GASTROENTEROLOGY TiKi TaKa

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. U should exclude MI with AS in a pt with epigastric pain radiating to the mid-

scapulae.

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. When u r given a complaint of acute epigastric pain,
. radiating to the back inbet. the scapulae,
. with H/O of coronary artery disease,
. in addition to suspicion in pancreatitis & PUD,
. the 1st step to do is EKG to exclude MI !!!!!!!!!

. Chronic mesenteric ischemia:

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. Un-explained chronic abd. pain.
. weight loss.
. Food fear & avoidance of eating.
. Associated atherosclerotic disease.
. Abd. ex. may reveal a bruit.
. Dx: Doppler U/S.

. Mallory Weiss $:
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. is hematemesis due to ++ intra-abd. pressure with vomiting,
. leading to rupture of submucosal ARTERIES at the distal esophagus.

. Portal hypertension:
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. leads to hematemesis due to rupture of esophageal varices (submucosal VEINS).

. Diverticulitis:
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. LLQ pain + Constipation + Fevr + vomiting.
. The most appropriate test to confirm acute diverticulitis is Abd. CT.
. Sigmoidoscopy is contra-indicated for fear of perforation.

. ULCERATIVE COLITIS:
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. Young pt.
. Abd. pain.
. Bloody diarrhea.
. Rectal urgency.
. Anemia & reactive thrombocytopenia.
. Rectal tenderness.
. Stool mixed with mucous & blood.
. ++ WBCS with nausea ----> Toxemia.
. U should suspect TOXIC MEGACOLON.
. DO ABDOMINAL X-rays to search for Toxic Megacolon.

. Chron's disease:
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. Young pt.
. Chronic diarrhea.
. Abd. pain.
 . Weight loss.
. Mouth ulcers.
. Rt upper Q. tenderness without rebound.
. Gas in small & large intestines.
. Reactive thrombocytosis & anemia.

. DIVERTICULOSIS:
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. Old pt.
. is associated with constipation not diarrhea,
. with Left lower Q. pain.

. CANCER HEAD PANCREAS:

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. Enlarged (NON TENDER) Gall bladder.
. Weight loss.
. evidence of biliary obstuction (++ALP disproportionate with +AST & +ALT).
. Dx: Abd. CT !

. The most common cause of iron defeciency anemia in an elderly pt is GIT

bleeding.

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. The next step is COLONOSCOPY.
. A single -ve occult blood test doesn't exclude GIT bleeding.

. DYSPHAGIA:
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. Both sloids & liquids = Motility disorder e.g. ACHALASIA.
. Solids then progressing to liquids = Obstructing lesion e.g. esophageal
adenocarcinoma. . so .. You should perform BARIUM SWALLOW 1st before endoscopy.

. Spontaneous bacterial peritonitis:

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. should be considered in any pt. with cirrhosis & ascites,
. accompanied by fever or change in mental status.
. Paracentesis is the test of choice, with a +ve ascitic fluid cultue & PMN > 250
cells.

. Step wise approach of ttt of Ascites:

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1. Sodium & water retention.
2. Spironolactone.
3. Loop diuretic (Furosemide).. But not more than 1 L/day of diuresis.
4. Frequent abd. paracentesis (2-4 L/day).

. Aggressive diuresis > 1 L/day may worsen encephalopathy or precipitate hepato-

renal $.

. Liver cirrhosis ----> Renal hypo-perfusion -----> Hepato-Renal $ !

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. manifested by HIGH UREA & CREATININE.
. Very low urine Na < 10 meq = Pre-renal cause.
. No protein & No blood in dipstick urine = Not intrinsic glomerular cause.

. CARCINOID $ triad:
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. Flushing.
. Valvular heart disease.
 . Diarrhea.
. Ass. e' hepatic metastasis.
. ++ Serotonin & 5 HIAA in blood & urine.
. The precursor of Serotonin is Tryptophan,
. which is also utilized in the synthesis of Niacin.
. -- Niacin ----> PELLAGRA 4 Ds (Diarrhea-Dermatitis-Dementia-Death).

. Neutrophilic cryptitis is seen on bowel biopsy in pts with IBD.

. CARCINOID $ = Flushing + secretory diarrhea + Wheezing + cardiac problem.

. Intra-abdominal malignancy obstructing the biliary system:

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. Painless jaundice.
. Conjucated hyper-bilirubinemia.
. Elevated Alkaline phosphatase.
. ex. pancreatic adenocarcinoma.

. Pancreatic choleraa = VIPoma.

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. The pancreas secretes vaso-active intestinal peptide.
. Hypokalemia (leg cramps).
. chronic diarrhea --> dehydration.
. Abd. pain.
. weight loss.
. facial flushing & redness.
. Dx: Abd. CT.

. FOLIC ACID DEFECIENCY:

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. A tea & toast type of diet is associated with folic acid defeciency.
. Folic acid is heat sensitive.
. Folic acid defeciency causes macrocytic anemia.

. Corn based diets -> NIACIN defeciency -> PELLAGRA (4Ds):

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. Diarrhea + Dementia + Dermatitis + Death.

. DIVERTICULITIS:
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. H/O of costipation & little fiber in diet.
. Left lower quadrant pain & fever.
. Tx: IV Antibiotics.
. If no improvement ---> Abd. CT to detect complications.

. Tropical sprue:
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. Endemic tropical area e.g. Puertorico.
. Biopsy of S.I ---> Blunting of villi,
. with infiltration of chronic infl. cells e.g. lymphocytes, plasma cells &
eosinophils. . Malabsorption to Vit. B12 & folic acid ---> Megaloblastic anemia.
. Other signs of malabsorption e.g. glossitis - cheilosis - pallor.

. WHIPPLE's disease:
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. PAS +ve material in the lamina propria of the small intestine is diagnostic.

. Primary HIV infection:

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 . can present with a mononucleosis like syndrome,
. consisting of fever, night sweats, lymphadenopathy, arthralgia & diarrhea.

. JAUNDICE:
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.Abd. U/S is the best initial investigation for JAUNDICE.
.But .. once u suspect pancreatic cancer , then the best inv. is Abd. CT.
.Manif. of cancer include weight loss , pressure obstruction of CBD,
.leading to ++ direct bilirubin & ++ ALP.

. MEN 1 = 3 Ps:
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. Primary Hyperparathyroidism.
. Pituitary tumors.
. Pancreatic tumors (insulinoma-gastrinoma-VIPoma).
. GASTRINOMA = ZOLLINGER ELLISON's $ (Non B-cell pancreatic tumor).
. Endoscopy--> Multiple ulcerations & prominent gastric folds.

. MEN 2 A:
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. Medullary thyroid cancer & Pheochromocytoma.

. MEN 2 B:
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. Neuromas & Marfanoid habitus & Pheochromoytoma.

. Pts aged > 55ys with new onset dyspepsia with ALARM SYMPTOMS:
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* weight loss.
* dysphagia.
* persistent vomiting.
* should be evaluated with UPPER ENDOSCOPY.

. Pts < 55ys with no alarm symptoms:

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. should have 1st H.Pylori serology test,
. followed by empiric ttt with PPIs e.g. Omeprazole.
. If failed ----> ENDOSCOPY.

. Hemorrhage is the most common complication of peptic ulcer.

. CRYPTOSPORIDIUM PARVUM:
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. HIV pt. with chronic severe diarrhea with CD4 cells < 100.

. ZOLLINGER ELLISON's $YNDROME:

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. Endoscopic findings of prominent gastric folds.
. Chronic duodenal ulcer.
. upper jejunal ulcer.
. Serum GASTRIN conc. < 1000 is diagnostic.

. Bacterial overgrowth:
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. Malabsorption in a pt. with a H/O of abdominal surgery.
. Vit. D def. = Hypocalcemia.
. Vit. A def. = Night blinness.
. Vit. B12 def. = Neuropathy.
. LACTOSE INTOLERANCE:
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. Asian American.
. +ve Hydrogen breath test.
. +ve stool test for reducing substance.
. ++ stool osmotic gap.
. -- stool pH.
. No steatorrhea.

. ESOPHAGUS:
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. ADENO-carcinoma ------------> Chronic GERD & Barret's esophagus.
. Squamous cell carcinoma ----> Smoking & Alcohol.

. Acute Appendicitis:
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. VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS Visceral followed by somatic pain !!

. ACUTE EROSIVE GASTRITIS:

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. Massive doses of Aspirin & NSAIDS can cause upper GI bleeding.
. Alcohol can aggravate its effect.

. Mallory Weiss $:
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. occur in the distal esophagus at the gastro-esohageal junction,
. after repeated bouts of retching & vomiting.

. Zinc defeciency:
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. may result from total parenteral nutrition or malabsorption.
. Alopecia,skin lesions,abnormal taste,impaired wound healing.

. Drug induced pancreatitis:

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. Pts with H/O of VALPROIC ACID ttt for seizure disorder.

. Ulcerative colitis:
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. presents as diarrhea & bloody stools.
. The condition may be complicated by systemic toxicity : fever & weight loss,
. with dilated colon on CXR "TOXIC MEGA-COLON".
. Tx: I.V. fluids + Antibiotics + Bowel rest + I.V. corticosteroids.
. If failed: Emergency surgery with sub-total colectomy with end ileostomy.

. Minimal bleeding per rectum or scant hematochezia:

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. Dx -> Office based ANOSCOPY or PROCTOSCOPY.

. GIARDIASIS:
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. Foul smelling stool.
. Abd. cramps.
. Bloating = MALABSORPTION diarrhea.
. H/O of developing country e.g. South America.
. Tx: METRONIDAZOLE.

. MALIGNANT criteria of a colonic polyp:

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 . Villous adenoma.
. Sessile adenoma.
. Size > 2.5 cm.

. MULTIPLE MYELOMA:
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. Back pain + Renal dysfunction + High ESR + Anemia.
. MM ----> ++ Ca Hypercalcemia.
. ++ Ca ----> Constipation.
. so .. The cause of constipation in a pt. with MM is ELECTROLYTE DISTURBANCE (++
Ca).

. NON-CASEATING GRANULOMA ----> PATHOGNOMONIC to CHRON's disease !

. N.B. UC always involves the rectum while it is spared in CD.

. Angiodysplasia:
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. Pt. > 60 ys. with anemia.
. Painless GIT bleeding.
. Murmur of Aortic stenosis.

. DIVERTICULOSIS:
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. The most common cause of painless GIT bleeding.
. Not associated with AS.
. Endoscopy: Multiple out-pouchings of the mucosa through the hypertrophied
muscular layer.

. ZOLLINGER ELLISON's $:
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. Multiple duodenal ulcers + Single jejunal ulcer resistant to H2 blockers &
PPIs.
. GASTRIN producing PANCREATIC TUMOR.
. Un-controlled gastrin production
. ---> Parietal cell hyperplasia
. ----> +++ Stomach acid production
. ----> Inactivation of pancreatic enzymes
. ----> Steatorrhea.

. Inflammatory Bowel disease:

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. Bloody diarrhea + anemia + elevated ESR + Reactive thrombocytosis.
. The type of diarrhea is INFLAMMATORY.

. Newly diagnosed gastric carcinoma transformation in a gastric ulcer by an

endoscopy warrants an abdominal CT scan to evaluate the extent of the cancer.

. Pharyngo-esophageal (ZENKER's) diverticulum:

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. is due to motor dysfunction.
. Pt. < 50 ys.
. with oro-pharyngeal dysphagia & neck mass.
. Tx: Crico-pharyngeal Myotomy.

. Diffuse esophageal spasm:

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. Young female.
. intermittent episodes of chest pain & dysphagia.
 . Ba swallow: Cork screw esophagus.

. Causes of ++ BUN / Creatinine ratio:

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. Pre-renal RF.
. GIT bleeding due to reabsorption of blood from the GIT.
. Steroid adminstration.

. Esophageal dysmotility due to SCLERODERMA:

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. Sticking sensation in the throat.
. Significant -- in LES tone.
. Absence of peristaltic waves in the lower 2/3s of the esophagus.

. CHRONIC PANCREATITIS:
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. H/O of ALCOHOL use.
. Epigastric chronic abd. pain.
. Malabsorption (Steatorrhea & chronic diarrhea).
. Weight loss.
. Type 2 D.M.
. Amylase & Lipase may be normal (Not diagnostic).
. Dx: Abd. CT showing pancreatic calcifications.

.Duodenal ulcers:
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. typically presents with epigastric pain that improves with eating.
. OVER 90% of duodenal ulcers are infected with H. Pylori.
. Tx of H. Pylori ass. ulcers is acid suppression & organism eradication with
antibiotis. . 1st line regimen is OCA = OMEPRAZOLE + CLARITHROMYCIN +
AMOXICILLIN.

. In upper GIT bleeding:

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. If Hb < 10 ----> PACKED RBCs transf.
. If Ht < 30 ----> PACKED RBCs transf.

. Upper bleeding with coagulopathy:

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. is most likely to ruptured gastro-esophageal varices.
. Tx: FRESH FROZEN PLASMA: bec.FFP contains all the clotting factors & plasma
proteins.
. We never use whole blood transfusion.
. Cryoppt contains Factor 8, Fibrinogen, Von Willebrand factor & factor 10.
. FFP is preferred to cryoppt as it contains all clotting factors.
. Platelet transfusion is done when platelets < 50,000 !!

. Achalasia Manometry:
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. esophageal body peristalsis.
. Failure of relaxation of LES.

. Achalasia Ba Swallow:
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. Dilated esophagus.
. Bird's beak deformity of LES.

. HERPES ZOSTER (SHINGLES):

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 . Pt. with Rt. sided abd. pain.
. Light touch to the skin to the Rt. of the Umbilicus elicits intense pain.
. Immunocompromized pt. 2ry to chemotherapy.

. Digoxin side effects:

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. GIT-------> Anorexia, Nause & vomiting.
. Cardiac---> Biventricular Arrhythmia.
. VERAPAMIL ++ the Digoxin's toxicity.
. N.B. Mesenteric ischemia presents with severe abd. pain out of prop. to
exam. !!

. Ulcerative colitis:
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. Bloody diarrhea + tenesmus + abd. cramps + weight loss + anemia.
. Extraitestinal manifestations:
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.Sclerosing colangitis.
. Uveitis.
. Erythema nodosum.
. Spondyloarthropathy.
. Complications:
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. Toxic Megacolon.
. Colon cancer.
. Yearly colonoscopies is recommended for pts with UC,
. beginning 8-10 ys after diagnosis for prevention of cancer colon.

. Irritable bowel $yndrome:

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. Abd. pain + diarrhea and/or constipation.
. Endoscopy ---> NORMAL COLONIC MUCOSA!

. Dark melanotic stools = Upper GI bleeding.

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. The most common cause of upper GI bleeding is PUD.
. Duodenal ulcer's pain gets better with eating.
. while Gastric ulcer worsens with eating.

. PEPTIC STRICTURE:
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. Slowly progressive dysphagia to solids without anorexia & weight loss.
. As stricture progresses , it can actually block reflux,
. leading to improvement of heart burn symptoms.
. ENDOSCOPY --> SYMMETRIC circumferential narrowing.

. ADENO-CARCINOMA:
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. Pt with GERD < 20 ys.
. Weight loss.
. ASYMMETRIC narrowing of the esophageal lumen.

. REMEMBER:
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. Pt. with fever + chills + Lt upper Q. pain + splenic fluid collection
. = Lt. sided endocarditis with septic emboli to the spleen,
. causing splenic abscess.
. H/O of incarerated pt. with ++ liver enzymes (possible HCV),
. suggesting IV drug use as the cause of infective endocarditis.
. NERD FAULT !!
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. Pt. with upper GI bleeding (Hematemesis)
. who have depressed conscioussness level should be intubated with ??
. ENDO-TRACHEAL tube not naso-gastric tube to secure the airway.

. KCL Potassium chloride ----> Drug induced esophagitis.

Dr. Wael Tawfic Mohamed

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