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