOBT; colono/10y or sigmoido/5y
1* relative Hx: colono/5y start 40yo or start 10y prior
Ulcerative colitis: colono/1-2y start 8-10y after dg
(Crohn: cancer < UC but >general pop)
Upper vs lower gastrointestinal bleeding
Hematemesis, hematochezia, melena
Upper vs lower: ligament of Treitz (duod/jej)
Upper GI bleeding
Hematem, melena; hypovol
Etiologies: PUD; infl eso/gastr; Mallor-W; varices eso/gastr; GAVE; Dieulafoy lesion
Dg: NG tube+lavage; endosc (defin)
ttt: protect airway; stabilize ptt (fluids/RBCs); endosc; ttt cause
Lower GI bleeding
Hematoch>melena
Etiologies: D.osis; angiodyspl; IBD; hemorr/fissures; neopl; AVM
Dg: sigmoido; colono if stable; arteriography or laparotomy if unstable
ttt: protect airway; stabilize ptt (fluids/RBCs); ttt cause; endosc ttt (epineph injec, cauteriz, clip); intra-art vasopressin; emboliz; surg if divertic or angiodyspl
Ulcerative colitis (PE)
Rectum; prox extension; continuous
Mucosa + submucosa inflam
Cramps, bld D; aphthous stomatitis; episcl/uveitis; arthritis; primary scleros cholangitis; eryth nodosum; pyoderma gangr
Ulcerative colitis (dg, ttt)
Dg: AXR, stool Cx/O&P/Cdiff; colono (pseudopolyps)
Biopsy (defin)
ttt: 5-ASA (sulfasal, mesalam); CS (flare-ups); immunomodul (azathiop, inflix) for refract/mod-sev Total proctocolectomy (curative for fulmin col; toxic megac; ↓R cancer)
Crohn disease (PE)
Any portion og GI (esp ileocecal); discontin
Transmural inflam
Pain, fever, ↓weight, watery D; fissures; fistules; aphthous stomatitis; episcl/uveitis; arthritis; primary scleros cholangitis; eryth nodosum; pyoderma gangr
Crohn disease (dg, ttt)
Dg: AXR, stool Cx/O&P/Cdiff; follow upper GI also
Colono (cobblestone, skip lesion); biopsy (defin)
ttt: 5-ASA (sulfasal, mesalam); CS (flare-ups); immunomodul (azathiop, inflix) for refract/mod-sev/maint Surg resect (perfor, stricture, fistul, abscess)
3 types of hernias
Indirect: through external + internal rings; lateral to inf epig Vx; congen patent proces vaginalis
Direct: through Hasselb triang; medial to inf epig Vx; break in transvers fascia from age
Femoral: below ing ligam through femor canal; ↑abdo pressure, weak pelv floor
Hernias (complications, ttt)
Incarceration
Strangulation
ttt: surgery
Cholelithiasis and biliary colic
RF: female, fat, fertile, forty; OCP; rapid ↓weight; chron hemolysis; small bow resect; TPN
Asympt or biliary colic (postprand RUQ pain; transient cystic duct block); RUQ tendern; N/V; Nl total bili/ALP/amyl
Dg: RUQ US (defin)
ttt: cholecystectomy; no ttt is asympt gallstones
Acute cholecystitis
Prolong block of cystic duct (stone); distent/infl/inf of cystic duct; acalculous (in debilitated)
RUQ pain+tendern; N/V; fever; Murphy⊕
↑WBCs; Nl tot bili/ALP/amyl
Dg: US; HIDA scan
ttt: broad AB + IV fluids + cholecystectomy
If ptt too ill, transcut drain of GB
Choledocholithiasis
Stone in comm bile duct
Sympt vary (degree/duration obstr)
Jaundice; RUQ pain/colic; afeb; +/- pancreatitis
↑WBCs; ↑tot bili/ALP; +/-↑amyl/lipase
Dg: US (dilat CBD); MRCP and ERCP (defin)
ttt: ERCP + sphincterotomy (remov stone) then cholecystectomy
Acute cholangitis
Inf of comm bile duct after obstruction (stone; stricture; 1* scler chol; malign)
Charcot tri: RUQ pain + fever + jaundice
Reynolds pent: Charcot + shock + alter mental status
↑WBCs; ↑tot bili/ALP
Dg: US (CBD dilat); ERCP (defin)
ttt: ICU (monitor fluid/BP + broad AB); emergent ERCP/sphincterotomy; surg if ptt toxic
Gallstone ileus
Mechan obstr (ileocecal valv) from >2.5cm stone
Cholecystoduodenal fistula
Subacute SBO; esp elderly woman
Dg: AXR (SBO/pneumobilia); upper GI barium
ttt: laparotomy (stone extract + close fistula + cholecystectomy)
Cholestasis
↑ALP + ↑bili
Ductal dilation: biliary obstr (stone, stricture, cancer)
No duct dilat: intrahep cholestasis (meds, post-op, sepsis)
Isolated hyperbilirubenemia
Conjug: defective excretion (Dub-John, Rotor)
Unconj: overproduction (hemolytic anemia) or defective conjug (Gilbert <5; Crig-Najjar)
Hepatitis (etiologies)
Infl liver → cell injury + necrosis
- Acute: viruses or meds/alcohol
- Fulminant: acute liv failure; INR>1.5; hep encephalo; w/o underly liv ds
-Chronic: chron viral (HCV in USA; HBV in world), alcoh, autoimm, metab (Wilson, hemochrom, alpha1-antitr)
Hepatitis (PE)
Acute: nonspecif viral prodrome then jaundice + RUQ tendern
HAV/HEV: self-lim acute
HBV/HCV: mild acute or asympt
Chronic: asympt or fatigue/joint pain
80%HCV + 10%HBV: chronic active hepatitis
Hepatitis (dg)
Acute: very ↑AST/ALT + ↑bili/ALP; serology; +/- biopsy
Chronic: mild ↑AST/ALT or Nl for >3-6mo
Autoimm: ⊕ anti-nuclear and anti-smooth M, … Ab; ↑IgG; pANCA
Hemochrom: ↑ferritin; transf satur >50%; ↑iron
Wilson: ↓cerulopl; ↑ur copper; Kay-Flei rings
Hepatitis (ttt, complications)
Acute: support; HBV w/ antiviral
Chronic: cause; liv transpl (def for end-stage liv failure)
HBV: Tenofov/Entecav
HCV: meds/duration based on genotype/cirrhosis; 2 direct-acting antiV or 1 DAA+ribavirin.
Complic: cirrhosis, portal HTN, liv failure, hepatocell carcinoma (3-5%)
Cirrhosis (etiologies)
Chronic hep injury
USA: alcoh, chron HCV, NASH
Intrahep: all causes of chron hepatitis
Extrahep: bili tract ds; posthep like right heart failure, constric pericarditis, Budd-Chiari
Cirrhosis (PE)
Asympt or jaundice, easy bruising/coagulop, complic of portal HTN (ascites, hep enceph, GE varices, ↓plts); sympt of ↑estrog (spider nevi, gynecomast, test atrophy)
Complic ascites: spont bact peritonitis (>250 PMNs/mL)
Large palpable firm liver; anemia, LE edema
Cirrhosis (dg, ttt)
↓album; ↑PT/INR; ↑bili
↓plts (2/2 hypersplenism + ↓thrombopoietin)
Defin: biopsy (bridging fibrosis + nodular regeneration)
Etiol: hepatitis serologies, autoimm markers, ferritin, ceruloplasmin, alpha1-antitrypsin
SAAG = serum album - ascites album
ttt: ttt+prevent progress; minim factors that decompens
Management of ascites and SBP
ttt ascites: Na+ restric, diuretic; paracent; TIPS; underl ds
ttt SBP: acute IV AB (C3G); IV album; prophyl fluoroq (for recurr). ! poor 1y pg
Hepatorenal syndrome
Acute prerenal failure by splanchnic vasodil
ur Na+ <10
Poor pg; liv transpl may cure
ttt: volume replet + r/o other causes; octreotide (↓Vxdil); midodrine (↑BP); +/- dialysis
Hepatic encephalopathy
↓ clearance ammonia
By dehydr, inf, e- abNl, GI bld
ttt: lactulose; rifaximin; underl triggers
Management of esophageal varices and coagulopathy
Endosc surv in all cirrhosis; prophyl w/ B- or endosc ligation
ttt acute bld: endosc w/ ligation or sclerotherapy
If refractory, urgent TIPS
ttt coag: in acute bld, give FFP (Not vitK)
Primary sclerosing cholangitis (RF, PE)
Progr infl + fibrosis
Strictures of extrahep + intrahep bile ducts
Young men w/ ulcerative colitis
Jaundice, pruritus, fatigue
↑R of cholangiocarcinoma
Primary sclerosing cholangitis (dg, ttt)
Dg: ↑ALP, ↑bili; MRCP/ERCP (strictures/dilatations)
Liv biopsy (periduct sclerosis/onion skin)
After dg, !colono to evaluate IBD
ttt: ERCP w/ dilation+stenting; liv transplant (defin)
Primary biliary cirrhosis
Autoimm; destruction of intrahep bile ducts
Middle-age women (w/ other AI ds)
Progr jaundice, pruritus, vit ADEK deficit
Dg: ↑ALP, ↑bili, ↑cholest, ⊕anti-mitochondrial Ab
ttt: ursodeoxycholic acid (slow prog); cholestyramine (↓prurit); liv transplant
Non-alcoholic fatty liver disease
Steatosis of hepatocytes; liv injury
NASH → liv fibrosis and cirrhosis
Ass w/ insul resist and metab sd
Dg: of exclusion; biopsy
ttt: ↓weight/diet/exo; vitE and pioglitazone
Hepatocellular carcinoma (RF, PE)
US RF: cirrhosis (alcoh/HCV/NASH); chron HBV
Dev countr RF: HBV, aflatoxins
RUQ tendern, abdo dist, jaundice, easy bruis, coagulop, hepatomeg
Hepatocellular carcinoma (dg, ttt)
Dg: mass on US/CT; abNl LFTs; ↑AFP; biopsy
ttt: surg (partial hepatect) if feasible; liver tranpl (if cirrhosis + few small tumors)
non-surg (trans-art chemoemboliz +/- radiofqcy abl); sorafenib (adv meta ds)
Monitor AFP and US/CT
Hemochromatosis (etiologies, PE)
Iron overload; hemosiderin accum in organs
1: AR ds, excess absorp dietary iron
2: in chron transfusion (SCC, alpha-thal)
Abdo pain, DM, hypogonad, arthropathy (MCPs), CHF, cirrhosis, hepatomeg, bronze pigm
No eff on lung, kidney, eye
Hemochromatosis (dg, ttt, complications)
Dg: ↑iron/Sa/ferritin; ↓transferrin; liv biopsy; MRI; HFE mutation screen
ttt: phlebotomy/wk then /2-4mo; deferoxamine
Complic: cirrhosis, hepatoC carcinoma; restr CM; hypopituit; …
Wilson disease (Hepatolenticular degeneration) (PE)
AR ds; def copper transp → accum in liv/brain
At <30yo; 50% sympt at 15yo
Hepatitis/cirrhosis, neuro dysf (ataxia/tremor), psy abNl
Key-Fle rings, rigidity, choreiform mvts
Wilson disease (Hepatolenticular degeneration) (dg, ttt)
Dg: ↓cerulopl; ↑24h urin copper; liv biopsy
ttt: penicillamine/trientine (chelators); ↓dietary copper/zinc
Insulinoma (PE)
Ass w/ MEN1; benign
Hypoglyc w/ Whipple triad (docum hypogly + sympt sweat/palpit/anxiet/tremor/headac/conf + resolution w/ correct hypogly)
Insulinoma (dg, ttt)
Dg: ↑fasting insulin, ↑C-peptide
Defin test: 72h fasting (profound hypogly)
Localize tumor: abdo US/CT/MRI
ttt: surg resect
VIPoma
VIP tumor; highly malignant
Watery diarrhea, dehydration, muscle weak, flushing
Dg: ↓stool osm gap; ↑VIP; achlorhydria; hypergly; hyperCa; hypoK; CT scan
ttt: fluids + e-; surg resect; octreotide
Acute pancreatitis (RF, PE)
Abrupt severe pain
RF: gallstones, alcoh abuse, hyperCa, hyperTg, trauma, meds, viral, post-ERCP, scorpion
Severe epig pain (to back), N/V, weak, ARDS, …
Grey Turner sign (flank bruise)
Cullen sign (periumb discol)
Acute pancreatitis (dg, ttt)
Dg: ↑lipase (↑amylase), ↓Ca, AXR (sentinel loop)
Abdo US/CT (absc, hge, necros, pseudocyst)
ttt: off agent removal; support (IV fluids, e-, analgesia, NPO, NG suct, nutrition+O2)
If inf/necrosis: AB
Acute pancreatitis (pg, complications)
Pg: 85-90% mild/self-lim; 10-15% severe/ICU w/ 50% morta
Complic: pseudocyst, fistula, chronic P, sepsis, renal failure, ARDS
Chronic pancreatitis (RF, PE)
Irrev destr → panc dysfct + insuff
RF: alcoh abuse, gallstones, CF, smok
Persist, recurr epig pain; anorex/N; constip, flatus, steatorrhea, ↓weight, DM
Chronic pancreatitis (dg, ttt, complications)
Dg: ↑/Nl lipase/amylase, panc calcific; CT/US (stenosis+dilation)
ttt: analges, panc enz replac, avoid cause, celiac N block, endosc dilation P duct, +/- surg
Complic: chronic pain, opiate addict, DM, malnutr/↓weight, pancr cancer
Pancreatic cancer (RF, PE)
Adenocarcinoma in head P (75%)
RF: smok, chron P.itis, K in 1*relative
Abdo pain to back, obstr jaund, ↓appet, N/V, ↓weight, fatig, indigest; or asympt Palpable nontender gallbladder (Courvoisier sg) Migratory thrombophlebitis (Trousseau sg)
Pancreatic cancer (dg, ttt)
CT w/ contr: tumor, local invas, distant meta
If not visible, endosc US +/- ERCP
↑CA19-9
ttt: local adv/meta (palliative chemoth, support)
Small tum (Whipple proced)
Chemoth w/ 5-FU + gemcitabine (short-term surviv)
ERCP w/ stent (relieve if obstr sympt)
