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SGU Term 5 BSCE Book 2 Flashcards

1
Q

Colestyramine

A

management of cirrhosis
help puritis
4g/8h PO, 1 hr after other drugs

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2
Q

Bacterial Endocarditis

A

Janeway lesions
Osler nodes
Roth spots
Splinter hemorrhages

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3
Q

Causes of liver cirrhosis

A 
Alcohol
Hep B,C,D
Hemochromatosis
a1 antitrypsin def.
Wilson’s disease
Autoimmune hepatitis
NAFLD
Biliary tract disease
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4
Q

Cirrhosis complications

A 
Ascites
Spontaneous bacterial peritonitis
Gastroesophageal varices
Hepatic encephalopathy
Hepatorenal syndrome
Hepatopulmonary syndrome
Hepatocellular carcinoma
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5
Q

Palmar erythema

A

Increased estrogen bc cirrhosis

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6
Q

Decreased ammonia metabolism in cirrhosis

A

Hepatic encephalopathy

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7
Q

compensated cirrhosis

A

Calculate MELD every 6 mo

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8
Q

MELD >12

A

High risk of complications of cirrhosis

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9
Q

MELD score

A

3.78 x log serum bilirubin + 11.2 x log INR + 9.57 x log serum creatinine + 6.43

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10
Q

Pt has been dialyzed twice in last week

A

Serum creatinine 4 in MELD score

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11
Q

Child Tircotte Pugh Classification of Cirrhosis

A 
A = 5 to 6
B = 7 to 9
C = 10 to 15
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12
Q

Ascites management

A

Spironactone 100 mg/day increase dose every 2 days to 400 mg/day

Should have daily weight loss of .5 kg
If not, add furosemide 120 mg/day

Do U&E, Cr often

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13
Q

Ascites fluid restriction

A

1.5 L per day

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14
Q

Ascites low salt intake recommended

A

40-100 mmol/day

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15
Q

Therapeutic paracentesis for ascites

A

Concomitant albumin transfusion 6-8g/L removed

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16
Q

Refractory ascites

A

Trans jugular intrahepatic portosystemic shunt

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17
Q

Cirrhosis + ascites of 15g/L protein or less

A

Prophylactic oral ciprofloxacin or norfloxacin, until ascites resolves

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18
Q

Spontaneous bacterial peritonitis

A

Presenting w fever usually

WCC 250mm3 in ascitic fluid or more

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19
Q

Bacterial peritonitis empiric treatment

A

Cefotaxime (claforan) and ceftriaxone (rocephin)

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20
Q

Bacterial peritonitis prophylaxis

A

Ciprofloxacin 250mg PO daily
OR
CoTrimoxazole 960 mg weekdays only

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21
Q

Cirrhosis, esophageal varices screening

A

Endoscopy every 3 years

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22
Q

Cirrhosis + medium or large esophageal varices

A

Endoscopic variceal band ligation

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23
Q

Cirrhosis + upper GI bleeding

A

Prophylactic IV Abx and vasoactive drugs

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24
Q

Cirrhosis or significant fibrosis
METAVIR stage > or equal to F2
Ishak stage > or equal to 3

A

Surveillance every 6 mo for HCC by: hepatic ultrasound, alpha fetoprotein testing

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25
``` no significant fibrosis or cirrhosis METAVIR < F2 Ishak < 3 Older than 40 Family Hx of HCC HBV DNA > or equal to 20,000 ```
Surveillance every 6 mo
26
``` no significant fibrosis or cirrhosis METAVIR < F2 Ishak < 3 Younger than 40 HBV DNA < 20,000 ```
No surveillance
27
Early Hep C
``` Arthralgia Paresthesia Myalgia Pruritis Sicca Sensory neuropathy ```
28
Late Hep C
``` Hepatic encephalopathy Ascites Hematemesis or melena Palmar erythema Dupuytren contracture Asterixis Leukonychia Clubbing Icteric sclera Temporal muscle wasting Enlarged parotid Cyanosis Fetor hepaticus Gynecomastia Testicular atrophy Paraumbilical hernia Caput medusae Hepatosplenomegaly Abdominal bruit Scant body hair Spider nevi Petechiae Excoriations ```
29
Sustained eradication of HCV
Absence of HCV RNA in serum 12 weeks post antiviral treatment
30
Antiviral treatment for Hep C?
``` High ALT > 18y/o + HCV antibody and serum HCV RNA compensated Hb at least 12 for women 13 for men, neutrophil > 1500, creatinine <1.5 ```
31
Hep C treatment
``` Oral PI (boceprevir BOC or telaprevir TVR) Pegaylated IFN (PegIFN) Ribavirin RBV ```
32
Alcohol cirrhosis risk
7-13 drinks/week women | 14-27 drinks/week men
33
Alcoholic fatty liver
AST/ALT >2 | High GGT
34
Maddrey Discriminate function
Bilirubin + 4.6 x prothrombin time -control High if alcoholic hepatitis has poor prognosis >32: 50% mortality w/in 2 mo of onset of alcoholic hepatitis
35
DF>32
Corticosteroids
36
DF<32
Pentoxifylline
37
DF<32 MELD<21 Glasgow<9
Supportive care
38
DF>32 MELD>21 Glasgow>9
Prednisolone 40mg/day (Or pentoxyfylline 400mg 3x per day) Lillie score at one week <0.45 continue prednisolone 28 days >0.45 stop prednisolone
39
Upper GI bleed
Peptic ulcer Mallory weiss tears Esophageal varices Esophagitis
40
Glasgow Blatchford Score
0: low risk | >8: ICU admission
41
Glasgow score of 0
``` Hb>12.9 men or 11.9 women Systolic BP >109 Pulse <100 BUN <39 No melena or syncope No liver disease or heart failure ever ```
42
Upper GI bleed
Blood transfusion at 70-80 g/L Hb, higher threshhold of severe bleeding w hypotension
43
Upper GI bleed + glasgow <1
Outpatient endoscopy
44
Upper GI bleed treatment
Erythromycin (prokinetic agent) and PPI
45
Endoscopic therapy
``` Injection therapy (epi, always followed by second modality) Thermal probes (bipolar electrocoagulation, heater probe) Clips ```
46
Recurrent bleeding
Repeat endoscopic therapy
47
Subsequent bleeding
Trans arterial embolization | Surgery
48
Esophageal variceal bleeding
Ligation
49
Gastric varices
Injection of tissue adhesive
50
Massive refractory esophageal variceal bleeding
Removable covered metal stent is preferred to balloon tamponade as temporizing measure
51
Ulcers w high risk lesions post endoscopy
High dose PPI for 72 h
52
Post endoscopy, pts with cirrhosis
Continue Abx for a week regardless of bleeding source
53
Post endoscopic Variceal bleeding
Vasoactive drugs for 5 days
54
Following hemostasis post endoscopy
Reintroduce aspirin/antithrombotics
55
External hemorrhoids
Minimally invasive: Rubber band ligation Sclerotherapy Coagulation Hemorrhoidectomy Hemorrhoid stapling
56
Colon cancer clinical presentation
Iron deficiency anemia Rectal bleeding Abdominal pain Intestinal obstruction/perforation Early disease: nonspecific Advanced disease: abdominal tenderness, macroscopic rectal bleeding, palpable abdominal mass, hepatomegaly, ascites
57
Colon cancer marker
Serum carcinoembryonic antigen
58
Colon cancer in cecum and right colon
Right hemicolectomy
59
Colon cancer in proximal or middle transverse colon
Extended right hemicolectomy
60
Colon cancer in splenic flexure and left colon
Left hemicolectomy
61
Colon cancer in sigmoid colon
Sigmoid colectomy
62
For pts with HNPCC, FAP, metachronous cancers in separate colon segments, acute malignant colon obstructions w unknown status of proximal bowel
Total abdominal colectomy w ileorectal anastomosis
63
Chemo for colon cancer
5-FU w leucovorin or capecitabine (either alone or w oxaliplatin)
64
Non surgical colon cancer options
Cryotherapy Radiofrequency ablation Hepatic arterial infusion of chemo agents
65
Diverticulitis etiology
Perforation of diverticula causing extracolonic inflammation
66
Clinical diverticulitis
Abrupt onset LLQ pain/tenderness Low fever Constipation
67
Peritonitis caused by perforation
Rebound tenderness and abdominal rigidity
68
Diverticular abscess causing bowel obstruction
Diffuse abdominal pain Abdominal distention High fever
69
Diverticulitis I
Symptomatic uncomplicated Fever, abdominal pain Colonoscopy or enema to rule out neoplasms and colitis
70
Diverticulitis II
Recurrent symptomatic | CT or barium enema
71
Diverticulitis III
Complicated (Abscess, hemorrhage, stricture, fistula, peritonitis, obstruction, etc) CT
72
Uncomplicated diverticulitis
Abx
73
Conplicated diverticulitis | ACS hinchey Ib or II
Abx plus percutaneous drainage for large abscess, small one just Abx
74
Conplicated diverticulitis | ACD hinchey III or IV
Emergency surgery
75
Ib
Pericolic or mesenteric abscess
76
II
Large abscess extending into pelvis (walled off)
77
III
Gaseous release
78
IV
Fecal discharge
79
Drugs to avoid in diverticulitis
Nonsteroidal nonaspirin anti inflammatories
80
Resolution of acute diverticulitis (high quality exam not done in past 6 mo)
Colonoscopy
81
Colon cancer nutritional eval
Vit B12 Iron RBC folate
82
Marker of intestinal inflammation
Fecal calprotectin
83
Enzyme check before initiation of therapy w mercaptopurine and azathioprine
TPMT thiopurine methyltransferase If low, leukopenia, sepsis
84
pANCA
Ulcerative colitis
85
ASCA Anti saccharomyces cerevisiae antibodies
Crohn disease
86
Diagnose crohn’s using
Ultrasonography
87
Determine extent and severity of colitis
Colonoscopy | Flexible sigmoidoscopy
88
Crohns location
Entire GI tract | Mostly transition from small to large intestine
89
Ulcerative colitis location
Colon
90
Crohns etiology
Skip lesions | Increased risk of cancer
91
UC etiology
Uniform from rectum up to colon | Marked cancer risk
92
UC stmptoms
Bleeding
93
Crohns symptoms
Toxic megacolon | Perf of colon
94
UC extraintestinal
Liver disease
95
Crohns extraintestinal
Fistulas | Abscesses
96
Crohns histology
Granulomas Lymphocytic String sign on x ray
97
UC histology
Neutrophilic | Lead pipe colon on x ray
98
UC endoscopy
Crypts, continuous lesions, residual tissue
99
Crohns endoscopy
Discontinuous lesions, strictures, linear ulcerations
100
IBD diet
B12, D, iron
101
IBD meds
Aminosalicylates/metronidazole or ciprofloxacin Steroids (oral prednisone at 10-40 mg/day tapered once symptom relief) If steroids cant be tapered without recurrence, use immunomodulators or anti TNF therapy TNF monoclonal antibody therapies Immunomodulator azathioprine
102
Achalasia
Myenteric plexus degeneration Nitric oxide neurons (inhibition) VIP neurons
103
Achalasia due to malignancy secondary to
Pancreatic cancer Prostatic cancer Lymphoma
104
Achalasia due to diseases
Amyloidosis MEN glucocorticoid deficiency syndrome
105
Chagas disease may cause
Achalasia
106
Achalasia left untreated
Increased risk of squamous cell carcinoma after 50
107
Achalasia meds (not very useful)
Nitrates Ca channel blocker Viagra
108
Achalasia treatments
Pneumatic balloon dilation Surgical myotomy Endoscopic myotomy Botox injection
109
Achalasia on x ray
Bird’s beak
110
Scleroderma stages
Neuropathy Myopathy Fibrosis
111
Consequence of severe GERD
Scleroderma
112
Scleroderma and GERD
Complicated by decreased saliva production Decreased gastric emptying
113
Non cardiac chest pain
Nutcracker | DES
114
Diffuse esophageal spasm
Simultaneous prolonged contractions Intermittent dysphagia Atypical chest pain (Ca channel blockers, nitrates)
115
Nutcracker esophagus
High amplitude peristaltic contractions | Odynophagia
116
Boerhaave syndrome
Transmural distal esophageal rupture due to retching Surgical Emergency
117
Plummer vinson syndrome
Dysphagia (esophageal webs) Iron deficiency Glossitis In ELDERLY FEMALE
118
Eosinophilic esophagitis
Atopy in childhood Children>men>women Like GERD but doesn’t respond tk gerd tx PPI responsive EoE do not have gerd Omeprazole blocks IL13 induced Eotaxin-3 secretion
119
EoE path
> 15 eos/hpf High TGFB1 Subepithelial fibrosis/stenosis Mucosal fragility Rings/furrows/exudates/strictures
120
Cowdry Type A inclusion bodies
HSV esophagitis
121
Decreased LES
``` Drugs Alcohol Chocolate Peppermint Fatty foods Smoking ```
122
Hypersalivation
GERD symptom
123
Barrett’s esophagus
Metaplastic process Squamous to columnar epithelium w goblet cells Progresses to adenocarcinoma
124
Esophageal impedance
Measures reflux
125
GERD med adjustment
Discontinue aggravating meds (anticholinergics) Therapy: H2 antagonists PPI
126
Fundoplication
Surgery for GERD
127
Adenocarcinoma
Most common in US | lower 1/3
128
Squamous cell carcinoma
Most common in world Upper 2/3 Alcohol and smoking
129
Secondary esophageal cancer
Extrinsic: lung Submucosal: breast w pseudoachalasia
130
Cases entering population
Incidence
131
Current cases
Prevalence
132
Cases leaving population
Recovery, death, migration
133
Type 1 and 2 error
1: false pos 2: false neg
134
Variance
(Xi - mean)^2 / n-1
135
St deviation
Square root of variance
136
Positively skewed
Peak happens earlier
137
Interval variables
Temp in C or F | Exam score
138
Plus or minus 1 standard deviation
68%
139
R^2
Determination | Percentage of variance of y explained by x
140
Regression
Units of outcome
141
Lead time bias
Earlier detection by screening so longer survival
142
Length time bias
Excess of asymptomatic cases detected, while fast progressing only detected after symptoms
143
Deceleration of gastric motility
Pylorostenosis Hypokalemia Diabetes Peptic ulcer
144
Parietal cell
HCl | Intrinsic factor - B12 absorption
145
Chief cell
Pepsinogen - protein digestion
146
Surface mucous cells
Mucus, bucarbonate Trefoil factors For protectiob
147
ECL cells
Histamine - regulation
148
G cells
Gastrin - secretion
149
Nerves
Gastrin-releasing peptide - regulation ACh - regulation
150
D cells
Somatostatin - regulation
151
Achylia gastrica
No HCl | No enzymes
152
Long term increase of stomach secretion
``` Proteinases Hyperacidity Peptic ulcer Liver disease Hypercalcemia ```
153
Decreased stomach secretions
Achlorhydria Achylia Atrophic gastritis
154
Infectious gastritis
Decrease acid production in most people
155
Atrophic gastritis
Chronic
156
Type A gastritis
Autoimmune Corpus affected Pernicious anemia (B 12 def) Megaloblastic anemia
157
Type B gastritis
``` H pylori Corpus affected Gastric cancer phenotype Or Duodenal ulcer phenotype - Antral infection ```
158
Causes of gastritis
``` Crohns Sarcoidosis Syphilis Atrophic (Type A and B) Infectious NSAIDs ```
159
Curlings ulcer
Dec plasma volume | Burns
160
Cushings ulcer
Inc vagal stimulation High ACh High H+ Head injury
161
Gastritis vs ulcer
Gastritis - mucosa | Ulcer - muscularis/submucosa involvement
162
Chronic atrophic gastritis
Inflammatory cell infiltrate Atrophy of mastric mucosa Risk of adenocarcinoma
163
H pylori
``` Gram neg Spiral Microaerophilic Motile UREASE ``` Associated: gastritis, ulcer, adenocarcinoma, MALToma, non-ulcer dyspepsia
164
Chronic H pylori
Duodenal ulcer - high gastrin and acid, protection from gastric cancer Simple gastritis - majority, high gastrin, normal acid Gastric cancer - very rare, corpus, multifocal atrophic gastritis, high gastrin, low chloride, low pepsinogen
165
H pylori culture
100% specific | Affected by PPI
166
UBT
Most Sensitive
167
Serology
Sensitive | Not useful after eradication therapy
168
COX 1
GI mucosal integrity
169
Peptic ulcer disease pathophys
Increased vagal activity Parietal cell hyperplasia More acid
170
Alcohol diet and caffeine cause
Gastritis NOT peptic ulcer
171
Gastric ulcer causes
Impaired mucosal defense Motility defects (bile backs up and messes with mucous barrier) Delayed gastric emptying Mucosal ischemia
172
Weight loss is seen in
Only in gastric ulcer
173
Gastric ulcer | Duodenal ulcer
Gastric - aggravated by meals | Duodenal - relieved by meals then recurs a couple hours later
174
Gastric ulcer bleeding
Lesser curvature bleeds from left gastric artery
175
Gastric cancer after
Gastric ulcer
176
Men w Blood group o inc risk of
Duodenal ulcer (into submucosa)
177
Rapid gastric emptying causes
Duodenal ulcer
178
Zollinger ellison associated w
Duodenal ulcers most common tumor of G cells in langerhans islets of pancreas (can also come from duodenum) Secretory diarrhea
179
Posterior surface bleed
Gastroduodenal art
180
H pylori
Duodenal ulcer | High gastrin
181
Duodenal perforation
Ant > post
182
Bleeding va perf
Bleeding more in post wall | Perf more in ant wall
183
Duodenal perf leads to
``` Air under diaphragm on x ray Peritonitis Pancreatic pain Hypovolemic shock OBSTRUCTION ```
184
Diagnosis of duodenal ulcer
Stool antigen test UBT serology (active infx) Antral biopsy w urease test (endoscopic)
185
Refractory ulcer
Zollinger ellison syndrome Cancer Crohn’s Lymphoma
186
Hyperglycemia
Acute gastroparesis | Antral hypomotility
187
Scleroderma, vagotomy, hypothyroidism
Chronic gastroparesis
188
Motility disorders more in
Female
189
Diabetic gastroparesis
Autonomic neuropathy Reduced relaxation Inc pyloric pressure
190
Gastroparesis sympt
``` Bloating N/v Anorexia Dehydration Not much pain ```
191
Dumping syndrome
Hyperosmolarc cholesterol rich Early or late (hypoglycemia) Postvagotomy diarrhea Billroth ii surgery (stomach wall removed) - iron and calcium malabsorption
192
Infx leading to gastric cancer
EB virus | H pylori
193
Gastric cancer genetics
Germline mutation cdh1 (e-cadherin)
194
Predysposing syndrome for gastric cancer
Pernicious anemia (autoimmune atrophic gastritis)
195
Hypertrophic gastropathy leads to
Gastric cancer
196
Menetrier disease
``` Gastric hypertrophy Protein loss Parietal cell atrophy Inc mucous cells Stomach looks like brain Precancerous ```
197
Chronic gastritis leads to
Antral gastritis or | Multifocal atrophic gastritis -> adenocarcinoma
198
Acanthosis nigricans
Adenocarcinoma due to hp, early mets to liver and LN’s
199
Ulcer w raised margins
Intestinal type adenocarcinoma | Lesser curvature
200
Signet ring cells
Linitis plastica Diffuse type adenocarcinoma NO hp
201
Gastric lymphoma
Secondary to hp - MALToma
202
Symptoms of stomach cancer
Virchow nodes - left supraclavicular node Krukenberg tumor - bilateral ovaries, signet ring cells, mucous Sister mary joseph nodule - subcutaneous periumbilical mets
203
Interstitial cells of Cajal
GI stromal tumor | Mesenchymal tumor
204
Leiyomyoma sarcoma
Smooth muscle tumor | GIST
205
Acute diarrhea
Metabolic acidosis
206
Chronic diarrhea
Ca and P balance disturbance Steatorrhea Bleeding
207
Osmotic gap
<50 secretory | >125 osmotic
208
Cholera
Over secretion of Cl Na and water follow Night and day Fasting doesnt help
209
Vibrio cholera
``` Gram neg Oxidase pos Curved Flagellated rod Shooting star motility Rice water stool ```
210
Increase cAMP in intestinal mucosa
Increased Cl secretion
211
Cholera risk inc w
PPI | grows on highly alkaline media
212
ETEC
Heat labile toxin LT - inc camp Heat stable toxin ST Pili attach intestinal epithelial cells
213
Cholera toxin
Activates Gs
214
Osmotic diarrhea
``` Laxatives Lactose intolerance High fructose corn syrup Sorbitol Antibiotic related ```
215
Infx gastroenteritis
Norovirus - most common Rotavirus - child Usually viral, usually self limited
216
Severe diarrhea and pregnant
Listeria
217
Sympt w in 6 hours diarrhea
``` Preformed toxin Staph aureus (mayo) Bacillus cereus (rice) ```
218
8-16 hours diarrhea
C perfringes - reheated meat, gas gangrene (lecithinase)
219
Lecithinase
Splits phospholipids | C perf
220
After 16 hours
Viral | ETEC or EHEC
221
Bloody diarrhea
``` EHEC Campylobacter jejuni Yersinia enterocolitica Shigella Salmonella ```
222
EHEC
Shiga toxin (verotoxin) O157:H7 Hemolytic uremic syndrome (HUS) Undercooked ground beef
223
C jejuni
Children Domestic animal exposure Precedes guillan barre and reactive arthritis
224
Yersinia
Puppies | Mimics crohn disease
225
Shigella
Preschool outbreak | No HS on TSI agar
226
Salmonella
Undercooked poultry, eggs, produce Kids playing with pet reptiles HS on TSI agar
227
Shiga toxin vs Shiga like toxin
SLT does not cause host cell invasion Shiga invades intestinal mucosa Small inoculum 50-100 cells
228
Shiga toxin
Stops 60s ribosome | Blocks trna binding
229
Pediatric renal failure
HUS | bc cytokine release
230
HUS
Microangiopathic hemolytic anemia MAHA Thrombocytopenia Renal failure Schistocytes
231
Salmonella typhi
``` Gram neg rod Facultative anaerobe Fecal oral Flagella HS ENCAPSULATED Vi antigen - asplenics! ``` Rose spots on chest Sickle cell and osteomyelitis
232
Campylobacter
``` Gram neg Comma shaped Corkscrew motility 42 C Precedes guillan barre ```
233
Rotavirus
Infant | Dehydration and death
234
Cryptosporidium
Acid fast oocytes In water AIDS
235
Giardia
Camping/hiking Foul smelling Fatty diarrhea Smiley face trophozoites
236
Entamoeba
Bloody diarrhea Liver abscess Anchovy paste exudate
237
C dif
Toxin A - brush border, inflamm and fluid secretion Toxin B - cytotoxic, pseudomembrane ``` PPI inc risk Gram pos Spore forming Toxic megacolon Fecal transplant ```
238
Inflamm diarrhea can lead to
Obstruction
239
Pancreatic cholera
Non beta islet cell tumor VIP multiple endocrine tumors Chronic diarrhea - secretory
240
Carcinoid syndrome
``` 5-hydroxytryptophan Histamine Paroxysmal flushing, explosive diarrhea, tachycardia, low BP ELEVATED URINE 5-HIAA Chronic diarrhea - secretory ```
241
Limited ileal resection
<100 cm malabsorbed bile in colon causes secretion Rx - cholestyramine
242
Extensive ileal resection
``` >100 cm Impaired enterohepatic circulation Impaired micelles Fat malabsorption and secretion Rx - low fat diet, medium chain triglycerides ```
243
Uncontrolled diabetes
Constipation
244
Osmotic gap
290 - 2(Na + K) stool 50-125 mixed diarrhea
245
Stool fat > 14g/100g stool
Malabsorption Pancreatic insufficiency Bacterial overgrowth
246
Stool fat <14
Lactose intolerance (genetic or old) Laxatives Sugars
247
Normal stool weight
<300g/day
248
Normal osmotic gap or <50 Normal stool fat Increased wt >300
>1000 secretory diarrhea | Laxative abuse
249
Hematochezia
Bleeding from rectum, red
250
Stable
<500 cc
251
Orthostatic inc HR
500-700 cc
252
Orthostatic dec BP
700-1000 cc
253
Resting inc HR
20% or >1L
254
Resting dec BP
30-40%
255
Death
>50%
256
When to transfuse
High risk: HCT <27% Hb <9 | Variceal bleeding: <21% Hb <7
257
Melenic stool
200 cc blood
258
BUN/Cr >35
UGIB
259
Clean based ulcers
Almost no serious recurrent bleeding | Can go home
260
Vasoactive meds for esophageal varices
Octreotide Somatostatin Vapreotide Terlipressin For 2-5 days
261
Long term meds for esophageal varices
Nonselective Beta blockers + endoscopic ligation
262
Dont use barium x rays for
GI bleeding
263
Acute acid suppression in UGIB bc
Platelets aggregate poorly at pH < 6 | Inhibit pepsinogen
264
Small intestine bleeding in kids
Meckel’s diverticulum
265
Eval small intestine bleeding
Angio Second look procedure Capsule endoscopy to look at whole small intestine
266
Pts with small bowel narrowing
Use CT enterography instead of capsule endoscopy
267
Small intestine bleed meds
Hormonal tx: orthonovum 1/50 BID
268
LGIB in kids
IBD or juvenile polyps
269
Positive fecal occult blood
Colonoscopy Upper endoscopy if upper symptoms If iron deficiency do both
270
D-xylose
Differentiate btw malabsorption from small intestine vs pancreatic insufficiency
271
Celiac diseased
``` Diarrhea chylosa Consumption of bowels Small bowel disorder Mucosal inflammation Villous atrophy Crypt hyperplasia ```
272
Chances of getting celiac
1 first degree = 10% 2 first degree = 25% 1 second degree = 8% Identical twins = 70%
273
Celiac disease genetics
Genetic predisposition | HLA-DQ2 and/or DQ8 + other
274
Celiac trigger
Virus or bacteria allow gliadin to pass to lamina propria Adenovirus type 12 sensitizes T cells to gliadin TTG deaminates glutamine at 4,6,7 on gliadin Inc T cell response
275
Celiac serology
Anti-deamidated gliadin peptide (DGP) IgA, IgG DO NOT USE antigliadin IgA, IgG Antiendomysial IgA (EMA) ANTI-tissue transglutaminase IgA (TTG IgA)
276
Celiac symptoms
``` Diarrhea Overweight/obese - 32% Bruising, skin rash Dermatitis herpetiformis Iron deficiency anemia Bone pain Ascites Epilepsy Infertility Short stature ```
277
Extraintestinal celiac
Liver disease - elevated transaminases, autoimmune hepatitis, primary biliary corrhosis Ascites Weight loss Anemia (iron/folate def) Bruising - vit k def, elevated prothrombin time
278
Celiac path
``` Small intestine Villi blunted Crypts elongated Inflammatory infiltrate Mucosal cracks ```
279
Celiac treatment
Gluten free diet plus Take glutenases Tight junction modulator: larazotide .5 mg TID Antiinflammatory
280
Non-celiac gluten sensitivity
IBS-like symptoms More common than celiac No evidence of celiac or wheat allergy More symptoms than celiac
281
Wheat allergy
IgE mediated Itching Swelling of lips, tongue
282
Tropical sprue
Persistent Contamination of mucosa by: klebsiella, enterobacter cloacae, e coli) Toxins make structurally abnormal mucosa
283
Tropical sprue symptoms
Megaloblastic anemia (folate def) Watery diarrhea Abdominal cramps Flatulence
284
Tropical sprue treatment
Tetracycline and folate for 6 mo
285
Bacterial overgrowth dx
Small bowel barium x ray 13c-xylose breath test Lactulose hydrogen breath test
286
Whipple’s disease
Tropheryma whipplei - gram pos bacilli Small bowel, CNS, heart, kidneys, joints Edema PAS pos granules in macrophages on biopsy
287
Whipple’s disease tx
Ceftriaxone then bactrium
288
IBD smoking
Causes crohn’s | Prevents UC
289
Appendectomy IBD
Protective in UC
290
Abx use in first year of life: risk factor for
IBD
291
IBD breastfeeding
Protective
292
Omegas in IBD
High omega 6, low omega 3: inc risk
293
Vit D IBD
Protective
294
IBD: regulation of secretory activity
XBP1 ORMDL3 OCTN
295
IBD: innate immunity and autophagy
NOD2 ATG16L1 IRGM JAK2 STAT3 C13orf31
296
IBD: regulation of adaptive immunity
IL23R IL12B IL10 PTPN2
297
IBD: development and resolution of inflammation
MST1 CCR6 TNAAIP3 PTGER4
298
Fibrostenosing CD
NOD polymorphisms
299
Fistulizing CD
ATG16L1
300
Loss of haustrations No granuloma Limited to mucosa and submucosa
UC
301
Granuloma formation Transmural Rectum spaired
Crohns
302
Ilieocolitis mimics appendicitis
Crohns
303
Crohn’s
Oxalate kidney stones bc Ca bound by fat, so Na binds oxalate and is absorbed
304
Primary sclerosing cholangitis
UC
305
Gallstones
CD
306
Pyoderma gangrenosum
UC
307
Sweet’s syndrome
Map like red lesion High neutrophils Extraintestinal for IBD
308
Episcleritis
CD
309
Aphthous ulcers
CD
310
AA, hispanic, asian
Ileocolonic CD | pancolonic UC
311
East asians
Perianal disease
312
African American
Joint and ocular involvement
313
Hispanic
Dermatologic manifestations
314
Endoscopy in crohns
Cobblestoning Serpiginous ulcers Aphthous ulcers
315
IBD treatment
5-ASA (mesalamine) - remission Anti inflammatory Azathioprine, 6-mercaptopurine, methotrexate, tacrolimus anti TNF (infliximab, adalimumab) anti integrins (natalizumab, vedolizumab)
316
Rome IV diagnostic criteria
For IBS Symptom onset 6 mo ago Criteria fulfilled for last 3 mo Abdominal pain 1 day/week in 3 mo + 2: Defacation Frequency of stool Appearance of stool
317
Prolonged fasting
Improves diarrhea in IBS
318
IBS pathophys
Mid cingulate cortex - more pain More motility Inc IL-6,IL1ß, TNF and TRPV1 -> visceral hypersensitivity, permeability Inc EC cells, TPH1 polymorphism -> inc serotonin -> inc motility
319
Visceral hypersensitivity in IBS
Afferent disfunction
320
Hydrophilic colloid, psyllium
Stool bulling agents for IBS
321
Anti depressants for IBS
TCA’s - delay gut transit time, visceral afferent neural function changed
322
Post infectious IBS
Campylobacter Shigella Salmonella
323
Good bacteria in low levels in IBS
Bifidobacterium | Lactobacillus
324
True diverticulum
Ex. Meckel’s Herniation of entire bowel wall
325
False diverticulum
Mucosa and submucosa thru muscularis propria
326
Diverticula more common in
Left colon Sigmoid (Rectum spared)
327
Diverticula in Asians
70% in right colon and cecum
328
Diverticula pathophys
Nutrient artery (vasa recti) penetrates muscularis propria Vasa recti compressed or eroded -> bleeding or perf High press in sigmoid colon -> high amp contractions -> chronic inflamm -> neuron degeneration -> dysmotility and high intraluminal pressures High fat stool
329
Diverticulosis
Hematochezia Or Asymptomatic
330
Diverticulitis
Symptomatic uncomplicated diverticular disease (SUDD) fever Anorexia LLQ pain Obstipation Complicated: perf, abscess, stricture
331
Abdominal distension + localized peritonitis
Pericolonic abscess
332
Diverticulitis Tx
Bowel rest 3rd gen cephalosporin Cipro + metro Amp added for non responders
333
Most colorectal cancers arise from
Adenomatous polyps
334
Sessile, serrated polyps
Invasive cancer
335
Villous adenoma
Mostly sessile | Malignant 3x more than tubular
336
Colorectal cancer pathophys
Microsatellite/chromosomal instability APC inactivation or b catenin activation KRAS or BRAF activation SMAD4 or TGFbII inactivation TP53 inactivation
337
Polyposis coli
5q deletion Absence of tumor suppressors 1000s of adenomatous polyps, cancer by 40
338
MYH associated polyposis
MUT4H mutation | Polyposis coli or colorectal CA w/out polyposis
339
Hereditary nonpolyposis colon CA
Lynch’s syndrome hMSH2 or hMLH1 mutations Errors in DNA replication Proximal/ascending colon by 50
340
IBD and colorectal CA?
UC>CD
341
Endocarditis from Strep Bovis
Higher risk of colorectal CA
342
Tobacco use >35y
Higher risk of colorectal CA
343
Colorectal cancer - cecum
Tumor may be large w/out obstructive sympt bc stool is liquid here
344
Colorectal CA - right colon
Ulcerate Hypochromic microcytic anemia Fatigue Palpitations
345
Colorectal CA - transverse and descending colon
Obstruction Abd cramping “Apple core” lesion
346
Colorectal CA - rectosigmoid
Hematochezia Tenesmus Narrowed stool
347
Colorectal CA screening
Flexible sigmoidoscopy every 5 y after 50 Colonoscopy every 10 y after 50
348
Descending colon colorectal CA
Apple core | Napkin ring
349
Sigmoid colon CA
U shape
350
Lab tests for colorectal CA
``` Liver function (most common for mets) Plasma CEA ```
351
Post op colon CA
CEA every 3 mo PE every 6 mo for 5 yr Endoscopy every 3 yr
352
Rectal cancer
Recurrence of 25% so give post op radiation therapy
353
Primary prevention of colorectal CA
Aspirin and NSAIDs Suppress proliferation by inhibiting prostaglandin synthesis
354
Acute liver failure
In a previously healthy person Coagulopathy (PT>20 or 4-6 sec longer, INR>1.5) Encephalopathy
355
Fulminant liver failure
Encephalopathy w/in 2 weeks
356
Subfulminant liver failure
W/in 3 mo
357
Hyperacute LF
``` Acetaminophen toxicity Acute Hep A or E Jaundice -> encephalopathy <1 week Severe coagulopathy Moderate intracranial HTN ```
358
Acute LF
Hep B Jaundice -> encephalopathy 1-4 weeks Moderately severe coagulopathy Mild to moderate intracranial HTN
359
Subacute LF
``` Nonacetaminophen drug toxicity SEVERE JAUNDICE Jaundice -> encephalopathy 4-12 weeks Mild coagulopathy Absent or mild intracranial HTN ```
360
Viral Hepatitis
PAMPs | Innate immune mediated response leading to ALF
361
Toxin mediated liver injury
DAMPs Innate immune mediated response Leading to ALF
362
Acetaminophen liver damage
Causes necrosis of hepatocytes
363
Metabolism of acetaminophen
Some acetaminophen -> NAPQI (cyp450 2E1) NAPQI needs glutathione to flush it out as cysteine and mercapturic acid Not enough glutathione? Liver cell damage (covalently binds proteins, oxidative damage and mitochondrial dysfunction)
364
Acetaminophen toxicity antidote
N acetylcysteine Precursor of glutathione
365
NAPQI excretion?
Renally excreted
366
NAPQI hepatocellular damage
Necrosis in centrilobular (zone III) region bc greater production of NAPQI here
367
Liver biopsy indicated
Lymphoma | Wilson’s
368
Lab findings in ALF
Decreased platelets | Hypoglycemia
369
AST of 3500 units/L
Acetaminophen hepatotoxicity
370
Alcoholic liver injury fibrosis
Stellate cells
371
Wilson’s
``` Hepatolenticular degeneration Autosomal recessive Copper Mutation in ATP7B (chr 13q) Late childhood onset Acute hepatitis -> cirrhosis ```
372
Wilson disease pathophys
Defective copper transporting P-type ATPase bc of ATP7B mutation Most common: histidine to glutamine H1069Q Copper doesnt get into bile for excretion Copper not incorporated into apo-ceruloplasmin to form ceruloplasmin (binds Cu in blood) Free radicals, oxidation of lipids and proteins
373
Non toxic Cu storage
Metallothionein
374
Kayser fleischer
Cu in descemet membrane in limbus of cornea Electron dense granules rich in copper and sulfur Also seen in chronic cholestatic disorders - primary biliary cirrhosis
375
Wilson’s kidneys
Renal disease bc proximal tubule damage leading to Fanconi syndrome
376
Hemolytic anemia in wilsons
Oxidative injury by Cu
377
Lab findings in wilsons
Decreased total serum copper Decreased serum ceruloplasmin (early stage) Increased cerum and urine free copper (late stage)
378
Diagnosing wilsons
Low ceruloplasmin <50 Urinary Cu >100/day In hepatic tissue >250
379
Wilsons Tx
D-penicillamine or Trientine - Cu chelator Zinc therapy - inhibits Cu reabsorption in gut Ammonium tetrathiomolybdate - competes for Cu reabsorption in bowel, inc Cu excretion in urine
380
Alpha 1-Antitrypsin Def
``` Autosomal co-dominant Defects in SERPINA1 (chr 14q) North european Liver, lung, skin Most common cause of cirrhosis in kids Early onset panacinar emphysema ```
381
M/c cause of cirrhosis in children
Alpha-1 antitrypsin def
382
Alpha-1 antitrypsin
Inhibit neutrophil derived proteases - elastase MM - normal, 150-350 Def variants - Z, S Severe def - ZZ (PiZZ)
383
PiZZ
Misfolding and aggregation in liver bc glutamine to lysine Accumulate in endoplasmic reticulum Unfolded protein response -> apoptosis
384
Panniculitis
Painful cutaneous nodules at sites of trauma in alpha-1 antitrypsin def
385
Lab findings in alpha-1 antitrypsin def
Decreased a1-AT <80 or dec activity PAS-pos, diastase-resistant globules in periphery of hepatic lobule
386
a1-AT def Tx
IV a1-AT
387
Hereditary hemochromatosis
Iron in parenchymal organs Autosomal recessive HFE mutation - chr 6p Reduced Hepcidin secretion so overload of Fe released from macrophages and enterocytes, uncontrolled absorption Northern european
388
Hepcidin
Low in low Fe or anemia or hypoxia Elevated in inflammation, High Fe Binds ferroportin and internalizes it Loss of Fe absorption
389
HHC iron deposition
Liver then endocrine organs, heart etc
390
HHC asymptomatic until
20g of stored Fe accumulated
391
Liver damage in HHC
Lipid peroxidation Stimulation of collagen formation DNA damage by ROS
392
Nonreversible effects of HHC
``` Hypothyroidism DM Arthropathy (mp joints) - hemosiderin and Ca pyrophosphate in joints, pseudogout Chondrocalcinosis Pituitary gonadotropins MSH - Fe in pituitary, amenorrhea, dec libido Cirrhosis Hepatocellular carcinoma Testicular atrophy Impotence ```
393
Reversible HHC symptoms
Skin pigmentation Cardiomyopathy - a fib Liver biochemistries
394
Pigmentation in HHC
Inc melanin production | Hemosideron deposition in macrophage and fibroblast
395
DM in HHC
Bronze diabetes Destruction of ß islet cells -fibrosis, atrophy Inc insulin resistance
396
Malabsorption in HHC
Destruction of exocrine pancreas
397
HHC lab findings
Inc Fe, %transferrin sat, ferritin (ferritin used to follow therapy) Dec TIBC, LH, FSH
398
HHC best screening test
Inc % transferrin saturation, cutoff at 45% HFE gene testing for C282Y mutation
399
AIH pathophys
1) cytotoxic T cell, diverse autoantibodies - cell mediated cytotoxicity 2) plasma cell - antibody mediated cytotoxicity
400
Type 1 AIH
Middle age and older ANA, ASMA, anti-SLA/LP HLA DR3 and DR4
401
Type 2 AIH
Children and teens ALKM-1 antibody HLA DR7
402
Clinical AIH
Acute - inc transaminase Fulminant Cirrhosis Fatigue Dark urine light stool RUQ pain Anorexia Fever, hepatomegaly Scleral icterus Encephalopathy
403
AIH may be associated w
Autoimmune diseases | UC
404
AIH histo
Interface hepatitis Bridging necrosis Lymphocytes invading limiting plate Lymphoplasmocytic infiltrate in portal triad
405
AIH lab findings
Elevated ALT, AST (10x) | Serum gamma globulin (3x)
406
Bile components
Bile acids 80% Lecithin and PL 16% Cholesterol 4%
407
Pancreas secrets
3L alkaline fluid daily
408
Acinar cells secrete
``` Enzymes Amylase Lipase Phospholipase A2 Colesterol esterase Endopeptidases trypsin and chymotrypsin Exopeptidases carboxypeptidase and aminopeptidase Elastase ```
409
Ductal cells secrete
Fluid and bicarb
410
Enterokinase
In duodenum | Trypsinogen -> Trypsin
411
Pancreas intracellular Ca
Low in acinar cell to promote destruction of spontaneously activated trypsin
412
Pancreatic secretory trypsin inhibitor
PSTI | SPINK1
413
Bind and inactivate intracellular trypsin
Chymotrypsin C
414
Common Acute pancreatitis
``` Idiopathic Gallstones - microlithiasis Ethanol Trauma Steroids - estrogens Mumps Autoimmune Scorpion sting Hypercalcemia/hypertriglyceridemia ERCP Drugs - azathioprine, 6-MP, sulfonamides, tetracycline, valproic acid, antiretrovirals, 5-ASA ``` Postop
415
Uncommon acute pancreatitis
``` Vascular Connective tissue disorder, TTP Cancer Periampullary diverticulum Pancreas divisum Hereditary pancreatitis CF RF Infx - mumps, coxsackie, CMV, echo, parasite ```
416
Acute pancreatitis pathophys
1) digestive enzyme activation, acinar cell injury 2) leukocytes, macrophages, inflammation 3) effects on distant organs
417
Causes of acute pancreatitis
Duct obstruction Acinar cell injury Defective intracellular transport
418
Acute pancreatitis clinical features
``` And pain - steady and boring, radiate to back Abd distention - GI hypomotility PE: distressed Low fever Tachycardia Hypotension Rare Jaundice - edema of pancreatic head Abd rigidity Dec bowel sounds Basilar rales ```
419
Acute pancreatitis signs
Cullen sign - periumbilical | Grey turner sign - flank
420
Acute pancreatitis diagnosis
Atlanta classification (2/3) Abd pain acute persistent severe, radiates to back High serum lipase or amylase (3x upper limit) Imaging ``` Also: Leukocytosis (15-20k) Hemoconcentration (Hct >44%: necrotizing) Metabolic panel: Azotemia (BUN >22) hypoxemia (PaO2 <60) ``` ``` Hyperglycemia Hypocalcemia Hyperbilirubinemia Hypertroglyceridemia High LDH and persistent hypocalcemia: bad prognosis ```
421
Normal pancreatic secretion
``` Isoosmotic Higher bicarb Lower chloride Secretin triggers fluid and bicarb release Cck triggers enzyme release Somatostatin inhibits any release ```
422
Early acute pancreatitis complications | <2 weeks
Shock, SIRS DIC ARDS organ failure
423
Late acute pancreatitis complications | >2 weeks
``` Persistent organ failure (>2 days) Pancreatic paeudocysts Necrosis Pancreatic ascites Pancreatic fistulas ```
424
Modified Marshall scoring | Organ failure
Assesses CPR 2 or higher in any category - organ failure If 2 or more systems involved - multiorgan failure
425
Chronic pancreatitis
Toxic-metabolic - alcohol, tobacco, phenacetin abuse, DBTC Idiopathic Genetic - PRSS1, CFTR, CAASR, CTRC, SPINK1 Autoimmune - type 1,2, IgG4 systemic Recurrent Obstructive
426
Pancreatic stellate cells
Maintain architecture of pancreas Normally quiescent When activated -> fibrogenesis Periacinar myofibroblasts (other name)
427
Chronic pancreatitis clinical
Abd pain, diabetes, steatorrhea Eating makes pain worse N/V Maldigestion Weight loss
428
Chronic pancreatitis labs
``` Gold standard: secretin test (abnormal when 60% function lost) + MRCP Hyperglycemia Inc ALP X ray: calcifications FPE-1 <100 ```
429
Fecal pancreatic elastase-1
Marker of exocrine pancreatic function | <100 - severe insufficiency
430
Chronic pancreatitis on MRCP
Dilated pancreatic duct w side branches
431
Pancreatic cancer
``` Worst survival rate of any cancer African american males Cadmium Cigarette Meat, fat, fizzy sugary drinks BRCA2, PRSS1/SPIN11 DM ```
432
Pancreatic infiltrating ductal adenocarcinoma
Infiltrating desmoplastic stromal rxns Late dx bc posterior location KRAS p16/CDKn2A TP53 DPC4/MADH4
433
Elevated bilirubin in Pancreatic Cancer
Jaundice at 3 | Pruritis at 6
434
Pancreatic cancer clinical
``` Abd pain like CP worse when lying flat Weight loss Jaundice, pruritis Light stool Steatorrhea Diabetes onset in last year ```
435
PE for pancreatic cancer
``` Palpable gallbladder - courvoisier sign Hepatosplenomegaly Migratory superficial thrombophlebitis - Trousseau Syndrome Virchow node Sister mary joseph node ```
436
Pancreatic cancer diagnosis
Surrounds sma so contrast enhanced CT PET for mets Markers: CA19-9, CEA, CA125 (if others are neg) Whipple procedure - surgical resection
437
NPO
management of acute pancreatitis Dont eat until pain and nausea resolve
438
Gallstones
Cholesterol stones - cholesterol monohydrate Pigment stones - calcium bilirubinate Mexican female >50
439
Cholesterol stones
Clofibrate Inc HMG-CoA Reductase activity Gain of function ABCG5/G8 (hepatic cholestorl transporter) CYP7A1 mut -> low cholesterol 7-hydroxylase -> cholesterol not turned into bile MDR3 (ABCB4) mut - phospholipid/lecithin export pump to hepatic canaliculi (dec Lecithin) Inc pro nucleating - mucin, igg, pigment (gilbert syndrome) Dec anti nucleating - apo A-1, A-2 Pregnancy - 3rd trimester
440
Pigment stones
Black/dark green Ca w unconjugated bilirubin - ß glucuronidase (unconjugates) Chronic hemolytic state - sickle cell, spherocytosis, thalassemia, liver cirrhosis, gilbert, CF, ileal disease Infx - bacteria produce ß glucuronidase Asia
441
Cholelithiasis clinical
``` Biliary colic Sudden onset severe After fatty meal N/V Radiate to interscapular area or right shoulder ```
442
Cholelithiasis US
Acoustic shadowing
443
Gallbladder x ray
Porcelain GB emphysematous cholexystitis Limey bile - high Ca Gallstone ileus
444
Cholecystitis
After stone Mechanical - ischemia Chemical - phospholipase converts lecithin to lysolecithin (irritant) Bacterial - e coli, klebsiella, strep, clostridium
445
Acute cholecystitis
``` Progressively worse RUQ tenderness, fever, leukocytosis Murphy sign Abd distention Hypoactive bowel Pain w jarring movement ```
446
Bile duct obstruction dx
Bilirubin and aminotransferases mildly elevated
447
Mirizzi syndrome
Comp of cholecystitis | Gallstone in GB neck or cystic duct compresses common bile duct -> obstruction, jaundice
448
Choledocholithiasis
Cholesterol stones move into cbd De novo - pigment stones - MDR3 mut
449
Choledocholithiasis labs
Elevated liver enzymes acutely Alk phos elevated, bilirubin elevated Jaundice
450
Primary sclerosing cholangitis
IBD - UC Riedel struma, pseudotumor of orbit
451
PSC histo
Fibrous obliteration of small bile ducts replaced by connective tissue in ONION SKIN pattern Ludwig staging: 1) portal inflammed 2) periportal 3) septal fibrosis/necrosis 4) biliary cirrhosis
452
PSC Dx
Beaded appearance on cholangiography bc strictures
453
PSC Tx
Cholestyramine, Abx Vit D, Ca Balloon stenting
454
PBC vs PSC
PBC - female, older, intrahepatic, granulomatous, sjogren, RA, thyroid, AMA and ANCA, loss of small ducts PSC - male, younger, intra and extrahepatic, fibrosis, IBD-UC, pancreatitis, only ANCA, onion skin
455
Bilirubin
Normal <1 | Jaundice >2
456
First place to see jaundice
Conjunctiva | Under tongue
457
Hep B
``` Double stranded DNA hepadnavirus Reverse transcription like HIV (DNA to RNA) Sexual, blood, vertical Hepatocellular CA Acute phase - sicker patient more likely to clear it Mostly asymptomatic Vaccine - anti HBs pos only ```
458
Hep B associated conditions
Polyarteritis nodosa MPGN Cryoglobulinemia
459
Hep B phases
Proliferative - CD8 destroy hepatocytes Integrative
460
Hep B only hepatitis virus to have
DNA dependent DNA pol
461
HBsAg
First to appear in serum Screening Acute and chronic
462
Bilirubin
Normal <1 | Jaundice >2
462
First place to see jaundice
Conjunctiva | Under tongue
462
Hep B
``` Double stranded DNA Enveloped hepadnavirus Reverse transcription like HIV (DNA to RNA) Sexual, blood, vertical Hepatocellular CA Acute phase - sicker patient more likely to clear it Mostly asymptomatic Vaccine - anti HBs pos only ```
462
Hep B associated conditions
Polyarteritis nodosa MPGN Cryoglobulinemia
463
Hep B phases
Proliferative - CD8 destroy hepatocytes Integrative
464
Hep B only hepatitis virus to have
DNA dependent DNA policy
465
HBsAg
First to appear in serum Screening Acute and chronic
466
Anti-HBs
Previously vaccinated or | Recovered from acute hep b
467
HBcAg
Core antigen Not circulated in blood Cant be checked
468
Anti-HBc
IgM - acute hep b and window phase IgG - chronic hep b and recovery
469
HBeAg
High rates of viral replication | Acute and chronic hep B with high infectivity
470
Anti-HBe
Dec viral rep Pos for several years after acute infx Window phase, chronic hep with low infectivity, recovery
471
Immune due to natural infx Hep B
anti-HBc | anti-HBs
472
Immune due to hep B vacc
anti-HBs
473
Acutely infected
HBsAg anti-HBc IgM anti-HBc
474
Chronically infected hep B
HBsAg | anti-HBc
475
Only pos for anti-HBc
Resolved infx False pos Low level chronic Resolving acute
476
Hep C
``` RNA pos flavivirus enveloped Cirrhosis HCC No proofreading (no 3 - 5 exonuclease) Blood Chronic Acute - asymptomatic ```
477
Hep B transmission
Sex
478
Hep C screening
Anti-HCV Ab
479
Hep C Dx
HCV viral load
480
Hep C Tx
RNA dep pol inhibitors Inhibit enzymes needed for Hep C RNA synth Sofosbuvir Ledispasvir
481
Hep A
RNA pos naked picornavirus Raw or steamed SHELLFISH Fecal oral NO HCC RISK
482
Active Hep A
IgM antibody to HAV Acute only, resolves in 3-6 weeks Vaccinate international travelers
483
Hep D
Enveloped circular RNA Dane particle Requires Hep B surface antigen to coat hep d and allow hepatocyte entry Maternal fetal transmission HCC superinfection - hep d and chronic hep B Most fatal
484
Hep E
``` Naked ssRNA fecal oral Waterborne Clinically like hep A ```
485
Hep E Dx
Check HEV Ag or RNA in stool
486
Susceptible to Hep E
Expectant mothers | Immunosupression after organ transplant
487
Waterborne epidemics
Hep E
488
Alcoholic liver disease
>35 drinks per week (each one 10g ethanol) Female - bc less alcohol dehydrogenase and lower body fluid
489
At risk of developing ALD
Chronic hep C Acetaminophen overdose Hereditary hemochromatosis
490
Metabolism of alcohol
NAD used by cytosolic ADH NADPH and O2 used by MEOS (microsomal ethanol oxidizing system - cyp 450 2E1) Hydrogen peroxide used by peroxismal catalase Makes acetaldehyde
491
Consequences of too much NADH produced by alcohol metabolism
Fasting hypoglycemia Lactic acidosis Triglycerides ßOHB
492
Earliest response of liver to alcohol abuse
Hepatocellular steatosis
493
Alcohol increases fatty acid synth
SREBP-1c
494
Alcohol decreases mitochondrial ß oxidation of fatty acids bc
Less NAD+/NADH
495
Alcohol inhibits FA oxidation in liver by
Inactivation of PPAR-alpha
496
Long term alcohol consumption inhibits
Autophagy
497
Alcoholic hepatitis
Inflammation Bc acetaldehyde at toxic level Free radicals - produced by neutrophils
498
Final stage of ALD
Alcoholic cirrhosis Gut bacteria and bacterial LPS go to portal system Gut derived endotoxin activate kupffer cells TNF-alpha and TNF-ß Stellate cell activation
499
ALD labs
Hugh AST ALT, <500 High GGT (SER enzyme) Low folate - macrocytosis, MCV >100 Hypertriglyceridemia, neutrophilic leukocytosis, hypoglycemia
500
Hepatic steatosis
Macrovesicular fat Centrilobular Perivenular
501
Alcoholic hepatitis
Perivenular fibrosis -> pericellular fibrosis Ballooned hepatocytes w Mallory’s hyaline Fatty change Necrosis and neutrophil rxn
502
Mallory Bodies
Alcoholic hepatitis
503
NAFLD
Accumulation of triglycerides Either simple steatosis (no inflamm) or steatohepatitis (NASH - inflamm and fibrosis)
504
NAFLD associated w
Metabolic syndrome Obesity Diabetes Hyperlipidemia
505
NAFLD path
First hit - insulin resistance | Second hit - inflammatory cytokines, lipopolysaccharides, oxidative stress, TNF-alpha and interleukins
506
Absence of insulin in NAFLD
Failure of suppression of hormone sensitive lipase FFA come to liver
507
Elevated insulin in NAFLD
Synth of triglycerides
508
NAFLD lipid peroxidation and release of OH radicals caused by
FFA | hyperinsulinemia
509
NAFLD labs
AST/ALT < 1
510
NASH vs uncomplicated NAFLD
Liver biopsy
511
NASH Dx
Steatosis Lobular inflamm Ballooned hepatocytes
512
PBC path
Susceptible Exposure Molecular mimicry Anti mitochondrial antibodies to pyruvate dehydrogenase E2 complex (PDC-E2) CD8T cell infiltrate portal triad and ensue destruction of biliary epithelial cells of intrahepatic bile ducts BEC loss inflammation - mixed cells respond B T macro eos NK regeneration of bile ducts not possible
513
AMA+ against PDC-E2
PBC
514
PBC clinical
Early - skin hyperpigmentation, excoriation from itching, steatorrhea Late - jaundice, xanthomas, kayser fleischer, stigma of cirrhosis Sicca, systemic sclerosis Fatigue Pruritis - inc opioidergic tone, worse at night and exacerbated by heat RUQ discomfort
515
PBC labs
High ALP, GGT, cholesterol, IgM AMA+ not correlates w activity of disease
516
Addison’s
Def cortisol | Hyperpigmentation
517
Cushings
``` Cortisol excess Striae Telangiectasias Buffalo hump Hypertrichosis ```
518
Diabetes
``` Acanthosis nigricans Diabetic dermopathy Necrobiosis lipoidoica Eruptive xanthomas Foot ulcers ```
519
Hypothryroidism
``` Alopecia - lateral third of eyebrow Dry rough pale skin Myxedema Cool skin Brittle nails ```
520
Hyperthyroidism
``` Warm skin Thine fine hair Alopecia Vitiligo Pretibial myxedema - Graves Hyperpigmentation ```
521
Low thyroglobulin | Low thyroid uptake
Exogenous hormone for weight loss
522
Increased thyroglobulin | (Low thyroid uptake
Iodide exposure Thyroiditis Extraglandular production
523
High TSH | High T4
Secondary hyperthyroidism | In hypothalamus or pituitary
524
Suppressed TSH | Normal T3 and T4
Subclinical hyperthyroidism
525
Hyperthyroidism management
``` Beta blockers Antithyroid drugs (thionamides) - inhibit thyroid hormone synthesis ``` Methimazole Propylthiouracil SE: agranulocytosis
526
Propylthiouracil
For hyperthyroidism Inhibits T4 to T3 1at trimester pregnancy Less teratogenic than methimazole
527
Rapid decrease in thyroid hormone level
Iodides Sodium ipodate Iopanoic acid Block T4 to T3 and inhibit hormone release
528
Amiodarone induced hyperthyroidism
Iodides + antithyroid drugs
529
Graves disease tx
Radioiodine 131 - nonpregnant CONTRAINDICATED if moderate or severe ORBITOPATHY Destroys follicular cells Can cause hypothyroidism
530
Hashimoto’s thyroiditis labs
Increased antimicrosomal antibodies Anemia - normocytic High LDL, low HDL
531
Subclinical hypothyroidism Tx
``` Levothyroxine if: TSH>10 Inc thyroid peroxidase antibody titer Desires pregnancy Symptomatic ```
532
Cushings syndrome from ectopic ACTH
lung, small cell carcinoma
533
Cushings clinical
``` Weakness Weight gain HTN Amenorrhea Back pain Moon face Acne Purple striae ```
534
Cushings test
Late night salivatory cortisol 24 hr urine free cortisol 1mg overnight DST 48hr 2gm DST
535
1 mg DST
Given at night, cortisol should be suppressed in morning, if not, pos test
536
ACTH < 5
ACTH independent | Tumor in adrenals
537
ACTH > 15
ACTH dependent ``` Cushings disease (pituitary) Ectopic ACTH (malignancy, eg lung) ```
538
Pituitary source excreting excess ACTH
Cushings disease
539
Addison’s
``` Primary adrenal insufficiency Destruction of adrenals Cortisol and aldosterone def Inc ACTH Inc pro-opiomelanocortin synth Inc in melanocyte stimulating hormone ```
540
Addisons labs
``` Hypotension N/V Abd pain Low Na High K Metabolic acidosis ```
541
Standard ACTH test
Give IV ACTH, in primary adrenal insufficiency cortisol does not increase sufficiently
542
Primary adrenal insufficiency
Low cortisol | High ACTH
543
Secindary adrenal insufficiency
Low cortisol | Low ACTH
544
Adrenal insufficinecy Tx
Daily oral glucocorticoid (hydrocortisone or prednisone) and daily fludrocortisone (mineralocorticoid, only if primary)
545
PTH in kidney
25-hydroxyvitamin D to 1,25-dihgdroxyvitamin D
546
Hypocalcemia w hypoparathyroidism
Surgery (thyroidectomy, parathyroidectomy) Autoimmune polyglandular syndrome Radiation HIV
547
Hypocalcemia w secondary hyperparathyroidism in response
``` Vit D def PTH resistance Renal disease Pancreatitis Osteoblastic metastasis Phenytoin Disorders of Mg metabolism ```
548
Hypocalcemia
``` Paresthesias Muscle twitching Spasms Prolonged QT Papilledema ``` Chronic: parkinsonism, extopic calcification, extrapyramidal
549
Hypocalcemia signs
Chvostek’s sign - tap facial nerve, get contraction of facial muscles Trousseau’s sign - BP cuff higher than systolic for 3 min, elicits carpal spasms
550
Low Ca High P PTH way too low Low urine cAMP
Hypoparathyroid
551
Hypoparathyroid Tx
IV calcium gluconate if severe Oral calcium if mild or moderate Vit D supplement (calcitriol) Goal is Serum Ca 8-8.5
552
Autoimmune polyendocrine syndrome Type 1
Addison Hypoparathyroidism Chronic mucocutaneous candidiasis Onset in childhood, adolescents
553
Autoimmune polyendocrine Syndrome type II
Autoimmune adrenal insufficiency Autoimmune Thyroid disease Type I DM Onset adolescent to adulthood
554
Prolactin releasing hormone secreted by hypothalamus
thyrotropin releasing hormone (TRH)
555
Artery that supplies anterior pituitary
Superior hypophyseal artery
556
Artery supplying posterior pituitary
Inferior hypophyseal artery
557
Postpartum pituitary necrosis
Sheehan’s syndrome
558
Hypopituitarism in children
Growth retardation | Delayed puberty
559
Hypopituitary test for female (FSH LH)
17 ß-estradiol
560
Hypopituitary test GH
Arginine stimulation test
561
Pituitary adenoma
Benign, epithelial cell Micro - <10 , secretory, hormone overproduction Macro - >10 , non secretory, mass lesions
562
Incidence of pituitary adenoma
Prolactin - m/c Nonsecretory/null GH,ACTH,LH/FSH TSH - rare
563
Pit adenoma path
Single clone MEN-1, CNC, GNAS1 mut Chromosomal instability Aneuploidy
564
MEN-1
Pituitary Parathyroid Pancreas
565
Bitemporal hemianopsia
Nasal fibers pushed by pit tumor
566
Mild hyperprolactinemia
Maybe pit macroadenoma bc loss of dopamine inhibition bc infundibular stalk disrupted by tumor
567
Acromegaly labs
High GH in blood from inferior petrosal sinuses
568
Acromegaly associated w
Colonic polyps | Preneoplastic adenomatous polyps
569
GH direct action
Insulin resistance - causes HTN and hyperglycemia, DM | Lipolysis
570
GH indirect
IGF1 secretion Growth Protein synth Cell proliferation
571
Headache in Acromegaly
Stretching of dura matter
572
Acromegaly Dx
Elevated serum IGF-1, GH 2 hours after 75 g oral glucose
573
Prolactinoma Dx
Serum PRL >200 Mild elevation could be infundibular stalk compression Hypogonadism: low GnRH, LH, FSH, Sex steroids
574
Primary polydipsia
Psychiatric pt like diabetes insipidus Overdrinking in absence of genuine thirst
575
Central diabetes insipidus
Craniopharyngioma Pit macroadenoma Meningioma Vascular Sheehans Aneurysm Sarcoidosis Histiocytosis
576
Nephrogenic DI - congenital
Defect in V2 receptor in principal cell of distal nephron, x linked recessive (most) Aquaporin 2 channel defect, autosomal dom or rec
577
Acquired nephrogenic DI
Hypokalemia Hypercalcemia Lithium Demeclocycline All reversible!
578
Urine in DI
Always hypotonic Unlike osmotic diuresis or medullary washout by diuretics
579
Plasma ADH in DI
Central - low | Nephro - high
580
Water deprivation then vasopressin inj
Central - urine osmolarity inc | Nephro - no
581
SIADH
opposite of central DI | Primary polydypsia - like central DI, but low plasma osmolarity
582
Graves Dx
Detection of TSH receptor stimulating antibodies
583
Congenital hypothyroidism
Thyroid peroxidase def
584
Hashimoto’s antibodies
Thyroid peroxidase antibody - TPO Ab Thyroglobulin antibody - Tg Ab
585
Grave’s antibodies
TSH stimulating (TSH-R stim Ab)
586
Maternal serum of newborn w congenital hypothyroidism
TSH blocking (TSH-R block Ab)
587
Polyglandular failure syndrome
More than one endocrine gland being destroyed by autoimmunity
588
Myxedema
Hypothyroidism
589
Goiter vs thyroid nodule
Goiter - high TSH and diffuse | Nodule - benign or malignant neoplasm, focal
590
Toxic multinodular goiter | In hyperthyroidism
Autonomous hyperfunction
591
Follicular adenoma In hyperthyroidism
Autonomous hyperfunction
592
Pituitary adenoma In hyperthyroidism
TSH hyper secretions
593
Hypothalamic disease In hyperthyroidism
Excess TRH production
594
Hashimoto’s thyroiditis In hyperthyroidism
Transient release of stored hormone
595
Ingestion of excess exogenous thyroid hormone
Thyrotoxicosis medicamentosa | Thyrotoxicosis factitia
596
Cardio in hyperthyroidism
``` High CO Inc pulse pressure Tachycardia A fib High output heart failure ```
597
thyroid hormone and growth hormone
TH allows GH to exert its action | TH important in growing kids
598
Graves path
``` defect in suppressor T cells helper T's stimulate B's antibodies against TSH in follicular cells thyroid stimulated by LATS familial ```
599
Symptoms of hyperthyroidism ONLY IN GRAVES
eye complaints - proptosis | Swelling of legs - pretibial myxedema
600
Graves hypersensitivity
Type II hypersensitivity
601
orbital soft tissue in graves
inc sympathetic tone | infiltration of lymphocytes, mucopolysaccharides, edema
602
diplopia in graves
fibrosis of extraocular muscles
603
circulating autoantibodies in graves attack
thyroid and orbital fibroblasts
604
dermopathy in graves
late manifestation
605
pretibial myxedema
hyperthyroidism graves antibodies to fibroblasts in skin
606
Graves Dx
low TSH high fT4 TSH - R (stim) antibodies pos ophthalmopathy and/or dermopathy
607
Subacute granulomatous thyroiditis
de Quervain thyroiditis viral etiology self limited young girl
608
de Quervain thyroiditis path
triphasic 1) acute - tender enlarged gland 3-6 wk 2) hypothyroid phase - 2-4 mo 3) recovery 4-6 mo
609
follicular adenoma of thyroid
benign | fibrous capsule
610
radionuclide scanning of thyroid
cancer is a cold nodule
611
most aggresive thyroid neoplasm
anaplastic carcinoma
612
mets to lymph nodes of neck
thyroid papillary carcinoma | psammoma bodies
613
bloodstream to bone or lung
thyroid follicular carcinoma
614
medullary carcinoma of thyroid
C cells (parafollicular) calcitonin MEN2
615
hypophyseal arteries are branches of
internal carotid
616
cells of anterior pituitary
acidophil: somatotropes, lactotropes basophil: corticotropes, thyrotropes, gonadotropes chromophobes - nonsecretory, undifferentiated
617
GH increases bone mass by
endochondral formation
618
linear bone growth by GH
IGF-1 differentiating prechondrocytes inc epiphyseal plate growth
619
GH effects on adipose tissue
stimulates HSL | inhibits LPL
620
GH direct
lipolysis IGF-1 insulin resistance
621
endogenous GH in obese person
cleared rapidly
622
obesity causes
suppresses IGF-1 binding protein from liver high free plasma IGF-1 inhibition of pit GH release promotes more fat
623
V2 receptor mechanism for ADH
cAMP
624
V1 receptor mechanism for ADH
IP3
625
SIADH
small cell carcinoma of lung, ectopic ADH
626
pulmonary cause of SIADH
TB COPD (impaired baroreceptor input from thorax)
627
Drug induced SIADH
carbamazepine chlorpropamide narcotics phenothiazine
628
SIADH CNS effects
central pontine myelinolysis
629
SIADH clinical
euvolemia (bc ANP) | hyponatremia (<136)
630
cerebral salt washing (CSW) vs SIADH
extracellular volume inc in SIADH | dec in CSW
631
active thyroid histo
scanty colloid | reabsorption lacunae
632
graves histo
packed follicles | scalloping
633
hashimotos histo
scattered follicles eosinophilic hurthle cells lymphocytes and germinal centers fibrosis
634
T3 and T4 in serum
bound to thyroxine binding globulin (TBG) | Albumin and Transthyretin (30%)
635
interacts w intranuclear receptors more
T3
636
5′-deiodinase
converts T4 to T3 in target cells
637
5-deiodinase
converts T4 to rT3
638
congenital hypothyroidism
sporadic - PAX-8, TTF-2 (transcription factors) mut hereditary - inborn transient - transplacental TSH-R block Ab from mom
639
Thyroid hormones CNS effects
mental retardation in kids - irreversible | decreased hearing, "hung up" relaxation phase of reflexes in adults, slow thinking etc - reversible
640
hypothyroidism cardiac
mucopolysaccharide deposition | pericardial effusion w HIGH PROTEIN
641
hypothyroid skin
carotene makes u yellow, mistake for jaundice
642
hyperprolactinemia
hypothyroidism (thyroid hormone normally inhibits prolactin secretion) high TRH stimulates prolactin release
643
thyroid has permissive action on
GH
644
low T3 reduces
GH secretion
645
ECG in hypothyroidism
low voltage | inc circulation time
646
TRH administration in secondary hypothyroidism
corrected - hypothalamic | not corrected - pituitary
647
antithyroid meds
propylthiouracil methimazole both inhibit thyroid peroxidase
648
elevated CK in
hypothyroidism
649
Wolff-Chaikoff block
large amount of iodide -> blocks iodide organification in graves -> hypothyroidism
650
lithium
concentrated in thyroid, inhibits hormone secretion -> hypothyroidism
651
hashimoto's goiter
nontender
652
hashimoto's hypersensitivity
type IV
653
hashimoto's genetics
HLA-DR5
654
hashimoto's labs
Antithyroglobulin antibody Tg Ab - early stage | Antithyroid peroxidase Antibody TPO Ab - many years
655
parathyroid glands
superior: 4th pharyngeal pouches inferior: 3rd pharyngeal pouches (also gives rise to thymus) blood supply to all: inferior thyroid arteries
656
parathyroid histo
chief cells/clear cells
657
Type 1 PTH receptors
bone and kidney (PTH and PTHrP) cAMP Type 2: only PTH, no Ca homeostasis
658
PTH effect on bone
receptor on osteoblast, which then activates osteoclast | bone resorption
659
PTH on kidney
Ca resorption in DCT phosphate uric effect - PCT (Na,P cotransporter, Na in, P out) 1 alpha hydroxylase to get activated vit D
660
Ca sensing receptors (CaSR)
in parathyroid and kidney (thick ascending loop of henle)
661
Factitious Hypercalcemia
Hypergammaglobulinemia inc Ca binding proteins total Ca high, Ca2+ normal
662
drugs that cause hypercalcemia
lithium | thiazides
663
Squamous cell carcinoma secretes
PTHrP -> hypercalcemia
664
clinical hypercalcemia
``` short QT impaired concentration peptic ulcer pancreatitis muscle weakness ```
665
brown tumors
hyperparathyroidism, bone resorption, puched out lesions
666
familial benign hypocalciuric hypercalcemia
autosomal dominant | faulty CaSR
667
archibald sign
fist, if you can see dimples, shortened metacarpals
668
Pseudohypoparathyroidism
Albright's hereditary osteodystrophy - AD, cafe au lait spots, short stature, obese, mental retardation, short 4 and 5 joints defective PTH receptors of target organs hypocalcemia
669
hypocalcemia in Renal Failure
low GFR -> hyperphosphatemia -> Ca efflux from bone inhibited low 1 alpha -> low vit D3 -> low Ca absorption stimulates PTH -> secondary hyperparathyroidism
670
basal ganglia calcifications
HYPOcalcemia
671
PTH and phosphate both high
renal failure | pseudohypoparathyroidism
672
always low in vit D def
25-hydroxy vitamin D
673
hypomagnesemia can cause
hypocalcemia
674
confirm pseudohypoparathyroidism
inject PTH, measure urinary cAMP and Phosphate normal: both inc positive: no rise in either one
675
C-peptide catabolized only by
kidney
676
insulin catabolized in
liver and kidney
677
GLP and GIP
gut hormones/incretins | stimulate insulin release
678
glucose sensor in beta cells
GLUT2 - beta cells, hepatocytes
679
insulin responsive glucose transporter
GLUT4 - skeletal, cardiac, adipocyte
680
insulin enzyme effects
``` inc phosphofructokinase dec fructose 1,6-bisphosphatase dec hormone sensitive lipase inc acetyl co A carboxylase dec glycogen phosphorylase dec glucose-6-phosphatase ```
681
DM criteria
RBS 200 + classic symptoms fasting venous 126 HbA1c 6.5% OGTT 200 in 2 hr same test 2 diff times or 2 diff tests at one time
682
Type 1 DM antibodies
``` anti-GAD65 IAA ICA antityrosine phosphatase IA2 (ICA-512) anti-ZnT8 ```
683
signaling activated by insulin
tyrosine kinase phosphorylates IRS 1,2 -> P13k -> insulin actions
684
obesity and insulin
TNF-alpha, resistin, fatty acids activate serine/threonine kinase blocks IRS tyrosine phosphorylation
685
acanthosis nigricans in insulin resistance
bc epidermal karatinocyte proliferation | NOT MELANOCYTES
686
diabetic ketoacidosis
more common in type 1, in type 2 if stress kussmaul breathing hyperkalemia - bc k comes out of cells, but total k is low in body inc HSL activity
687
coma in DKA
hyperosmolarity and acidosis
688
hyperosmolar coma
type 2 DM dec fluid intake worse hyperglycemia and dehydration than DKA k loss less than DKA
689
somogyi effect
hyperglycemia after overcorrection of hypoglycemia in DM due to insulin Tx
690
B cells secrete
insulin, c-peptide, amylin
691
F cells secrete
pancreatic polypeptide
692
liver effects
both insulin and glucagon glycogenesis and lipid synth inc insulin
693
muscle protein catabolism
dec insulin
694
adipose fatty acid esterification
inc insulin
695
type 1 DM genetics
HLA-DR, HLA-DQ
696
HTN in DM
type 1 - nephropathy | type 2 - metabolic syndrome (syndrome x)
697
polyol pathway
inc aldose reductase
698
advanced glycated end products (AGE)
angiopathy
699
earliest clinical sign of diabetic retinopathy
microaneurysms
700
proliferative retinopathy
initiated by ischemia cotton wool spots/soft exudates vitreous hemorrhage/retinal damage
701
nonproliferative retinopathy
initiated by microaneurysms | hard exudates
702
prevent progression of diabetic nephropathy
control HTN
703
autonomic neuropathy
sexual dysfunction neurogenic bladder anhidrosis
704
hypoglycemia Dx
whipple's triad: symptoms, low gluc, better w food
705
sulfonylurea
hypoglycemia
706
zellballen
nests of cells in pheochromocytoma
707
sipple syndrome
MEN type 2a
708
pheochromocytoma screening
1) urine vanillylmandelic acid, metanephrine, normetanephrine 2) plasma metanephrine and normetanephrine (more sens and spec)
709
locating extraadrenal pheochromocytoma
radionuclide test - uptake of radioactive amine by chromaffin cells
710
MEN 1
Wermer's parathyroid pituitary pancreatic
711
MEN 2a
medullary carcinoma of thyroid parathyroid pheochromocytoma
712
MEN 2b/3
medullary carcinoma of thyroid neuromas of oral/intestinal mucosa pheochromocytoma
713
osteomalacia and rickets labs
low Ca and P | high ALP and PTH
714
phases of paget
lytic, mixed lytic and blastic, sclerotic
715
paget histo
mosaic pattern
716
paget clinical
inc hat size hearing loss high CO failure
717
paget labs
``` high BSAP (bone specific alkaline phosphatase) high urine hydroxyproline ```
718
congenital adrenal hyperplasia
autosomal recessive
719
21 hydroxylase def
``` elevated 17-OH progesterone virilization/ambiguous genitals in girls hypotension salt washing hyponatremia hyperkalemia ```
720
11 hydroxylase def
elevated 11-deoxycortisol virilization/ambiguous genitals in girls HTN hypokalemic alkalosis
721
ACTH affects which zones of adrenal gland
inner 2 (fasciculata and reticularis)
722
primary adrenal insufficiency
hyperkalemia and metabolic acidosis | hyperpigmentation
723
cushings disease
pituitary tumor that secretes high ACTH
724
high dose dexamethasone suppression test
to identify where ACTH secretion is coming from? pituitary or ectopic?
725
primary hyperaldosteronism
HTN hypokalemia high renin low aldosterone
726
Conn syndrome
hyperaldosteronism metabolic alkalosis solitary, unilateral
727
idiopathic hyperaldosteronism
bilateral
728
hyperaldosteronism Dx
PAC/PRA >20 gold standard - primary, if less, secondary low plasma renin high plasma aldosterone
729
bilateral adrenal vein catheterization
to determine if conn's or bilateral
730
SCID genetics
cytokine - IL2RG, JAK3, IL7Ra migration - ADA antigen receptor: RAG1, RAG2, ARTEMIS
731
x linked SCID
``` IL2RG mut gamma subunit problem IL 2,4,7,9,15,21 dont work T-NK-B+ (no antibodies produced tho) only boys ```
732
SCID bc JAK3
AR T-NK-B+ like x linked but more rare boys and girls
733
ADA def SCID
adenosine deaminase def (involved in purine metabolism) toxic levels of nucleotide metabolites - high in thymus and bone marrow T-NK-B- Tx - PEG-ADA, stem cell, gene therapy
734
ADA def SCID path
high d-adenosine activatese caspase 9 low ribonucleotide reductase activity block DNA synth
735
IL7RA def SCID
T-NK+B+ | IL7 alpha chain defect
736
di george
``` 22q11 deletion (TBX1 gene) 10p13 less common 3, 4 pharyngeal pouches not formed hypocalcemic seizures bc no parathyroid CHD7 mut -> charge association infant of diabetic mother ```
737
complete di george
low excision circles (TREC - marker of maturation/thymic development)
738
bruton's x linked agammaglobulinemia
BTK Xq21.22 drives maturation signals - stops after heavy chain rearrangement symptomatic at 6 mo when don't have moms ig
739
common variable immunodeficiency
heterogenous for ppl w symptoms autoimmunity - develop RA!!! lymphoproliferation, immunodef inc risk of lymphoma and gastric cancer
740
LRBA def - CVID
dec CTLA4 in T cell endocytic vesicles competes w CD28 for CD80/86 to downregulate costimulation Tx - abatacept - a CTLA4 Ig-fusion protein, chloroquine - prevents degradation of CTLA4 by inhibiting lysosomes
741
IgA def
usually asymptomatic <5, normal is 130-250 can get autoimmune naïve B cells don't become IgA plasma cells fatal anaphylaxis to transfused blood bc IgA in blood looks foreign to body
742
Chediak Higashi
``` AR CHS1/LYST mut microtubule dysfunction defective formation of melanin granules albinism, visual defects bone marrow transplant corrects immunologic but not neurologic probs ```
743
chronic granulomatous
``` phagocytes cant make H202 to counter microbial catalase recurrent catalase pos infx acne gingivitis granulomas nasal inflammation massive lymphadenopathy ```
744
cat pos infx in chronic granulomatous disease
``` staph aureus burkholderia cepacia serratia marcescens aspergillus nocardia ```
745
chronic granulomatous path
defect in NADPH oxidase complex
746
respiratory burst
identify chronic granulomatous no change - pos green - normal, neg
747
CGD Tx
``` trimethoprim sulfa itraconazole IFN-gamma 3 yrs old - x linked 8 yrs old - AR more ability to produse ROS, live longer ```
748
leukocyte adhesion def
leukocytes and monocytes Type 1 - ß-2 integrin CD18 mut delayed separation of umbilical cord, peridontal disease,
749
hypersensitivities
1) anaphylactic, allergy, asthma 2) Ab (killer cell w Fc, complement) 3) immune complex (serum sickness, SLE) 4) delayed or cell mediated - TB, contact dermatitis, cellular transplant rejection, also know it peaks 48-96 hr
750
idiopathic membranous glomerulopathy
autoantibodies to phospholipase A2 receptor (PLA2R1) | some have THSD7A - only 5% have autoantibodies to this
751
Th1 and Th17
Th1 - macrophages | Th17 - neutrophils, monocytes
752
nitroblue tetrazolium assay
insoluble blue formazan crystals in phagocytes that can oxidize
753
hyper IgM
``` defect in Ig class switching only have IgM ``` x linked - CD40L (CD154), NEMO AR - CD40, activation induced cytidine deaminase (AID), uracyl DNA glycosylase (UNG)
754
to opsonize bacteria you need
IgG
755
stem cell transplant for HIGM
busulfan, cyclophosphamide, ATG
756
hyper IgE (Job syndrome)
chronic skin infx - "cold" | bone defects, late shedding of baby teeth
757
HIES path
defect in Th17 dont respond to IFN-gamma, IL 6, 10,12,23 AD: STAT3 AR: Tyk2, DOCK8
758
LAD Type 1 Tx
neutrophil infusions IL 12/23 therapy GVHD chemo for stem cell transplants ustekinumab
759
LAD Type 2
rare mental retardation, short absence of E-selectin ligands (sialyl Lewis X, or CD15s) Tx fucose if defective fucose synth
760
Wiskott Aldrich
``` x linked recessive WAS gene mut T cell depletion in periphery low igM, high igA and igE no response to sugar or protein Ag thrombocytopenia eczma vasculitis ```
761
Ataxia Telangiectasia
AR ATM mut (imp for fixing ds DNA breaks, make cell cycle go) purkinje in cerebellum degenerate low Ig, low T cell function
762
C3 def
Fc receptor dependent leukocyte activation is impaired
763
C5-9 def
neisseria
764
C1 inhibitor def
hereditary angioedema AD high bradykinin C1R,C1S,XII,kallikrein targeted by C1 inh
765
defect in C' reg
glycophosphatidyl inositol linkages needed for CD55 and 59
766
paroxysmal nocturnal hemoglobinuria
``` PIGA mut (needed for GPI linkages) excessive C' activation -> hemolysis ```
767
HIV infx of non-T cells
lungs and brain dendritic - carry to LN polyclonal B cell activation
768
vpr gene
allow HIV replication in non-dividing cells
769
malignancy immunosuppresion
TGF-ß, T regs, myeloid derived suppressor cells indoleamine 2,3-dioxygenase (IDO) toxic products of Trp breakdown inactivate effector T cells and make DC immunosuppressive
770
sarcoidosis
non caseating granulomas | anergy due to expansion of Tregs
771
TB
lower lobes ghon foci - walled off calcified caseated granuloma ghon complex - LN involvement treat for 6 mo
772
PPD
Type IV hypersensitivity | if pos - 9 mo INH
773
interferon gamma release assay
Quantiferon-TB Gold BCG doesnt affect it measure IFN-gamma released by T lymphocytes
774
reactivation TB
upper lobes
775
scrofula
TB affecting LN of neck
776
TB meningitis
looks like bacterial meningitis EXCEPT: | LYMPHOCYTES instead of pmn
777
Thrush/candida
oral - red bleeding base, <400 CD4 esophageal - <100 , HIV KOH - pseudohyphae, budding yeast germ tube - true hyphae at 37
778
oral hairy leukoplakia
EBV cant scrape off tobacco lateral tongue
779
kaposi sarcoma
HHV 8 | purple nodules
780
pneumocystic jirovecci
``` CD4 100-200 fungal/yeast ground glass hypoxia more than CXray shows silver stain of lung - cysts/sporozoites TMP-SMX in <200 CD4 prophylaxis ```
781
histoplasmosis
``` soil fungus CD4 100-200 inhale spores, bird bat droppings tongue ulcer, hepatosplenomegaly ohio river valley lung granulomas Dx from lungs - OVAL yeast in macrophages at 37, branching hyphae at 25 - sabouraud agar ```
782
coccidiomycosis
``` valley fever CD4 100-200 soil fungus, larger than RBC earthquake erythema nodosum deser rheumatism thick walled spherules containing endospores hyphae at 25 southwest - AZ,NM,CA ```
783
cryptococcus neoformans
``` encapsulated fungus meningitis in AIDS, but signs may be absent soap bubble lesions in brain fatal pigeon droppings CD4 50-100 mucicarmine stain narrow based budding and large capsule culture on sabouraud agar ```
784
cryptosporidiosis
``` CD4 50-100 protozoan parasite severe diarrhea in AIDS mucous stools acid fast oocytes in stool contaminated water ```
785
CMV
``` HHV5 CD4 50-100 mono - like for immunocompetent for compromised - chorioretinitis - cotton wool, esophagitis, colitis, hepatitis transplant pts owl eyes inclusion bodies ```
786
MAC
``` CD4 <50 azithro prophylaxis intracellular acid fast, non branching bacilli fatal ```
787
Hegar's sign
pregnancy | softening of isthmus
788
chadwick's sign
pregnancy | blue cervix
789
naegle's rule
estimate due date | LMP - 3 mo + 7 days
790
normal fetal heart rate
120-160 BPM
791
pregnant mom weight gain, food
normal is about 25 lb | 300 kcal more food for baby
792
leopold's maneuver
head or is the baby breach
793
urine tests during pregnancy
ketones - dehydration proteins - pre eclampsia leukocyte esterase - UTI
794
20 weeks pregnant
uterus palpable at umbilicus | btw umbilicus and symphysis at 16 weeks
795
drugs to terminate pregnancy
mifepristone/RU486 - antiprogestin | misoprostol - prostaglandin E analog
796
small stable ectopic pregnancy
methotrexate
797
placentia previa
placenta overlies cervix painless bleeding needs a c section
798
hypoglycemic drugs for pregnant diabetics
metformin glyburide insulin
799
pre eclampsia
HTN 140/90 edema proteinuria 300g/day too much thromboxane, too little prostacyclin
800
HELLP
hemolysis elevated liver enzymes low platelets liver can rupture symptom of preeclampsia
801
abruptio placenta
placenta prematurely separates risks - HTN, cocaine medullary vessels of desidua basalis rupture
802
pre eclampsia Tx
hydralazine, labetalol, nifedipine for BP MgSO4 for seizures deliver baby immediately baby aspirin for prevention
803
eclampsia
new onset tonic clonic seizure headache hyperreflexia photophobia, blurry vision give valium, give MgSO4 for seizure, lower BP, deliver baby
804
HLA gene location
chr 6
805
acute humoral rejection
type 2/3 hypersensitivity | deposition of inactive C4d
806
acute cellular rejection
liver - venous endothelium lung - arterioles heart - myocytes therapy: pulse steroids, anti T cell Ab (OKT-3)
807
post transplant therapy
cyclosporine prednisone azathioprine
808
chronic allograft rejection
linked to all hypersensitivities kidney vasculature liver - vanishing bile ducts lung - bronchioles heart - vasculature thickening intimal vasculature
809
obliterative bronchiolitis
chronic rejection
810
chronic GVHD Tx after HSCT
ibrutinib - anti BTK mAb
811
acute GVHD
apoptosis
812
alpha subunit of which hormones is the same
TSH LH FSH HCG
813
when does implantation happen
6th day post fertilization
814
ectopic pregnancy rupture
6-8 wk: isthmus | 8-12 wk: ampulla
815
hCG discriminatory zone
above this level u should see gestational sack
816
progesterone
<5 - abnormal pregnancy | >20 - normal pregnancy
817
complete mole
empty ovum + haploid sperm that duplicates or 2 sperm 46XX (or 46XY - less common) 46YY - LETHAL, not seen high risk or choriocarcinoma
818
partial mole
normal ovum + 2 haploid sperm 69XXY 69XXX 69XYY
819
P57, PHLDA2 immunostaining
partial mole - pos | complete mole - neg
820
c-erbB-2, c-myc, c-fms, mdm-2 oncogenes
more aggressive mole
821
EGFR
highly expressed in complete mole and choriocarcinoma
822
choriocarcinoma
high EGFR downreg of p53, p21, Rb tumor suppressor genes malignant trophoblastic cells from normal or abnormal pregnancy or mole, anaplasmic tissue made of cyto and syncitiotrophoblast no villi! vs molar pregnancy which has villi
823
paternal vs maternal genes
paternal - placental | maternal - fetus
824
preeclamspsia before 20 weeks
mole
825
H mole complications
pulmonary embolism | high output congestive heart failure
826
blood in myometrium from abruptio placenta
uterine tetany | fibrinogen correlates w severity of bleeding
827
placentia previa
placenta covering inner cervical os, bc placenta grows toward areas that are well vascularized
828
bleeding pain or no pain
pain - abruptio | no pain - previa
829
abortion timeline
occurs before 20 weeks
830
prostatic carcinoma mets
check iliac LN
831
testicular tumor or ovarian
check para-aortic nodes
832
leydig cells
synth testosterone last step: androstenedione to testosterone via 17 beta-hydroxysteroid dehydrogenase
833
cholesterol desmolase in leydig cells
stimulated by LH | cholesterol to pregnenolone
834
17 beta-hydroxysteroid dehydrogenase
only present in leydig cells
835
testosterone to dihydrotestosterone in target cells
5alpha reductase
836
testosterone to estrogen
in bone and brain | by aromatase
837
sertoli cells
spermatogenesis and inhibin
838
inhibin feedback
only on FSH
839
testosterone feedback
only on LH
840
seminiferous tube failure
high FSH, low sperm count
841
absent seminal fructose
vas deferens or seminal vesicle problem
842
secondary hypogonadism
low testosterone, LH, FSH | hypothalamic or pituitary failure
843
primary ciliary diskynesia
abnormal sperm motility
844
everything normal but no conception
acrosomal enzyme defect
845
meds that inhibit testosterone synth
ketoconazole spironolactone alcohol
846
autoimmune male infertility
disruption of blood testes barrier anti-sperm antibodies trauma, torsion, mumps/orchitis etc
847
chlamydia
decreases sperm motility and viability
848
bladder cancer
painless hematuria
849
prostatitis
mostly gram neg aerobes - usually e coli | in young: gonorrhea or chlamydia
850
kallman's syndrome
GnRH def anosmia eunuchoid appearance KAL1,2 mut - migration of GnRH neurons during embryogenesis - don't migrate to ventral hypothalamus from olfactory placode
851
Turner syndrome
elevation of Gonadotropins (FSH and LH) by 12 yr bc low estrogen if y chr present, high risk for germ cell cancer
852
mayer rokitansky kuster hauser
mullerian dysgenesis no uterus or upper 1/3 vagina type 1: no uterus or vagina type 2: other defects - renal, cardiac etc
853
androgen insensitivity syndrome
``` AR gene mut x linked recessive anti mullerian hormone no internal genitalia at all risk of gonadoblastoma bc temp paramesonephric part of vagina is absent ```
854
DHT vs Testeosterone
DHT - external male genitalia | Testosterone - internal male genitalia
855
5 alpha reductase deficiency
AR in genetic males, voice deepens etc bc surge in testosterone in puberty SRD5A1 - chr 5 - male pattern hair SRD5A2 - chr 2p23 - no external genitalia
856
CAH
17a - hydroxyprogesterone accumulation -> androstenedione and testosterone zona reticularis hyperplasia hyponatremia hypoglycemia hyperkalemia advanced skeletal maturation
857
urinary dehydroepiandrosterone
DHEA <2x -> CAH >2x -> adrenal tumor
858
GnRH pulses
impaired in anorexia | originate in mediobasal hypothalamus, arcuate nucleus
859
PCOS path
SHBG dec steroid hormone binding globulin IGFBP-1 dec insulin growth factor binding protein 1 free testosterone and estradiol inc -> follicular atresia, hirsutism high insulin and IGAF -> theca cells -> more androgens LH inc FSH dec endometrial carcinoma
860
AMH in women tells you
ovarian follicle reserve
861
DUB
prolonged anovulation anovulatory DUB - too much estrogen ovulatory DUB - too much progesterone
862
amenorrhea alternating w prolonged bleeding
obese women, high estrogen, ovulatory DUB
863
ovary chocolate cyst
endometriosis
864
young syndrome
sinusitis bronchiectasis obstructive azoospermia
865
toxic to sperm
cyclophosphamide chlorambucil nitrogen mustard alkylating agents
866
genetic male infertility
deletion of Yq - long arm | AZFa,b,c - c most common (azoospermia factor regions) del
867
xx males
SRY translocation to x | sertoli cell only syndrome (SCOS)
868
klinefelter
47XXY
869
kallman
Kal1 - x linked | kal 2 - autosomal
870
kartagener
autosomal recessive defective dynein arms situs inversus chronic sinusitis primary ciliary dyskinesia
871
turner
low testosterone and inhibin high LH FSH and estradiol degenerated leydig cells tall stature
872
cryptorchidism
intratubular germ cell neoplasia - early, immunostain for placental alkaline phosphatase to detect seminoma
873
varicocele
pampiniform plexus - venous drainage of testes
874
alcohol and erectile dysfunction
low LH, leydig cell damage | cirrhosis - estrogen
875
innervation of penis
parasymp: cavernous S2-4 - autonomic -> helicine arteries dilate dorsal nerve: pudendal S2-4 - somatic -> contraction of ischiocavernosus muscles
876
erection chemicals
NO -> sequesters Ca in cytoplasm -> muscles relax | Ach
877
PDE5
removes cGMP during erection to stop erection | sildenafil/viagra -> inhibit PDE5 -> dec Ca
878
cavernous never
branch of pelvic splanchnic (which innervates bladder etc)
879
pretesticular, testicular, post
pre: kallman, steroids test: klinefelter, kartagener post: androgen receptor insensitivity, CF, erectile dysfunction
880
nonseminoma
grow and spread fast
881
seminoma
sensitive to radiation distinct cell borders clear glycogen rich cytoplasm
882
Yolk sack tumor
AFP | schiller duval body - central vessel surrounded by tumor
883
hCG
choriocarcinoma, embryonal carcinoma | leads to hyperthyroidism bc cross reactivity of hCG w TSH
884
choriocarcinoma of testis
``` extensive mets trophoblastic sheets of small cuboidal cells large eosinophilic syncitial cells pleomorphic nuclei blood tinged sputum, cough unilateral gynecomastia hepatomegaly supraclavicular lymph nodes palpable ß-hCG elevated CANNON BALL masses in lung ```
885
Teratoma
benign - prepuberty mature - fully differentiated tissues immature - small hyperchromatic, undifferentiated mesenchymal, little cytoplasm (blastema)
886
embryonal carcinoma
hemorrhage and necrosis primitive cells indistinct cell borders
887
leydig cell tumor
``` precocious puberty adults - asymptomatic high testosterone and estradiol golden brown tumor Reinke crytals on histo ```
888
Sertoli cell tumor
calcifications in lumen, next to normal tubules w advanced spermatogenesis
889
BPH
transition zone and central zone tall columnar cells and flattened basal cells corpora amylacea
890
BPH path
bc of DHT and androstanolone | age related inc estrogen -> inc DHT receptors
891
prostate cancer
african american peripheral single cell layer glands - basal layer absent osteoblastic mets - radiodense
892
why prostate cancer doesnt infiltrate rectum?
denonvillier's fascia / rectoprostatic fascia
893
PSA levels
normal - less than 4 above 20 - highly elevated: adenocarcinoma of prostate PSA density more than 0.15 - cancer PSA velocity of 0.75 per year - cancer
894
prostatic acid phosphatase - PAP
prognostic, not diagnostic
895
gleason score
cells got by needly biopsy 1- well diff, 5- poor diff add 2 most common patterns 6 or more = adenocarcinoma
896
prostate cancer and bone
cancer cells secrete bone paracrines -> inc osteoblastic activity osteoblasts -> growth factors -> more cancer
897
trichomoniasis
yellow-green frothy, mucopurulent WBC>10 whiff test pos strawberry cervix - colpitis macularis
898
chancre
primary syph | painless
899
chancroid
``` haemophilus ducreyi painful multiple lesions ragged edges, purulent base, bleeds "school of fish" ```
900
condyloma acuminata
HPV
901
condyloma lata
secondary syph | large raised grey lesion on warm mucous
902
chronic granulomas
tertiary syph
903
jarisch herxheimer rxn
Abx given for primary syph -> endotoxins released by dead syph -> resembles sepsis
904
lues maligna
ulcertations secondary syph HIV, immunocompromised
905
secondary syph
systemic alopecia - moth eaten - reversible uveitis hepatitis
906
tertiary syph
cardio - dilated aorta, regurg | gummatous - HIV pt
907
argyll robertson pupil
neurosyph
908
non treponemal tests NTT
reactivity of serum w cardiolipin-cholesterol-lecithin Ag VDRL - pos weeks after infx, rapid plasma regain (RPR), Toluidine Red Unheated Serum Test (TRUST) screening monitor response to therapy
909
NTT false pos
collagen vascular disorders yaws malaria leprosy
910
treponemal antibody tests TAT
``` fluorescent treponemal antibody absorption FTA-ABS micro hemagglutination assay MHA-TP t pallidum particle agglutination TP-PA enzyme immunoassays TP-EIA chemiluminescence immunoassays CIA ```
911
chlamydia tropism
columnar and transitional epithelium A-C - trachoma D-K urethritis, PID, conjunctivitis, reactive arthritis L1-3 lymphogranuloma venereum
912
fitz hugh curtis syndrome
perihepatitis - chlamydia and gonnhorea
913
gonorrhea evading immune system
IgA 1 protease blocking antibodies to reduction modifiable protein Rmp antigenic/phase variation of Opa, Pil, and LOS sialylation of LOS masks gonococcal antigen, prevents phagocytosis
914
giant cells on Tzanck smear w eosinophilic inclusions (Cowdry A)
herpes
915
HPV path
microscopic breaks in skin integrates genes into nuc of replicating basal epithelial cells 6 E - gene regulation, cell transformation 2 L - virus shell long control region/ upstream regulatory region malignant - E6 and E7 E7 binds Rb (E2F/pRb) E6 binds p53 G1 to S dysregulation (Rb issues)
916
pain from testes
sympathetic afferents T10 - L2
917
non infx epididymitis
amiodarone | cordarone
918
acute epididymitis
pos phren sign
919
scrotal lymphatics
inguinal nodes
920
nerves of scrotum
genital branch of genitofemoral nerve | ilioinguinal nerve
921
blue domed cysts of breast
fibrocystic - not malignant
922
intraductal papilloma
blood from nipple | lactiferous ducts
923
paget's
DCIS into lactiferous ducts eczematous rash intraepithelial adenocarcinoma noninvasive
924
invasive lobular carcinoma
bilateral multiple lesions dec E cadherin linear fashion-bulls eye, indian file
925
medullary carcinoma of breast
bulky soft tumor, large cells lymphoid infiltrate BRCA ER PR neg, poor prognosis
926
menopause
E1 predominant, E2 goes down | FSH drastically increase 20x, LH 3x
927
hot flashes
IL1,7 obese protected less estrogen induced opioid activity on hypothalamus
928
estrogen def
``` osteoclasts -> IL1,6, TNF-a, PGE2 inc IL7 -> T cell activation T cells -> IFN-gamma, TNFa IFN-gamma -> MHC II MHC II -> T cells secrete RANKL ```
929
RANK
receptor on osteoclasts
930
osteoprotegerin OPG
inhibitor of RANKL | suppresses bone resorption
931
bone density T , Z
T - same sex and age | Z - sex age race height weight
932
osteopenia, porosis, severe porosis
penia - 1-2.5 porosis - 2.5 severe - 2.5 and fractures
933
leiyomyomam
MED12 gene mut
934
tamoxifen in post menopausal
type 1 endometrial CA (too much estrogen)
935
nulliparity and breast CA risk for
type 2 endometrial CA (endometrial atrophy)
936
overexpression of p53 ki-67 EGFR HER2/neu
type 2 endometrial CA
937
PTEN | KRAS
type 1 endometrial carcinoma
938
area of squamous metaplasia
transformation zone of cervix
939
Dysgerminoma
LDH
940
non gestational choriocarcinoma
resistant to treatment
941
Meig's syndrome
fibroma/thecoma +ascites, pleural effusion
942
granulosa theca cell tumor
inhibin marker produce estrogen endometrial cancer association call-exner bodies, nests of cancer cells

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