Professional Documents
Culture Documents
Hx and Physical
• History: AMPLE, HISTORY, OPPQRST:
o Allergy, Medication, Past medical hx, Last menses/meal, Event of complaint
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
• Physical exam: Inspection, Auscultation, Percussion, Palpation
o Auscultation done 2nd to keep from altering sounds (bowel sounds, etc.)
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/Severity
- Timing (when does it happen and how long does it last)
o Constant = 24/7/365
o Serious
Picture
- 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
o
HISTORY
- Hospitalization
- Injuries/Immunizations
- Sugar Diabetes
- Tumors/Trauma
- Operations
- Review of Systems
- Youth Illness
Most Frequent Hernias
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
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 and 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 be incisions what it was at this point.
• Pt with scar always have 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 hig itched and get faster than 35/minute sign of obstruction
• No bowel sounds Para lytic (Adynamic0 ileus (blunt trauma, post
operative)
• Early bowel obstruction Rapid sounds to force fecal bolus
• Late bowel obstruction Shuts down and patient vomits (no bowel
sounds)
• Adnamic Illius now 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, 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
9large and near the surface.
o Percussion
Liver, spleen, diaphragm
1. Size
2. Diaphragmatic Excursion
3. Note pitch
LUQ: Not eaten tympanic (b/c air in the stomach)
Eaten dull
4. Spleen: dull
5. Liver: dull
6. Rest of the abdomen: resonance
7. Bowel obstruction: dull
Tympanic: proximal
? : 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
•
• Abdominal Exam Tips
o Comfortable room temp.
o Pt gowned with abdomen exposed.
You can use 2 white towels to drape the abdomen (crosswise), exposing only the
quadrant you are working on, which makes the Pt feel more comfortable.
o Groin uncovered with genitalia draped.
o Bladder empty (but not bowel – tricky TQ)
o Start in non-tender quadrant.
Save the tender quadrant for last. (Pt gets used to the palpation that way.)
o Use your hand over Pts’ hand if ticklish.
o Normal kidney is non-palpable. (TQ)
o Normal liver may be palpable (8-12 cm @ Mid Clavicle Line)
4 lobes (R, L, quadrate, and caudate)
Most common cause is alcoholism
o A palpable spleen is enlarged. (Normally not palpable) (TQ)
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
• Right kidney
• Gallbladder (porcelain gallbladder – calcified wall)
• Right renal artery
• Transverse colon
• Biliary tree
• Biliary aa & vein
• Pancreas (Head of)
LUQ
• Left kidney
• Splenic Flexure
• Stomach (fundus)
• Spleen
• Tail of the pancreas
• Left renal aa
• Aorta
RLQ
• Ascending colon
• Small intestine
• Right ovary
• Right kidney
• Lower portion of liver
• Right common iliac
• Cecum
• Appendix
LLQ
• Descending colon
• Sigmoid colon
• Left common iliac vein
• Small intestine
• Left kidney
• Inferior mesenteric artery
• Left ovary
• Left fallopian tubes
• uterus
(epigastric, suprapubic sometimes included as well)
o 9 regions
R/L hypochondriac (below the rib cartilage) (TQ)
Epigastric (midline between the hypochondriac regions)
R/L lumbar
Periumbilical
R/L pelvic
Suprapubic (also called the hypogastric region – a horrible label for it)
o 6 regions
Epigastric
Duodenum
Pylorus
Liver (left lobe)
Pancreas
Ascending colon
Aorta (Celiac trunk, renal aa. & veins)
RUQ
LUQ
RLQ
LLQ
Suprapubic (bladder, cystitis)
• Abdominal exam tests
o Rebound tenderness (TQ)
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 pathognomonic.
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 LQ 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.
o Obturator sign
Appendicitis
Pain on resisted internal right hip rotation.
No particular practical clinical application.
• Abdominal Distension
Also called protruberant abdomen. Not caused by obesity.
o 4 categories:
Excess fluid
• Most commonly from ascites (serous, serosanguinous, sanguinous, pustular)
• 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)
Excess gas
• Normally from excess gas, also from post-operative gas.
• Remember that gas will change position easily, and with the position of the
Pt.
• Gas is either intraluminal (inside bowel) or extraluminal (outside bowel).
A mass.
Organomegaly.
o Mechanical Intestinal Obstruction
Neoplasm (intraluminal/extraluminal)
• Ex:
o Intraluminal: colon cancer.
o Extraluminal: prostate cancer w/ lympadenopathy, uterine cancer,
baby, hernia, abscess from appendicitis, ovarian tumor, uterian
tumor/mass
Post-operative adhesions (TQ)
• Adhesions are typical following abdominal surgery. (The bowel does not
like to be manipulated during surgery). More diffuse adhesions may also
form following peritonitis.
Abscess
• Ex:
o Peri-appendocoele abscess (appendix)
o Sigmoid region (leading to diverticulitis, particularly in the
elderly)
Crohn’s disease (right lower quadrant) is also associated
with abcesses.
Appendicitis
Diverticulitis
Pregnancy
Hernias
Volvulus (TQ)
• A mesenteric portion of bowel twists on itself. Occurs in areas like the
caecum and sigmoid colon, in which at least one portion is already fixed in
one portion, but not fixed in the other.
Intusseception. (TQ)
• Telescoping of the bowel inside itself. Most common in small bowel and in
children.
• Large bowel intusseception may occur in the large bowel with a mass or
adhesion. Driven by peristalsis.
• 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) ()
Excess gas
• As from dietary sources.
Trauma
• Pts involved in MVA’s 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)
• 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
• Abdominal Pain Patterns
o Diffuse
Visceral pain
Organ involvement
Ex: Appendicitis (initially)
o Focal
Parietal pain.
Organ distension.
Ex: Peritonitis (late stage appendicitis) (TQ)
o [Photo: diastasis recti (splitting of the rectus abdominus)]
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
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.)
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
Peritonitis
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 and cholelithstasis. (Inflammation or stones)
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)
Gastritis
GERD
Dyspepsia
o RUQ
Biliary tree disease
• 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
• Mononucleosis, polycythemia vera, sickle cell and 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
• 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
(leimyomas – 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.
o VERY small chance of transformation to leimyosarcoma, but
VERY small. Normally benign. (TQ)
AAA
o LLQ
Diverticulosis/itis
• Diverticula are common with age, most people get them.
• Most often in the descending and sigmoid colon.
• Referred pain to the low back.
Obstruction
• 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.
o 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%
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 orst headache I’ve ever had.”]
• Abdominal Aortic Aneurysm (TQ’s – particularly on the diameters, and what to do in each case)
o Focal widening >3.5 cm
Diagnosed by seeing widening, usually on PFXR – as they tend to be atherosclerotic,
calcified, and visible on Xray.
o Typically > 60 years, M:F = 5:1
o Intrarenal (90%) (infrarenal?)
Below renal arteries, but above common iliac arteries.
This is a good thing – if involved the renal arteries, would have a much higher
mortality rate.
o Extension of aneurysm into iliac arteries (66%)
o Plain film: mural calcifications (75-90%)
Best seen on a lateral lumbar spine film (TQ)
• Can also see on A-P, but harder since overlaps the bony structures.
Aneurysm tends to be 25-30% larger on surgical excision than what is seen on PFXR
(plain films underestimate size) – due to incomplete calcification (only see the
calcification)
o CT: perianeurysmal fibrosis (10%), may cause ureteral obstruction.
The body is attempting to limit the expansion of the aneurysm, and this in turn might
cause the ureteral obstruction.
o Abdominal UltraSound: 98% accuracy in size measurement.
o Angio: mural thrombus (80%)
o Complications:
Rupture (25%): into retroperitoneum (usually left), GI tract, IVC
Peripheral embolization.
Spontaneous occlusion of aorta.
o Growth rate varies.
Hence the treatment protocols vary until the aneurysm reaches 7 cm (at that point,
chance of rupture is so high that surgery is non-elective)
Surgery generally not recommended until aneurysm is >5cm or the Pt becomes
symptomatic.
• [REDFLAG:Pt cannot find a comfortable position] (TQ)
o Indicates an organic cause, not a mechanical problem. (possible AAA)
o This is the Hallmark S/sx of AAA. ()
• Saccular or fusiform aneurysm – “football shaped” 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.
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.
• Abdominal Aortic Aneurysm (AAA)
o S/Sx
Most are asymptomatic (since are between 3.5-5 cm, and not dissecting)
Pulsating sensation in the abdomen
• On palpation, normal pulses A to P, lateral pulsation on palpation can be
indicative of AAA. (TQ)
Abdominal pain (unchanged by position) ()
LBP (unchanged by position)
Bruit (typically low pitched (blood flow slowed down))
• High pitched usually caused by stenosis.
Radiating pain into legs.
Cold Lower Extremities, peripheral pulse loss.
• Dorsalis pedis and posterior tibial are most common pulses on the foot.
Shock
• S/sx: cold clammy skin, pale skin, diaphoresis (sweating), pulse increases,
BP drops
• Quantifiable definition of shock: Systolic pressure of <90 mm Hg
o In practice: poor perfusion of the vital organs.
• 5 different kinds of shock: Hemorrhagic (hypovolemic)
o Other forms(?): anaphylactic, insulin, osmotic, protein, septic,
toxic (double check this)
o Know that septic shock is a major risk with appendicitis (TQ)
Sudden death.
o Imaging
Plain films
• Maximal measurable normally is 3.5 cm.
• Anything larger suggests aneurysm.
MRI, CT
o Treatment (big TQ)
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.
• Upper GI Bleeding
o Esophageal varices
Varicose veins common (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
– “Coughing up blood” (TQ)
• Remember that blood is VERY irritating to the GI tract, and will provoke
emesis.
o Pt’s with Upper GI bleeds can present with signs of upper GI bleed in lower GI tract.
(black tarry stools) is usually a lower GI sign of an upper GI bleed. (TQ)
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. ()
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 – 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 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 (and “Montezuma’s Revenge”) is the most common cause of
diarrhea.
o Inflammatory Bowel Diseases (IBD)
UC usually more often than Crohn’s, since affects the distal portion of the colon.
o IBS
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
o Lactose intolerance (TQ)
But NOT lipase deficiency (trick TQ)
• Nausea
o Def: The feeling of impending emesis (yacking, barfing, blowing chunks, praying to the
porcelain bowl, ralphing, spewing, hurling, Singing the College Frat Choir Song, etc.)
o Cool fact: There is some research supporting that acupuncture may be more effective than
shams, and even some meds, in post-op nausea.
• Vomiting
o Def: Emesis – the rapid, retrograde expulsion of stomach contents through the oro- and
nasopharynx.
• These are both reflexes (usually defensive in some fashion)
o Controlled in the emetic center in the base of the brain (targeted by the anti-emetic drugs)
• Possible causes
o Infectious gastroenteritis
o Obstruction
Has to be high in GI to lead to nausea and vomiting. Lower usually results in
constipation, and only in severe, chronic cases leads to nausea and vomiting.
• Know that post-stenotic narrowing occurs in a hollow lumen after
obstruction (TQ)
o Pregnancy
“Morning sickness” (hyperemesis gravidarum)
o Severe Pain (and pain medications)
o Cardiovascular disorders
Angina, MI’s
o Meds
o PUD
o GI CA
o Psychiatric d/o
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.
• Heartburn
o aka dyspepsia – burning pain in chest or epigastrum.
• Indigestion
o “Upset Stomach”
• Possible causes
o Gastritis – inflammation of stomach. Common ER diagnosis.
o GERD/Reflux Esophagitis – most common cause of burning chest pain.
o Excess intestinal gas
o Gas entrapments (hepatic/splenic flexures)
• Splenomegaly
o Common Causes
Anemias
• Removal of abnormal RBC’s
Infectious mononucleosis
• From Epstein Barr virus
HIV
Leukemia
Lymphoma
Myeloma
Polycythemia vera
• Increased red cell count (varying degrees)
• Clots tend to be the complicating effect.
• Common locations
o Epigastric
Dr. Wyatt has a small one here.
o Umbilical
Particularly in pregnant or multiparous females (TQ)
o Inguinal
Present in scrotum.
o Femoral
M/c in females.
• Valsalva maneuver accentuates the hernia.
• Hernia Examination in Men (most hernias occur in men)
o Fingertip at most dependent portion of scrotum (portion hanging the lowest)
o Invaginate scrotal wall to external inguinal ring.
Press up and slightly out into the ring.
o Gently insert finger into canal along spermatic cord.
o Move finger laterally and cephalad.
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 warm)
• 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 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
o Alcohol ingestion
• Persistent
o Uremia (renal failure), hyperventilation, IDDM
o Meds (steroids, barbiturates)
o General anesthesia
o Thoracic d/o (pneumonia, CA)
o Gastric d/o (PUD, CA)
• 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 (little known, but very common) (TQ)
• Direct Bilirubin (thin of liver and surrounding)
o Extrahepatic obstruction
Calculi, neoplasm, stricture, cholangitis (inflammation of collecting ducts)
Metastatic CA, pancreatic CA
o Hepatocellular disease (more common cause)
Hepatitis
• Alcoholic and otherwise (m/c infectious type is Hepatitis C)
Cirrhosis
o Meds (eg, estrogen)
o Jaundice of pregnancy (hormonal) severe itching
• Indirect Bilirubin (BM)
o Hemolysis
Congenital anemias (eg, sickle cell)
Acquired anemias
o Poor marrow production
o Neonatal jaundice (treated by UV light exposure)
o Impaired conjugation from meds.
• Hemorrhoids
o m/c organic cause: dilated rectal veins (varicose veins of rectum), both internal/external
• Anal Fissure (babies, people with chronic constipation/ diarrhea, anal sex, Crohn’s, UC, etc)
• Fecal Impaction
• Prostatitis
• Pelvic Inflammatory Disease
• Endometriosis
[END GI MATERIAL]
• Nephrolithiasis
o Kidney stones: Ca+ based – 80% – Murphy’s punch test: kidney infection
Calcium oxalate – Mg inhibits oxalate precipitation (and VitA?), but Mg can cause
the 2nd m/c type of kidney stones Mg stones (CLD exam material concurrent with
this section)(citrate inhibits Mg precipitation)
• Pyelonephritis - tubules (waxy casts)
o Infection of renal pelvis – upper UTI
o Most common from a poorly treated or untreated lower UTI (usually E.coli)
• Glomerulonephritis
o Inflammation of glomerulus - aseptic inflammation, usually after strep pharyngitis
Strep A infection m/c cause.
This is why Pt with strep throat must complete their antibiotic treatment (take all of
them)
o Often mistaken for kidney stone
o D/dx? (question for Wyatt)
• Renal Cancer
o AKA: hypernephroma (old term) – one of the fastest growing metastasis
• Renal abscess
o People with chronic renal disease, diabetics (most common), IV drug users, patients with TB
• Spinal disorder
o As from T12/L1 disc herniation
• Painful 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
(think Sailors on Shoreleave)
- Chemical Irritants
o Latex on a condom, Meds, Laundry Detergents, Lubricants, Douche, 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
o Two types
o Gross (macroscopic)
o Microscopic – not seen by the naked eye.
- M/C causes is menstruation
- Painless has worse prognosis (CA, don’t notice, chronic)
- “T.T.I.C.C.S.S.”
o Trauma
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.
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 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
Esophagus
• Description in 5 words or less: Hollow, food propelling muscular tube
• [picture: EGD of esophagus with varices (usually caused by alcoholic induced portal HTN)
• First tubular viscus, begins as pharynx (pharngoesophageal junction)
• Anatomy
o Pharynx
o Upper esophageal sphincter
Epiglottis
o Esophagus
o Lower esophageal sphincter at gastroesophageal junction.
Aka: Cardiac Sphincter
• Normal Esophagus
o Primary peristalsis
Initiated by swallowing (scientific name: deglutition) – voluntarily initiated.
• Soft palate, tongue assisted.
Propels food
• Strong propagating propulsive wave
o Secondary peristalsis
Not initiated by swallowing – involuntarily initiated.
Propels food through lower esophagus
o Tertiary peristalsis
Seen in elderly, abnormal
No propulsion – a feeble attempt at secondary peristalsis.
D/t degeneration of the nervous plexes and smooth muscle in the esophagus.
Similar to the fibrillation seen in a ventricular arrhythmia – just quivers.
• Esophageal Functions
o Lower esophageal sphincter at level of diaphragm.
o Esophagus contains smooth muscle.
Unique because it’s voluntary (almost the only instance of voluntary smooth muscle
control)
• Esophageal Tumors
o Normally not a very metabolically active area – purely propulsionary, no digestion occurs
there.
o As we age, the lower esophagus is exposed to years of reflux (everyone has it to some extent).
o Of those that do occur, most tumors are found in the lower esophagus and 90% of them are
malignant.
• Esophageal Neoplasms
o Malignant tumors are the most common. (90%)
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.
• Esophageal Carcinoma
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.
Chronic GERD
• May or may not lead to Barrett’s esophagus
o Dysplasia from squamous to columnar epithelia.
o Associated with adenocarcinoma.
o DDx (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)
• 70% of Pts with PSS have esophageal involvement – which becomes hard
and inflexible.
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)
Hematemesis/hemoptysis
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.
o Diagnostic Imaging
Double contrast esophagram
• Barium paste used. The bolus is then followed.
• Looking for “shouldering” – a square cut off at the beginning of a lesion
between it and the soft tissue.
• This is rarely used now, normally an EGD is done (which also allows the
obtaining of a biopsy.)
Esophagoscopy
Chest/abdominal CT
Abdominal MRI
o Laboratory tests
CBC
Blood chemistries
Liver enzymes.
o Treatment
Resection if no mets
Stomach/colon used for replacement
Radiation therapy
Chemotherapy.
o Prognosis
Surgery – 20-50%
Radiation – 6-20%
Chemotherapy – 15-80%
• Benign Esophageal Tumors
o Tumor types
Sessile (broad based) or pedunculated
Leiomyoma is most common
Papilloma
Fibrovascular polyps
o Very rare.
Esophagitis
o Reflux esophagitis
o Acute ulcerative esophagitis
o Esophageal PUD
o Crohn’s esophagitis
o Infectious esophagitis
o Chemical esophagitis
o Mechanical esophagitis
• Reflux esophagitis
o Reflux of gastric contents w/ 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 achalsia (non-relaxation of the lower esophageal
sphincter)
• Infectious Esophagitis
o Immunosupressed Pts
AIDS
Malignancies and other chronic systemic illnesses.
Diabetes
Transplant – on anti-rejection drugs.
o Organisms (3 primary)
Herpes simplex
Candida albicans
CMV (cytomegalovirus)
o Dysphagia, odynophagia (painful swallowing), chest pain.
o Treated with antibiotics.
• Mechanical Esophagitis
o Swallowed object becomes lodged.
o Lodge at narrowed portions
3 most common: Cardiac sphincter, thoracic inlet, aortic knob
• Also: Left atrial enlargement secondary to CHF impinges upon esophagus.
o Objects include coins, pills, bone pieces
o Leads to ulceration, maybe perforation.
BARRETT’S ESOPHAGUS
- Pre-malignant
- Associated with chronic reflux (5-10% incidence)
- Stratified squamous manifests to columnar epithelium, a pre-cancerous condition
- Increased risk of adenocarcinoma
o 30-50 times increased risk to develop adenocarcinoma of the esophagus
o 500/100,000 people with Barrett’s esophagus will progress to adenocarcinoma.
- Dx
o EGD, biopsy almost always accompanies an EGD
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 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
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
- Sometimes must replace the esophagus
o Peristalsis is affected, thus difficulty in swallowing, reflux
- Kidneys are often affected as well
- Vessels become calcified, thickened and hardened
- Female > Male, Early teens to 20’s
- Smooth mm relaxants used if esophagus does not need replacing, patient receives temporary relief,
usually do not work
- 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
EGD ANATTOMY
Normal antrum and pylorus (pictures)
GASTRIC CANCER
90% of tumors in the esophagus are malignant
- Occurs anywhere in the stomach
o With a greater occurrence in the greater curvature of the stomach due to the gravity of
material to this area of greater metabolism
- Incidence of proximal CA is increasing in the US (almost logrhythmically)
- 2 - 4X more common in 1st degree relatives
- Male : Female 1.6:1
- > 55 y/o
- 7/100,000/year (not all that common)
- Most common in blood group A
- No symptom complex presented early in the disease
- Pic: 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
-
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}
- 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)
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.
- 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.
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)
- 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 Sarcoidosis
(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
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)
Differential Diagnosis (other things that cause epigastric pain (burning, gnawing, etc.))
- GERD
- 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 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.
- 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
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
HIATUS HERNIAS
- Herniation of a portion of the stomach into the thoracic cavity (mediastinum) through
diaphragmatic hiatus
EPIDEMIOLOGY
- 50% of patients over 50
- Female: Male (4:1)
- Often associated with GERD
- 90% with EGD esophagitis have a hernia
- 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
TYPES OF HERNIAS
- Sliding (most common)
- 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)
MISCELLANEOUS HERNIAS
- Short Esophagus Type
o Variation of sliding hernia
o Uncommon
o Congenitally short esophagus or from surgery (enbloc resection from malignancy)
- Intrathoracic Stomach
o Very rare
o Entire stomach in chest
o Incompatible with life
- Bochdalek
o Gastric herniation into posterior mediastinum
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
- Antacids, H+ pump inhibitors, etc.…
- If all else fails, or sign of strangulation of the hernia, surgery for refractive disease
o Fundoplication.
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!
INFLAMMATORY BOWEL DISEASE
- Irritable Bowel Syndrome (IBS)
- Crohn’s Disease (agranulomatous)
- UC
- Antibiotic Associated Colitis
- Bacterial Colitis (Food Poisoning)
o Ex: including from bubonic plague
- Appendicitis
CROHN’S DISEASE
- Chronic granulomatous inflammatory Disease
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
o Transmural Disease
Inflammation (granulation tissue)
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)
- 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
o LGI
o The Pt Hx is very telling on this.
- Presentation Patterns
o Chronic inflammatory Disease (M/C)
Chronic relapsing inflammatory disease.
o Intestinal obstruction from stricture abscess
o Fistula formation
o Perianal disease
o Extraintestinal
- 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.
- 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)
o Hemorrhage/shock
If fistulas/abcesses hit and disrupt a major artery or vein.
o Malabsorption
Crohn’s disease presents with a wide variety of signs and symptoms because its involvement is
variable in both location and severity of inflammation
Intestinal obstruction
o Narrowing of the small bowel may occur as a result of inflammation of fibrotic
stenosis
o Patients report postprandial bloating, cramping pains, and loud borborygmi
Oral aphthous ulcers
Increased prevalence of gallstones due to malabsorption of bile salts
Nephrolithiasis with urate or calcium oxalate stones
Abscess
Obstruction
Fistulas
Perianal disease
Carcinoma – Patient’s with colonic disease are at a greater risk of developing colonic
carcinoma
Hemorrhage – unusual in Crohn’s disease (except for Crohn’s colitis)
Malabsorption – from bacterial over-growth in patients with fistulas
No specific treatment exists for Crohn’s disease, treatment is directed toward symptomatic
improvement and controlling the disease process
- Epidemiology
o Chronic superficial inflammation of the mucosal layer of the large bowel.
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
- 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 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 it’s 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.
DIVERTICULAR DISEASE
- 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
- 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.
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.
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 Presentation
• Normally unremarkable
o Normally only found after signs of bleeding (see below)
• DRE finds 50% of tumors (polyps and colon cancer)
• Palpable abdominal mass (mets most likely not the colon cancer itself)
• Abdominal tenderness
• Alternating constipation / diarrhea (blockage, attempt to flush, repeat)
• Hepatomegaly (mets)
• Rectal bleeding
• Hematochezia
• Melena
• Blood streaked stool
• Occult blood [blood mixed in with the stool]
• Abdominal distension
o Obstruction
o Initial symptom in 15% of patients
If gets to this point, probably already has metastasized, stage III or IV.
• Pencil thin stools
• Intusseception
• Volvulus
• Weight loss, suggest stage 3 or 4 carcinoma
• Anorexia
• Malaise
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
• 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
Cancer Staging
• Duke classification system (used almost universally for Colorectal CA Pts)
o A - Confined to the mucosa-submucosa (essentially a carcinoma in situ) (best prognosis)
o B - Invasion of muscularis (into vessels, chance of spread)
o C - Local node involvement (local spread)
o D - Distant mets (liver, lung, brain)
• [Look for “shouldering” on Ba Xray – the almost 90o cut off between edge of mass and normal
tissue]
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.
Signs / Symptoms
- Most are asymptomatic.
- Rectal bleeding is most common Sx (most in recto-sigmoid region)
o Hematochezia (BRBPR)
- 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
SIGMOID DIVERTICULITIS TX
- ↑ dietary fiber
- Broad spectrum antibiotics
- Reg. Exercise
- IV antibiotics in severe cases
- Surgical resection/re-anastomosis
- Colorectal CA
o 2nd leading cause of CA deaths in US
1st Lung CA
2nd Colorectal CA
3rd Breast CA
o Most common CA is skin CA
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
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 %
- 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
- 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
[Ok, guys, you are NOT going to like the slides on this section…]
• “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
- Will reoccur
(Kidney stones)
- 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
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
- 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)
- 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.
- 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
- Adenocarcinoma
- Malignant transformation of renal tubular cells
- A.k.a.: "Hyper-nephroma" (name no longer used because the name does not suggest malignancy)
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.
- 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
- Men over 50
- May be aseptic or septic (infectious or noninfectious)
- Signs/symptoms
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%)
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)
- 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
- 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)
- Liver inflammation
- Types
o Viral (A, B, C, D, E, X?)
o Alcoholic hepatitis
o Drug-induced hepatitis
o Toxic hepatitis (carbon tetrachloride, benzene)
o Leptospirosis
o Toxoplasmosis
o EBV, CMV, HIV, HIV
- 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
- 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
- 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%)
- 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
- 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
- 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))
- Autoimmune disease
- Destruction of intrahepatic bile ducts
- M/c in females (95%)
- 40-60 y/o age group
- Associated w/ PSS, SLE, Sjögren’s Synd., RA, and other connective tissue arthropathies
- S/Sx
o Fatigue (extreme fatigue)
o Pruritus
o ~50% are asymptomatic
o Hepatosplenomegaly, jaundice later on
- 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
- Benign
o Hemangioma
- Most common benign liver tumor
- 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
- 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
- Gallstones
- Affects 20,000,000 Americans
- Predisposing factors (Female, forty, fat, flatulence, fair skin)
o Fair skin
o Female
o Obesity
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
Pancreatic Disease
- Acute pancreatitis
- Chronic pancreatitis
- Pancreatic Cancer
- Treatment
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
- 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)
- 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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