Gastrointestinal — USMLE Step 2 CK Notes

Gallstones (tx if sx only)

Elective laparoscopic cholecystectomy

Acute cholecystitis, choledocholithiasis, gallstone pancreatitis —> cholecystectomy within 72hrs

Acute cholangitis. RF: PSC

Dx via US -> not definitive then HIDA: IV dye is excreted into the CBD

——> gallbladder is not visualized due to cystic duct obstruction.

MURPHYS SIGN: Cholecystitis: Cease in inspiration (catch breathe) when GB palpated

Choledolithiasis: Dx: US —-> RISK STRATIFICATION

High risk (US confirms Gallstone in CBD/ascending Cholangitis) —> ERCP +/- sphincterotomy

Int —> MRCP eg dilated CBD on US

Low —> Endoscopic US

Gallstone ileus: Episodic bowel obstruction

Gallstone the bowel through a biliary enteric fistula and creates an obstruction:

-> Usually at the ileocecal valve.

All gallstones can be visualized on a CT scan -> Dx of choice (X-ray: most gallstones are radiolucent)

Post cholecystectomy syndrome: Persistent pain after cholecystectomy

Use ERCP to directly visualise and correct causative factor

Complication of Cholecystectomy

Biliary leak: 2-10 days post op

Leukocytosis and obstructive liver enzyme pattern

—> Peritoneum can absorb most of the leak ==> Bilirubin elevation only mild

Bilious ascites can occur with large leaks

Dx: Relatively normal appearing biliary ducts/mild dilation (can be from postop state alone)

Gallstone Pancreatitis

Pancreatitis + ALT >150 has 95% PPV for gallstone pancreatitis

Once recovered early cholecystectomy indicated in all medically stable patients

Dx: US

PBC: Immune response against intrahepatic bile ducts

US suggestive of intrahepatic cholestasis (no biliary tract dilation)

—->> dx confirmed with anti-mitochondrial Ab titre

PSC: Fibrous obliteration with concentric replacement by CT in onion skin pattern

Cholestatic liver pattern of injury

Intrahepatic and/or extrahepatic ducts on cholangiography

Complications: Cholangitis/cholelithiasis; Cancer; Cholestasis d/t stricture/fibrosis: ## Malabsorption

Dx: MRCP

Management: Endoscopic interventions for strictures; ursodeoxycholic acid for some

Acalculous Cholecystitis: Acute inflamm of GB in absence of gallstones

Critically ill patients

Normal LFTs do not rule out dx

Dx: Abdo US

Tx: Enteric antibiotic coverage; Cholecystectomy once stable

Malignant biliary obstruction

Pancreatic/hepatocellular or Mestastases

Cholangiocarcinoma: Increased CEA/CA 19-9, norm AFP

RF: PSC (UC) and fibrocystic liver disease

Norm CBD (cf pancreatic)

Dx: Endoscopic US or ECRP

Emphysematous Cholecystitis

Life threatening acute cholecystitis d/t infection w gas forming bacteria ===> Clostridium; E Coli

Crepitus in abdo wall adj to GB sometimes detectable

Complications: Gangrene and perforation (transiently relieves pain)

Dx: Air fluid levels in GB, gas in GB wall and sometimes pneumobilia

==> extensive gas in GB wall may be falsely interpreted as overly bowel loops

Small elevations in LFTs and norm alk phos

Tx: Emergency cholecystectomy

Isolated Hyperbilirubinaemia

Unconjugated: Overproduction ——> Hemolytic Anemia

Defective Conjugation —-> Gilbert Syndrome or Crigler Najjar Syndrome

Conjugated: Defective Excretion

Crigler Najjar: NO UDP glucoronyltransferase (UGT)—-> Type 1 fatal

Tx: Plasmaphoresis removes albumin (tightly bound to Bilirubin); Liver transplant only definitive

Phenobarbital induces UGT (Type 2)

Gilberts: Decreased UGT

Dublin Johnson: Can’t excrete conjugated Bilirubin; Black Liver Can be triggered by illness, pregnancy or OCPs

Rotor Syndrome: Resembles Dublin Johnson w/o black liver; increased urinary coproporphyrin

Biliary Cyst: Extrahepatic single cystic dilation of bile duct

Triad: Pain, jaundice and palpable mass

Most present at age <10 years -> Older children can present with pancreatitis

Dx: Visualisation/US; ERCP

Tx: resection (also prevents malignant transformation)

Bowel Sounds

Hyperactive: obstruction

Gallstone ileus (mechanical obstruction)

High pitched: Incomplete Obstruction!

Inaudible/absent:

Peptic ulcer perforation

Complete obstruction

Peritonitis

Decreased (hypoactive)

Peritonitis/infection

Perforation

Peritonitis

Marked Abdo rigidity with guarding —-> mild guarding d/t peritoneal irritation

Rebound tenderness

Weight loss medications: BMI <40 w/o weight related comorbidity (bariatric needed)

Orlistat

Lorcaserin; Naltrexone/buproprion; Phentermine/topiramate; Liraglutide

HyperTriglyceridaemia —> classic sign is striate palmer xanthomas

Blood samples milky and opalescent

Fibric acid derivatives: Fenofibrate

High LDL

Statins

Cholestyramine (bile acid-binding resin) —> can cause increase in TG

Ezetimibe; prevents absorption of dietary cholesterol from gut —>> works best in combo with statin

Pancreatitis

Associated with anatomical defects etc

Initially d/t leak of pancreatic enzymes -> Late d/t pancreatic necrosis

Px determined by Ranson criteria: BUN; Calcium; Hematocrit etc

Acute Pancreatitis: US -> CT

RF: trauma, hypercalcaemia, hyperlipidaemia, drugs (thiazides/sulfa, HIV drugs), neoplasm

Acute epigastric pain radiating to the back, fever, Tachycardia, hypotension etc

Dx: US to assess for gallstones CT w contrast —-> confirmatory/shows complications/ US uncertain

Tx: hydration, pain control with opioids, NG suction, NPO, stop offending agent

Debridement of necrotic tissue

Abs not used unless evidence of infection

Complications: Abscess, fistula, renal failure, hemorrhage (Grey Turner Sign, Cullen Sign)

Shock, DIC, sepsis, respiratory failure (ARDs)

NB: amylase half life is 10 hrs so those presenting beyond this may have normal amylase levels!

Lipase more sensitive

Can be d/t cholesterol emboli —> cardiac cath/vascular procedure

Livedo reticularis w blue toe syndrome; AKI; Pancreatitis and Mesenteric ischemia

Ranson Criteria for Px during acute pancreatitis:

Increased mortality associated with admission values of: GA LAW -> Glucose; AST; LDH; Age; ## WBC

Increased mortality associated if values during initial 48hrs post admission: Calvin & HOBBeS

Calcium (low); Hct decrease; PaO2; BUN increase; Base deficit; Sequestration of fluid >6L

Chronic Pancreatitis: CT -> MRCP

Malabsorption; Mildly increased amylase+lipase, glycosuria, low fecal elastase

Pain relieved by leaning forward or sitting upright

Dx: calcifications, pancreatic enlargement or pseudocyst

Tx: opioid analgesia, enzyme supplements, dietary modification (small, low fat meals)

Complications: Ductal obstruction, pseudocyst, malnutrition, glucose intolerance, pancreatic cancer

Pseudocyst: enzyme rich fluids contained in sac of inflamed membranous tissue

Increased WBC, amylase; aspiration shows v high amylase content

Visible on US or CT

Tx: poss self resolving —-> if no sx then expectant management;

—> endoscopic drainage if lasts >6wks, painful or rapidly growing

Complications: rupture, abscess or pseudoaneurysm (digestion of adj vessels);

Pancreatic ascites; duodenal/biliary obstruction; spontaneous infection

Pancreatic Cyst (not pseudocyst)

Some carry higher risk of malignancy:

Large: >3cm; Solid components/calcifications; Main pancreatic duct involvement (eg dilation)

Thickened, irregular cyst wall

-> endoscopic US guided biopsy for high risk cyst before resection

—-> resection carries high risk for mobility and mortality

V Large (>4cm) adenomas should be removed —-> biopsy not needed

Pancreatic fistula

D/t acute or chronic pancreatitis; iatrogenic

Exudative pleural effusion: amylase rich; PH 7.3 -7.5

Management: Bowel rest to avoid pancreatic stimulation ———> enables fistula to close

ERCP/Stent to promote drainage via ampulla of Vater and not fistula

Exocrine Pancreatic Cancer:

Adenocarcinoma most common in head of pancreas

RFs: chronic pancreatitis, tobacco, high fat diet

Constant epigastric pain (worse at night) radiating to back; Malabsorption

Painless Jaundice if bile duct obstructed —>>>>> Palpable, nontender GB (Courvoisier Sign)

Splenomegaly if in tail, palpable deep Abdo mass, ascites

Labs: CEA and CA 19-9 tumour markers

Initial Test either US or CT:

Abdo US if jaundiced (pancreatic head)

CT w contrast if not jaundiced —> necrosis (body/tail) and metastasis; excludes other conditions

Endoscopic US good to guide FNA biopsy

Tx: limited to head: Whipple procedure: pancreatic head, distal stomach to proximal jejenum,

CBD+GB

Enzyme replacement; Endoscopic Stenting

Complications: Migratory thrombophlebitis (Trousseau Sign)

Endocrine Pancreatic Cancer: neuroendocrine

Zollinger Ellison Syndrome -> Secretin stimulation test —> gastrin rises

Insulinoma: Headache, visual changes, confusion, weakness, mood instability, palpitations,

Dx: Labs + CT

Tx: resection, diazoxide or octreotide to relieve sx in non resectable

Whipple’s Triad: sx of hypoglycaemia, hypoglycaemia, improvement in sx with carb load

Glucagonoma: alpha cell tumour -> May present as refractory DM

Abdo pain, diarrhoea, weight loss

Exfoliating rash (necrolytic migratory erythema) -> skin biopsy

Dx: CT

Tx: resection if localised, octreotide, IFN alpha -> often malignant w liver mets

Somatostatinoma: delta cell tumour -> blocks everything!

Achlorhydria (blocks gastrin); stones (blocks CCK); steatorrhea (blocks secretin); DM (blocks ## GLP)

VIPoma: Watery (secretory) diarrhoea (metabolic acidosis) Flushing and achlorhydria

Hypokalaemia d/t intestinal increased secretion, hypercalcaemia

Hyperglycaemia d/t increased glycogenolysis;

Tx: resection, corticosteroids, chemo, octreotide and embolisation in metastatic

Atraumatic Splenic Rupture

Decreased Bowel Sounds -> Intraperitineal free fluid on imaging

Life Threatening Complication of:

Haematological malignancy; Inflamm disorders (SLE, pancreatitis); Anticoagulation, G-CSF;

Infection (CMV, EBV, Malaria) and Splenic congestion (pregnancy, cirrhosis)

Kehr Sign: Referred L shoulder pain

Acute Anemia

Tx: Catheter based angioembolisation in stable pts or Splenectomy

Acute Hepatitis

Mild/moderate aminotransferase elevation (<500u/l) possible

Viral Hepatitis:

ALT> AST in the 1000s

A: Picornavirus; Dead Vaccine prior to travel

B: Body fluids esp sexual contact

Tx: IFN alpha/ antivirals (eg lamivudine), Majority resolve

C: Flavivirus (ssRNA), blood and poss sexually transmitted, NO Vaccine

Tx: IFN alpha; ribavirin, most develop chronic hepatitis

D: Delta agent (incomplete ssRNA), bloodborne but needs Hep B

Superinfection worse ——-> already has Hep B

Tx: IFN alpha, Hep B vaccine,

E: Calicivirus (ssRNA), F/O, water, self limited but high maternal mortality

Hepatitis B key serology. Most cases resolve!

Previous disease: HBs Ab + IgG to HBc

Vaccination: HBs Ab only PEP: Vaccine + Ig

Positive HBeAg shows active viral rep

Window period: Disappearance of HBsAg and appearance of anti-HBs

Best marker of acute infection: HBsAg and IgM Anti-HBc (window period) Hep B associated with Polyarteritis Nodosa

Acute Hep B may present as serum sickness like illness

Hepatitis C -> Chronic infection Asymp or non specific sx eg fatigue nausea and weight loss etc

Increased or normal transaminases

20% progress to cirrhosis

HEPATITIS A

Vaccine or IgG (CI to vaccine) if: Close personal contacts; Child care centre; Food prep workers

Cryoglobulinemia

Lymphoproliferative or haematological (eg multiple myeloma)

Hyperviscosity (eg blurry vision); thrombosis (eg Raynauds)

Skin: Livedo reticularis; palpable purpura

D/t immune complex deposition ==>> in bvs ==>> endothelial injury and end organ damage

Low complement; can have + rheumatoid factor

Associations: Chronic HCV, SLE

Systemic sx: Fatigue, arthralgias

Renal: Glomerulonephritis; HTN; Membranoproliferative Glomerulonephritis

Tx: Tx underlying disease; plasmapheresis and immunosuppression

Porphyria Cutanea Tarda: Hep C Association

Photosensitive skin that develops vesicles and bullae with trauma or sun exposure

Healed lesions scar and can form hypo and hyper pigmented areas

Tx: serial phlebotomy or hydroxychloroquine (excretes uropor.)

Alcohol and estrogen most common triggers of flares

Acute Intermittent Porphyria

AD: Reduced activity of porphobilinogen deaminase

Exacerbated by P450 Inducers inc sulfonamides; physiological stress; alcohol and tobacco

Abdo Pain; Peripheral neuropathy; Neuropsych manifestations; AN Dysfunction

Red tinged urine that oxidises w light/air exposure

Dx: Elevated serum and urine PBG, ALA, Porphyrins +/- hyponatraemia, elevated transaminases

Tx: Glucose w hemin (heme analogue)

Autoimmune hepatitis

Can progress to fulminant liver failure and/or cirrhosis

Elevated LFTs (hepatocellular pattern)

Elevated autoantibodies: anti SM; anti liver/kidney microsomes type 1; antinuclear (nonspecific)

—> hypergammaglobilinaemia w gamma gap (increased total protein in blood)

Portal and periportal lymphoplasmacytic infiltration

Tx: Prednisone +/- azathioprine

Irritable Bowel Syndrome

Chronic Abdo pain+irregular bowel habits

Half of pts have comorbid psychiatric disorder

Tx: assurance, high fibre diet, poss psychosocial therapy, antispasmodic, antidepressants (TCAs),

serotonin R antags can lessen sx

Inflammatory Bowel disease

Corticosteroids to induce remission during flare up

Metronidazole for ANY ulcer/abscess Pyoderma Gangrenosum: Do not give Abs! Tx IBD

Crohn’s Disease:

Non caseating granulomas, skipped areas; Distal ileum most commonly affected Perianal disease but rectum often spared

Watery diarrhoea, mimics appendicitis

Dx: Colonoscopy: cobblestoning (focal ulcers next to norm mucosa)

Bowel edema on barium swallow (and string sign)

Tx: sulfasalzine metabolised into Mesalasine (5 ASA) —->> MAINTAIN REMISSION

Broad spec Abs, corticosteroids, immunosuppressives (azathioprine)

Anti TNF: Infliximab (good for fistula) —->> Fistula give Metronidazole

Complications: Abscess, malabsorption (Fe deficiency anemia)

Smoking increases risk

Ulcerative Colitis: Crypt Abscess; pseudopolyps; no granulomas

Continuous starting at rectum+extending poss to distal ileum

Bloody diarrhoea, tenesmus

Barium shows lead pipe colon w/o haustra + colonic shortening

Tx: Mesalasine (5 ASA) —->> MAINTAIN REMISSION

iron supplement, corticosteroids, immunosuppressives, colectomy curative

Metronidazole +/- ciprofloxacin in those who do not improve/tolerate 5 ASAs

Complications: Significant risk of colon cancer, toxic megacolon

Smoking decreases risk

Toxic Megacolon:

Tx: IV steroids, NG tube for decompression, fluids, correct electrolytes and broad spec antibiotics

Colonoscopy 8 yrs post dx then every 1-2 yrs

Bowel obstruction: Indirect inguinal far more common than direct regardless of age

Small Bowel Obstruction. Amylase may be slightly raised!!!!!

Fever; Distended, tympanic abdomen; visible peristaltic waves

Postprandial pain relieved with vomiting (decreased intra abdo pressure)

Complete -> no air in colon (cf partial -> air)

Tx: NPO, hydration, nasogastric decompression may relieve obstruction, surgery if unresponsive

Dx: X-RAY best initial; CT diagnostic

Complications: Strangulation (ischaemia/necrosis); perforation

Large Bowel Obstruction

Dx: CT w contrast (gastrograffin used if perf suspected)

Tx: NPO, hydration, colonoscopy may relieve obstruction, surgery

Ischemic Colitis:

Bloody diarrhoea, vomiting; Increased WBC and serum lactate; Fever possible

CT w barium contrast initial test:

-> diffuse submucosal changes from localised bleeding (thumb printing) +bowel wall thickening

Dx: Endoscopy: bloody + edematous, friable mucosa

Tx: IV fluids, bowel rest, antibiotics for GI bacteria, surgical resection of necrotic bowel

Left side more commonly affected -> Potential complication of aortic graft d/y loss of IMA

Abdo pain less severe than in SI ischemia (severe and out of proportion to examination)

Appendicitis

D/t lymphoid hyperplasia (kids), fibroid bands (adults) or fecaliths (adults)

Tenderness at McBurney point (1/3 distance from R ASIS to umbilicus)

Rebound tenderness, psoas sign (psoas pain on passive hip extension)

Fever, Rovsing sign (RLQ pain with LLQ palpation)

Dx: CT w contrast most sensitive test: In pregnant/children US preferred test

Targetoid

Tx: Appendectomy, antibiotics (GNs+anaerobes) if ruptured

Complications: Abscess (post 48hrs after sx), perforation

Contrast

CT w/o contrast: caliculi; retroperitoneal hematoma or CI (eg renal)

Otherwise use contrast!

Ileus

Paralytic obstruction of bowel secondary to decreased peristalsis

D/t infection, ischemia, recent surgery, DM, opioids, hypothyroidism

No rebound tenderness

AXR shows distension of affected bowel w air in colon/rectum

Barium enema helps rule out obstruction

Tx: Stop opioids, NPO, colonoscopic decompression if no resolutions

Postoperative ileus typically lasts <5dys Prolonged postop ileus -> >72 hrs post surgery ==> Tx: Bowel rest and serial examinations

LOW ALBUMIN: norm is 3.4-5.4 AST: LIVER or Muscle (check CPK or CK)

ALP: Liver or Bone (GGT shows liver)

AST:ALT—->>> 2:1: Cirrhosis or EtOH Hep

Liver enzymes in the 1000s: 6As: A cetaminophen A flatoxin A utoimmune Hepatitis: ANA + antismooth muscle Ab A cute Hep (inc ischaemic): viral ALT>AST

A clot (Budd-Chiari) H ypotension

Jaundice:

Hemolysis: Unconj Bilirubin increased as overwhelms liver (prehepatic)

Obstruction: Conj Bilirubin spills back in to blood stream (posthepatic)

Wilson’s Disease

Mallory Bodies

Macrovesicular steatosis, vacuolated hepatocellular nuclei

Moderate inflamm, portal fibrosis and hepatocyte necrosis

Kayser Fleisher rings in cornea

Thrombocytopenia in chronic liver disease, poor px

Enlarged spleen d/t congestion from blocked portal system; Plts pool

Decreased Thrombopoeitin production by liver

Increased Plt destruction via various paths

Hereditary Hemochromatosis

Arthritis with chondrocalcinosis (calcium pyrophosphate): MCP joints

Increased risk of infections from Listeria, vibrio vulnificus and Yersinia enterocolitica

DM; Hypogonadism; Hypothyroidism; Pseudogout

Cardiomyopathy and conduction abnormalities

Bronze diabetes: hyperpigmentation

Elevated LFTs w hepatomegaly, cirrhosis and increased risk of HCC

Non alcoholic fatty liver disease

+/- Steatohepatitis (AST/ALT ratio <1) -> macrovesicular steatosis

——>>> LFTs can be normal

SIBO

Anatomical abnormalities: stricture, surgery (bypass); Motility disorders; hypochlorydia (eg PPIs)

Abdo pain, diarrhoea, bloating and flatulence

Malabsorption (Decreased urinary/venous D Xylose levels);

—-> weight loss, anemia, deficiencies in fat soluble vitamins, steatorrhea

Low B12, high Folate

Dx: Jejunal aspirate and culture; Carb breath testing (lactulose, glucose)

Tx: augmentin, Rifaximin; avoid antimotility drugs; high fat/low carb diet; promotility ## (metaclopramide)

False positive D Xylose (i.e. not d/t decreased mucosal absorption):

SIBO

Delayed gastric emptying

Hiatal hernia Herniation of part of stomach above diaphragm:

Sliding: GEJ and stomach displaced through diaphragm (95%)

Paraoesophageal: Stomach protrudes through diaphragm but GEJ remains in normal location

Sometimes associated with GERD

CXR: Air in stomach may be visible above diaphragm (best initial)

Dx: Barium Upper GI Series

Tx: sliding treated with observation and poss reflux control; paraoesophageal need surgery

Risk of incarceration of stomach in herniation in paraoesophageal type (type 2)

Gastritris

Acute (erosive) or chronic (nonerosive)

Acute: secondary to NSAID, alcohol, corrosive materials, or stress from severe illness:

-> Curling d/t burns; Cushing d/t intracranial bleed

Any region of stomach

Chronic: Type A (10%): Fundus -> AutoAbs for parietal cells,

Type B (90%): Antrum: Helicobacter pylori

Increased acid levels

Associated with Peptic ulcer disease and gastric cancer: MALToma

Dx: EGD detects lesions and biopsy

Tx: Stop alcohol/NSAIDs

Pernicious Anemia ===>> high risk for adenocarcioma gastric cancer

Peptic Ulcer Disease: impaired endothelial defences and increases gastric acidity

Risk Factors: tobacco, alcohol, corticosteroids

Burning epigastric pain that changes upon eating

Positive urea breath test, IgG Abs or biopsy to detect H pylori

->> postprandial epigastric pain+early satiety

Barium swallow AXR shows collections of barium in ulceration (irreg filling defects)

Dx: EGD to show active bleeding and biopsy; rule out adenocarcinoma

Duodenal ulcer: Nocturnal pain d/t circadian rhythm of gastric acid secretion

Tx: Decrease acid with PPI/H2 antag

Protect mucosa with sucralfate, bismuth subsalicylate or misoprostol

Eliminate H pylori

Complications:

Posterior ulcers may erode into gastroduodenal artery

Anterior ulcers more common and result in perforation

Lymphoproliferative disease

Give COX2 selective NSAID in PUD if NSAID required

Triple Therapy

PPI; clarithromycin; amoxicillin/metronidazole

Quadruple Therapy (Hx of Macrolide exposure or Pen allergy)

PPI; bismuth subcitrate; metronidazole; tetracycline

Zollinger Ellison Syndrome

Gastrin producing tumour frequently in duodenum (70%) or pancreas

Associated with malabsorption disorders

Refractory PUD

Increased fasting gastrin (PPI must be stopped prior to test)

Positive secretin stimulation test: Secretin admin results in higher than expected gastrin levels

Dx clinical

Tx: Resection; PPI and H2 Antag may ease sx

Octreotide may help sx in metastatic disease

Associated with MEN1; 60% lesions malignant

Acute Erosive Gastropathy. Cocaine + alcohol binge!

Development of severe hemorrhagic lesions after exposure of gastric mucosa to various injurious agents or after substantial reduction in blood flow

Aspirin and alcohol directly damage mucosa; Aspirin also decreases PGs

Cocaine reduces blood flow

Hematemesis with abdo pain

Gastric Cancer: Adenocarcinoma most common

Types:

Ulcerating: resembles PUD

Polyploid: large, intraluminal neoplasms

Superficial spreading: mucosal+submucosal involvement only, best px

Linitis Plastica: involves all layers, decreased stomach elasticity, worst px

Risk Facters: Japanese person living in Japan, tobacco, alcohol, Vit C deficiency, preserved foods

Worse on eating d/t gastric acid irritation of cancer

Enlarged Left supraclavicular node (Virchow) or periumbilical node (Sister Mary Joseph)

Increased CEA, increased 2-glucuronidase in gastric secretions, anemia if active bleeding

Barium may show mass or thickened ‘leather bottle’ stomach; Biopsy for dx (EGD)

Staging via CT needed prior to tx

Tx: gastrectomy -> Metastasis to liver common

Cachetic state: increased TNF

Weight loss, muscle atrophy, fatigue all mediated by cytokines

Appetite is usually suppressed (via hypothalamus); BMR is increased

Malabsorption disorders

Assay of stool fat most sensitive initial test: 48-72hr stool collection and Sudan stain

Sudan stain positive indicates steatorrhea: Do xylose test

Abnorm -> SI mucosal issue, norm indicates pancreatic insufficiency

False positive xylose test: delayed gastric emptying, impaired GF, SIBO

Negative Sudan stain: do stool pH

Low indicates lactase deficiency, if normal do Schilling Test: iliac disease or intestinal overgrowth

Sx: Large volume diarrhoea; steatorrhea; borborgmi (loud bowel sounds); weight loss

Celiac Disease (gluten sensitivity enteropathy) Genetic Gluten intolerance —-> villous atrophy —-> Malabsorption

IgA anti tissue transglutaminase and antiendomysial Abs and anti Gliadin Abs in serum

—-> OR NOT d/t selective IgA Deficiency (common in celiac disease)

Failure to thrive, bloating and abnormal stools in infants

Diarrhoea, steatorrhea (foul smelling), weight loss, iron def anaemia (beefy red tongue)

Osteomalacia (bone pain),osteoporosis; Easy bruising (Vit K); hyperkeratosis (Vit A)

Subepidermal grouped (herpetiform) microabscesses (blisters) -> Intensely pruritic

Some pts show depression, anxiety, ecchymoses/edema (malnutrition) or arthralgias

Associated with Down’s syndrome and dermatitis herpetiformis (tx with Dapsone)

Blunting of jejenal and duodenal villi on biopsy

Refractory Disease may need corticosteroids

Topical sprue

Similar to celiac but does not improve with elimination of gluten

Possible infectious or toxic etiology

Acquired disorders living in tropical areas, can present yrs after leaving tropics

Folic acid replacement, tetracycline

Lactose intolerance

D/t lactase deficiency (brush border enzyme)

Adult onset Diarrhoea, Abdo pain, flatulence and bloating after dairy

Positive lactose intolerance test: minimal increase in serum glucose after lactose consumption

Dx: Positive lactose breath hydrogen test after lactose meal

Tx: Diet restriction, lactase replacement may benefit some

Whipple disease

Secondary to Tropheryma whippelii infection

Likely immunodeficiency

Risks: White M of European ancestry

Weight loss, joint pain, Abdo pain, diarrhoea, dementia, cough, bloating, steatorrhea, fever

Vision abnormalities, LAD, new heart murmur, severe wasting in late diseases

Dx: Jejenal biopsy shows foamy macrophages on PAS stain with villous atrophy

Tx: TMP-SMX or ceftriaxone for 12 months

High mortality if untreated

Areas of absorption Duodenum: Folate, calcium, Mg, iron

Duodenum+jejenum: Glucose, galactose, fat soluble vitamins A+D

Jejenum+ileum: Water soluble vitamins (Bs), ascorbic acid, folic acid

Colon: potassium, NaCl, and water, some SCFAs

Dumping Syndrome

Post gastrectomy complication: 15-30 min after meals

D/t loss of norm action of pylori sphincter d/t injury/surgical bypass

-> rapid emptying of hypertonic gastric contents into SI -> Fluid shifts from intravascular space to SI

———> hypotension, Stimulation of AN reflexes and release of vasoactive polypeptides

Abdo pain, diarrhoea, nausea; Dizziness/confusion, fatigue, diaphoresis

Tx: Diet modification: small carb light foods (use complex carbs); high fibre and protein rich foods

Drink fluids between rather than with meals

Sx usually diminish with time

Octreotide/surgery is refractory

Diarrhoea

Acute: <2 wks duration usually d/t infection

Chronic may be d/t malabsorption or motility disorders (lactase def most common cause)

Secretory: usually hormone mediated (eg VIPoma) or d/t enterotoxic bacteria or CF

Occurs when fasting and asleep as well as after food

Bile acid diarrhoea post cholecystectomy/bowel resection: give choletyramine

Osmotic: Occurs after eating, lessens with fasting (d/t malabsorption/laxatives -> norm ## Sudan)

High osmotic gap in stool

Inflammatory: d/t autoimmune process or chronic infection

Acute: If high fever, bloody or >5 days likely bacterial, protozoan or parasitic

Stool culture; stool acid fast stain; fecal WBCs (enteroinvasive bacteria), ova, parasites

Hydration+antibiotics

Chronic: Measure stool pH, lactose tolerance test; Colonoscopy

Osmotic gap: 290-2(Na+K) <50 is normal

290-2(Na+K) >125 is high

Viral Gastroenteritis: No fecal WBCs Self limiting (48-72 hrs); Myalgias, low grade fever

Norwalk virus, Coxsackie A1, Echovirus and Adenovirus; Rotavirus most common in children

Tx: Maintain hydration

Bacterial Gastroenteritis: Usual d/t food contamination

B cereus: Rice, vomiting within hrs of eating, diarrhoea later

C jejuni: Poultry, Bloody diarrhoea, GBS, self limiting/erythromycin, second most common

C botulinum: 4Ds; Cleaves snare and I Ach release at NMJ

C. difficile: watery/bloody diarrhoea, grey pseudomembranes on colonic mucosa,

Toxin A is enterotoxin; toxin B is a cytotoxic that depolymerises actin

E. coli (enterotoxigenic): travellers diarrhoea (watery), vomiting+fever, self limit/fluoroquinolone

E. coli 0157:H7: Bloody diarrhoea, antibiotics may worsen d/t toxin release; HUS (self limited norm)

S aureus: D/t preformed toxin, room temp food (lack refrigeration), same as B cereus

Salmonella spp: Eggs, poultry, milk, bloody/watery diarrhoea, Tx immunocompromised with FQ

Shigella spp.: associated with overcrowding, severe bloody diarrhoea, HUS

Self limited/Ciprofloxacin or TMP-SMX if severe

V cholerae: copious watery diarrhoea, tetracycline/doxycycline decreases disease length

V parahaemolyticus: seafood (oysters), watery diarrhoea within hrs of eating

Y enterocolitica: Pork, fresh produce, bloody diarrhoea, RLQ pain+fever

Parasitic Gastroenteritis

Giardia: cysts+trophozoites in stool,

E. Histolytica: bloody diarrhoea, cysts+trophozoites in Stool, metronidazole, paromomycin

C parvum: Food/water, watery diarrhoea, acid fast stain of stool shows parasites,

Tx: nitazoxanide in immunocompetent (HAART if HIV)

T spiralis: undercooked pork, fever, myalgias, periorbital edema, eosinophilia,

Tx: albendazole

T solium: Intestinal: Ingestion of cysts in undercooked pork, nausea+Abdo pain,

Tx: praziquantel

Cysticercosis: Eggs from feces of human with intestinal taeniasis

Tx: albendazole+corticosteroids

Diverticulosis

Outpouchings of submucosa+mucosa that herniate through muscular layer

Incresased intraluminal P

Occasional cramping, bloating, flatulence, irregular defecation

Vague LLQ pain relieved by defecation

Poss painless rectal bleeding if erosion into blood vessels

Dx: Colonoscopy W BARIUM ENEMA (avoid in acute diverticulitis)

Diverticulitis

Poss palpable mass,

Dx: CT w contrast

Barium enema and colonoscopy CI d/t risk of perforation

Tx: Uncomplicated (no fever etc): Oral Abs

Complicated -> Inpatient: NPO w IV Abs

Complications of diverticulitis: Abscess: MOST COMMON

Colovesical fistula: Pneumaturia; pain on urination

Obstruction; perforation—-> peritonitis

Rectal conditions

Haemorrhoids

Internal d/t superior rectal veins above pectinate line (columnar epi): portal

Intermittent itching, painless bleeding, leakage of stool

Dx: DRE/Anoscopy (unless prolapsed)

External d/t inferior rectal veins below pectinate line (squamous epi): caval

Dusky/purple/lump or polyp; itching, bleeding

Thrombosis —> acute enlargement w pain —-> blue/purple bulge at all verge

Tx: warm baths, increased fibre, avoid prolonged straining

Anal Fissures (tears): secondary to trauma during defecation/anal intercourse

Tx: stool softeners, sitz baths, topical nitroglycerin (second line), partial sphincterotomy if recurrent

Nifedipine

Rectal Fistula

Unknown cause/secondary to IBD or abscess

Mild pain during defecation; poss visible site draining pus

Tx: fistulotomy; metronidazole if crohns

Pilonidal Disease

One or more cutaneous sinus tracts in superior midline gluteal cleft

Obstruction of sinus tract (hair/debris)

—->> mildly painful cyst/abscess + drainage (poss purulent)

Tx: incision+ drainage of abscesses; surgical closure of sinus tracts may prevent recurrence

Carcinoid Tumour

Poss asymp, Abdo pain, poss carcinoid syndrome:

Flushing, diarrhoea, bronchoconstriction, tricuspid/pulm valvular disease

-> Only seen with liver metastases or extraGI involvement (first pass)

Increased 5HIAA in urine; increased serum serotonin

CT or indium labelled octreotide scintigraphy can localise tumour

Tx: Metastatic disease tx with IFN alpha, octreotide and embolisation

Dysphagia (if oesophageal)

Dysphagia of solids progressing to liquids (mechanical obstruction)

Hx of radiation, caustic injury, stricture or surgery —> barium swallow then upper EGD (if higher risks)

NM Disorders (dysmotility): Achalasia, motility disorder, Scleroderma

-> limit swallowing of liquids+solids -> Barium swallow then manometry

Manometry may detect NM abnormality

Obstruction: Peptic strictures, oesophageal webs/rings, cancer, radiation fibrosis

-> Tends to limit swallowing of solids

Food ‘stuck in throat’, cough

Vascular ring dysphagia to solid food; level T3/4 aortic arch compresses oesophagus

Oropharyngeal Dysphagia:

Dysphagia w hx of difficulty initiating swallowing (cannot transfer food from mouth to pharynx)

Swallowing w cough, choking or nasal regurgitation

Dx: Videoflouroscopic modified barium swallow

RISK OF ASPIRATION

Achalasia

Aperistalsis and decreased LES relaxation d/t intramural neuron dysfunction (Auerbach)

Idiopathic, secondary to Chagas, neoplasm, scleroderma

Manometry-> GOLD STANDARD for Dx

Widened mediastinum on CXR; Barium swallow shows birds beak sign; EGD to rule out malignancy

Tx: nitrates and CCBs relax LES

Pneumatic dilation, Botox or Myotomy relieve obstruction

Diffuse oesophageal spasm

NM disorder where nonperistaltic contractions of oesophagus occur; norm LES

Chest pain, dysphagia

Dx: Manometry shows uncoordinated contractions

Barium shows corkscrew pattern (not specific)

Tx: CCBs, nitrates or TCAs may aid chest pain and dysphagia

Nitrates and CCBs worsen GERD (relax LES)

Zenker diverticulum

Outpouching in upper posterior oesophagus d/t SM weakness: Pseudodiverticulum

Bad breath, diff initiating swallowing, regurgitation of food several days post eating,

‘gurgling’ sound

Occasional dysphagia, feeling of aspiration, neck mass that increases in size while drinking fluids

Dx: Barium swallow Gold Standard: contrast traps in pouch

—-> between inferior pharyngeal constrictor fibres and cricopharyngeus muscle

Tx: cricopharyngeal Myotomy/diverticulotomy

GERD: Low P in LES

Risks: obesity, hiatal hernia, pregnancy, scleroderma

Sour taste in mouth, regurgitation, odynophagia, nausea, cough

Pain may worsen lying down and improve standing up

Radiology not needed for dx, use to rule out neoplasm etc

Tx: Elevation of head of bed, weight loss, diet

Antacids, H2 antagonists/PPIs

Refractory disease treated with Nissan fundoplication/hiatal hernia repair

Gold standard dx test is 24hr intraesophageal pH monitoring but rarely used

ANTACIDS: calcium carbonate etc

Aluminium hydroxide can cause constipation and magnesium can cause diarrhoea

H2 ANTAGS: Cimetidine can cause gynecoimastia+impotence

Headache, diarrhoea, thrombocytopenia

PPIs: May increase effects or warfarin, benzodiazepines or phenytoin

Oesophageal Cancer

Squamous cell carcinoma more common worldwide

Adenocarcinoma more common in US: Barrett oesophagus: intestinal metaplasia

Metaplasia: one differentiated cell to another differentiated cell d/t stress

Progressive dysphagia (eventually includes liquids), cough, hoarseness

Tx: esophagectomy if early stage, radiation and chemo if adv; Poor px

Oesophageal Stricture: Symmetric and circumferential narrowing

Dysphagia for solid foods but typically no weight loss

Causes: GERD, radiation, systemic sclerosis, caustic ingestion

Eosinophilia esophagitis; refractory heartburn; atopy and food impaction (d/t stricture formation)

Trachealisation of esophagus —->> multiple, stacked, ring like indentations

Food Impaction —->> Drooling, hypersalivation and inability to tolerate liquids are cardinal sings

Pill induced Esophagitis. Discrete ulcers

Most common in middle third d/t compression by aortic arch/enlarged LA

Mucosal Injury d/t acid effects (tetracyclines), NSAIDs, aspirin, biphosphonates, KCl and Fe

Odonyphagia, dysphagia

Ingestion of caustic substance: EGD within 24hrs

Acidic substances: Coagulative necrosis eg protein denaturation

——>> eschar; prevents deep penetrative injury

Alkaline substances (cleaning products): Liquefactive necrosis ——>> deeper more severe injury

OESOPHAGEAL chest pain

Oesophageal motility disorders; food regurgitate -> Relieved by anti reflux meds

Prolonged pain lasting >1hr; Postprandial

Associated with heartburn/dysphagia and/or chest pain

Angiodysplasia of Colon (vascular malformations) Tortuous dilated veins in submucosa (usually proximal colon) and AVMs

Common cause of lower GI bleeding in those over 60 -> most bleeding stops spontaneously

Dx: endoscopy (preferred over angiography)

Tx: endoscopic coagulation of lesion/right hemicolectomy

Associated with aortic stenosis

Acute mesenteric ischemia: SI

Usually Superior mesenteric vessels

4 types (3 arterial, 1 venous) starting with most common:

Arterial embolism > Arterial thrombus > Venous thrombosis

Nonocclusive mesenteric ischemia: Splanchnic vasoconstriction d/t low cardiac output

—> Typically seen in critically ill elderly

Severe Abdo pain disproportionate to physical findings; Mild GI bleeding

Dx: Mesenteric Angiography test of choice. (CT best initial)

Thumb printing on barium enema d/t thickened edematous mucosal folds

Signs of intestinal infarction:

Tx: Supportive; dependent on etiology

Direct intraarterial infusion of papaverine (vasodilator) if occlusive cause

Direct intraarterial infusion of thrombolytics/embolectomy

Heparin if venous thrombosis type

Surgery (resection of nonviable bowel) if signs of peritonitis/dead bowel:

Avoid vasopressers as can worsen ischemia

Chronic Mesenteric Ischemia

D/t atherosclerotic occlusive disease of main mesenteric vessels

Abdominal angina: Dull pain, typically postprandial

Significant weight loss

Dx: Mesenteric arteriography test of choice

Surgical revascularisation definitive tx

Ogilvie Syndrome: evidence of colon obstruction (marked DISTENSION) w/o mechanical obstruction

D/t recent surgery/trauma, serious illness/infection, medications

Electrolyte derangement (diuretics/diarrhoea); neuro disorder (dementia/stroke)

===> AN disruption of colon

Dx: CT rules out mechanical obstruction

Tx: stop offending agent, IV fluids, electrolytes etc

Decompression with gentle enema or nasogastric suction or surgery

Neostigmine if no improvement within 48hr

Pseudomembranous Colitis

Antibiotic associated as many pts don’t have grossly visible pseudomembranes

Frequently clindamycyin, ampicillin and cephalosporins

Profuse watery diarrhoea w Crampy Abdo pain

Toxic megacolon with risk of perforation: dx clinical + X-RAY

Dx: C Dif. Toxins in stool

Abdo radiograph (rule out toxic megacolon+perforation)

Tx: Discontinue offending agent

Oral vancomycin/fidaxomicin new DOC Metronidazole cannot be used in kids or pregnant: IV in megacolon with PO/PR Vanc

Chronic Ischaemic colitis: Mucosal atrophy and granulation tissue

Microscopic Colitis

Chronic watery diarrhoea w/o evidence of lactose intolerance or systemic sx

Fecal urgency, incontinence and nocturnal diarrhoea (CLASSIC)

RF: F; >50, smoking and poss NSAIDs

Dx: Colonoscopy shows inflamm infiltrates with mononuclear predominance

Subtypes: Collagenous colitis (thickened Subepithelial collagen layer)

Lymphocytic colitis (more pronounced intraepithelial lymphocytic inflamm infiltrate)

Management: Avoidance of NSAIDs; anti diarrhoea agents; corticosteroids if refractory

Colonic Volvulus. D/t chronic constipation or malrotation

Twisting of loop of intestine about its mesenteric attachment site

May cause obstruction or vascular compromise (necrosis and/or perforation may occur)

Most common site is sigmoid or Cecam

Occurs in elderly (non bilious vomiting) and infants (bilious)

Cecal volvulus d/t congenital lack of fixation of right colon

Malpositioned caecum with duodenum abnorm located in R abdomen —> duodenum fails to cross midline

Dx: Upper GI Series w barium enema

Birds beak shows narrowing of colon at point of twisting; Coffee bean sign

Plain Abdo films: Dilated + loss of haustra

Tx: Poss self limiting; Sigmoid: sigmoidoscopy

Recurrence high so elective resection indicated: Ladds Procedure

Cecal: Urgent surgery to prevent bowel necrosis

Malrotation w/o Volvulus -> Ladd

Midgut volvulus: pathological adhesions cause twisting around SMA; Ileum

—> surgical emergency

Fecal Occult Blood Test (FOBT)

IF POSITIVE:

<40 years give anoscopy

<50 years sigmoidoscopy

50 years colonoscopy

Appendiceal Cancer Most are carcinoid

Remember rule of 1/3s:

1/3 metastasize, 1/3 accompanied by second malignancy, 1/3 present with multiple carcinoid tumors.

Pseudomyoxma peritonnei: intraabdominal gelatinous ascites

Rectal Prolapse

RF: Prior pelvic surgery; Pelvic floor dysfunction or anatomical defects; Stroke; dementia

Abdo discomfort not pain

Straining or incomplete evacuation, fecal incontinence w mucus

Digital manoeuvres poss needed for defecation

Erythematous mass extending through anus w concentric rings of rectum

Management

Medical: Adequate fibre and fluid; pelvic floor exercises; biofeedback for incontinence

Surgical: Preferred for full thickness or symptomatic (incontinence) prolapse

Toxic Megacolon

Acute worsening IBD!

Dx: Systemic Toxicity (fever, tachycardia, hypotension)

Bloody diarrhoea; Abdo distension/peritonitis

Marked colonic distension on imaging ( >6 cm of R Colon)

Initial test of choice: Abdo X-RAY (also excludes perforation)

Management: Bowel rest, NG suction, Abs +/- corticosteroids if IBD-associated

Surgery if unresponsive

Anal cancer

Squamous epithelial cells

D/t HPV infection

Risk greatest in M who have receptive anal intercourse and those w adv HIV

Rectal bleeding (can be falsely attributed to haemorrhoids)

Anal pain and/or sensation of pressure

Mass or ulcerated anal lesion (friable)

Spread via lymphatic may cause nontender femoral/inguinal LAD

Radiation Proctitis

Acute: <8 wks post radiation -> Min bleeding; Diarrhoea, tenesmus

Endoscopy: Severe erythema, edema, ulcerations

Management: Antidiarrheals; Butyrate enemas

Chronic: >3moths to years post radiation -> Severe bleeding; constipation

Obliterative endarteritis and chronic mucosal ischemia

Submucosal fibrosis —-> decreased rectal compliance —>>> urgency and fecal incontinence

Endoscopy: Multiple telangiectasias; mucosal pallor & friability

Management: Endoscopic thermal coagulation; Sulcralfate or glucocorticoid enema

Neoplasm of Large bowel or rectum

Virtually all arise from adenomas

Rarely: carcinoid, lymphomas and Kaposi sarcoma

Micro satellite instability pathway: sporadic CRC and HNPCC (Lynch)

Screening:

Begins at 50 years and repeat every 10 years If 1 family member has colon cancer begin at age 40/10 yrs prior age of onset ## —-> REPEAT EVERY 5 YRS

Single negative FOBT not sufficient to rule out occult GI bleeding:

—> colonoscopy/endoscopy if elderly and Fe def

Barium enema evaluates entire colon: apple core lesion

Carcinoembryonic antigen (CEA) not useful for screening -> Monitors treatment efficacy/ surveillance

Staging: CT chest, Abdo and pelvis and via physical exam

Direct extension: invades abdominoperineal organs

Hematogenous: Portal circulation to liver (most common site of distant spread)

Lumbar/vertebral veins to lungs

Lymphatic—regionally

Transperitoneal and intraluminal

Metastasis most commonly to lung and liver

Risk Factors: Smoking; high fat diets; hereditary

Begin surveillance colonoscopy 8 years post dx of IBD and repeat every 1-3 years

Diet: Low in vitamin A/E/C and selenium increases risk

Dukes Classification for Px

Tx Surgery only curative: resection of bowel and regional lymphatics

Adjuvant (chemo/radiation) depends on stage of tumour

Stage 3: FOLFOX4 Bevacizumab for metastatic

Surveillance post cancer:

Stage 1: Colonoscopy in 1 year then every 3-5

Stage 2/3: Colonoscopy in 1 year then every 3-5 periodic CEA; annual CT chest, abdo +/- pelvis

Stage 4: More frequent CTs

CEA levels checked periodically (every 3-6 months) —> V v high levels suggest liver involvement

Major polyposis syndromes

Familial adenomatous polyposis (FAP)

AD disease d/t mutations in APC TSG

Hundreds of adenomatous polyps in colon, stomach and SI

Risk of CRC 100% by 30s and 40s: Prophylactic colectomy in early 20s

Screening sigmoidoscopies from age 10-12

—> once colorectal adenoma detected ===> annual colonoscopy

Screening for upper GIT tumours regularly

Attenuated version: Pts have delayed start of screening (25) and longer screening intervals ## (1-2yrs)

Gardner Syndrome

Variant of FAP, AD

Polyps + osteomas, dental abnormalities, benign soft tissue tumours, Desmoid tumours,

sebaceous cysts

Risk of CRC 100% by age 40

Turcot Syndrome

Variant of FAP

Polyps + Cerebellar medullblastoma/glioblastoma multiforme

Peutz-Jeghers

AD

Single/multiple hamartomas that may be scattered through entire GIT esp SI, Colon and ## Stomach

Pigmented spots around lips, oral mucosa, face, genitalia and palmar surfaces

Hamartomas has v low malignant potential

Intussusception or GI bleeding may occur

Familial juvenile polyposis Coli

Rare, presents in childhood, only minimal risk of CRC

10 and up to 100s of juvenile colon polyps

Hereditary non polyposis CRC—-w/o adenomatous polyposis (screen every 1-2yrs starting at

25)

Single polyp can transform into CRC

Lynch Syndrome I (site specific CRC), AD

Early onset CRC (right sided pref) with absence of antecedent multiple polyposis

Lynch Syndrome II (cancer family syndrome)

All features of Lynch Syndrome I + early occurrence of other cancers:

Endometrial, ovarian, skin, stomach, pancreas, brain, biliary tract, ureter+renal pelvis

Abdominal pain most common presenting Sx

D/t partial obstruction or peritoneal dissemination

Colonic perforation can cause peritonitis (most life threatening complication)

Right sided tumours

Obstruction rare d/t larger luminal diameter (cecum has largest lumen of entire colon)

-> Large tumour growth w/o detection

Lynch Syndrome

FOBT, iron deficiency anemia and melena, post prandial discomfort

Change in bowel habit uncommon

Triad: anemia, weakness and RLQ mass

Left sided tumours

Signs of obstruction

Change in bowel habits: alt constipation/diarrhoea

Narrowing of stools (pencil stools)

Hematochezia

Rectal Cancer (20-30% of CRC): Hematochezia most common sx

Tenesmus

Rectal mass: feeling of incomplete evacuation of stool d/t mass

Radiation Tx only indicated for rectal cancer Rectal cancer has higher recurrence rate and lower survival than colon cancer

Colonic Polyps: Most polyps in rectosigmoid region

If symptomatic then rectal bleeding most common sx

Noneneoplastic Polyps

Hyperplastic polyps are most common type

Juvenile polyps (<10yrs) are highly vascular and common, remove

Inflammatory polyps (psudopolyps) associated with UC

Adenomatous Polyps

Benign precursors of adenocarcinoma

Tubular (most common)—> smallest risk of malignancy

Tubulovillous—> intermediate risk; Villous—> greatest risk

Sessile serrated: sessile (flat, more likely malignant) vs pedunculated

AnoGenital wart: Cauliflower shaped/papule/plaque

Chronic onset

Mild itching w bleeding

Severity of Liver Disease: MELD-Na Score:

Serum Bilirubin, Cr, sodium, INR

Predicts 3 month mortality in pts with cirrhosis

Priorities pts on transplant list

Hyponatremia related to increased mortality

Child Pugh Classification

Ascites, Bilirubin, Albumin, Hepatic Encephalopathy, PT Time

Classes A (compensated cirrhosis) -> C (decomp cirrhosis)

Correlates with 1 and 2 year survival

Varices

Upper endoscopy for varices

Non selective beta blockers for non bleeding varices

Endoscopic ligation if pt CI beta blockers

Ongoing or recurrent variceal bleeding: TIPS

Bleeding varices:

Urgent endoscopy can tx and dx bleeding; IV octreotide and prophylactic antibiotics

——->> octreotide inhibits release of vasodilation hormones so indirectly results in splachnic

vasoconstriction

Hematemesis d/t oesophageal varices: 2 large bore IV lines

Octreotide infusion

Antibiotics

Followed by endoscopic repair of varices

PPIs

Screening endoscopy done in all cirrhosis pts to identify varices

Ascites

US to Dx SAAG >1.1 g/dL indicates portal HTN: (Serum albumin-peritoneal albumin) Cirrhosis: Clear yellow fluid

HF

Hepatic metastases

Thrombus (eg Budd chiari)

Constrictive pericarditis

SAAG <1.1 (Serum albumin-peritoneal albumin) ## Pancreatitis

Peritoneal TB

Serositis

Bowel Obstruction

Nephrotic Syn —> SBP

Bloody: Trauma; malignancy and TB (rare)

Milky: Chylous; pancreatic

Turbid: infection

Nitric oxide and other vasodilator factors accumulate d/t reduced clearance of bacterial products

—> splachnic vasodilation —> decreased SVR —->>> increased HR + CO (hyperdynamic circ)

RAAS activation —-> hypervolaemia —> third spacing —> ascites

Decreased renal perfusion —> hepatorenal syn (life threatening)

Ascites Management in Cirrhosis

Abdo US to Dx

Dx paracentesis (yellow/straw coloured) to confirm etiology and rule out infection

Tx: Avoid ACEIs, ARBs and NSAIDs (increased risk ESRD?)

Refractory ascites: Large volume paracentesis or TIPS

Hepatorenal syndrome is a severe complication of overly aggressive diuresis/tapping/SBP

—-> renal hypoperfusion

New onset ascites

Acute obstruction of portal or hepatic veins d/t thrombus or HCC ——> do US

SBP: Bacterial infection of ascitic fluid in absence of intra-abdominal surgically treatable source

Gut flora traverse intestine into mesenteric LNs -> E. Coli is most common, Kleb; Strep

Signs: Subtle changes in mental status or frank delirium/confusion

Painful Abdo, diffuse (ascites can mask pain); Diarrhoea

Fever (Pts with adv cirrhosis are usually mildly hypothermic so temp >37.7 is serious)

Hypothermia, hypotension; Paralytic ileus

No rigid abdomen although rebound tenderness possible (separation or peritoneal layers prevents rigid ## Abdo)

Leukocytosis with metabolic acidosis

Dx: Paracentesis: Positive ascites fluid culture with ABSOLUTE PMN count >250/mm3

Secondary bacterial peritonitis d/t GI perforation or intra Abdo abscess (surgically treatable sources)

Polymicrobial culture with poor response to Abs

High protein, low glucose (cf SBP)

Peritoneal dialysis RF

Dx: Gram stain

SBP Empiric tx:

Third gen cephalosporin (ceftriaxone/cefotaxime)

High risk pts given prophylaxis with TMX-SMP/fluoroquinolone

Hepatocellular Carcinoma

RF: Alcohol; Nonfatty fatty liver disease (DM, Obesity; chronic viral hepatitis

AFP only raised in 50%; LFTs may be Normal

In cirrhotic pts US screen every 6 months

Can cause obstruction: acute ascites

Hepatic Adenoma: Poss malignant transformation/HEMORRHAGE

Benign, SOLID mass

Young F on contraception

Cachexia, weight loss, anorexia

RUQ or epigastric pain; hepatomegaly

Can rupture —> FNA and biopsies CI d/t bleeding risk

Centripetal enhancement on triphasic scan —> develops from periphery

Cyst: Not SOLID

Focal Nodular Hyperplasia

Benign

D/t aberrant congenital artery

Young F

May be oestrogen sensitive —-> larger more vascular lesions in F on OCPs

Most asymp/ palpable nodule

Arterial flow and central scar on imaging (hypodense, stellate) in hyperdense lesion

===> enhances during hepatic arterial phase

Radiating fibrous bands

Remember: hypOdense foCal nOdulAR scAR in centre

Hepatic Encephalopathy

Patient Cirrhotic! Asterixis and palmer erythema

Hypokalaemia exacerbates this => IC acidosis increasing NH3 production in renal tubular cells

——->> give potassium!!!!! First Alkalosis worsens condition -> hypokalaemia

Rifaximin and lactulose: if cannot tolerate rifaximin and unresponsive to lactulose then neomycin

TIPS can cause hepatic encephalopathy d/t NH3 rich blood bypassing liver

Protein restriction CI as pts often malnourished

Hepatic Hydrothorax: Pleural effusion not d/t underlying cardiac or pulm abnormalities Pts with cirrhosis and portal HTN with ascites Occurs through small defects in diaphragm

Occurs much more commonly on the R d/t less muscular R hemidiaphragm

Dx: Documentation of effusion and testing to exclude other causes

Tx: Salt restriction and diuretics; therapeutic thoracocentesis

Avoid chest tube as can cause large volume protein, fluid and electrolyte losses and other

complications eg renal failure

Chronic Liver disease

Decreased synthesis of serum binding proteins for thyroid hormones:

Low total T3 and T4 but norm free levels and norm TSH (euthyroid state)

Increased circulating E2: Gynecomastia, telangiectasias, palmar erythema, testicular atrophy

Vomiting can cause elevation in amylase