Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Gastroenterology 1st Year Handwritten Notes, 2nd Year Handwritten Notes, 3rd Year Handwritten Notes & Final Year Handwritten Notes (Lecture Notes)
? Review, review, review
? I'l focus on key points
? Special attention to red text
? Special attention to "most common cause of..."
? Special attention to triads, quadrads
? Always consider deadly causes first
2
Dysphagia
? Difficulty swal owing, sensation of
impaired food passage
? Solids: mechanical (obstructive)
? Solids and liquids: motility disorder
? Oropharyngeal dysphagia:
neuromuscular disorder (CVA)
? Progressive (CA) vs. non-progressive (web)
? Strictures 2? to reflux
? Workup
?Esophagram, endoscopy, motility studies
? Treat underlying disease process
3
Dysphagia
? Infectious
?Botulism, diptheria, poliomyelitis, rabies,
Sydenham's chorea (rheumatic fever), tetanus
? Immunologic
?Scleroderma, multiple sclerosis, myasthenia
gravis, polymyositis
? Motor/nerve dysfunction
? Achalasia
?Aperistalsis of esophagus
(loss of Auerbach's plexus in the esophagus)
?Cranial nerve palsies
4
Dysphagia
Mechanical
? CA (usual y squamous)
?Risk factors: smoking, achalasia,
caustic ingestion
? Extraluminal obstruction (tumor)
? Thyroid goiter
? Zenker's diverticulum
?Rare, elderly patients
?Pharyngoesophageal outpouching
(above the upper esophageal sphincter)
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Dysphagia Obstructive
Mechanical
? Proximal obstruction
?Caf? coronary: Sudden cyanosis and col apse
caused by food obstruction
? Distal obstruction
?Steakhouse syndrome: Most common cause of distal
obstruction (improperly chewed meat)
?Schatzki ring: ring-like constriction of lower esophagus
? Webs (Congenital or acquired)
?Circumferential mucosal outpouchings
?Plummer-Vinson syndrome: anterior esophageal webs+
iron deficiency anemia + spooning of the nails
6
Singultus
7
Hiccups/Hiccoughs/Singultus
? Involuntary stimulation of the respiratory reflex
with spastic contraction of inspiratory muscles
on closed glottis
? Benign: gastric distention, smoking, EtOH
? Persistent: damage to vagus or phrenic
nerves, CNS lesions
? Treatment: Chlorpromazine (Thorazine) if
persistent
? Organic
? CNS: neoplasm, MS, ICP
? PUD, goiter, pericarditis, pacemaker, STEMI? 8
Esophageal Rupture
? Majority are iatrogenic
?Endoscopy, dilatation, biopsy, sclerotherapy
?Most at pharyngoespohageal junction
? Mal ory-Weiss tear (partial thickness tear)
?Location: GE junction
?Common cause of upper GI bleeding
?Vomiting, retching
?Risk factors: EtOH, hiatal hernia
?Spontaneous resolution is common
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Esophageal Rupture
? Boerhaave's syndrome (ful -thickness tear)
?Usual y males, ages 40-60
?Typical y associated with vomiting
?Left posterior distal rupture
?Mediastinitis (first chemical, then infectious)
?Severe chest pain, shock, sepsis (antibiotics)
?Air in mediastinum (Hamman's crunch)
?Pyopneumothorax
?Gastrografin (water-soluble) UGI, CT
? X-ray: mediastinal air, left pleural effusion,
pneumothorax, widened mediastinum
10
Pneumomediastinum / Subcutaneous
Emphysema
11
Esophageal Foreign Bodies
? Levels of narrowing
?Cricopharyngeus muscle (C6)
?Aortic arch (T4)
?Tracheal bifurcation (T6)
?Gastroesophageal junction (T11)
? Coin X-rays
?AP orientation: coin in trachea (same plane as
vocal cord orientation- sagittal)
?Transverse orientation: coin in esophagus
12
Foreign Body
13
Med-Chal enger ? EM
Esophageal Foreign Body
14
Med-Chal enger ? EM
Esophageal Foreign Bodies
? Disk batteries characteristic double density
radiographic appearance.
? Soft drink aluminium pul tabs - radiolucent
? Contrast studies may be required
? CT scan- good for chicken and fish bones,
smal plastic pieces
? Most foreign bodies wil pass if they traverse
the pylorus (exceptions: pointed, sharp, large)
15
Sharp Foreign Body
16
Large-corrosive-impacted
foreign Body
17
Esophageal Foreign Bodies
? Button batteries
?If seen in esophagus, must be removed immediately
?Rapid burns with perforation in 6 hours
?Lithium batteries have the worst outcomes
?Batteries that do not need to be removed
?Passed esophagus, asymptomatic
?Passed the pylorus within 48 hours
?Most wil pass completely in 48-72 hours
?Asymptomatic batteries in the stomach are fol owed by
serial X-rays
? Treatment if in esophagus: GI consult
broad-spectrum antibiotics
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Esophageal Food Impaction
? Most patients with food impaction have
underlying esophageal pathology
? Must evaluate for cause after dislodgement
? Treatment options
?Endoscopic retrieval
?Foley catheter removal
?Glucagon: relaxes lower esophageal sphincter
?Nifedipine: reduces lower esophageal tone
?Carbonated beverages: gaseous distention may
push bolus into the stomach
?Avoid meat tenderizers (papain)
21
Caustic Ingestions
? Inconsistent relationship between oral and
esophageal findings
? Gastric decontamination is contraindicated
? Dilution (water or milk) can cause vomiting
?Indicated only for solid alkali ingestions
? Neutralization can generate excess heat
?Indicated only for hydrofluoric acid ingestions
(milk or magnesium citrate)
Endoscopy is the best diagnostic tool
22
Caustic Ingestions
? Complications
?Early: acute airway compromise due to edema,
perforation
?Late: stricture, perforation
23
Peptic Ulcer Disease
? Incidence decreasing in general population and
increasing in the elderly (liberal use of NSAIDs)
? Duodenal > gastric (relief of pain with eating)
? Helicobacter pylori responsible for most cases
- Smoking, alcohol
? Predisposing factors:
-NSAIDs and steroids
-Zol inger-Ellison syndrome
? Treatment:
- Antibiotics against H. pylori (amox, flagyl)
- H2 blockers
- Proton pump inhibitors (omeprazole)
- Surface protectants (sucralfate)
? Complications: - Bleeding
- Perforation (can cause pancreatitis)
- Gastric outlet obstruction
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GI Bleeding
Definitions
? Hematemesis
?UGI bleeding (proximal to ligament of Treitz)
? Hematochezia
?Anus, rectum, sigmoid: bright red
?Transverse and right colon: maroon
?Rapid UGI bleed (uncommon)
?Usual y colon or smal bowel
? Melena (black, tarry stools)
?Usual y UGI bleed
?Black color from effects of acid and digestion
? GI breakdown of blood causes increased BUN
? Bismuth (Pepto-Bismol) black stool- heme-neg
28
Upper GI Bleeding Adults
? PUD most common (usual y duodenal)
? Gastric erosions (alcohol, NSAIDs)
? Varices
? Mal ory-Weiss tears
? Esophagitis (common in pregnancy)
? Duodenitis
? Patients with a previously documented GI
lesion bleed from the same site in only 60% of
cases
29
Upper GI Bleed
Therapies
? No benefit to initiating PPI or H2 blocker in the
ED for patients with UGIB
? Octreotide (Somatostatin) for esophageal
varices / causes splanchnic blood flow
reduction / sclerotherapy
? Vasopressin (vasconstrictor) ? used in variceal
hemorrhage to limit exsanguination when
endoscopy unavailable or delayed
? Sengstaken-Blakemore tube ? esophageal
varices
? Linton tube ? Gastric varices
30
Upper GI Bleed
Sengstaken Blakemore Tube
31
From Google Images
Upper GI Bleed
LintonTube
32
From Google Images
Lower GI Bleeding Adults
? Upper GI Bleeding most common cause of LGIB
? Diverticulosis
? Angiodysplasia (AV malformations)
?Associated with hypertension and aortic stenosis
? Cancer/polyps
? Rectal disease
? Inflammatory bowel disease
? Aortoenteric fistula
?Erosion of synthetic vascular graft into gut
(often preceded by premonitory bleed- prompt
surgical consultation)
33
GI Bleeding
Low Risk Criteria ?Discharge Home
? No comorbid diseases
? Normal vital signs
? Negative or trace positive stool guaiac
? Negative GI aspirate (if done)
? Normal H/H (consider pt's baseline)
? Good home support
? Understanding of signs & symptoms of
significant bleeding
? F/U arranged in 24hrs
34
Osler-Weber-Rendu Syndrome
? Hereditary hemorrhagic telangiectasias
? Autosomal dominant
? Multiple smal telangiectasias of the skin,
mucous membranes, GI tract
? Recurrent epistaxis, positive family history
? Recurrent episodes of GI bleeding,
gross or occult
35
Bilirubin
? Increased unconjugated (indirect) bilirubin
?Hemolysis
?Decreased conjugation (Gilbert's syndrome,
neonatal jaundice, sepsis)
? Increased conjugated (direct) bilirubin
?Hepatocel ular disease (viral hepatitis, drug-
induced hepatitis, cirrhosis, sepsis)
?Obstruction (stone, tumor, infection)
?CHF
36
Hepatitis
? Alcoholic hepatitis
? Causes: viral and toxic
?Malaise, jaundice, increased ALT (SGPT) and
AST (SGOT), increased bilirubin
?Increased PT/INR: marker of significant liver
dysfunction
37
Hepatitis A
? Viral Type A (infectious)
?Fecal-oral transmission, contaminated water or
food. Not associated with chronic carrier state
?Prophylaxis: Hep A vaccine
?Immune globulin within 2 weeks of exposure
(travel ers, household contacts)
38
Hepatitis B
? Viral Type B (HBV)
?Percutaneous, parenteral or sexual exposure
?Incubation period is 1-6 months
?Complications: cirrhosis, liver cancer,
carrier state (10%)
? Markers
HBsAg: positive early, active infection
HBsAb: positive after clearance of HBsAg
best marker for immunity to HBV
HBeAg: implies high infectivity
HBcAb: Appears afte r HBsAg, persists for life.
Best indicator of history of HBV infection
39
Hepatitis B
? Healthcare worker hepatitis B exposure
(source known to be HBsAg-positive)
? Unvaccinated
?HB immune globulin
?Vaccination (0, 1 mo, 6 mos)
? Vaccinated
?Incomplete series: vaccine booster
?Test for HBsAb: if adequate antibodies, no
treatment; otherwise: HBIG and vaccine booster
40
Hepatitis C
? Formal y referred to as non-A, non-B
? Linked to blood transfusions, injection drug use
? Higher incidence in HIV victims
? 50% develop chronic disease cirrhosis, CA
? Seroconversion after percutaneous exposure
HCV-positive source is about 2%
? No effective vaccine for HCV
41
Other Hepatitis Types
? Hepatitis delta (HDV): Requires HBsAG for co-
infection
?IV drug users, homosexual patient population,
hemophiliacs / high likelihood for sequelae
? Hepatitis E Virus
?Oral?fecal transmission
?Encountered in Asia, Africa, Russia
? Hep G Virus: blood transfusions, sexual contact
? Indications for hospitalization (any hepatitis)
?Encephalopathy, PT/INR significantly increased,
dehydration, hypoglycemia, bilirubin over 20,
age over 45, immunosuppression
42
Hepatic Encephalopathy
? Precipitants: "LIVER"
(Librium [sedatives], Infection, Volume loss,
Electrolytes disorders, Red blood cel s in the gut)
? Others: dietary protein excess,
worsening hepatocel ular function
? Early sign is "sleep inversion" (sleeping during the
day, awake at night)
? Asterixis ("liver flap")
? Ammonia levels: arterial is best
? Check for hypoglycemia
? Treatment: neomycin, lactulose, decrease dietary
protein, avoid sedatives, avoid bicarbonate (alkalosis
can worsen encephalopathy)
43
Spontaneous Bacterial Peritonitis
? Occurs with chronic liver disease
?Portal hypertension bowel edema
migration and leakage of enteric organisms
(E. coli, Enterococcus)
? Abdominal tenderness, worsening ascites,
encephalopathy, fever, sepsis, shock
? Diagnosis: paracentesis with increased WBCs
?Neutrophil count > 250 cel s/?L
44
Gallbladder (1)
? Stones: bilirubin or cholesterol (radiolucent)
? Biliary colic: pain and vomiting due to obstruction
by stones (without inflammation)
? Cholecystitis
?Most common cause of surgical abdominal pain
in the elderly
?Obstruction distention pain / vomiting /
inflammation infection (usual y E. coli,
Klebsiel a) increased WBCs
? Gal stone ileus: rupture of stone into smal bowel
with obstruction at ileocecal valve
?Pneumobilia: air in biliary tree (from bowel)
45
Gallbladder (1)
46
Gallbladder (2)
? Acalculous cholecystitis
?No stones
?Usual y a complication of another process
(trauma, burn, postpartum, post-op, narcotics)
?Patients often critical y il
?Can cause GB perforation
?Increased risk with diabetics and elderly
?Greater morbidity than calculous cholecystitis
? Ascending cholangitis
?Infection spreading through biliary tree
?Charcot's triad: jaundice, fever, RUQ pain
47
Hepatic
duct
Cystic
duct
Common
duct
Pancreatic duct
Ampul a of Vater
Sphincter of Oddi
Gallbladder (3)
? Biliary ducts
?Common bile duct: from junction of cystic and
hepatic ducts to duodenum
?Ultrasound is the diagnostic study of choice
(shows stones, wal thickening, duct dilatation,
sonographic Murphy's sign, but not inflammation)
?HIDA scan and U/S have similar sensitivities and
specificities
?HIDA scan is positive if GB is not visualized
(cystic duct obstruction; best test for GB function)
Contrast excreted by hepatocytes into the biliary
tree.
?ERCP: Indicated for choledocholithiasis (stone
near ampula of vater)
49
Gallbladder Ultrasound & HIDA Scan
50
Pancreatitis Causes
Two leading causes: gal stones, ethanol abuse
? Obstructive: gal stones, tumors
? Toxic: ethanol, methanol
? Traumatic injury (pediatrics)
? Drugs: thiazides, estrogens, salicylates,
acetaminophen, antibiotics
? Metabolic disorders: hyperlipidemias, hypercalcemia
DKA, uremia
? Viral infections: mumps, Coxsackie B, hepatitis,
adenovirus, EBV
? Bacterial infections: Salmonel a, Streptococcus,
51
Mycoplasma, Legionel a
Pancreatitis
? Amylase
?Non-pancreatic sources (parotid, SBO, ectopic preg)
?Height of amylase not related to severity
?Provides no value over lipase alone
? Lipase
?Equal y sensitive/ more specific than amylase
?Closely fol ows clinical course
? Plain X-ray
?Routine imaging is not indicated
?Colon cutoff: dilatation only over pancreas
?Sentinel loop: smal bowel air over pancreas
?Pancreatic calcifications (chronic pancreatitis)
?Contrast CT is imaging study of choice
52
Sentinel Loop (Pancreatitis)
53
Pancreatitis
? Ranson's criteria (prognostic)
? On admission (ED) ? At 48 hours (ICU)
?Age > 55
?Decrease in HCT >10%
?Glucose > 200 mg/dL ?Increase in BUN over
5 mg/dL
?WBC > 16,000
?Ca++ below 8 mg/dL
?SGOT(AST) > 250
?PaO < 60 mm Hg
2
?LDH > 350
?Base deficit > 4 mEq/L
?Rapid fluid sequestration
(over 6L)
3 positives: severe disease
(Poor predictive value in acute settings)
54
Pancreatitis
? Complications of acute pancreatitis
?Pseudocyst, necrosis
?Hyperglycemia, hypocalcemia
?Volume loss, acidosis, GI Bleed
?ARDS, DIC, renal failure
?Death
55
Ileus
? Cessation of normal peristalsis without
mechanical obstruction
? Continuous pain, distention, decreased bowel
sounds, minimal or no tenderness, no flatus or
BM, usual y self-limited
? Ileus is more common than mechanical bowel
obstruction
? X-ray: dilated, fluid-fil ed loops
throughout entire bowel;
air-fluid levels not as prominent
as with mechanical obstruction
56
Ileus
57
Bowel Obstruction
? Smal bowel
?Adhesions (#1 cause), hernias, malignancy
?General y more intense pain, more vomiting
and less distention than large bowel obstruction
?X-ray: "step ladder," "string of pearls;" plicae
circulares (traverse bowel width)
?CT scan complimentary diagnostic study
? Surgical adage: "Never let the sun set or rise
on a bowel obstruction"
? SBO from adhesions- laparoscopic approach
58
Small Bowel Obstruction
59
Med-Chal enger ? EM
Small Bowel Obstruction
60
Med-Chal enger ? EM
Bowel Obstruction
? Large bowel
?Cancer (#1 cause), volvulus, diverticulitis
?Obstructive series: distended colon, haustral
pattern (doesn't traverse entire bowel width)
?CT scan if diverticular etiology or
intussusception
? "Closed-loop" bowel obstruction
?Requires competent ileocecal valve
?Dangerous (risk of perforation)
?Coffee bean
61
Volvulus
? Sigmoid volvulus
?Typical y elderly, debilitated, chronic motility
disorder, insidious onset; high fiber diet
?X-ray: inverted "U" or "bent inner tube"
Loops project obliquely to RUQ
?Sigmoidoscopy decompression & detorsion
62
Volvulus
? Cecal volvulus
?Young (20-40), acute onset
?Congenital freely-mobile cecum
?X-ray: kidney-shaped loop in LUQ
"bird's beak" with contrast studies
?Requires surgery
Cecal volvulus: most common cause
of bowel obstruction in pregnancy
63
Sigmoid Volvulus
64
Cecal Volvulus
65
HERNIAS
66
Hernias (1)
? Incarcerated: irreducible
(bowel obstruction is common)
? Strangulated: irreducible with vascular compromise
and ischemic bowel (do not manual y reduce)
? Inguinal
?Indirect inguinal: herniates through inguinal canal,
extends into scrotal sac. Common in boys
?Direct inguinal: herniates through abdominal wal .
Common in middle age men
? Pantaloon: indirect and direct at the same time
? Femoral: common in women. Incarceration and
strangulation more likely than in inguinal hernia
67
Hernias (2)
68
Hernias (3)
? Umbilical
?Congenital: usual y appear in first month, closed by end of first
year
?Acquired: obesity, pregnancy, ascites. Incarceration and
strangulation are more common
? Spigelian: lateral edge of rectus abdominis. Difficult to
diagnose (CT, ultrasound)
? Obturator (rare): through obturator foramen. More
common in woman. Presents as obstruction, pain in
medial thigh (obturator nerve)
? Richter: only a portion of the bowel herniates. Even if
the hernia is incarcerated or strangulated, the bowel
may not be obstructed
69
Bowel Perforation
? Large bowel > smal bowel
? Mechanisms: inflammation, ulceration, trauma,
obstruction
? Causes: diverticulitis, appendicitis (especial y at
extremes of age), colitis, inflammatory bowel
disease, ischemia, cancer, foreign body, PUD,
radiation, trauma
? Cecum is the most common site
? X-rays may miss smal amounts of free air or
retroperitoneal air. Best view is upright CXR
Ulcers are the most common cause of visceral perforation
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Free Air; Thickened Bowel Wall
71
Pediatric Bowel Obstruction (1)
? Obstructive GI lesions 1st year
?Gut atresia and stenosis
?Incarcerated inguinal hernia
?Intussusception
?Meconium ileus (earliest sign of cystic fibrosis)
?Hirschsprung's disease
?Duplication cysts of intestine
?Malrotation with volvulus
BE is diagnostic study
of choice after plain X-ray
72
Pediatric Bowel Obstruction (2)
? Malrotation with volvulus
?Early infancy (first month).
?Sudden onset of bilious vomiting
?Early diagnosis is crucial to
prevent gangrene of midgut
?Abnormal rotation & fixation of midgut
?X-ray: double bubble sign
(air-fluid levels in stomach and in distended
duodenum)
?Rigid, distended abdomen, bilious vomiting,
heme-positive stools, shock
?Prompt surgical consultation
73
Pediatric Bowel Obstruction (3)
? Intussusception
?Most common cause of surgical abdomen & SBO
3 months to 6 years
?Rare under 3 months, uncommon after age 3
?Intermittent pain, vomiting, heme-positive stools
("currant jel y" is late finding)
?Child appears healthy between paroxysms of pain
?"Sausage-shaped" mass in right abdomen (ileocecal
area most common)
?Increased risk with HSP and cystic fibrosis
?Diagnosis: plain x-ray, ultrasound, barium enema
("coiled spring" sign)
?Treatment: air contrast enema, surgery
74
Intussusception
75
Med-Chal enger ? EM
Intussusception - Barium Enema
76
Med-Chal enger ? EM
Intussusception - Barium Enema
77
Med-Chal enger ? EM
Pediatric Bowel Obstructions (4)
? Pyloric stenosis
?Non-bilious projectile vomiting after feeding;
dehydration, hypochloremic metabolic alkalosis
?Increased incidence in first-born males;
familial propensity
?Third week to third month of life
?Palpable "olive" (pylorus) in RUQ
?Diagnosis: ultrasound, upper GI series (delayed
gastric emptying)
?Treatment: Surgery
78
Pediatric Bowel Obstruction (5)
? Hirschsprung's disease
?Congenital megacolon
?Newborn: failure to pass meconium
?Children: chronic constipation
?Enterocolitis is potential y fatal complication
79
Constipation
? Most common digestive complaint in US
? Acute causes: obstruction, medication (narcotics,
CCBs, psychiatric meds, iron, antacids)
? Common causes: decreased fiber and fluid intake,
lack of exercise
? Chronic causes: slow-growing tumor,
hypothyroidism, hypoparathyroidism, lead,
neurologic dysfunction
? Rectal exam for fecal impaction, rectal mass,
heme-positive stool, anal fissure
? Treatment: diet changes, medical adjuncts,
identify and treat underlying cause
80
Irritable Bowel Syndrome
? Disorder of altered gut motility, gut sensation,
perception of intestinal activity
? Abdominal pain, bloating, constipation or
diarrhea
? EM Dx: "Abdominal pain of unclear etiology"
? Treatment: Osmotic laxatives, antidiarrheals,
antispasmotics
? Psychiatric conditions often co-exist
81
Inflammatory Bowel Disease
? Crohn's disease & ulcerative colitis
? Idiopathic, chronic
? High rate of colon CA with disease >10 years
? Exacerbation-remission pattern
? Peak incidence ages 15-40
? Extra-intestinal manifestations: arthritis,
dermatologic (erythema nodosum, pyoderma
gangrenosum), hepatobiliary disease,
vasculitis, uveitis
? Treatment: sulfasalazine, mesalamine,
prednisone, metronidazole, ciprofloxacin
82
Crohn's Disease (Regional Enteritis)
? Chronic inflammatory disease of the entire GI
tract (mouth to anus) - entire colonic wal
? Segmental involvement is characteristic
("skip lesions")
? Abdominal pain, cramps, diarrhea (sometimes
bloody), fever, perianal fissures, fistulas and
abscesses, rectal prolapse, toxic megacolon
? Gross blood is uncommon
? Increased oxalate absorption leads to calcium
oxalate kidney stones
83
Ulcerative Colitis
? Chronic inflammatory disease of colon
? GI symptoms similar to Crohn's disease
? Major finding is bloody diarrhea
? Toxic megacolon
?Transverse colon, gross distention (over 6 cm)
?Peritonitis, systemic toxicity
? Location: rectum and colon (smal bowel not
affected - unlike Crohn's)
? Risk of colon cancer increased 30-fold
84
Mesenteric Ischemia
? "Abdominal angina"
? Risk factors: dysrhythmias (Afib), low-flow &
hypercoagulable states, vascular disease
? Deadly disease of the elderly. Diagnose with
CT (thumbprinting sign), angiography
? Causes
Sudden onset with
?Embolic
pain out of proportion
?AV thrombus
to physical findings
? Leukocytosis (present in most cases),
lactic acidosis, hyperphosphatemia,
hyperamylasemia (inconsistently present)
? Avoid digoxin, beta blockers, vasopressors
(decrease splanchnic blood flow)
85
Focal thickening causing
thumbprinting
86
87
88
89
90
Angiogram?
91
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Appendicitis
? Anorexia is often present; low grade fever 15%
? High positive likelihood: McBurney's point pain,
rigidity, migration of periumbilical pain to RLQ
? Increased frequency of perforation in elderly
and smal children
? WBC may be normal
? BE: mass effect and non-fil ing
? Ultrasound: dilated, non-compressible >6mm
? CT: usual y diagnostic- best with female cases
? KUB: appendicolith (rare)
Most common cause of surgical abdomen
94
Appendicolith
95
Med-Chal enger ? EM
Appendicitis
? Confounders: Pregnancy, situs inversus,
retrocecal, malrotation, very long appendix
?Result is uncommon pain location: right upper
quadrant, back, flank, testicular, suprapubic
? Rovsing's sign: LLQ palpation causes RLQ pain
? Psoas sign: RLQ pain on thigh extension while
lying in left lateral decubitus position
? Obturator sign: RLQ pain with internal rotation of
the flexed right thigh
96
Appendicitis
? Rectal tenderness with low lying appendix
Although more common in PID,
may have cervical motion tenderness
? May have pyuria: often misdiagnosed as UTI
97
Diverticular Disease
98
Diverticular Disease(1)
? Pain is the most common symptom
?Steady, deep, LLQ location (Western world)
?RLQ Japan-Hawai
? Bowel habits may be altered
(diarrhea or constipation)
? May mimic appendicitis
? Intraluminal pressure is greatest in the sigmoid
(most diverticula there)
99
Diverticular Disease (2)
? Manifestations: pain (inflammation, infection)
and bleeding.
? Free perforation is rare; most are contained
within the mesentery
? May cause urinary frequency and urgency due
to irritation of underlying GU structures
? CT scan preferred method of evaluation
? Colon cancer must be excluded
? High fiber diet, analgesics, broad spectrum
antibiotics with anaerobic coverage
100
Diarrhea - Viral
? Most common cause of diarrhea
? Winter and spring seasons
? Children, daycare centers
? Rotavirus, adenovirus, calicivirus, enterovirus,
Norwalk virus ("RACE to Norwalk")
? Norovirus (Norwalk-like) virus is the leading
cause of gastroenteritis in the US ? cruise ships
? Rotavirus is the most common cause of
diarrhea in children
? No blood or WBCs in stool
101
Diarrhea - Invasive (1)
? Inflammation (stool WBCs) and bleeding
(degree varies by pathogen)
? E. coli 0157:H7
?Enterohemorrhagic E. coli (gross blood in stools)
?Undercooked hamburger, petting zoos, raw milk,
untreated water
?Causes HUS (in children), TTP (in elderly)
?Antibiotics may increase risk of HUS
102
Diarrhea - Invasive (2)
? Shigel a
? Salmonel a
?Very infectious
?Very common bacterial
?High fever, febrile
diarrhea
seizures, bloody
?Watery or mucoid stools
diarrhea, dysentary ?Cafeteria food, pet turtles,
?Incubation 2-6
amphibians, eggs, chickens
days
?Osteomyelitis can occur in
?Ciprofloxacin
sicklers (autosplenectomy)
and after splenectomy
?Ciprofloxacin
103
Diarrhea - Invasive (3)
? Campylobacter
?Most common cause of bacterial diarrhea
?Contaminated food/water, backpacker's diarrhea
?Fecal-oral spread; incubation 2-6 days
?Bloody diarrhea, fever, mimics IBD, appendicitis
?Erythromycin (children), fluoroquinolones (adults)
?Acute infection is associated with development of
Guil ain-Barr? syndrome
? Vibrio
?Parahaemolyticus: raw oysters, clams, shrimp;
6-24 hour incubation
?Vulnificus: oysters, shel fish; increased morbidity
with preexisting liver disease
104
Diarrhea - Invasive (4)
? Yersinia enterocolitica
?Invasive Gram negative bacterium
?Can also mimic appendicitis
?Fever
?Colicky abdominal pain (may be prolonged)
?Diarrhea
?May persist 10-14 days
? Diagnosis: fecal Wright stain positive,
stool C&S
? Treatment: supportive if uncomplicated,
quinolones or TMP-SMX if complicated
105
PROTOZOANS
106
Diarrhea - Protozoan (1)
? Giardia
?Most common cause of water-borne diarrheal
outbreak in US, "backpacker's" diarrhea
?Contaminated streams from beavers, dogs,
raccoons, muskrats, pools, day care centers
(fecal-oral spread), sexual y transmitted
?Symptoms begin after 1-4 weeks
?Audible borborygmi, floating, frothy,
foul-smel ing stools
?Stool specimens to identify cysts/trophozoites
?Metronidazole, furazolidone
107
Diarrhea - Protozoan (2)
? Amebiasis (Entamoeba histolytica)
?Spreads between family members and
sexual partners
?Fecal-oral contact and
anal intercourse
?Diarrhea can be bloody
?Extra-intestinal manifestations: liver abscess,
pericarditis, pleuropulmonary disease,
cerebral amebiasis
?Wide variety of presentations,
from asymptomatic cyst-passer to colitis
to fatal cerebral amebiasis
108
Diarrhea - Protozoan (3)
? Cryptosporidium
?Intestinal protozoan parasite
?Most common cause of chronic diarrhea in AIDS
?Contaminated water supply
?Children, animal handlers, immunocompromised
?Ingestion of oocysts; trophozoites attack intestinal
membrane
?1 week incubation, severe watery diarrhea,
abdominal pain
?Diagnosis: oocysts in stool
? Treatment: fluid replacement, paromomycin
(Humatin) plus azithromycin
109
Food Poisoning
110
Diarrhea - Bacterial (1)
? Toxigenic bacteria produce enterotoxins
? Foodborne infections
? Diarrhea is watery and voluminous
? Minor fever, no septicemia
? No WBCs or RBCs in stool
111
Diarrhea - Bacterial (2)
? Staph
?Contaminated foods (dairy, meat, poultry, eggs,
potato salads, cream-fil ed pastries)
?Nausea, vomiting, diarrhea
?Most common cause of food-borne disease-
Large outbreaks
?Symptoms within 6 hours of ingestion
?Afebrile, no antibiotics, proper refrigeration
112
Diarrhea - Bacterial (2)
? E. coli
?Water contaminated by feces
?The most common cause of traveler's diarrhea
?Pepto Bismol prophylaxis, antiperistaltic agents
?TMP/SMX, ciprofloxacin
113
Diarrhea - Bacterial (3)
? Clostridium perfringens
?Common, large outbreaks (buffets, schools)
?Casseroles, stews, gravies, steam table meats
?Spores survive cooking, then produce toxins
?6-24 hour onset
?Watery diarrhea, no fever or vomiting
?Fecal WBCs and RBCs negative
?Treatment: fluids (antibiotics not helpful)
114
Diarrhea - Bacterial (3)
? Vibrio cholera
?Copious watery "rice water" diarrhea
?Severe fluid and electrolyte problems
?Treatment: WHO rehydration, ciprofloxacin,
TMP-SMX
115
Vibrio cholera
116
Diarrhea ? Bacterial (4)
? Bacil us cereus
(aerobic spore-forming bacterium)
?Common in fried rice (Chinese restaurants),
starchy foods, vegetables, meat
?Spores germinate when boiled rice not
refrigerated
?Two forms
?"Violent vomiting": 2-3 hours post ingestion
(much like Staph)
?Diarrheal: 6-14 hours post ingestion
(much like Clostridia)
?Self-limited; no specific therapy or test
117
Diarrhea - Bacterial (5)
? Scombroid poisoning
?Deep ocean fish (tuna, mackerel, mahi-mahi)
?Heat-stable toxin from bacterial action on dark meat
fish not promptly refrigerated
?Histamine-like toxin, rapid symptom onset
(30 minutes)
?Fish tastes "peppery"
?Facial flushing, diarrhea, throbbing headache,
abdominal cramps, palpitations
?Give antihistamines
?Suspect when multiple patients
have "al ergic reaction"
118
Diarrhea - Other
? Ciguatera (Gambierdiscus toxicus)
?Reef fish (groupers, red snapper, barracuda)
?Fish eat dinoflagellates containing ciguatoxins
that accumulate in the food chain
?Muscle weakness, paresthesias (perioral,
burning hands and feet), distorted or reversed
temperature sensation, vomiting, diarrhea
?Neuro symptoms worsened with alcohol
?Treatment: mannitol, amitriptyline,
diphenhydramine
?Symptoms can last for years.
Avoid fish, alcohol
119
Pseudomembranous Enterocolitis
? Varieties: neonatal, post-op, antibiotic-related
? Due to overgrowth of toxin-producing C. difficile
? Begins 7-10 days after antibiotics
? Patients may be quite sick (high fever, toxic,
profuse diarrhea, dehydration)
? Diagnosis: immunoassay for toxin in stool
? Inflammatory disease, membrane-like yel ow
plaques
? Treatment: stop the precipitating antibiotics; oral
metronidazole or vancomycin
? No anti-diarrheals
120
Rectal Prolapse (Procidentia)
? Ful -thickness protrusion of rectum through anal
canal
? Sensation of rectal mass
? In children, intussusception more likely
? Differentiation from internal hemorrhoids and
intussusception
?Intussusception: can place finger between
protruding rectum and anus
?Internal hemorrhoids: fold of mucosa radiates out
like spoke on a wheel
?Rectal prolapse: folds of mucosa are circular 121
Prolapsed Internal Hemorrhoid
122
Rectal Prolapse (Procidentia)
123
Hemorrhoids
? Engorgement, prolapse or thrombosis of the
hemorrhoidal veins
? Internal hemorrhoids are located at 2, 5 and 9 o'clock
? Risk factors: constipation, pregnancy, ascites, portal
hypertension
? Painless, self-limited, BRBPR
? Treatment
?Non-complicated (non-surgical) WASH:
Warm water, analgesics, stool softeners, high fiber diet
?Topical steroids
?Complicated: large, incarcerated, strangulated,
intractable pain (require surgery)
?Thrombosed: el iptical incision (in ED) to remove clot
124
Perianal Fissure
125
Med-Chal enger ? EM
Anal Fissure
? Most common causes of painful rectal bleeding in
adults and children
? Usual y midline, posterior
? Non-midline fissures suggest more serious
conditions (IBD, CA, sexual abuse)
? Sharp cutting pain, especial y with bowel
movements; blood-streaked stools
? Perianal hygiene, WASH regimen, NTG ointment,
anal dilatation, surgical intervention, BOTOX
126
Botulism (1)
? Characteristics
?Heat-labile neurotoxin, short onset (half hour)
?Inadequately processed canned foods
?Bulbar symptoms, descending paralysis,
anticholinergic findings
?Potential contaminant in street drugs
? Infants
?Floppy baby, constipation, feeble cry
?Honey can be source
?Most common in breastfed
(also less severe in this subset)
127
Infantile Botulism
128
Botulism (2)
? Adults
?Diplopia (the most common early finding),
dysphonia, ptosis, dysarthria, dysphagia
?Anticholinergic symptoms (urinary retention,
pupil abnormalities, dry mouth, abdominal
cramps, nausea and vomiting)
? Antitoxin available
129
GI QUESTIONS
130
GI
A 30 y/o in her third trimester presents
with nausea, fever and abdominal pain.
She is diagnosed with appendicitis.
Which of the following is true?
A. Most common surgical emergency in
pregnancy
B. Incidence in pregnancy is lower than the general
population
C. The diagnosis is rarely delayed
D. There is no increased fetal mortality with rupture
E. The appendix moves in a counter clock-wise
fashion as pregnancy progresses
GI 1
GI
Which is true of acalculous
cholecystitis?
A. Stones are present but are radiolucent
B. Perforation is extremely unlikely
C. It occurs in nearly half of al cases of
cholecystitis
D. Diabetics are at increased risk
E. Is less severe than calculous cholecystitis
GI 2
GI
A 72 y/o presents with abdominal pain out of proportion
to her examination. Rectal: Heme + PMHx: A-fib. Serum
CO2 = 12. The intern wants to administer a stool softener
and discharge the patient home. Which of the following
statements is true regarding this patient's diagnosis?
A. This is a classic presentation for cecal volvulus
B. This diagnosis is associated with lactic
acidosis
C. This patient wil demonstrate peritoneal signs
D. Systemic anticoagulation is indicated in al
cases
E. US is the diagnostic modality of choice
GI 3
GI
Which of the following is a true
statement regarding GI perforations?
A. The best view for free intra-abdominal air is an upright
abdominal x-ray
B. The most frequent cause of a large bowel
perforation is appendicitis
C. Ulcers are the most common cause of
perforations
D. Smal bowel perforations are more common
than large bowel perforations
E. The highest percentage of bowel perforations occur in
middle-aged patients
GI 4
GI
A 52 y/o presents with nausea, vomiting
and epigastric abdominal pain. His
amylase = 1300. Which of the following
statements is true?
A. The elevated serum amylase is predictive of this
patient's severity of disease
B. This test is highly specific for acute pancreatitis
C. This patient requires an emergent surgical procedure
D. A serum lipase is a superior diagnostic test for
pancreatitis
E. Narcotic administration is contraindicated in this
patient due to acute spasms in the sphincter of Oddi
GI 5
GI
A concerned healthcare worker presents
to the ED following a needle stick from a
"patient with hepatitis". Which of the
following statements is true?:
A. The employee should be reassured that a vaccine for
hepatitis C does exist
B. Since the "patient" most likely has hepatitis A, no
chronic carrier state would be expected
C. The employee should be asked about their hepatitis
B vaccination history and serum HBsAb titers drawn
D. As long as the employee's liver transaminases and
PT are normal, no treatment is necessary
E. Hepatitis E and hepatitis G vaccines should be
administered
GI 6
GI
A 25 y/o male patient with Crohn's
disease presents with multiple complaints.
Which of the following is an extraintestinal
manifestation of Crohn's disease?
A. Sarcoidosis
B. Pneumonitis
C. Erythema marginatum
D. Pyoderma migrans
E. Ankylosing spondylitis
GI 7
GI
A 33 y/o patient was taking Clindamycin
for 2 weeks for an odontogenic abscess.
He developed profuse, watery diarrhea.
Which of the following is the most likely
cause?
A. Shigel a
B. Giardia
C. Clostridium difficile
D. Yersinia enterocolitica
E. Vibrio parahaemolyticus
GI 8
GI
Which of the following is true
regarding Boerhaave's Syndrome?
A. The patient may demonstrate a "Hamman's crunch"
from pneumomediastinum
B. It usual y causes a rupture in the proximal
espohagus
C. The CXR may demonstrate pneumothorax with a
narrowed mediastinum
D. An upper GI series with barium swal ow should be
performed in order to establish the diagnosis
E. It occurs more frequently in women
GI 9
GI
Which is true about appendicitis?
A. It is distinctly uncommon during pregnancy
B. Perforation is very frequent in young females
of childbearing age
C. A negative CT rules out appendicitis
D. Is never associated with Crohn's disease
E. An appendicolith on KUB is an uncommon
radiographic finding
GI 10
GI
Which of the following is true
regarding volvulus?
A. Cecal volvulus is more common in the young
than the elderly
B. Sigmoid volvulus is associated with coffee
bean appearance on an acute abdominal
series
C. Sigmoidoscopy is usual y therapeutic for cecal
volvulus
D. Sigmoid volvulus is more common in the young
than the elderly
E. Sigmoid volvulus usual y requires surgical
intervention
GI 11
GI
Which of the following is associated with a
poor prognosis in pancreatitis?
A. Hypercalcemia
B. Metabolic alkalosis
C. Hypoglycemia
D. LDH > 350
E. GLC > 150
GI 12
GI
Of the following, what is the best test
to diagnose cholelithiasis?
A. Ultrasound
B. CT
C. MRI
D. HIDA
E. Upper GI
GI 13
GI
Indications for hospitalization for
hepatitis include:
A. SGOT > 2500
B. Bilirubin > 10
C. INR of 1.5
D. Encephalopathy
E. Telangectasias
GI 14
GI
Which of the following is true
regarding ulcerative colitis?
A. Can be associated with toxic megacolon and
peritonitis
B. Is rarely associated with bloody diarrhea
C. Involves smal and large bowel
D. Is rarely associated colon cancer
E. Skip lesions are common
GI 15
GI
Which of the following are true concerning
large bowel obstructions?
A. General y are associated with more vomiting
and more pain than smal bowel obstructions
B. Typical y are associated with "step ladder"
plicae circulares on x-ray
C. A potential carcinoma should be ruled-out
D. Most commonly caused by adhesions
E. More common than generalized ileus
GI 16
GI
Which of the following is
characteristic of viral diarrhea?
A. Norovirus is most common in preschools
B. Rotavirus is a common cause in adults
C. It is the usual cause of traveler's diarrhea
D. More common than bacterial causes of
diarrhea
E. Fecal WBCs are frequently present
GI 17
GI
Holy mackerel! A patient presents with
flushing, palpitations, nausea and diarrhea
10 minutes after eating some fish. He has
a diffuse macular rash. Which is true
about scombroid poisoning?
A. Has a slow symptom onset
B. Imparts a "salty" taste to the fish
C. The treatment is H1 and H2 blockers
D. Is caused by the ingestion of dinoflagel ates
E. Causes a classic reversal of hot and cold
sensation
GI 18
GI
A 45 y/o presents from home complaining
of double vision, trouble swallowing and
speaking, after eating a 12 yr old can of
baked beans. Which is true regarding this
diagnosis?
A. Results in ascending paralysis and
anticholinergic symptoms
B. 72 hour onset of symptoms
C. Diplopia is the latest symptom
D. Produces cholinergic symptoms
E. Results in descending paralysis
GI 19
GI
The most common cause of bacterial
enteritis in sickle cell patients is which of
the following?
A. Campylobacter
B. Shigel a
C. Salmonel a
D. Vibrio parahaemolyticus
E. E. coli
GI 20
GI
The agent causing this diarrhea
is typically treated with oral
metronidazole:
A. Salmonel a
B. Amebiasis
C. C. difficile
D. Campylobacter
E. Enterobius vermicularis
GI 21
GI
GI Answer Key
1. A
11. A
2. D
12.D
3. B
13.A
4.
14.
C
D
15.
5.
A
D
16.C
6. C
17.D
7. E
18.C
8. C
19.E
9. A
20.C
10.E
21.C
This post was last modified on 24 July 2021