It's a series of tubes Flashcards
What is more malignant, a Villous polyp or a tubular polyp?
Villous
Diagnostic study for colon cancer
Colonoscopy
Risks for colon cancer
Age over 50 Adenomatous polyps Ibd Family history of colon cancer High fat low fiber diet
Hamartomas throughout the gi tract, spots on face, lips, oral mucosa, genitals and palms
Peutz Jaegher’s - low malignant potential but may progress to intussusception or bleeding
Polyps, osteomas, dental abnormalities, benign soft rumors, sebaceous cysts
Gardners syndrome - 100% risk of cancer by age 40
Hundreds of polyps throughout GI tract
Familial adenomatous polyposis - 100% risk of colorectal cancer by 30-50
Most common cause of large bowel obstruction in adults
Colorectal cancer
Most common presenting symptom of colorectal cancer
Abdominal pain
Change in bowel habits, obstruction, hematochezia
Left sided colorectal cancer
Occult blood, Melena, iron deficiency anemia.
Right sided colorectal cancer. Obstruction and change in bowel habits are rare because the tube is bigger on the right.
What are some things the increase the malignant potential of polyps
Large, flat, large numbers, Villous rather than tubular
Pathogenisis of diverticulosis
Increased infra luminal pressure causes the intestine to bulge at a point of weakness - usually the sigmoid colon
Complications of diverticulosis
Painless bleeding, diverticulitis.
Can you use a barium enema to diagnose diverticulitis?
No. It is contraindicated due to risk of perforation
Is bleeding more common in diverticulosis or diverticulitis?
Diverticulosis
Severe pain out of proportion to physical findings, sudden onset, benign exam. Anorexia, vomiting, mild GI bleed.
Mesenteric ischemia
Sudden onset mesenteric ischemia in the context of atrial fibrillation
Arterial embolism
Slow onset mesenteric ischemia with development of collateral circulation
Venous thrombosis
Brisk, painless, self limited GI bleed
Diverticulosis
Left lower quadrant pain, leukocytosis
Diverticulitis
Tortuous, dilated veins colon wall,found in patients over60
Angiodysplasia- treat with colonoscopic coagulation
Can you use a barium enema to diagnose diverticulitis?
No - it is contraindicated due to risk of perforation
Symptoms of obstruction without recent surgery or mechanical obstruction
Ogilvie syndrome
Abdominal angina and weight loss
Chronic mesenteric ischemia -
Acute abdominal pain out of proportion to physical exam findings in a patient with underlying cardiac arrhythmia
Mesenteric ischemia due to embolus
Slow onset of severe abdominal, pain, no significant findings on physical exam, underlying atherosclerosis
Mesenteric ischemia due to thrombosis
Treatment for mesenteric ischemia
Supportive, iv rehydration, papaverine vasodilator injection into superior mesenteric artery, heparin for venous thrombosis
Treatment of esophageal varies
Transjugular intrahepatic portal systemic shunt.
Stomach ulcers in patients under severe physiologic stress (ICU)
Cushing’s ulcers
What causes hepatic encephalopathy
Ammonia, toxic metabolite that accumulates in the blood
Stomach ulcers in patients under severe physiologic stress (ICU)
Cushing’s ulcers
Isolated (no other liver function abnormalities or symptoms) unconjugated bilirubinemia
Gilbert’s syndrome, a congenital decreased ability to glucoronidate bilirubin. No treatment needed.
Melena, hematemesis, jaundice, RUQ pain in a patient with a history of surgery, trauma, tumor, or infection
Hemobilia - blood entering the duodenum via CBD due to biliary or hepatic bleeding.
What are the two kinds of hepatocellular carcinoma?
Fibrillomellar and nonfibrillomellar. Nonfibrillomellar is caused by hepatitis B and C, and cirrhosis. It has the worse prognosis. Fibrillomellar is resectable and a better prognosis.
What is Budd-Chiari Syndrome?
Slow onset portal hypertension secondary to hepatic vein thrombosis
What kind of bilirubin is excreted in urine?
Conjugated only.
What are some causes of unconjugated bilirubinemia?
Think prehepatic or inflow problem - HEMOLYTIC ANEMIA, also Drugs, Gilbert’s, Crigler-Najjar, diffuse liver disease.
What are some causes of conjugated bilirubinemia
Outflow problem - Hepatocellular disease, drugs, PBC, PSC.
AST, ALT elevations in asymptomatic patients
ABCDEFGHI Autoimmune Hepatitis B Hepatitis C Drugs/Toxins Etoh Fatty Liver Growth (tumor) Hemodynamic changes (CHF) Iron (hemochromatosis)
What causes mild elevation of AST, ALT?
chronic hepatitis - alcoholic or viral
What causes ALT, AST levels in the 100’s to 1000’s?
Acute viral hepatitis
What causes ALT, AST levels greater than 10,000?
Hepatic necrosis due to ischemia, shock, acetominophen toxicity, or severe viral hepatitis
Can you diagnose cirrhosis based on elevated AST, ALT?
No. They may be low to normal.
What causes cholesterol gallstones?
Impaired fat metabolism leading to accumulation and precipitation of fats in the gallbladder - obesity, DM, Crohn’s disease, ileal resection, oral contraceptive use.
What causes black gallstones?
Accumulation of bilirubin in the bile - hemolytic anemia
What causes brown gallstones?
Ascending biliary tract infections
Is acute cholecystitis caused by infection?
No - it is caused by an obstruction of the cystic duct. The backup causes inflammation of the gallbladder wall.
How do you confirm the diagnosis of cholecystitis?
Murphy’s sign, RUQ ultrasound. If those are inconclusive, HIDA scan.
Acute cholecystitis treatment
NPO, IV hydration, analgesics. Consider surgery
If the patient has RUQ pain, elevated total bilirubin and alk phosphatase, a negative ultrasound, what are you worried about, and what is the test of choice?
Choledocholithiasis - ECRP for diagnosis and treatment.
RUQ pain, jaundice and fever
Charcot’s Triad for Cholangitis - ascending infection of biliary tract.
RUQ pain, jaundice, fever, septic shock, altered mental status
Reynold’s pentad - SEVERE Cholangitis
If you see calcifications on the gallbladder on plain xray, what is that called, and why is it important?
Porcelain gallbladder - it needs to come out due to cancer risk.
Idiopathic thickening of the hepatic bile ductules, and ducts, associated with ulcerative colitis
Primary Sclerosing Cholangitis
Autoimmune destruction of bile ductules with inflammation and scarring, found in middle aged women and associated with other autoimmune disease.
Primary Biliary Cirrhosis
Four F’s of Gallstones
Female, Fertile, Fat, and Forty
Liver disease, Kayser-Fleisher Rings, CNS findings, psychiatric disturbances, aminoaciduria, nephrocalcinosis
Wilson’s disease, an autosomal recessive disease of copper metabolism
Hallmark location of inflammation in Crohn’s disease
Distal Ileum
Most common site of metastic spread of colorectal cancer
The liver, via the portal system
Can you use CEA level to diagnose colorectal cancer?
No. Too many other things elevate it, but get a level before surgery, because an increase in a year or more can indicate recurrence of the tumor.
Most common type of colonic polyp
Hyperplastic (metaplastic) polyps. Small, non-neoplastic, and asymptomatic.
Most common location of diverticulosis
Sigmoid colon
What is the worst complication of diverticulitis? how do you diagnose it?
Perforation - X ray for free air.
Can also lead to abscess, colovesical fistula, or obstruction due to scarring.
What causes pseudomembraneous colitis?
C. Diff overgrowth after antibiotic use.
Profuse, watery diarrhea without water or mucus, crampy abdominal pain, possible toxic megacolon, in a patient status post antibiotic use.
pseudomembraneous colitis
How do you treat C Diff?
Discontinue the offending abx if possible. Metronidazole or vancomycin.
Acute onset of colicky abdominal pain, obstipation, abdominal distension, anorexia, nausea, vomiting in an older patient with a history of surgery, chronic illness, chronic constipation.
Colonic Volvulus - sigmoid colon 75% of the time
How do you diagnose colonic volvulus?
X ray
Sigmoid - omega loop sign.
Cecum - Coffee Bean sign
If an abdominal x ray shows multiple air-fluid levels, what does that mean?
obstruction
Esophageal varices, caput medusae, hemorrhoids, ascites, splenomegaly
Portal hypertension.
Most common causes of cirrhosis
Alcoholism, Chronic Hep B and C.
Liver disease, fatigue, arthritis, impotence/amenorrhea, abdominal pain, cardiac arrythmias, MARKEDLY ELEVATED SERUM IRON AND FERRITIN, elevated transferrin saturation, decreased TIBC.
Hemochromatosis - get a liver biopsy.
If you diagnose hemochromatosis, who needs to be told?
The patient’s first degree relatives. It is autosomal recessive and they need to be tested.
Most common benign liver tumor
Cavernous hemangioma, a small vascular tumor.
Cirrhosis raised your risk of what?
Hepatocellular carcinoma.
Portal HTN, ascites, jaundice, splenomegaly, erythrocytosis, thrombocytosis, hypercalcemia, carcinoid syndrome, hypertrophic pulmonary osteopathy, hypoglycemia, high cholesterol.
Hepatocellular carcinoma
Causes of short bowel syndrome
Crohn’s, ischemia, radiation, trauma
malabsorbtion, dehydration, loss of electrolytes, water, bile salts, B12, history of bowel resection
Short bowel syndrome
Acute severe abdominal pain, frequent vomiting, minimal abdominal distension,
proximal SBO
Acute sudden crampy periumbilical pain, significant distension, n/v, obstipation, decreased bowel sounds, tympanic to percussion, tachycardia, hypotension,
Distal SBO.
Insidious onset, esophageal dysphagia of solids and liquids, Regurgitation, chest pain, weight loss, recurrent pulmonary infections.
achalasia
Bird’s beak barium swallow
achalasia
Dysphagia, weight loss, anorexia, odynophagia, hematemesis, history of smoking or GERD
esophageal cancer, SCC (upper 1/3) or Adenocarcinoma (lower 1/3)
Anemia, hematemesis, melena, heme positive stool, persistent abdominal pain radiating to back, possible perforation, history of NSAID use
NSAID induced ulcer
Growth patterns of gastric cancer
Superficial, polyploid, ulcerating, diffusely infiltrating
abdominal pain, weight loss, reduced appetite, anorexia, dyspepsia, early satiety, N,V, anemia, melena, guiac-positive stool
Gastric cancer - poor prognosis
Causes of osmotic diarrhea
lactase deficiency, laxative, antacids, medications
Causes of secretory diarrhea
Cholera, E. Coli, Cereus, Clostridium perforingens, neoplasms
Causes of exudative diarrhea
Salmonella, shigella, campylobacter, entamoeba, rotavirus, norwalk virus.
Most common cause of chronic diarrhea
IBS
Diarrhea that is reduced by fasting
Osmotic
Diarrhea that is NOT reduced by fasting
Secretory
Low volume diarrhea, Fecal water and electrolytes high
Exudative diarrhea
Osmotic or secretory diarrhea, weight loss, hyperphagia, bone pain, fractures, dermatitis, anemia, kidney stones, vitamin deficiency
Malabsorbtion - infection, deficient mucosal surface, tumor, lymphoma, granuloma
Weight loss, chronic diarrhea, weakness, growth retardation, anemia, symptoms cluster in family and start in early childhood
Celiac disease
Flattened villi, leading to decreased absorption
Celiac
RLQ pain, N/V, fever, malaise, perianal disease, anemia, eye lesions, mouth lesions, diarrhea WITHOUT BLOOD
Crohn’s disease
Bloody diarrhea, urgency, abdominal pain, fevere, anorexia, weight loss, tenesmus
Ulcerative colitis
Why is a colectomy sometimes necessary in ulcerative colitis?
Pseudopolyps (not actually polyps, but normal mucosa sticking up out of inflammed mucosa), make it very difficult to monitor for colon cancer. Also the risk of colon cancer goes up.
Watery diarrhea, wheezing, intestinal colic, facial flushing. Endocardial fibrosis.
Carcinoid - Releases serotonin and bradykinin, mets to local lymph nodes and liver.
Failure to pass muconium in the first 48 hours of life, distension, feeding difficulties
Hirschprung disease, congenital aganglionosis leading to toxic megacolon
Severe, tearing pain during defecation, followed by throbbing discomfort, mild hematochezia
Anal fissure
Sharp abdominal pain, rebound tenderness, voluntary guarding. History of PID, abcess, ascites
Bacterial peritonitis
Sharp abdominal pain, rebound tenderness, voluntary guarding. History of pancreatitis, cholecystitis, or surgery
Sterile peritonitis
Flank, periumbilical, or inguinal ligament ecchymoses
Grey Turner’s, Cullen’s, and Fox’s signs, respectively. Incredibly rare signs of pancreatitis
Do you treat acute pancreatitis with antibiotics?
Only if you’re too dumb to diagnose it correctly.
Causes of acute pancreatitis
Etoh abuse, gallstones, post ERCP, viral infection, post-surgical, hypercalcemia, uremia, blunt trauma
What happens to your abdomen in acute pancreatitis?
Trypsin and elastase get released into the abdomen, causing necrosis of protein and connective tissue. Lipase causes fat necrosis. The pancreas itself gets liquefied. Pseudocysts form, necrotic fluid surrounded by fibrosis
Abdominal pain, paralytic ileus, decreased or absent bowel sounds, hypotension, leukocytosis, epigastric tenderness, apprehensiveness, great distress, elevated Amylase, and, more importantly, elevated Lipase.
Acute Pancreatitis
What does the pancreatic duct look like via ERCP in chronic pancreatitis ?
A “chain of lakes” due to dilations
Severe epigastric pain radiating to the back, aggravated by drinking or eating, malabsorbtion syndrome, new onset diabetes. Normal serum amylase and lipase.
Chronic pancreatitis
Epigastric pain with radiations to back, Jaundice, weight loss, weakness, fatigue. History of smoking, heavy etoh use, high fat diet.
Pancreatic Adenocarcinoma - usually found in the head, which obstructs the bile duct, causing jaundice. Mets to local lymph nodes, liver, lungs, bones
What kind of disease causes Zollinger-Ellison syndrome?
Gastrinoma, a malignant endocrine tumor of the pancreas.
What kind of cancer causes hypoglycemia?
Insulinoma, a beta-cell tumor of the pancreas. Better prognosis, resectable. Hypoglycemia responds to glucose.
What is the confirmatory finding in a biopsy diagnosing PBC?
Antimitochondrial antibodies
Small yellow nodules in connective tissues
Xanthomas, associated with cirrhosis due to impaired lipid metabolism
PSC increses the risk of?
Cholangiocarcinoma
What is the only really effective treatment for ascites secondary to severe chronic liver disease?
Liver transplant.
Bronze diabetes
Hemochromatosis - treatment is repeated phlebotomy
