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229 Cards in this Set

  • Front
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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
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")
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
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
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