Bulbar palsy (lower motor neuron lesion) causes dysphagia due to muscles weakness, whereas pseudobulbar palsy (upper motor neuron lesion) causes dysphagia due to disordered contractions GE Reflux due to lower esophageal sphincter (LES) can be caused by the effect of recently ingested fat in the duodenum or because of over distension of the stomach Suspect GE reflux in patients with persistent non productive cough especially if there is hoarseness 70% of non cardiac chest pain caused by GE reflux disease and not necessarily associated with heart burn No need for endoscopy in patient with classic symptoms of GERD, the diagnostic workup starts with therapeutic trail Drugs that may delay gastric emptying and promote reflux are: calcium channel blockers, antihistamines, tricyclic anti depressing, and anticholinergics Don’t stop PPIs abruptly after several months of use because that may cause H+ rebound Serum gastrin level as very high in patients with achlorhydria (autoimmune gastritis, pernicious anemia) because there is no inhibitory effect Corticosteroids alone are not a cause of peptic ulcer, but they increase the risk of NSAIDS associated gastrointestinal complications The most common presentation of Zollinger-Ellison syndrome is diarrhea/steatorrhea Neither gastric ulcer nor alcohol consumption has been proven to cause gastric cancer String sign seen in the terminal ileum is a classic but not common feature in crohn disease, it cause because of terminal ileum edema If you see this sign other place in the colon then it will be called apple-core lesion which suggests cancer Complications of terminal ileum problems (resection, crohn disease): Calcium oxalate kidney stones Cholesterol gallstones B12 deficiency Hypocalcemia Bile acid induced diarrhea Nutrient malabsorption Ulcerative colitis Ulcerative colitis (UC) causes uniform continuous mucosal inflammation with shallow ulcers extending proximally from the rectum Extraintestinal manifestations of inflammatory bowel disease (IBD) are usually seen in IBD patients with colitis (usually associate with ulcerative colitis (UC) and can be seen in crohn disease (CD) involving the colon) Primary sclerosing cholangitis associated with HLA-B8, whereas ankylosing spondylitis and uveitis are associated with HLA-B27 In general, stool osmolality equal serum osmolality, if stool osmolality comes more than serum osmolality that indicates improper stool collection procedure 24 – 48 hours fasting does not stop secretory diarrhea except in fatty acid and bile acid related diarrhea, whereas 24 -48 hours fasting resolve the osmotic diarrhea MP/SMX may prolong salmonella infection which usually self limited infection Antibiotics are contraindicated in the treatment of E. coli O157:H7, because antibiotics may increase the chances of developing HUS (up to 17-fold). This effect is thought to occur because the antibiotic damages the bacteria, causing them to release even more toxin. Treatment is symptomatically In amebic liver abscess, don’t aspirate or surgically drain the abscess unless there is no response to medical treatment with metronidazole The most common presentation of celiac sprue is iron deficiency anemia Upper endoscopy with small bowed biopsy is the diagnostic procedure of choice for whipple disease, the small bowel biopsy shows foamy macrophages which is specific for whipple disease CSF can be checked for T. whippelii by PCR which if found diagnostic for whipple disease Whipple disease relapse often manifests with CNS symptoms Endocarditis caused by strep bovis or clostridium septicus is often associated with colon cancer, so if you have a patient with above diagnosis then screen him for colon cancer The risk of colon cancer in familial adenomatous polyposis is 100% if not treated If you have a patient with multiple osteomas found incidentally in x-ray, then screen him to roll out gardner syndrome which is pre cancer familial polyposis syndrome If a patient has 1st degree relative with colon cancer then colonoscopy should be done in age 50 or 10 years before the age at which index case diagnosed which is first Survey for colon cancer after diverticulitis in older patients because sigmoid colon cancer can perforate the bowel wall giving the symptoms of diverticulitis Colon cancer usually metastasizes to the liver first via the portal circulation. If the cancer involves the rectum it may bypass the portal circulation and metastasizes to lung, brain, and bone without liver metastases In upper GI bleeding, usually BUN/Cr is mora than 30:1 because the blood being digested and breakdown products absorbed Classic triad for chronic mesenteric ischemia: 1- Abdominal pain after meals 2- Abdominal bruit 3- Weight loss (can only tolerate small meals) In acute pancreatitis, amylase level may be normal in cases caused by hypertriglyceridemia In acute pancreatitis: Amylase elevated early and decreases within 2-3 days after disease onset while lipase elevated late and lasted for about 7-14 days Acute pancreatitis: Patient should be NPO, the criteria for resume oral feeding are: The presence of bowel sounds, passing flatus/stool No need for narcotics Hunger Classic triad for chronic pancreatitis: Pancreatic calcification Diabetes Steatorrhea In chronic pancreatitis, there is decreased production of insulin and glucagon and because of that the patient is very prone to hypoglycemia In general, patients with DM due to chronic pancreatitis don’t have the usual retinopathy and nephropathy associated with usual DM, they usually have neuropathy but it more likely caused by alcoholism and /or malnutrition Rapid weight loss in obese pateins may cause cholelithiasis (cholesterol stones), can be prevented by aspirin or ursodeoxycholic acid Acute cholangitis is suggested by charcot`s triad: Fever Chills Jaundice In primary biliary cirrhosis, patient can get xanthomas and xanthelasmas because of hypercholesterolemia, but this does not increase the risk of CAD because there is also an increase in HDL level Primary sclerosing cholangitis strongly associates with colitis, so it mainly seen in ulcerative colitis, but also can be seen in crohn disease involving the colon Elevated hepatic copper level can be seen in: Wilson disease, Primary biliary cirrhosis, and Primary sclerosing cholangitis In hepatitis B, the prodromal constitutional symptoms typically resolve at the time jaundice becomes apparent Hepatitis A transmission: Fecal orally Can be sexually transmitted (during oral-anal sexual contact with an infected person) There is no transplacental transmission Alpha interferon is used as a treatment in chronic hepatitis A & C, but it is contraindicated in autoimmune hepatitis because it exacerbate the disease Acetaminophen liver toxicity may develop by not eating for 3-4 days for any reason and taking acetaminophen in therapeutic doses because glutathione levels are depressed in malnutrition Acetaminophen liver damage is potentiated with: Chronic alcohol use Heavy alcohol use Malnutrition Sever diet If the prolonged prothrombin time (PT) in alcoholic patient easily corrected after IM vitamin K, then the cause is malabsorption not liver disease For more please download Best medical pearls application For android https://play.google.com/store/apps/details?id=com.best.medical.pearls&hl=en For iOS https://itunes.apple.com/sa/app/best-medical-pearls/id1316367658?mt=8 Follow us on twitter: https://twitter.com/pearls_best thank you
