Exam 2 - GI (liver, gall bladder, pancreas, colon) Flashcards
AST and ALT are formed in which organ?
Liver
Alk Phos formed in which two organs?
Liver and bone
Normal bile duct diameter for a 20 y/o?
2mm
Common Bile duct made of which two ducts?
Cystic Duct + Hepatic Duct
Role of bile?
Emulsifies fat, assists in fat absorption
Describe Hepatocellular Pattern (AST, ALK, etc)
Up: AST and ALT
Down: Alk Phos
+/- up: Bili
Describe Cholestasis Pattern (AST, ALK, etc)
Up: Alk Phos
Down: AST, ALT
+/- up: Bili
Elevated GGT suggests what?
Indicator of biliary injury
Hepatocellular pattern seen with what sort of injury?
Intrahepatic injuries
Cholestatis pattern seen in with what sort of injuries?
Extrahepatic (biliary obstruction)
Intrahepatic (primary biliary cholangitis)
Most common and costly digestive dz?
Cholelithiasis
Etiology of Cholelithiasis?
Gall stone in gallbladder.
No inflammation!
Is Cholelithiasis inflammatory?
NO!
5 Fs of Cholelithiasis?
Fat, fair, female, forty, fertile
What is most common complication of Cholelithiasis?
Acute Cholecystitis
Sx of Cholelithiasis?
Most commonly ASx. RUQ biliary colic.
When would Cholelithiasis present with sx?
Post-high-fat/greasy meal
Does Cholelithiasis make a PT look sick? Fever? Jaundice?
NO. They look and feel fine.
Dx of Cholelithiasis?
RUQ U/S
LFT in uncomplicated Cholelithiasis? Complicated?
Uncomplicated=Normal
Complicated=Cholestasis pattern (up Alk Phos, down AST and ALT)
Elevated GGT seen in?
Cholestasis
Tx of Cholelithiasis?
ASx=Expectant manageement.
Sx=Prophylactic cholecyctectomy
Tx for Cholelithiasis if can’t have surgery?
Bile salts for 2 years max.
Eti of Acute Cholecystitis?
Inflammation of Gall Bladder d/t cystic duct obstruction by gall stone. 90% of
What happens to GB in Acute Cholecystitis?
Gangrene of GB. GB perforates.
Where is pain in Acute Cholecystitis? Fever?
RUQ. Sudden epigastric pain onset.
+ fever
When does pain start in Acute Cholecystitis? What triggers it?
30 minutes after fatty food or large meal
What is Murphy’s Sign?
In Acute Cholecystitis.
Acute RUQ pain and inspiratory arrest with Gall Bladder palpation.
Imaging in Acute Cholecystitis?
Initial=U/S
Gold standard=HIDA scan
CBC and LFT in Acute Cholecystitis?
Leukocytosis w/left shift.
Elevated LFTs, no specific pattern.
Tx in Acute Cholecystitis?
Admit to hosp. IV fluis, pain mgt, abx. Drain before surgery is complications.
<24h=laparotic cholecystectomy
>24h=open cholecystectomy
Eti of Choledocolithiasis?
Gallstones in Bile Duct. Formed or returned after cholecystectomy.
Pain location and type in Choledocolithiasis? Fever?
RUQ or midepigastric pain. Biliary-type pain. No fever.
LFTs in Choledocolithiasis?
Cholestatic pattern!
Up: Alk Phos, +/- bili
Down: AST, ALT
Dx of Choledocolithiasis?
U/S showing gall stone in common bile duct
Tx of Choledocolithiasis?
ERCP.
Most also have cholecystectomy.
Eti of Acute Cholangitis?
Bacterial infx d/t obstructive gall stone.
M.C.=E. Coli
70% of in Acute Cholangitis due to what?
Choledocolithiasis
What triad in in Acute Cholangitis?
Charcot Triad= Fever, ABD/RUQ pain, jaundice
What pentad in Acute Cholangitis?
Reynold Pentad=Charcot + Hypotension + Confusion
LFT in Acute Cholangitis?
Cholestatic pattern!
Up: Alk phos, +/- bili
Down: AST, ALT
CBC in Acute Cholangitis?
Leukocytosis w/Left shift
Initial imaging dx in Acute Cholangitis? Test of choice?
Initial=ABD U/S
TOC=ERCP
Tx of Acute Cholangitis?
-Admit
-ABX=PCN + Aminoglycosides for empiric treatment
ERCP=drain biliary tree and extract gall stone
Primary Sclerosing Cholangitis occurs to who?
Men, 20-25 y/o
Primary Sclerosing Cholangitis increases risk for what?
Cholangiocarcinoma, GB cancer, hepatocellular carcinoma
Primary Sclerosing Cholangitis highly correlated with what other dz?
Ulcerative Colitis
Primary Sclerosing Cholangitis leads failure of what?
Liver
Sx in Primary Sclerosing Cholangitis
ASx, fatigue, pruritus
PE in Primary Sclerosing Cholangitis
ASx, jaundice, splenomegaly
LFT in Primary Sclerosing Cholangitis
Cholestatic pattern
Up: Alk Phos (a lot!), GGT
Down: ALT, AST
Dx of Primary Sclerosing Cholangitis
MRCP (other sources say ERCP, lecture notes say MRCP)
Tx of symptoms of Primary Sclerosing Cholangitis? Definitive tx?
Sx=UDCA for 2 years. Stents. Buys time.
Def=liver transplant
What is the #1 GI in-patient issue?
Acute Pancreatitis
Etiology of Acute Pancreatitis?
Intracellular enzyme activation leads to autodigestion of pancreas
90-95% of Acute Pancreatitis is which type? Necrosis?
Interstitial. No necrosis.
2 major Causes of Acute Pancreatitis?
EtOH abuse, gall stones
Where and what time of pain in Acute Pancreatitis?
Sudden midepigastric pain. Radiates (boring) to back.
Sx of Acute Pancreatitis?
Midepigastric pain, nausea, vomiting, dyspnea
PTs with Acute Pancreatitis sit in what position?
Lean forward
PE of severe Acute Pancreatitis?
Tachypnea, hypoxemia, hypotension.
Cullens Sign=bruising of embilicus d/t int bleed
Grey-Turner Sign=discolored flanks d/t severe nectrotizing pancreatisis
Describe Cullens Sign and which dz
Bruising of embilicus d/t int bleed. Severe acute pancreatitis.
Describe Grey-Turner Sign and which dz
discolored flanks d/t severe nectrotizing pancreatisis. Severe acute pancreatitis.
Which two main labs in Acute Pancreatitis?
Amylase and Lipase. Both 3x ULN.
Bilirubin in Acute Pancreatitis?
Direct bili higher than indirect
Fasting Triglycerides in Acute Pancreatitis?
> 1000
Imaging TOC in Acute Pancreatitis?
ABD CT
Dx of Acute Pancreatitis required ≥ 2 of…
- Midepigastric abd pain
- Amylast and/or Lipase 3x ULN
- Positive CT showing pancreatitis
Tx of Acute Pancreatitis?
Admit, NPO, IV fluids, analgesia, antiemetics. Find underlying cause.
When to repeat labs in Acute Pancreatitis?
q8-12h. Check BMP, CBC, etc.
Serial Exams in Acute Pancreatitis to prevent what?
Prevent fluid overloading!
What is Ranson Score in Acute Pancreatitis? Good or bad test?
Estimates mortality from pancreatitis. Done on admission (5 tests) and after 48h (6 tests). Poor predictor but used often.
What is SIRS Score in Acute Pancreatitis? Specific for it?
Preduct severity of pancreatitis. Easily done at bedside. Temp, HR, RR, WBC.
Not specific for Acute Pancreatitis.
What is #1 cause of Chronic Pancreatitis?
EtOH abuse.
Idiopathic 25%.
Is damage to pancreas reversible in Chronic Pancreatitis?
No. Irreversible dmg to pancreas.
What happens to tissue and histologic findings in Chronic Pancreatitis?
Histologic abnormalities. Fibrosis, atrophied/destroyed exocrine and endocrine tissue.
If PE in Chronic Pancreatitis impressive? What might see?
No, mostly unimpressive. Weight loss, abd pain, anorexia.
What is poop like in Chronic Pancreatitis?
Steatorrhea (fatty and foul smelling poop!)
Are there biomarkers for Chronic Pancreatitis?
Nope
Easy or hard to dx early and mild Chronic Pancreatitis?
HARD!
Imagine for Chronic Pancreatitis? When?
ABD CT showing necrotic pancreas.
Only for initial dx, not after.
Tx of Chronic Pancreatitis?
Low fat diet, no EtOH.
Abd pain=Hard to treat, try TCAs. Avoid opiates.
Steatorrhea=pancreatic enzyme
Whipple procedure, total pancreatectomy.
What is Diverticulosis?
Mucosal sac-like herniations protruding through colon muscle layer
Where is 95% of Diverticulosis?
Sigmoid colon due to HIGH pressure
Diverticulosis sx or asx?
70-80% Asx
Is colon muscle wall inflammed in Diverticulosis?
NO
What is main cause of lower GI bleed?
Diverticulosis?
Dx for Diverticulosis?
Colonoscopy
Tx for Diverticulosis?
High fiber diet, fiber supplements
Etiology of Diverticulitis? What percent of diverticulosis?
Inflammation of diverticulum secondary to obstruction/infx causing distension. 4%.
Where is pain in Diverticulitis? Lasts how long?
LLQ pain. Constant for days.
PE of LLQ in Diverticulitis?
Rigid. Tender, palpable mass.
Imaging to dx Diverticulitis?
ABD CT w/IV contrast, +/- PO contrast
WBC and guaiac in Diverticulitis?
Elevated WBC.
Positive stool guaiac.
Tx of micro perf in Diverticulitis? Abscess?
Micro perf=Medical tx
Abscess=I.R. drainage
Tx of free perf in Diverticulitis? Significant obstruction?
Free perf=Emergency surgery
Sig obstruction=Urgent to emergent surgery
Which ABX and bacteria to tx in Diverticulitis?
Entero and gram - anaerobes (B. Frag).
Cipro + Flagyl
When and what in follow-up of in new dx Diverticulitis?
6 weeks post-abx get colonoscopy if not had in past year
What is main cause of hematochezia/lower GI bleed?
Diverticular Bleed
Diverticular Bleed caused by injury to what?
Injury to vasa recta from recurrent injury
What is major source/location of Diverticular Bleed?
Right colon, hepatoflexure
Diverticular Bleed often self-limited?
Yes!
Pain in Diverticular Bleed?
No! Painless!
PE if bad Diverticular Bleed?
Hemodynaically unstable. Pallor, tachycardia.
Normal labs in Diverticular Bleed?
Yes, normal labs.
How to dx Diverticular Bleed?
Colonoscopy after resuscitation
Resuscitation in Diverticular Bleed?
2 large bore IVs, type & cross-match blood, transfuse PRBCs
Tx of active Diverticular Bleed?
Colonoscopy w/submucosal epi or endoscopic tamponade
Tx if fail colonoscopy treatment and unstable in Diverticular Bleed?
Segmental colectomy
