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GI Review (CM)
| Question | Answer |
|---|---|
| Functional abd pain: | lack laboratory or radiographic abnormalities |
| Functional abd pain: dx: | Should always be dx of exclusion |
| chronic or recurrent pain or discomfort in the upper abdomen = | dyspepsia; epigastric pain (not GERD or PUD) |
| Functional abd pain: Causes: | altered gut motility; exaggerated visceral responses to noxious stimuli; altered processing of visceral stimuli |
| pyrosis = | heartburn |
| Abd: alarm sx (malig): | early satiety; dysphagia; altered bowel habits |
| odynophagia = | painful swallowing (food or liquid) |
| 3 types of abd pain | visceral (dermatomes), somatic (pain rec in parietal peritoneum), referred |
| Referred: classic sx = | right shoulder pain (biliary pain/gall bladder) |
| Periumbilical pain that is crampy that pts can sleep thru: | classic sx of IBS |
| Dyspepsia: tx: pts >55 yo OR those with alarm sx: | Prompt endoscopy |
| Dyspepsia: tx: Patients < 55yrs and no alarm symptoms | Test & treat for H. pylori and initiate trial of PPI; OR initiate trial of PPI |
| Dyspepsia: alarm sx | bleeding, anemia, wt loss >10% body wt, progressive dysphagia, odynophagia, persistent vomiting, h/o PUD, FH gastric malig, abd mass |
| Predominant feature of dyspepsia (which distinguishes it from GERD): | pain or discomfort |
| Most common complication of diverticulosis: | Diverticulitis |
| Diverticulitis: most common presenting sx: | pain, often LLQ w/inc WBC/left shift (resembles left-sided appendix); poss acute GI bleed |
| Diverticulitis: Imaging study of choice | CT |
| Diverticulitis: Tx | clear liquids; 7-10 days Abx (cipro & flagyl); close f/u |
| Diverticulitis complications | Bleeding; intra abscess; fistulas; obstruction |
| Acute lower GI bleed: most common causes: | diverticular disease; vascular malformations |
| Most common cause of acute lower GI bleed in young pts: | anorectal lesion |
| Obscure GI bleed = | source of bleeding is not identified after endoscopic evaluation of both upper & lower GI tract |
| Occult GI bleed = | detection of asymptomatic bleeding from GI tract |
| Chronic diarrhea: 3 types: | osmotic (aka malabsorption), secretory and inflammatory |
| Malabsorption: most common sx | diarrhea & wt loss; but sx can manifest outside GI tract (classic dz = celiac dz) |
| Fat malabsorption: testing gold standard: | fecal fat analysis |
| CHO malabsorption: S/S | bloating; soft diarrhea |
| Protein malabsorption: S/S | Edema (d/t 3rd spacing); muscle wasting |
| 3 subtypes of constipation | slowed transit thru colon; obstructive defecation (aka dyssynergic); constipation-predominant IBS |
| constipation: causes | functional (e.g. diet); drugs; endocrine/ metabolic; neuro; structural lesions |
| Most common cause of dysphagia | esophageal disease |
| esophageal dz: motility disorder vs mech obstruction | motility: prob swallowing solid/liquid; mech obstruction: prob swallowing solid |
| GI labs: | CBC, chemistries, LFTs, amylase & lipase, stool exam |
| Rectal pain: severe pain (like a cut) immed after BM: | anal fissure |
| Rectal pain: dull, aching after BM: | extensive inflammation of internal hemorrhoids |
| Proctalgia fugax: | unique, spasmodic anal pain that is usually unrelated to bowel movements |
| Anal fissures: position | usu posterior (may be anterior); if lateral: suspect TB, syphilis, occult abscesses or carcinoma |
| Panc functional units | exocrine: acinus; endo: islet of Langerhans (alpha: glucagon; beta: insulin) |
| Acute pancreatitis | syndrome: enzymatic damage to pancreas, results in discrete episodes of abd pain |
| Acute pancreatitis: pathophys | Inappropriate activation of trypsinogen to trypsin w/in pancreas; trypsin activates other proteases; cascade: local autodigestion; distal: release of proinflam mediators |
| Acute pancreatitis: 2 types | acute interstitial; acute necrotizing |
| Acute interstitial pancreatitis: | mild pancreatitis with pancreatic edema |
| Acute necrotizing pancreatitis: | severe pancreatitis with necrosis of parenchyma & blood vessels |
| Acute pancreatitis: Classic sx: | Constant, epigastric pain radiating to back; usu assoc w/ N&V |
| Acute pancreatitis: other sx: | tachycardia (2/2 hypovolemia); fever (1-3 days from onset); icterus/jaundice; dec breath sounds (Pl eff); abd tenderness (rebound); necrotizing: systemic toxicity, sepsis |
| Gray Turner's sx | Flank ecchymosis from retroperitoneal hemorrhage; in acute necro panc |
| Cullen's sx | Periumbilical ecchymosis; in acute necro panc |
| Acute pancreatitis: labs | elevated amylase, lipase (more spec) |
| Acute panc: plain films | calcified gall stone/panc; sentinel loop of sm bowel; colon cut-off sx (no air distal to splenic flexure) |
| Acute panc: US/CT | US: enlarged hypoechoic pancreas; CT: enlarged panc, peripancreatic edema |
| Imaging of choice for panc parenchyma | CT |
| Acute panc: prognosis based on: | Ranson criteria (on admission & after 48 hr); APACHE II score (immed & daily); Glasgow; CT severity score |
| Acute panc: Tx | Pancreatic rest (NPO); IVF; pain meds; Abx if >30% necrosis |
| Acute panc: complications | ARDS, sepsis, renal fail; fluid collections; panc necrosis (sterile/infected); panc abscess |
| Acute panc: most common comp | pseudocyst: collection of panc juice encased by granulation tissue; > 4 wks |
| Chronic panc: causes | Chronic alcohol use (70%); chronic obstruction of pancreatic duct |
| Chronic panc: clin findings | Persistent/recurrent epigastric & LUQ pain; Steatorrhea; DM |
| Chronic panc: dx | no lab tests (amy/lipase usu not inc); fecal fat/elastase; secretin stim test |
| Chronic panc: Abd plain film: | Pancreatic calcifications (classic finding) |
| Chronic panc: CT | Pancreatic calcifications, atrophied pancreas |
| Chronic panc: MRCP/ERCP | Chain of lakes (areas of dilation / stenosis along pancreatic duct) |
| Chronic panc: Tx | Abstain from EtOH; tx pain (panc enzyme replacement; H2 blocker/PPI) |
| Chronic panc: Surg | Puestow (lateral pancreatojejunostomy) if duct dilated >6 mm; OR subtotal or total pancreatectomy |
| Panc ca: RFs | tobacco; chronic panc; exposure to dyes; non-IDDM in pt >50; h/o partial gastrectomy or cholescystectomy; genetics |
| Panc ca: clin findings | jaundice, wt loss; Courvoisier sx; Trousseau sx |
| Panc ca: head vs body/tail | Most common location: head; painless jaundice (compresses CBD); body/tail: abd pain d/t retroperitoneal invasion into celiac plexus |
| Courvoisier sx | palpable GB due to head mass compressing CBD |
| Trousseau sx | migratory thrombophlebitis |
| Panc ca: labs | Alk Phos; Bilirubin, CA 19-9 |
| Panc ca: dx: | CT; MRI; EUS (if no lesion on CT/MRI & still have high suspicion) |
| Panc ca: surg: | in head: Whipple; in body/tail: distal pancreatectomy & splenectomy & 5FU C/RTx |
| Panc ca: Tx if not resectable | Locally advanced: 5FU Chemoradiation; mets: Gemcitabine; Pain control, palliative stents |
| Panc ca: prognosis | 15-20% candidates for pancreatectomy; 50% mets at time of dx; if resectable: 15-17 mos (if not: worse) |
| Upper vs lower GI bleed: anatomy | ligament of Treitz |
| Meds assoc w/GI bleed | NSAIDs; Steroids (in setting of NSAID); Warfarin; Heparin, Enoxaparin; Clopidogrel (Plavix) |
| 3 most common causes of upper GI bleed | PUD (55%); Varices (14%); AVM (6%) |
| 3 most common causes of lower GI bleed | Diverticular Dz (33%); Neoplastic Dz (Polyps, Ca; 19%); Colitis (18%) |
| Resting Tachycardia: blood loss = | 10% of intravascular volume lost |
| Orthostasis: blood loss = | Significant loss, 10-20% of intravascular volume |
| Shock: blood loss = | Loss of 20-40% of intravascular volume |
| Chronic GI blood loss: defined by: | Fe def anemia: Low Ferritin (<30); Low Fe, High TIBC; Low MCV; also Anemia w/brown stool (Guaiac pos) |
| GI bleed: mainstay of initial tx | Resuscitation; goal = normal vital sx; 2 lg bore IVs; ICU monitoring if needed |
| Dieulafoy's Lesion = | Dilated submucosal artery erodes into mucosa with subsequent rupture of the vessel; bleeding often massive & recurrent |
| Mallory-Weiss tear: | Laceration in the mucosa, usually near GE junction; commonly after retching |
| Diagnostic tools for LGIB | Anoscopy; Flexible Sigmoidoscopy; Colonoscopy; Tagged red blood cell scan; Angiography |
| Diverticular bleeding | Acute, painless hematochezia; most bleeds are right sided |
| Role of tagged scan | help localize bleeding; pre-test for angiography; detects bleeding (0.1 to 0.5 mL/min; less sensitive w/inc bowel motility); no tx capability |
| LGIB: Angiography: caution: | Caution w/renal failure given IV contrast load |
| LGIB: Angiography: utility | Coil microembolization of bleeding vessel; blood flow must be 1 mL/min |
| Colon ca risk: | doubles each decade after 40 yo; M>F; 90% occur after 50; sig higher risk if 1st-degree relative with colon ca |
| Colon ca Genl RFs | Age; Personal hx colon polyps or ca; FH; inherited syndromes; T2DM; IBD |
| Colon ca Liefstyle RFs | Diet (red meat); physical inactivity; obesity; smoking; heavy alcohol use |
| 2 types of dx criteria for HNPCC | Amsterdam; Bethesda |
| S/S colon ca | Rectal bleeding; Fe def anemia; Fatigue / wt loss; obstruction (left sided tumors); change in stool quality/caliber; abdominal mass or abd pain |
| Colon ca: most common metastases are to: | liver, then lung (colon); liver or lung (rectal ca) |
| Colon ca: gold standard of dx eval: | colonoscopy |
| Colon ca: other dx eval | CT with contrast abd/pelvis (for staging); CXR; needle bx of suspected mets dz; PET Scan only for suspected mets dz |
| Colon ca: labs | CBC, chemistry; may check CEA, but not for dx (help w/staging) |
| Cancer stage is determined from: | PE, biopsy, imaging, lymph node dissection |
| Layers of colon wall | Mucosa; muscularis mucosa; submucosa; muscularis propia; subserosa/serosa |
| Types of ablation of mets | Radiofrequency Ablation; Ethanol ablation; Cryosurgery; Hepatic artery embolization |
| Goal of chemo: | Eradicate micrometastasis to increase likelihood of cure; none for stage 0 or I; resected stage II: poss modest survival benefit but not routinely recommended |
| Radiation tx | not typically used for colon ca; used for rectal ca |
| Screening: stool Tests: | primarily detect cancer; Guaiac FOBT & immunochemical-based FIT; Stool DNA (sDNA) |
| Screening: Structural Exams: | Detect cancer and polyps; Colonoscopy; CT colonography; Flexible Sigmoidoscopy; Double-contrast barium enema (uncommon) |
| Best mortality data for CRC screening: | Guiac FOBT |
| Never screen for colon ca with: | DRE |
| Positive FOBT should always be followed by: | colonoscopy (and no more FOBTs needed) |
| Negative FOBT tests: | should be repeated annually |
| Flexible Sigmoidoscopy | Examines left colon; some bowel prep needed; can performed w/o sedation in Dr's office; 5-year interval between exams |
| Patients w/ adenomas found on flex sig: | should go for colonoscopy |
| Colonoscopy | Direct inspection of entire colon with sedation (usu conscious); thorough bowel prep required |
| Colonoscopy: miss rates | 6-12% miss rates for large adenomas; 5% miss rates for cancer |
| Most common serious complication of colonoscopy: | bleeding post-polypectomy; Perforation = 1/1000 and increases with age and diverticular disease |
| Colon ca screening | Screening: can be every 10 yr; |
| Colon ca surveillance: | once ca/adenomatous polyps are detected, occurs at shorter intervals (usually repeat colonoscopy in 3-5 years); If FH CRC: every 5 yr; IBD: yearly once disease present for more than 15 yr |
| Colon polyps (types) | adenomatous (poss pre-malig: req shorter surveillance colonoscopy interval); hyperplastic (not considered pre-malig) |
| CT colonography | No sedation; req bowel prep; pos result req f/u colonoscopy |
| Defn diarrhea | >3/day; 200 g or ml; loose/liquid consistency |
| Acute/ persistent/ chronic | Acute <14 days; Chronic >1 month |
| Chronic diarrhea: etiology | Malabsorption; motility disorders; inflammation |
| Assessing severity of illness | dehydration; duration of sx; inflammation (fever, blood, tenesmus) |
| Order stool studies if: | Diarrhea is persistent or recurring; h/o fever or tenesmus |
| E. histolytica | necrosis of lg intestine; tropical; abd pain, cramping, colitis; can be bloody/fevers; travelers, MSM |
| Vibrio | watery dia, abd cramping; V para: also wound infxn; heat to >75C to destroy; susceptible: liver dz & Fe overload states |
| V cholera MOA | activates adenylate cyclase (cAMP regulates Na & Cl absorpn/secretion) |
| V cholera S/S | rice-water stools; poss hypotensive shock within 2 hrs; dose fx; tx rehydrate & 1 dose Cipro; untx'd 50% mortality |
| Pre-formed toxins: organisms | S aureus; B Cereus; Clostridium Perfringens |
| Giardia: most susceptible | immunocompromised; immunocompetent w/Ig def |
| Dx giardiasis with: | giardia antigen stool assay |
| C perfringens sx | Abd cramps & watery diarrhea without fever or N/V; lasts <24 hr |
| Invasive pathogens (most common causes infxs dia) | Salmonella, shigella, campy |
| E coli: most likely from: | undercooked beef; unpasteurized juice; spinach; in warm weather |
| E coli: hemorrhagic colitis: | severe abd pain, bloody diarrhea (no fever usually) caused by shiga or shiga-like toxin |
| HUS may be due to: | E coli; shigella |
| ETEC: tx | travelers diarrhea; Abx after sx onset may decrease duration; Cipro or rifaximin |
| Salmonella Sx | fevers, myalgias, abd cramping, HA; |
| Salmonella complications | Septicemia/Bacteremia; poss osteomyelitis, endocarditis, arthritis |
| Salmonella typhi Sx | 10-14d post-ingestion: fever, HA, myalgia, malaise, anorexia; followed by GI sx (GB colonization & intestine reinfxn); typhoid fever: pulse-temperature discordance; 1-5% chronic carriers |
| Shigella Sx | Lower abd cramps, diarrhea, fever, bloody, purulent stools & tenesmus; usu self-ltg (7 days) |
| Shigella Tx | Abx recommended (FQ or Bactrim) |
| Yersinia Sx: | Diarrhea, fever, abdominal pain for 1-2 wks (chronic: poss for mos); fx terminal ileum; lg lymph nodes (mimics appy); systemic dz: high mortality |
| Campy Sx: | dysentery; poss bacteremia; usu self ltg (may last 1 wk/longer); assoc w/GBS & Reiters |
| Most common cause of nosocomial diarrhea | C diff (Abx-induced diarrhea); tx w/Flagyl or oral vanco |
| Loperamide | opiate w/o systemic fx; inhibits peristalsis; can use w/Abx for traveler's diarrhea |
| DO NOT use anti-motility agents in: | pts w/shigella, C diff, E coli O157 (inflammatory diarrhea) |
| Antimicrobial tx: used for: | shigellosis, traveler's diarrhea, C.difficile, campylobacter; can prolong salmo/C diff shedding, or worsen shiga toxin course |
| Tx of choice for more severe infxs diarrhea: | FQ; TMP-SMX = 2nd-line tx; Add azithro for Campy |
| Gastritis sx | Abd pain; Indigestion; Loss of appetite; N/V; Melena |
| Causes of acute hemo gastritis | Stress lesions, drugs, trauma (for body, NG tube, radiation); embolism/vasculitis; reflux injury; HP |
| Non-erosive chronic gastritis causes | chronic superficial HP or chem gastritis; Metaplastic atrophic: autoimmune (AD, F>M 3:1, inc ca, fundus/body) or environmental (HP & diet) |
| Forms of gastritis | infxs (CMV, HIV, herpes, fungal, TB, syphilis); sarcoid; eosinophilic; Crohns |
| 3 most important etiological factors for PUD are: | H.Pylori; NSAIDs; Acid |
| HP dx | serology; bx w/histo; bx w/urease test; urease breath test; stool antigen; PPI, Abx, or bismuth gives false neg (except serology or bx w/histo) |
| HP eradication tx | triple tx: PPI, clarithro, amox; confirm eradication w/stool Ag; 20% need re-tx |
| HP & ca | causal: gastric adenoCa; assoc w/ MALT |
| ZE testing | fasting gastrin level (>1000 is dx); secretin stim test (normal pt: no fx on gastrin; ZE pt: dramatic increase) |
| ZE tx | HD PPI; resect if no mets (30-50%); mets: tx sx |
| ZE prognosis | no mets: 15-yr 83%; mets: 10-yr 30%; fasting gastrin level prognostic |
| PUD sx | Burning pain localized to the epigastrum, non-radiating; gastric ulcer: worse with meals; duod ulcer: better with meals, more often pain at night (wakes pt 2-3 AM)(DU>GU); |
| PUD dx | EGD & bx (4% PUD become malig); HP test |
| PUD comps | hemorrhage (Most Common); perf; gastric outlet obstruction |
| PUD tx | antacids, H2 blockers, PPI |
| Acid secretion | 3 stimuli of HCl prod in parietal cell: histamine, Ach, gastrin (synergistic); somatostatin is inhibitor |
| PPI AE | Diarrhea, nausea, abdominal pain, HA; poss C diff; hip fx risk if used LT |
| PUD: surg | rare; gastric patch or gastrectomy w/vagotomy |
| High risk for NSAID complications | Previous GI event; Older Age; Concomitant use of anticoagulants, corticosteroids or other NSAIDs; HD NSAID tx |
| NSAID complication: prevention | COX-2 tx; Mucosal Protection (Misoprostol; PPI; High-dose H2 blocker) |
| Misoprostol | Synthetic PGE1 analog; prevent NSAID-induced gastric ulcers; sig reduction (GU > DU); AE abd discomfort & diarrhea; CI in women of childbearing age |
| Gastric ca S/S | Asx early; indigestion, nausea, early satiety, anorexia, wt loss; Late complications: Pl eff; GOO, GE obstruction, SBO, bleed; palpable stomach, hepatomegaly, pallor, Virchow & Sister Mary Joseph nodes |
| Gastric ca etiology | Diet (pickled, salted foods, smoked meats); HP; atrophic gastritis; Polyps (rare); Radiation |
| Gastric ca: histo | 95% adenocarcinoma; other: lymphoma, SSC |
| Gastric ca: imaging | EGD; EUS; Barium Swallow (Upper GI); CT/MRI |
| Gastric ca: Tx | Surgical resection (best chance for cure); Neoadjuvant CTx & XRT; Adjuvant CTx |
| Esoph dx studies | Barium Esophagram; Upper Endoscopy; Esophageal Manometry; Ambulatory Esophageal pH monitoring |
| Heartburn (pyrosis) | substernal burning, epigastric pain radiating to the neck |
| Transfer dysphagia: | Oropharyngeal; or Neurologic Dysfunction (CVA, ALS), Zenker Diverticulum |
| Transport dysphagia: | Esophageal: food sticks |
| Odynophagia: Causes | Caustic (corrosive injury); infxs (CMV, Herpes, Candida, HIV) |
| GERD requires 3 factors: | Reflux (dysfn of anti-reflux mechms); reflux of caustic materials; sufficient duration of contact |
| Chest Pain can be due to: | GERD, diffuse esophageal spasm, nutcracker esophagus, achalasia |
| GERD sx | Heartburn (30-60 min after meals); Regurgitation; Sour brash; Dysphagia; Relief with antacids |
| Alarm sx: | Dysphagia, wt loss, hematemesis, melena; Sx age > 50 |
| Upper endoscopy: purpose: | document type/ extent of tissue damage in GERD; look for erythema, friability, stricture, Barrett's |
| Barrett esophagus: pathophys | change of squamous epi cells to columnar epi; stomach creeping up into esophagus |
| Standard procedure for detecting pathologic acid reflux in the esophagus: | ambulatory pH monitoring |
| Manometry tests: | function of the esophageal mx contractions & esophageal sphincters; to ensure proper peristalsis, & proper sphincter fn prior to any surg/endoscopic correction for reflux |
| GERD complications | Barrett esophagus; stricture (scarred down) |
| GERD tx | Medical (lifestyle mod; Reglan, motility agents); Surg; Barrett screening EGD |
| Barrett screening EGD | Sx > 10 years, age >50, white males |
| Barrett dx requires: | bx-proven presence of specialized intestinal metaplasia in the tubular esophagus |
| Metaplasia/Dysplasia/Car: poss interventions | Medical acid suppression tx; Anti-reflux surg; Endoscopic surveil; Endoscopic ablation tx; Esophagectomy |
| Infxs esophagitis: common agents: | Candida; CMV; HSV |
| Infxs esophagitis: Eval: | Sx: Odynophagia, dysphagia, CP; w/u = EGD with biopsies |
| Web = | a thin infolding of mucosa that narrows the lumen |
| Plummer Vinson Syndrome | Symptomatic proximal webs in middle-aged women with evidence of Fe deficiency anemia; increased risk of cancer |
| Schatzki ring = | a web that occurs in the distal esophagus |
| Zenker diverticulum | Outpouching of upper esophagus; always involves post wall of pharynx; most common cause of transfer dysphagia; Men >60 yo |
| Zenker sx | regurgitation, dysphagia, halitosis |
| Eo esophagitis | Dysphagia, food impaction, reflux; strictures; mucosal rings; concern for perf w/dilation |
| Eosinophilic esophagitis: mgmt | PPI; allergy testing & elim diet; topical corticosteroids (fluticasone); systemic corticosteroids |
| GI bleed 2/2 esophageal dz: | esophageal varices (2/2 portal HTN); Mallory Weiss tear; esophageal ulceration |
| Achalasia: | absence of esophageal smooth mx peristalsis w/ inc tonus of lower esophageal sphincter |
| Achalasia: S/S | Gradual, progressive dysphagia; regurg; substernal discomfort/fullness |
| Achalasia: dx gold standard = | manometry; see complete absence of peristalsis, with simultaneous, low amplitude waves; very tight LES, lack of contractions in esophagus |
| Achalasia imaging | CXR (air fluid level in enlarged fluid filled esoph); Barium esophagography (birds beak: smooth symmetric tapering; esophageal dilatation; loss of peristalsis); upper endoscopy |
| Achalasia: Tx | Pharm (nifedipine); pneumatic dilation; botox; Myotomy (85% success rate) |
| Diffuse esophageal spasm: s/s | ant CP (unrelated to exertion/eating); simultaneous, nonperistaltic contractions of esophagus; usu self-ltd |
| Diffuse esophageal spasm dx | Barium Esophagography: corkscrew contractn, rosary; manometry: intermittent simult contractn |
| Most common connective tissue disorder involving the esophagus: | Scleroderma esophagus (atrophy & fibrosis of esophageal smooth mx) |
| Scleroderma esophagus: sx | heartburn, dysphagia; Patulous LES with free reflux; manometry: low/absent LES pressure |
| Esophageal ca: presentation | Progressive solid food dysphagia, weight loss |
| Esophageal ca eval | CXR (mediastinal widening, lung or bony mets); barium esophagram (polypoid, infiltrative, or ulcerative lesion); EGD w/ bx (gold standard); Chest CT/EUS for staging |
| Esoph ca: tx | mainstay: surg resection (complete esophagectomy); unresectable: Rtx, Ctx, endoscopic stenting for palliation |
| Viral hep that can cause cirrhosis | Hep B & C |
| Conj bili | direct; bound to gluc acid; water soluble; caused by obstruction of outflow tract or in the liver |
| Unconj bili | indirect; water insoluble; caused by hemolysis |
| Fulminant acute liver dz: | progress to liver fail in 14 days; no h/o liver dz; develop coagulopathy (INR >2), encephalopathy |
| ALT/AST | hepatocell injury: correlates w/degree of cell death; >1000: hepatitis, shock, toxins (Tylenol) |
| Abnormal AST/ALT | AST:ALT >2:1 = alcoholic hep; <500: EtOH; poss normal in cirrhosis |
| Alk phos | liver, bone, intestinal tract, placenta, kidney; elevated in liver damage/obstruction; if elevated more than AST/ALT, more likely biliary disorder |
| Child-Pugh score | assesses prognosis of chronic liver dz |
| AFP for: | hepatocellular ca; inflam |
| Liver dz lab w/u | Hep A, B, C; ANA; ASMA; IgG; Anti-mito Ab (primary biliary cirrhosis) |
| Labs for hemochromatosis | ferritin, iron sat, HFE gene |
| Hep A | ave 30d incub; 80% jaundice pts >14 yo; fulminant or cholestatic hep; IVIG within 14d post exposure |
| Hep B | ave 60-90d incub; 15-25% premature mortality; cirrhosis/hepatocell ca; Asians |
| Hep C | ave 6-7 wk incub; 40% jaundice; 70% chronic; persistent; AA men in 40s; No. 1 indication for liver transplant |
| Hep C dx labs | ELISA (pos in 8-10 wks; good screen for chronic); HCV RNA; HCV genotype |
| Alcoholic hepatitis | 40-60 g EtOH/day (less for women); jaundice, fever, anorexia, nausea; TBil, alb, INR; histo makes the dx; hepatomegaly, steatohepatitis; Tx supportive (severe: prednisone/pentoxifylline) |
| Cirrhosis: dx | pathologic; Fibrosis, Regenerated nodules, Vascular distortion |
| Cirrhosis: complications | Hepatorenal syndrome; Hepatoma (hepatocell ca); Portal HTN (Varices, Ascites, Encephalopathy, GI bleeding) |
| Varices Tx | Active bleed (Hematemesis, melena, hematochezia; Hypotension, tachy): Emergent endoscopy; Octreotide (splanchnic VC to reduce portal pressure; dec collateral flow & variceal pressure); Minnesota tube: Last chance (bridge to TIPS) |
| Varices prevention | screening endoscopy; endo banding (if large varices & prior bleed); beta blockers to HR<60; nitrates |
| Ascites | 60% develop within 10 yrs of cirrhosis dx; US (check for fluid & portal v. thrombosis) |
| Serum ascites albumin gradient | paracentesis; if gradient >1.1: portal HTN |
| Spont bac peritonitis | peritoneal cell count: >500 PMN confirms dx |
| Ascites mgmt | Na & fluid restriction; diuretic tx (Aldactone/Lasix); LVP & albumin replacement; TIPS for refractory ascites |
| Encephalopathy tx | r/o infxn, correct lytes; lactulose; neomycin; rifaximin |
| Cirrhosis & Hepatoma (HCC) | screen (US & AFP 6-12 mos); common/increasing worldwide ca; tx Partial hepatectomy, Chemoembolization, RF ablation; poss TP |
| Liver TP indications | Hep C (No. 1 in US); EtOH (abstinent >6 mos); Cryptogenic/NASH; PBC, PSC; Autoimmune hep; Hep B; risk of relapse in new liver |
| NASH | chronic hep or metab syn; usu Asx; liver bx; hepatocytes replaced; tx: stop offending meds; wt/glycemic ctrl |
| Benign masses: dx | imaging > bx; 20% of popn |
| Most common benign liver tumor | hemangioma; W>M, 20-40 (2nd most common: FNH) |
| Hepatic adenoma | W>M, young, LT estrogen use; anabolic steroids |
| HCC/malignant mass | usu in setting of chronic liver injury or cirrhosis; need multi-phasic imaging to dx (arterial phase hypervascularity; delayed phase wash-out) |
| IBS prognosis | Once diagnosed 75% of pts remain symptomatic 5 yrs later, and 55% at 7 yrs |
| IBS Sx | chronic abd pain & bloating relieved by defecation; changes in stool frequency or appearance |
| IBS dx criteria | Manning; Kruis; Rome (I, II, III) |
| Considered a hallmark sx of IBS: | Lowered rectal pain threshold |
| IBS & psych: | 50% of pts seeking IBS med care also have depression/anxiety |
| IBS & post-infxn: often assoc with: | Entamoeba, Salmonella and Campylobacter |
| Initial eval for IBS includes: | PE; CBC, ESR; labs (FOBT, fecal leukocytes, O&P, cx), poss sigmoidoscopy |
| Current thought about IBS etiology: | brain-gut dysregulation |
| IBS eval red flags (suggesting dz other than IBS) | onset in pt >40; wt loss; nocturnal waking; FH ca/IBD; abnml exam; fever; pos FOBT; low HGB; high WBC; high ESR; abnml chems |
| Which tx have best evidence? | antispasmodics; anti-diarrheals (?); SSRI/TCA (IBS-D not IBS-C); poss new probiotics (not lactobacillus); Amitiza |
| IBS tx having independent analgesis properties: | antidepressants |
| Zelnorm & serotonin | serotonin release in plasma reduced in IBS-C & increased in IBS-D |
| IBD common sx | Diarrhea (often bloody); Fatigue (poss rel to anemia, not nec); wt loss; anorexia; N/V; crampy abdominal pain (d/t obstructive sx?) |
| Features of CD | Any part of GI tract; skips areas; transmural |
| Features of UC | Limited to colon; starts in rectum; usually continuous; superficial |
| Specifics of UC | Proctitis: tenesmus; bloody diarrhea more common; high risk of CRC |
| Specifics of CD | fistula: abscesses; more common at anus; strictures of the intestine; CRC risk increased if > 1/3 colon involved; smoking & CD: bad |
| Extra intestinal manifestations: | may involve any area; usu eye, skin, liver, and joints (arthralgias, AS) |
| EIM: arthralgia Type 1: | self limited, short lived, affecting 6 or fewer joints. Associated with disease flares |
| EIM: arthralgia Type 2: | multiple joints, can be migratory, can be more chronic; NOT associated with disease flares. |
| Primary sclerosing cholangitis (PSC) | UC>CD; stricture of biliary ducts; Dx high alk phos; LFT, anti-mito Ab; ERCP/MRCP; risk for CRC; refer to hepatologist |
| Erythema nodosum | raised tender red-purplish nodules; most commonly on extensor surfaces of extremities; parallels IBD activity/tx; may req steroids |
| Pyoderma gangrenosum | wide spectrum of necrotic inflam; IBD tx, topical tx, or poss colectomy; DO NOT BX |
| IBD eye complications | episcleritis; uveitis: refer to Ophtho (blindness risk) |
| IBD: DDx includes: | infxs diarrhea; ischemia (elderly, PVD, thrombosis); meds (PCN, NSAID, CellCept); diverticular dz; perianal fistula |
| IBD dx/ eval: | Combo of endoscopy, histology, radiography, labs & clinical data; Colonoscopy with ileal intubation & bx (should see chronic colitis/enteritis); Small bowel follow-through, enteroclysis (+/- CT), MR enterography |
| IBD labs | often anemic (Fe def & chronic dz), leukocytosis, elevated CRP (CD); DO NOT ORDER serologies (ASCA, Cbir, OmpC & Crohns; p-ANCA & UC) |
| Genl principles of tx | Tx affected area (enema/supp: mild-mod proctitis; budesonide: ileal CD); use as little steroid as poss; not everyone needs tx or responds to same tx |
| Tx: defn Mild UC: | ≤4 BM/day; no sx systemic tox; normal ESR |
| Tx: defn Severe UC: | >6 BM/day and sx systemic toxicity |
| IBD tx options | 5-ASA; corticosteroids; 6MP/AZA; anti-TNF Ab |
| 6MP/AZA | impair T cell fn; slow onset of action; AE pancreatitis, liver tox, cytopenia; |
| IBD colon ca risk/surveillance | CD/UC colitis >1/3 colon: colonoscopies starting 8 yrs from sx onset; q1-3 years; if comorbid PSC: immed start annual colonoscopy; FH also inc CRC risk |
| Dysplasia, cancer, or toxic colitis may: | necessitate colectomy. |
| Fibrotic strictures, obstruction, fistulae may: | necessitate segmental resection in CD (try to avoid surg if poss in CD) |
| IBD: Worrisome signs | frequent UTIs/pneumaturia (fistula to bladder); High fever/abd mass (abscess, liver abscess); severe abd pain (perf); N/V (obstruction); severe rectal pain (perirectal abscess) |
| Managing IBD flares | Similar to previous flares? Worrisome features; R/O infxn; labs (WBC, H/H); 5ASA (UC) or budesonide (ileal CD) |
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