#azt contraindications

[drpedi07]

AZT Drug

Medical information for AZT on Pediatric Oncall including Mechanism, Indication, Contraindications, Dosing, Adverse Effect, Interaction, Renal Dose, Hepatic Dose.

[garden-of-everything]

ABIM: Hematology

ABIM syllabus can be found here Let me know if you find any errors Sources: UWorld, MKSAP 16/17, Rizk Review Course, Louisville Lectures, Knowmedge (free version)

Hypoproliferative anemia

Aplastic anemia: - associated with autoimmune diseases, thymomas <-- need CT chest, Tx with resection - Tx all patients with PPx anticoagulation + iron + folic acid; if <40yo: stem cell transplant - associated with PNH: pancytopenia/hemolytic anemia with need for transfusions + Budd-Chiari/venous thrombosis/CVA/MI + morning hematuria/iron deficiency, associated with AML; Dx: flow cytometry shows lack of CD55, CD59; Tx: iron + Eculizumab to decrease need for transfusions (AE of Eculizumab is increased risk of meningococcal infections) +/- (if thrombus) warfarin; if <40yo: allogenic BMT Iron deficiency anemia: - decreased iron, ferritin, transferrin; increased TIBC, RDW - associated with gastric surgery, restless leg syndrome - colon cancer until proven otherwise - also seen in: (1) Celiac disease:  IBS Sx with iron deficiency that is unresponsive to oral supplementation; Dx: tissue transglutaminase Ab --> if neg: small bowel biopsy (2) Plummer-Vinson: esophageal webs, glossitis; associated with squamous cell esophageal carcinoma (3) Osler-Weber-Rendu/Hereditary Hemorrhagic Telangiectasia: lip/oral telangiectasias + epistaxis + +FOBT associated with hemoptysis/brain bleed - Tx iron deficiency: PO supplementation x6mo or IV iron gluconate (dextran is associated with anaphylaxis) Sideroblastic anemia: - ringed sideroblasts/basophilic stippling on PBS seen in EtOH, lead toxicity (Burton line on teeth, deposition in metaphysis, RTA type II (hypokalemia, glucosuria)), copper deficiency, and use of INH (from B6 deficiency), chloramphenicol, Linezolid - Tx hereditary sideroblastic anemia with pyridoxine/B6 Megaloblastic anemia:  MCV>100, hypersegmented PMNs, associated with EtOH use (1) B12 deficiency: peripheral paresthesias; associated with strict vegetarians and Crohn’s disease (terminal ileum disease), elevated methylmalonic acid > homocysteine (2) Pernicious anemia: anti-IF antibodies causing B12 deficiency; associated with autoimmune diseases and increased risk of gastric cancer (3) folate deficiency: no paresthesias; associated with pregnancy, EtOH, and Bactrim use; elevated homocysteine only Pure red cell aplasia:  associated with AIDS + Parvovirus B19; Dx: flow cytometry shows monoclonal CD57+ T-cells; Tx: IVIg and check for thymoma with CT chest

Hemolytic anemia

- PBS shows schistocytes (vs. dacryocytes/tear drop cells with 2 line involvement in Myelodysplastic syndrome) - appropriate reticulocyte response = >100,000/uL - Tx chronic hemolytic anemia with folate - Scleroderma renal crisis (HTN, AKI, MAHA):  Tx with ACEi (Captopril) even iff pregnant - MAHA in the setting of mechanical heart valve needs emergent TEE to check for leak/regurg Glucose-6-phosphate dehydrogenase deficiency: - remember food: fava beans, bite cells, Heinz bodies (red spots in RBCs; looks kind of like a pink boob with 1 or more red nipples) - associated with sulfa drugs, infection, and DKA --> hemolysis - has decreased glutathione levels Pyruvate kinase deficiency: Tx with PRN transfusions --> severe?: splenectomy Autoimmune hemolytic anemia:  Coomb’s/DAT positive (1) warm immunoglobulins: - IgG, DAT+ with spherocytosis - associated with autoimmune (SLE, UC), HIV, CLL - Tx steroids --> splenectomy --> refractory Tx: IVIg, AZT, cyclophosphamide, Rituximab (2) cold: - IgM (Mmm cold ice cream), occurs in cold temperatures - associated with malignancies, mono, mycoplasma - Tx: avoid the cold, Rituxan Microangiopathic hemolytic anemia:  Tx: plasma exchange +/- corticosteroids - Sx:  “FAT RN” (fever, anemia, thrombocytopenia, renal failure, neuro sx) - Dx: normal coags, D-dimer, fibrinogen (vs. DIC = elevated coags and D-dimer; decreased fibrinogen, platelets) *FYI:  ITP, TTP/HUS, and HELLP all have normal coags (1)  TTP:  primarily neurologic symptoms - increased vWF multimers/decreased ADAMSTS13 (NOT needed for diagnosis) - associated with tacrolimus, cyclosporine, plavix/ticlodipine, quinine - Tx: plasmapheresis *if >20 weeks pregnant, this is TTP and does NOT resolve with delivery (2)  HUS:  primarily renal symptoms - associated with E.coli/Shigella diarrhea and cyclosporine - Tx: discontinue cyclosporine!, supportive, plasmapheresis Hereditary spherocytosis: - jaundice from unconj/indirect hyperbilirubinemia, pigmented gallstones, splenomegaly, leg ulcers - PBS shows spherocytes and Howell-Jolly bodies (blue dot in RBC seen in splenectomy); DAT negative (vs. DAT+ in warm hemolytic anemia; see above) - Dx: osmotic fragility test --> flow cytometry - Tx: splenectomy Wilson’s: young patient with hemolytic anemia + psychosis + transaminitis

Hemoglobinopathies and thalassemias

- present as microcytic anemias: MCV <80; target cells Alpha thalassemia: has normal Hb electrophoresis --, -x = HbH: hemolysis, splenomegaly, Heinz body - --,-- = Barts / Hydrops fetalis (dies before birth) Beta thalassemia:  abnormal Hb electrophoresis - minor: elevated HbA2 (alpha 2 gamma 2) and HbF - intermedia:  elevated HbA2 only; Tx: intermittent transfusion +/- iron chelation if Fe>1000 - Major:  elevated HbF, decreased HbA;  Tx: splenectomy and allogenic stem cell transplant Hemoglobinopathy:  severe disease requires stem cell transplant

Leukocyte disorders

(1) AML:  t(15;17) - associated with PCV, Fanconi’s, Down’s, Klinefelter’s, CML, XRT/chemo, benzenes, MDS - presents acutely as sepsis (decreased PMNs, anemia, thrombocytopenia) - pallor, gingival hypertrophy (M5), fatigue, easy spontaneous bleeding/purpura (due to thrombocytopenia), and NO hepatosplenomegaly or lymphadenopathy -  M3 (Auer rods) associated with DIC Tx: ATRA *ATRA AE: after 1-3 weeks --> fever, leukocytosis, pulmonary infiltrates/hypoxemia; Tx: dexamethasone *prevent TLS (hyperkalemic paresthesia/weakness, hypocalcemic tetany, bronchospasm, AKI) with Allopurinol BEFORE chemo --> Rasburicase (2) CML: t(9;22)/BCR-ABL, decreased LAP - asymptomatic splenomegaly with elevated WBC (symptomatic when >200) with increased Eosinophils and Basophils - Tx: Imatinib/Gleevec (TKI) (3) ALL:  TdT, anterior mediastinal mass (thymoma <-- chest CT)/bulky mediastinal lymphadenopathy with bone pain and CNS involvement - increased blasts (>30%) - Tx: combo chemo (intrathecal if CNS involvement) +/- XRT if bulky disease --> stem cell (4) CLL:  B2microglobulin; CD5, CD23 B-cells; smudge cells - asymptomatic, lymphadenopathy, hepatosplenomegaly, lymphocytosis, thrombocytopenia - Tx: watchful waiting if asymptomatic; Bendamustine+Rituxan > Fludarabine + Bactrim PPx *AE:  Richter’s syndrome: transformation into aggressive large cell lymphoma *Evan’s syndrome: AIHA + ITP (5) Hairy cell:  older patient with pancytopenia, splenomegaly, dry fibrotic bone marrow - associated with PAN - Dx: flow-cytometry: CD11c, CD103+; +TRAP - Tx: Cladribine

Platelet disorders

*Rule of thumb:  transfuse if Plt <10 or if ICH/pulm hemorrhage <40-50; 1 bag of platelets corrects by 25k *give IVIg + steroids if pregnant with Plt <50 *Plt >50 = okay for surgery Idiopathic thrombocytopenic purpura:  diagnosis of exclusion - Dx: PBS, DAT+ (don’t order anti-Plt antibodies) - Tx (if symptomatic or Plt <15): steroids --> IVIg/Rhogam --> refractory: splenectomy, Rituxan Heparin-induced thrombocytopenia (HIT): - 4T’s: thrombocytopenia (2pts: >50%, 1pt: 30-50, 0pt: <30), timing (>5days, ?>5, <4), thrombosis (+, ?, -), no other cause (yes, maybe, no); score 6-8 = high, 0-3 low - Dx: PF4, SRA - Tx: stop Heparin (warfarin is NOT contraindicated!); switch to Argatroban Essential thrombocythemia: - “Jack et Vera are Buddies” (”et” in Latin is “and”): Jak2 mutations are associated with ET, polycythemia Vera, and Budd-Chiari” - JAK2, CALR, BCR-ABL, NPL1 - Plt >600 --> livedo reticularis, erythromelagia (painful red hands/feet, Tx: ASA), headache, vision changes - Tx: ASA + (if symptomatic) Hydroxyurea +/- (if TIA/CVA/MI/GIB) pheresis Other platelet dysfunction:  increased bleeding time; bleeding from small injuries, epistaxis, menorrhagia (1) vWF: increased PTT/low-normal VIII corrected with mixing study; Dx: vWF Ag; Tx: pre-dental DDAVP or for active bleed, recombinant factor VIII (2) Bernard-Soulier: X glycoprotein Ib --> thrombocytopenia (3) Glanzmann (~Abciximab/Eptifibatide): X gpIIb-IIIa --> normal platelet counts

Coagulation factor disorders and thrombotic disorders

Rule of Thumb: PeT PiTTbull - PT extrinsic pathway (VII, X) - PTT intrinsic pathway (VIII, IX, XI, XII) *mixing studies correct = deficiency --> present as bleeding into muscle/joint; Tx with DDAVP for mild disease or missing factor for active bleed *mixing studies don’t correct = (1) if there is bleeding: presence of factor antibody: Tx with recombinant FVII (2) if there is no bleeding:  antiphospholipid Ab

Coagulation factor deficiencies: - VII:  elevated PT (it’s pretty much the only one that isn’t elevated PTT), presents as ICH, Tx: rfVII - VIII/Hem A:  elevated PTT, bleeding into muscles/joints, no excessive bleed after minor cuts; Tx: DDAVP before dental work, fVIII - acquired VIII: elevated PTT that doesn’t correct, Tx: rFVII (<--yes, Tx is rf7, NOT 8) - IX/Hem B:  elevated PTT, bleeding into muscles/joints, no excessive bleeding after minor cuts; Tx: fIX - XI/Rosenthal: elevated PTT in Ashkenazi Jews; Tx: FFP prior to major surgeries - XII:  asymptomatic and totally benign elevated PTT - XIII:  coags look normal, but has severe post-op bleed; Dx: urease clot dissolves; Tx: Qmonthly FFP - acquired X/AL amyloid:  elevated INR with postural hypotension, macroglossia, heart failure, and proteinuria/kidney failure; Dx: serum/urine electrophoresis, free light chain assay, BMB, fat pad aspirate vs.  vWF: increased bleeding time, normal/elevated PTT that corrects with mixing stud - Dx: vWF Ag, vWF activy assay, VIII, level, subtype multimer study - Sx: gingival/mucocutaneus bleed, menorrhagia, easy bruising - Tx: DDAVP prior to dental work, active bleed: rfVIII

Thrombophilia:  DVT/PE’s (1) Antiphospholipid antibody syndrome: anti-beta2glycoprotein I Ab - blood clots, miscarriage; associated with SLE - apTT doesn’t correct with mixing study --> Dx: anticardiolipin IgG/IgM ELISA (2) Factor V Leiden: most common - Dx (check months after DVT): clotting assay (resistance to Protein C) --> genetic prothrombin G20210A mutation 

Porphyria

-morning hematuria, blistering photosensitive rash, abdominal pain, nausea/vomiting, HTN, tachycardia, psychosis, seizures all exacerbated by EtOH, smoking, stress, sulfa drugs - increased risk of HCC, lymphoma - Dx: elevated urine uroporphyrinogen (urine turns purple in sunlight) --> check for Hep C and hemochromatosis - Porphyria cutanea tarda: associated with HIV, Hep C; Tx: phlebotomy to decrease iron stores

Myeloproliferative disorders

Polychythemia vera and other erythrocytosis:  JAK2V617F, associated with Budd-Chiari, facial plethora, pruritus with hot baths - BMB is hypercellular, decreased EPO levels - Tx: ASA and phlebotomy to Hct <45 +/- Hydrea - also Tx hyperuricemia with allopurinol, pruritus with antihistamines Essential thrombocythemia:  JAK2, decreased EPO levels; associated with vWF disease (more info under Platelet Disorders above); Tx: ASA + Hydroxyurea +/- pheresis if TIA/CVA/MI/GIB Agnogenic myeloid metaplasia and myelofibrosis: - splenomegaly, dacryocytes, giant megakaryocytes/platelets, BM fibrosis - portal HTN - Tx: supportive (NOT splenectomy); if <60yo, stem cell transplant

Myelodysplastic syndrome

- cytopenia of 2 cell lines + tear drop cells + nucleated RBCs, elevated MVC - r/o B12 deficiency (PBS macrocytosis) - BMB shows ringed sideroblasts, Pseudo Pelger-Huetz cell (looks like 2-lobed PMN or cell wearing blue sunglasses) - Tx: Azacitidine to keep Plt >100k, Epo, GCSF; if young: stem cell transplant - 5q-subtype Tx (best prognosis): Thalidomide (AE: rash, peripheral neuropathy), Lenalidomide (AE: less neuropathy, but more decr PMN, thrombocytopenia)

Hematologic malignancies

Acute and chronic leukemias (see Leukocyte Disorders above) Hodgkin’s disease:  B-symptoms, non-tender contiguous nodes with Reed-Sternberg (owl-eye) B-cells, associated with EBV; Dx: full excision of lymph node + pan-CT + PET + BMB if Bsx or stage III/VI; Tx: ABVD + rads if same side of diaphragm --> screen for breast cancer 8 years after XRT or at 40yo Non-Hodgkin’s lymphoma:  multiple nodes with extranodal involvement, B>T cells, associated with autoimmune dz (Sjogrens: parotid MALT), HIV (1) Indolent: (a) Follicular: painless swelling in neck, armpit, groin; Tx: watchful waiting, but if symptomatic: XRT if limited, Bendamustine-Rituxan or R-CHOP if outside XRT field (b) MALT: Tx H.pylori (2)  Aggressive: (a) Diffuse large B-cell:  B-symptoms; Dx: biopsy, Tx: CHOP --> R-CHOP --> XRT (b) AIDs-associated lymphoma:  EBV in CSF --> primary cerebral lymphoma (c) Burkitt’s lymphoma:  African jaw mass/U.S.A. abdominal mass, associated with EBV, increased LDH, starry sky (3) Cutaneous T-cell (CD4): Sezary/Mycosis Fungoides:  plaque --> nodular lesions with cerbriform nuclei (epidermis: Pautrier microabscess) Plasma cell disorder / Multiple Myeloma: - “CRAB” hypercalcemia, renal injury, anemia, lytic bone lesions - >3gM protein, >10% plasma cells in BM, normal ALP, discrepancy between urine protein and urine dipstick (due to inability to detect light chains) - Dx: BMB, XR>bone survey; serum and urine electrophoresis Q6 months - Tx: (1) <75yo: Lenalidomide/Thalidomide + Dexamethasone --> stem cell transplant --> Bortezomib (2) can’t or >75yo: Melphalan + Prednisone vs. Smoldering MM: MM without Sx vs. Plasmacytoma: solitary lytic bone lesion; Dx: tissue Bx; Tx: follow vs. MGUS: no CRAB, few clonal plasma cells, serum monoclonal protein <3g *AE of Thalidomide = DVTs

Transfusion medicine

Indications for transfusion:  Hb <7 or <10 for acute MI Complications of transfusion: (1) ABO/acute hemolytic transfusion: fever, flank pain, tachycardia, hypotension --> stop transfusion (2) Delayed: elevated bili and LDH, decreased Hb and Haptoglobin, increased retic (3) Post-transfusion purpura: within 1 week, anti-HPA-1a Ab; Tx: IVIg and watch for transfusion-induced thrombocytopenia with next transfusion (4) TRALI (ARDs picture with hypotension after transfusion; Tx: vent/supportive fluids) vs TACO (hypertension; Tx: diuretics)

Other

Sickle Cell: - may present as diffuse pulmonary infiltrates that mimic PE/PNA/appendicitis, but with >2g/dL Hb drop and elevated LDH/retic - acute chest syndrome --> Tx: exchange transfusion if Hb <10 - associated with pulmonary HTN and increased risk for CVA (BUT DO NOT NEED PLAVIX; instead CVA PPx with monthly 2 unit transfusions) - Dx: Hb electrophoresis - chronic Tx with 2 pain crisis/year or h/o ACS: hydroxyurea (but CI in pregnancy and AKI) *vs Fat embolus (long bone fx): fever, CP, thrombocytopenia, multiorgan failure; BAL shows fat bodies *vs. Aplastic crisis (Parvovirus/B19): low retic count

Plasma exchange indications: (1) Guillain Barre (symmetric ascending flaccid paralysis with reduced DTRs) (2) Myasthenia gravis (ocular-->facial -->proximal muscle weakness that doesn’t fatigue) (3) TTP (neurologic symptoms with hemolytic anemia and thrombocytopenia) (4) Goodpasture (anti-GBM nephritis (hematuria, hypertension) with hemoptysis) (5) Cryoglobulinemia (cold-induced nephritis, low complements, associated with HCV) *AE of plasma exchange = hypocalcemia from citrate: perioral numbness, tingling, anxiety/vomit; Tx: calcium gluconate

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AZT Drug Information

Medical information for AZT including Mechanism, Indication, Contraindications, Dosing, Adverse Effect, Interaction, Renal Dose, Hepatic Dose. To know more about AZT read this article https://www.pediatriconcall.com/drugs/azt/301

[garden-of-everything]

ABIM: Gastroenterology

ABIM syllabus can be found here Let me know if you find any errors Sources: UWorld, MKSAP 16/17, Rizk Review Course, Louisville Lectures, Knowmedge (free version)

Esophageal disease

Gastroesophageal reflux: - Dx/Tx:  PPI --> endoscopy --> ambulatory esophageal pH monitoring with PPI - Endoscopy first if: >50yo (white male), alarm symptoms (weight loss/dysphagia), symptoms >5 years *young patient without alarm signs: test for H.pylori (urea breath test, stool Ag, serum Ab (useless to test for eradication)) and treat empirically WITHOUT endoscopy Barrett’s esophagus:  EGD Q3-5 years; if high grade dysplasia --> esophagectomy Esophageal carcinoma:  progressive solid to liquid dysphagia Esophageal dysphagia --> endoscopy vs. Oropharyngeal dysphagia (i.e., CVA, Parkinson’s, Zenker’s, MG, ALS) --> videofluoroscopy > barium swallow *Esophageal diverticula (Zenker’s) --> videofluoroscopy Achalasia:  liquid +/- solid dysphagia; associated with Chaga’s disease - Dx: barium esophagram “bird’s beak” --> manometry --> endoscopy - Tx: LES surgery / pneumatic dilation > CCB / Nitrate / Botox Medication-induced esophageal disorder: KCl, tetracyclines, bisphosphonates, iron, NSAIDs Esophageal strictures or webs: solid food dysphagia; associated with iron deficiency anemia Gastroesophageal varices: - PPx: non-selective BB (Propranolol/Nadolol) > ligation - Tx: octreotide + ligation +/- if bleeding/SBP, protein<1: FQ > TIPS/shunt Infectious esophagitis: - Candida esophagitis: Tx empirically with Fluconazole/Itraconazole --> fail?: endoscopy - HSV esophagitis: Tx with acyclovir/famciclovir --> fail?: IV foscarnet - CMV esophagitis: Tx foscarnet / ganciclovir *Viruses rarely cause oropharyngeal ulcers Mallory-Weiss syndrome: heavy EtOH + wretching/weight lifting/bulimia; Dx: endoscopy Eosinophilic esophagitis: young adult with extreme dysphagia and food impaction - Dx: esophageal Bx - Tx: steroids

Stomach or duodenal disease

Helicobacter pylori infection: - Dx: upper endoscopy + bx of ulcer and + (1) histologic assessment of H.pylori or (2) rapid urease test - Tx: PPI and 2 abx x2 weeks (Clarithromycin + (1)Amoxicillin or (2)Metronidazole) --> if fail: different Abx (i.e., tetracycline) + bismuth Peptic ulcer disease:  gastric ulcers need bx, but duodenal ulcers don’t unless they’re refractory to treatment or suspicious looking Stomach cancer:  Sister-Mary-Joseph nodule at umbilicus; CEA is positive and nonspecific for everything in the abdomen Non-ulcer dyspepsia: usually due to NSAIDs, Abx, Bisphosphonates, KCl; if alarm signs --> endoscopy Disorders of gastric emptying / gastroparesis: - Dx: endoscopy --> NM solid-phase gastric emptying (NOT KUB) - acute Tx: erythromycin; chronic Tx: metoclopramide Gastric outlet obstruction: - nausea/vomiting, early satiety - PEx: “succussion splash” (roll patient back and forth and hear sloshing sound in stomach) - Tx: PPI + NG tube Mentrier’s disease:  associated with gastric cancer - protein-losing enteropathy c/o epigastric pain, N/V, edema - associated with CMV, H.pylori - increased TGFalpha, huge gastric folds, significantly decreased protein/decreased albumin - Dx: endoscopy with bx - Tx: Cetuximab

Small intestine disease

Celiac disease: - Dx: small bowel biopsy OR dermatitis herpetiformis (pruritic papulovesicular rash on extensors) - associated with small bowel lymphoma, osteomalacia, iron deficiency/microcytic anemia, malabsorption (Vits ADEK)/increased PT, elevated AST Bacterial overgrowth syndrome: - diarrhea in the setting of previous abdominal surgery / small bowel diverticulosis, systemic sclerosis, Diabetes - Dx: hydrogen breath test - Tx: empiric antibiotics Short bowel syndrome: - if <100cm resection --> Tx: cholestyramine - if >200cm: nutritional supplementation Whipple’s disease: - diarrhea/steatorrhea, fever, arthralgia, oculomasticatory myorhythmia (eye movement disorders and rapid repetitive movements of facial muscles), seizures/ataxia/confusion, endocarditis - Dx: small bowel biopsy + PCR for Tropheryma whipelli - Tx: 12 mo Abx (doxycycline, PCN) Mesenteric ischemia and ischemic colitis: - bowel rest / IVF - acute Dx: selective mesenteric angiography --> Tx: surgery - chronic Dx: conventional angiography or MRA --> Tx: stent *ischemic colitis needs colonoscopy IBS:  3 months of abdominal pain with BM changes - if >50yo or severe sx: get colonoscopy and test for Celiac disease - Tx: Dicyclomine / Hyoscyamine (antispasmodic) > TCA, Paroxetine IBD:  associated with uveitis, arthritis, pyoderma gangrenosum *needs colonoscopy with bx 8 years after diagnosis and then every 1-2 years after; if dysplasia --> proctocolectomy (1) Crohn’s disease including Crohn’s colitis: ASCA>pANCA - skip lesions, involves entirety of GI but usually spares rectum - associated with fissures and crypts - mild Tx: use Budesonide if involves ileum/R colon, 5-ASA doesn’t work well - mod Tx: prednisone / MTX / AZT - refractory / fistula Tx: infliximab / adalimumab (2) Ulcerative colitis: pANCA > ASCA - continuous lesions starting from rectum; smoking relieves symptoms - associated with primary sclerosing cholangitis, ankylosing spondylitis, pyoderma gangrenosum - Dx: colonoscopy - mild Tx: 5-ASA - mod Tx: prednisone / 6MP / AT - severe Tx: IV steroid + cyclosporine / infliximab --> surgery vs. Microscopic colitis:  associated with NSAIDs; Tx: Budesonide > Loperamide / Bismuth GIB of unknown origin:  Dx: endoscopy/colonoscopy --> repeat a scope --> capsule endoscopy - Angiodysplasia: painless hematochezia and chronic anemia in elderly vs. - Meckel’s diverticulum: painless hematochezia in young with normal upper and lower endoscopy Gastric bypass complications:  macrocytic anemia, steatorrhea (1) Blind loop syndrome: loose stools + malabsorption - Tx: Abx + nutritional support (2) Dumping syndrome: abdominal cramping, nausea, loose stools 15 minutes after eating --> 90 minutes after: tachycardia, diaphoresis, lightheadedness - Tx: small frequent low carb diet Diarrhea: (1) CVID: pulmonary diseases + Giardia; Dx: Ig levels (2) Traveler’s diarrhea: FQ + Loperamide (3) C. diff: if pregnant GIVE PO VANC Gastric bypass complications: (4)  Chronic diarrhea:  stool osmolar gap = stool osm(~290) - 2(Na+K): - <50 = 5ecretory diarrhea (5higella / cholera / bacteria, 5tool 5ofteners, VIPoma, carcinoid (Dx: 24hr urinary excretion of 5HIAA)) <--nocturnal symptoms - >125 = osmotic/fatty diarrhea (1actase deficiency, 1axatives (1actulose / Mg citrate), Ce1iac, chronic pancreatitis

Colonic and anorectal disease

Colon cancer screening:  colonoscopy - Normal:  start >= 50 years old, colonoscopy Q10 years OR get a yearly fecal occult blood test +/- sigmoidoscopy Q5 years - FAP:  start at 12 years old with yearly sigmoidoscopy; colectomy by 20 years old - HNPCC:  start at 20 years old or 10 years younger than relative with youngest diagnosis, repeat Q1-2 years - IBD:  start 8-10 years after initial diagnosis of IBD, repeat with biopsy Q1-2 years - Family history of colon cancer at <60 years old:  start at 40 years old or 10 years younger than relative with youngest diagnosis, repeat Q3-5 years Surveillance: - 2-3 months if: adenocarcinoma with >=2mm margin and minimal invasion - 2-6months if: >2cm sessile polyp removed piecemeal - <3 years if: >10 adenomas - 3 years if: >3 adenomas, any adenoma >1cm, villous or high-grade dysplasia - 5 years if: 1-2 <1cm tubular adenomas - 10 years if: small hyperplastic polyps

Diverticular disease: - Dx: CT abdomen (no need for colonoscopy for initial diagnosis) - Tx: 7-10 days cipro or metro --> post-recovery colonoscopy to rule out cancer

Pancreatic disease

Acute pancreatitis: - Dx: U/S --> if severe symptoms/suspect complication or >48 hours: CT scan - labs: elevated Hct, elevated BUN/Cr, lipase > amylase - complications: necrosis / abscess (Tx: surgery); pseudocyst (Tx: Abx and usually resolves spontaneously, otherwise surgery) Autoimmune pancreatitis: - elevated IgG4 - found as a mass in the pancreas that mimics cancer - Tx: steroids Chronic pancreatitis: - associated with EtOH, DM, steatorrhea - Dx: CT abdomen shows pancreatic calcifications *if young patient, do Cystic Fibrosis genetic testing - Tx: supportive / enzyme replacement

Biliary tract disease

Cholelithiasis: elective cholecystectomy Choledocholithiasis: ERCP *Mirizzi: impacted gallstones in cystic duct --> external compression of common bile duct --> obstructive jaundice --> Tx: cholecystectomy Cholecystitis: fevers, leukocytosis, pain - Tx: start broad spec Abx: (1) Amp / Gent / Metro, (2) Ceftaz / Metro, (3) Zosyn /  Unasyn + SURGERY WITHIN 48 HOURS vs. Biliary colic: no fevers, no leukocytosis, symptoms <6 hours --> Tx: NSAIDs only vs. Cholangitis: fever / RUQ pain / jaundice + SHOCK + AMS - bilirubin >4, AST/ALT > 1000 - Dx: U/S --> HIDA --> stones?: ERCP - Tx: FQ + ERCP (NOT surgery) Primary sclerosing cholangitis: - young men - associated with UC, cholangiocarcinoma, HCC, BG cancer, colon cancer - Dx: US (with increased Alk Phos) show dilated bile ducts --> ERCP “beads on a string” - Tx: liver transplant; manage symptoms with ursodeoxycholic acid Cholecystenteric fistula: SBO and air in biliary tree AIDs cholangiopathy: RUQ pain, jaundice, and diarrhea associated with Cryptosporidium (CD4<100); Tx: Ursodeoxycholic acid, stenting / sphincterotomy *IFN alpha in HIV Tx is contraindicated in cytopenias, decompensated cirrhosis, active autoimmune diseases, and major depression; associated with causing hypothyroidism vs. Fitz-Hugh-Curtis:  RUQ pain (liver capsule inflammation) 2/2 Gonorrhea/Chlamydia PID

Liver disease

Viral hepatitis: (1) Hepatitis A: - give Hep A vaccine to travelers to continents that start with A: Africa/Asia/central or south America - if traveling within 2 weeks, give Ig instead (2) Hepatitis B: - post-exposure PPx:  Hep B vaccine + HBIg - associated with membranous GN (and blood clots), PAN - Tx: Lamivudine (3)  Hepatitis C: - Dx: antiHCV Ab --> HCV RNA - HBsAb = immunity (via vaccine or past exposure); HBsAg = current infection, HBeAg = high replication - associated with porphyria cutanea tarda (blistering hyperpigmented rash with alcohol and sunlight, hypertrichosis, Tx w phlebotomy), cryoglobulinemia (cold agluttinins, cold fingers, low complement), leukocytoclastic vasculitis - Tx for genotype 2-4: peg-IFN + Ribavirin - Tx for genotype 1: PI (Boceprevir/Telaprevir) Cirrhosis and portal hypertension: - be sure to check endoscopy to rule out varices - calculate SAAG: (1) SAAG >1.1: (a) ascites protein <2.5 = cirrhosis (b) ascites >2.5 = RHF, Budd-Chiari (2) SAAG<1.1: (a) ascites protein <2.5 = nephrotic syndrome (b) ascites protein >2.5 = TB, cancer - SBP: --> Dx: ascites granulocytes > 250, albumin <1g/dL --> Tx: Cefotaxime + Albumin on day 1 and 3  *Hepatic encephalopathy Tx: Rifaximin / lactulose (NOT protein restriction) Drug-induced liver disease other than acetaminophen: amanita mushroom Autoimmune hepatitis: - young female with autoimmune disease (UC, thyroid) with transaminitis, elevated protein, decreased albumin - elevated IgG, antismooth muscle Ab, antiLKM --> Dx: liver biopsy - Tx: steroids + AZT Primary biliary cholangitis: - middle-aged lady with jaundice - Dx: antimitochondrial antibody + RUQ US + liver bx Cholestasis:  elevated bili, elevated AlkPhos>>>>AST/ALT elevation Wilson’s disease: - young patient with psych issues, transaminitis, hemolysis, and athetoid movements - Dx: serum copper, ceruloplasmin - Tx: D-Penicillamine or trientine Liver disease in pregnancy: (1) HELLP: 3rd trimester, associated with DIC, MAHA (2) AFLP (acute fatty liver of pregnancy): HELLP with hypoglycemia + AMS + elevated PT Hemochromatosis: - bronze DM, cirrhosis, 2nd and 3rd MCP joint osteoarthritis with hooked osteophytes, also affects shoulders, ankles, and elbows - significantly elevated Ferritin, elevated transferrin (if transferrin >45% --> HFE genetic testing (CY282/H63D)) - Dx: liver biopsy to confirm - Tx: phlebotomy; if cirrhosis: check alpha fetoprotein and get Q6mo US Hepatic vein thrombosis (Budd-Chiari): - SAAG >1.1, ascites protein >2.5 - associated with essential thrombocytosis / JAK2 mutation Fatty liver and nonalcoholic steatohepatitis: Dx: liver bx Alcoholic hepatitis: - severe if Maddrey >32, MELD >18, Glasgow Alcoholic Hepatitis Score (GAHS) >9, ascites or AMS - Tx severe with steroids (*CI in GIB) + pentoxyfylline Gilbert’s syndrome: elevated indirect/unconjugated bilirubin with normal AST/ALT with stress; don’t Tx Hepatocellular carcinoma: - liver nodule <1cm: f/u US in 3mo - >1cm --> MRI with contrast or 4 phase MDCT -->+ = HCC, unsure --> other image or biopsy - Tx: surgical only (no chemo)