Docmark | medical students committee 21 September University Second batch | 2017 | Telegram @DOCMARK21 CamScanner = &Auto-Immune Poss Metabolic Dx AH, PBC, PSC ROH Infections eure Genetic Dx Sey, Hey HH, Wilson's, ALAT ar =—* Liver Cirrhosis ae Oe Hee 2 Sep 5 ass oxcurin - sea Reduced liver function/ “ao pension insufficiency we — Varices a Siew Jaundice > conjugation of bi (ober) 3 secretion at conjugated bi int le dt cana Splenomegaly / Coagulopathy 4 drainage of conjugated bit v (conmenparmayetieced — etinemue “joctrs 10, 5,2 ae ou) : ee Encephalopathy ren > jaundice Shigh err high tbvinogen acto) and high Factor Vil (Acute ‘phase reactants) CamScanner = &Remember: pain presentations can be atypical in diabetes (europathy) eldeiy/infants, pregnant wornen, the immuno Suppressed, and those who have taken antibiotics recent Locations can be atypia! as well Role out (R/O) surgical abdomen: pt lying Acute Abdominal Pain (<72 hours) severe pain with abdominal vibration (Le. coughing, rebound) Causes of Surgical abdomen are in bold, below Do not miss: * Ectopic pregnancy + Ruptured/leaking AAA * Perforated viscus * Bowel obstruction “+ Mesenteric ischemia stil, rigid/hard abdomen, guarding, wlenamalrotated gt w/the —_— + Acute pancreatitis Gecuminthe WUQ,apperdctis * Appendicitis may present with Ua point Diffuse Flnpeasilicitateesiloe f _— epic resentation) Non-Peritoneal Peritoneal Upper Quadrants Lower Quadrants ~ Perforated Vieus (90 cardio nonar/MSKcauses) (670 Genitourinary eauses) Z \ abdominal artic ae Z aneurysm (AAA eae gt 3 a Bowel _ Non-Bowel orrupture Peritoneal E 185 PWetaboleDisexe pancreatitis Nom-peritaneal Srerfortedulcer Peritoneal Non-peritoneal Deesroeneris(e-diabelic—>bowel obstruction 1 raneeste / Constipation most constipation _ketoscidoss) (epecayn/prr | Seroleematis(rugy —/ canwmonin >) ‘Si8D Selec anemia ebdosurgerouemay Sehoangis (Rua) / >is Shovel aranad rotneed sen) esophageal rupture / Pureterie ena cburicion syndrome Epigastrie Gablacder rupture / \ cote Seresentene PAdleonian es “_—sepuevieer Syintwae \ Sun ischemia: | >Musculoseetl Right Upper. _2Cax"ts Left Upper a. Pendometrs fenbal/trombiy trauma Seutar/cole Rex ood >eplene dx Pehic/Adnexal Bowel Pox Absess ‘all Bowel “Shepotis — asoclated and prc, abscess, Peewpierreenancy Appendicitis (rel) Infaretion (re) Hepat abscess pestonal) rupture Sovacan Torsion (aunty Ria) “SrepticUeer Schotngtis >Bilarcote “Stung ax Pe, Srestclartrsion >0Wvertiltis Disease ryelonepmits CMEC Mi, preumoni rate (oust a) opie: tung, eval ion Infammatory Strangle syndrome preumoria, —_dsection, seas (710) hernia pleurletision) rptured AAA Saints ‘All reproductive-age women with abdominal pain > ectopie pregnancy! [Unt a proper urine BHCG (with SG> 1.015), ora serum BHCG proves otherwise} CamScanner = &Chronic Abdo Pain >Recurrent Pain? R/o tumor ‘Think: 1) type of pain and 2) location (what structures are underneath)! ‘Supper Quadrant/Epigastric Pain? R/o cardiac, pulmonary, renal cases (esp In seniors) Dtower Quadrant pain? R/o genito-urinary causes Upper quadrants ~ PUD or gases Lower quadrants astriccancer crohns eynecologica pelvic inflammatorde, tumor, ‘endometviess) Testicular torsion in men Chronic pancreatitis “> Pancrestic tumor Polen tabseess, splenomegaly) ther distension (hepatomegaly, tu, fa, etc) Diffuse / ascites Upper quadrants PNeuropathic pain lary cole 2Musde wall sphincter of oad somatization ‘dstunction ‘small imeestinal malignancies Renal eae rare: adenocarcinoma, ‘atcnold, lymphoma, mets) Crampy/Fleeting/ Intermittent bitfuse Sus Sobeructin (ex adhesions crohns, volvulus neoplasm, hernia) waves of peristalsis pushes food against obaruction, causing crampyffesting pai. Post-Prandial aaa Upper Quadrants | Lower Quadrants 3cER0 obstructing Cancer PUD/Dyspepsa \ 318s Seaiceancer Dervemiepancreatea \ \ ‘Sehiany cate Sangre Diffuse % Powel obstruction . rowel ischemia Lower quadrants atherosclerosis 10 3185 Soliac disease iactose tolerance tumors CamScanner = &{(coffee-ground emesis/melena = usually slow, low-volume, venous bleed) (hematemesishematochezia = usually acute, large-volume, arterial bleed) (BUN will be high ~ iff from lower Gi bleeds) GE Junction Upper GI Bleeding DDx Esophagus Esophagitis, Ruptured Esophageal and \Varices— (15%) ‘Mallory-Weiss Tears: Gastritis: hageal —(varces caused by portal Retehingand vomiting Duetosties, espa iperiensontoncemred —fepentedyferceopentheGE EtOH te tere Iver, which ace then Junction, tating TH PP, HE ooeker ‘purest ood passing ‘Tas injeet epinephrine antacid acd and ‘through esophagus) (vasoconstriction); clip tears + reflux) Tecbanding/igation, together (sc healing) ‘octreotide | blood ow to region) Hyperseretion Estrame stress CU (Zollinger-Ellison 2E settings), other syndrome SRomaeh cancers, 2nd Gastrmoma gastrin ther contributory produengtumorlin factors (rare) Godenumor pancreas (are) Indications for surgery: * Failed medical mgmt (.e. endoscopy, angiography) Ro excess anticonguiation(.. coumadin, heparin), ic, and congenital bleeding dx Duodenum. Cancer (almost aways benign in duodenum) Peptic Ulcer Disease (55%) (where 2¢i overwhelms G1 mucosal setense) Se: 30% asymptomatic, epigasti pn ‘lating to back, pain correlated w/ eating, NIV. early satiety “Te Pl, H2-blockers; endoscope: cauteriz, clipping, ep-injecton; surgery. H. pylori Aentates antrum, inducing ‘massive Ht secretion, overcoming mucosa defense 95% duodenal, 7% gastric ‘De Hp Pae— PP, amoxil, elarithryomycin NSAIDs ASA asprin}, Ibuprofen (motrin, adi, naproxen = protective prostaglandin ‘rocuction, | blooe flow to Gitroet. duodenal, 24M gastric + Prolonged bleeding/significant loss (>6 units of pRBCS in short period of time, Fast bleed, hypotension) CamScanner = &Lower GI Bleeding DDx (Fecal occult blood test positive, BUN willbe normal) Osi Neoplasm Diverticulosis Vascular ca ase (30-50%) often asymptomatic, healthy, Z Out-pouchings of ; 3 /ron dfiensy ji colon wall; the strain - ) ‘ Anciadysplosia Anorectal malibu ror (most \ barststhe capillaries (29.30%) (esp <50 vrs old) aiwoys ben gn) ie f ‘BRBPR. Blood NOT mixed 51094 usu: Most: painless belly, ‘Arion peel th stool! On toil ‘ood weve inet ine them. Infections of sinless bell, Vasculature rising to esta (esol toe Previously Wel. We clon mucoas Socpeme- | en ‘Te: endoscopic me 180 a - Fistula/Abscess vascularized "s seeuherteation: Fissures, = Swi bieed abscess region afeoion) (Crohn's, UC) Pet Ms ruptures These two are abrupt lower Gi bleeds ee Anal cancer (Acute, <2-3 months): they do NOT Hemorrhoids Poleein, discharge ie ciency! vealed \ Ppresence of mass i i, eas Sprartue Theyre seen mostly in older people gin sles! Solitary 3 hatemal-bhe Saliten leer usualy wort bced + Lower GI bleeds usually less severe than Upper Gl bleeds Indications for surgery: + 80% stop bleeding on their own * Falee medical mgmt (Le:calononenpy, '* mortality only 5% (much lower) angiography) © Dx: ‘+ Made by plain films (thumb-printing), nuclear scan, abdominal CT, angiography. + Confirmed, and often treated, with colonoscopy + Proianged bleeding/significant loss (26 units ‘of pRACS in short period of time, fast bleed, hypotension) CamScanner = &Dysphagia (Problem with swallowing) = 2Where is the swallowing difficulty coming from? Oropharyngeal heartburn + regurgration (‘ood repeats on me"), ‘esp stooping ving down, GERD! > -Most GERD + dysphagia alarm symotom)t “GERD tefux esophagitis > secture or met (Garett) > dysplasia > Padenocarcinoma (Immediate swallowing difficulty; in throat) {citficuty initiating swallow, choking, nasal regurgitation) Esophageal (delayed swallowing difficulty in sternal, lower region; food sticks seconds later/further down) Neuromuscluler/ od Va Structural Functional toxic/metabolic >Forcignbody ——_>xerostomia (ry mouth, suroke (cv) enlarged mph no saliva) Shyasthenis Gravis nodes cueto Palate hytericus Sans tumors torsiitsfrono ——_{rflarymation or anaety Shute sclerosis rumors {omatoform); presents Pamyotrophiclaeral —_Zenker's ‘w/out food) sclerosis, ‘diverticulum polymyositis encice yeast) Epieotiis also presents with dysphani with dioaling Intermittent PSehaislin Seongontal wet osinophiie saophonis concen tnesen ‘endoscoce and bart contrat: Te steroids PI ict with Seis Only ‘Mechanical obstru Progressive (worse overtime) Neoplasm stiawe senn (as) leiomyoma Malignant 39%)- edenocorcinore, squamous cl carcinoma (age>50, weight ose) Dithculy with Sous + taulds: ‘Motor/neuromuscular Disorder Intormitont Progressive > Esophase! {worse overtime) seuimaleentral — PAchalazia chest pai mistaken for heart stacks) (bird's beak esophagus) {Tee preumatie dilation of 1S, heller motomy, botox) eystemic diseases lseroderms, diabetic euconathy loss |oramdcinervatonof tes) CamScanner = &Acute Diarrhea Could be start of chronic («2 weeks, >3x/day, >175-200e/day) ‘auarrtead {smoking high Acheter diabetes, Infectious an hyperipdemi, mal, pro tof CV, (raver Anebioee wee? 898 3 CAD, PVD rls on abdominal aery rte? Bo fod?) ~ ‘selation) ‘Mestcommon Non-tloody Bloody pe aa Soomisiekts — ->ULcatne colts * —s = ~ PCrohn’s colitis Crohn's cobs seomeenere — SHIBE BOWE! arrhea-predominant Nausea + vomiting chemin easy Need CT (orig ite of aN predominant angen!) arastmoresiniarge \ ae ‘owe usdenamles theo wt - price - abacterlenes Bocos ichentfcetie! small Bowel Large Bowel aunt oor {UsusLtr watery dares dve (USUALLY: Hoody dares Stonpens win? ha {tov relate, fngervolumes, _duetotisve nitration, 32S dahon ody Compsanddiusetenesmus, Gar sin, Seng no Te peiumbieal pin that doesn't goes aay alo deletion sp auaystterpeaping, posble urgncyincontienee, stentorhea) netunal dare} Pius retaveus, norowrus) Sacer Campycbacs Poactern(C peingens Eset shzotySaimorel £0 (EC (erecand che) teria age: Aste Coal emake ‘ome picture choker, ‘piture) Dietary (osmotic diarrhea) salncncla “Prarostes Est) + ingestion anal Percess fiber ingest SExcess fat ingestion SNon-absorbed sugars (Le. from gum) CamScanner = &Chronic Diarrhea All ehronie dacrhea cases go (02-4 weeks, >3x/day,>175-2008/d0y) through an acute phase! (he. can a be infectious) Steatorrhea small Bowel Large Bowel (oly ousting har ih, (arg sue, watery no tao {smal wae, ot, cae bdo pi teesms, Tost) efatse pam wat oss, ‘reenen alu) et AS | Secreto Malabsorption/Maldigestion ee (rneccorn vn “Span hsuieny aa | ‘stn “Stetae >tioes tena “>a obi be eset) \ . teas “Sih bowel/esecton r \ Motility | sctlontancer “oes detec fer lesa, ‘ oscarent | syeroscpe cats ‘a vxssuec pane Eee, | one -pasceral vent Secretory (a¥mosteormer) osmotic 2 | Dleencnte th : f (danberstape wi vPEHS Shtsemerc heres Noga daha! - ‘sn a ‘ind \ ——— Staanivld (ta, Mucor meets bone! Msabserpton a Mg sased on media & seul pers ast \ mmeverets) ror, sot, cbohdetes io mal Soisbeteneuonahy —— lacoseiterance ‘Sadavon ats Sain (engeital qe) Stanmccatte Seon Senter a acre (gastrinoma/Vt pom, mastoeytoss, earcnoids) adanocacinom, Drugs: Hymphoma Antibiotics Dwnipoe’s Diszase Colchicine (basically anything..ask ‘about medication changes!) CamScanner = &\ Abdominal Distension a, Flatus a (Bowel Dilatation) fs Free ascites) loratized : “sessegiite | -Shepsarten PAbscess e ‘ ‘Carb. malabsorption: megaly , Pham | 3a ovarian itive ‘Exudate ‘Transudate a % wat tame exnermatmanes Low SARG(etie/) gh sARG O38/) Mechanical % Serle 97% due to 997% due to Portal Obstruction Fibroids carcinomatosis ‘hypertension (clerhosis— adhesions latestinel Pseudo ‘Bladder (extensive cancer 80%, alcoholic hepatitis, Hemias sbstnucaion {(hydronephrosis/ cysts) rmetasai oughout ‘ude chan algnaney (Emote) abdo cavity) PCardiac: CHF, constrictive >Volwulus (sigmoid, cecal) - — infection (PMN > pericarditis: 3180 = — 2sofe) ese ee — ‘PPancreatitis ee Ria Peresitis Acute colonic obstruction: Chronic intestinal Sehr -prowemegseon eo 0. seh -prenortes wscous infection or Cait) "> Oblve's syndrome (colanicestenson in ‘bechidden tft trauma) trauma sugary, dues (opis, at ‘hoinerics) medial ness, CHF) J “Retrportoncalhomorshage / ‘Sealer Myopathic seleroderms “Samia ‘obstruction Other: paralytic ileus 9¢- dif (tone megacolon) SPeritenits 3Po0s-0p -fusully a few doys ofter operation) PHypokalemia \ Hypothyroidism Neuropathic Ener (OM, amyios, paraneoplastic, narcotes) Datrnse (MS, spinal injury, stroke) 6 F's of abdominal distension: Fluid, Flatus, Feces, Fetus, Fat, Fatal Tumor! CamScanner = &Approach to Abdominal Distension 6 F’s of abdominal distension: Fluid, Flatus, Feces, Fetus, Fat, Fatal Tumor! Imaging of Abdomen Abdominal X-rays (3 views: upright, supine, and CXR) Abdominal/pelvic Ultrasound (cifferentiates between fluid or gas distension) ICT (ascites shows up as grey fluid surrounding internal argans MRI necessary) Contrast studies (barium swallow, small bowel follow-through, water-soluble contrast for obstructions) Sigmoid volvulus 8% of all intestinal obstructions, ‘more common in elderly; coffee-bean on X-ray = ae diagnostic! eeal volvulus ~ dilated cecum in LUG n X-ray = diagnostic! (1-2% ofall intest. obstruction) {also, bird's beak on contrast enema ~ tapering off at end of cecum near IC valvel) CamScanner = &Hepatomegaly: 213cm in the MCL {rule out concurrent splenomegaly and jaundice) Congestive Proliferative ~ Right Heart Failure . Budd-Chiari syndrome E 2 Donstrctive Pericarditis Benign Mafigaant Infectious Inflammatory Fay liver 31° carcinoma Hepatitis A, B,C ~PAlcoholic hepatitis ‘Cirrhosis: ‘Metastases Mononucleosis Autoimmune PCysts lymphoma Tuberculosis hepatitis Hemochormatosis Heukemia Bacterial cholangitis >brug:induced wilson aisease >Poiyeythemia Abscess hepatitis PAmyloidosis Multiple Schistosomiasis Sarcoidosis: myelofibrosis myeloma Hstocytosisx Liver Transplants (tT) * Indications: Priority given by MELD-score (>15)~ combin'n of INR, Bili, and creatinine * 95% due to complications of cirrhosis (HCV, HBV, HCC, NAFLD, AIH, PSC, PBC, Wilson's, hemochromatosis, A1AT...) + 5% due to ALF + Complications: * ‘Acute/Chronic rejection, infections from the procedure, biliary leaks/strictures * Due to chronic immunosuppression: infections, renal failure, DM, HTN, hyperlipidemia, bone weakening, * Drug interactions: affect CYP liver proteins (CYP3A4) ‘+ Survival post LT: 90%@1yr, 75%@5yr, 50%@ 20yrs CamScanner = &Bowel Obstruction: Pathogenesis and clinical findings Pathogenesis. Sepals Some Drugs Post operation ibetes sae = ————domenswithAbdomens that have Nonescoortratingtowel — ROpOUBEry: Been operated on: erhcasearedemprad wales ssuay adhesions ' oe Forctina!"bockags™ hyskal blocage ot {eus) No perstas ‘wal amen Sallowed er and ingested Gl contents, {accumulate before the ebstructon + ‘Acomulted coments consn | alee tot outlay craw —| ator ntothe Gl trat ‘ther end! itavenef eutoneme nerves Taeroting the vizea eran esta debydration Tow orev oe volume) Perstonizchove the sv af [ —sbstractionesecnty physical ‘bsructionscotinvs fo push ‘bowel detenson, (teantort geist astaction ‘luminal pressure ‘irsoundsFeow te percoson obstruction Kose to Tout) Nghe urinal eressure a7 {orcereguratation of contents ‘Bowel chemi + Ifarction, issue necro, and possbiepefaratan ‘erbacteral invasion Clinical findings ‘¢Sumatoms and Physical ‘xom sions} Nothing comes utthe _, >Obsinatan:no Hatsfofarting > Nobows! movements > Boating comin > Diuse visor] abdominal ain > yi esting acronis enhostare hypotension Paine come in waves, and can be severe ghana ‘thpptacie bowel sounds lblore 2 ahal ststucton, OF absent bowel sounds) Abdomen tpanc to pscssion ou i | seen smaneton boven nd boven. idertinoe posers ope enemies CamScanner = &