Gastroenterology Flashcards
What are the complications of diverticulitis? (3)
- Free colonic perforation
- Abscess formation
- Fistula
What causes angiodysplasia of the colon?
Tortuous dilated veins in the submucosa of the colon
What are clinical features of angiodysplasia of the colon?
GI bleeding in patients over 60
How is agniodysplasia diagnosed and treated?
Diagnosed with colonoscopy and treated with colonoscopic coagulation
While all antibiotics are associated with C Diff, what 3 groups of antibiotics are more frequently implicated?
Cephalosporins, clindamycin, ampillicin
What are two complications of C Diff?
Colonic perforation and Toxic Megacolon
What are two clinical features of C Diff?
Crampy abdominal pain and profuse watery diarrhea
How is C Diff colitis treated?
Metronidazole or oral vancyomycin
How can C diff be diagnosed?
C diff toxins in stool; abdominal radiograph to rule out toxic megacolon followed by a flexible sigmiodoscopy
What groups of patients is metronidazole contraindicated in?
Babies and pregnant women
What are the clinical features of acute mesenteric ischemia?
Severe abdominal pain that is disproportionate to physical findings
What key lab points to intestinal infarction (and any type of general infarction)?
Elevated lactic acidosis
What is the definitive test for acute mesenteric ischemia?
Mesenteric angiography
How are all arterial causes of acute mesenteric ischemia treated?
Direct injection of papverine (vasodilator) into SMA
How are venous thrombosis treated if they cause acute mesenteric ischemia?
Heparin anticougulation
How is embolytic acute mesenteric ischemia treated?
Thrombolytic injection or embolectomy
What is the third most common cause of cancer in the United States
Colon Cancer
What type of cancers are the vast majorities of CRC?
Adenocarcinomas
What is the most specific and sensitive test for CRC?
Colonoscopy
What percent of CRC can flex sigmoidoscopy detect?
2/3
Why is CEA used in CRC?
As a prognostic factor, to help determine patient’s baseline before treatment. Not of any diagnostic value
What are two common ways CRC spreads?
Direct spread to other abdominoperineal organs or hematogenous spread to the lungs
Describe CRC screening protocol?
If no family history, start at age 50.
If family history, start 10 years before family member was diagnosed or age 40 (whichever is earlier)
What type of colonic polyps have the most malignant potential?
Villous adenomas (villian)
What type of diet shows an increased risk of CRC?
High fat and low fiber
How does IBD affect CRC risk and how does this impact screening?
IBD (both UC and Chron’s) increase risk of CRC, but UC increases risk more. Begin colonoscopy screening 8 years after diagnosis of IBD
What is the most common cause of large bowel obstruction in adults?
CRC
What is the most common non-neoplastic polyp?
Hyperplastic polyp
Are flat or pedunculated polyps more likely to be malignant?
Flat
What causes diverticulosis?
Increased intraluminal pressure, inner layer of colon bulges through focal areas of weakness in the colon wall, low fiber diets and positive family history
Where are most diverticuli located?
Sigmoid Colon
What are the clinical features of diverticulosis?
- Painless rectal bleeding
- LLQ discomfort (sigmoid colon)
- Bloating
- Constipation
How can diverticulosis be diagnosed?
Barium enema
When the large bowel is greater than ______ cm it is at risk of rupturing, peritonitis, or even death?
10 cm
How is ogilive syndrome treated?
IV fluids, stop narcotics and colonic decompression
What are the clinical features of ogilive syndrome?
Signs, symptoms and radiology point to a large bowel obstruction but there is no mechanical obstruction
Ogilive syndrome cannot be confirmed until ______ is ruled out?
Mechanical obstruction
What causes chronic mesenteric ischemia?
Atherosclerotic occlusive disease of main mesenteric vessels (celiac artery, SMA, IMA)
What are the clinical features of chronic mesenteric ischemia?
Dull post prandial pain
How is chronic mesenteric ischemia diagnosed?
Mesenteric angiography
What are some clinical features of CRC (5)?
- melena/hematochezia **
- abdominal pain
- change in bowel habits
- Iron Deficiency anemia *****
- Weight loss
Which sided CRC is more prone to obstruction?
Left (smaLLer Lumin)
Which sided CRC is more prone to melana? Which sided CRC is more prone to hematochezia?
Melana = right Hematochezia = left
What are two clinical features of rectal cancer?
Hematochezia and mass feeling
What type of therapy is not indicated in CRC?
Radiotherapy
What is typical treatment for CRC?
Surgical recesection and adjuvant chemotherapy
What is followup protocol for CRC in remission?
Colonoscopy at 1 year and then every 3 years
What is genetic inheritance pattern for Peutz Jegher?
Autosomal dominant
What are the clinical features of Peutz-Jegher? (3)
Single or multiple HEMARTOMAS throughout the GI tract; PIGMENTED SPOTS around lips, palmar surfaces, oral mucosa; INTUSSUCEPTION or GI Bleeding
Where are hemartomas located in Peutz-Jegher?
small bowel, colon, stomach
What is the risk of carcinomas in Peutz-Jegher?
slightly increased risk of stomach, ovary, and breast cancers
What is malignant potential for hemartomas?
Low malignant potential
What are two hereditary nonpolyposis CRC syndromes?
Lynch 1 and Lynch 2
Describe Lynch 1
Early onset CRC, no antecedent multiple polyposis
Describe Lynch 2
Lynch 1 + early occurrences of other cancers
What generally causes colonic volvulus?
Twisting of a loop of intestine about its mesenteric attachment site
Which type of colonic volvulus is more common in kids vs adults?
Kids = cecal volvulus Adults = Sigmoid Volvulus
What is seen on barium enema for sigmoid volvulus?
Bird Beak
What sign on radiography helps distinguish sigmoid volvulus from cecal volvulus?
sigmoid = omega sign cecal = coffee bean sign
What is preferred dx and tx for colonic volvulus?
Sigmoidoscopy (helps untwist colon)
Describe genetics of familal adenomatous polyposis?
AD mutation in tumor supressor gene
What is risk of CRC in Familal adenomatous polyposis?
100% by 40 years old
How does familal adenomatous polyposis present?
Hundreds of adenomatous polyps in colon
What preventative measure is needed in patients with familal adenomatous polyposis?
Prophylatic colectomy
What are genetics and clinical presentation of Gardner syndrome?
Variant of familal adenomatous polyposis, autosomal dominant, patient gets polyps and osteomas and soft tissue tumors. Risk of CRC is 100% by 40 years old.
Turcot syndrome genetics and clinical presentation
Turcot syndrome can be autosomal dominant and autosomal recessive. Polyps plus CNS tumors
How does familal juvenile polyposis clinically present? Risk of CRC?
Hundreds of juvenile polyps; low risk of CRC
What are two problems caused by diverticulosis
painless GI bleeding and diverticulitis
What causes diverticulitis?
Fecal impaction in diverticulum leading to erosion and microperforation
How does diverticulitis present? (3)
Fever, leukocytosis, and LLQ pain
How is diverticulitis diagnosed and what is contraindicated?
CT scan with contrast; DO NOT give patient a colonoscopy or barium enema (risk of perforation)
How is diverticulitis managed?
NPO, antibiotics, fluids
When is surgery indicated for diverticulitis?
If symptoms persist for 3-4 days or if recurrent episodes
What causes acute mesenteric ischemia?
compromised blood supply to intestines
What blood vessel is affected in acute mesenteric ischemia
SMA
Patients with acute mesenteric ischemia are more likely to have underlying _______
Preexisting heart disease
How many different types of acute mesenteric ischemia are there? What are they?
Embolic, arterial thrombosis, nonocclusive ischemia, venous thrombosis
How do the symptoms vary between the four types of acute mesenteric ischemia? (Venous, embolic, nonocclusive thrombosis, arterial thrombosis)?
Embolic = symptoms are sudden and painful
Arterial Thrombosis = symptoms are more gradual and less severe
Nonocclusive ischemia = occurs in critically ill patients
Venous thrombosis = symptoms may be present for days or weeks with gradual worsening
What is definitive diagnostic test for acute mesenteric ischemia?
Mesenteric angiography
What are two of the most common causes of acute appendicitis?
- Lymphoid hyperplasia (60% of cases)
2. Fecal obstruction (35% of cases)
What is a risk factor for appendix perforation?
Delay in treatment (>24 hours of acute appendicitis)
What are the clinical features of acute appendicitis?
3 signs, one behavioral and one location
- Anorexia (always present). Appendicitis is unlikely if the patient is hungry
- Tenderness at McBurney’s point (2/3 of the way from umbilicus to right anterior superior iliac spine)
- Rovsing sign: deep palpation in LLQ causes referred pain in the RLQ
- Psoas sign: RLQ pain when right thigh is extended as patient lies on left side
- Obturator sign: Pain in RLQ when flexed right thigh is internally rotated when patient is supine
Describe how symptoms of acute appendicitis progress?
Classically starts in the epigastrium, moves towards umbilicus, and then to RLQ.
How is acute appendicitis diagnosed?
Clinical diagnosis, however, CT scan is useful in cases where diagnosis is unclear
How is acute appendicitis treated?
Laparoscopic appendectomy
What are carcinoid tumors and where are they usually located?
Located usually in the appendix but can be found anywhere. Composed of neuroendocrine cells and secrete serotonin
What percent of patients with carcinoid tumors go on to develop carcinoid syndrome? What are the risk factors for metastasis of carcinoid tumors? How are carcinoid tumors treated?
- 10%
- Risk factors for metastasis is location and size of tumor (increase in size = higher chance of metastasis), appendix carcinoid tumors are less likely to metastasize but illeal have the greatest likelihood of spreading
What are some symptoms of carcinoid syndrome?
Cutaneous flushing, diarrhea, sweating, wheezing, abdominal pain, and heart valve dysfunction
Describe pathogenesis of acute pancreatitis?
Inflammation of the pancreas resulting from prematurely activated pancreatic digestive enzymes that invoke pancreatic tissue autodigestion
What are the two forms of acute pancreatitis and how do they differ in mortality and morbidity?
- Mild form is most common and responds well to supportive treatment.
- Severe form has significant morbidity and mortality
What are the two biggest causes of acute pancreatitis?
- Alcohol abuse (40%) and
2. Gallstones (40%)
What are the clinical features of acute pancreatitis?
Abdominal pain in the epigastric region
50% of cases will radiate to the back
Pain characterized as dull steady, worse with meals
What three signs indicate hemorrhagic pancreatitis?
- Grey Turn sign: flank ecchymosis
- Cullen sign: periumbilical ecchymosis
- Fox sign: ecchymosis of the inguinal ligament
What diagnostic test is confirmatory for acute pancreatitis?
CT scan
What are some lab tests to check for in acute pancreatitis? (5)
- Serum amylase (nonspecific) however five times the upper limit is highly specific
- Serum lipase: more specific than amylase
- LFTs: to identify gallstones as a cause
- WBC
- LDH
What are the acronyms for acute pancreatitis prognosis?
- GA-LAW for admissions criteria
2. C HOBBS for initial 48 hours criteria
What are two types of pancreatic necrosis? and how can someone distinguish between them?
- Sterile pancreatic necrosis - infection may develop, but half of these cases resolve spontaneously
- Infected pancreatic necrosis - high mortality rate: surgical debridement and antibiotics are indicated
Distinguish between them using CT-guided percutaneous aspiration and Gram stain/culture
What is a pancreatic pseudocyst and when does it appear in relation to an episode of acute pancreatitis?
Encapsulated fluid collection that appears 2-3 weeks after an acute attack
How are pancreatic pseudocysts diagnosed?
CT-scan
What are some complications of pancreatic pseudocysts?
Rupture, infection, fistula, hemorrhage into cyst
What is the treatment for pancreatic pseudocysts?
Cysts < 5 cm: observation
Cysts > 5 cm: drain either percutaneously or surgically
When does a pancreatic abscess develop?
4-6 weeks after acute pancreatitis
What is a respiratory complication of acute pancreatitis?
Adult respiratory distress syndrome
What is treatment for mild acute pancreatitis?
- NPO
- IV fluids
- Pain control (fentanyl and meperidine over morphine)
- Nasogastric tube
How is severe acute pancreatitis treated?
- Admit to ICU
2. Early enteral nutrition in the first 72 hours via nasojejunal tube
What is diagnostic for chronic pancreatitis? (2)
- Chronic epigastric pain
2. Calcifications seen on CT Scan
What is the most common cause of chronic pancreatitis?
- Alcohol abuse (80%)
Describe what happens in chronic pancreatitis?
Persistent and chronic inflammation of the pancreas leads to fibrotic tissue replacing pancreatic parenchyma and alteration of the pancreatic ducts. Endocrine and exocrine functions of the pancreas are impaired.
What are some clinical features of chronic pancreatitis?
- Severe pain in the epigastrium
- Radiates to the back (50%)
- Chronic in nature
What is the initial test of choice for chronic pancreatitis?
CT scan
What are serum amylase and lipase levels in chronic pancreatitis?
Not elevated, (possibly normal)
What are some complications of chronic pancreatitis (4)
- Pancreatic cancer (recurrent chronic pancreatitis increases risk of cancer)
- Diabetes mellitus (loss of islets of langerhans)
- Pseudocyst formation
- Malabsorption and steatorrhea (loss of exocrine pancreatic function)
How is chronic pancreatitis managed?
- Nonoperatively: Narcotics for pain, bowel rest, pancreatic enzymes and H2 blockers, insulin, and short low-fat meals
- Surgery: Pancreatic duct drainage to decompress the dilated pancreatic duct; Pancreatic resection (Whipple procedure)
What are some risk factors for pancreatic cancer?
- Age (> 60 years old)
- African American
- Diabetes Mellitus
- Chronic pancreatitis
- Alcohol use
- SMOKING (MOST IMPORTANT)
What is the most common location of pancreatic cancer?
75% are in the pancreatic head
What are the clinical features of pancreatic cancer?
- Abdominal pain (vague, dull)
- Jaundice
- Weight loss
- Migratory thrombophlebitis (10% of cases)
What is one sign on physical exam that indicates pancreatic cancer
Courvoisier sign: palpable gallbladder
What are two tumor markers for pancreatic cancer and what is the test of choice?
Test of choice is CT scan and tumor markers are CEA and CA19-9
What is treatment for pancreatic cancer?
Whipple - low survival rates
What are causes of Peptic ulcer disease (3)
- H pylori infection
- NSAID use (inhibits prostaglandin production which leads to impaired mucosal defenses)
- Acid hypersecretory states (Zollinger-Ellison Syndrome)
What are some unproven causes of peptic ulcer disease that the public thinks about?
Emotional stress (malcolm in the middle) Type A personality disorder Caffeine and coffee intake
What are the clinical features of peptic ulcer disease?
- Epigastric pain (aching or gnawing in nature)
2. Nausea/vomiting, early satiety, weight loss)
What is the most accurate test in diagnosing ulcers?
Endoscopy (biopsy is necessary to rule out malignancy)
What type of ulcers require biopsy? (Gastric or duodenal)?
Gastric ulcers require biopsy, duodenal ulcers do not
How is H pylori infection detected?
Urease detection via urea breath test
How is zollinger-ellison syndrome diagnosed?
Serum gastric measurement
Describe the pathogenesis of duodenal and gastric ulcers?
Duodenal ulcers are caused by an increase in offensive factors (higher rates of basal and gastric acid secretion).
Gastric ulcers are caused by a decrease in defensive factors
Is H pylori infection more likely to cause ulcers in duodenal ulcers or gastric ulcers?
More likely to be the cause of duodenal ulcers
Which types of ulcers (gastric or duodenal) are more likely to be malignant?
Gastric ulcers are more likely to be malignant
Where are most gastric ulcers located?
On the lesser curvature of the stomach
How does pain defer in gastric and duodenal ulcers in relation to eating?
In duodenal ulcers, eating relives pain.
In gastric ulcers, eating does not relieve pain
How is peptic ulcer disease treated? (3)
- avoid NSAIDS
- Eradicate H pylori infection
- Appropriate use of antisecretory drugs
How is H pylori infection eradicated?
For initial treatment, use triple therapy (PPI, amoxicillin, and clarithromycin).
For retreatment, use quadruple therapy (PPI, bismuth, metronidazole, and tetracycline)
What are two categories of acid suppression drugs and what is their MOA?
- H2 blockers (-tidine drugs). Block histidine based parietal cell acid secretion.
- PPIs (-prazole): Block H+/K+ ATPase pump directly in the parietal cell membrane
What are some causes of acute gastritis? (3) What does acute gastritis mean?
NSAIDs/asprin use, smoking, H pylori infection
It means inflammation of the gastric mucosa
How is acute gastritis managed?
If patient has low or moderate levels of pain, empiric treatment with acid suppression is appropriate. If this fails, investigate using endoscopy or ultrasound.
What can be seen on imaging for gastric ulcer perforation?
On CXR, patient will have free air under the diaphragm,
How is gastric ulcer perforation managed?
Surgery to close it up
What are the symptoms of gastric ulcer perforation?
Acute, severe abdominal pain, signs of peritonitis, hemodynamic instability.
What is the most common cause of UPPER GI bleeding?
Peptic ulcer disease
What is the best diagnostic study in diagnosing patients with epigastric pain?
Upper GI endoscopy because it can diagnose esophagitis, PUD, gastritis, rule out cancers of esophagus and stomach
What is the most common cause of chronic gastritis and how is it managed?
Most common cause is H pylori infection and managed with eradication of H pylori infection
What type of cancers are most gastric cancers?
Adenocarcinomas
Where are gastric cancers more common?
Japan
What are some risk factors for gastric cancer?
High intake of preserved foods like smoked fish
H pylori infections
What are the clinical features of gastric cancer?
Abdominal pain and weight loss
What is the most accurate test for gastric cancer?
Endoscopy
How is gastric cancer treated?
Surgery
What are the following:
Krukenberg tumor? Blumer's shelf? Sister Mary Joseph Node? Virchow node? Irish node?
Krukenberg - gastric cancer that metastasized to the ovaries
Blumer’s shelf - gastric cancer that metastasized to the rectum (palpate on rectal exam)
Sister Mary Joseph - gastric cancer that metastasized to the periumbilical lymph node
Virchow - gastric cancer that metastasized to the supraclavicular lymph nodes
Irish node - gastric cancer that spread to the left axillary
What is gastric lymphoma?
A type of non-hodgkin lymphoma that arises in the stomach
What is the clinical difference between partial and complete small bowel obstruction?
In partial obstruction, patients can still pass gas and have bowel movements. In complete obstruction, patients are usually unable to pass gas or have bowel movements unless the gas or feces are in the colon/distal to obstruction
What are the clinical features of proximal obstruction and distal small bowel obstruction?
In partial obstruction, patients have frequent vomiting, severe pain, minimal abdominal distention
In distal obstruction, patients have less frequent vomiting, and significant abdominal distention
What are some systemic symptoms of small intestine obstruction?
Dehydration from vomiting leads to systemic signs like tachycardia, hypochloremia, hypokalemia, and metabolic alkalosis, and hypotension
What is a dangerous complication of small bowel obstruction?
Excessive extraluminal pressure can lead to a compromise of the blood supply causing strangulation of the intestine and subsequent gangrene, peritonitis, or perforation of the bowel.
What is the most common cause of small bowel obstruction in adults?
Adhesions from previous abdominal surgery
How can you distinguish small bowel obstruction from strangulation of the intestines?
In strangulation, patient may have peritonitis, fever, hematemesis, increased lactic acidosis, and abdominal pain is severe and continuous.
In your garden variety small bowel obstruction, pain is cramping.
What the clinical features of small bowel obstruction?
Cramping abdominal pain, nausea, vomiting (may be feculent), obstipation (absence of gas or stool), abdominal distention.
How is small bowel obstruction diagnosed?
abdominal plain films show obstruction or dilated loops of small bowel, and air-fluid levels proximal to point of obstruction.
How is small bowel obstruction treated?
If it is partial and no signs of strangulation, give fluids, withhold food, give nasogastric tube.
If it is complete or if signs of strangulation, perform exploratory laparotomy
What distinguishes paralytic ileus from small bowel obstruction or colonic obstruction on imaging?
In paralytic obstruction, there is a uniform distribution of gas in the small bowel, colon and rectum
What is celiac sprue?
Hypersensitivity to gluten
What are the symptoms of celiac sprue?
Diarrhea, weight loss, abdominal distention, bloating, weakness, and fatigue
What skin disorder is associated with celiac sprue and what percentage of patients with celiac sprue have this skin disorder?
Dermatitis herpetiformis (papulovesicular lesion on extensor surfaces) is found in 10-20% of patients with celiac disease
What does biopsy in celiac sprue show?
flattening of the villi in the proximal small bowel which causes malabsorption (fat soluble vitamin malabsorption)
What is Whipple Disease?
Rare infection caused the infection by bacterium Tropheryma Whipplei
How is Whipple Disease diagnosed?
PAS-postive macrophages are seen in the lamina propria containing non-acid fast gram-positive bacteria
What is tropical sprue?
Environmental enteropathy that occurs in people who livin in or visit tropical areas
What can be seen on endoscopy in patients with tropical sprue?
Flattening of villi
How is tropical sprue managed?
Treated with antibiotics and folic acid
What are the symptoms of tropical sprue?
Similar as the symptoms of celiac sprue: weight loss, diarrhea, cramps, fatigue, and malabsorption.
What is the cause of tropical sprue?
Unknown, expected to be caused by bacterial overgrowth
What are two effects that are caused by a distortion of liver anatomy in hepatic cirrhosis?
- Decreased blood flow through the liver with subsequent hypertension in portal circulation has widespread manifestations such as ascites, peripheral edema, splenomegaly, and varicosity of veins.
- Liver failure leads to decreased albumin synthesis and decreased clotting factor synthesis
What are some causes of liver cirrhosis
Alcohol abuse Chronic Hepatitis B Chronic Hepatitis C Alpha 1 antitrypsin deficiency Autoimmune hepatitis Primary biliary cirrhosis NASH
What are some classic signs of chronic liver disease?
Ascites, varices, gynecomastia, testicular atrophy, palmar erythema, spider angiomas, hemorrhoids, caput medusa
What procedure can decrease portal hypertension in the setting of liver cirrhosis?
TIPS (transjugular intrahepatic portal systemic shunt)
What can be used to prevent esophageal varices from bleeding? (prophylactic measures)
Use non-selective beta blockers
How can emergent esophageal variceal bleeding be treated?
Treatment of bleeding esophageal varices involves pharmacological treatment with IV octreotide in addition to endoscopic treatment (variceal ligation or sclerotherapy)
What are some causes of ascites?
Portal Hypertension CHF chronic renal disease malignancy hypoalbuminemia
What is caput medusa?
Distension of abdominal wall veins
How can ascites be managed (in most cases)
Using salt restriction and diuretics
What are complications of liver failure (AC, 9H)
Ascites Coagulopathy Hypoalbuminemia Portal Hypertension Hyperammonemia Hepatic encephalopathy Hepatorenal syndrome Hypoglycemia Hyperbilirubinemia Hypertension HCC
What is measured and what is the cutoff for causes of ascites when performing a diagnostic paracentesis?
Measure serum ascites albumin gradient.
If SAAC is > 1.1 portal hypertension is cause for ascites
If SAAC is <=1.1, portal hypertension is unlikely
When should a patient with ascites undergo therapeutic paracentesis?
If patient has tense ascites that is causing shortness of breath or early satiety
What is a cause of hepatic encephalopathy?
Toxic metabolite ammonia builds up in the body because the liver cannot remove it
What are clinical features of hepatic encephalopathy?
Stupor, confusion, poor concentration, decreased mental functions, asterixis (flapping tremor)
What is used to prevent hepatic encephalopathy and how does it work?
Lactulose prevents absorption of ammonia.
What is used to treat hepatic encephalopathy?
Rifaximin because it kills bowel flora that produce ammonia
What are the clinical features of spontaneous bacterial peritonitis?
Look for fever and/or changes in mental status in a patient with known ascites
rebound tenderness, fever, vomiting
What are some etiological causes of SBP?
E coli (most common)
Klebsiella
Strep pneumo
How is SBP diagnosed?
Paracentesis that shows presence of WBC in ascitic fluid (WBC > 500 PMN > 250)
How is SBP treated?
Broad spectrum antibiotics followed by specific antibiotics once cause has been identified
Repeat paracentesis in 2-3 days to document a decrease in ascitic fluid PMN (<250)
What is hepatorenal syndrome and what does it indicate?
Progressive renal failure secondary to renal hypoperfusion. Indicates end-stage liver disease
Kidneys are _____ in terms of morphology and they ____ respond to volume expansion in hepatorenal syndrome
Kidneys are normal in terms of morphology and they do not respond to volume expansion in hepatorenal syndrome
What are the clinical features of hepatorenal syndrome?
Azotemia, oliguria, hyponatremia, hypotension, low urine sodium (<10 mEq/L)
Why are estrogens elevated in liver cirrhosis and how does this clinical manifest (4)
Estrogens are elevated because the liver can no longer catabolize estrogens.
Clinical features of hyperestrinism:
- Spider angiomas
- Palmar erythema
- Gynecomastia
- Testicular atrophy
What are the genetics of Wilson’s disease?
Autosomal Recessive
What is the pathology of Wilson’s disease?
Mutations in ATP7B gene lead to impairment in copper excretion and incorporation of copper into ceruloplasmin, a cooper binding protein that is necessary for copper excretion
What are some of the organs affected by Wilson’s disease? (4)
- Liver (can cause cirrhosis)
- Cornea (Kayser-Fleischer rings)
- CNS findings (Extrapyramidal signs such as parkinsonian symptoms (resting tremor, rigidity, bradykinesia) and Psychiatric disturbances)
- Renal involvement
What lab value should be tested for in patients suspected of having Wilson’s disease?
Decreased serum ceruloplasmin levels
What is the treatment for Wilson’s disease? (2)
- Chelating agents like d-penicillamine
2. Zinc to prevent uptake of dietary cooper
What are the genetics of hemochromatosis?
Autosomal recessive
What is the pathogenesis of hemochromatosis?
Excessive iron absorption in the intestines buildups in various organs. Iron causes free radicals to buildup in the body.
What organs are affected by hemochromatosis? (5)
- Skin
- Liver
- Pancreas
- Heart
- Joints
What are the complications of hemochromatosis? (6)
- Heart: cardiomyopathies
- Liver: Cirrhosis
- Pancreas: Diabetes Mellitus
- Joints: Arthritis
- Skin: Bronzelike skin
- Hypogonadism: amenorrhea, impotence, loss of libido.
What happens to iron, ferratin, transferrin saturation, TIBC, and what test is required for diagnosis of hemochromatosis?
- Elevated serum iron
- Elevated serum ferritin
- Elevated transferrin saturation
- Decreased TIBC
- Liver biopsy confirms diagnosis
How is hemochromatosis treated?
Repeated phlebotomies
What are three kinds of benign liver tumors?
- Focal nodular hyperplasia
- Cavernous hemangiomas (most common type of liver tumor)
- Hepatocellular adenoma
When should a benign liver tumor be investigated for possible resection?
When greater than 5 cm
What type of benign liver tumor is not associated with oral contraceptives as a risk factor?
Focal nodular hyperplasia
What are the two types of hepatocellular carcinoma and what is the difference between the two?
Nonfibrolamellar and fibrolamellar
Nonfibrolamellar is associated with Hep B, Hep C, and cirrhosis and is usually not resectable.
Fibrolamellar is not associated with Hep B, Hep C, and cirrhosis and is usually resectable
What are some risk factors for hepatocellular carcinomas?
Hep B, Hep C, alcohol abuse, AAT deficiency, hemochromatosis, Wilson’s disease, smoking
What are the clinical features of hepatocellular carcinomas?
Abdominal Pain, weight loss, anorexia, signs and symptoms of chronic liver disease
What percentage of non-alcoholic steatohepatitis patients develop liver cirrhosis?
10-15%
How is non-alcoholic steatohepatitis usually discovered?
Mild elevation in AST and ALT
What causes Hydatid liver cysts, what is the risk with having this infection and how are they treated?
Caused by infection from Echinococcus granulosus tapeworm.
If cysts rupture, they may cause fatal anaphylactic shock.
They are treated with surgery and after surgical resection, the patient gets mebendazole
What is the cause of pyogenic liver abscesses?
Obstruction of bile causes a breeding ground to form for bacteria.
Describe the pathogenesis for Budd-Chiari Syndrome?
Liver disease caused by occlusion of hepatic venous outflow which leads to hepatic congestion and subsequent microvascular ischemia
What are the clinical features of Budd-Chiari Syndrome?
Hepatomegaly, ascites, abdominal pain, jaundice, and variceal bleeding
What is the treatment for Budd-Chiari syndrome?
Medical therapy is usually not enough, surgery is usually needed
What are the three main causes of jaundice?
Hemolysis, Liver disease, and biliary obstruction
Describe how hemoglobin is broken down (3)
Hemoglobin is broken down in the spleen into unconjugated bilirubin.
Unconjugated bilirubin is not water soluble and travels with albumin to the liver.
The liver conjugates bilirubin and excretes into the urine
Dark urine is seen with conjugated or unconjugated bilirubin?
Only seen with conjugated bilirubin
What is so dangerous about a buildup of unconjugated bilirubin?
Unconjugated bilirubin can cross the blood brain barrier causing neurological deficits
What are two major causes of conjugated hyperbilirubinemia?
- Decreased intrahepatic excretion of bilirubin (conjugated bilirubin is stuck in the liver)
- Extrahepatic biliary obstruction (ie gallstones)
What are two major causes of unconjugated hyperbilirubinemia?
- Excessive production of bilirubin (hemolytic anemia)
- Impaired bilirubin conjugation due to decrease function of UDP glucoronosyltransferase (two subtypes = Gilbert syndrome and Crigler-Najjar syndrome)
What precipitates Gilbert syndrome and what are the genetics of Gilbert Syndrome?
Fasting, fever, alcohol, infection
Autosomal dominant
What is the function of UDP glucuronosyltransferase?
Conjugates unconjugated bilirubin into conjugated bilirubin
ALT or AST is more specific for liver damage?
ALT is more specific
AST is less Specific
What are the upper cutoff levels for AST and ALT in alcoholic hepatitis?
AST is never > 500
ALT is never > 300
If ALT and AST are moderately elevated (high hundreds to thousands) think of? (1)
acute viral hepatitis
If AST and ALT are mildly elevated (low hundreds) think of? (2)
chronic viral hepatitis or acute alcoholic hepatitis
What levels of AST and ALT are seen in acetaminophen toxicity?
> 10,0000
What value is affected by decreased hepatic function? PT or PTT?
PT. Liver synthesizes factors 1, 2, 5, 7, 9, 10, 12, 13
Normal levels of what makes cholestasis unlikely?
Normal levels of Alkaline phosphatase makes cholestasis unlikely
Why does one check GGT along with Alkaline phosphatase and what does this show?
Alkaline phosphatase is also found in bone, gut, placenta.
GGT helps confirm that elevated alkaline phosphatase is due to hepatic issues.
If GGT is normal, but alkaline phosphatase is elevated consider bone disease or pregnancy
If GGT and alkaline phosphatase are elevated consider hepatic origin (hepatic bile obstruction)
How is hepatic functional reserve measured in patients with liver cirrhosis?
Child-Pugh Score
What does cholelithiasis refer to?
Stones in the gallbladder
What are the four types of gallstones and what diseases are each associated with?
- Green/Yellow gallstones = cholesterol gallstones, associated with obesity, diabetes, hyperlipidemia
- Black gallstones = pigment gallstones, associated with hemolysis
- Brown gallstones = biliary tract infection
- Mixed gallstones = combination of above
What causes the pain in biliary colic?
Biliary colic refers to temporary obstruction of the cystic duct due to gallstones. The pain occurs as the gallbladder contracts against an obstructed cystic duct.
What forms the common hepatic duct?
The right and left hepatic ducts join to form the common hepatic duct
What duct is the outflow from the gallbladder?
The cystic duct
What makes up the common bile duct?
The cystic duct joins with the common hepatic duct (which is made up of the right and left hepatic ducts)
Describe the pain associated with biliary colic? (location, what makes it worse, how long does it last, any referred pain?)
Typically presents in the RUQ and epigastrium. Pain is worse after meals. Pain lasts only a few hours. Boas sign is referred right subscapular pain of biliary colic.
What are some complications of biliary colic? (2)
Cholecystitis, choledocholithiasis
How is biliary colic diagnosed?
RUQ ultrasound
How is biliary colic treated?
No treatment if the patient is asymptomatic. Elective cholecystectomy if the patient has recurrent bouts of biliary colic
What causes the pain in acute cholecystitis and how long does this pain last?
Pain in acute cholecystitis is from gallbladder wall inflammation. This pain lasts several days
Define acute cholecystitis?
Obstruction of the cystic duct (not infection) induces acute inflammation of the gallbladder wall.
What are the symptoms (3) and signs (1) of acute cholecystitis?
Symptoms:
- Symptoms are pain in RUQ or epigastrium. May radiate to the right shoulder/scapula.
- Nausea/vomiting
- Anorexia
Signs:
Murphy’s sign = inspiratory arrest during deep palpation of the RUQ.
What are the findings of acute cholecystitis on RUQ ultrasound?
Thickened gallbladder wall, pericholecystic fluid, distended gallbladder, presence of stones
When could acute cholecystitis be ruled out? (test). What is seen in a positive HIDA scan?
If Hida scan is normal, acute cholecystitis is ruled out. If gallbladder is not visualized, acute cholecystitis is confirmed.
What is the treatment for acute cholecystitis?
Cholecystectomy
What is gallstone ileus and what does it cause?
Gallstone enters the bowel lumen and gets stuck causing bowel obstruction (1-2% of cases of bowel obstruction are from gallstone ileus.
What is acalculous cholecystitis?
Acute cholecystitis without a stone obstructing the cystic duct
What causes acalculous cholecystitis and what are the signs and symptoms?
Severe illness is the cause. Signs and symptoms are the same as acute cholecystitis
How is acalculous cholecystitis treated?
Treated with emergent cholecystectomy.
What are some life-threatening complications of acute cholecystitis?
Gangrene and Gallbladder Perforation
What does choledolithiasis refer to?
Gallstones in the common bile duct
What are the clinical features of choledocholithiasis?
Patients may be asymptomatic for years. Symptoms, when present, include RUQ or epigastric pain and jaundice.
How sensitive is RUQ US for choledocholithiasis?
50% sensitive. Normal RUQ scan does not rule out choledocholithiasis.
What are the labs can you expect for choledocholithiasis
Total and direct bilirubin is elevated. ALK-P is elevated
What is the gold standard for diagnosis and treatment for choledocholithiasis?
ERCP
How are the presenting symptoms different for choledocholithiasis and acute cholecystitis?
Patients with CBD stones may be asymptomatic for years. However, unlike patients with cholelithiasis, in which biliary colic may lead to acute cholecystitis, the onset of choledocholithiasis can signal the development of life-threatening complications like cholangitis and pancreatitis.
Do patients with acute cholecystitis have jaundice?
No
What two disorders affect the cystic duct?
- Biliary colic
2. Acute cholecystitis
What disorders affect the common bile duct?
- Cholangitis
2. Choledocholithiasis
What is cholangitis?
Infection of the biliary tract secondary to obstruction which leads to biliary stasis and bacterial overgrowth
What is Charcot triad and what disease process does it indicate?
RUQ pain
Jaundice
Fever
Indicates cholangitis
What is Reynolds Pentad and what disease process does it indicate?
RUQ pain Jaundice Fever Septic Shock Altered Mental Status
What are the lab findings in cholangitis?
Leukocytosis
Hyperbilirubinemia
Increased LFTs (mild)
How is cholangitis treated?
IV antibiotics and IV fluids
Closely monitor hemodynamics, BP and urine output.
Once patient has been afebrile for 48 hours, consider ERCP, PTC (catheter drainage), or laparotomy (T-tube insertion)
What is the most deadly complication of cholangitis?
Hepatic abscess
What is gallbladder cancer associated with?
Elderly patients with a history of gallstones or porcelain gallbladder.
What is the pathology underlying primary sclerosing cholangitis?
Intra and extra hepatic bile ducts thicken and have luminal narrowing.
What is the pathology for primary biliary cirrhosis?
Intrahepatic bile duct destruction
Which is associated with UC, primary biliary cirrhosis or primary sclerosing cholangitis?
PSC is associated with UC
