4 Gastrointestinal/ Nutrition Disorders FINAL

SA P
M RO
PL P
E ER
C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
4
Gastrointestinal/
Nutrition Disorders
66
“Something stuck in
my throat”
Usu viral or fungal
Dysphagia, achalasia
Tear at esophageal
junction
Hx of vomiting (bulimics)
Dysphagia, wt loss, Hx of
smoking, ETOH
Dysphagia, regurgitation
of food, pernicious
anemia, Hx of ETOH,
smoking
Hx of ETOH
Motor disorders
Mallory-Weiss tear
Neoplasms
(60-70 yr)
Strictures (autoimmune)
(web rings and
diverticula)
Varices (venous
collaterals secondary
to portal HTN)
Endoscopy
Barium swallow
Endoscopy
Endoscopy
CT
Hx, clinical exam
Endoscopy
Barium swallow
Barium swallow
Endoscopy
Dx
Referral
Sclerotherapy BB Abx
w/bleeding
Dilation of esophagus
PPI
Surgery + chemo for SCC
Surgery or chemo for
adenocarcinoma
None
Surgery if severe
Nifedipine (CCB)
Botox
Lifestyle changes,
antacids, H2 blocker, PPI,
CCB, nitrates
Tx
SA P
M RO
PL P
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C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Signs/Sxs
Esophagitis
Esophagus
Disorder
(Continued)
UGI bleed in 10%-20%
95% SCC
Survival rate: 5%-10%
at 5 yr
GERD often precipitates
✓ HIV
Pearls
Gastrointestinal/Nutrition Disorders
67
Vomiting, diarrhea,
cramping; usu w/o fever
Wt loss, anemia,
anorexia, GI upset,
severe pain, early satiety
Epigastric pain, NSAID
use, gnawing/burning
epigastric pain
Vomiting (projectile)
after eating
Gastroenteritis
Neoplasms (>50 yr
old ♂)
Peptic ulcer disease
(PUD)—routine/urgent
Pyloric stenosis (6-8 wk
newborn)
Acute cholecystitis (5 Fs:
fat, ♀, 40, fair, fertile)
RUQ pain (+ Murphy
sign), fever, ♀ > ♂,
30-60 yr
N&V, hematemesis, Hx
of NSAID use
Gastritis
Gallbladder
Hea tburn 30-60 min
postprandial, cough,
throat clearing
UTZ, HIDA scan, ERCP
Olive-shaped mass,
barium X-ray, UTZ
Barium, breath test,
endoscopy w/biopsy,
H. pylori
Biopsy (get a piece of it)
Clinical
Endoscopy, H. pylori,
anemia panel
Esophagoscopy, 24 hr
pH, H. pylori (to r/o PUD)
Dx
NPO, fluids, pain relief,
Abx (DM), surgery if
symptomatic
Referral to surgery
H2 blocker, PPI, Abx
(H. pylori = 3-med
regimen)
Palliative, surgery +
chemo (radiation =
help)
Viral = symptomatic
Bacterial = Abx
Stop NSAIDs
PPI, H. pylori Tx
Antacid, PPI, H2 blocker,
lifestyle changes
Tx
SA P
M RO
PL P
E ER
C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Signs/Sxs
Gastroesophageal reflux
disease (GERD)
Stomach
Disorder
In 90%, gallbladder
inflamed due to stone,
prolonged block in
gallbladder duct
Dx = narrow pylorus
✓ Gastrin levels for
Zollinger-Ellison (tumor)
Prognosis: 5% survival
at 5 yr
Usu adenocarcinoma
Usu unable to determine
viral vs bacterial
Dx = stomach lining
inflammation
Leads to Barrett esophagus, adenocarcinoma
✓ Anticholinergic
Rx
Pearls
68
Review 2 Rounds: Visual Review and Clinical Reference
Usu secondary to
infection w/hepatitis
B, C, D
✓ Rx,
✓ Wilson Dz
Benign or secondary to
metastases
+ Abdominal pain,
+ wt loss, N&V, Hx of
ETOH (45%), ascites
Neoplasms
Cirrhosis
(end-stage disease)
RUQ pain → right
shoulder, N&V, jaundice,
fever, anorexia
Chronic hepatitis
Acute ETOH hepatitis
Acute hepatitis
Liver—Routine/Urgent
Charcot triad: jaundice,
RUQ pain, fever; nausea;
quiet bowel; + Murphy
sign
Cholangitis
Emergency!
Anemia panel, UTZ, CT,
AST > ALT by 2:1 (not
always end stage), PTT
UTZ, CT
Serology—chronic Dz
AST > ALT by 2:1
LFT , WBC, serology
(type)
UTZ
Plain films, UTZ, CT, MRI,
ERCP
ETOH, ↓ Na+,
liver transp ant
Surgery if able
(transplant)
B, C, D = IFN-α
Autoimmune =
corticosteroid
Wilson Dz = copper
chelation
Pain control + fluids
Viral (B) = acyclovir?
Pain control + fluids
Viral (B) = acyclovir?
NPO, fluids, Abx, pain
relief
Emergency surgery
Usu asymptomatic
Lithotripsy (sound waves)
Surgery if symptomatic
= laparoscopic removal
SA P
M RO
PL P
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C T
O Y
N O
TE F
N EL
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- N SE
O VIE
T R
FI
N
AL
Asymptomatic;
abdominal pain after
fatty meal
Cholelithiasis
(Continued)
Ascites = late-stage Dz
Prognosis poor
(average survival 6 mo)
Viral, acute attack = core
antigen
Stop drinking!
Viral
Gallstone in common
bile duct; can lead to
sepsis
Stones—cholesterol,
pigmented
Gastrointestinal/Nutrition Disorders
69
ETOH w/recurrent
episodes
Jaundice, wt loss,
abdominal pain, usu late
finding if Sxs
Chronic pancreatitis
Neoplasms (usu in head
of pancreas)
Hx
✓ Meds (CCBs)
↓ Stool volume,
↑ hardness
LLQ pain (colicky), fever,
chills
Constipation
Diverticular disease
(left-sided appendicitis)
—urgent
CT
Barium enema
(not w/acute)
UTZ, CT, WBCs
+ RLQ pain (McBurney),
N&V, anorexia, guarding
Carbohydrate antigen
19-9
CT
Calcification on X-ray
UTZ, CT, X-ray,
CBC w/differential,
amylase/lipase
Appendicitis
(10-30 yr)
Emergency!
Small Intestine/Colon
ETOH, Hx of gallstones,
+ abdominal pain
radiates to back, N&V
Acute pancreatitis
(gallstone in common
bile duct)
Dx
Pain management,
fluid restriction,
possible su gery
Abx,
nuts or seeds
↑ Fiber, ↑exercise,
↑ fluids
Osmotic laxatives
Appendectomy—even if
normal
Abx if perforation
Surgery—Whipple
procedure
ETOH, pain
management (opiates)
NPO, PO fluid restriction,
IV fluids OK, pain control
Surgery if stone involved
Tx
SA P
M RO
PL P
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C T
O Y
N O
TE F
N EL
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- N SE
O VIE
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FI
N
AL
Signs/Sxs
Pancreas—Urgent/Emergent
Disorder
Usu sigmoid colon
>50 yr old, ✓ colon CA
Early = umbilical pain
Late = RLQ pain
Ruptured = generalized
90% adenocarcinoma
Trousseau sign
Prognosis: 5% survival
at 5 yr
↓ Pain when leaning
forward
Ranson criteria
Serum Ca++ <7.0 = poor
prognosis (tetany)
Pseudocyst risk
Pearls
70
Review 2 Rounds: Visual Review and Clinical Reference
Clinical
+ Hx of stress; ↑,
↓ pain w/defecation;
+ diarrhea and/or
constipation
+ Sudden abdominal
pain; + Hx of CHF, MI,
hypotension
Silent, + rectal bleed, +
change in bowel habits, Hx
of CA (metastases?)
+ Vomiting,
+ distention, + pain,
+ shock =
Emergency!
Irritable bowel syndrome
(IBS)
Ischemic bowel disease
(↓ blood flow)
Neoplasms
(60-80 yr)
Obstruction (small
intestine)—urgent
3-way X-ray =
air-fluid levels
Colonoscopy
w/biopsy
X-ray, UTZ, CT lab tests,
angiography
Barium enema
CT
“Currant jelly” stools
= mucus
Severe colicky pain
Intussusception
Barium enema =
Dx and Tx
1. NPO, fluid restriction,
NG tube decompression
2. Surgery if complete
block
1 Surgery
2. Radiation/chemo
3. ✓ CEA
Tx of cause
Laparotomy
Antidiarrheal,
antispasmodic,
antidepressive
Children: barium enema
Adults: surgery
Rx sulfasalazine, steroids
Surgery = UC (cure),
CD ( cure)
UC (large intestine and
more superficial mucosa)
vs CD (terminal ileum/small
intestine/deeper layers)
SA P
M RO
PL P
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C T
O Y
N O
TE F
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- N SE
O VIE
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FI
N
AL
+ Bloody diarrhea,
+ rash + tenesmus
(spasms) erythema
nodosum
Inflammatory bowel
disease (IBD; aka UC
or CD)
(Continued)
Usu mechanical or
adhesions from surgery
98% adenocarcinoma
✓ DDx; ischemic colitis
= different Tx
✓ Anxiety, depression
95% children age
<2 yr
+ Jewish ethnicity
Usu diagnosed at
early age
CD = vitamin B12
deficiency
Gastrointestinal/Nutrition Disorders
71
+ Fever, + abdominal
distention, peritonitis
+ Fever, + abdominal
distention, pain,
constipation
Toxic megacolon
Emergency!
Hirschsprung megacolon
(pediatric—urgent)
+ Skin tags, + ulcer,
pain
Palpable tenderness,
+ pain w/defecation
+ Pelvic pain, + N&V,
+ distention
Pain = external
Pain = internal (bright
red blood)
Anal fissure
Anorectal abscess/fistula
Fecal impaction
Hemorrhoids
Rectum
Age >65 yr, Hx of laxative
use, con tipation, LLQ
pain (sigmoid), RLQ pain
(cecum)
Volvulus
Emergency!
Hx Anoscopy
Physical exam
Physical exam
Barium enema + X-ray
Biopsy
Manometry
X-ray of >6 cm colon
3 abdominal series
Dx
Dietary change stool
softener, ↑ H2O
Surgery if large
Enema, dig tal removal,
stool softener
I&D
Stool softeners
Referral
Surgery consult
(pull-through procedure)
1. Fluids
2. IV steroids
3. IV Abx
4. Surgery if no change
at 24-48 hr
Surgical emergency
Tx
SA P
M RO
PL P
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C T
O Y
N O
TE F
N EL
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- N SE
O VIE
T R
FI
N
AL
Signs/Sxs
Disorder
May thrombose
✓ Meds, psychiatric
status, activity level
Associated w/CD
Due to lack of nerve cell
growth in last part of
large intestine
Associated w/UC
Pearls
72
Review 2 Rounds: Visual Review and Clinical Reference
Physical exam
Clinical
Asymptomatic;
+ pain in groin, + lump in
groin that ↑s
w/standing or straining,
+ hernia ✓
↑ Mass of umbilical ring
Inguinal (direct vs
indirect)
Umbilical
Ventral
Clinical
+ Mass at surgical site
Incisional
UG series
1. Endoscopy
2. Barium enema
3. Colonoscopy
+ Reflux, + dysphagia
Sxs, hematochezia?
Physical exam
Hiatal
Hernia
Polyps (elderly)
Abscess near coccyx,
sacrum; Hx of poor
hygiene
Pilonidal disease
(15-40 yr)
Biopsy
Children = resolves by
12 mo
Adults = surgical repair
Surgical consult
Surgical repair
Hiatal = metoclopramide,
H2 blocker, PPI
Paraesophageal = surgery
Surgery = removal
Recheck in 3 yr
I&D
↑ Hygiene
Surgery = excision
Radiation/chemo = large
size and metastases
SA P
M RO
PL P
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C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Rectal mass, bleeding,
pain DC, itching,
tenesmus
Neoplasms (rare)
(Continued)
Direct = acquired (adults)
Indirect = congenital
(children)
Can lead to bowel
strangulation
Hx of abdominal surgery
Hiatal = LES
Paraesophageal =
stomach/thorax
Can lead to CA
Rectal CA associated
w/HPV and rectal sex
Gastrointestinal/Nutrition Disorders
73
Sudden change in bowel
habits
Asymptomatic or
pulsatile mass =
rupture + pain,
tearing feeling = rupture
Colicky abdominal pain
Fever, abdominal pain,
ascites?
+ PVD, + meds, pain out
of proportion to physical
findings, bruit
Abdominal aortic
aneurysm (AAA)
Renal calculi—urgent
Peritonitis—urgent
Mesenteric ischemia
Emergency!
Angiography
Paracentesis, plain films,
CT
Plain films in 80%
CT w/contrast
in 20%
Urine pH
CT, UTZ
Fecal WBCs
Stool culture
Dx
Emergency surgery
(arterial reconstruction)
Look for reason for
secondary peritonitis
Other chronic Dz
Struvite = catch at home
Uric acid = ↑ urine pH
>6 5 (dissolves)
Ca++ (most common) = catch
Surgery if ruptured
Elective surgery at 4 cm
> 6 cm = emergency
surgery
1. Rehydrate (electrolytes)
2. Abx (especially if
C. diff)
3. Loperamide
4. Metronidazole
Tx
SA P
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PL P
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C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Signs/Sxs
Other Abdominal Illnesses
Infectious diarrhea
Infectious
Disorder
Urinary pH:
>7.5 = struvite
<5.0 = uric acid/cystine
N/A = Ca++
See Infectious
Diarrhea table
Pearls
74
Review 2 Rounds: Visual Review and Clinical Reference
Pellagra coenzyme
Stomatitis, glossitis
Beriberi—irregular HR,
encephalopathy, weakness/
pain in limbs, signs of HF
Night blindness
Glossitis, cheilosis, stomatitis
Scurvy—bleeding gums,
purple skin spots (LEs),
opening of healed scars
Rickets, osteomalacia
Hemorrhage
Abdominal pain, flatulence,
diarrhea
Metabolism error, odorous
urine
Thiamine—B1
Vitamin A
Riboflavin
Vitamin C
Vitamin D
Vitamin K
Lactose intolerance
(↓ intestinal
lactase)
Phenylketonuria
(PKU)
Infancy screening
Clinical, Hx
Lactose intolerance test
Lactose breath
hydrogen test
Dietary restrict on of phenylalanine
Dietary restriction of dairy products
Supplementary lactase intake
Probiotics
Ca++ and vitam n D supplements
Liver, oils, green leafy vegetables
Mi k, liver eggs, tuna, salmon
Renal problems, ↑ Ca++
Dyspnea, CV collapse
Citrus fruits, tomato
Organ meat, dairy, green leafy
vegetable
Liver, dairy, yellow/green leafy
vegetables
Organ meat, beans, grains, wheat
Meats, grains, milk
Found In
Nausea, diarrhea
No significant
problems
Liver cell death,
intracranial HTN
Ataxia, lethargy
Liver damage
Hyperglycemia
↑↑ Leads To
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PL P
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C T
O Y
N O
TE F
N EL
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- N SE
O VIE
T R
FI
N
AL
↓ Leads To
Niacin—B3
Nutritional
Disorders
Can lead to mitral
regurgitation
✓ Allergy Hx
Used as warfarin
OD Rx
Can be fatal if
severe
Pearls
Gastrointestinal/Nutrition Disorders
75
76
Review 2 Rounds: Visual Review and Clinical Reference
Anatomy and Testing of the Gastrointestinal
System
See Figures 4-1 and 4-2.
Pearls for the Abdominal Pain Patient
SA P
M RO
PL P
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C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
The workup for “my stomach hurts”
• Lab tests for acute abdominal pain
• CBC, chem 7, LFTs, amylase, lipase, β-HCG, lactate, UA, G&C
• UTZ, abdominal obstructive series, CXR, CT, UGI, colonoscopy,
paracentesis
• Rectal (all pts); pelvic (all ♀)
• Red flags for emergency department evaluation or admission
• Pain out of proportion
• Pulsatile mass
• Bilious vomit
• Nonreducible hernia
• + Pregnancy test
• Peritoneal signs (guarding, rigid abdomen)
• Groin pain radiating to flank
• RUQ pain, obstructive LFTs, fever
• Periumbilical-RLQ pain, N&V, fever
• Acute abdomen
• Surgical emergency!
1
2
Transverse
colon
3
8
7
4
6
9
5
Appendix
10
Sigmoid
colon
Figure 4-1. Gross anatomy of the GI tract.
1. Esophagus
2. Stomach
Small bowel:
3. Duodenum
4. Jejunum
5. Ileum
6. Cecum
Large bowel:
7. Ascending colon
8. Transverse colon
9. Descending colon
10. Rectum
Gastrointestinal/Nutrition Disorders
Esophagus
Liver
77
Endoscopy
Stomach
Gallbladder
Biopsy
Duodenum
Pancreas
CT
SA P
M RO
PL P
E ER
C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Ileum
Haustra
Ascending
colon
Appendix
Colonoscopy
Jejunum
Flexible
sigmoidoscopy
Rectum
Anus
Ultrasound
ERCP enables the physician to diagnose problems
in the liver, gallbladder, bile ducts, and pancreas
Figure 4-2. Testing of the GI system.
• Signs and Sxs: distention, quiet abdomen, involuntary
guarding vital signs changes, free air under diaphragm
• Tx: NPO, IV fluids, Fo ey catheter, CVP line, arterial line,
attempt to find cause, get blood products, consults
• Additional Pearls
• Solid organ = constant pain
• Hollow organ = colicky pain (spasm of tube, hollow organ)
• The smaller the tube, the greater the pain
• Spikes of pain = obstruction during peristalsis, crescendo
• Diffuse pain = visceral peritoneum (autonomic nerves)
• Localized pain = parietal peritoneum (somatosensory nerves)
• Higher abdominal pain = foregut pathology (esophagus,
stomach, duodenum, liver, gallbladder, superior pancreas)
• Lower abdominal pain = hindgut pathology (distal third of
transverse colon, splenic flexure, descending and sigmoid
colons, rectum and upper anal canal)
• Recurrent pain = PUD, gastroenteritis, renal stones, biliary
colic, cholecystitis, pancreatitis, diverticulitis, irritable bowel
• Meds that cause abdominal pain = NSAIDs, Abx,
anticholinergics, narcotics, steroids
• Cardinal signs of pain = fever, chills, N&V, changes in stool
patterns, anorexia, jaundice
78
Review 2 Rounds: Visual Review and Clinical Reference
Abdominal Pain by Type
Gradual Onset
Referred Pain
Ectopic pregnancy
Intestinal obstruction
Mesenteric ischemia
Peritonitis
Renal stone
Splenic rupture
Perforation
Appendicitis
Diverticulitis
IBS
IBD
GERD
Cholecystitis
Gallbladder → right
shoulder
Hepatic abscess →
right shoulder
Pancreas → straight
through to back
GERD → burning
sensation, rising up
below sternum
Renal stone → loin
to groin
Splenic rupture →
left shoulder
SA P
M RO
PL P
E ER
C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Sudden Onset
Abdominal Pain by Quadrant
RUQ
LUQ
Generalized
Cholecystitis
Pancreatitis
Appendicitis
Hepatitis
Hepatic abscess
CHF
Herpes zoster
Myocardial ischemia
Perforated duodenal
ulcer
Right lower lobe PNA
Pancreatitis
Gastritis
MI
Left lower lobe PNA
Gastric ulcer
Splenic enlargement,
rupture, infarction,
or aneurysm
Pancreatitis
AAA
Bowel obstruction
Gastroenteritis
Mesenteric ischemia
Appendicitis
Abdominal wall
strain
Peritonitis
Sickle cell crisis
RLQ
LLQ
Appendicitis
Diverticulitis
AAA
Ectopic pregnancy
Endometriosis
Inguinal hernia
PID
Mittelschmerz
Psoas abscess
Regional enteritis
Seminal vesiculitis
Torsed ovarian cyst
Ureteral calculi
Diverticulitis
AAA
Ectopic pregnancy
Endometriosis
Inguinal hernia
PID
Mittelschmerz
Psoas abscess
Regional enteritis
Seminal vesiculitis
Torsed ovarian cyst
Ureteral calculi
Bactrim/ciprofloxacin
Erythromycin
Ciprofloxacin/3G
cephalosporin (Rocephin)
Campylobacter (C)
Salmonella (C, eggs)
Yes
Fecal leukocytes
Shigella (C, F, day care)
Fecal urgency
Other
Cause
Lower abdominal
Pain
Treatment
(Supportive +)
↑, watery
↓, bloody
Volume
Vibrio parahaemolyticus/
E. coli (F, H2O)
Giardia (H2O)
Protozoan
Vibrio (H2O, F)
Cause
No
N&V
Upper abdominal
Noninflammatory
Inflammatory
Distinguishing
Factors
SA P
M RO
PL P
E ER
C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Infectious Diarrhea
(Continued)
Bactrim/ciprofloxacin
Flagyl
TCN/doxycycline
Treatment
(Supportive +)
Gastrointestinal/Nutrition Disorders
79
Rotavirus
Flagyl
Flagyl vancomycin
None
Entamoeba h stolytica
(H2O)
Parasite
C. diff (Abx)
E. coli
0157:H7 (B)—(HUS)
None
None
Clostridium perfringens
(canned foods; 24 hr)
Electrolytes
Electrolytes
S. aureus (mayo, cream; 1-6hr)
Norwalk virus
Noninflammatory
SA P
M RO
PL P
E ER
C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Inflammatory
Bacillus aureus (inflammatory): caused by poorly refrigerated food; Sxs = 1-6 hr vomiting, 8-16 hr diarrhea, “fried rice”;
Tx = symptomatic; serious infections = ED
Vibrio cholerae: death in 3-4 hr if no Tx; “rice-water” stools; severe diarrh a; Tx = replace fluids, ?Abx
B, bacteria; C, chicken; F, fish.
Distinguishing
Factors
80
Review 2 Rounds: Visual Review and Clinical Reference
Fecal-oral
Blood, sex
IV drug use
IV drug use, sex
Hemophilines (needs hepatitis
B to exist)
Fecal-oral
A
B
C
D
E
Wilson disease
Autoimmune
Route of Infection
Supportive only
None
IFN-α and ribavirin
Vaccine, IgG
Vaccine, IgG (family)
Acute Tx
SA P
M RO
PL P
E ER
C T
O Y
N O
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Hepatitis Type
Hepatitis
Copper chelation
Corticosteroids
IFN-α
IFN-α
IFN-α
Chronic Tx
Gastrointestinal/Nutrition Disorders
81
Ch04-B0169.indd 82
IgM
Surface antigen
HCV (core)
Needs B to exist, see above
IgM
Hepatitis A
Hepatitis B and D
Hepatitis C
Hepatitis D
Hepatitis E
• The body makes IgM to:
• Core antigens (hepatitis C)
• The Evil guy (hepatitis E)
• Surface antigen (subway that transports other types)
• IV drug users: + core and surface antigens
• Health care workers: + surface antigens only
Present Infection = +
Wilson Dz
Autoimmune
Hepatitis D
Hepatitis C
Hepatitis B
Infection Type
SA P
M RO
PL P
E ER
C T
O Y
N O
Pearls to Test Interpretation
TE F
N EL
T
- N SE
O VIE
T R
FI
N
AL
Infection Type
Lab Tests
Ceruloplasmin
ANA
Hepatitis D virus
HCV
Surface antigen
Chronic Infection = +
82
Review 2 Rounds: Visual Review and Clinical Reference
5/6/2009 1:06:46 AM
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