UW 1 Flashcards
Evaluation of dysphagia
History of diffic initiating swallowing with cough, chocking or nasal regurg?
YES –> likely oropharyngeal –> Videofluor modiefied barium swallow
NO –> Likely esoph dysphag:
- solid + liquids –> Motility disorder –> Barium swallow followed by pssible manometry
- solid progressing to liquids –> if history of prior radiatio, caustic injury, complex stricure, surgery then barium swallow followed by possible endoscopy, if no: upper endoscopy
oropharyngeal dysphagia
difficulty initiating swallowing de to inabiity to properly transfer food from mount to pharynx (due to stroke, dementia, maligancy, neuromuscular disorders etc)
pseudoachalasia
due to narrowing of the distal esophagus 2ry to causes other than denervation (eg. cancer) –> can mimic achalasia
- cluses: significant weight loss, rapid onset of symptoms, older than 60
- endoscopy
endoscopy (+) esophag ca –> next step
CT for staging
if endoscopy nonrevealing and there is still concern for esoph ca
CT
HCV chronic infection - manifestation
elevated liver functio n test, mild hepatomegaly, increased liver echogenicity, (+) HCV antibodies)), elevated HCV RNA
HCV management - generaly
antivaral agents (sofosbuvir-valpatasvir) - prevent liver damage: avoid alcool, HAV, + HBV vaccination
treatment for HIV and chronic HBV co-infection
lamivudine
severe alcoholic hepatitis treatment
prednisolone
diarrhea in celiac disease vs lactose def
celiac –> foul-smelling and greasy
lactose –> water
factors that increase the risk for complications in diverticulosis
- heavy meat consumption
- aspirirn or NSAID use
- obesity
- smoking
- alcohol is associated with the formation but no with the complications
alcohol - diverticula
associated in the formation
not associated with complications
caffeine - diverticula
no association
Wilson - pathogenesis
AR mutation of ATP7B –> hepatic copper accumulation –> leak from damaged hepatocytes –> deposits in tissues (eg. basal ganglia, cornea)
wilson disease - clinical findings
- hepatic (acute liver failure, chronic hepatitis, corrhosis)
- neurologic (parkinsonism, gait disturbance, dysarthria)
- psychiatic (depression, personality changes, psychosis)
Wilson - diagnosis
- low ceruloplasmin
- increased urinary cpper
- Kayser Fleisher rings
- Increased copper content on liver biopsy
Wilosn treatment
chelators (eg. D. penicillamine, trientine)
zing: interferes with copper abortion
GI bleeding causes increased BUN/cr ratio - mechanism
- urea production (from intestinal breakdown of Hb)
2. increased urea reabsorption (hypovolemia)
staging of gastric adenocarcinoma - steps
initial endoscopy/biopsy (+_
- -> CT of the abdomen –> PET/CT, endoscopic U/S laparoscopy, CT chest +/- paracentesis/peritoneal lavage)
- limited stage –> surgical resenction
2. advancedchemo +/- palliative surgery
the most appropriate diagnostic tests for acute HBV infection
HBsAg and anti-HBc : both elevatd intiial infection and anti HBc remain (+) during window
cocaine causes gastritis - mechanism
vasoconstriction –> reducing gastric blood flow
another RF for Mallory Weiss tear
hiatal hernia
Mallory Weiss treatment
- spontaneously
- endoscopic therapy if persistent bleeding (electrocoagulation or locan injection of epinephrine)
clue that suggests biliary pancreatitis
ALP more than 150
illicit drug that can cause acute pancreatitis
cannabis
nonalcoholic fatty liver disease - definition
hepatic steatosis on imaging or biopsy
- exclusion of significant alcohol use
- exclusion of other causes of fatty liver
nonalcoholic fatty liver disease - U/S
hyperechoic tecture on U/S
nonalcoholic fatty liver disease - treatment
- diet + exercise - consider bariatric surgery if BMI 35 or greater
Crohn disease - extrainestinal findings
musculoskeletal (arthritis), eye (uveitis, scleritis, episcleritis), skin (erythema nodosum, puoderam gangrenosum)
Crohn - diagnosis
- elevated WBC, iron def anemia, elevated inlf markers
- endoscopy: focal ulcerations adjacent to normal mucosa (cobblestoning) skin areas of disease
- radiography: strictures, bowel wall thickening
Crohn - treatment
5-ASA drugs, corticosteroids, antibiotics
- azathioprine
- Anti-TNF
suspected gastrinoma –>
endoscopy shows multiple stomach ulcers + thickened gastric folds –> check gastrin levels off PPI threapy for 1 week
- less than 110 –> no gastrinoma
- more than 1000 –> check gastric ph: more than 4 it is no gastrinoma, 4 or less to further test to localize it
- 100-1000 –> secretin stimulation test
hepatic encephalopahty - diuretics
low intravascular volume with:
hypokelamia –> exacerbate HE
2. metab alkalosis –> exacerbate HE
protein restriction to avoid hepatic encephalopaty
no because chirrotic patients need protein
- only if TIPS
manifestation of high estrogen in chirrosis
- testicular atrophy
- gynecomastia
- decreased body hair
- spider angiomas
- plamar erythema
1st step in evaluating asymptomatic elevation of aminotransferases
take a thorough history to rule out the more common hepattis RFs (eg. alcohol, drugs, travels, bood transfusion, sex, etc) –> life modification –> repeat –> if still high –> tests
Hamman sign
crushing sounds on chest ausculation (esophageal perforation)
esophageal perforation - diagnosis
- CXR or CT scan: wide mediastinum, pneumomediastinum, pneumothorax, air around paraspinal muscles, pleural effusion (late)
2 .CT: esophageal wall thickening, mediastinal air fluid level - water soluble contrast esophagogram: leak at perforation site
esophageal perforation - management
- antibiotcs + supportive care for all patients
2. surgical repair for significant leakage with systemic infl response
H. pylory - vagotomy
only if refractory
boerhaave syndrome - treatment
for thoracic perforation: surgery
for cervical perforations: conservative measures (eg. antibiotics)
pleural fluid in Boerhaave syndrome)
exudatitve with low pH and ver high amyase (more than 2500), may contain food particles
USUALLY LEFT
empiric treatment for travelers diarrhea (E. coli)
short term of fluoroquinolone
it establish the diagnosis of diffuse esophageal spasm / treatment / pattern on esophagram
manometry
- CCBs
- crockscrew
common drugs associated with acute pancreatitis
- diuretics
- anti-seizures (eg. valproic)
- antibiotics
(eg. metronidazole, tetracycline) - drugs for IBD (sulfasalazine, 5-ASA)
- HIV related (didanosine, pentamidine)
usually mild and resolves with supportive care
management of gallstones
- no symptoms: no treatment
- biliary colic symptoms: elective laparoscopic cholecystectomy, possible ursodeoxycholic acid in poor surgical candidates
- complicated (acute cholecystitis, choledocholithiasis, gallstone pancreatitis: cholecystectomy within 72 hours
postcholecystecomy syndrome
persistent abd pain or dyspepsia either postoperatively (early) or months to years (late) after cholecystecomy.
etiologies: biliary (retain bile duct, cystic stone) or extrabiliary (pancreatitis, PUD) causes
- abd imaging (U/S) followed by direct visualzation can establish the diagnosis and guide therapy
mechanism of malabsorption in Zollinger Ellison
pancreatic enzyme inactivation by increased production of stomache acid
isonizid on liver
idiosyncratic liver injury with histological features similar to those seen in patients with viral hepatitis
suspected galstone induced pancreatitis - test
U/S –> if not diagnostic –> ERCP
CT to diagnose pancreatitis
NOT required if typical symptom
drug that can cause pelagra
isoniazid –> B6 def –> niacin (B3) def
Zenker diverticulim - clinical features
- older than 60, males
- dysphagia, halitosis
- regurgiation + aspiration
- variable neck mass
Zenker diagnosis
- Barium esophagram
2. esophag manometry
Zenker - management
- open/endoscopic surgery
2. cricopharyngeal myotomy
acalculous cholecystitis
in critically ill patients
similar presentation
image: wall thickening and distention + pericholecystic fluid
- antibiotcs + percutaneous chocystostomy, followed by cholecystectomy when medical condition stabilize
how to confirm primary biliary cirrhosis
anti-mit
autoimmune hepatitis - antibodies / TREATMENT
- anti-SMC 2. ANA
- oral glucocorticoids
prencicious anemia - cancer
increased risk for gastric adenoca and gastric carcinoids
gastric Maltoma - management
test for H. pylori
- if (+) and low grade MALTOMA - only treat the pylori
- if (-) or high grade maltoma –> radiation, immunotherapy or single agent chemo
total parentarl nutrition mechanism of stone formation
no CCK secretion
ascites fluid characteristic - color
bloody: trauma, malignancy, TB (rarely)
milky: chylous, PANCREATIC
turbid: infection
straw: benign
ascites fluid characteristic - neutrophils
less than 250: no peritonitis
more than 250: peritonitis (2ry or spontaneous bacterial)
ascites fluid characteristic - ascites albumin
- more than 2/5 (high protein ascites): CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd- Chiari syndrome, fungal)
- less than 2.5: Chirrosis, nephrotic syndrome
ascites fluid characteristic - serum-ascites albumin gradient
- 1.1 or more: portal hypertension
- less than 1.1: no portal hypertension
hepatopulmonary syndrome
intrapulmonary vascular dilations in the setting of chronic liver disease –: platypnea (dyspnea while upright) or orthodeoxia (oxygen desaturation while upright)
1ry sclerosing cholangitis is associated with
- intrahepatic or extraphepatic strictures
- cholangitis + cholelithiasis
- cholangiocarcinoma
- cholestasis (low fat soluble vitamins, osteopororsis)
- colon cancer
abdominal succussion splash?
place the stethoscope over the upper abdomen and rocking the patient back and forth at the hips –> retained gastric material more than 3 h after a meal will generate a splash sound –> indicating the presence of a hollow viscous filled with fluid and gas
- modest sensitivity + specificity for diagnosing gastric outlet obstruction
Major RF for pancreatic Ca
- hereditary: 1st defree relatice
- hereditary pancreatitis
- Germline mutation (eg. BRCA, Peutz)
- smoking (Most significant)
- obesity
- low physical activity
- Nonhereditary chronic pancreatitis
how to confirm diagnosis of carcinoid syndrome
elevated 24h urinary5-hydroxyindoleacetic acid
polyps that carry the greatest risk for malignant transformation
- large (more than 1 cm)
- high grade dysplacia
- villous features
- high number (3 or more)
- sessile (nonpedunculated)
Spontaneous Bacterial peritonitis - clinical presentation
- Q more than 37.7
2 abdominal tenderness - Altered mental status
- hypotension, ypothermia, paralytic ileus with severe infection
Spontaneous bacterial peritonitis - diagnosis
- paracentesis:
More than 250 PMNs - (+) culture, ofter gram (-) (E. coli, Klebsiella)
- Less than 1g/dL protein
- serum ascites albumin gradient less than 1.1
spontaneous bacterial peritonitis - treatment
- 3rd gen cephalosporin
- fluoroquinolone for prophylaxis
initial episode of Difficile - treatment
Vanco PO or fidaxomicin
reccurence episode of Difficile - treatment
- 1st reccurence: vanco PO in a prolonged pulse taper course oOR fidaxomicin if vanco was used in initial
- miultiple recurnce: PO vanco followed by rifamixin OR fecal microbiota transplant)
Fulminant Difficile - treatment
- metronidazole IV + high dose PO vanco (per recum if ileus)
- surgical evaluation
1ry biliary cirrhosis - drug of choice
ursodeoxycholic acid
elevated ALP - management
Check gGT:
A. normal: bone origin
B. high: biliary origin –> RUQ U/S + antimitochondrial:
- Dialated bile: ERCP
- antim (+) or abnormal hepatic parenchyma –> liver biopsy
- both normal –> consider liver biopsy, ERCP, observation
Red flags of GI bleeding
- change in bowel habits
- abd pain
- weight loss
- Iron def anemia
- family history of colon cancer
minimal bright red blood per rectum - management
- more than 50 or red flags –> colonoscopy
- 40-49 without flags –> sigmoidiscopy or colonoscopy
- younger than 40 without flags –> asnoscopy:
- hemorrhoids –> no further
- no source –> sigmoidoscopy or colonoscopy
AIDS enteropathy - mechanism
impaired intestinal surface epitihelium –> steatorrhea
intestinal bacterial overgrowth syndrome
abd pain/bloating and symptoms of malabsoprtion
- associated with anatomical abnormalities (eg. surgical blind loo) or motility disorders (eg. scleroderm)
- RIFAMIXIN
PPI increases the risk of C. dificcile - mechanism
acid suppression
other RF is age older than 65
1ry biliary cirrhosis - complications
- malabsorption, fat soluble vit def
- metabolic bone disease (osteoporosis, osteomalacia)
- HCC
toxic megacolon
total or segmental nonobstructive colonic dilation, severe bloody diarrhea, and systemic findings (eg. tachycardia)
- causes: UC (within 3 years of diagnosis), ischemic colitis, volculus, diverticulitis, infections (Difficile), obsrtuctive colon cnacer (less common)
Toxic megacolon - diagnosis is confirmed by
plain abd x-rays + 3 or more of the following
1. fever 2. pulse more than 120 3. WBC more than 10.5 4. anemia
toxic megacolon treatment
- meical emergency
- IV fluids, antibiotcs, bowel rest
- IV steroids for IBD
- emergency surgery if refractory
esophageal web - MC location
upper esophagus
achalasia - diagnosis
manometry: key of diagnosis –> elevated LES resting pressure, incomplete LES relaxation, decreased peristalsis of distal esophagus
- Barium esophagram: bird beak
achalasia - management
- upper endoscopy to exclude malignancy
- lapar myotomy or balloon dilation
- botulinum toxin injection, nitrates + CCBs
cholestatic pattern - immediate next step
U/S (NOT ERCP)
Suspected esophageal variceal hemorrhage –> …
place 2 large-bore IV catheters –> give fluids, octreotide, antibiotics –> Urgent endoscopic therapy:
A. No further bleeding –> 2ry prophylaxis: β-blockers, endoscopic ligation 1-2 wks later
B. continued bleeding –> balloon tamponade –> TIPS or shunt surgery
C. early rebleeding –> repeat endoscopic therapy –> reccurent hemor –> TIPS or shunt surgery
when to do endoscopy in dyspepsia
if red flags or older than 55
dyspepsia in younger than 55 and no red flags –>
evaluation of H. pylori (urea breath testing, stool antigen testing) can be performed –> fail to improve –> endoscopy
preferred test to diagnose chronic mesenteric ischemia
CT angiography
chronic mesenteric ischemia - treatment
- risk reduction (eg. smoking) and nutritional support
2. endovascular or open surgical revascularization
Spontaneous Bacterial peritonitis - proteins level
less than 1
