GI Flashcards
(214 cards)
1
Q
GI embryo
A
Foregut- esophagus to duodenum at level of pancreatic duct and common bile duct insertion
Midgut- lower duodenum to proximal 2/3 transverse colon
Hindgut- distal 1/3 transverse colon to anal canal above pectinate line
2
Q
Gastroschisis
A
extrusion of abdominal contents through abdominal folds
NOT covered by peritoneum or amnion
NOT associated with chromosome abnormalities
Good prognosis
3
Q
Omphalocele
A
failure of lateral walls to migrate at umbilical ring –> persistent midline herniation of abdominal contents into umbilical cord
Surrounded by peritoneum
Associated with congenital anomalies
4
Q
Congenital umbilical hernia
A
failure of umbilical ring to close after physiologic herniation of the midgut
Small defects close spontaneously
5
Q
Tracheoesophageal anomalies
A
esophageal atresia with distal trancheoesophageal fistula
present with polyhydramnios
neonates drool, choke and vomit with first feeding, cyanosis
Failure to pass nasogastric tube into stomach
6
Q
Duodenal Atresia
A
bilious vomiting and abdominal distention within first few days of life
failure to recanalize
Ab XRAY –> double bubble
Associated with Downs
7
Q
Jejunal and ileal atresia
A
bilious vomiting and abdominal distention within first few days of life
disruption of mesenteric vessels –> ischemic necrosis of fetal intestine –> segmental resorption, bowel become discontinuous
XRAY –> dilated loops of small bowel with air fluid levels
8
Q
Hypertrophic pyloric stenosis
A
palpable olive shaped mass in epigastric region, visible peristaltic waves, nonbilous projectile vomiting at 2-6 weeks
Associated with macrolide exposure
US –> thicked and lengthened pylorus
T(x) surgical incision of pyloric muscle
9
Q
Pancreas embryo
A
Foregut
central pancreatic bud contributes to uncinate process and main pancreatic duct
Dorsal pancreatic bud becomes body tail isthmus and accessory pancreatic duct
Both contribute to head
10
Q
Annular pancreas
A
abnormal rotation of central pancreatic bud forms a ring of pancreatic tissue–> encircle 2nd part of duodenum –> vomiting
11
Q
Pancreas divisum
A
central and dorsal parts fail to fuse at 8 weeks.
chronic ab pain or pancreatitis
12
Q
spleen embryo
A
arise in mesentery of stomach but has foregut supply (celiac trunk –> splenic A)
13
Q
Retroperitoneal structures
A
posterior to the peritoneal cavity injuries --> blood or gas accumulation suprarenal gland aorta and IVC Duodenum (2-4) pancreas (except tail) ureters Colon (ascending and descending) kidneys esophagus rectum
14
Q
Falciform L
A
liver to anterior ab wall
hold Ligamentum teres hepatis and patent paraumbilical V
Derivative of ventral mesentery
15
Q
Hepatoduodenal L
A
liver to duodenum
contains portal triad
Derivative of ventral mesentery
Part of lesser omentum
16
Q
Pringle Maneuver
A
Ligament is compressed manually or with clamp in omental foramen to control bleeding from hepatic inflow source
17
Q
Gastrohepatic L
A
liver to lesser stomach contains gastric vessels Derivative of ventral mesentery Separates greater and lesser sacs o right Lesser omentum
18
Q
Gatrosplenic L
A
greater stomach and spleen
contains short gastrics, left gasroepiploic vessels
Dorsal mesentery
greater omentum
19
Q
Gastrocolic L
A
greater stomach and transverse colon
contain gastroepiploic A
dorsal mesentery
greater omentum
20
Q
splenorenal L
A
spleen to left pararenal space
contains splenic artery and vein, tail of pancreas
Dorsal mesentery
21
Q
Nutcracker Syndrome
A
compression of L renal V between SMA and aorta
ab pain, gross hematuria
22
Q
SMA syndrome
A
intermittent intestinal obstruction symptoms when SMA and aorta compress transverse portion of duodenum
Associated with diminished mesenteric fat
23
Q
Esophagus anatasmosis
A
esophageal varices
L gastric to esophagus
drains into azygous
24
Q
Umbilicus anastamosis
A
Caput Medusae
paraumbilical to small epigasstric veins of the anterior abdominal wall
25
Rectum anastamosis
anorectal varices
| superior rectum to middle and inferior rectum
26
Internal hemorrhoids
receive visceral innervation and therefore not painful
| above pectinate line
27
External hemorrhoids
receive somatic innervation and therefore painful
| below pectinate line
28
Anal fissure
tear in anal mucosa below pectinate line. Pain while pooping, blood on toilet paper
located posterior
innervated by pudendal N
associated with low fiber diets and constipation
29
Zone 1 of Liver
periportal zone
affected 1st by viral hepatitis
best oxygenated, most resistant to circulatory compromise
ingested toxins
30
Zone 2 of liver
intermediate zone
| yellow fever
31
Zone 3 of liver
```
pericentral vein
affected 1st by ischemia
high concentration of cytochrome p450
most sensitive to metabolic toxins
site of alcoholic hepatitis
```
32
Gallstone that reach the confluence of the common bile and pancreatic duct at the ampulla of vater
block common bile duct and pancreatic ducts causing cholangitis and pancreatitis
33
Tumors that arise in the head of the pancreas
obstruct common bile duct --> enlarge gallbladder with painless jaundice
34
Femoral vasculature organization
lateral to medial Nerve, Artery, Vein, Lymphatics
35
Femoral Triangle
contains femoral nerve artery and vein
36
femoral sheath
fascial tube 3-4 cm below inguinal L
| contain femoral vein, artery and canal but not nerve
37
Sliding hiatal hernia
gastroesophageal junction is displaced upward as gastric cardia slides into hiatus. Hourglass stomach
Most common
GERD
38
Paraesophageal hiatal hernia
gastroesophageal junction is usually normal but gastric fundus protrudes into the thorax
39
Indirect inguinal hernia
goes through internal inguinal ring, external inguinal ring and into the groin.
Enters internal inguinal ring lateral to inferior epigastric vessels.
Caused by failure of processus vaginalis to close
Males
covered by all 3 layers of spermatic fascia
40
Direct inguinal hernia
protrudes through inguinal triangle. Bulges directly through parietal peritoneum medial to the inferior epigastric vessels but lateral to the rectus abdominis. Goes through the external inguinal ring only
covered by extend spermatic fascia.
older when due to weakness transversalis fascia
41
Femoral Hernia
protrudes below inguinal L through femoral canal below and lateral to pubic tubercle
Females
present incarceration or strangulation
42
Gastrin
G cells (antrum,duodenum)
increase gastric H+ secretion, growth of gastric mucosa and gastric motility
decreased by pH <1.5
43
Somatostatin
```
D cells (pancreatic islet, GI mucosa)
decrease gastric acid and pepsinogen, pancreatic and small intestine fluid secretion, gallbladder contraction, insulin and glucagon.
```
44
Cholecystokinin
I cells (duodenum and jejunum)
increase pancreatic secretion, gallbladder contraction, sphincter of oddi relaxation. Decrease gastric emptying
increase by FA and AA
45
Secretin
S cells (duodenum)
increase pancreatic bicarb, bile secretion
decrease gastric acid secretion
Increased by acid, FA in duodenum
46
Glucose dependent insulinotropic peptide
K cells (duodenum, jejunum)
decrease gastric H+ secretion
increased by FA, AA and oral glucose
47
Motilin
Small intestine
produce migrating motor complex
increase in fasting state
48
Vasoactive Intestinal polypeptide
PNS ganglia in sphincters, gallbladder, SI
increase intestinal water and electrolyte, relxation of intestinal smooth muscle and sphincters
Increased by distention and vagal stimulation, decrease adrenergic input
49
VIPoma
water diarrhea, hypokalemia, achlorhydria
50
NO
increase smooth muscle relaxation of LES
51
Ghrelin
Stomach
increase appetite
increased in fasting state and decreased by food
52
Intrinsic Factor
Parietal cells
| Vitamin B12 binding
53
Gastric acid
parietal cells
decrease stomach pH
increase histamine, vagal stimulation, decrease by somatostatin, GIP, PG, secretin
54
Pepsin
chief cells
protein digestion
increase vagal stimulation
55
Bicarconate
mucosal cells and brunner glands
neutralize acid
increased by pancreatic and biliary secretion wiht secretin
56
Pancreatic secretion
a amylase
Lipase
Protease
Trypsinogen
57
Carb absorption
Glucose and galactose --> SGLT1 (Na+ dependent)
Fructose -->GLUT5
All transported by GLUT2
58
Iron absorption
absorbed Fe2+ in duodenum
59
Folate
absorbed in small bowel
60
Vitamin B12
absorbed in terminal ileum along with bile salts, requires IF
61
Peyer Patches
Unencapsulated lymphoid tissue found in lamina propria and submucosa and ileum
Contain specialized M cells that sample and present antigens to immune cells
B cells stimulated in germinal centers of Peyer patches differentiate into IgA secreting plasma cells, which ultimately reside in lamina propria.
IgA receives protective secretory component and is then transported across the epithelium to the gut to deal with intraluminal Ag
62
Bile
Composed of bile salts, phospholipids, cholesterol, bilirubin water and ions
Rate limiting bile synthesis: Cholesterol 7a hydroxylase
63
Bile functions
Digestion and absorption of lipids and fat soluble vitamins
Cholesterol excretion
Antimicrobial activity
64
Bilirubin
Heme is metabolized by heme oxygenase to biliverdin, --> bilirubin
Unconjugated bilirubin is removed from blood to liver, conjugated with glucuronate and excreted in bile
65
Sialolithiasis
stones in salivary gland duct
Single stone in submandibular gland (wharton duct)
Presents as recurrent pre/periprandial pain and selling in affected gland
Caused by dehydration or trauma
Treat with NSAIDs, gland massage, warm compresses, sour candies
66
Sialadenitis
inflammation of salivary gland due to obstruction, infection, immune mediated mechanisms
67
Pleomorphic adenoma
benign mixed tumor
most common salivary gland tumor
Composed of chondromyxoid stroma and epithelium and recurs if incompletely excised or ruptured intraoperatively
may undergo malignant transformation
68
Mucoepidermoid carcinoma
most common malignant tumor, has mucinous and squamous components
69
Warthin Tumor
benign cystic tumor wiht germinal centers
Smokes
bilateral Multifocal
70
Achalasia
Failure of LES to relax due to degeneration of inhibitory neurons in the myenteric plexus of the esophageal wall
Manometry findings include uncoordinated or absent peristalsis with high LES resting pressure --> progressive dysphagia to solids and liquids,
Barium swallow
Associated with high risk of esophageal cancer
71
Secondary Achalasia
Chagas disease or extraesophageal malignancies
72
Diffuse esophageal spasm
spontaneous, nonperistaltic contractions of the esophagus with normal LES pressure.
Presents with dysphagia and angina like chest pain
CORKSCREW esophagus
Treat with nitrates and CCBs
73
Eosinophilic Esophagitis
infiltration of eosinophils in the esophagus often in atopic patients
Food allergens --> dysphagia, food impaction
Esophageal rings and linear furrows often seen on fundoscopy
Unresponsive to GERD therapy
74
Esophageal perforation
iatrogenic post esophageal instrumentation
| pneumomediastinum, subcutaneous emphysema
75
Boerhaave syndrome
transmural, distal esophageal rupture due to violent retching
76
Esophageal strictures
associated with caustic ingestion, acid reflux, esophagitis
77
Esophageal varices
dilated submucosal veins in lower 1/3 of esophagus secondary to portal HTN
cirrhotics --> life threatening hematemesis
78
Esophagitis
```
Associated with reflux, infection in immunocompromised
Candida- white pseudomembrane
HSV1- punched out ulcers
CMV- linear ulcers
caustic ingestion, or pill induced
```
79
GERD
heartburn, regurgitation, dysphagia
chronic cough, hoarseness
Associated with asthma
Transient decreased in LES tone
80
Mallory Weiss Syndrome
partial thickness, longitudinal lacerations of gastroesophageal junction, confined to mucosa/ submucosa due to severe vomiting.
present as hematemesis
ALCHOLICS and BULIMICS
81
Plummer Vinson Syndrome
Dysphagia, Iron deficiency anemia, esophageal webs
increase risk of esophageal SCC
may be associated with glossitis
82
Schatzki rings
rings formed at gastroesophageal junction via chronic acid reflux
dysphagia
83
Sclerodermal esophageal dysmotility
Esophageal smooth muscle atrophy --> low LES pressure and dysmotility --> acid reflux and dysphagia --> stricture , Barrett esophagus and aspiration
Part of CREST syndrome
84
Barrett Esophagus
specialized intestinal metaplasia --> replacement of nonkeratinized stratified squamous epithelium with intestinal epithelium in distal esophagus
Due to chronic GERD
associated with increased risk of esophageal adenocarcinoma
85
Esophageal cancer
```
progressive dysphagia (solids then liquids) and weight loss
Aggressive course due to lack of serosa in esophageal wall, allowing rapid extension
```
86
SCC of esophagus
upper 2/3
| Risk factors alcohol, hot liquids, caustic strictures, smoking, achalasia
87
Adenocarcinoma of esophagus
Lower 1/3
| chronic GERD, Barrett esophagus, obesity, smoking, achalasia
88
Acute Gastritis
via NSAIDs, burns, brain injury, ALCOHOLICS
89
H. pylori gastritis
chronic
increase risk of PUD, MALT lymphoma
Antrum --> body
90
Autoimmune gastritis
Chronic
autoantibodies to H+/K+ ATPase on parietal cells and IF
increase risk of pernicious anemia
body/fundus
91
Menetrier Disease
Hyperplasia of gastric mucosa --> hypertrophied rugae
excess mucus production with resultant protein loss and parietal cell atrophy with low acid production
precancerous
weight loss, anorexia, vomiting, epigastric pain, edema
92
Gastric Cancer
Adenocarcinoma
early aggressive local spread with lode/ liver metz
wright loss, ab pain, early satiety, acanthosis nigricans, Leser Trelat sign
Associated with blood type A
Intestinal --> H. pylori, smoked foods (lesser curvature)
Diffuse --> E cadherin mutation, signet cells
Virchow node, Krukenberg tumor, sister mary joseph nodule, blumer shelf
93
Gastric ulcer
pain greater with meals --> weight loss
low mucosal protection against gastric acid
via NSAIDs
increase risk of carcinoma
94
Duodenal ulcer
decreases with meal --> weight gain
H. pylori, Zollinger Ellison
low mucosal protection of increased gastric acid secretion
95
Ulcer complications Hemorrhage
ruptured gastric ulcer on the lesser curvature of stomach --> bleeding from L gastric A
Ulcer on posterior duodenum --> bleeding from gastroduodenal A
96
Ulcer complications Obstruction
pyloric channel, duodenal
97
Ulcer complications Perforation
Duodenal
Anterior can perforate into anterior ab cavity --> pneumoperitoneum
Referred pain to shoulder via phrenic
98
Celiac Disease
Gluten sensitive enteropathy
Autoimmune mediated intolerance of gliadin --> malabsorption and steatorrhea
Associated with HLA DQ2, DQ8, dermatitis herpetiformis
IgA anti tissue transglutmainase, anti endomysial, anti deamidated gliadin prptide Ab.
99
Lactose intolerance
Lactase deficiency
Normal vili
osmotic diarrhea with low stool pH
Lactose H+ breath test
100
Pancreatic insufficiency
Due to chronic pancreatitis, cystic fibrosis, obstructing cancer
malabsorption of fat and fat soluble vitamins and B12
decrease duodenal bicarb and fecal elastase
101
Trpoical sprue
```
Similar to celiac sprue
respond to Abx
tropics
decrease mucosal absorption affecting duodenum and jejunum
Associated wtih megaloblastic anemia
```
102
Whipple disease
Gram + PAS + foamy macrophades in intestinal lamina propria, mesenteric nodes
Cardiac, arthralgias, neuro, diarrhea/ steatorrhea
old men
103
Crohn
any portion of GI (usually terminal ileum)
transmural inflammation --> cobblestone mucosa, creeping fat, string sign, linear ulcers, fissures
Noncaseating granuloma Th1
complications: malabsorption, colorectal cancer, fistulas, strictures, perianal disease
Diarrhea
Tx corticosteroids, azathioprine, Abx
104
Ulcerative colitis
colon (mucosal and submucosal) inflammation, ALWAYS RECTAL
loss of haustra--> lead pipe
Th2
colorectal cancer
toxic megacolon, perforation
bloody diarrhea
Primary sclerosing cholangitis associated with p-ANCA
105
Irritable Bowel Syndrome
Recurrent abdominal pain associated with defecation, change in stool frequency, change in stool consistency
no structural abnormalities
Middle age women
diarrhea predominant, constipation predominant, or mixed
106
Appendicitis
acute inflammation of appendix via obstruction of fecalith or lymphoid hyperplasia
closed loop obstruction -->visceral T8-10 --> periumbilical pain --> irritation of parietal peritoneum --> localize to RLQ
McBurney, Rovsing
Tx appendectomy
107
Diverticulum
blind pouch protruding form the alimentary tract that communicates with the lumen of the gut.
108
True diverticulum
all gut wall layer outpouch
109
False diverticulum
only mucosa and submucosa outpouch. Where vasa recta perforate muscularis externa
110
Diverticulosis
increased intraluminal pressure and focal weakness in colonic wall
Associated with obesity and diets low in fiber, high in total fat or red meat
vague discomfort
Complications: bleeding (painless blood in stool), diverticulitis
111
Diverticulitis
inflammation of diverticula with wall thickening --> LLQ pain, fever, leukocytosis
Tx Abx
Complications: abscess, fistula, obstruction, perforation
112
Zenker Diverticulum
Pharyngoesophageal false diverticulum
esophageal dysmotility causes herniation of mucosal tissue at killian triangle
dysphagia, obstruction, gurgling, aspiration, foul breath, neck mass
elderly mailes
113
Meckels Diverticulum
```
True diverticulum
persistent vitelline duct
CONGENITAL ANOMALY
RLQ pain, intussception, volvulus, obstruction near terminal ileum, melena
Rule of 2's
gastric and pancreatic epithelia
```
114
Hirschsprung disease
congenital megacolon via lack of ganglion/ enteric nerve plexus in distal colon.
RET mutation
bilious emesis, ab distention, failure to pas meconium in 48 hours
Increased risk with Down
Tx Resection
115
Malrotation
Anomaly of midgut roatation during fetal development --> improper positioning of bowel, formation of fibrous bands
lead to volvulus, duodenal obstruction
116
Intussception
telescoping of proximal bowel segment into a distal segment
ILEOCECAL JUNCTION
compromised blood supple --> severe ab pain with currant jelly dark red stools
INFANTS
draw legs to chest to ease pain, sausage mass on palpation
Target sign on US
Associated with IgA vasculitis, viral infection
117
Volvulus
twisting bowel around its mesentery --> obstruction/ infarction
Midgut = more common in infants and children
Sigmoid = more common in elderly
118
Acute mesenteric ischemia
critical blockage of intestinal blood flow --> small bowel necrosis --> ab pain out of proportion
currant jelly stool
119
Adhesion
fibrous band of scar tissue via small bowel obstruction
| MULTIPLE DILATED SMALL BOWEL LOOPS
120
Angiodysplasia
tortuous dilation of vessels --> hematochezia
right sided colon
older
assoicated with end stage renal disease, von willebrand, aortic stenosis
121
chronic mesenteric ischemia
intestinal angina
atherosclerosis of celiac A, SMA or IMA --> intestinal hypoperfusion --> postprandial epigastric pain --> food aversion and weight loss
122
Colonic ischemia
```
reduction in intestinal blood flow causes ischemia
crampy ab pain --> hematochezia
watershed area
elderly
thumbprint sign
```
123
Ileus
intestinal hypomotility wihtout obstruction --> constipation and decreased flatus, distended ab with low bowel sounds
Associated with ab surgery, opiates, hypokalemia, sepsis
124
Meconium ileus
meconium plug obstructs intestine, prevents stool passage at birth
associated with cystic fibrosis
125
Necrotizing Enterocolitis
premature, formula fed infants with immature immune system
| Necrosis of intestinal mucosa with possible perforation --> pneumatosis intestinalis, pneumoperitoneum, portal vein gas
126
Hamartomatous polyp
solitary lesions do not have significant risk of transformation
growth of normal colonic tissue with distorted architecture
Associated with Peutz Jegher sundrome and juvenile polyposis
127
Hyperplastic polyps
Most common
smaller and located in rectosigmoidal region
evolves into serrated polyp and more advanced lesions
128
inflammatory pseudopolyps
due to mucosal erosion in inflammatory bowel disease
129
Mucosal polyps
small usually <5 mm insignficant
130
Submucosal polyps
may include lipomas, leiomyomas, fibromas, and other lesions
131
Adenomatous polyps
neoplastic via APC and KRAS mut
tubular less malignant than villous
Asymptomatic, occult bleeding
132
Serrated polyps
Neoplastic
CpG island methylation --> silence MMR gene --> microsatellite instability and BRAF mut
saw tooth pattern of crypts
133
Familial adenomatous polyposis
AD APC mut on 5q22
1000s of polyps arise starting after puberty
ALWAYS RECTUM
prophylactic colectomy or progress to CRC
134
Gardner Syndrome
FAP + osseous and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium, impacted teeth
135
Tucot Syndrome
FAP or Lynch syndrome + malignant CNS tumor
136
Peutz Jegher Syndrome
AD
hamartomas + hyperigmented macules on mouth, hands, genitalia
increased risk of breast and GI cancers
137
Juvenile polyposis syndrome
AD children
hamartomatous polyps in colon, stomach, small bowel
Increased risk of CRC
138
Lynch syndrome
HNPCC
AD mut MLH1 MSH2 with microsatellite instability
progress to CRC
proximal colon
Associated with endometrial, ovarian and skin cancers
139
Colorectal Cancer Screening
Low risk: 50 yr with colonoscopy, FOBT, FIT, FIT fecal DNA, CT colonography
Patients with first degree relative with colon cancer--> screen at 40 or 10 years prior to relative's presentation
Apple core lesion on barium X ray
CEA tumor marker- monitor recurrence
140
Colorectal cancer presentation
Rectosigmoidal > ascending > descending
Right side associated with occult bleeding, left side with hematochezia and obstruction
Ascending- exophytic mass, iron deficient anemia, weight loss
Descending- infiltrating mass, partial obstruction, colickly pain, hematochezia
Can present with S. bovis or diverticulitis
141
Risk factors for colorectal cancer
adenomatous and serrated polyps, familial cancer syndromes, IBD, tobacco, diet with processed meat and low fiber
142
PATH of colorectial cancer
mut of APC --> FAP and sporadic CRC
Mut of MLH1 --> Lynch syndrome
Overexpress COX 2
143
Cirrhosis
diffuse bridging fibrosis and regenerative nodules disrupt architecture of liver
increase risk for HCC
via alcohol, nonalcoholic steatohepatiis, chronic viral hepatitis, autoimmune hepatitis, biliary disease, genetic
144
Portal HTN
increase pressure in portal venous system
| via cirrhosis, vascular obstruction, schistosomiasis
145
Spontaneous bacterial peritonitis
fatal bacteria in patients with cirrhosis or ascites
asymptomatic but fever, chills, ab pain, ileus or encephalopathy
Gram - organisms
Dx paracentesis with ascitic fluid ANC > 250
Tx Cephalosporin
146
ALT and AST
increase in liver disease
increase in alcoholic liver disease
AST>ALT without alcohol --> advanced fibrosis or cirrhosis
>1000 --> drug induced, ischemic, acute viral, autoimmune
147
ALP
increase in cholestasis
infiltrating disorders
bone disease
148
GGT
increase in liver and biliary disease but not bone disease
| associated with alcohol use
149
Bilirubin
increase in liver disease and hemolysis
150
Albumin
decrease in advanced liver disease
151
PTT
increase in advanced liver disease
152
platelets
decrease in advanced liver disease and portal HTN
153
Reye Syndrome
fatal childhood hepatic encephalopathy
associated with viral infection treated with aspirin
mitochondrial abnormalities, fatty liver, hypoglycemia, vomiting, heptaomegaly, coma
154
Hepatic steatosis
macrovesicular fatty change that may be reversible with alcohol cessation
155
Alcoholic hepatitis
sustained long term consumption
swollen and necrotic hepatocytes with neutrophilic infiltration
Mallory bodies
156
Alcoholic cirrhosis
irreversible
sclerosis around central V
regenerative nodules surrounded by fibrous bands in response to chronic liver injury --> portal HTN and end stage liver disease
157
Nonalcoholic fatty liver disease
metabolic syndrome
obesity --> fatty infiltration of hepatocytes --> cellular ballooning and necrosis
May cause cirrhosis and HCC
ALT >AST
158
Hepatic encephalopathy
cirrhosis --> portosystemic shunts --> low ammonia metabolism --> neuro dysfunction
reversible
Triggered by GI bleed or renal failure
T(x): laculose increase ammonia generation and rifaximin decrease ammonium producing gut bacteria
159
HCC
```
Associated with HBV, HCV, alcohol
May lead to budd chiari
jaundice, tender hepatomegaly, ascites, polycythemia, anorexia
spread via blood
increase AFP
```
160
Angiosarcoma
malignant tumor of endothelial origin
| associated with exposure to aresenic, vinyl chloride
161
Cavernous hemangioma
benign liver tumor
30-50
contraindicated biopsy
162
Hepatic adenoma
benign liver tumor
related to OTC or steroid
may regress or rupture
163
Metastases
GI, breast and lung
164
Budd Chiari
Thrombosis or compression of hepatic V with centrilobar congestion and necrosis --> congestive liver disease
absent JVD
associated with hypercoaguable states, polycythemia vera, postpartum state, HCC
nutmeg liver
165
a1 antitrypsin deficiency
misfolded gene product protein aggregates in hepatocellular ER --> cirrhosis PAS +
young with liver damage and dyspnea (panacinar emphysema)
166
Jaundice
Hemolysis
Obstruction
Tumor
Liver Disease
167
Conjugated hyperbilirubinemia
gallstone, cholangiocarcinoma, pancreatic or liver cancer, liver fluke
PSC, PBC
Dubin johnson, Rotor syndrome
168
Unconjugated hyperbilirubinemia
hemolytic, newborns, Crigler Najjar, Gilbert
169
Mixed hyperbilirubinemia
Hepatits, cirrhosis
170
Neonatal Jaundice
immature UDP GT --> unconjugated hyperbilirubinemia --> jaundice/ Kernicterus
after 24 hours of life and resolves within 1-2 weeks
T(x) phototherapy
171
Biliary atresia
fibro obliterative destruction of extrahepatic bile ducts --> cholestasis
persistent jaundice after 2 weeks of life, dark urine, white stool, hepatomegaly
Increase direct bilirubin and GGT
172
Gilbert
low UDP GT and impaired bilirubin uptake
asymptomatic, mild jaundice with stress, illness or fasting
increased unconjugated bilirubin
173
Criggler Najjar Type 1
Absent UDP GT
Jaundice, kernicterus, high unconjugated bilirubin
T(x) plasmapheresis and phototherapy
174
Crigger Najjar Type 2
Less severe
| responds to phenobarbital
175
Dubin Johnson
conjugated hyperbilirubinemia due to defect in liver excretion
Black liver
176
Rotor syndrome
Similar to Dubin Johnson but milder
without black liver
impaired hepatic uptake and excretion
177
Wilson Disease
AR
ATP7B mut Chr 13 --> low copper incorporation into apoceruloplasmin and excretion into bile --> low serum ceruloplasmin
Copper accumulates in liver, brain, cornea, kidney
<40 years
liver disease, neuro, psych, Kayser Fleischer rings, hemolytic anemia, renal disease
T(x) chelation with penicillamine, oral zinc
178
Hemochromatosis
AR HFE gene chr 6
associated with HLA A3
abnormal iron sensing and increased intestinal absorption
Secondary to transfusion
>40 years
cirrhosis, DM, skin pigmentation, restrictive/dilated cardiomyopathy hypogonadism
HCC common cause of death
T(x): repeat phlebotomy, Fe chelation with defe-
179
PSC
onion skin bile duct fibrosis --> alternating stricture and dilations (beading)
Middle aged men with UC
p-ANCA, high IgM
increased risk of cholangiocarcinoma and gallbladder cancer
180
PBC
Autoimmune reaction --> lymphocytic infiltrate +/- granuloma --> destroy lobular bile ducts
middle age women
Anti mitochondria, high IgM, associated with other autoimmune conditions
T(x) ursodiol
181
Secondary billiary cirrhosis
extrahepatic biliary obstruction --> high pressure in intrahepatic ducts --> injury/ fibrosis and bile stasis
patients with known obstructive lesions
complicated by ascending cholangitis
182
Cholelithiasis
increase cholesterol or bilirubine, low bile salts and gallbladder stasis
Female, fat, fertile, forty
Complication: cholecystitis, acute pancreatitis, ascending cholangitis
Dx US
Tx cholecystectomy
183
Cholesterol stones
Radiolucent
| obesity, Crohn, old, estrogen therapy, multiparity, rapid weight loss
184
Pigment stones
black
| Crohn disease, chronic hemolysis, alcoholic cirrhosis, old, biliary infections, total parental nutrition
185
Biliary Colic
Nausea and vomiting and dull RUQ
neurohormonal activation trigger contractions of gallbladder, forcing stone into cystic duct
Labs normal
US cholelithiasis
186
Choledocholithiasis
gallstones in common bile duct
| elevated ALP, GGT, direct bilirubin, AST/ALT
187
Calculous cholecystitis
via gallstone impaction in the cystic duct resulting in inflammation and gallbladder wall thickening
188
Acalculous cholecystitis
via gallbladder stasis, hypoperfusion, CMV
Murphy sign- inspiratory arrest on RUQ due to pain. Pain radiate to right shoulder. High ALP
Dx with HIDA
189
Gallstone ileus
fistula between gallbladder and GI tract --> stone enters GI lumen --> obstructs at ileocecal valve
pneumobilia + SBO + gallstone
190
Porcelain gallbladder
calcified gallbladder due to chronic cholecystitis
| T(x) prophylactic cholecystectomy
191
Ascending cholangitis
infection of biliary tree via obstruction that leads to stasis/ bacterial overgrowth
JAUNDICE, FEVER, RUQ PAIN (AMS, SHOCK)
192
Acute pancreatitis
autodigestion of pancreas
causes: idiopathic, gallstones, alcohol, trauma, steroids, Mumps, autoimmune disease, ERCP, drugs
acute epigastric pain radiating to back, increase amylase or lipase
complications: pseudocyst, abscess, necrosis, hemorrhage, infection, organ failure, hypocalcemia
193
Chronic pancreatitis
chronic inflammation, atrophy, calcification
via alcohol abuse and genetics
Complications: pancreatic insufficiency pseudocysts
194
Pancreatic adenocarcinom
pancreatic head
CA 19-9, CEA
Risk factors: smoking, chronic pancreatitis, DM, old, male
ab pain radiate to back, weight loss, migratory thrombophlebitis, obstructive jaundice with palpable nontender gallbladder
195
Histamine 2 blockers
-idine
Reversible block of H2 receptor --> decrease H secretion
used for peptic ulcer, gastritis, esophageal reflux
196
Cimetidine side effects
inhibit Cytochrome p 450
antiandrogenic effects
cross BBB and placenta
decrease renal excretion of creatinine
197
PPI
-prazole
irreversibly inhibit H+/K+ ATPase in stomach parietal cells
used in peptic ulcer, gastritis, Zollinger Ellison
Side effects: increase risk of C difficile, pneumonia, acute interstitial nephritis, Vitamin B 12 malabsorption
198
Antacids
affect absorption, bioavailability or urinary excretion by altering gastric and urinary pH
cause hypokalemia
199
Aluminum hydroxide
Antacid
| Constipation, hypophosphatemia, osteodystrophy, proximal muscle weakness, seizures
200
Calcium carbonate
Antacid
| hypercalcemia, rebound acid increase
201
Mg Hydroxide
Antacid
| diarrhea, hyporeflexia, hypotension, cardiac arrest
202
Bismuth, sucralfate
bind to ulcer base, allow HCO3 secretion to reestablish pH
| used in ulcer healing, travelers diarrhea, H. pylori gastritis
203
Misoprostol
PGE1 analog --> increase secretion of gastric mucous barrier, decrease acid production
used in prevention of NSAID induced peptic ulcers, induce labor
Adverse: diarrhea
204
Ocreotide
somatostatin analog
used in acute variceal bleeds, acromegalu, VIPoma, carcinoid tumors
Adverse: nausea, cramps, steatorrhea, increase risk of cholelithiasis
205
Sulfasalazine
used for UC and Crohns
| Adverse: malaise, nausea, tox, oligospermia
206
Loperamide
Agonist of mu opioid receptor --> slow gut motility
used for diarrhea
Adverse: constipation, nausea
207
Ondansetron
5HT3 antagonist --> decrease vagal stimulation
used to control post op vomiting and chemo
Adverse: HA, constipation, QT prolong, serotonin syndrome
208
Metoclopramide
D2 receptor antagonist --> increase resting tone, contractility, LES tone, motility, promote gastric emptying
used in diabetic and post op gastroparesis, antiemetic, GERD
Adverse: parkinson, interact with digoxin and diabetic meds
contra in SBO, parkinsons
209
Orlistat
inhibit gastric and pancreatic lipase --> decrease breakdown and absorption of dietary fats
used for weight loss
Adverse: ab pain, flatulent, bowel urgency, steatorrhea, decreased absorption of fat soluble vitamins
210
Bulk forming laxatives
psyllium, methylcellulose
soluble fibers draw water into gut lumen --> promote peristalsis
Adverse: bloating
211
Osmotic laxatives
Mg hydroxide, Mg citrate, polyethylene glycol, lactulose
draw water into GI lumen
Adverse: diarrhea, dehydration, bulimic abuse
212
stimulant laxatives
Senna
enteric ner stimulation --> contraction
Adverse: diarrhea, melanosis coli
213
Emollient laxative
Docusate
promote incorporation of water and fat into stool
Adverse: diarrhea
214
Aprepitant
Substance P antagonist, block NK1 receptors in brain
| used for antiemetic for chemo induced nausea and vomiting
