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Dysphagias
- Oropharyngeal: liquids more than solids, asp into lung can be stroke, PD, MG, zenkers
- Esoph: Obstruction: solids>liquids, strictures/webs
- Motility: liquid and solids (acalasia, scleroderma, esoph spasm)
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Diffuse esoph spasm
- normal peristalsis interrupted by high amp nonperistaltic contractions, nutcracker eso
- chest pain, dysphagia, precipitated by ingestion of hot or cold liquids and relieved by NG
- barium swallow with corkscrew shaped eso
- rx: nitrate/ccb
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Achalasia
- motility disorder of eso with impaired relaxation of LES and loss of peristalsis in distal 2/3 of esoph. degen myenteric plexus
- Progressive dysphagia, CP, regurg, weight loss, cough
- bird beak esoph, inc resting les pressure and incomplete relaxation
- rx: nitrate, ccb, bot tox
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Gastritis
- Acute: NSAIDS, alcohol, h pylori, stress, burns, cns injury
- Chronic gastritis:
- A: less common, autoantibodies to parietal cells, causes pernicious anemia, inc risk adenocarc
- B:90%, nsaid or h pylori, often asx but assoc with pud
- Dx: upper endoscopy, h pylori detection
- rx: antacids, sucralafate, h2 blocker, ppi
- triple rx if hpylori infection
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PUD risk factors
- NOT STRESS.
- h.pylori, cst, nsaid, alcohol, tobacco
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PUD
- chronic epigastric pain, hematemesis
- can perf and get free air under diaphragm, is suspected do ct with iv contrast
- long term rx: mild-antacids, ppi, h2 blockers
- if h pylori: triple rx
- Complications: hemorrhage, gastric outlet obstruction, perf
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Zollinger ellison syndome
- gastrin producing tumor in duodenum or pancreas oversecreting gastrin, this causes increased gastric acid production leading to recurrent or intractable ulcers in stomach and duodenum; assoc with MEN1
- sx: burning abd pain, diarrhea, gi bleed
- dx: inc fasting serum gastrin levels and inc gastrin with admin of secretin=mat
- RX: ppi, surg resection
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Bloody diarrhea
ehec, salmonella, shigella, campylobacter
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Campylobacter
- MC bac diarrhea, food or water, young kids, 7-10 days
- bloody
- r/o appendicitis and ibd
- rx: erythromycin
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entamoeba histolytica
- food or water, travel in developing country, can incubate for 3 months
- flask shaped ulcer on endoscopy, rbcs
- mimics ibd
- rx: metronidazole
- CST can lead to FATAL perf
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Salmonella
- poultry or eggs, kids and old, 2-5 days
- prodromal period
- sepsis possible
- sickle cell can have invasive disease leading to osteomyelitis
- rx: if sickle cell: bactrim
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shigella
- extremely contagious, fecal roal spread, young kids
- can cause febrile seizures in kids
- rx: bactrim to dec spread
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Watery diarrhea
cholera, rotavirus, ETEC, cryptosporidium, giardia
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Carcinoid tumor
- must met to liver to have sx, arise in ileum and appendix, flushing diarrhea cramps wheezing
- dx: high levels of urine 5-hiaa
- rx: octreotide or resect
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DX of IBD
- at least 3 months of episodic abdominal pain that is 1. relieved by defecation and 2 associated with a change in stool frequency or consistency
- rx: psych, fiber, antispasmotics
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SBO vs ileus Xray
- Ileus: air seen througohut colon and rectum
- vs SBO has no air distal to obstruction
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SBO vs LBO
- SBO: severe and pain, cramping, fever, hypotn, abdominal distention, tinkly/high pitched bowel sounds, due to adhesions/hernia
- Rx: NG decomp, npo
- LBO: constipation, n/v, distention, high pitched sounds, causes: cancer. Rx: enema, colonoscopy, surg
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ischemic colitis
- insuff blood to colon
- usually splenic flexure watershed area
- crampy lower abd pain and bloo diarrhea, fever and peritoneal signs suggest necrosis
- CT with thickened bowel wall, colonoscopy with pale mucosa and petechial bleed
- rx: bowel rest, iv fluid, BS abx
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UGI vs LGI bleed
- Upper: coffee ground emesis and melena, dX: ng tube and lavage, cause: pud, varicose, mallory weiss/gastritis
- dx: intubation maybe, iv
- rx: endoscopy for cause
- Lower: fresh blood in stool, sigmoidosc if <45, colonoscop is stable. mc diverticulitis
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Indirect vs direct hernia
- indirect: through int and ext inguinal ring, congenital processus vaginalis, lat to inf epi
- direct: through floor of hesselbach triangle, medial to epi vessels, due to acquired defect in transversalis fascia
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choledocholithiasis
- gall stone in common bile duct not cystic duct, biliary colic jaundice fever can get pancreatitis
- inc alk phos, inc total and direct bili
- rx: ercp with spincterotomy then cholecystectomy
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Crohn vs uc
- UC: rectum always, continuous, mucosa and submuc, Assoc: primary sclerosing cholangitis, erythema nodosum, uveitis
- inc CRC
- Crohns: any part gi but ileum usually, skip lesions, transmural, perianal fissures, tags, fistulas, cobblestoning, crypt lesions
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Charcots triad/reynolds pentad
- Charcots: ruq pain, jaundice, fever/chills: classic sign ascending cholangitis
- reynolds: charcots triad plus septic shock and altered mental status: acute suppurative cholangitis
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Hyperbilirubinemia causes, conj vs unconj
- Conj: defected excretion: dubin johnson or rotors
- Unconj: either overproduction(hemo anemia) or def conjugation(gilberts<5 or crigler najjar)
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Autoimmune hepatitis
positive anti smooth muscle antibodies
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Rx chronic HBV and HCV
- HBV: inf and lamivudine or adefovir
- HCV: inf and ribavirin
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SAAG
- Serum albumin-ascites albumin
- >1.1: splenic or portal vein thrombosis, cirrhosis, R heart failure, constrictive pericarditis
- <1.1: nephrotic syn, TB, malignancy
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Wilsons diease
- AR defective copper transport, accum in liver and brain
- hepatitis/cirrhosis/tremor/psych prob
- kayser fleischer ring
- Dx: dec serum ceruloplasmin but inc urinary copper excretion
- Rx: dietary copper restriction, penicillamine, zinc
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Pancreatic cancer
- 75% adenocarc in head, rf: smoking, chronic panc, family hx
- obstructie janduice, palp gallbladder:courvoisier sign or migratory thrombophlebitis:trousseaus
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Ransons criteria
- Acute panc mortality, 20% with 3-4, 40% with 5-6 and 100% with 7
- On admission: glucose >200, age >55, LDH >350, AST >250, WBC >16000
- Within 48 hrs
- Ca <8, hct dec by 10%, PaO2 <60, base deficit >4, Bun inc by >5, sequestered fluid >6L
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