Liver Cirrhosis

Ascites: spontaneous bacterial peritonitis (SBP) is determined by white cell count, treat with cefotaxime/ceftriaxone and albumin infusion (decrease hepatorenal syndrome)

Serum Ascites Albumin Gradient (SAAG)
SAAG>1.1 --> portal hypertension
SAAG<1.1> cancer or infection

General Txt
1. spironolactone to reduce ascites and edema
2. propranolol to prevent bleeding
3. neomycin and lactulose to prevent encephalopathy
4. vit K is in general useless

Primary Biliary Cirrhosis(PBC)
fatigue + pruritus + elevated alkaline phosphatase + osteoporosis
Lab: elevated alkaline phosphatase, GGTP, IgM, and antimitochondrial antibody(most specific)

Primary Sclerosis Cholangitis
PBC - antimitochondrial antibody
Dx: ERCP or transhepatic cholangiogram, No biopsy

Hemochromatosis
Cirrhosis + cancer + restrictive cardiopathy + vibrio/Yersinia infection
Dx: elevated iron, ferritin, diminished iron binding capacity, biopsy
Txt: phlebotomy, deferoxamine

Wilson Disease
choreoathetoid movement + psychosis + K-F rings + Fanconi syndrome + type II renal tubular acidosis + hemolytic anemia
Dx: low ceruloplasmin + high urinary copper level + biopsy
Txt: penicillamine + transplant

Alpha-1 antitrypsin deficiency
cirrhosis + COPD(emphysema in young non-smoker)

Txt for HBV and HCV
HBV: interferon or lamivudine or adefovir
HCV: interferon and ribavirin

Syndromes related to colon cancer

Gardner's Syndrome


Peutz-Jeghers syndrome


Turcot Syndrome

Malabsorption disorder

Vit A, D, E, K, B12, and Iron deficiency

A. Celiac disease: anemia, dermatitis herpitiformis Dx: antigliadin, antiendomysial, antitransgultaminase Ab, small bowel biopsy showing flattened villi


B. Chronic pancreatitis: Dx: xray, CT, secretin testing, low trypsin level
To differentiate A & B: 1. D-xylose test: B absorb, A doesn't 2. iron deficiency in A not in B

C. Tropical sprue: biopsy

D. Wipple: dementia, arthralgia, ophthalmopledia Dx: biopsy, PCR, foamy macrophage with PAS+

C & D have same treatment: sulfamethoxazole/trimethoprim or doxycycline for 6 mos. or ceftriaxone for 1 year

Diarrhea

First thing to look: hypotension & othostasis
First thing to treat: IV fluids & antibiotics

Infectious diarrhea
Dx: fecal leukocytes, culture, ova, parasite examination, c. Difficle toxin, Giardia antigen
MC: Campylobacter & Salmonella

Empirical Txt: fluoroquinolones + metronidazole
Scombroid: diphenhydramine
Giardia: metronidazole, tinidazole
Isopora: TMP/SMX
Vibrio vulnificus: Doxycycline
Giardia: paromomycin, raise CD4

C. difficle: DOC: metronidazole. oral vancomycin if metro doesn't work

IBD

IBD: diarrhea, bleeding, fever, weight loss, abdominal pain, Dx: endoscopy
CD: palpable pain, skipping lesions, kidney stone, gallstone, vitB12, calcium, iron, vit K deficiency, ASCA antibody,
UC: confine to large bowel, No mouth or anal involvment, No fistula, No skip lesions, more bleeding, ANCA,

Txt: mesalamine , or sulfasalazine, acute exacerbation using steroid
CD: pentasa
UC: Asacol
rowasa for rectal disease

azathioprine and 6-mercaptopurine to substitue steroid
anal CD: ciprofoxacin and metronidazole
CD with fistula: infliximab, do PPD first

Surgery: curative for UC, not used for CD

Gastric disease

GERD: PPI + lifestyle modification

Barret: GERD --> squamous ->columnar, repeat endoscopy 2-3years, endoscopy if GERD>5 years or alarm symptoms

Ulcer: usually nontender, Dx: endoscopy,
gastric: pain on eating, weight loss
duodendal: pain relieving on eating,
H. Pylori: serology, breath urea test, stool antigen. the latter two are used to test therapy effect
NSAID ulcer: misoprostol
Cox-2: celecoxib, valdecoxib

Gastritis: asymptomatic bleeding, type A gastritis: gastric mucosa atrophy, vitB12 deficiency, increased gastrin, MALT

Zollinger-Ellison syndrome: duodenum and pancreas gastrinomas, MEN I.
ulcer + diarrhea + metastasis
Dx: increased gastrin when off anti-acid treatment, concurrent rise of acid and gastrin, positive secretin stimulate test, then US, CT, MRI, somatostatin scintigraphy to exclude metastasis
Txt: surgery, PPI for metastasis

Gastroparesis: fullness, diabetes Dx: clinical Txt: erythromycin or metoclopramide

Nonulcer dyspepsia: rule out all other disease, treat H. Pylori if has.

Esophageal diseases

Achalasia: Loss of neural structure of LES, difficulty in swallowing both solid and liquid food, EGD is the best initial test, barium is more accurate, manometry is most accurate. Txt: pneumatic dilation, botunilum toxin inject, eventually myotomy.

Esophageal cancer:
alcohol, smoking --> squamous cancer proximal
GERD, barret --> adenomous cancer distal
solid, then fluid, weight loss, hoarseness, hypercalcemia
DX: barium --> EGD -->CT-->bronchoscopy-->endoscopic US
TxT: surgical resection, 5-FU, radiation

Scleroderma: GERD + scleroderma Dx: motility study Txt: omeprazole + metoclopramide

Nutcraker esophagus: spasm, chest pain with cold water + dysphagia. Dx: barium(corkscrew) + manometry. Txt: calium channel blocker + reassurance

Rings and webs: non-progressive dysphagia, Dx Barrium, Txt: dilation + iron for PVS
ring: distal,
Web(PVS): proximal, Iorn deficiency anemia

esophagitis: candida(HIV, DB), odynophagia, Dx: empirical fluconazole response, then endoscopy
pill esophgitis: young treat with acne developes acute onset of odynophagia

Zenker diverticulum: outpocketing of posterior pharyngeal constrictor muscle, Dx: barrium, endoscopy and nasal gastric tube are contraindicated, Txt: surgical resection

Mallory-Weiss syndrom: painless upper GI bleeding, melenoma Dx: endoscopy, Txt: no treatment or injection of epinephrine or cauterization