Gastroenterology Shelf Study Guide

Published on January 2017 | Categories: Documents | Downloads: 48 | Comments: 0 | Views: 332
of 16
Download PDF   Embed   Report

Comments

Content

1
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

Initial
laboratories
EKG
Gastric &
duodenal
ulcers
Variceal
bleeding
Colonic
bleeding

 CBC, BMP; blood type & cross-match; coag profile; BUN & serum Cr

2

 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
o




Anorectal problems: hemorrhoids, fissures
Endocrine / metabolic: hypothyroidism, HYPERCALCEMIA (MULTIPLE MYELOMA*,
metastatic bone CA), hypokalemia, uremia, dehydration
NM d/o, Parkinson’s, MS, CNS lesions, scleroderma, DIABETES*

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*

3

4












 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

5

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

6



 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)

7

8
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





Unpredictable, variable periodic
exacerbation
Fecal leukocytes*

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

9













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


o








TNM: 1 = mucosa/submucoda  2 = muscularis, NO LN  3 = regional lN, 4 =
distant mets

Rx



10

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

11





 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:

12

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**





13

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)

14













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

**NOTE: ACUTE LIVER FAILURE + encephalopathy = FULMINANT liver failure  Rx =
LIVER TRANSPLANT


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

15

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

Children = rickets, adults =
osteomalacia (MSK pain, weak)
Areflexia,  proprioception = dorsal
column degeneration

16

Overload

Peripheral neuropathy -  proprioception

Acanthosis nigricans
Cholestatic jaundice (flushing & pruritus)
Oxalate KIDNEY stones
Headache, pseudotumor cerebri*
(papilledema), dry skin and HSM
Calcium KIDNEY stones*; hypercalciuria
Potentiation of oral anticoagulants

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close