Step Up to Medicine: Chapter 03 Diseases of the GI System

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What are the three major causes of JAUNDICE:

1. Hemolysis of RBC
2. Liver DZ
3. Biliary obstruction

Treatment of acalculous cholecystitis

Emergent cholecystectomy is the treatment of choice - patients who are too ill for surgery, perform percutaneous drainage of he GB with cholecystostomy

What are the complications of acute pancreatitis?

Complications of pancreatitis (ACUTE):
1. Pancreatic necrosis - can be sterile or infected
a. sterile heals on own
b. infected has high mortlatlity rate 2/2 multiple organ failure in 50% of causes; surgical debridement and antibodics indicated
2. Pancreatic pseudocyst
a. encapsulated fluid collection that appears 2-3 weeks after an acute attack - unlieke a true cyst, it lacks an epitheliel lining.
b. complications of untreated pseudocysts include rupture, infection, gastric outlet obstruction, fistula, hemorrhage into cyst, and pancreatic ascites. It may impinge on adjacent abdominal organs (duodenum, stomach, transverse colon) if large enough; or if located at the head of the pancreas, can cause comepression of the CBD
c. diagnosis by CT
d. IF cysts < 5cm then observe, if > 5cm then drain

Clostridium difficile presents with which hypervirulent features?

Severe ileus
Fever
hypotension
marked leukocytosis (15k-50k)
ARF
Hypoalbuminemia
severe metaboli acidosis with elevated LACTATE levels
Increased need for colectomy

DIAGNOSIS OF ESOPHAGEAL HIATAL HERNIA

barium swallow

Cirrhosis of the liver v. Hepatitis of the liver

Cirrhoses - chronic liver dz characterised by fibrosis, disruption of the liver architecture and widespread nodules in the liver (the fibrous tissue replaces damaged or dead hepatocytes)

Hepatitis - inflammation of the liver hepatocytes.

Coagulopathy occurs 2/2 synthesis of clotting factors being decreased:

1. Prolonged PT; PTT may be prolonged with severe disease
2. Vitamin K is ineffective because it cannot be used by diseased liver
3. Treatment of coag is FFP

Prognosis of carcinoma of the GB

90% die of advanced disease within 1 year of dx 2/2 underdetection

Adenocarcinoma of the esophagus is one of two types of esophageal CA that affects what population?

Risk factors?

Most common in white males
most common in distal 1/3 of esophagus @ GE junction

RF: GERD and Barretts esophagus are main risk facors; alcohol and tobacco may not be as important as in SCC

IF a PEPTIC ULCER is uncomplicated, then a _____ _____ or ______ is not needed initially. Initiate empiric therapy. If you suspect any complications of PUD, order confirmatory testss

barium swallow, endoscopy

Patients with UC may have ______ ____ at first with eventual progression to bloody diarrhea

nonbloody diarrhea

Murphys sign v. BOAS sign

Murphy's sign: RUQ pain, inspiratory arrest during deep palpation of RUQ, not present in many causes) - fever and leukocytosis - cholecystitis

BOAS sign - right should pain 2/2 that of gall stone - cholelithiasis

What is the most common location for liver abscesses (both pyogenic and amebic)?

Right lobe of the liver

What is the diagnosis of jaundice?

Serum levels of unconjugated v. conjugated BR.
-if unconjugated, then there must have been an issue prior to hepatic uptake and thus check CBC, reticulocyte count, haptoglobin, and LDH (with peripheral smear) to r/o hemolytic anemia
-if conjugated hyperbilirubinemia, then there must have been an issue after the bilirubin-albumin complex formed and after hepatic uptake either within or after the hepatic ducts. LFTS may points to cause
-get US/CT to assess biliary tract for obstruction or anatomic changes
-additional tests ERCP if conj with obstruction 2/2 US/CT
-liver biopsy is the last resort and indicated in some cases to determine cause of HCC injury

Clinical features of SBO?

Cramping abdominal pain (if continuous and severe then expect strangulanous activity.
-n/v may be feculent
-obstipation (LACK OF STOOL and FLATUS)
-abdominal distention

Radiation therapy is indicated in patients with ____ cancer but NOT indicated in patients with >>>>

Can use for patients with rectal cancer
Cannot use for patients with colon CA

Treatment of hemochromatosis? Diagnosis?

1. Marked elevation in serum iron and serum ferritin
2. Elevation of iron saturation (transferritin sat)
3. Decreased TIBC
4. Liver biopsy (determines hepatic iron concentration)
5. Genetic testing for chromosomal abnormality

TREATMENT: perform phlebotomies to removes excessive serum iron
-treat any complications (CHF. DM. hypothyroidism, arthritis) and consider liver transplantation if late stage hemacrhomatosos

Inflammatory bowel disease (IBD)

1. Regional enteriritis (CROHNS DZ)
2. Ulcerative enteritis

Diseases of the appendix:

Acute appendicitis:

Lumen of the appendix is obstructed by:
1. Hyperplasia of lymphoid tissues (60%) of cases
2. Fecalith (35% of cases)
3. Foreign body
4. PARASITE/CARCINOID TUMOR (other rare causes)

Treatment of zenkers diverticulum

surgical: cricopharyngeal myotomy

Skin and soft tissue infections (SSTI's) are the most common of all infections

What are the categories?

Superficial uncomplicated infections
Necrotizing infections
Infections associated with bites and animal contact
surgical site infections
infections of the immunocompromised host

Most patients with acute pancreatitis have mild to moderate disease, but to up 25% have severe disease

What are the causes of acute pancreatitis:

1. Alcohol abuse (40%)
2. gallstones (40%) - galllstone passes into the bile duct and blocks the ampulla of vater
3. post ERCP - pancreatitis occurs in up to 10% of patients undergoing ERCP
4. VIral infections (mumps or COXSACKIEBVIRUS)
5. Drugs (sulfonamides), HCTZ, ferusemide, estrogens, HIV medications, and many other drugs have been implicated
6. Post operative complications (HIGH MORTALITY RATE)
7. Scoprion bites
8. Pncreas divisum
9. Pacnreatic CA
10. HyperTG hyperCa
11. uremia
12. blunt abdominal trauma (most common cause of pancreatitis in children)

What are the clinical features of pseudomembranous colitis?

1. Profuse watery diarrhea
2. Crampy abdominal pain
3. Toxic megacolon with risk of perforation

Choledocholithiasis clinical presentation:

ASymptomatic for years
-RUQ pain/epigastric pain and jaundice

Autosomal recessive - Polyps plus cerebellar medulloblastoma or glioblastoma multiforme?

TURCOTS SYNDROME

PERSISTANT OR CONTINUING INFFLAMMATION OF THE PANCREAS WITH FIBROTIC TISSUE REPLACEMENT OF PANCREATIC PARENCHYMA AND ALTERATION OF PANCREATIC DUCTS (AREAS OF STRICTURE/DILATION); EVENTUALLY RESULTS IN IRREVERSIBLE DESTRUCTION OF THE PANCREAS

CHRONIC PANCREATITIS - BOTH ENDOCRINE (INSULIN) AND EXOCRINE (ENZYMES) ARE AFFECTED

Albumin as a liver function test:

Albumin is decreased in chronic liver disease, nephrotic syndrome, malnutrition and inflammatory states *burns/sepsis/trauma

Clinical features of PANCREATIC CA

Very nonspecific - thus by the time dx is made, often too late and incurable.

1. Abdominal pain
2. Painless jaundice bc @ head of pancreas
3. Weight loss
4. Onset of glucose intolerance but the GM is mild
5. Depression/weakness/fatigue
6. Migratory thrombophelbitis - develops in 10% of cases
7. Courvoisier's sign (palpable GB) present in 30% of patients involved head of pancreas - presents without pain

RISK FACTOR FOR CHOLANGIOCARCINOMA:

1. PSC major RF
2. UC
3. CHoleochal cysts
4. Clonorchis sinensis infestation (Hong kong)

Treatment for patients with achalasia

1. Adaptive measures: chew food to consistency of pea soup b4 swallowing; sleep with trunk elevated, avoid eating before sleeping
2. Medical therapy
a. antimuscarinics (DICYCLOMINE) usually unsatisfactory
b. sublingual nitroglycerine - long acting nitrates, CCB
3. injection of outlimun toxin into the LES during endoscopy
-blocks cholinergic activity in the LES
-can be effective in up to 65% of cases; however, repeat procedure needs to be performed every 2 hrs

Tests to order in patients with GI bleeding and hematochezia:

first rule out anorectal cause (hemorrhoids). Colonoscopy is the intial test bc colon cancer is the main concern in patients > 50YO

Acute infectious diarrhea - top cases are what organisms?

1. Salmonella (14.6 cases)
2. Campylobacter (12.7 cases)
3. Shigella (4.7 cases)
4. E. Coli O157H7 (1.1)
5. Crptosporidia (3.0 cases)

What is alreay present (symptomatically) in a MW syndrome

Hematemesis is always present - it varies from steaks of blood in vomitus to massive bright red blood.

As many as 25% of patients with bleeding AV malformations have aortic stenosis however, no ____ and _____ relationship has been noted.

cause and effect (AVM and AVS)

Clinical features of esophageal cancer:

-dysphagia (MOST COMMON - to solids only then to liquids!)
-weight loss (second most common symptom)
-anorexia
-odynophasia (pain with swallowing)-late finding that suggests extraesophageal involvement (mediastinal invasion)
-hematemesis, hoarseness of voice, recurrent laryngeal nerve involvement
-aspiration pneumonia, respiratory symptoms due to involvement of traceobronchial tree
-chest pain

If ALT and AST levels are mildly elevated (low hundreds), think of what diagnosis?

Chronic viral hepatitis or acute alcoholic hepatitis (AST < 500) and (ALT < 300)

ORGANS effected by Wilsons dz v. Hemochromatosis

Kidney, liver, cornea = wilsons

liver (primary), pancreas, heart, joints, skin, thyroid, gonads, hypothalamus = hemo

Pigmented stones are the second type of GB stones that occur 2/2?

Black stones found in the GB associated with HEMOLYSIS, SCA, THALASSEMIA, HEREDITARY SPHEROCYTOSIS, ARTIFICIAL VALVES, ALCOHOLIC CIRRHOSIS

BROWN stones are usually found in BILE ducts and are associated with a BILIARY tract infection

Hematochezia

bright red blood per rectum
-represents lower GI source (LEFT COLON OR RECTUM)
-consider diverticulosis, arteriovenous malformations, hemorrhoids, and colon CA

What is a bleeding scan?

radionucleotide scanning that reveals bleeding even with a low rate of blood loss. It does not localize the lesion; it only identifies continued bleeding. Role is controversial but it may help determine where arteriography is needed

Clinical features of cirrhosis?

-asymptomatic in early dz
-portal HTN, varices, ASCITES, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, hyperestrinism

How do signs and symptoms change in relation to the effected side of colon (right v. left)

Right sided colon tumors:
-obstruction is unusual because of the larger luminal diameter (the cecum has the largest luminal diameter of any part of the colon that often allows for tumor growth to go undetected.
-common finding is occult blood in stool , iron deficiency anemia and MELENA (BLACK STOOL)
-change in bowel habits is uncommon
-triad of anemia, weakness, RLQ mass (occasionally) is present

Metastasis of GASTRIC carcinoma

1. Krukenberg's tumor: metastasis to ovary
2. Blumer's shelf: metastasis to rectum
3. Sister Mary Josephs node: met to periunbilival lymph node
4. Virchows node - metastasis to the supraclavicular fossa nodes
5. Irish's node (metastasis to the left axillary adenompathy

Acute uncomplicated UTI prevention of precurrences

Some supportive evdience
-cranberry juice (200-750 mL/d) or cranverryo concentrate tablets (12-20% reduction)
-topical estrogen creams
-avoid exposure to vaginal spermicides

No supportive evidence
-postcoital voiding
-"enhanced" urinary hygiene
-oral estrogen replacement

Toxic megacolon, growth retardation, narcotic abuse all can result from Crohns. T or F

T

RUQ ultrasound has high sensitivity AND specificity when accounting or stones that are > ___mm.

2

Gastric lymphoma

A type of NHL that arises in the stomach

Celiac sprue

Hypersensitivity to gluten
-weight loss, abdominal distention, bloating diarrhea
-biopsy in prximal small bowel reveals flattenng of villi which causes malabsorption
-strict adherence to gluten free diet

What are the majority of cases regarding PUD related to?

1. Helicobactor pylori infection
2. NSAIDS-inhibit prostaglandin production which leads to impaired mucosal defenses.
3. Acid hypersecretory states like ZE syndrome (excessive production of gastrin)

Considerations with acute bacterial sinusitis that recurs?

1. Inadequate course of therapy
2. Concurrrent allergic rhinitis
3. Anatomic abnormalities that block ostia
4. undiagnosed immundeficiency states
-cystic fibrosis
-common variable immunodeficiency
-immotile cilia syndrome (karteganer's)

The level of either _____ or _______ in acute pancreatitis does not reliably predict the severity of disease.

amylase
lipase

What are the clinical feature of budd-chiari syndrome:

Hepatomegaly, ascites, abdominal pain RUQ; jaundice, variceal bleeding

Complication to ACUTE PANCREATITIS:

Ascending cholangitis and be 2/2 ______ obstruction in the ampulla of Vater, leading to infection of the biliary tract.

gallstone

The higher the AST-ALT ratio the greater the likelihood that ------ is contributing to the abnormal LFTs

alcohol

What patients should not be treated if acute infections diarrhea is clinically present?

Pts with mild disease without systemic toxicity or dehydration
pts with spontaneously remitting sxs
pts with suspected shiga toxin-producing e. coli infection (O157H7) --> bloody diarrhea in an afebrile pt with a h/o eating raw hamburger or seed sprouts or visiting a petting zoo

Paraesophageal hernias tend to enlarge with time, and the entire stomach may ultimately move into the _____. Type 3 hernias (combination of type 1 and 3) are treated as type _____ surgically.

thorax
type 2

Complication of diverticulosis versus diverticulitis

Diverticulosis: painless rectal bleeding and diverticulitis

Diverticulitis: includes bowel obstruction, abscess and fistulas

How are CIRRHOTIC patients managed LONGTERM?

1. Periodic lab values 3-4 months (CBC, CMP, RFTs, LFTs, coagulation tests)
2. Perform an endoscopy to determine the presense of varices
3. If hepatocellular carcinoma is suspected then perform a CT guided biopsy for diagnosis

Treatment of pancreatic CA

1. Whipples procedure is the only hope for cure; only a minority of tumors resectable. Pronosis post resection with 5 year survival rate of 10% - grim.
2. If the tumor is unresectable and biliary obstruction is present , perform PTC or ERCP with stent placement across the obstruction for palliation.

What exacerbates GILBERTS syndrome?

fasting (crash diets); fever, alcohol, and infection. Asymptomatic in most cases, but occasionally jaundice is seen.

Clinical geatures of HCC

-abdominal pain
-hepatomegaly
-weiht loss, anorexia, fatigue
-signs and symptoms of CLD; portal HTN, ascites, jaundice, splenomegaly
-paraneoplastic syndromes:
a. ERYTHROCYTOSIS
b. THROMBOCYTOSIS
c. HYPERCALCEMIA
D. CARCINOID SYNDROME
E. HYPERTROPHIC PULMONARY OSTEODYSTROPHY
F. hypoglycemia
g. HYPERCHOLESTEROLEMIA

80% of episodes of upper GI bleeding stop spontaneously and only need supportive therapy - T OR F?

TRUE

The development of a palpable mass in the epigastrium four weeks after the onset of acute pancreatitis is HIGHLY suggestive of a ______ _______ formation

Pancreatic pseudocyst formation

What is ACUTE GASTRITIS?

inflammation of the gastric mucosa 2/2 NSAIDS/ASA, H. pylori, alcohol, heavy cigarette use, smoking, caffeinel extreme physiologic stress (eg shock, sepsis, burns). It can either be asymptomatic or cause epigastric pain. The relationship between eating and pain is NOT consistent.

IF LOW PAIN or MODERATE and not worrisome, empiric therapy + acid suppress is good treatment with the stopping of NSAIDs

Ulcerative colitis:

CHRONIC INFLAMMATORY DISEASE of colon or rectal mucosa that occurs at any age but usually young adulthood.

-distribution os UC involves to rectum in all caes and can involve the colon paritally or entirely
a. rectum along (10%)
b. rectum and left colon (40%)
c. rectum, left colon, right colon *30%)
d. pancolitis

unpredictable course and variable

Acalculous cholecystitis

Acute cholecystitis without stones that obstruct the cystic duct (up to 10% of patients with acute cholecystitis)

-idiopathic in patienst with underlying illness associated to dehydration ischemia burns trauma and a postoperative state

-signs and symptoms are the same as for acute cholecystits

COMPLICATIONS WITH CROHNS!

1. fistula between colon and other segments of intestine (enteroenteral), bladder, and vagina and skin.
-anorectal dz in 30% pateints - fissues, abscesses, perianal fistulas
-SBO 20-30%
-malignancy
-

What are the signs of appendiceal rupture 2/2 untreated acute appendicitis?

Complications -20% of cases

RF: delay in treatment (>24 hours) and extremes of age
-signs of appendiceal rupture (high fever, tachycardia, marked leukocytosis, peritoneal signs, toxic appearance)

Percent of women per year diagnosed with acute uncomplicated UTI (cysitis)?

11%

HNPPCRC - without adenomatous polyposis
Lynch I v. Lynch II

Lynch syndrome I: site specific CRC - early onset CRC without multiple polyposis
Lynch syndrome II: cancer family syndrome - all features of lunch 1 plus increased number and early occurrence of other cancers (female genital tract, skin, stomach, pancrea, brain, breast, biliary tract).

Causes of hepatic encephalopathy:

1. Toxic metabolites
2. occurs in 50% of all cirrhosis cases
3. Hypokalemia and alkalosis (2/2 diuretics), dedating drugs (narcotics, sleeping meds), GI bleeding, systemic infection, and hypovolemia
4. Clinical features: confusion, asterixis, rigidity and fetor hepaticus

Rectal cancer versus CRC

20-30% of all CRC are rectal
1. Hematochezia is the most common symptom
2. Tenemus
3. Rectal mass, feelin of incomplete evacuation of stool due to mass

What indicates a non-neoplastic polyp?

A benign lesions with no malignant potential
-hyperplastic (metaplastic polyp) most common (90%); generally remain small and asymptomatic
-no specific therapy required but difficult to distinguish from neoplastic polyps
-juvenile polyps are highly vascular and common (if younger than 10) so remove
-inflammatory polyps (pseudopolyps) are associated with UC

What is the treatment of patients with suspected ascending cholangitis?

1. Blood cultures
2. IV fluids
3. Empiric antibiotics with good anaerobe and gram - coverage -
4. Decompress the CBD when patient becomes hemodynaicmally stable.

Signs of intestinal infarction:

hypotension, tachypnea, lactic acidosis, fever and AMS
-CHECK THE LACTATE LEVEL IF ACUTE MESENTERIC ISCHEMIA IS SUSPECTED

What is the prognosis of acute pancreatitis?
WHAT IS RANSON'S CRITERIA?

RANSON'S CRITERIA is used to determine the prognosis and mortality rates:

*pts with more than 3 or 4 Ranson's criteria should be monitored in ICU

1. (GALAW) Admission criteria:
Glucose >200;
Age>55YO;
LDH >350;
AST>250;
WBC>16,000
2. Initial 48 hours criteria (C HOBBS)
Ca2+ < 8 mg/dL
Decrease in Hematocrit (>10%)
PaO2 < 60 mm Hg
BUN increase >8mg/dL
Base deficit > 4 mg/dL
Fluid sequestration > 6L
3. Mortality
<3 criteria - 1%
3-4 criteria - 15%
5-6 criteria - 40%
>7 criteria - 100%

#1 cause of PANCREATIC CA?

SMOKING!

Arteriography is used for which reason in GI BLEEDING?

DEFINITIVELY LOCATES THE POINT OF BLEEDING
-mostly used in pts with lower GI bleeding
-should be performed during active bleeding
-potentially therapeutic (embolization or intra-arterial vasopressin infusion)

Pateint with a history of AORTIC GRAFT SURGERY who has a small bleed of GI involving the duodenum before massive, fatal hemorrhage hours to weeks later.

Performing an endoscopy or surgery during this small window of opportunity to prevent death is quinticential to survivial.

DX:

AORTOENTERIC FISTULA

CA-P duration of therapy

1. ID society:
- s pneumona treat until afebrile for >72 hr
- s aureus< GNRS, anaerobes, atpicals, > 2 weeks

ACHALASIA HAS NORMAL ____ PRESSURE UNLIKE THAT OF DES

normal LES pressure

SCHATZKIS RING (Distal esophageal web)

circumferential ring in the lower esophagus that is always accompanied by a sliding hiatial hernia.

What are the clinical symptoms of primary biliary cirrhosis of the intrahepatic bile ducts?

Fatigue
Pruritis
Jaundice
RUQ discomfort
Xanthomata and xanthelasmata
Osteoporosis
Portal HTN with resultant sequelae

Treatment for ESOPHAGEAL CA

Palliation is the goal in most patients becase the disease is usually advanced at presentation HOWEVER PERFORMATION OF AN ESOPHAGECTOMY MAY BE CURATIVE IF STAGE 0,1,2A.

-CHEMO + RADIATION B4 SURGERY PROLONGS SURVIVAL

Complications of hemachromatosis:

#CIRRHOSIS INCREASES RISK OF HCC BY 200; PRESENSE OF LIVER DISEASE IS ESSNTIAL FOR PROGNOSIS OF DZ

#Cardiomyopathy - CHF, arrhythmias

#DM - due to iron deposition in the pancreas

#Arthritis-most common sites are the 2nd and 3rd metacarpelphysial joints HIPs and KNEES

#Hypogonadism - loss of labido, mensus, impotence

#hypothyoid

#hyperpigmentation of skin

WHAT ARE THE CLINICAL FEATURES OF WILSONS DISEASE

1. Liver disease with acute hepatitis, cirrhosis or fulminant hepatic failure
2. KAYSER-FLEISCHER RINGS (yellow rings in the cornea representative of cu2+ accumulation and deposition in cornea...do not interfere with vision.
3. CNS findings:
-extrapyramidal signs= parkinsonian symptoms with resting tremor, rigitity, radykinesia, chorea, drooling, incoordination due to copper depostition in BG
-psychiatric distrubances - depression, neuroses, peraonlity changes, psychosis
4. Renal involvment
-aminoaciduria, neprhocalcinosis

Symptoms of SCHATZKIs RING v. PV SYNDROME

SR: moderate dysphagia may be present; 2/2 alkali, acids, bleach, detergents (suicide attempts). Stricture formation indicates inc risk for esophageal cancer

Treatment: esophagectomy i full thickness necrosis has occurred. Pt should avoid vomiting, gastric lavage and all orgal intake which cnan compound the original injury. Give the pt steroids and AB its well

PVS: Anemia, oral mucosa, upper GI esophageal webbing causing dysphagia

Major differential points of SSTI's (skin and soft tissue infections)

Community v. Hospital acquired
-community: s aureus >>> group A streptococci and GBS
-hospital: s aureus, GNRs, enterococci

Erythema only v. pus &/or open wound
-erythema only: strept
-pus/open wound: s aureus

+ROVSINGS SIGN, + PSOAS SIGN, + OBTURATOR SIGN

acute appendicitis

What is a flexible sigmoidoscopy?

Can be used to reach the area where approximately 50-70% of polyps and CA occur
Can be diagnostic in about 2/3 of all CRCs

How is hepatic functional reserve assessed?

Child's classification
-estimates hepatic reserve in liver failure; it is used to measure disease severity and is a predictor of morbidity and mortality.
-childs class C is the most severe disease and childs class A is the least severe disease.

Chronic gastritis

MOST COMMON CAUSE = H PYLORI (>80%) cases
-autoimmune gastritis lads to chornic atrophic gastritis with serum antipareital and anti-intrinsic factor antiboide (possible dvelopment of pernicious anemia)
-most pts are asymptomatic and never develop complications - manifests as epigastric pain similar to PUD

complications: gastritis, carcinoma, mucosa-associated lymphoid tissue lymphoma (MALT)
-UPPER GI ENDOSCOPY WITH BIOPSY IS THE TEST OF CHOICE FOR Dx OF CHRONIC GASTRITIS

Acute UTI uncomplicated diagnosis:

Consistent symptoms + positive dipstick (U/A) = UTI (culture NOT NEEDED)

Pathophysiology of SBO

Dehydration is a key event in SBO
-intesntinal distention causes reflex vomiting, increased intesinal secretion proimal to point of obstruction and decreased absorption. This leads to hypochloremia, hypokalemia and metabolic alkalosis

Third most common cancer in the United States (in men and women)

CRC

WHAT IS THE TREATMENT FOR BILE DUCT STRICTURE

ENDOSCOPING STENTING IS PREFERRED OR SURGICAL BYPASS IF OBSTRUCTION IS COMPLETE OR IF ENDOSCOPIC SPINCTEROTOMY

Reynolds pentad is associated with ____ _ and is a highly toxic state that requires emergency treatment and can be rapidly fatal

acute cholangitis

COMPLICATIONS OF CBD stones

Cholangitis
Obstructive jaundice
Acute pancreatitis
Biliary colic
biliary cirrhosis

Diagnosis of HCC

Liver biopsy - required for definitive diagnosis
-lab tests (hepatitis B and C serology, LFTs, coagulation tests
-imaging studies: US, CT scan (chest abdomen pelvis; MRI/MRA if surgery is an options because they provide more detail about anatomy.
-tumor marker elevation of AFP is useful as a screening tool. AFP level may be elevated in 40-70% of patients with HCC and is also helpful in monitoring response to therapy.

What is the general characteristic of diverticulosis?

1. Increased intraluminal pressure-inner layer of colon bulges through focal area of weakness in colon wall (usually an area of blood vessel penetration)

2. LOW FIBER diets: contipation cause sintraluminal pressures to increase with a positive family history increases the risk

3. Most common location is the sigmoid colon however diverticula may occur anywhere in the colon.

Hemorrhagic pancreatitis is another complication of acute pancreatitis:

Cullen's sign (periumbilical bleeding)
Grays sign (flank ecchymoses)
Fox's sign (inguinal ecchymoses)

CT scan with TV contrast is the study of choice

BLEEDING FROM THE SMALL BOWL CAN PRESENT AS EITHER _____ OR ______

Melena or hematochezia

Alkaline phosphatase (ALK-P) is elevated in which clinical scenarios?

1. ALK-P is elevated when obstruction to bile flow(cholestasis); in any part or biliary tree. If normal, unlikely biliary obstruction
2. IF EXCESSIVELY high (10 fold) think of extrahepatic hiliary tree obstruction or intrhepatic cholestass (PBC or DI-cirrhosis)
3. If level are elevated, measure the GGT (gamma-glutamyl transferase) level to make sure the elevation is HEPATIC origin (rather than bone or intestinal). If GGT is also elevated, then strongly suggests hepatic origin. If GGT level is normal but ALP elevated - think bone or pregnancy issue

What are the clinical features of achalasia:

1. Dysphagia (odynophgia less common) - both solids and liquids
2. Regurgitation
3. Chest pain
4. Recurrent pulmonary complications secondary to aspiration, which may cause lung abscess, bronchiectasis, hemoptysis

What is the LAB TEST that diagnosis for GI bleeding?

-stool guiac for occult blood
-Hgb/hct level (may not be decreased in acute bleeds)
-A hgb level >7-8 acceptable in young health patients without active bleeds
-A hgb level in most elderly patients should have hgb level ?10 g/dL
-low MCV is suggestive of iron deficiency anemia and chronic blood loss
-coag profile (plt ct, PT, PTT, INR)
-LFTs, renal function
-the BUN-creatinine ratio is elevated with upper GI bleeding. This is suggestive of upper GI bleeding if patient has no renal insufficiency

What is the TREATMENT of PBC?

Rx:
1. Cholestyramine for the pruritis
2. Vitamin D, Calcium, Bisphosphonates for osteoporosis
3. Ursodeoxycholic acid (hydrophilic bile acid) has been shown to slow progression
4. Liver transplantation is only curative therapy.

AUTOIMMUNE AB: (+) antimitochondrial antibodies

What medication should be avoided in patients with mesenteric ischemia?

Vasopressors because it worsens the ischemia.

Treatment of GALLSTONES

symptomatic v. asymptomatic

SYmptomatic-elective cholecustectomy for patients with recurrent bouts of biliary colic

asymptomatic - no treatment

Dark urine and pale stools signal a diagnosis of?

CONJUGATED HYPERBILIRUBINEMIA

NASH histologically is identical to patients with ____ liver disease, but these patients do not usually have a history of substance abuse.

alcohol

Treatment of SBP:

spontaneous bacterial peritonitis
1. Broad spec therapy then give specific once identify bacteria.
-clinical improvement should be seen within 24-48 hours. Repreat paraventesis in 2-3 days to document a decrease in ascitis fluid PMN < 250

What risks can exacerbate PUD?

1. Smoking
2. Alcohol and coffee
3. Emotional stress and type A personality

Empirical treatment for CA-MRSA:

TSX, clinda, mino

Signs of acute liver failure:

1. Jaundice
2. Elevated LFTs
3. Coagulopathy
4. Hypoglycemia(liver stones glycogen)
5. Hepatice encephalopathy 2/2 ammonia intoxication
-Infection

In acute pancreatitis:
1. Serum amylase:
2. Serum lipase:
3. LFTs:
4. Hyperglycemia/hypoxemia/leukocytosis:
5. Order the following for assessment of prognosis:
"ransons criteria"

1. Amylase = most common tests but many conditions cause hyperamylasemia and its absense doesnt rule out acute pancreatitis. If levels are >5x NL then highly specific for acute pancreas.
2. Lipase = more specific for pancreatitis than amylase
3. LFTs - to identify cause (gallstone pancreatitis)
4. Glucose, Ca@+. hct, BUN, ABG, LDH, WBC count

Treatment for PUD: Medical

SUPPORTIVE!
1. d/c nsaids/asa
2. rstrict -OH use but not foods
3. Stop smoking/dec emotional stress
4. Avoid eating before bedtime and dec coffee intake

ACID RESTRICTION!
1. H2 blockers, PPIs, antacids

ERATICATE H. PYLORI with tripple therapy regimen

CYTOPROTECTION - sucralfate and MISOPROSTOL

Surgical: Rarely needed - required for ocmplication of PUD(bleeding performation gastric outlet obstruction

Barium enema are good for?

Evaluates the entire colon, completmentary to fleximble signmoidocopy - disadvantage is that any abnormal finding needs to be evaluated by colonoscopy

Complications of UC

1. IDA
2. Hemorrhage
3. Lytes and h20
4. Structures, benign, malignant usally malignant
5. Colon ca- increas risk
6. Cholangiocarcinoa (half of all biles duct CA are associated with UC)
7. Sclerosing cholngitis
8. Toxic mega
9. MR

Diagnosis of crohns

-diarrhea (nonbloody)
-malabsorption and weight loss
-abdominal pain RLQ n/v
-fever malaise
-extraintestinal manifestiations in 15% - uveitis, arthritis, anklosing SpA, erythema nodosum, pyoderma gangrenosum, aphthough oral ulcers cholelithiasis and neprholithiasis

If a patient with GERD also has a diatal hernia, the hernia often wrosens the symptoms of GERD - T or F

T

Types of varices 2/2 liver disease:

1. Esophageal
2. Gastric
3. Hemorrhoids
4. Caput medusae (distention of abdominal wall veins)

In cholelthiasis, biliary colic can lead to acute ________.
In choledocholithiasis, onset of symptoms leads to _____ and/or ______ which are life threatening causes.

Acute cholecystitis (obstruction of the GB leading to inflammation - not due to infection).

Acute pancreatitis or CHOLANGITIS

The distortion of the liver anatomy in CIRRHOSIS causes which two major events:
1.
2.

1. Decreased blood flow through the liver and thus causing PORTAL HTN (therefore associated ascites, esophageal varices, splenomegaly, peripheral edema, variscosity of veins "back stream" in circulation, hemorrhoids)

2. Hepatocellular failure that leads to impairment of biochemical functions such as decreased albumin synthesis and decreased clotting factor synthesis (thus can no longer carry Ca2+ or protein and will have increased bleeding 2/2 decreased coag.

Complications with CHRONIC pancreatitis:

1. Narcotic addiction - most common complication
2. DM/impaired glucose tolerance
3. Malapsorption/steatorrhea
4. Pseudocyst formation
5. Pancreatic ductal dilitation
6. CBD obstruction (2/2 to fibrosed portion in head of gland)
7. VItamin B12 malabsorption
8. Effusions (pleural, pericardial, peritoneal)
9. Pancreatic carcinoma (increased risk)

If prolonged PT -

advanced liver disease

Porcelain gallbladder is defined as:

intramural calcification of the gallbladder wall
-prophylactic cholecystectomy is recommended bc 50% becomes malignant

SCC is most commonly seen in which patients regarding esophageal CA?

black males
most commonly located in upper thoacic and mid thoacic esophagus
1/3 in distal 10 cm of esophagus

RF: alcohol and tobacco use, nitrosamines (diet), achlasia, PV syndrome, caustic ingestion, nasopharyngeal carcinoma

A lower GI bleed or positive occult blood test in stool in patients > 40YO is ___ ___ until proven otherwise

colon cancer

COmplication of cholecystitis: (inflammation of the GB)

1. Gangrenous cholecystitis
2. Perforation of GB
3. Emphysematous cholecystitis
4. CHolecystenteric fistula with gallstone ileus
5. Empyema of the GB

How should JAUNDICE be evaluated?

Initial step:
--> Hx, PE, LABS: ALT, AST, Bilirubin, ALKPHOS, ALBUMIN, PT

If normal LFTs (ALT, AST, ALKPHOS, albumin, PT)
-->conjugated hyperbilirubinemia
-DJ syndrome/rotors syndrome
-->unconjugated hyperbilirubinemia
-see test for differential; hemolysis and gilberts syndrome most common

If abnormal LFTS (intrahepatic issue)
-->suspected intrahepatic disease based on LFT
-viral seriology/AMA/ANA/SMA/cerruloplasmin/Fe-TIBC/AAT
-STOP drugs
-consider liver bx
-consider CT scan to r/o structureal dz
-medical management v. observation
-ducts will be normal
-->suspected extrahepatic obstruction
-noninvasive imaging (US/CT)
a. Normal ducts
b. Normal ducts but suspecte extrahepatic cholestasis
c. Dilated ducts
i. Direct duct visulaization - ERCP or PTC
--> if seen, then relieve obstruction
(surgically, endoscopicallly, percutaneously)

Hundreds of adenomatous polyps in the clon, the colon is always involved and the duodenum is involved in 90% of cases . Polyps may also form in the stomach, jejunum and ileum. This is an autosomal dominant d/o

FAP

Metabolic activity post SBO?

Hypovolemia, tachycardia, hypotension, teachypnea, AMS, oliguira

What is the hormone that relaxes the sphictor of Oddi and contracts the gallbladder:

CCK

Treatment of epiphrenic diverticulum (distal 1/3)

esophagomyotomy

AR disorder with increased skin pigmentation, DM, cirrosis and arthralgia in late stages

hemochromatosis

Clinical features of cholelithiasis?

1. MAJORITY ARE ASYMPTOMATIC - if found incidentally - dont touch it no need to remove
2. Biliary colic is due to temporary obstruction of the cystic duct by a gallstone.
3. Pain is 2/2 the gallbladder contractng AGAINST the obstruction
4. RUQ or epigastrium and mild-severe pain
5. BOAS SIGN - riht subscapular pain of biliary colic

Most common causes of ACUTE pancreatitis:

1. ALCOHOL
2. GALLSTONES

Sulfasalazine is metabolized by bacteria to 5-ASA and sulfapyridine. 5ASA is the _____ _______ of the drug

effective moality

Pseudomembranous colitis

-Antibiotic associated colitis because many patients do not have grossly visible pseudomembranes

a. AB rx kills organisms that normally inhibit the growth of Cdiff.
b. Overgrowth of C. diff and toxin production
c. almost all antibiotics have been associated but the most common include;
i. Clindamycin
ii. Ampicillin
iii. Cephalosporins

Symptoms usually begin during first week of antibiotic therapy but can continue 6 weeks after stopping AB.

HOW does CRC spread?

Direct extension - circumferencially and then through the bowel wall to invade other abdominal organs.

hematogenous
-portal circulation to the liver, liver is the most common site of distant spread
-lumbar/vertebral veins to lungs
-lymphatic (regionally)
-transperitoneal and intraluminal

Decreased liver syntheic function will cause a decrease in serum albumin concentration and an increase in INR (why?) Hypoalbuminemia can contribute to edemain end stage liver disease.

because the liver produces albumin and clotting factors. If clotting factors are low, then PT and PTT times will take longer and the INR will be hypercoaguable because there are minimal being produced

Diagnos gastric CA
Stage gastric CA

Endoscopy with multiple biopsies
Abdominal CT

Multiple hamartomas that may be scattered through the GI tract that cause pigmented spots around the lips, oral mucosa, face, genitalia and palmar surfaces. These are very low malignant potential. Intussesception or GI bleeding may occur.

Peutz Jeghers

Prognosis of PANCREATIC CA?

Dismal - diet within months of diagnosis

Diagnosis of ACHALASIA

Dx: barium swallow ("birds beak") beak-like narrowing of distal esophagus and a alrge, dilated esophgus proximal to the narrowing

dx: UPPER GI endoscopy to r/o secondary causes of achalasia (gastric carcinoma) and retention esophagitis or esophageal CANCER

dx: manometry to confirm the dz; reveals failure of LES relaxation and aperistalsis of esophageal body

When is discharge appropriate for CA-P?

When VS are stable for 24hr (temp <100; RR<24; HR<100, SBP >90, sat 90%)
-able to take ATB po
-able to maintain hydration and nutrition
-MS is normal or at baseline
-no other active clinical or psychosocial issues requireing ongoing hositalization

Treatment of MW syndrome/tear

upper endoscopy is diagnostic, most causes stop bleeding without any treatment but if treatment is required it is surgical (overing the tear) or angiographic embolization if bleeding continues, but this is raraely necessary. Acid suppression is used to promote healing.

Clinical features of PSC:

1. Begin insidiously
2. Chronic cholestasis include jaundive, pruritis; all patients eventually present with chronic obstructive jaundice.
3. Other symptoms include: fatigue, malaise, weight loss

SQAA of the esophagus

20% survivial rate at 1 year
5% survival rate at 5 years

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