Digestive System

Treatment of Diffuse Esophageal Spasm (DES)

• Ca channel blockers :: -Dipines
• Reuptake inhibitors :: TCAs
• Nitrates :: Nitroglycerin & Isosorbide

Treatment of Esophageal Varices

• Somatostatin analogs
• Vasopressin
• β antagonists :: Propranolol
• Nitrates :: Nitroglycerin & Isosorbide
• Balloon tamponade
• Endoscopy
  • Endoscopic variceal ligation (EVL)
  • Endoscopic sclerotherapy (ES)

Management of Abdominal Trauma

Condition	Management
Blunt trauma	Focused assessment with sonography in trauma (FAST)
Stable blunt trauma	Abdominal CT
Unstable blunt trauma	Diagnostic peritoneal lavage (DPL)
Known etiology	Exploratory laparotomy

Signs of Retroperitoneal Hemorrhage

• Cullen sign
• Grey Turner sign
• Fox sign
• Bryant sign

Etiology of Gastritis

• Achlorhydria
• Alcohol
• Autoimmune gastritis
• Biliary reflux
• Brain injury → Cushing ulcer
• Burns → Curling ulcer
• Drugs
  • NSAIDs
  • Corticosteroids
• Ischemia
• Smoking
• Stress
• Helicobacter pylori

Brochardt Triad of Gastric Volvulus

• Intermittent epigastric pain and distention
• Inability to vomit
• Difficult passage of nasogastric (NG) tube

Medications for PUD

Mechanism	Medication
H-K pump blockers [Proton pump inhibitors (PPI)]	-Prazoles
H2 antagonists	Cimetidine Ranitidine Famotidine Nizatidine
PGE1 agonists	Misoprostol
Antacids	Aluminum hydroxide Calcium carbonate Magnesium hydroxide
Antimicrobials	Amoxicillin / Metronidazole Macrolides
-	Bismuth
-	Sucralfate

Presentation of Gastric Adenocarcinoma

• Acanthosis nigricans
• Leser-Trélat sign
• Virchow node
• Sister Mary Joseph nodule
• Krukenberg tumor
• Blumer shelf

Types of Gastrectomy

• Local [Wedge] resection
• Sleeve gastrectomy
• Proximal gastrectomy
• Segmental [Pylorus-preserving] gastrectomy
• Distal gastrectomy
• Total gastrectomy

Gastric Reconstruction

Proximal Gastrectomy

Segmental Gastrectomy

Distal Gastrectomy

Total Gastrectomy

Complications of Gastrectomy

• Afferent & Efferent loop syndrome
• Internal hernia
• Marginal ulcer
• Dumping syndrome
  • Early dumping syndrome
  • Late dumping syndrome
• Postvagotomy diarrhea
• Alkaline gastritis
• Nutritional deficiencies
  • Vitamin B₁₂ deficiency
  • Iron deficiency

Types of Bariatric Surgery

• Vertical banded gastroplasty (VBG)
• Laparoscopic adjustable gastric band (LAGB)
• Sleeve gastrectomy
• Biliopancreatic diversion
• Roux-en-Y gastric bypass (RYGB)

Types of Hernia

Hernia	IL	Triangle	IIR	EIR
Indirect inguinal hernia	Above	-	+	+
Direct inguinal hernia	Above	Inguinal	-	+
Femoral hernia	Below	Femoral	-	-

• Inguinal ligament (IL)
• Internal inguinal ring (IIR)
• External inguinal ring (EIR)

Presentation of Appendicitis {PROM}

• Psoas sign
• Rovsing sign
• Obturator sign
• McBurney's point

Etiology of Nausea and Vomiting

• Gastroparesis
• Motion sickness
• Morning sickness
• Radiation
• Chemotherapy
• Postoperation

Prokinetics

Mechanism	Medication
D2 antagonists	Metoclopramide Prochlorperazine Domperidone Droperidol
5-HT4 agonists	Cisapride Mosapride
Stimulants	Macrolides

Antiemetics

Mechanism	Medication	Indications
M antagonists	Scopolamine	Motion sickness
D2 antagonists	Metoclopramide Prochlorperazine Domperidone Droperidol	Postoperation Chemotherapy
5-HT3 antagonists	-Setrons	Postoperation Chemotherapy
H1 antagonists	1° Antihistamines	Motion sickness Morning sickness
Neurokinin antagonists	Aprepitant	Chemotherapy
Cannabinoid agonists	Dronabinol	Chemotherapy
-	Corticosteroids	Chemotherapy

Laxatives {SHELB}

Mechanism	Medication
5-HT4 agonists	Cisapride Mosapride
Stimulants	Senna Bisacodyl
Hyperosmotics	Magnesium Polyethylene glycol Lactulose Enema
Emollients	Docusate
Lubricants	Mineral oil
Bulk-formers	Psyllium

Etiology of Diarrhea

• Osmotic
• Secretory
• Exudative
  • Infectious
  • Inflammatory
• Dysmotility

Malabsorption Syndromes

• Pancreatic insufficiency
• Celiac disease
• Tropical sprue
• Whipple disease

Pathogens of Infectious Diarrhea

Watery {GBS-CAVERN}

• Giardia lamblia
• Bacillus cereus
• Staphylococcus aureus: heat-stable
• Clostridium difficile
• Cryptosporidium
• Adenovirus
• Vibrio cholerae
• ETEC & EPEC
• Rotavirus
• Norovirus

Bloody {SYCE}

• Salmonella
• Shigella
• Yersinia enterocolitica
• Campylobacter
• EHEC & EIEC
• Entamoeba histolytica

Indications for Antibiotic Treatment of Diarrhea

• Pathogens w/o shiga toxin
• Pathogens w/ low infectious dose
• Immunodeficiency
• Hemodynamic instability

Rome Criteria for Irritable Bowel Syndrome (IBS)

• Recurrent abdominal discomfort
• Relief a/w defecation
• Onset a/w frequency of stool
• Onset a/w appearance of stool

Etiology of Hematochezia

Painless

• Allergic proctocolitis
• Meckel diverticulum
• Diverticulosis
• Angiodysplasia
• Hemorrhoids
• Malignancy

Painful

• Intussusception
• Anal fissures
• Inflammatory bowel disease
• Infectious colitis
• Diverticulitis
• Necrotizing enterocolitis (NEC)
• Ischemic colitis

Classification of Inflammatory Bowel Disease (IBD)

	Crohn Disease	Ulcerative Colitis
Involvement	Ileum & Colon	Colon & Rectum
Pattern	Skip	Contiguous
Depth	Transmural	Mucosal Submucosal
Radiography	String sign	Lead pipe
Colonoscopy	Cobblestones	Pseudopolyps
Histology	Noncaseating granuloma	Crypt abscess
Immunology	Th1	Th2
Autoantibody	ASCA	Anti-MPO [p-ANCA]
Risk of colorectal cancer	↑	↑↑

Grading of Hemorrhoids

Grade	Proplase	Reduction
1	-	-
2	+	Spontaneous
3	+	Manual
4	+	Irreducible

Triad of Chronic Anal Fissures

• Sentinel pile
• Hypertrophied papilla
• Ulcer with scarred edges

Park Classification of Anal Fistulas

Goodsall Rule for Anal Fistulas

Anorectal Malformation

• Pubococcygeal (PC) line
• Ischial (I) line

Etiology of Ascites

	SAAG < 1.1	SAAG > 1.1
Ascites TP < 2.5	Nephrosis	Cirrhosis
Ascites TP > 2.5	Cancer Infection	Right heart failure Budd-Chiari syndrome

• Serum-Ascites albumin gradient (SAAG)
• Total protein (TP)

Child-Pugh Score for Cirrhosis {ABATE}

Score	1	2	3
Ascites	Grade 0	Grade 1 & 2	Grade 3 & 4
Bilirubin	< 2	2 ~ 3	> 3
Albumin	> 3.5	2.8 ~ 3.5	< 2.8
Time :: prothrombin [INR]	< 1.7	1.7 ~ 2.3	> 2.3
Encephalopathy	Grade 0	Grade 1 & 2	Grade 3 & 4

• Class A: 5 ~ 6
• Class B: 7 ~ 9
• Class C: 10 ~ 15

Complications of Cirrhosis

• Jaundice
• Spider angioma
• Palmar erythema
• Varices
  • Esophageal varices
  • Caput medusae
  • Hemorrhoid
• Hepatic encephalopathy
• Hepatopulmonary syndrome
• Hepatorenal syndrome
• Hepatocellular carcinoma (HCC)
• Coagulopathy

Triad of Budd-Chiari Syndrome

• Pain :: RUQ
• Ascites
• Hepatomegaly

Types of Portosystemic Shunts for Portal Hypertension

Shunt	Portal	System
Splenorenal [Warren] shunt	Splenic vein	Renal vein
Mesocaval H graft	SMV	IVC
Portacaval H graft	Portal vein	IVC
End-to-side portacaval anastomosis	Portal vein	IVC
Side-to-side portacaval anastomosis	Portal vein	IVC
Transjugular intrahepatic portosystemic shunt (TIPS)	Portal vein	Hepatic vein

Etiology of Hepatitis

• Ischemic hepatitis
• Congestive hepatopathy
• Viral hepatitis
• Malignant infiltration
• Drug-induced liver injury (DILI)
• α₁-antitrypsin deficiency
• Hemochromatosis
• Wilson disease
• Autoimmune hepatitis
• Alcoholic hepatitis

Management of Hepatocellular Carcinoma (HCC)

Resectable	VI/EM	Child-Pugh Score	Management
+	-	≤ B	Hepatectomy Radiofrequency ablation (RFA)
+	-	C	Liver transplantation
-	-	≤ B	Transarterial chemoembolization (TACE)
-	+	≤ B	Chemotherapy
-	±	C	Supportive care

• Vascular invasion (VI)
• Extrahepatic metastasis (EM)

Model for End Stage Liver Disease (MELD)

Parameter	(0.957 × ln Cr + 0.378 × ln Bilirubin + 1.120 × ln INR) × 10
Cr	Serum creatinine
Bilirubin	Serum bilirubin
INR	Serum INR

Makuuchi Criteria for Hepatectomy

Criteria for Liver Transplantation in Hepatocellular Carcinoma (HCC)

Milan Criteria

• Resectable tumor(s):
  • 1 tumor: < 5 cm
  • ≤ 3 tumors: each < 3 cm
• No vascular invasion
• No extrahepatic metastasis

UCSF Criteria

• Resectable tumor(s):
  • 1 tumor: < 6.5 cm
  • ≤ 3 tumors: each < 4.5 cm & total < 8 cm
• No vascular invasion
• No extrahepatic metastasis

Etiology of Hyperbilirubinemia

	Indirect	Direct	Mixed
Serum indirect bilirubin	↑	-	↑
Serum direct bilirubin	-	↑	↑
Urine bilirubin	-	↑	↑
Urine urobilinogen	↑	↓	-
Tea-colored urine	-	+	+
Clay-colored stool	-	+	+

• Indirect
  • Gilbert syndrome
  • Crigler-Najjar syndrome
  • Neonatal jaundice
  • Extravascular hemolysis
• Direct
  • Dubin-Johnson syndrome
  • Rotor syndrome
  • Obstructive jaundice
• Mixed
  • Hepatitis
  • Cirrhosis

Comparison Between Biliary Diseases

Disease	Pain	Fever	Bil
Cholelithiasis	±	-	-
Cholecystitis	+	+	-
Choledocholithiasis	±	-	↑
Cholangitis	+	+	↑

Charcot Triad of Cholangitis

• Pain :: RUQ
• Fever
• Jaundice

Pathogens of Biliary Tract Infection (BTI)

• Enterococcus
• Escherichia coli
• Klebsiella
• Pseudomonas aeruginosa
• Anaerobes

Etiology of Acute Pancreatitis

• Gallstones
• Alcohol
• Hypertriglyceridemia
• Drugs

Indications for Whipple Procedure

• Cholangiocarcinoma
• Pancreatic adenocarcinoma
• Ampullary carcinoma
• Duodenal neoplasm
• Chronic pancreatitis

Whipple Procedure

• Pancreaticoduodenectomy
• Gastrojejunostomy
• Pancreaticojejunostomy
• Cholangiojejunostomy
• ± Roux-en-Y reconstruction

Presentation of VIPoma {WDHA}

• Watery diarrhea
• Hypokalemia
• Achlorhydria