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Amboss > Gastrointestinal System > Flashcards

Gastrointestinal System Flashcards

1
Q

Primary biliary cirrhosis/cholangitis (PBC)

A

DEF.

  1. Is a chronic cholangitis ( autoimmune liver disease)
  2. Affects women 35-60 years
  3. Leads to liver cirrhosis & cholestasis in later stages

Sign/symptoms:

  1. Extensive pruritus
  2. Fatigue
  3. Elevated cholestatic parameters (bilirubin, alkaline phosphate, gamma-glutamyl transferase)
  4. Normal transaminase

Symptoms of:
1. Cholestasis (jaundice, pale stools, dark urine, pruritus, and symptoms of fat malabsorption (e.g., steatorrhea, weight loss)

Investigation:

  1. Elevated conjugated bilirubin
  2. Elevated gamma-GT
  3. Elevated alkaline phosphatase (
  4. Normal Transaminase (ALT & AST)

Diagnosis:

  1. Positive Anti-mitochondrial antibodies (AMA)
  2. Positive Anti-nuclear antibody (ANA)

Treatment:
1st line: Ursodeoxycholic acid (bile acid) : slow down disease progression/ relief from itching

2nd line: obeticholic acid: slow down disease progression, but has more adverse effects

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2
Q

Hepatitis A

A

Def:
1. Acute viral hepatitis, caused by Hepatitis A virus (HAV)
2. Transmitted via oral-fecal route, by ingestion of raw shellfish
3. Acute liver inflammation
4. Acute Infection (within a week) (fever, elevated transaminase & unconjugated bilirubin)
5

Signs/symptoms:

  1. Stomach flu (prodormal phase)
  2. Scleral icterus + dark urine + pale stool (signs of cholestasis)
  3. Fever
  4. Elevated unconjugated bilirubin
  5. Elevated transaminase

Diagnosed:
1. Anti-HAV IgM

Note:
If Anti-HAV IgG is detected = former infection or past vaccination against HAV

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3
Q

Primary sclerosing cholangitis (PSC)

A

Def:

  1. Progressive inflammation of the intrahepatic & extrahepatic bile ducts
  2. Autoimmune disease
  3. Associated with ulcerative colitis (IBD)

Signs:

  1. Asymptomatic
  2. Later stage (cholestasis & cirrhosis)
  3. Elevated alkaline phosphatase

Diagnosis:
1. P-ANCA

Signs of cholestasis:

  1. Jaundice
  2. Dark urine
  3. Pale stool
  4. Nausea
  5. Pruritus
  6. Fatigue
  7. Abdominal pain
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4
Q

Staphylococcus aureus

A
  1. Common cause of food poisoning within 1-8 hours of eating (eggs, mayonnaise, diary products, coleslaw)
  2. Signs: N/V & abdominal pain & no fever & no diarrhea
  3. Resolved 24-48 hours with no antibiotics
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5
Q

Campylobacter jejuni

A
  1. Common cause of bacterial diarrhea (in the USA)
  2. Commonly affects children & leads to bloody diarrhea
  3. Transmitted by food or contact animals (puppies)
  4. Incubation period = 2 days
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6
Q

Bacillus cereus

A
  1. Heated rice is common source of infection
  2. Pathogen is heat-stable & produce enterotoxin 1 (emetic form)
  3. N/V occurs within 30 min-6 hours after ingestion
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7
Q

Yersinia enterocolitica

A
  1. Common cause of inflammatory diarrhea ( maybe bloody in severe cases)
  2. After ingestion of contaminated milk or pork
  3. Causes N/V & abdominal pain ( RLQ = mimic appendicitis = psuedoappendicitis)
  4. Incubation period = 2 days
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8
Q

E.Coli (enterohemorrhagic) (EHEC)

A
  1. Common cause of bloody diarrhea due to verotoxin/ shiga-like toxin
  2. N/V
  3. Affects newborn, healthy adults, & elderly
  4. Ingestion of contaminated food ( raw beef, vegetable, milk)
  5. Incubation period = 2-10 days
  6. If toxin becomes systemic = hemolytic uremic syndrome (HUS) occurs
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9
Q

Entamoeba histolytica

A
  1. Causes intestinal amebiasis (loose stools containing mucus & bright red blood, painful defecation, abdominal pain, cramps, anorexia, fever)
  2. Long incubation period = 1-4 weeks
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10
Q

Salmonella enteritidis

A
  1. Causes high-grade fever, severe vomiting & inflammatory (watery-bloody) diarrhea
  2. Ingestion of contaminated food ( poultry, poorly pasteurized eggs, milk)
  3. Incubation period = 6-48 hours
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11
Q

Enterotoxigenic E.coli (ETEC)

A
  1. Common cause of traveller diarrhea
  2. Produce heat-liable & heat-stable enterotoxin
  3. Causes diffused watery diarrhea, abdominal cramping, N/V
  4. Incubation period = 9 hr-3 days
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12
Q

Shigella dysenteriae

A
  1. Enters the GI tract, leading to inflammation, mucosal damage, & bloody diarrhea
  2. Incubation period = 1-3 days
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13
Q

Vibrio parahaemolyticus

A
  1. Causes food-brone illness
  2. Occurs 16-72 hours after eating contaminated seafood
  3. Common in japan
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14
Q

Amebias

A
  1. Caused by protozoan entamoeba histolytica
  2. Occurs via fecal-oral route (via contaminated water) in endemic region ( Mexico, southeast Asia, India)
  3. Lead to: intestinal disease (bloody diarrhea) & extra-intestinal disease (amebic liver abscess; shows leukocytosis without eosinophilia, transaminitis, & elevated alkaline phosphatase )
  4. Incubation period = 1-4 weeks, but can take weeks-years for extra-intestinal disease to manifest
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15
Q

Hepatic hydated cyst

A

Signs:

  1. RUQ pain (no fever)
  2. Pruritus
  3. Urticaria
  4. +/- anaphylaxis (only if cyst leaks or rupture)

Diagnosis:
1. Ultrasonography shows daughter cysts +/- echogenic hydatid sand within the main cyst.

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16
Q

Liver hemangioma

A
  1. Most common benign lesion of the liver
  2. Asymptomatic
  3. Seen in women ( 30-50 yrs)
  4. Hyper-echoic on Ultrasonography
  5. Large hemangioma can lead to abdominal discomfort, Nausea, early satiety
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17
Q

Pyogenic liver abscess

A
  1. Common in (> 50) years patients
  2. Patient have underlying bowel disease, intra-abdominal infection +/- history of recent surgery.

Signs:

  1. RUQ pain
  2. Fever
  3. N/V
  4. Leukocytosis
  5. Focal hypo-echoic lesion (in the right lobe of liver)
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18
Q

Hepatocellular carcinoma

A
  1. Usually occurs in patient with chronic liver disease (cirrhosis, hepatitis B or C, hemochromatosis, alcoholic cirrhosis, & non-alcoholic fatty liver disease)
  2. Shows hypo-echoic lesion on US
  3. Associated with RUQ pain
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19
Q

Liver cirrhosis

A

Sign:

  1. Jaundice
  2. Weight loss
  3. Splenomegaly
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20
Q

Abdominal CT scan with contrast

A

To diagnose:
1. Abdominal aneurysm
2. Acute appendicitis
Abdominal tumor

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21
Q

IV octreotide

A
  1. Bleeding secondary to esophageal varices, complication of liver cirrhosis (can cause tarry stool)
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22
Q

Diagnostic laparoscopy

A
  1. Indicated for unexplained abdominal pain
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23
Q

Colonoscopy

A
  1. Diagnose Lower GI bleeding & screen for colorectal cancer ( sign: hematochezia)
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24
Q

Flexible sigmoidoscopy

A
  1. Screen for colorectal cancer & lower GI bleeding
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25
Q

Esophagogastroduodenoscopy (ECG)

A
  1. Indicated for Upper GI bleed
  2. Hemostatic intervention (cauterization, epinephrine injection)
  3. Severe hemorrhagic secondary to PUD = IV PPI &blood transfusions
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26
Q

UGI Bleed

A

Tarry bowel movements and abdominal pain are consistent with upper GI bleeding (UGIB), likely arising as a complication of peptic ulcer disease (PUD) from NSAID use. Hypotension and tachycardia indicate the development of hypovolemic shock.

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27
Q

Liver abscess

A

This patient’s right upper quadrant (RUQ) abdominal pain and fever in combination with a hypoechoic lesion in the right hepatic lobe are suggestive of a liver abscess.

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28
Q

Iatrogenic esophageal perforation

A

patient presents with chest pain, tachycardia, tachypnea, and crepitus over the chest (mediastinal emphysema) one day after an endoscopic procedure.

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29
Q

Metronidazole (or tinidazole)

A
  1. Metronidazole (or tinidazole) is considered the first-line treatment to eradicate invasive trophozoites in patients with symptomatic intestinal amebiasis (amebic dysentery) and extraintestinal amebiasis (e.g., amebic liver abscess). Following treatment with metronidazole or tinidazole, patients should also receive an intraluminal amebicide (e.g., paromomycin) to eradicate intestinal cysts and prevent relapse.

In travelers with asymptomatic infection, treatment with luminal agents is usually sufficient. Individuals from endemic areas with asymptomatic infection do not require treatment

  1. Metronidazole is indicated for giardiasis and is common in Southeast Asia. However, the incubation period is 7–14 days.
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30
Q

Erythromycin

A

Erythromycin is a macrolide antibiotic that may be considered for the treatment of fluoroquinolone-resistant Campylobacter jejuni. Infections with Campylobacter cause inflammatory diarrhea with blood-tinged stools and fever.

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31
Q

Iron supplementation

A

Iron supplementation can result in dark stools, which may be mistaken for melena. Melena (black, tarry stools) occurs as a result of upper gastrointestinal bleeding. Since this patient has stools that are blood-tinged rather than tar-like, the site of blood loss is most likely the lower GI tract.

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32
Q

Albendazole

A

Albendazole is used to treat nematode infections and certain cestode infections (e.g., cysticercosis, echinococcosis). Although patients with intestinal helminthic infections can present with abdominal pain and/or blood in stools. Albendazole is not effective against protozoa such as Entamoeba histolytica.

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33
Q

Praziquantel

A

Praziquantel is used to treat most trematode infections (e.g., schistosomiasis, clonorchiasis) and certain cestode infections (e.g., taeniasis). Intestinal taeniasis, clonorchiasis, and certain forms of schistosomiasis (Schistosoma japonicum, Schistosoma mansoni) are diagnosed by the presence of eggs in feces.

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34
Q

Doxycycline

A

Doxycycline is the treatment of choice for diarrhea due to cholera. However, patients with cholera have frequent, voluminous “rice water” stools, are often severely dehydrated, and are usually febrile.

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35
Q

Trimethoprim-sulfamethoxazole (TMP-SMX)

A
  1. TMP-SMX is not the treatment of choice for intestinal amebiasis. Instead, it is used in the treatment of diarrhea due to cyclosporiasis. Diarrhea in patients with cyclosporiasis is typically watery and nonbloody, and stool microscopy reveals acid-fast oocysts instead of hematogenous trophozoites.
  2. TMP-SMX is used to treat Whipple’s disease, which has a highly variable presentation but commonly manifests with diarrhea and gastrointestinal symptoms. Whipple’s disease, however, typically involves extraintestinal symptoms such as arthritis and is not associated with a positive IgA TTGA.
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36
Q

Pilonidal sinus surgery

A

Def:

  1. A small hole or tunnel in the skin at the top of the buttocks (where they divide).
  2. Does not cause symptoms (maybe, discomfort and irritation around the tailbone), but can lead to infection (infection—> abscess —> draining pus through the sinus) if left untreated.
  3. The abscess leads to pain, foul smell, & drainage
  4. Treatment: abscess drainage or sinus removal.
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37
Q

Anal fissure

A

Def:
1. A small tear in the mucosa that lines the anus.

Sign/symptoms:

  1. Extreme pain & discomfort around the anus
  2. Inability to sit
  3. Inability to defecate due to extreme pain

Initial treatment:

(purpose: reduce anal sphincter tone & promote mucosal healing, by increasing blood flow to the anal mucosa)
1. Sitz bath
2. Topical therapy with calcium channel blockers (nifedipine, diltiazem)

Refractory to conservative therapy:

  1. Botulinum toxin injection (relaxes the hypertonic anal sphincter, not a first line treatment)
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38
Q

Anal fistula

A

Def:

  1. Abnormal tunnel under the skin that connects the anal canal in the colon to the skin of the buttocks.
  2. Can be caused after a surgery or by IBD ( Crohn’s disease or ulcerative colitis)

Signs:

  1. Bloody stool
  2. Rectal pain
  3. Malodorous perianal discharge

Treatment:
1. Tract curettage ( also, used in treatment of pilonidal disease and hidradenitis suppurativa )

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39
Q

Colorectal cancer

A

Sign/symptoms:

  1. Bloody stool
  2. Weight loss
  3. Constipation
  4. Reduction in stool caliber

Treatment:
1. Colonoscopy ( every 10 years, if family history is positive, or 10 years before the age of diagnosis of the fist relative)

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40
Q

Anorectal abscess

A

Def:
1. Pus-filled cavity developed after obstruction & bacterial overgrowth.

Sign/symptoms:

  1. Pain on defecation
  2. No bloody stool
  3. Purulent perianal discharge

Complication: can develop into anal fistula (chronic manifistation)

Treatment:
1. Combination of Metronidazole & ciprofloxacin

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41
Q

Abdominal ultrasound

A
  1. Used for diagnosis of appendicitis in children & pregnant women
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42
Q

Appendicitis

A

Sign/symptoms:

  1. Low-grade fever
  2. Elevated WBC ( leukocytosis)
  3. Migrating abdominal pain
  4. RLQ pain- tenderness
  5. Rebound pain

Finding on US:

  1. Non-compressible & distended appendix (> 6-8 mm)
  2. Fluid around the appendix
  3. Target sign
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43
Q

Volvulus

A

Def:
1. Twisting of an intraperitoneal loop of intestine around its mesentery.

Sign/symptoms:

  1. Vomiting
  2. Abdominal pain & distention
  3. Bowel obstruction (abdominal tenderness)
  4. Bloody stool in infant
  5. Hemodynamic instability

Diagnosis:
1. Upper GI series

Treatment:
1. Surgery

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44
Q

Cyclical vomiting syndrome

A

Def:
1. Recurrent, self limited episode of vomiting (bilious or non-bilious) associated with psychological stressors

Sign/symptoms:

  1. Recurrent, self-limited vomiting
  2. Abdominal pain (hours to days)
  3. Absence of symptoms between episodes
45
Q

Gastroenteritis

A

Sign/symptoms:

  1. Diarrhea
  2. Maybe, vomiting
  3. Self limited (3-7 days)
46
Q

Hypertrophic pyloric stenosis

A

Def:

  1. Vomiting causes dehydration (dry mucous membrane) with loss of HCl & KCl
  2. Hypovolemia = secretes Aldosterone = worsen Hypokalemia = causes paradoxical aciduria = & contraction alkalosis

Sign/symptoms:

  1. Newborn infants (less than 6 weeks of age)
  2. Non-bilious Projectile vomiting after feeding
  3. Palpable abdominal mass “ olive-shaped”
  4. If left untreated, will lead to dehydration, weight loss, failure to thrive

Laboratory:

  1. Hypokalemia
  2. Hypochloremic metabolic alkalosis

Initial treatment:

  1. IV-fluid therapy with 0.9% NaCl (adequate rehydration & correction of electrolyte imbalance)
  2. Surgery: Ramstedt pyloromyotomy
47
Q

Gastroesophageal reflux disease (GERD)

A

Sign/symptoms:

  1. Common in children
  2. Heartburn
  3. Regurgitation
48
Q

Acute intermittent porphyria (AIP)

A

Sign/symptoms:

  1. Life-threatening
  2. Intermittent episode of abdominal pain
  3. Tachycardia
  4. Hypertension
  5. Neuropathy
  6. Red urine ( wine-like)
49
Q

Hepatitis C virus

A

Def:

  1. Acute liver inflammation
  2. Acute infection

Caused by:
1. History of IV-Drug use

Sign/symptoms:

  1. Fatigue
  2. Jaundice
  3. Hepatomegaly
  4. History of past IV-drug use

Screening:
1. Hepatitis C antibody test (positive in active, chronic or previous infection)

Diagnosis:
1. PCR for hepatitis C virus RNA

Complication:
1. Porphyria Cutanea Tarda (PCT): common extra-hepatic manifestation of chronic hepatitis C (shows erosions/blisters at the dorsum of hand)

Treatment: (chronic HCV)
1. Combination of direct-acting antiviral ( ledipasvir & sofosbuvir)

50
Q

Viral hepatitis or cirrhosis

A

Triad of:

  1. Fatigue
  2. Jaundice
  3. Hepatomegaly
51
Q

Functional constipation

A
  1. Common cause of abdominal pain in children (who begin toilet training or those who start going to school)
  2. Treatment:
    1st: Oral osmotic laxative (poly-ethyelene glycol)
    2nd: enema
  3. Early treatment prevents fecal impaction (seen with U/S)
52
Q

Intussusception

A
  1. Common in children less than 2 years of age
  2. Happens when the ileum folds into the cecum
  3. Signs:
    * Colicky abdominal pain lasts 15-20 min
    * non-bilious vomiting
    * currant jelly stool (reddish mucoid stool)
    * palpable mass at RLQ
    * U/S shows: target sign at site of intussusception
    * ** “grabs his abdomen & draws up his legs”***
  • mechanical bowel obstruction (constipation & hyperactive bowel sounds)
    3. Treat with: barium enema (perform air enema on the infant)
53
Q

Empirical antibiotic treatment

A

Indicated in case of:

  1. Acute appendicitis (RLQ pain, N/V, fever, leukocytosis, U/S dilated non-compressible appendicitis, peri-appendiceal fluid collection)
  2. Acute dysentery ( blood in stool & diarrhea) (caused by shigella or entaemoba histolytica)
54
Q

Peritonitis

A

Signs:

  1. Extremely ill patient
  2. Hypoactive bowel sound
  3. Usually lie still ( not restless)
  4. Rebound tenderness & guarding
  5. Tachycardia
  6. Hypotension
55
Q

Shell-food (seafood) poisoning

A
  1. Vibrio cholera
  2. Vibro parahaemolyticus (fever, abdominal cramps, vomiting, watery diarrhea within 12-52 hours)
  3. Hepatitis A virus
  4. Hepatitis E virus
  5. Norovirus
  6. Paragonimus
56
Q

C. Difficile infection

A

Signs:

  1. Can occur following antibiotic use
  2. Watery, foul smelling stool, occasionally streaked with blood
  3. Leukocytosis
  4. Mild diffused tenderness through Lower abdominal quadrants (inflamed colon)

Diagnosis:

  1. Stool toxin test: PCR is used to detect C.difficile toxin gene in stool sample
  2. Enzyme immunoassay (EIA): detect glutamate dehydrogenase (GDH), toxin A, or Toxin B.
57
Q

Food-protein-induced proctocolitis (diet-associated colitis)

A
  1. Presence of blood-tinged stool & mucus in new born baby
  2. No sign of obstruction (vomiting, diarrhea, fever, hypotension)
  3. Treat: continue breastfeeding & advise mother to avoid diary & soy products
  4. Rectal bleeding resolve within 3 days of removal of offending food antigen
  5. The baby will be able to tolerate the offending antigen if introduced again when they are 1 year old
58
Q

Celiac disease (CD)

A

Def:
1. Can manifest in infancy, but usually 8-12 months of age (2-3 months after introduction of gluten to the diet)

Sign/symptoms:
1. Steatorrhea
2. Signs of Malabsorption (vitamin deficiency, anemia, failure to thrive)
3. No GI bleeding
4. Pruritic vesicles in both elbow & knee (dermatitis herpetiformis)
Diagnose:
1. IgA anti-tissue Transglutaminase antibody

59
Q

H.pylori

A
  1. Detected by stool antigen immunoassay
  2. Associated with peptic ulcer disease, manifest later in life with: abdominal pain worsen with eating, GI bleeding, vomiting.
60
Q

Necrotizing enterocolitis

A

Sign: (in preterm-premature infants)

  1. Abdominal distention
  2. Blood-tinged stool
  3. Systemic signs of illness (vomiting, diarrhea, fever, hypotension)
  4. Feeding intolerance

Diagnosis:
1. Abdominal X-ray shows: Pneumatosis intestinalis (gas within the wall of intestine)

Treatment:
1. Administer a broad-spectrum parental antibiotics (combination of ampicillin, tobramycin, & metronidazole)

Note:
1. preterm infant presents with poor feeding, vomiting, lethargy, peritonitis on examination, thrombocytopenia, and metabolic acidosis, all of which are consistent with the diagnosis of severe necrotizing enterocolitis (NEC). An x-ray showing bubbles of gas within intestinal wall (pneumatosis intestinalis) confirms the diagnosis.

  1. Surgical intervention (Exploratory laparotomy) for NEC is warranted when there is evidence of peritonitis (concerning for gangrenous bowel), perforation (pneumoperitoneum on x-ray), metabolic acidosis, elevated lactate, and/or portal venous gas on x-ray. The severity of this patient’s symptoms warrants emergency exploratory laparotomy and will likely include removal of necrotic portions of the bowel.
61
Q

Inflammatory Bowel syndrome (IBS)

A
  1. The combination of recurrent episodes of abdominal pain with varying location and intensity that are exacerbated by emotional stress, altered bowel habits (change in stool frequency and form), and normal physical examination and laboratory studies (e.g., hemoglobin, ESR) are suggestive of irritable bowel syndrome (IBS), which is most commonly seen in individuals aged 20–39 years.
  2. Relief of abdominal pain after defecation is often seen in patients with IBS, which is a common chronic gastrointestinal disease with an unknown underlying pathophysiology. In some patients, pain may increase upon defecation or remain unchanged. In the absence of red flag symptoms (e.g., nighttime pain, blood in the stool, weight loss, fever), diagnosis of IBS is based on the Rome IV criteria. Treatment includes regular consultations and reassurance that the disease, although chronic, is benign; dietary adjustments (e.g., avoidance of gas‑producing foods); physical activity; stress management; and possibly psychological therapy.
  3. In patients with suspected IBS and the predominant symptom of diarrhea, additional testing should be considered, e.g., fecal calprotectin or fecal lactoferrin, stool antigen test for Giardia lamblia, serological celiac disease testing, and CRP levels.
62
Q

Inflammatory bowel disease (IBD)

A
  1. classic symptoms associated with either Crohn’s disease (abdominal pain due to perianal abscesses/fistulas) or ulcerative colitis (bloody stool).

Diagnosed by:
1. Fecal calprotectin concentration: (neutrophil secretes calprotectin after migration to acute inflammatory site; concentration correspond to severity of inflammation)

  1. Fecal lactoferrin concentration (secreted by active neutrophil in response to acute inflammation; concentration correspond to severity of inflammation)

Treat with:
1. Sulfasalazine is a first-line therapy for inflammatory bowel disease (IBD).

63
Q

C-reactive protein (CRP)

A
  1. Not specific

2. Increases about 6–12 hours after the inflammatory process begins.

64
Q

Duodenal peptic ulcer (DPU)

A

epigastric abdominal pain especially at night, GI bleeding, vomiting, dyspepsia, anemia, pain relieved by eating.

65
Q

B-symptoms

A

Associated with:
1. Increased CRP & cytokines (IL-6)
Signs:

  1. Fever
  2. Drenching Night sweat
  3. Weight loss (> 10% over 6 months)
66
Q

Unintentional Weight loss with history of chronic GI symptoms

A

Associated with:

  1. Celiac disease (anemia, steatorrhea, positive IgA tissue transglutaminase antibody test)
  2. Peptic ulcer disease (PUD) ( dyspepsia, anemia, pain typically worsened by eating)
  3. IBD (crohn’s disease or ulcerative colitis) (elevated ESR, extra-intestinal manifistation)
67
Q

Meckel diverticulum

A
  1. An outpouching of the ileal bowel wall that results from a remnant of the embryological omphalomesenteric duct (vitelline duct).
  2. Common in males
  3. Rule of 2: 2% of population, 2 feet away from ileocecal, presents at 2 years of age.

Signs:

  1. Asymptomatic
  2. Symptomatic:
    * hematochezia (bright-red blood in stool)

Complication:

  1. Intussusception
  2. Ulceration
  3. Hemorrhage
  4. Intestinal obstruction

Diagnosis:
1. Technetium-99m pertechnetate scan

68
Q

Hydated cyst disease (HCD)

A

Caused by:

  1. Ingestion of Echinococcosis (shed in feces of dogs)
  2. Affects liver & lungs

Symptoms:

  1. RUQ pain, N/V, close contact with a dog, eosinophilia, and focal cyst within the liver.
  2. The contents of a hydatid cyst are highly antigenic.

Treatment:

  1. Oral albendazole (for 1-6 months) (CBC should be performed before treatment, and every 2-weeks to avoid leukopenia)
  2. Cysts larger than 5 cm requires surgery-excision or CT-guided PAIR ( Puncture, aspiration, injection, re-aspiration) + medical therapy.

*** PAIR can lead to anaphylaxis ( tachycardia, hypotension, decrease O2 saturation, & severe bronchospasm) due to leakage of highly antigenic cystic fluid into blood or peritoneal cavity

*** PAIR = percutaneous draining of a hepatic cyst.

Signs:

  1. Intermittent abdominal pain & fullness
  2. Pain extends from epigastrium to RUQ
  3. Episode lasts 2 hours
  4. Not worsen by food
  5. Severe N/V (multiple episodes of vomiting) for few days
  6. Works with animals (shelters)
  7. Smooth & palpable mass below right costal margin
  8. X-ray shows: unilocular cyst 4 cm in diameter with daughter cysts within the liver
  9. Absent of fever & leukocytosis
69
Q

Pyogenic liver abscess vs amebic liver abscess

A

Pyogenic liver abscess

  1. Older patients
  2. Affect both male/female
  3. Left shift on WBC count
  4. Elevated bilirubin
  5. History of diabetes & gallstones
  6. Caused by anaerobic bacteria (bacteroids)
  7. Symptoms: RUQ pain, fever, leukocytosis, & a cystic lesion on U/S
  8. Treat with: IV clindamycin

amebic liver abscess

  1. Younger patients
  2. Affects male
  3. Absent of left shift of WBC count
  4. Normal bilirubin
  5. History of traveling to endemic area
70
Q

Hepatocellular carcinoma

A
  1. Occurs in people with chronic liver disease
  2. Signs: hepatomegaly, RUQ pain, N/V, presence of cystic lesion within the liver
  3. Treat with: IV- doxorubicin
71
Q

Endoscopic retrograde cholangiopancreatography (ERCP)

A

To diagnose:

  1. Choledocholithiasis
  2. Cholangitis
  • presence of dilated biliary tree
72
Q

Turner syndrome is associated with celiac disease

A

Signs of celiac disease:

  1. Diarrhea
  2. Abdominal bloating
  3. Sign of iron deficiency anemia ( fatigue, pale conjunctivae, angular stomatitis)
  4. Positive IgA tissue transglutaminase antibody

Treat with:

  1. Gluten-free diet (1st)
  2. Biopsy (2nd)
73
Q

Whipple’s disease

A
  1. infectious disease caused by the bacterium Tropheryma whipplei
  2. Difficult to diagnose
  3. Signs:
    * Early (weight loss & migratory/non-deforming arthritis)
    * Late (chronic malabsorption diarrhea)
  4. Treat with: Trimethoprim-sulfamethaxazole therapy (TMP-SMX)
74
Q

Anaphylaxis

A

Sign:

  1. Tachycardia
  2. Hypotension
  3. Decrease oxygen saturation
  4. Severe bronchospasm (sudden decrease in end-tidal CO2 & absent of breath sounds)

Treat with:
1. Epinephrine

75
Q

Pneumothorax

A
  1. Loss of negative pressure between visceral and parietal pleural membranes that occurs when air abnormally enters the pleural space.

Sign:
1. pleuritic chest pain, dyspnea (SOB), tachycardia, and reduced breath sounds on the ipsilateral side.

76
Q

SOB & pleuritic chest pain

A
  1. Shortness of breath and pleuritic chest pain may suggest pulmonary embolism, pneumonia, or pneumothorax.
  2. Pleuritic chest pain that is worse when the person is lying on their back compared with when they are upright may indicate pericarditis.
77
Q

Hemothorax

A
  1. The presence of blood in the pleural cavity.
  2. Presents with diminished breath sounds and hyporesonant chest percussion.
  3. Usually the result of chest trauma
78
Q

Pneumothorax & hemothorax

A
  1. present with hypoxemia, tachycardia, and decreased breath sounds on the ipsilateral side
  2. Use chest tube insertion (4th intercostal anterior axillary - skin incision 1 ICS below)
79
Q

Chest tube insertion

A

4th intercostal anterior axillary (skin incision 1 ICS. Below)

80
Q

Pulmonary embolism

A
  1. An obstruction of the pulmonary artery and/or one of its branches by a thrombus that most commonly originates from the deep vein system in the legs or pelvis and embolizes to the lungs via the inferior vena cava.
  2. Less commonly, the cause of obstruction is a fat or air embolus.
  3. Risk factors include stasis (e.g., immobility, surgery), hypercoagulable states (e.g., pregnancy and the puerperium), and endothelial dysfunction (e.g., trauma).
  4. Sign: tachycardia, hypotension, decrease in end tidal CO2 (breath sound is not affected)
  5. Treat with: Norepinephrine ( inotropic support for patient with cardiogenic shock)
81
Q

Polyhydramnios

A

An excess of amniotic fluid (> 1.5 to 2 L) during gestation, as a result of either increased production or decreased resorption. Can be due to fetal gastrointestinal abnormalities (e.g., esophageal or duodenal atresia), impaired swallowing (e.g., anencephaly), or associated with maternal factors such as diabetes mellitus, infection, or Rh incompatibility.

82
Q

Amniotic fluid index (AFI)

A

Abbreviation: AFI

  1. A semi-quantitative estimate of amniotic fluid volume measured antenatally via ultrasonography of a pregnant uterus.
  2. It is part of the biophysical profile. An AFI between 8-18 = normal, AFI ≤5 cm = oligohydramnios, AFI ≥24 cm = polyhydramnios.
83
Q

Polyhydramnios

A

An excess of amniotic fluid (> 1.5 to 2 L) during gestation, as a result of either increased production or decreased resorption. Can be due to fetal gastrointestinal abnormalities (e.g., esophageal or duodenal atresia), impaired swallowing (e.g., anencephaly), or associated with maternal factors such as diabetes mellitus, infection, or Rh incompatibility.

84
Q

Esophageal atresia

A

Sign:

  1. Unable to swallow during prenatal period (explains polyhydramnios)
  2. Coughing spells
  3. Drooling
  4. Foaming at the mouth
  5. Episode of cyanosis ( at lips & mucosa) that does not resolve when the infant cries !!
85
Q

Esophageal stricture

A
  1. Esophageal stenosis (narrowing)

Sign:

  1. usually not apparent at birth and only becomes apparent through dysphagia and regurgitation once the infant begins feeding with solid foods (i.e. around the weaning period).
  2. t does not affect the airways and does not cause cyanotic attacks.
86
Q

Achalasia

A
  1. Achalasia is very rare in infants and occurs most commonly in middle-aged individuals.
  2. It causes dysphagia and regurgitation. Moreover, because it does not primarily affect the airways, it does not cause cyanosis.
  3. Patients with achalasia are prone to developing respiratory symptoms if aspiration pneumonia develops as a sequela.
87
Q

Pulmonary hypoplasia

A
  1. commonly presents with cyanosis in newborns, but it does not cause coughing spells or drooling and it is associated with oligohydramnios, not polyhydramnios.
88
Q

Hemorrhoids

A

Types:

  1. Internal hemorrhoids: originate above dentate line & causes bleeding
  2. External hemorrhoids: originate below dentate line and causes pain

Treatment:

1st: conservative treatment ( grade 1/2 internal & external hemorrhoids)

  1. Stool softeners (docusate & topical/suppository lidocaine if painful)
  2. Sitz baths & lifestyle modification (weight loss, exercise, high fiber diet, avoid fatty & spicy food)

2nd: rubber band ligation (placed at apex of grade 1/2 internal H to stimulate inflammatory & fibrosis)
3rd: infrared coagulation ( used for grade 3 internal H. Or grade 1/2 internal hemorrhoids that failed conservative treatment)
4th: hemorrhoidectomy (for grade IV internal H. That cant be reduced & acutely thrombosed external H. That is paiful)

Types of internal hemorrhoids :

Grade 1: not prolapsed

Grade 2: reduced at rest (spontaneous)

Grade 3: prolapse when straining + manual reduction

Grade 4: cannot be reduced manually or spontaneously

89
Q

Antineutrophil cytoplasmic antibodies (ANCA)

A

Antineutrophil cytoplasmic antibodies (ANCA) are found in several vasculitic conditions, including granulomatosis with polyangiitis, microscopic polyangiitis, and Churg-Strauss syndrome.

90
Q

Hyper-cholesterolemia

A
  1. A condition of elevated total cholesterol (> 200 mg/dL).
  2. Can be acquired and/or as a result of inherited conditions (e.g., familial hypercholesterolemia).

Treat with:

  1. Atorvastatin
  2. Cholestyramine
91
Q

Primary sclerosing cholangitis (PSC)

A
  1. A progressive chronic inflammation of both the intrahepatic and extrahepatic bile ducts
  2. Associated with Ulcerative colitis (IBD)

Signs:

  1. Fatigue
  2. Pruritus
  3. History of inflammatory bowel disease (Ulcerative colitis)

Diagnosed by:

  1. ERCP
  2. MRCP
92
Q

Primary biliary Cholangitis (PBC)

A
  1. Inflammation of intra-hepatic bile duct, which may lead to fibrosis & cirrhosis
  2. Females (30-50)
  3. Often asymptomatic; pruritus, fatigue, abdominal pain, jaundice after years
    1. Lab: cholestatic picture with elevated bilirubin, alkaline phosphatase, & gamma-GT
  5. Positive Anti-mitochondrial antibody (AMA)
  6. Associated conditions: Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis
  7. Complication: Cirrhosis
  8. Treatment:
    • choletyramine: for pruritus
    • ursodeoxycholic acid: improves survival & delay
      transplantation
    • liver transplantation
93
Q

Primary sclerosing cholangitis (PSC)

A
  1. Inflammation of both intra- & extra-hepatic bile duct
  2. Most common: male
  3. Sign: fatigue, pruritus, cholangitis
  4. Lab: cholestatic picture with elevated bilirubin, alkaline phosphatase, & gamma-GT
  5. Investigation: ERCP/MRCP shows beaded appearance of bile duct
  6. Associated condition: ulcerative colitis
  7. Complication: increase risk of cholangio & colorectal carcinoma / cirrhosis
  8. Treatment:
    • choletyramine for pruritus
    • ursodeoxycholic acid: may imrove LFT, but does not improve survival
    • liver transplantation
94
Q

Obstipation ( inability to pass gas/ stool)

A

Caused by:

  1. Bowel obstruction
  2. Severe hypothyroidism
  3. Diabetes
  4. Fecal impaction
  5. Volvulus
95
Q

Small bowel obstruction (SBO)

A
  1. An interruption in the normal passage of contents of the small bowel due to a structural barrier/strictures.
  2. Most commonly caused by adhesions (e.g., from prior abdominal surgery) and incarcerated hernias.
  3. Manifestations include colicky abdominal pain, constipation, abdominal distention, and early-onset vomiting
  4. any abdominal surgical procedure should focus on bowel preservation and minimize further complications (e.g., short bowel syndrome, postoperative adhesions and fistulas).
96
Q

Peritoneal carcinomatosis

A
  1. A terminal feature of abdominal cancers (commonly of the ovary, appendix, or the colon) characterized by seeding of the tumor to the peritoneum.
  2. Treat with: Discontinue surgery and start palliative care
97
Q

Small bowel resection & primary anastomosis

A
  1. indicated to remove a diseased part of the small intestine in patients with cancer, a bleeding ulcer, or Meckel diverticulum.
98
Q

Peripheral vascular disease (PVD)

A
  1. Atherosclerotic occlusion of lower extremities artery
  2. Most common “superficial femoral artery” occlusion in Hunter’s canal

Symptoms:

  1. Intermittent claudication (painful leg cramping that occurs with exercise and is relieved by rest or just standing)
  2. Rest pain (pain in the foot at the distal metatarsal; pain arise at rest; pain starts at night/ awaken patient from sleep) (resolve with hanging foot over side of bed/ standing/ effect of gravity)
  3. Erectile dysfunction
  4. Sensorimotor impairment
  5. Tissue loss

Signs:

  1. Absent pulses
  2. Bruits
  3. Muscular atrophy
  4. Decreased hair growth
  5. Thickened toenails
  6. Tissue necrosis, ulceration, infection (ulcer starts at toes/foot vs. venous stasis ulcer that starts at the medial malleolus/ankle) (painful foot ulcer in PAD vs. painless foot ulcer in diabetes)

Diagnosis:

  1. Ankle-Brachial Index (ABI): normal (> 1.0) ; claudicators (<0.6); rest pain/gangrene (<0.4)
    * ** false positive reading can occur in patients with calcified arteries/diabetics (monkeberg sclerosis)
  2. Pulse-volume recording (PVR): records volume of blood per heart beat down the legs (large waveform=good collateral blood flow)

Investigation:
1. A-gram (arteriogram= dye in vessels + X-ray)

Treatment:

  1. Conservative therapy for claudication (exercise, stop smoking, control HTN, aspirin, oentoxifylline)
  2. Angioplasty (ballon dilation)
  3. Surgical graft-bypass (autolologous vein graft or Gortex)
  4. Endarterectomy (removal of atherosclerotic plaque/intima/media)

Post-operation:

  1. Sheep skin
  2. Foot cradle
  3. Lotion: to prevent fissure that later forms ulcer
  4. Check cardiac status & MI: most pt. With PVD have CAD & AAA
  5. patients with PAD are at significantly increased risk for myocardial infarction and stroke.
  6. In patients with Critical limb ischemia (rest pain, ulcer & gangrene) , urgent revascularization therapy is indicated to prevent limb-threatening arterial occlusion.

Notes:

  1. Aspirin/clopidogrel/ticagrelor: inhibits platelets formation
  2. Pentoxifylline/cilostazol: increase RBC flexibility
99
Q

Dry gangrene

A
  1. Dry necrotic tissue without sign of infection (mummified tissue)
  2. Common lower limbs
  3. Common arterial occlusion
  4. Organ is dry, shrunken, & black
  5. Line of demarcation presents between gangrenous & healthy part
  6. Bacteria fail to survive
  7. Better prognosis due to little septicemia
100
Q

Wet gangrene

A
  1. Moist necrotic tissue with sign of infection
  2. Common in bowel
  3. Common venous occlusion
  4. Moist, soft, swollen & dark
  5. No line of demarcation
  6. Numerous bacteria is present
  7. Poor prognosis due to profound toxemia

emergency amputation and debridement of infected and necrotic tissue are indicated.

101
Q

Blue-toe syndrome

A
  1. Intermittent painful blue toes (or fingers)

2. Due to micro-emboli from proximal arterial plaque

102
Q

acute arterial occlusion

A
  1. Acute occlusion of an artery by embolization or thrombosis

Source of emboli:

  1. Heart (A.fib, clot forming on dead muscle after MI, endocarditis, myxoma)
  2. Aneurysms
  3. Atheromatous plaque (embolism)

Sign/symptoms (6-P’s): * acute onset *

  1. Pain
  2. Pallor (paleness)
  3. Paralysis
  4. Paresthesia
  5. Polar (Poikilothermia) (cold sensation)
  6. Pulselessness

Immediate treatment:

  1. IV-anticoagulation with heparin
  2. A-gram
103
Q

Aortoiliac disease (leriche syndrome)

Peripheral vascular disease

A

Peripheral artery disease at the level of the aortic bifurcation or bilateral occlusion of the iliac arteries that leads to the classic triad of bilateral buttock, hip, or thigh claudication; erectile dysfunction; and absent/diminished femoral pulses.

PAD vs. AID:

  1. PAD shows femoral pulse are palpable, but pedal pulse are absent.
  2. AID: absent of femoral pulse
104
Q

Chronic venous insufficiency (CVI)

A
  1. Muscle cramp/pain with standing & improves with walking
  2. Occurs when your leg veins don’t allow blood to flow back up to your heart.

Signs:

  1. Pain
  2. Bleeding
  3. Ulcer
  4. Hyperpigmentation

Treatment:

  1. Compression stocking
  2. Endo-venous thermal ablation (Laser or high-frequency radio waves are applied to the affected vein to seal it off and prevent further blood flow through it. Blood can then be diverted to veins with proper valve functioning.)
105
Q

Limb reperfusion (post-Opt

A

Lead to:

  1. Compartment syndrome (tissue swelling from reperfusion causes increase intra-compartmental pressure)
  2. Hyperkalemia
  3. MI
  4. Renal failure due to myoglobinuria
106
Q

Compartment syndrome

A
  1. Occurs due to reperfusion injury
  2. increased pressure leads to impaired perfusion

Signs:

  1. Pallor
  2. Paresthesia
  3. Paralysis
  4. Presence of pulses
  5. Pain with passive extension/flexion of the foot

Note:

pale, cool skin, weak peripheral pulses, as well as increased capillary refill time and a positive stretch test (pain in the calf muscle on passively dorsiflexing the foot)

Treatment:
1. Fasciotomy: within 6 hours of the onset of clinical symptoms (to prevent necrosis) & followed up with open wound management.

107
Q
A

Ischemic features (e.g., pallor, pulselessness, increased capillary refill time, poikilothermia, paralysis) are usually late findin

108
Q

Retroperitoneal hematoma

A
  1. Complication of cardiac catheterization
  2. Causes hemodynamic instability + back & flank pain
  3. Diagnosed with non-contrast CT scan of abdomen & pelvis OR abdominal U/S
  4. Treatment: bed rest, intensive monitoring, IV fluid & blood transfusion
109
Q

Carotid vascular disease

A

Signs:

  1. Amaurosis fugax (transient loss of vision in 1 or 2 eyes)
  2. Transient ischemic attack
  3. Reversible ischemic neurologic deficit
  4. Cerebrovascular accident (stroke)

Diagnose it:

  1. A-gram (invasive)
  2. Carotid U/S or Doppler (non-invasive)—> stenosis of carotid (50%)
  3. Head CT

Treatment:

  1. Carotid endarterectomy (CEA)
  2. Aspirin

Death after surgery—> due to MI

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