BOARD REVIEW

Class of 2014
Gastrointestinal System
Jason Dominguez, MPAS, PA-C
Texas Tech University Health
Sciences Center
Physician Assistant Program

DISEASES OF THE ESOPHAGUS

GERD
INFECTIOUS ESOPHAGITIS
ESOPHAGEAL DYSMOTILITY
ESOPHAGEAL NEOPLASMS
ESOPHAGEAL VARICES

GERD
General
10% of population
Minority develop Barretts
Replacement of normal squamous
epithelium with metaplastic columnar
epithelium predispose to malignancy

GERD
S/S
Heartburn (most common presenting sx)
Worse after meals, lying down, often
relieved by antacids
Atyp sxs
Hoarseness, halitosis, cough, hiccups, chest
pain

GERD
LAB/RAD
Endoscopy
>45 y.o with new sx onset
Dysphagia
No response to therapy
Anemia
Recurrent vomiting

GERD
pH, EMS studies, Barium Swallow
May be used prior to surgery or
depending on case

GERD
TX
Lifestyle mod
No smoke, no eating late or large, elev bed head

OTC antacids mild sxs

H2 blocker provide symptomatic relief
PPI most powerful 1st line mod to severe
Surgery refract
Avoid CCB, Anticholinergics, B-adrenergics
All lower LES pressure

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Grade 4 erosive esophagitis. (Courtesy of K McQuaid.)

Date of download: 7/29/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

Infectious Esophagitis
General
Rare except in immunocompromised
Causes
Fungal candida if thrush present
Viral CMV/Herpes
HIV, Mycobacterium tb, EBV, - all uncommon

Infectious Esophagitis
S/S
Odynophagia painful swallowing
most common
Dysphagia difficult swallowing

Infectious Esophagitis
LAB/RAD
Endoscopy
CMV/HIV large, deep ulcers
HSV multiple shallow ulcers
Candida white plaques
Cytology or culture from brushings for def dx

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Cytomegalovirus esophagitis. (Courtesy of J Cello.)

Date of download: 7/31/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Herpes Esophagitis: In herpes esophagitis, typically ulcers are seen in the mid- to distal esophagus. These ulcers are whitish
lesions that are umbilicated with areas of central clearing. (Used with permission from Michelle Nazareth, MD)

Date of download: 7/31/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

Infectious Esophagitis
TX
Candida
Fluconazole, ketoconazole

HSV
Acyclovir

CMV
Ganciclovir

Esophageal Dysmotility
General
Disorders
Neurogenic dysphagia dz of brainstem or CN
Zenkers diverticulum outpouching of post.
hypopharynx
Esophagel stenosis webs, rings
Achalasia peristalsis decreased, LES increased
Diffuse esophageal spasm
Scleroderma decreased LES tone, decreased
peristalsis (cant swallow plus a lot of reflux)

Esophageal Dysmotility
S/S
Dysphagia most common presenting
symptom for all
Neurogenic dysphagia difficulty
swallowing liquids and solids
Zenkers regurg of undigested food
Stenosis solid food dysphagia rapid
progression could mean malignancy
Achalasia Chest pain, episodic regurg

Esophageal Dysmotility
LAB/RAD
Barium swallow can reveal structural
and motor abnormalities
Achalasia bird beak on BS dilated
esophagus tapering to distal obstruction
EGD to detect nature of structural
lesions
Manometry assess strength and
peristalsis

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Esophageal Stricture: The esophageal lumen is narrowed significantly in this patient complaining of dysphagia. The endoscopic
appearance is consistent with a benign stricture. (Used with permission from Michelle Nazareth, MD)

Date of download: 7/31/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

Esophageal Dysmotility
TX
Treat any underlying disease
Dilatation for benign strictures
Resection for malignant strictures

Esophageal Neoplasms
General
Squamous cell and adenocarcinoma are
most common with Barretts esophagus
being associated with the latter
Majority related to cigs and chronic
ETOH abuse

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Esophageal Adenocarcinoma: Note the ulcerated mass with fungating heaped up borders in this esophageal mass seen in the
lower end of the esophagus (Used with permission from Michelle Nazareth, MD).

Date of download: 7/31/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

Esophageal Neoplasms
S/S
Most common clinical picture is
progressive dysphagia for solid foods
with marked weight loss

Esophageal Neoplasms
LAB/RAD
Barium swallow
Endoscopy with brushings for dx
CT for staging

Esophageal Neoplasms
TX
Surgery
Low 5-10% survival rate

Mallory Weiss Tear

General
Linear mucosal tear at GE junction
Often associated with alcohol use,
forceful vomiting, retching
Diagnosed by endoscopy
Usually resolves spontaneously but may
require endoscopic injection of epi or
thermal coagulation

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Mallory-Weiss tear. (Courtesy of K McQuaid.)

Date of download: 7/29/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

Esophageal Varices
General
Dilatation of veins of the esophagus
Caused by portal hypertension most
commonly caused by cirrhosis (alcohol
abuse or viral hepatitis)

Esophageal Varices
S/S
Patient with signs of Cirrhosis presents
with hematemesis
Life threatening

Esophageal Varices
TX
Fluids
High dose intravenous PPI
IV octreotide (decreases splanchnic
blood flow)
Bleeding control
Endoscopic banding

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Large esophageal varices. (Courtesy of K McQuaid.)

Date of download: 7/29/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Esophageal Varices: There is active bleeding present. Based on their size and the fact that they do not flatten with insufflation of
the esophagus, these would be classified as Grade II varices. (Used with permission from Robert Osterhoff, MD)

Date of download: 7/31/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Esophageal varices after band ligation. (Courtesy of K McQuaid.)

Date of download: 7/29/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

Diseases Of The Stomach

Gastritis and Duodenitis
Peptic Ulcer Disease
Gastric Neoplasms
ZE
Gastric Adenocarcinoma
Carcinoid
Gastric Lymphoma

Gastritis and Duodenitis

General
Causes
Type A (body of stomach)
Autoimmune d/o pernicious anemia
Other noninfectious causes

Type B (antrum and body of stomach)

HP a G- spiral bacillus
Implicated in almost all non-nsaid induced
ulcers
Associated with pud, gastric
lymphoma/adenocarcinoma

Gastritis/Duodenitis
General
NSAIDS cause by decreasing protective
prostoglandins
Stress (burns, sepsis, surgery)
Alcohol

Gastritis/Duodenitis
S/S
Dyspepsia
Abdominal pain

Gastritis/Duodenitis
LAB/RAD
Urea breath test, FAT, serology for HP
Endoscopy with bx for location, extent,
and HP

Gastritis/Duodenitis
TX
Underlying cause (eradicate HP)
Remove other factors (alcohol, NSAIDS)
Symptomatic (PPI/H2)

PUD
General
HP is the most common cause
Gastric ulcers and HP highly associated
with gastric ca. Almost all patients with
gastric ca have had HP or a gastric ulcer
Very rare for duodenal to be associated
with ca
Most common cause of nonhemmorhagic GI bleeds

PUD
S/S
Abdominal pain is most common sx
Gnawing, burning, radiating to back
Duodenal improves with food
Gastric worsens with food and is
associated with wt loss
Dyspepsia
Complications
Bleeding, perf, penetration

PUD
LAB/RAD
Endoscopy is best
Allows for biopsies of gastric ulcers and
other suspicious lesions

Testing for HP
Breath test, FAT, bx, serology

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Superficial Gastric Ulcers: There are several areas of superficial ulceration with overlying white exudate in the stomach. This patient
had been taking a non-steroidal anti-inflammatory agent, ibuprofen, daily for several weeks after an ankle injury. (Used with
permission from Robert Osterhoff, MD)

Date of download: 7/31/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

From: Chapter 15. Gastrointestinal Disorders

CURRENT Medical Diagnosis & Treatment 2014, 2014

Legend:
Gastric Ulcer: Note this large gastric ulcer seen best on retroflexed view of the stomach near the incisura angularis. This ulcer has
heaped-up edges with central necrotic eschar. (Used with permission from Michelle Nazareth, MD)

Date of download: 7/31/2014

Copyright 2014 McGraw-Hill Education. All rights reserved.

PUD
TX
Avoid irritants
Smoking, alcohol, nsaids

Antacids(PPI best) and Sucralfate

Heal duodenal in 4-6 wk gastric in 8

Eradicate HP
Triple therapy (PPI, clarithromycin, amox)

Prophylaxis
Misoprostol/PPI for those that must have NSAID

Zollinger Ellison
General
Gastrin secreting tumor causes
hypergastrinemia resulting in refractory
PUD
Most in pancreas or duodenum
Can be anywhere, can MET

Can be associated with MEN-I

ZE
S/S
Same as PUD but more
advanced/refractory
Abdominal pain
Secretory diarrhea

ZE
LAB/RAD
Elevated serum fasting gastrin
>150pg/ml
Secretin test to confirm
Give secretin and gastrin increases
>200pg/ml

Endoscopy, CT, MRI to locate tumor

ZE
TX
Surgical resection of tumor

Gastric Adenocarcinoma
General
Common worldwide less common in
US
Early dx 80% cure rate lymphatic
spread 10%
Strongly associated with HP

Gastric Adenocarcinoma
S/S
Dyspepsia, wt loss, anemia, occult gi
bleed in patient >40 is classic picture
Virchows node (left supraclavicular
nodule)
Sister Mary Joseph nodule (umbilical
nodule)
Both indicate METS

Gastric Adenocarcinoma
LAB/RAD
Fe def anemia
Endoscopy with brushings
After dx. CT for staging/extent

Gastric Adenocarcinoma
TX
Surgical resection
Curative/palliative

Chemo/radiation

Carcinoid
General
Usually benign

Gastric Lymphoma
General
Only 2% of gastric cancers, but most
common extranodal site of non-hodgkins
Highly associated with HP
S/S, Lab/Rad, TX are the same as for
gastric adenocarcinoma except
pathology of lesion

Diseases Of The Small Intestine

and Colon

Diarrhea
Constipation
SBO
Malabsorption
Crohns
Ulcerative colitis
IBS
Intussusception
Diverticular disease
Ischemic Bowel Disease
Toxic Megacolon
Polyps
Colon Cancer

Diarrhea
General
3 or more liquid or semi-solid stools daily
for at least 2-3 consecutive days
Causes

Infectious
Toxic
Dietary (laxative use)
Other GI disease

Always get a detailed history. One mans

diarrhea is another mans constipation.

Diarrhea
S/S
Secretory (lg volume no inflammation)
Pancreatic insufficiency
Ingestion of preformed bacterial toxins
Laxative use

Inflammatory (fever/bloody diarrhea)

Invasive organisms or IBD

Antibiotic associated
C-diff colitis
Pseudomembranous colitis

Diarrhea
LAB/RAD
Stool studies

WBCs inflammatory process

Cultures bacteria
O & P giardia other
Toxin id invasive e-coli, c-dif

Diarrhea
TX
Supportive/symptomatic good enough
for most
Antibiotics for severe and systemic
symptoms
Shigella
Campy
C-diff

Constipation
General
Older than 50 with new-onset need eval
for colon ca

Constipation
TX
Increase fiber, fiber, fiber and fiber,
fluids
If longer than two weeks refract to diet,
exercise, fluids needs a work up

SBO
General
Most common cause in US is adhesions
Worldwide is hernias

SBO
S/S
Abd pain
Distension
Vomiting partially digested food
High pitched rushes bowel sounds

SBO
LAB/RAD
Upright plain films air fluid levels
Flat Dilated loops of small bowel

Volvulus
Portion of bowel twisting on itself
Mostly occurs in sigmoid or cecal
area
Complications
Ischemic injury

Volvulus
S/S
Nausea/vomiting
Abdominal pain

LAB/RAD
Plain film will reveal colonic distension

Tx
Endoscopic decompression
Surgery

Malabsorption
General
May be single nutrient
Pernicious anemia (b-12)
Lactase defeciency (lactose)

May be global
Celiac disease
AIDS

Malabsorption
S/S
Chief symptom is diarrhea
Bloating
Abdominal discomfort
Wt loss, edema
Steattorhea

Malabsorption
LAB/RAD
72 hour fecal fat test
If normal consider other reasons for sx
(pancreatic insuff)

D-oxylase
Distinguished malabsorption from
maldigestion

Malabsorption
TX (therapy may help you find the
dx.)
Lactose free diet lactase def
Gluten free diet celiac dz
Pancreatic enzymes
Vitamin and mineral replacement (b-12
inj etc)

Crohns
General
Can involve mouth to anus
Most common is right colon and terminal
ileum
Fistulas, abscesses, aphthous ulcers,
colon ca, all may be complications

Crohns
S/S
Most common abd cramping, diarrhea
in <40 y/o
Fever, polyarthralgias, anemia, fatigue

Crohns
LAB/RAD
Contrast BE or CT
Cobblestone filling defects
Segmental involvement (skipped lesions)
Fistulas, strictures

C-scope
Best for evaluation colonic involvement
but never during excacerbation (no contrast
studies either) may cause perf or toxic
megacolon

Crohns
LAB/RAD
Granulomas frequent on bx
Increased sed rate
anemia

Crohns
TX
First line
Aminosalicylates (sulfasalazine, mesalamine)
comes in oral, enema, suppository

Corticosteroids great for calming

excacerbation not for long term use if
can avoid
Refractory/frequent flare
Immunomodulatory agents
Azathioprine, mercaptopurine, infliximab (great but
expensive needed if fistulas)

Crohns
TX
Surgery not curative
Reserved for complications (segmental
resection)

Ulcerative Colitis
General
Usually starts distally progresses
proximally
Continuous no skipped lesions

Ulcerative Colitis
S/S
Hallmark is bloody diarrhea
Pus filled diarrhea
Tenesmus
Wt loss, malaise, fever
Greater risk for TM and Ca than Crohns
Scleritis, arthritides, sclerosing cholangitis,
erythema nodosum, pyoderma
gangrenosum may all be complications

Ulcerative Colitis
LAB/RAD
C-scope, flex sig best
Avoid colonoscopy or BE during excac for
same reasons as Crohns

Increased sed rate

Decreased albumin

Ulcerative Colitis
TX
Aminosalicylates and corticosteroids
(topical and oral) are TOC
Immunomodulators for refract
Surgery is curative but not common
because total proctocolectomy is most
common approach

IBS
General
Functional d/o no known pathology
The most common cause of
chronic/recurrent abd pain in US

IBS
S/S
Typical pain is hypogastrium or LLQ
Worse with food relieved with BM
Postprandial urgency common
Constipation, diarrhea, or alternating
both

IBS
Lab/Rad
Test stool for blood, parasites
Test for lactose intolerance
Imaging to r/o other pathology
Endoscopy if wt loss, anorexia, bleeding,
h/o other GI path
All should be normal

IBS
TX
Reassurance
High fiber (helps some, bothers some)
Antispasmodics
Antidiarrheals
Prokinetics
Antidepressants

Intussusception
General
Telescoping of proximal segment of
bowel into portion distal to it
95% in children general after viral infx
In adults usually caused by a neoplasm

Intussusception
S/S
Children
Severe colicky pain
Currant jelly stools (blood and mucus in
stools)
Sausage like mass on palp

Adults
More indolent course
Bloody stool and mass rare

Intussusception
Lab/Rad
Children
BE or air enema diagnostic and therapeutic

Adults
CT is best
BE should not be done
Many cases diagnosed at surgery

Intussusception
TX
Children
BE if doesnt work surgery

Adults
Usually surgery

Diverticular Disease
General
Diverticulosis
Outpouchings of diverticula in colon

Diverticulitis
Inflammation of diverticula caused by
obstructing matter

Diverticular disease
S/S
Diverticulitis
Sudden onset abd pain LLQ or suprapubic
Mild dz to peritonitis
Altered BM, N, V

Diverticulosis most common cause of

severe lower GI bleeding

Diverticular Disease
LAB/RAD
Occult blood in stool and WBS in
diverticulitis
Plain film to r/o free air
CT if not resolving
No BE or C-scope during acute episode
(perf)

Diverticular Disease
TX
Broad spectrum abx and low-residue diet
for mild diverticulitis
If worse admit, IV abx, bowel rest,
analgesics, NG tube if ileus
Surg if severe, peritonitis, lg abscess,
fistulas, obstruction
High fiber diet and avoidance of
obstructing food may prevent development
of diverticulitis in those with diverticuli

Ischemic Bowel Disease

General
Generally over 50 and with other
athersclerotic of collagen vascular disease
Acute is an Emergency with high mortality
may be caused by embolus, thrombosis
May be chronic from chronic ischemia,
more indolent
Intestinal infarction in small bowel
common, shock common

Ischemic Bowel Disease

S/S
Acute is sudden onset severe out of
proportion to exam finding later
guarding, rebound etc
Chronic is pain of abdominal angina
usually after eating relieved somewhat
by squatting or lying down

Ischemic Bowel Disease

Lab/Rad
Plain film/CT to rule out other
Contrast CT
Angiography

Ischemic Bowel Disease

TX
Surgical revascularization

Toxic Megacolon
General
Extreme dilatation/immobility of colon
Emergency
Occurs as complication of UC, Crohns,
Pseudomembranous colitis, and some
amebiasis and bacterial infections

Toxic Megacolon
S/S
Fever
Severe cramping
Abd distension
Rigid abdomen, rebound

Toxic Megacolon
Lab/Rad
Colonic dilatation on plain film

Toxic Megacolon
TX
Decompression of colon
In some colostomy, complete colonic
resection
Maintain fluid and electrolytes

Colonic Polyps
General
Common benign or malignant
Familial Polyposis genetically
predisposes to multiple polyps and high
risk of colon ca

Colon Polyps
S/S
Generally none
May be bleeding or occult blood, may be
FE defeciency

Colon Polyps
Lab/Rad
Can be seen on BE, Sig, C-scope
BX to determine dysplasia/malignancy
Family member of those with familial
polyposis syndrome need evaluation
every 1-2 yrs starting at 10-12

Colon Polyps
TX
Depends on size/path
Lg or dysplastic polyps should be
removed and frequent f/u

Colorectal Cancer
General
3rd mc cause of ca death in US (lung and
skin)
90% in >50

Colorectal Cancer
S/S
Slow growing making symptoms
appear late in dz
Abd pain
Change in BM
Obstruction
Blood
Wt loss, fatigue, anemia

Colorectal Cancer
Lab/Rad
Occult blood can be used for screening
>40
Colonoscopy is test of choice
Debate over specific screening
schedules but overall data supports
screening >50
CT to help stage and check METS
CEA to monitor after tx. Not to detect

Colorectal Cancer
TX
Surgical resection
Various combos chemo/radiation

Prognosis
Dukes A (only mucosa) 5 yr >90%
Dukes B (through wall or regional lymph
nodes 5 yr 70-80%
Dukes C (METS) 5 yr 5%

Diseases of Rectum/Anus

Abscess/Fistula
Fissure
Hemorrhoids
Pilonidal Disease
Impaction

Abscesses/Fistulas
General
Abscess is result of infx. Fistula is
chronic complication of abscess

Abscesses/Fistula
S/S
Peri rectal/peri anal painful swelling at
anus and pain with defecation, tender,
erythema swelling, fever is uncommon
Deeper abscess cause rectal fullness,
buttock or coccyx pain, fever likely
Fistula cause anal discharge and pain

Abscess/Fistula
TX
Abscess requires drainage followed by
WASH regimen
Warm water cleansing, analgesics, stool
softener and high fiber diet

Surgery for fistulas

Anal Fissures
Linear rectal tears
Most common in posterior midline
Severe tearing pain with BM, BRBPR on
TP
Treatment is increase fluids, bulking
agents, Sitz baths
Topical nitro, silver nitrate, gention
violet have all been used to help healing

Hemorrhoids
S/S
External visible perianally
Stage 1 internal (confined to anal canal) may
bleed with defecation
Stage 2 internal (protrude from anus but
reduce spontaneously) bleeding/mucoid d/c
St 3 inter (require manual reduction after BM)
pain/discomfort
St 4 inter (chronically protruding risk
strangulation

Hemorrhoids
TX
Stage 1/2 high fiber increase fluids
Higher stage suppositories with
anesthetic/astringent properties
Surgery for those unresponsive to
therapy and all stage 4 (Injection,
banding)

Pilonidal Disease
General
Abscess in sacrococcygeal cleft with
sinus involvement
Usually males, hirsute, obese, rare >40

Pilonidal Disease
S/S
Pain, fluctuance at sacrococcygeal cleft,
visible sinuses

Pilonidal Disease
TX
Surgical drainage
Follicle removal with unroofing of
sinuses later by surgery

Fecal Impaction
General
Hard retained stool
Generally in rectum
Can be complicated with
UTI and obstruction
Perf of colon
Appendicitis by obstructing fecalith

Fecal Impaction
S/S
Non specific pain, n, v, anorexia
Incontinence of small amounts of water
around stool
Rock hard stool in rectal vault

Fecal Impaction
TX
Digitally break up impaction
Follow with saline enema
Attention to bowel habits and hydration
to prevent recurrence

Diseases of Appendix and

Pancreas

Appendicitis
Acute pancreatitis
Chronic pancreatitis
Pancreatic neoplasm

Appendicitis
General
Inflammation, infection of appendix
caused by obstruction
10-30 yrs of age
The most common abd surgical
emergency

Appendicitis
S/S
Initial periumbilical pain
Localization to RLQ (Mcburneys point)
Nausea, anorexia
Low grade fever
Vomiting isolated after onset of pain
Peritoneal signs
Rebound
Psoas (supine and attempts to raise leg against
resistance)
Obturator (supine and attempts to flex and internally
rotate rt hip with knee bent)

Appendicitis
Lab/Rad
WBC 10-20,000
Hematuria/pyruia
CT

Appendicitis
TX
Appendectomy
Broad spectrum abx before surgery

Acute Pancreatitis
General
Most common cause is alcohol abuse
Others cholelithiasis, hyperlipidemia,
trauma, drugs, hypercalcemia, and
penetrating PUD

Acute Pancreatitis
S/S
Epigastric pain radiating to back
Lessens when patient leans forward or in
fetal position
N, V, Fever, peritonitis
Hypovolemia, ARDS may develop

Acute Pancreatitis
Lab/Rad
Elevated amylase, lipase (more sensitive
and specific)
Elevated WBC
Increased LFTs/bili if biliary obstruction

Ransons criteria
Indicator of prognosis, risk of mortality
rises with each factor

Acute Pancreatitis
TX
NPO (stop secretion of pancreatic juices)
Volume restoration
TPN
Pain management
Antibiotics may need to be started
Monitor for pseudocyst, renal failure,
pleural effusions, hypocalcemia, abscess

Chronic Pancreatitis
90% caused by alcohol abuse other
causes same as acute
May resolve if ETOH is discontinued
Classic triad is
Pancreatic calcification
Steatorrhea
Diabetes Mellitus

Chronic Pancreatitis
S/S
Same as acute
Fat malabsorption and steatorrhea
develop later

Chronic Pancreatitis
Lab/Rad
Amylase not useful after repeat
episodes
Plain films reveal pancreatic calcification
in 20-30%

Chronic Pancreatitis
TX
Same as acute
Low fat diet
Surgical removal of part of pancreas
Underlying cause is only treatment
(etoh, lipids)

Pancreatic Neoplasm
General
Risk factors

Age
Obesity
Tobacco
Chronic pancreatitis
Abdominal radiation
FMH

Pancreatic Neoplasm
S/S
Abd pain
Palpable gallbladder (courvoisiers sign)
Jaundice

Pancreatic Neoplasm
Lab/Rad
CT
CT for mets
Angiography (vascular invasion)

Pancreatic Neoplasm
TX
Surgical Resection (modified whipple) if
no METS
Combo chemo/radiation controversial
Poor prognosis

Diseases of the Biliary Tract

Acute Cholecystitis
Choledocholilithiasis

Acute Cholecystitis
General
Usually caused by obstruction of bile
duct by a stone

Acute Cholecystitis
S/S
RUQ especially after a fatty meal
Right shoulder or subscapular pain
N,V,F

Acute Cholecystitis
Lab/Rad
Elevated bili
Elevated WBC
Gallstones in 95% (only 20%
radiopaque)
HIDA scan can confirm
ERCP can indentify cause, location,
extent

Acute Cholecystitis
TX
NPO
Abx
TPN
Analgesics
Lap Chole

Choledocholilithiasis
Only 30% will develop symptomatic
dz
Generally treat only complications
Cholecystitis
Pancreatitis
Acute cholangitis

Diseases of the Liver

Hepatitis Viral/Toxic
Cirrhosis
Liver neoplasm

Hepatitis
General
Most common cause is viral
Second is toxins (alcohol)

Viral Hepatitis
General
A and E transmitted FO
B,C,D transmitted BF

Viral Hepatitis
S/S
Fatigue, anorexia, nausea, tea-colored urine,
abd discomfort
A/E self limited, usually no long term
sequelae
B/C highly variable, asymptomatic to
fulminant, may become chronic
D only in conjunction with B more severe
course
B/C frequently co-infect with HIV

Viral Hepatitis
Lab
LFTs up in all
Bili >3.0mg/dl causes scleral
icterus/jaundice
Anti-HAV IgM
Acute Hep A infx. Present at onset
disappears after a few mos.

HAV IgG
Resolved Hep A

Viral Hepatitis
Lab
HBsAg
Ongoing Hep B infx any duration

Anti-HBs
Immunity from past infx or vaccination

Anti-HBc
Present between disappearance of HBsAg
and appearance of Anti-HBs indicates infx

HBeAg
Indicates higher viral load , more contagious

Viral Hepatitis
Lab
Hepatitis C antibody
If positive should be eval for genotype and
viral load
Type 1 has worse prognosis than 2 or 3
Higher viral load has worse prognosis

Viral Hepatitis
TX
For acute is supportive
Hep A no sharing food, dishes, wash
hands frequently
Avoid alcohol, other hepatotoxins
Chronic B or C refer to specialist, protease
inhibitors now available for hepatitis C
Patients with C get vaccinated for B and A

Toxic Hepatitis
Numerous agents
ETOH, Acetaminophen, INH, Phenytoin
TX is discontinue offender, acetylcystine
for acetaminophen

Cirrhosis
General
Irreversible fibrosis, nodular
regeneration
About half related to alcohol others Hep
B, C, or congenital d/o

Cirrhosis
S/S
Weakness, fatigue, N,V,anorexia
Menstrual irreg, impotence, gynecomastia
Abd pain, hepatomegaly
Day-Night reversal
Later ascites, edema, varices,
encephalopathy (asterixis, tremor,
delirium, coma)

Cirrhosis
Lab/Rad
Anemia, AST, AlK Phos, Alphafetoprotein
US, CT, MRI to assess nodules and guide
BX.

Cirrhosis
TX
No Alcohol
Salt restriction, rest, spironolactone for
ascites
Liver transplant in select

Liver Neoplasm
General
Benign, Primary, METS
B9 Hemangioma, adenoma
METS common site especially from
lung, breast
Primary Usually related to B, C, or
cirrhosis

Liver Neoplasm
S/S
If MET that of primary tumor (lung etc)
If primary like hepatitis/cirrhosis

Liver Neoplasm
Lab/Rad
A-fetoprotein
CT, MRI to locate lesion
No needle bx if resectable

Liver Neoplasm
TX
B9
Nothing unless becomes large enough to
disrupt liver function or rupture capsule

MET
Tx primary lesion

Primary malignant
Resect if possible
Liver transplant in select
Prognosis poor

Hernias

Umbilical
Hiatal/diaphragmatic
Incisional
Inguinal
Ventral

Umbilical Hernia
Generally congenital appears at birth
Most resolve on own
May need surgery if not healed by
age 4, extremely large, or risk of
incarc or strang

Hiatal/Diaphramatic
Sliding
Protrusion of part of stomach straight up
displacing LES into thorax
Most common complication is GERD
TX is as for reflux
Paraesophageal
Stomach and possibly intestines, spleen
enter thorax along side the esophagus
Asymptomatic usually
TX is surgery due to higher risk of more
severe complications (obstruction,
strangulation)

Incisional
Associated more commonly with
vertical incisions, obesity, and wound
infection
Small defect generally worse than
large

Inguinal
Indirect
Passes through internal inguinal ring through
inguinal canal and may pass into the
scrotum Most common

Direct
Passes through external inguinal ring at
Hesselbachs triangle

Femoral
Passes through femoral ring least common

Ventral Hernia
Weakening in ant abdominal wall
can be incisional or umbilical

Definitive tx for all hernias is surgical

Congenital Abnormalities

Esophageal Atresia
Pyloric stenosis
Bowel atresia
Hirschprungs disease

Esophageal Atresia
Associated with tracheoesophageal
fistula
Newborn, excessive saliva, choking,
coughing
Inability to pass NG tube
TX is surgery suctioning and NPO
until surgery to help prevent
aspiration

Hypertrophic Pyloric
Stenosis
Projectile Vomiting
Palpable olive mass in epigastrium
String sign and delayed emptying
on barium swallow
TX
surgery

Bowel Atresia
Ileum most common but can be
anywhere
Presents with signs of obstruction

Hirschsprungs disease
Denervation of bowel wall caused by
congenital absence of Meissners and
Auerbachs plexuses
Constip, vomiting, failure to thrive
TX is surgical resection of affected
bowel

Metabolic Disorders
Lactose intolerance
Phenylketonuria

Lactose Intolerance
No or not enough lactase produced in
small intestine to digest lactose
containing products well
Nausea, bloating, flatulance,
diarrhea, cramping
TX avoid milk, dairy, use lactase
enzyme tabs or drops

Phenylketonuria
Autosomal recessive
Cannot metabolize phenylalanine
Accumulation in CNS results in mental
retardation and movement disorders
Screen at birth
Tx
Low-phenylalanine diet and tyrosine
supplement

References
A Comprehensive Review for the
Certification and Recertification
Examinations. Fifth Edition. Claire
Babcock OConnell, Sarah F. Babcock
2015
CMDT 2014