gold standard for dx. kidney stones in someone who presents with unilateral flank pain
non-contrast helical CT scan
acute abdomen
sudden and severe abdominal pain less than 24 hours in duration
next best step in pt presenting with acute abdomen
chest XR
supine and upright abdominal radiographs - to exclude bowel obstruction or perforation
what is definitive diagnostic test for acute abdominal pain?
abdominal CT scan
elderly man presents with severe back pain with syncope followed by abdominal discomfort - dx?
ruptured aortic aneurysm
- medical emergency
what diagnostic test should be performed in someone suspected of having ruptured aortic aneurysm
CT scan followed by surgery
patient presents with fever, crampy abdominal pain (LLQ) and an associated change in bowel habits; labs show leukocytosis - dx?
diverticulitis
Rome III criteria
atleast two of:
- pain releived with defecation
- onset assoc. w/ change in stool frequency
- onset assoc. w/ change in consistency of stool
alarm symptoms
older age male sex nocturnal awakening rectal bleeding weight loss family history of colon cancer
tx. of constipation-predom IBS in a pt whom fibre supplements did not work
reassurance and polyethylene glycol
an elderly patient with known atherosclerotic disease presents with rapid onset, severe abdominal pain or tenderness; she also notes bright red rectal bleeding and diarrhea - what test should you do? what will you find? and what is diagnosis?
do CT scan abdomen
dx. ischemic colitis
- will show segmental thickening of bowel wall
how do you establish diagnosis of ischemic colitis?
colonscopy - patchy segmental ulcerations (in pt with compatible history)
patient presents with signs/symptoms of acute diverticulitis - what imaging/diagnostic test should you do?
contrast-enhanced CT scan of abdomen and pelvis
- confirms diagnosis as well as evaluates for any complications
what two tests should be avoided in suspected acute diverticulitis?
colonscopy
barium enema
- both pose risk of perforation with air insufflation
complications of diverticulitis
obstruction
perforation
abscess
fistulas
chronic alcoholic patient presents with chronic upper abdominal pain radiating to the back, diabetes and steatorrhea - what do you consider?
chronic pancreatitis
how do you confirm dx of chronic pancreatitis?
calcififcations on plain films or CT scan
patient presents with pain, fever and jaundice; there is also elevation of pancreatic enzymes in the setting of biliary obstruction…
acute cholangitis
diagnostic criteria of HUS
thrombocytopenia
microangiopathic hemolytic anemia (schistocytes, elevated reticulocytes, elevated LDH)
tx. of HUS
supportive with fluids and monitoring of electrolytes and blood counts
- packed RBC is anemia is severe
- antibiotics and platelets are not recommeneded
patient presents with diarrhea and tenesmus; she recently underwent chemotherapy and radiation for rectal cancer - dx?
radiation proctitis
- develops within 6 weeks after tx and resolves on its own usually
how do you diagnose radiation proctitis?
flexible sigmoidoscopy
- mucosal telengiectasias
- submucosal fibrosis
- arteriole endarteritis
when does stool osmolality test come in handy?
when you want to distinguish osmotic diarrhea from secretory diarrhea - ie. in pts having factitious diarrhea (low stool osmolality)
how does malabsorption present in chronic pancreatitis?
diarrhea, steatorrhea
weight loss
deficiency in fat soluble vitamins
definitive diagnostic test for chronic pancreatitis
abdominal CT scan
tx. of severe CDI with colitis
oral vancomycin
IV metronidazole
Tx. of ischemic colitis
IV fluids and bowel rest
- symptoms resolve w/in 48 hrs
what patients with salmonella gastroenteritis should receive antibiotic therapy?
- pts < 2y yo or > 50 yo
- pts with severe illness - toxicity/bacteremia
- pts with atherosclerotic plaques, endovascular or bone prosthesis - seeding
- immunocompromised pts
what drugs should be avoided in pts with infectious diarrhea (fever, bloody stools, systemic toxicity)
bowel paralytics such as loperamide
how do you diagnose hepatocellular injury?
elevation of ALT (more specific )and AST
direct (CB) hyperbilirubinemia > 50%
how do you diagnose cholestatic injury?
elevation of ALP (minimal elevations of ALT and AST)
first step to evaluate cholestatic pattern of injury?
USG - determine if intrahepatic or extrahepatic biliary obstruction is present
how do you diagnose non-hepatic injury such as muscle injury?
striking elevations of AST (less ALT)
no assoc. elevation of CB
incidental finding of indirect (UCB) hyperbilirubinemia in an asymptomatic patient, with normal Hb and LFTs - dx?
Gilbert’s syndrome
Gilbert’s syndrome
total bilirubin conc. up to 3.0 mg/dL resulting from a reduced expression of enzyme that conjugates bilirubin
lab findings in pts with hemolysis
UCB high
low Hb level, low MCV and high RDW
cholestatic dz due to OCP
CB high
elevated ALP
ERCP with sphincerterectomy is recommended for…
pts with biliary obstruction due to choledocholithiasis
definitive tx. for pts with symptomatic gallstone disease
laparoscopic cholecystectomy
chronic cholestatic disease, associated with IBD, characterized by fibrosis, inflammation and stricturing of the biliary tree
primary sclerosing cholangitis
dx. of primary sclerosing cholangitis
elevated ALP
dx. ERCP - take biopsy, place stent if needed
patient presents with history of pain that radiates to right shoulder, Murphy sign, fever, leukocytosis, mild elevation in LFTs - what diagnostic test should you do?
USG - to dx. acute cholecystitis: will reveal gallstones, pericholecystic fluid and thickened gallbladder wall
patient presents with fever, jaundice and RUQ pain; on USG there is bile duct dilation and gallstones in gallbladder - dx?
acute cholangitis
Tx. of acute cholangitis
broad spectrum empiric antibiotics
ERCP with sphincterectomy to remove impacted stones
how do you confirm diagnosis of acute pancreatitis?
serum conc. of amylase and lipase at least 3x the upper limit of normal
next steps in someone with elevated pancreatic enzymes and suspected acute pancreatitis?
abdominal USG - to detect cholelithiasis
ERCP - pts with evidence of gallstone pancreatitis and suspected biliary obstruction
preferred immediate intervention for removing obstructing stones in acute pancreatitis
ERCP w/ spincterectomy and stone extraction
preferred route for providing nutrition in patients with severe acute pancreatitis
enteral feeding w/ nasojejunal tube
tx. of pancreatic necrosis
imipenem
- antibiotics should only be used in this case
surgical debridement
dx. of pancreatic necrosis
contrast enhanced CT scan showing non-enhancing pancreatic tissue
pt presents with burning pain releived by antacids and worsened by lying down/bending forward
GERD
how do you diagnose and confirm GERD in pt absent of alarm symptoms?
trial of PPI
pt with GERD and alarm symptoms, ie. dysphagia - what do you do?
upper endoscopy
gold standard for dx. GERD
ambulatory 24hr pH monitoring
- for pts in whom dx is uncertain or are unresponsive to therapy
Tx of choice for erosive esophagitis
PPI
a pt is found to have a gastric ulcer on endoscopy - what should you do?
biopsy!! - even benign appearing ulcers may harbor malignancy
test of choice for dx. h.pylori
endoscopy with biopsy
triple therapy for h.pylori
PPI
amoxicillin
clarithromycin
2 MCC of peptic ulcer disease
NSAIDs
h.pylori
pt presents with multiple ulcers in unusual locations, severe esophagitis and fat malabsorption - dx?
Zollinger-Ellison
- measure serum gastrin to confirm
indications for upper endscopy in evaluation of dyspepsia
- pt > 55 yo w new onset dyspepsia
- alarm symptoms
functional dyspepsia
chronic or recurrent discomfort in epigastrium w. no organic cause determined
recommended tx. for functional dyspepsia
do a trial of PPI
most accurate method of confirming GERD
ambulatory pH monitoring for 24 hrs
- do if dx is uncertain or GERD therapy is unsuccessful
Cameron lesions
linear gastric ulcers or erosions in a hiatal hernia sac - usually incidental findings but may cause chronic or acute blood loss
what do you do next in someone who had a non-diagnostic Upper EGD and lower endoscopy but it still bleeding?
repeat upper EGD or wireless capsule endoscpy
indications for double balloon endoscopy
- evaluate/tx findings on capsule endoscopy
- evaluation of ongoing bleeding with endoscopic hemostasis needed
- nondiagnostic wireless capsule endoscopy
male, 60 yo, presents with LLQ pain, urgent defecation and red/marroon rectal bleeding; colonscopy shows segmental and hemorrhagic nodules and possible gangrene- dx?
ischemic colitis
therapy of ischemic colitis
IVF
antibiotics - to cover anaerobes and gram neg bacteria
pt presents with abdominal pain out of proportion to the P/E findings; occult (not overt) blood is present
acute mesenteric ischemia
important cause of massive painless lower GI Bleeding in older patients
diverticulosis
pt presents with LLQ pain, fever, leukocytosis; not overt rectal bleeding is seen - dx? what test should you avoid?
diverticulitis
- avoid colonscopy for risk of perforation
first management of choice for upper GI Bleeding
endoscopic intervention
what drug has been shown to reduce the risk of recurrent upper GI bleeding in peptic ulcers after endoscopic hemostasis?
IV omeprazole
when is arteriography useful in management of upper GI Bleeds?
pts with presume arterial bleed as in PUD or tumors of GI tract
- can be used to identify and embolize the vessel
next step after IVF resuscitation in acute variceal bleed?
EGD with band ligation (sclerotherapy as effective)
chronic anal fissures are often accompanied by…
skin tags
recurrent or nonhealing anal fissures should raise concern for…
Crohn’s disease
how do you screen for HCC in a pt with chronic hep B or C or alcoholic liver disease/
USG
how can you diagnose HCC without biopsy?
positive ultrasound results
AFP > 500
antibodies present in autoimmune hepatitis
ANA
anti-sm mm ab’s
anti-LKM1 ab’s
screening test to determine exposure to Hep C virus
anti-HCV antibody
test to determine active Hep C infection
HCV RNA test
highest risk for acquiring hep D
injection drug users with Hep B
who is non-alcoholic steatohepatitis most commonly seen in?
obesity, insulin resistance, HTN, hyperlipidemia, metabolic syndrome
how can you diagnose non-alcoholic steatohepatitis?
patients with characteristic clinical risk factors have mildly elevated serum aminotransferase concentrations; imaging confirms steatosis
a pt with UC presents with significantly elevated ALP levels; he is experiencing pruritus and fatigue - what should you consider?
primary sclerosing cholangitis
- inflammation and fibrosis of intra and extra hepatic bile ducts leading to cirrhosis
how can you tell apart PBC and PSC?
PBC is associated with presence of other autoimmune conditions and most pts have a positive antimitochondrial ab’s assay
serum-to-ascites albumin gradient
subtract the ascitic fluid albumin level from the serum albumin level
SAAG > 1.1 g/dL
indicates portal hypertension -can be due to cirrhosis, RHF or Budd-Chiari syndrome
SAAG < 1.1 g/dL
no portal HTN; it is associated with other conditions such as infection, inflammation and low serum oncotic pressure
inciting events that can precipitate hepatic encepahlopathy in pts with cirrhosis
dehydration - diuretic therapy infection - peritonitis, UTIs diet indiscretions GI bleeding medications
what is the optimal dose of lactulose for tx. of hepatic encephalopathy?
titrated to achieve two-three soft stools per day with a pH < 6.0
kidney failure in pts with portal HTN and normal renal tubular function
hepatorenal syndrome
- must exclude all other causes of renal failure first
most effective tx. for hepatorenal syndrome
liver transplantation
MC cutaneous manifestation of IBD, most common in Crohns
erythema nodosum
MC cutaneous manifestation of UC
pyoderma gangrenosum
pyoderma gangrenosum
neutrophillic, ulcerative skin disease with multiple lesions on lower extremities; begin as tender papules/pustules that ulcerate leaving a purulent base and ragged, violoceaous borders
MC location of rheumatoid nodules
subcutaneous tissue just distal to elbow on extensor surface of forearm
first line therapy for induction and maintenance of remission in UC
mesalamine
tx. of microscopic colitis
loperamide, diphenoxylate, bismuth subsalicylate
