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GASTROINTESTINAL
Approach to GI bleeding
Upper GI Bleed
Gastric & duodenal Dyspepsia, H. pylori infx, NSAID use, anticoagulation, severe medical illness
ulcers
Chronic liver disease; portal HTN or risk factors for cirrhosis
Variceal bleeding
History of retching prior to hematemesis
Mallory-Weiss tear
Heartburn, regurgitation, dysphagia; usually small volume or occult
Esophagitis
NSAID use, heavy alcohol, severe medical illness; small volume or occult
Gastroduodenal
erosions
Progressive dysphagia, weight loss, early satiety, abd pain; small or occult
Esophageal /
gastric CA
Dieulafoy’s
Submucosal dilated arterial lesion massive GI bleed
Hemobilia
After aortic surgery* = prior aortic aneurysm / graft
Aoroenteric fistula
Lower GI Bleed
Diverticula
Painless, self-limited hematochezia – MC in pts < 60 yo
Angiodysplasia
Chronic blood loss (occult) OR painless hematochezia – MC > 60yo;
AORTIC STENOSIS*
Usually asymptomatic; occult blood positive stool
Colonic polyp
Age >50 yrs & usually asymptomatic; change in bowel pattern or microcytic
Colon cancer
anemia
Ischemic colitis
Risk for atherosclerosis & vascular disease; lactic acidosis*;
“thumbprinting”
Intermittent mild rectal bleeding w/ straining on BM
Hemorrhoids
Bloody diarrhea, fever, urgency, tenesmus & exposure history
Infectious colitis
History of condition; bloody diarrhea, tenesmus, abd pain, fever
Inflammatory
bowel dz
Meckel’s
Painless hematochezia in YOUNG pt & normal EGD & colonoscopy
diverticulum
Clinical
o Hematemesis: upper GI endoscopy
o Hematochezia: r/o rectal bleed (hemorrhoids) – COLONOSCOPY*
NOTE: YOUNG pt < 50yo with minimal BRBPR* office ANOSCOPY
colonoscopy if needed
o Melena: upper GI endoscopy THEN colonoscopy if no bleeding site
Hb degraded by bacteria in colon blood remained in GI tract for several hours
OTHER causes of dark stool: iron, spinach, charcoal, licorice
o Occult blood: colonoscopy* THEN upper endoscopy if no bleeding site
o **ALWAYS ask about NSAIDs / aspirin use and/or ANTICOAGULATION
Diagnosis
o Lab: stool guiac for occult blod; Hb/Hct; coags, LFTs
o BUN/Cr ratio (HIGH BUN) in UPPER GI bleed - if NO renal insufficiency! (b/c urea is
reabsorbed**)
Management
o Determine upper (hematemesis, melena) vs. lower (hematochezia) source
If suspect upper: upper endoscopy
If suspect lower: r/o upper source (endoscopy OR NG tube aspiration = neg if contains
bile*) colonoscopy
Hemodynami Large-bore IV access or central venous access
c
Resuscitation w/ IV fluids & blood products
stabilization Endotracheal intubation prior to endoscopy to prevent aspiration w/
ongoing UGI bleed
CBC, BMP; blood type & cross-match; coag profile; BUN & serum Cr
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All pts >50 yrs & all pts w/ underlying cardiac disease OR features of ischemia
IV PPI & endoscopic therapy (for high-risk) to risk of recurrent bleeding
Triple therapy for H. pylori for pts found to be infected
Prophylactic abx for all pts
1st line: Endoscopic band ligation or sclerotherapy & octreotide
2nd line: TIPS, balloon tamponade
1st line: colonoscopy & endoscopy
2nd line: arteriography when endoscopy NOT possible
3rd line: exploratory lap & segmental colectomy
APPROACH TO DYSPHGIA
WORKUP: barium swallow EGD (r/o malignancy) MANOMETRY*
APPROACH TO DIARRHEA
Acute vs. chronic
o Acute: INFECTIOUS or MEDICATIONS
Infectious
Viral: rotavirus, Norwalk* (+ nausea & vomiting)
Bacterial: Shigella, E. Coli, Salmonella, Campylobacter, C. perfringens, C. diff
o E. Coli is MOST COMMON traveler’s diarrhea cause*
o Shigella, Campylobacter, Salmonella: fever + blood**
o Food poisoning: NO fever and NO blood (S. aureus, C. perfringens)
o C. diff: associated w/ abx use
Protozoa: Giardia, entamoeba histolycia, cryptosporidium
Medications
Abx: C. diff**
Others: laxatives, antacids, digitalis, alcohol, chemotherapy
Malabsorption: lactose intolerance
Ischemic bowel: peripheral vascular disease + blood diarrhea + abd pain
o Chronic: IBS, IBD, meds (laxatives), infx, colon cancer, malabsorption
WORKUP
o Stool sample
Fecal leukocytes (if neg, NO cx) – ABSENT in VIRAL gastroenteritis
Test for OVA & PARASITES (esp for Giardia – enzyme-linked immunosorbent assay
test for ANTIGEN)
Stool sample: measure C. diff toxin (stool cytotoxin assay) & C. diff CULTURE
o Lab tests for INFLAMMATORY diarrhea
ESR, fecal leukocytes, elevated WBCs; reactive thrombocytosis (IBD)
Complications: METABOLIC ACIDOSIS & HYPOKALEMIA
Rx
o Hydration & correct electrolytes
o Antibiotics ONLY IF:
High fever, bloody stools, severe diarrhea = floruoquinolones
C. diff = metronidazole*, Giardia = metronidazole
o Loperamide (Imodium) = anti-diarrheal ONLY if diarrhea is mild
APPROACH TO CONSTIPATION
Causes
o Diet: lack of fiber
o Medications: anticholinergic (antipsychotic), NARCOTICS, IRON, Ca-channel blockers,
laxative abuse & dependence
o Obstruction: COLON CANCER, strictures, hemorrhoids
o
Dx
o R/O obstruction if HP suggestive – AXR
o Flexible sigmoidoscopy if suspect COLON CANCER
Complications
o Hemorrhoids, rectal prolapse, anal fissures, fecal impaction
Rx
o Diet & behavioral modifications
o ENEMA* - temporary relief if NO mvt
GI DISEASES
Diseases of Esophagus
GERD
o Pathophysiology: LES retrograde flow of stomach contents into esophagus
Gastric outlet obstruction, hiatal hernia***, other dietary (alcohol, coffee, smoking,
high-fat foods)
o Clinical: restrosternal pain/burning after EATING**; may mimic cardiac chest pain
Cough: aspiration or refluxed material or reflex-triggered
Hoarseness, sore throat, lump feeling
Usually NO DYSPHAGIA** - if dysphagia, then peptic stricture!
o Diagnosis
**diagnostic tests usually NOT NECESSARY for TYPICAL CASES!
24-hour pH monitoring ** = GOLD STANDARD = but usually unnecessary
Esophageal manometry: ONLY if MOTILITY issues!
Endoscopy w/ biopsy – if COMPLICATED or UNRESPONSIVE to treatment*
Complicated: dysphagia, odynophagia, weight loss, iron def anemia, bleeding
(overt or occult)
Upper GI series: only to detect strictures or ulcerations
o Complications
Erosive esophagitis: stricture, ulcer, Barrett’s
Peptic stricture: fibrotic rings obstruct food passage; dysphagia*
Esophageal ulcer: upper GI bleed?
Barrett’s esophagus: 10% - stratified, squamous COLUMNAR EPITHELIUM
**Symptomatic GERD for at least 5 yrs screen for Barrett’s esophagus
If Barrett’s screen every 3 years!
Recurrent pneumonia: ASPIRATION! = lipid-laden macrophages*
Laryngitis, pharyngitis
o Rx
Behavior modification – foods, antacids, change habits
Medical: H2 blocker and/or PPI; promotility agent (metoclopramide = DOPA-ant,
bethanechol = cholinergic)
Surgery: Nissen fundoplication*, partial fundoplication (if poor esophageal motility)
Esophageal cancer
o Types
Squamous: alcohol, tobacco use, diet*, Plummer-Vinson
Adenocarcinoma: GERD & Barret’s**
o Features
Dysphagia*, weight loss, anorexia, odynophagia (LATE finding), hematemesis,
hoarseness
Aspiration PNA, resp symptoms, chest pain
o Dx
Barium swallow*
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Upper endoscopy for DEFINITIVE diagnosis
TE ultrasound to determine staging
o Treatment
Palliative
Surgery (esophagectomy) if early disease; chemotherapy + radiation before surgery
Achalasia
o General
Incomplete relaxation of LES & aperistalsis of esophagus
o Causes
Idiopahic**; adenocarcinoma; CHAGA’S!
o Clinical features
Dysphagia: EQUALLY difficult swallowing solids & liquids
Regurgitation: food STUCK in esophagus
Chest pain & weight loss
PULMONARY COMPLICATIONS
o Dx
Barium swallow: “bird’s beak*, diffuse esophageal spasm
Upper GI endoscopy*: MUST r/o MALIGNANCY (esophageal & gastric CA) &
esophagitis
Manometry: CONFIRM DIAGNOSIS – failure of LES relaxation
o Rx
Pneumatic dilatation
Botulinium toxin injection* - relapse
Surgical myotomy: REFLUX is MAJOR complication!
o NOTE: DISTINGUISH dysphagia reasons with MANOMETRY findings
LES tone (failure to relaxa) = achalasia
LES tone (always open) = scleroderma
NORMAL LES tone = diffuse esophageal spasm
Schatzki’s Ring (distal esophageal webs)
o ALWAYS accompanies sliding hiatal hernia
o Si/sx: intermittent solid food dysphagia
Compare to esophageal stricture = CONSTANT solid food dysphagia
o Usually due to ingestion of alkali, acids, bleach or detergents
o Complications: stricture formation, esophageal cancer
o Rx: esophagectomy if full-thickness necrosis occurs* - avoid vomiting, gastric lavage and ALL
oral intake
Diffuse esophageal spasm
o General: uncoordinated contraction of esophagus
o Si/sx: spontaneous pain, odynophagia for COLD/HOT foods, intermittent CHEST PAIN*
o Dx: manometry = normal LES pres; repetitive, HIGH amp contractions, bariums
swallow = “corkscrew pattern”;
o Rx: NOTHING; reassurance*
Scleroderma
o General: connective tissue disorder
o Dx: manometry = wide-open LES* (NO tone or pressure)
Esophageal hiatal hernias
o General
Type 1 (sliding): GE jct and stomach into thorax*
Type 2 (paraesophageal): ONLY stomach – stomach remains below diaphragm* =
uncommon hernia can become strangulated & should be repaired SURGICALLY
o Diagnosis: BARIUM UPPER GI series & upper endoscopy
o Treatment
Type 1: medical*; surgery only if fail
Type 2: elective surgery due to complications
Mallory-Weiss Syndrome
o Mucosal tears near GE jct (distal esophagus OR stomach cardia) due to forceful vomiting
o Si/sx: hematemesis* (streaks to massive bright red blood)
o Rx: usually NOTHING; if SEVERE = vasopressin, endoscopic injection or electrocautery
Plummer-Vinson Syndrome = UPPER ESOPHAGEAL WEBS
o General: upper esophageal web, iron deficiency anemia, koilonychias (spoon-shaped
fingernails), atrophic oral mucosa
o risk of SCC of oral cavity, esophagus*
Esophageal diverticula
o MOST due to underlying motility disorder* = just above UES
ZENKER’S DIVERTICULUM* = upper 1/3 of esophagus
Muscles do not relax during swallowing intraluminal pressures outpouching of
mucosa
o Si/sx: dysphagia, regurgitation ASP PNA, halitosis, chronic cough, NECK MASS*
Traction diverticula: traction near tracheal birufcation* = tuberculosis!
Epiphrenic diverticula: lower 1/3 of esophagus – usually due to achalasia
o Dx: barium esophagography*
Esophageal perforation
o Etiology: BLUNT TRAUMA, forceful vomiting = Boerhaave’s Syndrome)
o Clinical: Hamman’s sign (mediastinal crunch) – heart beating against air-filled tissues
o Contrast esophagram
o CXR: air in mediastinum
o If pt stable & perforation is small = medical mgmt*
Esophagitis
o Allergic esophagitis
Cause: chronic inflam disorder of esophagus* - high igE
Dx: EGD = “scalloped appearance”; bx = dense eosinophilic infiltration
Rx: allergy testing & avoid; fluticasone or budesonide
o Pill-induced
Cause: potassium, NSAIDs, bisphosphonates, doxycycline
Rx: STOP offending med
o Opportunistic infx: diabetes or HIV
Candida, HSV, CMV* - if THRUSH = CANDIDA fluconazole
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Diseases of the STOMACH
Peptic ulcer disease
o Risk factors: H. pylori infx, NSAID use, Zollinger-Ellison; SMOKING, alcohol*
o Clinical: aching / gnawing epigastric pain
Duodenal ulcers
Gastric ulcers
Pathogene offensive factors
protective factors
sis
Malignanc LOW risk
HIGH 5-10%
y
Location
1-2 cm distal to pylorus Type: MC* lesser curvature
Risk
NSAIDs
Smoking
factors
Other
Eating RELIEVES pain Eating does NOT relieve pain
Nocturnal pain
High recurrence rates
o Diagnosis
CLINICAL* initially
Upper endoscopy; BIOPSY for H. Pylori
EGD immediately if alarm sx: n/v, hematochezia, weight loss, anorexia, anemia
24-hr pH monitor: ONLY for ATYPICAL (refractory, atypical sx, failure to respond ot PPI)
Lab tests: urease detection** (breath test) – ACTIVE infx & assess antibiotic
Serology: LOW specificity
Serum gastrin* = ONLY if concern for Zollinger-Ellison
o
Rx
Supportive: stop NSAIDs, restrict alcohol use, stop smoking
Acid suppression: PPIs*, H2 blockers, antacids (adjunc); ERADICATE H. Pylori
Classic heartburn: TRIAL w/ PPI if PERSISTS, then do endoscopy*
Misoprostol: risk of ulcer formation associated w/ NSAID = GI UPSET
*if H. pylori infx = TRIPLE (PPI + 2 abx) or quadruple (PPI + 2 abx + bismuth)
o Complications
Perforation
Sx: acute, severe abd pain, hemodynamic instability
Dx: free air on CXR
Rx: emergency surgery
Gastric outlet obstruction
Sx: n/v, epigastric fullness, early satiety
Dx: barium swallow & upper endoscopy
Rx: supplement nutrition, NG tube
GI bleeding
Gastritis
o ACUTE gastritis (similar to PUD)
NSAIDs/aspirin, H. pylori, alcohol, smoking, caffeine, extreme physiologic stress
o Type A: autoimmune / atrophic / anemia / achlorhydria = autoAbs against IF & parietal cells
Associated with pernicious anemia and gastric CA
o Type B: chronic gastritis* = due to H. pylori
Decreases absorption of thyroxine and ketoconazole*
H. pylori
o Dx
Urea breath tests: FIRST CHOICE for assessing rx
Fecal antigen test: primary dx**
Serologic: ONLY to confirm
Urease test: active disease & response to therapy* = less sensitive if on PPI or abx
o Rx
Triple drug: 2 abx (clarithromycin, amoxicillin) + PPI
Gastric cancer
o Risk factors
Severe atrophic gastritis, intestinal metaplasia, gastric polyps
H. pylori infx (3-6x risk)
Billroth II anastomosis (post-antrectomy)
Pernicious anemia**
Preserved food instake: high salt, nitrates, nitrites
o Metastases
Krukenbergy’s tumor: OVARY
Sister Mary Joseph’s Node: periumbilical LN
Virchow’’s Node: supraclavicular fossa nodes
Irish’s node: L axillary adenopathy
o Clinical
Abd pain, weight loss, appetite / anorexia, dyspepsia, early satiety
N/v, anemia, melena, guaiac + stool
o Diagnosis
Endoscopy w/ biopsies
Barium upper GI series
Abd CT: staging & mets
o **GASTRIC LYMPHOMA: non-Hodgkin’s lympha* = similar to adenoCA of stomach – EGD +
BIOPSY
Post-gastrectomy Syndromes
o Dumping syndrome: post-prandial vasomotor = sweating, palpitations, lightheadedness
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Rx: restriction of sweets, lactose-foods and frequent small meals
o Blind loop syndrome: bacterial overgrowth in LOOP fat & B12 malabsorption
Dx: low D-xylose absorption test*
o Afferent loop syndrome: abdominal bloating & pain 20 min after eating; vomiting
Gastroparesis
o Cause: DIABETICS* (type 1 DM), scleroderma / amyloidosis (infiltrative); CNS d/o
(Parkinson’s, SC injuries, post-vagotomy)
o Si/sx: n/v, early satiety
o Dx: radioisotope-labeled solid meal
o Rx: good hydration & nutrition, METOCLOPRAMIDE* (diabetics), erythromycin (NOT used)
Diseases of Small Intestine
Small bowel obstruction
o General
Partial vs. complete: pass gas or pass stool*
Closed vs. open loop: closed = TWO points of occlusion compromise blood supply
Proximal vs. distal: distal = EASIER diagnosis
Proximal: VOMITING, severe pain, less distension
Distal: less vomiting, SIGNIFICANT distension
o Pathophysiology
DEHYDRATION*: intestinal distension reflex vomiting hypochloremia,
hypokalemia, metabolic alkalosis
o Causes
Adhesions from previous abd surgery: MC
Incarcerated hernias
Malignancy, intussusception, Crohn’s, carcinomatosis, SMA syndrome*
o Clinical
OTHERS: abdominal free air***, peritoneal signs
Cramping abdominal pain
N/V, hematemesis, SHOCK
Obstipation: NO stool and flatus
Abdominal distension
o **Large bowel obstruction = volvulus, adhesions, hernias, COLON CANCER**
o Dx
AXR: AIR-FLUID LEVELS proximal to obstruction; dilated bowel loops
Barium enema: IDENTIFY site of obstruction
Upper GI: last resort
o Rx
OPERATION if FEVER, TACHYCARDIA, PERITONEAL SIGNS, LEUKOCYTOSIS
**correct HYPOKALEMIA
NG tube to decompress stomach
Abx
Exploratory lap to LYSE ADHESIONS and RESECT necrotic bowel
Paralytic ileus
o Causes: meds = narcotics, ANTI-CHOLINERGICS, post-op states, shock, HYPOKALEMIA,
peritonitis
o Dx: AXR = uniform gas everywhere; FAILURE to pass contrast medium beyond fixed point
o Rx: IV fluids, NPO, correct electrolytes, NG suction
Inflammatory bowel disease
Crohn’s
Ulcerative colitis
Terminal ileum; rectal-sparing RECTUM* proximal
Location
Transmural, DEEP
SHALLOW
SKIP lesions
CONTINUOUS
Clinical
DIARRHEA*; malabsorption
HEMATOCHEZIA*, tenesmus (rectal
dry heave)
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Patchy, COBBLESTONE
Non-caseating granulomas
Mesenteric “fat-creeping”
Complicati Abscesses & fistulas COLON CANCER
Iron deficiency anemia & hemorrhage
ons
perianal
Sclerosing cholangitis & cholangioCA
Malbasorption of vit B12 &
bile acids
Hypocalcemia
Systemic corticosteroids
Treatment Sulfasalazine (mesalamine =
5ASA)
Sulfasalazine (mesalamine = 5-ASA)
AZA, 6-MP
Surgical: often CURATIVE
Metronidazole
Systemic corticosteorids
(ACUTE)
Surgical: HIGH recurrence
o EXTRA-INTESTINAL
Eye: episcleritis* (WITH bowel disease) vs. anterior uveitis (INDEPENDENT)
Skin: erythema nodosum* (Crohn’s); pyoderma gangrenosum (UC) – tender red nodules
Mouth: ORAL APTHOUS ULCERS
Arthritis**: migratory monoarticular*, ankylosing spondylitis (UC), sacroilitis
Thromboembolic hypercoagulable state, DVT, PE, CVAs
ITP
Osoteoporosis
Primary sclerosing cholangitis (UC)
Irritable Bowel Syndrome
o General
Association w/ PSYCHIATRIC (dep, anxiety, somatization) = worsened by intestinal
stress & irritation
ALL tests NORMAL – no mucosal lesions
o Si/sx
Changes in FREQUENCY / CONSISTENCY of stool – diarrhea, constipation or
ALTERNATING
Cramping abd pain: relieved by DEFECTION
Bloating or feeling of abd distension
o Diagnosis – DX of EXCLUSION!!
R/O: OBSTRUCTION (AXR), IBD, lactose intolerance, malignancy* (colonoscopy, occult
blood in stool)
Carcinoid Syndrome
o General: serotonin-secreting neuro-endocrine tumor (MC in SMALL INTESTINE)
o Si/sx: flushing, valvular dz (TR), hepatic mets – Ds (diarrhea, dermatitis, dementia)
risk of NIACIN def
o Dx: urinary 5-HIAA levels*
Histology
Malabsorption
Celiac sprue
o General: gluten-sensitive enteropathy*; gluten in WHEAT, RYE, BARLEY
o Si/sx: malabsorption (steatorrhea), failure to thrive*, bloating
Others: iron deficiency anemia, dermatitis herpetiformis (vesiculopapular rash),
osteoporosis
o Dx: (+) anti-endomysial Ab or anti-TG (transglutaminase); (+) BIOPSY* (villous atrophy*)
o Rx: gluten-free diet!
Tropical sprue
o General: INFECTIOUS sprue* (equatorial areas) – MEGALOBLASTIC anemia
o Dx: biopsy = blunted villi, LYMPHOCYTIC/eosinophils/plasma cell infiltration
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o Rx: BACTRIM for 6mo; folic acid replacement
Whipple disease
o General: Tropheryma whippeli*
o Si/sx: arthralgias*, abd pain, weight loss, diarrhea, skin hyperpigmentation, LAP
o Dx: EGD with small intestine bx* (FOAMY macrophages + PAS staining); PCR testing
o Rx: ceftriaxone or PCN x 14d
Lactose intolerance
o General: lactase deficiency* - common in ASIANS
o Si/sx: osmotic gap, abd cramps, bloating / flatulence
o Dx: lactose hydrogen breath test*; stool osmotic gap
Short Bowel Syndrome
o Cause: RESECTION (ischemic injury, bypass, Crohn’s)
o Si/sx: steatorrhea Ca-oxalate stones, gastric acid hypersecretion
Pancreatic insufficiency
o Causes: chronic pancreatitis, cystic fibrosis
o Dx: Sudan stain of stool (BEST screening); 3-day quantitative fecal fat (GOLD standard*
for STEATORRHEA)
NORMAL D-xylose test (NORMAL test can r/o SB absorption problem)
Bacterial overgrowth
o Causes: previous abdominal surgery, diverticula, motility issues (diabetes, scleroderma,
achlorhydria, immune d/o)
o Dx: LACTULOSE breath test
o Rx: empiric abx (Augmentin + metronidazole)
Factitious diarrhea (LAXATIVE abuse)
o Si/sx: VERY frequent, watery, nocturnal diarrhea*
o Dx: endoscopy = DARK BROWN discoloration of colon + PALE PATCHES of LYMPH follicles
(melanosis coli)
Diseases of Large Intestine
Colon cancer
o Risk factors: age > 50, UC*, adenomatous polyps, SMOKING, genetic (FAP/HNPCC)
NOTE: ENDOCARDITIS w/ S. bovis or C. septicus = associated with COLN CA
o Histology
MOST arise from adenoma
“Advanced”: number, large > 1cm, villous / tubulovillous* (vs. tubular = BENIGN)
NOTE: HYPERPLASTIC polyps have NO malignant potential
o Related syndromes
Familial Polyposis Syndromes
FAP: 100s of adenomas in colon 100% risk of CA if UNTREATED protocolectomy
Gardner syndrome: variant of FAP w/ OSTEOMA and SOFT-TISSUE tumors
o Note: pt with multiple osteomas on X-ray do COLONOSCOPY
Puetz-Jeghers Syndrome: MANY hamartomatous small bowel polyps +
MELANOSIS (freckles) on lips & buccal mucosa
Juvenile polyposis: NO MALIGNANT potential* = no f/u needed
Hereditary Nonpolyposis Colon Cancer (HNPCC or Lynch Syndrome)
At least 3 1st relative over 2 generation and 1 person dx < age 50
risk of OVARIAN and ENDOMETRIAL CA*
Start screening at age 25
o Screening
Annual guaiac fecal occult blood test* - if (+) COLONOSCOPY
Flexible sig every 5 yrs, colonoscopy every 10 yrs OR CT colonograophy every 5 yrs
o Staging
SURGICAL resection*
Adjuvant chemo: FLIP (5-FU, leuvocorin, irinotecan, platin) – ONLY for stage III or
advanced II
Hepatic resection survival w/ SOLITARY liver mets
Diverticular
o Diverticulosis
Painful: luminal narrowing, “pencil-thin stools” Rx: BULKING agents* = FIBER (
dietary intake)
o Diverticular bleeding: PAINLESS, MAROON stool – most COMMON cause of bleeding
Dx: endoscopy to r/o upper GI, colonoscopy if doesn’t stop
o Diverticulitis
Si/sx: LLQ pain + rebound tenderness / guarding, fever, high WBC (“LEFT-sided acute
appendicitis*”)
Dx: abd CT scan = thickened sigmoid & pericolic fluid accumulation
Imaging required ONLY if unresponsive to abx* = dx abscess
Rx: metronidazole + ciprofloxacin OR Bactrim (uncomplicated); DRAIN abscesses!
Angiodysplasia
o 2nd most COMMON cause of GI bleeding – may be occult or SEVERE
o Osler-Rendu-Weber: multiple AVMs of ALL organs (brain, lung, GI, skin)
Intestinal ischemia
o Colonic
Cause: low-flow (CHF, hypercoagulable*) – sudden LLQ pain
Dx: “THUMBPRINTING” on KUB; colonoscopy – do NOT do angiography!
o Mesenteric ischemia (INTESTINAL ANGINA)
Cause: atherosclerosis of intestinal arteries with GASTRIC steal*
Si/sx: post-prandial abd pain, abdominal BRUITS, weight loss
Chronic: abdominal pain, weight loss, food aversion*
Dx
ACUTE: ANGIOGRAPHY* unless sx of perforation = SURGERY DIRECTLY!
CHRONIC: MRA (MR angiogram) or CT angiography if tests abnormal
Rx: surgical bypass sor angioplasty
Hemorrhoids
o General: VARICOSE veins of ANUS & RECTUM
External: inferior hemorrhoidal plexus – BELOW dentate line
Internal: dilated submucosal veins of SUPERIOR rectal plexus – ABOVE dentate line
o Risk factors: constipation / straiing, PREGNANCY, portal HTN*, obesity, prolonged sitting OR
standing
o Si/sx
BRBPR** - PAINLESS (iron Ueficiency anemia)
Internal = only when prolapse, have sx vs. external = only when thrombosed
o Rx (SAME for ANAL fissure*)
Dietary modifications* (high-fiber, fluids)
Stool softeners, topical steroids / anesthetic; Sitz bath
Rubber band ligation for INTERNAL hemorrhoids
Hemorrhoidectomy: ONLY if does NOT respond to conservative methods OR if severe
prolapse, very large anal tags, fissures
Pancreas
Acute pancreatitis
o Causes: ALCOHOL or GALLSTONES; hyper-TG*, hypercalcemia
o Severity: BMI > 25, high Hct, SIRS
o Si/sx
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PAIN*
Cullen’s (umbilicus), Grey-Turner’s (flanks)*
Acute fluid collections within 48 hrs
o Dx: amylase & lipase** (BETTER)
Abdominal CT HIDA scan
o Complications
Pseudocyst (2-4 wk): collection of pancreatic fluid – RUPTURE, hemorrhage, etc
NOTE: if amylase STILL elevated after 10d = consider pseudocyst
Rx: NOTHING MONITOR
o Percutaneous drain ONLY if: <5cm, lasts > 6 wks, secondary infx
Abscess (4-6 wks): “soap-bubble” sign - LIFE-THREATENING
o Rx
SUPPORTIVE* - NPO, IV fluids & albumin; enteral feeds
RESUME oral feeds when: + BS, passing stool; NO narcotics
Recurrent pancreatitis: ERCP to INVESTIGATE*
Chronic pancreatitis
o Si/sx: pancreatic calcification, diabetes, steatorrhea
o Dx: CT abd (calcifications), serum trypsin (LOW)
MCRP: NO risk of inducing pancreatitis
ERCP: can induce BUT can also REMOVE stones
Complications: ACUTE pancreatitis*, biliary enteric fistula (free AIR in biliary
duct), biliary peritonitis
o Rx
Pancreatic enzymes
Analgesia*
Pancreatic neoplasms
o Pancreatic CA: jaundice, LUQ pain, weight loss
Risk factors: chronic pancreatitis, smoking**, DM, hyperlipidemia (NOTE: alcohol is
NOT*)
Si/sx: head = painless jaundice vs. tail = pain & weight loss (MUCH MORE advanced )
Dx: abdominal U/S abdominal CT scan (if unresolved)
Rx: RESECTION ONLY* = pancreaticoduodenectomy (Whipple) but if mets = ONLY
gemcitabine*
o Glucagonoma: persistent HYPERGLYCEMIA*
o Insulinoma: RARE, insulin-secreting = hypoglycemia
o Gastrinoma: ZOLLINGER-ELLISON – serum gastrin>500, gastric acid*
Excess gastrin inactivates pancreatic enzymes malabsorption* + MULTIPLE ulcers
Dx: serum gastrin levels secretin stimulation test (NOT necessary)
o VIPoma: severe SECRETORY diarrhea* (pancreatic cholera); abd cramping & facial
flushing, redness
serum VIP level & HYPOKALEMIA* leg cramps!
HEPATOLOGY
Biliary System
Cholelithiasis
o Risk factors: obesity, OC, ileal dz / resection (FAT, FERTILE, FEMALE of FORTY)
Cholesterol stones: RAPID weight loss in OBESE pts, American Indian, octreotide;
RADIOLUCENT
Pigment stones: ileal resection, sickle cell dz, ANY hemolysis*; RADIO-OPAQUE
o Dx: RUQ ultrasound* MRCP or ERCP if needed
HIDA scan: best for confirming acute CYSTIC duct obstruction = BILE DUCT imaging
o Rx: asymptomatic = NOTHING vs. symptomatic = elective laparascopic cholecystectomy
o NOTE: acalculous cholecystitis* = VERY ill pts (major trauma, burns, surgeries) – NO stones
but large, thickened gallbladder w/ pericholecystic fluid & cystic duct obstruction
Emphysematous cholecystis:
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Risk factors: vascular compromise (obstruction or stenosis), immunosuppression,
gallstones, bacterial infx*
o Dx: AXR = air-fluid level in gallbladder; mild-mod unconjugated hyperbili & mildly elevated
LFTs
o Rx: IV fluids & electrolytes emergent cholecystectomy + abx* (Augmentin, Zosyn)
Cholangitis
o General: complication of COMMON BILE DUCT blockage
COMMON duct stones: obstructive jaundice* = alk phos & bili
Rx: remove by ERCP with prn sphincterotomy
o Si/sx: CHARCOT’S TRIAD = biliary colic, fevers/chills, jaundice
Suppurative cholangitis: AMS, bacteremia, septic shock – rx: ERCP w/ endoscopic
sphincterotomy
o Rx: supportive: IV abx + fluids ERCP if DOES NOT resolve
Primary biliary cirrhosis (PBC)
o General: SLOW onset, middle-aged women* = autoimmune dz
Associated w/ Sjogren’s, Raynaud’s, scleroderma, autoimmune thyroid dz, celiac dz
o Si/sx: BILE DUCT INFLAMMATION obstructive jaundice & liver cirrhosis
Liver dz: pruritus, jaundice, hyperpigmentation, osteomalacia, osteoporosis;
hypercholestoleremia (xanthomas)
o Dx: (+) AMA antibodies*; liver biopsy (GOLD STANDARD) = granulomas
o Rx: UDCA (synthetic bile acid)* liver transplantation (advanced dz)
Symptomatic: cholestyramine for pruritus, vit D / Ca for osteomalacia
Primary sclerosing cholangitis (PSC)
o General: SLOW onset, middle-aged MALES*; STRONG association w/ COLITIS (ulcerative
colitis)
ALL PSC pts should have colonoscopy and ALL UC pts w/ alk-pho = screen for PSC
o Si/sx: inflammation of ENTIRE biliary tract* obstructive jaundice & cirrhosis
If STRICTURES w/in biliary duct risk of cholangioCA* = evaluate w/ BIOPSY
o Dx: MRCP or ERCP = narrowed bile ducts with “BEADED” appearance; “onion skin fibrosis”
on liver bx
Note: (-) AMA* - distinguish from PBC
o Rx: LIVER TRANSPLANT*
Porcelain gallbladder: “calcified outline” = suggestive of CANCER gallbladder CA
o Dx: AXR = intramural deposition of calcium salts
o Rx: open cholecystectomy
Choledochal cyst: CONGENITAL abnormality – dilatation of intra/extrahepatic biliary ducts
(Caroli’s = inrahepatic)
o Si/sx: jaundice, abd pain, recurrent pancreatitis*
o Dx: abdominal US CT or MRI
Post-operative cholestasis
o Gen: develop after PROONGED surgery + hypotension / extensive blood loss / massive blood
replacement
o Si/sx: painless jaundice with hyperbilirubinemia and alk phos* = ASYMPTOMATIC
o
Liver
Evaluation of abnormal LFTs
o transaminases: full liver fx tests hepatitis labs & iron studies (hemochromatosis)
o alk phos: GGT (confirm liver source) abdominal U/S (biliary ducts or liver) AMA
(screen for PBC)
Viral hepatitis
o Hepatitis A
General: fecal-oral transmission*; prolonged cholestasis = jaundice in 3 WEEKS
Dx: acute infx = HAV-Ab IgM; previous infx = IgG
Ppx: High-risk behavior, chronic liver dz, travel to high-risk pts, hep C pts**
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Travelers: immune globulin if travel in < 4wks vs. vaccine if travel in > 4
wks
Vaccine: hep A vaccine for pts > 2yo
o Hepatitis E
General: fecal-oral – in contaminated water supplies* = travelers
NO progression to chronic hepatitis, cirrhosis or HCC
NOTE: fulminant hepatitis can occur in PREGNANT women w/ Hep E*
o Hepatitis B
STRONG association with polyarteritis nodosa** = autoimmune rxn
Serologies
HBsAg = ACUTE infx
Anti-HBc = acute or chronic infx, “window” period (only HBcAb-IgM* + in early
infx)
Anti-HBs = protected
*NOTE: super-infection with hepatitis D = FULMINANT ( anti-HDV IgM for acute
infx**)
Si/sx
Prodromal constitutional serum-sickness-like (fever, arthritis, angioedema,
urticaria) jaundice
<5% develop CHRONIC hepatitis
Chronic hepatitis
Inactive carrier (asymptomatic + normal LFTs) and chronic hepatitis (abnormal
LFTs)
o Inactive carrier chronic if become IMUNOCOMPROMISED* = give
LAMIVUDINE to prevent viral replication and activation*
o Associated with HCC* = screen every 6mo with AFP & ultrasound
Dx: LIVER BIOPSY* (BEST way to determine current hepatic fx)
Rx
IFN-: primary rx for young pts & women contemplating pregnancy
Lamivudine: primary treatment entecavir or adefovir if resistant
INDICATIONS: HBV DNA > 20,000 and ALT > 2 x normal
Vaccines: effective & safe for pregnant pts; uses HBsAg to stimulate HBsAb*
Newborn of mother w/ Hep B: HBIG + HBV vaccine
Close-contacts of acute HBV infx: HBIG + HBV vaccine
o Hepatitis C
General: MOST COMMON liver dz in US
Progression risk factors: male, infx > 40, co-existing dz (alcoholic liver dz,
hemochr), co-infx (HBV, HIV)
Risk: IV drug users*; high-risk sexual activity; blood transfusions BEFORE 1990; tattoos,
shared razors
CO-INFECTION with HIV very COMMON! = combo therapy of pegylated-IFN and
ribavarin
Si/sx
Insidious onset – only 25% of infx are symptomatic MAJORITY become CHRONIC
Mixed cryoglobulinemia: small-vessel vasculitis with “palpable purpura” and
glomerulonephritis
Dx: serology - HCV-RNA PCR* ; HCV-Ab does NOT CONFER immunity
Rx: pegylated IFN- + oral ribavarin* = measure response by following HCV-RNA
Ribavarin hemolytic anemia* = give EPOETIN rather than stopping treatment
NOTE: should get Hep A & B vaccine**
*Pts with PERSISTENTLY NORMAL LFTs & asymptomatic = NO rx needed!
Autoimmune hepatitis
o General: YOUNG WOMEN*; associated w/ other autoimmune (thyroiditis, ITP, Coombs+
anemia)
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o Dx: labs = (+) ANA, anti-dsDNA, anti-SMA*; liver biopsy = diagnostic
o Rx: prednisone + AZA = VERY EFFECTIVE
Alcoholic hepatitis
o General: MACROvesicular fat accumulation*
o Labs: AST:ALT ratio > 3:1
NASH (non-alcoholic steatohepatitis)
o General: IDENTICAL to alcoholic hepatitis but NO hx of alcohol use
o Risk factors: hyperlipidemia, type 2DM, obesity; protein malnutrition
o Labs: ALT > AST**
o Rx: weight loss & control of metabolic syndrome / LOW-fat diet
Drug-related liver disease
o Acetaminophen* = WORSENED w/ chronic alcohol use, malnutrition, chronic use
o Methotrexate
o INH: MILD transient in LFTs = idiosyncratic HEPATITIS
o Aspirin: Reye Syndrome = CHILDREN < 15yo* - occurs after VIRAL ILLNESS
Hepatic adenomas
o Associated with long-term OCP use*, anabolic steroid use, pregnancy, DM become
malignant ~10%
o Dx: biopsy = enlarged adenoma cells with glycogen & lipid
o Rx: usually REESECTION b/c of possibility of rupture (hemorrhage) or malignant
transformation
Hepatocellular carcinoma
o *Alcoholic liver dz + hepatitis C = MOST COMMON causes
o Si/sx: tender hepatomegaly, bruit in RUQ, bloody ascites, high alk-phos
Hyatid cysts
o Gen: echinococcus infx* = EGGSHELL calcifications – CENTRAL round cyst + DAUGHTER
cysts
o Aspiration NOT indicated due to risk of anaphylactic shock – rx = surgical resection +
albendazole
Amebic liver abscess
o Si/sx: RUQ pain, leukocytosis, = LIVER abscess and RECENT immigration from endemic area
o Dx: abd U/S, CT or MRI
o Rx: metronidazole
Cirrhosis
o Esophageal varices: HIGH mortality*
ALL cirrhosis pts should be screened for ESOPHAGEAL VARICES by endoscopy
Rx
NOTHING if small varices
**Ppx w/ propanolol = ALL PTS with large varices OR hx of bleeding varices
Active bleeds: band ligation OR sclerotherapy; somatostatin (octreotide) = stop
bleding
TIPS for REBLEEDS* - note: complication of HEPATIC ENCEPHALOPATHY*
*Ppx ORAL ABX to prevent SBP!
o Hepatic encephalopathy
Si/sx: hyper-reflexia, asterixis
Rx: PROTEIN RESTRICTION and LACTULOSE* (inhibits intestinal bacteria = NH3
production)
Acarbose (used for DM), probiotics, oral abx (metronidazole, rifampin, vanco)
o Hepatorenal Syndrome
General: renal vasoconstrx during severe, decompensated cirrhosis; LOW URINE Na
Rx: VOLUME management (fluid loading) + midodrine + octreotide
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Prothrombin time
Coagulopathy: severe cirrhosis unable to synthesize clotting factors = signs of
bleeding
Rx: fresh frozen plasma*
NOTE: alcohol causes MALABSORPTION of vitamins – so if PT time corrected by IM
vitamin K = due to MALABSORPTION and NOT liver disease
Ascites
o Paracentesis tap
SAAG > 1.1 = cirrhosis, heart failure, Budd-Chiari = PORTAL HTN
SAAG < 1.1 = TB peritonitis, nephrotic syndrome, pancreatitis*
o Rx for
Na & water restriction
Spironolactone +/- loop diuretics
Large-volume paracentesis (if NO GI bleeding, renal dysfx, encephalopathy)
MUST replace 8g albumin for each L of fluid*
TIPS procedure = if refractory
o Spontaneous bacterial peritonitis (SBP)
Dx: PMN > 250/mL in peritoneal fluid
Rx: ppx oral abx therapy for ANY pt with ascites protein < 1.0, hx of variceal bleed, prior
SBP
ACUTE infx: cefotaxime* and IV ALBUMIN!
o
Hereditary Liver Disease
o UNCONJUGATED hyperbili
Gilbert: MILD d/o; /absent glucoronyl-transferase* = liver uptake of unconjugated
bilirubin
Triggers: hemolysis, fasting, fat-free diet, illness/stress/fatigue
Crigler-Najjar: MUCH MORE severe dz
Rx: phototherapy or plasmaphresis*; liver transplant ONLY is curative
o CONJUGATED hyperbili (biliriubin in urine = DARK)
Dubin Johnson: DARK granular pigments in hepatocytes
Rotor: NO dark granular pigments
Alpha 1-antitrypsin deficiency
o Chronic hepatitis cirrhosis & EMPHYSEMA* @ young age
o Dx: electrophoresis*
o Rx: LIVER TRANSPLANT curative
Hemochromatosis
o Types: genetic: HFE gene* (AR) vs. secondary (sideroblastic anemia OR thalassemia)
o Si/sx: IRON DEPOSITION fibrosis & end-organ damage = liver, heart, pancreas, pituitary
Hepatomegaly, hyperpigmentation, new-onset DM*, arthropathy, cardiac; secondary
hypogonadism
o Dx: IRON STUDIES = high Fe, ferritin and transferrin (transferrin sat > 45%); liver bx
CONFIRMS
o Rx: weekly PHLEBOTOMIES*
Wilson Disease (COPPER overload)
o Si/sx: neuro/psychiatric dysfx in adolescents (ages 15-25*); arthritis; hemolysis
Slit lamp exam (EYES): Kayser-Flesicher rings (single, brownish corneal ring)
o Dx: LOW ceruloplasmin*, HIGH urinary copper; liver bx = DIAGNOSTIC
o Rx: chelation (penicillamine*) and low-copper diet (no nuts, peas, chocolate); LIVER
TRANSPLANT curative
Liver transplant
o Indications: nearly ALL pts with irreversible ESLD
Metabolic liver disease, primary & secondary biliary cirrhosis, PSC, fulminant hepatitis
CONTRAindications: alcohol/drug abuse, metastatic CA, HIV infx
o MELD score: bilirubin, Cr, INR and etiology (>20 = candidate for transplant)
JAUNDICE workup
o LFTs other liver fx tests
o Abd ultrasound ERCP or CT depending on results; if NO dilated duts = liver biopsy
Vitamin deficiencies
Vitamin
Deficiency
Vit B1
WET beriberi: heart failure, peripheral
(thiamin edema, ascites
DRY beriberi: nervous system* –
e)
neuropathy, Wernicke encephalopathy,
Korsakoff (confab)
*Alcoholics: THIAMINE be4 starting IV
glucose
Normochromic normocytic anemia, sore
Vit B2
(riboflavi throat, glossitis, cheilosis, stomatotis,
seborrheic dermatitis
n)
Glossitis, cheilosis, vomiting, SEIZURES
Vit B6
(pyridoxi Causes: malabsorption & chronic
alcoholism, drugs (INH*)
ne)
Macrocytic anemia, degeneration; LOSS
Vit B12
of proprioception & stocking/glove;
dementia
PELLAGRA: dermatitis, diarrhea,
Niacin
dementia psychosis
SCURVY* = petechial hemorrhages &
Vit C
ecchymoses; purpura, splinter
hemorrhage
Blindness (night)
Vit A
Vit D
Vit E