Internal Medicine EOR: Gastroenterology and Nutrition (Smarty PANCE)

What is acute viral hepatitis?

Inflammation of the liver caused by hepatotropic viruses (HAV, HBV, HCV, HDV, HEV) - presents with jaundice, elevated transaminases, malaise

What are the transmission routes for hepatitis viruses? Use mnemonic FECES-BLOOD

Fecal-oral: HAV, HEV; Bloodborne/sexual: HBV, HCV, HDV

What serologic marker indicates acute Hepatitis B infection?

Anti-HBc IgM positive with HBsAg positive - indicates acute or recent infection

What serologic pattern indicates chronic Hepatitis B?

HBsAg positive >6 months, anti-HBc IgG positive, HBeAg may be positive (high infectivity)

What is the most common cause of chronic hepatitis in the US?

Hepatitis C virus (HCV) - often asymptomatic until cirrhosis develops

What laboratory findings suggest acute hepatitis?

Markedly elevated ALT/AST (>1000 U/L typical in viral), elevated bilirubin, elevated PT/INR in severe cases

How is chronic Hepatitis C treated?

Direct-acting antivirals (DAAs) - sofosbuvir-based regimens for 8-12 weeks, cure rate >95%

What is autoimmune hepatitis and its characteristic findings?

Chronic hepatitis with elevated IgG, positive ANA or anti-smooth muscle antibodies, interface hepatitis on biopsy

How is autoimmune hepatitis treated?

Corticosteroids (prednisone) plus azathioprine - lifelong immunosuppression often required

What is fulminant hepatic failure?

Acute liver failure with hepatic encephalopathy developing within 8 weeks of symptom onset - high mortality without transplant

What are esophageal varices?

Dilated submucosal veins in esophagus due to portal hypertension - most commonly from cirrhosis

What is the most common cause of esophageal varices?

Cirrhosis causing portal hypertension (portal vein pressure >12 mmHg creates portosystemic collaterals)

What is the classic presentation of bleeding esophageal varices?

Massive painless hematemesis in patient with cirrhosis, stigmata of chronic liver disease, hemodynamic instability

What is the acute management of bleeding esophageal varices?

Octreotide IV, emergent EGD with band ligation, antibiotics (ceftriaxone), blood transfusion to Hgb 7-9 g/dL

What is octreotide's mechanism in variceal bleeding?

Splanchnic vasoconstriction reducing portal blood flow and portal pressure

What is the role of antibiotics in variceal bleeding?

Prevent spontaneous bacterial peritonitis and reduce rebleeding - ceftriaxone or norfloxacin prophylaxis

What is used for primary prophylaxis of variceal bleeding?

Non-selective beta-blockers (propranolol, nadolol) to reduce portal pressure - reduce first bleed risk by 50%

What procedure is used when endoscopic therapy fails?

Transjugular intrahepatic portosystemic shunt (TIPS) - creates shunt between portal and hepatic veins

What is the mortality rate of acute variceal bleeding?

15-20% mortality with each bleeding episode despite treatment

What is acute pancreatitis?

Acute inflammation of pancreas causing autodigestion - presents with severe epigastric pain radiating to back

What are the most common causes of acute pancreatitis? Use mnemonic GET SMASHED

Gallstones (40%), Ethanol (30%), Trauma, Steroids, Mumps, Autoimmune, Scorpion sting, Hyperlipidemia/Hypercalcemia, ERCP, Drugs

What are the diagnostic criteria for acute pancreatitis?

Requires 2 of 3: characteristic abdominal pain, lipase or amylase >3x ULN, imaging findings of pancreatitis

What imaging is preferred for acute pancreatitis diagnosis?

CT abdomen with IV contrast - identifies necrosis, fluid collections, complications (perform after 48-72 hours)

What is Ranson's criteria used for?

Prognostic scoring system for acute pancreatitis severity - >3 criteria predicts severe disease

What is the management of acute pancreatitis?

NPO initially, aggressive IV fluid resuscitation (250-500 mL/hr), pain control, early enteral nutrition (within 24-48 hours)

What defines chronic pancreatitis?

Irreversible pancreatic damage with fibrosis, calcifications, and exocrine/endocrine insufficiency

What is the classic triad of chronic pancreatitis?

Pancreatic calcifications, steatorrhea (fat malabsorption), diabetes mellitus

What is the most common cause of chronic pancreatitis?

Chronic alcohol abuse (70-80% of cases) - requires years of heavy drinking

What is the treatment for chronic pancreatitis?

Alcohol cessation, pancreatic enzyme replacement (lipase with meals), fat-soluble vitamins, pain management, treat diabetes

What is esophagitis?

Inflammation of esophageal mucosa - most commonly from GERD, infections, or medications

What are the most common causes of infectious esophagitis?

Candida (most common), HSV, CMV - typically in immunocompromised patients

What are the endoscopic findings in Candida esophagitis?

White plaques or pseudomembranes that can be scraped off - cottage cheese appearance

What are the endoscopic findings in HSV esophagitis?

Small, well-circumscribed ulcers with raised edges - punched-out appearance

What are the endoscopic findings in CMV esophagitis?

Large, deep, linear ulcers in distal esophagus - occurs in severe immunosuppression (CD4 <50)

What is pill esophagitis?

Medication-induced esophageal injury - common culprits: doxycycline, bisphosphonates, NSAIDs, potassium chloride

How is Candida esophagitis treated?

Fluconazole 200-400 mg daily for 14-21 days (first-line for mild-moderate cases)

How is CMV esophagitis treated?

Ganciclovir IV or valganciclovir PO for 3-6 weeks - may require maintenance in AIDS patients

What is eosinophilic esophagitis?

Chronic immune-mediated esophageal disease with eosinophilic infiltration - presents with dysphagia and food impaction

What is the treatment for eosinophilic esophagitis?

Proton pump inhibitors, swallowed topical corticosteroids (fluticasone), dietary elimination (6-food elimination diet)

What is an anal fissure?

Linear tear in anoderm distal to dentate line - typically posterior midline, causes severe pain with defecation

What is the classic presentation of anal fissure?

Severe sharp pain during and after bowel movements, bright red blood on toilet paper, constipation from pain avoidance

What is the most common location of anal fissures?

Posterior midline (90%) due to relative ischemia - lateral fissures suggest Crohn's, trauma, or malignancy

What is the initial treatment for acute anal fissures?

Conservative: high-fiber diet, stool softeners, sitz baths, topical nitroglycerin 0.4% or diltiazem 2%

What is the mechanism of nitroglycerin in anal fissures?

Relaxes internal anal sphincter reducing pressure and improving blood flow for healing

What is the definitive treatment for chronic anal fissures?

Lateral internal sphincterotomy - surgical division of internal anal sphincter (cure rate >95%)

What is an anal fistula?

Abnormal tract between anal canal and perianal skin - usually from cryptoglandular infection/abscess

What is Goodsall's rule for anal fistulas?

Anterior fistulas track radially; posterior fistulas track to posterior midline - helps predict internal opening

What is the treatment for anal fistula?

Fistulotomy (unroofing fistula tract) or seton placement - surgery required for cure

What disease should be considered with complex or recurrent anal fistulas?

Crohn's disease - causes complex fistulizing perianal disease

What is gastritis?

Inflammation of gastric mucosa - can be acute (erosive) or chronic (non-erosive)

What is the most common cause of acute gastritis?

NSAIDs - inhibit COX-1 reducing protective prostaglandins in gastric mucosa

What is the most common cause of chronic gastritis?

Helicobacter pylori infection - causes chronic inflammation and increases gastric cancer risk

What are the types of chronic gastritis?

Type A (autoimmune - fundus/body), Type B (H. pylori - antrum), Type C (chemical - NSAIDs, bile reflux)

What antibodies are present in autoimmune gastritis?

Anti-parietal cell antibodies and anti-intrinsic factor antibodies - leads to pernicious anemia (B12 deficiency)

How is H. pylori gastritis diagnosed?

Urea breath test, stool antigen test (non-invasive), or biopsy with rapid urease test during endoscopy

What is the treatment for H. pylori gastritis?

Triple therapy: PPI + clarithromycin + amoxicillin for 14 days OR quadruple therapy with bismuth

What are complications of chronic gastritis?

Peptic ulcer disease, gastric adenocarcinoma, MALT lymphoma, pernicious anemia (autoimmune type)

What is the presentation of acute erosive gastritis?

Epigastric pain, nausea, vomiting, upper GI bleeding in severe cases - often asymptomatic

What is stress gastritis?

Acute gastritis in critically ill patients - prevented with PPI or H2 blocker prophylaxis in ICU

What is rectal cancer?

Adenocarcinoma arising from rectal mucosa (within 15 cm of anal verge) - distinct staging and treatment from colon cancer

What is the most common presenting symptom of rectal cancer?

Hematochezia (bright red blood per rectum) - also tenesmus, change in bowel habits, rectal mass

What is the primary screening/diagnostic test for rectal cancer?

Colonoscopy with biopsy - allows visualization, tissue diagnosis, and assessment of proximal colon

What imaging is essential for rectal cancer staging?

MRI pelvis - assesses depth of invasion, lymph node involvement, relationship to mesorectal fascia

What is the TNM staging for rectal cancer?

T (tumor depth), N (lymph nodes), M (metastases) - determines treatment approach

What is neoadjuvant therapy for rectal cancer?

Chemoradiation before surgery for stage II-III disease - improves local control and sphincter preservation

What is the surgical treatment for rectal cancer?

Low anterior resection (LAR) or abdominoperineal resection (APR) - depends on tumor location relative to sphincter

When is abdominoperineal resection required?

Tumors involving anal sphincter complex or within 1-2 cm of sphincter - results in permanent colostomy

What tumor marker is used to monitor rectal cancer?

CEA (carcinoembryonic antigen) - elevated in 60-70%, used for surveillance post-treatment

What is the 5-year survival for localized rectal cancer?

Approximately 90% for stage I, 70-80% for stage II-III with appropriate treatment

What is colon cancer?

Adenocarcinoma arising from colonic epithelium - third most common cancer in US

What are risk factors for colon cancer? Use mnemonic FAMILY

Family history/FAP, Age >50, Male gender, IBD (UC, Crohn's), Lynch syndrome, high-fat diet/obesity

What is the classic presentation of right-sided colon cancer?

Iron deficiency anemia, occult bleeding, vague abdominal pain, weight loss, palpable mass

What is the classic presentation of left-sided colon cancer?

Change in bowel habits, hematochezia, pencil-thin stools, bowel obstruction

What are the screening recommendations for average-risk adults?

Begin at age 45: colonoscopy every 10 years OR annual FIT OR Cologuard every 3 years

What genetic syndrome causes most hereditary colon cancer?

Lynch syndrome (HNPCC) - DNA mismatch repair defect, accounts for 3-5% of colon cancers

What is familial adenomatous polyposis (FAP)?

Autosomal dominant APC gene mutation causing hundreds-thousands of polyps - 100% cancer risk by age 40

What is the definitive treatment for colon cancer?

Surgical resection with adequate margins and lymph node removal - hemicolectomy based on location

When is adjuvant chemotherapy indicated for colon cancer?

Stage III (node-positive) disease - FOLFOX or CAPOX regimen reduces recurrence

What is the 5-year survival for stage I colon cancer?

>90% with surgical resection alone

What is esophageal cancer?

Malignancy of esophagus - two types: squamous cell carcinoma (upper/middle) and adenocarcinoma (lower/GEJ)

What are the risk factors for esophageal squamous cell carcinoma?

Smoking, alcohol, achalasia, caustic injury, Plummer-Vinson syndrome, hot beverages

What are the risk factors for esophageal adenocarcinoma?

Chronic GERD, Barrett's esophagus (intestinal metaplasia), obesity, smoking

What is the classic presentation of esophageal cancer?

Progressive dysphagia (solids→liquids), odynophagia, weight loss, regurgitation - late presentation common

What is the gold standard diagnostic test for esophageal cancer?

Upper endoscopy (EGD) with biopsy - allows direct visualization and tissue diagnosis

What staging studies are required for esophageal cancer?

CT chest/abdomen/pelvis, PET scan, endoscopic ultrasound (EUS) - assess depth, nodes, metastases

What is Barrett's esophagus?

Intestinal metaplasia of distal esophagus from chronic GERD - precursor to adenocarcinoma (0.5% annual cancer risk)

How is Barrett's esophagus managed?

High-grade dysplasia: endoscopic ablation (RFA) or resection; Low-grade: surveillance endoscopy every 3-5 years

What is the treatment for localized esophageal cancer?

Neoadjuvant chemoradiation followed by esophagectomy - curative intent for stage I-III

What is the prognosis for esophageal cancer?

Poor overall - 5-year survival 20% (often presents at advanced stage)

What is stomach cancer (gastric adenocarcinoma)?

Malignant tumor of stomach lining - declining incidence in US but high in Asia

What are the major risk factors for gastric cancer?

H. pylori infection (most important), smoking, high-salt diet, smoked/pickled foods, pernicious anemia, blood type A

What is the classic presentation of gastric cancer?

Vague epigastric pain, early satiety, weight loss, nausea/vomiting - often asymptomatic until advanced

What is Virchow's node?

Left supraclavicular lymphadenopathy - indicates metastatic gastric cancer (Troisier's sign)

What physical exam findings suggest advanced gastric cancer?

Sister Mary Joseph node (periumbilical), Krukenberg tumor (ovarian mets), Blumer's shelf (rectal shelf)

What is the diagnostic test for gastric cancer?

Upper endoscopy with multiple biopsies - allows visualization and histologic diagnosis

What staging is required for gastric cancer?

CT chest/abdomen/pelvis, endoscopic ultrasound, laparoscopy for advanced disease - assess resectability

What is the treatment for resectable gastric cancer?

Partial or total gastrectomy with lymph node dissection, perioperative chemotherapy improves outcomes

What is linitis plastica?

Diffuse infiltrative gastric cancer causing rigid, leather bottle stomach - poor prognosis

What is the 5-year survival for localized gastric cancer?

Approximately 70% for early stage, <30% overall due to late presentation

What is gastroenteritis?

Inflammation of GI tract causing diarrhea, nausea, vomiting, abdominal cramping - usually infectious