G.I.T. Flashcards
Most accurate test for achlasia
Manometry
Most accurate test for cancer esophagus
Endoscopy with biopsy
Most common site for sq and adenoca in esophagus
SCC:most common
proximal 2/3
ADENOCARCINOMA
Distal 1/3
Precursor baretts esophagus
Which type of angina is mimicked by DES
Primzmetal
Main complaint of DES/Nutcracker esophagus
PAIN
How will u differentiate bw pain of DES and esophagitis
Pain only on swallowing in esophagitis
DES not related to food
Manometry is the most accurte test for
Achlasia
DES
Nutcracker esophagus
Most common cause of epigastric pain
NONULCER DYSPEPSIA
What it indicates if there is difficulty with solids only
Mechanical obstruction
Like lower isophageal ring
Peptic stricture
Esophageal ca.
What is the pathology if there is dysphagia with both solids and liquids
Motility problem
Like DES, scleroderma, achlasia
Haman sign
Mediastinal crunch produced by heart beating against air filled tissues
Seen in esophageal perforation
Most accurte test for esophageal perforation
Contrast esophaogram with gastrograffin not barium
Till what Sx can be done in case of esophageal perforation
Within 24 hrs
Otherwise risk of fistulization
RX OF esophageal perforation
SMALL
Medical: iv fluids, NPO ,Abs , H2 blockers
LARGE/COMMUNICATES WITH PLEURAL CAVITY
Sx within 24 hrs
Most accurate diagnostic test for esophageal diverticula
Barium swallow
Endoscopy can cause perforation
Cause of zenkers diverticula
Faiilure of cricopharyngeal m relaxation during swallowing
Differentiating between regurgitation of achlasia and zenker
Zenker : food can be expressed by oneself
RX of esophageal diverticula
If the diverticula is caused by motility ds like zenker/epiphrenic
Then Rx motility ds by myotomy
Diverticulectomy is of secondry importance
Types of hiatal hernia
TYPE 1
Sliding:GEJ is disturbed so GERD main complaint
Rx: benign , anatacids and lifestyle modification, if not then nissens fundoplication
TYPE2
Rolling/paraesophageal:strangulation/obstruction is the main complication.
Rx: elective surgery to reduce complication
TYPE3
Mixed
TYPE4
Mixed+abdominal content like biwels, spleen
Manometry is diagnostic test for
Achlasia
DES/Nutcracker
Mechanism of DES and achlasia
DES
Nonperistaltic spontaneuos contractions of esophagus but LES tone is normal
Achlasia
Abscence peristalsis
High LES pressure
Is plummer winson syndrome a premalignant condition?
Yes because 10 % develop SCC of oral cabity,hypopharynx,esophagus
Most common risk factor for scc and adenoca of esophagus
SCC
alcohol,tabacco
Diet; HPV, PV syn, caustic ing, nasopharyngeal ca
ADENOCA
GERD and baretts
Rx of achlasia
pneumatic dilation
Botulin toxin(repeat every 2 yrs)
Heller myotomy
What is most sensitive and specific test for H.pylori
Sensitive(SNOUT)
serology
specific(SPIN)
Biopsy
Which is the best test to see response to Rx in H.pylori
Urea breath test
Or
Stool antigen
But done only if there is persistance /reccurence/recrudenscence of symptoms
What are the common causes of epigastric pain related to git
Non ulcer dyspepsia(mc) GERD DU/GU gastritis Cancer
What is the single most important stimulant for gastrin and mucus secretion
STRETCH
Release both acid and mucus
When is Sx indicated in PUD
When complication develops
Bleeding
Perforation
Gastric outlet obstruction
Best triple and quadruple regimen for h.pylori eradication are
TRIPLE
PPI+ amoxicillin+ clarithromycin
QUADRUPLE
PPI+ bismuth subsalicylate+ metronidazole+ tetracycline
Best triple and quadruple regimen for h.pylori eradication are
TRIPLE
PPI+ amoxicillin+ clarithromycin
QUADRUPLE
PPI+ bismuth subsalicylate+ metronidazole+ tetracycline
Mcc of upper git bleeding
Peptic ulcer
Metastasis of gastric carcinoma
KRUKENBERG
to ovary
BLUMER SHELF To rectum(pelvic cul de sac)
SISTER MARY JOSEPH NODE
Periumblical
VIRCHOW NODE
Supraclavicular
IRISH NODE
Lefy axillary adenopathy
Drug for fistulas in crohns ds
Infliximab
TNF alpha inhibitor
Can reactivate TB so get a PPD done
Antibodies found in UC and CD
UC:ANCA
CD:ASCA
Drug used to relieve the spasm of irritable bowel syndrome
DICYCLOMINE
HYOSCYAMINE
Antispasmodic drugs
ANTIMUSCAINIC
Dicyclomine
Hyoscyamine
How to differentiate bw proximal and distal small bowel obstruction
PROXIMAL
more vomiting
Less distension
DISTAL
Less vomiting
More distension
Difference in abdominal plain films of small bowel obstruction and paralytic ileus
SMALL BOWEL OBSTRUCTION
Air-fluid level proximal to the point of obstruction(on upright film) and minimal gas in colon(if complete SBO)
PARALYTIC ILIEUS
Uniforn distribution of gas in small bowel ,colon and rectum
Dematitis herpetiformis seen in
Celiac sprue
What is seen in biopsy for whipple ds
PAS positive macrophages in the lamina propria containg non acid fast gram bacilli
Surgical rx is for which type of IBD
UC
Curative since involvement is limited to colon so total colectomy
CD
Various sites
Recurrence at the site of Sx in the form of stricture
Extraintestinal manifestations of IBD
EYE
Episcleritis
Ant uvietis
SKIN
Erthyema nodosum
Pyoderma gangrenosum
ARTHRITIS:MC
migratory monoarticular arthritis
AS
Sacroiliatis
THROMBOEMBOLIC HYPERCOAGUABLE STATE
ITP
OSTEOPOROSIS(Dec ca and vit D absorption)
GALL STONES(CD:bile salts are not absorbed)
SCLERORISING CHOLANGITIS
Most common extraintestinal manifestation of IBD
Arthritis
Migartory monoarticular, AS
Which type of stones are formed in CD
Calcium oxalate on kidney
Because of increased colonic absorption of dietery oxalate
Why is there gallstones in CD
Because bile salts are normally involved in terminal ileum and if it is diseased no absorption leadinv to cholesterol concentration
Drugs used for perianal ds in CD
Ciprofloxacin and metronidazole
Drugs used for diverticulitis
Metronidazole and ciprofloxacin
All the clotting factors are made in liver except
Factor 8 and vWF which are made in endothelium
Drugs used for hepatic encephalopathy
Lactulose
Or
Neomycin
Dx of Spontaneous bacterial peritonitis
More than 5000 WBC
More than 250 neutrophils
Rx:cefotaxime(ad: renally metabolised)
Most accurate diagnostic test for primary scleosing cholangitis
ERCP
Shows beading and tortusity of biliary tree
IT IS NOT LIVER BIOPSY
Anti-mitochondrial Abs are found in
Primary biliary cirrhosis
Not in PSC
What is the initial step for patient who presents with Git bleeding?
Fluids , blood , platelets , plasma
NOT TO WASTE TIME ON FINDING THE EITIOLOGY OF BLEEDING
What is the sequence of Mx for variceal bleeding?
Fluids, blood,platelets,plasma
Octreotide
If not banding
If not TJIH shunt
Start Propanolol once the pateint has been stabilised and are better
What is the sequence of Mx for variceal bleeding?
Fluids, blood,platelets,plasma
Octreotide
If not banding
If not TJIH shunt
Start Propanolol prophylactically once the pateint has been stabilised and are better simce it prevents next episode.it has no role in acute episode
Cause of steatorrhoea
Pancreatitis
Celiac sprue
Most accurate test for chronic pancreatitis
Secretin stimulation test
(SECRETIN: stimulates production of bicarbonate from pancreas and bicarbonate rich bile)
Serum amylase and lipase have no role, they may be normal beacuse pancreas has been burnt out
Most sensitive and specific test for CRC
Colonoscopy
Most common histological type of ca in colon
Adenocarcinoma
Most common site of distant metastasis of CRC
Liver
What is the age limit to begin screening for CRC
begin at age of 50yrs
If one family member has colon ca , begin at age of 40 or 10 yrs before the age of onset of family member
Major polyposis synd
FAP
gardner
Turcot
Peutz jeghers
Familial juvenile polyposis coli
HNPCRC
Gardner syndrome
Polyps
Osteoma
Dental abnormality
Benign soft tissue tumors( Desmoid tumors,Sebaceous cyst)
Turcot syndrome
Polyps
Cerebellar medulloblastoma or glioblastoma multiforme
Peutz jeher syndrome
Polypsosis syn
AD
Single/multiple hamartomas that may be scattered throughout git
PIGMENTED SPOTS ON LIPS, ORAL MUCOSA , FACE , GENITALIA, PALMAR SURFACES.
Slight inc Risk of other ca
HNPCRC
WITHOUT ADEMATOUS POLYPOSIS
inc risk for other types of ca also
When to begin CRC surveillance in a person with IBD
Whether CD(in case of colon involvement) or UC both have risk of colon ca.
Begin surveillance colonoscopy for CRC 8 yrs following diagnosis
Mc cause of large bowel obstructiom in adults
CRC
Difference in presentation left and right side CRC
RIGHT
Obstuction is unusual due to large luminal diameter
Change in bowel habits less
Malena usually
LEFT
Onstruction common
Change in bowel habit as alternating diarrhoea and constipation,pencil stools
Hematochezia
Test of choice for diverticulosis and diverticulitis
DIVERTICULOSIS
barium enema
DIVERTICULITIS
CT scan with contrast (barium enema and colonoscopy are c/i because of risk of perforation)
Complications of DIVERTICULOSIS AND DIVERRICULITIS
DIVERTICULOSIS
Painless rectal bleeding
Diverticulitis
DIVERTICULITIS Abcess fornation Colovesical fistula Obstruction Free colonic perforation
Classic presentation of acute mesentric ischemia
Severe abdominal pain disproportionate to physical findings
Most accurate test for acute mesenteric ischemia
Mesentric angiography
Thumbprinting on plain abd film indicates
Thickened edematous mucosal fold of intestine
Cause of chronic mesentric ischemia
Artherosclerotic ds
Special features of chronic mesentric ischemia
Postprandial abd pain like MI
Weight loss (fear of food due to pain not due to loss of appetite)
Ogilive syn
S/s,radiographs esuggests large bowel obstruction but there is no mechanical obstruction
Usually ill
H/o recent Sx, serous medical illness (sepsis,malignancy), medications(narcotics, psychotropic drugs, anticholinergic)
Types of acute mesentric ischemia
ARTERIAL EMBOLISM
Cardiac origin
ARTERIAL THROMBOSIS
Artherosclerotic ds
NONOCCLUSIVE MESENTRIC ISCHEMIA
Splanchnic vasoconstriction 2° to low CO
Seen in Critically ill
VENOUS THROMBOSIS
Hypercoaguable state, OCP,portal htn, malignancy ,pancreatitis.
How does pseudomembranous colitis present
Profuse watery diarrhoea
Crampy abd pain
Toxic megacolon with risk of perforation
Diagnostic test for c.difficle
TOXIN in stool
DOC for c .difficle
METRONIDAZOLE (if recurr retreat with metronidazole only)
VANCOMYCIN(if resistant to metronidazole, cant give , no change in symptoms)
Mc site for colonic volvulus
Sigmoid colon
Omega loop and coffe bean sign seen in
Volvulus
Differentiating be caecal and sigmoid volvulus
Caecal: ass with small bowel obstruction
Can go anywhere
Sigmoid: ass with large bowel obst also
Goes up and right
Test of choice for sigmoid colon volvulus
Sigmoidosopy
Dx as well as therapeutic(unwind)
For caecal:Sx has to be done
Role of ursodeoxycholoc acidin PBC
First, it increases the rate of bile flow from the hepatocytes.
Second, it inhibits the body’s production of toxic bile acids.
Third, it inhibits apoptosis
Fourth, it mildly inhibits the immune response in the liver and injury
Ursodeoxycholic acid used in
PBC (not psc)
To prevent or dissolve gallstones
Cholesyramine used in
Reduce itching(PBS,PSC)
Lowering cholesterol
Treat diarrhoea due to bile acid (ikeal resection,CD)
Most accurate test for diagnosis of acute and chronic pancreatitis
ACUTE PANCREATITIS
Ct scan abdomen
CHRONIC PANCRATITIS
ERCP
Pseudocyst
Encapsulated fluid collection that appears 2- 3 weeks after an acute attack(it lacks epithelial lining unlike true cyst)
Complications of acute pancreatitis
Pancreatic necrosis(sterile/infective)
Pancreatic pseudocyst
Haemorrhagic pancreatitis
ARDS
Pancreatic ascites /effusion
Ascending cholangitis(in gallstone)
Pancreatic abcess
Why morphine should not be used in pancreatitis for pain relief
Cause spasm of shincter of oddi and can worsen it
Causes of acute pancreatitis
Alcohol
Gallstones
Post ERCP
Viral(mumps, coxsackie)
Drugs-sulfonamides,thiazide, furosemide, estrogens, hiv medications
Scorpion bites
Pancreatic divisum
Pancreatic ca
Hypertriglyceridemia
Hypercalcemia
Uremia
Blunt abdominal trauma
Ranson criteria used for
Tells aboit the prognosis of patient with acute pancreatitis
Consists of 2 parts
ADMISSION CRITERIA(GA LAW) glucose Age Ldh Ast Wbc
INITIAL 48 HR CROTERIA(C HOBBS) Calcium Hct SO2 bun Base deficiet Fluid sequestration
What type of vit deficiency is seen in chronic pancreatitis
Fat soluble vitamins (due to steatorrhoea)
Vit B12 (lack of pancreatic protease leads to non dissociation of B12-R binder complex such that IF is not able to bind)
Chain of lakes appearance on ERCP is seen in which condition?
Chronic pancreatitis
leads to fibrotic tissue replacement of pancreatic parenchyma and alternation of pancreatic ducts( areas of stricture/ dilation)
Mc site for pancreatic ca
Head>body>tail
Tumor markers for pancreatic ca
CA 19-9
CEA
Mcc of upper and lower git bleeding
UPPER GIT
Peptic ulcer ds
LOWER GIT
<60yr
Diverticulosis
> 60yr
Angiodysplasia
Cause of malena , hemetemeis and hematochezia
HEMETEMESIS
upper git bleeding that may be ongoing
HEMATOCHEZIA
Mostly due to lower git bleeding(typically left colon and rectum)
BUT can be due to upper git if it is severe
MALENA
Mostly due to upper git bleeding
BUT can be due to lower git(ascending colon)
A lower git bleed (or a positive FOBT) in a person over 40 yrs is ____until proven otherwise
Colon cancer
____of upper git bleeding stop spntaneously and only need supportive therapy
80%
Causes of dark coloured (black,tarry) stools
Malena
Bismuth
Fe
Spinach
Charcoal
Licorice
What is the initial test for haemetemsis
Upper Git endoscopy
Initial test in case of hematochezia
First rule out anoractal ds(heamorrhoids etc)
Colonoscopy should be initial test because colon ca is main concern in patients over 50 yrs
What is the initial test in order to investigate malena
Upper endoscopy(because mc)
Colonoscopy if no bleeding site identified from endoscopy
What is the initial test in case of positive FOBT
Colonoscopy is the initial test (colon ca is the main concern)
What happen to BUN-creatinine ration in upper git bleeding
Rise
Most accurate diagnostic test in case of upper git bleeding
Upper endoscopy
Sequence of pain in appendicitis
First pain then n/v
Diagnostic test in appendicitis
It is a clinical diagnosis
Warfarin and heparin therapy is monitered by
WARFARIN:PT
VII
HEPARIN:PTT
XII factor onwards
what is INR
PT patient/PT normal
Normal value is 2-3
Types of stones in cholelithiasis
Cholesterol: yellow to green(gb)
Pigment: black due to hemolysis(gb)
Infection:brown(in ducts)
Cause of biliary colic
Cardinal symptom of gallstones and is due to temporary obstruction of cystic duct by a gallstone .
Pain occurs as the gb contracts against thsi obstruction.
Boas sign
Refered right subscapular pain of biliary colic seen in cholelithiasis
Murphys sign
Pathognomic for acute cholecystitis
Inspiratory arrest during deep palpation of RUQ pain
Not present in many cases
Cause of pain of biliary colic and acute cholecystitis
BILIARY COLIC
Contraction of gb against obstructed cystic duct
ACUTE CHOLECYSTITIS
Secondry to gb wall inflammation
Initial test of choice for acute cholecystitis
USG
Thickened gb
Pericholecystic fluid
Distended gb
Presence of stones
Cause of acalculous cholecystitis
Seen in
Severe underlying ds Ass with dehydration Ischemia Burns Severe trauma Postop state
What are the causes of cholangitis
Infection of the biliary tract secondry to obstruction which leads to biliary stasis and bacterial overgrowth.
choledocholithoasis Pancreatic ca Biliary ca Postop strictures ERCP,PTC
Charcots triad
Seen in Cholangitis:
RUQ pain
Jaundice
Fever
Reynolds triad
Seen in cholangitis:
Charcots triad
Shock
Altered mental status
PSC and PBCdefination
PSC
Progressive ds of intrahepatic and/or extrahepatic bile ducts characterised by thickening of bile duct walls and narrowing of their lumen
PBC
Progressive cholestatic ds characterised by destruction of intrahepatic bile ducts with portal inflammation and scarring
PSC is strongly associated with__
UC>CD
The course of PSC os unaffected by a colectomy done for UC
Moat accurate test for PSC and PBC
PSC:ERCP
PBC:liver biopsy (not Anti- mitochondrial Ab)
Klatskin tumor
Cholangiocarcinoma occurring at the confluence of the right and left hepatic bile ducts
Risk factors for cholangioca.
PSC
Choledochal cyst
Clonorchis sinensis
Choledochol cyst
Cystic dilatation of biliary tree involving either extrahepatic or intrahepatic ducts or both
Biliary dyskinesia
Motor dysfxn of the sphincter of oddi which leads to recurrent episodes of biliary colic without any evidence of gallstones
What is SAAG
Serum ascites albumin gradient
SAAG of more than 1.1 most likely indicates
Portal hypertension
Cause of hepatic encephalopathy
Toxic metabolites( that are many , but ammonia is believed to be the most important) that are normally detoxified or removed by liver accumulates and reach brain
Precipitants: Alkalosis Hypokalemia Sedating drugs Gi bleeding Systemic infection Hypovolemia
Cf: Dec mental fxn Confusion Stupor,coma Asterexia Rigidity hypereflexia Fetor hepaticus
Rx:lactulose
Rifaximin
(Neomycin)
Hepatorenal syndrome cause
The predominant theory (termed theunderfilltheory) is that blood vessels in the kidney circulation are constricted because of the dilation of blood vessels in thesplanchnic circulation(which supplies theintestines), which is mediated by factors released by liver disease.Nitric oxide,prostaglandins,and other vasoactive substances.
The consequence of this phenomenon is a decrease in the “effective” volume of blood sensed by thejuxtaglomerular apparatus, leading to the secretion ofreninand the activation of therenin–angiotensin system, which results in the vasoconstriction of vessels systemically and in the kidney specifically.However, the effect of this is insufficient to counteract the mediators of vasodilation in the splanchnic circulation, leading to persistent “underfilling” of the kidney circulation and worsening kidney vasoconstriction, leading to kidney failure
What is hepatopulmonary syn
The hepatopulmonary syndrome results from the formation of microscopic intrapulmonary arteriovenous dilatations.
The mechanism is unknown but is thought to be due to increased liver production or decreased liver clearance ofvasodilators, possibly involvingnitric oxide
The dilation of these blood vessels causes overperfusion relative to ventilation, leading toventilation-perfusion mismatchand hypoxemia
Pathophysiology of hepatorenal and hepatopulmonary syn
HEPATORENAL
Vasoconstriction
HEPATOPULMONARY
Due to vasodilation
Acitic fluid cell count in SBP
Paracentesis and examn:
WBC>500
neutrophils>250
Etiologic agents for SBP
E.coli(mc)
Klebsiella
S.pnemonia
