Pancreas

Posted on 8 August، 201913 August، 2019 Tagged GILeave a comment

Pancreatitis

· This is for the medicine folks

· Chronic pancreatitis –> NEVER SURGICAL

· Pancreatitis

o When to do CT?

Pancreatic adenocarcinoma:

RF	· Smoking · Rx pancreatitis for whatever reason · Obesity and lack of physical activity
S/S	· Weight loss · Abdominal pain (tenderness) · Jaundice (if obstructive) · Recent dx of atypical DM · Migratory superficial thrombophlebitis · Hepatomegaly and ascites (mets)
Dx	· Cholestasis (↑ ALP and direct bilirubin) · ↑Cancer-associated antigen 19-9 · Abdominal ultrasound (if jaundiced) or CT scan (if no jaundice)

Liver/Jaundice

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HCC:	· Cirrhosis / Hep C+B · Vague RUQ pain + weight loss + a-fetoprotein · Tx: resection is possible
Mets to liver:	· Suspect if multiple · ⤴️ CEA in colon cancer · Dx: CT · Tx: resection if possible
Hep Adenoma:	· OCPs · Tendency to rupture (presents w/ hypotension) · Dx: US → CT · Tx: stop OCPs + Surgery
Abscess:	· Pain + fever · Happen w/ biliary tree pathologies (ascending cholangitis) · Dx: US or CT · Tx: Drainage o If u suspect Ameoba (mexico, Clx suspected) –> Metronidazole (cont if clx imrovement) o –(didn’t improve)–> drainage.

Jaundice:

Screen Shot 2019-08-13 at 9.45.43 AM

Gallbladder

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	Benign Postoperative cholestasis
Features	Post prolonged surgery
S/S	Asx
Dx	US
Tx	Nothing. This will go with time.

Tx of Gallstones
w/o sx	· No treatment necessary in most patients
w/ typical biliary colic sx	· Elective laparoscopic cholecystectomy · Possible ursodeoxycholic acid in poor surgical candidates
Complicated gallstones disease (acute cholecystitis, choledocholithiasis, gallstone pancreatitis)	· Cholecystectomy within 72 hours

	Emphysematous cholecystitis
RF	· DM · Vascular compromise · Immunosuppression
Clx	· Fever, RUQ pain, N/V · Crepitus in abdominal wall adjacent to gallbladder
Dx	· Air-fluid levels in gallbladder, gas in gallbladder wall · Cx with gas-forming Clostridium, Escherichia coli · Unconjugated hyperbilirubinemia · Mildly elevated aminotransferases
Tx	· Emergency cholecystectomy · Broad-spectrum ABx with Clostridium coverage (e.g., piperacillin-tazobactam)

	Acute cholangitis
Clx	· ∆ fever, jaundice, RUQ pain
Dx	· LFT o ↑ direct bilirubin and ALP o Mildly ↑ aminotransferases · Biliary dilation on US/CT
Tx	1˚ Abx coverage of enteric bacteria 2˚ ERCP within 24-48 hours

Colon

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COLON CA

· family history

· IBD

· colorectal polyps

· low fiber, high fat diet (now controversial)

· diet low in vitamin A, E, C, and selenium

S/S

Ⓡ

Ⓛ

· typically shows up with anemia (hypochromic, iron deficiency)

· the right age group (elderly), for no good reason.

· Stools will be 4+ for occult blood.

· Colonoscopy and biopsies are diagnostic;

· surgery (right hemicolectomy) is treatment of choice.

· typically shows with bloody bowel movements. Blood coats the outside of the stool,

· there may be constipation,

· stools may have narrow caliber.

· Flexible proctosigmoidoscopic exam (45 or 60 cm) and biopsies are usually the first diagnostic study.

· Before surgery is done, full colonoscopy is needed to rule out synchronous second primary.

· CT scan helps assess operability and extent.

· Pre-op chemotherapy and radiation may be needed for large rectal cancers.

· Colonoscopy + Bx

· Evaluate for mets w/ CT

Classification	Description	5y survival
Duke A	Tumor limited to mucosa or submucosa (mus. propia)	80%
Duke B1	Tumor invades but not through muscle wall	60%
Duke B2	Tumor penetrates entire wall but no node involvement.	55%
Duke C1	Tumor into but not through wall but positive lymph nodes	30%
Duke D	Distant metastasis regardless of invasion	<5%

Resection

PPx

PREVENT COLON CA?

If there is Aspirin in the choices choose it, then choose fiber, then go with vitamin D.

Prog

Regardless of stage, the overall five year survival is 35%

Crohn’s

· Crohn’s disease is surgically treated only when there are complications such as bleeding, stricture, or fistulization.

· We can tx it surgically, but it’s not a wise choice (stoma or illioanal anastomosis are not very nice)

· When to tx surgically?

o active disease for more than 20 years (malignant degeneration),

o severe nutritional depletion,

o multiple hospitalizations,

o need for high-dose steroids or immunosuppressants

o development of toxic megacolon (fever, leukocytosis, abdominal pain and tenderness, and massively dilated colon with gas within the wall).

Pseudomembranous enterocolitis

· caused by overgrowth of Clostridium difficile in patients who have been on antibiotics.

· Any antibiotic can do it. Clindamycin was the first one described, and, currently, cephalosporins are the most common cause.

· There is profuse, watery diarrhea, crampy abdominal pain, fever, and leukocytosis.

· The diagnosis is best made by identifying the toxin in the stool.

· The culpable antibiotic should be discontinued, and no antidiarrheals should be used.

· Metronidazole is the treatment of choice, with vancomycin serving as an alternate.

· A virulent form of the disease, unresponsive to treatment, with a WBC above 50,000 and serum lactate above 5, requires emergency colectomy.

Sigmoid volvulus:

· Old pt

· S/S of obsturction

· Dx: KUB (Parrot’s peak) –> Air-fluid level + dilated colon + SB

· Tx: proctosigmoidoscopy

· If rx –> remove affecetd segment

GI Bleeding

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UGIB

	UGIB
Features	· proximal to ligament of Treitz · Multiple causes: · PUD · Varices · Mallory weiss tear
S/S	Bleeding from mouth
Dx	· H&P · CBC · NGT · Endoscopy
Tx	· 1˚ ABC · intubation may be indicated · IVF · blood transfusions to raise hematocrit / hemodynamic instability (7) · 2˚ Treat U/C · PPIs for PUD · octreotide for varices · Surgical intervention · varices: endoscopic banding/sclerotherapy · Transjugular intrahepatic portasystemic shunt (TIPS) · consider in patients with recurrent variceal bleeding (3rd episode)

LGIB

	LGIB
Features	· distal to ligament of Treitz · Multiple causes: · mcc is diverticulosis · Hemorrhoids (rx surgery)
S/S	Bleeding from rectum
Dx	· Anoscope / sigmoidoscopy / colonoscopy · if bleeding minimal and patient is stable · if pt is over 40 and no warning signs, → colonoscopy to r/o malignancy · NGT or endoscopy → r/o UGIB · Angiography · Tagged-RBC study
Tx	· 1˚ Stabilize patient (ABC), give fluids, type and cross · IV fluids and transfusions for hemodynamic stability · When to transfuse blood? Hgb 7 / Hct 30 · When to give PLT? if less than 50

	Blood per rectum DDx
Hemorrhoids	· Painless · Associated w/ bowel movement · Coats the stool
Anal fissures	· PAINFUL DEFECATION · Bright blood
Polyps	· Asx · Minimal bleeding
Proctitis	· Intermittent bleeding · Passage of mucus
Rectal ulcers	· Bleeding · Mucus · Straining during defecation
Cancer	· Hematochezia · Pain · Change in bowel habits

	Mesenteric Ischemia (MI of GI)
Features	· basically, gut MI · can be chronic or acute · Atherosclerosis RF (smoking, dyslipidemia)
S/S	· pain out of proportion to PEx · Postprandial, crampy · pt has hx of vasculopathy (angina) · pt avoids eating, because it hurts (sign of chronic mesenteric ischemia) · Weight loss
Dx	· CT Angio
Tx	· Resect if necrosis · Revascularize · Avoid RFs

	Ischemic colitis
Features	· watershed area · Most commonly involves splenic flexure · pt gets hypotensive, the area dies
S/S	In general, the initial presentation of patients with ischemic colitis includes the acute onset of lower abdominal pain, followed by bloody diarrhea within 12-24 hours.
Dx	Abdominal x-ray and CT scan of the abdomen may show changes such as thumb-printing (indicating submucosal edema) and hemorrhage. However, in the early stages, there are often no signs.

	Angiodysplasia
Features	· AV Malformation + dilated submucosal veins · Associated w/ Renal dz + VW factor defeciency · Also Associated w/ AS (can cause VW factor defeciency) · Common in Right colon, but can happens anywhere in GI tract
S/S	· Painless bleeding · Bleeding is slow (melena), not usually fresh blood · DDx from others by: · No anal sx (hemorrhoids) · No diverticula or masses on colonoscopy (Cancer/ diverticulosis) · Bleeding of diverticulosis is usually heavier
Dx	· Colonoscopy
Tx	· Asx: No Tx · Bleeding/Anemic: Endoscopy + cautery

GI Bleeding

Upper gastrointestinal bleeding (UGIB), likely due to NSAIDs drug use.

1˚ Large-bores + IVF

2˚ IV PPI

Stable + no comorbid conditions → if hgb <7 = RBC

A higher threshold of hemoglobin <9 g/dL can be considered for patients with acute coronary syndrome.

INR >1.6 = FFP

Severe coagulopathy (liver dz, DIC) = FFP

– PPI ⤵️ Rebleeding and the need for transfusions, and help stabilize clots in patients with UGIB.

– Somatostatin analogs such as octreotide are a mainstay in management of variceal bleeding.

– PLT <50k + ACTIVE BLEEDING = give PLT

– PLT <10k regardless of bleeding = give PLT

Extrapoints

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New Onset ascites, what to do next?	· Abdominal US (can be d/t acute obstruction by HCC) · In pts w/ Ascites, routine US is recommened q 6 months
Does cirhosis cause hypogonadism?	Yes, by 3 mechanisms: 1. ❌ HPA axis 2. ❌ Testicles 3. ⤴️ Estriol
Lactose intolerance is characterized by?	· ⊕ Hydrogen breath test · ⊕ STOOL test for reducing substance · ⤵️ Stool PH · ⤴️ Osmotic gap
What’s a vascular ring?	Vascular rings encompass congenital malformations of the aortic arch system that encircle the trachea and/or esophagus and cause compressive symptoms. Vascular rings can also present with esophageal compression symptoms, as in this patient with severe solid-food dysphagia.
Upper GI bleeding and BUN:Cr?	BUN/Cr ⤴️
endoscopic findings in ischemic colitis?	pale mucosa / patechial bleeding / hemorrhagic nodules & ulcers / cyanotic mucosa
Shigella Abx choice?	· Ciprofloxacin · Ceftriaxone · Azithromycin
Splenic Abscess?	Post-cholecystectomy. Sx: A (Fever, LUQ Pain, +1- Splenomegaly) Dx: CT Tx: Abx + Splenectomy (not drainage)
How to dx Acute liver failure?	These 3 things should be there: 1. ⤴️ LFTs >1000 2. Hepatic encephalopathy 3. Liver synthetic dysfunction (🆎 PT)
Tx of severe Alcoholic hepatitis?	Prednisone (presents w/ ∆: Fever / Abd pain / Jaundice / ⊕ PMHx of Alcohol)
Tx of chronic Hep c?	1. Stop Alcohol 2. Vaccinate against Hep A + B 3. Anti-HCV 💊 (Sofosbuvir + Lamo)
HCV Dx	2 Step Process: 1˚ Serology → Confirm: Molecular (PCR) After confirmation: Liver Bx: check extent of fibrosis Tx: ledipasvir-sofosbuvir
ERCP indications?	· Sphincterotomy · Stone removal · In pt w/ GS pancreatitis & cholangitis
Tx of Toxic Megacolon?	Bowel rest / NGT / Abx (*Against C.diff: vancomycin + metronidazole*)
Hypersplenism?	· Concequence of Cirrhosis · portal HTN · Splenomegaly · leads to thrombocytopenia
Asx pt presents w/ ⤴️ LFT?	1˚ Take more hx 2˚ Rx tests w/i 6 months → if 🆎 → Keep investigations 3˚ Serology (viral hepatitis) / Hemochromatosis / fatty liver 4˚ TSH + Muscle do
Pt w/ UGIB, when to transfuse blood?	Hgb <7
Abdominal Succession splash?	Test for gastric outlet obsruction
Alcoholic liver dz dx?	Alcoholic liver disease is generally characterized by modest elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT), usually <300 IU/L and almost always <500 IU/L. A ratio of AST to ALT ⤴️ GGT \| ⤴️ Ferritin
Conjugated bilirubinemia?	>2 direct bilirubin >20% of total bilirubin is direct bilirubin

Viral Hepatitis

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	Viral Hepatitis
👾	· Hep A: Feco-oral · Hep B + C: Blood / sex
Path	Viral infection of liver parynchma
Clx	· Jaundice + Fever · Dark urine · HSM · weight loss, and fatigue
Dx	· LFT: ⤴️ direct bilirubin / ALP / AST&ALT · Serology (for all except hep B): · IgM antibody for the acute infection · IgG antibody to detect resolution of infection. · Disease activity of hepatitis C is assessed with PCR for RNA level · Hep B: u know it
Tx	· Hepatitis A and E resolve spontaneously · Tx only Hep C: · Genotype 1: ledipasvir and sofosbuvir · Other genotype: sofosbuvir and velpatasvir · Tx of Chronic Hep B: · positive for e-antigen with an elevated level of DNA polymerase, treatment is any one of the following: entecavir, adefovir, lamivudine, telbivudine, interferon, or tenofovir.
Extra	· If pt has fibrosis on Bx (Hep b / c): start tx · In Hep C: If the PCR-RNA viral load is elevated, patients should be treated.

	Hepatitis C
Dx	· IgG + IgM · PCR RNA · Everyone born between 1945 and 1965 is tested for hepatitis C regardless of risk factors. · Viral load testing has nearly eliminated the need for liver biopsy.
Tx	· If the PCR-RNA viral load is elevated, patients should be treated. · If there is fibrosis on liver biopsy, initiating treatment becomes more urgent · Genotype 1 is treated with sofosbuvir + ledipasvir orally for 12 weeks. · The other genotypes are treated with sofosbuvir and velpatasvir orally. · Interferon is only used in treatment failure.

Gastritis & Peptic Ulcer Disease

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Epigastric pain

If this is in the history:	The most likely diagnosis is:
Pain WORSE with food	Gastric ulcer
Pain BETTER with food	Duodenal ulcer
Weight loss	Cancer, gastric ulcer
Tenderness	Pancreatitis
Bad taste, cough, hoarse	GERD
Diabetes, bloating	Gastroparesis
Nothing	Non-ulcer dyspepsia
Dx?	Only Endoscopy is good for dx.

Gastritis

Inflammation of gastric mucosa

Many causes:

1. Alcohol

2. NSAIDs

3. portal HTN

4. H.pylori

5. Acute: Trauma, burns, multiorgan failure

6. Atrophic gastritis (B12)

Chronic Atrophic Gastritis

Type A	Type B
· A: Anemia · Pernicous Anemia · Affects FB (fundus & body) · Low Acid → Acholrhydria → ⤴️ Gastrin · G cell hyperplasia · MCC of B12 def	· B: Bacteria · H.Pylori affects pylorus · Gastic + doudenal ulcers · ⤴️ Risk of MALT lymphoma

S/S

· PAINLESS Bleeding (upper or lower)

· ⊕ pain if erosive

· Endoscopy only

· Test for H.pylori

· PPI

PUD

H.pylori

NSAIDs

Doudenal or Gastric ulcers

S/S

· Epigastric burning pain

· +/- weight loss

· DU: more H. Pylori cases, associated with Zollinger.

· GU: more NSAIDs, associated with cancer.

· Endoscopy + Bx

· Test for H.pylori

· PPI

· if ⊕ H.pylori: triple therapy

	Advantage	Disadvantage
Endoscopic biopsy	most accurate + specific	Invasive
Serology	Most sensitive if ⊖ = exclude	⊕ doesnt ddx bw active infxn or previous infxn
Urea breath testing	⊕ only in active infection;	Requires expensive equipment in office
H. pylori stool antigen	⊕ only in active infection; noninvasive	Requires stool sample

How to test for eradication?

· STOOL Antigen

If Tx doesn’t resolve the issue:

· DU: Check resistance of H.pylori + change ABx

· GU: Endo + Bx (r/o cancer)

Complications

1. Perforation 🚨

1. Sudden SEVERE Abd pain + peritoneal sign

2. 1˚ KUB (air under diaghragm)

3. Tx: SURGERY

2. Cancer (Adenocarcinoma / MALT) → Bx → Surgery

Non-Ulcer Dyspepsia

Esophagus

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GERD

Path

· Decreased tone or excessive transient relaxations of LES

· Anatomic disruption to gastroesophageal junction (hiatal hernia)

· ⤴️ risk with obesity, pregnancy, smoking, alcohol intake

S/S

· Regurgitation of acidic material in mouth

· Heartburn

· Odynophagia (often indicates reflux esophagitis)

· Extraesophageal manifestations – cough, hoarseness, wheezing

· Esophageal – erosive esophagitis, Barrett esophagus, strictures

· Extraesophageal – asthma, laryngitis

Alarming Sx 🚨:

· >10 ys of sx

· Dysphagia

· Bleeding (heme ⊕ stool / hemoptysis / anemia)

· Unintentional weight loss

· >50

· when pt presents w/ sx → offer PPI for 6 weeks

· If no improvement –> endoscopy + Bx

· IF RED FLAGS (N&V / Anemia / weight loss / bleeding / >10 ys sx) –> endoscopy + bx

· GOLD STANDARD: 24h PH monitoring

	No alarm sx	Alarm Sx
>50 ys	Upper endoscopy	Upper endoscopy
Questionable GERD	24h pH test + manometry
Persistent sx depite tx
<50 ys (Clear GERD)	Upper endoscopy

· Mild (<2 Sx/Week): Antacids

· Moderate (>2 Sx/week): PPI

· ❌ Response: surgery

When u do endoscopy and its ⊕:

· If GERD: PPI

· If METAPLASIA/BARRET: PPI ⤴️ dose

· If DYSPLASIA: Local Ablation Tx

· If Adenocarcinoma: Stage (CT) → Resect → Chemo / radio

Finding	Tx
Barret	PPI & Rx endoscopy 2-3 ys
Low-grade dysplasia	PPI & Rx endoscopy 6-12 ms
High-grade dysplasia	Ablation w/ endoscopy

· When to do nissen fundoplication? when PPI fails, or pt wants surgery.

	Endoscopy – Esophagitis – Findings
Candida	⊕ Oral thrush – White plaques
CMV	Linear ulcers
HSV	Ovoid ulcers – Vesicles
Pill-induced	Round ulcers – ⓝ Surrounding

	Medication-induced Esophagitis
Drugs	Abx (Tetracycline) NSAIDs Bisphosphonates
Sx	Odynophagia – Sudden onset
EGD	Ulcer w/ NO surrounding erythema
Tx	Stop the drug

	Zenker’s Diverticulum
Features	· Elderly · Pouch
S/S	· Halitosis · Dysphagia · Regurgitation · ⤴️ Risk for Aspiration pneumonia
Dx	· Barium (SE: risk of pneumonitis) · Use of other methods is contraindicated ~ upper GI endoscopy, b/c it can cause perforation.
Tx	Surgical repair

	Eosinophilic esophagitis
Path	Chronic, immune-mediated esophageal inflammation
Clx	· Dysphagia · Chest/epigastric pain · Reflux/vomiting · Food impaction (steak / chicken) · Associated atopy
Dx	Endoscopy & esophageal bx (≥15 eosinophils)
Tx	· Dietary modification · ± Topical GCS

	Achalasia
S/S	· Chronic dysphagia to solids & liquids, · regurgitation · Heartbum, weight loss
Dx	· Manometry: ⤴️ LES resting pressure, incomplete LES relaxation, peristalsis of distal esophagus · Barium esophagram: Smooth “bird-beak” narrowing at gastroesophageal junction
Tx	Upper endoscopy to exclude malignancy Laparoscopic myotomy or pneumatic balloon dilation Botulinum toxin injection, nitrates & CCB

	Diffuse esophageal spasm
Path	Uncoordinated, simultaneous contractions of esophageal body
S/S	· Intermittent chest pain · Dysphagia for solids & liquids
Dx	· Manometry: Intermittent peristalsis, · Multiple Simultaneous Contractions · Esophagram: “Corkscrew” pattern
Tx	· CCB · Alternates. Nitrates or TCA

	Eosinophilic Esophagitis
RF	· ⊕ Allergy (asthma)
S/S	· Dysphagia, heartburn, · *Food impaction*
Dx	· Endoscopy shows RINGs · Bx: Eosinphils
Tx	· 1˚ PPI + eliminate allergic food · Failed? swallowing steroids inhalers

	Esophageal Cancer
Types	Adenocarcinoma · Distal esophagus, · Barrett esophagus Squamous cell carcinoma · Anywhere in the esophagus
RF	· Acid reflux, obesity (adenocarcinoma) · Smoking, alcohol, caustic injury (squamous cell)
Sx	· Chest pain · Weight loss · Dysphagla (solids)
Dx	· Endoscopy w/ bx · CT (PET/CT) for staging

ER:

	Esophageal Perforation
Causes	· Instrumentation (eg, endoscopy), trauma · Effort/vomiting rupture (Boerhaave syndrome) · Esophagitis (infectious/pills/caustic)
Clx	· Chest/back &/or epigastric pain, · Systemic signs (eg, fever) · Crepitus, Hamman sign (crunching sound on auscultation) · Pleural effusion with atypical (eg, green) fluid
Dx	CXR: widened mediastinum, pneumomediastinum, P TX, pleural effusion CT scan: esophageal wall thickening, mediastinal fluid collection Esophagography with water-soluble contrast: leak from perforation
Tx	· NPO, IV antibiotics & PPI · Emergency surgical consultation

	Mallory-Weiss	Boerhaave
?	· Forceful retching · Mucosal tear · Submucosal venous or arterial plexus bleeding	· Forceful retching · Transmural tear · Spillage of esophageal air/fluid into surrounding tissues
Clx	· Epigastric/back pain · Hematemesis (bright red or coffee-ground) · hypovolemia	· Chest/back/epigastric pain · Crepitus, crunching sound (Hamman sign) · Odynophagia, dyspnea, fever, sepsis
Dx	Upper GI endoscopy confirms diagnosis	· 1˚ CXR: PTX, pneumomediastinum, pleural effusion · Esophagography or CT scan with water-soluble contrast confirms dx
Tx	· Acid suppression · Most heal alone	· Acid suppression, Abx, NPO · Emergency surgery 🚨

	Mallory-Weiss
?	· Sudden increase in abdominal pressure (forceful retching) · Mucosal tear in esophagus or stomach (submucosal arterial or venous plexus bleeding)
RF	Hiatal hernia, alcoholism
S/S	Vomiting, retching Hematemesis Epigastric pain
Dx	Endoscopy: Longitudinal laceration
Tx	· Most heal spontaneously · Endoscopic therapy for persistent bleeding

Anal Diseases

Posted on 6 August، 2019 Tagged GILeave a comment

Check out GS Notes as well (More on Anal Diseases there).

	Anal & perianal masses
External hemorrhoid	· Dusky/purple lump or polyp · Associated itching, bleeding · Thrombosis: acute enlargement with pain
Internal hemorrhoid	· Intermittent itching, painless bleeding, leakage of stool · Detected with digital rectal exam or anoscopy (unless prolapsed)
Perianal abscess	· Fluctuant mass/swelling with erythema · Fever · Gradual onset
Anogenital wart	· Pink or flesh-colored papules, plaques, or cauliflower-shaped masses · Chronic onset · Mild itching, bleeding
Anorectal cancer	· Squamous cell carcinoma most common · Bleeding, pain · Ulcerating, enlarging mass
Skin tags	· Small, flesh-colored papules · May represent external terminus of anal fissure (sentinel tag)

	Anal fissures
Causes	· Local trauma (constipation, prolonged diarrhea, anal sex) · Inflammatory bowel disease (Crohn disease) · Malignancy
Clx	· Pain with bowel movements · Bright red blood on toilet paper or stool surface · Most conunon at posteriw anal midline · Chronic fissure may have skin tag at distal end
Tx	· High-fiber diet & adequate fluid intake · Stool softeners · Sitz baths · Topical anesthetics & vasodilators (nifedipine, nitroglycerin)

Fast HY Review

Tag: GI

Pancreas

Liver/Jaundice

Gallbladder

Colon

GI Bleeding

Extrapoints

Viral Hepatitis

Gastritis & Peptic Ulcer Disease

Esophagus

Anal Diseases