2-HELLP syndrome -

pg 23-

HELLP syndrome →

acute fatty liver of pregnancy (AFLP) →

haemolysis, elevated liver enzyme, low platelet

no haemolysis, low glucose ± high ammonia, vomit ± DIC, prolonged PT and PTT

acute fatty liver of pregnancy

risk factors → ___________, ___________, ___________

SX → (7)

occurs after _____________ typically / ________________.

it may lead to ________ and _______ →_______ → ______

DX → __________

pre-eclampsia, first pregnancy, multiple pregnancy

nausea, vomit, abdominal pain, fever, jaundice, headache, itch (pruritus)

30 weeks after gestation…right after delivery

severe hyperglycemia…abnormal clotting factor…stoke…death

liver biopsy

presentation of acute cholecystitis

pain (right upper quadrant/epigastric) radiates to flank, back, R shoulder

MURPHY SIGN - pain or inspiration arrest when pressed at R costal margin of midclav line

± pain precipitated by meals

± nausea, vomit, fever

± deranged LFT (hight alk. phosphatase → biliary obstruction)

± inflammatory elements : WBC and fever

*jaundice - if stone in common bile duct.

*in AC, cystic duct is blocked, so mild or no jaundice

acute cholecystitis

risk factors →

DX →

TX →

5F syndrome (fat, forty, female, fertile, fair) / men, thin, < 40

high WBC, abdomen U/S → thick wall, shrunken gallbladder

IV analgesic, IV fluids, IV AB

early laparoscopic cholecystectomy < 1 week

incidental finding during CT or U/S of

gallstone + asymptomatic patient →

CBD stone ± asymptomatic →

reassurance (no interventions needed)

ERCP or laparoscopic cholecystectomy

*Endoscopic retrograde cholangiopancreatography (ERCP)

features of plummer vinson syndrome

→

→

→

TX → ___________ + ___________

oesophageal web, dysphagia, iron def anemia

iron supplement…web dilatation

alderonate biphosphonate used in _________ and NSAIDS can worsen ___________ and ___________.

leading to _____________ → ______________.

this condition is characterised by _____________ without ____________

osteoporosis…oesophagitis...gerd

scarring of oesophagus…benign oesophageal stricture

persistent dysphagia…regurgitation

*HX of taking H2 blockers (ranitidine) for retrosternal discomfort (GERD) for long period → benign oesophageal/peptic stricture

barret’s oesophagus is similar to benign oesophageal stricture except

the dysphagia is occasional, not persisted like the latter

persistent dysphagia + alendronate for osteoporosis + no regurgitation

benign oesophageal stricture

acute pancreatitis

HX of _________, _________, _________, _________.

SX → _________, ___________

± _________, _________, _________, _________, ________

DX → ___________ (______>______) and ____________

TX → _________, ________, ________. then _________ (eg _________). ___________ is done only if there is __________ using minimally invasive procedures such as _______________ and _________________

gallstone, alcoholism, trauma, ercp

nausea, vomit

tenderness, shock, tachycardia, cullen’s sign, jaundice

lipase > amylase serum (X3 norm), CT w contrast of pancreas

IV fluid, analgesics, nutritional support → IV AB (IV imipenem)

surgical debridement…necrosis…transgastric endoscopy…VATRN(video assisted translumbar retroperitoneal necrosectomy)

*cullen’s sign is periumbilical bleeding(within or behind the peritoneum)

acute cholangitis “ascending cholangitis” is _______________.

main feature is _______ which includes _____,_____, _____

± _______ and _______

DX → _________ and ________

TX → ________, _________, _________, __________

inflammation of the bile duct

charcot’s triad → fever, R upper quadrant pain, jaundice

HL - hypotension and leucocytosis

U/S, blood culture

IV fluid, IV AB broad, correct coagulopathy, early ERCP

organisms causing diarrhea

e.coli → ________, _________, _________

giardia → ______, ______, ______, ______, _______

campylobacter jejuni → ______, ______, ______ then ________

bloody diarrhea organisms → ________, ________, ________

(traveller’s diarrhea) short period,self limiting, hx of travel to africa

watery, weight loss(chronic), abd pain, bloating (symptoms >10d)

fever, headache, myalgia (muscle pain) → bloody diarrhea

campylobacter, shigella, salmonella

bloody diarrhea → (2)

traveller’s diarrhea →

diarrhea in paeds →

diarrhea + weakness + areflexia →

diarrhea + renal impairment + hemolysis →

diarrhea + RUQ pain →

watery diarrhea + long camp/travel in EU →

diarrhea after long term AB → (+TX)

diarrhea after eating eggs/chicken →

diarrhea just hours after meal →

diarrhea in bedridden-patient + stony hard stool →

campylobacter(more common), shigella

e.coli

rotavirus

guillain-barre syndrome

haemolytic uremic syndrome

amoeba

giardia

clostridium difficile (1st line - vancomycin / 2nd - metronidazole)

salmonella

staph toxins

fecal impaction

young + diarrhea, sometimes bloody + chronic abdominal pain, tenesmus → ____________

why not diverticulosis?

why not irritable bowel syndrome?

inflammatory bowel disease (UC/CD)

diverticulosis - usually asymptomatic

irritable bowel syndrome - no bloody diarrhea

*tenesmus - the feeling that you need to pass stools, even though your bowels are already empty

oesophageal cancer + liver metastasis

TX →

to relieve the symptoms of severe dysphagia →

no surgery, stage 4 cancer is inoperable

‘endoluminal stenting’

left supraclavicular mass →

indicates →

SX →

sign →

right supraclavicular mass

indicates →

pancoast tumour →

virchow’s node

gastric carcinoma (anorexia, dyspepsia, weight loss, old age)

troisier’s sign

oesophageal cancer, lung cancer, hodgkin’s lymphoma

tumour at the apex of the lung (L/R), spreads to ribs & vertebrae

• Virchow’s Node = The physical finding (enlarged left supraclavicular node)

• Troisier’s Sign = The clinical significance (strong suspicion of metastatic cancer due to this finding)

priMary biliary cirrhosis features

3M →

others →

TX →

common association → _______________ syndrome

anti Mitochondrial antibodies, Middle age, igM

pruritus, jaundice, high ALP (alkaline phosphatase)

ursodeoxycholic acid, cholestyramine

sjogren’s

primary sclerosing cholangitis

diagnosed by →

common association →

features →

TX →

ercp

IBD - ulcerative colitis

pruritus, jaundice, high ALP

ursodeoxycholic acid, cholestyramine

mid age female + abnormal LFT + 2ry amenorrhea + presence of autoimmune disease (e.g. hyperthyroidism) →

*ALP is norm or mildly increased

autoimmune hepatitis

hx of heavy alcohol consumption + signs of liver disease (ascites, hepatomegaly, jaundice, spider naevi, hematemesis) →

alcoholic liver disease

+ increased AST : ALT ratio (e.g. AST:150, ALT:70)

+ increased GGT

albumin infusion → increases ___________ → shift of _________ from ______________ → reduces _______and________ → good perfusion to ____________→ thus restoration of ____________

oncotic pressure

fluids…extracellular to intracellular

ascites…edema

kidneys

norm urine output

haloperidol can be used in small doses as __________.

it can cause __________

anti-emetic

hyponatremia

in ascites secondary to cirrhosis, we give _______ and _______

spironolactone…albumin infusion

50 y/o male + celiac disease since childhood + diarrhea + weight loss, complication of celiac →

intestinal lymphoma

conditions that may develop due to celiac disease (7)

iron def anemia (**)

folic acid def

vitamin b12 def

osteoporosis

t-cell lymphoma

dermatitis herpetiformis

DM 1

TX of acute cholecystitis

-stable patient →

-unstable patient (temperature, tenderness, low bp) →

laparoscopic cholecystectomy

emergency laparotomy

perforated peptic ulcer

features →

X-ray →

TX →

sudden severe abdominal pain

ill looking (motionless, diaphoretic, shallow rapid breathing)

abdominal tenderness and guarding

FREE AIR under diaphragm

NBM : IV fluids, antiemetics, analgesics, AB → urgent surgery

nil by mouth

you are not allowed to have any form of food, drink or medications by mouth

triple therapy for eradication of h.pylori →

(7-14 days)

PPI - omeprazole, esomeprazole 20mg BID

amoxicillin 1g BID

clarithromycin 500mg BID

PPI should be stopped 14d before h.pylori test, AB 28d

in treated patient of h.pylori + symptoms persistence, we do

carbon13 urea breath test

if N/A then stool antigen test

SX of H.pylori infection (10)

abdominal pain (burning)

pain worse on empty stomach or night

poor appetite

weight loss

heart burn

indigestion (dyspepsia)

belching/burping

nausea

vomit

blood in stool

≥ 55y/o + dyspepsia +weight loss →

urgent upper GI endoscopy to exclude oesophageal/gastric cancer