GI 4 highlights Flashcards by Morgan Evans

Cholelithiasis/ gallstones:
1) What sex is it more common in?
2) What are some important risk factors?

1) Female predominance
2) Obesity; 4F’s- fat, female, forty, fertile

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High fiber diet & statin use __________ risk of cholecystectomy

reduce

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Most stones are made from __________ and in the gallbladder

Cholesterol

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List the 3 steps of lithogenesis

1) Supersat. of bile
2) Destabilization of bile
3) Stasis of bile in gallbladder

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What is the most common symptom of cholelithiasis/ gallstones?

Asymptomatic (majority)

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Cholelithiasis/ gallstones: What is almost always the first Sx in symptomatic pts?

Pain

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Give 2 important details of cholelithiasis/ gallstone pain

RUQ; steady/constant

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Where does cholelithiasis/ gallstone pain typically radiate to? (3 places)

Interscapular area, right scapula, or Right shoulder

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Cholelithiasis/ gallstones: How long does the pain usually persist? When does it often occur?

Persisting 15 min-4 hours; nocturnal awakening common

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Cholelithiasis/ gallstones: What does the pain result from?

Obstruction of cystic duct or CBD by stone/s; visceral distention

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What is the imaging method of choice for cholelithiasis/ gallstones?

U/S of RUQ

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U/S RUQ has a low-moderate sensitivity for _______ stones

CBD

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What imaging is not useful in screening for gallstones?

MRI (and HIDA scans too)

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Cholelithiasis/ gallstones:
What is useful for visualizing bile & pancreatic ducts and is useful as diagnostic alternative to ERCP?

MRCP (magnetic resonance cholangiopancreatography)

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ERCP (Endoscopic Retrograde CholangioPancreatography) is not useful for detection of gallstones in the _________________

gallbladder

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Method of choice for the detection of bile duct stones is what?

ERCP

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What is a nuclear med test that looks at function of the gb?

HIDA (Hepatic IminoDiacetic Acid) cholescintigraphy (can add CCK)

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HIDA scan: When given an injection of CCK to ____________ the gallbladder, MAY reproduce GB symptoms

contract

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> 90% of cases of what condition are caused by gallstones in cystic duct?

Acute cholecystitis

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What is the main Sx of Acute cholecystitis?

Sudden onset RUQ or epigastric pain
[gradually subsides over 12-18 hours]

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List 2 important clinical features of acute cholecystitis

1) RUQ tenderness & often + Murphy sign
2) Hyperbilirubinemia

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What does jaundice in cases of acute cholecystitis suggest when it’s persistent or severe?

Choledocholithiasis

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Standard method of Tx for symptomatic gallstones is what?

Laparoscopic cholecystectomy

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What is the gold standard for management of acute calculous cholecystitis?

Cholecystectomy

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**Choledocholithiasis & Cholangitis:** Where do most originate? Where else may they form?

Most originate in gallbladder; may form in bile duct after cholecystectomy

**Choledocholithiasis & Cholangitis:** What are the key Sx?

1) Frequent, recurring attacks RUQ pain, severe, lasting hours 2) **Chills & fever with severe pain** 3) H/o jaundice with episodes of pain

Chills & fever with severe pain is a key Sx for what conditions?

Choledocholithiasis & Cholangitis

Differentiate choledocholithiasis and cholangitis

Cholangitis is an infection

Choledocholithiasis & Cholangitis: List some important clinical features

1) (ALT, AST) > 1000 units/L 2) Elevated serum bilirubin + ALP 3) Leukocytosis/ fever if acute cholangitis 4) Charcot’s Triad (indicates obstruction); Reynold’s Pentad

What is Charcot’s Triad?

RUQ pain, fever/chills and jaundice

What is Reynold's pentad (aka Charcot's triad but worse)

RUQ pain, fever/chills, jaundice, & AMS/ hypotension

Cholangitis: 1) List some extrinsic etiologies 2) List some intrinsic etiologies

1) Extrinsic: Pancreatitis, cystic duct stone, duodenal diverticulum, tumor in gb, CBD, or pancreas 2) Intrinsic: blood clots, parasites

Cholangitis: What is an important lab finding?

Cholestatic pattern of liver tests (elevated ALP & bilirubin)

True or false: Evidence of cholestasis is a diagnostic criteria that a pt must have to be diagnosed with cholangitis

True

Cholangitis: What do you need to observe pts for?

Organ dysfunction & shock

Cholangitis: List the most important aspects of Tx

1) IV abx 2) Biliary drainage -Procedure of choice: Endoscopic sphincterotomy (ERCP) with stone extraction and/or stent insertion

What is the procedure of choice for cholangitis?

Endoscopic sphincterotomy (ERCP) with stone extraction and/or stent insertion

Choledocholithiasis & Cholangitis: When is ERCP with sphincterotomy & stone extraction the procedure of choice?

If a high likelihood that obstruction caused by stone. Or ERCP with stent placement if caused by mass.

__________ disease is a small bowel disorder characterized by mucosal inflammation, **villous atrophy**

Celiac

Celiac is diagnosed by endoscopic biopsies of what? What else needs to be done to Dx?

Small bowel biopsy + serum tissue transglutaminase (tTG)-IgA and genetic testing

Extraintestinal signs/symptoms suggestive of celiac disease include what?

1) Dermatitis herpetiformis 2) Recurrent fetal loss 3) Reduced fertility 4) Persistent aphthous stomatitis 5) Cerebellar ataxia

Chronic or recurrent diarrhea or constipation, malabsorption, unexpected weight loss, abdominal pain, distension, or bloating are all GI Sx of what condition?

Celiac

Dermatitis herpatiformis is linked to what condition?

Celiac

1) When should you test for gluten intolerance? 2) Once Dx is confirmed, what is an important part of mgmt?

1) Test before eliminating gluten (false negative tests) 2) Involve dietician

What are 2 kinds of lactose malabsorption?

Lactase deficiency and lactose intolerance

Differentiate lactase deficiency vs lactose intolerance

1) **Lactase deficiency:** the intestinal brush border (villa) lactase enzyme activity is lower than that of normal individuals 2) **Lactose intolerance:** clinical syndrome in which ingestion of lactose or lactose-containing food (milk, milk products) causes symptoms such as abdominal cramping, bloating, flatulence, pain and diarrhea

Prevalence of what absorption issue increases with age?

Lactose malabsorption

What is a big part of lactose malabsorption pathogenesis?

Bacteria producing gas [via fermentation]

True or false: Ovarian cancer mimics IBS

True

Lactose malabsorption Sx severity depends on what 2 things?

Lactase deficiency & amount of ingested lactose

Lactose malabsorption: list some mild to moderate Sx

Bloating, abdominal cramps, & flatulence; diarrhea

Isolated lactase deficiency does not result in signs of _____________ or ______________.

malabsorption; weight loss

Most widely available test for diagnosis of lactose malabsorption is a ___________ breath test

hydrogen

What is the goal of lactose malabsorption Tx?

Achieve patient comfort

Lactose malabsorption: 1) What is an OTC Tx? 2) What Tx may increase risk of osteoporosis?

1) Lactase enzyme replacement 2) Restriction or elimination of milk products

True or false: Lactose is mostly a sugar

True

Define bacterial overgrowth

Colonic bacteria are in excess in the small intestine

What are 2 main Sx of bacterial overgrowth?

Diarrhea & increased flatulence

List some protective mechanisms against bacterial overgrowth

1) Gastric acid & bile 2) Proteolytic enzyme digestion, therefore, chronic pancreatitis is a known contributor 3) IC valve & antegrade motility 4) Secretory IgA (protects mucous membranes)

What is a noninvasive way to test for bacterial overgrowth (SIBO)?

Breath hydrogen & methane tests

What is the main Tx for bacterial overgrowth (SIBO)?

Empiric PO antibiotic x 1-2 weeks: **Rifaximin (xifaxan) 1 PO TID for 14 days**

What are 3 synthetic markers of hepatic function?

PT/INR, PLT, & albumin

On exam: If a pt has isolated thrombocytopenia, what is your main differential?

Cirrhosis

Markers of liver disease: What condition will cause isolated mild hyperbilirubinemia that increases with fasting?

Gilbert’s syndrome

What condition is marked by an elevated bilirubin level (nl <1.0) with normal serum aminotransferases and alkaline phosphatase?

Isolated hyperbilirubinemia

ALT & AST values >25xULN primarily seen in ___________________ diseases

hepatocellular

**AST to ALT ratio of >2:1** suggests ______________ liver disease (supported with elevated GGT)

alcoholic

Typical AST to ALT patterns of liver disease: Acute viral hepatitis or toxin-related hepatitis with jaundice = AST & ALT >_____x ULN

>25x

Name one condition that can cause ischemic hepatitis (has AST and ALT >50x ULN)

Shock liver

Acute liver failure is indicated by what test?

INR >1.5

1) AST/ALT >5,000 U/mL usually due to what? 2) Pts with acute liver failure freq. have what?

1) Ischemic or drug-inducted hepatitis 2) Acute hepatitis

Most common precursor of cirrhosis in U.S is what?

Alcoholic hepatitis

What are 2 key parts of managing alcoholic liver disease?

1) Abstinence from alcohol is ESSENTIAL 2) Need vaccination for hepatitis A & B

Most common cause of acute liver failure in U.S. is what?

Drug-induced liver injury (DILI)

What are the 2 most common drug implicated in DILI in U.S.?

Acetaminophen (then antibiotics)

Describe DILI classification by type of hepatic injury (clinical presentation)

1) Hepatocellular injury (hepatitis) 2) Cholestatic injury (cholestasis)

Differentiate acute and chronic DILI

1) Acute DILI: liver tests abnormal < 3 months 2) Chronic DILI: liver tests abnormal > 3 months

DILI: Which kind has disproportionate elevation ALT & AST compared with ALP?

Hepatocellular injury (hepatitis)

DILI: Which kind has disproportionate elevation of ALP compared with ALT & AST, and + Sr bilirubin elevation?

Cholestatic injury (cholestasis)

What are 3 Pathogenesis/mechanism of hepatotoxicity of DILI?

1) Direct 2) Idiosyncratic (most severe cases) 3) Indirect

What are 2 Sx of a severe case of DILI?

Coagulopathy, hepatic encephalopathy (indicating acute liver failure)

What are 2 key parts of DILI management?

1) Withdrawal of offending drug 2) Serial biochemical measurements until liver tests normalize

DILI management: When should you consult hepatology and/or GI?

If concern for acute liver failure, signs of chronic liver disease, or if diagnosis uncertain after eval

Most common cause of acute liver failure (ALF) in U.S. is what?

Acetaminophen hepatotoxicity

Unintentional acetaminophen OD: _____% also taking APAP/opioid combo

63%

Stage I symptoms resolve, appear to improve during what stage of acetaminophen management

Stage II (24 to 72 hours)

Acetaminophen hepatotoxicity: Death usually occurs in what stage, usually from multi-system organ failure?

Stage III

Stage IV (four days to two weeks) of APAP toxicity: 1) How long may it take Sx and labs to resolve? 2) Is chronic hepatic dysfunction is a sequela of acetaminophen poisoning?

1) Several weeks 2) No; recovery is complete

APAP toxicity 1) Serum acetaminophen concentration should be measured in _________ patient suspected of an intentional or unintentional overdose 2) Serum concentration should also be obtained _________ hours following the time of acute ingestion or presentation

1) every 2) four hours

Acetaminophen hepatotoxicity: **True or false:** Undetectable initial concentration must not be misinterpreted to mean that hepatotoxicity is not present.

True

Repeat acetaminophen concentration should be measured at __________ hours.

four

What is the antidote for acetaminophen toxicity?

N-acetylcysteine (NAC)

List the 5 indications for NAC (starred slide)

1) Sr APAP concentration at >4 hrs above nomogram treatment line 2) Suspect single ingestion >150 mg/kg (7.5 gm total dose regardless of weight) with no Sr APAP conc. within 8 hrs 3) Unknown time of ingestion & Sr APAP conc. >10 mcg/mL 4) H/o any APAP ingestion PLUS any evidence of liver injury 5) Delayed presentation (>24hrs) with evidence of liver injury & h/o excessive APAP ingestion

N-acetylcysteine for APAP overdose: What is the most common protocol?

20-hour IV protocol (most common)