Gastroenterology

Esophageal Pathology

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• Dx: Adenocarcinoma is more common in the mid to distal esophagus, while squamous cell carcinoma is found in the upper 1/3.
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GERD

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PUD

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IBD

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IBS

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Diarrhea

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• Dx: For chronic diarrhea, send stool microscopy, electrolytes, and fat content.
• Tx: For acute viral gastroenteritis. Diet recommendation is to resume normal eating without excessive sugars. For Giardia (chronic, oily, nonbloody, weight loss, bloating), treat with tinidazole.

Celiac Sprue

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• Tx: Patients may require higher doses of levothyroxine.

UGIB

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• Dx: Nasopharyngeal laryngoscopy is preferred over EGD when there is a possible upper esophageal mass
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LGIB

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• Dx: Angiodysplasias (e.g. AVMs) are associated with AS, vWD, and ESRD. Workup for hematochezia is colonoscopy if HDS, resuscitate, ± surgery/IR consult, EGD if HDUS.
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Pancreatitis

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• Dx: 2 of 3 criteria—acute onset severe epigastric pain, elevation of lipase or amylase ≥ 3x ULN, characteristic findings on imaging. Thiazide diuretics and most loop diuretics are in important cause of drug-induced pancreatitis. Hypertriglyceridemia can also cause pancreatitis.
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Approach to LFTs

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• Dx: GGT measurement helps differentiate if elevated alk phos is from liver (elevated) or bone (normal)
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Gallstone Disease

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• Dx: Cholestatic pattern of elevated bilirubin and alk phos, Charcot triad for ascending cholangitis includes RUQ pain, fever, jaundice. When clinical suspicion for acute cholecystitis is high, but US is negative or inconclusive, get HIDA scan.
• Tx: For acute/ascending cholangitis, treat with ERCP within 24-48 hrs

Viral and Non-viral Hepatitis

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• Dx: HBsAg, HBeAg, HBV DNA, and ALT are elevated during the early symptomatic phase of infection. In later stages anti-HBs, anti-HBe, and total anti-HBc are all elevated. In the window period, only IgM anti-HBc and anti-HBe will be elevated.
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Cirrhosis and Ascites

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• Dx: Calculate SAAG, if ≥ 1.1, think portal hypertension (from CHF, cirrhosis, EtOH hepatitis); if < 1.1, think cancer, pancreatitis, nephrotic syndrome.
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Acetaminophen Toxicity

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Heredity Hemochromatosis

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Wilson Disease

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α1-Antitrypsin Disease

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Autoimmune Hepatitis

• H&P: Young to middle-aged women. Painless hepatomegaly.
• Dx: Elevated AST and ALT, normal ALK and TBili. ANA and anti smooth muscle antibodies are positive.
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PBC

• H&P: Age 30-65, F>M; Fatigue and jaundice;
• Dx: Positive AMA, elevated ALK
• Tx: Ursodeoxycholic acid

PSC

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Missed Concepts

• Food protein-induced allergic proctocolitis shows up at 1-4 weeks of age with blood and mucus streaked stools. Treat by eliminating dairy from the maternal diet. It is benign and self-limited.
• The shortest interval for repeat colonoscopy is for large adenomas (>2 cm) removed piecemeal. Second shortest interval is 1 year for > 10 adenomas.
• Thyroid hormone replacement doses are higher in patients with Celiac disease due to levothyroxine malabsorption.