Gastroenterology

Diagnostic Methods
Diagnostic Test
Measures
24 Hour 5Hydroxyindolacetic Acid
Breakdown product of
serotonin
Amylase
Digestive enzyme made

mostly by the pancreas
and salivary glands
Lipase
Digestive enzyme made mostly by

the pancreas that breaks down
triglycerides
Liver Function
Tests
Group of blood labs designed to

give infomration about the state
of the liver
Indications
Result
Carcinoid Syndrome
Test Interpretation
Parameters
Normal
2 - 9 mg
Carcinoid
Syndrome
50 - 500 mg
Acute pancreatitis
Pancreatic pseudocyst
Pancreatic cancer
Mumps
Salivary gland
inflammation
Perforated peptic ulcer
Pancreatic cancer
Acute pancreatitis
Moderately HIGH
Pancreatic disease
HIGH
Total protein
Albumin
ALT
AST
Alkaline phosphatase
Total bilirubin
Conjugated bilirubin
Moderately HIGH
HIGH
Cholangitis
Normal
Hepatitis
Pregnancy
Excessive IV fluid
Cirrhosis
Liver disease
Chronic alcoholism
Heart failure
Nephrotic syndrome
Burns
Dehydration
Waldenstrm's
macroglobulinemia
Multiple myeloma
Hyperglobulinemia
Granulomatous diseases
Some tropical disease
LOW
Total Serum
Protein
Total amount of protein

in the serum
Nutritional status
Liver function
HIGH
Normal
Albumin
Major protein
component of blood
Liver disease
Liver damage
LOW
Patient prep involves avoiding

serotonin-rich foods (bananas,
pineapples, avocados, mushrooms,
and walnuts)
Can be obtain through serum, urine,
pleural fluid, or peritoneal fluid
Pancreatic cancer
Mumps
Salivary gland
inflammation
Acute cholecystitis
Perforated peptic ulcer
Acute pancreatitis
Pancreatic cancer
Serum sample
Acute cholecystitis
Acute pancreatitis
HIGH
Serum protein disorders
Other
Hepatitis
Acute hepatocellular
dysfunction
Cirrhosis
The liver makes 12 g of albumin daily.

Serum prealbumin can be used as a
more sensitive test to assess rapid
liver damage (acute viral or toxic
etiologies)
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods
Diagnostic Test
Alanine
Aminotransferase
(ALT)
Measures
Test Interpretation
Result
Parameters
Normal
10 - 60 U/L
Indications
Moderately HIGH
Hepatocellular enzyme
Liver damage
Aspartate
Aminotransferase
(AST)
Acute cholecystitis
HIGH
MI
PE
Skeletal muscle trauma
Alcholoic cirrhosis
Viral hepatitis
Cirrhosis
Drug-induced hepatitis
Cell necrosis
Heart
Important enzyme in
amino acid metabolism
Effectiveness of the
extrinsic pathway of
coagulation
Hepatic
Function Panel
Group of assays
concerning the function
of the liver
-Glutamyltransferase
(GGT)
Moderately HIGH
HIGH
Prothrombin
Time
Alkaline
Phosphatase
(ALP)
Normal
Liver damage
Severe muscle injury
Hepatitis
Cirrhosis
Hemolysis
10 - 60 U/L
Liver inflammation
Liver
High Level of AST

Brain
Skeletal muscle
Moderate Level of AST
RBCs
Warfarin therapy
Liver disease
Vitamin K deficiency
Sodium
Chloride
Glucose
Creatinine
Albumin
Enzyme involved with the

transport of amino acids
into cells
Moderate ALT content in kidneys,

heart, and skeletal muscle
ALT is ubiquitous at lower
concentrations.
Some drugs and patient conditions

alter AST levels.
Hemolysis causes elevation due to
RBC contents.
Only a screening test of coagulation

Will not being to prolong until one of
the PT-based clotting factor
decreases to < 30 - 40% of normal
Potassium
Carbon dioxide
Urea
Calcium
Phosphorus
Normal
Enzyme at high levels in

rapidly dividing or
metabolically active cells
Acute cholecystitis
Other
Bile duct destruction
Liver disease
Cholestasis
Biliary obstruction
Liver damage
Hepatocellular disease
Hepatobillary disease
Biliary stasis
HIGH
HIGH
30 - 135 U/L
Active bone formation
Pregnancy
Some intestinal
disorders
Cirrhosis
Bile duct destruction
Alcohol-induced hepatic
changes
Hepatocellular disease
Hepatobillary disease
Hepatitis
(can be normal)
Cirrhosis
(can be normal)
Diagnostic Methods
Diagnostic Test
Measures
Indications
Result
Test Interpretation
Parameters
Not as subject to elevation from

drugs as ALP/GGT
If ALP but 5'-nucleotidase is
normal, look for a source outside the
liver (bone, kidney, or spleen)
ALP
5'-Nucleotidase
Hepatic enzyme
Cholestasis
Liver metastases
Normal
Moderately HIGH
Gallbladder disease
Other
Hepatocellular function
0.2 - 1.2 U/L

Acute cholecystitis
Choledocholithiasis
Production from
heme
Exposure to light may alter bilirubin

chemical and spectral properties
because of the formation of
photobilirubin
Defective heme removal
Total Bilirubin
Total amount of bilirubin

in the blood
HIGH
Degree of hemolytic
disease
Some hereditary disease
Gilbert syndrome
Neonatal jaundice
Severe Crigler-Najjar
syndrome
Alcoholic hepatitis
Infectious hepatitis
Autoimmune conditions
Intrahepatic obstruction
Extrahepatic obstruction
Conjugated
Bilirubin
Unconjugated
Bilirubin
Diagnostic
Peritoneal Lavage
> 50% of elevated total

bilirubin level is conjugated
< 15 - 20% of the total
bilirubin is unconjugated
Surgical diagnostic procedure
to determine if there is free
floating fluid in the
abdominal cavity
Intrahepatic cholestasis
Hepatocellular damage
Extrahepatic biliary
obstruction
Acclerated RBC
hemolysis
Total bilirubin
Using conjugated and unconjugated

bilirubin, you can differentiate
between hepatic disease and
hemolysis
Hepatitis
Drugs
Abdominal trauma
Intraperitoneal
hemorrhage
Ruptured intestine
Ruptured organs
Can test for cell counts and chemical

analysis
Diagnostic Methods
Diagnostic Test
Measures
Indications
Ascites
Paracentesis
Cell counts
Procedure to obtain
peritoneal fluid for
diagnosis or therapeutics
Cytology
Testing
Gram stain
Chemical testing
Non-Liver Targeting
Pathogens
Hepatitis
Inflammation / infection
of the liver
Liver Targeting
Pathogens
Test Interpretation
Parameters
WBC
Bacterial
Neutrophils
Peritonitis
(+) Culture
Pancreatic Ascites
Amylase
Malignant
Blood fluid
Peritonitis
(nontraumatic tap)
Cirrhosis
CHF
HIGH SAAG
Alcoholic hepatitis
( 1.1)
Myxedema
Portal vein thrombosis
Bacterial peritonitis
Malignancy
LOW SAAG
Nephrotic syndrome
(< 1.1)
Pancreatitis
TB
Peritonitis
WBC
Normal or low
AST
Striking
ALT
Striking
Follows AST and ALT
Total Bilirubin
elevations
Alkaline
Parallels bilirubin
Phosphatase
Result
Epstein-Barr virus
Cyctomegalovirus
Herpes simplex virus
Yellow fever
Mumps
Rubella
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Hepatitis G
Antigens and
Antibodies
Urine
IgM
Anti-HAV
Antibody against HAVAg
Hepatitis A
Traveling to endemic
areas
IgG
Other
Pathogen-specific
Mild proteinuria
Bilirubinuria
Acute infection
Previous exposure
Noninfectivity
Immunity
Total anti-HAV may be used to screen

people at risk who may need
vaccination
Diagnostic Methods
Diagnostic Test
Measures
HBsAg
Outer surface coat

antigen
Indications
Hepatitis B
Anti-HBs
Antibodies against HBsAg
Anti-HBc
Antibodies against the

core antigen C
HBeAg
Anti-HBe
Secretory form of HBcAg
HBV DNA
Pieces of DNA from

hepatitis B
Hepatitis B
Hepatitis B
Antibody for HBeAg

Hepatitis B
Test Interpretation
Parameters
First evidence of
infection
POSITIVE
Infection with HBV
Implies infectivity
Recovery from HBV
infection
POSITIVE
Noninfectivity
Vaccination
Immunity
Appears soon after
HBsAg but before
IgM
anti-HBs
Acute hepatitis B
Persists 3 - 6 months
Persists beyond IgM
IgG
Immunity
Viral replication
POSITIVE
Infectivity
Less viral replication
POSITIVE
Less infectivity
Result
LOW
Post-recovery from
acute hepatitis B in
serum and liver
Frequent cause of
cyroglobulinemia
HCV RNA
Anti-HCV RIBA
Antibody Levels
Hepatitis D
Requires coinfection with

hepatitis B
Hepatitis E
Generally benign and selflimiting
Acute Hepatitis
Panel
Assessment of a patient with

acute hepatitis symptoms
Persists throughout clinical illness
Parallels HBeAg
More sensitive and precise marker of
viral replication and infectivity
Often silently progressive
Anti-HCV by ELISA
Hepatitis C
Other
Diagnostic
Rise slowly
Anti-HDV
Worsening hepatitis B
POSITIVE
Risk for liver cancer

HDV RNA
Acute hepatitis after

travel to endemic area
Pregnancy
(10 - 20% mortality rate)
Anti-HEV
POSITIVE
More severe in patients with underlying chronic

liver disease
Hep C virus antibody
Hep B core IgM antibody
Hep B surface antigen
Hepatitis A IgM antibody
Diagnostic Methods
Diagnostic Test
Measures
Radiograph
Use of X-rays to view a nonuniformly composed object
Fluoroscopy with
Barium
Use of X-rays to obtain realtime moving images of

internal structures
Gastrointestinal
Endoscopy
Direct visualization of the

GI tract
Indications
Calcifications
Foreign bodies
Free air
Obstruction
Transit times
Mucosal abnormalities
Need to biopsy lesions
Any GI disease
Risks
Dysphagia
Refractory GERD
PUD
Esophagogastroduodenenoscopy
Direct visualization of
esophagus, stomach, and
duodenum
Result
Malabsorption
Dilation of esophageal
strictures
Removal of polyps /
neoplasms
Test Interpretation
Parameters
Other
Enteroscopy
"Push" endoscopy of small bowel
Perforation
Bleeding
Infection
Cardiopulmonary
complications 2 to
sedation
Death
Odynophagia
Screening for Barrett's
esophagus
Upper GI bleeding
Treatment of varices /
bleeding
Rupture of esophageal
webs
Stent placement
Radiofrequency ablation
Flexible
Sigmoidoscopy
Visualization descending
colon, sigmoid colon, and
rectum
Colonoscopy
Visualization of entire colon

and portion of terminal ileum
Inflammatory diarrhea
Need a view of the distal

colon only
Colorectal cancer
screening
Anemia evaluation
Bleeding
Assesment of IBD
Requires sedation
Diagnostic Methods
Diagnostic Test
Measures
Indications
Pancreatic cancer
Endoscopic
Retrograde
Cholangiopancreatography
Combines the use of

endoscopy and fluoroscopy
to diagnose and treat certain
biliary and pancreatic ductal
diseases
Endoscopic
Ultrasound
Ultrasound on an
endoscope
Video Capsule
Endoscopy
Pill-sized cameras travel

the GI tract and capture
video
Allow visualization of entire

small bowel in most patients
High-Resolution
Endoscopy
Magnifiable endoscopy
Chromoendoscopy
Dyes / stains applied to tissue to

enhance location and diagnosis of
lesions
Narrow Band
Imaging
Enhances mucosal
morphology and vascularity
Test Interpretation
Parameters
Other
Choledocholithiasis
Malignant and benign

Sphincter of Oddi
biliary strictures
dysfunction
Recurrent acute /
Pancreatic malignancies
chronic pancreatitis
Ampullary adenomas
Stone extraction
Sphincterotomy
Stent placement
Stricture dilation
Drain fluid
Biopsy
Staging of rectal,
esophageal, and gastric
tumors
Identification of
pancreatic tumors
Aspiration biopsies
Tumors
Obscure bleeding
Survey in polyposis
syndromes
Refractory
malabsorption
syndromes
Gold-standard for visualizing small

bowel
Avoid in patients with GI distress,
fistulas, pregnancy, or swallowing
disorders
Uncertain diagnosis of Crohn's disease

Screening
Double Balloon
Endoscopy
Result
Varices
GERD complications
Esophagitis
Allows procedures (when compared to VCE)
Flat lesions
Requires general anesthesia (can take

3 hours)
Two balloons are attached to distal
end of the enteroscope
Barrett's esophagus
Occult lesions
Neoplasia
Adenoma
Diagnostic Methods
Diagnostic Test
Measures
Autofluorescence
Uses short light wave source

to exploit natural tissue
fluorescence
Transabdominal
Ultrasound
Radionuclide
Imaging
Cholescintigraphy
Ultrasound through the

abdominal wall
Biliary disease
Cystic duct obstruction by gall stone
Strong magnetic fields and

radiowaves are used to form
images of the body
Use of contrast to
distend small bowel
Computer-assisted high-resolution
two-dimensional image of abdomen /
pelvis generated by spiral CT
Histologic analysis of
hepatic tissue
Other
Pediatric appendicitis
Use of Tc-iminodiacetic acid

(IDA) to visualize the
gallbladder
Magnetic Resonance
Imaging
Test Interpretation
Parameters
Liver disease
Gastrointestinal bleed
Computer-processed x-rays
produce tomographic images
of specific areas in an object
Liver Biopsy
Result
Tagged (technitum-99m) red

blood cells to detect obscure
bleeding
Computerized
Topography
CT / MR
Enterography
Virtual
Colonoscopy
Indications
Trauma
Infectious /
inflammatory lesions
Obstruction
Unexplained pain
Pancreatitis
Liver malignancies
Pancreas malignancies
Liver lesions
Biliary tract lesions
Mucosal abnormalities
Colon cancer screening
Abnormal LFTs
Suspected neoplasm
Confirmation of
diagnosis /
prognostication
Evaluation of
granulomatous disease
Unexplained jaundice or
suspected drug reaction
Management of posttransplantation care
Low specificity and sensitivity (but

being constantly improved)
Requires prep and rectal tube
Contraindications
PT
Thrombocytopenia
Ascites
Difficult body habitus
Suspected hemangioma
Complications
RUQ, brief pain
Bleeding
Biliary peritonitis
Bacteremia
Diagnostic Methods
Diagnostic Test
Measures
Fecal Occult
Blood Testing
Qualitiative method of
determine the presence
of blood in stool
Hemoccult Sensa
Screening
Part of the screening for

colon cancer
Hemoccult
Sensa Testing
Method for detecting

non-visible blood in stool
Indications
Cancer
Test Interpretation
Parameters
GI bleeding
Requires 3 serial stools

Avoid NSAIDs or aspirin prior to or
during specimen collection
False Positives
Red meats
Aspirin
NSAIDs
Alcohol in excess
Other drugs
Iodine preparation
False Negatives
Ascorbic acid
Citrus fruit / juice
> 250 mg/day
intake
Iron supplements
Microorganism
overgrowth
Other
The oxidation of guaiac by hydrogen
perioxide causes blue color when
exposed to "heme" found in stool
Sensa FOBT
Enhancer that allows greater
sensitivity and ease of interpretation
Risk of colon cancer
Bowel infection
Fecal
Leukocytes
Result
Specimens innoculated onto card 3

days (ideally) prior to development
For immediate results, wait at least 3 5 minutes before development
NEGATIVE
WBCs in stool
Variable
Inflammatory bowel disorders

POSITIVE
Norovirus
Rotavirus
CMV*
ETEC
EHEC
Giardia lamblia
Entamoeba histolytica*
Crytosporidium
S. aureus
C. perfringens
Salmonella
Yersinia
Vibrio parahemo.
C. difficile
Aeromonas
Shigella
Camplyobacter
EIEC
Ulceraive colitis
Crohn's disease
Radiation colitis
Ischemic colitis
Bacterial stool culture re not

routinely gram stained due to futility.
Entamoeba histolytica causes
attacking WBC rupture, and fecal
leukocytes may not be seen.
Diagnostic Methods
Diagnostic Test
Measures
Clostridium
Difficile Toxin
Predominant causative
enterotoxin for
pseudomembranous colitis
Tissue Culture
Gold-standard test for

C. difficile infection
Indications
Result
Identification of bacteria
in stool
Other
93 - 100% specific
Diarrhea
Recent antibiotic use
ELISA
63 - 99% specific
Rarely performed
Pseudomemberanous colitis
Salmonella
Bacterial Stool
Cultures
Test Interpretation
Parameters
Fresh stool to lab < 2

hours
Shigella
Acceptable
Campylobacter
Require a Special
Request for
Indentification
Vibrio
Aeromonas
Yersinia
E. coli O157:H7
Animal contact
Children at daycare
Fecal Acid-Fast
Stain
Acid-fast stain of stool
IFA Indirect ImmunoFluorescence Assay
Use of fluorescent monoclonal

antibodies to identify
microorganisms
Giardia lamblia
H. Pylori Serologic
Enzyme-Linked
Immunoassay
Detects either IgG or IgA to

Helicobacter pylori
Active / past H. pylori

infection
Urea Breath
Test
Radioactively labeled CO2 (by

ingesting radioactive 13C urea) is
exhaled and detected
H. pylori infection
Rotavirus EIA
Detection of rotavirus
Gastroenteritis
Norovirus PCR
Detection of norovirus that is

only performed for
epidemiologic reasons
Immunocompromised
Preserved in Cary-Blair
medium < 96 hours
Rejected
Hospitalized > 3 days
"Ghost" Cells
Cyclospora oocytes
Cryptosporidium parvum Cyclospora cayetanensis

Superior sensitivity and equal
specificity to O&P if performed < 1
hour
Cryptosporidium parvum
Antibodies can persist for years

50% of adults > 60 years old are
positive
Gastritis
Peptic ulcers
Excellent sensitivity and specificity

Non-invasive test of choice to
document successful treatment of H.
pylori
Sensitivity
93%
Specificity
96%
Nursing homes
Long-term care facilities
Cruise ships
Diagnostic Methods
Diagnostic Test
Fecal Fat
Measures
Measures amount of fat

present in stools
Indications
Malabsorption disorders
Celiac / tropical sprue
Whipple's disease
Zolinger-Ellison
syndrome
Crohn's disease
Result
Test Interpretation
Parameters
Other
Quantitative Stool Fat Test
Gold-standard
Fat diet for 2 days before and
during collection
Qualitative Stool Fat Test
Sudan stain of stool sample and
microscopic evaluation
Clinical Medicine
Condition / Disease
Functional
Abdominal
Disorders
Cause
Common GI disorders
without discernable
cause
Signs and Symptoms

Atypical chest pain
Any disease of the

gastrointestinal system
Laboratory
Result
Treatment
Medications
Altered Bowel Habits

Nausea vomiting
Pyrosis
Odynophagia
Jaundice
IBS
Dyspepsia
Diverticulitis
Diarrhea
Constipation
Bleeding
Dysphagia
Early satiety
Anorectal symptoms
Visceral Abdominal Pain
Poorly localized
Produced by dermatome
Somatic Abdominal Pain
Well localized
Initiated by pain receptors in parietal
peritoneum
Referred Abdominal Pain
Poorly localized
Felt in areas that may be remote
from disease site
Acute Etiologies
Abdominal
Pain
Pain as a result from

complex interaction of
sensory receptors in the
GI tract, spinal cord
nuclei, and CNS
Acute pancreatitis
Acute appendicities
Intestinal ischemia
Bowel obstruction
Incarcerated hernia
Acute cholecystitis
Diverticulitis
PUD
Infectious diarrhea
Gynecological causes
Chronic Etiologies
GERD
IBS
Chronic pancreatitis
Other
Causes
Altered gut motility
Exaggerated visceral responses to
noxious stimuli
Altered processing of visceral stimuli
Diagnoses of exclusion
Dyspepsia
Abdominal Pain
Gastrointestinal
Disease
Test
Non-ulcer dyspepsia
IBD
Infectious diarrhea
Only patients with chronic symptoms
require management
Dyspepsia
Diverticular
Disease
Diverticulitis
Constipation
Painful, difficult, or
disturbed digestion
Group of disease that are

characterized by pouch
formation in the weak spots
in the colonic wall
Inflammation of colonic
diverticula
Functional defecation
disorder due to slowed
transit through the colon,
obstruction, or irritable
bowel syndrome
Pain
Discomfort
Diverticulosis
Diverticulitis
LLQ pain
palpable mass
Suprapubic pain
"Left-sided" appendicitis
May present as an acute

GI bleed
Malaise
Diarrhea
Vomiting
Urinary frequency
Difficult-to-pass stools
Fever
Constipation
Nausea
Dysuria
Infrequent stools
Sense of incomplete
Abdominal distention
evacuation
Bloating
Pain
Etiologies
Functional
Drugs
Endocrine / metabolic
Neurologic
Structural lesions
Endoscopy
> 55 years old OR

alarm symptoms
Non-Endoscopic
Indicated Patients
Test and treat for

H. pylori
Initiate trial of PPI
Risk Factors
Low fiber diet
Red meat
Obesity
Age
CBC
CT
X-Ray
CBC
TSH
BMP
Colon Transit
Study
Anorectal
Manometry
Colonoscopy
Leukocytosis with
left shift
Gold-standard
Assess disease
severity
Free air
Ileus
Obstruction
Evaluation
Clear liquids
7 - 10 days of antibotics
Close follow-up
Surgical consult
(if not improved in 72 hours)
R/O Underlying causes
Laxatives
Medical therapy
Fiber diet ( 30 g / day)
Adequate hydration
Regular exercise
Bowel training
Digital disimpaction
Ciprofloxacin +
Metronidazole
Co-morbidities increase the

likelihood of severity.
Complications
Bleeding
Intra-abdominal abscesses
Fistulas
Obstruction
Rome Criteria (> of defecations)

Straining
Lumpy or hard stools
Sense of incomplete evacuation
Sense of anorectal obstruction
Manual maneuvers
Prokinetic Agents
And/or < 3 defecations and no loose
stools
Lubiprostone
Clinical Medicine
Condition / Disease
Nausea and
Vomiting
Cause
Sensation and action of

ejecting stomach
contents
Dysphagia
Difficult swallowing
Odynophagia
Painful swallowing due to

the inflammation of
esophageal mucosa
Pyrosis
Exposure of esophageal
epithelium to gastric acid
causes a burning
sensation
Signs and Symptoms
Test
Laboratory
Result
Treatment
Medications
Other
Acute Etiologies
Appendicitis
Cholecystitis
Pancreatitis
Peritonitis
Small or large bowel obstruction
Chronic Etiologies
Esophageal disorders
Gastric malignancy
PUD
Difficulty swallowing
Motility Disorders
both liquids and solids
Difficulty swallowing
Mechanical Disorders
solids
Etiologies
Pill-induced esophagitis
AIDS
Infection
Immunosuppressive
disease
Ingestion of caustic substances
Doxycycline
Medications
Tetracycline
Etiology can be outside the GI tract.
EGD
Early Satiety
Pruritus Ani
Decreased appetite
Irritation of the skin at

the exit of the rectum
Heartburn
Malignancy (especially in older patients)

Delayed gastric
emptying
Gastric outlet
obstruction caused by
Non-Malignant
PUD
Etiologies
Adhesions of small
bowel obstruction
Small bowel obstruction
of Crohn's disease
Systemic Illness
Diabetes
Malignancies
Thyroid disease
Mechanical Triggers / Irritants
Diarrhea / constipation
Soaps
Anorectal lesions
Wipes
Tight-fitting clothes
Over-cleansing
Dermatologic Conditions
Atopic dermatitis
Lichen planus
Psoriasis
Infections
Intertrigo
HPV / HSV
Scabies
Pinworms
Barium
Studies
Esophageal
Manometry
24 Hour
Esophageal
Probes
Diagnostic
Tomatoes, citrus foods and

beverages, and caffienated drinks can
cause pruritus ani.
Exquisite hygiene
Xylocaine
Remove offending agents
Mild topical steroids
(1% hydrocortisone)
Antihistamines
Pramoxine
Antipruritics
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Tenderness
Anal Fissure
Split, tear, or erosion in

the epithelium of anal
canal
Venous edema in the

anus that breaches the
anal wall
External
Hemorrhoid
Increased venous pressure

within the external
hemorrhoidal veins
Diarrhea
Reversal of the normal

net absorptive status of
water and electrolytes
that results in water
secretion into the gut and
enhanced anion
secretion from
enterocytes
Infectious
Diarrhea
Diarrhea caused by a
pathogen
Pain
Large or hard-to-pass
stools
Trauma (rarely)
Painless bleeding after defectation
Visible with anoscopy

Rarely bleed
Inflammation of the
gastrointestinal tract due
to viral infection
Painful
Readily seen on perianal exam

Usually self-limited and last less than one day
Monitor Symptoms For
Severe abdominal pain
Hopsitalized patients /
recent antibiotic use
Systemic illness with

diarrhea (especially in
pregnant)
Bloody Diarrhea (MESSY CACA)
Medical disease
E. coli
Shigella
Salmonella
Yersinia
Campylobacter
Amoeba
C. difficile
(E. histolytica)
Aeromonas
Watery Diarrhea
Rotavirus
Viral
Norovirus
Adenovirus
S. aureus
Bacterial
B. cereus
Vibrio
Giardia
Parastic
Cryptosporidia
E. histolytica
In elderly (> 70 years

old) or in I-C patients
Noroviruses / Norwalk
Virus
Rotaviruses
Adenovirus
Stool Anion
Gap
Dehydration
Duration
Inflammation
Warning Signs
Diarrhea
Viral
Gastroenteritis
Laboratory
Result
Bleed easily
Etiologies
Internal
Hemorrhoid
Test
Abdominal pain
Familial outbreaks
Nursing homes
Cruise ships
Highly contagious
Vaccine available
Year-round
Stool Studies
Indications
Fecal
Leukocytes in
Inflam.
Diarrhea
< 50
(secretory)
> 125
(osmotic)
Persistent or
recurring
History of fever or
tenesmus
Other warning
signs exist
Treatment
BRAT Diet
73% sensitive
84% specificity
Medications
Stool softeners
Protective ointments
Sitz baths
Topical steroids
Nitroglycerin 2% ointment
Botulinum toxin
Surgical referral
(if fissure fails to heal)
Pain treatment
Topical steroids
Rubber band
ligation
For Prolapse
Infrared
coagulation
Sitz baths
Topical steroids
Stool softeners
Removal of clot (if thrombosed)
3.5 g NaCl
1.5 g KCl
20 g glucose
Oral Rehydration
Solution
Optional 2.5 g
sodium bicarb
1 L water
Bananas
Rice
Applesause
Toast
Other
Posterior anal fissures are the more
common form, followed by anterior.
Recovery is often prolonged

compared to internal hemorrhoids.
2 million deaths / year worldwide

Loperamide
Bismuth
Subsalicylate
Lomotil
Avoid milk products
Diarrheal medications
(except with Shigella, C. difficilie, and
E. coli O157)
Enteropathogens Tracked by CDC

E. coli
Salmonella
Shigella
Y. enterocolitica, Vibro histolytica /
cholera, Listeria, Cyclospora
Campylobacter
Cryptosporidium
Antibiotic therapy
Transmission
Fecal-oral
Person-to-person
Contaminated foods
Most common in the US during the
winter months
Clinical Medicine
Condition / Disease
Giardia
Lamblia
Entamoeba
Histolytica
Cause
Flagellated protozoa
associated water
transmission in
contaminated streams, day
care centers, or well water
Infectious diarrhea that does

not usually affect normal
hosts
Vibrio
Parahaemolyticus
Gram negative rods
Vibrio Cholera
Gram negative rod that

activates adenylate cyclase
enzyme in intestinal cells
E. Coli
O157:H7
Gram negative rod that is

tranmitted through
undercooked beef,
unpasteurized juices (apple
ciders), or spinach
Traveler's
Diarrhea
Microbial contamination of
food and water usually by
enter-toxigenic E. coli
Samonella
Typhi
Shigella
Test
Laboratory
Result
Foul-smelling watery
diarrhea

one of the most common
causes of infectious
diarrhea
Gram negative rod that

causes typhoid fever
Cyclospora
Isospora
Cryptosporidium
Microsporidia
Watery diarrhea
Abdominal cramping
Symptoms no more than 3 days after seafood or
contaminated water ingestion
Wound infection
Abdominal cramping
Rice-water stools
Hypotension
(< 2 hours due to severe diarrhea)
Mild or severe
Hemorrhagic colitis
symptoms
Treatment
Medications
50% rate of spontaneous resolution
HIV with CD4

Count
POSITIVE
Metronidazole treatment
More common in tropical and
subtropical regions
Metronidazole treatment
(even if asymptomatic)
Albendazole
< 100
Antiprotozoal treatment
No fever (usually)
Hemolytic Uremic Syndrome
Microangiopathic
Acute renal failure
hemolytic anemia
Thrombocytopenia
Watery diarrhea
History of travel in
less-developed areas
Diarrhea
(maybe bloody)
Abdominal cramping
Fever
Myalgia
Headache
Septicemia / bacteremia
(2 - 14%)
Osteomyelitis
(10%)
Endocarditis
(10%)
Pulse-temperature
discordance
Fever
Arthritis
(10%)
10 - 14 days after
ingestion
Headaches
Myalgia
Malaise
No treatment necessary
Deoxycycline
Antibiotics (if required)
Floroquinolone
Oral rehydration solution
Gram negative rod

associated with day
cares, nurseries, and longterm care
Diarrhea
Fever
Bloody, purulent stools
Tenesmus
1 - 3 days after ingestion

Usually self-limited to < 7 days
Patients with liver disease and iron

overload states are more
susceptible.
12 - 24 hour incubation
50% mortality if untreated
Toxins have a dose effect.
Single-dose fluoroquinilone /
doxycycline
Incubation is dependent on whether
the organism is toxin-producing or
not.
Associated with warm weather
20,000 cases / year in US
No anti-motility medications
Supportative care
Antibiotics are not beneficial
Antibiotic therapy
(may decrease the duration of illness)
Cirpofloxacin
Rifaximin
Associations
Incidence is higher in children < 5
years old and adults > 60 years old.
Diseases is worse in old, young, and
immunosuppressed.
Ciprofloxacin (in severe cases)
Ciprofloxacin for 10 days
Anorexia
Lower abdominal
cramps
Many of these organisms are present

in the environment and water supply.
TMP / SMX
Bloody diarrhea
Other
20,000 cases / year in US
Nausea
Cramps
Flatulence
Giardia
Life Cycles
Antigen Stool
Cysts are ingested
Testing
Gastric acid releases trophozoites into duodenum
and jejunum
Attachment to villi
Abdominal pain
Cramping
Anaerobic parastic protozoan that
Diarrhea
Colitis
causes necrosis of the large
(may be bloody)
intestine
Travelers
Homosexual
Parastic Diarrhea in the

Immunocompromised
Salmonella
Signs and Symptoms
Floroquinolone
Vaccine for travelers

Asymptomatic carrier state is
possible.
Bacteria will pass through cells lining
the small intesting and go to liver,
spleen, and bone marrow.
Children are prone to infection.
Antibiotic therapy
TMP/SMX
Clinical Medicine
Condition / Disease
Yersinia
Enterocolitica
Cause
Gram negative rod

acquired after ingestion
of contaminated food
(pork) or water
Signs and Symptoms

a very common cause of
infectious diarrhea
Clostridium
Difficile
Spore-forming, Gram positive

rods that are the most
common cause of
nosocomial diarrhea
Fever
Symptoms for
Abdominal pain
1 - 2 weeks
Chronic form can
Can mimic
last months
Crohn's disease
Lymphadenopathy
Bacteremia
Transmission
Gram positive cocci
Bacillus Cereus
Gram positive rods
Clostridium
Perfringens
Gram positive rods
Antibiotic-Induced
Intestinal metaplasia of
the esophagus
Medications
Clindamycin
Fluoroquinolones
PCN
Cephalosporins
Other
Systemic disease with high mortality.
No treatment is indicated
Doxycycline
Antibiotic treatment (if severly ill)
Azithromycin
Antibiotic treatment
Contaminated food,
water, or milk
Animal contact
( from chickens)
Associations
Guillain-Barre Syndrome
(ascending paralysis)
Reactive arthritis
Up to 1 week incubation period
Fluoroquinolone
75% sensitivity
EIA Testing for Need 3 (-) tests to
Toxins A and B
rule out
Highly specific
> 99% sensitivity
PCR
Highly specific
Flagyl
Alcohol foam does not kill the spores.

Oral vancomycin
(severe disease or refractory)
Fidaxomicin
Symptoms < 4 hours
Food contact with

infected skin or human
carrier
Transmission
Potato salad
Meats
Custard-filled pastries
Ice cream
1 - 6 hour incubation
(emetic form)
Pre-formed toxin
> 6 hour incubation
(diarrheal illness)
Fried rice
Transmission
Meats
Sauces
Abdominal cramping
Watery diarrhea
No fever, nausea, or
Symptoms last
vomiting
< 24 hours
Pigbell (rare)
Meats
Transmission
Poultry
Reflux
Barrett's
Esophagus
Treatment
Self-limiting but may last

> 1 week
Diarrhea from hell
Pre-formed toxin
Staphococcus
Aureus
Laboratory
Result
Diarrhea
Dysentery
Campylobacter
Jejuni
Test
Refrigeration prevents germination

of spores.
Heat Labile
Toxin
POSITIVE
55 years old
(at diagnosis)
Pathogenesis
Chronic gastroesophageal reflux
Reflux esophagitis
Squamous epithelial injury
Intestinal metaplasia
Screening and surveillance

Endoscopic
Biospy
Diagnostic
2:1
Whites > hispanics
Endoscopic ablation therapy

Esophagectomy
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Regurgitation
Heatburn
(30 - 60 minutes after
meals)
Sour brash
Dysphagia
Gastroesophageal
Reflux Disease
Chronic symptom of
mucosal damage caused
by stomach acid coming
up from the stomach into
the esophagus
Extraesophageal / Atypical Symptoms

Asthma
Cough
Non-cardiac chest pain
Laryngitis
Hoarseness
Loss of dental enamel
Laboratory
Treatment
Result
Type and extent of
PPI (empirical)
tissue damage
Upper
Normal in cases
Endoscopy
Does not detect Lifestyle modifications
mild disease
Detects strictures,
Prokinetics
ulceration, and
H2RA
Barium
abnormal folds
Medical
Antacids
Radiography Reveals abnormal
Treatment
Mucosal
motility or
protectants
clearance
TLESR inhibitors
Ambulatory Detects pathologic
pH Testing
acid reflux
Nissen fundoplication
Test
Complicated Disease / Alarm Symptoms
Infectious
Esophagitis
Inflammation of the
esophagus due to
infection
Schatzki's Ring
Narrowing of the lower

part of the esophagus
Weight loss
Hematemesis
Melena
Thin membranes in the

esophagus
Zenker's
Diverticulum
Outpouching of the
upper esophagus
Symptoms > 10
years
Barrett's
Screening EGD
Age > 50
White
Common Etiologies
Candida
CMV
Herpes simplex
HIV idiopathic ulceration
Odynophagia
Dysphagia
EGD with
Biopsies
Diagnostic
Chest pain
Internal diameter < 13 mm
Recurs in 60 - 90% of patients 3 - 6

years after dilation
Dilation
GERD symptoms
PPIs
Cervical web
Dysphagia
Iron-deficient anemia
Etiologies
Congenital
Bullous pephigoid
Epidermolysis bullosa
Pemphigus vulgaris
Post-Barrett's ablation
GVHD
Post-perforation
Post-surgical
Regurgitation
Dysphagia
Halitosis
> 60 years old
Narrowing of the esophagus as a

result of healing ulcerative
esophagitis
Eosinophilic infiltration of
the esophagus from
allergic or idiopathic
etiology
Correct iron-deficiency anemia
Involves the posterior wall of the pharynx

Usually contiguous with the gastroesophageal
junction
Reflux esophagitis
(8 - 20%)
Dysphagia
Eosinophilic
Esophagitis
Manometry
Other
Symptom onset in ages > 50 warrants
further investigation
Etiologies
Incompetent lower esophageal
sphincter
TLESR
Irritant effects of refluxate
Delayed gastric emptying
Abnormal esophageal clearance
Scleroderma
Plummer-Vinson
Syndrome
Esophageal
Web
Peptic Strictures
Dysphagia
Function of
esophageal
muscle
contractions and
esophageal
sphincters
Medications
Food impaction
"Reflux"
Strictures
Mucosal rings
Linear furrowing
Ulceration
"Feline" esophagus
Eosinophilic abscess
Esophageal polyps
Barium
Swallow
Abnormal
Acid suppression
PPIs
Dilation
H2RA
PPIs
Swallowed fluticasone
Leukotriene inhibitors
Mast cell inhibitors / antihistamines
Histology
Endoscopic dilation
> 15 eosinophils
Elimination diets
/ HPF
Viscous budesonide suspension
Systemic steroids
Associations
Asthma
Allergic rhinitis
Urticaria
Hay fever
Atopic dermatitis
Food allergy
Medicine allergy
Higher concern for perforation with
dilation
Clinical Medicine
Condition / Disease
Achalasia
Cause
Signs and Symptoms
Gradual, progressive
dysphagia
Disease of unknown etiology
Ages 25 - 60
characterized by the absence of
Weight loss
esophageal smooth muscle
Substernal discomfort /
peristalsis with increased tonus of
fullness after eating
the lower esophageal sphincter
Regurgitation of
undigested foods
Symptoms are chronic
Chest pain
Poor esophageal
emptying
Test
Laboratory
Result
Only method
conclusively for
diagnosis
Manometry
Nocturnal regurgitation
Anterior chest pain
Diffuse
Esophageal
Spasm
Simultaneous,
nonperistaltic
contractions of the
esophagus
Nutcracker
Esophagus
Esophageal movement disorder

characterized by peristaltic waves of
abnormally high amplitude
Scleroderma
Esophagus
Atrophy and fibrosis of the

esophageal smooth muscle
common in patients with
progressive systemic
sclerosis, Raynaud's
phenomena, or CREST
Esophageal
Cancer
Intermittent dysphagia
Barisum
Esophagography
Provoked by stress, large food boluses,

or hot or cold liquids
Manometry
Chest pain
Manometry
Severe acid reflux
Dysphagia
Manometry
Strictures
Erosion
Barium
Swallow
Progressive solid food

dysphagia
Weight loss
50 - 70 years old
Most present in late

stages
Neoplasm of the
esophagus
Hoarsness
Surgery
Polypoid,
infiltrative, or
ulcerative lesion
Radiation
Nitrates
CCBs
Most common connective tissue

disorder involving the esophagus.
Cisplatin / 5 FU
Assessment
Staging
20 - 50% 5-year
survival
Unresectable
disease for
palliation
Cisplatin / 5 FU
21% 5-year
survival
Pneumonia
Malnutrition
Botox
Markedly dilated,
flaccid esophagus
Local tumor extension into the traceo-bronchial

tree
Endoscopic
Ultrasound
Nitrates
Low amplitude
Botulinum toxin injection
waves
Simultaneous cork
screw
contractions
"Rosary bead"
appearance
Intermittent,
Symptom reduction and reassurance
simultaneous
contractions of
high amplitdue
along with periods
of normal
peristalsis
Intermittent high
pressure
Strong
contractions
or absent LES
pressure
Markedly
diminished
Lung or bony
metastases
Chest CT
Other
Nifedipine
Pneumatic dilation
Complete absence
of peristalsis
Surigcal myotomy
Mediastinal
widening
Barium
Esophogram
Medications
Medical treatment
CXR
Complications
Chest / back pain
Treatment
Endoscopic
Treatment
Life expectancy
to 33 weeks from
27 weeks
Stenting for
palliation
Photodynamic
therapy
ChemoRad
Staging
Tis - Carcinoma in situ
T1 - Invades lamina propria or
submucosa
T2 - Invades muscularis propria
T3 - Invades adventitia
T4 - Invades adjacent structures
Nx - Cannot be assessed
N0 - No regional nodal metastases
N1 - Regional nodal metastases
M0 - No distant metastases
M1 - Distant metastases
Stage Groupings
I - T1 N0 M0
IIA - T2-3 N0 M0
IIB - T1-2 N1 M0
III - T3 N1 M0, T4 any N M0
IV - Any T Any N M1
IVA - Any T Any N M1a
IVB - Any T Any N M1b
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Test
Laboratory
Result
Bloody emesis
Hematemesis
Intraluminal blood loss

anywhere from the
oropharynx to anus
Coffee Ground Emesis
Old blood from stomach
Hematochezia
Red blood stool

Bright red blood per
rectum
Hematocrit
Stabilize patient
Correlates with
severity of bleed
at initial
evaluation
Determine Source
of Bleeding
Medications
EGD
Colonoscopy
NG lavage
Radionuclide
imaging
Angiography
May take 2 days to

reflect the extent Treat underlying source
of bleeding
Prevent re-bleeding
Dark tarry stools
Gastrointestinal
Bleeding
Melena
Foul, unforgettable smell
Upper GI Bleed
Above the ligament of Treitz
Lower GI Bleed
Below the ligament of Treitz
Gastrointestinal
Ulcers
Sign of upper GI bleeding
Treatment
Discontinuity or break in
the epithelium of the GI
tract
Resting tachycardia
(10% volume loss)
Orthostasis
(10 - 20% volume loss)
Shock
(20 - 40% volume loss)
NSAIDs
Steriods in the setting of
NSAIDs
Associated Medications
Warfarin
Heparin
Plavix
Pradaxa
Bleeding
(erosion into a vessel)
NSAIDs
Helicobacter pylori
Acid
Risk Factors
Steroids with NSAIDs
Anti-coagulation
Ethanol
Fluid resuscitation
MCV
Normal in acute Blood transfusion

blood loss
Discontinue all anticoagulants and antiplatelet agents
Other
100 new cases / 100k
Etiologies of Upper GI Bleed
Peptic ulcer disease
Varices
Arteriovenous malformation
Mallory Weiss tear
Tumors and erosions
Dieulafoy's lesion
Esophagitis
Aorto-enteric fistula
Etiologies of Lower GI Bleeding
Diverticular disease
Neoplastic disease
Colitis
Unknown
Angiodysplasia
Hemorrhoids / fissures
PPIs (if suspect upper bleed)
BUN
Rise out of
proportion to
creatinine level
Octreotide drip
Protonix drip
Antibiotics
Platelets (for renal disease or Plavix
patients)
Variceal Bleeds
PPIs
Eradication of H. pylori (if present)
Endoscopic therapy
If endoscopic
therapy fails
Angiogram
Surgery
Airway management
Esophageal or
Gastric Varices
Abnormally dilated vessel

with a tortuous course
secondary to portal
hypertension
Medical
Treatment
Massive upper GI bleed with hemodynamic
instability
Intervetions
Octreotide
Antibiotics
(for cirrhotics)
EGD with
endoscopic
banding
Compression with
Minnesota tube
TIPS
Dieulafoy's Lesion
Mallory-Weiss
Tear
Diverticular
Bleeding
Dilated submucosal artery erodes

into the muscosa with subsequent
rupture of the vessel
Bleeding is often massive and recurrent
Laceration in the mucosa

usually near the GE junction
Occurs after retching
Rupture of an outpouching of the

mucosa and submucosa through the
muscular layer of the colon
Acute, painless hematochezia
80 - 90% stop bleeding spontaneously

Supportative care
Usually stops spontaneously
Most diverticular bleeds are rightsided.

Risk of rebleed appears to increase
with time.
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Group of inflammatory
conditions of the colon
and small intestines
Laboratory
Result
Diarrhea
(nocturnal or bloody)
Fatigue
CBC
Weight loss
Fever
CMP
Anorexia
Nausea / vomiting
SED / CRP
Abdominal pain
Arthralgias
Erythema nodosum
Episcleritis
Uveitis
Pyoderma gangrenosum
TSH with
Reflex T4
Celiac
Serologies
Worrisome Signs
Inflammatory
Bowel Disease
Test
Frequent UTIs /
pneumaturia
High fever / abdominal

mass
Nausea / vomiting
Obstruction
Severe rectal pain
Small Bowel
FollowThrough
CT / MR
Enterography
Crohn's Disease
Can affect any portion of
the GI tract
Tends to skip areas
Transmural
Stricturing
Fistulizing
Ulcerative Colitis
Limited to the colon
Stool Studies
Starts in the rectum
Ova and parasite
Usually continuous
More superficial disease
Fecal leukocytes
or fecal
calprotectin
Tenesmus
Fecal urgency
Primary
Sclerosing
Cholangitis
Stricturing of the bile

ducts with risk for
cholangitis
Asymptomatic
Hematochezia
Itching
Treatment
Medications
Ulcerative Colitis
Corticosteroids
5-ASA
Immunomodulators
TNF- inhibitors
Leukocyte trafficking inhibitors
Workup for
Janus kinase inhibitors
diarrhea
Crohn's Disease
Corticosteroids
Immunomodulators
5-ASA
TNF- inhibitors
Leukocyte trafficking inhibitors
Dysplasia
Malignancy
UC Surgical
Toxic colitis
Differentiate CD
Indications
Hemorrhage
and UC
Intractable
symptoms
Fibrotic strictures
CD Surgical
Obstruction
Indications
Fistulae
Avoid if possible
Stool culture
DEXA
Lifestyle
modifications
Osteoporosis
Clostridium
Vitamin D and
Prevention
difficile
calcium
Minimize steriods
Biphosphonates
Mesalamine
Sulfasalazine
6-MP
Azathioprine
Adalimumab
Other
Descriptions of UC by Extent of
Involvement
proctitis - anus / rectum
proctosigmoiditis - to sigmoid colon
left-sided colitis - to splenic flexure
pancolitis / universal colitis - total
colon
Descriptions of CD by Extent of
Involvement
ileitis - ileal
ileocolitis - ileal and colonic
colitis - colon only
perianal - worse prognosis
Use as little steroid as possible
Risk for Colon Cancer in IBD
Colitis
Concomitant PSC
Family history of colon cacer
Time and degree of inflammation
Infliximab
Golimumab
Vedolizumab
Rule out infection

Flare
Management
Routine labs
Follow-up
5-ASA (UC) or
budesonide (CD)
Tofacitinib
Methotrexate
Anti-TNF
Alkaline
Phosphate
LFTs
p-ANCA
MRCP / ERCP
HIGH
Diagnostic
High-risk for colon cancer

No effective medical therapy
Hepatologist referral
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Burning pain localized to
the epigastrium
Pain in non-radiating
Nighttime awakenings
from pain
Asymptomatic
(30 - 40% of NSAID users
with ulcers)
COPD
Test
Laboratory
Result
H. Pylori
Serology False
Negatives
EGD
Cirrhosis
Peptic Ulcer
Disease
Breach in the mucosa of

the stomach that leads to
ulcer formation
Associations
Systemic mastocytosis
Uremia
High-Risk Patients for

NSAID Damage
Age > 65
Higher dose NSAIDs
Corticosteroids
Anticoagulants
H. pylori infection
Indications for
EGD
PPIs
Antibiotics
Treatment
Odynophagia
Dysphagia
Iron deficiency
Perforation
Age > 55
Gastric outlet obstruction

PUD
(majority in duodenal
bulb)
ZollingerEllison
Syndrome
Indications to Check Serum Gastrin
Tumor of gastrinsecreting G cells
Multiple ulcers
Gastric Cancer
Ulcers in distal
duodenum and jejunum
Ulcers associated with severe esophagitis

Extensive family history
of PUD
Post-op ulcer recurrence
Stress-Induced
Ulcers
Diarrhea
Ulcers due to multifactorial, mucosal

ischemia due to decreased
mesenteric blood flow
Neoplasm of the stomach
Ulcer resistant to
medical treatment
Unexplained diarrhea
Hypercalcemia
Preventing Complications of NSAIDs

Cox-2 selective therapy
> 1000 pg/mL
Secretin
Stimulation
Test
Most sensitive
(94%) and specific
(100%)
Multiple, swallow ulcers

Extensive burns
Cranial trauma
Asymptomatic
Indigestion
(early disease)
Early satiety
Nausea
Anorexia
Virchow and sister Mary
Weight loss
Joseph nodes
Palpable stomach
Pallor
Hepatomegaly
Late Symptoms
Pleural effusions
GOO
GE obstruction
SBO
Bleeding
Etiologies
Diet
H. pylori
Atrophic gastritis
Polyps (rare)
Radiation
Misoprostol
PPI
High-dose H2
blockers
Mucosal
Protection
High-dose PPI
Fasting Serum
Gastrin
Endoscopic
Ultrasound
and
Somatostatin
Receptor
Other
500k new cases / year
4 million recurrences / year
> 80% prev. in developed nations
Bismuth
Confirmation of eradication
Allows
characterization of
May require retreatment in 20%
the lesion and
biopsy
Antacids
GI bleeding
H2 blockers
Unintended
weight loss
PPIs
Family Hx of GI
Gastrectomy
Surgery (rare)
malignancy
Vagotomy
Complications
Hemorrhage
Medications
H. pylori Eradication
PPI
Triple Therapy for
Clarithromycin
2 Weeks
Amoxicillin
Surgical resection
(if not metastatic)
Vagotomy
Metastatic
Disease
Successful in 90%
Somatostatin
analogs
Interferon
Cytotoxic
chemotherapy
Surgical resection
Chemoembolization
Gastrinoma Triangle (90%)

Pancreas ductular epithelium (50%)
Duodenum (40%)
Stomach, liver, bones, and LN (<10%)
30 - 50% metastasize
83% 15-year survival without
metastasis
30% 10-year survival with metastasis
Typically found at the gastric fundus
Histamine-2 blockers
PPIs
Critically Ill
Histology
EGD
EUS
Barium
Swallow
CT / MRI
Adenocarcinoma
(95%)
Surgical resection
Carcinoid,
squamous cell
Lymphoma
Safe, easy, and Neoadjuvant chemotherapy and
able to obtain radiation therapy
tissue
Able to obtain
5-FU
tissue and good
for staging
Adjuvant
Doxorubicin
Chemotherapy
Diagnostic
Cisplatin
2nd most common cancer with very

high incidence in Korea, Japan, and
China
>
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Gallstone
Types of Stones
Cholesterol Stones
5 F's
(gallbladder)
Drugs
Black Pigment Stones
Cirrhosis
(gallbladder)
Chronic hemolysis
Brown Pigment Stones
Bile duct infection
(bile ducts)
Fever
Cholecystitis
Impacted stone in the

gallbladder neck or cystic
duct
Nausea
Vomiting
Severe RUQ / epigastric

pain
(> 6 hours)
(+) Murphy's sign
Cholecystitis in the
absence of gallstones
Critically ill
Emphysematous
Cholecystitis
Type of acalculous cholecystitis

due to gallbladder infection by a
gas-forming organism
See Acalculous Cholecystitis
Choledocholithiasis
Ascending
Cholangitis
Stone, occluded stent, or

stricture in bile duct
Sphincter of Oddi
Dysfunction
Stenosis or dyskinesia of
the sphincter of Oddi
Malignant
Biliary
Obstruction
No treatment for asymptomatic
Ideally after 8
hour fast
Cholecystectomy
WBC
AST
AP
Gallbladder
Ultrasound
HIDA
HIGH
HIGH
HIGH or Normal
Reynold's Pentad
Impacted stone leads to acute

gallbladder inflammation and may
cause a secondary bacterial infection
NPO
Supportative Care
Other
10% of general population
Risk Factors (5 F's, 2 C's, 2 D's)
Female, fat, fertile, age > 40, and
family history
Crohn's disease or cirrhosis
Diabetes or Drugs
IV fluids
1st line test

Analgesics
If GU is (-) but still
IV antibiotics
suspect
cholecystitis
Not ideal choices
Cholecystectomy (48 - 72 hours)

IV antibiotics
Cholecystectomy
Intermittent RUQ discomfort similar to

cholelithiasis
Charcot's Triad
Medications
Gold-standard
Same labs as cholecystitis
Complications
Treatment
Gallbladder
Ultrasound
CT / MRI
Acalculous
Cholecystitis
Gallstone in the common bile

duct
Laboratory
Result
RUQ pain after a fatty

meal
Asymptomatic
Cholelithiasis
Test
Cholangitis
Pancreatitis
Fever
RUQ pain
Jaundice
Charcot's triad
Hypotension
AMS
Biliary colic type of pain
Insidious onset of painless jaundice
Neoplasm blocks the

biliary duct
(+) Courvoisier sign
AP
HIGH
Gallbladder
Ultrasound
Bubbles in
gallbladder wall
Alkaline
Phosphatase
Gallbladder
Ultrasound
CT / MRI
MRCP
WBC
Direct
Bilirubin
AP
Blood Cultures
LFTs
Gallbladder
Ultrasound
HIDA
AP
Direct
Bilirubin
HIGH
Percutaneous cholecystostomy
(if too ill for surgery)
Emergent surgery
ERCP with stone extraction
Stone dilated
ducts proximal of
Cholecystectomy after ERCP
stome
HIGH
HIGH
HIGH
Can be (+)
IV antibiotics
IV fluids
Narrowing causes bile stasis proximal

to stone that leads to bile duct
infection.
ERCP
Cholecystectomy after ERCP
(if stones)
ERCP with manometry
Diagnostic
Sphincterotomy
HIGH
HIGH
Poor prognosis
Surgery
> 10 more likely to

Total Bilirubin
be from cancer Chemotherapy (for later stages)
Dilated duct
proximal to
CT / MRI
obstructions
ERCP with stent placement (pallative)
Double duct sign
Clinical Medicine
Condition / Disease
Cause
Malabsorption
Abnormality in the
absorption of nutrients
Celiac Disease
Intestinal mucosal injury

secondary to an immune
response to gluten in
genetically susceptible
individuals
Laboratory
Treatment
Test
Result
Change in bowel
CBC
Weight loss
movements
CMP
Bacterial overgrowth
PT / INR
Helpful in
Mucosal disease
TSH
Steatorrhea
determining
Pancreatic insufficiency
Folate
severity
Fat absorption issue
B12
Pale Skin
Anemia
Lipid Panel
Qualitative
Petechiae
Vitamin K
Stool Fat Test
Vitamin deficiency
Mouth Changes
Quantitative
Dental changes
Gold-standard
Stool Fat Test
Peripheral Neuropathy
Vitamin B12
Identifies mucosal
D-Xylose Test
Muscle Wasting /
malabsorption
Protein malabsorption
Edema
in SI
Carbohydrate
Most useful for
Abdominal Distention
Breath Test diagnosing lactase
malabsorption
Associated Clinical Syndromes
deficiency
Distinguishes
Lactase deficiency
Giardiasis
Schilling Test
causes of B12
Celiac disease
Tropical sprue
deficiency
Amyloidosis
Lymphoma
Hypoparathyroidism
Hyperthyroidism
CT / MRI /
Helpful in
Whipple's disease
Lymphoma
ERCP
diagnosis
Bacterial overgrowth
Short gut syndrome
Adrenal insufficiency
Carcinoid syndrome
Diarrhea with
AntiWeight loss
steatorrhea
Endomysial
Most specific
IgA
Bloating
Nutritional deficiencies
Serology test of Gluten-Free Diet
Chronic diarrhea
choice
Flatulence
Lactose intolerance
Anti-tTGA
> 90% sensitivity
Nutrient deficiencies
Borborygmi
> 95 specificity
Persistent diarrhea resembling traveler's diarrhea
IgA or IgG
Less sensitive
Extra-Intestinal Manifestations
Antigliadin
Malignancy
Short stature
Fatigue
May be indicated
Total IgA
Amenorrhea
Fertility
if IgA deficient
Iron deficiency anemia
Arthropathy
Folate / vitamin K
Osteopenia /
DQ2 / DQ8
Not fully
deficiency
osteoporosis
Genetic
Other
necessary
Screen
autoimmune
Muscle atrophy
Neurologic symptoms
Dental enamel
Autoimmune
diseases
Gold-standard
hypoplasia
myocarditis
Villous atrophy
Complications
Definite Associated Conditions
Autoimmune thyroid
Dermatitis herpetiformis
Lymphocytic
Nutritional
disease
infiltration of
deficiencies
Mucosal
Type 1 DM
RA
lamina propria
Biopsy
Sjgren's syndrome
Down's syndrome
Probable Associated Conditions
Crypt hyperplasia
Musculoskeletal
Sarcoidosis
Congenital heart disease
injuries and
Cystic fibrosis
Intraepithelial
deformities
IBD
Autoimmune hepatitis
lymphocytes
Myasthenia gravis
Signs and Symptoms
Medications
Other
Luminal Phase
Nutrients are hydrolyzed and
solubilized
Mucosal Phase
Futher processing takes place at the
brush border of the epithelial cell
with transfer into the cell
Transport Phase
Nutrients are moved from the
epithelium to the portal venous or
lymphatic circulation
Associated Drugs and Foods
Cholestyramine
Fiber diets
Tetracycline
Antacids
Sorbitol
Fructose
Xenical
Metformin
Colchicine
Methotrexate
Sulfasalazine
Phenytoin
Common in Middle East and India
Rare in Japan and China
10% of US American
Gluten is found in wheat, rye, barley,
and any foods made with these
grains.
There is a higher incidence of
lymphoma associated with celiac
disease.
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Chronic blistering skin

condition
Oral (rare)
Gastrointestinal
Tropical Sprue
Inflammatory disease of
small bowel secondary to
overgrowth of coliforms
Laboratory
Result
Multiple intensely
pruritic papules and
vesicles that occur in
groups
Vesicles
Erosions
Erythematous macules
Abdominal bloating
Cramping
Pain
Diarrhea
Constipation
Skin
Dermatitis
Herpetiformis
Test
Dapsone therapy
Megaloblastic anemia
Folate / B12 supplementation
Lipase
(+) Gray Turner's sign
BUN
Hct
(+) Cullen's sign

Abdominal
X-Ray
Gallstones (35%)
Alcohol (30%)
Obstruction
Medications
Ultrasound
Infections
Metabolic
Toxins
Vascular
Trauma
Post-ERCP
Inherited
Idiopathic
Ranson Criteria
Admission
Age > 55
Glucose > 200
Collection of pancreatic juice

encased by granulation tissue that
persists > 4 weeks after episode of
acute pancreatitis
Emergent ERCP to removed stones
CT
Abdominal pain
Abdominal pressure
Infection
Rupture
"Sentinel loop
of SB"
"Colon cut-off
sign"
Enlarged
hypoechoic
pancreas
Gallstones
Biliary ductal
dilation
IV fluids
Pain medications
MRCP
ERECP
Pancreatic
enlargement
Peripancreatic
edema
Necrosis
Extrapancreatic
fluid
Assesses
complications
Evaluate biliary
tree and
pancreatic duct
Evaluate biliary
tree and
pancreatic duct
Most common in India and southeast

Asia
Also known as bacterial overgrowth
syndrome
Acute intersitial pancreatitis
Mild pancreatitis with pancreatic
edema
Acute necrotizing pancreatitis
Severe pancreatitis with necrosis of
parenchyma and blood vessels
Complications
ARDS, sepsis, renal failure
Fluid collections
Pancreatic necrosis (sterile)
Pancreatic necrosis (infected)
Pancreatic abscess
Pseudocyst
Monitor in ICU
Modality of choice
for pancreatic
parenchyma
WBC > 16
LDH > 350
AST > 250

48 Hours Later
Hct > 10
BUN > 5
Calcium < 8
Fluid deficit > 6 L
PO2 < 60
Base deficit > 4
Criteria
<2
3-4
(< 5% mortality)
(15 - 20% mortality)
5-6
>7
(40% mortality)
(> 99% mortality)
Pancreatic
Pseudocyst
HIGH
HIGH
More specific
> 25
> 44
Calcified gallstone Pancreatic rest
Etiologies
Other
Strict gluten-free diet
Extended antibiotic therapy

Diarrhea
Abdominal pain
Inappropriate activation
of trypsinogen causing
inflammation
Medications
Life-long condition
Amylase
Acute
Pancreatitis
Treatment
Abdominal CT in
72 hours to assess
necrosis /
complications
Severe
Pancreatitis
Prophylatic
antibiotics if
> 30% necrosis
Jejunal feeds
early
Drainage (if infected)

Surveillance
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Test
Laboratory
Result
Amylase
Persistent / recurrent episodes of epigastsric and
LUQ pain
Lipase
Usually not
elevated
Treatment
Abstince from alcohol
Pancreatic
enzymes
replacement + H2
blocker / PPI +
fat diet
Fecal Fat
Pain with no radiologic
evidence
Steatorrhea
Fecal Elastase
Narcotics
Diagnostic
Pain
Chronic
Pancreatitis
Secretin
Stimulation
Test
Diabetes
Chronic inflammatory
process leading to
irreversible fibrosis of
pancreas
Abdominal
X-Ray
Etiologies
ERCP with
sphincterotomy or
stent placement
Other
Most acute pancreatitis does not go
to chronic pancreatitis.
Tropical Chronic Pancreatitis
Due to childhood malnutrition in
underdeveloped countries
Chronic Obstruction of Pancreatic
Duct
Pancreatic duct strictures
Pancreatic tumor
Papillary stenosis
There are no blood tests to diagnose
chronic pancreatits.
Celiac plexus or
splanchnic nerve
block
Surgery
Pancreatic
calcifications
Pancreatic
calcifications
Medications
Pancreatic enzyme replacement
CT
Chronic alcohol use
(70%)
Chronic obstruction of
pancreatic duct
Tropical chronic
pancreatitis
Autoimmune
pancreatitis
Genetic
Idiopathic
(20%)
Jaundice
Weight loss
Painless
(in pancreatic head)
Abdominal pain
(in pancr. body / tail)
Atrophied
pancreas
MRCP / ERCP
"Chain of lakes"
(areas of dilation
and stenosis along
pancreatic duct)
Bilirubin
Signs of Metastatic Disease
Pancreatic
Adenocarcinoma
Supraclavicular LN
Lungs
Peritoneum
Liver
Bone
Cancer of the pancreas
Risk Factors
Tobacco use
Chronic pancreatitis
Exposure to Bnaphthylamine or
benzidine
Non-insulin dependent
DM arising in nonobese
person > 50 years old
Hereditary chronic
pancreatitis
H/O Partial gastrectomy

or cholescystectomy
Peutz-Jeghers
BRCA 2 mutation
CT
Double duct sign
MRI
Assessment
Endoscopic
Ultrasound
If no lesion seen
on CT / MRI and
still have high
suspicion
Puestow
procedures
Subtotal
pancreatectomy
Total
pancreatectomy
( autologous islet
cell
transplantation)
Whipple
procedure
(if in head)
Diagnostic
(+) Trousseau's sign
Sister Mary Joseph node
Surgery
Alkaline
Phosphatase
CA 19-9
(+) Courvoisier's sign
Insulin therapy
Resection
(no vascular
invasion,
lymphatic
involvement, or
metastasis)
Distal
pancreatectomy +
splenectomy
(if in tail)
4th leading cause of cancer-related

deaths
1.3 : 1
15 - 20% of patients are candidates
for pancreatectomy.
50% metastatic at time of diagnosis
Medial Survival
Resectable - 15 - 17 months
Locally-advanced - 6 - 10 months
Metastatic - 3 - 6 months
Also get 5-FU

chemoradiation
5-FU chemoradiation
Not always
(if locally advanced and not
needed if imaging resectable)
is convincing
Tissue
Diagnosis
ERCP with
brushing +
intraductal biopsy
CT-guided biopsy
(risk of seeding)
EU with FNA
(best option)
Gemcitabine
Metastatic
Pain control
Palliative stents
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Abdominal pain
(44%)
Change in bowel habit

(43%)
Hematochezia / melena
(40%)
Weakness
(20%)
Anemia without other GI

symptoms
(11%)
Weight loss
(6%)
Test
Laboratory
Result
Colonsopy
Gold-standard
Abdominal
and Pelvis CT
Staging
CXR
Diagnostic
Needle Biopsy
If suspected to be
metastatic disease
Unusual Presentations
Local invasion or
malignant fistula
Fever of unknown origin
formation into adjacent
Intra-abdominal or retroperitoneal abscesses
Colorectal
Cancer
Neoplasm of the colon

and/or rectum
Streptococcus bovis
bacteremia
Clostridium septicum
sepsis
Risk Factors
Age
Personal history of colon

polyps or cancer
CBC
Family history of colon cancer

Diagnostic
Carcinoid
Rare neuroendocrine
tumor that arise at
several body sites
Inherited syndromes
Type II diabetes
Metabolic syndrome
Ethnicity
Inflammatory bowel
disease
Diets red and

processed meats
Physcial inactivity
Obesity
Smoking
Heavy alcohol use
Familial adeomatous
polyposis
Hereditary NonPolyposis Colorectal

Cancer
Abdominal pain
Intermittent
obstruction
Locations in GI Tract
(most common first)
Ileum
Rectum
Appendix
Colon
Stomach
CMP
PET
24 Hour Urine
HIAA
Chromogranin
A, B, and C
Biopsy
Imaging
If suspected to be
metastatic disease
Diagnostic
Treatment
Medications
Other
10% of new cancer diagnoses

Colectomy / hemicolectomy +
1 in 18 people will develop colorectal
lymph node dissection
cancer.
19% of cases have metastatic disease
Colostomy (sometimes required)
5-FU / Leukovorin at the time of diagnosis.
/ Oxaliplatin
Metastatizes most commonly to liver
and lung
Endoscopic removal (early stages)
Staging
T1 - Through muscularis mucosa,
extends into submucosa
Metastatses resection
T2 - Through the submucosa and into
(primarily liver)
musclaris propria
Radiofrequency
T3 - Through the muscularis propria
ablation
and into subserosa but not to any
neighboring organs
Ethanol ablation
Capecitabine
Ablation of
T4 - Through the wall of the colon or
Metastases
rectum and into nearby tissues and
Cryosurgery
organs
Hepatic artery
N0 - No LN involvement
embolization
N1 - 1 - 3 nearby LN involvement
N2 - 4 nearby LN involvement
Resected stage II
M0 - No distant spread
M1 - Distant spread present
Chemotherapy
Resected stage III
Stage Grouping
Metastatic /
I - T1-2 N0 M0
5-FU / Leukovorin
unresectable
IIa - T3 N0 M0
IIb - T4 N0 M0
Radiation therapy (rectal cancer)
IIIa - T1-2 N1 M0
IIIb - T3-4 N1 M0
Healthy diet with
IIIc - T3-4 N1 M0
emphasis on plant
IV - T3-4 N2 M1
sources
Radiation is not typically used for
Maintain healthy
colon cancer due to its high toxicity
BMI
to the gut.
Prevention
FOLFIRI
Colonoscopy Screening
Limit red meats
Q 1 year - IBD once disease present
Encourage
for > 15 years
physical activity
Q 3 - 5 years - Cancer or
Vitamin D /
adenomatous polyps have already
calcium
been detected
Q 5 years - Family history of
Occult blood
colorectal cancer
Stool DNA
Colonoscopy
Q 10 years - Everyone else
FOLFOX
Polyps
CT colonoscopy
Screening
Flexible
Some are adenomatous and some
sigmoidoscopy
are hyperplastic
Double-contrast
Hyperplastic polyps are not
barium enema
considered pre-malignant
Arise from enterochromaffin cells
Surgery (localized disease)
Metastatic potential of localized
carcinoid tumors correlates with
Surgery
Hepatic artery
tumor size, location, and histologic
embolization
grade.
Metastatic
Disease
No great evidence
Appendiceal carcinoids are the most
for systemic
common neoplasm found in the
therapy
appendix.
Clinical Medicine
Condition / Disease
Jaundice
Cause
Hyperbilirubinemia
Signs and Symptoms
Test
Yellowing of the oral mucosa, conjunctiva,

and skin
Dark urine
Very light stool
RUQ pain
Nausea / vomiting
Jaundice
Hepatitis A
Inflammation of the liver

due to HAV infection
Transmission
Incubation Period
Complications
Chronic Sequelae
Transmission
Fecal-oral
Average = 30 days
15 - 30 days
Fulminant hepatitis
Cholestatic hepatitis
None
Parenteral
Blood
Body fluids
Laboratory
Result
Bilirubin
HIGH
ALT
AST
Hepatitis A
IgM Antibody
HIGH
HIGH
Hepatitis A
IgG Antibody
Hepatitis B
HbSAg
HbSAb
HbCAb
30 - 50% < 5 years old

Chronic Infection
Premature Mortality
from Chronic Liver
Disease
2 - 10% teenagers /
adults
HbEAg
HbEAb
15 - 25%
Risk Factors
Travelers to intermediate and
HAV-endemic countries
Homo- / bisexual
Drug users
Chronic liver disease
Rate communities (Alaska natives
and Amercian Indians)
Acute infection
Vaccination
Infection
Prior infection
Vaccination
Immunity
Hepatologist referral
Active or prior
infection
Not positive with
vaccination
Active replication
of virus
Chronic infection
Antiviral therapy
No active
replication
HBV DNA in
Blood
Infection
HbCAb
Present or cleared
infection
Parental
Transmission
Very little sexual
Hepatitis C

due to HCV infection
Alcoholic Liver
Disease
Liver damage due to

heavy alcohol use
Non-Alcoholic
Fatty Liver
Disease
Chronic alcohol liver

disease without
significant alcohol
consumption
HCV infection
2 - 26 weeks
Chronic Hepatitis
70%
Predicts response
and guides
duration
HCV Genotype
Persistent Infection
85 - 100%
RUQ pain
Nausea / vomiting
Jaundice
History of heavy alcohol

use / binge drinking
Asymptomatic
Obesity
ALT
Diabetes /
insulin resistance
Hyperlipidemia
AST
6 Phenotypes
2x ALT
AST
Bilirubin
INR
Lamivudine
Entacavir
Tenofovir
Pegylated
interferon- +
ribavirin
Genotype 2 / 3
HCV RNA
Interferon
Telbivudine
Average = 6 - 7 weeks
Incubation Period
Other
Immunity
Incubation Period
45 - 180 days
Medications
Prior infection
Average = 60 - 90 days

due to HBV infection
Treatment
Genotype 1
24 weeks of
treatment
Treatment difficult
to tolerate
Telaprevir
Boceprevir
Combination with
pegylated
interferon- +
ribavirin
Interferon-
Ribavirin
Prevention
Prevent perinatal HBV transmission
Routine vaccination of all infants
Vaccination of adolescents
Vaccination of high risk groups
High Risk Groups
Houshold member of HBV-infected
patients
Sexual parteners of HBV-infected
patients
Health care workers
Prisoners
Travelers to endemic areas visiting
6 months
#1 indication for liver transplant
Prevention
No vaccine
Avoid sharing needles
Use barrier protection if multiple
sexual partners
Telaprevir
Boceprevir
Calculated discriminant function (uses

bilirubin and INR)
Neither go above
500 U/L
Prednisone pnetoxyfylline
HIGH
(if DF > 32)
HIGH
Weight loss and exercise
Mildly elevated
Tight glucose control

Management of hyperlipidemia and
hypertension
Clinical Medicine
Condition / Disease
Cause
Test
Laboratory
Result
Persistent / recurrent
hepatitis
Cirrhosis
End result of chronic

inflammation from a
variety of etiologies
Hemochromatosis
Wilson's disease
-1-antitrysin deficiency
Breached abnormallydilated blood vessels
Portal hypertension
Ascites
CBC
Platelets
Gastro-esophageal
varices
Splenomegaly
Albumin
INR
LOW
HIGH
Lack of toxin clearance
Encephalopathy
Bilirubin
HIGH
Hematemesis
Melena
IV octreotide
Hematochezia in a patient with cirrhosis

Hypotension
-Blockers
Emergent endoscopy
Tachycardia
Ultrasound
Spontaneous
Bacterial Peritonitis
Encephalopathy
Accumulation of fluid in
the peritoneal cavity
Shifting abdominal
dullness
Fluid wave
Abdominal pain
Fever
Bacterial infection of ascites

Renal insufficiency
Brain disease
Euphoria
Confusion
Asterixis
Coma
Precipitating Factors
Infection
Bleeding
Hyponatremia
Hypokalemia
Sedatives
Azotemia
Blood transfusion
TIPS
Hemangioma
Other
Replacement of a
diseased liver with a
healthy liver
Most common benign

tumor of the liver
Hepatitis C
Cyrptogenic / NASH
Serum
Albumin Ascities
Albumin
CBC with
Differential
Ascites
Culture
Portal
hypertension if
> 1.1
> 250 PMNs
60% develop 10 years of cirrhosis

diagnosis
Salt restriction (2 g / day)
Check for portal

vein thrombosis Diuretic therapy
(with acute
accumulation)
Large volume paracentesis
Pathologic Diagnosis
Fibrosis
Regenerated nodules
Vascular distortion
See PowerPoints for grading of
cirrhosis.
All patients with cirrhosis should
have an upper endoscopy to look for
varices.
Spironolactone
Furosemide
TIPS for refractory ascites
Antibiotics
(3rd generation cephalosporin)
Identify organism Hold diuretics

R/O Infection
Correct electrolytes
Lactulose
Rifaximin
85% 1-year survival
70% 3-year survival
Indications
Liver
Transplantation
Medications
Medication effects
Check for fluid
Ascites
Treatment
Other Etiologies
Chronic
Hepatitis
Bleeding Varices
Signs and Symptoms
Alcohol
(abstinent 6 months)
PBC
PSC
Hepatitis B
Asymptomatic
Found incidentally
Most are very small.
Clinical Medicine
Condition / Disease
Cause
Hepatic
Adenoma
Liver cancer associated with

long-term estrogen use
Focal Nodular
Hyperplasia
Nonneoplastic response to a
congential vascular
malformation
Hepatocellular
Carcinoma
Cancer secondary to
either viral hepatitis
infection or cirrhosis
Signs and Symptoms
Possible rupture
Test
Laboratory
Result
Bleeding
Treatment
Medications
Other
Resection
Asymptomatic
Must be
multphasic
Chronic liver injury or cirrhosis (80%)

Imaging
Cirrhosis symptoms
Resection
Arterial phase Embolization

hypervascularity
Radiofrequency ablation
(possibly curative)
Delayed phase
"wash-out"
Transplantation (curative)
Milan Criteria for Transplant

1 HCC < 5 cm
3 HCCs with none that are > 3 cm
Pharmacology
Drug
Generic Examples /
Brand Name
Triple Therapy for

Heliobacter
Eradication
Metronidazole / PPI /
Clarithromycin
Quadruple Therapy
for Heliobacter
Eradication
Pepto Bismol /
Metronidazole /
Tetracycline /
Randitidine
Mechanism of Action
Indications
Kill Heliobacter pylori
Pharmacokinetics
Maalox
Mylanta
Amphojel
GI effects
Altered taste
Disulfiram reaction
Eradication: 75 - 90%
GI effects
Metallic taste
Disulfiram reaction
Photosensitivity
Black tongue / stools
Kill Heliobacter pylori
Triple therapy failure
O: 5 - 15 minutes
Duration: 1 - 2 hours
Neutralize gastric
acid
Renal failure
CHF
Hypertension
GERD
Tums
cimetidine
H2 Receptor
Antagonist
Adverse Effects
Amoxicillin / PPI /
Clarithromycin
Alka-Seltzer
Antacids
Contraindications
Eradication: 70 - 85%
ranitidine
nizatidine
Block histamine
production in
parietal cells
Duodenal ulcer
Gastric ulcer
GERD
A: Oral, IV, or IM
O: 30 min
Duration: 10 hours
Fluid overload
Alkalosis
Diarrhea / constipation
Hypermagnesemia
Hypercalcemia
Aluminum neurotoxicity
Drug interactions
Headache
Nausea
Abdominal pain
Thrombocytopenia
Heal 90% of DU at 8 weeks and

80% of GU at 12 weeks.
Cimetidine has drug
interactions with CYP450
inhibitors (theophylline,
lidocaine, phenytoin, and
warfarin).
Headache
Nausea
Abdominal pain
Diarrhea
Long-Term Effects
B12 / calcium dysabsorption
Fractures
C. difficile-associated diarrhea
Pneumonia
Do not cut, crush, or chew pills

because they are entericcoated.
Breakdown symptoms
(particularly at night) can
happen while on PPI therapy
PPIs may fail to heal moderate
to severe esophagitis.
famotidine
omeprazole
GERD
lansoprazole
Proton Pump
Inhibitors
Acute Duodenal Ulcer
rabeprazole
esomeprazole
Inhibit active proton

pumps
Acute Gastric Ulcers

NSAID Ulcers
Heliobacter Eradication
dexlansoprazole
Esophageal Erosion
Maintenance
pantoprazole
Sucralfate
Carafate
Forms cytoprotective
complex that covers
ulcers
DU maintenance
(lansoprazole)
Esophageal erosion
healing
Omeprazole
Omeprazole / NaHCO3
Lansoprazole
Rabepazole
Omeprazole
Omeprazole / NaHCO3
Lansoprazole
Lansoprazole
Esomeprazole
Omeprazole
Lansoprazole
Rabepazole
Esomeprazole
Omeprazole
Omeprazole / NaHCO3
Lansoprazole
Dexlansoprazole
Rabepazole
Duodenal ulcer healing
Duodenal ulcer maintenance
A: Oral or IV
Adminster: 30 min
before breakfast
Peak: 1 - 2 hours
(Zegerid = 30 min)
Duration: Longer
A: Oral on empty
stomach
D: 1 g QID
CYP450 inhibitors
(omeprazole, Zegerid, and
esomeprazole)
Metabolic alkalosis
(Zegerid)
Monitoring / Other
Considerations
PCN allergy
Previous antibiotic use
Pill count
Side effects
Cost
Considerations
PCN allergy
Previous antibiotic use
Pill count
Side effects
Cost
Constipation
Gastric bezoar
Aluminum accumulation
Hypophosphatemia
Drug Interactions
Warfarin
Digoxin
Quinolones
These drugs need to be
separated by 2 hours.
Pharmacology
Drug
Misoprostol
Metoclopramide
Generic Examples /
Brand Name
Cytotec
Mechanism of Action
Synthetic
prostglandin E1
analog
NSAID ulcers
Blocks dopamine receptors

in the gut
GERD
Increases LES tone, gastric

tone, and transit time
Diabetic gastroparesis
Domperidone
Peripherally-acting
dopamine agonist
Baclofen
Lioresal
GABA agonist that

reduces tLESs
Bulk Laxatives
methycellulose
psyllium
polycarbophil
Docusate
Sodium
PEG 3350
lactulose
Colace
Increase stool bulk

Decrease transit time
Increase motility
Retain water
Draws water into

intestines along an
osmotic gradient
Surfactant agent that allows
water to enter the bowel
more readily
Pharmacokinetics
Bisacodyl
Anthraquinones
Saline
Laxatives
Castor Oil
Adverse Effects
Pregnancy
Diarrhea
Abdominal cramping
Flatulence
Nausea
Headache
CNS effects
Diarrhea
Headache
Sedation
EPS (especially in elderly)
Chemotherapy-induced
nausea and vomiting
GERD
Monitoring / Other
Modest efficacy
Requires an IND permit from

the FDA
GERD
Symptoms refractory to
PPIs
Constipation
A: Oral with 8 oz of
water
O: 1 - 3 days
Bowel obstruction
Stricture
Crohn's disease
Constipation
Constipation (ineffective)
Bloating / gas
Shoud be titrated
Mechanical obstruction of colon and
esophagus
Bloating
Nausea
Gas
Cramping
(lactulose > PEG 3350)
A: Oral
O: 1 - 3 days
A: Oral
Patients that need to avoid straining or prevent

constipation
A: Oral
O: 1 - 3 days
Mineral Oil
Contraindications
Need to reduce risk for

NSAID ulcer
Reglan
Motilium
Osmotic
Laxatives
Indications
Lubricant laxative
Constipation
Stimulant laxative
Constipation
Stimulant laxative
Constipation
Duclolax
Correctol
Ex-Lax
A: Oral
O: 6 - 12 hours
D: Not recommended for
daily use
A: Oral
O: 6 - 12 hours
Elderly
Children < 6 years old
Anal seepage
Pruritus
Incontinence
Malabsorption of fat-soluble vitamins
(long-term use)
< 1 hour of antacid or milk

ingestion
Severe cramping
Diarrhea
Electrolyte imbalance
Mineral oil and docusate are

useful in same clinical situation,
but docusate is safer.
Risk of aspiration and lipoid
pneumonia if taken before bed
or in a recumbent position
Abdominal cramping
Melanosis coli
Senokot-S
magnesium hydroxide
magnesium citrate
sodium phosphate
Pulls water into the

intestines along an
osmotic gradient
Acute evacuation of stool
Stimulant laxative
Constipation
Fluid / electrolyte depletion

Cramping / bloating
Hypermangesemia /
hyperphosphatemia
(in renal disease)
A: Oral
O: 1 - 6 hours
D: Not for daily use
A: Oral
O: 1 - 6 hours
D: Not for daily use
Elderly
Cramping
Severe diarrhea
Dehydration
Premature labor
Pharmacology
Drug
Enemas and
Suppositories
Lubiprostone
Generic Examples /
Brand Name
glycerin suppositories
Mechanism of Action
Indications
Distends the rectum
Pharmacokinetics
Acute constipation
Contraindications
Softens hard stool

sodium phosphate
enema
Amitiza
Increase luminal fluid secetion
Monitoring / Other
Fecal impaction
Stimulates colonic mucose

contraction
Locally activates ClC-2

chloride channels in the
microvilli cell membrane
Adverse Effects
Hyperphosphatemia
(NaPO4 enema)
Electrolyte abnormalities
A: Rectal :-(
O: 15 - 30 min
Nausea (29%)
Diarrhea (12%)
Headache (11%)
A: Oral with meals

Bowel Movements:
Every 1 - 2 days
Chronic idiopathic
constipation
Pills cannot be crushed or

chewed.
IBS constipation
Acclerate intestinal transit
Linaclotide
Linzess
Activates gyanylate
cyclase C in the
interstinal epithelium
Chronic idiopathic constipation
A: Oral 30 minutes
before first meal
D: 145 g daily
Children < 6 years old
Diarrhea (16%)
Abdominal pain (7%)
Acute bacterial diarrhea
Dizziness
Constipation
Increase luminal fluid secretion

IBS constipation
Acclerate intestinal transit
Antimotility
Agents
Absorbents
loperamide
diphenoxylate /
atropine
paregoric
attapulgite
calcium polycarbophil
Bismuth
Subsalicylate
Pepto-Bismol
Octreotide
Sandostatin
Emetrol
Mixture of fructose,
dextrose, and
phosphoric acid
Opiate derivative that

slows intestinal transit
Diarrhea
Absorb toxins,
bacteria, gases, and
fluids
Diarrhea
Decrease water
secretion into the
bowel
Safe, but efficacy not well

established
Children / teenagers with viral

illness
Aspirin sensitivity
Pregnancy
Diarrhea
Traveler's diarrhea
Decrease water secretion into Diarrhea associated with

the bowel
carcinoid tumors
Blocks release of SE and other
Short-gut syndrome
peptides
Chronic idiopathic
diarrhea
Abdominal pain
Diarrhea
Dysglycemia (in diabetics)
Nausea
Unknown
Vomiting
Sedation
Anticholinergic effects
dimenhydrinate
diphenhydramine
scopolamine
prochlorperazine
Nausea
Chemotheapy-induced nausea and vomiting
dolasteron
granisetron
ondansetron
palonosetron
A: Oral, IV, IM, or rectal
Block D2 receptors
promethazine
Serotonin
Receptor (5-HT3)
Antagonist
Vomiting
Block serotonin
receptors in gut wall
Chemotheapy-induced
nausea and vomiting
Post-operative nausea
and vomiting
Radiotherapy-induced nausea and vomitting

(granisteron and ondansetron)
A: Oral or IV
Less effective than loperamide

in most cases.
Drug Interactions
Warfarin
Probenecid
MTX
Not more effective than
opioids in chronic idiopathic
diarrhea
Minimal efficacy
Caution in
Narrow-angle glaucoma
BPH
CV disease
Seizure disorders
Motion sickness
chlopromazine
Phenothiazines
Black tongue and stools
AIDS-related diarrhea
meclizine
Antihistamines /
Anticholinergics
Loperamide is the drug of

choice for most cases of
diarrhea.
EPS
Sedation
Anticholinergic effects
Drug interactions
Headache
Dizziness
Constipation
Asthenia
LFTs
QT prolongation (rare)
Better treating vomiting than

nausea
Not as effective for motion
sickness
Pharmacology
Drug
Corticosteroids
Generic Examples /
Brand Name
dexamethasone
haloperidol
Butyrophenones
droperidol
Cannabinoids
Benzodiazepines
Neurokinin-1
Antagonist
dronabinol
nabilone
Mechanism of Action
Unknown
Blocks dopamine
stimulation of CTZ
Indications
Pharmacokinetics
Contraindications
Adverse Effects
Moderately emetogenic chemotherapy
Chemotheapy-induced
nausea and vomiting
Monitoring / Other
Increase the efficacy of other
antiemetics
Not 1st line
A: Oral, IV, or IM
Post-operative nausea
and vomiting
Pallative care
Inhibits
neurotransmitter
release
Chemotherapy-induced nausea and vomiting

(when other agents fail)
Enhance GABA
Anticipatory nausea and vomiting
Inhibits substance P /
neurokinin 1 receptors
Chemotherapy-induced nausea and vomiting
Euphoria
Drowsiness
Hallucination
Paranoia
Anamnestic effects
A: Oral
A: Oral
alprazolam
lorazepam
aprepitant
fosaprepitant
CYP3A4 substrates
CYP2C9 inducers
Post-operative nausea and vomiting
Antiemetics
Class
Antihistamine
Anticholinergic
Phenothiazine
Serotonin Receptor
(5-HT3) Antagonist
Neurokinin-1 Antagonist
Generic Name
dimenhydrinate
Anti-Diarrheal Agents / Laxatives
Scopolamine
promethazine
ondansetron
granisteron
palonosetron
Brand Name
Dramamine
Antivert
Bonine
TransdermScop
Phenergan
Zofran
Kytril
Aloxi
aprepitant
Emend
meclizine
Class
Antimotility
Stimulant
Emollient
Osmotic
Chloride Channel
Activator
Guanylate Cyclase-C
Agonist
Generic Name
loperamide
Brand Name
Imodium A-D
diphenoxylate / atropine
Lomotil
bisacodyl
ducosate sodium
PEG 3350
Dulcolax
Colace
Miralax
lubiprostone
Amitiza
linaclotide
Linzess
Generic Name
esomeprazole
lansoprazole
rabeprazole
Brand Name
Nexium
Prevacid
Prilosec
Zegerid
AcipHex
pantoprazole
Protonix
PUD / GERD
Class
GI Protectant
Generic Name
cimetidine
famotidine
ranitidine
sucralfate
Brand Name
Tagament HB
Pepcid
Zantac
Carafate
Prostaglandin E1 Analog
misoprostol
Cytotec
Prokinetic Agent
metoclopramide
Reglan
Histamine H2
Antagonist
Class
Proton Pump Inhibitor
omeprazole

Gastroenterology

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Diagnostic Methods

24 Hour 5Hydroxyindolacetic Acid

Digestive enzyme made

Digestive enzyme made mostly by

Group of blood labs designed to

Perforated peptic ulcer

Total amount of protein

Patient prep involves avoiding

Serum protein disorders

The liver makes 12 g of albumin daily.

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

High Level of AST

Enzyme involved with the

Moderate ALT content in kidneys,

Some drugs and patient conditions

Only a screening test of coagulation

Enzyme at high levels in

Bile duct destruction

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Not as subject to elevation from

0.2 - 1.2 U/L

Exposure to light may alter bilirubin

Defective heme removal

Total amount of bilirubin

Some hereditary disease

> 50% of elevated total

Using conjugated and unconjugated

Can test for cell counts and chemical

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Antibody against HAVAg

Total anti-HAV may be used to screen

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Outer surface coat

Antibodies against HBsAg

Antibodies against the

Secretory form of HBcAg

Pieces of DNA from

Antibody for HBeAg

Requires coinfection with

Generally benign and selflimiting

Assessment of a patient with

Persists throughout clinical illness

Risk for liver cancer

Acute hepatitis after

More severe in patients with underlying chronic

Hep B core IgM antibody

Hep B surface antigen

Hepatitis A IgM antibody

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Use of X-rays to view a nonuniformly composed object

Use of X-rays to obtain realtime moving images of

Direct visualization of the

Need to biopsy lesions

Visualization of entire colon

Need a view of the distal

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Combines the use of

Pill-sized cameras travel

Allow visualization of entire

Dyes / stains applied to tissue to

Malignant and benign

Gold-standard for visualizing small

Uncertain diagnosis of Crohn's disease

Allows procedures (when compared to VCE)