GI Primary Care

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What is the care for Constipation?
What is the care for Diarrhea?
What is the care for Nausea/Vomiting?
What is the care for GERD?: Stage I: Lifestyle modifications; Elevate head of bed 6-8 inches or sleep on foam wedge, avoid alcohol, chocolate, caffeine, fats, peppermint and spearmint, spicy foods, stop smoking, eat small meals and use antacids AND/OR low dose, OTC H2 receptor antagonists taken up to 2X/day. If symptoms do not change after 2 weeks go to Phase II. Phase II: (H2 inhibitors- Cimetidine and PPI's- Omeprazole - low dose), Phase III (increase doses), Phase IV (surgery). Must maintain pH above 4 for healing of esophagitis and/or ulceration.
What is the care for Esophagitis?
What is the care for Esophageal Cancer/: Surgery only - 3-20% survival, Surgery and radiation - 30% survival.
What is the care for Peptic Ulcer Disease?: Histamine 2 receptor antagonists-block action of histamine on gastric parietal cells, reducing acid secretion. Treat 6 weeks for DU and 3 months for GU. H. pylori treatment (3 drug regimen): Option #1: Clarithromycin, Amoxicillin, and PPI for 10-14 days, Option #2: Clarithromycin, Metronidazole and PPI for 10-14 days (Metronidazole has alcohol producing disulfram -like effect). H. pylori antigen stool test should be negative after 4 week of completing treatment. Bismuth triple play - (bismuth, tetracycline, and metronidazole)
What is the care for Zollinger-Ellison Syndrome (ZE)?: Max dose PPI -Omeprazole.
What is the care for Gastric Tumors?: Surgery. Only 50% are resectable and of these 25% are curable.
What is the care for Pancreatic Cancer?: Dx with CT scan of abdomen, ultrasound is also good. Surgery effective only 10% of time. Survival without surgery= 5 months. Gemzar is a drug that has some promise (gives another 6 months to year). It decrease WBC making prone to infection.
What is the care for Acute Pancreatitis?: Dx: Cullen's sign (bluish discoloration of skin around umbilicus), Grey Turner's sign (bluish discoloration around flanks due to blood seeping into tissues), Amylase: Elevated in first 2-12 hrs and declines in 3-5 days. Lipase: more specific for pancreatitis decreases in 7-10 days (numbers will be 3X normal). Pain control with meperidine or morphine (does not cause spasm at sphincter of odi), dilandid, methadone. Somatostatin and otreotide inhibit panreatic enzyme secretion. NPO. NG tube with low suction and volume replacement with IV fluids over the course of 3-7 days
What is the care for Chronic Pancreatitis?: CT scan. Pain control, avoid all alcohol, cholcystectomy. Use pancreatic enzymes (Pancreatin and Pancrelipase)
What is the care for Ulcerative Colitis?: Dx via flexible sigmoidoscopy (granular appearance, bleeds easily) and a stool culture to detect or rule out infectious colitis (salmonella, shigella, campylobacter). A barium enema will show loss of haustration and pipestem appearance but don't use during an acute attack (will increase infection risk). Supportive nutrition-keep fluids up, use corticosteriodis in enema form for acute attack then switch over to 5-Aminosalicylate (5-ASA)[anti-inflammatory]. If unresponsive and/or disease is prolonged - colectomy and get family involved in support group.
What is the care for Crohn's Disease?: Dx via double contrast barium enema. May have remissions lasting years, surgery is not curative. Supportive nutrition, Metronidazole (Abx), 5-ASA. If have continued activity add prednisone then add immunomodualtor then add Infliximab
What is the care for Irritable Bowel Syndrome?: If tender sigmoid full of stool noted in LLQ-wait till pt. defecates then reassess. Patient must exhibit the following criteria for at least 3 months: Abdominal pain or discomfort that is : relieved with defecation, and/or associated with change in frequency of defecation, and/or associated with change in consistency of stool. Plus two or more of the following (which occur at least 1/4 of the time): Altered stool frequency (>3/day or <3/week), altered stool form, altered stool passage (straining, urgency, incomplete), passage of mucus, bloating of abdomen. To rule out other conditions, perform stool cultures, colonoscopy and test TSH to rule out the thyroid. Increase fiber intake (25-30g/day) when have constipation (also use Tegaserod-Zelnorm) and (Loperamide)-Imodium D when have diarrhea.
What is the care for Diverticulosis?: Dx via sigmoidoscopy. Usually self limiting with no manifestations.
What is the care for Diverticulitis?: CT scan is best. Mild, non-perforating with no high risk factors (DM, Cancer, CAD) use TMP/SMX (Bactrim) plus Metronidazole (parasites) if allergic to Bactrim (sub. Cipro.)[Oral]. Moderately ill, possible abscess and high risk factors us Ampicillin plus Aminoglycosides plus metronidazole (IV)
What is the care for Maldigestion?: Dx via screening (Qualitative fecal fat; tells if fat present or not, CBC (Chemistry profile), Quantitative Stool Fat -72 hr. sample (<100g of fat per day should be consumed during test). D-xylose test-give 25g oral D-xylose and collect urine for 5 hours (should have 4-6 grams in urine if absorbed, values lower indicate malabsorption), Assess bacterial overgrowth with Bile acid Breath test-give labeled conjugated bile acid, if overgrowth will be deconjugated, metabolized and blow-off radioactive CO2, can also do small bowel aspirate for Giardia.
What is the care for Malabsorption?: Dx via screening (Qualitative fecal fat; tells if fat present or not, CBC (Chemistry profile), Quantitative Stool Fat -72 hr. sample (<100g of fat per day should be consumed during test). D-xylose test-give 25g oral D-xylose and collect urine for 5 hours (should have 4-6 grams in urine if absorbed, values lower indicate malabsorption), Assess bacterial overgrowth with Bile acid Breath test-give labeled conjugated bile acid, if overgrowth will be deconjugated, metabolized and blow-off radioactive CO2, can also do small bowel aspirate for Giardia.
What is the care for Hepatitis A?: Dx via serologic testing: HAV capsid causes host production of anti-HAV IgM which indicates acute infection. Presence of anti-HAV IgG indicates previous infection. Treatment does not change course of infection. Use supportive measures-rest and nutrition with abstinence of hepatotoxic agents such as Tylenol, alcohol and use of proper hand washing and cleaning of personal items. Patients should who are anti-HAV IgG negative should receive passive immunity (pooled human immunoglobulin-gives immediate protection but lasts only few months) in addition to active vaccination. The live vaccine is ideally administered at least 2 weeks prior to exposure.
What is the care for Hepatitis B?: Dx via serologic testing: HBV core antigen (HBcAg) appears first, followed by seroconversion to core antibody (HBcAb). Presence of HBV surface antigen = active infection. Anti-HBsAg = immunity, no active disease (may take up to 1 year to appear). HBcAg-IgM = acute disease. HBcAg-IgG = chronic disease. HBeAg = viral replication and high infectivity. Anti-HBeAg = low infectivity (these last two are not screening tests but used to determine infectious state of those who have HBV). Treatment - supportive care, three shot series for HBV as well as HBIG (high dose immunoglobin for temporary immunity), if have chronic active hepatitis (should give 2-dose vaccine against HAV). Interferon and lamivudine are possible meds.
What is the care for Chemotherapy-Induced Emesis?: Combination therapy: Serotonin receptor antagonist plus dexamethosone is current treatment of choice. Lorazepam is added to reduce anxiety and anticipatory emesis and to provide amnesia. Option #1: Ondanstron (Zofran), Dexamethason, Lorazepam.
What is the care for Hepatitis C ?: Tx: alpha interferon by itself has 30-40% success but also has flu like symtoms and produce severe depression. Lamivudine (Epivir) has 15% success rate by itself. These 2 together have an 80% success rate. Ribavirin orally twice daily has been used with alpha interferon. Chronic HCV patients should be vaccinated against HAV and HBV.
What is the care for Hepatitis D?: Control HBV infection is only way to protect against HDV.
What is the care for Hepatitis E?: Tx: is supportive. No vaccine available. Prophylaxis - avoid undercooked foods, careful hand washing, drinking of safe water.
What is the care for Drug Induced Hepatitis?: Stop the drug
What is the care for Chronic Hepatitis?
What is the care for Cirrhosis?: Dx via liver bx and negative hepatitis screen. Up to 25% of patients thought to have alcoholic cirrhosis will have another etiology (Hemochromatosis, Wilson's disease, drug-induced, alpha -1-antitrypsin, sclerosing cholangitis) Tx: damage already done, abstinence of alcohol improves 5 year outlook from 63% vs 40%. Liver transplant ultimate outcome but person may not get it since they can't stop drinking. Don't want to waste the liver.
What is the care for Alcoholic Liver Disease?: Dx via liver bx. Tx: abstinence, thiamine (B1) to prevent encephalopathy and folate to prevent anemia, watch for delerium tremens from withdrawalâ†’give Librium to knock them out. This is completely reversible.
What is the care for Acute Alcoholic Hepatitis (active inflammation of the centrilobular region of the liver): Dx: History and liver bx (fat, fibrosis, central sclerosis alcoholic hyaline). Tx: Hospital based - abstinence, supportive, watch for complications (GI bleeding, DT's, encephalopathy, hypoglycemia, ascites, peritonitis, renal failure). 70-90% recover to healthy liver, 1 in 4 severe patients die due to multiple organ failure.
What is the care for Complications of Liver Disease?
What is the care for Hepatic Encephalopathy?: Dx: Eleveated serum ammonia (other conditions mimic thisâ†’acute alcohol intoxication, sedative overdose, delirium tremens, wernicke's encephalopathy. Tx: Lowering of blood ammonia levels by decreasing protein absorption and nitrogen products from intestin: Lactulose acts as osmotic laxative to decrease ammonia production through effects on bacterial metabolism (30cc q 1-2 hours until diarrhea), limit protein intake as low as 40g/day.
What is the care for Ascites?: Tx: 1. start with sodium restriction and potassium sparing diuretic (Spironolactone or Triamterene), 2. If diuresis is not suitable add loop diuretic (Furosemide, Bumetanide), 3. With the combined use of both diuretics - 90% success rate. 4) If resistant to diuretic therapy or those with tense ascites or respiratory difficulty then perform paracentesis (if first time, pull-off 2 liters then wait couple of days then pull off more, if pull too much too fast can cause flash 3rd space filling)
What are the characteristics of Constipation?: Normal: Defecate 250g/day. Normal frequency vary from 5/day -1 every two weeks. Obstipation - incurable constipation with hard rock like stools
What are the characteristics of Diarrhea?
What are the characteristics of Nausea/Vomiting?: Key clinical feature to look for is blood. Vomit character gives lesion location: Unchanged food -esophagus, Partially digested/sour food-stomach, Bitter food-duodenum, Food eaten day before-gastric outlet obstruction, Feculent vomiting-intestinal problem.
What are the characteristics of GERD?: Heartburn, regurgitation, chest pain, and dysphagia. If chronic may lead to Barrett esophagus in which columnar tissue replaces normal squamous epithelium of the distal esophagus increasing the risk of esophageal cancer. Often see with Hiatal hernia. Alarm Sx: Bleeding, anemia, wt. loss, anorexia, odynophagia/dyspahgia. Dx via EGD and biopsy.
What are the characteristics of Esophagitis?
What are the characteristics of Esophageal Cancer?: Dysphagia, Weight loss, Regurg., Odynophagia. Dx-EGD. Very low 5 year survival rate.
What are the characteristics of Peptic Ulcer Disease?: Duodenal Ulcer - burning midepigastric pain, pain relieved by food or antacids, pain return 1-3 hours after meal and may awaken at night. Gastric-pain localized to midline or to left of midline, food may alleviate but hot liquids and alcohol aggravate, may have early satiety, N/V if ulcer located distally. Both are Dx via EGD.
What are the characteristics of Zollinger-Ellison Syndrome (ZE)?: Multiple ulcers, ages 45-51 with abdominal pain and diarrhea. Fasting serum gastrin level will be elevated (>1000pg/ml) and pH less than 2.5). Make sure to stop any PPI's before recording measurement.
What are the characteristics of Gastric Tumors?: Higher rates in Japan, 50-60 year olds, located in lesser curve of antrum, 20% 5 year survival rate. No early signs of cancer, may have postmeal fullness or indigestion, anorexia, weight loss and elevated CEA (Carcinogenic Embryonic Antigen) in 65% of cases and occult blood in stools (50%). Diagnosis via biopsy and EGD
What are the characteristics of Pancreatic Cancer?: Abdominal pain (radiates thru to back), weight loss, jaundice (these usually appear after advanced stages of the cancer). 70% occur in the head of the pancreas. Liver Function Tests - AST, ALT when elevated indicate liver cell damage. When Alk Phos and GGT are elevated = liver obstruction. 5% survival rate
What are the characteristics of Acute Pancreatitis?: Slow onset of pain over a couple of hours (in the epigastrium or LUQ) that gets worse and radiates thru to back. If pain is sudden more likely to be GB. Temp. of 100-101, N/V, and early increase in BP with later drop due to 3rd spacing of fluid. Complications - associated pain, chills, fever, increased WBC persisting more than 5 days. Diff. Dx - perforated peptic ulcer, GB disease, mesenteric thrombosis.
What are the characteristics of Chronic Pancreatitis?: Epigastric pain radiating thru to back, weight loss, anorexia, N/V. Destruction of parenchyma leads to fibrosis and calcification of the area visible on CT and X-ray.
What are the characteristics of Ulcerative Colitis?: Bloody diarrhea and abdominal pain that hurts all over (feel better after defecation). If severe: fever, weakness, malaise, tachycardia. Extracolonic manifestations: non-deforming arthritis, iritis, liver disease, iron deficiency, hypokalemia and hypoalbminemia and increased Alk phos. Complications - toxic megacolon (dilation of colon greater than 6 cm) and colon cancer.
What are the characteristics of Crohn's Disease?: RLQ abdominal pain that is constant, cobblestone mucosa, discontinuous in nature, transmural (goes thru entire mucosal wall), chronic watery (non-bloody) diarrhea, perianal/perirectal fistulas, non-deforming arthritis and liver disease. Primary complications - Small bowel obstruction and fistula formation. Nutritional deficiency develops due to poor Vit. B12 absorption at terminal ilieum.
What are the characteristics of Irritable Bowel Syndrome?: Chronic intermittent symptoms including recurrent abdominal pain, usually LLQ, altered frequency of defecation with hard stools or watery stools; stool urgency and abdominal distension. Spastic colitis- chronic abdominal pain and constipation, Chronic intermittent diarrhea without pain or combination of both.
What are the characteristics of Diverticulosis?: Herniations of the submucosa and mucosa through the circular muscle layer of the bowel wall mainly of left side of colon. Episodic crampy, LLQ pain lasting hours to days with no rebound tenderness.
What are the characteristics of Diverticulitis?: LLQ pain and tenderness, N/V, fever, chills, rebound tenderness, pain on left side during rectal exam, leukocytosis with left shift. Orientals have more rt.side sx. Corticosteroids make it very difficult to knock out the infection.
What are the characteristics of Maldigestion?: Early-wt. loss, anorexia, no appetite, abdominal distension, bloating, diarrhea, fatty stools. Late-weakness, pallor, osteomalacia and bone pain due to decrease in Vitamin D and Calcium.
What are the characteristics of Malabsorption?: Early-wt. loss, anorexia, no appetite, abdominal distension, bloating, diarrhea, fatty stools. Late-weakness, pallor, osteomalacia and bone pain due to decrease in Vitamin D and Calcium.
What are the characteristics of Hepatitis A?: Malaise, anorexia, nausea, low-grade fever, RUQ pain and possibly jaundice. Can only cause acute infection, no chronic disease.
What are the characteristics of Hepatitis B?: Prodrome Sx are more insidius and longer lasting than HAV (urticaria,rashes, arthralgia, arthritis, angioedema, serum sickness, jaundice, glomerulonephritis). May lead to acute hepatitis, fulminant hepatitis (severe acute hepatitis with rapid liver destruction), chronic hepatitis - several states: (Asymptomatic carrier-never develops antibodies and harbors virus without liver damage); Chronic-persistent hepatitis-pt. has low grade "smoldering" hepatitis; Chronic active hepatitis-pt. has an acute hepatitis state that continues without the normal recovery time of 6-12 months; Co-infection with hepatitis delta virus -only get if have HBV)
What are the characteristics of Chemotherapy-Induced Emesis?
What are the characteristics of Hepatitis C ?: HCV has 3 genotypes. Type I is the most common and also most difficult to treat - confirm type via polymerase chain reaction (PCR). 60-85% become chronic while 10-20% become cirrhosis. Increased risk of hepatocellular carcinoma. Screening via HCV RNA viral load and anti-HCV antibodies.
What are the characteristics of Hepatitis D?: Coinfection of HBV and HDV causes acute hapatitis and leads to accelerated liver diseaseâ†’fulminant hepatitis and cirrhosis. Dx via anti-HDV IgM and IgG enzyme-linked immunosorbent assays (ELISAs).
What are the characteristics of Hepatitis E?: Prodrome similar to HAV but usually last only 2 weeks. Mainly get when travel to 3rd world countries.
What are the characteristics of Drug Induced Hepatitis?: 10-20% present with fever, rash, and eosinophilia (increase in drug and allergic reactions)
What are the characteristics of Chronic Hepatitis?: Low grade liver inflammation that lasts longer than 6 months. Transaminases must be elevated greater than 6 months. Liver bx often helpful.
What are the characteristics of Cirrhosis?: Diffuse hepatic fibrosis resulting in permanent alteration in hepatic flood flow and liver function. May have no symptoms but typically see: portal hypertension (don't clear toxins very quicklyâ†’watch drug dosing and mental confusion), muscle loss, impotence, small (rock hard)liver, vascular spiders, palmar erythema, abdominal collateral. Slight increase in AST and GGT (not huge since most cells have been destroyedâ†’no enzymes to release), decrease in albumin
What are the characteristics of Alcoholic Liver Disease?: Fatty liver: often have no symptoms, some hypoglycemic, ketoacidosis, gout and increased liver span and firmness. Normal to mild AST increase and GGT elevation, normal ALT, normal to elevated bilirubin.
What are the characteristics of Acute Alcoholic Hepatitis (active inflammation of the centrilobular region of ?the liver): Inflammatory state with liver cell death. May have few symptoms due to massive hepatic reserve, palpably enlarged liver, if full blown (fever, jaundice, abdominal pain, ascites, muscle wasting, palmar erythema), liver tender due to capsule inflammation. Labs: AST/ALT ratio 3:1, increase in BUN, bilirubin, Alk phos. If AST greater than 400 think virus.
What are the characteristics of Complications of Liver Disease?: Spider angioma (often of back and chest due to excessive estrogens, turn white when push on it), ecchymosis (no clotting factors 7, 9, 10 from destroyed liver, so bleed large bruises), gynecomastia, palmer erythema, clubbing, testicular atrophy, splenomegaly, parotid gland enlargement, malnourished, caput Medusae (varicose veins around umbilicus), hepatic encephalopathy, Ascites.
What are the characteristics of Hepatic Encephalopathy?: 4 key symptoms together is highly significant (acute or chronic hepatocellular disease, distrubances of awareness and mentation, hyper-reflexes/asterexis and symmetric high voltage slow wave pattern on EEG.
What are the characteristics of Ascites?: Complications: mostly cosmetic, can become infected (bacterial peritonitis), compression of renal vein and artery (â†“GFR), compression of IVC, elevated diaphragm, decreased protein causing edema and pleural effusions.
What is the cause of Constipation?: Hypothyroidism, nerve or muscle dysfunction, narcotics, colon obstructing lesions, hold feces too long
What is the cause of Diarrhea?: Hyperthyroidism, intestinal infections, fat and lactose malabsorption, Crohns and ulcerative colitis, diverticulitis, neoplasm, laxative abuse
What is the cause of Nausea/Vomiting?: #1 (pregnancy), GI disease, trauma, metabolic disorders, CNS lesions, anxiety, pain, Infections - Viral (norwalk agent/rotovirus), Bacterial (salmonella, shigella, E. coli), Parasite - E. histo, Giardia. Drugs -(Chemo, Abx, narcotics, digoxin)
What is the cause of GERD?: Anything that alters the closure of the LES or increases intraabdominal pressure. Fatty foods, caffeine, alcohol, cigarettes side-lying position or sitting, birth control pills and morphine decrease LES closure. Ascites, pregnancy,obestiy and chronic straining or coughing increase intraabdominal pressure.
What is the cause of Esophagitis?: Major cause:GERD. Minor causes:Irradiation (mediastinum tumor), Infection: Herpes (look for oral/genital lesions, often present with odynophagia. Usually see in immunocompromised. EGD. Tx with Acyclovir), Candida (look for oral lesions and white coating. Usually see with dysphagia and in diabetics. EGD. Tx with Nystatin), CMV (same sx as herpes, confirm w/ EGD. Tx with Gancyclovir), Corrosive injury (Lye and Pills).
What is the cause of Esophageal Cancer?: GERD, Diet (Low Vit. A), Smoke, Alcohol
What is the cause of Peptic Ulcer Disease?: Gastric acid secretion vs. protective mechanism of mucous. Gastric Ulcer- presence of aspirin, NSAIDs, alcohol, and bile salts breakdown mucous barrier. NSAIDs inhibit endogenous GI mucosal prostaglandin synthesis: COX -1(mucosal integrity) and COX-2(pain and inflammation)â†’use selective COX-2 inhibitors like Celecoxib (Celebrex) and Naproxyn (Alleve). Duodenal Ulcer-excess vagal nerve activity during fasting and at sleep stimulates release of gastrin which increases HCl release. H. Pylori produce protein toxin (Vac A) forming cellular vacuole. Stress-increases acid production through glucocorticoid release.
What is the cause of Zollinger-Ellison Syndrome (ZE)?: Gastrin-releasing tumor usually in pancreas or duodenum causing gastric acid hypersecretion.
What is the cause of Gastric Tumors?: H.pylori, Nitrate consumption, Pernicious anemia, chronic peptic ulcer
What is the cause of Pancreatic Cancer?: Smoking, chronic pancreatitis, high intake of animal fat, prolonged contact with protroleum products
What is the cause of Acute Pancreatitis?: Gallstone disease (enzymes are still released but due to blockage autodigestion takes place) and alcoholism make up 70% of cases. Post-ERCP and drugs (erythromycin, Tylenol, steroids, tetracycline)
What is the cause of Chronic Pancreatitis?: 75% of cases due to excessive alcohol consumption
What is the cause of Ulcerative Colitis?: Unknown cause. Inflammation begins at the crypts of Lieberkuhnâ†’damage results and leukocytes invade forming abscesses in the cryptsâ†’ulcerations developâ†’attempts to repair result in granulation tissue which is very susceptible to bleedingâ†’diarrhea results from inability of destroyed muscosal tissue to absorb water and sodiumâ†’increased volume of fluid in the intestinal contents
What is the cause of Crohn's Disease?: Unknown cause. Possibly a process in which the lymphoid and lymphatic structures of the GI tract become blockedâ†’engorgement and inflammation of surrounding tissueâ†’development of deep linear ulcers in bowel wallâ†’may lead to fistulas extending to other organs or even the skin and narrowing and thickening of the bowel. Smoking increases risk.
What is the cause of Irritable Bowel Syndrome?: Unknown. Possibly disorder of bowel motility
What is the cause of Diverticulosis?: Areas of weakness in the bowel wall, particularly where blood vessels enter, are subject to damage from high intraluminal pressures (high fiber diets dampen pressure variations)
What is the cause of Diverticulitis?: Inflamed diverticula that is contaminated with bacteria or fecal material that can lead to breakdown of bowel wallâ†’peritonitis and intestinal obstruction.
What is the cause of Maldigestion?: Hepatobiliary disease-anything that â†“bile salts, Post-gastric surgery-loss of normal anatomy and adhesions lead to bowel obstruction, Small Bowel Bacterial Overgrowth-bile salts deconjugated to bile acidsâ†’no micelle formationâ†’(megaloblastic anemia, steatorrhea, decreased protein), Pancreatic Disorders (most common maldigestion cause)-CF, Chronic pancreatitis, ZE, Cancer, Lactose Intolerance (no steatorrhea)-follow lactose free diet for 3 weeks to confirm diagnoses.
What is the cause of Malabsorption?: Celiac sprue (allergy/immune response to glutenâ†’epithelial inflammation)-villi flatten outâ†’no absorptive surface (Dx via Antigliadin Antibody which is present in celiac disease. If negative, due biopsy to confirm)-stool volume >250 g/day. Destruction of absorptive surface - cancers and ZE. Bacterial overgrowth, parasite invasion - Giardia (fatty greasy looking stool). Drugs - Neomycin, Colchicine (gout), cholestyramine (Binds bile salts). HIV
What is the cause of Hepatitis A?: Hepatitis A virus (HAV) - RNA virus that is usually spread by fecal-oral contact and has 15-40 day incubation. Death is very rare
What is the cause of Hepatitis B?: Hepatitis B virus (HBV) - double stranded DNA virus transmitted by blood contact (needle stick, blood spray, sexual contact) - incubation period of 2-6 months
What is the cause of Chemotherapy-Induced Emesis?: Anticipatory-occurs before chemo session. Acute-occurs 1-2 hours after chemo. Delayed-develops a day or more after chemo.
What is the cause of Hepatitis C ?: Hepatitis C virus (HCV) - single stranded RNA virus. Transmitted via blood transfusions, needle sticks, sexual, across the placenta.
What is the cause of Hepatitis D?: Hepatitis D virus (HDV) -incomplete RNA virus only infective with the help of HBV. Transmitted via blood transfusion, needle sticks, sexual contact, across the placenta. (primarily via sex)
What is the cause of Hepatitis E?: Hepatitis E virus (HEV)-single stranded RNA transmitted via fecal-oral route especially through contaminated water.
What is the cause of Drug Induced Hepatitis?: Drugs: Acetaminophen, methotrexate (arthritis), alcohol, halothane (anesthesia), INH (Isoniazid), birth control pills, phenytoin (dilantin)
What is the cause of Chronic Hepatitis?: Drug induced is most common cause. HCV most common in US. HAV never causes chronic hepatitis and HBV 2-4% develop chronic hepatitis.
What is the cause of Cirrhosis?: Represents the irreversibe end stage of many different hepatic injuries: Acute hepatitis, chronic hepatitis (alcohol most common cause, risk high with 8-10 beers/day for years), toxic hepatitis.
What is the cause of Alcoholic Liver Disease?: Manifested by fatty liver, hepatitis, and cirrhosis. 90-95% of alcohol metabolism takes place in liver (alcoholâ†’acetaldehydeâ†’acetate). Alcohol consumption leads to: Impaired gluconeogenesisâ†’hypoglycemia (give alcoholics with lowered mental status glucose..Amp p50), increased lactate production as body tries to free up NADH by reducing pyruvate to lactateâ†’metabolic acidosis), increased ketone body formation (metabolic acidosis), inhibited uric acid excretionâ†’gout and â†‘mean corpuscular volume (MCV), decreased fatty acid oxidationâ†’â†‘TG's and â†‘VLDL, fatty liver (results from decreased FA oxidation and increased TG's).
What is the cause of Acute Alcoholic Hepatitis (active inflammation of the centrilobular region of the liver): Often occurs in chronic alcoholics that "go on a bender" and binge on quantities much greater than their normal intake.
What is the cause of Complications of Liver Disease?
What is the cause of Hepatic Encephalopathy?: Specific cause unknown. Major factors: severe hepatocellular dysfunction and shunting of portal venous blood into systemic circulationâ†’toxic substances absorbed by the intestine are not detoxified (Ammonia is most important one). GI bleeding, excess dietary protein, hypokalemia, drugs, infection (UTI or pneumonia), constipation (can't get rid of toxins)
What is the cause of Ascites?: Increased portal pressure (cirrhosis, rt.side heart failure), decreased serum albumin (â†“oncotic pressure), increased sodium retention (retain water), overwhelmed hepatic lymphatics, tumor metastasis (ovarian most common)
What is the care for Hepatocellular Adenomas (Benign Liver Tumor): Dx via CT scan. Tx: take off BCP.
What is the care for Hemangioma (most common benign liver tumor): Dx: Inadvertently when doing abdominal imaging or surgery (GB). Don't remove unless really large and pushing on organs (can lead to excessive bleeding)
What is the care for Hepatocellular Carcinoma (one of most common tumors in world, 1-2% of US): Dx: â†‘Alk phos and GGT. Alpha-Fetoprotein is elevated (this is also high in testicular cancer), Ultrasound. Need to bx to confirm dx. Tx: Surgical resection only chance of cure (chemo will not cure)
What is the care for Metastatic tumors: Dx: always look for liver mets in any pt. with cancer. The bx will show cellular reminants of primary orgination. Tx: respond poorly to any treatment, intrahepatic chemo (5-flurouricil [5-FU])â†’direct line to liver (casues a lot of N/V)
What is the care for Gallbladder Disease: Dx: Test of choice = U/S, duct will be >5mm. Also use HIDA scan (radioactive marker to see if gets taken up in GB) -can use when bilirubin is elevated. Tx: Asymptomatic cholelithiasis (no treatment). Acute cholecystitis - cholecytectomy (laparoscopy). Chemical dissolution (effective only with cholesterol stones), use Ursodeoxycholic acid (Ursodiol)â†’reduces cholesterol production and increases bile acid activity to dissolve stone about 1mm/month. Shock-Wave lithotripsy (can't have more than 3 stones >3cm in diameter and must have functioning GB, if duct is blocked, can't dissolve stone in bladder because it can't be passed.
What is the care for Sclerosing Cholangitis: Dx: ERCP (procedure of choice) - find strictures, beading, and irregularities throughout biliary tree. Tx:Symptomatic therapy and liver transplant.
What is the care for Pyogenic (Bacterial) Liver Abcess: Dx: CT scan, U/S. Tx: Drainage, use abx for organism. IV for 10-14 days then give PO abx for one month. When in doubt, use 3rd generation cephalosporin plus flagyl. Imipenem also kills everything.
What is the care for Amebic Liver Abcess: Dx: stool exam for ova and parasite (O & P), serology, liver imaging. Have to show history of contact such as travel. Tx: Luminal amebicides - reach high conc. in bowel but limited to cysts and trophozoites (Iodoquinol and Paromomycin), Tissue Amebicides - high concentration in blood (Metronidazole).
What is the care for Osmotic Diarrhea: Maintain hydration (pedialyte) - water does not make diarrhea worse, Avoid lactose containing foods, caffeine, raw fruits, chewing gum, and drugs that cause diarrhea. Avoid abx unless there is a life threatening infection (never us abx for Salmonella because the toxins are released upon death), avoid anticholinergic agents. Kaopectate decreases liquidity of stool, Pepto-bismal should be first line agent. Opiate derivatives (Imodium, Lomotil) inhibit intestinal motility and promote absorption - use with caution in inflammatory, bloody diarrhea because may worsen and prolong disease state.
What is the care for Secretory Diarrhea
What is the care for Exudative Diarrhea: Dx: C.diff toxin screen Tx: Use flagyl first - IV/PO, then use Vancomycin 2nd.
What is the care for Defective Mixing or Mucosal Contact
What is the care for Infectious Diarrhea
What is the care for Inflammatory Diarrhea: Note: IBD, radiation colitis and ischemic colitis can cause elevated WBC
What is the care for Non-Inflammatory Diarrhea
What is the care for Nosocomial Diarrhea
What is the care for Traveler's Diarrhea: Fluid replacement and bismuth subsalicylate (Pepto-bismal). If moderate illness or persistent bloody diarrhea - treat with Bactrim, Cipro
What is the care for Foodborne Gastroenteritis: Supportive
What is the care for AIDS Diarrhea: Therapy not effective for these organisms.
What is the care for Volvulus: Timely dx within 24 hrs.. Tx: IV fluids, laparotomy to untwist, appendix removed
What is the care for Intussception: Tx: IV fluids and correct electolytes, Hydrostatic reduction by barium enema therapeutic in 50-90%. Barium enema will show a "coiled spring" look. Call surgeon to administer barium and be on hand in case of perforation.
What is the care for Pyloric Stenosis: Tx: Correction of hypochloremic metabolic alkalosis and dehydration, once stabilized then treat via surgery (may have post emesis due to swelling after surgery)
What is the care for Constipation (Children): Tx for Hirschsprung: Fluid replacement, saline enemas, broad spectrum abx, Surgical repair - endorectal pull-through (strip aganglionic rectum of mucosa, bring normally innervated colon through residual rectal muscular cuff); or rectorectal transanal pull-through (creates neorectum behind abnormally innervated segment)
What is the care for Colonic Polyps: Dx: Flexible sig. (>50 yrs. old), remove polyps and bx; colonoscopy to evaluate rest of colon, perform another colonoscopy one year later, if no polyps found, repeat in 3-4 years. Educate pt. in the importance of follow-up due to increase cancer risk. Should always send registered letter to contact regarding follow-up (2-3X) if person fails to show up for follow-up retesting.
What is the care for Hemartomas
What is the care for Colon Adenocarcinoma: Metastases: Colon cancer goes to bone, lung and liver. Duke's classification for adenocarcinoma of colon: Class A (5-year survival of 80-100%), Class B (5-year survival 50-80%), Class C (20-30%), Class D (<5%). Tx: Surgery only chance for cure. Chemotherapy (5-Flurouricil) - 15-20% response rate. Radiation - makes smaller to reduce bowel obstruction.
What is the care for Familial Polyposis Coli (Precancerous Lesions): Dx: If parents have at age 50, screen the family at age 40. Tx: remove entire colon and rectum.
What is the care for Gardners Syndrome (Precancerous Lesions): Tx: remove colon
What is the care for Hemorrhoids: Tx: High fiber diet, Anusol (steroids and benzocal), surgery is only cure (reserved for pts with chronic severe bleeding due to stage III or IV
What is the care for Proctitis
What is the care for Proctocolitis
What is the care for Rectal prolapse
What is the care for Fecal Incontinence: Minor Tx: with fiber. Major Tx: underlying cause, bulking agents, scheduled toilet use.
What is the care for Anal Fissures: Tx: Fiber, stool softener, sitz bath.
What is the care for Perianal Abscess: Tx: Incision and drainage
What is the care for Pruritus Ani: Dx: Often see scratches from itching at night. If child itching butt, check for pinworms in the morning by placing scotch tape over the anus then have tested. Tx: Education
What is the care for Rectal Cancer: Tx: Radiation therapy.
What is the care for Appendicitis: Dx with U/S. Highly effective to also identify ectopic pregnancy. Can also CT without contrast. Tx: appendectomy and systemic abx prior to surgery
What is the care for Reye Syndrome: Tx: Watch intracranial pressure - if cerebral edema, restrict fluids1500ml/m2/day (fluid should be saline water not FREE WATER such as glucose water because fluid will go right into the tissues), give glucose (10-15%) IV, coagulopathy (give Vit. K (12-20 hr response), hyperthermia (cool down with ice), endotracheal intubation if needed (too much suction will increase brain swelling)
What is the care for Inborn errors of metabolism (Niemann-Pick disease, Tay-Sachs disease): If see macular cherry-red spot, automatically think inborn metabolic disorder.
What is the care for Phenylketonuria: Dx: Elevated serum phenylalanine. Tx: limit phenylalanine intake throughout lifetime. Best if treatment began in first month of life.
What is the care for Maple Syrup Disease: Dx: marked elevation of branched-chain amino acids. Tx: Unless diagnosis made and diet restricted most will die in first month. Must treat within 10 days to have normal growth and development.
What is the care for Homocystinuria: Dx: Homocysteine levels. Tx: large dose of pyridoxine (Vitamin B6).
What are the characteristics of Hepatocellular Adenomas (Benign Liver Tumor): Women age 20-40, pain due to stretching of rt. lobe of liver. Palpable liver. Can have multiple tumors. 10% risk of malignancy as tumor increases in size >10cm and if have multiple adenomas.
What are the characteristics of Hemangioma (most common benign liver tumor): Mainly in women. Vascular lesion that can grow and push on other organs
What are the characteristics of Hepatocellular Carcinoma (one of most common tumors in world, 1-2% of US): More common in males (4:1), 40-50 yrs. old. Abdominal pain and RUQ mass, may have friction rub or bruit over the liver that can wax and wane. Course of disease is rapid.
What are the characteristics of Metastatic tumors: Symptoms referrable to primary tumor, weakness, wt. loss, fever, seating, abd. pain, hepatomegaly or ascites, increased Alk phos.
What are the characteristics of Gallbladder Disease: Biliary colic (wax and wane pain), RUQ and/or epigastric pain with radiation to the right scapula or back (positive Murphy's sign with pain on deep inspiration). Pain onset often after meal (especially high fat)â†’causes the GB to contract but the stone blocks the ductâ†’spasm. Pain intense, lasting 15min to 4 hours. May have N/V and mild fever (obstruction is normally at cystic duct), jaundiceâ†’stone in common bile duct preventing bile helping to break down bilirubinâ†’urine tea colored and feces will be gray (feces is normal route to get rid of bilirubin). May also see decreased bowel sounds, tachycardia and tachypnea. Lab test: Leukocytosis, elevated serum bilirubin (3mg/dl)
What are the characteristics of Sclerosing Cholangitis: Elevated Alk phos, IBD, ulcerative colitis (pts are at risk for cholangiocarcinoma), fatigue, fever, abd. pain, pruitis (problem with bile salts), jaundice. Complications: portal htn and liver failure. Key test to distinguish Primary Sclerosis Cholangitis from Primary Biliary Cirrhosis is Anti-mitochondrial Ab (cirrhosis has low incidence of IBD and test value of +90-98%, whereas Cholangitis has high IBD occurrence and low test values - <5%).
What are the characteristics of Pyogenic (Bacterial) Liver Abcess: Fever most common presenting sign (liver abscess often involved in fever of unknown origin), flu like symptoms, 50% have enlarged liver, RUQ tenderness, jaundice. Labs: leukocytosis, elevated Alk Phos and GGT
What are the characteristics of Amebic Liver Abcess: Fever, RUQ pain radiate to shoulder, point tender over liver.
What are the characteristics of What are the characteristics of Osmotic Diarrhea: Dx: confirmed by response to elimination of milk.
What are the characteristics of Secretory Diarrhea: Rice water stool
What are the characteristics of Exudative Diarrhea: Pseudomembranous colitis-sigmoid or colon show grayish-yellow membrane plaques that are difficult to remove with cotton swab. Fever, watery diarrhea containing pus, mucus
What are the characteristics of Defective Mixing or Mucosal Contact: IBD
What are the characteristics of Infectious Diarrhea
What are the characteristics of Inflammatory Diarrhea: Fecal WBC - positive; Clinical presentations - bloody small volume diarrhea, LLQ cramps, maybe febrile, no N/V. Site of involvement - Colon; Diagnostic evaluation - indicated
What are the characteristics of Non-Inflammatory Diarrhea: Fecal WBC - negative; Clinical presentations - large-voume, watery diarrhea, may have N/V, cramps. Site of involvement - Small intestine. Diagnostic evaluation - if severly dehydrated or toxic
What are the characteristics of Nosocomial Diarrhea
What are the characteristics of Traveler's Diarrhea
What are the characteristics of Foodborne Gastroenteritis
What are the characteristics of AIDS Diarrhea
What are the characteristics of Volvulus: Abdominal tenderness, bloody stools, drawing up of legs, irritability, tachypnea and tachycardia, metabolic acidosis, leukocytosis, corkscrew appearance of midgut. Strangulation can lead to loss of gut (short gut syndrome).
What are the characteristics of Intussception: Complications: bowel necrosis secondary to local ischemia leading to GI bleeding bowel perforation. Colicky pain is the main symptom. Currant jelly stools . Absence of bowel signs in RLQ. If high WBC=perforation may be present--don't due barium enema.
What are the characteristics of Pyloric Stenosis: Most common cause of nonbilious emesis in infants.Projectal vommitting (non-bilious), hypochloremic, metabolic alkalosis and dehydration. Lethargy, visibile peristalsis seen just after infant feeds, palpable, hard, mobile and nontender mass in epigastrium referred to as "olive", elongated, narrow pyloric canal (string sign). Begins 3-6 weeks of age.
What are the characteristics of Constipation (Children): Delay or difficulty defecating present for 2 or more weeks or decrease in bowel activity from usual pattern. 0-3 month old (Breast milk, 5-40 stools/week; Formula 5-28/week). 6-12months (5-28 stools/week); 1-3 yrs. old (4-21 stools/week); >3yrs old (3-14 stools/week). Mean colonic transit time increases with age - 1-3months (8.5 hours), 3-13 yrs (26 hours), 90% of children have transit times of 33 hours.
What are the characteristics of Colonic Polyps: Sessile - fat, broad based. Pedunculated - on top of stalk. Histologic types: Hyperplastic (most common, sessile, non-malignant), Tubular adenomas (branching tubules), Villous adenomas (worst type, malignant change 40% of time, cauliflower appearance), Mixed adenomatous polyps. Factors relating to cancer risk: Degree of dysplasia, size of polyp (>2cm 46%), villous (46%) and number of polyps. Usually asymptomatic with rectal bleeding most common symptom (abdominal pain is rare).
What are the characteristics of Hemartomas: Contains variety of different connective tissue: fibrous, adipose, myxomatuous or endothelial. Juvenile polyps (most common hemartomatous polyp - not malignant), Peutz-Jeghers (autosomal dominant, frickles on lips, bucosal region, anus, 2-3% develop adenocarcinomas of GI tract and most occur in small bowel.
What are the characteristics of Colon Adenocarcinoma: Very common cancer. 98-99% of colon cancers are adenocarcinoma. 5 year survival is 50%. Most lesions are in the rectum and sigmoid colon. Sx: Abdominal pain (50-75%), weight loss (40%), change in bowel habits (50-60%) - pencil thin stools, blood in stool. Occult blood in stool in anyone over 40 is colon cancer until proven otherwise. If any of these are present, 80% poor prognosis. Labs: CBC (for anemia), LFT's.
What are the characteristics of Familial Polyposis Coli (Precancerous Lesions): 100-1000's occuring anywhere in GI tract with colon most common location. Sx include rectal bleeding, change in bowel habits. Not born with polyps, start occuring around age 10, symptoms start age 35 or so. If not caught will die from metastatic cancer by age 42.
What are the characteristics of Gardners Syndrome (Precancerous Lesions): Triad: Adenomatous polyps of colon, soft tissue lesion (fibromas, lipomas), bony lesions (cysts, osteomas)
What are the characteristics of Hemorrhoids: Internal hemorrhoids (bleeding and mucoid discharge (minimal pain due to lack of nerves above dentate line). Stage I: Confined to anal canal, Stage II: Enlarged and protruding from anal opening - pop out on straining then goes back in on own, Stage III: Strainng pops out but have to manually put back in - feeling of fullness after defecation, Stage IV: Always prolapsed. External hemorrhoids visible on perianal inspection (painful), internal hemorrhoids visible only with straining or anoscope.
What are the characteristics of Proctitis: Inflammation of the distal 15 cm of rectum
What are the characteristics of Proctocolitis: Inflammation extends above the rectum to sigmoid colon
What are the characteristics of Rectal prolapse: Protrusion through the anus of some or all of the layers of the rectum (tissue more pinkish whereas hemorrhoids are purple to black)
What are the characteristics of Fecal Incontinence: Minor incontinence: due to local anal problems. Major incontinence: complete uncontrolled loss of stool due to sphincter or neurologic damage (rectal tone loss due to trauma, surgery, age, DM, MS)
What are the characteristics of Anal Fissures: Linear ulcers that extend from the anal verge to dentate line. Severe tearing pain during defecation followed by throbbing discomfort. Confirm by visual inspection
What are the characteristics of Perianal Abscess: Perianal pain, push on skin and feels mushy and is tender
What are the characteristics of Pruritus Ani: Perianal itching and discomfort
What are the characteristics of Rectal Cancer: Bleeding and pain
What are the characteristics of Appendicitis: Ages (10-30 yr.olds and elderly). Sx: vague colicky periumbilical or epigastric pain that shifts to RLQ within 12 hours, N/V (if repeated protracted vomitting - probably something else), Low grade fever (if high = perforation. Pain may disappear on rupture then reappear as peritonitis 4-6 hours later), tenderness and guarding in RLQ and positive for psoas/obturator. Labs: Increased WBC with Left shift (also do a pregnancy test)
What are the characteristics of Reye Syndrome: 5-7 days after febrile illness: protracted vomiting, delirium, stupor, seizures, coma, death. Focal or diffuse neurological signs and enlarged liver without jaundice. Labs: Elevated AST/ALT, CPK and LDH; elevated serum ammonia (poor prognosis); hypoprothrombinemia (PT goes up due to lack of clotting factors, correct with Vit. K. If don't respond=poor prognosis); hypoglycemia. Clinical staging: Grade I-V (V = bad news, coma, respiratory arrest). Liver will be yellow to white due to high content of TG's.
What are the characteristics of Inborn errors of metabolism (Niemann-Pick disease, Tay-Sachs disease): All newborns must be screened before discharge and before day seven of life. Specimen obtained from heel stick. Screening tests in Michigan: PKU, Hypothyroidism, Sickle Cell Trait, Biotinidase deficiency, General adrenal hyperplasia, Maple Syrup Urine.
What are the characteristics of Phenylketonuria: Mental retardation, hyperactivity, seizures, light complexion, Urine "mouse-like" odor.
What are the characteristics of Maple Syrup Disease: Accumulated leucine and isoleucine cause the odor. Urine odor normal at birth then develops odor, lethargy, feeding difficulties, coma, seizures.
What are the characteristics of Homocystinuria: Tall and skinny, decreased mental capacity, osteoporosis, dislocated lens, thromboembolic disorders
What is the cause of Hepatocellular Adenomas (Benign Liver Tumor): Hormone induced -Birth control pills
What is the cause of Hemangioma (most common benign liver tumor)
What is the cause of Hepatocellular Carcinoma (one of most common tumors in world, 1-2% of US): Usually see in cirrhotic liver, possible cause HCV.
What is the cause of Metastatic tumors: Primary tumor develops and spreads to liverâ†’metastatic tumors second only to cirrohsis as cause of fatal liver disease. All types of cancers can spread to liver except brain cancers.
What is the cause of Gallbladder Disease: 80-90% involve cholesterol stonesâ†’too much cholesterol for amount of lecithin and bile salts leads to crystal formation. Gall stones grow slowly, 2-3mm/year (takes years to get big enough to cause sysmptoms). Choledocholithiasis - gallstone in common bile duct (15% of pts. with gall stones)â†’cholangitis, bacterial infection (main concern), pancreatitis or liver failure. Risk factors - Female, Forty, Flatulent, Fat and Fertile (lipid lowering drugs/estrogens-BCP), steatorrhea, crohn's disease, terminal ileum resection.
What is the cause of Sclerosing Cholangitis: Unknown. Possible autoimmune
What is the cause of Pyogenic (Bacterial) Liver Abcess: If arise from biliary tract - enteric gram neg. rods, enterococci; from pelvis - mixed flora (B. fragilus); hematogenous spread (Staph, Strep); chemo - Candida
What is the cause of Amebic Liver Abcess: E. histolytica (don't see elevated eosinophilla because it is walled off and non-invasive)
What is the cause of What is the cause of Osmotic Diarrhea: Ingestion of large quantities of di- or trivalent ions (Mg, Phosphates, Sulfates)â†’antacids and saline laxatives; Indigestible carbs (most common cause) - .5-2.0 L of water pulled in to flush out lactose and sucroseâ†’lactase deficient by age 3-14. Also may see with the sorbitol in chewing gum.
What is the cause of Secretory Diarrhea: Most common cause is bacterial and irritative laxative. Bacterial - E. coli and V. cholerae produce enterotoxinsâ†’increase water secretion. Irritative laxatives - castor oil. Also see with ZE, fat malabsorption, and bile acid induced diarrhea.
What is the cause of Exudative Diarrhea: Prior abx therapy creates imbalance in intestinal floraâ†’C.difficile toxin A binds to intestinal membrane leading to pseudomembrane formation.
What is the cause of Defective Mixing or Mucosal Contact: Intestinal resection, surgical bypass, enteroenteric fistulas
What is the cause of Infectious Diarrhea: Viral - Rotavirus, Norwalk agent (often in kids), Bacterial - Shigella, Salmonella, Campylobacter, E. coli, Protozoal - Giardia, E. histolytica, Cryptosporidium. Mainly acquired through food and water contaminated with human/animla feces.
What is the cause of Inflammatory Diarrhea: Invasion of bacterial or parasitic organisms - Shigella, Salmonella, Amebic Colitis, Campylobacter, Yersinia, Clostridium
What is the cause of Non-Inflammatory Diarrhea: Viruses, Vibrio, Giardia, E. coli, foodborne gastroenteritis.
What is the cause of Nosocomial Diarrhea: Most common cause - C.difficile, 2nd most common - drugs (Amoxicillin)
What is the cause of Traveler's Diarrhea: Enterotoxic E.coli, Salmonella and Shigella via oral ingestion of fecal contaminated water.
What is the cause of Foodborne Gastroenteritis: Bacteria (buffet), raw or undercooked seafood and meats
What is the cause of AIDS Diarrhea: Cryptosporidium, CMV, Microspria, Isospora belli, also get the viruses
What is the cause of Volvulus: Malrotation of the gut during fetal development.
What is the cause of Intussception: Idiopathic. Lead points (polyps, cysts, lymphoma, hypertrophied Peyer patches (seen in terminal ileum). Rotavirus vaccine was a common cause until removed from market. Telescoping of bowel at ileocolic region
What is the cause of Pyloric Stenosis
What is the cause of Constipation (Children): Non-organic most common. Organic causes - structural related (Ex. tethered cord-spinal cord tapered at lower spine in cerebral palsy pts.) Hirschsprung disease is most common cause of lower bowel obstruction (abnormal innervation of distal bowel, little ribbon stools, transition zone is funnel shaped, removal of finger from sphincter may be followed by explosive diarrhea)
What is the cause of Colonic Polyps
What is the cause of Hemartomas
What is the cause of Colon Adenocarcinoma
What is the cause of Familial Polyposis Coli (Precancerous Lesions): Autosomal dominance.
What is the cause of Gardners Syndrome (Precancerous Lesions): Autosomal dominance.
What is the cause of Hemorrhoids: Increase in venous pressure due to straining, constipation, prolonged sitting, pregnancy, obesity, low-fiber diets.
What is the cause of Proctitis
What is the cause of Proctocolitis: Neisseria gonorrhoeae, treponema pallidum (look for syphillis chancre), chlamydia trachomatis, herpes simplex II, veneral warts.
What is the cause of Rectal prolapse: Chronic excessive straining at stool in conjunction with weakening of pelvic suppurt structures. Commonly seen in elderly with straining
What is the cause of Fecal Incontinence: Requirements for bowel continence: Solid or semisolid stools, distensible rectal reservoir, sensation of rectal fullness, intact pelvic nerves and muscle, ability to reach toilet in a timely fashion (biggest issue in nursing homes)
What is the cause of Anal Fissures: Trauma to the anal canal during defecation
What is the cause of Perianal Abscess: Infected anal glands at the base of the anal crypts. Seen in patients with anal fissures and Crohn's disease
What is the cause of Pruritus Ani: Poor anal hygiene or excessive anal hygiene. Associated with fistulas, fissures, prolapsed hemorrhoids, skin tags, minor incontinence.
What is the cause of Rectal Cancer
What is the cause of Appendicitis: Obstruction of the appendix (fecolith - hard stool)
What is the cause of Reye Syndrome: Aspirin administration for viral infection. Prodromal febrile illness (URI, chicken pox). Major site of damage is mitochondria.
What is the cause of Inborn errors of metabolism (Niemann-Pick disease, Tay-Sachs disease): Defects of single genes cause blocks in metabolic pathways. Outcome: No product, build-up of substrate causing toxicity or re-routed pathway produces toxic product.
What is the cause of Phenylketonuria: Decrease activity of phenylalaine hydroxylase. Autosomal recessive.
What is the cause of Maple Syrup Disease: Deficiency of enzyme that catalyzes oxidative decarboxylation of the branched-chain keto acid derivatives of leucine, isoleucine, and valine.
What is the cause of Homocystinuria: Deficiency of cystathionine synthase. Autosomal recessive

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