DCM Flashcards
(121 cards)
1
Q
Causes of DIFFUSE abdominal pain (7)
A
- Acute Pancreatitis
- Early Appendicitis
- Diabetic Ketoacidosis
- Gastroenteritis
- Intestinal Obstruction
- Mesenteric Ischemia
- Peritonitis
2
Q
Causes of URQ Abdominal Pain
A
- Biliary Tract Disease
- Perforated Peptic Ulcer
3
Q
Causes of ULQ Abdominal Pain
A
Gastric & Spleen disorders
4
Q
Causes of LRQ abdominal pain
A
- Appendicitis
- Chron’s Disease
- Meckel’s Diverticulum
5
Q
Causes of LLQ abdominal pain
A
Diverticular disease
6
Q
Causes of LOWER abdominal pain
A
- PID
- Abscess
- Ruptured AAA
- Ectopic Pregnancy
- Torsion of ovarian cyst or testis
- Ovulation
7
Q
Non-surgical/Extra-peritoneal Pain
A
- Acute MI
- Pericarditis
- Sickle Cell Crisis
8
Q
Acute Cholecystitis:
- symptoms
- investigations
- treatment
A
= obstruction of cystic duct, most often due to gallstones
Sx: Acute RUQ or epigastric pain
- Choledocholiathiasis presents with CHARCOT’S TRIAD (pain+jaundice+fever)
Dx: US, CT, HIDA
Tx: ERCP! or cholecystectomy
9
Q
Perforated Peptic Ulcer:
- symptoms
- diagnosis
- treatment
A
Sx: Acute & SEVERE abdominal pain, peritonitis, hemodynamic instability
Dx: CHEST X-RAY shows FREE GAS UNDER DIAPHRAGM
Tx: resuscitation & surgery
10
Q
Acute Pancreatitis:
- symptoms
- diagnosis
- treatment
A
= auto-digestion of pancreas seen in GALLSTONE DISEASE & ALCOHOLISM
Sx: Epigastric abd pain RADIATING TO BACK, worse in SUPINE (will be leaning forward), and after eating
- Grey Turner’s Sign (bruised flanks)
- Cullen’s sign (superficial edema + bruising around umbilicus)
- abdominal distension & epigastric tenderness
- decreased bowel sounds
Dx: Serum amylase & lipase, LFTs, CT!! (most accurate for Dx & ID), US, ERCP
11
Q
Diverticular Disease
- symptoms
- diagnosis
- treatment
A
= Increased intraluminal P in colon –> inner colonic layer bulges out => false diverticuli
Sx: vague LLQ pain, bloating, diarrhea
Dx: Barium enema (NOT in ACUTE Diverticulitis), CT abdomen & pelvis with oral & IV contrast
Tx: IV abx, IV fluids
12
Q
Complications of Diverticulosis
A
Painless rectal bleeding
13
Q
Complications & Management of Diverticulitis
A
Bowel Obstruction, Pericolic abscess, perforation & peritonitis, fistula formation
Management: CT-guided surgical drainage of abscess, resection of fistulas
***DON’T DO ENEMA OR COLONOSCOPY– could perforate!
14
Q
Acute abdomen.. can’t rule out appendicitis.
A
TAKE IT OUT
15
Q
What are the types of Jaundice?
A
- Prehepatic– mainly hemolytic
- Hepatic – hepatocellular or intrahepatic obstruction
- Post-hepatic – obstruction/pressure of bile duct
- Cholestatic – intra-/extra-hepatic stasis of bile
- Physiological
- Hemolytic disease of newborn
16
Q
Signs of Pre-hepatic Jaundice
A
Due to hemolysis.
Patient is Pale (anemia) and lemon yellow (UCB)
Splenomegaly
High reticulocytes, ↓ Hb
17
Q
Causes & Signs of Post-hepatic Jaundice
A
Due to obstruction/pressure of bile duct (biliary atresia, BILE DUCT STONE (MCC), Head of Pancreas CA, UC, 1* biliary cirrhosis)
↓ or absent bile pigments in gut –> STEATORRHEA - Fat soluble vit defx
18
Q
Gilbert Syndrome: - Etiology - Clinical
A
AD mutation of promotor of UGT1A1 (Bilirubin UDP Glucuronosyl Transferase) –> decr hepatic bilirubin uptake —–> unconjugated hyperbilirubinemia
7% pop, not severe– no tx
19
Q
Dubin-Johnson Syndrome: - etiology - clinical
A
- *Faulty excretory fx** of hepatocytes due to pt mutation in gene for organic anion transporter
- -> ↑ CONJ Bilirubin
Gall bladder not visualized on cholecystography;
Bx reveals CENTRILOBULAR BROWN/BLACK PIGMENT
Great prognosis
20
Q
G6PD Deficiency dx
A
G6PD level assessed WEEKS AFTER crisis
21
Q
Hereditary Spherocytosis: - Etiology - Dx - Tx
A
AD abnormality of SPECTRIN or other mem. protein –> SPHEROCYTES (incr cell fragility –> hemolysis –> jaundice)
Dx: RBC fragility test
Tx: Splenectomy after 6y
22
Q
ALT:AST ratio in ALCOHOLIC HEPATITIS
A
AST:ALT > 2
23
Q
Where is ALT found?
A
Hepatocytes— more sensitive than AST in liver damage
24
Q
Next step if ALP is found elevated?
A
Assess GGT– if also elevated, consider Hepatobiliary/bone/placenta/intestinal path
25
ALP levels in cholestasis?
\>10x elevated due to extra-hepatic biliary tract obstruction
26
What is the best indicator of **EXCESSIVE ALCOHOL CONSUMPTION?**
GGT (Gamma Glutamyl Transpeptidase)
27
Significance of
1. Mild ↑ of AST & ALT (low 100s)
2. Moderate ↑ of AST & ALT (high 100s to 1000s)
3. Severe ↑↑ of AST & ALT (\>10k)
4. AST & ALT normal or ↓
5. ↑↑ ALP & GGT, ↑ AST & ALT
6. ↑↑ AST & ALT, ↑ ALP
1. Chronic viral or acute alcoholic hep
2. Acute viral hep
3. Extensive hepatic necrosis (ischemia, acetaminophen tox, severe viral hep)
4. Cirrhosis, metastatic liver dis (↓ # normal hepatocytes)
5. Cholestasis
6. Hepatocellular Path
28
Non-Alcoholic Fatty Liver Disease - Etiology
= **STEATOHEPATITIS** & **CIRRHOSIS** due to **INSULIN RESISTANCE** associated with obesity
--greater BMI = more liver damage
29
Carcinoma of Head of Pancreas: - S/S - Labs
* Jaundice, dark urine, pale stoole, DISTENDED, NON-TENDER GALLBLADDER
* ↑ ALP, ↑ CB
* **_Courvoisier's Law_**: Enlarged, NON-tender gallbladder caused by MALIGNANCY, not gallstones
30
High levels of HBeAg indicate what?
Infectivity.
Usually present @6w-3m
31
Anti-HbcAg is indicative of?
past infection
32
ONLY Anti-HbS detected is indicative of?
vaccine
33
After exposure, HBsAg is present for \_\_\_\_, or ____ in carriers/chronic infx
1-6mo exposure, \>6mo chronic
34
What is the demographics of an **Ulcerative Colitis** pt?
Caucasian
Jewish
NON-Smoker!! (quitting smoking may worsen)
Young
35
What is **backwash ileitis**?
When ulcerative colitis extends proximally and reaches the **terminal ileum,** but NO ULCERS are present there
36
What are the features of UC?
* Only colon is affected (rectum always)
* Mainly involves mucosa
* Confluent
* Resection is CURATIVE
* Cancer is more common
37
What are the features of CD?
* ANY part of GIT is affected-- **skip lesions** present
* Involves **full bowel wall** (deep ulcers)
* **Stricture** & **Fistulae** common
* **Perianal diseases** are common
38
**Ulcerative Colitis**: S/S
* Bloody diarrhea +/- mucus
* Lower abd cramps
* Fecal urgency (**tenesmus**)
* Anemia
* **↓ albumin**
* Negative stool culture
* Bright red blood on DRE
39
Disease stages of Ulcerative Colitis
* **Severe Disease**
* anorexia, malnutrition, fever
* hypovolemia (\>6 bloody BM/day)
* ↑ ESR & CRP
* ↓ Hb & Albumin
* **Fulminant Disease**
* Rapid progression of severe toxicity over 1-2w
* Requires transfustion
* **Toxic Megacolon**
* Colonic dilation of \>6cm on radiograph
* Heightened risk of perforation
40
Pharmacological treatment options for **Ulverative Colitis & Chron's Disease?**
* Supplementation
* Mesalazine (anti-inflamm)
* Corticosteroids
* Cyclosporine & Infliximab in severe cases
*
41
IBS treatment:
* Diet change (avoid insoluble fiber in
* Anti-diarrheals (**Loperamide**)
* **Dicyclomin** (anti-spasmodic)
* **Amitriptyline** (tricyclic AD)
42
Diagnosis of IBS
Generally young women (20s) (rule out cancer in older pts)
at least 6 months of recurrent abdominal pain for 3days/month in last 3 months associated with 2+ of:
1. improvement with defecation
2. onset assoc w/change in frequency of stool
3. Onset assoc w/change in appearance of stool
43
What is:
1. Hematemesis
2. Melena
3. Hematemesis AND Melena?!?!?!
4. Hematochezia
5. Occult Blood Test
1. Blood in vomit
2. Black tarry stools due to blood
→ intestinal enzymes & bacteria acting on blood (\>60mL for 10-14h)
3. Both → Upper GI hemorrhage
4. Red blood from rectum (\>1000mL blood loss)
5. Occult blood test: (+) = \>1mL, \<60mL blood
44
Where is the bleeding?
1. Bright red blood streaks on stool
2. Bright red within stool
3. Maroon
4. Melena
1. Rectum, anal canal, lower sigmoid
2. Left colon
3. Right colon / Small intestine
4. Upper GI
45
Features of Acute Severe Bleeding
* SOB, dizziness, fainting
* Crampy abdominal pain, diarrhea
* Anemia 1-3 days *later*
\>500mL loss → systemic signs
20%-40% → orthostatic hypotension
\>40% → shock → flat JVP, _supine_ hyptoension
46
Causes of Severe GI Bleed
* Rupture of esophageal varices
* Peptic ulcer disease (→ torrential hemorrhage)
* Diverticulitis
* Amylodysplasia
* Ischemic colitis → ↓ blood to splenic flexure → mucus membrane sloughs off
* _Meckel's Diverticulum_ (40-50% cases, Patent artery = source of bleed)
47
Features of Chronic Bleeding
* Weakness, fainting
* Fatigue, lethargy
* SOB
* Anemia
If Hb is low, do CBC--
* NO ↑ Reticulocytes if *bone marrow depletion* or *Fe defx anemia.*
48
Causes of Upper GI Hemorrhage
Common:
* Peptic ulcer
* Erosive gastritis, esophagitis
* Esophageal variceal rupture
* Mallory-weiss
Less common:
* esophageal / gastric cancer
* Duodenal, diverticular, hemobilia (mix bile & blood due to injury to liver)
* Arteroenteric fistula (communication bt/w aorta & enterics after removal of AAA)
49
**Posterior duodenal** ulcers can perforate to **pancreas** and erode __________ artery?
Gastroduodenal
( Anterior ulcers perforate more frequently )
50
Blood vessel visible in gastric ulcer
**EMERGENCY SURGERY!!!**
may rebleed in 1-2y
Upper GI endoscopy is both diagnostic & therapeutic
51
Benign Gastric Antral Ulcer
1. Small
2. Mucosa surrounding base-- NOT swollen
3. Rugae extend to BASE
4. REPEAT BIOPSIES! to confirm not bleeding & benign, every 6mo
52
Malignant Gastric Ulcer
Difficult to differentiate from benign
Biopsy edge of non-healing ulcer
Most are near **gastroesophageal junction**
53
Esophageal Varices
* Pressure buildup of L Gastric vein
* In submucosal layer of esophagus
→ torrential hemorrhage if rupture
54
Ruptured Esophageal Varices
* Stop bleeding in ER!
* Urgent endoscopy-- confirm Dx then transfuse or ressucitate pt
* Intubate to protect airway
55
Management of Ruptured Varices
IV Octreotide / terlipress, balloon tamponade if bleeding cont.
If rebleed - repeat tx; if not - B-blocker to prevent
56
Mallory Weiss
Alcoholic, middle-aged men
**INITIAL vomitus has NO blood
2-3 vomits later = bloody**
Gastric mucosa moves into LES via a-peristalsis during vomiting → ischemia → bleeding!!
Tx: ressuscitate, stop vomit, endoscopy to confirm
57
Gastric Cancer
* Growth in pre-pyloric region
* non-specific sx early on
* later, when symptomatic, it has probably metastasized and has a poor prognosis :(
* indegestion, burning sensation
* anorexia
* severe bleed @ late stage
Tx: radical surgery, Chemo, radio adjuvant
58
Gastric Cancer-- late symptoms
1. Kruckenberg
2. Blumer's Shelf
3. Sister Joseph's Nodule
4. Virchow's Node
5. Trosseau's Sign
1. Spread to ovary
2. Can palpate mass in rectouterine/rectovesicular pouch
3. Tumor spread to umbilicus
4. Supraclavicular LN
5. Venous thrombosis & hypercoaguabiltiy where clots form, resolve, & form elsewhere *(fleeting thrombophlebitis)*
59
Lower GI Bleed causes
* MCC: Piles/Hemmorhoids
* Hematochezia
* Fecal occult blood
* Anemia (of chronic dz)
* Hemorrhoids: dilation & tortuosity of anal canal veins
* Infectious diarrhea
* Anal fissure/fistula
* Proctitis secondary to radiation
* Colon cancer
* Angiodysplasia
* Meckel's
* Diverticular disease
60
Anal fissure
MC position @ 6:00 (40%)
painful- don't wanna poo -- severe constipation
Tx: relax sphincter spasm (Ca2+ blocker, B-blocker)
\*heal spontaneously
61
Anal Fistula
Abnormal communication between hollow organ/skin, or Hollow organ/hollow organ
MC = subcutaneous type (good prognosis)
Bad prognosis: intersphincteric, transphincteric, suprasphincteric, extrasphincteric :(
62
Colonoscopy
Both diagnostic & therapeutic
Colonoscopic snare is used to remove colonic polyps
63
1. Angiodysplasia
2. Gold standard for detection of colorectal cancer
1. Due to *AV malformation*-- causes torrential bleeds!!
2. Do **total colonoscopy** to detect colorectal cancer
64
Management of Lower GI Bleed
* Stabilize
* Rule out Upper GI bleed (esophagogastroduodenoscopy)
* Lower GI Dx of choice - selective mesenteric angiography
* Can use to embolize
* Surgery
65
Colon Cancer
@ LEFT colon (more common)
* Collicky pain (constant pain = advanced dz)
* Change in bowel habits
* Rectal bleeds, diarrhea
* Palpable lump @ sigmoid colon
@ RIGHT colon
* anemia, weakness, abdominal lump (LRQ)
* \*obstruction unlikely
66
_Apple Core appearance_ on barium enema = **carcinoma of sigmoid colon**
\*\*most common site of colon malignancy is the rectosigmoid junction-- more exposed to carcinogens\*\*
67
Innervation of : Longitudinal muscle | Circular muscle | Submucosa
Vagus n.
Auerbach / Myenteric Plexus
Meisssner's Plexus
68
Stages of swallowing
1. Oral phase (voluntary)
2. Pharyngeal phase (involuntary)
3. Esophageal phase (involuntary)
69
Motor Dysphagia
* Neuromscular abnormalities
* Sjögren's
* Sensory loss
* Striated muscle disorder (MG, ALS, polio..)
70
Mechanical Esophageal Dysphagia
* Damage to esophagus proper (rings & webs, tumor, compression)
* Large bolus, epiglottitis, pharyngitis
* Plummer-Vinson Syndrome (esophageal webs + Fe defx anemia in post-menopausal women)
* Schatzki's Rings (narrow of lower esophagus)
* Strictures & tumors
71
Dysphagia + fever, foul breath, sore throat = ?
Retropharyngeal Abscess
72
Dysphagia + chest pain radiating thru to back = ?
Esophageal cancer
-risk factors: family hx, alcohol/smoking
73
Esophageal stenosis
- barium trickling down after narrowed area
74
**bird's beak appearance** of the gastroesophageal junction and total aperistalsis of the esophageal body consistent with the diagnosis of **_achalasia_**.
75
This is the esophagogram from a patient who experienced **progressive solid-food dysphagia** for several months. He also experienced a **20-pound weight loss** during that same period.
Esophagogram showed a **malignant neoplasm** involving the esophagus.
76
high-grade, smooth-walled distal esophageal stricture that resulted from reflux esophagitis
**heartburn** + dysphagia. T**he dysphagia is for solids and not liquids,** indicating the presence of a *lumen-narrowing lesion*.
* NO anorexia or weight loss and slow rate of progression of dysphagia -- benign peptic process.
* Presence of anorexia and weight loss and rapid progression of dysphagia -- malignant and most likely an adenocarcinoma arising in a Barrett's esophagus
77
Scleroderma
78
GERD Pathway
* Initial esophageal lesion
* --\> Scar
* --\> Incompetent LES
* --\> Reflux - recurrent injury -------\> Scar (restart cycle) OR
* Stricture, Pan, Obstruction, Perforation
* Barrett's Esophagus
* -\> Cancer
79
Screening of Barrett's pts
Patients with Barrett's esophagus should get a surveillance endoscopy _every 3 years_ to check for **adenocarcenoma**
80
81
Respiratory Symptoms of **Tracheoesophageal Fistula**
\*\*Asymptomatic at birth\*\*
* Excessive drooling
* Aspiration -- distress, atelectasis, pneumonia
* Cyanosis 2ry to coughing/choking
82
**Tracheoesophageal Fistual:** gastric presentation
* **Gastric distention** since respiratory status is compromised because inhaled air goes into the *abdomen*, causing **pulmonary compression** (--\> cause of death)
83
**Tracheoesophageal Fistula:** presentation
* @ first few hours of life: hypersecretion, choking, cyanosis, respiratory distress
* TEF @ _distal_ esophagus (esophageal atresia): NO gaseous distention!
84
Tracheoesophageal Fistula: Investigation
* Catheter in nose-- see how far it goes.
* inject dye and take X-ray-- is there a blind pouch?
* (Follow w/ aspiration of medium so it doesn't get into lungs)
* Abdominal Distention
* Bronchoscopy (abnormal communication) + esophaguscopy (blind puch)
* Echo for heart defect (TOF, VSD)
* Look @ aortic arch: if on right, then consider L thoracotomy
85
**Tracheoesophageal Fistula:** associated abnormalities
**V**ertebral
**A**nal
_**C**ardiac_
**T**EF
_**R**enal_
**L**imp
\*\***polyhydramnios** in prenatal ultrasound
86
**Tracheoesophageal Fistula**: treatment
* IV abx, parenteral nutrition
* Reconstruction of air & food passage
87
**Pyloric Stenosis**
* Congenital hypertrophy of muscles
2\* to healing duodenal ulcer
Gastric malignancy
* Distended stomach, **projectile vomit (non billious)**
* NOT present @ birth-- usually @ 2-8w
\>3mo is unlikely
* **Olive-shaped lump** in upper abdomen after feeding
88
**Pyloric Stenosis**: investigations
**ULTRASOUND!!!!** + Hx & Physical
89
**Pyloric Stenosis**: Treatment
* Correct fluid, electrolyte abnormality
* Hypochloremic metabolic acidosis & dehydration control
* NO oral feeding
* Pylorotomy
90
Familial Adenomatous Polyposis
* AD mutation APC
* Need \<100 polyps
* Adenoma by 15y
* 100% will get adenocarcinoma by 30y
* May have rectal bleeding, anemia
\*R/O Upper GI probs since assoc w/ gastric, pancreatic cancer @ young age, plus extra-intestinal manifestations
91
**FAP:** Tx
Removal of Polyp-bearing area of colon
**_GOLD STANDARD:_ Remove entire rectum & colon!!!! (can be dangerous)**
92
**Peutz-Jegher's Syndrome**
* AD
* Polyps in small intestine
* Hemorrhage, intestinal obstruction, intussception (emergency!)
* FRECKLES ON LIP/GINGIVA -- fades w/age
* Associated with pancreas, lung, breast, ovarian cancer
* Malignancy unlikely to derive directly from PJS
93
Necrotizing Enterocolitis
One of MC surgical emergencies in neonates
Necrosis of colon & intestine in neonate (\<1mo) - immature immunity
Infections cause ulceration & necrosis
- -\> enterocolitis, hemorrhage, perforation
- -\> peritoneal contamination w/ fecal biota --\> sepsis --\> death :(
94
**Necrotizing Enterocolitis**: Clinical Features
* **GAS UNDER DIAPHRAGM due to perforation**
* Poor feeding, **bilious** vomit, abd distension, blood in stool
* Diarrhea after milk ingestion due to disaccharide defx
* Sepsis
* Tender abdomen, periumbilical darkening/erythema
95
What is **Pneumatosis intestinalis?**
**Necrotizing Enterocolitis:** tx
1. Pneumatosis intestinalis = gas in wall of intestine 2\* to necrotizing enterocolitis
2. Tx: Surgery, NOTHING BY MOUTH (parenteral nutrition), IV Abx, aspirate stomach
96
**Meckel's Diverticulum**
**TRUE diverticulum**
Common (2%), asymptomatic
Vitelline duct does not obliterate!
RULE OF 2s
* 2% have it
* 2" in length
* 2 ft prox of ileocecal junction
* 1/2 present before 2y
* 1/2 made up of 2 epithelia (1/2 gastric)
97
Meckel's Diverticulum: Clinical Signs
* Hemorrhage
* Intussception
* Inflammation
* Chronic Peptic Ulcer
* Intestinal Obstruction
MCC rectal bleeding in children-- maroon hematochezia
98
Meckel's Diverticulum:
Diagnosis
Treatment
Management
Good prognosis
Diagnosis:
* DRE with maroon blood W/IN stool
* **Radioactive Technicium Scan** (accurate)
Treatment:
* Symptomatic -- RESECT
* Silent & found incidentally-- leave it UNLESS \*narrow mouth, \*thick-walled
99
**Intussusception**
* MC @ 6-8mo
* Telescopic invagination of 1 part of gut to distal part
* Elderly: occurs 2\* to colonic polps
* Due to change in food habit --\> infx --\> swollen Peyer's patches --\> bridge for intussusception
* Swollen lymphatic vessels follow due to compression
* decreased blood flow to affected intestine
100
**Intussusception**: presentation
* MC @ 6-8mo; MCC intestinal obstruction between 3-6y
* Colicky abdominal pain
* **Red-currant Jelly stool** (blood + mucus- no fecal matter)
* _Bilious_ vomit
* Episodes of screaming & drawing up legs
* Sausage-shaped mass; empty R iliac fossa
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Intussusception: **Treatment**
* IV fluid + resusscitation
* NOTHING by mouth
* IV abx if infx or gangrene
* **_DO NOT OPERATE_**
* BARIUM ENEMA: diagnosis & therapy
* pressure pushes up intussusception & frees it
*Only do surgery IF*: barium enema doesn't work, recurrent, secondary to malignancy, unstable pt
102
**Cystic Fibrosis:**
First sign
Complications
Tx
Management
* First sign: **meconium ileus-** normally, pancreatic enzymes keep meconium liquid--
* in CF, it is dry and causes intestinal obstruction @ terminal ileum
* Complication: perforation, volvolus (axial rotation)
* Tx: Hyperosmolar gastrogratin enema- absorbs water from wall -\> relief of obstruction
* Management: Supplement Vit KADE, feed via ng tube or gastrostomy tube
103
**Celiac Disease**
* infants & elderly
* T-cell mediated Hypersensitive reaction to whet protein (anti-gliadin, anit-endomysial abs)
* Death of epithelial cells in upper intestine -- Malabsorption
Present with: abd pain, bloating, steatorrhea, weight loss
104
**Celiac Disease:** Investigation
Endoscopic small bowel biopsy
* Atrophy of villi
* Intraepithelial lymphocytes
* migration of activated lymphocytes to tip of intestinal villi
105
**Celiac Disease**: Tx
* Avoid proteins pt is allergic to (**prolamins- glaidin & gultenins**)
* Steroids (if that doesn't work, use steroid + immunosuppressant)
* Complications: anemia, lactose intolerance, GI lymphoma, etc)
106
**Hereditary Spherocytosis**
* Weak RBC membrane due to decreased **spectrin**
* **Na+ influx**
* Swollen cell = **spherocyte**
* Fragile cell membrane
* Macrophages in spleen destroy them --\> excessive hemolysis
107
**Hereditary Spherocytosis:**
presentation, diagnosis, management
Presentation:
* Anemia
* Gallstones, Jaundice
* Splenomegaly
* Unconjugated Billirubinemia
Diagnosis: RBC fragility test, Flow Cytometry w/ EMA
Management: Asymptomatic - leave alone; Symptomatic - splenectomy
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109
110
Patient with **TRAUMA** and **5L** of **200 mOsm/kg** urine per day and *undetectable ADH*
Dx?
**Central Diabetes Insipidus-**- post-traumatic polyuria (water diuresis)
111
Middle-aged woman with breast cancer. Polyuria. What do you think of?
**Central Diabetes Insipidus**
Breast cancer commonly metastasizes to pituitary, causing Centra DI
112
Patient with Water Diuresis:
What test needs to be run to distinguish between Central and Nephrogenic Diabetes Insipidus?
_Water Deprivation Test_
increased osmolality = CDI
no change = NDI
113
**Central Diabetes Isipidus:**
S/S
Causes
1. S/S:
- Polyuria + polydypsia
- Abrupt onset
- Near normal or mildly elevated Serum Na+
2. Causes
1. 75% idipathic
2. Neurosurgical
3. Head trauma
4. Ischemic encephalopathy or hypoxia
5. Neoplasm
6. Misc. (pregnancy)
114
Nephrogenic Diabetes Insipidus:
S/S
Causes
1. S/S: *Gradual* onset of polyura + polydypsia
2. Causes:
* *Acquired*: Chronic Renal dis, electrolyte disorders, drugs (lithium)
* *Congenital/Hereditary*: Polycystic Kidney, Medullary Cystic Dis
115
Causes of **Water Diuresis**?
Lack of urine concentration from...
* Pituitary diabetes insipidus (ADH deficiency)-- central diabetes insipidus
* Primary polydypsia
* Neprogenic Diabetes Insipidus (renal resistance to vasopressin)
116
What is **Diabetes Insipidus?**
Excessive water loss & inability of kidney to concentrate urine due to
* ADH deficiency (central DI)
* Renal resistance to ADH (nephrogenic DI)
117
**Primary polydypsia**
S/S
Causes
Labs
* Polyuria + polydypsia
* Causes
* Psych disorder (irregular water consumption)
* Hypothalamic disorder (sarcoidosis)
* Labs:
* Na+: normal or mildly decreased
* rare caes of lethal hyponatremia
* After WTD- urine osmolality = 600-800 mOsmol
* After dDAVP inhalation: \<10% increase of urine osmolality
118
Blue: normal
Green: Primary Polydypsia
Orange: Partial Central Diabetes Insipidus
Light Blue: Complete Central Diabetes Insipidus
Purple: Nephrogenic Diabetes Insipidus
119
Patient who is a smoker, small cell carcinoma, gained weight.
Highly concentrated urine, low volume.
SIADH - paraneoplastic
120
What are the serum & urine lab values of SIADH?
* Serum Na+: very low
* Serum osmolality: low (normal = 285-295 mOsm/kg)
* Urine output: low (oliguria)
* Urine Osmolality: HIGH
121
