Sx: GERD + dysphagia
Possible developed peptic stricture
Gold std = 24 hr pH monitoring
Endoscopy bx not necessary for uncomplicated cases
Dx aspiration of gastric contents result in PNA
Lipid laden macrophages on bronch
Bloody diarrhea bacteria causes
SECS Salmonela Ecoli Campylobacter Shigella
Diarrhea acid/base disturbance
metabolic acidosis + hypo K
Fecal leukocytes in stool - what do you think of?
Campylobacter Salmonella Shigella E coli C diff
DO NOT give for diarrhea w/ fever of blood in stool
Dx of exclusion
Need sx for 3 mon
change in freq or consistency of stool (diarrhea or constipation)
management of hyperbilirubinemia in the newborn infant at 35 or more weeks gestation
frequent clinical assessment of jaundice
treatment based on the total serum bilirubin level, the infants age in hours, and risk factors.
Phototherapy should not be started based solely on the total serum bilirubin level.
double bubble sign in newborn..what is it?
usually begins during the second week of life and typically occurs in the evening.
characterized by screaming episodes and a distended or tight abdomen.
no abnormalities on physical examination and ancillary studies,
symptoms usually resolve spontaneously around 12 weeks of age.
child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools.
Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition.
Hypertrophic pyloric stenosis
is a narrowing of the pyloric canal caused by hypertrophy of the musculature.
Usually 3rd-5th wks of life
Projectile NON BILIOUS vomiting after feeding, weight loss, and dehydration are common.
US to confirm dx
Usually in 3 months - 5 years
Mostly in males.
intermittent colicky abdominal pain,
bloody, mucous stools
Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as currant jelly.
Dx and Tx: air enema using fluoroscopic guidance
is the most common congenital abnormality of the small intestine.
It is prone to bleeding because it may contain heterotopic gastric mucosa.
Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis.
Eradication of Helicobacter pylori significantly reduces the risk of
ulcer recurrence and rebleeding in patients with duodenal ulcer,
reduces the risk of peptic ulcer development in patients on chronic NSAID therapy.
No effect on GERD
an autoimmune disorder characterized by inflammation of the small bowel wall, blunting of the villi, and resultant malabsorption
Fe deficiency anemia
What is dx for peritonitis?
Next step once diagnosed?
neutrophil count >250/mL
antibiotic therapy should be started immediately without waiting for culture results
GI pathogens resistant to chlorine water
Hep B needle stick. What do youdo?
Vaccinated = test for hep B antibodies
- if ab levels not ok, give HBIG + hep B booster
Unvaccinated = HBIG ASAP + Hep B vaccine series
leading cause of bacterial diarrhea in the U.S.
Tx thrombosed external hemorrhoid
If within 48 hrs onset
- elliptical excision of hemorrhoid
If no pain or > 48 hrs onset
- Sitz baths
- stool softners
- local analgesia
Travelers Diarrhea ppx
Azithromycin for tx
Rifamixin for tx if no blood
Acute gastroenteritis suspected next step is what?
Order stool for fecal leukocytes
Recent reports of epidemics of gastroenteritis on cruise ships are consistent with
Norwalk virus infections due to waterborne or foodborne spread
A 24-year-old white female presents to the office with a 6-month history of abdominal pain. A physical examination, including pelvic and rectal examinations, is normal. Which one of the following would indicate a need for further evaluation?
A. Relief of symptoms with defecation
B. Changes in stool consistency from loose and watery to constipation
C. Passage of mucus with bowel movements
D. Abdominal bloating
E. Worsening of symptoms at night
Irritable bowel syndrome (IBS) is a benign, chronic symptom complex of altered bowel habits and abdominal pain. It is the most common functional disorder of the gastrointestinal tract. The presence of nocturnal symptoms is a red flag which should alert the physician to an alternate diagnosis and may require further evaluation. The other symptoms listed are Rome I and II criteria for diagnosing irritable bowel syndrome.
Key risk factors for hepatitis C infection are
long-term hemodialysis, intravenous drug use, blood transfusion or organ transplantation prior to 1992, and receipt of clotting factors before 1987
Not as much sexually transmitted, rare from mom to baby
Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if
neuroblastoma or pheochromocytoma is suspected
Prelim eval for IBD
A CBC, serum chemistry panel, and erythrocyte sedimentation rate
Omeprazole is associated with an increased risk of
Clostridium difficile colitis.
acutely decrease the absorption of vitamin B 12 ,
decreases calcium absorption, leading to an increased risk of hip fracture.
The rotavirus vaccine is an oral vaccine recommended for infants in a 3-dose schedule at
ages 2, 4, and 6 months.
The first dose should be given between 6 and 12 weeks of age, with additional doses given at 4 to 10-week intervals.
The vaccine cannot be initiated after 12 weeks of age and should not be administered after 32 weeks of age.
The diagnosis of giardiasis is suggested by
foul-smelling, soft, or loose stools; foul-smelling flatus; belching; marked abdominal distention; the virtual absence of mucus or blood in the stool.
Bilious vomiting Currant jelly stools Sausage shaped mass in abdomen Young person Intermittent pain
Barium enema is dx and tx
Water soluble contrast better if think perf as it doesn’t irritate peritoneum
1 cause of obstruction in baby
Surgery if hemodynamically unstable
Upper GI series imaging if hemodynamically stable
Labs for obese pt
LFTS for fatty liver
BMI is not an accurate measure of overweight/obesity in patients with
heart failure, pregnant women, body builders, and certain ethnic groups
Meds for obesity that are ok long term
potential candidates for surgical treatment of obesity.
Types of surgery?
Patients with a BMI > 40,
or > 35 with comorbid conditions (severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, and severe diabetes mellitus)
2 most common surgeries: Roux-en-Y gastric bypass and “lap banding.”
Roux-en-Y gastric bypass involves the construction of a small (10-30 mL) gastric pouch that empties into a segment of jejunum. This is mostly a restrictive procedure, but there is some degree of associated malabsorption.
In lap banding, an adjustable silicone gastric band is laparoscopically placed around the upper stomach just distal to the gastroesophageal junction. The band has a balloon connected to a subcutaneously implanted port, which can be inflated or deflated to reduce the circumference of the band.
current practice is to introduce solid foods into the diet at what age
extrusion reflex (pushing foreign material out of the mouth with the tongue) makes feeding of solids difficult and often forced. This reflex disappears around the age of 4 months, making feeding easier
can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally).
These shifts result from hormonal and metabolic changes and may cause serious clinical complications.
The hallmark biochemical feature of refeeding syndrome is hypophosphatemia.
Macroglossia is associated with…
Down syndrome Tumor Amyloidosis Acromegaly Cretinism
Deep abdominal infections are often treated with
a cephalosporin, such as cefoxitin,
or a combination of fluoroquinolone plus metronidazole to cover anaerobic infections.
FDA approved for IBS in women with constipation
MoA: selectively activates intestinal chloride channels and increases fluid secretion
has a side effect of nausea in significant percentage of patients
What can you use for ab pain in IBS?
mild-to-moderate abdominal pain: Dicyclomine, an antispasmodic anticholinergic medication
more persistent and severe pain: low-dose TCAs, like amitriptyline
UA with bilirubin. What does this suggest?
Conjugated bilirubin is excreted in the urine, whereas unconjugated bilirubin is not.
is a congenital reduction of conjuga- tion of bilirubin in the liver.
Causes of elevated unconj hyperbilirubinemia
Causes conjugated hyperbilirubinemia
Hep a, b, c
Post hepatic obstruction (eg pancreatic ca, gallstones)
Hep C Disease activity can be monitored by
serial measurements of HCV RNA
Hep C tx
Chronic hepatitis C can be treated with antiviral therapy, using ribavirin and/or interferon
Transaminase levels from alcohol abuse typically show
the aspartate aminotransferase (AST) being elevated out of proportion to the alanine aminotransferase (ALT)
viral hepatitis usually causes greater elevations of the ALT
Serology of chronic hep c
Both HCV RNA and Anti-HCV antibodies are present in chronic Hep C
Early diagnostic endoscopy should be considered for patients with
new- onset dyspepsia who are older than age 55 years
who have symptoms that may be associated with upper GI malignancy
Family history of cancer
PUD distribution in GI
Duodenal ulcers are more prevalent overall,
gastric ulcers are more common in NSAID users
Tests for h pylori
Stool antigen testing
- now the preferred non-invasive office test
- superior positive predictive value and ability to be used posttreatment to test for eradication.
- However, for this test to be accurate, patients must not have been treated with PPIs for at least 2 weeks prior to testing.
Serologic testing for anti–H pylori antibodies
- It is highly sensitive for the presence of a history of infection but cannot distinguish an active infection from a treated infection.
Active infection can be confirmed by urea breath testing. This test is performed by having the patient ingest a carbon-labeled urea compound, which is then metabolized by urease from the H pylori organism. The labeled CO2 released by this process is measured in exhaled breath. This test is highly sensitive and specific, but is limited by availability and expense.
The gold standard for diagnosis is endoscopy with biopsy testing for H pylori
the most common cause of abnormal liver tests in the developed world
Non-alcoholic fatty liver disease (NAFLD)
What has been shown to relieve symptoms of IBS?
Daily use of peppermint oil
test for an active H pylori infection
Urea breath test
Grade 2 ascites (visible clinically by abdominal distention, not just with ultrasonography), the initial treatment of choice is diuretics along with salt restriction.
- spironolactone better than loops
- NOT thiazides
Grade 3 ascites. (gross ascites with marked abdominal distention),
- large volume paracentesis
- then salt restriction + diuretics.
Why do you avoid NSAIDs in cirrhotics?
they can increase the risk of bleeding in cirrhotic patients, as they further impair platelet function.
NSAIDs decrease blood flow to the kidneys and can increase the risk of renal failure in patients with cirrhosis.
is a febrile disease caused by coxsackieviruses and echoviruses.
Vesicles and subsequent ulcers develop in the posterior pharyngeal area
Which one of the following is found most consistently in patients diagnosed with irritable bowel syndrome? (check one) A. Passage of blood per rectum B. Passage of mucus per rectum C. Abdominal pain D. Constipation E. Diarrhea
A large review of multiple studies identified abdominal pain as the most consistent feature found in irritable bowel syndrome (IBS), and its absence makes the diagnosis less likely. Of the symptoms listed, passage of blood is least likely with IBS, and passage of mucus, constipation, and diarrhea are less consistent than abdominal pain
ppx for traveler’s diarrhea
Not recommended - only if immunocompromised or diarrhea would be too much of a hardship for trip
Increased ALP and 5’ nucleotidase
Alkaline phosphatase is elevated in conditions affecting the bones, liver, small intestine, and placenta. The addition of elevated 5’-nucleotidase suggests the liver as the focus of the problem. Measuring 5’-nucleotidase to determine whether the alkaline phosphatase elevation is due to a hepatic problem is well substantiated, practical, and cost effective
An accepted regimen for outpatient treatment of diverticulitis is
What is associated with decreased absorption of calcium carbonate
Long-term histamine H2 -blocker or proton pump inhibitor use
Patients taking these medications who require calcium supplementation should use calcium citrate to improve absorption.
A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The pregnancy and delivery were normal; the infant received phototherapy for 1 day for hyperbilirubinemia. He had an episode of otitis media 1 month ago. There is no chronic runny nose or strong family history of asthma. He spits up small amounts of formula several times a day, but otherwise appears well. His growth curve is normal. An examination is unremarkable except for mild wheezing.
Which one of the following is the most likely diagnosis?
A. Benign reactive airway disease of infancy
B. Gastroesophageal reflux
C. Unresolved respiratory syncytial virus infection
D. Early asthma
E. Cystic fibrosis
Gastroesophageal reflux is a common cause of wheezing in infants. At 5 months of age, most infants no longer spit up several times a day, and this is a major clue that this child’s wheezing may be from the reflux. In addition, there is no family history of asthma and the wheezing is not related to infections.Cystic fibrosis is more likely to present with recurrent infections and failure to thrive than with intermittent wheezing.
Intrahepatic cholestasis of pregnancy
classically presents as severe pruritus in the third trimester.
Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.
When give infants cow’s milk
DO NOT give if < 12 mo old
Can give solid foods after 4-6mo age
Whole cow’s milk does not supply infants with enough vitamin E, iron, and essential fatty acids, and overburdens their system with too much protein, sodium, and potassium.
1 cause of death after bariatric surgery
1 = Pulmonary emboli
- anastomotic leaks
- resp failure
pANCA positive in which IBD?
Malabsorptive diarrhea Wt loss Migratory non-deforming arthritis LAD low grade fever
what is this?
GM+ bacillus Tropheryma whippelii