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294 Cards in this Set
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viral gastro bugs |
Noro, Cox A1, echo, adeno, Rota in children
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bacterial gastro bugs that cause bloody diarrhea
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C.jejuni, EC O157:H7 (entrohemorrhagic), Salmonella, Shigella, Yersinia, sometimes CDiff
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bacterial gastro bugs that have risk of HUS
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EC O157:H7, Shigella
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HUS characteristics
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thrombocytopenia, hemolytic anemia, renal failure
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hepatitis h/p
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RUQ pain, jaundice, scleral icterus, hepatomegaly, splenomegaly, LAD, fatigue, malaise
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hepatitis treatments
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A and E: supportive
B: HBVax immediately after exp; interferon or antivirals C:IFN and maybe ribavarin D: IFN |
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which Hepatitis has vaccines
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A, B, D
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complications of Hepatitis?
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B: 5% dev chronic hepatitis, cirrhosis, 3-5% dev hepatocellular carcinoma
C: 80% dev chronic hepatitis, 50% dev cirrhosis, slightly increased risk of hepatocellular carcinoma E: high infant mort when preg women get it |
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what can cause salivary duct obstruction
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sialolithiasis in any salivary gland, sarcoid, infection, neoplasms
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salivary gland disorder h/p
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enlarged, painful glands, pain worsens with eating, painless swelling
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what can cause dysphagia
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achalasia, motility disorders, scleroderma, peptic strictures, esophageal webs or rings, cancer, radiation fibrosis
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dysphagia labs
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esophageal manometry
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dysphagia rads
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barium swallow, esophagogastroduodenoscopy (EGD)
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what can cause achalasia
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Chagas, scleroderma, neoplasms
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achalasia h/p
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progressive dysphagia, regurg, cough, aspiration, heartburn, weight loss
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achalasia rads
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barium swallow: bird's beak, need EGD to rule out cancer
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achalasia tx
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pneumatic dilation, botox injections, myotomy can cause GERD
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diffuse esophageal spasm h/p
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chest pain, dysphagia
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diffuse esophageal spasm rads
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barium swallow shows corkscrew pattern
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diffuse esophageal spasm tx
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ca channel blockers, nitrates relieve pain but worsen GERD, TCAs
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what is Zenker diverticulum
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divert of upper posterior esophagus from smooth muscle weakness
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Zenker's divert h/p
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bad breath, difficulty swallowing, regurg of food several days after eating, dysphagia, feeling of aspiration
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Zenker's divert rads
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barium swallow
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Zenker's divert tx
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cricopharyngeal myotomy/ diverticulectomy
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risk factors for GERD
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obesity, hiatal hernia, preg, scleroderma
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what can worsen GERD
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alcohol, smoking, fatty foods
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GERD h/p
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burning chest pain, sour taste in mouth, regurg, dysphagia, odynophagia, nausea, cough, pain worse with lying down relieved by standing
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GERD labs
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esophageal pH monitoring
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GERD rads
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not necessary, but EGD/cxr/barium swallow can r/o neoplasm Barrett's esophagus, hiatal hernia
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GERD tx
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elevate head of bed, WL, diet mod, Antacids with H2 blockers/PPIs
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tx of refractory GERD
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Nissen fundoplication, hiatal hernia repair
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complications of GERD
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Barrett's esophagus, ulceration, strictures, adenocarcinoma
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2 types of esophageal cancer
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squamous (more common) and adeno (less common)
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what usually precedes adenocarcinoma of esophagus
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Barrett's esophagus
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risk factors for adeno esophageal cancer
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alcohol, tobacco, GERD, obesity
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2 types of hiatal hernia
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1. sliding
2. Paraesophageal |
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Tx of hiatal hernias
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sliding: reflux control
paraesophageal: surgical Nissen or gastropexy |
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hiatal hernia complications
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incarceration
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esophageal spasm rads
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corkscrew on barium swallow
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side effects of H2 antagonists
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HA, diarrhea, thrombocytopenia rare, cimetidine can cause gynecomnastia and impotence
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side effects of PPIs
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may increase effects of Warfarin, benzos, phenytoin, dig, carbamazepine
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Type A vs type B chronic gastritis
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A: Fundus, autoAb against parietal cells leads to pernicious anemia, decreased gastric acid level and decreased gastrin, achlorhydria, thyroiditis
B: Antrum, Hpylori infection, increased gastric acid level, PUD, gastric cancer |
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acute vs chronic gastritis
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acute is erosive, chronic is not
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how does a urea breath test work
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detects increase in pH from ammonia producing H pylori
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tx of all acute and chronic gastritis
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acute: stop offending agents like alcohol, acidic foods, give H2 antagonists or PPIs
Chronic: type A give B12 type B triple therapy vs HPylori: PPI+Clarithro+ Amox/Metro for 7-14 days |
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causes of gastric ulcers mnemonic
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ANGST HAM: aspirin, NSAIDS, Gastrinoma, Steroids, Tobacco, HPylori, Alcohol, MEN1
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gastric ulcers from stress for severe burns and intracranial injuries are called what
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Curling's and Cushing's ulcers
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how to diff b/w gastric and deodenal ulcer?
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Gastric: younger <50, NSAID users, pain SOON and worse after eating, normal/low gastric acid level, HIGH gastrin level
Duodenal: Younger, pain 2-4 h after eating which can initially improve sxs, high gastric acid level with normal Gastrin level |
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PUD rads
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axr to detect perfs, barium swallow can collect in ulcerations (abnormal mucosal folds/mass/filling defects in region of ulcer suggests malig), EGD for biopsy and active bleeds
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surgical tx of non neoplastic refractory PUD
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antrectomy/ parietal cell vagotomy
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complications of PUD
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hemorrhage: posterior ulcers erode into GDA, anterior ulcers more likely to perf
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where gastrinomas usually found
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duodenum (70%) or pancreas
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ZE h/p
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refractory PUD
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ZE labs
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increased fasting gastrin, positive secretin stim test (give secretin and higher than expected levels of gastrin result)
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ZE rads
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somatostatin receptor imaging with SPECT
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ZE Tx
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surgery for nonmetastatic, PPI and H2Inhibitors can ease sxs, octreotide can also help in metastatic cases
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MEN1
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Parathyroid hyperplasia/adenoma with hypercal
Pancreatic islet cell neoplasia (Gastrin, VIP, insulin, glucagon) Pituitary adenomas |
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MEN2A
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Parathyroid hyperplasic (15-20% hypercal)
Pheo MTC |
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MEN2B
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MTC
Pheo Mucosal and GI neuromas |
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2 types of gastric cancer
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Adeno (common) and squam (less common usually from esophagus)
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4 subtypes of gastric cancer
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Ulcerating, Polypoid, Superficial spreading (only mucosal and submucosal good prog), Linitis plastica (all layers, decreased stomach elasticity, bad prog)
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gastric cancer risk factors
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HPylori, fam hx, Japanese person in Japan, tobacco, alcohol, vitamin C def, high consumption of preserved foods, males>females
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gastric cancer h/p
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WL, anorexia, pain, early satiety, enlarged left supraclavicular LN (Virchow's node), periumbilical node (Sister Mary Joseph's node)
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gastric ca labs
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inc CEA, inc glucuronidase in gastric secretions
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gastric ca rads
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barium swallow: thickened leather bottle stomach= linitis plastica, do an EGD for biopsy and visuals
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gastric ca tx
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subtotal gastrectomy: for lesions in distal third of stomach
Total gastrectomy: for lesions in middle or upper third of stomach or invasive lesions, needs adj chemo and rad |
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gastric cancer prog
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early detection: 70% cure rate but poor prog in later detection <15% 5 year survival
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autoantibodies that cause celiac sprue
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antiendomysial
antigliadin |
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where in GI tract does celiac sprue affect
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duodenal/jejunal mucosa
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celiac sprue labs
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antiendomysial
antigliadin abs biopsy shows loss of duodenal and jejunal villi |
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diff b/w tropical and celiac sprue
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no autoabs, tropical is for people who have spent time in tropics, removal of gluten from diet has no effect on tropical sprue
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h/p of malabsorption disorders
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WL, diarrhea, steatorrhea, bloating, glossitis, dermatitis, edema
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Tx of sprues
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removal of gluten and steroids for celiac
FA replacement and tetracycline for tropical |
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where in GI tract is lactose normally absorbed
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jejunum
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what is lactose tolerance/breath test
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give lactose, minimal increase in glucose in serum/breath hydrogen test after lactose meal
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what bug causes Whipple's dz
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Tropheryma whippelii
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Whipple's dz risk factors
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white male european
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Whipple's dz h/p
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same as for other malabsorption disorders: WL, joint pain, abd pain, diarrhea, dementia, cough, bloating, steatorrhea, fever, vision abn, LAD, new heart murmur, severe wasting late
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Whipple's dz labs
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PAS stain on jejunal biopsy shows foamy macros and villous atrophy
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Whipple's dz tx
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Bactrim or Ceftriaxone for 1 year
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what test detects steatorrhea
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Sudan stain
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when do you work up acute diarrhea? how
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with high fever/bloody/>5d
1. if yes, stool culture, stool acid-fast, fecal leuks for enteroinvasive bacteria, O+Px3, hydration and abx 2. If no, hydration, antimotility agents unless there's no resolution then goto 1 |
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3 types of chronic diarrhea
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secretory, osmotic, inflammatory
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how do you work up chronic diarrhea (>2wks)
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1. r/o infection, recent surg, meds
2. sudan stain for fecal fat: malabsorption 3. FOB, WBC, Lactoferrin, Calpotectin for inflammatory causes: do stool Cx and colonoscopy 4. measure stool pH and lactose tol test for lactase def 5. If normal, do stool lytes and osmolality: stool mOsm/kg= 290 - 2(Na+K) >50 is high osmotic gap=osmotic cause: lactase def <50 is normal osmotic gap = secretory: do CT, colonoscopy, hormone levels 6. If high osmotic gap, could be lax abuse or lac def 7. If normal osmotic gap, do stool weight for IBS (normal) |
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Rome III criteria for IBS
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recurrent abd pain for 3 or more days over the last 3 mo plus 2 of the following:
improvement with def pain then change in freq of stool pain then change in form of stool |
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Manning Criteria for IBS
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1. pain improves with def
2. pain then change in freq of stool 3. pain then change in form of stool 4. visible abd distension 5. passage of mucus with stool 6. feeling of incomplete defecation |
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what ages does IBS usually start
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teens or young adulthood
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workup for IBS
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axr, abd ct, barium to rule out other GI causes, colonoscopy in older to r/o cancer
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IBS tx
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assurance, high fiber diet, psychosocial tx, antidepressants
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Crohn's vs UC sites
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Crohn's: skip lesions and entire bowel wall involved
UC: continuous starting at rectum, only mucosa and submucosa affected |
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Crohn's vs UC sxs
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Crohn's: abd pain, WL, watery dia
UC: abd pain, urgency, tenesmus, bloody diarrhea |
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Crohn's vs UC physical
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Crohn's: fever, RLQ mass, perianal fissures/fistulas, oral ulcers
UC: fever, orthostatic, tachy, gross blood on rectal exam |
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Crohn's vs UC extraintestinal manifestation
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Both have arthritis, uveitis, ankylosing spondylitis, PSC, erythema nodosum, fatty liver
nephrolithiasis more common with Crohns pyoderma gangrenosum more common with UC |
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Crohn's vs UC labs
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Crohn's: ASCA+, pANCA rare
UC: ASCA rare, pANCA+ |
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Crohn's vs UC rads
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Crohn's: cobblestoning, fissures, skip lesions, string sign
UC: continuous, lead pipe |
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Crohn's vs UC tx
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Both: Mesalamine, steroids, immunosuppressives
Crohn's: surgical resection of severely affected areas/strictures/fistulas UC: total colectomy is curative |
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Crohn's vs UC comps
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Both: Toxic Megacolon
Crohn's: abscess/fistulas/fissures UC: increased risk of Colon Cancer |
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most common causes of obstruction
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adhesions, hernias, neoplasms (large bowel)
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which part of GI tract is usually spared from ischemia
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rectum cause there's collateral circ
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which is the most painful type of GI ischemia
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small bowel ischemia: pain out of proportion to exam
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which part of GI tract is usually involved in ischemic colitis
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left colon
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what causes ischemic colitis
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embolus, obstruction, inadequate perfusion, medication, surgery-induced vascular compromise
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ischemic colitis risk factors
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DM, athero, CHF, peripheral vasc, lupus
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ischemic colitis h/p
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abd pain, bloody diarrhea, vomiting, mild tenderness
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ischemic colitis labs
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inc WBC and lactate
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ischemic colitis rads
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thumb printing
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ischemic colitis tx
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fluids bowel rest, abx, resection of necrotic bowel
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RLQ pain differential mnemonic
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APPENDICITIS: Appendicitis, PID/Period, Pancreatitis, Ectopic/Endometriosis, Neoplasm, Diverticulitis(rare), Intussusception, Crohns/Cyst ovarian, IBD, Torsion, IBS, Stones (kidney, gallbladder)
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causes of appendicitis by age
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children: lymphoid hyperplasia
adults: fibroid bands, fecaliths |
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appendicitis h/p
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periumbilical tenderness moves to RLQ at McBurney's point (1/3 from R ASIS to umbilicus), rebound, Psoas sign, Rovsing's sign (RLQ pain with LLQ palp),
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appendicitis labs
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WBC with left shift (more leukocytes vs neutrophils)
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appendicitis rads
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free air under diaphragm if perfed, CT is most sens
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appendicitis tx
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appendectomy, abx for ruptured
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appendicitis complications
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abscess form, perf
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how long does postop ileus last?
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<5 days. Small bowel recovers in 24h, stomach in 48-72h, and large bowel in 3-5 days
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what causes ileus
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postop, infection, ischemia, DM, opioid use
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ileus h/p
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pain, nausea, bloating, no bowel mvmts, can't eat, no rebound
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ileus rads
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distention of bowel, air-fluid levels
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ileus tx
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stop opioids, NPO, colonoscopic decompression if no resolution
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where in GI tract does volvulus mostly occur
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cecum, sigmoid
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who gets volvulus usually
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infants and elderly
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volvulus rads
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double bubble on axr, barium enema shows birds beak for distal volvulus
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volvulus tx
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maybe self limited, colonoscopic detorsion of sigmoid volvulus, resection maybe required in cecal volvulus if can't detorse
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most common cause of acute lower GI bleeding over 40y
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diverticulitis
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diverticulitis more commonly occurs where
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sigmoid colon
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what is diverticulitis
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outpouchings of colonic mucosa and submucosa that herniate through muscular layer
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diverticulitis h/p
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LLQ pain, nausea, vomiting, melena, hematochezia, tenderness, fever, distension
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diverticulitis labs
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WBC, guaiac pos
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diverticulitis rads
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free air under diaphragm if perfed, tics on barium enema/colonoscopy, CT shows soft tissue density , bowel wall thickening, possible abscess
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diverticulitis tx
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no perf: bowel rest, liquids only for 3 days, abx: Fluoro+Metro OR Bactrim+Metro OR Augmentin
Perf: resect segment of colon, diverting colostomy for 3 mo in cases of peritonitis + Broad spec abx |
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diverticulitis comp
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abscess, fistula, sepsis
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where to internal/external hemorrhoids get their blood supply from
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internal: superior rectal veins above pectinate line
external: inferior rectal veins below pectinate line |
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which type of hemorrhoids are painful
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external only
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cell types for internal/external hemorrhoids
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internal: columnar rectal epith
external: squamous rectal epith |
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hemmorrhoids rads
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sigmoidoscopy to r/o other caues of bleeding
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hemmorhoids tx
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warm baths, increase in fiber, sclerotx, ligation, excision
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tx for anal fissures
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stool softeners, topical nitro, partial spincterotomy if recurrent
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where do pilonidal cysts occur
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superior gluteal cleft
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where are carcinoids usually found
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appendix, ileum, rectum, stomach
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carcinoids h/p
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abd pain, carcinoid syndrome: flushing, diarrhea, bronchoconstriction, valvular dz, caused by serotonin secretion by tumor (only seen with liver mets or extra-GI involvement)
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carcinoids labs
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inc 5HIAA in urine, inc serum serotonin
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carcinoids rads
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CT/ Indium-labeled octreotide scintigraphy
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carcinoid tx
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tumors <2cm low incidence of mets and can be resected
tumors >2cm higher risk of mets need greater extent of resection, tx with IFNa, octreotide, embolization |
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colorectal ca most common type
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adeno
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colorectal ca risk factors
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fam hx, UC, polyps, hereditary polyposis syndromes, low fiber high fat diet, prev colon ca, alcohol, smoking, DM
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colorectal ca most common mets to
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lung and liver
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colorectal ca h/p
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change in bowel habits (more common in left sided ca), weakness, pain, constipation, hematochezia, melena, WL, abd or rectal mass
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colorectal ca labs
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guiac, anemia, CEA increased in 70% of pts, useful for monitoring purposes, biopsy is diagnostic
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colorectal ca rads
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barium enema, colonoscopy, CT/PET can det extent and mets
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Fe def anemia in old men is what until proven otherwise
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colorectal ca
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which hereditary polyposis syndromes are caused by mutation in APC gene
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FAP, Gardner's, Turcot
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Duke's criteria for prognosis of colorectal ca
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Class A: TMN1: tumor confined to bowel wall: cure rate 90%
Class B: TMN2: penetration of tumor into colonic serosa/perirectal fat: cure rate 80% Class C: TMN3: LN involvement: cure rate <60% Class D: TMN4: distant mets: cure rate <5% |
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colorectal ca prev
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screening >50y
annual fobt flex sig q5y colonoscopy q10y |
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what about FAP
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tons of polyps, almost always dev into ca, prophylactic subtotal colectomy
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HNPCC
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multiple mutations, usually in proximal colon
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Gardner's syndrome
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similar to FAP with common bone and soft tissue tumors
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Peutz-Jeghers synd
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polyps are hamartomas with low risk of malig; mucocutaneous pigmentation of mouth, hands, genitals
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Turcot synd
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many colonic adenomas with high malig potential, comorbid malignant CNS tumors
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Juvenile polyposis
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colon, small bowel, stomach polyps are source of GI bleeds, slightly increased risk of ca later in life
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what's the first thing you have to do with upper and lower GI bleeds
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NG tube and lavage
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Crit goal with GI bleeds
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>30%
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UGIB diff
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PUD, mallory weiss tears, esophagitis, esophageal varices, gastritis
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LGIB diff
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diverticulosis, neoplasm, UC, mesenteric ischemia, AVMs, hemorrhoids, Meckel's
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GI Bleeds rads
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EGD/colonoscopy, barium swallow/enema, angiography, technetium scan for Meckel's
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GI bleeds tx
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fluid resus, PPI for UGIB until gastric cause is ruled out, prophylactic BBlockers for known varices to decrease chance of rebleeding, sclerotx, vasopressin may stop bleeding from AVMs and diverticula
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what causes pancreatitis
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GET SMASHED
Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion Sting Hypercal/Hyperlip ERCP, Drugs like Sulfa drugs |
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Ranson's Criteria on admission
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GA LAW:
Glucose >200 AST>250 LDH>350 Age>55 WBC >16000 |
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Ranson's Criteria during initial 48 hours post presentation
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Cal<8
Hct dec >10% PaO2<60mmHg BUN inc >5 Base deficit >4 Sequestration of fluid >6L |
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pancreatitis h/p
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epigastric pain rad to back, fever, n/v, Grey Turner's sign, Cullen' sign, steatorrhea if chronic, tachy
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pancreatitis labs
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increased amylase and lipase, glycosuria if chronic
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pancreatitis rads
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dilated loops of bowel near pancrease (sentinal loop), R colon distended until near pancreas (colon cutoff sign), enlarged pancreas, pseudocyst, pancreatic calc,
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pancreatitis tx
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hydration, opioids, NG suction, NPO, prophylactic abx for GI bacteria, debridement, enzyme supp if chronic
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pancreatitis comp
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abscess, pseudocyst, necrosis, obstruction, flstula formation, shock, DIC, sepsis, cancer if chronic
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Exocrine pancreatic cancer location and type
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head of pancreas, adeno
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Exocrine pancreatic cancer risk factors
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chronic pancreatitis, DM, fam hx, tobacco, high fat diet, male
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Exocrine pancreatic cancer h/p
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abdominal pain rad to back, nause, vom, WL, statorrhea, jaundice if bile duct obstructed, palpable nontender gallbladder (Courvoisier's Sign for gallbladder of pancreatic malignancy)
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Exocrine pancreatic cancer labs
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inc CEA and CA 19-9, hypergly, increased bilis, inc alk phos with bile duct obstruction
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Exocrine pancreatic cancer rads
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CT mass, dilated pancreas, local spread, ERCP can locate tumors
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Exocrine pancreatic cancer tx
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nonmets and limited to head can be treated with Whipple procedure, enzyme replacement, stenting of ducts for pallation
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Exocrine pancreatic cancer comps
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usually not detected until progressed, 5yr survival <2%, 20-30% 5 year survival after successful Whipple procedure, migratory thrombophlebitis (Trousseau's syndrome)
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triad to start insulinoma workup
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1. sxs of hypogly when fasting
2. hypogly 3. improvement with carb load |
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multiple insulinomas assoc w?
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MEN1
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What about insulinomas
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HA, visual changes, confusion, weakness, mood instability, palps, diaphoresis
Inc fasting insulin, positive C peptide Use CT/US/Indium Octreotide scan to localize Tx: resection; diazoxide or octreotide can alleviate sxs |
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What about Glucagonomas
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alpha cell tumor causing hypergly
refractory DM abd pain, diarrhea, WL, MSchange, Migratory necrolytic erythema, DM sxs hypergly, increased glucagon CT/endoscopic US to localize need surg, octreotide, IFNalpha, chemo, embolization |
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What about VIPomas
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VIP from nonbeta islet cells
Water Diarrhea, weakness, N/V high stool osmolality points to secretory cause of watery diarrhea Rads: CT Tx: Steroids, chemo, resection, octreotide, embolization for mets |
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5 Fs for patients susceptible to gallstones
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Fat, Forty, Female, Fertile, Fam Hx
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Cholithiasis risk factors
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5 Fs, OCP use, TPN, rapid WL, DM
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what are gallstones usually made of
|
cholesterol, unless it's calcium bilirubinate (Pigmented stones) secondary to chronic hemolysis
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Cholithiasis h/p
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postprandial RUQ pain, n/v, palpable gallbladder
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Cholithiasis rads
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US
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Cholithiasis tx
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bile salts dissolve stones, shock wave lithotripsy, cholecystectomy
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Cholithiasis comps
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recurrent stones, acute cholecystitis, pancreatitis
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who can get acalculous Acute cholecystitis
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TPN or critically ill
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Acute cholecystitis h/p
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RUQ pain rad to back, n/v, fever, tenderness
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Acute cholecystitis labs
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WBC, inc bilis, inc alk phos with impacted stone or cholangitis
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Acute cholecystitis rads
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US, HIDA scan will show that gallbladder fails to fill normally
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Acute cholecystitis tx
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fluids, abx, endoscopic drainage followed by cholecystectomy after it calms down, if mild can to lithitripsy and bile salts, ERCP to deliver stone solvents
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Acute cholecystitis comps
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perf, ileus, abscess
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Charcot's triad for cholangitis
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Fever, RUQ pain, Jaundice
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Reynold's pentad for cholangitis
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Fever, RUQ pain, Jaundice, change in MS, Hypotension
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rask factors for Cholangitis
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cholithiasis, anatomic defect, biliary cancer
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Cholangitis labs
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WBC, positive cultures, bilis, alk phos, AST/ALT increase, increased amylase
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Cholangitis rads
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HIDA scan more sensitive than US
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Cholangitis tx
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hyd, abx, endoscopic drainage with cholecystectomy, emergency bile duct decompression and relief of obstruction if emergent and sxs severe
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gallbladder cancer rads
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calcified gallbladder from axr or US, ERCP to bipsy
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Viral hepatitis vs alcohol hepatitis enzyme patterns
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Viral hep: AST and ALT equally elevated
Alcoholic AST>ALT |
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alcohol related liver dz h/p
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ascites, HSmegaly, fever, jaundice, testicular atrophy, gynecomnastia, digital clubbing
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alcohol related liver dz labs
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increased AST and ALT, inc GGT, inc alk phos, inc bilis, longer PT, WBC
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alcohol related liver dz tx
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thiamine, folate, high caloric intake, liver txplant
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alcohol related liver dz comp
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hepatic encephalopathy, cirrhosis, coag disorders
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causes of cirrhosis
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HEPATIC
Hemochromatosis Enzyme def (alpha antitrypsin) PBC/PSC Alcoholism Tumor (hepatoma) Infection (Hepatitis) Chronic cholecystitis/Copper (Wilson's) |
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Cirrhosis h/p
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GI bleeding, HSmegaly, Jaundice, ascites, Caput Medusae, Spider Telangectasias, Palmar erythema, Dupuytren's contractures in hands, testicular atrophy, gynecomnastia, MS change, asterixis
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Cirrhosis labs
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AST ALT GGT Alk Phos, dec alb, anemia, dec platelets, longer PT
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Cirrhosis tx
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treat varices with beta blockers or sclerotx, lactulose + neomycin + low protein diet can improve encephalopathy, liver txplant
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Cirrhosis comp
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portal htn, varices, hepatic encephalopathy, renal failure, bacterial peritonitis
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Portal HTN prehepatic/hepatic/posthepatic causes
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prehepatic: portal vein thrombosis
hepatic: cirrhosis, schisto, granulomatous dz posthepatic: right sided heart failure, hepatic vein thrombosis, Budd-Chiari syndrome |
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5 locations of varices as a result of portal HTN
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1. esophageal
2. Hemorrhoids 3. Caput medusae (paraumbilical vein to external iliacs) 4. Renal (Gastro/Splenorenal veins) 5. Paravertebral |
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Portal HTN h/p
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ascites, pain, change in MS, GI bleeds, HSmegaly, testicular atrophy, gynecomnastia
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what does serum-ascites albumin gap (SAAG) tell you
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high gradient >1.1 is portal htn
high gradient with high protein >2.5 is Budd Chiari or heart failure, with low protein <2.5 is cirrhosis of liver Low SAAG <1.1is ascites not due to portal htn, like nephrotic synd, TB, cancer |
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portal htn tx
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salt restriction
IV abx for bac peritonitis Dialysis for renal failure lactulose neomycin low protein diet for hep enc Vasopressin/sclerotx for varices TIPS (Transjugular Intrahepatic Portocaval shunting) Liver txplant |
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portal htn labs
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do a SAAG, increased serum ammonium, WBC, normal glucose
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lab signs for spontaneous bac peritonitis on paracentesis
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PMN>250
Total protein >1 glucose <50 LDH >Normal serum LDH |
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what lab signs on paracentesis make you suspicious of cancer
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if very high albumin and LDH is 60% of serum LDH
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hemochromotosis leads to Fe dep which organs
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liver, pancreas, heart, pituitary
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Hemochromatosis h/p
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abd pain, polyuria, polydipsia, pigmented bronze rash, hepatomegaly, testicular atrophy, may resemble DM or CHF
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Hemochromatosis labs
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inc Fe, Fesat, ferritin
slightly inc AST and ALT |
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Hemochromatosis tx
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weekly/biweekly phlebotomy, avoid alcohol, deferoxamine for chelation
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Hemochromatosis comp
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cirrhosis, hepatoma, CHF, DM, hypopit
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Wilson's dz deposits copper where
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liver, brain, cornea
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Wilson's dz h/p
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psych dist, personality changes, loss of coordination, tremor, Keyser-Fleischer rings, hepatomegaly
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Wilson's dz labs
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dec serum ceruloplasmin, inc urine copper,
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Wilson's dz tx
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trientine or penicillamine for copper chelation, lifelong zinc, copper restriction, B6 supp
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Wilson's dz comp
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hepatic failure, cirrhosis
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what does alpha 1 antitrypsin def cause
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cirrhosis, panlobular emphysema
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what is PBC
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autoimmune intrahepatic bile duct obstruction leads to accum of bili, bile acids, cholesterol
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PBC risk factors
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older females, autoimmune dz such as rheumatoid arth, scleroderma
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PBC h/p
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jaundice, HSmegaly, pruritis, skin hyperpig, xanthomas
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PBC labs
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inc alk phos and GGT, inc bili, but normal liver enzymes
ANA and AMA positive |
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PBC tx
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Ursodeoxycholic acid, fat soluble vitamins
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what is PSC
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destruction of larger intra and extra hepatic bile ducts leading to fibrosis and cirrhosis
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PSC risk factors
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younger males, UC
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PSC h/p
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RUQ pain, pruritis, jaundice, fever, night sweats, xanthomas
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PSC labs
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inc alk phos and GGT, normal liver enzymes, increased bilis and cholesterol, possibly positive pANCA
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PSC rads
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ERCP pearls on a string bile ducts
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PSC tx
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Ursodeoxycholic acid, MTX, steroids, endoscopic stenting of strictures, surgical resection of affected ducts
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enzyme that conjugates bilis
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glucuronosyl transferase
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Gilbert's dz
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mild def of glucuronosyl transferase: mild jaundice after exercise, increased indirect bilis<5
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Crigler-Najjar syndrome type I
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severe def in glucuronosyl transferase: peristent jaundice and CNS sxs (kernicterus in infants), increased indirect >5
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Crigler-Najjar tx
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phototx, plasmapheresis, cal phos w/orlistat, liver tx
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Crigler-Najjar syndrome type II TX
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phenobarb which increases liver enzymes
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benign hepatic tumor types
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hepatic adenoma, focal nodular hyperplasia, hemangiomas, hepatic cysts
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who gets benign hepatic tumor
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women with hx of OCP use
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benign hepatic tumor rads
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hypervascular liver mass on CT, MRI or angio
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Hepatocellular carcinoma risk factors
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HBV, HCV, cirrhosis, hemochromatosis, Aspergillus infection, schisto
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Hepatocellular carcinoma h/p
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jaundice, diarrhea, WL, RUQ pain, hepatomegaly, bruit over liver, ascites
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enzyme that conjugates bilis
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glucuronosyl transferase
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Gilbert's dz
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mild def of glucuronosyl transferase: mild jaundice after exercise, increased indirect bilis<5
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Crigler-Najjar syndrome type I
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severe def in glucuronosyl transferase: peristent jaundice and CNS sxs (kernicterus in infants), increased indirect >5
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Crigler-Najjar tx
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phototx, plasmapheresis, cal phos w/orlistat, liver tx
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Crigler-Najjar syndrome type II TX
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phenobarb which increases liver enzymes
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benign hepatic tumor types
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hepatic adenoma, focal nodular hyperplasia, hemangiomas, hepatic cysts
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who gets benign hepatic tumor
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women with hx of OCP use
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benign hepatic tumor rads
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hypervascular liver mass on CT, MRI or angio
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Hepatocellular carcinoma risk factors
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HBV, HCV, cirrhosis, hemochromatosis, Aspergillus infection, schisto
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enzyme that conjugates bilis
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glucuronosyl transferase
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Hepatocellular carcinoma h/p
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jaundice, diarrhea, WL, RUQ pain, hepatomegaly, bruit over liver, ascites
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Gilbert's dz
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mild def of glucuronosyl transferase: mild jaundice after exercise, increased indirect bilis<5
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Crigler-Najjar syndrome type I
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severe def in glucuronosyl transferase: peristent jaundice and CNS sxs (kernicterus in infants), increased indirect >5
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Crigler-Najjar tx
|
phototx, plasmapheresis, cal phos w/orlistat, liver tx
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Crigler-Najjar syndrome type II TX
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phenobarb which increases liver enzymes
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benign hepatic tumor types
|
hepatic adenoma, focal nodular hyperplasia, hemangiomas, hepatic cysts
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who gets benign hepatic tumor
|
women with hx of OCP use
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benign hepatic tumor rads
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hypervascular liver mass on CT, MRI or angio
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Hepatocellular carcinoma risk factors
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HBV, HCV, cirrhosis, hemochromatosis, Aspergillus infection, schisto
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Hepatocellular carcinoma h/p
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jaundice, diarrhea, WL, RUQ pain, hepatomegaly, bruit over liver, ascites
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paraneoplastic syndrome of hepatoma
|
hypogly, inc RBC production, refractory watery diarrhea, hyper cal, skin lesions
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Hepatocellular carcinoma labs
|
increased AFP,slightly inc AST and ALT, in alk phos, inc bilis t and d, biopsy has to be carefully done cause it can hemorrhage
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Hepatocellular carcinoma comps
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poor prog, portal vein obstruction, Budd Chiari, liver failure
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what are Dubin-Johnson and Rotor's syndromes
|
inability to excrete conjugated bilis from liver: benign but black liver
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most common type of TEF
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distal fistula with proximal esophageal atresia
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TEF h/p
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coughing, cyanosis during feeding, food filled blind pouch, abdominal distention, hx of aspiration pna
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TEF rads
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do a cxr with NG tube insertion which demonstrates tube in lung or blind pouch
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what about Pyloric stenosis
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olive sized epigastric mass, projective vomiting, barium swallow shows thin pyloric channel (string sign), US shows inc pyloric muscle thickness
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pyloric stenosis tx
|
pyloric myotomy
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what about Necrotizing enterocolitis
|
risks: preterm, LBW, bilious vomiting, hematochezia, abdominal distention and tenderness, signs of shock
labs: met acidosis, hypoNa Rads: bowel distention, air in bowel wall, portal vein gas, or free air under diaphragm. Tx: TPN, abx, NG suction, resection of affected bowel |
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what about Hirschsprung's Dz
|
obstipation, failure to pass stool, abd distention, bowel biopsy shows absence of ganglion cells
Rads: dilated bowel, barium enema shows proximal dilation with distal narrowing (Megacolon) Tx: colostomy and resection |
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what about Intussusception
|
most common cause of obstruction in first 2 years, most commonly at ileocecal valve
It's considered cancer in an adult until proven otherwise risks: Meckel's, HSP, adenovirus, CF intermittent abdominal pain, currant jelly stool, palpable sausage like abd mass labs: inc WBC Rads: barium enema shows obstruction, US or CT can detect abnormal bowel Tx: barium enema can reduce, if not surg Comp: bowel ischemia esp appendix |
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what about Meckels
|
rule of 2s: Males 2x more likely, within 2ft of ileocecal valve, 2 types of ectopic tissue (gastric/pancreatic), 2% of population, most comps before 2yrs
remnant of vitelline duct, outpouching of ileum painless rectal bleeding, intussusception, diverticulitis rads: detected by nuclear scan technetium tx: surgical resection |
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causes of neonatal jaundice
|
physiologic, G6Pd, bili overproduction without hemolysis: hemm, mat-fet transfusion, Gilbert's, Crigler-Najjar, biliary atresia
|
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kernicterus sxs
|
jaundice, scleral icterus, lethargy, high pitched cry, seizures, apnea
|
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what points to nonphysiologic jaundice in newborn
|
total bilis >15 or direct bili >2
|
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neonatal jaundice tx
|
phototx, exchange txfusion, IVIG if blood incompatibility
|
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FTT definition
|
below 3rd percentile weight for age
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FTT workup
|
UA, CBC, cultures, lytes, CF, food records, suspect neglect or abuse, parental training for feeding and nutrition
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