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DIT Level 2 > Gastroenterology > Flashcards

Gastroenterology Flashcards

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1
Q

Causes of dysphagia

A

Neuromuscular motility disorders - solids and liquids

  • Achalasia
  • Scleroderma

Esophageal obstruction - solids

  • Strictures - d/t esophageal reflux, alkali ingestion, or radiation to chest
  • Cancer
  • Esophageal webs or rings
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2
Q

Plummer-Vinson Syndrome

A

Esophageal webs
Dysphagia
iron deficiency anemia

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3
Q

Diagnostic testing for dysphagia

A

EGD - most common
Barium swallow - when diverticula/risk of perf is high
Manometry if EGD unrevealing and/or esophageal motility disorder suspected

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4
Q

Radiologic studies for anatomic structures of GI tract

A

barium swallow - esophagus, LES, stomach

Gastric emptying study - stomach, pyloric sphincter, duodenum - eval gastroparesis

Small bowel follow-through (SBFT) - stomach to terminal ileum

Barium enema - rectum to appendix

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5
Q

Feeding methods when unable to eat by mouth and complications/risks associated

A

NG tube - complication: worsening GERD, pressure necrosis

Percutaneous endoscopic gastrostomy (PEG) tube

TPN - risk sepsis, infections including fungal with central line; increased risk bile stasis and calculus cholecystitis

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6
Q

Causes of pseudoachalasia

A

chagas dz
neoplasm
scleroderma

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7
Q

Achalasia

A

Impaired peristalsis, decreased LES relaxation d/t intramural neuron dysfunction

Clinical features

  • Progressive dysphagia of solids and liquids
  • Regurgitation, cough, aspiration, heartburn
  • wt loss - from poor intake

Diagnostics:
EGD r/o neoplasm
Manometry - increased LES pressure, incomplete LES relaxation, decreased peristalsis
“Birds beak” on barium swallow

Tx:
Pneumatic dilation and myotomy - risk GERD or perf
-botox
-nitrates and/or dihydropyridine CCBs - cardiac effects

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8
Q

Diffuse esophageal spasm

A

disorder, non peristaltic contractions of lower esophagus

CP and dysphagia of liquids and solids

Dx:
barium swallow - corkscrew pattern
Manometry - non peristaltic, uncoordinated esophageal contractions
Endoscopy - r/o structural disorders

Tx: CCB, TCAs
Nitrates relieve pain but worsen reflux

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9
Q

Esophageal diverticula and location

A

Zenker diverticulum - immediately before upper sphincter
Traction diverticulum - mid esophagus
Epiphrenic diverticulum - immediately above LES

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10
Q

Zenker diverticulum

A

Outpouching in upper posterior esophagus d/t striated muscle weakness

halitosis
difficulting instating swallowing
regurgitation of food several days after eating it
Dysphagia
Aspiration

Dx: barium swallow - EGD dangerous - risk perf

Tx: cricopharyngeal myotomy and diverticulectomy

Complications: aspiration pna, squamous cell carcinoma

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11
Q

GERD

A

transient relaxation of LES -> reflux of gastric content into esophagus

Risk: obesity, hiatal hernia, pregnancy, scleroderma

Burning CP 30-90 min after eating
sour taste
regurgitation
Nausea
Cough
Aggravating factors: etoh, fatty foods, tobacco, lying down

Dx: - clinical
EGD with tx failure/red flags (bleeding, wt loss, dysphagia, odynophagia, protracted vomiting)
Ambulatory pH monitoring to verify GERD
Manometry assess other causes of dysphagia

Tx: refractory: nissen fundoplication

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12
Q

Complications of GERD

A 
ulceration -> bleeding
stricture
Barrett's esophagus
Adenocarcinoma
Reflux-induced asthma
laryngeal disorders
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13
Q

Squamous cell carcinoma of esophagus

A

MC worldwide

Risk: alcohol and tobacco use

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14
Q

Adenocarcinoma of esophagus

A

more common in US

Risk: obesity, tobacco use, barrett’s esophagus

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15
Q

Esophageal cancer - clinical features, Dx, Tx

A 
Features:
progressive dysphagia
Wt loss
Odynophagia, reflux
GI bleeding
Vomiting, weakness, cough, hoarseness

Dx:
barium swallow - esophageal narrowing and mass
Test of choice: EGD - bx
MRI, CT, PET scan - determine extension and metastases

Tx:
Total esophagectomy for early disease
Radiation and chemo in advanced or as neoadjuvant therapy

Poor prognosis

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16
Q

Mallory weiss tear vs boerhaave syndrome

A

MW: longitudinal mucosa laceration - MC distal esophagus/proximal stomach

BS: esophageal perforation or rupture - MC distal; life threatening

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17
Q

Hiatal hernia - types and tx

A

Sliding - MC

  • GE junction and stomach displaced through diaphragm
  • Tx with PPIs

Paraesophageal

  • stomach protrudes through diaphragm, GE junction remains in normal location
  • risk incarceration, ischemia
  • Tx: surgical repair, especially w/ sxs

Dx: barium swallow

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18
Q

Gastritis

A

Causes:
H.pylori, NSAIDs, etOH, smoking, severe illness, autoimmune dz, Crohn dz, radiation

Clinical features:
epigastric pain with tenderness
N/V
loss of appetitie
early satiety
wt loss

DX:
EGD
H. pylori - urea breath test, antral bx, serum Ab (+ if ever exposed), stool antigen

Tx:
Stop offending meds
H. pylori negative: PPI, H2 blockers
H. pylori positive: PPIs, Amox (metronidazole if pcn allergic), clarithromycin x2 weeks

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19
Q 
Gastric vs duodenal ulcer
Age -
Cause-
% of cases
Pain occurs -
Gastric acid - 
Gastrin level -
A 
Gastric:
Age - older
Cause- H. pylori, NSAIDs
% of cases - 25%
Pain occurs - soon after eating -> N/V
Gastric acid - normal or low
Gastrin level - high
Duodenal:
Age - younger
Cause- H pylori >90%
% of cases - 75%
Pain occurs - 2-5 hours after eating; eating initially improves, worse later
Gastric acid - high
Gastrin level - low
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20
Q

Curling ulcer

A

Severe burns -> duodenal ulcer

reduced plasma volume -> ischemia and cell necrosis

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21
Q

Cushing ulcer

A

Increased ICP -> stimulation of vagal nuclei

-> increased gastric acid secretion

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22
Q

What do you check if GERD refractory to treatment?

A

gastrin level

R/o Zollinger ellison sn

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23
Q

PUD

A 
Sx:
GERD
epigastric pain
N/V
bleeding

Dx:
Abd XR - perf, free air under diaphragm
Barium study - collection of barium in ulcer pits
EGD - most effective - bx - r/o cancer, test for H. pylori

Tx:
Control active bleeding
Acid suppression
Protect mucosa
Eradicate H. pylori
Severe dz: parietal cell vagotomy or antrectomy
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24
Q

Types of gastric cancer

A

Adenocarcinoma - MC

squamous cell carcinoma

Linitis plastica - all layers of stomach - leather bottle - poor prognosis

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25
Q

Gastric cancer - risk, features, markers, dx, tx

A

Risk:
H. pylori, FHx, tobacco use, etoh use, consumption of nitrosamine (preserved foods), Men > women

Features:
Wt loss, anorexia, early satiety, vomiting/dysphagia, epigastric pain
Virchow node - left supraclavicular LN
Sister Mary Joseph node - periumbilical node

Markers:
CEA - increased in 50%
CA 19-9 increased in 20%

Tx:
distal 1/3 - subtotal gastrectomy
Middle or upper - total gastrectomy (or invasive lesions)
Chemo and radiation

Early detection - 70% cure rate
Most late = poor, less than 15% 5 yr survival

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26
Q

Nutritional deficiency associated with surgical therapy for obesity

A

Iron, vit B12, folate, thiamine, vit D

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27
Q

Most common causes of SBO

A

A - adhesions - 70%
B - bulge - incarcerated hernias 10%
C - Cancer - colon, ovarian mets 15%

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28
Q

Less common causes of SBO

A

Bowel wall inflammation - Crohn disease, appendicitis, diverticulitis

Bowel wall hematoma d/t trauma

Strictures - Crohn dz, radiation enteritis, prior surgery

Gallstone ileus

Bezoar

Intussusception

Volvulus - large > small intestine

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29
Q

S/S of SBO

A

N/V
Diffuse abdominal pain and distension
No BM or flatus
dehydration -> orthostatic hypotension, tenting of skin

Bowel sounds high pitched and hyperactive early - “tinkly”
Later hypoactive

Abd XR: distended loops of bowel, multiple air-fluid levels

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30
Q

Management of SBO

A

NPO - bowel rest
IVF
Correct electrolyte derangements - esp vomiting
NG tube - low intermittent suction to decompress

Hospital observation with frequent assessments

Avoid opioids - worsen disease

surgery - laparotomy and lysis of adhesions

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31
Q

Whipple disease

A

Malabsorptive dz - Tropheryma whipplei infection
White males

Abd pain
Diarrhea
Wt loss
JOINT PAIN
Neurologic problems - dementia, cerebellar ataxia

Dx: intestinal bx:

  • blunting of villi
  • lamina propria filled with fat droplets and PAS+ foamy macrophages (bright pink) contain T. whipplei

Tx:
IV ceftriaxone x2 weeks
TMP-SMX x 12 mo to prevent relapse

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32
Q

Features of malabsorption

A 
Wt loss
edema - protein malabsorption
Diarrhea - osmotic load
Steatorrhea
Glossitis - B vit def
Dermatitis - niacin def, zinc def
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33
Q

Site of ethanol absorption

A

stomach

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34
Q

Vit B12 site of absorption

A

terminal ileum

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35
Q

Tropical sprue

A

Caribbean, India, SE Asia

Steatorrhea, Chronic D - fat malabsorption
Megaloblastic anemia - B12/folate malabsorption
Abdominal distention - sugar malabsorption
Pedal edema - protein malabsorption

Bx:
blunting villi
Inflammatory cells in lamina propria
Dx of exclusion

Tx: tetracycline
Folic acid 3-6 mo
B12 shots

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36
Q

Celiac sprue

A

Sensitive to gluten - gliadin
Northern European ancestry

Bulky, foul-smelling diarrhea
Steatorrhea
Wt loss
Iron def anemia
Osteopenia
Dermatitis herpetiformis - elbows, knees

Serology:
IgA anti tissue transglutaminase Ab - not rec anymore
Anti-endomysial Ab

Bx:
Blunting of villi
Hypertrophy of crypts

Tx: GF diet
Dapsone for dermatitis herpetiformis

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37
Q

Diagnostic testing for inflammatory diarrhea

A

Occult blood

fecal leukocytes

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38
Q

Diagnostic testing for steatorrhea

A 
sudan stain (qualitative)
Quantitative fecal fat - 72 hr stool collection
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39
Q

D-xylose test

A

Carbohydrate malabsorption

tests for passive absorption of carbs, normal suggests pancreatic insufficiency

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40
Q

Lactose breath hydrogen test

A

Carbohydrate malabsorption

measure H content inn reach following oral lactose challenge - high breath H suggests lactase deficiency

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41
Q

Lactose absorption test

A

Carbohydrate malabsorption

measure blood glucose following oral lactose challenge - failure of blood glucose to rise suggests lactase deficiency

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42
Q

Stool pH test

A

Carbohydrate malabsorption

lactase deficiency - not reliable

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43
Q

Formula and interpretation of stool osmotic gap

A

290 - 2 (Na+stool + K+stool)

normal 50-100

> 125 - osmotic diarrhea - extra osmoles in stool

less than 50 - secretory diarrhea

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44
Q

Causes of osmotic diarrhea and definition

A

watery diarrhea - water drawn into lumen by undigested solutes
-better when stop eating

lacunose, milk of magnesia
Carbohydrate malabsorption - celiac, Whipple dz
Fat malabsorption - pancreatic insufficiency

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45
Q

Causes and definition of secretory diarrhea

A

High volume stool output even when fasting

Carcinoid syndrome
VIPoma, gastrinoma
Cholera
ETEC

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46
Q

Viral gastroenteritis - adults vs kids

A

Adults: norovirus MC, rotavirus, adenovirus, astrovirus

Kids: rotavirus

Diarrhea, N/V, abdominal pain
Low grade fever
Blood or mucus in stool rare

labs - normal

Tx: hydrate

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47
Q

Rotavirus

A 
very common in kids
profuse diarrhea - bright green/yellow, foul smelling
dehydration
winter months
ELISA or PCR
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48
Q

Norovirus

A

Vomiting prominent
diarrhea
Winter months

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49
Q

Bacillus cereus

A

Fried rice

Sxs within hours of eating

Tx: hydration

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50
Q

Campylobacter jejuni

A

Poultry
2nd MC foodborne bacterial GI infection

can have Bloody D, often watery
Abdominal pain
Fever

Rare association w/ Guillian-Barre 2-3 weeks after; reactive arthritis

Tx: hydration
severe cases - fluoroquinolone (cipro, levo) or azithromycin

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51
Q

Clostridium botulinum

A

Honey and home canned foods - preformed toxin = quick onset

N/V/D
B/l symmetric DESCENDING weakness starting with b/l CN neuropathies

Tx: monitor closely
Intubate if needed
Botulinum antitoxin with PCN G

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52
Q

Infant botulism

A

honey

colonize GI tract - release toxin in vivo

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53
Q

Clostridium difficile

A

Superinfection begins after use of broad-spectrum abx - Clindamycin

watery or blood diarrhea
can develop pseudomembranous colitis

Tx: metronidazole or vancomycin PO
-recurrent - adjunct tx - cholestyramine - binds toxin

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54
Q

Enterotoxigenic Escherichia coli

A

contaminated food and water - foreign travel

watery diarrhea, V, fever

Tx: hydration

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55
Q

Enterohemorrhagic Escherichia coli type O157:H7

A

undercooked ground beef

Bloody diarrhea, vomiting, fever, abdominal pain

Hemolytic uremic syndrome

Treatment - hydration, supportive
Abx worsens d/t toxin release

56
Q

Hemolytic uremic syndrome (HUS)

A

Thrombocytopenia
hemolytic anemia
Acute renal failure -> risk death

57
Q

Staphylococcus aureus

A

poultry, dairy, eggs, produce (room temp) - picnic salads

early sxs d/t toxin - Vomiting within hours, D later

tx: hydration

58
Q

Salmonella spp.

A

MC: food borne bacterial GI infection

Raw meat, poultry, fresh produce

bloody diarrhea, fever, vomiting

Tx: hydration
Immunocompromised or severely ill: fluoroquinolone - cipro/levo

59
Q

Shigella spp.

A

food and waterborne - overcrowding population

“Bacterial dysentery”

Fever
N/V
Severe bloody diarrhea
Abdominal pain
HUS

Tx: hydration, fluoroquinolone (cipro), TMP-SMX

60
Q

Vibrio cholerae

A

“rice water diarrhea”
seafood

Copious watery diarrhea
Severe electrolyte imbalances
death

Tx: aggressive hydration
Tetracycline, doxycycline decrease duration

61
Q

Vibrio parahaemolyticus

A

seafood - oysters

Tx: hydration

62
Q

Yersinia enterocolitica

A

pork, produce, puppy feces

Diarrhea
20% pharyngitis
Pseudoappendicitis

Tx: hydration

63
Q

Giardia lamblia

A

surface water, streams

greasy, foul-smelling diarrhea
abdominal pian
malaise

dx: cysts and trophozoites in stool

Tx: metronidazole

64
Q

Entamoeba histolytica

A

water/streams

“Amoebic dysentery”

Bloody diarrhea - mild to severe
abdominal pain

Severe disease -> liver abscess

Tx: metronidazole, paromomycin

65
Q

Cryptosporidium parvum

A

food or waterborne
Immunocompromised - HIV

Watery D
abdominal pain
malaise

acid-fast stain shows parasites

Tx: nitazoxanide

66
Q

Trichinella spiralis

A

worm
undercooked pork

fever
myalgia
PERIORBITAL EDEMA
eosinophilia
CNS sxs
Cardiac sxs

Tx: albendazole, mebendazole

67
Q

Taenia solium

A

worm
undercooked pork

mild diarrhea
CNS symptoms

Taeniasis - tapeworm in gut only
Cysticercosis - cysts in muscle
Neurocysticercosis - cysts in brain

Tx: praziquantel for gut infection; albendazole for CNS infection +/- corticosteroids

68
Q

Approach to acute diarrhea

A

Non - severe: self limiting

Severe: hypovolemia, bloody stools, fever, >6 stools per day, duration >1 week, severe abdominal pain, older age and immunocompromised

Testing:
Fecal leukocytes, stool cx, +/- ova and parasites if immunocompromised, +/- Giardia and E. histolytica if assoc with surface water; c. diff if recent abx

Empiric abx: fluoroquinolone for 3-5 days
-bloody diarrhea, fever, severe dehydration, immunocompromised state

69
Q

Irritable bowel syndrome

A

Dx of exclusion

Sxs: chronic abdominal pain, D and/or C, bloating, N, mild abd tenderness, frequent/urgent urinary sxs, fibromyalgia sxs

Rome criteria - recurrent abd pain/discomfort at least 3 days/mo in last 3 mo associated with at least 2:

  • relief with defecation
  • Onset assoc w/ change in frequency of stool
  • Onset assoc with change in form of stool

Not consistent with IBS: anorexia, wt loss, malnutrition, progressively worsening pain, pain that prevents sleep, rectal bleeding
-electrolyte disturbances, anemia, increasing inflammatory markers

Non pharm tx:
High fiber diet, avoid gas producing foods, avoid lactose/gluten controversial
Psychotherapy to relieve stress

Pharma:
Constipation predominant: psyllium, polyethylene glycol, lubiprostone, linaclotide

Diarrhea predominant: loperamide (imodium), eluxadoline

Abd pain and bloating: antispasmodics - diclycomine, hyoscyamine

Antidepressants - SSRI for pain

70
Q

Crohn disease

A

Reaction to intestinal flora
Transmural inflammation - anyway mouth to anus
Spares rectum - skip lesions

Barium study: “String sign”, cobblestone pattern

Presentation:
strictures, D, malabsorption, wt loss, rare bloody stools, fistulas
Arthritis (HLA-B27), immunologic problems, dermatologic - erythema nodosum

Increased colon cancer risk - not as much as UC

Tx: 
Mesalamine, sulfasalazine - 5-ASAs
Azothioprine, mercaptopurine, methotrexate
Infliximab, adalimumab - anti-TNF
Steroids
Abx
71
Q

Ulcerative colitis

A

Autoimmune reaction
Inflammation limited to colon
Continuous inflammation - always affects rectum
Inflammation limited to mucosa and submucosa

Barium study - “Lead pipe” obliterated haustra
Bx: crypt abscess, ulcerations

Presentation:
bloody D, malnutrition, increased risk of colon CA
PSC, pyoderma gangrenosum
HLA-B27 - sacroilitis, uveitis

Tx:
Sulfasalazine
6-mercaptopurine
infliximab
colon resection - curative
72
Q

Ileus

A

Disruption of normal propulsive ability of bowel d/t decreased peristalsis

MC: recent surgery
infection, opiates, DM

Vague abd pain
N/V
bloating
No BM
Decreased bowel sounds
mild abdominal tenderness
No rebound
Unable to tolerate meals

Abd XR: mild distension of affective bowel and air-fluid levels
Barium enema - r/o true obstruction

Tx: erythromycin, neostigmine, or metoclopramide
Decrease or stop opioids
IVF
NPO +/- NG tube

Serial abdominal exams to monitor worsening

73
Q

Volvulus

A

elderly, children
Air-filled loop of sigmoid colon twists about mesentery
Severe -> obstruct, impair blood supply

Slowly progressive abd pain, N/C, late V

+/- double bubble on abd XR
+/- “bird beak” on barium enema
CT scan - dx

Tx: self limited
No signs of perf -> flex sig
If signs of perf -> laparotomy
detorsion followed by sigmoid resection - high recurrence

74
Q

Intestinal ischemia

A

elderly
Mesenteric ischemia - small intestine - SMA
Ischemic colitis - large intestine - SMA/IMA
Watershed area highest risk - splenic flexure

Causes:
Splanchnic vasoconstriction
acute arterial occlusion
Venous thrombosis or hypo perfusion
chronic form d/t atherosclerosis - pain after eating

Abd pain out of proportion to exam

Elevated WBC - severe dz
XR: dilated loops of bowel, bowel wall thickening

Dx: CT angio

Tx:
Venous thrombosis - anticoagulate chronically
Arterial embolism - surgical laparotomy with embolectomy
Non-occulsive vasoconstriction - stop drugs causing vasoconstriction
Bowel necrosis - surgical resection

75
Q

Appendicitis

A

Obstruction - fecalith, calculi, lymphoid hyperplasia, tumors
Infection

Periumbilical pain -> RLQ
McBurney’s point
Psoas sign - RLQ with passive hip extension
Rovsing sign - RLQ pain with LLQ palpation

WBC elevated with left shift - >17K assoc with perf
CT scan with IV/PO contrast - enlarged appendix, wall thickening, periappendical fat stranding
U/S in kids

Tx: IVF, correct electrolyte abnormalities
Non-perf: single dose cefoxatin, ampicillin/sulbactum, or cefazolin plus metronidazole

Perf: pip/tazo, ticarcillin/clavulanate or ceftriaxone plus metronidazole

Appendectomy

76
Q

Carcinoid tumor

A

Neuroendocrine tumor - secretes serotonin

MC site ileum; lungs, rectum, appendix (MC appendix tumor)

Asx if not mets; +/- abd pain

Carcinoid syndrome: d/t large quantity of serotonin
“Be FDR” - Bronchoconstriction (wheezing), Flushing, Diarrhea, Right-sided valve dz (restrictive CM - serotonin induced fibrosis of valvular endocardium)

Dx:
Incidental in asx
24 hr urine - 5-HIAA if sxs

Tx:
Non-metastatic - remove tumor
Carcinoid syndrome: octreotide or depot lanreotide - suppress gut hormones, decrease motility
Bronchoconstriction: b2-agonists
Diarrhea: loperamide
77
Q

Anorectal abscess

A

infection of anal crypt or hemorrhoid, hair follicle

throbbing rectal pain
fever
tenderness on DRE

Tx: abx and drain

78
Q

Pilonidal disease

A

1 or more cutaneous sinus tracts in superior midline gluteal cleft

obstruction -> cysts with drainage, abscesses
painful

Tx: I&D, surgical closure of sinus tracts

79
Q

Diverticulosis

A

MC sigmoid colon
MC cause of acute lower GI bleeding over 40 yo

Risk:
Low fiber/high fat diet, older age

Cramping, bloating, flatuence, irregular defecation
painless rectal bleeding

Dx:
barium enema
Colonoscopy - sclerose vessel

Tx:
high-fiber diet/low fat - control bleeding
Angiography - embolization
Resect if unable to control bleeding

80
Q

Presentation of diverticulutis

A

mean age 63 yo

LLQ pain
constipation
fever
elevated WBC with left shift or normal

Perf: CXR - free air
CT - oral and IV contrast - localized bowel wall thickening, diverticula

Colonoscopy no role, risk of perf

81
Q

Outpatient vs inpatient treatment for diverticulitis

A

Out pt: - mild
bowel rest, PO abx

Fluoroquinolone (cipro) + metronidazole
Amox-clav
TMP-SMX + Metronidazole

Inpatient: elderly, immunocompromised, significant co-morbiditities
High fever
Significant leukocytosis
Unable to maintain hydration

IVF
Amp-sulbactam
pip-taco
Ticarcillin-clav

S/S of acute abd -> surgical exploration via midline incision

82
Q

Hemorrhoids

A

Internal - superior rectal v., above pectinate (dentate) line, painless

External: inferior rectal v. , below pectinate line, painful

Dx:
Sigmoidoscopy
Colonoscopy
Anoscope

Tx: 
sitz baths
high fiber diet
avoid straining
Rubber banding
surgical excision - significant post op pain
83
Q

Anal fissures

A

posterior wall of anus
painful
2/2 trauma - defecation, anal sex
-> spasm of rectal sphincter

Tx:
1st line: stool softeners, adequate hydration, typical nitroglycerin
botox in sphincter muscle - prevent spasm
Partial spincterotomy -> 10-30% risk of fecal incontinence

84
Q

Rectal fistulas (fistula in ano)

A

tract between rectum and other structure - MC skin
2/2 inflammation
easily infected

S/S:
pain with defecation
visible draining tract - pus or fluid

Tx:
Fistulotomy
If Crohns - abx, immunosuppressants

85
Q

Complications of diverticulitis

A

colonic abscesses
fistulas
sepsis

86
Q

Major risk factors for adenocarcinoma of pancreas

A

exocrine tumor

FHx
Chronic pancreatitis
DM
Tobacco use
High fat diet
obesity
physical inactivity
87
Q

Pancreatic adenocarcinoma - presentation, dx, tx, complications

A

Presentation:
abd pain - gradual, gnawing, epigastric, may radiate to back
Wt loss - d/t anorexia, malabsorption; n/v
Jaundice - d/t biliary obstruction
+/- palpable abd mass
+/- palpable contender gallbladder (Courvoisier sign)

Dx:
High bilirubin and alk phos
CA 19-9
Mass visible on US or CT
Bx via endoscopic US, ERCP, or percutaneous needle bx
Tx:
Whipple procedure (no mets) - pancreaticoduodenectomy plus chemo +/- radiation

Advanced dz: palliative care - biliary stunting, duodenal stunting, pancreatic enzyme supplements

Complications: trousseau syndrome - migratory thrombophlebitis

88
Q

Zollinger-Ellison syndrome (gastronoma) - presentation, dx, tx

A

Gastrin secreting tumor
More common in duodenum
MC type of functional pancreatic neuroendocrine tumor

Presentation:
PUD and D
Common in MEN type 1
Frequently malignant

Dx:
Best test: fasting gastrin usually >1000
Secretin stimulation test: stimulates gastrin secretion in gastrinoma (usually suppresses gastrin)
Imaging to locate tumor:
-CT
-MRI
-Octreotide scan (somatostatin receptor scintigraphy, SRS)
-Endoscopic U/S - can do FNA

Tx:
High dose PPIs or octreotide to suppress acid secretion
Surgical resection - if resettable

89
Q

Insulinoma - presentation, dx, tx

A

insulin-secreting tumor -> hypoglycemia

Dx:
Labs: hypoglycemia, elevated fasting insulin level, elevated C peptide
CT or abd U/S to locate tumor

Tx:
Surgical resection if resectable
If not - diazoxide (prevents insulin release) or octreotide (shuts down production of insulin)

90
Q

Glucagonoma- presentation, dx, tx

A

Glucagon-secreting tumor

Presentation:
Hyperglycemia and refractory DM
Necrolytic migratory erythema - painful, pruritic, migratory rash on face, perineum, sometimes extremities

Dx:
Labs: hyperglycemia, elevated glucagon level
CT, MRI, or octreotide scan to locate tumor

Tx:
Octreotide to suppress glucagon secretion
Surgical resection if possible

Frequently malignant and often widely metastatic at dx -> poor prognosis

91
Q

VIPoma - presentation, dx, tx

A

Islet cell tumor secretes vasoactive intestinal peptide -> increased secretion of water into lumen and increased motility

Presentation: high volume water diarrhea

Dx:
Labs: elevated serum VIP, low stool osmotic gap (secretory)
CT, MRI, octreotide scan to locate tumor

Tx:
hydration and electrolyte replacement -esp K+
Octreotide to suppress VIP secretion
Surgical resection but usually mets at dx

92
Q

major risk factors for cholelithiasis

A

Fat
Fertile
Females
over 40

OCPs and HRT
FHx
Prolonged TPN
Rapid weight loss

93
Q

Cholelithiasis - presentation, dx, tx

A

Often asx
Postprandial RUQ abd pain - “biliary colic”, worse after fatty meals
Possible N/V, abdominal fullness
PE generally negative

Dx:
Labs normal
RUQ U/S shows hyperlucent gallstones

Tx: cholecystectomy - if symptomatic

Complications: acute cholecystitis, cholangitis, acute pancreatitis

94
Q

Acute cholecystitis- causes, presentation, dx, tx

A

Causes:
gallstone obstruction
Acalculous - critically ill (ischemia/necrosis) or TPN

Features:
Severe RUQ abd - may radiate to back or right shoulder
Fever
Possible N/V, anorexia
Abd tenderness and guarding
Positive Murphy sign

Dx:
Labs: leukocytosis with left shift; serum bilirubin and alk phos usually not elevated

U/S: gallstones, thickening of gallbladder wall; sonographic murphy sign
HIDA scan - gallbladder fails to fill normally

Tx: cholecystectomy for mild to moderate disease
Abx and biliary stenting for critically ill who can’t tolerate surgery (organ failure)

95
Q

Acute cholangitis- presentation, dx, tx

A

Bile duct obstruction (MC gallstones, stricture, cancer of pancreatic or biliary tree) -> infection of proximal biliary tree

Features:
Charcot’s triad - fever, jaundice, RUQ pain
Reynolds pentad - AMS, hypotension (shock)

Dx:
Leukocytosis with left shift
Elevated conjugated bilirubin and alk phos
+/- elevated AST/ALT (hepatocyte damage)
Check blood cx - E.coli, Klebsiella, Enterococci

Best radiologic test: ERCP

Tx:
Broad spectrum abx x7-10 days - pip-taco, levofloxacin
Endoscopic biliary drainage
Delayed cholecystectomy once cooled off

96
Q

Gallbladder cancer - presentation, dx, tx

A

90% adenocarcinoma - aggressive
Risk factors - mainly gallstones

Presentation:
Often asx - may cause abd pain, jaundice, wt loss, V
Palpable gallbladder

Dx:
Labs: elevated bili and alk phos
endoscopic U/S: gallbladder mass, thickening of wall, possibly gallbladder calcification (porcelain gallbladder 10-30% CA)

Tx:
Cholecystectomy and LN dissection and local hepatic resection (gallbladder fossa)
Post-op or palliative chemo/radiation

97
Q

Primary Biliary Cholangitis- description, risk, presentation, dx, tx

A

Autoimmune destruction of intrahepatic bile ductules -> cholestasis -> cirrhosis (late)

Risk: Women 30-65 yo; assoc with Sjogren’s, CREST, RA

Features:
frequently asx - incidental finding
Sxs: fatigue and pruritis w/ excoriations
-pruritis often starting during pregnancy but not received postpartum
Skin changes: hyper pigmentation, xerosis, dermatographism
Xanthomas and xanthelasms
Hepatomegaly progressively worsens +/- splenomegaly
Malabsorption and steatorrhea from less bile acid secretion
Cirrhosis, jaundice, ascites, edema, and portal htn late

Dx:
Elevated alk phos, bili (late), cholesterol
ANTI-MITOCHONDRIAL Ab
ANA

Tx:
URSODEOXYCHOLID ACID - changes bile composition, delays progression, not curative
Liver transplant

98
Q

Primary sclerosis cholangitis description, risk, presentation, dx, tx

A

Progressive inflammation, fibrosis, and sclerosis of intra AND extra hepatic bile ducts

Risk: males, 40 yo
Strong association with UC

Features:
Frequently asx
Fatigue, pruritis w/ excoriations, jaundice, hepatomegaly

Dx:
Elevated alk phos +/- elevated bili
ANA negative
p-ANCA positive
ERCP - irregular biliary stricturing and dilation "beads on string"

Tx: Liver treatment - no medical tx available

Complication: risk of cholangiocarcinoma

99
Q

Causes of secondary sclerosis cholangitis

A 
Intraductal biliary stones
Surgical trauma or blunt abdominal trauma to biliary tree
Drugs -IV chemo
Recurrent pancreatitis
Autoimmune pancreatitis
AIDS cholangiopathy
100
Q

Causes of unconjugated hyperbilirubinemia

A

Increased bilirubin production:

  • hemolytic anemia
  • hematoma breakdown

Impaired bilirubin uptake and storage:

  • viral hepatitis
  • Drugs - rifampin

Decreased UDPGT activity

  • neonatal physiologic jaundice
  • Gilbert syndrome
  • Crigler Najjar Syndrome type 1 and 2
101
Q

Causes of conjugated hyperbilirubinemia

A

Impaired bilirubin transport - can’t excrete

  • Dubin Johnson Sn - black
  • Rotor Sn

Biliary epithelial damage

  • hepatitis
  • cirrhosis
  • liver failure

Intrahepatic biliary obstruction

  • PBC
  • PSC
  • Drugs - chlorpromazine, arsenic

Extrahepatic biliary obstruction

  • pancreatic neoplasm
  • pancreatitis
  • cholangiocarcinoma
  • choledocholithiasis
  • biliary strictures
102
Q

Gilbert Syndrome

A

AR
Mild UDPGT deficiency

Mild jaundice following exercise, stress, fasting

Labs: mild elevated indirect bili (less than 3)

Tx: none

103
Q

Crigler-Najjar type 1

A

AR
Severe UDPGT deficiency

Persistent neonatal jaundice at 1-2 days old
Kernicterus

labs: markedly elevated indirect bili (>5)

Tx:
Phototherapy
Plasmapheresis
Liver transplant as adolescent

104
Q

Crigler-Najjar type 2

A

Mild UDPGT deficiency

Jaundice begins in childhood or adolescence

Labs: mildy elevated indirect bili

Tx:
Phenobarbital to induce UDPGT

105
Q

Hepatitis symptoms

A

asx or…

malaise
arthralgia 
fatigue 
N/V
RUQ pain
Scleral icteris
HSM
LAD

Rare -> fulminant failure -> coagulopathy, ascites

106
Q

Hepatits A

A

Transmission: Fecal-oral, poor sanitation

Risk: international travel - S. and Central America

Labs:
Hep A IgM during illness
Hep A IgG after resolution or vaccine

Tx: supportive - self limited
Vaccine available - given 1 yr, 2 yr

107
Q

Hepatitis E

A

Southeast Asia

Fecal/oral, contaminated water

More likely to cause fulminant hepatic failure in pregnancy

Labs: PCR, Hep E IgM
Tx: supportive

108
Q

Hepatitis B

A

perinatal, sex (MC), blood

Chronic infection: 90% prenatal transmission; adults less than 5%

Extrahepatic: polyarteritis nodosa, nephropathy, aplastic anemia

Increased risk of HCC - U/S q6mo, +/- AFP

109
Q

Significance of HBsAg

A

active disease

110
Q

Significance of HBsAb

A

recovery from active infection or immunization

111
Q

Significance of HBcAb

A

History of infection - IgM early, IgG late

112
Q

Significance of HBeAg

A

Active viral replication, high transmissibility

113
Q

Significance of HBeAb

A

low transmissibility

114
Q

Significance of HBV DNA

A

active viral réplication, treatment indicated when high

115
Q

Hepatitis D

A

Delta virus - defective pathogen requiring Hep B confection

Blood, sex
Highest mortality - 20%

Tx: pegylated IFN-a x 1 yr - causes flu like sxs

116
Q

Hepatitis C

A

50-85% remain chronically infected
Increased risk of HCC - U/S q6 mo

Extrahepatic manifestations: membranoproliferazive glomerulonephritis, essential mixed cryoglobulinemia, lymphoma, thyroiditis, polyarteritis nods, porphyria cutaneous trade, lichen plans, DM

Blood and sex (rare)

Dx: Hep C Ab, RNA

Tx: Ledipasvir-sofosbuvir; ombitasvir-paritaprevir-ritonavir + dasabuvir

117
Q

Types of alcoholic liver disease

A

Alcoholic fatty liver disease (steatosis)

  • 90% of heavy drinkers >30 g etOH/day
  • Fat droplets within hepatocytes
  • rapidly reversible with abstinence

Alcoholic hepatitis (steatohepatitis)

  • 33% of steatosis who continue to drink
  • Fat infiltration plus neutrophil inflammation; hepatocyte swelling and necrosis; some fibrosis

Cirrhosis

  • 50% of steatohepatitis
  • progressive fibrosis surrounds nodules of regenerative hepatocytes
  • becomes irreversible -> liver failure
  • increased risk of HCC
118
Q

Nonalcoholic steatohepatitis (NASH)

A

Causes: obesity, DM, hld, insulin resistance
Hepatic insulin resistance -> excess lipid accumulation in liver
->cirrhosis and HCC

Dx:
Chronically elevated LFTs
Liver U/S, CT, MRI: steatosis but cannot detect inflammation/fibrosis
Fibrosure

Tx:
Avoid all etoh
Wt loss
Keep HbA1c under 7
TZD (pioglitazone) - improve LFTs, possible histology improvement
119
Q

Alcoholic liver disease

A

Long asx period >20 yr
S/s: jaundice, anorexia, N/V, RUQ pain, abd distention, ascites, HSM, liver tenderness, muscle wasting, encephalopathy

Dx:
Elevated AST/ALT 2:1, elevated alk phos, bili
low albumin
Prolonged PT/PTT
Leukocytosis (neutrophil predominance)
Macrocytosis (folate/B12 deficiency)
Thrombocytopenia

Tx:
Stop etoh use
Diet mod
Liver transplant if abstinent for at least 6 mo

120
Q

Findings consistent with hepatocyte failure in cirrhosis

A

Jaundice - impaired bilirubin conjugation
bleeding/bruising - impaired synthesis of coagulation factors (elevated PT/PTT)
Edema and ascites - impaired synthesis of albumin
Hepatic encephalopathy and asterisks - impaired ammonia metabolism

Impaired sex hormone metabolism -> testicular atrophy, gynecomastia, spider telangiectasis, palmar erythema

121
Q

Treatment of hepatic encephalopathy

A

lactulose - lowers colonic pH, prevents ammonia reabsorption in GI tract, facilitates fecal ammonia excretion

Rifaximan - kills enteric bacteria that generate ammonia

122
Q

Causes of portal hypertension

A

Prehepatic: portal vein thombosis

Intrahepatic:

  • cirrhosis
  • Hepatic parenchymal disease (alcoholic liver dz, PBC, PSC, amyloidosis)
  • Granulomatous dz (sarcoidosis)
  • Schistosomiasis (outside US)

Posthepatic

  • Right sided heart failure
  • Budd-Chiari syndrome
  • Thrombosis of hepatic v.
123
Q

Budd-Chiari Syndrome

A

thrombosis and occlusion of hepatic v or intrahepatic/suprahepatic portion of IVC

Presentation:
Acute: acute RUQ, hepatomegaly, rapid jaundice and ascites
Subacute/chronic: gradual ascites, LE edema, cirrhosis, portal htn over few months

Eventual liver failure and hepatic encephalopathy

Dx:
U/S - best test
Hepatic venography gold standard

Tx:

  • thrombolytics
  • Diuretics and anticoagulation
  • Angioplasty
  • Shunt
124
Q

Clinical presentation of portal hypertension

A 
HSM
ascites
portosystemic anastomoses (gut, butt, caput)
-esophageal varices
-Anorectal varices
-Caput medusae
-Renal varices
-Paravertebral varices
125
Q

Serum-ascites albumin gradient (SAAG)

A

Serum albumin - ascites albumin

> or equal to 1.1 - portal htn - low albumin

  • Cirrhosis
  • alcoholic hepatitis
  • heart failure/constrictive pericarditis
  • massive hepatic mets
  • Budd-Chiari syndrome
less than 1.1 - ascites not due to portal htn
High albumin ascites:
-peritoneal carcinomatosis (ovarian CA)
-Peritoneal TB
-Pancreatitis
-Serositis
Low serum albumin
-Nephrotic syndrome

High albumin + high LDH r/o cancer

126
Q

Spontaneous bacterial peritonitis

A

Infection of ascitic fluid

Fever
+/- abd pain/tenderness
AMS common
Diarrhea 2/2 overgrowth of enteric bacteria (esp E. coli)

Dx:
SAAG >1.1
Ascites gram stain and cx
Ascites neutrophil count >250
Low ascites glucose
High ascites LDH - lysis of neutrophils

Tx:
Cefotaxime, ceftriaxone x5 day - cover E.coli, Klebsiella, Enterococcus, Staph and strep
Albumin - maintains plasma volume -> preserves renal function -> reduces renal impairment and mortality

127
Q

Treatment of portal hypertension

A

Ascites: daily morning dose of spironolactone + furosemide

Esophageal varices:

  • propranolol or nadalol to prevent hemorrhage
  • Bleeding: octreotide or terlipressin to reduce splanchnic blood flow; endoscopic ligation/sclerotherapy

Hepatic shunting or trans jugular intrahepatic portosystemic shunt (TIPS)
-increased risk of hepatic encephalopathy (no filtering through liver)

128
Q

Hereditary hemochromatosis

A

AR

Hepatomegaly, abd pain, cirrhosis
DM
Skin hyper pigmentation
Hypogonadism (anterior pituitary) -> testicular atrophy, impotence, amenorrhea
Restrictive or dilated (MC) CM
Arthralgia and arthropathy - squaring off of end of bones, hook like osteophytes of 2nd-3rd MCP joints

Dx:
Elevated AST/ALT +/- hyperglycemia
Elevated serum iron, ferritin, and transferrin
Genetic testing
Liver bx - blue dots (iron granules) inside hepatocytes

Tx:
Phlebotomy
Rarely used - deferoxamine or other iron chelation
Avoid etoh

Risk HCC

129
Q

Wilson disease

A

AR

Mean age 12-23
Hepatomegaly, hepatic steatosis, cirrosis -> liver failure
Neuro: dysarthria, dystonia, tremor, parkinsonism
Psych: depression, personality changes, psychosis
Kayser-Fleischer rings

Dx:
Elevated LFTs
LOW SERUM CERULOPLASM
increased urinary copper
genetic testing
Liver bx - brown, steatosis, fibrosis

Tx:
Copper chelation - trientine (fewer s/e) or penicillamine
Zinc supplements (interferes with Cu absorption)
Restrict dietary copper (shellfish, organ meats, chocolates, nuts, mushrooms)
Liver transplant may be necessary

130
Q

Alpha 1 antitrypsin deficiency

A

Panacinar emphysema d/t elastin destruction in lungs
mutated a1 antitrypsin accumulates in hepatocytes

Autosomal co-dominant
Increased risk of HCC

Dx:
Genetic testing
Liver bx

Tx: liver and lung transplant

131
Q

Autoimmune hepatitis

A

Women > Men
Asx or subclinical can -> acute liver failure or cirrhosis

Dx:
Type 1 (classic): ANA and Anti-Smooth Muscle Abs
Type 2: Abs against Liver-Kidney Microsomal (LKM) Ag or liver cytosol antigens

Tx: glucocorticoids +/- azathioprine

132
Q

Hepatic adenoma

A

Benign
Women 20-44 - OCP
Anabolic steroids
Glycogen storage disease type I and III

usually asx
+/- RUQ pain or fullness
Malignant transformation in 10%

Tx:
DC OCPs
Monitor with serial imaging and serial AFT
+/- resection if >5 cm

133
Q

Hepatocellular carcinoma

A

Risk:
HepB/C
Cirrhosis
Aflatoxin - aspergillus contaminated corn, peanuts, soybeans

Presentation:
Decompensation of chronic liver disease
Wt loss, hepatomegaly, RUQ pain, hepatic bruit (highly vascular tumor)

Paraneoplastic syndromes

Dx:
elevated LFTs, elevated AFP
U/S - solid tumor; CT/MRI - malignant features
Core needle bx only if dx unclear on imaging - risk of bleeding

Tx:
Small: resect, chemo
Unresectable: liver transplant, radio frequency ablation, chemoembolization

Aggressive - high mortality

134
Q

Paraneoplastic syndromes associated with HCC

A

Polycythemia - secretion of expo
Hypercalcemia - secretion of PTH-rP (like squamous cell lung CA)
Watery diarrhea - secretion of VIP and other factors
Hypoglycemia - high metabolic needs
Skin lesions

135
Q

Cancers association with polycythemia as a paraneoplastic syndrome

A

Pheo
RCC
HCC
Hemangioblastoma

DIT Level 2 (49 decks)

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