Disease

Risk Factors

History/Presentation

Esophagitis

immunocompromised

Odynophagia, dysphagia,
substernal CP, sometimes
asymptomatic, oral ulcers with
HSV

Mallory-Weiss tear

alcoholism, lifting, retching,

vomiting

hematemesis, melena, hx of
vomiting, retching, straining
(50%)

Gastroesophageal
reflux disease

hiatal hernia, truncal obesity,

heartburn, dyspepsia,
regurgitation, dysphagia,
asthma, cough, sore throat,
chest pain

Barrett's esophagitis

GERD, truncal obesity

GERD symptoms

Esophageal
malignancy

Barrett esophagus, chronic

GERD, hiatal hernia, obesity,
white, male, >50

dysphagia, odynophagia,
weight loss

Esophageal cancer

Esophageal dysmotility
(Achalasia)
age
Dysphagia
Gastric Neoplasm

dysphagia of solid foods and

eventually liquids, early satiety,
regurgitation, cough, aspiration,
substernal CP, weight loss

H. pylori infection

age, non-whites, immigrants

from developing countries,
socioeconomic status

alcoholism, critically ill pts,

NSAID gastritis/ Acute NSAID use, H. pylori most
gastritis
common cause, autoimmune
Gastric ulcer

nausea, abdominal pain, PUD,

gastritis

often asymptomatic; epigastric

pain, nausea, vomiting,
anorexia, early satiety, weight
loss, hematemesis
immediately post prandial

Peptic ulcer

dyspepsia, rhythmicity and

periodicity, asymptomatic,
smoking, long-term NSAID use, abdominal pain - burning,
H. pylori infection, stress
gnawing

Duodenal ulcer

most common type of peptic

ulcer

2-3 hrs post prandial

age, hereditary nonpolyposis

symptoms appear late,

abdominal pain, change in
bowel habits, occult bleeding,
intestinal obstruction

fecalith, infection, lymphoid

hyperplasia, 10-30 yo

intermittent periumbilical or
epigastric pain; after 12hrs pain
localizes to RLQ, becomes
constant, worsened by
movement; nausea, anorexia,
vomiting, diarrhea, fever

genetics

diarrhea, bloating, abd

discomfort; weight loss, edema;
steatorrhea; bone
demineralization, tetany,
bleeding, anemia

antibiotic use

diarrhea, fever, loss of appetite,

nausea, abdominal
pain/tenderness

Colorectal cancer

Acute appendicitis

Malabsorption
syndrome

C. difficile infection

Inflammatory bowel
disease (UC/Crohns)

Crohn's - "skip lesions"

insidious, fever, diarrhea, RLQ
pain (intermittent bouts),
perianal disease with abscess,
fistulas; chronic inflammatory
disease; intestinal obstruction;
cigarette smoking - Crohn's; UC UC - bloody diarrhea, low abd
- idiopathic
cramps, fecal urgency

Irritable bowel
syndrome

symptoms begin late teens early twenties; 2/3 women;

idiopathic

abd pain, alterations in bowel

habits, pain relieved by
defecation; chronic - >3months

surgery, peritonitis, electrolyte

Bowel strictures/bowel abnorm, meds, severe med
obstruction
illness
abd discomfort, n/v
Colon neoplasm

Colorectal cancer

Acute Diarrhea

FAP (young age), HPS, HNPCC

(Lynch); FHx; age; diet

FAP - 100-1000's polyps

inevitably develop into CA;
HNPCC - only a few adenomas

pathogen infection or
medication use

noninflam - watery, nonbloody,

mild, virus or noninvasive
bacteria; inflamm - blood or
pus, fever, invasive or toxinproducing bacteria

Diverticular disease

age, uncertain etiology

losis - 90% no symptoms,

constipation, abd pain, fluct
bowel habits; litis - acute abd
pain and fever, n/v,
constipation or loose stools

Peritonitis, the Acute

Abdomen

perforated viscus, wound of

abdominal wall, foreign object

acute abd pain and tenderness,

fever

Acute appendicitis

abd discomfort, anorexia, pain

2nd-3rd decades of life,
in periumbilical initially then
fecalith, appendiceal ulceration migrates to RLQ, N/V

GI bleed

5 ways (hematemesis, melena,

hematochezia, occult GI
increasing age, peptic ulcers,
bleeding, symptoms of blood
NSAID use, helicobacter pylori, loss or anemia Mallory-Weiss tears, carices,
lightheadedness, syncope,
alcoholism
angina, dyspnea

Gallstones
Cholecystitis

biliary colic - constant and longlasting pain RUQ - radiationt o

interscapular area, right
4 F's = female, fat, fertile, forty scapula, or shoulder; N/V

Acute pancreatitis

Chronic Pancreatitis

Cholangitis
Viral Hepatitis

biliary tract disease; heavy

alcohol intake; hypercalcemia;
hyperlipidemia; abd trauma;
drugs; vaculitis; infections;
dialysis; cardiopulm bypass;
genetic mutations; celiac
abrupt epigastric pain, radiates
disease; smoking; abd
to back; hx of previous
adiposity; older age and obesity episodes (alcohol intake); N/V;
increase severity
sweating, weakness

alcoholism, tobacco smoking,

hyperparathyroidism,
malnutrition,

hx biliary pain with jaundice

Hep C&D gives liver CA

chronic or intermittent
epigastric pain, and LUQ pain
steatorrhea, weight loss,
anorexia, constipation,
flatulence, N/V
N/V, jaundice, fever followed by
hypothermia and gram
negative shock, jaundice, and
leukocytosis

Drug induced liver

disease
alcohol toxicity, chemical
ingestion, FHx, tattoos,
piercings, acetaminophen
toxicity, mushroom poisoning,
Fulminant liver failure ebola, sepsis

Hepatic neoplasm
Pancreatic cancer
Cirrhosis

common site of malignancy

from lung and breast
alcoholism, obesity, smoking

rapid deterioration of liver

function, encephalopathy, abd
pain, distention
jaundice, organomegaly,
ascites, wasting

Constipation
Toxic Megacolon
Rectal disorders
(fissure, hemorrhoid,
abscess, cancer)

Physical Exam Findings

Work-up labs/testing

endoscopy - diffuse, linear

yellow-white plaques adherent
to mucosa
may be empiric; endoscopy

0.5 - 4 cm linear mucosal tear

usually at gastroesophageal
juction or below junction in
gastric mucosa seen on
endoscopy

endoscopy

normal in uncomplicated
disease

empiric; endoscopy for

persistent

orange, gastric type epithelium

that extends upward from
stomach
endoscopy

endoscopy
gastrin level or secretin
stimulation test (Zollinger)

unhelpful

chest radiographs - air-fluid

level in enlarged, fluid-filled
esophagus; barium
esophagography - dilation, loss
of peristalsis, poor emptying,
smooth, symmetric "bird's
beak" tapering of distal
esophagus; endoscopy;
esophageal manometry

PUD, gastritis

fecal antigen immunoassay and

[C] urea breath test; serologic
ELISA test; endoscopy usually
not indicated - biopsy if have
one

epigastric pain

CBC - nonspecific, hematcrit

low if significant bleeding, iron
deficiency; upper endoscopy;
B12 deficiency - CBC will be
megaloblastic, pepsinogen,
shilling test

normal in uncomplicated
disease; mild, localized
epigastric tenderness to deep
palpation; frank bleeding

upper endoscopy with gastric

biopsy for H. pylori; hemoccult;
urea breath test

occult blood in stool

colonoscopy, sigmoidoscopy, or
barium enema - colonic
masses; CXR or CT metastases; look for tumor
marker CEA

CBC - leukocytosis, UA microscopic hematuria and

pyuria; abdominal CT preferred
rebound tenderness; Psoas sign to diagnose; can also clincical
(retrocecal) and obturator sign or US

72 hour fecal fat test; D-xylose

test differs maldigestion from
malabsorption; specific test for
B21, calcium, or albumin; IGA
level for IGA deficiency; serum
antigliadin - celiac; TTG
test for toxin they produce;
yellow pseudomembranous
plaques on scope

RLQ mass and tenderness;

blood

CBC and albumin - anemia,

leukocytosis, hypoalbuminemia;
colonoscopy - apthoid, linear
ulcers, strictures, segmental
involvement, granulomas; US anemia, low serum albumin,
negative stool cultures,
sigmoidoscopy

normal - ruling out signs of

organic disease; lower abd
tenderness common but not
pronounced

tests should be kept to a

minimum especially if no alarm
symptoms and young age if
meets diagnostic requirements

distention, no signs of
peritoneal irritation, BS
diminished - absent

attributable to underlying
disease - serum electrolytes
should be obtained; plain film
rad - distended gas-filled loops

genetic testing; colonoscopy

fever

90% diagnostic eval

unnecessary; distinguish pts
from mild to more serious - if
worsens after 7 days - send for
fecal leukocyte or lactoferrin
determination, ovum and
parasite eval, and bact culture

losis - normal labs; litis leukocytosis, stool occult blood,

losis - normal, maybe mild LLQ colonoscopy - colonic
tend, thickened, palpable
diverticula, wall thickening,
sigmoid and descending colon; pericolic fat infiltration, abscess
litis - LLQ tenderness and mass form, extraluminal air

CBC - leukocytosis, acidosis,

plain abd film - dilation of large
and small bowel with edema of
abd tenderness, rebound,
bowel wall, free air under
rigidity of abd wall, bowel
diaphragm (perforated viscus),
sounds absent, tachycardia,
CT and/or US - free fluid or
hypotension, dehydration signs abscess

vary with time after onset,

diagnosis cannot be est unless
tenderness elicited, McBurney's
point tenderness, positive
psoas and obturator (late), mild
fever, tachycardia, rigidity

moderate leukocytosis (left

shift), UA - exclude
genitourinary, CT - thickend
appendix with periappendiceal
stranding and often fecalith

tachycardia, hypotension,
postural changes in heart rate
or BP

upper endoscopy - endoscopic

hemodynamic therapy for
Upper GIB; lower GIB - upper
endoscopy first to rule out then
sigmoidoscopy - colonoscopy
Gallbladder US, plain film Abd
XR, Radioisotope scans;
increased levels of serum
bilirubin and/or alkaline
phosphatase

Abd tenderness, distention,

fever

leukocytosis, elevated serum

amylase, elevated serum
lipase; plain radiographs - may
show gallstones, sentinel loop,
colon cutoff sign, or focal linear
atelectasis of lower lobe of
lungs w/ or w/o pleural effusion

serum amylase and lipase

elevated during attacks; serum
alkaline phosphatase and
bilirubin may be elevated;
glycosuria; excess fecal fat;
secretin stimulation test;
decreased fecal chymotrypsin
or elastase levels; Vit B12
deficiency; plain film calcifications due to
pancreaticolithiasis; ERCP mild muscle guarding,
dilated ducts, intraductal
tenderness over pancreas, and stones, strictures, or
ileus during attacks
pseudocyst
stones in duct must reliably be
detected by ERCP or endoscopic
US

jaundicce, asterixis

PTT, INR, LFTs, bilirubin,

ammonia level encephalopathy, CBC thrombocytopenia, serum
lactase, drug screen, blood
cultures, hep panel, CT
serum fetal, alpha fetoprotein,
US, CT, MRI, hepatic angiogram

1st line meds/treatment

2nd line meds/treatment

Candida - Fluconazole; CMV Ganciclovir (HAART for HIV pts);

Herpes - symptomatic
treatment
Candida - itraconazole or
(immunocompromised voriconazole; CMV - foscarnet;
acyclovir or famciclovir)
Herpes - foscarnet

fluids and blood as needed;

most self-limited and no
treatment needed; endoscopic
hemostatic therapy for
continuing bleed - epinephrine
injection, cautery, or
angiographic arterial
mechanical compression of
embolization or operative
artery
intervention

H2 blockers

PPI

long term PPIs once or twice

daily

Botulinum Toxin Injection into

LES for pts with comorbidities;
pneumatic dilation

cardiomyotomy of LES and

cardia

triple and quadruple: PPI, amox,

clarithro; tetra, PPI, flagyl;
bismuth too 10-14 days

PPI; sucralfate - stress gastritis;

discontinuation of use of
NSAIDS; H2 inhibitors

PPI; H2 receptor antagonists;

bismuth, misoprostol, and
clip, coag any bleeding (during
antacids; antibiotics if H. pylori scope)

surgical resection;
chemotherapy in stage III or
higher; radiation for rectal
tumors

neoadjuvunct chemo - means

before surgery (shrinks tumor)

appendectomy

broad-spectrium antibiotics if
suspect perforation (before and
after surgery) (gram neg and
anaerobes - Flagyl, betalactam, cephalosporins)

lactose-free diet; gluten-free

diet for celiac; pancreatic
enzyme replacement for
pancreatic insufficiency;
antibiotics for infections

metronidazole (flagyl),
vancomycin oral, or fidaxomicin fecal transplant

5-aminosalicylic acid (5-ASA)

corticosteroids (hydrocortisone
or methylprednisolone) then
refer

reassure, educate, and dietary

changes; mod - severe -antispasmodic agents
(anticholinergic); antidiarrheal
agents (Loperamide prophylactic); anticonstipation
agents (laxatives)

Psychotropic agents, serotonin

receptor agonists and
antagonists, nonabsorbable
abx, probiotics

FAP - complete proctocolectomy

Diet - fluids with carbs and

elctrolytes (avoid fiber, fats,
milk, caffeine, alcohol); IV fluids
- severe; antidiarrheal agents loperamide, Bismuth
subsalicylate (Pepto-Bismol) antiinflammatory and
antibacterial properties
(anticholinergics
contraindicated bc megacolon antibiotics - fluoroquinolones or
chance)
Bactrim or doxy

losis - high fiber diet or

supplements; litis - clear liquid
diet (mild), abx - Augmentin,
high fiber diet; hospitalization
(elder, severe) - IV fluids, NG
tube - ileus, IV abx (2nd gen
ceph plus amino or 3rd gen
ceph)

rehydration, correct electrolye

abnormalities, antibiotics, and
surgical correction of
underlying defect

early operation and

appendectomy

Ulcer - PPI, Varices - ligation,

mallory-weiss tear - endoscopic
therapy

cholecystectomy (if needed);

ursodeoxycholic acid (UDCA) gallstone dissolution - if pt does

not want cholecystectomy

Mild - most - self-limited - "rest"

with withholding food and
liquids by mouth , bed rest, and
NG suction; merperidine for
exploratory laparoscopy if
pain or morphine
surgeon suggests

low-fat diet; alcohol forbidden;

avoid opioids; acetaminophen,
NSAIDS, or tramadol for pain;
endoscopic and surgical
treatment

liver transplant

hemorrohoids - witch hazel,

preparation H, 5% lidocaine

Follow-up

2 weeks

surveillance endoscopy every

3-5 years to watch for dysplasia
or adenocarcinoma

Emergent presentation

can cause cancer, MALT mucosa associated tissue

lymphoma; so need to be
tested for cure in 3-4 weeks

colonoscopy year 1, 3, every 3

years after

can lead to abscess or fistula

toxic megacolon - sepsis

lifelong illness - encourage pts

to become involved in Crohn's
and Colitis Foundation of
America (CCFA)

surgeon consult with severe;

pancreatic abscess - prompt
percutnaeous or surgical
drainage

Miscellaneous

can lead to cancer if not treated

most common place to

metastasize - liver; hyperplastic
polyps usually benign

retrocecal IE - may have back

pain (McBurney's won't be
tender)

lastose intolerance, celiac,

pancreatic insufficiency, crohn's
(keep CF and whipple disease in
differential); weight loss
surgery can cause; short gut
syndrome too (rapid colonic
transit time)

DVT and GI prophylaxis;

fidaxomicin - new abx for c.dif

mild - less than 4 stool; mod more than 4; severe - more

than for and systemic illness

Risk Factors

History/Presentation

Management of
Hypertension

age, obesity, FHx, race, highsodium diet, excessive alcohol

consumption, inactivity,
diabetes, DLD, sleep apnea

usually asymptomatic (maybe

headache) (ask about CP, SOB,
hx stroke, steroid/drug use,
stress, anxiety, edema, thyroid)

Peripheral arterial
disease

atherosclerosis - chronic - most

common, eboli (acute), lower
extremities most common femoral artery; smoking, DM,
intermittent claudication,
high lipids, etc.
muscle pain upon exertion

Arterial
embolism/thrombosis

Phlebitis/
thrombophlebitis

Heart Failure R&L

Management of Lipid
Disorders
High Cholesterol

pregnancy, sitting, local

trauma, venous stasis

acute localized pain, feels hard

Smoking, HTN, CHD, obesity,

DM, valvular heart disease

edema; rales and crackles;

peripheral edema; JVD
increases with inspiration Kussnaul sign; pulses irregular

Tricuspid stenosis
Tricuspid regurgitation
Pulmonary stenosis
Pulmonary regurgitation
Mitral stenosis
Mitral regurgitation
Mitral valve prolapse
Aortic stenosis
Aortic regurgitation

occurs with other valvular

lesions, rheumatic etiology,

low CO, fatigue, systemic

venous HTN

Physical Exam Findings

Work-up labs/testing

140/90 - HTN; hypertensive

retinopathy in really bad

electrolytes, serum creatinine,

fasting glucose, urinalysis, lipid
profile, electrocardiogram; to
diagnose - 3 elevated readings,
both arms, rest for 5 mins, one
in leg

THE 5 P's: pulselessness,

paralysis, paresthesias, pallor,
pain; livito leticularis; cold;
ulcers/gangrene; ankle/brachial US extremities, ABI's - <0.9 index test
indicates severe
blue toe syndrome - small
vessel rather than large emboli in digital arteries
redness on top and along
course, swelling (if a lot think
DVT), warm, tender, induration US to rule out DVT
Plasma BNP (brain natriuremic
peptide), ECG, lipid panel, CXR,
echocardiogram, stress test,
heart catheterization

xanthomas (esp butt),

fasting lipid panel

fasting lipid panel

increase in R atrial and jugular

venous pressure, jugular
venous pulsations, JVD,
hepatomegaly, hepatic
pulsations, ascites, peripheral
edema, anasarca, Auscultation - Echocardiogram - limited
opening snap of tricuspid valve mobility of leaflets, reduced
(follows opening snap of mitral separation of leaflet tips,
valve), low freq diastolic
reduction in diameter of
murmur heard at LL sternal
tricuspid annulus, diastolic
border in 4th intercostal space, doming of valve; Doppler
increase with maneuvers that echocardiography - high
increase bld flow across
velocity turbulent diastolic dlow
tricuspid valve (inspiration, leg across stenotic orifice and
raising, squatting)
prolonged pressure half-time

1st Line Meds/Treatment

2nd Line Meds/treatment

thiazide diuretics, long acting

calcium channel blockers, ACE
inhibitors, angiotensin II
receptor blockers

combination therapy

self-limiting usually, warm

compress, elevate, Ibuprofen,
keep walking, compression
stockings

anticoagulant if signs of DVT

oxygen, DASH diet, restrict

sodium, restrict fluids, ACE
inhibitors or beta blockers first

diuretics, ARBs, pace-maker,

defibrillator

statins - HNG co-A reducatase

inhibitor

Follow-up

Emergent Presentation

MI, atherosclerosis; CP, SOB,

AMS, blurred vision, bruits
(carotid and abdomen); loss of
peripheral pulses,
radial/femoral delay

DVT

Miscellaneous