McGowan Flashcards
cxr w widen mediastinum
aortic dissection
ct w contrast is definitive, tearing cp
S1Q3T3 on ecg, or sinus tach
pe
auscultation of crunch/rasp sound w hb, hear in precordium during systole, in L lat decubitus position,
hamman’s sign
“gnawing, dull aching, hunger like”
atyp cp
signs of gi bleed: coffee ground emesis, hematemesis, melena, hematocheiza
mild, localized epigastric tenderness to deep palpation
you should check for? What are you at risk for having?How do you diagnosis?
H. Pylori
PUD
can lead to pancreatitis if ulcerates
EGD w biopsy (exclude malig in GU), Nasogastric lavage (neg doesn’t rule out DU)
Fecal antigen and urea breath test confirms eradication
hypertensive peristalsis, contractions are too powerful (amp and duration) but normal coordinated contraction
LES elevated pressure at baseline
intermittent dysphagia to solid and lq,
atypical chest pain
nutcracker esophagus
check w manometry - EGD
mult spastic contractions in circular m,
disrupted coordinated peristalsis,
LES normal function
intermittent dysphagia to solid and lq,
atypical chest pain
diffuse esophageal spasm
barium swallow: corckscrew eso, rosary bead esophagus, manometry
30-60 min after eating (spicy, alc, caffeine),
reclining give symp,
epigastric abd p,
“waterbrash” (bad taste in mouth from reflux),
asthma, chronic cough, hoarseness
this can lead to what?
what causes this most commonly?
GERD
barrett eso -> adenoca
and laryngopharyngeal reflux
reflux esophagitis, dysphagia and odynophagia, doesn’t respond to therapy w esophagitis
what are the alarming fx of gerd?
what should you do next if you see these?
alarm fx: weight loss, persistent vomiting, severe constant pain, dysphagia, odynophagia, palpable mass or adenopathy, hematemesis, melena, anemia (occult bleed?), >60yr, persistent sx despite tx
egd or abd imaging, if no alarming fx tx empiric
hypersalivation (inability to swallow liquids including saliva, drool, froth, foam at mouth) is indicative of what?
foreign bodies or food bolus impaction/obstruction
inability to move liquid in mouth, orophar, eso etc
how do you dx?
dysphagia
oropharyngeal - video fluoroscopy w swallowing
esophageal - mechanical cause (barium swallow, esophagogastroscopy w biospy),
motor (barium or esophageal `motility study (manometry))
esophageal web?
common presentation?
tx?
middle age female
structural problem, esophageal dysphagia (prox to mid eso), can be oropharyngeal too (specifically solids), not whole circumference (according to dobson), can also lead to mechanical obstruction
intermittent symp, NOT progressive
barium swallow - esophagram -> best view
dilatation = bougie dilator, or small endoscopic electrosurgical incision, PPI long term
angular chelitis, glossitis, symptomatic proximal esophageal webs, IDA, koilonychia middle age female indicates?
plummer vison syndrome
false diverticulum involving hern of mucosa and submucosa through m layer of eso posteriorly bw cricophargneus m and inf pharyngeal constrictor m at PE jxn (in killian’s triangle)
Loss of elasticity of UES
oropharyngeal dysphagia that starts with coughing and throat discomfort -> progress to diverticulum enlarge to hold food (halitosis, spont regurg, night choking, gurgling, protrusion in neck), PROGRESSIVE
voice change, wt loss,
aspiration -> pna/lung abcess
zenker diverticulum
video esophagography or barium swallow before egd, tx surgery
gradual, progressive, solids -> solids + lq, reflux/heartburn improves as it progresses bc acts as barrier to reflux
structural prob, at GE junction
MC place this will be?
esophageal stricture
EGD w biopsy to make sure not carcinoma
Peptic stricture
specialized intestinal columnar metaplasia (norm squamous) in distal esophagus,
prox displace of squamocolumnar junction,
complication from gerd or truncal obesity,
male white 50> and smokers
heartburn, regurg, most asymptomatic
what can it progress to?
barretts
mostly asymp
egd w bx = goblet w columnar cells, will see orange gastric epi that extends up from stomach into distal eso in tongue like or circumferential fashion
surveillance endoscopy for adenoca
tx ppi, endoscopic ablation in pt will high grad dysphasia or intramucosal adenoca
esophageal adenocarcinoma (RF: chronic gerd, hiatal hernia, obesity, white, male, 50>)
mc ca in eso in the world
male, AA, >50, heavy smoker, alc use
associated w these disorders: achalasia, hpv, plummer-vinson, tylosis
caustic chem or thermal injury, progressive dysphagia, wt loss, anorexia, bleeding, hoarse, cough
squamous cell carcinoma of esophagus, most mid 1/3, egd w bx
tx: surgery
white, male, distal 1/3, rf: Gerd, barretts
see columnar cells on bx
esophageal adenocarcinoma
endoscopic therapy - ablation
solids, intermittent symp, NOT progressive,
reflux common,
steakhouse syndrome = large poorly chewed food bolus, food bolus impaction = need more water to pass,
esophageal dysphagia, structural prob = distal esophagus (smooth circumferential thin mucosal structures), associated w hiatal hernia
dx w barium swallow
Schatzki’s Ring
dilation, ppi, small endoscopic electro surgical incision
whole circumference according to dobson boy
esophageal dysphagia that increases w age motility disorder (solids and lq progression)
“loss of NO inhibitory neurons in myenteric plexus”,
loss of peristalsis of distal 2/3, fail of LES relaxation
regurg of undigested food,
nocturnal regurg, substernal discomfort,
do adaptive maneuvers (eat slow, lfit neck and shoulders back to empty),
weight loss & romana sign (periorb swelling),
untx then can lead to sigmoid esophagus
secondary cause of this?
achalasia
esophageal manometry confirms - abs of normal peristalsis and incomplete LES relaxation
peripheral blood smear of TC parasite, barium esophagram = Bird Beak (dilation, loss of peristalisis, poor emptying), EGD (biopsy show loss og gang cells in eso myenteric plexus)
chagas disease or pseudoachalasia - tumors that invade ge jxn that look like this
large, shallow, superficial ulceration(s) in eso
cmv
in immunosuppressed
mult small, deep ulcerations, could have oral lesions too
hsv
in immunosuppressed
diffuse linear yellow-white plaques adherent to mucosa
candida
common in uncontrolled dm, systemic corticosteroids, radiation, systemic antibiotics ex fluconazole
hx: allergies or atopic cond (asthma, eczema),
male, dysphagia, hx of food bolus impaction
adults: dysphagia, pyrosis, poor med response, regurg of undigested food
kid: vomit, diff to feed, dysphagia, FTT
EGD: loss of vas markings edema,
- long oriented furrows, punctate exudate,
- mult circular esophageal rings giving corrugated
appearance,
- feline or tracheal esophagus,
- bx: squamous epithelial eosinophil - predom inflam
complications?
eosinophilic esophagitis
be careful with eso dilation effect but risk of deep, esophageal mural laceration or perf
food impaction, esophageal perf
ingestion of liq or crystalline alkali (drain cleaners) or acid
ingestion causes severe burning, varying cp, gag, dysphagia, drool, aspiration (stridor, wheeze)
acute: perf, bleeding, esophageal tracheal fistulas,
long term: strictures w injury, esophageal squamous carcinoma = survey 15-20yr
caustic esophageal injury
no ng tube, oral antidotes, dangerous
dx w laryngoscopy esp if pt is in tracheostomy and chest/abd xray
waxing and waning
chronic or intermittent symp of postprandial fullness (early satiety), n/v 1-3 hr after meals
rf: diabetes,infections post-viral,
gastroparesis
dx: gastric scintigraphy
tx: metoclopramide (tardive dyskinesia - invol movement like lip smack, twitch), erythromycin
avoid agents that reduce gastrointestinal motility. - opioids, anticholingergics, hyperglycemia - slows gastric emptying
loss of peristalsis in intestine in abs of any mechanical obstruction
n/v, obstipation, distention, no bowel sounds, seen in hosp pt as result from surgery, electrolyte abnormalities, severe med illness
acute paralytic ileus
dx: plain abd xray or ct scan = gas and fluid distention
tx: tx precipitating condition, NG, avoid opioids, early ambulation, gum chewing, initiation of clear lq diet
decreased bowel sounds, high pitched tinkling bowel sounds
from adhesions, abd surgery, N/V w feces, obstipation no bm/farts
dilated loops and air fluid levels on xray, kub
acute SBO
tx: NG tube
idiopathic
giant thickened gastric folds w/ chronic protein loss,
can have severe hypoproteinemia and anasarca (fully body swell)
NO gi bleed, will have n/epigastric pain, wt loss, diarhhea
menetrier disease
risk gastric adenocarcinoma
alc, meds (nsaid, steroids) cocaine, ischemia, viral, bact h pylori, stress, rad, allergy increases risk of ?
erosive or non-erosive (H plyori)
normal w epi p, n/v/anoerixa, belch, bloating
acute gastritis
tx: underlying cause
neutrophils and sub epithelial plasma cell w inflammmatory infiltration,
increased acid production,
gastrin normal,
hyperplastic inflam polyps
h pylori (b12 def) antrum, low se status, poor, rural
chronic gastritis, Type B, H pylori
risk of peptic ulcer, adenocarcinoma, MALToma, b12 def?, gastric b cell lymphoma
antibodies toward H Pylori
lymphocytes and macro inflam infiltration, decreased acid, increased gastrin, neuroendocrine hyperplasia, carcinoid or vit b12 def
body of stomach,
disease: thyroiditis, dm, graves, loss of rugal folds
antibodies to parietal cells, hk atpase, IF
chronic gastritis, Type A, autoimmune
risk of adenoCA carcinoid tumor, pern anemia, megaloblastic anemia (females)
tx: parental b12 supplementation
gastric acid hyper secretion, inflammation cell cytokines stimulating antral g cells
mucosal defense compromised by toxic h pylori infection on patches of gastric metaplasia,
gnawing burning epi p,
60-3hr after meals, nocturnal,
relieved by food, mc anterior wall
low somatostatin
rf: glucocorticoids and nsaid
duodenal ulcer
asym, burning epi pain,
worse by food win 30 min of eating,
food AVERSION,
mc antrum of stomach
h pylori + smoking,
gastric acid normal or reduced,
rf: chronic nsaid/ salicylate use
gastric ulcer
spiral g- microaerophlic urease producing rods w flagella, cag-A + toxin
h pylori
orthostatic, confusion , angina, tachy, syncope, weak, sob, palpitations, cold extremities, co morbid cond: aortic stenosis, renal disease (avm, telangiectasias, angiodysplasia), smoking, portal htxn, alc abuse pud, medications
signs of hypovolemia: vitals, resting tachy, blood loss = orhtostatics, volume loses 40% = hypotension supine, acute abd: p +rebound, guarding, perforation
UGIB
acute gastro hemorrhage w melena, hematochezia, hematemesis - hypovolemia manifested by vital signs and shock
dilated submucosal v in esophagus, secondary portal htn from cirrhosis
esophageal varices`
risk of bleeds eso varices:
size larger than 5mm, red wale markings (long dilated venules on varix), severity of liver disease, active alc abuse
primary gastrinoma- non beta islet cell gastrin secret tumor, mostly proximal duodenum, 2/3 malig, associated w MEN1 AD = pancreatic gastrinoma or insulinoma, hyperparathyroidism increase ca, pituitary neoplasm - gigantism
large mucosal folds - hypertrophic gastric mucosa, >1000 serum gastin fasting, secretin stim test is positive, eus,ct, mri, draw levels of PTH, prolactin LH-FSH, GH checking MEN1
zollinger ellision syndrome
superficial, non transmural tear at ge jxn, vomit, retching, coughing mc ugib
superficial, non transmural tear at ge jxn, vomit, retching, coughing mc ugib
mallory weiss tear
transmural rupture at ES jxn, spontaneous, all layers have ruptured, hx alc
life threatening, hematemesis, pneumomediastinum or sub cut emphysema, pleuritic and retrosternal cp
clinical suspicion, cxr w air in mediastinum, subq emphysema, ct chest w contrast, hammans sign
Boerhaaves
elderly, male, hospitalized pt, nsaids, aspirin, warfarin
life threatening, large caliber submucosal artery, cause obscure gastrointerstinal bleeding cause treacherous and life threatening hemorrhage, hematemesis, obscure gi and occult gi bleed IDA
dieulafoy lesion
LGIB in pt over 50 mc:
malignancy, diverticulosis, angiectasias, ischemic colitis
LGIB in pt younger 50yo
infectious colitis, anorectal disease, IBD, meckel diverticulum
ppl w/ hematomchezia need to ask about what also?
meds, lq med w red dye or diet, kool aid or beets
herniation/sac protrusions of mucosa,
mc LGIB, mc in sigmoid
asymptomatic
PAINLESS large vol maroon or bright red blood HEMATOCHEZIA
diverticuLOSIS
transmural recently started smoking, spares rectum, mc in small bowl and terminal ileum noncaseating granulomas on bx, skip lesions, string sign \+ ASCA CARD15/NOD2 on ch 16 diarrhea with or without blood, cramping in RLQ pain, acute ileitis (mimics appendicitis), abscesses, strictures, fistulas, anorectal fissures, cobblestoning,
risk for colon ca, bile salt malabsrp and secretory diarrhea, gallstones or oxalate kidney stones
chrons
chrons tx
surgery only when necess -> exacerbated disease, responds to antibiotics, corticosteroids, immunomodulating agents, biologic agents
mucosal and colon only recently stopped tobacco, continuous, pseudopolyps bloody diarrhea with mucous, starts in rectum (always involved), tenesmus/fecal urgency, pANCA dvt/toxic megacolon
ulcerative colitis
A cocaine addict came into the hospital because he had diffuse crampy of abd pain, perfuse red blood per rectum, and Increased urgency to poop. What is an imaging choice for this? What does he have? And who else can have it? Where is the most common location?
sudden onset of LLQ cramps and pain,
urgency to poop
thumb print on abd xray from submuco edema,
hemorrhage and friability in sigmoidoscopy
ischemic colitis
Ct w PO contrast
Splenic flexure
Some sort of occlusion runners, vasocon in opioid users
what should you consider if a pt has a family/personal hx:
- colorectal ca that has affected more than 1 family mem
- colorectal ca developing at an early age
- of multiple polyps
- mult extracolonic malignancies
hereditary colorectal ca and polyposis syndromes
early devlp of polyps - hundo - thousands
congenital hypertrophy of retinal pigment epithelium detected at birth
familial adenomatous polyposis FAP
familial adenomatous polyposis mut and tx
APC gene AD, mutation in MUTYH gene AR
complete proctocolectomy w ieloanal anastomosis before 20, prophylactic colectomy
ca at young age, polyps undergo rapid transformation over 1-2 yr from normal tissue -> adenoma -> ca,
AD, dna base pair mismatches: MLH1, MSH2, MSH6, PMS2
What is this disease and tx?
lynch syndrome (hereditary nonpolyposis colon cancer)
tx: subtotal colectomy w ileorectal anastomosis, prophylactic hysterectomy and oophorectomy recomm to women at 40
hamartomatous polyps through gi
in SI, can become large, and lead to bleeds, intussusception, obstruction
Mucocutaneous pigment macules on lips, buccal mucosa and skin
AD, serine threonine kinase 11 gene
peutz jeghers syndrome
more than 10 juvenile hamartomatous polyps in colon, risk of adenoca
familial juvenile polyposis
AD, 18q and 10q, MADH4, BMPR1A
polyps, trichilemmonmas, cerebellar lesions,
risk of ca in the thyroid, breast, urogential tract
PTEN multiple hamartoma syndrome (cowden disease)
high prevalance in pt with strep bovis bacteremia or strep gallolyticus,
>45yo,
metastasis to the liver
left sided colon -> rectal bleeds, alter bowel habits, abd or back p
right sided colon - Anemia, occult blood in stool, wt loss, perf, fistula, vovlulus inguinal hernia
adenocarcinoma or colon ca
painless bleeding form melena or hematochezia to occult blood loss,
chronic renal fail or aortic stenosis
cbc w/iron studies like a capsule
angioectasias
bright red blood per rectum, usually only drops on tissue or in toilet
constipation or preg straining can cause it
can thrombose
hemorrhoids
strain/ cough heavy lift, painful tense blue perianal nodule w skin, goes away in 2-3 days
thrombosed external hemorrhoid
severe tearing pain during bm, followed throbbing discomfort,
mild associated hematocheiza blood in stool or paper, severe pain but can be inspected
linear or rocket shaped ulcers posterior midline
anal fissures
Epigastric
dissecting/ruptured aortic aneurysm, peptic ulcer disease, hiatal hernia, gerd, gastritis, esophagitis
increased intraabd pressure from abd obesity, preg and hereditary, propensity of affected ind to have gerd
sliding hiatal hernia
hern into mediastinum, visceral structure other than gastric cardia, mc colon
leads to upside down stomach, gastric volvulus, stranulation of stomach
dx barium rxray
paraesophageal hernia
-bigger the size, more likely it is to rupture
-asymp, incidental finding on exam or imaging: palable, pulsatile, expansive and nontender mass
-rupture w/o warning -> death
-emergent surgery
-abd US diagnosis
<5 cm, cont monitor
-highest risk, prevent screen: men 65-75 who smoked
-can expand and be painful, strong pulsations in abd, aneurysmal pain -> MED EMERGENCY
-shows up as acute pain, w hypotension - surgery needed
Aortic Aneurysm: Rupture
transverse tear in the intima
mc in R lateral wall of ascending aorta, where hydraulic shear stress is high
pulsatile aortic flow dissects along elastic lamellar plates of aorta and creates false lumen
presents: atyp cp, widen mediastinum, vs abnormalities, emergency
vital sign abnormalities
Aortic aneurysm dissection
LUQ
gastric ulcer, gastritis, pancreatitis, perf sub-diaphragmatic viscus
RLQ
appendicitis, ectopic preg, ovarian torsion, IBD, ogilvie syndrome, meckel’s diverticulitis
etiology: obstruction by fecalith -> increases pressure, congestion, infection, perf
vague collickly around belly button (periumbical) then moves to RLQ
usually w/in 12 hrs
fever, PE findings - Mcburneys, cough localizes the painful area, psoas sign, obturator sign, heel strike, rebound tenderness
varied presentation
retrocecal, pelvic, elderly, prego
CT test of choice, US
complications: perf, peritinitis
Appendicitis
mc death of mom in first trimester
any cond that prevents migration of fertilized ovum to uterus can predispose
including hx of infertility, PID, ruptured appendix,
prior tubal surgery
Severe pain LQ, right or left
US transvaginal + beta hcg
ectopic pregnancy +/- rupture
there is risk if pelvic exam preformed- get shock afterwards
pt presents w sudden onset severe unilateral LQ pain that develop after episodes of exertion
she has nausea and vomiting, and palpable R sided mass
The test beta-HCG is +.
What most likely caused this?
Why is the R most common? What is the diagnostic modality?
Ovarian Torsion
70% are on the right side due to the increased length of utero ovarian ligament on the R and sigmoid on the L limiting space for movement
transvag US w doppler in primary diagnostic modality for suspected torsion
spont massive dilation of cecum or R colon w/o mechanical obstruction
Xray or CT, upper limit of normal for cecal size is 9 cm, so greater than 10-12 is increased risk of perf
What is this and how would you tx?
What drugs should you avoid?
acute colonic pseudo-obstruction (ogilvie syndrome)
tx underlying illness, NG tube or rectal tube is placed,
avoid oral laxatives or drugs that reduce intestinal motility (opioids, anticholingergics, ca channel blockers)
abd xray every 12 hours for conservative tx
- intervention if: no improvement after 2 days
- tx w neostigmine, colonoscopic decrompression,
surgery
remnants of vitelline duct,
RLQ, rectal bleeding/intuss/perf/inflamm in adults
nuclear diagnosis - technetium - 99 Scan
rule of 2s
2 feet from ileocecal valve, 2% pop, 2in long, 2 type
of ectopic tissue - gastric or pancreatic
surgical resection for tx
Meckels Diverticulitis
LLQ
diverticulitis, ischemic colitis, ectopic preg, ovarian torsion, ibd, colon ca
mild LLQ tenderness, thickened palpable sigmoid and descending colon
feel constipated, but getting some loose stool out, fever, nausea/vomiting
dx: CT with contrast
you find out this is from macroscopic inflammation of an outpouching
What could cause this? What is contraindicated?
egd is contraindicated, risk of perf increases air and increases perf risk
diverticular disease, diverticulitis
egd is contraindicated, risk of perf
periumbilical and suprapubic pelvic
early appendicitis, mesenteric artery ischemia, ruptured aortic aneurysm, bowel obstruction, IBD
Pt comes in w n/v, distention, gi bleeding, and altered bowel habits. You see this most often in all the patients. It hurts so bad to eat that they have a fear of food. They will also have some sort of vascular disease.
Periumbilical Pain out of proportion to tenderness.
You see thumbprinting (submucosal edema) on xray.
“seems malingering, pe doesn’t seem that bad” Pain out of proportion to physical exam, writhing in pain, seems malingering
acute mesenteric ischemia
CT angiography of abd and pelvis w IV contrast is gold std.
a old pt comes in with dull crampy periumbilical p. He says this always happens when he eats and starts 20min after a meal. It always last for a few hours before it will go away. He is at the pt now where he doesn’t even want to eat anymore. He has loss 10lb because of this. What does he have? How do you evaluate it?
chronic mesenteric ischemia
eval w mesenteric arteriography
abd angina - dull crampy periumbilical p
15-30 after meal, last for several hrs
food fear - wt loss, scared to eat, mc in old
mc (mechanical) peritoneal adhesion
colikcy ab p, n/v/feculent vomit
plain radigraphs and ct will show dilated bowl and air fluid
ng tube for decompression, fluids
tx: laparotomy
intestinal obstruction
N/V FECULENT
PLAIN ABD RADIOGRAPHHY - KUB, ABD SERIES, CT SCAN = DILATED LOOPS OF SMALL BOWEL AIR FLUID LEVES
NG
ADHESIONS, HIGH PITCHED TINKLING SOUNDS
acute small bowel obstruction
diffuse
irritable bowel syndrome, mesenteric artery ischemia, peritonitis, intestinal obstruction, ibd, toxic megacolon, constipation
mc in pt w cirrhosis
gram neg bacillis - e coli
gram postive - strep, enterococci, pneumococci
only single org is isolated
dx if peritoneal fluid contains 250 pmn
blood cultures bc bacteremia is common
tx: 3rd gen cephalosporin like ceftriaxone or pipercillin tazobactam
primary (spont.) Bacterial peritonitis
bact contaminate the peritoneum - spillage from intraabd viscus
mixed flora - gram neg bacilli and anaerobes predom
spread to peritoneal cavit - increase pain
pt lies motionless, often w knees drawn up to avoid stretching nerve fibers of peritoneal cavity
invol guarding
dx: radiographic studies to find source or immediate surg intervention, abd tap done only to exclude hemoperitoneum in trauma
tx: antibotics aimed at inciting flora
surgery needed often
secondary peritonitis
mc from inflam bowel disease (UC) and cdiff
septic
total segment non obstructive colonic dilatation + systemic toxicity
xray - air filled, abd distension and acute/chronic
high risk of perf
toxic megacolon
fatigue is most commonly from
occult gib, ca, ibd, chornic liver disease, malnutrition, malabsorb
unintentional wt loss in old and young looks like?
old: ca lung and gi, benign gi disease, depression
young: dm, hyperthyroidism, anorexia nervosa, infection, hiv
watery non bloody, mild self lim, virus or noninvasive bact
most don’t need work up
noninflammatory acute diarrhea
blood or pus in stool, fever, invasive or toxin producing bac.
eval diag required - stool bac cultures in all pt (E coli O157:H7) and if indicated c diff toxin and ova/parasites
inflammatory acute diarrhea
non infectious causes of diarrhea more than 14 days
meds are mc
med: antibiotics, nsaids, antidepress, chemo, antacids
food sweeteners, sorbitol, chewing gum
- better with fasting, vol goes down without eating
- increase stool osmotic gap
- symptom: abd distention, bloat, fart
mc are medications, disaccharidase def/carb malabsorption, laxative abuse, malabsorption syndrome
osmotic diarrhea, chronic
doesn’t improve with eating, stool vol the same
normal osmotic gap
high vol, over 1l a day
mc are endocrine tumor (hormonally med), bile salt malabs, facitious diarrhea (laxative abuse), villous adenoma
secretory diarrhea, chronic
leukocytes, calprotectin, lactoferrin are dx of what
ibd
how to specific dx for giardia and e histolytica
fecal antigen
initial diagnostic endoscopic exam and bx are to check for what?
colonoscopy w mucosal bx = ibd, microscopic colitis, colonic neoplasia
egd w small bowel bx = SI malabsorptive disorder (celiac/whipple) or aids - cryptosporidium, microsporida and m avium intracellular infection
alarm symptoms that atypical, warrant further investing are?
acute onste of symp: organic disease, esp in 40-50yo nocturnal diarrhea severe constipation or diarrhea hematochezia wt loss fever hx in family of ca, ibd, celiac
spastic colon
alt constipation and diarrhea
chronic painless diarrhea
alter bowel habits, abd p - crampy, abs of detectable organic path
females
abd distention, relief w bm, freq and loose stool w pain, mucus w stool, sense of incomplete poop
Irritable bowel syndrome
how to dx and tx ibs
rome iv clinical diagnostic criteria for diagnosis
fodmaps: fermentabel oligosacc, disacc, monosacc, polyols
dietary intolerances pt report, restriction from these
d, bloat, fart, abd p after diary products
dx: lactose free diet or hydrogen breath test
tx: calcium supp, lactase enzyme replacemnt
lactase def
lactase on brush border is insucc, or could be secondary to chrons, celiac, viral gastroenteritis, giardiasis, short bowel syndrome, malnutrition
mc cause of antibiotic associated colitis
anaerobic, gram +, spore forming bacillius
cytotoxin a and b production
nosocomial - fecal oral
old, debilitated, immunocom, hospitalized more than 3 days, antibiotics, PPI, chemo
green foul smell water diarrhea 5-15x, bloody if assoc w IBD - UC
complications: toxic megacolon, hemodynamic instabilitiy
c diff
c diff causing antiboitics
antibiotics mc: ampicillin, clindamycin, 3rd gen cephalosporins, fluoroquinolones
loss of villi, less textured and more smooth
immunlogic response to storage protein gluten (wheat, rye, barley)
diffuse dam to proximal SI mucosa w malabsorption of nutreints
HLA-DQ2 OR DQ8
See antibodies to gluten, tissue transglutaminase (tTG)
hx/pe: wt loss, chronic diarrhea, dyspepsia, fart, abd distention/bloat, growth retarding, fatique
atyp symp: dermatitis herpetiformis, IDA, osteoporosis
minimal or no gi symp by extraintestinal: fatigue, depression, ida, osteoporosis, short stature, delayed pub, amenorrhea, reduced fertility
DH: pruritic papulovesicles over extensor surfaces
celiac disease
mild steatorrhea, wt loss min, impaired abs of fat-soluble vit ADEK, watery secretory diarrhea
Bile Salt Malabsorption
rare mutli-system gram + bacillus, not acid fast, Tropheryma whipplei wt loss, malabsoprtion, chronic diarrhea dx: EGD w bx of duo tx antibiotics if untreated, then is fatal
Whipple Disease
freq small vol of stool
pseudo-diarrhea
NM disorder or structural anoretal prob
invol discharge of rectal contents
diarrhea, urg, if severe -> aggravate or cause incont
fecal incont
severe constip-> only contents that get by are lqs
old, nursing home
fecal impaction that is detectable by rectal exam
overflow diarrhea
meds: opioids
hx: paradoxical diarrhea, lq leaks out bc impacted feces
overflow incont
digital rectal exam, don’t do if leukopenia from ca
chronic use of laxatives -> melanosis coli: benign hyperpigmentation of colon
constipation -> fecal impaction
60yo male, obese, heavy smoker thinking he has MI symptoms w severe chest pain. he often has heartburn, dysphagia, regur of sour tasting gastric contents. what does he have and what can it lead to?
gerd
barretts
eso adenocarcinoma
atrophic glossitis (smooth swollen tongue)
megaloblastic anemia
peripheral neuropathies
b12 def
autoimmune gastritis
body lymphocytes/macrophages decreased acid increased gastrin neuroendocrine hyperplasia antiboides to parietal cells atrophy pern anemia, adenocarcinoma, carcinoid tumor associated in autoimmune - thyroiditis, dm, graves
autoimmune, type a gastritis
antrum neutrophils, subepi plasma cells increased to slight dec acid normal to decreased gastrin hyperplastic, inflam polyps antibodies to h pylori peptic ulcer, adenoca, malt low socioeconomic status, poverty, rural
chronic type b gastritis, hypolri associated
uncommon forms of gastritis
allergies, immune disorders, parasites, hylori
women, celiac disease, t lymph
chrons, sarcoidosis, infection
eosinophillic
lymphocytic (varioliform gastritis)
granulomatous
50yo, fundus, parietal cell perdom type, neutrophils infiltrate, peptic ulcers can arise
what is riskfactors
zollinger ellison syndrome
men 1
not at risk for adenoca
30-60yo, body and fundus, mucous predom cell, limited lymphocytes inflitrate, hypoproteinenmia, wt loss, diarrhea,
risk factors?
menetrier disease
risk of adenoca
loss of e - cadherin is key step in this ca
mc sporadic and familial forms
linitis plastic - desmoplastic rxn that stiffens the gastric wall and caused early satiety
has no geographic preference, no gender or precursor lesions
diffuse gastric ca
sporadic and fap pt due to apc mut
increased signaling via Wnt pathway, LOF apc, GOF B catenin
high risk areas, precuroser lesions - metaplasia, atrophy, dysplasia, adenoma, menetriers
male, 55yo
intestinal gastric ca
the stomach is mc extranodal site of what ca
what is the translocation
marginal zone b cell lymphoma
malt is from chronic gastritis H pylori
11:18
carcinoid tumor mc where and is it aggresive?
jejunum and ileum
aggresive!
secrets serotonin, substance p, pYY
asymp, obstruction, metasistatic
cut flushing, sweating, bronchospasm, colicky abd p, diarrhea, r side cadiac valvular fibrosis
circumscribed yellow mass
salt and peper crhomatin
+ synaptophysin, chromogranin, nse by immunohisto
neurosecretory granules
carcinoid tumor that has metastisized
mc mesenchymal tumor of abd
come from what
gist
intersittial cells of cajal
sjogrens syndrome complication?
b cell NHL
has oropharyngeal dysphagiea due to dry mouth
top I antibodies (scl-70) or anti centromere antibodies
esophagus dysphagia (leads to risk of what)
What stomach issue will they have?
What gb issue will arise?
scleroderma
GAVE - watermelon stomach
- gastric antral vascular ectasia (common in cirrhosis too)
primary biliary cirrhosis/cholangitis, anti-mitochondrial ab
severe retrosternal cp, odynophagia, dysphagia, elderly
egd shows several discrete ulcers that are shallow but some deep
tx: remove agent, and drink lots of water with and stay upright (bc most of time it happens w pt is w/o water and supine)
pill induced esophagitis
mc w nsaids, antibotitics, Kcl, iron, alendronate and risdronate (osteoporosis)
what will you see with gastri adenocarcinoma
physically, histology?
virchow node
histology: signet- ring cells, linitis plastic
extensive burns in duodenum - peptic ulcer
curling ulcers
peptic ulcer from severe head injury or with other lesions of cns
cushing ulcer
what serologic test should you run if you suspect a neuroendocrine tumor?
vasoactive intestinal peptide (VIP -VIPoma)
calcintonin (medullary thryoid carinoma)
gastrin (zollinger-ellison syndrome)
urinary 5-Hydroxyindoleacetic acid (5-HIAA)
A Patient comes in with peripheral Edema, Weight loss, and diarrhea. She’s seven years old and came into the clinic last week for an upper respiratory infection. They do an egd, You see enlarged gastric rugae in the body and fundus With abundance of mucus. What should you be concerned with this little girl having? What is she at risk for developing?
She has Menetriers disease
She is at risk of developing gastric adenocarcinoma
Peripheral edema is from hypoproteinemia
Do you to over production of TGFa
A 40-year-old female comes into the clinic with increased pain two hours after eating. It gets better when she eats more food. She also has chronic diarrhea. You do a EGD, and see that there is doubling of the oxyntic mucosal Thickness due to an increase in the number of parietal cells in the fundus. there are duodenal ulcers. You check gastric levels and it is >1000.
What does this patient have and what is she at risk of developing?
She has Zollinger Ellison syndrome. She is at risk of developing multiple endocrine neoplasia one
78-year-old woman comes into the office with sudden onset cramping in her left lower abdominal area. SHe said the pain came out of nowhere. With an increase desire and need to poop. When she went to the restroom she noticed she had lots of bloody diarrhea. She is typically healthy but is on warfarin currently. What could’ve caused this? Where is the most likely location for this to occur?
Acute colonic ischemia
Splenic flexure most likely, then sigmoid and rectum location
What causes a loss of brush border surface area, including villas atrophy, and deficient enterocyte maturation as a result of immune mediated epithelial damage? What type of diarrhea does this cause?
Celiac disease, this causes a malabsorptive diarrhea, Defects in terminal digestion in transepithelial transport
Lactase deficiency causes what type of diarrhea? And due to what defect?
Osmotic diarrhea, Deficiency in terminal digestion
Peyer patch hyperplasia That can lead to intussecption and Lymphoid parenchyma necrosis Replace by aggregates of macrophages is what infectious agent? Where does it colonize in the human?
The aggregates of macrophages are called typhoidNodules. This is typhi salmonella. It colonizers in the gallbladder.
A patient comes in with an acute infection from something that has caused decreased appetite abdominal pain bloating nausea vomiting and bloody diarrhea. They said that it developed into a fever with the flu like symptoms. It mimics appendicitis with right lower quadrant pain. They develop an erythematous macular papular rash called rose spots.If it is not treated then they can lead to encephalopathy seizures myocarditis pneumonia and Coley cystitis. You look in the colon and see typhoid nodules. What are the at risk groups?
Salmonella, cancer immunosuppressed alcoholics CV sickle cell leading to osteomyelitis and hemolytic anemia
