GI Flashcards
1
Q
Parts of GI sxs and organs that fall into them
- foregut
- midgut
- hindgut
A
- esophagus to upper duodenum
- lower duodenum to proximal 2/3 transverse colon
- distal 1/4 transverse colon to anal canal above pectinate line
2
Q
Ventral wall defects
- gastroschisis: what is it, genetics
- omphalocele:
- congenital umbiical hernia: what is it
A
- extrusion of abdominal contents through abdominal folds w/o surrounding peritoneum; not associated with chromosomal defects
- failure of lateral walls to migrate to umbilical ring -> midline herniation of abdominal contents into umbilical cord; surrounded by peritoneum, associated with trisomy 13 and 18
- failure of umbilical ring to close after physio herniation of intestines, small defects close spontaneously
3
Q
Traheoesophageal anomalies
- esophageal atresia
- tracheoesophageal fistula: distal vs pure; sxs
- most common
- DX
A
- the esophagus ends in blind sac
- trachea attaches to esophagus; distal will have prox esophageal atresia with distal esophagus attaching to trachea; allows air to enter stomach
- esophageal atresia w/ distal tracheoesophageal fistula
- unable to pass NG tube into stomach
4
Q
Intestinal atresia
- duodenal: what is it, xray, associated w/
- jejunal: what is it, sequalae, xray
A
- failure to recanilize, double bubble, Downs
- disruption of mesenteric vessels causing necrosis of fetal intestines -> bowel becomes discontinuous of assumes a spiral configuration; x-rays show dilated loops of small bowel w/ air-fluid levels
5
Q
Hypertrophic pyloric stenosis
- what is it
- epi
- sxs
- sequelae
- US
- Tx
A
- stenosis of pyloric valve and so stomach contents unable to enter into intestine easily
- most common gastric outlet obstruction
- palpable olive shaped mass in epigastric region, peristaltic wave, nonbilious projectile vomiting
- hypokalemic, hypochloremic met alk
- thickened and lengthened pylorus; surgery
6
Q
Pancreas embryology
- ventral bud
- dorsal bud
- annular
- divisum
A
- uncinate and main pancreatic duct
- body, tail, accessory pancreatic duct
- abnormal rotation of ventral bud forms a ring of pancreas that encircle second part of duodenum -> duodenal narrowing and vomiting
- ventral and dorsal parts fail to fuse at 8 wks, common, mostly asymptomatic
7
Q
spleen embryology
- comes from
- blood supply
A
- mesentary of stomach
- foregut supply
8
Q
Retroperitoneal strx
- SADPUCKER
A
- suprarenal glands, aorta/IVC, duodenum (2-4), pancreas (except tail), ureter, colon (D and A), Kindeys, Esophagus, Rectum
9
Q
GI ligaments
- Falciform: connects; contains
- Hepatoduodenal
- Gastrohepatic
- Gastrocolic
- Gastrosplenic
- Splenorenal
A
- liver to ant abdominal wall; fetal umbilical vein
- liver to duodenum; proper hepatic a, portal v, common bile duct
- liver to lesser curve of stomach; gastric vessels
- greater curvature and transverse colon, gastroepiploic a
- greater curvature and spleen; short gastric
- spleen to post abd wall, splenic artery and vein
10
Q
Digestive Tract Anatomy
- mucosa
- submucosa
- muscularis externa
- serosa/ adventitia
- ulcers vs erosions
A
- epi, lamina propria, muscularis mucosa
- submucousal glands and nerve plexus
- inner circular layer, myenteric nerve plexus, outer longitudinal layer
- intraperitoneal vs retroperitoneal
- ulcers can go into submucosa and erosions are only in the mucosa
11
Q
Digestive Histo
- esophagus
- stomach
- duodenum
- jejunum
- ileum
- colon
A
- nonkeratinized stratified squamous epi, upper 1/3 striated muscle, lower 2/3 is smooth
- gastric glands
- villi and micro villi, brunner glands (secrete HCO3), crypts of Lieberkuhn (stem cells that replace enterocytes/goblet cells
- villi, crypts of lieberkuhn
- peyer patches, crypts of lieberkuhn, largest number of goblet cells
- crypts of lieberkuhn w/ abundant goblet cells and no villi
12
Q
Abdominal Aorta and branches
- T12
- L1
- L2
- L3
- L4
- L5
A
- inferior phrenic -> superior renal, middle suprarenal, and celiac
- SMA, renal -> inferior suprarenal
- Gonadal
- IMA
- aorta bi4cates
- median sacral, common iliacs
13
Q
GI blood supply and innervation
- Foregut
- Midgut
- Hindgut
A
- celiac, vagus, T12/L1
- SMA, vagus, L1
- IMA, pelvic, L3
14
Q
Celiac Trunk branches
- supplies spleen
- supplies stomach
- supplies liver
- supplies duodenum
- extra
A
- splenic artery
- left gastric, splenic -> short gastric and left epiploic; common hepatic -> right gastric and gastroduodenal -> right epiploic
- common hepatic -> proper hepatic
- common hepatic -> gastroduodenal -> ant/post superior pancreaticoduodenal
- esophageal
15
Q
Varices/ anastamoses
- esophagus
- umbilicus
- rectum
- tx
A
- left gastric and azygous
- paraumbilical and small epigastric v
- superior rectal and inferior rectal
- transjugular intrahepatic portosystemic shunt between portal v and hepatic v
16
Q
Pectinate Line
- internal hemorrhoid
- external hemorrhoid
- anal fissure
A
- receive visceral innervation -> not painful
- receive somatic innervation -> painful
- tear in anal mucosa below pectinate line
17
Q
Liver tissue architecture
- main architecture
- apical surfaces
- basolateral
- kuppfer cells
- stellate cells
A
- hexagonal lobules surrounding central v
- face bile canaliculi
- face sinusoids
- specialized macrophages of the liver in sinusoids
- produce vitamin A, but when activated will produce ECM
18
Q
Zones of the liver
- I: fxn, blood supply, infections
- II: affected by
- III: blood supply, function
A
- ingested toxins, most oxygenated, first affected by hepatitis
- affected by yellow fever
- least amount of blood -> 1st affected by ischemia, highest [ ] of cyctochrome p450, most sensative to metabolic toxins, site of EtOH hepatitis
19
Q
Biliary Strx
- duct system
- how does it empty
A
- cystic duct (from gallbladder) + common hepatic duct (from liver) -> common bile duct
- combines with the main pancreatic duct forming the ampulla of vater where the bile and pancreatic exocrine secretions are released into the duodenum
20
Q
Spermatic Cord and abdomen
- Transversalis facia
- Internal oblique
- External oblique
A
- internal spermatic fascia
- cremasteric muscle and fascia
- external spermatic fascia
21
Q
Muscles layers of abdomen
A
- sponeurosis of external obliqe, external oblique, internal oblique, transversus abdominus, transversalis fascia, subcutaneous tissue, peritoneum of GI organs
22
Q
Diaphragmatic hernia
- what is it
- cause
- most common
- sliding vs paraesophageal
A
- abdominal strx enter the thorax
- congenital defect or trauma
- commonly occurs on left side because of protection on right side from liver
- hiatal hernia
- gastroesophageal junction displaced upward as gastric cardia slide into hiatus vs gastroesophageal junction is normal but fundus protrudes into thorax
23
Q
Hernias
- direct inguinal: position to inferior epigastric vessels, which rings does it pass though, covered by
- indirect inguinal: position to inferior epigastric vessels, which rings does it pass though, caused by
- femoral: where does it protrude,
A
- protrudes through the inguinal triangle, medial to inferior epigastric vessels, only through external inguinal ring, covered by external spermatic fascia, acquired weakness of transvesalis fascia
- goes through deep and superficial inguinal rings and into the scrotum, lateral to inferior epigastric vessels, failure of processes vaginal to close
- protrudes below inguinal ligament through femoral canal below and lateral to pubic tubercle
24
Q
Gastrin
- source
- action
- reg
- effect with PPI, H yplori and ZE syndrome
A
- g cells in the antrum of stomach and duodenum
- increase gastric H+ secretion,growth of gastric mucosa and gastric motility
- increased by stomach distention, alkalinization, AA/peptides, vagal stimulation; decreased by PH lower than 1.5
- increased with PPI use, atrophic gastritis bc of H pylori and in zollinger ellison syndrome
25
Somatostatin
- source
- action
- reg
- D cells
- decrease gastric acid and pepsinogen secretion, pancreatic and small intestine secretion, gall bladder contraction and insulin/glucagon release
- increased by acid and decrease by vagal stimulation
26
CCK
- source
- action
- reg
- how does it exert effects on pancreas?
- I cells (duodenum and jejunum)
- Increase pancreatic secretion, gllabladder contraction, relaxation of sphincter of Oddi and decrease gastric emptying
- increased by fatty acids and AA
- neural muscarinic pathways
27
Secretin
- source
- action
- reg
- S cells (duodenum)
- increase pancreatic HCO3 and bile secretion, decrease gastric acid secretion
- increased by acid and FA in lumen of duodenum
28
glucose dependent insulinotropic peptide
- source
- action
- reg
- importance with glucose administration
- K cells (duodenum and jejunum)
- exo: decrease gastric H+ secretion; end: increase insulin release
- increased by fatty acid. AA, and oral glucose
- oral glucose is better than IV because it stimulates release of glucose dependent ....
29
motilin
- source
- action
- reg
- agonists
- small intestine
- produces migrating motor complexes
- increased in fasting state
- stimulate intestinal peristalsis
30
VIP
- source
- action
- reg
- VIPOMA
- parasympathetic ganglia in sphincters, gallbladder, small intestine
- increase intestinal water and electrolyte secretion and relaxation of intestinal SM and sphincters
- increase by distention and vagal stimulation, decrease by adrenergic input
- tumor that secretes VIP -> causes watery diarrhea, hypokalemia and achlorhydria
31
Ghrelin
- source
- action
- reg
- effects with Prader-Willi vs gastric bypass
- stomach
- increases appetite
- increased in fasting state and decreased by food
- increased in Prader Willi vs decreased with gastric bypass
32
Intrinsic Factor
- source
- action
- what happens with destruction of source
- Parietal cells
- Vit B 12 binding protein needed in order to absorb Vit B 12
- pernicious anemia
33
Gastric acid
- source
- action
- reg
- parietal cells
- decrease stomach pH
- increased by histamine, vagal stimulation, and gastrin
- decreased by somatostatin, GIP, prostaglandin and secretin
34
Pepsin
- source
- action
- reg
- activation
- chief cells
- protein digestion
- increased by vagal stimulation and local acid
- must be converted from pepsinogen to pepsin by H+ in order to be active
35
Bicarb
- source
- action
- reg
- how does it get out into lumen
- mucousal cells and brunner glands
- neutralizes acid
- increase by pancreatic and biliary secretions with secretin
- trapped in mucus that covers gastric epi
36
Pancreatic secretions
- type of fluid
- differences w/ flow
- alpha amylase
- lipase
- protease
- tryspinogen
- isotonic
- low -> high in Cl, high -> high in HCO3
- starch digestion
- fat digestion
- protein digestion; trypsin, chymotrypsin, elastase and carboxypeptidase
- converted to trypsin by brush border enzyme enteropeptidase -> and activates other proenzymes
37
Carb absorption
- form of sugar into enterocyte
- SGLT1
- GLUT5
- GLUT2
- D-xylose absorption test
- only monosaccharide
- needs Na, for glucose and galactose
- for fructose
- transport glucose, galactose, and fructose into blood
- simple sugar that requires intact mmucosa for absorption but does not need digestive enzymes
38
Vitamin absorption
- iron
- folate
- Vit B12
- Fe 2+ in duodenum
- absorbed in small intestine
- absorbed in terminal ileum w/ bile salts and needs intrinsic factor
39
Peyer patches
- what is it
- M cells
- B cell stimulation
- Plasma cells
- IgA
- lymph tissue in lamina propria and submucosa of ileum
- sample and present antigens to immune cells
- in the germinal cells of peyer patches class switch to secrete IgA
- Located in lamina propria and secrete IgA
- recieves protective secretory component and then transported across the epithelium to gyt to deal with intraluminal antigen
40
Bile
- composed of
- function (3)
- where is it secreted
- bile salts, phospholipids, cholesterol, bili, water, and ions
- digestion and absorption of lipids and fat soluble vitamins. anitmicrobial activity by disrupting their membranes and primary way for body to get rid of excess cholesterol
- secreted in distal ileum to help with fat absorption
41
Bilirubin Pathway
- RBC -> heme -> unconjugated bili + albumin -> to liver, complex + UDP glucouronysl transferase -> conjugated bili -> to gut -> gut bacteria breaks it down to urobilinogen -> can be excreted into feces, to kidney to color urine, or back to liver to make more bili
42
Sialolithiasis
- what is it
- where
- presentation
- pathogen
- TX
- sialadenitis
- stones in the salivary gland duct
- parotid, submandibular, sublingual
- recurrent pre/periparandial pain and swelling in affected gland
- dehydration or trauma
- tx w/ NSAIDs, gland massage, warm compress, sour candies
- inflammation of salivary gland due to obstruction, infection, or immune mediated mechanisms
43
Salivary gland tumor
- which gland
- which are malignant
- sxs
- pleomorphic adenoma: epi, histo, prognosis
- mucoepidermoid carcinoma: epi, histo
- warthin tumor: histo, risk factors
- parotid
- half of all submandibular, most sublingual and minor salivary gland
- painless mass/swelling, facial paralysis/pain
- most common, composed of chondromyxoid stroma and epithelium, will recur if incompletely excised or ruptured intraoperatively, may undergo malignant transformation
- most common malignant tumor, mucinous and squamous components
- benign cystic w/ germinal centers, found in smokers,
44
Achalasia
- pathogenesis
- manometry findings
- sxs
- barium swallow
- secondary to
- failure of LES to relax bc loss of myenteric plexus since postganglionic inhibitory neurons no longer working
- uncoordinated/absent peristalsis w/ high LES resting pressure
- progressive dysphagia to solids and liquids
- dilated esophagus w/ area of distal stenosis
- chagas dx
45
Eshophageal Pathologies
- diffuse spasm: what is it; LES pressure; sxs; BS; tx
- eosinophilic esophagitis: what is it; risk; endo; tx
- esophageal perforation: causes; sxs; boerhaave syndrome
- esophageal strictures: what is it, causes
- esophageal varices: what is it, found in pts wl/, sequalae
- esophagitis: causes (3)
- GERD: cause; sxs
- Mallory-Weiss syndrome: what is it; cause; sxs; found in pts w/
- Plummer- Vinson syndrome: comprised of; increased risk of
- Schatzki rings: what is it; sxs
- Sclerodermal esophageal dysmotility: what is it; sequalae; part of
- DS: spontaneous, non peristatlic contrations; normal LES pressure; dysphagia and angina; BA w/ corkscrew esophagus; nitrates and CCBs
- EE: infiltration of eosinophils in esophagus; atopic pts; endo w/ esophageal rings and linear furrows; unresponsive to GERD meds
- EP: iatrogenic or spontaneous rupture, trauma, mailgnancy, foreign body ingestion; pneumomediastinum and crepitus in neck region; transmural, distal esophagus bc of violent retching
- ES: abnormally narrow esophagus bc of eating something damaging or acid reflux or esophagitis
- EV: dilated submucousal v in lower 1/3 of esophagus bc of portal htn; cirrhosis pts; can cause hematemesis
- E- itis: reflux, meds ( tetracycline, bisphos, NSAID), or in immuno comp (HSV-1: punched out ulcers, CMV: linear ulcers, Candida: white pseudomembrane)
- GERD: transient decreases in LES tone; heartburn, re-gurg, dysphagia, hoarseness, cough
- MWS: partial thickness (mucosa and sub) longitudinal laceration of gastroesophageal junction bc of vommitting; hematemesis; alcoholics and bulimics
- PL: Dysphagia, iron deficient anemia and esophageal webs; increased risk of esophageal squamous cell CA
- SR: rings formed at gastroesophageal junction bc of chronic acid reflux, present w/ dysphagia
- SED: esophageal SM atrophy -> decrease in LES pressure -> acid reflux and dysphagia -> stricture, barrets, and aspiration, part of CREST syndrome
46
Barrets Esophagus
- what is it/histo
- caused by
- increased risk of
- replacement of nonkeratinized stratified squamous epi w/ intestinal epi (nonciliated columnar w/ goblet cells) in distal esophagus
- chronic GERD
- esophageal adenocarcinoma
47
Esophageal CA
- sxs
- Squamous Cell: location, risks, prevalence
- Adenocarcinoma: location, risks, prevalence
- dysphagia (solids then liquids) and weight loss
- upper 2/3; EtOH, hot liquid, smoking, achalasia (LES wont open); more common world wide
- lower 2/3; chronic GERD, barrets, obesity, smoking; more common in America
48
Gastritis
- what is it
- acute: causes and pathogenesis of dx
- chronic: what happens and what does it lead to
- H pylori: prevalence, increased risk of, location
- AI: what is it. increased risk of, location
- inflammation of the stomach
- can be caused by NSAIDS (decrease prostaglandin -> decrease prostaglandin mucosa protection), Burns (hypovolemia caused by 3rd spacing will cause ischemia to gastric mucosa), or Brain injury (increase in vagal stimulation will increase Ach and increase H+ production)
- mucousal inflammation, leading to atrophy and intestinal metaplasia
- most common; increased risk of peptic ulcer Dx and MALT lymphoma; affects antrum first and spreads to body of stomach
- antibodies directed at H+/K+ ATPase on parietal cells and to intrinsic factor; increased risk of pernicious anemia; affects body and fundus of stomach
49
Menetrier Dx
- what is it
- what does it cause
- sequalae
- sxs
- Hyperplasia of gastric mucosa causing hypertrophied rugae
- causes excess mucus production with w/ protein loss and parietal cell atrophy causing decrease in acid production
- precancerous
- weight loss, anorexia, vomitting, epigastric pain, edema
50
Gastric CA
- most common
- prognosis
- sxs
- associated w/
- intestinal vs diffuse
- virchow node
- krukenberg tumor
- sister mary joseph nodule
- blumer shelf
- gastric adenocarcinoma
- early aggressive spread with LN or liver mets
- late, weight loss, abdominal pain, early satiety
- blood type A
- intestinal is associated w/ H pylori and in on lesser curvature, looks like an ulcer w/ raised margins; diffuse is not associated w/ H pylori, has signet ring cells (mucin filled cells w/ peripheral nuclei); and stomach walls are thick and leathery
- left supraclavicular node involved
- bilateral mets to ovaries
- subcutaneous periumbilical mets
- palpable mass on DRE suggesting mets to pouch of douglas
51
Peptic Ulcer Dx
- gastric: pain, h pylori involvement, mechanism, other causes, risk of CA
- duodenal: pain, h pylori involvement, mechanism, other causes, risk of CA
- greater w/ meals; 70%; decrease in mucousal protection against gastric acids; NSAIDS, high
- decreases w/ meals; 90%; decrease in mucousal protection or increase in gastric acid secretion; zollinger ellison syndrome; benign
52
Ulcer complications:
- Bleed: common location and cause
- Obstruct
- Perforate: location and what does it cause
- gastric ulcer on lesser curvature -> from left gastric a; posterior wall of duodenum -> gastroduodenal a
- pyloric channel and duodenum
- normally on anterior of duodenum -> cause pneumoperitonuem w/ air trapping under diaphragm and referred pain to shoulder bc of irritation of phrenic n
53
Malabsorption Syndromes
- Celiac: what is it, HLA associations, sxs, DX/histo, location affected
- lactose intolerance: what is it, histo, sxs, testing and results
- pancreatic insuff: caused by; sequalae; DX
- tropical sprue: cause, sxs, tx
- whipple dx: caused by, histo, sxs
- gluten sensitivity because AI attack against gliadin in wheat products (HLA-DQ2 and 8); steatorrhea; IgA anti -tissue transgultaminase, villous atrophy, crypt hyperplasia and intaepi lymphocytosis; decreased mucousal absorption in distal duodenum and prox jejunum; gluten-free diet
- lactase deficiency; normal villi; osmotic diarrhea w/ decreased stool pH because lactose becomes fermented in colon; lactose hydrogen breath test is positive if H+ in breath rises 20 ppm after intake of lactose
- caused by chronic pancreatitis/ CF/ obstructing CA; malabsorption of fat soluble vit and B12; decrease in duodenal bicarb and fecal elastase
- unknown cause but seen in pts that travel to tropics, similar sxs to celiac spure with affects seen in small intestine, but resolves w/ antibiotics
- infection w/ T whipplei (inctracellular gram +), PAS+ foamy macrophages in intestinal lamina propria; cardiac sxs, arthralgias, and neuro sxs w/ diarrhea occuring later in dx
54
Crohns Dx
- location
- gross
- histo
- complications
- intestinal sxs
- extraintestinal sxs
- tx
- any portion of GI tract, normally terminal ileum and colon -> w/ skip lesions and rectal sparing
- transmural inflammation causing fistulas w/ cobblestone mucosa
- noncaseating granulomas w/ lymphoid aggregates, Th1 mediated
- malabsorption, colorectal CA, strictures, entero vesical fistula
- diarrhea
- rash, eye inflammation, oral ulceration, arthritis, kidney stones
- steroids, azathioprine, antibiotics, biologics (MABS)
55
```
Ulcerative Colitis
- location
- gross
- histo
complications
- intestinal sxs
- extraintestinal sxs
- tx
```
- only in colon w/ continuous lesions and rectal involvement
- mucousal and submucousal inflammation ONLY, lead pipe appearance
- crypt abcesses and ulcers, Th2 mediated
- malabsorption, colorectal CA, fulminant colitis and toxic megacolon
- rash, eye inflammation, oral ulceration, primary sclerosing colangitis
- 5-aminosalicyclic preparations, colectomy
56
IBS
- what is it
- cant have
- epi
- types
- tx
- recurrent abdominal pain, related to defecation, change in stool frequency, change in form of stool
- no structural abnormalities
- middle aged women
- can be diarrhea, constipation, or both
- lifestyle mods and diet changes
57
Appendicitis
- what is it
- causes in adults vs children
- cause of periumbilical pain
- cause of RLQ pain
- tx
- inflammation of the appendicits
- obstuction of fecalith (adults) or lymph hyperplasia (kids)
- prox obstruction of appendix lumen produced closed loop pbstruction -> increases intraluminal pressure -> simulates visceral afferent nerve fibers 8-10
- inflammation extend to serosa and irritates parietal peritoneum -> pain localizes to RLQ
- appendectomy
58
Diverticula of GI tract
- diverticulum: what is it, where can it be found, true vs false
- diverticulosis: what is it, caused by, associated w/ , sxs; complications
- diverticulitis: what is it, sxs, tx, complications
- Zenker: what is it, cause, location, sxs
- Meckel: what is it; caused by; histo; complications
- blind pouch protruding from lumen of GI tract, can occur in any part of GI tract; true is all gut wall layers and false is aquired and only mucose and submucosa
- many false diverticula of colon, increased intraluminal pressure and focal weakness in colonic wall; obesity and diets w/ low fiber and high red meat; vague abd discomfort; diverticular bleeding (painless hematochezia) and diverticulitis
- inflammation of the diverticula causing wall thickening; LLQ pain, fever, leukocytosis; antibiotics; abcess, fistula, obstruction, perforation
- phayrngoesophageal false diverticulum; esophageal dysmotility causes herniation of mucousal tissue; at killian triangle between thyropharyngeal and cricopharyngeal parts of inferior pharyngeal constrictor; dysphagia, obstruction, gurgling aspiration, foul breath, neck mass
- true diverticulum; persistence of vitelline ducts; may have ectopic acid secreting gastric mucosa or pancreatic tissue; intussusception or volvus causing obstruction RLQ pain
59
Hirschsprung dx
- what is it
- caused by, genetics
- sxs
- increased risk
- dx
- tx
- congenital megacolon
- lack of innervation to descending colon so it does not contract and is dilated -> RET mutation
- bilious emesis, abd distention, failure to pass meconium in 48 hrs
- downs
- empty rectum on DRE, and absence of ganglionic cells on rectal section biopsy
- resection
60
Malrotation
- what is it
- sequalae
- complication
- midgut rotation during fetal development does not occur correctly
- small intestine in RLQ and colon in LLQ w/ labb bands connecting it to liver and stomach
- volvulus and obstruction
61
Intussusception
- what is it
- location
- causes in children vs adult
- exam
- imaging
- telescoping of prox bowel into distal segment
- ileoceccal junction
- meckel diverticulum in children intraluminal mass/tumor in adults/ IgA vasculitis or recent viral infection
- sausage shaped mass on palpation
- target sign
62
Volvulus
- what is it
- complications
- location in children vs elderly
- twisting of portion of bowel around mesentery
- obstruction and infarction
- midgut in children and sigmoid in elderly
63
Intestinal Disorders
- acute mesenteric ischemia: what is it, leads to, sxs
- adhesion: what is it, what does it lead to
- angiodysplasia: what is it
- chronic mesenteric ischemia
- colonic ischemia: what is it, what does it lead to, sxs
- ileus: pathogenesis, sxs, caused by, tx
- meconium ileus: what is it, associated with CF
- necrotizing enterocolitis: what is it, found in
- AMI: critical blockage of intestinal blood flow -> small bowel necrosis; abdominal pain out of proportion to PE findings
- Ad: fibrous band of scar tissue; most common cause of small bowel obstruction
- angio: tortuous dilation of vessels -> hematochezia; right sided colon; VWF and aortic stenosis
- CMI: atherosclerosis of celiac a, SMA, or IMA -> intestinal hypo-perfusion -> postprandial epi pain -> food aversion and weight loss
- Ileus: reduction in blood flow causes ischemia to splenic flexure or distal colon; crampy abdominal pain followed by hematochezia; thumb print sign
- intestinal hypomotility w/o obstruction; leads to constipation and decrease in flatus; distended abdomen with decreased bowel sounds; abdominal surgeries, opiates, sepsis; bowel rest, electrolyte correction, cholinergic drugs
- meconium plug obstruct intestine; CF
- necrosis of intestinal mucosa w/ possible perforation; pre-mature, formula fed infants with immature immune system
64
Non-neoplastic colon polyps
- hamartomatous: what is it
- hyperplastic: epi, location, size
- inflammatory psuedo: cause
- mucousal: size, cell type
- submucousal: examples
- solitary growth of normal colonic tissue w/ distorted architecture
- most common; small and located in rectosigmoid region
- cause by mucousal erosion in IBD
- small, look similar to normal mucosa
- lipomas, leimyomas, fibromas
65
Malignant colon polyps
- adenomatous: mutation, histo, sxs
- serrated: mutation, histo, sporadic
- mutation in APC or KRAS, histo is tubular or villous, asymptomatic with occult bleeding
- CpG methylation to MMR gene (DNA mismatch repair), histo is sawtooth pattern of crypts on biopsy, 20% sporadic
66
Polyposis syndromes
- familial adenomatous polyposis
- gardner syndrome
- turcot syndrome
- peutz-jeghers syndrome
- juvenile polyposis syndrome
- auto dom mutation of APC, thousands of polyps develop after puberty, always involves rectum, prophylactic colectomy or else 100% progress to colon CA
- FAP + osseous and ST tumors, impacted/super numerary teeth
- FAP or Lynch + malignant CNS tumors
- auto dom dx causing numerous hamartomatous throughout GI tract; hyperpigmented macules on mouth, lips, hands, genitalia, increase risk of breast and GI CA
- auto dom dx in children w/ lots of hamartomatous polyps in colon, stomach and small bowel, high risk of colon CA
67
Lynch syndrome
- mutation
- chance of getting colon CA
- associated w/
- auto dom mutation of DNA mismatch repair gene w/ microsattelite instability
- 80% progresses
- endometrial, ovarian and skin CA
68
Colorectal CA
- dx
- screening; first degree relative;
- barium enema
- CEA marker
- epi
- location occurence
- sxs of ascending
- sxs of decending
- iron deficiency in older individuals
- colonoscopy/ fecal occult blood testing at 50; start at 40 or 10 yrs prior to relatives dx
- apple core lesion
- use for monitoring recurrence
- greater than 50
- recto/sigmoid > ascending> descending
- iron deficient anemia and weight loss
- obstruction
69
Pathogenesis of colorectal CA
- chromosomal instability
- microsatellite instability
- loss of APC gene will decrease intracellular adhesion and increase proliferation -> KRAS mutation causing unregulated intracellular signaling -> creastes adenoma -> loss of tumor suppressor (TP53) -> carcinoma
- mutation or methylation of mismatch repair genes
70
Cirrhosis
- what is it
- increased risk
- diffuse fibrosis caused by stellate cells
| - hepatocellular carcinoma
71
Portal HTN
- what is it
- etiologies
- increased pressure in portal venous sxs
| - cirrhosis or vascular obstruction
72
Spontaneous bacterial peritonitis
- what is it
- bugs
- DX
- TX
- bacterial infection in pts with cirrhosis and ascities
- e coli, klebsiella, or strep
- paracentises of fluid from ascities w/ PMN count higher than 250
- 3rd gen cephalosporin
73
Enzymes release in liver damage
- AST and ALT: liver dx, EtOH liver dx, fibrosis/cirrhosis, greater than 1000
- Alk phos: when is it elevated
- gamma-glut-transpeptidase: when is it elevated
- ALT > AST is higher in liver dx; AST> ALT in EtOH liver dx; AST > ALT in non EtOH liver dx means that there is advanced fibrosis of cirrhosis; drug induced liver injury, ischemic hepatitis or acute viral hepatitis
- biliary obstruction, infiltrative disorder, bone dx
- increased in various liver and biliary dx but not in bone dx
74
Alcoholic liver dx
- hepatic steatosis: what is it, tx
- EtOH hepatitis: histo
- EtOH cirrhosis: prognosis, histo, sxs
- micro-vesicular fatty change that may be reversible w/ EtOH cessation
- swollen and necrotic hepatocytes w/ PMN infiltration and mallory bodies
- irreversible form, sclerosis around central w/ fibrous bands around regenerative nodules; potal HTN and end stage liver dx
75
Non alcoholic fatty liver
- pathogenesis
- sequlae
- obesity -> fatty infiltration of hepatocytes -> cellular ballooning -> necrosis
- cirrhosis and HCC
76
Hepatic encephalopathy
- what is it
- pathogenesis
- prognosis
- tx
- liver damage causes neuropsych dysfxn
- cirrhosis -> portosystemic shunt -> decrease NH3 metabolism -> neurpsych dysfxn
- reversible
- lactulose (increase NH4+ generation) and rifaximin or neomycin (decrease NH3+ producing bacteria)
77
Hepatocellular Carcinoma
- epi
- associated w/
- sxs
- DX
- most common primary malignant tumor
- anything that causes cirrhosis
- jaundice, tender hepatomegaly, ascites, anorexia
- through blood
- increased alpha-fetoprotein or on CT
78
Budd-chiari syndrome
- what is it
- associated w/
- thrombosis or compression of hepatic v w/ centrilobar congestion and necrosis
- hepatomegaly, ascities, abd pain, liver failure w/o JVD
- hypercoagulable state, postpartum state, HCC
79
alpha 1 antitrypsin deficiency
| - what is it
- misfolded trypsin protein aggregates in hepatocellular ER
- cirrhosis w/ PAS+ globules
- young pts w/ liver damage and dyspnea (emphysema in children)
80
Jaundice
- common causes
- direct
- indirect
- mixed
- Hemolysis, obstruction, tumor, liver dx
- conjugated; biliary tract obstruction or dx
- unconjugated; hemolysis
- hepatitis or cirrhosis
81
Neonatal jaundice
- what is it
- when does it occur
- tx
- immature UDP glucuronosyltransferase -> unconj hyperbili -> jaudince/kernicterus
- first 24 hrs of birth and resolves within 1-4 weeks w/o tx
- phototherapy
82
Biliary atresia
- what is it
- sequelae
- sxs
- biliary tract does not form
- most common reason for liver transplant in baby
- newborn w/ continued jaundice after 2 weeks, darkening urine, hepatomegaly
83
Hereditary hyperbili
- gilbert: what is it; sxs; labs
- cigler najjar: what is it; sxs; labs; tx
- dubin johnson: what is it; gross
- mildly decreased UDP gluco transferase conjugation and impaired bili uptake, mild jaundice w/ stress, increase in unconjugated bili w/o hemolysis
- absent UDP gluco transferase; jaundice, kernicterus; high uncojugated bili; plasmapharesis and phototherapy OR liver transplant
- conjugated hyperbili bc not excreting correctly; liver is black on gross inspection
84
Wilson Dx
- what is it
- sxs
- tx
- auto recessive mutation that causes hepatocyte copper transporting -> copper accumulates in liver, brain, cornea, kidneys
- liver disease, neuro disease, psych deposits, kayser fleischer deposits
- chelation w/ penicillamine or oral zinc, might need liver transplant
85
Hemochromatosis
- abnormal iron sensing and increase intestinal iron absorption -> iron accumulates in liver
- cirrhosis, DM, and bronze skin
- C282Y mutation on HFe gene, chrom 6
- phlebotomy, iron chelation
86
Biliary tract Dx
- primary sclerosing cholangitis: histo, epi
- primary biliary cholangitis: histo, epi
- secondary biliary cholangitis: pathogenesis
- onion skin bile duct fibrosis, w/ beading of intra and extrahepatic bile ducts on ERCP; middle aged men w/ IBD
- AI reaction w/ lymph infiltrate and granulomas -> destruction of lobular bile ducts; middle age women
- extrahepatic bili obstruction -> increase pressure in intrahepatic ducts -> injury/fibrosis and bile stasis
87
Cholelithiasis
- what is it
- types of stones
- risk factors
- increase cholesterol or bilirubin w/ decrease bile salts and gallbladder stasis causing stones
- cholesterol (obesity, rapid weight loss, estrogen therapy, crohns dx) or pigmented
- forty, female, fat, fertile
88
- Biliary colic: what is it, sxs, labs, US
- choledocholithiasis: what is it, labs
- cholecystitis: what is it, types, PE test, imaging
- porcelain gallbladder: what is it, tx
- ascending cholangitis: what is it, charcot triad, reynolds rentad
- CCK triggers contraction of gallbladder forcing stone into cystic duct; n/v, dull RUQ pain; labs normal; US shows cholelithiasis
- presence of gallstone in common bile duct, leading to increase in liver enzymes
- acute or chronic inflamm of galbladder; calculous- caused by stone, acalculous- galbladder stasis, hypoperfusion, infection; murphys; visualize stone on US or HIDA
- calcified galbladder bc of chronic cholecysitis, found incidentally; remove bc increased risk galbladder CA
- infection of biliary tree bc of obstruction that causes stasis; cholangitis, fever, RUQ pain vs 3 + altered mental status and hypotension (shock)
89
Acute pancreatitis
- what is it
- I GET SMASHED
- dx
- autodigestion of pancreas by pancreatic enzymes
- Idiopathic, gallstones, ethanol, trauma, steroids, mumps, AI dx, Scorpion sting, hypercalcemia, ERCP, Drugs (sulfa, NRTI, protease inhib)
- acute epi pain radiating to back, high serum amylase pr lipase, or characteristic imaging findings
90
Chronic pancreatits
- what is it
- causes
- sequelae
- chronic inflammation, atrophy, and calcification of pancreas
- alcohol and genetic pre-disposition
- pancreatic insuff
91
Pancreatic adenocarcinoma
- what is it
- prognosis
- location
- marker
- risks
- sxs
- tx
- tumor arising from pancreatic ducts
- poor, very aggressive, about 1 yr after dx
- pancreatic head
- CA19-9
- tobacco use, chronic pancreatitis, DM, older than 50,
- abd pain radiating to back, weight loss, redness and tenderness to palpation of extremities, obstructive jaundice
- whipple (pancreaticoduodenectomy), chemo and radiation
92
Acid suppression meds
- Histamine 2 blockers: suffix, MOA,
- PPI: MOA, side effects, examples
- antacids: MOA
- dine, reversible blockage of H2 receptors -> decrease H secretion
- irreversibly inhibits H/K ATPase; increase risk of c diff, and decrease in Mg absorption; omepra, esompra, pantoprazole,
- alter gastric pH
93
Antacids
- Aluminum Hydroxide
- Ca Carbonate
- Mag Hydroxide
- constipation, hypophosphatemia, osteodystrophy, muscle weakness, seizures
- hyper Ca
- diarrhea, hyporeflexia, hypotension, cardiac arrest
94
Bismuth
| - MOA
- binds to ulcer base and allows HCO3 secretion to re-establish pH gradient in mucous layer
95
Misoprostol
- MOA
- indication
- side effects
- PGE1 analog, increase production and secretion of gastric mucosa barrier
- prevntion for NSAID induced ulcers
- diarrhea and can cause abortions
96
Octreotide
- MOA
- indication
- side effects
- long acting somatostatin analog -> prevents splanchnic vasodilatory hormones
- acute variceal bleeds, acromegaly, VIPoma
- nausea, cramps, increaed risk of gallstones bc CCK inhibition
97
Sulfasalazine
- MOA
- indication
- side effects
- combination of sulfapyridine (antibiotic) and 5-aminosalicyclic acid (anti-inflamm), activated by colonic bacteria
- UC and Crohns
- nausea, sulfa tox, reversible oligospermia
98
Loperamide
- MOA
- indication
- side effects
- mu opioid receptor agonits -> slows gut motility
- diarrhea
- constipation
99
Ondansetron
- MOA
- indication
- side effects
- 5 HT antagonist, decrease vagal stimulation -> central acting anti-emetic
- control vommitting
- headache, constipation, QT prolongation
100
Metoclopramide
- MOA
- indication
- side effects
- D2 receptor antagonist -> increasing resting tone, LES tone, motility and promotes gastric emptying
- post op gastroparesis, anti-emetic, persistent GERD
- parkinsonian effects, interacts w/ digoxin and diabetic meds
101
Laxatives
- bulk forming
- osmotic
- stimulants
- emollients
- soluble fiber draw water into gut lumen -> forming viscous fluid that promotes peristalsis, psyllium
- provides osmotic load to drive water into lumen, mag hydroxide/ citrate, poly ethylene glycol, lactulose
- enteric nerve stimulation -> colonic contraction; senna
- promotes incorporation of fat and water into stool; docusate
102
Aprepitant
- MOA
- indications
- blocks neurokinin 1 receptors in brain
| - anti-emetic for chemo
103
Lactulose
- normal use
- other use
- osmotic laxative
| - promotes nitrogen excretion as NH4 so can be helpful with hepatic encephalopathy
