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Hx and Physical
• History: AMPLE, HISTORY, OPPQRST:
o Allergy, Medication, Past medical hx, Last menses/meal, Event of complaint
o Hospitalizations, Immunizations, Sugar diabetes/Social Hx, Tumors/Trauma, Operations,
Review of systems, Youth Illnesses.
o Onset, Palliative, Provocative, Quality, Radiation/Region, Setting/Site/Severity, Timing
• Physical exam: Inspection, Auscultation, Percussion, Palpation
o Ausculatation done 2nd to keep from altering sounds (bowel sounds, etc.)
• Abdominal Distension
Also called protruberant abdomen. Not caused by obesity.
o 4 categories:
Excess fluid
• Most commonly from ascites (serous, serosanguinous, sanguinous, pustular)
• KUB – “Kidneys Ureter and Bladder” – a flat plate X-ray of the abdomen,
done both standing and supine (to look for fluid levels) (lateral view instead
of standing if Pt cannot stand)
Excess gas
• Normally from excess gas, also from post-operative gas.
• Remember that gas will change position easily, and with the position of the
Pt.
• Gas is either intraluminal (inside bowel) or extraluminal (outside bowel).
A mass.
Organomegaly.
o Mechanical Intestinal Obstruction
Neoplasm (intraluminal/extraluminal)
• Ex:
o Intraluminal: colon cancer.
o Extraluminal: prostate cancer w/ lympadenopathy, uterine cancer
Post-operative adhesions (TQ)
• Adhesions are typical following abdominal surgery. (The bowel does not
like to be manipulated during surgery). More diffuse adhesions may also
form following peritonitis.
Abcess
• Ex:
o Peri-appendocoele abscess (appendix)
o Sigmoid region (leading to diverticulitis, particularly in the
elderly)
Crohn’s disease (right lower quadrant) is also associated
with abcesses.
Pregnancy
Hernias
Volvulus (TQ)
• A mesenteric portion of bowel twists on itself. Occurs in areas like the
caecum and sigmoid colon, in which at least one portion is already fixed in
one portion, but not fixed in the other.
Intusseception. (TQ)
• Telescoping of the bowel inside itself. Most common in small bowel and in
children.
• Large bowel intusseception may occur in the large bowel with a mass or
adhesion. Driven by peristalsis.
• Some will relieve themselves, while others require surgical intervention.
o Non mechanical obstruction of the bowel
• Not a good nomenclature.
Ascites
• Most common from alcoholic hepatitis (portal hypertension) (TQ)
Excess gas
• As from dietary sources.
Trauma
• Pts involved in MVA’s sometimes show this, as lapbelts can shove into
bowel during impact. Usually resolve within 24 to 48 hours.
Infection
Peritonitis.
Adynamic/paralytic ileus – will get distention of bowel. (TQ)
• Most commonly from surgery. As bowel tends to shut down for a short
time after being handled during surgery.
• Abdominal Pain Patterns
o Diffuse
Visceral pain
Organ involvement
Ex: Appendicitis (initially)
o Focal
Parietal pain.
Organ distension.
Ex: Peritonitis (late stage appendicitis) (TQ)
o [Photo: diastasis recti (splitting of the rectus abdominus)]
o Burning
PUD (pain upon defecation), GERD, dyspepsia (gastritis)
• Do not ignore burning epigastric pain. (Possible cardiac involvement)
o Cramping (usually from organ distension or peristalsis)
Biliary colic, IBD, IBS, mesenteric ischemia
• Note: Men tend to have more active gastro-colic reflexes than women
(When put fresh stuff in, not-so-fresh stuff comes out. A useful bit of trivia
to defend yourself from your wife’s pointed comments after a spicy meal.)
• Note: Mesenteric infarct is supposed to be THE most painful condition in
medicine. (Possible TQ)
o Colicky
Renal stones, biliary colic, appendicitis.
• Note: crescendo/decrescendo pain pattern in stone obstruction due to
peristalsis waves (try, stop, try, stop, etc.)
o Achy
Constipation, appendicitis (early), AAA (saccular)
o Knife-like (usually very serious)
AAA (dissecting/saccular rupture), pancreatitis.
Pt’s will usually lie on their side in flexion (the fetal position) due to pain.
o Sudden onset
Perforation, obstruction, pancreatitis, ruptured ectopic pregnancy, dissecting
aneurysm
• Abdominal Pain Patterns
o Diffuse
Early appendicitis
AAA
IBD
Peritonitis
Trauma
Obstruction
Look for abdominal guarding (voluntary) and abdominal rigidity (involuntary)
o Epigastric
• Common region for abdominal pain, lots of different organs
PUD
• (Peptic Ulcer Disease in this case)
• Often described as “gnawing”, “chewing”, or “burning” type pain.
• Usually duodenal disease.
Gall Bladder (GB) disease
• Cholecystitis and cholelithstasis. (Inflammation or stones)
o Commonly found together.
Hepatic disease
• Particularly in left lobe of liver.
Cardiac disease (Red flag)
• Referred pain to upper abdomen.
Pancreatitis
• Pts assume the fetal position.
• Severe pain radiating from abdomen to low back (Lumbar and thoracic
spine) (TQ)
Gastritis
GERD
Dyspepsia
o RUQ
Biliary tree disease
• Both intrahepatic and extrahepatic portions.
• Liver, gall bladder and collecting ducts.
PUD
• Particularly involving the duodenum.
Pancreatitis (head of pancreas can go that far over)
Renal disease
• Particularly the pole of the right kidney.
• Renal cysts (uncomplicated) are the most common renal disease.
o Usually only symptomatic if the cyst grows large enough to
distend the renal capsule.
Cardiopulmonary disease
• Referred from heart or lungs (portal effusion, lower pneumonia)
o LUQ
PUD
• Usually from stomach.
Pancreatitis
Splenic diseases
• Mononucleosis, polycythemia vera, sickle cell and other anemias, splenic
artery aneurysm.
o Splenic artery is a VERY tortuous, twisty artery as it moves
laterally. Viewable on X-ray.
Renal disease
• Left kidney (higher than the right)
Cardiopulmonary disease
• More often causes LUQ pain than RUQ pain.
o RLQ
Late appendicitis
• Once peritoneum is involved, focal pain.
Crohn’s disease
• Chronic granulomatous disease of the GI tract, hence causes granulomas,
effecting the entire thickness of the bowel wall (as opposed to UC).
• Can affect any region of the GI tract.
• Typically in the young (late teens to early 20’s)
• Debilitating, sometimes requiring colostomy, etc.
• Most commonly in distal portion of small bowel, beginning of large bowel.
Obstruction.
• RLQ is a very common area, because is attached, and hence common for
volvulus formation (coecle volvulus or sigmoid volvulus)
Reproductive disease
• Ovaries, fallopian tubes, or uterus
• Ex: Cancer, PID (if affect ovaries), endometriosis, fibroid tumors
(leimyomas – smooth muscle tumors)
o Leiomyomas can be HUGE (largest on record was 350 lbs)
Pt can actually think they’re pregnant (TQ)
o Can be calcified, looking like a ‘popcorn ball’ on PFXR.
o Can interfere with menstrual cycle, fertility, etc.
o Can also cause low back pain.
o VERY small chance of transformation to leimyosarcoma, but
VERY small. Normally benign. (TQ)
AAA
o LLQ
Diverticulosis/itis
• Diverticula are common with age, most people get them.
• Most often in the descending and sigmoid colon.
• Referred pain to the low back.
Obstruction
• Sigmoid volvulus most often.
Colon cancer
• More than ½ of colon cancers in the sigmoid/descending colon.
• Alternating constipation/diarrhea.
o Body has obstruction from tumor, floods bowel with water to
remove it, resets, cycle repeats.
Ulcerative colitis (UC)
• Causes superficial inflammation/ulceration (innermost layer)
• But because of the number of vessels in this region, there is a LOT of
bleeding. (an important differential from Crohn’s)
• Late teens/early 20’s, with bloody diarrhea.
Reproductive disease
AAA
o Periumbilical
Obstruction
• Small bowel in this region.
• Small bowel obstructions are usually intussceceptive.
Early appendicitis
AAA
Mesenteric thrombosis.
• Lack of blood supply (embolism) in mesenteric arterial tree.
• Again, supposedly the most painful condition in medicine. (Shoots a lot of
holes in that labor and delivery guilt trip, eh? Sorry Mom.)
Pancreatitis.
• Pt in fetal position, very painful. (So possible matching TQ is fetal position
– pancreatitis)
• Causes of Abdominal Pain
o Most common cause of abdominal pain is non-organic. (TQ)
Lot of musculoskeletal origin, believe it or not.
o Non-specific abdominal pain – 35%
o Acute appendicitis – 17% (know this TQ) (most common source of organic abdominal pain)
o Intestinal obstruction – 15%
o Urologic causes – 6%
o Gallstone disease - 5%
o Colonic diverticular disease – 4%
o Abdominal trauma – 3%
o Abdominal malignancy – 3%
o Perforated peptic ulcer - 3%
o Pancreatitis – 2%
o Ruptured AAA - <1%
o Inflammatory bowel disease - <1%
o Gastroenteritis - <1%
o Mesenteric ischemia - <1%
• [VBA dissection – REDFLAG: “The worst headache I’ve ever had.”]
• Abdominal Aortic Aneurysm (TQ’s – particularly on the diameters, and what to do in each case)
o Focal widening >3.5 cm
Diagnosed by seeing widening, usually on PFXR – as they tend to be atherosclerotic,
calcified, and visible on Xray.
o Typically > 60 years, M:F = 5:1
o Intrarenal (90%) (infrarenal?)
Below renal arteries, but above common iliac arteries.
This is a good thing – if involved the renal arteries, would have a much higher
mortality rate.
o Extension of aneurysm into iliac arteries (66%)
o Plain film: mural calcifications (75-90%)
Best seen on a lateral lumbar spine film (TQ)
• Can also see on A-P, but harder since overlaps the bony structures.
Aneurysm tends to be 25-30% larger on surgical excision than what is seen on PFXR
(plain films underestimate size) – due to incomplete calcification (only see the
calcification)
o CT: perianeurysmal fibrosis (10%), may cause ureteral obstruction.
The body is attempting to limit the expansion of the aneurysm, and this in turn might
cause the ureteral obstruction.
o Abdominal UltraSound: 98% accuracy in size measurement.
o Angio: mural thrombus (80%)
o Complications:
Rupture (25%): into retroperitoneum (usually left), GI tract, IVC
Peripheral embolization.
Spontaneous occlusion of aorta.
o Growth rate varies.
Hence the treatment protocols vary until the aneurysm reaches 7 cm (at that point,
chance of rupture is so high that surgery is non-elective)
Surgery generally not recommended until aneurysm is >5cm or the Pt becomes
symptomatic.
• [REDFLAG:Pt cannot find a comfortable position] (TQ)
o Indicates an organic cause, not a mechanical problem. (possible AAA)
o This is the Hallmark S/sx of AAA. (TQ)
• Saccular or fusiform aneurysm – “football shaped” aneurysm.
• Dissecting AAA
o There is a separation between the interior and middle walls of the aorta (intima and media).
o Can be traumatic or atherosclerotic.
o When wall separates, the force of exiting blood causes increased widening of the separation.
o Pt can easily exsanguinate (bleed out) without actually losing blood from vascular system.
The blood is trapped in the wall of the artery (between media and intima)
o Mortality rate with AAA dissection is very high, unless they catch them very early.
o Do NOT show up on PFXR.
o Hallmark S/sx of AAA dissection.
“Tearing” abdominal pain.
Shock.
o Odd trivia fact: Dissecting aneurysms used to show up most commonly in the aortic arch as a
S/sx of tertiary syphilis. Now (with less cases of syphilis around) is most common in
abdominal aorta.
• Abdominal Aortic Aneurysm (AAA)
o S/Sx
Most are asymptomatic (since are between 3.5-5 cm, and not dissecting)
Pulsating sensation in the abdomen
• On palpation, normal pulses A to P, lateral pulsation on palpation can be
indicative of AAA. (TQ)
Abdominal pain (unchanged by position) (TQ)
LBP (unchanged by position)
Bruit (typically low pitched (blood flow slowed down))
• High pitched usually caused by stenosis.
Radiating pain into legs.
Cold Lower Extremities, peripheral pulse loss.
• Dorsalis pedis and posterior tibial are most common pulses on the foot.
Shock
• S/sx: cold clammy skin, pale skin, diaphoresis (sweating), pulse increases,
BP drops
• Quantifiable definition of shock: Systolic pressure of <90 mm Hg
o In practice: poor perfusion of the vital organs.
• 5 different kinds of shock: Hemorrhagic (hypovolemic)
o Other forms(?): anaphylactic, insulin, osmotic, protein, septic,
toxic (double check this)
o Know that septic shock is a major risk with appendicitis (TQ)
Sudden death.
o Imaging
Plain films
• Maximal measurable normally is 3.5 cm.
• Anything larger suggests aneurysm.
MRI, CT
o Treatment (big TQ)
3.5-5 cm – careful observation
• Tell Pt to avoid anything that might increase risk of trauma or intra-
abdominal pressure.
• Careful to absolute contraindications for adjustment.
o Only in small size aneurysms. Perhaps mobilization only.
5-7 cm – elective surgery (10% rupture/yr)
>7 cm – non-elective surgery (25% rupture/6 mos)
Symptomatic – non-elective surgery.
If Pt is bleeding, condition is emergent. (well duh…)
o Surgical procedures
Open laparotomy
Endoscopic stent replacement.
<50% w/ rupture survive.
Anorexia
• Anorexia – lack of appetite.
o Anorexia nervosa – psychologic disease leading to wasting.
• Possible Causes
o Infection.
o Neoplastic (particularly malignant)
o IBD
o Constipation.
o GERD
o PUD (peptic ulcer disease)
o Swallowing disorder.
• [Picture: Old man with Anorexia, Cachexia, and Ascites]
o Cachexia – wasting associated with disease and malnutrition. (possible TQ)
D/Dx: Possible end stage liver disease, endstage cancer, endstage AIDS
GI Bleeding
• [Picture: Meckle’s scan]
o Radionucleotide scan collecting in high blood flow areas.
o Common usage to Dx appendicitis.
• Ligament of Treitz differentiates the upper and lower GI tract (TQ)
o This ligament suspends the last portion of the duodenum (suspensory ligament of the
duodenum) and keeps it in a C-shaped loop (which enfolds the head of the pancreas).
• GI Bleeding can take a variety of different forms
o Blood in Upper GI tract coming back up through oral cavity, blood appears in one of two
forms: hematemesis or ‘coffee-ground’ emesis. (TQ)
o Type of blood seen in upper GI suggests type of bleeding.
Hematemesis – more acute type of bleeding (bright red blood) (TQ)
Coffee-ground emesis – more chronic, slow type bleeding.
• (looks darks and clumped, coagulated, like coffee grounds)
• Gastric enzymes act on blood, denaturing proteins, which then coagulate.
o Can have a combination of both types of presentation, depending on pathology
Ex: Chronic condition that finally ruptures, etc.
• Upper GI Bleeding
o Esophageal varices
Varicose veins (dilated veins) in the submucosal layer of the esophagus, usually in
the lower portion of the esophagus.
Erosion occurs with long term passage of food over them.
Over time can progress to a massive bleed.
Usually due to alcoholic hepatitis and cirrhosis leading to portal and venous
hypertension.
o Esophageal CA
Long-standing, chronic bleed with coffee-ground presentation.
o Esophagitis
Depending upon degree and cause, can have either coffee-ground (more common) or
hematemesis presentations.
o PUD (peptic ulcer disease)
More often coffee-ground presentation, but if erodes into a gastric/epiploic arteries,
can present as hematemesis.
o Gastric CA
Most often coffee-ground presentation, or mixed presentation.
o Hiatal hernia
o Swallowed hemoptysis
Hemoptysis – “Coughing up blood” (TQ)
• Remember that blood is VERY irritating to the GI tract, and will provoke
emesis.
o Pt’s with Upper GI bleeds can present with signs of upper GI bleed in lower GI tract.
Melena (black tarry stools) is usually a lower GI sign of an upper GI bleed. (TQ)
Occasionally occult fecal blood.
• Detectable through hemocult or FOB (fecal occult blood) testing (also
called GUIAC).
o False positives for GI bleed with PeptoBismol (contains the same
enzyme as in GUIAC test)
o Hence must have 3 separate positives on 3 separate occasions for
true Dx. (TQ)
o Hematochasia – “Bright Red Blood Per Rectum” – abbreviated BRBPR (possible TQ)
• Most common cause: hemorrhoids (TQ)
• Lower GI Bleeding
(causes are a TQ)
o Mesenteric thrombosis
Said to be the most painful condition in medicine (mesenteric ischemia as a result)
(He’s said this often, possible TQ)
o Meckel’s diverticulum
Blind fibrous tube associated with the ileum, as a development defect from the
umbilicus.
o Volvulus/intusseception.
Volvulus – twisting of bowel on itself.
Intusseception – telescoping of bowel.
Most common in sigmoid colon (?) and caecum.
o Colon CA
Blood streaked stool or occult blood, not often hematochasia.
o Colonic polyps
o Inflammatory Bowel Diseases (Crohn’s, UC)
Common causes of hematochasia.
o Diverticulosis/it is
Particularly in older patients.
• (Helpful D/Dx – say if have 65 year old with rectal bleeding. Can D/dx
from Crohn’s (which is most often in the young))
o Hemorrhoids
Most common source of lower GI bleeding. (TQ)
Are varicose veins in the rectum/colon.
• Varices in the GI tract are the most common cause of GI bleeding, both
upper and lower. Upper most often due to alcohol induced portal
hypertension. (TQ) Lower GI usually due to poor bowel hygiene – high
fiber diet, lots of fluids, and “going when you need to go” (as the urge due
to the gastrocolic reflex)
o Anal fissures
Cracks along the edge of the anus, as due to chronic constipation or inflammatory
bowel diseases.
Constipation/Diarrhea
• Constipation – “reduction in the production of the volume of stool”.
o More common in females.
o Most commonly due to poor bowel hygiene (see above).
o Look for change in bowel habits (normal defecation roughly every 36 hours.)
o Other causes
Fecal impaction
Poor fiber intake.
Poor fluid intake.
Colon CA
• From obstruction. Tends to a constipation/diarrhea cycle.
IBD
Psychiatric causes
Meds
• Particularly parasympatholytic drugs ( parasympathetics) or
sympathomimetic ( sympathetics) drugs
Hemorrhoids
• Pain particularly is part of this cycle, as hemorrhoids cause constipation and
vice versa.
o Tx:
Recommend gentle exercise.
Increase fluid intake (assuming no contraindications)
Increase fiber intake (if not due to inflammatory bowel disease)
Promotion of good bowel hygiene.
Laxatives (natural and prescription)
• Avoid if possible, as Pts can become addicted to laxatives, even to the point
of needing them to defecate at all.
• Diarrhea – “Overproduction of (watery) stool”
o Infection.
Viral gastroenteritis (and “Montezuma’s Revenge”) is the most common cause of
diarrhea.
o Inflammatory Bowel Diseases (IBD)
UC usually more often than Crohn’s, since affects the distal portion of the colon.
o IBS
o Stress
Part of the fight or flight syndrome, as the body shuts down all other non-essential
functions.
o Colon CA
From obstruction. Tends to a constipation/diarrhea cycle. (Obstruction leads to body
flooding bowel with water to flush, the reset to normal, obstruction causes
constipation, etc.) (possible TQ)
o Psychiatric causes
o Meds
o Lactose intolerance (TQ)
But NOT lipase deficiency (trick TQ)
Intussuception
• Telescoping of bowel onto itself.
• Sort of looks like a doughnut or bulls-eye on MRI.
Heartburn, Indigestion
• Heartburn
o aka dyspepsia – burning pain in chest or epigastrum.
• Indigestion
o “Upset Stomach”
• Possible causes
o Gastritis – inflammation of stomach. Common ER diagnosis.
o GERD/Reflux Esophagitis – most common cause of burning chest pain.
o Excess intestinal gas
o Gas entrapments (hepatic/splenic flexures)
Hepatosplenomegaly
• Both organs attached to the portal venous system.
o Hence portal venous hypertension will cause enlargement of both. (TQ)
o Hepatomegaly m/c is cirrhosis
o Lymphoma and hematopoetic diseases tend to affect spleen more than liver.
o Other diseases cause both.
• Hepatomegaly
o Measure by percussion, for example.
10-12 cm usually
Usually can’t palpate the liver border.
In LUQ
o Inferior aspect of liver is concave – worry about hepatomegaly if flat or convex.
o Magenblase – Ger. “ice cream cone”
Term for the gastric air bubble, right under the left hemidiaphragm.
Will shift down and inwards in a Pt with hepatomegaly.
o Common causes:
Cirrhosis
Hepatitis
• Most common form is alcoholic hepatitis/alcoholic cirrhosis in US (TQ)
• Most common form of INFECTIOUS hepatitis is Hep. C in US
o But Hep C is the most common cause worldwide.
Pancreatic CA
Hepatobiliary CA
Cholangitis
• Inflammation of the biliary collecting duct
Late right sided CHF
Infectious mononucleosis
Lymphoma
Leukemia
Cause of pancreatitis to have hepatomaglay compression of pancreomagaly on the
common bile duct incr. portal hypertension
• Splenomegaly
o Common Causes
Anemias
• Removal of abnormal RBC’s
Infectious mononucleosis
• From Epstein Barr virus
HIV
Leukemia
Lymphoma
Myeloma
Polycythemia vera
• Increased red cell count (varying degrees)
• Clots tend to be the complicating effect.
Hernias
• An outpouching of material through a hole (natural or unnatural)
• Types:
o Groin
Inguinal (96%) males
• Direct (external) worse - acquired
• Indirect (more common) congenital
Femoral (4%) - women
o Umbilical – females (postpartum or gravid or multiparous)
o Incisional -
o Hiatal
• Common locations
o Epigastric
Dr. Wyatt has a small one here.
o Umbilical
Particularly in pregnant or multiparous females (TQ)
o Inguinal
Present in scrotum.
o Femoral
M/c in females.
• Valsalva maneuver accentuates the hernia.
• Hernia Examination in Men (most hernias occur in men)
o Fingertip at most dependent portion of scrotum (portion hanging the lowest)
o Invaginate scrotal wall to external inguinal ring.
Press up and slightly out into the ring.
o Gently insert finger into canal along spermatic cord.
o Move finger laterally and cephalad.
o Pt coughs, strains, or performs valsalva maneuver
Pt turns head so that they don’t cough on the Dr. (it’s that simple, turning the head
doesn’t change the outcome of the test)
o Findings
Inguinal hernia
• Small indirect hernia may slightly tap end of finger.
• Large indirect hernia may be palpable as mass.
• Direct Inguinal hernia may be felt on pad (side) of finger.
Spermatic cord tenderness (Funiculitis)
Spermatic cord lipoma
Hydrocele – water (fluid) in the scrotum; varicocele (bag of warm)
• Types of Hernias
o Indirect inguinal hernia
Most common type, M=F
Through deep (lateral, internal) inguinal ring (entrance to canal)
Touches fingertip on examination.
Can be difficult to distinguish clinically from direct hernia.
o Direct inguinal hernia
M>F
>40 y/o
Though posterior wall of inguinal canal into superficial ring (exit)
Touches side of finger (pad) on examination (since comes through side of canal)
Easily reduced, rarely enters scrotum.
o Femoral Hernia
Least common, elderly, F>M (3:1)
Though femoral ring/canal
Often asymptomatic (even when strangulated), but can be very painful in cases.
• Can remain asymptommatic until develop peritonitis, etc.
• Strangulated hernia
o A hernia that has become cut off and lost its blood supply.
o Can lead to necrotic bowel.
• Mesh hernia repair
o Sutured mesh tends to patch the hole pretty well.
o Like patching a tire (actually, the same tool and underlying process…sorta disturbing, ain’t
it?)
Hiccoughs
• Hiccoughs occur when the glottis closes suddenly when the diaphragm suddenly contracts.
• The closing of the glottis stops the air from going down into the lungs and produces the “hiccup”
sound.
• Transient
o High emotion or temperature change. (hot to cold)
o Gastric distension
o Alcohol ingestion
• Persistent
o Uremia, hyperventilation, IDDM
o Meds (steroids, barbiturates)
o General anesthesia
o Thoracic d/o (pneumonia, CA)
o Gastric d/o (PUD, CA)
Jaundice
• Jaundice: abnormal buildup of bilirubin buildup in the body tissues, seen most obviously in sclera
(icterus) and skin.
o Seen first in sclera since is the “whitest” part of the body, and is among the thinnest.
• [picture: bearded white, middle aged male with icterus and jaundice.]
• Many also have bilirubinuria.
• One side effect is severe itching (little known, but very common) (TQ)
• Direct Bilirubin (thin of liver and surrounding)
o Extrahepatic obstruction
Calculi, neoplasm, stricture, cholangitis (inflammation of collecting ducts)
Metastatic CA, pancreatic CA
o Hepatocellular disease (more common cause)
Hepatitis
• Alcoholic and otherwise (m/c infectious type is Hepatitis C)
Cirrhosis
o Meds (eg, estrogen)
o Jaundice of pregnancy (hormonal) severe itching
• Indirect Bilirubin (BM)
o Hemolysis
Congenital anemias (eg, sickle cell)
Acquired anemias
o Poor marrow production
o Neonatal jaundice (treated by UV light exposure)
o Impaired conjugation from meds.
[END GI MATERIAL]
CVA Pain
• Nephrolithiasis
o Kidney stones: Ca+ based – 80% – Murphy’s punch test: kidney infection
Calcium oxalate – Mg inhibits oxalate precipitation (and VitA?), but Mg can cause
the 2nd m/c type of kidney stones Mg stones (CLD exam material concurrent with
this section)(citrate inhibits Mg precipitation)
• Pyelonephritis - tubules (waxy casts)
o Infection of renal pelvis – upper UTI
o Most common from a poorly treated or untreated lower UTI (usually E.coli)
• Glomerulonephritis
o Inflammation of glomerulus - aseptic inflammation, usually after strep pharyngitis
Strep A infection m/c cause.
This is why Pt with strep throat must complete their antibiotic treatment (take all of
them)
o Often mistaken for kidney stone
o D/dx? (question for Wyatt)
• Renal Cancer
o AKA: hypernephroma (old term) – one of the fastest growing metastasis
• Renal abscess
o People with chronic renal disease, diabetics (most common), IV drug users, patients with TB
• Spinal disorder
o As from T12/L1 disc herniation
Dysuria
• Painful urination
• Cystitis (Urinary Bladder Infection)
o Infasimatacis Cystitis
Air in the bladder wall
o E. Coli most common bacteria to cause infection
o Diabetics get cystitis a lot
o More common in women
Urethra is shorter in women – shorter pathway for bacteria
Wiping from P to A instead of A to P
Holding the urge to pee
o In the suprapubic region.
- Urethritis
o Usually infectious
o Causes: Gonorrhea (gonococcal urethritis), Chlamydia (M/C cause) (non-specific or
non-gonococcal urethritis)
- Vaginitis
o Inflammation of the vaginal introitus (opening)
Poor hygiene leads to Fungal Infection, m/c Candida Albicans (Yeast Infection)
- Prostatitis
o Bacterial Prostatitis (Septic)
o Aseptic Prostatitis
Both very painful
Can be caused by stones
Aseptic prostatitis can be a side effect of overuse (think Sailors on
Shoreleave)
- Chemical Irritants
o Latex on a condom, Meds, Laundry Detergents, Lubricants, Douche, Deodorant spray
- Urethral Diverticulum
o Outpouching from a hollow viscus in the ureter (rarely urethra)
Can become infected and cause pain
Can be from high pressure in the system (such as a stone) or congenital
weakness in the wall
-
- Bladder CA
o Usually asymptomatic
o Very aggressive
Polyuria
- Excess/increased production of urine
o Too much fluid in the body (volume overload)
As from CHF (main cause of volume overload)
• Know that clubbing hypertrophic osteoarthropathy (normally
associated with CHF) is associated with GI disease, GERD, cardiac,
and pulmonary disease (TQ).
• Digital clubbing & cyanosis – CHF
•
- Relative term compared to how much pt used to produce
- Nocturia – getting up excessively at night to urinate
o Usually with a sudden onset in someone who has not had to get up before.
- Cystitis/ Lower UTI
o Heightens micturation reflex
- Upper UTI
- Diabetes Mellitus
o Glucose changes the osmolality of the blood
o Patient pees a lot
o Triad:
Polyuria
Polyphagia
Polydipsia
(Polyneuropathy)
(Polyvasculopathy) (There are actually 5P’s according to Wyatt)
- Diabetes Insipidus
o Lack of anti-diuretic hormone which causes more diuresis (excess production of urine)
o Or decreased sensitivity thereto.
- Meds (diuretics)
o Blood pressure control, congestive heart failure (increase in volume lowers ejection
fraction)
- Anxiety
o Got to pee when you get nervous
- Hypokalemia and other electrolyte imbalances
o Low serum potassium level
o Be very careful if you see a Pt with increased K levels.
Urethral Discharge
• Some abnormal fluid from the urethra when not urinating
• Discharge can be bloody (sanguinous), clear (serous), serosanguinous (mixed), pus (purulent)
o Can have an odor
• [picture: Gonococcal infection of the penis] (Not too pleasant to see first thing in the morning)
• Things within the urethra, along its course, within the prostate gland, etc. can cause discharge.
• Prostatitis
o Bacterial Infection (septic and aseptic)
o Prostatic fluid and/or WBC
• UTI
o Milky discharge (composed of pus)
• Interstitial Cystitis
o Most common in Diabetics
o Affects interstitial rather than serous tissues
• Vaginitis
o Yeast infection
o Most commonly from Candida albicans
• Gonococcal Urethritis
o “The clap”
Historically, a “clap” on the male member was how it was treated. (OW! And
ineffective to boot.)
• NGU- Nongonococcal urethritis
o Most commonly due to Chlamydia
M/C STD
Oliguria/anuria
• Reduced output of urine/absence of urine production (12oo ml/day)
• < 100 ml/day = Anuria
• < 600 ml/day = Oliguria
• M/c cause of oliguria is dehydration.
• M/c cause of anuria is renal failure.
• Renal failure = DM
o TX: dialysis, transplant
• Kidney failure = uremia
o Affects BP, acid/base balance, electrolytes
o Can be fatal if not treated.
• Decreased fluid intake = usually oliguria
o Can only go w/o fluid for 48-72 hrs (TQ)
• Strenuous exercise
• Sweat the most when sleeping (besides exercise)
• CHF can cause renal failure
• Pre-renal failure = m/c not enough blood going to kidneys
• Intrarenal failure = problem in actual kidney
• Postrenal failure = obstruction past the kidneys
Pelvic Pain
- Just the anterior soft tissue, not the bony structure.
- M/c in women.
- 80-90% of cases are undiagnosed.
- Treatment of pelvic musculature and joints can help non-organic pelvic pain (supported in
urologic data)
o A chiropractor hooked up with an Ob/Gyn to treat non-organic pelvic pain can make a
mint.
- M/c cause = constipation (left side)
- Pelvis is triangle b/w both ASIS and pubic symphysis
• Dysmenorrhea – m/c organic cause
o Abnormally painful menstruation
(All periods are painful to some extent due to uterine contraction)
o Cz: thyroid problem, infection, premenopause, fibroids, endometriosis
• Fibroids
o Benign tumor of uterus
Uterine leiomyoma - smooth muscle tumor with fibrous tissue (TQ)
Found on plain films of lumbar spine – very common
• Look for a “popcorn ball” apperance in the region of the uterus. (TQ)
Can have dysmenorreha, infertility, pain, etc.
Very occasionally possible to become malignant (RARE: leiomyosarcoma)
• Hence usually benign (TQ)
Can be VERY large (largest at 350 lbs in one Pt), and even can make women
think they are pregnant (TQ)
• Adhesions after surgery
• Cystitis
o M/c cause: E. coli
• Endometriosis
o Abnormal deposition of ectopic endometrial tissue outside of the uterus
• IBD
o Crohn’s, Ulcerative Colitis
Proteinuria
• Not normally in urine because it’s too large
• Occurs w/damage to basement membrane (in the glomerulus)
• Malignant HTN: Increased BP, enough to cause tissue damage
• Idiopathic proteinuria
o Ok if everything else has been ruled out
o Ok if it’s mild
• Nephrotic syndrome - classically associated with proteinuria (waxy casts)
o Diffuse swelling associated with proteinuria
o Associated with renal failure
o Sicker than Pts with nephritic syndrome.
o Nephritic syndrome secondary to glomerulonephritis
o Nephrotic – non inflammatory, nephritic – inflammatory
o But both allow proteinuria
o The difference is not heavily hit on Exam 1.
• Malignant HTN
• CHF
• Diabetes mellitus (know the 5 P’s)
• Sickle cell disease
• 3 things that occur with sickle cell: Infection, Ischemia, Infarction
• Idiopathic proteinuria
• Pyelonephritis (m/c from UTI from E.coli)
• Glomerulonephritis
• Most commonly post-strep infection. (important point)
• Pregnancy (can be an early onset sign/risk for ecclampsia and pre-eclampisa)
• Myeloma
• Pt’s produce Bence Jones proteins, which are small enough to naturally go through the
glomerulus
• Leukemia
• Lymphoma
Scrotal Swelling
• Swelling of either scrotal sac or the growth of a mass that actually causes enlargement (as with
hernias)
• Testicular torsion
o Spermatic cord & vessels twist on themselves (volvulus)
o Can lead to infarction in the testicle – very painful (GREAT GOOGLY MOOGLY!)
• Epididymitis
o Epidydymis – storage system on the back of the testicle – so inflammation thereof.
o Can occur from STD’s and other infections.
• Trauma
• Hernia
• Tumor
o Testicular carcinoma
• Very aggressive tumor, which can occur in relatively young men.
• Varicocele
o “Bag of worms” palpation feel due to varicose veins in the pampiniform plexus
• Hydrocele
o Dilated, cystic mass
o Transilluminates easily.
o Fluid filled, tubular cysts
Esophagus
• Description in 5 words or less: Hollow, food propelling muscular tube
• [picture: EGD of esophagus with varices (usually caused by alcoholic induced portal HTN)
• First tubular viscus, begins as pharynx (pharngoesophageal junction)
• Anatomy
o Pharynx
o Upper esophageal sphincter
Epiglottis
o Esophagus
o Lower esophageal sphincter at gastroesophageal junction.
Aka: Cardiac Sphincter
• Normal Esophagus
o Primary peristalsis
Initiated by swallowing (scientific name: deglutition) – voluntarily initiated.
• Soft palate, tongue assisted.
Propels food
• Strong propagating propulsive wave
o Secondary peristalsis
Not initiated by swallowing – involuntarily initiated.
Propels food through lower esophagus
o Tertiary peristalsis
Seen in elderly, abnormal
No propulsion – a feeble attempt at secondary peristalsis.
D/t degeneration of the nervous plexes and smooth muscle in the esophagus.
Similar to the fibrillation seen in a ventricular arrhythmia – just quivers.
• Esophageal Functions
o Lower esophageal sphincter at level of diaphragm.
o Esophagus contains smooth muscle.
Unique because it’s voluntary (almost the only instance of voluntary smooth muscle
control)
• Esophageal Tumors
o Normally not a very metabolically active area – purely propulsionary, no digestion occurs
there.
o As we age, the lower esophagus is exposed to years of reflux (everyone has it to some extent).
o Of those that do occur, most tumors are found in the lower esophagus and 90% of them are
malignant.
• Esophageal Neoplasms
o Malignant tumors are the most common. (90%)
High mortality rate, since are hollow organs and not well innervated (pain generation
by a tumor) – hence pain only occurs when tumor grows beyond capsule or capsule
is distended from tumor growth. S/sx usually only occur after 75% of the diameter
of the lumen is occluded by growth.
Cost benefit must be done to determine whether or not it is prudent to screen EVERY
Pt EVERY year for these tumors.
• But costs are usually high (EGD’s) and these are rare, so the cost benefit is
not good for yearly screening.
Fecal occult blood testing routinely done (as a general screen).
Also remember (takehome message from this class): any male over 40 with Iron
deficiency type anemia has a malignancy until proven otherwise.
o Leiomyoma is the m/c benign tumor
o Most tumors occur in the lower esophagus
o Squamous cell carcinoma is m/c
o 7.6/100,000 in USA
But this rate has increased in the last 25 years or so.
• D/t increasing popularity of BBQ’ing (or blackening) of food – the burning
increases the nitrate concentration. (also a theory on acrylamide
responsibility in smoked foods)
o 130/100,000 in China
D/t the processing of the foods in that area of the world – most smoking and
pickling, which includes a lot of nitrates, which has a metaplastic effect on the
esophageal epithelia.
o M:F 3:1
o Most Pts >60 yoa.
• Esophageal Carcinoma
o Etiology
Alcohol abuse association w/ 80-90% of cases
Cigarette smoking
• Aerophagia and swallowing saliva exposed to smoke, w/ all the oxidative
radicals.
Nitrate ingestion.
• Smoked or burned foods, pickled foods
Chronic achalasia
• Poor relaxation of the lower esophageal sphincter (LES)
• Spasm in LES, which closes – food just sits in the lower esophagus, with a
fermenting effect in the static bolus, which in turn leads to damage.
Chronic GERD
• May or may not lead to Barrett’s esophagus
o Dysplasia from squamous to columnar epithelia.
o Associated with adenocarcinoma.
o DDx (think S/sx of obstruction)
Achalasia (particularly in the elderly)
DES – Diffuse Esophageal Spasm
• Think of chest pain when eating ice cream too fast – like that for hours on
end.
• Also a D/Dx for MI.
Esophageal rings
• Congenital rings that narrow portions of the esophagus.
Scleroderma
• Progressive systemic sclerosis (PSS)– connective tissue arthropathy,
causing calcification in the digits. Taut red skin (fingertips become pencil
like, and may fall off, as well as the nose)
• 70% of Pts with PSS have esophageal involvement – which becomes hard
and inflexible.
o [picture: adenocarcinoma]
o Physical findings
Dysphagia (first for solids, then liquid)
• Liquids can move around an obstructive mass early.
o If liquid dysphagia right off the bat, think paralysis of some sort
(or acute, massive obstruction).
Weight loss
• Usually in late stage disease. (cachexia (wasting))
Cervical adenopathy
• Like a Virchow’s node (sentinel node in the left supraclavicular space for
lymphadenopathy)
Hematemesis/hemoptysis
Hoarseness
• Damage from reflux
• Extension of tumor into trachea, larynx, or recurrent laryngeal nerve (larynx
innervation)
Cough w/ clear sputum
Mets from Esophageal cancer go to liver, pleura, lungs w/ associated S/sx
• Since both drained by portal venous system.
o Diagnostic Imaging
Double contrast esophagram
• Barium paste used. The bolus is then followed.
• Looking for “shouldering” – a square cut off at the beginning of a lesion
between it and the soft tissue.
• This is rarely used now, normally an EGD is done (which also allows the
obtaining of a biopsy.)
Esophagoscopy
Chest/abdominal CT
Abdominal MRI
o Laboratory tests
CBC
Blood chemistries
Liver enzymes.
o Treatment
Resection if no mets
Stomach/colon used for replacement
Radiation therapy
Chemotherapy.
o Prognosis
Surgery – 20-50%
Radiation – 6-20%
Chemotherapy – 15-80%
• Benign Esophageal Tumors
o Tumor types
Sessile (broad based) or pedunculated
Leiomyoma is most common
Papilloma
Fibrovascular polyps
o Very rare.
Esophagitis
o Reflux esophagitis
o Acute ulcerative esophagitis
o Esophageal PUD
o Crohn’s esophagitis
o Infectious esophagitis
o Chemical esophagitis
o Mechanical esophagitis
• Reflux esophagitis
o Reflux of gastric contents w/ damage
o Progression of GERD
Possible progression to Barrett’s esophagus (squamous to columnar epithelial
metaplasia)
o Incompetent LES
o Often associated with hiatal hernia (50-70%)
o 30-60’ post-parandial/reclining heartburn.
• Acute Ulcerative Esophagitis
o Seen in Pts with PUD (tend to vomit a lot)
o Contracted fibrotic lower esophagus results.
Results in stricture – mimics achalsia (non-relaxation of the lower esophageal
sphincter)
• Infectious Esophagitis
o Immunosupressed Pts
AIDS
Malignancies and other chronic systemic illnesses.
Diabetes
Transplant – on anti-rejection drugs.
o Organisms (3 primary)
Herpes simplex
Candida albicans
CMV (cytomegalovirus)
o Dysphagia, odynophagia (painful swallowing), chest pain.
o Treated with antibiotics.
• Mechanical Esophagitis
o Swallowed object becomes lodged.
o Lodge at narrowed portions
3 most common: Cardiac sphincter, thoracic inlet, aortic knob
• Also: Left atrial enlargement secondary to CHF impinges upon esophagus.
o Objects include coins, pills, bone pieces
o Leads to ulceration, maybe perforation.
G.E.R.D.
- GERD reflux esophagitis Barrett’s esophagus. Esophageal. CA always rule out
cardiac Disease first
- Cough & bronchospasm or laryngitis from aspiration
- Early satiety GERD get “full” quickly
- Chocolate fat & caffeine contents cause GERD episode
- Tobacco when chemicals are swallowed
- Commonly assoc. with hiatal hernia (>70%)
- Nitroglycerin will make anginal chest pain better
o Makes GERD chest pain worse
- Gastroesophageal Reflux Disease
- Reflux of gastric contents into lower esophagus
- Incompetent lower esophageal sphincter
o Stuff from your stomach comes back up into the lower esophagus because the esophageal
sphincter is not functioning correctly
o Believes because of aging
o Reflux Esophagitis Barrett’s Esophagus Squamous cell carcinoma
o Heavier a person is the more chance they can have because increase in intra-abdominal
pressure
- Incidence
o 60% of adults have heartburn
o 80% of pregnant women have GERD
- S/Sx
o Heartburn (pyrosis) (burning pain the middle of the chest)
o Dysphagia
o Regurgitation
o Sour taste in the mouth
Pt can also have excessive salivation (as a pseudo-Pavlovian response)
o Can be confused with angina pectoris
o Chronic cough
Refluxant comes up into larynx
o Bronchospasm, due to irritation of the bronchi airway
o Laryngitis (yes, from reflux – call it, “Mexican Food Induced Laryngitis”)
o Early Satiety (Getting full fast)
o Belching/Bloating
- Contributing Factors
o Chocolate (caffeine and fat), Yellow Onions (particularly raw), Peppermint, Garlic
o Tobacco (nicotine and causes sphincter to relax), Alcohol (fat and causes sphincter to
relax), Caffeine (anything caffeinated)
Spicy foods make the reflux more irritative, but doesn’t CAUSE reflux itself.
o 70% of GERD suffers have a hiatal hernia (usually sliding type)
o Beta Blockers (control BP and angina), Ca++ Channel Blockers, nitroglycerin
Causes dilation of lower esophageal sphincter (since are systemic smooth
muscle relaxants and are not specific for cardiac muscle.)
o Gastric Acid Hypersecretion
- Diagnosis
o 24 esophageal pH monitoring
o E.G.D. – final Dx for GERD
o U.G.I
o Manometry, (pressure measurement) to rule out diffuse esophageal spasms
- Treatment
o Avoid triggers (diet modification) (most effective Tx honestly)
o Proton pump inhibitors
o H2-blockers (cimetidine – Prilosec )
o Antacids
o Fundoplication
Reserved for pts with daily reflux (chronic intractable)
Stomach is wrapped around esophagus and sutured in place.
Three types
• Nissen (complete)
• Posterior (partial)
• Anterior (partial)
o Drink excessive amount of water, water helps to dilute the acid and provide weight to the
stomach to pull the hiatal hernia down.
- Can result in esophageal strictures etc. if untreated.
BARRETT’S ESOPHAGUS
- Pre-malignant
- Associated with chronic reflux (5-10% incidence)
- Stratified squamous manifests to columnar epithelium, a pre-cancerous condition
- Increased risk of adenocarcinoma
o 30-50 times increased risk to develop adenocarcinoma of the esophagus
o 500/100,000 people with Barrett’s esophagus will progress to adenocarcinoma.
- Dx
o EGD, biopsy almost always accompanies an EGD
o Biopsy
- Rx
o Laser Ablation
o Fundoplication
o Surgical Resection (En Bloc if area is large enough)
ESOPHAGEAL ACHALASIA
- Spasm (shut tight) of lower esophagus with pre-stenotic dilation which makes peristalsis
ineffective
- (Inability of LES to relax, leading to storage of food product in the lower esophagus.)
- Chest pain can occur when peristalsis is attempted
o Pain usually colicky
- Functional esophageal obstruction
- Inadequate relaxation of the LES
- Ineffective Peristalsis
- 1/100,000 incidence; 30-50 y/o
- S/Sx
o Solid/liquid dysphagia, patient indicates they can feel the food sticking usually in the
lower chest
Dysphagia for liquids and solids suggests a motor disorder.
Dysphagia for solids that PROGRESSES to liquids suggests an obstruction
(growing).
o Chest pain
D/dx for angina.
o Vomiting of undigested food
o Aspiration, can develop pneumonia and die
o May be confused with angina
o Colicky type pain
Crescendo/decrescendo type pain
Stone, Ureters
- Etiology
o Degeneration of myenteric plexus
Viral
• Herpes Zoster
• Measles Virus
Autoimmune
o Not completely understood, true etiology not known
- Diagnosis
o EGD with manometry
o UGI
o Tests to rule out other causes (eg: EKG for cardiac differential)
Especially with age group one wants to rule out MI
- Treatment
o Medical
Smooth muscle relaxants (70% effective)
• Nitrates
• Calcium channel blockers
• Botulinum toxins injection
Mechanical dilation (90% effective)
• Bouginage (mechanical dilation by balloon)
Esophagomyotomy (90% effective), incise into the muscle (sphincter – draw
back, reflux)
- Prognosis
o Excellent with appropriate Rx
o Long standing Disease increases risk of CA
SCLERODERMA
- Aka: progressive systemic sclerosis (PSS)
- Means hardening of the skin and other tissues.
o Primarily (most obviously) effects the skin, but is not limited to the skin
o Tissue thickens and hardens
ANY connective tissue can be affected, even those holding in their teeth and
vascular tissue.
o Tends to onset in girls in their late teens to women in their early 20’s.
Runs a harsh course over 20-25 years. (not immediately fatal, but progressive
difficulty).
o Severe hardening of lips to point must be tube feed in late stages.
o Tight, red, hard, fibrotic skin.
o Fingers will come to a point, like a pencil and may tips may fall off. (a hallmark sign)
Radiographically, the distal tuft of finger is lost – with the bone of the phalanges
coming right to the end of the finger with almost no soft tissue between bone
and skin.
• Flocculant calcifications in the para-articular distal fingertips.
Same applies to tip of nose.
o Affects the esophagus in 3/4 of cases.
Hardening decreases peristalsis, leading to dysphagia, reflux, regurgitation
- Sometimes must replace the esophagus
o Peristalsis is affected, thus difficulty in swallowing, reflux
- Kidneys are often affected as well
- Vessels become calcified, thickened and hardened
- Female > Male, Early teens to 20’s
- Smooth mm relaxants used if esophagus does not need replacing, patient receives temporary relief,
usually do not work
- Multisystem disorder often affecting the esophagus
o Lose ability to have peristalsis
o Becomes very narrow and can develop strictures
o EGD used to diagnose
- 75% have esophageal involvement
- Fibrosis and inelasticity results
- Signs & Symptoms
o Dysphagia
o Esophageal reflux/regurgitation
o S/Sx associated with scleroderma
- Diagnosis
o EGD
o UGI
- Tx with smooth muscle relaxants, but there is no cure.
- Etiology - unknown
GASTRIC ANATOMY
o Stomach B12 absorption (intrinsic factor), storage, mixing, mineral absorption
o Rugae increases surface area inside the stomach for production of HCl and pepsin
o GE Junction
o Gastroesophageal Reflux Disease
o Fundus
o Usually holds gas
“Magenblase” air in the stomach (in upper left stomach, near hemidiaphragm)
o Antrum
o Pylorus
o Narrowed portion of the distal most aspect of the stomach
o Pyloric Sphincter b/w stomach and duodenum help prevent outflow of gastric juices
that could lead to PUD
o Pyloric stenosis prevents outflow, causes regurgitation
o Curvatures
Lesser curvature
Greater curvature
• More metabolically active (because of where food sits)
• Also where most of the diseases of the stomach occur, for the same reasons.
o Estimated that 3 – 5 cc of blood is lost with each aspirin taken that is not buffered
o Layers to the stomach (4)
o Mucosa, submucosa, muscle layer, serosa (inner to outermost)
EGD ANATTOMY
Normal antrum and pylorus (pictures)
GASTRIC PERISTALSIS
GASTRIC TUMORS
GASTRIC CANCER
90% of tumors in the esophagus are malignant
- Occurs anywhere in the stomach
o With a greater occurrence in the greater curvature of the stomach due to the gravity of
material to this area of greater metabolism
- Incidence of proximal CA is increasing in the US (almost logrhythmically)
- 2 - 4X more common in 1st degree relatives
- Male : Female 1.6:1
- > 55 y/o
- 7/100,000/year (not all that common)
- Most common in blood group A
- No symptom complex presented early in the disease
- Pic: Linitis Plastica, an invasive form of gastric carcinoma , not a single tumor mass, the tumor
cells spread throughout the entire stomach without causing a single tumor.
o Aggressive, Infiltrated carcinoma invades entire organ and cause thickening of entire
organ - rarely found before stage 3 or 4
o S/SX
Cramps
Loss of appetite
Very low bleeding
No ulceration
Poor intrinsic factor production
- Risk factors
o Diet rich in additives (smoked, pickled) (increased level of nitrates)
o Atrophic gastritis
Inflammatory disease of the stomach where there is atrophy of the rugae
Sequela : B12 deficiency pernicious anemia
o Pernicious anemia
o Tobacco use
o Hispanic, Japanese
o Polyps
Growth into lumen
Sessile and pedunculated
Usually premalignant mass (some benign)
o H. pylori infection (PUD associated with H. pylori)
o Barrett’s Esophagus
o [picture: Linitus Plastica – thickened wall of the stomach leading to decreased pliability,
d/t an invasive malignancy (non-focal mass, which instead invades whole thickness of the
gastric wall)]
- DX
o Stool guaiac test test for blood
o Any male > 40 with anemia, has GI malignancy until proven otherwise
- Any male over the age 40 who is anemic has a GI malignancy until proven otherwise (blood
loss from the malignancy)
GASTRIC CA PATHOLOGY
- Adenocarcinoma 90%
o Due to the abundance of glandular tissue, {adeno-, glandular}
- Lymphoma 6%
o Malignancy of lymphocytes {mediastinum area is the most common area for a
lymphoma}
- Gastric Sarcoma < 4%
- Leiomyosarcoma < 1 %
GASTRIC CA TREATMENT
- Surgical resection, quite often an en bloc gastrectomy (resect until healthy tissue is found)
- Node resection (when larger then 1cm)
- Radiation non-beneficial (tumors are non-sensitivity to radiation)
- Chemotherapy non beneficial
o Research has shown this treatment has very low benefit for gastric cancer.
o Chemotherapy is designed to “attack” fast growing tissue.
GASTRIC CA PROGNOSIS
- No S/sx until late in course, primarily due to the size of the hollow organ. It takes a rather large
amount before it interferes with the function of the stomach. Therefore survival rates are typically
low.
- 18% 5 year survival rate
o 57% with local Disease (stage I)
o 19% with regional spread (stage II)
o 2% with distal mets (staged III)
GASTRITIS
- Gastritis is a “catch-all” term.
o Most common emergency room Dx for abdominal pain.
- Gastritis has:
o Erythema – reddening
o Hemorrhage Atrophic gastritis – associated with
o Erosions
- Types
anemia
o Erosive
o Non-erosive, non-specific
o Specific
- S/sx
o Post-prandial (after eating) indigestion/pain (dyspepsia)
o Nausea and vomiting
o Bloating
- 50% have H. pylori (spiral shaped bacteria)
EROSIVE GASTRITIS
- Etiology
o NSAID’s
Gastric bleeding occurs frequently with all NSAIDs, but more frequently with
the COX1 inhibitors than COX2.
Each non-buffered aspirin reduces blood supply by 3-5 ml.
• Buffered: has a gelatinous coating that allows the drug to be broken
down in the small bowel, as opposed to the stomach (gelatin as a carb
is broken down in small intestine rather than the stomach).
o Alcohol(ism) d/t portal HTN
Venous congestion decreases the removal of waste from the stomach blood
supply.
o Stress from major illness (burns)
- Hemorrhage also common with this Disease
- Usually asymptomatic
- Can produce pain, hematemesis, nausea/vomiting
- Diagnosed with EGD
SPECIFIC GASTRITIS
- Ménétrier’s Disease
o Giant fold gastritis (the rugae become very large, (friggin huge))
o Enlarged, thickened gastric rugae
Get hypoproteinemia due to enlarged rugae
• Causes edema, pleural effusions, and other 3rd space fluid effusions,etc.
• This causes an overload on the kidneys and heart, leading to heart and
renal failure.
o Severe protein loss
Proteins are metabolized in stomach
o Hypoproteinemia
o Idiopathic
- Granulomatous gastritis
o Crohn’s Disease (a chronic inflammatory granulomatous bowel Disease)
o TB
o Sarcoidosis
(idiopathic autoimmune disease that normally affects the lymph nodes of the
chest, found primarily in young black males)
o Tx: Treat the specific disorder
- Phlegmonous gastritis
o Chronic abscess.
o Phlegmon – aggressive large abscess
o Abscess from fungal, bacterial, parasitic infection
o Emergent gastrectomy and IV antibiotics
o Treatment is the removal of the stomach.
o Common among AIDS patients (the immunosuppressed)
Differential Diagnosis (other things that cause epigastric pain (burning, gnawing, etc.))
- GERD
- Reflux Esophagitis, most common condition confused with PUD
- Gastric CA, particularly if there is a change in the pain pattern
- Gastritis
- Pancreatitis
- Cholecystitis
- Cardiac disease (don’t forget this one)
Diagnostic Workup
- Endoscopy
o Esophagogastroduodenoscopy (EGD), almost universally the means of diagnosis
o 95% accurate (5% due to human error)
o Biopsy ALL lesions
o Cancer: benign vs. malignant cannot be differentially diagnosed by sight
More ragged the edge, the larger – the more likely is malignant.
o Also biopsy for H. pylori
- Upper GI series
o BaSO4 swallow, then X-ray results.
o Not as reliable as EGD
o No biopsy capabilities.
o Not used much anymore.
Treatment
- Antibiotic therapy (clarithromycin – which is harsh on the stomach lining)
- Omeprazole (Prevacid)
- H+ pump inhibitors
- Stop Smoking
- Stop NSAID use
- Stop/minimal antacid use
o Not good in long term. Is addictive (gastric mucosa becomes so used to antacid, you
have functionally altered it and decreased it’s effectiveness)
o Also some risk of aluminum toxicity and hypercalcemia.
- Diet Changes
o Bland Diet
o Don’t use milk anymore, because the sugar in it can help feed the bacterial and can
actually make the ulcer worse in the long run.
- Stress Reduction
o Because of sympathetic reaction
o Valium (classic drug prescribed)
- Manipulation in conjunction with medical therapy has been proven beneficial to the patient
Zollinger-Ellison Syndrome
o Uncommon cause for PUD
o Occur because of Gastrin secreting tumors (gastrinoma)
o Cause multiple peptic ulcers (literally hundreds of small ones)
o Perforation is relatively common
Bleed outs common
o 2/3 of gastrinomas are malignant
Will metastasize
Can lead to death
o Hard to manage these cases due to the continuous production of gastrin from the tumor
HIATUS HERNIAS
- Herniation of a portion of the stomach into the thoracic cavity (mediastinum) through
diaphragmatic hiatus
EPIDEMIOLOGY
- 50% of patients over 50
- Female: Male (4:1)
- Often associated with GERD
- 90% with EGD esophagitis have a hernia
- Etiology unknown, age most likely culprit due to weakening of the sphincteric
- May be congenital or post-traumatic
- Bowel and stomach in the middle of the chest compressing the lungs and heart is termed a
Bochdalek
TYPES OF HERNIAS
- Sliding (most common)
- Paraesophageal (AKA: Rolling Esophageal Hernia)
- Short Esophagus
- Intrathoracic Stomach
SIGNS AND SYMPTOMS (same as reflux with the exception of the addition of borborygmi
• Heartburn
o Because also have GERD
- Dysphagia
- Regurgitation
- Chest Pain (burning)
- Postprandial fullness
o After eating
- GI Bleeding
- Dyspnea
o Most often with hiatal hernia, a useful d/dx from GERD. (possible TQ)
o From impingement of the left lung.
- Hoarseness
o Irritation of larynx from GERD
- Cough
o Irritation and to keep stuff from going into the trachea
- Wheezing
PARAESOPHAGEAL HERNIA
- Second most common
- AKA: Rolling Hiatus Hernia
- GE junction in normal position
- Fundus herniates through diaphragm
- Usually asymptomatic
o A self containing condition, hence not as much GERD and reflux.
- Should be surgically reduced
- May become strangulated
o Lead to ischemia (loss of blood supply)
MISCELLANEOUS HERNIAS
- Short Esophagus Type
o Variation of sliding hernia
o Uncommon
o Congenitally short esophagus or from surgery (enbloc resection from malignancy)
- Intrathoracic Stomach
o Very rare
o Entire stomach in chest
o Incompatible with life
- Bochdalek
o Gastric herniation into posterior mediastinum
DIAGNOSTIC WORKUP
- Exclude other more serious conditions
- EGD
- UGI
- Blood tests non-specific
- Ex: On contrast PFXR, can see rugae above the hemidiaphragm
TREATMENT
- This is a common condition, remember.
- Diet changes
o Avoid caffeine, chocolate, mint, uncooked white onion, etc.…
o Avoid drugs (Ca++ channel blockers), nitrates, etc.
- Weight loss (most hiatal Pts are overweight)
- Small meals (6 small meals is better than 3 large meals)
o Keep metabolism up over a longer period of time.
- Sleep with head elevated
- Manipulation
- Antacids, H+ pump inhibitors, etc.…
- If all else fails, or sign of strangulation of the hernia, surgery for refractive disease
o Fundoplication.
Colon
- Review normal anatomy and structure of the color
o (Vermiform appendix), Ascending colon, transverse colon, splenic flexure, descending
colon, sigmoid colon, rectum, anus.
- 2 Functions:
o Fluid control and storage of feces
- Review blood supply to colon
o Superior mesenteric artery is larger than the inferior mesenteric artery
o Blood supply interruption
Mesenteric Thrombosis
• Diabetics
• Trauma causing vasocompression
- Sigmoscopes, anoscopes, and colonoscopes used to view the colon.
o Used to be rigid, now are flexible. (…yaiiigghh!!)
o Can view the haustra easily. (not that you WANT to…)
Tapeworm (Taenia)–
- S/SX abdominal pain, weight loss
- Can grow to be 20-25 FEET long.
- Pork (Taenia solis) and beef (Taenia sanguinatum) most common.
- Can regrow if only partially removed.
- Most Pts are asymptomatic, some are anemia, weight loss, etc.
- EWW!
INFLAMMATORY BOWEL DISEASE
- Irritable Bowel Syndrome (IBS)
- Crohn’s Disease (agranulomatous)
- UC
- Antibiotic Associated Colitis
- Bacterial Colitis (Food Poisoning)
o Ex: including from bubonic plague
- Appendicitis
CROHN’S DISEASE
- Chronic granulomatous inflammatory Disease
o Transmural (across the entire wall) GI inflammation
o Causes granulomas – localized areas of necrosis.
“Lumpy, Bumpy Bowel Disease” – causes lots of lumps and bumps.
- Regional enteritis (AKA for Crohn’s)
o ½ of all Pts affected in the iliocecal region.
- Debilitating, often requiring surgery
- 1:1000 population
o So fairly common.
- Caucasians, Jews
- Unknown etiology
o Autoimmune is the current guess.
- Affects young people
o Teens to 20’s.
- Pathophysiology
o Location
Anywhere in the GI (“Tongue to Bung”)
33% involve terminal ileum
50% involve distal ileum/proximal colon
20% involve colon only
o Transmural Disease
Inflammation (granulation tissue)
Ulceration
• But not as much bleeding as in UC (ulcerative colitis – which is
hallmarked by bloody diarrhea, and important D/dx)
Stricture
Fistula (connection between 2 organs not normally connected)
• Starts as an adhesion, then progresses.
Abscess (walled off pocket of infection)
(look for thickening and reddening of the wall in association with the
inflammation)
- S/SX
o Abdominal distention/bloating
o Mass suggests abscess formation
o “Crampy” abdominal pain (RLQ)
o Hyperactive Bowel Sounds
o Non-bloody/bloody diarrhea
o Perianal fissures/fistulas
o Bowel obstruction
o Crohn’s arthropathy
o Low grade fever, pallor
o Weight loss, fatigue
- Diagnostic Evaluation
o “Skip lesion” presentation.
o CBC
Anemia
Decreased H&H
o Electrolyte imbalance
o Vitamin B12 deficiency
o Endoscopy
o UGI
o LGI
o The Pt Hx is very telling on this.
- Presentation Patterns
o Chronic inflammatory Disease (M/C)
Chronic relapsing inflammatory disease.
o Intestinal obstruction from stricture abscess
o Fistula formation
o Perianal disease
o Extraintestinal
- D/DX
o UC (differentiated since UC has a lot of blood in the diarrhea)
o IBS (more common differential, since this does not produce as much blood in the
diarrhea)
o Infectious colitis (Yersinia pestis (bubonic plague), TB, Salmonella)
o Parasitic infection (amoebiasis)
o Ischemic colitis (tends to happen in older folks with atherosclerosis or diabetes mellitus)
o Diverticulitis
o Colon CA
- Tx
o Nutritional supplementation
o Low residue diet with obstruction
o High fiber diet with diarrhea
o Medications
Sulfasalazine
Corticosteroids
Immunosuppressive drugs
o Monitor vitamin levels
o Surgery for obstruction, fistulae, etc.
- Complications
o Obstruction (common)
o Abscess formation (common)
o Fistula formation (inter-organ, skin) (common)
o Perianal fissures
o Colon carcinoma
(Slightly increased risk, but not the same risk as in UC (substantially increased
chance)
o Hemorrhage/shock
If fistulas/abcesses hit and disrupt a major artery or vein.
o Malabsorption
Crohn’s disease presents with a wide variety of signs and symptoms because its involvement is
variable in both location and severity of inflammation
Intestinal obstruction
o Narrowing of the small bowel may occur as a result of inflammation of fibrotic
stenosis
o Patients report postprandial bloating, cramping pains, and loud borborygmi
Perianal disease (other presentation of Crohn’s): which usually includes anal fissures, perianal
abscesses, and fistulas
Extraintestinal manifestations
Oral aphthous ulcers
Increased prevalence of gallstones due to malabsorption of bile salts
Nephrolithiasis with urate or calcium oxalate stones
Complications
Abscess
Obstruction
Fistulas
Perianal disease
Carcinoma – Patient’s with colonic disease are at a greater risk of developing colonic
carcinoma
Hemorrhage – unusual in Crohn’s disease (except for Crohn’s colitis)
Malabsorption – from bacterial over-growth in patients with fistulas
No specific treatment exists for Crohn’s disease, treatment is directed toward symptomatic
improvement and controlling the disease process
APPENDICITIS
- Vermiform appendix can be at a variety of positions on the caecum.
- Inflammation of appendix secondary to obstruction
- Clinical symptom complex
o Periumbilical/diffuse pain (initially)
o RLQ pain
12-24 hrs later
Sign of regional peritonitis
Rebound tenderness
• Pain is on release of pressure, not on placing of pressure AND pain is
in a different place than the point of pressure application (Rousing sign)
High fever
o Can rupture
Within 36 hours of the pain moving to the RLQ, the appendix is usually
enlarged enough to be at substantial risk of leaking and rupture.
Enlargement of the appendix can become HUGE.
o May cause diffuse peritonitis
o May result in abscess formation
o Only in about 10-15% of the time AT BEST, appendicitis will remit on it’s own. Don’t
take this risk.
o If pain getting worse and worse, then gets better suddenly – usually a hallmark sign that
the appendix has ruptured (rapid reduction of pressure on the serosa).
Within 12 hours, can get onset of sepsis, toxosis, and eventual death.
DIVERTICULAR DISEASE
- Epidemiology
o Herniation(s) of mucosa and submucosa through muscularis (at points at which vessels
penetrate the GI wall) from low fiber diet
o Occur because of poor bowel hygiene
(Low water intake, straining, “holding it too long”, low fiber in diet, etc.)
o Occur at vasa recta (weakened area)
o Diverticulosis is asymptomatic
o Diverticulitis is symptomatic
Only when 1 or more of the ostia become obstructed are Sx present.
Can rupture and bleed (sometime asymptomatically) like appendicitis.
o 30% of Pts over 40; 50% of Pts over 70 have diverticula (very common).
o Most respond well to antibiotics
o Up to 30% require surgery
- S/sx
o Diverticulosis exam is normal
o LLQ pain most commonly.
o Pain relieved with BM
o Abdominal guarding
Voluntary contraction of abdominal mm, as opposed to abdominal rigidity,
which is involuntary (d/t peritonitis)
o Rebound tenderness suggests peritonitis
o +/- small amount of blood in stool
DIVERTICULAR BLEEDING
- 70% occurs in right colon (don’t know why, when it mostly occurs in the left colon)
- Bleeding is painless
- Resolves spontaneously in 60%
- Erosion of vessels from fecalith (fecolith?)
- 15 – 20 % re-bleed within 5 yrs
- Diagnostic workup
o CBC (elevated WBC with diverticulitis)
o Microcytic anemia
o Barium enema (BE)
o Sigmoidoscopy
o Abdominal CT for abscess formation
- D/dx (you’ve seen this list before, as they all are D/dx for each other)
o IBS
o Crohn’s disease (which also has masses and abscesses)
o UC
o Colon CA
o Ischemic Colitis
o Infectious Colitis
- Tx
o Good bowel hygiene
Increased dietary fiber
Increased fluids.
Regular bowel habits (when you need to go)
o Avoid foods with residue (seeds and things that could obstruct the ostia of the diverticula)
o Regular exercise
Used for constipation too.
o Broad spectrum antibiotics
Makes Pt more regular.
o IV Antibiotics in severe cases
o Surgical resection/re-anastomosis
1Colorectal Cancer
• Almost impossible to tell just by looking if a polyp is benign or malignant.
• Polyps can be found by DRE (digital rectal exam) depending on size and location.
• Second leading cause of CA deaths in USA (secondary to lung CA)
o 135K new cases/yr
o 50K deaths/yr
• 15% of all organ based cancers (except skin cancers)
• Peak incidence in the 7th decade
• Location
o Descending colon – 40%
o Rectosigmoid – 30%
o Cecum/ascending – 25%
o Transverse – 10%
• Remember: any male over 40 with anemia must be assumed to have a GI CA until proven otherwise.
o Remember that GI CA can present as alternating diarrhea/constipation
o DRE’s – need to be done regularly as the Pt ages.
Risk Factors
• Hereditary Polyposis syndromes
o 100’s to 1000’s of polyps in their colon.
Pts usually have prophylactic colectomies – as they WILL develop
malignancies.
o Familial polyposis, teens to 30's, pts have thousands of polyps
o Gardner’s Syndrome
Colonic polyposis associated with osteomas in the skull.
• Inflammatory bowel diseases
• History of previous colorectal CA
• 1st degree relative with colorectal CA
• Age >40
• High fat, low fiber diet
• Regional radiation therapy (eg. Female receives radiation for ovarian cancer - if the colon is in the
port, the fast turnover of the epithelial cells makes them prone to damage from the radiation, due
to the effect of radiation on fast growing tissue) [brain tumors can be treated with stereotactic
radiation]
Clinical Presentation
• Normally unremarkable
o Normally only found after signs of bleeding (see below)
• DRE finds 50% of tumors (polyps and colon cancer)
• Palpable abdominal mass (mets most likely not the colon cancer itself)
• Abdominal tenderness
• Alternating constipation / diarrhea (blockage, attempt to flush, repeat)
• Hepatomegaly (mets)
• Rectal bleeding
• Hematochezia
• Melena
• Blood streaked stool
• Occult blood [blood mixed in with the stool]
• Abdominal distension
o Obstruction
o Initial symptom in 15% of patients
If gets to this point, probably already has metastasized, stage III or IV.
• Pencil thin stools
• Intusseception
• Volvulus
• Weight loss, suggest stage 3 or 4 carcinoma
• Anorexia
• Malaise
Clinical Investigation
• Anemia (microcytic) [Any male patient over 40 with rectal bleeding is to be considered positive
for colon cancer](Ya think this is gonna be a TQ?)
• Positive FOB test
• Elevated CEA (carcinoid embryonic antigen)
o Not as good for presence of colon CA, but good to monitor Pt response to treatment (Rx)
• Elevated LFT’s (liver function tests) (usually indicating mets)
• Colonoscopy
• Double contrast BE
• CT for staging
• CXR (chest X ray)
o Chest is a common place for mets of colon cancer
• 25% have mets at presentation, they are in stage four of the cancer
Differential Diagnosis
• Diverticular disease
• Bowel stricture
• Inflammatory bowel diseases
• Adhesions
• Mets
• Extraluminal masses (ovarian mass)
• AVMs (arterial/venous malformation)
o Usually a congenital lesion, with a tumor like mass of arteries and veins.
o Can present with alternating diarrhea/constipation, colorectal bleeding, etc.
o Usually occur in younger Pts
Cancer Staging
• Duke classification system (used almost universally for Colorectal CA Pts)
o A - Confined to the mucosa-submucosa (essentially a carcinoma in situ) (best prognosis)
o B - Invasion of muscularis (into vessels, chance of spread)
o C - Local node involvement (local spread)
o D - Distant mets (liver, lung, brain)
• [Look for “shouldering” on Ba Xray – the almost 90o cut off between edge of mass and normal
tissue]
Treatment
• Surgical resection (often done for palliative reduction of S/sx, rather than curative reasons)
o 70% are resectable at presentation (usually stages A and B)
o 45% cured by primary resection
• Radiation therapy (stages B & C)
• Chemotherapy (stages B & C)
o 5-fluoroucacil
o Levamisole
• FOB q 6 months
• Colonoscopy q year x 2 years, then q 3 years
o If they are clear.
• Monitor CEA levels (Carcinoma Embryonic antigen)
Prognosis
• Duke A: >80%
• Duke B: 60%
• Duke C: 20%
• Duke D: 3%
Overall 5 year survival rate: 50%
Pts usually are cachexic.
Colon Polyps
- 50% patients have polyps
o Hyperplastic
o Adenomas
Of concern for degradation to adenocarcinoma.
DRE’s and FOB testing encouraged.
o Lipomas
Common.
o Leiomyomas (smooth muscle tumors)
Longitudinal strips of smooth muscle transversing the colon.
- Sessile / pedunculated
- 25% patients with colon cancer have polyps
- There is also Familial Adenomatous Polyposis (FAP) (see above)
Signs / Symptoms
- Most are asymptomatic.
- Rectal bleeding is most common Sx (most in recto-sigmoid region)
o Hematochezia (BRBPR)
- Cramps
- Abdominal pain
- Obstruction
- Anal polyps may prolapse
- Generally polyps are small, but the larger they get, the higher the chance of malignant
degeneration.
- Cannot tell by external observation whether a polyp is malignant or benign
o Which is why most are removed and biopsied to tell.
Diagnosis
- DRE (digital rectal exam) (aigh!)
- Endoscopy
- Double contrast BE
Treatment
- Careful observation (hyperplastic, lipoma)
- Endoscopic surgery
- Open laparotomy
SIGMOID DIVERTICULITIS TX
- ↑ dietary fiber
- Broad spectrum antibiotics
- Reg. Exercise
- IV antibiotics in severe cases
- Surgical resection/re-anastomosis
COLON POLYPS
- Most non-inflammatory CA arise from polyps
- 50 % patients have polyps
o Hyperplastic
o Adenomas
o Lipomas
o leiomyomas
- sessile/pedunculated
- 25% pts with colon CA have polyps
- S/SX
o Most are asymptomatic
o Rectal bleeding mc
o Cramps
o Abdominal pain
o Obstruction
o Anal polyps may prolapse
- DX
o DRE
o Endoscopy
Complicated with severe inflammation disease
May perforate bowel
Do BE instead
o Double contrast BE
- TX
o Careful observation (hyperplastic, lipoma)
o Endoscopic surgery
o Open laparotomy
CELIAC SPRUE
- AKA: Gluten enteropathy non-tropical sprue
o Antigen mediated rxn.
- Gliadin protein fraction in gluten
o Wheat
o Rye
o Barley
o Oats
- Gluten intolerance
- 50-500/100,000 people
- Incidence ↑ during 1-36 months
- F>M
o Mc to find in a child
- Clinical Presentation
o May be normal presentation
o Weight loss
o Dyspepsia (indigestion)
o FTT in children (failure to thrive)
o Bloating
o Diarrhea
o Pallor/fatigue (anemia)
o Angular cheilosis
o Osteomalacia
o Dermatitis
- Lab tests
o Iron ↓ anemia
o Folic acid ↓
o B 12 ↓
o Presence of Antigliadin IgA and IgG
o Small bowel biopsy
Show villi atrophy
Signs of inflammation
- D/DX
o IBS (mc d/dx)
More mucous in IBS stools
Age 20 - 40
o Laxative abuse
Yes, Pts can become addicted to laxatives.
o Intestinal Parasites
o Tropical Sprue
o Lymphoma
- TX/PX
o Gluten Free Diet
o Iron supplementation
o Folate supplementation
WHIPPLES DISEASE
- Caused by bacteria, Tropheryma whippelii (gram +)
- Multisystem Disease
- Aka: intestinal lipodystrophy
o Poor digestion of fats.
- Uncommon disease
- 30-60 yr. olds
- M>F
- Clinical Presentation
o Irregular folds in the small bowel, and thickening of the wall.
o Malabsorption
Diarrhea
Bloating/cramps
Anorexia
Weight loss / fatigue
anemia
o Extra intestinal Sx
Arthritis
• Can be peripheral or sero-negative
o Similar to UC and Crohn’s which both can have arthritis Sx.
Pleuritic chest pain (localized pain)
Pericarditis
Osteomalacia
- Pathology
o Bacteria never cultured
Cannot find an agar to culture it in, must be cultured in human tissue.
o No human to human transmission.
Mode of transmission unknown.
o Appearance of bacterium can change (overall morphology: longer/shorter,
thicker/thinner, etc.)
o Response to antibiotics confirms Dx
- D/dx
o Celiac sprue
o Lymphoma
o Crohn’s disease
Consider this on just about all small bowel D/dx.
Crohn’s has more inflammatory symptoms than Whipple’s, but is included
because of the extraintestinal Sx, particularly the arthritis.
o Short bowel syndrome
Take portion of bowel out
Get malabsorption
o Pancreatic insufficiency
Fatty stools
o Lactose intolerance
- TX/PX
o Antibiotics: trimethoprim, sulfamethoxazole
o Treat Vitamin deficiencies.
o Iron supplementation.
o Pts respond well to antibiotics.
Prognosis very good, once antibiotics have been administered.
LACTOSE INTOLERANCE
- Can have a transient form in people that are ill
- 1 in 6 of all people have it
- Have malabsorption symptoms
o But vitamin deficiencies are usually not as bad
- Insufficient concentration of lactase
- Results in fermentation of lactose
- Aka: “milk intolerance”
- 50 million are affected (about 18% of the population)
- > 85% Asian American affected
- > 60 % African American affected
- < 25% Caucasians affected
- There can be conditional lactose intolerance.
o Pts presenting with food poisoning or occasionally other infections, can have a transient
lactose intolerance after an illness for a couple of days to a week or so.
o Common in infants and children.
o Take them off milk for a few days, then gradually add it back in. (for infants, but them
on pedialyte in the intermediate.)
- Clinical presentation
o May be normal
o Bloating
o Diarrhea
o Cramping
o Abdominal pain
o Flatulence
- DX workup
o Hydrogen Breath test
Ingest 50 gm of lactose
Rise in breath hydrogen to > 20 ppm in 90 min after lactose administration.
o Exclude other disease
o Imaging studies not indicated (sorry Dr. Fritsch)
- D/DX
o IBS
o IBD
o Pancreatic insufficiency
o Sprue, Celiac Disease (gluten intolerance)
- TX/PX
o Lactose free diet
Milk
Bread
Candies
Cold cuts
Commercial sauces
o Read labels
o LactAid tablets
o Ca2+ supplementation (since don’t drink milk)
o Excellent prognosis – easily treatable, if inconvenient.
MECKEL’S DIVERTICULUM
- Remnant of vitelline (omphalomesenteric) duct.
- Most commonly misdiagnosed as appendicitis
- Even looks like an appendix at the end of the ileum (as opposed to the ileocecal region)
o About 12 cm long (~4 inches).
o Some of them contain gastric mucosa – which can have ulcers, which in turn can bleed
and perforate. Risk of feces in mesentery.
- Congenital lesion
o 2% of Population
o Failure of obliteration of vitelli intestinal
o Duct connecting interesting 2 yolk sac
o Most common anomaly of SI
- Found w/in 3 ft of IC valve
- Less than 12 cm (4 inches) in length
- Complications
o Bleeding
o Obstruction
o Diverticulitis (contains gastric mucosa) perforation
- RX w/diverticutomy
MESENTERIC ISCHEMIA
- Most painful condition in medicine
o Very painful, high mortality rate.
- More proximal obstruction of artery, the higher the risk of mortality.
- Occurs as a result of either superior mesenteric arterial or venous occlusion
o Less commonly from the inferior mesenteric artery (which largely affects small bowel)
- Affects the bowel from 2nd part of duodenum 2 transverse colon
- 50% embolic, 25% atheromatous, 10% venous occlusion
- Overall mortality is approx. 90%
o Usually within a few hours.
- DX features
o Nothing highly suggestive
o Central abdominal pain, out of proportion
Arterial obstructions appear more acute, venous appear more chronic.
o KUB may be normal
KUB: Kidney, Ureter, Bladder – plain film X-ray of the abdomen.
o Look for in diabetics, alcoholics, people with long standing systemic diseases.
GENITOURINARY DISEASES
• Up to 75% of kidney tissue can be destroyed before affecting renal function.
• Surviving on one kidney is not difficult.
• Normal congenital anomalies include pelvic kidneys (unascended), Horseshoe shaped kidney (1
big one), agenesis of kidney, urethra diverticula or bifurcations, etc.
• Polycystic disease is the most common disease of the kidney. Usually benign.
LOWER UTI
- Presentation inconsistent
o Some asymptomatic, some just have urgency, some have extreme pain
- Testing (?)
- Polyuria (increase in Urinary frequency), with minimal quantity
- Dysuria (painful urination)
- Urgency
- Urge incontinence
- Suprapubic pain
- Hematuria (menstruation most common caused, bladder infection most common pathogenic
cause)
o Gross
Patient will see blood in toilet
o Microscopic
If the infection is mild to moderate
PYELONEPHRITIS
- More common in immunocompromised patients, diabetics, and other constitutional illnesses.
- Usually secondary to a UTI
- Patient will be positive for a kidney punch
- Fever, more prevalent then with a UTI
- CVA (costovertebral angle) pain
- Radiating pain into groin
o Anterior and inner thighs, males will refer to the ipsilateral testicle
- Chills
o Fever, night sweats
- Malaise
o Fatigue
- Vomiting
- Diarrhea
Clinical testing
- Clean catch UA
o Wipe w/alcohol pad → start urination → stop → catch → mid-steam urine → stop before
urination is complete
- Urine Culture & Sensitivity, by culturing you are able to determine the type of bug and degree of
activity level and then the sensitivity to antibodies so as to determine treatment plan
- CBC
o Elevated WBC, anemia (mild)
- KUB (kidney, ureter, bladder) (a plain film Xrayof the abdomen)
- Ultrasound
- IVP (Intravenous Pyelogram)
o Outlines renal substance
o Uses iodine, as it’s cleared by the renal system (not GI, respiratory, or biliary system)
- CT scan
o For tumors or abscess
- Cystoscopy
- Retrograde pyelography (obstruction)
o Dye from urethra up (via catheter) and stops where infection is
o 2 check for stones
o Surplanted now as a technique by Ultrasound.
[Ok, guys, you are NOT going to like the slides on this section…]
Non-gonococcal Urethritis
- NGU is the most common STD
o More than gonorrhea or syphilis.
o NGU twice as common as gonorrhea (the clap)
- Chlamydia is the most common bug
- Often asymptomatic (~25%), especially in women
o Which is why the spread can occur so quickly and broadly.
- Symptoms
o Dysuria
o Whitish discharge from urethra meatus.
o Meatal edema
• Treatment w/ antibiotics
Gonorrhea
• “The Clap”
- That’s how they used to treat it….no really.
• Neisseria gonorrhoeae
• Urethra is most common sight of infection
- Can have Gonococcal urethritis, Gonococcal cervicitis, Gonococcal opthalmia, and
Bartholin’s abcesses
• Contraction rates(single intercourse)
- 20% for males
- 80% for females, will tear up the cervix and cause sterility if not aggressively treated
• Can be mistaken for Candida albicans infection, due to the itching.
• Symptoms
- Dysuria
- Urethral discharge
- Urethral itching
• Treatment w/ antibiotics
Herpes Simplex
-HSV II infection affecting ~20% of adults
-Spread through direct contact
Can be infectious, even if no direct lesions are present.
-Causes blisters/ulcers around genitals
Blisters release clear fluid which contains high levels of the infected agent
-May also infect the eye, skin, other organs
-No cure, only symptom control
Acylovir
Genital Warts
- Condylomata acuminata
- Caused by a form of HPV
- Represents 1/3 of cases of STDs, 20 million people
- Most people are exposed at some point in life
-
-
- Will reoccur
- Hydronephrosis (water in the kidney) results from obstructed ureters, blocking outflow.
o Will only show up on venous pyelogram (IVP), as opposed to a retrograde pyelogram, which
will not detect it.
- Signs/symptoms
o Acute colicky CVA, flank, low back pain.
- “Renal Colic” – crescendo/decrescendo pain presentation.
• Occurs as a peristaltic wave passes a stone in the ureter as it is propelling
urine to the bladder.
o N/V (nausea and vomiting)
o Referred pain to testes/vulva/groin
o FCNS (Fever, Chills, Night Sweats) suggests infection
- Diagnostic work-up
o UA (hematuria) (gross or microscopic)
o Plain film radiography
o Renal Ultrasound
o IVP (intra venous pyelogram)
- DDx
o L1/L2 disc herniation (pain in the same areas)
o Pyelonephritis
o Cystitis
o Diverticulitis
o PID
- Rx
o Increased fluid intake, low calcium diet (contraindicated if an obstruction exists)
- “Just let them pass”
o Uteroscopic stone removal
o Extracorporeal shockwave lithotripsy
- High-energy ultrasound. Pt is usually sedated.
- 50% pass within 48 hrs
- 50% recurrence rate without Rx
Glomerulonephritis
- Autoimmune inflammation of glomerulus
- Synonyms
o Post-infectious GN
o Acute nephritic syndrome
- Deposition of various immune complement precipitates after infection into glomeruluar basement
membrane. Can lead to renal damage/failure.
o Remember that failure only occurs after destruction of 75% of kidney.
- Epidemiology
o 50% affect < 13 y/o
o Most common cause of chronic renal failure (~25%), these individuals wind up on dialysis
- Most common cause of renal failure from diabetes mellitus.
o Post group A beta strep infection mc
o Collagen vascular disease (SLE)
o Idiopathic
Proteinuria
- Normal adult excretes ~150 mg/day of short and long chain proteins (0 - +2 on a UA dipstick)
o 3.5% prevalence (idiopathic) in normal adults
- Perform 3 separate tests
o You must not assume that finding protein equates the “normal” amounts excreted. You must
rule out all possible causes.
o If positive again, then follow up a third time.
o Negative- Dx “transient functional proteinuria”
- Causes
o IDDM
o Nephrotic syndrome
o Amyloid
o Lymphoma
o NSAID use
o Orthostatic proteinuria (only occurs when Pt is upright)
Nephritic Syndrome
- Secondary to GN
- Signs/symptoms
o Edema (periorbital, scrotal), due to loss of protein
o HTN, damage to kidneys which help regulate HTN
o Hematuria (d/t damage to basement membrane)
o Proteinuria
- Will result in renal failure if continues for any period of time.
Nephrotic Syndrome
- Most common cause is membranous GN
- Signs/symptoms
o Peripheral edema, protein loss
o Ascites
o HTN,
o Pleural effusion
o Hypoalbuminemia
o Hyperlipidemia / hypercholesterolemia
o 1/3 of pts have DM, SLE, amyloidosis
- Many of these patients end up on dialysis. These patients are placed very low on the transplant list due
to DM, they are poor surgical candidates and the DM is not reversible, thus damage to the new organ is
inevitable
- Signs/symptoms {often the tumor is very asymptomatic for long periods prior to its discovery}
o Hematuria (50-60%)
About ½ microscopic and ½ macroscopic hematuria.
o Abdominal mass (25-45%), found on individuals who are relatively thin or found rather
incidentally
o Anemia (20-40%)
o Flank pain (35-40%) - there is no major distention of the capsule thus no pain.
o HTN (20-40%) – sudden hypertensive changes are a red flag
o Weight loss (30-35%)
o
- Classic Triad (5-10%) for adenocarcinoma of kidney.
Prostatitis
- Men over 50
- May be aseptic or septic (infectious or noninfectious)
- Signs/symptoms
o Dysuria (painful urination and in the case the pain is deep inside the pelvis)
o Polyuria (because they don’t want to urinate thus they urinate a little at a time)
o Pelvic/ back pain
o Urethral discharge
o Fever
- Dx made by culture and stain of prostate secretions
- Antibiotics if infectious
DDx
- prostatitis
- Prostate CA
- Urethral stricture
- Dx workup
- PSA
- Protease secreted by epithelial cells
- Elevated in ~40% pts w/ BPH
- UA
- Ultrasound to ensure to hidden masses
- Treatment
- Avoid caffeine
- Avoid medications (cold and allergy drugs)
- Medications
- TURP
- Stents
- Laser
- Coils
- Prognosis is good (>70%)
Prostate Cancer
DDx
- BPH
- prostatitis
- Prostate stones
Diagnosis
- Elevated PSA (may be normal in 20%)
- Elevated acid phos (extracapsular extension)
- Biopsy
Treatment (chemo, rad, prostatectomy)
Px depends on stage (~90% w/ stage I)
Testicular Torsion
- Twisting of spermatic cord
- [!]
Leads to testicular ischemia / infarct
- 1:4000 incidence
- 70% occur between 1 – 18 y/o
- DDX
o Testicular tumors
o Epididymitis
o Incarcerated hernia
o Orchitis – caused by mumps virus
o Hydrocele – an obstructive disease where there is enlargement of the epididymis
Testicular Torsion
- Clinical Findings
o Sudden hemi scrotal pain (10% are painless)
o Swelling
o Nausea and vomiting
o Afebrile – no fever
o 30% patients report previous episode of pain
- Dx based on H and P
- Surgical de-rotation with suture fixation
Epididymitis
- Septic/traumatic inflammation of epididymis
- >600k visits per year
- Occurs in sexually active men
- DDX
o Orchitis
o Testicular torsion
o Hydrocele / varicocele
- Agents
o N. gonorrhoeae
o C. trachomatis
- Clinical presentation
o Tender scrotal swelling
o Erythema
o Dysuria
o Urethral discharge
o Fever
- RX
o Ice packs with scrotal elevation
o Analgesics
o Antibiotics
- Px
o Usually self limited
Hydrocele
- Fluid collection in the scrotal space
- If congenital, associated with inguinal hernia
- In adults
o Infection
o Tumor
o Trauma
- Clinical presentation
o Scrotal enlargement / pain / radiating to back
o Transillumination
- Rx
o None if asymptomatic
Orchitis
Bladder Cancer
- Range from low-grade to high-grade
- Cell types
o Transitional cell (93%)
o Squamous cell (6%)
o Adenocarcinoma (1%)
- 54,000 new cases/yr; 12,000 deaths
- 4(F)-10(M)% of all cancers
- M/c over age 60
- 25% result from occupational exposure
o Dye, textile, rubber tire, petroleum workers
- 15-65% associated w/ smoking
- Clinical presentation
o Gross painless hematuria
o Painless microscopic hematuria
o Frequency, urgency – due to bladder becoming filled with the mass
o mets causes pain in distant organ (eg, back pain)
- Diagnosis
o H&P History and physical examination
o UA, cystoscopy – and endoscopic procedure for the bladder
- Rx- chemo, radiations, TURP, cystectomy
- Px- dependent on cell type and grade
Liver Function
- Anatomy
o Four lobes – right, left, caudate and quadrate
o Weighs – 3 lbs
- Blood Supply
o Hepatic artery (oxygenated blood) (20%)
o Hepatic portal vein (nutrients) 80%
o Hepatic veins (drain liver)
o Holds 1 pint of blood
- Only organ that can regenerate
- 75% damaged before failure
- Over 500 functions
- Produces bile
- Produces plasma proteins
- Produces cholesterol
- Converts glucose to glycogen
- Stores iron
- Converts ammonia to urea (one of the reasons that BUN levels can be elevated in the liver as well as
the kidney
- Clears drugs
- Blood clotting
- Normal portal venous pressure = 5-10 mm Hg (a relatively low pressure system)
Hepatitis
- Liver inflammation
- Types
o Viral (A, B, C, D, E, X?)
o Alcoholic hepatitis
o Drug-induced hepatitis
o Toxic hepatitis (carbon tetrachloride, benzene)
o Leptospirosis
o Toxoplasmosis
o EBV, CMV, HIV, HIV
Hepatitis A
- Caused by HAV (RNA virus)
- Fecal-oral route, close family contacts
- 9-45/100,000/yr
o Institutionalized children
o Daycare centers
o Male homosexuals
o Exposure to imported apes
o Undercooked mussels, clams, oysters
- Highly contagious
- Represents 33% of viral hepatitides in USA
- Clinical presentation
o Often asymptomatic (25% adults, 90% <2 y/o)
o Anorexia, malaise
o hepatomegaly (87%), RUQ tenderness
o splenomegaly rare (9%)
o Jaundice
o Dark urine (bilirubinuria)
o Fever variable (precedes jaundice)
- Workup
o LFTs (Liver Function Test)
o HAV antibody
- Laboratory tests
o ALT/AST (often > 8x normal)
o Bilirubin (usually 5-15x normal)
o Alkaline phosphatase (1-3x normal)
o Albumin, prothrombin normal
o WBC most often normal
o Hepatitis A IgM
- Imaging studies not normally useful
- No such thing as chronic hepatitis A it is an acute disease whose course rarely exceeds 8 weeks
- Acute disease lasting < 6 wks
- Rarely prolonged (3-5 mos), no carrier state
- Treatment
o Avoid hepatically metabolized drugs
o IV fluid replacement for vomiting (rare)
o Steroids not normally helpful
o Follow-up as outpatient
o Overall do not over tax the liver, no alcohol
- Px
o <0.1% fatality rate
o 60% w/ fulminant recover
o Evidence of previous disease in 40% of adults
Hepatitis B
- Acute viral hepatitis (a.k.a. serum hepatitis)
- Uncommon chronic form (5-10%)
- 4000-5000 deaths/yr from chronic HBV
- Incubation 30-180 days
- DNA virus
- 200-300k new acute cases/yr (300 deaths)
- At risk populations (blood transmission)
o IV drug users
o Homosexual males
o hemodialysis and hemophilic pts
o Health care workers
o Neonates/infants
- Treatment
o IV fluids for dehydration (increased vomiting over Hep A)
o Treat for hepatic failure, if present
o Avoid hepatically metabolized drugs (including alcohol)
o Steroids not helpful
o Interferon for chronic cases
o Antiviral agents
- famciclovir
- lamivudine
o Liver transplant
- Prevention
o Avoid high-risk behaviors
o Testing blood supply
o Hepatitis B vaccine
- High risk groups (90% effective)
- Childhood vaccination
- HBV hyperimmune globulin
o Given after needle stick
o Given after birth w/ infected mom
o Given after sexual exposure
Hepatitis C
- Viral infection of the liver with HCV
- Non-A, non-B RNA virus
- Intermediate incubation (15-150 days)
- Most common cause of non-alcoholic liver disease in US (40%)
- Epidemiology
o Transfused hemophiliacs
o IV drug users
o Occupational needle sticks
o hemodialysis
- Male = female
- 18-39 y/o mc
- Clinical presentation
- Gradual symptom onset
- Milder that HAV/HBV
- RUQ tenderness
- Hepatomegaly
- Jaundice
- Dark urine (bilirubinuria)
- Many are anicteric asymptomatic (75%)
- Male = female
- 18-39 y/o mc
- Clinical presentation
o Gradual symptom onset
o Milder that HAV/HBV
o RUQ tenderness
o Hepatomegaly
o Jaundice
o Dark urine (bilirubinuria)
o Many are anicteric asymptomatic (75%)
- Immunity after infection is incomplete
- Fulminant acute disease is rare (0.1%)
- Persistent infection is common (50-70%)
- Results in chronic hepatitis
- Cirrhosis develops in 20-50%
- Hepatocellular CA develops in 50%
- DDx (other inflammation hepatic diseases)
- Diagnostic workup
o Acute hepatitis c antibody
o LFTs
o Biopsy for complications
- Rx
o Avoid meds metabolized by liver
o Otherwise acute Rx is non-specific
o Follow-up for complications
o Interferon may be helpful in relapses
- Acute disease lasts <6 wks
- No vaccine
- Immune globulin injections are not helpful
Alcoholic Hepatitis
- Most common form of hepatitis
- Most common cause of cirrhosis
- SSx similar to other hepatitis x flu-like Sx
- Hepatomegaly
- Splenomegaly more common than viral
- Ascites
Hepatic Cirrhosis
- Clinical Presentation
o Early
- Weakness, fatigability, disturbed sleep
- Muscle cramps, weight loss
- Advanced
o Anorexia, weight loss
o N/V, hematemesis, due to esophageal varices
o Jaundice
o Hepatomegaly, ascites
o Amenorrhea, due to cholesterol production interference
o Impotence in men
- Skin lesions
o Spider nevi
o Palmar erythema(alcohol abuse)
o Glossitis, cheilitis
o Ecchymosis
- CNS damage
o Asterixis (intermittent lapse of body position)
o Tremor
o Delirium
o Dysarthria, slurred speech
o Coma
- Laboratory findings
o Macrocytic anemia
o Abnormal LFTs
o Decreased albumin
o Leukopenia
- Rx
o Avoid hepatotoxic meds
o Treat disease that caused cirrhosis
o Treat complications (ascites, varices, CHF))
- Laboratory tests
o Anti-mitochondrial antibodies (98% specific), almost pathognomonic for this disease
o Abnormal LFTs
- Rx
o Methotrexate, a commonly used chemotherapy agent, which helps control the over
growth of cell in the bile duct
o Colchicine
o Ursodiol
o Liver transplant
- Px-
o Asymptomatic- 10-16 yrs from time of diagnosis
o Symptomatic- 7 yrs from time of diagnosis
Hepatic Tumors
- Benign
o Hemangioma
- Most common benign liver tumor
- Vascular tumor
- Asymptomatic
- Found incidentally
o Adenoma
- Rare solitary or multiple tumor
- Usually asymptomatic
- Found in steroid abusers, OCA users
- Malignant
o Hepatocellular Carcinoma (old term Hepatomas)
o Cholangiocarcinoma
o Metastasis (Most common cause liver malignancy), colon cancer is the most common
malignancy which mets to the liver
Hepatocellular CA
- Malignant tumor of hepatocytes
- Associated with:
o Chronic liver disease
o Cirrhosis
o HBV, HCV
o Hepatotoxins(ETOH, steroids)
- Clinical presentation
o Weight loss, anorexia
o Ascites
o Hepatomegaly
o 33% are asymptomatic
- Diagnostic evaluation
o Elevated AFP in ~90% (alpha-fetoprotein – this protein non-specific)
o Elevated LFTs
o MRI
o Ultra Sound/CT-guided biopsy
- Treatment
o Dependent on size of lesion/mets
o Resection
o Chemotherapy
- Px is 20-30% following resection
Cholangiocarcinoma
- Intra-hepatic bile duct malignancy
- Rare in USA and Europe – more common in Asia
- Presents as a liver mass
- Associated with liver fluke infestation – more common in Asian culture
- Slow progression to metastasis
Gallbladder Diseases
Cholelithiasis
- Gallstones
- Affects 20,000,000 Americans
- Predisposing factors (Female, forty, fat, flatulence, fair skin)
o Fair skin
o Female
o Obesity
o ~40 y/o
o OCA use
o DM
- ~20% chance of developing biliary colic, passage of gallstones
- Pts are asymptomatic unless passing a stone
- S/sx
o Colicky RUQ pain
o Night pain
o Refers to right shoulder
o Lasts mins to hours depends on the amount of time is takes for the gallbladder to push the
stone through
- 75% of stones contain cholesterol
- Ultrasound is imaging procedure of choice
- Rx-cholecystectomy, ESWL, dissolution (substances which will dissolve gallstones)
- Px-good
- Diagnostic workup
o Ultrasound
o MRI/CT to rule out more ominous causes
- Treatment
o Laparoscopic cholecystectomy (lap chole)
o Open cholecystectomy
o Broad-spectrum antibiotics
- Prognosis
o Excellent
o 1% complication rate with lap chole
Cholangitis
- Inflammation of bile ducts
- Complication of cholelithiasis(~1%)
- Occurs during 7th decade and older
- Clinical presentation
o Charcot's Triad
- Fever/chills
- RUQ pain
- Jaundice
o Bilirubinuria
- All S/Sx present in 50-85% of pts
- Diagnostic workup
o Ultrasound
o ERCP endoscopic retro (if US is inconclusive)
- Treatment
o Biliary decompression
- ERCP (maybe w/ stent placement)
- percutaneous transhepatic biliary drainage
o Broad-spectrum antibiotics
- Prognosis is excellent
- Chronic disease associated w/ porcelain gallbladder, a premalignant condition
Gallbladder Cancer
Adenocarcinoma most common
- Asymptomatic unless disease is advanced
- Usually found during surgery for stones
Pancreatic Disease
- Acute pancreatitis
- Chronic pancreatitis
- Pancreatic Cancer
Acute Pancreatitis
- Most often secondary to biliary disease
- Enzymes released into pancreas
- S/Sx
o Severe abdominal/back pain
o Fetal position
o N/v
o Mild jaundice
o Shock – as a reaction to the pain
- Lipase and amylase levels increased
- CT/MRI for Dx
- Treatment
o IV hydration
o NPO
o NG suction
o Pain control
o Treat complications
- Prognosis
o 5-10% mortality associated with the shock
o Worse in older, sicker patients
Chronic Pancreatitis
- Recurrent pancreatitis
- Male: female = 5:1
- S/Sx
o Recurrent epigastric/back pain
o Abdominal tenderness/guarding
o Weight loss
o Foul-smelling stools, that are chalky white in color and float
- Associated with alcoholism/biliary disease
- Major DDx is pancreatic CA
- KUB may reveal calcifications
- 50% pts die w/in 10 yrs(malignancy)
Pancreatic Carcinoma
- adenocarcinoma
- 2nd mc tumor of GI system (colon cancer is #1)
- Male: Female = 2:1
- M/c in head of pancreas, carcinoma in the tail will not cause jaundice, because it does not block the
duct.
- S/Sx
o Jaundice
o Abdominal pain
o Weight loss, anorexia, nausea
o Biliary obstruction S/Sx(head tumor)
- CT/MRI are best imaging procedures
- Poor Px from early mets
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