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Spontaneous Bacterial Peritonitis
- Common in Pt w liver cirrhosis fin hepatitis or alcohol.
- P/E: ascites, +/- fever and diffuse abd pain
- Ans: gallstone in the common bile duct
- Sx and PE: Abd pain, jaundice, N/V, pruritis
- When evidence of infection is apparent: Dx is then Cholangitis
- Infection: of CBD
- P/w: Reynold's Pentad: Charcot's triad (RUQ pain, jaundice, fever), /> in mental status, and shock
- Ans: inflam of gallbladder, often d/t gallstones.
- Sx: RUQ pain and have signs of infection. LFTs NOT elevated
- Ans: Occlusion of hepatic veins or IVC that is common in myoproliferative disorders (e.g. polycythemia vera, tumors, and hypercoagulable states.
- P/E: ascites, and fever (not as common as in cholangitis)
- Pt won't have positive blood cultures
How to ans "What is the most likely (M.L.) Dx?"
- If this is in the Hx: The M.L. Dx is:
- Pain worse with food --> Gastric UlcerPain better with food --> Duodenal UlcerWeight Loss --> CA, Gastric Ulcer
- Tenderness --> Pancreatitis
- Bad Taste, cough, hoarse --> Acid reflux
- Diabetes, bloating --> Gastroparesis
- Nothing --> Non-ulcer dyspepsia
- ABx assoc: C. difficile, caused by any ABx; blood+WBC found in stool; usu presents days-wks after abx. Best Test= stool C.diff toxin test or PCR. Best Tx= Metronidazole (2ndLine: PO vanco (never IV since it won't reach intestines) or fidaxomicin)
- Malabsorption: (Celiac; rare Tropical sprue and Whipple Dz)
- Chronic Pancreatitis:
- Carcinoid Syndrome:
- Lactose Intolerance:
- nothing clinically to distinguish tropical sprue from celiac (gluten-sens enteropathy)
- Celiac: dermatitis herpetiformis in 10% of cases.
- B12 absorption needs: intact bowel wall & pancreatic enz
- Whipple Dz also p/w: arthralgias, ocular findings, neurologic abnormalities (dementia, seizures), fever, lymphadenopathy, treat with ceftriaxone followed by TMP/SMX
Distinction of Chr Pancreatitis and Gluten-sens Enteropathy: presence of Iron Deficiency
(Fe needs intact bowel wall, but doesn't need pancreatic enz.
- Unique Tests: !
- Celiac: !
- 1st test: Anti-tissue transglutaminase
- Others: Antiendomysial Ab, IgA antigliadin Ab
- Gold Standard: Duodenal Bx
Pro Tip: Bowel Bx necessary with Celiac to exclude Lymphoma
- Disease: --> Specific Tx
- Chronic Pancreatitis: ---> Enzyme Replacement
- Celiac Dz: ---> Gluten-free diet (no wheat, oats, rye, barley)
- Whipple Dz: ---> Ceftriaxone, TMP/SMX
- Tropical Sprue: ---> TMP/SMX, and tetracycline
Deficiencies ---> Manifestations
- Vit D: ---> hypocalcemia, osteporosis
- Vit K: ---> bleeding, easy bruising
- Vit B12: ---> Anemia, hypersegmented neutrophils, neuropathy