GI Flashcards
Dysphagia
- means
- anatomic presentation differences
- swallowing difficulty
- oropharynx=liquid dysphagia
- esophagus=solid dysphagia
Infectious esophagitis
-ddx w/ diagnostics & treatment
1) Candida
- yellow-white plaques on palate/tongue
- nystatin or fluconazole
2) HSV
- small, deep ulcerations
- multinucleated giant cells w/ intranuclear inclusions
- +tzank smear
- acyclovir
3) CMV
- large, superficial ulcerations
- intranuclear and intracytoplasmic inclusions
- gancyclovir
Diffuse Esophageal Spasm path, presentation, dx, tx
High amplitude non-peristaltic contraction of esophagus with normal* LES relaxation
chest pain, dysphagia ==>precipitated by cold/hot liquids*
Barium swallow: corkscrewing
Manometry: high-amplitude contractions w/ normal LES
nitrates & calcium channel blockers; surgery if severe
Achalasia path*, dx, tx
impaired relaxation of LE sphincter & impaired peristalsis of lower 2/3 esophageal smooth muscle
2/2 degeneration of inhibitory neurons of auerbach’s plexus
Barium: bird’s beak @ LES
Manometry: *required for dx… impaired relaxation of LES & impaired peristalsis
Endoscopy: recommended to r/o cancer
Surgery, if healthy
Nitrates & calcium channel blockers, if not
Esophageal diverticula presentation, dx
Regurgitating undigested food
Halitosis
Barium swallow outpouchings
Esophageal SCC anatomy, risk factors, dx*
upper 2/3 of esophagus 2/2 tobacco & ETOH
barium swallow showing irregular borders ==> CT & ultrasound for staging
Esophageal Adenocarcinoma path, anatomy, risk factors, dx
Carcinoma @ lower 1/3 esophagus 2/2 GERD or Barrett’s
barium swallow showing irregular borders ==> CT & ultrasound for staging
GERD pathophysiology, sequelae, presentation*, dx, tx
LES relaxation 2/2 incompetence or hiatal hernia ==> barrett’s (columnar intestinal metaplasia) and/or benign peptic strictures
Burn 30-90 after meal Worse with reclining* Cough Water brash Globus (lump in throat) Exacerbated by: ETOH, caffeine, chocolate, garlic, onions, mints, nicotine
Clinical…but if not resolving:
- barium swallow to look for hiatal hernia
- EGD w/ biopsy to rule out barrett’s
1- lifestyle
2-PPIs (-prazole) or H2 antagonists (-idine)
3- nissen fundoplication (wrap fundus around esophagus)
Barrett’s pathophysiology, dx*
Squamocolumnar metaplasia @ LES border 2/2 GERD
EGD: irregularity of border
Hiatal hernia path w/ commonality, dx
1- sliding: GE junction & nearby stomach slides above diaphragm* into esophagus
2- paraesophageal: GE junction stays below diaphragm while other part herniates into thorax
==>95% sliding
CXR (incidental) or barium swallow/EGD
Ascites tx*
Na/water restriction ==> spironolactone ==> furosemide ==> paracentesis
*Stop diuresis @ 1L to avoid hepatorenal
SBP presentation, dx, tx
Abdominal pain, fever, chills, MS change
Ascites PMN > 250/mL & +Gram Stain
3rd gen cephalosporin
IV albumin
Floroquinolone prophylaxis
Hepatorenal syndrome path, dx, tx
Prerenal failure in setting of cirrhosis
Diagnosis of exclusion: urine Na <10, pre-renal Cr elevation, failure to respond to NS bolus
Dialysis & liver transplant
Non-alcoholic fatty liver disease path, presentation, dx, tx
Hepatitis progressing to cirrhosis 2/2 metabolic syndrome & insulin resistance
RUQ pain w/ metabolic syndrome (being fat) and/or diabetes
elevated AST/ALT in absence of other lab abnormalities + being fat
Weight loss & fat-restricted diet
Hepatic encephalopathy path, presentation, dx, tx
Inability to convert ammonia to urea in liver
2/2 cirrhosis, GI bleed
Insomnia
MS change
Asterixis
Lactulose / lactitol ==> lower serum ammonia
Rifaxamin ==> antibiotic kills ammonia-producing bacteria
Laxative
Protein restriction
Esophageal varices anatomy, tx*
?
Non-bleeding: beta blockers
Bleeding: band ligation/sclerotherapy if acute bleeding
Hepatic coagulopathy path**, tx
?
Impaired synthesis of clotting factors except VIII
Fresh frozen plasma
(Vitamin K will not work)
Primary biliary cirrhosis path, presentation, dx, tx
Autoimmune destruction of intrahepatic bile ducts
Autoimmune hx (usually women) Jaundice, pruritis, fat-soluble vitamin deficiencies Xanthomas 2/2 impaired fat storage*
+antimitochondrial antibody
Elevated Alk-P & bilirubin
Ursodial (aka ursodeoxycholic acid) to slow disease
[Cholestyramine for pruritis]
Liver transplant
Hepatocellular carcinoma risk factors, presentation, dx, tx
Alcoholic & HCV cirrhosis
Aflotoxins
HBV cirrhosis
RUQ pain, jaundice, bruisability, bleeding
Enlarged liver
Elevated alpha-fetoprotein, LFT abnormalities
Ultrasound or CT
Resection for non-cirrhotic lesions 5cm and/or cirrhotic lesions
Hemochromatosis path, presentation, dx, tx
Excessive hemosiderin lodges in heart, liver, pancreatic islet cells, adrenals, testes, kidneys, pituitary
1- autosomal recessive excessive absorption
2- 2/2 transfusions from blood disorders
Bronze skin
Diabetes, hypogonadism, heart failure, cirrhosis, MCP joint pain
Increase serum Fe, ferritin, & transferrin saturation >45% (serum Fe/TIBC)
Decreased transferrin
Biopsy/MRI/HFE gene test
Weekly phlebotomy + deferoxamine
Wilson’s disease path, presentation, dx, tx
Autosomal recessive copper transport disorder depositing in liver, basal ganglia, eyes
Hepatitis & cirrhosis
Ataxia, tremor, psychiatric changes <30y/o
Kayser-Fleischer rings, ataxia, choreiform movements, jaundice
Liver biopsy: Mallory bodies, steatosis
Decreased ceruloplasmin
Increased urinary copper
Slit lamp exam
Penicillamine = plasma copper chelator Zinc = dietary copper chelator
Acute pancreatitis path, risk factors, presentation, dx, complication, tx
Leakage of pancreatic enzymes causing auto-destruction
ETOH > gallstones > post-ERCP > hypercalcemia, hypertriglyceridemia, drugs > scorpion bites
Abrupt onset epigastric pain radiating to back, n/v, fever
Grey Turner’s flank discoloration & Cullen’s periumbilical discoloration
Dx: 2+
Amylase / lipase 3x elevation
Characteristic history/PE
Characteristic imaging
==> Abdominal ultrasound: better for showing stones if suspecting cholelithiasis etiology (i.e. non-alcoholic patient)
==> CT: showing enlarged pancreas w/ fluid & fat stranding
ALWAYS DO BOTH*
Pancreatic pseudocyst, shock, fistula, hypocalcemia, pleural effusion
*IV fluids + Analgesia + Bowel rest
Chronic pancreatitis path & risk factors, presentation, dx,
Parenchymal destruction leading to insufficiency
ETOH»_space;> gallstones, CF, autoimmune, smoking
Chronic epigastric pain
Onset of DM
Steatorrhea
Anorexia, weight loss
Normal-high amylase/lipase
Xray (or CT): calcifications, chain of lakes pancreatic duct, ileus
Pancreatic cancer path, anatomy, risks, presentation*, dx, tx
Adenocarcinoma, 75% in head of pancreas
Smoking, chronic pancreatitis, obesity
Late-onset: jaundice, weight loss, anorexia
- Courvoisier’s sign: nontender palpable GB
- Trousseau’s sign: migratory thrombophlebitis
Biliary obstruction: elevated bilirubin, alk-p ==> CT scan if suspecting pancreatic cancer!
Usually palliative
If small in pancreatic head without vessel involvement ==> whipple
Chemo & 5-FU ==> improves survival
Acute gastritis causes
ETOH, NSAIDs, H. Pylori, stress
Chronic gastritis types w/ path, sequelae
Type A: autoantibodies to fundus parietal cells ⇒ no IF ⇒ no B12 absorption ⇒ anemia
Type B: NSAIDs & H. Pylori damage antrum
gastric adenocarcinoma ==> ovarian met (Krukenberg carcinoid tumor)
H. pylori dx, tx
Urease breath test
Stool antigen
IgG (only tests previous infection, not if currently active like above 2)
Triple therapy: omeprazole, clarithromycin, amoxicillin/metronidazole
H. pylori cancer type, location, treatment
MALT: mucosa-associated lymphoid tissue
Stomach
Triple therapy
“Stress” ulcer causes
Burns
TBI
Other severe illnesses
Gastric adenocarcinoma pathophysiology w/ risk factors, presentation, dx, tx
- Intestinal: differentiated gastric mucosal cells 2/2 nitrates (think Asians), H. pylori, chronic gastritis
- Undifferentiated: no known risk factors
Late-stage presentation of indigestion, weight loss, GI bleeding
Left supraclavicular Virchow’s node
Endoscopy
Undifferentiated: Signet ring cells
==> surgery but rarely resectable because of late presentation
Peptic Ulcer Disease (PUD) pathophysiology w/ risk factors, presentation, dx
Gastric OR duodenal mucosal irritation 2/2 H. pylori, ETOH, tobacco, NSAIDs, corticosteroids (not stress), ZE
Dull, burning epigastric pain (worse with food if gastric, better with food if duodenal). Coffee ground emesis. Dark stool.
Sometimes epigastric tenderness & guiac +
H. pylori testing
MUST RULE OUT: perforation & cancer
Upright XR for air under diaphragm
Biopsy ulcer
Zollinger-Ellison Syndrome pathophysiology w/ association, dx, tx
Elevated gastric acid 2/2 gastrin producing tumor in duodenum or pancreas ==> inactivates pancreatic enzymes ==> malabsorption
Associated with MEN-1 (20% of gastrinomas)
Ulcers extending into jejunum
Increased serum gastrin ==> if non-diagnostic, secretin injection (gastrinoma secretes gastrin with secretin but gastric G cells are inhibited)
CT to localize tumor then PPIs + resection of tumor
SBO path, presentation*, dx, tx
Adhesions 2/2 surgery, hernias, neoplasms
Crampy abdominal pain. Vomiting (bilious if proximal; feculent if distal). No to minimal flatus.
Partial = flatus without stool
Complete = no flatus or stool
Distention, diffuse pain & high-pitched “tinkles”
CXR/CT air-fluid levels, dilated small bowel w/ transition point
NG tube, fluid resuscitation ==> laparatomy if peritoneal OR septic-looking (hypotensive, fever, significant leukocytosis, acidosis)
Ileus pathophysiology w/ risk factors, presentation, dx, tx
Loss of peristalsis 2/2 electrolyte derangement, abdominal surgery, other illnesses
n/v, no flatus or BM
distention
absent bowel sounds (unlike tinkling of SBO)
Air throughout large & small bowel without transition point
NPO. NG suction. Parenteral feeds. Remove narcotics that slow motility
Gallstone ileus pathophysiology, dx
Gallstone erodes through wall into small bowel & lodges in ileocecal valve
Upright XR showing SBO + gas in biliary tree
Acute mesenteric ischemia etiologies, presentation, dx, tx
Thrombotic, usually 2/2 SMA atherosclerosis
Embolic, usually 2/2 A-fib
Nonocclusive 2/2 low cardiac output
Venous thrombosis
n/v, diarrhea, bloody stools
pain out of proportion to exam
Elevated WBC, LDH, etc.
Angiography = diagnostic
Anticoagulate or laparotomy
Diverticulosis path w/ risk factors, presentation*, dx, tx
Mucosal outpouchings, usually sigmoid colon 2/2 low fiber diet & age
Acute painless GI bleeding
Constipation
Abdominal pain
Colonoscopy after resolution…risk of perforation if too soon
High fiber diet
Diverticulitis path, presentation*, dx, tx**
Infected diverticum 2/2 fecalith
n/v, fever, abdominal pain [note no diarrhea necessary]
LLQ abdominal pain
Uncomplicated: Leukocytosis CT ==> inflammation & wall thickening -------- Complicated: CT ==> fluid (aka abscess) perforation, fistula
Complicated:
Abscess 3cm: CT drainage ==> surgical drainage if not resolving by day 5
Resection: fistula, perforation, repeated episodes
Large bowel obstruction etiology, presentation, dx, tx
Assume cancer
Less intense n/v & distention than SBO
XR w/ enema or CT showing dilated sigmoid colon
Rectal tube or surgery
Colorectal cancer risks
Polyp types* (high-yield)
Age >70
UC > Chrons
Strep bovis*
Adenomas:
Sessile»_space; stalked
Villous»_space; tubular
>2.5cm = bad!
Non-adenomas:
Hyperplastic & hamartomatous = non-neoplastic
Colorectal cancer screening recommendations
No hx: @50, guiac Q1year + colonoscopy Q10 or sigmoid Q5
Ca hx: @40 or 10 years younger than relative, colonoscopy Q10
UC: Colonoscopy Q2 8-ish years after diagnosis
Colorectal cancer presentation
R-sided: fatigue 2/2 anemia, anorexia, rarely obstruction
L-sided: change in bowel habits, obstruction, bloody stools
Ischemic colitis path, presentation, dx, tx
Watershed areas: splenic flexure & rectosigmoid junction
Atherosclerosis hx Hypotensive event Abdominal pain Bloody diarrhea Fever, n/v
Extreme leukocytosis
Colonoscopy showing pale mucosa & bleeding
Fluid & broad spectrum abx
Surgery if peritonitis
Upper GI vs lower GI bleed anatomical distinction
Ligament of Treitz @ duodenum/jejunum
Upper GI bleed ddx, presentation, workup, tx*
PUD > esophageal varices, Mallory Weiss tear, Boerhaven(?), esophagitis, gastritis
Hematemesis (coffee ground) or melena (dark stool) > hematochezia
NG tube w/ lavage ⇒ endoscopy if stable
Fluid / pRBCs
Intubate if airway at risk*
Endoscopy
Lower GI bleed ddx, presentation, workup*
Diverticulosis > angiodysplasia, IBD, hemorrhoids, AVM
Hematochezia
NG lavage to r/o UGI bleed ⇒ ano/colonoscopy if stable [*anoscopy first if RBC scintigraphy if colonoscopy fails
When to give pRBCs & how much*
@7Hgb (?)
1 unit increases Hgb g/dL & hematocrit 3-4units
Crohn’s path, anatomy, presentation, associations, dx, tx
Transmural inflammation (neutrophilic cryptitis) with discontinuous skip lesions, fistulas, fat, non-caseating granuloma*, bowel wall thickening
Anywhere in GI tract especially ileocecal region, EXCEPT rectum
Bimodal age distribution: 20’s and 60’s
Watery diarrhea, abdominal discomfort
Perianal fissures/fistulas
Erythema nodosum
Migratory polyarthritis
Kidney stones
leukocytosis & anemia during flares
XR: string sign bowel thickening
Colo: strictures on XR, cobblestoning/skip lesions
Biopsy: transmural, cobblestone, fat, granuloma
5-asa (sulfasalazine, mesalamine) ⇒ azathiophrine/infliximab
Ulcerative colitis path w/ anatomy, presentation w/ associated findings*, dx, tx
Mucosal & submucosal inflammation (neutrophilic cryptitis) in continuous fashion, crypt abscess, pseudopolyps
Only colon (hence name), ALWAYS rectum
Bimodal age distribution: 20’s and 60’s
Bloody diarrhea, abdominal discomfort
Pyoderma gangenosum, increased colorectal cancer risk, apthous stomatitis, uveitis, arthritis, primary sclerosing cholangitis, erythema nodosum
Leukocytosis & anemia during flares
Colo: lead pipe loss of haustra on XR, continuous ulcers & polyps
5-asa (sulfasalazine, mesalamine) ⇒ azathiophrine/infliximab ==> proctocolectomy
Crohn’s vs UC diagnosis*
Crohn’s: strictures on XR, cobblestoning/skip lesions on colonoscopy, non-caseating granuloma, rectal sparing
UC: lead pipe loss of haustra on XR, continuous lesions & pseudopolyps on colonoscopy, rectal involvement
Both: leukocytosis & anemia during flares
Crohn’s vs UC tx
Both: 5-asa (sulfasalazine, mesalamine) ⇒ azathiophrine/infliximab
UC: proctocolectomy
Crohn’s vs. UC risks**
Crohn’s: increased cancer
UC: markedly increased cancer risk requiring Q1-2 colonoscopies 8 years post-dx
Direct vs. indirect inguinal hernia, anatomy
?
Acute cholecystitis path* w/ associations, presentation, dx, tx
GB stone + inflammation
Chronically ill / TPN: acalculous
Ileal resection: Decrease bile acid recirculation ⇒ changes bile composition ⇒ cholesterol supersaturation causing gallstone formation
RUQ pain
n/v, fever
stone/sludge+inflammation+murphy’s on ultrasound, leukocytosis
Tx: cholecystectomy +/- abx if cholecystitis
Acalculous cholecystitis path, dx
Chronically ill / TPN patients lack CCK release 2/2 no food, thus stasis
Pericholecystic fluid without stones
If cholecytitis ultrasound is equivocal
HIDA scan showing no tracer entering GB
Choledocholithiasis path, presentation, dx
Stone in CBD
Jaundice, biliary colic, fever, +/-pancreatitis
Elevated T&D bilirubin, elevated Alk-P
ERCP = diagnostic & therapeutic (ultrasound is low sensitivity
Cholelithiasis/colic path, presentation, dx, tx*
Stone in GB ==> no inflammation
post-prandial RUQ pain
n/v
stone on ultrasound
Surgery only if symptomatic
Ascending cholangitis path, presentation, dx, tx
Infection of biliary tree (gram negative enterics E. coli, Klebsiella) 2/2 choledocholithiasis, sclerosing cholangitis, biliary stricture, malignancy
Charcot’s triad: jaundice, RUQ pain, fever/chills
Reynold’s pentad: jaundice, RUQ pain, fever/chills, sepsis, AMS
Leukocytosis, elevated T&D bilirubin, elevated Alk-P
ERCP + broad spectrum abx
Primary sclerosing cholangitis path w/ association, presentation, dx, tx
Idiopathic inflammation/fibrosis of larger intra&extra hepatic bile ducts
Jaundice, pruritis, fatigue
IBD, esp. UC**
Elevated Alk-P bilirubins
Maybe +p-anca
ERCP showing beading of biliary tree
Liver biopsy showing ductal sclerosis (“onion skinning”)
Ursodiol/ursodeoxycholic (reduce bilirubins?)
ERCP + stenting
Liver transplant
Bilirubin metabolism mechanism
RBC breakdown in spleen ⇒ hemoglobin ⇒ unconjugated/indirect bilirubin-albumin complex ⇒ conjugated/direct in liver ⇒ excreted via GI or as dark urine if backed up
Conjugated elevation = hepatic backup
Unconjugate elevation = hemolysis etc.
Hyperbilirubinemia ddx*
Conjugated/direct: defective excretion, Dubin-Johnson, Rotor’s
Indirect: hemolytic anemia, Gilbert’s (high-normal), Crigler-Najjar
Hepatitis A path, presentation, dx, tx
RNA virus transmitted fecal-oral
Usually 2/2 overcrowded conditions (3rd world)
Acute abdominal pain, malaise
Dark urine
Aversion to smoking
Transient ALT/ASK, Alk-P, bilirubin elevations
Supportive care
HBV path, presentation courses, dx w/ serum marker time courses, clearance dx, tx
DNA virus transmitted sexually, parenterally, vertically
90%: acute with full recovery
5%: chronic HBV
5%: fulminant hepatic failure ==> increasing PT/PTT, decreasing AST/ALT 2/2 fewer hepatocytes, encephalopathy*, etc
HBsAg: HBV antigen indicating viral carrier; earliest marker of infection
*Anti-HBsAg: HBV antibody indicating vaccine immunity or viral clearance
*Anti-HBc: first antibody to HBsAg, prior to “window phase” of anti-HBsAg. IgM version indicates acute infection. IgG version indicates chronic infection or recovery (if anti-HBs present)
*HBeAg: early phase antigen indicating viral replication and transmissibility risk… if it persists, risk for chronic infection increases
Anti-HBe: antibody arising in “window” period that indicates low transmissibility risk
Inactive carrier: Positive HBsAg, Positive Anti-HBe, Negative HBeAg, Positive 3+ ALT or 2+ DNA normal levels
All: Interferon + lamivudine / adefovir
Fulminant: STAT liver transplant…IF not abusing drugs
Autoimmune hepatitis dx*
Anti-smooth muscle Ab
HCV path, presentation, dx, tx*
RNA virus transmitted parenterally, mostly
Mild hepatitis prodrome ==> progresses to cirrhosis and HCC
HCV RNA level ==> if present, liver biopsy* to assess stage
Ultrasound q6 months for cirrhotics to r/o HCC
Interferon & ribavirin (after liver biopsy*)
Sequelae of chronic hepatitis
HCC, cirrhosis, liver failure
Cirrhosis pathophysiology, causes, presentation
Fibrosis & nodularity of liver
Hepatitis, biliary tract disease, Budd-Chiari (hypercoagulability thromboses hepatic vein), R-sided heart failure, hemochromatosis, Wilson’s disease, alpha-1-antritrypsin deficiency*, drugs/alcohol
Amenorrhea (women)
Men: hyperestrogen 2/2 inability to metabolize ==> hypogonadism, decreased libido, telangiectasias, gynecomastia, palmar erythema
Low T3/T4 (2/2 decreased serum binding proteins)*
SAAG meaning*
SAAG: serum albumin MINUS ascites albumin
> 1.1=portal hypertension (increased capillary hydrostatic pressure*)
<1.1.=non-portal HTN (nephrotic, TB, malignancy)
Tropical sprue hx/pe
Travel
Malabsorptive diarrhea
Hyperactive bowels
Whipple’s disease presentation, dx*, tx
Older white male
Weight loss, diarrhea/malabsorption
Extra intestinal manifestations: migratory polyarthritis, cough, hyperpigmentation, fever, lymphadenopathy, valvular disease/heart failure, CNS dysfunction
Small intestine biopsy: PAS-positive macrophages in lamina propria with gram+ bacilli
Abx
C. diff presentation, sequalae, dx, tx*
Abx hx
Watery BM ==> toxic megacolon
Leukocytosis, fever
Toxic megacolon
C. diff stool PCR
Oral metronidazole: WBC15,000 or Cr >1.5
Vanc + metronidazole: ileus + above
Colectomy: WBC>20,000 peritoneal
Endoscopy vs PPI as initial management in dyspepsia
Endoscopy: If >55 or warning signs of weight loss, dysphagia, vomiting, bleeding, family history)
PPI/Hpylori test: If none of above
Giardia dx, tx
Stool sample ⇒ ova and parasites
Metronidazole
VIPoma path, presentation, dx, tx
Vasoactive intestinal peptide tumor in pancreas
Diffuse watery diarrhea (hallmark), cramps 2/2 hypokalemia, abdominal pain, flushing
High VIP in blood stream ⇒ CT to locate
Surgical resection if not metastasized
Toxic megacolon presentation, dx, tx
Bloody diarrhea
Often IBD hx
Fever, tachycardia, neutrophilic leukocytosis, anemia, volume depletion
X-ray: distension >6cm
IV steroids (if IBD) or abx (if bacterial) + NG tube ==> surgery if unresolving
Celiac path, presentation, dx
Gluten (gliadin) allergy causing villous blunting 2/2 IgA deposition
Weight loss, foul bulky stools, joint pain
Fe deficiency anemia 2/2 malabsorption
Dermatitis herpetiformis: extensor elbow/knee rash
Often associated with type 1DM
Biopsy: villous atrophy
D-xylose test: should absorb in proximal small intestine unless malabsorption occurring
IgA anti-tissue transglutaminase and/or IgA anti-endomysial antibodies…unless! Selective IgA deficiency which is common in celiac
Pharyngeoesophageal (Zenker’s) diverticulum path, presentation*
Herniation posteriorly above UES through cricopharyngeal muscle 2/2 sphincter & esophageal dysmotility
Liquid/solid dysphagia @ oropharynx with mass
Dubin-Johnson path, presentation, dx*, tx
Icterus
Fatigue
+/- trigger
Elevated direct bilirubin (Gilbert’s is indirect)
Otherwise normal
Elevated coporphyrin 1
No treatment
Drug-induced esophagitis causes
Tetracyclines
Aspirins/NSAIDs
Alendronate
KCl, quinidine, Fe
Zinc deficiency path & PE
Jejunum absorption
Alopecia, skin lesions, poor wound healing
Vitamin A deficiency hx/pe
Blindness, dry skin, poor immunity
GI bleeding effect on kidney
Elevated BUN:Cr ratio 2/2 blood reabsorption increasing urea levels
Benign peptic stricture path, presentation, dx
GERD causing symmetric stricture @ distal esophagus
GERD hx that resolves (2/2 narrowing)
Solid dysphagia
Barium swallowing showing symmetric ring
Angiodysplasia presentation
Painless rectal bleeding
Aortic stenosis
Renal failure
Anal fissure presentation, dx, tx*
Painful shits 2/2 constipation
Tear on anus
Local anesthetic, stool softener, high-fiber diet
Most common cause of iron deficiency anemia in elderly:
GI bleed ==> colonoscopy then endoscopy
Carcinoid syndrome path, presentation, dx, tx*
Tumor of ileum or appendix ==> secrete serotonin ==> once metastasized to liver, symptoms begin
TRIAD: Flushing/wheezing Diarrhea Cardiac valve lesions ----- 3D'S of niacin deficiency 2/2 increased serotonin diarrhea, dermatitis, dementia, death
High urine 5-HIAA (serotonin metabolite)
CT & octreotide scans localize tumor
Octreotide & surgical resection
Mallory-weiss tear path, presentation, tx*
Ruptured artery @ GE junction with incomplete mucosal tear
Recent vomiting
Hematemesis
Usually resolves
Vasopressin or endoscopy may be required
Boerhaave tear path, presentation, dx, tx*
Full-thickness esophageal rupture, usually above GE junction
Pain post-vomiting
Septic-looking
Crepitus @ suprasternal notch*
Hamman’s sign: crunch sound on cardiac auscultation 2/2 air
CXR showing pleural effusion, pneumomediastinum, pneumothorax ==> water soluble contrast esophagram*
Surgery
Tropical sprue dx
Macrocytic anemia (2/2 B12 folate deficiency) Blunted villi w/ chronic inflammatory cells
Factitious diarrhea dx
Profuse watery stools
Brown colon w/ shiny lymph patches (melanosis coli)
Niacin deficiency name, hx, pe
Pellagra
Corn-based diets
Alcoholics
Carcinoid syndrome 2/2 serotonin overproduction
4D’s: dermatitis, diarrhea, dementia, death
Small intestinal bacterial overgrowth presentation*, dx
Surgeries, motility disorders (scleroderma, diabetes) etc. ==> bloating, diarrhea
Dx: Jejunal aspirate
Lactose intolerance dx
+hydrogen breath test
+stool reducing substances
Low stool pH
Increase stool osmotic gap
Drug induced pancreatitis drugs*: (memorize for USMLE)
Diuretics: furosemide, thiazides IBD drugs: sulfasalazine, 5asa Immunosuppresed patients: azathioprine Bipolar/seizure: valproic acid AIDs: ARVs Abx: metronidazole, tetracycline
Esophageal dysmotility path (???)
Absent peristaltic waves and decreased LES tone
2/2 scleroderma
Dumping syndrome path, presentation, tx
Post gastrectomy excess tonicity enters duodenum => pulls fluid and releases vasoactive peptides
Weakness, cramps, sweating
Dietary change
Octreotide if refractory
Pyloric stricture path, hx/pe*, tx
Gastric outlet stricture 2/2 malignancy, PUD, ingestion, bezor
Vomiting partially digested food Succussion splash (stethoscope on belly ==> splash)
Surgery
Bowel ischemia vs acute mesenteric ischemia*
Bowel:
- less severe pain
- CT shows thickened bowel
- colonoscopy shows focal area of ulceration with normal sites above and below
Crohn’s and urinary stones path*
Crohns fat malabsorption causes excess calcium:fat binding resulting in increased free oxalate for absorption ==> oxalate stone predisposition
True for any malabsorptive disorder
Nasopharyngeal carcinoma path, presentation*, dx, tx
Squamous cell undifferentiated cancer 2/2 EBV, nitrosamines
Mediterranean and eastern men
Epistaxis
Otitis media
Nasal obstruction
Elevated EBV level
Biopsy
Usually metastatic once found
Gilbert syndrome path, presentation, dx, tx
Enzyme deficiency preventing bilirubin conjugation ==> asymptomatic / benign
Icterus
Malaise
Often 2/2 stressful event
Mildly elevated unconjugated (indirect) bilirubin
No tx
Crigler Najar syndromes 1 & 2 path, presentation, dx, tx
Autosomal recessive inability to conjugate bilirubin
Type 1: infantile severe jaundice and kernitcerus (bilirubin encephalpathy)
Type 2: milder jaundice without kernicterus
Type 1: normal liver histology; severe indirect bilirubin elevation WITHOUT decrease with phenobarbitol administration
Type 2: normal liver histology; milder indirect bilirubin elevation WITH decrease with phenobarb administration
Type 1: phototherapy and plasmapheresis ==> liver transplant
Type 2: none
Rotor syndrome path, presentation, dx, tx
Defect of hepatic storage of conjugated / direct bilirubin
Jaundice
Benign elevation of conjugated AND unconjugated bilirubin
None
Porcelain gallbladder path, presentation, risk, dx, tx
Calcium deposition 2/2 chronic cholecystitis
Biliary colic
Progresses to gallbladder carcinoma*
Calcified rim
Cholecystectomy
Biliary tree anatomy*
Liver: common hepatic GB: cystic ==> converge @ CBD Pancreatic duct joins CBD ==> all juices exit @ sphincter of Oddi
