GERD sequelae
Adenocarcinoma of the esophagus, esophageal strictures
Esophageal Strictures
Symmetric circumferential narrowing on barrium swallow. Caused by GERD. May improve GERD symptoms. Biopsy is necessary to rule out Adenocarcinoma. Dilation is the tx.
Meconium Ileus
Commonly seen in Cystic Fibrosis. Obstruction at Ileum and early colon. Thick, inspissated meconium. Microcolon. Dx: Xray for pneumoperitoneum (surgery) then contrast enema (in a stable patient) to determine level of obstruction.
Dubin-Johnson Syndrome
Rare, benign, hereditary condition with chronic or fluctuating conjugated hyperbilirubinemia due to a hepatocyte excretion defect.
Jaundice typically triggered by illness, pregnancy, or OCPs. Urine will appear dark due to the presence of conjugated bilirubin that is usually degraded. The presence of urobilinogen (as in other diseases) in the urine usually indicates elevated unconjugated bilirubin.
Labs: Elevated total and conjugated bili, other liver labs will be normal.
Factious Diarrhea
Female more common, often healthcare workers, history of multiple hospitalizations.
Usually taking laxatives that will cause profuse watery diarrhea, hypokalemia, metabolic ALKAlosis.
Colonoscopy will show brown pigments in the bowel wall, melanosis coli.
Dx: Stool laxative testing.
Glucagonoma
Presents with weight loss, possible diarrhea, constipation. Patients will often have mild DM, possible neuropsychiatric symptoms, DVTs.
Necrolytic Migratory Erythema: papules or plaques with central clearing, crusting, erosion on borders that occur on face, limbs, perineum,
Patients will be anemia due to anemia of chronic disease or glucagons effect on erythropoesis.
Abdominal imaging to find tumor.
Mild Constipation
Constipation without severe pain and vomiting. Does not require abdominal xray. May begin laxatives.
Chronic Hepatitis C
Asymptomatic or nonspecific symptoms: fatigue, nausea, anorexia, myalgia, arthralgia, weight loss.
Transaminases increased in 2/3rds of patients, 20% will progress to cirrhosis
Types of watery diarrhea
Secretory: >1L/day, often happens during sleep, stool osmotic gap low
Osmotic: Increased stool osmotic gap
Functional:
Stool osmotic gap = plasma osmolality - 2x (stool Na + Stool K) normal is around 125
Food protein induced allergic protocolitis
young infant with painless bloody stools +/- spit up. FMH of eczema, asthma, or allergies. Maternal ingestion of milk or soy products that causes a non IgE allergic reaction in infants.
Eliminate offending agent from maternal diet or hydrolyzed formula. Will resolve by 1 year old.
Chemistries on a person who has been vomiting
Hypochloremic, hypokalemic, increased bicarb. Metabolic alkalosis (relative loss of H+ and loss of fluid causes retention of bicarb)
Chronic Pancreatitis
Etiology: alcohol, obstruction, autoimmune, CF
Presentation: Chronic epigastric pain, malabsorption, DM
Labs/Imaging: Amylase/lipase often normal, CT or MRCP can show calcification, dilation of ducts, and an enlarged pancreas.
Toxic Megacolon
Abdominal pain, bloody diarrhea, fever, abdominal distention, peritonitis.
Xray: marked colonic distention
Risks: Inflammatory Bowel Disease, C diff
Tx: Bowel rest, NG suction, abx, steroids if associated with IBD. If refractory then you proceed to surgery.
Hepatic Hydrothorax
Small defects in the diaphragm that allow transudative fluids into the thorax. More common on the right because the right hemidiaphragm is less muscular.
Tx: Salt restriction, thoracentesis
Tests following diagnosis of GERD
EGD w/ biopsy,
If EGD negative, consider 24 hr pH.
Carcinoid Syndrome Presentation
Skin: Flushing, telangiectasia, cyanosis
GI: diarrhea
Cardio: Right-sided valvular lesions (occasionally left)
Pulm: Bronchospasm
Niacin deficiency (dermatitis, diarrhea, dementia)
Necrotizing Enterocolitis
Risks: Low birth weight, enteral feedings, prematurity
Features: Poor vitals, lethargy, bilious emesis, bloody BMs, abdominal distension.
Xray: Gas patterns, portal venous gas, pneumoperitoneum
Tx: Bowel rest, parenteral feedings, broadspectrum abx, +/- surgery
Mild Non-bleeding esophageal varices
Beta blocker
HbsAg
First serologic marker of HepB
igM anti HBc
appears shortly after HbsAg
HbeAg
Indicator of infectivity
Chronic HepC extrahepatic findings
Mixed cryoglobulinemia, membranoproliferative glomerulonephritis, lichen planus, porphyria cutanea tarda
Acalculous cholecystitis
seen in severely ill patients with poor perfusion to the gallbladder.
Leukocytosis, RUQ pain +/- mass, +/- jaundice, +/- abnormal LFTs
Basically the worst.
Dx: Ultrasound
Tx: Abx and Cholecystostomy and eventual cholecystectomy
Patient presentation of pancreatic cancer
vague epigastric pain, weight loss, cigarette smoking, recent onset DM, chronic pancreatitis
