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443 Cards in this Set

  • Front
  • Back
difficulty swallowing
DYSPHAGIA

*subjective
Cranial nerves 5,7,9,10,11
Infection, obstruction, choking, thyroid goiter
pain upon swallowing
ODYNOPHAGIA
ice eating

*cause?
PAGOPHAGIA

*due to iron deficiency anemia
indigestion (sense of fullness)

*related to?
DYSPEPSIA

*related to GERD
inability to swallow
ACHALASIA
burning sensation often called heartburn

*related to?
PYROSIS

(get it? PYROmania)
*related to GERD
Reproducible, non-cardiac chest pain
costochondritis
ESO and SB
ESO = Esophagus
SB = Small Bowel
Which is best, a SINGLE or DOUBLE barium contrast study?
DOUBLE

*single is full column, LESS detail. Double is best, MOST CONTRAST
How can barium appear on X-RAY?
white spots
Why shouldn't barium be used if GI perforated?
Barium is water soluble (inert) so could cause diverticulitis if GI perforated.
May appear as white spots on x-ray.
Name some upper GI symptoms
Non-cardiac CHEST PAIN
ABDOMINAL pain
DIARRHEA
CONSTIPATION
FLATULENCE
BLOODY STOOLS
BELCHING
REGURGITATION [GERD]
DYSPEPSIA (indigestion)
PYROSIS (heartburn)
destruction of lining from reflux, causing change of esophageal cells into stomach columnar mucosal cells
BARRETT's esophagus
What kind of diagnostic procedures are used to evaluate the GI tract:
conventional radiography
upper GI studies
esophagram (barium swallow)
small bowel follow-through
small bowel enema (enteroclysis)
barium enema
endoscopy, ultrasonography, ERCP
CT, MRI
nuclear radiography
fluoroscopy and other interventional methods
Which study type for dyspepsia, epigastric pain, vomiting?
UPPER GI study
Which type of study for difficulty swallowing (dysphagia) or reflux (GERD) symptoms?
ESOPHAGRAM = barium swallow
Which type of study for abdominal pain or diarrhea?

*think: would you investigate the large or small intestines?
SMALL bowel follow through
SMALL bowel enema (enteroclysis)
Chromoendoscopy

*think: what does 'chromo' mean?
sprays stain on tissue
damage turns BLUE
('chromo' means color)

*Crohn's disease study
Which type of study for rectal bleeding, colonic symptoms or colon cancer screening?
BARIUM ENEMA
Why discuss DISH for exam I?
Because patients w/ DISH [Forestier's dz, OPLL, OVAL] may have compression of the esophagus, causing DYSPHASIA {20%}, HOARSENESS, DYSPNEA, etc.
Scleroderma d/dx
Soft tissue pathology
Raynaud's PHENOMENON
GI involvement
Scleroderma GI presentation
Difficulty chewing
Dysphagia
Esophageal strictures
GERD
Delayed gastric emptying
Dysmotility of sm & lg bowel >> bloating/abdominal distention and diarrhea/constipation
How to study scleroderma GI?
endoscopy & barium swallow
Pericardial effusion, arrythmia, congestive heart failure, myocardial FIBROSIS indicates?
Scleroderma

*FIBROSIS is key
Scleroderma renal presentation
Hypertensive renal crisis w/ microangiopathy
En coup de sabre
linear lesions of scalp or face in LOCALIZED scleroderma
(cutaneous fibrosis)
Limited/generalized MORPHEA
LOCALIZED scleroderma -
circumscribed patches of sclerosis
CREST syndrome
SYSTEMIC scleroderma (both cutaneous & non-cutaneous involvement)
C = Calcinosis of digits
R = Raynaud's Phenomenon
E = Esophageal dysmotility/strictures
S = Sclerodactyly
T = Telangiectasias
Where are the primary scleroses of SYSTEMIC [CREST] scleroderma?
PROXIMAL extremities, trunk, face
Scleroderma SINE sclerosis
SYSTEMIC scleroderma w/ ORGAN fibrosis and NO skin lesions
MAJOR criteria for scleroderma D/dx:
PROXIMAL sclerodermatous skin changes
(prox to the MCP joints)
means CREST is probably there, too.
minor criteria for scleroderma d/dx
Sclerodactyly (creSt)
Digital PITTING scars of fingertips or loss of substance of pads
BIBASILAR PULMONARY FIBROSIS (on x-ray)
40 year old white woman w/ 2 year hx of Raynaud's phenomenon. Skin on hands previously swollen, red/erythymatous, pruritic, and flulike sx. Dyspnea w/o chest pain, heartburn, dysphagia, and bloating w/ abdominal distention.
D/dx:
#1 = Scleroderma
Systemic Lupus Erythematosus
Polymyositis
Rheumatoid Arthritis
Pulmonary findings in scleroderma presentation pre-imaging
reduction in vital capacity
decreased lung compliance
Lab results of scleroderma
Elevated ESR
(+) ANA [antinuclear antibodies]
(+) ANTICENTROMERE antibodies
Radiograph findings of scleroderma
BIBASILAR INTERSTITIAL MARKINGS (pulmonary fibrosis)

Degrees of DISTAL TUFT RESORPTION & PENCILING

Subcutaneous CALCINOSIS
Pathology of scleroderma (3)
1. tissue FIBROSIS
2. small vessel VASCULOPATHY
3. autoimmune response of AUTOANTIBODIES
Describe fibrosis phases of scleroderma
edematous (inflammatory: erythema, non-pitting edema, pruritis)

fibrotic (excess collagen deposition in small vessels leading to RAYNAUD'S PHENOMENON + Telangiectasias)

contractures and atrophy
Most significant morbidity of scleroderma
presence of pulmonary involvement:

FIBROSING ALVEOLITIS leads to PULMONARY FIBROSIS leads to PULMONARY HYPERTENSION

BIBASILAR PULMONARY FIBROSIS is associated strongly w/ GERD!
ACROOSTEOLYSIS
absorption of distal tuft seen in scleroderma along w/ subcutaneous calcinosis

Penciling also occurs.

**Acroosteolysis & Calcinosis are pathognomic for scleroderma
buzzwords:
flulike
fatigue, myalgia, arthralgia
tendon friction rubs
flexion contractures
swollen fingers and hands
MEDIAN NERVE ENTRAPMENT
WATERMELON STOMACH
GERD
Hypothyroidism
scleroderma
GI presentation of scleroderma
Difficulty chewing
Dysphagia
Esophageal strictures
GERD************
delayed gastric emptying
dysmotility of bowel
Bloating/abdominal distention
Diarrhea/constipation
WATERMELON STOMACH
GERD
MEDIAN N. ENTRAPMENT
SCLERODERMA

(CREST)
In many cases, the diagnosis and treatment of a patient are directly dependent on
the intimate personal relationship b/w physician and patient
One of the essential qualities of the clinician is interest in ________, for the secret of patient care is in _______ for the patient.
humanity, caring
SUBJECTIVE indication of patient's symptom

What the patient feels and reports
SYMPTOM
OBJECTIVE indication of patient's symptom

What is seen, heard, felt, or smelled by another person (the clinician's appraisal)
SIGN

(signs are present or absent; tests are positive or negative)
The single most important diagnostic tool?
health HISTORY
List of related symptoms experienced by the patient prior to visiting your office
Chief Complaint
How should all physical findings, labs, and imaging be interpreted?
in the light of PERTINENT HISTORY
What should you obtain for patients w/ chronic illnesses?
prior medical records

*do not look at the primary dx until you make your own
Who, what, where, when and how...you figure out the ____ by synthesizing the info you gathered in the other 5 questions
WHY

Now make your diagnosis
In what part of the visit is the doctor's skill most apparent?
obtaining the history
Following the health hx, the doctor makes a
GENERAL SURVEY STATEMENT

A general impression, a scanning procedure.
What part of the patient's family matters when taking the history?
DIRECT BLOOD RELATIVES
Functional status at home
Social and economic circumstances
Goals for the future
Best way to manage patient's medical problem
What may reveal the cause of illness even though apparently unrelated symptoms?
REVIEW OF SYSTEMS
Systemic assessment of physical and mental status of patient
OBJECTIVE PHYSICAL EXAM

*phys exam results are subject to change
*subjective data may be obtained from patient during exam
*Significance enhanced when signs (objective) confirm a functional or structural change already suggested by history
Types of physical examinations
1. REGIONAL (BRANCHING)

2. COMPLETE
What are Dr. Finn's 4 tenents of a physical exam?
Inspection
Palpation
Percussion
Instrumentation

IPPI
When you complete the health hx and physical exam (IPPI), you are ready to develop a ?
PROBLEM list

*actual [current], potential [highly likely to occur in the future], and resolved [finito - needs no intervention]
A working list of POSSIBILITIES used in the process of DIAGNOSING a specific disease
DIFFERENTIAL DIAGNOSIS LIST
4 steps to systemic solving of clinical problems:
1. make the diagnosis
2. assess the severity/stage
3. render the treatment based on stage
4. follow patient response to treatment
In the first step, making the diagnosis, we use ______recognition and _______ reasoning.
PATTERN recognition
&
diagnostic REASONING:
**gather information
**subjective to objective
**discriminating features
Read the 7 fundamental clinical questions:
1. Most likely diagnosis? (the hoofbeats are from horses, not zebras)
2. Next step?
3. Most likely mechanism for this process?
4. Risk factors for this condition?
5. Complications of this disease?
6. Best treatment/therapy?
7. How will you confirm the dx?
28 year old woman complains of severe epigastric pain RADIATING TO THE BACK, nausea and vomiting.
Labs: elevated serum amylase
Acute pancreatitis > gall bladder and alcohol > ultrasound negative
3 functions of patient interview
Gather data
Establish therapeutic rapport
Educate the patient
71% of patients stated poor relationships as a reason for
their MALPRACTICE claims.

Effective communication reduces malpractice risk. Docs w/ good communication skill get sued less.
What does a doctor do when a patient invents health concerns (lies)?
Desire for attention
Secondary gains ('essential' statements)
Feelings of inadequacy
Denial
Desire for medication
Communication barriers
Is a neutral reaction or a sympathetic reaction better to handle a patient who is feigning sx?
NEUTRAL

*do not reinforce w/ attention
B.A.T.H.E. technique
Background
Affect
Trouble
Handling
Empathy

(ways to ask patients what's going on - way to organize an interview)
name a cultural competency about Asian patients
rarely seek pain medication
name a cultural competency about Mediterranean patients
seem to need pain meds for the slightest discomfort
name a cultural competency about Middle Eastern men
They will not permit a male doctor to examine their women
Coin rubbing is an
Asian method of medical treatment, not child abuse
What impact have women doctors had on women's health?
Ordered more preventative tests for women
More attuned to womens psychosocial needs
More patient-oriented communication styles
Brought attention to gender gaps in medicine (ie, research and dosage)
Chest pain is a _______ often described as a tightness or squeeze-like pain centered in the mid-sternal region
SYMPTOM (subjective)
When a cardiac cause has been ruled out for symptomatic chest pain, it is called NON-cardiac chest pain.
What is it associated with?
ESOPHAGEAL DYSMOTILITY disorders

ex: DES (diffuse esophageal spasm) and NUTCRACKER esophagus
Cause of non-cardiac chest pain
esophagus

*Patients w/ esophageal pain have nearly indistinguishable pain from cardiac pain: diaphoresis, pallor and dizziness just like angina
Non-cardiac chest pain, when not related to esophageal dysmotility, is often related to ________ and can be relieved w/ ______ and _______.
exertion

nitrates and calcium channel blockers
Where do patients frequently localize the site of their esophageal pain?
ABOVE the level of the obstruction
Pillcam used for
BARRETT's esophagus dx
often affords glimpse fo oral structures
CAPSULE ENTEROSCOPY
Patient lays supine for a _____ of the stomach study
supine

and prone for body, mucosal surface
A long, thin lighted flexible tube w/ a small camera on the end, inserted through patient mouth and into the esophagus.
FUNDOSCOPE
EGD or upper endoscopy is also called an (long word)
Esophagogastroduodenoscopy
brushes against the lumen of the stomach to collect cells
CYTOLOGY BRUSH

ROTH BASKET
Removes polyps
POLYP SNARE
Opens constriction of esophageal stricture
BALLOON dilator
What are SCINTIGRAPHIC RADIOLABELLED CORNFLAKES for? Breakfast?
Mark transition time from stricture to non strictured area

ex: Achalasia (LES stricture that causes dilation below constriction)
MANOMETRY
The GOLD STANDARD = a PRESSURE PROBE to measure DES or Nutcracker esophagus:

Used when barium swallow and endoscopy unremarkable.
Determines ESOPHAGEAL disorders & COLLAGEN VASCULAR DISEASES
Advantages of manometry
The only PRESSURE WAVE TEST

disadvantage: cannot diagnose visible lesions and is unpleasant for patient
OPLL
Ossification of Posterior Longitudinal Ligament

*DISH/Forestier's = mc ALL
OVAL
Ossification of the Vertebral Arch Ligaments

*DISH/Forestier's = mc ALL
DISH patient
50 yo Male

*A 50 year old male, while not often a real dish, could be a guy handy in the forest who likes to buy you oval opals.
Most common ligament involved in DISH
ALL
Describe DISH clinical presentation [cp]:
50 year old guy w/ back stiffness in morning and a low grade msk ache. He has dysphasia due to compression by the flowing hyperostosis on his spine, and it also makes him hoarse, maybe he has difficulty breathing (dyspnea). Chronic pneumonia.
*There is weird swelling or mass on his Achilles tendon or his quadriceps tendon.

DISH/Forestier's/ALL/OPLL/OVAL
Describe DISH diagnostic images
PELVIC WHISKERING
FLOWING HYPEROSTOSIS of 4 or more contiguous segments
ALL calcification (can be PLL or adjacents)
*PRESERVATION of IVD heights, no ankylosing, no apophyseal joint affects
BRIDGING of ribs and tp's to vertebrae (20%)
SI ligament involvement

*Left side has minimal involvement d/t pulsation inhibition of calcification by aortic pumping/massaging action
DISH labs
HLA-B8 (celiac dz, myasthenia gravis, primary sclerosing cholangitis of bile ducts, DISH)

Increased FBG [DISH + Diabetes mellitus go together]
He's a 50 year old man, not what you'd consider to be a dish, but he's handy in the forest and likes to buy you oval opals. He's overweight and has diabetes, his whiskers tickle your nose, and he likes to watch the wax flow down 4 candles every night. He's maintained his height and you can still adjust him w/ no problem since all his facet joints are good, but he is ALL hunched over so no extension moves. He's always saying corny stuff like, "I coulda had a B8!"
Who is he?
DISH/Forestier's/ALL
DISH/Forestier's character for memory
He's a 50 year old man, not what you'd consider to be a dish, but he's handy in the forest and likes to buy you oval opals. He's overweight and has diabetes, his whiskers tickle your nose, and he likes to watch the wax flow down 4 candles every night. He's maintained his height and you can still adjust him w/ no problem since all his facet joints are good, but he is ALL hunched over so no extension moves. He's always saying corny stuff like, "I coulda had a B8!"
Myasthenia gravis general definition/background
Autoimmune
Neuromuscular disorder
MUSCLE WEAKNESS increases during activity d/t BLOCKING action of ANTIBODIES for ACETYLCHOLINE receptors at POST-synaptic neuromuscular jcn.
What makes myasthenia gravis WORSE?
INCREASED TEMPERATURE

REPETITIVE mm. stress

Some medications
What makes myasthenia gravis BETTER...
REST

COOLING the mm.
What is the antibody mechanism that causes myasthenia gravis?
Antibodies against ACh receptors prevent ACh from attaching and therefore, PREVENT the muscle from CONTRACTION
Think of the mechanism of myasthenia gravis = antibodies block ACh receptors and prevent muscle contraction. What is the patient presentation?
EYE mm weakness = PTOSIS, DIPLOPIA

Altered FACIAL EXPRESSION (droopy)

DYSPHAGIA (eso ring mm are weak)

DYSARTHRIA (weak mm make for weak joints)

Difficulty CHEWING (weak masticators)

***GENERAL FLUCTUATING MM WEAKNESS (can't lift heavy things or climb stairs)

SOB (short of breath, weak mm of inspiration)

CHEST PAIN
For myasthenia gravis patient, what other dz should you screen for?
Other AUTOIMMUNE dz:
SLE [LUPUS]
HYPERTHYROID/GRAVES
RHEUMATOID ARTHRITIS
SCLERODERMA
a type of myasthenia gravis assoc. w/ the dysfunction of the Ca+ CHANNELS that affect mm contraction
LAMBERT-ETON Myasthenia

*old pdf only
Does myasthenia gravis weakness get better after the patient rests? What else helps?
REST + ICE helps

*remember back in neuro lab the case study w/ Dr. Barr about the college girl who got tired all the time
Myasthenia gravis X-RAY clue
anterior mediastinal mass = THYMOMA

*10% of patients w/ MG have benign thymic tumor and 70% have hyperplastic changes assoc. w/ active immune response

Pts w/ thymoma usually have more SEVERE MG and higher levels of AChR antibodies.
Tests for Myasthenia gravis

(what are the 2 most important antibody tests? ocular test?)
pulmonary (weak breathing)
blood tests for antibodies to AChReceptors
EDROPHORIUM Chloride [Tensilon, Reversol]
single fiber EMG [SFEMG]
repetitive nerve stim [EMG]

***MuSK protein antibodies
***AChR antibodies

PPD for latent TB
HLA- B8, DR3, DR1 (ocular)
Jane is a 25 year old who gets tired as hell by the end of the day. She can barely keep her eyes open and gets short of breath just walking up stairs. She's lost a lot of weight without dieting, even though she gets tired chewing food! Her joints hurt and she's developed an unattractive waddle gait because her knees hurt. She f***ing hates living in Florida now, because it seems like the heat makes her so tired! Lately, she's just been lying in a cool dark room with an ice pack on her head.
Myasthenia gravis

(women under 40, men over 60)
ONLY test for pressure wave physiology of esophageal dysmotility
MANOMETRY (gold standard)
The esophagus is naturally narrow at the _____of the aorta and the ____ main stem bronchus.
arch of aorta
right main stem bronchus
Double contrast study uses
Barium + air (mucosal detail)
Smooth, eccentric structural abnormality of the esophagus
Esophageal WEB

Indention of 2-3 mm of normal tissue
esophageal WEB eccentric or concentric?
ECCENTRIC

*(ingrowth of tissue) = WEB
Layers of esophageal WEB?
MUCOSA + SUBmucosa
Tell me about the esophageal WEB patient
Female asymptomatic until after 40 who has trouble swallowing solids for a long time.

She is probably anemic (IDA sx) meaning she's tired, dizzy and headache, paler than you and has chest pain.

Koilonychia, cheilosis and glossitis (think brittle nails, cracked lips and fat tongue).
Esophageal WEB aka (2):
PLUMMER-VINSON (post cricoid esophageal web + IDA)

PATTERSON-KELLY-BROWN
Describe esophageal WEB appearance
Thin membrane arising from ANTERIOR wall of CERVICAL esophagus
WITHOUT circumferential involvement (strictly eccentric protrusion)
LABS for esophageal WEB
CBC w/ differential - IRON + FERRITIN

****anti-GLIADIN antibodies

****anti-ENDOMYSIAL antibodies (celiac dz)
How does one get Plummer-Vinson syndrome?
Esophageal WEB may be acquired [GERD/injury] or congenital

*Patterson - Kelly - Brown/ Plummer - Vinson/ Esophageal WEB all the same thing
A smooth, concentric structural abnormality of the esophagus
SCHATZKI'S RING

3-5 mm CONCENTRIC growth of all 3 layers (mucosa, submucosa, muscle)
Where is SCHATZKI's ring found?
DISTAL esophagus
How many types of SCHATZKI's deli meat are there?
3

[type A, B or C]
SCHATZKI's ring is usually assoc. w/ a __________.
HIATAL HERNIA
A cat walks into SCHATZKI's deli and orders a Steakhouse Sandwhich. . SCHATZKI himself remarks what a lovely concentric ring pattern the cat has on his tail. What symptoms did the cat have while eating the Steakhouse sandwich?
He had crushing, non-cardiac chest pain due to his SLIDING HIATAL HERNIA
GERD is not listed in the class notes as related to esophageal web, but it is listed in the pdf. In Jarrett's notes, which esophageal structural abnormality IS listed as due to gastroesophageal reflux?
SCHATZKI'S RING

(hiatal hernia w/ meganblasse, concentric ring, steakhouse syndrome, feline esophagus, GERD assoc.)
Imaging for SCHATZKI's ring?
Barium esophogram and video fluoroscopy

EGD-scopy may rupture concentric ring

Esophageal MANOMETRY (pressure measure = gold standard)
Out of all the rings [A B or C], which one is SCHATZKI's on the drawing?
B = middle concentric ring is Schatzki in the distal esophagus
UN-coordinated esophageal contractions (name and 3 aka's)
DES [Diffuse Esophageal Spasm]

aka:
CORKSCREW esophagus
ROSARY BEAD esophagus
SPASTIC PSEUDODIVERTICULOSIS
A monk holding a CORKSCREW in one hand and ROSARY BEADS in the other, felt a lump in his throat when he drank warmed wine. He thought God was punishing him for drinking by making swallowing painful and sending angina through his chest and arms. He added some seltzer to the wine and drank it cold, but that made it worse. Monks don't wear undes, and he was anxious about that, too.
Un-DES

Uncoordinated Diffuse Esophageal Spasm. Have you got on clean Un-des?
The DES monk will experience what symptoms besides angina and intermittent odynophagia?
Reflux, Regurgitation, Vomit
COORDINATED esophageal contraction of a high amplitude (not random)
NUTCRACKER esophagus

*propagation of a severe single wave and pressure (vs. DES which is diffuse, uncoordinated several waves)
Uncoordinated undes
vs.
Tight Nutcracker briefs
DES (uncoordinated, diffuse waves)
vs
Nutcracker (coordinated, high amp, one ball buster at a time)
Imaging of choice for DES and Nutcracker
MANOMETRY = gold standard
an OUTPOUCHING of the esophagus
Esophageal diverticula:

1. Zenker's
2. Traction
3. Epiphrenic
Esophageal DIVERTICULA are outpouchings that are either congenital or acquired. What is the difference between TRUE & FALSE esophageal diverticula?
TRUE = all 3 layers [mucosa, submucosa, muscular]

FALSE = pseudodiverticula only 2 layers [mucosa and subm]
ZENKER'S diverticula
PULSATION

FALSE (only mucosa and submucosa)

POSTERIOR HYPOpharynx PROXIMAL

MOST COMMON type to cause symptoms in BABY BOOMERS
What causes ZENKER's diverticula
Incomplete relaxation of the UPPER esophageal sphincter (proximal posterior hypopharynx)
Baby boomer Zenk is in your office complaining, in a hoarse voice, about chest pain and vomiting into his mouth (regurgitation). As you lean in to listen to his lungs, his breath almost knocks you on the floor. You notice a VERY LARGE mass on his neck and that he looks really thin these days. What do you hear during the pulmonary exam?
Crackling and rasping! This guy has aspirated food into his lungs because his UES would NOT relax. He has pneumonia from food backing into his trachea and a big tongue-like thing hanging off the back of his esophagus, an outpouching.
The neck mass? ZENKER'S DIVERTICULUM. Thankfully, it's a false pulsation and only involves the mucosa and submucosa. You send him out for an upper GI but not an endoscopy because that could perforate his esophagus.
Which diverticula looks like a big tongue hanging off the posterior hypopharynx right under the inferior constrictor muscle?
ZENKER's diverticulum

Contains a trapped bolus of food inside an outpouching right above the tense UES.
Why wouldn't you do a barium swallow or an upper GI endoscopy on ZENKER's?
Barium is water insoluble. If endoscope perforates the wall, barium can get in the chest cavity
Where is a TRACTION diverticula?
Right in the middle.

Zenker's is above, Traction in the middle, Epiphrenic is below.
What causes TRACTION diverticula?
PULLING of the esophagus

ie, in TB, the lymph nodes are swollen and pull at the esophagus
What diverticula is seen in the DISTAL esophagus?
EPIPHRENIC diverticula

*Phrenic nerve goes to diaphragm so think epiphrenic is just above it, very low in chest and so is the lowest, most distal type of diverticula.
PULSATION diverticula
inflammation and wearing away of the gastric mucosa causes
GASTRITIS
Gastritis may be chronic or acute and is much more common than ___________
gastric ULCERS

*ergo, H. Pylori is the MC form of gastritis
Most common form of GASTRITIS
H. PYLORI
BALD FUNDUS sign
ATROPHIC gastritis = absent rugal folds in Upper stomach
Leads to MALABSORPTION
EMPHYSEMATOUS gastritis
Within wall of stomach, there is AIR
Abdominal surgery can lead to _______ between between components of intestines that can lead to blockage or torsion.
ADHESIONS
hyperplasic hypersecretory gastropathy
MENETRIER's disease [GYRI]

*big heavy rugae/folds
Reasons for gastritis
autoimmune
H. Pylori ** MC form chronic gastritis
reflux
alcohol
erosive gastritis
erosion of stomach lining

NTQ
Pt hx and complaint for GASTRITIS
EIPGASTRIC DISCOMFORT/BLOATING

d/dx GERD, Myasthenia Gravis, Autoimmune dz, many have melena
Physical exam GASTRITIS
non-contributory
related to underlying cause
EPIGASTRIC TENDERNESS
fever, lethargy
Why are biopsies taken for Gastritis?
Rule out ADENOCARCINOMA
Diagnostic imaging of gastritis depends on
the cause
Most common polyp
HYPERPLASTIC polyp
On a barium study for polyp, what happens?
Barium flows around polyp (not inside it, like diverticulitis)
how to sample polyp
endoscopy polypectomy
Biggest risk factor for gastric adenocarcinoma
H. Pylori
Physical exam of gastric adenocarcinoma buzz words
Krekenberg tumor - ovarian
Blumer's shelf
Sister Mary Joseph sign
Virchow's node/SENTINAL node - left supraclav. node
Succusion splash - fluid sound
Chronic ulcers go all the way down to the muscle layer
muscularis
What causes peptic ulcers
Cocaine
H. Pylori***MC
NSAIDS
Aspirin
bile

add from notes
Gastric vs duodenal ulcer
Gastric = pain 1.5 hour after meal - eating makes WORSE so weight LOSS

Duodenal = 2-3 hours after meal - eating makes BETTER so WEIGHT GAIN
TEST of peptic ulcer
urease breath test
With a _________ulcer, mucosal folds are radiating to central ulcer
Duodenal
When an ulcer in is the _________. when it heals it could lead to an obstruction.
DUODENAL (peptic)

*duodenum ulcer heals by drawing tissue down towards it, leading to an obstruction (EXAM QUES) - obstruction can also be caused by abdominal surgery
If there is a perforation, a CT scan will show
air on the top. When they stand up, there are 2 lucent arcs signifying a PNEUMOPERITONEUM.

Air from an ulcer perforation
Breath test for peptic ulcer
Urea breath test determines presence of H. Pylori

(ammonia and CO2/tagged is exhaled)
a NON beta islet cell gastrin secreting tumor of the pancreas
ZOLLINGER-ELLISON syndrome

where tumor produces lots of GASTRIN hormone, hence GASTRINOMA
Zollinger Ellison complaint
severe epigastric pain/ discomfort, diarrhea

No gastritis or gastric ulcer but lots of watery diarrhea, steattorhea
characterized by numerous, minute FLASK-like outpouchings along esophageal wall
EIPD = Esophageal Intramural Pseudodiverticulosis

-can be segmental OR generalized
-associated w/ STRICTURES, carcinoma, candidiasis, motor abnormalities

-PSEUDO indicates mucosa and submucosa only
Diverticula of the POSTERIOR hypopharynx

-Halitosis
-GERD
-Weight loss
ZENKER'S diverticulum
Abnormal NARROWING of the esophageal lumen causing difficulty swallowing
esophageal STRICTURE

1. PROXIMAL
2. DISTAL
INTRINSIC factors that can inhibit SIZE of lumen:
Tumors, Fibrosis (CREST) and/or Inflammation
EXTRINSIC factors that inhibit MOTILITY of esophagus
MEDIASTINAL MASSES
esophageal SPASM
abnormal NARROWING of the esophageal lumen, causing difficulty (DYSphagia) in swallowing
Esophageal STRICTURE
failure of the LES (cardiac) sphincter to relax, resistricting passage of food to the stomach.
ACHALASIA

In some cases, dysphagia (difficulty) and marked dilation of the esophagus may occur due to backed up food.
W/ Achalasia, the wall of the esophagus becomes thicker, causing the lumen to become
narrower


*sim to Crohn's dz where wall of small intestine becomes thicker hence lumen becomes smaller
Patient history/complaint of esophageal STRICTURE
progressive dysphagia (difficulty) or odynophagia (pain) w/ swallowing
regurgitation
food impaction
chest pain
dental erosion (vomitorium)
weight loss [can't get food into stomach and feel nauseous - who wants to eat?]
Diagnostic imaging for esophageal stricture (general)
Plain film/barium swallow/ CT/ MRI/ endoscopy/ MANOMETRY

*lab findings depend on the cause
What would cause PROXIMAL esophageal stricture?
Malignancy
Radiation therapy
Infectious esophagitis = candida, herpes simplex, HIV, CMV
AIDS or immunosuppression (ie, transplant)
***Medication*** - induced stricture (PILL ESOPHAGITIS) mainly NSAIDS and tetracyclines b/c acidic pills inflame/irritate the esophagus if stuck
Diseases of the skin = p. vulgaris, benign mucous membrane pemphigoid and e. bullosa dystrophica [inflammatory conditions tx w/ immunosuppresants]
Caustic indigestion [acid]
Extrinsic compression [concentric growths, tumors]
Squamous cell carcinoma
Trauma
What might cause DISTAL esophageal compression?
Extrinsic compression [tumors, concentric growths]
Adenocarcinoma
Peptic stricture = GERD, Zollinger-Ellison syndrome
Crohn's disease
Sclerotherapy or prolonged intubation (nasogastric/trach tube)
Collagen vascular dz = Scleroderma CREST, RA, SLE
Alkaline reflux
Post gastric resection
MALIGNANCY of the esophagus
Esophageal CARCINOMA

*most tumors involve the LOWER esophagus
*Males 60-80 yo
What patient has the greatest chance of developing esophageal carcinoma?
BARRETT'S esophagus (30-125x higher chance)

Barrett's eso most common in White Males
Esophageal CARCINOMA SIGNS on barium swallow
APPLE CORE appearance (overhanging margin sign)
&
STRING SIGN
Pt hx/complaint for esophageal carcinoma:
Painless>>>
Progressively worse dysphagia, first to SOLIDS then LIQUIDS = STEAKHOUSE SYNDROME
Describe the other pt hx/ complaint in addition to STEAKHOUSE syndrome
Odynophagia, unintentional weight loss, nausea/vomiting/hematemesis, regurgitation, COUGHING - compression of trachea can cause coughing, Symptoms of ASPIRATION pneumonia
FISTULAS - abnormal connections b/w trachea and esophagus leading to aspiration of esophageal contents into bronchi
persistent _________ in addition to weight loss and dysphagia could be a warning sign of esophageal cancer
hiccups
What represents a metastatic finding on physical exam for esophageal carcinoma?
LYMPHADENOPATHY in the laterocervical or supraclavicular areas
Diagnostic imaging for esophageal carcinoma
Plain film/ barium swallow/ chromoendoscopy/biopsy/CT/bone scan

*chromoendoscopy
LAB findings of esophageal carcinoma
biopsy and Brush cytology
CBC w/ differential
chem-18 blood panel

OCCULT BLOOD IN STOOL
SQUAMOUS cell carcinoma of ESOPHAGUS arises from the
esophageal LINING
and
commonly found in UPPER-MID esophagus
Causes of Squamous cell esophageal cancer
ALCOHOL & SMOKING (chronic irritation)
Swallowing a CAUSTIC agent
Nutritional DEFICIENCIES (riboflavin, niacin, iron)
Chronic esophagitis from GERD
ACHALASIA = stasis induced inflammation
TYLOSIS - autosomal dominant hyperKERATINization of the SOLES of FEET and PALMS of HANDS
PLUMMER-VINSON syndrome
NITROsamines
Previous diagnosis of ssc of head or neck
BUSH teas containing tannins or diterpene phorbol esters
What kind of cancer arises from esophageal GLANDS?
ADENOCARCINOMA

*usually found in LOWER esophagus
Risk factors for esophageal adenocarcinoma
from eso glands:
BARRETT'S esophagus
Where do esophageal ULCERS/erosions occur?
MUCOSAL layer

*acute occur in mucosal and submucosal
**chronic occur in 3 layers (mucosal, submucosal, muscularis)
What can create a predisposition to esophageal ulcer/erosion
Anything that narrows the esophagus or creates dysmotility

*scleroderma, caustic agents, Crohn's, tumors, reflux/GERD
How can prolonged use of NSAIDs cause ULCERS of esophagus
BLOCKS gastric mucosal CYCLOOXYGENASE activity, leading to decreased EPITHELIAL cell generation then INJURY and low gastric mucosal SECRETION.

All this craps out the mucosal BARRIER and leads to ULCERATION of gastric nature
EIPD
Esophageal Intramural Pseudodiverticulosis

Numerous FLASK-like outpouchings along eso. wall.

Seen w/ CANDIDA, STRICTURES, carcinoma and motor abnormalities
esophageal strictures caused by
infection, trauma, neoplasm
extrinsic esophageal strictures caused by
enlarged lymph nodes, mass/neoplasm in lung, congenital anomaly
An abnormal peristaltic wave of esophagus
DYSMOTILITY of esophagus
LENGTH of esophageal stricture
4cm. in length
Why does the wall become thicker (and the lumen narrower) in esophageal stricture?
Damage to wall caused by REFLUX

****BIGGEST CAUSE OF ESOPHAGEAL STRICTURE IS GERD******
DISTAL esophageal stricture (more common than proximal) is caused by
******GERD (pyrosis) ****

Zollinger-Ellison syndrom
CREST (scleroderma)
EXTRINSIC compression
Adenocarcinoma
NERD
Non-Erosive Reflux Disease

*use cell staining to see it
Provocative for GERD
Any foods that lower the LES pressure : chocolate, fatty and spicy foods, tomatoes, coffee

Tight clothing

Alcohol and tobacco use *****
Acid reflux >>> Barrett's esophagus >>>> ____________
Adenocarcinoma
#1 association of GERD
SLIDING hiatal hernia (fundus displaced through diaphragm)

MEGANBLASSE moves to middle (gas air bubble no longer on the left)

Hiatal's are also associated w/ Schatzki's ring
GERD barium studies will show**8
***SLIDING and PARA-ESOPHAGEAL HIATAL HERNIAS
w/ and air/fluid level in the midline ABOVE the level of the diaphragm

**MC: SLIDING hiatal hernia where displaces fundus to chest cavity.

**Paraesophageal is NEXT TO esophagus, where meganblasse will be in the midline instead of to left of it
GERD patient complaints
May be asymptomatic, but...
DYSPHAGIA
PYROSIS (years of heartburn complaints)
CHRONIC ANGINA-LIKE CHEST PAIN
HIATAL HERNIA
HOARSENESS IN MORNING
Due to change of esophageal to stomach cell types, patient will complain of intermittent pain b/c the irritation will diminish as the change occurs, hence INTERMITTENT pain.
Physical exam findings for GERD
Hoarseness in morning
ASCULTATION of PERISTALSIS in CHEST should suggest large hernia

SUCCUSSION SPLASH in patients w/ gastric dilation or pyloric obstruction
3 COMPLICATIONS of GERD
1. STRICTURE

2. BARRETT'S

3. ULCERS
If you suspect a sliding hiatal hernia associated w/ GERD, what should you do?
Valsalva maneuver to see if air above diaphragm. Meganblasse on x-ray will be in midline instead of to left because hernia above diaphragm pushing stomach to midline.
Esophageal cancer complaints/pt hx
STEAKHOUSE SYNDROME (dysphagia to solids, then liquids)

VIRCHOW'S NODE over left supraclavicular ***lymphadenopathy in laterocervical or supraclavicular areas represents metastasis****

FISTULAS abnormal cx from esophagus to trachea

HICCUPS w/ weight loss and dysphagia might be CA of esophagus warning signs
Lab findings of esophageal CA
can look normal bc/ squamous cells have covered the Barrett's areaa

Look for OCCULT blood in stool
Pt complaint:
dysphagia
unintentional weight loss
epigastric pain
hoarseness
esophageal ADENOCARCINOMA

**Barrett's is the pre-malignant condition
SQUAMOUS cell of esophagus buzz words
Lining
Upper to mid esophagus
Alcohol & tobacco
GERD
Achalasia
Tylosis (Hyperkeratinization soles and palms)
Plummer-Vinson
Previous diagnosis of squamous of head or neck
Bush teas
melena
found wi/ active esophageal bleeding
What bug causes ACHALASIA?
CHAGAS disease - Kissing bug - T. CRUZI

hence CHAGOMA = inflammation
Cardiospasm
esophageal aperistalsis
megaesophagus
Achalasia
Achalasia
an esophageal motility disorder causing a functional obstruction of the eso characterized by a-peristalsis and FAILURE of the LES to relax adequately in repsonse to swallowing = PRIMARY achalasia

Excitatory (ACh and Substance P ) take over inhibitory (N.O.) so AUERBACH'S PLEXUS FAILS due to disruption of these inhibitory neurons
Secondary achalasia is due to
an EXTERNAL MASS

ie, a tumor wrapping around the LES preventing relaxation
Of the 3 stages of achalasia, what is the worst?
CHRONIC because of the CARDIAC effect
Treatment for ACHALASIA
BALLOON
CHAGAS' disease causes
2* achalasia:

ROMANA sign of edema
CHAGOMA sign of inflammation

T. Cruzi is the kissing bug
Achalasia diagnostic imaging signs
BIRD'S BEAK DEFORMITY - dilation of esophagus above hypertensive/stuck LES

STRING SIGN is usually longer in 2* achalasia than in 1* achalasia

Imaging shows WIDENED MEDIASTINUM and air/fluid level meaning food is stuck in esophagus
GERD is hoarseness in the morning.

________ is hoarseness w/ nighttime coughing.
ACHALASIA (NTQ is listed on this card?)

*hoarseness, nocturnal coughing
*Progressive pain/odynophagia to solids and liquids
*substernal chest pain IMMEDIATELY after eating
*unintentional weight loss
*halitosis
What will x-ray show of barium in achalasia?
It's all stuck above the stomach in a dilated esophagus. The LES won't let it through.
Esophageal ulcers/erosions occur in the __________ layer
mucosal

*acute are often in mucosal and submucosal layers
*chronic are in all three layers
What physical changes predispose one to esophageal ulcers/erosions?
Motility disorders and esophageal narrowing
Examples of motility disorders and that cause esophageal narrowing, predisposing pt to ulcer/erosion:
Scleroderma
Caustic agent ingestion
Prolonged naso-gastric INTUBATION
Achalasia (failure of the LES to relax)
Radiation
Crohn's disease
Tumors
Reflux (GERD)
How can prolonged use of NSAIDs cause esophageal erosion/ulcers?
Inhibiting gastric mucosal COX-2 (cyclooxygenase activity) leading to depleted epithelial cell regeneration and decreased mucosal secretion =

SCREWS MUCOSAL BARRIER and leads to gastric ulceration
Esophageal ____ are dilated SUBMUCOSAL VEINS of the esophagus.
VARICES are dilated veins

*usually caused by PORTAL HYPERTENSION
2 things that lead to portal hypertension (and esophageal varices):

Name 3rd thing for just females:
1. Alcoholic liver disease
2. Hepatitis C
3. Females only: vein-occlusive dz
From where does PORTAL VEIN get blood?
ABDOMEN

Empties it into the liver so it can be detoxified. HEPATIC ENCEPHALY occurs when toxins aren't removed b/c liver is too sick. Toxins build up in BRAIN as a result.
Increased blood flow + increased resistance (due to SCAR tissue in liver from cirrhosis or heppy-C) leads to ________ & formation of ____________ veins.
BACK-UP & formation of COLLATERAL VEINS
abnormally dilated veins of the esophagus. They are native veins that serve as collaterals to the central venous circulation when flow through the portal venous system or superior vena cava (SVC) is obstructed.
Esophageal and paraesophageal varices

http://emedicine.medscape.com/article/367986-overview
Esophageal varices are ___________veins within the wall of the esophagus that project directly into the ______. The veins are of clinical concern because they are prone to hemorrhage.
collateral

lumen
__________ ________are collateral veins beyond the adventitial surface of the esophagus that parallel intramural esophageal veins.
Paraesophageal varices

Paraesophageal varices are less prone to hemorrhage.

http://emedicine.medscape.com/article/367986-overview
* Barium swallow demonstrates multiple serpiginous filling defects primarily involving the lower one third of the esophagus with striking prominence around the gastroesophageal junction. The patient had cirrhosis secondary to alcohol abuse.
Esophageal Varices = SERPIGINOUS FILLING DEFECTS on radiograph

Due to cirrhosis.
Today, more sophisticated imaging with computed tomography (CT) scanning, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and endoscopic ultrasonography (EUS) plays an important role in the evaluation of portal hypertension and esophageal varices
In 1931, Schatzki established the basis for the modern-day fluoroscopic detection of esophageal varices by refining positional and physiologic maneuvers to optimize visualization.
_________ is the criterion standard for evaluating esophageal varices and assessing the bleeding risk.
ENDOSCOPY
why are CT and MRI more valuable to evaluate esophageal varices?
CT scanning and MRI can help in evaluating the surrounding anatomic structures, both above and below the diaphragm. CT scanning and MRI are also valuable in evaluating the liver and the entire portal circulation.
Lab findings esophageal varices
MELENA (DARK) blood in stool

CBC: anemia, leuco and thrombo-penia
Get a liver biopsy. Increased AST/ALT/BUN/creatinine.
Patient hx or complaint w/ esophageal varices
***DYSPHAGIA
***Pruritis (itchy skin due to toxin build up b/c liver sick)
****Easy bruising

**hematemesis
**Muscle cramps (common w/ cirrhosis)
Superior Vena Cava syndrome results in __________ esophageal varices.
DOWNHILL esophageal varices
Portal venous hypertension results in _________ esophageal varices.
UPHILL esophageal varices
Patient presentation of esophageal varices (how does patient look?)
JAUNDICED
CAPUT MEDUSAE (visible swollen veins over abdomen)
Ascites [proteins have leaked into interstitial spaces]
Splenomegaly [back up of portal vein backs up splenic vein]
LOW b.p., HIGH heart rate [working too hard but liver backed up]
Orthostatic hypertension b/c varices can LEAK LARGE AMTS of blood.
Esophageal mucosal tear caused by forceful vomiting that causes the esophagus to bleed.
MALLORY-WEISS SYNDROME

*after a night of binge drinking or having an eating disorder [bulimia]

**NON-transmural laceration - just the muscosa is torn.
What kind of injury to the esophagus does Mallory-Weiss syndrome vomiting cause?
NON-transmural. Only tears mucosa.
Common cause of bleeding in GI?
ulcer.
What else besides vomiting after binge drinking or a bulimic episode could cause Mallory-Weiss syndrome?
CPR
Hiatal Hernia
Abdominal trauma!

(NON-transmural laceration)
When Mallory-Weiss syndrome presents with a TRANSMURAL TEAR, what is the new name?
BOERHAAVE's syndrome:
complete TRANSMURAL laceration of lower esophagus w/ stomach contents spilling into MEDIASTINUM.
Bleeding caused by forceful vomiting is still the cause.
Any disorder that initiates vomiting may result in the development of a Mallory-Weiss tear, which develops as a linear laceration at the gastroesophageal junction because the esophagus and stomach are cylindrical. The cylindrical shape allows longitudinal tears to occur more easily than circumferential tears.
These tears have been postulated to occur either by a rapid increase in intragastric pressure and distention, which increases the forceful fluid ejection through the esophagus [medscape]
Aside from those patients who present with upper GI bleeding secondary to an alcohol binge, Mallory-Weiss tears occur more commonly in people with ___________________
HIATAL HERNIA

[medscape]
Although most cases of Mallory-Weiss tears are self-limiting, patients with severe or recurrent episodes of bleeding that require intensive care therapy and interventional endoscopy have been reported. Typically these patients have underlying conditions, including portal hypertension and hepatic insufficiency.
Although upper GI bleeding is generally assumed to be secondary to varices in these patients, the physician must also be aware of the potential for Mallory-Weiss tears. [medscape]
The major complication of a Mallory-Weiss tear is bleeding.[3] Patients present with variable bleeding, which can range from a few specks or streaks of blood mixed with mucus to copious amounts of fresh red blood. [Loss of blood does what to blood pressure?]
In adults, shock occurs in as many as 20% of patients bleeding from Mallory-Weiss tears who present to emergency departments; as many as 45% of patients develop postural hypotension [medscape]
A young woman presents w/ HEMATEMESIS, NAUSEA, EPIGASTRIC DISCOMFORT.

What should she be evaluated for and why (3 things):
In women of childbearing age, the most common cause of these tears is hyperemesis gravidarum, which usually occurs in the first trimester, causing severe persistent nausea and vomiting. Any adolescent female presenting with a Mallory-Weiss tear should be evaluated for pregnancy, as well as bulimia and anorexia nervosa
seen as an air lucency outlining the medial portion of the left hemidiaphragm and the lower lateral mediastinal border
V-sign of NACLERIO

*post esophageal puncture. Air dissects behind the heart in Boerhaave's transmural tear 2-3 cm above esophageal sphincter.
As many as 50% of patients with ___________ syndrome have a hematocrit value that approaches 50%. This may be due to fluid loss into pleural spaces and tissues
Boerhaave's
hematemesis, melena, light-headedness, dizziness, syncope, and abdominal pain.
Mallory-Weiss syndrome
the presenting symptom in all patients diagnosed with a Mallory-Weiss tear
HEMATEMESIS
D/dx of Mallory-Weiss
Gastroenteritis & Peptic Ulcer dz
Describe Mallory-Weiss patient
40-70 male

*alcoholic 55 year old male; see air on x-ray (do not use barium). CBC will suggest blood loss
Mackler's Triangle:
Subcutaneous emphysema
Lower thoracic pain
Vomiting

*all point to:
BOERHAAVE's syndrome of transmural laceration due to forceful vomiting. Males 40-70 years old.

Low blood volume/count because all going into mediastinum. Will see V-sign of Naclerio on x-ray.
a clinical condition in which there are specific diseases that lead to HYPERMETABOLISM and and INCREASE in THYROID HORMONES
THYROTOXICOSIS

*SERUM elevation of thyroid hormones [T3 & T4]. Because commonly d/t HYPERfunction of thyroid gland itself, it is called HYPERTHYROIDISM and SUBACUTE Thyroiditis OR caused by something outside the thyroid= EXTRATHYROIDAL.
Most common cause of THYROTOXICOSIS?
HYPERTHYROIDISM:

d/t increase in BILE synthesis
d/t increase in release of thyroid HORMONE amounts
patient w/ thyrotoxicosis?
female 20-40 y.o.
Excessive release of pre-formed thyroid hormone
SUBACUTE THYROIDITIS

(one form of thyrotoxicosis)
What term can be used interchangeably w/ thyrotoxicosis?
hyperthyroidism
THYROID STORM
Thyrotoxic crisis = abrupt onset of SEVERE HYPERthyroidism.
It's untreated thyrotoxicosis where too much thyroid hormone is released [T3 & T4].
Medical emergency. Death from cardiac arrhythmia.
What 5 things can cause a THYROID STORM
1. Surgery
2. Trauma
3. MI
4. Infection
5. Ingestion of thyroid hormone (taking Mom's thyroid meds)
Describe a patient presentation in a thyroid STORM
Thyrotoxic crisis: abrupt onset of severe hyPERthyroidism

FEVER, TACHYCARDIA, HEART FAILURE, NEURO + GI ABNORMALITIES = EMERGENCY!
Patient presentation HYPERthyroidism
Increased symptoms of metabolic activity:
Nervous/anxious/hyperactive
Warm, moist skin and diaphoresis (sweating)
Heat intolerance
*Weight loss despite healthy appetite (^ BMR)
*Fine resting tremor
*Exophthalamos
Fracture b/c TH stimulates bone resorption
Physical exam findings HYPERthyroidism:
Thyromegaly + Bruit

Vital signs: ^^DTR, LID LAG

atrial fib [elderly] and tachy w/ palpitations
Diagnostic imaging for HYPERthyroid
nuclear thyroid scyntigraphy

thyroid ultrasound/CT
LAB Findings for
PRIMARY HYPERthyroidism *********************************
Primary:
INCREASED THYROID HORMONE because coming directly from thyroid = primary

DECREASED TSH because signal BLOCKED by ANTIBODIES on TSH-Receptors. Nothing can tell the TSH receptors to respond.

Thyroid ANTIBODIES [GRAVE'S]

EKG abnormalities
MOST COMMON cause of hyperthyroidism
GRAVE's disease [PRIMARY hyperthyroidism]

Increased TH [T3 + T4]
but decreased TSH so coming from THYMOMA on thyroid, not on the pituitary gland!

Primary means it's coming from the thyroid directly.
When I say HYPERthyroidism, you say

GOITER - EXOPHTHALAMOS - pretibial (notes) or periorbital (lecture) MYXEDEMA
GRAVES - a NON-tender, enlarged thyroid gland = GOITER
THYMOMA
PRIMARY
INCREASED TH
Decreased TSH
ANTIBODIES to TSH receptors
SECONDARY hyperthyroidism:

Labs?
What is responsible, the pituitary or the thyroid or a tumor elsewhere?
Increased TH (T3 & T4)
AND
Increased TSH

so...PITUITARY is responsible
Patient presentation in your office of GRAVE's dz w/ most prominent labs?
1. Von GRAEFE'S sign: LID LAG

2. DALRYMPLE sign: wide staring gaze

3. Decreased TSH {not coming from pituitary because of TSH receptor antibodies}

4. Increased TH because of GOITER so thyroid itself is cause
Radiography and scintigraphy for Graves' dz
Diffuse UPTAKE in radioactive iodine

Tracheal air shadow due to substernal goiter on plain film. Order CT.
When I say TOXIC MULTINODULAR GOITER, you say
PLUMMERS' dz (think of the House episode)

No exophthalmos or myxedema. INCREASED T4 thyroid hormone.
Decreased T3 and TSH
Labs for TOXIC MULTINODULAR GOITER
INCREASED T4 TH= because the thyroid itself has induced a toxic goiter

Decreased TSH and T3 - what comes from the pituitary is down.
Plummer's Disease--also known as "toxic (multi)nodular goiter"--is a condition in which the body produces too much thyroid hormone. The extra node(s) produce excess thyroxine (T-4) and triiodothyronine (T-3). The pituitary gland and hypothalamus controls how many of these hormones are released. T-4 and T-3 control your body's metabolism, temperature, heart rate, and affect the rate of protein production (they're pretty important).

If the body is too low on T-3 and T-4, the hypothalamus will release the thyroid stimulating hormone (TSH). If T-3 and T-4 are too high, TSH levels will taper off. Therefore, House was able to find that Benjamin's TSH levels were lower than normal.
Not all nodules (adenomas) produce excess T-4 (thyroxine), but in Benjamin's case, his nodule did, which caused the symptoms he experienced.
Let's see. What potential complications could have arisen had Benjamin not been treated? Well, seeing as too much T-4 is responsible for arrhythmias, heart problems would have been highly likely. Too much thyroid hormone affects your body's ability to bind calcium to your bones, and therefore, Benjamin would have had brittle bones.
http://thediaryofapremed.blogspot.com/2011/12/case-1-plummers-disease.html
And I think the worst complication would have been thyrotoxic crisis, which is an intensification of symptoms related to hyperthyroidism (and that could lead to mental disorders).
House used TSH and radioactive iodine uptake to diagnose Plummer's Disease (radioactive iodine uptake during his CT scan when it was thought he had a neurological disorder).
Treatment options: radioactive iodine (supplemented with iodine pills to regulate the body's thyroxine levels), surgery (House's preferred treatment), anti-thyroid medication, beta blockers (won't do much for your thyroid but will reduce the stress on your heart)

History: Plummer's diease is an eponym. It is named after Henry Stanley Plummer, a physician. He was also one of the founders of the prestigious Mayo Clinic. Plummer first described this case of hyperthyroidism in 1913.
TOXIC ADENOMA
FUNCTIONAL toxic adenoma:

INCREASE T4 only, just like toxic multinodular goiter

SINGLE enlarged node so FUNCTIONAL thyroid

SINGLE area of radioactive iodine uptake on scintigraphy
thyrotoxicosis FICTITIA
When someone takes thyroid medication to increase BMR/lose weight, they get Thyrotoxicosis FICTITIOUS = a form of exogenous thyrotoxicosis.
EXOGENOUS thyrotoxicosis
Hyperthyroidism due to increase in exogenous thyroid hormone or iodine

CORDARONE heart med increases iodine uptake

Radiation and imaging can also increase iodine uptake

Increased thyroid medication
Primary hyperthyroidism is ________.

Secondary hyperthyroidism is from an ______ source.
primary = intrinsic (the thyroid itself)

secondary = outside source such as TSH-secreting pituitary adenoma (rare)

Lab tests will show increased TSH and TH in secondary pituitary adenoma hyperthyroidism
What will lab tests show in SECONDARY hyperthyroidism?
Increased TSH and TH

*due to a TSH-secreting pituitary adenoma
*secondary
SUBACUTE THYROIDITIS is _________________!!!!!!!!

aka:
PAINFUL!!!!!!!!!!!!

aka: DeQuervain Thyroiditis

Caused by VIRAL/post viral inflammatory process
UPPER RESPIRATORY inf.

Increased TH (the 'itis' should tell you it's coming directly from the thyroid) and Decreased TSH
LYMPHOCYTIC thyroiditis is painless.
painless.
middle-aged women
triphasic presentation [hyper>hypo>normal]
Increased TH only.
Caused by ANY disorder that prevents delivery of TRH from the hypothalamus to the pituitary
TERTIARY (central) hyperthyroidism
the most common cause of hypOthyroidism in the United States
HASHIMOTO'S THYROIDITIS
hypOthyroidism is an under-production of serum ___
TH

Females 30-50 y.o.
PRIMARY hypOthyroidism is decreased ____
TH because it is primarily/directly a problem thyroid.

*Iodine deficiency, thyroidectomy, radioactive iodine therapy, DeQuervain's or post-partum thyroiditis, lithium [bipolar], amidarone [anti-arrhythmic], phenytoin [anti-epileptic], carbamazepine [anti-convulsant, mood stabilizer], and rifampin [antibiotic]
SECONDARY hypOthyroidism is decreased ____
TSH

*Secondary means coming from a source other than the thyroid, meaning anything that whacks the pituitary and causes it to not produce enough TSH

*Acromegaly, Irradiation, Sheehan's syndrome (post-partum hemorrhage that causes necrosis), pituitary dz, meds (steroids, DA, dobutamine, octreotide). Dobutamine increases cardiac output. Octreotide mimics somatostatin, used to treat severe diarrhea, acromegaly or esophageal varices.
Tertiary hypOthyroidism
decreased TRH

Hypothalamic destruction after cranial irradiation or surgery stops the TRH from getting to the pituitary
hypOthyroidism patient
QUEEN ANNE'S SIGN = loss of lateral 1/3 eyebrow
HOARSENESS
DRY, ROUGH, COOL, PALE SKIN
EYE PUFFINESS
COLD INTOLERANCE
Weight gain, lack of sweat, headaches
Physical exam findings of hypOthyroid pt
PAINLESS, firm goiter w/ NO bruit
*PERIORBITAL edema, blurred vision
*Decreased DTR, especially ACHILLES
Decreased vitals
NON-PITTING PERIPHERAL EDEMA of hands and feet but PITTING edema of lower extremites
Peripheral neuropathy
*if ANEMIC, pale skin, brittle fingernails
**CARPAL TUNNEL SYNDROME (+ Phalen's and thenar atrophy)
Fx from osteoporosis because TH therapy can DECREASE bone density
QUEEN ANNE'S SIGN
+
CARPAL TUNNEL
=> HASHIMOTO'S <=

hypOthyroidism
how can PERNICIOUS ANEMIA lead to gastritis
autoimmune destruction of parietal cells
leads to decreased IF and decreased absorption of B12
leads to megaloblastic anemia
2 types of gastritis
hemorrhagic & erosive
`
Patient complaints of gastritis
Stabbing pain, cramping
epigastric pain, bloating, discomfort
indigestion
nausea, vomiting, hematemesis
Melena
black, tarry stools indicates UPPER GI bleed (distal esophagus, stomach, duodenum)
Hematochezia
bright red blood on stool

*indicates LOWER GI or Rectal bleed (hemorrhoids or diverticulosis)
COFFEE-GROUND EMESIS
vomiting blood w/ BLACK specks

Indicates a STOMACH bleed (enzymes in stomach darken the blood)
The most common cause of gastritis is H. pylori.

Lab tests for H. pylori?
Lab tests for gastritis?
What's the most common reason for anemia/blood loss, accd'ing to Dr. Wells?
Urea breath test for H. pylori

Occult blood in stool if gastric bleeding so blood antibody and stool antigen tests.

If patient anemic due to GI bleed (most common reason for anemia), low H&H
Most common gastric POLYP
HYPERPLASTIC polyp = benign and glandular
PEUTZ-JEGHER'S SYNDROME
GASTRIC POLYPS
HYPERPIGMENTATION {freckles} around mouth and anus

Polyps may become malignant
ADENOMATOUS polyps are
malignant
Patient hx/complaint of gastric POLYPS
small are asymptomatic but large can ulcerate, lead to occult bleeding and anemia

Large antral polyps can cause intermittent gastric obstruction of the gastric outlet and cause pt to vomit/nausea

Early satiety [fullness]
Abdominal distension
Epigastric pain
cancer of the stomach
gastric ADENOCARCINOMA

males 50-70

Japanese, E. Europeans, Costa Ricans, Chinese
Causes of gastric adenocarcinoma include:
Peptic Ulcer Disease
Chronic BILE and PANCREATIC reflux
NSAIDS, aspirin, excess alcohol
Smoking, radiation,
Pernicious anemia
**BACTERIAL INFECTION of H. PYLORI can result from anything that lowers stomach acid levels [hypochorhydria]. This produces CARCINOGENIC NITRATES.
LINITIS PLASTICA
LEATHER BOTTLE STOMACH associated w/ gastric adenocarcinoma

CA infiltrates submucosa and prevents normal distension of stomach
Achlorhydria

Hypochlorhydria
A - absence of stomach acid
H- lowered stomach acid, due to bacterial infection of H. pylori or antacids or pernicious anemia (low HCl and IF).
Risk factors for gastric Adenocarcinoma
************H. pylori *********
salted, smoked or pickled foods (nitrates)
Smoking
Poor
Polyps
Family hx of gastric adenocarcinoma
GASTRITIS
OBESITY
radiation therapy
diet low in fruits and veggies
partial gastrectomy
In early stages of gastric carcinoma, what often relieves pain?
acid-buffering effect of food or antacids
Late sx of gastric adenocarcinoma
UNINTENTIONAL WEIGHT LOSS
DYSPHAGIA (GERD, decrease in size of lumen as it is occluded by cancer)
POST-PRANDIAL FULLNESS, EARLY SAIETY (b/c stomach doesn't properly distend)
MELENA
Bloating, weakness, fatigue
HEMATEMESIS
Physical exam gastric adenocarcinoma [5 signs]

SuVS BooK of gastric cancer

*Can always enter vowels between consonants as a mnemonic trick.
SuVS BooK:

SUCCUSION SPLASH: fluid sound when abdomen palpated. Means hollow area due to obstruction.

VIRCHOW'S NODE: sentinal node left supraclavicular node at thoracic duct venous entry via subclavian

SISTER MARY JOSEPH SIGN: nod bulging into umbilicus d/t cancer

BLUMER'S SHELF: mass felt on rectal exam

KRUKENBERG'S TUMOR: 2* ovary malignancy originating from gastro adenocarcinoma mets
Imaging results of gastric adenocarcinoma
APPLE CORE appearance (like esophageal ca)
Mets show on chest radiograph

Laproscopy is best method to stage tumors
Labs for gastric adenocarcinoma

*what's in the stool?
*name 2 tumor markers:
GUAIAC (+) stools
CEA & CA tumor markers

Anemia
LFT (liver fcn test) for mets to liver
*CEA=carcinoembyronic antigen
**CA= carbohydrate antigen
ZOLLINGER-ELLISON SYNDROME
ZE PANCREAS is sick!
Gastrinoma tumor of pancrea
Watery diarrhea and steattohea but NO ulcer.

NON-beta islet cell GASTRIN-secreting tumor of the pancreas

OVERPRODUCTION of gastrin from gastrinoma = OVERPRODUCTION of stomach acid = ulcers of stomach and small intestine
Whats the problem w/ Sollinger-Ellison syndrome
males 30-60

50% progress to MALIGNANCY
Heartburn which mimics GERD
Steatorrhea (increased acid inhibits bile, leading to steatorrhea)
Sx of Peptic ulcer dz
Signs of perforation (+Rosving's, Blumberg's)
GUAIC + stools
anemia

***INCREASED FASTING SERUM GASTRIN******
ZOLLINGER-ELLISON syndrome

pancreas gastrinoma (excess prod of gastrin >> excess HCl >>stomach and sm intestine ulcers)`
MEN
parathyroid tumor
pancreatic islet cell tumor
pituitary adenoma
all causing increased plasma Ca+, PTH and prolactin
and ZOLLINGER-ELLISON syndrome`
an ulcer arising from the lining of the GI tract
PEPTIC ulcer

various locations: GASTRIC & DUODENAL w/ esophageal least common
Causes of PEPTIC ulcer
Cocaine, smoking, alcohol, caffeine

H. pylori infection

NSAID regular use, glucocorticoids

Family hx, antacids, anti-coagulants

Gastrinoma
PEPTIC ulcer may cause air w/in the peritoneum, called a
PNEUMOPERITONEUM
commonly caused by perforated ulcer

*signs of peptic ulcer include anemia, tenderness and perforation
Imaging a PEPTIC ulcer
upper GI Barium study [UGI}
and endoscopy
2 best tests for PEPTIC ulcers:
1. UREA BREATH TEST - pts swallow urea w/ a carbon marker. CO2 exhale containing UREASE means H. pylori is present in stomach, since the bacteria uses the enzyme urease to metabolize urea. Means they are there and they are busy as hell.
2. UREASE TESTE - urease made by H. pylorE RAISES pH of stomach and changes colour when Exposed to a DYE

Other tests: guaiac + stool, CBC, stool antigen test HpSA, antibody test, biopsy
GASTRIC ulcer
elderly men
Cause is most commonly H.PYLORI
but chronic use of NSAIDS, alcohol and smoking counts (make pain worse, too).

****Intermittent, recurrent PAIN 30min -1.5 hr AFTER eating*****
Weight loss
Hematemesis
MELENA (Upper GI blood)
syncope
DUODENAL ulcer
males 20-60
most common cause is H. PYLORI

****Onset 2-3 HOURS after eating****
*Pain WORSE AT NIGHT
*Pain RADIATES TO BACK
*Pain RELIEVED w/ FOOD or antacids

****CLOVER LEAF = scarring pulls lumen into a clover pattern
How can a DUODENAL ulcer lead to NAUSEA?
Scarring over (clover leaf) can lead to obstruction and cause nausea.
cholelithiasis
gall STONES:
1. can be cholesterol (80%)
2. pigmented Ca+ bilirubinate
3. Both

Cholesterol = ULTRASOUND or CONTRAST study as FILLING DEFECTS.

Pigmented = PLAIN FILM
How will cholesterol stones in gall bladder CHOLELITHIASIS be seen on plain film?
They are NOT seen on plain film.

They ARE seen on ULTRASOUND or CONTRAST STUDY as FILLING DEFECTS.
Gallstones usually block the ________, due to its twisted course.
cystic duct
Inflammation of the BILE DUCT itself.
CHOL-ANGITIS

*Most commonly from H. Pylori bacterial infection

*"ANG" for duct like artery, angio
Inflammation of the GALL BLADDER
CHOLE-CYSTITIS
GALLSTONES in the COMMON bile duct
CHOLE-DOCHO-LITHIASIS

*leads to cholangitis (inflammation of gall bladder)
a change in the gallbladder WALL due to excess cholesterol/cholesterol stones.
CHOLESTERO-LOSIS

"LOSe the WALL"
autoimmune dz of LIVER marked by slow, progressive destruction of small BILE DUCTS in the liver
BILIARY CIRRHOSIS

Duct damage = bile buildup in liver. Scarring, fibrosis, cirrhosis, liver failure.
IMPACTION of a gallstone in the ILEUM after being passed through a BILIARY-ENTERIC FISTULA
GALLSTONE ILEUS

"ILEUS for ILEUM"
CALCIFICATION of wall of gallbladder
PORCELAIN GALL BLADDER
calcification of the wall of the bladder is called PORCELAIN gall bladder. What can it lead to?
carcinoma

(the gallbladder has become irritated w. the collection of stones)
patient experiences same or worse sx AFTER GALL BLADDER REMOVED
POST-choleycystectomy syndrome
Gimme the 5 F's of gall stones
Fat
Female
Fair
Forties
Fertile
Describe gall bladder PAIN
SUDDEN pain upon eating (w/in 30 min of a FATTY meal) in RUQ

May RADIATE around to INFERIOR ANGLE of RIGHT scapula

RIGHT SHOULDER pain
Intolerance to fatty or greasy food
Physical findings during exam for gall bladder
MURPHY'S SIGN: liver palpation. Ask patient to exhale, palpate liver. If pt cannot inhale or stops breathing due to pain, test is POSITIVE

Guarding on palpation
CHOLESCINTIGRAPHY
HIDA; hydroxyiminodacetic acid skan for gall bladder and ducts in and out of it.
Used if suspected gall stone in CYSTIC DUCT
gallbladder labs
C-reactive protein ELEVATED

Alk phos, bilirubin, WBC possible elevated
PANCREATITIS

35-60 y.o.
INFLAMMATION of pancreas
swelling of gland and surrounding blood vessels
bleeding, infection and damage

Pancreas may AUTODIGEST due to trapped digestive juices
2 causes pancreatitis
1. GALL STONES
2. ALCOHOL ABUSE

could be post surgical (post ERCP)
Is pancreatitis irreversible?
Only if acute turns to chronic and scarring damages normal fcn
Chronic pancreatitis >> abcess >>>__________
abscess >> pseudocyst of amylase, etc, blood and necrotic tissue
PANCREATITIS pt complaint
sudden or gradual EPIGASTRIC pain that RADIATES TO BACK straight through

Nausea, vomiting, fever
flatulence, steatorrhea, bloating, weight loss
Can't digest fatty foods
PROVOCATIVE pancreatitis
SUPINE position, FATTY meals, ALCOHOL ingestion
PALLIATIVE pancreatitis
SITTING, LEANING SLIGHTLY FORWARD
FETAL POSITION
Vitamin lost in pancreatitis
B12

decrease in protease release so B12 cannot be properly cleaved to bind to Intrinsic Factor
TWO signs of PANCREATITIS

{Grey Water filter}
1. CULLEN'S SIGN: bruising around ***umbilicus** (retroperitoneal bleed)
2. GREY-TURNER'S SIGN; ***flank*** bruising (retroperitoneal bleed)
X-ray PANCREATITIS sign

{backwards letter}
REVERSE 'C'

pattern of barium study showing enlarged pancreas pushing into sm. intestine
pancreatitis labs
***elevated PANCREATIC ENZYMES (amylase and lipase)

CBC, blood glucose, LFT, RFT
Electrolytes
ADENOCARCINOMA of the pancreas most commonly comes from the __________ pancreas.
EXOCRINE

One of most aggressive cancers known. Patrick Swayze last year.
By the time it's diagnosed, it's metastasized to lungs, liver, lymph.
Cancer of the HEAD OF THE PANCREAS shows more sx because
the DUCT is OBSTRUCTED.
3 stages of pancreatic adenocarcinoma
LOCALIZED to pancreas only
LOCALLY ADVANCED to nearby blood vessels or organs
METASTATIC spread
Risk factors for pancreatic adenocarcinoma (unless you are Patrick Swayze)
Black
Smoker
Fat
Hx of pancreatic in family
Diet high in meat and fats
H. pylori infection
ERCP
Endoscopic Retrograde Cold Pancreatogram surgical procedure that predisposes people to pancreatitis
Pancreatitis ultimate sign
 sudden or gradual epigastric pain which radiates to the back, lasting hours to days
One thing that makes pancreatitis better physically
sitting and leaning slightly forward, supine
 signs of DM
 B12 deficiency
 Cullen’s sign
Grey-Turner’s sign
PANCREATITIS
(KUB) Kidney-Ureter-Bladder plain film of abdomen
PANCREATITIS:
barium study shows “reverse C” pattern where the enlarged pancreas pushes into the small intestine
A CT scan for PANCREATITIS shows areas of diffuse enlargement of pancreas and ____________ w/ ill defined, fuzzy margins. On plain film, you see _________
CALCIFICATIONS = PANCREATITIS
large cyst in pancreas found when pancreatitis exists
PANCREATIC PSEUDOCYST large cyst in pancreas, c/o steatorrhea
Labs for PANCREATITIS
Lab Findings
  pancreatic enzymes (amylase and lipase)
 *******CBC/blood glucose/LiverFunctionTest/RenalFunctionTest*******
 electrolytes
What glands of pancreas cause most common type of pancreas cancer?
 the most common type of pancreatic cancer arises from the EXOCRINE glands pancreas. Adenocarcinoma of head of pancreas FROM PANCREATITIS– adenocarcinoma of the pancreas
Why does pt w/ pancreatic cancer have JAUNDICE?
Duct blocked.
#1 risk for PANCREATIC CANCER
*********** smoking**************
 advancing age
 M>F
 chronic pancreatitis
 diabetes
 family hx of pancreatic cancer
 African American
 obesity
 occupational exposures – dyes, chemical gases, pesticides
 diet high in meat and fats
 H. pylori infection
COURVOSIER SIGN
Courvoisier sign – non-tender, enlarged gall bladder with associated jaundice PANCREATIC CANCER
Why isn't jaundice likely to be from gall stones but from pancreatic cancer instead?
Jaundice unlikely to be caused by gall stones. This is because gall stones are formed over a longer period of time, and this results in a shrunken, fibrotic gall bladder which does not distend easily. Therefore the gall bladder is more often enlarged in pathologies that cause obstruction of the biliary tree over a shorter period of time such as pancreatic malignancy.
non-tender, enlarged gall bladder w/ jaundice
Courvosier's sign of pancreatic cancer
Lab findings for pancreatic cancer:
Name the functional test that comes back abnormal because of BILE OBSTRUCTION?
What is the TUMOR MARKER?
 liver function test (LFT) abnormal with bile obstruction

 tumor marker CA 19.9
When are pancreatic enzymes elevated?
During PANCREATITIS, not pancreatic cancer
If OBSTRUCTIVE JAUNDICE, what labs are elevated? [5]
BILIRUBIN (conjugated and total)
alkaline phosphatase (ALP)
glutamyl transpeptidase (GGT)
aspartate aminotransferase (AST)
alanine aminotransferase (ALT)
Do liver mets cause jaundice?
Rarely.
CIRRHOSIS
a result of CHRONIC LIVER DZ characterized by replacement of liver tissue by FIBROTIC scar tissue and regenerative NODULES, leading to progressive loss of liver function
FIBROTIC SCAR TISSUE
REGENERATIVE NODULES
CIRRHOSIS
2 common causes of C-IRRHOSIS:
1. HEPATITIS-C

2. C-HRONIC ALCOHOLISM
Besides the major 2 causes of Cirrhosis of the liver (Hep C and Alcohol), name a few others:
BILIARY cirrhosis (autoimmune), primary sclerosing CHOLANGITIS (autoimmune inflammation of the bile ducts), autoimmune hepatitis, non-alcoholic FATTY Liver, inherited diseases (hemochromatosis – iron, WILSON'S disease – copper, cystic FIBROSIS– scar tissue), medications (chronic ACETAMINOPHEN), toxins, infections, cardiac disease=RSHF!
Patient hx/ complaint of CIRRHOSIS
*****ASCITES*****

 cognitive changes (hepatic encephalopathy
 jaundice/ pruritis
 abdominal pain
 sensitivity to medication
 shortness of breath (SOB)
 palmar erythema – palms flush red & blanch (due to  estrogen)
*the impairment of hormone production and metabolism
PALMS FLUSH RED & BLANCH due to estrogen
 PALMER ERYTHEMA: palms flush red & blanch (due to  estrogen)

= CIRRHOSIS
SPIDER ANGIOMA
spider angiomata (people who have significant hepatic disease show many spider angiomas, as they are not making sufficient of coagulation factors abnormal estrogen production.) = CIRRHOSIS
CAPUT MEDUSAE
 caput medusa - the appearance of distended and engorged umbilical veins which are seen radiating from the umbilicus across the abdomen to join systemic veins) = CIRRHOSIS
ascites know 4 changes
Terry’s Nails
caput medusa
spider angiomata
palmar erythema
CIRRHOSIS:
ascites
Terry’s Nails
caput medusa
spider angiomata
palmar erythema
NAFLD

NASH
NAFLD Non Alcoholic Fattly Liver Disease
NASH Non Alcoholic Steato Hepatitis
labs for cirrhosis that look like everything else
INCREASED bilirubin, ALT, AST, ALP, PTT

All the PENIA's: thrombo, leuko, neutro

l
Labs for CIRRHOSIS
Lab Findings
 unremarkable
  bilirubin, AST, ALT, ALP, PTT, globulins, serum Na
 thrombocytopenia
 leukopenia
 neutropenia
 hepatitis C antibody
 viral RNA
 EIA-2 enzyme immunoassay (ELISA)
LACTOSE INTOLERANCE
the inability to digest lactose due to  levels of lactase, found in the brush border of the duodenum
 as a result, lactose ferments in the intestines
Where is lactose intolerance found?
DUODENUM BRUSH BORDER
What type of LACTOSE INTOLERANCE can be TREATED?
SECONDARY/ACQUIRED! – occurs due to intestinal damage from disease such as celiac sprue, Whipple’s, Crohn’s, gastrinoma, chemo, radiation enteritis or diabetic gastropathy.
*This type can be treated
4 lactose intolerance tests:

Lmsh
 lactose tolerance test
 milk tolerance test
 stool acidity test
 hydrogen breath test (used as a clinical medical diagnosis for people with irritable bowel syndrome, and common food intolerances.)
What is the HYDROGEN BREATH TEST used for?
hydrogen breath test (used as a clinical medical diagnosis for people with irritable bowel syndrome, and common food intolerances like LACTOSE INTOLERANCE)
CELIAC SPRUE definition
chronic, autoimmune, GLUTEN-sensitive enteropathy resulting in maldigestion
 causes is a genetic predisposition GLIADIN of wheat, barley, rye
GLUTEN & GLIADIN
Sawtooth
Chvostek
Trousseau
Dermatitis herpetiformis
Celiac sprue
CELIAC SPRUE buzzwords
GLUTEN & GLIADIN
Sawtooth
Chvostek
Trousseau
Dermatitis herpetiformis
Describe CELIAC SPRUE
GENETIC predisposition to GLUTEN sensitivity. GLIADIN (Gliadin is a glycoprotein present in wheat and several other cereals) sensitivity. Barley, wheat, rye.
Almost TOTAL ABSENCE OF VILLI in bowel and disordered blood supply
What causes MALABSORPTION of celiac sprue
THICKENED BORDER of intestines w/ MISSING VILLI =

sawtooth sawtooth sawtooth sawtooth pattern of mucosa w/ increase in lymphocytes sawtooth sawtooth sprue sawtooth sprue
symptoms of vitamin deficiencies
 stunted growth in children
paresthesias of lips, hands, fingers, feet, tongue
 hyperreflexia
Celiac sprue odd presentations (usual are abdominal bloating, steatorrhea, vomiting, diarrhea, weight loss)
 signs of nutrient deficiency – CELIAC SPRUE
glossitis, angular cheilitis, gingivitis, periorbital hyperpigmentation
CHVOSTEK SIGN for celiac sprue due to nutrient deficiency.

Which nutrient? What does this cause?
celiac sprue: \
Chvostek sign - When the facial nerve is tapped at the angle of the jaw, the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of HYPOCALCEMIA and hyperexcitability of nerves.
TROUSSEAU SIGN for celiac sprue:

Due to what nutrient deficiency?
Aka: _________ Hand.
celiac sprue:
Trousseau sign – To perform the maneuver, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. If carpal spasm occurs, manifested as flexion at the wrist and metacarpophalangeal joints, extension of the distal interphalangeal and proximal interphalangeal joints, and adduction of the thumb and fingers, the sign is said to be positive and the patient likely has hypocalcemia. OBSTETRIC hand.
DERMATITIS HERPETIFORMIS
celiac sprue:
dermatitis herpetiformis – a chronic itchy rash of papules and vesicles associated with Celiac Sprue
Chovstek
Trousseau
Herpetiformis
Celiac Sprue

Hypocalcemia and signs of anemia (B12, IDA, folic acid crashed)
Lab findings for CELIAC SPRUE
1. Electrolyte >< hypoK+alemia, hypoNa+tremia
2. HypO: albumin, protein & cholesterol
3. Anemia
4. coagulation
5. Renal and Liver fcn
6. Glucose Tolerance Test - down
7. Stool specimen - steatorrhea
8. see slide for ANTIBODY tests to actually know.
Name the 3 ANTIBODY tests for celiac sprue:
Which one is most specific?
8. PAY ATTENTION:
IgA anti-ENDOMYSIAL Ab {96-100% specific for celiac}

IgA anti-TRANSAMINASE Ab [90% specificity]
IgA anti-GLIADIN Ab (65-100% specificity)
WHIPPLE'S DZ

Caused by? (BACTERIA)
Primarily affects? (2)
a systemic infections disease caused by infiltration of tissues by Tropheryma Whipplei bacteria, primarily affecting the SMALL INTESTINES & JOINTS
Patient complaint for WHIPPLE'S DZ
Distention of the SMALL INTESTINES

Symptoms of MALABSORPTION
Abdominal pain, diarrhea, fever
CHVOSTEK and TROUSSEAU signs are present for what 2 disorders?
CELIAC SPRUE
&
WHIPPLE'S DISEASE
To distinguish WHIPPLE's from CELIAC SPRUE, test for
T. WHIPPLEI

Tropheryma Whipplei bacteria affecting small intestine and joints
What are the usual nutrient deficiencies of TROPICAL SPRUE
FOLIC ACID
B12
IRON
TROPICAL SPRUE can be bacterial, viral or parasitic. What part of the body does it affect? What does it do to it?
Small intestine
thick and flat border of small intestine
TROPICAL SPRUE is a syndrome characterized by
acute or chronic DIARRHEA
WEIGHT LOSS
MALABSORPTION of at least 2 different substances when other causes are excluded
PAIN 15 min after eating because NOT ENOUGH BLOOD to meet visceral demands
ABDOMINAL ANGINA

aka: "Bowelgina"
Why do mainly older people suffer from ABDOMINAL ANGINA (bowelgina)?
****atherosclerosis****

caused by atherosclerosis of celiac, superior or inferior mesenteric arteries
Postprandial Angina
bowelgina
atherosclerotic vascular disease
ABDOMINAL ANGINA
abdominal angina buzzwords (3)
Postprandial Angina
bowelgina
atherosclerotic vascular disease
diagnostic tests for ABDOMINAL ANGINA
 AORTOGRAPHY!
 MRI
 duplex US – visualizes blood flow
AUTONOMIC NEUROPATHY
 damage to NERVES affecting the GI tract leads to  ability to move food during digestions and symptoms of diarrhea/constipation, nausea/vomiting, bloating and pain
 damage to NERVES affecting the GI tract leads to  ability to move food during digestions and symptoms of diarrhea/constipation, nausea/vomiting, bloating and pain
autonomic neuropathy
ACUTE APPENDICITIS
inflammation of the appendix in patient 10-30 yoa
How should the appendix normally appear?
the appendix should normally appear lily white
Symptoms of appendicitis
vague peri-umbilical pain localizing to the RLQ within24 hours
 loss of appetite
 low grade fever (becomes high with peritonitis)
 nausea/vomiting
 temporary relief from pain if the appendix ruptures
most common COMPLICATIONs of acute appendicitis

*P.A.P.
PERFORATION
ABCESS
PERITONITIS
Physical exam ACUTE APPENDICTIS
RLQ pain at MCBURNEY'S POINT
DUNPHY'S SIGN - increased pain w/ coughing
OBTURATOR SIGN - pain on extension of R thigh (appendix is retroperitoneal or retrocaecal)
PSOAS SIGN - pain on internal rotation of R thigh (if appendix is pelvic)
JAR/ANVIL test
no bowel sounds if obstructed
Psoas test vs. Obturator test for acute appendix
P for Psoas & Pelvic (internal rotation)

Obturator is extension

Both pain on R side
Diagnostic imaging for ACUTE APPENDICITIS
US/CT/KUB/radionucleide scanning - attaches to WBC and shows inflammation