GI/Hepatology Flashcards
Typical sources of upper abdominal pain
- gastric
- hepatobiliary
- pancreatic
Typical sources of lower abdominal pain
- hindgut
- lower small/large intestine
- genitourinary
Typical sources of periumbilical abdominal pain
- midgut
- pancreas
hematemesis =>
upper GI source
melena/maroon stools/hematochezia ==>
upper or lower GI source
Charcot’s triad (GI) + meaning
- abdominal pain
- jaundice
- fever
- suggests cholecystitis or ascending cholangitis
Peptic ulcer disease presentation
- burning vs. cramping/vague pain
- typically epigastric, but may also be LUQ/RUQ
- radiation to back unusual, suggests alternate (pancreatitis, vascular) or penetrating PUD
- some patients food worsens gastric ulcer, improves peptic ulcers (<50%)
Pancreatitis presentation
- acute epigastric pain, often w/radiation to back
- pain may decrease w/fetal or lying on side
- (+) vomiting
- gallstone panc => jaundice
- hx Etoh => alcoholic
- dx via serum lipase
Grey-turner sign
- flank ecchymoses seen in pancreatitis
- results from retroperitoneal bleeding
foregut components
Esophagus (distal end) Stomach Duodenum (proximal half) Liver Gallbladder Pancreas Spleen
midgut components
Duodenum (distal half of 2nd part, 3rd and 4th parts) Jejunum Ileum Cecum/Appendix Ascending colon Hepatic flexure of colon Transverse colon (proximal two-thirds) -supplied by superior mesenteric a./nerve plexus
hindgut components
- distal third of the transverse colon and the splenic flexure, the descending colon, sigmoid colon and rectum
- supplied by inferior mesenteric a./nerve plexus
Retroperitoneal organs
P: pancreas (except tail) U: ureters. C: colon (ascending and descending) K: kidneys. E: (o)esophagus. R: rectum.
abdominal aorta
cullen sign
-periumbilical ecchymoses associated with pancreatitis
radiologic eval of pancreatitis
US for stones
CT w/oral and IV contrast
RUQ pain ddx
- cholecystitis
- acute cholangitis
- acute viral hepatitis
- acute alcoholic hepatitis
- gonococcal perhihepatitis
- PNA
Midepigastric or periumbilical pain ddx
- acute pancreatitis
- perforating peptic ulcer
- mesenteric ischemia
- SBO
- celiac
- DKA
- aortic dissection/rupture
- inferior myocardial infarction
RLQ pain ddx
- acute appendicitis
- ectopic pregnancy; ovarian cyst; ovarian torsion
- pelvic inflammatory disease
- nephrolithiasis
- pyelonephritis
LLQ pain ddx
- acute diverticulitis
- toxic megacolon
dx of appendicitis
- missed in 20% of cases
- classic: periumbilical => RLQ
- +anorexia, may be followed by N/V
- dx of appendicitis is doubtful if N/V are first signs
- PE: mcburney’s point (1/3 ASIS to umb), psoas sign (pain w/ext of right thigh while lying on left side; +/- rigidity
- leukocytosis/fever = sensitive, not specific
SBO presentation
- central abd pain + vomiting/constipation
- hx abdominal surgey
- abd. distension, hyperactive bowel sounds
- abd xr: multiple dilated loops bowel + air-fluid levels
Causes of colonic distension
- mechanical obstruction (tumors, stool)
- toxic megacolon
- pseudo-obstruction (ogilvie syndrome)
Toxic megacolon presentation
- c.diff complication
- bloody diarrhea
- fever, tachy, abd. tenderness
- abd xray: thumbprinting
Pseudo-obstruction causes/presentation
- dilation of cecum/right hemi-colon w/out mechanical obstruction
- cases: trauma, infection, cardiac disease
acute diverticulitis presentation
- LLQ abdominal pain + TTP
- hx of chronic consipation and intermittent low-grad abd. pain
- if gaurding, rigidity, fluctuant mass ==> abscess
- ==> abd CT w/oral + IV contrast`\
Most sens/spec imaging for evaluating flank pain
helical CT
Criteria used to dx IBS
- Rome criteria (sens 48%, spec 100%)
- Manning criteria (sens 60%, spec 80%)
Red flags in chronic abd pain
- onset after 50
- weight loss
- anorexia
- malnutrition
- bleeding
- fhx of IBD
Tx of IBS
- sx management
- fiber @ constipation-pred
- loperamide @ diarrhea-pred (after celiac excluded0
- SSRIs (const) or TCA (diarrhea)
cardinal signs of chronic pancreatitis (4)
- pain
- DM
- steatorrhea
- pancreatic calculi (on CT)
courvoisier sign
- nontender palpable gallbladder
- sign of cancer of pancreatic head (w/jaundice)
Most common complication of PUD
- GI bleeding: hematemesis, melena, hematochezia
- occult bleeding presenting as iron-def anemia is less common but occurs
indication for upper endoscopy
pts >55yo w/unexplained epigastric abd pain AND patietns with abd pain + unexplained weight loss, GI bleeding, microcytic anemai, recurrent vomiting
H. pylori testing
- endoscopic: histologic assessment or rapid urease test
- nonendoscopic: serum ab, urea breath test, stool antigen (stool/breath can be used for confirmation of elimination)
Gastrinoma presentation
- mass of cells producing gastrin => excess acid production => “Zollinger-Ellison syndrome”:
- recurrent/refractory ulcers
- ulcers @ distal duodenum
- watery diarrhea
- associated w/MEN I (hyperparathyroidism, pancreatic islet cell tumor, pituitary adenoma)
Management of PUD
- 4-6 weeks of PPI
- stop/decrease NSAIDs
- H. pylori: PPI + amoxicillin + clarithromycin OR PPI + clarithromycin + metronidazole
Stimulants for acid production
- gastrin
- ACh
- histamine
Hepatocellular injury ==> enzyme elevations
AST & ALT
ALT = greater specificity for liver injury (minimally produced elsewhere)
Cholestasis definition & dx
- cholestasis = impaired flow of bile from liver
- ==> elevated alk-phos +/- elevated bilirubin + elevated GGT, 5’-nucleotidase
Unconjugated (indirect) vs. conjugated (direct) hyperbilirubinemia
unconjugated (indirect) = overproduction/hemolysis or impaired conjugation (e.g. gilbert syndrome)
conjugated (direct) = hepatocellular dysfxn/injury or cholestasis or inherited (Dubin-johnson, rotor syndrome)
Liver chemistry for acute viral hep
- AST: +++
- ALT: +++
- AlkPhos: ++
- Bili: varies
- other: exposure hx, constitutional sx
Liver chemistry for alcoholic hepatitis
- AST: +++
- ALT: +
- AlkPhos: Normal to +
- Bili: varies
- other: hx alcohol abuse
Liver chemistry for acute autoimmune hepatitis
- AST: +++
- ALT: +++
- AlkPhos: normal to +
- Bili: varies
- other: autoab
Liver chemistry for wilson dz
- AST: ++
- ALT: ++
- AlkPhos: low
- Bili: + (unconj.)
- other: hemolysis, neuropsych sx, renal tubular acidosis
Liver chemistry for alpha-1-antitrypsin/hemochromatosi dz
- AST: +
- ALT: +
- AlkPhos: normal to +
- Bili: normal
- other: @alpha1 = lung disease; @hemo=elevated ferritin
Liver chemistry for primary biliary cirrhosis/sclerosing cholangitis
- AST: +
- ALT: +
- AlkPhos: +++
- Bili: normal to ++
- other: @PBC= (+)AMA ab; @PSC=presence of IBD
Liver chemistry for large bile duct obstruction
- AST: ++
- ALT: ++
- AlkPhos: ++
- Bili: ++
- other: abdominal pain
Liver chemistry for infiltrative liver dz (eg lymphoma)
- AST: +
- ALT: +
- AlkPhos: +++
- Bili: normal
- other: malaise, hepatomegaly
Liver chemistry for ischemic hep (“shock liver”)
- AST: +++
- ALT: +++
- AlkPhos: normal to +
- Bili: normal
- other: hx hypotension, rapid resolution of studies
Tests for liver synthetic fxn
PT
INR
non-specific/insensitive test
Hepatocellular pattern vs. cholestatic pattern LFTs
- hepatocellular: AST/ALT»_space; Alk phos
- cholestatic: Alk phos»_space; AST/ALT
general symptoms of hepatitis
- n/v
- abd pain
- malaise
- jaundice
Long-term risk in HBV/HCV
hepatocellular carcinoma
causes of non-viral hepatitis
- alcoholic
- autoimmune
- toxin/drug-induced
- genetic causes
- metabolic liver disease
Most common causes of acute viral hepatitis
- Hep A (50%) - may not have any classical risk factors
- Hep B (33%) - may not have any classical risk factors
- Hep D
- Hep C NOT usually acute, typically viral
Serologic dx in acute HBV
- HBsAg: +
- Anti-Hbc: +
- Anti-Hbs: -
- HBV DNA: +
- HBeAg: +
- Anti-HbeAg: +/-
Extrahepatic manifestations of hep B
- glomerulonephritis
- polyarteritis nodosa
- cryoglobulinemia
Serologic dx in inactive HBV carriers
- HBsAg: +
- Anti-Hbc: +
- Anti-Hbs: -
- HBV DNA: -
- HBeAg: -
- Anti-HbeAg: +
Serologic dx in chronic HBV hepatitis
- HBsAg: +
- Anti-Hbc: +
- Anti-Hbs: -
- HBV DNA: +
- HBeAg: +/-
- Anti-HbeAg: +/-
Criteria for hospitalization in acute hepatitis
- inability to maintain oral hydration
- signs/sx of liver failure
Common tx for chronic hep B
- interferon (contraindicated in advanced chronic dz => decompensation)
- lamivudine
Indication for glucocorticoid tx in alcoholic hepatitis
- maddrey discriminant fucntion score ==> indicates whether improved short-term survival w/GC therapy
- DF = 4.6 (PT [s] - control PT time [s]) + serum bili
- DF>32 ==> candidate for prednisone
Antidote for tylenol toxicity
n-acetylcysteine
antidote for valproic acid toxicity
L-carnitine
symptoms of cirrhosis
- hepatocyte dysfxn ==> jaundice, coagulopathy (bleeding)
- increased portal venous pressure ==> ascites, edema, SBP, bleeding esophogeal varices, hepatic encephalopathy, hypersplenism
Signs of jaundice
- yellowed sclera
- yellowed skin
- urine color changes
- pruritis related to cholestasis
