Final exam Flashcards
what are the components of bile
1) 90% water
2) bile acids
3) phospholipid (lecithin)
4) cholesterol (from LIV)
5) bilirubin (from heme)
what are the role of bile acids:
solubilize glycerides, FAs, dietary cholesterol in upper intestine
what percentage of bile acids are reabsorbed in lower SI for secretion?
50%
what percentage of bile acids are lost in feces?
7-20%
excess bile acid production caused by:
vagus nerve/parasympathetic damage
deficient bile acid production is caused by:
1) re-absorption problems/inflammation (chrones)
2) bacterial overgrowth of SI (dysentery)
how much bile does the LIV secrete every day?
250-1100ml
what is cholelithiasis?
gall stones
what are gall stones made up of?
85% cholesterol
15% bilirubin
what are the risk factors of asymptomatic gallstones?
1) females
2) excess biliary content from obesity, OCAs, estrogen usage, multiple childbirths, Dz of terminal ileum
3) skipping breakfast (stg bile acids)
4) prolonged/repeated fasting
why are bilirubin gallstones more common in developing countries?
produce excess bilirubin from:
parasites, malaria, sickle cell anemia, macrocytic anemias
how many gall stones are asymptomatic?
50%
chronic cholecyctitis risk factors
1) large fatty meal
2) history of: dyspepsia, fatty food intolerance, flatulence, HT burn, belching
chronic cholecystitis SX
1) epigastric pain, abrupt onset
2) residual ache after attack
3) nausea, diaphoresis
4) vomiting with attack without relief
5) restlessness and want to curl up
how long does chronic cholecystitis last?
15-60 min
where does chronic cholecystitis pain refer to
R-hypochondrium/iliac crest/subscap region
diagnosis for chronic cholecystitis
physical examination offers few findings
non-specific (no masses, remarkable tenderness, muscle spasm, fever)
chronic cholecystitis facts
infrequent episodic, unpredictable
asymptomatic before and after attack
complications of chronic cholecystitits
1) recurrent episodes
2) choledocholelithiasis (impaction of a stone within a duct)
3) pancreatitis
chronic cholecystitis TX
1) increase dietary fiber
2) decrease dietary fat/cholesterol
3) weightloss (for obese)
4) allergy elimination to reduce risk of bowel inflammation
what is usually the cause of acute cholecystitis?
obstruction of cystic duct causing inflammation of duct and GB
acute cholecystitis SX
1) steady, severe pain in epigastrium/R-hypochondrium
2) pain precipitated by fatty meal
3) nausea, vomit, diaphoresis
4) fever
5) slight jaundice presents 20-25% cases
where does acute cholecystitis pain refer to?
R-hypochondrium, iliac crest, subscap region (same as chronic)
diagnosis for acute cholecystitis
- specific
1) upper right quadrant tenderness
2) palpable tenderness of GB
3) murphys sign
how to differentiate acute cholecystitis
1) acute pancreatitis
2) appendicitis
3) perforated peptic ulcer
4) hepatitis
5) R-lower side plueritis
acute cholecystitis complications
1) gangrene GB
2) cholangitis (inflammation of bile duct)
acute cholecyctitis TX
cholecystectomy
Biliary tract facts:
GB stores 40-50ml bile
concentrates hepatic bile via water absorption
lowers PH of bile (by reabsorbing bicarbonate ions)
Anatomy of the Pancreas
- The pancreas is a retroperitoneal organ overlying the L1 or L2 vertebra
- The pancreas drains via the main pancreatic duct into the duodenum via the common bile duct and the sphincter of Oddi
- The pancreatic head rests in the concavity of the duodenum and contains the common bile duct
Inflammation and/or enlargement of the pancreatic head can lead to..
a) Localized ileus of the duodenum
b) Compression or obstruction of the common bile duct
c) Compression or partial obstruction of the duodenum
d) Pain referred to the back and upper lumbar spine
What does the body of the Pancreas lie close to?
The pancreatic body lies close to the stomach, jejunum, aorta, left kidney, left crus of the diaphragm
Inflammation and/or enlargement of the pancreatic body can lead to..
a) Localized ileus of stomach and jejunum
b) Pain referred to the back, upper lumbar spine and/or left flank
The Pancreatic tail lies close to what?
The pancreatic tail is in close proximity of the spleen, left kidney and left splenic flexure of the colon
Inflammation and/or enlargement of the pancreatic tail can lead to:
Pain referred to the left flank
2 Types of Alcholism
Acute
Chronic
What happens to the pancreas with acute alcoholism?
The pancreas temporarily ceases to function. There is inhibition of water, bicarbonate, and proenzyme production
~There is also increased muscle tone at the sphincter of Oddi
What happens to the pancreas in Chronic Alcoholism?
The pancreas becomes hypersecretory resulting in increased water, bicarbonate and proenzyme production
~This leads to hyperplasia of the acini and ductules causing the pancreas to become endurated (inflammation, fibrosed, and hardened)
An alcohol binge accounts for what percentage of Acute Pancreatitis?
An alcoholic binge is responsible for 60-70% of the cases in North America
Whats the definition of an Acute Pancreatitis?
Is the inflammation of an otherwise normal pancreas and may either occur once or in recurrent relapsing form
Acute Pancreatitis Facts
- Acute pancreatitis is usually initiated by a specific event
- An alcoholic binge is responsible for 60-70% of the cases in North America
- Passing a gallstone is the cause of 20-30% of the cases in North America
- Acute pancreatitis is the inflammation of an otherwise normal pancreas and may either occur once or in recurrent relapsing form
a) In either case, the pancreas returns to normal once the inflammation subsides
SSX of Acute Pancreatitis
~In most patients, acute pancreatitis is a relatively mild disease that subsides spontaneously within several days
~Most signs and symptoms are non-specific for pancreatitis
~ Epigastric pain is often initiated by a large meal, or alcohol ingestion
~Pain is described as constant, steady and boring
~Pain radiates to the back in more than half the cases
~This may be accompanied by vomiting without cause or relief
~The antalgic position is often sitting in a slightly flexed position
~here is epigastric tenderness upon palpation with abdominal guarding
~Rebound tenderness is not likely to be elicited
~There is often abdominal ileus that may cause abdominal bloating
~Varying degrees of fever, tachycardia, nausea, vomiting, sweating, weakness and mild jaundice
Complications associated with Acute Pancreatitis
Mortality - the first attack is usually most likely fatal
Retroperitoneal hemorrhage: observe for Cullen’s and Turner’s signs
Serous fluid transudation/sequestration resulting in depleted intravascular volume, ascites, left pleural effusion, and others
Chronic pancreatitis occurs in 10% of cases
Permanent diabetes and exocrine insufficiency
Chronic Pancreatitis Facts
The attacks often become progressively more severe
It is often associated with weight loss due to anorexia
As the condition progresses, the pancreatic ductules become fibrotic and scarred and pancreatic proenzymes may become active within the organ itself
Chronic pancreatitis is a self-perpetuating condition
Chronic alcoholic pancreatitis normally forms after 6-12 years of heavy alcohol consumption (not a common finding for most alcoholics)
The chronic form of this disease, the pancreas does not return to normal between attacks
SSX of Chronic Pancreatitis
~Epigastric pain with possible radiation to the back, upper lumbar spine and left flank
~Epigastric pain may also involve the upper left and right quadrants
~The episodes last for days at a time
~Weekend bingers may experience symptoms 12-48 hours after the cessation of alcohol consumption
~Nausea & vomiting may also suggest ileus with pancreatitis
~Steatorrhea: pancreatic insufficiency is a serious complication of chronic pancreatitis
~Diabetes mellitus may follow the onset of this condition
~The patient may also exhibit signs and symptoms of pleural effusion associated with significant pancreatic inflammation
~Other evidence of possible pancreatic inflammation includes GI bleeding, multiple bruising, peripheral edema, metastatic fat necrosis and polyarthritis
What is Seatorrhea?
Pancreatic insufficiency is a serious complication of chronic pancreatitis
Whats usually a condition that occurs after Chronic Pancreatitis
Diabetes mellitus
Physical Exam findings in Chronic Pancreatitis
Epigastric tenderness with or without guarding
Abdominal rigidity
Management of Chronic Pancreatitis
a) Abstinence from alcohol
b) Eating small meals (6/day)
c) Using pancreatic enzymes with meals
What is the 5th most common cause of death due to cancer?
Pancreatic Carcinoma
What is Pancreatic Adenocarcinoma?
often involves the head of the pancreas (leading to less severe chronic pain compared to cancers of the body or tail)
What is the most common type of Jaundice?
Obstructive jaundice is very common = painless jaundice
What’s the cause of Pancreatic Cancer?
Unknown
Risk Factors for Pancreatic Cancer
a) Males (2M:1W) over the age of 60
b) Cigarette smoking is a risk factor
c) Hx of hereditary or chronic pancreatitis
d) Hx of diabetes mellitus
e) Inherited polyposis syndromes (growths of glandular origin) or colorectal cancer
SSX of Pancreatic Carcinoma
a) The early sx are variable and insidious as most patients report nonspecific abdominal discomfort, anorexia, early satiety or diarrhea
b) The chronic epigastric pain is reported as dull in the RUQ from the head and in the LUQ from the tail of the pancreas
c) Thoracolumbar pain is normally a late finding associated with pancreatic carcinoma
d) Jaundice is also observed along with unexplained weight loss
Whats the treatment for Pancreatic Carcinoma?
Surgery
What is Diabetes Mellitus
Syndrome resulting from impaired secretion and/or effectiveness associated with the risk of diabetic ketoacidosis and late complications including retinopathy, nephropathy, atherosclerotic coronary and peripheral artery disease, and peripheral and autonomic neuropathies
2 Forms of Diabetes Mellitus
Insulin dependent DM (IDDM)
Non-insulin dependent DM (NIDDM)
What type of Diabetes is increasing in our society?
Non Insulin Dependant Diabetes Mellitus
NIDDM (Non Insulin Dependant Diabetes Mellitus) usually presents with symptomatic hyperglycaemia which includes..
a) Polyuria
b) Polydipsia
c) Weight loss despite increased dietary intake (polyphagia)
d) Osmotic diuresis resulting in dehydration
Most of the complications associated with diabetes are the result of..
Glycosylation of endothelial tissues that alter vascular permeability
Are obese patients with NIDDM symptomatic or asymptomatic?
Many obese patients with NIDDM are seldom symptomatic
What is Diabetic Gastroparesis?
delayed gastric [gastro] emptying
Whats a common complication of the GI tract of NIDDM patients?
Diabetic gastroparesis (delayed gastric [gastro] emptying d/t partial paralysis [paresis])resulting in a loss of normal peristaltic activity within the GI tract
~The result is bloating and accumulation of flatus along the GI tract causing significant abdominal discomfort
What is Functional Dyspepsia?
The irritable bowel syndrome of the upper GI tract (Non Ulcer Pain)
Functional Dyspepsia SSX
Frequent, chronic recurrent upper abdominal discomfort with:
a) Eructation
b) Bloating
c) Anorexia or nausea
Functional Dyspepsia Info
- The discomfort is most often related to food intake, but it may not be
- The discomfort may not be relieved by antacids
- The diagnosis is often one of exclusion
Esophagitis SSX
~Frequent, recurrent retrosternal burning with:
a) Acid ‘brash’ in the throat with eructation
b) Mid-thoracic (intrascapular) discomfort
c) Left arm discomfort
~The discomfort often occurs 30-60 minutes after a meal
~The discomfort is often precipitated by:
a) Large meals and/or dietary indiscretion
b) Recumbency
c) Bending forward
~The Dx is usually made by Hx
Duodenal Ulcer SSX
~The symptoms of duodenal ulcer tend to be predictable
~Periods of recurrent epigastric discomfort (“burning”, “hunger pains”)
~The discomfort is most prominent when the stomach is empty
a)The symptoms awaken the patient at night
~Antacids usually give temporary relief from the discomfort
~Sx usually begin early in life: early adulthood
~Sx recur intermittently with prolonged pain free intervals
~The Dx is usually made by endoscopy
Gastric Ulcer SSX
~ The Sx are less predictable than those of duodenal ulcer
~Epigastric pain and burning are more variable than with duodenal ulcer
~The discomfort may or may not be related to the intake of food
~Antacids may or may not give relief from the discomfort
~The peak incidence is in the 40-60 age group
~Definitive Dx requires endoscopy
Gastritis SSX
Frequent, recurrent ulcer Sx with Hx of:
a) Aspirin or NSAID use
b) Alcohol use or abuse
Definitive Dx requires endoscopy
Gastric Carcinoma SSX
- Early disease: frequent, recurrent ulcer Sx in older patients
- 85% of patients are over the age of 50
- Later disease: Frequent, recurrent ulcer Sx with early satiety, post-parandial vomiting, anorexia, weight loss and occult GI bleeding
Biliary Colic SSX
1.Infrequent episodes of gastric or RUQ pain with nausea, anorexia and vomiting
- Attacks typically last 1-2 hours
a) There is often a residual ache for the next day or so
Where do most Diverticular Diseases occur?
In the sigmoid colon (95%)
What is Diverticulitis?
A pulsion herniation of the colon wall causing “sacculations” to protrude into the pericolic fat
The true diverticulae involve all layers of the bowel wall
What happens with pseudodiverticuli?
The mucosal and submucosal layers herniate through the circular muscle layer if the colon
What part of the colon has the highest intraluminal pressure?
The sigmoid colon is the site of the highest intraluminal pressure
What do the herniated saccules in diverticulitis contain?
Usually contain fecal matter and are asymptomatic until they become inflamed
Diverticulitis is the inflammation of a…
Pre-existing diverticulum
a) The inflammation is due to fecal impaction and/or secondary bacterial infection
b) The patient may or may not have abdominal complaints
What is the most common colon problem in N.America?
Diverticulosis is most common in N. America and is associated with increasing age. On autopsy, 66% of patients over the age of 80 demonstrate diverticuli
What is Diverticulosis associated with?
Diverticulosis is associated with a lack of bulk fiber in the diet
Diverticulitis SSX
a) All the symptoms are degree dependent
b) Persistent lower abdominal pain
c) Low grade fever
d) Nausea
e) Altered bowel function
f) There may be minimum palpatory tenderness in the LLQ
Complications of Diverticulitis
a) Abcess formation
b) Pericolitis: microperforation of a diverticulum leading to an inflammation outside of the colon. This may cause “left sided appendicitis” sx
c) Obstruction and/or hemorrhage
Indications of complication in Diverticulitis
a) Fever and lymph node inflammation
b) Bleeding per rectum
c) Marked tenderness to palpation (LLQ)
What is Pericolitis?
Microperforation of a diverticulum leading to an inflammation outside of the colon. This may cause “left sided appendicitis” sx
Conservative treatment of uncomplicated diverticula include:
~Increased dietary fiber
~Fiber will reduce the sx but no eliminate the occurrence of complications
What is Appendicitis?
Appendicitis usually begins with obstruciton of the appendix.
Types of Obstructions in Appendices
Neoplasm
fecalith
foreign body
inflammation
What’s the common age group for Appendicitis
It is most often occurs between the ages of 10-30
The length of Acute Appendicitis usually resolves within what time frame?
normally resolves within 12-48 hours
What happens if Appendicitis is left untreated?
Gangrene and perforation can occur within 36 hours
How many stages are in Classic Appendicitis?
3 stages
Stage 1 Appendicitis SSX
•Stage One: Early acute appendicitis
a) Distention of the appendix compresses the vasculature & initiates edema
b) Vague pain referral to the umbilicus or epigastrium
c) Pain might be absent in older patients
d) This pain is usually followed by anorexia and nausea
Stage 2 Appendicitis SSX
Occurs 4 hours later as the appendix becomes distended
The patient experiences a constant, colicky ache in the RLQ
The colicky pain is made worse by walking or coughing
The RLQ is now tender to palpation: guarding is apparent
Palpation of McBurney’s point elicits abdominal pain
Palpation of the corresponding point in the LLQ elicits pain in the RLQ: Positive Rovsign’s sign
Anorexia and nausea continue
Stage 3 Appendicitis SSX
This occurs as the inflammation progresses through the tissues
Pain is severely and precisely localized (McBurney’s Point)
Localized pain when coughing indicates peritoneal inflammation
Localized pain on light palpation with rebound tenderness also indicates peritoneal inflammation
A low-grade fever is often present
Complications associated with Appendicitis
Perforation: occurs in up to 20% of cases
Perforation should be suspected in Appendicitis if…
- Pain persists over 36 hours
- High fever
- Diffuse abdominal tenderness or peritoneal findings
- A palpable abdominal mass is apparent
Chronic Inflammatory bowel disease usually takes one of two forms?
Ulcerative Colitis
Crohn’s Disease
Can you cure inflammatory bowel disease?
IBD is a lifelong illness that is manages but not cured
Peak age range for people with Ulcerative Colitis
Peak age range is 15-35 with a strong history of family occurrence
Is Ulcerative Colitis more common in men or women?
UC is equally common in men as in women
In Ulcerative Colitis where are 50% of cases confined to?
About 50% of the cases are confined to the recto-sigmoid area
Is UC more common in caucasians or non-caucasians?
UC affects caucasians more commonly than non-caucasians
UC Facts
UC is usually a uniform and continuous inflammation of the mucosa and sub-mucosa
Most patients have intermittent bouts of colitis with variable periods of remission
Common Clinical Features of UC
a) Realatively abrupt onset of symptoms
b) Diarrhea
c) Rectal bleeding/bloody diarrhea
d) Rectal urgency - urgent sensation of having to defecate
e) Tenesmus - painful spasm of pelvic floor musculature
f) Abdominal pain & tenderness especially in LLQ
What is Tenesmus
Painful spasm of pelvic floor musculature
Local Complications associated with UC?
a) Colon cancer - increased risk
b) Strictures develop in sigmoid colon
c) Hemorrhage and colonic perforation is common in the more severe cases of UC
d) Toxic Megacolon is a potentially lethal complication of UC
Conservative Management of UC
Reduce stress, avoid sugar and refined CHO’s, restrict caffeine and gas producing vegetables
Consider a normal fiber, high protein diet
Anti-diarrheal agents are not used in the acute phase of the disease
Should Anti-Diarrheal agents be used in the Acute Phase of Ulcerative Colitis?
Anti-diarrheal agents are not used in the acute phase of the disease
What is Crohn’s Disease?
Crohn’s is an idiopathic transmural inflammatory process that is characterized by a painless, non-specific, granulomatous inflammatory process
Whats the age range for Crohn’s?
Peak age range is 10-30 years old and a second incidence amongst 40-50 year olds
What does Crohn’s distribution act similarily to?
Crohn’s familial distribution is similar to that of UC
How does Crohn’s disease begin?
It begins as isolated ulcers surrounded by normal mucosa
What happens when Crohn’s progresses?
- As the disease progresses, the ulcers become linear and larger, resulting in a “cobblestoning” of the mucosa
- Fibrosis of the submucosa leads to thickening of the bowel wall that narrows the lumen of the bowel
- The affected areas are separated by healthy mucosa causing discontinuous damage to the bowel wall
What part of the GI tract does Crohn’s affect?
Crohn’s can affect any portion of the GI tract from the mouth to the anus therefore it can cause a variety of sx
Where are the most common sites affected by Crohn’s?
Distal small intestine and the proximal colon
A patient with Crohn’s disease typical presents what..
Patient in late teeens or early twenties
Insidious onset of sub-clinical sx
Abdominal pain is frequent but usually not severe
Weight loss on the range of 10-20% of body weight
Diarrhea
There are 2-5 years of chronic, intermittent sx before the diagnosis is made
Local Complications of Crohn’s
Intestinal obstruction with post-parandial bloating, cramping pains and loud borborygmi
Hemorrhage - may lead to anemia
Abscess formation
Perianal disease
Toxic megacolon
Conservative management of Crohn’s
Check patient for food sensitivities
Avoid sugar and refined CHO’s
Consider a hypoallergenic diet during the active disease
Anti-diarrheal medication
Try a high protein, normal fiber diet when the condition is mainly colonic in presentation
Other conditions and findings associated with Inflammatory bowel Disease?
Peripheral lower extremity arthritis parallels the presentation of IBD
Enthesopathies:Plantar fasciitis, achilles tendonitis also parallel the presentation of IBD
Some axial arthropathies such as anjylosing spondylitis and sacroilitis precede the development of bowel symptoms
Skin lesions such as erythema nodosum parallel the activity of IBD
Irititis (anterior uveitis) is fairly common ocular manifestation
What is the second most common cause of cancer related deaths in N.America?
Colorectal cancer after lung cancer
Risk Factors for Colon Cancer?
Age - incidence rises sharply after the age of 40
Gender - males are only slightly more affected than females
High Risk Factors for Colon Cancer?
a) Rectal polyps
b) Family history of colorectal cancer
c) Familial polyposis syndrome
d) Inflammatory bowel disease
Potential Risk Factors for Colon Cancer?
a) High dietary fat
b) Low dietary fiber
c) Obesity
d) Sedentary lifestyle
e) Alcohol
What’s a Polyp
Any lesion that protrudes above the mucosal surface
Where do most Colorectal Cancers arise from?
The malignant transformation of the coloractal polyp
Colorectal Polyp Facts
Polyps increase in prevalence with advancing age and occur in 30-40% of the adult population
Transformation from adenoma to carcinoma takes a decade or more
Familial Polyposis
a) An autosomal dominant condition that results in 1000’s of colonic polyps
b) The polyps begin to form during adolescence
c) These patients almost uniformly begin developing colon cancers in their fifth decade of life (40’s)
2. The overall survival rate for colon cancers is only 35%
Are colon cancers symptomatic?
Most colon cancers are asymptomatic
Possible SSX of a patient having colon cancer?
a) GI bleeding that may be occult or frank
b) Change in stool pattern such as reduced caliber or unexplained constipation
c) Unexplained weight loss
d) Unexplained anemia
e) Obstruction of the bowel
f) Rarely, patients report vague abdominal discompfort
Excess fat in feces
Steatorrhea
