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Goljan HY GI

Cleft lip/palate failure of fusion of facial processes
Herpes labialis multinucleated giant cell with acidophilic intranuclear inclusions on Tzanck prep
Hairy leukoplakia EBV glossitis; pre-AIDS defining lesion; not precursor to cancer
Mumps bilateral parotitis; unilateral orchitis; ↑ amylase
Diphtheria pseudomembrane pharynx and trachea with cervical lymphadenopathy
Congenital syphilis notched central incisors
Actinomycosis anaerobic gram + filamentous bacteria; complication extracted dental abscess
S/S draining sinuses with sulfur granules
Exudative tonsillitis majority are viral; 20% group A streptococcus
Oral thrush common in newborn; pre-AIDS defining lesion; yeasts and pseudohyphae
Dental caries Streptococcus mutans
Peutz-Jegher’s syndrome mucosal pigmentation; hamartomatous polyps
Leukoplakia/erythroleukoplakia biopsy to rule out squamous dysplasia or cancer
Squamous cell carcinoma smoking and alcohol association; lower lip MC site
Smokeless tobacco verrucoid squamous cell carcinoma
Gum hyperplasia phenytoin, pregnancy, scurvy
Pleomorphic adenoma MC benign tumor of salivary glands; parotid MC site
Mucoepidermoid carcinoma MC malignant tumor major and minor salivary glands
Dysphagia for solids only lesion obstructing esophagus; e.g., cancer, web
Plummer-Vinson syndrome iron deficiency anemia causes esophageal web, glossitis, achlorhydria (↓ HCl in gastric acid)
Dysphagia for solids and liquids motor abnormality; e.g., achalasia MCC, PSS or CREST syndrome
TE fistula polyhydramnios; proximal esophagus ends blindly; distal esophagus derives from trachea
VATER syndrome vertebral abnormalities, anal atresia, TE fistula, renal disease/radius abnormality
Zenker’s diverticulum MC pulsion diverticulum of esophagus; halitosis (stinky breath, food gets stuck); near UES
GERD relaxation of lower esophageal sphincter (LES) with acid reflux
GERD MCC nocturnal cough and asthma
AIDS esophagitis Candida MC, CMV, HSV
Barrett’s esophagus glandular metaplasia distal esophagus in GERD
Complications of Barrett’s precursor for adenocarcinoma, stricture
Esophageal varices dilated left gastric vein; sign of portal hypertension due to cirrhosis
Mallory Weiss syndrome tear of distal esophagus from retching in alcoholic or bulimic
Boerhaave’s syndrome rupture of distal esophagus from retching; pneumomediastinum
Hamman’s mediastinal crunch pneumomediastinum (air in subcutaneous tissue)
LES ganglion cells contain VIP - relaxes LES
Achalasia failure of LES relaxation (no VIP); absent ganglion cells in the myenteric plexus
S/S aperistalsis/dilation of esophagus; regurgitation of undigested food at night
X-ray achalasia bird’s beak appearance
Acquired achalasia Chagas’ disease; leishmania destroy ganglion cells
Distal adenocarcinoma esophagus MC primary cancer; due to Barrett’s esophagus
Squamous cell carcinoma of esophagus smoking MCC; alcohol also causes
Melena sign of upper GI bleed; acid changes Hb to hematin; peptic ulcer disease MCC
Hematemesis vomiting blood; peptic ulcers MCC
Congenital pyloric stenosis hypertrophy pyloric muscle; vomiting non-bile stained fluid in 2-4 weeks
Acute hemorrhagic (erosive) gastritis NSAIDs MCC
Mucous barrier stomach maintained by PGE; misoprostol PGE analog
Type A chronic gastritis due to PA; achlorhydria with ↑ serum gastrin
Type B chronic gastritis due to H. pylori; involves pylorus and antrum
H. pylori curved rod; urease producer; MCC PUD, adenocarcinoma, gastric lymphoma
Gastric ulcer lesser curvature pylorus and antrum; poor defense against acid; food aggravates pain
Duodenal ulcer never malignant; ↑ acid production; food relieves pain
Perforated peptic ulcer air under diaphragm causes pain in left shoulder
Menetrier’s disease giant rugal hyperplasia; protein loss from increased mucus
Zollinger-Ellison syndrome malignant islet cell tumor secreting gastrin; part of MEN I syndrome
S/S PUD in usual locations; sometimes multiple ulcers
Hypergastrinemia ZE, achlorhydria, gastric distention, H2 or proton blockers; renal failure
Leiomyoma MC benign tumor of stomach
Intestinal type adenocarcinoma H pylori related; ↓ incidence; lesser curvature pylorus/antrum
Diffuse type adenocarcinoma linitis plastica; signet ring cells; Krukenberg tumors ovaries
Gastric lymphoma stomach MC site for extranodal lymphomas; H. pylori associated
Malabsorption steatorrhea; chronic pancreatitis, bile salt deficiency, small bowel disease
Causes bile salt deficiency liver disease, bile salt resins, cholestasis, bacterial overgrowth, Crohn’s
D-xylose screen failure to reabsorb xylose indicates small bowel disease
Calcification of pancreas chronic pancreatitis cause of malabsorption
Celiac disease autoimmune disease; antibodies against gliadin in gluten; flat villi
Celiac disease association with dermatitis herpetiformis
Whipple’s disease systemic infection; foamy macrophages with bacteria (PAS+ inclusions) in small bowel submucosa
S/S fever, polyarthritis, skin pigmentation
Invasive diarrhea Campylobacter jejuni MCC; positive fecal smear for leukocytes
Secretory diarrhea loss isotonic fluid; enterotoxins from E. coli and V. cholerae
Osmotic diarrhea hypotonic loss fluid; laxatives, lactase deficiency
Rotavirus MCC diarrhea in children
Norwalk virus MCC diarrhea in adults
Cytomegalovirus common cause diarrhea in AIDS; MCC cholecystitis and pancreatitis in AIDS
Staphylococcus aureus preformed toxin causes food poisoning; culture food
Bacillus cereus preformed toxin in fried rice and tacos; gram positive rods in stool
Clostridium botulinum (adult) preformed neurotoxin (blocks acetylcholine release); paralysis and mydriasis
Clostridium botulinum (child) colonization of bowel with release of neurotoxin; eating honey
Clostridium difficile pseudomembranous colitis; post-antibiotics; toxin assay stool; Rx metronidazole
Shigella sonnei produces dysentery (bloody diarrhea); associated with HUS
Salmonella enteritidis gastroenteritis; animal reservoirs - poultry, turtles
Salmonella paratyphi sepsis; osteomyelitis in HbSS
Salmonella typhi typhoid fever; human transmission; bradycardia, neutropenia, splenomegaly
Carrier state site gallbladder
M. tuberculosis MCC intestinal TB in United States (swallow TB); Peyer’s patch site of infection
Enterotoxigenic E. coli secretory diarrhea (traveler’s diarrhea); toxin stimulates guanylate cyclase
Vibrio cholerae secretory diarrhea; toxin stimulates adenylate cyclase to produce cAMP
Oral Rx cholera solution must contain glucose to reabsorb Na+ (co-transport)
Yersinia enterocolitica mesenteric lymphadenitis; sepsis in iron overload states
Entamoeba histolytica dysentery; trophozoites phagocytose RBCs; liver abscess; Rx metronidazole
Cryptosporidium parvum MCC diarrhea in AIDS; acid-fast oocysts
Giardia lamblia MC protozoal cause of diarrhea; cause of malabsorption; Rx metronidazole
Trichuris trichiura rectal prolapse in children
Enterobius vermicularis anal pruritus; urethritis in girls; no eosinophilia
Ascaris lumbricoides intestinal obstruction due to adult worms; no eosinophilia
Necator americanus hookworm; iron deficiency anemia
Strongyloides stercoralis rhabditiform larvae in stool not eggs
Diphyllobothrium latum fish tapeworm; vitamin B12 deficiency
Signs of small bowel obstruction colicky pain; constipation and obstipation
Radiograph small bowel obstruction air-fluid levels on x-ray
MCC small bowel obstruction adhesions from previous surgery
Duodenal atresia vomiting bile-stained fluid at birth; double bubble sign; Down syndrome
Hirschsprung disease absent ganglion cells in submucosal/myenteric plexus rectosigmoid
S/S proximal bowel dilated but peristalses; no stool in rectal vault
Hirschsprung association Down syndrome; Chagas disease
Intussusception terminal ileum telescopes into cecum; obstruction plus bloody diarrhea
Meconium ileus complication of cystic fibrosis
Indirect inguinal hernia second MCC of small bowel obstruction; common in weight lifting
Gallstone ileus obstruction of small bowel with gallstone + air in biliary tree
Volvulus MC due to sigmoid colon twisting around mesentery
Direct inguinal hernia protrudes through center of triangle of Hesselbach; no obstruction
Umbilical hernia common in black children; may entrap bowel in adults
Sigmoid colon MC site for polyps, cancer, diverticula
Small bowel infarction diffuse abdominal pain with bloody diarrhea
Causes small bowel infarction embolism (atrial fibrillation), thrombosis SMA or SMV
Ischemic colitis splenic flexure pain with bloody diarrhea
Mesenteric angina pain in splenic flexure 30 minutes after eating
Angiodysplasia submucosal dilation of venules in cecum; cause of hematochezia
Hematochezia massive loss of blood per rectum; diverticulosis MCC
Meckel’s diverticulum persistence omphalomesenteric duct
S/S bleeding MC (iron deficiency in children), diverticulitis
Meckel’s diverticulitis mimics acute appendicitis; cannot differentiate without radionuclide scan
Sigmoid diverticulum diverticulitis MC complication; MCC hematochezia and fistula formation
Diverticulitis “left-sided acute appendicitis”
Ulcerative colitis mucosal/submucosal ulceration; starts in rectum; crypt abscess; ↑ risk adenocarcinoma
S/S left lower quadrant crampy pain with bloody diarrhea
UC associations primary sclerosing cholangitis, seronegative HLA B27 + spondyloarthropathy
Crohn’s disease transmural inflammation; terminal ileum involved 80%; granulomas; skip lesions
S/S colicky pain and diarrhea; fistulas (anal, bowl to bowel)
Carcinoid tumor appendix MC site; terminal ileum MC site for carcinoid syndrome
Carcinoid syndrome liver metastasis; flushing/diarrhea due to serotonin; increased urine 5-HIAA
Tubular adenomas precursor lesion colon cancer; size and number determine risk of malignancy
Villous adenoma greatest risk for colon cancer (30%); secrete mucus rich in protein and potassium
Familial polyposis AD with 100% penetrance for developing colon cancer
Gardner’s syndrome AD, polyposis plus osteomas and desmoid tumors
Turcot’s syndrome AD, polyposis plus brain tumors
Colorectal cancer second MC cancer and cancer killer in adults
Left-sided colorectal cancer obstruct; MC location rectosigmoid
Right-sided colorectal cancer bleed
Acute appendicitis due to lymphoid hyperplasia in children and obstruction by fecalith in adults
External hemorrhoids thrombose
Internal hemorrhoids bleed; prolapse out of rectum
Urobilinogen (UBG) breakdown product CB in bowel (color of stool)
UBG enterohepatic circulation to liver and kidney (color of urine)
Alcoholic liver disease serum AST>ALT; ↑ serum GGT
Viral hepatitis serum ALT>AST
Cholestasis markers serum AP and GGT
Unconjugated bilirubin macrophage degradation of heme; lipid soluble; never in urine
Conjugated bilirubin (CB) water soluble; never normal in urine
% CB <20% (unconjugated) Gilberts, spherocytosis, physiologic jaundice newborn, ABO/Rh HDN
Gilbert’s disease AD; ↓ uptake and conjugation; bilirubin increases with fasting
Physiologic jaundice newborn unconjugated hyperbilirubinemia; begins on day three
% CB 20-50% viral/alcoholic hepatitis
% CB >50% bile duct obstruction (intra or extrahepatic); carcinoma head of pancreas
Negative urine bilirubin + trace urobilinogen normal urine
Positive urine bilirubin, absent urobilinogen obstructive jaundice
Positive urine bilirubin + increased urobilinogen hepatitis
Negative urine bilirubin + increased urobilinogen extravascular hemolytic anemia
Markers of severity of liver disease albumin, PT
Hepatitis A protective antibodies; day care centers, jails, homosexuals, traveling; not chronic
Hepatitis B protective antibodies; accidental needle stick, IVDA; hepatocellular carcinoma
Hepatitis C no protective antibodies; post-transfusion hepatitis; chronic state; hepatocellular carcinoma
Hepatitis D no protective antibodies; requires HBsAg to replicate
Anti-HBs alone vaccination
Anti-HBs + anti-HBc-IgG recovered from HBV
HBsAg + HBeAg + HBVDNA + anti-HBc-IgM acute HBV/chronic HBV infective carrier if >6 months
Anti HBc-IgM alone serologic gap; not infective
HBsAg + anti-HBc-IgM chronic HBV healthy carrier
Fulminant hepatic failure viral hepatitis and acetaminophen MCCs
Spontaneous peritonitis E. coli in adults; S. pneumoniae in children; complication of ascites
Granulomatous hepatitis TB MC bacteria
Amebiasis Entamoeba histolytica; flash shaped ulcers in cecum; liver abscess; Rx
Echinococcosis Echinococcus granulosis; sheep dog definitive host; man intermediate host
Schistosomiasis Schistosoma mansoni; adult worms in portal vein; “pipe stem cirrhosis”
Clonorchiasis Clonorchis sinensis; ingesting encysted larvae in fish; cholangiocarcinoma
Congestive hepatomegaly (centrilobular necrosis) “nutmeg” liver; RHF MCC
Hepatic vein thrombosis Budd-Chiari syndrome; painful hepatomegaly; ascites; portal hypertension
Portal vein thrombosis ascites, portal hypertension, no hepatomegaly
Alcohol related disorders fatty change; alcoholic hepatitis; cirrhosis
Hypertriglyceridemia in alcoholics ↑ synthesis of glycerol 3P (substrate for TG synthesis)
Hypoglycemia in alcoholics ↓ gluconeogenesis (↑ NADH causes pyruvate to convert to lactate)
Ketoacidosis in alcoholics ↑ lactate, ↑ ßOHB (acetyl CoA converted to AcAc and then ßOHB)
Primary biliary cirrhosis granulomatous destruction triad bile ducts; anti-mitochondrial antibody
Primary sclerosing cholangitis association with ulcerative colitis; MCC of cholangiocarcinoma
Extrahepatic biliary atresia neonatal cholestasis
Drugs causing hepatitis acetaminophen, isoniazid, halothane
Anabolic steroids intrahepatic cholestasis
Estrogen/oral contraceptives intrahepatic cholestasis; hepatic adenoma (intraperitoneal hemorrhage)
Methotrexate liver fibrosis, fatty change
Liver angiosarcoma vinyl chloride
Hemochromatosis AR; increased iron reabsorption; liver target organ
S/S cirrhosis; “bronze diabetes” - skin pigmentation + destruction of islet cells; malabsorption
Lab ↑ serum ferritin, iron, % saturation; ↓ TIBC
Wilson’s disease AR disease; defect in copper excretion in bile and synthesis of ceruloplasmin
S/S cirrhosis, movement disorder (necrosis in putamen), Kayser Fleisher ring (Descemet’s membrane)
Lab ↓ ceruloplasmin (causes ↓ total copper); ↑ serum/urine free copper
HELLP syndrome pre-eclampsia; Hemolytic anemia, ELevated transaminases, Low Platelets
AAT deficiency in child AR, cannot secrete AAT from liver cell; cirrhosis; hepatocellular carcinoma
Reye syndrome coma and microvesicular fatty change post viral infection; increased ammonia
Cirrhosis irreversible fibrosis; regenerative nodules; portal hypertension
Causes cirrhosis alcohol (MC), HBV/HCV, hemochromatosis, Wilson’s, AAT deficiency, 1° biliary
Hepatic encephalopathy mental status changes; ↑ serum ammonia
Portal hypertension ascites; varices; splenomegaly; hemorrhoids; caput medusae
Cause of ascites portal hypertension; hypoalbuminemia; secondary aldosteronism
Rx use aldosterone blocker (acidosis increases loss ammonium in stool)
Hyperestrinism in men gynecomastia; spider angiomas; female hair distribution
Lab findings cirrhosis ↓ BUN, glucose, sodium, potassium, calcium (↓ vitamin D); ↑ PT
Liver cell adenoma estrogen related (steroids, oral contraceptives); intraperitoneal hemorrhage
Liver cancer metastasis MC cancer; lung cancer MC primary site
Hepatocellular carcinoma chronic HBV and HCV MCC; ↑ AFP; hepatic/portal vein invasion
Cholangiocarcinoma primary sclerosing cholangitis MCC, C.C sinensis
Pathogenesis of cholesterol stones bile with too much cholesterol and too little bile salts
Black pigment stones sign of extravascular hemolytic anemia (spherocytosis, HbSS)
Acute cholecystitis stone impacted in cystic duct; right upper quadrant colicky pain with radiation to shoulder
Chronic cholecystitis chemical inflammation
Gallbladder cancer risk factors - cholelithiasis and porcelain gallbladder
Acute pancreatitis causes - alcohol and gallstones; ↑ amylase and lipase (more specific)
S/S epigastric pain with radiation into back
Sentinel loop localized ileus of duodenum due to acute pancreatitis
Pancreatic pseudocyst abdominal mass; persistence of ↑ serum amylase >1 week
Chronic pancreatitis alcohol abuse, CF; malabsorption, pain, type I diabetes
Pancreatic cancer smoking MCC
S/S jaundice/acholic (gray/pale) stools; palpable gallbladder; superficial migratory thrombophlebitis (Trousseau's sign); ↑ CA 19-9
Negative urine bilirubin + trace urobilinogen normal urine
Positive urine bilirubin, absent urobilinogen obstructive jaundice
Positive urine bilirubin + increased urobilinogen hepatitis
Negative urine bilirubin + increased urobilinogen extravascular hemolytic anemia
Created by: megankirch