Gastro SMLE Review 2023 PDF

GASTRO SMLE review Abdulrahman A. Alahmadi Tw: @Abdulrahman95AA ESOPHAGEAL DISEASE Reflex symptoms: After meal there’s heartburn Management: No need diagnostic test, PPI trial for 8 Week then evaluate Indication of endoscopy in GERD (Red flags) 1. New onset of dyspepsia in patient ≥60 years. 2. Evid...

GASTRO SMLE review Abdulrahman A. Alahmadi Tw: @Abdulrahman95AA ESOPHAGEAL DISEASE Reflex symptoms: After meal there’s heartburn Management: No need diagnostic test, PPI trial for 8 Week then evaluate Indication of endoscopy in GERD (Red flags) 1. New onset of dyspepsia in patient ≥60 years. 2. Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, occult blood in stool) 3. Iron deficiency anemia. 4. Anorexia or unexplained weight loss. 5. Dysphagia or odynophagia. 6. Persistent vomiting. 7. Gastrointestinal cancer in a first-degree relative. Refractory GERD Pt not improvement on PPI optimal dose (40mg for 8 week) Endoscopy Normal Reflux esophagitis 24h PH monitoring (to confirm GERD as the cause of patient symptoms) Manometry (to rule out motility disorder) If manometry is normal proceed with Nissen fundoplication As Achalasia surgical Any Pt with esophageal Dysphagia: What’s initial Management? Upper GI Endoscopy Or liquid more than solid = motility disorder Bec pt have mild improvement but Endoscopy was normal Achalasia Reflected by inc pressure lower esophageal sphincter Reflex Pt have reflex developed to Barrett's esophagus (Metaplasia) then progresses to dysplasia, then adenocarcinoma, Have symptoms + weight loss + have risk factor of cancer (long-standing reflux + smoker) Change mucosa from stratified squamous epithelium of the esophagus to columnar epithelium replaces This pt Need screening bc at any time developments to dysplasia then esophageal cancer Not suggesting of Achalasia What’s Cause dysphagia to solid after 10y reflex? here maybe cancer or structural Both initial OGD If there specific Indication (hx of prior radiation,…) Or if Q about diagnostic test in pt with achalasia Unlikely to be malignancy Bec risk of cancer after 55 y Achalasia No need bec there’s reflux esophagitis = confirm gastro reflux disease so ‫ راح اختاره‬Manometry ‫لو ما في في خيارات‬ If there same case and Ask about First line of Tx : Advice weigh loss , lifestyle modification PANCREATIC DISEASES Acute pancreatitis: to diagnosis need clinical + laps + radiological but need 2-3 of criteria. Here there Symptoms + labs so need for imaging Not indicating even if high WBC, except if there confirm infected pancreatic necrosis = painless jaundice + obstructive picture + palpable gallbladder Typically picture of acute pancreatitis + jaundice + dilated CBD + high labs = biliary acute pancreatitis with obstruction CBD Management of Acute pancreatitis: Start fluid US to check if there stone If there obstruction CBD next step? ERCP within same admission to remove stone If no obstruction CBD ? No need for ERCP, what’s the management? Iv fluid + observes Acute pancreatitis Amylase and lipase role Diagnoses only not for severity Not specific Sever acidosis may lactic acidosis gastric pain Pancreatic Cancer Hepatocellular carcinoma (HCC) Testicular cancer Breast Cancer Pancreatic Cancer INFLAMMATORY BOWEL DISEASE cobblestone Extra intestinal manifestations MANAGEMENT OF UC Ulcerative Colitis Proctitis Extensive left sided disease Steroid for unresponsive or severe disease = systemic manifestation: (Fever, leukocytosis, high CRP, 6-7 times diarrhea,anemia Topical (suppository) mesalamine 5-aminosalicylic acid (5-ASA) Topical and oral mesalamine Ulcerative colitis Pt with fever and systemic manifestation = sever flare + admitted pt hospital if there ileocolonic ‫نختاره‬ Pellagra = Dermatitis + Dementia + Diarrhea Perianal abscess Mild case Complication if Crohn’s disease: Perianal abscess: Swelling and tenderness and discharge. Tx: incisions & Drainage Perianal Discharge: fistula : First step imaging (MRI pelvic) bec this complex fistula iEnema Extensive left side bloody diarrhea for 6 months, episode Old age, risk factor, bloody diarrhea for 1day Most likely chron’s HEPATITIS HEPATITIS B SEROLOGY Hepatitis B surface antigen (HBsAg): evidence of infection (ID). Anti-HBs: Indicates immunity to HBV due to vaccination or resolved infection. Anti-HBc A. Anti-HBc IgM indicates acute infection with HBV. B. Anti-HBc IgG indicates resolved or chronic infections. HBeAg: indicates viral replication and infectivity. Screening: HBsAg and anti-HBc IgM. HEPATITIS B TREATMENT Acute hepatitis B: Supportive care. Chronic hepatitis B A. Antiviral treatment for those with chronic active hepatitis B. B. Tenofovir is commonly the drug of choice. C. Entecavir. HEPATITIS D Hepatitis D virus is an RNA virus. Course: A. Coinfection: more severe acute hepatitis, but 90% rate of recovery. B. Superinfection of a chronic HBsAg carrier: sudden worsening or deterioration in the patient clinical condition and his LFTs. C. In rare cases, fulminant hepatitis. Diagnosis: detection of anti HDV antibodies. (anti-delta antibodies) Liver fruitionabnound Jundice PIR Now even if it Negative Cirrhotic + nodules + jaundice + old age = Cancer If Q choice between Hepatitis B and hepatitis C as Worse risk factor of liver cancer and Hepatocellular carcinoma? Is HBV Pt have symptoms + high liver enzymes + high DNA (viral level) you have to start treatment Any pt has shock or hypotension or arrhythmia then AST and ALT more than 1000 = ischemic hepatitis Bec pt have hypotension Sudden worse of chronic hepatitis B = hepatitis D Superinfection UGIB GASTROESOPHAGEAL VARICES First ABC Octreotide and sepsis Or Oral ciprofloxacin Reduce of mortality Alcoholic pt + Repeat vomiting + hematemesis+ liver function normal + no past history of cirrhosis or NSID use Complication PTC is Hemobilia (blood in the biliary tract) pt present by hematemesis so next step is Angiography to confirm diagnosis and treat First line BB CHRONIC LIVER DISEASE Management of ascites Sodium and Water restriction. Diuretic therapy A. Portal hypertensive ascites: usually responsive. B. Non-portal hypertensive ascites (exudate): usually not effective. C. Spironolactone (first-line). D. Furosemide (second-line). Refractory ascites (inadequate response to diuretics, frequent recurrence, or when diuretic therapy is contraindicated) A. Therapeutic large-volume paracentesis B. Transjugular intrahepatic portosystemic shunt (TIPS) If cirrhotic ascites on Spironolactone & Furosemide and not improved increase dose if still not improved and come with large ascites you should start IV diuretic (iv Spironolactone), if no improvement this refractory ascites or tenes ascitis tx by Therapeutic large-volume paracentesis Spontaneous bacterial peritonitis (SBP) Diagnosis A. Gold standard: diagnostic paracentesis BEFORE application of antibiotics B. > 250 polymorphonuclear leukocytes/μL ascites: SBP per definition Treatment A. First-line: 3rd generation cephalosporin IV broad spectrum therapy. B. Follow-up after 48 h via repeated paracentesis. Recurrence of SBP is common but can be reduced with prophylactic quinolones such as ciprofloxacin. HEPATOCELLULAR CARCINOMA CARCINOMA (HCC) HEPATOCELLULAR (HCC) HCC screening: abdominal ultrasound with or without alpha-feto protein for patients with cirrhosis every 6 month. Any pt with cirrhosis or hepatitis C should screening Budd-Chiari syndrome (BCS) = Transudate Transudate Transudate Exudates hyponatremia Hypervolamic hyponatremia Latent Tb and treated Restrictive cardiomyopathy Multiple liver lesion Not come with loss weight Peptic ulcer Young pt + behavior changes, Kayser-Fleischer rings, femaly hx, neurological manifestation Emphysema, cirrhosis Heartburn more than pain There’s rigid abdomen, generalize sever tenderness Hepatorenal syndrome Any pt on mechanical ventilation high risk so should this pt on prophylaxis PPI Prognosis: 2 Clinical and 3 Labs: Ascities Encephalopathy INR Bilirubin Albumin Diuretic If pt heart failure Spontaneous bacterial peritonitis (SBP) Serum Albumin - Ascitic fluid albumin = 3.7 - 2 = 1.7 1.7 is more than 1.1 = Transudate (cirrhosis or heart failure) Ascitic Fluid total protein = 3.3 is more than 2.5 so it’s heart failure If there evidences of SBP Serum Albumin - Ascitic fluid albumin = 3.2 - 1.9 = 1.3 1.7 is more than 1.1 = Transudate (cirrhosis or heart failure) JAUNDICE Primary biliary cirrhosis Autoimmune hepatitis Primary sclerosing cholangitis Gender More common in middle-aged women (40-50) More common in young females (25–40 years) More common in young males (25–40 years) Clinical Fatigue Pruritus Scratch marks Jaundice Hepatomegaly Fatigue abdominal pain jaundice Hepatomegaly Pruritus Jaundice Hepatomegaly Associations Autoimmune connective tissue diseases Coeliac disease Thyroid diseases Autoimmune connective tissue diseases Coeliac disease Thyroid diseases Ulcerative colitis High alkaline phosphatase and GGTP Mild increase in ALT/AST Elevated ALT/AST (200-300) Mild increase in alkaline phosphatase (could be normal) High alkaline phosphatase and GGTP Mild increase in ALT/AST Antimitochondrial antibodies (AMA) Antinuclear antibodies (ANA) Anti-smooth muscle antibodies (ASMA) ANCA MRCP Next step Labs Diagnostic test Mid age In Primary biliary cirrhosis after do liver US To complete Evaluation, this PT and INR if high indication Acute liver failure, management is Liver transplantation JAUNDICE Celiac Disease If in case say pt stop PPI now Bec it’s complication of H.pylori To eradication H.pylori So next step in celiac is anti tTG-IgA Fat in stool “Steatorrhea”: may be Pancreatitis Celiac Disease and giardiasis infection If ask about Most accurate or definitive test in Celiac? Is Biopsy Stop PPI and when finish Antibiotic Reflux Usually epigastric abdomen pain Usually epigastric abdomen pain H.pylori triple therapy? Amoxicillin or metronidazole (if have Penicillin allergy) Clarithromycin PPI H.pylori Quadrate therapy? amoxicillin, clarithromycin, metronidazole and tetracycline. Miscellaneous Associated with plural effusion (Boerhaave's syndrome) Pyogenic liver abscess Amebic liver abscess Single Mass and less than 5cm Multiple or Single Mass and more than 5cm UpToDate Medscape AMBOSS