GI Flashcards
cholelithiasis (gallstones) types
cholesterol (green) - fat female fertile forty (native american, fmexican)
pigmented stones (black) - hemolysis
presentation of cholelithiasis
colicky RUQ abd pain radiates to the shoulder
worse with fatty foods - due to fats making the gallbladder contract more around sharp stones
dx and tx of choleliathiasis
dx - RUQ US
tx - cholecystectomy (elective) if pt not a surgical candidate then ursodeoxycholic acid
cholecystitis cause
obstruction in cystic duct + gall stone in gall bladder and gallstone is inflamed
cholecystitis presentation
constat RUQ pain
murphy signs +
inflammation –> mild fever and mild leukcytosis
dx of cholecystitis
dx - RUQ US - pericholecystic fluid, thickened gallbladder wall, glass stones present
- if not conclusive –> HIDA scan –> monitors perfusion via tracer uptake which will show no uptake in the gallbladder due to an obstruction
tx of cholecystitis
NPO, IVF, IV ABX (cipro + metro or amp + genta + metro)
then
cholecystectomy (within 72-96hrs)
if not sx candidate - cholecystostomy - tube to drain the fluid
choledocolithiasis
gallstone somewhere in the common bile duct
liver keeps making bile –> it has nowhere to go so the bilirubin the bile leaks into the blood –> painful jaundice
choledocolithiasis presentation
if stone in ampulla vader –> liver inflammation (elevated AST and ALT) along with possible pancreatitis (elevated lipase and amylase)
+ painful jaundice
+/- murphy signs
elevated temp and WBC
dx of choledocolithiasis
RUQ US - showing dilated ducts due to an unseen obstruction
if inconclusive –> MRCP
tx of choledocolithaisis
NPO, IVF, IV ABX (genta + amp + metro or cipro + metro)
then
ERCP (urgently) –> cholecystectomy (electively)
cholangitis
dilated ducts due to stone obstruction as well as stagnant fluid which –> infection that can ascend the bile tract
infection is with the gut flora - so gram - rods anaerobics
presentation of cholangitis
charcots triad RUQ pain painful jaundice fever \+ hypotension and AMS = reynolds pentad
dx and tx of cholangitis
dx - RUQ US - obstruction effects
tx - IVF, IV ABX (genta + amp + metro or cipro + metro) –> emergent ERCP —> cholecystectomy (urgently)
overview of the causes of raquetball
P-pill induce I-infectious E-eosinophilic C-caustic E- gErd/everything else
odonophagia - painful swallowing
dysphagia - difficulty swallowing
Pill induced esophagitis path
pills getting stuck typically temporarily –> inflammation and burning
common culprits in pill induced esophagitis
non enteric coated NSAIDs
abx - such as tetracycline
bisphonates
HAARTs
dx and tx of pill induced esophagitis
dx - endoscopy with biopsy
tx - if pill there remove it + remove offending agent + PPI
drink water with pill
avoid recumbency after taking pills
infectious esophagitis most common causes
Candidiasis
HSV
CMV
HIV
cadidiasis esophagitis
typically oral thrush seen as well
tx - fluconazole
HSV esophagitis
oral lesions
painful prodrome
vesicles on an erythematous base
multiple ulcers in different stages of healing
tx - Valacyclovir or acyclovir
CMV esophagitis
requires biopsy
tx - valacyclovir or agancyclovir
HIV esophagitis
opportunistic infections
HAART = tx
eosinophilic esophagitis
pathophys and causes
allergic rx to food –> eosinophils in the esophagus
asthma, allergies, atopy (eczema)
eosinophilic esophagitis dx and tx
endoscopy with biopsy showing > 15 eosinophils per high powered field
tx - PPI x 6wks - if fails –> oral aerosolized steroids
caustic esophagitis
kid who drinks draino
adult with suicide attempt drinks stuff
strong base or strong acid – > damage everything on the way down
larynx damage –> hoarse voice - if there is stridor intubate immediately as it is a sign of impending resp collapse
esophagus damage - drooling
dx of caustic esophagitis and tx
endoscopy with biopsy
mild severity - liquid diet high severity (aka strictures, necrotic black esophagus) ----> tx = NPO for 72hrs and repeat EGD
things you dont do with casutic esophagitis
dont neutralize the pH you will causes a thermophilic rx –> more burning
never induce emesis as it allows chemicals a second pass for destruction in the esophagus
if caustic esophagitis is caught very early on what can you do
insert NG tube and perform a lavage basically flush with water suction it up and do it over and over again
approach to dysphagia basics
motility (food and liquid issue) vs mechanical (progressive first food issues –> then liquid issues)
achalasia pathophys
absent myenteric plexus –> absence of inhibitory neurons –> LES cant relax –> always tight
achalasia presentation
motility disorder
food gets stuck at the mid sternum (GE junction) feels like a knot or a ball after they eat
dx of achalasia
barium swallow test –> shows birds beak
manometry –> shows abnormal high tone in LES
EGD with biopsy to r/o cancer
tx of achalasia
botilinum toxin - short acting - for non sx candidate
esophageal dilation - risk for perforation
myometry (best option) - ADR bad GERD
scleroderma pathophys
collagen deposition dz – > collagen replaces the smooth muscle of the LES –> no muscle no contraction of LES
scleroderma presentation
CREST - anticentromere
Systemic sclerosis - anti scl 70, anti topoisomerase
relentless GERD
dx and tx of scleroderma of the esophagus
barium - wide open
manometry - no contraction of LES
EGD with biopsy - lack of muscle
antibodies
tx - symptomatic PPIs
diffuse esophageal spasm
pathophys and presentation
random contractions of esophagus
MI like presentation retrosternal pain relieved by CCBs and NTG
dx and tx of diffuse esophageal spasm
r/o ACS –> barium (shows corkscrew appearance) –> manometry (shows random contractions)
EGD with biopsy
tx - CCBs and prn NTG
schatzki’s ring
ring at the GE junction
steakhouse dysphagia
dx and tx of schatzki’s ring
dx - barium –> narrowed lumen –> EGD with biopsy to r/o cancer –>
tx - during endoscopy lyse the ring
esophageal webs
plummer vinson syndrome
- women with dysphagia
- iron def anemia
- webs
- eventually esophageal cancer
- koilonychia - spoon shaped finger nails
dx and tx of esophageal webs
dx - barium swallow
tx - Iron –> screen for cancer using EGD with biopsy
zenkers diverticulum presentation
halitosis - food sitting in the diverticulum
older man
regurgitation of undigested food
dx and tx of zenkers diverticulum
dx - barium study - diverticulum will fill –> EGD with biopsy
tx - surgical repair
stricture pathophys and presentation
Stage IV GERD –> progressive GERD that leads to stricture in bottom 1/3 of esophagus
progressive dysphagia and weight loss
dx and tx of an esophageal stricture
barium - circumfrential or symmetric loss of lumen –> EGD with biopsy
tx - high dose PPI with dilation of esophagus
Adenocarcinoma of the esophagus
long standing GERD –> irritation and change in bottom 1/3 of esophagus
GERD and weight loss dyshagia with solids first then liquids
more common in white men
dx and tx of adenocarcinoma of the esophagus
dx - barium - asymetric loss of the lumen –> EGD with biopsy
tx - chemo/radiation +/- surgery
squamous cell carcinoma of the esophagus
smoker and alcoholic + hot tea + hot food
african americans
upper 1/3 of esophagus affected
GERD pathophys
weakened LES –> acid continously regurgitating back into the esophagus
GERD presentation typical
burning chest pain
made worse by –> lying flat (recumbent position) and spicy foods
made better by –> sitting up and antacids
dx and tx of GERD
PPI + lifestyle modifications (avoid chocolate, peppermint, smoking, alcohol) for 6 weeks
if fails –> EGD + biopsy –> 24 hr pH monitor
alarm symptoms of GERD and workup
N/V
anemia (typically microcystic)
weight loss
EGD with biopsy
barrets esophagus
chronic GERD –> metaplasia to better handle acidity (leads to decreased pain)
tx - high dose PPI and recurrent EGDs for surveillance
however can lead to dysplasia (30-50 times increased risk for cancer (adenocarcinoma)
GERD and dysplasia seen on EGD with biopsy
tx - local ablation with either cryo, laser, radio frequency ablation and recurrent EGDs for surveillance
Nissen Fundoplication
person cant tolerate PPIs or doesnt want PPIs
mechanism = create a tighter LES if too tight leads to achalasia like symptoms
atypical symptoms of GERD
hoarseness
coughing
stridor
nocturnal asthma *
peptic ulcer disease basics
either gastric (gets worse with food) or duodenal (gets better with food then 2-5hrs later pain)
duodenal typically caused by H pylori
tx - stop smoking, stop drinking, stop NSAIDs
causes of peptic ulcer dz
h pylori NSAIDs malignancy curling ulcers cushing ulcers zollinger ellison
NSAID PUD
multiple shallow ulcers - dx - with EGD with biopsy
tx - stop NSAID –> PPI BID then PPI daily
Malignancy PUD
EGD with biopsy –> big heaped up margins and necrotic centers - since cancer is outgrowing its blood supply
tx - stage and tx
Curling Ulcers
vs
Cushing ulcers
curling - burn pts
cushing - increased ICP —> tx - gut prophylaxis NGT and PPI
H Pylori - PUD
presentation
most pts asymptomatic, but some dyspepsia (indigestion) + epigastric pain
can present with a MALTOMA which will get better with tx of the h pylori
H pylori dx
serology - cant have a previous PUD dx - if + tx pt
urea breath test - need to be off PPI for test
stool antigen - after tx to see if eradicated
EGD with biopsy - best test - histology (best) can also do a rapid urease test
tx of h pylori
triple therapy
clarithromycin
amoxicillin (or metro if PCN allergy)
PPI
Zollinger Ellison syndrome
gastrinoma –> continously make gastrin –>which secretes HCl
big virulent refractory ulcers
pts keep failing PPI tx
dx of zollinger ellison syndrome
gastrin level > 1600 = diagnostic
gastrin levels 250-1600 –> secretin skin test –> gastrin levels go up = gastrinoma
somatostatin receptor syntography – looks for receptors of gastrinoma
CT scan
tx and complications of Zollinger Ellison syndrome
tx - resection
complication - malignancy
gastroperesis
gastric paralysis - fails to empty
MCC - idiopathic and another cause is diabetes —>(peripheral neuropathy of the vagus nerve)
presentation of gastroperesis
delayed gastric emptying
N/V, abdominal pain with eating
peripheral neuropathy (if diabetic)
dx of gastroperesis
endoscopy - r/o other dzs –> emptying study
> 60% after 2hrs = + result
> 10% after 4 hrs = + result
pts must be off opiates, anticholinergics, and have good blood glucose to do this study as these things delay emptying
tx of gastroperesis
avoid things that delay gastric emptying
low fiber and small volume diet
prokinetic agents
- metachlopromide (PO) - good for chronic tx
- erythromycin (IV) - good for flare up tx
donperidone - banned due to ADR - cardiac
cyclic vomiting syndrome
habitual chronic use of TSH
N/V cycles that can last wks
tx - stop TSH and metachlropromide or erythromycin and antiemetics (ondasterone)
gastric adenocarcinoma
increased incidence in east Asia
associated with nitrites
early satiety, weight loss, gastric outlet obstruction
dx and tx of gastric adenocarcinoma
dx - EGD with biopsy –> shows signet rings –> PET CT/ Pan CT
tx - resection and chemo
acute diarrhea timeline vs chronic diarrhea timeline
acute diarrhea <2wks
chronic diarrhea >4wks
signs of enterotoxic acute diarrhea
watery diarrhea only
most common cause = viral gastroenteritis –> tx = rehydration either PO > IV and loperimide
causes of enterotoxic acute diarrhea
C diff - recent abx
ETEC - travelers diarrhea, central America
Vibrio Cholera - contaminated water, fecal oral, 3rd world
S Aureus - proteinaceous food, eggs or potato salad
B Cereus - reheated rice, chinese buffet
Giardia - camping, fresh water
Invasive acute diarrhea signs and symptoms
bloody diarrhea
fever
leukocytosis
fecal wbcs –> lactoferrin test necessary to confirm
causes of invasive acute diarrhea
salmonella - raw eggs, raw chicken
shigella - HUS
EHEC - HUS, uncooked beef
Camplyobacter - MCC of invasive bloody diarrhea
A Histolyticum - Immunocompromised, HIV, AIDS
acute diarrhea signs that lead to a workup
Fever >104 electrolyte imbalances recent abx use > 3 days bloody/pus severe abdominal pain immunocompromised hospitalized
workup steps for acute diarrhea
viral gastro –> no –> c diff –> no –> stool WBCs/RBCs –>
–> if + = invasive –> stool culture and colonoscopy –> if stool culture + and colonoscopy (-) = infection but if stool culture (-) and colonoscopy (+) medical dz
—> stool WBCs/RBCs = (-) –> enterotoxic –> parasites –> if (+) = parasitic infection if (-) = viral causes
c diff
path
presentation
dx
overgrowth of natural flora due to systemic abx killing normal flora off
watery diarrhea with smell
dx - c diff NAAT (nucleic acid amplification test)
tx - oral metro -> oral metro -> oral vancyo -> oral fidaxomycin –> fecal transplant
severe c diff
presentation and tx
fever, leukocytosis
megacolon
BUN/Creatine issues
tx - both oral vancomycin and IV metro
HUS
bloody diarrhea after eating uncooked meat renal failure (increased Cr decreased BUN)
microcytic anemia –> schistocytes on blood smear
decreased platelets
Dx and tx of HUS
dx - shigella like toxin assay
tx - supportive - if renal failure –> diaylize
best tx = plasma exchange
secretory diarrhea
nml osm gap
volumous
neg - fecal wbcs/rbcs/fat/ mucous
no change NPO
no night symptoms
osmotic diarrhea
increased osm gap
+ changes with NPO
+ fat
neg fecal wbcs/rbcs/ mucous
neg night symptoms
inflammatory diarrhea
+ fecal rbcs/wbcs/ mucous
stool osm gap
measure osm (290) - calculated [ x2 (Na + K)]
<50 = secretory >100 = osmotic
usual suspects for chronic diarrhea
laxative abuse medications lactose intolerance c diff celiac sprue
VIPoma
secretes VIP –> activates intestines
chronic diarrhea
dx - increased VIP levels
tx- resection
carcinoid
secretes serotonin –> GI symptoms only appear when metastasis to liver occurs
right sided heart fibrosis, valve problems, flushing, and diarrhea
dx - 5-HIAA in urine
tx - resection
Minerals absorbed in the duodenum
F - folate –> anemia
I - iron – > anemia
C - calcium –> osteoporosis
carbs –> bloating flatulence foul smelling belching
minerals absorbed in the terminal ileum
b12 –> anemia + peripheral neuropathy
bile salts –> loss of vit KADE
- vit K loss –> bleeding
- vit A loss –> night vision
- vit D loss –> osteoporosis
- vit E loss - -> nystagmus
pancreas’s role in absorption
protein breakdown –> problems here lead to low albumin like state
- ascites
- lower leg edema
malabsorption workup
100g Fat diet with stool collection for 72hrs
- if < 14g/day = healthy
- if > 14g/day –> malabsorption –> D -xylose absorption ——> absorbed = intestinal lumen is intact –> pancreas issue –> give pancreatic enzymes
- –> not absorbed = intestinal lumen issue –> EGD with biopsy
celiac sprue
gluten allergy, autoimmune dz, IgA mediated
diarrhea, bloating, weight loss, iron def, osteoporosis
dermatitis herpitiformis –> celiac sprue
dx and tx of celiac sprue
dx - Abs - tissue transglutaminase (TTG)* or endomysial –> EGD with biopsy showing blunting of vili = loss of surface area for absorption
tx - avoid gluten (takes 3 to 4 months for affect)
lactose intolerance
older patients, asians, bloating, flatulence, foul smelling, diarrhea
brush border enzyme def
dx -avoid dairy
tx - avoid dairy or lactase enzymes
tropical sprue
causes by an infection
caribbean farmer, diarrhea, bloating, weight loss
dx - EGD with biopsy showing sprue
tx - abx
whipples disease
infection with T whippeli
malabsorptio, brain issues, joint issues, lymph issues
dx - EGD with biopsy –> (+) PAS macrophages or organisms on electron microscopy
tx - TMP-SMP or Doxycycline
presentation of a pt with diverticula
older pt > 50 y/o
constipation
diet - low fiber, no fruits, no veggies, increased red meat
dx - colonoscopy
diverticulosis
asymptomatic
tx - high fiber diet, increased fruits and veggies
diverticulosis uncomplicated
post prandial LLQ abd pain that is relieved by having a BM
> 50 years old
dx - clinical
tx- high fiber diet
diverticula hemorrhage
painless hematochezia
age > 50y/o
manage like GI bleed initially –> colonoscopy (after bleeding) or arteriogram (allows for embolization)
fecalith forming around diverticula
lead to perforation
bacteria set up shop
Left sided appendicitis –> constant LLQ abd pain –> fever, leukocytosis, tenderness LLQ
workup of fecalith and diverticula
KUB - if perf –> sx (ex lap) with IV abx
- if loops of small bowel and air fluid levels –> obstruction —-> sx
if nothing –> CT abd with contrast
tx of fecalith diverticula - mild abscess severe refractory
mild - Abx cirpo + metro or genta + ampicillin + metro (PO) liquids
abscess - NPO, IV abx, drain
severe - NPO, IV abx
refractory - hemicolectomy after treating initial diverticulitis episode
risks for colon cancer
age > 50
alcohol, smoking
obesity, processed red meats
inflammatory disorders (UC, crohns, primary sclerosing cholangitis)
presentations of colon cancer
1 - asymptomatic - found on screen
2- iron def anemia in older men and post menopausal women
3 - lumen obstruction - change in caliber of stools, constipation - diarrhea - constipation - thin
good polys vs bad polyps
good polyps - pedunculated, tubular, small
bad polyps - sessile, villous, large
tx of colorectal surgery
resection
stage and chemo
Fol Fox/ Fol Firi (VEGF - inhibitor) - bevacuzimab
turcots
brain tumors
colorectal cancer
gardners
jaw tumors
colorectal cancer
screen for colon cancer
colonoscopy - 50 y/o - every 10 yrs - up 75yrs old
flexible sigmoidoscopy - age 50 - every 5 years with fecal occult blood testing every 3 years
fecal occult blood testing every year
barium enema - apple core signs
colonoscopy severity levels
no risk - repeat 10 yrs
low risk - 1-2 polyps, <1cm, tubular, low grade dysplasia - repeat colonoscopy 5-10yrs
high risk - >3 polyps, >1cm, villious, high grade dysplasia - repeat colonoscopy 1-3 yrs
Mega risk - >10polyps, piece meal, sessile polyp - repeat colonoscopy in 2-6 months
FAP
APC gene defect
thousands of polyps
- prophylactic colectomy by age 18yrs
lynch syndrome (HNPCC)
defect in DNA mismatch repair
C-colorectal cancer
E - endometrial cancer
O - ovarian cancer
3 members of family in 2 generations and 1 early diagnosed cancer
peutz jegher syndrome
freckles around mouth and on lips
no colon cancer
cancer of small intestine
dx - endoscopy
Causes of Cirrhosis
V -viral hep b,c W- wilsons H-hematochromatosis A-alpha 1 antitrypsin def P-primary sclerosing cholangitis P - primary biliary cirrhosis E- etoh N-NASH/Non alcoholic fatty liver dz S-something else
Viral Hepatitis B and C
chronic inflammation
Hep C - IV drugs
Hep B - sex workers
dx - abs
tx - direct acting antagonists
Wilsons dz
copper deposition - basal ganglia - chorea - liver cirrhosis - eyes keyser fleischer rings
dx - slit laamp, serum ceruplasmin, urinary copper, biopsy = best
tx - penicllamine –> Transplant
hemachromatosis
iron overload, bronze diabetes, iron in skin and iron in pancreas, HFE mutation
cirrhosis, diastolic CHF,
dx and tx of hemachromatosis
dx - ferritin level >1000 or transferrin > 50%, biopsy with increase iron
tx - deforaxamine, blood letting
alpha 1 antitrypsin def
accumulates in liver, young COPD pt with cirrhosis
dx - biopsy with PAS + macrophages
tx - transplant
primary sclerosing cholangitis
PSC - s for sons of bitches
extrahepatic dz
pruritus, painless jaundice
30-50 y/o Men
associated with UC, IBD
dx and tx of primary sclerosing cholangitis
dx - ANCA, MRCP - beads on string - biopsy showing onion skinning and fibrosis
tx - ursodeoxycholic acid –> transplant
primary biliary cirrhosis
PBS - b for bitches
intrahepatic dz
pruritis, painless jaundice
30-50 y/o Females
dx - nml imaging - AMA - biopsy best
tx - transplant
Liver functions
make bile and bile salts - jaundice + pruritus
make albumin - low albumin
make clotting factors 2, 7, 9, 10 - bleed
process toxins (NH3) - hepatic encephalopathy
makes estrogen - gynecomastia, spider angiomatas, palmar erythema
hepatic encephalopathy
NH4+ goes to brain
confused AMS, asterexis (Flapping tremor)
dx lcinical
tx- lactulose + rifaximin + Zinc
Portal HTN
thrombocytopenic, splenic sequestration
ascites
portal caval shunts - varices, hemorrhoids, caput medusa
Varices presentation
in esophagus
- either dx by accident with endoscopy or
- dx by bleeding fast and hard from both ends
management of bleeding varice
bleeding - bound them for short term, balloon, banding
reduce portal pressure with beta blockers such as nadolol and propranolol
+ ceftriaxone + octreotide (reduces portal pressure acutely)
last resort TIPS procedure until transplant - plastic tube that bypasses the liver shunt from portal vein to vena cava - can lead to worsening of hepatic encephalopathy
Ascites
fluid in the belly
portal HTN = SAAG >1.0 - cirrhosis, RHF
non portal HTN = <1.1 - infection TB, cancer
dx - paracentesis
presentation of ascites and tx
bulging, flanks, shifting dullness, fluid wave
tx - furosemide + spiranolactone and therapeutic paracentesis
Spontaneous bacterial peritonitis
strep and gram neg rods
asymptomatic and occasionally fever and abd pain
dx - paracentesis - PMNs > 250
tx - IV ceftriaxone, if protein < 1 - prophylaxis fluoroquinolone
secondary bacterial peritonitis
culture comes back + with many diff types of organisms = perforated bowel –> tx ex lap
hepatocellular carcinoma
path - chronic inflammation - cirrhosis or hep B
asymptomatic
risk - black, asian, aflatoxin, vinyl chloride, AAT def
screen = RUQ US + AFP - confirmatory test = triple phase CT - cancer lights up in arterial phase
tx of hepatocellular carcinoma
small - resect
medium - transplant
big - radiofrequency ablation or chemo/embolization
what separates a lower GI bleed from an upper GI Bleed
ligament of treit
upper Gi bleed - hematemesis, melena, hemaochezia (unstable)
lower Gi bleed - hematochezia (stable)
most common causes of an upper GI bleed
PUD - in non cirrhotic
Varices - in cirrhotic
GERD
Dieulafuys lesion
AVM
most common causes of a lower GI bleed
Diverticular hemorrhage
hemorrhoids
cancer
AVM
stabilizing an acute GI bleed
2 large bore IVs 18gauge or higher
IVF
IV PPI
Type and cross –> transfuse
if cirrhotic - octreotide and ceftriaxone
lower Gi bleed workup - rate of bleeding
brisk - arteriogram - dx and embolize if needed
ongoing not brisk - tagged RBC scan
no bleeding - colonoscopy
nothing found after all this - pill camera endoscopy
mallory weiss tear
superficial esophageal mucosa tear
weekend warrior that parties too much
dx - EGD
tx - supportive, self limiting
boorheaves syndrome
transmural tear in the esophagus
career vomiter - alcoholic, bulimics
sick appearing, fever, dyspneic,
on CXR or physical exam - air in the mediastinum (rice crispy crackles)
dx and tx of boorheaves syndrome
dx - 1st gastrografffin if nml –> barium if nml –> EGD
- if any point = perf –> surgery = tx
Dieulafoys lesion
anatomical variant - artery close to the mucosal surface t
erosions eventually get into it and cause bleeding
brisk painful bleed
dx - EGD
tx - resect
hemorrhoids
internal - bleed, painless
external - painful, itchy, no bleeding
blood on toilet paper or on stool but not mixed in
dx - clinical
tx of hemorrhoids
sitz bath
prep H
hemorrhoidectomy
diverticular hemorrhage
> 50 yr painless bright red blood per rectum
arteriole in the dome of the diverticula = cause
dx - colonoscopy
tx - hemicolectomy
mesenteric ischemia
CAD of the gut “gut attack”
vasculopath - afib, CAD, recent arteriography
pain out of proportion to physical exam
abd pain with eating -> avoid eating -> weight loss
dx and tx of mesenteric ischemia
dx - arteriogram
tx - resect or revascularize
ischemic colitis
watershed arteries
hypotensive pts
painful bright red blood per rectum
dx and tx of ischemic colitis
dx - colonoscopy
tx .- supportive
AVM has an association with
Aortic stenosis
causes of pancreatitis
MCCs in US = alcohol and gallstone
other causes - meds, hypertriglycedemia, trauma (due to ERCP)
presentation of pancreatitis
epigastric abdominal pain that radiates to back
positional pain - worse leaning back, better leaning forward
N/V and anorexia (return of appetite - good sign)
cullens sign - periumbilical hematoma
turners sign - flank hematoma
dx of pancreatitis
Lipase - 3x upper limit of nml
amylase - amylase p
if enzymes dont support dx get CT if sure
US will show gallstones if they are the cause
MRCP will show cause if they are strictures/malignancy
tx of pancreatitis
NPO, IVF, pain meds –> refeed them on demand
if abx need to be used -> meropenim > cipro
if gallstone = cause - ERCP if stone fails to pass on its own
early complications of pancreatitis 1-3 days
ARDS - noncardiogenic pulm edema - dx - CXR - tx - intubate
Saponification - low Ca turns pancreas into soap - dx - ion Ca [ ] -> tx - give Ca
Fluid shift - ascities (dx - US) and/or pleural effusion (dx - CXR) dont drain either unless its infectious
mid complication of pancreatitis (1-3wks)
Infection - necrosis on CT –> biopsy for dx
tx - meropenem until cultures show specific sensitivity
late complications of pancreatitis (3-7wks)
abscess - fevers, swelling, induration, redness - dx - CT - tx - drain and abx
pseudocyst - CT for dx - pocket of fluid - Small bowel obstruction, early satiety, abd fullness
- –> tx = < 6wks + < 6cm = watch and wait
- —> tx = > 6cm or > 6wks = drain and biopsy
best test to assess prognosis in pancreatitis
BUN (most sensitive)
Ulcerative Colitis basics
age range
endoscopy
biopsy
20-30yrs old
endoscopy - continuous lesions from rectum through colon
Biopsy - superficial crypt abscess
UC
risk of malignancy
extra intestinal manifestations
role of surgery
increased risk of colon cancer
colonoscopy at year 8 and every year after
primary sclerosing cholangitis
P- ANCA
surgery = curative (colectomy)
Crohns disease basics
age
endoscopy
biopsy
age - 20s and 50-70s
endoscopy - skip lesions throughout entire GI tract, cobblestoning
biopsy - transmural noncasseating granulomas
UC - presentation
bloody diarrhea
Crohns disease presentation
watery diarrhea,
multiple bowel movements per day
nutritional def
weight loss
Crohns
risk of malignancy
extra intestinal manifestations
role of sx
no risk of malignancy
fistulas
terminal ileum - B12, fats def
duodenum - iron def, osteopenia
sx only for complications - fistulas and abscesses
tx of mild IBD
for UC - 5-ASA compounds - such as mesalmine - anti inflammatory
tx of moderate IBD
Immunomodulators for both UC and crohns
- 6 mercaptopurine, Azothiprine, and MTX
tx of severe IBD
UC - surgery
Crohns - TNF inhibitors - Infliximab
tx of flares for IBD
steroids (IV vs po) dependent on severity
+
Abx (cipro + metro) or (ampicillin + genta + metro)
—–> covers gram - and anaerobes
perianal dz needs to be drained
rate limiting step of bilirubin conjugation
2,3 UDP gluconuryl transferase
- makes unconjugated –> conjugated
prehepatic jaundice causes
hemolysis
reabsorption of a hematoma
increased unconjugated bilirubin
posthepatic jaundice causes
obstruction
- painful = gallstones
- painless = cancer, stricture, PSC, PBC
increased conjugated bilirubin
intrahepatic jaundice
criggler naiger + gilberts = increased unconjugated
dubin and rotors = increased conjugated
—-> roto - black on MRI
hepatitis and cirrhosis = mixed picture
conjugated bilirubin basics
water soluble – cant cross BBB
excreted in urine –> dark urine
unconjugated bilirubin basics
fat soluble —> can cross BBB –> kernicterus (peds)
not excreted in urine
Hep A basics
transmission
serology
etc
fecal oral - contaminated water, no hand washing
acute infection, no cancer risk
RNA virus with Vaccine
IgM = infected
IgG = Immune
Hep B basics
transmission
etc no serology
SEX, blood transfusion or IV drug users
chronicity = cancer risk with cirrhosis is possible
DNA virus with Vaccine
Hep C basics
transmission
etc no serology
Blood transfusion and IV drug users
chronicity = cancer risk
RNA virus
No vaccine
Hep D
Hep E
Hep D - RNA virus must have Hep B present or chronic to get infected with Hep D
Hep E - 3rd world pregnant women
No vaccines for either
Hep C serology
+Ab and +HCV RNA =
- Ab and + HCV RNA =
+ Ab and - HCV RNA =
+Ab and + HCV RNA = infected
(-) Ab and + HCV RNA = acute infection
+Ab and (-) HCV RNA = treated
treatment of Hep C
protease inhibitors (direct acting antagonists) such as ——–> Borcepravir
old school = ribavirin and interferon
Hep B serology
HBs Ag =
infected
HBeAg
infectious
IgM HBsAg
early infection
IgG HBsAg
immune (either exposed or vaccinated)
IgG HBcAg
immune due to exposure
toxic megacolon
presentation
increased risk if hx of IBD
sepsis + bloody diarrhea
- fever, leukocytosis tachy, AMS, anemia, hypotension
toxic megacolon dx
plain abd X-rays = dilated right or transverse colon > 6cm
multiple air fluid levels
thick haustral markings that dont cross entire lumen
toxic megacolon tx
medical emergency - since it can lead to perf
IVF, broad spectrum abx, bowel rest, NGT decompression
if IBD Hx –> IV corticosteroids
toxic megacolon in HIV pts caused by
CMV
right colon cancer vs left colon cancer
right colon - anemia
left colon - obstruction
Non alcoholic fatty liver dz associated with
insulin resistance and if BMI > 35 consider bariatric surgery
what can exacerbate hepatic encephalopathy
hypokalemia –> lead to increased NH3
Neomycin
nonabsorbable abx that is used to tx hepatic encephalopathy in pts unrepsonsive to lactulose and those who cant tolerate rifaximin
Chronic pancreatitis causes
alcohol
CF
ductal obstruction
autoimmune
chronic pancreatitis presentation
chronic epigastric pain that is intermittent with pain free episodes
malabsorption - steatorrhea, and weight loss
DM
chronic pancreatitis dx
CT scan or MRCP showing calcifications and an enlarged pancreas
complications of primary biliary cholangitis
malabsorption fat soluble vitamin def
metabolic bone dz - osteoparosis, osteomalacia
hepatocellular carcinoma
alcoholic hepatitis dx
AST/ALT about 300s
increased gamma glutamyl transferase
increased ferritin
signs of acute liver failure
hepatic encephalopathy
AST, ALT > 1000s
INR > 1.5
drugs that cause drug induced pancreatitis
furosemide
thiazides
tetracyclines
metronidazole
NSAIDS are a common cause of
iron def anemia
pancreatic tumor presentation
weight loss
painless jaundice
nontender distended gallbladder
imaging findings of pancreatic cancer
intra and extrahepatic biliary tract dilation
increased alk phosp
alcoholic hepatitis presentation
jaundice
anorexia
fever
RUQ pain
abdominal distension
proximal muscle weakness
when is a transfusion is recommended for a GI bleed and esophageal varices
GI bleed <7
Esophageal < 9
when is a platelet transfusion indicated
<72,000
biggest environmental risk factor for pancreatic cancer =
smoking
followed by obesity and chronic pancreatitis
laxative abuse
frequent watery nocturnal diarrhea
colonoscopy –> + if melanosis coli is seen –> dark brown discoloration with pale patches of lymph follicles
SAAG formula
serum albumin - peritoneal fluid albumin
SAAG >1.0 = increased hydrostatic pressure in capillaries
wilsons disease
5-35years old
hepatic - ALF, chronic hepatitis, cirrhosis,
neuro - parkinsonism, gait disturbance, dysarythria
psych - depression, personality changes, psychosis
dx test of choice in almost all esophageal swallowing diseases
barium swallow test
angiodysplasia
dilated submucosal veins and arteriovenous malformations
common cause of recurrent painless GI bleeding
dx colonoscopy
tx - asymptomatic
large linear ulcers in the esophagus =
CMV
potassium chloride = risk factor for
pill induced esophagitis
acute erosive gastropathy
development of hemorrhagic lesions after ischemia or the exposure of gastric mucosa to various injurious agents (aspirin, cocaine, alcohol)
total parental nutrition risk factors
gallbladder stasis and predisposes to gallstone formation and bile sludging –> both can lead to cholecystitis
pseudoachalasia
narrowing of distal esophagus secondary to causes other than denervation (esophageal cancer)
endoscopy required for dx
spontaneous bacterial peritonitis
pt with cirrhosis and ascites
low grade fever, abd discomfort, AMS
dx - PMNs > 250, + cultures, SAAG >1.0, protein <1
tx - ceftriaxone or fluoroquinolones for prophylaxis
alarm symptoms of GERD that suggest performing and endoscopy
melena persistent vomiting hematemesis weight loss anemia dysphagia/odonyphagia
the hallmark of ischemic hepatopahty
rapid rise and significant increase in the transaminases
increased bili and alkaline phosphatase
when is an ERCP performed
when CT or US have shown the presence of an obstruction that is due to cholelithiasis or malignancy
ERCP here = diagnostic and therapeutic
elevated alk phos
and elevated GGT
think cholestasis
or
malignancy if pt presentation is consistent
INH side effects
idiosyncratic liver injury
Histo resembles viral hepatitis - panlobular mononuclear infiltration and hepatic cell necrosis
elevated BUN and BUN:Cr
upper GI bleed
DOC of primary biliary cholangitis
ursodeoxycholic acid
- increases hydrophobic endogenous bile acids which decreases biliary injury
CT findings of mesenteric ischemia
bowel wall thickening
pneumatosis intestinalis
mesenteric thrombi
polyps that carry increased risk for malignancy
adenomatous polpys
- large >1cm
- high grade dysplasia
villous features = greatest risk of malignancy
Niacin def
can be caused by prolonged INH therapy
3 D’s - diarrhea, dementia, dermatitis (Pellagra)
esophageal stricture
product of GERD and barretts esophagitis
symmetric and circumferential narrowing of the lumen of the esophagus —> dysphagia of solids
D-xylose cannot be absorbed -
proximal small intestine mucosal dz (Celiacs)
there will be lose D-xylose in urinary and venous systems
Normal D-xylose absorption
overall malabsorption in this pt is due to enzyme deficiencies
hepatic adenoma
well demarcated, hyperechoic lesions
young woman with OCP hx
anabolic steroid user
C diff risk factors
recent abx use
hospitalization
PPI use - gastric acid suppression
copper def
brittle hair
skin depigmentation
neuro - ataxia, peripheral neuropathy
sideroblastic anemia
osteoporosis
chromium def
impaired glucose control in diabetics .
selenium def
thyroid dysfunction
cardiomyopathy
immune dysfunction
Zinc def
alopecia - pustular skin rash (perioral and extremeties)
impaired wound healing
impaired taste
hypogonadism
immune dysfunction
hepatic hydrothorax
results in transudative pleural effusions
thought to occur due to small defects in the diaphragm
tense ascites can lead to
decreased range of diaphragmatic excursion –> increased intraabdominal pressure
MCC of large bowel obstruction in adults
colorectal carcinoma
rectal cancer presentation
hematochezia - MC symptom
tenesmus
rectal mass - incomplete evacuation
complications of diverticulitis
bowel obstruction
abscess
fistula
clonic perf - rare
test of choice for diverticulosis
barium enema
CT = test of choice for diverticulitis with oral and iv contrast
what tests are contraindicated in acute diverticulitis
barium enema and colonoscopy as they can cause a perforation
acute mesenteric ischemia path
compromised blood supply - typically the superior mesenteric vessels
avoid vasopressors as they worsen ischemia
4 types of acute mesenteric ischemia causes
embolic - cardiac origin - sudden and painful
arterial thrombis - CAD hx, PVD hx- more gradual less severe
nonocclusive mesenteric ischemia - splanchnic vasoconstriction - ill old pts
venous thrombus - predisposing virchow triad - gradually worsening over course of weeks
signs of intestinal infarction
hypotension, tachypnea
lactic acidosis
fever, AMS
dx test for mesenteric ischemia
mesenteric angiography and check the lactate levels
colon distension past >10cm
impending rupture –> peritonitis and death - decompress immediately
most freq implicated abx for c diff
clindamycin
ampicllin
cephalosporin
complications of c diff
toxic megacolon
colonic perforation
anasarca
electryolyte imbalances
colonic volvulus
twisting of loop of intestine about mesenteric attachment site –> vascular compromise
most commonly = sigmoid colon
dx of colonic volvulus and tx
dx - plain abd films - omega loop sign
tx - sigmoidoscopy can be therapeutic
octeotride MOA for varices tx
causes splanchnic vasoconstriction and reduces portal pressure
gold standard for cirrhosis dx
biopsy
precipitants to hepatic encephalopathy
alkalosis - hypokalemia due to diuretics
sedating drugs (narcotics, sleep medications)
GI bleeding, systemic infection
MOA of lactulose
prevents absorption of ammonia by favoring formation of NH4 which is excreted
rifaxmin MOA for Hepatic encephalopathy
kills bowel flora so decreased ammonia production by intestinal bacteria
tx of coagulopathy in cirrhosis
fresh frozen plasma
tx of wilson dz
chelators - penicallimine and zinc - prevents uptake of di
most common malignant liver tumor
most common bengin liver tumor
malignant = HCC and cholangiocarcinoma
benign - hemangioma
tumor marker = AFP
hemobilia
caused by trauma
blood draining into duodenum via the CBD
dx - arteriogram
Tx - resect
hydatid liver cyts
echinoccocus granulossis - MC right lobe
larger cysts may rupture –> anaphylactic shock
tx - resect without spilling contents
amebic liver disease
MC in men 9:1 gay men, fecal oral route
reach the liver via the hepatic portal vein
RUQ pain, N/V, diarrhea (bloody)
tx- IV metro
Budd Chiari Syndrome
liver disease caused by occlusion of hepatic venous outflow which leads to hepatic congestion and subsequent microvesicular ischemia
- cause - hypercoagulable state and idiopathic
causes of conjugated hyperbilirubenemia
decreased intrahepatic excretion of bili
extraheaptic biliary obstruction
causes of unconjugated hyperbilirubenemia
excess production of bili
reduced hepatic uptake of bilirubin
impaired conjugation
gilbert syndrome can be exacerbated by
fasting - fad diet
fever
alcohol
infection
ALT, AST
100s
800s
1000s
100s - chronic hepatitis or acute alcoholic hepatitis
800s - acute viral hepatitis
1000s - extensive hepatic necrosis
- ischemia
- acetaminophen toxicity
- severe viral hepatitis
murpheys sign
pathognomonic for acute cholecystitis
inspriatory arrest during deep palpation of the RUQ
HIDA scan
used when US inconclusive - if gallbladder not visualized after 4hrs post injection - dx of acute cholecystis is confirmed
signs of biliary tract obstruction
increased alk phos
increased GGT
increased conjugated bilirubin - juandice, pruritus pale colored stools, dark urine
complications of cholecystitis
gangrenous cholecystitis
perf of gallbladder
emphysematous cholecystitis
cholecysteoenteric fistula with gall stone ileus
empyema of gall bladder
tx of choledocolithiasis
ERCP with stone removal and sphinctomoty
most serious complication of cholangitis
hepatic abscess - high mortality rate
dx appearance of PSC on ERCP
beadlike dilitations
CCK hormone
relaxes sphincter of oddi
contracts the gallbladder
biliary dyskinesia
motor dysfunction of sphincter of oddi –> recurrent episodes of biliary colic without evidence of gallstones
dx of biliary dyskinesia
HIDA scan - once gallbladder is filled with radionucleotide –> inject CCK –> if EF of gallbladder is low = dyskinesia
risk factors for appendix perf
> 24hrs
extremes of ages (toddler or elderly)
signs and symptoms of appendix rupture
high fever, tachypnea, marked leukocytosis
peritoneal signs - rigid abdomen, guarding, rebound tenderness
sick as shit
peritoneal signs
rigid abdomen, guarding rebound tenderness
acute appendicitis path
lumen obstructed by hyperplasia of lymphoid tissue –> fecalith or FB –> stasis –> bacteria grows –> inflammatio –> distension –> compromise of blood supply –> ischemia –> necrosis –> perf or peritonitis
presentation of appendicits
epigastrium abd pain –> umbilicus pain –> RLQ
sharp pain due to irritation to parietal peritoneum
anorexia, N/V
Where do carcinoid tumors originate from
neuroendocrine cells and secrete serotonin
ileal carcinoid tumors have the greatest risk of malignancy
MCC of pancreatitis in kids
blunt abd trauma
pancreatic pseudocyst
lack epithelial lining - encapsulated fluid collection that appears 2-3 wks after pancreatitis
dx - C scan and tx - if >5cm drain it
aortoenteric fistula
pt has hx of aortic graft surgery
presents with small GI bleed and then has a massive GI bleed hrs to weeks later - perform endoscopy early to prevent second bleed
dark stools can also be caused by
bismuth iron spinach charcoal licorice
ingesting alkali or acids is worse
alkali - may lead to liquefactive necrosis of esophagus with full thickness perf
most important determining factor for survival in an esophageal perf
time from perf to surgery
Misoprostol
reduces risk for ulcer formation associated with NSAID therapy
krunkenberg tumor
gastric carcinoma that mets to ovary
causes of small bowel obstruction
adhesions from previous sx = MCC
incarcerated hernia
presentation of SBO
cramping abdominal pain - if continuous can be a sign of strangulation
obstipation
dx of SBO
plain abd films - dilated loops of small bowel air fluid levels proximal
MCC of a large bowel obstruction
colon cancer
presentation of bowel strangulation
fever, severe and continuous pain
hematemesis
shock
gas in bowel wall or portal vein
abdominal free air
acidosis - increased lasctic acid
other complications of crohns disease
kidney stones
gallstones
