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229 Cards in this Set
- Front
- Back
Cholelithiasis -
Colic results from what? Risk factors 3 types |
Colic from transient cystic duct blockage.
Risk factors - female, fat, forty, fertile. Cholesterol (80%) - originate from gallbladder risk factors: obesity rapid weight loss Crohn's CF estrogens Native Americans Pigment - originate from common bile duct calcium bilirubinate risk factors: chronic hemolysis biliary infections alcohol abuse cirrhosis Mixed |
|
Cholelithiasis -
History/PE |
Postprandial abdom pain
RUQ pain radiates to rt. subscapular or epigastrium (can be asymptomatic) n/v fatty food intolerance dyspepsia flatus RUQ tenderness |
|
Cholelithiasis -
Diagnosis |
not XR - only 15% radiopaque
RUQ US |
|
Cholelithiasis -
Tx |
Cholecystectomy with Sxs
ERCP - common bile duct stones dietary modification UDCA - if don't want surgery effective in noncalcified cholesterol stones < 5 mm |
|
Cholelithasis -
Complications |
recurrent biliary colic
acute cholecystitis choledocholithiasis acute cholangitis gallstone ileus gallstone pancreatitis carcinoma of the gallbladder |
|
Acute Cholecystitis -
Results from what Leads to what |
Prolonged obstruction of cystic duct (usually stone)
Distention, inflammation, infection, gangrenous, acalculous Acalculous - in absence of cholelithiasis in TPN, trauma, burn pts. |
|
Acute Cholecystitis -
History/PE |
RUQ pain
n/v low-grade fever Murphy's sign |
|
Acute Cholecystitis -
Dx |
US
HIDA scan CBC amylase, lipase bilirubin LFT |
|
Acute Cholecystitis -
Tx |
IV ABx
IV fluids replete electrolytes early cholecystectomy preop ERCP intraop cholangiogram |
|
Acute Cholecystitis -
Complications |
gangrene
abscess perforation empyema sepsis gallstone ileus fistulization |
|
Choledocholithiasis -
Results from what |
gallstones in the CBD
|
|
Choledocholithiasis -
History/PE |
biliary pain
jaundice colic fever pancreatitis |
|
Choledocholithiasis -
Dx |
Inc. alk phos and total bili
|
|
Choledocholithiasis -
Tx |
ERCP with stone extraction and sphincterotomy
cholecystectomy |
|
Acute Cholangitis -
Results from what Leads to what |
Acute bacterial infection of biliary tree -
from primary sclerosing cholangitis or obstruction (gallstones) as obstruction persists (usu from choledocholelith.) inc. in intraluminal pressure reflux of bacteria to systemic circulation why Charcot's triad => Reynolds' pentad |
|
Acute Cholangitis -
Bacteria |
E Coli
Pseudomonas Enterobacter |
|
Acute Cholangitis -
History/PE |
Charcot's triad
Reynold's pentad |
|
Acute Cholangitis -
What is Reynold's pentad and what does it suggest |
RUQ pain
jaundice fever/chills shock altered mental status suggests sepsis |
|
Acute Cholangitis -
Dx |
leukocytosis
increased alk phos and bili BC (to r/o sepsis) US or CT - may be useful ERCP |
|
Acute Cholangitis -
Tx |
ICU
IV ABx IV hydration bile duct decompression - open surgical, percutan transhepatic drain or ERCP sphincterotomy |
|
Diarrhea -
What is it Risk factors |
> 200 gm feces/day
change in stool consistency viral/bact. gi infection systemic infection sick contacts immunosuppression recent ABx use recent travel |
|
Diarrhea -
What are the types |
Acute -
< 2 wks of Sx infectious and self-limited 2nd MCC - drug side effect chronic - > 2-3 wks of Sx disrupted secretion malabsorption altered motility MCC in adults - lactase def. pediatric - usually rotavirus can also divide as - infectious, secretory, osmotic infectious - • enterotoxigenic: E. coli (traveller's diarrhea) • enteroinvasive: bloody diarrhea & fever •campylobacter - MC bacteria to cause diarrhea MCC of reactive arthritis •shigella - transferred by food & water found in daycare •salmonella raw eggs & dairy • V. vulnificus: severe if have liver dis. • Yersinia: abdom pain, joint pain, rash may resemble appendicitis • E. coli O157:H7 HUS • viral: MCC of infectious diarrhea secretory - diarrhea > 1L carcinoid syndrome Zollinger-Ellison syndrome VIPoma phenolphthalein (laxative) osmotic - > 50 osmol/kg osmolality lactose, fructose, sorbitol MCC - lactase def. |
|
Diarrhea -
Dx |
• stool electrolytes -
secretory vs. osmotic • fecal leukocytes - enteroinvasive IBD • methylene blue - checks for WBC • stool Cx, O&P • giardia - string test & stool giardia Ag • cryptosporidia - modified AFB stain • NaOH - turns stool red if phenolphthalein use • colonoscopy or Bx |
|
Diarrhea -
Tx |
infectious - self-limited
mild - oral fluids & electrolytes severe - IV fluids & oral ABx initial empiric- ciprofloxacin invasive - TMP-SMX or ciprofloxacin giardia - metro c. diff - metro campylobacter - erythromycin scombroid - antihistamine cryptosporidium - control underlying HIV with antiretrovirals |
|
IBS -
What is it |
abdom pain
changes in bowel habits increased with stress relieved by BM 1/2 of pts. have comorbid psych disorders |
|
IBS -
History/PE |
Sxs for at least 3 mos.
usually absent at night abdom pain change in bowel habits abdom distention stools with mucus relief of pain with a BM |
|
IBS -
Dx |
Dx of exclusion
r/o - lactose intolerance IBD hypo- or hyperthyroidism always flexible sigmoidoscopy if pt. > 40 y/o |
|
IBS -
Tx |
fiber supplements
TCAs, antidiarrheals, antispasmodics tegaserod - constipation-predominant. |
|
SBO -
History/PE |
cramping - crescendo-descrendo every 5-10 min.
vomiting bilious - early feculent - distal partial obstruction - flatus, no stool complete obstruction - no flatus or stool T/D (accum of gas and fluid) prior surgical scars high-pitched tinkles peristaltic rushes later, peristalsis disappears |
|
SBO -
Causes |
adhesions from prior abdom
surgery (60%) hernias neoplasms intussusception gallstone ileus stricture from IBD volvulus CF |
|
SBO -
Dx |
• leukocytosis -
if strangulation • dehydration (vomiting) • metab. alkalosis (vomiting) • lactic acidosis - if necrotic bowel need emergency surgery • radiopaque in cecum - gallstone ileus • XR - stepladder pattern air-fluid levels |
|
SBO -
Tx |
partial -
NPO NG suction IV hydration correct electrolytes Foley surgery if - complete obstruction necrotic bowel Sx > 3D with no resolution exploratory laparotomy |
|
Ileus -
what is it Risk factors |
temp arrest of
intestinal peristalsis Risk factors - recent surgery/GI procedures immobility hypokalemia hypothyroidism DM meds (anticholinergics, opioids) After every abdom operation for 24-48 hours Due to - sympathetic overaction bowel manipulation K+ depletion (preop vomiting) peritoneal irritation - from blood or peritonitis atony of colon & stomach |
|
Ileus -
History/PE |
abdom discomfort
n/v no flatus or BM abdom distention decreased or no bowel sounds rectal exam if elderly to r/o fecal impaction |
|
Ileus -
Dx |
AXR -
distended loops air-fluid levels (upright) gastrografin - r/o partial obstruction CT - r/o neoplasm |
|
Ileus -
Tx |
decrease meds that reduce
bowel motility decrease/discont. oral feeds NG suction parenteral feeds replete electrolytes |
|
Carcinoid Syndrome -
What causes it |
Carcinoid tumors -
neuroendrocrine cells enterochromaffin cells usually from ileum, appendix |
|
Carcinoid Syndrome -
What do they secrete |
serotonin
tryptophan tachykinin (substance P) ACTH, gastrin secrete high levels => depletion of tryptophan => pellagra (niacin def.) levels do not get metabolized by liver due to liver mets MC found incidentally during appendectomy |
|
Carcinoid Syndrome -
History/PE |
flushing
diarrhea wheezing right-sided valvular disease |
|
Carcinoid Syndrome -
Dx |
high urine levels of 5-HIAA - diagnostic
chest and abdom CT |
|
Carcinoid Syndrome -
Tx |
octreotide (for symptoms)
surgery |
|
Diverticular Disease -
What is it |
Outpouching of mucosa and submucosa that herniate in areas of high intraluminal pressure
common in sigmoid colon MCC of acute lwr GI bleeding in pts. > 40 |
|
Diverticular Disease -
Risk factors |
low-fiber and high-fat diet
advanced age connective tissue disorders (Ehlers-Danlos, Marfans) |
|
Diverticular Disease -
History/PE |
LLQ abdom pain
abnormal bowel habits bleeding painless and sudden usually hematochezia Sx of anemia |
|
Diverticulitis -
PE |
LLQ pain
fever n/v perforation - complication |
|
Diverticular Disease -
Dx |
CBC (leukocytosis)
AXR colonoscopy or barium enema avoid invasive techniques in early diverticulitis - risk of perforation CT - check for abscess, free air after acute episode if >50 y/o flexible sigmoidoscopy (r/o perforating colon cancer) |
|
Diverticular Disease -
Tx for uncomplicated disease |
high-fiber diet
|
|
Diverticular Disease -
Tx for bleeding |
bleeding usually stops spontaneously
transfuse and hydrate if bleeding doesn't stop - angiography with embolization surgery |
|
Diverticular Disease -
Tx for diverticulitis |
NPO
NGT metro and fluoroquinolone or cephalosporin if perforation - resect anastomosis or temp colostomy |
|
LBO -
Hx |
constipation
cramping abdominal pain n/v feculent vomiting tenderness significant distention tympany high-pitched tinkly BS later, no BS |
|
LBO -
Causes |
colon cancer
benign tumors diverticulitis volvulus fecal impaction assume colon ca until proven otherwise |
|
LBO -
Tx |
tx obstruction with -
gastrograffin enema colonoscopy rectal tube surgery usually needed tx underlying cause |
|
Colon and Rectal Cancer -
History/PE |
presents with sx after long
period of silent growth abdom pain and sx based on location rt-sided lesion - stool is liquid ca can get large before sx lesions commonly ulcerate => chronic blood loss can bleed intermittently lt-sided lesion - stool more concentrated apple-core lesions rectal - BRBPR rectal pain can coexist with hemorrhoids so r/o in all pts with rectal bleeding |
|
Colon and Rectal Cancer -
Dx |
CBC (anemia)
guiac sigmoidoscopy - left colonoscopy/barium enema - rt US (how much invaded) CT/MRI (to stage) CXR, LFT, abdom CT - metas |
|
Colon and Rectal Cancer -
How does mets spread |
direct
hematogenous - liver primary lymphatic -pelvic lymph nodes |
|
Colon and Rectal Cancer -
Tx |
bowel prep - Golytely, ABx
colon - resect colon, lymph, mesentery anastomosis rectum - if < 10cm from anal verge - abdominoperineal resection rectum and anus resected permanent colostomy if > 10cm - low anterior resection anas bet. colon & rectum wide local excise - low stage also chemo - colon with nodes also radiation - rectum F/U with CEA, colonoscopy, LFTs, CXR, abdom CT Duke classification surgery - stages A&B stages C1 & C2 - surgery and chemo 5-FU and leucovorin |
|
Colon and Rectal Cancer -
Risk factors |
age
hereditary - FAP, Gardner's, HNPCC APC gene, p54 Strep bovis bacteremia family Hx UC adenomatous polyps past Hx of colorectal ca high-fat, low-fiber diet |
|
Colon and Rectal Cancer -
Screening |
DRE yearly > 50 y/o
guaiac yearly > 50 y/o colonoscopy every 10 yrs > 50 or sigmoidoscopy every 3-5 > 50 or colonoscopy every 10 yrs > 40 with family hx of ca/polyp or 10 yrs prior to age of dx of youngest family member with colorectal ca |
|
Dysphagia -
What is it |
Difficulty swallowing due to abnormalities of the oropharynx or esophagus.
|
|
Odynophagia -
What is it |
Pain with swallowing due to abnormalities of the oropharynx or esophagus.
|
|
Dysphagia -
Etiologic factors (Caused by) |
Achalasia
peptic stricture esophageal webs or rings carcinoma Scleroderma spastic motility disorders Sjogren's meds radiation injury |
|
Dysphagia -
PE |
examine for masses
(goiter, tumor) examine for anatomical defects |
|
Dysphagia -
Dx |
oropharyngeal -
cine-esophagram esophageal - barium swallow then endoscopy manometry pH monitoring odynophagia - upper endoscopy |
|
Dysphagia -
Tx Tx for Achalasia |
Etiology dependent
achalasia - botulinum toxin calcium channel blockers balloon dilatation all 3 temporizing measures esophageal myotomy for long-term tx |
|
Esophageal Cancer -
What is it |
squamous cell ca -
midesophagus from smoking and alcohol can dev. fistulas to bronchi adenocarcinoma - barrett's esophagus columnar metaplasia replaces squamous distal esophagus secondary to chronic GERD |
|
Esophageal Cancer -
Risk factors |
achalasia
barrett's cigarettes etoh webs male gender |
|
Esophageal Cancer -
History/PE |
progressive dysphagia -
first solids then liquids weight loss GERD GI bleeding vomiting |
|
Esophageal Cancer -
Dx |
barium swallow 1st
EGD biopsy - confirm (MRI/CT - evaluate for mets) |
|
Esophageal Cancer -
Tx |
surgery if local
metastatic - cisplatin, 5-FU & radiation chemoradiation - poor prognosis esophageal stent - palliation |
|
GERD -
What is it |
transient LES relaxation
from - incompetent LES gastroparesis hiatal hernia |
|
GERD -
Risk factors |
inc. intra-abdom pressure
(obesity, pregnancy) scleroderma alcohol caffeine nicotine chocolate fatty foods |
|
GERD -
History/PE |
heartburn 30-90 min post meal
pain worse with reclining pain better with antacids, sitting, standing sour taste ("water brash") |
|
GERD -
Dx |
Based largely on Hx
confirm - respond to Tx 24hr pH monitor- gold standard Bernstein test - confirms origin of pain |
|
GERD -
Tx |
■ lifestyle -
weight loss head-of-bed elevation stop eating 3 hrs before bed eat small meals ■ monitor for barretts/adenoca serial EGD Bx ■ antacids - if intermittent ■ H2 blockers and PPI ■ surgery - nissen fundoplication |
|
GERD -
Complications |
esophageal ulceration
esophageal stricture aspiration of gastric content upper GI bleeding Barrett's Barrett's - when to do EGD - no dysplasia - every 2-5 yrs. low-grade - every 3-6 mos. high-grade - resection |
|
Hiatal Hernia -
What are types |
sliding -
ge junction and part of stomach above diaphragm due to - weakening of anchors of ge junction to diaphragm longitudinal contractions of diaphragm inc. intra-abdom pressure paraesophageal - ge junction below diaphragm part of fundus herniates |
|
Hiatal Hernia -
History/PE |
May be asymptomatic
with sliding, may have GERD |
|
Hiatal Hernia -
Dx |
CXR (incidental finding)
barium swallow EGD |
|
Hiatal Hernia -
Tx |
sliding - lifestyle changes
paraesoph - gastropexy |
|
Gastritis -
What are types |
Erosive (acute) -
rapidly developing conditions that erode mucosa NSAIDs alcohol H pylori stress from severe illness (burns, CNS injury) hemorrhagic gastritis alkaline gastritis reflux gastritis chronic - type A - (10%) autoab to parietal cells pernicious anemia achlorhydria inc. risk of gastric ca fundus G cells in antrum G cells make gastrin gastrin stim acid secretion => hypergastrinemia type B - (90%) H pylori inc. risk of gastric ca antrum |
|
Gastritis -
History/PE |
may be asymptomatic
n/v indigestion hematemesis melena |
|
Gastritis -
Dx |
Upper endoscopy
Type B - must confirm H. pylori antral Bx - gold standard CLO test urease breath test serum IgG - ELISA to confirm or r/o only shows exposure (H pylori stool Ag) |
|
Gastritis -
Tx |
Erosive - same as for PUD
type A - need B12 for life type B - must eradicate H. py Dec. offending agents antacids sucralfate H2 blockers PPIs triple therapy - to tx H pylori infection clarithromycin amoxicillin (or metro) PPI quadruple therapy - bismuth metro tetracycline PPI or H2 blocker |
|
Gastric Ca -
What are the types |
2 types of adenocarcinoma -
intestinal - metaplasia of mucosa by intestinal-type cells ulcerates pyloric antrum & lsr curvature high in Japan risk factors - diet high in nitrites, salt, low veggies H pylori, chronic gastritis diffuse - younger pts. dev. throughout stomach linitis plastica poorer prognosis |
|
Gastric Ca -
History/PE |
advanced cases -
abdom pain early satiety weight loss 5-yr survival < 10% mets - Virchow's node Krukenberg's tumor Sister Mary Joseph nodule |
|
Gastric Ca -
Dx |
early - asymp, superficial,
surgically curable endoscopy |
|
Gastric Ca -
Tx |
must have early detection and
removal of tumor |
|
PUD -
What are types |
gastric -
pain greater with meals weight loss H pylori 70% NSAIDs dec. mucosal protection duodenal - pain init. dec. with food or antacids worsens in 2-3 hrs can radiate to back nocturnal pain 100% H pylori inc. acid secretion |
|
PUD -
Risk factors |
duodenal -
O blood type men MEN I other risk factors - corticosteroids NSAIDs alcohol tobacco Curling ulcers Cushing ulcers corrosives - acids strong alkali (lye, NaOH) |
|
PUD -
History/PE |
nausea
hematemesis coffee-ground emesis melena or hematochezia epigastric tenderness if acute perforation - rebound tenderness guarding NSAID-associated - GI hemorrhage & perforation gastric - n/v don't improve with antacids & H2-blockers duodenal - no n/v wake up in middle of night |
|
PUD -
Dx |
Upper endoscopy with Bx
or barium swallow then must test for H pylori - invasive: culture histology urease noninvasive: urease breath test serum IgG stool Ag test |
|
PUD -
Tx |
For H. pylori -
2 wks of combination Tx 2 ABx and bismuth, H2 blocker or PPI: BMT (bismuth, metro and tetracycline) Prevpac (2 ABx & PPI) - prepacked Helidac (2 ABx & bismuth) - prepacked for NSAID-induced - H2 blocker or PPI misoprostol - for prevention |
|
PUD -
Complications |
"HOPI"
Hemorrhage - posterior ulcers erode into gastroduodenal artery obstruction (gastric outlet) perforation - anterior ulcer intractable pain long-term effects of H. pylori PUD MALT chronic superficial gastritis chronic atrophic gastritis => cancer |
|
ZE Syndrome -
What is it |
Gastrin-producing tumors
mainly in head of pancreas can also be in duodenum, stomach or spleen 60% are malignant => oversecretion of gastrin => high levels of HCl (from the parietal cells) => ulcers in stomach, duoden. associated with MEN I |
|
ZE Syndrome -
History/PE |
Gnawing, burning abdom pain
n/v diarrhea weakness GI bleeding most common presentation - PUD & diarrhea or steatorrhea if hypercalcemia - associated with MEN I |
|
ZE Syndrome -
Dx |
measure serum gastrin -
increased gastrin levels stop PPIs before testing abnormal IV secretin confirms |
|
ZE Syndrome -
Tx |
Surgical resection
if mets at presentation (30-50%) - PPIs |
|
Upper GI Bleeding -
History/PE |
hematemesis -
bright red or coffee-brown melena possible iron def. anemia anemia increased BUN depleted volume status - tachy light-headedness orthostatic hypotension |
|
Upper GI Bleeding -
Dx |
NGT and lavage
endoscopy - 1st test clinical Hx |
|
Upper GI Bleeding -
Common Causes |
gastritis
PUD Mallory-Weiss tear esophageal varices vascular abnormalities neoplasm esophagitis gastric erosions |
|
Upper GI Bleeding -
Initial Tx |
protect airway (intubation)
IV fluids transfusion |
|
Upper GI Bleeding -
Long-term management |
tx underlying cause
PUD - IV PPI endoscopic tx for varices - bipolar electrocoagulation injection therapy octreotide sclerotherapy band ligation |
|
Lower GI Bleeding -
History/PE |
hematochezia > melena
|
|
Lower GI Bleeding -
Dx |
anoscopy,
flexible sigmoidoscopy or colonoscopy bleeding scan NG lavage negative r/o upper GI bleed - if pos. stool and neg. colonoscopy |
|
Lower GI Bleeding -
Common Causes |
diverticulosis- MCC in elderly
hemorrhoids - MCC in young angiodysplasia (AVM) neoplasm IBD anorectal disease mesenteric ischemia Meckel's infectious |
|
Lower GI Bleeding -
Initial Tx |
protect airway (intubation)
IV fluids transfusion |
|
Lower GI Bleeding -
Long-term management |
endoscopic therapy -
bipolar electrocoagulation injection therapy angiography surgery |
|
UC -
Prevalence Site of involvement |
Prevalence higher than Crohn's
bimodal starts at rectum then upwards continuous mucosa and submucosa granular mucosa pseudopolyps |
|
UC -
History/PE |
bloody diarrhea
pus lower abdom cramps |
|
UC -
Extraintestinal manifestations |
pyoderma gangrenosum
primary sclerosing cholangitis colorectal ca toxic megacolon aphthous stomatitis arthritis uveitis erythema nodosum |
|
UC -
Dx |
CBC
AXR stool cultures O&P stool assay for C. difficile colonoscopy Bx - definitive Dx |
|
UC -
Tx |
sulfasalazine
5-ASA (mesalamine) corticosteroids immunosuppressants total colectomy |
|
Crohn's -
Distribution Site of involvement |
Bimodal
any portion of GI tract usually terminal ileum, small intestine and colon cobblestone (skip) lesions transmural |
|
Crohn's -
History/PE |
watery diarrhea (most common)
(bloody diarrhea only if rectum involved) abdom pain fistulas bet. bowel & bladder or bowel & skin noncaseating granulomas |
|
Crohn's -
Extraintestinal manifestations |
pyoderma gangrenosum
primary sclerosing cholangitis toxic megacolon aphthous stomatitis arthritis uveitis erythema nodosum *nephrolithiasis* |
|
Crohn's -
Dx |
CBC
AXR stool culture O&P stool assay for C. difficile colonoscopy Bx - definitive Dx |
|
Crohn's -
Tx |
mesalamine
sulfasalazine not as effective corticosteroids immunosuppressants - 6-mercaptopurine azathioprine infliximab metro - for fistulas resection may recur anywhere in GI tract (after resection) |
|
Inguinal Hernia -
Types |
Indirect -
congenital patent processus vaginalis internal inguinal ring => external inguinal ring => scrotum Most common type for both genders Direct - through floor of Hesselbach's triangle goes direct thru abdom wall in aponeurosis of ext. obliq acquired defect in transversalis fascia inc. with age |
|
Inguinal Hernia -
What is Hesselbach's triangle |
inferior epigastric artery
inguinal ligament rectus abdominis |
|
Inguinal Hernia -
Tx |
Surgery
Direct - also correct defect in transversalis fascia Indirect - ligate hernia sac reduce size of internal inguinal ring |
|
Portal Hypertension -
Definition |
Portal vein pressure > 5 mmHg greater than the pressure in the IVC
|
|
Portal Hypertension -
Causes |
Presinusoidal -
splenic or portal vein thrombosis schistosomiasis granulomatous disease Sinusoidal - cirrhosis granulomatous disease Postsinusoidal - RHF constrictive pericarditis Budd-Chiari syndrome hepatic vein thrombosis |
|
Budd-Chiari Syndrome -
Definition |
thrombotic occlusion of IVC
or hepatic vein centrilobular congestion and necrosis => congestive liver disease (hepatomegaly, ascites, abdom pain, liver failure) from PCV, pregnancy & hepatocellular ca |
|
Portal Hypertension -
History/PE |
Hx -
jaundice ascites esophageal varices hemorrhoids caput medusa spontaneous bacterial peritonitis hepatic encephalopathy renal dysfunction PE - icteric sclerae abdominal fluid wave shifting dullness splenomegaly easy bruising spider angioma caput medusa palmar erythema gynecomastia testicular atophy |
|
Portal Hypertension -
Dx |
LFTs
alk phos bilirubin albumin PT/PTT serum ferritin ceruloplasmin a1-antitrypsin US inc. indirect hepatic vein wedge pressure SAAG |
|
Portal Hypertension -
What is SAAG SAAG > 1.1 SAAG < 1.1 |
serum-ascites
albumin gradient serum albumin-ascitic albumin SAAG > 1.1 portal HTN - inc. pressure in portal v. chronic liver dis. hepatic mets SAAG < 1.1 nonportal HTN - nephrotic syndrome TB malignancy |
|
Portal Hypertension -
Tx for ascites |
restrict Na
diuretics r/o infection & neoplasms paracentesis - to get SAAG, CBC, cultures tx underlying liver disease |
|
Portal Hypertension -
Tx for spontaneous bacterial peritonitis |
Indolent infection of ascitic fluid
pos. if > 250 PMNs/ml or > 500 WBC Cx and gram stain usually neg. IV 3rd gen. cephalosporin (covers Enterococcus, E. Coli or Klebsiella) |
|
Portal Hypertension -
Tx for hepatorenal syndrome |
Dx of exclusion
Hard to tx Often requires dialysis |
|
Portal Hypertension -
Tx for hepatic encephalopathy |
Dec. protein consumption
lactulose metronidazole |
|
Portal Hypertension -
Tx for esophageal varices |
Monitor for GI bleeding
B blockers band ligation sclerotherapy or portocaval shunt |
|
Hepatocellular Ca -
Risk factors for primary |
US -
cirrhosis chronic HBV or HCV worldwide - HBV, HCV, aflatoxin |
|
Hepatocellular Ca -
History/PE |
RUQ tenderness
abdom distention hepatomegaly signs of chronic liver dis. - jaundice easy bruisability coagulopathy nodular cirrhotic liver |
|
Hepatocellular Ca -
Dx |
US
CT increased LFTs significantly increased AFP Bx - definitive Dx |
|
Hepatocellular Ca -
Tx |
early detection -
resection or orthotopic liver transplant neoadjuvant therapy - chemo and radiation to shrink large tumor before surgery serial AFP - monitor recurrence |
|
Hemochromatosis -
What is it |
inc. in int. iron absorption
=> too much deposited accums in skin, pancreas, liver, heart, joints, kidney, pituitary, gonads, adrenals primary - auto recessive secondary - chronic transfusions alcoholics |
|
Hemochromatosis -
History/PE |
DM
hypogonadism arthritis CHF restrictive cardiomyopathy cirrhosis adrenal insufficiency hypothyroidism, hypoparathyr. abdom pain |
|
Hemochromatosis -
Dx |
Inc. serum iron
inc. % iron saturation inc. ferritin dec. serum transferrin fasting transferrin satura- tion > 45% glucose intolerance inc. AST inc. alk phos liver Bx MRI C282Y mutation hepatic iron index > 2.0 |
|
Hemochromatosis -
Tx |
weekly phlebotomy (1-2 yrs.)
then maintenance phlebotomy every 2-4 months deferoxamine (maintenance) liver transplant cures |
|
Hemochromatosis -
Complications |
cirrhosis
hepatocellular ca cardiomegaly CHF DM impotence arthropathy hypopituitarism |
|
Wilson's Disease -
What is it |
Hepatolenticular degeneration
Dec. syn of ceruloplasmin => too much copper deposited in liver, brain, cornea auto recessive (chrom 13) usually presents 15-25 y/o |
|
Wilson's Disease -
History |
ABCD
asterixis basal ganglia degenerates ceruloplasmin dec. copper deposited cirrhosis => hepatocellular ca choreiform movements (tremor) corneal deposits dementia 1st sign - neuro or psych kayser-fleischer rings always accompany neuro or psych |
|
Wilson's Disease -
PE |
Kayser-Fleischer rings -
copper in Descemet's membrane jaundice hepatomegaly asterixis choreiform movements |
|
Wilson's Disease -
Dx |
dec. serum ceruloplasmin
inc. urinary copper excretion elevated hepatic copper |
|
Wilson's Disease -
Tx |
dietary copper restriction
no shellfish, liver, legume penicillamine (urine excretes) oral zinc (fecal excretion) cured by liver transplant |
|
Acute Pancreatitis -
What is it |
Leakage of pancreatic enzymes into pancreatic and peripancreatic tissue.
|
|
Acute Pancreatitis -
Risk factors |
GET SMASHeD
gallstones ethanol trauma steroids mumps autoimmune dis. scorpion sting hyperlipidemia hypercalcemia drugs (thiazide) |
|
Acute Pancreatitis -
History/PE |
Severe epigastric pain
radiates to the back cullen's (periumbilical) grey-turner (flank) |
|
Acute Pancreatitis -
Dx |
Inc. amylase -
but amylase can read normal if hypertriglyceridemia inc. lipase - more specific dec. calcium (fat necrosis) "sentinel loop" on AXR "colon cutoff" on AXR US or CT - enlarged pancreas pseudocysts abscess hemorrhage necrosis |
|
Acute Pancreatitis -
Tx |
IV fluids
electolyte replacement analgesia NPO NG suction nutritional support O2 if necrotizing - IV Abx respiratory support surgical debridement ERCP - if stone in CBD debridement - if necrosis CT-guided drainage - abscess pseudocyst > 5cm lasts > 1 mo. |
|
Acute Pancreatitis -
Complications |
pseudocyst
fistulas hypocalcemia renal failure pleural effusion sepsis chronic pancreatitis splenic vein thrombosis mortality - Ranson's criteria |
|
Acute Pancreatitis -
Ranson's Criteria |
GA LAW -
On Admission Glucose > 200 mg/dl Age > 55 yrs. LDH > 350 IU/L AST > 250 IU/dl WBC > 16,000/ml C HOBBS - After 48 hours Ca2+ < 8.0 mg/dl Hct dec. by > 10% O2 PaO2 < 60 mmHg Base excess > 4 mEq/l BUN inc. > 5 mg/dl Sequestered fluid > 6L Mortality risk - 20% with 3-4 signs 40% with 5-6 signs 100% with > 7 signs |
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Chronic Pancreatitis -
What is it |
recurrent attacks of acute
=> irreversible destruction => pancreatic dysfunction |
|
Chronic Pancreatitis -
Risk factors |
alcoholism (90%)
gallstones hyperparathyroidism idiopathic congenital - pancreas divisum CF |
|
Chronic Pancreatitis -
History/PE |
recurrent episodes of
persistent epigastric pain steatorrhea weight loss nausea diabetes |
|
Chronic Pancreatitis -
Dx |
Abdom XR - calcifications
low trypsin amylase and lipase - normal secretin stimulation test - most sensitive glycosuria mild ileus on AXR and CT ("chain of lakes") |
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Chronic Pancreatitis -
Tx |
Pancreatic enzymes replaced
med-chain trigly in diet dec. fat intake vitamins analgesics Puestow procedure stop alcohol celiac nerve block surgery for - intractable pain structural causes |
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Chronic Pancreatitis -
Complications |
chronic pain
pancreatic cancer |
|
Pancreatic Cancer -
What is it |
pancr. head adenocarcinoma
prognosis 6 mos. or less usu metas at presentation |
|
Pancreatic Cancer -
Risk factors |
smoking
chronic pancreatitis high-fat diet long-standing DM |
|
Pancreatic Cancer -
History/PE |
abdom pain radiates to back
painless jaundice loss of appetite n/v weight loss Courvoisier's sign - palpable NT gallbladder Trousseau's sign - migratory thrombophlebitis |
|
Pancreatic Cancer -
Dx |
CT
US ERCP |
|
Pancreatic Cancer -
Tx |
Palliative
Whipple - pancreaticoduodenectomy if no evidence of mets (10-20%) chemo - 5-FU gemcitabine |
|
Jaundice -
What is it Causes |
excess bilirubin in blood
pathological in adults from - overload damage to liver inability to excrete causes - congenital (Gilbert's, Dubin-Johnson, Crigler-Najjar) hemolytic anemia hepatitis alcoholic cirrhosis obstruction pancreatic ca |
|
Hepatitis -
History/PE |
Acute Viral -
incubation period - virus multiplies & spreads no Sxs prodromal period - anorexia malaise n/v fever RUQ pain joint pain (occasionally) 3-10 days- urine darkens icteric phase - jaundice systemic Sxs regress pt. feels better despite worsening jaundice liver enlarged and tender jaundice peaks 1-2 wks, then fades acute usu resolves spontan in 4-8 weeks Chronic hepatitis - lasts > 6 mos. many pts. asymp - esp. HCV malaise anorexia jaundice - usu absent scleral icterus tender hepatomegaly splenomegaly lymphadenopathy spider nevi palmar erythema autoimmune - can involve any body sys |
|
Chronic Hepatitis -
Etiologies |
HCV (80% with HCV progress)
HBV (10%, cum or sin HDV prog) autoimmune hepatitis alcoholic hepatitis nonalcoholic steatohepatitis right-sided heart failure Wilson's hemochromatosis a1-antitrypsin deficiency neoplasm drug-induced disease - INH methyldopa acetaminophen nitrofurantoin |
|
Hepatitis -
Dx |
WBC -
normal count relative leukocytosis very high ALT and AST high bilirubin high alk phos hypoalbuminemia (chronic) hepatitis serology severe cases - PT prolonged (all clotting factors except factor VIII made by liver) Bx autoimmune - ANA anti-LKM1 antibody anti-smooth muscle antibody antimitochondrial antibody |
|
Hepatitis -
Tx |
Etiology specific
monitor for resolution of Sx severe alcoholic - steroids autoimmune - steroids azathioprine chronic HBV - IFN-a lamivudine (3TC) adefovir chronic HCV - peginterferon IFN-B ribavirin end-stage liver failure - liver transplant fulminant hepatic failure - ICU emergent transplant |
|
Hepatitis -
Complications |
Cirrhosis
liver failure hepatocellular ca mortality in 5 yrs (50%) |
|
Hepatitis -
IgM HAVAb |
IgM Ab to HAV
best test to detect active hepatitis A |
|
Hepatitis -
HBsAg |
Ag on surface of HBV
continued presence indicates carrier state |
|
Hepatitis -
HBsAb |
Ab to HBsAg
provides immunity to hep B |
|
Hepatitis -
HBcAg |
Ag associated with the core
of HBV |
|
Hepatitis -
HBcAb |
Ab to HBcAg
positive during window period indicator of recent disease |
|
Hepatitis -
HBeAg |
A second, different antigenic
determinant in the HBV core important indicator of transmissibility (BEware) |
|
Hepatitis -
HBeAb |
Ab to e antigen
indicates low transmissibility |
|
Infectious Diarrhea -
Campylobacter History |
Most common etiology of
infectious diarrhea Ingestion of contaminated food or water Affects young kids and young adults Usually last 7-10 days |
|
Infectious Diarrhea -
Campylobacter PE |
Fecal RBCs and WBCs
|
|
Infectious Diarrhea -
Campylobacter Comments |
R/o appendicitis and IBD
|
|
Infectious Diarrhea -
Campylobacter Tx |
Erythromycin
|
|
Infectious Diarrhea -
C. difficile History |
Recent tx with antibiotics
cephalosporins, clindamycin Affects hospitalized adult pt Watch for toxic megacolon |
|
Infectious Diarrhea -
C. difficile PE |
Fever
abdominal pain possible systemic toxicity Fecal RBCs and WBCs |
|
Infectious Diarrhea -
C. difficile Comments |
Most commonly in large bowel
can involve small bowel ID C. Diff toxin in stool |
|
Infectious Diarrhea -
C. difficile Tx |
PO metro or vanco
IV metro if can't tolerate oral meds |
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Infectious Diarrhea -
Entamoeba histolytica History |
Contaminated food or water
h/o travel in dev. countries Incubation period can last up to 3 mos. |
|
Infectious Diarrhea -
Entamoeba histolytica PE |
Severe abdom pain
fever Fecal RBCs and WBCs |
|
Infectious Diarrhea -
Entamoeba histolytica Comments |
Chronic amebic colitis
mimics IBD |
|
Infectious Diarrhea -
Entamoeba histolytica Tx |
Steroids can lead to
fatal perforation Tx with metro |
|
Infectious Diarrhea -
E. Coli O157:H7 History |
Contaminated food -
undercooked hamburger apple cider Affects kids and the elderly Usually lasts 5-10 days |
|
Infectious Diarrhea -
E. Coli O157:H7 PE |
Severe abdominal pain
low-grade fever vomiting Fecal RBCs and WBCs |
|
Infectious Diarrhea -
E. Coli O157:H7 Comments |
Must r/o GI bleed and
ischemic colitis HUS possible complication |
|
Infectious Diarrhea -
E. Coli O157:H7 Tx |
Avoid Abx therapy -
resistance has increased |
|
Infectious Diarrhea -
Salmonella History |
Contaminated poultry or eggs
Affects young kids and the elderly Usually lasts 2-5 days |
|
Infectious Diarrhea -
Salmonella PE |
Prodromal headache
fever myalgia abdominal pain Fecal WBCs |
|
Infectious Diarrhea -
Salmonella Comments |
Sepsis
Sickle cell pts. susceptible to osteomyelitis |
|
Infectious Diarrhea -
Salmonella Tx |
Tx bacteremia or at-risk pts.
(sickle cell) - oral quinolone or TMP-SMX |
|
Infectious Diarrhea -
Shigella History |
Extremely contagious
transmitted between people Affects young kids and institutionalized pts. |
|
Infectious Diarrhea -
Shigella PE |
Fecal RBCs and WBCs
|
|
Infectious Diarrhea -
Shigella Comments |
Can => severe dehydration
Can => febrile seizures in the very young |
|
Infectious Diarrhea -
Shigella Tx |
TMP-SMX
to dec. person-to-person spread |
|
Achalasia -
Features Secondary Causes |
Increased tone
decreased or abnormal peristalsis decreased inhib neurons in LES smooth muscle secondary causes - Chagas gastric carcinoma lymphoma scleroderma |
|
Achalasia -
Dx |
Barium swallow - always 1st
manometry EGD - to r/o gastric carcinoma or lymphoma |
|
Achalasia -
Tx |
Pneumatic dilation
botulinum toxin - every 2 yrs. Ca2+ chan blockers & nitrates surgical myotomy - definitive |
|
Scleroderma -
Features |
Mid or distal esophagus
dec. or no peristalsis LES incompetent => GERD Sxs progressive dysphagia |
|
Scleroderma -
Dx |
Barium swallow 1st
motility studies |
|
Scleroderma -
Tx |
Antireflux
|
|
Diffuse Esophageal Spasm -
Features |
Nonperistaltic spontaneous
contractions usually due to degeneration of nerve processes chest pain dysphagia |
|
Diffuse Esophageal Spasm -
Dx |
Barium swallow - "corkscrew"
manometry confirms |
|
Diffuse Esophageal Spasm -
Tx |
Ca2+ chan blockers & nitrates
|
|
Nutcracker Esophagus -
Features |
Inc. excitatory activities
=> high-amplitude contractions chest pain dysphagia |
|
Nutcracker Esophagus -
Dx |
Manometry
|
|
Nutcracker Esophagus -
Tx |
Ca2+ chan blockers & nitrates
|
|
Familial Polyposis Syndromes -
What causes it Three Names |
Caused by adenomatous polyps
which transform into cancer AD Familial Polyposis Coli Gardner Syndrome Turcot Syndrome |
|
Familial Polyposis Syndromes -
Familial Polyposis Coli What is it |
Thousands of colonic polyps
deletion in chromosome 5 100% malignancy if total colectomy not done |
|
Familial Polyposis Syndromes -
Gardner Syndrome What is it |
Polyps & osteomas
|
|
Familial Polyposis Syndromes -
Turcot Syndrome What is it |
Polyps & CNS tumors
|
|
Peutz-Jeghers Syndrome
What is it |
Not malignant
hamartomatous polyps in large & small intestines mucocutaneous pigmentation |
|
Juvenile Polyposis Syndrome
What is it |
Not malignant
hamartomatous polyps in large & small intestines |
|
Hereditary Nonpolyposis
Syndrome (HNPCC) - What is it |
Also called Lynch Syndrome
AD mutations of several genes colon ca from normal mucosa cancer Hx in - 3 first-degree relatives, 2 generations, 1 < 5 y/o associated with - ovarian & endometrial cancer |
|
A1-Antitrypsin Deficiency -
What is it |
AR
=> chronic hepatitis & cirrhosis 20% of liver dis. in neonates |
|
A1-Antitrypsin Deficiency -
Hx |
Asymp transaminase inc. in
pt. with emphysema |
|
A1-Antitrypsin Deficiency -
Dx |
Electrophoresis
confirm by low serum levels |
|
A1-Antitrypsin Deficiency -
Tx |
Liver transplant cures
|
|
NonUlcer Dyspepsia -
What is it |
Abdominal pain
or fullness & bloating may be postprandial gastric acid secretion is normal may have abnormal gastric or small intestine motility |
|
NonUlcer Dyspepsia -
Dx |
Normal EGD or barium
|
|
Dumping Syndrome -
What is it |
Rapid emptying from stomach
=> shift of fluids and distention of small intestines associated with PUD surgery |
|
Dumping Syndrome -
Hx/PE |
Diaphoresis
lightheaded palpitations n/v 30 min. postprandial if 90 min. postprandial - CHO- or sucrose-rich meals |
|
Dumping Syndrome -
Dx |
Clinical Hx
|
|
Dumping Syndrome -
Tx |
Restrict sweets
frequent small meals dec. liquid intake with meals |