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GEN MED GI > Gen Med GI > Flashcards

Gen Med GI Flashcards

1
Q

Gallbladder Cancer Develops From

A

Chronic Cholesystitis

Polyps - a small % are Adenocarcinomic

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2
Q

Types of GB Cancers & incidence

A

Adenocarcinoma 90%

Squamous Cell Carcinoma 10%

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3
Q

Dx Test for GB Polyps

A

Sonogram shows them nicely

Likewise all GB maladies show on Sonogram

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4
Q

Calcification of the gallbladder usually brought on by Gallstones, increases risk of GB Cancer

A

Porcelain Gallbladder

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5
Q

Endoscopic
Retrograde
Cholangeopancreatography

A

ERCP

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6
Q

ERCP enables

A 
Via Endoscopy Visualization of :
Common Bile Duct via Ampulla of Vader
Hepatic Ducts
Cystic Duct
Gallbladder Interior

Stone removal, if small enough

Radiographic dyes can also be injected into the ducts to highlight blockages on Xray

Also used to place stents & dilate as in sclerosing

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7
Q

Dx test for Gall Bladder function

A

HIDA w/Ejection Fraction

Essentially an echo of the GB

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8
Q

HIDA w/ ejection Fraction used when

A

Gallstone Sxs but stones don’t show on soon

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9
Q

Sm Hard Black gallstones

A

Calcium Bilirubinate Stones

Fatty (Alcoholic) Liver
Chronic Hemolysis & Old Age

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10
Q

Soft Greasy Brown gallstones

A

Bilirubinate, Cholesterol & Fatty Acids

Most Common

Infection, Inflammation, Parasites (liver flukes)
Praziquantil for the parasite in case it’s elsewhere too. GB probably still needs to come out.

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11
Q

Biliary Colic,
Pancreatitis,
Ruptured Aortic Thoracic Aneurysm
Perforated Ulcer and Splenic pain travel up this nerve :

A

Phrenic, pain is felt in the C4 dematome

Biliary Colic pain @ Rt subscapular

Perforated Ulcer pain @ Rt Subscapular

Splenic pain @ Left shoulder

Pancreatitis & Aortic Aneurysm @ Back, between shoulder blades

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12
Q

Sign for Cholecystitis

A

Murphy’s Sign

locate lower liver border from pelvis up
Ask Pt to inspire & press up into liver

Wince/pain, sometimes severe is + for cholecystitis AND/or gallstones.

It’s thought to be more cholecystitis but you can’t conclude no gallstones if it’s negative as they’re often the cause of cholecystitis by blocking the cystic duct and causing backup & inflammation and a nice place for B. Fragilis to spawn.

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13
Q

Charcot’s Triad

A

RUQ Pain
Fever
Jaundice

911 for Cholangitis

Order ERCP: Endoscopic Retrograde CholeAngioPancreatography to see and hopefully remove whatever is blocking the hepatic bile ducts

Skip the sonogram if you have the Triad & go STRAIGHT to ERCP

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14
Q

A bacterial Infection superimposed on Hepatic Duct blockage

A

Cholangitis

aka: Ascending or Acute Cholangitis

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15
Q

Primary Sclerosing Cholangitis

A

There WAS an infection of the hepatic ducts and now scar tissue is backing bile up into the liver

Associated with Irritable Bowel

If you don’t have fever or high WBCs, do a SONOGRAM. If fever/infection sign, treat as acute cholangitis and go right to ERCP to view and remove blockage AND place stent. ERCP will be needed for its stenting capacity
or
A liver transplant will be needed

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16
Q

Cholescintigraphy

A

HIDA w/Ejection Fraction

Radioisotopes are ingested and should make it to the gallbladder within 4 hrs. If not, there is a blockage and it can differentiate cholecystitis from early cholangitis. It’s essentially a GB echogram

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17
Q

Dx Tests for Cholangitis before ERCP

A

CBC w/diff

Blood Culture (will need to Rx w/ABX so find out what the bug is, likely B. Fragilis though)

CMP - need liver function tests
- need [Ca++] incase of Pancreatitis also

Blood Type and Match - may need blood if Surgery

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18
Q

CHALOT’S TRIANGLE

A

CYSTIC DUCT
COMMON HEPATIC DUCT
MARGIN OF THE LIVER

Don’t cut the Common Hepatic Duct in your cholecystectomy or bile will drain into the peritoneum and not the duodenum!

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19
Q

A collection of pus w/in a body cavity or hollow organ

A

EMPYEMA

GB
PLEURAL CAVITY
THORACIC, ABD CAVITIES
UTERUS
APPENDIX
MENINGES
JOINTS
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20
Q

Why does Pancreatitis cause Hypocalcemia?

A

Pancreatitis results in secretion of pancreatic enzymes directly into the blood stream via inflammation.

They damage vessel walls (they’re ENZYMES after all) and escape into the abdominal cavity where LIPASE encounters ADIPOSE tissue and digests it to triglyceride & free fatty acids.

Free FA love to bind Ca++ on their anionic end and do so all over the place, reducing the Ca++ available

The degree of hypocalcemia is indicative of the seriousness of the pancreatitis

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21
Q

Sentinel Lymph Node for Gallbladder

A

Mascagni’s Node
aka
Lund’s Node

Located in Chalot’s

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22
Q

Electrolyte Panel Tests for

A

Na, K, Cl, BiCarb

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23
Q

Albumin:

A

3.9 to 5.0 g/dL

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24
Q

Alkaline phosphatase:

ALT (alanine aminotransferase):

AST (aspartate aminotransferase):

A

44-147

8-37

10-34

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25
Q

BUN (blood urea nitrogen):

Creatinine:

A

7-20 BUN

0.8 - 1.4 Cr

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26
Q

Calcium:

Chloride:

A

8.5 - 10.9 Ca

96 - 106 Cl

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27
Q

Potassium test:

Sodium:

A

3.7 - 5.2 K

136 - 144 Na

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28
Q

Total bilirubin:

Total protein:
A
  1. 2 - 1.9 mg/dL bilirubin

6. 3 - 7.9 GRAMS/dL more Albumin!!

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29
Q

Difference between BMP & CMP

A

CMP is BMP + :

Proteins - Alb & Total
Bilirubin - Total
Alk Phos
ALT
AST
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30
Q

On BMP

A 
Electrolytes:
     Ca, Cl, K, Na
Kidney Function:
     BUN & Cr
Glucose
CO2
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31
Q

Ursodiol

A

Oral Bile Acid
Dissolves gallstones over many months

Works on tiny cholesterol stones

(Ursodeoxycholic Acid)

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32
Q

Most common complication of cholelithiasis

A

Acute Cholecystitis

95% cholecystitis pts have stones

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33
Q

Cholecystitis

A

Inflamm of GB second to blockage of cystic duct by gallstone

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34
Q

Risks of Cholecycistis

A

Rupture & Peritonitis

Get Sonogram &

stabilize ASAP with ABX Then

Remove GB w/in 48 Hrs!!!

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35
Q

Describe Biliary Colic Pain

A

Begins 1-2 hrs after eating (fat) sometimes waking if ate late

RUQ w/shoulder and/or back radiation

Increases in intensity like a bell curve is then steady for 6-12 hrs while fats are digested

Sore (Murphy sign possible) even after episode passes between meals.

36
Q

Cholecystitis stabilization Abx

A

Cephtriaxone + Flagyl + Pip/Taz (Zosyn)

37
Q

Flagyl

A

Metronidazole

Anaerobes & Protozoa & Yeasts

Always one of the combos for gut infection as they’re all anaerobes of one sort or another

38
Q

Zosyn

A

Piperacilin/Tazobactam

4th gen Penicilin, great on pseudomonas

Good for Peritonitis & Pneumonia

Delivered q6-8 hrs IV over 30 min or steady over 4 hrs to achieve best MIC

39
Q

Gallstone perforates gallbladder & sm. bowell creating direct connection between the two organs

A

Cholecystoenteric Fistula

40
Q

Gallstone Pancreatitis

A

Stone blocks Sphincter of ODI or Ampulla of Vader & backs up bile & pancreatic secretions into Pancreas causing Pancreatitis and eventually Cholangitis/Cholecystitis

41
Q

Tumor or Growth doesn’t belong but not necessarily malignant

A

Neoplasm

42
Q

Gastrinoma

A

Gastrin Secreting Tumor

Causes high Gastrin between meals

Dx is Secretin Stimulation Test. Secretin inhibits gastrin unless its from a gastrinoma, in which case gastrin levels will remain high

43
Q

Zollinger-Ellison Syndrome

Heartburn sxs soon after eating, like PUD
Steatorrhea

A

Pancreatic Gastrinoma

If H. Pylori Test is Neg., refer pt to GI for endoscopy

Curable w/surgery if no mets so if Endo is +, put them on H2/PPI to control acid day to day, get a CT & PET to look for mets.

Remove Pancreas or most thereof if no mets

Chemo/Rad if Mets - fairly fast to end though and 2/3 are Metastatic on Dx as sxs seem just like heartburn immediately on eating.

44
Q

Extra-nodal Site

A

Cancer starts elsewhere & mets to extra nodal sites:

Stomach is often extra nodal except in ‘nomad that are caused by H. Pylori

45
Q

H. Pylori caused Cancers

A

Gastric Lymphoma

Gastric Adenocarcinoma

46
Q

Starts in the stomach
H.Pylori is primary infection

Over 60/epigastric pain/weightloss/fatigue
early satiety

Very Slow progression
Very Curable Early

A

Gastric Lymphoma
aka
MALT Lymphoma (mucosa assosiated lymphoid tumor)

47
Q

H. Pylori Eradication Therapy

A

Endoscopy/Biopsy to Definitive Dx or…
Urease Breath Test/ H. Pylori blood AB test

For 10 days
Omeprazole BID
Clarithromycin 500 mg PO BID
Amoxicillin        500 mg PO BID
Flagyl                500 mg PO BID

Redo Biopsy 4 weeks after abx therapy ends to ensure it worked

If it doesn’t work, do it again and add Pepto Bismol

48
Q

Gastric Lymphoma Rx

A

H. Pylori Eradication Therapy (if no mets)

Rituximab (if mets)

49
Q

“Flushing, Palpitations & Diarrhea”

are classic triad for:

A

Gastric Carcinoid Tumor

Endoscopy/Biopsy to Dx

Remove stomach to Rx, all if necessary

50
Q

Type I Gastric Carcinoid Tumor

Mets to

A

Liver

Adrenals (MenI & Cushings are assoc.)

51
Q

Dx Tests for Gastric Carcinoid Tumor

A

25-HIAA Test (a 24 hr urine test for 5HT3)

Somatostatin Receptor Scintigraphy (SRS)

CT/MRI

Endo/Biopsy is Diagnosic though

52
Q

Gastric Carcinoid Tumor Secretes

A

Serotonin

Hence the flushing, palps & diarrhea sxs

53
Q

2nd Most Common Cause of Cancer Deaths World-Wide

A

Gastric Adenocarcinoma

Caused by LONG term H. Pylori

54
Q

Location of Virchow’s Node & significance

A

Left Supraclavicular

Classic sign of Gastric Adenocarcinoma if swollen

55
Q

Location & Significance of Sr. Mary Joseph Nodule

A

Umbillicus

Classic Sigh of Gastric Adenocarcinoma

56
Q

Anemia not due to low iron/hemolysis
+
Weight Loss Suspicious for what:

A

Gastric Adenocarcinoma

57
Q

Adenocarcinoma Staging

A

1-3 remove stomach

4 mets, palliative care

58
Q

Cholestatic Pruritis

A

Bile back up causes itching

Too much conjugated bilirubin - unconjugated bilirubin in the blood does NOT cause itching.

Cirrhosis usually but any blockage will do it

59
Q

Continuous areas of ulceration in rectum/colon ONLY
shallow ulcerations & pseudo polyps
Fistula Rare

A

Ulcerative colitis Endoscopy findings

60
Q

Feeling of not having emptied the rectum

A

Tenesmus

61
Q 
Mild to severe abd cramping
Freq, Mucusy soft stool/diarrhea often w/blood
Tenesmus Common
Fever indicative of severe disease
Often anemia/ +guiac
A

Ulcerative Colitis Abdominal Sxs/ signs

62
Q

porridge-like stool often w/steatorrhea
Tenesmus Rare
Fever & weightless Common

A

Crohn’s Disease Symptoms

63
Q

Extra-Abdominal Signs of Ulcerative Colitis

A 
Uveitis
Mouth Ulcers
Arthritis
Erythema Nodosum (sub Q fat inflam. on shins)
Necrotic skin ulcerations
DVT/PE
Clubbing
Primary Sclerosing Colangitis & all its attendant     
        signs & sxs
64
Q

Pyoderma Gangrenosum

A

Necrotic Skin Ulcerations - Ulcerative Colitis

65
Q

Peak Onset of Ulcerative Colitis

A

15- 25 yrs

Nonsmokers or those who recently stopped smoking

66
Q

Peak Onset of Crohns

A

15-30

Smokers

67
Q

Differentials for Ulcerative Colitis

A 
#1: Crohns Disease is hard to differentiate
#2:  C. Dif  (get stool cultu & Toxicology ELISA)
        AKA:  Pseudomembranous Colitis
68
Q

Antibiotic causes of c. Dificile

A

Quinolones, Carbapenems, Clindamycin & Cephalosporins

69
Q

Diagnostic Testing for C Dif

A

Toxin Screen is gold std,

Colonoscopy/biopsy

70
Q

C. Dif Rx

A

Metronidazole, 3x/day 10 days

ORAL Vanco (only use of this orally) of resistant to Flagyl. Cdif is a G+ Anaerobe

Questran, bile acid sequestrate that also seems to sequester Cdif toxins WITH Vanco

Stool Transplant IS effective esp in abx resistnt cdif

71
Q

First line Rx for Ulcerative Colitis

A

Aminosalicylates: Sulfasalazine & Mesasalazine are
anti-inflammatories to control inflammation

Corticosteroids short term to suppress immune response

Mabs: Infliximab last resort to target tissue necrosis factor

Nicotine Patches strangely work

IV iron for the anemia due to constant bleeding

72
Q

Patchy transmural ulcerations “skip lesions” anywhere from mouth to anus. “Cobblestoning” of colon

Cramping & Diarrhea, bloody if severe disease but melena is more likely than hematochezia

Anemia, Weight Loss, Skin

Fever is common and malabsorption due to involvement of small bowel

A

Crohn’s Disease sxs

73
Q

Best test for Crohns

A

Colonoscopy - it can usually visualize the terminal ilium and if lesions extend into there, it isn’t ulcerative colitis.

Obviously upper GI endoscopy would be needed to biopsy stomach and duodenum. Jejunum is hard to get at.

Barium follow through can be helpful

74
Q

Anal lesions Common/Rare in:

A

Common in Crohns

Rare in Ulcerative Colitis

75
Q

Rectal involvement Common/Rare in:

A

Common in Ulcerative Colitis

Rare in Crohns

76
Q

Epigastric Pain worse on eating and there is weight loss

A

Peptic Ulcer

H. Pylori Test likely +
In Office Maalox Test likely +
Refer for endoscopy, may cause hematemesis

77
Q

Epigastric Pain relieved by eating, keeps pt awake at night (when not eating) and there is weight gain

A

Duodenal Ulcer

78
Q

+ ASCA and

- pANCA

A

Crohns

79
Q

-ASCA and

+pANCA

A

Ulcerative Colitis

80
Q

NSAIDS damage Stomach Lining by

A

Inhibiting COX 1 & 2 (mainly 1)
Thus decreasing release of mucosal-protective prostaglandins in the stomach.

Even IM NSAIDS can do this, it isn’t just oral route.

81
Q

indirect bilirubin =

A

unconjugated

High levels in neonates suggests immature liver is unable to conjugate - Rx is billi-light

high levels in adults are usually upstream of the liver bleeding, hemolysis, spleen issue

82
Q

direct bilirubin

A

Has Been Conjugated by the liver

If serum levels of indirect are high it means liver is producing but it can’t secrete - biliary obstruction - so bilirubin seeps into blood

If serum levels are low but indirect levels are high it means the liver is not conjugating

83
Q

ANA (Anti-Nuclear Antibodies)

A 
Antibodies to core antigens
Hepatitis core antigens
Primary Biliary Cirrhosis
Hashimotos
Alcoholic Liver Disease...

Procainamide
Hydralazine
Dilantin can cause ANAs to circulate

84
Q

Constipated during pregnancy, used laxitives

Postpartum w/rectal bleed , no pain

A

internal hemorroids don’t always hurt

85
Q

Spastic Colon

A

IBS

86
Q

IBS criteria

A

No other diagnosis
A change in bowel habits and appearance
Crampy/bloaty 3days/mo for 3 months
Improves w/defecation

87
Q

Zenker’s Diverticulum

A

Esophagus herniates thru weakness in it’s muscular wall then muscle constricts around it. Relax the wall and it may pull back in.

Very bad breath/Cough/Reflux

Barium Swallow

Resection or staple

GEN MED GI (4 decks)

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