GI Flashcards
GI embryo
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
Gastroschisis
extrusion of abdominal contents through abdominal folds
NOT covered by peritoneum or amnion
NOT associated with chromosome abnormalities
Good prognosis
Omphalocele
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
Congenital umbilical hernia
failure of umbilical ring to close after physiologic herniation of the midgut
Small defects close spontaneously
Tracheoesophageal anomalies
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
Duodenal Atresia
bilious vomiting and abdominal distention within first few days of life
failure to recanalize
Ab XRAY –> double bubble
Associated with Downs
Jejunal and ileal atresia
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
Hypertrophic pyloric stenosis
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
Pancreas embryo
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
Annular pancreas
abnormal rotation of central pancreatic bud forms a ring of pancreatic tissue–> encircle 2nd part of duodenum –> vomiting
Pancreas divisum
central and dorsal parts fail to fuse at 8 weeks.
chronic ab pain or pancreatitis
spleen embryo
arise in mesentery of stomach but has foregut supply (celiac trunk –> splenic A)
Retroperitoneal structures
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
Falciform L
liver to anterior ab wall
hold Ligamentum teres hepatis and patent paraumbilical V
Derivative of ventral mesentery
Hepatoduodenal L
liver to duodenum
contains portal triad
Derivative of ventral mesentery
Part of lesser omentum
Pringle Maneuver
Ligament is compressed manually or with clamp in omental foramen to control bleeding from hepatic inflow source
Gastrohepatic L
liver to lesser stomach contains gastric vessels Derivative of ventral mesentery Separates greater and lesser sacs o right Lesser omentum
Gatrosplenic L
greater stomach and spleen
contains short gastrics, left gasroepiploic vessels
Dorsal mesentery
greater omentum
Gastrocolic L
greater stomach and transverse colon
contain gastroepiploic A
dorsal mesentery
greater omentum
splenorenal L
spleen to left pararenal space
contains splenic artery and vein, tail of pancreas
Dorsal mesentery
Nutcracker Syndrome
compression of L renal V between SMA and aorta
ab pain, gross hematuria
SMA syndrome
intermittent intestinal obstruction symptoms when SMA and aorta compress transverse portion of duodenum
Associated with diminished mesenteric fat
Esophagus anatasmosis
esophageal varices
L gastric to esophagus
drains into azygous
Umbilicus anastamosis
Caput Medusae
paraumbilical to small epigasstric veins of the anterior abdominal wall
Rectum anastamosis
anorectal varices
superior rectum to middle and inferior rectum
Internal hemorrhoids
receive visceral innervation and therefore not painful
above pectinate line
External hemorrhoids
receive somatic innervation and therefore painful
below pectinate line
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
Zone 1 of Liver
periportal zone
affected 1st by viral hepatitis
best oxygenated, most resistant to circulatory compromise
ingested toxins
Zone 2 of liver
intermediate zone
yellow fever
Zone 3 of liver
pericentral vein affected 1st by ischemia high concentration of cytochrome p450 most sensitive to metabolic toxins site of alcoholic hepatitis
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
Tumors that arise in the head of the pancreas
obstruct common bile duct –> enlarge gallbladder with painless jaundice
Femoral vasculature organization
lateral to medial Nerve, Artery, Vein, Lymphatics
Femoral Triangle
contains femoral nerve artery and vein
femoral sheath
fascial tube 3-4 cm below inguinal L
contain femoral vein, artery and canal but not nerve
Sliding hiatal hernia
gastroesophageal junction is displaced upward as gastric cardia slides into hiatus. Hourglass stomach
Most common
GERD
Paraesophageal hiatal hernia
gastroesophageal junction is usually normal but gastric fundus protrudes into the thorax
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
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
Femoral Hernia
protrudes below inguinal L through femoral canal below and lateral to pubic tubercle
Females
present incarceration or strangulation
Gastrin
G cells (antrum,duodenum)
increase gastric H+ secretion, growth of gastric mucosa and gastric motility
decreased by pH <1.5
Somatostatin
D cells (pancreatic islet, GI mucosa) decrease gastric acid and pepsinogen, pancreatic and small intestine fluid secretion, gallbladder contraction, insulin and glucagon.
Cholecystokinin
I cells (duodenum and jejunum)
increase pancreatic secretion, gallbladder contraction, sphincter of oddi relaxation. Decrease gastric emptying
increase by FA and AA
Secretin
S cells (duodenum)
increase pancreatic bicarb, bile secretion
decrease gastric acid secretion
Increased by acid, FA in duodenum
Glucose dependent insulinotropic peptide
K cells (duodenum, jejunum)
decrease gastric H+ secretion
increased by FA, AA and oral glucose
Motilin
Small intestine
produce migrating motor complex
increase in fasting state
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
VIPoma
water diarrhea, hypokalemia, achlorhydria
NO
increase smooth muscle relaxation of LES
Ghrelin
Stomach
increase appetite
increased in fasting state and decreased by food
Intrinsic Factor
Parietal cells
Vitamin B12 binding
Gastric acid
parietal cells
decrease stomach pH
increase histamine, vagal stimulation, decrease by somatostatin, GIP, PG, secretin
Pepsin
chief cells
protein digestion
increase vagal stimulation
Bicarconate
mucosal cells and brunner glands
neutralize acid
increased by pancreatic and biliary secretion wiht secretin
Pancreatic secretion
a amylase
Lipase
Protease
Trypsinogen
Carb absorption
Glucose and galactose –> SGLT1 (Na+ dependent)
Fructose –>GLUT5
All transported by GLUT2
Iron absorption
absorbed Fe2+ in duodenum
Folate
absorbed in small bowel
Vitamin B12
absorbed in terminal ileum along with bile salts, requires IF
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
Bile
Composed of bile salts, phospholipids, cholesterol, bilirubin water and ions
Rate limiting bile synthesis: Cholesterol 7a hydroxylase
Bile functions
Digestion and absorption of lipids and fat soluble vitamins
Cholesterol excretion
Antimicrobial activity
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
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
Sialadenitis
inflammation of salivary gland due to obstruction, infection, immune mediated mechanisms
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
Mucoepidermoid carcinoma
most common malignant tumor, has mucinous and squamous components
Warthin Tumor
benign cystic tumor wiht germinal centers
Smokes
bilateral Multifocal
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
Secondary Achalasia
Chagas disease or extraesophageal malignancies
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
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
Esophageal perforation
iatrogenic post esophageal instrumentation
pneumomediastinum, subcutaneous emphysema
Boerhaave syndrome
transmural, distal esophageal rupture due to violent retching
Esophageal strictures
associated with caustic ingestion, acid reflux, esophagitis
Esophageal varices
dilated submucosal veins in lower 1/3 of esophagus secondary to portal HTN
cirrhotics –> life threatening hematemesis
Esophagitis
Associated with reflux, infection in immunocompromised Candida- white pseudomembrane HSV1- punched out ulcers CMV- linear ulcers caustic ingestion, or pill induced
GERD
heartburn, regurgitation, dysphagia
chronic cough, hoarseness
Associated with asthma
Transient decreased in LES tone
Mallory Weiss Syndrome
partial thickness, longitudinal lacerations of gastroesophageal junction, confined to mucosa/ submucosa due to severe vomiting.
present as hematemesis
ALCHOLICS and BULIMICS
Plummer Vinson Syndrome
Dysphagia, Iron deficiency anemia, esophageal webs
increase risk of esophageal SCC
may be associated with glossitis
Schatzki rings
rings formed at gastroesophageal junction via chronic acid reflux
dysphagia
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
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
Esophageal cancer
progressive dysphagia (solids then liquids) and weight loss Aggressive course due to lack of serosa in esophageal wall, allowing rapid extension
SCC of esophagus
upper 2/3
Risk factors alcohol, hot liquids, caustic strictures, smoking, achalasia
Adenocarcinoma of esophagus
Lower 1/3
chronic GERD, Barrett esophagus, obesity, smoking, achalasia
Acute Gastritis
via NSAIDs, burns, brain injury, ALCOHOLICS
H. pylori gastritis
chronic
increase risk of PUD, MALT lymphoma
Antrum –> body
Autoimmune gastritis
Chronic
autoantibodies to H+/K+ ATPase on parietal cells and IF
increase risk of pernicious anemia
body/fundus
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
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
Gastric ulcer
pain greater with meals –> weight loss
low mucosal protection against gastric acid
via NSAIDs
increase risk of carcinoma
Duodenal ulcer
decreases with meal –> weight gain
H. pylori, Zollinger Ellison
low mucosal protection of increased gastric acid secretion
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
Ulcer complications Obstruction
pyloric channel, duodenal
Ulcer complications Perforation
Duodenal
Anterior can perforate into anterior ab cavity –> pneumoperitoneum
Referred pain to shoulder via phrenic
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.
Lactose intolerance
Lactase deficiency
Normal vili
osmotic diarrhea with low stool pH
Lactose H+ breath test
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
Trpoical sprue
Similar to celiac sprue respond to Abx tropics decrease mucosal absorption affecting duodenum and jejunum Associated wtih megaloblastic anemia
Whipple disease
Gram + PAS + foamy macrophades in intestinal lamina propria, mesenteric nodes
Cardiac, arthralgias, neuro, diarrhea/ steatorrhea
old men
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
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
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
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
Diverticulum
blind pouch protruding form the alimentary tract that communicates with the lumen of the gut.
True diverticulum
all gut wall layer outpouch
False diverticulum
only mucosa and submucosa outpouch. Where vasa recta perforate muscularis externa
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
Diverticulitis
inflammation of diverticula with wall thickening –> LLQ pain, fever, leukocytosis
Tx Abx
Complications: abscess, fistula, obstruction, perforation
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
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
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
Malrotation
Anomaly of midgut roatation during fetal development –> improper positioning of bowel, formation of fibrous bands
lead to volvulus, duodenal obstruction
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
Volvulus
twisting bowel around its mesentery –> obstruction/ infarction
Midgut = more common in infants and children
Sigmoid = more common in elderly
Acute mesenteric ischemia
critical blockage of intestinal blood flow –> small bowel necrosis –> ab pain out of proportion
currant jelly stool
Adhesion
fibrous band of scar tissue via small bowel obstruction
MULTIPLE DILATED SMALL BOWEL LOOPS
Angiodysplasia
tortuous dilation of vessels –> hematochezia
right sided colon
older
assoicated with end stage renal disease, von willebrand, aortic stenosis
chronic mesenteric ischemia
intestinal angina
atherosclerosis of celiac A, SMA or IMA –> intestinal hypoperfusion –> postprandial epigastric pain –> food aversion and weight loss
Colonic ischemia
reduction in intestinal blood flow causes ischemia crampy ab pain --> hematochezia watershed area elderly thumbprint sign
Ileus
intestinal hypomotility wihtout obstruction –> constipation and decreased flatus, distended ab with low bowel sounds
Associated with ab surgery, opiates, hypokalemia, sepsis
Meconium ileus
meconium plug obstructs intestine, prevents stool passage at birth
associated with cystic fibrosis
Necrotizing Enterocolitis
premature, formula fed infants with immature immune system
Necrosis of intestinal mucosa with possible perforation –> pneumatosis intestinalis, pneumoperitoneum, portal vein gas
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
Hyperplastic polyps
Most common
smaller and located in rectosigmoidal region
evolves into serrated polyp and more advanced lesions
inflammatory pseudopolyps
due to mucosal erosion in inflammatory bowel disease
Mucosal polyps
small usually <5 mm insignficant
Submucosal polyps
may include lipomas, leiomyomas, fibromas, and other lesions
Adenomatous polyps
neoplastic via APC and KRAS mut
tubular less malignant than villous
Asymptomatic, occult bleeding
Serrated polyps
Neoplastic
CpG island methylation –> silence MMR gene –> microsatellite instability and BRAF mut
saw tooth pattern of crypts
Familial adenomatous polyposis
AD APC mut on 5q22
1000s of polyps arise starting after puberty
ALWAYS RECTUM
prophylactic colectomy or progress to CRC
Gardner Syndrome
FAP + osseous and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium, impacted teeth
Tucot Syndrome
FAP or Lynch syndrome + malignant CNS tumor
Peutz Jegher Syndrome
AD
hamartomas + hyperigmented macules on mouth, hands, genitalia
increased risk of breast and GI cancers
Juvenile polyposis syndrome
AD children
hamartomatous polyps in colon, stomach, small bowel
Increased risk of CRC
Lynch syndrome
HNPCC
AD mut MLH1 MSH2 with microsatellite instability
progress to CRC
proximal colon
Associated with endometrial, ovarian and skin cancers
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
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
Risk factors for colorectal cancer
adenomatous and serrated polyps, familial cancer syndromes, IBD, tobacco, diet with processed meat and low fiber
PATH of colorectial cancer
mut of APC –> FAP and sporadic CRC
Mut of MLH1 –> Lynch syndrome
Overexpress COX 2
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
Portal HTN
increase pressure in portal venous system
via cirrhosis, vascular obstruction, schistosomiasis
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
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
ALP
increase in cholestasis
infiltrating disorders
bone disease
GGT
increase in liver and biliary disease but not bone disease
associated with alcohol use
Bilirubin
increase in liver disease and hemolysis
Albumin
decrease in advanced liver disease
PTT
increase in advanced liver disease
platelets
decrease in advanced liver disease and portal HTN
Reye Syndrome
fatal childhood hepatic encephalopathy
associated with viral infection treated with aspirin
mitochondrial abnormalities, fatty liver, hypoglycemia, vomiting, heptaomegaly, coma
Hepatic steatosis
macrovesicular fatty change that may be reversible with alcohol cessation
Alcoholic hepatitis
sustained long term consumption
swollen and necrotic hepatocytes with neutrophilic infiltration
Mallory bodies
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
Nonalcoholic fatty liver disease
metabolic syndrome
obesity –> fatty infiltration of hepatocytes –> cellular ballooning and necrosis
May cause cirrhosis and HCC
ALT >AST
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
HCC
Associated with HBV, HCV, alcohol May lead to budd chiari jaundice, tender hepatomegaly, ascites, polycythemia, anorexia spread via blood increase AFP
Angiosarcoma
malignant tumor of endothelial origin
associated with exposure to aresenic, vinyl chloride
Cavernous hemangioma
benign liver tumor
30-50
contraindicated biopsy
Hepatic adenoma
benign liver tumor
related to OTC or steroid
may regress or rupture
Metastases
GI, breast and lung
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
a1 antitrypsin deficiency
misfolded gene product protein aggregates in hepatocellular ER –> cirrhosis PAS +
young with liver damage and dyspnea (panacinar emphysema)
Jaundice
Hemolysis
Obstruction
Tumor
Liver Disease
Conjugated hyperbilirubinemia
gallstone, cholangiocarcinoma, pancreatic or liver cancer, liver fluke
PSC, PBC
Dubin johnson, Rotor syndrome
Unconjugated hyperbilirubinemia
hemolytic, newborns, Crigler Najjar, Gilbert
Mixed hyperbilirubinemia
Hepatits, cirrhosis
Neonatal Jaundice
immature UDP GT –> unconjugated hyperbilirubinemia –> jaundice/ Kernicterus
after 24 hours of life and resolves within 1-2 weeks
T(x) phototherapy
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
Gilbert
low UDP GT and impaired bilirubin uptake
asymptomatic, mild jaundice with stress, illness or fasting
increased unconjugated bilirubin
Criggler Najjar Type 1
Absent UDP GT
Jaundice, kernicterus, high unconjugated bilirubin
T(x) plasmapheresis and phototherapy
Crigger Najjar Type 2
Less severe
responds to phenobarbital
Dubin Johnson
conjugated hyperbilirubinemia due to defect in liver excretion
Black liver
Rotor syndrome
Similar to Dubin Johnson but milder
without black liver
impaired hepatic uptake and excretion
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
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-
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
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
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
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
Cholesterol stones
Radiolucent
obesity, Crohn, old, estrogen therapy, multiparity, rapid weight loss
Pigment stones
black
Crohn disease, chronic hemolysis, alcoholic cirrhosis, old, biliary infections, total parental nutrition
Biliary Colic
Nausea and vomiting and dull RUQ
neurohormonal activation trigger contractions of gallbladder, forcing stone into cystic duct
Labs normal
US cholelithiasis
Choledocholithiasis
gallstones in common bile duct
elevated ALP, GGT, direct bilirubin, AST/ALT
Calculous cholecystitis
via gallstone impaction in the cystic duct resulting in inflammation and gallbladder wall thickening
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
Gallstone ileus
fistula between gallbladder and GI tract –> stone enters GI lumen –> obstructs at ileocecal valve
pneumobilia + SBO + gallstone
Porcelain gallbladder
calcified gallbladder due to chronic cholecystitis
T(x) prophylactic cholecystectomy
Ascending cholangitis
infection of biliary tree via obstruction that leads to stasis/ bacterial overgrowth
JAUNDICE, FEVER, RUQ PAIN (AMS, SHOCK)
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
Chronic pancreatitis
chronic inflammation, atrophy, calcification
via alcohol abuse and genetics
Complications: pancreatic insufficiency pseudocysts
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
Histamine 2 blockers
-idine
Reversible block of H2 receptor –> decrease H secretion
used for peptic ulcer, gastritis, esophageal reflux
Cimetidine side effects
inhibit Cytochrome p 450
antiandrogenic effects
cross BBB and placenta
decrease renal excretion of creatinine
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
Antacids
affect absorption, bioavailability or urinary excretion by altering gastric and urinary pH
cause hypokalemia
Aluminum hydroxide
Antacid
Constipation, hypophosphatemia, osteodystrophy, proximal muscle weakness, seizures
Calcium carbonate
Antacid
hypercalcemia, rebound acid increase
Mg Hydroxide
Antacid
diarrhea, hyporeflexia, hypotension, cardiac arrest
Bismuth, sucralfate
bind to ulcer base, allow HCO3 secretion to reestablish pH
used in ulcer healing, travelers diarrhea, H. pylori gastritis
Misoprostol
PGE1 analog –> increase secretion of gastric mucous barrier, decrease acid production
used in prevention of NSAID induced peptic ulcers, induce labor
Adverse: diarrhea
Ocreotide
somatostatin analog
used in acute variceal bleeds, acromegalu, VIPoma, carcinoid tumors
Adverse: nausea, cramps, steatorrhea, increase risk of cholelithiasis
Sulfasalazine
used for UC and Crohns
Adverse: malaise, nausea, tox, oligospermia
Loperamide
Agonist of mu opioid receptor –> slow gut motility
used for diarrhea
Adverse: constipation, nausea
Ondansetron
5HT3 antagonist –> decrease vagal stimulation
used to control post op vomiting and chemo
Adverse: HA, constipation, QT prolong, serotonin syndrome
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
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
Bulk forming laxatives
psyllium, methylcellulose
soluble fibers draw water into gut lumen –> promote peristalsis
Adverse: bloating
Osmotic laxatives
Mg hydroxide, Mg citrate, polyethylene glycol, lactulose
draw water into GI lumen
Adverse: diarrhea, dehydration, bulimic abuse
stimulant laxatives
Senna
enteric ner stimulation –> contraction
Adverse: diarrhea, melanosis coli
Emollient laxative
Docusate
promote incorporation of water and fat into stool
Adverse: diarrhea
Aprepitant
Substance P antagonist, block NK1 receptors in brain
used for antiemetic for chemo induced nausea and vomiting
