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causes of chronic hepatitis?

Hep B, C, D; autoimmune Hep, alcoholic Hep, NASH, medications, Wilson disease



(liver inflm > 3-6 mo)

Pathophys Hep A

RNA hepatovirus;


incubation = 15-50 days;


fecal-oral (contaminated food/water, IVDU)



temporary, low mortality

S/Sx hepatitis

acute 2-3 wks:



low fever, N/V, diarrhea, constipation,


pale gray stools, fatigue, myalgia,


RUQ/epigastric pain, jaundice



aversion to smoking


Dx Hep A

IgM: peaks in 1 wk, gone in 3-6 mo


IgG: in 1 mo, lasts for years (= immunity)



elevated AST, ALT, bilirubin, ALP

preventing Hep A

hygiene, vaccine


(2 doses separated by 6-18 mo)



contraindicated in HIV (?)

Tx Hep A

supportive,


steroids ineffective



recovery in 3 mo;


avoid alcohol & exercise

Pathophys Hep B

DNA virus,


incubation = 6 wks - 6 mo;


more gradual onset than HAV & lasts longer;



blood transmission


(highest transmission = heterosexual)


preventing Hep B

vaccine (0 mo, 1 mo, 6 mo)



If exposed, Hep B globulin w/i 7d, then vaccine

Tx Hep B

supportive;


if Sx of encephalopathy/coagulopathy, hospitalize



recovery in 3-6 mo



r/o co-infx w/ Hep D

pathophys Hep C

ssRNA virus;


incubation = 6-7 wks



>50% from IVDU


low risk of sexual/maternal transmission



blood transmission

Tx Hep C

aggressive;


peginterferon 6-24 wks (NOT w/ preg/lactation);


if still present after 3 mo, add ribavirin



80% become chronic,


30% get cirrhosis,


risk of non-Hodgkins & DMII

Tx chronic HBV/HDV

nucleoside & nucleotide analogs


(entecavir, tenofavir, etc)



risks: cirrhosis, liver failure, CA

pathophys autoimmune Hep

most common = young women;


assoc. w/ HLA-B8, -DR4, -DR3;



triggered by viral illness, drugs, postpartum

S/Sx autoimmune Hep

spider nevi, striae, acne,


Hirsutism (manly hair), hepatomegaly,


arthritis, thyroiditis, hemolytic anemia

Dx autoimmune Hep

p-ANCA, anti-SLA Ab;


positive ANA or smooth muscle antibodies



elevated ALT, AST, & total bilirubin

Tx autoimmune Hep

prednisone +/- azathioprine



40% recurrence; may need liver transplant

What is NASH?

non-alcoholic steatohepatitis;


is most severe form of non-alcoholic fatty liver disease



at risk = obese, elderly, non-AA, females, DM, HTN

causes of non-alcoholic fatty liver disease

obesity, DM, hypertriglyceridemia, meds (steroids, amiodarone, tamoxifen), toxins, endocrine (Cushings, PCOS), TPN, pregnancy



higher risk = metabolic syndrome, hispanic, psoriasis, soft drinks

S/Sx non-alcoholic fatty liver disease

asymptomatic;


RUQ pain, hepatomegaly;


rarely present w/ liver failure;



ALT > AST

Dx non-alcoholic fatty liver disease

liver biopsy

Tx for non-alcoholic fatty liver disease

wt loss, exercise, reduce alcohol intake;



consider gastric bypass, metformin, vit E, liver transplant

prognosis for non-alcoholic fatty liver disease

reversible if underlying cause is Tx;


1-3% of untreated -> cirrhosis

pathophys primary biliary cirrhosis

AI destruction of bile ducts -> cholestasis;


women 40-60 y/o, genetic



may be assoc. w/ scleroderma, Raynauds, Celiac disease



develops after infx;


risks = recurrent UTI, smoking, hormone replacement therapy

S/Sx primary biliary cirrhosis

asymptomatic for years;


fatigue & pruritus;


xanthomatous skin lesions,


orthostatic hypotension



higher risk for osteoporosis, fractures

Dx primary biliary cirrhosis

elevated ALP,


anti-mitochondrial antibodies



liver biopsy (for staging only)

Tx primary biliary cirrhosis

supportive;


cholestyramine/naloxone/zofran for itch



ursodeoxycholic acid slows progression;


if advanced = liver transplant

prognosis primary biliary cirrhosis

survival rate = 7-10 yrs;


increased risk of liver CA



20% recurs even w/ transplant

pathophys hemochromatosis

auto recessive; HFE mutation, chrom 6;


increased Fe absorption from duodenum



usually >50 y/o

S/Sx hemochromatosis

hepatomegaly,


arthropathy,


gray/brown/bronzy skin,


cardiomegaly,


erectile dysfunction,


DM, CA risk,


esophageal varices

Dx hemochromatosis

elevated AST, ALP;


elevated iron, transferrin sat, & ferritin



any pt w/ iron overload = test for HFE mutation;



MRI & CT; liver biopsy confirms



(test all 1st degree relatives for HFE!)

Tx hemochromatosis

if symptomatic/severe, weekly phlebotomy


until iron depleted (2-3 yr), then PRN;


may need liver transplant



PPIs, deferoxamine (if can't phlebotomy)



avoid iron, EtOH, vit C, shellfish

pathophys Wilson's disease

chrom. 13; excess copper;


deposits in liver, brain, cornea, kidney



usually <40 y/o

S/Sx Wilson's disease

liver/neuro disease in young adults;


may have cirrhosis, portal HTN



Parkinson's-like rigidity,


personality changes/swings,


Kayser-Fleischer rings,


hypoparathyroidism, infertility, hemolytic anemia

Tx Wilson's disease

penicillamine + pyridoxine (PO)


(increases urinary copper excretion)



lifelong Tx; restrict copper intake


(shellfish, nuts, mushrooms, chocolate)



family members need screened

most common pathogens for liver abscess?

E. coli, Klebsiella, Proteus, Enterobacter

Most common cause of liver abscess?

ascending cholangitis



(can also be secondary to appendicitis, diverticulitis, or idiopathic)

S/Sx liver abscess

insidious onset,


RUQ pain, jaundice, fever

Dx liver abscess

elevated WBC, LFTs;


visible on CT, US, MRI

Tx liver abscess

cephalosporin + flagyl



may need drainage

pathophys primary sclerosing cholangitis (PSC)

inflm, fibrosis, strictures of biliary system;


males > females; assoc. w/ IBD



risks: familial, elderly, low BMI, smoking, longterm IBD, AI pancreatitis


(HLA-B8, -DR3, -DR4)

S/Sx primary sclerosing cholangitis (PSC)

asymptomatic;


jaundice, fatigue, pruritus, anorexia;


esophageal varices

Dx primary sclerosing cholangitis (PSC)

elevated ALP;


gold = MRCP, ERCP



fibrosis on liver biopsy

Tx primary sclerosing cholangitis (PSC) & prognosis

ciprofloxacin,


+/- balloon dilation/stenting of strictures



if cirrhosis, prefer liver transplant



avg survival = 12-17 yrs

most common cause of cirrhosis in the US?

alcoholic liver disease

pathophys alcoholic liver disease

alcohol abuse



women > men; often reversible


most common cause of cirrhosis in the US

S/Sx alcoholic liver disease

hepatomegaly -> end-stage cirrhosis,


jaundice, nausea, splenomegaly,


ascites, fever, encephalopathy



susceptible to infection

Dx alcoholic liver disease

AST > ALT (usually >2:1); high GGT



high ALP, bilirubin;


low albumin

Tx alcoholic liver disease

No alcohol;


thiamine + glucose together


(to avoid Wernicke-Korsakoff);



methylprednisolone or pentoxifylline


(TNF-inhibitor)



liver transplant

Most common causes of drug/toxin induced liver disease?

APAP (tylenol),


NSAIDs + abx



(others: niacin, heavy metals, 6MP, valproic acid, amiodarone, duloxetine, phenytoin)

Subfulminant vs. fulminant liver failure?

Subfulminant: encephalopathy >8 wks after onset



Fulminant: encephalopathy within 8 wks of onset

pathophys of acute liver failure

either subfulminant or fulminant;


higher risk w/ diabetes;


APAP most common cause



worse prognosis in obesty, <10 y/o, >40 y/o

S/Sx of acute liver failure

N/V, SIRS, renal dysfunction, hemorrhage;


RUQ pain, abd swelling, jaundice;


fatigue, confusion

stages of acetaminophen toxicity

1: asymptomatic; anorexia, N/V, malaise



2: (18-72h) RUQ pain, tachycardia, HOTN



3: (72-96h) hepatic necrosis, jaundice, coagulopathy, encephalopathy, acute renal failure



4: (4d-3wks) recovery

Dx acute liver failure

high AST, ALT, ALP, bilirubin;


elevated serum amylase & ammonia



(if APAP toxicity, AST & ALT often >5000


- get serum acetaminophen levels)


Tx acute liver failure

correct metabolic abnormalities;


prevent cerebral edema (Mannitol) & sepsis;


lactulose for encephalopathy;


consider hypothermia



if APAP, acetylcysteine;


if mushroom, penicillin G or silibinin

pathophys of cirrhosis

hepatocellular injury causing fibrosis/nodules;


higher risk in AA, Mexicans;



common causes = EtOH, Hep C, NAFLD, Hep B


main genetic cause = hemochromatosis

S/Sx cirrhosis

fatigue, wt loss, abd pain w/ N/V, hematemesis, hepatosplenomegaly,


sexual dysfunctions, spider angioma,


palmar erythema, Dupuytren contractures, asterixis, GI bleed

Dx cirrhosis

liver biopsy



anemia, prolonged PT,


elevated AST, ALP, bilirubin,


decreased albumin

Tx cirrhosis

liver transplant (cure)



balanced diet, d/c alcohol,


vaccinate for Hep A & B

possible complications of cirrhosis


& their treatments

ascites & edema (paracentesis);


bacterial peritonitis (ceftriaxone, augmentin);


hepatorenal syndrome (transplant);


encephalopathy (lactulose);


coagulopathy (vit K, clot factors);


esophageal varices (octreotide, tamponade);


hepatopulmonary syndrome (O2)

Risk factors for hepatocellular carcinoma?
How to Dx?

cirrhosis, males, >55 y/o;


Asian, Hispanic, FHx;


obesity, EtOH, DM, hypothyroid, Hep C



(Dx = liver biopsy)

T staging of hepatocellular carcinoma

T1: single avascular tumor


T2: single vascular tumor, or multiple <5 cm


T3: multiple tumors >5 cm


T4: tumor w/ invasion of other organs

monitoring pts w/ liver disease?

a-fetoprotein & US q6 month in pts w/:


- chronic Hep B


- chronic Hep C


- cirrhosis

absolute contraindications for liver transplant

malignancy (unless small),


advanced cardiopulmonary disease,


sepsis

relative contraindications for liver transplant

>70 y/o, morbid obesity,


portal or mesenteric vein thrombosis,


active EtOH or drug abuse,


noncompliance

Tx & prognosis of hepatocellular carcinoma

resection, chemo, radiation,


tumor embolization



1 yr survival = 23%


5 yr survival = 5%


high AFP at diagnosis -> worse prognosis

most common type of benign liver mass?

hemangioma

hepatocellular adenoma

is a benign liver mass;


assoc. w/ oral contraceptives,


often resolve once OCP d/c



surgical resection unnecessary unless


painful or concern for malignancy

cancers that commonly metastasize to the liver?

colorectal, pancreatic, stomach, lung, breast

risk factors for acute pancreatitis?

Celiac disease, smoking, age, obesity, hypertriglyceridemia, peritoneal dialysis



(most common causes = gallstones, alcohol)

assessing severity of pancreatitis

Ranson criteria, SODA, APACHE II score

S/Sx of acute pancreatitis

sudden onset;


severe epigastric pain, radiation to back;


worse w/ activity, laying flat;


improved w/ sitting, leaning forward (tripod)



N/V, fever, tachycardia, HOTN

Dx acute pancreatitis

amylase & lipase >3x ULN


(lipase is more specific)



elevated BUN, creatinine, ALP, AST, ALT, CRP;



US only for gallstones;


CT & MRI useful (caution w/ contrast)

Ranson criteria (on admission)

(3+ = pancreatic necrosis)



55+ y/o


WBC >16


glucose >200


LDH >350


AST >250


(scale for acute pancreatitis severity)

biggest risk factor for chronic pancreatitis?

alcoholism ( up to 80% of cases)

risk factors assoc. with chronic pancreatitis?

alcohol, smoking, obstructing stone,


cystic fibrosis, hyperparathyroidism,


recurrent pancreatitis, idiopathic

S/Sx of acute pancreatitis vs. chronic pancreatitis?

both: epigastric/LUQ pain radiating to back, N/V, can be episodic



chronic: anorexia, wt loss, steatorrhea (bulky, fatty stool), constipation, pain may become constant

Most sensitive imaging for chronic pancreatitis? What's its downside? Alternatives?

ERCP (but may cause pancreatitis itself)



alternates: MRCP, EUS


consider biopsy?

Tx chronic pancreatitis

lifestyle: no alcohol, low-fat diet, avoid opioids, check pancreatic enzymes before & after meals



H2 blockers, PPI, sodium bicarb,


octreotide (for idiopathic),


prednisone or azathioprine (for autoimmune),


surgery, stents +/- radiation

possible complications of chronic pancreatitis?

80% develop DM, opioid addiction, pancreatic CA, pseudocyst, mechanical obstruction

most common type of pancreatic CA?

carcinoma

risk factors for pancreatic CA?

age (strongest factor), alcoholism, obesity, chronic pancreatitis, abd radiation, FHx

T staging pancreatic cancer

T1: in pancreas, 2 cm or less


T2: in pancreas, >2 cm


T3: beyond pancreas, but no celiac or mesenteric


T4: involves celiac & mesenteric

S/Sx pancreatic cancer

asymptomatic,


epigastric/diffuse pain radiating to back;


decreased by sitting/leaning forward;


diarrhea, wt loss, depression, jaundice



new onset DM >45 y/o or acute pancreatitis;



palpable gallbladder (Courvoisier law),


Sister Joseph nodule (hard periumbilical node from metastasis)



Courvoisier's law

enlarged, non-tender gallbladder w/ mild jaundice = malignancy of gallbladder or pancreas



(unlikely to be gallstones)

Dx pancreatic cancer

hyperglycemia,


LFT, amylase, & lipase elevation,


CA 19-9, CT, MRI, EUS, MRCP/ERCP

Tx pancreatic cancer

Whipple procedure,


bile duct decompression,


chemo,


celiac plexus block (pain relief)



poor prognosis

What presentation suggests the problem is gallbladder-related?

"I ate a fatty meal and got symptoms."

pathophys: cholelithiasis

gallstones; idiopathic


assoc. w/ high cholesterol or calcium



women > men, >60 y/o,


5 "F"s = fair, fat, female, fertile, forty

Tx cholelithiasis

laparoscopic cholecystectomy



(no treatment unless Sx)

pathophys: acute cholecystitis

inflm of gallbladder;


most from stone obstructing cystic duct

S/Sx of acute cholecystitis

triggered by large/fatty meal;


RUQ/epigastric pain > 12-18h,


N/V, loss of appetite



if severe jaundice, suggests choledocholithiasis

Dx acute cholecystitis

+ Murphy sign,


leukocytosis, elevated LFTs;


US is best imaging,


may need HIDA scan (bile tracer)



if suspect choledocholithiasis, MRCP or ERCP

Tx acute cholecystitis

pain meds, IV abx, NPO



Zosyn, cephalosporin, or


ciprofloxacin +/- flagyl



cholecystectomy within 2-4 days of admission

Pathophys choledocholithiasis

stone in common bile duct;


risk greater w/ age;


leads to cholangitis (inflm common bile duct)



may have Hx of recurrent biliary pain, indicating prev. episodes of cholecystitis

Charcot's triad


(& Reynold's pentad?)

recurrent RUQ pain,


fever & chills,


jaundice



(indicative of acute cholangitis)



Reynold's: w/AMS, HOTN (ascending cholangitis)

Dx choledocholithiasis

very high AST & ALT (often >1000),


elevated bilirubin, ALP, amylase, lipase


do MRCP, ERCP (diagnostic)



if acute cholangitis, leukocytosis

Tx choledocholithiasis

IV abx (cipro +/- flagyl or zosyn)



remove stones to prevent complications


(e.g. pancreatitis) via ERCP,


then laparoscopic cholecystectomy

biliary dyskinesia

altered tone of Sphincter of Odi;


EF <35% on HIDA scan



Tx w/ cholecystectomy

cause & Tx of bile salt diarrhea

may develop post-cholecystectomy;



Tx cholestyramine

pathophys: cholangiocarcinoma

carcinoma in the bile ducts;


50-70 y/o M;


most common site = junction of hepatic ducts


(aka Klatskin tumor)



risks: UC, cirrhosis, DM, hyperthyroid, pancreatitis, EtOH, helminth infx, Hep C, HIV, NASH, obesity, tobacco

Dx cholangiocarcinoma

conjug. hyperbilirubinemia,


elevated ALP,


normal/slightly elevated AST,


CA 19-9



US, CT, MRCP, EUS

Tx cholangiocarcinoma

surgery (if young, healthy),


chemo, palliative



liver transplant may slow progression

prognosis: cholangiocarcinoma

rapid & progressive;


death typically in a few months

pathophys: achalasia

"without relaxation" of LES;


1/100,000; 25-60 y/o



loss of ganglion cells @ LES -> no relaxation

S/Sx achalasia

Bird's beak,


dysphagia of both solids & liquids,


regurg. of undigested food,


can't belch

Dx achalasia

manometry (needed for Dx);


need endoscopy to r/o CA



"Bird's beak" on barium swallow;


on x-ray, dilated esophagus

Tx achalasia

low risk: pneumatic dilatation, myotomy



high risk: botulinum to relax sphincter, SL nitrates or nifedipine (CCB)

pathophys: scleroderma

smooth muscle fibrosis;


often affects lower esophagus first


(upper esophagus is spared)

S/Sx scleroderma of esophagus

reflux, eroded teeth, dysphagia, aspiration PNA

Dx scleroderma of the esophagus

manometry,


endoscopy (Dx reflux esophagitis, Barrett's, stricture, candida)

Tx scleroderma

PPI (for reflux), monitor for Barrett's;


prokinetics (metoclopramide, erythromycin)

Dx diffuse esophageal spasm

manometry (constant high amp. contraction);



on barium swallow: corkscrew, rosary beads, pseudodiverticula

pathophys: Zenker diverticulum

hernia above UES,


mostly male, >60 y/o

S/Sx Zenker diverticulum

dysphagia, halitosis,


regurgitation,


"food stuck in throat,"


aspiration

Dx Zenker diverticulum

barium swallow

Tx Zenker diverticulum

surgery

pathophys: Schatzki ring

found in 15% of barium swallows;


defined as <12 mm;


occur at GE junction;


almost always assoc w/ hiatal hernia

S/Sx & Dx of Schatzki ring?

S/Sx: solid food dysphagia



Dx: endoscopy

Contrary to popular belief, GERD is NOT related to...

smoking, NSAIDs, gastric hypersecretion

S/Sx GERD

heartburn (pyrosis)


- postprandial, reclining, better w/ antacid;



regurg. of bitter & sour tastes,


chest pain w/ radiation to neck,


wheezing/coughing


Dx GERD

mainly based on history;


may feel better w/ PPI;



most have no signs on endoscopy,


barium swallow not helpful,


Berstein test (acid/saline infusion) is mean

Most effective treatment for reflux?

weight loss

Tx GERD

PPIs 30 min before meals


(fails b/c heartburn, improper use)



surgery - Nissen fundoplication (meat wrap)

Gold standard for Dx hiatal hernia?

barium swallow


(look for air fluid level)

Tx hiatal hernia

if asymptomatic, nothing;


Tx underlying GERD

risk factors for Barrett's esophagus?

white, male, smoker, chronic GERD, obesity

S/Sx of Barrett's esophagus

salmon-colored change in esophagus;


S/Sx of GERD

Whom might we screen for Barrett's esophagus?

chronic GERD, hiatal hernia,


>50 y/o, male, white, obese

Tx Barrett's esophagus

PPIs for underlying GERD;


endoscopic ablation (1st step);


esophagectomy (3-15% mortality)

S/Sx of medication-induced esophagitis

may be asymptomatic;


retrosternal pain,


odynophagia, dysphagia,


located near aortic arch

Dx medication-induced esophagitis

endoscopy

S/Sx of infectious esophagitis? Implicated pathogens?

(candida, CMV, HSV1)



may be asymptomatic;


cottony feeling, odynophagia,


scrape-able pseudomembrane

Dx infectious esophagitis

KOH prep

When do we see infectious esophagitis from HSV? CMV?

HSV: solid organ transplant



CMV: AIDS

most common agents causing caustic esophagitis?

strong alkali (KOH, NaOH),


drain cleaner, battery, lye

Dx caustic esophagitis

endoscopy (necrosis),


barium swallow

Biggest contributors to esophageal SCC in the US?

smoking & alcohol

Esophageal cancer is typically one of these 2 types:

squamous cell carcinoma (smoking, alcohol)


adenocarcinoma (from Barrett's, obesity)



adenoCA more common in US,


SCC more common worldwide

Name 4 factors that can contribute to the development of adenocarcinoma?

GERD (Barrett's), obesity, smoking, hypersecretion (e.g. Zollinger Ellison syndrome)



(alcohol is NOT a risk factor)

S/Sx of esophageal cancer

solid food dysphagia, then both solid & liquid;


rapid wt loss, iron deficient anemia



(mid-esophagus = SCC,


lower esophagus = adenoCA)

Dx esophageal cancer

endoscopy


(look for "apple core")

most common specific cause of upper GI bleed?

peptic ulcer


(is from H. pylori, NSAIDs, etc)

Dx upper GI bleed

endoscopy (sensitive & specific)



if perforation risk, esophageal capsule



(NO barium - interferes w/ future endoscopy or surgery)

What does an elevated BUN to creatinine ratio suggest?

GI bleed


(>20-100:1)

Tx upper GI varices

transfusion, PPI, abx,


octreotide (to constrict vessels),


vasopressin (decrease flow),


vit K (but probs won't work),


endoscopic band ligation, TIP,


balloon tamponade



longterm: liver transplant

S/Sx peptic ulcer disease

dyspepsia, burning/hunger pain;



duodenal ulcer = relief w/ food


gastric ulcer = worse w/ food


Dx peptic ulcer disease

barium swallow, endoscopy



H. pylori test


(may be false neg. w/ bismuth, abx, UGI bleed, PPI - need 2 tests)

DDx peptic ulcer disease

gastric carcinoma


(every gastric ulcer must be biopsied);


drug-induced (esp. NSAIDs)

Tx peptic ulcer disease

no smoking, NSAIDs, smoking, alcohol, stress



eradicate H. pylori


(metronidazole, macrolide, PPI, peptobismol),


PPI (omeprazole),
(maintenance = H2 blockers (cimetidine))



if duodenal: antacids, sucralfate

Drugs to eradicate H. pylori?

metronidazole, macrolide, PPI, peptobismol

Precipitating factors for Mallory-Weiss syndrome

vomiting, straining, seizure, trauma, colonoscopy prep, hiatal hernia

Tx Mallory-Weiss syndrome

many resolve on own



blood transfusion,


inject Epi, ethanol, other sclerosants

Boerhaave syndrome

UGI bleeding,


shoulder pain,


free air under diaphragm on xray



rare but fatal

S/Sx of lactase deficiency

bloating, cramps, flatulence, osmotic diarrhea



(no malabsorption or wt loss)

Dx lactase deficiency

hydrogen breath test,


trial of lactose-free diet

S/Sx Celiac disease

diarrhea, steatorrhea, wt loss, distention, weakness, growth retardation (if <2 y/o);


fatigue, osteoporosis,


iron deficiency anemia,


infertility, dermatitis herpetiformis

Dx Celiac disease

IgA tTG antibody,


IgA endomysial antibody



biopsy of distal duodenum or proximal jejunum (by EGD) - blunting of villi

possible causes of small intestinal bacterial overgrowth (SIBO)

gastric achlorhydria (decreased HCl),


anatomic abnormality (surgery),


motility disorder (scleroderma, DM),


fistula

S/Sx of SIBO

malabsorption (diarrhea, gas),


asymptomatic, wt loss,


vit/mineral deficiencies

Dx SIBO

jejunal aspiration/culture;



fecal fat, hydrogen breath testing, may need CT enterography

Tx SIBO

Rifaxmin (cyclic therapy),


cipro, norfloxacin, augmentin,


flagyl + bactrim, cephalexin

S/Sx short bowel syndrome

Terminal ileum:


>50 cm removed = malabsorp. B12


>100 cm removed = malabsorp. bile salts



Duodenal resection:


folate, iron, calcium malabsorption

Tx short bowel syndrome

Vit/Mineral replacement:


B12 injections,


cholestyramine (bile salts)



loperamide, lomotil, octreotide


S/Sx of Whipple disease

arthralgia/arthritis,


abd pain, diarrhea, malabsorption,


wt loss, fever, hyperpigmentation

Dx Whipple disease

endoscopic biopsy


(PAS-positive macrophages w/ G+ bacilli;


may need PCR to confirm)

Tx Whipple disease

abx for 1 year


(ceftriaxone, meropenem, bactrim)



if untreated, fatal

colon polyps - pathologic groups

mucosal adenomatous,


serrated, neoplastic, submucosal

S/Sx colon polyps

usually asymptomatic,


chronic blood loss or hematochezia

Dx colon polyps

colonoscopy



FOBT, barium enema,


CT colonography, capsule endoscopy

Tx colon polyps

remove during colonoscopy

surveillance of adenomatous colon polyp

1-2 small polyps: q5-10y


3+ small polyps, or >1cm: q3y


>10 polyps: q1-2y

surveillance of serrated colon polyp

1-2 small polyps: q5y


>1 cm polyp: q3y

pathophys: familial adenomatous polyposis

auto dominant on chrom 5;


avg polyps at 15, colon cancer at 40

S/Sx familial adenomatous polyposis

colon polyps



+ extra-intestinal manifestations


(soft tissue tumors, osteomas, hypertrophy of retinal pigment)

Dx familial adenomatous polyposis

colonoscopy q1-2 starting at age 10-12



screen 1st deg relatives

pathophys: Lynch syndrome

auto dominant; "nonpolyposis colon CA"


increased risk of colorectal, endometrial, renal, etc. CA

surveillance of Lynch syndrome

colonoscopy yearly beginning age 25


(or 5 years younger than Dx age)



screen family members too

Tx Lynch syndrome

yearly monitoring w/ colonoscopy, etc.



if CA, subtotal colectomy w/ ileorectal anastomosis

Most common type of colorectal cancer? Where are they located

adenocarcinoma;


distal to splenic flexure

risk factors for colorectal cancer?

FHx, IBS, high fat/red meat diet, DM,


obesity, smoking, etc.


African Americans

R-sided vs. L-sided lesions in colorectal CA?

R-sided: more likely to bleed



L sided: more likely to cause abd pain, changes in bowel habits, obstruction

S/Sx colorectal CA

grow slowly;


palpable mass, urgency, hematochezia,


tenesmus (sense have to go, but don't)

Dx colorectal CA

Gold = colonoscopy; CEA



CBC for anemia, LFTs to r/o mets;


CT for staging

surveillance after colorectal CA

CEA q3-6m for 3-5 years



CT annually for 3 years



colonoscopy q3-5 years

T staging for colorectal CA

T1: thru muscularis mucosa into submucosa



T2: thru submucosa into muscularis propria



T3: thru muscularis propria; not colon/rectum



T4: thru serosa

Tx for colorectal CA

surgery, chemo, radiation



stage I-II = surgery


stage III = chemo (FOLFOX)


stage IV = FOLFOX + bio agent


(bevacizumab, cetuximab, etc)

screening for colorectal CA

>50 y/o: annual FOBT, colonoscopy q10y



if 1st deg relative, start at 40, q5y


(or 10 years before Dx)

most common type of anal carcinoma?

squamous cell;


risk: Hx anal sex, anorectal warts, HPV

Dx anal carcinoma

CT or MRI



(PET used for staging)

pathophys small intestine adenocarcinoma

aggressive (most have mets @ Dx);


often in duodenum or prox. jejunum;


increased incidence w/ Crohn's

Tx small intestine adenocarcinoma

resection, chemo



poor prognosis

pathophys: small intestine lymphoma

most common in ileum;


most are non-Hodgkin's lymphoma;


increased incidence w/ Crohn's, Celiac, etc.

Dx small intestine lymphoma

biopsy

Tx small intestine lymphoma

resection +/- chemo, radiation

S/Sx carcinoid syndrome?

facial flushing, cramps, diarrhea


(from small intestine carcinoid tumor)

"step-up" therapy for IBD

5-ASAs (Pentasa)


-> steroids (prednisone)


-> immunomodulators (AZA/MTX)


-> anti-TNF (infliximab)

specific corticosteroid used for Tx of Crohn's?

budesonide (Entocort)

The only biologic agent approved for use in UC?

infliximab

S/Sx ulcerative colitis?

bloody diarrhea,


flares & remission



may have: abd pain, fever, anemia

Dx ulcerative colitis

endoscopy


(edema, friability, erosions);


p-ANCA,


x-ray can assess dilation



**avoid endoscopy in fulminant disease

Key points about Crohn's disease

anywhere along GI tract (mouth-to-anus);


transmural inflammation,


crampy RLQ/periumbilical pain,


skip lesions, granulomas



no surgical cure

Dx Crohn's disease

ASCA (vs. p-ANCA in UC), skip leions

Chrohn's vs. UC?

UC: localized to colon, continuous, superficial, bleeding, is curable


(-> toxic megacolon, CA)



Crohns: throughout GI tract, skip lesions, transmural, non-bleeding, more aggressive Tx, incurable


(-> abscess, obstx, stricture, fistula)

surveillance of pts w/ IBD?

colonoscopy w/ biopsy q1-2 years starting 8 years after Dx (for colon CA)



If dysplasia or carcinoma, do colectomy

S/Sx of fulminant colitis

toxic appearance,


fever, hypovolemia,


profuse bleeding


(often need transfusion)



high risk for toxic megacolon

Tx fulminant colitis

IV steroids (if no abscess),


IV abx



may need surgery

toxic megacolon

colon dilation >6 cm



Dx: abd exam & X-ray



Tx: ambulate or roll from side-to-side to decompress colon; may need surgery

best diagnostic test for appendicitis?

CT

Tx appendicitis

appendectomy;



broad spec abx (unasyn) before surgery

Location of most diverticula?

sigmoid colon & descending colon;


more common on left side


(but bleeding more common on R-side)

most common cause of lower GI bleed?

diverticular bleeding


(large vol. hematochezia, may be maroon)

Tx diverticulitis

clear liquid diet,


augmentin, cipro/flagyl 7-10d



if hospitalized, zosyn



surgery = Hartmann procedure



(get colonoscopy 1 mo after Tx to r/o CA)

Most common cause of small bowel obstruction? Large bowel obstruction?

Small: adhesions from surgery



Large: malignancy

S/Sx of bowel obstruction

N/V, abd pain, distention, constipation, lack of flatulence, belching

pathophys: colonic pseudo-obstruction (ogilivie syndrome)

spontaneous dilation of cecum & prox. colon;


may occur after surgery/trauma

Tx colonic pseudo-obstruction

roll pt from side to side, knee-chest position;


avoid laxatives (enemas are okay);



Neostigmine (decompresses)

pathophys ileus

no peristalsis w/o signs of actual obstruction;


usually after surgery;


assoc. w/ hypokalemia

Tx ileus

manage possible causes; NPO



if opioid-related, alvimopan


(mu-opioid receptor antagonist)

Most common cause of intestinal obstruction in kids <3 y/o?

intussusception

S/Sx of intussusception?

N/V, cramping,


red currant jelly stool (blood & mucus);


kid cries, draws knees to chest

Tx intussusception

air/barium enema



prevent dehydration & shock


(NG tube, IVF, abx, surgery)

pathophys: volvulus

bowel twists on itself;


males, often in 1st year



signs of obstruction, bilious vomiting


Dx volvulus

barium enema, CT

Tx volvulus

surgery

Types of lower GI bleeds in older pts vs younger pts?

<50 y/o: anorectal (hemorrhoids, etc), colitis



>50 y/o: diverticulitis, CA, angiectasia, ischemia

Dx ischemic colitis

colonoscopy (preferred)



ABG (acidosis), CT,


barium enema (thumbprinting, air-filled loops)

Tx ischemic colitis

mild: supportive (bowel rest, IVF)



most improve 1-2 days

Dx constipation

DRE, abd exam


CBC, BMP, TSH, FOBT

Tx fecal impaction

enema (saline, mineral oil) or digital removal,


then prevent constipation

If diarrhea worsens or lasts >7 days, send for these labs...

fecal leukocyte/lactoferrin,


O & P, bacterial culture

antidiarrheal agents

loperamide, lomotil,


clonidine (for secretory diarrhea),


octreotide (for secretory diarrhea)

inflammatory vs. non-inflammatory diarrhea?

inflm: more common in colon; freq. small volume; +/- bleeding, fever, cramps, urgency


(shigella, salmonella, campylobacter)



non-inflm: more mild; in small intestine; large-volume; +/- N/V, cramps


(viruses, vibrio, ET E. coli, giardia)

staph aureus diarrhea

meat, dairy, bakery products



abrupt N/V



clinical Dx; supportive Tx


bacillus cereus diarrhea

fried rice



acute N/V



clinical Dx; supportive Tx

clostridium botulinum diarrhea

canned foods, warmed foods



diplopia, dysphagia, resp. depression



Dx toxin screen; Tx antitoxin

enterohemorrhagic E. coli diarrhea

undercooked beef, unpasteurized milk/juice, raw fruit/vegetables



abrupt diarrhea, often bloody



Dx culture; Tx supportive


(abx may increase HUS risk)

enterotoxigenic E. coli diarrhea

water/food contaminated w/ feces;



watery diarrhea, cramps



Dx culture; Tx fluoroquinolones if severe

vibrio cholerae diarrhea

water, fish, shellfish, vendor food



"rice water stool"



Dx culture; Tx fluids, tetracyclines or azithro

campylobacter jejuni

poultry, unpasteurized milk, water



fever, bloody diarrhea, cramps



can develop Guillain-Barre or reactive arthritis


Dx culture; Tx azithro or quinolone if severe

yersinia enterocolitica diarrhea

pork, water, unpasteurized milk, tofu



severe pain (mimics appendicitis), fever, diarrhea x1-3 weeks



Dx: culture; Tx: tetracycline or fluoroquinolone

giardia diarrhea

fecal-oral; drinking on camping trip



diarrhea, bloating



Dx stool antigen; Tx flagyl or tinidazole

Dx C diff

gold = cytotoxicity assay for toxin B



EIA for glutamate dehydrogenase,


PCR assay for toxin B

Tx C diff

mild: flagyl x10-14 days



severe: vancomycin

patho & S/Sx of hookworm

skin contact w/ larvae (walking thru soil);


travels to lungs & small intestines



itchy rash, cough, pain, diarrhea, wt loss

Tx hookworm

medendazole, ivermectin, albendazole

S/Sx of IBS

intermittent lower abd pain


relieved by defecation;


does not wake pt at night;


normal PE

Tx IBS

fiber supplement,


antispasmotics (bentil),


antidiarrheal (loperamide),


laxative (polyethylene glycol),


abx (rifaximin)

risk factors for hemorrhoids?

constipation, straining,


prolonged sitting, obesity,


low-fiber diet

S/Sx of anal fissure

"tearing" pain;


throbbing pain after defecation;


hematochezia

Dx anal fissure

DRE (if too painful, may need anesthesia)

Tx anal fissure

fiber supplements,


Sitz bath, topical anesthetics,


topical nitro, diltiazem, botox;


sphincterectomy

S/Sx & Tx of perianal abscess

redness, flatulence, swelling



Tx: I&D, may need abx