Gastrointestinal Flashcards
Where is niacin found?
- Protein
- Dairy products
- Many cereals
- Vegetables
Why would a bulimic patient present with dental decay?
Gastric acid in vomit
Where is vitamin E found?
- Vegetable oils
- Nuts
- Legumes
- Whole grains
What other signs would you see in Vitamin A deficiency (secondary)?
- Dry skin
- Keratinization of lungs, GI, urinary epithelium
What does pyridoxine deficiency result in?
- Seborrheic dermatitis
- Cheilosis
- Glossitis
In severe deficiency: - Peripheral neuropathy
- Lymphopenia
- Anemia
How does pyridoxine deficiency occur?
Rare but may occur because of:
- Alcoholism
- Interactions with medications (INH)
In an anorexic patient, what can lead to sudden death?
Ventricular Arryhthmia
Prevalence of obesity increases with what?
It is higher among who?
- Age
- African American women
- People of low socioeconomic status
What are the signs / symptoms of anorexic patients?
- Increasingly cachectic
- Amenorrhea
- Bradycardia
- Low BP
- Hypothermia
- Edema
- Lanugo hair growth (fine hair)
Vitamin K is a cofactor in the synthesis of what clotting factors?
- II (2)
- VII (7)
- IX (9)
- X (10)
Where does vitamin K come from?
- Leafy greens
- Normal intestinal bacteria
Which is increased with vitamin K deficiency - PTT or PT?
PT (although both may be affected)
What is a condition of extreme weight loss, severe disturbance in body image, and fear of obesity?
Anorexia Nervosa
What happens with vitamin E toxicity?
Nothing… It’s rare
Which three conditions are keys to diagnosing pernicious anemia?
What is confirmed with?
- Megaloblastic anemia, Neurologic disturbances, Ataxia
- Schilling Test
What condition can overweight teenagers develop?
Slipped Capital Femoral Epiphysis
How does dermatitis present in pellagra?
Dark, scaly lesions on sun-exposed skin
What stains the skin orange?
Excess beta-carotene
Once Cobalamin (B12) is ingested, what does it bind to? What does this allow?
- Intrinsic factor from the parietal cells
- Absorption
Which vitamin is important for DNA synthesis and myelin formation?
Cobalamin (B12)
What can vitamin D deficiency cause?
- Rickets in children
- Osteomalacia
How is vitamin D make in the skin?
Exposure to sunlight
What are the symptoms of advanced lesions of dental caries?
Pain from eating hot, cold, and sugary foods
Which vitamin deficiency causes beriberi?
Thiamine (B1)
How does wet beriberi present?
- Cardiovascular disease
- High output heart failure
What BMI is considered overweight? obese?
Overweight… > 25
Obese… > 30 unless they have a high muscle mass
What is another name for B1?
Thiamine
Why would vitamin deficiency develop in a developed country?
- Chronic alcohol use
- Medication misuse
- Food faddism
- Long-term parenteral nutrition
What might happen to infants with pyridoxine insufficiency?
Seizures
Who is a typical anorexic patient?
- Teenage girl
- Higher socioeconomic status
- Perfectionist
What provides substrate for bacterial production of lactic acid on teeth, which erodes enamel?
Dietary carbohydrates (sucrose)
What can have a protected effect on osteoporosis?
Obesity
What is another name for vitamin D?
Calciferol
What is another name for B3?
Niacin
What is seen in riboflavin (B2) deficiency?
- Cheilosis
- Angular stomatitis
- Seborrheic dermatitis
- Corneal vascularization
- Anemia
What is angular stomatitis?
Fissuring at the angles of the mouth
What must children outside of the US do to ensure protection of dental caries? Why?
- Take fluoride supplements, Use fluoride compounds applied directly to teeth (mouth rinse / toothpaste)
- In US, water is fluoridated
Is the first or second dose of the Schilling test radioactive? How are each dose given?
- First
- First → PO / Second → Injection
What is a condition particularly common in alcoholics in which nystagmus, ataxia, confusion, and confabulation are present? What may it lead to?
- Wernicke-Korsakoff Syndrome
- Come and death
What is ingested which offers protection against forming dental caries while the teeth are developing? At what ages are the teeth developing?
- Fluoride
- Birth-13
Which vitamin is a coenzyme in carbohydrate metabolism?
Niacin (B3)
What is the recommended treatment of dental caries?
Dental fillings
What is the mortality rate in anorexic hospitalized patients?
6%
What is scurvy?
Vitamin C deficiency
What does scurvy present with?
- Splinter hemorrhages
- Spontaneous hemorrhage
- Swollen, friable gums
- Secondary infections
- Myalgias
- Hemarthrosis
- Tooth loss
- Gangrene
- Also anemia
Which vitamin is needed for the formation of collagen and the maintenance of connective tissue, bone, and teeth, wound healing, and iron absorption?
Vitamin C (ascorbic acid)
What is another name for vitamin C?
Ascorbic acid
What is another name for B12?
Cobalamin
What is another name for vitamin A?
Retinol
Vitamin D enhances absorption of what two things from the gut?
- Calcium
- Phosphate
What is a rapid correction for vitamin K deficiency?
Injection of vitamin K
What is another name for B2?
Riboflavin
Which vitamin is a component of the coenzymes flavin adenine dinucleotide (FAD) and flavin mono nucleotide (FMN)?
Riboflavin (B2)
What would be the treatment for anorexia?
- Psychiatric
- Family counseling
(Tubes, IV feeds rarely needed)
What surgery involves decreasing the patient’s stomach capacity with a vertical banded gastroplasty?
Roux-en-Y Banding
What does pyridoxine (B6) toxicity cause?
Sensory neuropathy
What does vitamin A toxicity cause?
- Mouth sores
- Anorexia
- Vomiting
- Increased intracranial pressure → Papilledema / headaches
What is cheilosis?
Swollen, cracked, bright red lips
How does riboflavin (B2) insufficiency occur?
Insufficient milk and animal product consumption
What are obese people more prone to get?
- Osteoarthritis
- Gall bladder disease
- Urinary stress incontinence
- Infertility
- Venous stasis disease
What is a condition in which the destruction of parietal cells results in insufficient amounts of intrinsic factor, which then leads to vitamin B12 deficiency?
Pernicious anemia
What would deficiency of vitamin A cause? (main deficiencies)
- Night blindness
- Conjunctival dryness
- Corneal keratinization
- Epithelial cells loose moisture and are replaced by horny cells
Niacin deficiency can occur in the setting of what four things? (excluding maize as diet staple)
- Diarrhea
- Cirrhosis
- Alcoholism
- Isoniazid use (INH)
How would vitamin D deficiency present on an x-ray?
- Long-bone bowing in children
- Demineralization in adults
Niacin deficiency occurs when what is a diet staple?
Maize (milled corn)
What does vitamin E insufficiency result from?
- Vitamin-insufficient infant formulas
- Protein-energy malnutrition
- Some malabsorption syndromes with steatorrhea
What vitamin maintains cell membranes by protecting lipids from oxidation? Why does this happen?
- Vitamin E
- Sucks up free radicals
Where else is vitamin D found (other than skin)?
- Dairy
- Fish
Which disorder is associated with binge eating, induced vomiting, and laxative use?
Bulimia
What are the normal values for PT, PTT, and INR?
- PT = 10-12s
- PTT = 30-45s
- INR = 1-2
What is vitamin A a component of in the retina?
Photoreceptor pigments → maintain normal epithelium
How does dry beriberi present?
Bilateral symmetrical peripheral neuropathy
What is the second most common cause of premature death in the US? What’s the first?
#2 = Obesity #1 = Smoking
Which conditions would increase the need for B1 (Thiamine)?
- Pregnancy
- Hyperthyroidism
Where is Thiamine (B1) found?
Grains
Removed in production of polished rice
Which vitamin is used in the metabolism of amino acids and the synthesis of heme?
Pyridoxine (B6)
What is another name for vitamin B6?
Pyridoxine
What does vitamin E insufficiency cause?
- Red blood cell hemolysis → anemia in infants
- Neurologic changes such as gait changes, areflexia, decreased vibration / position sense
How is anorexia diagnosed?
Loss of more than 15% of body weight in a thin patient who denies illness and has a fear of obesity
How many American adults are overweight or obese?
1/3
What can vitamin K toxicity cause?
Hemolysis (but rare…)
How is vitamin A formed by the body?
From beta-carotene (found in yellow, orange, and leafy green vegetables)
High doses of which vitamin can be used to lower LDLs and raise HDLs?
What is a common side effect of taking it?
- Niacin (B3)
- Flushing
Where is vitamin A found?
- Egg yolks
- Dairy products
- Liver
- Fish
What suggests the diagnoses of depletion of folate body stores?
Megaloblastic anemia without neurologic changes
Folate deficiency is often seen in who?
- Elderly
- Alcoholics
- Poor
(Inadequate nutrition)
What can vitamin D toxicity cause?
- Hypercalcemia
- Calcification in kidney, liver, eyes, and joints
What can vitamin K deficiency result in?
- Spontaneous bleeding
- Prolonged oozing
Which vitamin is used in the synthesis of DNA?
Folate
Niacin deficiency leads to what?
What does this consist of?
- Pellagra
- Four D’s = Diarrhea, Dermatitis, Dementia, Death
If someone passed out and was brought to the ER, what cocktail of drugs would you give?
- Thiamine (B1 deficiency)
- Narcan (Reverse drug effects)
- Dextrose (Sugar replenishment)
Where is folate found?
- Leafy green vegetables
- Citrus fruits
How is pernicious anemia treated?
IM injections of B12
Which vitamin contributes to carbohydrates metabolism as a coenzyme?
Thiamine (B1)
What is the treatment for a fistula?
Fistulotomy
-the tract is completely opened and allowed to heal from within.
What is a common cause of gastroenteritis outbreaks?
The Norwalk Virus
What virus causes severe diarrhea in small children and causes significant mortality in third world countries?
Rotavirus
- “rotates” out of the world
What are some other sources of viral gastroenteritis (besides Norwalk and Rotavirus)?
Enterovirus
Coxsackie A1 Virus
Echovirus
Adenovirus
Does viral gastroenteritis require treatment?
Rarely. The generally resolve without treatment.
What do you remember from Micro about Staph A.?
Coagulase positive
Catalase positive
Gram positive
Purple on staining
How does Staph Gastroenteritis occur?
From eating food containing the toxin- Staph A. particularly from foods left out at room temperature-milk,cheese, some meat and fish.
Within how many hours will a person experience vomiting, cramping and diarrhea after ingesting a food containing Staph A.?
8 hours
How soon can a person recover from being infected with Staph Gastroenteritis?
24-48 hours
How is Staph Gastroenteritis treated?
Fluid and electrolytes
What does the enterotoxin from Vibrio cholera do to the bowel lumen?
It causes electrolytes and water to be secreted into the bowel lumen.
How is cholera spread?
Fecal contamination of water, seafood and other products.
Where are endemic cases of cholera found?
Along the Gulf Coast of the US
Asia
Africa
Middle East
“Rice water” stools are found in what GI disorder?
Vibrio cholera
Are the rice water stools passed with Vibrio cholera painful?
No, they are passed without pain.
Why isnt the diarrhea bloody with Vibrio cholera?
Because the bowel mucosa remains intact.
Is fever seen in vibrio cholera?
Rare.
A patient comes in to your office with severe dehydration that leads to thirst,oliguria or anuria, cramps, weakness and loss of skin tone. What is on the top of your DD of GI disorders?
Cholera
What can circulatory collapse seen in Cholera cause?
Cyanosis
Stupor
Renal tubular necrosis
and Death…
What is the pH in the mouth- acidic or basic?
Basic
What will the labs show in a patient with Cholera?
Metabolic Acidosis because of the loss of Bicarb in the stool.
What is imperative with treatment of Cholera?
Maintaining fluid and electrolyte balance.
Why is Ciprofloxacin and Doxycycline used in treatment of Cholera?
They are broad spectrum antibiotics.
Cipro- is gyrase inhibitor (inhibits the bacterial DNA from unwinding)
What is used to confirm the diagnosis of GERD?
- Endoscopy
- pH probe
- Motility studies
Other than an abnormal LES, what are some other causes of GERD?
- Hiatal hernia
- Pregnancy
- Obesity
- Scleroderma
- Cigarettes
- Alcohol
- Meds that dilate / relax
What are some medications that would relax / dilate the lower esophageal sphincter and may result in GERD?
- Anticholinergics
- Antipsychotics
- Beta-blockers
- Beta 2 agonists
- Calcium channel blockers
(AABBC)
What’s the first-line therapy for GERD?
Patients should:
- Elevate head of their beds
- Lose weight
- Change their diets to decrease intake of fat, alcohol, chocolate, caffeine, and late-night snacks
What is the medical treatment for GERD?
- Antacids
- H2-receptor antagonists (-dine)
- Short-term trial of metoclopramide (Reglan)
- Proton pump blocker (omeprazole, lansoprazole)
What is a surgical procedure to treat severe GERD?
Nissen fundoplication
What is Nissen fundoplication?
Surgical procedure which wrap stomach tissue (fundus) around the LES to tighten it
What are the two cancer types of esophageal cancer? Which one is more common?
- Squamous cell carcinoma
- Adenocarcinoma
(Squamous cell is more common but adenocarcinoma now accounts for almost half of the cases)
What are two risk factors for squamous cell carcinoma in esophageal cancer?
- Heavy alcohol
- Tobacco
At the time of presentation, most patients with esophageal cancer have metastases where?
To lymph nodes
and local extension with invasion of nearby structures
What is the initial symptom of esophageal cancer? What does this lead to?
Dysphagia → weight loss
True or false: Patients with esophageal cancer first experience difficulty swallowing liquids, which gradually progresses to difficulty swallowing solids as well.
False (other way around)
What might be present in esophageal cancer if the laryngeal nerves are involved?
Coughing or hoarseness
Besides dysphagia, what other symptoms might be noted in esophageal cancer?
- Weakness
- Anemia
- Pain
- Regurgitation
- Aspiration
In patients with esophageal cancer, barium swallow typically shows what?
Lumen narrowed by an irregular mass
In patients with esophageal cancer, constricting bands are usually seen with what?
Annular lesions
In esophageal cancer, what is used for tissue diagnosis?
Esophagoscopy with biopsy
In esophageal cancer, what test will show extension and metastases?
CT scan
What is the treatment for esophageal cancer?
Some combination of surgery, radiation, and chemotherapy
True or false: Prognosis in esophageal cancer is poor.
True
Why is prognosis of esophageal cancer poor?
Highly vascularized GI tract
True or false: Sialolithiasis causes pain with eating
False
How are sialolithiasis treated?
Sialagogues (lemon drops), warm compresses, and massage → excision might be needed
What might painless swelling of the parotid gland result with?
- Mumps
- Sarcoidosis
- Cirrhosis
- Neoplasms
- Infection
What happens in a dehydrated person which would cause infection and swelling of the parotid glands?
Oral bacteria are not sufficiently washed away and may ascend into the ducts
How would an infection of the parotid glands be treated?
Hydration and antibiotics
Difficulty in swallowing can be divided into problems of what two things?
Oropharyngeal transport and esophageal transport
What are oropharyngeal problems usually caused by?
Neurologic or muscular disorders such as stroke, multiple sclerosis, myasthenia gravis
In esophageal dysphagia, what affects the swallowing of only fluids?
Obstructive disorders such as tumors, strictures, and rings
In esophageal dysphagia, what affects the swallowing of solids and fluids equally?
Motor disorders such as achalasia, spasms, and scleroderma
What is Schatzki’s ring?
Where the esophagus joins the stomach
What occurs if a lesion is pre-esophageal?
Nasal regurgitation or cough secondary to tracheal aspiration
What do patients with esophageal lesions complain of?
Food getting stuck
What may supraclavicular lymphadenopathy indicate?
- Cancer
- Nerve, problems
- Muscular problems
- Other
What is key in diagnosing the location and type of dysphagia?
Chronology, including whether onset involved solids, liquids, or both
What tests may be useful in diagnosing dysphagia?
- Barium swallow studies
- Upper endoscopy
- Esophageal manometry
- Esophageal pH monitoring
What is globes hystericus?
Lump in throat → usually psychogenic
How are patients who develop dysphagia because of stroke or other neuromuscular disorders treated?
Therapy
How are patients who develop dysphagia because of an obstruction treated?
Correction with surgery
What is achalasia?
Disorder of the esophagus which involves impairment of peristalsis and lower esophageal sphincter relaxation
What is the etiology of achalasia?
Unknown
When does achalasia commonly occur?
Gradual onset most commonly begins between 20 and 40
How may patients presenting with achalasia have a malignancy of the gastroesophageal junction?
Small minority
What is the major symptom of achalasia?
Gradual onset of dysphagia of both solids and liquids
Regurgitation is common in achalasia. What does this cause at night?
Cough and aspiration
In a patient with achalasia, what would a barium swallow study show?
Dilated esophagus, with a classic beak-like lower portion
True of false: In achalasia, peristalsis is absent.
True
What is used to rule out stricture and carcinoma of achalsia?
Endoscopy with biopsy
What is the treatment for achalasia?
- Pneumatic dilation
- Botulinum toxin
- Laparoscopic myotomy
- Fundoplication
What is laparoscopic myotomy?
The surgical division of the involved muscle
What could laparoscopy myotomy result in?
Gastroesophageal reflux
What is gastroesophageal reflux disease (GERD)?
Esophageal inflammation results when low pressures at the lower esophageal sphincter allow reflux of gastric contents into the esophagus
In addition to inflammation and ulceration, what else could patients with GERD develop?
- Strictures
- Barrett’s esophagus
- Bleeding
- Aspiration
What is Barrett’s esophagus?
Stratified squamous turning to columnar metaplasia → sometimes leading to adenocarcinoma
What kinds of patients is GERD seen in?
- Common in overweight
- May be seen in infants who present with vomiting, failure to thrive, anemia, or pulmonary symptoms
What is heartburn?
Burning behind the sternum that rises from the stomach toward the mouth
When does heartburn occur? How is it relieved?
Occurs when the patient lies down after eating / Resolved by sitting up, drinking fluids, and taking antacids
What are some atypical symptoms that occur because of reflux?
- Sore throat
- Cough
- Asthma
- Non-cardiac chest pain
What is a hiatal hernia?
Common disorder that involves protrusion of part of the stomach above the diaphragm
What are the two types of hiatal hernias?
- Sliding hiatal hernia
- Paraesophageal hiatal hernia
What does a sliding hiatal hernia involve?
Involves upward displacement of both the gastroesophageal junction and the stomach through the diaphragm
What does a paraesophageal hiatal hernia result from?
Results when part of the stomach is pushed through the diaphragm next to a normally located esophagus and gastroesophageal junction
True or false: If the lower esophageal sphincter is displaced upward, it is exposed to a higher pressure in the thoracic cavity and may not be able to remained closed.
False (it is exposed to a lower pressure)
What may occur due to a displacement upward of the LES?
Gastroesophageal reflux
In a hiatal hernia, what will x-rays and barium studies show?
A portion of the stomach above the diaphragm
What are some causes of a hiatal hernia?
- Age
- Obesity
- Smoking
What is an EGD?
Esaphagogastroduodenoscopy
What is the only therapy needed for a sliding hiatal hernia?
Control reflux, if present
What are some complications of a paraesophageal hernia?
Incarcerated or strangulated
What is indicated for recurrent or intractable symptoms of hiatal hernias?
Surgery → often involves a Nissen fundoplication
What is gastritis? How can it be classified?
- Inflammation of the gastric mucosa
- It can be classified erosive or nonerosive
What is gastritis usually due to?
- NSAID use
- Alcohol
- Severe illness (viral infection)
- Trauma
What is nonerosive gastritis caused by?
Helicobacter pylori
Nonerosive gastritis is present in what percentage of the population?
30 - 50%
What could nonerosive gastritis cause?
Gland atrophy or metaplasia
What is the presenting symptom of gastritis?
Mild dyspepsia
What is often the first sign of hospitalized patients with stress gastritis?
Blood in the nasogastric aspirate or hematemesis (“coffee grounds” emesis)
True or false: There is usually not significant bleeding in gastritis?
True (because lesions are superficial)
Why does alcohol cause gastritis?
Alcohol is a relaxant → makes it easier to vomit and acid comes up
In gastritis, endoscopy should be done promptly to rule out bleeding from more serious lesions such as what?
- Ulcers
- Esophageal varices
True or false: Nonerosive gastritis is usually asymptomatic.
True
True or false: In nonerosive gastritis, petechiae and erosions may be seen.
False (this happens in erosive gastritis → in nonerosive gastritis, the stomach appears normal but biopsy shows inflammation with neutrophils and lymphocytes)
What might be sufficient treatment for erosive gastritis? What else are commonly used?
- Avoidance of NSAIDs and alcohol
- Antacids and H2-blockers
What is used as a prophylactic to prevent stress gastritis in intensive care units?
H2-blockers
In peptic ulcer disease, where is ulcerative corrosion of the epithelium more common - stomach or duodenum?
Duodenum
What is the injurious agent in peptic ulcer disease?
Gastric acid
In peptic ulcer disease, what plays an important role in weakening the epithelium and making it susceptible to damage?
H. pylori
Besides H. pylori, what are other risk factors for peptic ulcer disease?
- NSAIDs
- Smoking
- Alcohol
- Radiation treatments
- Being very ill (ventilator)
True or false: Numerous ulcer patients have higher-than-normal acid secretion.
False (few ulcer patients…)
True or false: Nausea and epigastric tenderness are common in PUD patients.
True
Fecal occult blood is present in what number of PUD patients?
1/3
Ulcers may be complicated by what three things?
- Bleeding
- Perforation
- Obstruction
What test may an ulcer be seen on?
GI series
What test identifies active H. pylori infection or malignancy in PUD patients?
Endoscopy with biopsy
What is a particular concern of gastric ulcers in a patient without history of NSAID use?
- H. pylori Infection
- Malignancy
How is H. pylori tested for in biopsy tissue with PUD patients?
Urease using pH-sensitive media
In PUD patients, what noninvasive test is used to document H. pylori eradication after therapy?
14C and 13C urea breath tests
When assessing for H. pylori in PUD patients, why are serum antibodies only sometimes useful?
They cannot distinguish between active and resolved infection
In PUD patients, what levels should be measured to exclude hypersecretory states such as Zollinger-Ellison syndrome?
Serum gastrin levels
Zollinger-Ellison syndrome may be single or small multiple tumors. How many of the single gastrinomas are cancerous? Where do they spread to?
- 1/2 to 2/3 are cancerous
- Spread to nearby organs (liver)
What combination of antibiotics are used to treat H. pylori?
- Tetracycline
- Metronidazole
- Amoxicillin
- Clarithromycin
What drugs could be added to the antibiotic regimen to treat H. pylori?
Bismuth subsalicylate (Pepto-Bismol) or proton pump blockers
True or false: After successful treatment of an infection of H. pylori, ulcers are still common.
False (ulcers are rare)
Nonhealing ulcers → what should you think?
Cancer
True or false: With ulcers, chronic H2-blocker therapy and surgical treatment are now rarely necessary.
True
In patients who cannot stop NSAID treatment, what would be given to patients with ulcers to reduce ulcer recurrence?
Coadminstration of H2-blockers, proton pump inhibitors, or prostaglandin analog misopristol (use of COX-2 selective NSAIDs also helps)
Which drug protects tissue lining in PUD?
Carafate (Sucralfate)
What is the normal regimen of PUD?
2 antibiotics + bismuth
In PUD, what percentage is a gastric ulcer? duodenal ulcer?
Gastric = 25% Duodenal = 75%
True of false: Gastric ulcers occur in younger people; duodenal ulcers occur in older.
False (opposite)
What is the major risk factor for gastric ulcers?
NSAIDs
What is the major risk factor for duodenal ulcers?
H. pylori
True or false: Pain with gastric ulcers varies, often not relieved by eating.
True
True or false: Pain with duodenal ulcers improves with food, worse 6-8 hours later.
False (it is true that duodenal ulcers improve with food but it gets worse 2-4 hours later
Stomach cancer is almost always what kind of cancer?
Adenocarcinoma (although squamous cell tumors may invade from the esophagus)
What four forms can gastric carcinoma take?
- Ulcerating carcinoma
- Polypoid carcinoma
- Superficial spreading carcinoma - Linitis plastica
What is ulcerating carcinoma?
Penetrating, ulcer like tumor with shallow edges
How would you differentiate an ulcer in PUD with an ulcer from gastric cancer?
Raised edges seen in peptic ulcer disease and shallow edges in cancer
What is polypoid carcinoma?
Involves a bulky, intraluminal tumor that metastasizes late
What is superficial spreading carcinoma?
Confined to the mucosa and submucosa (also called early gastric carcinoma)
Out of the four types of gastric carcinoma, which one has the best prognosis?
Superficial spreading carcinoma
What is linitis plastica?
Spreads throughout all the layers of the stomach, decreasing in elasticity
Out of the four types of gastric carcinoma, which one has a poor prognosis?
Linitis plastica
What is a risk for stomach cancer?
H. pylori
Who are most at risk for gastric cancer?
- Older men
- African Americans
- Hispanics
- Asian-Americans
- Chileans
- Icelanders
- Japanese
- Chinese
Where is there a high incidence of gastric cancer?
Japan
What are the most common symptoms of stomach cancer?
- Abdominal heaviness
- Early satiety
- Anorexia
- Weight loss
- Rarely, melena
What is melena?
Black, tarry stools
Vomiting may occur in gastric cancer. What would this be due to?
Pyloric obstruction
Why would the vomitus from stomach cancer have a “coffee-ground” appearance?
Bleeding
What two things cause “coffee-ground” appearing vomitus?
- Stress gastritis
- Gastric carcinoma
True or false: Many gastric carcinoma patients have a positive guaiac test and over 70% have a palpable epigastric mass.
False (It is true that many gastric carcinoma patients have a positive guaiac test but less that 20% have a palpable mass)
What does a Virchow’s node indicate in gastric cancer?
Metastasis
What is a Virchow’s node?
An enlarged left supraclavicular node
What are Krukenberg’s tumors? What do they show metastases of?
- Ovarian massess
- Gastric carcinoma to the ovary
What levels are often elevated in gastric carcinoma? What does this mean?
- Carcinoembryonic antigen (CEA)
- Tumor has spread
In gastric cancer, why is hematocrit low in many patients?
Occult blood loss
In gastric cancer, what test will show most tumors?
Upper GI series
What test would differentiate gastric cancer from benign lesions?
Gastroscopy and biopsy
What is the sole treatment option for gastric cancer?
Surgical resection
What are the survival rates for early gastric cancer? What is the overall 5-year survival in the United States?
- 90%
- 12%
What is normal hemoglobin? What is normal Hct?
Hemoglobin = 12-15
Hct is 3x that = 36-45
When do hernias occur?
Intra-abdominal tissue protrudes through a defect in the abdominal wall
Where are hernias commonly found?
- Umbilicus
- Along the linea alba
- Along the femoral sheath
- In the inguinal region
What are indirect inguinal hernias?
Congenital defects that result when the process vaginalis fails to close after the testicle has descended into the scrotum
What are direct inguinal hernias?
Caused by a weakness of the abdominal musculature in Hesselbach’s triangle
What are the borders of Hesselbach’s triangle?
- Rectus abdominus medially
- Inguinal ligament inferiorly
- Inferior epigastric vessels laterally
Who do direct inguinal hernias develop in?
Adults
What is a reducible hernia?
One in which the abdominal contents can be manipulated back into the abdominal cavity
What may an irreducible hernia or incarcerated hernia result in?
Bowel obstruction or tissue strangulation
How would a person with a hernia present?
May be asymptomatic or may report an aching discomfort in the region
What could cause a hernia?
- Heavy lifting
- Pregnancy
- Straining
- Over-weight
How would you diagnose a hernia?
Clinical inspection
How would you distinguish between a direct and an indirect hernia?
Requires digital invagination of the skin along the spermatic cord and palpation of the internal ring. An indirect hernia protrudes at this point, whereas a direct hernia will be felt medial to the ring
Why is surgical repair necessary for a hernia?
To prevent bowel incarceration, obstruction, and infarction
Why would you have a patient bear down or cough while doing an examination for hernias?
A mass may bulge when intra-abdominal pressure increases
What is diverticulosis?
An acquired condition of multiple diverticula in which the colonic mucosa and submucosa herniate through the muscular layer
What part of the GI tract is diverticulosis most common?
Sigmoid colon
Diverticulosis is common in what kind of nation? Why?
- Developed nations
- Low-fiber diet, resulting in increased intraluminal pressure
What are the signs / symptoms of diverticulosis?
Generally asymptomatic but may arise from a lower GI bleed or from diverticulitis
How is diverticulosis diagnosed?
Barium enema or colonoscopy
What might reduce the risk of complications in diverticulosis?
High-fiber diet
What should be avoided in diverticulosis?
Foods that can become impacted in the diverticulum, such as small seeds and peanuts
What is diverticulitis?
A complication of diverticulosis → occurs when a diverticulum becomes infected or perforates, causing an abscess or peritonitis
How might diverticulitis become further complicated?
- Formation of fistulas to the bladder, vagina, or skin
- By the development of adhesions that cause small bowel obstruction
What are the signs / symptoms of diverticulitis?
Acute lower abdominal pain on the left side (LLQ), accompanied by:
- Fever
- Chills
- Constipation
- Loose stools
True or false: In diverticulitis, occult blood in stool is common and frank bleeding may occur.
True
In a patient with diverticulitis, what might be present on examination?
Lower abdominal mass
What can confirm perforation in diverticulitis?
A plain abdominal film showing free air under the diaphragm
What can be used to locate an abscess during an acute attack of diverticulitis? What can be used after the acute attack has been completely resolved?
- CT scan with water-soluble contrast
- Barium enema x-ray or colonoscopy
What is the treatment for mild cases of diverticulitis?
Managed on an outpatient basis with a clear liquid diet and oral antibiotics to cover both gram-negative bacteria and anaerobes
What is the treatment for severe cases of diverticulitis?
Hospitalization, with nasogastric tube placement, IV antibiotics, and surgical resection
What is a fistula?
An abnormal connection between two epithelium-lined organ or vessels that usually do not connect
What might happen if the enzymes are absent in the small bowel or the mucosa is inflamed?
Malabsorption
What are symptoms of malabsorption due to?
- Increased fecal fat
- Bacterial fermentation of unabsorbed food
- Vitamin and nutrient deficiencies
What does lactose intolerance result from?
A deficiency of the enzyme lactase
What is the function of lactase?
Splits lactose into glucose and galactose
What does unsplit lactose in the bowel lumen cause?
- Osmotic diarrhea
- Bacterial fermentation of lactose produces excessive gas
What is lactase deficiency characterized by?
Bloating and explosive diarrhea after milk intake
Where is lactase usually located?
Jejunal brush border
What disease can result in lactase deficiency?
- Crohn’s disease
- Other types of malabsorption disease
- Gastritis
What can cause temporary lactase deficiency?
Viral gastroenteritis
Who dose lactase insufficiency normally occur in?
- 75% of adults in most ethnic groups
- Less than 20% of those of northwestern European descent
When is the onset of lactase insufficiency?
Between 10-20 years of age
How can you prevent the symptoms of lactase insufficiency?
Lactose-free diet
What is celiac sprue?
Hereditary sensitivity to the gliadin component of gluten
What is gluten?
A protein found in wheat, barley, and rye
In celiac sprue, interaction of gliadin with antibodies initiates what to happen?
Immune reaction that causes jejunal mucosal damage
What are common symptoms of celiac sprue in children?
- Failure to thrive
- Abnormal stools
- Bloating
What are common symptoms of celiac sprue in adults?
- Syndrome of malabsorption
- Vitamin deficiency
How do you diagnose celiac sprue?
Finding antiendomysial or antigliadin antibodies in the serum or by biopsy showing loss of normal villi in the jejunal mucosa
Patients with celiac spur have an increase of developing what?
Other autoimmune diseases and intestinal lymphoma
What is tropical sprue?
A malabsorption syndrome of unknown etiology → characterized by nutritional deficiencies and small-bowel mucosal abnormalities
Tropical sprue is an acquired disorder primarily found where?
- Caribbean
- South India
- Southeast Asia
What are curative for tropical sprue?
- Folic acid replacement
- Tetracycline
What is Whipple’s disease?
Rare disorder of middle-aged men, caused by infection with the bacillus Tropheryma whippeli
What symptoms present with Whipple’s disease?
- Joint pain
- Weight loss
- Other symptoms of malabsorption
- Fever
- Cough
- Lymphadenopathy
- Congestive heart failure
- New murmurs due to myocardial involvement
- Neurologic symptoms such as seizures or dementia
Whipple’s disease is diagnosed by jejunal biopsy. What will be seen?
Foamy macrophages containing masses of gram-positive, rod-shaped bacilli that stain with the periodic acid-Schiff (PAS) reagent
What happens if Whipple’s disease is untreated?
Death
What may cure Whipple’s disease?
Antibiotics
What are the general signs / symptoms of malabsorption?
- Weight loss
- Abdominal distention
- Flatulence
- Diarrhea
- Steatorrhea (fatty stools)
What can protein malabsorption cause?
Hypoproteinemic edema
In malabsorption, nutrient deficiencies are common. What do the symptoms include?
- Glossitis (B6)
- Stomatitis (B12)
- Dermatitis (B13)
- Anemia (B6)
- Easy bruising (Vitamin K)
Which anemia reflects iron deficiency?
Microcytic anemia → most common in the US
Which anemia points to folic acid defiency?
Megaloblastic anemia
In malabsorption, low serum ferritin generally indicates what? Why?
- Celiac disease
- Postgastrectomy state → iron absorption occurs in the duodenum and upper jejunum
In malabsorption, what is often positive if fecal fat is present? What test does this make unnecessary?
- Sudan stain
- Quantative 72-hour fecal fat study is unnecessary
In diagnosing malabsorption, what three things usually occur together?
- Weight loss
- Diarrhea
- Anemia
To diagnose malabsorption, direct measurement of what is reliable?
Fecal fat
In diagnosing malabsorption, what test measures xylose excreted in the urine after an oral load? An abnormality will point to what?
- D-xylose absorption test
- Mucosal abnormalities
What is diagnostic for malabsorption?
Biopsy
How do you treat malabsorption?
Treat the underlying disorder
What is irritable bowel syndrome?
A common disorder involving chronic GI symptoms, often associated with psychiatric symptoms
What are the signs / symptoms of irritable bowel syndrome?
Chronic, crampy abdominal pain, bloating, flatulence, and diarrhea or constipation
How do you diagnose irritable bowel syndrome?
Diagnosis of exclusion → presumptive diagnosis may be made in the context of chronic symptoms without weight change or findings on physical examination
What should be ruled out when diagnosing irritable bowel syndrome?
- Malabsorption
- Thyroid dysfunction
- Parasitic infections
How do you treat IBS?
- Dietary bulk supplements
- Anticholinergics to decrease spasms (Dicyclomine)
- Antidiarrheals (Imodium / Lomitil)
- Tricyclic antidepressants (Elavil)
What are two other names for Crohn’s disease?
- Regional enteritis
- Granulomatous colitis
What is Crohn’s disease?
A chronic and progressive inflammation of the GI tract. Its course is variable and is marked by remissions and exacerbations.
Where does Crohn’s disease occur in the GI tract?
Anywhere along the GI tract, with lesions most frequently occurring in the distal ileum
What does the distal ileum absorb?
B12 and bile salts
What are “skip lesions”? What disease does this occur in?
- Discontinuous lesions with normal bowel in between
- Crohn’s disease
A majority of patients with what disease have granulomas in the bowel wall or mesenteric lymph nodes?
Crohn’s disease
Besides “skip lesions” and granulomas, what are other characteristics of Crohn’s disease?
- Fissures
- Strictures
- Ulcers
- Transmural involvement
What are some complications of Crohn’s disease?
- Intestinal obstruction
- Abscess formation
- Fistulas
- Colon cancer
- Systemic manifestations
Both Crohn’s disease and ulcerative colitis have extracolonic complications. What do they include?
- Peripheral arthritis
- Ankylosing spondylitis
- Uveitis
- Primary sclerosing cholangitis
Signs / symptoms of Crohn’s disease include manifestations of what?
- Anemia
- Anorectal fissures
- Abscesses
- Recurrent abdominal pain
- Right lower quadrant abdominal mass (due to an inflamed ileum)
- Low-grade fever
- Diarrhea
- Malnutrition
- Weight loss
- Fistulas
- Oral ulcers
When testing for Crohn’s disease, what would a barium enema or endoscopy show?
- Edema
- Ulceration
- Fistulas
- Strictures
- “Cobblestone” patterns
What diagnostic testing would distinguishing between Crohn’s disease and ulcerative colitis in subtle cases?
Serologic testing:
- pANCA (antineutrophil cytoplasmic antibodies with perinuclear staining)
- ASCA (anti-yeast S cerevisiae antibodies)
What is the initial treatment for Crohn’s disease?
- Rest
- Antidiarrheal agents
- Dietary changes with supplemental parenteral nutrition if disease is severe
(Steroids, sulfasalazine, immunosuppressives, and antibiotics are all used with some success)
If complications arise from Crohn’s disease, such as fistulas and obstruction, what is necessary?
Surgery
Is surgery for Crohn’s disease curative or palliative?
Palliative
What is ulcerative colitis?
A chronic, idiopathic inflammation of the colon and rectum → it has a variable course of remissions and exacerbations
What part of the GI tract does ulcerative colitis involve?
Generally the rectum, and in half of the cases it is confined solely to this region (ulcerative proctitis)
Which disease is more associated with cancer - Crohn’s disease or ulcerative colitis?
Ulcerative colitis
In a minority of ulcerative colitis patients, where does inflammation spread to?
Proximally to the distal ileum
Ulcerative colitis or Crohn’s disease?
The affected colon is contiguous, without skip lesions.
Ulcerative colitis
In ulcerative colitis, where do ulcers and abscesses form? What may this develop into?
- Form in the mucosa and submucosa
- May develop into characteristic pseudopolyps, which occur when inflammatory growths from the intestinal mucosa have a polyplike appearance
What is a frequent complication of ulcerative colitis? What may this do to the colon?
- Hemorrhage
- Colon may become dilated and perforated
What are frequent symptoms of ulcerative colitis?
- Rectal bleeding
- Tenesmus
- Crampy abdominal pain
- Blood or mucus with diarrhea
May also experience: - Fever
- Nausea and vomiting
- Weight loss
- Dehydration
What do researchers think might trigger the immune system, leading to inflammation in ulcerative colitis?
Viruses or bacteria
True or false: Heredity might play a role in Crohn’s disease.
False (Ulcerative colitis)
What does sigmoidoscopy show in ulcerative colitis?
Dull, granular, friable mucosa
In patients with suspected ulcerative colitis, what must be done to rule out infectious and ischemic colitis?
Biopsy of affected area
Barium enemas should not be performed in acutely ill patients of ulcerative colitis, but in its chronic state, what is the typical mucosal irregularity?
“Lead pipe” appearance as the colon narrows, shortens, and loses its haustrations
What is used to treat mild exacerbations of ulcerative colitis and maintain periods of remission?
- Sulfasalazine
- Steroids
- Immunosuppressives
What is the treatment for more severe episodes of ulcerative colitis?
Hospitalization with nasogastric tube, parenteral nutrition, IV steroids, and antibiotics
After diagnosing ulcerative colitis, when should you begin annual colonoscopy and biopsies to check for cancer?
8-10 years after diagnoses
How long is a colonoscope?
4-5 ft
In ulcerative colitis, which one will be elevated - pANCA or ASCA?
pANCA (60-70%)
In Crohn’s disease, which one will be elevated - pANCA or ASCA?
ASCA (60-70%)
What does the diameter of the transverse colon have to be to diagnose toxic megacolon?
6 cm
In adults, what precedes toxic megacolon?
Inflammatory bowel disease (ulcerative colitis and Crohn’s)
In children, what precedes toxic megacolon?
Hirschsprung’s disease
What is Hirschsrprung’s disease?
Absence of colonic nerve plexus
What can toxic megacolon result in?
- Septicemia
- Generalized peritonitis
- Perforation
(carries high mortality rate)
What are the signs / symptoms of toxic megacolon?
Patients are severely ill, with high fever, abdominal pain, distention, and hypotension
In toxic megacolon, what do abdominal x-rays show?
Intraluminal has along a continuous segment of very dilated bowel
How is toxic megacolon treated?
- Patients must be NPO with IV fluid replacement and electrolyte maintenance
- Antibiotics and steroids are administered in IBS
Why must passage of a rectal tube be necessary in toxic megacolon?
Alleviate megacolon to prevent sepsis (may cause perforation)
What is located between longitudinal and circular layers of muscular is externa in the GI tract which gives motor innervation to both layers and secretory innervation to the mucosa?
Auerbach’s plexus (myenteric plexus)
True or false: Auerbach’s plexus has both parasympathetic and sympathetic input.
True
Who usually gets ischemic colitis?
50 y/o or more with history of peripheral vascular disease
What is ischemic colitis caused by?
Insufficient blood supply to the colon, leading to inflammation and eventually necrosis.
What is the etiology of ischemic colitis?
Atherosclerotic or embolic
Younger patients who have ischemic colitis usually have what chronic diseases?
- Diabetes
- Lupus
- Sickle cell anemia
Reversible ischemic colitis heals with medical management, but irreversible cases require what?
Surgical treatment
True or false: Ischemic colitis has a low mortality rate.
False (it has a high mortality rate)
What are the signs / symptoms of ischemic colitis?
Patients experience an abrupt onset of abdominal pain after eating and may have bloody diarrhea, fever, and vomiting.
In which disease is the patient’s pain out of proportion to the examination findings?
Ischemic colitis
In ischemic colitis, what does endoscopy show?
Bloody, edematous, friable mucosa and may reveal ulcers or a gray membrane.
If you see a gray membrane during endoscopy of a patient with ischemic colitis, why must you check the stool?
To check for clostridium difficile.
What does barium x-ray demonstrate on a patient with ischemic colitis?
“Thumb print” or pseudotumor pattern caused by thickened, edematous mucosal folds.
What is usually sufficient therapy for ischemic colitis? But what must be done in the case of irreversible damage?
- IV fluids and antibiotics
- Resection of the ischemic portion of the colon (if irreversible)
When should people get a colonoscopy?
Every 10 years starting at age 50 unless otherwise needed
What are the risk factors for colonic polyps?
- Greater than 50 y/o
- Family member with polyps
- Family history of colon cancer
What are colonic polyps?
Small tissue masses projecting into the colonic lumen
What are two different kinds of colonic polyps? What are three different origins?
- Sessile or pedunculated
- Mucosal, submucosal, muscular
True or false: Neoplastic polyps may be inflammatory, hyperplastic, or hamartomatous.
False (Neoplastic polyps are adenomas; Non-neoplastic are inflammatory, hyperplastic, or hamartomatous)
What is a sessile colonic polyp?
Attached directly by its broad base without a stem or peduncle.
What percentage of 70 year olds have adenomatous polpys?
50%
What are probably the origin of most large-bowel adenocarcinomas?
Adenomatous polyps
Fill in the blank concerning colonic polyps:
Cancer is found in only 1% of adenomas less than ___ cm in diameter, but it is found in 45% of adenomas more than ___ cm in diameter, making size an important predictor of histology.
1 cm / 2 cm
True or false: Villous adenomas are more frequently malignant than tubular adenomas.
True
True or false: Penduculated polyps are more often malignant than sessile polyps.
False (opposite)
What is familial adenomatous polyposis?
Rare, autosomal-dominant condition involving multiple polyps that eventually develop into colorectal cancer if left untreated.
What is acquired by ingesting undercooked or raw oysters?
Vibrio Parahaemolyticus
What is the smallest inoculate?
Shigella
At any time that a GI infection is suspected, what test should be done?
Stool culture
What should NOT be given for Shigellosis and why?
Anti-diarrheals, such as Lomotil, because they may prolong the course.
What is the most common syndrome caused by Salmonella?
Gastroenteritis
You’re at a restaurant and are considering the poached eggs, why should you NOT get them?
Because the bacteria is not cooked out totally and you may get gastroenteritis from Salmonella.
How soon do symptoms from Salmonella Gastroenteritis appear?
Within 2 days of eating the infected food.
Which is more serious hemorrhagic colitis or pseudomembraneous colitis?
Hemorrhagic
What causes hemorrhagic colitis?
enterohemorrhagic E. coli
How long can an uncomplicated case of hemorrhagic colitis last?
Approx 1 week
What complicates hemorrhagic colitis?
- Hemolytic-uremic syndrome: Anemia, Renal, Thrombocytopenia
- Thrombotic thrombocytopenic purpura: Fever, Anemia, Renal, Thrombocytopenia, Neurological
What bacterium most often causes pseudomembranous colitis?
Clostridium difficile
What is the treatment for pseudomembranous colitis?
Metronidazole or oral Vancomycin
Can antibiotics cause pseudomembranous colitis?
YES- Clindamycin, Ampicillin and Cephalosporins.
What is a benign tumor-like nodule composed of overgrowth of mature cells and tissues? They are normally present in the affected part, but often with one element predominating.
Harmatoma
What is Peutz-Jeghers associated with?
Associated with freckling of lips; polyps carry low but definite risk
True or false: Polyps are generally asymptotic.
True
Larger lesions in the GI tract can cause intermittent bleeding and changes in bowel habits such as what?
- Increased frequency
- Constipation
- Tenesmus
True or false: Proximal polyps may be felt on digital rectal examination.
False (distal polyps)
In trying to diagnose colonic polyps, what will barium enema show?
Colonic lesions suggestive of polyps
How can you confirm diagnosis of colonic polyps?
Colonoscopy
A patient has colonic polyps. Why must you biopsy them?
To rule out cancer
What is the second most common site of visceral cancer in Western countries?
Colon
At what age does the incidence of colon cancer increase?
Above age 40
The vast majority of colon cancer are what kind of cancer?
Adenocarcinoma
What are the risks of colon cancer?
- Personal history of previous colon cancer or adenomatous polyps
- Family history of colon cancer - Ulcerative colitis
- Autosomal-dominant familial adenomatous polyposis
Where is there an increased incidence of colon cancer?
- Higher socioeconomic classes
- Related to high-fat, high-calorie, low-fiber, and low-calcium diets
Where does colon cancer frequently spread?
Regional lymph nodes
Besides spreading to regional lymph nodes, how else might colon cancer spread?
- Direct extension - Hematogenous spread
- “Seeding,” or transperitoneal metastasis
True or false: Colon cancer spreading by direct extension is seen with the common circumferential growth pattern of left colon lesions, and it can invade nearby structures.
True
True or false: Hematogenous spread may cause local implants or generalized abdominal carcinomatosis.
False (this is describing “Seeding” or transperitoneal metastases → Hematogenous spread commonly leads to metastases in the liver and lungs)
Which two systems are used to classify colon cancer?
TNM and Dukes classification
In colon cancer, how long does adenocarcinoma remain asymptomatic?
Approximately 5 years
Right or left-sided colon cancer? Lesions typically cause weakness secondary to anemia and discomfort or fullness.
Right-sided (it causes right-sided discomfort or fullness)
Right or left-sided colon cancer? More often causes changes in bowl habits from occlusion of the lumen, with alternating constipation and increased frequency, blood-streaked stool, and stool with decreased diameter (“pencil stools”)
Left-sided
What test should you follow to see if treatment of colon cancer is working?
CEA
In 70% of colon cancer patients, what is elevated in the serum? Is this specific to colon cancer?
- CEA (carcinoembryonic antigen)
- No
In colon cancer patients, what do CBCs often reveal?
Anemia
What are the principle means of diagnosis for colon cancer?
Barium enema examination and colonoscopy with biopsy
On contrast examination, what does colon cancer appear as?
An annular, “apple core” filling defect
What is the first step in the treatment of colon cancer?
Surgical resection of the lesion
What is important to stage colon cancer? What does this help with?
- Regional lymph node dissection
- Deciding about adjuvant radiation or chemotherapy
In advanced stages of colon cancer, what is often helpful for palliation? What does this prevent?
- Resection
- Obstruction and bleeding
What is the overall percentage of survival in colon cancer patients?
35%
According to the American Cancer Society, when should annual digital rectal exams begin?
40 years of age
According to the American Cancer Society, annual stool occult blood tests and flexible sigmoidoscopy every five year is recommend to start at what age?
50 years of age
Which stage of colon cancer? Very early cancer on innermost layer of intestines
0
Which stage of colon cancer? Cancer of innermost layers of colon
1
Which stage of colon cancer? Cancer of muscle wall
2
Which stage of colon cancer? Lymph nodes
3
Which stage of colon cancer? Metastases
4
True or false: Colon cancer is related to red meat.
True
Rectal cancer is usually what kind of cancer?
Adenocarcinoma
What is the most frequent presenting symptom of rectal cancer?
Persistent hematochezia, which must be evaluated for cancer even in the presence of hemorrhoids
What is hematochezia?
Blood-streaked stools
What are common symptoms of rectal cancer besides hematochezia?
- Tenesmus
- Altered bowel habit
- Sensation of incomplete evacuation
In rectal cancer, what can be palpated on digital examination?
Distal lesions
What is the treatment for rectal cancer?
Surgical resection, often with adjuvant radiation terapy
Where do internal hemorrhoids arise from?
A cushion of veins above the dentate line
Where do external hemorrhoids arise from?
Veins below the dentate line
What are hemorrhoids?
Swollen veins in lower portion of rectum or anus
What is the dentate line? What is another name for it?
- Divides upper 2/3 from lower 1/3 of anal canal
- Pectonate line
When do hemorrhoids engorge due to increased venous pressure?
- Constipation / straining
- Prolonged sitting
- Pregnancy
- Obesity
What are symptoms of hemorrhoids?
Discomfort and small amounts of bright red bleeding
Internal or external hemorrhoids? Don’t hurt but may bleed painlessly.
Internal
Internal or external hemorrhoids? Can be itchy / painful and can come times crack and bleed.
External
Internal or external hemorrhoids? Are visible around the anus
External
Internal or external hemorrhoids? Can be visualized using an anoscope
Internal
What diagnostic tool is frequently indicated to rule out causes of bleeding in the rectum or sigmoid colon, despite the presence of hemorrhoids?
Sigmoidoscopy
What is indicated in a patient with hemorrhoids if microcytic anemia is present?
Colonoscopy
What is the first line of treatment for hemorrhoids?
- Increasing dietary fiber and avoiding prolonged sitting and straining
- Sclerotherapy, rubber band ligation, and excision are also options
What is sclerotherapy?
Injecting sclerosing agent
What is rubber band ligation?
Hemorrhoid is tied off at its base with rubber band, cutting off blood supply leading to shrinkage and death. It will fall off in around a weak. Pain for 1-2 days. Take analgesics and use a stool softener.
What are anal fissures?
Painful, linear tears in the epithelium of the anal verge, usually in the posterior midline
What is the anal verge?
Opening of the anus onto surface of body
Why do anal fissures occur?
Generally result from trauma during defecation
Atypical fissures should raise the suspicion of what disease?
Crohn’s
What are the symptoms of anal fissures?
Intense pain with defecation, which may lead to constipation, and spots of bright red bleeding
What is the treatment for anal fissures?
- Softening of stools to allow healing
- Sitz-bath-sit
What may develop at the site of anal fissures?
Skin tag (sentinel pile)
A patient with recurrent anal fissures would benefit from what procedure? What might this cause?
- Partial sphincterotomy
- Fecal incontinence is at risk
What is Sitz-bath-sit?
Treatment for anal fissures → sit in hot water which causes vessels to expand and blood to flow
What exam should be performed for anal fissures?
Rectal exam with rectal tissue biopsy
What arise from infection of anal crypts at the dentate line, infection of a prolapsed internal hemorrhoid, and infection of a hair follicle or local abrasion?
Anorectal abscess
What are the symptoms of anorectal abscesses?
Throbbing rectal pain and, if the abscess is large, systemic signs of infection
Superficial or deeper abscess? Indurated, red, and may be fluctuant
Superficial
Superficial or deeper abscess? Tender on digital rectal exam
Deeper
How do you diagnose anorectal abscesses?
Clinical examination → collection of pus in area of anus and rectum
What is the treatment for anorectal abscesses?
- Antibiotics to cover both aerobic and anaerobic gram-negative rods
- Complete incision and drainage (which may need to be done in the operating room depending on the extent of the abscess)
What might abscesses be complicated by?
Formation of a fistula, usually between the anal crypt and the site from which the abscess drains
What might be palpated if there is a fistula?
Cord-like tract
What is the treatment for a fistula?
Fistulotomy, in which the tract is completely opened and allowed to heal from within.
Where does Amebiasis cause abscesses in?
The liver.
How many O&P need to be done to diagnose Amebiasis?
Three sequential O&P.
How is Amebiasis treated?
Metronidazole and Paromomycin.
“Explosive gas” is seen in?
Giardiasis
How is giardiasis diagnosed?
Cysts, trophozoites OR the giardia antigen is identified in a stool sample.
Why is metronidazole used to treat Giardiasis?
It is used to treat anything anaerobic.
Acute pancreatitis is MOST commonly caused by?
Gallstone disease Alcoholism or Hypercalcemia Hyperlipidemia Drugs or other unidentified causes.
Do Grey Turner and Cullen’s sign occur in most cases of acute pancreatitis?
No, only 1-2% of cases.
What is the “colon cutoff sign” and what is it seen in?
Gas distending the right colon that abruptly stops near the pancreas.
Seen in acute pancreatitis
What is used to predict the diagnosis of acute pancreatitis?
Ranson’s criteria:
The presence of three of more are associated with increased mortality.
On admission: A-age > 55 B-blood sugar > 200 mg/dl C-cells (wbc) > 16,000/ml D-dehydrogenase >350 IU/L E-enzymes (ast) >250 units
Within 48 hours: ( Calvin and Hobbs - C’HOBBS)
C’-calcium (serum) < 8 mg/dl
H-hematocrit >10%
O-partial Oxygen < 60 mm Hg
B- blood Urea Nitrogen > 5 mg/dl
B- base deficit >4 meq/l
S- Sequestration (fluid sequestration) > 6 L
0-2 criteria: 2% mortality
3-4 criteria: 15% mortality
5-6 criteria: 40% mortality
>6 criteria: 100% mortality
When will amylase level be normal with acute pancreatitis?
When the pancreas is fibrotic.
What makes something a pseudocyst?
When the walls consist of inflamed membranous material not epithelial tissue as in a true cyst.
Are pseudocysts sterile?
Generally, but infection can lead to abscess formation.
How are pseudocysts seen?
Ultrasound or CT scan.
Where are adenocarcinomas found in the exocrine pancreas?
ductal, in the head of the pancreas.
Who does cancer of the exocrine pancreas mostly happen to?
Middle-aged men.
From diagnosis to death with exocrine pancreatic cancer is generally how long?
A year.
When would obstructive jaundice occur with cancer of the exocrine pancreas?
If the tumor is in the head of the pancreas and impinges on the bile duct.
What are the four cancers of the endocrine pancreas?
- Insulinoma
- Zollinger-Ellison syndrome
- VIPoma
- Glucagonoma
What is Whipple’s triad and what will it confirm?
- Hypoglycemia
- Low blood sugar at time of symptom
- Relief when glucose is given
It confirms that hypoglycemia is the source of the insulinoma.
What does a C-peptide assay confirm and why?
It confirms that insulin is endogenous.
C-peptide is like a cap on top of insulin, manufactured with insulin and then cleaved. If present- insulin= endogenous.
Which of the cancers of the endocrine pancreas is gastrin producing?
Zollinger-Ellison syndrome
Which of the cancers of the endocrine pancreas is a non-beta islet-cell tumor that produces vasoactive intestinal peptide?
VIPoma
VIPoma is also known as WDHA, why?
Because it usually involves Watery Diarrhea, Hypokalemia and Achlorhydria. (WDHA)
Which of the cancers of the endocrine pancreas is a tumor of the alpha islet cells, rare and slow growing?
Glucagonoma
Necrolytic migratory erythema is a characteristic exfoliating lesion of which of the cancers of the endocrine pancreas?
Glucagonoma
What are the 4 F risk factors for cholelithiasis?
Female, fertile, forty and fat.
In most cases what type of stones will patients have with gallstones?
Cholesterol stones.
What are other increased risks for developing gallstones?
- In pregnancy-with failure of the gallbladder to empty.
- Anemic patients-increased bilirubin.
- Cirrhosis
- Biliary tract infection.
- Diabetes mellitus
- Long term parenteral nutrition
Why would acalculous cholecystitis occur?
- Patients on total parenteral nutrition
2. Critically ill patient with no oral intake.
What does a positive Murphy’s sign indicate?
Cholecystitis
What is more accurate to diagnose cholecystitis- U/S or HIDA scan?
HIDA (hepatic iminodiacetic acid) which uses radioactive isotopes taken up by the liver and excreted in the bile.
What is Charcot’s triad a sign of?
Cholangitis:
Biliary colic
Jaundice
Fever
Which labs are most strikingly elevated with biliary tract neoplasm?
Elevated conjugated bilirubin.
What are some treatment options biliary tract neoplasm?
- Surgery- if small and caught early
- Liver transplant- if not spread outside the liver.
- Chemo and radiation
- Photodynamic treatment
Spiking fever, chills, RUQ pain and tender hepatomegaly are seen in?
Hepatic abscess
If a patient isnt treated for hepatic abscess can it be deadly?
Yes- it can be fatal due to sepsis, empyema, peritonitis and rupture.
Subphrenic abscesses are often seen in what type of people?
The elderly.
What is the most common cause of prehepatic jaundice?
Hemolysis
What are two hepatic jaundices?
Hepatocellular- acute hepatitis, chronic cirrhosis
Cholestatic- primary biliary cirrhosis, toxic drug jaundice and jaundice in pregnancy.
What is Crigler Najjar syndrome?
Hepatic jaundice.
Type I: child gets defective allele from each parent= absent glucoronyl transferase = death.
Type II: Carriers with one defective allele= 1/2 the enzymes as normal. CJ II and Gilbert’s disease are the same.
What is Dubin- Johnson syndrome?
Defect in the ability of hepatocytes to secrete conjugated bili into bile- similar to Rotter syndrome.
Labs with prehepatic jaundice will show?
Increased bilirubin- in UNconjugated form.
What is typical in labs with hepatocellular disease?
A mixture on conjugated and unconjugated bilirubin.
When would conjugated bilirubin be increased?
With intrahepatic cholestatis and post-hepatic disease.
What is the normal BUN level?
8-20
What is the normal bilirubin level?
.6-1.2
Is cirrhosis reversible?
No
Is hepatic steatosis reversible?
Yes- it is fatty liver which is the first stage.
What is GGT used for?
with alcohol related hepatic disease- used to detect disease of the liver or bile ducts.
Which level is higher in alcoholic ALT or AST?
AST- because you have to be as “ass” to be drinking!
What are good indices of liver function?
- Albumin
- Clotting factors
- Cholesterol
7% of American consume how much of alcohol?
50%
What is the primary cause of injury-related deaths?
Alcohol
What are some complications from alcohol use during pregnancy?
Premature labor
Low birth weight
Fetal alcohol syndrome - microencephaly and mental retardation
What is the third leading cause of death in 45-65 year olds in the US?
Cirrhosis
Common physical exam findings such as hepatomegaly, splenomegaly, jaundice,wasting, ascites, caput medusa, palmar erythema Duputryen’s palmar contracture, peripheral neuropathy,testicular atrophy and gynecomastia are seen with?
Cirrhosis
What is Dupuytren’s palmar contractures?
Associated with tobacco or alcohol use. It is a painless thickening and contracture between the skin of the palm of the hands and fingers.
Can HBV or HCV cause cirrhosis?
Yes
What is portal hypertension?
Elevated pressure in the portal vein due to hepatic obstruction, liver disease or extrahepatic portal vein occlusion.
What is the most common treatment to control bleeding of esophageal varices?
Octreocide
Is hepatic encephalopathy reversible?
Yes
Increased rate of breathing, foul smelling breath, altered conciousness and abnormal neuromuscular activity such as asterixis are symptoms of?
hepatic encephalopathy
Where is urea produced?
Liver and kidneys
Why would you administer lactulose for hepatic encephalopathy?
to decrease intestinal absorption of ammonia
Where is the fluid collection in ascites?
The peritoneal cavity.
What is done to sample the fluid in ascites?
Paracentesis
If there is an increase concentration in of albumin in the ascitic fluid what does that suggest?
Infection or malignancy
What is a Leveen shunt used for?
Ascites
Benign hepatic adenomas are seen almost exclusively in what patients?
Women taking oral contraceptive pills.
What does coffee ground appearance in vomitus indicate?
That the blood has been in the stomach long enough to be digested partially.
What is a Mallory-Weiss tears?
Gastroesophageal tears due to retching.
What is the lower GI bleeding location?
distal to the ligament of Treitz (duodenal/jejunal border)
Passage of bright red blood suggests upper or lower GI bleed?
Lower
Guarding and rebound tenderness are signs of what?
Peritonitis
Temperature in appendicitis is usually?
Low grade temp
What test is done to aid in the diagnosis of appendicitis?
Rovsing test
What are the three most common causes of mechanical obstruction of the bowel?
Adhesions
Hernias
Tumors
Adhesions are secondary to ?
Surgery and inflammation
What are common causes of obstruction in the duodenum in a neonate?
Atresia
Volvulus
Congenital bands
What is the “double bubble” sign and where is it seen?
pockets of air on both sides of the obstruction. Seen in volvulus
Why does a paralytic ileus occur?
Loss of peristalsis
Should patients remain NPO until ileus resolves?
yes
