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Gastrointestinal Flashcards

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1
Q

Dysphagia / Odynophagia (PE)

A

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

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2
Q

Dysphagia / Odynophagia (dg, ttt)

A
  • Oroph: barium swallow #1; rarely EGD
  • Esoph: EGD #1; barium before if Hx of esoph radiation/stricture (! perforation)
  • Odynophagia: EGD

ttt: cause

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3
Q

Infectious esophagitis

A

Immcomprom

  • Candida alb: oral thrush; fluconazole PO
  • HSV: oral ulcers; acyclovir IV
  • CMV: retinitis, colitis; gancyclovir IV
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4
Q

Diffuse esophageal spasm

A

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)

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5
Q

Achalasia (PE)

A

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

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6
Q

Achalasia (dg, ttt)

A 
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)

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7
Q

Esophageal diverticula

A

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

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8
Q

Esophageal cancer

A 
#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

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9
Q

Gastroesophageal reflux disease (PE, dg)

A

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)

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10
Q

Gastroesophageal reflux disease (complic, ttt)

A

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)

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11
Q

Hiatal hernia

A
  • 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)

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12
Q

Gastritis (etiologies)

A

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

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13
Q

Gastritis (PE, ttt)

A

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

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14
Q

H pylori (dg)

A

! 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

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15
Q

Gastric cancer (RF)

A

Esp adenocarcinoma
Common in Korea, Japan

RF: diet w/ ↑nitrites+salt and ↓fresh vegetables; H pylori coloniz; chronic gastritis; pernicious An

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16
Q

Gastric cancer (PE, dg, ttt)

A

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

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17
Q

Only malignancy cured w/ antibiotics

A

MALT lymphoma
Ass w/ chronic H pylori inf
ttt: triple therapy

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18
Q

Peptic ulcer disease (RF; PE)

A

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

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19
Q

Peptic ulcer disease (dg, complications)

A

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

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20
Q

Peptic ulcer disease (ttt)

A

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

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21
Q

Zollinger-Ellison syndrome (PE)

A

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

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22
Q

Zollinger-Ellison syndrome (dg, ttt)

A

Dg: ↑fasting serum gastrin + ↑gastrin w/ secretin admin
CT for staging

ttt: moder/high-dose PPI; surg resect

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23
Q

Diarrhea (etiologies)

A

> 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)

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24
Q

Diarrhea (dg)

A

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

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25
Q

Diarrhea caused by Campylobacter

A 
#1 bacterial cause of D
Contaminated food/water
Bloody D
R/o appendicitis; IBD
ttt: supportive #1, then fluoroqu or azithrom
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26
Q

Diarrhea caused by Clostridium difficile

A

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)

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27
Q

Diarrhea caused by Entamoeba histolytica

A 
Contaminated foor/water (develop country)
Incubation ≤ 3mo
Flask shaped ulcers (colono)
R/o IBD
ttt: metronid
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28
Q

Diarrhea caused by E coli O157:H7

A

Contaminated raw meat
R/o GI bld, ischem colitis
Complic: HUS
ttt: Nothing; avoid AB or antidiarrheal bcz ↑R of HUS

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29
Q

Diarrhea caused by Salmonella

A

Contaminated poultry/eggs
! sepsis; ! osteomyel in SCD
ttt: fluids; if high risk PO quinolone or TMP-SMX

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30
Q

Diarrhea caused by Shigella

A

! Contagious; fecal-oral route
Complic: severe dehydr; febrile seizures
ttt: TMP-SMX

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31
Q

Malabsorption / maldigestion (etiologies, PE)

A

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

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32
Q

Malabsorption / maldigestion (dg, ttt)

A

Dg: lab tests
Biopsy is definitive

ttt: etiology
If severe: TPN, immunosuppressants, anti-inflam

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33
Q

Lactose intolerance

A

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

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34
Q

Carcinoid syndrome

A

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

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35
Q

Irritable bowel syndrome

A

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

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36
Q

Small bowel obstruction (etiologies, PE, #dg)

A

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
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37
Q

Small bowel obstruction (complications, dg, ttt)

A

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)

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38
Q

Ileus (RF, PE)

A

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

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39
Q

Ileus (dg, ttt)

A

Dg: AXR (w/ air); CT (defin)

ttt: stop cause; ↓oral intake; NG suction; parenteral feeds; correct e-; IV hydration

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40
Q

Mesenteric ischemia (etiologies, PE)

A

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)

41
Q

Mesenteric ischemia (dg, ttt)

A

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

42
Q

Diverticular disease (RF)

A

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

43
Q

Diverticular disease (PE, dg)

A

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

44
Q

Diverticular disease (ttt)

A

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

45
Q

Large bowel obstruction (PE, etiologies, #dg)

A

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
46
Q

Large bowel obstruction (dg, ttt)

A

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

47
Q

Colorectal cancer (PE, RF)

A

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

48
Q

Colorectal cancer (dg, ttt)

A

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

49
Q

Ischemic colitis (RF, PE)

A

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

50
Q

Ischemic colitis (dg, ttt)

A

Dg: CT w/ contrast; colono

ttt: bowel rest (NPO), IV fluids, broad AB
If infarct, fulmin colitis, obstruc: surg resect

51
Q

Screening recommendations for colorectal cancer

A

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)

52
Q

Upper vs lower gastrointestinal bleeding

A

Hematemesis, hematochezia, melena

Upper vs lower: ligament of Treitz (duod/jej)

53
Q

Upper GI bleeding

A

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

54
Q

Lower GI bleeding

A

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

55
Q

Ulcerative colitis (PE)

A

Rectum; prox extension; continuous
Mucosa + submucosa inflam

Cramps, bld D; aphthous stomatitis; episcl/uveitis; arthritis; primary scleros cholangitis; eryth nodosum; pyoderma gangr

56
Q

Ulcerative colitis (dg, ttt)

A

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)
57
Q

Crohn disease (PE)

A

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

58
Q

Crohn disease (dg, ttt)

A

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)
59
Q

3 types of hernias

A

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

60
Q

Hernias (complications, ttt)

A

Incarceration
Strangulation

ttt: surgery

61
Q

Cholelithiasis and biliary colic

A

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

62
Q

Acute cholecystitis

A

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

63
Q

Choledocholithiasis

A

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

64
Q

Acute cholangitis

A

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

65
Q

Gallstone ileus

A

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)

66
Q

Cholestasis

A

↑ALP + ↑bili
Ductal dilation: biliary obstr (stone, stricture, cancer)
No duct dilat: intrahep cholestasis (meds, post-op, sepsis)

67
Q

Isolated hyperbilirubenemia

A

Conjug: defective excretion (Dub-John, Rotor)
Unconj: overproduction (hemolytic anemia) or defective conjug (Gilbert <5; Crig-Najjar)

68
Q

Hepatitis (etiologies)

A

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)

69
Q

Hepatitis (PE)

A

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

70
Q

Hepatitis (dg)

A

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

71
Q

Hepatitis (ttt, complications)

A

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%)

72
Q

Cirrhosis (etiologies)

A

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

73
Q

Cirrhosis (PE)

A

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

74
Q

Cirrhosis (dg, ttt)

A

↓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

75
Q

Management of ascites and SBP

A

ttt ascites: Na+ restric, diuretic; paracent; TIPS; underl ds

ttt SBP: acute IV AB (C3G); IV album; prophyl fluoroq (for recurr). ! poor 1y pg

76
Q

Hepatorenal syndrome

A

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

77
Q

Hepatic encephalopathy

A

↓ clearance ammonia
By dehydr, inf, e- abNl, GI bld

ttt: lactulose; rifaximin; underl triggers

78
Q

Management of esophageal varices and coagulopathy

A

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)

79
Q

Primary sclerosing cholangitis (RF, PE)

A

Progr infl + fibrosis
Strictures of extrahep + intrahep bile ducts
Young men w/ ulcerative colitis

Jaundice, pruritus, fatigue
↑R of cholangiocarcinoma

80
Q

Primary sclerosing cholangitis (dg, ttt)

A

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)

81
Q

Primary biliary cirrhosis

A

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

82
Q

Non-alcoholic fatty liver disease

A

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

83
Q

Hepatocellular carcinoma (RF, PE)

A

US RF: cirrhosis (alcoh/HCV/NASH); chron HBV
Dev countr RF: HBV, aflatoxins

RUQ tendern, abdo dist, jaundice, easy bruis, coagulop, hepatomeg

84
Q

Hepatocellular carcinoma (dg, ttt)

A

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

85
Q

Hemochromatosis (etiologies, PE)

A

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

86
Q

Hemochromatosis (dg, ttt, complications)

A

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; …

87
Q

Wilson disease (Hepatolenticular degeneration) (PE)

A

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

88
Q

Wilson disease (Hepatolenticular degeneration) (dg, ttt)

A

Dg: ↓cerulopl; ↑24h urin copper; liv biopsy

ttt: penicillamine/trientine (chelators); ↓dietary copper/zinc

89
Q

Insulinoma (PE)

A

Ass w/ MEN1; benign

Hypoglyc w/ Whipple triad (docum hypogly + sympt sweat/palpit/anxiet/tremor/headac/conf + resolution w/ correct hypogly)

90
Q

Insulinoma (dg, ttt)

A

Dg: ↑fasting insulin, ↑C-peptide
Defin test: 72h fasting (profound hypogly)
Localize tumor: abdo US/CT/MRI

ttt: surg resect

91
Q

VIPoma

A

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

92
Q

Acute pancreatitis (RF, PE)

A

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)

93
Q

Acute pancreatitis (dg, ttt)

A

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

94
Q

Acute pancreatitis (pg, complications)

A

Pg: 85-90% mild/self-lim; 10-15% severe/ICU w/ 50% morta

Complic: pseudocyst, fistula, chronic P, sepsis, renal failure, ARDS

95
Q

Chronic pancreatitis (RF, PE)

A

Irrev destr → panc dysfct + insuff
RF: alcoh abuse, gallstones, CF, smok

Persist, recurr epig pain; anorex/N; constip, flatus, steatorrhea, ↓weight, DM

96
Q

Chronic pancreatitis (dg, ttt, complications)

A

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

97
Q

Pancreatic cancer (RF, PE)

A

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)
98
Q

Pancreatic cancer (dg, ttt)

A

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)

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