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Terms Definitions
Ranson's criteria for acute pancreatitis on admission (GA LAW) Glucose >200
Age >55
LDH >350
AST >250
WBC >16,000
Ranson's criteria for acute pancreatitis after 48 hours (C HOBBS) Calcium <8.0mg/dl
Hematocrit decreased by >10%
PaO2 <60 mmHg
Base excess >4 mEq/L
BUN increased by >5 mg/dl
Sequestered fluid >6L
Criteria for predicting mortality associated with acute pancreatitis Ranson's criteria
Ranson's criteria risk percentage for mortality 20% with 3-4 signs
40% with 5-6 signs
100% with >7 signs
Courvoisier's sign Palpable, nontender gallbladder, a sign of pancreatitis
3 most common pathogens of infectious esophagitis Candida albicans, CMV, and HSV
Oropharyngeal dysphagia: does it involve liquids or solids more? Liquids
Obstructive esophageal dysphagia: does it involve liquids or solids more? Solids
Esophageal motility disorders (name some) Achalasia, scleroderma, and esophageal spasm
Barium swallow shows a corkscrew-shaped esophagus Diffuse esophageal spasm
Impaired relaxation of the lower esophageal sphincter, loss of peristalsis in the lower 2/3 of the esophagus Achalasia
Barium swallow shows esophageal dilation with a "bird's beak" tapering of the distal esophagus Achalasia
Treatment for achalasia Nitrates, CCBs, or endoscopic injection of botox into the LES for short-term relief. Pneumatic dilation or surgical myotomy for long-term relief
2 most common types of esophageal cancer Squamous cell carcinoma and adenocarcinoma
Risk factors of esophageal cancer Alcohol use, male gender, smoking, and age >50
Symptomatic reflux of gastric contents into the esophagus, most commonly as a result of transient lower esophageal sphincter (LES) relaxation GERD
BARRett's esophagus Becomes
Adenocarcinoma,
Results from
Reflux
The gastroesophageal junction and a portion of the stomach displaced above the diaphragm Sliding hiatal hernia
Treatment for gastritis Stop offending agents. Antacids, sucralfate, H2 blockers, and/or PPIs.
H. pylori treatment Triple therapy with amoxicillin, clarithromycin, and omeprazole
H. pylori treatment triple therapy
Abdominal pain, early satiety, and weight loss Gastric cancer. Usually presents with an advanced case, and has a 5-year survival of <10%
Risk factors for gastric cancer Diet high in nitrites and salt and low in fresh vegetables (antioxidants), H. pylori colonization, and chronic gastritis
Risk factors for peptic ulcer disease H. pylori infection, corticosteroid use, NSAIDs, alcohol, and tobacco. Males > females
Chronic or periodic dull, burning epigastric pain that improves with meals, worsens 2-3 hours after eating, and can radiate to the back Peptic ulcer disease
Diagnostic study to evaluate for perforated peptic ulcer Abdominal X-ray (free air under the diaphragm). CBC to assess for GI bleed (decreased hematocrit)
How do you rule out Zollinger-Ellison syndrome in patients with GERD or PUD that are refractory to medical management Serum gastrin levels
Gastrin-producing tumors in the duodenum and/or pancrease Zollinger-Ellison syndrome
Complications of peptic ulcer disease (acronym HOPI) Hemorrhage
Obstruction
Perforation
Intractable pain
Zollinger-Ellison syndrome is associated with what type of multiple endocrine neoplasia? MEN I
Gnawing, burning abdominal pain with diarrhea, N/V, fatigue, weight loss, GI bleed, all of which is recurrent and unresponsive to treatment? Zollinger-Ellison syndrome
Common cause of pediatric diarrhea Rotavirus infection
Most common etiology of infectious diarrhea. Campylobacter
Diarrhea that results from recent treatment with antibiotics (penicillins, cephalosporins, and clindamycin) Clostridium difficile
Complication of clostridium difficile Toxic megacolon
Treatment for C-diff Stop inciting antibiotic. PO metronidazole or vancomycin. If the pt can't tolerate oral medication, then IV metronidazole
Treatment for campylobacter associated diarrhea Erythromycin
When does acute diarrhea require laboratory testing? If the patient has a high fever, bloody diarrhea, or diarrhea lasting >4-5 days
Laboratory studies for acute diarrhea Send stool for fecal leucocytes, bacterial culture,, C-diff toxin, and ova and parasites
Cause of pseudomembranous colitis Clostridium difficile
Complication of entamoeba histolytica with administered steroids Can lead to fatal perforation
Treatment for children with diarrhea who cannot take medication or PO fluids Hospitalize, give IV fluids, and treat the underlying cause
Treatment for patients with celiac sprue Gluten-free diet
Abdominal bloating, flatulence, cramping, and watery diarrhea following milk ingestion Lactose intolerance (results from a deficiency of lactase)
Idiopathic bowel function disorder characterized by abdominal pain and changes in bowel habits that increase with stress and are relieved by bowel movements Irritable bowel syndrome
A patient presents with abdominal pain, change in bowel habits (diarrhea or constipation), abdominal distention, stools with mucus, and pain relief with bowel movement. What diagnostic studies should be done? CBC, TSH, electrolytes, stool cultures, abdominal films, and barium contrast studies. Also, take a good history to determine the cause. The diagnosis of exclusion would be IBS.
Dietary treatment for IBS Fiber supplements
Pharmocologic treatment for IBS TCAs, antidiarrheals (loperamide), antispasmodics (dicyclomine such as Bentyl, anticholinergics), or tegaserod (for those with constipation-predominant IBS)
Most common cause of small bowel obstruction in adults Adhesions from a prior abdominal surgery
Leading cause of small bowel obstruction in children Hernias
Abdominal films show a stepladder pattern of dilated small bowel loops and air-fluid levels Small bowel obstruction
Abdominal X-ray shows radiopaque material at the cecum Gallstone ileus
The presence of lactic acidosis in small bowel obstruction indicates... Necrotic bowel: a surgical emergency
Loss of bowel peristalsis without structural obstruction Ileus
Abdominal X-ray shows distended loops of small and large bowel on supine x-ray and air-fluid levels on upright view Ileus
What effect do anticholinergics, opioids, and hypokalemia have on GI motility? They slow GI motility
Most common cause of acute GI bleeding in patients >40 Diverticulosis
Risk factors for diverticulosis Low fiber, high fat diet, advanced age, and connective tissue disorders
Lower left quadrant pain, fever, nausea, vomiting, and constipation is likely... Diverticulitis
Treatment of uncomplicated diverticular disease High fiber diet or fiber supplements
Treatment for diverticulitis Bowel rest (NPO), NG tube, broad-spectrum antibiotics (metronidazole and a fluoroquinolone or a 2nd or 3rd generation cephalosporin) if the pt is stable. Avoid barium enema and flexible sigmoidoscopy.
A patient has a large bowel obstruction. What should be assumed until proven otherwise? Colon cancer
Barium enema study shows "bird beak" sign Large bowel obstruction
Barium enema X-ray shows an "apple-core" filling defect in the descending colon Colon carcinoma
GI manifestation of scleroderma (CREST syndrome) Esophageal dysmotility. May be the presenting complaint leading to the diagnosis of scleroderma
Lower weblike constriction located at the squamocolumnar mucosal junction of the esophagus Schatzki's ring. Associated with GERD.
Esophageal diverticula Zenker's diverticulum
Gradual onset dysphagia, spontaneous regurgitation of undigested food, halitosis, neck mass on physical exam Zenker's diverticulum
Dilated submucosal veins in the esophagus secondary to portal hypertension, seen in half of patients with cirrhosis Esophageal varices
Management of esophageal varices Endoscopic evaluation with therapeutic banding or sclerotherapy of varix. If hemorrhage is too vigorous, balloon tube tamponade. Vasoconstrictive drugs (vasopressin, somatostatin).
Superficial mucosal tear at the gastroesophageal junction Mallory-Weiss Tear
Pharmacologic treatment of choice for peptic ulcer disease PPIs
Iron deficiency anemia in an elderly male Colorectal cancer until proven otherwise
Tumor marker in colorectal cancer, used to monitor recurrence CEA
Type of inflammatory bowel disease in which the rectum is always involved Ulcerative colitis
Type of IBD that may involve any portion of the GI tract Crohn's disease
Colonoscopy reveals aphthoid, linear, or stellate ulcers, strictures, "cobblestoning", and "skip lesions" Crohn's disease
Test to make a definitive diagnosis of either type of inflammatory bowel disease Biopsy
Pharmacologic treatment for inflammatory bowel disease 5-ASA agents (sulfasalazine, mesalamine), corticosteroids and immunomodulating agents (azathioprine, infliximab) if no improvement
Curative treatment for long-standing ulcerative colitis or toxic megacolon Total colectomy
Which has a higher risk of colon cancer: ulcerative colitis or Crohn's disease? Ulcerative colitis
What are the structures that comprise Hasselbach's triangle? Inguinal ligament, inferior gastric artery, and the rectus abdominis
Herniation of abdominal contents through the floor of Hasselbach's triangle Direct inguinal hernia
Herniation of abdominal contents through the internal and then external inguinal rings and eventually into the scrotum (in males) Indirect inguinal hernia
The most common hernia in both genders Indirect inguinal hernia.
Etiology of indirect inguinal hernia Congenital patent processus vaginalis
Risk factors for cholelithiasis 4 F's: female, fat, fertile, forty (however it is common and can occur in any patient)
Also OCPs, rapid weight loss, positive family history, chronic hemolysis, small bowel resection, and TPN
Postprandial RUQ abdominal pain that radiates to the right subscapular area or the epigastrum biliary colic
Inspiratory arrest during deep palpation of the RUQ Murphy's sign, indicative of cholecystitis
Gallstones in the common bile duct choledocholithiasis
Hallmark lab values in choledocholithiasis elevated alkaline phosphatase and total bilirubin
Acute bacterial infection of the biliary tree that occurs secondary to obstruction, usually from gallstones Acute cholangitis
Charcot's triad RUQ pain, jaundice, and fever/chills. Classic signs of acute cholangitis
Reynold's pentad Charcot's triad plus shock and altered mental status. Signs of acute suppurative cholangitis; suggests sepsis
An idiopathic disorder characterized by inflammation, fibrosis, and strictures of extra and intrahepatic bile ducts. Usually presents in young men with IBD, especially UC. Primary sclerosing cholangitis
LFTs in hepatocellular injury Marked elevation of AST and ALT, mild elevation of bilirubin and alk phos
LLQ abdominal tenderness to palpation associated with constipation and a low grade fever Acute diverticulitis
70 year old with fatigue, no history of alcohol abuse or liver disease, no meds. PE shows scleral icterus. Lab reveals normocytic normochromic anemia, conjugated hyperbilirubinemia with bilirubin in the urine. Serum bilirubin is 12mg/dl with ALT and AST i Biliary obstruction. Confirm with an ultrasound or CT scan.
Villous atrophy with with increased lymphocytes in the lamina propria is found on small bowel biopsy. Likely diagnosis? Ulcerative colitis
Mucosal inflammation and edema with crypt abscesses are found on sigmoidoscopy. Likely diagnosis? Crohn's disease.
If a patient has completed their hepatitis B vaccine series, what would you expect to find on their hepatitis profile? antibody against the hepatitis B surface antigen (anti-HBS)
40 year old male has a history of 3 duodenal ulcers with prompt recurrence after medical treatment. Serum gastrin was reported as 200pg/ml. What test will confirm your diagnosis? Secretin injection test. The history fits the profile of Zollinger-Ellison syndrome. The secretin injection test will cause another increase in gastrin from a duodenal or pancreatic tumor.
Initial treatment for Zollinger-Ellison syndrome. PPI. If this fails, then surgical resection. (Drug treatment is usually successful.)
30 year old female has a 3 week history of diarrhea with blood and mucus. Colonoscopy reveals inflamed friable mucosa from rectum to midsigmoid. Biopsy reveals inflammation with erosions. Likely diagnosis? Ulcerative colitis
32 year old female presents with 3 week history of diarrhea and RLQ abdominal pain. Biopsy findings reveal inflamed areas with nodular thickening especially at the terminal ileum. Likely diagnosis? Crohn's disease
69 year old female smoker presents with a 3 week history of low grade fever and bloody diarrhea. Colonoscopy reveals continuous erythema in the colon only. Likely diagnosis? Ulcerative colitis. The combined risk factors of age (69) and smoking, with the presentation of low grade fever and the passage of blood is classic for ulcerative colitis.
Differentiating sign between acute cholecystitis and acute cholangitis Acute cholangitis will have a fever as high as 105 (F). In acute cholecystitis, the fever rarely goes above 100 (F).
An 18 year old male develops enteric hepatitis. Which hepatitis virus is the most likely cause? Hepatitis A. Fecal-oral transmission.
On colonoscopy of a 50 year old asymptomatic man, a 0.5cm tubular adenoma was found and removed. When should he return for a repeat colonoscopy? 3 years. In patients with only one polyp found and removed on initial exam, the optimal follow-up interval is every 3 years. In patients with no polyps on initial colonoscopy, a follow up interval of 5 years should be safe.
What vitamin supplementation should be given to a patient with ulcerative colitis who is treated with sulfasalazine? Folate
The most clinically useful marker for the presence of acute and chronic hepatitis B is... hepatitis B surface antigen
LFTs in cholestasis Marked elevation of alk phos and bilirubin, with or without increased aminotransferases
A clinical sign that arises when excess bilirubin (>2.5mg/dl) is circulating the blood Jaundice
Prodrome of malaise, fever, joint pain, fatigue, URI symptoms, N/V, and change in bowel habits followed by jaundice and RUQ tenderness Acute hepatitis (viral)
IgM HAVAb: what is it and what does its presence indicate? IgM antibody to hepatitis A virus; best test to detect active hepatitis A
HBsAg: what is it and what does its presence indicate? Antigen found on the surface of Hepatitis B virus. Continued presence indicates carrier state.
Sudden, steady epigastric pain, often radiating to the back, aggravated by walking and lying supine, relieved by sitting and leaning forward. May have mild jaundice and fever. Acute pancreatitis
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