Gastroenterology

     gastroenterology
      Celiac disease (especially in patients with a history of diarrhea or unexplained iron deficiency)

      serum antiendomysial IgA or anti tissue transglutaminase IgA antibodies are reasonable screening tests.

      IBS

        At least 12 weeks, which need not be consecutive, of the preceding 12 months there was abdominal discomfort or pain that had 2/3 of these features:

        • Relieved with defecation
        • Onset associated with a change in frequency of stool
        • Onset associated with a change in appearance of stool.

        Symptoms that cumulatively support the diagnosis of IBS:

        • Abnormal stool frequency (for research purposes, "abnormal" may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week);
        • Abnormal stool form (lumpy/hard or loose/watery stool);
        • Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);
        • Bloating or feeling of abdominal distention.

        Supportive symptoms of IBS:

        • A) Fewer than three bowel movements a week
        • B) More than three bowel movements a day
        • C) Hard or lumpy stools
        • D) Loose (mushy) or watery stools
        • E) Straining during a bowel movement
        • F) Urgency (having to rush to have a bowel movement)
        • G) Feeling of incomplete bowel movement
        • H) Passing mucus (white material) during a bowel movement
        • I) Abdominal fullness, bloating, or swelling

        Diarrhea-predominant: At least 1 of B, D, F and none of A, C, E; or at least 2 of B, D, F and one of A or E.
        Constipation-predominant: At least 1 of A, C, E and none of B, D, F; or at least 2 of A, C, E and one of B, D, F.

        Red flag symptoms which are not typical of IBS:

        • Pain that awakens/interferes with sleep
        • Diarrhea that awakens/interferes with sleep
        • Blood in the stool (visible or occult)
        • Weight loss
        • Fever
        • Abnormal physical examination

      Liver disorders

        Hepatic failure

        AST, ALT, ALP, GGT
        T & D bilirubin, INR, Albumin,

        Jaundice

        ↑ conj (direct) bilirubin (> 20% T bili):

          hepatocellular damage
            hepatitis - viral, alcoholic, drug-induced, autoimmmune
          cholestasis
            intra-hepatic - PSC, PBC, toxins
            extra-hepatic - choledocholithiasis, stricture, Ca head of pancreas

        ↑ unconj (indirect) bilirubin:

          hemolysis
          megaloblastic anemia
          thallesemia
          neonatal jaundice
            physiologic
            Gilbert Sx
            Crigler-Najar Sx

        Elevated liver enzymes

        Hepatitis C screening if:

          Ever injected illegal drugs
          Received clotting factors made before 1987
          Received blood/organs before July 1992
          Ever on chronic hemodialysis
          Evidence of liver disease
          After needle stick/mucosal exposure to HCV-positive blood
          Children born to HCV-positive women

        Cirrhosis physical findings

          Spider angiomata (associated with ↑ estradiol/free testosterone ratio). Patients with numerous and large spider angiomata may be at increased risk for variceal hemorrhage.

          Palmar erythema (associated with ↑ estradiol/free testosterone ratio). It is an exaggeration of the normal speckled mottling of the palm

          Nail changes — Muehrcke's nails are paired horizontal white bands separated by normal color. The exact pathogenesis is unknown but it is believed to be caused by hypoalbuminemia. They are not specific for cirrhosis since they may also be seen in other conditions associated with a low serum albumin, such as the nephrotic syndrome.
          Terry's nails can also be seen in patients with cirrhosis. The proximal two-thirds of the nail plate appears white whereas the distal one-third is red. This finding is also believed to be secondary to a low serum albumin.

          Clubbing and hypertrophic osteoarthropathy. Hypertrophic osteoarthropathy (HOA) is a chronic proliferative periostitis of the long bones that can cause considerable pain. Clubbing is more common in biliary causes of cirrhosis (particularly primary biliary cirrhosis).

          Dupuytren's contracture. Pathogenesis is unknown but may be related to free radical formation generated by the oxidative metabolism of hypoxanthine. However, it can also be seen in several other conditions including in workers exposed to repetitive handling tasks or vibration, diabetes mellitus, reflex sympathetic dystrophy, cigarette smoking and alcohol consumption, and Peyronie's disease.

          Gynecomastia. It is possibly caused by increased production of androstenedione from the adrenals, enhanced aromatization of androstenedione to estrone, and increased conversion of estrone to estradiol. Men may also develop other features reflecting feminization such as loss of chest or axillary hair and inversion of the normal male pubic hair pattern.

          Testicular atrophy

          Hepatomegaly — The cirrhotic liver may be enlarged, normal sized, or small.

          Caput medusae
          Jaundice is usually not detectable until the bilirubin is greater than 2 to 3 mg/dL.
          Asterixis
          Constitutional symptoms: e.g. weakness, fatigue, anorexia, weight loss, malnutrition.
          Pigment gallstones resulting from hemolysis
          Parotid gland enlargement (probably due to alcohol, not cirrhosis per se). Enlargement is usually secondary to fatty infiltration, fibrosis, and edema rather than a hyperfunctioning gland.