GASTROENTEROLOGY TiKi TaKa

---------------------------. U should exclude MI with AS in a pt with epigastric pain radiating to the mid
-scapulae.
--------------------------------------------------------------------------------------. When u r given a complaint of acute epigastric pain,
. radiating to the back inbet. the scapulae,
. with H/O of coronary artery disease,
. in addition to suspicion in pancreatitis & PUD,
. the 1st step to do is EKG to exclude MI !!!!!!!!!
. Chronic mesenteric ischemia:
---------------------------. Un-explained chronic abd. pain.
. weight loss.
. Food fear & avoidance of eating.
. Associated atherosclerotic disease.
. Abd. ex. may reveal a bruit.
. Dx: Doppler U/S.
. Mallory Weiss $:
----------------. is hematemesis due to ++ intra-abd. pressure with vomiting,
. leading to rupture of submucosal ARTERIES at the distal esophagus.
. Portal hypertension:
--------------------. leads to hematemesis due to rupture of esophageal varices (submucosal VEINS)
.
. Diverticulitis:
---------------. LLQ pain + Constipation + Fevr + vomiting.
. The most appropriate test to confirm acute diverticulitis is Abd. CT.
. Sigmoidoscopy is contra-indicated for fear of perforation.
. ULCERATIVE COLITIS:
-------------------. Young pt.
. Abd. pain.
. Bloody diarrhea.
. Rectal urgency.
. Anemia & reactive thrombocytopenia.
. Rectal tenderness.
. Stool mixed with mucous & blood.
. ++ WBCS with nausea ----> Toxemia.
. U should suspect TOXIC MEGACOLON.
. DO ABDOMINAL X-rays to search for Toxic Megacolon.
. Chron's disease:
-----------------. Young pt.
. Chronic diarrhea.
. Abd. pain.
. Weight loss.

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Mouth ulcers.
Rt upper Q. tenderness without rebound.
Gas in small & large intestines.
Reactive thrombocytosis & anemia.

. DIVERTICULOSIS:
---------------. Old pt.
. is associated with constipation not diarrhea,
. with Left lower Q. pain.
. CANCER HEAD PANCREAS:
----------------------. Enlarged (NON TENDER) Gall bladder.
. Weight loss.
. evidence of biliary obstuction (++ALP disproportionate with +AST & +ALT).
. Dx: Abd. CT !
. The most common cause of iron defeciency anemia in an elderly pt is GIT bleed
ing.
---------------------------------------------------------------------------------. The next step is COLONOSCOPY.
. A single -ve occult blood test doesn't exclude GIT bleeding.
. DYSPHAGIA:
-----------. Both sloids & liquids = Motility disorder e.g. ACHALASIA.
. Solids then progressing to liquids = Obstructing lesion e.g. esophageal
adenocarcinoma. . so .. You should perform BARIUM SWALLOW 1st before endoscopy
.
. Spontaneous bacterial peritonitis:
-----------------------------------. should be considered in any pt. with cirrhosis & ascites,
. accompanied by fever or change in mental status.
. Paracentesis is the test of choice, with a +ve ascitic fluid cultue & PMN >
250 cells.
. Step wise approach of ttt of Ascites:
--------------------------------------1. Sodium & water retention.
2. Spironolactone.
3. Loop diuretic (Furosemide).. But not more than 1 L/day of diuresis.
4. Frequent abd. paracentesis (2-4 L/day).
. Aggressive diuresis > 1 L/day may worsen encephalopathy or precipitate hepat
o-renal $.
. Liver cirrhosis ----> Renal hypo-perfusion -----> Hepato-Renal $ !
------------------------------------------------------------------. manifested by HIGH UREA & CREATININE.
. Very low urine Na < 10 meq = Pre-renal cause.
. No protein & No blood in dipstick urine = Not intrinsic glomerular cause.
. CARCINOID $ triad:
------------------. Flushing.
. Valvular heart disease.
. Diarrhea.

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Ass. e' hepatic metastasis.

++ Serotonin & 5 HIAA in blood & urine.
The precursor of Serotonin is Tryptophan,
which is also utilized in the synthesis of Niacin.
-- Niacin ----> PELLAGRA 4 Ds (Diarrhea-Dermatitis-Dementia-Death).

. Neutrophilic cryptitis is seen on bowel biopsy in pts with IBD.

. CARCINOID $ = Flushing + secretory diarrhea + Wheezing + cardiac problem.
. Intra-abdominal malignancy obstructing the biliary system:
-----------------------------------------------------------. Painless jaundice.
. Conjucated hyper-bilirubinemia.
. Elevated Alkaline phosphatase.
. ex. pancreatic adenocarcinoma.
. Pancreatic choleraa = VIPoma.
------------------------------. The pancreas secretes vaso-active intestinal peptide.
. Hypokalemia (leg cramps).
. chronic diarrhea --> dehydration.
. Abd. pain.
. weight loss.
. facial flushing & redness.
. Dx: Abd. CT.
. FOLIC ACID DEFECIENCY:
-----------------------. A tea & toast type of diet is associated with folic acid defeciency.
. Folic acid is heat sensitive.
. Folic acid defeciency causes macrocytic anemia.
. Corn based diets -> NIACIN defeciency -> PELLAGRA (4Ds):
---------------------------------------------------------. Diarrhea + Dementia + Dermatitis + Death.
. DIVERTICULITIS:
---------------. H/O of costipation & little fiber in diet.
. Left lower quadrant pain & fever.
. Tx: IV Antibiotics.
. If no improvement ---> Abd. CT to detect complications.
. Tropical sprue:
----------------. Endemic tropical area e.g. Puertorico.
. Biopsy of S.I ---> Blunting of villi,
. with infiltration of chronic infl. cells e.g. lymphocytes, plasma cells & eo
sinophils. . Malabsorption to Vit. B12 & folic acid ---> Megaloblastic anemia.
. Other signs of malabsorption e.g. glossitis - cheilosis - pallor.
. WHIPPLE's disease:
-------------------. PAS +ve material in the lamina propria of the small intestine is diagnostic.
. Primary HIV infection:
-----------------------. can present with a mononucleosis like syndrome,
. consisting of fever, night sweats, lymphadenopathy, arthralgia & diarrhea.

. JAUNDICE:
----------.Abd. U/S is the best initial investigation for JAUNDICE.
.But .. once u suspect pancreatic cancer , then the best inv. is Abd. CT.
.Manif. of cancer include weight loss , pressure obstruction of CBD,
.leading to ++ direct bilirubin & ++ ALP.
. MEN 1 = 3 Ps:
--------------. Primary Hyperparathyroidism.
. Pituitary tumors.
. Pancreatic tumors (insulinoma-gastrinoma-VIPoma).
. GASTRINOMA = ZOLLINGER ELLISON's $ (Non B-cell pancreatic tumor).
. Endoscopy--> Multiple ulcerations & prominent gastric folds.
. MEN 2 A:
---------. Medullary thyroid cancer & Pheochromocytoma.
. MEN 2 B:
---------. Neuromas & Marfanoid habitus & Pheochromoytoma.
. Pts aged > 55ys with new onset dyspepsia with ALARM SYMPTOMS: -------------------------------------------------------------* weight loss.
* dysphagia.
* persistent vomiting.
* should be evaluated with UPPER ENDOSCOPY.
. Pts < 55ys with no alarm symptoms:
-----------------------------------. should have 1st H.Pylori serology test,
. followed by empiric ttt with PPIs e.g. Omeprazole.
. If failed ----> ENDOSCOPY.
. Hemorrhage is the most common complication of peptic ulcer.
. CRYPTOSPORIDIUM PARVUM:
------------------------. HIV pt. with chronic severe diarrhea with CD4 cells < 100.
. ZOLLINGER ELLISON's $YNDROME:
------------------------------. Endoscopic findings of prominent gastric folds.
. Chronic duodenal ulcer.
. upper jejunal ulcer.
. Serum GASTRIN conc. < 1000 is diagnostic.
. Bacterial overgrowth:
----------------------. Malabsorption in a pt. with a H/O of abdominal surgery.
. Vit. D def. = Hypocalcemia.
. Vit. A def. = Night blinness.
. Vit. B12 def. = Neuropathy.
. LACTOSE INTOLERANCE:
-------------------. Asian American.

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+ve Hydrogen breath test.

+ve stool test for reducing substance.
++ stool osmotic gap.
-- stool pH.
No steatorrhea.

. ESOPHAGUS:
---------. ADENO-carcinoma ------------> Chronic GERD & Barret's esophagus.
. Squamous cell carcinoma ----> Smoking & Alcohol.
. Acute Appendicitis:
------------------. VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS Visceral followed by somatic pain !!
. ACUTE EROSIVE GASTRITIS:
-------------------------. Massive doses of Aspirin & NSAIDS can cause upper GI bleeding.
. Alcohol can aggravate its effect.
. Mallory Weiss $:
-----------------. occur in the distal esophagus at the gastro-esohageal junction,
. after repeated bouts of retching & vomiting.
. Zinc defeciency:
-----------------. may result from total parenteral nutrition or malabsorption.
. Alopecia,skin lesions,abnormal taste,impaired wound healing.
. Drug induced pancreatitis:
---------------------------. Pts with H/O of VALPROIC ACID ttt for seizure disorder.
. Ulcerative colitis:
--------------------. presents as diarrhea & bloody stools.
. The condition may be complicated by systemic toxicity : fever & weight loss,
. with dilated colon on CXR "TOXIC MEGA-COLON".
. Tx: I.V. fluids + Antibiotics + Bowel rest + I.V. corticosteroids.
. If failed: Emergency surgery with sub-total colectomy with end ileostomy.
. Minimal bleeding per rectum or scant hematochezia:
---------------------------------------------------. Dx -> Office based ANOSCOPY or PROCTOSCOPY.
. GIARDIASIS:
------------. Foul smelling stool.
. Abd. cramps.
. Bloating = MALABSORPTION diarrhea.
. H/O of developing country e.g. South America.
. Tx: METRONIDAZOLE.
. MALIGNANT criteria of a colonic polyp:
--------------------------------------. Villous adenoma.
. Sessile adenoma.
. Size > 2.5 cm.

. MULTIPLE MYELOMA:
------------------. Back pain + Renal dysfunction + High ESR + Anemia.
. MM ----> ++ Ca Hypercalcemia.
. ++ Ca ----> Constipation.
. so .. The cause of constipation in a pt. with MM is ELECTROLYTE DISTURBANCE
(++ Ca).
. NON-CASEATING GRANULOMA ----> PATHOGNOMONIC to CHRON's disease !
. N.B. UC always involves the rectum while it is spared in CD.
. Angiodysplasia:
---------------. Pt. > 60 ys. with anemia.
. Painless GIT bleeding.
. Murmur of Aortic stenosis.
. DIVERTICULOSIS:
---------------. The most common cause of painless GIT bleeding.
. Not associated with AS.
. Endoscopy: Multiple out-pouchings of the mucosa through the hypertrophied mu
scular
layer.
. ZOLLINGER ELLISON's $:
-----------------------. Multiple duodenal ulcers + Single jejunal ulcer resistant to H2 blockers & P
PIs.
. GASTRIN producing PANCREATIC TUMOR.
. Un-controlled gastrin production
. ---> Parietal cell hyperplasia
. ----> +++ Stomach acid production
. ----> Inactivation of pancreatic enzymes
. ----> Steatorrhea.
. Inflammatory Bowel disease:
----------------------------. Bloody diarrhea + anemia + elevated ESR + Reactive thrombocytosis.
. The type of diarrhea is INFLAMMATORY.
. Newly diagnosed gastric carcinoma transformation in a gastric ulcer by an end
oscopy
warrants an abdominal CT scan to evaluate the extent of the cancer.
. Pharyngo-esophageal (ZENKER's) diverticulum:
---------------------------------------------. is due to motor dysfunction.
. Pt. < 50 ys.
. with oro-pharyngeal dysphagia & neck mass.
. Tx: Crico-pharyngeal Myotomy.
. Diffuse esophageal spasm:
-------------------------. Young female.
. intermittent episodes of chest pain & dysphagia.
. Ba swallow: Cork screw esophagus.
. Causes of ++ BUN / Creatinine ratio:
-------------------------------------. Pre-renal RF.

. GIT bleeding due to reabsorption of blood from the GIT.

. Steroid adminstration.
. Esophageal dysmotility due to SCLERODERMA:
-------------------------------------------. Sticking sensation in the throat.
. Significant -- in LES tone.
. Absence of peristaltic waves in the lower 2/3s of the esophagus.
. CHRONIC PANCREATITIS:
---------------------. H/O of ALCOHOL use.
. Epigastric chronic abd. pain.
. Malabsorption (Steatorrhea & chronic diarrhea).
. Weight loss.
. Type 2 D.M.
. Amylase & Lipase may be normal (Not diagnostic).
. Dx: Abd. CT showing pancreatic calcifications.
.Duodenal ulcers:
-----------------. typically presents with epigastric pain that improves with eating.
. OVER 90% of duodenal ulcers are infected with H. Pylori.
. Tx of H. Pylori ass. ulcers is acid suppression & organism eradication with
antibiotis. . 1st line regimen is OCA = OMEPRAZOLE + CLARITHROMYCIN + AMOX
ICILLIN.
. In upper GIT bleeding:
---------------------. If Hb < 10 ----> PACKED RBCs transf.
. If Ht < 30 ----> PACKED RBCs transf.
. Upper bleeding with coagulopathy:
----------------------------------. is most likely to ruptured gastro-esophageal varices.
. Tx: FRESH FROZEN PLASMA: bec.FFP contains all the clotting factors & plasma
proteins.
. We never use whole blood transfusion.
. Cryoppt contains Factor 8, Fibrinogen, Von Willebrand factor & factor 10.
. FFP is preferred to cryoppt as it contains all clotting factors.
. Platelet transfusion is done when platelets < 50,000 !!
. Achalasia Manometry:
--------------------. esophageal body peristalsis.
. Failure of relaxation of LES.
. Achalasia Ba Swallow:
---------------------. Dilated esophagus.
. Bird's beak deformity of LES.
. HERPES ZOSTER (SHINGLES):
-------------------------. Pt. with Rt. sided abd. pain.
. Light touch to the skin to the Rt. of the Umbilicus elicits intense pain.
. Immunocompromized pt. 2ry to chemotherapy.
. Digoxin side effects:
----------------------

. GIT-------> Anorexia, Nause & vomiting.

. Cardiac---> Biventricular Arrhythmia.
. VERAPAMIL ++ the Digoxin's toxicity.
. N.B. Mesenteric ischemia presents with severe abd. pain out of prop. to exam
. !!
. Ulcerative colitis:
-------------------. Bloody diarrhea + tenesmus + abd. cramps + weight loss + anemia.
. Extraitestinal manifestations:
-----------------------------.Sclerosing colangitis.
. Uveitis.
. Erythema nodosum.
. Spondyloarthropathy.
. Complications:
-------------. Toxic Megacolon.
. Colon cancer.
. Yearly colonoscopies is recommended for pts with UC,
. beginning 8-10 ys after diagnosis for prevention of cancer colon.
. Irritable bowel $yndrome:
--------------------------. Abd. pain + diarrhea and/or constipation.
. Endoscopy ---> NORMAL COLONIC MUCOSA!
. Dark melanotic stools = Upper GI bleeding.
-------------------------------------------. The most common cause of upper GI bleeding is PUD.
. Duodenal ulcer's pain gets better with eating.
. while Gastric ulcer worsens with eating.
. PEPTIC STRICTURE:
------------------. Slowly progressive dysphagia to solids without anorexia & weight loss.
. As stricture progresses , it can actually block reflux,
. leading to improvement of heart burn symptoms.
. ENDOSCOPY --> SYMMETRIC circumferential narrowing.
. ADENO-CARCINOMA:
---------------. Pt with GERD < 20 ys.
. Weight loss.
. ASYMMETRIC narrowing of the esophageal lumen.
. REMEMBER:
----------. Pt. with fever + chills + Lt upper Q. pain + splenic fluid collection
. = Lt. sided endocarditis with septic emboli to the spleen,
. causing splenic abscess.
. H/O of incarerated pt. with ++ liver enzymes (possible HCV),
. suggesting IV drug use as the cause of infective endocarditis.
. NERD FAULT !!
--------------. Pt. with upper GI bleeding (Hematemesis)
. who have depressed conscioussness level should be intubated with ??
. ENDO-TRACHEAL tube not naso-gastric tube to secure the airway.

. KCL Potassium chloride ----> Drug induced esophagitis.

Dr. Wael Tawfic Mohamed
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