Episodic, abd or epigastric pain + signs of bleeding (hematemesis, coffee-ground emesis melena) = DYSPEPSIA

- Abd pain is burning, gnawing

- Post-prandial discomfort, bloating
- Intermittent and chronic nature

GERD Gastritis PUD

Differential Acute (H. pylori, NAS, Stress) vs H. Pylori, Substances, ZE
Chronic (H. pylori or Autoimmune)
Epi
Path Reduced LES tone Damage to gastric mucosa Ulcerations of mucosa
Px EPIGASTRIC or CHEST PAIN
Heartburn 30-90 mins after meal, worsens with reclining but
improves with sitting or standing
Sour taste/globus sensation
Dx 1)Clinical Dx where first treat with lifestyle modifications and PPI EGD

2)EGD w bx is performed if pt is 1) refractory to initial therapy, 2)

has long standing disease (rule out Barrett) 3) alarm symptoms
(blood in stool, weight loss, dysphagia,)

3) 24 hour pH monitoring is the DEFINITIVE test though only used

when dx is uncertain or patient failed PPI trial.
Tx Lifestyle Weight loss, Head of bed elevation, small, frequent
meals, no meals at night, decrease Coffee, Chocolate, and alcohol
Meds:
Mild/Intermittent: Antacids
Chronic/Frequent: H2 blocker or PPI
Severe/erosive: Nissen fundoplication
Gastritis

Acute Gastritis Chronic Gastritis

Differential H. pylori, Nsaids, Alcohol, Smoking, Steroids, Autoimmune H. pylori

Stress (Burns, or CNS injury)
Epi
Path Acute disruption of mucosal protection Autoimmune: Ab made against IF and parietal H. pylori causes chronic inflammation in antrum
cells in body of stomach
Px ACUTE, abd pain + bleeding More chronic abd pain + bleeding MALTOMA
Signs of Vitamin B12 deficiency aka pernicious
anemia
Dx
Tx Symptomatic management: PPIs or H2 Symptomatic management: PPIs or H2 blockers,
blockers, Sucralfate, Sucralfate,
Stop offending agent; triple therapy for H. Triple therapy for H pylori
pylori

Peptic Ulcer Disease

Gnawing epigastric pain related to food intake

H. Pylori Nsaids, Alcohol, Smoking, Zollinger Ellison Syndrome

Stress
Differential
Epi 90% of duodenal, 70% of gastric ulcers
Endemic in developing countries eg India
Path Bacteria produce urease and disrupt mucosa Decrease mucosal defenses Gastrin secreting tumor in pancreas or duodenum
against acid leading to acid overproduction
Px Recent use of these Diarrhea, Weight loss
substances Recurrent/intractable ulcers
Dx 1) Urea breath test 1 Elevated fasting gastrin levels
2) Stool antigen test 2 Secretin stimulating test shows elevated
3) Endocopy w bx(DEFINITIVE dx) but only done in 1) gastrin
patients > 55, 2) alarm symptoms: dysphagia, weight 3 CT scan to stage tumor
loss, bleeding, 3) failure to improve on triple therapy
Tx Triple therapy (Clarithromycin, Amoxicillin (metro) Omeprazole Stop offending agent 1) Immediate: PPI to control symptoms
PPI 2) Resection of tumor
Complications in PUD

Perforation Bleeding
Differential
Epi
Path
Px Rigid abd, rebound tenderness and guarding Hypotensive, hematemesis, melena
Dx 1) AXR or KUB to look for free air under diaphragm to 1) EGD w bx to confirm or rule out active bleeding
look for perf
2) CT is (DEFINITIVE test) to confirm perforation

Tx NPO, IV PPIs, Surgery Monitor BP,

IVF, transfuse, IV PPIs
EGD to control bleeding
Trouble initiating swallow, choking, drooling = Oropharyngeal Dysphagia

DDx: N M Z

Neurologic (Stroke), Muscular (Myasthenia gravis, Polymyositiss), and Zenkers Diverticulum

Dysphagia + Chest pain

DDx: ADEMSZ

Achalasia, Diffuse Esophageal Spasm, Esophageal Cancer, Mechanical (Webs, Rings, Stricture), Scleroderma, Zenkers diverticulum

Heartburn + mouth findings + immunocompromised = Infectious Esophagitis

DDx = Can Herpes Cyt my Esophagitis

Candida = scrapable, yellow, white plaques - tx fluconazole/nystatin

Herpes = small, deep ulcers, w Tzank smear tx: IV acyclovir

Cytomegalovirus = Large, superficial ulcers w inlcusions tx: IV Ganciclovir

GERD + physical abnormalities = Hiatal Hernias = Para/Slide Hernias

Para is tara = need to surgery

Slide is easy = medical and lifestyle management

Chronic, periodic epigastric/abd pain +/- bleeding = Dyspepsia

Ddx = GERD, Gastritis, PUD

Diarrhea

Acute < 2 weeks = Infectious (Bacterial or Viral)

Chronic > 4 weeks Secretory, Malabsorption, Inflammatory, Motility

Acute diarrhea = Infectious agent

Bloody diarrhea : Shigella, Campylobacter, Salmonella, Y. enterocolitica

Vs
Non-bloody diarrhea (secretory) C. diff colitis

Chronic Diarrhea, steatorrhea (pale, foul-smelling, and bulky stools), flatus, bloating, weight loss = Malabsorption

Mucosal abnormalities: Celiac, Tropical Sprue, Whipple disease,

vs

Enzyme deficiencies

Crohn Disease, Lactose intolerance, SIBO, Chronic pancreatitis,

Chronic Watery, secretory diarrhea + flushing = Carcinoid vs VIPoma

Chronic diarrhea w/alternating constipation = IBS

Abd Distention, N/V, and pain = Obstruction

SBO, LBO, Ileus, Volvulus etc

Abd pain, tenderness to palpation, + Fever + N/V = Colitis

DDx: Appendicits, Diverticulitis,

Abd pain, hematemesis, coffee grounds +/- SIRS = Upper GI bleed

DDx: Mallory Weiss tear, Perforated Ulcer,

Bright red blood per rectum, or maroon stools = Lower GI Bleed

Ddx: Diverticulosis, Angiodysplasia, Hemorrhoids, Colorectal Cancer, Ischemic colitis, Mesenteric Ischemia, Upper GI Bleed
RUQ pain +/- signs of Jaundice, Fever, etc

DDx

Cholelithasis, Acute cholecystitis, Choledocholithasis, Cholangitis, Acalculous cholecystitis

Jaundice + elevated Enzymes

Acute hepatitis

Cirrhosis

Severe ACUTE epigastric/abd pain = disease in Abd

DDx. Acute pancreatitis

Chronic Abd pain

Jaundice + RUQ

Jaundice w/o Pain