1
Q
DDx of hematemesis
A
Mallory-Weiss Tear
Esophageal Varices
Boerhaave’s Syndrome (effort rupture)
2
Q
Boerhaave’s Syndrome
A
Esophageal rupture/perforation
Secondary to severe retching/vomiting causing increase in intraoresophageal pressure combined with negative intrathoracic pressure
- Painful (severe, retrosternal “tearing”), NOT self-limiting, emergency
3
Q
Mallory-Weiss Tear
A
Mucosal tear of gastroesophageal (GE)
junction from vomiting
H/o vomiting, retching (50%); Benign, self-limited (usually); PAINLESS hematemesis; frequently associated with Alcoholics/hyperemesis grav.
4
Q
Dysphagia (difficulty swallowing) w/u
A
- EGD- gold standard-diagnostic/therapeutic
- Solid & Liquid: assessed on barium swallow or esophageal manometry (*achalasia)
- ->assess peristalsis/lower esophageal sphincter (LES)
5
Q
Dysphagia ETIOL/DDx
A
- Oropharyngeal – CNS
- Esophageal
- Motility disorders (achalasia)
**SOLIDS & LIQUIDS
- Mechanical disorders (obstructive)
**SOLIDS ONLY - Innervation abnormalities
- Primary: achalasia or esoph spasm
- Secondary: scleroderma vs CVA - Structural abnormalities
- Schatzki’s ring/strictures, Zenker’s
Diverticulum, esophageal web & strictures
- CANCER
6
Q
Achalasia is
A
ineffective
- parastalsis
- swallow induced relaxation of the lower esophageal sphincter
7
Q
Achalasia presentation/Dx
A
- Dysphagia for SOLIDS & mostly LIQUIDS
- Regurgitation of undigested food
- Esophagram with “bird’s beak” distal esophagus
- Esophageal manometry confirms dx
8
Q
gastroparesis is:
Assoc with:
Sxs
Tx
A
- Delayed gastric emptying
- Most often with poorly controlled diabetes
hgb A1C high; hyperglycemia - Sxs: early satiety, feeling of fullness,
bloating, stomach pain, nausea, wt loss - Tx: promotility/prokinetic agents
(metaclopramide *black box warning;
domperidone *check ekg; gastric pacer)
*BETTER GLYCEMIC CONTROL/HgB A1C
9
Q
Mechanical / structural disorders assoc with dysphagia
A
- Schatzki’s ring
- Esophageal Stricture
- Zenker’s diverticulum: False diverticulum/ outpouching. Sxs: dysphagia, choking, cough, aspiration,regurgitation of undigested food (esp. in am)
- Esophageal Web: r/t Iron Deficiency Anemia. part of Plummer Vinson Syndrome
- Esophageal Cancer: solids only
10
Q
Peptic Ulcer Dz: two types
compared?
assoc with what?
A
Gastric vs Duodenal 1:5 ratio (duodenal 5x more common) 55-70 yrs vs 30-55 yrs both MC w/ NSAID use and H.Pylori + ETOH and smoking decr ulcer healing
11
Q
H. Pylori Tx
A
- Amoxicillin 1 gm BID and
- Clarithromycin 500 mgm. BID and
- PPI BID
all for 10-14 days
- if PCN allergic - substitute
Metronidazole 500 mg. BID - f/u with *urea breath test or stool 1-3 months after completion - OFF PPI
12
Q
If PUD present and not on NSAID/ASA,
assume ??????
A
H Pylori
13
Q
PUD typical presentation
A
Dyspepsia
- worse after eating–> lose wt (gastric)
(duodenal- relieved with food–> gain wt)
- Periodicity (exacerbations/remissions)
May be asymptomatic and appear as a GI bleed acutely
14
Q
GI/PUD Red Flags
A
- Anemia
- Weight loss
- Positive hemoccult
- Hematemesis/melena
- Persistent vomiting
- Hepatomegaly/abd mass
- Dysphagia
- Progressive symptoms
15
Q
PUD: Empiric Tx vs. imaging/EGD
A
- Empiric if 50 yrs (?)
- Are these new sxs? Are they also iron def anemic? wt loss? Other alarm symptoms? —> cancer?????
16
Q
When to consider Zollinger-Ellison Syndrome?
A
- Recurrent PUD patients
- PUD with hypercalcemia
- Neg H. Pylori, Neg NSAID/ASA use
- Those with severe abd pain, diarrhea
- Elevated serum gastrin level
17
Q
Cholangitis is what?
Diagnosed by what symptom clusters?
A
- infection of the common bile duct, usually gallstone or tumor - HIGH M&M
- Charcot’s triad
- fever > 40
- RUQ pain
- Jaundice
and Reynold’s pentad
- Above PLUS
- Altered mental status
- Hypotension
18
Q
Cholelithiasis presentation?
A
- Often asymptomatic or recurrent RUQ/epigastric abd px, postprandial nausea +/- vomiting
- 5 F’s: female, fat, forty, fertile, fair
- 75% cholesterol stones
- Estrogen, fibric acid drugs
- hypertriglyceridemia
- Type II DM
- Estrogen, fibric acid drugs
19
Q
Biliary Colic is?
Presentation?
A
- Transient cystic duct obstruction
- Right upper quadrant or epigastric pain that radiates to back
- 15 min-2 hr after fatty foods
- Nocturnal pain is common
- Abdominal exam and labs will often be
normal if the patient isn’t having an attack
20
Q
Anatomy and pathology
- Biliary Colic
- Acute Cholecystitis
- Choledocholithiasis
- Cholangitis
A
- Biliary Colic: Transient cystic duct obstruction
- Acute Cholecystitis: Sustained obstruction of cystic duct
- Choledocholithiasis: common bile duct stones (incr LFT’s, jaundice, n/v, biliary colic)
- Acute Cholecystitis: infection of the common bile duct (charcot’s triad)
21
Q
Primary sclerosing cholangitis is caused by?
often associated with?
A
Autoimmune, post-infectious, vascular
Mostly young men 20-40 y/o
Often associated w/ IBD (2/3 have UC)
22
Q
Autoimmune Hepatitis
A
Younger women ages 30-50 y/o No serological evidence of viral hep or h/o etoh, parenternal exposure Labs: Elevated transaminases +ANA (anti-nuclear antibody) +ASMA (anti-smooth muscle antibody)
23
Q
Acute pancreatitis Clinical Presentation
A
Severe epigastric pain radiating into back
Nausea and vomiting
Tachycardia
Orthostasis/dehydration/hypotension
Dx:
- Increased S. amylase and S. lipase
- Leukocytosis with a left shift
- CT
24
Q
Ranson’s criteria
A
3 or more:
- Age >55
- WBC > 16,000
- Blood Sugar >200
- Lact. Dehydrogenase (LDH) > 350
- AST > 250
- high incidence of pancreatic necrosis
- Low S. Calcium
25
CA 19-9 tumor marker for ?
Pancreatic Cancer
26
Labs that show liver FUNCTION
albumin
coagulation factors
conjugation of bilirubin
27
Liver Enzymes are?
| Elevation shows?
AST
ALT
Alk p’tase
GGTP (Gamma-glutamyl transferase)/ 5’nucleotidase
Elevated in hepatocellular inflammation or destruction/necrosis
28
Wilson’s Disease
1. what?
2. Dx by?
3. Tx
1. copper overload
2. Kay-Fleischer ring on eye exam
Low serum ceruloplasmin
3. penicillamine- copper chelation
29
Presence of HBsAg in HEP B serology means?
Active Disease
30
Liver Enzymes in Viral vs ETOH Hepatitis
Viral Hepatitis: ALT>AST (20+ times elevated)
| ETOH Hepatitis: AST > ALT (rarely above 300) and usually AST/ALT >2
31
AFP (alpha fetoprotein) is a marker for
Hepatocellular carcinoma
32
***String sign
Cobblestoning
***Skip lesions are seen in?
small bowel contrast films in Crohn's Dz
33
air/fluid levels on upright KUB are seen in
SBO
34
Labs for Sprue
```
1. Malabsorption findings:
Fe deficiency
Ca deficiency
Vit. D deficiency
B-12 deficiency
2. SEROLOGIES:
*anti-endomysial antibody
tTG antibody
total serum IgA
3. MUCOSAL BIOPSY --> villous atrophy; blunting of villi duodenum
```
35
Dermatitis herpetiformis is what? It is seen in what GI Dz?
Pruritic papulovesicles over extensor surfaces and the trunk and neck
-
36
What those with Sprue can and can't eat?
Can't: BROW (Barley, Rye, Oats, Wheat)
| Can: CRAP (Corn, Rice, Arrowroot, Potatoes)
37
Short Bowel Syndrome secondary to:
| what do you need if you lose >50cm?
Secondary to removal of small intestine
(Crohn’s resection, mesenteric infarct,
tumor resection)
If more than 50 cm of ileum is resected,
patient needs monthly B-12 injections.
If larger section, weight loss, diarrhea,
electrolyte malabsorption occurs
38
Diverticular hemorrhage
1. 5-15% of patient with diverticulosis
-->50% of all lower GI bleeds
**most common**
2. 80-90% of episodes will be self-limiting
3. Elderly patient
4. *acute, painless, large volume maroon or
BRB in patient > 50 y.o.
5. *** remember HCT may not reflect amt of
bleeding if volume depleted
39
Clinical Presentation of Diverticulitis
1. LLQ pain and mass
2. Fever
3. Leukocytosis
..may also see constipation leading up
to attack
40
Diverticulitis Dx
```
1. Mainly a clinical dx (fever, pain, change in
bowel habit)
2. Plain films on all to look for abd free air or
obstruction
3. Leukocytosis (only 50% early)
4. If classic sxs, no imaging necessary
5. CT if sxs don’t resolve in 2-4 days
**no Ba Enema or scoping acutely
```
41
Diverticulitis Management
1. Most require hospitalization (especially elderly)
2. IV antibiotics
**broad spectrum + anaerobic coverage:
Ciprofloxacin and metronidazole = gold std.
3. Rehydration
4. Pain control
5. Bland diet, slowly advance
6. Oral antibiotics for 7-10 days
** 2+ diverticulitis attacks -> surgical consultation for elective resection (typically sigmoid)
42
Microcytic anemia + >50 =
colon Ca
90% are >50yo
FHx in 25% of new cases
43
Familial adenomatous polyposis
| (FAP) is transmitted how? Why do I care? Intervention?
1. Genetic / Autosomal dominant
2. 100% risk of colorectal cancer by age 50
3. Elective total colectomy is the only
intervention
44
In ulcerative colitis > is always involved? Describe lesion?
1. Rectum is always involved
| 2. continuous lesions, sharply demarcated
45
*acute, painless, large volume maroon or
| BRB in patient > 50 y.o.
Diverticular Hemorrhage ---> Most Common cause of lower GI bleed (50%)
46
Screening for colon cancer
1. First degree relative w/ cancer/adenoma >60 OR 2+ second degree relatives
w/cancer/adenoma
- Screen at age 50 – colonoscopy preferred
2. First degree relative with cancer
47
Irritable Bowel Syndrome (IBS): is what?
```
1. a diagnosis of exclusion
Functional bowel disorder
Chronic (>3 mos) Lower GI sxs
Continuous or intermittent
Plus 2 of these 3:
Relieved with defecation
Change in frequency of stool
Change in stool caliber
```
48
Vit. A deficiency causes
Vit. A – night blindness, poor wound healing
49
Thiamine (B1) deficiency causes
B1: ETOH – Beri-beri
| High output CHF/ Wernicke’s encephalopathy
50
Niacin (B3) deficiency causes:?
Pellagra (3-D’s)
| Dermatitis, dementia, diarrhea
51
Causes of UGI bleeding
```
PUD (50%+): hx GERD sxs
Varices (10-20%): ETOH abuse
NSAID gastropathy (10%)
Mallory-Weiss tear – (5 - 10%):
- h/o recent vomiting
Vascular ectasias & AVM’s – 7% Boerhaave’s syndrome
```
52
Amount of UGI Bleeding to get:
1. Melena
2. Hematochezia (BRBPR)
1. 50-100 ml
| 2. 1000 ml
53
source of Hematochezia %?
90% Lower GI
| 10% Upper GI
54
Unconjugated bilirubinemia
| (Indirect) causes?
1. Hemolysis
| 2. Inherited - Gilbert’s Disease
55
Conjugated Bilirubinemia
| (Direct) causes?
1. Hepatocellular dysfunction
2. Biliary obstruction
3. Inherited – Dubin-Johnson syndrome
56
antiendomysial antibody (AEA) associated with?
1. Celiac Sprue:
90-95% sensitivity and
90-95% specificity
57
ASCA (Anti-Saccharomyces cerevisiae antibodies) assoc with?
Crohn's Dz
58
CEA is marker for
Colon CA
PANRE
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