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