+cannot do version in active labor

+pap screen 21-65/ every 3 year/5 year if with hpv screeen only after 30
+valproate NTD
1+Gallstones and chronic alcohol abuse are the most common causes of acute
pancreatitis. Abdominal ultrasound Is the most sensitive and specific imaging study
to
detect gallstones and should be performed in all patients with suspected
gallstone-induced pancreatitis
2+Hepatoblllary lmlnodlacetlc acid (HIDA) scan (cholescintigraphy) Is used to
diagnose acute cholecystitis If ultrasound does not provide a clear diagnosis.?
3+Acute liver failure (ALF) Is characterized by elevated aminotransferases,
encephalopathy,
and INR ~1 . 5. Acetaminophen toxicity Is a common cause of ALF that may be
potentiated
by chronic alcohol use.

4.Gastric outlet obstruction can be caused by many disease processes and is

characterized by early satiety, nausea, nonbilious vomiting, and weight loss AND
SUCCUSION SPALSH. In a patient
with a history of acid ingestion, pytorlc stricture is the most likely cause Upper
endoscopy Is usually required to confirm the diagnosis, and
treatment is primarily surgical

5.Patients with upper gastrointestinal bleeding often have an elevated blood urea
nitrogen
(BUN) and elevated BUN/creatinine ratio, possibly due to increased urea production
(from intestinal breakdown of hemoglobin) and increase<! urea reabsorption {due to
hypovolemia

7.Patients with typical gastroesophageal reflux symptoms require an upper

gastrointestinal
(GI} endoscopy if they have alarm symptoms (dysphagia, odynophagia, weight loss,
anemia, Gl bleeding, or recurrent vomiting) or are men age >50 wtth chronic (>5
years}
symptoms and cancer risk factors (eg. tobacco use). All other patients can receive
an
empiric trial of proton pump inhibitor therapy and further evaluation if refractory
to therapy

8.Patients with upper gastrointestinal bleeding who have a depressed level of

consciousness and ongoing hematemesis should be intubated to protect the airway as
a
part of initial stabilization and resuscitation. Prompt endoscopic treatment with
band
ligation or sclerotherapy should then be performed to stop the bleeding

9.Minimal rectal bleeding Is usually due to hemorrhoids or other benign

conditions. Evaluation depends on the patient's presentation and risk factors.
Patients
age 2:50 or with clinical features suggesting malignancy should undergo
colonoscopy. For younger patients (age <40) and no other risk factors, office-based
anoscopy may be performed first.

10.Total parenteral nutrition causes gallbladder stasis and predisposes to

gallstone
formation and bile sludglng, both of which may lead to cholecystitis.

11.Pancreatic cancer can be due to hereditary (eg, first-degree relative with

pancreatic
cancer, hereditary pancreatitis) or environmental (eg. cigarette smoking, obesity)
risk
factors. Cigarette smoking Is the most consistent reversible risk factor for
pancreatic
cancer.

Educational objective:
12.Patients with hepatic encephalopathy on diuretics can develop low intravascular
volume
despite having total volume overload. leading to a metabolic alkalosis with
associated
hypokalemia. Treatment Includes volume resuscitation and repletion of hypokalemia
In
addition to serum ammonia-lowering medications (eg. lactulose).

1.Lynch syndrome causes colorectal cancer and imparts an extremely high risk of
endometrial carcinoma for female carriers. An annual endometrial biopsy, as well as
prophylactic hysterectomy, Is recommended to prevent endometrial cancer. LUNCH WITH
CEO

2.Toxic megacolon may be the initial presentation of inflammatory bowel disease.

Key to
the diagnosis are radiologic evidence of colonic distension with manifestations of
severe
systemic toxicity (eg. fever. leukocytosis. hemodynamic instability}. About 50% of
patients improve with conservative management and corticosteroids.

3.Pill esophagitis Is due to a direct effect of certain medications on esophageal

mucosa.
Tetracyclines, potassium chloride,bisphosphonates,and nonsteroidal anti-
inflammatory
drugs are common causes. Patients experience sudden-onset odynophagia and
retrosternal pain that can sometimes cause difficulty swallowing.

4Biliary colic occurs due to increased intra-gallbladder pressure that is created

when the
gallbladder contracts against an obstructed cystic duct The pain is exacerbated by
fatty
meals. usually lasts less than 6 hours, and resolves completely between episodes.
There is no fever, abdominal tenderness on palpation, or leukocytosis.

5Suspect vitamin A deficiency in a 2 or 3-year-old child with impaired adaptation

to
darkness, photophobia, dry scaly skin, xerosis conjunctiva, xerosis cornea,
keratomalacia, Bltot spots and follicular hyperkeratosis of the shoulders,
buttocks, and
extensor surfaces

6 Ischemic colitis is characterized by acute abdominal pain and lower

gastrointestinal
bleeding. It typically follows an episode of hypotension and most commonly affects
arterial watershed areas at the splenic flexure and rectosigmoid junction. CT scan
may
show a thickened bowel wall. Colonoscopy can confirm the diagnosis

7 A perforated viscus typically presents with severe abdominal pain. fever,

tachycardia,
and signs of peritonitis (eg, rigidity, reduced bowel sounds, rebound tenderness).
It can
occur in the setting of peptic ulcer disease. which is often associated with NSAID
and
alcohol use. The diagnosis of gastrointestinal perforation is confirmed with
upright x-ray
of the chest and abdomen showing free intraperitoneal air under the diaphragm.

8 Patients with risk factors for hepatitis B virus should be vaccinated, which is
especially
important in patients already infected with hepatitis C virus who are continuing
their high
riskbehaviors.elevated serum creatine phosphokinase level Indicates muscle
damage, with evidence of rhabdomyolysls from the tonic-clonic seizure and/or
cocaine
use. Aggressive nuld resuscitation rather than restriction is required to prevent
renal
failure from myoglobinuria
.Beta-blockers should be avoided in patients with cocaine intoxication
because unopposed alpha activation can worsen hypertension and lead to coronary
.vasospasm.

9 Acute erosive gastropathy Is characterized by the development of hemorrhagic

lesions
after ischemia or the exposure of gastric mucosa to various injurious agents (eg,
alcohol,
aspirin, cocaine).

10 The most common cause of Iron deficiency anemia in the elderly is

gastrointestinal blood
loss. The next step In evaluation would be colonoscopy and endoscopy. A single
negative occult blood test does not exclude the possibility of gastrointestinal
bleeding.

11 Nonalcoholic fatty liver disease resembles alcohol-induced liver disease but

occurs In
patients with minimal or no alcohol history. It is associated with insulin
resistance.
Severity can range from bland steatosis to steatohepatitis to fibrosis and
cirrhosis

12 Tachycardia or hypotension after blunt abdominal or thoracic trauma is

concerning for
hemorrhage from either a solid organ or vascular injury. Signs of left chest and
abdominal trauma In such patients are suggestive of splenic lacerations.

13 Toxic megacolon typically presents with total or segmental nonobstructive

colonic
dilation, severe bloody diarrhea, and systemic findings (eg, fever, tachycardia).
Patients
with inflammatory bowel disease are at higher risk of developing toxic
megacolon. Diagnosis Is confirmed by plain abdominal x-rays and >3 of the
following:
fever >38 C (100.4 F). pulse >120/min, white blood cell count >10,500/IJL. and
anemia. Toxic megacolon Is a medical emergency that requires prompt intravenous
steroids, nasogastric decompression, antibiotics, and fluid management

14 Infantile hypertrophic pyloric stenosis Is most common in first-born boys age 3-

5 weeks.
Protracted projectile, nonbillous vomiting causes a hypochloremic metabolic
alkalosis.
Abdominal ultrasonography confirms the diagnosis

15 Anal cancer is usually caused by human papillomavirus and occurs most often In
men
who have receptive anal Intercourse and/or HIV infection. Manifestations include
anal
bleeding, pain, sensation of fullness. and an anal mass or ulcerated lesion

16 Celiac disease should be suspected In any patient with malabsorption and iron
deficiency
anemia. lgA anti-endomysia! and anti-tissue transglutaminase antibodies are highly
predictive of cellae disease but may be absent if there is concurrent selective lgA
deficiency.

17Malrotation with midgut volvulus usually presents in neonates with bilious

vomiting and
abdominal distension. Untreated volvulus can progres.s to frank bowel ischemia,
bloody
stools, and perforation. An upper gastrointestinal contrast study is the gold
standard for
diagnosing malrotation

18Complete small-bowel obstruction usually presents with nausea, vomiting.

abdominal
bloating, and dilated loops of bowel on abdominal x-ray. Adhesions. typically
postoperative. are the most common etiology

19Isoniazid causes Idiosyncratic liver Injury with histological features similar to

those seen
in patients with viral hepatitis ie panlobufar mononuclear infilt ration and
hepatic cell necrosis

20Achalasia commonly presents with chronic dysphagia to both solids and liquids,
regurgitation, difficulty belching, and weight loss. Achalasia is caused by
impaired
peristalsis of the distal esophagus and failure of the lower esophageal sphincter
to relax
when food boluses reach it. Manometry is key to diagnosis.

Growth failure and recurrent respiratory infections in infants should raise concern
for
cystic fibrosis. Pancreatic enzyme deficiency causes steatorrhea and fat-soluble
vitamin
malabsorption, resulting in poor weight gain

The most common site of colon cancer metastasis is the liver. Liver metastases
manifest
as right upper quadrant pain, mildly elevated liver enzymes, and firm hepatomegaly.
The
diagnosis is confirmed by CT of the abdomen

Oropharyngeal dysphagia presents as difficulty initiating swallowing associated

with
coughing, choking, aspiration. or nasal regurgitation. TypicaUy, patients are
evaluated
initially with videoftuoroscopic modified barium swallow to evaluate swallowing
mechanics. degree of dysfunction, and severity of aspiration.

Nonsteroidal anti-Inflammatory drugs are a common cause of iron deficiency anemia,

often through chronic blood loss from the gastrointestinal tract. Iron deficiency
anemia
should prompt a thorough evaluation for the cause as early low-grade bleeding can
herald later catastrophic hemorrhage. Elderly patients often have a low-grade
chronic
anemia at baseline and may not tolerate additional blood loss.

Acute liver failure Is defined as acute onset of severe liver injury with
encephalopathy
and impaired synthetic function (defined as INR >1.5) in a patient without
cirrhosis or
underlying liver disease. Drug toxicity and acute viral hepatitis are the most
common
causes.

Liver transplantation should be considered in all patients with acute liver failure
and
indications that the disease Is worsening or failing to improve.

Primary biliary cholangitis (previously termed primary biliary cirrtlosis) is a

chronic liver
disease characterized by Intrahepatic cholestasis due to autoimmune destruction of
small
bile ducts. It presents In middle-aged women with fatigue, pruritus, hepatomegaly,
and
elevated alkaline phosphatase. The diagnosis is confinned with serum anti-
mitochondrial
antibody titers

Wilson's disease Is the likely diagnosis in a patient younger than 30 years old
with
unexplained chronic hepatitis. The presence of low serum ceruloplasmin and
increased
urinary copper excretion or Kayser-Fleischer rings confirms the diagnosis.

Ischemic hepatic Injury occurs In the setting of hypotension and manifests as

acute,
massive increases In the AST and AL T with milder associated increases in the total
bilirubin and alkaline phosphatase. In patients who survive the inciting condition,
liver
enzymes typically return to normal within a few weeks.

Patients with ulcerative colitis are at Increased risk for colorectal cancer.
Screening
colonoscopy with mucosal sampling should be offered to patients with ulcerative
colitis
beginning 8 years after the Initial diagnosis, and repeated every 1-2 years
thereafter.

positive urine bilirubin assay Is typically indicative of a buildup of conjugated

bilirubin.only direct billi can cross membrane.

Hyperestrinism In cirrhosis leads to gynecomastia, testicular atrophy, decreased

body
hair, spider angiomas, and palmar erythema.

Irritable bowel syndrome is a functional disorder of the gastrointestinal tract

characterized
by chronic abdominal pain with diarrhea and/or constipation. Patients with symptoms
consistent with the ROME Ill criteria and no alarm features do not require
extensive
workup for diagnosis

Emphysematous cholecystitis Is a life-threatening form of acute cholecystitis that

occurs
more commonly in Immunosuppressed patients (eg. with diabetes). It arises due to
infection of the gallbladder wall with gas-forming bacteria and requires emergent
cholecystectomy

Painless jaundice In a patient with conjugated hyperbilirubinemia and markedly

elevated
alkaline phosphatase should raise concem for biliary obstruction due to pancreatic
or
biliary cancer. Other common causes of biliary obstruction include
choledocholithiasis
and benign biliary strictures

Educational objective:
Multiple liver masses are much more likely to be the result of metastatic disease
than
infectious causes or primary liver malignancy. Primary tumors of the
gastrointestinal
tract, lung, and breast are the most common diseases causing liver metastases