GI Flashcards

Question

Cholangitis: Treatment

Answer 1

``` Treatment § ERCP: Stone removal, Stenting of bile duct (To allow for biliary drainage) § Infection: Antibiotics § Sepsis (+/- shock): Fluids, Pressors § Cholecystectomy: To prevent recurrence ```

Answer 2

-secrete product (hormone) directly into the bloodstream -The islets of Langerhans are small collections of cells in the pancreas that secrete hormones ¤ α - glucagon - ↑ glycogenolysis --> ↑ glucose ¤ β - insulin - Shift glucose intracellularly ¤ δ – somatostatin - ↓ glucagon ↓ insulin

Answer 3

Exocrine = secrete product through a duct directly onto epithelium Acinar cells (acini) secrete pancreatic enzymes into the duodenum to aid with digestion ¤ Amylase – starches ¤ Lipase – triglycerides ¤ Protease – proteins Ductal cells secrete water and bicarbonate in response to food intake and secretin release from the small intestine ¤ The pancreatic duct and common bile duct join together to form the hepatopancreatic duct or ampulla of vater

Answer 4

Acinar cell injury --> Chemo-attraction of leukocytes & macrophages in the pancreas = inflammation --> Cytokine and proteolytic enzyme release = breakdown of pancreatic tissue and edema -Cycle repeats ``` Causes: Acute ¤ Gall-stone associated ¤ Alcoholic ¤ Hypertriglyceridemia ¤ Drug-Induced ¤ Post-endoscopic retrograde cholangiopancreatography (ERCP) ``` Chronic ¤ M-ANNHEIM

Answer 5

Gallstones that lodge in the hepatopancreatic duct can prevent the normal flow of enzymes into the small intestine ¤ This can lead to breakdown and inflammation of the pancreatic tissue

Answer 6

Associated with large consumption of alcohol for an extended period of time ¨ Exact mechanism unknown ¨ Proposed mechanism multifactorial: ¤ Alcohol ingestion stimulates pancreatic enzyme production ¤ Formation of reactive oxygen species (ROS) can damage pancreatic tissue and cause inflammation

Answer 7

Free fatty acid production via the breakdown of lipids by pancreatic lipase causes pancreatic inflammation

Answer 8

``` Acute: Abdominal pain/distention Nausea/Vomiting Fever Leukocytosis Jaundice ``` ``` Chronic: Abdominal pain Steatorrhea Weight loss Jaundice Hyperglycemia ```

Answer 9

Acute: ¨ Physical findings consistent with pancreatitis: abdominal pain ¨ Lipase or amylase > 3x ULN ¤ Lipase is the most sensitive ¨ Imaging-CT ¤ Not routinely done for uncomplicated cases Chronic: Amylase and lipase may be normal ¤ Damage to exocrine pancreatic cells may prevent adequate production of pancreatic enzymes ¨ Imaging may reveal atrophic pancreas and complications of chronic pancreatitis ¤ Calcifications, dilations of pancreatic duct, pseudocysts ¨ Secretin stimulation test ¤ Measures the ability of the pancreas to respond to secretin

Answer 10

``` Acute: Necrosis Hemorrhage Pseudocyst Infection ¤ Abscess ¤ Systemic infection --> shock ``` ``` Chronic: ¨ Loss of endocrine and exocrine function ¤ Diabetes ¤ Nutritional deficiencies ¨ Pseudocyst ¨ Ascites ¨ Biliary stricture ¨ Pancreatic cancer ```

Answer 11

``` Acute Goal: supportive Remove/avoid cause ¤ Medication, triglycerides, alcohol Re-hydration Avoid oral intake Treat complications ¤ Pain management ¤ Antiemetics ¤ Antibiotics? ``` ``` Chronic: Goal: symptom management ¤ Pain management ¤ Antiemetics ¨ Optimize nutrition ¤ Low-fat meals ¤ Frequent small meals ¤ Fat-soluble vitamin supplementation ¨ Avoid cause ¤ Alcohol ¨ Pancreatic enzyme replacement ```

Answer 12

Liver Disease § Any disease or disorder that causes the liver to function improperly § Can be acute or chronic ``` Cirrhosis § Final phase of chronic liver disease § Fibrosis and scarring present § Poor liver function § Not to be confused with elevated LFTs ```

Answer 13

Alcohol Hepatitis B & C Primary biliary cirrhosis, primary sclerosing cholangitis Nonalcoholic fatty liver disease (NAFLD) Genetic/Metabolic: Hemochromatosis, alpha 1 antitrypsin deficiency, Wilson’s Disease Drugs: More commonly acute liver injury

Answer 14

``` ¡ Hepatomegaly ¡ Pruritus, jaundice ¡ Palmar erythema, spider angiomata ¡ Ascites, edema, ¡ Painful, tense abdomen ¡ Confusion-if encephalopathic ¡ Asterixis ```

Answer 15

It all starts with increased sinusoidal pressure § Hepatocytes fibrose and scar over, impeding blood flow through the sinusoids § Forcing blood to run through other still functioning areas of the liver ¡ The pressure in the sinusoids of the remaining functional lobules increases ¡ Eventually the pressure is so high that the blood can no longer overcome that pressure and the blood will back up in the portal vein all the way into the small splanchnic vessels. ¡ The pressure in the splanchnic vessels increases due to increased blood flow ¡ The body releases vasodilatory nitric oxide to dilate the splanchnic vessels to compensate ¡ At the same time, there is now more blood in the splanchnic vessels and less blood coming through the liver because of the impedance to flow ¡ Therefore, less blood ultimately returns to the heart through the hepatic vein then through the heart and into arterial circulation resulting in decreased effective circulating volume and reduced blood pressure. ¡ Baroreceptors sense this reduction in effective circulating volume and activate a neurohormonal response. ¡ The sympathetic nervous system, Renin-angiotensin-aldosterone-system (RAAS) and anti-diuretic hormone (ADH) all become activated in response to the detected decreased effective circulating volume and hypotension signaling the retention in the kidney causing fluid overload. ¡ Splanchnic vessel permeability is increased due to loss of oncotic pressure between intravascular and extravascular space due to decreased albumin ¡ Increased vasodilation of the splanchnic vessels causes increased lymph production ¡ Increased lymph production coupled with increased vessel permeability results in fluid and lymph leakage into the peritoneal cavity ¡ Effective circulating volume continues to remain low as fluid continues to move into the peritoneum ¡ The body continues neurohormonal activation to attempt to increase effective circulating volume resulting in more fluid accumulation…the cycle continues….

Answer 16

¡ Physical examination § Full, tense, bulging abdomen § Abdominal ultrasound ``` Abdominal paracentesis § Removal of ascitic fluid from the peritoneum § Ascitic fluid analysis § SAAG= Serum-ascites albumin gradient § Use same day values § SAAG ≥ 1.1 g/dL = portal hypertension ```

Answer 17

Na+ restriction § 2 grams/day Aldosterone antagonists +/- Loop diuretics Diuretic refractory ascites § Large volume paracentesis (4-8 L) § Rapidly removes fluid § Does nothing to correct the underlying problem though § Needs to be in combination with Na+ restriction and diuretics

Answer 18

Hepatic venous pressure gradient (HVPG) § Difference between the portal vein and inferior vena cava § Portal hypertension = HVPG > 5 mmHg § SAAG ≥ 1.1 g/dL also used for diagnosis

Answer 19

Ascites | Variceal bleeding

Answer 20

Gastric and esophageal varices form as a result of shunting of blood away from the liver into splanchnic collaterals § Collaterals = growth of or several blood vessels to provide blood to an organ or vascular bed § Varices = abnormally dilated vessels § 1/3 of cirrhotic related deaths § Risk factor for SBP § Complication of portal hypertension

Answer 21

Goal: Prevent variceal bleeding § How? § Treat the portal hypertension ¡ Non-selective beta blockers (Propanolol, nadolol) -Transjugular intrahepatic portosystemic shunt (TIPS): Shunt bypasses the liver providing immediate relief for the high pressure portal vein § Side effect: Hepatic encephalopathy ¡ Used for refractory acute variceal bleeding or ¡ Refractory ascites patients intolerant of large-volume paracentesis

Answer 22

Bacterial infection of the ascitic fluid ¡ Often caused by enteric gram negatives found in the GI tract ¡ Pathogenesis § Not completely known § Bacterial translocation from gut to lymph § Reduced host defense

Answer 23

Elevated ascitic fluid white blood cell count Positive ascitic fluid bacterial culture

Answer 24

¡ Antibiotic therapy § 3rd generation cephalosporin § Ciprofloxacin would be alternative therapy

Answer 25

``` Accumulation of toxins from § Declining hepatic function § Portal-systemic blood flow shunting ¡ Toxins § Ammonia ¡ Results in altered mental status ¡ Ammonia levels are not correlated with HE severity ```

Answer 26

¡ Decrease ammonia production by increasing ammonia excretion through the GI tract § Lactulose ¡ Dietary protein § Balance between protein restriction and correcting malnutrition