00 Gi Disorders Chp 03. Usmle Step 2 Step Up

Front 1

nausea, vomiting, diarrhea, abdominal pain, myalgias; low-grade fever
Labs = no fecal WBC; viral culture indicates pathogen (usually unnecessary)

Back 1

Viral Gastroenteritis
Self-limited viral infection of GI tract

Hint 1

Treatment = maintain hydration status; self-limited (48–72 hours)

Front 2

Vomiting within several hours of eating, diarrhea later
Source=Fried rice

Back 2

Bacterial Gastroenteritis
Bacillus cereus

Hint 2

Treatment = maintain hydration status; self-limited

Front 3

Bloody diarrhea, abdominal pain, fever; rare Guillain-Barré syndrome
Source=Poultry

Back 3

Bacterial Gastroenteritis Campylobacter jejuni

Hint 3

Treatment=Hydration, erythromycin; generally self-limited

Front 4

Nausea, vomiting, diarrhea, flaccid paralysis
Source=Honey, home-canned foods

Back 4

Bacterial Gastroenteritis
Clostridium botulinum

Hint 4

Treatment=Botulism antitoxin (not given to infants); self-limited

Front 5

Watery diarrhea; gray pseudomembranes seen on colonic mucosa
Source=Antibiotic-induced suppression

Back 5

Bacterial Gastroenteritis
Clostridium difficile

Hint 5

Treatment=Metronidazole, Vancomycin

Front 6

Watery diarrhea, vomiting, fever
Source=travelers' Food/water

Back 6

Bacterial Gastroenteritis
Escherichia coli (enterotoxigenic)

Hint 6

Treatment=Hydration; self-limited

Front 7

Bloody diarrhea, vomiting, fever, abdominal pain (risk of HUS)
Source=Ground beef, indirect fecal contamination

Back 7

Bacterial Gastroenteritis
E. coli type O157:H7 (enterohemorrhagic)

Hint 7

Treatment=Hydration; self-limited; antibiotics may actually worsen symptoms

Front 8

Vomiting, within several hours of eating; diarrhea later
Source=Room-temperature food

Back 8

Bacterial Gastroenteritis
Staphylococcus aureus

Hint 8

Treatment=Self-limited; hydration

Front 9

Nausea, abdominal pain, bloody diarrhea, fever, vomiting
Source=Eggs, poultry, milk, fresh produce

Back 9

Bacterial Gastroenteritis
Salmonella species (MCC)

Hint 9

Treatment=Hydration; self-limited; fluoroquinolone for immunocompromised

Front 10

Fever, nausea, vomiting, severe bloody diarrhea, abdominal pain (risk of HUS)
Source=food/water, overcrowding

Back 10

Bacterial Gastroenteritis
Shigella species

Hint 10

Treatment=Hydration; self-limited; ciprofloxacin, TMP- SMX in severe cases

Front 11

Copious watery diarrhea, signs of dehydration
Source=Water, seafood

Back 11

Bacterial Gastroenteritis
Vibrio cholerae

Hint 11

Treatment=Hydration; tetracycline or doxycycline decreases disease length

Front 12

Abdominal pain, watery diarrhea within 24 hr of eating
Source=Seafood (oysters)

Back 12

Bacterial Gastroenteritis
Vibrio parahaemolyticus

Hint 12

Treatment=Hydration; self-limited

Front 13

Abdominal pain, bloody diarrhea, right lower quadrant pain, fever
Source=Pork, produce

Back 13

Bacterial Gastroenteritis
Yersinia enterocolitica

Hint 13

Treatment=Hydration; self-limited

Front 14

Greasy, foul-smelling diarrhea; abdominal pain, malaise; cysts and trophozoites seen in stool sample
Source=Surface water (usually limited to wilderness or other countries)

Back 14

Parasitic and Protozoan Gastrointestinal Infections
Giardia lamblia

Hint 14

Treatment=Metronidazole; hydration

Front 15

Mild to severe bloody diarrhea, abdominal pain; cysts and trophozoites seen in stool sample
Source=Water, areas of poor sanitation

Back 15

Parasitic and Protozoan Gastrointestinal Infections
Entamoeba histolytica

Hint 15

Treatment=Metronidazole, paromomycin

Front 16

Watery diarrhea, abdominal pain, malaise in immunocompromised patients; acid-fast stain of stool shows parasites

Back 16

Parasitic and Protozoan Gastrointestinal Infections
Cryptosporidium parvum

Hint 16

Treatment=Control immune suppression; nitazoxanide

Front 17

Fever, myalgias, periorbital edema; eosinophilia
Source=Undercooked pork

Back 17

Parasitic and Protozoan Gastrointestinal Infections
Trichinella spiralis

Hint 17

Treatment=Albendazole, mebendazole if CNS or cardiac symptoms

Front 18

Mild diarrhea, CNS symptoms
Source=Undercooked pork

Back 18

Parasitic and Protozoan Gastrointestinal Infections
Taenia solium

Hint 18

Treatment=Praziquantel, corticosteroids if >5 cysts

Front 19

H/P = possibly asymptomatic; malaise, arthralgias, fatigue, nausea, vomiting, right upper quadrant pain; jaundice, scleral icterus, tender hepatomegaly, splenomegaly, lymphadenopathy
Labs = bilirubinuria, increased aspartate aminotransferase (AST), increased alanine aminotransferase (ALT), increased bilirubin (total), increased alkaline phosphatase

Back 19

Hepatitis
RF=IV drug, alcoholism, travel to developing nations, poor sanitation

Front 20

Hepatitis
Picornavirus (single-stranded RNA)
by Food (shellfish), fecal-oral

Back 20

Hepatitis A

Hint 20

Treatment=Self-limited; supportive care
Prevention=Vaccine before travel

Front 21

Hepatitis
Hepadnavirus (double-stranded DNA)
by Blood, other body fluids (including sexual contact)

Back 21

Hepatitis B
Complication=chronic hepatitis (5% adult,90%kid), cirrhosis, hepatocellular carcinoma(3-5%), persistent carrier state, 1% develop fulminant hepatic failure

Hint 21

Treatment=HBV immediately after exposure in unvaccinated patients; IFN-α or antivirals (lamivudine, adefovir, entecavir)
Vaccine

Front 22

Hepatitis
by Blood, possibly sexual contact
Flavivirus (single-stranded RNA)

Back 22

Hepatitis C
Complication=chronic hepatitis(80%), cirrhosis(50% of chronic ), slightly increased risk of hepatocellular carcinoma, persistent carrier state

Hint 22

Treatment=IFN-α; consider ribavirin
NO vaccine

Front 23

Hepatitis D
by Blood; requires coexistent hepatitis B infection
Delta agent (incomplete single-stranded RNA)

Back 23

Hepatitis D
Complication=Severe hepatitis, cirrhosis, persistent carrier state

Hint 23

Treatment=IFN-α, Hepatitis B vaccine

Front 24

Hepatitis
by Water, fecal-oral
Calicivirus (single-stranded RNA)

Back 24

Hepatitis E
Complication=High infant mortality in pregnancy

Hint 24

Treatment=Self-limited; supportive care
No Vaccine

Front 25

Hepatitis B Serology
HBsAg+, HBeAg+, anti-HBs Ab-, anti-HBe Ab-, anti-HBc IgM+

Back 25

Acute infection

Hint 25

(4–12 wk postexposure)

Front 26

Hepatitis B Serology
HBsAg-, HBeAg-, anti-HBs Ab-, anti-HBe Ab-, anti-HBc IgM+

Back 26

Acute infection window period

Hint 26

(12–20 wk postexposure)

Front 27

Hepatitis B Serology
HBsAg+, HBeAg+, anti-HBs Ab-, anti-HBe Ab-, anti-HBc IgG+

Back 27

Chronic infection, active viral replication

Front 28

Hepatitis B Serology
HBsAg+, HBeAg-, anti-HBs Ab-, anti-HBe Ab+, anti-HBc IgG+

Back 28

Chronic infection, lesser viral replication

Hint 28

(good prognosis)

Front 29

Hepatitis B Serology
HBsAg-, HBeAg-, anti-HBs Ab+, anti-HBe Ab+, anti-HBc IgG+

Back 29

Past infection (recovered)

Front 30

Hepatitis B Serology
HBsAg-, HBeAg-, anti-HBs Ab+, anti-HBe Ab-, anti-HBc IgG-

Back 30

Vaccination

Front 31

H/P = enlarged and painful glands; pain worsens during eating; parotid glands may have painless swelling

Back 31

Salivary gland disorders
Dysfunction in sublingual, submandibular, or parotid glands resulting from ductal obstruction or inflammation
sialolithiasis (ductal stone) in any salivary gland; parotid disease can also be caused by sarcoidosis, infection, or neoplasm

Hint 31

Treatment = warm compresses, massage, or cough drops may help remove ductal stones; antibiotics and hydration for infection; surgery may be required for relief in refractory cases

Front 32

H/P = feeling of “food stuck in throat” when swallowing, cough, solids (mechanical pathology) or solids and liquids (dysmotility) may be difficult to swallow

Back 32

Dysphagia
Difficulty swallowing because of oropharyngeal or esophageal transport dysfunction or pain with swallowing (i.e., odynophagia)
caused by neuromuscular disorders (e.g., achalasia, motility disorders, scleroderma) or obstruction (e.g., peptic strictures, esophageal webs or rings, cancer, radiation fibrosis)
Obstructive pathology tends to limit swallowing of solids; neuromuscular pathology tends to limit swallowing of solids and liquids

Hint 32

Labs = manometry measures esophageal pressure and may detect neuromuscular abnormality
Radiology = barium swallow before esophagogastroduodenoscopy (EGD) may be helpful for diagnosis

Front 33

H/P = gradually progressive dysphagia of solids and liquids, regurgitation, cough, aspiration, heartburn, weight loss from poor intake

Back 33

Achalasia
Neuromuscular disorder of esophagus with impaired peristalsis and decreased lower esophageal sphincter (LES) relaxation because intramural neuron dysfunction

Hint 33

Labs = manometry shows increased LES pressure, incomplete LES relaxation, and decreased peristalsis
Radiology = barium swallow shows “bird's beak” sign, with tapering at the LES; EGD r/o malignancy
Treatment =pneumatic dilation, botulinum injections, or myotomy relieve obstruction; nitrates and calcium channel blockers relax LES, but are rarely used because of simultaneous cardiac effects

Front 34

H/P = chest pain, dysphagia

Back 34

Diffuse esophageal spasm
Neuromuscular disorder in which nonperistaltic contractions of the esophagus occur

Hint 34

Labs = manometry shows nonperistaltic, uncoordinated esophageal contractions
Radiology = barium swallow shows “corkscrew” pattern
Treatment = calcium channel blockers, nitrates, or tricyclic antidepressants help reduce chest pain and dysphagia

Front 35

H/P = regurgitation of food several days after eating, bad breath, difficulty initiating swallowing, occasional dysphagia, feeling of aspiration

Back 35

Zenker diverticulum
Outpouching in upper posterior esophagus caused by smooth muscle weakness

Hint 35

Radiology = barium swallow shows outpouching
Treatment = cricopharyngeal myotomy or diverticulectomy
Complications = EGD can perforate weakness in esophageal wall; vocal cord paralysis, mediastinitis possible with surgery

Front 36

H/P = burning chest pain (“heartburn”) 30–90 min after eating, sour taste in mouth, regurgitation, dysphagia, odynophagia, nausea, cough; pain may worsen when lying down and lessens with standing

Back 36

Gastroesophageal reflux disease (GERD)
Low pressure in LES leads to abnormal reflux of gastric contents into esophagus
Risk factors = obesity, hiatal hernia, pregnancy, scleroderma
Complications = esophageal ulceration, esophageal stricture, Barrett's esophagus, adenocarcinoma

Hint 36

Labs = esophageal pH monitoring can detect increased acidity from reflux
Radiology = usually unneeded for diagnosis; EGD, chest radiograph, or barium swallow can help r/o neoplasm, Barrett's esophagus&hiatal hernia
Treatment = Elevation of head of bed, weight loss, dietary modification. Initial medications are antacids followed by H2 antagonists (10%–25% effective), proton pump inhibitors (PPI) (60%–75% effective), and promotility agents; Refractory disease may be treated with Nissen fundoplication or hiatal hernia repair

Front 37

H/P = progressive dysphagia (initially solids, later solids and liquids), weight loss, odynophagia, reflux, GI bleeding, vomiting, weakness, cough, hoarseness

Back 37

Esophageal cancer
Squamous> adenocarcinoma Barrett's esophagus (columnar metaplasia of distal esophagus secondary to chronic GERD) commonly precedes adenocarcinoma
Risk factors = alcohol, tobacco, chronic GERD, obesity (only for adenocarcinoma)
Complications = poor prognosis; local extension and metastases frequently present by time of diagnosis

Hint 37

Labs = biopsy used to make diagnosis
Radiology = barium swallow shows narrowing of esophagus and abnormal mass; MRI, CT w/contrast, or PET scan can determine extension and mets; EGD used to identify mass and perform biopsy
Treatment = surgical resection (including total esophagectomy) for early stage disease; radiation and chemotherapy used in nonoperative (advanced) cases or as neoadjuvant therapy to surgery

Front 38

H/P = possibly asymptomatic; symptoms associated with GERD

Back 38

Hiatal hernia
Herniation of part of stomach above diaphragm
Sliding: gastroesophageal junction and stomach displaced through diaphragm (95% cases)
Paraesophageal: stomach protrudes through diaphragm, but gastroesophageal junction remains in normal location
Complications = incarceration of stomach in herniation (seen in paraesophageal type)

Hint 38

Radiology = barium swallow shows portion of stomach above diaphragm; chest radiograph may detect hernia without barium swallow if air in stomach is visible above diaphragm
Treatment = sliding hernias treated w/ reflux control; paraesophageal hernias may need surgical repair (e.g., gastropexy, Nissen fundoplication)

Front 39

H/P = possibly asymptomatic; epigastric pain, indigestion, nausea, vomiting, hematemesis, melena

Back 39

Acute Gastritis
Inflammation of gastric mucosa characterized by rapidly developing, superficial lesions; can involve any region of the stomach

RF: nonsteroidal anti-inflammatory drug (NSAID) use, alcohol, ingestion of corrosive materials, or stress from severe illness;

Hint 39

Treatment =
Treat acute form as peptic ulcer disease (PUD) and stop alcohol and offending medications; give H2 antagonists or PPI to patients with severe illnesses

Front 40

Gastritis
Lab=Decreased gastric acid level, decreased gastrin

Back 40

Type A Chronic Gastritis
Inflammation of gastric mucosa
@ Fundus
Ab for parietal cells->low levels of intrinsic factor, vitamin B12 malabsorption, and megaloblastic anemia.
Ass. w/ Pernicious anemia, achlorhydria, thyroiditis

Hint 40

Lab=ratio of pepsinogen isoenzymes useful to detect autoimmune cause
Treatment = requires vitamin B12 replacement

Front 41

Gastritis
Lab=Increased gastric acid level->+ urea breath test;

Back 41

Type B Chronic Gastritis
Inflammation of gastric mucosa
@ Antrum
Helicobacter pylori infection
Ass. w/ Peptic ulcer disease, gastric cancer

Hint 41

Lab=+ IgG Ab to Helicobacter pylori; antral biopsy can detect H. pylori infection
Treatment = eradication of H. pylori through multidrug treatment (typically, PPI, clarithromycin, & either amoxicillin or metronidazole × 7–14 days)

Front 42

H/P = periodic burning epigastric pain that can change (better or worse) with eating, nausea, hematemesis, melena, hematochezia; epigastric tenderness; abdominal rigidity, rebound tenderness, and rigidity seen following acute perforation of ulcer

Back 42

Peptic ulcer disease (PUD)
Erosion of gastric and duodenal mucosa 2nd to impaired endothelial defenses and increased gastric acidity
RF: ANGST HAM: Aspirin, NSAIDs, Gastrinoma (ZES), Steroids, Tobacco, H. pylori, Alcohol, MEN type I.
Complications = hemorrhage (posterior ulcers may erode into gastroduodenal artery), perforation (most commonly anterior ulcers), lymphoproliferative disease

Hint 42

Labs = + urea breath test, IgG Ab, or biopsy detect H. pylori; CBC assess degree of bleeding
Radiology = abdominal x-ray (AXR) to detect perforation (free air under diaphragm seen following perforation); barium swallow AXR can demonstrate collections of barium in ulcerations; EGD for biopsy & detect active bleeding, r/o gastric adenocarcinoma if symptoms lasting >2 months;
Treatment = Decrease gastric acid levels with PPI and H2 antagonist; protect mucosa with sucralfate, bismuth subsalicylate, or misoprostol; eliminate H. pylori infection (as described above for treatment of gastritis);
Surgery required to repair acute perforations; persistent, non-neoplastic refractory cases may require parietal cell vagotomy or antrectomy

Front 43

PUD: Ab pain Soon after eating, Eating worsen symptoms and cause nausea and vomiting
Age >50 yr old, Helicobacter pylori infection, NSAID users

Back 43

Gastric Ulcer

Hint 43

Lab=Normal/low Gastric acid level; High Gastrin level

Front 44

PUD: Ab pain 2–4 hr after eating, Eating make initial improvement in symptoms, with later worsening
Younger patient

Back 44

Duodenal Ulcer

Hint 44

Lab=High Gastric acid level; Normal Gastrin level

Front 45

H/P = refractory PUD, abdominal pain, nausea, vomiting, indigestion, diarrhea, steatorrhea, possible history of other endocrine abnormalities

Back 45

Zollinger-Ellison syndrome
Syndrome secondary to gastrin-producing tumor most frequently located in duodenum (70% cases) or pancreas
Ass w/ malabsorption disorders
Complications = occasional w/ other endocrine tumors (e.g., multiple endocrine neoplasia I [MEN I]) 60% of lesions are malignant

Hint 45

Labs = increased fasting gastrin; + secretin-stimulation test (i.e., administration causes > expected serum gastrin levels); specific gastrin sampling in several pancreatic or abdominal veins can help localize tumor
Radiology = somatostatin receptor imaging using single-photon emission computed tomography (SPECT) can localize tumors; angiography may detect tumor if hypervascular
Treatment = surgical resection for nonmetastatic disease w/ localized tumor; PPI and H2 antagonists may ease symptoms; octreotide may help reduce symptoms in metastatic disease

Front 46

H/P = weight loss, anorexia, early satiety, vomiting, dysphagia, epigastric pain; enlarged left supraclavicular lymph node (i.e., Virchow's node) or periumbilical node (i.e., Sister Mary Joseph's node)

Back 46

Gastric cancer
Adenocarcinoma (common) or squamous cell carcinoma (rare; caused by invasion from esophagus) affecting stomach
Types
Ulcerating: resembles ulcers seen in PUD
Polypoid: large, intraluminal neoplasms
Superficial spreading: mucosal and submucosal involvement only; best prognosis
Linitis plastica: all layers of stomach involved; decreased stomach elasticity; poor prognosis
RF= H. pylori, family history, Japanese person living in Japan, tobacco, alcohol, vitamin C deficiency, high consumption of preserved foods; males > females
Complications = early detection=high cure rate (>70%), poor prognosis in later detection (<15% 5-yr survival)

Hint 46

Labs = increased carcinoembryonic antigen (CEA), increased 2-glucuronidase in gastric secretions, anemia if active bleeding; biopsy used for diagnosis
Radiology = barium swallow may show mass or thickened “leather bottle” stomach (linitis plastica); EGD used to perform biopsy and visualize ulcers
Treatment = subtotal gastrectomy for lesions in distal third of stomach, total gastrectomy for lesions in middle or upper stomach or invasive lesions; adjuvant chemotherapy and radiation therapy

Front 47

H/P = failure to thrive, bloating, and abnormal stools in infants; diarrhea, steatorrhea, weight loss, and bloating in adults; some patients will exhibit depression, anxiety, or arthralgias
Labs = + antiendomysial & antigliadin Ab in serum; biopsy shows loss of duodenal & jejunal villi

Back 47

Celiac sprue
Genetic disorder characterized by gluten intolerance (e.g., wheat, barley, rye)
Immune-mediated process with antiendomysial & antigliadin antibodies that cause jejunal mucosal damage

Hint 47

Treatment = removal of gluten from diet (can still eat corn, rice); refractory disease may require corticosteroids

Front 48

H/P = failure to thrive, bloating, and abnormal stools in infants; diarrhea, steatorrhea, weight loss, and bloating in adults; some patients will exhibit depression, anxiety, or arthralgias
Acquired disorder in patients living in tropical areas; can present years after leaving tropics

Back 48

Tropical sprue
Malabsorption syndrome similar to celiac sprue, with possible infectious or toxic etiology

Hint 48

Treatment = folic acid replacement, tetracycline; removal of gluten from diet has no effect
Labs = cultures&appropriate serology r/o acute GI infection, celiac sprue, & autoimmune diseases

Front 49

H/P = diarrhea, abdominal pain, flatulence, and bloating after dairy consumption

Back 49

Lactose intolerance
Malabsorption syndrome resulting from deficiency of lactase; can also be secondary to Crohn's disease or bacterial overgrowth
Lactose not metabolized in jejunum, leading to osmotic diarrhea

Hint 49

Labs = + lactose tolerance test (i.e., min increase in serum glucose following ingestion of lactose),+ lactose breath hydrogen test after lactose meal
Treatment = lactose-restricted or lactose-free diet; adequate dietary protein, fat, calcium, and vitamins; lactase replacement may benefit some patients

Front 50

H/P = weight loss, joint pain, abdominal pain, diarrhea, dementia, cough, bloating, steatorrhea; fever, vision abnormalities, lymphadenopathy, new heart murmur; severe wasting late in disease course
Labs = jejunal biopsy shows foamy macrophages on periodic acid-Schiff (PAS) stain and villous atrophy

Back 50

Whipple disease
Malabsorption disorder 2nd to Tropheryma whippelii infection & likely immune deficiency
RF= white males with European ancestry

Hint 50

Treatment = trimethoprim-sulfamethoxazole (TMP-SMX) or ceftriaxone for 12 months

Front 51

H/P=chronic abdominal pain and irregular bowel habits
begins during teens or young adulthood
Pain relieved with defecation
Stool frequency increases following onset of pain
Stools become looser following onset of pain
Visible abdominal distention
Passage of mucus with stool
Feeling of incomplete defecation

Back 51

Irritable bowel syndrome (IBS)
Females > males (2 to 1)
Manning Criteria (seeH/P)

Hint 51

Labs = r/o other GI diseases with CBC, electrolytes, stool culture
Radiology = consider AXR, abdominal CT, or barium studies to r/o other GI causes; colonoscopy may be performed in older to r/o neoplasm
Treatment = assurance from physician, high-fiber diet, possible psychosocial therapy; antispasmodic, antidepressants, serotonin receptor antagonists have shown use in lessening symptoms

Front 52

H/P = acute abdominal pain out of proportion to examination, bloody diarrhea, vomiting; mild abdominal tenderness

Back 52

Ischemic colitis
Ischemia and necrosis of bowel secondary to vascular compromise
Caused by embolus, bowel obstruction, inadequate systemic perfusion, medication, or surgery-induced vascular compromise
Left side of the colon is most commonly involved in ischemic colitis
RF=DM, atherosclerosis, CHF, peripheral vascular disease, lupus
Complications = high mortality in cases of irreversible damage

Hint 52

Labs = increased white blood cell count (WBC), increased serum lactate
Radiology = barium enema shows diffuse submucosal changes from localized bleeding (i.e., “thumb printing”); sigmoidoscopy may show bloody and edematous mucosa; CT may show air within bowel wall and bowel wall thickening
Treatment = intravenous (IV) fluids, bowel rest, antibiotics for GI bacteria; surgical resection of necrotic bowel

Front 53

H/P=Abdominal pain, weight loss, watery diarrhea
Fever, RLQ abdominal mass, abdominal tenderness, perianal fissures&fistulas, oral ulcers blood on rectal examination
Lab=ASCA+, hemoccult +

Back 53

Crohn's Disease
Entire GI tract may be involved with multiple “skipped” areas; distal ileum most commonly involved; entire bowel wall affected
Ass. w/ nephrolithiasis, arthritis, ankylosing spondylitis, uveitis, primary sclerosing cholangitis
Complication=Abscess formation, fistulas, fissures, malabsorption, toxic megacolon

Hint 53

Radiology=Colonoscopy shows colonic ulcers, strictures, “cobblestoning,” fissures, and “skipped” areas of bowel; barium barium enema shows fissures, ulcers, and bowel edema
Treatment=Mesalamine, broad-spectrum antibiotics, corticosteroids, immunosuppressives; surgical resections of severely affected areas, fistulas, or strictures

Front 54

H/P=Abdominal pain, urgency, bloody diarrhea, tenesmus, nausea, vomiting, weight loss
Fever, abdominal tenderness, orthostatic hypotension, tachycardia, gross
Lab=pANCA +

Back 54

Ulcerative Colitis
Continuous disease beginning at rectum and extending possibly as far as distal ileum; only mucosa and submucosa affected
Ass. w/ erythema nodosum, pyoderma gangrenosum, arthritis, uveitis, ankylosing spondylitis, primary sclerosing cholangitis
Complication=Significantly increased risk of colon cancer, hemorrhage, bowel obstruction, toxic megacolon

Hint 54

Radiology=Colonoscopy shows continuous involvement, pseudopolyps, friable mucosa; enema shows “lead pipe” colon without haustra and colon shortening
Treatment=Mesalamine, supplemental iron, corticosteroids, immunosuppressives; total colectomy is curative

Front 55

H/P = dull periumbilical pain followed by nausea, vomiting, and anorexia; pain gradually moves to RLQ and increases; tenderness at McBurney's point (1/3 distance from right anterior superior iliac spine to umbilicus), rebound tenderness, psoas sign (psoas pain on hip extension), fever, Rovsing's sign (RLQ pain w/ LLQ palpation); perforation produces severe pain and distention with rebound tenderness, rigidity, and guarding
Labs = increased WBC w/ left shift

Back 55

Appendicitis
Inflammation of appendix with possible infection or perforation
Caused by lymphoid hyperplasia (children), fibroid bands (adults), or fecaliths (adults)
Complications = abscess formation, perforation

Hint 55

Lab=CBC
Radiology = AXR or chest x-ray may show fecalith or free air under the diaphragm (due to perforation); CT most sensitive test and may show bowel wall thickening, appendicolith, abscess, phlegmon, free fluid, or right lower quadrant fat-stranding
Treatment = appendectomy; antibiotics added (covering Gram-negatives and anaerobes) for ruptured appendix

Front 56

H/P = vague abdominal pain, nausea, vomiting, bloating, no bowel movements, inability to tolerate meals; decreased bowel sounds, no rebound tenderness

Back 56

Ileus
Paralytic obstruction of bowel 2nd to decreased peristalsis
Caused by infection, ischemia, recent surgery, DM, opioid use

Hint 56

Radiology = AXR shows distention of affected bowel, air–fluid levels; barium enema can help r/o obstruction
Treatment = stop opioids, make patient NPO (i.e., nothing by mouth); colonoscopic decompression if no resolution

Front 57

H/P = distention, abdominal pain, vomiting, obstipation; possible palpable abdominal mass
Tends to occur in elderly and infants

Back 57

Volvulus
Rotation of bowel creates obstruction and possible ischemia; most commonly occurs at cecum and sigmoid colon

Hint 57

Radiology = AXR may show “double bubble” proximal and distal to volvulus; barium enema shows “bird's beak” for distal volvulus
Treatment = possibly self-limited; colonoscopic decompression of sigmoid volvulus; surgical repair or resection may be required in cecal volvulus or failed colonoscopic detorsion

Front 58

H/P = frequently asymptomatic during uncomplicated diverticulosis; occasional cramping, bloating, flatulence, irregular defecation; possible painless rectal bleeding if erosion into vessel occurs

Back 58

Diverticulosis
Outpouchings of colonic mucosa and submucosa that herniate through muscular layer (i.e., diverticulosis); may erode into colonic blood vessel to cause bleeding
RF= low-fiber diet, high-fat diet, >60 yr of age
Complications = diverticulitis, diverticular colitis (i.e., inflammation of section of colon)

Hint 58

Radiology = diverticula seen on barium enema and colonoscopy
Treatment = high-fiber diet may help prevent development of additional diverticuli or diverticular bleeding

Front 59

H/P = LLQ pain, nausea, vomiting, melena, hematochezia; abdominal tenderness, possible palpable abdominal mass, fever, abdominal distention
Labs = increased WBC

Back 59

Diverticulitis
Obstruction of a diverticulum leading to significant inflammation, focal bowel wall necrosis, and perforation; poor containment of colonic rupture leads to peritonitis
Complications = colonic abscess, fistula formation, sepsis

Hint 59

Labs=CBC
Radiology = CXR or AXR may demonstrate free air under the diaphragm; CT shows increased soft tissue density caused by inflammation, colonic diverticula, bowel wall thickening, and possible abscess formation
Treatment =
Mild early cases without perforation can be treated by bowel rest (liquids only for at least 3 days) and PO antibiotics (e.g., fluoroquinolone and metronidazole, TMP-SMX and metronidazole, or amoxicillin-clavulanate)
Surgery required in most cases to resect involved segment of colon and remove any obstruction or fistula; diverting colostomy performed in cases of peritonitis (reanastomosis in 3 months)
Broad-spectrum antibiotics required for any case of bowel rupture

Front 60

H/P=Abdominal pain, vomiting, distention, obstipation
Visible peristaltic waves, ab tenderness,high-pitched bowel sounds, absence of bowel sounds, fever

Back 60

Small Bowel Obstruction
Due to Adhesions, incarcerated hernias, neoplasm, intussusception, volvulus, Crohn's disease, congenital stricture

Hint 60

Radiology=AXR shows ladder-like dilated loops of bowel, air-fluid levels
Treatment=Make patient NPO, maintain hydration; nasogastric decompression may relieve obstruction but, if unsuccessful, surgery is required

Front 61

H/P=Abdominal pain, obstipation, distention, nausea, late feculent vomiting
Palpable mass, ab tenderness, high-pitched bowel sounds, absence of bowel sounds

Back 61

Large Bowel Obstruction
Due to Neoplasm, diverticulitis, volvulus, congenital stricture

Hint 61

Radiology=AXR shows bowel distention proximal to obstruction; barium enema may detect obstruction near rectum
Treatment=Make patient NPO, maintain hydration; colonoscopy may relieve obstruction but, if unsuccessful, surgery is required

Front 62

Internal and external engorged rectal veins causing bleeding (bright-red blood)

Back 62

Hemorrhoids
Internal hemorrhoids arise from superior rectal veins above the pectinate line (columnar rectal epithelium); characteristically painless
External hemorrhoids arise from inferior rectal veins below the pectinate line (squamous rectal epithelium); frequently painful (especially if thrombosed)

Hint 62

Radiology = sigmoidoscopy r/o other causes of bleeding
Treatment = warm baths, increase fiber in diet, avoid prolonged straining; sclerotherapy, ligation, or excision can be performed for worsening symptoms

Front 63

Painful, bleeding tears in posterior wall of anus secondary to trauma during defecation or anal intercourse

Back 63

Anal fissures

Hint 63

Treatment = stool softeners, topical nitroglycerin; partial sphincterotomy may be performed for recurrent fissures

Front 64

H/P = throbbing rectal pain; fever, tenderness on digital examination

Back 64

Anorectal abscesses
Infection of anal crypts, internal hemorrhoids, or hair follicle leading to abscess formation

Hint 64

Treatment = antibiotics, surgical incision and drainage

Front 65

H/P = mild pain during defecation; possible visible site draining pus

Back 65

Rectal fistula
Formation of tract between rectum and adjacent structures from unknown cause or secondary to IBD or abscess formation

Hint 65

Treatment = fistulotomy; treat patients with Crohn's disease w/ antibiotics & immunosuppressants unless refractory disease

Front 66

H/P = usually asymptomatic; obstruction of sinus leads to mildly painful cyst with drainage (possibly purulent); small cysts can progress to larger abscesses

Back 66

Pilonidal disease
Presence of one or more cutaneous sinus tracts in the superior midline gluteal cleft
Obstruction of sinus tract by hair or debris can lead to cyst and abscess formation

Hint 66

Treatment = incision and drainage of abscesses; surgical closure of sinus tracts may prevent recurrence

Front 67

H/P = possibly asymptomatic; abdominal pain; possible carcinoid syndrome (i.e., flushing, diarrhea, bronchoconstriction, tricuspid/pulmonary valvular disease) caused by serotonin secretion by tumor (only seen with liver metastases or extragastrointestinal involvement)

Back 67

Carcinoid tumor
Tumors arising from neuroectodermal cells that function as amine-precursor-uptake and decarboxylation (APUD) cells
Most commonly in appendix, ileum, rectum, stomach

Hint 67

Labs = increased 5-HIAA in urine, serum serotonin level
Radiology = CT or indium-labeled octreotide scintigraphy can localize tumor
Treatment = tumors <2 cm have very low incidence of metastases and should be resected; tumors >2 cm have high risk of metastases and require extensive resection; metastatic disease treated with IFN-α, octreotide, and embolization

Front 68

H/P = change in bowel habits (more common in left-sided disease), weakness, right-sided abdominal pain (in right-sided disease), constipation, hematochezia, melena, malaise, weight loss; abdominal or rectal mass may be palpated

Back 68

Colorectal cancer
Neoplasm of large bowel or rectum; most commonly adenocarcinoma
Risk factors = family history, ulcerative colitis, colonic polyps, hereditary polyposis syndromes, low-fiber/high-fat diet, previous colon cancer, alcohol, smoking, DM
Spreads to regional lymph nodes; metastasizes most commonly to lung and liver
Prevention =Regular screening for colon cancer recommended in patients >50 yr of age
Annual fecal occult blood test (FOBT)
Flexible sigmoidoscopy every 5 yr (in addition to FOBT)
Colonoscopy is more sensitive than sigmoidoscopy

Hint 68

Labs = + stool guaiac test, decreased hemoglobin & hematocrit; biopsy is diagnostic; CEA useful for monitoring treatment success and cancer recurrence
Radiology = barium enema may detect lesion; colonoscopy may detect lesion and obtain biopsy specimens; CT or PET used to determine local extent of disease and spread of metastases
Treatment =
Surgical resection, regional lymph node dissection; adjuvant chemotherapy in cases of positive lymph nodes; palliative resections are helpful in metastatic disease to reduce symptoms and remove obstruction
Preventative colectomy may be indicated for hereditary syndromes
Duke's classification can be used for prognosis; CEA may be followed after treatment to monitor for recurrence

Front 69

Bright-red blood (e.g., hematochezia) suggests a rapid or heavy bleed; dark blood (e.g., melena, coffee-grounds emesis) suggests either blood that has passed through much of the GI tract or has been sitting in the stomach for some time

Back 69

GI Bleeding
Upper:PUD, Mallory-Weiss tears (longitudinal esophageal tears secondary to violent retching), esophagitis, esophageal varices, gastritis
Lower:diverticulosis, neoplasm, ulcerative colitis, mesenteric ischemia, AVMs, hemorrhoids, Meckel's diverticulum

Hint 69

Radiology = NG tube lavage to r/o upper/rapid->EGD or colonoscopy shows most sources of bleeding; barium studies may detect defects; angiography can help locate AVMs; technetium scan can locate Meckel's diverticulum
Treatment = fluid replacement is vital; transfusion for increased blood loss; some small bleeds stop automatically; treat underlying cause; PPI for upper GI bleeds until gastric cause ruled out; prophylactic antibiotics in patients with a known history of cirrhosis; sclerotherapy may help stop bleeding from varices; vasopressin may stop bleeding from AVMs and diverticula; surgical resection of tumors and diverticula may be needed

Front 70

H/P=Acute epigastric pain radiating to back, nausea, vomiting, Grey Turner's sign (bluish discoloration of flank), Cullen's sign (periumbilical discoloration), fever, tachycardia; hypotension, shock if severe

Back 70

Acute Pancreatitis
Initially, results from leak of pancreatic enzymes into pancreatic and surrounding tissues; later caused by pancreatic tissue necrosis;
RF=Gallstones, alcoholism, trauma, hypercalcemia, hyperlipidemia, drugs
Complication=Complications Pancreatic abscess, pseudocyst, necrosis, fistula formation, renal failure, chronic pancreatitis, hemorrhage, shock, DIC, sepsis, respiratory failure
Ranson's Criteria for mortality: GA LAW on admission: Glucose >200 mg/dL, AST >250 IU/L, LDH >350 IU/L, Age >55 yr, WBC >16,000/mL;
Calvin & HOBBeS in48hr: Calcium <8 mg/dL, Hct decrease >10%, O2 (Pao2) <60 mm Hg, BUN increase >5 mg/dL, Base deficit >4 mEq/L, Sequestration of fluid >6 L.

Hint 70

Labs=Increased amylase and lipase
Radiology=AXR may show dilated loop of bowel near pancreas (sentinel loop) or right colon distended until near pancreas (colon cutoff sign); CXR may show pleural effusion, hemidiaphragm elevation; CT may show pseudocyst or enlarged pancreas; US may detect gallstones
Treatment=Hydration, pain control with opioids, nasogastric suction, make patient NPO, stop offending agent, prophylactic antibiotics for GI bacteria; debridement of necrotic tissue

Front 71

H/P=Recurrent epigastric pain, steatorrhea, weight loss, nausea, constipation

Back 71

Chronic Pancreatitis
RF=Alcoholism, congenital defect
Complication=Ductal obstruction, pseudocyst, malnutrition, glucose intolerance, pancreatic cancer

Hint 71

Labs=Mildly increased amylase and lipase, glycosuria
Radiology=Abdominal radiograph may show pancreatic calcifications; CT may show calcifications, pancreatic enlargement, or pseudocyst; ERCP may be helpful for diagnosis
Treatment=Stop alcohol use, opioid analgesia, enzyme supplementation; surgery may be required to repair ductal damage

Front 72

H/P = possibly asymptomatic; recent acute pancreatitis, epigastric pain; fever

Back 72

Pancreatic pseudocyst
Fluid collection arising from pancreas consisting of enzyme-rich fluids contained in sac of inflamed membranous tissue
Complications = rupture, hemorrhage, abscess formation

Hint 72

Labs = increased WBC, increased amylase; aspiration of pseudocyst demonstrates very high amylase content
Radiology = pseudocyst visible on ultrasound (US) or CT
Treatment = possibly self-resolving; drainage (surgical, endoscopic, or percutaneous) indicated if lasting >6 wks, painful, or rapidly growing; débride necrotic pancreatic tissue

Front 73

H/P = abdominal pain radiating to back, anorexia, nausea, vomiting, weight loss, fatigue, steatorrhea; jaundice (if bile duct obstructed); palpable, nontender gallbladder (i.e., Courvoisier's sign); splenomegaly (if in tail), palpable deep abdominal mass, ascites

Back 73

Exocrine pancreatic cancer
Adenocarcinoma of pancreas most commonly in head of pancreas
RF= chronic pancreatitis, DM, family history, tobacco, high-fat diet; male > female
Complications = usually not detected until progressed; 5-yr survival <2%; 20–30% 5-yr survival following successful Whipple procedure; migratory thrombophlebitis (i.e., Trousseau's syndrome)

Hint 73

Labs = possible hyperglycemia; increased CEA and CA 19-9 tumor markers; increased bilirubin (total and direct) and increased alkaline phosphatase with bile duct obstruction; biopsy used to make diagnosis
Radiology = CT shows mass, dilated pancreas, local spread, and dilated bile ducts; US also useful for imaging mass, but not as sensitive as CT; endoscopic retrograde cholangiopancreatography (ERCP) locates tumors not seen with CT
Treatment =
Nonmetastatic disease limited to head of pancreas may be resected with Whipple procedure (i.e., removal of pancreatic head, duodenum, proximal jejunum, common bile duct, gallbladder, and distal stomach)
Lesions in body or tail rarely amenable to surgery, but can be resected via subtotal pancreatectomy if found early
Adjuvant chemotherapy may be beneficial in respectable disease
Enzyme deficiency treated with replacement therapy
Stenting of pancreatic ducts, biliary ducts, or duodenum can be performed as palliative therapy in advanced disease

Front 74

H/P = headache, visual changes, confusion, weakness, mood instability, palpitations, diaphoresis

Back 74

Insulinoma
Insulin-secreting β-islet cell tumor causing hypoglycemia
Insulinomas are almost always solitary; multiple insulinomas may be seen in MEN 1.

Hint 74

Whipple's triad=symptoms of hypoglycemia while fasting, hypoglycemia, and improvement in symptoms w/ carbohydrate load
Labs = increased fasting insulin, spontaneous hypoglycemia, positive C-peptide
Radiology = CT, US, or indium-labeled octreotide scintigraphy may be useful for localizing tumor
Treatment = surgical resection; diazoxide or octreotide may relieve symptoms in nonresectable disease

Front 75

H/P = exfoliating rash (migratory necrolytic erythema); symptoms of DM refractory; abdominal pain, diarrhea, weight loss, mental status changes;

Back 75

Glucagonoma
Glucagon-secreting α-cell tumor causing hyperglycemia
Complications = frequently malignant; poor prognosis

Hint 75

Labs = hyperglycemia, increased glucagon; biopsy confirms diagnosis
Radiology = CT or endoscopic US may localize tumor
Treatment = surgical resection if localized lesion; octreotide, IFN-α, chemotherapy, and embolization may be used in metastatic disease

Front 76

H/P = watery diarrhea, weakness, nausea, vomiting, abdominal pain

Back 76

VIPoma
Vasoactive intestinal peptide (VIP)-producing tumor of non–β-islet cells

Hint 76

Labs = increased serum VIP, stool osmolality suggests secretory cause
Radiology = CT may detect tumor
Treatment = surgical resection for localized tumors; corticosteroids, chemotherapy, octreotide, and embolization used in metastatic disease

Front 77

H/P = postprandial abdominal pain (worst in right upper quadrant [RUQ]), nausea, vomiting, indigestion, flatulence; RUQ tenderness, palpable gallbladder

Back 77

Cholelithiasis
Gallstone formation in the gallbladder that can cause cystic duct obstruction
Most stones are composed of cholesterol; others are calcium bilirubinate (i.e., pigmented stones) secondary to chronic hemolysis
RF = age >40 yrs, obesity, female, multiparity, oral contraceptive use, total parenteral nutrition (TPN), recent rapid weight loss, family history, DM,
Complications = recurrent stones, acute cholecystitis, pancreatitis

Hint 77

Radiology = US may show gallstones; AXR will only show some pigmented stones (because of high iron content from bilirubin)
Treatment = dietary modification (decrease fatty food intake), bile salts (dissolve stones), shock wave lithotripsy (uses sound waves to break up stones); cholecystectomy is typically performed in symptomatic patients

Front 78

H/P = RUQ pain radiating to back, nausea, vomiting, anorexia; fever, palpable gallbladder, RUQ tenderness; symptoms more severe and longer in duration than typical cholelithiasis

Back 78

Acute cholecystitis
Inflammation of gallbladder commonly caused by gallstone obstruction of cystic duct; acalculous cholecystitis can occur in patients on TPN or in those who are critically ill
Complications = perforation, gallstone ileus, abscess formation

Hint 78

Labs = increased WBC; increased bilirubin (total and direct) and increased alkaline phosphatase seen when condition related to impacted stone or cholangitis
Radiology = US may show gallstones, sludge, or thickened gallbladder wall; hepatic iminodiacetic acid (HIDA) scan will detect cystic duct obstruction (gallbladder fails to fill normally during scan)
Treatment = hydration, antibiotics, cholecystectomy (frequently delayed after 24–48 hrs of supportive care); patients with more mild symptoms can be treated with lithotripsy and bile salts; patients who are not stable for surgery can be treated with ERCP delivery of stone solvents

Front 79

H/P = Jaundice, fever, RUQ tenderness;RUQ pain, chills; change in mental status or signs of shock seen in severe cases

Back 79

Cholangitis
Infection of bile ducts secondary to ductal obstruction
RF=cholelithiasis, anatomic duct defect, biliary cancer

Hint 79

Labs = + blood cultures, increased WBC, increased bilirubin (total and direct), increased alkaline phosphatase, increased AST and ALT, increased amylase with associated pancreatic inflammation
Radiology = US may detect obstruction; HIDA scan is more sensitive
Treatment = hydration, IV antibiotics, endoscopic biliary drainage followed by delayed cholecystectomy; severe symptoms demand emergency bile duct decompression and relief of obstruction

Front 80

H/P = similar symptoms to acute cholecystitis; anorexia, weight loss, abdominal pain radiating to back; palpable gallbladder, jaundice

Back 80

Gallbladder cancer
Adenocarcinoma of gallbladder associated with cholelithiasis, chronic infection, and biliary tract disease; generally poor prognosis

Hint 80

Labs = increased bilirubin (total and direct), increased alkaline phosphatase, increased cholesterol; biopsy provides diagnosis
Radiology = abdominal radiograph may show calcified gallbladder (i.e., porcelain gallbladder); US or endoscopic US may detect invasive mass; ERCP can localize lesion and perform biopsy
Treatment = cholecystectomy, lymph node dissection, partial removal of adjacent hepatic tissue; adjuvant radiation therapy and chemotherapy may reduce recurrence rates and are used as primary therapies in unresectable disease

Front 81

H/P = asymptomatic for many years of alcoholism; anorexia, nausea, vomiting late in disease course; abdominal tenderness, ascites, splenomegaly, hepatomegaly, fever, jaundice, testicular atrophy, gynecomastia, digital clubbing

Back 81

Alcohol-related liver disease
Progressive liver damage secondary to alcoholism
Initially characterized by fatty deposits in liver; reversible with alcohol cessation
Continued alcoholism causes hepatic inflammation and early necrosis
Progressive damage results in cirrhosis
Complications = cirrhosis, hepatic encephalopathy, coagulation disorders

Hint 81

Labs = increased ALT, increased AST, increased γ-glutamyl transferase (GGT), increased alkaline phosphatase, increased bilirubin (total and direct), prolonged prothrombin time (PT), increased WBC; biopsy provides diagnosis (fatty liver, many polymorphonuclear leukocytes (PMNs), areas of necrosis)
Treatment = cessation of alcohol use, thiamine, folate, high caloric intake (2,500–3,000 kcal/day); liver transplant is a consideration in patients who are able to maintain abstinence from alcohol

Front 82

H/P = symptoms follow continuum from early liver diseases; weakness, weight loss, GI bleeding; hepatomegaly, splenomegaly, jaundice, ascites, abdominal wall varicosities (i.e., caput medusae), spider telangiectasias, palmar erythema, digital clubbing, Dupuytren's contractures in hands, testicular atrophy, gynecomastia, possible mental status changes (from encephalopathy), asterixis (i.e., asynchronous flapping of hands)

Back 82

Cirrhosis
Persistent liver damage leading to necrosis and fibrosis of hepatic parenchyma
Caused by alcoholism, chronic HBV or HCV infection, chronic bile duct obstruction, biliary and hepatic parenchymal diseases, drugs, toxins
Complications = portal hypertension, varices (caused by venous hypertension), ascites, hepatic encephalopathy (because of poor filtering of blood), renal failure, spontaneous bacterial peritonitis

Hint 82

Labs = increased ALT, increased AST, increased GGT, increased alkaline phosphatase, decreased albumin, anemia, decreased platelets, prolonged PT; paracentesis of ascites shows fluid with <2.5 g/dL protein, WBC <300/µL, normal glucose level, and decreased amylase; biopsy shows fibrosis and hepatic necrosis
Radiology = US detects small, nodular liver
Treatment = nonreversible, but progression may be halted; stop offending agent (e.g., alcohol); treat varices with β-blockers or sclerotherapy to reduce bleeding risk; lactulose, neomycin, and low-protein diet may improve encephalopathy; liver transplant may be needed in progressive cases

Front 83

H/P = ascites, abdominal pain, change in mental status (from hepatic encephalopathy), hematemesis (caused by esophageal varices), symptoms of cirrhosis; hepatomegaly, splenomegaly, fever, abdominal wall varices, testicular atrophy, gynecomastia

Back 83

Portal hypertension
Increase in portal vein pressure giving it a higher pressure than the inferior vena cava; may result from prehepatic, intrahepatic, or posthepatic causes
Prehepatic causes include portal vein thrombosis
Intrahepatic causes include cirrhosis, schistosomiasis, parenchymal disease, and granulomatous disease
Posthepatic causes include right-sided heart failure, hepatic vein thrombosis, and Budd-Chiari syndrome (i.e., hepatic vein thrombosis secondary to hypercoagulability)
Shunting of blood into systemic veins causes varices in several locations

Hint 83

Labs = increased ammonium (NH4+); paracentesis shows ascites with albumin > serum albumin by at least 1.1 g/dL, increased WBC, and normal glucose
Radiology = CT may show ascites and obstructing mass; EGD may show esophageal varices
Treatment =
Salt restriction and diuretics for ascites
IV antibiotics for bacterial peritonitis
Dialysis for renal failure
Lactulose, neomycin, and low-protein diet for hepatic encephalopathy
Vasopressin or sclerotherapy for bleeding varices
Hepatic shunting via laparotomy or transjugular intrahepatic portal-caval shunting (TIPS) is short-term solution for severe disease; liver transplant often required as eventual treatment in progressive cases

Front 84

systemic infection and comorbid portal hypertension

Back 84

Spontaneous bacterial peritonitis

Hint 84

paracentesis will show >250 PMN/µL, total protein >1 g/dL, glucose <50 mg/dL, and lactate dehydrogenase (LDH) > normal serum LDH.

Front 85

H/P = abdominal pain, polydipsia, polyuria, arthralgias, impotence, lethargy; pigmented rash (bronze hue), hepatomegaly, testicular atrophy; may see symptoms and signs that resemble DM and CHF

Back 85

Hemochromatosis
Autosomal-recessive disease of iron absorption
Excess iron absorption causes iron deposition in liver, pancreas, heart, and pituitary, leading to eventual fibrosis
Rarely is result of chronic blood transfusions or alcoholism
Complications = cirrhosis, hepatoma, CHF, DM, hypopituitarism

Hint 85

Labs = increased iron, increased percentage saturation of iron, increased ferritin, increased transferring saturation, slightly increased AST and ALT; biopsy shows increased iron content in liver
Treatment = weekly or biweekly phlebotomy until normal iron, then monthly phlebotomy; avoid excess alcohol consumption; deferoxamine for iron chelation

Front 86

H/P = psychiatric disturbances (e.g., depression, neuroses, personality changes), loss of coordination, dysphagia; jaundice, tremor, possible green-brown rings in cornea (i.e., Kayser-Fleischer rings), hepatomegaly; signs may precede symptoms

Back 86

Wilson's disease
Autosomal-recessive disorder of impaired copper secretion, primarily in young adults
Excess copper deposits in liver, brain, cornea
Complications = fulminant hepatic failure, cirrhosis

Hint 86

Labs = decreased serum ceruloplasmin, increased urinary copper, slightly increased AST and ALT; biopsy shows increased copper deposits in liver
Treatment = trientine or penicillamine for copper chelation; life-long zinc for maintenance therapy; dietary copper restriction (no organ meats, shellfish, chocolate, nuts, or mushrooms), supplementary vitamin B6; liver transplantation may be needed in cases of liver failure

Front 87

H/P=cirrhosis & panlobular emphysema

Back 87

α1-Antitrypsin deficiency
Autosomal-recessive disorder with decreased α1-antitrypsin production
Most symptoms arise from emphysemic component of disease

Hint 87

Labs = increased AST, increased ALT; pulmonary function tests (PFTs) demonstrate obstructive disease
Treatment = liver transplant or lung transplant may be needed in severe cases; enzyme replacement may be helpful in stopping disease progression

Front 88

H/P = possibly asymptomatic; fatigue, pruritus, arthralgias; jaundice, xanthomas, skin hyperpigmentation, hepatosplenomegaly
Labs = increased alkaline phosphatase, increased GGT, normal AST and ALT, increased cholesterol, increased bilirubin (total and direct) later in disease course; + antinuclear antibody (ANA), + antimitochondrial antibodies;

Back 88

Primary biliary cirrhosis (PBC)
Autoimmune disease with intrahepatic bile duct destruction leading to accumulation of cholesterol, bile acids, and bilirubin
RF= rheumatoid arthritis, Sjögren syndrome, scleroderma; female > male

Hint 88

Labs = increased alkaline phosphatase, increased GGT, normal AST and ALT, increased cholesterol, increased bilirubin (total and direct) later in disease course; + antinuclear antibody (ANA), + antimitochondrial antibodies; workup may indicate comorbid autoimmune diseases; biopsy shows inflammation and necrosis in bile ducts
Treatment = ursodeoxycholic acid improves liver function and reduces symptoms; colchicines or methotrexate can be added in more severe cases; liver transplant needed in progressive disease

Front 89

H/P = possibly asymptomatic; fatigue, pruritus, RUQ pain; fever, night sweats, jaundice, xanthomas
Labs = increased alkaline phosphatase, increased GGT, normal AST and ALT, increased cholesterol, increased bilirubin (total and direct), possible + perinuclear antineutrophil cytoplasmic antibodies (pANCA);
Radiology = ERCP shows stricturing and irregularity of extrahepatic and intrahepatic bile ducts (i.e., “pearls on string”)

Back 89

Primary sclerosing cholangitis (PSC)
Progressive destruction of intrahepatic and extrahepatic bile ducts leading to fibrosis and cirrhosis
RF= ulcerative colitis; male > female

Hint 89

Labs = increased alkaline phosphatase, increased GGT, normal AST and ALT, increased cholesterol, increased bilirubin (total and direct), possible + perinuclear antineutrophil cytoplasmic antibodies (pANCA); biopsy appears similar to that for PBC
Treatment = ursodeoxycholic acid, methotrexate, corticosteroids; endoscopic stenting of strictures; surgical resection of affected ducts and liver transplant may be required in progressive cases

Front 90

H/P = mild jaundice following fasting, exercise, or stress
Labs = increased indirect bilirubin <5 mg/dL

Back 90

Gilbert's disease
Autosomal-recessive or dominant disease with mild deficiency of glucuronosyltransferase

Hint 90

Treatment = none necessary

Front 91

H/P = persistent jaundice and central nervous system (CNS) symptoms (due to kernicterus) in infants
Labs = increased indirect bilirubin >5 mg/dL

Back 91

Crigler-Najjar syndrome
Autosomal-recessive disease with severe deficiency in glucuronosyltransferase
Complications = early kernicterus can cause permanent CNS damage

Hint 91

Treatment = phototherapy, plasmapheresis, calcium phosphate combined with orlistat; liver transplantation is an option

Front 92

H/P = frequently asymptomatic; possible RUQ fullness
Women with history of oral contraceptive use

Back 92

Benign tumors (e.g., hepatic adenoma, focal nodular hyperplasia, hemangiomas, hepatic cysts)

Hint 92

Radiology = CT, MRI, or angiography detects hypervascular liver mass
Treatment = frequently untreated; larger tumors may be resected or embolized to prevent rupture

Front 93

H/P = RUQ pain, weight loss, malaise, anorexia, diarrhea, dyspnea; jaundice, hepatomegaly, bruit over liver, ascites
Labs = increased α-fetoprotein; slightly increased AST and ALT, increased alkaline phosphatase, increased bilirubin (total and direct);

Back 93

Hepatocellular carcinoma (hepatoma)
RF = HBV or HCV infection, cirrhosis, hemochromatosis, Aspergillus infection, schistosomiasis
Complications = poor prognosis; portal vein obstruction, Budd-Chiari syndrome, liver failure
Paraneoplastic syndromes associated with hepatoma include hypoglycemia, excessive RBC production, refractory watery diarrhea, hypercalcemia, and variable skin lesions.

Hint 93

Labs = biopsy provides diagnosis, but risks causing substantial hemorrhage
Radiology = CT, MRI, or US shows liver mass; angiography may show increased vascularity; PET can be used to determine extent of spread
Treatment = surgical resection of small tumors (lobectomy or partial hepatectomy) and chemotherapy; transplant may be an option for limited disease; radiofrequency ablation and chemoembolization are options for unresectable tumors

Front 94

H/P = coughing and cyanosis during feeding, food may fill blind pouch, abdominal distention, possible history of aspiration pneumonia
Pediatric

Back 94

Tracheoesophageal fistula
Malformation of trachea and esophagus resulting in tract formation between structures (see Figure 3-17)
Frequently associated with esophageal atresia

Hint 94

Radiology = chest radiograph following nasogastric tube insertion demonstrates malformation (tube in lung or blind pouch)
Treatment = surgical repair

Front 95

H/P = symptoms begin a few weeks after birth; nonbilious emesis, projectile emesis; palpable epigastric olive-sized mass
Pediatric

Back 95

Pyloric stenosis
Hypertrophy of pyloric sphincter causing obstruction of gastric outlet

Hint 95

Radiology = barium swallow shows thin pyloric channel (i.e., string sign); US shows increased pyloric muscle thickness (see Figure 3-18)
Treatment = pyloromyotomy

Front 96

H/P =hematochezia, bilious vomiting, lethargy, poor feeding, diarrhea; abdominal distention, abdominal tenderness; signs of shock in severe cases
Pediatric

Back 96

Necrotizing enterocolitis
Idiopathic mucosal necrosis and epithelial cell sloughing
RF = preterm birth, low birth weight

Hint 96

Labs = metabolic acidosis, decreased Na+
Radiology = abdominal radiograph shows bowel distention, air in bowel wall, portal vein gas, or free air under the diaphragm
Treatment = TPN, IV antibiotics, broad-spectrum antibiotics, nasogastric suction, surgical resection of affected bowel

Front 97

H/P = obstipation, vomiting, failure to pass stool; abdominal distention
Pediatric

Back 97

Hirschsprung's disease
Absence of bowel autonomic innervation causing bowel spasm and obstruction

Hint 97

Labs = bowel biopsy shows absence of ganglia
Radiology = AXR demonstrates dilated bowel; barium enema shows proximal dilation (megacolon) with distal narrowing
Treatment = colostomy and resection of affected area

Front 98

H/P = sudden abdominal pain that lasts <1 min and is episodic; palpable sausage-like abdominal mass, ab tenderness; pallor, sweating, vomiting, bloody mucus in stool (i.e., currant jelly stool);
Pediatric

Back 98

Intussusception
Telescoping of bowel into adjacent segment of bowel, leading to obstruction; most frequently proximal to ileocecal valve
RF= Meckel's diverticulum, Henoch-Schönlein purpura, adenovirus infection, cystic fibrosis
Complications = bowel ischemia (appendix particularly susceptible)
Intussusception is the most common cause of bowel obstruction in the first 2 yrs of life.
Intussusception in an adult is considered cancer until proven otherwise and usually will require surgical reduction.

Hint 98

Labs = increased WBC
Radiology = barium enema will show obstruction; US or CT may detect abnormal bowel
Treatment = barium enema may reduce defect; surgery required for refractory cases

Front 99

H/P = asymptomatic; occasionally presents with painless rectal bleeding, intussusception, diverticulitis, or abscess formation
Pediatric

Back 99

Meckel's diverticulum
Common remnant of vitelline duct that exists as outpouching of ileum and may contain ectopic tissue
Meckel's diverticulum rule of 2s—males 2 times more common than females, occurs within 2 ft of ileocecal valve, 2 types of ectopic tissue (gastric, pancreatic), found in 2% of the population, most complications occur before 2 yrs of age

Hint 99

Radiology = gastric mucosa may be detected by technetium radionucleotide scan (i.e., Meckel's scan)
Treatment = surgical resection if symptomatic

Front 100

H/P = jaundice, scleral icterus; lethargy, high-pitched cry, seizures, and apnea seen with kernicterus
Pediatric

Back 100

Neonatal jaundice
Physiologic (common): physiologic undersecretion, breast-feeding failure; resolve within 2 wks
Increased hemolysis: maternal-fetal ABO incompatibility, hereditary RBC abnormalities, glucose 6-phosphate dehydrogenase (G6PD) deficiency
Bilirubin overproduction without hemolysis: hemorrhage, maternal-fetal transfusion
Hepatic abnormalities: Gilbert's syndrome, Crigler-Najjar syndrome, biliary atresia
Kernicterus is deposition of bilirubin in basal ganglia and hippocampus and may cause permanent damage; results from extremely high serum bilirubin and is typically only seen with hepatic abnormalities

Hint 100

Labs = frequently indirect hyperbilirubinemia (due to hemolysis); jaundice developing with initial 24 hrs after birth, total bilirubin >15 mg/dL, or direct bilirubin >2 mg/dL suggests nonphysiologic cause
Treatment = phototherapy used for physiologic jaundice lasting several days; suspected nonphysiologic causes should be worked up and may require exchange transfusion; intravenous immunoglobulin may reduce need for exchange transfusion in cases of maternal-fetal blood type incompatibility

Front 101

H/P = look for leads to organic causes; screen for abuse

Back 101

Failure to thrive
Children below 3rd-percentile weight for age or failure to gain weight appropriate for age
May be due to underlying illness or neglect

Hint 101

Labs = urinalysis, CBC, blood culture, urine culture, serum electrolytes, cystic fibrosis testing, and caloric intake records may be helpful in making diagnosis
Treatment = high-calorie diet, treat underlying disorder; educate parents in proper nutrition and feeding; contact social support services in cases of neglect or abuse

Front 102

Colorectal Cancer Staging/TMN
Tumor confined to bowel wall

Back 102

Duke Class A, TMN I

Hint 102

Cure Rate 90%

Front 103

Colorectal Cancer Staging/TMN
Penetration of tumor into colonic serosa or perirectal fat

Back 103

Duke Class B, TMN II

Hint 103

Cure Rate 80%

Front 104

Colorectal Cancer Staging/TMN
Lymph node involvement

Back 104

Duke Class C, TMN III

Hint 104

Cure Rate <60%

Front 105

Colorectal Cancer Staging/TMN
Distant metastases

Back 105

Duke Class D, TMN IV

Hint 105

Cure Rate 5%