Q6 Gnmd Week 2 Martin's Study Guide Pathologies

Front 1

GI DISORDERS REVIEW

I. Gallbladder disease (stages, incidence, clinical, PE, Imaging, Tx)

Back 1

A. Stages of gallbladder disease
a. Asymptomatic Gallstones
b. Biliary Colic: temporary obstruction d/t smaller stones
c. Cholecystitis
d. Choledocolithiasis: cholangitis and ascending infection
i. Cholangitis: inflammation of ducts in GB
ii. Ascending infection: stones lodged in common bile duct.
B. Incidence: 10-15% of adults have gallstones; 1-2% will develop symptoms
a. Higher risk: fertile women, whites, Hispanics, Pima Indians, OCP users
C. Clinical presentation:
a. Gallbladder colic: recurrent episodes of constricting pain (<4-6 hours), often come on after large, fatty meal d/t temporary obstruction
b. Acute cholecystitis: 1-5 hours of constant and severe constricting pain, localizing to RUQ, low-grade fever, N/V, wakes pt up at night and have severe diaphoresis
i. may radiate to R lower scapula.
D. Physical exam:
a. V/S parallel degree of illness
b. RUQ tenderness and guarding
c. Murphy’s Sign
d. Peritoneal Signs w/ complications
e. Jaundice w/ CBD obstruction in 20% patients d/t conjugated hyperbilirubinemia
E. Imaging studies and labs
a. Ultrasound is best
b. HIDA – if obstruction detected to visualize biliary tree
c. CT scan if diagnosis unclear
F. Prehospital treatment: monitoring of V/S – O2, IVF, rapid transport

Front 2

II. Appendicitis sx, PE, labs

Back 2

A. Symptoms: anorexia for a couple of days → non-specific periumbilical pain → N/V → RLQ pain
B. Physical exam: rebound tenderness, +Rovsing’s, +Psoas, pain w/ heel percussion, rectal exam if retrocecal appendix and suspect appendicitis but no +rebound/Rovsing’s.
C. Labs and imaging studies
a. CT – imaging study of choice
b. WBC w/ left shift, UA, Urine C/S, CMP

Front 3

III. Pancreatitis etiologies, systemic effects, sx, PE, Labs/imaging

Back 3

A. Etiologies: EtOH, gallstones,
B. Systemic effects
a. Vasodilation and shock
b. 3rd spacing: increased permeability of blood vessels – tea colored ascites
c. Hypocalcemia, hyperglycemia
d. ARDS and renal failure in severe cases
C. Symptoms
a. Epigastric pain, steady/boring and can radiate to the back
b. N/V
D. Physical exam
a. Tachycardia, tachypnea, shallow respirations
b. Hypotension, fever,
c. Decreased or absent bowel sounds
d. Gray-Turner: bluish discoloration of flanks
e. Cullen signs: bluish discoloration of peri-umbilical area
E. Labs and imaging studies
a. Leukocytosis, hypocalcemia, hyperglycemia, amylase 3x normal, elevated lipase, HCT w/ severe 3rd spacing
b. CT scan imaging of choice
c. KUB (Kidney Ureter Bladder Film): to R/O perforation

Front 4

IV. Diverticular Disease definition

Back 4

A. Definition: mucosal projection/herniations through muscular walls in colon
B. Dietary causes of diverticulosis: low fiber diets
C. Symptoms: 80% asymptomatic, tenderness and aching LLQ, fever, N/V, pain may be relieved by defecation
D. Dx: Barium Enema and colonscopy, CT scan to R/O appendicits
E. Indications for surgery for diverticulitis: if there is an abscess, obstruction, fistulas or if it is the 2nd episode of diverticulitis

Front 5

V. Small Bowel Obstruction

Back 5

A. Etiology: adhesions (most common cause), malignancy, hernias, Crohn’s Disease
B. Symptoms/PE: V/D early on, then diarrhea will stop once complete obstruction, severe spasmodic pain from epigastric area → umbilical area, strangulating, change in pain w/ complications, diffuse abdominal tenderness w/ distal obstructions, hyperactive bowel sounds early on, hypoactive or absent sounds later on.
C. Dx: CT scan, supine and upright plan films (dilated loops of bowel/air/fluid levels proximal to obstruction)

Front 6

Pediatric GI Disorders
I. Non-GI Causes of GI Symptoms

Back 6

o Vomiting: How often, weight gain (losing), and development; when vomiting occurs is important
o Have to R/O CNS problems, like meningitis
• 100.5 fever in baby <2 months → rule out sepsis & meningitis
A. Trauma – look at fundi (retinas), look for petechiae
B. Abdominal pain: renal disorders, abuse, neglect

Front 7

II. Vomiting in Infants
A. GE reflux – cause and tx

Back 7

a. Cause:
• Decreased LES tone – born prematurely usually, goes away as they get older
• Treatment:
• Thickening of feedings w/ rice cereal for bottle-fed babies, burping often
• Elevation of head of crib 30 degrees

Front 8

• Vomiting in Infants
B. Pyloric stenosis – cause, onset, sx and exam, dx

Back 8

a. Cause: hypertrophy and hyperplasia of pyloric sphincter after birth
b. Onset: 2nd or 3rd week of life
c. Sxs: frequent, projectile vomiting, hungry all the time, few BM, dehydration
d. Exam: palpation of an “olive shaped mass”
e. Diagnosis: US
C. R/O sepsis/meningitis in infants younger than 8 weeks, etc

Front 9

III. Intussusception (age, sxs/exam, Tx)

Back 9

A. Age: 5-9 months old, more common in males
B. Sxs & Exam:
a. Sudden, onset paroxysmal pain
b. Frequent vomiting
c. Currant jelly stools in 60%
d. Sausage-shaped mass in RUQ
C. Tx: rehydration, stabilization, Barium Enema (which usually treats it)

Front 10

IV. Hirschprung Disease (cause/sws/dx)

Back 10

A. Cause: congenital absence of bowel wall innervation
B. Sxs: variable
a. If Complete: fail to pass meconium
b. If Partial: chronic constipation as they grow up
C. Diagnosis: biopsy

Front 11

Esophageal Disorders
I. Dysphagia
A. Oropharyngeal –definition, causes, sx

Back 11

a. Def: difficulty w/ initiating swallowing or transferring food from mouth → upper esophagus.
b. Causes: neurological
c. Sxs: nasal regurgitation, aspiration, coughing

Front 12

Esophageal disorders: dysphagia:
B. Esophageal – definition and causes

Back 12

a. Def: difficulty in passage of food from suprasternal notch → xyphoid
b. Causes: obstruction by foreign body?

Front 13

Esophageal disorders:

II. Achalasia

Back 13

a. Defintion: motility disorder of esophagus; LES fails to relax during swallowing & pressures become elevated.
b. Sxs: gradual dysphagia for solids and liquids, regurgitation, chest pain, nocturnal cough
c. Dx: Barium swallow (beaking), monometry
d. Tx: dilation of LES, myotomy if dilations fail (surgery)

Front 14

Esophageal disorders: dysphagia:
III. GERD (etiology, sxs, dx)

Back 14

A. Etiology: incompetent LES, meds, tobacco/alcohol/coffee/chocolate, pregnancy (70%)
B. Sxs: heartburn, dysphagia, sour taste, regurgitation of gastric contents, chronic cough/bronchospasm, chest pain, laryngitis, bloating/belching, dental erosions in children
C. Dx:
a. Upper GI: ulcers, strictures
b. EGD: document type and extent of damage, R/O potentially malignant conditions (Barrett’s), biopsy if needed

Front 15

IBS (definition, factors, sxs, dx)

Back 15

A. Definition: chronic functiona disorder of the bowel – alteration of GI motility and hyperalgesia.
B. Precipitating factors of exacerbation: 50% have coexistant psychiatric conditions (anxiety), depression, personality disorder, childhood sexual abuse, domestic abuse
C. Sxs:
a. Diffuse abdominal pain: relieved by defecation
b. Abnormalities in defecation: loose stools after meals or in the AM, diarrhea alternating w/ constipation
D. Dx:
a. >3 months of abd pain relieved by BM or pain w/ a change in bowel pattern and abnormality in BM >25% of the time, characterized by >2 of the following:
i. Abd distention, consistency, defecation, frequency; Mucus w/ BM

Front 16

I. Crohn’s Disease (pathphysiology, sx/signs, extraintestinal sx coinciding, and not coinciding)

Back 16

A. Pathophysiology:
a. Earliest lesions: tiny, discrete erosions over lymphoid follicles
b. Development of linear and interconnected mucosal ulcers
c. Ulcerations + erosions → cobblestone appearance
d. Deep ulceration w/ transmural inflammation develops
e. 50% form non-caseating granulomas
f. Rectum is not involved, but perianal lesions occur
B. Sx and signs ( children and adults)
a. Children: FUO, arthritis, anemia, FTT
b. Adults: abdominal pain and chronic diarrhea

Front 17

Crohns C. Extraintestinal sx coinciding with intestinal sx intensity

Back 17

a. Peripheral arthritis
b. Erythema Nodosum
c. Pyoderma Gangrenosum
d. Aphthous Stomatitis

Front 18

Crohns D. Extraintestnal sx not coinciding with intestinal sx intensity – more common in UC

Back 18

a. Ankylosing Spondylitis
b. Uveitis

Front 19

II. Ulcerative Colitis (Incidence, pathology, sx/signs, complications/risks)

Back 19

A. Incidence: bimodal age distribution
a. Major peak: 15-30 y/o
b. Minor peak: 50-70 y/o
B. Pathology: diffuse necrosis and ulceration, confined to the mucosa, begins in rectosigmoid area, then spreads to entire colon.
C. Sx and signs:
a. Asymptomatic intervals alternate w/ insidious or fulminant attacks
i. Fulminant attacks: high fever, urgency, cramping, bloody diarrhea
b. As ulceration extends proximally, stools may become entirely blood and pus
c. No skip lesions, no perianal lesions
d. Anemia, hypoalbuminemia, weight loss
D. Complications and risks:
a. Toxic megacolon
b. Toxic colitis w/ ileus & peritonitis
c. Severe bleeding

Front 20

Upper GI Bleeding
I. Peptic Ulcer Disease (et, incidence, location, Sxs, signs,Dx, complications)

Back 20

A. Etiology: imbalance between mucosal protective factors in various mucosal damaging mechanisms; H. Pylori, medications, incompetent pylorus or LES, bile acids, impaired proximal duodenal HCO3- secretion, decreased blood flow to gastric mucosa, increased acid, cigarettes/alcohol, stress
B. Incidence: duodenal ulcer more common than gastric (4:1)
C. Location of ulcers: 90% of DU in 1st portion of duodenum; GU: lesser curvature
D. Sxs:
a. History of heartburn, abdominal pain, belching, bloating, +/- blood in emesis, stools, +/- N/V, +/- weight loss
E. Signs: exam often unremarkable, epigastric tenderness, tachycardia, pallor, hypotension, rigidity and rebound tenderness, hematemesis and melena
F. Dx: comprehensive history and PE, endoscopy or upper GI series
G. Complications: hemorrhage most common, hematemesis, melena, 3-6x increased risk of carcinoma w/ H. Pylori infection.

Front 21

Upper GI Bleeding
II. Esophageal Varices (cause, sxs, Dx)

Back 21

A. Cause: portal HTN, cirrhosis
B. Sxs: asymptomatic for long periods of time, painless large volume hematemesis or melena, minimal abd pain, volume depletion (BP, tachycardia, pallor), anemia
C. Dx: visualize bleeding source, EGD is best

Front 22

Upper GI Bleeding
III. Mallory – Weiss Tears (et, sxs, dx)

Back 22

A. Etiology: alcoholics, especially binge drinkers
B. Sxs: 1 or more episodes of non-bloody vomiting followed by BRB, GI hemorrhage from arterial site
C. Dx: endoscopy or arteriography, lesions not seen on upper GI series

Front 23

Pseudomembranous Colitis path, s/s, dx, complications

Back 23

A. Pathogenesis:
a. Acute inflammation of colon caused by C. Difficile
b. Bowel is colonized via fecal-oral route via ingesting of heat-resistant spores
c. Antibiotics alter the balance of the flora allowing overgrowth of C. Difficile
d. Spores prevalent in healthcare facilities
e. Toxins produced by pathogenic strains of C. Difficile → diarrhea and constipation
B. Signs & sxs:
a. Loose stools
b. Diarrhea, abdominal pain
c. Fever, leukocytosis
d. Dehydration, hypotension
e. Toxic megacolon and colonic perforation
i. Mucoid, w/ profuse bloody diarrhea → ER!!!!
C. Dx: pain, distended abdomen, fever, tachycardia, dehydration
a. BE contraindicated secondary to perforation risk
D. Complications: UC, Crohn’s, Ischemic Colitis, Pseudomembranous Colitis

Front 24

I. Primary Biliary Cirrhosis (definitions, association w hla, incidence, sxs, labs, dx)

Back 24

A. Definition: chronic progressive inflammatory disease of the liver
B. Association with HLA antigens: no association
C. Incidence: women, 35-65 y/o; <15% are men; familial cases and w/ + antimitochondrial antibody
D. Sxs: 50% asymptomatic (found by hepatomegaly or elevated alkaline phosphatase aminotransferase levels), pruritis w/ or without fatigue, jaundice, xanthomas, weight loss, RUQ pain, anorexia, N/V
a. Terminal features: variceal bleeding, ascites, hepatic failure, vertebral collapse secondary to osteomalacia/osteoporosis
E. Labs:
a. Elevated alkaline phosphatase 2x upper limit of normal +/- increased transaminases
b. Increased IgM in 50% patients
c. +anti-mitochondrial Ab >95%
d. Mild elevations in bilirubin and cholesterol and increase over time
e. Malabsorption of Vit K, secondary to impaired bile salt excretion leading to PT prolongation
F. Dx: confirmed by liver biopsy

Front 25

II. Primary Sclerosing Cholangitis

Back 25

A. Same as PBC, except for HLA-B8, HLA-DR3 association, more insidious and gradual than PBC, and (-) anti-mitochondrial antibody test

Front 26

III. Signs and Sx of Liver Disease

Back 26

A. Symptoms:
a. Systemic: Anorexia, fatigue, weakness, Fever, Profound N/V, Cirrhotic Habitus
b. Skin changes: spider nevus, palmar erythema, dupuytrens contractures, hemochromatosis, excoriations from constant pruritis, cutaneous lipid deposits
B. Hematologic changes: blood loss, nutritional folate deficiency
C. Endocrine abnormalities: glucose intolerance, hyperinsulinism, insulin resistance, hyperglucagonemia
a. Complex abnormalities in sex hormone metabolism: amenorrhea, decreased fertility, hypogonadism, feminization in men

Front 27

Lower GI Bleeding
I. Colon Cancer risk factors, clinical, imaging studies/screening,

Back 27

A. Risk factors:
a. Hereditary Polyposis Syndrome
b. IBD (Crohn’s, UC)
c. Family history of cancer
d. History of previous colorectal cancer
e. Women having had radiation for gynecological cancer
f. First degree relatives
g. Age >40 y/o
h. Possible dietary factors: high fat diet, beer drinking, reduced veggie consumption
B. Clinical presentation:
a. Can be normal
b. Rectal exam → mass 50% of the time [metastases]
c. Abdominal distention and tenderness: colonic obstruction
d. Hepatomegaly
e. Right-sided cancers: anemia-iron deficient, dull/vague/uncharacteristic abd pain, or no sxs; occult blood
f. Left-sided cancers: change in bowel habits, rectal bleeding, obstruction
C. Imaging studies and screening:
a. Colonoscopy w/ biopsy
b. CT scan of abdomen – after biopsy to determine staging of caner
c. Chest X-ray to evaluate for metastases
d. Air Contrast Barium Enema (ACBE)

Front 28

Lower GI Bleeding
II. Colon Polyps clinical, characteristics that develop cancer

Back 28

A. Clinical findings: bleeding, potential for malignancy
B. Characteristics of polyps that ^risk of developing cancer: adenomatous polyp
a. Tubular (60%), tubulovillous (20-30%), villous (10%)

Front 29

Lower GI Bleeding
III. Meckel’s Diverticulum – location, sx

Back 29

a. Location: proximal to cecum – ileal diverticulum
b. Sxs: asymptomatic most of the time, painless lower GI bleeding, intestinal obstruction, mimics acute appendicitis

Front 30

Anorectal Disorders and GI Cancer
I. Puritus Ani – DDX

Back 30

May be idiopathic or secondary
Bowen’s disease or Paget’s disease
Precancerous lesions
Deserves full evaluation
** Dietary pruritis is symmetric
** Infectious is asymmetric
Examine rectum and sigmoid colon.
Biopsy any abnormal tissue
Dermatologic disorders
Allergic reactions
Superficial infections with fungi
Parasites
Oral antibiotics
Systemic diseases
Hygiene
Temperature and clothing

Front 31

Anorectal Disorders and GI Cancer
II. Gastric Cancer (risk factors, symptoms, signs)

Back 31

A. Risk factors: H. Pylori, older, male, smokes, diet of dry, salted foods
B. Symptoms:
a. Vague discomfort in abdomen at first → abd pain
b. Unintended weight loss, lack of appetite
c. Sense of fullness in upper abdomen
d. Heartburn, indigestion, ulcer-type symptoms
e. N/V, with or without blood
f. Swelling of abdomen due to accumulation of fluid and cancer cells
C. Signs:
a. Sister Mary Joseph node: firm, periumbilical node – seen w/ tumor metastasis
b. Virchow Nodes: left supraclavicular node, sentinel node of abdominal cancers

Front 32

Anorectal Disorders and GI Cancer
III. Pancreatic Cancer (location, risk factors, sx, labs, dx, prognosis)

Back 32

A. Location: duct cells more common than acinar cells
B. Risk factors: over 55, smoker, diabetic, males, African American, family history
C. Sx:
a. Initially asymptomatic
b. Pain in upper abdomen/upper back
c. Weakness, weight loss, loss of appetite
d. N/V
D. Labs:
a. Alkaline phosphatase and bilirubin may be increased if bile duct obstruction or liver metastases are present
b. Hyperglycemia occursin 25-50% of patients
E. Dx: routine lab tests are normal
a. CT more sensitive than MRI
F. Prognosis: overall 5 year survival is <2% ☹

Front 33

c. Primary Sclerosing Cholangitis

Back 33

E. Dx: endoscopy w/ biopsy, Barium studies
a. Discontinuous segmental disease w/ deep fissures, cobblestone appearance +/- granulomas
b. “string sign”
c. “thumbprinting”