Exam Flashcards
(347 cards)
1
Q
What should you always ask?
A
- eating/defecating make it better or worst
- last menstrual cycle
- what were you doing (trigger)
2
Q
Most common surgical emergency of the abdomen**
A
acute appendicitis
r/o 1st!
3
Q
acute appendicitis Sx
A
often inconsistent only 50% class RLQ pain, N/V Abdominal pain most common* (could be periumbilical/epigastric migrating to RLQ) Sx usu <48hrs N/V/D, constipation, anorexia vomit AFTER onset of pain*
4
Q
what should you worry about if vomiting precedes abdominal pain?
A
intestinal obstruction
5
Q
McBurney’s point
A
RLQ tenderness 96% in acute appendicitis
2/3 of way from umbilicus to ASIS
6
Q
Physical exam special tests for acute appendicitis
A
McBurney’s point
Rebound tenderness (Blumberg sign)
Rovsing sign: RLQ pain w/LLQ palpation
Obturator sign: RLQ pain w/int/ext rot of flexed R. hip
Psoas sign: RLQ pain w/extension of R. hip or flex of R. hip against resistance
7
Q
Acute appendicitis labs
A
leukocytosis w/left shift 80-85% (unreliable in infants/elderly/preg)
elevated CRP
8
Q
imaging study to eval for acute appendicitis
A
CT Abd/Pel w/oral contrast
9
Q
Acute appendicitis Tx
A
NPO, IVF, Pain control, Antibiotics, consult surgery
10
Q
what should you worry w/”pain out of proportion to exam***
A
mesenteric infarction
bowel is dying, surgical emergency! need to re-vascularize
often w/A.fib/CHF
CTA, MRA
11
Q
imaging of choice for suspected rupture abdominal aortic aneurysm
A
U/S standard (pt unstable)
CT/CTA confirm if pt stable
high pre-hospital mortality
12
Q
Classic triad for ectopic pregnancy*
A
abdominal pain
amenorrhea
vaginal bleeding
13
Q
Imaging/labs for suspected ectopic pregnancy
A
hCG
U/S
14
Q
when do MIs most often occur?
A
early in the morning, may only present w/indigestion
15
Q
most common Sx of GERD/Esophagitis
A
Burning pain, worse w/lying down
16
Q
abrupt onset of abdominal pain in PUD is worrisome of?**
A
ulcer perforation
Sx: gnawing/burning epigastric pain
17
Q
Test of choice to Dx PUD*
A
EGD (esophagogastroduodenoscopy)
18
Q
Biggest causes of acute appendicitis**
A
alcohol
gallstones
(constant boring pain)
19
Q
Acute pancreatitis signs
A
Cullen sign
Grey-Turner sign
20
Q
what can acute pancreatitis be caused by in the elderly?
A
pancreatic tumor
21
Q
Biliary colic
A
sudden constant pain, 1-5hrs, may radiate to R scapula
gallstone temp block cystic duct
N/V
can develop into acute cholecystitis if untreated
22
Q
acute cholecystitis
A
inflammation of GB wall RUQ pain, radiate to R. scapula N/V, anorexia, fever Labs: leukocytosis, mild LFT elevation U/S Dx, May need surgery
23
Q
Charcot’s Triad (Ascending Cholangitis)
A
Fever
RUQ pain
Jaundice
24
Q
biliary dyskinesia
A
recurrent RUQ pain in absence of gallstones
pain typically 30-60min after eating (spicy, greasy), last 1-4hours
25
most common cause of small bowel obstruction
intra-abdominal adhesions
26
acute gastroenteritis
self limiting
eval for dehydration
typically fever, vomiting first then diarrhea, anorexia
supportive care, no abiotic
27
C. diff colitis Tx
metronidazole (PO, IV)
| vancomycin (PO only! IV doesn't penetrate gut)*
28
most common type of peritonitis
secondary, identify source
29
Late complication of PID
Tubo-ovarian abscess
| can be fatal if ruptures --> endotoxic shock
30
PID Dx criteria
lower abd tenderness
cervical motion tenderness
adnexal tenderness
often vaginal discharge
31
what can be the only presenting Sx of ovarian torsion*
lower abd pain
| may resolve spontaneously, if not, can infarct
32
most nutrients are absorbed in...*
small intestines
33
Hepatitis A mode of transmission*
Almost exclusively fecal-oral
| person to person
34
Hep A virus type*
SS RNA
35
When is Hep A transmission highest*
anicteric prodrome
36
What can destroy Hep A virus?
boiling water, chlorine, iodine
37
Increasing age in Hep A results in*
increasing adverse events
| Sx variable w/age
38
Hep A prognosis
usu mild, self-limited illness
39
Icteric phase of Hep A
dark urine first
some have pale stools
Jaundice in adults
Hepatomegaly
40
Treat Hep A in developing countries*
sugar canes
41
Hep A IgG*
past infection; patient IMMUNE
| OR vaccinated*
42
Post exposure prophylaxis of Hep A
immune serum globulin (Gammaguard) w/in 2wks of exposure
43
Hep B virus type*
DNA virus
44
Incubation period of Hep B
1-6mon! (while Hep A is 2-6wks)
45
Estimated global prevalence of Hep B
Est 1/3 of global popu infected
46
How is Hep B transmitted?
```
bodily fluids (blood, semen, vaginal secretions)
sexual, needles, PERINATAL,
```
47
Hep B Sx
acute phase: many asymp
viral prodrome w/icteric hepatitis (arthralgia, myalgia, transient skin rash, fatigue,)
jaundice last 1-3mon
anicteric hepatitis more to develop into chronic (more common)
48
Hep B core IgG
Past infection
NOT pos from vaccine
(Hep B Surface AB: HAD virus or vaccine)
49
Hep B E Ag
active viral replication, highly contagious
50
Heb B E AB
Carrier
51
Hep B Surface AB
HAD virus or vaccinated
52
Hep B: IF SURFACE ANTIBODY IS POS AND NOTHING ELSE*
VACCINATED FOR HEP B!!!* (immune)
53
Hep B: IF SURFACE AB IS POS AND CORE AB IS POS*
THEY HAD Hep B; BC DON’T GET POS CORE AB FROM VACCINE
54
Hep B Surface Ag
Acute or chronic (+6mon) infection
55
Hep B: Surface Ag Pos and E Ag pos*
Highly contagious infectious Hep B!
56
Hep B: Surface Ag Pos and E AB pos*
CHRONIC Hep B
57
What do all pts w/chronic Hep B (carrier or active) need?
screening regimen for hepatocellular carcinoma (HCC)
| increased risk w/co-infection w/ Hep C or D
58
Hep B Tx
First line: pegylated interferon alpha, entecavir, tenofovir disoproxil fumarate (TDF)*
Goal: suppress viral load & boost patient's immune response
59
Hep B lab values
ALT > AST
| AlkPhos/GGT elevated (no more than 3x ULN)
60
What should you routinely screen for every women, every pregnancy, every time?*
Hep B surface antigen
61
Newborns born to mothers w/ chronic hepatitis B need...
hepatitis B immune globulin and hepatitis B vaccination within 12 hours of birth!
62
Hep C virus type
SS RNA
63
Most frequent cause for liver transplant in US
Hep C
64
Prognosis of Hep C
70-85% remain viremic --> can develop chronic Hep C --> fibrosis --> cirrhosis (25%) or hepatic carcinoma
65
Hep C transmission
needles (IVDU, tattoo), straw (intranasal cocaine), razor, blood infusion before 1990
sexual and maternal UNCOMMON
66
Dx Hep C
Check HCV PCR and HCV AB
| Classic acute picture = HCV RNA positive but HCV AB negative (takes wks to mon to convert)
67
Hep C prognosis
good if treated
| but incidence incr from opioid epidemic
68
Hep C Sx
most asymp, PE often normal, fatigue most common
| Often not symp until advanced liver dz w/decompensation: mental status changes, edema, ascites, variceal bleeding
69
Is Hep C a protective AB?
NO! Can get Hep C again!
70
most common Hep C genotype
Genotype 1 (80% in US)
71
Hep C Tx Guidelines
Acute: just monitor for spontaneous clearing (min 6mon)
Chronic: depends on Genotype
WHO: TX ALL 12YO and older
72
Hep C Tx
protease inhibitor (eg sofosbuvir/simeprevir)
73
Hep D is only seen in...
Pts w/Hep B
| worst prognosis, progresses to cirrhosis more rapidly, can lead to fulminant hepatic failure
74
Hep D Tx
supportive, Tx Hep B
75
Fatty Liver Dz types
alcoholic: reversible; any person who consumes >60g alcohol per day
non-alcoholic: commonly assoc w/metabolic syndrome
very common, 1/3 popu
76
fastest growing cause of liver disease in the Western world
Non-alcohol fatty liver dz
77
most common cause of chronic liver disease in US adults (followed by alcohol & hep C)
Non-alcoholic steatohepatitis
78
What is predicted to become leading cause of liver transplantation by 2030
NAFLD (no sepcific Tx: control diet, weight loss, alc abstinence)
79
Alcoholic liver disease stages
alcoholic fatty liver, alcoholic hepatitis, alcohol-related cirrhosis
80
Pathophysiology alcoholic liver dz
ETOH → activated Kuppfer cells → inflammation → fibrosis → cirrhosis
81
Alcoholic liver dz Lab values
AST>ALT (atleast 2x)
| marked elevation of GGT (but not specific)
82
Most common autosomal recessive genetic disorder among Caucasians in the US
hemochromatosis
83
hemochromatosis
autosomal recessive, iron deposition in multiple organs, including the liver
75% asymp
test Transferrin
84
70-80% of those w/Autoimmune hepatitis are...
women
screen w/ANA
Tx: corticosteroids +/- azathioprine
85
What can you eval for in pts w/unexplained liver dz?
alpha 1 antitrypsin deficiency, even w/o resp Sx
86
Most common initial presentation of Wilson's dz
cirrhosis
87
Wilson's dz SxS
Kayser-Fleischer Rings
Chronic active hepatitis
Cirrhosis – most common initial presentation
Fulminant hepatic failure
Serum ceruloplasmin <20 mg/dL
Tx: Lifelong chelating agents (penicillamine)
88
Goblet cells
secretes mucus to protect mucosa from digestive enzymes and acid
89
Parietal cells
secrete HCl, intrinsic factor (absorbs B12 in sm int)
90
Chief cells
secrete pepsinogen (inactive form of pepsin - breaks down protein)
91
pernicious anemia
B12 deficiency
| can result from gastric bypass surgery
92
Primary responsible agents for mucosal damage assoc w/PUD**
gastric acid and pepsin
93
Zollinger-Ellison syndrome
Rare: Caused by non-beta islet cell, gastrin-secreting tumor --> stimulates acid-secreting cells of the stomach --> gastric mucosal ulceration
primary tumor typ pancreas or duodenum
94
difference between stomach ulcer and erosion
ulcer is deeper, local inflammatory rxn, extends through muscularis mucosa
95
What doubles the risk of PUD?
H. pylori infection
96
Most cases of PUD are caused by**
H. pylori infection
| NSAIDs (submucosal erosions, inhib cyclooxygenase, dec prostaglandins, and their protective effects)
97
H. pylori infection
produce urease to alkalize acidic stomach, colonization of stomach causes inflammation, impairs duodenal bicarb secretion, inc gastrin/pepsinogen production
promote gastric metaplasia in duodenum, increased susceptibility to acid injury, causing duodenal ulcers (can lead to gastric outlet obstruction)
98
most common symptoms of PUD
epigastric pain (gnawing, burning)
99
GASTRIC ulcers*
eating exacerbates the pain, little relief w/antacids
100
DUODENAL ulcers*
eating diminishes pain, relief w/antacids
| nocturnal pain
101
Sudden onset of PUD Sx is worrisome for...
perforation
102
PUD Sx
```
MAY BE ASYMP
Dyspepsia (belching, bloating, fatty food intolerance, distention)
Chest discomfort
Heartburn
Hematemesis or melena if bleeding
```
103
Dx test for PUD
EGD (upper GI endoscopy)
104
if anemia in PUD...
alarm signal, endoscopy to rule out sources of chronic GI blood loss
105
H. pylori testing
Urea breath test
| stool antigen test
106
What should you do after treating PUD?***
repeat endoscopy in 6-8wks to verify healing!
| Non-healing ulcer is ca until proven otherwise***
107
Non-healing gastric ulcer is what until proven otherwise***
Gastric cancer
108
H. pylori Tx
1st line: Triple therapy regimen (10-14 days)
Clarithromycin: 500mg PO BID
Amoxicillin: 1g PO BID
Metronidazole: 500mg PO BID
PPI PO BID (eg esomeprazole, lansoprazole)
109
What is H. pylori infection associated with?
atrophic gastritis
MALT lymphoma
at risk for malignancy
110
PUD perforations can lead to...
fistulas
cause pancreatitis
need surgical eval
111
Best screening test for Zollinger-Ellison Syndrome*
fasting serum gastrin (pt ideally off PPI; serial measurements on diff days)
112
What can Zollinger-Ellison Syndrome be assoc w/?
multiple endocrine neoplasia - type 1
113
If pt has multiple ulcers or ulcers in weird places...
check gastrin level! (serial measurement on diff days)
114
Most common type of gastric cancer**
adenocarcinoma 90-95%*
115
What nodes are associated with gastric ca?
```
Sister Mary Joseph node (firm nodule in umbilicus)
Irish node (enlarged L axillary LN)
```
116
Dx tests for gastric ca
EGD for Dx (depth)
| EUS/CT for staging (mets)
117
Gastric ca prognosis
3rd most common cause of ca-related death
often found as advanced dz
early dz asymp or mimic PUD
118
What can be the 1st sign of gastric ca?
Virchow's node (L supraclavicular lymphadenopathy)
119
Boerhaave's syndrome
esophageal rupture
urgent surgical eval
Dx w/imaging
broad spectrum abiotics (rapid sepsis)
120
Mallory-Weiss Tear*
mucosal tear due to retching, non-bloody emesis followed by bloody emesis
Longitudinal mucosal laceration at the gastroesophageal junction or gastric cardia*
121
Mackler's Triad for Boerhaave Syndrome
lower chest pain
vomiting
subQ emphysema
122
Gastroparesis
Delayed emptying of the stomach due to an issue with motility, NOT a mechanical obstruction
DM a common cause*
123
Gastroparesis Tx**
Metoclopramide (Reglan) – acts on dopamine receptors in stomach/intestines/brain
**watch for tardive dyskinesias (stop medication to prevent permanent Sx)
124
Ligament of Treitz*
Landmark that determines UGI vs LGI bleed (determines Tx)
| located: 4th portion of duodenum*
125
most common site of GI bleeding*
Upper GI tract
126
Iron deficiency anemia, (+) hemoccult in the elderly is...**
CANCER until proven otherwise*
127
testing required after heme (+) stool
EGD
Colonoscopy
^neg then eval small bowels
128
#1 cause of Upper GI bleed**
Ulcer disease, erosions (esophageal, stomach, duodenum)
129
What are Mallory-Weiss tears often assoc w/?
alcohol
130
Portal hypertension*
Shunting of hepatic blood away from liver due to increased resistance typically from CIRRHOSIS*.
131
Bleeding Varices
Usu sudden, overt , major bleeding
75% esophageal**
in 50% of cirrhosis pts (can be fatal)
132
How to eval for UGI Bleed?
stabilize pt then EGD** (Dx AND Tx)
133
AIMS65 Score*
```
determines risk of in-hospital mortality from upper GI bleeding: greater than 2, high risk
Albumin <3 g/dl
INR >1.5
Mental status altered
SBP <90
Age >65yo
```
134
Where do diverticular bleeds most often occur?*
Right 50-90%
Ascending colon**
(not assoc w/diverticulitis, typically PAINLESS*)
135
Where does diverticulitis most commonly occur?*
primarily left colon
136
Most common source of lower GI bleed
Colon carcinoma (but often occult)
137
Most common source of OVERT lower GI bleed
Diverticular bleed
138
Most common LGIB in elderly
Diverticular bleed
139
Diverticular bleed prognosis
```
Many stop spontaneously (75%)
Typically PAINLESS (diverticulitis painful)
```
140
Ischemic Colitis
Hematochezia (+) cramping abdominal pain
develops when blood flow to a part of your colon is reduced (predom NON-occlusive ischemia)
Tx: supportive, self-resolving
141
Angiodysplasia
ACQUIRED vascular ectasia, degenerative, possibly from chronic venous congestion of the intestine; mostly elderly
self-limiting
142
Where does angiodysplasia most commonly occur?
80% proximal colon
143
Bright red rectal bleeding
| Maroon Stools
Irritable Bowel Dz
144
Which hemorrhoids are painful?*
External (distal to dentate line)
145
What lab should you also order w/hematochezia
BUN/CREAT
146
Pt. w/ h/o abdominal aortic graft who enter the ER with GIB must receive immediate surgical attention to r/o...
aortoenteric fistula (1%, rare, life-threatening)
147
“Herald" bleed
episode of acute hemorrhage that ceases spontaneously-
148
Postural hypotension in suspected GI bleed
(supine-to-upright fall in systolic BP of >10 mm Hg or increase in heart rate of >20 beats per minute) indicates moderate blood loss (10-20% of circulatory volume)
149
Supine hypotension in suspected GI bleed
suggests severe blood loss (usually >20% of circulatory volume)
150
Gold standard study for LGIB*
Colonoscopy
151
UGIB & Treatment of Varices*
EGD with therapeutic banding/clipping/cauterization
152
Tx for UGI bleeds secondary to esophageal varices
Intrahepatic Portosystemic Shunt (Reduces the pressure gradient between portal and systemic circulations)*
transjugular if also portal HTN
153
False diverticula
only involve mucosa and submucosa (true: all layers)
154
Diverticulosis
having non-inflamed diverticula
155
Diverticula
small pouches created by the herniation of the mucosa into the wall of the colon through intestinal layers and smooth muscle
156
Diverticulitis
inflammation of one or more diverticula
157
Where does diverticula most commonly occur?*
```
sigmoid colon (highest intraluminal pressure)
(L more common in US but mostly false diverticula)
```
158
Most common Sx of diverticulitis
LLQ pain 70%
159
fecal matter in urine, think...
colovesicular fistula (could be a complication of diverticulitis)
160
Best imaging study to eval diverticulitis
CT abdomen/pelvis
| Colonoscopy contraindicated during acute ep bc high risk for rupture; can be used after to r/o malignancy
161
What should you rule out w/diverticulitis?
Cancer
162
What medications should you avoid in treating diverticulitis
NSAIDs
Corticosteroids
greater risk of perforation
163
Meckel Diverticulum
Congenital abnormality that is a true diverticulum of the small bowel
164
Rules of 2s for Meckel Diverticulum (PIMP)
2% of the population, within 2 feet of the ileocecal valve, 2 inches in length, two types of heterotopic mucosa (gastric and pancreatic), and presentation before the age of two.
165
ALT correlates w/...
degree of abdominal adiposity
166
AST increases w/...
skeletal muscle injury
167
Is ALT or AST more specific for liver injury and death?
ALT (bc AST also found in mito of cardiac, skeletal muscle, blood cells)
(but normal ALT doesn't mean no liver inflammation; damage reach certain point, stop leaking damaged enzymes)
168
Slight elevations of transaminases (50-200)
Low-grade inflammation
169
Huge elevations (+1,000) of transaminases
Acute liver injury/necrosis
170
Tests indicating liver "plumbing problems"
Bilirubin
Alk Phos: bile duct inflammation (obstruction, autoimmune, infection); high levels = inflammation; low = no dz or pancreatic ca
171
GGT
Specific to liver
172
Indirect Bilirubin
product of breakdown of heme, NOT water-soluble. Bound to albumin and sent to the liver (won't cause dark urine but may cause jaundice if high)
173
Direct Bilirubin
conjugated in the liver → makes it water-soluble. Converted to urobilinogen (makes urine yellow)
174
Bilirubin levels in PRE hepatic jaundice
elevated UNconjugated Bili
175
Bilirubin levels in POST hepatic jaundice
elevated conjugated bili
176
Bilirubin levels in hepatic jaundice
BOTH conjugated and unconjugated may be elevated
177
Nutrition on LFTs
albumin low due to low nutrition status (but low albumin can also suggest chronic dz like ca, cirrhosis)
178
TYLENOL MAX DOSE IN 24HRS*
```
3 grams (those w/o liver dz)
2 gram (Liver dz)
```
179
alk phos elevated out of proportion to aminotransferases
Think obstruction (liver/bile ducts) - CHOLESTATIC
180
aminotransferases elevated out of proportion to alk phos
Think liver inflammation - hepatocellular
181
Isolated Hyperbilirubinemia - CONJUGATED**
think decreased excretion or leakage of pigment from hepatocytes
Dubin-Johnson Syndrome*
Rotor Syndrome*
182
Isolated Hyperbilirubinemia - UNCONJUGATED**
Gilbert's Syndrome: Bili goes up in period of stress*
| Crigler-Najjar Syndrome*
183
Most common cause of drug-induced liver injury**
Acetaminophen*
184
Augmentin (amoxicillin/clavulanate) induced liver injury pattern on LFT*
Cholestatic pattern
185
Ibuprofen induced liver injury pattern on LFT*
Mixed
186
Diarrhea
passage of frequent (3 or more a day), small volume loose stools; alteration in normal absorption
187
leading cause of malnutrition in children under five years old*
diarrhea
188
Osmotic diarrhea causes*
Celiac Sprue/disease
| Lactose intolerance
189
what is not impaired in osmotic diarrhea?*
Electrolyte absorption is not impaired
190
#1 cause of secretory diarrhea*
Infections (eg S. Aureus, E.Coli, Vibrio Cholerae)
191
Secretory Diarrhea
```
Diarrhea that occurs when excretion of water in the intestines exceeds absorption:
low stool osmolality
frequently electrolyte loss
usually does not resolve if fasting
often nocturnal
```
192
Functional Diarrhea
Improvement at night and with fasting
| Cause: Irritable bowel disease*
193
#1 parasitic cause of diarrhea in US and worldwide.
Giardia (NO fever usu)*
194
Dx and Tx: Giardia
Stool O&P: 3 samples
| Tx: metronidazole
195
Entamoeba Histolytica
Parasitic infection - diarrhea
Common in tropical countries
Contaminated food or water
196
Cryptosporidiosis
Parasitic infection - diarrhea
One of the most common causes of waterborne disease
Can live in humans and animals and passed in stool
Has a shell that allows it to survive for long periods of time and protect from chlorine disinfectants
Could be cause of chronic diarrhea in HIV/immunocompromised
197
Tx Cryptosporidiosis
Nitazoxanide
198
2 Most common Viral Causes of acute gastroenteritis*
```
Norwalk Virus (“winter stomach flu”): Common cause of acute gastroenteritis in the US
Rotavirus
```
199
Most common GI disease in children 6-24 months
Rotavirus
200
Fever absent bacterial infection
Staph
| Clostridium perfringens
201
Most common cause of Travelers diarrhea**
Enterotoxigenic E. Coli: ETEC
| Food or water contaminated with animal/human feces
202
Typhoid Fever
Severe form of salmonella (due to salmonella typhi)
| life threatening
203
Common bacterial cause of diarrhea in the USA
Campylobacter Jejuni
204
(“rice water stool”)
Vibrio cholera (usu uncomplicated w/limited Sx)
205
What do you not give to Enterohemorrhagic E.Coli (Shiga Toxin Producing)
Antibiotics - increased risk of HUS
206
C. diff Tx
Metronidazole tx of choice for initial episodes and mild-moderate disease
Vancomycin or Fidaxomicin PO if severe or failure to Metronidazole
PO ONLY**
207
INR that does not correct with parenteral vitamin K is suspicious for
severe hepatocellular injury
208
#1 clue to advanced liver disease that is missed by PCP*
the low platelet count (nl = 150K), esp if combined with prolonged INR!
pt has ADVANCED liver dz until proven otherwise
209
most sensitive indicator of how the liver is functioning***
INR
210
Acute Liver Failure
Acute hepatocellular injury + hepatic encephalopathy + prolonged PT (elevated INR)
LFTs are typically >10 x upper limits of normal
211
Endocrine cells of pancreas
Alpha cells - Glucagon
Beta cells – Insulin
Delta cells - Somatostatin (inhibit insulin and glucagon release)
PP cell: pancreatic polypeptide hormone
212
Causes of acute pancreatitis
```
Biliary tract stones
Drugs
ERCP
Ethanol abuse*
Metabolic
Idiopathic
Infections: viral, bac, fung
Ischemia
Parasites
Postoperative
Scorpion sting*
Trauma
```
213
Causes of chronic pancreatitis
```
Autoimmune
Duct obstruction
Ethanol abuse*** (Most often the cause!)
Hereditary
Hypercalcemia* - 25%
Hyperlipidemia
Triglycerides* (play a big role in pancreatitis!) - 15%
Idiopathic
```
214
most common cause of pancreatitis*
Gallstones
215
"Female, Fair, Fat, Fertile, 40 yo"
Gallstones (cholelithiasis)
216
second leading cause of pancreatitis**
ETOH
217
most common identifiable cause of acute pancreatitis in CHILDREN
TRAUMA
218
Pancreatitis - Presentation
```
Acute Onset of Abdominal Pain:
Usually Mid-Epigastric
Knife Like
Radiates to back (~50%)
May have lower chest pain (trouble taking a deep breath)
May have had previous episodes
Often assoc w/N/V
Later: abd fullness, GI bleed
(KEEP MI IN DDX)
```
219
Pancreatitis PE
```
Typically seen “writhing” in pain
May not be able to find comfortable position: may have slight relief leaning forward
Febrile
Tachycardia
Tachypnea
Hypotension
Abdominal distension/ascites
```
220
Signs of Pancreatitis
Cullen's sign: periumbilical ecchymosis
| Grey-Turner's sign: flank bruising
221
What lab study is specific for pancreatic dz*
Lipase (order daily ASAP)
| Amylase nonspecific
222
What electrolyte imbalance is present in 25% of pancreatitis*
hypocalcemia
223
Hypoalbuminemia in pancreatitis
poor prognosis bc pt malnourished (cant eat, digest, or only drinking ETOH)
(Elevated LDH also poor prognosis)
224
Daily Labs for pancreatitis
Amylase, Lipase
LDH
Ca
CBC
225
thought to be the most sensitive test for pancreatitis, particularly chronic pancreatitis
trypsin (breaks down protein)
| but not widely available
226
Imaging studies for pancreatitis
abdominal U/S
Preferred: abd CT w/contrast
ERCP: for atyp causes
227
ERCP urgent interventions in pancreatitis
Biliary sepsis
Biliary obstruction and severe pancreatitis
Ascending cholangitis
Progressive jaundice or hyperbilirubinemia
228
Pancreatitis Tx
```
DO NOT SEND PTS HOME (acute)
Maintain pt NPO
IV fluids* (helps)
Pain control – meperidine standard but shifting now to dilaudid (concern that morphine and its derivatives can cause spasm at sphincter of Oddi and increased biliary pressure, can make ab pain/Sx worst)
Anti-emetic – IV zofran, phenergan
Parenteral antacid (H2 blocker or PPI)
```
229
1st line Tx of hypertriglyceridemia
Fibrates
230
Ranson’s Criteria
```
Acute PancreatitisClinical Course scoring sys
≤ 2, 0% mortality
3-4, 15 %
5-6, 50%
≥7, ~95%
```
231
Leading cause of chronic pancreatitis*
70% ETOH
232
Most common type of pancreatic ca**
Ductal epithelium (adenocarcinoma)
233
Best imaging study for pancreatic ca*
helical CT
234
Pancreatic Cancer:Presentation
Unexplained weight loss (>5 pounds per month)
Biliary duct blockage (if head of pancreas involved): Jaundice, Dark urine and light colored stool
Epigastric abdominal pain radiating to back
Nausea or vomiting
Anorexia
Weakness
(check Virchow's node)
235
Painless jaundice**
Pancreatic ca until proven otherwise!!
236
Courvoisier's Sign**
Non-tender, but distended, palpable Gall Bladder
| Associated with Jaundice
237
Pancreatic ca usu found at*
head of pancreas
238
bile
produced by hepatocytes
bile acids, bilirubin, cholesterol, phospholipids, water, electrolytes
Emulsifies fats
239
CCK
stimulates GB to contract
| secreted from duodenal mucosa when fatty chyme enters
240
Most common type of cholelithiasis*
cholesterol stones 80%
241
What happens to your biliary system when pts stop eating
decreased enteral stimulation of the gallbladder (no CCK release) with resultant biliary stasis and stone formation
242
Biliary colic
stones or sludge obstruct the cystic duct during GB contraction
Pain in epigastric/RUQ area with radiation to right scapula
Usually lasts 30-90 minutes, but up to 5hr
no fever or jaundice
243
Imaging test of choice for gallbladder or biliary disease*
U/S (good for stones >2mm)
| but CT and MRI/MRCP – superior for CBD stones
244
Cholelithiasis Tx - symptomatic
cholecystectomy first-line
| Asymptomatic stones – typically no intervention unless stones >2.5 cm or calcification of GB wall
245
Acute Cholecystitis
Inflammation of the GB due to a stone impacted in the cystic duct (prolonged)
246
Acute Cholecystitis PE
RUQ tenderness, fever, tachycardia, palpable GB/RUQ fullness (30-40%)
Murphy sign – tenderness and inspiratory pause with palpation of RUQ
Dx: U/S
247
Diffusely calcified GB ("porcelain GB")*
malignancy until proven otherwise
248
Acute Cholecystitis Tx
Initial: bowel rest, IVF, analgesia, antibiotics, electrolyte correction
Antibiotics: piperacillin/tazobactam, ampicillin/sulbactam, or meropenem. If severe life-threatening cases, then imipenem/cilastatin; alt: 3rd gen ceph, Metronidazole
Laparoscopic cholecystectomy is standard of care for surgical treatment – early operation (within 72 hrs) is preferred (better outcomes)
Percutaneous drainage if surgery high risk
249
Acalculous Cholecystitis population
very sick patients, elderly men
250
Chronic Cholecystitis
repeated attacks of pain (biliary colic) that occur when gallstones periodically block the cystic duct.
GB can become thick-walled, scarred, and small
Tx: cholecystectomy
251
Acute Cholangitis
Bile duct obstruction allows bacteria from duodenum to ascend; usu gram neg
Tx: antibiotics FIRST, then relieve obstruction w/ERCP
252
Reynold's pentad
Acute suppurative cholangitis:
| Charcot's triad plus confusion and hypotension
253
What is Primary Sclerosing Cholangitis strongly assoc w/?*
STRONG association with IBD, especially ulcerative colitis***
thought to be autoimmune; Can lead to cirrhosis and portal HTN
254
leading cause of chronic hepatitis and cirrhosis
Hep C
255
As hepatic fibrosis progresses, steatosis...
regresses (may make diagnosis of NAFLD as cause more difficult)
256
Medications that can cause chronic liver dz and cirrhosis**
Amiodarone
| Methotrexate
257
If pt has gastroesophageal varices on EGD, by definition they have clinically significant*
portal HTN
258
Gastric varices*
less likely to bleed but if bleed then more severe - can be fatal
259
Esophageal varices Tx
Tx: non-selective BB or banding
260
serum-ascites albumin gradient (SAAG)**
Attribute ascites to peritoneal or non-peritoneal causes
| SAAG = (albumin concentration of serum) – (albumin concentration of ascitic fluid)
261
Non-peritoneal SAAG
SAAG > 1.1 g/dL
portal HTN, hypoalbuminemia (nephrotic syndrome, malnutrition), malignancy, pancreatic ascites, biliary ascites, trauma, myxedema
262
Peritoneal SAAG
```
SAAG <1.1 g/dL
malignancy ascites (peritoneal implants), TB peritonitis, sarcoidosis, FBs, vasculitis (SLE, HSP), endometriosis, fungal or parasitic infections
```
263
ascites Tx
Mild ascites: sodium restrictions, diuretics 1-2x/week
Moderate to severe ascites: aggressive diuretics, monitor electrolytes:
Spironolactone*: K sparing
Furosemide*
(often used in combo)
264
Spontaneous Bacterial Peritonitis
Caused by translocation of GI tract bacteria across gut wall or by hematogenous spread of bacteria
265
Spontaneous Bacterial Peritonitis Dx**
ascites: >250 PMNs per mm3 with positive culture (classic)
266
culture-negative neutrocytic ascites
still significant mortality (still need abiotics!)
267
Spontaneous Bacterial Peritonitis tx**
Cefotaxime x 5 days
| repeat paracentesis in 48-72hrs
268
Hepatic Encephalopathy is assoc w/
elevated ammonia level (normally detoxified by liver), but not always!
Tx: Lactulose, Rifaximin
269
TIPS
Transjugular, intrahepatic, portosystemic shunt – connects portal vein to the hepatic vein, bypassing liver circulation
270
10-25% of pts with cirrhosis HAVE...
Hepatocellular carcinoma (HCC), esp w/Hep B, C, etoh
271
Crohn’s Disease*
Inflammation and ulceration of the GI tract that can involve the full thickness of the bowel* in a patchy, non-continuous distribution (skip lesions)**
(terminal ileum and colon most common)
chronic, recurrent condition
272
Rectum involvement in Crohn's Dz
rectum itself is relatively spared compared to the rest of the colon
273
Complications of Crohn's Dz
fistulae, abscesses, perianal disease, and strictures
274
Crohn's Dz Etiology
strong genetic component*
| defect in immune response
275
Common PE finding in Crohn's Dz
FISTULAS* between colon/small bowel and other organs (bladder, vagina, rectum).
276
Bloody Diarrhea, keep what on your DDx?*
Crohn's Dz, Ulcerative colitis
277
Sx of Crohn's Dz
weight loss, lethargy, fever, and general malaise
N/V/D intermittent, could be bloody
pain usu RLQ, quality ranges
278
PYODERMA GANGRENOSUM
cutaneous ulcerations in Crohn's Dz
279
When does Crohn's Dz require urgent eval?**
High fever, severe abdominal pain, or symptoms of small bowel obstruction
280
Dx test of choice for Crohn's*
colonoscopy, biopsy affected areas
281
String Sign on Small bowel series
Crohn's Dz, colonoscopy
282
Cobblestoning of small bowel
Crohn's Dz, patchy lesions (fissures, elcers), severe case
| Dx w/colonoscopy
283
what test is 90% sensitive for detection of IBD
Fecal Lactoferrin
284
40% to 80% of patients with ulcerative colitis is positive for...
p-ANCA
285
ASCA
antibodies to baker's yeast and brewer's yeast found in up to 68% of patients with Crohn's disease
286
What medication should you avoid in Crohn's Dz
NSAIDs
287
Crohn's Dz Tx
mild to mod: salicylate (5 ASA: 5 aminosalicylates), maintenance mesalamine
mod to sev: systemic corticosteroids (prednisone or Budesonide), consider immunosup maintenance (azathioprine)
Humira, Infliximab, methotrexate, tacrolimus f refractory
no immunosuppressants if infectious colitis on DDx
288
any pt w/anemia, weight loss, and fever of unknown origin, consider
Crohn's Dz
289
where is the inflammation in ulcerative colitis?*
localized primarily in the mucosa and is uniform and continuous (not full thickness and patchy as in Crohn’s)*
Perirectal involvement is a typical feature of ulcerative colitis*
only colon and rectum involved
290
Hallmark feature of ulcerative colitis**
bloody diarrhea
| assoc w/tenesmus
291
cigarette smoking in ulcerative colitis
protect against UC (but worsens in Crohn's)
292
Examples of 5-ASA (5-aminosalicylates)
Rowasa, Pentasa, Asacol
| 1st step Tx in IBD
293
Anti-TNF’s
Remicade, Humira, Cimzia
| block major step in inflammatory path, quick in IBD Tx but expensive
294
Acute Dysphagia
Typically foreign body impaction in esophagus, such as food bolus, inability to swallow saliva
Tx: remove FB during endoscopy
295
Causes of Chronic Dysphagia
```
Esophageal or Peptic Stricture
Esophageal Cancer
Eosinophilic Esophagitis
Esophageal Webs and Rings
Esophageal Motility Disorders
Systemic Sclerosis
Achalasia
Erosive Esophagitis
```
296
dysphagia, dysphagia, dysphagia*
Esophageal Cancer: progressive dysphagia (solids to liquids)
| Dx: endoscopy (Ct staging, PET distant mets)
297
When reflux symptoms do not improve with acid suppression, consider*
Eosinophilic esophagitis (EGD and biopsy: >15 eosinophils per hpf*; ring formation*)
298
Eosinophilic esophagitis tx
First line – inhaled corticosteroid (spray during breath hold then swallow) x 8 wks
Candida esophagitis – most common adverse reaction
299
Esophageal Web – most common in
```
cervical esophagus (typically anterior) --> narrowing post-cricoid area
<2 mm thick tissue membrane protruding into lumen
(esophageal ring most common in distal esophagus)
```
300
Plummer-Vinson Syndrome
(anemia + cervical esophageal web + dysphagia)
301
Zenker Diverticulum
Pulsion diverticulum of the hypopharynx – herniation of esophageal mucosa (false diverticulum)
Rare, typically elderly population
Dx: barium swallow
302
solids AND liquids dysphagia
Scleroderma
| achalasia
303
Achalasia*
Inadequate peristalsis in lower esophagus with tight LES (doesn’t relax)
progressive dysphagia for solids AND liquids**
"bird beak" esophagus*
304
Esophageal Motility Disorders Tx
CCB or TCA (EG IMIPRAMINE)
305
Alarming Sx in GERD (or risk for Barret's)
GIB, IDA, unexplained wt loss, anorexia, dysphagia/odynophagia, intractable vomiting, new onset dyspepsia ≥ 60 yrs
306
GERD Tx
H2 receptor antagonist: pepcid
| then PPI instead
307
Barrett’s Esophagus**
```
Replacement of the stratified squamous epithelium in the distal esophagus with metaplastic columnar epithelium
(Z line = junction between cell types)
risk of esophageal ca >30fold
Asymp, BUT many have GERD
Tx: indefinite PPI for all pts
```
308
Celiac Disease
malabsorptive immune mediated disorder, triggered by environmental agent (gluten) in genetically predisposed individuals
- Specifically intolerance to gliadin (alcohol-soluble fraction of gluten)
- villous atrophy on sm int biopsy
- Assoc with HLA-DQ2 and HLA-DQ8 gene loci
309
What genetic disorders are assoc with Celiac Dz?*
Down syndrome, Turner's syndrome and Type 1 Diabetes
310
Classic Sx of Celiac Dz
foul-smelling diarrhea with floating stools and steatorrhea, flatulence
weight loss or other evidence of malabsorption (vitamin or nutrient deficiency, osteopenia)
*but most don't come classically...
311
Skin manifestation of Celiac Dz
dermatitis herpetiformis
312
When should testing be done on pt w/suspected celiac dz
while pt on gluten rich diet
| serologic eval: anti-tTG and/or IgA; endoscopy if pos
313
How many specimens from duodenum to make Celiac Dz Dx?
6 biopsy specimens
314
Hydrogen Breath Test
Lactose tolerance testing
315
When is orthostatic BP suggestive of impending shock?
Decrease 10-20 mmHg systolic pressure with a reflex increase in pulse > 15 bpm
316
Most common condition causing acute episodes of vomiting
viral gastroenteritis
317
What can you assume w/pts on marijuana
Assume pt has some level of gastroparesis
| Treatment: diet + promotility drugs (ex: Metoclopramide, Erythromycin) + glucose control
318
Most urgent DDx to consider w/vomiting
MI
| CVA/cerebral hemorrhage
319
Mackler triad (Boerhaave's syndrome)
chest pain
vomiting
subcutaneous emphysema due to esophageal rupture
320
What is Crohn's Dz at risk for?
4 to 20 fold inc risk of colon ca
321
high risk genetic syndromes for Colorectal ca
```
Lynch Syndrome (HNPCC)
Familial Adenomatous Polyposis (FAP): nearly 100% develop <50yo
```
322
USPTF screening guidelines Colon ca
50-75yo
323
Irritable bowel syndrome Sx
Abdominal pain, usually lower quadrant, relieved by defecation
Bloating / Distention
Mucus in stools
Constipation
Diarrhea
Abdominal discomfort after eating
*strongly influenced by emotional factors
324
Most common IBS subtype
IBS with predominant constipation (50%)
| Functional, chronic constipation not explained by another disease
325
IBS Dx test
Fecal calprotectin or fecal lactoferrin
326
Meds that can cause constipation
Diuretics
Antacids
Antidepressants
327
75% of hepatic blood supply comes from*
portal vein (and 50% O2)
328
Functions of hepatocyte*
```
Glycogen storage
Decomposition of Red Blood Cells
Plasma Protein synthesis – albumin, alpha/beta globulins
Production of Non-Essential amino acids
Gluconeogenesis
Hormone production
Detoxification
Bile production
Urea production – from Ammonia and CO2
(thousands of enzymes)
```
329
KUPFFER CELL- FUNCTION
RBC Destruction – worn out cells (life span 100-120 days)
Aid in production of Antibodies/ plasma proteins and bile pigments
Phagocytic clearing of pathogens
Activation is responsible for early ETOH-induced liver injury
330
Where is RBC broken down?
spleen
331
Which form of bilirubin is water soluble?
conjugated bilirubin (direct bilirubin)
332
determining jaundice etiology through lab values
look at direct bili levels (total high, indirect high)
Prehepatic: normal
Intrahepatic: low
Posthepatic: high
333
acute onset of watery, nonbloody, voluminous diarrhea accompanied by nausea and vomiting
Enterotoxigenic Escherichia coli
334
A patient has had problems with prolonged diarrhea. Stool cultures grow out Cryptosporidium. It is important to?
Test the patient for HIV
335
treatment of choice for diarrhea caused by Giardia lamblia is?
Metronidazole
336
most common cause of traveler’s diarrhea is adults?
E. coli
337
Most commonly used NG tube for decompression
Salem Sump (dual lumen)
338
When are NG tubes indicated?
treatment of ileus or bowel obstruction (decompression)
administer medications
enteral nutrition
contraindications: esophageal stricture, basilar skull fracture, esophageal varices
not recommended for long term enteral nutrition
339
How to measure NG tube*
xyphoid to earlobe, then earlobe to nares
image w/XRay to confirm placement
tip of tube below diaphragm
340
Meissner’s plexus
nervous plexus of submucosa; glands and smooth muscles
341
Auerbach's plexus
nervous plexus of muscularis externa; GI motility
342
Retroperitoneal organs
```
S = Suprarenal (adrenal) glands
A = Aorta/Inferior Vena Cava
D = Duodenum (second and third segments)
P = Pancreas
U = Ureters
C = Colon (ascending and descending only)
K = Kidneys
E = Esophagus
R = Rectum
```
343
What does the stomach absorb*
ETOH, Aspirin, NSAIDS
344
Marasmus
Protein and calorie deficiency
| NO edema
345
Kwashiorkor
protein deficiency resulting in edema
346
“Bird beak sign” on film
achalasia
347
SENTINEL LOOP on film
short segment of adynamic ileus close to intra-abdominal inflammatory process (e.g., pancreatitis, appendicitis)
