GERD

2nd - infections in IC (candida, CMV, HSV)

pregnancy

smoking

obesity

ETOH

chocolate

spicy foods

meds (NSAIDS, BB, CCB)

odynophagia (painful swallowing)

dysphagia (difficulty swallowing)

retrosternal chest pain

odynophagia is the hallmark

dysphagia

retrosternal chest pain

PO fluconazole

2nd line - voriconazole, capsofungin

Ganciclovir

2nd line - valganciclovir, foscarnet

acyclovir

2nd line - foscarnet

dysphagia (esp with solids)

may have feeding difficulties in children or reflux

remove foods that incite allergic response

topical steroids via inhaler (without using the spacer)

NSAIDS

bisphosphonates

potassium chloride

iron pills

vitamin C

BB

CCB

drink pills with at least 4 ounces of water

avoid recumbency for @ least 30-60 minutes of ingestion

endoscopy used to dtermine damage and look for complications 

(ex esophageal perforation, pneumonitis, esophageal fistula)

retching/vomiting --> hematemesis after an ETOH binge

melena

hematochezia

syncope

abdominal pain

hydrophobia

supportive if no active bleeding

active bleeding -- epi injection, sclerosing agent, band ligation, hemo-clipping or balloon tamponage (Sengstaken-Blakemore tube or Minnesota tube)

multifactorial:

increased gastric acid

incompetent lower esophgeal sphincter (LES)

esophageal motility disorders 

delayed gastric emptying

+- hiatal hernia

esophagitis

esophagus stricture

Barrett's esophagus

esophageal adenocarcinoma 

esophageal squalous epithelium replaced by precancerous metaplastic columnar cells from the cardia of the stomach

(those cells are used to acidic environment but don't belong there)

heartburn (pyrosis) hallmark

often retrosternal & postprandial (MC 30-60 min) 

increased with supine position & often relieved w/ antacids

regurgitation (water brash or sour taste in mouth)

dysphagia

cough at night (acid aspiration into lungs -irritation

hoarseness

aspiration pneumonia

"asthma" -bronchospasm from lung contact w/ acid

noncardiac chest pain

weight loss 

dysphagia

odynophagia

weight loss

bleeding

(suspect malignancy or cx)

1. clinical dx

2. endoscopy - often used 1st 

3. esophageal manometry: decreased LES pressure (done if normal upper endoscopy)

4. 24h ambulatory pH monitoring : gold standard (not usually done-often done if sx persistent)

elevation of HOB by 6 inches 

avoid recumbency for 3 hrs after eating

eating small meals

avoiding certain foods (fatty/spicy, citrus, chocolate, caffeine, peppermint)

decrease fat & ETOH intake

weight loss

smoking cessation

anacids & OTC H₂ receptor antagonists 

if alarm or atypical sx, upper endoscopy is next step

H₂RA, PPI & prokinetic agents (cisapride

PPI- DOC in severe disease

Nissen fundoplication if refractory

"sliding hernia" 

GE junction & stomach slide into mediastinum (increases reflux)

treat as GERD

MC type (95%)

"rolling hernia" (paraesophageal)

fundus of stomach protrude through diaphragm w/ the GE junction remaining in its anatomic location

Mngt: surgical repair of defect to avoid complications

esophageal varices 

30% of them bleed

UGIB- upper GI bleed (hematemesis, melena, hematochezia)

5-11% of UGIB

may develop signs & sx of hypovolemia d/t bleed

uper endoscopy: enlarged veins

+ red wale markings & cherry red spots increase risk of bleed 

stabilize pt with 2 large bore IV lines, IV fluids, +- blood transfusion

If coagulopathy present --> +- FFP, +- vitamin K (if increased PT)

1. endoscopic intervention: endoscopic ligation tx of choice - lower cx & re-bleed rate. +- sclerotherapy

2. pharmacologic vasoconstrictors - octreotide: DOC - MOA: somastatin analog that causes vasoconstriction of the portal venous flow, reducing bleeding.  Vasopressin: decreases portal venous pressure.  S/E: vessel constriction in other areas (coronary artery vasospasm, MI, bowel ischemia)

3. balloon tamponade: stabilize bleeding not controlled by endoscopic or pharm intervention

4. surgical decompression - TIPS - if bleeding despite endoscopic or pharm tx.  Cx: hepatic encephalopathy, infections OR Devascularization & embolization: may be used in severe cases or cases of thrombosis

1. nonselective beta blockers: tx of choice in primary prophylaxis to prevent rebleed.  ie propranolol, nadolol.  MOA: reduces portal venous pressure. NOT used in acute bleeds 

2. isosorbide: long acting nitrate (vasodilator) that reduces esophageal variceal pressure 

1. Helicobacter Pylori : MCC

2. NSAIDs/ASA: 2nd MCC. disrupts mucosal protective barrier by prostaglandin inhibition

3. Acute stress (in critically ill pts)

Others: heavy ETOH, bile salt reflux, meds, radiation, trauma, corrosives, ischemia, pernicious anemia, portal HTN

MC asymptomatic

if symptomatic - upper GI bleed (hematemesis, melena)

bleeding usually minimal

Epigastric pain, N/V, anorexia

endoscopy gold standard : thick, edematous erosions < 0.5 cm

H. pylori testing

clarithromycin + amoxicillin + PPI   (CAP)

Metronidazole if allergic to PCN

assoc w/ tobbaco/ETOH use 

decreased fruit/vegetables intake

achalasia

hot beverage ingestion

exposure of esophagus to noxious stimuli (causing dysplasia)

men

nitrates

1. solid food dysphagia --> fluids (fluids/soft foods usually tolerated initially), odynophagia

2. weight loss, CP, anorexia, cough, hoarseness, reflux, hematemesis, +- Virchow's node

3. Hypercalcemia in pts w squamous cell (d/t ectopic PTH related protein tumor secretion)

upper endoscopy w/ bx dx test of choice

double-contrast barium esophagram

esophageal resection

XRT

chemotherapy (ex 5-FU)

males and >40y

patients usually present late in dz

H. pylori most important risk factor! 

salted, cured, smoked, pickled foods containg nitrites (thought to be converted by H. pylori into noxious compounds)

prenicious anemia

chronic atrophic gastritis

achlorhydria

smoking

ETOH

blood type A

1. indigestion, weight loss, early satiety, abdominal pain/fullness, post-prandial vomiting. Patients often have Fe deficiency anemia

2. signs of metastasis: supraventircular LN (Virchow's node), umbilical LN (sister mary joseph's node), ovarian METS (Krukenburn tumor), palpable nodule on rectal exam (Blumer's shelf).  Left axillary lymph node involvement (Irish sign)

upper endoscopy with biopsy

linitis plastica: diffuse thickening of stomach wall d/t cancer infiltration (worse type of gastric CA)

gastrectomy

XRT & chemotherapy (both adenocarcinoma & lymphoma)

poor prognosis

black stones: hemolytic d/o

brown stones: Asian, parasitic/bacterial infections

fat

fair

female

forty

fertile

OCP's (increased estrogen), Native Americans, bile stasis, chronic hemolysis, cirrhosis, infection, rapid weight loss, IPD, TPN, fibrates, increased triglycerides 

1. MC asymptomatic (may be incidental finding)

2. "Biliary colic" - (episodic RUQ/epigastric pain beginning abruptly, continuous in duration, resolves slowly lasting 30m-hours assoc w/ nausea precipitated by fatty foods or large meals)

1. if asymptomatic may observe or use oral bile dissolution tx (ursodeoxycholic acid)

2. cholecystectomy (usually laparoscopic) in symptomatic patients

1. choledocholithiasis: gallstones in biliary tree (CBD)

2. cholangitis: biliary tract infection 2ry to obstruction by gallstone

3. cholecystitis 

fevers/chills

RUQ pain 

jaundice

CHOLANGITIS

Abx (PCN + aminoglycoside)

decompression of biliary tree via ERCP stone extraction

1. biliary colic = episodic RUQ/epigastric pain beginning abruptly, continuous in duration, resolves slowly lasting 30m-hours assoc w nausea precipitated by fatty foods or large meals

2. fever, N/V, palpable GB, + murphys sign, + boas sign, guarding, anorexia, jaundice not common 

acute RUQ pain/inspiratory arrest w/ GB palpation

acute cholecystitis

referred pain to right subscapular area d/t phrenic nerve irritation

acute cholecystitis

1. U/S-initial test of choice, +- thickened GB (>3mm); distended GB, sludge, gallstones, pericholecystic fluid, + sonographic murphy's sign.  KUB: 10% of stones seen

2. Labs: increased WBC's (leukocytosis c left shift).  increased bili, increased ALP & LFT's

3.  HIDA scan: Gold standard. + Hida scan = nonvisualization of gallbladder in cholecystitis 

NPO, IVF, abx (3rd gen cephalosporin + flagyl) --> cholecystectomy (us c/n 72h)

cholecystostomy if nonoperative

Meperidine preferred (morphine assoc c sphincter of Oddi spasm)

MC occur in seriously ill pts (post op, ICU pts)

2ry to dehydration

prolonged fasting, total parental nutrition, GB stasis, burns, DM

not 2ry to stone formation but GB sludge

assoc w/ gallstones may result from repeated bouts of acute/subacute cholecystitis

strawberry GB (inferior of GB resembles strawberry secondary to cholesterol submucosal aggregation) --> porcelian GB (premalignant condition)

chronic pancreatitis 

2% will develop pancreatic cancer

1. ETOH abuse (70%)

2. idiopathic (15%)

hypocalcemia, hyperlipidemia, islet cell tumors, familial, trauma, iatrogenic

gallstones don't play significant role as in acute

AXR (abd x-ray): calcified pancreas

amylase & lipase usually not elevated

endoscopic US sensitive

1. malabsorption: diarrhea, abd pain/distention, bloating, steatorrhea, +- growth delays, weight loss

2. dermatitis herpetiformis: pruritic, papulovesicular rash on extensor surfaces, neck, trunk & scalp

+ endomysial IgA Ab & transglutaminase Ab

Definitive dx - small bowel biopsy

gluten free diet (avoid wheat, rye, barley)

oats, rice & corn don't cause celiac dz 

fever

LLQ pain (may be assoc w/ changes in bowel habits)

N/V/D

constipation

flatulence

bloating

CT scan test of choice

Ba enema not done in acute phase

increased WBC's

+ Guaiac

clear liquid diet

broad spectrum abx: cipro (or Bactrim) + Metronidazole

high fiber diet 

fiber supplements

bleeding stops in 90% (+- vasopressin if not)

1. abnormal motility-chemical imbalance in intestine (including serotonin & Ach) causing abnormal movements and spasm --> abd pain

2. visceral hypersensitivity -patients have lower pain thresholds to intestinal distention

3. psychosocial interactions 

abdominal pain or discomfort with 2 of 3 features for at least 12 weeks (not necessarily consecutive), during preceding 12 months.  

1. relief with defecation

2. onset associated with change in stool frequency

3. onset associated with change in stool formation

1. evidence of GI bleeding: occult blood in stool, rectal bleeding, anemia

2. anorexia or weight loss, fever, nocturnal sxs, family h/o GI cancer, IBD, or celiac sprue

3. persistent diarrhea causing dehydration; severe constipation or fecal impaction; onset > 45 yo

1. lifestyle changes - smoking cessation, eat low fat/unprocessed foods. Avoid sorbitol or fructose, avoid cruciferous veggies. Sleep, exercise

2. diarrhea sx: anticholinergics/spasm (Dicyclomine), antidiarrheal (Loperamide)

3. constipation sx: prokinetics, bulk-forming laxatives, saline or osmotic laxatives (Lubiprostone - activates intestinal chloride transporter --> increased intestine fluid & motility)

TCA (amitriptyline) & serotonin receptor agonists for intractable pain

sorbitol - sugarless gum and mints, artificial sweetener

fructose - honey & many fruits

pregnancy

defecation (esp. if constipated)

prolonged sitting

obesity

hematochezia - bright red blood per rectum

(seen on toilet paper, coating the stool or dispersed in toilet water after defecation)

+- vague anal discomfort (may worsen w/ prolapse)

rectal pain w/ internal suggest complication

purple nodules if prolapsed

uncomplicated internal are neighter palpable or tender 

MC perianal pain - aggravated w/ defecation (covered by pain sensitive skin)

+- tender palpable mass

thrombosis may be precipitated by cough, heavy lifting

1. visual inspection, digital rectal exam, fecal occult blood

2. proctosigmoidoscopy, colonoscopy in pts w/ hematochezia to r/o proximal sigmoid dz

high fiber diet

increased fluids

warm sitz baths

topical rectal hydrocortisone for pruritis & discomfort 

+- analgesics

rubber band ligation

sclerotherapy if failed above tx

Staph aureus

E. coli

Bacteroides

Proteus

Streptococcus 

incision and drainage

NO antibiotics

low fiber diets

passage of large, hard stool 

other anal trauma

severe painful BM causing patient to refrain from BM

leading to constipation

bright red blood per rectum

rectal pain

+- mucoid discharge

skin tags seen in chronic

MC posterior midline (99% men 90% women)

>80% resolve spontaneously

warm water (sitz baths)

analgesics

stool softeners 

high fiber diet

laxatives

mineral oil

Second line tx: topical 0.4% nitro (SE: HA, dizziness)

nifedipine ointment

botox

1. cirrhosis, nonalcoholic fatty liver, hep B or C

2. In Africa & Asia - hep B more common

3. In west and Japan - hep C & alcoholic cirrhosis

4. hemochromatosis

cachexia, weakness, & weight loss

sudden appearance of ascites

palpable mass

bruit over tumor or friction rub when tumor has extended to surface of liver

leukocytosis

anemia is common

sudden & sustained elevation of serum alk phos in formerly stable pt

chemo

liver transplant

fever

RUQ pain

jaundice more than seen w/ cholecystitis/stones

(Cholangitis)

fever

RUQ pain

jaundice + AMS

hypotension

(cholangitis)

pus under pressure in a completely obstructed ductal system leads = severe toxicity 

• mental confusion, bacteremia, septic shock
• response to abx alone is poor
• multiple hepatic abscesses are often present
• motality rate approaches 100%

ERCP - permits stone extraction w/ stenting

acute cholangitis - Cipro +- metronidazole

flex sigmoidoscopy 

colonoscopy CI in acute colitis --> +- case perforation

BE is CI in acute colitis (may cause toxic megacolon)

1. abd. pain: LLQ MC, colicky
2. tenesmus, urgency
3. blood diarrhea hallmark (stools w/ mucous/pus)
4. Hematochezia MC in UC 

primary sclerosing cholangitis

colon CA

toxic megacolon (more common in UC)

uniform inflammation +- ulceration in rectum &/or colon "sandpaper" appearance 

pseudo polyps

1. abd. pain: RLQ pain (crampy) & weight loss 
2. diarrhea w/ no visible blood usually

perianal dz: fistuals, stricture, abscesses, granulomas

malabsorption: B12 & Fe deficiency

aminosalicylates (sulfasalazone, mesalamine) --> steroids --> immune modifying agents (azathioprine, 6-mercaptopurine, cyclosporine)

inflammatory bowel disease (UC & crohns)

MOA: anti-inflammatory. good for flares & remission

1. oral mesalamine (ex asacol) esp. active in terminal small bowel & colon.  Long acting (pentasa) works through the entire small intestine & colon. Best for maintenance
2. Topical mesalamine: rectal suppositories & enemas (ex Rowasa) Topical mesalamines are effective in the distal colon
3. Sulfasalazine - works primarily in the colon (UC) SE: higher side effect profile w/ sulfasalazine (hepatitis, pancreatitis, allergic rxn, fever, rash) give colic acid w/ sulfasalazine 

used for inflammatory bowel disease (UC and crohns)

rapid acting anti-inflammatory drugs used for acute flares

oral (prednisone, methylprednisolone) & topical (rectal suppositories, foams, & enemas)

long term risks include osteoporosis, increased infections, weight gain, edema, and cataracts

used for inflammatory bowel disease (UC & crohns)

6-mercaptopurine, azathioprine, & methotrexate

steroid-sparing agents

used for irritable bowel disease (UC & crohns)

inhibits proinflammatory cytokines 

adalimumab, infliximab, certolizumab

anti-integrins (natalizumab)

1. age > 50 (peaks 65y)
2. UC/Crohns dz; polyps
3. familial adenomatous polyps (genetic mutation on the APC gene - 100% develop colon CA by age 40
4. diet (low fiber, high in red/processed meat, animal fat)
5. smoking
6. ETOH
7. AA
8. UC
9. Peutz-Jehgers: age 20y autosomal dominant, polyposis, mucocutaneous hyperpigmentation (lips, buccal, hands)

1. iron deficiency anemia
2. rectal bleeding
3. abd. pain
4. change in bowel habits
5. intestinal obstruction
6. Right-sided (proximal) lesions tend to bleed (anemia & fecal occult blood) & cause diarrhea
7. Left-side (distal) tends to cause bowel obstruction & present later. Changes in stool diameter

colonoscopy w/ bx

barium enema (apple core lesion classic)

increased CEA

CBC: anemia

5FU mainstay of chemotherapy

surgical resection

monitor CEA w/ treatment 

1. weakness, fatigue, weight loss common
2. N/V, anorexia usually present
3. menstrual changes (generally amenorrhea), impotence, loss of libido, gynecomastia occur
4. abd. pain & hepatomegaly generally present

• ascites
• pleural effusions
• peripheral edema
• ecchymoses
• esophageal varices
• signs of hepatic encephalopathy (asteriixis, tremor, dysarhria, delrium, coma)

1. labs often minimally abnl until late in disease
2. anemia common
3. mild elevations of AST & alk phosph
4. increaed gamma-globulin
5. decreased albumin
6. abnormal coag studies
7. U/S, CT, or MRI can confirm size and number of nodules, helpful in guiding biopsy

1. abstinece of ETOH key feature
2. salt restriction & bed rest - tx for ascities, although spironolactone 100 mg daily may be added as diuretic
3. liver tranplant is indicated in selected patients
4. spontaneous bacterial peritonitis tx with abx

viral

toxins are second MCC

viral infection (hep B,C,D)

but often is caused by:

• inheritied d/o
•  autoimmune disease of liver
•  heaptic effects of systemic dz

fecal -oral

maintain a sanitary water supply & washing hands

parenteral, sexual, by mucous membranes

fatigue, malaise, anorexia, nausea, tea-colored urine

• aminotransferase elevations are seen in all types of acute hepatitis, indicating hepatocellular damage
• bili > 3 will be assoc w/ scleral icterus, if not frank jaundice
• immunoglobulin antibodies - page 113 

tenofovir w. either emtricitabine or lamivudine - Hep B

antiretroval med for HIV 

• alcohol
• acetaminophen
• carbon tetrachloride
• isoniazid
• halothane
• phenytoin

1. any discreet break in mucosa by injury, NSAIDS, stress, alcohol, or other irritants
2. H. pylori is MCC 

1. abd pain or discomfort primary clinical feature (burning or gnawaing, radiates to back)
2. dyspepsia (belching, bloating, distention, heartburn)

improves with food

(pain of gastric ulcer - worsens)

• bleeding
• perforation
• penetration

• endoscopy best 
• barium radiography cheaper but less sensitive
• detect H. pylori - serum antibody tests highly sensitive and moderately specific but cannot be used to confirm cure. Stool antigen testing is comparably sensitive, more specific, and can be used to evaluate for cure.  urea breath test can be used to test for cure but neither test for cure is accurate until 4 weeks post tx

• avoid irritating factors (smoking, NSAIDs, alcohol) 
• combination therapy for H. pylori 

• for 2-4 weeks
• PPI w/ clarithromycin & amoxicillin or clarithromycin + metronidazole 
• OR
• Bismuth subsalicylate + tetracycline, metronidazole, & PPI