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