GI Test 2 STUDY! Flashcards
What is a polyp and what are the 3 things they can lead to
a protuberance extending into the lumen of the colon
Typically asymptomatic, but may lead to
Bleeding (commonly)
Tenesmus
Obstruction
What are the 3 different types of polyps
Pedunculated (can get really large)
Flat
Sessile (most common)
What are the 4 major pathological groups of polyps
Mucosal Adenomatous (neoplastic)
Mucosal Serrated (neoplastic)
Mucosal Non-Neoplastic
Submucosal Lesions
What are the two types of neoplastic polyps
Adenomatous (most common) - malignant potential
Serrated:
- Hyperplastic, very common, but no sig RSK. Skin tag.
- Sessile serrated polyps have a similar risk/ greater risk to malignancy as Adenomatous polyps
Non- neoplastic polyps are a low risk for
Cancer
What are the mucosal non neoplastic polyps
Juvenile polyps, hamartomas, inflammatory polyps – increased risk of cancer
What are the Submucosal lesions that have no cancer risk vs the one that does
Lipomas, lymphoid aggregates - no clinical significance
Pneumatosis cystoides intestinalis – air filled cysts
Carcinoid tumor - cancer
What polyps have the highest risk for cancer
Mucosal non-neoplastic
Juvenile polyps, hamartomas, inflammatory polyps – increased risk of cancer
DO name: inherited DO, 100-1000 polyps, by age 15, cancer development is inevitable by age 40-50.
What is the Tx?
FAP ( familial Adenomatous polypsosis)
Treatment:
Prophylactic colectomy, typically before age 20
Annual colonoscopy until colectomy
hamartomatous polyps + oral mucocutaneous pigmented macules, increased risk of GI cancer
= peutz-jeghers syndrome ( hamartomatous polyposis)
multiple hamartomatous polyps, increased risk of GI cancer
Familial Juvenile Polyposis
hamartomatous polyps + lipomas throughout GI tract, increased risk of non-GI cancer
Cowdens Dz
Large polyps can cause
Bleeding,
GI obstruction
Intussusception
What is Lynch syndrome
Hereditary Nonpolyposis Colon Cancer (HNPCC)
Autosomal dominant condition
Increased risk of cancer: Colorectal Endometrial Ovarian Renal Vesical Hepatobiliary Gastric Small intestinal
Bethesda Criteria used for screening
What are the RSK FX for Colorectal Cancer
Age
-Incidence rises after age 45
Family history
-First degree relatives
Inflammatory Bowel Disease
Dietary and Lifestyle Factors
- High fat, processed, red meat vs high fiber
- Physical activity, obesity
- Smoking
What can you add to your diet to decrease colorectal cancer
High fiber diets
What is the most common cause of large bowel obstruction in adults
Colorectal Cancer
What is the gold standard screen for colorectal cancer
Colonoscopy
What is the most common cause of occult GI bleeding in adults
Colorectal cancer
Tests:
FOBT and Iron deficiency anemia
What is the most commonly monitored tumor marker for colorectal cancer and how is it monitored
Carcinoembryonic antigen (CEA)
- NOT a screening test
- Useful for prognosis after diagnosis
- Used as marker for recurrence after treatment
What is the test interval for colonoscopy?
For Flexible Sigmoidscopy?
Colonoscopy q 10 yrs
Flexible Sigmoidoscopy q 5 yrs
If a polyp is found with flexible sigmoidoscopy then what must be done next
Colonoscopy
What is the confirmatory test for colorectal test
BIOPSY!
At what age should African American begin getting screened for colon cancer
45 yo
What is the preferred cancer detection test
Anual FIT for blood
What is the option for pts who don’t want colonoscopy
CT Colonography (“virtual colonoscopy”)
Every 5 yrs
Used if colonoscopy not desired or contraindicated
Less sensitive for polyps <1 cm, flat adenomas, and serrated polyps
Requires bowel prep, no sedation
What are the CRC screening recommendations
Cancer prevention tests should be ordered first,
Preferred test is colonoscopy q 10 yrs at 45 yo
Cancer detection test- FIT blood test preferred or FIT DNA test
A pt with colon cancer with iron deficiency and weaknesss/ fatigue.. where is the cancer location
Right Colon likely
Pt with colon cancer with change in bowel habits, stool streaked with blood, and obstructive S/s ( constipation/ or increased frequency), + colicky abdominal pain
Left Colon most likely
Pt with colon cancer with hematochezia, tenesmus, BM urgency and decrease in caliber of stool “ ribbon stool”
Where is the cancer location
Rectum likely
What is the general W-up and Tx for colorectal cancer
Work up: Fecal occult blood test (FOBT) Guaiac or FIT CBC CMP UA
Colonoscopy ( gold standard)
Treatment: Surgical Resection -Full or partial colectomy Chemotherapy Radiotherapy
What are the 5 stages of prognosis for colorectal cancer
Stage I - greater than 90% SR
Stage II – 70 - 85%SR
Stage III with < 4 positive lymph nodes - 67% SR
Stage III with > 4 positive lymph nodes - 33% SR
Stage IV – 5 -7%. SR
For each stage, rectal cancers have a worse prognosis/ Survival rate ( SR)
What is the 1st line TX for C. Diff colitis
Oral Vancomycin
Antibiotic assoc colitis relapses require
7 week taper of Vanc
What is Crohns Dz
Chronic inflammatory disease
!Transmural process !
Variable locations - may involve the entire GI tract from mouth to anus
Variable severity of inflammation - mild to severe/fulminant disease
Worse in smokers!
What is the characteristic endoscopy finding in crohn Dz
Skip lesions
What are the Hallmark S/s of crohns
Abdominal pain Diarrhea +/- blood Fatigue Weight loss Fever Growth failure (younger patients) Anemia
What are the main c/o of patients with Crohns
Cramp ab pain, RLQ, diarrhea, Wt loss, Growth delays
Malabsorption leads to Iron Def and B12 def.
Anorectal fístulas and bowel obstruction
What is the def of ileitis
SB only (terminal ileum (ileitis) – Crohns
What is ileocolitis
SB + colon Crohns
What are the RSKs of Crohns Dz complications
May result in mucosal inflammation and ulceration, structuring (obstruction), fistula development, and abscess formation
Ileal, ileocolonic, or proximal GI involvement Extensive anatomic involvement Deep ulcerations Young age at diagnosis Perianal/severe rectal disease Penetrating or stenosis on presentation
What is phlegmon
walled off inflammatory mass without bacterial infection
may be palpable on physical examination
most often presents as an indolent process, and not as an acute abdomen
Penetration of Crohns Dz can lead to an intra abdominal abcess, which present how?
acute presentation of localized peritonitis with fever, abdominal pain and tenderness
What are the 4 common sites for fistula formation in crohns Dz
Bladder (enterovesical)
Skin (enterocutaneous)
Small bowel (enteroenteric)
Vagina (enterovaginal)
What complication is associated with fístulas to the retro peritoneum
Fistulas to the retroperitoneum may lead to psoas abscesses or ureteral obstruction with hydronephrosis
What are some extra intestinal manifestestions
Apthous ulcers, inflammatory skin conditions, Joint pains, MSK pains, Inflammations of the Iris or Uvula, can also effect the gall bladder increasing gall stones
What are the inflammations of the skin with Crohns
Pyoderma Gangrenosum and Erthyma Nodosum
Is there a specific lab work up for Crohns
NO
What does crohns look like on endoscopy
Cobblestoning of the mucosal surface
How is the managment of Crohns tracked
Colonoscopy and Endoscopys
How do you evaluate for small bowel involvement in Crohns
Capsule endoscopy
What is the DO criteria for Crohns
BIOPSY!
What level of Crohns is a pt that Responded to medical or surgical therapy
No current active disease
Asymptomatic remission
What level of Crohns is a pt that is Ambulatory, eating/drinking normally
<10% weight loss
No complications, dehydration, systemic toxicity, abdominal tenderness, painful mass
Endoscopy – lesions which are not severe
Mild- Moderate Crohns
What is the crohns level for a pt with Failed treatment for mild-moderate disease
Fever, weight loss > 10%, abdominal pain or tenderness, N/V without obstruction, significant anemia.
Endoscopy: Moderate to severely active mucosal disease
Moderate to Severe Crohns
What level of crohns is a pt with Significant/extreme weight loss and muscle wasting
Persistent symptoms despite steroids or biologic agents as outpatient
High fever, persistent vomiting, intestinal obstruction, involuntary guarding or rebound tenderness, or evidence of abscess
Endoscopy: Severe mucosal disease
Sever/ Fulminant Crohns
What is the Tx approach to Crohns
Avoid NSAIDs when possible
- Often associated with flares
- Cause damage to small intestine mucosa
Smoking Cessation
Stress Management
Treat Depression and Anxiety
Dietary Therapy
Anti diarrhea: Loperamide and Bile Acid Sequestrants
Oral Steroids for apthous ulcers: Kenalog
Glucocorticoids and Corticosteroids ( MILD or SEVERE)
Tax regimen for Mild to Moderate Crohns
isolated to the ileal and proximal colon: budesonide
Flares: predinose
What is the Tx of active Crohns that is moderate to severe
Prednisone
Pts who fail to respond to oral steroid therapy for chrons should be considered for…
Admission
Admit patient to inpatient ward (Internal Med)
IV Systemic Corticosteroids
bolus prior to starting infusion of infliximab
IV prednisone 40-60mg per day
What are the maintenance remission therapy drugs for Crohns Dz
Azathioprine
6-Mercaptopurine
Methotrexate
If immunomodualators do not work for Crohns what is the next step
1st steroids Then immunmodulators Then TNFS like : Infliximab (Remicade) Adalimumab (Humira) Certolizumab (Cimiza)
What are the surgical indications for Crohns Dz
Resection of a segment of diseased intestine - most common indication
Penetrating disease - second most common
Recurrent intestinal obstruction
Abscess formation
Complex perianal fistula
SURGERY IS NOT THE 1st LINE
What is the admission criteria for Crohns Dz
Suspected intestinal obstruction
Suspected intra-abdominal or perirectal abscess
Serious infectious complication
-especially in patients who are immunocompromised due to concomitant use of corticosteroids, immunomodulators, or anti-TNF agents.
Severe symptoms of diarrhea, dehydration, weight loss, or abdominal pain
Severe or persisting symptoms despite treatment with corticosteroids
If a pt has mild or moderate chrons, what is the pharm approach
Short-term use if disease is confined to terminal ileum and right colon, since medication is formulated to be released in this area
-Budesonide
If the pt has flares: Prednisone
If the pt is high RSK: Sulasalazine
What is the difference of Crohns vs UC
Crohns: transdural
UC: Involves the mucosal surface of the colon, resulting in diffuse friability and erosions with bleeding
What are the Montreal classifications of UC
- proctitis
- left sided colitis
- extensive colitis
Where does UC start and where does it progress
Starts in the rectum and advances proximally
What is the hallmark sign of UC
Blood diarrhea (hallmark) Rectal bleeding Cramps Abdominal pain Fecal urgency Tenesmus Extraintestinal symptoms
A patient with 4 or less BM/ Day, WIth episodes of constipation, mild abdominal pain, and no signs of Systemic Dz, what severity UC
Mild
A pt with more than 4 BM/ day, abdominal pain and may be anemic from bloody stools, what severity of UC
Moderate
A pt with 6 or more BM/day, sever ab pain , systemic fever, anemia, elevated ESR and CRP, may have wt loss is what severity UC
Severe
What is the DOC for UC
Topical Mesalamine ( suppository or enema)
If no improvement at 4 weeks with mesalamine in UC, what drug can be added
Prednisone
In Severe colitis what is the 1st line
Oral corticosteroid x 14 days, consider adding anti-TNF
infliximab, adalimumab, or golimumab
What is the Tx option for moderate to severe ulcerative colitis in patients who have not responded, lost response, or been intolerant of other therapies
Vedolizumab ( Anti-integrity)
What is the approach to sever or Fulminant Colitis
Inpatient care
Surgical consultation early
NPO
Parenteral fluid/electrolyte replacement
IV corticosteroids
What is the maintenance Tx for UC
Oral Mesalamine
> 2 relapses a year:
Mercaptopurine or Azathioprine
What are the screening recommendations for UC
Colonoscopy with biopsies every 1-2 years, beginning 8 years after diagnosis
What are the absolute and relative surgical indications for UC
Absolute:
Severe hemorrhage
Perforation
Carcinoma
Relative:
Severe colitis unresponsive to maximal medical therapy
Less severe colitis but medically intractable symptoms or intolerable medication side effects
A pt with UC and rapid progression of S/s, with worsening ab pain, Distention, High fever and tachycardia, has what severity of UC
Fulminant
What is the characteristic pattern of microscopic colitis
Chronic water diarrhea, with every other cause R/o
What are the two subtypes of microscopic colitis
Lymphocytic colitis – Lymphocytic colitis is characterized by an intraepithelial lymphocytic infiltrate
Collagenous colitis – Collagenous colitis is characterized by colonic subepithelial collagen band >10 micrometers in thickness
Who is at most RSK for microscopic colitis
Women
What is the clinical presentation of Microscopic colitis
Chronic, non-bloody diarrhea that is typically watery
between four and nine watery stools per day
Abdominal pain
May also experience:
Fatigue, dehydration, weight loss
If diarheaa persists with microscopic colitis what is the DOC
Budesonide
What is IBS
Function Bowel DO
Absence of organic Cause
DO of exclusion
Idiopathic
What is the hallmark presentation of IBS
Ab pain (often lower ab) assoc w/ altered BM habits (Constipation/ Diarrhea) . Pain often relieved with defecation.
What is IBS-C
Constipation predominant
Patients typically report ≤ 3 BM/week, with straining
What is IBS-D
Diarrhea predominant
Patients typically report ≥ 3 BM/day, with urgency or fecal incontinence
What is the DO for IBS
≥ 3 months of abdominal pain or discomfort and altered bowel habits
AND
The abdominal pain is associated with 2/3 of the following
- Relieved with defecation
- Onset associated with change in defecation frequency
- Onset associated with change in stool appearance
Pts with IBS should avoid what foods
Avoid sorbitol and fructose, gas producing foods, and cruciferous vegetables.
What should a IBS pt be recommended for Diet
Low fat, High fiber, unprocessed food diet
What diet modifications can be tried specifically with IBS-D
Trial of lactose elimination
Trial of gluten elimination
What diet modifications can be tried specifically with IBS-C
increase fiber, increase fluids
What is the 1st line Tx for IBS
Dietary and Lifesytle mods
Dicyclomine and Hyosyncamine are what agents
Antispasmodic
My help with pain and bloating in IBS
What are lubiprostone and linaclotide
Anticonstipation medications
Osmotic laxatives- use first
What is in a normal LFT
Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Alkaline Phosphatase Total Protein Bilirubin Albumin
What is a hepatocellular pattern on LFT
Elevated AST and ALT compared to ALP ,
Says that the damage is in the hepatocytes
What does a 2:1 elevation in AST:ALT indicate
Alcohol related liver disease
Particularly in light of a elevated GGT
What does GGT tell you
Elevated GGT levels can be observed in a variety of nonhepatic diseases, including chronic obstructive pulmonary disease and renal failure
What does a cholestatic pattern on LFT tell you
Elevated ALK PHOS (ALP)
Says a stoppage of the flow ( cholestasis)
What is the pressure gradient between the portal vein and IVC that causes Portal HTN
Greater than 10 mmHg
What is the most common etiology of portal HTN
Cirrhosis
When is Jaundice clinically apparent
> 2 mg/dl appears first in the conjunctiva
Jaundice caused by unconjugated bilirubin is due to
overproduction of bilirubin
- Hemolytic anemias
- Hemolytic reactions
- Hematoma
- Pulmonary infarction
impaired bilirubin uptake by the liver
- Posthepatitis hyperbilirubinemia
- Gilbert syndrome
- Crigler-Najjar syndrome
- Drug reactions
abnormalities of bilirubin conjugation
What does elevation of unconjugated and conjugated bilirubin tell you
hepatocellular disease
impaired canalicular excretion of bilirubin
biliary obstruction
Often referred to as conjugated hyperbilirubinemia, even though both fractions of bilirubin are elevated.
What can cause conjugated hyperbilirubinemia
Hepatocellular dysfunction Hepatitis, cirrhosis Biliary obstruction Choledocholithiasis, biliary atresia, carcinoma Hereditary cholestatic syndromes
A pt with Normal stool and urine color
No bilirubin in urine
Splenomegaly if etiology is hemolytic disorder
And mild jaundice has what kind of bilirubin problem
Unconjugated
A pt with jaundice, malaise, anorexia
low-grade fever, right upper quadrant discomfort
dark urine, amenorrhea
enlarged tender liver, spider telangiectasias, palmar erythema
ascites
gynecomastia
Has what kind of bilirubin problem
Conjugated
A pt with jaundice right upper quadrant pain weight loss (suggesting carcinoma) pruritus dark urine light-colored stools(acholic stools)
Biliary obstruction, Conjugatged
What is the W-up for Jaundice
Lab studies:
- Hepatic labs
- CBC, CMP, UA
Radiographs
-Hepatic ultrasound
ERCP to evaluate bile ducts
-If obstruction is suspected
What is an ERCP
An endoscopic technique in which a specialized side-viewing upper endoscope is guided into the duodenum, allowing for instruments to be passed into the bile and pancreatic ducts
Indicated in jaundiced patient suspected of having biliary obstruction.
What is the most common cause of acute liver failure
Acetaminophen
What is the INR in acute liver failure
> 1.5
A pt with INR > 1.5, elevated Aminotranferease, elevated bilirubin and ALP, low platelet count, elevated ammonia, elevated amylase and lipase, elevated BUN and Cr
Acute liver failure
What is the Tx approach to ALI
Acute liver injury/ failure
Admission for inpatient management
IV fluid and electrolyte replacement
Dietary monitoring
Gastroprotective measures (prevention of stress gastropathy)
IV PPI or H2
Other treatments as indicated based on etiology
What are the 4 phases of hepatitis
Viral replication
Prodromal
Icteric
Convalescent
What is phase 1 hepatitis
Phase 1 (viral replication phase)
Patients are asymptomatic during this phase
Laboratory studies demonstrate serologic and enzyme markers of hepatitis
What is phase 2 hepatitis
Phase 2 (prodromal phase) Anorexia, nausea, vomiting Arthralgias, malaise, fatigue Urticaria, pruritus Alterations in taste Development of an aversion to cigarette smoke
What is phase 3 hepatitis
Phase 3 (icteric phase) Predominant gastrointestinal symptoms Jaundice Dark urine, followed by pale-colored stools Malaise May develop RUQ pain with hepatomegaly
What is phase 4 hepatitis
Phase 4 (convalescent phase) Symptoms and jaundice resolve Liver enzymes return to normal
What is the transmission and incubation period for HepA
Fecal oral
30 day incubation
Viral shedding in feces for up to 2 weeks prior to onset of S/s
A pt with Malaise, myalgia, arthralgia Easy fatigability Upper respiratory symptoms Nausea & vomiting Anorexia Smokers develop distaste for cigarettes* Low grade fever Fever breaks - onset of jaundice (after 5-10 days)
What type of hepatitis
A
What lab marker is elevated in acute Hep A
IgM anti HAV in acute
IgG HAV Ab in chronic
What is the Tx approach to Acute Hep A
Bed rest if needed Symptomatic care Antiemetic, antidiarrheal Fluids regular meals Avoid strenuous exercise or work NO ALCOHOL OR HEPATOTOXIC MEDS
What is the mode of transmission of Acute Hep B
Inoculation of infected blood or blood products
Sexual contact
-Virus present in saliva, semen, and vaginal secretions
HBsAg positive mothers may transmit to newborn during delivery
What groups are at high risk for Acute Hep B
Healthcare workers
-Including staff at hemodialysis centers
IV drug users
Prisoners
incubation period for Acute Hep B
6weeks to 6 months ave. 12-14 weeks
What are the S/s and Lab findings for Acute Hep B (sub clinical, icteric, fulminant)
Sub clinical: malaise, arthalgia, fatigue, URI, N/V abdominal pain, anorexia, decreased desire to smoke
Icteric: Jaundince
Fulminant: Acute hepatic failure, encephalopathy, coagulapathy, jaundice, edema, ascites
LABS:
HB surface antigen, surface antibody, and core antibody
A pt presents with a Postive HBsAg and negative Anti-HBs, their AntiHBc is IgM, what is their phase of HEPB infx
Acute hepatitis B
A pt has negative HBsAG and positive antiHBs, the antiHBc is IgG, and both HBeAg and AntiHbe is negative,
What level of Hepatitis B do they have
Recovery/ resolved Hep B
note the HBsAG is negative, the Ig is IgG, which is long term
What is the serologic hallmark of acute HBV infx
HBsAg
When does anti-HBs appear
appears in most individuals after clearance of HBsAg and after successful vaccination against hepatitis B
What does HBeAg
a secretory protein that is processed from the pre-core protein
indicates viral replication and infectivity
Persistence of HBeAg beyond 3 months indicates increased likelihood of chronic HBV
How long does Anti-HBc persist for
For life
What is the best way to determine viral replication of HEP B
HBV DNA
What is the managment of acute HEPB
Supportive care
What is tx for chronic HBV
Antiviral therapy, for pts with severe s/s, marked jaundice, inflammation of the liver, elevated ALT,
Rx: entecavir, tenofovir
When can Tx be stopped for HBV
After two confirmed consecutive tests four weeks apart that the pt is cleared for HBsAG
What are the modes of infx for Hep C
50% by injection drug use
Transfusion of infected blood
Body piercing, tattoos, hemodialysis
STI and Maternal transmission possible
What is the incubation period for Hep C
6-7 weeks
What are the S/s of hep C
Waxing and waning of AST/ALT
Fatigue, N, RUQ pain, Jaundince, dark urine, clay colored stools
What are the screening and confirmatory test for HCV
Screen: HCV antibodies, with increased LFTs
Confirm: HCV RNA,
What is the managment approach to HepC
Some can spontaneously recover,
PCR-RNA determines approach to Tx, Antivirals are the DOC
Ledipasvir- Sofosbuvir
Elbasvir- grazoprevir
(Drugs that end in vir)
Older regimen: Interferion or Ribavirin
What is the prognosis of Hep C
Cirrhosis, Carnicoma of the liver, and liver failure
What is the transmission of Hep D
Coinfection with Hep B, primarily parenteral
What is the most common acute hepatitis world wide
Hep E
What defines chronic viral hepatitis
Infection with HBV (+/- HDV) or HCV for greater than 3 months
Persistently elevated AST/ALT
Persistent presence of:
HBsAG and anti-HBc
anti-HCV
Or histologic findings on liver biopsy
What is the antiviral regiment for chronic Hepatitis
Nucleoside or Nucleoside Analog
-entecavir, tenofovir, lamivudine, adefovir, telbivudine
Pegylated interferon
What is autoimmune hepatitis
Form of chronic hepatitis due to autoantibodies
Much more common in women
Varying clinical presentation
-Some patients discovered incidentally
What is NAFLD
Non alcoholic non fatty liver dz
Etiology: obesity, hyperlipidemia, glucocorticoid use, DM
Two types: fatty liver or steatohepatitis
What is the most accurate test for NAFLD
Biopsy, microvesicular fatty deposits similar to alcoholic liver disease without the history of heavy alcohol consumption
How is NAFLD usually discovered
Patients with NAFLD usually discovered because of elevated transaminase levels
Or incidental finding of hepatic steatosis on abdominal imaging ordered for another reason
Lab findings in NAFLD
Lab findings:
- Elevated transaminases
- 1:1 AST:ALT ratio
- Elevated ALK PHOS
Hepatic ultrasonography & biopsy
-Evidence of steatosis
What is steatosis
Fatty liver dz
What are the two subdivisions of NAFLD
Non-alcoholic Fatty Liver (NAFL)
Non-alcoholic Steatohepatitis (NASH)
What is required to differentiate into NASH and NAFL
Liver biopsy
Define NAFLD vs NASH
NAFL:
Hepatic steatosis without significant inflammation, hepatocellular injury, or fibrosis
Minimal risk of progression to cirrhosis
Can be diagnosed noninvasively (labs, imaging)
NASH:
Hepatic steatosis in association with inflammation and hepatocellular injury (ballooning hepatocytes), with or without fibrosis
Can progress to cirrhosis and liver failure
Requires biopsy for histologic confirmation
Fever with ascites indicate
Bacterial peritonitis
How does SAAG relate to ascites
(serum albumin) – (ascitic fluid albumin)
1.1 g/dL or higher : portal hypertension
Less than 1.1 g/dL : other cause
What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Insertion of an expandable metal stent between a branch of the hepatic vein and the portal vein over a catheter inserted via the internal jugular vein
For treatment of portal hypertension as an etiology of ascites
Most common agents of bacterial peritonitis
E coli Klebsiella pneumonia Streptococcus pneumonia viridans streptococci Enterococcus species
What is the Most important lab test is evaluation of ascitic fluid via paracentesis of the abdomen
Gram stain and culture
Cell count with differential
What image study should be ordered If secondary bacterial peritonitis is suspected
Abdominal CT
Tax approach to Bacterial peritonitis
Treatment: ADMIT
Empiric – IV 3rd generation cephalosporin
Ceftriaxone (Rocephin)
Specific treatment guided by culture and stain results
Prophylaxis for bacterial peritonitis
Once-daily ciprofloxacin or TMP-SMX DS
Reduces rate of recurrence to < 20%
What is Hepatorenal syndrome in cirrhosis
Occurs in 10% of patients with advanced cirrhosis
Represents the end-stage of a sequence of reductions in renal perfusion induced by increasingly severe hepatic injury
Prognosis is poor once this develops
Characterized by azotemia in the absence of parenchymal renal injury or disease
Serum creatinine of 1.5 mg/dL or higher
What is hepatic encephalopathy
Neuropsychiatric abnormalities seen in patients with liver dysfunction
develops in 30 - 45% of patients with cirrhosis
Systemic build up of ammonia
Due to hepatocellular dysfunction and lack of hepatic ammonia clearance
What are the two types of toxic liver injury
Direct hepatotoxicity (predictable):
Dose related severity
Latent period after exposure
Universal susceptibility
Idiosyncratic reaction:
Unpredictable and not dose related
What is the Tx for acetaminophen liver injury
Treatment with N-acetylcysteine
What is Rumack-Matthew Nomogram
Predictable, dose-related pattern and progression of injury seen on a graph for acetaminophen injury/ toxin
What are the S/s of primary biliary cholangitis
Many asymptomatic at diagnosis
Diagnosis detected by hepatic panel abnormalities
Asymptomatic hepatomegaly
Vague, non-specific symptoms early
Fatigue is usual first symptom
Pruritus
Xanthamatous lesions of the skin or tendons
Jaundice, steatorrhea, portal HTN later
What is the most signifigant lab test in Primary Biliary Cholangitis
Antimitochondrial antibodies (AMA) present in 95%
What is the Tx approach to Primary Biliary Cholangitis
First rule out other etiologies of biliary tract obstruction
Carcinoma, cholangitis
Ursodeoxycholic acid
FDA approved pharmacotherapy for PBC
Slows progression of disease
Symptomatic treatment for pruritis
Bile salt sequestrants
Likely progression to liver transplantation
What is hemochromatosis
Autosomal recessive disorder
Results in accumulation of iron as hemosiderin in the liver, pancreas, heart, adrenals, testes, pituitary, and kidneys
Hemosiderin – intracellular iron storage complex
May lead to cirrhosis and/or hepatic failure
Higher risk if high ETOH intake
What are the S/s of hemochromatosis
Typical clinical onset after age 50
Diagnosis usually made earlier
Found incidentally on routine lab abnormalities
-Elevations in AST and ALK PHOS
-Elevated plasma iron and elevated serum ferritin
What is the Tx goal of hemochromatosis
Treatment goal is to remove excess iron to prevent end-organ dysfunction and related complications
Treatment measures include:
- Therapeutic phlebotomy – first line
- Chelation with deferoxamine – for secondary iron overload or if phlebotomy ineffective/poorly tolerated
- Liver transplant for advanced disease (cirrhosis or hepatocellular carcinoma)
What is the 1st live Tx for hemochromatosis
Therapeutic phlebotomy
What is the pathological sign for Wilsons Dz
Pathognomonic sign – Kayser-Fleischer Rings
Brownish or greenish ring at the corneo-scleral junction
What are the lab findings in Wilson Dz
Low serum ceruloplasmin
High Urinary excretion of copper ( >40mcg/24hrs)
High copper concentration in the liver biopsy
What is the Tx for Wilson Dz
Chelation
Trientine (triethylenetetramine)
Penicillamine
Zinc (Inhibits intestinal copper absorption)
Refer to GI and Neuro
What is the most common cause of Portal HTN in a child
BuDD-Chiari syndrome
What is Budd-chiari syndrome
Hepatic Venous Outflow Tract Obstruction
-Results in post-hepatic portal HTN
Primary Budd-Chiari:
-Obstruction due to a predominantly venous process (thrombosis or phlebitis)
Secondary Budd-Chiari:
-Compression or invasion of the hepatic veins and/or the inferior vena cava by a lesion that originates outside of the vein (eg, a malignancy)
What is the study of choice for Budd-chiari syndorme
Color Doppler ultrasound
What is the clinical presentation of Pyogenic Hepatic Abcess
Fever RUQ pain & TTP Jaundice Nausea, vomiting Anorexia, weight loss, malaise
Laboratory Findings:
Leukocytosis on CBC
Positive blood cultures
Nonspecific abnormalities on hepatic panel
What is the most common cause of hepatocellulr carcinoma
Cirrhosis
A pt with Leukocytosis on CBC
Sudden & sustained elevation of ALK PHOS
Increase in alpha-fetoprotein indicates what liver problem
Hepatocellular carcinoma
What pts should we screen for hepatocellular carcinoma
Recommended for patients: With cirrhosis With chronic HBV or HCV Family history of HCC Hepatic ultrasound and Alpha-fetoprotein level Every 6 months
Does cholelithiais effect men or women more
Women
What are the 5 Fs of cholelithiasis
Fat Fair Forty Fertile (female) Flatulent
What are the two signs that present with acute cholecystitis
Murphys sign, and Boas sign
What is the physical exam presentation of Acute cholecystisis
Physical Exam:
Ill appearing patient, lying still on the exam table
RUQ TTP
Abdominal muscle guarding
Positive Murphy’s Sign
Jaundice is UNCOMMON
-Should raise suspicion for more serious process
What are the Lab findings in Acute Cholecystitis
CBC reveals leukocytosis Increase in serum bilirubin is UNCOMMON -Should raise suspicion for more serious process Elevations of ALK PHOS and AST/ALT -Non-specific elevations -Should NOT reveal a cholestatic pattern Modest elevation of amylase
What are the common complications of acute cholecystitis
Gangrenous cholecystitis
- Most common complication in diabetics or elderly
- Presents with sepsis in addition to common symptoms
Perforation – common complication of gangrene
Cholecystoenteric fistula
Gallstone ileus
-Result of gallstone passing through a fistula – usually in the terminal ileum
What are the S/s of chledocholithiasis and key lab findings
Severe biliary colic
RUQ or epigastric pain
Nausea and vomiting
Jaundice (may be intermittent – during attacks)
Cholestatic pattern of hepatic panel
-Higher elevations of ALK PHOS and bilirubin, than of AST/ALT
What is a hepatocellular pattern
ALT or AST> ALP
What is the cholestatic pattern
ALP> ALT or AST
What is the Tx approach to Choldochlithiaisis
In general, bile duct stones, even small ones, should be removed, even in an asymptomatic patient
ERCP with stone extraction
Followed by laparoscopic cholecystectomy within 72 hours in patients with cholecystitis and within 2 weeks in those without cholecystitis
What is Charcot triad
RUQ Pain
Fever/Chills
Jaundice
Acute cholangitis
What is Reynolds Pentad and what does it indicate
RUQ Pain Fever/Chills (rigors) Jaundice Altered Mental Status Hypotension
Indicates Acute Suppurative Cholangitis
Surgical emergency!
What does C-reactive protein indicate
Levels of inflammation
What is the Tx approach to Acute Cholangitis
Admission
-For supportive care and antibiotics
ERCP
-For biliary drainage and removal of obstruction
Surgery
-Only if ERCP fails or is unavailable
Cholecystectomy follows once infection is cleared
-To prevent recurrence
What is primary sclerosing Cholangitis
Increased immune response to intestinal endotoxins
-Results in diffuse inflammation of the biliary tract with fibrosis and stricture formation
Strong association with IBD
UC > Crohn
Presents as progressive obstructive jaundice
With fatigue, pruritus, anorexia, and indigestion
What is the med term for asymptomatic gallstone
Cholelithiasis
What is the med term for gallstone +fever/ pain
Cholecystitis
What is the med term for a gallstone lodged causing jaundice
Choledocolithisais
What is the med term for gallstone+ jaundice+ fever
Cholangitis
What is the med term for a gall stone+ jaundice + fever + AMS+ HOTN
Suppurations cholangitis ( Reynolds triad)
Who is most likely to present with Primary Sclerosing Cholangitis
A pt with ulcerative colitis
What is courvoisier sign
Palpable gallbladder with painless obstructive jaundice
Also associated with pancreatic cancer
Indication of cholangiocarcinoma
In a pt with s/s of biliary obstruction without an explanation ( no stones, no lesions) what should you suspect
Carcinoma of the Biliary Tract
What are the specific lab findings in acute pancreatitis
↑↑Serum amylase and lipase (3x upper limit)
-Lipase increases earlier, remains elevated longer & has higher sensitivity for pancreatitis
CBC – Leukocytosis
CMP:
-Elevated BUN
Hepatic Panel
-Elevated ALK PHOS & Bilirubin
Elevated CRP – marker of inflammation
What is the Radiograph of choice for Acute pancreatitis
CT scan
What is the Tx for Acute Pancreatitis
Clear any obstructions with ERCP
Pancreatic rest- NPO
Bed rest
IV fluids
Pain control- meperidne >morphine ( causes less Oddi spasm)
What is the Tx approach for severe Pancreatitis
Admission to ICU
Surgical consult
IV fluids and Monitoring
ABX
What is the clinical presentation of chronic pancreatitis
Recurrent episodes of LUQ and epigastric pain Attacks may last hours to days Anorexia & weight loss Nausea & vomiting Constipation Flatulence Steatorrhea!!!
What is the DO testing for chronic pancreatitis
Eval fecal fat
Calcification on CT scans
Must R/o Pancreatic Cancer
Tax approach to chronic pancreatitis
Referral to GI/Pancreatology Low fat diet NO ETOH!! ( most common cause) Non-opioid pain control Pancreatic enzyme supplementation
What are the C/c of exocrine pancreatic insufficiency
Patients complain of dyspepsia, abdominal cramping bloating with flatulence, and watery diarrhea, may also complain about steatorrhea ( due to lack of lipase)
What are the two most common etiológicos of exocrine pancreatic insufficiency
Chronic pancreatitis and cystitis fibrosis
Steatorrhea is almost always associated with
Pancreatic DO
What is the management approach to Exocrine pancreatic insufficiency
Enzyme replacement therapy
A pt with abdominal pain, jaundice, Wt loss, LUQ pain, with a non tender- palpable gall bladder, is a 50 year old male, DM and smoker… what should you think
Pancreatic Cancer
What is the serum tumor marker for Pancreatic Cancer
CA19-9
Where does Diverticular dz most present
On the Left side of the abdomen, Left descending colon
Where do most colon cancers occur
On the left side of the abdomen, Left descending colon
What is the Gold standard of Colon imagining
Colonoscopy
If a patient refuses a colonoscopy, what imaging method can you use
Virtual Colonoscopy
True colitis is nearly always a result of infection with….
C. Diff
A pt with watery, greening, foul smelling, mucus like diarrhea, with abdominal cramping and WBC < 15, 000 has what level of colitis
Mild- Moderate
What are the DO criteria for Severe Colitis
Profuse Diarrhea, fever > 101.3, Hypoalbuminemia <3 g/ dl
And either Abdominal Pain (TTP) or Luekoctosis > 15, 000
What defines Fulminant Collitis
HOTN, Fever >101.3, End organ failure, Ileus, WBC > 35, 000
What is the SOC for ABX Colitis
PCR,
Then EIAs determine active or chronic
What is the perferred imaging for ABX colitis
Abdominal CT, looking for the Thumbprinting
What is the Tx approach to ABX assoc Colitis
Admit, Isolation, Correct fluid imbalances
MILD:
Metronidazole (cheaper) or Vancomycin (668 dollars)
Severe: Vancomycin
Fulminant: PO Vanc+ IV Metro+ PR Vanc (in 500 ml of NS enema)
(and early surgical consultation)
What is the measurements for toxic vs megacolon
Megacolon is larger than 6 cm
What is the DO criteria for Toxic Megacolon
Dilation of 6 cm
Plus Fever, Pulse >120, Luekocytosis > 10.5, Anemia
Plus: dehydration or AMS or Electrolyte Abnormal, or HOTN
Tx for Toxic megacolon
Bowel rest, IV fluids, Tx the toxemia, and surgical consult
What is a diverticulum
A sac like protrusion of the colonic wall
What is the diet recommendation for Diverticulum
High fiber and fluids
Pts with active diverticular bleeding need what approach
Resus and Stabilize, then endoscopy
Without bleeding: referral for scope
How does a typical diverticulitis pt present
Abdominal Pain in the LLQ, Fever, N/V
What is present of physical exam of diverticulitis
LLQ TTP, LLQ mass, Fever
Luekocytosis. , +/- occult blood
What is the imaging of choice for diverticulitis
Abdominal CT!
What is the managment approach to Diverticulitis
Conservative Managment :
Metronidazole plus Ciprofloxacin ( or TMP-SMX)
Alternative: Augmentin
X 7-10 days BID
Clear Liquid Diet
Severe managment:
Admit and Treat impatient
NPO, Broad spec ABX, Fluids, PAIN managment, Surgery Consult
What are the common complications of diverticulitis and what is the managment
Per formation, Abscess, Fistualsa, or obstruction
Order a CT scan
What is Olivies Syndrome
Acute colonic psuedo obstruction
What is the most common site for a vulvulus
In the sigmoid colon
What is the Tx approach to sigmoid volvulus
Detorsion with flexible sigmoidscopy
What does an apple core lesion on Imaging suggest
Colorectal Cancer
What are sinus tracts in Crohns Dz
Transmural bowel Inflamation is associated with the development of sinus tracts with Crohn’s disease
What is perianal dz in Crohns dz
Large painful tags, anal fissures, and Perianal abscesses
What are the lab findings in Crohns
Anemia, elevated platelets
Malnutrition
Inflammation
Fecal blood
What drug should be used in high risk ASA Crohns dz pts
Sulfaslazine
Which has more fístulas? Crohns or UC
Crohns
What is the most common indication in the US for liver transplant
Chronic Hep C that progresses to cirrhosis and liver failure
A pt with 2:1 elevation of AST/ ALT with a elevated GGT is what
Alcoholic fatty liver
What endocrine s/s develop with sirrhosis
Amenorrhea and Gynomastica
Lab findings in cirrhosis
Thrombocytopenia
Anemia
Luekocytosis or luekopenia
With evidence of renal failure Increase BUN, Cr
Elevated AST ALT
S/s of hepatic encephalopathy
Inversion of sleep wake cycle Personality changes Tremor, Somnolent Slurred speech Agitation Confusion Coma
What is azotemia
Characteristic finding in cirrhosis ( hepatorenal syndrome)
Serum Cr > 1.5
Tx for hepatic encephalopathy
Admission and lactulose
Tx for Primary Biliray cholangitis
Ursodeoxycholic acid
And bile salt sequestratnts
Xanthomas are an indication of
Primary Biliary Cholangitis
What is Ranson Criteria
A point system for severity of pancreatitis
