Exam 2 Flashcards
effect of aging on hepatic and biliary perfusion
decreased by 30-40%
effect of aging on caffeine clearance
decreased
effect of aging on bile flow
decreased by 50%
effect of aging on hepatic function
hepatic function remains intact
effect of aging on liver regeneration capacity
reduced
effect of aging on antiviral therapy for hepatitis
elderly may not respond
effect of aging on risk of colelithiasis
elevated risk
why elevated risk of cholelithiasis in elderly
increased cholesterol synthesis with decreased bile acid secretion
why is gallbladder function impaired with age
impaired contractility, increased volume, decreased CCK receptors
“classic” signs of cholelithiasis that are absent in 50% of cases in elderly
fever, N/V
why are women more prone to cholelithiasis
estrogen’s effects on cholesterol synthesis
effects of aging on exocrine pancreas
pancreatic juice steadily decreases after the age of 50, limited ability to increase lipase and amylase, but there is adequate reserve to maintain normal digestive capacity. Increased production of autoimmune antibodies
what % of cases of pancreatitis are due to alcohol abuse
70%
when does alcoholic pancreatitis classically present
middle age
what etiology of pancreatitis increases in older people
gallstones
what to watch out for if underling pancreatitis is not due to ETOH or gallstones
adenocarcinoma
acute pancreatitis labs
amylase/lipase 3x upper limit
acute pancreatitis tx
bowel rest, IV fluids, pain control, ERCP if gallstones, IV abx if necrosis on CT scan, gastric decompression
when to use abx for acute pancreatitis
if necrosis on CT scan
how long does lipase remain elevated
5-7 days
which elevates first, amylase or lipase
amylase
when does amylase return to normal
48 hours
when does lipase elevate
24-48 hours
when does oral intake resume in acute pancreatitis
when pain free
what pain med to use in acute pancreatitis
meperidine
chronic pancreatitis usual etiology
alcoholism
most common location/type for pancreatic cancer
70% is adenocarcinoma of pancreas
what % of NASH progresses to cirrhosis and what % dies
4%, 2%
NASH ssx
asymptomatic or vague RUQ discomfort
risk factors for NAFLD/NASH
BMI>40, male, DM, metabolic syndrome, “hispanic”
what drugs can precipitate NAFLD
tamoxifen, methotrexate, amiodarone, prednisone
first step and gold standard for NAFLD diagnosis
abdominal US, biopsy
what intervention can lower ALT/AST and insulin level in NAFLD
10% weight loss
risk factors for HCC
hepatitis (of any cause), cirrhosis, hemochromatosis, alpha-1 antitrypsin, Wilson’s, NAFLD
screening for HCC
AFP followed by US
ssx of HCC
jaundice, anorexia, fatigue, weight loss, upper abdominal pain, ascites, LFT changes
what imaging to obtain after HCC diagnosis
chest x-ray to look for mets
gallbladder cancer is usually what kind
adenocarcinoma
CEA/CA 19-9 in gallbladder cancer
not specific
cholangiocarcinoma is usually what kind
adenocarcinoma (90%)
what % of acute cholelithiasis are geriatric
50-70%
test of choice for cholelithiasis/cholecystitis
US/HIDA
benefit of ERCP in cholelithiasis/cholecystitis
can be diagnostic and therapeutic
tx of choice for cholelithiasis/cholecystitis
laparoscopic removal
pancreatic exocrine deficiency in elderly
rare without underlying pathology
bicarbonate in the elderly
decreases steadily after 4th decade
what scale is used to assess severity of acute pancreatitis
Ranson criteria
amylase/lipase in chronic pancreatitis
mildly elevated
imaging findings in chronic pancreatitis
calcifications
what may be needed to make diagnosis of chronic pancreatitis
ERCP, MRCP, EUS
chronic pancreatitis treatment
pancreatic enzyme replacement
what % of pancreatic cancer pts are >55
87%
5-year survival of pancreatic cancer
5%
effect of aging on liver volume
40% decrease
effect of aging on coags/LFTs
unaffected
NAFLD pathophys
insulin resistance enhances triglyceride lipolysis and increases serum free fatty acids which are taken up by the liver
conditions associated with NAFLD
hyperlipidemia, insulin resistance/DM, metabolic syndrome, hep C, rapid weight loss, TPN, Wilson’s disease, diverticulosis, PCOS, OSA
risk factors for NAFLD
insulin resistance, metabolic syndrome, jejunoileal bypass, age, genetics, some drugs
HCC screening for patients at risk
AFP (alpha-fetoprotein) and US q 6-12 months
what to do if screening AFPs are rising
order imaging to see if there is a mass
what to do if no mass is confirmed after AFP is elevated
follow up q 3 months with AFP, liver imaging
which ethnic group has lowest incidence of NAFLD
African Americans
Claire is 69 and has had non-alcoholic fatty liver for about five years. Recently, she was diagnosed with atherosclerosis in her coronary arteries. The most likely mechanism that links these two disorders is
endothelial dysfunction
aging effect on gastric acid
decreased due to fewer cells and use of acid suppressing meds
implications of decreased gastric acid in elderly
decreased B12, iron, folic acid, altered gut flora leading to diminished immune response
effect of aging on GI motility and why
decreased, loss of neurons and atrophy of muscle layer
implications of decreased GI motility in elderly
atrophy of muscle layer leads to diverticula
effect of aging on splanchnic bloodflow and implications
reduced, results in decreased nutrient absorption
implications of SIBO in elderly
bacteria take up nutrients, bacterial proliferation damages epithelium brush border leading to malabsorption
causes of SIBO in elderly
impaired motility, abx disrupting balance, undigested carbs feed bacteria
SIBO diagnosis
breath tests or biopsy
abx associated colitis prognosis
usually mild and self-limited, resolves after discontinuation of abx
cautions with vancomycin
ototoxic, nephrotoxic
tx for mild/moderate c diff
metronidazole
tx for severe c diff
vanc
tx for very severe c diff
both metronidazole and vancomycin possible colectomy
gold standard for c diff diagnosis
stool culture
when will they test formed stool for c diff
only if you suspect ileus/obstruction
considerations with metronidazole for c diff
don[t use it after the first occurrence or for long-term treatment due to neurotoxicity
considerations for c diff testing
don’t test asymptomatic or test for cure
how many have c diff relapse within 1-2 weeks after abx
20%
infection control measures for c diff
decon with bleach, glove/gown upon entry to pt room
treatment for diverticulitis
cipro plus metronidazole (or bactrim plus metronidazole) 10-14 days and clear liquid diet
what to do if initial diverticulitis treatment doesn’t help
get imaging, must r/o malignancy
when to get colonoscopy with diverticulitis
after resolution of attack, usually at least 6 weeks after discharge
risk of colonoscopy during diverticulitis attack
converting sealed perforation into free perforation
differences in how appendicitis may present in elderly
fewer have fever, may have diffuse pain, delayed left shift
colon cancer screening after age 75
if no previous diagnosis of colon cancer, colonoscopy risk is greater that colon cancer risk
reasons for increased polyp formation with age
NSAID use, calcium supplementation
ulcerative colitis in the elderly
symptoms are similar as in younger people but milder
which type of laxative does she think we should avoid
osmotic/magnesium
which laxative does she think is safe for long term use
senna +/- stool softener
how long does it generally take for diverticulitis ssx to resolve
48-72 hours
diverticulitis complications
perforations, abscess
which colon cancer annual test is recommended by USPTF
Cologuard instead of FOBT
which IBD is more common in elderly
Crohns
most prevalent neoplastic polyps
adenomatous
risk of developing cancer in high-grade adenomatous polyps
25%
what makes adenomatous polyps more risky
quantity, large size (at least 1 cm)
what triggers colon cancer screening q 3 years
large number of polyps, high-grade adenomatous, large size of polyps
screening frequency for 1-2 tubular adenomas
q 5 years
mainstays of treatment in IBD in elderly
sulfasalazine, mesalamine, corticosteroids
when does colon cancer risk increase with IBD
after 8-10 years of the disease
“most common complaint in elderly”
constipation
what to assess in elderly pt complaining of constipation
DRE, assess pelvic floor/rectal prolapse in females
constipation diagnostic criteria
2 or more: straining, hard stools, incomplete evacuation, feeling of anorectal obstruction, manual maneuvers in 25% or more of defecations. LEss than 3 bowel movements/week
most common cause of constipation
dehydration, low fiber diet
initial treatment of constipation
drink 2x current amount of water (up to half body weight in ounces), fiber supplementation, increase physical activity
“safest laxative option”
senna-based
diverticulosis tx
increase fiber, prevent constipation, decrease fat, avoid seeds
“class” diverticulitis ssx commonly absent in elderly
fever, rebound tenderness
treatment of mild diverticulitis can be
empiric
moderate-severe diverticulitis needs
CT +/- hospitalization
tx for recurrent c diff
vancomycin taper x 1 month
indications for fecal transplant with c diff
recurrent c diff not responding to vancomycin taper, 2 or more c diff episodes causing hospitalization, refractory moderate c diff infection, severe c diff not responding to tx within 48 hours
when to consider SIBO diagnosis
weight loss, diarrhea, abd pain, macrocytic anemia, protein malnutrition
gold standard SIBO diagnosis
aspirate and culture of proximal jejunal secretion
SIBO tx
1-2 week broad spectrum abx with low fodmap diet
