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175 Cards in this Set
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this is the recurrent reflux of gastric contents into the distal esophagus because of mechanical or functional abnormality of lower esophageal sphincter |
reflux esophagitis
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reflux causes erosion of the esophagus that leads to this in a minority of pts
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barrett esophagitis (replacement of normal squamous epithelium with metaplastic columnar epithelium) which can predispose to malignancy
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symptoms of reflux
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heartburn worse after eating or lying down, regurgitation or dysphagia; hoarseness, halitosis, cough, hiccups, chest pain
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when do you do a barium swallow in a pt with reflux
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dysphagia; it may identify a large hiatal hernia
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when do an EGD in pt with reflux
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symptoms are sever or do not respond to medicine
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when do you do pH monitoring in pt with reflux
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this is done to confirm and quantify pathology; indicated in pt who do not respond to treatment, recurrence of symptoms after treatment, need surgery
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treatment of reflux
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antacids or alginic acid (gaviscon) for mild symptoms, H2 blockers for mild symptoms, PPIs for mod-severe symptoms or evidence of erosive gastritis
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what meds should be avoided in pts with reflux
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anticholinergic, beta adrenergic and calcium channel blockers
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what pt migh have infectious esophagitis
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immunocompromised persons
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common causes of infectious esophagitis
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Fungal (candida, look for oral thrush), Viral (CMV, herpes simplex), rare causes include TB, HIV, EBV
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main clinical feature in immunocompromised pt with infectious esophagitis is....
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odynophagia (painful swallowing) or dysphagia (difficult swallowing)
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most common symptom for esophageal motility disorder
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dysphagia
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will neurogenic dysphagia affect swallowing of solids or liquids
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both
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this esophageal motility disorder can cause regurgitation of undigested food and liquid into the pharynx several hours after eating
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zenker's diverticulum
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slow progression of solid food dysphagia suggests
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esophageal stenosis, slow progression...webs/rings, rapid progression....malignancy
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global esophageal motor disorder in which peristalsis is decreased and lower esophageal sphincter tone increased, causing slowly progressive dysphagia with episodic regurgitation and chest pain
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achalasia
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what diagnostic study would show you both structural and motor abnormality of the esopagus that may cuase dysphagia
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barium swallow
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typical appearance of achalasia on barium swallow
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"parrot-beaked" appearance`
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most common type of esophageal neoplasm
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95% are squamous cell carcinoma
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linear mucosal tear in esophagus, generally at GE junction, occurs with forceful vomiting or retching causing hematemesis
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mallory-weiss tear
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mallory-weiss tear is often associated with this....
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alcohol use
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diagnosis and treatment of mallory-weiss tear
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diagnose by EGD, most resolve without treatment, can inject epinephrin or thermal coagulation may be required
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this is dilation of the veins of the esophagus, generally at distal end
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esophageal varices
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this is the underlying cause of esophageal varices in adults
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portal hypertension
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most common causes of portal hypertension
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cirrhosis either from alcohol abuse or from chronic viral hepatitis
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diagnosis of esophageal varices
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pt with cirrhosis presents with hematemesis
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2 steps of treatment of esophageal varices
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hemodynamic support and control bleeding, (30% mortality with 1st bleed & 50% within 6 weeks);
endoscopic therapy and pharmocologic vasoconstriction (octreotide) are preferred therapy |
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this is inflammation of the stomach
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gastritis
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name an example of an autoimmune disorder that causes type A gastritis (involves the body of the stomach)
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pernicious anemia
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this is a Gram-negative, spiral-shaped bacillus which can cause type B gastritis (involves the antrum and body of stomach)
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Helicobacter Pylori
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H. Pylori is often associated with these three conditions
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Peptic ulcer, gastric adenocarcinoma, gastric lymphoma
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common indicators of gastritis
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abdominal pain, dyspepsia
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this is defined as an alteration in gastric motility
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delayed gastric emptying
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causes of delayed gastric emptying
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myopathic diseases of the smooth muscles & neurologic dysfunction
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clinical features of delayed gastric emptying
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nausea and feeling of excessive fullness after meals
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treatment of delayed gastric emptying
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prokinetic agents (cisapride, metoclopramide)
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an ulcer of the upper digestive tract
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Peptic ulcer disease (gastric or duodenal ulcer)
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most common cause of PUD
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H. pylori
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lifetime risk of ulcer disease
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5-10%
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clinical features of PUD
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abdominal pain or discomfort (primary feature, descibed as burning or gnawing, often radiates to back, [duodenal ulcer pain often improves with food, gastric ulcer typically worsens causing associated weight loss]), dyspepsia (belching, bloating, distention, heartburn) or nausea
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treatment for PUD
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avoid smoking, alcohol, NSAIDs; antacids, H2 blockers, sucralfate heal duodenal ulcers 4-6 wks, gastric ulcers within 8 wks
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treatment for PUD + H pylori
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PPI with clarithrobycin & amoxil; bismuth subsalicylate + tetracycline, metronidazole, & PPI; ranitidine, clarithromycin & amoxil, tetracycline or netronidazole
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use this prophylactically for pt who has history of ulcer who needs daily NSAID, chronic steroids or anticoagulants
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misoprostol or PPI
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gastrin-secreting tumor causing hypergastrinemia which results in refractory PUD
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zollinger-ellison syndrome (ZES)
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labs in pt with zollinger-ellison syndrome
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fasting gastrin level >150 indicates hypergastrinemia; need secretin test to confirm ZES, give secretin 2 U/kg IV, gastrin levels go up by more than 200 pg/mL in ZES
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treatment of ZES
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PPIs to control gastrin secretion; surgical resection of gastrinoma
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most common cause of cancer worldwide but less common in US
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gastric adenocarcinoma
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pt that you need to consider gastric adenocarcinoma in
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men 2x more likely than women, almost never occurs under age of 40
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there is a strong association of gastric adenocarcinoma and.....
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H pylori
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signs & symptoms of gastric adenocarcinoma
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dyspepsia, weight loss, anemia, occult GI bleeding in pt >40 yo. progressive dysphagia if ceoplasm impinging on esophagus, postprandial vomiting if near pylorus
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signs of metastatic spread of gastric adenocarcinoma include virchow's node and sister mary joseph nodule. what are they....
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Virchow's node-left supraclavicular lymphadenopathy, Sister Mary Joseph nodule-an umbilical nodule
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this is the most common extranodal site for non-Hodgkin's lympoma
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stomach
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increased frequency or volume of stool (3 or more liquid or semisolid stools daily for at least 2-3 consecutive days)
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diarrhea
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secretory diarrhea (large volume without inflammation) indicates
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pancreatic insufficiency, ingestion of preformed bacterial toxins, laxative use
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symptoms of inflammatory diarrhea
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bloody diarrhea & fever
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causes of inflammatory diarrhea
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invasive organisms or inflammatory bowel disease
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antibiotic associated diarrhea is almost always caused by...
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clostridium difficile colitis (C. diff), which n most sever cases causes classic pseudomembranous colitis
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lab findings if inflammatory process is cause of diarrhea
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WBCs in stool
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treatment of diarrhea
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supportive is sufficient for most pts w/ viral or bacterial; antibiotics for pts w/ severe diarrhea & systemic symptoms
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this can be the cause of diarrhea in a patient that has eaten poultry
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salmonella, campylobacter if undercooked poultry
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this can be the cause of diarrhea in a patient that has eaten undercooked ground beef
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enterohemorrhagic (E. coli)
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normal bowel function is what
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3 stools/day to 3 stools/week
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define constipation
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decrease in stool volume and increase in stool firmness accompanied by straining
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in what pts with constipation should you evaluate for colon cancer
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pts >50yo with new onset constipation
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nonpharmacological treatment for constipation
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increase in fiber (to 10-20 g daily) & fluid intake (up to 1.5-2 L/day), increased exercise
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abdominal pain, distention, vomiting of partially digested food, & obstipation suggests
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small bowel obstruction
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treatment of bowel obstruction
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surgical, large bowel being more urgent than small bowel
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Examples of malabsorption that involves a single nutrient
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pernicious anemai (B12), lactase deficiency (lactose)
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causes of malabsorption
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problems in digestion, absorption, or impaired blood and lymph flow
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complaints in pt with malabsorption
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diarrhea is primary complaint, bloating and abdominal discomfort, weight loss, edema, steatorrhea (excessive fat in feces)
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use this test to distinguish maldigestion (pancreatic insufficiency, bile salt deficiency) from malabsorption
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D-xylose test
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if this test is normal in a pt with malabsorption symptoms u should consider pancreatic insufficiency and abnormal bile salt metabolism
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72 hour fecal fat test
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treatment of celiac disease
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gluten-free diet
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treatment for pancreatic insufficency
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pancreatic enzyme replacement
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another name for regional enteritis
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Crohn's disease
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this is an inflammatory bowel disease for which there is some genetic predisposition, cause is unknown
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Crohn's disease
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organs involved in Crohn's disease
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small & large intestine, mouth, esophagus, & stomach; most commonly terminal ileum & right colon; rectum is frequently spared
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complications of Crohn's disease
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fistulas, abscesses, aphthous ulcers, renal stones, predisposition to colonic cancer
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clinical features of Crohn's disease
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abdominal cramps & diarrhea in pt < 40 r most common, low grade fever, polyarthralgia, anemia, fatigue, blood in stool
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findings on barium enema or CT in Crohn's disease
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cobblestone-pattern filling defects with segmental areas of involvement (skip lesions)
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In pt with Crohn's disease, colonoscopy is valuable in diagnosis, but contrast studies and endoscopic procedures should be avoided with fulminant disease because of.....
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possibility of inducing toxic megacolon
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what will biopsy show in pt with Crohn's disease
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involvement of entire bowel wall
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first step in medical treatment for pt with crohn's
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aminosalicylates (sulfasalazine, mesalamine); metronidazole or cipro is added in perianal disease, fissures, or fistulae
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treatment for Crohn's if aminosalicylates are not effective
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corticosteroids
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Crohn's disease treatment for refractory or frequent flare-ups requiring corticosteroids
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immunomodulatory agents (6-mercaptopurine or azathioprine); infliximab is also approved but very $$$$$
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This disease generally starts distally, at the rectum and pregresses proximally, it is continuous, skip areas are not seen, onset is usually gradual
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ulcerative colitis
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clinical features of this include tenesmus & bloody, pus-filled diarrhea, (less commonly--- LLQ pain, weight loss, malaise, fever
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ulcerative colitis
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is toxic megacolon and malignancy more likely in ulcerative colitis or Crohn's disease
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ulcerative colitis
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lab findings in ulcerative colitis
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anemia, elevated sed rate, low albumin
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best method to diagnose ulcerative colitis
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sigmoidoscopy or colonoscopy (avoid in acute disease b/c risks of perforation & toxic megacolon
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treatment of ulcerative colitis
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topical or oral aminosalicylates & corticosteroids; surgery can be curative, segmental resection if possible, total proctocolectomy is most common surgical cure
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a functional disorder without pathology, thought to be a combination of altered motility, hypersensitivity to intestinal distention and psychological distress
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irritable bowel syndrome (IBS)
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this is the most common cause of chronic or recurrent abdominal pain in the US
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IBS
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when do symptoms of IBS typically begin
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early to mid adulthood
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differential diagnosis in pt with IBS
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lactose intolerance, cholecystitis, chronic pancreatitis, intestinal obstruction, chronic peritonitis, carcinoma of pancreas and stomach
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physical exam findings in IBS
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gernerally normal but may be tender, palpable sigmoid colon and hyperresonance on percussion over the abdomen
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factors that affect abdominal pain in IBS
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worsened with food intake, relieved with defacation, pain may be axxociated with bowel distention from acumulation of gas and associated spasm, postprandial urgency is common
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what urinary symptoms may be found in IBS
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urinary urgency & frequency in women
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labs in IBS
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usually normal, test stool for blood, bacteria, parasites, lactose tolerance; barium enema, u/s or CT to r/o other pathology; endoscope for persistent symptoms, weight loss, anorexia, bleeding, history of other GI pathology
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treatment of IBS
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reassurance, high fiber diet, bulking agents (psyllium hydrophilic mucilloid), antispasmodics, antidiarrheals, prokinetics, antidepressants if indicated by pt's symptoms
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invagination of proximal segment of bowel into portion just distal to it
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intussusception
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who and when might you see intussusception
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children (95% of time) following a viral illness, in adults, almost always caused by neoplasm
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exam findings in intussusception
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children-severe, colicky pain, mucus/blood in stool if passed,
sausage-like mass may be felt on abd. exam; adults-crampy abdominal pain, bloody stool and mass are rare |
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radiology & treatment for intussusception
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children-barium/air enema is diagnostic & therapeutic, if not then surgery; adults-do not do barium enema, CT scan but most cases not found till surgery, treatment is surgery
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large outpouchings of diverticula in the colon
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diverticulosis
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this is inflammation of diverticula caused by obstructing matter
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diverticulitis
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how can u prevent diverticulitis in a pt who has diverticulosis
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high-fiber diet & avoiding obstructing foods
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sudden onset of abdominal pain, usually left lower quadrant or suprapubic region, with or without fever; altered bowel movement, nausea & vomiting are common
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diverticulitis
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generally presents with large volume sudden-onset hematochezia, resolves spontaneously, continuous or recurrent bleeding are indications for surgery
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diverticular bleeding
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treatment for diverticulitis
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low residue diet, broad spectrum antibiotics, bowel rest, analgesics, NG tube for ileus, surgery if peritonitis, large abscess, fistula or obstruction
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causes of acute mesenteric ischemia
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arterial embolus, arterial thrombosis, venous thrombosis
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this condition presents with abdominal angina, with pain occu occurring 10-30 minutes after eating that is relieved somewhat by squatting or lying down
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chronic mesenteric angina
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presentation of acute mesenteric angina
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sudden onset severe abdominal pain out of proportion to exam
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radiology for mesenteric ischemia
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plain-film or CT to rule out other cuases, CT can help delineate extent of ischemia, angiography may be helpful
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this is extreme dilatation & immobility of colon & represents a true emergency
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toxic megacolon
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this is a congenital aganglionosis of colon, leading to functional obstruction in the newborn
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Hirschsprung's disease
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In adults, toxic megacolon is a complication of one of these diseases.....
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ulcerative colitis, Crohn's colitis, pseudomembranous colitis, specific infectious causes (amebiasis, shigella, campylobacter, C-diff)
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clinical findings in toxic megacolon
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fever, prostration, severe cramps abdominal distention, rigid abdomen, localized diffuse or rebound abdominal tenderness
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x-ray findings in toxic megacolon
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colonic dilatation
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treatment of toxic megacolon
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decompression of colon, colostomy or complete colon resection may be required
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this is a genetic predisposition to multiple colonic polyps & a high risk of colonic cancer
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familial polyposis syndrome
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3rd leading sause of cancer death in the US
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colorectal cancer
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abdominal pain, occult bleeding, intestinal obstruction, change in bowel habits (change in stool shape or size)
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colorectal cancer
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what role does CEA levels play in diagnosing colorectal cancer
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none, may be used to monitor but not detect it
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why would you give radiation to pt with colorectal cancer
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reduce tumor size preoperatively
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when would you give chemo to pt with colorectal cancer
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with any extension through the serosa or with lymphatic spread
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painful swelling at anus & painful defecation, localized tenderness, erythema, swelling, fluctuance (indication of the presence of pus in a bacterial infection), fever is uncommon
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perirectal & perianal abscesses
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treatment for anorectal abscess
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surgical drainage followed by warm-water clensing, analgesics, stool softeners, high-fiber diet; do not explore tract on exam as this may open new tracts
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this is linear lesions in rectal wall, most commonly found on posterior midline
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anal fissures
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severe tearing pain on defecation, hematochezia, bright red blood noted on stool or tissure paper
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anal fissure
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this is a vaice of the hemorrhoidal plexus
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hemorrhoids
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this hemorrhoid is confined to the anal canal and may bleed with defecation
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stage I internal hemorrhoids
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this hemorrhoid protrudes from the anal opening but reduces spontaneously, bleeding & mucoid discharge may occur
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Stage II internal hemorrhoids
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this hemorrhoid requires manual reduction after bowel movements, pts may develop pain and discomfort
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Stage III internal hemorrhoids
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this hemorrhoid is chronically protruding and risk strangulation
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Stage IV internal hemorrhoids
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treatment for stage I & II hemorrhoids
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high fiber diet, increase fluids, bulk laxatives, high stage hemorrhoids treated with suppositories
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treatment for stage IV hemorrhoids & hemorrhoids unresponsive to conservative treatment
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surgical treatment (infection, rubber band ligation, sclerotherapy
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this is an abscess in the sacrococcygeal cleft associated with subsequent sinus tract development
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pilonidal cyst
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typical pts you may see a pilonidal cyst in
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hairy, obese individual, almost always under the age of 40
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treatment of pilonidal cyst
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surgery
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complications of fecal impaction
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urinary tract obstruction, UTI, spontaneous perforation of the colon
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what is the cause of appendicitis
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obstruction of the appenix, by fecalith or other cause, leads to inflammation & infection
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typical age of appendicitis
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10-30
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complications of appendicitis
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perforation & peritonitis occur 20% of time, causing high fever, generalized abdominal pain, increased WBCs
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clinical features of appendicitis
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intermittent periumbilical or epigastric pain, followed by RLQ pain (McBurney's point), worse with movement, rebound tenderness, nausea, anorexia, low grade fever, psoas and obturator sign
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what is psoas sign
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pt is supine and attempts to raise the leg against resistance
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what is obturator sign
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pt is supine and attempts to flex and internally rotate the right hip with knee bent
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causes of acute pancreatitis
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alcohol (most common), cholelithiasis, hyperlipidemia, trauma, drugs, hypercalcemia, penetrating PUD
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medications that you might suspect to be the cause of pancreatitis
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antiretoviral medications used to treat HIV
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clinical features of acute pancreatitis
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epigastric pain radiating into back, typically improves when pt leans forward or lies in fetal position
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symptoms other than pain you may see with acute pancreatitis
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nausea, vomiting, fever, leukocytosis, sterile peritonitis
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lab findings in acute pancreatitis
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elevations in wbc, amylase, lipase, liver enzymes, bilirubin, glucose, pt may also develop hypocalcemia
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this lab is more sensitive and specific
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lipase-but only with elevations of threefold or greater
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treatment of acute pancreatitis
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NPO, parenteral hyperalimentation, meperidine for pain, consider antibiotics
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complications of acute pancreatitis
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pancreatic pseudocys, renal failure, pleural effusion, hypocalcemia, pancreatic abscess
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most common cause of chronic pancreatitis
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alcohol abuse (90%), other causes: cholelithiasis, PUD, hyperparathyroidism, hyperlipidemia
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classic triad in chronic pancreatitis
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DM, pancreatic calcification, steatorrhea
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treatment for chronic pancreatitis
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low-fat diet, surgical removal of part of pancreas can control pain, treat underlying cause i.e. alcohol
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5th leading cause of cancer death n U.S.
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pancreatic
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signs & symptoms of pancreatic cancer
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jaundice, palpable gallbladder (Courvier's sign)
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most common cause of acute hepatitis
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viral
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2 types of hepatitis transmitted by fecal-oral contamination
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A & E
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How r hepatitis B, C & D transmitted
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parenterally or by mucous membrane contact
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fatigue, malaise, anorexia, nausea, tea-colored urine, vague abdominal discomfort suggests
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hepatitis
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this hepatitis is only seen in conjunction with hep. B
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D
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these two types of hepatits are frequent co-existent with HIV
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B & C
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elevation of aminotransferase indicate
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hepatocellular damage; this is seen in all types of acute hepatitis
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HAV IgG (hepatitis A virus IgG) indicates
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resolved hepatitis A
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causes of toxic hepatitis
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alcohol, tylenol, isoniazid phenytoin
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irreversible fibrosis & nodular regeneration throughout liver
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cirrhosis
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treatment of cirrhosis
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no alcohol, salt restriction, spironolactone 100 mg daily if diuretic needed; liver transplant in selected pts
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2 types of primary cancer that commonly metastasize to liver
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lung, breast
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in hepatic carcinoma this lab test will be elevated
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alpha-fetoprotein
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explain pyloric stenosis
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projectile vomiting, usually 4-6 weeks into life, palpable "olive" mass deep in epigastrium on exam, "sting sign" on the pyloric lumen on barium swallow, treat with surgery
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what is hirschprung's disease
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congenital megacolon
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