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Maternal or environmental causes of CHD (1-2%) (are preventable!)

Pre-Gestational Diabetes: 50 % inc. risk (poorly controlled, not gestational DM): risk for VSD, Transposition (TGA), Coarctation (COA)

-Lupus: complete heart block (may do C-section, watch moms w. SLE)
-Infection (Viral): rubella in 1st 7 wks = Patent Ductus Arteriosus
-Substance Abuse: Severe FAS (EtOH) = 50 % have CHD


ERCP provides ??

ERCP provides the most accurate determination of the extent of the obstruction especially when bile duct diameter is >6mm, when ductal stones are seen on ultrasound, or when bilirubin is >4mg/dL

Sphincterotomy with stone extraction or stenting can be done as needed during this procedure


more Primary Sclerosing Cholangitis tx

Ursodeoxycholic acid can improve LFTs and decrease itching
Possible balloon intervention of some of the sclerosed areas
Possible stenting as a short term solution to relieve symptoms
Long-term stenting may increase complications
Liver transplantation for those with cirrhosis and clinical decompensation


Primary Sclerosing Cholangitis px

Average survival 9-17 years and up to 21 years in some studies
Survival may be less with a dominant bile duct stricture
Higher risk for colon cancer associated with longer survival
Survival rates with liver transplantation are as high as 85% at 3 years


tx: Acute bacterial cholangitis component of Primary Sclerosing Cholangitis

tx: Cholangitis

tx: cholecystitis

-abx against G-s: ciprofloxacin, 3rd generation cephalosporins, piperacillin/tazobactam, carbapenems

-abx against G-s (acutely IV) and ~2 weeks of p.o. agents
Ciprofloxacin/metronidazole, cefuroxime/metronidazole, amoxicillin/clavulanate

-gut rest, pain medications, and abx:
A cephalosporin + metronidazole
Fluoroquinolone + metronidazole
Carbapenem (imipenem, meropenem, ertapenem)


Ranson's criteria

Blood glucose > 200 mg/dL
Age in years > 55 years
Serum LDH > 350 IU/L
Serum AST > 250 IU/L
White blood cell count > 16000 cells/mm3
Within 48 hours:
Serum calcium less than 8.0 mg/dL
Hematocrit fall > 10%
Oxygen: PaO2 below 60mmHg
BUN rise more than 5 mg/dL
base deficit more than 4 mEq/L
Sequestration of fluids > 6 L

mnemonic GALAW AND CHOBBS: Glucose, Age, LDH, AST and Whites; Calcium, Hematocrit, Oxygen, BUN, Base, Sequestration.


pancreatitis complications: Pancreatic necrosis and fluid collections (pseudocysts)

can be acute or chronic and can be sterile or infected
This complication occurs in 5-10% of cases and is a frequent predictor of mortality
An infected pseudocyst can form a pancreatic abscess
Often associated with splenic vein thrombosis and L sided pleural effusions as well

about 50% mortality, not good candidate for sx, can only effectively drain thru tubes


tx of pancreatitis complications

Surgery should follow all severe cases especially with nercocosis/pseudocyst:
Some mild cases with stones may need a cholecystectomy or cholecystotomy
Necrosectomy may improve survival but patient must be good candidates: If possible delay until patient is stable and necrosis has organized
Internal or external drainage of pseudocysts a consideration as well:
Risk for infection, fistula formation

Mortality: 25% and if there is multiorgan failure present, 50%


Barium esophagography

Dysphagia patients often evaluated via barium swallow first before EGD is performed
If a high suspicion exists for a mechanical lesion, EGD often is done first
(intervention can be done at same time)


Esophageal Varices tx options

-Antibiotic prophylaxis: High risk of SBP (spont. bac. peritonitis) or pneumonia
-Vasoactive drugs: Somatostatin and octreotide – reduce splanchnic and hepatic blood flow
-Vitamin K
-Lactulose for encephalopathy which can complicate an acute variceal bleeding episode
-Emergent endoscopy: Banding or balloon tamponade


Esophageal Achalasia

Gradual, progressive dysphagia for solids and liquids
-Loss of peristalsis in the distal 2/3rds (smooth muscle) of the esophagus
-50% experience substernal chest pain
-Regurgitation of undigested food
-Patients may lift their chins or throw their shoulders back to get food to move through
-Barium esophagram with “bird’s beak” appearance to the distal esophagus (also looks like esophageal ca, but w. less systemic symps)
-Diagnosis confirmed with esophageal manometry



A peptic ulcer is a break in the gastric mucosa that can occur when usual defense factors are impaired or there is a hypersecretion of acid/low pH environment
-Ulcers extend through the muscularis mucosa and are over 5mm in diameter.
-May be singular or multiple
Lifetime prevalence in adults is 10%
Gastric ulcers are located most commonly in the antrum of the stomach (60%)
More common in smokers, drinkers, and men aged 30-55yo.


more perforated ulcer tx (after sx and abx)

PPI therapy should be initiated
-H2 blocker therapy is effective in the treatment of PUD, however PPIs have superior efficacy
-Caveat – H2 blockers remain the drugs of choice for patients taking other medications that require an acidic gastric environment (certain HIV medications, for example)
-Appropriate triple or quadruple H.pylori therapy if indicated


ZES dx: Most sensitive test is ??
what should be withheld??
what may be concurrently elevated implying ??
Why do CT ??

demonstration of an increased serum gastrin concentration >150pg/mL
-H2 blockers should be held for 24 hours, PPIs should be held for 6 days
-Withdrawal of PPI may cause massive gastrin hypersecretion and miserable results for the patient
-Concurrent elevated serum calcium suggests hyperparathyroidism and a possible diagnosis of MEN-I
-CT scan should be performed in an attempt to determine the site of the primary tumor and possible metastasis


Pre-Hepatic Etiology: Hemolysis can be investigated by examining ??

-Peripheral blood smear (and bone marrow smear)
-Measuring reticulocyte count, haptoglobin, lactate dehydrogenase (LDH), erythrocyte fragility and Coomb’s test (done by specialist, not PC)


drugs that can induce cholestasis (impaired hepatic excretion, C bill)

-Nitrofurantoin, oral contraceptives, anabolic steroids
-Erythromycin, cimetidine, chlorpromazine
-Prochlorperazine, imipramine, sulindac, and Penicillins

ALSO Post-operative Jaundice:
Occurs 1-10 days after surgery, 15% incidence after heart surgery


ascites flow chart: if refractory ascites despite max diuretic dose OR e-lyte abnormality/renal dysfunction at submax dose

-large-volume paracentesis w. colloid expansion (IV albumin)
-shunt placement: TIPS/sx shunt

if these fail, consider liver transplant


Term infant. Born via c section for failure to progress. Mom’s blood type is A+. Infant is A+ coombs negative. Mom is breastfeeding.
At 24 hours, infant is jaundiced

consider dehydration, just a little bit of colostrum
-slow gut, reabsorbing bilirubin
-C-section, not as much trauma
-asian races more hyperbili, harder to see on darker skin
-also worry about infection, (chorio/congenital infection)
-physiologic jaundice assoc. w. breastfeeding; Uncon.hyperbili that occurs after the first postnatal day and can last up to 1 week.
-3-5 pk for normal Hgb
-5-7 for premies
-more than 15 not physiologic


Rh and ABO incompatibility

-ABO and Rh (D) blood T/S for other isoimmune antibodies should be evaluated in all pregs
-if not done or mom is O or Rh-negative, the infant’s cord blood should be evaluated for a direct antibody (Coombs) test, blood type, and Rh determination.
-Mother-infant ABO incompatibility (more common than Rh- typically given Rhogam) occurs in approximately 15% of all pregnancies, but symptomatic hemolytic disease occurs in only 5% of these infants.


Maternal Blood type is O+
Infant Blood type is B+, COOMBs +
Reticulocyte count is 14 (high)
Hemoglobin is 17 (normal?)

hemorrhagic/hemolytic, due to ABO incompatability


TEF and VACTERL (if have one congenital problem, need to look for others)

V: Vertebral Hemivertebrae (etiology: sacral element agenesis, caudal regression, Dx: Plain radiography, spine US, MRI (if U/S +)
A: Anorectum Imperforate anus: Dx: Exam
C: Cardiac Structural congenital heart dz: Dx: Echo
T: TE fistula: Suspect with esophageal atresia
E: Esophageal atresia: Dx: NG tube passage with plain radiography
R: Renal Horseshoe kidney, renal collecting system anomalies: Dx: Renal ultrasound
L: Limb Radial hypoplasia, atresia: Dx: Plain radiography


diarrhea definitions

10L approximately entering duodenum, all but 1.5 L absorbed, colon absorbs rest less 200ml in stool lost
Definition: 200-300g in 24 hour period
Alternate Definition: more than 3 bowel movements per day or liquidity


N/V: Brainstem mediated in medulla, stimulated by:

-Afferent vagal fibers from GI viscera 5-HT3 receptors due to biliary or GI distention, mucosal or peritoneal irritation, or infections.
-Vestibular system, H1 and muscarinic cholinergic receptors
-Amygdala, sights/smells/emotion
-Chemoreceptor trigger zone (outside blood brain barrier): Rich in opioid, serotonin 5-HT3, dopamine D2 receptors


Early Goal Directed Therapy for Septic Shock

- 0.9 NS (saline) to achieve CVP 8-12 mmHg
- vasopressors to achieve MAP 65 or greater → given through central line (NOT iv → local necrosis)
- PRBCs to achieve Hgb 10 or greater