GASTROENTEROLOGY

Vitamin A Night blindness, conjunctival dryness, corneal keratinization Vitamin D Ricketts - kids, long bone bowing; Osteomalacia-adults, demineralization Vitamin K Clotting deficiency with prolonged PT Thiamine (B1) Beriberi - peripheral neuropathy, Cardiomyopathy - dry or wet (high output failure) Wernicke-Korsakoff - Alcoholics, confabulation, nystagmus, confusion Niacin Pellagra - Diarrhea, dermatitis, dementia, death Pyroxidone (B6) Rare, neuropathy, Cheilosis (swollen cracked bright red lips) Cobalamin (B12) Macrocytosis, Pernicious Anemia- megaloblastic, neuro chg. ataxia, Schilling test , more in Strict Vegitarian. Folate Macrocytosis, megaloblastic anemia w/o neuro chgs., common in alcoholics Vitamin C Scurvy, bleeding gums, Connective Tissue problems, Can manifest 1 yr post defic. Failure to Thrive Org.= decr. wt gain w/ other disease; Nonorg.=growth failure due to neglect stimulation < 80% wt for Ht Obesity mild 20-40%, moderate 41-100, severe <101%; age, black women, low income BMI= body wt (kg)/Ht (mm2) Normal 20-25 Pickwickian Syndrome = obesity, dyspnea, hypovent, CO2 retention, hypoxia Boerhaave's Syndrome esophageal rupture due to forceful vomit; Gastromediastinal fistula, dyspnea w/o hemetemesis, + Hammonds sign = pneumomediastinum, L lung effusion Dysphagia Obstructive - solids 1st; Motor -solids = liquids

Infectious Esophagitis Candida (thrush), HSV, CMV, immunocomp, diabetics, Dysphagia & odynophagia Esophageal Atresia Proximal esophagus, blind pouch Trachesoph Fistula Congenital defect, distal esoph, coughing & cyanosis when feeding, abd distention Achalasia Dysphagia for solids & liquids, nocturnal cough, aspiration; Absent peristalsis & tight LES, "Beak" esoph on x-ray, 20-40 yrs old Esophageal Cancer squamous 90% Dysphagia solids 1st, Cough & hoarse = laryngeal nerve, constricting bands = annular lesion, Risk factors= smoking, alcohol, GERD, Barretts Esoph = adeno CA Gastritis Antral Creep =fundal tissue replaced by antral mucosa, Not preCA, Risk Factors = NSAIDS, Alcohol, H.Pylori PUD Gastric = NSAIDS, eating no help, COPD,blood type A; 25% Duodenal = H.Pylori, better w/ food, Liver cirrhosis, Blood type O ; 75% Cullen's Sign Periumbilical cyanosis d/t hemoperitoneum = hemorrhagic pancreatitis, ruptured ectopic, ruptured spleen Zollinger-Ellison Synd. Gastrinoma ( incr. gastrin); recurrent ulcers, are malignant Gastric CA Adeno, H.Pylori gastritis, Virchow's Nodes, Types = ulcerating (shallow edges); polyploid (intraluminal late mets); superficial (early CA) ; Linitus Plastica (all layers decr. elasticity) Metastasis to ovary = Krukenberg Tumor Diarrhea Osmotic = incr. H2O lumen incr. solutes in bowel; Secretory = electrolytes & H2O secreted not absorbed; Malabsorption; Exudative secretion of blood plasma & mucus (mucosal inflammation); decr. transit time (short bowel); incr. transit (bact. Proliferation)

Ischemic Colitis Vascular compromise (atherosclerotic or embolic); abrupt abd pain after eating, bloody diarrhea, systemic sx.; Barium X-Ray - Thumbprint = pseudo tumor Irritable Bowel Synd. Dx of exclusion (psych?); Tx: bulk supp, anticholinergics, antidiarrheals, TCA Colonic Polyps villous>tubular ; sessile>pedunculated for being CA; familial adeno polyps autodom. Lactose Intolerance Lactase deficiency, bloating & explosive diarrhea after milk; Ages 10-20 Celiac Sprue Gluten sensitivity (wheat, rye, barley); amenorrhea 1st sx girls, Infants = FTT, abnormal stool, bloating, Adults = malabsorption, vit deficiency; X-ray - dilated loops of bowel with thin mucosal folds; most common cause of malbsorption Tropical Sprue nutritional defic, small bowel mucosal abnormal; Acquired - Caribbean, India, SE Asia; Megaloblastic Anemia, glossitis, diarrhea, wt loss Tx Folic Acid & Tetracycline Whipple's Disease Infectious; middle aged men; multi-organ; Thickened mucosal folds, Foamy macrophage with rod shaped bacilli that stain w/periodic acid (Schiff's Reagent) Intestinal Lymphangiectasia Children & young adults; cong or acquired telangiectasia of intramucosal lymphatic. Massive extremity edema w/ diarrhea, N/V; Tx: low fat w/ triglyceride supplement Toxic Megacolon Dilation > 6cm, Adults preceded by IBD (UC or Crohn's) Kids preceded by Hirschsprungs Ds; Sx: severely ill, incr. temp, abd pain, rebound, leukocytosis; Xray - intraluminal gas along continuous seg of dilated bowel; Tx: NPO, IV fluids & electrolytes, Antibiotics & Steroids, Rectal tube may alleviate but can cause perforation Inguinal Hernia Indirect = infants, persistent processus vaginalis, protrudes thru ring, lateral Inf Epig. Direct = Adults, medial to ing ring & inf epig artery, Weakness in Hesselbach's

Ulcerative Colitis Colon & Terminal Ileum w/o skip lesions, w/ rectal bleeding, "lead Pipe" on X-ray (shortened, narrowed, loses haustrations) Tx: Sulfasalazine, steroids, Immunosuppresents; Complications=perf, hemorrhage, Toxic Megacolon, Colon CA Diverticular Disease Diverticulosis = false diverticulae, pearl sign on xray Diverticulitis = infection, acute abd pain usually on left, may form fistulas to bladder, vagina or skin, CT w/ water soluble contrast during acute attack Crohn's Disease Granulomatous colitis; No bloody stools, 1st in terminal ileum, transmural, skip lesions, cobblestoning: Complications=small bowel abscess, obstruction, perianal disease, malabsorption, toxic megacolo, Colon CA. Surgery is not curative Colon CA Right Sided=napkin ring, anemia Left Sided=Apple core, pencil stools; Genetic; Annual rectal>40, Annual Guaiac >50; Flex Sig q3-5y >50; Rectal CAhematochezia Volvulus Rotation of Bowel; Newborns & elderly; Double Bubble; Birds Beak on Barium Enema, Tx: Left Sided = decompression; Rt sided & kids = surgery Intussusception Telescoping of large bowel into an adjacent section; most common cause of obstruction in kids under 2; Episodic Abd pain 1-2 min. Reflex = early vomit; Obstructive = vomit late; Currant Jelly Stool; Small Infants = Pallor, sweating, and vomiting. Leukocytosis with hemoconcentration, BE to reduce x 2 before surgery Necrotizing Enterocolitis Premature, decr. birth weight, older infants with malnutrition; bilious vomit, abd distention, bloody stool, lethargy; Thrombocytopenia; Small Bowel Distention; pneumatosis (air in bowel wall) TX; NG, TPN, IV antibiotics, surgical Rx necrotic part Cholera Fecal - Oral, Rice Water Stools, Vibro Cholera; Endemic gulfcoast, Asia, Africa, Mid East; Severe dehydration, Metabolic Acidosis, Tx: Tetracycline or Doxycycline Shigella Dysentery

Small bact dose needed, Blood & mucous, Kids worse than adults, Fluid Replacement & Ciprofloxacin Staph Enteritis Onset 3-6 hrs; "Church Picnic epidemic; N/V/D, HA, fever recovery w/in 24 hrs Salmonella Enteritis Undercooked Poultry; nausea & cramps => watery &/or bloody diarrhea; No antibiotics prolongs excretion of the organism Viral Enteritis Norwalk = yr round, Rota (kids) = winter; Coxsackie A1; echo, adeno Botulism Clostridium Botulinum, neuromuscular; onset 12-36 hrs; N/V/D, cranial nerve palsy, fixed dilated pupils, resp failure, no fever, Wound induced = neuro w/o gi sx Infants constipation 1st=> cranial nerve sx => cranial nerve Sx => Neuromuscular Hemorrhagic Colitis E coli 157, cramps, => watery diarrhea => bloody diarrhea Complications= Hemolytic-Uremic Syndrome, thrombotic thrombocytopenic pupura Pseudomembraneous Colitis Antibiotic induced (clindamycin, ampicillin, cephalosporin) C. Diff; mail -> severe bloody diarrhea; Tx: stop antibiotics, oral metronidazole in severe cases Acute Pancreatitis Pain radiates to back w/ N/V; Grey Turner's Sign (blue flank) Cullen's Sign (blue at umbilicus; Amylase & Lipase incr. ; Ranson's Criteria: 3 or more = incr mortality Admission: >55, gluc>200, LDH >350, AST >250 WBC > 16000 Within 48 hrs: Hct decr. 10%, BUN incr. >5, Ca< 8, PaO2 < 60, Base Def > 4, Fluid Seq>6L Chronic Pancreatitis ERCP to Dx; Alcoholics, Malabsorption & diabetes are results Hepatitis Hep A = Fecal oral, shedding before Sx; IG to travelers & contact with HAV infected Heb B= Blood & STD; HbsAg early if persists = carrier; HbcIGM then HbcIgG for life HBIG for needle sticks and infants born to + moms; assoc w/ hepatocell CA Hep C Most common post transfusion hepatitis

Hep D = Co infection with B; Hep E = fecal oral Cholelithiasis Female, fertile, fat, forty; Ultrasound, RUQ pain after fatty meals, Calcified = preCA Cholangitis Charcot's Triad = Biliary Colic, Jaundice, Fever; Leukocytosis, incr. Alk Phos Hepatocellular CA Mets 2x more than primary CA (breast, lung, colon), Budd Chari-thrombosis hep V. Risk Factors = HBV, HCV, Alcoholic cirrhosis, Aflatoxins (fungal metabolites) Benign Hep Adenomas, oral contraceptives Exocrine Pancreatic CA Ductal CA, Courvoiser's Law=palpable nontender GB in a jaundiced patient is a head of Pancreas tumor. Tumor Body or Tail=splenic vein obstruction=> splenomegaly, gastritis, esoph varices Insulinoma Insulin hypersecretion, hypoglycemic symptoms, Insulin levels still incr. after fasting Whipple Triad: confirms hypoglycemia as source of Sx 1. Hypoglycemia, 2. Relieved with carb ingestion 3. Sx occur while fasting VIPoma Makes Vasoactive peptide (VIP); Sx WDHA (watery diarrhea, hypokalemia, achlohydria; unexplained secretory diarrhea; laparoscopy for Dx Glucagonoma tumor of alpha islet cells; 80% women; 80% malignant; Necrolytic Exfoliating Erythema characteristic exfoliating lesion of the extremities Pompe's Disease a 1,4 glucosidase deficiency; fatal by age 2 VonGierke's Disease glucose-6-phosphatase def.; big liver & kidneys, growth retardation, electrolyte prob. McArdles Disease musclephosphorylase is absent, muscle cramps & incr. myoglobin after exercise Jaundice

Prehepatic = hemolysis, gilbert's disease, Crigler Najjar; Hepatic = hepatocellular or cholestatic; Post Hepatic = Biliary obstruction, AST & LDH also incr. ; incr. unconj prehepatic; incr. conj = intrahepatic cholestasis or post hepatic disease ; incr. all fractions = hepatocellular, hyperbilirubinuria = conj bili water soluble ETOH Hepatic Disease Fatty liver => ETOH hepatitis => cirrhosis; AST incr. > ALT incr. ; incr. PT; decr. II, VII, IX, X Clot Cirrhosis necrosis and fibrosis, decr. serum albumin, anemia incr. PT, Not curable or reversible Esophageal Varices veins that expand to circumvent congested hepatic flow; Tx: vasopressin, balloon tamponade, endoscopic sclerotherapy, transjugular hepatoporto shunt (TIPS Hepatic Encephalopathy altered consciousness, incr. ammonia incr. glutamine in CSF, EEG abnormal Ascites Complication of hepatic disease; Paracentesis to examine ascitic fluid values should equal serum if incr. albumin = malignant; incr. LDH > 60% of serum = malig or infective; incr. WBC = infection GI Bleeding Upper GI = melaena (black tarry) ; Lower GI = hematochezia (bright red) decr. Lig Trietz Intestinal Obstruction Vomiting common in small bowel, late in lg bowel, High pitched "tinkling" BS. X-ray - prox dist = lg bowel; dilated loops of bowel with air fluid levels = sm bowel Ileus Paralytic obstruction of bowel due to loss of peristalsis Pyloric Stenosis Projectile vomit in neonates, visible peristaltic wave, String Sign Meconium Ileus

Abnormal thick Meconium with undigested protein, associated with CF Hirschsprung's Disease No autonomic nerves in colon, cbstipation, late vomit, Megacolon, Toxic Enterocolitis if left untreated, BE proximal dilated & distal narrow, Colostomy