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96 Cards in this Set
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diseases that present with prominent dysphagia/odynophagia
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achalasia
esophageal cancer (SCC, adenocarcinoma) scleroderma diffuse esophageal spasm Plummer-Vinson Schatzcki's rings esophagitis Zenker diverticulum Mallory-Weiss syndrome |
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achalasia presentation
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progressive dysphagia to solids and liquids
regurgitation weight loss due to loss of inhibitory neurons of LES |
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achalasia diagnosis
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most accurate test is manometry
also barium esophagography (bird beak sign) if alarm symptoms (>60, heme-positive stools, >6 months, weight loss) esophagogastroduodenoscopy |
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achalasia management
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pneumatic dilation or botulinum toxin injections; if fails then surgical myotomy
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esophageal cancer etiology
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SCC is in upper two thirds and due to alcohol and tobacco
adenocarcinoma in lower third and is associated with reflux disease or Barret's |
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esophageal cancer presentation
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progressive dysphagia to solids then to liquids
weight loss can have halitosis regurgitation hoarseness hypercalcemia |
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esophageal cancer diagnosis
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barium swallow
endoscopy with biopsy is mandatory CT to detect local spread bronchoscopy to detect spread to bronchi endoscopic ultrasound for staging |
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esophageal cancer management
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surgery
if metastasis --> 5-fluoracil and radiotherapy |
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esophageal scleroderma
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dysphagia or reflux in scleroderma patient
diagnose with manometry treat with omeprazole and metoclopramide (promotility) |
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diffuse esophageal spasm/ nutcracker esophagus
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intermittent chest pain simulates myocardial infarction with dysphagia
no relation with exertion or swallowing precipitated by cold liquids screen with barium swallow (corkscrew pattern) most accurate test is manometry (disorganized contractions) treat with nifedipine and nitrates |
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Schatzcki's ring
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painless intermittent dysphagia located distally at squamous-columnar junction of LES
barium esophagram and pneumatic dilation |
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Plummer-Vinson syndrome
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intermittent dysphagia without pain located in hydropharynx (proximal)
associated with iron defficiency anemia and predisposes to SCC diagnose wih barium esophagram treat iron defficiency and pneumatic dilation |
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esophagitis
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due mostly to candida in HIV patients; also CMV, HSV or diabetes
also drugs such as alendronate, quinine, risedronate, vitamin C, pottasium, doxycycline, NSAIDs presents with progressive odynophagia only when swallowing (not intermittent) fluconazole or endoscopy |
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Zenker diverticulum
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outpouching of posterior pharyngeal muscles; halitosis, difficulty initiating swallow, undigested regurgitated food; barium studies; surgery (endoscopy or tube is contraindicated)
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Mallory-Weiss syndrome
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painless upper GI bleeding without dysphagia or odynopahgia
melena or hematemesis diagnose with upper endoscopy resolves spontaneously or epinephrine injections or cauterization |
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etilogy of epigastric pain
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ulcer disease
pancreatitis GERD gastritis gastric cancer (rare) most common etiology is nonulcer dyspepsia (all tests are normal) |
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diagnosis of diseases causing epigastric pain
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if >45
and/or alarm symptoms (weight loss, dysphagia, odynophagia, bleeding) and/or nonrespondant to PPIs or H2 blockers --> endoscopy for cancer, lower esophagus dysplasia biopsy ulcer, serology, breath tests and stool antigen detection can be used for H. pylori diagnosis |
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diseases that manifest with epigastric pain
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GERD
Barret peptic ulcer disease gastritis Zollinger-Ellison gastroparesis dumping syndrome pancreatitis gastric cancer nonulcer dyspepsia |
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GERD etiology
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idiopathic
nicotine alcohol caffeine peppermint chocolate anticholinergics CCBs nitrates |
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GERD presentation
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epigastric pain, sore-throat, metal taste, hoarseness, cough, wheezing
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GERD diagnosis
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if symptoms are clear, clinical diagnosis
if equivocal, 24h pH monitoring |
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GERD management
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PPIs (omeprazole); if nonrespondant then surgery
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Barret esophagus
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complication of GERD
if patient has GERD > 5 year --> endoscopy if Barret --> endoscopy every 2-3 years to check for dysplasia or cancer if low-grade dysplasia --> endoscopy in 3-6 months to check progression if high-grade dysplasia --> distal esophagectomy all should be given PPIs |
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peptic ulcer disease etiology
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90% of duodenal ulcers and 70-80% of gastric ulcers are due to H. pylori
NSAIDs is second cause also Zollinger Ellison gastric cancer Crohn disease burns head trauma prolonged intubation mechanical ventilation |
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peptic ulcer disease presentation
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midepigastric pain after eating (gastric) or relieved by eating (duodenal)
could have nausea or vomit there's rarely abdominal tenderness |
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peptic ulcer disease diagnosis
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most sensitive and specific is upper endoscopy with biopsy and it's performed routinely on those over 45 or with alarm symptoms (weight loss anemia, heme+ stools, dysphagia)
it's the only test to exclude gastric cancer serum antibody against H. pylori is sensitive and cheap; stool antigen and breath tests are also sensitive and can diffferentiate between new and old disease as well as determine if it's cured after treatment |
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peptic ulcer disease management
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if H. pylori --> PPI+clarithromycin+amoxicillin or tetracycline+metronidazole+-bismuth
ordinary ulcers w/o H. pylori --> PPI alone, misoprostol (rarely), celecoxib indications for surgery --> UGI bleeding or perforation, refractory ulcers, gastric outlet obstruction |
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type A gastritis etiology
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alcohol, NSAIDs, H. pylori, head trauma, burns, mechanical ventilation
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type B gastritis etiology
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gastric atrophy due to autoimmune destruction of parietal cells with pernicious anemia
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gastritis presentation
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epigastric pain, nausea/vomitting, hematemesis, melena
it can also manifest as asymptomatic bleeding |
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gastritis diagnosis and treatment
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if H. pylori, dignose and treat as peptic ulcer disease
type B gastritis diagnose with low B12 levels and high methylmalonic acid levels and also antiparietal cell antibodies, anti-intrinsic factor antibodies treat with B12 replacement |
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Zollinger-Ellison presentation
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95% present with ulcer disease that is recurrent after therapy
multiple ulcers at distal duodenum or resistant to therapy watery diarrhea or steatorrhea due to inhibition of lipase by acid can also present metastatic disease or hypercalcemia in MEN I |
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Zollinger-Ellison diagnosis
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after clinical suspicion --> elevated gastrin levels while off antisecretory medication
can also measure elevated gastric acid output positive secretin stimulation test (rise in gastrin after secretin injection, abnormal) CT/MRI/ultrasound to localize is 60-80% sensitive for metastasis and can include but not exclude somatostatin receptor scintigraphy is 90% sensitive for metastatic disease endoscopic ultrasound is most sensitive for metastatic disease |
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gastroparesis
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early satiety, posprandial nausea, sense of abdominal fullness
clinical diagnosis --> abdominal pain and bloating in patient with long history of diabetes treat ith promotility agents such as metoclopramide or erythromycin |
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dumping syndrome
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rapid release of hypertonic chyme into duodenum with osmotic effects and sudden glucose/insulin peak with hypoglycemia; presents with sweating, shaking, palpitations, lightheadedness shortly after a meal; treat by eating multiple small meals
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nonulcer dyspepsia
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of unknown etiology and diagnosed when all causes of epigastric pain have been excluded and there is still pain
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Crohn disease presentation
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discontinuous transmural granulomas in small or large intestines result in
fever, diarrhea, weight loss abdominal pain and bleeding episcleritis, scleritis, iritis cholangitis arthritis pyoderma gangrenosum erythema nodosum calcium/cholesterol stones painful abdominal masses can be palpated can cause fistulas and predisposes to colon cancer if lessions are located in colon |
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ulcerative colitis presentation
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continuous ulcerations limited to the mucosa and submucosa of large intestines result in
fever, bloody diarrhea, abdominal pain, weight loss episcleritis, scleritis, iritis cholangitis arthritis pyoderma gangrenosum erythema nodosum no fistulas, no masses predisposes to colon cancer |
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inflammatory bowel disease diagnosis
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gold standard is endoscopy
CD has vitamin and iron deficiencies; anti-Saccharomyces cerevisiae antibodies (ASCA); increased PT due to vit K deficiency; calcium kidney stones in CD ANCA antibodies in UC |
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inflammatory bowel disease management
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mesalamine derivatives: pentasa for CD, asacol for UC, rowasa for rectal disease
acute episodes treated with budesonide azathiorprine and 6MP used for long term infliximab for CD in case of fistulas surgery will be required in 60% UC cases and is effective |
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general considerations about diarrhea
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can be infectious, antibiotic-associated, lactose-intolerance, irritable bowel or carcinoid syndrome
if patient is hypotensive, has orthostasis, fever, abdominal pain or bloody stools is more important to hospitalize and treat than to determine etiology |
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bacillus cereus diarrhea
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ingestion of spores in refried chinese food
1-6 hour onset vomitting is prominent and no fecal blood |
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campylobacter diarrhea
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most common cause of infectious diarrhea
can be bloody or not associated with reactive arthritis and Guillain-Barre |
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cryptosporidia, isospora diarrhea
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found in AIDS < 100 CD4
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E. coli O157:H7 diarrhea
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bloody stools
associated with contaminated hamburger meat and shiga-like toxin antibiotics are contraindicated because dead organism causes HUS platelet transfusions are contraindicated in HUS |
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giardia diarrhea
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ingestion of unfiltered river or lake water
no bloody stools fullness, bloating and gas can simulate celiac disease |
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salmonella diarrhea
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most commonly due to ingestion of chicken and eggs or dairy products
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shigella diarrhea
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no clues in diarrhea are strong enough to point to this etiology; only stool culture
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yersinia diarrhea
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no clues in diarrhea are strong enough to point to this etiology, only stool culture
can mimic appendicitis common in people with iron overload/hemochromatosis |
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vibrio diarrhea
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ingestion of raw shellfish
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viral diarrhea
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associated with children in day-cares; there's absence of red or white cells in stools
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staph diarrhea
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ingestion of dairies, eggs, salads, custards
1-6 hour onset nausea and vomitting predominate |
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ciguatera toxin diarrhea
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2-6 hours after ingestion of large reef fish (grouper, red snapper, barracuda)
paresthesias, weakness, reversal of heat and cold |
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diagnosis of diarrhea
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invasive organisms produce fecal leukocytes within 24-36 hours
salmonella, shigella, e. coli, campylobacter, yersinia, vibrio definitive diagnosis of diarrhea is stool culture and fecal analysis for ova for giardia can use ELISA stool antigen detection for cryptosporidia need modified acid-fast test |
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diarrhea management
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empiric antibiotics until stool culture and if there's abdominal pain, bloody stools and fever;
high-volume stools and dehydration don't justify antibiotics; empirical treatment is ciprofloxacin or fluoroquinolone+metronidazole scombroid is treated with antihistamines giardia with metronidazole isospora with TMP/SMX doxycycline for vibrio |
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antibiotic-associated diarrhea
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caused mostly by C. difficile and by any antibiotic but mostly associated with clindamycin; history of antibiotics + diarrhea makes diagnosis and patient should have stool C. difficile toxin test; treat with metronidazole or oral vancomycin if resistance
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lactose intolerance
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high prevalence; diarrhea associated with bloating and gas but no blood or leukocytes in stools; empirical diagnosis and treatment is to remove milk, cheese and dairies (except yogurt) with resolution of symptoms in 24-36 hours; precise diagnosis is increased stool osmolality and increased stool osmolar gap
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irritable bowel syndrome presentation and diagnosis
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abdominal pain plus constipation alone (20%) or diarrhea alone or both
diagnosis of exclusion: lactose intolerance, IBD, celiac, carcinoid, giardia, anatomic defects diagnostic criteria: pain relieved by bowel movement, fewer symptoms at night, diarrhea alternating with constipation |
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irritable bowel syndrome management
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high-fiber diet
antidiarrheals (loperamide, diphenoxylate) antispasmodics (hyoscyamine, dicyclomine, alkaloids) tricyclics for resistant cases intestinal serotonin agents: tegaserod (constipation-predominant) or alosetron (diarrhea-predominant) |
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carcinoid syndrome
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most located in appendix or ileum but could be bronchial
implies metastatic disease presents with diarrhea, flushing, tachychardia, hypotension, niacin deficiency rash (depletion of tryptophan), endocardial fibrosis (right heart) diagnose with high urinary 5-HIAA treat with octeotride or surgery if tumor is localized |
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malabsorption/steatorrhea syndromes
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celiac disease, chronic pancreatitis, tropical sprue, Whipple's
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malabsorption syndromes general presentation
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steatorrhea, weight loss, ADEK deficiency, hypocalcemia, easy-bruising/increased PT, iron deficiency (duodenum), folate deficiency megaloblastic anemia), B12 deficiency (megaloblastic anemia, terminal ileum)
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malabsorption syndromes specific presentation
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celiac --> iron deficiency anemia and dermatitis herpetiformis
chronic pancreatitis --> recurrent episodes from alcohol or gallstones tropical sprue --> history of tropical country travel Whipple --> dementia, arthralgias, opthalmoplegia |
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celiac disease diagnosis
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screen with antigliadin, antiendomysial and antiglutaminase antibodies
endoscopic biopsy is required to exclude small bowel lymphoma and confirm diagnosis |
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chronic pancreatitis diagnosis
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history of repeated pancreatitis episodes with pancreatic calcifications on x-rays or CT
secretin stimulation test (gold standard but rarely performed) or low trypsin levels |
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tropical sprue and Whipple diagnosis
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biopsy showing organisms
for Whipple, most sensitive test is PCR of biopsy showing PAS+ macrophages |
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how to differentiate between malabsorption diseases
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d-xylose, iron, folate and carotene malabsorption point to mucosal problems (celiac, sprue, Whipple)
vitamin B12 malabsortion can also indicate pancreatic enzyme deficiency vitamin K and calcium deficiencies are due to fat malabsorption |
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malabsorption syndromes treatment
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celiac --> gluten-free diet
chronic pancreatitis --> pancreatic enzyme pills tropical sprue --> TMP-SMX or doxycycline for 6 months Whipple --> TMP-SMX or doxycycline or ceftriaxone for 1 year |
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diverticulosis
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50% prevalent over 50
asymptomatic or left lower quadrant colicky pain +- painless bleeding diagnose with colonoscopy treat with increased dietary fiber and bulking agents |
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diverticulitis
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infected diverticula
fever, tenderness, pain, leukocytosis diagnose with CT barium and endoscopy are contraindicated treat with ciprofloxacin/metronidazole, ampicillin/sulbactam, piperazillin/tazobactam, cefotetan/gentamycin |
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constipation
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can be due to lack of dietary fiber, insuficient fluid intake, CCBs, oral ferrous sulfate, hypothyroidism, opiates, anticholinergics; painful defecation can be dark due to bismuth or iron; treat by stopping medications, hydration, bulking agents, milk of magenesia, docusate
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colon cancer
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heme-positive brown stool and chronic anemia for right side
obstruction and decreased stool caliber for left side can present with strep bovis or C. septicum endocarditis diagnose with colonoscopy or sigmoidoscopy if located 60cm of distal colon if localized to mucosa or submucosa then surgery, else 5FU chemotherapy |
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hereditary nonpolyposis syndrome
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no polyps
three family members in at least two generations with colon cancer increased incidence of ovarian and endometrial cancer start screening at age 25 and then every 1-2 years |
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hereditary polyposis syndromes
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FAP has APC gene which confers 100% penetrance for adenomas by 35 and colon cancer by 50
screen with flexible sigmoidoscopy at age 12 and 1-2 years thereafter perform colectomy when first polyp is found juvenile polyposis syndromes has 10% risk of colon cancer and produces hamartomas, not adenomas Cowden syndrome is colon hamartomas with slight risk of colon cancer all can present with rectal bleeding as a child |
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Gardner syndrome
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colon cancer with multiple, soft tissue tumors such as osteoma, lipoma, cysts, fibrosarcomas
if casual osteoma found in x-ray --> colonoscopy |
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Peutz-Jeghers syndrome
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hamartomatous polyps in colon with hyperpigmented melanotic spots on lips and skin
abdominal pain due to intussusception/bowel obstruction |
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Turcot syndrome
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colon cancer with CNS malignancies
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GI bleeding etiology
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upper GI bleed: ulcer, gastritis, Mallory-Weis, esophagitis, gastric cancer, esophageal varices from portal hypertension
lower GI bleed: diverticulosis, angiodysplasia, hemorrhoids, cancer, inflammatory bowel disease; |
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GI bleeding management
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first fluid resucitation with saline or Ringer
hemogram, PT, type and crossmatch if elevated PT --> fresh frozen plasma if platelets <50,000 transfuse platelets if concomitant cirrhosis --> octeotride to decrease portal hypertension if severe bleed or coagulopathy --> fluids, blood, platelets and plasma if esophageal varices --> octeotride or place bands by endoscopy or perform TIPS elderly --> maintain hematocrit >30% with fluids and/or transfusion younger --> transfuse if hematocrit <20% after these measures --> endoscopy to determine etiology |
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GI bleeding presentation
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red blood in stools if lower GI bleed
ocult blood with >5-10ml or melena with >100ml of upper GI blood orthostasis: >10 point rise in pulse or >20 point drop in systolic pressure from supine to sitting or standing after 1 minute between measurements indicates 15-20% blood loss pulse above 100 or systolic pressure below 100 indicates 30% blood loss |
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GI bleeding diagnosis
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endoscopy
nuclear bleeding scan (technetium tagged red blood cells from the patient) angiography usefull in high-volume bleeding also capsule endoscopy |
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acute pancreatitis etiology
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alcoholism, gallstones, hypercalcemia, hypertriglyceridemia, medications (pentamidine, didanosine, azathiorpine, sulfas), ERCP, trauma, mumps virus
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acute pancreatitis presentation
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midepigastric pain radiates to the back, nausea, vomitting
severe disease can have fever, hypotension, ARDS, leukocytosis Cullen sign (blue umbilical discoloration) Turner's sign (bluish discoloration of flanks) |
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acute pancreatitis diagnosis
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screening with amylase and lipase levels
Ranson criteria for severity (leukocytosis, hypoxia, hyperglycemia, high LDH and AST) hypocalcemia, high BUN CT scan is more accurate than Ranson criteria for severity gold standard is ERCP |
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acute pancreatitis management
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supportive with fluids, bowel rest and analgesics
necrosis on CT is indicative of imipenem or cefuroxime to diminish infection risk severe necrosis is indication for percutaneous needle biopsy of pancreas if there's necrosis and infection surgical debridement is indicated drain pseudocyst if >5cm, pain, fistula or rupture |
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acute pancreatitis complications
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ascites high in amylase
pleural effusion is transudate high in amylase splenic vein thrombosis |
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cirrhosis etiology
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alcohol (#1 cause)
primary billiary cirrhosis sclerosing cholangitis alpha-1 antitrypsin deficiency hemochromatosis Wilson disease |
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general presentation of cirrhosis
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low albumin level
portal hypertension esophageal varices ascites (do paracenthesis to exclude infection) peripheral edema increased PT spider angiomata palmar erythema asterixis encephalopathy jaundice low clotting factors except factor VIII and vonWillebrand spontaneou bacterial peritonitis (WBC count >500/mm3 or >250/mm3 neutrophils, treat with ceftriaxone) |
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serum-ascites albumin gradient
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serum albumin is always higher than ascitic fluid
when SAAG >1.1 then portal hypertension when SAAG <1.1 (high ascitic albumin) then cancer and infections |
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cirrhosis management
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edema --> diuretics (spironolactone because of high aldosterone levels)
portal hypertension and varices --> propanolol (prevents bleeding) encephalopathy --> neomycin or lactulose (metabolized by bacteria in colon which increases acidity and converts NH3 into amonium which is not absorbed well and eliminated vitamin K is not effective because there are no clotting factors |
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primary billiary cirrhosis
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fatigue and pruritus
osteoporosis in 20-30% and cirrhosis signs associated with Sjogren, RA, scleroderma diagnose with normal transaminases, high alkaline phosphatase and GGTP, high IgM and antimitochondrial antibodies (specific) biopsy is gold standard treat with orsodeoxycholic acid and cholestyramine UV light for pruritus and liver transplant in late stages |
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primary sclerosing cholangitis
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fatigue and pruritus, elevated alkaline phosphatase, osteoporosis in 20-30% and cirrhosis signs
associated with inflammatory bowel disease (specially UC) can predispose to cancer of billiary system (15%) diagnose with normal transaminases, high alkaline phosphatase and GGTP, high IgM no antimitochondrial antibodies biopsy is not gold standard, it's ERCP or cholangiogram treat with orsodeoxycholic acid and cholestyramine UV light for pruritus and liver transplant in late stages |
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hemochromatosis
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genetically predisposed overabsorption of iron in duodenum with accumulation
cirrhosis is most common finding hepatocellular CA (15-20%) restrictive cardiomyopathy (15%) arthralgias, skin hyperpigmentation, diabetes, hypogonadism, vibrio vulfinicus and yersinia infections screen with elevated iron levels, low iron binding capacity and high ferritin biopsy is gold standard treat with phlebotomy or deferoxamine |
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Wilson disease
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underexcretion and overabsorption of copper with deposition in brain, liver and cornea
coreathetoid movements with psychosis --> slit lamp exam --> Kayser-Fleischer corneal rings also cirrhosis lab tests: low ceruloplasmin and high urinary copper gold standard is biopsy treat with copper chelator penicillamine or liver transplant; |
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alpha-1 antitrypsin deficiency
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antiprotease is not produced enough by liver
leads to cirrhosis and emphysema at young age in nonsmoker confirm diagnosis with enzyme levels enzyme replacement therapy and smoke cessation |
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chronic hepatitis B/C
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virus transmitted by blood transfusions, needle sticks and sex
mostly asymptomatic until advanced disease then cirrhosis HbSAg >6 months makes chronic hep B diagnosis hep C antibody and high viral load on PCR is diagnosis for chronic hep C treat hep B with interferon, lamiduvine or adefovir monotherapy treat hep C with pegylated interferon and ribavirin multitherapy |
