TIKI TAKA GATROENTEROLGY

((U should exclude MI with AS in a pt with epigastric pain radiating to the

mid-scapulae))
. When u r given a complaint of acute epigastric pain radiating to the back in
between the scapulae with H/O of coronary artery disease in addition to suspicion in
pancreatitis & PUD the 1st step to do is EKG to exclude MI !!!!!!!!!
((Chronic mesenteric ischemia))
. Un-explained chronic abd. pain.
. weight loss.
. Food fear & avoidance of eating.
. Associated atherosclerotic disease.
. Abd. ex. may reveal a bruit.
. Dx: Doppler U/S. !!!
((Mallory Weiss $))
. is hematemesis due to ++ intra-abd. pressure with vomiting,
. leading to rupture of submucosal ARTERIES at the distal esophagus.
((Portal hypertension))
. leads to hematemesis due to rupture of esophageal varices (submucosal
VEINS).
((ULCERATIVE COLITIS))
. Young pt.
. Abd. pain.
. Bloody diarrhea.
. Rectal urgency.
. Anemia & reactive thrombocytopenia.
. Rectal tenderness.
. Stool mixed with mucous & blood.

. ++ WBCS with nausea ----> Toxemia.

. U should suspect TOXIC MEGACOLON.
. DO ABDOMINAL X-rays to search for Toxic Megacolon.
((Chron's disease))
. Young pt.
. Chronic diarrhea.
. Abd. pain.
. Weight loss.
. Mouth ulcers.
. Rt upper Q. tenderness without rebound.
. Gas in small & large intestines.
. Reactive thrombocytosis & anemia.
((CANCER HEAD PANCREAS))
. Enlarged (NON TENDER) Gall bladder.
. Weight loss.
. evidence of biliary obstuction (++ALP disproportionate with +AST & +ALT).
. Dx: Abd. CT !
((The most common cause of iron deficiency anemia in an elderly pt is GIT
bleeding))
. The next step is COLONOSCOPY.
. A single -ve occult blood test doesn't exclude GIT bleeding.
((DYSPHAGIA))
. Both sloids & liquids = Motility disorder e.g. ACHALASIA.
. Solids then progressing to liquids = Obstructing lesion e.g. esophageal
adenocarcinoma so you should perform BARIUM SWALLOW 1st before endoscopy.
!!!
((Spontaneous bacterial peritonitis))
. should be considered in any pt. with cirrhosis & ascites,

. accompanied by fever or change in mental status.

. Paracentesis is the test of choice, with a +ve ascitic fluid cultue & PMN > 250
cells.
((Aggressive diuresis > 1 L/day may worsen encephalopathy or precipitate
hepato-renal $))
((Liver cirrhosis ----> renal hypo-perfusion -----> Hepato-Renal $))
. Manifested by HIGH UREA & CREATININE.
. Very low urine Na < 10 meq = Pre-renal cause.
. No protein & No blood in dipstick urine = Not intrinsic glomerular cause.
((CARCINOID $ triad))
. Flushing.
. Valvular heart disease.
. Diarrhea.
. Ass. e' hepatic metastasis.
. ++ Serotonin & 5 HIAA in blood & urine.
. The precursor of Serotonin is Tryptophan which is also utilized in the
synthesis of Niacin.
. -- Niacin ----> PELLAGRA 4 Ds (Diarrhea-Dermatitis-Dementia-Death).
((Neutrophilic cryptitis is seen on bowel biopsy in pts with IBD))
((Intra-abdominal malignancy obstructing the biliary system))
. Painless jaundice.
. Conjucated hyper-bilirubinemia.
. Elevated Alkaline phosphatase.
. ex. pancreatic adenocarcinoma.
((Pancreatic choleraa = VIPoma))
. The pancreas secretes vaso-active intestinal peptide.
. Hypokalemia (leg cramps).

. chronic diarrhea --> dehydration.

. Abd. pain.
. weight loss.
. facial flushing & redness.
. Dx: Abd. CT.
((FOLIC ACID DEFECIENCY))
. A tea & toast type of diet is associated with folic acid defeciency.
. Folic acid is heat sensitive.
. Folic acid defeciency causes macrocytic anemia.
((Corn based diets -> NIACIN defeciency -> PELLAGRA (4Ds)))
. Diarrhea + Dementia + Dermatitis + Death.
((DIVERTICULITIS))
. If no improvement ---> Abd. CT to detect complications.
((Tropical sprue))
. Endemic tropical area e.g. Puertorico.
. Biopsy of S.I ---> Blunting of villi with infiltration of chronic infl. cells e.g.
lymphocytes, plasma cells & eosinophils.
. Malabsorption to Vit. B12 & folic acid ---> Megaloblastic anemia.
. Other signs of malabsorption e.g. glossitis - cheilosis - pallor.
((WHIPPLE's disease))
. PAS +ve material in the lamina propria of the small intestine is diagnostic.
((Primary HIV infection))
. can present with a mononucleosis like syndrome,
. consisting of fever, night sweats, lymphadenopathy, arthralgia & diarrhea.
((JAUNDICE))
.Abd. U/S is the best initial investigation for JAUNDICE.
.But .. once u suspect pancreatic cancer , then the best inv. is Abd. CT.

.Manif. of cancer include weight loss , pressure obstruction of CBD,

.leading to ++ direct bilirubin & ++ ALP.
((GASTRINOMA = ZOLLINGER ELLISON's $ (Non B-cell pancreatic tumor)))
. Endoscopy--> Multiple ulcerations & prominent gastric folds.
((Pts < 55ys with no alarm symptoms))
. should have 1st H.Pylori serology test,
. followed by empiric ttt with PPIs e.g. Omeprazole.
. If failed ----> ENDOSCOPY.
((Hemorrhage is the most common complication of peptic ulcer))
((CRYPTOSPORIDIUM PARVUM))
. HIV pt. with chronic severe diarrhea with CD4 cells < 100.
((Bacterial overgrowth))
. Malabsorption in a pt. with a H/O of abdominal surgery.
. Vit. D def. = Hypocalcemia.
. Vit. A def. = Night blinness.
. Vit. B12 def. = Neuropathy.
((LACTOSE INTOLERANCE))
. Asian American.
. +ve Hydrogen breath test.
. +ve stool test for reducing substance.
. ++ stool osmotic gap.
. -- stool pH.
. No steatorrhea.
((Zinc deficiency))
. may result from total parenteral nutrition or malabsorption.
. Alopecia,skin lesions,abnormal taste,impaired wound healing.

((Acute Appendicitis))
. VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS Visceral followed by somatic pain !!
((Drug induced pancreatitis))
. Pts with H/O of VALPROIC ACID ttt for seizure disorder.
((Ulcerative colitis))
. presents as diarrhea & bloody stools.
. The condition may be complicated by systemic toxicity: fever & weight
loss with dilated colon on CXR "TOXIC MEGA-COLON".
. Tx: I.V. fluids + Antibiotics + Bowel rest + I.V. corticosteroids.
. If failed: Emergency surgery with sub-total colectomy with end ileostomy.
((Minimal bleeding per rectum or scant hematochezia))
. Dx -> Office based ANOSCOPY or PROCTOSCOPY.
((GIARDIASIS))
. Foul smelling stool.
. Abd. cramps.
. Bloating = MALABSORPTION diarrhea.
. H/O of developing country e.g. South America.
. Tx: METRONIDAZOLE.
((MALIGNANT criteria of a colonic polyp))
. Villous adenoma.
. Sessile adenoma.
. Size > 2.5 cm.
((MULTIPLE MYELOMA))
. Back pain + Renal dysfunction + High ESR + Anemia.
. MM ----> ++ Ca Hypercalcemia.
. ++ Ca ----> Constipation.

. so .. The cause of constipation in a pt. with MM is ELECTROLYTE DISTURBANCE (+

+ Ca).
((NON-CASEATING GRANULOMA ----> PATHOGNOMONIC to CHRON's
disease))
((N.B. UC always involves the rectum while it is spared in CD))
((Angiodysplasia))
. Pt. > 60 ys. with anemia.
. Painless GIT bleeding.
. Murmur of Aortic stenosis.
((Inflammatory Bowel disease))
. Bloody diarrhea + anemia + elevated ESR + Reactive thrombocytosis.
. The type of diarrhea is INFLAMMATORY.
((Newly diagnosed gastric carcinoma transformation in a gastric ulcer by
an endoscopy warrants an abdominal CT scan to evaluate the extent of the
cancer))
((Pharyngo-esophageal (ZENKER's) diverticulum))
. is due to motor dysfunction.
. Pt. < 50 ys.
. with oro-pharyngeal dysphagia & neck mass.
. Tx: Crico-pharyngeal Myotomy.
((Causes of ++ BUN / Creatinine ratio))
. Pre-renal RF.
. GIT bleeding due to reabsorption of blood from the GIT.
. Steroid adminstration.
((In upper GIT bleeding))
. If Hb < 10 ----> PACKED RBCs transf.
. If Ht < 30 ----> PACKED RBCs transf.

((HERPES ZOSTER (SHINGLES)))

. Pt. with Rt. sided abd. pain.
. Light touch to the skin to the Rt. of the Umbilicus elicits intense pain.
. Immunocompromized pt. 2ry to chemotherapy.
((Digoxin side effects))
. GIT-------> Anorexia, Nause & vomiting.
. Cardiac---> Biventricular Arrhythmia.
. VERAPAMIL ++ the Digoxin's toxicity.
((N.B. Mesenteric ischemia presents with severe abd. pain out of prop. to
exam.))
((PEPTIC STRICTURE))
. Slowly progressive dysphagia to solids without anorexia & weight loss.
. As stricture progresses , it can actually block reflux leading to improvement of
heart burn symptoms.
. ENDOSCOPY --> SYMMETRIC circumferential narrowing.
((ADENO-CARCINOMA))
. Pt with GERD < 20 ys.
. Weight loss.
. ASYMMETRIC narrowing of the esophageal lumen.
((REMEMBER))
. Pt. with fever + chills + Lt upper Q. pain + splenic fluid collection = Lt.
sided endocarditis with septic emboli to the spleen causing splenic
abscess.
. H/O of incarcerated pt. with ++ liver enzymes (possible HCV) suggesting
IV drug use as the cause of infective endocarditis.
((Pt. with upper GI bleeding (Hematemesis) who have depressed
consciousness level should be intubated with ??))
. ENDO-TRACHEAL tube not naso-gastric tube to secure the airway.

Edited by : Dr. ALA HAWA

Written by : Dr. Wael Mohamed