GI
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  • Liver: elevated liver panel (LFTs)
    • Cirrhosis: portal hypertension (varices, splenomegaly), skin (jaundice, spider angiomata, palmar erythema), ascites, coagulopathy, hx of EtOH, hepatitis, LFTs↑, dx w US and biopsy.
    • Cirrhosis causes: any chronic liver disease
    • Cirrhosis complications
      • Hepatocellular carcinoma: decompensated cirrhosis (ascites, encephalopathy, jaundice, variceal bleed), hx of hepatitis, AFP↑, dx w CT showing vascular/enhancing mass.
      • Ascites: fluid-filled abdomen w flank dullness, cirrhosis symptoms (spider angioma, varices), hx of cirrhosis (EtOH, hepatitis), dx w ultrasound.
      • SBP: fever, ab pain, altered mental status, ascites, dx w paracentesis (culture + PMN count), tx w cefotaxime.
      • HRS: Cirrhosis with ascites presents with renal failure, tx with albumin.
      • Hepatic encephalopathy: dysfunctional liver can't detox NH3 from portal vein, reaches brain, dx by altered mental status w liver symptoms (jaundice, spider angio, ascites, asterixis, LFTs), tx w lactulose.
      • Variceal hemorrhage: bleeding symptoms (pain, anemia, tarry vomit/stool), dx w endoscopy, tx w band ligation, sclerotherapy, octreotide, ceftriaxone.
    • Congestive hepatopathy: Liver dysfunction (LFTs↑) due to vascular congestion: portal vein, hepatic vein (Budd-Chiari), CHF (rt hrt failure).
      • Portal vein thrombosis: varices (esophageal, gastric, bleeding), splenomegaly, mild LFT abnormalities, dx w venous phase angiography showing occlusion.
      • Budd-Chiari syndrome: outflow obstruction causes liver dysfunction, ascites, acute = tender, swollen liver, chronic = cirrhotic liver w caudate hypertrophy, dx w dopper US or CT showing hepatic vein obstruction.
      • CHF: exertional dyspnea, JVD, peripheral edema, elevated BNP, can be chronic or acute decompensated.
    • Itch
      • PSC: fatigue, itching, fever, AP↑ more than ALT & AST, dx w cholangiography showing bile duct strictures (beads on string), most also have UC.
      • PBC: woman with fatigue, itch, darker skin, hepatomegaly, severe AP↑, anti-mitochondrial Ab, biopsy shows lymphocytes destroying small bile ducts.
      • Autoimmune hepatitis: fatigue, itch, arthralgia, hepatosplenomegaly, AST & ALT elevated more so than AP, IgG↑, anti-smooth muscle Ab, biopsy shows plasma cells & fibrosis.
    • Metabolic disorders: metals, inclusions
      • Hemochromatosis: fatigue, arthralgia, bronze skin, diabetes, LFTs↑, Fe↑ (ferritin, transferrin sat).
      • Wilson's disease: tremor, ataxia, Cu ring around cornea, ceruloplasmin↓, Cu↑ in urine & liver, tx w penicillamine.
      • AAT deficiency: emphysema in young, non-smoker, LFTs↑, AAT↓.
    • Acute liver failure: no PHx
      • Acetaminophen poisoning: nausea/vomiting followed by encephalopathy, coagulopathy, AST↑,ALT↑, NH3↑, dx w blood acetaminophen lvl, tx w N-acetyl cysteine.
      • Hepatitis A: fever, malaise, nausea, vomit, diarrhea, jaundice, hepatomegaly, dx w anti-HAV IgM.
      • Hepatitis B: varied presentation from asymptomatic to fever, nausea, vomit, jaundice, icterus, AST↑, ALT↑, dx w serology (HB antigens & antibodies).
      • Hepatitis E: mostly asymptomatic or mild disease that becomes severe only in pregnancy, fecal oral transmission.
    • Hepatitis
      • Hepatitis A: fever, malaise, nausea, vomit, diarrhea, jaundice, hepatomegaly, dx w anti-HAV IgM.
      • Hepatitis B: varied presentation from asymptomatic to fever, nausea, vomit, jaundice, icterus, AST↑, ALT↑, dx w serology (HB antigens & antibodies).
      • Hepatitis C: mostly asymptomatic, hx of IV drugs, dx w HCV Ab (exposure), RNA (viral load), watch out for cirrhosis, HCC.
      • Hepatitis D: chronic hepatitis B patient who is symptomatic but has low HBV DNA, Hep D (delta virus) piggy backs on Hep B.
      • Hepatitis E: mostly asymptomatic or mild disease that becomes severe only in pregnancy, fecal oral transmission.
    • DILI: Liver damage due to acetaminophen, NSAIDs, antibiotics (INH).
    • Hepatic steatosis: CT shows liver darker than spleen, biopsy shows fat droplets, perisinusoidal fibrosis, mild AST & ALT elevation, can be alcoholic (AST/ALT > 2, mallory bodies) or non-alcoholic (ALT > AST).
    • Steatohepatitis: steatosis + inflammation = steatohepatitis, AST & ALT elevated, WBC↑, dx w biopsy (fat, fibrosis, inflammation, necrosis), can be alcoholic (AST > ALT) or non-alcoholic (ALT > AST).
  • Stones
    • Cholelithiasis (Gallstone): short, episodic RUQ pain esp after fatty meal, normal LFTs, dx w US.
      • Biliary colic: cystic duct obstr (spares liver so nl LFTs) w/o inflammation: short episodic RUQ pain, dx w US.
      • Cholecystitis: Cystic duct obstr (spares liver so nl LFTs) w inflammation: fever, prolonged RUQ pain after fatty meal, nausea, vomiting, Murphy's sign, WBC↑, dx w ultrasound, HIDA scan.
    • Choledocholithiasis: common bile duct stone: affects gallbladder, liver (LFTs↑), and pancreas (if low enough, lipase↑), presents w prolonged RUQ pain, jaundice, dx w US, ERCP.
      • Cholangitis: common bile duct stone w inflammation: affects gallbladder and liver (LFTs↑), presents w fever, prolonged RUQ pain, jaundice, dx w US, ERCP.
      • Pancreatitis: fever, prolonged upper abdominal pain, caused either by EtOH or stones, dx w lipase↑, CT.
  • Diarrhea
    • Shortly after eating: Staph, B cereus = preformed toxin, 6 hr onset
    • Malabsorption/osmotic: stops w fasting, osmal gap, fatty, smelly, sudan stain
      • Biliary/gall bladder problems
      • Lactose intolerance: diarrhea, gas, ab cramps after eating dairy.
      • SIBO: ab pain, chronic malabsorption diarrhea, gas, dx w H2 breath test.
      • Celiac disease: pale, foul-smelling diarrhea, gas, malabsorption (wt loss, vit def), dx w serology (anti-gliadin) and biopsy (villus blunting).
      • Whipple's disease: joint pain, diarrhea, dx w SI biopsy showing PAS+ macrophages in lamina propria, tx w ceftriaxone.
      • Cryptosporidiosis: crampy, watery diarrhea dx w oocyst in stool (microscopy, acid fast).
      • Giardiasis: watery diarrhea (smelly, fatty, malabsorption), gas, hx of travel, dx w stool microscopy, tx w metronidazole.
    • Secretory: occurs even when fasting, at night
      • Cholera: severe diarrhea, rice water stools, vomiting, dehydration, dx w stool microscopy, tx w rehydration, doxycycline.
      • VIPoma: severe diarrhea (secretory), dehydration, dx w elev VIP lvl, CT shows tumor in pancreas, tx w octreotide.
      • Microscopic colitis: middle-aged ladies with watery diarrhea, normal endoscopy, biopsy shows lymphocytic infiltration and/or collagen, tx w budesonide.
    • Inflammatory: WBCs, bloody, fever
      • Bacteria: Enteroinvasive E coli, Shigella, Salmonella, C difficile
      • Clostridium difficile: fever, water diarrhea, hx of antibiotics, WBC↑, dx by stool sample (AB toxin assay, PCR).
      • Amebiasis: bloody diarrhea, hx of travel, dx w stool microscopy, serology, Ag testing, tx w metronidazole.
      • IBD: diarrhea, uveitis, erythema nodosum, CRP/sed rate↑, can be either ulcerative colitis (continuous ulcers from rectum upward, limited to colon) or Crohn's disease (cobblestoning anywhere in GI tract, transmural w fistulas).
        • Ulcerative colitis: fever, bloody diarrhea, ab cramps, dx w endoscopy (continuous from rectum), biopsy (mucosal only), tx w 5-ASA, sulfasalazine, steroids.
        • Crohn's disease: fever, diarrhea, wt loss, dx w endoscopy (cobblestone), biopsy (transmural), tx w 5-ASA, infliximab, steroids.
    • IBS: sensitive bowels, stress/infection triggers ab discomfort, diarrhea, constipation, improves w defecation.
    • Carcinoid syndrome: episodic flushing, diarrhea, dx w 24hr HIAA, CT to localize tumor, tx w octreotide, resection.
    • Menetrier's disease: epigastric pain, nausea/vomiting, diarrhea, albumin↓, dx w endoscopy (giant rugal folds), biopsy (mucous cell hyperplasia).
  • Esophagus: dysphagia, substernal chest pain
    • GERD: heartburn after meals and at night, relieved by antacid, dx w endoscopy, tx w PPI.
    • Barrett's esophagus: long standing GERD, dysphagia, dx w endoscopy (metaplasia, redder, columnar).
    • Esophageal cancer: dysphagia, hx of smoking, GERD, dx w endoscopy, biopsy.
    • Achalasia: dysphagia, regurgitation, dx w barium swallow (beak bottle neck), manometry (no peristalsis, LES no relax).
    • Esophageal spasm: Substernal chest pain worsened by swallowing, dysphagia, dx w manometry, tx w Ca ch blk.
    • Eosinophilic esophagitis: dysphagia, food impaction, hx of allergies, asthma, biopsy shows eosinophilia, endoscopy shows ringed esophagus.
    • Mallory-Weiss syndrome: bloody vomit, epigastric pain, hx of retching, vomiting, dx w endoscopy showing surface tear in esophagus (submucosal).
    • Boerhaave syndrome: bloody vomit, severe chest pain, shock, caused by esophageal wall rupture dx w CXR, CT.
    • Variceal hemorrhage: bleeding symptoms (pain, anemia, tarry vomit/stool), dx w endoscopy, tx w band ligation, sclerotherapy, octreotide, ceftriaxone.
  • Stomach: pain, alleviate w antacid, assoc w food
    • PUD: epigastric pain, indigestion, gets better w antacids, dx w endoscopy, tx w PPI.
    • ZES: GERD, PUD, steatorrhea, dx w fasting serum gastrin↑, secretin stimulation causes gastrin↑, tx w PPI, resection, ablation.
    • Stomach cancer: stomach discomfort, esp after meals, anorexia, wt loss, hx of PUD, dx w endoscopy, biopsy.
    • Gastritis: stomach pain, belching, early satiety, wt loss, dx w endoscopy w biopsy.
    • Gastroparesis: chronic nausea, vomiting, early satiety, succussion splash.
    • Menetrier's disease: epigastric pain, nausea/vomiting, diarrhea, albumin↓, dx w endoscopy (giant rugal folds), biopsy (mucous cell hyperplasia).
  • Small intestine: pain, malabsorption
    • SIBO: ab pain, chronic malabsorption diarrhea, gas, dx w H2 breath test.
    • Celiac disease: pale, foul-smelling diarrhea, gas, malabsorption (wt loss, vit def), dx w serology (anti-gliadin) and biopsy (villus blunting).
    • Crohn's disease: fever, diarrhea, wt loss, dx w endoscopy (cobblestone), biopsy (transmural), tx w 5-ASA, infliximab, steroids.
    • Ischemia: pain out of proportion to Px, volvulus, intussusception
  • Colon: lower ab pain
    • Ulcerative colitis: fever, bloody diarrhea, ab cramps, dx w endoscopy (continuous from rectum), biopsy (mucosal only), tx w 5-ASA, sulfasalazine, steroids.
    • Colorectal cancer: ab pain, tarry stool, wt loss, dx w colonoscopy.
    • Appendicitis: fever, umbilical pain that migrates to RLQ, anorexia, n/v, dx w CT.
    • Diverticulitis: elderly w fever, LLQ pain, leukocytosis, dx w CT, tx w surgery, antibiotics.
    • Hirschsprung's disease: delayed meconium passage (>48hr), childhood constipation, dx w rectal biopsy, contrast enema (aganglionic, constitutively contracted bowel segment), tx w resection.
  • Nutrition
    • Vitamin A deficiency (retinol): night blindness, dry eyes.
    • Biotin deficiency: dermatitis, alopecia, AMS, Hx of raw egg white ingestion.
    • Vitamin B1 deficiency (thiamin): Beriberi: dry (wasting, periph neuropathy), wet (CHF, cardiomegaly, periph edema, neuropathy), Wernicke-Korsakoff (nystagmus, ophthalmoplegia, ataxia, confusion).
    • Vitamin B2 deficiency (riboflavin): cheilosis, corneal vascularization, sore throat.
    • Vitamin B3 deficiency (niacin): pellagra: dermatitis (rash on sun-exosed skin), diarrhea, dementia.
    • Vitamin B5 deficiency (pantothenate): diarrhea, burning sensation in feet, hypoglycemia, adrenal insufficiency.
    • Vitamin B6 deficiency (pyridoxine): seizures, cheilosis, neuropathy, Hx of isoniazid.
    • Vitamin B12 deficiency (cobalamine): macrocytic anemia + neuro, Hx of being vegetarian, malabsorptive dz (Crohn, bypass), dx w homocysteine↑ methylmalonic acid↑, B12↓.
    • Folate deficiency: macrocytic anemia, Hx of EtOH, diet lacking vegees, dx w serum homocysteine↑, folate↓.
    • Vitamin C deficiency (ascorbic acid): bleeding gums, petechiae, poor wound healing.
    • Vitamin D deficiency: rickets in kids (bones bend), osteomalacia in adults (bones pain, back pain, fractures), 25 Vit D↓, Ca↓, PO4↓.
    • Vitamin E deficiency: hemolytic anemia, neuro (ataxia, sensory loss, Babinski), myopathy (weakness).
    • Vitamin K deficiency: easy bruising, bleeding, PT↑, PTT↑ bcz factors 2 (both), 7 (PT), 9 (PTT), 10 (both) affected.
    • Zinc deficiency: freq infections, bullous pustular dermatitis, diarrhea, alopecia.
    • Kwashiorkor: small child w swollen belly, due to inadequate protein intake.
    • Marasmus: skin on bone, skin folds (loss of fat), bcz inadequate carb intake.
  • Other
    • Peutz-Jeghers syndrome: hyperpigmented spots (mouth, hands, feet), GI hamartoma polyps, AD FHx.
    • Hemorrhoids: painless rectal bleeding (internal hemorrhoid), painful itchy (external hemorrhoid).
    • Pancreatitis: fever, prolonged upper abdominal pain, caused either by EtOH or stones, dx w lipase↑, CT.
    • Pancreatic cancer: upper ab pain, diarrhea, wt loss, jaundice new onset of diabetes, depression, dx w CT, biopsy.