UW 2 Flashcards
diffuse esoph spasm - symptoms
- intermittent chest pain
2. dysphagia for solids + liquids
diffuse esoph spasm - diagnosis
- manometry: intermittent peristalsis, multiple simultaneous contractions
- esophagram: corkscrew pattern
diffuse esoph spasm - treatment
CCB
alternates: nitrates or tricyclics
upper GI bleeding with depressed level of consciousness and ongoing hematemesis –> next..
intubate to protect airway and then endoscopic treatment with ligation or sclerotherapy
hepatic adenoma - complications
- hemorrhage
2. MALIGNANT TRANSFORMATION
focal nodular hyperplasia
anomalous arteries
- arterial flow + central scar on imaging
- resemble to adenoma, but not associated to OCPs
Ulcerative colitis - complications
- toxic megalcolon
- 1ry sclerosing cholangitis
- Colorectal Ca
- Erythema nodousm, pyoderma gangrenosum
- spondyloarthritis
UC - biopsy
- mucosal + submucosal infl
2, crypt abscessess
UC - Endoscopic findings - endoscopic findings
- erythema, griable mucosa
- pseudopolyps
- involvement of rectosigmoid
- no skip lesions
alcoholic hepatitis - LABS
AST + ALT usually less than 300 AST: ALT: MORE THAN 2 - Leukocytotis (esp neutrophils) - low albumin in malnourishedt - elevated ferritin
acetaminophen intoxitation - level of AST/ALT
more than 1000
suspect toxic megacolon - initial test
abdominal X-ray
acute diverticulitis - diagnosis
abd CT (oral + IV contrast)
acute diverticulitis - management
bowel rest
- antibiotics: cipro or metronidazole)
colonoscopy in acute diverticulitis
never –> it can cause perforation
liver enzymes in hypotension
iscehemic hepatic injury –> massive increase in the AST and ALT with milder associated increases in the total bilirubin and ALP
lactose intolerance - labs
- (+) hydrogen breath test
- (+) stool test for reducing substance
- low stool ph
- increased stool osmotic gap
DDX of very high AST and ALT
- toxin induced (eg. acetaminophen)
- ischemic
- viral hepatitis
nonalcoholic fatty liver disease is frequently associated with
insulin resistance –> increased peripheral lipolysis, TG synthesis, and hepatic uptake of fatty acids
- hepatic free fatty acids increases oxidative stress and production of proinflammatory cytokines
nonbleeding varices - prevention
- nonselective beta blockers (eg. propranolol, nadolol)
- if contraindications of beta blockers –> endoscopic variceal ligation
octreotide for active varices bleeding
used in active bleeding
no prole in primary prophulaxis
Management of Cirrhosis
periodic surveillance of LFT
- Compensated: U/S for HCC ever 6 months and EGD
- decompensated –> assess complications:
a. variceal hemor: start beta blocker and EGD every year
b. ascitie: low sodium, diuretics, paracentesis, no alcohol
c. encephalopathy: lactulose
clinical findings suggest cirrhosis - next step
ensoscopy to screen for varices
- biopsy is not required
Lynch syndrome - type of cancer
- CRC
- Endometrial
- Ovarian
Crohn vs UC regarding intestinal complications
Crohn: fistulas, stricutres, abscesses
UC: toxic megacolon
Cholesterol embolism can occur after vasculr procedure - complications
- skin (eg. livedo reticularis, blue toe)
- GI (eg. mesenteric ischemia, acute pancreatitis)
- Acute kidney injury
acute pancreatitis by uncorrectable causes can be ….. (treatment)
conservatively management with analgesics and IV fluids
esophageal cancer - diagnosis
- endoscopy with biopsy
2. CT (PET/CT) for staging
IBD - age of onset
Bimodal: 15-40, 50-80
chronic pancreatitis - treatment
- pain management
- alcohol + smoking cessation
- frequent, small meals
- pancreatic enzyme supplements
Chronic pancreatitis - manurves to relief pain
- sitting upright
2. leaning forward
causes of renal insufficiency in acute liver failure
common esp when acetaminophen induced, due to drug’s direct renal tubular toxicity
drugs that cause esophagitis
- tetracyclines
- Aspirin + NSAID
- Alendronate
- Iron
- Potasium chloride
acute cholangitis - clinical presentation
Charcot triad: Fever, jaundice, pain
Reynolds pentad: PLUS hypotension and alter mental status
Acute cholangitis - treatment
- antibiotic to cover enteric bacteria
2. biliary drainage by ERCP within 24-48 h
secretory diarrhea
larger daily stool vomulumes and diarrhea that occurs even during fasting, reduced stool omotic gap
- due to increased secretion of ions
- causes: V. cholera, rotavirus, CF, early ielocolitis, POSTSURGICAL CHANGES
ERCP for diagnosis of Pancreatic cancer
vert sensitive + specific
- reserved for those who have already undergone nondiagnostic U/S and CT
laxative abuse - diagnosis
- (+) laxative screen
- colonoscopy with characteristic melanosis coli (dark brown discoloration with pale patches of lymph follicles)
- biopsy: pigment in the macrophages of the lamina propria
Clinical features of irritable bowel syndrome - Rome diagnostic criteria
Reccurent abd pain / discomfort 3 or more days per month for the past 3 months PLUS at least 2 of:
- change in form of stool
- change in frequency of stool
- symptom improvement with bowel movement
sings and symptoms suggenstin other than IBS
- bleeding
- nocturnal or worsening pain
- woight loss
- abnormal labs (anemia, electrolytes etc)
colovesical fistula - etiology (MCC)
- diverticular disease (MC)
- Crohn disease
- Maligancy (clon, bladder, pelvic organ)
colovesicular fistula - diagnosis
- abdominal CT with oral or rectal (NOT IV) contrast
2. colonoscopy to exclude colonic malignancy
colovesicular fistula - treatment
usually surgery
emphysematous pyelonephritis
pyelonephritis due to gas-producing infection, typically in patients with DM
recovery vs resolved HBV
- resolved: (+) antiHBs + HBc but (-) HBsAG
- recovery: anti-HBs, HBc (IgG and HbE
typical clinical presentation + enzymes - how to confirm pancreatitis
no need to confirm
if unclear or fail to improve –> CT
colon cancer screening in patients at increased risk - indications
- Family history of adenomatous polyps or CRC
- FAP
- IBD (UC or Crohn with colonic involvement)
- Lynch syndrome
familty history of adematoys polyps or CRC - screening
- 1st degree relative under 60 or 2 first degree relatives any age
- start colonoscopy at 40 or 10 years before the age of diagnosis of relative
- every 5 years
IBD - screening for CRC
colonoscopy 8-10 years postdiagnosis (12-15 if disease only in Left colon)
- every 1-3 years
FAP - screening
start colonoscopy at 10-12 years old
repeat every year
- also regular screening for upper GI
Lynch syndrome - screening
- start at 20-25
- every 1-2 years
IBD - dysplasia in colonoscopy - management
prophylactic colectomy
diverticular hemorrhage - management
usually resolves sponanteously
ocassionally requires endoscopic or surgical intervention
likely pancreatic cancer - U/S vs CT
if jaundice –> U/S
if not jaundice –> CT
GERD management
Men older than 50 or symptoms more than 5 years, or cancer risk factors or alarm symptoms?
A. NO – once daily PPI for 2 months –> if refractory switch to different PPI or increase PPI to 2 daily –> if controlled then continue, if not the endoscopy or ph minoring
B. YES –> endoscopy:
- esophagitis: treat it
- no esophagitis –> consider further testing for: achalasia, gastroparesis, nonacid reflux, etc –> manometry, impedance testngm gastric scintigraphy
GERD - alarm symptoms
- melena
- persistent vomiting
- hematemesis
- weight loss
- anemia
- dysphagia/odynophagia
DDX of esophagitis
- pill esophagitis
- autoimmune skin disease
- Zollinger ellison
- eosinophilic esophagitis
- Barrett
elderly with new iron depleted anemi and single negative fecal occult blood tests - next step
endoscopy and colonoscopy
FAP syndrome - aspirin
aspirin reduces the risk for CRC in avarage, non in FAP
management of FAP
annual screening sigmoidoscopies for children starting at 10-12 followed by annual colonoscopies once corlorectal adenomas are detected or if the patient is age more than 50. Patients with attenuated version of FAP can have delayed start of screening (25) and longer intervals (1-2 years)
- Proctocolectomy if present with CRC r adenomas with high grade dysplasia)
indications for proctocolectomy in fap
- present with CRC or adenomas with high dysplasia
- symptoms from colonic neoplasia (hemorrhage)
- signif increase in polyp number during interval
- if not all above –> surgey at 20
worsening after n-acetylcysteine for acetaminophen overedose –> ….
transplantation
a potential complication of acute liver failure
cerebral edema –> coma + brain stem herniation –> death
chronium def - manifestation
impaired glucose control in DM
copper deficiency - manifestation
- brittle haie
- skin depigmentation
- neurologic dysfunction
- sideroblastic anemia
- osteoporosis
selenium deficiency - manifestation
- thyroid dysfunction
- cardiomyopathy
- immune dysfunction
zinc deficiency - manifestation
- alopecia
- pustular skin rash (perioral region + extr_
- hypogonadism
- impaired wound healing
- impaired taste
- immune dysfunction
angiodysplasia?
dilated submucosal veins and AV malformations –> recurrent painless GI bleeding
- diagnosis with colonoscopy (frequently missed)
angiodysplasia - treatment
if asymptomatic no
if anemia or bleeding –> cautery
angiodysplasia is associated with
- advanced renal disease
- VWF
- aortic stenosis
acute liver failure - diagnostic requirements
- severe acute liver injury (enzymes more than 1000)
- signs of hepatic encphalopathy
- Syntehtic liver dysfunction (INR more than 1.5)
features associated with severe pancreatitis
- older than 75
- obesity
- alcoholism
- CRP greater than 150 at 48h
- Rising BUN + creatining in 48h
- Chest x-ray with pulm infiltrates or pleural effusion
- CT/MRI with necrosis + extrapancreatic infl
mechanism of hypotension is severe pancreatitis
increased vascular permeability
marked elevation of liver enzymes - think of
toxic (acetaminophen), ischemic, viral
under 300 in alcohol
ferritin levels in alcohol liver disease
elevated
another cause of acute pancreatitis
cholesterol embolism
hepatic encephalopathy on diuretics - next step
volume resuscitation and correct poassium
esophageal adenoca - how many years of GERD
20
autoimmune hepatitis - antibodies
- ANA - sensitive
2. Anti- SMC senseitive and sepcific
GI bleeding - indications for Packed red blood cell transfusion
under 7
- - under 9 if ACS
platelet transfusion indications
under 10
under 50 with active bleeding
Whole blood transfusion
sever haemorrhage (eg. major trauma) requiring massive blood transfusion to assist in volume expansion
hepatic adenoma - image
U/S well demarcated, hyperechoic lesions
CT with contrast: early periphearl enchancement
- NO BIOPSY
types of diarrhea
- fatty
- watary –> secretory, watery, osmotic
- inflammatory
how to distinguish secretory from osmotic diarrhea
stool osmotic gap = plasma - 2 x (stool Na2+ + stool K+)
- increased in osmotic
- decreased in secretory
