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453 Cards in this Set
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characteristics of pericarditis |
pleuritic CP (worse in supine position)JVDpulsus paradoxuspericardial friction rubdiffuse ST elevationsfever, dyspnea, & cough
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what is an acceptable urine output in a trauma patient
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NORMAL: 30 cc per hourTRAUMA: 50cc per hour
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what are some causes of exudative pleural effusion
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malignancyTBbacterial infectionPEpancreatitis
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GI infection a/w:food poisoning with mayo |
s aureussalmonella |
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GI infection a/w:rice water stools
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V. cholera
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GI infection a/w:diarrhea from pet feces
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Yersinia enterocolitica |
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GI infection a/w:reheated fried rice
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B cereus
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GI infection a/w:travelers diarrhea
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ETEC
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GI infection a/w:diarrhea after antibiotics
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C diff |
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GI infection a/w:diarrhea with stream ingestion
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giardiaE histolytica
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GI infection a/w: a/w neurocysticerosis
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T solium
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GI infection a/w:undercooked hamburger
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EHEC (0157:H7)
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GI infection a/w:diarrhea from sea food
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V. choleraV. parahaemolyticus
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GI infection a/w:diarrhea with poultry
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#1 salmonella#2 campylobacter
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GI infection a/w:diarrhea with pink eye
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adenovirus
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GI infection a/w:bloody diarrhea with liver abscess
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entamoeba histolytica
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GI infection a/w:diarrhea in AIDS
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cryptosporidium parvum
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GI infection a/w:dehydrated child with foul-smelling greenish diarrhea
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rotavirus
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GI infection a/w:cruise ships
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Norwalk virus
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GI infection a/w:summer months
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coxsackie & echovirus
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GI infection a/w:winter months
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rotavirus
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GI infection a/w:respiratory infection
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adenovirus
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GI infection a/w:Triad: thrombocytopenia, hemolytic anemia, acute RF
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hemolytic uremic syndrome (HUS) = E. Coli 0157:H7
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Rx for:e histolytica
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metronidazole or paramomycin
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Rx for:giardia
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hydration & metronidazole |
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Rx for:salmonella
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hydrationfluoroquinilones (in immunocompromised pt's)
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Rx for:shigella
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hydrationfluoroquinilones/TMP-SMX if severe
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Rx for:campylobacter
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hydrationpossibly erythromycin
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Rx for Hep B
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IFN-a (pegylated)ANTIVIRALS:lamivudineadefovirentecavirtelbivudine
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Rx for Hep C
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IFN-a (pegylated)ribavirin
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hepatitis a/w chronic hepatitis
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Hep C
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hepatitis a/w hepatocellular carcinoma
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Hep B (check AFP levels)
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Hep status a/w:Hep BcAb (IgM)
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acute infection within the window period
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Hep status a/w:Hep BsAg BcAb (IgG)
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chronic infection
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Hep status a/w:Hep BsAb
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vaccinated
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Hep status a/w:Hep BsAb BcAb (IgG)
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recovered
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cafe au lait spots are a/w
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NF1
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px with repeated pneumonia in the same locationwhat is the next step
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CT scan of chest("same location" = red flag for for cancer causing broncho obstruction)
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what is the next step in a px with dysphagia
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barium swallow
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barium swallow showing corkscrew is a/w
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diffuse esophageal spasm |
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barium swallow with birds beak is a/w
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achalasia
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Rx for diffuse esophageal spasm
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CCB (e.g. nifedipine)NitratesTCAs
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Rx for achalasia
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dilationbotox injectionmyotomy
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px with bad breathe, regurgitation of food eaten days ago
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zenkers diverticulum
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besides heart burn, what is the MC symptom of GERD
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persistant cough
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What is Barrett's Esophagus & why is it important
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esophageal epithelium has undergone "intestinal metaplasia": normally squamous epithelium --> columnar epitheliumBarrett's is a RF for adenocarcinoma
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MC type of esophageal cancer in US
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adenocarcinoma
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Compare Mallory-Weiss syndrome to Boerhaave syndrome
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MALLORY-WEISS SYNDROME:mucosal laceration/teardistal esophagusminor injury with some bleeding/hematemesisBOERHAAVE SYNDROME:perforation/rupture of distal esophaguslife-threatening injury: lots of bleeding
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imaging study used to Dx DVT
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compressive venous US
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Rx for coccidiomycosis
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fluconazole
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what is the most effective treatment for duodenal ulcer not due to ZES
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H PYLORI TRIPLE THERAPY:Amoxicillin/metronidazoleClarithromycinPPI
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what is the Rx for gastric cancer
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distal 1/3 = subtotal gastrectomyproximal 2/3 = total gastrectomyadjuvant chemo and radiation
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what are the 3 areas of enlarged nodes from metastatic gastric cancer
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VIRCHOW'S NODE:left supraclavicular nodea/w GI malignancySISTER MARY JOSEPH'S NODE:periumbilical nodea/w any GI malignancya/w some GYN cancersKRUKENBERG'S TUMOR:ovarian tumora/w GI malignancya/w breast malignancy |
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px with duodenal ulcer has been refractory to PPIswhat 2 tests will help Dx
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Dx: ZESfasting serum gastrin levelsecretin stimulation test(secretin normally inhibits gastrin secretion; not so in ZES)
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compare gastric vs duodenal ulcer
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GASTRIC ULCER:pain soon after eating"s" for soon & stomachDUODENAL ULCER:delayed pain (2-4 hours post-prandial)"d" for delayed & duodenal
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what is used to Dx urethral injury
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retrograde cysturethralgram
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infection of branching rods in mouth
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actinomyces israelli
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cuban immigrant with malabsorption and megaloblastic anemia
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tropical sprue
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Rx for tropical sprue
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Folate and tetracyclines
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MCC of malabsorption in px with + sudan stain and normal D-xylose test
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pancreatic insufficiency(i.e. fat malabsorption with normal carbohydrate absorption)
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Rx for whipples disease
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TMP-SMX or ceftriaxone
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what tumors cause secretory diarrhea
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VIPomagastrinomacarcinoidmedullary thyroid cancer
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MCC of adult chronic diarrhea
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lactose intolerance
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what are the SE's of corticosteroids
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immunosuppressionosteoporosisthinning skinacneinsomniamania/psychosiscataractsmoon-shape facies, buffalo hump, abdominal striae
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Dxhypoxemia, pulmonary edema, normal pulmonary capillary wedge pressure
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ARDS
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MC foodborne bacterial GI tract infection |
campylobactersalmonella
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symptoms of basilar skull fracture
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raccoon eye (orbital bruising)battle sign (bruising over mastoid process)hemotympanum (bleeding behind TM)CSF from nose or ear
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what are some symptoms of IBS
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change in frquency of stoolchange in stool formrelief with defecation
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Rx for crohns
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5-ASA (e.g. mesalamine, sulfasalazine)azathioprineanti-TNF-a agents (e.g. infliximab, adalimumab)steroids |
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next step in a px with severe abdominal pain and AXR shows free air in abdomen
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exploratory laparotomy
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IBD a/w fissures and fistulas
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crohns
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antibodies a/w crohns and UC
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crohns = ASCA UC = pANCA+ |
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MCC of small bowel obstruction
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adhesionsbulge (hernia)cancer (tumors)
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how can small bowel obstruction be Dx
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dilated loops on plain film abdominal series"ladder-like" appearance on CT scan
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signs of small bowel obstruction
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painhyperactive high pitched sounds
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MC benign small bowel tumor
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leiomyoma
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MC malignant small bowel tumor
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adenocarcinoma
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MCC of large bowel obstruction
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neoplasm
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initial Rx for child presenting with acute asthma attack
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short-acting B2-agonist (e.g. albuterol or levalbuterol)IV steroids (takes 4 hrs to "kick-in")oxygen (if SaO2 < 92%)
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a normalizing PCO2 in a patient with an asthma exacerbation may indicate
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IMPENDING RESPIRATORY FAILURE:normally asthma pt's blow off lots of CO2 (tachypnea)blow off less CO2 --> normalizes --> NOT ventilating well --> sign of muscle fatigue
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what is the most accurate test to Dx appendicitis
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CT scan
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a women with appendicitis presentation should have what done before going to surgery
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B-HCG (r/o ectopic pregnancy)
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what is the classic characteristic of acute mesenteric ischemia
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extreme pain out of proportion to exam
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px presents with vomiting and abdominal pain and distention, AXR shows two areas with distended airDx and Rx
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volvuluscolonoscopy
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what is seen on CT in a px suspected of having ischemic colitis
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bowel wall thickeningair within bowel wall (aka pneumatosis coli)
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classic time frame that post op ileus resolves in the small bowel, stomach, & colon |
small bowel: 1 day (<24hrs)stomach: 2 - 3 dayscolon: 3 -5 days
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Dxpx with dyspnea, hilar lymphadenopathy and hypercalcemia
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sarcoidosis
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what characteristics favor an isolated pulmonary malignant nodule
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smoker>45 yonew lesionold lesion with incr'd sizeabsence/irregular calcificationsirregular marginssize > 2 cm |
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what is the Rx for normal pressure hydrocephalus
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VP shunt (shunts CSF from ventricles to peritoneum)
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Rx for pseudotumor cerebri
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acetozolamideweight lossserial LP (refractory cases)VP shunt |
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what are the indications for a px to be admitted with diverticulitis |
immunocompromisedelderlysignigicant comorbiditieshigh feversignificant leukocytosisunable to tolerate PO intake |
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risk factor for diverticulosis
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> 60 y/olow fiber, high fat diet
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Rx for diverticulitis
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bowel rest x 3 daysbroad spectrum AB's to cover G-'s & anaerobes(e.g. Metronidazole + Ciprofloxacin)
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Rx for diverticulitis with abscess formation
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percutaneous drainage of abscessIVF'sbowel restIV antibiotics
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Rx for carcinoid syndorme
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somatostatin (shuts down 5-HT production)
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Rx for carcinoid syndrome that is refractory to octreotide
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Octreotide + IFN-alpha
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next step in management in a patient younger than 50 yo with bright red blood only seen on toilet paper
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most likely dx: hemorrhoidsDx'c test: anoscopy
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MCC of acute pain and swelling of the midline sacrococcygeal skin and subcutaneous tissue
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pilonidal cyst
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MCC of recurrent LLQ abdominal pain that improves with defecation
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diverticulosis
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how are anal fissures managed
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stool softenersnifedipine, diltiazem, bethanacholbotoxpartial sphicterotomy |
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immunodeficiency a/w increased risk of anaphylactic transfusion reaction
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selective IgA def
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px with silicosis are at higher risk for
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TB
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px with severe diffuse abdominal pain with AXR that shows free air under diaphragm, next step
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emergency laparotomy
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recommendations for colonoscopy if:1-2 tubular adenomas < 1cm
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5 years
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recommendations for colonoscopy if:3-9 or more tubular adenomas < 1 cm
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3 years
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recommendations for colonoscopy if:tubular adenoma 1+ cm
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3 years
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recommendations for colonoscopy if:villous adenoma or high-grade dysplasia
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3 years
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recommendations for colonoscopy if:> 10 adenomas
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< 3 years
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recommendations for colonoscopy if:FH of colon cancer
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10 years prior to the age that the youngest family member was dx'd with colon cancer (e.g. Father dx'd at age 53, colonoscopy should begin at age 43)
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tumor marker for cancer in the colon
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CEA
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gene responsible for familial adenomatous polyposis
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APC
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next steppx in ER has thrown up two basin full of blood, is drunk and tachycardic
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IVF's
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Dx px with new onset iron def in 70 yo
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colon cancer until ruled otherwise
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MC etologies for upper GI bleeds
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PUD (MCC)mallory Weiss tearsesophageal varicesAVM'stumorserosions
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MC etiologies of lower GI Bleeds
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diverticulosisneoplasmsischemiahemorroidsanal fissures |
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how is volume status assessed in a px with GI bleed
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BPHRurine output
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what are the HACEK organisms |
HemophilusEikenellaActinobacillusCardiobacteriumKingella
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Rx for chronic pancreatitis
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alcohol cessationpancreatic enzyme replacementpain controldietary modification (low fat, small meals)
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What are the MCC of acute pancreatitis in the US |
gall stonesalcohol (35%)
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what procedure is done to treat isolated cancer of the head of the pancreas
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whipple procedure(aka pancreaticoduodenectomy)
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tumor marker useful in the Dx of pancreatic cancer
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CA 19-9
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Ranson criteria for prognosis of acute pancreatitis at admisssion
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"GA LAW"Glucsoe > 200AST > 250LDH > 350AGE > 55WBC > 16,000
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Ranson criteria for prognosis of acute pancreatitis < 48 hrs after admission
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"CALvin & HOBBeS"[Ca2+] < 8 ng/dlHct decr'd > 10 %O2 --> PaO2 < 60 mm HGBase deficit > 4 mEq/LBUN incr'd > 5 mg/dLSequestration of fluids > 6L
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What are some causes of acute pancreatitis
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"BAD HITS"Biliary obstruction (40%)Alcohol (35%)Drugs (e.g. HIV meds, diuretics, valproic acid, azathioprine, E2's, pantamidine)Hypercalcemia/TG'sIdeopathicTraumaScorpion stings
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what are the criteria for px with COPD to qualify for home O2
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pulse ox < 88%peripheral edemapolycythemiapulm HTN
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lung cancer a/w SIADH
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small cell cancer
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What is Charcot's triad
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RUQ painjaundicefeverDx = cholangitis
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what is reynolds pentad
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RUQ painjaundicefeverHypotension Altered Mental Status Dx = cholangitis |
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Rx for cholecystitis
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cholecystectomy |
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what type of pt is at high risk of acalculous cholecystits
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pts on TPN or in ICU
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Rx for cholangitis
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drain bile ducts (ERCP)fluid & IV antibioticscholecystectomy (LATER)
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what are the MC presenting symptoms of primary biliary cirrhosis
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fatigue and pruruitis
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Rx for primary biliary cirrhosis
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ursodeoxycholic acid (delays progression of ds & enhances survival)
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Rx for pruritis in primary biliary cirrhosis
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cholestyramine
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what is the definitive Rx for primary biliary cirrhosis
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liver transplant
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antibodies in primary biliary cirrhosis
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anti-mitochondrial
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antibodies in primary sclerosing cholangitis
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pANCA
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what is seen on imagine of primary sclerosing cholangitis
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ERCP: beads on a string
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Sign/Dx:deep palpation of RUQ causes arrest of inspiration due to pain
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murphy's sign/cholecystitis
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Sign/Dx:fever, jaundice, RUQ pain
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reynold's pentad/cholangitis
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Sign/Dx:RLQ pain on passive extension of hip
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psoas sign/appendicitis
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Sign/Dx:RLQ pain on passive internal rotation of flexed hip
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obturator's sign/appendicitis
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Sign/Dx:LUQ pain that refers to left shoulder
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kehr's sign/splenic rupture
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Sign/Dx:ecchymosis of the skin overlying the flank
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grey turner's sign/pancreatitis |
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Sign/Dx: ecchymosis of skin overlying the periumbilical area |
cullen's sign/pancreatitis
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Compare location of pathology of primary biliary cirrhosis vs primary sclerosing cholangitis
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PBC: intrahepatic ducts ONLYPSC: intra & extrahepatic ducts
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MCC of travelers diarrhea
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ETEC
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initial Rx for localized non small cell lung cancer
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surgical resection + chemo
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Rx for IBD
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SMALL BOWEL ONLY:mesalemine (5-ASA)LARGE BOWEL INVOLVED:sulfasalazine (SSZ)ACUTE EXACERBATIONS:steroids
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S/Sx's of Cirrhosis
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PORTAL HTN:varices (esophageal & caput medusa)hepatosplenomegalyascitesLIVER FAILURE:decr'd conjugation (jaundice)decr'd proteins (coagulopathy & peripheral edema)incr'd toxins (encephalopathy/asterixis)incr'd estrogen (testicular atrophy, gynecomastia, spider angioma, & palmer erythema)OTHER:weaknesswt lossdigital clubbingdupuytren's contractures
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what is NASH stand for & what are the MCC's
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NASH = NonAlcoholic SteatoHepatitisMCC's (think metabolic syndrome):obesityDMhyperlipidemiainsulin resistance
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what is rx for NASH
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avoidance of alcoholwt lossaggressive control of DMTZDs (eg. pioglitazone) improve LFTs
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What is Budd-Chiari Syndrome
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thrombosis & occlusion of hepatic vein or intrahepatic/suprahepatic portion of IVC
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S/Sx's of Budd-Chiari Syndrome
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ascites (84%)hepatomegaly (76%)jaundiceRUQ pain (if acute)eventual liver failure --> hepatic encephalopathy(no fever, t/f no cholangitis; no JVD, t/f no rt-side HF)
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Dx'c tests & Rx for Budd-Chiari Syndrome
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Initial Dx'c test: ultrasoundGold Standard: hepatic venographyTx:thrombolyticsanticoagulationangioplastydiuretics
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diuretics used to Rx ascites/portal HTN
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furosemidespironolactone
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Rx for hepatic encephalopathy
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lactuloserifaximindecreased protein intake
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antibiotics used in spontaneous bacterial peritonitis
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cefotaximeceftriaxoneother 3rd Gen Ceph's
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screening test for hemochromatosis
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ferritin levels
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Rx for hemochromatosis
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phlebotomydeferoxamine (rarely)
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lab value a/w wilson disease
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serum cerruloplasmin levels (low)
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tumor marker for hepatocellular carcinoma
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AFP
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tumor marker a/w colon cancer
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CEA
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tumor marker a/w gastric cancer
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CEA
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tumor marker a/w pancreatic cancer
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CA 19-9
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tumor marker a/w ovarian cancer
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CA 125
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what is SAAG & how is it calculated
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SAAG = serum-ascites albumin gradientSAAG = [serum albumin] - [ascites albumin]
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What does SAAG indicate & what are the possible etiologies |
SAAG >/= 1.1 --> portal HTN (low albumin in ascites relative to serum) cirrhosis alcoholic hepatitis HF/constrictive pericarditis massive hepatic metastases Budd-Chiari syndrome SAAG < 1.1 --> NOT due to portal HTN (high albumin in ascites relative to serum) Nephrotic Syndrome (2nd/2 decr'd serum albumin) Infection (2nd/2 incr'd ascites albumin) Neoplasm (2nd/2 incr'd ascites albumin) |
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What labs are concerning for neoplastic cause of ascites |
SAAG > 1.1 + high ascites LDH (i.e. > 60% of serum LDH)
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Dxpx with diarrhea after meals. PE shows fistulas between bowel and skin & nodular lesions on his tibias
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crohns
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rx for prophylactic bacterial meningitis & when is it indicated
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Rifampin to close contacts of pt's with:N. Meningitidis meningitisH. Influenzae meningitis
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what pattern does jaundice develop & at what level is a known value of jaundice
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develops from the head downwardnipple line = approx. 10 mg/dL
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Dx2 year old with painless rectal bleeding
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meckels diverticulum
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what antibiotic is CI in neonates with hyperbilirubinemia and why
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ceftriaxonedisplaces bilirubin from albuminincr'd likelihood of kernicterus or encephalopathyalso: causes biliary sludging (from DIT Neuro 1)
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what characteristics help you identify pathologic newborn jaundice
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*jaundice in first 24 hours*direct (conjugated) > 20% of total bilirubin*direct (conjugated) > 2 mg/dL*total bilirubin > 15 mg/dL in term neonatesjaundice after 2-3 weeks of agerise in total bilirubin > 0.5 mg/dL/hrrise in total bilirubin >5 mg/dL/day
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Age, total bilirubin level, etiology, & tx:physiologic jaundice
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AGE: 2-3 daysTOT BILI <10ETIOLOGY: immature UDP-GTTREATMENT: resolves in 2 weeks+/- phototherapy
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Age, total bilirubin level, etiology, & tx:breast feeding jaundice
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AGE: < 1 weekTOT BILI < 15ETIOLOGY: dehydrationTREATMENT:increase feedsimprove feeding techniques
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Age, total bilirubin level, etiology, & tx:breast millk jaundice
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AGE: > 1 weekTOT BILI > 5.5ETIOLOGY: unknown factor in milkTREATMENT:resolvesswitch to formula
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What is the MC type of TE fistula
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blind upper esophageal pouch with distal esophagus attached to the trachea
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classic presenting scenario for necrotizing enterocolitis
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premature or low birth wt infant started on tube feedsincreasing abdominal distensionsigns of enterocolitis
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what are criteria for failure to thrive in a child younger than 2 y/o
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PERCENTILE:Wt < 3rd - 5th percentile for gest age (corrected if Down's or Turner's) on 2+ occasionsWt crosses 2 major percentiles downward over timeWt::length ratio < 10th percentilePERCENTAGE:Wt < 80% of ideal wt for ageOTHER:Rate of daily wt gain less than expected for age
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viral gastro bugs
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Noro, Cox A1, echo, adeno, Rota in children
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bacterial gastro bugs that cause bloody diarrhea
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C.jejuni, EC O157:H7 (entrohemorrhagic), Salmonella, Shigella, Yersinia, sometimes CDiff
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bacterial gastro bugs that have risk of HUS
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EC O157:H7, Shigella
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HUS characteristics
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thrombocytopenia, hemolytic anemia, renal failure
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hepatitis h/p
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RUQ pain, jaundice, scleral icterus, hepatomegaly, splenomegaly, LAD, fatigue, malaise
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hepatitis treatments
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A and E: supportiveB: HBVax immediately after exp; interferon or antiviralsC:IFN and maybe ribavarinD: IFN
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which Hepatitis has vaccines
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A, B, D
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complications of Hepatitis?
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B: 5% dev chronic hepatitis, cirrhosis, 3-5% dev hepatocellular carcinomaC: 80% dev chronic hepatitis, 50% dev cirrhosis, slightly increased risk of hepatocellular carcinomaE: high infant mort when preg women get it
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what can cause salivary duct obstruction
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sialolithiasis in any salivary gland, sarcoid, infection, neoplasms
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salivary gland disorder h/p
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enlarged, painful glands, pain worsens with eating, painless swelling
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what can cause dysphagia
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achalasia, motility disorders, scleroderma, peptic strictures, esophageal webs or rings, cancer, radiation fibrosis
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dysphagia labs
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esophageal manometry
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dysphagia rads
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barium swallow, esophagogastroduodenoscopy (EGD) |
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what can cause achalasia
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Chagas, scleroderma, neoplasms
|
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achalasia h/p
|
progressive dysphagia, regurg, cough, aspiration, heartburn, weight loss
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achalasia rads
|
barium swallow: bird's beak, need EGD to rule out cancer
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achalasia tx
|
pneumatic dilation, botox injections, myotomy can cause GERD
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diffuse esophageal spasm h/p
|
chest pain, dysphagia
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diffuse esophageal spasm rads
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barium swallow shows corkscrew pattern
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diffuse esophageal spasm tx
|
ca channel blockers, nitrates relieve pain but worsen GERD, TCAs
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what is Zenker diverticulum
|
divert of upper posterior esophagus from smooth muscle weakness
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Zenker's divert h/p
|
bad breath, difficulty swallowing, regurg of food several days after eating, dysphagia, feeling of aspiration |
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Zenker's divert rads
|
barium swallow
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Zenker's divert tx
|
cricopharyngeal myotomy/ diverticulectomy
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risk factors for GERD
|
obesity, hiatal hernia, preg, scleroderma
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what can worsen GERD
|
alcohol, smoking, fatty foods
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GERD h/p
|
burning chest pain, sour taste in mouth, regurg, dysphagia, odynophagia, nausea, cough, pain worse with lying down relieved by standing
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GERD labs
|
esophageal pH monitoring
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GERD rads
|
not necessary, but EGD/cxr/barium swallow can r/o neoplasm Barrett's esophagus, hiatal hernia |
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GERD tx
|
elevate head of bed, WL, diet mod, Antacids with H2 blockers/PPIs
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tx of refractory GERD
|
Nissen fundoplication, hiatal hernia repair
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complications of GERD |
Barrett's esophagus, ulceration, strictures, adenocarcinoma
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what usually precedes adenocarcinoma of esophagus
|
Barrett's esophagus
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risk factors for adeno esophageal cancer
|
alcohol, tobacco, GERD, obesity
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2 types of hiatal hernia
|
1. sliding2. Paraesophageal
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Tx of hiatal hernias
|
sliding: reflux controlparaesophageal: surgical Nissen or gastropexy
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hiatal hernia complications
|
incarceration
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esophageal spasm rads
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corkscrew on barium swallow
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side effects of H2 antagonists
|
HA, diarrhea, thrombocytopenia rare, cimetidine can cause gynecomnastia and impotence
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side effects of PPIs
|
may increase effects of Warfarin, benzos, phenytoin, dig, carbamazepine
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Type A vs type B chronic gastritis
|
A: Fundus, autoAb against parietal cells leads to pernicious anemia, decreased gastric acid level and decreased gastrin, achlorhydria, thyroiditisB: Antrum, Hpylori infection, increased gastric acid level, PUD, gastric cancer
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acute vs chronic gastritis
|
acute is erosive, chronic is not
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how does a urea breath test work
|
detects increase in pH from ammonia producing H pylori
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tx of all acute and chronic gastritis
|
acute: stop offending agents like alcohol, acidic foods, give H2 antagonists or PPIsChronic: type A give B12type B triple therapy vs HPylori: PPI+Clarithro+ Amox/Metro for 7-14 days
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causes of gastric ulcers mnemonic
|
ANGST HAM: aspirin, NSAIDS, Gastrinoma, Steroids, Tobacco, HPylori, Alcohol, MEN1
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gastric ulcers from stress for severe burns and intracranial injuries are called what
|
Curling's and Cushing's ulcers
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how to diff b/w gastric and deodenal ulcer?
|
Gastric: younger <50, NSAID users, pain SOON and worse after eating, normal/low gastric acid level, HIGH gastrin levelDuodenal: Younger, pain 2-4 h after eating which can initially improve sxs, high gastric acid level with normal Gastrin level
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PUD rads
|
axr to detect perfs, barium swallow can collect in ulcerations (abnormal mucosal folds/mass/filling defects in region of ulcer suggests malig), EGD for biopsy and active bleeds
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surgical tx of non neoplastic refractory PUD
|
antrectomy/ parietal cell vagotomy
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complications of PUD
|
hemorrhage: posterior ulcers erode into GDA, anterior ulcers more likely to perf
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where gastrinomas usually found
|
duodenum (70%) or pancreas
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ZE h/p
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refractory PUD
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ZE labs
|
increased fasting gastrin, positive secretin stim test (give secretin and higher than expected levels of gastrin result)
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ZE rads
|
somatostatin receptor imaging with SPECT
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ZE Tx
|
surgery for nonmetastatic, PPI and H2Inhibitors can ease sxs, octreotide can also help in metastatic cases
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MEN1
|
Parathyroid hyperplasia/adenoma with hypercalPancreatic islet cell neoplasia (Gastrin, VIP, insulin, glucagon)Pituitary adenomas
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MEN2A
|
Parathyroid hyperplasic (15-20% hypercal)PheoMTC
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MEN2B
|
MTCPheoMucosal and GI neuromas
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2 types of gastric cancer
|
Adeno (common) and squam (less common usually from esophagus)
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4 subtypes of gastric cancer
|
Ulcerating, Polypoid, Superficial spreading (only mucosal and submucosal good prog), Linitis plastica (all layers, decreased stomach elasticity, bad prog)
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gastric cancer risk factors
|
HPylori, fam hx, Japanese person in Japan, tobacco, alcohol, vitamin C def, high consumption of preserved foods, males>females
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gastric cancer h/p
|
WL, anorexia, pain, early satiety, enlarged left supraclavicular LN (Virchow's node), periumbilical node (Sister Mary Joseph's node)
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gastric ca labs
|
inc CEA, inc glucuronidase in gastric secretions
|
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gastric ca rads
|
barium swallow: thickened leather bottle stomach= linitis plastica, do an EGD for biopsy and visuals
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gastric ca tx
|
subtotal gastrectomy: for lesions in distal third of stomachTotal gastrectomy: for lesions in middle or upper third of stomach or invasive lesions, needs adj chemo and rad
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gastric cancer prog
|
early detection: 70% cure rate but poor prog in later detection <15% 5 year survival
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autoantibodies that cause celiac sprue
|
antiendomysialantigliadin
|
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where in GI tract does celiac sprue affect
|
duodenal/jejunal mucosa
|
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celiac sprue labs
|
antiendomysialantigliadin absbiopsy shows loss of duodenal and jejunal villi
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diff b/w tropical and celiac sprue
|
no autoabs, tropical is for people who have spent time in tropics, removal of gluten from diet has no effect on tropical sprue
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h/p of malabsorption disorders
|
WL, diarrhea, steatorrhea, bloating, glossitis, dermatitis, edema
|
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Tx of sprues
|
removal of gluten and steroids for celiacFA replacement and tetracycline for tropical
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where in GI tract is lactose normally absorbed
|
jejunum
|
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what is lactose tolerance/breath test
|
give lactose, minimal increase in glucose in serum/breath hydrogen test after lactose meal
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|
what bug causes Whipple's dz
|
Tropheryma whippelii
|
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Whipple's dz risk factors
|
white male european
|
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Whipple's dz h/p
|
same as for other malabsorption disorders: WL, joint pain, abd pain, diarrhea, dementia, cough, bloating, steatorrhea, fever, vision abn, LAD, new heart murmur, severe wasting late
|
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Whipple's dz labs
|
PAS stain on jejunal biopsy shows foamy macros and villous atrophy
|
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Whipple's dz tx
|
Bactrim or Ceftriaxone for 1 year
|
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|
what test detects steatorrhea
|
Sudan stain
|
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|
when do you work up acute diarrhea? how
|
with high fever/bloody/>5d1. if yes, stool culture, stool acid-fast, fecal leuks for enteroinvasive bacteria, O+Px3, hydration and abx2. If no, hydration, antimotility agents unless there's no resolution then goto 1
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3 types of chronic diarrhea
|
secretory, osmotic, inflammatory
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how do you work up chronic diarrhea (>2wks)
|
1. r/o infection, recent surg, meds2. sudan stain for fecal fat: malabsorption3. FOB, WBC, Lactoferrin, Calpotectin for inflammatory causes: do stool Cx and colonoscopy4. measure stool pH and lactose tol test for lactase def5. If normal, do stool lytes and osmolality: stool mOsm/kg= 290 - 2(Na+K)>50 is high osmotic gap=osmotic cause: lactase def<50 is normal osmotic gap = secretory: do CT, colonoscopy, hormone levels6. If high osmotic gap, could be lax abuse or lac def7. If normal osmotic gap, do stool weight for IBS (normal)
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Rome III criteria for IBS
|
recurrent abd pain for 3 or more days over the last 3 mo plus 2 of the following: improvement with def pain then change in freq of stool pain then change in form of stool
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|
Manning Criteria for IBS
|
1. pain improves with def2. pain then change in freq of stool 3. pain then change in form of stool4. visible abd distension5. passage of mucus with stool6. feeling of incomplete defecation
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what ages does IBS usually start
|
teens or young adulthood
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|
workup for IBS
|
axr, abd ct, barium to rule out other GI causes, colonoscopy in older to r/o cancer
|
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IBS tx
|
assurance, high fiber diet, psychosocial tx, antidepressants
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Crohn's vs UC sites
|
Crohn's: skip lesions and entire bowel wall involvedUC: continuous starting at rectum, only mucosa and submucosa affected
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Crohn's vs UC sxs
|
Crohn's: abd pain, WL, watery diaUC: abd pain, urgency, tenesmus, bloody diarrhea
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Crohn's vs UC physical
|
Crohn's: fever, RLQ mass, perianal fissures/fistulas, oral ulcersUC: fever, orthostatic, tachy, gross blood on rectal exam
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Crohn's vs UC extraintestinal manifestation
|
Both have arthritis, uveitis, ankylosing spondylitis, PSC, erythema nodosum, fatty livernephrolithiasis more common with Crohnspyoderma gangrenosum more common with UC
|
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Crohn's vs UC labs
|
Crohn's: ASCA+, pANCA rareUC: ASCA rare, pANCA+
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Crohn's vs UC rads
|
Crohn's: cobblestoning, fissures, skip lesions, string signUC: continuous, lead pipe
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Crohn's vs UC tx
|
Both: Mesalamine, steroids, immunosuppressivesCrohn's: surgical resection of severely affected areas/strictures/fistulasUC: total colectomy is curative
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Crohn's vs UC comps
|
Both: Toxic MegacolonCrohn's: abscess/fistulas/fissuresUC: increased risk of Colon Cancer
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|
most common causes of obstruction
|
adhesions, hernias, neoplasms (large bowel)
|
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|
which part of GI tract is usually spared from ischemia
|
rectum cause there's collateral circ
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which is the most painful type of GI ischemia
|
small bowel ischemia: pain out of proportion to exam
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|
which part of GI tract is usually involved in ischemic colitis
|
left colon
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what causes ischemic colitis
|
embolus, obstruction, inadequate perfusion, medication, surgery-induced vascular compromise
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ischemic colitis risk factors
|
DM, athero, CHF, peripheral vasc, lupus
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ischemic colitis h/p
|
abd pain, bloody diarrhea, vomiting, mild tenderness
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ischemic colitis labs
|
inc WBC and lactate
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ischemic colitis rads
|
thumb printing
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ischemic colitis tx
|
fluids bowel rest, abx, resection of necrotic bowel
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RLQ pain differential mnemonic
|
APPENDICITIS: Appendicitis, PID/Period, Pancreatitis, Ectopic/Endometriosis, Neoplasm, Diverticulitis(rare), Intussusception, Crohns/Cyst ovarian, IBD, Torsion, IBS, Stones (kidney, gallbladder)
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|
causes of appendicitis by age
|
children: lymphoid hyperplasiaadults: fibroid bands, fecaliths
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appendicitis h/p
|
periumbilical tenderness moves to RLQ at McBurney's point (1/3 from R ASIS to umbilicus), rebound, Psoas sign, Rovsing's sign (RLQ pain with LLQ palp),
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appendicitis labs
|
WBC with left shift (more leukocytes vs neutrophils)
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appendicitis rads
|
free air under diaphragm if perfed, CT is most sens
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appendicitis tx
|
appendectomy, abx for ruptured
|
|
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appendicitis complications
|
abscess form, perf
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|
|
how long does postop ileus last?
|
<5 days. Small bowel recovers in 24h, stomach in 48-72h, and large bowel in 3-5 days
|
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|
what causes ileus
|
postop, infection, ischemia, DM, opioid use
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|
|
ileus h/p
|
pain, nausea, bloating, no bowel mvmts, can't eat, no rebound
|
|
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ileus rads
|
distention of bowel, air-fluid levels
|
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|
ileus tx
|
stop opioids, NPO, colonoscopic decompression if no resolution
|
|
|
where in GI tract does volvulus mostly occur
|
cecum, sigmoid
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|
|
who gets volvulus usually
|
infants and elderly
|
|
|
volvulus rads
|
double bubble on axr, barium enema shows birds beak for distal volvulus
|
|
|
volvulus tx
|
maybe self limited, colonoscopic detorsion of sigmoid volvulus, resection maybe required in cecal volvulus if can't detorse
|
|
|
most common cause of acute lower GI bleeding over 40y
|
diverticulitis
|
|
|
diverticulitis more commonly occurs where
|
sigmoid colon
|
|
|
what is diverticulitis
|
outpouchings of colonic mucosa and submucosa that herniate through muscular layer
|
|
|
diverticulitis h/p
|
LLQ pain, nausea, vomiting, melena, hematochezia, tenderness, fever, distension
|
|
|
diverticulitis labs
|
WBC, guaiac pos
|
|
|
diverticulitis rads
|
free air under diaphragm if perfed, tics on barium enema/colonoscopy, CT shows soft tissue density , bowel wall thickening, possible abscess
|
|
|
diverticulitis tx
|
no perf: bowel rest, liquids only for 3 days, abx: Fluoro+Metro OR Bactrim+Metro OR AugmentinPerf: resect segment of colon, diverting colostomy for 3 mo in cases of peritonitis + Broad spec abx
|
|
|
diverticulitis comp
|
abscess, fistula, sepsis
|
|
|
where to internal/external hemorrhoids get their blood supply from
|
internal: superior rectal veins above pectinate lineexternal: inferior rectal veins below pectinate line
|
|
|
which type of hemorrhoids are painful
|
external only
|
|
|
cell types for internal/external hemorrhoids
|
internal: columnar rectal epithexternal: squamous rectal epith
|
|
|
hemmorrhoids rads
|
sigmoidoscopy to r/o other caues of bleeding
|
|
|
hemmorhoids tx
|
warm baths, increase in fiber, sclerotx, ligation, excision
|
|
|
tx for anal fissures
|
stool softeners, topical nitro, partial spincterotomy if recurrent
|
|
|
where do pilonidal cysts occur
|
superior gluteal cleft
|
|
|
where are carcinoids usually found
|
appendix, ileum, rectum, stomach
|
|
|
carcinoids h/p
|
abd pain, carcinoid syndrome: flushing, diarrhea, bronchoconstriction, valvular dz, caused by serotonin secretion by tumor (only seen with liver mets or extra-GI involvement)
|
|
|
carcinoids labs
|
inc 5HIAA in urine, inc serum serotonin
|
|
|
carcinoids rads
|
CT/ Indium-labeled octreotide scintigraphy
|
|
|
carcinoid tx
|
tumors <2cm low incidence of mets and can be resectedtumors >2cm higher risk of mets need greater extent of resection, tx with IFNa, octreotide, embolization
|
|
|
colorectal ca most common type
|
adeno
|
|
|
colorectal ca risk factors
|
fam hx, UC, polyps, hereditary polyposis syndromes, low fiber high fat diet, prev colon ca, alcohol, smoking, DM
|
|
|
colorectal ca most common mets to
|
lung and liver
|
|
|
colorectal ca h/p
|
change in bowel habits (more common in left sided ca), weakness, pain, constipation, hematochezia, melena, WL, abd or rectal mass
|
|
|
colorectal ca labs
|
guiac, anemia, CEA increased in 70% of pts, useful for monitoring purposes, biopsy is diagnostic
|
|
|
colorectal ca rads
|
barium enema, colonoscopy, CT/PET can det extent and mets
|
|
|
Fe def anemia in old men is what until proven otherwise
|
colorectal ca
|
|
|
which hereditary polyposis syndromes are caused by mutation in APC gene
|
FAP, Gardner's, Turcot
|
|
|
Duke's criteria for prognosis of colorectal ca
|
Class A: TMN1: tumor confined to bowel wall: cure rate 90%Class B: TMN2: penetration of tumor into colonic serosa/perirectal fat: cure rate 80%Class C: TMN3: LN involvement: cure rate <60%Class D: TMN4: distant mets: cure rate <5%
|
|
|
colorectal ca prev
|
screening >50yannual fobtflex sig q5ycolonoscopy q10y
|
|
|
what about FAP
|
tons of polyps, almost always dev into ca, prophylactic subtotal colectomy
|
|
|
HNPCC
|
multiple mutations, usually in proximal colon
|
|
|
Gardner's syndrome
|
similar to FAP with common bone and soft tissue tumors
|
|
|
Peutz-Jeghers synd
|
polyps are hamartomas with low risk of malig; mucocutaneous pigmentation of mouth, hands, genitals
|
|
|
Turcot synd
|
many colonic adenomas with high malig potential, comorbid malignant CNS tumors
|
|
|
Juvenile polyposis
|
colon, small bowel, stomach polyps are source of GI bleeds, slightly increased risk of ca later in life
|
|
|
what's the first thing you have to do with upper and lower GI bleeds
|
NG tube and lavage
|
|
|
Crit goal with GI bleeds
|
>30%
|
|
|
UGIB diff
|
PUD, mallory weiss tears, esophagitis, esophageal varices, gastritis
|
|
|
LGIB diff
|
diverticulosis, neoplasm, UC, mesenteric ischemia, AVMs, hemorrhoids, Meckel's
|
|
|
GI Bleeds rads
|
EGD/colonoscopy, barium swallow/enema, angiography, technetium scan for Meckel's
|
|
|
GI bleeds tx
|
fluid resus, PPI for UGIB until gastric cause is ruled out, prophylactic BBlockers for known varices to decrease chance of rebleeding, sclerotx, vasopressin may stop bleeding from AVMs and diverticula
|
|
|
what causes pancreatitis
|
GET SMASHEDGallstonesEthanol TraumaSteroidsMumpsAutoimmuneScorpion StingHypercal/HyperlipERCP, Drugs like Sulfa drugs
|
|
|
Ranson's Criteria on admission
|
GA LAW: Glucose >200AST>250LDH>350Age>55WBC >16000
|
|
|
Ranson's Criteria during initial 48 hours post presentation
|
Cal<8Hct dec >10%PaO2<60mmHgBUN inc >5Base deficit >4Sequestration of fluid >6L
|
|
|
pancreatitis h/p
|
epigastric pain rad to back, fever, n/v, Grey Turner's sign, Cullen' sign, steatorrhea if chronic, tachy
|
|
|
pancreatitis labs
|
increased amylase and lipase, glycosuria if chronic
|
|
|
pancreatitis rads
|
dilated loops of bowel near pancrease (sentinal loop), R colon distended until near pancreas (colon cutoff sign), enlarged pancreas, pseudocyst, pancreatic calc,
|
|
|
pancreatitis tx
|
hydration, opioids, NG suction, NPO, prophylactic abx for GI bacteria, debridement, enzyme supp if chronic
|
|
|
pancreatitis comp
|
abscess, pseudocyst, necrosis, obstruction, flstula formation, shock, DIC, sepsis, cancer if chronic
|
|
|
Exocrine pancreatic cancer location and type
|
head of pancreas, adeno
|
|
|
Exocrine pancreatic cancer risk factors
|
chronic pancreatitis, DM, fam hx, tobacco, high fat diet, male
|
|
|
Exocrine pancreatic cancer h/p
|
abdominal pain rad to back, nause, vom, WL, statorrhea, jaundice if bile duct obstructed, palpable nontender gallbladder (Courvoisier's Sign for gallbladder of pancreatic malignancy)
|
|
|
Exocrine pancreatic cancer labs
|
inc CEA and CA 19-9, hypergly, increased bilis, inc alk phos with bile duct obstruction
|
|
|
Exocrine pancreatic cancer rads
|
CT mass, dilated pancreas, local spread, ERCP can locate tumors
|
|
|
Exocrine pancreatic cancer tx
|
nonmets and limited to head can be treated with Whipple procedure, enzyme replacement, stenting of ducts for pallation
|
|
|
Exocrine pancreatic cancer comps
|
usually not detected until progressed, 5yr survival <2%, 20-30% 5 year survival after successful Whipple procedure, migratory thrombophlebitis (Trousseau's syndrome)
|
|
|
triad to start insulinoma workup
|
1. sxs of hypogly when fasting2. hypogly3. improvement with carb load
|
|
|
multiple insulinomas assoc w?
|
MEN1
|
|
|
What about insulinomas
|
HA, visual changes, confusion, weakness, mood instability, palps, diaphoresis Inc fasting insulin, positive C peptideUse CT/US/Indium Octreotide scan to localizeTx: resection; diazoxide or octreotide can alleviate sxs
|
|
|
What about Glucagonomas
|
alpha cell tumor causing hyperglyrefractory DMabd pain, diarrhea, WL, MSchange, Migratory necrolytic erythema, DM sxshypergly, increased glucagonCT/endoscopic US to localizeneed surg, octreotide, IFNalpha, chemo, embolization
|
|
|
What about VIPomas
|
VIP from nonbeta islet cellsWater Diarrhea, weakness, N/Vhigh stool osmolality points to secretory cause of watery diarrheaRads: CTTx: Steroids, chemo, resection, octreotide, embolization for mets
|
|
|
5 Fs for patients susceptible to gallstones
|
Fat, Forty, Female, Fertile, Fam Hx
|
|
|
Cholithiasis risk factors
|
5 Fs, OCP use, TPN, rapid WL, DM
|
|
|
what are gallstones usually made of
|
cholesterol, unless it's calcium bilirubinate (Pigmented stones) secondary to chronic hemolysis
|
|
|
Cholithiasis h/p
|
postprandial RUQ pain, n/v, palpable gallbladder
|
|
|
Cholithiasis rads
|
US
|
|
|
Cholithiasis tx
|
bile salts dissolve stones, shock wave lithotripsy, cholecystectomy
|
|
|
Cholithiasis comps
|
recurrent stones, acute cholecystitis, pancreatitis
|
|
|
who can get acalculous Acute cholecystitis
|
TPN or critically ill
|
|
|
Acute cholecystitis h/p
|
RUQ pain rad to back, n/v, fever, tenderness
|
|
|
Acute cholecystitis labs
|
WBC, inc bilis, inc alk phos with impacted stone or cholangitis
|
|
|
Acute cholecystitis rads
|
US, HIDA scan will show that gallbladder fails to fill normally
|
|
|
Acute cholecystitis tx
|
fluids, abx, endoscopic drainage followed by cholecystectomy after it calms down, if mild can to lithitripsy and bile salts, ERCP to deliver stone solvents
|
|
|
Acute cholecystitis comps
|
perf, ileus, abscess
|
|
|
Charcot's triad for cholangitis
|
Fever, RUQ pain, Jaundice
|
|
|
Reynold's pentad for cholangitis
|
Fever, RUQ pain, Jaundice, change in MS, Hypotension
|
|
|
rask factors for Cholangitis
|
cholithiasis, anatomic defect, biliary cancer
|
|
|
Cholangitis labs
|
WBC, positive cultures, bilis, alk phos, AST/ALT increase, increased amylase
|
|
|
Cholangitis rads
|
HIDA scan more sensitive than US
|
|
|
Cholangitis tx
|
hyd, abx, endoscopic drainage with cholecystectomy, emergency bile duct decompression and relief of obstruction if emergent and sxs severe
|
|
|
gallbladder cancer rads
|
calcified gallbladder from axr or US, ERCP to bipsy
|
|
|
Viral hepatitis vs alcohol hepatitis enzyme patterns
|
Viral hep: AST and ALT equally elevatedAlcoholic AST>ALT
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alcohol related liver dz h/p
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ascites, HSmegaly, fever, jaundice, testicular atrophy, gynecomnastia, digital clubbing
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alcohol related liver dz labs
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increased AST and ALT, inc GGT, inc alk phos, inc bilis, longer PT, WBC
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alcohol related liver dz tx
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thiamine, folate, high caloric intake, liver txplant
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alcohol related liver dz comp
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hepatic encephalopathy, cirrhosis, coag disorders
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causes of cirrhosis
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HEPATICHemochromatosisEnzyme def (alpha antitrypsin)PBC/PSCAlcoholismTumor (hepatoma)Infection (Hepatitis)Chronic cholecystitis/Copper (Wilson's)
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Cirrhosis h/p
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GI bleeding, HSmegaly, Jaundice, ascites, Caput Medusae, Spider Telangectasias, Palmar erythema, Dupuytren's contractures in hands, testicular atrophy, gynecomnastia, MS change, asterixis
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Cirrhosis labs
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AST ALT GGT Alk Phos, dec alb, anemia, dec platelets, longer PT
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Cirrhosis tx
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treat varices with beta blockers or sclerotx, lactulose + neomycin + low protein diet can improve encephalopathy, liver txplant
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Cirrhosis comp
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portal htn, varices, hepatic encephalopathy, renal failure, bacterial peritonitis
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Portal HTN prehepatic/hepatic/posthepatic causes
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prehepatic: portal vein thrombosishepatic: cirrhosis, schisto, granulomatous dzposthepatic: right sided heart failure, hepatic vein thrombosis, Budd-Chiari syndrome
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5 locations of varices as a result of portal HTN
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1. esophageal2. Hemorrhoids3. Caput medusae (paraumbilical vein to external iliacs)4. Renal (Gastro/Splenorenal veins)5. Paravertebral
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Portal HTN h/p
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ascites, pain, change in MS, GI bleeds, HSmegaly, testicular atrophy, gynecomnastia
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what does serum-ascites albumin gap (SAAG) tell you
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high gradient >1.1 is portal htnhigh gradient with high protein >2.5 is Budd Chiari or heart failure, with low protein <2.5 is cirrhosis of liverLow SAAG <1.1is ascites not due to portal htn, like nephrotic synd, TB, cancer
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portal htn tx
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salt restrictionIV abx for bac peritonitisDialysis for renal failurelactulose neomycin low protein diet for hep encVasopressin/sclerotx for varicesTIPS (Transjugular Intrahepatic Portocaval shunting)Liver txplant
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portal htn labs
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do a SAAG, increased serum ammonium, WBC, normal glucose
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lab signs for spontaneous bac peritonitis on paracentesis
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PMN>250Total protein >1glucose <50LDH >Normal serum LDH
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what lab signs on paracentesis make you suspicious of cancer
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if very high albumin and LDH is 60% of serum LDH
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hemochromotosis leads to Fe dep which organs
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liver, pancreas, heart, pituitary
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Hemochromatosis h/p
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abd pain, polyuria, polydipsia, pigmented bronze rash, hepatomegaly, testicular atrophy, may resemble DM or CHF
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Hemochromatosis labs
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inc Fe, Fesat, ferritinslightly inc AST and ALT
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Hemochromatosis tx
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weekly/biweekly phlebotomy, avoid alcohol, deferoxamine for chelation
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Hemochromatosis comp
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cirrhosis, hepatoma, CHF, DM, hypopit
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Wilson's dz deposits copper where
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liver, brain, cornea
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Wilson's dz h/p
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psych dist, personality changes, loss of coordination, tremor, Keyser-Fleischer rings, hepatomegaly
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Wilson's dz labs
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dec serum ceruloplasmin, inc urine copper,
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Wilson's dz tx
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trientine or penicillamine for copper chelation, lifelong zinc, copper restriction, B6 supp
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Wilson's dz comp
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hepatic failure, cirrhosis
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what does alpha 1 antitrypsin def cause
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cirrhosis, panlobular emphysema
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what is PBC
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autoimmune intrahepatic bile duct obstruction leads to accum of bili, bile acids, cholesterol
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PBC risk factors
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older females, autoimmune dz such as rheumatoid arth, scleroderma
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PBC h/p
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jaundice, HSmegaly, pruritis, skin hyperpig, xanthomas
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PBC labs
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inc alk phos and GGT, inc bili, but normal liver enzymesANA and AMA positive
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PBC tx
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Ursodeoxycholic acid, fat soluble vitamins
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what is PSC
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destruction of larger intra and extra hepatic bile ducts leading to fibrosis and cirrhosis
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PSC risk factors
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younger males, UC
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PSC h/p
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RUQ pain, pruritis, jaundice, fever, night sweats, xanthomas
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PSC labs
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inc alk phos and GGT, normal liver enzymes, increased bilis and cholesterol, possibly positive pANCA
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PSC rads
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ERCP pearls on a string bile ducts
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PSC tx
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Ursodeoxycholic acid, MTX, steroids, endoscopic stenting of strictures, surgical resection of affected ducts
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enzyme that conjugates bilis
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glucuronosyl transferase
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Gilbert's dz
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mild def of glucuronosyl transferase: mild jaundice after exercise, increased indirect bilis<5
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Crigler-Najjar syndrome type I
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severe def in glucuronosyl transferase: peristent jaundice and CNS sxs (kernicterus in infants), increased indirect >5
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Crigler-Najjar tx
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phototx, plasmapheresis, cal phos w/orlistat, liver tx
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Crigler-Najjar syndrome type II TX
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phenobarb which increases liver enzymes
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benign hepatic tumor types
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hepatic adenoma, focal nodular hyperplasia, hemangiomas, hepatic cysts
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who gets benign hepatic tumor
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women with hx of OCP use
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benign hepatic tumor rads
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hypervascular liver mass on CT, MRI or angio
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Hepatocellular carcinoma risk factors
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HBV, HCV, cirrhosis, hemochromatosis, Aspergillus infection, schisto
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Hepatocellular carcinoma h/p
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jaundice, diarrhea, WL, RUQ pain, hepatomegaly, bruit over liver, ascites
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Hepatocellular carcinoma labs
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increased AFP,slightly inc AST and ALT, in alk phos, inc bilis t and d, biopsy has to be carefully done cause it can hemorrhage
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Hepatocellular carcinoma comps |
poor prog, portal vein obstruction, Budd Chiari, liver failure |
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what are Dubin-Johnson and Rotor's syndromes
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inability to excrete conjugated bilis from liver: benign but black liver
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most common type of TEF
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distal fistula with proximal esophageal atresia
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TEF h/p
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coughing, cyanosis during feeding, food filled blind pouch, abdominal distention, hx of aspiration pna
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TEF rads
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do a cxr with NG tube insertion which demonstrates tube in lung or blind pouch
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what about Pyloric stenosis
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olive sized epigastric mass, projective vomiting, barium swallow shows thin pyloric channel (string sign), US shows inc pyloric muscle thickness
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pyloric stenosis tx
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pyloric myotomy
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what about Necrotizing enterocolitis
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risks: preterm, LBW, bilious vomiting, hematochezia, abdominal distention and tenderness, signs of shocklabs: met acidosis, hypoNaRads: bowel distention, air in bowel wall, portal vein gas, or free air under diaphragm. Tx: TPN, abx, NG suction, resection of affected bowel
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what about Hirschsprung's Dz
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obstipation, failure to pass stool, abd distention, bowel biopsy shows absence of ganglion cellsRads: dilated bowel, barium enema shows proximal dilation with distal narrowing (Megacolon)Tx: colostomy and resection
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what about Intussusception
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most common cause of obstruction in first 2 years, most commonly at ileocecal valveIt's considered cancer in an adult until proven otherwiserisks: Meckel's, HSP, adenovirus, CFintermittent abdominal pain, currant jelly stool, palpable sausage like abd masslabs: inc WBCRads: barium enema shows obstruction, US or CT can detect abnormal bowelTx: barium enema can reduce, if not surgComp: bowel ischemia esp appendix
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what about Meckels
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rule of 2s: Males 2x more likely, within 2ft of ileocecal valve, 2 types of ectopic tissue (gastric/pancreatic), 2% of population, most comps before 2yrsremnant of vitelline duct, outpouching of ileumpainless rectal bleeding, intussusception, diverticulitisrads: detected by nuclear scan technetiumtx: surgical resection
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causes of neonatal jaundice
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physiologic, G6Pd, bili overproduction without hemolysis: hemm, mat-fet transfusion, Gilbert's, Crigler-Najjar, biliary atresia
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kernicterus sxs
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jaundice, scleral icterus, lethargy, high pitched cry, seizures, apnea
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what points to nonphysiologic jaundice in newborn
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total bilis >15 or direct bili >2
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neonatal jaundice tx
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phototx, exchange txfusion, IVIG if blood incompatibility
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FTT definition
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below 3rd percentile weight for age
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FTT workup
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UA, CBC, cultures, lytes, CF, food records, suspect neglect or abuse, parental training for feeding and nutrition
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