Gastrointestinal - 9% Flashcards
Achalasia
Ineffected - 1. parastalsis, 2. swallowed induced relaxation of L esophageal sphinctor
Sxs
- Dysphagia for solids & mostly liquids
- progressive
- regurgitation of undigested food
Dx
- Esophagram - bird’s beak of distal esophagus
- Esophageal manometry - gold confirmatory
Tx
- Limited - botox
- Surgical myotomy
Acute and Chronic Pancreatitis
dx
Dx:
- Serum Amylase x5 ULN (non spec)
- Serum Lipase x3 ULN specific
- CT scan - gold standard
- +/- jaundice
Ranson’s Criteria
At admission:
- Age > 55
- Glucose > 200
- AST > 250
- LDH > 350
- WBC > 16,000
48 hrs after admission
- Hematocrit fall > 10%
- BUN Rise > 5mg/dl
- Ca < 8 mg/dl
- PO2 < 60 mmHG
- Base deficit > 4 mEq/L
- Fluid sequestration > 6L
Acute Pancreatitis
eti, sxs
MC gallstones, 2/2 ETOH N/V
Sxs:
- Epigastric abd pain
- r-> back worse supine and
- post prandial
- hemorrhagic
- Grey Turner - flank ecchymosis
- Cullen - periumb ecchymosis
Acute Pancreatitis
tx
Mild - bowel rest NPO Pain control Severe - ICU
Anal Abscess and Fistula
Dx, tx
Clinical
I&D followed by WASH
- Warm water
- Cleansing
- Analgesics
- Sitz Bath
- High fiber diet
Anal Abscess
eti, sxs
Bacterial infx of perianal ducts/glands - MC S Aureus
MC posterior rectal wall
Sxs:
- Painful defecation
- Rectal pain worse with sitting, coughing
Anal Fissures
dx and tx
- clinical
- Sigmoidoscopy if < 50 yo to r/o FH of colon ca
- Analgesics
- High fiber diet
- Stool softener, laxatives, mineral oils
Anal Fissures
eti, sxs
Painful, linear tear/crack low fiber diet
MC in posterior midline
2/2 Crohn’s and Granulomatous (TB or sarcoid)
Sxs:
- Severe, tearing pain with defecation
- Pt afraid of BM —> Constipation and
- BRBPR
Anal Fistula
eti, sxs
open tract btwn two epithelial-lined areas
MC with Crohn’s
Sxs:
- Perirectal/anal swelling
- painful defecation
- Malodorous drainage
Anorexia Ddx
Appendicitis
- Periumbi pain, N/V, anorexia, RLQ
Gastric Ulcers
- epigastric pain, N/V, anorexia
Duodenal Ulcers
- Epigastric pain - burning aching, anorexia, decr appetite
Gastric Cancer
- WEAPON
Lower GI Bleed
- abd pain, melena, anorexia, fatigue, syncope
Carcinoma of GB
- biliary colic, wt loss, anorexia, asymp til late
Pancreatic carcinoma
- painless jaundice from CBD obstruction; wt loss, abd pain -> back, weakness, pruritus from bile salts, anorexia, courvoisier’s sign, acholic stool, dark urine, DM
Appendicitis
Obstruction of appendix,
MC d/t fecalith, malignancy, inflammation, foreign body
Sxs:
- 10-30 yo
- anorexia, N/V, leukocytosis
- periumbilical pain -> RLQ pain
Dx
- PE signs
- Rovsing sign - RLQ pain w/ LLQ palp
- Obturator sign - pain with internal/external hip rotation w/ flexed knee
- Psoas sign - RLQ pain w/ hip flexion/extension against resistance
- McBurney’s point of tenderness- 1/3 of distance from ant sup iliac spine and navel
- Abd US - initial test
- CT - non contrast - gold
Tx
- appendectomy
- IV Abx - Cipro + Metronidazole
Bariatric Surgery
complications
Early complications
- anastomostic leak
- presents with hemodynamic instability
- DVT/PE
- bleeding
- infx
- Splenic injury
Late complications
- Malnutrition + nutritional probs
- Marginal Ulcers, anastomastic stricturs
- Internal Hernia
- Band slippage
- Band erosion
- esophogeal dilatation
Bariatric Surgery
types
Indications
- BMI > 40 or BMI >35 + medical problem related to morbid obesity
- individuals must have failed other non-surgical wt loss program
- Psychologicall stable - follow post op orders
- No caused by medical disease
Restrictive procedures - less extensive but less wt loss +decr in morbidity
- Adjustable Gastric banding
- band slippage can cause vomiting/regurgitation, inability to keep food down
- Vertical Banded Gastroplasty
- Sleeve Gastrectomy
Malabsorptive procedures - more wt loss, but probs with malnutrition
- Biliopancreatic diversion
- Biliopancreatic diversion w/ or w/o Duodenal Switch
Combination of restrictive and Malabsorptive procedures
- Roux-en-Y Bypass - mean wt loss 50% of excess weight
- MC type used
- proximal gastric pouch - Roux-en-Y gastrojejunostomy
Large Bowel Obstruction
Causes - volvulus, adhesions, hernias, colon cancer (MCC in elderly ppl)
Sxs:
- Constipation, obstipation, high pitched BS
- N/V
- gradually increasing distention and pain (longer eps btwn pain)
Dx:
- KUB/abd Xray - distended proximal colon w/ haustra, air fluid levels, no gas in rectum
Tx:
- NPO
- NG suction
- IV fluids
- monitoring pain
- Surgery if mechanical obstruction w/in 48 hrs
Small Bowel Obstruction
MCC - adhesions d/t previous abd surgeries
Sxs:
- Colicky abd pain, obstipation
- N, bilious vomiting
- Abd distention, rigid or firm
- hyperactive BS => hypoactive BS
Dx
- KUB - air fluid level on upright
Tx
- NG tube
- Bowel rest
- Surgery if unresolved
Volvulus
Bowel Obstruction
Twisting of any part of the bowel @ its mesenteric attachment site
MC Sigmoid Colon & cecum
Sxs - obstruction
- abd pain, distention
- N/V
- Fever
- tachycardia
Dx - KUB series
Tx -
- endoscopic decompression - initial TOC
- Surgical correction - 2nd line
Cholangiocarcinoma
Neoplasms
Rare biliary tumor, MC adenocarcinoma
RF - PSC, parasitic infx
Klatskin tumor - hilar cholangiocarcinoma (MC at junction of R and L main hepatic ducts)
Sxs
- non tender palpable GB w/ hx of wt loss
Dx - usu found late
Tx - improved prognosis if complete resection of tumor
Cholangitis
dx, tx
Dx:
- 1st - RUQ US or CT gold -
- ERCP for cholangiography after afebrile for 48 hrs
- ERCP for decompression
- PTC if can’t do ERCP
Tx with Abx - Ceft + Metro - Zosyn (pip/tazo)
Cholangitis
eti, sxs
info of biliary tract 2/2 to obstruction - gallstones
MC Ecoli or Kleb
Charcot’s Triad
- RUQ pain
- Jaundice
- Fever
Reynold’s Pentad
- above + AMS & Sepsis
Cholecystitis
dx & tx
Dx with RUQ US >3mm
HIDA scan (gold std)
Tx:
NPO IV fluids Abx (ceft + metron) Definitive - cholecystectomy
Cholecystitis
eti, sxs
Inflammation of GB
MC gall stones
Sxs:
- RUQ/epigastric pain
- N/V/Anorexia
- R-> R shoulder/scapular - Boas’s sign
- Inspiratory halt during deep palpi = Murphy’s sign
Choledocholithiasis
dx, tx
Trans abd US gold - ERCP extraction tx
cholecystectomy definitive
Choledocholithiasis
eti, sxs
GS in Common Bile Duct
1ry - formation of gs in CBD
2ry - passage of gs from GB to CBD
Sxs:
asymp 50%
Biliary colic w/ RUQ tenderness +/- jaundice
may lead to shock
Cholelithiasis
dx, tx
Gold - RUQ US > 2mm
3 types deps on color (yellow for cholesterol
black - hemolysis, ETOH, cirrhosis
brown - biliary tract infx observation if asymp
Tx - Urseodeoxycholic acide to dissolve GS Elective cholecystectomy
Cholelithiasis eti, sxs
Gallstones + pain when GB compresses on GS
Fat Forty Fertile Female Flatulence
Sxs:
- MC asymp Biliary colic
- episodic RUQ/epig pain —> resolves in 30-1h
- post prandial pain + at night
Chronic Pancreatitis
tx
Pancreaticojejunostomy -> Whipple PO
Pancreatic enzyme replacement
ETOH abstinence
Pain control
Colorectal Carcinoma (CRC)
dx
Colonoscopy with bx - gold
barium enema - apple core lesion
+ CEA - marker
CBC - anemia
Colorectal Carcinoma (CRC)
eti
3rd MC Cancer in US Genetics
Familial Adenomatous Polyposis (APC gene - develop colon cancer by 40yo —> prophylactic colectomy
RFs
- age > 50yo -
- UC > Crohn’s -
- Low fiber diet -
- smoking -
- etoh -
- AAs -
- fam hx of CRC
Colorectal Carcinoma (CRC)
Screening
average risk
- start at 50 yo
- FOBT q 1 year
- Colonoscopy q 10y or Flex sig q 5 y
1st degree Relative or high RFs
- FOBT q1y
- starting at 40y or 10 yrs younger than earliest dx age Colo - q 5y
Highest risk
- UC or Crohn’s >8yrs,
- FAP
- FOBT any age
- Colonoscopy q5y
Colorectal Carcinoma (CRC)
sxs
MCC large bowel obstruction in adults
Painless rectal bleeding; changes in bowel habits
Right sided - ascending colon
- proximal - lesions tend to bleed
- occult blood loss = anemia/+ FOBT
- non-spec sxs - fatigue, wt loss
Left sided - descending colon
- changes in bowel habits - constipation
- sxs of obstructions; present later
- abd pain, N/V, distention
Colorectal Carcinoma (CRC)
tx
localized (stage 1 to 3) - resection
Stage 3 to Mets - chemotherapy with 5FU/Fluorouracil
Diarrhea
Pseudomembranous colitis
Inflammation of colon d/t C. Diff 2/2 abx penicillin, cephalosporins, FQ
disrupts normal colonic flora
Sxs
- Mild watery foul smelling diarrhea (>3 but < 20 stools/d)
- Fever
- Abd pain, gen constitutional sxs
Dx
- PCR - C diff toxin- Toxin B (clinically important)
- Stool culture
- Leukocytosis
Tx
- IV metronidazole, or PO Vanc
- Strict hand washing
- Complications - bowel perf/ toxic megacolon
Diverticulitis
dx, tx
gold - CT scan
FOBT + CBC Leuks
Tx:
- Abx - Cipro/Bactrim + MNZ
- Clear liquid diet
- colonoscopy in 6 wks to r/o cancer
Diverticulitis
eti, sxs
Infection and inflammation of outpouchings d/t fecalith
Sxs:
- LLQ abd pain
- Fever N/V/D
- Constipation
- bowel changes and bloating
Diverticulosis
dx, tx
CT - TOC***
- avoid barium enema
Tx:
- high fiber diet
- psyllium - fiber supplement
Diverticulosis
eti, sxs
Outpouchings d/t intestinal mucosa herniation
Sxs:
- MCC BRBPR
- Low fiber diet
- LLQ discomfort
- fever, chills
Adenocarcinoma
eti, sxs
Esophageal Carcinoma
MCC esophageal ca in US - White Males
a/w Barrett’s esophagus and GERD; lower 1/3 of esophagus
Sxs:
- progressive dysphagia solids -> fluids odynophagia
- chest pain not related to eating
- reflux hoarseness
Dx - Endoscopy with Bx - gold Barium; esophagram CT for staging
Tx - Esophageal resection chemo 5FU
Squamous Cell Carcinoma
Esophageal Carcinoma
MCC Esophageal worldwide; 50-70yo; a/w smoking/etoh
upper 2/3 of esophagus
Dx - Endoscopy w/ bx and diagnosis
Chemo or radiation or resection
Esophageal Strictures
Strictures - scarring from healing process of ulcerative esophagitis
Schatzki Ring - diaphragm mucosal ring that causes sxs if is too small.
Sxs
- solid food dysphage w/ hx of GERD
Dx
- Barium swallow/ esophagram
- Endoscopy is confirmatory
Tx
- Endoscopy and dilatation
- sx rarely needed
Esophageal Varices
Hematemesis
Dilated submucosal veisn in distal esophagus or proximal stomach
hx of portal HTN & Cirrhosis; high mortality
Sxs:
- Hematemesis - coffee ground appearance
- melena -black tarry stool
- VS instability
- hypovolemia/tachycardia
- shock
Dx:
- Emergent endoscopy (EGD)
- Band ligation**** & IV Ocreotide for vasoconstriction
- sclerotherapy
- If fails - Balloon tamponade or TIPS (transjugular intrahepatitc portosystemic shunt)
- Longterm - BB (propanolol), no etoh
Gluten Intolerance
Food allergies and sensitivities
Inflammation of small bowel 2/2 ingestion of gluten; autoimmune disorder, hereditary
Sxs
- Diarrhea, steatorrhea, flatulence, weight loss
- weakness and abd distention
- infants/children = FTT
Dx
- IgA antiendomysial (EMA) and antitissue Transglutaminase (anti-tTG) abs
- Endoscopic intestinal mucosal biopsy of proximal and distal duodenum- confirmatory
Tx - GF Diet
Lactose Intolerance
Food allergies and sensitivities
Inability to digest lactose - predom sugar of milk, via lack of lactase
Sxs
- abd bloating and cramps, flatulence
- diarrhea, N, borborygmi, vomiting
- usu 30mins to 2 hrs
Dx
- Lactose breath hydrogen test - positive if > 20ppm
- Stool acidity test (fecal pH test) - acidic = acid producing bacteria
Tx
- avoid dairy product
- lactase supplement
Nut Allergies
Food allergies and sensitivities
linked to anaphylaxis
Sxs/ Dx
- Derm - pruritis, erythema, urticaria, angioedema
- GI manifestation - N/V, abd cramps, diarrhea
- Anaphylactic reaction - respiratory syst and can be fatal
- Cutaneous manifestation - angioedema, urticaria
Avoid nuts, and nut products
administer epinephrine asap
Gastric Carcinoma
MC adenocarcinoma; can be lymphoma (rarer, a/w Non Hodgkin Lymphoma)
RFs:
- H pylori*** salted, cured, pickled food
- Etoh, Smoking
- Blood type A
WEAPONS
- Weight loss + Fe deficiency Anemia
- Emesis
- Anorexia
- Pain/abd discomfort
- Obstruction
- Nausea
Dx
- Endoscopy with Biopsy - Linitis plastica - thickening of gastric wall
Tx - poor prognosis- resection
Abdominal Carcinoma
signs of metastasis
Virchow’s Node - Left supraclavicular LN
Sister Mary Joseph’s Nodule - umbilical LN
GERD
Relaxation of LES
Sxs:
- Heartburn* w/ meals, wt gain, N, recumbency
- Throat irritation and cough
Tx - symptom relief w/ PPO and H2 Blockers
- PPI - sx relief + promote healing
- Tx empircally on PPI x 4 wks (failed H2blockers w/ mod-severe GERD)
Dx
-
Endoscopy - if failed empirical tx on PPI OR
- GI bleeding/anemia
- Dysphagia/odynophagia
- unintentional wt loss
- H/o heavy NSAIDs
- Risk of UGI cancers
H. pylori
Peptic Ulcer Disase
Dx
-
Urea Breath test * gold - needs to be off PPI, bismuth and abx
- active infection
- urea as byproduct of metabolism
- Stool antigen
- Endoscopy bx
Tx
- Clarithromycin 500 mg BID
- Amoxicillin 1g BID
-
PPI BID
- Metronidazole 500 mg if pcn allergic
- Follow up with urea breath test 1 mo post tx to ensure eradication
Heartburn and Dyspepsia
ddx
Burning pain or discomfort - after eating at night, worsen when lying down
GERD
- Acid reflux + HB > 2x/wk = GERD
Food Intolerance
Esophagitis
- painful, difficulty swallowing + CP w/ eating
Gastritis
- H. pylori or NSAIDs, or etoh
Hiatal hernia
- no sxs but can be a/w HB and abd discomfort
PUD
- burning abd pain, N/V, bloating
Hemorrhoids
varicose vein of anus and rectum
RFs - constipation/straining, pregnancy, portal HTN
Dx - Anoscopy if BRBPR or suspected thrombosis
External
- lower 1/3 of anus
- thrombosed
- significant pain, pruritis, NO bleeding
- palpable perianal mass w/ purplish hue
- Tx - excision
Internal
- upper 1/3 of anus
- BRBPR, pruritis, rectal discomfort
- Tx - Fiber, sitz bath, ice packs, stool softeners
- Rubber band ligation - if +protrudes, enlargement and intmt bleeding
- Hemorrhoidectomy if prolapse
Hepatocellular Carcinoma
dx, tx
Alpha fetoprotein (AFP) marker esp in pst with hep C or cirrhosis
Ultrasound, MRI lesions >/= 1cm
Liver transplant for
- single lesion < 5cm or
- = 3 lesions that are all = 3cm
Surgical resection - cancer can recur
Hepatocellular Carcinoma
eti, sxs
Primary Cancer - HCC
2/2 to mets from lungs and breast Ca (MC)
RFs:
- Hepatitis B, C, D
- Cirrhosis
- Aflatoxin B1 exposure (Aspergillus spp)
Sxs
- Malaise, wt loss
- Jaundice, ascites, Hepatosplenomegaly
Hernia (incarcerated/strangulated)
Protrusion of organ/structure through abd wall
Inguinal hernias
- MC - through internal ring down the inguinal canal (into scrotum)
Direct inguinal hernias
- passage of intestines through external inguinal ring at Hesselbach’s triangle
Sxs:
- Reducible bulge when patient coughs or strains
- Usu painless unless
- Incarcerated - can’t be reduced
- Obstructed - irreducible hernia but no interference w/ blood flow
- Strangulated - blood supply cut off - bowel ischemia, necrosis perforation
Tx - Open repair or lap w/ mesh reinforcement
Femoral, Incisional
Hernia
Femoral - into groin at the top of inner thigh
Incisional - a/w vertical incisions - esp with obesity
Hiatal Hernia
Sliding hernia (type 1) - >90% cases, GE junction and portion of stomach herniates into thorax through esophageal hiatus (GE junction above diaphragm)
Paraesophageal Hiatal Hernia (type 2) - <5% cases . Stomach herniates into thorax through esophageal hiatus, but GE junciton does not. Remains below diaphragm.
- can become strangulated
Sxs
- heartburn, chest pain, dysphagia
Dx
- Upper GI series, endoscopy
Tx
- Type 1 - antacid, small meals, ele of head after meal - can do Nissen fundoplication
- Type 2 - elective surgery
Crohn’s Disease
IBD
Genetic +environmental factors; peaks at 15-35 yo
Mouth to anus - transmural, “Skip lesions”
Sxs:
- Colicky RLQ pain
- Diarrhea/ malabsorption
- Low grade fever
- Wt loss
- a/w anal fistulas, aphthous ulcers
Dx:
- Colonoscopy - gold
- cobblestoning
- skip lesions
- small bowel films
- string sign - barium study
- Lab - CBC, ESR, CRP, B-12, stool culture
- +ASCA
Ulcerative Colitis
IBD
Idiopathetic, inflammatory dz
Friable mucosa and submucosa, limited to colon = Rectum MC
bimodal distr - 15-25yo and 55-65
Sxs:
- Bloody, pus filled diarrhea
- LLQ pain
- fever
Dx:
- Barium enema - lead pipe appearance
-
coloscopy with bx - gold = loss of haustral markings and lumen narrowing
- risk of toxic megacolon
- pANCA
IBD Treatment
Medical Management
5-Aminosalicylates ASA
-
Mesalamine
- SE - NV, HA, rash, fever
- replace folic acid
- Sulfasalazine
Immunomodulators
-
Azothioprine/6-mercaptopurine
- maintenance therapy
- takes 3-6 mos for full effect
- can come off 5ASA
- check LFTs and CBC q 90 ds
Biologics
- TNF-inhibitors (Infliximab/Remicade, Adalimumab/Humira)
- SE - reactivate of Hep B and TB (check prior to initiation)
- expensive
Corticosteroids
- high dose, short course => acute exacerbations
- Prednisone in taper 30-40mg
Abx - for fistula
- Metronidazole
- Cipro
- Rifaximin
Infectious Diarrhea
Causes of Diarrhea - infectious, toxic, dietary, or other GI diseases
- Traveler’s Diarrhea - E coli
- Picnic and egg salad - S aureus
- Shellfish - Vibrio cholera
- Poultry or pork - Salmonella
- Pt post abx - C diff
- poorly canned home foods - C perfringens
- Breakout in a daycare center - Rotavirus
- Cruise ship - Norovirus
- Fresh mountain stream water - Giardia lamblia - foul smelling bulky stool
Infectious Esophagitis
MC in IMC hosts;
Sxs:
- Odynophagia* (painful swallowing) - food or liquid
- Dysphagia (difficult swallow)
- Chest/substernal pain/fever
Dx/Tx - EGD
-
Candida MC - linear yellow white plaques
- Fluconazole 100 mg PO QD
- HSV - shallow punched out lesions
- Acyclovir
- CMV - large solitary ulcers or erosions
- Ganciclovir
Tx - EGD dilation
Intussusception
Intestinal obstruction; part of bowel telescopes into nearby segment
MC in children 3mos to 6yo; MC a/w adenovirus
Sxs
- Severe, colicky abd pain => lethargy
- Abd mass - sausage shaped
- bilious emesis, stool with mucus or blood (currant jelly)
- decr stool if obstruction +
Dx
- abd US** gold = telescoping
Tx
- Air/Contrast enema
- Surgery if + free air under diaphragm, peritonitis, hemodynamic instability
Jaundice ddx
Bilirubin deposition = hyperbilirubinemia
1st sign - scleral icterus; serum bilirubin > 2.5mg/dl
pathophys
- RBC breakdown = globin + Heme => iron + protoporphyrin
- unconjugated bilirubin +albumin -> liver + uridine glucuronyl transferase (UGT) = conjugated bilirubin
- Conjugated BR => bile formation in GB
Eti: Unconjugated Bilirubinemia - no acholic stools, jaundice
Extravascular hemolysis, ineffective erythropoiesis
Physiological jaundice of newborn
- can lead to kernicterus, neuro deficits and death = tx w/ phototherapy
Gilbert Syndrome
- mildly low UGT increases UCB = jaundice during physio stress- fasting
Crigler-Najjar Syndrome
- RARE - toxif levels of indirect bilirubin - Jaundice at birth*
- abs of UGT = incr UCB = kernicterus
Conjugated Bilirubinemia - Direct - usu d/t obstruction, jaundince, acolic stools
Dubin-Johnson Syndrome - opps of Gilberts
- deficiency of bilirubin canaliculi = incr CB
- liver is pitch dark
- Rare benign - seen in pregnancy, etoh, OCP use
- Jewish descent
Biliary Tract Obstruction
- gall stones, pancreatic carcinoma, liver fluke, cholangiocarcinoma
Viral hepatitis
Mallory Weiss Tear
Hematemesis
Mucosal tearing of gastroesophageal junction from vomiting
Sxs:
- Hx of vomiting/retching or alcohol intake
- PainLESS hematemesis
Dx - Esophagogastroduodenoscopy (EGD)
Tx - self limited, supportive
Mesenteric Ischemia
Hypoperfusion to bowel vasculature
Sxs:
- abd pain OOP to PE
- h/x of afib, vascular dz
Dx - CT angio, treat in surgery
G6PD Deficiency
Metabolic Disorders
X linked Recessive; Hemolytic anemia d/t oxidative stress = 2-4d post exposure
Sxs:
- Patient taking antimalarials, sulfonamides, nitrofurantoin, Fava beans
- Malarial protection
Dx
- Peripheral blood smear - Heinz bodies
- Results in bite cells
Tx
- self limited, maintain hydration
- severe anemia - iron/folic acid supp
Paget Disease of Bone (Osteitis Deformans)
Metabolic Disorders
Incr in osteocastic activity, then incr in osteoblastic activity
Sxs
- Asymp MC
- arthritis, pain = vertebral involvement => stenosis, nerve compression
- bone deformity, fracture
Dx
- ele alk phos; normal Ca, Normal phosphorus
- X-ray - bone thickening, enlarge thickened cortices**
Tx
- Bisphosphonates
Phenylketonuria (PKU)
Metabolic Disorders
MC autosomal recessive; lack of amino acid phenylalamine hydroxylase protein to convert into Tyrosine
Newborn screening 2-3 days after birth
Sxs
- musty urine or body odor, microcephaly
- mental or growth retardation
Dx
- decr phenylalanine hydroxylase => incr phenylalanine and decr tyrosine
Tx
- Avoid phenylalanine in diet = no beef, pork, chicken
- limit carb
- Lots of fruits and vegetables - tyrosine
- Nutritional supplements
Rickets
Metabolic Disorders
Softening and weakening of bones d/t lack of Vitamin D; defective mineralization of cartilage in epiphyseal growth plates
MCC- insufficient intestinal absorption
RFs - little sun exposure, darker pigmente skin, BF’ing w/o vit D supplementation
Sxs
- Bowed legs, stunted growth, bone pain
- Large forehead, trouble sleeping
- Bone frx, muscle spasms, abn curved spine or intellectual disability
Dx
- AP Radiographs of Knees and Wrist - Osteopenia, metaphyseal cupping, distal physis widened
- Labs - ↓ 25-hydroxyvitamin D,
- ↓ calcium, ↓ phosphate
- ↑ alkaline phosphatase, ↑ parathyroid hormone levels
Tx
- Vitamin D supplementation = maintain target of > 20 ng/mL
- Breastfed infants = 400 IU or 10 mcg daily of Vit D supp, few days after birth
- Children 1-18 yo = 600 IU or 15 mcg daily
Non-Infectious Esophagitis
- Reflux Esophagitis
- mechanical or functional abn from LES - refer to GERD
- Medication induced
- Usu NSAIDs or bisphosphonates - drink 4oz of water, sit upright
- Eosinophilic - allergic eosinophilic infiltration of esophageal epithelium
- dx w/ Barium swallow = ribbed esophagus and multiple corrugated rings
Obstipation ddx
Bowel Obstruction - small and large
Small Bowel Intussusception
Ileus
Gastroparesis
- condition that affects stomach muscles, prevents proper emptying
- MCC - DM, anorexia/bulimia, scleroderma, Ehlers-Danlos, abd surgery
- N, early satiety, palps, HB, bloating
- Dx - KUB, manometry, gastric emptying scan
- Tx - Lower fiber and low residue diet, small meals
- Metoclopramide
Pancreatic Carcinoma
MCC smoking*, chronic pancreatitis, ETOH, DM, M, obesity, AA
Adenocarcinoma - ductal, and head of pancreas MC
Sxs:
- MC metasis at dx - regional LN or liver
- Abd pain => back
- painless jaundice* classic - 2/2 common bile duct obstruction
- Wt loss
- Pruritis - incr bile salts, acholic stools/dark urine
- Courvoisier’s sign - palpable, NT, distended GB a/w jaundice
Dx
- CT scan - initial TOC
- CA 19-9 tumor markers
Tx
- Whipple procedure
- Advanced or inoperative
- ERCP w/ palliative stent for itching
Pancreatic Pseudocyst
Cystic collection of tissue, fluid, & necrotic debris surrounding the pancreas. Wall is from inflammatory fibrosis, not epithelial lining
a/w - chronic pancreatitis, occurs 2-3 wks after acute pancreatitis, trauma to chest (steering wheel trauma)
Sxs
- Abdominal pain
- hx of chronic pancreatitis
Dx
- CT** - TOC
- US
- elevated amylase/lipase
- Bilirubin, CBC
Tx
- if persists 4-6 wks, or enlarges
- Percutaneous drainage > 5cm
- Surgical decompression - pancreaticogastrostomy
- Cystic fluid - drained into stomach or bowel
Peptic Ulcer Disease
eti, sxs, dx, tx
MCC of non hemorrhagic GI bleeds
Duodenal 5x > Gastric; MCC H pylori > NSAIDs, ETOH, smoking
Sxs:
-
Gastric Ulcers
- abd pain worse with meals - get better after eating
- patient refuses to eat (losing weight)
-
Duodenal Ulcers
- Pain gets better with eating - worse after eating
- Patient gaining weight
- hemorrhage from gastroduodenal artery
- MC than gastric ulcer*
Dx
- Endoscopy* - gold
Tx
- PPI qd-BID x 8 to 12 weeks; confirm EGD w/ gastric ulcer healing
Pyloric Stenosis
Hypertrophy and hyperplasia of muscular layers of pylorus = functional outlet obstruction
Infants, first 2-3 wks of life or < 3mos
Sxs
- projectile vomiting
- non bilious after every feed
- DeH2O - hypochloremic, hypokalemia, metabolic alkalosis
- palpable olive mass in epigastric region
Dx
- US - double track sign
- Barium study - string sign
Tx
- IV fluids rehydration
- Pyloromyotomy - Ramstedt procedure
Small Bowel Carcinoma
Rare, delay in dx common
MC adenocarcinoma, highest in duodenum.; RF - hereditary nonpolyposis colorectal ca, CF, Crohns
Sxs:
- Abdominal pain - intermittent and crampy
- N/V, wt loss, jaundice, Anemia
- Obstruction > perforation
Dx
- CT
- Screen for FOBT, LFTs, CBC
- some +CEA
Tx
- Surgery - localized
- Adjuvant chemo for LN+
Toxic Megacolon
Non obstructive, extreme colonic dilation > 6cm + signs of systemic toxicity
Eti - Crohns, UC, infection, radiation
Sxs:
- fever, abd pain, N/V
- tenesmus
- rigidity, tachycardia, dehydration, hypotension, AMS
Dx
- Abd radiographs - large dilated colon > 6cm
- 3 of the following
- Fever > 101.5
- HR > 120 bpm
- Neutrophilic leukocytosis >10.5 x 10^9
- Anemia
Tx
- bowel decompression
- Bowel Rest, NG tube, broad spectrum abx
- Colostomy reserved for refractory cases
Zenker’s Diverticulum
False outpouching in posterior hypopharynx - uncoordinated swallow/occlusive ep
Sxs
- Dysphagia, choking, cough, halitosis**
- aspiration, regurgitation of undigested food
- aspiration pna or bronchiectasis
Dx
- Barium esophagram
- EGD - Contrast CT of neck
Tx
- Surgical if severe
Zollinger-Ellison Syndrome
PUD ddx
Gastrinoma of pancreas* or duodenum
PUD develops in 90% of pts
Consider if
- Recurrent PUD
- Neg H. pylori, Neg NSAID/ASA use
- Severe abd pain, diarrhea
Dx
- secretin test => gastrin level will rise
Tx
- Surgical resection of gastrinoma
