- 1. By James K. Rustad, MD Copyright 2009 All Rights Reserved.
GI: Step 3 Review
2. Outline Liver disease Abdominal pain Inflammatory Bowel
Disease GI Bleeding Pathology of the Esophagus Peptic Ulcer Disease
3. Acute Hepatitis Jaundice Fatigue Weight loss Dark urine from
bilirubin in urine 4. Hepatitis Viral hepatitis Drugs (Drug
induced) Elevated ALT Elevated AST 5. Hepatitis B HBsAg Anti-HBs
antibody Anti-HBc antibody Acute Hepatitis + - IgM Chronic
Hepatitis + - IgG Carrier + - IgG Past infection - + IgG
Vaccination - + - 6. Quiz Which test indicates immunity to
Hepatitis B? A) HBsAg B) Anti-HBc antibody C) Anti-HBs antibody D)
All of the above E) None of the above C) Anti-HBs antibody 7.
Hepatitis B Presence of HBeAg suggests active replication (Highly
infectious). Best test for acute Hep B is: anti-HBc IgM
Extra-hepatic manifestions: Polyarteritis Nodosa (vasculitis)
Arthritis Membranous Nephropathy Glomerulonephritis 8. Clinical
Scenario 45 year old male - Hep B surface antigen positive with
Foot Drop and Wrist Drop, Livedo Reticularis (a mottled purplish
skin discoloration over the extremities or torso), testicular pain
and BP 140/99. What is the most likely diagnosis? A) Lead poisoning
B) Lyme disease C) Polyarteritis Nodosa 9. Chronic Active Hep B
treatment Lamivudine (Or Adefovir dipivoxil if resistant to
Lamivudine) Or Alpha- Interferon (HBeAg positive). 10. Clinical
Scenario A patient with chronic Hepatitis B comes to clinic with
acute worsening of liver disease: coagulopathy, ascites, increasing
ALT and AST, hepatic encephalopathy. What lab test would you like
to order? Test for anti-HDV! 11. Quiz Question Which type of
hepatitis is transmitted by fecal-oral route, is epidemic in Asia,
and has very high mortality in pregnant women? 12. Hepatitis C Most
common cause of chronic liver disease (up to 80% of acute hepatitis
C can be chronic). Extra-hepatic manifestations: Mixed
cryoglobulinemia, glomerulonephritis. Phil Lynott 1949-1986 13.
Hepatitis C Best initial test: Hepatitis C antibody Most accurate
for learning degree of viral replication/activity of disease:
Hepatitis C PCR for RNA Liver biopsy to determine seriousness/liver
damage 14. Hepatitis C treatment Acute Hep C: alpha- interferon for
24 weeks Chronic Hep C: alpha- interferon and Ribavirin OR
Pegylated interferon and ribavirin. Genotype I: treat for one year.
Genotype II and III: six months. 15. Hepatitis C with cirrhosis
Treatment: liver transplant Screen for Hepatocellular carcinoma q6
monthly with alpha feto protein and RUQ Ultrasound 16. Allen
Ginsberg 1926-1997 17. Clinical Scenario A patient with Hepatitis C
with purpuric rash in the lower extremites, increased BUN and
Creatinine, and Protein/RBC in the urine. Most likely diagnosis?
Mixed Cryoglobulinemia 18. Clinical Scenario 36 y.o. man with
Hepatitis C presents with fever, abdominal pain, and altered mental
status On physical exam: spider angiomata, palmar erythema,
gynecomastia, distended abdomen with fluid wave (no
rebound/guarding). The most appropriate next study is: A) abdominal
CT B) paracentesis C) stool for culture, C. diff toxin, fecal
leukocytes D) abdominal films (upright and supine) E) abdominal
ultrasound 19. Spontaneous bacterial peritonitis Frequent
complication of cirrhosis and large ascites. Diarrhea, ileus and
hypotension can also occur. Diagnosis: Paracentesis (B is answer to
question from prior slide). Cell count with PMN >250. Treatment:
Cefotaxime 20. Hepatic Encephalopathy Signs: Asterixis (flapping
tremor), delirium, drowsiness. Day-Night reversal: Sleep during the
day and stay awake at night. Impairment in spatial perception. 21.
HE: Neuropsychiatric Disturbance Precipitants Treatment SBP GI
bleed High protein diet Hypnotics and Sedatives Alkalosis Neomycin
kills bacteria that break down protein into ammonia. Lactulose
causes osmotic diarrhea, lessening the time available for
intestinal bacteria to metabolize protein into ammonia. Acidifies
environment of lumen of bowel - promotes conversion NH3 to ammonium
(NH4 +) - less readily absorbed into bloodstream from bowel lumen.
22. Ascites Diagnostic Testing Serum to Ascites Albumin Gradient =
(albumin concentration of serum) - (albumin concentration of
ascitic fluid). SAAG > or = 1.1, portal hypertension from
congestive failure (high protein) or cirrhosis present. Increased
hydrostatic pressure within blood vessels of hepatic portal system
forces water out into peritoneal cavity; leaves proteins (albumin)
within vasculature. 23. Ascites - treatment Low sodium diet
Spironolactone, then Lasix Large volume: paracentesis
Peritoneo-venous shunt TIPS (only if patient on liver transplant
list) Liver Transplant 24. Esophageal varices Upper GI bleed
Treatment: Endoscopic band ligation or sclerotherapy IV Octreotide
Next step: balloon tamponade > OR for shunt operation
Prophlaxis: Propranolol 25. Hepatorenal syndrome Major criteria
include liver disease in the setting of portal hypertension; renal
failure; absence of shock, infection, recent treatment with
nephrotoxins, fluid losses; absence of sustained improvement in
renal function despite treatment with 1.5 L IV NS; absence of
proteinuria, absence of renal disease or obstruction of renal
outflow as seen on ultrasound. Minor criteria: less than 500 mL per
day of urine, low Na+ concentration in the urine, urine osmolality
that is greater than blood osmolality, no RBCs in the urine, and a
serum Na+ less than 130 mmol/L. 26. Hepatorenal Syndrome Underfill
theory: vessels in the renal circulation constricted due to
dilation of blood vessels in splanchnic circulation (supplies
intestines), mediated by factors released by liver disease.
Decrease in "effective" volume of blood sensed by the
juxtaglomerular apparatus > renin secretion and activation of
RAS Vasoconstriction of vessels systemically (and kidney).
Insufficient to counteract mediators of vasodilation in splanchnic
circulation, leading to persistent "underfilling" of the renal
circulation and worsening renal vasoconstriction > renal
failure. 27. HRS: Totally tubular, dude! Tubular functional
integrity maintained during renal failure. Relatively unimpaired
sodium reabsorptive capacity and concentrating ability. Definitive
treatment is Liver Transplant. 28. Clinical Scenario 50 year old
male w/ chronic hepatitis comes to clinic with increasing abdominal
girth and worsening of liver disease. The patient is on Lasix and
Spironolactone.He has developed renal failure with increased
BUN/Cr, decreased Urine output and Urine sodium less than 10. Most
important step in management? Fluid challenge with Normal Saline!
If not improving after Fluid Challenge > Liver Transplant. 29.
Clinical Scenario 23 year old male brought by friends to ER.
Personality change and disorganized. Physical: splenomegaly and
slit lamp eye exam: with brownish ring in the cornea. Diagnosis ?
30. Wilsons Disease Treatment: Low Copper Diet, oral Penicillamine
(or Trientine). 31. Clinical Scenario A 32 yo male w/out known
liver disease with painful enlarged liver, new onset ascites,
jaundice. History notable for Factor V Leiden deficiency. What is
the most likely diagnosis? Hepatic Vein Obstruction (Budd Chiari
Syndrome) Test to order: Doppler U/S for hepatic vein. 32. Clinical
Scenario A 27 year old female presents to your office with jaundice
and amenorrhea. Labs show elevated total protein but normal albumin
and Anti-smooth muscle antibody positive. Most likely diagnosis?
What study to confirm diagnosis and how would you treat? Autoimmune
Hepatitis Liver biopsy to confirm and treatment with Prednisone.
33. Clinical Scenario 45 year old female comes to your office
complaining of pruritis and fat in her stool. Xanthoma around
eyelids. Labs show increased Alk. Phos., Antimitochondrial Antibody
and elevated Cholesterol. Diagnosis and treatment? Primary Biliary
Cirrhosis Confirm with Liver Biopsy Treatment: Ursodeoxycholic Acid
34. Quiz Whats the diagnosis? Non-Alcoholic Steatohepatitis (NASH)
35. Clinical Scenario 32 year old male has a blood draw at 8 am and
comes into your office as a walk-in at 2 pm that same day
complaining of icterus. Otherwise asymptomatic. Most likely
diagnosis? Gilbert Syndrome unconjugated hyperbilirubinemia.
Precipitated by fasting. 36. Abdominal Pain 37. Epigastric
Abdominal Pain Gastric: PUD, ulcer, gastric outlet obstruction
Duodenal: PUD, duodenitis Biliary: cholecystitis, cholangitis
Hepatic: hepatitis Pancreatic: pancreatitis Intestinal: high SBO,
early appendicitis Cardiac: angina, MI, pericarditis Pulmonary:
pneumonia, pleurisy, pneumothorax Subphrenic abscess Vascular:
dissecting aneurysm, mesenteric ischemia 38. Clinical Scenario 47
year old obese female with severe abdominal pain, mid-epigastric,
radiating to back. The most appropriate diagnostic study at this
time is: A) an abdominal CT scan B) a HIDA scan C) LFTs with
amylase and lipase levels D) no study is indicated E) RUQ
ultrasound 39. Test results Alk phos: 450, Direct bili 3.4, Serum
glucose 180, Amylase 267, Serum calcium 8.8, Lipase 101, SGOT 45,
SGPT 33. RUQ ultrasound shows distended CBD and Abdominal CT shows
stranding and inflammatory changes in pancreatic head. Most
appropriate management? A) IV Opioids continuous infusion B) daily
abdominal CT C) IV antibiotics D) IV fluids and NPO E) surgical
debridement 40. If patient develops high fever? Most appropriate
management is to draw blood cultures and initiate ampicillin,
gentamicin and metronidazole therapy. IV antibiotics are only
indicated if there is evidence of pancreatic necrosis or if patient
develops a fever after the diagnosis of pancreatitis is made. 41.
Ransons Criteria On admission During 48 hours of admission Age >
50 Hematocrit drop > 10 % WBC > 16,000 Serum calcium < 8
Glucose > 250 BUN rise > 5 AST > 250 Base deficit > 4
LDH > 350 Fluid sequestration > 6 liter 42. Acute
Pancreatitis Treatment Bed rest NPO NG tube suction IV fluid
Fentanyl, Morphine, or Meperidine for pain If pancreatic necrosis
and febrile > CT guided aspiration 43. Right Upper Quadrant Pain
Biliary: calculi, infection, inflammation, neoplasm Hepatic:
hepatitis, abscess, congestion, neoplasm, trauma Gastric: PUD,
pyloric stenosis, neoplasm, alcoholic gastritis, hiatal hernia
Pancreatic: pancreatitis, neoplasm, stone in pancreatic duct or
ampulla Cardiac: MI (inferior wall), pericarditis Pulmonary:
pneumonia, infarction, R-sided pleurisy Renal: calculi, infection,
inflammation, neoplasm, rupture 44. Clinical Scenario 29 year old
female presents with fever, leukocytosis, and pain with inspiratory
arrest during inspiration while palpating the RUQ. The next most
appropriate step in management is? 45. Ultrasound 46. Murphys Sign
Pain with inspiratory arrest during inspiration while palpating the
RUQ 47. Another Clinical Scenario What is the next step if the u/s
shows the following? 48. Emergency Cholecystectomy Needed if there
is generalized peritonitis or emphysematous cholecystitis (suggests
perforation or gangrene). 49. Cholangitis Charcots Triad High fever
with chills,RUQ pain, yellow skin (Jaundice) U/S: Dilated Bile Duct
RUQ tender but Murphys sign negative Significant elevation of Alk
Phos/ Total bilirubin 50. Cholangitis ERCP for dx and tx. Also:
Papillotomy, balloon dilatation and stent placement. 51. Right
Lower Quadrant Pain Reproductive: Ectopic, Ovarian cyst (or
torsion), salpingitis, tuboovarian abscess, mittelschmerz,
endometriosis, seminal vesiculitis. Renal: renal and ureteral
calculi, pyelonephritis, neoplasms. Vascular: leaking aortic
aneurysm Trauma Psoas abscess Intestinal: acute appendicitis,
regional enteritis, incarcerated hernia, cecal diverticulitis,
intestinal obstruction, perforated ulcer or cecum, Meckels
diverticulitis. 52. Clinical Scenario 25 year old woman reported
that she experienced decreased appetite, followed by vague
periumbilical pain. Several hours later this became sharp, severe,
constant and in the RLQ. She had tenderness, guarding and rebound
to the right and below the umbilicus (but not elsewhere in belly).
She also had fever and leukocytosis. 53. Imaging 54. Left Upper
Quadrant Pain Gastric: PUD, gastritis, pyloric stenosis, hiatal
hernia Cardiac: MI, angina pectoris Vascular: ruptured aortic
aneurysm Pancreatic: pancreatitis, neoplasm, stone in pancreatic
duct or ampulla Splenic: splenomegaly, ruptured spleen, abscess,
infarction Pulmonary: pneumonia, empyema, infarction Intestinal:
high fecal impaction, perforated colon, diverticulitis 55. Clinical
Scenario 66 year old man has vague, poorly described epigastric and
upper back discomfort. U/S shows 6 cm aneurysm. Next step in
management? 56. Aortic Aneurysms If < 5 cm, serial annual
imaging. > or = to 5 cm should have elective repair. Tender AAA
will rupture within a day or two and requires urgent repair (within
24 hours). Excruciating back pain with large AAA (already leaking
and needs emergency surgery). 57. Left Lower Quadrant
PainIntestinal: diverticulitis, obstruction, perf. ulcer, IBD,
perf. Descend.colon, ing. hernia, appendicitis, adhesions, neoplasm
Psoas abscess Trauma Renal: renal or ureteral calculi,
pyelonephritis, neoplasm Vascular: leaking aortic aneurysm
Reproductive: ectopic, ovarian cyst (or torsion of cyst),
tuboovarian abscess, mittelschmerz, endometriosis 58. Clinical
Scenario Elderly male patient comes to the ER with a palpable mass
and pain in LLQ, tenderness. Fever + Leukocytosis 59. Imaging
Diverticulitis with wall thickening, diverticulosis, and stranding.
60. Treatment Mild: Metronidazole and cipro Moderate to severe:
admit with IV fluid, NG tube 1. Metro or clinda and aminoglycoside
2. Ticarcillin- Clavulanate If severe, or moderate unimproved in 72
hours, call Surgery! 61. Inflammatory Bowel Disease 62. Crohns
disease Most commonly involves terminal ileum and adjacent colon.
Transmural (whole thickness of colon) with skip areas. Perianal
disease with abscess and fistula. Antisaccharomyces cervisiae
antibody NBA Star Rafer Skip to my Lou Alston 63. Crohns Treatment
Mild to moderate 5- Aminosalicylic acid No response/intolerance:
Metronidazole, Cipro Severe: corticosteroids NFL QB David Garrard
64. Ulcerative Colitis Most commonly rectosigmoid colon. Mucosa and
submucosa only - Diffuse involvement. Dx: Flex. Sig. and biopsy
with crypt abscess. Friable lesions cause bloody diarrhea. 65. UC
treatment/complications Mild: Topical 5- ASA enemas or
suppositories. Moderate: Oral Sulfasalazine, Mesalamine. Next:
steroids. Next: 6-MP or AZA immunomodul ator. Severe: hospitalize.
Consider surgery if no improvement in 1 week. Complication: Toxic
megacolon. Severe symptoms, hypotension, tachycardia, dilated colon
> 6 cm. High risk of perforation. No response in 48 hours to
treatment: surgery! Another Complication of UC: PSC 66. IBD
Extra-intestinal manifestations Joints: Ankylosing spondylitis,
Oligoarticul ar arthritis. Eye: Uveitis, episclerit is. Skin:
Erythema nodosum , pyoderm a gangreno sum 67. Special Topic 25 year
old male with hx of UC comes to clinic complaining of anorexia,
pruritis, jaundice (progressive), and steatorrhea. Labs show
increased Alk. Phos. Most likely diagnosis? Primary Sclerosing
Cholangitis. Dx: ERCP 68. GI Bleeding 69. Clinical Case A 58 year
old man with a history of alcoholism presents to clinic complaining
of abdominal pain (occasional and relieved with food). Recently
stools have been black. Which is the most likely cause of bleeding?
A) Esophageal varices B) Duodenal ulcer C) Mallory-Weiss tear D)
Angiodysplasia E) Diverticulosis 70. Upper GI bleeding Originating
above the ligament of Treitz Most common causes: Duodenal ulcer
Gastric ulcer, Gastritis Esophageal varices, Mallory-Weiss tears
Gastric cancer, esophagitis, aortoenteric fistulas, epistaxis,
duodenal diverticulosis Black stool (melena) suggests blood in GI
tract that has been acted on by the gut enzymes. 71. Differential
Dx, Upper GI Bleed Oral or pharyngeal lesions, swallowed blood from
nose or oropharynx. Swallowed hemoptysis. Esophageal: varices,
ulceration, esophagitis, Mallory-Weiss tear, carcinoma, trauma.
Gastric: Peptic ulcer, gastritis, angiodysplasia, gastric
neoplasms, hiatal hernia, gastric diverticulum, Rendu-Osler- Weber
syndrome, pseudoxanthoma elasticum. Duodenal: peptic ulcer,
duodenitis, angiodysplasia, aortoduodenal fistula, duodenal
diverticulum/tumors, carcinoma of Ampulla of Vater, parasites,
Crohns. Biliary: hematobilia (penetrating injury to liver,
malignancy, endoscopic papillotomy). 72. Clinical Case Part Deux 3
months later, the man presents with BRB per rectum (hematochezia).
BP is 110/80 supine and 85/60 sitting. Which condition is probably
present? A) Esophageal perforation B) Variceal hemorrhage
C)Gastroduodenal artery bleeding 73. Clinical Scenario Patient
Post-op Day 1 after AAA repair has GI bleeding. Which is most
likely cause? A) Diverticulosis B) Gastric ulcer C) Angiodysplasia
D) Colonic ischemia E) Stress gastritis Inferior mesenteric artery
is often sacrificed during AAA repair procedure if inadequate
collaterals from left colon, ischemia will occur. 74. Colonic
ischemia Diagnostic study of choice? A) Barium enema B) CT of
abdomen C) Upper GI series D) Colonoscopy 75. Lower GI Bleeding
(small intestine) Originating below Ligament of Treitz Ischemic
bowel disease (mesenteric thrombosis, embolism, vasculitis, trauma)
Small bowel neoplasm: leiomyomas, carcinoids Hereditary hemorrhagic
telangiectasia (Rendu-Osler-Weber syndrome) Meckels diverticulum,
Aortoenteric fistula Intestinal hemangiomas, IBD, Polyarteritis
nodosa Hamartomatous polyps: Peutz-Jeghers, infectious of small
bowel, volvulus, intussusception, irradiation ileitis, lymphoma of
small bowel 76. Lower GI Bleeding (Colon) Carcinoma (particularly
left colon), diverticular disease, IBD, Ischemic colitis, colonic
polyps, Vascular abnormalities (angiodysplasia, vascular ectasia).
Radiation colitis, infectious colitis, uremic colitis Aortoentertic
fistula, lymphoma of large bowel, hemorrhoids, anal fissure Trauma,
foreign body Solitary rectal/cecal ulcers Long distance running 77.
Pathology of the Esophagus 78. Dysphagia for Solids Only Diagnosis
Cause Confirm Treat Intermittent Schatzki Ring or Esophageal Web
Congential (mostly) Barium esophago- graphy or upper GI endoscopy
Bougienage Progressive and Heartburn Peptic stricture GERD 24 hour
pH monitoring Proton pump inhibitor andd Dilation Progressive, no
Heartburn Carcinoma Endoscopy with biopsy Surgery, stent, XR and
chemo 79. Dysphagia for Solid and Liquid Diagnosis Cause Confirm
Treat Intermittent Diffuse spasm Motility d/o Manometry Calcium
channel blocker, nitrate Progressive and Heartburn Scleroderma
Unknown Manometry Calcium channel blocker Progressive/ no heartburn
Achalasia Unknown Barium esophagogra m bird beak like tapering of
distal esophagus - then next: manometry. Pneumatic dilatation next
modified Hellers cardio- myotomy or Lap. Surgery 80. Diffuse
Esophageal spasm Progressive dysphagia for both solid and liquid.
Precipitator: hot/cold liquid or large food bolus. Retrosternal
chest pain relieved by Nitro. Dx: manometry. Barium esophagogram
may be normal but may have corkscrew esophagus. 81. Achalasia
(causes regurgitation!) Barium esophagogram bird beak like tapering
of distal esophagus. Manometry shows increased pressure and
decreased peristalsis at lower end. Impaired peristalsis in distal
2/3rd of esophagus and impaired relaxation of lower esophageal
sphincter. 82. Esophageal manometry Disorder Finding Diffuse
esophageal spasm Increased peristalsis, increased pressure at lower
esophageal sphincter. Achalasia Decreased peristalsis, increased
pressure at lower esophageal sphincter. Scleroderma Decreased
peristalsis and decreased pressure at lower esophageal sphincter.
83. Mallory-Weiss Syndrome Mucosal laceration, GE junction. Usually
alcoholic patient hx of vomit/retching. Dx: Endoscopy Tx:
supportive. If active bleed: cautery or epi. local injection 84.
Clinical Scenario Patient comes to clinic reporting heartburn after
meal or when lying down after dinner. Relief from antacid. Best
test to confirm diagnosis? 24 hour esophageal pH monitoring (not
usually done). Should you perform endoscopy? 85. GERD Not so
fast!first try life style modification: weight loss, dont go to bed
after dinner. Avoid spicy food, soda, coffee. Then start empiric
treatment with: Proton pump inhibitor or H2 receptor antagonist for
4 weeks. Endoscopy in GE reflux: Treatment refractory Heartburn
responding to tx but needs continuous tx (rule out Barretts)
Heartburn + Dysphagia, Odynophagia, and/or Iron def. anemia 86.
Barretts Esophagus Complication of GERD. Columnar epithelium
replaces squamous. Increased risk of adenocarcinoma. Confirm:
Endoscopic biopsy. Tx: Proton pump inhibitor. Follow up endoscopy
every 3-5 yrs with biopsy. If low grade dysplasia: endoscopy
yearly. If high grade: surgery!! 87. Barretts Esophagus The
epithelium is composed mainly of goblet cells (asterisks) and
intervening nongoblet columnar cells (arrows). The crypts show
slight architectural irregularity, budding, and distortion. The
lamina propria shows a mild lymphocytic and plasma- cell infiltrate
(arrowheads). 88. Peptic Ulcer Disease 89. Peptic Ulcer Patient
complains of epigastric pain of dull and aching quality states that
he wakes up at night with pain and it is relieved with food. Where
is the most likely location of the ulcer? Duodenal ulcer Gastric
ulcers: usually pain increases with food. 90. Endoscopy for PUD
Confirmatory test. Required if patient is > 50 years of age,
anemia, or is complaining of weight loss. 4 weeks of treatment with
proton pump inhibitor of H2 blocker. If no improvement: test for H.
pylori! 91. Peptic Ulcer Surgery Duodenal Ulcer Gastric Ulcer
Highly selective vagotomy Other: Antrectomy, gastric resection
Gastrectomy or Antrectomy + Gastrojejunostomy/ga stroduodenostomy
Billroth I (end to end gastroduodenostomy anastomosis) Billroth II
reconstruction (end to side gastrojejunostomy) 92. Thank you for
your attention!
