Gastrenterology for Studs

GASTRENTEROLOGY

· Choanal atresia – Child become cyanotic when feeds and turn pink when cries
· Gastroschisis ® first step? ® Sterile wrapping of exposed bowel; next? 
orogasric tube to decompress stomach & IV nutrition
· Omphalocele ® shiny, thin, membranous sac at the base of the umbilical cord,
cord goes to the defect, not to the baby ® can have multiple defects
· Pyloric Stenosis ® Projectile vomiting in infants – hypertrophy of pyloric region
® Usage of Erythromycin is associated with infantile hypertrophic pyloric
stenosis ® Diagnostic test: Abdominal USG ® First step in management: IV
fluids & K+ supplement ® Tx: Pyloroplasty
· Infant with congenital diaphragmatic hernia, next step?  orogastric tube
placement
* Dysphagia :
 Best Initial Test ® barium swallow / barium esophagus
 Dysphagia for solids not liquid ® Obstruction – stricture, esophageal CA
Plummer–Vinson Syndrome
· Dysphagia for solids and liquid ® Peristalsis problem – Achalasia , Systemic Sclerosis, CREST, Polymyositis
* Achalasia – Absent myenteric ganglion
· Most accurate test – esophageal manometry [normal amplitude contraction with
high tone of lower sphincter (failure to relax)]
· Best Initial Therapy – pneumatic dilatation
* Esophageal spasm – “corkscrew” pattern on barium study
· Most accurate test – esophageal manometry [high amplitude contraction with
normal relaxation of lower esophageal sphincter]
· Tx : Ca + 2 channel blockers, Nitrates
* Scleroderma [Progressive Systemic Sclerosis (PSS)]
· Most Accurate test – esophageal manometry (absence peristalsis wave with
very low tone of lower esophageal sphincter)
· Tx : Proton-pump inhibitors, Metoclopramide
* Ring & Webs :
· Schatzki’s ring – more distal & located at the squamocolumnar junction
· Plummer-Vinson – more proximal & located in the hypopharynx [iron deficiency anemia]
· Diagnosis ® Barium swallow / Barium esophagus – Tx: Dilatation

* Esophageal CA : Tobacco + Alcohol ® SCC ®Upper 2/3
· GERD & Barrett esophagus ® Adenocarcinoma ® lower 1/3
· Endoscopy is mandatory . CT chest ® to detect degree of spread
* Zenker’s Diverticulum : out pocketing of the posterior pharyngeal Constrictor
muscles at the back of the pharynx
· Bad breath, aspiration pneumonia / lung abscess (anaerobic)
· Diagnosis ® Barium study (Esophagography)
· Tx : Surgical resection (Endoscopy & placement of nasogastric tubes are C/I)
· Patient present with aspiration pneumonia due to Zenker’s diverticulum started on
antibiotics (treatment for pneumonia), next step? Esophagography (barium). [Not
scopy]
* Gastroesophageal Reflux Disease ( GERD ) :
· Epigastric pain going under sternum , non-productive cough at night (it can cause
worsening of asthma at night by irritating bronchus), bad taste in mouth
· Most Accurate Test ® 24-hrs PH monitoring
· Tx : PPIs (best initial), Metoclopramide, H2 – blockers, Nissen fundoplication
· Sliding Hernia of esophagus – GE junction displaced & reach above
· Paraesophageal Hernia – GE junction not displaced
* Barrett Esophagus : Metaplasia (squamous ® columnar)
˗ Repeat Endoscopy every 2-3 yrs
˗ Low grade dysplasia ® repeat endoscopy in 3-6 months
˗ High grade dysplasia ® distal esophagecomy
˗ All patients with Barrett esophagus should be on PPIs
* Mallory Weiss Tear ® continuous retching followed by large painless bloody vomiting (mucosal tear) ® Hiatal hernia [predisposing factor] ® Endoscopy (best initial) ® Tx: resolve itself

* Boerhaave Syndrome ® continuous retching followed by severe chest pain,
Crepitation in the neck, air in mediastinum on CXR [Esophageal rupture – usually
in distal third, posterolateral segment (where there is no serosa) is the most
common site] ® Tx: emergency surgical repair
· Esophagitis : Candida Albicans (MCC) typically in HIV patient (CD 4 < 200)
· Next step ® Empiric Tx with Fluconazole
· HIV positive ® C/O Odenophagia ®Already on Anti-fungal ® Endoscopy (next
step) Other causes of Esophagitis ® HSV, CMV, Aphthus ulcers

* Epigastric Pain
½
¯ ¯
Young Patient without any S/S Patient > 45 yrs. Old
Suggestive of CA with / without S/S suggestive of CA
(Dysphagia, wt. loss)
¯ ¯
Empirical Treatment Endoscopy with biopsy
(PPIs / H2 – blockers)
¯ If no improvement
Endoscopy with biopsy
* Diagnosis of H.pylori :
· Serology (Best initial test), urea breath testing, stool antigen
· Endoscopy with biopsy & histology (Most accurate test)
· CLO test ® rapid test on biopsy which check Urease produced by H. pylori
· Breath & Stool Test ® Best post-treatment test to check eradication of H. pylori
· Tx : PPI + Clarithromycin + Amoxicillin
· If organism is eradicated & still ulcer persist ® check for ZE syndrome
* Zollinger–Ellison Syndrome (ZE syndrome) :
· Multiple recurrent ulcers (usually duodenum) , Steatorrhea
· Associated with MEN – I (Parathyroid, Pituitary, Pancreas)
· ↑↑↑ acid production inactivate pancreatic enzymes ® malabsorption
· Diagnosis : Elevated gastrin level
· Secretin stimulation test (if gastrin level is non diagnostic in suspected patient)
· Next step after Diagnosis ® search for metastasis
¯
Nuclear test (Somatostatin receptor scintigraphy)
· Tx : Localize ® Surgical resection, Metastasis ® PPIs
* Gastritis :
· Type – A ® Atrophic gastritis (Autoimmune) , Vit-B12 deficiency , gastrin
· Type – B ® NSAID, H. Pylori, Alcohol
· Tx : Vit- B12 replacement, PPIs, H2 – blockers
· Increase chance of gastric CA in patient with Type-A gastritis
* Gastroparesis : weak stomach
· Diabetes neuropathy (MCC)
· C/O early satiety, Postprandial nausea, Abdominal fullness
· Diagnosis ® gastric emptying study
· Tx : Erythromycin / Metoclopramide

* Dumping Syndrome :
· 1St ® hypertonic chyme release in duodenum ® osmotic draw into duodenum
leading to intravascular volume depletion
· 2nd ® sudden in glucose level ® insulin release ® Hypoglycemia
· Tx : Eat multiple, small meals
· Protein loosing enteropathy : Enlarge rugal folds – hypertrophy of mucous
cells (Menetrier disease, ZES, lymphoma)
■ Inflammatory Bowel Disease :
* Crohn’s Disease [CD] : Oral / Perianal involvement , palpable Abdominal mass
(granuloma – characteristic of Crohn), Transmural involvement, Skip lesions,
Fistula formation
* Ulcerative colitis : rectum involvement, bloody diarrhea , exclusive mucosal
disease – Patient with ulcerative colitis and pancolitis should begin surveillance
colonoscopy after 8 yrs of having the disease
* Best diagnostic Test ® Endoscopy
˗ CD ® Anti–Saccharomyces cerevisiae antibodies (ASCA)
˗ UC ® ANCA
· CD ® Vit–B12, Vit–K, Ca +2, iron deficiency ® elevated PT, kidney stones,
Megaloblastic anemia
* Tx : Mesalamine [5-Aminosalicylic acid (5-ASA)] derivatives (best initial)
· Infliximab ® CD with fistula formation / refractory to other therapy
· Acute Exacerbation ® High dose steroids (Budesonide)
· Young patient with bloody diarrhea, if normal rectosigmoidoscopy – Crohn’s
disease; If rectum if affected – Ulcerative colitis
* Lactose Intolerance : lactase deficiency
· Diarrhea associated with gas & bloating after drinking milk
· Never has blood / WBC in stool
· Diagnosis : stool osmolarity > expected osmolarity, Positive Hydrogen breath test,
positive Clinitest of stool for reducing sugar
· Tx : Remove milk product from diet (symptoms resolve in 24-36 hrs)
* Irritable Bowel Syndrome :
· Abdominal pain relieved by bowel movement
· Diarrhea alternating with constipation
· Tx : High – fiber Diet. Diarrhea predominant ® loperamide / diphenoxylate
· Anti–spasmodic agent ® dicyclomine / hyoscyamine
· Alosetron ® Diarrhea predominant [restricted access in USA]
· Tricyclic Antidepressant ® resistant cases
· Tx of chronic constipation in child – dietary modification; If it fails, use laxatives
(milk of magnesia)

* Carcinoid Syndrome : tumors of the neuroendocrine syndrome
· Tip of vermiform appendix (most common site) but carcinoid tumors of terminal
ileum most commonly metastasize (liver) and produce carcinoid syndrome
· Diarrhea, Flushing, Tachycardia and Hypotension
· Niacin deficiency (Serotonin & Niacin ® Tryptophan)
· Endocardial fibrosis , Tricuspid Regurgitation , Pulmonic stenosis
· Diagnosis : urinary 5 – HIAA ( 5- hydroxyindolacetic acid )
· Tx : Octreotide
* Celiac Disease :
· Anti-gliadin, Anti-endomysial, Anti-transglutaminase antibodies
· Loss of intestinal villi (malabsorption – diarrhea, abd distension, abd pain)
· Celiac disease affect PROXIMAL small bowel
· Function returns if patient is on gluten free diet
· Dermatitis herpetiformis ® strong association with celiac disease
· No wheat, rye, oat [contains gluten]
* Whipple’s Disease : Tropheryma whippeli bacilli
· PAS–positive macrophage obstruct lymphatic & reabsorption of chylomicrons
· Chronic diarrhea and weight loss
· Tx : Sulfamehoxazole / trimethoprim or Doxycyclin ´ 6 months
· Chronic diarrhea, WT loss, generalized lymphadenopathy but no risk factor for
HIV  Whipple diseases  endoscopy with small bowel biopsy (PAS-positive material in lamina propria) [HIV will always there in 5 choices to confuse]
* Diverticulosis :
· Lack of fibers in the diet
· Right sided bleed / Left sided obstruct
· Most common cause of lower GI bleed. (Angiodysplasia – 2nd MCC)
· Most common source of diverticular bleeding – erosion of the artery
· Tx : Increase fibers in diet
· Patient with diverticulosis (showed on colonoscopy) present with active Bleeding
& now stabilized after resuscitation, next step? labeled erythrocyte scintigraphy
(to find source of bleeding)
* Diverticulitis : (left sided appendicitis)
· CT scan (Best test) [Barium study & Endoscopy – contraindicated]
· Tx : Ciprofloxacin and Metronidazole
· Sigmoid colon : most common site for diverticulosis, diverticulitis and polyp
· Rectosigmoid colon : most common site for colon CA

· Volvulus of Sigmoid colon ® Elderly patient ® distended abdomen, similar
episodes in past which resolve itself ® Parrot’s beak appearance (coffee bean
sign / omega sign) of large gas shadow on X-ray ® Tx : Rigid sigmoidscopy –
Rectal tube ® bowel preparation & elective surgery
 Ogilvie Syndrome ® Abdominal distension , without tenderness in elderly
sedentary patient after surgery elsewhere in the body (but not Abdominal
surgery) ® X-ray : distended colon with cut-off at splenic flexure ® Tx :
colonoscopy (both diagnostic & therapeutic); if recur then do colonoscopy one
more time; if still recur then start Neostigmine drip; Cecostomy is the last resort
· Mesenteric Ischemia ® Patient with h/o AF / atherosclerotic disease present
with acute abdomen and low bicarbonate (pain out of proportion to physical
findings like absent rebound tenderness, guarding, rigidity, etc) & blood in stool
· Mechanical Intestinal Obstruction ® Abdominal pain, constipation, distension
& vomiting (cardinal features of obstruction) ® Adhesion / Indirect Inguinal
Hernia
- Fever, leukocytosis, rebound tenderness in patient with indirect inguinal hernia
suggest strangulation
 Paralytic Ileus ® post-op-abdominal distension, without tenderness ® X-ray ®
dilated small bowel, without air fluid level ® Absent bowel sound ® Tx : NPO
and NG tube suctioning until peristalsis resumes
 Post-op-Intestinal Obstruction : Adhesion ® X-ray: multiple air fluid level ®
Barium tag: it will “hang” somewhere if there is a mechanical obstruction ® Tx:
Reoperation
· Meconium ileus ® cystic fibrosis ® ground glass appearance on abd x-ray ®
Gastrografin enema (both diagnostic & therapeutic)
* Meckle’s Diverticulum ® painless large bloody bowel movement in child
(brick red stool) ® Technetium scan (99mTc scan) to identify ectopic gastric
mucosa [rule of 2’s – 2 ft from ileocecal valve, 2 inches long, 2 yrs of age, 2% of
population; remnant of Vitelline duct (Omphalomesenteric duct)]
· Hirschsprung Disease (aganglionic megacolon) ® Rectal exam may lead to
explosive expulsion of stool & flatus ® X-ray: distended proximal colon
(normal) and “normal looking” distal colon (aganglionic).
· Intussception ® sausage shaped mass on the right side of the abdomen,
“empty” looking right lower quadrant (Dancing sign), “currant jelly stool”

· Acute Abdomen : (rebound tenderness, guarding, rigidity) ® Exploratory
laparotomy (1st step in management) [Medical treatment for Any Acute
Abdomen ® NPO, NG suction, IV fluids]
 Classic presentation of Acute Appendicitis [pain start in mid epigastric region
and then shifted to RLQ, positive rebound tenderness, Psoas sign, Rovsing’s sign,
etc], next step? ® Appendicectomy
 Above presentation, On Abdominal exploration, Appendix is normal but ileum is
inflamed (Crohn’s ileitis), next step? ® Proceed with Appendicectomy and close
the abdomen
 Above presentation, On Abdominal exploration, Appendix is normal but ileum &
cecum are inflamed, next step? ® Do nothing and close the abdomen [when
cecum is inflamed, Appendicular stump doesn’t heal and it can cause fecal fistula
which leads a hemicolectomy]
 Female patient without classical presentation of appendicitis, next step? ® USG
 Classic presentation of appendicitis but 6-7 days old pain, mass on abdominal
palpation, diagnosis? ® Appendicular mass, next step? ® IV fluid, bowel rest,
IV antibiotics, serial examinations
 If above scenario, 24-hrs after starting treatment, patient is getting worse (spiking
fever, tachycardia, increase in localize tenderness), next step? ® CT scan
(Appendicular abscess) ® Tx : CT guided drainage
* Gastrointestinal Bleeding :
· First step ® Resuscitation / Treatment then find etiology
· FFP ® if PT is elevated
· Platelate transfusion ® if count < 50,000 / mm3 & Patient is acutely bleeding
· If h/o cirrhosis ® Octreotide
* Esophageal Varices ® Octreotide during acute episodes
· If still bleeding ® emergency endoscopy & place bands around the bleeding
Varices
· If still bleeding ® TIPS (complication ® worsening of hepatic encephalopathy)
· Propranolol ® for prophylaxis of portal HTN
· BUN level is often elevated in patient with upper GI bleed. BUN level >40 in the
presence of normal serum creatinine is very suggestive of upper GI bleed
· Diagnosis of GI bleed :
· Endoscopy (most accurate test)
· Nuclear bleeding scan
· Angiography
· Capsule endoscopy (to visualize small bowel)
· Angiodysplasia (vascular ectasia) – Second most common cause of lower GI
bleeding – Aortic stenosis has been associated with Angiodyplasia
* Colon Cancer : colonoscopy
· Hyperplastic polyp , Juvenile polyp , Peutz –Jeghers ® No malignant potential

· Tubular polyp (most common neoplastic polyp) , villous polyp , Familial
Polyposis , Turcot syndrome , Gardner syndrome ® malignant potential
* Hereditary Non-Polyposis Syndrome (HNPCC) (Lynch Syndrome):
· Mis-match base repair defect
· Colonoscopy every 1-2 yrs start at age of 25 yrs
· Very high incidence of ovarian and endometrial cancer
* Familial Adenomatous Polyposis :
· APC gene confers 100 % penetrance for the development of adenomas by the age
of 35 & colon cancer by the age of 50
· Flexible sigmoidoscopy every 1-2 yrs start at age of 12
· As soon as polyps are found ® colectomy .
* Cowden Syndrome :
· Hemartomas, rectal bleeding in a child
* Gardner Syndrome :
· Colon CA + multiple soft – tissue tumors (osteoma, lipoma, fibrosarcoma)
* Turcot Syndrome :
· Colon CA + CNS malignancy
* Peutz – Jeghers Syndrome :
· Hemartomatous polyp + Hyperpigmented spots (lips, buccal mucosa, skin)
· Hemorrhoids / Anal fissure ® Proctosigmoidscopy [ 1 s t examination then Tx]
[Any anorectal problem (even abscess) ® rule out cancer 1st by appropriate
examination and then treatment]
* Acute Pancreatitis :
 Mid epigastric pain classically radiates straight to the back.
 Amylase & lipase (most specific) are extremely elevated
 CT scan (Most accurate test)
 Ranson’s criteria: within first 48-hrs [age(>55yrs), WBCs (>16,000), LDH
(>350 IU/L), Blood sugar (>200 mg/dl), AST (>250 IU/L)] After 48-hrs [Po2

 Billiary & Pancreatic ductal pathology ® ERCP (most accurate test)
 Tx : Supportive (NPO, IV fluids, etc). ERCP (sometimes) to remove stone in the
pancreatic duct or to dilate a stricture
 h/o Acute Hemorrhagic pancreatitis + fever & leucocytosis ® Pancreatic
Abscess ® Tx : Require Drainage
 Pseudopancreatic cyst of less than 6 weeks ® observe
 Pseudopancreatic cyst of greater than 6 weeks ® intervene

* Chronic Pancreatitis :
· Chronic abdominal pain in chronic alcoholics; h/o recurrent acute pancreatitis
· Calcification of pancreas on x-ray / CT scan (initial test)
· Stool elastase; Secretin Test ® low trypsin level (most accurate test)
· D-Xylose Test ® to differentiate b/w celiac disease / chronic pancreatitis
· If no Absorption of D–Xylose ® Celiac Disease
· Tx of Steatorrhea due to chronic pancreatitis – diet modification (low fat diet); If
it fails, give pancreatic enzyme supplements
 Pancreatic head cancer : Palpable gallbladder without significant tenderness
* Billirubin : Senescent RBC → Heme → unconjugated Bilirubin (lipid soluble – can
accumulate in tissue so large amt in blood can cause problem) → bind with
albumin and goes to liver → conjugated in liver [water soluble – easy for our body
to excrete] → secreted in bile → 80% excreted in feces & 20% extrahepatic
circulation [90% liver and 10% renal (in urine)]
* Jaundice : ↑ unconjugated [more hemolysis, liver unable to pick up (Gilbert
syndrome – jaundice with fasting), liver unable to conjugate (Crigler-Najjar syndrome – deficient enzyme)] ↑ conjugated [liver unable to excrete in bile
(Dubin-Johnson syndrome – black liver) (OCP), ↓ extrahepatic bile flow (gallstone, CA of head of pancrease)] ↑ Both [liver dysfunction (hepatitis)]
· Pruritus in Billiary disease is due to bile salt which deposits in skin
· For Jaundice, we test billirubin in urine with strip test not urobillinogen (UBG).
UBG is normally present in urine. UBG is absent in obstructive jaundice but billirubin (conjugated – water soluble) is present in urine in obstructive jaundice
■ Neonatal Jaundice :
- Within first 24-hrs – Pathological [ABO incompatibility (most common cause),
Rh incompatibility, Sepsis, Spherocytosis, G6PD, etc], >13 mg/dl (indirect /
direct hyperbilirubinemia)
- Between 24-36 hrs – Physiological [resolved by 7-10 days, monitor bilirubin
level to prevent Kernicterus (lethargy, irritability, hypotonic seizure) (rare)],
rarely exceed 12.9–15 mg/dl (indirect hyperbilirubinemia)
- After 1 week – Breast milk [diagnosis of exclusion]
- Tx : Phototherapy for indirect hyperbilirubinemia to prevent kernicterus
· Billiary Atresia ® Persistent, Progressively increasing jaundice in newborn ®
HIDA scan after week of Phenobarbital ® If no bile reaches the duodenum after
Phenobarbital stimulation ® surgery
* Cirrhosis :
· Best initial test to assess liver cell damage – serum Transaminases
· Liver biopsy (most specific test)
· AST/ALT - >2 is quite specific for alcoholic liver disease. (increase GGT is also
seen in alcoholic liver disease)
· AST - >500 – should suspect viral / toxins / ischemia (AST level in alcoholic liver
problem is usually below 450)

· Portal HTN, Esophageal Varices, Ascites, Peripheral edema, elevated PT, low Albumin,
spider angioma, palmar erythema, asterixis
· Serum : Ascites albumin gradient ( SAAG ) :
SAAG > 1.1 ® portal HTN
SAAG < 1.1 ® cancer, Infection
· Ascitic patient, already on furosemide, spironolactone, protein & salt restriction
diet, has passed little urine, diagnosis?  Hepato-renal syndrome; next step? 
careful volume loading and stop diuretics
· Respiratory distress due to abdominal distension in cirrhotic patient, next step? 
Paracentesis (diagnostic & therapeutic)
· Management of Ascitic patient:
1. Sodium and water restriction
2. Spironolactone [Anti-androgenic action helps decreasing effect of estrogen]
3. Loop diuretics (furosemide)
4. Frequent abdominal tapping
* Spontaneous Bacterial Peritonitis (SBP) :
· Culture of the fluid (most specific test)
· Total WBC > 500 / mm 3 / > 250 /mm 3 neutrophils ® Infection is present
· Cefotaxime / Ceftriaxone (drug of choice)
· Subacute bacterial peritonitis in Ascitic patient, next step?  paracentesis; not
diagnostic peritoneal lavage which is done in blunt abdominal trauma
* Primary Billiary Cirrhosis :
· Anti-mitochondrial antibody
· Granulomatous destruction of bile ducts in portal triad
· Middle – aged women, very less elevation of bilirubin, strong association with
other auto-immune diseases ® Sjogren Syndrome, RA, Scleroderma
· Diagnosis : Transaminase are often normal
Alkaline Phosphatase & g - glutamyl transpeptidase
· ↑ risk for hepatocellular carcinoma [HCC]
· Tx : Bile acid sequesters (cholestyramine, Ursodeoxycholic acid), UV light for
Pruritus
· Ursodeoxycholic acid slows the progression of Primary Billiary Cirrhosis (PBC).
* Primary Sclerosing Cholangitis :
· Obliterative fibrosis of intrahepatic & extrahepatic bile ducts
· Strong association with Ulcerative colitis
· Sx – same as primary billiary cirrhosis ( Pruritus; etc)
· Anti-mitochondrial Antibody ® negative
· ↑ risk for cholangiocarcinoma (CA of bile duct)

* Hemochromatosis :
· Most common inherited genetic disease
· Over absorption of iron [Ferritin (major storage protein) store iron in macrophage
in bone marrow and hepatocytes, circulate in small amt in serum (↓ in iron
deficiency anemia); Hemosiderin degradation product of Ferritin in cell, (doesn’t
circulate) golden brown granules in tissue & blue with Prussian blue]
· Intracellular iron produce hydroxyl ions which damage parenchymal cells
· Cirrhosis, Restrictive cardiomyopathy, Arthralgia, skin hyperpigmentation,
diabetes, Hypogonadism
· infection with Vibrio vulnificus, Yersinia & L.monocytogens
· Most appropriate treatment of Hemochromatosis – therapeutic phlebotomy
* Wilson Disease :
· Autosomal recessive disease
· ¯ copper transport into bile and ¯ ceruloplasmin synthesis leads to ¯ excretion of
copper from body & free Cu +2 in the body which deposited in various tissue and produce damage
· Basal ganglia dysfunction (choreoathetoid movements), Kayser-Fleischer ring (Slit – lamp Examination), Fanconi Syndrome
· Ruptured Hepatic Adenoma ® young woman on birth control pills present
with abdominal pain, low hemoglobin, hypovolemic shock ® CT Scan ®
Surgical removal
· Amebic liver abscess ® h/o Travel to Mexico ® jaundice, weight loss, right
upper quadrant pain, diarrhea ® Serology for amebic titers ® Metronidazole ( if
not cured with Metronidazole ® Aspiration )
· Liver Problem ® transaminase Billiary Problem ® Alkaline
Phosphatase Alcoholic liver Problem ® GGT (γ–glutamyl transferase )
* Choledochal cyst – congenital benign dilatation of bile ducts
* Caroli’s Syndrome – congenital cystic dilatation of the intrahepatic biliary tree –
associated with polycystic kidney disease – Cholangitis & Cholangio CA
* Gall stone (Cholelithiasis) :
· Cholesterol (80%) (radiolucent) - ↑cholesterol in bile and ↓bile salt & lecithin
· Pigment stone (20%) (radio-opaque) – calcium bilirubinate [Sickle cell anemia]
· Billiary colic ® colicky right upper quadrant pain, radiate to the right shoulder,
often aggravated after ingestion of fatty food / Anti-cholinergic drug ® USG
[presence of gall stones, no thickening of GB wall]
· Acute Cholecystitis ® Female , Forty , Fertile , Fatty ® colicky right upper
quadrant pain, radiate to the right shoulder, often aggravated after ingestion of
fatty food ® USG [presence of gall stones, thickening of GB wall,
pericholecystic fluid]

˗ Typical acute Cholecystitis presentation but negative USG ® HIDA scan
˗ Tx : If patient present within 3 days of onset of pain ® Emergent laparoscopic
cholecystectomy; If patient present after 3 days of onset of pain ® medical
treatment as of acute abdomen followed by elective cholecystectomy; but if
medical treatment fail ® Emergent open laparotomy
˗ Air in GB wall on X-ray ® emergent laparotomy
˗ Air in GB, stone in terminal ileum (small bowel obstruction) ® GB-enteric fistula
˗ Air within Billiary tree after ERCP → billiary enteric fistula
˗ Any patient with symptomatic gall stones / gall stones complications
(Pancreatitis, Cholangitis, Obstructive jaundice) should not go home without
cholecystectomy
˗ Post-cholecystectomy pain ® sphincter of oddi dysfunction, CBD stone or
functional pain
· Obstructive Jaundice ® USG (Best next / 1st step in management)
˗ if it is due to gall stone ® ERCP (remove gall stone) then laparoscopic
cholecystectomy
˗ If it is due to CA (wt. Loss, Asymptomatic Jaundice) ® CT scan ® Percutaneous
biopsy ® T x
˗ If it is due to CA (wt. Loss, Asymptomatic Jaundice) ® CT scan (negative) ®
ERCP ® Tx
* Gallbladder adenocarcinoma :
· Risk factors – cholelithiasis, porcelain gallbladder [calcification of GB wall]
 Infant on milk formula – necrotizing enterocolitis – transmural necrosis
 Reye Syndrome :
- Encephalopathy and microvesicular steatosis in Liver
- Recent viral URI, [Varicella, Influenza + Aspirin use].
- Ammonia, Transaminases are markedly elevated
- Liver biopsy ® non-inflammatory fatty infiltration, mitochondrial injury
· Hep A vaccine should be given to all unimmunized patient with underlying
chronic liver disease
· Almost all patients with Hep C infection who undergo transplantation have a
documented recurrence of Hep C infection in the transplant liver.
· Tx of acute Hep B (patient already have symptoms) – supportive care
· Tx (prophylaxis) of Hep B exposure (patient has exposed but doesn’t have
symptoms, eg. Needle prick) – Immunoglobulin + Hep B vaccine

Diseases of the Small Intestine

Chronic Mesenteric Ischemia

My babies, you know these poor little patients have postprandial periumbilical pain and therefore develop 'Fear of food'! Poor bastards!

'He slowly parted my lips with his thumb and index finger -
he thrust his middle finger in my oral cavity as he undressed me fully with his other hand all the while keeping his eyes fixed on mine and started looking for hyperpigmented spots on my lips, buccal mucosa, and skin: a sign of Peutz – Jeghers Syndrome - he then announced his intention to check for hamartomatous polyps...'

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Wednesday, February 3, 2010