GI Flashcards
Hepatic Vein Obstruction
Sx
Dx
Tx
Usually due to hepatic vein thrombosis or hepatic vein occlusion
Results in decreased liver trainage, portal HTN and cirrhosis
Sx: Ascites, Hepatomegaly, and RUQ abdominal pain
Rapid development of jaundice and hepatosplenomegaly
Dx: Ultrasound shows occlusion of hpeatic vein or inferior vena cava
Tx: Shunts (TIPS), Angioplasty with stent, Anticoagulation, Diruetics for ascities, low sodium diet for ascites, paracentesis for ascites
What is Cholelithiasis
Sx
Dx
Tx
Gallstones in the gall bladder without inflammation
Risk Factors: 5 F’s (Fat, Female, Fertile, Forty, Fair)
Sx: Biliary Coli: episodic RUQ/epigastric pain that starts abruptly, is continuous and resolves slowly
Dx: Ultrasound
Tx: Observation if asymptomatic, Cholecystetcomy if symptomatic
What is Choledocholithiasis
Gallstones in biliary tree (Common bile duct)
See dilated ducts
Tx: ERCP with stone extraction
What is Cholangitis
Sx
Dx
Tx
Biliary tract infection secondary to gallstone obstruction
Sx: Charcot’s Triad: Fevers/chills, RUQ pain, Jaundice
Dx: ERCP
Tx: Abx (PCN and Aminoglycoside), ERCP with stone extraction
What is Acute Cholecystitis
Sx
Dx
Tx
Gallbladder obstruction by gallstone, leads to infection and inflammation
E.Coli is most common pathogen
Sx: Biliary Colic, nausea preciptiated by fatty foods or large meals
Fevers, N/V, palpable GB, Positive Murphy’s Sign, Positive Goas Sign (referred pain to right subscapular area due to phrenic nerve irritation)
Dx: Ultrasound (see thickened GB, sludge, gallstones)
Increased WBC with left shift, Increased Bilirubin, Increased ALP and lftS
HIDA Scan is GOLD STANDARD, you won’t see the gallbladder with cholecystitis
Tx: NPO, IVF, Abx (3rd gen cephalosporin + Metronidazole), Cholecystectomy within 72 hours
What is Chronic Cholecystitis
Sx
Dx
Tx
Associated with gallstones
May result from repeated bouts of acute/subacute cholecystitis
Strawberry Gallbladder
Alcoholic Hepatitis
Sx
Dx
Tx
AST:ALT >2
Pentoxifylline decreases hepatorenal syndrome
What is Fulminant Hepatitis
Sx
Dx
Tx
Rapid liver failure with Hepatic Encephalopathy
Reye’s Syndrome is seen in kids and associated with ASA use during viral infection
Caused by acetaminophen, drug reactions, viral hepatitis
Sx: Encephalopathy (vomiting, coma, seizures, asterixis)
Coagulopathy
Dx: Increased ammonia, hypoglycemia
Tx: Treat encephalopathy with Lactulose, Neomycin, Protein restriction
Liver transplant is the only definitive treatment
Hepatitis A Transmission Sx Dx Tx
Feco-oral
Contaminated water/food during international travel, day care, food handlers
Sx: Malaise, arthrlagia, fatigue, URI, spiking fevers, jaundice
Dx: Positive IgM Hep.A antibodies
Tx: Self-Limited
Post-exposure prophylaxis for close contacts: Hep.A Immunoglobulin
Hepatitis C Transmission Sx Dx Tx
Parenteral (Blood, Sex, Drugs)
Dx: Positive Anti-HCV
Tx: Pegylated interferon alpha-2b and Ribavirin for choronich
SE: Psychosis and Depression
Hepatitis B
What do you see in Window period
Immunized or Previously Resolved Infection
Acute Infection
Chronic Infection
Increased Viral Replication and Infectivity
Decreased Viral Replication and Infectivity
Tx
Window Period: Hepatitis B Surface Antigen (first indication of disease before sx even begin)
Immunized: Hepatitis B Surface Antibody
Person was infected but now resolved: Hepatitis B CORE Antibody
-IgM: Acute
-IgG: Chronic
Increased Viral Replication and Infectivity: Hep.B Envelope Antigen
Decreased Viral Replication and Infectivity: Hep.B Envelope Antibody
Tx: Alpha-Interferon 2b, Lamivudine, Adefovir
Hepatitis B vaccine contraindicated if allergic to Baker’s Yest
Hepatitis D
Needs Hepatitis B to cause co0infection
Hepatitis E
Transmission
Similar to Hepatitis A
Feco-Oral
ASsociated with waterborne outbreaks, self-limiting infection
Cirrhosis
Sx
Dx
Tx
Irreversible liver fibrosis with nodular regeneration secondary to chronic liver disase
Nodules cause increased portal pressure
Alcohol is most common cause, Chronic viral hepatitis and non-alcoholic fatty liver disease
Sx: Fatigue, weakness, weight loss, muscle cramps, anorexia
Spider Angioma, Caput medusa, muscle wasting, bleeds, hepatosplenomegaly
Hepatic Encephalopathy: Confusion and Lethargy, Asterixis, Increased ammonia levels
Esophageal varices (due to portal HTNA)
Dx: Ultrasound, Liver is definitive
Tx: Treat Encephalopathy with Lactulose, reduced protein intake and Neomycin
Ascites is treated with sodium restriction
Pruritis is treated with Cholestyramine
Liver Cancer
What biological marker can you use
Dx: Ultrasound, Increased Alpha-Fetoprotein and Biopsy
What is Primary Biliary Cirrhosis
Sx
Dx
Tx
Idiopathic autoimmune disorder of intrahepatic small bile ducts
Leads to decreased bile salt excretion, cirrhosis, and ESLD
Sx: Fatigue, Pruritis, Jaundice, RUQ discomfort, Hepatomegaly
Dx: Positive Anti-Mitochondrial antibody
Increased GGT
Tx: Ursodeoxycholic acid is 1st line
Cholestyramine and UV light for pruritus
Primary Sclerosing Cholangitis
Sx
Dx
Tx
Autoimmune, progressive cholestasis with diffuse fibrosis of intrahepatic and extra hepatic ducts
Seen commonly with Ulcerative Colitis
Sx: Progressive jaundice, pruritis, RUQ pain, Hepatosplenomegaly
Dx: Increased ALP, Increased GGT, Positive P-Anca
ERCP is gold standard
What is Wilson’s Disease
Sx
Dx
Tx
Free copper accumulation in liver, brain, kidney, cornea
Sx: CNS copper deposits, basal ganglia deposition
Liver Disease: Hepatitis, Hepatosplenomegaly, cirrhosis
Corneal Copper Deposits: Kayser0Fleischer Rings
Dx: Increased urinary copper deposits, Decreased Ceruloplasmin
Tx: Ammonia Tetrathiomolybdate binds to copper
Pencillamine Chelates copper
Zing enhances Cu excretion and blocks intestinal absoprtion
Acute Pancreatitis
Sx
Dx
Tx
Alcohol and Gallstones are the most common causes
Sx: Epigastric abdominal pain that is constant, boring, radiating to the back, relieved with leaning forward, sitting in the fetal position
N/V, Fevers
Cullen sign, Grey Turners sign
Dx: Lipase is most specific
Increased TRG, Increased Amylase, ALT, Hypocalcemia
CT is gold standard
Tx: Supportive, NPO, IV fluid, Analgesia with Demerol
ERCP if biliary sepsis suspected
RANSONS CRITERIA examines pancreatitis level Glucose Age LDH AST WBC Ca, Hct, Oxygen, BUN, Base Deficit
Chronic Pancreatitis
Sx
Dx
Tx
Loss of exocrine and sometimes endocrine function
Due to alcohol abuse, idiopathic
Cystic Fibrosis
Sx: Calcifications, Steatorrhea, DM
Dx: Calcified Pancreas
Tx: Oral Pancreatic enzyme replacement, Pain control
Pancreatic Cancer
Sx
Dx
Tx
Adenocarcinoma is most common
Sx: PAINLESS JAUNDICE, weight loss, abdominal pain that radaites to the back, pruritis, Courvoiseir’s sign (palpable, nontender, distneded gallbladder)
Dx: CT
Tumor Markers: DEA, CA 19-9
Tx: Whipple Procedure, ERCP with stent is palliative in inoperable patients
Meckel’s Diverticulum
Sx
Dx
Tx
Ileal diverticulum persistent portion of embryonic vitteline duct (yolk stalk)
Rule of 2’s: 2% of population, 2 feet from ileocecal valve, 2% sx, 2 inches in length, 2 types of ectopic tissue, 2 years most common age of presentation, 2 times more common in boys
Sx: Asymptomatic
Painless rectal bleeding or ulceration
Dx: Meckel’s Scan (look for ectopic gastric tissue in ileal area)
Tx: Excision
Small Bowel Obstruction
Sx
Dx
Tx
Post-surgical adhesions are most common reason, Hernias, Crohn’s Disease
Sx: Crampy abdominal pain, vomiting, diarrhea, obstipation (severe constipation)
High pitched tinkles and visible peristalsis is early finding (hyperactive bowel sounds), hypoactive bowel sounds are late findings
Dx: Abdominal Xray shows Air-Fluid Levels, Dilated bowel loops
Tx: NPO, NG tube, IV fluids
Intussusception
Sx
Dx
Tx
Intestinal segment invaginates into adjoining intestinal lumen, leads to bowel obstruction
Sx: Vomiting, abdominal pain, passage of blood per rectum “currant jelly stools” which is a mixture of blood and mucosa and mucosal tissue
Dance’s Sign: SAUSAGE SHAPED MASS in RUQ
DX: Barium/Air Enema
Tx: Barium/Air Enema
What is Celiac Disease
Sx
Dx
Tx
Small bowel autoimmune inflammation secondary to alpha-gliadin in gluten
Loss of villi and absorptive area leads to imparied fat absorption
Sx: Diarrhea, abdominal pain, distention, weight loss, Dermatitis Herpetiformis (pruriritc, papulovesicular rash on extensor surfaces)
Dx: Positive Endomysial IgA antibodies and Transglutaminase Antibodies
Small bowel biopsy is definitive
Tx: Gluten free diet (avoid wheat, rye, barley)
Oats, rice, cron are ok
Lactose Intolerance
Sx
Dx
Tx
Inability to digest lactose due to low enzyme levels
Sx: Loose stools, abdominal pain, flatulence
Dx: Hydrogen breath test
Tx: Lactase enzyme, Lactaid, Lactose free diet
What is Diverticula
Small mucosal herniations protruding through intestinal and smooth muscle layer along natural openings of colon
Commonly found at sigmoid colon
What is Diverticulosis
Uninflamed diverticula
Associated with low fiber diet
May cause acute lower GI bleed
Tx: High fiber diet, fiber supplements
What is Diverticulitis
Inflamed Diverticula secondary to obstructions (fecalith)
Sx: Fever, LLQ pain, N/V, Diarrhea
Dx: CT scan
Tx: Clear liquid diet, broad spectrum Abx (Cipro + Metronidazole)
What is Volvulus
Sx
Dx
Tx
Twisting of any part of the bowel on itself
Usually at sigmoid or cecum
Sx: Abdominal pain, distention, N/V, fever, tachycardia
Tx: Endoscopic decompression at first then surgery if doesn’t work
Appendicitis
Sx
Dx
Tx
Obstruction of the appendix, usually due to fecalith
Sx: Anorexia, Periumbilical/Epigastric pain followed by RLQ pain, N/V
Rebound tenderness, rigidity and guarding
Rovsing Sign: RLQ pain with LLQ palpation
Obturator Sign: RLQ pain with internal and external hip rotation with bent knee
Psoas SignL RLQ pain with right hip flexion/extension
McBurney’s Point Tenderness: area between atnerior superior iliac spine and navel
Dx: CT scan
Tx: Appendectomy
Irritable Bowel Syndrome
Sx
Dx
Tx
Chronic FUnctional idiopathic disorder with no organic cause
Sx: ABdominal pain associated with altered defecation/bowel habits
Tx: Lifestyle changes, diet, smoking cessation
TCA/SSRI for intractable pain
What is Acute Mesenteric Ischemia
Sx
Dx
Tx
Ischemic bowel disease, sudden decrease of mesenterial blood supply to the bowel
Usually due to embolus, thrombus
Sx: Severe abdominal pain out of proportion to physical findings
Dx: Angiogram is defintiive
Tx: Revascularization (angioplasty with stenting or bypass_
What is Ischemic Colitis
LLQ pain with tenderness, bloody diarrhea
Tx: Restore perfusion and observe for performation
Dx: Colonoscopy, see segmental ischemic change sin areas of low perfsuion (splenic flexure)
Toxic Megacolon
Sx
Dx
Tx
Nonobstructive severe colon dilation >6cm and signs of systemic toxicity
Usually due to UC, Crohns, Pseudomembranous colitis, Infections, Hirschsprung
Sx: Abdominal pain, diarrhea, N/V, rectal bleeding
Dx: Xray shows dilated colon
Tx: Bowel decompression, bowel rest, NG tube, broad spectrum abx
Features of Ulcerative Coliitis
Limited to colon, starts in rectum an dmoves up to colon
Mucosa and submucosa only
LLQ, colicky pain, BLOODY DIARRHEA
Can lead to Primary sclerosing cholangitis and colon CA and Toxic Megacolon
Colonoscopy shows Uniform inflammation, sandpaper appearance, pseudo polyps
Positive P-ANCA
Surgery is Curative
If acute flare, use Flex Sigmoidoscopy
Tx: 5-Aminosalicylic Acids (Oral Mesalamine, Topical Meslamine, Sulfasalazine)
Corticosteroids for acute flares
Immune modifying agents (6-mercaptopurine, azathioprine, methotrexate)
Anti-TNF agents (Adalimumab, Infliximab, Certolizumab)
Features of Crohn’s disease
Can occur anywhere in GI tract from mouth to anus
Usually seen in terminal ileum
RLQ pain, weight loss, Non-bloody diarrhea
Transmural pattern
Can cause perianal disease like fistulas, strictures, abscesses, granulomas
Colonoscopy shows skip lesions with cobblestone apperance
Positive ASCA
Surgery is not curative
Upper GI series in acute flares
Tx: 5-aminosalicylic acids (Mesalamine, Sulfasalazine)
Corticosteroids for acute
Immune Modifying agents (6-mercaptopurine, Methotrexate)
Anti-TNF agents (adalimumab, infliximab)
Colorectal Cancer Risk Factors Sx Dx Tx Screening
Progression of adenomatous polyps into malignancy
RF: Age >50 yrs, smoking, alcohol, family histroy, diet low in fiber, high in red/processed meats
Sx: Iron deficiency anemia, change in bowel habits, bloody diarrhea
Dx: Colonoscopy with biopsy
Increased CEA
Tx: 5-FU is chemo, Monitor CEA levels
Screening
-Normally at 50 years with colonoscopy, every 10 years
-Start at 40yrs if 1st degree relative dx with CA if they were >60 years, every 10 years
-Start at 40 years, or 10 years before relative was diagnosed if they were dx <60yrs old, every 5 years
Hernias Indirect Direct FEmoral Umbilical
Indirect hernias are most common
Due to persistent patent process vaginalis, follows the testicle tract into the scrotum
Direct inguinal is due to weak Hesselbach triangle, it doesn’t reach the scrotum
Femoral is below the inguinal ligament, usually seen in women
Umbilical is seen in kids, usually resolves by 2 yrs old, if not then do surgery at 5 years old
Sx: Swelling or fullness at hernia site, usually enlarged with intrabdominal pressure like valsalva
Tx: Surgery
Incarcerated: Irreducible hernias, usually painful
Strangulated: Irreducible with compromised blood supply
External Hemorrhoids
Perianal PAIN, tender palpable mass
Dx: Visiaul insepction, DRE, fecal occult blood testing
Tx: High fiber diet, increase fluids, warm sitz baths, Rubber band ligation, sclerotherapy
Internal Hemorrhoids
PainLESS, intermittent rectal bleeding, bright red blood per rectum
Dx: Visual, DRE, Proctosigmoidsocopy, colonoscopy
Tx: High fiber diet, increased fluids, warm sitz baths, rubber band ligation, sclerotherapy
Rectal Abscess and Fistula
Results from bacterial infection, usually S. Aureus, E.Coli
Usually in posterior rectal wall
Sx: Throbbing rectal pain worse with sitting, coughing, defectation
Tx of abscess, I&D, NO abx
Anal Fissure
Sx
Dx
Tx
Painful linear tear/crack in distal anal canal
Usually at posterior midline
Due to low fiber diet, passage of large stools or anal trauma
Sx: Severe painful BM, patient may refrain from having BM due to pain, constipation, bright red blood per rectum, rectal pain
May see skin tags
Tx: Sitz bath, analgesics, stool softeners, high fiber diet
What leads to Vitamin C deficieincy
Scurvy
Vascular fragility, recurrent hemorrhages in gums, skin and joints
Imparied wound healing
Hyperkeratosis, Hemorrhage, Hematologic (Anemia)
What leads to Vitamin D Deficiency
In kids: Rickets, softening of bones, bowing deformities
In adults: Osteomalacia, diffuse body pains, muscle weakness, fractures
Tx: Ergocalciferol (Vitamin D)
What leads to Vitamin A Deficiency
Visual Changes, night blindness, Squamous metaplasia, Bitot spots (white spots on conjunctive)
What leads to Vitamin B Deficiency
-Niacin, Thamine, B12
Niacin: Pellagra: Diarrhea, dementia, dermatitis
Thamine: usually due alcohol abuse, Parasthesias, demyleination, peripheral neuropathy, dilated cardiomypathy
-May lead to Wernicke’s Encephalopathy: Ophthalmoplegia (paralysis of ocular muscles), Ataxia, Global Confusion
-Korsakoff’s dementia, short term memory loss, confabulation, IRREVERSIBLE
B12: Parasthesias, gait abnormalities, memory loss, Glossitis
- Pernicious Anemia (destruction of parietal cells which typically secrete Intrinsic Factor which is needed for B12 absorption) Dx: Schilling Test, Antibody test
- Alcoholism and malabsorption like Celiac disease and Crohns can also cause this
Phenylketonuria
Sx
Dx
Tx
Autosomal recessive disorder of amino acid metabolism
Leads to accumulation of Phenylalaline
Sx: Present after birth with vomiting, mental retardation, convulsions, increased DTR
Dx: Urine with musty odor
Tx: Lifetime dietary restriction of Phenylalaline (cheese, nuts, fish, meats, eggs, chicken, milk, legumes, aspartame)
What are types of Infectious Diarrhea
Sx
Dx
Tx
Shigella, Salmonella, Yersinia, E.Coli H7, Campylobacter
High fevers, Blood and fecal leukocytes, mucus
Tx: Most need FQ abx or Bactrim or Ceftriaxone
What are types of noninvasive infectious diarrhea
Sx
Dx
Tx
Staphylococcus
Bacillus Cereus
Vibrio Cholerae, Entertoxogenic E. Coli (Traveler’s Diarrhea), C. Diff
Vomiting, water, voluminous diarrhea, no fecal WBC or blood
Tx: Fluid replacement
C.Diff: Metronidazole, Oral Vancomycin is 2nd line
Entertoxogenic E. Coli: FQ
What are types of Protozoan Infections
Sx
Dx
Tx
Giardia, Amebiasis
Giardia is from contaminated water from remote streams, backpacker’s diarrhea
Dx: Trophozites, cysts in stool
Tx: Metronidazole
Pyloric Stenosis
Sx
Dx
Tx
Hypertrophy and Hyperplasia of muscular layers of pylorus
Most common reason for intenstinal obstruction in infancy
Sx: Nonbilious vomiting/regurgitation PROJECTILE, emesis after feeding
Olive shaped mass, nontender, mobile hard pylorus
Dx: Ultrasound shows elongation/thickening of pylorus
UPper GI contrast study shows string sign
Tx: Pyloromyotomy, Rehydration
What is Zollinger Ellison Syndrome
Sx
Dx
Tx
Gastrinomas that results in Gastric Acid Hypersecrtion, leads to PUD
Seen duodenal wall, pancreas
Sx: Multiple peptic ulcers, refractory kissing ulcers, diarrhea
Dx: Fasting gastrin levels
Positive SEcretin Test (Secretin normally inhibits gastrin, so if you see increased levels it means gastrinoma present)
Tx: Remove tumor, If mets give PPI
Gastric Carcinoma
Sx
Dx
Tx
Aenocarcinoma is most common
H.Pylori is biggest risk factor, salted, cured, smoked pickled foods containig nitrites
Sx: Weight loss, early satiety, abdominal pain/fullness
Dx: Upper endoscopy with biopsy, Initius Plastica
Tx: Gastrectomy, Radiation, Chemo
Peptic Ulcer Disease
Sx
Dx
Tx
Duodenal ulcers are more common
Due to H.Pylori, NSAIDS, Zollinger Ellison
Sx: Epigsatric pain, burning, gnawing, hunger like, wrose at night
Duodenal Ulcer is worse before meals and 2-5 hours after meals
Gastric Ulcers are worse 1-2 hours after meals, associated with weight loss
Dx: Endoscopy is GOLD STANDARD
Upper GI series
H.Pylori Testing
- Endoscopy with biopsy is GOLD STANDARD
- Urea Breath Test for both dx and eradication confirmation
- Stool Antigen for dx and confirmation of eradication
- Serologic Antibodies, only for dx NOT eradication
Tx: If H.Pylori positive then triple therapy: Clarithromycin, Amoxicillin, PPI (Metronidazole if PCN allergy)
If H.Pylori Negative, PPI and H2 blockers, Antacids
Gastritis
Sx
Dx
Tx
Superficial inflammation of stomach mucosa with injury
Due to H. Pylor, NSAIDS/ASA, Acute Stress
Sx: Usually asymptomtic, Upper GI bleeds, Epigastric pain, N/V
Dx: Endoscopy is GOLD STANDARD
Tx: If H. Pylori Positive give Triple Therapy
If negative give PPI, Antacids, H2 blockers
