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Noncontrast helical abdominal CT scan is the imaging choice to dx nephrolithiasis (kidney stones)
Initial screen in acute abdominal pain should include supine and upright abd plain films to look for air-fluid levels (indicates bowel obstruction) and free peritoneal air (indicates perforated viscus)
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Rupture of AAA is preceded by abdominal pain, back pain, and syncope
-leukocytosis and anemia are also common
-CT scan should be performed for dx
- -IBS: clinical dx made when pt meets Rome II criteria and do not have alarm indicators
- -Rome III Criteria: 2 of the following for 3 months -> pain relieved by defecation, pain onset with change in stool frequency, pain onset with change in stool consistency
- -Alarm indicators: older age, male sex, noctural awakening from pain, rectal bleeding, weight loss, or FH colon cancer
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Ischemic colitis presents most commonly in elderly pt with athersclerotic vascular disease with crampy abdominal pain and bloody stool; usually self-limited
Contrast-enhanced CT is image choice to confirm suspected diverticulitis and evaluate for extraluminal complications
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Chronic pancreatitis common in pt with hx alcoholism who presents with chronic upper abd pain that radiates to the back, DM, steatorrhea, and pancreatic calcifications on abd xray
- HUS is dx based on presence of microangiopathic hemolytic anemia and thrombocytopenia
- -See schistocytes on peripheral smear, elevated retic count, and elevated LDH level with MAHA
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Acute radiation proctitis can cause diarrhea and tenesmus within 6 weeks of therapy
Pt with chronic pancreatitis can present with abd pain, malabsorption, and endocrine insufficiency
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Invasive workup is not necessary in IBS in the absence of alarm symptoms
Pt with previous Abx exposure can develop C. diff and colitis, char by diarrhea 10-15 times daily, lower abd pain, cramping, fever, and leukocytosis
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Abx tx is generally not required for Salmonella gastroenteritis
- Abx tx is generally not required for Salmonella gastroenteritis because it is self limited
- Tx is recommended for
- 1) immunocompetent <2 yr or >50 yr
- 2) immunocompetent with severe illness that requires hospitalization
- 3) immunocompetent with athersclerotic plaques, endovascular/bone prostheses
- 4) immunocompromised pt
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Hepatocellular injury most often results in elevation of ALT and AST and is associated with direct hyperbilirubinemia
Incidental finding of indirect (unconjugated) hyperbilirubinemia in asx pt with normal Hb level and otherwise normal LFT indicates Gilbert syndrome
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Cholecystectomy provides definitive therapy for pt with symptomatic gallstone disease
Pt with acute hepatitis have marked elevation of aminotransferases
Pt with primary sclerosing cholangitis have cholestatic pattern (primary elevation of bilirubin and alk phos levels)
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Classic findings of acute cholecystitis: biliary colic, murphy sign, fever, leukocytosis, mild bilirubin and aminotransferase elevation, gallstones, pericholecystic fluid, thickening of gallbladder wall on US
Clinical dx of acute cholangitis based on presence of fever, jaundice, and RUQ abd pain with the finding of common bile duct obstruction
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ERCP with sphincterotomy and stone extraction is the initial tx choice for gallstone pancreatitis
Presence of stones in the gallbladder, dilated bile duct, and elevated aminotransferase levels highly suggest gallstones as cause of acute pancreatitis
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Enteral feeding is preferred route for providing nutrition in pt with severe acute pancreatitis
Endoscopy is indicated in pt with GERD who have alarm sx (dysphagia)
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PPI is tx of choice for erosive or severe esophagitis
Bx of all gastric ulcers should be preformed because even small benign-appearing gastric ulcers may harbor malignancy
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Two most common causes of PUD are NSAIDs and H. pylori infection (>90% of cases)
NSAIDs are potential causes of dyspepsia and should be stopped/changed in pt with dyspeptic syndrome
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Upper endoscopy is indicated in pt >55 with new-onset dyspepsia even without alarm features of iron def anemia, unintentional weight loss, dysphagia, odynophagia, palpable abd masses, or jaundice
Empiric trial of PPI is indicated for ulcer-like functional dyspepsia
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In GI bleeding of obscure origin, repeat upper endoscopy will ID bleeding source in significant proportion of pt
Most pt with colonic ischemia are >60 yr and present with LLQ pain, urgent defecation, and red or maroon rectal bleeding that does not require transfusion
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Upper endoscopy should be performed at time of upper GI bleed after appropriate volume resuscitation to provide dx of cause of bleeding, provide prognosis, and perform endoscopic guided therapy if required
Volume restoration if primary management intervention for Gi bleeding in hemodynamically unstable pt
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Most likely sources of painless lower GI bleeding are diverticulosis and vascular ectasia
Anal fissures general cause rectal outlet bleeding and pain with defecation
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Pt with chronic hep B infection in absence of cirrhosis may develop HCC and should undergo periodic screening via liver US
Patients with acute hepatitis generally have fatigue, vomiting, nausea, jaundice, and aminotransferase values >1000 U/L
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Pt with alcoholic hepatitis have hx of recent heavy EtOH use, elevated AST and ALT with AST:ALT ratio >2:1, and elevated alk phos
Lab findings of autoimmune hepatitis: Elevated serum aminotransferases, hypergammaglobulinemia, mild hyperbilirubinemia, mildly elevated serum alk phos, and presence of autoantibodies
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Positive hep B surface antigen and IgM antibody to hep B core antigen est dx of acute hep B infection
Anti-hepatitis C virus antibody test is screening test for at risk persons; positive test in person with risk factor confirms exposure to virus
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NASH is associated with obesity, DMII, hyperlipidemia, and is potential cuase of cirrhosis
Primary sclerosing cholangitis is strongly associated with ulcerative colitis and marked elevations of alk phos
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Ascitic fluid analysis showing serum-to-ascited albumin gradient >1.1 g/dL suggests chronic liver disease as cause (ex. cirrhosis, right sided HF, and Budd-Chiari syndrome)
First line tx for hepatic encephalopathy is lactulose
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Hepatorenal syndrome is defined as development of kidney dysfunction in pt with protal htn after exclusion of prerenal azotemia, renal parenchymal disease, or obstruction
Erythema nodosum (small, exquisitely tender nodules on anterior tibial surface) is most common cutaneous manifestion of IBD (more common in Crohn's; pyoderma gangrenosum is more common in ulcerative colitis)
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Ulcerative colitis typically involves rectum and extends proximally with contiguous inflammation that is generally limited to mucosa of colon and rectum
First line tx for induction and maintenance of remission in mild to moderate UC is mesalamine o another 5-aminosalicylate agent
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Microscopic colitis is char by chronic water diarrhea without bleeding; dx must be made by histologic examination of colonoscopic bx specimens
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