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137 Cards in this Set
- Front
- Back
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4 Major Pathophysiologic Mechanisms for Chronic Diarrhea
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1. Increased Secretion
2. Altered Intestinal Motility 3. Osmotic Load 4. Inflammation |
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What 2 laboratory tests can be used to distinguish between osmotic and secretory diarrhea?
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1. Fasting: persistent diarrhea if secretory
2. Stool Osmotic Gap: gap >50 = osmotic diarrhea |
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What additional labs are useful in the w/u of osmotic diarrhea?
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1. D-Xylose Test
2. Schilling Test (terminal ileum) 3. Lactose Challenge 4. Pancreatic Enzymes |
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What is the main cause of surreptitious diarrhea?
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Mg2+ Laxative Overuse
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Which syndrome is characterized by irregular bowel movements, abdominal pain, and comorbid psychiatric disorders (in 50% of cases)?
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Irritable Bowel Syndrome (IBS)
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Food Poisoning Bacteria:
Reheated rice |
Bacillus cereus
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Food Poisoning Bacteria:
Reheated meat dishes |
Clostridium perfringens
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Food Poisoning Bacteria:
Improperly canned food |
Clostridium botulinum
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Food Poisoning Bacteria:
Contaminated seafood or raw oysters |
Vibrio parahaemolyticus
Vibrio vulnificus |
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Food Poisoning Bacteria:
Meats, mayonnaise, custards |
Staphylococcus aureus
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Food Poisoning Bacteria:
Undercooked meats |
E. coli 0157:H7
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Food Poisoning Bacteria:
Raw poultry, milk, eggs, meat |
Salmonella
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6 Infectious Causes of Bloody Diarrhea
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1. Salmonella
2. Shigella 3. Campylobacter jejuni 4. Enteroinvasive & Enterohemorrhagic E. coli 5. Yersinia enterocolitica 6. Entamoeba histolytica |
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Diarrhea-Causing Organism:
Most common cause of diarrhea in infants |
Rotavirus
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Diarrhea-Causing Organism:
10-12 bloody and mucous diarrhea stools per day due to ingestion of cysts |
Entamoeba histolytica
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Diarrhea-Causing Organism:
Comma-shaped organisms causing rice-water stools |
Vibrio cholera
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Diarrhea-Causing Organism:
Second to rotavirus as a cause of gastroenteritis in kids |
Adenovirus
Serotypes 40 & 41 |
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Diarrhea-Causing Organism:
- Bloody diarrhea - Very low ID50 - Nonmotile |
Shigella
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Diarrhea-Causing Organism:
Usually transmitted from pet feces |
Yersinia enterocolitica
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Diarrhea-Causing Organism:
- Motile - Lactose non-fermenter - Causes bloody diarrhea |
Salmonella
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Diarrhea-Causing Organism:
- Comma- or S-shaped organisms causing bloody diarrhea - A/w Guillain-Barre Syndrome |
Campylobacter jejuni
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Diarrhea-Causing Organism:
Watery diarrhea with extensive fluid loss in AIDS patient |
Cryptosporidium
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Diarrhea-Causing Organism:
Foul-smelling diarrhea after returning from a camping trip |
Giardia lamblia
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Diarrhea-Causing Organism:
Watery diarrhea caused by antibiotic-induced suppression of colonic flora |
Clostridium difficile
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Diarrhea-Causing Organism:
- Avoid antibiotic therapy - Hemolytic-uremic syndrome (HUS) is a possible complication |
E. coli 0157:H7
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Diarrhea-Causing Organism:
AIDS |
1. Cryptosporidium
2. Mycobacterium avium complex (MAC) 3. Isospora |
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Diarrhea-Causing Organism:
Pseudoappendicitis |
Yersinia
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Ulcerative Colitis or Crohn's Disease:
Pancolitis with crypt abscesses |
Ulcerative Colitis
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Ulcerative Colitis or Crohn's Disease:
A/w Ankylosing Spondylitis |
Both
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Ulcerative Colitis or Crohn's Disease:
A/w Sclerosing Cholangitis |
Ulcerative Colitis
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Ulcerative Colitis or Crohn's Disease:
A/w Amyloidosis |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Longitudinal Ulcers |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Punched-out aphthous ulcers |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Can lead to Toxic Megacolon |
Ulcerative Colitis
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Ulcerative Colitis or Crohn's Disease:
Increased risk of Colorectal Carcinoma |
UC >>> Crohn's
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Ulcerative Colitis or Crohn's Disease:
Skip Lesions |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Can involve any portion of the GI tract (usually terminal ileum and colon) |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
"String Sign" on X-ray (due to small bowel thickening) |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
A/w Pyoderma Gangreosum |
Both
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Ulcerative Colitis or Crohn's Disease:
Transmural Inflammation |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Noncaseating Granulomas |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Cobblestone Mucosa |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Bloody Diarrhea |
Ulcerative Colitis
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Ulcerative Colitis or Crohn's Disease:
Watery Diarrhea |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Nephrolithiasis |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Stricture Formation |
Crohn's Disease
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Ulcerative Colitis or Crohn's Disease:
Pseudopolyps |
Ulcerative Colitis
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Ulcerative Colitis or Crohn's Disease:
Rectal Involvement |
Ulcerative Colitis
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Ulcerative Colitis or Crohn's Disease:
May mimic acute appendicitis |
Crohn's Disease
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What is the key component of a diagnostic w/u of a patient with suspected inflammatory bowel disease (IBD)?
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Colonoscopy with mucosal biopsies
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What additional radiologic tests are useful in the w/u of Crohn's disease?
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Upper GI series and small bowel follow through
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5 Classes of Medical Treatment of IBD
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1. Immunosuppressive Agents: 6-MP, Azathioprine, Methotrexate, Cyclosporine
2. 5-ASA Derivatives: Mesalamine, Sulfasalazine 3. Steroids: helpful in acute disease and during exacerbations 4. Antibiotics: Metronidazole for anal disease 5. Monoclonal Antibodies to Tumor Necrosis Factor (TNF)-alpha: Infliximab |
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What are the indications for surgery in a patient with Crohn's Disease?
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1. Intestinal Obstruction: most common indication for surgery
2. Anorectal Abscesses 3. Abdominal Abscesses: percutaneous drainage 4. Fistulas 5. Intractable Disease |
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What are the 2 options for operative management of an obstruction in Crohn's disease?
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Bowel Resection vs Strictureplasty
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What complication can occur in a patient with multiple bowel resections?
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Short Gut Syndrome
- diarrhea - malabsorption |
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Is surgery usually curative for Crohn's disease?
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No
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What are the indications for surgery in a patient with Ulcerative Colitis?
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1. Uncontrolled Hemorrhage
2. Fulminant Colitis 3. Toxic Megacolon 4. Dysplasia or Cancer 5. Intractable Disease |
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What are the 3 classic signs and symptoms of Toxic Megacolon?
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1. Fever
2. Abdominal Pain 3. Acutely Distended Colon |
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What is the initial treatment of Toxic Megacolon?
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1. Nothing by mouth (NPO)
2. IV Fluids 3. Nasogastric Tube (NGT) 4. Antibiotics |
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What surgical options are commonly used in patients with refractory Ulcerative Colitis?
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1. Total Proctocolectomy
2. Distal Rectal Mucosectomy 3. Ileoanal Pull Through |
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What is the risk of colon cancer in patients with Ulcerative Colitis?
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1-2% at 10 years
1% increase in risk every year thereafter |
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What are the recommendations for colon cancer surveillance in patients with Ulcerative Colitis?
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Yearly colonoscopy after 10 years of disease
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Is surgery curative for Ulcerative Colitis involving the colon?
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Yes
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What extraintestinal manifestations of Ulcerative Colitis are cured by surgery?
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Pathology of the skin, eyes, and joints
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What extraintestinal manifestations of Ulcerative Colitis are made worse by surgery?
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Liver Disease
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Viral Hepatitis Agent:
Fecal-Oral Transmission |
Hepatitis A Virus (HAV)
Hepatitis E Virus (HEV) |
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Viral Hepatitis Agent:
Infections lead to a carrier state |
HBV, HCV, HDV
80% of patients with HCV and 10% with HBV will develop chronic hepatitis |
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Viral Hepatitis Agent:
Defective virus requiring hepatitis B surface antigen (HBsAg) as its envelope |
Hepatitis D Virus (HDV)
(Delta Agent) |
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Viral Hepatitis Agent:
Sexual, parenteral, and transplacental transmission |
HBV, HCV, HDV
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Viral Hepatitis Agent:
High mortality rate in pregnant women |
HEV
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Viral Hepatitis Agent:
Most common cause of hepatitis a/w IV drug use in the U.S. |
HCV
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Viral Hepatitis Agent:
Long incubation (~3months) |
HBV, HCV
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Viral Hepatitis Agent:
Immune globulin vaccine available |
HAV, HBV, HDV
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Hepatitis Serologic Marker:
Antigen found on surface of HBV Continued presence suggests carrier state |
HBsAg
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Hepatitis Serologic Marker:
Antigen a/w core of HBV |
Hepatitis B Core Antigen
(HBcAg) |
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Hepatitis Serologic Marker:
Antigen in the HBV core that indicates transmissibility |
Hepatitis B Antigen
(HBeAg) |
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Hepatitis Serologic Marker:
Ab suggesting low HBV transmissibility |
Hepatitis B Antibody
(HBeAb) |
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Hepatitis Serologic Marker:
Acts as a marker for HBV infection during the "window" period |
Hepatitis B Core Antibody (HBcAb)
IgM in acute stage |
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Hepatitis Serologic Marker:
Provides immunity to HBV |
HBsAb
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What is the "window period" of a hepatitis infection?
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Period during acute infection when HBsAg has become undetectable, but HBsAb has not yet appeared
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Name the important indicator of hepatitis B transmissibility:
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HBeAg
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6 Common Causes of Cirrhosis
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1. Chronic Alcoholism
2. Hereditary Hemochromatosis 3. Primary Biliary Cirrhosis 4. Wilson Disease (Hepatolenticular Degeneration) 5. Viral (HBV, HCV) 6. Alpha-1-Antitrypsin Deficiency |
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Effect of Hepatic Failure:
Ocular |
Scleral Icterus
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Effect of Hepatic Failure:
Dermatologic |
Jaundice & Spider Nevi
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Effect of Hepatic Failure:
Reproductive |
1. Testicular Atrophy
2. Gynecomastia 3. Loss of pubic hair |
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Effect of Hepatic Failure:
Hematopoietic |
1. Anemia
2. Bleeding Tendency: decreased coagulation factors 3. Pancytopenia |
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Effect of Hepatic Failure:
Neurologic |
1. Coma
2. Hepatic Encephalopathy: asterixis, hyperreflexia 3. Behavioral Changes |
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Effect of Hepatic Failure:
Renal |
Hepatorenal Syndrome
Acute Renal Failure (ARF) 2/2 hypoperfusion |
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Effect of Hepatic Failure:
GI |
1. Esophageal Varicies
2. Peptic Ulcers 3. Hemorrhoids |
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Liver Disorder:
Mallory Bodies |
Alcoholic Hepatitis
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Liver Disorder:
Occlusion of IVC or hepatic veins with centrilobular congestion leading to congestive liver disease A/w polycythemia, pregnancy, and hepatocellular carcinoma |
Budd-Chiari Syndrome
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Liver Disorder:
Viral infection and salicylates in kids |
Reye Syndrome
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Liver Disorder:
Copper deposition in liver, kidney, brain, and cornea leading to asterixis, basal ganglia degeneration, and dementia |
Wilson Disease
aka, Hepatolenticular Degeneration |
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Liver Disorder:
AST:ALT >2 |
Alcoholic Hepatitis
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Liver Disorder:
Microvesicular fatty change occurring with fatal childhood hepatoencephalopathy |
Reye Syndrome
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Etiology of Cirrhosis:
Panacinar pulmonary emphysema |
Alpha-1-Antitrypsin Deficiency
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Etiology of Cirrhosis:
Decreased ceruloplasmin |
Wilson Disease
(Hepatolenticular Degeneration) |
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Etiology of Cirrhosis:
Triad of bronze diabetes, skin pigmentation, and micronodular pigment cirrhosis |
Hereditary Hemochromatosis
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Etiology of Cirrhosis:
Anti-mitochondrial antibodies |
Primary Biliary Cirrhosis
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Etiology of Cirrhosis:
Kayser-Fleischer Rings |
Wilson Disease
(Hepatolenticular Degeneration) |
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Etiology of Cirrhosis:
Micronodular fatty liver, portal HTN, asterixis, jaundice, and gynecomastia |
Chronic Alcohol Abuse
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Etiology of Cirrhosis:
Increased: ferritin, transferrin and total iron Decreased: TIBC |
Hereditary Hemochromatosis
Total body iron is high enough to trigger metal detectors |
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What test can be used to determine the etiology of ascites?
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Paracentesis and Serum-Ascites Albumin Gradient (SAAG)
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What is the mechanism of disease indicated by a Serum-Ascites Albumin Gradient (SAAG) of 1.1 vs >1.1?
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SAAG 1.1 = protein leakage
SAAG >1.1 = imbalance of hydrostatic and oncotic pressure |
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4 Etiologies of Ascites with SAAG of 1.1
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1. Malignancy
2. Tuberculosis 3. Pancreatitis 4. Nephrotic Syndrome |
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5 Etiologies of Ascites with SAAG >1.1
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1. Cirrhosis
2. Hepatic Metastases 3. Budd-Chiari Syndrome 4. Cardiac Disease 5. Myxedema |
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4 Therapeutic Options for Ascites
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1. Salt Restriction
2. Diuretics: Spironolactone, Furosemide 3. Large Volume Paracentesis 4. Peritoneovenous Shunting |
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3 General Etiologic Categories of Portal Hypertension
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1) Perisinusoidal:
- Splenic/Portal Vein Thrombosis - Schistosomiasis 2) Sinusoidal: - cirrhosis in 90% of all causes 3) Postsinusoidal: - Right Heart Failure - Hepatic Vein Thrombosis - Constrictive Pericarditis |
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5 Complications of Portal Hypertension
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1) Ascites
2) Spontaneous Bacterial Peritonitis (SBP) 3) Hepatorenal Syndrome 4) Hepatic Encephalopathy 5) Esophageal Varices |
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What must be present in ascitic fluid to make the diagnosis of Spontaneous Bacterial Peritonitis (SBP)?
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> 250 PMNs/mL
or > 500 WBCs |
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3 Clinical Manifestations in Portal HTN resulting from the Portal-Systemic Collateral Circulation
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1) Esophageal Varices
2) Caput Medusa 3) Hemorrhoids |
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Diagnostic Test for Bleeding Varices
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Esophagogastroduodenoscopy (EGD)
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Methods used to control Acute Upper GI Bleeding caused by Bleeding Esophageal Varices
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1) Endoscopic Sclerotherapy
2) Band Ligation 3) IV Vasopressin 4) Balloon Tamponade with Sengstaken-Blakemore Tube |
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Main Interventional Procedure to manage Portal HTN
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Shunt Procedure:
Transjugular Intrahepatic Portacaval Shunt (TIPS) |
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Main Complication of a Shunt Procedure
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Worsening of Hepatic Encephalopathy
2/2 increased flow to the liver |
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Classification System of Cirrhosis
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Child's Criteria
A, B, or C |
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5 Criteria for Child's Criteria for Cirrhosis
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1) Bilirubin
2) Albumin 3) Ascites 4) Encephalopathy 5) Nutrition |
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2 Drugs used to treat Hepatic Encephalopathy
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1) Laculose: decreased ammonia absorption
2) Neomycin: decreases ammonia production from GI tract |
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Only Definitive Therapy for Cirrhotic Liver Disease
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Liver Transplant
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3 Absolute Contraindications for Liver Transplantation
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1) Infection outside of Hepatobiliary System (eg, AIDS)
2) Metastatic Liver Disease 3) Uncorrectable Coagulopathy |
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20 yo female presents with bloody diarrhea and joint pain
PE: abdominal tenderness, guaiac positive stool W/U: increased ESR and CRP, HLA-B-27 positive Colonoscopy: granular, friable mucosa with pseudopolyps throughout the colon |
Ulcerative Colitis
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28 yo patient with h/o ulcerative colitis presents with severe abdominal pain, distention, and high fever
PE: severe abdominal tenderness W/U: leukocytosis AXR: dilated (>6cm) transverse colon |
Toxic Megacolon
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A cirrhotic patient presents with massive hematemesis
PE: jaundice, decreased BP, increased HR, ascites W/U: pancytopenia, increased ALT & AST EGD: actively bleeding vessel with numerous cherry red spots |
Esophageal Varices
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38 yo male with recent h/o fatigue, excessive thirst, and impotence presents with hyperpigmentation of his skin
PE: cardiomegaly, HSM W/U: increased glucose, ferritin, transferrin and serum iron |
Hemochromatosis
(Hereditary) |
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19 yo female with recent h/o behavioral disturbance presents with jaundice and resting tremor
PE: pigmented granules in cornea and HSM W/U: decreased serum ceruloplasmin |
Wilson Disease
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29 yo with h/o intermittent jaundice since receiving blood transfusion after motor vehicle accident (MVA) 2 years ago
PE: RUQ tenderness, hepatomegaly W/U: negative HBV serology |
Chronic Hepatitis C (HCV) Infection
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31 yo female presents with 10 month h/o foul-smelling greasy diarrhea
PE: pallor, hyperkeratosis, multiple ecchymoses, and abdominal distention W/U: abnormal D-xylose test |
Celiac Disease
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A patient with recent h/o antibiotic use for sinus infection presents with fever, bloody diarrhea, and abdominal pain
PE: tender leukocytosis Colonoscopy: tan nodules seen attached to erythematous bowel wall with superficial erosions |
Pseudomembranous Colitis
(C. difficile Colitis) |
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60 yo white male presents with steatorrhea, weight loss, arthritis, and fever
W/U: small bowel biopsy shows PAS-positive macrophages and gram-positive bacilli |
Whipple Disease
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A patient presents with sudden onset of severe watery diarrhea, vomiting, and abdominal discomfort 4 hours after eating potato salad at a picnic.
The symptoms resolve spontaneously within 24 hours. |
S. aureus-induced Diarrhea
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23 yo female with h/o depression presents with abdominal discomfort and irregular bowel habits
W/U: stool cultures, electrolytes, and imaging studies all WNL |
Irritable Bowel Syndrome (IBS)
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A patient traveling to Mexico presents with bloody diarrhea, vomiting, and abdominal cramps 16 hours after drinking tap water
PE: low-grade fever, abdominal pain W/U: ova and parasites in stool |
Entamoeba hystolytica-induced Diarrhea
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19 yo Jewish female with h/o chronic abdominal pain presents with recurrent UTIs and pneumaturia ("bubbles in the urine")
PE: diffuse abdominal pain CT: enterovesical fistula Colonoscopy: skip lesions of linear ulcers and transverse fissures giving cobble-stone appearance to mucosa |
Crohn's Disease
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28 yo homosexual male presents with RUQ pain, fever, anorexia N/V, dark urine, and clay-colored stool
PE: jaundice, tender hepatomegaly W/U: increased AST/ALT, increased bilirubin/ALP, normal WBC |
Acute Viral Hepatitis
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54 yo male with h/o HCV presents with increased abdominal girth, jaundice, and altered mental status
PE: asterixis, scleral icterus, hemorrhoids, bilateral lower extremity edema, ascites, and caput medusae W/U: pancytopenia, increased AST, ALT, ALP, bilirubin US: nodular liver |
Portal HTN / Cirrhosis
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26 yo female presents with pale, foul-smelling, bulky stools associated with abdominal pain and bloating occurring after meals
PE: normal W/U: fecal WBC/RBC wnl, increased osmotic gap, fecal fat wnl |
Lactose Intolerance
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28 yo male with h/o Crohn Disease (s/p surgical resection) presents with increased diarrhea, steatorrhea, and abdominal pain
PE: weight loss W/U: fecal WBC/RBC wnl, increased osmotic gap, increased fecal fat, Schillings test abnormal |
Malabsorption
Short Gut Syndrome |
