GI Flashcards
Appendicitis sx, PE, dx, tx
▪︎acute inflammation of vermiform appendix; peak incidence 10-19yo, ♂︎ > ♀︎
Etiology: obstruction of appendiceal lumen
▪︎lymphoid hyperplasia (60%) ⇢ MCC in children/adolescents
▪︎appendiceal fecalith (35%) ⇢ MCC in adults
» Migrating abdominal pain:
➀ periumbilical pain (visceral peritoneum irritation, referred pain to T8-T10)
➁ localizes to RLQ within ~12-24h (parietal peritoneum irritation)
» N/V (vomiting usually comes after pain)
» anorexia (Hamburger sign: if no loss of appetite, appendicitis unlikely)
» McBurney’s sign: tenderness 2/3 the distance from navel to ASIS (RLQ)
» Rovsing’s sign: RLQ pain elicited on LLQ palpation
» Obturator sign: RLQ pain elicited on passive R hip internal rotation w/ hip & knee flexed
» Psoas sign: RLQ pain elicited on passive R hip extension when patient positioned on left side
Tx: surgery
Appendicitis labs and imaging
LABS: leukocytosis w/ left shift, ⇡ CRP >10mg/L
U/S: preferred initial imaging (radiation avoided)
▪︎aperistaltic, noncompressible, distended appendix (∅ >6mm)
▪︎target sign on axial view (hypoechoic fluid-filled center w/
surrounding hyperechoic mucosa)
▪︎appendiceal fecalith: posterior acoustic shadow
CT abdomen w/ contrast:
▪︎distended appendix (∅ >6mm)
▪︎peri-appendiceal fat stranding (wall thickening >3mm)
▪︎appendiceal fecalith: focal hyperdensity within lumen
Acute pancreatitis MCC
gallstones, ETOH abuse 2nd MCC
Acute pancreatitis sx, dx, tx
S/SXS: epigastric pain, radiates to back, exacerbated when supine & relieved leaning forward; N/V, fever
▪︎epigastric tenderness, tachycardia
▪︎adynamic ileus ⇢ decreased bowel sounds
▪︎severe: dehydration, shock
Necrotizing/hemorrhagic:
▪Cullen’s sign (periumbilical ecchymosis)
▪︎Grey Turner sign (flank ecchymosis)
Criteria: 2/3 LABS: ⇡ amylase/lipase (lipase more specific); hypocalcemia
➀ acute onset epigastric pain radiating to back
➁ ⇡ lipase/amylase ≥3xULN
➂ CT, MRI, or U/S findings of acute pancreatitis
*no imaging required if pt meets first 2 criteria
ABD CT: imaging of choice
Transabdominal U/S: assess for gallstones & bile duct dilation- perform if no improvement/worsening after 48hrs
» colon cutoff sign (abrupt collapse of colon near pancreas)
MRCP: stones, stricture, tumor
CXR: mod-severe ⇢ L-sided, exudative pleural effusion
ABD XR:
» sentinel loop (localized ileus of small bowel segment in LUQ)
Tx: “rest the pancreas”
Supportive:
*NPO
*high-volume IVF (LR preferred)
*analgesia (Meperidine)
Antibiotics: indicated only if >30% necrosis seen
Anal Fissure definition
Painful linear tear/crack in the distal anal canal
Etiologies: low fiber diets, passage of large, hard stools, constipation, or other anal trauma
> 80% resolve spontaneously
Anal fissure sx, PE, dx, tx
Severe painful rectal pain & bowel movements causing the pt to refrain from defecating, bright red blood per rectum
PE: longitudinal tear in the anoderm that usually extends no more proximally than the dentate line – MC at the posterior midline (99% M, 90% W), skin tags seen in chronic
TX: supportive (e.g., warm sitz baths, high fiber diet, ⇡ water intake, stool softeners)
Second line tx: topical vasodilators ⇢ NTG (ADRs: HA, dizziness); nifedipine ointment
Botox injections: reduce spasm of internal sphincter
Surgery: lateral internal sphincterotomy reserved for refractory cases
» Complications: fecal incontinence
Perianal Abscess & Fistula definition
» ½ perianal abscesses are caused by fistulas
Abscess: infection from an obstructed anal crypt gland
» MC in posterior rectal wall
Fistula: epithelialized tract that connects an abscess w/ skin or adjacent organs
Cholelithiasis types of gall stones and MCC gallstone
Gallstones in the biliary tract (usually in the gallbladder) w/o inflammation
Types of Gallstones:
*cholesterol (MC)
*black stones: hemolysis or ETOH-related cirrhosis
*brown stones: ↑ in Asian population, parasitic, bacterial infections
Perianal Abscess & Fistula sx, dx, and tx
Abscess: severe pain in anal or rectal area, fever, malaise
Fistula: “non-healing” anorectal abscess, chronic purulent drainage, pain w/ defecation, sitting, & activity, malodorous perianal drainage & pruritis
» Fistula DX: MRI & endosonography
Perianal Abscess: I&D, ABX; sitz baths, high fiber
*Augmentin, cipro + metronidazole
Fistula: surgical
Cholelithiasis sx, dx, tx
Most are asymptomatic – may be an incidental finding
Biliary colic: episodic, abrupt RUQ or epigastric pain, resolves slowly, lasting 30min-hrs; may be associated w/ nausea & precipitated by fatty foods or large meals
U/S – initial TOC: stone in GB or cystic duct
Observation if asymptomatic
Symptomatic: ursodeoxycholic acid may be used to dissolve the gallstones (takes 6-9mo); elective cholecystectomy
Complications: choledocholithiasis, acute cholangitis, acute cholecystitis
Acute vs Chronic Cholecystitis
Acute: Inflammation & infection of the gallbladder due to obstruction of the cystic duct by gallstones
Chronic Cholecystitis:
*fibrosis & thickening of the gallbladder due to chronic inflammatory cell infiltration of the gallbladder evident on histopathology – almost always associated w/ gallstones
Acute cholecystitis sx, PE, dx, tx
Continuous RUQ or epigastric pain – may be precipitated by fatty foods or large meals
*may be associated w/ nausea, guarding, anorexia
PE:
*fever (often low-grade); enlarged, palpable gallbladder
*MURPHY’S SIGN: RUQ pain or inspiratory arrest w/ palpation of the gallbladder
*Boas sign: referred pain to the right shoulder or subscapular area (phrenic nerve irritation)
U/S – initial TOC: thickened or distended gallbladder, pericholecystic fluid, sonographic Murphy’s sign
CT scan: alternative to U/S; can detect complications
Labs: ↑ WBCs (leukocytosis w/ left shift), ↑ bilirubin, alk phos, & LFTs
HIDA scan: most accurate test – cholecystitis present if there is no visualization of the gallbladder
NPO, IV fluids, abx (ceftriaxone + metronidazole) followed by cholecystectomy (usually within 72hrs; laparoscopic preferred)
Cholecystostomy (percutaneous drainage) if nonoperative
Cholesterolosis: fat deposits on GB 🡪 “strawberry GB”; tx is cholecystectomy
Choledocholithiasis sx, PE, dx, tx
Gallstones in the common bile duct (can lead to cholestasis due to blockage)
Prolonged biliary colic: RUQ or epigastric pain, N/V – pain usually more prolonged due to the presence of the stone blocking the bile duct
PE: RUQ or epigastric tenderness, jaundice
Labs: ↑ AST/ALT, alk phos, & GGT (cholestasis)
U/S – initial
ERCP: dx TOC – diagnostic + therapeutic
ERCP stone extraction preferred over laparoscopic choledocholithotomy
Acute Ascending Cholangitis definition and MC pathogen
*biliary tract infection secondary to obstruction of the common bile duct – e.g., gallstones, malignancy
Etiologies: E. coli MC
Acute Ascending Cholangitis sx, PE, dx, tx
Charcot’s Triad: fever + RUQ pain + jaundice
Reynold’s Pentad: + shock or AMS
Labs:
*leukocytosis
*cholestasis: ↑ alk phos & GGT
*↑ bilirubin > increased ALT/AST
U/S – initial
MRCP
Cholangiography via ERCP: gold standard
*IV abx
*piperacillin/tazobactam
*metronidazole + cephalosporin
*metronidazole + cipro/levofloxacin
*CBD decompression & stone extraction (ERCP)
Eventually elective cholecystectomy
Primary Sclerosing Cholangitis definition and MCC
Autoimmune, progressive cholestasis leading to diffuse fibrosis of intra/extrahepatic biliary ducts
Risk Factors:
*MC associated w/ IBD – UC (90%)
*men 20-40yrs
Complications: cirrhosis, liver failure, cholangiocarcinoma
Primary Sclerosing Cholangitis sx, PE, dx, tx
Jaundice, pruritis, fatigue, RUQ pain, hepatomegaly, splenomegaly
Cholestatic pattern: ↑ alk phos & GGT, ↑ AST/ALT, bilirubin, IgM
+ P-ANCA hallmark
MRCP, ERCP – most accurate test: beaded appearance of biliary ducts (narrowing, strictures)
Liver bx – rarely used
Stricture dilation for symptomatic relief
Cholestyramine for pruritis
Liver transplant definitive
All hepatitis sx
Prodromal sxs:
*anorexia, N/V
*fatigue, malaise, arthralgias, myalgias
*HA, photophobia
*pharyngitis, cough, coryza
1-2wks later 🡪 jaundice, +/- RUQ pain
Dark urine, clay-colored stools – may appear 1-5d before onset of jaundice
Hep A transmission, labs, tx
Fecal-oral
Acute: IgM anti-HAV
Past exposure: IgG anti-HAV
LFTs: ↑ AST/ALT & bilirubin
No treatment needed (self-limiting)
Post-Exposure Prophylaxis:
*healthy, age 1-40: HAV vaccine preferred over immunoglobulin (within 2wks of exposure)
*immunocomp, chronic liver disease: HAV vaccine + HAV immunoglobulin (within 2wks)
Hep B transmission, labs, tx
Sex & blood
HBsAg (surface antigen): (+) in acute & chronic
Anti-HBs (surface antibody): (+) if recovered/immunized
Anti-HBc (core antibody):
*acute: IgM
*chronic/recovered: IgG
HbeAg (envelope antigen): replicative (chronic)
Anti-Hbe (envelope antibody): non-replicative (chronic)
LFTs: ↑ bilirubin
*acute: AST/ALT in the thousands
*chronic: AST/ALT in the hundreds
HBV DNA: best way to assess viral replications activity
Liver bx
Supportive – majority will not become chronic
Chronic Mgmt:
*antiviral therapy may be indicated if persistent, severe sxs, marked jaundice, (bilirubin >10), inflammation on liver bx, ↑ ALT or (+) HB envelope antigen present
*entecavir, tenofovir
*tx can be stopped after confirmation pt has cleared HBsAg
Vaccine: derived from yeast, CI if allergic to baker’s yeast
*infant: given @ birth, 1-2mo, 6-18mo
*adult: 3 doses @ 0, 1, 6mo
Hep C transmission, labs, tx
Blood (IVDU MC)
Screening test: HCV antibodies
Confirmatory: HCV RNA
Acute: (+) HCV RNA, (+/-) anti-HCV
Resolved: (-) HCV RNA, (+/-) anti-HCV
Chronic: (+) HCV RNA, (+) anti-HCV
USPSTF Screening Guidelines:
*one time screening for all adults 18-79yo
w/o cirrhosis:
*sofosbuvir + (velpatasvir or daclatasvir) x12wks or
*glecaprevir + pibrentasvir x8wks
w/ compensated cirrhosis:
*sofosbuvir + velpatasvir x12wks or
*glecaprevir + pibrentasvir x12wks or
*sofosbuvir + daclatasvir x24wks
w/ decompensated cirrhosis:
*sofosbuvir + velpatasvir x24wks or
*sofosbuvir + daclatasvir x12wks
Hep D transmission, labs, tx
Blood
*coinfection w/ HBV
Screening: total anti-HDV – confirmed by immunochemical staining of liver bx for HDAg or RT; PCR assays for HDV RNA in serum (HBV serologies also performed)
No FDA approved management
PEG-INF x12mo
Liver transplant definitive
Prevention: hepatitis B vaccine
Hep E transmission, labs, tx
Fecal-oral
LFTs: ↑ AST/ALT, bilirubin
IgM anti-HEV: (+) = infected
No treatment needed (self-limited) – not associated w/ a chronic state
Highest mortality due to fulminant hepatitis during pregnancy
Gastroenteritis viral causes
VIRUSES (75-90%):
1) Rotavirus – children <5y, peaks in cooler months – S/SXS: generally begins w/ vomiting followed by watery diarrhea; high fevers in 1/3 of cases
2) Norovirus – outbreaks in care centers, cruise ships – S/SXS: sudden onset vomiting, watery diarrhea, abdominal pain, fever
*MCC of foodborne disease outbreaks
3) Sapovirus, Adenovirus, Astrovirus – primarily <4yo –S/SXS: milder than rota/nora; watery diarrhea (vomiting/fever less common)
Gastroenteritis bacterial causes
BACTERIAL (10-20%):
1) Campylobacter jejuni – poultry, unpasteurized milk, untreated water, new pets, dairy farms – S/SXS: bloody diarrhea w/ severe abdominal pain, fever, occasional bacteremia
*Immune-Mediated Manifestations: Guillain-Barre, Miller-Fisher, reactive arthritis
2) C. diff – spectrum: mild diarrhea – pseudomembranous colitis – toxic megacolon – S/SXS: fever, crampy abdominal pain, foul-smelling, watery stools
*Pseudo Colitis: diarrhea w/ blood/mucus, abdominal pain, fever, systemic toxicity
3) E. coli, Shiga-toxin-producing (STEC) – beef, greens, unpasteurized milk, petting zoos, person-person – S/SXS: hemorrhagic colitis w/ bloody diarrhea appearing 3-4d after sxs onset; *may cause HUS
3) E. coli, Enterotoxigenic – “Traveler’s diarrhea” (resource-limited settings) – S/SXS: watery diarrhea, abdominal cramping
4) Nontyphoid Salmonella – poultry/beef, dairy, contaminated water, reptiles/amphibians, MC <4yo – S/SXS: diarrhea, abdominal cramps, fever
*Complications – bacteremia, osteomyelitis, brain abscess, meningitis
4) Salmonella typhi – humans are only hosts; resource-limited settings – S/SXS: initially – fever, malaise, myalgias, abdominal pain, constipation or bloody diarrhea; then – HSM & rose spots by wk2
*Associated w/ bacteremia & meningitis
5) Shigella – infection requires low inoculum; childcare outbreaks – S/SXS: varies; watery stools w/o other sxs – bloody stools + high fever, abdominal pain, tenesmus
*S. dysenteriae – HUS; seizures, reactive arthritis
7) Vibrio cholerae – shellfish; “rice water diarrhea” – S/SXS: painless, watery diarrhea w/ significant electrolyte imbalances
8) Yersinia enterocolitica – SWINE; pork, milk, well water, chitterlings, tofu; uncommon in US – S/SXS: fever, abdominal pain, bloody diarrhea in young children
*Pseudo-Appendicitis: mesenteric lymphadenitis w/ fever, abdominal pain/tenderness, leukocytosis – older children
Gastroenteritis parasite causes
PARASITES (up to 5%):
1) Giardia lamblia – daycare, camping trips, contaminated water; “backpacker’s diarrhea” – S/SXS: acute – watery diarrhea, foul-smell, flatulence, anorexia; can 🡪 FTT
2) Entamoeba histolytica – resource-limited – S/SXS: intestinal amebiasis MC – gradual onset bloody diarrhea, lower abd. pain, tenesmus, wt loss; complications: toxic megacolon, fulm. colitis
C Diff dx, tx
DX: two-step: enzyme immunoassay for glutamine dehydrogenase w/ confirmatory toxin testing by NAAT or toxin immunoassay
*CBC: leukocytosis; anemia possible if bloody
TX: metronidazole 30mg/kg/d divided 4x daily x10d; vancomycin 40mg/kg/d divided 4x daily x10d if severe; *fidaxomicin for continuous relapse
Nontyphiod vs typhoid salmonella tx
non: TX: initial dose of ceftriaxone followed by PO (azithromycin or amoxicillin or Bactrim)
* only in pts @ high risk of invasive disease – <3mo, chronic GI dz, HIV/immunocompromised
TX: empiric – ceftriaxone or azithromycin; then definitive therapy based on cultures x7-14d
*steroids may be beneficial in children w/ enteric fever (delirium, coma, shock)
Shigella tx
azithromycin, ceftriaxone, or FQ
Giardia lamblia tx
TX: tinidazole x1, metronidazole x5-10d, nitazoxanide x3d
Entamoeba histolytica tx
TX: metronidazole or tinidazole then iodoquinol or paromomycin
Antidiarrheals: Bismuth Subsalicylate, Diphenoxylate, Loperamide; MOA and CI
peptobismol: MOA: antimicrobial properties; salicylate: anti-secretory & anti-inflammatory properties
Indications: safe in pts w/ dysentery = significant fever, bloody diarrhea
*dark colored stools, darkening of tongue
Contraindications: children w/ viral illness (↑ risk of Reye syndrome)
Diphenoxylate: MOA: binds to gut wall opioid receptors, inhibiting peristalsis. *CNS (central opiate effects), anticholinergic, N/V, abd. pain, constipation
Loperamide: MOA: binds gut wall opioid receptors, inhibiting peristalsis; ⇡ anal sphincter tone
Indications: noninvasive diarrhea
*avoid in pts w/ acute dysentery or colitis
Antiemetics: Ondansetron (Zofran), Prochlorperazine Promethazine (Phenergan)
Metoclopramide
MOA and CI
Zofran
MOA: blocks serotonin receptors
CI: *neuro: HA, fatigue, sedation
*cardiac: QT prolongation, arrhythmias
*GI: bloating, diarrhea, constipation
dopamin blockers
MOA: blocks CNS dopamine receptors; mild antihistaminic/antimuscarinic
CI: *QT prolongation, anticholinergic, drowsiness, hypotension, hyperprolactinemia
*EPS: rigidity, bradykinesia, tremor, akathisia, dystonic reactions, parkinsonism
Constipation MCC, sx, PE, dx, tx
Etiologies:
*disordered movement of stool through colon/anus/rectum (usually proximal GI tract intact)
*slow colonic transport: idiopathic, motor disorders (CRC, DM, hypothyroid), adverse effects of drugs (verapamil, opioids); outlet delay: Hirschsprung’s disease
Gastroparesis: condition that affects the stomach muscles & prevents proper stomach emptying
*MCC: diabetes; others: anorexia, bulimia, scleroderma, Ehlers-Danlos, adnominal surgery
*S/SX: nausea, full feeling after little food is eaten; palpitations, heartburn, bloating, decreased appetite, GERD
S/SX: absent bowel sounds
*DX: CT scan w/ gastrografin – must exclude mechanical obstruction
*DX: KUB, manometry, gastric emptying scan
*TX: laxatives, low fiber & low residue diets, restrict fat intake, smaller meals spaced 2-3hrs apart; metoclopramide
Ileus: ileus that persists >3d following surgery is termed postoperative adynamic ileus or paralytic ileus
MOA of fiber
retains water & improves GI transit
Bulk forming laxatives: Polyethylene glycol (PEG), Lactulose, Sorbitol
Saline Laxatives: milk of magnesia, mag citrate
MOA and ADR
MOA: causes water retention in stool (osmotic effect pulls water into gut)
ADRs: flatulence, bloating
*saline laxatives 🡪 hypomagnesemia (esp. w/ chronic renal disease)
Stimulant laxatives
Bisacodyl, Senna
MOA and ADR
MOA: increases acetylcholine-regulated GI motility (peristalsis) & alters electrolyte transport in the mucosa
ADRs: diarrhea, abdominal pain
Celiac defintion and patho
Autoimmune-mediated inflammation of the small bowel due to reaction w/ alpha-gliadin in gluten-containing foods
PATHO:
*autoimmune damage leads to loss of villi w/ subsequent malabsorption
*increased incidence in females, European descent (Irish & Finnish)
Celiac sx, PE, dx, tx
Malabsorption: diarrhea, abdominal pain/distention, bloating, steatorrhea; growth delays in children
Dermatitis herpetiformis: pruritic, papulovesicular rash MC on extensor surfaces, neck, trunk, & scalp
Clinical: sxs improvement w/ trial of gluten-free diet
Screening: transglutaminase IgA antibodies; endomysial IgA antibodies
Definitive & confirmatory: small bowel bx (duodenum) – atrophy of the vill
GLUTEN-FREE DIET
*avoid wheat, rye, barley
*limit oat consumption
*vitamin supplementation
Cirrhosis MCC
*result of chronic hepatic injury w/ inflammation that leads to hepatic fibrosis & regenerative nodules, HCC PRECURSOR**
*prevalence rate 0.27%, ♂ > ♀︎ (2:1)
MCC ⇢ ▪︎chronic viral hepatitis (HBV, HCV**)
Cirrhosis clinical manifestations
Clinical Manifestations:
▪︎muscle cramps (can be severe), easy bruising, LE edema
▪︎anovulation (♀︎): amenorrhea, menstrual irregularities
▪︎fever, diarrhea, pruritis, muscle wasting ▪︎hypogonadism (♂): gynecomastia, ⇣ libido, testicular atrophy
▪︎⇣ MAP (contributes to hepatorenal syndrome)
▪︎Skin: jaundice, dark urine, spider angiomata (telangiectasia)
▪︎hepatosplenomegaly, ascites ⇡⇡ bilirubin: jaundice usually not detectable until >2-3mg/dL
▪︎caput medusae ⇢ dilated abdominal veins
▪︎Fetor hepaticus (sweet, pungent smelling breath): dimethyl
▪︎palmar erythema, clubbing (MC in 1° biliary cirrhosis)
sulfide accumulation, suggests severe portal-systemic shunting
Cirrhosis cx
Hepatic Encephalopathy ⇢ ammonia accumulation in brain
▪︎cognitive deficits + impaired neuromuscular function
▪︎asterixis: flapping tremor
Portal Vein Thrombosis (PVT) ⇢ thrombus in the portal vein
▪︎contributes to development of portal HTN
Cirrhosis labs and imaging
LABS:
▪︎hepatic studies: Modest ⇡ AST & alk phos
⇡ bilirubin, ⇣ albumin, ⇡ GGT
▪︎coagulation studies ⇡ PT, ⇡ INR
▪︎CBC: thrombocytopenia (MC), anemia, leukopenia
▪︎hyponatremia (common in cirrhosis + ascites)
IMAGING:
▪︎U/S: surface nodularity, ⇡ echogenicity, small liver
▪︎Caudate/left lobes: hypertrophy
▪︎Right lobe: atrophy
LIVER BX ⇢ confirmatory
Hemochromatosis:
▪︎transferrin sat ≥45%, ⇡ ferritin >200-300ng/mL
▪︎BX: ⇡ hemosiderin
Wilson: ⇣ ceruloplasmin, ⇡ urinary copper excretion
▪︎slit lamp (Kayser-Fleischer rings)
▪︎BX: ⇡ copper content
Cirrhosis tx
▪︎alcohol abstinence most important
▪︎treatment of underlying conditions
▪︎avoid hepatotoxic drugs: NSAIDs, opiates,
BDZs (HE)
▪︎vaccinations: PPSV23, HAV/HBV, influenza
▪︎adequate nutritional intake
Definitive ⇢ liver transplant
▪︎indications: index complication (e.g., ascites, HE, variceal hemorrhage) &/or MELD score ≥15
Hemochromatosis: phlebotomy, Deferoxamine (iron-chelation)
Wilson: Penicillamine, avoid seafood & other high-copper foods
Hepatic Encephalopathy:
▪︎lactulose + rifaximin, liver transplant
PVT: anticoagulation (enoxaparin)
Esophageal varices sx, dx, tx
S/SXS: hematemesis &/or melena
DX: EGD – prediction of variceal hemorrhage: location, size, appearance, clinical features, variceal pressure
▪︎⊕red signs associated w/ ⇡ bleeding risk
TX: bleeding prophylaxis ⇢ beta blockers (e.g., propranolol or nadolol), endoscopic variceal band ligation
TX: variceal hemorrhage ⇢ PRBCs to maintain Hgb ≥7g/dL, octreotide (preferred) or vasopressin
▪︎ABX prophylaxis: IV ceftriaxone x7d
▪︎endoscopic variceal band ligation** (1st line), sclerotherapy, balloon tamponade, TIPS (alternatives)
Ascites sx, dx, tx
Ascites ⇢ accumulation of fluid within the peritoneal cavity
S/SXS: abdominal distention/pain, early satiety
DX: paracentesis ▪︎diuretics (spironolactone, furosemide)
TX: therapeutic paracentesis, ▪︎salt restriction ≤2g/d, +/- fluid restriction
Spontaneous bacterial peritonitis (SBP) definition
infection of ascitic fluid w/o an intraabdominal secondary source
Spontaneous bacterial peritonitis (SBP) sx, dx, tx
▪︎common pathogens: E. coli, strep, Klebsiella
S/SXS: fever, abdominal pain/tenderness, AMS
DX: paracentesis ⇢ PMN (neutrophil) count ≥250 cells/mm3
TX: IV cefotaxime 2g q8h x5d, IV albumin
Hepatorenal syndrome definition, dx, tx
development of renal failure in a patient who has advanced liver disease d/t cirrhosis, severe alcoholic liver disease, acute liver failure, etc.
DX: ⇡ creatinine, normal urine sediment, no/minimal proteinuria (<500mg/d), urine Na <10mEq/L
TX: improve hepatic function, liver transplant
Portopulmonary HTN defintion
pulmonary HTN + portal HTN
Portopulmonary HTN sx, dx, tx
S/SXS: fatigue, dyspnea, peripheral edema, CP, syncope & a dysfunctional or blunted response to stress
DX: initial ⇢ TTE, confirmatory ⇢ right heart catheterization
TX: liver transplant definitive
Hepatic hydrothorax definition
pleural effusion in a patient w/ cirrhosis & no evidence of underlying cardiopulmonary disease resulting from movement of ascitic fluid into the pleural space through defects in the diaphragm
▪most commonly right-sided
Hepatic hydrothorax sx, dx, tx
S/SXS: dyspnea, nonproductive cough, pleuritic CP
DX: thoracentesis ⇢ transudative
TX: diuretics, sodium restriction, therapeutic thoracentesis, TIPS, NO CHEST TUBE*
Hepatopulmonary syndrome defintion
triad of abnormal arterial oxygenation + intrapulmonary vascular dilatations (IPVDs) + liver disease
Hepatopulmonary syndrome sx, dx, tx
S/SXS: dyspnea, platypnea (⇡ dyspnea when upright vs supine), orthodeoxia (⇣ arterial O2 saturation when going from supine to upright), SpO2 <96%
DX: ABG (⇡ A-a gradient ≥15mmHg), TTE (⊕IPVDs)
TX: medical therapies not effective, liver transplant*
Diverticulosis defintion, sx, dx, tx
Diverticula: outpouchings due to herniation of the mucosa into the wall of the colon along natural openings at the vasa recta of the colon
L colon MC in incidence, R colon MC for bleeding
Risk Factors: low fiber diet, constipation, obesity
Asymptomatic – incidental finding
Lower GI bleeding: diverticulosis MCC of acute lower GI bleed
*painless hematochezia
dx: Colonoscopy
tx: Bleeding usually stops spontaneously
Diverticulitis definition, sx, dx, tx
Microscopic perforation of a diverticulum leads to inflammation & focal necrosis
Complicated: bowel perforation, abscess, fistula, bowel obstruction
Sigmoid colon MC area; onset usually >40yrs
sx
*LLQ pain, LLQ tenderness
*low grade fever
+/- N/V/D/C, flatulence, bloating, changes in bowel habits
PE: +/- tender mass d/t inflammation or abscess
CT scan
Labs:
*leukocytosis
Uncomplicated:
*metronidazole + (ciprofloxacin or levofloxacin)
x7-10d
*clear liquid diet
Esophagitis different types and MCC
*GERD MC cause
*infectious: candida, CMV, HSV; MC associated w/ immunocompromised states
*eosinophilic: due to allergic reaction
*pill-induced: bisphosphonates, BBs, CCBs, NSAIDs
*caustic (corrosive): due to acidic or basic substances
Infectious Esophagitis MCC, sx, dx, tx
*immunocompromised states (HIV, post-transplant, malignancy, chemo) but can occur in healthy pts
candida is MC cause – in pts w/ classic sxs, empiric tx w/ fluconazole can be initiated w/ upper endoscopy reserved if no response to initial therapy
sx: Odynophagia + dysphagia + retrosternal chest pain
dx:
Endoscopic findings:
*candida: linear yellow-white plaques
*CMV: large superficial shallow ulcers
*HSV: small, deep ulcers
tx
Candida: PO fluconazole
CMV: ganciclovir
HSV: acyclovir
Eosinophilic Esophagitis definition, sx, dx, tx
*allergic inflammatory eosinophilic infiltration of the esophageal epithelium
*MC seen in children & associated w/ atopic disease (asthma, eczema)
Dysphagia (esp. solids), odynophagia; reflux or feeding difficulties in children
dx: Endoscopy: normal or multiple corrugated rings, white exudates
Bx: presence of abundance of eosinophils
tx: Remove foods that incite allergic response; PPIs may be needed in some
Inhaled topical corticosteroids (w/o using a spacer to allow for penetration)
Pill-Induced Esophagitis causes, sx, dx, tx
Esophagitis due to prolonged pill contact w/ the esophagus
Medications: NSAIDs, bisphosphonates, BBs, CCBs, potassium chloride, iron pills, vitamin B
sx: Odynophagia, dysphagia
dx: Endoscopy: small, well-defined ulcers of varying depths
tx: Take pills w/ at least 4 ounces of water, avoid recumbency at least 30-60min after pill ingestion
Caustic (Corrosive) Esophagitis causes, sx, dx, tx
Ingestion of corrosive substances: alkali (drain cleaner, lye, bleach) or acids
sx: Odynophagia, dysphagia, hematemesis, dyspnea
dx: Endoscopy – used to determine the extent of damage & look for complications (esophageal perforation, structure, fistula)
tx: Supportive, pain meds, IV fluids
Gastritis defintion, MCC, sx, dx, tx
Gastritis: superficial inflammation/irritation of stomach mucosa w/ mucosal injury
Gastropathy: mucosal injury without inflammation
PATHO: imbalance between aggressive & protective mechanisms of the gastric mucosa
MCC: H. pylori, NSAIDs/ASA 2nd MCC
S/SXS: most commonly asymptomatic; when symptoms present, similar to PUD (e.g., dyspepsia, N/V, epigastric pain)
DX: upper endoscopy w/ biopsy
▪︎thick, edematous erosion <0.5cm
H. pylori testing
TX: similar to PUD (e.g., H. pylori eradication, H2 antagonists/PPIs, stop offending agents)
▪︎H. pylori ⇢ “CAP”
» clarithromycin + amoxicillin + PPI
Prophylaxis: for patients w/ high risk of stress-related gastritis ⇢ PPI
What separates and upper and lower GI bleed?
Ligament of Treitz
Causes of upper GI bleeds
*PUD
*esophagitis
*portal HTN
*Mallory-Weiss tear
*angiodysplasia
Upper GI bleed sx, PE, dx, tx
Hematemesis – vomiting blood, “coffee-ground”
*bloody: suggests moderate-severe bleeding
*coffee ground: suggests more limited bleeding
Melena – black, tarry stools
*hematochezia usually indicates LGIB but can occur in massive UGIB
Symptom assessment:
*PUD – upper abdominal pain
*esophageal ulcer – odynophagia, reflux, dysphagia
*mallory-weiss tear – emesis, retching, or cough prior to bleeding
*variceal hemorrhage or portal HTN gastropathy – jaundice, abdominal distention (ascites)
*malignancy – early satiety, dysphagia, weight loss, cachexia
Medication hx
*aspirin/NSAIDs predispose to PUD
*anticoagulants/antiplatelets ↑ bleed risk
*SSRIs/CCBs/aldosterone antagonists have been associated w/ GI bleeding
Labs: CBC, CMP, electrolytes, lipids, liver enzymes, albumin, creatinine, BUN, thyroid, coagulation studies
*monitor Hgb every 2-8hrs
*typically have ↑ BUN-to-creatinine ratio
- >30:1 suggest UGIB
UPPER ENDOSCOPY (within 24hrs)
Tx: PPI
Octreotide for esophageal varices or cirrhosis
Causes of lower GI bleeds
*diverticulosis
*angiodysplasia
*colitis (infectious, ischemic, IBD)
*colon cancer
Lower GI bleeds sx, PE, dx, tx
Hematochezia – maroon/bright red blood, blood clots
*L colon origin: bright red
*R colon origin: dark/maroon colored
Symptom assessment:
*hemorrhoids: painless bleeding w/ wiping
*anal fissures: severe rectal pain w/ defecation
*proctitis: rectal bleeding & abdominal pain
*polyps: painless rectal bleeding, no red flag signs
*colorectal cancer: painless rectal bleeding & a change in bowel habits in a pt 50-80yrs
Labs: CBC, CMP, electrolytes, lipids, liver enzymes, albumin, creatinine, BUN, thyroid, coagulation studies
*typically have normal BUN-to-creatinine ratio
- <20:1
+/- upper endoscopy to r/o UGIB
COLONOSCOPY, CT angiography, radionucleotide scanning
tx: treat underlying cause
Gastric Ulcers sx and dx
sx: epigastric pain & vomiting, anorexia, & nausea
dx: HX/PE, EGD w/ multiple bx (looking for gastric cancer)
Duodenal Ulcers sx and dx
sx: epigastric pain – burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain)
*bleeding, back pain N/V, anorexia, ↓ appetite
dx: HX/PE, EGD, UGI series (if the pt is not actively bleeding)
Gastric cancer sx and dx
sx: weight loss, emesis, anorexia, pain/epigastric discomfort, obstruction, nausea
dx: EGD w/ bx, endoscopic U/S to evaluate the level of invasion, CT of abdomen/pelvis for metastasis, CXR, labs
Carcinoma of gallbladder sx and dx
sx: biliary colic, weight loss, anorexia
*many pts are symptomatic until late; may present as acute cholecystitis
dx: U/S, abdominal CT, ERCP
Pancreatic carcinoma sx and dx
sx: *painless jaundice from obstruction of the common biliary duct
*weight loss, abdominal pain, back pain, weakness
*pruritis from bile salts in the skin; anorexia
*Courvoisier’s sign
*acholic stools
*dark urine, diabetes
dx: abdominal CT, U/S, cholangiography (ERCP to r/o choledocholithiasis & cell brushings), endoscopic U/S w/ bx
Hemorrhoids defintion, dx, tx
dilated submucosal vascular cushions within the anal canal
▪︎excessive straining (chronic constipation, BPH), older age, extended periods of sitting, pregnancy (mainly 3rd TM)
dx: DRE, anoscopy, colonoscopy (high risk) or flexible sigmoidoscopy (low risk) if concern for malignancy
tx: Lifestyle modifications (all patients): high fiber diet (20-30g/d), ⇡ fluid intake, avoid fatty foods, regular physical activity, avoidance of excessive straining & limiting amount of time spent on toilet
» constipation: short-term (1wk max) use of stool softeners (docusate) or laxatives (PEG)
Symptom relief (pain, pruritis): sitz baths, topical anesthetics (lidocaine), steroids (hydrocortisone), &/or vasoconstrictors (phenylephrine)
Internal vs external hemorrhoids sx and tx
Internal hemorrhoids: originate from superior hemorrhoid vein above dentate line; ⊖cutaneous innervation = ⊖pain
▪︎S/SXS: painless, BRBPR at end of defecation; perianal mass if prolapsed, pruritis, anal discharge (mucus, fecal matter)
tx: » Internal, grades I-III unresponsive to conservative: rubber band ligation, sclerotherapy
» Internal, grade IV: surgery (hemorrhoidectomy)
External hemorrhoids: originate from inferior hemorrhoid vein below dentate line; ⊕cutaneous innervation = ⊕pain
▪︎S/SXS: similar to internal (e.g., BRBPR, pruritis), thrombosed external manifests w/ severe perianal pain & tender mass
tx: » Symptomatic external hemorrhoids refractory to conservative therapy: refer for surgery
» Thrombosed external hemorrhoids: surgical excision if duration <3-4d
▪︎duration >3-4d: antispasmodics (topical NTG or nifedipine), lidocaine, hydrocortisone, docusate
GERD definition, MOA, RF, cx
GERD: reflux of gastric contents into esophagus d/t an incompetent LES
Mechanism: transient relaxation of LES
RF: smoking, caffeine, & ETOH (⇣ LES tone); stress, obesity, pregnancy, scleroderma, sliding hiatal hernia
Complication ⇢ Barrett’s esophagus: intestinal metaplasia of esophageal mucosa induced by chronic reflux (columnar epithelium instead of normal squamous epithelium)
▪︎RF: ♂︎, European descent, age ≥50yo, obesity, SXS ≥5y
▪︎Barrett’s predisposes esophageal adenocarcinoma
Dyspepsia definition and causes
*acute, chronic, or recurrent pain/discomfort centered in the upper abdomen (epigastric)
*may be associated w/ heartburn, nausea, postprandial fullness, or vomiting
Heartburn: retrosternal burning – should be distinguished from dyspepsia
*when heartburn is predominant complaint ⇢ gastroesophageal reflux nearly always present
FOOD/DRUG INTOLERANCE: acute, self-limited
*overeating, eating too quickly, eating high-fat foods by endoscopy/other testing
*eating during stressful situations, alcohol/coffee
*MCC of chronic dyspepsia, often difficult to treat
*MEDS: ASA, NSAIDs, metronidazole, macrolides,
*PATHO: ⇡ visceral afferent sensitivity, delayed
metformin, GLP-1 antagonists, ACEI/ARBS, SSRIs, gastric emptying or impaired accommodation to
SNRIs, Parkinson RX (DA agonists, MAO-B), steroids, food/psychosocial stressors
estrogens, iron, opioids, digoxin
H. PYLORI INFECTION: chronic gastric infection w/
LUMINAL GI TRACT DYSFUNCTION: H. pylori important cause of PUD but may cause
*PUD present in 5-15% of patients w/ dyspepsia dyspepsia in a subset of patients in absence of PUD
*GERD present in up to 20%, even w/o significant HB
*gastric/esophageal cancer <1%, rare if <60yo
pancreatic carcinoma & chronic
*gastroparesis (diabetics) pancreatitis may cause chronic epigastric pain, but usually
*parasitic infections (Giardia, Strongyloids, Anisakis)
more severe, radiates to back, & associated w/ anorexia, weight loss, jaundice.
GERD sx, alarm sx, dx, tx
Typical SXS: retrosternal burning (heartburn), regurgitation, water brash (i.e., excessive salivation triggered by reflux of acid; bad/sour taste)
▪︎worsened by lying flat, foods (e.g., chocolate, spicy food)
Atypical SXS: persistent cough, asthma, hoarseness, dental erosion, halitosis (bad breath), N/V, belching, epigastric pain, bloating
ALARM SXS:
▪︎dysphagia, odynophagia
▪︎anemia
▪︎unintentional weight loss
▪︎GI bleeding (hematemesis, hematochezia)
EGD indications: ⊕alarm symptoms, risk factors for Barrett’s, no symptom improvement after PPI trial
» Findings (typically in lower 1/3 of esophagus):
▪︎erythema, edema, friability
▪︎erosions, mucosal breaks, ulcers
▪︎peptic strictures/rings
▪︎salmon pink mucosa (suggestive of Barrett’s)
Esophageal pH monitoring: indicated for patients w/ normal EGD & typical symptoms despite PPI TX
▪︎normal esophageal pH ~7
Lifestyle changes (all patients):
▪︎elevate head of bed 6-8in, weight loss if indicated
▪︎AVOID: eating 3h before bedtime, smoking,
triggering foods (coffee, ETOH, OJ, chocolate)
TX: PPIs (8wk trial for patients w/ typical SXS)
▪︎good response ⇢ discontinue PPI
▪︎no response or relapse after DC ⇢ GI for EGD
*controversy regarding long-term PPI therapy d/t
conflicting evidence about potential risks
H2 antagonists (famotidine, ranitidine): alternative maintenance for non-erosive reflux
Maintenance TX: lowest effective dose
Refractory: Nissen fundoplication
Biliary tract disease definition
abrupt onset epigastric/RUQ pain d/t cholelithiasis
or choledocholithiasis ischemia, intra-abdominal malignancy, gastric volvulus or paraoesophageal hernia, chronic gastric or intestinal
GERD dx and tx
UPPER ENDOSCOPY:
*mainly indicated to look for upper gastric or
esophageal malignancy in ALL patients >60yo
w/ new-onset dyspepsia (if ⇡ malignancy risk)
*guidelines recommended against routine
endoscopy for pts <60yo (risk of cancer <1%)
unless alarm features
TX:
⊕H. pylori: bismuth quadruple therapy x14d
*PPI + Bismuth subsalicylate 262mg +
tetracycline + metronidazole
*alternative ⇢
▪︎omeprazole + rifabutin + amoxicillin
*standard triple therapy w/ clarithromycin
no longer recommended
⊖endoscopy, <60yo w/o response to PPI:
⇢ presumed to have functional dyspepsia
*reassurance, lifestyle/dietary changes
*herbal therapies: peppermint, caraway
*low-dose TCAs (desipramine or nortriptyline)
Inguinal hernias: indirect vs direct
Indirect: (MC!!)
*bowel protrusion @ internal inguinal ring
*LATERAL to inferior epigastric artery
Direct:
*MEDIAL to the inferior epigastric artery
*Hesselbach’s triangle: “RIP” rectus abdominis, inferior epigastric, oupart’s (inguinal) ligament
*MC found on the right side
Inguinal hernias sx: nonstrangulated, incarceration, strangulated
Asymptomatic: swelling or fullness at the hernia site; enlarges w/ increased intraabdominal pressure &/or standing; may develop scrotal swelling
Incarcerated: painful, enlargement of an irreducible hernia
Strangulated: ischemic incarcerated hernias w/ systemic toxicity
tx for strangulated p emergent surgery
Femoral hernias defintion
Protrusion of the contents of the abdominal cavity through the femoral canal (below the inguinal ligament)
MC seen in women
Often become incarcerated or strangulated because femoral ring is smaller in women
Umbilical hernias definition and tx
Hernia through the umbilical fibromuscular ring
Congenital (failure of umbilical ring closure)
- usually due to loosening of the tissue around in the ring in adults
Observation: usually resolves by 2yrs of age
Surgical repair
Incisional hernias definition and sx
Herniation through weakness in the abdominal wall
Mostly occur w/ vertical incisions & in obese pts
Obturator hernias defintion and sx
Rare hernia through the pelvic floor in which abdominal/pelvic contents protrude through the obturator foramen
MC in women (esp. multiparous) or women w/ significant weight loss
Hiatal hernia defintion, sx, tx
Herniation of structures from the abdominal cavity through the esophageal hiatus of the diaphragm
sx: Usually an asymptomatic incidental finding
*may develop intermittent epigastric or substernal pain, postprandial fullness, retching, or nausea
tx: Sliding: management of GERD
*PPIs + weight loss
Paraoesophageal: surgical repair for complications
*volvulus, obstruction, strangulation, bleeding, perforation
Hiatal hernias: type 1 vs type 2
Type I: Sliding (95%)
*GE junction “slides” into the mediastinum (increases reflux)
Type II: Paraoesophageal (“rolling hernia”)
*fundus of stomach protrudes through diaphragm w/ the GE junction remaining its anatomic location
Pinworm pathogen, sx, dx, tx
pathogen: Enterobius vermicularis
sx: perianal pruritis that is worst at night
dx: *scotch tape test: done in early AM
Can see eggs under microscope
tx: *mebendazole
*pyrantel pamoate
Tapeworm causes, sx, dx, tx
causes: Transmission: raw or undercooked meat
*associated w/ B12 deficiency
sx: GI sxs, weight loss
dx: *tape test for D. latum
*stool sample: eggs
tx: *praziquantel
Hookworm cause, sx, dx, tx
Larvae invade the skin, travel to lung, cough, & swallow, reside in intestine
*eosinophilia & anemia
*recent travel
sx:
*cough
*weight loss
*anemia
dx: *stool sample: adult worms
tx: *mebendazole
*pyrantel
Roundworm causes, sx, dx, tx
MC intestinal helminth worldwide; found in contaminated soil
sx: Small worm load: asymptomatic
Larger load: vague abdominal sxs
High load: pancreatic duct, common bile duct, & bowel obstruction
dx: *stool sample: eggs or adult worms
tx: *albendazole
*mebendazole
*pyrantel pamoate
Schistosomiasis cause, sx, dx, tx
Also known as “Snail Fever” & “Bilharzia”
Etiology: parasitic flatworms called schistosomes
PATHO: penetrating of skin (contaminated freshwater) 🡪 enter the bloodstream & migrate to liver, intestines, etc.
sx: *rash
*abdominal pain, diarrhea
*bloody stool
*blood in urine
dx: *eggs in urine or feces
tx: *praziquantel
IBD extra intestinal manifestations and labs
Rheumatologic: MSK pain, arthritis, ankylosing spondylitis, osteoporosis
Dermatologic: erythema nodosum, pyoderma gangrenosum
Ocular: conjunctivitis, anterior uveitis/iritis (ocular pain, HA, blurred vision), episcleritis (mild ocular burning)
Hepatobiliary: fatty liver, primary sclerosing cholangitis
Hematologic: B12/iron deficiency (esp. w/ CD), ↑ r/o thromboembolism
Workup: CBC, ESR/CRP, albumin, electrolytes, AST/ALT, creatinine, urea nitrogen, fecal calprotectin, stool microscopy, stool cultures, testing for C. diff
Ulcerative colitis definition, location involved, sx, dx, tx
ULCERATIVE COLITIS (UC): chronic, recurrent disease involving only the colon characterized by diffuse mucosal inflammation that results in friability, erosions, & ulcers w/ bleeding; mucosa + submucosa
Bimodal: 15-25, 55-65, slightly more common in males
*MC in nonsmokers & previous smokers
*RECTUM ALWAYS INVOLVED
Complications:
*Primary Sclerosing Cholangitis
*Colon Cancer
*Toxic Megacolon
S/SXS: fecal urgency, abdominal pain & cramps, tenesmus
dx: Sigmoidoscopy: mucosa – edema, friability, mucopus, erosions; UNIFORM inflammation
Abdominal radiograph, CT: pts w/ severe colitis to look for significant colonic dilation
Barium studies: “stovepipe sign,” loss of haustral markings
*little use, can precipitate toxic megacolon in pts w/ severe disease
Labs: Hct, albumin (⇣), ESR/CRP, fecal calprotectin
*POSITIVE P-ANCA
tx
mild: mesalamine, steroids
severe: immunomodulators
Crohns sx, dx, tx
Cardinal SXS:
▪︎abdominal pain (crampy), RLQ pain if limited to terminal ileum (MC location)
▪︎diarrhea (+/- bleeding)
▪︎systemic symptoms ⇢ fatigue, weight loss (d/t ⇣ intake, malabsorption)
Transmural Inflammation
*associated w/ sinus tracts that may lead to fistulas & phlegmon formation
▪︎fistulas: enterovesical (bladder), enterocutaneous, enterovaginal
▪︎phlegmon: walled-off inflammatory mass w/o bacterial infection
▪︎abscess: acute ⇢ localized peritonitis + fever, abdominal pain, tenderness
▪︎perianal disease: perianal fistula, perianal abscess
Malabsorption: small bowel CD ⇢ bile salt malabsorption
Initial DX: compatible clinical picture + supporting endoscopic, pathologic, & radiographic findings
Colonoscopy: aphthoid, linear, or stellate ulcers; strictures; segmental involvement w/ areas of normal-appearing mucosa adjacent to inflamed mucosa (“skip lesions”); cobblestone appearance
BX: granulomas (seen in <25%)
CT/MR enterography: for suspected small bowel involvement
*ulcerations, strictures, fistulas
*bowel wall thickening & vascularity, mucosal enhancement, fat stranding
Barium studies: “string sign,” barium flow through narrowed inflamed/scarred area d/t transmural strictures
*only performed when CT/MR enterography unavailable
Labs: inflammatory markers – albumin, CRP, fecal calprotectin; CBC (anemia), C. diff testing
*⇣ albumin
*⇡ ESR/CRP during active inflammation
Induction TX (acute flares): agents w/ rapid onset ⇢ steroids, biologics
Maintenance TX: biologics & immunomodulators
Toxic megacolon definition, sx, dx, tx
▪︎life-threatening acute colonic dilation + systemic toxicity
» infectious colitis: C. difficile (pseudomembranous colitis)
» inflammatory colitis: ulcerative colitis
S/SXS: bloody diarrhea, vomiting, abdominal distention & pain, signs
of sepsis (e.g., fever, tachycardia, hypotension), dehydration, peritonitis
▪︎LABS: neutrophilic leukocytosis, ⇡ ESR/CRP, hypokalemia, anemia
▪︎abdominal XR: transverse colon >6cm, loss of haustration
▪︎colonoscopy/endoscopy contraindicated d/t high-risk of perforation
TX: ICU admission, complete bowel rest (NPO), bowel decompression w/ NG tube, broad-spectrum IV ABX (ampicillin, gentamicin, & metronidazole)
▪︎rotation techniques: frequent position changes to facilitate evacuation of
bowel gas (prone or knee-elbow position)
▪︎AVOID anticholinergics & narcotics
▪︎IV steroids (hydrocortisone, dexamethasone) for IBD
*contraindicated in infective colitis
Surgery: no response within 24-72h, development of complications
▪︎subtotal colectomy & end ileostomy
Mesenteric ischemia acute vs chronic
ACUTE (AMI): acute reduction in arterial or venous blood flow to small intestine, may ⇢ bowel ischemia or infarct
*SMA MC (~90%), SMV LC (<10%), IMA & celiac uncommon
S/SXS: pain out of proportion to exam**
*severe, steady, diffuse abdominal pain +/- N/V/D
*no focal tenderness or distention
CHRONIC (CMI) ⇢ “Intestinal Angina”
*atherosclerosis ⇢ ischemia (i.e., hypoperfusion) MCC
*⇣ supply during ⇡ demand (eating)
sx: S/SXS: epigastric/periumbilical postprandial pain
Mesenteric ischemia dx, tx
DX: CTA abdomen & pelvis
*mesenteric stenosis & thromboembolism
*bowel-wall thickening, hypoperfusion
*bowel dilation, mesenteric fat stranding
*pneumatosis intestinalis (gas within walls)
CT abdomen:
*bowel wall thickening, bowel edema
*thumbprint sign: edematous mucosal
thickening causing indentation in large bowel
colonoscopy ⇢ confirms
*clearly defined segmental ischemia in areas of
low perfusion (e.g., splenic fixture)
*edematous, friable mucosa w/ erosions
AMI – initial Measures:
*IV fluids, NPO, NG decompression
*anticoagulation ⇢ UFH
*empiric broad-spectrum antibiotics
*PPI, O2 PRN
Jaundice definition and causes
Yellowing of the skin, nail beds, & sclera by bilirubin deposition as a consequence of hyperbilirubinemia
FIRST SIGN 🡪 scleral icterus
Serum bilirubin >2.5mg/dL – not a disease but a sign of disease
Occurs w/ increased bilirubin overproductions (hemolysis)/ineffective erythropoiesis, decreased hepatic bilirubin uptake, impaired conjugation, biliary tract obstruction, viral hepatitis, physiologic jaundice of newborn, Gilbert syndrome, Dubin-Johnson syndrome
Causes:
Extravascular hemolysis/ineffective erythropoiesis
*increases the level of UCB which overwhelms the liver’s ability to conjugate UCB
*dark urine & increased risk for pigmented bilirubin gallstones results
Physiologic jaundice of the newborn
*newborn has transient low UGT which increases UCB
*it can present w/ kernicterus leading to neuro deficits & death
*tx w/ phototherapy
Crigler-Najjar Syndrome
*the absence of UGT (enzyme) which increases UCB causing kernicterus which is usually fatal
Gilbert syndrome
*mildly low UGT activity which increases UCB
*jaundice occurs during stress like a severe infection; otherwise, pts are asymptomatic
Dubin-Johnson Syndrome
*deficiency of bilirubin canaliculi transport protein which increases CB
*the liver is pitch-dark
*Rotor syndrome – liver is not dark
Biliary tract obstruction (obstructive jaundice)
*associated w/ gallstones, pancreatic carcinoma, liver fluke, & cholangiocarcinoma
*this also increases the CB, & alkaline phosphatase & decrease urine urobilinogen
*dark urine, pale stool, pruritis due to increased bile acids, steatorrhea
Jaundice initial labs
Initial lab tests:
*serum total & unconjugated bilirubin
*alk phos
*AST/ALT
*PT/INR
*albumin
Interpretation:
Normal alk phos & aminotransferases
*jaundice likely not due to hepatic injury or biliary tract disease
Predominant alk phos elevation
*suggests biliary obstruction or intrahepatic cholestasis
Predominant aminotransferase elevation
*suggests jaundice is caused by intrinsic hepatocellular disease
Elevated INR
*an elevated INR that corrects w/ vitamin K admin suggests impaired intestinal absorption of fat-soluble vitamins & is compatible w/ obstructive jaundice
Unconjugated hyperbilirubinemia
*typically involves evaluation for hemolytic anemia, drugs that impair hepatic uptake of bilirubin, & Gilbert syndrome
Conjugated hyperbilirubinemia
*evaluation will be based on whether the abnormalities are likely due to biliary obstruction, intrahepatic cholestasis, hepatocellular injury, or an inherited condition
Boerhaave Syndrome sx, PE, dx, tx
full thickness rupture, MC affecting the left posterolateral wall of the lower esophagus
Etiologies:
*iatrogenic perforation during endoscopy (MC)
*repeated, forceful retching or vomiting (Bulimia, alcoholism)
sx: *retrosternal chest pain worse w/ deep breathing & swallowing
*vomiting, hematemesis
PE:
*crepitus on chest auscultation (subcutaneous emphysema)
*Hamman’s sign: mediastinal “crackling” accompanying every heartbeat in the left lateral decubitus position
dx: Contrast esophagram: leakage
Chest CT, CXR
*left-sided hydropneumothorax (MC)
*pneumomediastinum
*esophageal thickening
tx: Small & stable:
*IV fluids, NPO, broad-spectrum abx, H2 receptor blockers
Large or severe: surgical repair
Mallory-Weiss Syndrome (Tears) causes, sx, dx, tx
PATHO:
*sudden rise in intraabdominal pressure or gastric prolapse into the esophagus (persistent retching or vomiting after ETOH binge)
*may also be associated w/ hiatal hernias
sx: *upper GI bleeding preceded by retching or vomiting
*hematemesis, melena, syncope
*may develop abdominal pain, back pain, or hydrophobia
dx: Upper endoscopy – superficial longitudinal mucosal erosions
tx: Not actively bleeding: supportive
*PPIs promotes healing
Severe bleeding:
*thermal coagulation, hemoclips, endoscopic band ligation, balloon tamponade
Paralytic Ileus
temporary functional impairment of peristalsis, ⊘physical barrier
*postoperative, peritonitis, meds (e.g., opioids, anticholinergics)
*electrolyte abnormalities (e.g., hypokalemia)
*hemoperitoneum/retroperitoneal hematoma
SBO vs LBO MCC
SBO MCC: adhesions from prior abdominal surgery (75%) > hernia > neoplasms
LBO MCC: adenocarcinoma > scarring secondary to diverticulitis > volvulus
Volvulus
torsion of bowel on its axis ⇢ closed loop obstruction; sigmoid MC (75%), cecal (25%)
*torsion of mesenteric vascular pedicle ⇢ occlusion/thrombosis of mesenteric vessels ⇢ bowel
SBO vs LBO sx
Both: *N/V, colicky abdominal pain, obstipation
*peristalsis (bowel sounds) ⇡⇡ in early phases of mechanical obstruction
d/t intense intestinal muscular contraction (“peristaltic rush”)
▪︎progressively ⇣ & eventually disappears in late obstruction
*strangulation: fever, crampy abdominal pain ⇢ peritonitis
*vitals: initially normal ⇢ tachycardia & hypotension d/t dehydration
SBO:
Proximal SBO: profuse emesis containing undigested food, upper abdominal discomfort, epigastric distention
Distal SBO: diffuse, poorly localized crampy abdominal pain
LBO:
*emesis is late finding, may be absent if ileocecal valve prevents reflux
*deep, visceral, cramping pain from colonic obstruction usually referred
to hypogastrium
*cancer ⇢ gradually progressive pain/symptoms, volvulus ⇢ acute
SBO vs LBO dx
DX: plain abdominal x-rays (supine/standing), CT w/w/o contrast
*dilated bowel loops w/ air-fluid levels in ladder-like appearance
▪︎3-6-9 rule: small bowel >3cm, large bowel >6cm, cecum >9cm
▪︎SBO dilated loops ⇢ central, LBO dilated loops ⇢ peripheral
*little/no air distal to obstruction
*pneumoperitoneum ⇢ perforation
Volvulus dx
SIGMOID Volvulus: coffee bean sign (bent inner tube, kidney bean)
*dilated loop w/ absent haustrae, arises in LLQ & extends ⇢ RUQ
*proximal colonic/small bowel dilation w/ air-fluid levels, ⊘distally
CECAL Volvulus:
*dilated loop w/ maintained haustrae, arises in RLQ & extends ⇢ LUQ
SBO vs LBO tx
SMALL BOWEL:
*NPO, IV fluids, foley to monitor urine output
*NGT for gastric decompression (⇣ N/V,
distention)
*monitor electrolytes for hypokalemia,
metabolic acidosis (signs of ischemia)
*pts w/ suspected strangulation need fluid
resuscitation prior to surgery
24h w/o improvement, deterioration:
*laparotomy, procedure depends on cause
▪︎adhesions: lysis of adhesions (LOA)
▪︎hernias: reduced/repaired
▪︎Crohn’s: resection or stricturoplasty
*entire small bowel should be examined
*resect nonviable intestine
*primary anastomosis of resected segments
LARGE BOWEL:
*surgery almost always required
*goals ⇢ resection of necrotic bowel &
decompression of obstructed segment
Options:
*resection + primary anastomosis
*resection + diversion, diversion alone
*endoscopic stent placement
Peptic Ulcer disease causes + duodenal vs gastric ulcers
Gastric erosions >0.5cm on imaging
Duodenal Ulcers: 4x more common, usually benign
Gastric Ulcers: 4% associated w/ gastric adenocarcinoma
PATHO: imbalance between
- ↑ aggressive factors in DU (hydrochloric acid, H. pylori)
- ↓ protective mechanisms w/ GU (mucus, bicarb, PGs)
Etiologies:
*H. pylori MC cause of gastritis
*NSAIDs/ASA – 2nd MC cause (GU – PG inhibition)
PUD sx, dx, and tx
Dyspepsia (burning, gnawing, epigastric pain) hallmark; N/V
DU: dyspepsia classically relieved w/ food
GU: sxs worsened w/ food
Bleeding ulcer: hematemesis, melena, hematochezia – PUD is MC cause of upper GI bleed
Perforated ulcer: sudden onset of severe abdominal pain (may radiate to shoulder); peritonitis (rebound tenderness, guarding, rigidity)
Upper endoscopy w/ bx – all GU need repeat endoscopy to document healing
H. pylori testing:
*endoscopy w/ bx – gold standard
*urea breath test (H. pylori converts labeled urea 🡪 labeled CO2; breathing out labeled urea = +)
H. pylori positive:
*bismuth quadruple therapy: bismuth subsalicylate + tetracycline + metronidazole + PPI x14d
H. pylori negative:
*PPI; H2 blocker, misoprostol, antacids, etc.
