GI Review (CM)
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| Functional abd pain: | lack laboratory or radiographic abnormalities
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| Functional abd pain: dx: | Should always be dx of exclusion
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| chronic or recurrent pain or discomfort in the upper abdomen = | dyspepsia; epigastric pain (not GERD or PUD)
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| Functional abd pain: Causes: | altered gut motility; exaggerated visceral responses to noxious stimuli; altered processing of visceral stimuli
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| pyrosis = | heartburn
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| Abd: alarm sx (malig): | early satiety; dysphagia; altered bowel habits
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| odynophagia = | painful swallowing (food or liquid)
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| 3 types of abd pain | visceral (dermatomes), somatic (pain rec in parietal peritoneum), referred
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| Referred: classic sx = | right shoulder pain (biliary pain/gall bladder)
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| Periumbilical pain that is crampy that pts can sleep thru: | classic sx of IBS
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| Dyspepsia: tx: pts >55 yo OR those with alarm sx: | Prompt endoscopy
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| Dyspepsia: tx: Patients < 55yrs and no alarm symptoms | Test & treat for H. pylori and initiate trial of PPI; OR initiate trial of PPI
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| Dyspepsia: alarm sx | bleeding, anemia, wt loss >10% body wt, progressive dysphagia, odynophagia, persistent vomiting, h/o PUD, FH gastric malig, abd mass
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| Predominant feature of dyspepsia (which distinguishes it from GERD): | pain or discomfort
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| Most common complication of diverticulosis: | Diverticulitis
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| Diverticulitis: most common presenting sx: | pain, often LLQ w/inc WBC/left shift (resembles left-sided appendix); poss acute GI bleed
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| Diverticulitis: Imaging study of choice | CT
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| Diverticulitis: Tx | clear liquids; 7-10 days Abx (cipro & flagyl); close f/u
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| Diverticulitis complications | Bleeding; intra abscess; fistulas; obstruction
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| Acute lower GI bleed: most common causes: | diverticular disease; vascular malformations
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| Most common cause of acute lower GI bleed in young pts: | anorectal lesion
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| Obscure GI bleed = | source of bleeding is not identified after endoscopic evaluation of both upper & lower GI tract
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| Occult GI bleed = | detection of asymptomatic bleeding from GI tract
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| Chronic diarrhea: 3 types: | osmotic (aka malabsorption), secretory and inflammatory
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| Malabsorption: most common sx | diarrhea & wt loss; but sx can manifest outside GI tract (classic dz = celiac dz)
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| Fat malabsorption: testing gold standard: | fecal fat analysis
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| CHO malabsorption: S/S | bloating; soft diarrhea
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| Protein malabsorption: S/S | Edema (d/t 3rd spacing); muscle wasting
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| 3 subtypes of constipation | slowed transit thru colon; obstructive defecation (aka dyssynergic); constipation-predominant IBS
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| constipation: causes | functional (e.g. diet); drugs; endocrine/ metabolic; neuro; structural lesions
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| Most common cause of dysphagia | esophageal disease
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| esophageal dz: motility disorder vs mech obstruction | motility: prob swallowing solid/liquid; mech obstruction: prob swallowing solid
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| GI labs: | CBC, chemistries, LFTs, amylase & lipase, stool exam
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| Rectal pain: severe pain (like a cut) immed after BM: | anal fissure
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| Rectal pain: dull, aching after BM: | extensive inflammation of internal hemorrhoids
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| Proctalgia fugax: | unique, spasmodic anal pain that is usually unrelated to bowel movements
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| Anal fissures: position | usu posterior (may be anterior); if lateral: suspect TB, syphilis, occult abscesses or carcinoma
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| Panc functional units | exocrine: acinus; endo: islet of Langerhans (alpha: glucagon; beta: insulin)
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| Acute pancreatitis | syndrome: enzymatic damage to pancreas, results in discrete episodes of abd pain
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| Acute pancreatitis: pathophys | Inappropriate activation of trypsinogen to trypsin w/in pancreas; trypsin activates other proteases; cascade: local autodigestion; distal: release of proinflam mediators
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| Acute pancreatitis: 2 types | acute interstitial; acute necrotizing
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| Acute interstitial pancreatitis: | mild pancreatitis with pancreatic edema
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| Acute necrotizing pancreatitis: | severe pancreatitis with necrosis of parenchyma & blood vessels
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| Acute pancreatitis: Classic sx: | Constant, epigastric pain radiating to back; usu assoc w/ N&V
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| 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
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| Gray Turner's sx | Flank ecchymosis from retroperitoneal hemorrhage; in acute necro panc
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| Cullen's sx | Periumbilical ecchymosis; in acute necro panc
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| Acute pancreatitis: labs | elevated amylase, lipase (more spec)
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| Acute panc: plain films | calcified gall stone/panc; sentinel loop of sm bowel; colon cut-off sx (no air distal to splenic flexure)
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| Acute panc: US/CT | US: enlarged hypoechoic pancreas; CT: enlarged panc, peripancreatic edema
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| Imaging of choice for panc parenchyma | CT
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| Acute panc: prognosis based on: | Ranson criteria (on admission & after 48 hr); APACHE II score (immed & daily); Glasgow; CT severity score
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| Acute panc: Tx | Pancreatic rest (NPO); IVF; pain meds; Abx if >30% necrosis
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| Acute panc: complications | ARDS, sepsis, renal fail; fluid collections; panc necrosis (sterile/infected); panc abscess
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| Acute panc: most common comp | pseudocyst: collection of panc juice encased by granulation tissue; > 4 wks
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| Chronic panc: causes | Chronic alcohol use (70%); chronic obstruction of pancreatic duct
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| Chronic panc: clin findings | Persistent/recurrent epigastric & LUQ pain; Steatorrhea; DM
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| Chronic panc: dx | no lab tests (amy/lipase usu not inc); fecal fat/elastase; secretin stim test
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| Chronic panc: Abd plain film: | Pancreatic calcifications (classic finding)
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| Chronic panc: CT | Pancreatic calcifications, atrophied pancreas
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| Chronic panc: MRCP/ERCP | Chain of lakes (areas of dilation / stenosis along pancreatic duct)
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| Chronic panc: Tx | Abstain from EtOH; tx pain (panc enzyme replacement; H2 blocker/PPI)
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| Chronic panc: Surg | Puestow (lateral pancreatojejunostomy) if duct dilated >6 mm; OR subtotal or total pancreatectomy
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| Panc ca: RFs | tobacco; chronic panc; exposure to dyes; non-IDDM in pt >50; h/o partial gastrectomy or cholescystectomy; genetics
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| Panc ca: clin findings | jaundice, wt loss; Courvoisier sx; Trousseau sx
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| 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
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| Courvoisier sx | palpable GB due to head mass compressing CBD
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| Trousseau sx | migratory thrombophlebitis
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| Panc ca: labs | Alk Phos; Bilirubin, CA 19-9
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| Panc ca: dx: | CT; MRI; EUS (if no lesion on CT/MRI & still have high suspicion)
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| Panc ca: surg: | in head: Whipple; in body/tail: distal pancreatectomy & splenectomy & 5FU C/RTx
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| Panc ca: Tx if not resectable | Locally advanced: 5FU Chemoradiation; mets: Gemcitabine; Pain control, palliative stents
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| Panc ca: prognosis | 15-20% candidates for pancreatectomy; 50% mets at time of dx; if resectable: 15-17 mos (if not: worse)
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| Upper vs lower GI bleed: anatomy | ligament of Treitz
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| Meds assoc w/GI bleed | NSAIDs; Steroids (in setting of NSAID); Warfarin; Heparin, Enoxaparin; Clopidogrel (Plavix)
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| 3 most common causes of upper GI bleed | PUD (55%); Varices (14%); AVM (6%)
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| 3 most common causes of lower GI bleed | Diverticular Dz (33%); Neoplastic Dz (Polyps, Ca; 19%); Colitis (18%)
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| Resting Tachycardia: blood loss = | 10% of intravascular volume lost
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| Orthostasis: blood loss = | Significant loss, 10-20% of intravascular volume
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| Shock: blood loss = | Loss of 20-40% of intravascular volume
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| 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)
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| GI bleed: mainstay of initial tx | Resuscitation; goal = normal vital sx; 2 lg bore IVs; ICU monitoring if needed
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| Dieulafoy's Lesion = | Dilated submucosal artery erodes into mucosa with subsequent rupture of the vessel; bleeding often massive & recurrent
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| Mallory-Weiss tear: | Laceration in the mucosa, usually near GE junction; commonly after retching
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| Diagnostic tools for LGIB | Anoscopy; Flexible Sigmoidoscopy; Colonoscopy; Tagged red blood cell scan; Angiography
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| Diverticular bleeding | Acute, painless hematochezia; most bleeds are right sided
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| 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
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| LGIB: Angiography: caution: | Caution w/renal failure given IV contrast load
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| LGIB: Angiography: utility | Coil microembolization of bleeding vessel; blood flow must be 1 mL/min
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| 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
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| Colon ca Genl RFs | Age; Personal hx colon polyps or ca; FH; inherited syndromes; T2DM; IBD
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| Colon ca Liefstyle RFs | Diet (red meat); physical inactivity; obesity; smoking; heavy alcohol use
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| 2 types of dx criteria for HNPCC | Amsterdam; Bethesda
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| 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
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| Colon ca: most common metastases are to: | liver, then lung (colon); liver or lung (rectal ca)
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| Colon ca: gold standard of dx eval: | colonoscopy
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| 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
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| Colon ca: labs | CBC, chemistry; may check CEA, but not for dx (help w/staging)
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| Cancer stage is determined from: | PE, biopsy, imaging, lymph node dissection
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| Layers of colon wall | Mucosa; muscularis mucosa; submucosa; muscularis propia; subserosa/serosa
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| Types of ablation of mets | Radiofrequency Ablation; Ethanol ablation; Cryosurgery; Hepatic artery embolization
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| 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
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| Radiation tx | not typically used for colon ca; used for rectal ca
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| Screening: stool Tests: | primarily detect cancer; Guaiac FOBT & immunochemical-based FIT; Stool DNA (sDNA)
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| Screening: Structural Exams: | Detect cancer and polyps; Colonoscopy; CT colonography; Flexible Sigmoidoscopy; Double-contrast barium enema (uncommon)
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| Best mortality data for CRC screening: | Guiac FOBT
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| Never screen for colon ca with: | DRE
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| Positive FOBT should always be followed by: | colonoscopy (and no more FOBTs needed)
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| Negative FOBT tests: | should be repeated annually
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| Flexible Sigmoidoscopy | Examines left colon; some bowel prep needed; can performed w/o sedation in Dr's office; 5-year interval between exams
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| Patients w/ adenomas found on flex sig: | should go for colonoscopy
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| Colonoscopy | Direct inspection of entire colon with sedation (usu conscious); thorough bowel prep required
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| Colonoscopy: miss rates | 6-12% miss rates for large adenomas; 5% miss rates for cancer
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| Most common serious complication of colonoscopy: | bleeding post-polypectomy; Perforation = 1/1000 and increases with age and diverticular disease
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| Colon ca screening | Screening: can be every 10 yr;
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| 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
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| Colon polyps (types) | adenomatous (poss pre-malig: req shorter surveillance colonoscopy interval); hyperplastic (not considered pre-malig)
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| CT colonography | No sedation; req bowel prep; pos result req f/u colonoscopy
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| Defn diarrhea | >3/day; 200 g or ml; loose/liquid consistency
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| Acute/ persistent/ chronic | Acute <14 days; Chronic >1 month
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| Chronic diarrhea: etiology | Malabsorption; motility disorders; inflammation
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| Assessing severity of illness | dehydration; duration of sx; inflammation (fever, blood, tenesmus)
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| Order stool studies if: | Diarrhea is persistent or recurring; h/o fever or tenesmus
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| E. histolytica | necrosis of lg intestine; tropical; abd pain, cramping, colitis; can be bloody/fevers; travelers, MSM
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| Vibrio | watery dia, abd cramping; V para: also wound infxn; heat to >75C to destroy; susceptible: liver dz & Fe overload states
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| V cholera MOA | activates adenylate cyclase (cAMP regulates Na & Cl absorpn/secretion)
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| V cholera S/S | rice-water stools; poss hypotensive shock within 2 hrs; dose fx; tx rehydrate & 1 dose Cipro; untx'd 50% mortality
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| Pre-formed toxins: organisms | S aureus; B Cereus; Clostridium Perfringens
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| Giardia: most susceptible | immunocompromised; immunocompetent w/Ig def
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| Dx giardiasis with: | giardia antigen stool assay
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| C perfringens sx | Abd cramps & watery diarrhea without fever or N/V; lasts <24 hr
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| Invasive pathogens (most common causes infxs dia) | Salmonella, shigella, campy
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| E coli: most likely from: | undercooked beef; unpasteurized juice; spinach; in warm weather
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| E coli: hemorrhagic colitis: | severe abd pain, bloody diarrhea (no fever usually) caused by shiga or shiga-like toxin
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| HUS may be due to: | E coli; shigella
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| ETEC: tx | travelers diarrhea; Abx after sx onset may decrease duration; Cipro or rifaximin
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| Salmonella Sx | fevers, myalgias, abd cramping, HA;
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| Salmonella complications | Septicemia/Bacteremia; poss osteomyelitis, endocarditis, arthritis
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| 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
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| Shigella Sx | Lower abd cramps, diarrhea, fever, bloody, purulent stools & tenesmus; usu self-ltg (7 days)
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| Shigella Tx | Abx recommended (FQ or Bactrim)
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| 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
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| Campy Sx: | dysentery; poss bacteremia; usu self ltg (may last 1 wk/longer); assoc w/GBS & Reiters
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| Most common cause of nosocomial diarrhea | C diff (Abx-induced diarrhea); tx w/Flagyl or oral vanco
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| Loperamide | opiate w/o systemic fx; inhibits peristalsis; can use w/Abx for traveler's diarrhea
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| DO NOT use anti-motility agents in: | pts w/shigella, C diff, E coli O157 (inflammatory diarrhea)
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| Antimicrobial tx: used for: | shigellosis, traveler's diarrhea, C.difficile, campylobacter; can prolong salmo/C diff shedding, or worsen shiga toxin course
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| Tx of choice for more severe infxs diarrhea: | FQ; TMP-SMX = 2nd-line tx; Add azithro for Campy
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| Gastritis sx | Abd pain; Indigestion; Loss of appetite; N/V; Melena
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| Causes of acute hemo gastritis | Stress lesions, drugs, trauma (for body, NG tube, radiation); embolism/vasculitis; reflux injury; HP
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| 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)
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| Forms of gastritis | infxs (CMV, HIV, herpes, fungal, TB, syphilis); sarcoid; eosinophilic; Crohns
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| 3 most important etiological factors for PUD are: | H.Pylori; NSAIDs; Acid
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| 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)
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| HP eradication tx | triple tx: PPI, clarithro, amox; confirm eradication w/stool Ag; 20% need re-tx
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| HP & ca | causal: gastric adenoCa; assoc w/ MALT
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| ZE testing | fasting gastrin level (>1000 is dx); secretin stim test (normal pt: no fx on gastrin; ZE pt: dramatic increase)
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| ZE tx | HD PPI; resect if no mets (30-50%); mets: tx sx
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| ZE prognosis | no mets: 15-yr 83%; mets: 10-yr 30%; fasting gastrin level prognostic
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| 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);
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| PUD dx | EGD & bx (4% PUD become malig); HP test
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| PUD comps | hemorrhage (Most Common); perf; gastric outlet obstruction
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| PUD tx | antacids, H2 blockers, PPI
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| Acid secretion | 3 stimuli of HCl prod in parietal cell: histamine, Ach, gastrin (synergistic); somatostatin is inhibitor
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| PPI AE | Diarrhea, nausea, abdominal pain, HA; poss C diff; hip fx risk if used LT
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| PUD: surg | rare; gastric patch or gastrectomy w/vagotomy
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| High risk for NSAID complications | Previous GI event; Older Age; Concomitant use of anticoagulants, corticosteroids or other NSAIDs; HD NSAID tx
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| NSAID complication: prevention | COX-2 tx; Mucosal Protection (Misoprostol; PPI; High-dose H2 blocker)
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| Misoprostol | Synthetic PGE1 analog; prevent NSAID-induced gastric ulcers; sig reduction (GU > DU); AE abd discomfort & diarrhea; CI in women of childbearing age
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| 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
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| Gastric ca etiology | Diet (pickled, salted foods, smoked meats); HP; atrophic gastritis; Polyps (rare); Radiation
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| Gastric ca: histo | 95% adenocarcinoma; other: lymphoma, SSC
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| Gastric ca: imaging | EGD; EUS; Barium Swallow (Upper GI); CT/MRI
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| Gastric ca: Tx | Surgical resection (best chance for cure); Neoadjuvant CTx & XRT; Adjuvant CTx
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| Esoph dx studies | Barium Esophagram; Upper Endoscopy; Esophageal Manometry; Ambulatory Esophageal pH monitoring
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| Heartburn (pyrosis) | substernal burning, epigastric pain radiating to the neck
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| Transfer dysphagia: | Oropharyngeal; or Neurologic Dysfunction (CVA, ALS), Zenker Diverticulum
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| Transport dysphagia: | Esophageal: food sticks
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| Odynophagia: Causes | Caustic (corrosive injury); infxs (CMV, Herpes, Candida, HIV)
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| GERD requires 3 factors: | Reflux (dysfn of anti-reflux mechms); reflux of caustic materials; sufficient duration of contact
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| Chest Pain can be due to: | GERD, diffuse esophageal spasm, nutcracker esophagus, achalasia
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| GERD sx | Heartburn (30-60 min after meals); Regurgitation; Sour brash; Dysphagia; Relief with antacids
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| Alarm sx: | Dysphagia, wt loss, hematemesis, melena; Sx age > 50
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| Upper endoscopy: purpose: | document type/ extent of tissue damage in GERD; look for erythema, friability, stricture, Barrett's
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| Barrett esophagus: pathophys | change of squamous epi cells to columnar epi; stomach creeping up into esophagus
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| Standard procedure for detecting pathologic acid reflux in the esophagus: | ambulatory pH monitoring
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| 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
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| GERD complications | Barrett esophagus; stricture (scarred down)
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| GERD tx | Medical (lifestyle mod; Reglan, motility agents); Surg; Barrett screening EGD
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| Barrett screening EGD | Sx > 10 years, age >50, white males
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| Barrett dx requires: | bx-proven presence of specialized intestinal metaplasia in the tubular esophagus
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| Metaplasia/Dysplasia/Car: poss interventions | Medical acid suppression tx; Anti-reflux surg; Endoscopic surveil; Endoscopic ablation tx; Esophagectomy
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| Infxs esophagitis: common agents: | Candida; CMV; HSV
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| Infxs esophagitis: Eval: | Sx: Odynophagia, dysphagia, CP; w/u = EGD with biopsies
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| Web = | a thin infolding of mucosa that narrows the lumen
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| Plummer Vinson Syndrome | Symptomatic proximal webs in middle-aged women with evidence of Fe deficiency anemia; increased risk of cancer
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| Schatzki ring = | a web that occurs in the distal esophagus
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| Zenker diverticulum | Outpouching of upper esophagus; always involves post wall of pharynx; most common cause of transfer dysphagia; Men >60 yo
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| Zenker sx | regurgitation, dysphagia, halitosis
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| Eo esophagitis | Dysphagia, food impaction, reflux; strictures; mucosal rings; concern for perf w/dilation
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| Eosinophilic esophagitis: mgmt | PPI; allergy testing & elim diet; topical corticosteroids (fluticasone); systemic corticosteroids
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| GI bleed 2/2 esophageal dz: | esophageal varices (2/2 portal HTN); Mallory Weiss tear; esophageal ulceration
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| Achalasia: | absence of esophageal smooth mx peristalsis w/ inc tonus of lower esophageal sphincter
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| Achalasia: S/S | Gradual, progressive dysphagia; regurg; substernal discomfort/fullness
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| Achalasia: dx gold standard = | manometry; see complete absence of peristalsis, with simultaneous, low amplitude waves; very tight LES, lack of contractions in esophagus
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| 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
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| Achalasia: Tx | Pharm (nifedipine); pneumatic dilation; botox; Myotomy (85% success rate)
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| Diffuse esophageal spasm: s/s | ant CP (unrelated to exertion/eating); simultaneous, nonperistaltic contractions of esophagus; usu self-ltd
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| Diffuse esophageal spasm dx | Barium Esophagography: corkscrew contractn, rosary; manometry: intermittent simult contractn
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| Most common connective tissue disorder involving the esophagus: | Scleroderma esophagus (atrophy & fibrosis of esophageal smooth mx)
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| Scleroderma esophagus: sx | heartburn, dysphagia; Patulous LES with free reflux; manometry: low/absent LES pressure
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| Esophageal ca: presentation | Progressive solid food dysphagia, weight loss
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| 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
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| Esoph ca: tx | mainstay: surg resection (complete esophagectomy); unresectable: Rtx, Ctx, endoscopic stenting for palliation
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| Viral hep that can cause cirrhosis | Hep B & C
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| Conj bili | direct; bound to gluc acid; water soluble; caused by obstruction of outflow tract or in the liver
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| Unconj bili | indirect; water insoluble; caused by hemolysis
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| Fulminant acute liver dz: | progress to liver fail in 14 days; no h/o liver dz; develop coagulopathy (INR >2), encephalopathy
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| ALT/AST | hepatocell injury: correlates w/degree of cell death; >1000: hepatitis, shock, toxins (Tylenol)
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| Abnormal AST/ALT | AST:ALT >2:1 = alcoholic hep; <500: EtOH; poss normal in cirrhosis
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| Alk phos | liver, bone, intestinal tract, placenta, kidney; elevated in liver damage/obstruction; if elevated more than AST/ALT, more likely biliary disorder
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| Child-Pugh score | assesses prognosis of chronic liver dz
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| AFP for: | hepatocellular ca; inflam
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| Liver dz lab w/u | Hep A, B, C; ANA; ASMA; IgG; Anti-mito Ab (primary biliary cirrhosis)
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| Labs for hemochromatosis | ferritin, iron sat, HFE gene
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| Hep A | ave 30d incub; 80% jaundice pts >14 yo; fulminant or cholestatic hep; IVIG within 14d post exposure
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| Hep B | ave 60-90d incub; 15-25% premature mortality; cirrhosis/hepatocell ca; Asians
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| Hep C | ave 6-7 wk incub; 40% jaundice; 70% chronic; persistent; AA men in 40s; No. 1 indication for liver transplant
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| Hep C dx labs | ELISA (pos in 8-10 wks; good screen for chronic); HCV RNA; HCV genotype
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| 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)
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| Cirrhosis: dx | pathologic; Fibrosis, Regenerated nodules, Vascular distortion
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| Cirrhosis: complications | Hepatorenal syndrome; Hepatoma (hepatocell ca); Portal HTN (Varices, Ascites, Encephalopathy, GI bleeding)
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| 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)
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| Varices prevention | screening endoscopy; endo banding (if large varices & prior bleed); beta blockers to HR<60; nitrates
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|
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| Ascites | 60% develop within 10 yrs of cirrhosis dx; US (check for fluid & portal v. thrombosis)
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|
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| Serum ascites albumin gradient | paracentesis; if gradient >1.1: portal HTN
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|
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| Spont bac peritonitis | peritoneal cell count: >500 PMN confirms dx
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| Ascites mgmt | Na & fluid restriction; diuretic tx (Aldactone/Lasix); LVP & albumin replacement; TIPS for refractory ascites
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| Encephalopathy tx | r/o infxn, correct lytes; lactulose; neomycin; rifaximin
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| Cirrhosis & Hepatoma (HCC) | screen (US & AFP 6-12 mos); common/increasing worldwide ca; tx Partial hepatectomy, Chemoembolization, RF ablation; poss TP
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| 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
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| NASH | chronic hep or metab syn; usu Asx; liver bx; hepatocytes replaced; tx: stop offending meds; wt/glycemic ctrl
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| Benign masses: dx | imaging > bx; 20% of popn
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| Most common benign liver tumor | hemangioma; W>M, 20-40 (2nd most common: FNH)
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| Hepatic adenoma | W>M, young, LT estrogen use; anabolic steroids
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| 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)
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|
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| IBS prognosis | Once diagnosed 75% of pts remain symptomatic 5 yrs later, and 55% at 7 yrs
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| IBS Sx | chronic abd pain & bloating relieved by defecation; changes in stool frequency or appearance
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|
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| IBS dx criteria | Manning; Kruis; Rome (I, II, III)
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| Considered a hallmark sx of IBS: | Lowered rectal pain threshold
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| IBS & psych: | 50% of pts seeking IBS med care also have depression/anxiety
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|
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| IBS & post-infxn: often assoc with: | Entamoeba, Salmonella and Campylobacter
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|
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| Initial eval for IBS includes: | PE; CBC, ESR; labs (FOBT, fecal leukocytes, O&P, cx), poss sigmoidoscopy
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|
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| Current thought about IBS etiology: | brain-gut dysregulation
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|
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| 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
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| Which tx have best evidence? | antispasmodics; anti-diarrheals (?); SSRI/TCA (IBS-D not IBS-C); poss new probiotics (not lactobacillus); Amitiza
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| IBS tx having independent analgesis properties: | antidepressants
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|
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| Zelnorm & serotonin | serotonin release in plasma reduced in IBS-C & increased in IBS-D
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|
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| 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?)
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|
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| Features of CD | Any part of GI tract; skips areas; transmural
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|
||||
| Features of UC | Limited to colon; starts in rectum; usually continuous; superficial
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|
||||
| Specifics of UC | Proctitis: tenesmus; bloody diarrhea more common; high risk of CRC
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|
||||
| Specifics of CD | fistula: abscesses; more common at anus; strictures of the intestine; CRC risk increased if > 1/3 colon involved; smoking & CD: bad
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|
||||
| Extra intestinal manifestations: | may involve any area; usu eye, skin, liver, and joints (arthralgias, AS)
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|
||||
| EIM: arthralgia Type 1: | self limited, short lived, affecting 6 or fewer joints. Associated with disease flares
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|
||||
| EIM: arthralgia Type 2: | multiple joints, can be migratory, can be more chronic; NOT associated with disease flares.
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|
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| 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
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|
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| Erythema nodosum | raised tender red-purplish nodules; most commonly on extensor surfaces of extremities; parallels IBD activity/tx; may req steroids
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|
||||
| Pyoderma gangrenosum | wide spectrum of necrotic inflam; IBD tx, topical tx, or poss colectomy; DO NOT BX
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|
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| IBD eye complications | episcleritis; uveitis: refer to Ophtho (blindness risk)
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|
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| IBD: DDx includes: | infxs diarrhea; ischemia (elderly, PVD, thrombosis); meds (PCN, NSAID, CellCept); diverticular dz; perianal fistula
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|
||||
| 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
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|
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| IBD labs | often anemic (Fe def & chronic dz), leukocytosis, elevated CRP (CD); DO NOT ORDER serologies (ASCA, Cbir, OmpC & Crohns; p-ANCA & UC)
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|
||||
| 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
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|
||||
| Tx: defn Mild UC: | ≤4 BM/day; no sx systemic tox; normal ESR
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|
||||
| Tx: defn Severe UC: | >6 BM/day and sx systemic toxicity
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|
||||
| IBD tx options | 5-ASA; corticosteroids; 6MP/AZA; anti-TNF Ab
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|
||||
| 6MP/AZA | impair T cell fn; slow onset of action; AE pancreatitis, liver tox, cytopenia;
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|
||||
| 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
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|
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| Dysplasia, cancer, or toxic colitis may: | necessitate colectomy.
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|
||||
| Fibrotic strictures, obstruction, fistulae may: | necessitate segmental resection in CD (try to avoid surg if poss in CD)
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|
||||
| 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)
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|
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| Managing IBD flares | Similar to previous flares? Worrisome features; R/O infxn; labs (WBC, H/H); 5ASA (UC) or budesonide (ileal CD)
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|
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