GI/GU/Renal - Blueprint

esophagitis cause

#1: reflux

RF: obesity, pregnancy, high estrogen states, hiatal hernia

esophagitis findings

multiple areas of mucosal inflammation, ulcerations, esophageal rings/furrows/fibrosis → biopsy

meds that cause esophagitis

• ABX (tetracycline, doxy, bactrim, clindamycin), NSAIDs, bisphosphonates, KCl, Vitamin C, Fe compounds

esophagitis sx

heartburn

retrosternal burning

odynophagia

dysphagia

WARNING SIGNS: positive fecal occult blood, weight loss, anemia

esophagitis dx

clinical

(if warning signs/fam hx → upper endoscopy)

esophagitis tx

depends on underlying cause

• GERD: PPI (omeprazole) or H2 blocker

• Candida: fluconazole

• Eosinophilic: avoidance of food allergens

• CMV: ganciclovir

• HSV: acyclovir

• After 8 weeks therapy a repeat upper endoscopy performed to re-evaluate mucosal response to treatment

esophageal spasm definition

Abnormal peristalsis → Impairment of inhibitory innervation, leading to both premature and rapidly propagated or simultaneous contractions in the distal esophagus during swallowing

esophageal spasm sx

weight loss

regurgitation, heartburn, chest pain

esophageal spasm dx

upper endoscopy w/ or w/o biopsy (if no radiation)

if normal → esophageal manometry (Elevated integrated relaxation pressure of esophogastric junction → achalasia identified)

barium swallow → “nutcracker” or “corkscrew” appearance

esophagitis tx

CCB monotherapy

→ + TCAs → + CCB

achalasia definition

degeneration of myenteric plexus ganglion cells in the esophageal wall (absence of peristalsis in esophagus and lack of lower esophageal sphincter to relax)

achalasia sx

dysphagia to solids AND liquids

dx for achalasia

esophageam manometry

( incomplete LES relaxation and absent peristalsis in the distal esophagus)

achalasia - tx

pneumatic dilation, surgical myotomy, POEM, botulinum injection

mallory weiss syndrome RF

drinking alc and FORCEFUL VOMITING → hematemesis (“coffee ground or blood”

mallory weiss syndrome dx

upper endoscopy

mallory weiss tx

• acid suppression (PPI for everyone), endoscopic therapy (band ligation or thermal coagulation)

  • Hemodynamic instability (d/t significant GI bleeding) → fluid resuscitation + blood transfusion + PPI

  • Prognosis: generally heal rapidly, majority have spontaneous resolution

Esophageal Neoplasm RF

• male sex, age 50-60, chronic GERD, tobacco and alcohol use, HPV infection, Barrett esophagus

(middle-lower esophagus)

Esophageal Neoplasm sx

 progressive dysphagia to solid foods, weight loss, anorexia, iron

Esophageal Neoplasm initial + definitive

initial: barium esophagram

definitive: endoscopy with biopsy

Esophageal Neoplasm main type in US

adenocarcinoma - usually related to barett esophagus

(worldwide = SCC)

esophageal stricture most common cause

GERD

esophageal stricture dx

endoscopy UNLESS has sx of proximal esophageal lesion (surger, zenker) → barium esophagram first

Esophageal Varices cause

portal hypertension,

chronic liver disease,

portal vein thrombosis,

Budd-Chiari syndrome (hepatic vein thrombosis),

chronic alcohol use (in adults)

(sx similar to cirrhosis)

esophageal varices dx

upper endoscopy

esophageal varices tx

banding ligation**

ocreotide

prophylactic NON-SELECTIVE BB (and ceftrixone)

fluid resuscitation** (transfusion goal is 7)

definitive = liver transplant or transjugular shunt

esophageal perforation PE

pleuritic pain along esophagus,

worsens with neck flexion or swallowing,

mediastinal air surrounding heart could produce a systolic crunching sound (Hamman crunch)

, subcutaneous emphysema of the neck

• Mackler Triad: lower chest pain, vomiting, and subcutaneous emphysema

esophageal perforation dx

CXR - nonspecific, pleural effusion, widened mediastinum

contrast studies - spillage of contrast

esophageal perforation tx*

IV, abx

surgery 9repar/esophagectomy)

asplenia complication*

INC susceptibility to infections (encapsulated bacteria)

→ N. meningitidis, H. influenzae type B, Strep. pneumoniae vaccines

MC of hiatal hernia

sliding

hiatal hernia description

stomach enters through diaphgramatic esophageal hiatus

RF: preg, muscle weakening, low fiber diet, obesity, ascies

sliding hiatal hernia

asymptomatic or gerd

paraesophageal hiatal hernia sx

epigastric pain,heartburn, dysphagia, regurgitation, postprandial pain or fullness, N/V, dysphagia, intermittent chest discomfort

dx for hiatal hernia*

upper endoscopy → retrocardiac air fluid level

hiatal hernia tx

tx of gerd or niseen fundoplication

→ incarceration hernia

GERD gold standard dx*

esophageal pH testing

gastroenteritis cause

viral pathogen (norovirus) or bacteria

gastroenteritis PE

• abdominal tenderness w/o rigidity or rebound, fever, dehydration

  • Dehydration sx: dry mucous membranes, sunken eyes, decreased skin turgor, lethargy, tachycardia, low BP, weak radial pulses

warning stomach signs

bloody stool, weight loss, severe abdominal pain, symptoms lasting longer then 1 week recent hospitalization or abx use, pregnancy, age > 65, presence of comorbidities like DM or HIV, lab abnormalities in electrolyte or renal function, severe volume depletion and dehydration

gastroenteritis tx

self limited, supportive, avoid antidiarrheals

oral (or IV) hydration, probiotic

h pylor gastritis endoscopy finding

loss of normal rugae

→ urea breath testing

→ test 4 weeks again after tx

tx for h pylori

Bismuth subsalicylate, metronidazole, tetracycline, and PPI

charithromycin triple therapy for h pylori

Amoxicillin, clarithromycin, and PPI

gastric carcinoma RF

dietary factors* (e.g., salt-preserved foods, nitrites/nitroso compounds)

abdominal epigastric pain, dysphagia, virchows node, sister mary joseph node → ?

gastric carcinoma

increase the gastric acid secretion and inhibit mucosal prostaglandin production

h pylori and NSAIDs

which ulcer is alleviated by ingesting food?

duodenal ulcer (DUDe, give me food)

Gastrin-secreting tumor (gastrinoma), causes peptic ulcer disease that loves the first part of the duodenum

zollinger-ellison syndrome

elevated fasting serum gastrin level >1000 pg/mL = ?

zollinger-ellison syndrome → secretin stimulation test and upper endoscopy

assoc with MEN1

ecurrent bilious vomiting on 1st or 2nd day of life, double-bubble sign = ?

duodenal atresia

→ u/s or xr → duodenoduodenostomy

pyloric stenosis

2-8 weeks old

RF: macrolide

nonbilious projectile vomiting after feeding “hungry vomiter”

RUQ olvie mass, hypochloremic, hypoK metabolic alkalosis

target sign, string sign, shoulder sign, barium swallow

tx of pyloric stenosis

pyloromyotomy

cholelithiasis tx

NSAIDS

small + cholesterol = ursodiol

surgical = cholecystectomy

cholecystitis

obstruction by gallstone

positive murphy sign, boas sign

RUQ or epigastric pain after eating fatty foods

initial = u/s

gold standard = HIDA

tx = cholecystotomy

acute cholangitis

• bdominal pain, jaundice, fever (Charcot triad)

•  Reynolds pentad (Charcot triad + hypotension and AMS)

• RUQ U/S initial, ERCP = gold standard

cholangitis tx

hospital → zosyn (piperacillin-tazobactum)

TOC: endoscopic sphincterectomy with stone extraction

pancreatitis standard

MRCP

Classic triad for chronic pancreatitis

diabetes, steatorrhea, and calcifications on CT

infant colic

persistent crying for no reason

Wessel criteria: ≥ 3 hours/day, ≥ 3 days/week, ≥ 3 weeks duration, ≤ 3 months old

high risk of PPD, shaken baby sydnrome

self limited

tx for intussusception*

air/hydrostatic enema

malrotation complications

volvulus

duodenal obstruction

intestinal malrotation tx

ladd procedre

which vax recommended for celiac disease?

pneumoccocal vaccination

most common extraintestinal manifestation of celiacs?

dermatitis herpetiformis

constipation tx

lubiprostone

miralax/psyllium/osmotic laxatives

diarrhea tx

loperamide

cholestyramine

IBS 2nd aim of tx (relief of abnormal pain)

diet modifications

#1: antispasmodics (hyoscamine, dicyclomine

#2: antidepressants (TCA)

X-ray with dilated bowel, air-fluid levels, a stack of coins or string of pearls sign =

SBO

Hirschsprung Disease

Caused by failure of neural crest cells to migrate to the intestine

Absence of ganglion cells in the distal colon, leading to functional obstruction → no peristalsis so relaxation of anal sphincter

failure to pass meconium within 24-48 hours = ?

hirschsprung disease/CF

hirschspruing disease dx

rectal suction biopsy

empty rectal vault (loops of bowel without gas/stool in rectum) makes you think? + gold standard

hirschsprung disease

(rectal biopsy gold standard)

Meckel Diverticulum

< 5 years old

painless rectal bleeding, abdominal pain, or obstruction

diverticulitis dx*

CT with contrast

upper vs. lower GI bleed

upper: hematemesis, melena, hyperactive bowel sounds, high BUN/creat ratio

lower: hematochezia, normal bowel sounds and bun/cr

best test for upper GI bleed

EGD (esophagogastoduodenoscopy)

best test for lowe rGI bleed

colonoscopy

RLQ pain on extension of right hip, a/w retrocecal position

psoas sign

appendicitis imaging

adults = ct

peds/preg = U/S

preg w/ U/S not working = MRI

Indirect (unconjugated) Bilirubin

• from breakdown of Hg

• Elevated in hemolysis, Gilbert’s (impaired processing/conjugation)

Direct (conjugated) Bilirubin

• Elevated when Liver has Processed the bilirubin but can't excrete it and it backs up into the blood.

• Elevated in Cholestasis, obstruction, hepatocellular dysfunction

high AST/ALT is caused by

Acute Hepatitis, Alcoholic Liver Disease, Cirrhosis (AST >ALT)

high alk phos is seen in?

• shows problems with the Bile Ducts but can be elevated in Bone disease as well.

  • Elevated in: Gallstones, Bile Duct Blockages, tumors, Cholangitis.

main cause of hepatic cirrhosis

chronic hepatitis C virus (HCV) infection secondary to IV heroin use

ALT > AST

_ is hallmark of acute infection of hep b

HBsAG (Hep. B surface antigen)

anti-HBs (Hep. B surface antibody)

persists for life, long term immunity

hep B vaccine

all adults aged 19–59 years

Portal hypertension

caput medusae, splenomegaly, ascites

Hepatic encephalopathy

asterixis, confusion, hyperreactive DTRs, insomnia, decerebrate posturing

cirrhosis tx

• ascites → diuretics (spironolactone or furosemide)

• hyponatremia → stop thiazides/BB/alpha blockers

• hepatic encephalopathy → lactulose and rifampin

• plt transfusion, stop PPI usage

Hepatocellular Carcinoma screening

abdominal (liver) U/S q6 months

positive AFP makes you think?

hepatocellular carcinoma

HFE gene mutation = ?

hemochromatosis

bronze colord skin

HIGH ferritin and transferrin

hemochromatosis diagnosis

MRI

hemachromatosis tx

phlebotomy

Serum bilirubin level that’s a/w jaundice → ≥ 3 mg/dL

gilbert syndrome (DEC UGT1A1 gene activity)

high indirect bilirubin but normal CBC (def = genetic testing)

hepatic encephalopathy

caused by lots of ammonium and toxic build up

→ confusion, bad sleep, scleral icterus, asterixis

tx for hepatic encephalopathy*

lactulose, rifaximin

campylobactor jejuni

bloody diarrhea and abdominal cramping, often acquired from consuming undercooked poultry or contaminated food and water