GI Flashcards
Intussception
Currant jelly stools (blood and mucus from the necrosed bowel wall)
Intermittent pain
Sausage shaped mass
Diagnosis - Target Sign on Ultra Sound GOLD STANDRD for diagnosis. US has a 100% sensitivity and specificity.
Treatment - Air enema
Risk factors: Hypertrophied Pyers patches Rotavirus vaccination! Viral illness Henoch schonlein purpura
Infant is cyanotic and tachypneic at rest.
Turns pink when he cries.
Cyanosis worsens when he tries to feed.
what is the diagnosis?
CHOANAL ATRESIA!!!
Unilateral Choanal Atresia may remain un-diagnosed until the development of a first upper resp infection.
FAILURE to PASS a CATHETER through the nares into the oropharynx is suggestive of choanal atresia.
diagnosis - CONFIRMED with CT scan.
Tracheoesophageal FIstula
Cause feeding problems IMMEDIATELY after birth as feeds CANNOT PASS the esophagus and end up in the airway.
Tehse patients have coughing, respiratory distress, and adventitious lung sounds in addition to CYANOSIS.
Necrotizing Enterocolitis signs and symptoms
Premature babies or very LOW BIRTH weight babies (less than 3.3lbs) are at risk for NEC.
Babies who are fed formula over breast milk are also at risk.
Clinical features:
Vital sign instability, Lethargy, BILLIOUS EMESIS, BLOODY STOOLS, Abdominal distension
X-ray - PNEUMATOSIS INTESTINALIS, portal venous gas, PNEUMOPERITONEUM.
Treatment - Bowel rest, parenteral nutrition, Broad spec IV antibiotics, SURGERY!
Abdominal pain related to eating, and that DOES NOT respond to PPIs.
Eosinophilic Esophagitis.
Caused by esophageal inflammation triggered by food allergens.
These patients will present with ECZEMA or other allergic conditions (ASTHMA, RHINITIS etc..)
Presentation includes –> DYSPHAGIA, mid-chest and EPIGASTRIC PAIN, VOMITING and FOOD IMPACTION.
Diagnosis and treatment:
2 month trial of PPIs.. if no improvement then must do ENDOSCOPY with ESOPHAGEAL BIOPSY.
CIRCULAR RINGS and ESOPHAGEAL FURROWS are non-specific findings on biopsy.
Diagnosis is confirmed with > 15 EOSINOPHILS per high-power field on histology.
Skin discoloration, anorexia, unintentional weight loss, dark urine, and PALE stoos.
Enlarged nontender galbladder.
what is the diagnosis and what iwll u see on abdominal imaging
PANCRATIC CANCER
on imaging - intra and extrahepatic billiary tract dilation.
Management of gallstones
gallstones with NO SYMPTOMS - No treatment.
Gallstones with Typical biliary colic - Elective lap choley.. or in poor surgical candidates - ursodeoxycholic acid
Complicated gallstone disease - CHOLECYSTECTOMY within 72 hrs.
Giardia confirmatory test?
Stool Antigen Assay (direct immunofluorescence or ELISA)
Treatment - metro
asymptomatic carriers DO NOT need treatment
12 year old receives Blunt abdominal trauma and then has Postprandial, COLICKY abdominal pain and BILIOUS VOMITING.
Tenderness in epigastric area
Duodenal Hematomas
Commonly occur after Blunt abdominal trauma. Most commonly seen in children. Caused by blunt force pushing the duodenum against the vertebral column… –> following this trauma.. BLOOD COLLECTS between the submucosal AND muscular layers of the duodenum causing a PARTIAL OR COMPLETE OBSTRUCTION.
Patinets present with pain 24-36 hours later due to inability to pass gastric contents beyond the obstructing hematoma.
Confirm Diangosis with CT of the abdomen.
Treatment - resolve in 1-2 weeks most of the time. Manage by putting in NG tube and decompressing, and providing parenteral nutrition.
Following Blunt Abdominal Trauma, patient has RUQ tenderness, Free INTRAPERITONEAL FLUID, HEMOdynamic INstability and abnomral CBC
what is the diagnosis?
Liver laceration.
one of the most common complications of Blunt abdominal trauma
abdominal succussion splash manuver is done to identify what?
Gastric outlet obstruction
After Appendectomy 10 days ago patient gets right upper quadrant pain, fever, leukocytosis and pulmonary manifestations (shortness of breath, hiccups, right sided effusion)
What diagnosis does this suggest?
SUBPHRENIC ABSCESS
Erythematous mass near the ANAL orfice associated with severe, CONSTANT pain and a low grade fever is what?
PERIANAL abscess
Caused by occlusion of anal crypt gland - which allows for BACTERIAL INFECTION.
Constant pain and can be associated with systemic manifestations such as FEVER.
Treatment - Incision and Drainage
anal fissure treatment
High fiber and adequate fluid intake
stool softners
sitz baths
Topical anesthetics and vasodilators (Nifedipine, nitroglycerin)
Multiple ulcers. Prominent gastric folds, 3 duodenal ulcers and upper jejunal ulcerations
Zolinger Ellison syndrome.
Endoscopy - THICKENED GASTRIC FOLDS, Multiple ulcers, abdominal pain, Refractory to PPIs or Ulcers distal to the duodenum.
FASTING SERUM GASTRIN level should be checked in suspected gastrinoma. a level above 1000 is diagnostic!
Gastrin levels below this are non-diagnostic and should be foolowed up with a SECRETIN STIMULATION test.
Laxative abuse presentation
Watery, Frequent, stools.
NOCTURNAL bowel movements and abdominal cramps.
DIarrhea normally causes metabolic acidosis..
However in Laxative abuse METABOLIC ALKALOSIS Is a classic finding!
Dark Brown Discoloration of the colon (melanosis coli) (seen on colonoscopy).
Diarrhea during FASTING and DEHYDRATION. TEA COLORED stools. What is the diagnosis?
VIPoma
DIarrhea + Cutaneous flushing + Venous Telangiectasia + BRONCHOSPASM + Valvular abnormalities (cardiac) what is the diagnosis?
Carcinoid - Elevated URINE 5 - HIAA
Carcinoid patients can end up with a NIACIN deficiency (dermatitis, dementia, diarrhea).. because all precursors are being used to develop serotonin.
Treatment;
Octreotide for symptomatic patients PRIOR to doing surgery.
SURGERY for liver mets.
Rapid onset Periumbilical pain (pain out of proportion to exam findings) + Hematochezia –> what is diagnosis?
Acute Mesenteric Ischemia
Risk factors:
- Atherosclerosis
- Embolism.. or hypercoag disorders.
Labs:
- METABOLIC ACIDOSIS (lactate elevated due to necrosis)
- elevated AMYLASE and PHOSPHATE levels
Diagnosis:
CT (1st line) or MR angiography
Opioid withdrawl bowel symptoms?
HYPERACTIVE bowel sounds.
History of DIarrhea and Intermittent abdominal cramps + Multiple BLOODY bowel movements containing mucus and blood + TENDERNESS in left lower quadrant + ERYTHEMATOUS FRIBABLE mucosa from RECTUM to SIGMOID colon + SHALLOW ULCERS on Flexible sigmoidoscopy –> what is the diagnosis?
Ulcerative Colitis
Pancreatic adenocarcinoma diagnosis
Cancers in the head of the pancrase –> JAUNDICE (due to CBD obstruction –> elevated alkphos and bilirubin)
FOr these patients use ABDOMINAL ULTRASOUND.
Cancers in the body or tail –> NO jaundice. Use Abdominal CT scan for these (cannot visualize with abdominal ultrasound)
Chronic Mesenteric Ischemia
Presents with CRAMPY POSTPRANDIAL EPIGASTRIC PAIN (intestinal angina), FOOD AVERSION and thus WEIGHT LOSS.
ATHEROSCLEROTIC narrowing of the celeiac or superior mesentaric arteries –> decreased blood supply to the stomach.
ABDOMINAL BRUIT present in 50% of patients.
CT ANGIO preffered choice for diagnosis.
when should you do endoscoopy in someone with supected H. Pylori?
Start by doing the Urease Breath test or Stool antigen test first. Then Perscribe meds accordingly.
Patients who fail to respond to meds (ABX for H. Pylori or PPIs) should get ENDOSCOPY!
what is the diagnostic test of choice for zenkers?
Contrast Esophagram.
Duodenal or Jejunal atresia is associated with what matrenal risk factors?
These atresias occur due to vasuclar accidents in utero.
The in utero vascular accidents occur by the moms usage of VASOCONSTRICTIVE meds or substances like Cocaine or tobacco
Duodenal atreia = double bubble
Jejunal atresia = tripple bubble
Duodenal atresia vs Pyloric stenosis emesis.
Duodenal atresia = billious emesis
Pyloric stenosis = NO Bile in emesis
Biliary atresia presentation
Infant (asymptomatic at birth) then after 1 week develops jaundice. PALE stools and HEPATOMEGALLY. the DIRECT bilirubin is elevated as is TOtal.
Pathogenesis - idopathic - progressive OBLITERATION of EXTRAHEPATIC bile ducts.
Appears at 1-8 weeks (normal at birth).
Diagnosis: Conjugated HYperbilirubinemia
Liver biopsy - Bile Duct Plugs and Proliferation. PORTAL tract EDEMA and FIBROSIS.
GOLD STANDARD for diagnosis - INTRAOPERATIVE CHOLANGIOGRAM –> will show billiary obstruction.
Treatment - First do KASAI procedure which is a hepatoportoenterostomy. This will buy time.. because eventually the patient must get a Liver transplant
Crigler Najjar vs Gilberts syndrome
BOTH are inherited deficiencies of UDP- GLUCURONYL TRANSFERASE.
Gilbert = mild. Most patients are ASYMPTOMATIC or have MILD JAUNDICE only in times of STRESS.
Crigler-Najjar = Enzyme is ABSENT. Presents early in life and REQUIRES LIVER TRANSPLANT.
What is the inital treatment done for SUSPECTED esophageal varicies?
3 things.
- VOlume Ressucc
- Prophylactic ABX (Ceftriaxone)
- Somatostatin analogues (Octreotide)
After providing initial treatment in esophageal varicies… what is the next step?
URGENT ENDOSCOPIC TREATMENT (within 12 hours) –> ENDOSCOPIC BAND LIGATION for active bleeding.
Patients with uncontrollable bleeding will get a temporary balloon tamponade (SENGSTAKEN-BLAKEMORE) before gettings a TIPS done.
If bleeding stops.. then give BB as prophylaxis and schedule endoscopic band ligation 1-2 weeks later.
what is Murphy sign
when positive is a sign of CHOLECYSTITIS.
Acute pain when the examiner palpates under the costal margin and asks the patient to breathe in.
Patient has SUBacute fever, abdominal / flank pain that radiates to the GROIN. His symptoms include anorexia and weight loss. He has pain in the abdomen when the hip is extended.
Psoas Abscess.
Pain with Hip extension = PSOAS sign.
CT scans are required to CONFIRM the diagnosis. MUST do ABX and DRAINAGE!.
1/3 of patients with duodenal atresia have what other condition?
DOWNS syndrome
Duodenal atresia presents with BILLIOUS vomiting in the first 2 days of life.
NO ABDOMINAL distention.. because gas CANNOT pass the duodenum.
Congential Aganglionic Megacolon (HIRSCHSPRUNG disease) is also associated with DOWNS.. what are the symptoms of hirschsprung?
BILLIOUS EMESIS and Delayed passage of MECONIUM (more than 2 days post birth without meconium)
MARKED ABDOMINAL DISTENSION and DILATED LOOPS OF SMALL AND LARGE BOWEL on x-ray.
NO AIR IN RECTUM!!
Impaired night vision + dry scaly skin, dry conjunctiva, dry cornea and a wrinkled, cloudy cornea.
Follicular hyperkeratosis of the shoulders, buttocks, and extensors
All indicate what vitamin deficency?
VItamin A
A capillary refil greater than how many seconds is considered dehydration?
2-3 seconds = moderate dehydration
more than 3 seconds = SEVERE dehydration.
Mild / moderate dehydration = oral re-hydration for the baby / child
Severe Dehydration = IV fluids!
Symmetric LES narrowing + difficulty swallowing solids (not liquids) + NO weight loss or anorexia. what is the most likely diagnosis?
Esophageal (peptic) Stricture
Symmetric narrowing. Normally a result of long term GERD –> barretts –> stricture formation.
Other causes of peptic strictures:
- Radiation
- Systemic sclerosis
- Caustic ingestion
Must do endoscopy in these patients and get a biopsy to RULE OUT cancer.
Cancer (ADENOCARCINOMA of the esophagus) will be ASYMMETRIC narrowing of the esophageal lumen.
Gastric folds protruding above the diaphragm seen on barium swallow.
Patient has GERD as well.. what is the diagnosis?
Hiatal hernia.
Protrusion of stomach above the diaphragm.
These patients are at risk for barrets, peptic strictures and adenocarcinoma.
Esophageal Cancer - Squamous vs Adenocarcinoma
Distal esophagus –Barrets = ADENOCARCINOMA.
ANywhere in the esophagus = squamous.
Adenocarcinoma risk factors:
1. Acid reflux and obesity
Squamous cell risk factors:
1. Smoking, alcohol and caustic injury
Diagnosis for both = endoscopy with biopsy
CT / PET for staging
Fatigue, Jaundice, GWNAWING abdominal pain WORSE at NIGHT, weight loss, Migratory Thrombophlebitis are all signs of what?
Pancreatic ADENOCARCINOMA.
Diagnosis - Ultra sound in patiehts WITH Jauncide (indicates tumor of head of pancrase)
Or
CT scan in patients WITHOUT Jaundice (indicates tumor of body or tail)
Causes of acute pancreatitis in order of most common to least common?
- Alcohol
- Gallstones
- Hypertriglyceridemia (MUST be above 1000 for diagnosis)
- Drugs (azathioprine, valproic acid, THIAZIDES)
- Infections (CMV, Legionella, Aspergillus)
- Iatrogenic (POST ERCP!)
stress ulcers and gastritis occur when?
when the body is subjected to severe and prolonged stress.
Usually seen in ICU patients or BURN UNIT setting.
To diagnosis Acute Liver Failure you need to have 1 of 3 findings. WHat are these 3 findings?
- Elevated AMINOtransferases (above 1000)
- Signs of HEPATIC ENCEPHALOPATHY (Confusion, asterixis)
- INR > 1.5
VZV - Shingles presents with a vesicular rash. Can pain present before the rash?
yes. In many patients the Pain in a dermatomal distribution (Constant, Burning, severe pain) may PRECEDE the vesicular rash by several days.
What is the preferred way to reduce intussusception in neonates
AIR enema.
Not barium - barium leads to perforation and subsequently peritonitis if it leaks in to the peritoneum.
what kind of granulomas are found in chrons?
NON-caseating.
Chrons has TRANSMURAL inflammation
Treatment for chrons - Asprin for patients without systemic symptoms. Steroids for patients with systemic symptoms or biologics like infliximab.
Ulcerative Colitis DOES NOT have granulomas
Subcutaneous Emphysema + Mediastinal widening + Pleural EFFUSION with HIGH AMYLASE content –> what is the most likely diagnosis?
Esophageal perforaration (BOorehave).
Mediastinal widening because of mediastiniits (the fluid and air accumulate in the mediastinum causing inflammation).
High amylase content of fluid –> Due to saliva in the esophageal contents.
Pancreatitis also has high amylase content with pulmonary edema however it does NOT cause mediastinal widening.
In a patient with elevated serum alk phos whats the next step?
Check the GGT.
Normal GGT means akl phos is elevated due to bone origin.
Elevated GGT means alk phos is elevated to billiary disease.
Elevated alk phos + normal AST and ALT + nomral RUQ US + Positive ANTIMICTOCHONDRIAL ANTIBODY ASSAY
Primary Biliary Cholangitis (used to be called primary billiary chirosis).
CHaracterized by CHOLESTASIS with AUToimmune destruction of INTRAHEPATIC bile ducts.
Middle aged women –> Puritis and fatigue are the first symptoms.
as the disease progresses –> jaundice, steatorrhea, hepatomegaly, eyelid xanthelasma, portal HTN and osteopenia.
Treatment = URSODEOXYCHOLID acid… later stage will require liver transplantation.
when suspecting bowel perforation by any cause.. ulcer.. caustic substance etc.. what is the BEST test to confirm diagnosis?
Upright X-ray of the CHEST and ABDOMEN
will show FREE AIR under the diaphragm!
Perotonitis signs?
guarding, rigidity, reduced bowel sounds, rebound tenderness.
can be seen in a perforated viscus of the bowel… some causes include PUD.. which can be caused by NSAIDS or alcohol
elevated HOMOcystiene but normal Methylmalonic acid?
Folate deficency.
Elevated homocystine AND methylmalonic acid?
B12 deficency
does breast feeding reduce the risk of breast and ovarian cancer in the mom?
YES!
It also PREVENTS otitis media, resp illness, gi ilness and UTIs in the BABY!
what is a contraindication to breastfeeding in the infant?
If the infant has GALACTOSEMIA!
or if the mom has..
- Active untreated Tb
- HIV
- Herpes on breast
- VZV 5 days prior to breast feeding or within 2 days of delivery
- CHemo
- Street drugs / alcohol
What causes zenkers diverticulum and how do you diagnose it?
Sphincter dysfunction and esophageal dysmotility are believed to cause Zenkers.
Diagnose with barium.
Post abdominal surgery patient develops diarrhea.. what kind of diarreha is it most likely?
secretory diarrhea.
Hallmarks of secretory diarrhea = larger daily stool volumes (more than 1 liter per day) and diarrhea that occurs even during fasting or sleeping.
PAINLESS episodic GI Bleeding with no findings on colonoscopy is most likely what?
ANGIODYSPLASIA.
Angiodysplasia is characterized by DILATED SUBMUCOSAL VEINS AND AVMs.
it can occur anywhere in the GI tract but most commonly occurs in the right colon.
Seen more commonly in patients with renal disease, aortic stenosis and vWF disease.
Diagnosis is done through endoscopy (upper gi or colonoscopy) but can be missed due to poor bowel prep or the angiodysplaisa being behind a HAUSTRAL FOLD.
Treatment = cautarization.
How is it diff from colon cancer?
Colon cancer also causes painless bleeding but would cause small amounts.. if causing large amounts it would NOT be missed on colonoscopy.
