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GI Review (CM)

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)
Created by: duanea00