Professional Documents
Culture Documents
Hx and Physical
• History: AMPLE, HISTORY, OPPQRST:
o Allergy, Medication, Past medical hx, Last menses/meal, Event of complaint (illness)
o Hospitalizations, Immunizations, Sugar diabetes/Social Hx, Tumors/Trauma, Operations, Review of systems, Youth
Illnesses.
o Onset, Palliative, Provocative, Quality, Radiation/Region, Setting/Site/Severity, Timing
1
• Clubbing (right hand)
o Findings:
White male
40’s
Swelling at DIP
Enlarged nails (no splinter hemorrhage)
• Psoriasis has pitted nails
o Enlargement of the terminal tuffs (seen on x-ray)
o AKA: Hypertrophic Osteoarthropathy (digital clubbing)
Lung disease because of hypoxia (most common)
Can be associated with GI and GU problems
A.M.P.L.E.
- Allergies (wheat, soy, peanut, shellfish, iodine, meds)
- Medications (what, how much, ? for, how long)
- Past Medical “HISTORY”
- Last Meal/Last Menstrual Period (1st day of mense) (onset)
- Events of the present illness
O.P.P.Q.R.S.T.
- Onset (what cause, when, how long it takes)
- Provocative (what makes it worse)
- Palliative (what makes it better)
- Quality (sharp, dull, aching, intermittent, cramping, cholicing)
- Radiation/Region of pain (where does it hurt)
- Setting (when – time)/Site (where is it located)/Severity
- Timing (when does it happen and how long does it last)
o Constant = 24/7/365
o Serious
- Large smooth dome-shaped mass in the LUQ
- Appears pale over lesion
- Have pt do a sit up so that abdominal muscles contract
- Incisional Hernia (past surgery)
o Gets larger when she bears down and painful
o Auscultation will hear bowel sounds
o Feels like it is filled with air (like balloon)
o Very mobile
o When blood supply is lost to a hernia is call
strangulation
o Tender
o Lateral debicutis Most Frequent Hernias
o
HISTORY
- Hospitalization
- Injuries/Immunizations
- Sugar Diabetes
- Tumors/Trauma
- Operations
- Review of Systems
2
- Youth Illness
10-Day rule
• Can only take X-ray’s first 10 days of cycle (starting at 1st day of menses)
• Unless chance Mom’s life is in danger or severe morbidity
• History [The History and Interviewing Process (06)]
o Hospitalizations
When? What for? How long? What was outcome?
Recent surgery – mobilization/manipulation not recommended within 2 months. If doing sooner – call and
discuss with their surgeon.
o Injuries
When? What happened? What done? Outcome?
o Sugar diabetes
Insipidus or mellitus (NIDDM or IDDM)
Look for increased adipose tissue in belly.
Remember DM causes microvasculopathy and microneuropathy.
• Hence these Pt’s have a lot of GI/GU problems, such as renal problems.
o Tumors
Lipoma is the most common, benign tumor.
Most common malignant tumor is skin cancer (basal cell carcinoma or melanoma).
o Operations
In-patient as well as out-patient.
o Review of Systems
o Youth Diseases
Measles, Mumps, Rubella, Diptheria, Pertussus, Tetanus and chicken pox.
• Physical Examination (abdomen)
o Inspection
Symmetry, size, shape
• If abdomen is distended (besides obesity): fluid and gas (or
combination)
o Look for fluid wave, etc. to check for fluid. Can detect
down to about 20 ml of excess fluid.
Puddle test – pt on all 4 for a few minutes.
Percuss on Pt and listen for sound as percuss.
Tough to do.
o Percussion notes for excess gas are higher than for fluid.
There will also be a palpatory difference (fluid is less “squishy” and rebounds less than gas)
Lumps, bumps, scars, ecchymoses (bruising)
• Hernias are common “bumps”, for example.
• Large scars used to be common for abdominal surgery, but with endoscopic surgery, can’t tell just by
incisions or what it was at this point.
• Pt with scar always has to bear down to look for hernia.
• Laprocholecystecomy, hysterectomy, appendectomy scars most common.
o Auscultation
Bowel sounds (5-35/minute) (listen for about 1 minute)
• AKA Borborygmi
• Relatively high pitched use diaphragm
• Very high pitched and get faster than 35/minute sign of obstruction
• No bowel sounds Paralytic (Adynamic illeus (blunt trauma, post operative)
• Early bowel obstruction Rapid sounds to force fecal bolus
3
• Late bowel obstruction Shuts down and patient vomits (no bowel sounds)
• Adynamic Illeus no bowel sounds b/c no peristalsis
• We percuss/palpate after auscultation to avoid altering bowel sounds.
o But DO palpate, even if suspect AAA (TQ)
• Most bowel sounds come from the small bowel. (peristalsis)
• Not regular, hence Dr needs to listen for a full minute in each quadrant.
• Decreased bowel sounds – less peristalsis. (hypoactive bowel sounds)
• Increased bowel sounds – more peristalsis (hyperactive bowel sounds)
o Oddly, in obstructions, there is initially a transient increase in bowel sounds, then it decreases
as the bowel shuts down.
o Prognosis is worse with decreased/absent bowel sounds.
• Adynamic/paralytic ileus – common after injury to the bowel, particularly after trauma, abdominal
surgery, anesthesia.
Bruits
• Normal vessels have a trilaminar flow.
• Disruptions to this flow cause microeddies, which generate the bruit sound.
• Renal arteries and abdominal aorta near the bifurcation into the common iliac are the most common
sites for high pitched, stenotic bruits.
• Occurs with aneurysm and stenosis
• M/c in the aorta (infrarenal AAA)
• Low pitched, rumbling bruits are usually found in aneurysms, such as aorta below the renal arteries
and above the common iliacs.
o Common. You will see them.
o High pitched bruits = stenosis
o Low pitched bruits = aneurysms. (possible TQ)
• Venous hum is also possible to hear.
o Obstruction of one of the major veins in the belly.
Ex: inferior vena cava (most common)
• As with bowel masses (small bowel obstruction, large lymph node, etc.) or
enlargement of the liver.
o Not very pulsified, as in arterial problems. More constant, humming noise as the blood
moves through the stenosis.
Other noises
• Friction rubs – rubbing noise
o As in the liver with Pts with hepatitis.
o As with abdominal adhesions, where portions of mesentery or small bowel are adhering to
each other.
o Listen over the liver (2nd most vascular structure in body next to the skin).
Hemangiomas are VERY common (half the population) in the liver.
Can have a noise like a venous hum, if the hemangioma is large and near the surface.
o Percussion
Liver, spleen, diaphragm
1. Size Five Percussionary Notes
2. Diaphragmatic Excursion 1. Flatness: muscular area
3. Note pitch • ex: thigh
LUQ: Not eaten tympanic 2. Dullness: organs
(b/c air in the stomach) • ex: liver
Eaten dull 3. Resonance: normal lung field
4. Spleen: dull 4. Hyper-resonance: abnormal lungs
5. Liver: dull • Ex: emphysema, Pneumothorax
6. Rest of the abdomen: tympany 5. Tympany: normal abdominal
• gastric air bubble
4
7. Bowel obstruction: dull
Tympanic: proximal
Dull: distal
o Palpation
Organomegaly
• Cannot normally palpate either kidney or spleen (TQ)
• Hepatosplenomegaly
o Caused by sickle cell, etc.
Aneurysms
• Palpate for tenderness, for guarding (voluntary), and for abdominal rigidity (involuntary).
o Abdominal rigidity is textbook sign for peritonitis.
• Also palpating for masses (are they tender? Mobile? Size? Shape? Contour? Pulsates (vascularity)?
1. Start in non-tender quadrant and go to tender quadrant
2. Superficial mass: in abdominal wall
3. Contraction of abdominal mm
Accentuated: in abdominal wall
If not in abdomen
4. If mobile: better than mass that is non mobile
Malignant masses do not move b/c not encapsulated and they invade other
tumors and inflammatory tumor that makes scar tissue and makes more immobile
Benign tumors grow in the original tissue and do not invade
- Two types of abd organs:
1. Solid
2. tubular
- Palpation of organs
1. Liver
2. Spleen
3. Cholecystitis
4. Gallbladder – porcelain gallbladder (calcified wall)
5. Pancreas
6. Kidney
7. Duodenum
- Aorta
1. Lateral pulsation is not good, could represent AAA
2. 3.5 cm or less is normal size of aneurysm
3. AAA produce non-mechanical back pain
5
Normally tucked up left of stomach and under left
costal margin.
When it enlarged, enlarges into a mass medial and
inferior.
o In a chiropractors office – you ought to give an abdomen exam
to someone with low back pain.
o Remember that this is not necessarily an easy exam as it takes a
lot of Pt involvement.
o If a mass is palpable, have Pt bear down to help determine
origin.
Hernias will usually protrude with valsalva maneuver.
o When abdomen is involuntarily flex and is very hard
abdominal rigidity usually caused by peritonitis
• Abdominal regions
o 4 quadrants
• RUQ • LUQ
o Liver o Stomach (fundus)
o Right kidney o Left kidney
o Gallbladder o Spleen
o Hepatic flexure o Splenic Flexure
o Right renal artery o Left renal artery
o Transverse colon o Transverse colon
o Head of Pancreas o Tail of the pancreas
o Biliary tree (bile ducts) o Aorta
o Biliary aa & vein
• RLQ • LLQ
o Ascending colon o Descending colon
o Small intestine o Small intestine
o Right common iliac o Left common iliac vein
o Right ovary o Left ovary
o Cecum o Inferior mesenteric artery
o Right fallopian tubes o Left fallopian tubes
o Appendix o Sigmoid colon
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o 9 regions
• Right Hypochondrium • Epigastric • Left Hypochondrium
o Liver (R lobe) o Liver (L lobe) o Stomach (Fundus)
o Gallbladder o Pancreas o Spleen
o Hepatic flexure o Stomach (Antrum) o Splenic flexure
o Transverse colon
• Right Lumbar • Periumbilical • Left Lumbar
o Kidney (R) o Intestines o Kidney (L)
o Ascending colon o Aorta o Descending Colon
• Right Inguinal (Iliac) • Suprapubic (hypogastric) • Left Inguinal (Iliac)
o Cecum o Bladder o Sigrnoid Colon
o Appendix o Uterus
o 6 regions
• RUQ • Epigastric • LUQ
o Liver o Duodenum o Stomach (fundus)
o Right kidney o Pylorus o Left kidney
o Gallbladder o Liver (left lobe) o Spleen
o Hepatic flexure o Pancreas o Splenic Flexure
o Right renal artery o Transverse colon o Left renal artery
o Transverse colon o Aorta (Celiac trunk, o Transverse colon
o Head of Pancreas renal aa. & veins) o Tail of the pancreas
o Biliary tree (bile ducts) o Descending colon
o Biliary aa & vein
o Ascending colon
• RLQ Suprapubi (hypogastric) • LLQ
o Lower portion of liver o Bladder o Sigmoid colon
o Ascending colon o Uterus o Descending colon
o Small intestine o Small intestine
o Right ovary o Left ovary
o Right common iliac o Left common iliac vein
o Cecum o Inferior mesenteric
o Appendix artery
o Left fallopian tubes
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• Abdominal exam tests
o Rebound tenderness (TQ)
Rovsing’s Sign: pain in the RLQ only
Peritonitis (Rovsing’s Sign) (classic sign)
• (If appendicitis - Pain in RLQ. Appendicitis is a type of peritonitis, and is the most common organic
source of rebound pain in the abdomen)
• Highly suggestive of appendicitis, but not pa-thog-no-monic (indicative of a disease).
Pt with recoil palpation (on rebound of organs back to their original position)
1. Push in an area where there is no pain and then quickly let go and pt will feel pain in a quadrant
other than where you pushed (classic is appendix)
2. Peritonitis (Rovsing’s Sign – only on RLQ) → push in quadrant pain and hurt in same area
(appendicitis)
3. Pain with recoil palpation
If pain in another quadrant then the test is positive
• Peritonitis
If pain in RLQ and doing test in a LLQ than can be
positive for appendicitis
o Costovertebral angle (CVA) tenderness (angle at junction of last rib and spine) (TQ)
Generally used to find retroperitoneal organs,
such as the kidney.
Kidney disease
AKA: Kidney Punch Test
Also remember the quadratus lumborum
muscle is there, and is prone to spasm.
o Shifting dullness
Done while palpation abdomen
Ascites
Fluid shifts as Pt moves in different
positions. For small amounts of ascites called
“Puddle Sign”
Pt on all fours for ~ 5-10 min
Start out to in and when run into dull mark
Move to different side and repeat
Will end up with outline of the “puddle”
o Psoas sign
Appendicitis
Pain on resisted right hip flexion (supine)
Put knee and hip in flexion have pt try resist
as Dr tries to extend leg
No particular practical clinical application.
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o Obturator sign
Appendicitis
Pain on resisted internal right hip rotation.
No particular practical clinical application.
o Barium enema
Barium Dx not used much any more. Popular
a few years ago, but now used only selectively, as endoscopy has
become the preferred methodology.
Zenker’s diverticulum
Barium or barium with air forces barium
against the wall
Show endothelial wall in detail
o Endoscopy
Most common, 80% of the time to investigate bowel complaints.
Small endoscopes can even go into the pancreatic ducts.
Typically used in either nasal or rectal insertion. (Not together,
hopefully)
Some of the false negatives with an endoscopy are from user
error.
• Hence if referring out, make sure the operator/physician
is well practiced.
Esophagogastroduodenoscopy (EGD) (WHEW! Spelling bee
word from hell…) (TQ)
From bottom Anoscopy, Rectoscopy, Sigmoscopy,
Colonoscopy
Can be both diagnostic and therapeutic/operative (additional
machinery for biopsy, microsurgery, electrocautery, etc. which can be done as an
outpatient procedure.)
There are rigid and flexible endoscopes, with various lengths.
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Ulcerative Colitis (UC), severe Crohn’s, or other conditions with
fragile bowel are contraindications to the use of endoscopy.
o Ultrasound
Quick and easy
Low resolution
• Common GI Signs/Symptoms
Picture:
o Abdominal distension
- Black/Hispanic Female/20-30
o Abdominal pain
- Valgus elbow
o Anorexia (loss of appetite) - Very large umbilical hernia
o Belching, bloating, flatulence - Hernia is div into compartments
o Bleeding - LR bulb is largest, LL, UR, and UL is
o Constipation/diarrhea smallest.
o Nausea/vomiting - Well defined line separating LL and LR
o Heartburn/indigestion/dyspepsia bulbs.
o Hepatomegaly/splenomegaly - Purple variscosities at center.
o Hernias - Lighter skin on mass compare to natural
o Hiccoughs skin.
o Jaundice
o Rectal pain/itching Pertinent negative:
- No hair
- Drainage
(Get .PDF from him on spine cancer from Australian journal)
- No color
- No deformities
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a. Most commonly from ascites (serous, serosanguinous, sanguinous, pustular)
b. KUB – “Kidneys Ureter and Bladder” – a flat plate X-ray of the abdomen, done both standing and supine
(to look for fluid levels) (lateral view instead of standing if Pt cannot stand)
2. Excess air
a. Normally from excess gas, also from post-operative gas.
b. Remember that gas will change position easily, and with the position of the Pt.
c. Gas is either intraluminal (inside bowel) or extraluminal (outside bowel).
3. A mass
a. Abdominal hernia
4. Organomegaly.
a. Splenomegally
b. Epatomegally
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• Some will relieve themselves, while others require surgical
intervention.
• Adhesions
• Paralyzed persons (bowel doesn’t work as well)
• Kid’s may be hypermobile bowel (not really sure though)
• Trauma
• Ischemia
o Non mechanical obstruction of the bowel
• Not a good nomenclature.
Ascites
• Most common from alcoholic hepatitis (portal hypertension) (TQ)
• World wide – m/c is Hep C
What cause Distented Abdominal
• Water
• Interstitial
• Fecal
• Urine
• Blood
• Pus
Excess gas
• As from dietary sources.
Trauma
• Pts involved in motor vehicle accidents (MVA) sometimes show this, as seat belts can shove into
bowel during impact. Usually resolve within 24 to 48 hours.
Infection
Peritonitis.
Adynamic/paralytic ileus – will get distention of bowel. (TQ)
• Ileus resulting from failure of peristalsis
• Most commonly from surgery. As bowel tends to shut down for a short time after being handled
during surgery.
o Take KUB (kidney, ureters, bladder) x-ray as a start of diagnosing abdominal problems
o Burning
PUD (pain upon defecation), GERD, dyspepsia (gastritis)
• Do not ignore burning epigastric pain. (Possible cardiac involvement)
• Can be caused by nicotine, alcohol, mint
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o Cramping (usually from organ distension or peristalsis)
Biliary colic, IBD, IBS, mesenteric ischemia
• Note: Men tend to have more active gastro-colic reflexes than women (When put fresh stuff in, not-so-
fresh stuff comes out. A useful bit of trivia to defend yourself from your wife’s pointed comments after
a spicy meal.)
• Note: Mesenteric infarct is supposed to be THE most painful condition in medicine. (Possible TQ)
o Colicky
Renal stones, biliary colic, appendicitis.
• Note: crescendo/decrescendo pain pattern in stone obstruction due to peristalsis waves (try, stop, try,
stop, etc.)
• Pain that goes up and down
o Achy
Constipation, appendicitis (early), AAA (saccular)
o Knife-like (usually very serious)
AAA (dissecting/saccular rupture), pancreatitis.
Pt’s will usually lie on their side in flexion (the fetal position) due to pain.
o Sudden onset
Perforation, obstruction, pancreatitis, ruptured ectopic pregnancy, dissecting aneurysm
• Abdominal Pain Patterns
o Diffuse
Early appendicitis
AAA
IBD – Inflammatory bowel disease [Crohn’s and Ulcerative colitis – typically of the left colon]
Peritonitis – if diffuse peritonitis, if the peritonitis is localized then so will the pain
Trauma
Obstruction
Look for abdominal guarding (voluntary) and abdominal rigidity (involuntary)
o Epigastric
• Common region for abdominal pain, lots of different organs
PUD
• (Peptic Ulcer Disease in this case)
• Often described as “gnawing”, “chewing”, or “burning” type pain.
• Usually duodenal disease.
Gall Bladder (GB) disease
• Cholecystitis (inflammation) and cholelithiasis(gallstones production)
o Commonly found together.
Hepatic disease
• Particularly in left lobe of liver.
Cardiac disease (Red flag)
• Referred pain to upper abdomen.
Pancreatitis
• Pts assume the fetal position.
• Severe pain radiating from abdomen to
low back (Lumbar and thoracic spine) (TQ)
Gastritis
GERD
Dyspepsia
o RUQ
Biliary tree disease
13
• Both intrahepatic and extrahepatic portions.
• Liver, gall bladder and collecting ducts.
PUD
• Particularly involving the duodenum.
Pancreatitis (head of pancreas can go that far over)
Renal disease
• Particularly the pole of the right kidney.
• Renal cysts (uncomplicated) are the most common renal disease.
o Usually only symptomatic if the cyst grows large enough to distend the renal capsule.
Cardiopulmonary disease
• Referred from heart or lungs (portal effusion, lower pneumonia)
o LUQ
PUD
• Usually from stomach.
Pancreatitis
Splenic diseases
1. Mononucleosis
2. Polycythemia vera (inc conc of hemoglobin in blood)
3. Sickle cell
4. other anemias, splenic artery aneurysm.
o Splenic artery is a VERY tortuous, twisty artery as it moves laterally. Viewable on X-ray.
Renal disease
• Left kidney (higher than the right)
Cardiopulmonary disease
• More often causes LUQ pain than RUQ pain.
o RLQ
Late appendicitis
• Once peritoneum is involved, focal pain.
Crohn’s disease (aka inflammatory enteropathy)
• Chronic granulomatous disease of the GI tract, hence causes granulomas, effecting the entire thickness
of the bowel wall (as opposed to UC).
• Can affect any region of the GI tract.
• Typically in the young (late teens to early 20’s)
• Debilitating, sometimes requiring colostomy, etc.
• Most commonly in distal portion of small bowel, beginning of large bowel.
Obstruction.
• RLQ is a very common area, because is attached, and hence common for volvulus formation (coecle
volvulus or sigmoid volvulus)
Reproductive disease
• Ovaries, fallopian tubes, or uterus
• Ex: Cancer, PID (if affect ovaries),
endometriosis, fibroid tumors (leiomyomas – smooth muscle tumors)
o Leiomyomas can be HUGE (largest on
record was 350 lbs)
Pt can actually think they’re
pregnant (TQ)
o Can be calcified, looking like a
‘popcorn ball’ on PFXR.
o Can interfere with menstrual cycle,
fertility, etc.
o Can also cause low back pain.
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o VERY small chance of transformation
to leiomyosarcoma, but VERY small. Normally benign. (TQ)
AAA
o LLQ
Diverticulosis/itis
• Diverticula are common with old age, most people get them.
• 75% of patients over 70 has it
• Most often in the descending and sigmoid
Zenker's diverticulum
colon (local is a –diverticulum
vasa recta of the mucous
asymptomatic)
membrane of the oesophagus through a defect in the wall of
• Referred pain to the low back. oesophagus.
• pulsion- occurs in area of weakness
o pressure within esophagus causes area to
push out
• Likely to cause Odynophagia (pain on swallowing)
o A similar abnormality occurs in the
intestines, but tends to be multiple.
Obstruction o Zenker's Diverticulum is solitary.
• Sigmoid volvulus most often.
Colon cancer
• More than ½ of colon cancers in the sigmoid/descending colon.
• Alternating constipation/diarrhea.
o Body has obstruction from tumor, floods bowel with water to remove it, resets, cycle repeats.
Ulcerative colitis (UC)
• Causes superficial inflammation/ulceration (innermost layer)
• But because of the number of vessels in this region, there is a LOT of bleeding. (an important
differential from Crohn’s)
• Late teens/early 20’s, with bloody diarrhea.
Reproductive disease
AAA
o Periumbilical
Obstruction
• Small bowel in this region.
• Small bowel obstructions are usually intussceceptive.
Early appendicitis
AAA
Mesenteric thrombosis.
• Lack of blood supply (embolism) in mesenteric arterial tree.
• Again, supposedly the most painful condition in medicine. (Shoots a lot of holes in that labor and
delivery guilt trip, eh? Sorry Mom.)
Pancreatitis.
• Pt in fetal position, very painful. (So
possible matching TQ is fetal position – pancreatitis)
• Causes of Abdominal Pain
o Most common cause of abdominal pain is non-organic. (TQ)
Lot of musculoskeletal origin, believe it or not.
Non-specific abdominal pain – 35%
o Acute appendicitis – 17% (know this TQ) (most common source of organic abdominal pain)
o Intestinal obstruction – 15%
o Urologic causes – 6%
o Gallstone disease - 5%
o Colonic diverticular disease – 4%
o Abdominal trauma – 3%
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o Abdominal malignancy – 3%
o Perforated peptic ulcer - 3%
o Pancreatitis – 2%
o Ruptured AAA - <1%
o Inflammatory bowel disease - <1%
o Gastroenteritis - <1%
o Mesenteric ischemia - <1%
• [VBA dissection – REDFLAG: “The worst headache I’ve ever had.”]
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2. Dissecting aneurysm
• Dissecting AAA
o There is a separation between the interior and middle
walls of the aorta (intima and media).
o Can be traumatic or atherosclerotic.
o When wall separates, the force of exiting blood causes
increased widening of the separation.
o Pt can easily exsanguinate (bleed out) without actually
losing blood from vascular system.
The blood is trapped in the wall of the artery
(between media and intima)
o Mortality rate with AAA dissection is very high, unless
they catch them very early.
o Do NOT show up on PFXR (plain film X-ray).
o Hallmark S/sx of AAA dissection.
“Tearing” abdominal pain.
Shock.
o Odd trivia fact: Dissecting aneurysms used to show up most commonly in the aortic arch as a S/sx of tertiary syphilis.
Now (with less cases of syphilis around) is most common in abdominal aorta.
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Sudden death.
o Imaging
Plain films
• Maximal measurable normally is 3.5 cm.
• Anything larger suggests aneurysm.
MRI, CT
o Treatment (big TQ) (Picture)
3.5-5 cm – careful observation
• Tell Pt to avoid anything that might increase risk of trauma or intra-abdominal pressure.
• Careful to absolute contraindications for adjustment.
o Only in small size aneurysms. Perhaps mobilization only.
5-7 cm – elective surgery (10% rupture/yr)
>7 cm – non-elective surgery (25% rupture/6 mos)
Symptomatic – non-elective surgery.
If Pt is bleeding, condition is emergent. (well duh…)
o Surgical procedures
Open laparotomy
Endoscopic stent replacement.
<50% w/ rupture survive.
Anorexia
• Anorexia – lack of appetite.
o Anorexia nervosa – psychologic disease
leading to wasting.
o Self image problem (think they’re too
fat)
• Possible Causes
o Infection.
o Neoplastic (particularly malignant)
o IBD
o Constipation.
o GERD
o PUD (peptic ulcer disease)
o Swallowing disorder.
• [Picture: Old man with Anorexia, Cachexia, and
Ascites]
o Cachexia – wasting associated with
disease and malnutrition. (possible TQ)
D/Dx: Possible end stage liver disease, endstage cancer, endstage AIDS
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o Aerophagia (belching)
Primary cause. Natural part of eating, swallowing, chewing, talking, smoking, etc.
o Insoluble carbohydrate ingestion. (flatulence)
o Malabsorption syndromes
o Lactose intolerance.
o Diarrhea
• Upper GI Bleeding
o Esophageal varices (most common)
Varicose veins (dilated veins) in the submucosal layer of the esophagus, usually in the lower portion of the
esophagus.
Erosion occurs with long term passage of food over them.
Over time can progress to a massive bleed.
Usually due to alcoholic hepatitis and cirrhosis leading to portal and venous hypertension.
o Esophageal CA
Long-standing, chronic bleed with coffee-ground presentation.
o Esophagitis
Depending upon degree and cause, can have either coffee-ground (more common) or hematemesis
presentations.
o PUD (peptic ulcer disease)
More often coffee-ground presentation, but if erodes into a gastric/epiploic arteries, can present as hematemesis.
o Gastric CA
Most often coffee-ground presentation, or mixed presentation.
o Hiatal hernia
o Swallowed hemoptysis
Hemoptysis – “Coughing up blood” (TQ)
• Remember that blood is VERY irritating to the GI tract, and will provoke emesis (vomit).
o Pt’s with Upper GI bleeds can present with signs of upper GI bleed in lower GI tract.
Melena (black tarry stools – occult blood) is usually a lower GI sign of an upper GI bleed. (TQ)
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• Make sure pt. doesn’t have pulmonary condition.
Blood streak stool – mix with blood
Occasionally occult fecal blood.
• Detectable through hemocult or FOB (fecal occult blood) testing (also called GUIAC).
o False positives for GI bleed with PeptoBismol (contains the same enzyme as in GUIAC test)
o Hence must have 3 separate positives on 3 separate occasions for true Dx. (TQ)
o Hematochasia – “Bright Red Blood Per Rectum” – abbreviated BRBPR (possible TQ)
• Most common cause: hemorrhoids (TQ)
• Lower GI Bleeding
(causes are a TQ)
o Mesenteric thrombosis
Said to be the most painful condition in medicine (mesenteric ischemia as a result)
(He’s said this often, possible TQ)
o Meckel’s diverticulum
Blind fibrous tube associated with the ileum, as a development defect from the umbilicus.
o Volvulus/intusseception.
Volvulus – twisting of bowel on itself.
Intusseception – telescoping of bowel.
Most common in sigmoid colon (?) and caecum.
o Colon CA
Blood streaked stool or occult blood, not often hematochasia.
o Colonic polyps
o Inflammatory Bowel Diseases (Crohn’s, UC)
Common causes of hematochasia.
o Diverticulosis/it is
Particularly in older patients.
- (Helpful D/Dx – say if have 65 year old with rectal bleeding. Can D/dx from Crohn’s (which is most often
in the young))
o Hemorrhoids
Most common source of lower GI bleeding. (TQ)
Are varicose veins in the rectum/colon.
- Varices in the GI tract are the most common cause of GI bleeding, both upper and lower.
- Upper most often due to alcohol induced portal hypertension.
- (TQ) Lower GI usually due to poor bowel hygiene
- Prevention:
i. high fiber diet, lots of fluids, and “going when you need to go” (as the urge due to
the gastrocolic reflex)
o Anal fissures
Cracks along the edge of the anus, as due to chronic constipation or inflammatory bowel diseases.
Constipation/Diarrhea
• Constipation – “reduction in the production of the volume of stool”.
o Large, hard, and dry (brick)
20
o Pt usually have fissures and tears
o More common in females.
o Most commonly due to poor bowel hygiene (see above).
o Look for change in bowel habits (normal defecation roughly every 36 hours.)
o Other causes
Fecal impaction
Poor fiber intake.
Poor fluid intake.
Colon CA
• From obstruction. Tends to a constipation/diarrhea cycle.
IBD
Psychiatric causes
Meds
• Particularly parasympatholytic drugs ( parasympathetics) or
• Sympathomimetic ( sympathetics) drugs
Hemorrhoids
• Pain particularly is part of this cycle, as hemorrhoids cause constipation and vice versa.
o Tx:
Recommend gentle exercise.
Increase fluid intake (assuming no contraindications)
Increase fiber intake (if not due to inflammatory bowel disease)
Promotion of good bowel hygiene.
Laxatives (natural and prescription)
• Avoid if possible, as Pts can become addicted to laxatives, even to the point of needing them to
defecate at all.
• Diarrhea – “Overproduction of (watery) stool”
o Infection.
Viral gastroenteritis (stomach flu and “Montezuma’s Revenge”) is the most common cause of diarrhea.
E. Coli (food poisoning)
Cholera
o Inflammatory Bowel Diseases (IBD)
UC (LLQ) usually more often than Crohn’s (LRQ), since affects the distal portion of the colon.
Accounting for far fewer cases are other forms of IBD:
• Collagenous colitis
• Lymphocytic colitis
• Ischaemic colitis
• Diversion colitis
• Behçet's syndrome
• Infective colitis
• Indeterminate colitis
o IBS
Aka mucus colitis
Supportive Symptoms of IBS:
• Fewer than three bowel movements a week
• More than three bowel movements a day
• Hard or lumpy stools
• Loose (mushy) or watery stools
• Straining during a bowel movement
• Urgency (having to rush to have a bowel movement)
21
• Feeling of incomplete bowel movement
• Passing mucus (white material) during a bowel movement
• Abdominal fullness, bloating, or swelling
o Stress
Part of the fight or flight syndrome, as the body shuts down all other non-essential functions.
o Colon CA
From obstruction. Tends to a constipation/diarrhea cycle. (Obstruction leads to body flooding bowel with water
to flush, the reset to normal, obstruction causes constipation, etc.) (possible TQ)
o Psychiatric causes
o Meds
Antibiotic
Laxative
o Lactose intolerance (TQ)
But NOT lipase deficiency (trick TQ)
22
o Certain sights, sounds, SMELLS (have you ever BEEN in Deer Park?)
o Honestly almost anything in the GI tract, or almost anything in general (injuries, etc.) can cause nausea and vomiting.
Intussuception (Picture)
• Telescoping of bowel onto itself.
• Sort of looks like a doughnut or bulls-eye on MRI.
Hepatosplenomegaly
• Both organs attached to the portal venous system.
o Hence portal venous hypertension will cause enlargement of both. (TQ)
o Hepatomegaly m/c is cirrhosis
o Lymphoma and hematopoetic diseases tend to affect spleen more than liver.
o Other diseases cause both.
• Hepatomegaly
o Measure by percussion, for example.
10-12 cm usually
Usually can’t palpate the liver border.
In LUQ
o Inferior aspect of liver is concave – worry about hepatomegaly if flat or convex.
o Magenblase – Ger. “ice cream cone”
Term for the gastric air bubble, right under the left hemidiaphragm.
Will shift down and inwards in a Pt with hepatomegaly.
o Common causes:
Cirrhosis
Hepatitis
Most common form is alcoholic hepatitis/alcoholic cirrhosis in US (TQ)
Most common form of INFECTIOUS hepatitis is Hep. C in US
o But Hep C is the most common cause worldwide.
Pancreatic CA – obstruction of common bile duct
Hepatobiliary CA
Cholangitis
Inflammation of the biliary collecting duct
Late right sided CHF
Infectious mononucleosis (Epstein Bar – contagious)
Lymphoma
Leukemia
Cause of pancreatitis to have hepatomegaly compression of pancreomegaly on the common bile duct incr.
portal hypertension
23
• Splenomegaly
o Part of portal system
o Physical filter
o Common Causes
Anemias
Removal of abnormal RBC’s
Infectious mononucleosis
From Epstein Barr virus
HIV
Leukemia
Lymphoma
Myeloma
Polycythemia vera and reactive polycythemia (From TX and going snow ski in Colorado)
Increased red cell count (varying degrees)
Clots tend to be the complicating effect.
Hernias
• An outpouching of material through a hole (natural or unnatural)
• Types:
o Groin (most common)
Inguinal (96%) males
Direct (external) worse – acquired
- Thru weak fascia
Indirect (more common) congenital
- Follow inguinal ring
Femoral (4%) - women
o Umbilical – females (postpartum or gravid or multiparous) (picture) Indirect Direct
o Incisional (2nd common)
o Hiatal (2nd common)
24
o Pt coughs, strains, or performs valsalva maneuver
Pt turns head so that they don’t cough on the Dr. (it’s that
simple, turning the head doesn’t change the outcome of the test)
o Findings
Inguinal hernia
• Small indirect hernia may slightly tap end of finger.
• Large indirect hernia may be palpable as mass.
• Direct Inguinal hernia may be felt on pad (side) of finger.
Spermatic cord tenderness (Funiculitis)
Spermatic cord lipoma
Hydrocele – water (fluid) in the scrotum; varicocele (bag of worm)
• Types of Hernias
o Indirect inguinal hernia
Most common type, M=F
Through deep (lateral, internal) inguinal
ring (entrance to canal)
Touches fingertip on examination.
Can be difficult to distinguish clinically
from direct hernia.
o Direct inguinal hernia
M>F
>40 y/o
Though posterior wall of inguinal canal
into superficial ring (exit)
Touches side of finger (pad) on
examination (since comes through side of canal)
Easily reduced, rarely enters scrotum.
o Femoral Hernia
Least common, elderly, F>M (3:1)
Though femoral ring/canal
Often asymptomatic (even when
strangulated), but can be very painful in cases.
• Can remain asymptommatic
until develop peritonitis, etc.
• Strangulated hernia
o A hernia that has become cut off and lost its blood supply.
o Can lead to necrotic bowel.
• Mesh hernia repair
o Sutured mesh tends to patch the hole pretty well.
o Like patching a tire (actually, the same tool and
underlying process…sorta disturbing, ain’t it?)
Hiccoughs
• Hiccoughs occur when the glottis closes suddenly when the diaphragm suddenly contracts.
• The closing of the glottis stops the air from going down into the lungs and produces the “hiccup” sound.
• Transient
o High emotion or temperature change. (hot to cold)
o Gastric distension
25
o Alcohol ingestion
• Persistent
o Uremia, hyperventilation, IDDM
o Meds (steroids, barbiturates)
o General anesthesia
o Thoracic d/o (pneumonia, CA)
o Gastric d/o (PUD, CA)
o Causes suicide
Jaundice
• Jaundice: abnormal buildup of bilirubin buildup in the body
tissues, seen most obviously in sclera (icterus) and skin.
o Seen first in sclera since is the “whitest” part of the body,
and is among the thinnest.
• [picture: bearded white, middle aged male with icterus and
jaundice.]
• Many also have bilirubinuria.
• One side effect is severe itching (little known, but very Bilirubin is formed when red blood cells die and their hemoglobin is
common) (TQ) broken down within the macrophages to heme and globins. The heme
• Conjugated form – convert into a usable form is further degraded to Fe2+, carbon monoxide and bilirubin via the
intermediate compound biliverdin. Since bilirubin is poorly soluble in
• Direct Bilirubin (think of liver and surrounding) TQ water, it is carried to the liver and bound to albumin (protein; also
o Extrahepatic obstruction found in egg whites). Bilirubin is made water-soluble in the liver by
Calculi, neoplasm, stricture, cholangitis conjugation with glucuronic acid. Conjugated bilirubin, or
(inflammation of collecting ducts) bilirubinglucuronide, moves into the bile canaliculi of the liver and
then to the gall bladder. When stimulated by eating, bile (including the
Metastatic CA, pancreatic CA
conjugated bilirubin) is excreted into the small intestine. In the later
o Hepatocellular disease (more common cause) portions of the small intestine (ileum) and the colon, about half of the
Hepatitis bilirubinglucuronide is converted into urobilinogen. Urobilinogen is
• Alcoholic and otherwise (m/c either reabsorbed or converted by the presence of oxygen to
infectious type is Hepatitis C) stercobilin. The stercobilin and remaining bilirubinglucuronide are
excreted in the feces. These two metabolites of bilirubin are what give
Cirrhosis
feces their characteristic brown color. Small amounts of urobilinogen
o Meds (eg, estrogen) remaining in the blood are filtered by the kidneys, ending up in the
o Jaundice of pregnancy (hormonal) severe urine as urobilin. This bilirubin metabolite gives urine its
itching characteristic yellow color.
• Indirect Bilirubin (BM) TQ
o Hemolysis (RBC breakdown)
Congenital anemias (eg, sickle cell)
Acquired anemias
o Poor marrow production
o Neonatal jaundice (treated by UV light exposure)
o Impaired conjugation from meds.
26
[END GI MATERIAL]
27
Dysuria
• Painful or difficult urination
• Cystitis (Urinary Bladder Infection)
o Infasimatacis Cystitis
Air in the bladder wall
o E. Coli most common bacteria to cause infection
o Diabetics get cystitis a lot
o More common in women
Urethra is shorter in women – shorter pathway for bacteria
Wiping from P to A instead of A to P
Holding the urge to pee
o In the suprapubic region.
• Urethritis
o Usually infectious
o Causes: Gonorrhea (gonococcal urethritis), Chlamydia (M/C cause) (non-specific or non-gonococcal urethritis)
• Vaginitis
o Inflammation of the vaginal introitus (opening)
Poor hygiene leads to Fungal Infection, m/c Candida Albicans (Yeast Infection)
• Prostatitis
o Bacterial Prostatitis (Septic)
o Aseptic Prostatitis
Both very painful
Can be caused by stones
Aseptic prostatitis can be a side effect of overuse (think Sailors on Shore leave)
Thought Keagel exercise may help prevent prostatitis
• Chemical Irritants
o Latex on a condom, Meds, Laundry Detergents, Lubricants, Douche (common in female), Deodorant spray
• Urethral Diverticulum
o Outpouching from a hollow viscus in the ureter (rarely urethra)
Can become infected and cause pain
Can be from high pressure in the system (such as a stone) or congenital weakness in the wall
• Bladder CA
o Usually asymptomatic
o Very aggressive
Polyuria
• Excess/increased production of urine
o Frequency, production, or both
o Infection cause pain during urination leads to polyuria because to painful
o Renal disorder cause both production(dilute concentration) and frequency
o Too much fluid in the body (volume overload)
As from CHF (main cause of volume overload)
• Know that clubbing hypertrophic osteoarthropathy (normally associated with CHF) is associated
with GI disease, GERD, cardiac, and pulmonary disease (TQ).
• Digital clubbing & cyanosis – CHF
• Relative term compared to how much pt used to produce
• Nocturia – getting up excessively at night to urinate
o Usually with a sudden onset in someone who has not had to get up before.
• Cystitis/ Lower UTI
o Heightens micturation reflex
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• Upper UTI
• Diabetes Mellitus
o Glucose changes the osmolality of the blood
o Patient pees a lot
o Triad:
Polyuria
Polyphagia
Polydipsia
(Polyneuropathy)
(Polyvasculopathy) (There are actually 5P’s according to Wyatt)
• Diabetes Insipidus
o Lack of anti-diuretic hormone which causes more diuresis (excess production of urine)
o Or decreased sensitivity thereto.
• Meds (diuretics)
o Blood pressure control, congestive heart failure (increase in volume lowers ejection fraction)
o CHF – give lasik (? Is the generic name)
Polyuria at early stage
Oliguria at late stage b/c can’t get enough blood to the kidney
• Anxiety
o Got to pee when you get nervous
• Hypokalemia and other electrolyte imbalances
o Low serum potassium level
o Be very careful if you see a Pt with increased K levels.
Urethral Discharge
• Some abnormal fluid from the urethra when not urinating
• Discharge can be:
o bloody (sanguinous)
o clear (serous)
o serosanguinous (mixed)
o pus (purulent)
o Can have an odor
• [picture: Gonococcal infection of the penis] (Not too pleasant
to see first thing in the morning)
• Things within the urethra, along its course, within the prostate
gland, etc. can cause discharge.
• Prostatitis
o Bacterial Infection (septic and aseptic)
o Prostatic fluid and/or WBC
• UTI
o Milky discharge (composed of pus)
• Interstitial Cystitis
o Most common in Diabetics
o Affects interstitial rather than serous tissues
• Vaginitis
o Yeast infection
o Most commonly from Candida albicans
• Gonococcal Urethritis
o “The clap”
Historically, a “clap” on the male member was how it was treated. (OW! And ineffective to boot.)
Pus, blood, or semen.
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• NGU- Non-gonococcal urethritis
o Most commonly due to Chlamydia
M/C STD
June 1, 2006
Impotence (Erectile dysfunction, Ejaculatory dysfunction)
- Inability in males to attain or sustain an erection.
- Erectile process:
o Autonomic NS controls erection
o Parasympathetic controls or maintains erection
o Sympathetic interference (stress) can prevent from getting erection
However sympathetic system promotes the ejaculatory process.
Mnemonic: “Point and Shoot”
o Also remember that as we age the nervous system doesn’t work as well as it did.
- Psychogenic
o M/C cause of impotence (90%)
o Stress
Sympathetic NS overloads the parasympathetic NS.
o A side effect of the chronic stress lifestyle that predominates our culture.
- Diabetes Mellitus (type I and type II)
o M/C other than psychogenic (organic)
o Poor blood supply
o Micro neuropathies & Micro vasculopathies
o 5 P’s – polyuria, polyphagia, polydipsia, polyneuropathy, polyvasculopathies
- Vascular Insufficiency
o Smokers
o Also peripheral insufficiencies
LeReischies syndrome – presence of a saddle thrombus at the bifurcation of the common iliac arteries
• Leads to poor blood flow to anything lower on the chain, including ischemic effects to the penis
and other reproductive organs.
- Medications
o Parasympatholytic ( Parasymp) and Sympathomimetic (symp) medications.
o Parasympathetic NS controls erection and sympathetic NS controls ejaculation
- Neurologic disease
o Quadriplegic, Paraplegic
o Cauda Equina Syndrome (as compressed from a low back injury – the loss of morning erection is one of the earliest
signs)
o Cancer, Chronic Heart Disease
- Systemic diseases
- Prostatectomy
o Cut regional nerves innervating penis in about 10% of post surgical cases.
30
Painful hematuria
Renal damage (particularly in young people)
Severe Exercise
• Kidneys will bounce up and down.
• Marathon runners frequently present with microscopic hematuria.
• Football players clipped hard in the costovertebral angle.
• Kidneys can even fracture obliquely in major trauma (MVA)
• Intercourse or masturbation can cause hematuria in both sexes, both gross and microscopic.
o Tumor
Presents as painless hematuria
Bladder Cancer
Renal cell carcinoma
o Infection
Presents as painful hematuria
Any form of UTI can cause hematuria.
Bladder cystitis is most common
Glomerulonephritis: infectious and noninfectious types.
• Secondary to strep throat red casts
Pyelonephritis white casts
• Infection of the kidneys
o Calculi
Kidney stones
• Calcified stones (gallstones m/c made with cholesterol)
• Form b/c of stasis in system that slows the urine down
Happen more often in the summer due to dehydration (from excess perspiration)
o Cysts (renal)
Over 50% of population has at least 1 renal cyst at autopsy.
Epithelial lined from a couple mm across to 10-12 cm across.
Not the same as polycystic (causes still borne) disease.
Usually asymptomatic, but occasionally can rupture, resulting in hematuria.
o Surgery in the Urinary tract
o Sickle Cell Disease (Ischemia, Infarction, and Infection)
Due to abnormally shaped RBC
Oliguria/anuria
• Reduced output of urine/absence of urine production (1200 ml/day)
• < 100 ml/day = Anuria
• < 600 ml/day = Oliguria
• M/c cause of oliguria is dehydration, decrease fluid intake, diarrhea.
• M/c cause of anuria is renal failure.
• Renal failure = DM
o TX: dialysis, transplant
• Kidney failure = uremia
o Affects BP, acid/base balance, electrolytes
o Can be fatal if not treated.
• Decreased fluid intake = usually oliguria
o Can only go w/o fluid for 48-72 hrs (TQ)
• Strenuous exercise
• Sweat the most when sleeping (besides exercise)
• CHF can cause renal failure
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• Pre-renal failure = m/c not enough blood going to kidneys
• Intrarenal failure = problem in actual kidney
• Postrenal failure = obstruction past the kidneys
Pelvic Pain
- Just the anterior soft tissue, not the bony structure.
- M/c in women.
- 80-90% of cases are undiagnosed.
- M/c cause is inorganic (don’t know)
- Treatment of pelvic musculature and joints can help non-organic pelvic pain (supported in urologic data)
o A chiropractor hooked up with an Ob/Gyn to treat non-organic pelvic pain can make a mint.
- M/c cause = constipation (left side)
- Pelvis is triangle b/w both ASIS and pubic symphysis
• Dysmenorrhea – m/c organic cause
o Abnormally painful menstruation
(All periods are painful to some extent due to uterine contraction)
o Cz: thyroid problem, infection, premenopause, fibroids, endometriosis
• Fibroids
o Benign tumor of uterus
Uterine leiomyoma - smooth muscle tumor with fibrous tissue (TQ)
Found on plain films of lumbar spine – very common
• Look for a “popcorn ball” apperance in the region of the uterus. (TQ)
Can have dysmenorreha, infertility, pain, etc.
Very occasionally possible to become malignant (RARE: leiomyosarcoma)
• Hence usually benign (TQ)
Can be VERY large (largest at 350 lbs in one Pt), and even can make women think they are pregnant (TQ)
• Adhesions after surgery
• Cystitis
o Suprapubic region
o M/c cause: E. coli
• Endometriosis
o Abnormal deposition of ectopic endometrial tissue outside of the uterus
• IBD
o Crohn’s, Ulcerative Colitis
Proteinuria
• Not normally in urine because it’s too large
• Occurs w/damage to basement membrane (in the glomerulus)
• Malignant HTN: Increased BP, enough to cause tissue damage
• Idiopathic proteinuria
o Ok if everything else has been ruled out
o Ok if it’s mild
• Nephrotic syndrome - classically associated with proteinuria (waxy casts)
o Post strept
o Diffuse swelling associated with proteinuria
o Associated with renal failure
o Sicker than Pts with nephritic syndrome.
o Nephritic syndrome secondary to glomerulonephritis
o Nephrotic – non inflammatory, nephritic – inflammatory
o But both allow proteinuria
o The difference is not heavily hit on Exam 1.
32
• Malignant HTN
• CHF
• Diabetes mellitus (know the 5 P’s)
• Sickle cell disease
• 3 things that occur with sickle cell: Infection, Ischemia, Infarction
• Idiopathic proteinuria
• Pyelonephritis (m/c from UTI from E.coli)
• Ascending infection from bladder
• Glomerulonephritis
• Most commonly post-strep infection. (important point)
• Pregnancy (can be an early onset sign/risk for ecclampsia and pre-eclampisa)
• Myeloma
• Pt’s produce Bence Jones proteins, which are small enough to naturally go through the glomerulus
• Leukemia
• Lymphoma
33
[END TEST ONE]
34
High mortality rate, since are hollow organs and not well innervated (pain generation by a tumor) – hence pain
only occurs when tumor grows beyond capsule or capsule is distended from tumor growth. S/sx usually only
occur after 75% of the diameter of the lumen is occluded by growth.
Cost benefit must be done to determine whether or not it is prudent to screen EVERY Pt EVERY year for these
tumors.
• But costs are usually high (EGD’s) and these are rare, so the cost benefit is not good for yearly
screening.
Fecal occult blood testing routinely done (as a general screen).
Also remember (takehome message from this class): any male over 40 with Iron deficiency type anemia has a
malignancy until proven otherwise.
o Leiomyoma is the m/c benign tumor
o Most tumors occur in the lower esophagus
o Squamous cell carcinoma is m/c
o 7.6/100,000 in USA
But this rate has increased in the last 25 years or so.
• D/t increasing popularity of BBQ’ing (or blackening) of food – the burning increases the nitrate
concentration. (also a theory on acrylamide responsibility in smoked foods)
o 130/100,000 in China
D/t the processing of the foods in that area of the world – most smoking and pickling, which includes a lot of
nitrates, which has a metaplastic effect on the esophageal epithelia.
o M:F 3:1
o Most Pts >60 yoa.
o Dysphagia to solid and later fluid is due to esophageal dysfunctions
o Dysphagia to both fluid and solid is due to neurological condition
• Esophageal Carcinoma (Cancer)
o Etiology
Alcohol abuse association w/ 80-90% of cases
Cigarette smoking
• Aerophagia and swallowing saliva exposed to smoke, w/ all the oxidative radicals.
Nitrate ingestion.
• Smoked or burned foods, pickled foods
Chronic achalasia
• Poor relaxation of the lower esophageal sphincter (LES)
• Spasm in LES, which closes – food just sits in the lower esophagus, with a fermenting effect in the
static bolus, which in turn leads to damage.
• Lead to bad breath
Chronic GERD
• May or may not lead to Barrett’s esophagus
o Dysplasia from squamous to columnar epithelia.
o Associated with adenocarcinoma.
o D/Dx (think S/sx of obstruction)
Achalasia (particularly in the elderly)
DES – Diffuse Esophageal Spasm
• Think of chest pain when eating ice cream too fast – like that for hours on end.
• Also a D/Dx for MI.
Esophageal rings
• Congenital rings that narrow portions of the esophagus.
Scleroderma
• Progressive systemic sclerosis (PSS) – connective tissue arthropathy, causing calcification in the
digits.
• Taut red skin (fingertips become pencil like, and may fall off, as well as the nose)
35
• 70% of Pts with PSS have esophageal involvement – which becomes hard and inflexible.
o Stages of Malignancy:
Stage 1: Well contain within an organ
Stage 2: lymph node on same side
Stage 3: Lymph node on opposite side
Stage 4: Distant metastasis to another organ.
o [picture: adenocarcinoma]
o Physical findings
Dysphagia (first for solids, then liquid)
• Liquids can move around an obstructive mass
early.
o If liquid dysphagia right off the bat,
think paralysis of some sort (or acute, massive obstruction).
Weight loss
• Usually in late stage disease. [cachexia (wasting)]
Cervical adenopathy
• Like a Virchow’s node (sentinel node in the left supraclavicular space for lymphadenopathy)
Hematemesisj(throw up blood)/hemoptysis (cough up blood)
Hoarseness
• Damage from reflux
• Extension of tumor into trachea, larynx, or recurrent laryngeal nerve (larynx innervation)
Cough w/ clear sputum
Mets from Esophageal cancer go to liver, pleura, lungs w/ associated S/sx
• Since both drained by portal venous system.
36
• Benign Esophageal Tumors
o Tumor types
Sessile (broad based) or pedunculated
Leiomyoma is most common
Papilloma
Fibrovascular polyps
o Very rare.
Esophagitis
1. Reflux esophagitis
2. Acute ulcerative esophagitis
3. Esophageal PUD
4. Crohn’s esophagitis
5. Infectious esophagitis
6. Chemical esophagitis
7. Mechanical esophagitis
• Reflux esophagitis
o Reflux of gastric contents w/ permanent damage
o Progression of GERD
Possible progression to Barrett’s esophagus
(squamous to columnar epithelial metaplasia)
o Incompetent LES
o Often associated with hiatal hernia (50-70%)
o 30-60’ post-parandial/reclining heartburn.
• Acute Ulcerative Esophagitis
o Seen in Pts with PUD (tend to vomit a lot)
o Contracted fibrotic lower esophagus results.
Results in stricture – mimics achalasia (non-
relaxation of the lower esophageal sphincter)
• Infectious Esophagitis
o Immunosupressed Pts (picture)
AIDS
Malignancies and other chronic
systemic illnesses.
Diabetes
Transplant – on anti-rejection drugs.
o Organisms (3 primary) (picture)
Herpes simplex
Candida albicans
CMV (cytomegalovirus)
o Dysphagia, odynophagia (painful swallowing),
chest pain.
o Treated with antibiotics.
• Mechanical Esophagitis (picture of two safety pins stuck
together)
o Swallowed object becomes lodged.
o Lodge at narrowed portions
37
3 most common: Cardiac sphincter,
thoracic inlet, at the aortic knob area
• Also: Left atrial enlargement
secondary to CHF impinges upon esophagus.
o Objects include coins, pills, bone pieces
o Leads to ulceration, maybe perforation.
• Esophageal Diverticula
o Diverticula – out pouching of a hollow viscous.
Something either pushing from the inside or
something pulling from the outside to pull the blind end pouch out.
Appendicitis is most common.
o Usually acquired
o Two types
Traction (pulled from outside of viscus)
• When esophagus contracts during
peristalsis and esophagus is has external adhesion cause traction.
• Source from in the mediastinum, such
as inflammation and subsequent fibrosis of lymph nodes
(paraesophageal)
Pulsion (pushed from inside the viscus)
• Pressure push on weak wall
• Usually upper 1/3 of esophagus
o Occur anywhere in esophagus
Middle esophageal are traction
Upper/lower are pulsion
• Zenker’s Diverticulum (picture)
o Pulsion type
o Occurs at pharyngoesophageal junction
o Loss of upper esophageal sphincter laxity.
o Retains food
o Can get large, to the point of looking like a gall
bladder at the esophagopharyngeal junction.
o S/sx
38
Halitosis
Spontaneous regurgitation
Noctural choking
The position they are in (Need to
be in incline)
Recommended not to eat within a
few hours before bedtime
Neck mass
• Can sometimes see
peristalsis in the mass
Neck mass (particularly when eating)
o Complications cause by regurgitation during sleep and laying on the stomach
aspiration (particulate matter into the lungs)
• Causes abcess and bronchiectasis.
Aspiration (inhaling something that wasn’t there Aspiration pneumonia – which has a high mortality rate)
Abscess (walled off chronic infection)
Bronchiectasis (chronic obstruction of the air flow that results in fluid build up infection; 3 layered mucous
(trilayers sputum), foul smelling sputum)
Miscellaneous Diverticula
- Epiphrenic Diverticulum
o Occur in lower esophagus
o Normally asymptomatic and small
- Middle Esophageal Diverticulum
o Usually traction
o From mediastinal lymphadenitis
June 12, 2006 (2nd Hour)
G.E.R.D.
- GERD reflux esophagitis Barrett’s esophagus. Esophageal. CA always rule out cardiac Disease first
- Cough & bronchospasm or laryngitis from aspiration
- Early satiety GERD get “full” quickly
- Chocolate fat & caffeine contents cause GERD episode
- Tobacco when chemicals are swallowed
- Commonly assoc. with hiatal hernia (>70%)
- Nitroglycerin will make anginal chest pain better
o Makes GERD chest pain worse
- Gastroesophageal Reflux Disease
- Reflux of gastric contents into lower esophagus
- Incompetent lower esophageal sphincter
o Stuff from your stomach comes back up into the lower esophagus because the esophageal sphincter is not
functioning correctly
o Believes because of aging
o Reflux Esophagitis Barrett’s Esophagus Squamous cell carcinoma
o Heavier a person is the more chance they can have because increase in intra-abdominal pressure
- Incidence
o 60% of adults have heartburn
o 80% of pregnant women have GERD
- S/Sx
o Heartburn (pyrosis) (burning pain the middle of the chest)
o Dysphagia
o Regurgitation
39
Sour taste in the mouth
Pt can also have excessive salivation (as a pseudo-Pavlovian response)
o Can be confused with angina pectoris
o Chronic cough
Refluxant comes up into larynx
o Bronchospasm, due to irritation of the bronchi airway
o Laryngitis (yes, from reflux – call it, “Mexican Food Induced Laryngitis”)
o Early Satiety (Getting full fast)
o Belching/Bloating
- Contributing Factors
o Chocolate (caffeine and fat), Yellow Onions (particularly raw), Peppermint (oil), Garlic
o Tobacco (nicotine and causes sphincter to relax), Alcohol (fat and causes sphincter to relax), Caffeine (anything
caffeinated)
Spicy foods make the reflux more irritative, but doesn’t CAUSE reflux itself.
o 70% of GERD suffers have a hiatal hernia (usually sliding type)
o Beta Blockers (control BP and angina), Ca++ Channel Blockers, nitroglycerin
Causes dilation of lower esophageal sphincter (since are systemic smooth muscle relaxants and are not
specific for cardiac muscle.)
o Gastric Acid Hypersecretion
- Diagnosis
o 24 esophageal pH monitoring
o E.G.D. – final Dx for GERD
o U.G.I
o Manometry, (pressure measurement) to rule out diffuse esophageal spasms
- Treatment
o Avoid triggers (diet modification) (most effective Tx honestly)
o Proton pump inhibitors
o H2-blockers (cimetidine – Prilosec )
o Antacids
o Fundoplication
Reserved for pts with daily reflux (chronic intractable)
Stomach is wrapped around esophagus and sutured in place.
Three types
• Nissen (complete)
• Posterior (partial)
• Anterior (partial)
o Drink excessive amount of water, water helps to dilute the acid and provide weight to the stomach to pull the hiatal
hernia down.
Columnar epithelium in the
- Can result in esophageal strictures etc. if untreated. esophagus has a characteristic red
color and velvet-like texture
BARRETT’S ESOPHAGUS (grossly indistinguishable from
the normal lining of the stomach)
- Pre-malignant that contrast sharply with the pale,
- Associated with chronic reflux (5-10% incidence) glossy appearance of the adjacent
- Stratified squamous manifests to columnar epithelium, a pre- squamous epithelium.
cancerous condition Endoscopists recognize Barrett's
esophagus when they see reddish
- Increased risk of adenocarcinoma epithelium extending above the
o 30-50 times increased risk to develop anatomic gastroesophageal
adenocarcinoma of the esophagus junction well into the distal
esophagus. In this endoscopic
o 500/100,000 people with Barrett’s esophagus will photograph, the metaplastic
progress to adenocarcinoma. columnar lining is seen tc extend
- Dx up the esophagus in the form of
o EGD, biopsy almost always accompanies an EGD flame-shaped tongues. The
esophageal columnar epithelium
also may take the form of a
circumferential sheet, and islands
of columnar mucosa occasionally
40 are observed surrounded by
squamous epithelium in the distal
esophagus.
o Biopsy
- Rx
o Laser Ablation
o Fundoplication
o Surgical Resection (En Bloc if area is large enough)
ESOPHAGEAL ACHALASIA
- Spasm (shut tight) of lower esophagus with pre-stenotic
dilation which makes peristalsis ineffective
- (Inability of LES to relax, leading to storage of food product
in the lower esophagus.)
- Chest pain can occur when peristalsis is attempted
o Pain usually colicky
- Functional esophageal obstruction
- Inadequate relaxation of the LES
- Ineffective Peristalsis
- 1/100,000 incidence; 30-50 y/o
- S/Sx
o Solid/liquid dysphagia, patient indicates they can feel
the food sticking usually in the lower chest
Dysphagia for liquids and solids suggests a
motor disorder.
Dysphagia for solids that PROGRESSES to
liquids suggests an obstruction (growing).
o Chest pain
D/dx for angina.
o Vomiting of undigested food
o Aspiration, can develop pneumonia, abcesses,
bronchoastasis and die
o May be confused with angina
o Colicky type pain
Crescendo/decrescendo type pain
Stone, Ureters
- Etiology
o Degeneration of myenteric plexus
Viral
• Herpes Zoster
• Measles Virus
Autoimmune
o Not completely understood, true etiology not known
- Diagnosis
o EGD with manometry
o UGI
41
o Tests to rule out other causes (eg: EKG for cardiac
differential)
Especially with age group one wants to rule
out MI
- Treatment
o Medical
Smooth muscle relaxants (70% effective)
• Nitrates
• Calcium channel blockers
• Botulinum toxins injection
Mechanical dilation (90% effective)
• Bouginage (mechanical dilation by
balloon)
Esophagomyotomy (90% effective), incise
into the muscle (sphincter – draw back, reflux)
- Prognosis
o Excellent with appropriate Rx
o Long standing Disease increases risk of CA
SCLERODERMA
- Aka: progressive systemic sclerosis (PSS)
- Means hardening of the skin and other tissues.
o Primarily (most obviously) effects the skin, but is not
limited to the skin
o Tissue thickens and hardens
ANY connective tissue can be affected, even
those holding in their teeth and vascular tissue.
o Tends to onset in girls in their late teens to women in
their early 20’s.
Runs a harsh course over 20-25 years. (not
immediately fatal, but progressive difficulty).
o Severe hardening of lips to point must be tube feed in
late stages.
o Tight, red, hard, fibrotic skin.
o Fingers will come to a point, like a pencil and may
tips may fall off. (a hallmark sign)
Radiographically, the distal tuft of finger is
lost – with the bone of the phalanges coming right to the end of the
finger with almost no soft tissue between bone and skin.
• Flocculant calcifications in the
para-articular distal fingertips.
Same applies to tip of nose.
o Affects the esophagus in 3/4 of cases.
Hardening decreases peristalsis, leading to
dysphagia, reflux, regurgitation
The CREST syndrome is a variant of scleroderma. The acronym
- Sometimes must replace the esophagus stands for Calcinosis, Raynauds’s phenomenon, Esophageal
o Peristalsis is affected, thus difficulty in swallowing, dysmotility, Sclerodactyly, and Telangiectasias. By definition,
reflux therefore, the full-blown syndrome always involves the esophagus.
- Kidneys are often affected as well This slide illustrates the calcinosis (left panel) and Raynauds’s
phenomenon (right panel) typical of CREST syndrome. [Reprinted
- Vessels become calcified, thickened and hardened from the Clinical Slide Collection on the Rheumatic Diseases,
- Female > Male, Early teens to 20’s copyright 1991. Used by permission of the American College of
- Smooth mm relaxants used if esophagus does not need Rheumatology.]
replacing, patient receives temporary relief, usually do not work
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- Multisystem disorder often affecting the esophagus
o Lose ability to have peristalsis
o Becomes very narrow and can develop strictures
o EGD used to diagnose
- 75% have esophageal involvement
- Fibrosis and inelasticity results
- Signs & Symptoms
o Dysphagia
o Esophageal reflux/regurgitation
o S/Sx associated with scleroderma
- Diagnosis
o EGD
o UGI
- Tx with smooth muscle relaxants, but there is no cure.
- Etiology - unknown
GASTRIC ANATOMY
43
o Stomach B12 absorption (intrinsic factor), storage, mixing,
mineral absorption, protein breakdown
o Rugae increases surface area inside the stomach for production
of HCl and pepsin ,
o GE Junction
o Gastroesophageal Reflux Disease
o Fundus
o Usually holds gas
“Magenblase” air in the stomach (in upper
left stomach, near hemidiaphragm) at the fundus area
o Antrum
o Pylorus
o Narrowed portion of the distal most aspect of the stomach
o Pyloric Sphincter b/w stomach and duodenum help
prevent outflow of gastric juices that could lead to PUD
o Pyloric stenosis prevents outflow, causes regurgitation
o Curvatures
Lesser curvature
Greater curvature
• More metabolically active (because of
where food sits)
• Also where most of the diseases of the
stomach occur, for the same reasons.
o Estimated that 3 – 5 cc of blood is lost with each aspirin taken that
is not buffered
o Layers to the stomach (4)
o Mucosa, submucosa, muscle layer, serosa (inner to
outermost)
EGD ANATTOMY
Normal antrum and pylorus (pictures)
GASTRIC PERISTALSIS
GASTRIC TUMORS
44
- 7/100,000/year (not all that common)
- Most common in blood group A
- No symptom complex presented early in the disease
- Pictures: Linitis Plastica, an invasive form of gastric carcinoma , not a single
tumor mass, the tumor cells spread throughout the entire stomach without causing a
single tumor.
o Aggressive, Infiltrated carcinoma invades entire organ and cause
thickening of entire organ - rarely found before stage 3 or 4
o S/SX
Cramps
Loss of appetite
Very low bleeding
No ulceration
Poor intrinsic factor production
- Risk factors
o Diet rich in additives (smoked, pickled) (increased level of nitrates)
o Atrophic gastritis
Inflammatory disease of the stomach where there is atrophy of
the rugae
Sequela : B12 deficiency pernicious anemia
o Pernicious anemia
o Tobacco use
o Hispanic, Japanese
o Polyps
Growth into lumen
Sessile and pedunculated
Usually premalignant mass (some benign)
o H. pylori infection (PUD associated with H. pylori)
o Barrett’s Esophagus
o [picture: Linitus Plastica – thickened wall of the stomach leading to
decreased pliability, d/t an invasive malignancy (non-focal mass, which instead invades
whole thickness of the gastric wall)]
- DX
o Stool guaiac test test for blood
o Any male > 40 with anemia, has GI malignancy until proven
otherwise
45
- Dysphagia
o When this tumor is near proximal stomach (the fundus)
- Nausea and Vomiting
o From bleeding (coffee brown)
- Constipation
- Early Satiety feeling full comes from hypothalamus
[Picture] Ulcer mass greater than 1 cm in width, thus increasing the risk for
gastric cancer dramatically
When a tumor out grows it’s own blood supply the area becomes ischemic
and ulcerates
GASTRIC CA PATHOLOGY
- Adenocarcinoma 90%
o Due to the abundance of glandular tissue, {adeno-,
glandular}
- Lymphoma 6%
o Malignancy of lymphocytes {mediastinum area is the
most common area for a lymphoma}
o Hodgekin
o Non-Hodgekin lymphoma
- Gastric Sarcoma < 4%
- Leiomyosarcoma < 1 %
GASTRIC CA TREATMENT
- Surgical resection, quite often an en bloc gastrectomy (resect until healthy tissue is found)
- Node resection (when larger then 1cm)
- Radiation non-beneficial (tumors are non-sensitivity to radiation)
- Chemotherapy non beneficial
o Research has shown this treatment has very low benefit for gastric cancer.
o Chemotherapy is designed to “attack” fast growing tissue.
GASTRIC CA PROGNOSIS
- No S/sx until late in course, primarily due to the size of the hollow organ. It takes a rather large amount before it interferes
with the function of the stomach. Therefore survival rates are typically low.
- 18% 5 year survival rate
o 57% with local Disease (stage I)
46
o 19% with regional spread (stage II)
o 2% with distal mets (staged III)
GASTRITIS
- Gastritis is a “catch-all” term.
o Most common emergency room Dx for abdominal pain.
o Septsis (bacterial) or nonseptsis (non-bacterial)
- Gastritis has:
o Erythema – reddening
o Hemorrhage Atrophic gastritis – associated with
o Erosions
anemia
- Types
o Erosive
o Non-erosive, non-specific
o Specific
- S/sx
o Post-prandial (after eating) indigestion/pain (dyspepsia)
o Nausea and vomiting
o Bloating
- 50% have H. pylori (spiral shaped bacteria)
EROSIVE GASTRITIS
- Etiology
o NSAID’s
Gastric bleeding occurs frequently with all NSAIDs,
but more frequently with the COX1 inhibitors than COX2.
47
Each non-buffered aspirin reduces blood supply by 3-
5 ml.
• Buffered: has a gelatinous coating that
allows the drug to be broken down in the small bowel, as opposed to the
stomach (gelatin as a carb is broken down in small intestine rather than the
stomach).
o Alcohol(ism) d/t portal HTN
Venous congestion decreases the removal of waste
from the stomach blood supply.
o Stress from major illness (burns, multi trauma from MVA)
- Hemorrhage also common with this Disease
- Usually asymptomatic
- Can produce pain, hematemesis, nausea/vomiting
- Diagnosed with EGD
SPECIFIC GASTRITIS
- Ménétrier’s Disease
o Giant fold gastritis (the rugae become very large, (friggin
huge))
o Enlarged, thickened gastric rugae
Get hypoproteinemia due to enlarged rugae
• Causes edema, pleural effusions, and other
3rd space fluid effusions,etc.
• This causes an overload on the kidneys and
heart, leading to heart and renal failure.
o Severe protein loss
Proteins are metabolized in stomach
o Hypoproteinemia
o Idiopathic
- Granulomatous gastritis
o Crohn’s Disease (a chronic inflammatory granulomatous
bowel Disease)
o TB
o Sarcoidiosis
(idiopathic autoimmune disease that normally affects
the lymph nodes of the chest, found primarily in young black males)
o Tx: Treat the specific disorder
- Phlegmonous gastritis (nastiest you can ever have)
48
o Chronic abscess.
o Phlegmon – aggressive large abscess
o Abscess from fungal, bacterial, parasitic infection
o Emergent gastrectomy and IV antibiotics
o Treatment is the removal of the stomach.
o Common among AIDS patients (the immunosuppressed)
49
Irritating to the gastric mucosa – COX
inhibitors stop prostaglandin production which stops blood flow to the
stomach and inhibits protection to lining
o Delayed gastric emptying
Food stays in stomach & irritates
• Common in Diabetics
o Decreased bowel function,
high incident of PUD d/t the microneuropathies.
- H. pylori (produces urease) there is a inferred or coincidental correlation between H. pylori existence and ulcers
o Increases gastric acid secretion
o 75% of patients are infected with H. pylori
o 75% have recurrence in 1 year without antibiotics
o 20% have recurrence in 1 year with antibiotics
Suspect that the H. pylori are the main etiologic agent.
Most likely, though, that the H. pylori really just makes the situation worse, as opposed to being the initial
causative agent.
Wyatt suggests that H. pylori is a natural endogenous flora to the GI tract, but that it is opportunistic
with impairment of the protection mechanisms of the stomach.
- NSAID use
o Cause decrease bicarbonate the base which counter acts
stomach acid and pepsin, mucus and blood flow
o Aspirin is most ulcerogenic, buffered aspirin helps protect
stomach but still begins to break down in the duodenum thus the increase in
ulcers in this area
o 40x increased risk of PUD over the general population.
However chronic use of NSAIDs in the US may
ACTUALLY be the reason that peptic ulcer disease has become so common in
the US.
- Peptic ulcers
o Usually effect the mucosa and submucosa (about 1-2 mm deep)
o But spares muscular layer in most cases.
But can if progresses, even to perforation.
50
Differential Diagnosis (other things that cause epigastric pain (burning, gnawing, etc.))
- GERD (esophagogastroduodenoscopy)
- Reflux Esophagitis, most common condition confused with PUD
- Gastric CA, particularly if there is a change in the pain pattern
- Gastritis
- Pancreatitis
- Cholecystitis
- Cardiac disease (don’t forget this one)
Diagnostic Workup
- Endoscopy
o Esophagogastroduodenoscopy (EGD), almost
universally the means of diagnosis
o 95% accurate (5% due to human error)
o Biopsy ALL lesions
o Cancer: benign vs. malignant cannot be differentially
diagnosed by sight
More ragged the edge, the larger – the more
likely is malignant.
o Also biopsy for H. pylori
- Upper GI series
o BaSO4 swallow, then X-ray results.
o Not as reliable as EGD
o No biopsy capabilities.
o Not used much anymore.
Treatment
- Antibiotic therapy (clarithromycin – which is harsh on the stomach lining)
- Omeprazole (Prevacid)
- H+ pump inhibitors
- Stop Smoking
- Stop NSAID use
- Stop/minimal antacid use
o Not good in long term. Is addictive (gastric mucosa becomes so used to antacid, you have functionally altered it and
decreased it’s effectiveness)
o Also some risk of aluminum toxicity and hypercalcemia.
- Diet Changes
o Bland Diet
o Don’t use milk anymore, because the sugar in it can help feed the bacterial and can actually make the ulcer worse in
the long run.
Milk produce lots of mucous
- Stress Reduction
o Because of sympathetic reaction
o Valium (classic drug prescribed)
- Manipulation in conjunction with medical therapy has been proven beneficial to the patient
COMPLICATIONS (“da stuff dat will bite you in da azz”)
- GI Hemorrhage
o Most common (50% of all UGI bleeding)
Ulcer is m/c
Varices is 2nd
o 80% stop bleeding spontaneously
51
o 10-20% is bleeding clinically significant
Cause sx and problems
Mortality rate is 6-10% of the 20% who do not stop bleeding spontaneously
• Occult blood don’t know it’s there
• Some die because of vessel size that he ulcer is local to.
o Anemia
o Cancer
- Perforation
o 5% incidence
o Usually on anterior wall
Because it’s thinner
o Gastric contents now leaking into peritoneum.
o These Pts will have a RAPID progression of symptoms.
(They go quickly)
High morbidity rate.
o Zollinger-Ellison should be considered
- Gastric Outlet Obstruction
o At pylorus or duodenal bulb
o 2% Incidence
o From tissue obstruction scar tissue (fibrosis) obstruction
o S/sx: regurgitation, distension, pain, nausea and vomiting.
Zollinger-Ellison Syndrome
o Uncommon cause for PUD
o Occur because of Gastrin secreting tumors (gastrinoma)
o Cause multiple peptic ulcers (literally hundreds of small ones)
o Perforation is relatively common
Bleed outs common
o 2/3 of gastrinomas are malignant
Will metastasize
Can lead to death
o Hard to manage these cases due to the continuous production of gastrin from the
tumor
EPIDEMIOLOGY
- 50% of patients over 50
- Female: Male (4:1)
- Often associated with GERD (70%)
- 90% with EGD esophagitis have a hernia (could be permanent damage)
- Etiology unknown, age most likely culprit due to weakening of the sphincteric
- May be congenital or post-traumatic
- Bowel and stomach in the middle of the chest compressing the lungs and heart is termed a Bochdalek
o The largest one
52
TYPES OF HERNIAS
- Sliding or rolling hiatus hernia (most common)
o Fundus of stomach slide up the hiatus (sliding)
o Roling hernia - Sphincter remain the same where
fundus role up next to it.
- Paraesophageal (AKA: Rolling Esophageal Hernia)
- Short Esophagus
- Intrathoracic Stomach
SIGNS AND SYMPTOMS (same as reflux with the exception of the addition of borborygmi
• Heartburn
o Because also have GERD
- Dysphagia
- Regurgitation
- Chest Pain (burning)
- Postprandial fullness
o After eating
- GI Bleeding
- Dyspnea
o Most often with hiatal hernia, a useful d/dx from GERD. (possible TQ)
o From impingement of the left lung.
- Hoarseness
o Irritation of larynx from GERD
- Cough
o Irritation and to keep stuff from going into the trachea
- Wheezing
PARAESOPHAGEAL HERNIA
- Second most common
- AKA: Rolling Hiatus Hernia
- GE junction in normal position
- Fundus herniates through diaphragm
- Usually asymptomatic
o A self containing condition, hence not as much GERD and reflux.
- Should be surgically reduced
- May become strangulated
o Lead to ischemia (loss of blood supply)
53
MISCELLANEOUS HERNIAS Diaphragmatic hernias
- Short Esophagus Type are classified as
o Variation of sliding hernia Bochdalek's hernia
o Uncommon (90%), hiatal hernia,
o Congenitally short esophagus or from and Morgagni's hernia.
The parahiatal hernias
surgery (enbloc resection from malignancy) are characterized by
- Intrathoracic Stomach herniation through a
o Very rare small defect adjacent
o Entire stomach in chest to the esophageal
o Incompatible with life hiatus. They are rarely
- Bochdalek seen and may be
associated with
o Gastric herniation into posterior
previous trauma.
mediastinum
- Incompatible with life
o Tamponage –
o Can’t breath
DIAGNOSTIC WORKUP
- Exclude other more serious conditions
- EGD
- UGI
- Blood tests non-specific
- Ex: On contrast PFXR, can see rugae above the hemidiaphragm
TREATMENT
- This is a common condition, remember.
- Diet changes
o Avoid caffeine, chocolate, mint, uncooked white onion, etc.…
o Avoid drugs (Ca++ channel blockers), nitrates, etc.
- Weight loss (most hiatal Pts are overweight)
- Small meals (6 small meals is better than 3 large meals)
o Keep metabolism up over a longer period of time.
- Sleep with head elevated
- Manipulation
o Drink a glass of water and take a walk or jump up and down barefoot (remove shock absorbed)
- Antacids, H+ pump inhibitors, etc.…
- If all else fails, or sign of strangulation of the hernia, surgery for refractive disease
o Fundoplication.
54
- Barrett’s esophagitis
- Stricture
- GI hemorrhage
[End stomach material]
55
56
Colon
- Review normal anatomy and structure of the color
1. Vermiform appendix
2. Cecum
3. Ascending colon
4. Hepatic flexure
5. Transverse colon
6. Splenic flexure
7. Descending colon
8. Sigmoid colon (8)
o Rectum and anus are separate.
- 2 Functions:
o Fluid control and storage of feces
- Review blood supply to colon
o Superior mesenteric artery is larger than the
inferior mesenteric artery
Superior mesenteric artery
• Supply the right side
Inferior mesenteric artery
• Supply the left side
o Blood supply interruption
Mesenteric Thrombosis
• Diabetics
• Trauma causing
vasocompression
- Sigmoscopes, anoscopes, and colonoscopes used to
view the colon.
o Used to be rigid, now are flexible. (…
yaiiigghh!!)
o Can view the haustra easily. (not that you
WANT to…)
Increase surface area
- Normal Colon (Pictures)
o Normal transverse colon
o Undissoved tablets
o Normal cecum/appendix
o Undigested berry
o Normal vesels
o Tapeworm
Tapeworm (Taenia)–
- S/SX abdominal pain, weight loss
- Can grow to be 20-25 FEET long.
- Pork (Taenia solis) and beef (Taenia sanguinatum) most common.
- Can regrow if only partially removed.
- Most Pts are asymptomatic, some are anemia, weight loss, etc.
- EWW!
57
June 26, 2006 (2nd hour)
INFLAMMATORY BOWEL DISEASE (IBD)
1. Irritable Bowel Syndrome (IBS)
2. Crohn’s Disease (agranulomatous)
3. Ulcerative Colitis
4. Antibiotic Associated Colitis
5. Bacterial Colitis (Food Poisoning)
a. Ex: including from bubonic plague
6. Appendicitis
58
- DIFFERENTIAL DIAGNOSIS (other inflammatory bowel diseases
which cause cramp type pain and diarrhea)
o Crohn’s Disease
o UC
o Diverticulitis
o Colon CA
Alternating constipation and diarrhea.
o PUD
o Chronic pancreatitis
Colon does not react well to fatty stool.
o Biliary Disease
- TX
o High fiber diet – helps bulk up the stool and helps retain fluid
o Fiber supplementation (psyllium)
o Anti-spasmodics
Imodium
Lonotil
Bentyl
• Parasympatholytics (block parasymps),
usually working in 24 hours.
o Eliminate stress
o > 60% respond to Rx within 1 year
o Fairly easily managed.
o There are a number of natural anti-spasmotics.
CROHN’S DISEASE
- Chronic granulomatous inflammatory Disease (Picture of oral crohn’s dz)
o Transmural (across the entire wall) GI inflammation
o Causes granulomas – localized areas of necrosis.
“Lumpy, Bumpy Bowel Disease” – causes lots of lumps and bumps.
- Regional enteritis (AKA for Crohn’s)
o ½ of all Pts affected in the iliocecal region.
- Debilitating, often requiring surgery
- 1:1000 population
o So fairly common.
- Caucasians, Jews
- Unknown etiology
o Autoimmune is the current guess.
- Affects young people
o Teens to 20’s.
- Pathophysiology
o Location
Anywhere in the GI (“Tongue to Bung”)
33% involve terminal ileum
50% involve distal ileum/proximal colon
20% involve colon only
Can involve any portion of GI tract
o Transmural Disease
59
Inflammation (granulation tissue)
• Most common is TB
Ulceration
• But not as much bleeding as in UC (ulcerative colitis – which is hallmarked by bloody diarrhea,
and important D/dx)
Stricture
Fistula (connection between 2 organs not normally connected)
• Starts as an adhesion, then progresses.
Abscess (walled off pocket of infection)
(look for thickening and reddening of the wall in association with the inflammation)
Crohn’s disease presents with a wide variety of signs and symptoms because its involvement is variable in
both location and severity of inflammation
- S/SX
o Abdominal distention/bloating
o Mass suggests abscess formation
o “Crampy” abdominal pain (RLQ)
o Hyperactive Bowel Sounds
o Non-bloody/bloody diarrhea
o Perianal fissures/fistulas
o Bowel obstruction
o Crohn’s arthropathy
o Low grade fever, pallor
o Weight loss, fatigue
- Diagnostic Evaluation
o “Skip lesion” presentation.
o CBC
Anemia
Decreased H&H
o Electrolyte imbalance
o Vitamin B12 deficiency
o Endoscopy
o UGI (Upper GI)
o LGI (Lower GI)
o The Pt Hx is very telling on this.
60
Fistulas to the mesentery are usually asymptomatic (loose fatty CT that connect the bowel, organs)
Fistulas from the colon to the small intestine or stomach can result in bacterial overgrowth with diarrhea,
weight loss and malnutrition
Fistulas to the bladder or vagina produce recurrent infections
o Perianal disease (other presentation of Crohn’s): which usually includes anal fissures, perianal abscesses, and
fistulas
o Extraintestinal manifestations
Oral aphthous ulcers
Increased prevalence of gallstones due to malabsorption of bile salts
Nephrolithiasis with urate or calcium oxalate stones
- Complications
o Obstruction (common)
o Abscess formation (common)
o Fistula formation (inter-organ, skin) (common)
o Perianal fissures
o Colon carcinoma
(Slightly increased risk, but not the same risk as in UC (substantially increased chance)
Patient’s with colonic disease are at a greater risk of developing colonic carcinoma
o Hemorrhage/shock
If fistulas/abcesses hit and disrupt a major artery or vein.
unusual in Crohn’s disease (except for Crohn’s colitis)
o Malabsorption - from bacterial over-growth in patients with fistulas
o Loss of haustration is the hallmark
o
- D/DX
o UC (differentiated since UC has a lot of blood in the diarrhea)
o IBS (more common differential, since this does not produce as much blood in the diarrhea)
o Infectious colitis (Yersinia pestis (bubonic plague), TB, Salmonella)
o Parasitic infection (amoebiasis)
o Ischemic colitis (tends to happen in older folks with atherosclerosis or diabetes mellitus)
o Diverticulitis
o Colon CA
- Tx
o Nutritional supplementation
o Low residue diet with obstruction
o High fiber diet with diarrhea
o Medications
Sulfasalazine
Corticosteroids
Immunosuppressive drugs
o Monitor vitamin levels
o Surgery for obstruction, fistulae, etc.
o No specific treatment exists for Crohn’s disease, treatment is directed toward symptomatic improvement and
controlling the disease process
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ULCERATIVE COLITIS (UC)
- Epidemiology
o Chronic superficial inflammation of the mucosal layer of the
large bowel.
o Occurs in descending and sigmoid colon (even the rectum)
o Unknown etiology
o Aka-idiopathic proctolitis
o 100/100,000 incidence
o Most common: 14 – 38 years
o 15-20 % of pts require at least a partial colectomy (~1 out of 5
Pts)
- Presentation patterns
o 70 % relapsing
o 20 % chronic continuous
o 10 % fulminate (Toxic Megacolon)
The large bowel becomes massively distended.
• Can rupture, leading to peritonitis, sepsis,
and possible death.
- S/sx
o Similar to Crohn’s disease, but in different location.
Left, as opposed to Right in Crohn’s.
o Abdominal distention
o Abdominal pain/tenderness (LLQ, LUQ)
o Bloody diarrhea (Hallmark sign of UC, more common and
more severe than in Crohn’s)
o Fevers
o Dehydration
Because involves large bowel.
o Extraintestinal manifestation
Liver Disease
Sclerosing cholangitis (see below)
• Walter Peyton had this (football player)
Arthritis (like Crohn’s)
Ocular Disease (uveitis, iritis, conjunctivitis, etc.)
- DX workup
o “Cobblestone” appearance on scoping.
o Comprehensive H&P
o Laboratory studies
CBC (anemia, elevated ESR)
SMAC (electrolytes, LFTs)
UA (dehydration)
o Sigmoidoscopy
o Double-contrast BE
- D/DX
o Crohn’s Disease
o Bacterial infection
o IBS
o Protozoal infection
o Colon CA
o Diverticulitis
o Ischemic Bowel DISEASE
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- TX
o Correct nutritional deficiencies
o May need “bowel rest” with TPN (Total Parenteral Nutrition)
Totally fed by IV.
o Folate supplementation (decrease CA Risk)
o Low roughage diet during exacerbations
o Meds
Sulfasalazme
Corticosteroids
o Colectomy/colostomy (about 1 in 5 Pts)
- Complications [pictures]
o Vesicocolic (colovesical) Fistula with Pneumaturia
Between bladder and bowel, with air sign in bladder
on PFXR
o Rectovaginal fistula
APPENDICITIS
- Vermiform appendix can be at a variety of positions on the
caecum.
- Inflammation of appendix secondary to obstruction
- Clinical symptom complex
o Periumbilical/diffuse pain (initially)
o RLQ pain
12-24 hrs later
Sign of regional peritonitis
Rebound tenderness
• Pain is on release of pressure, not
on placing of pressure AND pain is in a different place than the point of
pressure application (Rousing sign)
High fever
o Can rupture
Within 36 hours of the pain moving to the
RLQ, the appendix is usually enlarged enough to be at substantial risk
of leaking and rupture.
Enlargement of the appendix can become
HUGE.
o May cause diffuse peritonitis
o May result in abscess formation
o Only in about 10-15% of the time AT BEST,
appendicitis will remit on its own. Don’t take this risk.
o If pain getting worse and worse, then gets better
suddenly – usually a hallmark sign that the appendix has ruptured
(rapid reduction of pressure on the serosa).
Within 12 hours, can get onset of sepsis,
toxosis, and eventual death.
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DIVERTICULAR DISEASE Picture of X-ray
- Epidemiology
o Herniation(s) of mucosa and submucosa through
muscularis (at points at which vessels penetrate the GI wall) from low
fiber diet
o Occur because of poor bowel hygiene
(Low water intake, straining, “holding it too
long”, low fiber in diet, etc.)
o Occur at vasa recta (weakened area)
o Diverticulosis is asymptomatic
o Diverticulitis is symptomatic
Only when 1 or more of the ostia become
obstructed are Sx present.
Can rupture and bleed (sometime
asymptomatically) like appendicitis.
o 30% of Pts over 40; 50% of Pts over 70 have
diverticula (very common).
o Most respond well to antibiotics
o Up to 30% require surgery
- S/sx
o Diverticulosis exam is normal
o LLQ pain most commonly.
o Pain relieved with BM
o Abdominal guarding
Voluntary contraction of abdominal mm, as opposed to abdominal rigidity, which is involuntary (d/t
peritonitis)
o Rebound tenderness suggests peritonitis
o +/- small amount of blood in stool
DIVERTICULAR BLEEDING
- 70% occurs in right colon (don’t know why, when it mostly occurs in the left colon)
- Bleeding is painless
- Resolves spontaneously in 60%
- Erosion of vessels from fecalith (fecolith?)
- 15 – 20 % re-bleed within 5 yrs (deadly)
- Diagnostic workup
o CBC (elevated WBC with diverticulitis)
o Microcytic anemia
o Barium enema (BE)
o Sigmoidoscopy
o Abdominal CT for abscess formation
- D/dx (you’ve seen this list before, as they all are D/dx for each other)
o IBS
o Crohn’s disease (which also has masses and abscesses)
o UC
o Colon CA
o Ischemic Colitis
o Infectious Colitis
- Tx
o Good bowel hygiene
Increased dietary fiber
Increased fluids.
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Regular bowel habits (when you need to go)
o Avoid foods with residue (seeds and things that could obstruct the ostia of the diverticula)
o Regular exercise
Used for constipation too.
o Broad spectrum antibiotics
Makes Pt more regular.
o IV Antibiotics in severe cases
o Surgical resection/re-anastomosis
Risk Factors
• Hereditary Polyposis syndromes
o 100’s to 1000’s of polyps in their colon.
Pts usually have prophylactic colectomies –
as they WILL develop malignancies.
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o Familial polyposis
teens to 30's, pts have thousands of polyps
o Gardner’s Syndrome
Colonic polyposis associated with osteomas
in the skull.
• Inflammatory bowel diseases
• History of previous colorectal CA
• 1st degree relative with colorectal CA
• Age >40
• High fat, low fiber diet
• Regional radiation therapy (eg. Female receives
radiation for ovarian cancer - if the colon is in the port, the fast
turnover of the epithelial cells makes them prone to damage
from the radiation, due to the effect of radiation on fast
growing tissue) [brain tumors can be treated with stereotactic
radiation]
Clinical Investigation
• Anemia (microcytic) [Any male patient over 40 with rectal bleeding is to be considered positive for colon cancer](Ya think
this is gonna be a TQ?)
• Positive FOB test
• Elevated CEA (carcinoid embryonic antigen)
o Not as good for presence of colon CA, but good to monitor Pt response to treatment (Rx)
• Elevated LFT’s (liver function tests) (usually indicating mets)
• Colonoscopy
• Double contrast BE
• CT for staging
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• CXR (chest X ray)
o Chest is a common place for mets of colon cancer
• 25% have mets at presentation, they are in stage four of the cancer
Differential Diagnosis
• Diverticular disease
• Bowel stricture
• Inflammatory bowel diseases
• Adhesions
• Mets
• Extraluminal masses (ovarian mass)
• AVMs (arterial/venous malformation)
o Usually a congenital lesion, with a tumor like mass of
arteries and veins.
o Can present with alternating diarrhea/constipation,
colorectal bleeding, etc.
o Usually occur in younger Pts
Treatment
• Surgical resection (often done for palliative reduction of S/sx, rather than curative reasons)
o 70% are resectable at presentation (usually stages A and B)
o 45% cured by primary resection
• Radiation therapy (stages B & C)
• Chemotherapy (stages B & C)
o 5-fluoroucacil
o Levamisole
• FOB q 6 months
• Colonoscopy q year x 2 years, then q 3 years
o If they are clear.
• Monitor CEA levels (Carcinoma Embryonic antigen)
Prognosis
• Duke A: >80%
• Duke B: 60%
• Duke C: 20%
• Duke D: 3%
Overall 5 year survival rate: 50%
Pts usually are cachexic.
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Colon Polyps
- 50% patients have polyps
o Hyperplastic
o Adenomas
Of concern for degradation to adenocarcinoma.
DRE’s and FOB testing encouraged.
o Lipomas
Common.
o Leiomyomas (smooth muscle tumors)
Longitudinal strips of smooth muscle transversing the colon.
- Sessile / pedunculated
- 25% patients with colon cancer have polyps
- There is also Familial Adenomatous Polyposis (FAP) (see above)
Signs / Symptoms
- Most are asymptomatic.
- Rectal bleeding is most common Sx (most in recto-sigmoid region)
o Hematochezia (BRBPR)
Familial Adenomatous Polyposis (FAP)
- Cramps
- Abdominal pain
- Obstruction
- Anal polyps may prolapse
- Generally polyps are small, but the larger they get, the higher the chance of malignant degeneration.
- Cannot tell by external observation whether a polyp is malignant or benign
o Which is why most are removed and biopsied to tell.
Diagnosis
- DRE (digital rectal exam) (aigh!)
- Endoscopy
- Double contrast BE
Treatment
- Careful observation (hyperplastic, lipoma)
- Endoscopic surgery
- Open laparotomy
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o 135,000 new cases/year
o 50,000 deaths/yr.
o 15% of all cancers (except skin cancers)
o Peak incidence in the 7th decade
o Location
Lower colon – 40%
rectosigmoid - 30 %
cecum / ascending – 25 %
transverse – 10%
- 2 types of CA can occur
o adenocarcinoma
o squamous cell CA – Most common with HPV (condylomata)
- Risk factors
o Hereditary polyposis syndromes
Familial polyposis
Gardner’s syndrome
• Polyposis & osteoma in skull
o Inflammatory bowel Disease
o H/o previous colorectal CA
o 1st degree relative with colorectal CA
o age > 40
o high fat, low fiber diet
o regional radiation therapy
- Clinical presentation
o Normally unremarkable
o DRE finds 50% of tumors
o Palpable abdominal mass (mets)
o Abdominal tenderness
o Alternating constipation/diarrhea
o Hepatomegaly (mets)
Mets usually to liver (stage 4 colorectal Ca)
• Liver drains all of GI
o Rectal bleeding
Hematochezia
Melena
Blood streaked stool
o Abdominal distention
Obstruction
Initial sx in 15%
o Pencil thin stools
o Intussusceptions
o Volvulus
o Wt loss
o Anorexia
o Malaise
o Colon CA can cause lumbar & sacral back pain
- Clinical investigation
o Anemia (microcytic)
o Positive FOB test
o Elevated CEA (used for RX response)
o Elevated LFTs
o Colonoscopy
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o Double contrast
o CT for staging
o CXR
o 25% have mets at presentation
- D/DX
o Diverticular Disease
o Bowel stricture
o Inflammatory bowel Disease
o Adhesions
o Mets
o Extraluminal masses (ovarian)
o AVMs (Arterial venous malformations)
- Cancerous staging
o Duke Classification system
A – confined to the mucosa – submucosa
B – Invasion of muscularis
C – local node involvement
D – Distant mets
- TX
o Surgical resection
70% are respectable at presentation
45% cured by primary resection
o radiation therapy (Stages B & C)
o chemotherapy (stages B & C )
5-flourouracil
levamisole
o FOB (fecal occult blood) every 6 months
Guaiac test finds occult blood in feces
o Colonoscopy every year x 2 years, then every 3 years
o CEA level
Carcinogenic embryonic antigen
- Prognosis
o Duke A – 80 %
o Duke B – 60%
o Duke C – 20 %
o Duke D – 3 %
o Overall 5 yr. survival rate – 50 %
COLON POLYPS
- Most non-inflammatory CA arise from polyps
- 50 % patients have polyps
o Hyperplastic
o Adenomas
o Lipomas
o leiomyomas
- sessile/pedunculated
- 25% pts with colon CA have polyps
- S/SX
o Most are asymptomatic
o Rectal bleeding mc
o Cramps
o Abdominal pain
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o Obstruction
o Anal polyps may prolapse
- DX
o DRE
o Endoscopy
Complicated with severe inflammation disease
May perforate bowel
Do BE instead
o Double contrast BE
- TX
o Careful observation (hyperplastic, lipoma)
o Endoscopic surgery
o Open laparotomy
CELIAC SPRUE
- AKA: Gluten enteropathy non-tropical sprue
o Antigen mediated rxn.
- Gliadin protein fraction in gluten
o Wheat
o Rye
o Barley
o Oats
- Gluten intolerance
- 50-500/100,000 people
- Incidence ↑ during 1-36 months
- F>M
o Mc to find in a child
- Clinical Presentation
o May be normal presentation
o Weight loss
o Dyspepsia (indigestion)
o FTT in children (failure to thrive)
o Bloating
o Diarrhea
o Pallor/fatigue (anemia)
o Angular cheilosis (Vit B def.)
o Osteomalacia (malabsorption of Vit D)
o Dermatitis
- Lab tests
o Iron ↓ anemia
o Folic acid ↓
o B 12 ↓
o Antigliadin IgA and IgG antibodies elevated
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o Small bowel biopsy
Show villi atrophy
Signs of inflammation
- D/DX
o IBS (mc d/dx)
More mucous in IBS stools
Age 20 - 40
o Laxative abuse
Yes, Pts can become addicted to laxatives.
o Intestinal Parasites
o Tropical Sprue
o Lymphoma
Always include as D/Dx
- TX/PX
o Gluten Free Diet
o Iron supplementation
o Folate supplementation
o B12 supplementation
o Good Px w/ diet
WHIPPLES DISEASE
- Caused by bacteria, Tropheryma whippelii (gram +)
- Multisystem Disease
- Aka: intestinal lipodystrophy
o Poor digestion of fats.
- Uncommon disease
- 30-60 yr. olds
- M>F
- Clinical Presentation
o Irregular folds (giant) in the small bowel, and thickening of the wall.
o Malabsorption
Diarrhea
Bloating/cramps
Anorexia
Weight loss / fatigue
anemia
o Extra intestinal Sx
Arthritis
• Can be peripheral or sero-negative
o Similar to UC and Crohn’s which both can have arthritis Sx.
Pleuritic chest pain (localized pain)
Pericarditis
Osteomalacia
- Pathology
o Bacteria never been able to cultured
Cannot find an agar to culture it in, must be cultured in human tissue.
o No human to human transmission.
Mode of transmission unknown.
o Appearance of bacterium can change (overall morphology: longer/shorter, thicker/thinner, etc.)
o Response to antibiotics confirms Dx
- D/dx
o Celiac sprue
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o Lymphoma
o Crohn’s disease
Consider this on just about all small bowel D/dx.
Crohn’s has more inflammatory symptoms than Whipple’s, but is included because of the extraintestinal
Sx, particularly the arthritis.
o Short bowel syndrome
Take portion of bowel out
Get malabsorption
o Pancreatic insufficiency
Fatty stools
o Lactose intolerance
- TX/PX
o Antibiotics:
Trimethoprim
Sulfamethoxazole
o Treat Vitamin deficiencies.
o Iron supplementation.
o Pts respond well to antibiotics.
Prognosis very good, once antibiotics have been administered.
LACTOSE INTOLERANCE
- Can have a transient form in people that are ill
- 1 in 6 of all people have it
- Have malabsorption symptoms
o But vitamin deficiencies are usually not as bad
- Insufficient concentration of lactase
- Results in fermentation of lactose
- Aka: “milk intolerance”
o Thickening agent
o Sweetener
- 50 million are affected (about 18% of the population)
- > 85% Asian American affected
- > 60 % African American affected
- < 25% Caucasians affected
- There can be conditional lactose intolerance.
o Pts presenting with food poisoning or occasionally other infections, can have a transient lactose intolerance after an
illness for a couple of days to a week or so.
o Common in infants and children.
o Take them off milk for a few days, then gradually add it back in. (for infants, but them on pedialyte in the
intermediate.)
- Clinical presentation
o May be normal
o Bloating
o Diarrhea
o Cramping
o Abdominal pain
o Flatulence
- DX workup
o Hydrogen Breath test
Ingest 50 gm of lactose
Rise in breath hydrogen to > 20 ppm in 90 min after lactose administration.
o Exclude other disease
o Imaging studies not indicated (sorry Dr. Fritsch)
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- D/DX
o IBS
o IBD
o Pancreatic insufficiency
o Sprue, Celiac Disease (gluten intolerance)
- TX/PX
o Lactose free diet
Milk
Bread
Candies
Cold cuts
Commercial sauces
o Read labels
o LactAid tablets
o Ca2+ supplementation (since don’t drink milk)
o Excellent prognosis – easily treatable, if inconvenient.
MECKEL’S DIVERTICULUM
- Of the small bowel
- Remnant of vitelline (omphalomesenteric) duct.
o Duct that used to feed the fetus
o Right before the cecum at the ileum.
- Most commonly misdiagnosed as appendicitis
o Because of its location
- Even looks like an appendix at the end of the ileum (as opposed to the ileocecal region)
o About 12 cm long (~4 inches).
o Some of them contain gastric mucosa – which can have ulcers, which in turn can bleed and perforate. Risk of feces
in mesentery.
- Congenital lesion
o 2% of Population
o Failure of obliteration of vitelli intestinal
o Duct connecting interesting 2 yolk sac
o Most common anomaly of SI
- Found w/in 3 ft of IC valve
- Less than 12 cm (4 inches) in length
- Complications
o Bleeding
o Obstruction
o Diverticulitis (contains gastric mucosa) perforation
- RX w/diverticutomy
MESENTERIC ISCHEMIA
- Most painful condition in medicine
o Very painful, high mortality rate.
- Pancreatitis is pretty painful as well.
- Most painful procedure in med is bone marrow test.
- More proximal obstruction of artery, the higher the risk of mortality.
- Occurs as a result of either superior mesenteric arterial or venous occlusion
o Less commonly from the inferior mesenteric artery (which largely affects small bowel)
- Affects the bowel from 2nd part of duodenum 2 transverse colon
- 50% embolic, 25% atheromatous, 10% venous occlusion
- Overall mortality is approx. 90%
o Usually within a few hours.
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- DX features
o Nothing highly suggestive
o Central abdominal pain, out of proportion
Arterial obstructions appear more acute, venous appear more chronic.
o KUB may be normal
KUB: Kidney, Ureter, Bladder – plain film X-ray of the abdomen.
o Look for in diabetics, alcoholics, people with long standing systemic diseases.
GENITOURINARY DISEASES
• Up to 75% of kidney tissue can be destroyed before affecting renal function.
• Surviving on one kidney is not difficult.
• Normal congenital anomalies include pelvic kidneys (unascended), Horseshoe shaped kidney (1 big one), agenesis of kidney,
urethra diverticula or bifurcations, etc.
• Polycystic disease is the most common disease of the kidney. Usually benign.
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o Hematogenous spread
o Direct extension
Pelvic abscess from ovary or uterus
- Diabetics have sugar in urine that bacteria can feed off of and therefore are more prone to UTI’s (Infra somatic cystitis air
in wall of bladder from aerobic bacteria)
- Pregnancy → higher risk d/t incomplete emptying or obstructed ureters
- Risk factors
o Neurologic disease
o Diabetes
o Renal failure
o Pregnancy
- Pathogens
o E. Coli
o Proteus Mirabilis
- Defense Mechanisms
o Low pH
o Normal Micturition
Detrusor mm contracts
Trigone muscle relaxes
o High Osmolarity
LOWER UTI
- Presentation inconsistent
o Some asymptomatic, some just have urgency, some have extreme pain
- Testing (?)
- Polyuria (increase in Urinary frequency), with minimal quantity
- Dysuria (painful urination)
- Urgency
- Urge incontinence
- Suprapubic pain aka hypogastric region
- Hematuria (menstruation most common caused, bladder infection most common pathogenic cause)
o Gross
Patient will see blood in toilet
o Microscopic
If the infection is mild to moderate
PYELONEPHRITIS
- More common in immunocompromised patients, diabetics, and other constitutional illnesses.
- Usually secondary to a UTI
- Patient will be positive for a kidney punch
- Fever, more prevalent then with a UTI
- CVA (costovertebral angle) pain
- Radiating pain into groin
o Anterior and inner thighs, males will refer to the ipsilateral testicle
- Chills
o Fever, night sweats
- Malaise
o Fatigue
- Vomiting
- Diarrhea
Clinical testing
- Clean catch UA
o Wipe w/alcohol pad → start urination → stop → catch → mid-steam urine → stop before urination is complete
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- Urine Culture & Sensitivity, by culturing you are able to determine the type of bug and degree of activity level and then the
sensitivity to antibodies so as to determine treatment plan
- CBC
o Elevated WBC, anemia (mild)
- KUB (kidney, ureter, bladder) (a plain film Xrayof the abdomen)
- Ultrasound
- IVP (Intravenous Pyelogram)
o Outlines renal substance
o Uses iodine, as it’s cleared by the renal system (not GI, respiratory, or biliary system)
- CT scan
o For tumors or abscess
- Cystoscopy
- Retrograde pyelography (obstruction)
o Dye from urethra up (via catheter) and stops where infection is
o 2 check for stones
o Surplanted now as a technique by Ultrasound.
[Ok, guys, you are NOT going to like the slides on this section…]
Non-gonococcal Urethritis
- NGU is the most common STD
o More than gonorrhea or syphilis.
o NGU twice as common as gonorrhea (the clap)
- Chlamydia is the most common bug
- Often asymptomatic (~25%), especially in women
o Which is why the spread can occur so quickly and broadly.
- Symptoms
o Dysuria
o Whitish discharge from urethra meatus.
o Meatal edema
• Treatment w/ antibiotics
Gonorrhea
• “The Clap”
- That’s how they used to treat it….no really.
• Neisseria gonorrhoeae
• Urethra is most common sight of infection
- Can have Gonococcal urethritis, Gonococcal cervicitis, Gonococcal opthalmia, and Bartholin’s abcesses
• Contraction rates(single intercourse)
- 20% for males
- 80% for females, will tear up the cervix and cause sterility if not aggressively treated
• Can be mistaken for Candida albicans infection, due to the itching.
• Symptoms
- Dysuria
- Urethral discharge
- Urethral itching
• Treatment w/ antibiotics
Herpes Simplex
-HSV II infection affecting ~20% of adults
-Spread through direct contact
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Can be infectious, even if no direct lesions are present.
-Causes blisters/ulcers around genitals
Blisters release clear fluid which contains high levels of the infected agent
-May also infect the eye, skin, other organs
-No cure, only symptom control
Acylovir and Valtrex
Genital Warts
- Condylomata acuminata
- Caused by a form of HPV
- Represents 1/3 of cases of STDs, 20 million people
- Most people are exposed at some point in life
-
-
- Will reoccur
- Hydronephrosis (water in the kidney) results from obstructed ureters, blocking outflow.
o Will only show up on venous pyelogram (IVP), as opposed to a retrograde pyelogram, which will not detect it.
- Signs/symptoms
o Acute colicky CVA, flank, low back pain.
- “Renal Colic” – crescendo/decrescendo pain presentation.
• Occurs as a peristaltic wave passes a stone in the ureter as it is propelling urine to the bladder.
o N/V (nausea and vomiting)
o Referred pain to testes/vulva/groin
o FCNS (Fever, Chills, Night Sweats) suggests infection
- Diagnostic work-up
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o UA (hematuria) (gross or microscopic)
o Plain film radiography
o Renal Ultrasound
o IVP (intra venous pyelogram)
- DDx
o L1/L2 disc herniation (pain in the same areas)
o Pyelonephritis
o Cystitis
o Diverticulitis
o PID
- Rx
o Increased fluid intake, low calcium diet (contraindicated if an obstruction exists)
- “Just let them pass”
o Uteroscopic stone removal
o Extracorporeal shockwave lithotripsy
- High-energy ultrasound. Pt is usually sedated.
- 50% pass within 48 hrs
- 50% recurrence rate without Rx
Glomerulonephritis
- Autoimmune inflammation of glomerulus
- Synonyms
- Post-infectious GN Usually after strep infection
o
o Acute nephritic syndrome
- Deposition of various immune complement precipitates after infection into glomeruluar basement membrane. Can lead to renal
damage/failure.
o Remember that failure only occurs after destruction of 75% of kidney.
- Epidemiology
o 50% affect < 13 y/o
o Most common cause of chronic renal failure (~25%), these individuals wind up on dialysis
- Most common cause of renal failure from diabetes mellitus.
o Post group A beta strep infection mc
o Collagen vascular disease (SLE)
o Idiopathic
Proteinuria
- Normal adult excretes ~150 mg/day of short and long chain proteins (0 - +2 on a UA dipstick)
o 3.5% prevalence (idiopathic) in normal adults
- Perform 3 separate tests
o You must not assume that finding protein equates the “normal” amounts excreted. You must rule out all possible causes.
o If positive again, then follow up a third time.
o Negative- Dx “transient functional proteinuria”
- Causes
o IDDM
o Nephrotic syndrome
o Amyloid
o Lymphoma
o NSAID use
o Orthostatic proteinuria (only occurs when Pt is upright)
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Nephritic Syndrome
- Secondary to GN
- Signs/symptoms
o Edema (periorbital, scrotal), due to loss of protein
o HTN, damage to kidneys which help regulate HTN
o Hematuria (d/t damage to basement membrane)
o Proteinuria
- Will result in renal failure if continues for any period of time.
Nephrotic Syndrome
- Most common cause is membranous GN
- Signs/symptoms
o Peripheral edema, protein loss
o Ascites
o HTN,
o Pleural effusion
o Hypoalbuminemia
o Hyperlipidemia / hypercholesterolemia
o 1/3 of pts have DM, SLE, amyloidosis, or scleroderma
- Many of these patients end up on dialysis. These patients are placed very low on the transplant list due to DM, they are poor
surgical candidates and the DM is not reversible, thus damage to the new organ is inevitable
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• Ureteral stones (as in repeated stone producers)
• Intra-abdominal mass
• Metstatic lesions in the abdomen.
• Bilateral renal vein occlusion
Renal Cysts
- Fluid-filled epithelium-lined cavities
- Found on 50% of autopsies
- Rarely symptomatic
- Simple cysts are ~70% of all renal masses
o So unlike esophagus or stomach, masses in kidney are usually benign (possible TQ)
- Polycystic renal disease
o M/c hereditary disease in the USA
o 50% have renal failure by age 60
o Repeated UTIs, large kidneys, flank pain
o 50% pts also have liver, pancreas cysts
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o Accurately describes how fast it grows and metastasizes (“blow out” mets, similar to blow out mets in bone.)
- 1:10,000 people/yr
- 50-70 y/o
- Male: female = 2:1
- No S/sx until late in the disease progression.
- Etiology
o Familial (genetic predisposition, particularly in 1st degree relatives)
o Smoking, obesity, diuretics, Tylenol {chronic long term use}
- Signs/symptoms {often the tumor is very asymptomatic for long periods prior to its discovery}
o Hematuria (50-60%)
About ½ microscopic and ½ macroscopic hematuria.
o Abdominal mass (25-45%), found on individuals who are relatively thin or found rather incidentally
o Anemia (20-40%)
o Flank pain (35-40%) - there is no major distention of the capsule thus no pain.
o HTN (20-40%) – sudden hypertensive changes are a red flag
o Weight loss (30-35%)
o
- Classic Triad (5-10%) for adenocarcinoma of kidney.
Prostate Diseases
- Prostatitis
- Benign prostatic hyperplasia
- Prostate carcinoma
- Prostate specific antigen
o Normal 0-4 ng/ml (nanograms)
o Elevated in:
BPH
Prostate CA (not 100% accurate)
Post-rectal examination
Prostate trauma
Prostatitis
- Men over 50
- May be aseptic or septic (infectious or noninfectious)
- Signs/symptoms
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o Dysuria (painful urination and in the case the pain is deep inside the pelvis)
o Polyuria (because they don’t want to urinate thus they urinate a little at a time)
o Pelvic/ back pain
o Urethral discharge
o Fever
- Dx made by culture and stain of prostate secretions
- Antibiotics if infectious
DDx
- prostatitis
- Prostate CA
- Urethral stricture
- Dx workup
- PSA
- Protease secreted by epithelial cells
- Elevated in ~40% pts w/ BPH
- UA
- Ultrasound to ensure to hidden masses
- Treatment
- Avoid caffeine
- Avoid medications (cold and allergy drugs)
- Medications
- TURP
- Stents
- Laser
- Coils
- Prognosis is good (>70%)
Prostate Cancer
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o Outflow obstruction
o Mass on DRE (10% have normal DRE)
DDx
- BPH
- prostatitis
- Prostate stones
Diagnosis
- Elevated PSA (may be normal in 20%)
- Elevated acid phos (extracapsular extension)
- Biopsy
Treatment (chemo, rad, prostatectomy)
Px depends on stage (~90% w/ stage I)
Testicular Torsion
- Twisting of spermatic cord
- [!]
Leads to testicular ischemia / infarct
- 1:4000 incidence
- 70% occur between 1 – 18 y/o
- DDX
o Testicular tumors
o Epididymitis
o Incarcerated hernia
o Orchitis – caused by mumps virus
o Hydrocele – an obstructive disease where there is enlargement of the epididymis
Testicular Torsion
- Clinical Findings
o Sudden hemi scrotal pain (10% are painless)
o Swelling
o Nausea and vomiting
o Afebrile – no fever
o 30% patients report previous episode of pain
- Dx based on H and P
- Surgical de-rotation with suture fixation
Epididymitis
- Septic/traumatic inflammation of epididymis
- >600k visits per year
- Occurs in sexually active men
- DDX
o Orchitis
o Testicular torsion
o Hydrocele / varicocele
- Agents
o N. gonorrhoeae
o C. trachomatis
- Clinical presentation
o Tender scrotal swelling
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o Erythema
o Dysuria
o Urethral discharge
o Fever
- RX
o Ice packs with scrotal elevation
o Analgesics
o Antibiotics
- Px
o Usually self limited
Hydrocele
- Fluid collection in the scrotal space
- If congenital, associated with inguinal hernia
- In adults
o Infection
o Tumor
o Trauma
- Clinical presentation
o Scrotal enlargement / pain / radiating to back
o Transillumination
- Rx
o None if asymptomatic
Orchitis
Testicular Cancer
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Bladder Cancer
- Range from low-grade to high-grade
- Cell types
o Transitional cell (93%)
o Squamous cell (6%)
o Adenocarcinoma (1%)
- 54,000 new cases/yr; 12,000 deaths
- 4(F)-10(M)% of all cancers
- M/c over age 60
- 25% result from occupational exposure
o Dye, textile, rubber tire, petroleum workers
- 15-65% associated w/ smoking
- Clinical presentation
o Gross painless hematuria
o Painless microscopic hematuria
o Frequency, urgency – due to bladder becoming filled with the mass
o mets causes pain in distant organ (eg, back pain)
- Diagnosis
o H&P History and physical examination
o UA, cystoscopy – and endoscopic procedure for the bladder
- Rx- chemo, radiations, TURP, cystectomy
- Px- dependent on cell type and grade
(high grade indicates how fast grows)
Liver Function
- Anatomy
o Four lobes – right, left, caudate and quadrate
o Weighs – 3 lbs
- Blood Supply
o Hepatic artery (oxygenated blood) (20%)
o Hepatic portal vein (nutrients) 80%
o Hepatic veins (drain liver)
o Holds 1 pint of blood
- Only organ that can regenerate
- 75% damaged before failure
- Over 500 functions
- Produces bile
- Produces plasma proteins
- Produces cholesterol
- Converts glucose to glycogen
- Stores iron
- Converts ammonia to urea (one of the reasons that BUN levels can be elevated in the liver as well as the kidney
- Clears drugs
- Blood clotting
- Normal portal venous pressure = 5-10 mm Hg (a relatively low pressure system)
Hepatitis
- Liver inflammation
- Types
o Viral (A, B, C, D, E, X?)
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o Alcoholic hepatitis
o Drug-induced hepatitis
o Toxic hepatitis (carbon tetrachloride, benzene)
o Leptospirosis
o Toxoplasmosis
o EBV, CMV, HIV,
o Most common is alcoholic, and viral
o Most common is C typeHIV
Hepatitis A
- Caused by HAV (RNA virus)
- Fecal-oral route, close family contacts
- 9-45/100,000/yr
o Institutionalized children
o Daycare centers
o Male homosexuals
o Exposure to imported apes
o Undercooked mussels, clams, oysters
- Highly contagious
- Represents 33% of viral hepatitides in USA
- Clinical presentation
o Often asymptomatic (25% adults, 90% <2 y/o)
o Anorexia, malaise
o hepatomegaly (87%), RUQ tenderness
o splenomegaly rare (9%)
o Jaundice
o Dark urine (bilirubinuria)
o Fever variable (precedes jaundice)
- Workup
o LFTs (Liver Function Test)
o HAV antibody
- Laboratory tests
o ALT/AST (often > 8x normal)
o Bilirubin (usually 5-15x normal)
o Alkaline phosphatase (1-3x normal)
o Albumin, prothrombin normal
o WBC most often normal
o Hepatitis A IgM
- Imaging studies not normally useful
- No such thing as chronic hepatitis A it is an acute disease whose course rarely exceeds 8 weeks
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- Acute disease lasting < 6 wks
- Rarely prolonged (3-5 mos), no carrier state
- Treatment
o Avoid hepatically metabolized drugs
o IV fluid replacement for vomiting (rare)
o Steroids not normally helpful
o Follow-up as outpatient
o Overall do not over tax the liver, no alcohol
- Px
o <0.1% fatality rate
o 60% w/ fulminant recover
o Evidence of previous disease in 40% of adults
Hepatitis B
- Acute viral hepatitis (a.k.a. serum hepatitis)
- Uncommon chronic form (5-10%)
- 4000-5000 deaths/yr from chronic HBV
- Incubation 30-180 days
- DNA virus
- 200-300k new acute cases/yr (300 deaths)
- At risk populations (blood transmission)
o IV drug users
o Homosexual males
o hemodialysis and hemophilic pts
o Health care workers
o Neonates/infants
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- Treatment
o IV fluids for dehydration (increased vomiting over Hep A)
o Treat for hepatic failure, if present
o Avoid hepatically metabolized drugs (including alcohol)
o Steroids not helpful
o Interferon for chronic cases
o Antiviral agents
- famciclovir
- lamivudine
o Liver transplant
- Prevention
o Avoid high-risk behaviors
o Testing blood supply
o Hepatitis B vaccine
- High risk groups (90% effective)
- Childhood vaccination
- HBV hyperimmune globulin
o Given after needle stick
o Given after birth w/ infected mom
o Given after sexual exposure
Hepatitis C
- Viral infection of the liver with HCV
- Non-A, non-B RNA virus
- Intermediate incubation (15-150 days)
- Most common cause of non-alcoholic liver disease in US (40%)
- Epidemiology
o Transfused hemophiliacs
o IV drug users
o Occupational needle sticks
o hemodialysis
- Male = female
- 18-39 y/o mc
- Clinical presentation
- Gradual symptom onset
- Milder that HAV/HBV
- RUQ tenderness
- Hepatomegaly
- Jaundice
- Dark urine (bilirubinuria)
- Many are anicteric asymptomatic (75%)
- Male = female
- 18-39 y/o mc
- Clinical presentation
o Gradual symptom onset
o Milder that HAV/HBV
o RUQ tenderness
o Hepatomegaly
o Jaundice
o Dark urine (bilirubinuria)
o Many are anicteric asymptomatic (75%)
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- Immunity after infection is incomplete
- Fulminant acute disease is rare (0.1%)
- Persistent infection is common (50-70%)
- Results in chronic hepatitis
- Cirrhosis develops in 20-50%
- Hepatocellular CA develops in 50%
- DDx (other inflammation hepatic diseases)
- Diagnostic workup
o Acute hepatitis c antibody
o LFTs
o Biopsy for complications
- Rx
o Avoid meds metabolized by liver
o Otherwise acute Rx is non-specific
o Follow-up for complications
o Interferon may be helpful in relapses
- Acute disease lasts <6 wks
- No vaccine
- Immune globulin injections are not helpful
Alcoholic Hepatitis
- Most common form of hepatitis
- Most common cause of cirrhosis
- SSx similar to other hepatitis x flu-like Sx
- Hepatomegaly
- Splenomegaly more common than viral
- Ascites
Hepatic Cirrhosis
- Clinical Presentation
o Early
- Weakness, fatigability, disturbed sleep
- Muscle cramps, weight loss
- Advanced
o Anorexia, weight loss
o N/V, hematemesis, due to esophageal varices
o Jaundice
o Hepatomegaly, ascites
o Amenorrhea, due to cholesterol production interference
o Impotence in men
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- Skin lesions
o Spider nevi
o Palmar erythema(alcohol abuse)
o Glossitis, cheilitis
o Ecchymosis
- CNS damage
o Asterixis (intermittent lapse of body position)
o Tremor
o Delirium
o Dysarthria, slurred speech
o Coma
- Laboratory findings
o Macrocytic anemia
o Abnormal LFTs
o Decreased albumin
o Leukopenia
- Rx
o Avoid hepatotoxic meds
o Treat disease that caused cirrhosis
o Treat complications (ascites, varices, CHF))
- Laboratory tests
o Anti-mitochondrial antibodies (98% specific), almost pathognomonic for this disease
o Abnormal LFTs
- Rx
o Methotrexate, a commonly used chemotherapy agent, which helps control the over growth of cell in the bile duct
o Colchicine
o Ursodiol
o Liver transplant
- Px-
o Asymptomatic- 10-16 yrs from time of diagnosis
o Symptomatic- 7 yrs from time of diagnosis
Hepatic Tumors
- Benign
o Hemangioma
- Most common benign liver tumor
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- Vascular tumor
- Asymptomatic
- Found incidentally
o Adenoma
- Rare solitary or multiple tumor
- Usually asymptomatic
- Found in steroid abusers, OCA users
- Malignant
o Hepatocellular Carcinoma (old term Hepatomas)
o Cholangiocarcinoma
o Metastasis (Most common cause liver malignancy), colon cancer is the most common malignancy which mets to the
liver
Hepatocellular CA
- Malignant tumor of hepatocytes
- Associated with:
o Chronic liver disease
o Cirrhosis
o HBV, HCV
o Hepatotoxins(ETOH, steroids)
- Clinical presentation
o Weight loss, anorexia
o Ascites
o Hepatomegaly
o 33% are asymptomatic
- Diagnostic evaluation
o Elevated AFP in ~90% (alpha-fetoprotein – this protein non-specific)
o Elevated LFTs
o MRI
o Ultra Sound/CT-guided biopsy
- Treatment
o Dependent on size of lesion/mets
o Resection
o Chemotherapy
- Px is 20-30% following resection
Cholangiocarcinoma
- Intra-hepatic bile duct malignancy
- Rare in USA and Europe – more common in Asia
- Presents as a liver mass
- Associated with liver fluke infestation – more common in Asian culture
- Slow progression to metastasis
Gallbladder Diseases
Cholelithiasis
- Gallstones
- Affects 20,000,000 Americans
- Predisposing factors (Female, forty, fat, flatulence, fair skin)
o Fair skin
o Female
o Obesity
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o ~40 y/o
o OCA use
o DM
- ~20% chance of developing biliary colic, passage of gallstones
- Pts are asymptomatic unless passing a stone
- S/sx
o Colicky RUQ pain
o Night pain
o Refers to right shoulder
o Lasts mins to hours depends on the amount of time is takes for the gallbladder to push the stone through
- 75% of stones contain cholesterol
- Ultrasound is imaging procedure of choice
- Rx-cholecystectomy, ESWL, dissolution (substances which will dissolve gallstones)
- Px-good
- Diagnostic workup
o Ultrasound
o MRI/CT to rule out more ominous causes
- Treatment
o Laparoscopic cholecystectomy (lap chole)
o Open cholecystectomy
o Broad-spectrum antibiotics
- Prognosis
o Excellent
o 1% complication rate with lap chole
Cholangitis
- Inflammation of bile ducts
- Complication of cholelithiasis(~1%)
- Occurs during 7th decade and older
- Clinical presentation
o Charcot's Triad
- Fever/chills
- RUQ pain
- Jaundice
o Bilirubinuria
- All S/Sx present in 50-85% of pts
- Diagnostic workup
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o Ultrasound
o ERCP endoscopic retro (if US is inconclusive)
- Treatment
o Biliary decompression
- ERCP (maybe w/ stent placement)
- percutaneous transhepatic biliary drainage
o Broad-spectrum antibiotics
- Prognosis is excellent
- Chronic disease associated w/ porcelain gallbladder, a premalignant condition
Gallbladder Cancer
Adenocarcinoma most common
- Asymptomatic unless disease is advanced
- Usually found during surgery for stones
Pancreatic Disease
- Acute pancreatitis
- Chronic pancreatitis
- Pancreatic Cancer
Acute Pancreatitis
- Most often secondary to biliary disease
- Enzymes released into pancreas
- S/Sx
o Severe abdominal/back pain
o Fetal position
o N/v
o Mild jaundice
o Shock – as a reaction to the pain
- Lipase and amylase levels increased
- CT/MRI for Dx
- Treatment
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o IV hydration
o NPO
o NG suction
o Pain control
o Treat complications
- Prognosis
o 5-10% mortality associated with the shock
o Worse in older, sicker patients
Chronic Pancreatitis
- Recurrent pancreatitis
- Male: female = 5:1
- S/Sx
o Recurrent epigastric/back pain
o Abdominal tenderness/guarding
o Weight loss
o Foul-smelling stools, that are chalky white in color and float
- Associated with alcoholism/biliary disease
- Major DDx is pancreatic CA
- KUB may reveal calcifications
- 50% pts die w/in 10 yrs(malignancy)
Pancreatic Carcinoma
- adenocarcinoma
- 2nd mc tumor of GI system (colon cancer is #1)
- Male: Female = 2:1
- M/c in head of pancreas, carcinoma in the tail will not cause jaundice, because it does not block the duct.
- S/Sx
o Jaundice
o Abdominal pain
o Weight loss, anorexia, nausea
o Biliary obstruction S/Sx(head tumor)
- CT/MRI are best imaging procedures
- Poor Px from early mets
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o [test material?]
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