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Gastrointestinal Flashcards

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1
Q

Dysphagia / Odynophagia (PE)

A

Oropharyngeal dysph: prob w/ initiation of swallowing
! aspiration of food, cough, choke, drool
Etiologies: neuro (stroke, Parkins), muscul (myast gr), prol intubat, Zenker divert.
Prob w/ liquids > solids

Esophageal dysph: prob w/ obstruction (strictures, webs, carcinoma) or w/ mobility (achala, scleroderm, spasm)
Obstruction: solids > liquids; Mobility: both

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2
Q

Dysphagia / Odynophagia (dg, ttt)

A
  • Oroph: barium swallow #1; rarely EGD
  • Esoph: EGD #1; barium before if Hx of esoph radiation/stricture (! perforation)
  • Odynophagia: EGD

ttt: cause

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3
Q

Infectious esophagitis

A

Immcomprom

  • Candida alb: oral thrush; fluconazole PO
  • HSV: oral ulcers; acyclovir IV
  • CMV: retinitis, colitis; gancyclovir IV
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4
Q

Diffuse esophageal spasm

A

Peristalsis periodic interrupted by high-amplit nonperistal contractions
Heartburn, chest pain, dysph, odynoph
↑ w/ hot/cold liquids; ↓ w/ nitroglyc

Dg: EGD (r/o structural abNl); barium swal (corkscrew esoph); manometry (definitive test)
ttt: CCB/TCA/nitrates (↓ sympt); if severe, surgery (myotomy)

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5
Q

Achalasia (PE)

A

Impaired relaxation of lower esoph sphincter + loss of peristal in dist 2/3 of esoph (smooth M)
By degeneration of inhib neurons in Auerbach plex

Progress dysph, chest pain, regurg undigest food, ↓weight, noctur cough

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6
Q

Achalasia (dg, ttt)

A 
Dg: EGD (r/o structural abNl) (cancer causes pseudoachal)
Barium swal (dilation w/ bird's beak); manometry (definitive test)

ttt: short-term (nitrates, CCB, endosc inject botulinum toxin in LES); long-term (balloon dilation or surg myotomy)

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7
Q

Esophageal diverticula

A

Zenker: false divert; cervical outpouch in cricopharyng muscle; post
Chest pain, dysph, halitosis, regurg undigest food

Dg: barium swal
ttt: surg excision if sympt; myotomy of cricoph for Zenker

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8
Q

Esophageal cancer

A 
#1 world: squamous cell carcinoma (RF: alcohol, tobacco, nitrosamines); up 2/3
#1 (US/EU/AUS): adenocarcinoma (RF: Barrett esoph); down 1/3

Progr dysph, ↓weight, odynoph, GERD, GI bld, vomit
Dg: barium (narrow, irreg border); EGD+biopsy (confirm dg); CT+echoendo (stage)
ttt: chemoradiation + surgical resec
Early metast: poor pg

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9
Q

Gastroesophageal reflux disease (PE, dg)

A

Transient LES relaxation; incompet LES; gastroparesis; hiatal hernia
Heartburn 30-90min after meal, ↑reclining, ↓antacids/sit; globus sensat; morning hoars, chest pain (!CAD)

Dg: clinical (+ empiric ttt)
EGD+biopsy if refract, long-stand (r/o Barrett, adenoK), alarm sympt (bld, ↓weight, dysph/odynoph)
24h pH monitor (definitive if uncertain)
Other (barium, manometry)

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10
Q

Gastroesophageal reflux disease (complic, ttt)

A

Complic: erosive esoph, esoph peptic stricture, aspir pneum, up GI bld, Barrett esoph

ttt: lifestyle (↓weight, head elev, small meals, no noct meals, avoid alcoh/choc/coff)
Mild/intermitt: antacids
Chronic/fqt: H2 recept antag, PPI
Severe/erosive: PPI; if refract, surgery (fundoplication)

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11
Q

Hiatal hernia

A
  • Sliding HH: 95%; GEjunct+part of stom abov diaph; asympt or GERD
  • Paraesoph HH: 5%; GEjunct below diaph; fundus above; strangulation
  • Mixed HH: rare

Dg: incident on CXR; barium swal or EGD
ttt: sliding (lifestyle+drug to ↓GERD); paraesoph (surg gastropexy)

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12
Q

Gastritis (etiologies)

A

Acute: rapid, superf; by NSAID, alcoh, H pylori, stress (burns/CNS injury)

Chronic: A(10%) in fundus, autoAb to parietal cells, pernic anem, ↑R of adenoK+carcinoid tum
B(90%) in antrum, by NSAIDs or H pylori, ↑R peptic ulcer ds and gastric cancer

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13
Q

Gastritis (PE, ttt)

A

Asympt or epig pain, N/V, hematem, melena

ttt: stop exacerb agent; antacids/sucralfate/H2 recept block/PPI
H pylori: amoxic+clarithrom+omepraz (metronid if All to amoxi)
PPI prophyl if R stress ulcers

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14
Q

H pylori (dg)

A

! H pylori does not always cause gastritis

Serology: IgG (screen); ⊕ if cured or active
Urea breath T: ammonia (urease=urea to CO2+NH3); PPI may false⊖; to see if cured
Stool Ag T: initial T + to see if cured
Endoscopic biopsy: histo/culture + detect intest metapl, MALT, widespr gastritis; Gold stand but invasive

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15
Q

Gastric cancer (RF)

A

Esp adenocarcinoma
Common in Korea, Japan

RF: diet w/ ↑nitrites+salt and ↓fresh vegetables; H pylori coloniz; chronic gastritis; pernicious An

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16
Q

Gastric cancer (PE, dg, ttt)

A

Early: asympt; ass w/ indigest, ↓appetite
Late: abdo pain, ↓weight, upper GI bld; Virchow node

Dg: upper endosc + biopsy
ttt: if early, surg resect; if late, incurable
Poor pg: <10% surv in 5y if adv

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17
Q

Only malignancy cured w/ antibiotics

A

MALT lymphoma
Ass w/ chronic H pylori inf
ttt: triple therapy

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18
Q

Peptic ulcer disease (RF; PE)

A

Damage to gastric or duod mucosa
↓ mucosal defense or ↑ acid
RF: H pylori (>90% duod; 70% gastric), NSAIDs, Alcoh, tobacco; CS+NSAIDs; male>fem

Chron/period dull, burn, epig pain; nausea; hematem; hematochez
Pain ↑w/ meal if gastr ulc and ↓w/ meal if duod ulc

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19
Q

Peptic ulcer disease (dg, complications)

A

Dg: Upright KUB or CT (if perfor suspect); upper endosc w/ biop; H pylori test; gastrin level (Zol-Ell sd)

Complic: hge (post ulcer erode gastroduodenal art); gastr outlet obstruct; perforation; intract pain
All gastric ulc biopsied to r/o cancer

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20
Q

Peptic ulcer disease (ttt)

A

Acute: surg if perfor confirmed (AXR/CT)
R/o activ bld (Ht, DRE, NG lavage), monit BP + give IV fluids/bld transf/IV PPI, urgent EGD

Long-term: antacids, PPI, H2 blockers (mild ds)
Triple therapy (H pylori)
Stop exacerb agents
If refractory, EGD w/ biopsy (r/o adenoK) or surgery

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21
Q

Zollinger-Ellison syndrome (PE)

A

Gastrin-prod tumor; ass w/ MEN1 (20%)
In duodenum and/or pancreas
↑ gastr acid; recurrent intract ulcers

Unresp, recurr, burn abdo pain; diarrhea; N/V; fatigue; ↓weight; GI bld

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22
Q

Zollinger-Ellison syndrome (dg, ttt)

A

Dg: ↑fasting serum gastrin + ↑gastrin w/ secretin admin
CT for staging

ttt: moder/high-dose PPI; surg resect

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23
Q

Diarrhea (etiologies)

A

> 200g feces/day w/ ↑fqcy or ↑liquidity
Etiologies: malabsorption, maldigestive/osmotic, secretory, inflammatory/infectious, ↑motility

Acute D: < 2wks; inf and self-limit; pediat (rotaV, norwalk V, enteroV)
Chronic D: > 4wks; secretory (carcinoid T, VIPoma); malabs/maldig (bact overgrowth, pancr insuff, mucos dam, lacto intol, celiac ds, laxativ abuse, postsurg short bow sd); infl/inf (IBD); ↑motility (IBS)

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24
Q

Diarrhea (dg)

A

Acute: no tests unless high fever/bloody D/ >4-5d
Chronic: stool analysis (WBCs, culture, C diff toxin, ova, parasite); sigmoidoscopy (bld D w/o dg)

ttt: acute (hydration; AB just if Cdiff or epidemy; antidiarrheal only if No high fever + No bloody D)
Chronic: ttt etiology

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25
Diarrhea caused by Campylobacter
``` #1 bacterial cause of D Contaminated food/water Bloody D R/o appendicitis; IBD ttt: supportive #1, then fluoroqu or azithrom ```
26
Diarrhea caused by Clostridium difficile
Ass w/ AB (penic, quinol, clindamyc) AXR (toxic megacolon) Toxin in stool; pseudomembr on sigmoidosc ttt: Stop the cause; PO metronid (mild); PO vancom (mod-sev); IV metronid (ileus)
27
Diarrhea caused by Entamoeba histolytica
``` Contaminated foor/water (develop country) Incubation ≤ 3mo Flask shaped ulcers (colono) R/o IBD ttt: metronid ```
28
Diarrhea caused by E coli O157:H7
Contaminated raw meat R/o GI bld, ischem colitis Complic: HUS ttt: Nothing; avoid AB or antidiarrheal bcz ↑R of HUS
29
Diarrhea caused by Salmonella
Contaminated poultry/eggs ! sepsis; ! osteomyel in SCD ttt: fluids; if high risk PO quinolone or TMP-SMX
30
Diarrhea caused by Shigella
! Contagious; fecal-oral route Complic: severe dehydr; febrile seizures ttt: TMP-SMX
31
Malabsorption / maldigestion (etiologies, PE)
Inability to absorb macro/micronutrients - Mucosal abNl: celiac ds, Whipple ds, tropical sprue - Bile salt def: ileal ds, bacterial overgrowth Carb malabs: frequent, loose, watery stools Fat maldigest: pale, foul-smell, bulky stools + abdo pain, flatus, bloat, ↓weight, nutritional def, fatigue
32
Malabsorption / maldigestion (dg, ttt)
Dg: lab tests Biopsy is definitive ttt: etiology If severe: TPN, immunosuppressants, anti-inflam
33
Lactose intolerance
Lactase def African/Asian/Native Amer; after acute gastroenteritis After milk: abdo bloat; flatus, cramp, watery D Dg: empiric ttt lactose-free diet; Hydrogen breath test ttt: avoid dairy prod; oral lactase enz
34
Carcinoid syndrome
Before meta, firt-pass metab of serotonin (no sympt) Sd: when weta of carcinoid tumors in ileum, appendix Flushing, diarrhea, abdo cramp, wheezing, right valvular lesion; +niacin def (pellagra) Dg: ↑5-HIAA in urine; CT and octreotide scan ttt: octreotide; surg resect
35
Irritable bowel syndrome
Chron, interm, abdo pain + changes bowel habits; ↓by bowel mvt; mucous stools; ↑by stress No alarm sympt Dg: ≥3d in 3mo of ≥2 (↓w/ defec; change stool fqcy/consist; change stool appear) R/o organic ds; !↑ incid of celiac ds in IBS so r/o ttt: psychological (offer reassur); fiber suppl; exclude gas-food; antispasm; +/-TCA/SSRI
36
Small bowel obstruction (etiologies, PE, #dg)
Partial (yes flatus) or complete (no flatus/stool) Adhesions from surg; hernia; neopl; intuss; gallst ileus; stricture (IBD); volvulus ``` Cramp abdo pain; vomit after pain Distention, tender, scar, hernia, hyperactive perist #dg: LBO, paralytic ileus, gastroenteritis ```
37
Small bowel obstruction (complications, dg, ttt)
Complic: ischem necrosis; rupture if prolong; peritonitis Dg: AXR (no gas); CT (defin); ↑WBCs if isch/necrosis; dehydr/metab alk ttt: fluids; partial (NPO, NG suct, IV hydr, correct e-, Foley to monitor fluid, ↓pain (No opioids/anticholin) Laparotomy (complete obs, isch, necros, refract)
38
Ileus (RF, PE)
Loss of perist w/o obstruction RF: recent surg/proced; severe medic ds, immobil; hypoK; e- imbal; hypothyr; DM; drugs (opiod; anticholin) Diffuse, constant discomf, N/V, No flatus/feces Diffuse tender, distension, ↓/No sounds; DRE to r/o fecal impaction
39
Ileus (dg, ttt)
Dg: AXR (w/ air); CT (defin) ttt: stop cause; ↓oral intake; NG suction; parenteral feeds; correct e-; IV hydration
40
Mesenteric ischemia (etiologies, PE)
Insuff bld to small intest → isch → necrosis - Emboli: from heart (AFib; stasis from ↓EF) - Thrombi: esp in prox SMA (#1 atheroscl) - Other: nonocclus arterial ds (atheroscl, vasospasm), venous thromb (hypercoag), shock Severe abdo pain out of prop to PE; N/V; diarr; bld stools; intest angina (after meals)
41
Mesenteric ischemia (dg, ttt)
Dg: AXR and CT (bowel wall edema + air) Mesenteric/CT angiography (defin): dg +/- intervention Complic: septic shock, multiorg failure, death ttt: volume resuscit; broad-sp AB Art embol/thromb: anticoag + laparotomy or angioplasty Venous thromb: anticoag Surg: infarcted bowel
42
Diverticular disease (RF)
Outpouch mucosa + submucosa through muscularis Esp sigmoid; ↑intraluminal pressure Diverticulosis: many; #1 cause lower GI bld in >40yo Diverticulitis: infl + microperf 2* to fecalith RF: ↓fiber, ↑fat; adv age; connect T disorder
43
Diverticular disease (PE, dg)
D.osis: asympt until painless bld (anemia if severe) D.itis: LLQ abdo pain, fever, N/V; peritonitis (if perf) Dg: ↑WBCs, anemia; CT; colono (def) No colono if acute D.itis
44
Diverticular disease (ttt)
Uncompl: follow-up, ↑fiber D. bleeding: stops spont, transfuse, hydrate If not stopped: hemostasis (colono), emboliz (angiography), surg D.itis: NPO, +/-NG tube, broad AB (metronid + fluoroq or C2G or C3G), colono after acute Perfor: immediate surg resect of bowel part + colostomy
45
Large bowel obstruction (PE, etiologies, #dg)
Constip/Obstip; deep cram abdo pain; feculent N/V ↑distention, tender, high-pitch sounds then no sounds Perfor/peritonitis or isch/necr: fever, shock ``` Colon cancer (until proven otherw/), D.itis, volvulus, fecal impact, benign tumor #dg: SBO, paral ileus, appendic, IBD, pseudo-obstr ```
46
Large bowel obstruction (dg, ttt)
Dg: e-, lactic acid, AXR, CT, water contrast enema; sigmoid/colono if stable ttt: gastrografin enema, colono, rectal tube; surg usually requ.; ttt cause If ischem, partial colectomy w/ colostomy
47
Colorectal cancer (PE, RF)
#2 cancer morta in USA Right-side: bulky, ulcerat mass; anemia; ↓weight,... Left-side: apple-core obstruct mass; change bowel habits, bld in stool Rectal: red bld, tenesmus, rect pain RF: ↑w/ age; FAP (100% by 40yo); HNPCC; fam Hx; UC>Crohn; villous>tubular, sessile>pedunc adeno
48
Colorectal cancer (dg, ttt)
Dg: colono + biopsy (def); check meta (CXR/LFTs/CT) Stage (TNM) ttt: surg resect (#1); adjuv chemoth (if ⊕LN) Follow w/ serial CEA/colono/LFTs/CXR/abdo CT
49
Ischemic colitis (RF, PE)
Insuff bld → isch → necrosis; usual w/ atheroscl Esp left colon; esp watershed area (splenic flexure) Crampy lower abdo pain then bld diarrhea; after meals/heat/exertion Necros: fever, periton signs
50
Ischemic colitis (dg, ttt)
Dg: CT w/ contrast; colono ttt: bowel rest (NPO), IV fluids, broad AB If infarct, fulmin colitis, obstruc: surg resect
51
Screening recommendations for colorectal cancer
No Hx: start 50yo; annual DRE+FOBT; colono/10y or sigmoido/5y 1* relative Hx: colono/5y start 40yo or start 10y prior Ulcerative colitis: colono/1-2y start 8-10y after dg (Crohn: cancer < UC but >general pop)
52
Upper vs lower gastrointestinal bleeding
Hematemesis, hematochezia, melena | Upper vs lower: ligament of Treitz (duod/jej)
53
Upper GI bleeding
Hematem, melena; hypovol Etiologies: PUD; infl eso/gastr; Mallor-W; varices eso/gastr; GAVE; Dieulafoy lesion Dg: NG tube+lavage; endosc (defin) ttt: protect airway; stabilize ptt (fluids/RBCs); endosc; ttt cause
54
Lower GI bleeding
Hematoch>melena Etiologies: D.osis; angiodyspl; IBD; hemorr/fissures; neopl; AVM Dg: sigmoido; colono if stable; arteriography or laparotomy if unstable ttt: protect airway; stabilize ptt (fluids/RBCs); ttt cause; endosc ttt (epineph injec, cauteriz, clip); intra-art vasopressin; emboliz; surg if divertic or angiodyspl
55
Ulcerative colitis (PE)
Rectum; prox extension; continuous Mucosa + submucosa inflam Cramps, bld D; aphthous stomatitis; episcl/uveitis; arthritis; primary scleros cholangitis; eryth nodosum; pyoderma gangr
56
Ulcerative colitis (dg, ttt)
Dg: AXR, stool Cx/O&P/Cdiff; colono (pseudopolyps) Biopsy (defin) ``` ttt: 5-ASA (sulfasal, mesalam); CS (flare-ups); immunomodul (azathiop, inflix) for refract/mod-sev Total proctocolectomy (curative for fulmin col; toxic megac; ↓R cancer) ```
57
Crohn disease (PE)
Any portion og GI (esp ileocecal); discontin Transmural inflam Pain, fever, ↓weight, watery D; fissures; fistules; aphthous stomatitis; episcl/uveitis; arthritis; primary scleros cholangitis; eryth nodosum; pyoderma gangr
58
Crohn disease (dg, ttt)
Dg: AXR, stool Cx/O&P/Cdiff; follow upper GI also Colono (cobblestone, skip lesion); biopsy (defin) ``` ttt: 5-ASA (sulfasal, mesalam); CS (flare-ups); immunomodul (azathiop, inflix) for refract/mod-sev/maint Surg resect (perfor, stricture, fistul, abscess) ```
59
3 types of hernias
Indirect: through external + internal rings; lateral to inf epig Vx; congen patent proces vaginalis Direct: through Hasselb triang; medial to inf epig Vx; break in transvers fascia from age Femoral: below ing ligam through femor canal; ↑abdo pressure, weak pelv floor
60
Hernias (complications, ttt)
Incarceration Strangulation ttt: surgery
61
Cholelithiasis and biliary colic
RF: female, fat, fertile, forty; OCP; rapid ↓weight; chron hemolysis; small bow resect; TPN Asympt or biliary colic (postprand RUQ pain; transient cystic duct block); RUQ tendern; N/V; Nl total bili/ALP/amyl Dg: RUQ US (defin) ttt: cholecystectomy; no ttt is asympt gallstones
62
Acute cholecystitis
Prolong block of cystic duct (stone); distent/infl/inf of cystic duct; acalculous (in debilitated) RUQ pain+tendern; N/V; fever; Murphy⊕ ↑WBCs; Nl tot bili/ALP/amyl Dg: US; HIDA scan ttt: broad AB + IV fluids + cholecystectomy If ptt too ill, transcut drain of GB
63
Choledocholithiasis
Stone in comm bile duct Sympt vary (degree/duration obstr) Jaundice; RUQ pain/colic; afeb; +/- pancreatitis ↑WBCs; ↑tot bili/ALP; +/-↑amyl/lipase Dg: US (dilat CBD); MRCP and ERCP (defin) ttt: ERCP + sphincterotomy (remov stone) then cholecystectomy
64
Acute cholangitis
Inf of comm bile duct after obstruction (stone; stricture; 1* scler chol; malign) Charcot tri: RUQ pain + fever + jaundice Reynolds pent: Charcot + shock + alter mental status ↑WBCs; ↑tot bili/ALP Dg: US (CBD dilat); ERCP (defin) ttt: ICU (monitor fluid/BP + broad AB); emergent ERCP/sphincterotomy; surg if ptt toxic
65
Gallstone ileus
Mechan obstr (ileocecal valv) from >2.5cm stone Cholecystoduodenal fistula Subacute SBO; esp elderly woman Dg: AXR (SBO/pneumobilia); upper GI barium ttt: laparotomy (stone extract + close fistula + cholecystectomy)
66
Cholestasis
↑ALP + ↑bili Ductal dilation: biliary obstr (stone, stricture, cancer) No duct dilat: intrahep cholestasis (meds, post-op, sepsis)
67
Isolated hyperbilirubenemia
Conjug: defective excretion (Dub-John, Rotor) Unconj: overproduction (hemolytic anemia) or defective conjug (Gilbert <5; Crig-Najjar)
68
Hepatitis (etiologies)
Infl liver → cell injury + necrosis - Acute: viruses or meds/alcohol - Fulminant: acute liv failure; INR>1.5; hep encephalo; w/o underly liv ds -Chronic: chron viral (HCV in USA; HBV in world), alcoh, autoimm, metab (Wilson, hemochrom, alpha1-antitr)
69
Hepatitis (PE)
Acute: nonspecif viral prodrome then jaundice + RUQ tendern HAV/HEV: self-lim acute HBV/HCV: mild acute or asympt Chronic: asympt or fatigue/joint pain 80%HCV + 10%HBV: chronic active hepatitis
70
Hepatitis (dg)
Acute: very ↑AST/ALT + ↑bili/ALP; serology; +/- biopsy Chronic: mild ↑AST/ALT or Nl for >3-6mo Autoimm: ⊕ anti-nuclear and anti-smooth M, ... Ab; ↑IgG; pANCA Hemochrom: ↑ferritin; transf satur >50%; ↑iron Wilson: ↓cerulopl; ↑ur copper; Kay-Flei rings
71
Hepatitis (ttt, complications)
Acute: support; HBV w/ antiviral Chronic: cause; liv transpl (def for end-stage liv failure) HBV: Tenofov/Entecav HCV: meds/duration based on genotype/cirrhosis; 2 direct-acting antiV or 1 DAA+ribavirin. Complic: cirrhosis, portal HTN, liv failure, hepatocell carcinoma (3-5%)
72
Cirrhosis (etiologies)
Chronic hep injury USA: alcoh, chron HCV, NASH Intrahep: all causes of chron hepatitis Extrahep: bili tract ds; posthep like right heart failure, constric pericarditis, Budd-Chiari
73
Cirrhosis (PE)
Asympt or jaundice, easy bruising/coagulop, complic of portal HTN (ascites, hep enceph, GE varices, ↓plts); sympt of ↑estrog (spider nevi, gynecomast, test atrophy) Complic ascites: spont bact peritonitis (>250 PMNs/mL) Large palpable firm liver; anemia, LE edema
74
Cirrhosis (dg, ttt)
↓album; ↑PT/INR; ↑bili ↓plts (2/2 hypersplenism + ↓thrombopoietin) Defin: biopsy (bridging fibrosis + nodular regeneration) Etiol: hepatitis serologies, autoimm markers, ferritin, ceruloplasmin, alpha1-antitrypsin SAAG = serum album - ascites album ttt: ttt+prevent progress; minim factors that decompens
75
Management of ascites and SBP
ttt ascites: Na+ restric, diuretic; paracent; TIPS; underl ds ttt SBP: acute IV AB (C3G); IV album; prophyl fluoroq (for recurr). ! poor 1y pg
76
Hepatorenal syndrome
Acute prerenal failure by splanchnic vasodil ur Na+ <10 Poor pg; liv transpl may cure ttt: volume replet + r/o other causes; octreotide (↓Vxdil); midodrine (↑BP); +/- dialysis
77
Hepatic encephalopathy
↓ clearance ammonia By dehydr, inf, e- abNl, GI bld ttt: lactulose; rifaximin; underl triggers
78
Management of esophageal varices and coagulopathy
Endosc surv in all cirrhosis; prophyl w/ B- or endosc ligation ttt acute bld: endosc w/ ligation or sclerotherapy If refractory, urgent TIPS ttt coag: in acute bld, give FFP (Not vitK)
79
Primary sclerosing cholangitis (RF, PE)
Progr infl + fibrosis Strictures of extrahep + intrahep bile ducts Young men w/ ulcerative colitis Jaundice, pruritus, fatigue ↑R of cholangiocarcinoma
80
Primary sclerosing cholangitis (dg, ttt)
Dg: ↑ALP, ↑bili; MRCP/ERCP (strictures/dilatations) Liv biopsy (periduct sclerosis/onion skin) After dg, !colono to evaluate IBD ttt: ERCP w/ dilation+stenting; liv transplant (defin)
81
Primary biliary cirrhosis
Autoimm; destruction of intrahep bile ducts Middle-age women (w/ other AI ds) Progr jaundice, pruritus, vit ADEK deficit Dg: ↑ALP, ↑bili, ↑cholest, ⊕anti-mitochondrial Ab ttt: ursodeoxycholic acid (slow prog); cholestyramine (↓prurit); liv transplant
82
Non-alcoholic fatty liver disease
Steatosis of hepatocytes; liv injury NASH → liv fibrosis and cirrhosis Ass w/ insul resist and metab sd Dg: of exclusion; biopsy ttt: ↓weight/diet/exo; vitE and pioglitazone
83
Hepatocellular carcinoma (RF, PE)
US RF: cirrhosis (alcoh/HCV/NASH); chron HBV Dev countr RF: HBV, aflatoxins RUQ tendern, abdo dist, jaundice, easy bruis, coagulop, hepatomeg
84
Hepatocellular carcinoma (dg, ttt)
Dg: mass on US/CT; abNl LFTs; ↑AFP; biopsy ttt: surg (partial hepatect) if feasible; liver tranpl (if cirrhosis + few small tumors) non-surg (trans-art chemoemboliz +/- radiofqcy abl); sorafenib (adv meta ds) Monitor AFP and US/CT
85
Hemochromatosis (etiologies, PE)
Iron overload; hemosiderin accum in organs 1*: AR ds, excess absorp dietary iron 2*: in chron transfusion (SCC, alpha-thal) Abdo pain, DM, hypogonad, arthropathy (MCPs), CHF, cirrhosis, hepatomeg, bronze pigm No eff on lung, kidney, eye
86
Hemochromatosis (dg, ttt, complications)
Dg: ↑iron/Sa/ferritin; ↓transferrin; liv biopsy; MRI; HFE mutation screen ttt: phlebotomy/wk then /2-4mo; deferoxamine Complic: cirrhosis, hepatoC carcinoma; restr CM; hypopituit; ...
87
Wilson disease (Hepatolenticular degeneration) (PE)
AR ds; def copper transp → accum in liv/brain At <30yo; 50% sympt at 15yo Hepatitis/cirrhosis, neuro dysf (ataxia/tremor), psy abNl Key-Fle rings, rigidity, choreiform mvts
88
Wilson disease (Hepatolenticular degeneration) (dg, ttt)
Dg: ↓cerulopl; ↑24h urin copper; liv biopsy ttt: penicillamine/trientine (chelators); ↓dietary copper/zinc
89
Insulinoma (PE)
Ass w/ MEN1; benign Hypoglyc w/ Whipple triad (docum hypogly + sympt sweat/palpit/anxiet/tremor/headac/conf + resolution w/ correct hypogly)
90
Insulinoma (dg, ttt)
Dg: ↑fasting insulin, ↑C-peptide Defin test: 72h fasting (profound hypogly) Localize tumor: abdo US/CT/MRI ttt: surg resect
91
VIPoma
VIP tumor; highly malignant Watery diarrhea, dehydration, muscle weak, flushing Dg: ↓stool osm gap; ↑VIP; achlorhydria; hypergly; hyperCa; hypoK; CT scan ttt: fluids + e-; surg resect; octreotide
92
Acute pancreatitis (RF, PE)
Abrupt severe pain RF: gallstones, alcoh abuse, hyperCa, hyperTg, trauma, meds, viral, post-ERCP, scorpion Severe epig pain (to back), N/V, weak, ARDS, ... Grey Turner sign (flank bruise) Cullen sign (periumb discol)
93
Acute pancreatitis (dg, ttt)
Dg: ↑lipase (↑amylase), ↓Ca, AXR (sentinel loop) Abdo US/CT (absc, hge, necros, pseudocyst) ttt: off agent removal; support (IV fluids, e-, analgesia, NPO, NG suct, nutrition+O2) If inf/necrosis: AB
94
Acute pancreatitis (pg, complications)
Pg: 85-90% mild/self-lim; 10-15% severe/ICU w/ 50% morta Complic: pseudocyst, fistula, chronic P, sepsis, renal failure, ARDS
95
Chronic pancreatitis (RF, PE)
Irrev destr → panc dysfct + insuff RF: alcoh abuse, gallstones, CF, smok Persist, recurr epig pain; anorex/N; constip, flatus, steatorrhea, ↓weight, DM
96
Chronic pancreatitis (dg, ttt, complications)
Dg: ↑/Nl lipase/amylase, panc calcific; CT/US (stenosis+dilation) ttt: analges, panc enz replac, avoid cause, celiac N block, endosc dilation P duct, +/- surg Complic: chronic pain, opiate addict, DM, malnutr/↓weight, pancr cancer
97
Pancreatic cancer (RF, PE)
Adenocarcinoma in head P (75%) RF: smok, chron P.itis, K in 1*relative ``` Abdo pain to back, obstr jaund, ↓appet, N/V, ↓weight, fatig, indigest; or asympt Palpable nontender gallbladder (Courvoisier sg) Migratory thrombophlebitis (Trousseau sg) ```
98
Pancreatic cancer (dg, ttt)
CT w/ contr: tumor, local invas, distant meta If not visible, endosc US +/- ERCP ↑CA19-9 ttt: local adv/meta (palliative chemoth, support) Small tum (Whipple proced) Chemoth w/ 5-FU + gemcitabine (short-term surviv) ERCP w/ stent (relieve if obstr sympt)

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