Last minute revision of Gastro Intestinal Medicine

Important topics in Gastro Intestinal Medicine.

Aphthos ulcer

Painful, superficial ulceration of the oral mucosa , Characterized by a grayish base surrounded by erythema .

Behcet syndrome

Recurrent aphthous ulcers, genital ulcers, and uveitis

Oral herpes

Vesicles involving oral mucosa that rupture, resulting in shallow, painful, red ulcers

Squamous cell carcinoma of Mouth

Oral leukoplakia and erythroplakia are precursor lesions.

l. Leukoplakia is a white plaque that cannot be scraped away; often represents squamous cell dysplasia.

2.Leukoplakia is distinct from oral candidiasis (thrush) and hairy leukoplakia.

                i. Oral candidiasis is a white deposit on the tongue, which is easily scraped away; usually seen in immunocompromised states

                ii. Hairy leukoplakia is a white, rough (‘hairy’) patch that arises on the lateral tongue. It is usually seen in immunocompromised individuals (e.g., AIDS) and is due to EBV-induced squamous cell hyperplasia; not pre malignant

3.Erythroplakia (red plaque) represents vascularized leukoplakia and is highly suggestive of squamous cell dysplasia.

Mumps

prodromal symptoms including low-grade fever, headache, and malaise. This is followed by progressive swelling of one or both parotid glands. Parotid gland swelling usually lasts about one week. Other symptoms of mumps can include dry mouth, sore face and/or ears and some patients find it difficult to talk

 

Complications

Painful testicular inflammation

spontaneous abortion

Meningitis

Ovarian inflammation

Acute pancreatic inflammation

hearing loss

Sialadenitis

•             Painful swelling

•             Reddened skin

•             Edema of the cheek, Periorbital region and neck

•             low grade fever

•             malaise

•             raised ESR, CRP, leucocytosis

•             purulent exudate from duct punctum

Pleomorphoic adenoma

presents as a mobile, painless, circumscribed mass at the angle of the jaw

Warthin tumor

The tumor is slow growing, painless, and usually appears in the tail of the parotid gland near the angle of the mandible

Mucoepidermoid carcinoma

painless, slow-growing mass that is firm or hard.

Tracheoesophageal fistula

vomiting, polyhydramnios, abdominal distension, and aspiration

Esophageal atresia (EA)

Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common : Neonates drool, choke, and vomit with first feeding , Cyanosis is 2° to laryngospasm .

Boerhave syndrome

severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain,Odynophagia , tachypnea , dyspnea , cyanosis, fever, and shock develop rapidly thereafter .

Mackler’s triad includes chest pain, vomiting, and subcutaneous emphysema Pain can occasionally radiate to the left shoulder .

Esophagitis

•             Heartburn (pain in chest – retrosternal)

•             Nausea

•             Postprandial worsening of symptoms

 

Symptoms may be relieved by antacids. Esophagitis causes symptoms of abdominal pain and vomiting. If not treated, it causes discomfort and scarring of the esophagus. This makes swallowing food more difficult.

Eosinophilic esophagitis

Food allergens → dysphagia, food impaction.

Esophageal Stricture

heartburn, bitter or acid taste in the mouth, choking, coughing, shortness of breath, frequent burping or hiccups, pain or trouble swallowing, throwing up blood, or weight loss

Esophageal web

dysphagia for poorly chewed food

Zenker diverticulum

dysphagia, obstruction, and halitosis (bad breath) , gurgling , aspiration, neck mass.

Mallory-weiss syndrome

hematemesis and may be misdiagnosed as ruptured esophageal varices .

Esophageal varices

asymptomatic , but there is risk of painless hematemesis .

Achalasia

progressive dysphagia to solids and liquids (vs obstruction—solids only).

Gastroesophageal reflux disease

heartburn, regurgitation, dysphagia. May also present as chronic cough, hoarseness (laryngopharyngeal reflux), Damage to enamel of teeth. Associated with asthma .

Barret esophagus

•             frequent and longstanding heartburn

•             trouble swallowing (dysphagia)

•             vomiting blood (hematemesis)

•             pain under the sternum where the esophagus meets the stomach

•             unintentional weight loss because eating is painful (odynophagia)

 

May progress to dysplasia and adenocarcinoma.

Esophageal carcinoma

Symptoms include progressive dysphagia (solids to liquids), weight loss, pain, and hematemesis , hoarse voice (recurrent Laryngeal nerve involvement) and cough (tracheal involvement).

Plummer Vinson syndrome

Triad of Dysphagia, Iron deficiency anemia, and Esophageal webs. May be associated with glossitis. Increased risk of esophageal squamous cell carcinoma.

Sclerodermal esophageal dysmotility

acid reflux and dysphagia → stricture, Barrett esophagus, and aspiration.

Gastroschisis

a defect in the anterior abdominal wall through which the abdominal contents freely protrude. There is no overlying sac or peritoneum, and the size of the defect is usually less than 4 centimetres (1.6 in). The abdominal wall defect is located at the junction of the umbilicus and normal skin, and is almost always to the right of the umbilicus .

Omphalocele

a rare abdominal wall defect in which the intestines, liver, and occasionally other organs remain outside of the abdomen in a sac because of a defect in the development of the muscles of the abdominal wall (exomphalos) associated with a

high rate of mortality (25%) and severe malformations, such as cardiac anomalies (50%) and neural tube defect (40%).

Congenital abdominal hernia

incomplete closure of umbilical ring.

Pyloric stenosis

presents two weeks after birth as

1. Projectile non bilious vomiting

2.Visible peristalsis

3.Olive-like mass in the abdomen , visible peristaltic waves

 

Results in hypokalemic hypochloremic metabolic alkalosis (2° to vomiting of gastric acid and subsequent volume contraction).

Gastritis

Many people with gastritis experience no symptoms at all. However, upper central abdominal pain is the most common symptom; the pain may be dull, vague, burning, aching, gnawing, sore, or sharp.

Pain is usually located in the upper central portion of the abdomen, but it may occur anywhere from the upper left portion of the abdomen around to the back.

 

Other signs and symptoms may include the following:

Nausea , Vomiting (if present, may be clear, green or yellow, blood-streaked, or completely bloody, depending on the severity of the stomach inflammation) , Belching (if present, usually does not relieve the pain much) , Bloating , Early satiety , Loss of appetite , Unexplained weight loss .

 

Peptic ulcer

Duodenal : Presents with epigastric pain that improves with meals , no loss of appetite , weight gain .

Gastric : Presents with epigastric pain that worsens with meals , loss of appetite , weight loss .

Gastric carcinoma

presents late with weight loss, abdominal pain, anemia, and early satiety; rarely presents as acanthosis nigricans or Leser-Trelat sign. Spread to lymph nodes can involve the left supraclavicular node (Virchow node).

Distant metastasis most commonly involves liver; other sites include :

1.            Periumbilical region (Sister Mary Joseph nodule); seen with intestinal type

2.            Bilateral ovaries (Krukenberg tumor); seen with diffuse type

Menetrier disease

upper abdominal pain (epigastric), at times accompanied by nausea, vomiting, loss of appetite, edema, and weight loss. A small amount of gastrointestinal bleeding may occur , a protein-losing gastropathy accompanied by low blood albumin and edema.

Intestinal atresia

Presents with bilious vomiting and abdominal distension within first 1–2 days of life. Hyperbilirubinemia is also common → jaundice .

Duodenal atresia : Associated with Down syndrome

Jejunal ileal atresia:

Superior mesenteric artery syndrome

intermittent intestinal obstruction symptoms (primarily postprandial pain) when transverse (third) portion of duodenum is compressed between SMA and aorta.

Meckel diverticulum

Can present during the first 2 years of life with bleeding : melena/ hematochezia (due to heterotopic gastric mucosa), RLQ pain, volvulus, intussusception, or obstruction (mimics appendicitis); however, most cases are asymptomatic.

Diverticulosis

Often asymptomatic or associated with vague discomfort.

Complications include diverticular bleeding (painless hematochezia), diverticulitis.

Diverticulitis

LLQ pain, fever, leukocytosis , Complications: abscess, fistula (colovesical fistula → pneumaturia), obstruction (inflammatory stenosis), perforation (→ peritonitis).

Volvulus

volvulus causes symptoms by two mechanisms:

•             Bowel obstruction manifested as abdominal distension and bilious vomiting.

•             Ischemia (loss of blood flow) to the affected portion of intestine.

 

Depending on the location of the volvulus, symptoms may vary. For example, in patients with a cecal volvulus, the predominant symptoms may be those of a small bowel obstruction (nausea, vomiting and lack of stool or flatus)

 

In patients with a sigmoid volvulus, although abdominal pain may be present, symptoms of constipation may be more prominent.

 

Volvulus causes severe pain and progressive injury to the intestinal wall, with accumulation of gas and fluid in the portion of the bowel obstructed. Ultimately, this can result in necrosis of the affected intestinal wall, acidosis, and death.

Intussusceptions

periodic abdominal pain , nausea , vomiting (sometimes green in color from bile), pulling legs to the chest area, and intermittent moderate to severe cramping abdominal pain , rectal bleeding, often with “red currant jelly” stool (stool mixed with blood and mucus), and lethargy . intussusception can cause a loop of bowel to become necrotic, secondary to ischemia due to compression to arterial blood supply. This leads to perforation and sepsis, which causes fever.

Acute mesenteric ischemia

abdominal pain out of proportion to physical findings. May see red “currant jelly” stools.

Adhesion

most common cause of small bowel Obstruction

Ileus

constipation and ↓ flatus; distended/tympanic abdomen with ↓ bowel sounds

Meconium ileus

There is normally a delay in your baby passing meconium (black sticky stool normally passed within 24 hours of delivery) and your baby may also be reluctant to feed and may vomit a green fluid called bile which would normally pass through the bowel.

 

Your baby may be uncomfortable because of constipation and trapped air in the bowel and the abdomen (tummy) will become distended. Some babies present at delivery with a distended abdomen and may be unwell due to infection around the bowel.

Necrotizing enterocolitis

feeding intolerance, increased gastric residuals, abdominal distension and bloody stools. Symptoms may progress rapidly to abdominal discoloration with intestinal perforation and peritonitis and systemic hypotension requiring intensive medical support.

Small bowel infarction : transmural and mucosal

include abdominal pain, bloody diarrhea, and decreased bowel sounds.

Lactose intolerance

abdominal distension and diarrhea upon consumption of milk products; undigested lactose is osmotically active with ↓ stool pH

Celiac disease

1.            Children classically present with abdominal distension, diarrhea, and failure to thrive.

2.            Adults classically present with chronic diarrhea ( steatorrhea ) and bloating.

3.            Small, herpes-like vesicles may arise on skin (dermatitis herpetiformis). Due to IgA deposition at the tips of dermal papillae; resolves with gluten-free diet

4.            ↓ bone density

Tropical sprue

Similar findings as celiac sprue

Whipple disease

Cardiac symptoms, Arthralgias, and Neurologic symptoms are common. Diarrhea/steatorrhea occur later in disease course.

Disacchridase deficiency

carbohydrate intolerance induced by bacterial fermentation of undigested sugars which are delivered to the colon. Abdominal symptoms (e.g. nausea, bloating, distension, colicky pain, watery diarrhoea) are usually noticed within an hour of the ingestion of foods containing the offending sugars.

Pancreatic insufficiency

Loss of Pancreatic enzymes leads to maldigestions and malabsorption which may lead to:

•             steatorrhea

•             weight loss

•             fatigue

•             flatulence and abdominal distention (bacterial fermentation of unabsorbed food)

•             edema (hypoalbuminemia)

•             anemia (B-12, Iron, folic acid deficiency)

•             bleeding disorders (vitamin K malabsorption)

•             Metabolic bone disease (Vitamin D deficiency)

•             neurologic manifestation

•             hypocalcemia

Abetalipoproteinemia

failure to gain weight and grow at the expected rate (failure to thrive); diarrhea; abnormal star-shaped red blood cells (acanthocytosis); and fatty, foul-smelling stools (steatorrhea).

1.            Malabsorption-due to defective chylomicron formation (requires B-48)

2.            Absent plasma VLDL and LDL (require B-100) .

 

poor muscle coordination, difficulty with balance and movement (ataxia), and progressive degeneration of the retina (the light-sensitive layer in the posterior eye) that can progress to near-blindness (due to deficiency of vitamin A, retinol).

Malrotation

Patients (often infants) present acutely with midgut volvulus, manifested by bilious vomiting, crampy abdominal pain, abdominal distention, and the passage of blood and mucus in their stools. Patients with chronic, uncorrected malrotation can have recurrent abdominal pain and vomiting.

 

Malrotation can also be asymptomatic.

Acute appendicitis

l. Periumbilical pain, fever, and nausea; pain eventually localizes to right lower quadrant (McBurney point).

2.Rupture results in peritonitis that presents with guarding and rebound Tenderness ; may elicit psoas, obturator, and Rovsing signs, on exam.

3.Periappendiceal abscess is a common complication.

 

Obturator sign: The person being evaluated lies on her or his back with the hip and knee both flexed at ninety degrees. The examiner holds the person’s ankle with one hand and knee with the other hand. The examiner rotates the hip by moving the person’s ankle away from his or her body while allowing the knee to move only inward. A positive test is pain with internal rotation of the hip.

 

Psoas sign, also known as “Obraztsova’s sign”, is right lower-quadrant pain that is produced with either the passive extension of the right hip or by the active flexion of the person’s right hip while supine. The pain that is elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and causes pain.

 

Rovsing’s sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon). The thought is there will be increased pressure around the appendix by pushing bowel contents and air toward the ileocaecal valve provoking right-sided abdominal pain.

ulcerative colitis

Left lower quadrant pain (rectum) with Bloody diarrhea , Rash (pyoderma gangrenosum, erythema nodosum), eye inflammation (episcleritis, uveitis), oral ulcerations (aphthous stomatitis), arthritis (peripheral, spondylitis). , 1° sclerosing cholangitis. Complications : Fulminant colitis, toxic megacolon, perforation.

Crohn’s Disease

Right lower quadrant pain (ileum) with Diarrhea that may or may not be bloody , Rash (pyoderma gangrenosum, erythema nodosum), eye inflammation (episcleritis, uveitis), oral ulcerations (aphthous stomatitis), arthritis (peripheral, spondylitis).

Kidney stones (usually calcium oxalate), gallstones.

 

Complications : Malabsorption/malnutrition, colorectal cancer (↑ risk with pancolitis). Fistulas (eg, enterovesical fistulae, which can cause recurrent UTI and pneumaturia), phlegmon/abscess, strictures (causing obstruction), perianal disease.

colonic atresia

intestinal obstruction .

hirschprung disease

bilious emesis, abdominal distention , and failure to pass meconium within 48 hours → chronic constipation.

Normal portion of the colon proximal to the aganglionic segment is dilated, resulting in a “transition zone. Explosive expulsion of feces

(squirt sign) → empty rectum on digital exam.

colonic diverticula

Usually asymptomatic; complications include

1.            Rectal bleeding (hematochezia)

2.            Diverticulitis-due to obstructing fecal material; presents with appendicitis-like symptoms in the left lower quadrant

3.            Fistula-Inflamed diverticulum ruptures and attaches to a local structure.

Colovesicular fistula presents with air (or stool) in urine.

Angiodysplasia

Rupture classically presents as hematochezia in an

older adult.

 

heredetary hemorrhagic telangiectasia

Rupture presents as bleeding.

 

ischemic colitis

postprandial pain and weight loss; infarction results in pain and bloody diarrhea.

irritable bowel syndrome

Relapsing abdominal pain with bloating, flatulence, and change in bowel habits (diarrhea or constipation) that improves with defecation; classically seen in middleaged Females

colonic polyps

familial adenomatous polyposis : characterized by lOOs to 1000s of adenoma to us colonic polyps

 

gardener synd. : FAP + osseous and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium, impacted/supernumerary teeth.

 

Juvenile polyposis synd. Hamartomatous (benign) polyps throughout GI tract and mucocutaneous hyperpigmentation (freckle-like spots) on lips, oral mucosa , and genital skin;. Associated with ↑ risk of CRC.

Peutz jegher synd. : numerous hamartomas throughout GI tract, along with hyperpigmented mouth, lips, hands, genitalia. Associated with ↑ risk of breast and GI cancers (eg, colorectal, stomach, small bowel, pancreatic).

 

Turcot syndrome : FAP/Lynch syndrome + malignant CNS tumor (eg, medulloblastoma, glioma).

Colorectal carcinoma

Rectosigmoid > ascending > descending. Ascending—exophytic mass, iron deficiency anemia, weight loss. Descending—infiltrating mass, partial obstruction, colicky pain, hematochezia.

 

Rarely, presents with S bovis (gallolyticus) bacteremia.

External hemorrhoides

If not thrombosed, external hemorrhoids may cause few problems. However, when thrombosed, hemorrhoids may be very painful. Nevertheless,. A skin tag may remain after healing. If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus.

Internal hemorrhoids

painless, bright red rectal bleeding during or following a bowel movement. The blood typically covers the stool (a condition known as hematochezia), is on the toilet paper, or drips into the toilet bowl. The stool itself is usually normally coloured . Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence .

Anal fissure

Pain while Pooping; blood on toilet Paper

Hernias

Diaphragmatic : Abdominal structures enter the thorax .

 

Sliding hiatal hernia : the stomach herniates upward through the esophageal hiatus of the diaphragm.

 

Paraesophageal hernia : Gastroesophageal junction is displaced upward; “hourglass stomach.”

 

Hiatal hernia : gastroesophageal junction is usually normal. Fundus protrudes into the thorax.

 

Inguinal Hernia:

                Indirect : Goes through the internal (deep) inguinal ring, external (superficial) inguinal ring, and into the scrotum. Enters internal inguinal ring lateral to inferior epigastric vessels

                Direct : Protrudes through the inguinal (Hesselbach) triangle. Bulges directly through parietal peritoneum medial to the inferior epigastric vessels but lateral to the rectus abdominis.

Goes through the external (superficial) inguinal ring only. Covered by external spermatic fascia .

 

Femoral hernia : Protrudes below inguinal ligament through femoral canal below and lateral to pubic Tubercle .

  

Annular pancreas

Newborns may not tolerate feedings. They may spit up more than normal, not drink enough breast milk or formula, and cry.

 

Adult symptoms may include:

•             Fullness after eating

•             Nausea or vomiting

Pancrease divisum

chronic abdominal pain and/or pancreatitis.

Acute pancreatitis

Clinical features

1.            Epigastric abdominal pain that radiates to the back

2.            Nausea and vomiting

3.            Periumbilical and flank hemorrhage (necrosis spreads into the periumbilical soft tissue and retroperitoneum)

4.            Elevated serum lipase and amylase; lipase is more specific for pancreatic damage.

5.            Hypocalcemia (calcium is consumed during saponification in fat necrosis)

 

Complications

1.            Shock-due to peri pancreatic hemorrhage and fluid sequestration

2.            Pancreatic pseudocyst-formed by fibrous tissue surrounding liquefactive necrosis and pancreatic enzymes

i. Presents as an abdominal mass with persistently elevated serum amylase

ii. Rupture is associated with release of enzymes into the abdominal cavity and hemorrhage.

3.            Pancreatic abscess-often due to E coli; presents with abdominal pain, high fever, and persistently elevated amylase

4.DIC and ARDS

Chronic pancreatitis

1.Epigastric abdominal pain that radiates to the back

2.Pancreatic insufficiency-results in malabsorption with steatorrhea and fatsoluble vitamin deficiencies. Amylase and lipase are not useful serologic markers of chronic pancreatitis.

3.Dystrophic calcification of pancreatic parenchyma on imaging; contrast studies reveal a ‘chain of lakes’ pattern due to dilatation of pancreatic ducts.

4.diabetes mellitus .

Pancreatic carcinoma

1. Epigastric abdominal pain radiating to back and weight loss (due to malabsorption and anorexia)

2.Obstructive jaundice with pale stools and palpable nontender gallbladder (Courvoisier sign); associated with tumors that arise in the head of the pancreas (most common location)

3.Secondary diabetes mellitus; associated with tumors that arise in the body or tail

4.Pancreatitis

5.Migratory thrombophlebitis (Trousseau sign); presents as swelling, erythema, and tenderness in the extremities (seen in 10% of patients) (Trousseau syndrome)

6.Serum tumor marker is CA 19-9.

Biliary atresia

Presents with jaundice and progresses to cirrhosis .

biliary tract disease

Typically with cholestatic pattern of LFTs ( ↑ conjugated bilirubin, ↑ cholesterol, ↑ ALP).

 

Types :

Primary biliary cirrhosis : Classically in middle-aged men with IBD. Associated with ulcerative colitis .

Secondary biliary cirrhosis : Patients with known obstructive lesions (gallstones, biliary strictures , pancreatic carcinoma).

Primary sclerosing cholangitis : Classically in middle-aged women. Associated with other autoimmune conditions(eg, Sjögren syndrome, Hashimoto thyroiditis, CREST, rheumatoid arthritis , celiac disease).

Cholelithiasis

usually asymptomatic; complications include biliary colic, acute and chronic cholecystitis, ascending cholangitis, gallstone ileus, and gallbladder cancer.

 

Types :

Cholesterol stones : Associated with obesity, Crohn disease, advanced age, estrogen therapy, multiparity, rapid weight loss, Native American origin.

Pigment stones : Associated with Crohn disease, chronic hemolysis, alcoholic cirrhosis, advanced age, biliary infections, total parenteral nutrition (TPN).

Biliary colic

Associated with nausea/vomiting and dull RUQ pain

Acute cholecystitis

right upper quadrant pain, often radiating to right scapula, fever with ↑ WBC count, nausea , vomiting, and i serum alkaline phosphatase (from duct damage) . Risk of rupture if left untreated .

Chronic cholecystitis

vague right upper quadrant pain, especially after eating .

Ascending cholangitis

Charcot triad of cholangitis:

                Jaundice

                Fever ( and chills )

                RUQ pain

 

Reynolds pentad adds:

                Altered mental status

                Shock (hypotension)

Gall stone ileus

Can cause fistula between gallbladder and GI tract → air in biliary tree (pneumobilia) → passage of gallstones into intestinal tract → obstruction of ileocecal valve (gallstone ileus).

findings are known as Rigler’s triad: pneumobilia (air within the biliary tree) , evidence of small bowel obstruction , radiopaque gallstone on abdominal radiograph .

Gall bladder carcinoma

Steady pain in the upper right abdomen , Indigestion Dyspepsia (gas) , Bile (dark green color) in vomit. Weakness , Loss of appetite , Weight loss ,

Jaundice and vomiting due to obstruction .

Early symptoms mimic gallbladder inflammation due to gallstones. Later, the symptoms may be that of biliary and stomach obstruction.

Porcelain gallbladder

Calcified gallbladder due to chronic cholecystitis; usually found incidentally on imaging . high risk of carcinoma .

Jaundice

Yellow discoloration ofthe skin , earliest sign is scleral icterus (yellow discoloration of the sclera) :

 

Paravascular hemolysis / ineffective erythropoiesis : Dark urine due tot urine urobilinogen (UCB is not water soluble and, thus, is absent from urine) Increased risk for pigmented bilirubin gallstones .

Physiologic jaundice of the newborn : UCB is fat soluble and can deposit in the basal ganglia (kernicterus) leading to neurological deficits and death .

Gilbert syndrome : jaundice during stress (e.g., severe infection , fasting ); otherwise, not clinically significant .

Criggler najjar syndrome : Kernicterus; usually fatal .

Dubin Johnson syndrome : Liver is dark; otherwise, not clinically significant . Rotor syndrome is similar to Dubin-johnson syndrome, but lacks liver discoloration .

Biliary tract obstruction : Dark urine (due to bilirubinuria) and pale stool Pruritus due to ↑ plasma bile acids , Hypercholesterolemia with xanthomas , Steatorrhea with malabsorption of fat-soluble Vitamins .

Viral hepatitis : Dark urine due tot urine bilirubin; urine urobilinogen is normal or decreased.

Spontaneous bacterial peritonitis

Often asymptomatic, but can cause fevers, chills, abdominal pain, ileus, or worsening encephalopathy.

Viral hepatitis

Acute hepatitis : episodes of fever , fatigue , nausea , appetite loss , abdominal discomfort , jaundice , dark urine , ↑AST , ALT .

 

Chronic hepatitis is characterized by symptoms that last > 6 months, Inflammation predominantly involves portal tract , Risk of progression to cirrhosis

 

Hepatitis A and E : Acute hepatitis; no chronic state. HEV infection in pregnant women is associated with fulminant hepatitis (liver failure with massive liver necrosis).

 

Hepatitis B : Results in acute hepatitis; chronic disease occurs in 20% of cases

 

Hepatitis C : Results in acute hepatitis; chronic disease occurs in most cases .

 

Hepatitis D : Dependent on HBV for infection; superinfection upon existing HBV is more severe than coinfection (infection with HBV and HDV at the same time) .

Portal hypertension

i.              Ascites (fluid in the peritoneal cavity)

ii.             Congestive splenomegaly/hypersplenism

iii.            Portosystemic shunts (esophageal varices, hemorrhoids, and caput medusae)

iv.           Hepatorenal syndrome (rapidly developing renal failure secondary to cirrhosis) .

Liver cell failure

Testicular atrophy , Gynecomastia , Amenorrhea Cardiomyopathy , Peripheral edema , Hyperbilirubinemia , Hyponatremia , Hepatorenal syndrome , Thrombocytopenia , Anemia , Coagulation disorders , Anorexia , Nausea, vomiting , Dull abdominal pain , Fetor hepaticus , Hepatic encephalopathy , Asterixis (”flapping tremor”) , and eventual coma (due to ↑ serum ammonia) , Jaundice , Spider angiomas , Palmar erythema due to hyperestrinism, Purpura , Petechiae .

Alcohol related diseases

A / alcoholic Fatty liver : a heavy, greasy liver; resolves with abstinence.

B / alcoholic Hepatitis : painful hepatomegaly and elevated liver enzymes (AST > ALT); may result in death .

C / alcoholic Cirrhosis : chronic alcohol-induced liver damage; occurs in 10-20% of alcoholic.

Non alcoholic fatty liver disease

Fatty change, hepatitis, and/or cirrhosis that develop without exposure to alcohol (or other known insult) , Associated with obesity . Metabolic syndrome (insulin resistance); obesity → fatty infiltration of hepatocytes.

Hemochromatosis

Presents after age 40 when total body iron > 20 g; iron loss through menstruation slows progression in women. Classic triad of cirrhosis, diabetes mellitus, skin pigmentation (“bronze diabetes ”). Also causes restrictive cardiomyopathy (classic) or dilated cardiomyopathy (reversible), hypogonadism, arthropathy (calcium pyrophosphate deposition; especially metacarpophalangeal joints). HCC is common cause of death.

Hepatic encephalopathy

ranging from disorientation /asterixis (mild) to difficult arousal or coma (severe).

Triggers:

↑ NH3 production and absorption (due to dietary protein, GI bleed, constipation, infection).

↓ NH3 removal (due to renal failure, diuretics, bypassed hepatic blood flow post-TIPS).

Wilson disease

Presents before age 40 with liver disease (eg, hepatitis, acute liver failure, cirrhosis), neurologic disease (eg, dysarthria, dystonia, tremor, parkinsonism), psychiatric disease, Kayser-Fleischer rings (deposits in Descemet membrane of cornea) , hemolytic anemia, renal disease (eg, Fanconi syndrome).

Reye syndrome

fatal childhood hepatic encephalopathy. Findings: mitochondrial abnormalities, fatty liver (microvesicular fatty change), hypoglycemia, vomiting, hepatomegaly, coma. Associated with viral infection (especially VZV and influenza B) that has been treated with aspirin .

Cavernous hemangioma

Usually liver cavernoma patients are asymptomatic.

Major

                Pain in the upper right abdomen

Minor

                Feeling full after eating only a small amount of food

                Lack of appetite

                Nausea

                Vomiting

Hepatic adenoma

pain in the right upper quadrant or epigastric region of the abdomen , patients may notice a palpable mass , If not treated, there is a 30% risk of bleeding. Bleeding may lead to hypotension, tachycardia , and sweating (diaphoresis).

Angiosarcoma

vague complaints of abdominal pain, weakness, fatigue, and weight loss.Only 10% of individuals have edema initially.

Hepatocellular carcinoma

Most cases of hepatocellular carcinoma occur in people who already have symptoms of chronic liver disease and present either with worsening of symptoms or during surveillance that is used to screen patients who are at risk the most. In other cases, HCC may directly present with yellow skin, bloating from fluid in the abdomen, easy bruising from blood clotting abnormalities , loss of appetite, unintentional weight loss, abdominal pain especially in the right upper quadrant , nausea , vomiting , or feeling tired.

Metastasis to liver

GI malignancies, breast and lung cancer , may be detected as hepatomegaly with a nodular free edge of the liver .

Budd Chiari syndrome

congestive liver disease (hepatomegaly, ascites, varices, abdominal pain, liver failure). Absence of JVD. Associated with hypercoagulable states, polycythemia vera, postpartum state, HCC.

Last minute revision of Gastro Intestinal Medicine
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