ICM II TA session 1

GIT
ESOPHAGUS
Swallowing
Odyanophagia: painful swallowing
- Esophagitis
1. Candida white plaques. Tx w/ oral fluconazole
2. HSV Vesicles. Tx w/ acyclovir
3. CMV Vesicles. Tx w/ gancyclovir
4. Pill Esophagitis kissing ulcer (occurs from NSAIDS, K pills,
alendronate,
Tetracyclines. Erosion on where pill makes
contact and
***Hyperkalemia***
First 3 the pts are immunocompromised
Dysphagia: Trouble swallowing
- Pseduodysphagia: Pts w/severe neuromuscular disorder
(Parkinsons, ALS, MS, Myasthenia gravis)
1. Trouble INITIATING swallowing
2. Pts at risk for aspiration pneumonia
-

True Dysphagia
1. Solids Only mechanical obstruction
Intermittent: Bread, steak. Due to an ESOPHAGEAL

RING

Due to Peptic

Progressive: Chronic heartburn w/o weight loss.

STRICTURE
***pt over 50 presents with weight loss

esophageal cancer
2. Solids and Liquids neuromuscular disorder
Intermittent: If occurs w/chest pain diffuse
esophageal
spasm /Nutcracker syndrome
(spiralingknow pic)
TX: CCBs
Progressive: Heart Burn Scleroderma
***Bland regurgitation and weight loss
ACALASHIA***
***Barium Swallow: Classic Bird beak sign***
TX: 1. Botox every 6-8 months, Heller's myotomy,
Balloon
dilation

GERD
Increase in transient relaxation of LES
Incomplete LES
S/S: Heart burn (pyrosis), chest pain, acidic taste in mouth
TX: Diet changes
- Dec. acidic foods
- Dec. alcohol
- Dec. smoking
- Dec. caffeine
- Exercise/weight loss
- Dec. Stress
- No meals close to bedtime
- Sleep w/head elevated
Proton pump inhibitors (PPIs) Omeprazole (risk of osteoporosis)
H2 Blockers Cimetidine (S/E: inhibits cytP450, gynocomastia)

Barretts Esophagus: Squamous to Columnar (columnar metaplasia)

- Goblet/Paneth cells
- 10 % of untreated GERD becomes this
- Adenocarcinoma if barretts goes untreated (progressive dysphagia)
Squamous Cell carcinoma (middle esophageal cancer)
- Smoking (tobacco)
- Alcohol
- Achalasia***
- Age > 50
- M>F
Tracheoesophageal Fistula
- After FIRST feed
Congenital Pyloric Stenosis
- After 2-4 weeks***
- OLIVE like mass
- Hypertrophic pyloric sphincter

STOMACH
Gastritis
Acute
- Stress ischemia (2* to catecholamine release)
- Release of cortisol blocks PLA2 PGs inhibited

1. Erosive
- NSAIDS
2. Curling ulcers
- Burns
3. Cushing ulcers
- Head injury
Chronic
- Type A: Autoimmune ABs to parietal cells (IF and HCL) can
lead to pernicious anemia and achloryhydria
- Binding of B12 and IF occurs in duodenum
- R protein binds B12 from mouth to duodenum and is cleaved by
pancreatic enzymes B12 free to bind w/ IF and go to terminal
ileum for reabsorption
- Megaloblastic Anemia (Hypersegmented neutrophils)
-

Type B: H Pylori. TX: Triple therapy amoxicillin, PPI,

Clarithromycin. MALToma. Test by urease breath test and stool
antigen

Peptic Ulcer Disease

- Epigastric pain
- Duodenum: Pain relieved by eating, weight gain
- Stomach: Pain after eating, weight loss
Protective factors
- PGs
- Mucosa
- Blood Flow
- HCO3
Zollinger - Ellisons Syndrome
- Gastrinoma (gastrin secreting tumor)
- Ulcers in weird places (ileum, jejenum, recurrent ulcers)
- Multiple endocrine neoplasia type 1 (MEN 1)
- MEN 1: Pituitary, parathyroid, pancreas (VIPoma)
Complications: Bleeding*** (proximal to ligament of tres)and perforation
(tx w/ surgery)

SMALL INTESTINE
Malabsorption
Chronic pancreatitis leads to problems in reabsorption of luminal phase
Mucosal Phase
- Celiac Spruce (Gluten sensitive enteropathy) blunting of villi
(brush border), explosive diarrhea, bloating, flatulence
- IgA against Glidian
- Antitransglutaminase

Dermatitis herpatiformis***

Duodenum: absorbs divalent ions

- *Ca2+ hypocalcemia osteoporosis
- *Fe2+ microcytic hypochromic anemia (weakness, fatigue, SOB)
- *Mg2+
- Cu2+
- Zn2+
Terminal Ileum
- B12
- Bile salts
- Vit. D dec problems absorbing Ca
- Vit . A def night blindness, alopecia
- Vit. K def Clotting factors 2, 7,9,10
- Vit. E def hemolytic anemia
Tropical Spruce
Whipples disease
- Multisystemic disease
- Macrophages invade tissue and engulf microbes (PAS +)
INFLAMMATOY BOWEL DISEASE
Crohns
- Skip lesions
- Transmural
- Worsens with smoking
- Biopsy: Noncaseating granulomas***
- Uvietis, sacroilitis (sacro-iliac joint), sero-negative athropathy (not
associated w/ HLA-B27)
- Complications: fistula due to transmural involvement, strictures,
calcium oxylate stones (kidney stones)***
- TX: 5-ASA, corticosteroids, methotrexate, 6-mercaptopurine,
Azithroprine
Ulcerative Colitis
- Continuous
- Involves rectum
- PSC
- Limited to mucosa and submucosa
- Improves with tobacco smoke
- More likely to develop colon cancer
- S/S: Rectal bleeding (hematochezia), bloody diarrhea
- Primary Sclerosing Cholingitis*** cholangiocarcinoma
- Pyoderma granginosum ulcer that occurs on lower extremities
- Complications: Toxic megacolon, anemia
Diverticulosis/ Diverticulitis

Outpouching
Can get infected diverticulitis (LLQ pain)
TX: IV fluids, antibiotics
Complications: perforation, fistulas

Angiodyplasia
- BVs in right side of colon are tortuous bleeding
- Associated w/ AORTIC STENOSIS*** (presents w/ syncope, angina,
dyspnea)
Colon cancer
- Right Sided: bleeding iron def anemia
- Left sided: alternating constipation and diarrhea
- Risk factors: Ulcerative colitis, LOW FIBER HIGH FAT DIET***,
smoking, villous polyps