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2010-07-14 #1

Gastrointestinal disorder

bimodal; risk for esophageal cancer: Dx? achalasia
pathogenesis: achalasia autoimmune destruction of ganglion cells in myenteric (Auerback) plexus > decreased proximal smooth muscle contraction + loss of NO synthase producing neurons > incomplete relaxation
Cx: achalasia nocturnal regurgitation of undigested food > nocturnal cough from aspiration; dysphagia for solids & liquids
Dx: achalasia barium swallow: beak-like tapering at distal end + dilated, aperistaltic esophagus
Rx: achalasia long-acting nitrates; calcium channel blocker; botulinum toxin injection
MC benign tumor of esophagus leiomyoma
MC malignant tumor of esophagus adenocarcinoma
MC predisposing cause of adenocarcinoma of esophagus barrett's esophagus
MC primary cancer of esophagus in developing countries squamous cell carcinoma
MCC of squamous cell carcinoma of esophagus cigarettes smoking
Cx: squamous cell carcinoma of esophagus progressive dysphagia (solids > liquid); weight loss; local invasion: trachea (dry cough & hemoptysis), recurrent laryngeal nerve (hoarseness), hypercalcemia (PTH-related peptide)
MC cause of hematemesis & melena peptic ulcer disease; melena: conversion of Hb into hemetin by acid = bleed proximal to duodenojejunal junction
what does "gastric analysis" measures basal acid output (5); maximal acid output (5~20); BAO:MAO ratio
projectile vomiting of non-bile-stained fluid; hypertrophied pylorus; olive palpation in "epigastrium": Dx? Mx? congenital pyloric stenosis; hypertrophy of pyloric sphincter muscles
gastroparesis: indication? sign of autonomic neuropathy (diabetes mellitus); previous vagotomy
Cx: gastroparesis early satiety; vomiting of undigested food
Rx: gastroparesis metoclopramide
difference between erosion & ulcer erosion: epithelium of mucosa; ulcer: mucosa > submucosa or deeper
MCC of acute hemorrhagic (erosive) gastritis; 2nd MCC as well; burns; CNS injury NSAIDs; alcohol; Curling; Cushing; uremia
Rx: acute hemorrhagic gastritis misoprostol; proton pump inhibitors
MC site of type A chronic atrophic gastritis; MCC body and fundus; pernicious anemia (Autoimmune)
MC site of type B chronic atrophic gastritis; MCC antrum & pylorus; H.pylori
pathophysiology of type B chronic atrophic gastritis mediated by H.pylori urease; colonizes mucus layer lining; noninvasive
chronic inflammatory infiltrate in lamina propria; intestinal metaplasia > precursor lesion for adenocarcinoma: Dx? H.pylori-mediated chronic gastritis
most excellent screen test for H.pylori stool antigen test; if active, [+]; if eradicated, [-]
disadvantage of urea breath test/serology do not distinguish active vs old infection
Rx: H.pylori, consequence bismuth, metronidazole/omeprazole, tetracycline; omeprazole, amoxicillin, clarithromycin; decreased risk of gastric cancer & B cell lymphoma
hyperplasia of mucus-secreting cells; hypoproteinemia; atrophy of parietal cells (achlorhydria): terminology, Dx? giant rugal folds; menetrier's disease (hypertrophic gastropathy)
MCC of peptic ulcer disease H.pylori; thus, eradication of H.pylori markedly reduces PUD recurrence
common type of PUD duodenal > gastric: lesser curvature near incisura angularis
difference between duodenal & gastric ulcers in association with malignancy duodenal: NEVER malignant; gastric: benign to malignant
secretion of excess gastrin; thus, producing hyperacidity: Dx? Zollinger-Ellision (ZE) syndrome
malignant islet cell tumor secreting gastrin; single or multiple ulcers; Dx? Ax? ZE syndrome; MEN type I in 20 to 30% of cases
suspicious for ZE syndrome peptic ulcer disease + diarrhea; association with MEN I syndrome
heartburn; epigastric pain; weight loss; solitary duodenal ulcers; acid hypersecretion with diarrhea; maldigestion of food; increased BAO:MAO ratio; serum gastrin level > 1000 pg/mL: Dx? ZE syndrome
complication of chronic gastritis & achlorhydria: Dx? gastric polyps
MC gastric polyp type hyperplastic polyp; hamartoma with no malignant potential
gastric polyp with potential for malignant transformation adenomatous polyp
MC benign tumor in stomach leiomyoma
decreasing incidence in US; increasing incidence in Japan with blood A type: Dx? primary stomach adenocarcinomas
MC gastric carcinoma intestinal type of gastric adenocarcinoma
precursor lesion for gastric adenocarcinoma intestinal metaplasia due to H.pylori
MC site of intestinal type of gastric adenocarcinoma lesser curvature pylorus & antrum
risk factor for intestinal type of gastric adenocarcinoma intestinal metaplasia due to H.pylori; nitrosamines (smoked foods); achlorhydria; chronic gastritis; type A blood
not associated with H.pylori; linitis plastica: Dx? diffuse gastric adenocarcinoma
X peristalsis of stomach; signet-ring cells infiltration into the stomach wall; Dx? diffuse gastric adenocarcinoma
metastatic signet ring cells to both ovaries: Dx? Krunkenberg tumor of ovaries: hematogenous spread
Virchow's node left supraclaviular node: abdomen > stomach or pancreas
Cx: gastric adenocarcinoma MC: cachexia & weight loss; paraneoplastic skin lesions: acanthosis nigricans; multiple outcroppings of seborrheic keratoses (Leser-Trelat sing); metastasis to umbilicus (Sister Mary Joseph sign)
MC site for extranodal malignant lymphoma stomach; primary gastric malignant lymphoma
MCC of gastric lymphoma H.pylori; low-grade B-cell lymphoma "MALToma"
symptom of small bowel obstruction colicky pain; pain followed by a pain-free interval
blood diarrhea (small bowel): sign? infarction; volvulus; dysentery
difference of diarrhea between small & large bowels? small bowel: infection, malabsorption, osmotic diarrhea; large bowel: infection, laxative abuse, inflammatory bowel disease
definition of dysentery bloody diarrhea + mucus
melanosis of the large intestinal mucosa due to accumulation of pigment of uncertain composition within macrophages in the lamina propria: term? melanosis coli
massive loss of whole blood per rectum: Dx? causes? hematochezia; signmoid diverticulosis (MC), angiodysplasia
criteria for diarrhea: stool/acute/chronic/types more than 250g of stool; < 3wks = acute; > 4 wks = chronic; invasive, osmotic, secretory
screen test for invasive diarrhea fecal smear for leukocytes
loss of isotonic fluid secretory fluid
loss of hypotonic fluid osmotic diarrhea
stool osmotic gap < 50 mOsm/kg from POsm: type/indication secretory diarrhea; diarrheal fluid approximates POsm
stool ostmoic gap < 100 mOsm/kg from POsm: type/indication osmotic diarrhea; hypotonic loss of stool due to presence of osmotically active subsutances
causes of malabsorption pancreatic insufficiency; bile salt/acid deficiency; small bowel disease
signs & symptoms of malabsorption diarrhea; steatorrhea; weight loss; weakness
MCC of pancreatic insufficiency chronic pancreatitis; alcohol in adults; CF in children
pathogenesis of pancreatic insufficiency malabsorption of fat & proteins(trypsin-related); X carbohydrate-related(amylase, disaccharidase in brush border of intestinal epithelium)
function of bile salt/acid to micellarize monoglycerides & FAs
loss of villous absorptive surface: Dx? function of villi? small bowel disease; villi required to reabsorb micelles into enterocytes (increased surface absorptive surface)
inability to reabsorb micelles due to loss of villous surface celiac disease; Whipple's disease
inability to reabsorb micelles due to lymphatic obstruction Whipple's disease; abetalipoproteinemia
general screening test for malabsorption quantitative stool for fat(best: [+] > 7g of fat/24hrs); qualitative stool for fat (X sensitivity); serum beta carotene (decreased due to decreased vitamion A)
decreased reabsorption of D-Xylose: indication small bowel disease; Xylose X require pancreatic enzyme for absorption
excellent newborn screen for CF & chronic pancreatitis kserum immunoreactive trypsin; trypsin specific for the pancreas
CT scan of pancreas with dystrophic calcifications chronic pancreatitis
functional tests for pancreatic insufficiency secretin stimulation test: ability of pancreas to secret fluids & electrolyes; bentiromide test: ability of pancreatic chymotrypsin to cleave orally administered bentiromide to para-aminobenzoic acid (measured in urine)
test for bile salt/acid deficiency serum bile acids(decreased in liver disease); bile breath test(oral radioactive test): decreased amount radioactive cholylglycine in breath = bacterial overgrowth or terminal ileal disease
clinical findings in malabsorption fat/water[folate & B12] soluble vitamin deficiencies; anemia[folate & B12 & iron]; ascites[hypoproteinemia]; steatorrhea
immune disease directed against gluten in wheat, rye, barley: Dx? celiac disease
disease associated with dermatitis herpetiformis celiac disease[sprue]
pivotal role in celiac sprue tissue transglutaminase [tTG: deamidating enzyme]: CD4 Th cell-related pathogenesis
Dx: celiac sprue ↑anti-tissue transglutaminase IgA(MIP), IgG; ↑anti-endomysial (EMA) IgA antibodies; gliadin IgA antibodies; endoscopy: flattened villi in duodenum & jejunum[proximal small bowels] + hyperplastic glands
steatorrhea; weight loss; vesicles with erythema on the extensor surface of the forearm; villous atrophy; lymphocyte in lamina propria: Dx? celiac sprue
Rx: celiac sprue gluten-free diet; if refractory, corticosteroids
infectious agent causing Whipple's disease Tropheryma whippelii
foamy PAS[+] macrophages in lamina propria & mesenteric nodes; obstructing lymphatics & reabsorption of chylomicrons: Dx? consequence? Whipple's disease; malabsorption of fats
clinical findings in Whipple's disease; epidemiology arthralgias; cardiac & neurologic symptoms in older men
MC site for obstruction in bowel small bowel (SB) obstruction
bowel distention; air/fluid levels; absence of air distal to obstruction; Dx? SB obstruction
pain alternating with pain free intervals: Dx? colicky pain due to bowel obstruction
MC hernia indirect inguinal hernia
↑intra-abdominal pressure(cough, heavy weight lift); weakness in abdominal wall: Dx? hernia
superior mesenteric artery (SMA) + inferior mesenteric artery (IMA) watershed area: splenic flexure
MCC of SB infarction occlusion of SMA; mostly transmural(mural or mucosal in hypoperfusion)
MC arrhythmia associated embolization acute fibrillation: embolus from LH to SMA
sudden onset of diffuse abdominal pain; blood diarrhea; absent bowel sounds (ileus); X rebound tenderness (peritonitis); distention: Dx? SB infarction
radiographic finding in SB infarction "thumbprint sign": edema in bowel wall; bowel distention with air-fluid levels S/A bowel obstruction
Rx: SB infarction thrombotic disease: anticoagulation & surgery
mesenteric angina after eating > weight loss: Dx? MCS? C of mesenteric angina? ischemic colitis; splenic flexure of large bowel (Watershed area); atherosclerotic narrowing of SMA
Dx: ischemic colitis + infarction mesenteric angina + bloody diarrhea (due to mucsoal or mural infarction); thumb-printing of colonic mucosa
CC of ischemic strictures & obstruction ischemic colitis > normal repair of infarction site > fibrosis
dilation of mucosal & submucosal venules in cecum & R.colon: Dx? Cx? angiodysplasia; hematochezia
2nd MCC of hematochezia; epidemiology? angiodysplasia; elder patients
vWD & calcific aortic stenosis associated disease angiodysplasia
newborn with fecal material in umbilical area: Dx? Meckel diverticulum; persistence of vitelline(omphalomesenteric) duct remnant
MC complication of Meckel diverticulum bleeding; common cause of iron deficiency in newborns & young children
disease mimicking acute appendicitis Meckel diverticulum (Y.enterocolitica)
2 inches long; 2 feet from ileocecal valve; 2% of population; 2% symptomatic; first 2 years; 2 types of epithelia(gastric & pancreatic) Meckel diverticulum; MC congenital anomaly of GIT
DDx: Meckel diverticulum diverticulitis; contrast with omphalomesenteric cyst = cystic dilation of vitelline duct
MCS for SB diverticula duodenum; wide-mouthed diverticula = systemic sclerosis
complication of SB diverticula diverticulitis(perforation); bacteral growth(deficiency of nutrients)
Created by: mataos



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