Gastrointestinal Flashcards
1
Q
What is esophageal atresia with distal tracheosophageal fistula?
What are the symptoms?
How to determine if this is problem?
A
The most common Polyhydraminos in utero
The esophagus is blind end, and the lower esophagus connects to the trachea
Symptoms: Drool, choke with feeding, cyanosis due to laryngospasm
Test: Failure to pass the NG tube into the stomach
2
Q
What is intestinal atresia?
Symptoms?
A
1) Duodenal atresia (failure to recanulize with dilatation of the stomach and proximal duodenum).
2) Jejunal and ileal atresia: disruption of the mesenteric vessels with ischemic necrosis and segmental resorption
Symptoms: bilous vomiting, abdominal distention within the first 1-2 days of life
3
Q
What is hypertrophic pyloric stenosis?
What are the symptoms?
A
1) Cause of outlet obstruction
2) Will have a palpable olive mass with non-bilous projectile vomiting at 2-6 weeks old
3) Usually in males that were exposed to macrolides
4) Can result in hypokalemic, hypochloremic metabolic acidosis
5) Treatment is surgical incision
4
Q
What is an annular pancrease?
A
1) Parts of the pancrease encircle the duodenum and have a ring around the duodenum which can cause vomiting
5
Q
What is pancrease divisum?
A
1) Ventral and dorsal fail to fuse after 8 weeks
2) Usually assymptomatic, but might cause chronic abdominal pain
6
Q
What is the histology of the esophagus?
A
squamous epithelium
7
Q
What are cells of stomach?
A
Gastric glands
8
Q
What are cells in the duodenum?
A
Villi and microvilli (increase absorptive surface)
9
Q
What are cells in the jejunum?
A
Plicae circulares and crypts of Liberkuhn
10
Q
What are cells of the ileum?
A
Peyer pathches (lymphoid)
Crypts of Lieberkuhn
Largest number of goblet cells
11
Q
What are the cells of the colon?
A
Crypts of
12
Q
From head to toe, what are the arteries supplying the aorta?
A
1) Celiac trunk
2) Superior mesenteric trunk
3) Inferior mesenteric trunk
4) right and left common iliac
13
Q
Which vessel will noursih the foregut?
A
Celiac artery (lower esophagus and the proximal duoenemum) liver, gallbladder, pancrease, spleen
14
Q
Which vessels will nourish the midgut?
A
Superior mesenteric
Distal duodenum to promximal 2/3 of the transverse colon
15
Q
Which vessels will nourish the hindgut?
A
Distal 1/3 of the transverse colon to upper portion of the rectum
16
Q
What are the branches of the celiac trunk?
A
1) Common hepatic
2) Spleenic
3) Left gastric
17
Q
What are the signs of portal hypertension? And why?
A
1) esophagus (esophageal varices)
2) Umbilicus: Caput medusae (paraombilical) small epigastric veins of the anterior abdominal wall
3) Rectum: anorectal varices (superior rectal-middle and inferior rectal)
18
Q
How to treat portal hypertension?
A
TIPS
Tranjugular intrahepatic portosystemic shunt (between the portal vein and hepatic vein) will shunt the blood into systemic circulation bypassing the liver
19
Q
What are the differences between the internal and external hemorroids?
What type of cancer depending on the pectinate line?
A
Internal hemorroids: above the pectinate line (blood supply from the IMA( and be painfuless)
Adenocarcinoma
External: Below pectinate line (fissures) painful if thrombosed (associated with squamous cell carcinoma)
Can also be a fissure
20
Q
What are the characterstics of anal fissure?
A
1) Pain
2) Blood
3) Posterior location (because poorly perfused) associated with constipation and low fiber diets
21
Q
What are the zones of the liver, and what are the diseases that can affect them?
A
Zone1: periportal zone (affected by viral hepatitis and ingested toxins such as cocaine
Zone 2: intermediate zone, affected by yellow fever
Zone 3: pericentral vein ( first affected by sichemia, most sensitive to metabolic toxin)
22
Q
Where can the gallstones be located? What is the implication?
A
Can reach the confluance of the common bile duct and cause blockage
This can cause cholangitis and pancreatitis
23
Q
What are the tumors that can arise with the pancrease?
A
Can be in the head of the pancrease and cause obstruction of the common bile duct
Usually will cause painless jaunedice
24
Q
What is the anatomy of the vessels in the femoral region?
A
NAVEL
Nerve, artery, vein, lympatics
(start at the thigh and move in)
25
What is the definition of a hernia?
Protrusion of the peritoneum through an opening (usually at the site of weakness)
Can become incarcerated and strangulation
26
What is a diaphgramatic hernia?
| What are the causes>
1) Abdominal structures enter the thorax (may occur due to congenital defect of the pleuroperitoneal membrane)
2) Commonly occurs on the left side, due to the relative protection of the right hemidiaphgram by the liver
27
What is the difference between the sliding hiatal hernia, the paraesophageal hernia, and the hiatal hernia?
Sliding hiatal: gastroesophageal junction is displaces upwards (hourglass stomach)
Paraesophageal hernia: gastroesophageal junction is unusally normal, fundus protrudes into the thorax
28
What is an indirect hernia?
Goes through the internal ring, and into the scrotum
occurs within infants
Failure of the processus vaginalis to close
Covered by all 3 layers of the spermatic fascia
29
What is a direct hernia?
Protrudes through the inguinal triangle (bulges)
| Covered by external spermatic fascia
30
What is a femoral hernia?
Protrudes below the inguinal ligament
More common in females
More likely to become incarcerated and herniated
31
What are structures that make up Hasselbach triangle?
Inferior epigastric artery
Lateral border of the retus abdominis
Inguinal ligament
32
What does gastrin do?
| Source, action, regulation?
Source: G cells in the antrum
Action: increased H+ secretion, and growth of the mucosa
Regulation: decreases the pH
33
What happens to gastrin with increased PP1 use?
Decrease in gastrin
34
What happens in gastrin if have H pylori?
Increased in chronic atrophic gastritis
35
What happens in Zollinger-Ellison syndrome?
Increase in gastrin (gastrinoma)
36
What is the function, regulation, of somatostatin?
```
D cells (pancreatic islets)
Action: decrease gastric acid and pepsinogen
Decrease pancreatic and small intestine
Decrease in gallbladder contraction
Decrease insulin and glucagon
```
37
What does Cholecystokinin do?
```
Produced by the duodenum
Increases pancreatic secretion
Decrease gastric emptying
Increases sphincter of Oddi releaxation
Increased production when have fatty acids and amino acids
```
38
What does secretin do?
S cells in duodenum
Function: Increases HCo3
Decrease gastric acid secretion
Allows pancreatic enzymes to function
39
What does glucose dependent insulinotropic peptide include ?
K cell in the duodenum
Action: duodenum and jejunum
Decreases gastric secretion of H+
Increase secretion of insulin
40
What does motilin do?
Released by the small intestine
Produces migrating complexes (MMC)
It is increased in fasting state
Can be used to stimulate intestinal peristalsis
41
What do vasoactive intestinal polypetide do?
1) parasympathetic ganglia in sphincters, gallbladers, and small intestine
2) Increase intestinal and electrolyte secretion
3) Relaxation of intestinal smooth muscles and sphincters
42
What is a Vipoma?
Islet pancretic cell tumor that secretes VIP
43
What does nitric oxide do?
Increase smooth muscle relaxation (including the lower esophageal sphincter)
Loss of NO leads to achalasia
44
What does Grehlin do?
Released from the stomach
Increases the appetite
Increased in fasting state
Increased in Prader-Willi syndrome
45
What does intrinsic factor do?
Found in parietal cells
Binds to Vitamin B12
Can have destruction of the parietal cells if have chronic gasrtis and pernacious anemia
46
What does gastric acid do?
Parietal cells (stomach)
Decrease the pH
Increase the Histamine, and decrease the gastrin
47
What does pepsin do?
Cheif cells (stomach)
Increases vagal stimulation due to local acid
Pepsinogen is converted to pepsin in the presence of H+
48
What does bicarbonate do?
Mucosal cells of the (stomach, duodenum, salivary glands) and Brunner glands
Serves to neutralize the acid
Increased by pancreatic and bilary secretion with secretin
Trapped the mucos that covers the gastric epithelium
49
What are the enzymes secreted by pancreatic enzymes? And what is their role?
1) Amylase: starch digestion
2) Lipases: fat digestion
3) Proteases: Protein digestion
4) Trypsinogen: converted to trypsin
50
How are carbohydrates absorbed? (glucose, galactose and fructose) ?
Glucose and galactose taken by SGLT1 (Na+ dependent)
Fructose by GLUT 5
Both are transported through the blood by GLUT-2
51
How and where is the Iron absorbed?
In the duodenum
52
Where is the folate absorbed?
In the small bowel
53
Where is the B12 absorbed?
In the terminal ileum along with bile slats, requires intrinsic factor
54
What are the Peyer patches?
Lymphoid tissue in the ileum
| Secrete IgA plasma cells (antibody)
55
What is the composition of bile?
| What are the functions of bile salts?
1) Bile salts
2) Functions: digestion and absorption of lipid and fat soluable proteins
3) Cholesterol excretion
4) Anti-microbial activity.
56
What is Bilirubin?
Heme that is metabolized to biliverdin which is then reduced to bilirubin
57
What happens to unconjugated bilirubin?
Removed from the blood by the liver, it is conjugated, and then excreted in bile
58
What happens to direct bilirubin?
Conjugated with glucuronic acid (water soluable)
59
What happens to indirect bilirubin?
Unconjugated (water insoluable)
60
What are the 3 types of salivery tumors?
1) Pleomorphic adenoma
2) Mucoepidermoid carcinoma
3) Warthin tumor
61
what are charactersitics of pleomorphic tumor?
Benign mixed tumor (most comon), reoccurs if not removed completely
62
What are characteristics of mucoepidermoid carcinoma?
Most common malignant tumor (has mucinous and squamous components)
63
What are the warthin tumor?
Benigh cyst tumor with germinal centers
64
What are the findings of achalasia?
Have progressive dysphagia to solids and liquids
Barium will show dilated esophagus with area of distal stenosis
Will have increased risk of squamous cell carcinoma
65
What is Boerhaave syndrome?
Distal esophageal rupture with pneumomediastinum, due to retching
66
What is eosinophilic esophagitis?
Infiltration of esonophils in the esophagus with atopic patinets
Will often have esophageal rings and linear furrows
67
What are esophageal strictures?
Associated with caustic ingestion and acid reflux
68
What are esophageal varices?
Dilated submucosal veins in lower 1/3 of esophagus secondary to portal hypertension
69
What isesophagitis?
Associated with reflux
Infection of immunocompromised individuals
HSV-1 punched out ulcers
70
What is GERD?
Presents as heartburn or regurgitation, dysphagia
May present as chronic cough
Can be associated with asthma
Can have transient decrease in LEStone
71
What is Mallory-Weiss syndrome?
Mucosoal lacerations at the gastroesophageal junction due to severe vomiting
Leads to hematoma
Can be found in alcoholics and bulimics
72
What is Plummer-Vinson syndrome?
Triad: Dysphagia, Iron deficiency anemia, Esophageal webs (increased risk of esophageal squamous cell carcinoma)
73
What is scleordermal esophageal dysmotility?
Smooth muscle atrophy
Decreased LES pressure and dysmotility
Have acid reflux and dysphagia leading to stricture
74
What is Barrett's esophagus?
Intestinal metaplasia, with squamous epithelium
| Due to GERD
75
What are the types of esophageal cancer?
Squamous cell carcinoma: upper 2/3 (risk factors ETOH, hot liquids, strictures and smoking)
Adenocarcinoma: Lower 1/3 chronic GERD, Barrett esophagus, smoking (more common in the Amercian)
76
What are the causes of acute gastritis?
1) NSAIDS ( decrease PGE), decrease gastric mucosa
2) Burns (Curling ulcer) hypovolemia leading to intestinal ischemia
3) Brain injury (Cushing ulcer) increase vagel stimulation (increase ACh and increase H+)
77
What are the causes of Chronic gastritis?
H. Pylori (most common) increased risk of peptic ulcer disease, MALT lymphoma
Autoimmune: Autoantibodies to parietal cells and intrinsic factor
78
What are the most common types of gastric cancer?
Adenocarcinoma and lymphoma
| GI stromal tumor carcinoid (rare)
79
What are some clinical signs of gastric cancer?
Virchow node: involvement of left supraclavicular node by mets from the stomach
Krukenberg tumor: bilateral mets to the ovaries, abundant mucin secreting cells
Sister Mary Joseph: subcutaneous periumbilicus metastasis
80
How to tell the difference between a gastric and duodenal ucler?
Gastric ulcer:
1) Pain is greater with meals
2) H pylori in 70%
3) Mechanism: decreased mucosal protection against gastric acid
4) can be caused by NSAIDS
5) Increased risk of carcinoma
6) Need to biospy the margins to rule out malignancy
Duodenal ulcer:
1) Decreased pain with meals
2) 90% association
3) Other causes can be Zollinger-Ellison syndrome
4) Generally benign
5) Hypertrophy of the Brunner glands
81
what are possible complications of ulcers?
1) Hemorrage
2) Obstruction
3) Perforation
82
What are the symptoms of malabsortion syndrome?
1) Diarrhea
2) Steatorrhea
3) weight loss
4) Weakness
5) Vitamin and mineral deficiency
83
What are the signs of celiac disease?
| How is celiac disease diagnosed?
1) Gluten sensitive enteropathy
2) Celiac sprue
3) European descent
4) Increased chance of malignancy
5) D-xylose test: absorbed in the small intestine (blood and urine level decreased with mucosa defects)
Treatment is gluten free diet
84
How to test for lactose intolerance?
Lactose hydrogen breath test (+ for lactose malabsorption if postlactulose breath hydrogen value rises above 20 ppm compared to baseline
85
What are some causes of pancreatic insufficency?
1) Chronic pancreatitis
2) cystic fibrosis
3) Obstructing cancer
86
what is tropical sprue?
Similar to celiac sprue (affects the small bowel) however, it requires antibiotics. Unknown cause
87
What are the symptoms and the cause of Whipple disease? How is it treated?
1) Caused by infectionTrophyerma whipplie
2) Symptoms include lymph node
Cardiac symtoms
Arthalgias
Neurological symptoms
88
What are the differences between Crohn'sand Ulcerative Colitis?
Location (always Crohn vs Ulcerative)
1) Locaton: any portion of the GI tract vs. colon with rectal involvement
2) Gross morphology: transmural vs submucosal
3) Microscopic: non caseating granulomas vs bleeding crypt ulcers
4) Complications: malabsorption (colorectal cancer) fistulas, recurrent UTI vs Cancer, toxic megacolon, perforation
5) Intestinal manisfestations: diarrhea that may or may not be bloody vs bloody diarrhea
6) External manifestations: Rash, ulcerations in the mouth vs. uvertits, episcelritis, spondylotitis, P-ANCA and scleorising cholangitis
7) Crohn's is cobblestone lesions, while the ulcerative colitis is the continuous
89
What are signs of irritable bowel syndrome?
Recurrent abdominal pain that is associated with
1) Pain that improves with defecation
2) Change in stool frequency
3) Change in appearance of the stool
90
What are the characteristics of appendicitis?
Initially have diffuse ombilical pain that migrates to McBurney's point (1/3 the distance from the right anterior obturator)
Can have Roving signs, which is guarding and rebound tenderness
91
What is diveritculum?
Blind pouch protruding from the alimentary tract
| Communicates with the lumen of the gut
92
What is the difference between a true and false diverticulum?
True has all three walls of the gut
| False is only the mucosa and the submucosa
93
What are complications of diverticulosis?
Painless bleeding
| Diverticulitis
94
What are the symptoms and treatement for diveriticulitis?
| What are the complications for diverticulitis?
1) Left lower quadrant pain
2) Fever
3) Leucocytosis
```
Complications of diverticulitis:
Abcess
Pneumonia
Obstruction
Perfortation with peritonitis ( treat with percutaneous drainage or surgery)
```
95
What is Zenker's diverticulum?
Pharynesopageha; false diverticulum
Presents with dysphagia, obstruction, gurgling, aspiration, foul breath and neck mass
Sticks out through Killian triangle
96
What is Meckel's diverticulum?
True diverticulum caused by persistence of vitelline duct
Can have ectopic acid secreting gastric mucosa
Can lead to Melena, RLQ pain, intussusception, volvulus or obstruction
97
What are the classic 6 signs of Meckel's diverticulum?
1) 2 times more likely in males
2) 2 inches long
3) 2 feet from ileoccecal valve
4) 2% of the population
Commonly presents in the first 2 years of life
98
What is Hirschsprung's disease?
Congenital megacolon with lack of ganglion cells and enteric nervous plexus
Presents with:
1) Bilous emesis
2) Abdominal distention
3) Failure to pass meconium within 48 hours
4) Chronic constipation
Treatment: resection
99
What is malrotation of the stomach?
Anomaly of the midgut rotation during fetal developpement
Improper positioning of bowel with formation of fibrous bands
Can lead to volvulous or duodenal obstruction
100
What is a volvulus?
1) Twisting of the bowel around the mesentery can lead to obstruction and infarction
Sigmoid volvulus are more common in the elderly
101
What is intussception?
Telescoping of the proximal bowel segment into the distal segment
Compromised blood supply
Will have intermittent abdominal pain with currant stools
102
What are the causes of acute mesenteric ischemia?
1) Have critical blockage of intestinal blood flow (usually due to embolic occlusion of the SMA)
Will have abdominal pain out of proportion with physical findings
103
What are the causes of chronic mesenteric ischemia?
Intestinal angina
| Artherosclerosis of the celiac artery (SMA or IMA) with intestinal hypoperfusion
104
What is colonic ischemia?
Reduction in intestinal blood flow causing ischemia
Crampy, abdominal pain followed by hemtochezia
Commonly occurs at watershed areas (splenic flexure)
Typically occurs within the elderly
105
What is angiodysplasia?
Torturous dilatation of the blood vessels (hematochezia)
Most often found in the cecum, terminal ileum and ascending colon
Confirmed by angiography
106
What are adhesions?
Fibrous bands of scar tissue after surgery (most common cause of small bowel obstruction)
Can have well demarcated necrotic zones
107
What is ileus?
Intestinal hypomotility without obstruction
Have constipation and flatus
Usually associated with abdominal surgery, opiates, hypokalemia, and spesis
Treatement: bowel rest, electrolyte correction, anc cholinergic drugs
108
What is meconium ileus?
cystic fibrosis, necrosis of the intestinal mucosa leads to perforation and pneumotosis intesinalis
109
What are the colonic polyps?
Growths of tissue within the colon (may be neoplastic or non neoplastic( can be flat, sessile, or pedunculated with protrustion into the colonic lumen
110
What is a hyperplastic polyp?
Non neoplastc (smaller, and in the rectosigmoid region)
111
What is a hamartous polyp?
Non neoplastic, solitary lesions without significant risk of malignant transformation
Growths of normal colonic tissue with distorted architecture
112
What is adenomatous polyp?
Neoplasm (chromosome abnormality through APC and KRAS) tubular histology has less malignant potential then villous
Usually assymptomatic (may present with occult bleeding)
113
What is serrated polyp?
Premalignant via CpG, hypermethylation phenotype. Has a saw tooth pattern on biospy
Is involved in 20% of sporadic CRC
114
What are the polyposis syndromes?
1) Familial adenomatous
2) Gardner
3) Turcot
4) Peutz-Jeghers
5) Juvenile polyposis
6) Lynch syndrome
115
What is familial adenomatous?
Autosomal dominent mutation of the APC (chromosome 5q2hit) , many polyps arise after starting puberty.
Always involves the rectum
Need colectomy
116
What is GArdener syndrome?
FAP with osseus and soft tissue tumors
| Have retinal pigment epithelium
117
What is Turcot syndrome?
FAP with malignant CNS tumor
118
What is Peutx-Jeghers syndrome?
Autosomal dominent with hamartomas throughout the GI tract, can have hyperpigmented mouth, lips, hands, genitalia
Associated with increased risk of breast and GI cancer
(Colorectal, stomach, small bowel)
119
What is juvenilepolyposis syndrome?
Autosomal dominent in children (less then 5 years old)
| Harmatomatous polyps in the colon, stomach, small bowel. Associated with increased risk of CRC
120
What is lynch syndrome?
Hereditary non-polyposis colorectal cancer
Autosomal dominant mutation
80% progress to CRC
Proximal colon involved
Associated with endometrial, ovarian, and skin cancer
121
What is the epidemiology, risk factors, presentation, and diagnosis of colon cancer
Epi: most patients are over 50 years old (only 25% family history)
Risk factors: adenomatous and serrated polyps and familial cancers, IBD, tobacco, and diet of processed meats and low fiber
presentation: Rectosigmoid > ascending> descending
Ascending: exophytic mass, iron deficiency anemia , weight loss
Descending: infiltrating mass, partial obstruction, colicky pain, hematochezia
Can sometimes present with streptococcus bovis bacteriemia
Diagnosis: Iron deficiency anemia in males > 50 years old
Apple fore lesion seen on the barium enema
CEA tumor, good for monitoring, but not for screening
122
What is the molecular basis of the colorectal cancer?
Mutation in the APC gene can cause FAP
123
What is cirrhosis?
Diffuse fibrosis hat disrupt the normal archtecture of the liver
Increase risk of hepatocellular carcinoma
ETOH most commun cause in 60-70% of the cases
124
What are the types of non-alcholic cirrhosis?
```
Steatohepatitis
Chronic viral hepatitis
Autoimmune hepatitis
Bilary disease
Genetic/metabolic
```
125
what are the causes of portal hypertension other then cirrhosis?
1) Portal vein thrombosis
Budd chiari syndrome
Schistosomiasis
126
What are the signs of portal hypertension
1) Esophageal varices
2) Hemtamesis
3) Gastric varices
4) Melena
5) Spleenomegaly
6) Caput medusa
7) Ascites
8) Anorectal varices
127
What are some signs of cirrhosis?
1) Jaunedice, spider angiomas, palmer erythema, purpura, petechiae
2) Testicular atrophy
3) Gynecomastia
4) Amenorrhea
5) Hepatic encephalopathy
6) Asterixis
7) Anorexia
8) nausea.vomiting
9) abdominal pain
10) Fetor hepaticus
11) Thrombocytopenia/anemia
12) Metabolic: hyperbilirubinemia, hyponatremia
13) Cardiovascular: cardiomyopathy, periphereal edema
128
What are the liver markers for disease?
| What happens to them in the liver disease?
Aspartate increased in most liver disease ( ALT more then AST)
Aminotransferase Increased in ETHOH AST> ALT
Alanine aminotransferase AST > ALT means advanced fibrosis
Alkaline phosphatase increased in cholestasis, infiltrative disorders, bone disease
Glutamyl-transpeptidase: increased in liver and bilary disease (not in bone disease)
129
Why is bilirubin increased?
Liver disease, bilary obstruction, ETOH, and vrial hepatitis
130
What happens to albumin in the liver disease?
Decreased
131
What happens to prothrombin in liver disease?
Increased in liver disease
| Decreased production of clotting factors
132
What happens to platelets in liver disease?
Decreased thrombopoietin
Decreased liver sequestration
Causes portal hypertension
133
What is Reye's syndorome?
```
Fatal hepatic encephalopathy
Fatty liver
Hypoglycemia
Vomiting
Heptomegaly
Coma
Viral infection (treated with ASA)
```
134
What is hepatic steatosis?
Macrovesicular fatty changes (maybe reversible with ETOH cessation)
135
What is ETOH hepatitis?
Long term ETOH
Swollen and necrotic heptocytes (neutrophil infiltration)
Mallory bodies
136
What is ETOH cirrhosis?
Final and irreversible
Micronodular and shrunken liver
Scelrosis
Manifestations of chronic liver disease
137
What are non-ETOH fatty liver diseases?
Due to metabolic syndrome
Fatty infiltration of hepatocytes
Cellular ballooning
138
How does hepatic encephalopathy occur?
| Signs?
```
Portosystemic shunts, that decrease the NH3 metbolism and cause neuropsyhciatric dysfunction
Signs:
disorientation
Asterix
different arousal or coma
```
139
What are the triggers of metabolic encephalopathy?
Increased NH3 production and absoprtion (Dietery protein, GI bleed, constipation, and infection)
140
What causes decreased NH3 removal?
Renal failure, diuretics, bypassed hepatic blood flow (post TIPS)
141
How to treat hepatic encephalopathy?
Lactulose
rifaximin
neomycin
142
What are the associations with hepatocellular carcinoma?
Most comon malignant tumor of the liver
| Usually associated with HCV, ETOH, and non-ETOH (fatty liver), hemochromatosis, alpha antitrypsin
143
What are findings associated with hepato cellular carcinoma?
```
Jaundice
Hepatomegaly
Anorexia
Ascites
Polycythemia
```
144
How is the diagnosis of the heptocellular carcinoma made?
Elevated alpha-fetoprotein
Ultrasound
CT or MRI
145
What is a cavernous hemangioma?
Common, benign tumor
| Typically occurs between 30-50 years of age.
146
Should a hemangioma be biospied?
There is risk of hemorrage (contra indication)
147
What are characteristics of hepatic adenoma?
Rare, bengin tumor
Related to oral contraception or anabolic steroids
Can spontaneously rupture
148
What is angiosarcoma?
Malignant tumor of endothelial origin
| Associated with exposure to arsenic and vinyl chloride
149
What are common mets to the liver?
GI malignancies
Breats
Lung cancer
150
What is Budd Chiari syndrome
Thrombosis of the hepatic veins with congestion and necrosis
Results in hepatomegaly, ascites, varices, abdomingal pain, liver failure, and JVD
Associated with hypercoagulable states, polycythemia, postpartum.
151
What are characteristics of alpha antitrypsin deficiency?
1) Misfolding gene prodyct protein aggregates in hepatocellular ER
Results in cirrhsis with PAS globules
152
What are manifestations of alpha antitrypsin defieciency in the lungs?
Uninhibited elastase in alveoli
Decrease elastic tissue
Leads to panacinar emphysema
153
What are the characteristics of Jaunedice?
Abnormal yellowing of the skin or sclera
| Caused by Bilirubin deposition
154
What are the causes of hyperbilirubinemia?
1) Increased production
2) Decreased hepatic uptake
3) Increased conjugation
4) Decreased excretion
155
What are causes of unconjugated (indirect hyperbilirubinemia)?
Hemolytic
Crigler-Najaar
Gilbert syndrome
156
What are causes of elevated direct hyperbilirubinemia?
Bilary obstrcution: gallstones, cholangiocarcinoma, liver cancer, liver fluke
Bilary tract disease
Scleorosing cholangitis
Biliary Cirrhosis
Excretion defect: Dubin-Johnson Syndrome
157
What are the causes of mixed hyperbilirubinemia?
Hepatitis
| Cirrhosis
158
What is the cause of physiologic neonatal jaundice?
At birth have immature UDP-glucuronosyltrasnferase
Leads to unconjugated hyperbilirubinemia
Leads to jaunedice and kernicterius
159
How to treat physiologic neonatal jaundice?
Usaully occurs 24 hours after life
Usually resolves 1-2 weeks
Treatment is with phototherapy (non-UV light)
Changes the non-conjugated bilirubin to water soluable form.
160
What is Gilbert's syndrome?
Mildly decreased UDP glucronosytransferase conjugation and impaired bilirubin uptake
Asymtomatic of mild jaunedice
Bilirubin increases with fasting and stress
Increase in unconjugated bilirubin without overt hemolysis
161
What is Crigler-Najjar syndrome?
NO UDP-glucuronosyltrasnferase
Presents early in life
Findings:kernicterus, increase unconjugated bilirubin
Treatement: plasmapheresis, phototherapy
162
What is the Dubin-Johnson syndrome?
Hyperbilirubinmia due to liver excretion
Will have a grossly black liver
Benign
163
What is rotor syndrome?
Milder then presentation of the Dublin-Johnson, has no black liver
Due to impaired hepatic uptake and excretion
164
What are characteristics of Wilson's disease?
Recessive mutation in ATPase (copper transporting)
Inadequate copper excretion
Presents before age of 40 with liver disease (hepatits, acute liver failure, cirrhosis) neurological disease
Treatement: chelation with penicillamine
165
What are charcteristics of hemochromatosis?
Recessive HFE gene
Increased intestinal absorption of ferritin, increased iron, decreased TIBC
Have iron overload and accumulates in the liver, pancrease, skin, heart, etc
Can have hemosiderin on MRI
Biospy with prussian stain
166
What is presentation of hemochromatosis in women?
1) Presents before 40 (because iron is loss through mentrusation)
167
what is classic triad of hemochromatosis?
Cirrhosis
DM
Skin pigmentation (bronze)
```
Can also cause:
Cardiomyopahty
Hypogonadism
Arthropathy
HCC is common cause of death
```
168
How is hemochromatosis treated?
Repeated phlebotomy
| Chelation with deferasirox (deferoxamine) oral deferipone
169
What is path, epi, of scleorising cholanitis?
Unknown cause, has strictures and dilatation of bilary duct
Usually middle age men with IBD
Associated with p-ANCA And IGM
Can lead to cholangiocarcinoma or gallbladder cancer
Diagnosis with ERCP or MRCP
170
What is path, epi, of primary biliary cirrhosis?
Autoimmune reaction
Usually middle aged women
Anti-michrondrial
Associated with Sjogren, CREST, hasimotot
171
What is secondary biliary cirrhosis?
Extrahepatic biliary obstrcution
Increased pressure in hepatic ducts
Injury/ fibrosis to bile ducts
Patients often are known for gallstones, bilary structres, or pancreatic carciunoma
Can be complicated by ascending cholangitis
172
How are gallstones caused?
Increased cholesterol
Increased bilirubin
Decreased bile salts
173
What are the risk factors for gallstones?
Female
Fat
Fertile
Forty
174
what are the two types of gallstones?
Cholesterol (radiolucent in 10-20%)
Pigment (black biliary colic)
Associated with cirrhosis, advanced age,
175
How does gallstones manifest?
```
Biliary colic (neurohormonal activation with CCK)
or a fatty meal
```
Triggers contraction of the gallbladder, forcing the stone into the cystic duct
176
What is the treatment of cholecystitis?
Diagnose with U/S, treat with Cholecystectomy
177
What are the symptoms of Charcot cholangitis?
Jaunedice
Fever
Right upper quadrant pain
178
How can a fistula be caused between the gallbladder and the gastrointestinal tract?
Pneumobilia leads to passage of gallstones into the intestinal tract, leads to ileocecal valve (gallstone ileus)
179
What are signs of cholecystitis?
Acute or chronic inflammation of the gallbladder
Leads to infection (rarely acalculous due to ischemia and stasis)
Murphy's sign (inspiratory arrest on RUQ palpation due to pain)
180
How to diagnose a cholecystitis?
With U/S
Cholescintigraphy
HIDA scan
181
What is a procelain gallbladder?
Calcified gallbladder due to chronic cholecystitis found on imaging
Treatment: prophylactic cholecystectomy due to high rates of carcinoma
182
What are causes of acute pancreatitis?
```
Idiopathic
Gallstones
ETOH
Trauma
Steroids
Mumps
Autoimmune
Scorpion
Hypercalcemia
ERCP
Drugs
```
183
What are the characteristics of pancreatitis?
acute epigastric pain, radiating to the back
increase in amylase or lipase (3X upper limit of normal)
Imaging that is characteristic of pancreatitis
184
What are the complications of pancreatitis?
```
1)Pseudocyst
Necrosis
hemorrage
infection
organ failure
hypocalcemia
```
185
What are the causes of chronic pancreatitis?
ETOH
cystic fibrosis
Chronic pancreatic insufficiency
DM
186
What happens to the amylase and lipase within chronic pancreatitis?
Can sometimes stay normal
187
What are the characteristics of pancreatic adenocarcinoma?
Tumor arising from the pancreatic ducts
Often mets upon presentation
More common at the pancreatic head which can cause obstructive jaunedice
High CA 19-9
188
What are the risk factors for pancreatic adenocarcinoma?
```
Tobacco use
Chronic pancreatitis (especially more 20 yers)
DM
Age more 50
Jewish and African American
```
189
How does pancreatitis present itself?
```
Abdominal pain radiating to the back
weight loss
Migratory thrombophlebitis
Trousseau syndroms
Obstructive jaundice
```
190
what is the treatment for pancreatic cancer?
Whipple procedure
Chemotherapy
Radiation Therapy
191
what are the mechanism, use, effects of H2 blocker?
Cimentidine, ranitidine
Mechanism: Blocks H2 receptors and leads to decreased H2 secretion
Adverse effects: inhibits cytochrome P-450 (multiple drug interactions)
Can cause prolactin release, gynecomastia,impotence, decrease in libido
192
What is the mechanism, clinical use, adverse of proton pump inhibitors?
Omeprazole, lansprazole, esomeprazole
Mechainsm: irreverisble inhibit H+/K+
Treatment of peptic ulcers, GERD and Zollinger-Ellison
Can have increase of C.Difficile infection
193
What are side effects of antacid use?
affect absorption, bioavailability or urinary excretion by changing gastric and urinary pH
Can cause hypokalemia
194
Side effects of aluminum hydroxide?
Constipation
Hypophospatemia
Muscle weakness
Seizures
195
Side effects of calcium carbonate?
Hypercalcemia (milk-alkali syndrome) rebound acid
| Can chelate and decrease effectiveness of the other drugs
196
What are side effects of magnesium hydroxide?
Diarrhea
| Hyporelexia
197
Mechanism/use of bismuth, sucralfate?
Binds to ucler and makes a protective coat allowing HCO3 secretion
Can be used to heal ulcers
198
Mechanism for Misoprostol?
PGE analog
Increase the production and secretion of gastric mucous barrier
Decrease acid production
Can have diarrhea (don't give pregnant women)
199
Mechanism/adverse of oceterotide?
Long acting somatostatin
Inhibits secretion and splanic horomone
Adverse: nausea, cramps, steatorrhea
200
Mechanism of osmotic laxatives?
Include: magnesium hydroxide, magnesium citrate, polyethylene glycol, lactulose
Clincal use:constipation
Adverse effects: diarrhea, dehydration
201
Mechanism of sulfasalazine?
Combination of sulfapyridine (antibacterial) and 5 aminosalicylic acid (anti-inflammatory)
Clinical uses: Ulcerative colitis, Crohn's disease,
Adverse effects: Maliase, nausea, sulfonamide toxicity, oligosperimia
202
Mechanism/clinical use/adverse loperamide
Agonist of u-opiod
Slows gut motility
Clincial: diarrehea
Adverse: constipation and nausea
203
Mechanism/clinical/adverse Ondansetron?
5Ht antagonist
Clinical: postoperative vomiting and chemo
Adverse: headache, constipation, QT interval longer
204
Clincal/adverse Orlistat?
Mechanims: inhibits gastric and pancreatic lipase
Clincal use: weight loss
Adverse: steatorrhea, decreased absorption of fat soluable vitamins
205
Clincial/adverse of Ursodiol?
Mechanism: increase of nontoxic bile acid (increased bile secretion) decreased cholesterol secretion and reabsoprtion
Clinical: primary biliary cirrohisis (gallstone prevention or dissolution)
206
What are propoerties of erythrocytes?
Hvae Cl/HCO3 transporters to bring CO2 to the lungs
| Anucleate
207
What is erythrocytosis?
Polycythemia (increase in hematocrit)
208
What is anisocytosis?
Varying sizes
209
What is poikilocytosis?
Varying shapes
210
What are reticulocytes?
Immature RBC
211
What is a platelet?
Small cytoplasmic fragment
Contains ADP and Ca
Graulues with vWF, firbinogen, and fibronectin
212
What is the lifespan of platelet?
8-10 days
213
What percentage of the platelet pool is sequestered in the spleen?
1/3
214
what happens when there is thrombocytopenia?
Developpe petechiae
215
What percentage of leucocytes are neutrophils, lymphocytes, monocytes, eosinophils?
About 50% are neutrophils
| 25% lymphocytes
216
what is the use of neutrophils?
Acute inflammatory cells
Phagnocytic
Contain lyzosymes
217
what is seen in neutrophils if have vitamine B/folate deficiency?
Hypersegmented neutrophils
218
What do band cells suggest?
Increased myeloid proliferation (bacterial infection of CML)
219
Macrophages are important in what type of diseases?
Important component of granuloma formation in TB and sarcoidosis
Lipid A from bacterial LPS binds to CD 14
220
What are the causes of Esinophilia?
```
Neoplasia
Asthma
Allergic process
Chronic adrenal insufficiency
Parasites
```
