Gastrointestinal System

Question 1

Primary biliary cirrhosis/cholangitis (PBC)

Answer 1

DEF.

1. Is a chronic cholangitis ( autoimmune liver disease)
2. Affects women 35-60 years
3. Leads to liver cirrhosis & cholestasis in later stages

Sign/symptoms:

1. Extensive pruritus
2. Fatigue
3. Elevated cholestatic parameters (bilirubin, alkaline phosphate, gamma-glutamyl transferase)
4. Normal transaminase

Symptoms of:
1. Cholestasis (jaundice, pale stools, dark urine, pruritus, and symptoms of fat malabsorption (e.g., steatorrhea, weight loss)

Investigation:

1. Elevated conjugated bilirubin
2. Elevated gamma-GT
3. Elevated alkaline phosphatase (
4. Normal Transaminase (ALT & AST)

Diagnosis:

1. Positive Anti-mitochondrial antibodies (AMA)
2. Positive Anti-nuclear antibody (ANA)

Treatment:
1st line: Ursodeoxycholic acid (bile acid) : slow down disease progression/ relief from itching

2nd line: obeticholic acid: slow down disease progression, but has more adverse effects

Question 2

Hepatitis A

Answer 2

Def:
1. Acute viral hepatitis, caused by Hepatitis A virus (HAV)
2. Transmitted via oral-fecal route, by ingestion of raw shellfish
3. Acute liver inflammation
4. Acute Infection (within a week) (fever, elevated transaminase & unconjugated bilirubin)
5

Signs/symptoms:

1. Stomach flu (prodormal phase)
2. Scleral icterus + dark urine + pale stool (signs of cholestasis)
3. Fever
4. Elevated unconjugated bilirubin
5. Elevated transaminase

Diagnosed:
1. Anti-HAV IgM

Note:
If Anti-HAV IgG is detected = former infection or past vaccination against HAV

Question 3

Primary sclerosing cholangitis (PSC)

Answer 3

Def:

1. Progressive inflammation of the intrahepatic & extrahepatic bile ducts
2. Autoimmune disease
3. Associated with ulcerative colitis (IBD)

Signs:

1. Asymptomatic
2. Later stage (cholestasis & cirrhosis)
3. Elevated alkaline phosphatase

Diagnosis:
1. P-ANCA

Signs of cholestasis:

1. Jaundice
2. Dark urine
3. Pale stool
4. Nausea
5. Pruritus
6. Fatigue
7. Abdominal pain

Question 4

Staphylococcus aureus

Answer 4

1. Common cause of food poisoning within 1-8 hours of eating (eggs, mayonnaise, diary products, coleslaw)
2. Signs: N/V & abdominal pain & no fever & no diarrhea
3. Resolved 24-48 hours with no antibiotics

Question 5

Campylobacter jejuni

Answer 5

1. Common cause of bacterial diarrhea (in the USA)
2. Commonly affects children & leads to bloody diarrhea
3. Transmitted by food or contact animals (puppies)
4. Incubation period = 2 days

Question 6

Bacillus cereus

Answer 6

1. Heated rice is common source of infection
2. Pathogen is heat-stable & produce enterotoxin 1 (emetic form)
3. N/V occurs within 30 min-6 hours after ingestion

Question 7

Yersinia enterocolitica

Answer 7

1. Common cause of inflammatory diarrhea ( maybe bloody in severe cases)
2. After ingestion of contaminated milk or pork
3. Causes N/V & abdominal pain ( RLQ = mimic appendicitis = psuedoappendicitis)
4. Incubation period = 2 days

Question 8

E.Coli (enterohemorrhagic) (EHEC)

Answer 8

1. Common cause of bloody diarrhea due to verotoxin/ shiga-like toxin
2. N/V
3. Affects newborn, healthy adults, & elderly
4. Ingestion of contaminated food ( raw beef, vegetable, milk)
5. Incubation period = 2-10 days
6. If toxin becomes systemic = hemolytic uremic syndrome (HUS) occurs

Question 9

Entamoeba histolytica

Answer 9

1. Causes intestinal amebiasis (loose stools containing mucus & bright red blood, painful defecation, abdominal pain, cramps, anorexia, fever)
2. Long incubation period = 1-4 weeks

Question 10

Salmonella enteritidis

Answer 10

1. Causes high-grade fever, severe vomiting & inflammatory (watery-bloody) diarrhea
2. Ingestion of contaminated food ( poultry, poorly pasteurized eggs, milk)
3. Incubation period = 6-48 hours

Question 11

Enterotoxigenic E.coli (ETEC)

Answer 11

1. Common cause of traveller diarrhea
2. Produce heat-liable & heat-stable enterotoxin
3. Causes diffused watery diarrhea, abdominal cramping, N/V
4. Incubation period = 9 hr-3 days

Question 12

Shigella dysenteriae

Answer 12

1. Enters the GI tract, leading to inflammation, mucosal damage, & bloody diarrhea
2. Incubation period = 1-3 days

Question 13

Vibrio parahaemolyticus

Answer 13

1. Causes food-brone illness
2. Occurs 16-72 hours after eating contaminated seafood
3. Common in japan

Question 14

Amebias

Answer 14

1. Caused by protozoan entamoeba histolytica
2. Occurs via fecal-oral route (via contaminated water) in endemic region ( Mexico, southeast Asia, India)
3. Lead to: intestinal disease (bloody diarrhea) & extra-intestinal disease (amebic liver abscess; shows leukocytosis without eosinophilia, transaminitis, & elevated alkaline phosphatase )
4. Incubation period = 1-4 weeks, but can take weeks-years for extra-intestinal disease to manifest

Question 15

Hepatic hydated cyst

Answer 15

Signs:

1. RUQ pain (no fever)
2. Pruritus
3. Urticaria
4. +/- anaphylaxis (only if cyst leaks or rupture)

Diagnosis:
1. Ultrasonography shows daughter cysts +/- echogenic hydatid sand within the main cyst.

Question 16

Liver hemangioma

Answer 16

1. Most common benign lesion of the liver
2. Asymptomatic
3. Seen in women ( 30-50 yrs)
4. Hyper-echoic on Ultrasonography
5. Large hemangioma can lead to abdominal discomfort, Nausea, early satiety

Question 17

Pyogenic liver abscess

Answer 17

1. Common in (> 50) years patients
2. Patient have underlying bowel disease, intra-abdominal infection +/- history of recent surgery.

Signs:

1. RUQ pain
2. Fever
3. N/V
4. Leukocytosis
5. Focal hypo-echoic lesion (in the right lobe of liver)

Question 18

Hepatocellular carcinoma

Answer 18

1. Usually occurs in patient with chronic liver disease (cirrhosis, hepatitis B or C, hemochromatosis, alcoholic cirrhosis, & non-alcoholic fatty liver disease)
2. Shows hypo-echoic lesion on US
3. Associated with RUQ pain

Question 19

Liver cirrhosis

Answer 19

Sign:

1. Jaundice
2. Weight loss
3. Splenomegaly

Question 20

Abdominal CT scan with contrast

Answer 20

To diagnose:
1. Abdominal aneurysm
2. Acute appendicitis
Abdominal tumor

Question 21

IV octreotide

Answer 21

1. Bleeding secondary to esophageal varices, complication of liver cirrhosis (can cause tarry stool)

Question 22

Diagnostic laparoscopy

Answer 22

1. Indicated for unexplained abdominal pain

Question 23

Colonoscopy

Answer 23

1. Diagnose Lower GI bleeding & screen for colorectal cancer ( sign: hematochezia)

Question 24

Flexible sigmoidoscopy

Answer 24

1. Screen for colorectal cancer & lower GI bleeding

Question 25

Esophagogastroduodenoscopy (ECG)

Answer 25

1. Indicated for Upper GI bleed 2. Hemostatic intervention (cauterization, epinephrine injection) 3. Severe hemorrhagic secondary to PUD = IV PPI &blood transfusions

Question 26

UGI Bleed

Answer 26

Tarry bowel movements and abdominal pain are consistent with upper GI bleeding (UGIB), likely arising as a complication of peptic ulcer disease (PUD) from NSAID use. Hypotension and tachycardia indicate the development of hypovolemic shock.

Question 27

Liver abscess

Answer 27

This patient's right upper quadrant (RUQ) abdominal pain and fever in combination with a hypoechoic lesion in the right hepatic lobe are suggestive of a liver abscess.

Question 28

Iatrogenic esophageal perforation

Answer 28

patient presents with chest pain, tachycardia, tachypnea, and crepitus over the chest (mediastinal emphysema) one day after an endoscopic procedure.

Question 29

Metronidazole (or tinidazole)

Answer 29

1. Metronidazole (or tinidazole) is considered the first-line treatment to eradicate invasive trophozoites in patients with symptomatic intestinal amebiasis (amebic dysentery) and extraintestinal amebiasis (e.g., amebic liver abscess). Following treatment with metronidazole or tinidazole, patients should also receive an intraluminal amebicide (e.g., paromomycin) to eradicate intestinal cysts and prevent relapse. In travelers with asymptomatic infection, treatment with luminal agents is usually sufficient. Individuals from endemic areas with asymptomatic infection do not require treatment 2. Metronidazole is indicated for giardiasis and is common in Southeast Asia. However, the incubation period is 7–14 days.

Question 30

Erythromycin

Answer 30

Erythromycin is a macrolide antibiotic that may be considered for the treatment of fluoroquinolone-resistant Campylobacter jejuni. Infections with Campylobacter cause inflammatory diarrhea with blood-tinged stools and fever.

Question 31

Iron supplementation

Answer 31

Iron supplementation can result in dark stools, which may be mistaken for melena. Melena (black, tarry stools) occurs as a result of upper gastrointestinal bleeding. Since this patient has stools that are blood-tinged rather than tar-like, the site of blood loss is most likely the lower GI tract.

Question 32

Albendazole

Answer 32

Albendazole is used to treat nematode infections and certain cestode infections (e.g., cysticercosis, echinococcosis). Although patients with intestinal helminthic infections can present with abdominal pain and/or blood in stools. Albendazole is not effective against protozoa such as Entamoeba histolytica.

Question 33

Praziquantel

Answer 33

Praziquantel is used to treat most trematode infections (e.g., schistosomiasis, clonorchiasis) and certain cestode infections (e.g., taeniasis). Intestinal taeniasis, clonorchiasis, and certain forms of schistosomiasis (Schistosoma japonicum, Schistosoma mansoni) are diagnosed by the presence of eggs in feces.

Question 34

Doxycycline

Answer 34

Doxycycline is the treatment of choice for diarrhea due to cholera. However, patients with cholera have frequent, voluminous “rice water” stools, are often severely dehydrated, and are usually febrile.

Question 35

Trimethoprim-sulfamethoxazole (TMP-SMX)

Answer 35

1. TMP-SMX is not the treatment of choice for intestinal amebiasis. Instead, it is used in the treatment of diarrhea due to cyclosporiasis. Diarrhea in patients with cyclosporiasis is typically watery and nonbloody, and stool microscopy reveals acid-fast oocysts instead of hematogenous trophozoites. 2. TMP-SMX is used to treat Whipple's disease, which has a highly variable presentation but commonly manifests with diarrhea and gastrointestinal symptoms. Whipple's disease, however, typically involves extraintestinal symptoms such as arthritis and is not associated with a positive IgA TTGA.

Question 36

Pilonidal sinus surgery

Answer 36

Def: 1. A small hole or tunnel in the skin at the top of the buttocks (where they divide). 2. Does not cause symptoms (maybe, discomfort and irritation around the tailbone), but can lead to infection (infection—> abscess —> draining pus through the sinus) if left untreated. 3. The abscess leads to pain, foul smell, & drainage 4. Treatment: abscess drainage or sinus removal.

Question 37

Anal fissure

Answer 37

Def: 1. A small tear in the mucosa that lines the anus. Sign/symptoms: 1. Extreme pain & discomfort around the anus 2. Inability to sit 3. Inability to defecate due to extreme pain Initial treatment: (purpose: reduce anal sphincter tone & promote mucosal healing, by increasing blood flow to the anal mucosa) 1. Sitz bath 2. Topical therapy with calcium channel blockers (nifedipine, diltiazem) Refractory to conservative therapy: 1. Botulinum toxin injection (relaxes the hypertonic anal sphincter, not a first line treatment)

Question 38

Anal fistula

Answer 38

Def: 1. Abnormal tunnel under the skin that connects the anal canal in the colon to the skin of the buttocks. 2. Can be caused after a surgery or by IBD ( Crohn’s disease or ulcerative colitis) Signs: 1. Bloody stool 2. Rectal pain 3. Malodorous perianal discharge Treatment: 1. Tract curettage ( also, used in treatment of pilonidal disease and hidradenitis suppurativa )

Question 39

Colorectal cancer

Answer 39

Sign/symptoms: 1. Bloody stool 2. Weight loss 3. Constipation 4. Reduction in stool caliber Treatment: 1. Colonoscopy ( every 10 years, if family history is positive, or 10 years before the age of diagnosis of the fist relative)

Question 40

Anorectal abscess

Answer 40

Def: 1. Pus-filled cavity developed after obstruction & bacterial overgrowth. Sign/symptoms: 1. Pain on defecation 2. No bloody stool 3. Purulent perianal discharge Complication: can develop into anal fistula (chronic manifistation) Treatment: 1. Combination of Metronidazole & ciprofloxacin

Question 41

Abdominal ultrasound

Answer 41

1. Used for diagnosis of appendicitis in children & pregnant women

Question 42

Appendicitis

Answer 42

Sign/symptoms: 1. Low-grade fever 2. Elevated WBC ( leukocytosis) 3. Migrating abdominal pain 4. RLQ pain- tenderness 5. Rebound pain Finding on US: 1. Non-compressible & distended appendix (> 6-8 mm) 2. Fluid around the appendix 3. Target sign

Question 43

Volvulus

Answer 43

Def: 1. Twisting of an intraperitoneal loop of intestine around its mesentery. Sign/symptoms: 1. Vomiting 2. Abdominal pain & distention 3. Bowel obstruction (abdominal tenderness) 4. Bloody stool in infant 5. Hemodynamic instability Diagnosis: 1. Upper GI series Treatment: 1. Surgery

Question 44

Cyclical vomiting syndrome

Answer 44

Def: 1. Recurrent, self limited episode of vomiting (bilious or non-bilious) associated with psychological stressors Sign/symptoms: 1. Recurrent, self-limited vomiting 2. Abdominal pain (hours to days) 3. Absence of symptoms between episodes

Question 45

Gastroenteritis

Answer 45

Sign/symptoms: 1. Diarrhea 2. Maybe, vomiting 3. Self limited (3-7 days)

Question 46

Hypertrophic pyloric stenosis

Answer 46

Def: 1. Vomiting causes dehydration (dry mucous membrane) with loss of HCl & KCl 2. Hypovolemia = secretes Aldosterone = worsen Hypokalemia = causes paradoxical aciduria = & contraction alkalosis Sign/symptoms: 1. Newborn infants (less than 6 weeks of age) 2. Non-bilious Projectile vomiting after feeding 3. Palpable abdominal mass “ olive-shaped” 4. If left untreated, will lead to dehydration, weight loss, failure to thrive Laboratory: 1. Hypokalemia 2. Hypochloremic metabolic alkalosis Initial treatment: 1. IV-fluid therapy with 0.9% NaCl (adequate rehydration & correction of electrolyte imbalance) 2. Surgery: Ramstedt pyloromyotomy

Question 47

Gastroesophageal reflux disease (GERD)

Answer 47

Sign/symptoms: 1. Common in children 2. Heartburn 3. Regurgitation

Question 48

Acute intermittent porphyria (AIP)

Answer 48

Sign/symptoms: 1. Life-threatening 2. Intermittent episode of abdominal pain 3. Tachycardia 4. Hypertension 5. Neuropathy 6. Red urine ( wine-like)

Question 49

Hepatitis C virus

Answer 49

Def: 1. Acute liver inflammation 2. Acute infection Caused by: 1. History of IV-Drug use Sign/symptoms: 1. Fatigue 2. Jaundice 3. Hepatomegaly 4. History of past IV-drug use Screening: 1. Hepatitis C antibody test (positive in active, chronic or previous infection) Diagnosis: 1. PCR for hepatitis C virus RNA Complication: 1. Porphyria Cutanea Tarda (PCT): common extra-hepatic manifestation of chronic hepatitis C (shows erosions/blisters at the dorsum of hand) Treatment: (chronic HCV) 1. Combination of direct-acting antiviral ( ledipasvir & sofosbuvir)

Question 50

Viral hepatitis or cirrhosis

Answer 50

Triad of: 1. Fatigue 2. Jaundice 3. Hepatomegaly

Question 51

Functional constipation

Answer 51

1. Common cause of abdominal pain in children (who begin toilet training or those who start going to school) 2. Treatment: 1st: Oral osmotic laxative (poly-ethyelene glycol) 2nd: enema 3. Early treatment prevents fecal impaction (seen with U/S)

Question 52

Intussusception

Answer 52

1. Common in children less than 2 years of age 2. Happens when the ileum folds into the cecum 2. Signs: * Colicky abdominal pain lasts 15-20 min * non-bilious vomiting * currant jelly stool (reddish mucoid stool) * palpable mass at RLQ * U/S shows: target sign at site of intussusception * ** “grabs his abdomen & draws up his legs”*** * mechanical bowel obstruction (constipation & hyperactive bowel sounds) 3. Treat with: barium enema (perform air enema on the infant)

Question 53

Empirical antibiotic treatment

Answer 53

Indicated in case of: 1. Acute appendicitis (RLQ pain, N/V, fever, leukocytosis, U/S dilated non-compressible appendicitis, peri-appendiceal fluid collection) 2. Acute dysentery ( blood in stool & diarrhea) (caused by shigella or entaemoba histolytica)

Question 54

Peritonitis

Answer 54

Signs: 1. Extremely ill patient 2. Hypoactive bowel sound 3. Usually lie still ( not restless) 4. Rebound tenderness & guarding 5. Tachycardia 6. Hypotension

Question 55

Shell-food (seafood) poisoning

Answer 55

1. Vibrio cholera 2. Vibro parahaemolyticus (fever, abdominal cramps, vomiting, watery diarrhea within 12-52 hours) 3. Hepatitis A virus 4. Hepatitis E virus 5. Norovirus 6. Paragonimus

Question 56

C. Difficile infection

Answer 56

Signs: 1. Can occur following antibiotic use 1. Watery, foul smelling stool, occasionally streaked with blood 2. Leukocytosis 3. Mild diffused tenderness through Lower abdominal quadrants (inflamed colon) Diagnosis: 1. Stool toxin test: PCR is used to detect C.difficile toxin gene in stool sample 2. Enzyme immunoassay (EIA): detect glutamate dehydrogenase (GDH), toxin A, or Toxin B.

Question 57

Food-protein-induced proctocolitis (diet-associated colitis)

Answer 57

1. Presence of blood-tinged stool & mucus in new born baby 2. No sign of obstruction (vomiting, diarrhea, fever, hypotension) 3. Treat: continue breastfeeding & advise mother to avoid diary & soy products 4. Rectal bleeding resolve within 3 days of removal of offending food antigen 5. The baby will be able to tolerate the offending antigen if introduced again when they are 1 year old

Question 58

Celiac disease (CD)

Answer 58

Def: 1. Can manifest in infancy, but usually 8-12 months of age (2-3 months after introduction of gluten to the diet) Sign/symptoms: 1. Steatorrhea 2. Signs of Malabsorption (vitamin deficiency, anemia, failure to thrive) 3. No GI bleeding 4. Pruritic vesicles in both elbow & knee (dermatitis herpetiformis) Diagnose: 1. IgA anti-tissue Transglutaminase antibody

Question 59

H.pylori

Answer 59

1. Detected by stool antigen immunoassay 2. Associated with peptic ulcer disease, manifest later in life with: abdominal pain worsen with eating, GI bleeding, vomiting.

Question 60

Necrotizing enterocolitis

Answer 60

Sign: (in preterm-premature infants) 1. Abdominal distention 2. Blood-tinged stool 3. Systemic signs of illness (vomiting, diarrhea, fever, hypotension) 4. Feeding intolerance Diagnosis: 1. Abdominal X-ray shows: Pneumatosis intestinalis (gas within the wall of intestine) Treatment: 1. Administer a broad-spectrum parental antibiotics (combination of ampicillin, tobramycin, & metronidazole) Note: 1. preterm infant presents with poor feeding, vomiting, lethargy, peritonitis on examination, thrombocytopenia, and metabolic acidosis, all of which are consistent with the diagnosis of severe necrotizing enterocolitis (NEC). An x-ray showing bubbles of gas within intestinal wall (pneumatosis intestinalis) confirms the diagnosis. 2. Surgical intervention (Exploratory laparotomy) for NEC is warranted when there is evidence of peritonitis (concerning for gangrenous bowel), perforation (pneumoperitoneum on x-ray), metabolic acidosis, elevated lactate, and/or portal venous gas on x-ray. The severity of this patient's symptoms warrants emergency exploratory laparotomy and will likely include removal of necrotic portions of the bowel.

Question 61

Inflammatory Bowel syndrome (IBS)

Answer 61

1. The combination of recurrent episodes of abdominal pain with varying location and intensity that are exacerbated by emotional stress, altered bowel habits (change in stool frequency and form), and normal physical examination and laboratory studies (e.g., hemoglobin, ESR) are suggestive of irritable bowel syndrome (IBS), which is most commonly seen in individuals aged 20–39 years. 2. Relief of abdominal pain after defecation is often seen in patients with IBS, which is a common chronic gastrointestinal disease with an unknown underlying pathophysiology. In some patients, pain may increase upon defecation or remain unchanged. In the absence of red flag symptoms (e.g., nighttime pain, blood in the stool, weight loss, fever), diagnosis of IBS is based on the Rome IV criteria. Treatment includes regular consultations and reassurance that the disease, although chronic, is benign; dietary adjustments (e.g., avoidance of gas‑producing foods); physical activity; stress management; and possibly psychological therapy. 3. In patients with suspected IBS and the predominant symptom of diarrhea, additional testing should be considered, e.g., fecal calprotectin or fecal lactoferrin, stool antigen test for Giardia lamblia, serological celiac disease testing, and CRP levels.

Question 62

Inflammatory bowel disease (IBD)

Answer 62

1. classic symptoms associated with either Crohn's disease (abdominal pain due to perianal abscesses/fistulas) or ulcerative colitis (bloody stool). Diagnosed by: 1. Fecal calprotectin concentration: (neutrophil secretes calprotectin after migration to acute inflammatory site; concentration correspond to severity of inflammation) 2. Fecal lactoferrin concentration (secreted by active neutrophil in response to acute inflammation; concentration correspond to severity of inflammation) Treat with: 1. Sulfasalazine is a first-line therapy for inflammatory bowel disease (IBD).

Question 63

C-reactive protein (CRP)

Answer 63

1. Not specific | 2. Increases about 6–12 hours after the inflammatory process begins.

Question 64

Duodenal peptic ulcer (DPU)

Answer 64

epigastric abdominal pain especially at night, GI bleeding, vomiting, dyspepsia, anemia, pain relieved by eating.

Question 65

B-symptoms

Answer 65

Associated with: 1. Increased CRP & cytokines (IL-6) Signs: 1. Fever 2. Drenching Night sweat 3. Weight loss (> 10% over 6 months)

Question 66

Unintentional Weight loss with history of chronic GI symptoms

Answer 66

Associated with: 1. Celiac disease (anemia, steatorrhea, positive IgA tissue transglutaminase antibody test) 2. Peptic ulcer disease (PUD) ( dyspepsia, anemia, pain typically worsened by eating) 3. IBD (crohn’s disease or ulcerative colitis) (elevated ESR, extra-intestinal manifistation)

Question 67

Meckel diverticulum

Answer 67

1. An outpouching of the ileal bowel wall that results from a remnant of the embryological omphalomesenteric duct (vitelline duct). 2. Common in males 3. Rule of 2: 2% of population, 2 feet away from ileocecal, presents at 2 years of age. Signs: 1. Asymptomatic 2. Symptomatic: * hematochezia (bright-red blood in stool) Complication: 1. Intussusception 2. Ulceration 3. Hemorrhage 4. Intestinal obstruction Diagnosis: 1. Technetium-99m pertechnetate scan

Question 68

Hydated cyst disease (HCD)

Answer 68

Caused by: 1. Ingestion of Echinococcosis (shed in feces of dogs) 2. Affects liver & lungs Symptoms: 1. RUQ pain, N/V, close contact with a dog, eosinophilia, and focal cyst within the liver. 2. The contents of a hydatid cyst are highly antigenic. Treatment: 1. Oral albendazole (for 1-6 months) (CBC should be performed before treatment, and every 2-weeks to avoid leukopenia) 2. Cysts larger than 5 cm requires surgery-excision or CT-guided PAIR ( Puncture, aspiration, injection, re-aspiration) + medical therapy. *** PAIR can lead to anaphylaxis ( tachycardia, hypotension, decrease O2 saturation, & severe bronchospasm) due to leakage of highly antigenic cystic fluid into blood or peritoneal cavity *** PAIR = percutaneous draining of a hepatic cyst. Signs: 1. Intermittent abdominal pain & fullness 2. Pain extends from epigastrium to RUQ 3. Episode lasts 2 hours 4. Not worsen by food 5. Severe N/V (multiple episodes of vomiting) for few days 6. Works with animals (shelters) 7. Smooth & palpable mass below right costal margin 8. X-ray shows: unilocular cyst 4 cm in diameter with daughter cysts within the liver 9. Absent of fever & leukocytosis

Question 69

Pyogenic liver abscess vs amebic liver abscess

Answer 69

Pyogenic liver abscess 1. Older patients 2. Affect both male/female 3. Left shift on WBC count 4. Elevated bilirubin 5. History of diabetes & gallstones 6. Caused by anaerobic bacteria (bacteroids) 7. Symptoms: RUQ pain, fever, leukocytosis, & a cystic lesion on U/S 8. Treat with: IV clindamycin amebic liver abscess 1. Younger patients 2. Affects male 3. Absent of left shift of WBC count 3. Normal bilirubin 4. History of traveling to endemic area

Question 70

Hepatocellular carcinoma

Answer 70

1. Occurs in people with chronic liver disease 2. Signs: hepatomegaly, RUQ pain, N/V, presence of cystic lesion within the liver 3. Treat with: IV- doxorubicin

Question 71

Endoscopic retrograde cholangiopancreatography (ERCP)

Answer 71

To diagnose: 1. Choledocholithiasis 2. Cholangitis * presence of dilated biliary tree

Question 72

Turner syndrome is associated with celiac disease

Answer 72

Signs of celiac disease: 1. Diarrhea 2. Abdominal bloating 3. Sign of iron deficiency anemia ( fatigue, pale conjunctivae, angular stomatitis) 4. Positive IgA tissue transglutaminase antibody Treat with: 1. Gluten-free diet (1st) 2. Biopsy (2nd)

Question 73

Whipple’s disease

Answer 73

1. infectious disease caused by the bacterium Tropheryma whipplei 2. Difficult to diagnose 3. Signs: * Early (weight loss & migratory/non-deforming arthritis) * Late (chronic malabsorption diarrhea) 4. Treat with: Trimethoprim-sulfamethaxazole therapy (TMP-SMX)

Question 74

Anaphylaxis

Answer 74

Sign: 1. Tachycardia 2. Hypotension 3. Decrease oxygen saturation 4. Severe bronchospasm (sudden decrease in end-tidal CO2 & absent of breath sounds) Treat with: 1. Epinephrine

Question 75

Pneumothorax

Answer 75

1. Loss of negative pressure between visceral and parietal pleural membranes that occurs when air abnormally enters the pleural space. Sign: 1. pleuritic chest pain, dyspnea (SOB), tachycardia, and reduced breath sounds on the ipsilateral side.

Question 76

SOB & pleuritic chest pain

Answer 76

1. Shortness of breath and pleuritic chest pain may suggest pulmonary embolism, pneumonia, or pneumothorax. 2. Pleuritic chest pain that is worse when the person is lying on their back compared with when they are upright may indicate pericarditis.

Question 77

Hemothorax

Answer 77

1. The presence of blood in the pleural cavity. 2. Presents with diminished breath sounds and hyporesonant chest percussion. 3. Usually the result of chest trauma

Question 78

Pneumothorax & hemothorax

Answer 78

1. present with hypoxemia, tachycardia, and decreased breath sounds on the ipsilateral side 2. Use chest tube insertion (4th intercostal anterior axillary - skin incision 1 ICS below)

Question 79

Chest tube insertion

Answer 79

4th intercostal anterior axillary (skin incision 1 ICS. Below)

Question 80

Pulmonary embolism

Answer 80

1. An obstruction of the pulmonary artery and/or one of its branches by a thrombus that most commonly originates from the deep vein system in the legs or pelvis and embolizes to the lungs via the inferior vena cava. 2. Less commonly, the cause of obstruction is a fat or air embolus. 3. Risk factors include stasis (e.g., immobility, surgery), hypercoagulable states (e.g., pregnancy and the puerperium), and endothelial dysfunction (e.g., trauma). 4. Sign: tachycardia, hypotension, decrease in end tidal CO2 (breath sound is not affected) 5. Treat with: Norepinephrine ( inotropic support for patient with cardiogenic shock)

Question 81

Polyhydramnios

Answer 81

An excess of amniotic fluid (> 1.5 to 2 L) during gestation, as a result of either increased production or decreased resorption. Can be due to fetal gastrointestinal abnormalities (e.g., esophageal or duodenal atresia), impaired swallowing (e.g., anencephaly), or associated with maternal factors such as diabetes mellitus, infection, or Rh incompatibility.

Question 82

Amniotic fluid index (AFI)

Answer 82

Abbreviation: AFI 1. A semi-quantitative estimate of amniotic fluid volume measured antenatally via ultrasonography of a pregnant uterus. 2. It is part of the biophysical profile. An AFI between 8-18 = normal, AFI ≤5 cm = oligohydramnios, AFI ≥24 cm = polyhydramnios.

Question 83

Polyhydramnios

Answer 83

An excess of amniotic fluid (> 1.5 to 2 L) during gestation, as a result of either increased production or decreased resorption. Can be due to fetal gastrointestinal abnormalities (e.g., esophageal or duodenal atresia), impaired swallowing (e.g., anencephaly), or associated with maternal factors such as diabetes mellitus, infection, or Rh incompatibility.

Question 84

Esophageal atresia

Answer 84

Sign: 1. Unable to swallow during prenatal period (explains polyhydramnios) 2. Coughing spells 3. Drooling 4. Foaming at the mouth 5. Episode of cyanosis ( at lips & mucosa) that does not resolve when the infant cries !!

Question 85

Esophageal stricture

Answer 85

1. Esophageal stenosis (narrowing) Sign: 1. usually not apparent at birth and only becomes apparent through dysphagia and regurgitation once the infant begins feeding with solid foods (i.e. around the weaning period). 2. t does not affect the airways and does not cause cyanotic attacks.

Question 86

Achalasia

Answer 86

1. Achalasia is very rare in infants and occurs most commonly in middle-aged individuals. 2. It causes dysphagia and regurgitation. Moreover, because it does not primarily affect the airways, it does not cause cyanosis. 3. Patients with achalasia are prone to developing respiratory symptoms if aspiration pneumonia develops as a sequela.

Question 87

Pulmonary hypoplasia

Answer 87

1. commonly presents with cyanosis in newborns, but it does not cause coughing spells or drooling and it is associated with oligohydramnios, not polyhydramnios.

Question 88

Hemorrhoids

Answer 88

Types: 1. Internal hemorrhoids: originate above dentate line & causes bleeding 2. External hemorrhoids: originate below dentate line and causes pain Treatment: 1st: conservative treatment ( grade 1/2 internal & external hemorrhoids) 1. Stool softeners (docusate & topical/suppository lidocaine if painful) 2. Sitz baths & lifestyle modification (weight loss, exercise, high fiber diet, avoid fatty & spicy food) 2nd: rubber band ligation (placed at apex of grade 1/2 internal H to stimulate inflammatory & fibrosis) 3rd: infrared coagulation ( used for grade 3 internal H. Or grade 1/2 internal hemorrhoids that failed conservative treatment) 4th: hemorrhoidectomy (for grade IV internal H. That cant be reduced & acutely thrombosed external H. That is paiful) Types of internal hemorrhoids : Grade 1: not prolapsed Grade 2: reduced at rest (spontaneous) Grade 3: prolapse when straining + manual reduction Grade 4: cannot be reduced manually or spontaneously

Question 89

Antineutrophil cytoplasmic antibodies (ANCA)

Answer 89

Antineutrophil cytoplasmic antibodies (ANCA) are found in several vasculitic conditions, including granulomatosis with polyangiitis, microscopic polyangiitis, and Churg-Strauss syndrome.

Question 90

Hyper-cholesterolemia

Answer 90

1. A condition of elevated total cholesterol (> 200 mg/dL). 2. Can be acquired and/or as a result of inherited conditions (e.g., familial hypercholesterolemia). Treat with: 1. Atorvastatin 2. Cholestyramine

Question 91

Primary sclerosing cholangitis (PSC)

Answer 91

1. A progressive chronic inflammation of both the intrahepatic and extrahepatic bile ducts 2. Associated with Ulcerative colitis (IBD) Signs: 1. Fatigue 2. Pruritus 3. History of inflammatory bowel disease (Ulcerative colitis) Diagnosed by: 1. ERCP 2. MRCP

Question 92

Primary biliary Cholangitis (PBC)

Answer 92

1. Inflammation of intra-hepatic bile duct, which may lead to fibrosis & cirrhosis 2. Females (30-50) 3. Often asymptomatic; pruritus, fatigue, abdominal pain, jaundice after years 4. 4. Lab: cholestatic picture with elevated bilirubin, alkaline phosphatase, & gamma-GT 4. Positive Anti-mitochondrial antibody (AMA) 5. Associated conditions: Sjogren’s syndrome, rheumatoid arthritis, systemic sclerosis 6. Complication: Cirrhosis 7. Treatment: * choletyramine: for pruritus * ursodeoxycholic acid: improves survival & delay transplantation * liver transplantation

Question 93

Primary sclerosing cholangitis (PSC)

Answer 93

1. Inflammation of both intra- & extra-hepatic bile duct 2. Most common: male 3. Sign: fatigue, pruritus, cholangitis 4. Lab: cholestatic picture with elevated bilirubin, alkaline phosphatase, & gamma-GT 5. Investigation: ERCP/MRCP shows beaded appearance of bile duct 6. Associated condition: ulcerative colitis 7. Complication: increase risk of cholangio & colorectal carcinoma / cirrhosis 8. Treatment: * choletyramine for pruritus * ursodeoxycholic acid: may imrove LFT, but does not improve survival * liver transplantation

Question 94

Obstipation ( inability to pass gas/ stool)

Answer 94

Caused by: 1. Bowel obstruction 2. Severe hypothyroidism 3. Diabetes 4. Fecal impaction 5. Volvulus

Question 95

Small bowel obstruction (SBO)

Answer 95

1. An interruption in the normal passage of contents of the small bowel due to a structural barrier/strictures. 2. Most commonly caused by adhesions (e.g., from prior abdominal surgery) and incarcerated hernias. 3. Manifestations include colicky abdominal pain, constipation, abdominal distention, and early-onset vomiting 4. any abdominal surgical procedure should focus on bowel preservation and minimize further complications (e.g., short bowel syndrome, postoperative adhesions and fistulas).

Question 96

Peritoneal carcinomatosis

Answer 96

1. A terminal feature of abdominal cancers (commonly of the ovary, appendix, or the colon) characterized by seeding of the tumor to the peritoneum. 2. Treat with: Discontinue surgery and start palliative care

Question 97

Small bowel resection & primary anastomosis

Answer 97

1. indicated to remove a diseased part of the small intestine in patients with cancer, a bleeding ulcer, or Meckel diverticulum.

Question 98

Peripheral vascular disease (PVD)

Answer 98

1. Atherosclerotic occlusion of lower extremities artery 2. Most common “superficial femoral artery” occlusion in Hunter’s canal Symptoms: 1. Intermittent claudication (painful leg cramping that occurs with exercise and is relieved by rest or just standing) 2. Rest pain (pain in the foot at the distal metatarsal; pain arise at rest; pain starts at night/ awaken patient from sleep) (resolve with hanging foot over side of bed/ standing/ effect of gravity) 3. Erectile dysfunction 4. Sensorimotor impairment 5. Tissue loss Signs: 1. Absent pulses 2. Bruits 3. Muscular atrophy 4. Decreased hair growth 5. Thickened toenails 6. Tissue necrosis, ulceration, infection (ulcer starts at toes/foot vs. venous stasis ulcer that starts at the medial malleolus/ankle) (painful foot ulcer in PAD vs. painless foot ulcer in diabetes) Diagnosis: 1. Ankle-Brachial Index (ABI): normal (> 1.0) ; claudicators (<0.6); rest pain/gangrene (<0.4) * ** false positive reading can occur in patients with calcified arteries/diabetics (monkeberg sclerosis) 2. Pulse-volume recording (PVR): records volume of blood per heart beat down the legs (large waveform=good collateral blood flow) Investigation: 1. A-gram (arteriogram= dye in vessels + X-ray) Treatment: 1. Conservative therapy for claudication (exercise, stop smoking, control HTN, aspirin, oentoxifylline) 2. Angioplasty (ballon dilation) 3. Surgical graft-bypass (autolologous vein graft or Gortex) 4. Endarterectomy (removal of atherosclerotic plaque/intima/media) Post-operation: 1. Sheep skin 2. Foot cradle 3. Lotion: to prevent fissure that later forms ulcer 4. Check cardiac status & MI: most pt. With PVD have CAD & AAA 5. patients with PAD are at significantly increased risk for myocardial infarction and stroke. 6. In patients with Critical limb ischemia (rest pain, ulcer & gangrene) , urgent revascularization therapy is indicated to prevent limb-threatening arterial occlusion. Notes: 1. Aspirin/clopidogrel/ticagrelor: inhibits platelets formation 2. Pentoxifylline/cilostazol: increase RBC flexibility

Question 99

Dry gangrene

Answer 99

1. Dry necrotic tissue without sign of infection (mummified tissue) 2. Common lower limbs 3. Common arterial occlusion 4. Organ is dry, shrunken, & black 5. Line of demarcation presents between gangrenous & healthy part 6. Bacteria fail to survive 7. Better prognosis due to little septicemia

Question 100

Wet gangrene

Answer 100

1. Moist necrotic tissue with sign of infection 2. Common in bowel 3. Common venous occlusion 4. Moist, soft, swollen & dark 5. No line of demarcation 6. Numerous bacteria is present 7. Poor prognosis due to profound toxemia emergency amputation and debridement of infected and necrotic tissue are indicated.

Question 101

Blue-toe syndrome

Answer 101

1. Intermittent painful blue toes (or fingers) | 2. Due to micro-emboli from proximal arterial plaque

Question 102

acute arterial occlusion

Answer 102

1. Acute occlusion of an artery by embolization or thrombosis Source of emboli: 1. Heart (A.fib, clot forming on dead muscle after MI, endocarditis, myxoma) 2. Aneurysms 3. Atheromatous plaque (embolism) Sign/symptoms (6-P’s): * acute onset * 1. Pain 2. Pallor (paleness) 3. Paralysis 4. Paresthesia 5. Polar (Poikilothermia) (cold sensation) 6. Pulselessness Immediate treatment: 1. IV-anticoagulation with heparin 2. A-gram

Question 103

Aortoiliac disease (leriche syndrome) Peripheral vascular disease

Answer 103

Peripheral artery disease at the level of the aortic bifurcation or bilateral occlusion of the iliac arteries that leads to the classic triad of bilateral buttock, hip, or thigh claudication; erectile dysfunction; and absent/diminished femoral pulses. PAD vs. AID: 1. PAD shows femoral pulse are palpable, but pedal pulse are absent. 2. AID: absent of femoral pulse

Question 104

Chronic venous insufficiency (CVI)

Answer 104

1. Muscle cramp/pain with standing & improves with walking 2. Occurs when your leg veins don't allow blood to flow back up to your heart. Signs: 1. Pain 2. Bleeding 3. Ulcer 4. Hyperpigmentation Treatment: 1. Compression stocking 2. Endo-venous thermal ablation (Laser or high-frequency radio waves are applied to the affected vein to seal it off and prevent further blood flow through it. Blood can then be diverted to veins with proper valve functioning.)

Question 105

Limb reperfusion (post-Opt

Answer 105

Lead to: 1. Compartment syndrome (tissue swelling from reperfusion causes increase intra-compartmental pressure) 2. Hyperkalemia 3. MI 4. Renal failure due to myoglobinuria

Question 106

Compartment syndrome

Answer 106

1. Occurs due to reperfusion injury 2. increased pressure leads to impaired perfusion Signs: 1. Pallor 2. Paresthesia 3. Paralysis 4. Presence of pulses 5. Pain with passive extension/flexion of the foot Note: pale, cool skin, weak peripheral pulses, as well as increased capillary refill time and a positive stretch test (pain in the calf muscle on passively dorsiflexing the foot) Treatment: 1. Fasciotomy: within 6 hours of the onset of clinical symptoms (to prevent necrosis) & followed up with open wound management.

Answer 107

Ischemic features (e.g., pallor, pulselessness, increased capillary refill time, poikilothermia, paralysis) are usually late findin

Question 108

Retroperitoneal hematoma

Answer 108

1. Complication of cardiac catheterization 2. Causes hemodynamic instability + back & flank pain 3. Diagnosed with non-contrast CT scan of abdomen & pelvis OR abdominal U/S 4. Treatment: bed rest, intensive monitoring, IV fluid & blood transfusion

Question 109

Carotid vascular disease

Answer 109

Signs: 1. Amaurosis fugax (transient loss of vision in 1 or 2 eyes) 2. Transient ischemic attack 3. Reversible ischemic neurologic deficit 4. Cerebrovascular accident (stroke) Diagnose it: 1. A-gram (invasive) 2. Carotid U/S or Doppler (non-invasive)—> stenosis of carotid (50%) 3. Head CT Treatment: 1. Carotid endarterectomy (CEA) 2. Aspirin Death after surgery—> due to MI