GI Flashcards
Diaphragmatic Hernia
Def’n, Mech, Pres (Age Group)?
Ab structures enter thorax.
MECH = Defective devel of pleuroperitoneal memb.
PRES: Infants
Sliding Hiatal Hernia
Mech (3 steps), Pres (CLUE)?
MECH:
LES slides SUP -> GE junction displaced ->
Diaphragm can no longer reinforce it.
PRES:
- “Hourglass stomach”
Rolling / Paraesophageal Hernia
Def’n?
FUNDUS protrudes into thorax. GE junction normal.
Indirect Inguinal Hernia
Def’n, Embryo, Mech, Anat, Pres (Epi)?
Projects through INGUINAL RING.
Follows path of descent of testes.
Covered by all 3 layers of spermatic fascia.
MECH = Failure of PROCESSUS VAGINALIS to close.
** LATERAL to inf epigastric art. **
PRES = MC in Males
Direct Inguinal Hernia
Def’n, Embryo (layer of spermatic fascia covered by), Anat, Pres (Epi)?
Projects through AB WALL.
Covered by EXTERNAL layer of spermatic fascia only!
** MEDIAL to inf epigastric art. **
Passes thr Hesselbach’s Triangle -> SUP Inguinal Ring only!
PRES = MC in older men
Femoral Hernia
Def’n, Anat, Pres (Epi)?
Part of S.I protrudes through femoral ring.
Protrudes below inguinal ligament.
PRES = MC in Women (wider bony pelvis)
SMA Sx
Def’n?
Transverse portion of Duodenum entrapped b/w Aorta + SMA -> Intestinal Obstruction.
Internal Hemorrhoids
Anat, Innervation, Pres (CLUE), Assoc?
ABOVE pectinate line.
Visceral innervation.
PRES = NOT painful.
ASSOC:
- Portal Htn
External Hemorrhoids
Anat, Innervation, Pres?
BELOW pectinate line.
Somatic innervation (inf rectal branch of pudendal nerve).
PRES = Painful.
Anal Fissure
Def’n, Location, Pres (2)?
Tear in anal mucosa.
BELOW pectinate line.
PRES:
- Painful defecation
- Blood on toilet paper
Esophageal Webs
Def’n, MC Location?
Thin protrusions of esophageal mucosa.
MC in UPPER Esophagus.
Esophageal Varices
Def’n + Location, Cause, Pres, Comp?
Dilated submucosal veins in LOWER 1/3 of Esophagus.
CAUSES:
- Portal Htn
PRES = PAINLESS / Asymptomatic bleeding
COMP = ** Rupture **
Esophageal Strictures
Assoc (2)?
ASSOC:
- Lye ingestion
- Acid reflux
Esophagitis
Causes (4: 3 Micro + 1)?
CAUSES:
- HSV-1 (“punched-out” ulcers) in immunocompromised p/ts
- CMV (“linear” ulcers)
- Candida (“white pseudomemb”)
- Chemical ingestion
Eosinophilic Esophagitis
Def’n (incl Epi), Cause, Pres (Triad + 1)?
Infiltration of eosinophils into esophaguses of ATOPIC P/TS.
CAUSE = Exposure to food allergens.
PRES:
- Triad:
1. Strictures
2. Dysphagia
3. Heartburn - Unresponsive to GERD therapy *
Dysphagia
- To solids only -> ?
- Causes? - To solids + liquids -> ? (Progressive = solids first then liquids)
- Causes (3)?
- Obstruction
CAUSES:
- Esophageal Web (eg Plummer-Vinson Sx)
- Progressive Dysphagia
CAUSES:
- Achalasia
- Esophageal SCC
- Peristalsis problemAchalasia #1
Def’n, Causes, Assoc (2)?
Achalasia = absence of relaxation.
MECH:
↑LES tone due to loss of Myenteric (Auerbach’s) plexus.
-> HIGH LES opening pressure + UNCOORDINATED peristalsis.
CAUSES:
- Nitric Oxide secretion loss
ASSOC:
- Chagas Dz
- Scleroderma / CREST Sx (esophageal dysmotility due to LOW pressure proximal to LES)
Achalasia #2
Pres, Appearance on Ba Swallow (CLUE)?
PRES:
- Progressive dysphagia to solids + liquids
BA SWALLOW:
- “Bird’s beak” (dilated esoph with area of distal stenosis)
GERD
Def’n, Pres (CLUE + 2), Comp?
↓in LES tone.
PRES:
- “Heartburn + Regurg upon LYING DOWN”
- Nocturnal dyspnea + cough
- Adult-onset Asthma
COMP:
- Barrett’s
Mallory-Weiss Sx
Def’n, Pres (Epi CLUE + Pres CLUE), Comp?
Gastroesophageal lacerations due to frequent + severe vomiting.
PRES: Alcoholic + Bulimic patients
- “PAINFUL hematemesis”
COMP:
- Berhaave Sx
Boerhave Sx (** “Been-Heaving Sx” **)
Def’n?
Transmural esophageal RUPTURE -> Air in Mediastinum ->
Subcutaneous Emphysema.
Plummer-Vinson Sx
Pres (3), Comp (progression to)?
PRES: ** “Plumbers DIG” **
- Dysphagia ( / Esoph Webs)
- Iron Deficiency Anemia
- Glossitis (Atrophic)
COMP:
- Esophageal SCC
Barrett’s Esophagus
Mech + Location, Cause, Comp?
Glandular Metaplasia- replacement of normal esoph epithelium with INTESTINAL (COLUMNAR) epithelium + Goblet cells.
DISTAL Esophagus.
CAUSE = Chronic GERD
COMP:
- 30-40x↑risk of Esophageal SCC
Esophageal Cancer
Pres (4), Prog?
PRES:
- Progressive dysphagia
- Weight loss
- Pain
- Hematemesis
PROG = Poor. (Worse with later pres)
Esophageal SCC
Location, RF (3), Causes / Assoc (7), Pres (2)?
UPPER 2/3 of Esophagus.
RF:
- Very hot tea
- Cigarettes
- Alcohol
CAUSES / ASSOC:
- Diverticula
- Achalasia
- Esoph strictures
- Mallory-Weiss Sx
- Berhaave Sx
- Plummer-Vinson Sx
- ** Barrett’s **
PRES:
- Hoarse voice
- Cough
Esophageal Adenocarcinoma
Location, RF (2)?
LOWER 1/3 of Esophagus.
RF:
- Esophagitis
- Barrett’s
Acute Gastric Ulcers
2 Types: Mech of Production, Assoc?
CURLING ULCER:
Greatly↓PLASMA VOLUME -> SLOUGHING of gastric mucosa.
ASSOC = SEVERE BURNS
CUSHING ULCER: ↑INTRACRANIAL P -> ↑Vagal gastric secretion.
ASSOC = CNS injury
Acute Gastritis
RF (3 ‘substance consumers’ + 2 general states + 2 specific traumas)?
RF:
- Alcoholics
- P/ts taking daily NSAIDs (↓PGE1 -> ↓gastric mucosa protection)
- P/ts on Chemotherapy
- Stress
- Shock / Trauma
- Burns
- Brain injury
Chronic Atrophic / Autoimmune Gastritis
Mech, Comp (2)?
MECH = Autoimmune destruction of Parietal cells
COMP:
- Pernicious Anemia
- Gastric Carcinoma
Type A (fundus / body) Chronic Gastritis = Autoimmune Gastritis
Ab (2), Path, Pres, Labs (2), Prog?
Autoantibodies against Parietal cells and/or Intrinsic Factor.
PATH: T cell-mediated = Type 4 H-S.
PRES:
- Pernicious Anemia
LABS:
- Gastrin↑
- Cl↓
PROG:
- ↑risk for Gastric Carcinoma
Type B (antrum) Gastritis = H pylori Gastritis
Mech, Pres,
RX (incl 2 signs of eradication + 2 goals of therapy), Comp (3)?
MECH = Weakening of mucosal defenses due to:
- H pylori Proteases + Ureases
- Infl
PRES:
- Epigastric ab pain
RX = Triple Therapy: PPI + Amoxicillin + Clarithromycin
(Metronidazole if allergic to penicillin)
* Eradication when Urea Breath Test + Stool Antigen negative *
-> Elimination of gastritis / ulcer
-> Reversal of intestinal metaplasia
COMP:
- Ulceration / Peptic Ulcer Dz
- Gastric Adenocarcinoma
- MALT Lymphoma
Peptic Ulcer Disease
Def’n, 2 Types, Mech, RX, Comp (3)?
Solitary mucosal ulcer.
- Gastric ulcer
- Duodenal ulc
MECH = ↓mucosal protection against gastric acid
RX = (same as for H Pylori Gastritis if caused by H Pylori)
COMP:
- Rupture
- Acute Pancreatitis (rupture of POST ulcer)
- 1ry Hyperparathyroidism
Menetrier’s Dz
Pres (General Triad + CLUE)?
Precancerous
PRES:
- “Rugae of stomach so hypertrophied that they look like brain gyri”
- Triad:
- ↑mucous cells
- Parietal cell atrophy
- Protein loss
Gastrinoma
Def’n, Pres?
Gastrin-secreting tumor ->↑acid secretion -> Ulcers.
PRES = Gastric Ulcers
Gastric Adenocarcinoma
Def’n, Path (2, incl 3 mets), Assoc (3), Pres (3)?
Malignant proliferation of gastric surface epithelial cells.
PATH:
- Early aggressive local spread
- Mets:
- Virchow’s node
- Sister Mary Joseph’s nodule
- Krukenberg tumor
ASSOC:
- Type A blood
- Achlorhydria
- Chronic Gastritis
PRES: * Late *
- Ab pain
- Early satiety + Weight loss
- Anemia
Intestinal Gastric Adenocarcinoma
Location, Appearance, Assoc (2), Pres (CLUE)?
MC on Lesser Curvature of Stomach.
Resembles gastric ulcer (large + irregular with raised margins).
ASSOC:
- Smoke (tobacco smoking + smoked foods)
- H pylori infection
PRES:
- Sister Mary Joseph’s nodule (subcutaneous periumbilical mets)
Diffuse Gastric Adenocarcinoma
Pres (2 CLUES)?
PRES:
- Signet Ring cells that DIFFUSELY INFILTRATE gastric wall
- “Linitis Plastica” (thick + leathery stomach wall)
Krukenberg’s Tumor
Def’n, Micro Findings (2: CLUE + General)?
Diffuse Stomach Cancer -> Bilateral Mets to Ovaries.
FINDINGS:
- “Signet Ring” cells
- Abundant mucus
S.I Infarction
2 Types, Mech (Transmural), Pres?
- Transmural Infarction
- Mucosal Infarction
MECH (Transmural Infarction):
Thrombosis / embolism of Mesenteric artery or vein.
PRES = Severe Htn
Malabsorption Sx
Pres (5), Dx?
PRES:
- Diarrhea: bloody + steatorrhea
- Ab distension + pain
- ↓bowel sounds
- Weight loss (Adult) / Failure to thrive (Child)
- Weakness
DX = Steatorrhea!
Tropical Sprue
Location?
Can affect ENTIRE S.I.
** Difference from Celiac Sprue **
Whipple Disease (Tropheryma whipplei)
Locations (4),
Pres (Epi + 3 Categories: “Foamy whipped cream in a CAN”),
Micro Finding?
- Nodes: Intestinal or Mesenteric
- CNS
- Heart valves
- Synovia
PRES: Older men
- Cardiac symptoms
- Adenopathy + Arthralgias
- Neuro symptoms:
- Fever
- Weight loss
FINDING:
- PAS-positive foamy macrophages
Celiac Sprue
Def’n, Locations (2), Ab, HLAs (2),
Pres (Epi + 1 Assoc), Micro Findings (CLUE + 2),
RX?
Autoimmune-mediated damage to S.I VILLI due to gluten exposure.
Distal Duodenum and/or Proximal Jejunum
Anti-Gliadin / Anti-Transglutaminase / Anti-Endomysial Antibodies
HLA-DQ2 + HLA-DQ8
THINK: “Shaina was diagnosed at 28.”
PRES: MC in ppl of Northern European descent
- Dermatitis Herpetiformis (due to IgA deposition at tips of dermal papillae)
FINDINGS:
- “Blunting / flattening” of villi
- Hyperplasia of crypts
- Lymphocytes in lamina propria
RX = Gluten-free diet
Lactose Intolerance
Def’n, Mech (2 steps), Pres, Dx?
Absence of brush border Lactase.
MECH:
Undigested lactose = osmotically active ->
UNABS lactose + water in GI tract lumen.
PRES = Osmotic Diarrhea
DX: Lactose Tolerance Test
Abeta-Lipoproteinemia
Def’n, Inher, Mech (3 steps), Pres (Epi + 3)?
Deficiency of apolipoproteins B-48 + B-100.
AR.
MECH:
Deficicency of apolipoproteins B-48 + B-100 ->
Inability to generate chylomicrons (B-48) + LDL/VLDL (B-100) ->
Fat accumulation in enterocytes = Malabsorption.
PRES: Early childhood
- Failure to thrive
- Neuro manifestations: Ataxia + Night Blindness
- Acanthosis
Zollinger-Ellison Sx
Def’n / 2 Locations, Pres (2)?
Gastrinoma of Duodenum or Pancreas.
PRES:
- High Gastrin
- Duodenal ulcerations
“Red currant jelly stools”
Seen In (2)?
SEEN IN:
- Intussusception (Infants)
- Acute Mesenteric Ischemia (Adults)
Intussusception
Def’n + Location, Mech, Causes, Pres (Epi + CLUE + 1)?
Intussusception / “telescoping” of Terminal Ileum into Cecum.
(Pulled forward by peristalsis)
** THINK: In word ‘intussusception’, i comes before c.
= Ileum into Cecum. **
MECH = Obstruction + Infarction.
CAUSES:
- Meckel’s Diverticulum
PRES: MC in children
- “Currant jelly” / bloody stools (due to compromised bl supply)
- Colicky ab pain
- ** Ab emergency in early childhood ***
Volvulus
Def’n, MC Locations (2, incl Epi of each), Mech, Causes?
Twisting of portion of colon around its mesentery.
(In parts of colon where there is redundant mesentery)
- Cecum (MC in young adults)
- Sigmoid Colon (MC in elderly)
MECH = Obstruction + Infarction
CAUSES:
- Meckel’s Diverticulum
Meckel’s Diverticulum
Etiology, Histo (2 types of epithelia), Chars (** “5 2s” **),
Pres (2 Epi + 5), DX?
ET = Persistence of vitelline duct
2 types of epithelia:
- Gastric mucosa (ectopic acid-secreting)
- Pancreatic
CHARS:
- 2 inches long
- 2 feet from ileocecal valve
- 2 types of epithelia
- 2 yrs of life
- 2% of pop
PRES: First 2 yrs of life. 2 % of pop.
- Obstruction near Terminal Ileum
- RLQ pain
- Melena
- Intussusception
- Volvulus
DX: Pertechnetate Study
Diverticulosis
Etiology, Causes (2), Pres (CLUE), Comp (2)?
Many diverticula -> diverticulosis. Very common (~50%) of people > 60 yrs.
CAUSES:
- FOCAL WEAKNESS in colon wall
- ↑intraluminal pressure
PRES:
- “PAINLESS rectal bleeding”
(Often asymptomatic or vaguely uncomfortable)
COMP:
- Diverticulitis
- Fistulas
Diverticulitis
Def’n, Pres (4), Comp (1 + CLUE), RX?
Infl of diverticula due to OBSTRUCTING FECAL MATERIAL.
PRES: ** “L-sided Appendicitis” **
- “Bright red” rectal bleeding
- LLQ pain
- Fever
- Leukocytosis
COMP:
- Perforation -> Peritonitis
- > Abscess formation
- > Stenosis - “Colovescial fistula” (fistula with bladder) -> “air or stool in urine”
RX: Antibiotics
Inflammatory Bowel Disease (IBD)
Def’n, 2 Subtypes,
Pres (3 Epi + 1), EXTRAintestinal Manifestations (5),
Comp (2), RX (1 in common)?
Chronic and relapsing infl of bowel.
- Crohn’s Dz
- Ulcerative Colitis.
PRES: Young women. MC in West.
MC among Caucasians + Eastern-European Jews.
- Recurrent bouts of ab pain + BLOODY DIARRHEA
- Apthous Ulcers (cankers)
- Erythema Nodosum
- Pyoderma Gangrenosum
- Uveitis
- Ankylosing Spondylitis
COMP:
- Malabsorption / Malnutrition
- CRC
RX: Infliximab
Crohn Disease
Etiology, Location, Mediation,
Gross Findings (3 CLUES + 2), Micro Finding,
Pres (2 Intestinal + 3 Extra-Intestinal),
Appearance of bowel on Ba Swallow (CLUE),
Comp (2), RX (3)?
Disordered response to intestinal bacteria.
ANY portion of GI tract, however MC in Terminal Ileum + Colon =
“Skip lesions” (alternating areas of normal colon + transmural infl).
Rectal SPARING.
Th1-mediated.
FINDINGS:
- “Cobblestone mucosa”
- “Creeping fat”
- Bowel wall thickening -> “String Sign” (due to strictures)
- TRANSMURAL infl
- Linear ulcers, fissures + fistulas
- Noncaseating granulomas + lymphoid aggregates
PRES:
- Diarrhea (bloody or non-bloody)
- RLQ pain (ileum)
- Vit B12 def -> Macrocytic Megaloblastic Anemia
- Kidney stones
- Migratory polyarthritis ** THINK: Skipping **
BA SWALLOW: “String Sign” (strictures = narrowing of lumen)
COMP:
- Stones: Ca Oxalate kidney stones + Gallstones
- Perianal dz
RX:
- Corticosteroids
- Immunomodulators: Azathioprine + Methotrexate
- Infliximab
Ulcerative Colitis
Etiology, Mech, Location, Mediation,
Gross Findings (CLUE + 2), Micro Finding,
Pres (Intestinal + Extra-Intestinal),
Appearance of bowel on Ba Swallow (CLUE),
Comp, RX (4, incl 1 procedure)?
Autoimmune.
MECH = Loss of haustra
Colon = CONTINUOUS lesions.
Rectal INVOLVEMENT.
Th2-mediated. ** THINK: 2 words **
FINDINGS:
- “Friable mucosal pseudopolyps”
- MUCOSAL + SUBMUCOSAL infl only
- Freely hanging mesentery
- Crypt abscesses + ulcers
PRES:
- BLOODY diarrhea
- Primary Sclerosing Cholangitis
BA SWALLOW: “Lead pipe” appearance of colon
COMP:
- Toxic Megacolon
RX:
- Sulfasalazine
- 6-MP
- Infliximab
- Colectomy
Ischemic Collitis
MC Location, Causes (MCC), Pres (Epi + 2)?
MC at Splenic Flexure (watershed area of SMA).
MCC = Atherosclerosis of SMA
PRES: Elderly
- Pain after eating -> Weight loss
- (In case of Infarction) -> Pain + Bloody Diarrhea
Necrotizing Enterocolitis
Def’n, Pres (Epi)?
Necrosis of colon MUCOSA. Possible perforation.
PRES: Neonates (MC in preemies due to↓immunity)
Colonic Polyps
Def’n, MC Location,
Subtypes (4, last 3 = benign / hamartomatous),
Pres (3 general ‘polyp symptoms’),
Screening (2)?
90% non-neoplastic
Raised protrusions of colonic mucosa protruding into gut lumen ->”sawtooth” appearance.
MC in LEFT Colon (rectosigmoid).
Can be tubular or villous.
- Adenomatouuus
- Hyperplastic
- Juvenile / Juvenile Polyposis Sx
- Peutz-Jeghers Sx
PRES: Often assymptomatic
- Lower GI bleed (due to polyps bleeding)
- SECRETORY diarrhea
- Partial obstruction
SCREENING:
- Colonoscopy -> Polyp removal + examination
- Fecal Occult Bl test
Gardner Sx
Def’n, Pres (CLUE + 2), Comp?
FAP+ Fibromatosis (retroperitoneal) + Osteomas (MC in Skull).
PRES:
- “↑# of teeth => impacted teeth”
- Multiple colonic polyps
- Osteomas in skull
COMP:
- Congenital hypertrophy of retina (due to osteomas in skull)
Adenomatous Polyps
Cause, Malignant RF (3)?
*Precancerous = precursor to CRC* CAUSE = glandular neoplastic prolif.
MALIGNANT RF:
- ** - Villous histology of polyp (↑=↑risk of malignancy) ***
- ↑size
- ↑epithelial dysplasia
Familial Adenomatous Polyposis (FAP)
Locations (2), Inher, Genetics, Pres, RX?
100% progress to CRC
Colon + Rectum.
AD.
AD mutation of APC gene (chr 5q). “Two-Hit Hypothesis”.
PRES = Thousands of polyps
RX = Prophylactic removal of colon + rectum
Turcot Sx
Def’n?
** THINK: Turban **
FAP+ Malignant CNS tumor.
Peutz-Jeghers Sx
Def’n, MC Location, Inher, Pres (CLUE)?
*Malignant risk* MULTIPLE Hamartomas (benign) throughout GI tract.
MC Location = Small Intestine.
AD.
PRES:
- “Hyperpigmented / freckle-like spots on lips, mouth, hands + genitalia”
Juvenile Polyps / Juvenile Polyposis Sx
Def’n (both), MC Location, MC Pres?
Juvenile Polyps = sporadic lesions in children
HNPCC / Lynch Sx
MC Side, Inher, Genetics, Pres (general)?
80% progress to CRC
MC side = RIGHT.
AD.
AD mutation of DNA Mismatch-Repair genes.
MC Side = Right
PRES = Arises “de novo” at relatively early age.
Colorectal Cancer
Def’n, MC Side,
Molecular Path (2 pathways + what each lead to),
RF (5), Pres (2 Epi), Appearance on Ba Swallow (CLUE),
Screening, DX (3), Comp (2)?
Carcinoma arising from colonic or rectal mucosa.
MC Side = LEFT.
- Microsatellite Instability Pathway (DNA Mismatch-Repair gene mut)-> Sporadic Cancer + HNPCC Sx
- Chr Instability Pathway (APC + b-Catenin mut. 85%) -> Sporadic Cancer
- ** Order of gene events: “A, K, 53” ***
RF:
- Tobacco use
- Lynch Sx / Juvenile Polyposis Sx / Peutz-Jeghers Sx
- IBD
- Large villous adenoma
- Strep bovis bacteremia
PRES: > 50 yrs. 25% have family history.
BA SWALLOW: “Apple core” lesion
SCREENING:
- Begins at 50 yrs with Fecal Occult Blood Testing + Endoscopy
DX:
- “Apple core” lesion on XR
- CEA tumor marker (monitoring of treatment response + recurrence)
- Iron-Deficiency Anemia in older adult = CRC until proven otherwise!
COMP: (Strep bovis colonization of gut)
- Subacute Endocarditis
- Bacteremia
Right / Ascending / Proximal Colon CRC
Chars (2), Pres (3)?
CHARS:
- Exophytic mass
- Grows as a “raised lesion”
PRES:
- Fecal Occult bleeding -> Iron-Deficiency Anemia
- Vague pain
- Weight loss
Left / Descending / Distal Colon CRC
Chars (2), Pres (2), Appearance on XR (CLUE)?
CHARS:
- Infiltrating mass
- Partial obstruction
PRES:
- Hematochezia +↓stool caliber
- LLQ colicky pain
XR: “Napkin ring” lesion
Acute Appendicitis
Mech (General + Children + Adults),
Pres (2 MC signs + 2 other signs + CLUE + Triad),
DDX (2), Comp (2)?
MECH: Obstruction of appendix
- Viral infection -> lymphoid hyperplasia (Children)
- Fecalith (Adults)
PRES:
- McBurney Sign + Rovsing Sign
- Obturator + Psoas signs
- “Initial diffuse periumbilical pain” -> “Pain localizes to McBurney pt”
- Fever + Nausea + Anorexia
DDX:
- Ectopic Pregnancy
- Diverticulitis (Elderly)
COMP:
- Rupture (-> Peritonitis)
- Abscess
Peritonitis
Pres (CLUE)?
PRES:
- “Rebound tenderness” upon ab palpation
McBurney Sign
Def’n, Seen In?
Severe RLQ pain + REBOUND TENDERNESS.
SEEN IN:
- Acute Appendicitis
Rovsing Sign
Def’n, Seen In?
Severe RLQ pain + PALPATION OF LLQ.
SEEN IN:
- Acute Appendicitis
Liver Disease
Enzyme↑(2)?
- AST
- LD1 + LD5
Angiodysplasia
MC Location, Mech (3 steps), Pres (Epi + 1), DX?
R Colon: Terminal Ileum + Ascending Colon + Cecum
(due to highest wall tension)
MECH:
Malformation of mucosal + submucosal CAPILLARY BEDS ->
Tortuous dilation -> Bleeding.
PRES: MC in Elderly
- Hematochezia (in case of rupture)
DX:
- Angiography
Fatty Liver Disease
Etiologies (2), Micro Finding (CLUE)?
ET: Alcoholic or Metabolic Sx
FINDINGS:
- Fatty infiltration of hepatocytes -> hepatocyte “ballooning”+ eventual necrosis
Liver Damage
Enzyme↑(2)?
- ALT
- LD4 + LD5
Hirchsprung’s Dz
Def’n + Locations (2), Mech (3 steps), Assoc,
Pres (4), DX (3), Comp, RX?
Congenital failure of GANGLION CELLS to descend into 2 plexuses:
Auerbach’s / Myenteric + Meissner’s / Submucosal plexus.
MECH:
Defective relaxation / peristalsis of SIGMOID COLON + RECTUM ->
Dilated portion of colon proximal to aganglionic segment ->
‘Transition Zone’.
ASSOC:
- Down’s Sx
PRES: ** Based on OBSTRUCTION **. Very early in life.
- Failure to pass meconium
- Ab distension
- Constipation
- Bilicus emesis
DX:
- Failure to pass meconium
- DRE: Empty rectal ampulla / vault
- Rectal Suction Biopsy: Lack of ganglion cells
COMP:
- Rupture
RX:
- Resection
Alcoholic Liver Disease
Micro Finding, Comp?
FINDINGS:
- Mallory bodies
COMP:
- Bilirubin Stones
Non-Alcoholic Fatty Liver Disease
Etiology, Assoc, Labs, Comp (2)?
ET: Metabolic Sx (Insulin Resistance)
ASSOC:
- Obesity
LABS:
- ALT > AST ** THINK: “L for Lipids” **
COMP:
- Hepatitis / Cirrhosis
- HCC
Hepatic Steatosis
Def’n?
Accumulation of fat (fat droplets) in hepatocytes ->
Heavy + greasy liver.
** May be REVERSIBLE with alcohol cessation **
Hepatitis B + C
Conseq?
CONSEQ:
- Nephrotic Sx
Alcoholic Hepatitis
Def’n, Mediator,
Pres, Micro Findings (CLUE + 1), Labs?
Chemical injury to hepatocytes from sustained long-term consumption of alcohol.
MED of damage = Acetaldehyde (metabolite of alcohol).
PRES:
- Painful hepatomegaly
FINDINGS:
- “Mallory Bodies”
- Swollen + necrotic hepatocytes with NEUTROPHIL infiltration
LABS:
- AST > ALT **THINK: “Make a toAST with alcohol.” **
Alcoholic Cirrhosis
Def’n, Macro Findings (CLUE + 1), Pres?
** FINAL + IRREVERSIBLE form of Alcoholic Liver Dz **
FINDINGS:
- Shrunken liver with “hobnail appearance”
- Sclerosis around central vein
PRES: Occurs in 10-20% of alcoholics
(Same pres as Chronic Liver Dz)
Cirrhotic Liver
Def’n, Chars (2 Histo), Causes (6),
Pres (2 general), Labs (4), Seen In (2),
Comp (3)?
END-STAGE liver damage.
CHARS: Destruction of normal liver architecture / parenchyma
- Diffuse bands of FIBROSIS (mediated by TGF-β from Stellate cells)
- REGENERATIVE NODULES of hepatocytes
CAUSES:
- Alcohol
- a1-antitrypsin def
- Fructose intolerance (aldolase B def)
- Viral Hep
- Hemochromatosis
- Biliary Dz
PRES:
- ↓detox
- Portal Htn
LABS:
- Ammonia↑
- Estrogen↑
- Albumin↓
- Clotting Factors↓
SEEN IN:
- Alcoholism
- Hepatitis B + C
COMP:
- Hepatocellular Carcinoma
- Cholesterol Stones
- 1ry Hyperaldosteronism
Cirrhosis #1
Def’n, Chars (2 Histo)?
END-STAGE liver damage.
CHARS: Destruction of normal liver architecture / parenchyma
- Diffuse bands of FIBROSIS (mediated by TGF-β from Stellate cells)
- REGENERATIVE NODULES of hepatocytes
Cirrhosis #2
Causes (6)?
CAUSES:
- Alcohol
- Fructose intolerance (aldolase B def)
- a1-antitrypsin def
- Viral Hep
- Hemochromatosis
- Biliary Dz
Cirrhosis #3
Pres (4), Labs (4)?
PRES:
- ↓Detox
- ↓Protein Synthesis (->↓Albumin + Clotting Factors)
- > Ankle Edema
- > Anemia / Bleeding tendency
- Portal Htn
- Jaundice
- > Scleral Icterus
- > Fetor Hepaticus
LABS:
- Ammonia↑(-> Mental status changes, Asterixis, Coma)
- Metabolic therefore reversible!*
- Estrogen↑(-> Gynecomastia, Testicular Atrophy, Palmar Erythema, Spider Angiomata)
- Albumin↓
- Clotting Factors↓
Portal Htn
Causes, Pres (7)?
CAUSES:
- Schistosoma (trematode/fluke) infection
PRES:
- Esophageal Varices
(Shunt: Backup of L gastric vein into the Esoph vein)
-> Hematemesis
-> Melena
- Peptic Ulcer
- Splenomegaly
- Ascites / Caput Medusae (Shunt)
- Internal Hemorrhoids (Shunt)
Portosystemic Shunts partially alleviate portal htn
Budd-Chiari Sx
Def’n, Causes (2), Pres (3)?
Liver INFARCTION due to Hepatic Vein destruction.
CAUSES:
- RHF
- Liver Cancer
PRES:
- Hepatomegaly
- Ascites
- Ab pain
Nutmeg Liver (Congestive Hepatopathy)
Causes (2), Mech, Assoc (3), Macro Finding (CLUE), Comp (2)?
CAUSES:
- RHF
- Budd-Chiari Sx
Liver CONGESTION (backup of blood into liver).
ASSOC:
- Hypercoaguable state
- Polycythemia Vera
- Pregnancy
FINDINGS:
- Liver appears mottled like a “nutmeg”
COMP:
- Cardiac Cirrhosis (due to centrilobular congestion + necrosis)
- HCC
a1-antitrypsin Deficiency
Mech, Genetics, Pres (Liver vs Lung)?
Misfolded gene product (protein) AGGREGATES in ER of hepatocytes.
Codominance.
PRES:
- Liver: Cirrhosis with “PAS-positive globules”
- Lungs: Panacinar Emphysema
(due to uninhibited elastase in alveoli -> ↓elastic tis)
Hepatitis
Micro Finding?
FINDING:
- Mallory Bodies
Viral / Toxic Hepatitis
Micro Finding?
FINDINGS:
- Councilman Bodies
Yellow Fever
Micro Finding?
FINDINGS:
- Councilman Bodies
Reye’s Sx
Mech, Assoc (2 Micro), Pres (CLUE + 5)?
Mitochondrial damage.
ASSOC:
- Influenza B
- VZV
PRES = “Child with viral illness who is given Aspirin”
- Vomiting
- Hepatomegaly
- Liver failure
- Encephalopathy
- Coma
- ** Often fatal ***
- ** Aspirin only recommended for children with KAWASAKI DZ ***
Hepatic Encephalopathy
Mech (3 steps), Etiologies (2), Pres (Spectrum), RX (3)?
MECH:
Cirrhosis -> Portosystemic Shunts ->↓NH3 metab
ET:
- ↑NH3 production (eg↑dietary protein, constipation, infection, GI bleed)
- ↓NH3 metab / removal (eg Renal Failure, Diuretics)
RX:
- Lactulose (↑NH4 production)
- Rifaximin (kills intestinal bacteria)
- Low-protein diet
Crigler-Naijar Sx (Congenital UNconjugated Hyperbillirubinemia)
Def’n / Mech, Pres (CLUE), RX (3)?
ABSENT UDP-glucuronyl transferase.
PRES = “Severe jaundice in NEONATE”
** Patients die within a few years **
RX:
- Plasmapheresis
- Phototherapy
- Phenobarbital (Type II only)
Dubin-Johnson Sx (Congenital Conjugated Hyperbilirubinemia)
Def’n (2 steps), Pres (CLUE)?
Def of BRB Canalicular Transport Protein ->
Hepatocytes unable to secrete conjugated BRB into bile.
PRES = “BLACK Liver”
Wilson Disease (Hepatolenticular degeneration)
Locations (3 MC + 2), Inher + Genetics,
Pres (Epi +1 Liver + 1 Heme + 4 Neuro),
Micro Finding (CLUE), Labs (2 CLUES: Blood + Urine),
Comp (2), RX?
- Liver
- Brain (esp Basal Ganglia)
- Cornea (K-F ring)
- Kidneys
- Joints
AR. Chr 13.
PRES: Childhood
- Fatty change / Hepatitis / Cirrhosis of liver
- Hemolytic Anemia
- Asterixis
- Chorea
- Tremor
- Parkinsonian symptoms (Asterixis, Dementia, Dyskinesia, Dysarthria)
FINDING = “Kayser-Fleischer” rings.
LABS:
- Blood: Ceruloplasmin↓
- Urine: Cu↑
COMP:
- HCC
- Fanconi Sx
RX:
- Penicillamine (chelator)
Hemochromatosis (Bronze Diabetes)
Def’n, Causes (2, incl 1 genetic),
Pres (Epi + Triad + 3 Other), Micro Finding, Labs (4 Fe Studies)
DX, Comp (3), RX (2)?
Excess body iron -> Hemosiderosis (iron deposition)
-> Hemochromatosis (dz caused by iron dep)
CAUSES:
- HFE mutation
- Multiple blood transfusions
PRES: Late Adulthood. “Bronze Diabetes”.
- ** Iron loss thr MENSES slows progression in women ***
1. Cirrhosis
2. DM
3. Skin pigmentation - Arrhythmias
- CHF
- Testicular Atrophy
FINDINGS:
- Brown hepatocytes
LABS:
- Iron↑
- Ferritin↑
- % Saturation↑
- TIBC ↓
DX = Liver Biopsy
COMP:
- HCC
- Cardiomyopathy
- CHF
RX:
- Repeated Phlebotomy
- Deferoxamine
1ry Hemochromatosis
Def’n, Inher, Genetics (2 possible mutations), HLA Assoc?
Defect in iron ABS.
AR.
Mutations on HFE gene:
- C282Y mutation
- H63D mutation
HLA-A3 assoc.
Jaundice
Def’n, Mech (2 options), Causes (3)?
Yellow skin and/or sclerae due to elevated BILIRUBIN (BRB).
BRB > 2.5 mg/dL in blood.
MECH:
- ↑BRB production
- ↓BRB metab
CAUSES:
- Hepatocyte injury
- Obstruction to bile flow
- Hemolysis
Obstructive Jaundice
Pres (1 + 2 Excretion-Related + 2 Skin-Related), Labs (3)?
PRES:
- Hepatosplenomegaly
- Dark urine
- Light stools
- Jaundice
- Pruritus
LABS:
- Conjugated BRB↑
- Cholesterol ↑
- Alkaline Phosphatase↑
Hemolytic Jaundice
Urine (2: BRB + Urobilinogen)?
URINE:
- BRB ABSENT = Acholuria (absence of bile pigments in urine)
- Urobilinogen ↑
“Painless jaundice”
Cancer of the pancreatic HEAD (obstructs bile duct)
Liver Cancer (Hepatic Adenoma + HCC)
Assoc (6), Path,
Pres (4), Labs (CLUE + 2),
DX (2 options), Comp?
ASSOC:
- a1-antitrypsin deficiency
- Cirrhosis
- Hemochromatosis
- Hepatitis B + C
- Wilson dz
- Aflatoxin (can be produced by Aspergillus species)
Spreads by HEMATOGENOUS dissemination.
PRES:
- Ascites
- Jaundice
- TENDER Hepatomegaly
- Anorexia
LABS:
- a-fetoprotein
- Polycythemia
- Hypoglycemia
DX:
- CT
- U/S
COMP:
- Budd-Chiari Sx
Hepatic Adenoma
Assoc (2), Course (2 options)?
** RARE **
ASSOC:
- Anabolic Steroids
- ↑ Estrogen (ie OCPs or Pregnancy)
COURSE:
- Regress spontaneously OR
- Rupture -> Intraperitoneal bleeding (↑risk during Pregnancy)
Hepatic Angiosarcoma
Def’n, Causes (3: “VAT”)?
Malignancy of Liver. ** Highly lethal **
CAUSES: Exposure to “VAT”:
- Vinyl Chloride (plastics, rubber)
- Arsenic (pesticides)
- Thorotrast (radioactive diagnostic agent)
Metastasis to Liver
MC Sources (4), Pres (CLUE + 1)?
MC SOURCES:
- Lung
- Breast
- Colon
- Pancreas
PRES:
- “Hepatomegaly with NODULAR free edge of liver”
- Multiple nodules in liver
Biliary Tract Disease
Locations w/in Biliary Tract (2), Pres, Labs, Comp?
LOCATIONS:
- INTRAhepatic bile ducts: 1ry + 2ry Biliary Cirrhosis
- INTRA + EXTRAhepatic bile ducts: 1ry Sclerosing Cholangitis
PRES = (Pres of Obstructive Jaundice)
LABS = (Pres of Obstructive Jaundice)
COMP:
- Cirrhosis
Biliary Atresia
Mech (2 steps), Pres (Epi + 1)?
Failure to form OR Destruction of Biliary Tree ->
Biliary OBSTRUCTION.
PRES: 1st 3 months
- Jaundice -> Cirrhosis
1ry Biliary Cirrhosis
Mech, Assoc, Micro Findings (2), Ab?
MECH: AUTOIMMUNE. Lymphocytic infiltrate + Granulomas.
ASSOC = Other Autoimmune conditions.
FINDINGS:
- Lymphocytic infiltrate
- Granulomas
AB:
- IgM
2ry Biliary Cirrhosis
Etiology, Mech, Causes (4)?
ET: EXTRAhepatic biliary OBSTRUCTION
MECH:
↑Pressure in INTRAhepatic ducts -> Injury / Fibrosis
-> Bile Stasis
CAUSES (of extrahepatic biliary obstruction):
- Biliary stricture
- Gallstones
- Chronic Pancreatitis
- Pancreatic Adenocarcinoma (Head of pancreas)
Cholangitis
Pres (Charcot’s Triad)?
PRES: Charcot’s Triad
- Fever
- Jaundice
- RUQ pain
Primary Sclerosing Cholangitis
Mech, Assoc, Macro Findings (2 steps / CLUES), Ab, Comp (2)?
MECH = Infl + Fibrosis.
ASSOC:
- Ulcerative Collitis
FINDINGS: (On ERCP)
- Concentric “onion skin” bile duct fibrosis ->
- Alternating strictures / dilations of bile ducts = “beading”
AB:
- IgM↑(Hypergammaglobulinemia)
COMP:
- 2ry Biliary Cirrhosis
- Cholangiocarcinoma
Ascending Cholangitis
Def’n (incl CB), RF, Pres (2), Comp?
BACTERIAL INFECTION (usually ascending) of bile ducts, usually with Enteric Gram-Negative bacteria.
RF:
- Bile Duct Stones
PRES:
- Jaundice
- Ab pain
COMP:
- Sepsis
Cholangiocarcinoma
Assoc (Micro)?
ASSOC:
- Clonorchis sinensis (trematode) infection
Courvoisier Sign
Mech, Pres (2)?
Distal obstruction of biliary tree.
PRES:
- Obstructive Jaundice
- Gallbladder distended, palpable, NON-tender
Cholelithiasis / Gallstones #1
Causes (3), RF (6: “4 Fs” + 2),
DX (2: Phys Exam + U/S CLUE), RX?
CAUSES:
- ↓Bile Salts (b/c bile salts increase solubility)
- ↓Phospholipids (ie Lecithin)
- Gallbladder stasis
RF: “4 Fs”. ** Estrogen **
- Female
- Forty
- Fertile
- Fat
- Advanced age
- Cirrhosis
DX:
- Phys Exam: Murphy’s Sign
- U/S: “Air in biliary tree” ONLY in case of fistula or gallstone ileus
RX:
- Cholecystectomy ONLY if symptomatic
Cholelithiasis / Gallstones #2
Comp (6)?
COMP:
- Cholecystitis
- Ascending Cholangitis
- Acute Pancreatitis
- Biliary Colic
- Bile Stasis
- Fistula b/w Gallbladder + S.I / Gallstone Ileus
Cholesterol Gallstones
Appearance, Assoc (8)?
Yellow / radioLUCENT with opacities (due to calcifications).
ASSOC:
- Native American
- Multiparity
- Obesity
- Rapid weight loss
- Crohn’s
- Cystic Fibrosis
- Clofibrate
- Estrogens
Bilirubin / Pigment Gallstones
Appearance, Assoc (2: Micro + 1)?
RadiOPAQUE.
** BROWN = Infection. BLACK = Hemolysis. **
ASSOC:
- Biliary infection (E coli, Ascaris lumbricoides, Clonorchis sinensis)
- Chronic Hemolysis
Pancreatic Disease
Enzymes↑(3)?
- Amylase
- Elastase-1
- Lipase
Pancreatic Insufficiency
Causes (3), Pres (2), DX?
CAUSES:
- Cystic Fibrosis
- Pancreatitis
- Cancer (Obstructing)
PRES: MALABSORPTION with:
- Fat-Soluble Vitamin def
- Steatorrhea
DX: D-Xylose Abs Test
Acute Pancreatitis
Mech (3 steps), Path (incl 2 types of Necrosis),
Causes (10: “GET SMASHED”),
Pres (3), Labs (3),
Comp (6)?
MECH:
Premature activation of Trypsin ->
Activation of other panc enzymes ->
AUTODIGESTION of pancreas by panc enzymes.
PATH: Infl + Hem of pancreas:
- Liquefactive Hemorrhagic Necrosis of pancreas
- Fat Necrosis of peripancreatic fat
CAUSES:
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune dz
- Scorpion sting
- Hypercalcemia / Hypertriglyceridemia (> 1000)
- ERCP
- Drugs (Sulfa drugs)
PRES:
- Epigastric ab pain radiating to BACK
- Periumbilical / Flank hemorrhage (due to necrosis spreading)
- Anorexia + Nausea + Vomiting
LABS:
- Amylase↑
- Lipase↑ * More specific than amylase for pancreatic DAMAGE *
- Ca↓(Ca consumed during saponification in fat necrosis)
COMP:
- Pancreatic Abscess
- Pancreatic Pseudocyst
- 1ry Hyperparathyroidism
- ARDS
- DIC
- Infection / Shock / Organ failure
Chronic Pancreatitis
Causes (3, incl 2 specific to Adults / Kids), Path (4),
Labs (generalization), Imaging (CLUE),
Comp (4)?
CAUSES:
- Alcohol (Adults)
- Cystic Fibrosis (Kids)
- Recurrent Acute Pancreatitis
PATH: Damage to pancreatic parenchyma:
- Chronic infl
- Calcification
- Fibrosis
- Atrophy
LABS: * Amylase + Lipase LESS elevated than in Acute Pancreatitis *
IMAGING: Imaging with Contrast:
- “Chain of lakes” pattern
COMP:
- Pancreatic Insuf
- Pancreatic Adenocarcinoma
- DM
- 2ry Biliary Cirrhosis
Pancreatic Adenocarcinoma
Def’n, MC Location, Markers (2), RF (5),
Pres (3),
RX (3 Therapies), Prog?
VERY AGGRESSIVE tumor arising from pancreatic ducts.
MC LOCATION = Pancreatic Head.
MARKERS:
- CA 19-9
- CEA (however less specific)
RF:
- Male
- African-American or Jewish
- Age > 50 yrs
- Tobacco
- Chronic Pancreatitis
PRES:
- (Pres of Pancreatitis)
- Courvoisier’s Sign
- Trousseau’s Sx
RX:
- Whipple Procedure
- Chemotherapy
- Radiation therapy
PROG = 6 months or less.
Splenectomy / Nonfunctional Spleen AUTOSplenectomy
Def’n + MCC, Path, Pres (Epi), Micro Finding (CLUE)?
Fibrosis + shrinkage of spleen.
MCC = Sickle Cell Anemia.
↑risk of infection with encapsulated organisms.
PRES = functional splenic dysfunction in early childhood
FINDING = Howell-Jolly bodies
Curling Ulcer
Cause, Seen In?
** “Burned by the curling iron” **
CAUSE = Severe burns
(Hypovolemia -> Gastric Ischemia -> SLOUGHING of gastric mucosa)
SEEN IN: Acute Gastritis
Cushing Ulcer
Cause, Seen In?
** “Always cushion the brain” **
CAUSE = Brain Injury /↑ICP
(↑Vagal stim ->↑Ach ->↑digestion / H production)
SEEN IN: Acute Gastritis
Virchow Node
Cause, Pres?
CAUSE = Abdominal metastasis
PRES = enlarged + hard left supraclavicular node
VIPoma
Def’n, Pres, Labs (2 ions)?
Non-α + non-β islet cell pancreatic tumor that secretes VIP.
PRES = Copious watery diarrhea
LABS:
- K↓
- Cl↓
Carcinoid Tumor / Carcinoid Sx
Def’n, MC Locations (3: “AIR”),
Triggers (2), Pres (4 Chars of Carc Sx), Micro Findings, Urine,
RX?
Low-grade malignancy
Tumor of neuroendocrine cells of GI tract, esp metastatic S.I tumors.
MC Locations (although can arise anywhere along gut):
- Appendix
- Ileum
- Rectum
TRIGGERS: (stim Serotonin release from tumor)
- Emotional stress
- Alcohol
PRES: Carcinoid Sx: carcinoid tumor w mets to LIVER.
(Tumor secretes high levels of Serotonin)
- Flushing
- Wheezing
- Diarrhea
- Carcinoid Heart Dz / R-sided heart murmurs
FINDINGS:
- Dense Core Bodies (tumor grows as a submucosal POLYP-like nodule)
URINE:
- 5-HIAA↑
RX:
- Octreotide
Meconium Ileus (Newborn)
Causes?
CAUSES:
- Cystic Fibrosis
“Megaesophagus + Megacolon”
Chagas Dz (Trypanosoma cruzi, Reduviid bug, South America)
Fitz-Hugh-Curtis Sx
Def’n, Cause / Assoc, General Pres?
Infection of liver capsule.
CAUSE / ASSOC:
- PID
GEN PRES: “Violin string” adhesions of peritoneum to liver
