GI-/nutritional 11% Flashcards
Tearing rectal pain and bleeding which occurs with or shortly after defecation, bright red blood on toilet paper
Anal fissure
Treatment for anal fissure
Sitz baths, increase dietary fiber, and water intake, stool softeners or laxatives
Usually heals in 6 weeks
Botulinum toxin A injection (if failed conservative treatment)
What are the 4 cardinal signs of strangulated bowel?
The 4 cardinal signs of strangulated bowel: fever, tachycardia, leukocytosis, and localized abdominal tenderness.
Presents with: diffuse abdominal pain, nausea, and several episodes of emesis
He has not had any flatus for at least 2 days
He has a midline abdominal scar and a right subcostal scar
ABD X-ray: air fluid level
Small bowel obstruction
Diagnostics of small bowel obstruction
Abdominal series
CT Abdominal and pelvis
What is Treatment for SBO?
1st
Patients with SBO are often significantly dehydrated. Aggressive fluid resuscitation (with an isotonic intravenous fluid such as normal saline) and electrolyte repletion. + NGT
- Complete obstruction: 12-24 hr NPO
SBO with signs of bowel ischemia/peritonitis?
SURGICAL EMERGENCY
Gradually increasing abdominal pain with longer intervals between episodes of pain,
abdominal distention, obstipation,
less vomiting (feculent),
more common in the elderly
LARGE BOWEL OBSTRUCTION
FEBRILE + TACHYCARDIA –> SHOCK
MCC of large bowel obstruction
CANCER stricture hernia volvulus Fecal impaction
KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon is what?
Large bowel obstruction
Physical exam finding of LBO?
Look for vomiting of partially digested food, severe abdominal distensions and high pitched hyperactive bowel sounds progressing to silent bowel sounds.
The initial diagnosis of cholelithiasis is best made with what imaging technique?
US
stones in the gallbladder (i.e., gallstones) without inflammation
Cholelithiasis
CARDINAL SYMPTOM OF GALLSTONES DUE TO TEMPORARY OBSTRUCTION OF CYSTIC DUCT
biliary colic
Complications of cholelithiasis
CHOLECYSTITIS : cystic duct obstruction by gallstones
CHOLEDOCOLITHIASIS:
gallstones in the biliary tree – associated with ductal dilation and biliary colic or jaundice. Treat with stone extraction via ERCP
CHOLANGITIS
biliary tract INFECTION secondary to obstruction by gallstones. Diagnose with ERCP
Abrupt RUQ pain constant slowly resolves 20min- hrs nausea precipitated by fatty foods and large meals
BIliary colic
Right subscapular pain of biliary colic is known as?
BOAS SIGN
As ALK-P is not specific to liver what is it also elevated in?
Bone, gut and placenta
ELEVATED ALK-P with GGT
Obstruction to bile flow (cholestasis) in any part of biliary tree
IF normal makes cholestasis unlikely
What are some of the causes of DECREASED ALBUMIN
1st - Chronic liver disease
- Nephrotic syndrome
- -Malnutrition
- inflammatory state (Burn, sepsis, trauma)
When is PT prolonged?
PT is not prolonged until most of the liver’s synthetic capacity is lost, which corresponds to advanced liver disease.
Asx cholelithiasis aka Biliary colic TX
observe
symptomatic patients with cholelithiasis Tx?
Cholecystectomy
What does
4Fs represent?
Fat, Forty, Female, Fertile
What are Gallstones have been classified into all of the following
Cholesterol
Pigment
mixed
Which antibiotic is a major cause of biliary sludge?
Ceftriaxone is a major cause of biliary sludge. The mechanism of biliary sludge formation during ceftriaxone therapy appears to be the propensity of ceftriaxone to bind calcium and form insoluble crystals in bile in the gallbladder, resulting in biliary sludge or frank stones
Inflammation of the gallbladder; usually associated with gallstones
RUQ pain after a high-fat meal
Low-grade fever, leukocytosis, JAUNDICE
cholecystitis
What is the most specific test for acute cholecystitis?
HIDA SCAN
Chronic cholecystitis may lead to
porcelain GB (premalignant condition)
Patients with chronic cholecystitis rarely have abnormal laboratory studies
Which of the following signs is associated with acute cholecystitis?
Murphy’s sign
Prophylactic cholecystectomy for asymptomatic cholelithiasis is generally
not recommended
Ultrasound findings that suggest acute cholecystitis are
pericholecystic fluid, gallbladder thickening, and sonographic Murphy sign. CT scan and MRI is more sensitive in diagnosis of choledocholithiasis
The HIDA scan is expensive and reserved for cases in which the ultrasound study or CT scan is nondiagnostic but there is a high suspicion of cholecystitis.
WHAT ARE THE COMPLICATIONS OF GALLSTONES?
Acute cholecystitis
Hydrops of gallbladder
Gastric outlet obstruction
Acute biliary pancreatitis
A patient with cirrhosis develops acute hepatic encephalopathy. Initial pharmacologic treatment of this disorder consists of which of the following?
Asterixis (flapping tremor), dysarthria, delirium, coma
Lactulose
as it binds to ammonia in GI tract and comes out as diarrhea
What is late sign of hepatic fibrosis?
Cirrhosis
Characterized by regenerative nodules surrounded by dense fibrotic tissue
The liver unable to regenerate due to large amounts of scar tissue
most common cause of cirrhosis
Chronic hepatitis
Other causes:
Chronic HEP C
ALCOHOL ABUSE
↑ Copper, ↓ Ceruloplasmin + family history
Wilsons disease
spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation
Cirrhosis
α-fetoprotein level at diagnosis to screen for
hepatocellular carcinoma
Screen every 6 months with US
why All patients with cirrhosis should undergo esophagogastroduodenoscopy (EGD)
to rule out esophageal varices
best follow-up test for HCC if α-fetoprotein elevated and/or liver mass found on ultrasound
MRI
Fever and abdominal pain in a patient with cirrhosis think
SBP
Dx: with cell count of ascites fluid
triad of abdominal pain, ascites, and hepatomegaly
Budd Chiari (hepatic vein thrombosis)
GOLD STANDARD and is often required for definitive diagnosis of cirrhosis
Liver Biopsy
Typically AST > ALT. Enzymes normalize as cirrhosis progresses
↑ ALP and ↑ GGT
Anemia from hemolysis, folate deficiency, and splenomegaly
Decreased platelet count from portal hypertension with splenomegaly
Decreased bilirubin conjugation by the liver ⇒ ↑ unconjugated bilirubin ⇒ jaundice
Decreased albumin production by the liver ⇒ hypoalbuminemia
Decreased clotting factor production by the liver ⇒ Prolonged prothrombin (PT),
Liver cirrhosis
Ultrasound: helpful to determine liver size and evaluate for hepatocellular carcinoma
- Treatment for Cirrhosis?
- How to treat autoimmune hepatitis?
- how to Tx Wilson’s disease?
- How to treat DECOMPENSATION related to cirrhosis?
- What is the primary prophylaxis against variceal related hemorrhage?
- what is the treatment for encephalopathy?
- How to reduce ascites?
- Medication to treat pruritus related to uremia or cirrhosis?
- cirrhosis is irreversible
- –Stop alcohol
- –Antiviral treatment for Hepatitis C
- –For advanced cirrhosis ⇒ liver transplant may be necessary - Corticosteroids for autoimmune hepatitis
- Chelation therapy (e.g. penicillamine) for WILSONS Dz
- Diuretics, antibiotics, laxatives, enemas, thiamine, steroids, acetylcysteine, pentoxifylline for DECOMPENSATION
- Nonselective BB (nadolol and propranolol) for primary prophylaxis against
- -variceal hemorrhage or ——–esophageal variceal ligation (EVL) - Encephalopathy ⇒ lactulose + neomycin or Rifaximin
- ASCITES ⇒
sodium restriction, paracentesis, spironolactone, lasix - PRURITUS: ⇒ cholestyramine (QUESTRAN)
Polyps in the distal colon are commonly benign if seen in the proximal colon they are more likely
CANCEROUS
Villous adenomas have a 30-70% risk of malignant transformation
The most common cause of painless rectal bleeding in the pediatric population
polyp
Once identified follow-up colonoscopy in 3-5 years
development of hundreds to thousands of colonic adenomatous polyps
Familial adenomatous polyposis (FAP)
Autosomal dominant
Risk of colorectal cancer 100% by 30-40 years of age
The family should undergo yearly sigmoidoscopy beginning at 12 years of age
Prophylactic colectomy recommended
Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age
COLON CANCER
Apple core lesion on barium enema
ADENOMA MC
Screening with colonoscopy begins at 50 then every 10 years until
75
Fecal occult blood testing – annually after age 50
Flexible sigmoidoscopy – every 5 years with FOB testing
Colonoscopy – every 10 years
CT colonography – every 5 years
More likely to be malignant
sessile, > 1 cm, villous
Tumor Marker: CEA
Less likely to be malignant colon cancer
Pedunculated, < 1 cm, tubular
Patients who are older than 50 with new-onset constipation should be evaluated for
Colon cancer
laxatives? 3
Bulk-forming laxatives first line — Bulk-forming laxatives include psyllium seed (eg, Metamucil), methylcellulose (eg, Citrucel), calcium polycarbophil (eg, FiberCon®), and wheat dextrin (eg, Benefiber)
Osmotic laxatives can be used in patients not responding satisfactorily to bulking agents. Start with low-dose polyethylene glycol (PEG) as it has been demonstrated to be efficacious and well-tolerated in older adults.
Stimulant laxatives — Stimulant laxatives affect electrolyte transport across the intestinal mucosa and enhance colonic transport and motility.
The most common cause of acute diarrhea
Hypokalemia and metabolic acidosis
Diarrhea breakout in a daycare center: Rotavirus
Diarrhea on a Cruise Ship: Norovirus
Traveler’s diarrhea:
Prophylaxis:
FQ
E coli
Occurs in the first 2 weeks of travel, lasts 4 days without treatment
Defined as: 3+ unformed stools in 24 h with at least one of the following: fever, nausea, vomiting, abdominal cramps, tenesmus, bloody stools
Complications: Dehydration (MC), Guillain-Barre, Reiter syndrome
TX: Empiric treatment with ciprofloxacin 500 mg BID × 1-3 d and loperamide (if older than 2 y)
1.Diarrhea after a picnic and egg salad:
2Diarrhea from shellfish
- Diarrhea from poultry or pork
- Diarrhea in a patient post antibiotics
- Diarrhea in poorly canned home foods
1.Staph. A
2.Vibrio cholerae
Tx:
- Salmonella
Tx: Ceftriaxone and sometimes a fluoroquinolone or azithromycin - C. diff
- C. perfringens
Diarrhea after drinking (not so) fresh mountain stream water
Dx:
Tx:
Giardia lamblia - incubates for 1-3 weeks,
causes foul-smelling bulky stool and
wax and wane over weeks before resolving
Dx: stool cyst or trophozoites
Tx: Tinidazole
OR
flagyl
a flu-like bacterial infection characterized by fever, GI symptoms, and headache
Transmitted via the consumption of fecally contaminated food or water
GI symptoms may be marked constipation or “pea soup diarrhea”
Rose spots may be present (2-3 mm papule on trunk usually)
More common in the developing world (usually immigration cases)
- Enteric fever (salmonella typhi):
TX:
Ceftriaxone and sometimes a fluoroquinolone or azithromycin
No treatment except in immunocompromised or enteric fever (S. typhi)
predominantly affects children
and is often spread in areas with crowded conditions (like daycare centers)
Abdominal pain + inflammatory diarrhea (small volume) frequent, mucous and bloody stool,😡
nausea, vomiting (less common), possible fever
Shigellosis
Tx: TMP-SMX
Alternative:
Cipro/FQ
Drugs to stop diarrhea (such as diphenoxylate or loperamide) may prolong the infection and should not be used
Consumption of undercooked ground beef Shiga-like toxin
Watery, voluminous, nonbloody diarrhea with nausea and vomiting→ Dysentery (bloody)
No fecal leukocytes
Enterohemorrhagic E. coli (EHEC
Antibiotics not recommended, except in severe disease
Complication: Hemolytic uremic syndrome (AKI, thrombocytopenia, hemolytic anemia)
Causes a life-threatening, rice water diarrhea
The organism is typically found in seafood - Consumption of contaminated, locally harvested shellfish
CHOLERA
Treated with both glucose and Na rich electrolyte fluids
Doxycycline
What is the main risk factor for esophagitis?
Immunocompromised
An endoscopy for presumed esophagitis shows multiple shallow ulcers. What is the most likely diagnosis?
Tx?
Herpes simplex virus
Tx: Acyclovir
odynophagia (pain while swallowing food or liquids) is the hallmark sign of?
INFECTIVE ESOPHAGITIS
This occurs mainly in patients with impaired host defenses. Primary agents include Candida albicans, herpes simplex virus, and cytomegalovirus. Symptoms are odynophagia and chest pain
linear yellow-white plaques with odynophagia or pain on swallowing
TX?.
Candida
Fluconazole 100mg PO QD
large solitary ulcers or erosions on EGD,
TX?
Ganciclovir
mechanical or functional abnormality of the LES
Reflux esophagitis:
Patient with asthma symptoms + GERD not responsive to antacids
impaction (food being stuck at the lower end of the esophagus)
barium swallow will show a ribbed esophagus and multiple corrugated rings
TX?
Eosinophilic esophagitis
treat by removing foods that incite allergic response, topical steroids via inhaler
What medications x2 can cause esophagitis? or gastritis?
NSAIDS or bisphosphonates
Dysphagia lasting weeks-months after therapy
Radiation exposure of 5000 cGy associated with increased risk for stricture
Radiation: radiosensitizing drugs include doxorubicin, bleomycin, cyclophosphamide, cisplatin
Ingestion of alkali or acid from attempted suicide
Corrosive esophagitis
Tx:
Steroids
Dyspepsia (belching, bloating, distension, and heartburn) and abdominal pain are common indicators of gastritis
Three causes:
Gastritis: inflammation of the stomach lining
H.pylori
Inflammation: (NSAID and ALCOHOL)
–NSAIDs: cause gastric injury by diminishing local prostaglandin production in the stomach and duodenum
– Alcohol: a leading cause of gastritis
Autoimmune or hypersensitivity
Gram-negative spiral-shaped bacillus
H. pylori
most sensitive and specific for detection of Helicobacter infections?
correct combination for triple therapy ?
endoscopic biopsy with histologic examination
In the office setting, stool examination for H. pylori antigen
–C.-A.-P.
Clarithromycin + amoxicillin + PPI
disorders is most likely a side effect associated with proton pump inhibitors (PPIs)?
–3
At risk for?
Electrolyte issue and vitamin
Infection
Hip fracture
Proton pump inhibitors may promote hypochlorhydria and interfere with absorption of calcium, leading to increased frequency of hip fracture
LOW B-12 and MAg.
pneumonia
(Decreased gastric acid production may also allow for bacterial overgrowth and is associated with increased risk of respiratory infections such as pneumonia. PPIs have also been associated with C.diff associated diarrhea.)
Pernicious anemia: + schilling test + ↓ intrinsic factor and parietal cell antibodies
PErnicious anemia
1st line TX gastritis?
stop NSAIDs, empiric therapy with acid suppression 4-8 wk of PPI
If no response, consider upper GI endoscopy with biopsy and ultrasound
H.pylori TX?
treat with (CAP) – clarithromycin + amoxicillin +/- metronidazole + PPI (i.e. Omeprazole)
Quadruple therapy (PPI, Pepto, and 2 antibiotics) for one week
GERD
the test of choice but not necessary for typical uncomplicated cases
Indicated if refractory to treatment or is accompanied by dysphagia, odynophagia, or GI bleeding
gold standard for diagnosis (but usually unnecessary)
Endoscopy w/ bx
pH Probe
GERD Treatment
Mild
Severe
Complications?
Lifestyle:H2 receptor blockers, proton pump inhibitors, diet modification (avoid fatty foods, coffee, alcohol, orange juice, chocolate; avoid large meals before bedtime); sleep with trunk of body elevated; stop smoking
Nissen fundoplication
Barrett’s esophagus
What to do if Barrett’s esophagus?
Once Barrett’s esophagus has been identified, screening every 3 to 5 years by upper endoscopy is recommended to look for dysplasia or adenocarcinoma.
Patients with foul odor of the breath and increasing symptoms think
Zenker’s Diverticulum which is an outpouching of hypopharynx resulting in regurgitation of solid foods – needs surgical repair.
Melena
Upper GI bleed
Upper abdominal pain
Worse with meals
Better w/ meals –>
Dx: upper endoscopy
Bx for H.pylori
all ulcers with malignant features should be biopsied
In patients with active bleeding, a negative biopsy result does not exclude H. pylori. get breath test or stool antigen
Tx
PUD MC UPper GI bleed cause:
–>gastric ulcer
It is most commonly found at the lesser curvature of the antrum
Duodenal Duodenal ulcer (food classically decreases pain think Duodenum = Decreased pain with food)
Treatment for H.Pylori: PPI + Amoxicillin 1g PO BID + Metronidazole or Clarithromycin 500 mg PO BID
Think Baseball “CAP” = Clarithromycin + Amoxicillin + PPI
Odynophagia, gastroesophageal reflux, dysphagia
Dx.
esophageal ulcer
Esophagitis
endoscopy
What is a risk factor for an increased incidence of duodenal and gastric ulcers, as well as a decrease in rate of healing?
smoking
gastrinoma; tumor of the pancreas that causes the stomach to produce too much gastrin with subsequent acid secretion leading to ulcer formation. Diagnosed with gastrin levels >200 pg/mL)
Zollinger - Ellison syndrome
PPI and resect the tumor
Emesis, retching, or coughing prior to hematemesis
Mallory weiss tear
is a linear mucosal tear in the esophagus at the gastroesophageal junction
MCC alcohol
Dx:upper endoscopy
Tx: self limiting
Jaundice, abdominal distention (ascites)
Variceal hemorrhage or portal hypertensive gastropathy
Dysphagia, early satiety, involuntary weight loss, cachexia
Malignancy
H. Pylori is the most important risk factor
Treat with gastrectomy, radiation therapy and chemotherapy
Describe the mnemonic WEAPON for gastric cancer
WEAPON”: Weight loss, Emesis, Anorexia, Pain/epigastric discomfort, Obstruction, Nausea
What are the most common early symptoms? What is the most common symptom?
The most common early symptoms are mild epigastric discomfort and indigestion. The most common symptom is weight loss.
Which side is the supraclavicular lymph node involvement in gastric cancer?
The left side! Virchow’s node (left supraclavicular) is associated often with gastric cancer. The RIGHT supraclavicular node is associated with Hodgkins lymphoma, as the right node drains the mediastinum and it is common for HL to originate in the mediastinum.
Metastatic signs include
Virchow’s node (Supraclavicular)
Sister Mary Joseph’s node (Umbilical)
Hematochezia: bright red blood per rectum (BRBPR)
lower GI bleed
Diverticulosis is generally an incidental finding since diverticular bleeding is usually of greater volume. MCC
rectal bleeding and abdominal pain
Proctitis
painless rectal bleeding, no red flag signs
Polyp
Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age
Colorectal cancer:
What is the most common site of an anal fissure?
Posterior midline
are believed to result from laceration by a hard or large stool or from frequent loose bowel movements
anal fissure tx
accronym
WASH
topical vasodilators (nifedipine or nitroglycerin) for one month
W arm sitz baths
A nalgesics: 2% lidocaine jelly
S tool softeners (Colace)
H igh Fiber: the recommended dietary fiber intake is between 20 and 35 grams per day
Second-line therapy
Topical Ca channel blocker
treatment option following failure of conservative treatment for anal fissure?
Lateral anal sphincterotomy
Cisapride is a prokinetic agent. It’s not used in the treatment of anal fissure.
a 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid-abdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC.
Diverticulitis
is defined as inflammation of the diverticula caused by obstructing matter
Infection and macroperforation. Presents with constipation. LLQ pain, fever, ↑ WBC, ↑ CRP, and may bleed
a 63-year-old male who is being evaluated in the emergency department for an episode of painless bright red blood per rectum for two hours.
Diverticulosis will present as
is defined as large outpouchings of the mucosa in the colon
Presents with painless rectal bleeding, particularly in an elderly pa
complication of diverticulitis?
Fistula
B Colonic stricture
C Abscess
Diverticulitis presents commonly as left lower quadrant pain, tenderness, palpable mass, and abdominal distention.
CT scan is the best imaging modality during acute episode of diverticulitis
CT will demonstrate fat stranding and bowel wall thickening
Occult blood in the stool and mild to moderate leukocytosis may occur with diverticulitis.
Barium enema and endoscopy are contraindicated during the initial stages of an acute attack because of the risk of free perforation.
he most common organisms involved in the development of diverticulitis are
E. coli and B. fragili
perianal pruritus that is worse at night
Dx:
Tx
Pinworm (Enterobius vermicularis):
“scotch tape test’ done in the early morning. Can see the eggs under microscopy
TX with mebendazole
GI symptoms and weight loss
Transmission from raw or undercooked meat
Associated with B12 deficiency
Tx
TAPEWORM
DX: Tape test for D. latum, stool sample: eggs
TX: Praziquantel
cough, weight loss, anemia recent travel
Larvae invade the skin, travel to lung, cough, and swallow, reside in the intestine
EOSINOPHILLIA and ANEMIA
HOOKWORM
DX: Stool sample - adult worms
TX: mebendazole
pancreatic duct, common bile duct, and bowel obstruction
Most common intestinal helminth worldwide found in contaminated soil
ROUND WORM
A high load may cause pancreatic duct, common bile duct, and bowel obstruction
DX: stool sample eggs or adult worms
TX: albendazole
Fecal-oral, contaminated water/food, anal-oral
Bloody diarrhea, tenesmus. abdominal pain
Associated with LIVER ABSCESS
AMEBIASIS
DX: Stool sample—trophozoites
TX: Iodoquinol or paromomycin and Flagyl for liver abscess
also known as snail fever and bilharzia, is a disease caused by parasitic flatworms called
Schistosomiasis
Penetration of skin (contaminated freshwater) → enter the bloodstream and migrate to the liver, intestines, and other organs
Symptoms include rash, abdominal pain, diarrhea, bloody stool, or blood in the urine
DX: Eggs in urine or feces
TX: Praziquantel
if BRBPR or suspected thrombosis
Varicose veins of anus and rectum
Risk factor: Constipation/straining, pregnancy, portal HTN, obesity, prolonged sitting or standing, anal intercourse
ANOSCOPY FOR HEMORRHOIDS
lower 1/3 of the anus (below dentate line)
Thrombosed:
Significant pain, and pruritus but no bleeding
Palpable perianal mass with a purplish hue
EXTERNAL HEMORRHOID
Treat with excision for thrombosed external hemorrhoids
upper 1/3 of the anus
Bright red blood per rectum, pruritus and rectal discomfort
INTERNAL
Treatment: Fiber, sitz bath, ice packs, bed rest, stool softeners, topical steroids
Rubber band ligation If protrudes with defecation, enlargement, or intermittent bleeding
Closed hemorrhoidectomy if permanently prolapsed
Involves protrusion of the stomach through the diaphragm via the esophageal hiatus
It can cause symptoms of GERD
HIATAL HERNIA
DX: barium upper GI series, upper endoscopy
Tx: acid reduction may suffice, although surgical repair can be used for more serious cases (15%)
Hematochezia and pus-filled diarrhea, fever, tenesmus (feeling of incomplete defecation) anorexia, weight loss
UC
Barium enema: Lead pipe appearance (loss of haustral markings)
UC TX?
Colectomy is curative
Medications: Prednisone and mesalamine
Mouth to anus Skip lesions Transmural thickening Fistulas common, abscess Abdominal pain, aphthous ulcers,
Result of barium enema?
CHRONS
Barium enema: Cobblestone appearance
CHRON’S TX
Flares: Prednisone +/- Mesalamine +/-
Maintenance: Mesalamine
Surgery is not curative. Adjacent portion of the bowel is affected post-op
abdominal pain and altered bowel function
IRRITABLE BS
Comorbid: Depression, anxiety, somatization
According to the Rome IV criteria, IBS is defined as
DX of exclusion
All labs normal, no mucosal lesions: CBC, renal panel, FOBT, O&P, sed rate, ± flex sig
Colonoscopy, barium enema, ultrasound, or CT
Endoscopy in patients with persistent symptoms, weight loss/anorexia, bleeding or history of other GI
ABD PAIN
at least 1 day per week in the
last 3 months, associated W/ two or more of the following criteria:
- Related to defecation
- change in stool frequency
- change in stool form (appearance)
serotonin agonist introduced for the treatment of IBS
Tegaserod maleate (Zelnorm)
what is converted to unconjugated bilirubin from heme?
Heme is broken down into iron and protoporphyrin
iron is recycled
protoporphyrin
What makes stool brown and urine yellow?
Normal intestinal microflora will act on the bile and convert it to urobilinogen which is oxidized to stercobilin (which makes stool brown) and urobilin (which makes urine yellow)
increases the level of UCB which overwhelms the liver’s ability to conjugate UCB. Dark urine and increased risk for pigmented bilirubin gallstones result/.
Extravascular hemolysis/ineffective erythropoiesis: –> jaundice
what is uridine glucuronyl transferase (UGT)?
Albumin transports UCB to the liver for conjugation by uridine glucuronyl transferase (UGT) in hepatocytes
mildly low UGT activity which increases UCB. Jaundice occurs during stress like a severe infection. Otherwise, pts are asymptomatic.
Gilbert syndrome
the absence of UGT which increases UCB causing kernicterus which is usually fatal.
Crigler-Najjar syndrome
deficiency of bilirubin canaliculi transport protein which increases CB. The liver is pitch-dark.
Dubin-Johnson syndrome:Dubin-Johnson syndrome:
what is Rotor syndrome?
Rotor syndrome is similar to Dubin-Johnson syndrome except that the liver is not dark.
obstructive jaundice): associated with gallstones, pancreatic carcinoma, liver fluke, and cholangiocarcinoma. This also increases the CB, and alkaline phosphatase and decreases urine urobilinogen. Dark urine, pale stool, pruritus due to increased bile acids, steatorrhea.
Biliary tract obstruction
Predominant alkaline phosphatase elevation —
Elevation of the serum alkaline phosphatase out of proportion to the serum aminotransferases suggests biliary obstruction or intrahepatic cholestasis
disrupts both hepatocytes and small bile ductules which increases both CB and UCB.
Dark urine due to elevated urine bilirubin.
viral hep
Urinary bilirubin indicates that
conjugated hyperbilirubinemia present
Abdominal ultrasound (preferred) or CT abdomen Liver biopsy (definitive)
Elevated INR — An elevated INR that corrects with vitamin K administration suggests
impaired intestinal absorption of fat-soluble vitamins and is compatible with obstructive jaundice
the classic triad of pancreatic calcification (plain abdominal x-ray), steatorrhea (high fecal fat), and diabetes mellitus
chronic pancreatitis
Symptoms: Tea-colored urine, vague abdominal discomfort, nausea, pruritus, pale stool
viral hepatitis
Acute - fatigue malaise, nausea, vomiting, anorexia, fever and right upper quadrant pain.
Transmission: Fecal-oral
Serum IgM anti-HAV
Vaccine: killed (inactivated) - given in two doses, recommended for travelers.
hep A
Acute and Chronic Transmission: Sexual or sanguineous Serology: HBeAg – highly infectious HBsAg – ongoing infection
Anti-HBc –???
Anti-HBs – immune
Risk of hepatocellular carcinoma
HEP B ASSOCIATED WITH HEP D
The vaccine is given to all infants (birth, 1-2 mo, 6-18 mo)
Anti-HBc – had/have infection
IgM – acute
IgG – not acute
Transmission: IV drug use is the most common. Also sexual or sanguineous
Screen with testing for anti-HCV antibodies
Diagnosis with HCV RNA quantitation
Treatment: antiretrovirals target complex of enzymes needed for HCV RNA synthesis
Only occurs when coinfected with Hepatitis B
D
Liver enzymes: AST:ALT ratio > 2:1
Alcoholic Hepatitis
Acetaminophen toxicity TX
N-Acetylcysteine within 8-10 hrs
Risk factors: Obesity, hyperlipidemia, insulin resistance
Liver enzymes: ALT > AST
Fatty Liver Disease:
Liver biopsy: Large fat droplets (macrovesicular fatty infiltrates)
dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis
Presents with: hematemesis with coffee ground/ Melena
Initial presentation: tachycardia/hypotension ⇒ may bleed massively but cause no other symptoms
Esophageal varices
Varices offer a channel that diverts pressure from the portal circulation. Often found in lower 1/3 of the esophagus and can extend into gastric veins
Dx: EMERGENT EGD after stabilizing patient
diagnostic and therapeutic
Labs: Hgb, Hct and Platelet (usually low in liver patients)
Treatment for esophageal varices? Liver related
Treatment consists of intravenous octreotide which is a somatostatin analog that decreases portal blood flow
MOA:
Octreotide inhibits the release of glucagon, which is a splanchnic vasodilator.
Antibiotic prophylaxis with IV ciprofloxacin x1 week to lower the risk of a bacterial infection,
and
in severely-ill individuals, IV ceftriaxone is given instead
An upper endoscopy is done within 12 hours of presentation and variceal ligation with elastic bands placed on the varices to stop them from bleeding
What is endoscopic sclerotherapy?
a sclerosant solution like sodium morrhuate is injected in the varices endoscopically
What to do with massive bleed and if endoscopic therapy fails to stop the bleeding in esophageal varices?
Balloon tamponade using Blakemore tube
This applies direct pressure which can stop an ongoing bleed. It can be used for about 48 hours
When endoscopic approaches fail, another procedure is a
transjugular intrahepatic portosystemic shunt or TIPS, which creates a path between the portal and systemic circulation in order to lower the portal pressure
How to preventrebleeds?
Nonselective beta-blockers - propranolol, nadolol (treatment of choice in primary prophylaxis to prevent rebleeds)
Isosorbide: long-acting nitrate
What are considered alarm symptoms or features with abdominal pain, IBS?
x5
Alarm features include
- Weight loss
- Iron deficiency anemia –
-Family history of certain organic GI illnesses (eg, inflammatory bowel disease, celiac sprue, colorectal cancer)
Although rectal bleeding and nocturnal symptoms have also been considered alarm features
They are not specific for organic disease.
What is post-parandial urgency with irritable bowel disease?
Postprandial urgency is common, as is alternation between constipation and diarrhea.
Symptoms not consistent with IBS should alert the clinician to the possibility of an organic pathology.
Inconsistent symptoms include the following: Onset in middle or older age Acute symptoms (IBS is defined by chronicity) Progressive symptoms Nocturnal symptoms Anorexia or weight loss Fever Rectal bleeding Painless diarrhea Steatorrhea Gluten intolerance
Which of the following infections has been associated with an increased prevalence of IBS? Giardia lamblia Escherichia coli Shigella Salmonella
Infection with G lamblia has been shown to lead to an increased prevalence of IBS as well as chronic fatigue syndrome. In a historic cohort study of patients with G lamblia infection as detected by stool cysts, the prevalence of IBS was 46.1% as long as 3 years after exposure, compared with 14% in controls.
