GI - Medicine & Surgery Flashcards
(155 cards)
1
Q
What is hepatic hydrothorax?
A
Complication of cirrhosis. A transudative pleural effusion not due to underlying cardiac or pulmonary abnormalities. Occurs due to small defects in the DIAPHRAGM, more common on the R side due to less muscular hemidiaphragm.
Dx: documentation of effusion
Tx: salt restriction and diuretic administration
2
Q
What is hepatopulmonary syndrome?
A
It results from intrapulmonary vascular dilation in setting of chronic liver disease. Pt frequently has evidence of platypnea (increased dyspnea while upright) or orthodeoxia (O2 desaturation while upright).
3
Q
What is Primary Biliary Cholangitis?
A
Pathogenesis: autoimmune destruction of intrahepatic bile ducts leading to intrahepatic cholestasis
Clinical features: affects middle aged women, insidious onset of fatigue and pruritis, progressive jaundice, hepatomegaly, cirrhosis, cutaneous xanthomas and xanthelasmas
Labs: increased ALP, a little AST, ALT; AMA, severe hypercholesterolemia
Dx: anti-mitochondrial antibody (AMA) titers
Tx: ursodeoxycholic acid (delays progression and may improve sxs and possible survival), liver transplantation for advanced disease
Assoc. w/ ulcerative colitis
Complications: malabsorption, fat soluble vitamin deficiencies, metabolic bone disease (osteoporosis, osteomalacia), hepatocellular carcinoma
Assoc. w/ autoimmune thyroid disease
4
Q
What is spontaneous bacterial peritonitis?
A
Suspected in any patient with cirrhosis and ascites who presents with: temp >= 100F, abdominal pain/tenderness, altered mental status (abnormal connect the numbers test), hypotension, hypothermia, paralytic ileus with severe infection
Diagnosis from ascitic fluid: paracentesis; PMNs >= 250, positive culture, often gram-negative organisms (E. coli, Klebsiella), protein <1, SAAG >= 1.1
Tx: empiric antibiotics - 3rd gen cephalosporins (cefotaxime),
Fluroquinolones for SBP prophylaxis
5
Q
What is dyspepsia?
A
Intermittent epigastric pain and postprandial discomfort.
Caused by NSAIDs, gastric or esophageal cancer, functional dyspepsia, GERD, PUD w/ H. pylori
Dx: endoscopy
6
Q
What is chronic pancreatitis?
A
Etiology: etoh use, cystic fibrosis (common in children), ductal obstruction (e.g., malignancy, stones), autoimmune
Presentation: chronic epigastric pain radiating to the back w/ intermittent pain-free intervals, relieved by leaning forward, malabsorption-steatorrhea, weight loss, DM
Labs/imaging: amylase/lipase can be normal and non-diagnostic, plain film, CT scan or MRCP can show calcifications, dilated ducts, and enlarged pancreas
Low fecal elastase is diagnostic
Tx: pain mgmt, etoh and smoking cessation, frequent/small meals, pancreatic enzyme supplements
7
Q
What is metastatic liver disease?
A
The most common site of colon cancer metastasis is to the liver.
Presentation: RUQ pain, mildly elevated liver enzymes, firm hepatomegaly
Dx: CT of abdomen
8
Q
What is alcoholic cirrhosis?
A
Liver is often shrunken and edge is not palpable.
AST:ALT >2:1, <500
9
Q
What is autoimmune hepatitis?
A
Presentation: young to middle aged women, acute or chronic hepatitis, significant hepatocellular injury
Labs: transaminases often >1000 U/L;
ANA, Anti-smooth antibodies
Tx: oral glucocorticoids
10
Q
What is acute pancreatitis?
A
Etiology: chronic alcohol use, gallstones, hypertriglyceridemia, drugs (azathriprine, valproic acid, thiazides), infections (CMV, legionella, aspergillus), iatrogenic (post-ERCP, ischemic/atheroembolic), cholesterol emboli
Presentation: acute epigastric pain radiating to back, eruptive xanthomas (yellow-red papules due to subq fat deposition), livedo reticularis; severe disease - fever, tachypnea, hypoxemia, hypotension
Labs: fasting lipid profile, ALT >150 = biliary pancreatitis
Imaging: abdominal U/S (most sensitive and specific), then ERCP if that is nondiagnostic
Imaging: CT findings may remain normal for up to 48h
Dx: 2 of the following - acute epigastric pain radiating to back, increased amylase or lipase >3x normal limit (rise w/in several hours), abnormalities on imaging consistent with pancreatitis
Tx: IV fluids and supportive care
11
Q
What is cirrhosis?
A
Etiology: viral hepatitis B +C, chronic etoh abuse, NAFLD, hemochromatosis
Presentation: ascites, spider angiomata, gynecomastia, splenomegaly
Dx: Patients w/ cirrhosis should undergo screening endoscopy to exclude varices, indicate the risk of variceal hemorrhage, and determine strategies for primary prevention of variceal hemorrhage.
12
Q
What are esophageal varices?
A
Tx: PPx - non-selective beta blocker (propranolol, nadolol) to decrease progression to large varices and the risk of variceal hemorrhage.
Octreotide is used to treat active variceal bleeding, no role in primary ppx. MOA - inhibits release of vasodilator hormones leading to indirect splanchnic vasoconstriction and decreased portal flow
Endoscopic variceal ligation can be used as alternative primary preventive therapy in pts with contraindication to beta blocker therapy
Goal Hgb is above 9.
13
Q
What is Familial adenomatous polyposis?
A
Etiology: alteration in adenomatous polyposis coli (APC) gene
Presentation: development of >1000 polyps, universal development of CRC if left untreated
Screening sigmoidoscopies for children start at age 10-12, followed by annual colonoscopies once colorectal adenomas are detected or if pt is age >=50
Pts w/ attenuated version of FAP can have a delayed start of screening (age 25) and longer screening intervals (1-2 years)
Tx: increased screening and elective proctocolectomy
14
Q
What is lactose intolerance?
A
Lactose is processed into glucose and galactose by lactase on brush border. Inability to absorb lactose found in milk and dairy products. Most common in Asian Americans, and pts of African, Latin American, or Native American descent.
Presentation: osmotic diarrhea, abdominal cramps, bloating, and flatulence after ingestion of dairy products; no steatorrhea
Labs: high osmotic gap due to unmetabolized lactose and organic acids; acidic stool pH due to fermentation products
Dx: lactose hydrogen breath test - positive test characterized by rise in measured breath hydrogen level after ingestion of lactose indicating bacterial carbohydrate metabolism; positive stool test for reducing substances
High osmotic gap due to unmetabolized lactose and organic acids
15
Q
What is C. diff colitis?
A
Diarrhea and/or abdominal pain in pt who has been on antibiotics
Tx: Initial episode: vanc PO or fidaxomicin PO
Recurrence: 1st - vanc PO (taper) or fidaxomicin if vanc was used in initial episode;
multiple recurrences - van PO followed by rifaxmin, fecal microbiota transplant
Fulminant (e.g., hypotension/shock, ileus, megacolon): metro IV PLUS high dose vanc PO (or per rectum, if ileus is present), surgical evaluation
Dx: stool pcr for c. diff toxin
16
Q
What is the management of cirrhosis?
A
Compensated: U/S surveillance for hepatocellular carcinoma +/- alpha fetoprotein q6mo, EGD varices surveillance
Decompensated - liver can’t keep up with needs of body: variceal hemorrhage - nonselective bblockers, repeat EGD annually; ascites - dietary Na restriction, diurectics, paracentesis, abstinence from etoh; hepatic encephalopathy - identify underlying cause (e.g., infection, GI bleeding), lactulose therapy
17
Q
What is diffuse esophageal spasm?
A
Uncoordinated, simultaneous contractions of esophageal body
Presentation: intermittent chest pain, dysphagia for solids and liquids, regurgitation precipitated by emotional stress
Dx: manometry: intermittent peristalsis, multiple simultaneous contractions;
esophagram: “corkscrew” pattern
Tx: calcium channel blockers, alternatives: nitrates or TCAs
18
Q
What is Nonalcoholic fatty liver disease?
A
Most common in pts with obesity and diabetes.
Hepatic steatosis on imaging or biopsy, exclusion of significant alcohol use, exclusion of other causes of fatty liver; related to peripheral insulin resistance leading to increased peripheral lipolysis, triglyceride synthesis; hepatic uptake of fatty acids, which increases oxidative stress and production of proinflammatory cytokines
Presentation: mostly asx, metabolic syndrome, +/- steatohepatitis (AST/ALT ratio <1), hyperechoic texture on U/S
Dx: biopsy for confirmation
Tx: diet and exercise, consider bariatric surgery if BMI >= 35; safe to continue statins
19
Q
What is pellagra?
A
Due to niacin deficiency, prolonged isoniazid therapy
Niacin synthesized endogenously from tryptophan
Presentation: dermatitis, diarrhea, dementia; can be seen with carcinoid syndrome (depletion of trytophan) or HartNup disease (congenital disorder of tryptophan absorption)
20
Q
What is severe acute pancreatitis?
A
Pancreatitis with failure of at least 1 organ
Presentation: fever, tachycardia, hypotension, dyspnea, tachypnea and/or basilar crackles, abdominal tenderness and/or distension, Cullen sign (periumbilical bluish coloration indication hemoperitoneum), Grey-Turner sign (Reddish-brown coloration around flanks indicating retroperitoneal bleed); pancreatic enzymes enter vascular sys –>increase vascular permeability–>hypotension
Assoc. w/ increased risk: age >75, obesity, alcoholism, CRP >150 48h after presentation, rising BUN and Cr in first 48h, CXR w/ pulmonary infiltrates or pleural effusion, CT scan/MRCP w/ pancreatic necrosis and extrapancreatic inflammation
Complications: pseudocyst, peripancreatic fluid collection, necrotizing pancreatitis, ARDS, acute renal failure, GI bleeding
Tx: several liters of IV fluid
21
Q
What is a pseudocyst?
A
Complication of acute pancreatitis: A fluid collection containing pancreatic enzymes, blood, fluid, and tissue debris surrounded by a necrotic or fibrous capsule.
Typically takes 3-4w to develop after acute pancreatitis.
Can leak amylase-rich fluid into circulation and increase serum amylase
No sxs + no complications - expectant management
Sx - endoscopic drainage
22
Q
What is fecal impaction?
A
Common in older pts w/ impaired mobility, chronic constipation, or decreased sensation of stool in rectal vault
Presentation: obstruction of fecal flow in rectum can cause backup of stool; passage of stool around impaction leads to incontinence
Tx: manual disimpaction + enemas to clear rectal vault
23
Q
What is Crohn Disease?
A
Inflammatory Bowel Disease, mouth to anus (rectum is spared)
Risk factor: smoking
GI: abdominal pain, chronic nonbloody diarrhea (bloody if colitis), oral ulcers, malabsorption, weight loss, transmural inflammation, strictures, fistula/abscess formation, peri-anal skin tags, anal fissures, non-caseating granulomas, creeping fat
Extraintestinal: MSK (arthritis), eye (e.g., uveitis, scleritis, episcleritis), skin (e.g., erythema nodosum, pyoderma gangrenosum), lung disease, kidney stones
Dx: increased WBC, Fe deficiency anemia, increased inflammatory markers; endoscopy - focal linear ulcerations adjacent to normal mucosa (cobblestoning), skip lesions; radiography - strictures, bowel wall thickening
Tx: 5ASA drugs (w/o systemic sxs), corticosteroids, azathioprine, anti-TNF (severe disease), antibiotics
NSAIDs can relieve arthritis sxs but worsen underlying bowel disease
[5ASA drugs are ineffective and not recommended]
24
Q
What is the serology for hep b?
A
First marker to appear - HBsAg (4-8w after infection)
IgM anti-HBc appears around time of clinical sxs (ALT/AST >25x normal limit)
Window period = time between disappearance of HBsAg and appearance of anti-HBs, only IgM anti-HBc detectable
HbsAg and anti-HBc: most approp. dx test for acute hepatitis B infection as both are elevated during initial infection and IgM anti-HBc will remain elevated during window period.
Resolved infection: positive for anti-Hbs and IgG anti-Hbc
Recovery phase: anti-Hbs, IgG anti-Hbc, anti-Hbe
25
What is ischemic hepatic injury/shock liver?
Occurs in setting of hypotension or Budd Chiari syndrome (hepatic vein thrombosis) and manifests as acute, massive increases in transaminases (thousands, 25-250x normal, >10k) w/ milder increases in t bili and ALP
Presentation: diffuse liver injury, RUQ pain
Hallmark: rapid and significant increase in transaminases w/ modest accompanying elevations in total bili and ALP.
Liver enzymes return to normal in 1-2w
26
Liver enzymes in acute viral hep, alcoholic liver disease, autoimmune hep
Acute viral hep: large AST/ALT elevations (thousands) w/ significant hyperbilirubinemia
Alcoholic liver disease: AST/ALT ratio >2, AST rarely >300
Iron overload: low-grade increase in transaminases
Autoimmune hep: large increases in AST/ALT (thousands), dramatic increase in serum bili
Acetaminophen: thousands
27
What are colon cancer screening recommendation in pts at increased risk?
Fhx of adenomatous polyps or CRC - age 40 or 10y before age of dx in affected relative, repeat q5y
IBD: 8-10y postdx (12-15y if disease only in L colon and rectum), repeat q1-3y
FAP: age; 10-12, repeat annually
HNPCC (Lynch syndrome): age 20-25, repeat q1-2y
28
What is laxative abuse?
Presentation: water, frequent 10-20 episodes of diarrhea, nocturnal BMs and abdominal cramps
Labs: metabolic alkalosis, hypokalemia
Dx: positive stool screen for diphenolic (eg bisacodyl) or polyethylene containing laxatives; melanosis coli on colonoscopy, pigemented Macs of lamina propria on histology
29
What is acute liver failure?
Etiology: viral hep (eg HSV, CMV, hep ABDE), drug toxicity (acetaminophen overdose potentiated by chronic etoh use, idiosyncratic), ischemia (eg shock liver, budd-chiari), autoimmune hep, wilson's, malignant infiltration
Presentation: fatigue, lethargy, anorexia, nausea, RUQ pain, pruritus and jaundice due to hyperbilirubinemia, renal insufficiency, thrombocytopenia, hypoglycemia in pt w/o cirrhosis or underlying liver disease
Dx: triad of severe acute liver injury - (ALT/AST >1000s), signs of hep enceph (eg confusion, asterixis), synthetic liver dysfunction (prolonged PT w/ INR >=1.5)
Complications: cerebral edema, most common cause of death; renal insufficiency
Tx: N acetylcysteine for acetaminophen overdose; liver transplant
30
What is angiodysplasia?
Dilated submucosal veins and arteriovenous malformation; assoc. w/ advanced renal disease, vWf disease, and Aortic Stenosis
Presentation: recurrent, painless GI bleeds, maroon-colored stools
Dx: colonoscopy, though frequently missed
Tx: not required if asx; anemia or bleeding can be treated with cautery
31
What is the relationship between NSAIDs and iron deficiency anemia?
NSAIDs are a common cause through chronic blood loss from the GI tract. Fe deficiency anemia should prompt thorough evaluation for the cause as early low-grade bleeding can herald later catastrophic hemorrhage. Elderly pts often have a low-grade chronic anemia at baseline and may not tolerate additional blood loss.
32
What is Dubin-Johnson syndrome?
Benign, hereditary condition; defect in hepatic excretion of conjugated bilirubin
Presentation: icterus and positive urine bilirubin assay; discovered in puberty or early adulthood
Histology: grossly black liver w/ dark, lysosomal pigment
Labs: elevated conjugated bilirubin; normal AST, ALT, ALP
33
What is acute erosive gastropathy?
The development of hemorrhagic lesions after ischemia or the exposure of gastric mucosa to injurious agents (alcohol, aspirin, cocaine).
Aspirin: decreases protective prostaglandin production; Cocaine: results in vasoconstriction, reducing blood flow;
aspirin + etoh cause direct mucosal injury
Presentation: hematemesis and abdominal pain
34
What is ulcerative colitis?
Presents between 15-40 and 50-80, bimodal
Abdominal pain, bloody diarrhea, tenesmus, and fecal incontinence
Endoscopy: erythema, friable mucosa, pseudopolyps, involvement of rectosigmoid (always), continuous colonic involvement (no skip lesions)
Biopsy: mucosal and submucosal inflammation, crypt abscesses, NO granulomas
Labs: leukocytosis, Fe deficiency anemia, reactive thrombocytosis, increased ESR
Complications: toxic megacolon, primary sclerosing cholangitis, colorectal cancer, erythema nodosum, pyoderma gangrenosum, spondyloarthritis, uveitis
Tx: 5ASAs (mesalamine, sulfasalazine, balsalazide) mesalamine enema/suppository (preferred) for mild UC, oral for more extensive disease
NSAIDs relieve arthritis but worsen underlying bowel disease
35
What is oropharyngeal dysphagia?
Difficultly initiating swallowing due to inability to transfer food from mouth to pharynx.
Etiologies: stroke, advanced dementia, oropharyngeal malignancy, neuromuscular disorders (myasthenia gravis) Presentation: coughing, choking, nasal regurgitation on swallowing
Complications: aspiration pneumonia + weight loss
Dx: videofluororscopic modified barium swallow study to evaluate swallowing mechanics, degree of dysfunction, + severity of aspiration
36
What is esophageal dysphagia?
Sensation of food getting stuck in esophagus (not throat) a few seconds after a swallow.
Does not cause difficulty initiating swallowing.
37
What is carcinoid syndrome?
Presentation: skin - flushing, telangiectasias, cyanosis; GI - diarrhea, cramping; cardiac - valvular lesions (R>L; murmur of tricuspid regurg; episodic pounding sensation due to flushing and assoc. rise in pulse rate); pulm - bronchospasm; miscellaneous: Niacin deficiency (dermatitis, diarrhea, dementia)
Dx: elevated 24h urinary excretion of 5HIAA, CT/MRI of abdomen + pelvis to localize tumor, octreoScan to detect metastases, echocardiogram (if sxs of carcinoid heart disease are present)
Tx: octreotide for symptomatic pts; prior to surgery/anesthesia; surgery for liver metastases
38
What is infective endocarditis?
R sided infective endocarditis is assoc. w. IV drug use.
Presentation: fever, malaise, arthralgias, vascular or immunologic phenomena, and new valvular regurgitant murmur
No flushing or diarrhea present.
39
What is celiac disease?
Suspect if there is malabsorption and diarrhea.
Features of malabsorption:
general - bulky, foul-smelling, floating stools; fat and protein - loss of muscle mass, loss of sub-q fat, fatigue; Fe - pallor (anemia), fatigue; Ca and Vit. D - bone pain (osteomalacia), fracture (osteoporosis); Vit. K - easy bruising, Vit. A - hyperkeratosis
Confirmatory tests - antibodies and duodenal biospy
Biospy: villous atrophy
Labs: IgA anti-tissue transglutaminase, IgA anti-endomysial antibodies
Selective IgA deficiency is common, so measure total IgA or IgG
40
What is collagenous colitis?
Chronic watery diarrhea.
Colon is frequently involved, but colonoscopy shows normal mucosa.
Biopsy: subepithelial collagen depositon
41
What is an endoscopic retrograde cholangiopancreatogram (ERCP)?
Primarily used for suspected choledocholithiasis
Usually performed in pts when initial U/S or CT scan suggests presence of obstruction due to cholelithiasis or malignancy; used to visualize and intervene upon biliary and pancreatic ducts; widely used for stone removal, tissue sampling, stent placement, and sphincterotomy
ERCP in these settings can be both diagnostic and therapeutic by relieving obstruction and facilitating biliary drainage.
Indicated for gallstone in common biliary duct causing CBD dilation; acute cholangitis.
Most common complication is post-ERCP pancreatitis
42
What is alcoholic hepatitis?
Seen in pts w/ hx of chronic heavy alcohol use
Presentation: jaundice, anorexia, fever, RUQ or epigastric pain, abdominal distension due to ascites, proximal muscle weakness from muscle wasting (if malnourished), possible hepatic encephalopathy
Labs/imaging: Elevated AST/ALT, 300-500, AST:ALT >=2, elevated gamma-glutamyltransferase, ferritin (acute phase reactant), bilirubin, MCV, and/or INR, leukocytosis, predominantly neutrophils, decreased albumin if malnourished, abdominal imaging may show fatty liver
43
What can exacerbate hepatic encephalopathy?
```
Hypokalemia: resultant intracellular acidosis (excreted intracellular K replaced by H ions to maintain electroneutrality) causes increased NH3 production (glutamine conversion) in renal tubular cells
Metabolic alkalosis (elevated bicarb): promotes conversion of NH4+ (ammonium), which cannot enter CNS, to NH3 which can enter CNS
NH3 made to offset decrease in H
```
44
What is primary sclerosing cholangitis?
Presentation: fatigue and pruritis; majority of pts are asx at time of dx; about 90% have underlying IBD, mainly UC
Labs/imaging: cholestatic liver function pattern, elevated ALP (serum aminotransferases typically <300), multifocal stricturing/dilation of intrahepatic and/or extrahepatic bile ducts on MRCP
Elevated ESR, IgM; positive perineutrophil cytoplasmic antibody (ANCA)
Liver biopsy: fibrous obliteration of bile ducts w/ concentric replacement by connective tissue in an "onion-skin" pattern
Complications: intrahepatic and/or extrahepatic biliary stricture, cholangitis and cholelithiasis (cholesterol and/or pigment stones), cholangiocarcinoma (10-15% lifetime risk), cholestasis (e.g., decrease in fat-soluble vitamins, osteoporosis), colon cancer
45
What is medication-induced/pill esophagitis?
Etiology: tetracyclines - acid effect; aspirin and NSAIDs - disruption of gastroesophageal protection; alendronate, risedronate; KCl, Fe - osmotic tissue injury
Presentation: sudden onset of retrosternal pain and severe odynophagia
Pts may be unable to swallow saliva due to PAIN
Most common in mid-esophagus due to compression by aortic arch or an enlarged L atrium
Dx: endoscopy which shows discrete ulcers w/ relatively normal-appearing surrounding mucosa
Tx: stopping offending medication
46
What is pancreatic adenocarcinoma?
Assoc. b/n psychiatric manifestation (something bad is going to happen; feeling low for no reason) and pancreatic cancer is well documented
New onset DM, thin, older pts = pancreatic cancer
Risk factors: smoking (most significant; reversible), hereditary pancreatitis 1st degree relative with pancreatic cancer, germline mutations (BRCA1,2, peutz-jeghers syndrome), environmental (nonhereditary chronic pancreatitis, obesity and lack of physical activity)
Presentation: most common (epigastric gpain that is progressive and constant often radiating to the flanks or the back); systemic sxs (e.g. wt loss, anorexia), epigastric abdominal pain radiating to the back (worse at night, w/ eating, or when lying supine), jaundice, recent onset atypical DM in thin/older pt, unexplained migratory superficial thrombophlebitis/Trousseau's, hepatomegaly and ascites w/ metastasis; distended gb/painless jaundice (head), ab pain/no jaundice (body/tail)
Labs: cholestasis (increased ALP and direct bilirubin, intra and extrahepatic dilation), increased cancer assoc. antigen 19-9 (not as a screening test), abdominal U/S if jaundiced (= cancer in head of pancreas), CT scan w/ contrast (if no jaundice = cancer in body and tail of pancreas)
Dx workup: CT scan of the abdomen
47
What is Zollinger-Ellison Syndrome?
Etiology: sporadic or MEN1 gene mutation;
Recurrent peptic ulcer disease with multiple ulcers and jejunal ulceration + assoc. chronic diarrhea; excess gastric acid in small intestine causes diarrhea and steatorrhea due to inactivation of pancreatic enzymes and injury to mucosal brush border
Presentation: dyspepsia, reflux sxs, abdominal pain, wt loss, diarrhea, frank GI bleeds
Endoscopy: thickened gastric folds, multiple peptic ulcers, refractory ulcers despite PPI use, ulcers distal to duodenum in jej (suggesting excess gastric acid that can't be fully neutralized in duo)
Labs: fasting serum gastrin >1000 in the presence of normal gastric acid (pH <4)
Work-up: endoscopy, CT/MRI and somatostatin receptor scintigraphy for tumor localization
48
What is a jejunal ulcer?
Usually due to gastric acid hypersecretion rather than local tumor invasion.
49
What is a duodenal ulcer?
Etiology: H. pylori or NSAIDs; a result of acid secretion in absence of food buffer
Presentation: epigastric pain occurs in absence of food buffer (e.g., 2-5h after meals, on an empty stomach, or at night), GI bleed, and anemia
Pain improves after eating.
Dx: endoscopic biopsy or urea breath test
Tx: PPI and antibiotic eradication therapy
50
What is a false-positive D-xylose test?
Low urinary D-xylose level despite normal mucosal absorption.
Seen in delayed gastric emptying, impaired glomerular filtration, small intestinal bacterial overgrowth (SIBO)
51
What is small intestinal bacterial overgrowth (SIBO)?
Occurs when bacteria from colon are inappropriately present in small intestine.
Alteration in small intestinal flora (due to abnormal intestinal anatomy or motility), leading to bacterial fermentation of the d-xylose before it can be absorbed.
Assoc. w/ underlying motility disorders (e.g., DM) or anatomical abnormalities (e.g., jejunocolic fistula)
Presentation: abdominal pain, bloating, flatulence, watery diarrhea, diarrhea is frequently greasy.
Dx: jejunal aspiration demonstrating high bacterial concentration, however test is invasive and not easily performed; more commonly diagnosed by positive carbohydrate breath test using either glucose or lactulose (pts w/ SIBO have an earlier peak in breath hydrogen/methane due to carb metabolism in SI, compared to those w/o SIBO where carb metabolism normally occurs in the colon)
Tx: rifaximin, neomycin to reduce bacterial load
52
What s esophageal (peptic) stricture?
Etiology: GERD, radiation, systemic sclerosis, caustic ingestions
Presentation: symmetric and circumferential narrowing of esophagus on barium swallow w/ dysphagia for solids but typically no wt loss
As it progresses, it can block reflux leading to improvement of heart burn symptoms
Dx: endoscopy (can be therapeutic)
53
What is barium swallow?
Useful for evaluating esophageal abnormalities (e.g., dysphagia, odynophagia) or documenting aspiration.
54
How do you manage gallstones?
Gallstones w/o sxs: no treatment necessary in most patients
Gallstones w/ typical biliary colic symptoms: elective laparascopic cholecystectomy, possible ursodeoxycholic acid in poor surgical candidates
Complicated gallstone disease (acute cholecystitis, choledocholithiasis, gallstone pancreatitis): cholecystectomy w/in 72h
55
What is a hiatal hernia?
Common disorder that occurs when contents of abdominal cavity herniate through diaphragm into thoracic cavity at esophageal hiatus.
Etiology: laxity of phrenoesophageal membrane due to age-related degeneration or repetitive stress (e.g., vomiting, coughing)
Asx pts require no further evaluation beyond obs.
Pts w/ reflux sxs should be medically managed (eg PPI), those with refractory GERD sxs can be considered for antireflux surgery (e.g. Nissen fundoplication)
CXR: retrocardiac opacity, often w/ air fluid level w/in thoracic cavity
Barium swallow is most sensitive test for dx if there are sxs.
56
What is emphysematous cholecystitis?
Life-threatening form of acute cholecystitis more common in IC.
Risk factors: DM, vascular compromise (obstruction/stenosis of cystic artery), immunosuppression, gallstones
Presentation: fever, RUQ pain, n/v, crepitus in abdominal wall adjacent to gallbladder
Complications: gangrene and perforation
Dx: air-fluid levels in gb, gas in gb wall, pneumobilia (air w/in heaptobiliary sys), cultures w/ gas-forming clostridium, e. coli, UCB (from clostridium induced hemolysis), mildly elevated aminotransferases
Tx: emergeny cholecystectomy, broad-spectrum antibiotics w/ clostridium coverage (e.g, amp-sulbactam)
57
What is a mallory weiss tear?
Often seen in assoc. w/ alcohol abuse and hiatal hernia
Etiology: upper GI mucosal tear, caused by forceful retching (increased pressure), submucosal arterial or venule plexus bleeding
Presentation: vomiting, retching, hematemesis, epigastric pain
Labs/imaging: EGD confirms dx
Tx: most tears heal spontaneously, endoscopic tx for continual bleed with electrocoagulation or local injection of epinephrine
58
What is boerhaave syndrome/spontaneous esophageal rupture?
Etiology: Esophageal transmural tear, caused by forceful retching (increased pressure), esophageal air/fluid leakage into nearby areas (e.g., pleura)
Presentation: vomiting, retching, chest + upper abdominal pain, odynophagia, fever, dyspnea + septic shock can ensue, subcutaneous emphysema may be seen
Labs/imaging: CT or contrast esophagography w/ gastrofin confirms diagnosis;
CXR: pneumomediastinum and L unilateral pleural effusions; pleural fluid analysis: exudative, low pH, very high amylase (>2500; due to saliva in the esophageal contents)
Tx: surgery - for thoracic perforations, conservative measures (eg, antibiotics) - for cervical perforations
59
What is perforated viscus?
GI perforation
Etiology: hx of NSAID and alcohol use, peptic ulcer disease
Presentation: severe abdominal pain, fever, tachycardia, signs of peritonitis (rigidity, reduced bowel sounds, rebound tenderness, guarding), positive stool guiac test
Dx: upright xray of chest and abdomen showing free intraperitoneal air under the diaphragm
Tx: urgent exploratory laparatomy
60
What is a psoas absecess?
Etiology: hematologic seeding from a distant infection or from direct extension of an intraabdominal infection (eg diverticulitis, vertebral osteomyelitis)
Risk factors: HIV, IV drug use, DM, Crohn disease
Presentation: subacute fever, abdominal/flank pain radiating to groin, anorexia, wt loss, abdominal pain w/ hip extension (psoas sign)
Dx: CT scan of the abdomen and pelvis, leukocytosis, elevated inflammatory markers, blood and abscess cultures
Tx: drainage, broad-spectrum antibiotics
61
What is cholangiocarcinoma?
Highly lethal malignancy of bile duct epithelium
Risk greatest in those w/ fibropolycystic liver disease or primary sclerosing cholangitis due to underlying UC
Presentation: UC, subacute RUQ pain, wt loss, biliary obstruction (eg jaundice, dark urine, pruritus, elevated ALP, dilated intrahepatic/common bile ducts), hepatomegaly/palpable RUQ mass
Labs: elevated carcinoembryonic antigen (CEA) and CA19-9, normal AFP
Dx: Endoscopic US or ERCP for tissue dx
62
What is esophageal rupture?
Etiology: spontaneous rupture (boerhaave syndrome), instrumentation (endoscopy; most common cause), esophagitis (infectious/caustic), esophageal ulcer
Presentation: chest/back and abdominal pain, sys findings (fever), subcutaneous emphysema in the neck, hamman sign (crunching sounds on chest auscultation); pleural effusion w/ atypical (eg green fluid)
Dx: CXR or ct scan - wide mediastinum, pneumomediastinum, pneumothorax, air around paraspinal muscles, L-sided pleural effusion (late)
CT scan - esophageal wall thickening, mediastinal air fluid level; water-soluble contrast esophagogram (gold standard) - leak at perforation site
Mgmt: NPO, IV antibiotics, PPIs, and supportive care for all pts, surgical repair for significant leakage with sys inflammatory response
63
What is toxic megacolon?
May be the initial presentation of IBD.
RF: IBD, C diff infection/complication of UC
Etiology: ischemic colitits, volvulus, diverticulitis, infections, obstructive colon cancer
Presentation: systemic toxicity (fever, tachycardia, hypotension, high WBC, anemia), bloody diarrhea, abdominal distension/peritonitis
Dx: colonic distention (>6cm dilation of right colon), marked colonic distension on XR (thick haustral markings that do not extend across the entire lumen)
Mgmt: bowel rest, NG suction, antibiotics, +/- IV corticosteroids if IBD associated, surgery (subtotal colectomy w/ end-ileostomy) if unresponsive to medical mgmt; about 50% of pts improve w/ conservative mgmt and corticosteroids
Barium enema and endoscopic evaluation are contraindicated due to risk of PERFORATION.
64
What is acalculous cholecystitis?
Acute inflammation of gb in absence of gallstones; Most often seen in severely ill pts.
RF: severe trauma/recent surgery, prolonged fasting or TPN, critical illness
Likely due to cholestasis and gall bladder ischemia, leading to secondary infection by enteric organisms, resultant edema and necrosis of gb.
Presentation: fever, leukocytosis, increased LFTs, RUQ pain, jaundice and RUQ mass less common
Imaging: gb wall thickening and distension, presence of pericholecystic fluid
Dx: abd US (preferred), HIDA/CT if needed: gallbladder wall thickening and distention and presence of pericholecystic fluid
Tx: antibiotics followed by percutaneous cholecystostomy; cholecystectomy w/ drainage of assoc. abscesses is definitive therapy once medical condition stabilizes
65
What is blunt genitourinary trauma?
Common renal lesions are contusions, laceration, and renovascular injuries.
Dx: urinalysis for all pts, contrast-enhanced CT for HDS pts w/ evidence of hematuria; HD unstable pts w/ evidence of renal trauma should undergo IV pyelography prior to surgical evaluation
Retrograde cystourethrograms evaluate urethral injury and bladder rupture; pts typically have gross hematuria, difficulty urinating, and blood at the meatus or suprapubic pain
66
What is the clinical manifestation of chromium deficiency?
Impaired glucose control in diabetics.
67
What is the clinical manifestation of copper deficiency?
Skin depigmentation, brittle hair, osteoporosis, neurologic dysfunction (eg ataxia, peripheral neuropathy), sideroblastic anemia
68
What is the clinical manifestation of selenium deficiency?
Thyroid dysfunction, cardiomyopathy, immune dysfunction.
69
What is the clinical manifestation of zinc deficiency?
Alopecia, pustular skin rash (perioral region and extremities), hypogonadism, impaired wound healing, impaired taste, immune dysfunction
Can be due to malabsorption (eg Crohn's, celiac disease), bowel resection, gastric bypass, or poor nutritional intake
70
What is a duodenal hematoma?
Most commonly occurs after blunt abdominal trauma when blunt force rapidly compresses duodenum against vertebral column.
Commonly seen in children.
Presents 24-36h after injury with epigastric pain and vomiting due to failure to pass gastric contents past obstructing hematoma.
Dx: CT of abdomen
Tx: most resolve in 1-2w; decompression by NG tube, parenteral nutrition;
surgery or percutaneous drainage if nonoperative mgmt fails
71
What is sphincter of oddi dysfunction?
Develops after inflammatory process (surgery, pancreatitis), due to dyskinesia and stenosis of SOD; opioids cause sphincter contraction and precipitate sxs
Leads to retention of bile, causing functional biliary disorder
Presentation: recurrent, episodic pain in RUQ or epigastric region
Labs: elevations in aminotransferase and ALP
Imaging: dilated common bile duct in absence of stones
Dx: manometry is gold standard
Tx: sphincterotomy is TOC
72
What are solid liver masses?
Focal nodular hyperplasia: assoc. w/ anomalous arteries, arterial flow and CENTRAL SCAR/radiating fibrous bands on imaging; hyperdense lesion (filled w/ contrast during hepatic arterial phase)
Hepatic adenoma: R lobe; centripetal enhancement on triphasic CT scan; women on long-term OCPs, possible hemorrhage or malignant transformation; well demarcated, hyperechoic lesions on US
Regenerative nodules: acute or chronic liver injury (eg cirrhosis)
Hepatocellular carcinoma: systemic sxs, chronic hepatitis or cirrhosis, elevated AFP
Liver mets: single/multiple lesions, known extrahepatic malignancy
Hepatic angiosarcoma: rare, common in older men exposed to TOXINS (vinyl chloride gas, inorganic arsenic compounds, thorium dioxide)
73
What is acute mesenteric ischemia?
Presentation: severe pain w/ eating (intestinal angina), food aversion; pain is intermittent
Rapid onset of periumbilical pain (often severe); pain out of proportion to exam findings; hematochezia (late complication)
Risk factors: atherosclerosis (acute on chronic), embolic source (thrombus, vegetations), hypercoaguable disorders
Labs: leukocytosis, elevated amylase and phosphate levels, metabolic acidosis (elevated lactate)
Dx: CT (preferred) or MR angiography, mesenteric angiography (invasive), if dx is unclear
74
What is a small bowel obstruction?
Etiology: Adhesions (most common cause, post op); prior surgery (weeks to years)
Abd exam: distension, increased bowel sounds
Complete proximal: early vomiting, abd discomfort,
Mild/distal: colicky pain, delayed vomiting, prominent abd distension, constipation-obstipation, hyperactive bowel sounds
N/V/abd bloating, dilated loops of bowel w/ air fluid levels on abd XR
Small bowel dilation: present
LB dilation: absent
Tx: conservative (bowel rest, NG tub suction, correction of metabolic derangements), complicated - emergent abd exploration
75
What is ileus?
Etiology: recent surgery (hours to days), metabolic (eg hypokalemia), medication induced
Abd exam: possible distenstion, reduced/absent bowel sounds
N/V, abd distension, obstipation, hypoactive bowel sounds that persist post-op
SB and LB dilation: present on XR
XR: dilated gas filled loops of bowel w/ no transition point
Opioids make it worse.
Mgmt: bowel rest, supportive care
76
What is gastric outlet obstruction?
Etiology: gastric malignancy, peptic ulcer disease, Crohn's, strictures (w/ pyloric stenosis) 2/2 to ingestion of caustic agents, gastric bezoars
Presentation: Postprandial pain, non-bilious vomiting w/ early satiety, abdominal succussion splash (retained gastric material >3h after meal generate splash sound indicating presence of hollow viscus filled w/ fluid + gas)
Dx: upper endoscopy
Tx: initially - NG suctioning to decompress stomach, IV hydration; surgery
77
What is gastric cancer?
Presentation: persistent mid-epigastric abdominal pain worse with eating (due to irritant effects of gastric acid on the tumor), n/v, wt loss, microcytic anemia (b/c friable tumor vessels ooze blood into gastric lumen - slow bleed), hepatomegaly (due to mets to the liver)
RF: Eastern Asian, Eastern European, South American descent, H pylori infection, pernicious anemia, smoking
Labs: elevated ALP, AST, ALT, hypoalbuminemia (sign of liver failure)
Dx: EGD to visualize stomach and biopsy suspicious lesions;
CT abdomen to stage disease
78
What is dumping syndrome?
Etiology: common postgastrectomy; caused by loss of nl action of pyloric sphincter due to injury or surgical bypass leading to rapid emptying of hypertonic gastric contents into duo and small intestine
Presentation: abdominal pain, diarrhea, nausea, hypotension/tachycardia; dizziness/confusion, fatigue, diaphoresis
Timing: 15-30m after meals
Pathogenesis: Rapid emptying of hypertonic gastric contents
Initial mgmt: small/frequent meals; replace simple sugars w/ complex carbohydrates; incorporate high-fiber and protein-rich foods
If refractory: trial of octreotide or reconstructive surgery
79
What is a zenker diverticulum?
Etiology: upper esophageal sphincter dysfunction and esophageal dysmotility
Most common in elderly pts, men; occurs due to posterior herniation between fibers of cricopharyngeus muscle; develops immediately above upper esophageal sphincter
Presentation: dysphagia, regurgitation, halitosis, palpable diverticula/neck mass if large, at risk for aspiration pneumonia
Dx: contrast esophagram
Tx: surgical repair
80
What is warfarin reversal?
If pt is on warfarin, reversal of anticoagulation must be rapidly achieved pre-operatively by infusion of FFP.
81
What is steatorrhea?
Etiology: commonly caused by pancreatic exocrine insufficiency (loss of digestive enzymes) in pts w/ chronic alcoholic pancreatitis
Presentation: wt loss, loose, greasy, malodorous stools that float in the toilet, difficult to flush consistent w/ fat malabsorption
Tx: alcohol cessation and pancreatic enzyme supplementation in such pts
82
What are the common causes of steatorrhea?
Pancreatic insufficiency: chronic pancreatitis due to etoh abuse, cystic fibrosis, or autoimmune/hereditary pancreatitis; pancreatic cancer
Bile-salt related: small bowel crohn disease, bacterial overgrowth, primary biliary cirrhosis, primary sclerosing cholangitis, surgical resection of ileum (at least 60-100cm)
Impaired intestinal surface epithelium: celiac disease, AIDS enteropathy, giardiasis
Other rare causes: whipple disease, zollinger-ellison syndrome, medication induced
83
What is diverticular disease?
Presentation: LLQ pain, fever, leukocytosis, bladder sxs (urgency, frequency, dysuria, sterile pyuria)
RF: chronic constipation, low fiber, high fat diet
Uncomplicated: mgmt with bowel rest, oral abx, obs
Complicated: diverticulitis assoc. w/ an abscess, perforation (rigidity and guarding), obstruction, or fistula formation;
-fluid collection <3cm can be treated with IV abx and obs;
-fluid collection >3cm tx with CT guided percutaneous drainage
Surgical drainage and debridement if sxs are not controlled by 5th day
Dx: Abd CT (oral and IV contrast)
Sigmoid resection for pts w/ fistulas, perforation w/ peritonitis, obstruction, or recurrent attacks of diverticulitis
CT - soft-tissue stranding and colonic wall thickening
Mgmt: bowel rest, abx (cipro, metro)
84
What is a perianal abscess?
Etiology: due to occlusion of anal crypt gland, which can lead to bacterial infection
Presentation: indurated, erythematous mass near anal orifice; severe, constant anal pain and low grade fever
RF: anoreceptive intercourse, constipation
Untreated perianal abscess often progress to form anorectal fistula
Tx: incision and drainage
85
What is blunt abdominal trauma?
Presentation: "seat belt sign" (ecchymosis over the abdomen in pattern of seat belt), hypotension, rebound tenderness, abdominal guarding/distension, coexisting femur fracture
Dx: All pts, even those w/o specific signs of intra-abdominal injury, should be assessed for intraperitoneal free fluid/hemorrhage
FAST exam evaluates both abdomen and pericardium for evidence of organ injury/hemorrhage, should be first step in alert/HDS pts
Urgent exploratory laparotomy if there is perforation identified
86
What is a HIDA scan?
Used to diagnose acute cholecystitis, where abd US is equivocal, by demonstrating cystic duct obstruction.
87
What is the RUQ U/S used for?
To identify cholecystitis or biliary dilation due to cholangitis.
88
What is CT scan of the abdomen used for?
Most sensitive method for dx perforation (bowel wall, pancreatic/biliary duct) and it demonstrates intra-abdominal or retroperitoneal free air.
89
What is MR cholangiopancreatography (MRCP)?
Used to evaluate biliary and pancreatic ducts for stones, structural abnormalities (eg biliary duct perforation) and pancreatitis; obtained in those w/ suspected biliary obstruction or cholangiocarcinoma
However, it is expensive and timely.
90
What is biliary colic?
Occurs when the gb contracts against a gallstone temporarily blocking the cystic duct
RF for gallstone disease: female sex, >40yo, hypertriglyceridemia, obesity
Presentation: dull postprandial RUQ or epigastric pain that worsens over an hour and subsides w/ gb relaxation; nausea, vomiting, diaphoresis
Labs: WBC, LFTs normal
Most gallstones are radiolucent and may not be detected on abdominal XR or CT scan
Dx: RUQ abdominal US
91
What is a splenic abscess?
A rare, life-threatening complication of bacteremia from a distant infection (eg infective endocarditis, cholecystitis)
RF: immunocompromise from HIV, hematologic malignancy, diabetes mellitus*
Presentation: persistent fever, LUQ pain (sometimes radiating to the back) w/ or w/o splenomegaly; anorexia and wt loss may also be seen
Labs: leukocytosis w/ left shift, CXR frequently reveals an elevated left hemidiaphragm (and/or left pleural effusion)
Dx: CT scan of abdomen
Tx: abx + splenectomy
92
What is eosinophilic esophagitis?
Common in young men (20-30yo)
Pathogenesis: chronic, immune-mediated esophageal inflammation
More than 50% of pts have hx of food impaction
Progressive esophageal inflammation from untreated EoE leads to stricture formation
Presentation: intermittent solid food dysphagia, refractory heart burn despite PPI, substernal chest/epigastric pain; reflux/vomiting, inability to tolerate liquids (eg vomiting after drinking water); food impaction; associated atopy (eg seasonal allergies, eczema, asthma); drooling/hypersalivation
Dx: endoscopy and esophageal biopsy (>=15 eosinophils per hpf), food bolus removal
Tx: dietary modification, +/- topical glucocorticoids (eg fluticasone, budesonide); stricture dilation may be required if there is no response to medical therapy
93
What is metoclopramide (+prochlorperazine)?
Dopamine antagonist; anti-emetic
Side effects: acute dystonia (an extrapyramidal sx) - can develop w/in h to d, akathisia, and parkinsonism
Tx: discontinuation, anticholinergic (eg benztropine) or diphenhydramine
94
Cystic fibrosis
Autosomal recessive
Associated with meconium ileus.
Nearly all patients develop sino-pulmonary disease.
under 20y: bacterial colonization with s. aureus
over 20y: bacterial colonization wtih p. aeruginosa
95
What are common complicatioins of giardiasis?
Lactose intolerance and fat malabsorption.
96
What is breastfeeding jaundice?
```
Exaggerated UCB (indirect>direct) hyperbilirubinemia in the 1st week of life caused by insufficient intake of breast milk which leads to delayed stooling which leads to decreased bilirubin elimination + increased enterohepatic circulation.
Poor intake: dehydration, decreased bilirubin delivery to the liver + decreased conjugation
Etiology: mom (delayed milk production or inadequate milk supply, infrequent feeds); infant (poor latch, ineffective suck, falling asleep)
Tx: feed q2-3h
```
97
What is breastmilk jaundice?
"Human milk jaundice"
Physiologic jaundice (due to normal changes in neonatal bilirubin metabolism) persists beyond 1st week of life
Due to high levels of beta-glucuronidase in breast milk, which deconjugate intestinal bilirubin and increase enterohepatic circulation
No signs of dehydration or feeding difficulty
98
Acute cholangitis.
Etiology: gallstones, malignancy, or stenosis
RUQ pain + jaundice + fever (Charcots triad)
+ hypotension + AMS (Reynolds pentad)
AG metabolic acidosis may be present due to lactic acidosis in severe sepsis.
Imaging: dilations of intrahepatic and common bile duct
99
Intussusception.
Antecedent illness causes hypertrophy of peyer patches in lymphoid rich terminal ileum, thereby serving as a nidus for telescoping.
Children may draw up their legs in an attempt to relieve pain, but act normally b/n episodes.
Dx: u/s-guided AIR CONTRAST ENEMA, which can lead to nonoperative reduction of intussusception
If dx is uncertain, u/s may be performed to look for typical "target sign"
[Enema reduction of telescoped bowel carries a low risk of intestinal perforation. Although barium enema was once used to diagnose and treat intussusception, leakage of barium can cause peritonitis; therefore, air contrast enema is preferred.]
100
Inspissated stool (thickened or congealed).
In CF, can serve as a lead point due to an inability of the intestines to propel viscous stool effectively.
101
What is physiologic jaundice of the newborn?
All newborns on days 2-4 of life have physiologic jaundice due to indirect hyperbilirubinemia. Benign and resolves by 1-2 weeks.
- At brith, fetal RBCS are increased w/ a short life span resulting in high RBC turnover and increased bilirubin production
- Hepatic bilirubin clearance is decreased b/c UGT activity does not reach adult levels until age 2w. Eastern Asian newborns have decreased UGT compared to other ethnicities.
- Enterohepatic recycling is increased b/c the low bacterial load in the newborn gut results in slower conversion of bilirubin to urobilinogen for fecal excretion.
Frequent feeding promotes gut colonization and fecal excretion. Phototherapy may be indicated for rapidly rising levels of bilirubin to prevent kernicterus.
102
What is irritable bowel syndrome?
Recurrent abdominal pain, altered bowel habits w/ sxs that worsen/improve with bowel movements
Commonly occurs in younger women and is assoc. w/ fibromyalgia, depression, and anxiety
Alarm features include: nocturnal diarrhea, which suggests secretory diarrhea - sxs develop while fasting in the middle of the night
103
Mgmt of thrombosed hemorrhoids.
Sitz baths, stool softeners (docusate), topical anesthetics (eg lidocaine)
Incision or surgical excision can be considered, but most cases improve spontaneously.
104
Hepatocellular cancer.
Presents w/ decompensated liver failure (ascites, jaundice, hypoalbuminemia), wt loss, cachexia, hepatomegaly and a palpable liver nodule
Alpha fetoprotein, protein produced by the liver and yolk sac, is elevated in 50% of cases; therefore, AFP can serve as important diagnostic clue (when elevated) but cannot be used to rule out the diagnosis
Triple phase arterial contrast CT scan of the abdomen is diagnostic in most cases
105
Liver transplant + infection.
RUQ pain, high fever, hypotension, tachycardia, signficant leukocytosis
106
What is jejunal atresia?
bilious emesis, abdominal distension
Occurs due to VASCULAR ACCIDENT in utero that causes necrosis and resorption of fetal intestine leaving behind blind proximal and distal ends of intestine
RF: poor fetal gut perfusion from maternal use of vasoconstrictive meds or susbstances such as cocaine and tobacco
XR: triple bubble sign, gasless colon reflecting gas trapping in stomach, duodenum and jejunum
Tx: resuscitation, stabilization, surgial correction
Prognosis depends on length of affected bowel as well as pts gestation age and birth wt
107
What is duodenal atresia?
Assoc. w/ Down syndrome: ventricular and/or atrial septal defects
Results from failure of duodenum to recanalize
Presentation: polyhydramnios on u/s due to inability to swallow and remove amniotic fluid; abdominal distension b/c gas cannot pass the duodenum, bilious emesis, no distal intestinal gas
XR: double bubble sign (dilated stomach and duodenum)
Patients do not have yellow, seedy stools, as feeds cannot pass through the duodenum.
Tx: surgical repair
108
What is hirschsprung disease?
Abdominal distension, bilious emesis, delayed passage of meconium (age >48h)
Typically at level of rectosigmoid junction
XR: dilated loops of bowel
109
HPV
Can be transmitted via anorecptive intercourse and result in anogenital warts (condylomata acuminata)
Most warts are asymptomatic papules.
They are rarely assoc. w/ pain and usually not assoc. w/ fever.
110
Ascites.
Most commonly caused by cirrhosis.
| Cirrhosis most commonly caused by alcoholic liver disease and hep C.
111
What is peptic ulcer disease?
Epigastric pain + intermittent melena
Duodenal ulcer: worse on an empty stomach due to unopposed gastric acid empyting into duo, improves w/ food due to alkaline fluid secretion into the duo
Gastric ulcer: worse after eating due to increased acid secretion
DU mainly caused by either H. pylori or NSAIDs
Tx: PPI + abx (amox + clarithromycin)
Smoking apprears to increase the risk of peptic ulcer in pts infected w/ h pylori, but does not increase relapse following h pylori eradication.
112
What is congenital diaphragmatic hernia?
Abdominal viscera herniates into the chest resulting in pulmonary hypoplasia and pulmonary hypertension
Approx. 85% of cases occur on the L, 15% on the R
Polyhydramnios occurs as a result of esophageal compression
Deviation of abdominal viscera into the thorax results in concave (scaphoid) abdomen and barrel shaped chest= impaired L + R lung, and right sided heart sounds and fair R lung aeration
Tx: emergengency intubation with OT or NT due to hypoxia, respiratory distress
113
ERCP + pancreatititis.
Acute pancreatitis is the most common complication after ERCP and typically presents w/ abdominal pain radiating to the back, n/v.
Lipase and amylase levels will rise several hours after sxs onset whereas CT scans can be normal for up to 48h.
The most common complications in post ERCP pancreatitis which occurs in up to 10% of pts and is particularly prevent in those with sphincter of oddi dsyfunction.
114
GI fluid.
Rich in both hydrogen chloride and potassium chloride.
115
What is fecal elastase?
Noninvasive test w/ high sensitivity and specificity for severe pancreatic exocrine insufficiency.
Proenzyme produced in pancreatic acinar cells and activated by trypsin in duodenal lumen.
Low levels indicate severe exocrine insufficiency.
Low levels diagnostic for chronic pancreatitis.
Tx: pancreatic enzyme replacement
116
Fecal calprotectin
Increase occurs in pts with inflammatory bowel disease.
117
Colovesical fistula
Connection between the colon and bladder due to complication of acute diverticulitis; can also occur in pts w/ Crohn disease or malignancy of colon
Fecaluria (stool in urine)
Pneumaturia (air in urine)
UTIs (mixed flora w/ coliform organisms)
Dx: abdominal CT w/ oral or rectal (NOT IV) contrast shows contrast material in the bladder w/ thickened colonic and vesicular walls
Colonoscopy recommended to exclude colonic malignancy
Tx: surgical resection after resolution of infection
118
What is anorectal fistula (fistula in ano)?
Most often due to rupture of a perianal abscess w/ formation of a persistent sinus tract.
Sxs: pain w/ defecation and chronic discharge, pruritis
Mgmt: surgical intervention
119
What is post-cholecystectomy syndrome?
A persistent abdominal pain or dyspepsia either postop (early) or months to years (late) after cholecystectomy.
Etiologies: biliary (eg retained common bile duct stone, cystic duct stone) or extra biliary (eg pancreatitis, peptic ulcer disease)
Pts usually notice the same pain they had prior to surgery, new pain just after surgery, or the same pain that never went away.
Findings suggest common bile duct stones or biliary SOD dysfunction
Labs: elevated ALP, mildly abnormal serum LFTs, dilated common bile duct on abdominal u/s
Abdominal u/s followed by direct visualization (eg ERCP, MRCP) can establish dx and guide therapy toward causative factor.
120
Acute appendicitis
Develops after obstruction of the appendiceal lumen from a fecalith, cancer, or lymphoid follicular hyperplasia. The obstruction increases appendiceal intraluminal pressure, which occludes blood flow and results in ischemia.
121
Colonic polyps
Adenomas (adenomatous polyps) are considered neoplastic polyps w/ a high risk of malignant transformation: villous, large size >1cm, high # >=3 concurrent adenomas
Sessile (nonpedunculated) adenomatous polyps assoc. w/ increased risk of synchronous advanced neoplasia
Non-neoplastic polys: hyperplastic polyps (arising from hyperplastic mucosal proliferation), hamartomatous polyps (eg juvenile polyps, Peutz-Jeghers polyps), inflammatory pseudopolyps, submucosal polyps (lipomas, lyphoid aggregates) - low malignancy potential
122
What drugs can cause pancreatitis?
Diuretics (furosemide, thiazides)
Valproic acid
Drugs for inflammatory bowel disease (sulfasalazine, 5ASA)
Immunosuppressive agents (azathioprine)
HIV related meds (didanosine, pentamidine)
Antibiotics (metronidazole, tetracycline)
123
Acute pancreatitis complicated by hypotension.
Arises from intravascular volume loss secondary to local and systemic vascular endothelial injury.
Severe pancreatitis causes local release of activated pancreatic enzymes that enter vasc system.
This causes vasodilatioin, increased vascular permeability, and plasma leak into the retroperitoneum, resulting in systemic hypotension.
124
Acute viral hepatitis
Can present w/ upper abdominal pain in pts w/ recent travel to endemic regions.
Pt typically have assoc. jaundice and changes in stool color.
125
B12 deficiency + PPI
Older pts w/ a hx of chronic antacid use are at risk for B12 deficiency due to achlorhydria (absence of HCl).
Pts frequently have subtle neuro findings: LE paresthesias and signs of dorsal column injury (eg dimnished light touch/vibration sensation)
A serum B12 test is usually diagnostic
Methylmalonic acid or homocysteine testing may be required for confirmation in inconclusive cases
126
Hepatic adenoma
Young women on prolonged OCPs are at greatest risk for hepatic adenoma.
Although most lesions are benign and asymptomatic, life threatening complications such as malignant transformatioin or rupture can occur.
Rupture should be suspected in the setting of sudden-onset, severe RUQ pain and signs of hemorrhagic shock.
127
Hydatid cysts
Can occasionally rupture into the abdomen, leading to sudden-onset, RUQ pain, fever, and leukocytosis.
However, u/s would reveal a smooth, round cyst in the liver, not a solid liver mass.
128
What is wilson disease?
Commonly manifests in childhood or adolescence and should be suspected when psychiatric symptoms are accompanied by neurological dysfunction and/or abnormal liver function tests.
Rare, autosomal recessive; characterized by abnormal copper depositon in tissues such as liver, basal ganglia, and cornea
Presentation: liver disease, neuropsych disease
Imaging: steatosis, fibrosis-->inflammation, necrosis w/ hepatocyte ballooning and formation of Mallory bodies
Dx: low serum ceruloplasmin, increased urinary copper, Kayser Fleischer rings (due to copper deposition in Descemet's membrane)
129
Inguinal hernias (hernia located above inguinal ligament)
Can usually be managed w/ watchful waiting b/c hernia contents pass through a wider orifice.
130
Diverticular bleed
Most common cause of GROSS LGIB
Diverticulosis is common in the sigmoid colon, but diverticular bleed is more common in the R colon
Point of weakness in diverticulum reaches arterial supply
Bleeding is painless, large volume bleeding assoc./ lightheadedness and hemodynamic instability
Most resolve spontaneously
131
Colon cancer bleed
Tends to be chronic occult blood loss, with abdominal pain, altered passage of stool, and wt loss.
Gross bleeding is less likely.
132
Angiodysplasia bleed
Colonic angiodysplasia can cause painless bleeding in the R colon.
However, it is significantly less common than diverticular hemorrhage.
Usually causes low-volume (venous) bleeding, whereas diverticulosis can cause large volume arterial hemorrhage.
133
GI bleed and BUN
Pts w/ upper GI bleeding often have elevated BUN and elevated BUN/cr due to increased urea production (from intestinal breakdown of hemoglobin) and increased urea reabsorption (due to hypovolemia).
134
Ulcerative colitis + pregnancy
Pregnancy is high risk period for pts w/ UC due to worsening of disease due to placental cytokines
Hematochezia, abdominal pain, tenesmus (eg fecal urgency followed by straining and inability to defecate)
Maternal complication: worsening UC disease activity
Fetal risks: preterm delivery, small for gestational age
Mesalamine, TNFalpha-i are safe for continuation throughout pregnancy and breastfeeding (except sulfasalazine)
135
Shigellosis
Presents acutely w/ fevers, abdominal pain, tenesemus, and bloody diarrhea for up to 7d.
136
Hookworm infection
Cause abdominal pain, n/v, and microcytic anemia due to chronic GI blood loss.
However, hepatomegaly and elevated ALP/transaminases are uncommon.
Most cases are assoc. w/ peripheral eosinophilia (total peripheral eosinophils >7% or >500mm^3)
137
Urine test
Positive for reducing substances in pts w/ glucosuria, galactosuria.
138
What is acid steatocrit?
A test for fat malabsorption.
139
Esophageal cancer
Rarely causes food impaction.
| Tends to affect elderly pts and presents w/ progressive dysphagia (from solids to liquids) and wt loss.
140
What is ogilvie syndrome/acute colonic pseudoobstruction?
Typically presents w/ severe abdominal distension, pain, vomiting, and obstipation.
Common causes: electrolyte imbalance (hypokalemia, hypomagnesemia) and factors that lead to autonomic disruption of the colon (eg major surgery, neurologic disease, anticholinergic medication)
Dx: CT scan showing colonic dilation w/o anatomic obstruction
Tx: bowel rest and colonic decompression, sometimes aided by IV neostigmine
141
Roux en Y gastric bypass complications
Bypass induces wt loss by restricting food intake and promoting malabsorption.
Stomal stenosis is a potential complication that results from a narrowing of the gastrojejunal anasatamosis - usually occurs w/in first year of surgery likely due to local tissue ischemia and ulceration, leading to sxs of nausea, postrandial vomiting, gastroesophageal reflux, and dysphagia.
Dx and Tx: EGD
142
Gilbert's syndrome
Caused by reduced bilirubin glucuronidation and results in intermittent jaundice due to a mild, unconjugated hyperbilirubinemia.
Jaundice may be triggered by fasting or consumption of a fat-free diet, physical exertion, febrile illness, stress, or menstruation.
Mgmt: reassurance and supportive care
143
What is hereditary hemochromatosis?
Consider in pts who have elevated liver enzymes, DM, and skin hyperpigmentation.
Continued iron deposition can cause hepatic fibrosis and cirrhosis, skin pigmentation (sun exposed areas, scars, genitalia), DM (bronze diabetes), arthropathy, and hypogonadism (diminished libido, erectile dysfunction)
It can progress to cirrhosis and is assoc. w/ a signficantly increased risk for hepatocellular carcinoma.
Labs: elevated iron studies
Dx: HFE mutation
Tx: serial phlebotomy to deplete excess Fe stores
144
What is Reye syndrome?
A dangerous complication in children who receive aspirin for virus induced fever (influenza, varicella).
Hyperammonemia, transaminitis, coagulopathy (elevated PT, PTT, INR), n/v, hepatomegaly, and mental status changes (due to excess ammonia) are typical manifestations of fulminant failure and encephalopathy.
Biopsy: microvesicular steatosis ("think small children")
Aspirin use only for Kawasaki disease and rheum disease (juvenile idiopathic arthritis)
145
Macrovesicular fatty infiltration
Seen in alcoholic hepatitis and in obese patients w/
| Nonalcoholic fatty liver disease
146
What is microscopic colitis?
Disproportionately affects women age >60
RF: concurrent autoimmune conditions, smoking, meds (NSAIDs)
Presentation: chronic, watery diarrhea that may occur during periods of fasting and/or at night
Colonoscopy: growly normal appearing colonic mucosa however biopsy
-mononuclear infiltrate w/in lamina propria (lymphocytic colitis)
-thickened subepithelial collagen band (collagenous colitis)
Tx: budesonide, loperamide
147
Wernicke encephalopathy
May be seen in alcoholics due to poor dietary intake of thaimine.
Presents as altered mental status, ataxia, and nystagmus, but asterixis is NOT generally present.
148
Hepatic encephalopathy
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Tx involves identifying precipitant and lowering serum ammonia.
Nonabsorbable disaccharides (eg lactulose, lactitol) are preferred for lowering serum ammonia.
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149
Gallstone pancreatitis
Abdominal u/s is the most sensitive and specific imaging study to detect gallstones and should be performed in all pts suspected of gallstone induced pancreatitis.
CT scan not required if this is suspected.
Plain radiographs have low sensitivity for gallstones.
150
Motility disorder
Esophageal dysphagia to both solids and liquids w/ intermittent (esophageal spasm) or progressive (achalasia) symptoms
Esophageal dysphagia to solids generally reflects mechanical obstruction, sxs can also be progressive (eg from solids to liquids), which suggests a developing stricture or cancer, or intermittent.
151
Splenic rupture
Atraumatic splenic rupture is an uncommon but life-threatening complication of hematologic malignancy (CLL), infection, and systemic inflammatory disease, and anticoagulation increases the risk.
Pts develop acute abdominal pain, shock, and anemia.
Peritonitis and left shoulder pain may also be present.
152
Bile leak
Should be suspected in pts who develop fever, nausea, vomiting, and vague abdominal pain 2-10d after laparoscopic cholecystectomy.
Lab studies often reveal an elevated ALP and mildly elevated bilirubin w/ normal appearing bile ducts on imaging.
153
Anal cancer
Usually caused by HPV and occurs most often in men who have receptive anal intercourse and/or HIV infection.
Manifestations include anal bleeding, pain, sensation of fullness, and an anal mass or ulcerated lesion.
154
Secretory diarrhea
Occurs even during fasting or sleep
Due to increased secretion of ions;
stool osmotic gap is reduced <50
Etiology: bacterial infection, viral infection, congenital disorders of ion transport (CF), postsurgical changes
155
Osmotic diarrhea
Nonabsorbed and unmeasured osmotically active agents are presnt in the GI tract
Elevated osmotic gap >125
