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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
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

Classic triad for chronic pancreatitis:
Pancreatic calcification

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:

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
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

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