Rest Of GI Flashcards
Risk of esophageal eisonipholis
Perforation
Upper endoscopy
Persistent heartburn , dysphagia, odynophagia
Diagnostic, direct visualization, and therapeutic, can take biopsies
Video esophagogreaphy
Oropharyngeal dysphagia
Barium esophagography
Esophageal dysphagia
Differentiate mechanical lesion and motility disorder
Rings, achlasia, proximal lesions
Esophageal nanometer
Motility
Achlasia suspected
Dysphagia where no mechanical obstruction
PH test esophagus
Catheter based-trans nasal catheter
Wireless-capsule in esophagus mucosa
Info about acid reflux -do in ppl with persistent symptoms despite PPI
Causes of oropharyngeal dysphagia
Neurological
Muscular and rheumatologist
Metabolic disorders
Infectious disease
Structural disorders-zenker
Motility disorders
Clues of mechanical obstruction of esophagus
Solid food worse than liquid
Schatski ring
Not progressive
Peptic stricture
Chronic heart burn, progressice dysphagia
Esophageal cancer
Progressive dysphagia, over 50
Eosinophilic esophagitis
Young, corrugated rings, or white papules, proximal stricture
Achlasia
Progressive dysphagia,
Diffuse esophageal spasm
Intermittent, not progressive, ay have chest pain
Scleroderma
Chronic heart burn, raynaud
Ineffective esophageal motility
Intermittent, not progressice, commonly associated with GERD
Oropharyngeal dysphagia vs esophageal dysphagia
Neck, nasal regurgitation, aspiration, ENT
Chest or neck, food impaction
Cause of structural oropharyngeal dysphagia
Zenker
Neoplasm
Cervical web
Propulsive neurogenic oropharyngeal dysphagia
Cerebral vascular accident
Parkinson
ALS
Myotonic propulsive oropharyngeal dysphagia
Myasthenia gravis
Polymyositis
Propulsive esophageal dysphagia (solid and liquid)
GERD with weak peristalsis
Structural esophageal dysphagia (solid)
Intermittent-schatski, web
Progressive-neoplasm
Variable-peptic stricture, eosinophilic esophagitis
Pill esophagitis
Infectious esophagitis
GERD presentation
Esophageal dysphagia with weak peristalsis
Solids and liquids non progressice
Barretts and adenocarcinoma
PH test
Treat GERD
Acid suppression and lifestyle modicfications
Decreased etoh and caffeine
Low fat
Bed incline
H pylori eradication
Alarm features of GERD
Weight loss, resistant vomiting, constant or severe pain, dysphagia.odynophagia, hematemesis, melena, anemia,
Do endoscopy
Heart burn, regurgitation, dysphagia, patient takes baking sods
Atypical presentation GERD
Laryngopharyngeal reflux
Asthma chronic cough
Timing of symptoms with GERD
30 or 60 min after food and upon reclining
Diagnose GERD
Clinically
Alarm features warrant more studies
Dysphagia, odynophagia, hematemesis, melena, weight loss, vomit, severe pain, iron deficient anemia
GERD symptoms that get upper endoscopy
Persistent despite treatment or alarm features
For detecting complications of gerd-stricture, barrett, adenocarcinoma
Who with GERD gets barium esophagography
NOT DIAGNOSIS
In patients with dysphagia or before endoscopy to identify peptic stricture
Who with GERD gets esophageal pH testing
Atypical esophageal symptoms or considering anti reflux surgery
Treat extraesophageal reflux manifestation
PPI suggests that acid reflex is causative factor
For 3 months
Do pH test in persist 3 months on PPI
Hiatal hernia picture
Ok? Reflux LES issue
Scleroderma symptoms
Esophageal dysphagia, mainly solids, motility propulsion problem
(Ebsent peristalsis combined with severe weakness of the LES )
Progressive
Thickening and hardening of skin fibrosis
Chronic heart burn and raynaud
Who gets scleroderma
30-50 women
Zenker diverticulum
Upper esophagus structural
Between cricopharyngeus muscle and the inferior pharyngeal constrictor muscles
Symptoms zenker
Dysphagia, regurgitation, choking, aspiration, voice changes, bad breath
Where is zenker diverticulum
Jillian’s triangle area of weakness
Diagnose zenker
Barium
Sjorgens syndrome
Who gets it
Rheumatologist females 50s postmenopausal
Sjorgens symptoms
Dry eyes, dry mouth->oropharyngeal dysphagia, vaginal dryness, tracheo-bronchial dryness
Oral infections (candida) dental carries
Salivary gland enlargement
Keratoconjunctivitis-foreign body sensation in eyes
B cell non Hodgkin lymphoma
Barrett sign
Goblet and columnar cells
Squamous->columnar
Risk factors barrett
Chronic reflux
Truncus obesity independent of GERD
Symptoms BE
Not specific
90% asymptomatic
Heart burn regurgitation
Diagnose BE
Endoscopy suspect
Confirm biopsy
Treat barrett
PPI-don’t help barrett but may reduce risk of cancer
Endoscopic therapy to remove dysplastic barret epithelium
Should all people with GERD be screening for adenocarcinoma
No just ppl with multiple risk factors for adenocarcinoma
Chronic gerd, hiatal hernia, obesity, white race, male, over 50
Do endoscopy ever 3-5 years if have barrett
Where are peptic strictures
Gastroesophageal junction
Risk for peptic stricture
Esophagitis
Symptoms peptic stricture
Gradual and progressice development of solid food dysphagia over years
Heartbrurn bc stricture is barrier to reflux
Diagnosis peptic stricture
Endoscopy with biopsy is mandatory to differentiate it from esophageal carcinoma
Treat peptic stricture
Dilation. At time of endoscopy
PPI do decrease recurrence
Risk factor squamous cell carcinoma esophagus
Heavy smoking, alchol, achlasia, Plummer Vinson, Tylosis, hot beverage,
Esophagitis
Unresponsive reflux disease with esophagitis
What causes esophagitis
Gastrin OA Ze
Pill induced esophagitis
Resistance to PPI
Medical noncompliance
Swallowed without water of supine
Most common meds of pill endured esophagitis
NSAIDS< potassium chloride pulls, antibiotics, alendronate and risedronate
Symptoms pill endured esophagitis
Retrostenal chest pain, odynophagia, dysphagia,
Diagnose pill endured esophagitis
Endoscopy may reveal discrete ulcers
Complication pill induced esophagitis
Stricture, hemorrhage, perforation
Prevent pill endured esophagitis
Pill with water
Remain upright
Look out for esophageal dysmotility, dysphagia, or stricture
What causes infectious esophagitis
Candida, herpes, cmv, in immunosuppressed, diabetes,
Diagnose infectious esophagitis
Endoscopy with biopsy and culture
CMV
Large shallow superficial ulcers
Herpes esophagitis
Multiple small deep ulcerations
Oral ulcers associated
Candida esophagitis
Diffuse, liberal, yellow white plaques adherent to the mucosa
Pictures
Ok
What are causes of caustic esophageal injury
Accidental kids
Deliberate adults suicide
Symptoms caustic esophageal injury
Burning, chest pain, gagging, dysphagia, drooling
Aspiration strider wheezing
Diagnosis caustic esophageal injury
Circulatory status and airway potency and laryngoscopes
Chest and abdominal radiographs-pneumonitis or free perforation
Complications caustic esophageal injury
Phenumonitis
Perforation
Treat caustic esophageal injury
ICU
Nasogastric lovage and oral antidotes may be dangerous and NOT administered
Laryngoscopy to assess need for tracheostomy
Endoscopy
Psychiatric referral
Fasting and monitor start oral
Watch for strictures in coming months
Endoscopic superveillance of esophageal caustic injury for 15-20 years
Risk of esophageal squamous carcinoma
Diagnose mallory weiss
Endoscopy
What do if mallory weiss tears keep bleeding
Inject with epinephrine , cautery, mechanical compression with endoscopic therapy
What may cause eosinophilic esophagitis
Food or environmental antigens are through to stimulate an inflammatory response
History of atopy asthma
Symptoms eosinophilic esophagitis
Dysphagia
Food impaction,
Kids similar to gerd but no acid -pain, vomiting, chest pain, failure to thrive
Lab eosinophilic esophagitis
Eisoniphilia igE
MULTIPLE CONCENTRIC RINGS
Need biopsy
Treat esophageal eosinophilia
Corticosteroids
*dradula dilation of strictures in patients with dysphagia but cautious bc increased risk of perforation
Esophageal webs
Mid or upper esophagus,
Asymptomatic not progressice dysphagia
Barium
Boogie dilatory to treat
PPI if have heartburn or require repeated dilation
Esophageal rings
Distal
Dysphagia intermittent not progressive
Large poorly chewed food such as beef cause symptoms
Barium
Boogie dilator
PPI if heartburn or who require repeated dilation
Zenker
Pharyngoesophageal junction between inferior pharyngeal constrictor and cricopharyngeus from loss of elasticity
Retains food
Diagnose zenker
Video esophagography
Treat zenker
Myotome , surgical diverticulotomy
Small just observe
Who do we suspect eosinophilic esophagitis in
Dysphagia and esophageal food impaction
Complication eosinophilic esophagitis
Perforation
Stricture
Food impaction
Achlasia
No relaxation of LES and no peristalsis in distal two thirds loss of NO in myenteric plexus
Pseudoachlasia
Metastatic tumors invade gastroesophageal junction resulting
Chagas
Bite of reduviid bug trypsin cruzi
Ganglion gone
Symptoms achlasia
Gradual progressice dysphagia for solids and liquids months to years
Chest pain
Maneuvers to to help esophageal empty
Weight loss
Diagnose achlasia
Barium and confirm with esophageal manometry
Achlasia don’t treat
Sigmoid esophagus hugely dilated
Diffuse esophageal spasm
Spasm with tight LES
Treat achlasia
Botox, dilation, surgery, PPI
Nutcracker esophagus
Hypertensive peristalsis swallowing contractions oo powerful
Symptoms nutcracker
Dysphagia solid and liquids not progressice
Diagnose nutcracker
Manometry
LES relax normally but elevated pressure at baseline
Diffuse esophageal spasm
Uncoordinated esophageal contraction corkscrew
Rosary bead on barium
LES normal
Symptoms diffuse esophageal spasm
Dysphagia to solid and liquids chest pain
Not progressice
Diagnose diffuse esophageal spasm
Manometry EGD bariu
Esophageal perforation
Trauma from forceful vomiting
Not boerhaave if done with endoscope
Diagnose esophageal perfoation
CT of the chest detecting mediastinal air
Treat esophageal perforation
NGT, suction, NPA, antibiotic surgery
Signs of pneumomediastinum
Subcutaneous emphysema
Ham mans sign
Dyspnea but do not measure peak expiration flow rate
What causes gastric outlet obstruction
Peptic ulcer disease
Malignancy
Gastric volvulus
Cause of small intestinal obstruction
Adhesions, hernia, volvulus, Crohn’s disease, carcinoma
Gastroparesis
Diabetics, post viral, post vagotomy
Small intestine dysmotility cause
Scleroderma amyloidosis, chronic intestinal pseudo-obstruction
What causes peritonitis
Perforated viscous appendicitis
What causes viral gastroenteritis
Norwalk rotavirus
What causes hemorrhagic gastritis
NSAIDS, stress ulcers, alcoholic, portal HTN, ischemia, caustic ingestion, radiation
Treat stress ulcers
Enteral nutrition H2 blockers and PPI
Treat alcoholic hemorrhagic gastritis
Propranolol or nadolol
Manifestation hemorrhagi gastritis
Upper GI bleeding, hematemesis, coffee ground emesis, or bloody aspirate in nasogastric suction , melena
Diagnosis hemorrhagic gastriris
UE
No inflammation on histologic
Treat hemorrhagic gastritis
Remove agent and prevent ulcers
Chronic gastritis changes
Superficial (lamina propria)-> atrophic->atrophy
Type A gastritis
Fundic, body predominant and less common form
Asymptomatic
Old ppl
Autoimmune -achlorhydria, pernicious anemia, gastric cancer risk
Antibodies to parietal cell
Pernicious anemia
Pernicious anemia gastritis
Achlorhydria->hypergastrinemia due to loss of acid inhibition of G cells->hypergastrinemia hyperplasia of gastric Enterochromaffin like cells-> small multicentric carcinoid tumors
Decreased B12
Autoimmune destruction of the gastric fundic mucosa loss of rural folds
Anti IF and ATPase in them
Type B gastric helicobacter pylori
Antral predominant from H pylori
Type A was autoimmune
Signs of type B gastritis
Asymptomatic maybe dyspepsia
Atrophic gastrin, increased risk of gastric cancer
Menetrier disease
Giant thickened gastric folds involving body
Chronic protein loss
Hypoproteinemia, anascara, may need gastric resection
PUD signs
Coffee grounds emesis, hematemesis, melena, hematochezia, gnawing dull aching or hunger like gastric pain
Recovered nasogastric lovage fluid that is _ for blood does not exclude active DU bleeding
-
H pylori
Spiral curved gram negative rod urease producing organism microaerophilic with flagella; colonizers gastric antral mucosa
Genes h pylori
Vac-a can-a
Caga positive h pylori
Greater risk of ulcer
Test h pylori
Urea breath test, fecal antigen test, endoscopy
Major cause of ulcers not h pylor
NSAIDS
Over 60
Corticosteroids
Ze
Smoking
Warthin silver stsain and immunohistochemistry stain
H pylori
Serology h pylori
H pylori IgA
Possible lab findings h pylori
Anemia Leukocytosis(perforation) Up amylase-ulcer penetrate pancreas Gastrin up Ze Fall hematocrit (bleeding, ) BUN up-absorption of blood nitrogen from the small intestine and prerenal azotemia
Ulcer along posterior wall of duodenum may perforate what
Pancreas, liver, biliary tree
Complications gastric surgery PUD
Obstruction, bezoar, bile reflux gastritis, malabsorption
Differentials with upper GI bleed
PUD
Erosive gastritis
Malloy weiss
Varices (portal HTN)
Ulcer incidence with COX2 inhibitors, NSAIDS, asprin
COX2 less
NSAIDS yes
Asprin if history of PUD
Cardiovascular complications COX2 inhibitors, NSAIDS< asprin
Cox2-INCREASE
NSAIDS-less
Asprin-protective
DU from h pylori
Stimulate G cells
Dyspepsia, burning, epigastric pain, 60-3 hours after meal
Relieved by for
Gastric ulcer from H pylori
Smoking higher
Normal acid
Dyspepsia, made worse with food
Within 30 min
Anorexia, weight loss
Lesser curve
Treat ulcers
PPI
Gastric-exclude malignancy
Gastric adenocarcinoma
Benzpyrene, smoked fish meats,
Signet ring cells, linitis plastica, Virchow node, krukenberg tumor
Zollinger ellison
Tumors in pancreas, duodenum, lymph nodes
MEN1
-gastrin OA, hyperPTH, increase Ca, pituitary neoplasm
Diagnose Ze
Large mucosal folds on endoscopy
Confirm serum gastrin >1000
Secretin stimulation +
Draw serum PTH, prolactin, LH-FSH, GH
Treat ZE
PPI Exploratory laparotomy MEN1 Timor respectable Treat hyperPTH first may improve Chemo
SE
PUD that isn’t responding to treat, proximal duodenum tumor, pancreas, MEN1
Fasting gastrin +
Jupertrophic gastric mucosa
Secretin +
Gastroparesis
Obstruction in absence of mechanical lesions caused by
DM
Postdurgical
Neurologic chagas
Diagnose gastroparesis
Gastric scintigraphy-with low fat meal assess gastric emptying
Treat gastroparesis
Metoclopramide -risk of tardive dyskinesia
Food bolus impaction
Inability to swallow including saliva
Postvagotomy
Rapid food passage into small intestine->distension due to osmotic flow of water into lumen
Nausea and diarrhea, palpitations, sweating , hypoglycemia
Eat small meals, ingest solid and liquid separately
Post gastrectomy
Dumping syndrome
Weak, tachycardia, poop, epigastric full, 30 min after eat
Cramps
5789hematemesis
Vomit blood coffe grounds
Hematochezia
Bright red blood in rectum massive UGIB 100mL
Source of UGIB
Proximal to ligament of treitz
Diagnose and treat UGIB
Endoscopy
Angioectais
Submucosal vessels caused by chronic intermittent obstruction of submucosal veins
Bright red stellate appearance
Throughout GI right colon
Telangiectasia
Small, cherry red lesions caused by dilation of venues that may be part of systemic conditions or sporadic
Hereditary-loser Weber rendu of CREst
Dieulafoy lesion
NSAIDS
Bleed
Submucosal artery
UGIB assessment
Shock(acidosis, increased lactate)
Hematocrit not reliable of severity
How stabilize UGIB
Two large bore IV lines for diagnostic tests
Give saline or lactated ringer
Give PRBC hemoglobin should rise
BUN/Cr in UGIB
30:1
Treat UGIB
PPI IV or oral
Ocreotide -reduce splanchnic blood flow
BUN PUD
30:1 bc absorption of N from SI and prerenal azotemia
Hypotension with onset pain , what else consider besides PUD
Ruptured aortic aneurysm, mesenteric infarction, or acute pancreatitis
How diagnose ulcer penetration
CT
Gastric outlet obstruction
Narrow pylorus or duodenal bulb
Less commonly associated with PU bc h pylori and PPI control
LGIB
Hematochezia(10% UGIB)
See with colonoscopy
Distal to ligament of treitz
Increased risk with asprin, antiplatelet agents, NSAIDS
LGIB differential
Under 50-infectious colitis, anorectal disease, IBD, neoplasm , crohns, celiac
Over50-diverticulosis, angiectasis, malignancy or ischemia, angioctasias, telangiectasia, neoplas, hemorrhoids, fissure, ischemic colitis
Most common cause of LGIB
Diverticulosis
Ischemic colitis
Older with atherosclerosis
Crappy ab pain, followed by bloody diarrhea
Clinical manifestation LGIB
Black tarry melena proximal to ligament of treitz
Diagnostic test LGIB
Anoscopy, nuclear bleeding scans, SI push enteroscopy, capsule imaging
Diverticulosis
Most common in sigmoid
Increases with age
Diverticulosis
Asymptomatic
90%
Hemorrhage from ascending colon and self limited
Treat diverticulosis
High fiber
Acute mesenteric ischemia
Periumbilical pain out of proportion to tenderness (writhing pain but PE unimpressive)-NOT MALINGERING
Food fear
Diagnose acute mesenteric ischemia
Abdominal c ray bowel distension thumb printing (submucosal edema)
CT angiography
Laraptomy
Ischemic colitis
Severe lower ab pain followed by rectal bleeding
S ray thumb printing
Hemorrhoids
Anoscopic axam
Treat with site baths
External hemorrhoid
Pain
Over 24-48 hours
Occult gastrointestinal bleed
Not apparent to patient
Identify occult bleeding
FOBT, FIT(fecal immunochemical test), iron defiency anemia
6777what should patient with iron defiency anemia be evaluated for
Celiac, IgA antitransglutimase of duodenal biopsy
Meckel diverticulitis diagnose
Technetium 99 scan
What causes toxic megacolon
C diff, UC,
Most commmon cause acute liver failure
Acetaminophen
Perforated viscous
Any hallow organ (esophagus, stomach, intestine, uterus, bladder)
Emergency surgery
Free air under diaphragm seen on CT or plain X ray
What initiates appendicitis
Obstruction of appendix
Diagnose appendicitis
CT US
Strangulated hernia
Tender, firm, irreducible mass, bowel infarcts and dying need surgery!!
Irreducible hernia
Can’t be manipulated back into cavity
Incarcerated hernia
Imprisoned
Obstruction hernia
Loop of bowel non functioning with normal blood supply
Strangulated hernia
Cut off the blood supply to the content
Acute colonic pseudo obstruction (olive syndrome)
Severe abdominal distension in post op state with severe medical illness
Nausea, vomiting,
Spontaneous primary bacterial peritonitis
Review
AAA rupture
With increasing size of aneurysm
Aortic aneurysms
No symptoms, detect routine exam palpable or incidental finding
Harbinger pain of rupture and represents a medical emergency
Acute rupture with no warning
Acute pain and rupture
Who gets aortic aneurysm screening
Men 65-75 who have ever smoked
Aortic dissection
Tear of intima
Along the right lateral wall of the ascending aorta where the hydraulic shear stress is high
Ectopic preg
Transvaginal ultrasound with no intrauterine preg
Most common cause maternal death first trimester
Ovarian torsion
Surgical emergency
Prompt diagnosis
Can get rupture, bleeding, cysts, neoplasma,
Right side bc increased length of the utero ovarian ligament on the right and the sigmoid on the left, limiting space for movement
Presentation ovarian torsion
Sudden onset severe unilateral lower abdominal pain maya develop after episodes of exertion
Detect ovarian torsion
Transvaginal US with Doppler is primary
Greater than 4 cm ovary due to cyst, tumor or edema is most common finding associated with torsion
Testicular torsion
Emergency
Neonatal period and puberty
12-18
Testicle of neonates with prenatal torsion is not salvageable
Sign of testicular torsion
Pain is abrupt in onset and severe and is usually associated with nausea or vomiting
Painful!!
Swollen tender high rigid testis with abnormal transverse line, scrotal skin changes, ipsilateral loss of cremasteric reflec
Diagnose testicular torsion
Doppler US
Crohns genes
CARD15/NOD2 16p
Genes US
HLADR2
Extraintestinal manifestations IBD
Joints arthritis
Erythema nodosum, pyoderma gangrenosum
Thromboembolic events DVT< nephtolithiasis with irate or calcium oxalate stones may occur in CD
Infectious enterocolitis and UC
Clinically and endoscopically indistinguishable need stool
UC
Crypt abscess, blood diarrhea, ulcerated pseudopolyps, smoking protective
CD
Non caseating granuloma,
Strictures,
Creeping fat
Aphthous ulcers
Smoking worsens
What other disease have non caseating granuloma
Sarcoidosis
Erythema nodosum
UC
Pyoderma gangrenosum
UC
Diagnose UC
Sigmoidoscopy
Colon cancer UC
Start colonoscopy every year or two 8 years after diagnose bc increased disease proximal to rectum
5asa decrease risk of colonic ancer
CD
Cobblestone fistulae, oxalate kidney stones, bile salt malabsorption, intestinal obstruction, stop smoking
Carcinoma and CD
Annual screening to detect dysplasia annually with 8 or more years of CF
Both rare
Diagnose CD
Sigmoidoscopy, colonoscopy, barium enema, upper GI, small bowel series
CD CBC
Anemia
Serum albumin CD
Hypo from protein loss
ESR CD
INCREAED CRP
UC RISK
MEGACOLON LEAD PIPE FROM LOSS OF HAUSTRA
Crohns abscess
On CT
Give broad spectrum antibiotics
Percutaneous drainage or surgery
Symptoms intestinal obstruction with CD
Intravenous fluids with nasogastric suction
Low roughage diet-low fiber
Retroperitoneal phlegmon or abscess
Fever, chills, tender abdominal mass, leukocytosis
Enterocolitica fistula
Diarrhea, weight loss bacterial overgrowth
Colovesical, enterovesical fistula
Urinary infections
Colovaginal enterovaginal fistula
Malodorous drainage
Enterocutenaous or colocutaneous fistul
Skin, surgical scare
Perianal disease
Large painful skin tags, anal fissures, perianal abscesses, fistulae
Treat perianal disease
Colorectal surgeon
Metronidazole, ciproflaxin, tacrolimus
Diagnose perianal disease/fistula
Pelvic MR
Resection more than 100 c, terminal ileus
Fat malabsorption
Low fat diet and parenteral B12
Bile acid not absorbed cause secretory diarrhea
Steatorrhea
OXALATE KIDNEY STOMES -cholesterol gallstones
How prevent oxalate kidney stones
Calcium supplements
Glucocorticoids for IBD adverse events
Mood changes, insomnia, buffalo hump, weight gain (striae), edema, increased serum glucose levels, acne, and moon faces
5 Asa SE
Acute interstitial nephritis
Sulfasalazine is administered with ___
Folate
UC surgery
Protocolectomy
CD surgery
Fix obstruction , abscesses, persistent symptomatic fistulas
Anti TNFa risk
Non melanoma skin cancer, non Hodgkin lymphoma
Azathioprine or 6-MP for IBD CD UCwhat test before
TPMT functional activity is recommended prior to initiation
Non Hodgkin , allergic, toxicity
Why should prophylaxis be given to all hospitalized IBD patients
Risk of venous thromboembolic disease
Also social support
Antibiotics for IBD
Ciproflaxin, cyclosporine
Recurrent intrahepatic cholestasis
Early in life may persist for a lifetime
Benign but not in familial forms
Conjugated
Intrahepatic cholestasis of pregnancy
Conjugated
Benign
Recurrence with preg or OC
Post hepatic causes
Gallstones, inflammation, tumors
Diagnose obstructive jaundice
Conjugated
US
Cholangiography
Hepatocellular vs cholestatic
ATL ALT
ALP and bilirubin
Hemolysis
Indirect bilirubin
Anemia,
Gilberts
Indirect elevated
NO ABNORLA LIVER TESTS
Differential for Obstructive jaundice conjugated
Bile duct stone Neoplasm Cancer Hepatocellular jaundice, Pyogenic cholangitis
Right hepatic duct block
Ok
Cystic duct block
Ok
Sphincter oddi block
Ok
Left hepatic duct block
Ok
Common bile duct block
Ok
NAFLD lab
Alt ast up
Acute cholecystitis
Leukocytes
Choledocholithiasis
Stone remove and antibiotics
Biliary dyskinesia(bile cant move)
Similar symptoms to biliary colic-RUQ pain, limits activities, nausea
How diagnose biliary dyskinesia
US no stones or anything
Normal liver enxymes, conjugated bilirubin, amylase
HIDA scan-normal gallbladder
Abnormal gallbladder
Ejection fracture lesss than 35 ->cholecystectomy
Or stone seen
Risk of gallstones
Female
Age
Carb intake
.W if cirrhosis and hep c
Cholesterol or pigment
Stones
Brown stomes
Bacterial
Asian
Cholesterol pigment
Cholesterol
Pigment stone
Calcium bilirubinate
Symptoms cholelithiasis
RUQ pain after meals right scapula NV
Diagnose cholelithiasis
Bilirubin
US-acoustic shaddow
Where are most gallstones
Cystic duct
What causes acalculous cholecystitis
Acute illness , fasting, hyperalimenataion, carcinoma, infection
Labs acute cholecystitis
HIDA scan obstructed duct
Leukocytosis, bilirubinemia, AST, ALP, GGT< Amylase
Gallbladder in acute cholecystitis
Wall thickening, pericholecystic fluids, Murphy
Complication s cholecystisis
Perforation, pericholecystic abscess , peritonitis, emphysematous, emphysema
Choledochilitis
Common bile duct stone
ERCP or EUS
Can lead to acute ascending cholangitis
RUQ pain fever chills
Treat cholecocholithiasis
Cholecystectomy
ERCP with sphincterotomt and stone extraction or stent placement if the procedure of choice
Ascending cholangitis
Charcot triad
Reynaud pentad-altered mental status and hypotension
Endoscopic emergence
Risk factor for cholangitis
Primary sclerosing cholangitis
Men
Cholangiocarcinoma
Associated with IBD (UC), CVD, DM,
Beads on a string onion skinning
Primary biliary cirrhosis
Old females
AMA positive antibodies
Chronic cholecystitis
Chronic gallbladder inflammation
Asymptomatic
Porcelain-calcified x ray
Bad prognosis
Courvoisers gallbladder associated with what
Cancer of head of pancreas
Porcelain gallbladder
Associated with gallbladder carcinoma take it out@
Treat cholelithiasis
Just do cholecystectomy for ppl with symptoms , previous complications, porcelain
Laparoscopic cholecystectomy
Treat with ursodeoxycholic acid
Treat acute cholecystitis
NPO Nasogastric suction IV fluids Analgesics Antibiotics Surgery-if complication
Treat cholecocholithiasis
Cholecystectomy and ERCP
When CBD stones are suspected prior to laparoscopic cholecystectomy , preop ERCP with endoscopic papillotomy and stone extraction is the preferred approach
Cholangitis treat
Treat like acute cholangitis
Treat primary sclerosing cholangitis
No good therapy
Glucocorticoids, methotrexate, cyclosporine not good
Liver transplant in end stage cirrhosis
US benefits
No radiation safe in preg
EUS benefits
No radiation
Diagnostic and therapeutic
CT scan
Contrast used
Angiography for vessels->ischemic colitis
Good for soft tissue and bones
MRI
Radiation
Soft tissue
MRCP for GI
MRCP
Magnetic resonance cholangiopancreatography
Pancreas and biliary tree can see stones
ERCP
Endoscopic retrograde cholangiopancreatography
Invasive biliary tree and pancreatic duct
Measure INR first
HIDA
Hepatobiliary scan
See GB
Abnormal-GB most seen (stones)
OCG
Oral cholecystogram /cholecystography
Contrast medium tablets swallowed bight before
X ray
Evaluate GB for stones
Ok
Plain x ray gallbladder
Porcelain
KUB-kidney ureter, bladder
Small amount of radiation
Non invasive
Cheap
See stones
Cholangiography
Percutaneous transhepatic (through skin)
Radiation
Uses iodine contrast
Intraoperative-in OR while doing cholecystectomy
EGD
Esophagogastroduodenoscopy
Use endoscope
Diagnostic and therapeutic
See esophagus and stomach
Colonoscopy
Invasive
Need prep
Colonscope
Diagnostic and therapeutic
The diagnosis of acute pancreatitis two of the three criteria
Abdominal pain in epigastric may radiate to back
Threefold increase in serum lipase and/or amylase and
Confirmatory findings of acute pancreatitis on abdominal imaging
Causes of acute pancreatitis
Gallstones Alcohol Hypertg Trauma(surgery) Post op
Divisum
Scorpion
Autoimmune
Risk factors acut epancreatitis
Smoking
High dietary glycemic load
Fat
Age
Protective factors acute pancreatitis
Vegetables
Statins
Symptoms acute pancreatitis
Nausea, vomiting, sweating, abdominal tenderness, distension and fever, pain shock, radiate to back
PE acute pancreatitis
Left shift
Cullen grey turner
Lab acute pancreatitis
Lipase 3x up
If salivary gland disease and intestinal perforation/infarction are excluded
What other disease may cause amylase elevation
Intestinal obstruction Gastroenteritis Mumps Ectopic preg Administration of opoids Ab surgery
Acute pancreatitis saponification
Ya and have low serum ca
Hyper tg->check a lipid panel for SAP etiology
Hemoconcentration->pancreatic necrosis
Hypoalbuminemia and marked elevations of serum LDH are associated with increased mortality rate
Imaging acute pancreatitis
X ray-Sentinel loop (air filled)
Colon cutlass sign (gas filled segment)
CT-confirm and help look at complications
Rapid bolus IV contract CT-avoid is serum cr >1.5
MRI-fluid collection in pancreas correlates with mortality
EUS-biliary disease
ERCP-complication is pancreatitis-DO IT IN PATIENTS WITH CHOLANFITIS, JAUNDICE, BILE DUCT STONE , ASPIRATION OF BILE FOR CRYSTAL ANALYSIS MAY CONFRUM
Treat acute pancreatitis
ICU
Aggressive IV fluid
No oral alimenataion and parenteral analgesics
Eliminate precipitating factors
Risk factors for high levels of fluid sequestration in acute pancreatitis
Younger age, alcohol , higher hematocrit, higher serum glucose, systemic inflammatory response syndrome in first 48 hours of hospital admission
How treat hypocalcemia with tetany in acute pancreatitis
Calcium gluconate IV
How treat coagulopathy or hypoalbuminemia in acute pancreatitis
Infusion fresh frozen plasma or serum albumin
How treat shock with acute pancreatitis
Vasopressin
PRBC
Somplications SAP
Necrotizing pancreatitis
Intravascular volume depletion
Ileus
Elevations in amylase
Necrosis-pseudocysts
ARDS
Abscess
_ or _ should be considered with any change in clinical course to monitor for complications acute pancreatitis
CT MRI
Assessment of severity acute pancreatitis
Ransom criteria
Apache II
Bedside index for severity ina cute pancreatitis
Haps (harmless acute pancreatitis score0
Apache ))
Over 8 high mortality
Bedside index for severity in acute pancreatitis
BUN>25 age over 60
0-5
01% death
5 27% death
7-8 100%
HAPS
Non severe course with 98% accuracy
No ab tenderness, rebound , guarding
Normal hematocrit
Normal serum creatinine level
Revised Atlanta classification of the severity of acute pancreatitis
Mild-no organ failure, no local complications
Moderate-transient oragan failure, maybe local complications
Severe-persistent oral fail
CT grade of severity index for acute pancreatitis
A-normal pancreas, b-pancreatic enlargement, cpancreatic inflammation and or peripancreatic fat, d single acute peripancreatic fluid collection , e-two or more acute peripancreatic fluid collection or retroperitoneal air
SIRS and elevated BUN on admission with a rise in BUN within first 24 hours
-increased .com
0-4
4, over 50% pancreatic necrosis, 17% mortality
Chronic pancreatitis
Irreversible damage to pancreas
Pancreatic exocrine or endocrine insuffiency
Get DM and malabsorption
Most frequent cause of chronic pancreatitis
Alcoholism
TIGARO
Autoimmune pancreatitis
IgG4 autoantibodies
CFTR predispose
PRSS1 SPONK1
PAIN Steatorrhea malabsorption (exocrine pancreas insuffiency)
Lab chronic pancretitis
No specific lab test for chronic pancreatitis
Amylase normal
Fecal elastase 1 and small bowel biopsy are useful int he evaluation of pets with suspected pancreatic steatorrhea
Imaging chronic pancreatitis
Calcifications x ray
CT calcifications-tumefactive chronic pacnreatitis concer for pancreatic cancer
EUS-enlarge pancreat sutoimmune
Treat chronic pancreatitis
abstain from alchol
Control pain with acetaminophen, NSAIDS, tramadol
Low fat diet
Complications chronic pancreatitis
Chronic abdominal pain , DM, opoid narcotic addition, steatorrhea, malnutrition, pancreatic cancer
Manic ause of death chronic pancreatitis
Pancreatic cancer
Pancreatic adenocarcinoma
Trousseau sign of malignancy
Smoking, fat, male, old, DM, cirrhosis, family history, courvoiser sign, painless jaundice ,
MEN
AD
Type 1 pancreatic neuroendocrine islet cell tumors
Insulinoma , gastrin OA
Insulinoma
Insulin secretion hypoglycemia
Gastrin OA ZE
MEN1
Nonbeta islaet cell tumors, hypersecretion of gastrin , peptic ulcers, refractory to standard Tx , found in duodenum,
Men 1 tumors
Parathyroid(hyperca, PTH)
Pancreas (gastrin OA Ze, insulinoma)
Pituitary
MEN2A
Thyroid (calcitonin)
Adrenal (pheochromocytoma)
PTM hyperca and ph
MEN 2B
Marfanoid
Medullary thyroid cancer
Pheochromocytoma
Neuromas
Problem with free unconjugated bilirubin
Toxic to CNS
Usually bind albumin , if not can cross BBB
Why large amounts of unconjugated bilirubin in baby
Hemolysis inadequate clearance shorter half life
Inadequate conjugation
UGT levels low
What causes unconjugated bilirubin
Hemolysis
Breast feeding/breast milk jaundice
Function of dehydration and decreased excretion of bilirubin in the stool
Presence of bilirubin de conjugating enzymes in milk
Is conjugated hyperbilirubinemia ever non pathological
No
Why do babies have increased bilirubin production
Erythrocyte enzyme deficiencies
Blood group incompatibility
Structural defects in RBC
G6PD defiency
Why do babies have impaired conjugation of bilirubin
Gilbert
Crig naj
Ugt1a1 defiency
Why babies have increased enterohepatic circulation
Decreased intake, decreased passage of stool
ABO incompatibility
No big deal in first preg but after Rh antibodies can cross placenta and hurt Rh+ fetus causing hydrops fetalis
If mom is type O or Rh negative
If mom is type I or Rh negative what should we test infants cord
Direct antibody test Coombs
Blood type
Rh determination
How does Coombs test work
Patient sample put with anti-HU IgG Coombs reagent and get agglutination if positive for presence of mothers AB on surface
Conjugated hyperbilirubinemia
Biliary atresia cholestasis
Acute bilirubin toxicity
High unconjugated
Risk for hyperbilirubinemia
Jaundice in first 24 hours, gestational age 35-36 weeks
Bruising
Exclusive breastfeeding
Asian
What should be gotten on exam with jaundice baby
TSB
Prolonged jaundice greater than 3 weeks
2 months? Gilbert?
Breast milk jaundice
Treat baby bilirubin
Phototherapy which osomerizede bilirubin making it water soluble
Biliary atresia
Progressive destruction inflammatory process affecting extra and intrahepatic biliary tree
First few weeks
Cholestasis jaundice, hepatomegaly, alcholic stools
Crigler najjar syndrome and phenobarbital
Type 1 no decrease in bilirubin
Type II decrease with phenobarbital
Baby gastroesophageal reflux
Passage of gastric contents into esophagus
Happy spitter
Baby GERD
Hard to feed, cry a lot, arch and scream, not gaining weight
Treat GERD baby
Surgery
Fundoplication
More common in developmentally delayed children
Usually not until older and only if gerd is putting the child’s nutrition or respiratory status at risk
Intussusception baby
Ileum invaginsttes into colon at ileocecal valve junction
Clinical intussusception
Bright red blood mucus and currant jelly stools
Lethargy
Palpable tubular mass in abdomen
Air enema coiled spring
Treat intussusception
Pneumatic reduction air enemies
Pyloric stenosis
2-4 weeks Boys Hypochloremic, hypokalemia, metabolic alkalosis, nontender epigastric olive sized area, Dehydration poor weight gain US
Hirschsprung
Meconium none or require repeated rectal stimulation to induce bowel movements
Poor feeding villous vomiting
Celiac disease symptoms
Diarrhea, failure to thrive, distended belly, cvomiting
