ROSH GI Qbank quizlet

Pyloric Stenosis

Pyloric Stenosis Patient will be 2 - 6-weeks-old Complaining of non-bilious projectile vomiting after feeding and early satiety PE will show RUQ olive-like mass (hypertrophied pylorus) Labs will show hypochloremic hypokalemic metabolic alkalosis Diagnosis is made by ultrasound or UGI series (string sign) Treatment is surgical

most common form of liver disease

Nonalcoholic fatty liver disease

Entero-hemorrhagic E.Coli (O157:H7)

(B) produces Shigella-like toxins that are cytotoxic to the intestinal vascular endothelium resulting in bloody diarrhea, abdominal cramping, and low-grade fever. Antibiotics and antimotility agents should not be used in cases of suspected enterohemorrhagic E. Coli as it may increase the chance of complications (e.g. hemolytic uremic syndrome).

c-diff

1st episode: po metronidazole or vanco, if ileus, and fulminant, do iv metro and vanco enema. 2nd episode: same as 1st additional relapse: pulsed tapered vanco Clostridioides Difficile Colitis (Pseudomembranous Colitis) Patient with a history of recent ABX use (clinda most common) Complaining of frequent watery stools, abdominal pain Diagnosis is made by nucleic acid amplification test (NAAT) Treatment is: Adults Nonsevere or severe - oral vancomycin or oral fidaxomicin Fulminant - oral vancomycin with parenteral metronidazole Children Nonsevere - oral vancomycin or oral metronidazole Severe or fulminant - oral vancomycin Comments: Patients with at least two Clostridioides difficile infection recurrences treated with appropriate antibiotic therapy, the guidelines recommend use of fecal microbiota transplantation

Acute Cholangitis

Acute Cholangitis Patient will be complaining of right upper quadrant pain, jaundice, fever (Charcot triad) Diagnosis is made by RUQ ultrasound, CT scan, or ERCP (Gold standard) Most commonly caused by choledocholithiasis leading to bacterial infection, E.coli Treatment is antibiotics, definitive treatment is ERCP with antibiotics typically an adjunct Comments: Charcot triad + hypotension and AMS = Reynolds pentad, acute obstruction

Yersinia enterocolitica

A 23-year-old man presents with abdominal pain, vomiting and two loose, nonbloody stools. Physical examination reveals right lower quadrant tenderness to palpation. A CT is performed showing a normal appendix and some inflammation at the ileocecal junction. What pathogen is commonly implicated in this disorder? Yersinia enterocolitica infection can cause an ileocecitis, which may mimic the signs and symptoms of acute appendicitis. Y. enterocolitica infection results from oral ingestion of the bacteria with subsequent invasion of intestinal mucosa. About 2/3 of patients present with features of gastroenteritis - diarrhea, nausea, vomiting, colicky abdominal pain and fever. About 1/3 of patients will present with minimal or no diarrhea and a clinical presentation similar to appendicitis. Y. enterocolitica infection is typically self limited and requires supportive care only mimic appendiciris What other gastrointestinal pathogen can give an appendicitis-like presentation? Answer: Entamoeba histolytica. Yersinia Enterocolitica Patient with a history of eating undercooked pork Complaining of RLQ pain, fever, vomiting and then diarrhea Labs will show fecal WBCs and RBCs

Traveler's diarrhea(entero-toxigenic Escherichia coli )

A 29-year-old pregnant patient presents with a three day history of diarrhea following a trip to Mexico. The patient describes having seven to eight loose, watery stools per day. She does not note any blood in the diarrhea and is otherwise asymptomatic. Vital signs are BP 116/72, HR 86, RR 15, T 38.7°C. Physical exam reveals mild dehydration, but is otherwise normal. After providing fluid replacement, what is the indicated treatment? azithromycin ciprofloxacin and azithromycin, \Rifaximin. Traveler's Diarrhea Patient with a history of recent travel Complaining of abrupt onset of watery diarrhea, nausea, and abdominal cramping Most commonly caused by entero-toxigenic Escherichia coli (ETEC) Treatment is rehydration and ciprofloxacin or azithromycin (pregnant women and children)

Norovirus

A 35-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea, which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar symptoms. Findings on examination are negative, and a stool specimen is negative for white blood cells. Which one of the following is the most likely cause of his illness? Norovirus Patient with a history of recent travel on a cruise ship Complaining of nausea, vomiting, and diarrhea Treatment is supportive Comments: most common cause of viral gastroenteritis

Cholera (Vibrio cholera.) rice water, dehydration

A 35-year-old previously healthy man presents to your office with a complaint of diarrhea 24 hours after returning from a mission trip to Sierra Leone. He endorses hourly bouts of large volumes of stool that now have a white-colored liquid appearance. Physical exam findings include decreased skin turgor, dry buccal mucous membranes and a rapid, thready radial pulse. Which of the following is the most appropriate next step in management? AAdminister intravenous fluids Cholera Patient with a history of drinking contaminated water Complaining of severe, watery diarrhea flecked with mucus "rice water" PE will show dehydration Diagnosis is made by stool culture or dark field microscopy Most commonly caused by Vibrio cholerae Treatment is supportive. Moderate to severe -fluoroquinolones,macrolides, and tetracyclines

Acute mesenteric ischemia

A 72-year-old man presents to the emergency department with a 6-hour history of severe, diffuse abdominal pain. He has a past medical history diabetes mellitus, hypertension, and colon cancer. Physical exam reveals an abdomen that is extremely tender to light palpation and an irregularly, irregular heart rate. Digital rectal exam is notable for grossly bloody mucous. Laboratory findings are notable for leukocytosis, metabolic acidosis, elevated amylase, and elevated lactate dehydrogenase LDH. Which of the following is the most likely diagnosis? What are potential causes of nonocclusive mesenteric ischemia? Answer: Septic shock, hypovolemia, potent vasopressors.---decreased blood flow to the artery.

lateral femoral cutaneous nerve

A proximal branch of the L2 and L3 roots, the lateral femoral cutaneous nerve (B) is a pure sensory nerve. It subserves the mid-proximal lateral thigh, not the inguinal region. Meralgia paresthetica.

external hemorrhoids

A short course of a topical steroid cream (e.g. hydrocortisone) or suppositories used twice daily has been shown to improve pain and diminish swelling associated with external hemorrhoids.

Abdominal Pain in the Elderly

Abdominal Pain in the Elderly Poor historians ↓ PE reliability Polypharmacy 50% admitted 33% have surgery 10% mortality Fever (C), elevated WBC counts (B) and peritoneal pain (D) are less common in older patients in comparison to younger patients.More likely to need an emergent surgical procedure Older patients with abdominal pain are more likely to harbor serious pathology but will often present atypically and progress rapidly. The decrease in diagnostic accuracy and increased rate of severe disease results in an increased mortality for older patients. In those older patients where specific causes are found, they are more likely to require a surgical procedure.

diverticulitis

Abscesses over 5 cm in diameter should either be drained percutaneously or surgically. Diverticulitis Patient will be complaining of abdominal pain that is localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits--constipation or diarrhea PE will show localized guarding, rigidity, and rebound tenderness Diagnosis is made by CT scan Treatment is abx inpatient treated and discharged,:Low fiber diet until 6 weeks of no symptoms. A low fiber diet is especially effective in cases of acute diverticulitis, because it helps reduce the frequency of stools and allows the affected portion of the colon to adequately heal. Complicated acute diverticulitis can lead to fistula formation most commonly with which organ? Answer: The urinary bladder. Steady pain is the most common symptom in acute diverticulitis, not colicky pain. Bowel habits are commonly altered with diverticulitis, with constipation being more common than diarrhea, although an alternation between the two is also common. Urinary symptoms can occur due to intestinal inflammation near the ureter or bladder. Although stool samples may be guaiac positive for occult blood, gross bleeding is unusual. peri-diverticular abscess? Answer: Percutaneous drainage. tx: Bowel rest, intravenous fluid hydration, broad-spectrum antibiotics.

screen ang bmi

According to the AAP guidelines, children with a body mass index (BMI) between 85th and 94th percentile should get a fasting lipid panel, ALT, AST, fasting glucose, and complete blood count to screen for diabetes, dyslipidemia, iron deficiency anemia, and other nutritional depletions. A BMI higher than the 95th percentile should also get an abdominal ultrasonography to evaluate for fatty liver, urinalysis to screen for type 2 diabetes, and potentially other specific tests, for instance if Prader-Willi is suspected. All children, no matter their BMI, should get a serum cholesterol assessment once in childhood if there is a family history of hypercholesteremia and once in adolescence no matter their family history.

Achalasia

Achalasia Patient will be complaining of dysphagia to solids and liquids PE will show absent peristalsis in the lower esophagus Barium swallow shows "bird beak" appearance Diagnosis is made by esophageal manometry - increased LES pressure

pseudo-obstruction, also known as Ogilvie's syndrome.

An 83-year-old man from a nursing home is sent for evaluation of abdominal distention and vomiting. Nursing home records report no bowel movement for two days and no fevers. His X-ray is shown above. On CT scan, no obstructing lesion is identified. What of the following may be beneficial in relieving this condition? The X-ray demonstrates massive dilation of the colon through the cecum consistent with a large bowel obstruction. However, CT scan does not show any obstructing lesion and therefore this is a pseudo-obstruction, also known as Ogilvie's syndrome. The exact mechanism of the development of pseudo-obstruction is unknown but suspected to result from malfunction of the autonomic control of the bowel. Patients often have multiple other co-morbid conditions and risk factors include nursing home residence, anticholinergic medication, severe electrolyte disturbance, narcotic exposure, or a history of spine or retroperitoneal trauma. This is a diagnosis of exclusion. Patients may first be treated with a rectal tube and sigmoidoscopy and managed conservatively in the hospital. Neostigmine may be used as a pharmacologic intervention as it is an acetylcholinesterase inhibitor. It is not recommended in patients with a heart rate less than 60 bpm, systolic pressure less than 90 mm Hg or active bronchospasm. Patients receiving neostigmine should be on a cardiac monitor and atropine should be at the bedside. neostigmine side effect: Answer: Bradycardia and asystole. Nasogastric tube is also an option and is used in mild to moderate cases of Ogilvie syndrome. A nasogastric tube should be avoided with signs of ischemia or perforation or when the cecum is > 12 cm in diameter. Ogilvie Syndrome Massive dilation of colon without mechanical obstruction autonomic dysfunction Risk factors: elderly, bedbound, comorbidities Rx: colonic decompression, neostigmine

no Abx use in child with bloody diarrhea, but negaitve still culture Hemolytic Uremic Syndrome (HUS)

Antibiotics and antidiarrheal agents should be avoided in children who have hemorrhagic diarrhea because both agents may increase subsequent risk of developing HUS. Hemolytic uremic syndrome (HUS) ischaracterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS is the leading cause of renal failure in children in the United States. HUS is characterized by a prodrome of abdominal pain and bloody diarrhea. It develops 2-14 days after the start of diarrhea. It is associated with pallor with a petechial or purpural rash, decreased urine output, and rarely CNS symptoms. HUS is most commonly caused by Shiga toxinproducing E. coli; one well-known serotype is O157:H7. The CDC recommends that all patients with bloody diarrhea be tested for E. coli O157:H7 as part of the standard stool culture. What clinically distinguishes hemolytic uremic syndrome (HUS) from thrombocytopenic thrombotic purpura (TTP)? Answer: HUS causes less change in mental status and more renal dysfunction. Patients with HUS tend to be younger, and onset is associated with bacterial gastroenteritis. Hemolytic Uremic Syndrome (HUS) Patient will be complaining of bloody diarrhea Labs will show Anemia, Renal failure, Thrombocytopenia (ART) Most commonly caused by E. coli O157:H7 Treatment is supportive Comments: Avoid ABX

Primary biliary cirrhosis

Antimitochondrial antibodies

herniorrhaphy, hernioplasty

Any incision has the possibility of causing cutaneous nerve damage and irritation, which is referred to as inguinodynia or post-herniorrhaphy pain syndrome. Due to this problematic complication, herniorrhaphy is typically reserved for complicated cases, while watchful waiting is recommended is most non-strangulated, minimally symptomatic inguinal hernias. The most common irritated nerves are those in this region, namely the ilioinguinal, iliohypogastric and genitofemoral nerves. The ventral ramus of the L1 spinal root, and to a lesser extent the T12 spinal root, eventually becomes the ilioinguinal and iliohypogastric nerves. These nerves mainly provide sensation to the anterior L1 dermatome, mostly in the region of the inguinal ligament (commonly referred to as the "beltline").

Appendicitis

Appendicitis Patient will be complaining of fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia PE will show Psoas sign (RLQ pain on extension of right hip), Obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (right lower quadrant pain when the left lower quadrant is palpated) Diagnosis is made by ultrasound, CT Most commonly caused by fecalith. but this is not mc finding in OR, only 10% pt will present this. Treatment is surgery What are signs of a perforated appendix? Answer: Temperature > 103.0°F, WBC > 15K, fluid collection in the RLQ seen on imaging. pregnant patients to experience pain due to appendicitis? The right upper quadrant due to displacement of the appendix by the gravid uterus. Which of the following signs is indicative of a retrocecal location of the appendix?PSOAS which age group is perforation from appendicitis more likely? Answer: Children.

ascending cholangitis

Ascending cholangitis is characterized by fever, jaundice, and abdominal pain (Charcot triad); the addition of altered mentation and hypotension is known as Reynold's pentad. Both develop as a result of stasis of bile and bacterial infection in the biliary tract, and should be promptly addressed with intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) (D) to clear the duct. Acute Cholangitis Patient will be complaining of right upper quadrant pain, jaundice, fever (Charcot triad) Diagnosis is made by RUQ ultrasound, CT scan, or ERCP (Gold standard) Most commonly caused by choledocholithiasis leading to bacterial infection, E.coli Treatment is antibiotics, definitive treatment is ERCP with antibiotics typically an adjunct Comments: Charcot triad + hypotension and AMS = Reynolds pentad, acute obstruction

hepatitis

Autoimmune hepatitis: young females Alcoholic hepatitis: moderate transaminase elevation, AST > ALT (2:1) Supportive rx hep B .----> carcinoma 20-45%, more if the virus was parenterally transmitted. Which of the hepatitis viruses is the only one which is a DNA virus? Answer: Hepatitis B. Aplastic anemia is a known complication of acute hepatitis WBC decreased, RBC decreased, platelets decreased,seen 6-12 weeks after hepatitis,autoimmune bone marrow failure.

Boerhaave Syndrome

Boerhaave Syndrome Patient will be complaining of severe chest pain PE will show Hamman's crunch (mediastinal crackling with each heartbeat) Chest X-ray will show pneumomediastinum Diagnosis is made by esophogram with water-soluble oral contrast Most commonly caused by a full-thickness esophageal rupture due to iatrogenic > forceful vomiting Most common location is left posterolateral distal esophagus Treatment is emergent surgical consult and broad-spectrum antibiotics What is the most common complication of Boerhaave syndrome? Answer: Mediastinitis.

nsaids for pud

Celecoxib, or Celebrex®, selectively inhibits cyclooxygenase-2, making it moderately safer to use in patients at risk for gastrointestinal bleeding.

Cholecystitis

Cholecystitis Patient will be an overweight (Fat),Fertile,Female in her Forties (4Fs) Complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy's sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula) Diagnosis is made by:Initial - USGold standard - HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy

Cholelithiasis/Choledocholithiasis

Cholelithiasis/Choledocholithiasis Patient will be an obese woman 40 - 50-years-old Complaining of slowly resolving right upper quadrant pain that begins suddenly after eating a fatty or large meal Diagnosis is made by ultrasound Most commonly made of cholesterol Treatment is observation or cholecystectomy Comments: Four "F's": Female, Forty, Fat, Fertile 20% will develop acute cholecystitis

sigmoid volvulus

Coffee bean sign.

even if you worry about colon cancer . do not do colonoscopy during diverticulitis.

Colonoscopy (D) to assess the extent of diverticular disease and exclude colon cancer is indicated in all patients with diverticulitis who have not had a colonoscopy in the last year. This should occur after complete resolution of the diverticulitis. Colonoscopy is not indicated in acute diverticulitis and colonoscopy before resolution of the diverticulitis increases the risk of bowel perforation and serious complications.

Colorectal Cancer

Colorectal Cancer Second leading cause of death Third most common cancer in men and women Adenocarcinoma Risk factors: age, IBD, adenomatous polyps, FAP, HNPCC/lynsch Rectosigmoid > ascending > descending Left-sided cancer: tends to obstruct Right-sided cancer: tends to bleed Iron deficiency anemia Colonoscopy CEA drugs that protective effect against colorectal cancer Answer: Aspirin and other nonsteroidal anti-inflammatory drugs.

Colorectal Cancer Screening (AAFP)

Colorectal Cancer Screening (AAFP) 50 until 75: colonoscopy q 10 year, or CT q 5 years, or flexi sigmoid q 5 years. 1 relative with colon cancer: colonoscopy at 40 or 10 years earlier Familial adenomatous polyposis: sigmoidoscopy at age 12, then every 1-2 years

intussusception

Contraindications to the use of air-contrast enema include hemodynamic instability with shock, free air under the diaphragm, and peritonitis. Children with these features need emergent surgical intervention. What is Dance's sign? Answer: Considered pathognomonic for intussusception: a sausage-like mass in the RUQ representing the actual intussusceptum and an empty space in the RLQ representing the movement of the cecum out of its normal position What rash is associated with Henoch-Schonlein purpura, a common cause of intussusception? Answer: Palpable purpura. intussusception Most commonly caused by a tumor or meckels diverticulum. You see 12 month old boy with non-bilious vomit, progressive lethargy, bloody stool, x-ray show air below diaphragm. you do surgical reduction. What childhood vaccine is a risk factor for the development of intussusception? Answer: Rotavirus. associated with Adenovirus. peak between 5-9 month old MC caused for diff age ---- Under five years of age, enlarged Peyer's patches secondary to recent viral illness /adenovirus are the most common lead point. ---- over age five, Meckel's diverticulum or HSP vasculitis. -----adultt: 65% of adult cases are due to tumors (either benign or malignant). Intussusception in adults Intussusception in adults is rare but when present, involves the small bowel in 80% of cases signs of chilren's does not show in adult they most have a lesion "pseudo-kidney sign?" On ultrasound, the intussuscepted segment may have an appearance similar to that of a kidney.

rebound tenderness (Blumberg's sign) is an indication of

Gangrenous or perforated bowel. peritonitis secondary to perforation

Gastritis

Gastritis Acute: NSAIDs > alcohol Type A chronic: pernicious anemia\ Type B chronic : H. pylori

Crohns Disease

Crohns Disease Patient will be complaining of chronic nonbloody diarrhea, crampy abdominal pain, and weight loss PE will show aphthous ulcers, anal fissures, perirectal abscesses, anorectal fistulas Labs will show ASCA positive, p-ANCA negative Diagnosis is made by colonoscopy Colonoscopy will show skip lesions, cobblestone mucosa, transmural inflammation Surgery will not be curative Comments: Can occur anywhere on GI tract from mouth to anus first line medical therapy for Crohn's disease? Mesalamine (ileitis) --小肠 sulfasalazine (ileocolitis/colitis)---小肠和大肠 Small bowel 50%, colon 30%, and ileocolonic 20%.

altered intestinal motility: organic causes

Diabetic autonomic neuropathy, gastroparesis, hyperthyroidism, scleroderma, amyloidosis.

eosinophilic esophagitis (EE)

Dysphagia to solids, upper abdominal pain, GERD-like symptoms (eg, heartburn), food impaction, and a history of allergies suggests eosinophilic esophagitis (EE). He has a history of food allergies, asthma, and atopic dermatitis. Laboratory studies show markedly elevated serum IgE levels. Upper endoscopy shows stacked circular rings

GERD

Gastroesophageal Reflux Disease (GERD) Patient with a history of nocturnal cough or asthma Complaining of retrosternal burning sensation radiating upward ("heartburn") usually after eating Diagnosis is made by empiric trial of histamine 2 receptor antagonists (H2RAs), then PPIs Most commonly caused by LES dysfunction Treatment is weight loss, elevation head of bed during sleep, avoidance of certain foods (caffeine, alcohol, acidic foods) antiacid did not work, Which of the following would be most likely used to aid in the clinical diagnosis of gastroesophageal reflux disease (GERD) in this patient?Proton pump inhibitor trial

Gastric cancer --mc is adenocarcinoma

H.pylori infection (main cause, up to 65-80% of all gastric cancers),

celiac disaese

HLA DG8--->human leukocyte antigen Iron deficiency. Hep c pt, celiac dz, demetitis herpififorme Type 1 diabetes mellitusa all new pt shoud: Bone mineral density.

Hepatocellular Carcinoma

Hepatocellular Carcinoma Most common primary liver cancer Most common cause: chronic HBV/HCV cirrhosis Rapidly ↑ ascites Bloody ascitic fluid ↑ AFP

anterior L1 dermatome

Iliohypogastric nerve his "beltline. interrupted by hernia

Inguinal Hernias

Inguinal Hernias Bimodal: < 1 and > 40 Direct:Protrudes directly through Hesselbach's triangle and medial to the inferior epigastric artery (IEA)Bulge decreases upon reclining Indirect:​​Most common typeProtrudes through internal ring, lateral to IEA ​ Medial to IEA: Direct; Lateral to IEA: Indirect (MDs don't LIe) Strangulation risk: indirect > direct Nonreducible hernia: emergent surgery consultation

Irritable Bowel Syndrome IBS

Irritable Bowel Syndrome Patient will be a woman With a history of constipation alternating with diarrhea Complaining of abdominal discomfort which is relieved with bowel movements Diagnosis is made by Rome criteria Treatment is symptomatic - dietary management and drugs Cholestyramine (A) is a bile acid sequestrant used to treat diarrhea. Loperamide (B) is an antidiarrheal agent used in the treatment of patients with IBS associated diarrhea. Rifaximin (D) is an antimicrobial agent that may be used in patients with severe IBS without constipation who have failed other therapies. polyethylene glycol.:constipation first-line treatment Treatment for only pain without constipation or diarrhea SSRI: like citalopram, TCA: like desipramine, and Antispasmodics: such as atropine, hyoscyamine, dicyclomine or scopolamine. alarm features:Iron deficiency anemia, weight loss, and family history of certain organic gastrointestinal diseases such as colorectal cancer, inflammatory bowel disease or celiac disease Rome criteria A patient might have IBS if they had recurrent abdominal pain on average at least one day/week in the last three months, associated with two or more of the following criteria: related to defecation associated with a change in frequency of stool associated with a change in form (appearance) of stool *Criteria fulfilled for the last three months with symptom onset at least six months prior to diagnosis Kruis Score, Manning Criteria or Rome Criteria. Treatment regimens are geared toward which of the symptoms a patient with irritable bowel syndrome suffers from most: pain, diarrhea, bloating or constipation. The pain associated with irritable bowel syndrome can be treated with selective-serotonin reuptake inhibitors like citalopram, tricyclic antidepressants like desipramine, and antispasmodics such as atropine, hyoscyamine, dicyclomine or scopolamine. you suspect ibs, what test do you order first? Laboratory testing and diagnostic imaging are generally not recommended in patients younger than aged 50 years. Patients with alarm features including iron deficiency anemia, weight loss, and family history of IBD should have further evaluation. When laboratory testing is indicated, initial tests include a complete blood count to screen for anemia, infection, and inflammation. History-specific diagnostic testing can include gallbladder ultrasound, abdominal CT, and colonoscopy.

Large Bowel Obstruction

Large Bowel Obstruction Patient will be complaining of abdominal distension PE will show high-pitched bowel sounds Most commonly caused by colorectal cancer Most common location is sigmoid colon Treatment is NGT, surgery

gold standard in the treatment of chronic anal fissures?

Lateral internal sphincterotomy

Lynch syndrome

Lynch syndrome (C) is an autosomal dominant disease that is a major risk factor for colorectal and endometrial cancer. Patients with affected relatives should be screened with a colonoscopy beginning at the age of 25 years.

MEN1

MEN1, produces Menin MEN type 1 Pituitary Parathyroid Pancreas zollinger ellison sxs.

Mallory-Weiss Syndrome

Mallory-Weiss Syndrome Patient will have a history of drinking alcohol and forceful vomiting Complaining of hematemesis, striky blood, not much. Diagnosis is made by upper endoscopy Caused by an incomplete tear in the esophagus mucosa and proximal stomach pre-existing condition makes patients more prone to a Mallory Weiss tear? Answer: Presence of a hiatal hernia.

pill esophagitis,

Many medications can cause pill esophagitis, but NSAIDs, potassium chloride, iron, vitamin C, bisphosphonates, and antibiotics are most common. Medication-induced Esophagitis Remain upright after taking medications Take pills with sufficient quantities of water Use liquid formulation of medication when possible Attempt to switch the offending agent to a different medication What medication implicated in pill esophagitis carries the highest risk for subsequent stricture formation? Answer: Alendronate.

Mesenteric Ischemia

Mesenteric Ischemia Patient with a history of dysrhythmias (AF), recent MI, or CAD Complaining of abdominal pain out of proportion to exam Labs will show lactic acidosis Diagnosis is made by CTA, angiography (gold standard) ulcerative colitis is due to ischemia from low blood flow, most on left side, the two flextures. two water shedding areas.

vitamin B12 (cobalamin) deficienc

Methylmalonic acid and homocysteine levels Laboratory studies will show increased serum (and urine) concentrations of both methylmalonic acid (MMA) and homocysteine (HC). These increased levels occur as a result of their decreased rate of metabolism. n contrast, isolated levels of HC is only seen in folate deficiency. Thus, this test is critical in differentiating the specific vitamin deficiency as the etiology of the anemia.

greatest risk for developing gallstones and acute cholecystitis

Native Americans. Initial - US Gold standard - HIDA

Crohns Disease presentation early stage

Over the last 7 months a 13-year-old girl has had intermittent abdominal pain, which has made her quite irritable. The abdominal pain is associated with arthralgias and general malaise. Review of systems reveals that she has lost 5 kg (11 lb) and has painful bowel movements. Which one of the following is the most likely cause of these symptoms? Crohn's disease is the most common chronic inflammatory bowel disease which occurs during adolescence and young adulthood, with a second peak at 50-80 years of age. The manifestations of Crohn's disease are dependent on the site of involvement, but systemic signs and symptoms are more common than with ulcerative colitis. Crohn's disease presents with chronic diarrhea, crampy abdominal pain, fever, weight loss, and fatigue. Perianal disease (anal fissures, perirectal abscesses, and anorectal fistulas) is also common in Crohn's disease. Crohn's disease may affect any part of the GI tract, from the mouth to the anus, but typically affects the small bowel and colon. Irritable colon and celiac disease may mimic symptoms of Crohn's disease, but objective findings of weight loss and anal lesions are extremely uncommon. this is ulcerative colitis because there is not reporting about bloody stool/diarrhea.

symptomatic cholelithiasis in pregnancy?

Pain control and supportive care.

Pancytopenia

Pancytopenia Aplastic anemia Chloramphenicol Leishmania donovani Megaloblastic anemia Paroxysmal nocturnal hemoglobinuria (PNH) Radiation sickness Transfusion-associated GVHD

Right sided pelvic pain in women what test to order

Pelvic ultrasound with Doppler flow. It is sensitive for many GYN disorders and, in the hands of an experienced technician, compressive ultrasound can diagnose appendicitis.

esophageal varices

Schistosomiasis (trematode infection).

Constipation from DM

Secondary constipationis caused by systemic diseases such as diabetes mellitus, dietary issues including inadequate fluid intake or structural causes, such as hemorrhoids and anal fissures. Diagnosis is with the Rome III criteria which involves the patient experiencing at least two of the following symptoms for the past three months or more: straining, < 3 bowel movements per week, manual maneuvering in order to defecate, hard stools, and sensation of either anorectal obstruction or incomplete defecation. Initial management is with patient education, changes to diet including increased fiber intake, and bulk-forming laxatives or non-bulk-forming laxatives, or both.

shigellosis,shigella

Shigellosis Patient will be complaining of fever,bloody, mucoid diarrhea and seizures (more common in children), green color, Labs will show fecal RBCs and WBCs Treatment is based on resistance patterns but commonly azithromycin or ciprofloxacin Complications:HUS, reactive arthritis HUS is more related to E coli, do not use abx in ecoli, but use for shigella. Because Cipro-resistant Shigella is spreading, CDC recommends doctors use lab tests to determine which antibiotics will effectively treat shigellosis. Third generation cephalosporins can be used. Doctors and patients should consider carefully whether an infection requires antibiotics at all. Extra-intestinal manifestations such as hallucinations, confusion, and seizures may occur associated with febrile seizures most common cause of dysentery in the United States?--Shigella sonnei.

sigmoid volvulus.

Sigmoid Volvulus Elderly bedridden patient or patient with psychiatric/neurological history History of constipation Sigmoidoscopy

Small intestine infarction

Small intestine infarction usually occurs from which etiologies? Answer: Superior mesenteric arterial embolism or thrombosis, and abdominal venous thrombosis

Spontaneous Bacterial Peritonitis

Spontaneous Bacterial Peritonitis Patient will have a history of chronic liver disease or cirrhosis Complaining of fever, chills, and abdominal pain PE will show ascites, shifting dullness Labs will show PMNs > 250, WBC > 1,000, pH < 7.34 Diagnosis is made by analysis of the ascitic fluid Most commonly caused by E. coli, Streptococcus spp Treatment is immediate IV antibiotics (third-generation cephalosporin). Consider giving albumin ascitic fluid granulocyte count >500 correlates with positive cultures in more than 90% of cases; however, ED treatment for SBP should be initiated if the neutrophil count is greater than 250. prophylaxis: bactrim or fluoroquinolone tx: ceftaxime

obstipation

The inability to pass either stool or flatus for more than 8 hours despite a perceived need. It is highly suggestive of intestinal obstruction.

obturator nerve

The obturator nerve (C) supplies several proximal thigh muscles, such as gracilis and adductor longus. Its sensory contribution is to the distal medial thigh, just superior to the knee joint.

secondary anal fissure

Those with previous anal surgical procedures, inflammatory bowel disease, granulomatous diseases, malignancy and communicable diseases.

Ulcerative Colitis

Ulcerative Colitis Patient will be 15-30-year-old Complaining of bloody diarrhea, crampy abdominal pain, tenesmus PE will show continuous mucosal inflammation always involving the rectum Treatment is sulfasalazine, surgery is curative Complications: Toxic megacolon, ↑ colon cancer risk: because of inflammation. P-ANCA. ASCA extracolonic finding Hepatitis and cirrhosis, uveitis and episcleritis, and erythema nodosum and pyoderma gangrenosum. treatment: Rectal or oral 5-ASA medications (e.g. mesalamine or sulfasalazine) are used in maintenance treatment. Acute flares are treated with rectal or oral glucocorticoids.

ileus

What electrolyte disorder commonly causes an ileus?\肠阻塞Answer: Hypokalemia. because pt will vomit, ---no！this is wrong hypokalemia is causing ileus. What electrolyte must be given with potassium to ensure proper repletion? Answer: Magnesium. Ileus Postoperative, electrolyte abnormalities Nausea/vomiting, constant pain Distension + ↓ bowel sounds

size of bowel upper limit

What is the upper limit of normal diameter for the different segments of bowel? Answer: Small bowel (3 cm), colon (6 cm), cecum (9 cm)—the 3/6/9 rule.

cholecystitis

Which of the following contributed the most to the development AAlcohol consumption BCigarette smoking CEthnicity--native american DMarijuana smoking smoke, drink, marijuana do not relate to cholecystitis. Cholecystitis Patient will be an overweight (Fat),Fertile,Female in her Forties (4Fs) Complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy's sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula) Diagnosis is made by:Initial - USGold standard - HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy most accurate radiographic test to diagnose acute cholecystitis Cholescintigraphy--HIDA Cholecystitis Labs may show an elevated WBC and elevated total bilirubin and alkaline phosphatase. Ultrasound findings typically include a thickened gallbladder wall, pericholecystic fluid and a gallstone. if the patient is well appearing, with no pallor, jaundice or abdominal tenderness. Her AST, ALT, total bilirubin, alkaline phosphatase, and lipase are normal.only had pain. ----Symptomatic cholelithiasis--aka biliary colic Ultrasound: Biliary colic Wall echo sign (WES): gallbladder Wall, gallstone Echoes, gallstone Shadowing---you will see stone or sluge on the ultra sound common infectious agents: E.coli, Klebsiella and Enterobacter.

biliary colic and cholelithiasis

Which type of gallstone may not be visible on plain film or CT imaging? Answer: Cholesterol stones do not contain calcium and therefore may be radiolucent.. so use U/S INTERESTING****Most patients with biliary colic complain of a steady pain, not colicky, in the right upper quadrant or epigastrium Bilary Colic RUQ pain/tenderness Worsened by fatty foods US: Wall echo sign (WES): gallbladder Wall, gallstone Echoes, gallstone Shadowing Elective cholecystectomy

Small Bowel Obstruction

X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Treatment is NGT, surgery DX: CT scan of the abdomen is highly specific in small bowel obstruction Small Bowel Obstruction Patient with a history of prior abdominal/pelvic surgery Complaining of bilious vomiting PE will show high pitched bowel sounds X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Diagnosis is made by imaging Treatment is NGT, surgery What are the most common cancers associated with small bowel obstruction? Answer: Colonic and ovarian malignancies. 2nd mc cause: Adenocarcinoma Postoperative adhesions are the most common cause of SBOs, followed by cancer (20%), and then incarcerated hernias (10%)

Yersinia enterocolitis

Yersinia Enterocolitica Patient with a history of eating undercooked pork Complaining of RLQ pain, fever, vomiting and then diarrhea Labs will show fecal WBCs and RBCs A 22-year-old man who just returned from a trip to Scandinavia presents to the ED with complaints of severe cramping abdominal pain and diarrhea. The diarrhea was initially profuse and watery and is now bloody. His vital signs are HR 105 beats per minute, RR 18 per minute, BP 110/64 mm Hg, temperature 38.8 °C, and oxygen saturation 99% on room air. He has right lower quadrant tenderness on exam. Fecal occult blood test is positive; wet mount of the stool shows fecal leukocytes. Which of the following is the most likely diagnosis?

Hirschsprung's disease

\Toxic megacolon is a complication of Hirschsprung disease complications of toxic megacolon?Perforation, sepsis and shock. Hirschsprung Disease boy or have Down Syndrome delayed meconium passage Diagnosis rectal biopsy an absence of ganglion cells in the submucosal and myenteric plexus chromosomal abnormality is Hirschsprung disease commonly associated with? Answer: Down syndrome (trisomy 21)

Virchow node (left supraclavicular lymphadenopathy).

adenocarcinoma of the gastroesophageal junction?

valvulae conniventes (of the small bowel.)

band mark on small bowel, transverse the bowel

intestine blood supply

celiac trunk (A) is the first major branch of the abdominal aorta. Its branches supply the stomach, spleen, pancreas, liver, gallbladder and duodenum, but not the large intestine superior mesenteric artery (D) supplies the lower duodenum, proximal two-thirds of the transverse colon, and pancreas. The left "half" of the large intestine, sigmoid colon and rectum are supplied by the inferior mesenteric artery. The inferior mesenteric artery supplies the descending colon, sigmoid colon, and part of the rectum. It forms an anastomosis with the superior mesenteric artery.

haustra of large bowel

do not transverse the bowel

Fatty liver of pregnancy

does acute fatty liver of pregnancy typically occur? Answer: During the third trimester.

constipation

educating the patient, increasing fluid intake and dietary fiber, and bulk-forming laxatives such as methylcellulose or psyllium. initial treatment in patients with severe constipation? Answer: Suppositories. Constipation Rome criteria Acute or chronic Less than 3 BM per week Elderly/hospitalized at risk Evaluate for secondary causes Start with lifestyle modifications Trial fiber, laxatives, stool softeners Name one opioid antagonist used in the treatment of constipation? Answer: Methyl-naltrexone Functional constipation is diagnosed using the Rome IV criteria. This involves the patient experiencing at least two of the following symptoms for the past three months or more: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual maneuvers to facilate bowel movements, and < 3 bowel movements per week. In addition, loose stools should rarely be present without the use of laxatives and criteria for irritable bowel syndrome is not met. Constipation Rome criteria Acute or chronic Less than 3 BM per week Elderly/hospitalized at risk Evaluate for secondary causes Start with lifestyle modifications Trial fiber, laxatives, stool softeners alarm features in patients with a complaint of constipation? Answer: Hematochezia, family history of colon cancer or inflammatory bowel disease, weight loss of more than 10 pounds, positive fecal occult blood test, anemia, and acute onset of constipation in the elderly.

40 y/0 female LLQ pain

how to tell is it GYN issue or diverticualr? if you see constipation, then it is diverticulitis.

distinguishes cholangitis from acute cholecystitis

jaundice

Mallory-Weiss Syndrome

laceration of the gastric cardia due to forceful vomiting. Mallory-Weiss Syndrome Patient will have a history of drinking alcohol and forceful vomiting Complaining of hematemesis Diagnosis is made by upper endoscopy Caused by an incomplete tear in the esophagus mucosa and proximal stomach

bowel obstruction in pregnancy

most common cause of bowel obstruction in pregnancy? Answer: Cecal volvulus. 大肠第一段，

impaired liver function

most important marker of impaired liver function? Answer: Altered synthetic function (decreased serum albumin and elevated prothrombin time)

portal htn, cirrhsis , 1st line

not thiazide it is spironolactone

pudendal nerve

pudendal nerve (D) provides S2-4 sensory innervation to the penis, scrotum, perineum and anus, and motor control to the bladder and rectal sphincters.

Ramstedt procedure.

pyloromyotomy pyloric stenosis

Bacillus cereus

reheated rice A 15-year-old boy is brought by his mother to the Emergency Department due to nausea, multiple episodes of vomiting previously ingested food, and three loose bowel movements. His mother notes that the boy reheated the leftover rice stored in the refrigerator the night before. Physical examination reveals a tired child who is afebrile with dry mucous membranes. He has pink palpebral conjunctivae, clear breath sounds, a soft abdomen with mild tenderness at the epigastric area, and full pulses. Which of the following is the most likely causative agent? vomit, 3 loose stool, dehydration.

toxic megacolon:

toxic megacolon: Bowel rest and nasogastric tube placement are essential first steps in order to assist with gastrointestinal decompression. Initial treatment is medical, but a surgical consult should also be ordered at admission as urgent or emergent presentation may require subtotal colectomy with end-ileostomy, the surgical procedure of choice. What type of bacteria should empiric therapy for toxic megacolon cover? Answer: Gram-negative and anaerobic bacteria. ceftrixaxone and metronidazole/vanco? Toxic Megacolon Patient with a history of ulcerative colitis PE will show systemic toxicity Abdominal X-ray will show the colon dilated > 6 cm DX: plain x -ray,>6cm at transver colon Most commonly caused by inflammatory bowel disease bowel rest and decompression Treatment is IVF, ABX, IV corticosteroids, emergent surgical consultation A 35-year-old-man with a long history of occasional bloody diarrhea and abdominal pain presents with acute onset severe abdominal pain. Vital signs are significant for a temperature of 39°C, heart rate 140, and blood pressure 82/55 mm Hg. On physical exam, his abdomen is distended and tympanic. Which of the following diagnostic studies is indicated first at this time?x-ray disease processes that can precipitate toxic megacolon? Answer: IBD (most common), pseudomembranous colitis, CMV colitis, and bacterial colitis.

Misoprostol

used for prevent GI pain after nsaids use It can prevent stomach ulcers caused by anti-inflammatories (NSAIDs). Misoprostol is a synthetic prostaglandin E1 analog that replaces the protective prostaglandins consumed with prostaglandin-inhibiting therapies (e.g., NSAIDs). blackbox : Misoprostol should be avoided or used with extreme caution in this woman of childbearing age. Misoprostol carries a black box warning with the following information: "Use of misoprostol during pregnancy may cause abortion, birth defects, or premature birth. Uterine rupture has been reported when used to induce labor after the eighth week of pregnancy. Misoprostol is not to be used to reduce nonsteroidal antiinflammatory medication induced ulcers in a woman of childbearing potential unless she is capable of complying with effective contraceptive measures and is at high risk of developing gastric ulcers and their complications. If needed, the patient must have a negative pregnancy test within two weeks of starting therapy, she must use effective contraception during treatment, and therapy should begin on the second or third day of next normal menstrual period. Written and verbal warnings concerning the hazards of misoprostol should be provided."

acute ischemic colitis.

watershed areas (mainly on the left side): splenic flexure and recto-sigmoid junction. due to global low blood flow Ischemic Colitis Patient with a history of atherosclerotic disease Complaining of acute onset of crampy abdominal pain CT imaging will show bowel wall edema bloody stool Most commonly caused by inadequate blood flow through the mesenteric vessels Treatment: Most cases resolve with supportive care. no food, iv, NPO, Parietal nutrition. An 80-year-old man who presents to the emergency department with a complaint of sudden onset left-sided abdominal pain and bloody diarrhea. Abdominal CT demonstrates thickening of the bowel wall and free peritoneal fluid. ( not seen in diverticulitis) What is the most likely diagnosis? When evaluating for ischemic colitis, in what condition should a colonoscopy not be performed? Answer: Acute peritonitis. will cause perforation.

FB ingestion

看见正面，稍微好些， 没有呼吸问题 Swallowed foreign bodies most commonly obstruct at the level of C6, the cricopharyngeus muscle, one of the four natural areas of luminal narrowing in the esophagus. The cricopharyngeus is the muscle of the upper esophageal sphincter (UES). Most foreign bodies less than 2 cm x 5 cm will pass spontaneously through the GI tract. If the patient is without severe symptoms, foreign bodies less than this size are observed for 24 hours as only 10-20% require endoscopic removal. MOST common to least common 1: C6-cricopharyngeus CP muscle 2: T4-aortic arch 3: T11-gastroesophageal GE junction. 4: T6-tracheal bifurcation 5: T1-Thoracic inlet least common What objects require immediate endoscopic removal if they have not passed into the stomach? Answer: Button batteries and sharp objects. Esophageal Foreign Body Site of obstruction: C6 > T4 > T11 > T6 > T1 AP/PA view: Flat side of coin appears Esophageal necrosis → perforation Most FBs that pass pylorus pass spontaneously Observe most esophageal FBs for 24 hours Emergent endoscopy indicated if FB is battery, sharp, or signs of obstruction present