1
Q
A
2
Q
*** Inflammatory Bowel Disease Extra-Intestinal manifestation of IBD that is not associated with IBD progression.
A
- Primary Schlerosing Cholangitis - Uvitis - Axial artheropathy
3
Q
Achalasia
- Dz
- Dx
- Tx
A
- Pathogenesis
- ganglion cell degeneration of myenteric plexus
- Dx:
- Barium swallow
- EGD
- Motility/manometry :
- Showing no organized peristalsis / Non-relaxin
- high-pressure LES / Low-amplitude
- simultaneous contractions
- Tx:
- pneumatic dilation (this is different from regular dilations; a much larger balloon)
- Surgical - laparoscopic myotomy
- Endoscopic BOTOX for high-risk pt* “Never” on medicine Boards, but could be - reserve for the very old or very frail
4
Q
Achalasia - heartburn
A
heartburn - from lactic acid produced by fermentation of esophageal contents - doesn’t respond to PPI.
5
Q
Adenocarcinoma of Esophagus
A
- Location: Distal 1/3 of esophagus
- Related to reflux and Barrett’s
- Increasing incidence
- White males
6
Q
Aorto-enteric fistula
A
Always remember this if the patient has a past history of abdominal aortic aneurysm (AAA) repair
Presents with melena, then severe hemorrhage
7
Q
Ascites protien
> 2.5
A
> 2.5 CHF
8
Q
Bacterial endocarditis prophylaxis
A
- Prosthetic valves
- history of endocarditis
- unrepaired cyanotic congenital heart dz
- repaired CHD uwing prosthetic valves
- Heart transplant
LOW RISK procedure
- GI / GU / Vaginal or C-section
- Dental Rx: Amoxicillin, cephlexine, clindamycin or azithromycin (iv ampicillin, ceftriaxone, clindamycin)
- GI/GU prophylaxis: amoxicillin, ampicillin or vanc
- Skin/musculoskeletal (vanc)
9
Q
Barrett’s Esophagus F/U
A
- Biopsy: Specialized intestinal epithelium
- Symptoms of reflux may not be prominent
- Symptoms are 2° complications like stricture, esophagitis
- Predominantly in white males; mean age 60 / Unlikely women
- low gread dysplasia back in 6 months
- no dysplasia - every three years
- high grade dysplasia / rescect and sent to pathology
10
Q
Cancer Risk
Esophageal (scc)
Gastric Cancer
Colon Cancer
A
Esophageal cancer:
- Achalasia / atrophic gastritis
Gastric
- Atrophic gastritis / hpylori / gastri surgery
Colon
- IBD
11
Q
Celiac Dz Management?
- Gluten free diet
- Nutrition defn
- Preventative Bone loss
- Vaccination
- Dermatitis Herpetiformis
A
Gluten free diet : Dietary counseling
Nutrition defn : Iron, vit D, Ca
Preventative Bone loss Dexa
Vaccination Pneumo
Dermatitis Herpetiformis Dapson
12
Q
Complications of Sickle cell trait
A
Renal Dz
- Hematuria
- Increased UTI
- Renal medullary ca
Thrombosis
- Splenic infarct
- Venous thromboembolism
- priapism
13
Q
Crohn Disease
A
• Abdominal pain, diarrhea / Overt bleeding is unusual • Perirectal symptoms or lesions / Symptoms often prolonged, diagnosis delayed • Family history in 10% to 20%, association with smoking
14
Q
Crohn Disease Treatment
A
• Step-up approach, start simple • Mild disease: Mesalamine, sulfasalazine, budesonide • Acute flares: Prednisone • Save the immunocompromising drugs
15
Q
Crohn Disease: Treatment Scenarios • Colon only: • Small bowel involvement: • Fistula or perianal: • Steroid-dependent: • Acute small bowel obstruction:
A
Crohn Disease: Treatment Scenarios • Colon only: Mesalamine, also sulfasalazine • Small bowel involvement: Mesalamine and budesonide (if mild/very mild)
16
Q
Crohn Disease: Treatment Scenarios • Fistula or perianal: • Steroid-dependent: • Acute small bowel obstruction:
A
• Fistula or perianal: Metronidazole, 6MP, or infliximab • Steroid-dependent: 6MP/azathioprine, infliximab • Acute small bowel obstruction: Corticosteroids with NG tube —- • Only 30% have normal bone density • IBD and increased risk of DVT
17
Q
Crohn’s Disease / Complications
A
- Calcium oxalate kidney stones* - Cholesterol gallstones - B12 deficiency* - Hypocalcemia (vit D malabsorption) - Bile acid-induced diarrhea (less than 100 cm resected, cholestyramine)* • Steatorrhea 2° depleted bile acids (more than 100 cm resected, low-fat diet, and medium-chain triglycerides)
18
Q
Defn
- Zinc
- Iron
- Copper
- Vit A
- Vit D
- Vit K
- Ca
- Folate
- Thiamine
- B12
A
- Zinc: Alopecia, night blindness, skin rash
- Iron: anemia
- Copper: Fragile hair, neuropathy, ataxia
- Vit A: night blindness, immune defn
- Vit D: Bone Dz, 2n hyperparathyroidism
- Vit K: Coagulopathy
- Ca: osteopenia, hyperparathyroidsm
- Folate: macrocytic anemia
- Thiamine: wernicke / intractable vomiting
- B12 - you know dis biatch
19
Q
Diabetic Gastroparesis
A
• More prevalent in DM Type 1 • Usually long-standing, with other complications, esp. autonomic neuropathy • High blood sugar exacerbates symptoms • Likewise, gastroparesis leads to poor glycemic control • Variable Sxs N, V, distension, fullness, abdominal pain
20
Q
Diagnose celiac disease in a patient with iron-deficiency anemia.
A
Small-bowel biopsies should be obtained even if the tissue transglutaminase (tTG) antibody is negative in patients in whom there is ongoing concern about the diagnosis based on the disease probability in a specific patient, because the sensitivity of tTG varies significantly among laboratories (69%-93%). Because this patient has both Down syndrome and unexplained iron-deficiency anemia, small-bowel biopsies should be obtained even with a negative tTG, because both of these findings are associated with celiac disease.
21
Q
Diagnose fulminant Wilson disease.
A
A young patient who presents with acute liver failure should always be suspected of having Wilson disease.
22
Q
Diagnose rumination syndrome.
A
Rumination syndrome is characterized by effortless regurgitation of undigested food and reswallowing of the contents.
23
Q
Crohn’s Disease work up
A
• Colonoscopy - Findings: Patchy disease, aphthous and deep ulcers, strictures, fistula - Colonic disease: Rectal sparing, skip lesions, perirectal disease - Heal disease • CT or CT enterography: Shows small bowel or colonic inflammation or thickening • UGI with small bowel - String sign: Heal disease • Colon only: 30%, SB only: 30%; colon and small intestine: 40% • Granulomas not common, but diagnostic
24
Q
Diffuse Esophageal Spasm Tx:
A
Treatment?
- Trial proton pump inhibitor (PPI)
- Anti-spasm agents
- Anti-anxiety
- Calcium channel antagonists
25
**Discriminant function Calculation**
4.6 X [pt - control pt]+serum billi
**DF** \> 32 will benefit from 40 mg prednisone
Prothrombin time
26
Dyspepsia
* Dyspepsia
* Workup
* Test and treat H. pylori
* DC NSAIDs
* Trial PPI
* EGD (alarm Sxs, failure of Tx)
27
Eosinophilic Esophagitis
* Solid food dysphagia
* EGD shows "ringed" esophagus and biopsy reveals infiltrate of eosinophils
* **_Treat_**: PPI and ingested fluticasone
28
Eosinophillic esophagitis
history of Asthma / allergies
Develope intermittent Dysphagia or even sudden food bolus impaction
Could see furrows or rings
Avoid allergens
29
Fulminant hepatic failure (FHF) is defined as
hepatic encephalopathy in the setting of jaundice without preexisting liver disease.
Liver failure is classified by the number of weeks after jaundice onset that encephalopathy appears
30
Esophageal Cancer Tx:
* **_Treat_**: Surgery, if localized
* XRT + **_Cisplatin + 5FU_** (always have 5FU in regiment)
* Neoadjuvant Tx before surgery
31
Fundoplication
* Young patient
* definite GERD, intolerant of PPIs
* Any patient
* refractory regurgitation leading to cough, asthma, aspiration pneumonia
32
Colon cancer screening
* Avg risk
* 1st degree relative with colorectal cancer \< 60
* Ulcerative colitis proximal to splenic flexure or crohns colitis
* Left sided UC
Avg risk
* At 50 Q19 y
* Fit 3 yearly
* Stoll DNA q5y
* Double contrast barium enema / CT colongraphy Q5y
1st degree relative with colorectal cancer \< 60
* AT 40 start or 10 \< earliest family dx then Q5Y
Ulcerative colitis proximal to splenic flexure or crohns colitis
* 8yrs after start dz then yearly
Left sided UC
* 12 yrs after start dz then yearly
33
Gastric Adenocarcinoma
• Usually diagnosed after symptoms • Most with symptoms are advanced • Abdominal pain, nausea, satiety, wt loss • Most common of the gastric neoplasms - with recent trend of increase in proximal stomach near junction of esophagus and stomach
34
Chronic atrophic gastritis vs Zollinger Ellison Syndrome
Gastrin levels
PH
pH will be lower in ZES if patient is off of ppIs
Otherwise Chronic atrophic gastritis possible
Gastrin in both could be \> 1000
35
Gastric cancer / Diagnosis and Staging
• Endoscopy, brush, and biopsy - CT and EUS for staging - Most have regional nodes or direct invasion • Treatment and survival - Surgical resection if possible Node-negative: 5-year survival 85-90% Node-positive: 5-10% Chemotherapy - adjuvant post-op chemo-radiation 5FU based with leucovorin
36
Gastric Carcinoid
• Single or multiple polypoid lesions in fundus or body of stomach • Common gastrin elevation / Generally benign behavior • Least common Gl site • Very rare to have carcinoid syndrome with this • Possible Board question: 60-year-old pt. with small polyp in stomach; Bx shows carcinoid; Treatment - snare it off Repeat EGD / once out of stomach it becomes malignant
37
C-Diff Recurrent Disease
* First recurrance
* Second recurrance
* subsequent relapses
* **First infection -** Metro 14 days
* **First recurrance** - Metro for non sever / vanc for severe illness
* **Second recurrance** - Pulsed tapering oral vanc for 6-7 wks
* **Subsequent relapses** - Vanc for 14 days + oral rifaximin for 14 days or fidaxomicin
38
Gastric Lymphoma
• Diffuse histiocytic lymphoma • Better prognosis than adenocarcinoma • MALT - H. pylori • Possible Board question - treat MALT with omeprazole/ amoxicillin/ clarithromycin and F/U
39
Gastrinoma / Zollinger-Ellison Syndrome
* Ulcer disease of upper Gl tract / 30% have diarrhea
* Non-beta islet cell tumor of pancreas or duodenal wall
* Marked increase gastric acid and elevated serum gastrin
* 20% MEN I
* Workup:
* Somatostatin-receptor scintigraphy and endoscopic ultrasound (EUS)
* Surgical exploration \* Remember: Most common cause of increased gastrin is achlorhydria ("no acid" means no inhibition of gastrin secretion) atrophic gastritis/PPI/chronic gastritis
40
Gastroesophageal Reflux Disease Complications:
1. Ulcerative esophagitis
2. Bleeding
3. Stricture
4. Barrett's esophagus
41
Bacterial overgrowth
DM entropathy with painless and water diarrhea (at nights)
Fecal inconinence and some times with laternating normal Bowel movemnets or constipation.
42
Gastroparesis / Dx
Associated symptoms: Nausea, vomiting, abdominal pain, satiety, fullness Diagnosis confirmed by gastric emptying scan But, always exclude obstruction with EGD
43
GERD
Factors in pathogenesis
Factors in pathogenesis
* 1. Lower esophageal sphincter / - Defective or transient relaxation
* 2. Hiatal hernia
* 3. Poor esophageal clearance
* 4. Delayed gastric emptying
* 5. Association with BMI
44
GERD / Ulcerative esophagitis
Start with PPI qd / Re-scope to assess healing and exclude Barrett's esophagitis If persistent esophagitis: change PPI to bid Indefinite maintenance treatment - up to 80% recur off meds
45
Giardiasis
* Diarrhea
* Steatorrhea
* Abdominal crams and gas
* weight loss with good input
* Tx: Metro
46
HAV post exposure prophylaxis
HAV vaccine preferred over IG
47
HCV genotype I treatment
* Triple therapy
* Interferon, ribavirin and telaprevir
48
GERD Tx:
EGD if alarm symptoms, especially dysphagia, weight loss, heme+ stools
24-hour pH study - helpful in atypical cases, like refractory symptoms and normal EGD, or atypical symptoms like cough, hoarseness
49
Helicobacter pylori
* If Bx choronic gastritis / order serology and treate if needed Related to Gastritis
* PUD
* gastric adenocarcinoma
* gastric B-cell lymphoma
* Mucosa-associated lymphoid tissue/MALT\* (B cell lymphoma)
* Infected pts:
* 15% lifetime PUD risk
* But chronic gastritis in all patients\*
* Reduced acid secretion in most pts
* Dyspeptic symptoms:
* **_To test and treat_**, if age less than 50 and no alarm symptoms
50
Hepatic injuries
Autoimmune
Irion overload
CHF
Insuline / metabolic
Toxin injury
Autoimmune
* AST and ALT 300-1000
Irion overload
* Feritin \> 1000
CHF
* JVD would be seen with edema / DOE etc
Insulin / metabolic
* NAFLD non alcoholic fatty liver disease /
* middle aged obese and metabolic sndrome.
Toxin injury
ALT \> 4-5 times normal
51
Hepatopulmonary Syndrome
Dx: Contrast Echo
Triad : Hypoxemia / liver Dz /Intrapulmonary vascular dialatation
Will see hypoxemia and cyanosis
52
High risk ulcers
active arterial bleeders
Non bleeding visible vessel
adherent clot
oozing without visible vessel
72 hr keepers
53
Autoimmune hepatitis
serologic markers
False positives
Tx
* Anti nuclear Antibodies
* Anti smooth muscle antibody ASMA
* Anti Liver Kidney Microsomal LKM1
* Liver Cytosol
* Positive HCV ab - check with RNA
* Positive AMA
* Liver bx will show piece meal necrosis
54
When can a 24-hour pH study help?
60-year-old with 3 years of cough
EGD shows hernia but no esophagitis
PPI doesn't help
55
IBD Treatment Overview ABX:
• Metronidazole - Crohn's: Perianal abscess, fistula • Occ'l maintenance use - Ulcerative colitis: Only if peritonitis, toxic megacolon, pouchitis - Side effects, esp. neuropathy, limit long-term use - Ciprofloxacin also used
56
Alarm Symptoms
* Over 40
* Dysphagia
* Family history
* Weight loss
* Epigastric pain
* Anemia, iron deficiency (start workup from below, usually colonoscopy)
* Some occult Gl bleeding
* Follow up gastric adenoma, carcinoid
57
IBD: Treatment • Tumor necrosis factor (TNF) antagonists
IBD: Treatment • Tumor necrosis factor (TNF) antagonists - Infliximab, adalimumab, and certolizumab - Indications: Fistulous Crohn's, moderate-to-severe active Crohn's, and refractory UC - Generally requires ongoing treatment - Screen for TB before treating - Lymphoma Possible Board Question / Most common side effect from infJiximab? is Arthralgias
58
IBD: Treatment Overview • Immunosuppressants
• Immunosuppressants - Azathioprine and 6MP and methotrexate - Value as steroid-sparing - Maintenance agent - Takes 3-4 months to start working - Bone marrow suppression, esp. WBC - monthly CBC first year - Use for Crohn's or UC - Raises risk of lymphoma (so do anti-TNFs) - Board fodder ---Methotraxate not good for UC \*\*\*\*
59
Aortic valve stenosis
AVM formation
AS: Ejection type midsystolic mumur
TR / MR/VSD (holosystolic mumur)
AR Diastolic decresendo
MS mid diastolic rumble
60
IBD: Treatment Overview / Budesonide
IBD Treatment: Budesonide • Enteric-coated • Ileal Crohn's • Mild-to-moderate disease
61
IBD: Treatment Overview / Mesalamine (5-ASA)
Mesalamine (5-ASA) - Oral and enema preparations - Oral forms have delayed absorption • May be useful for Crohn's, even if small bowel disease and ulcerative colitis • / reserve for very mild Crohn's of the small bowel • Use in acute or maintenance • Side effect: Interstitial nephritis - follow kidney function
62
Ascites due to portal hypertension
SAAG \> 1.1
* Alcohol cessation
* Avoid ACEi / NSAIDs
* Sodium restricitons
Serum sodium \< 120
* Yes : fliud restriction / vasopressin receptor agonist
* No: Lasix 40 + aldactone 100 increase dose weekly
Refracotry ascites after Lasix/aldacton
* Hypotensive : Midodrine
* Normotensive: Consider Tips
63
IBD: Treatment Overview / Sulfasalazine
Sulfasalazine - Split by colonic bacteria - 5-ASA and sulfapyridine - Not very effective in small bowel - only in colon - Sulfa portion: Side effects, allergy (leukopenia, oligospermia) - Use in acute or maintenance
64
IBS
Meds for
Diarrhea
Constipation
**All IBS patients:**
* Antispasmodics: Dicyclomin, hyoscyamine
* TCA and SSRI
* Cognitive dynamic psychotherapy
**Diarrhea**
* Loperamid
* Rifaximine
* Alosetron
**Constipation**
* Lubiprostone
* Linaclotide
65
Inflammatory Bowel Disease
• Microscopic and collagenous colitis
66
Liver nodules
* \< 1 cm - repeat US in 4 months
* \> 1 cm 4 phase MDCT or MRI with contrast
* if positive then HCC
* else many need bx
67
Malignancies of the Stomach
• Carcinoid • Adenocarcinoma • Lymphoma • GIST-stromal tumor
68
Manage achalasia.
Surgical release of the lower esophageal sphincter by laparoscopic myotomy is first-line therapy for achalasia.
69
Methylnaltrexone
Methylnaltrexone has been found to help with opioid-induced constipation without negating the beneficial effects of the analgesia.
70
Non neoplasti polyps
Hyperplastic
Submucosal
inflammatory
mucosal
71
Odynophagia
* Rare for common entities of stricture, Schatzki ring\*
* Infections:
* CMV
* Candida / Treat first
* Herpes
* Medication-induced
* ASA, NSAIDs
* Doxycycline
* KCI,
* FeSO4
* alendronate
* quinidine
72
Osler-Weber-Rendu
Hereditary hemorrhagic telangiectasia)
telangiectasia of fingers and nasal and oral mucosa; history of nosebleeds; familial
73
PD peritonitis
* Common symptoms
* ABD pain
* Fever\> 37.5
* Nausea / Diarrhea
Intraperitoneal vanc and cefepime
74
Manage an incidentally discovered high-risk gallbladder polyp.
A polypoid lesion of the gallbladder that is larger than 10 mm has a 45% to 67% likelihood of cancer, and surgical resection of the gallbladder should be performed.
75
Peginterferon HEP C treatment Side effects
Bone Marro suppresion
Flu like symptoms (f, HA, malaise) worse the first 48 hrs and disappear after 3 months
Neuropsychiatric disturbances
76
Pentat
Cholangitis
Fever, RUQ pain, Jaundice
AMS, leukocytosis
Will need a ERCP within 24-48 hrs
77
Peutz-Jeghers
* perioral pigmentation; hamartomas of Gl tract can bleed
* Interstitial Cancer increased in chance
* Csope at 18 and EGD at 8 yrs old
78
Lower Esophageal Ring / Schatzki RingTreatment:
Treatment:
Dilation / PPI after dilation
79
PeutzJephers
Hmartomatous GI tract polyps
Pigmented mucocutaneous papules
Risk of malignancy (GI and non GI)
I
80
Post treatment of Hpylori
Tx
Test
* Stool antigen test for H. pylori
* Remember to confirm eradication
* Take patients off of ppi before the tests
81
Pregnancy and reflux
Acid reducing therapy
PPI
H2 inhibitors
82
Pregnancy fucking numbers ?
* Hb
* WBC
* D-Dimer
* INR
* ALT
* AST
* ALP or ALK
* Albumin
* LDH
* BUN
* ESR
* Hb Down 9.5-15
* WBC up
* D-Dimer UP 1.3-1.7
* INR
* ALT down 2-25
* AST down 4-32
* ALP or ALK UP 38-229
* Albumin Mild 2.3-4.2
* LDH UP 82-250
* BUN Down
* ESR UP 13-70
83
Primary billiary cirrhosis
Tx: Ursodeoxycholic acid treatment of choice
84
Acute pancreatitis with \> 30% necrosis
* IV hydartation with entral nutrition and phrophylactic antibiotics
* no improvment - CT guided aspiration
85
Primary Scelerosing Cholangitis
* Associated with which dz
* What kinda of screening is needed
* IBD - Ulcerative colitis
* Will need colonoscopyQ5 yrs to screen for colon cancer.
86
Psuedocyst
* Lipase will be elevated (may not have N/V with this)
* abd fullness
* most resolve by themselves
87
PUD Treatment: H. pylori
1. PPI + bismuth + metronidazole + tetracycline: 95%
2. PPI + amoxicillin + clarithromycin
3. \*\*\*\* CAP PPI + metronidazole + clarithromycin
88
Repeat colonocopy
1. 10 yrs
2. 5 yrs
3. 3 yrs
4. \< 3yrs
5. 2-6 months
1. smal recatal hyperplastic polyps
2. 1-2 \< 1 tubular adenomas
3. 3-10 adnomas or any \> 1 cm or high grade adenomas or villous futures
4. More than 10 adenomas
5. Large \> 2 cm sessile polyps
89
Dz associated with Restrictive cardiomyopathy
* Amyloidosis
* sarcoidosis
* hemochromatosis
90
ROME criteria for IBS
* \> 3 days a month for 3 montsh \> 2 of the following
* Improvement with BM
* Cahnge in freq of stool
* change in form of stool
91
S/P Diverticulitis
2-6 weeks best to have
* Colonscopy or
* Flexible simoidoscopy plus barium enema (if C-scope is not tolerated)
92
Abnormal AST / ALT
Rule out most common dz
Drug induced Hepatitis
HEP B and C
ETOH abuse AST / ALT 2:1
Fatty liver dz AST/ALT \< 1
Hemochromatosis
93
Scleroderma and the Esophagus
Cause
Dx
Tx
* Incompetent LES, poor peristalsis
* At risk for severe GERD
* Dysphagia can be due to esophagitis, stricture, or just poor motility
* **_Work up if dysphagia_**:
* Barium swallow and EGD
* Important to assess for GERD complications
* **_Only treatment_** is PPI
94
Seriouse C-Diff infection
WBC ? 20000
LACTATE \> 2.2
Toxic Megacolon
Severe ileus
95
Small intestinal Bacterial overgrowth
Sx: ABD pain, diarrhea, bloating, excess flatulenc, malabsorption, weight loss, anemia, nutritional def
Dx: endoscopy gold with jejunal aspirate
Glucose breath hydrogen testing
Tx: Avoid antimotility agents
Dietary change high fat low carb
Trial of metoclopramide
7 day course of Abs Rifaximin
96
Squamous Cell Esophageal Cancer
* **_Location_**: Proximal 2/3 of esophagus
* Smoking and alcohol are risk factors
* Other risk factors: Lye stricture, other head and neck malignancy
97
STool osmolol gap
**Stool Osm** - **2 \* (Na+K)** =
* \< 60
* 50-126
* \> 125
* Secretory diarrhea
* inflam diarrhea
* Indeterminate
* Osmotic diarrhea
* Magnesium citrate / lactulose
98
Suspect Gastrinoma
EGD shows multiple stomach ulcers
Check Gastrin
Gastrin level \< 110
Gastrin 110-1000
Gastrin \> 1000
99
Treat a patient with large esophageal varices ?
Small varices are usually less than 5 mm in diameter and easily flatten with air insufflation during endoscopy. Large varices are larger than 5 mm or persist despite air insufflation. The presence of red wale markings (longitudinal red streaks on varices) indicates an increased risk of rupture.
100
Treat a patient with microscopic colitis.
The first step in treatment of a patient with microscopic colitis is to stop any potentially causative drugs; the most commonly implicated drugs are lansoprazole, NSAIDs, sertraline, ranitidine, ticlopidine, and acarbose.
Colonoscopy reveals normal-appearing colonic mucosa, but colonic biopsies disclose an abnormally thickened subepithelial collagen band in the lamina propria.
101
Treat refractory hepatic encephalopathy.
Patients with refractory hepatic encephalopathy despite lactulose therapy may benefit from the addition of rifaximin.
102
Treatment of gastroparesis
• \*limprove diabetes control • Diet: Liquid if severe, low fiber • Metoclopramide (dopamine antagonist) useful, except for side effects such as tardive dyskinesia • Erythromycin (motilin agonist): Not indicated but does cause strong gastric contractions Domperidone : only from canada
103
UGI Hemorrhage
Current role for IV PPI in Gl bleed?
* Use for 72 hours in any patient with endoscopic therapy Other causes
* Mallory-Weiss tear
* Esophageal varices
* Aorto-enteric fistula - always remember this if the patient has a past history of abdominal aortic aneurysm (AAA) repair; Presents with melena, then severe hemorrhage
* Osler-Weber-Rendu (hereditary hemorrhagic telangiectasia), telangiectasia of fingers and nasal and oral mucosa; history of nosebleeds; familial
* Peutz-Jeghers perioral pigmentation; hamartomas of Gl tract can bleed
104
Ulcerative Colitis / Clinical
Clinical: • Main symptoms: Bloody diarrhea, abdominal pain • Variable extent - Proctitis: Rectum only - Proctosigmoiditis - Extensive colitis (pancolitis) • Constitutional Sxs. extraintestinal: \*Common 40%
105
Ulcerative colitis flare
After working up infectious causes
(ecoli / salmonella/ shigella / C difficile / Campylobacter)
Treat with IV steriods 20 mg 2-3 times daily
Complete response - change to oral steriods
partial - continue for 5-7 days and reassess
no Response on Day 3 (colectomy or / rescue pharm with cyclosporine or infliximab
106
Ulcerative Colitis Extraintestinal Manifestations:
• Relates to colonic disease • Peripheral polyarthritis (RF negative) • Ankylosing spondylitis (HLA-B27) • Skin lesions (E. nodosum, pyoderma) • Eye: Iritis, episcleritis, uveitis • \*HLA association tends not to improve with colitis Tx • \*Not unique to UC; seen with Crohn's
107
UPPER GI bleed
EGD assessment not treatment
Tx: Blood + resuscitate
108
Ursodeoxycholic acid
Reduces hepatic cholesterol secretion and fractional intestinal cholesterol reabsorption to decrease billiary cholesterol content. Help to prevent and desolve gallstones in primary biliary cirrhosis.
109
Variceal Hemorrhage
1. Volume resuscitation / IV octreotide or terlipressi + Abx
2. Endoscopy for sclerotherapy or band ligation
3. if not successfull temp. used **Balloon temponade**
4. **Tips** for shunt surgery (Transjugular intrahepatic postosystemic shunt)
110
Wilson's Dz
liver dz
neuropsychiatric
* Chronic hapatitis +elevated liver functions
* portal hypertension
* acute liver failure
* parkinson tremor
* bradykinesia
* cognitive impairment and mood disorder
* Abnormal gait
* Dysartheria
Non immune hemolytic anemia
111
Zollinger-Ellison syndrome
* Chronic diarrhea accompanies either bad esophagitis or peptic ulcer disease
* Fasting serum gastrin after stopping the omeprazole for 7 days
112
• Perirectal fistula with Crohn's What medication do you use?
Mesalamine, 6MP, infliximab, steroids I think the answer is infliximab
113
114
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