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61 Cards in this Set
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stepwise approach to ascites:
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Na & H2O retstrxn
2. spinonolactone 3. loop diruetic (<1L/d diuresis) 4. freq abdominal paracentesis (2-4L/d, monitor renal function, only if good) |
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pancreatic pseudocyst on CT
Tx |
most pancreatic pseudocysts resolve spontaneously only tap if >5cm, >6 weeks, infected, or eroding --> hemorrhage of blood vessel;
amylase can be levated because its's a soup with pancreatic juices and componenets, so when that leaks intto blood, amylase is increased |
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contraindication to succinylcholine for rapid sequence intubation
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hyperkalemia (depolarization can cause signifciant K release)
pts at risk: crush, burn (rhabdomyolysis), demyelinating syndromes, tumor lysis syumdromes; use non-depolarizing agnentts. |
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how does lactulose work:
what is the alternative |
bacteria ferment it and acidify their environment, traps ammonia
alternative is neomycin : kills amomonia producing bacteria, but is nephro-ototoxic. |
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Mechanism of Non-Alcoholic Liver Dz:
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Insulin Resistance --> Fat accumulation --> increased lipolysis --> oxidative stress
Dx: Bx |
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Palpable mass through abdomen near kidneys
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Adrenal masses are almost never palpable. if you can papate something you're palpating kidney.
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Rectal Examination reveals fluctuant mass at the tip of the finger
dz, tx |
pelvic abscess in rectovesicular pouch.
you can feel the whole prostate likely 2*/2 appendicitis tx: drainage |
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SAAG
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Serum-Ascites Albumin Gradient Gradter than 1.1 is indicative of portal hypertension as the etiology for ascites (vs pancreas)
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best dx test for sigmoid diverticulitis
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Abdominal CT
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High Amplitude Peristaltic Esophageal Contractions with Normal LES relaxn
Dz, Dx, Tx |
Diffuse Esophageal Spasm
eosphagram usually normal classical: "corkscrew" esophagus 2*/2 emotional disorders & functional GI disorders Dx: manomoatry Tx: antispasmotic, dietary modulation, counseling; CCCBs & nitrates |
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birds beak narrowing of distal esophagus
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achalasia
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Diverticulitis:
classes and courses |
Uncomplicated: no abscess: oral antibiotics & bowel rest
Complicated: <3cm abscess: IV abx >3cm: CT guided ddrainage no success --> sugical debridement surgery for fistulas, perforation, obstrx, recurrent |
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dyspepsia workup
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Dyspepsia: non-heart burn epigastric piain, fullneess/early satiety, bloating or nausea
Red Flags: weight loss, persistent vomiting, dysphagia, occult blood, odynophagia, FHx) without Red flags: test for H pylori serology if prevelently endemic if negative or not endemic: 8 week trial with PPI's & Follow Up |
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Familial Cholelithiasis
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think Hereditary spherocytosis
all these pts need folate supplementation |
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Drugs which cause pancreatitis:
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metronidazole, tetracycline
AIDS pts: didanosine, pentamidine Seizures/Bipolar: Valproate Immunosuppressants: Sulfalazine, 5-ASA Diuretics: Thiazides & Furosamide |
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MCC: Rectal Bleeding in elderly vs Frank Rectal Hemorrhage in elderly
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MCC: Rectal Bleeding in elderly, angiodysplasia
MCC: Frank Rectal Hemorrhage in elderly, diverticulosis |
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Ludwig's Angina:
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Strep + anaerobes
MCC Death = Asphyxiation Tx: remove tooth (source) + antibiotics |
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asx gallstones
course of action |
only 20% of pts with asx gallstones will dvlp sx or complciations --> do nothing
only remove prophlyactically if at risk for CA or complixsn: morbidly obese underoign Gastric Bypass and those with procelain gallbladders |
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Indications for ERCP:
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-interventional for gallstone pancreatitis
-diagnosis of choronic pancreatitis, dx of ampulaltory ca's need ts samples, need bile duct exploration |
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Crigler-Najjar:
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Type 1: two bad copies --> unconjugated hyperbilirubinemia --> must have liver transplant
type 2: one bad copy --> almost always okay, some phenobarbital or clofibrate to reduce serum bilirubine levels prn; CJ2: <20, gilbert's <3 |
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Tx: diabetic gastroparesis:
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improveged glycemic control
small freq meals DA agonists (metoclopramide, domperidone)_ before meals bethanechol erythromycin (normally produces diarrhea, this is from interation with motilin receptors) |
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Confirming Diagnosis of mesenteric angina
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angiography or doppler US
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15% of acute pancreatitis pts are complicated by
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by ARDS
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What is Reye Sro:
Tx? |
Fatty liver with Encephalopathy
Viral Illnesses treated with Aspirin Fatty vacuolization of liver s inflammation constellation of : elevated AST&ALT, elevated ammonia, PT prolongation, hypoglycemia, metabolic acidosis Mortality: 1/3 Tx: glucose + FFP + [mannitol vs cerebral edema] |
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Acute Pancreatitis Pt becomes hypotensive, pathology?
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most likely increased vascular permeability from enzyme spillage
if bleeding look for signs (Cullen, Grey Turner) |
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Ulcerative cholitis with RUQ pain, biliary Sx
Dz, Dx, Tx |
immediately think Primary Sclerosing Cholangitis
Confirm Dx with cholangiographic "Beading" of bile ducts Tx: control with ursodeoxycholic acid, dilation & stenting; ultimate tx is transplant Survival is 12 years from Dx due to hepatic failure |
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Pre-cirrhotic alcoholic liver px:
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dz will completely reverse with abstinence from ETOH (as long as not fully cirrhotic)
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Potassium Chloride pills complications
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pill esophagitis from
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Hepatic Encephalopathy superimposed on Acute Hepatitis
course of action |
80% mortality, high priority candidate for liver transplantation
contrad by non-hepatic likely causes of death or drug/etoh abuse |
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Noncaseating Granulomas
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are pathognomonic for Crohns
when differentiating Crohns vs UC |
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D-xylose test:
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D-xylose is a simple sugar which only requires access to mucosa to be absorbed
ie: it will still be absorbed with pancreatic & hepatic insufficiency normally a person ingests 25mg and excretes >4.5g within next 5 hours non-excretion = non-absorption = either celiac dz or bacterial overgrowth bacterial overgrowth responds to abx |
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cirrhosis with varices
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anyone with cirrhosis should get an endoscopy to screen for esophageal varicies
anyone with asymptomatic esophageal varices should be started on beta blockers prophylactically |
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Hepatic Adenoma Lab Abnormalities:
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Possibly elevated AP & GGT
Dx: CT + AFP levels to monitor for malignant transformation (10% of time) Bx: hepatocytes w/ glycogen & fat (normal looking) but lacking tissue architecture (ducts/septa, etc) |
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Acalculus colechystitis:
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critically ill noncommunicative pts
imaging: thickend GB wall & pericholecytic fluid EMERGENT --> SEPSIS --> DEATH Tx: IV ABx + Interventional Radiology percutaneous cholecystostomy |
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Choledochal cysts
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: congenital abomalies
dilation of biliary ducts weakness of wall due to reflexu of alkaline pancreatic secretions |
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Transaminases & PT as indicators of post-Hepatitis Liver fnx
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Transaminases Decreases + Stable PT = Recovering Liver
Transaminases Decrease + Increasing PT = Hepatocytes mostly dead, decreased number dying = decreased transaminases; liver function markedly deteriorate = increased PT. |
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Dubin Johnson Sro vs Rotor sro:
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conjugated hyperbilirubineamias
both benign disorders of bile secretion DJ is pigmentedhepatocytes, rotor is not. |
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acute ascending cholangitis course of action
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= ERCP, not surgery
much lower morbidity with ERCP |
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melanosis coli
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dark brown discoloration of colon with lymph follicles shining through as pale patches
diagnostic of factitious diarrhea pigment macorphages in lamina propria 4 months from use of laxatives to melanosis coli [only with anthraquinone containing laxatives like bisacodyl), 4 months to resolution after last use |
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dark brown discoloration of colon with lymph follicles shining through as pale patches
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melanosis coli
diagnostic of factitious diarrhea pigment macorphages in lamina propria 4 months from use of laxatives to melanosis coli [only with anthraquinone containing laxatives like bisacodyl), 4 months to resolution after last use |
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Pancreatitis Imaging:
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no imaging for acute pancreatitis until fail to respond to conservative treatment then CT
Diagnosti test for chronic pancreatitis best established by imaging best established by calcification |
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Tx: varices
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sclerotherapy/band ligation & surgery are all not indicated until after a variceal bleeding. they are not prophylaxisis; Protostystemic shunt is the last resort as it worsens encephalopathy.
Non bleeding varices are managed with propranolol. This reduces bleeding risk by half. |
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ZE: diagnoisis
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is fasting gastrin >1k
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MCSro assoc. w/ Increased Gastric Folding & Duodenal Ulcers
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Zollinger-Ellison Sro (GastrinOMA) <-- MEN I: 1* hyperparathyroidism, pituitary rumors & pancreatic tumors
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Hydatid Cyst
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means Echinococcus tapeworm infection - sheep *7 dogs
Tx: controversial, basically resect because they can all bleed or undergo malignant transformation |
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suspected esophageal perf
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when you'd like to perform both barium swallow and endoscopy for difficulty swallowing
perform the swallow first - because maybe esophagus is tortuous stricture or something you would perf. |
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inflam bowel dz vs EHEC:
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inflam bowel >4 wks
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Mallory Weiss Bleeding Stops Spontaneously in ?%
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90% of pts
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Mechanisms of hepatic encephalopathy:
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1. accumulation of ammonia
2. prodxn of false neurotransmitter 3. increased sensitivity to inhibiotry neurotransmitters like GABA 4. Zinc deficiency NB: charactreristic delta waves on EEG |
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Potential COmplications of Acute Pancreatitis:
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Left-Sided Pleual Exudative Effusion
Abd Compartment Sro IntraAbd hemorrhage Shock Diabetes, Pancreatic Pseudocyst Abdominal Pseudoaneurysm |
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Anytime you have epigastric pain
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include pancreatitis in your DDx
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Causes of Drug Induced Esophagitis
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(ie direct caustic injury to esophagus)
Antibiotics: Tetracyclines Anti-inflam: NSAIDS & Aspirin Bisphosphonates: Alendronate Others: KCl, quinidine, iron |
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pt with sx cholelithiasis does not want surgery
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--> ursodeoxycholic acid & avoid fattty foods
ursodeoxycholic acid reduces hepatic secretion of cholesterol & slowly dissolves stones expensive & stones recur |
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Hepatorenal Sro:
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Renal Failure of unknown cause (likely vasodilatory) from Hepatic Failure
Support: Vasporessin, Vasoconstrictors, Albuin Treatment: Liver Transplant is only Definitive Treatment |
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UC monitoring
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: colonoscopy every year after 8th year since dx
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Fleshy immobile mass midline hard palate
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Torus Palatinus
benign, ulcerates from poor vascular supply surgical exision if symptomatic congenital, may grow thorughout life |
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Why Steatorrhea in ZE Sro?
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Gastrin --> Acidification of Stomach --> inactive pancreatic enzymes
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ulcer locations
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Acid hurts ulcers
gastric ulcers get worse with eating duodenal ulcers get better with eating (pancreatic HCO3) duodenal ulcers higholy associated with H pylori |
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traumaticly induced duodenal hematoma
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Tx: NG tube, NPO & parenteral nutrition
ie best management is conservative, no need for abx, surgical only if failure of conservative measures |
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how different drugs cause hepatic damage:
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cholestasis: chlorpromazine, nitrofurantoin, erythromycin, anbolic steroids
fatty liver: tetracycline, valproate, anti-retrovirals hepatitis: halothane, phenytoin, INH, alpha methyldopa toxic/fulminant liver failure: carbon tetrachloride, acetaminophen granulomatous: allopurinol, phenylbutazone |
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Pt OD's on acetaminpophen, course of action:
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<4hours: administer charcoal (not useful thereafter)
@4hours: draw actetaminophen lvels (not accurate beforehand) thereafter: determine & administer loading dose of N-acetyl cysteine (no change in efficacy so long as given within 8 hours of ingestion) |