HARRISON'S Q&AQ Flashcards
the most common cause of acute hepatic failure is .
drug-induced liver injury
The most common drug or toxin causing direct hepatocyte toxicity is________
acetaminophen
one of the metabolites of acetaminophen, _____________ can overwhelm the glutathione stores of the liver that are necessary to convert NAPQI to a nontoxic metabolite and lead to hepatocyte necrosi
N-acetyl-p-benzoquinone imine (NAPQI),
Other medications or toxins that cause direct hepatocyte injury are carbon tetrachloride, trichloroethylene, tetracycline, and the _________ mushroom
Amanita phalloides
Common medications that can lead to idiosyncratic drug reactions include halothane, isothane, isoniazid, 3-hydroxy-3-methylglutaryl–coenzyme A (HMG-CoA) reductase inhibitors, and chlorpromazine.
idiosyncratic drug reactions i
Idiosyncratic drug reactions, also known as type B reactions
Syndromes with well-established association with GERD include chronic cough, laryngitis, asthma, and dental erosions
ss well established. These include pharyngitis, pulmonary fibrosis, chronic sinusitis, cardiac arrhythmias, sleep apnea, and recurrent aspiration pneumonia.
. Chylous ascites often is characterized by an opaque milky fluid with a triglyceride level greater tha______{mg/dL in addition to a low SAG.
1000
White, milky fluid indicates a triglyceride level ________ (and often >1000 mg/dL), which is the hallmark of chylous ascites.
White, milky fluid indicates a triglyceride level >200 mg/ dL (and often >1000 mg/dL), which is the hallmark of chylous ascites.
The SAAG is calculated by ______ and does not change with diuresis
The SAAG is calculated by subtracting the ascitic albumin concentration from the serum albumin level and does not change with diuresis
A SAAG ≥1.1 g/dL reflects the presence of _______ and indicate
portal hypertension
A SAAG <1.1 g/dL indicates that the ascites is not related to portal hypertension, as in
tuberculous peritonitis, peritoneal carcinomatosis, or pancreatic ascites.
In patients without cirrhosis, an elevated ascitic adenosine deaminase level has a sensitivity of >90% when a cut-off value of _______ is used.
30–45 U/L
postcricoid dysphagia, upper esophageal webs, and iron deficiency anemia
includes esophageal rings, but typically, the rings occur in the proximal esophagus, are associated with iron-deficiency anemia, and occur in middle-aged women.
Plummer-Vinson syndrome
ntermittent solid food dysphagia is a classic symptom in_____ in which a distal esophageal ring occurs at the squamocolumnar mucosal junction
Schatzki ring
When the lumen is less than 13 mm, dysphagia may occur
typically occur in persons older than 40 years and often cause “steakhouse syndrome” from meat getting stuck at the ring
_________ is the most common cause of acute liver failure and the most common cause of drug-induced liver failure that leads to transplantation.
Acetaminophen overdose
ith therapeutic use of acetaminophen, _______ in the liver rapidly converts NAPQI to a nontoxic metabolite that is excreted in the urine
glutathione
Given the known hepatotoxicity of acetaminophen, the U.S. Food and Drug Administration has recommended a maximum daily dose of no more than ____, with lower doses in individuals with chronic alcohol use
recommended a maximum daily dose of no more than 3.25 g
Acute ingestions of ______ of acetaminophen are sufficient to cause clinical evidence of liver injury, and doses higher than ____ can lead to fatal hepatic necrosis.
Acute ingestions of 10–15 g of acetaminophen are sufficient to cause clinical evidence of liver injury, and doses higher than 25 g can lead to fatal hepatic necrosis.
ACETAMINOPHEN TOXICITY
Nausea, vomiting, abdominal pain, and shock occur within 4–12 hours after ingestion
Within 24–48 hours, these symptoms subside and are followed by evidence of hepatic injury.
Maximal levels of aminotransferases can reach more than 10,000 IU/L and may not occur until ______ after ingestion
4-6 DAYS
ACETAMINOPHEN TOXICITY
The first level should be measured no sooner than ______ after a known ingestion.
The first level should be measured no sooner than 4 hours after a known ingestion.
If, at 4 hours, the acetaminophen level is greater than 300 μg/mL, significant hepatotoxicity is likely.
The primary treatment for acetaminophen overdose is _________.
acts to replete glutathione levels in the liver and also provides a reservoir of sulfhydryl groups to bind to the toxic metabolites
N-acetylcysteine
typical regimen of N-acetylcysteine is ______ given as a loading dose, followed by _____every 4 hours for a total of 15–20 dose
typical regimen of N-acetylcysteine is 140 mg/kg given as a loading dose, followed by 70 mg/kg every 4 hours for a total of 15–20 dose
Gastrin levels may go up with a meal (>200%), but this test does not distinguish G-cell hyperfunction from ZES. The best test in this setting is the secretin stimulation test. An increase in gastrin levels _______ WITHIN minutes of administering 2 µg/kg of secretin by intravenous bolus has a sensitivity and specificity of >90% for ZES.
> 200 pg within 15
Multiple endocrine neoplasia type 1 (MEN1) is an endocrine tumor syndrome caused by inactivating mutations of the ____tumor suppressor gene at the ____ locus.
MEN1
11q13
combination of parathyroid tumors, pancreatic islet cell tumors, and anterior pituitary tumors
Multiple endocrine neoplasia type 1 (MEN1)
Free peritoneal perforation occurs in _______ of DU patients
Free peritoneal perforation occurs in ~2%–3% of DU patients
IN PUD
The procedure that provides the lowest rates of ulcer recurrence (1%) but has the highest complication rate is ________.
_______is aimed at eliminating an additional stimulant of gastric acid secretion, gastrin.
vagotomy (truncal or selective) in combination with antrectomy
Antrectomy
arise from the rapid emptying of hyperosmolar gastric contents into the small intestine, resulting in a fluid shift into the gut lumen with plasma volume contraction and acute intestinal distention
consists of a series of vasomotor and GI signs and symptoms and occurs in patients who have undergone vagotomy and drainage (especially Billroth procedures)
eARLY Dumping syndrome
Early dumping takes place 15–30 minutes after meals and consists of crampy abdominal discomfort, nausea, diarrhea, belching, tachycardia, palpitations, diaphoresis, light-headedness, and, rarely, syncope
rarely, syncope
The late phase of dumping typically occurs _________ after meals. Vasomotor symptoms (light-headedness, diaphoresis, palpitations, tachycardia, and syncope) predominate during this phase
This component of dumping is thought to be secondary to hypoglycemia from excessive insulin release
90 minutes to 3 hours
worsening pain after eating suggesting a _____ ulcer
duodenaL
=occur most often in the first portion of the duodenum (>95%), with ~90% located within 3 cm of the pylorus.
DU
The typical pain pattern in DU occurs _______ after a meal and is frequently relieved by antacids or food.
Pain that awakes the patient from sleep (between midnight and 3 A.M.) is the most discriminating symptom, with two-thirds of DU patients describing this complaint.
90 minutes to 3 hour
Encephalopathy can occur in as many as _____ % of patients after TIPS and is particularly problematic in elderly patients and in patients with preexisting encephalopathy
20%
AUTOIMMUNE HEPATITIS
Antinuclear antibodies are positive in a ________staining pattern almost invariably in the disease, and rheumatoid factor is also common
homogeneous
AUTOIMMUNE HEPATITIS
Antinuclear antibodies are positive in a ________staining pattern almost invariably in the disease, and rheumatoid factor is also common
homogeneous
Perinuclear antineutrophilic cytoplasmic antibody may be positive, but in an atypical fashion. Anti–smooth muscle antibodies and anti-liver/kidney microsomal antibodies are frequently seen,
KIND of gallbladder stone in PBC
CHOLESTEROL
a chronic multisystem disease often including diarrhea/steatorrhea, migratory arthralgias, weight loss, and central nervous system (CNS) or cardiac problems. Generally the presentation is of insidious onset, and dementia is a late finding and poor prognostic sign.
Whipple disease,
a chronic multisystem disease often including diarrhea/steatorrhea, migratory arthralgias, weight loss, and central nervous system (CNS) or cardiac problems. Generally the presentation is of insidious onset, and dementia is a late finding and poor prognostic sign.
Whipple disease,
Whipple disease, most likely finding on small bowel biopsy
periodic acid–Schiff (PAS)–positive macrophages within the small bowel
Mononuclear cell infiltrate in the lamina propria is often demonstrated in patients with
tropical sprue
flat villi with crypt hyperplasia is the hallmark of
celiac disease.
Chronic hepatitis develops in about _____of all individuals affected with hepatitis C virus (HCV), and ______ of these individuals will progress to cirrhosis over about 20 years.
Chronic hepatitis develops in about 85% of all individuals affected with hepatitis C virus (HCV), and 20%–25% of these individuals will progress to cirrhosis over about 20 years.
Chronic pancreatitis VIT DEFICIENCY
Vitamin B12, or cobalamin
fat-soluble vitamins (A, D, E, and K
Generally, the clinical course of hepatitis E infection is mild and the rate of fulminant hepatitis is only 1%–2%. However, in pregnant women, this is as high as ?
10%–20%
When cholecystectomy is needed
SURGICAL THERAPY In asymptomatic gallstone patients, the risk of developing symptoms or complications requiring surgery is quite small (see above). Thus, a recommendation for cholecystectomy in a patient with gallstones should probably be based on assessment of three factors: (1) the presence of symptoms that are frequent enough or severe enough to interfere with the patient’s general routine;
(2) the presence of a prior complication of gallstone disease, i.e., history of acute cholecystitis, pancreatitis, gallstone fistula, etc.; or
(3) the presence of an underlying condition predisposing the patient to increased risk of gallstone complications (e.g., calcified or porcelain gallbladder and/or a previous attack of acute cholecystitis regardless of current symptomatic status). Patients with very large gallstones (>3 cm in diameter) and patients harboring gallstones in a congenitally anomalous gallbladder might also be considered for prophylactic cholecystectomy
In Gilbert syndrome, there is a mutation of the ________ that encodes bilirubin UDP-glucuronosyltransferase, which leads to a reduction in activity on the enzyme to 10%–35% of normal
UGT1A1 gene
The highest priority (status 1) for liver transplantation continues to be reserved for patients with___
fulminant hepatic failure or primary graft nonfunction.
multiple cystic dilatations of the intrahepatic biliary tree
Caroli disease
recurrent hepatitis C is insidiously progressive, allograft cirrhosis develops in _______, and cirrhosis and late organ failure occur at a higher frequency beyond 5 years.
20%–30% at 5 years
Because of the high rate of recurrent disease after transplantation, patients with ________ are not transplantation candidates.
cholangiocarcinoma
Patients with primary hepatocellular carcinoma with a single tumor _____ cm or _____# tumors of ____ cm have 5-year recurrence-free survival rates similar to those with nonmalignant disease
Patients with primary hepatocellular carcinoma with a single tumor <5 cm or three or fewer tumors of <3 cm have 5-year recurrence-free survival rates similar to those with nonmalignant disease
Cigarette smoking is associated with a decreased/increased incidence of ulcerative colitis but may cause Crohn disease. Oral contraceptive use is associated with a slightly higher incidence of______. __________ twins are highly concordant for Crohn disease but not ulcerative colitis.
Cigarette smoking is associated with a decreased incidence of ulcerative colitis but may cause Crohn disease. Oral contraceptive use is associated with a slightly higher incidence of Crohn disease but not ulcerative colitis. Monozygotic twins are highly concordant for Crohn disease but not ulcerative colitis.
BISAP incorporates five clinical and laboratory parameters obtained within the first 24 hours of hospitalization
BUN >25 mg/dL, impaired mental status (Glasgow coma score <15), systemic inflammatory response syndrome, age >60 years, and pleural effusion on radiography
he only clinical conditions in which absorption is increased are _______, in which absorption of iron and copper, respectively, is elevated
he only clinical conditions in which absorption is increased are hemochromatosis and Wilson disease, in which absorption of iron and copper, respectively, is elevated
_________ can occur in up to 12% of patients with ulcerative colitis and is characterized by a lesion that begins as a pustule and progresses concentrically to surrounding normal skin
Pyoderma gangrenosum
_________ can occur in up to 12% of patients with ulcerative colitis and is characterized by a lesion that begins as a pustule and progresses concentrically to surrounding normal skin
Pyoderma gangrenosum
Erythema nodosum is more common in Crohn disease and attacks correlate with bowel symptoms
is a rare disorder in intertriginous areas reported to be a manifestation of IBD in the skin.
pyoderma vegetans
Patients with Crohn disease may have an increased risk of non-Hodgkin lymphoma, leukemia, and myelodysplastic syndromes.
True
______ is the presumed mechanism for development of SBP, with gut flora traversing the intestine into mesenteric lymph nodes, leading to bacteremia and seeding of the ascitic fluid.
Bacterial translocation
The most common organisms are ____ and other gut bacteria; however, gram-positive bacteria, including Streptococcus viridans, Staphylococcus aureus, and Enterococcus spp., can also be found. If more than two organisms are identified, secondary bacterial peritonitis due to a perforated viscus should be considered.
E coli
The diagnosis of SBP is made when the fluid sample has an absolute neutrophil count
> 250/μL
prophylaxis against SBP is recommended when a patient presents with upper GI bleeding
TRUE
Treatment is with a second-generation cephalosporin, with ______ being the most commonly used antibiotic.
cefotaxime
Several distinct patterns can be observed. In acute hepatitis B, the core IgM, surface antigen, and e antigen are all positive, which is what is seen in this case. At this point, the patient is highly infectious, with viral shedding in body fluids, including saliva.
TRUE
Irritable bowel syndrome (IBS) is characterized by the following: recurrence of lower abdominal pain with altered bowel habits over a period of time without progressive deterioration, onset of symptoms during periods of stress or emotional upset, absence of other systemic symptoms such as fever and weight loss, and small-volume stool without evidence of blood.
Warning signs that the symptoms may be due to something other than IBS include presentation for the first time in old age, progressive course from the time of onset, persistent diarrhea after a 48-hour fast, and presence of nocturnal diarrhea or steatorrheal stools. Each patient, except for patient C, has “warning” symptoms that should prompt further evaluation.
IBS is a disorder that affects all ages, although most patients have their first symptoms before age ___
45.
Uncomplicated disease involves fever, abdominal pain, leukocytosis, and anorexia/obstipation, whereas complicated disease is characterized by ___________________
abscess formation, perforation, strictures, or fistulae
- inflammatory bowel disease
- discontinuous lesions
- typically affects the rectum and proceeds caudally from there without normal mucosa until the area of inflammation terminates
- presence of strictures and fissures
- more often transmural, full-thickness
Crohn disease Ulcerative colitis Crohn disease Crohn Crohn
The hallmark of Crohn disease is
granulomas
Bleeding is not a feature of I rritableBS unless hemorrhoids are present, and malabsorption or weight loss does not occur.
TRUE
