Question | Answer |
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 |