GI Flashcards
1
Q
Associations with PPI
A
HypoMg Low B12 C.diff Pneumonia AIN Dementia CKD Low BMD Gastric CA
2
Q
Treatment Barrett’s Esophagus
A
Dysplastic: Endoscopic eradication + PPI
Non-dysplastic: PPI OD, rpt OGD 3-5 years
3
Q
Dysphagia alarm symptoms (warrants OGD)
A
Weight loss, Anemia Hematemesis/Melena Onset >age 50 Emesis Odynophagia Persistent dysphagia despite PPI BID
*No alarm sx and <50yo + GERD –> PPI trial
4
Q
Diagnostic Test for Achalasia
A
- EGD to r/o pseudo-achalasia aka obstruction from Ca; narrow GEJ with dilated esophagus
- Manometry (gold standard - shows impaired relaxation or abnormal peristalsis) > barium swallow (shows bird beak)
5
Q
Treatment Achalasia
A
Good surgical candidate:
- Pneumatic dilatation (type 1+2) - risk of tear
- Laparascopic heller myotomy +/- fundoplication
- POEM (peroral endoscopic myotomy)
- Esophagectomy - if failed above or sigmoid- or mega - esophagus
Poor OR candidate: Endoscopic botox > CCB/ nitrates eg nifedipine or ISDN
6
Q
Risk factors for eosinophilic esophagitis
A
Male
Young (20-30)
Allergy/Atopy, Eczema, Asthma
Chronic rhinitis
7
Q
Secondary causes of eosinophilic esophagitis
A
Pill esophagitis CTD Hypermobility syndromes HyperIgE syndrome Pemphigus Untx Achalsia Untx GERD
8
Q
Treatment eosinophilic esophagitis
A
- 6 food elimination diet (eggs, soy, cow’s milk, wheat, tree nuts, seafood)
- 1st line = Topical swallowed steroid (fluticasone, budesonide)
- 2nd line = pred
- Consider dilation if symptomatic strictures
9
Q
Complications of celiac disease
A
Malnutrition: weight loss, vitamin and mineral deficiency: Fe/B12 (anemia), Ca/vit D (osteoporosis),
Mild transaminitis
Dermatitis Herpetiformis (Dapsone after r/o G6PD)
Enteropathy associated T-cell lymphoma (consider if pt stops responding to gluten fee diet)
10
Q
Celiac disease: Work-up
A
If high prob: OGD with duod bx + anti-TTG IgA +/- IgA
If low prob: 1st Anti-TTG IgA +/- IgA
- If high TTG IgA –> OGD with bx
- If normal TTG IgA and low serum IgA –> TTG IgG –> If positive proceed to OGD with bx
- If normal TTG IgA and normal IgA –> no celiac
If Bx + Anti-TTG IgA (or IgG if IgA deficient) + = CD
If both neg = no celiac
If Bx + TTG discordant-> HLADQ2/DQ8 to r/i or r/o
11
Q
Indications to order HLA DQ2/DQ8 for Celiac Disease
A
Discordant biopsy and anti-TTG
Patient unable to comply with gluten-rich diet x3 months
Down Syndrome
12
Q
Foods included in gluten free diet
A
BROW
Barley
Rye
Oats
Wheat
13
Q
Pathology in Crohn’s vs UC
A
Crohn’s: Gum to bum (MC small bowel, ileocolitis, colonic)
Transmural inflammation, non-caseating
Skip lesions “cobblestone mucosa”
Strictures, Fistulas, clubbing
UC: Extends from rectum proximally
Submucosal/mucosal inflammation
Crypt distortion/atrophy/abscess
Contiguous, rare clubbing
14
Q
Complications in Crohn’s vs UC
A
Crohn’s:
- Fistulas (intra-abdo, perianal)
- Abscess (intra-abdo, perianal)
- Strictures (cold/hot) and obstruction
- Peri-anal disease
- CRC
UC:
- Toxic megacolon
- Colonic perforation
- Refractory bleeding
- CRC
- Cholangiocarcinoma
- PSC
15
Q
Induction Treatment Crohn’s Disease
A
Mild-Mod: Budesonide (if terminal ileum +/- R colon), Pred (colon only). **No role for 5ASA or thioprine
Mod-Severe:
- Prednisone/Methylpred 40-60/d if low risk
- Anti-TNF + AZA or MTX +/- Pred/Methylpred if high risk (if already failed anti-TNF, vedolizumab or ustekinumab acceptable)
- always start TNFi with thioprine
- check TMPT before starting AZA/6MP
16
Q
Induction Treatment UC
A
Mild: Budesonide or 5-ASA (PO if extensive, PR enema if left sided colitis - sigmoid to splenic flexture, PR supp if proctitis <18cm)
Mod-Severe: Budesonide or Pred/Methylpred or anti-TNF (vedolizumab, ustekinumab, TNFi, JAK-2i acceptable if failed TNF)
17
Q
Maintenance Treatment Crohn’s Disease
A
Mild-Moderate: Thioprine
Moderate-Severe: - Thioprine - MTX - Anti-TNF (with Aza or MTX) - *esp if fistulas - Anti-integrin (Vedolizumab) - AntiIL12/23 (Ustekinumab) NO JAKi (ONLY UC)
18
Q
Maintenance Treatment UC
A
Mild: 5-ASA (PO/PR enema/PR sup)
Moderate-Severe:
- 5-ASA
- Azathioprine or 6-MP
- Anti-TNF (with Aza or MTX)
- Anti-integrin (Vedolizumab)
- AntiIL12/23 (Ustekinumab)
- JAK-2 inhibitor (Tofacitinib, Barocitinib)
19
Q
Treatment Crohn’s Disease Complications
A
- If fever - always R/O infxn with Cx +/- MRE/CTE (intra-abdo abscess) +/- EUS/MRI pelvis (perianal abscess)
- Perianal fistula: Anti-TNF + Thioprine/MTX (+surgery if intraabdo)
- Perianal Abscess: I&D (or surg if intraabdo) + Cipro/flagyl
- Cold Stricture: Conservative tx +/- endo dilatation/surgery
- Hot Stricture: Steroid induction –> biologic maintenance
20
Q
Classifying UC Severity
A
Mild: <4BMs/day Intermittent blood only Normal Hgb ESR <30
Severe: Vitals: T>37.8C, HR >90 >6BMs/day Frequent blood Low Hgb (<105) ESR >30 Dehydration requiring hospitalization
21
Q
Definition Toxic Megacolon in UC
A
- Megacolon > 6cm +
- > =3 of: Fever >38, HR >120, Anemia, Neuts >10.5 +
- > =1 of: Dehydration, Lyte abn, hypotension, altered LOC
22
Q
UC: Indications for colectomy
A
- Toxic megacolon
- Severe bleeding
- Perforation
- Flare refractory to medical tx x3-5 days
23
Q
Diagnostic tests for H. Pylori
A
Biopsy histology
Biopsy culture
Stool Ag
Urea breath test
*Serology does not differentiate current vs prior infxn
24
Q
Treatment H. Pylori
A
1st Line: PBMT x 14 days = PPI + Bismuth + Metronidazole + Tetracycline
OR
PAMC x 14 days = PPI + Amox + Metronidazole + Clarithro
Treatment failure: PBMT (if prior triple therapy) or PAL x14d (PPI/Amox/Levo)
*Urea breath test, biopsy, or stool Ag (NOT serology) >4 weeks post completion of tx
25
DDX Lower GI Bleed
Painless: Diverticular, hemorrhoids, polyp, CA, angiodysplasia, radiation proctitis or colitis, (IBD, infectious)
Painful: Ischemic colitis (low flow, atherosclerotic), Mesenteric (cardioembolic), thrombosed hemorrhoid, fissure, (IBD, infxn)
26
DDX Hepatocellular transaminitis in 1000s
```
Acetaminophen
AI Hepatitis
Viral hepatitis (A, B, D, E)
Ischemic hepatitis (Shock liver, Budd Chiari)
Acute Stone w/i 24h
Wilson's (rare)
```
27
DDX Hepatocellular transaminitis in 100s
Alcohol (AST/ALT >2; unlikely if LE >300)
Drugs (tyl, MTX, anti-thyroid, ABX)
Viral (Hep B, C, EBV, CMV)
28
DDX Hepatocellular transaminitis <100
```
NASH
Celiac
Hemochromatosis
Wilsons
A1AT
Drugs
```
29
DDX Cholestatic Transaminitis
Extra-hepatic:
- Stone
- PSC stricture
- Benign obstruction (IgG4/AIP, AIDS cholangiopathy)
- Malignant obstruction (pancreatic CA, cholangioCA)
Intra-hepatic:
- PBC
- Drugs (ABX, TPN, Estrogen, MTX)
- IHCP
- Hepatic infiltration
- Infection
30
Hepatitis B Serology: Immune from past infection
SAg - , SAb + , cIgM -, cIgG + , EAg - , EAb + , DNA neg
31
Hep B Serology: Immune from vaccine
SAg - , SAb +, cIgM - , cIgG -, EAg -, EAb - , DNA neg
32
Hep B Serology: Window Period
SAg- , SAb - , cIgM + , cIgG -, EAg +/- , EAb -/+, DNA neg
33
Hep B Serology: Acute infection
SAg+, SAb -, cIgM +, cIgG +/-, EAg +, EAb - , DNA pos
34
Hep B Serology: Chronic Infection (<5% with HepB) - 4 categories
1) EAg + chronic infection (Immune Tolerant):
SAg+, SAb-, cIgM-, cIgG +, EAg +, EAb -, DNA >1 mill
ALT normal, no fibrosis on biopsy or fibroscan
2) EAg + chronic hepatitis (Immune active):
SAg+, SAb-, cIgM-, cIgG +, EAg +, EAb -, DNA> 20,000
ALT elevated (>2x ULN), mod-sev inflmn/fibrosis on bx or fibroscan
3) EAg - chronic infection (inactive carrier):
SAg+, SAb-, cIgM-, cIgG +, EAg -, EAb +, DNA <2000
ALT normal, minimal fibrosis/inflmn on bx or fibroscan
4) EAg - chronic hepatitis (immune reactivation):
SAg+, SAb-, cIgM-, cIgG +, EAg -, EAb +, DNA >2000
ALT elevated, fibrosis/inflmn on bx or fibroscan
35
HepB Antiviral Treatment: Indications
Acute: Only if progressive liver failure
Chronic: (goal convert sAg and EAg --> Ab, dec DNA lvl and risk cirrhosis/HCC)
- Immune active: EAg+, ALT >2x ULN, + DNA >20,000
- Immune reactivation: EAg -, ALT >2x ULN, + DNA >2000
- Cirrhosis
- Fibrosis >stage1 with DNA>2000 regardless of ALT or HbeAg
- Extra-hepatic manifestations
- Pregnant (24-32wk) if DNA >200,000 (to dec fetal transmission) - use Tenofovir and give baby HBIG + HBV vaccine
36
HepB Antiviral Treatment
```
1st line: Nucleoside analogues (Tenofovir, entecavir, lamivudine)
Peg interferon (finite = 48w, ++side fx) - for low DNA, high ALT and noncirrhotic HbeAg+. NOT for decompensated cirrhotics
```
37
Hep B followup screening
Q6mo ALT + HBV DNA q6-12mo for all
```
US q6mo for HCC if:
All Cirrhotics
Asian M>40, F>50
African American >20
HIV or Hep D Co-infection
FHX HCC (1st deg)
```
*NO AFP screening
38
HepB: Extra-hepatic manifestations
Rheum: PAN
Renal: membranous nephropathy > MPGN
Haem: aplastic anemia
39
Natural history HepB after acute infection
95% resolve spontaneously
5% develop chronic hep B
1% develop fulminant hepatic failure
40
Natural history HepC after acute infection
33% resolve spontaneously
| 67% develop chronic infection
41
Hepatits C: Who to screen
```
All with cirrhosis
All Canadians born 1945-1975
Blood transfusion or transplant before 1992
Born in endemic area (africa, Asia, east europe, australia)
Current/past IVDU
Current/past incarceration
MSM
Household or sexual contact with HepC
HIV/HBV co-infection
Chronic dialysis patient
Increased ALT
```
42
Extra-hepatic manifestations HepC
Renal: MPGN > Membranous
Autoimmune: Thyroid, myasthenia, Cryoglobulinemia, Sjogren's, DM
Haem: ITP, AIHA, Lymphoma
Derm: Porphyria cutanea tarda, lichen planus, leukocytoclastic vasculitis
43
HepC Treatment Indications
ALL except short life expectancy
44
HepC Treatment Regimen
All based on direct antivirals, regimen deps on genotype, prognosis, co-infections and tx history
*Most: Sofosbuvir + (Ledipasvir or ribivarin) x 8-12 wks
2 Examples:
- Maviret: Glecaprevir/Pebrentasvir
- Epclusa: Sofosbuvir/Velpatasvir
Check viral load 12 weeks post treatment to confirm clearance (sustained virological response SVR12)
45
EtOH Hepatitis Treatment
1) Prednisolone 40 OD if MADDREYS >=32 or MELD >20 for 7days; If Lille score on d7 >0.45 --> DC bc non-responder. If <0.45 (responder) continue x28 days then taper. Ensure no C/I eg infection (SBP, HBV, TB), GIB
2) EtOH Cessation
3) Refer to transplant if MELD >20 or CP-C
4) +/- NAC (for 30d survival in severe)
* No role for pentoxifylline except in HRS
46
NAFLD Treatment
```
Weight loss (dietary changes + exercise): 3-5% for steatosis, 7-10% improves fibrosis
Pioglitozone + VitE if Bx confirmed NASH (NOT NAFLD)
Bariatric surgery (if obese)
Treat RFs: statins OK in compensated NAFLD/NASH cirrhosis, avoid in decompensation
```
47
Causes of cirrhosis
```
EtOH
NAFLD
Viral Hepatitis (C>B)
AI (auto-immune hepatitis, IgG4 Dz, PSC, PBC)
Cardiogenic
Genetic: Hemochromatosis, Wilson's, A1AT
VTE
Idiopathic
```
48
Work-up for new diagnosis cirrhosis
Hepatitis B/C serology
US with dopplers (r/o VTE)
Serum Igs
ANA, AMA, Anti-LKM, (+/- ASCA/ANCA if feats sugg)
Tsat/ferritin, ceruloplasmin, A1AT
+/- Biopsy if etiology not determined by above
Screen for complications:
- Varices (EGD at dx), Ascites/SBP (para at dx), encephalopathy, HRS, HCC (abdo US at dx)
49
Child Pugh Score
ABCDE:
Albumin (>35=1, 28-35 = 2, <28 = 3)
Bilirubin (<34 = 1, 34-51 = 2, >51 = 3)
Coag: INR (<1.7=1, 1.7-2.2 = 2, >2.2 =3)
Distension/ascites (Absent=1, mild = 2, mod/sev =3)
Encephalopathy (Absent =1, grd1/2 = 2, grd 3/4=3)
CP-A = 5-6, CP-B=7-9, CP-C = >9 (Refer B and C for Transplant or if MELD15+)
50
Treatment esophageal varices
If prior variceal bleed: EVL/Ligation + NSBB
If no past bleed (aka primary prevention):
- If large/medium varices: EVL (q2-8w until obliterated) or NSBB (no rpt OGD needed)
- If small w high risk feats (CP-C, whale or red spot) : Nadolol
- If small without high risk feats: Observe, repeat OGD 1-2 yrs
- If no varices: Rpt OGD q2-3 yrs for compensated, q1yr decomp
51
Treatment ascites from portal HTN
1. Salt restriction <2g/d (24h UNa <78 off diuretics = compliant)
2. Diuretics (Spirono 100/ lasix 40) if refractory/noncompliant
3. 24h uine Na on diuretics
a) If losing weight + UNa >78 = CCM
b) NOT losing weight + UNa>78 = noncompliant to Na restriction
C) UNa<78 = increase diuretic dose until s/e
4. Failing diuresis --> regular therapeutic para, TIPS (if no HCC or encephalopathy)
5. Transplant
52
Indications for SBP Prophylaxis
1. Acutely during UGIB (can be without ascites)
2. Past episode SBP (defined as ascitic PMN >250 or Cx+)
3. Ascitic albumin <15 with either: a) Renal impairment (Cr >=106, BUN >=8.9, Na<130) or b) Sev liver impairment (CP-C, Bili >=51)
53
Treatment SBP
1) Antibiotics: CTX 2g IV Q24hrs x5 days
| 2) Albumin: Day 1 = 1.5g/kg, Day 3 = 1 g/kg day if Cr >88, BUN >10.7, Bili>68
54
Diagnosis Hepatorenal Syndrome
1) Progressive oliguric renal failure +
2) Benign urine sediment +
3) Urine protein <0.5 g/24 hrs +
4) UNa <20 +
5) Other causes AKI ruled out +
6) No improvement with discontinuation of diuretics and 2 day trial albumin 1g/kg
```
Type1 = AKI (2x Cr to >221 in 2 wks),
Type2 = chronic renal failure with diuretic resistant ascites
```
55
Treatment Hepatorenal Syndrome
Ward: terlipressin (risk resp failure) + alb > midodrine + octreotide + albumin
ICU: Norepinephrine + IV Albumin
Definitive Tx = Transplant
56
Diagnosis Hepatopulmonary Syndrome
1) PaO2 <80, A-a gradient>=15 in pt with cirrhosis
2) Positive TTE Bubble study
Tx: O2 + liver transplant
57
HCC Treatment
Curative: Surgery, Radiofreq ablation, Transplant
Palliative: TKI, chemo, rads, Transarterial chemoembolization (TACE)
58
Hereditary Hemochromatosis: Screening and Diagnosis
Screening: Positive = Tsat >45% AND Ferritin >200 F/300 M (suspect organ dmg if ferritin>1000 --> MRI for HIC/fibroscan, bx if LE high)
Diagnosis: homozygous C282Y, hetero with H63D = less likely. Without C282Y = no risk
*screen all 1st deg relatives >18yo
59
Hereditary Hemochromatosis: Treatment
Treat C282Y Homozygotes + complex heterozyg (C282Y/H63D)
a) Phlebotomy: Target Ferritin 50-100
b) Chelation if phlebotomy refractory (risk of retinal/auditory tox, agranulocytosis, liver/renal tox)
c) Avoid VitC, Fe containing supplements, raw seafood (vibrio, listeria, yersinia), normal red meat if phlebotomy
d) transplant if decompensated cirrhosis/focal HCC
*other heterozygotes = annual iron markers & asses organ dmg. No Tx
60
Treatment PSC
ERCP Symptomatic strictures
MRCP q1yr r/o cholangioCA or GB Ca
Screen HCC/EoV if cirrhosis +/-transplant
NO Benefit of ursodeoxycholic acid
No curative Tx - progressive course
61
Diagnosis PBC
2/3 of:
1) ALP > ULN x6+mo
2) AMA > 1:40
3) Liver biopsy
62
Treatment PBC
Ursodeoxycholic acid (alters natural hx)
Management of cirrhosis if develops (only in 2/3)
Rarely need ERCP
63
Diagnosis acute pancreatitis
2/3 of:
1) Consistent abdominal pain
2) Lipase or amylase >3x ULN
3) Characteristic imaging
64
Treatment acute pancreatitis
- general
- gallstone
- AI
- TG
1) FLUIDS (250-500cc isotonic)
2) ANALGESIA
3) early enteral feeding (clear low at diet)
* If gallstone pancreatitis: ERCP (w/in 24 hrs if cholangitis/persistent obstruction/severe pancreatitis, otherwise >48h if non-resolving symptoms) AND Chole
* If AI Pancreatitis/IgG4 rltd: Steroid 40mg x4-6 wks then taper (steroids or aza or ritux if relapse)
* If TG pancreatitis: IV insulin, NPO +- PLEX, long-term fibrates
65
Early pancreatitis complications (<4 weeks)
Interstitial edematous pancreatitis
Acute peri-pancreatic fluid collection
Pancreatic necrosis
Infected pancreatic necrosis/collection (if stable FNA --> cabapenem or quinolone+metronidozole, if unstable ABX --> Steroids)
66
Late Pancreatitis Complications (>4 weeks)
Pseudocysts (endoscopic drainage if SS infxn)
Abscess
Walled off necrosis
67
Chronic Diarrhea: Differentiating Cause
Stool Osmolar Gap = 290 - [2 x (StoolNa + Stool K)]
If <50-100 = Secretory --> Toxins, cholera/ETEC, VIPoma, gastrinoma, non-osmotic laxative abuse
If >100 = Osmotic or malabsorptive --> Celiac, chronic pancreatitis, lactose intol, lactulose or PEG misuse, post-whipple
C-scope if alarm features
68
Microscopic Colitis Treatment
Budesonide PO, D/C NSAIDs, immodium
69
Acute Cholangitis Features
Fever + RUQ Pain + Jaundice + Hypotension + Alt LOC
WBC>10 or <4, ALP/GGT >1.5xULN, ALT>1.5xULN, Bili>34
70
Acute Cholangitis: Tx
1) ABX (CTX/flagyl, Cipro/Flagyl, Tazo, Carbapenem)
| 2) Source control (1st line = ERCP +/- sphincterotomy, 2nd = percut biliary drainage if ++comorbidities or failed ERCP
71
Auto-antibodies in autoimmune hepatitis
ANA
ASMA
Anti-LKM
Anti-LC1
72
Auto-antibodies in PBC
AMA
73
Auto-antibodies in Crohn's Disease
ASCA
74
Auto-antibodies in Ulcerative colitis
p-ANCA
75
Auto-antibodies in PSC
pANCA, ASCA, ANA
76
Best test for acalculous cholecystitis
HIDA Scan
77
Management of recurrent pleural effusions secondary to portal hypertension in cirrhosis
If requiring thoras more freq than q2-3 weeks + Age <70 + CP A or B --> TIPS
Otherwise, repeat thoras, Na restriction, diuretics
78
Who to immunize for Hep A, including post-exposure ppx
-Travelers to Hep A Endemic countries, liver disease, MSM, IVDU, recurrent plasma derived clotting factors, zoo/vets handling primates
• Post-exposure ppx: household contacts, co-workers/ clients of infected food handlers, contacts in childcare or JK/SK
79
Hep B factors increasing risk of cirrhosis/HCC
All of the below are for both, (HCC only)
- Host: older age, male, immunocompromised, coinfection with HIV/HCV/HDV, EtOH, metabolic syndrome, (aflatoxin ingestion, smoking)
Disease: High DNA/ALT, prolonged time to eAg seroconversion, eAg negative mutant, genotype C
-all of the disease factors also increase risk for HCC
80
Hep C factors increasing risk of cirrhosis/HCC
Cirrhosis: older age, male, HIV/HBV coinfection, obesity/dm/fatty liver, EtOH
HCC: cirrhosis or coexisting liver dz
81
Cirrhosis counseling
- EtOH abstinence, NAFLD weight loss
- Tylenol<2g/d
- No sedatives, NSAIDs, ACE/ARBs
- HAV/HBV/flu vaccines
82
Ascites SAAG
| serum ascites albumin gradient
```
>11 = transudative (portal HTN)
<11 = exudative (Ca, pancreatitis, TB, nephrotic syndrome)
```
83
Celiac RF's
```
Northern European
Family history - 1st deg
T1DM
AI Thyroid
Down/Turner
IgA def
```
84
Postendoscopy Mx for nonvariceal UGIB
| eg PPI duration, antiplatelets, anticoag
High risk ulcer: IV PPI BID or infusion x72h, then oral BID x2 weeks
Low risk: oral PPI
Restart antiplatelets, anticoag ASAP (timing dep on Forrest class and patient factors)
Assess RF:
-Test all PUD/gastritis for HPylori (EGD or serology), DC PPI after HP eradicated
-Indefinite PPI if ASA and/or Plavix for CAD
-Indefinite PPI if unclear PUD cause
85
Who to test H Pylori
- long term NSAIDs/ASA
- PUD
- unexplained Fe def,
- MALT lymphoma
- gastric Ca
- ITP
86
GERD Tx
Nonpharm: wt loss, avoid trigger food, no smoking, elevate HOB
Pharm: PPI OD 30-60min before meal x8 weeks (wean if improves), fail = ensure optimization and EGD off PPI
*NO prokinetics, sucralfate, baclofen, H2RA unless pregnant (sulcrate) or nocturnal acid reflux on monitoring pH (H2RA)
Surg for fundoplication, Roux en Y for eligible obese, or transesophageal incisionless fundoplication if declining classic lap fundo
87
Barrett's Presentation/RF
Metaplasia >1cm proximal to gastroesophageal jcn
Bx shows columnar intestinal metaplasia and goblet cells
RF:
Chronic GERD (>5y)
Fat white man >50yo that smokes
NOT affected by EtOH
88
Achalasia complications
Megaesophagus >6cm
Sigmoid esophagus
Esophageal SCC >>> adenoCa
89
Eosinophilic esophagitis findings
Dysphagia+food bolus obstruction with >15 eos/hpf and no secondary causes
Endoscopy: trachealization (feline) esophagus, linear furrows, white papules, crate paper,
90
Pancreatitis causes
Acute: Stones, EtOH, TG (>11mmol/L), hyperCa, drugs (GLP1, 5ASA, thiazides, azathioprine), AI, post ERCP, trauma, viral, Ca, hereditary, smoking, scorpion bites, vasculitis
Chronic: toxic (chronic EtOH, meds, toxins, smoking), metabolic (hyperCa, CF, hyper TG), idiopathic, AI, obstructive (pancreatic divisum, stricture, stone, tumor)
91
LGIB DDX
Painless: diverticular, hemorrhoids, angiodysplasia, Ca, polyp, radiation proctitis
Painful: fissue, thrombosed hemorrhoids, ischemic colitis (crampy abdo pain w bloody BM) req workup (afib, LV thrombus, endocarditis, AAA< dissection, shock, low flow, segmental, vasculitis, PAN)
92
Portal/Mesenteric Vein Thrombosis Workup
- Thrombophilia + Jak2 testing if: 1) NO cirrhosis 2) Prior thrombosis 3) unusual thrombotic site eg hepatic veins 4) family hx
- Imaging: US+ doppler
- EGD to r/o esophageal/gastric varices
93
Portal/Mesenteric Vein Thrombosis: who and how to Tx
No cirrhosis: Treat acute symptomatic or chronic w/ thrombophilia/ bowel ischemia/ clot progression into mesenteric veins
- IV UFH/LMWH --> warfarin/LMWH or offlabel DOAC x 6mo if acute trigger OR indefinite if thrombophilia -
If cirrhosis: treat as above, but also if awaiting liver transplant
94
Ischemic colitis findings and tx
C-scope shows pale mucosa with petechiae or transmural infarction
Tx: broad spectrum abx + bowel rest + IVF +/- surg
95
Esophageal Cancer risk factors
Squamous: Smoking, EtOH, Achalasia, Caustic injury, H&N cancer
Adeno: Barrett's, Reflux
