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Bellevue Medicine > Step Up 2 > Flashcards

Step Up 2 Flashcards

1
Q

What are carcinoid tumors? (cell of origin)

(a) Most common site

A

Carcinoid tumors originate from neuroendocrine cells and secrete serotonin

(a) Appendix

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2
Q

Most common organism causing SBP

A

E. Coli

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3
Q

Mechanism of acute pancreatitis

(a) 2 most common causes

A

Acute pancreatitis = premature activation of pancreatic enzymes => pancreatic autodigestion

(a) Together EtOH and gallstones cause about 80% of cases

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4
Q

What is carcinoid syndrome?

Cause
Symptoms
(a) What percent of pts w/ carcinoid tumors develop carcinoid tumors?

A

Carcinoid tumor = excess serotonin secretion causes flushing, diarrhea, sweating, wheezing, abdominal pain, heart valve dysfunction

(a) 10% of pts w/ carcinoid tumors developed carcinoid syndrome

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5
Q

What is a hiatal hernia?

(a) What type needs surgery?
(b) What type of surgery?

A

Hiatal hernia = when part of the stomach +/- GE junction penetrates thru the esophageal hiatus of the diaphragm and into the thorax

(a) Type 2 (only 5%) when only the stomach, not the GE jxn, goes thru => can get strangulated => needs surgery
- type 1 (like 90%) is when both GE jxn and part of stomach go thru, usually doesn’t need surgery, tho slowly does progress and get larger
(b) Nissen funduplication

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6
Q

Achalasia vs. diffuse esophageal spasm

(a) Barium radiographs
(b) LES function

A

(a) Barium radiograph shows
- bird beek narrowing = achalasia
- corkscrew esophagus representing multiple simultaneous contractions w/ open LES = diffuse esophageal spasm

(b) LES function is normal (normal LES pressure) in diffuse esophageal spasm

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7
Q

Most common cause of the following in adults

(a) SBO
(b) Large bowel obstruction

A

Most common cause of

(a) SBO in adults = adhesions from previous abdominal surgery
(b) Colon cancer

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8
Q

What to examine ascites fluid for to r/o SBP

A

Cell count w/ diff (for PMNs), ascites albumin (for SAAG score), gram stain, and culture

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9
Q

What could cause recurrent episodes of biliary colic w/o evidence of gallstones

A

Biliary dyskinesia = motor dysfunction of the sphincter of Oddi (at ampulla of vater into the duodenum)

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10
Q

Compare response to surgery of Crohn’’s disease vs. UC

A

Surgery (bowel resection) is curative for UC, while recurrence rate of Crohn’s aftery surgery is very high

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11
Q

Clinical features of Zenker diverticula

A

Dysphagia, regurgitation, halitosis, wt loss, chronic cough

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12
Q

Mechanism of chronic pancreatitis

(a) Most common cause

A

Chronic pancreatitis- fibrotic tissue replaced pancreatic parenchyma

(a) Chronic alcoholism causes over 80% of cases

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13
Q

Etiology of achalasia in third world countries

A

Chagas disease!

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14
Q

Clinical features of SBO

A

Cramping abdominal pain- severity may indicate strangulation

  • N/V
  • obstipation (absence of stool and flatulence)
  • abdominal distention
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15
Q

Wilsons disease and the following organs

(a) Kidney
(b) Cornea
(c) Brain
(d) Liver

A

Wilsons disease = autosomal recessive defect in copper excretion => build up of iron/ceruloplasm (Cp-binding protein) in many organs

(a) Kidneys- aminoaciduria, nephrocalcinosis
(b) Cornea = Kayser-Fleisher rings
(c) Brain = EPS, psychiatric symptoms
(d) Liver disease- anything from cirrhosis to fulminant hepatic failure

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16
Q

Ppx drugs for variceal bleed

A

Beta blockers (nonselective)

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17
Q

Name 3 risk factors for cholangiocarcinoma

A

Cholangiocarcinoma (adenocarcinoma) risk factors

  1. gallstones
  2. porcelain gallbladder- intramural calcification of the gallbladder
  3. cholecystoenteric fistula
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18
Q

How to treat acute pancreatitis

A

Bowel rest (NPO)
IVF, correct electrolyte imbalances
Pain control: prefer fentanyl and meperidine over morphine
-Dont routinely need abx!!! (only if other signs of extrapancreatic infection)

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19
Q

How UA can differentiate types of hyperbilirubinemia

A

ONLY CONJUGATED bili can be excreted in the urine when levels get too high => dark urine means CONJUGATED (not unconj) hyperbilirubinemia

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20
Q

How does bilirubin travel in the blood?

(a) When does bilirubin become conjugated?

A

Hgb broken down to bilirubin in the spleen, then unconjugated bili circulates in plasma bound to albumin

(a) Bili dissociates from albumin in the liver then is conjugated

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21
Q

Celiac sprue

(a) Clinical signs
(b) Biopsy signs

A

Celiac sprue = hypersensitivity to gluten

(a) Clinically: weight loss, abdominal distention, bloating, diarrhea
(b) Biopsy of PROXIMAL small bowel: flattening of villi (which causes malabsorption)

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22
Q

Differentiate pathology of Crohn’s vs. UC

A

Pathology

Crohn’s- transmural inflammation and skip lesions
-tranmsural inflammation anywhere in GI tract mouth to anus, most common terminal ileus
UC- only involves mucosa and submucosa (not transmural) and is continuous (no skip lesions)
-always involves the rectum

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23
Q

What disease is pseudopolyps associated with?

A

Pseudopolyps (inflammatory non-neoplastic polyps) are associated w/ Ulcerative Colitis

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24
Q

Most common cause of acute mesenteric ischemia

A 
Four types of acute mesenteric ischemic (3 arterial, 1 venous)
Most common (50%) caused by arterial embolism from the heart (Afib, MI, valvular disease)
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25
Q

Better prognosis: tubular or villous adenomatous polyp?

A

CRC: tubular/pedunculated (most common) have the smallest risk of malignancy

Villous have the greatest risk of malignancy (worse prognosis)

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26
Q

Compare the complications more commonly seen in Crohn’s vs. UC

A

Crohn’s- more common to see fistulae and abscesses bc the entire wall is involved

UC- squamous carcinoma and colorectal cancer more common than in Crohn’s

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27
Q

Melena vs. hematochezia

(a) Associated w/ which colon cancers?

A

Melena = tarry black stools
(a) Upper GI bleed => right sided CRC

Hematochezia = bright red blood/fresh blood
(a) Lower GI bleed => left sided CRC

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28
Q

Surgical tx of SBO

(a) Indications
(b) What does it involve

A

(a) Complete obstruction, or partial when tachy, fever, leukocytosis, or peritoneal signs are present
(b) Exploratory laparotomy w/ lysis of adhesions and resection of any necrotic bowel

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29
Q

PBC

(a) Path
(b) Gender
(c) How to make the diagnosis
(d) Tx

A

PBC = primary biliary cirrhosis

(a) intrahepatic bile duct destruction
- while PSC is both intra and extra
(b) F&raquo_space;> M
(c) +AMA antibodies then confirm dx w/ liver biopsy
(d) Tx = ursodeoxycholic acid slows progression of disease, other liver transplant

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30
Q

How to tell if ascites fluid is due to portal HTN?

(a) Diagnostic of SBP

A

Calculate SAAG (serum albumin to ascites gradiet)

SAAG > 1.1 means portal HTN is very likely as the cause of the ascites

SAAG under 1.1 suggests another process (not portal HTN): malignancy, infection

(a) WBC over 500, ANC over 250 = diagnostic for SBP

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31
Q

What is paralytic ileus?

(a) Some causes
(b) Tx

A

Paralytic ileus = decreased or absent peristalsis (no mechanical obstruction present)

(a) Postop state, meds (narcotics, meds w/ anticholinergic effects)
(b) Tx- surgery not usually needed, address medically w/ IV fluids, NPO, replacing K+

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32
Q

Esophageal cancer: SCC vs. adenocarcinoma

(a) which is more common?
(b) Risk factors

A

Esophageal cancer

(a) SCC used to be way more common, now about equal
(b) RIsk factors for squamous cell carcinoma = AA race, EtOH, tobacco, hot tees, Plummer-Vinson syndrome, cuastic ingestion, achalasia

Risk factors for adenocarcinoma = Barret’s esophagus, GERD

33
Q

Fxn of the following spinal tracts

(a) spinothalamic
(b) corticospinal
(c) dorsal column

A

Spinal tracts

(a) Spinothalamic = pain and temperature sensation
(b) Corticospinal = motor
(c) Dorsal column = position/vibration sense

34
Q

What do flank ecchymoses indicate?

A

Flank echymoses (Gray Turner sign) is a sign of hemorrhagic pancreatitis

-is one of the three types of blood tracks along fascial planes: periumbilical ecchymoses, ecchymosis of inguinal ligament

35
Q

Differentiate basic concept/location of Crohn’s vs. Ulcerative cholitis

A

Crohn’s = chronic transmural inflammatory disease that can affect any part of the GI tract (mouth to anus), most commonly the terminal ileus

UC = chronic inflammatory disease (not transmural) of the colonic and/or rectal mucosa

  • always involves rectal mucosa
  • confined to colon and rectum (so if small intestines is involved, it’s NOT UC) UNLESS it’s just the terminal ileum: ‘backwash ileitis’ when UC sometimes involves the terminal ileum
36
Q

When is immediate decompression of the bowel indicated?

A

When colonic distention is so bad that colon diameter exceeds 10cm
Immediate compression b/c bowel is at risk of rupture => peritonitis => death

37
Q

What is colonic volvulus?

(a) Presentation

A

Colonic volvulus = when a segment of bowel (intestinal loop) twists around its mesenteric attachment

(a) Colicky abdominal pain

38
Q

Describe how Budd-Chiari presents

A

Budd-Chiari (hepatic venous occlusion) presents as indolent, gradual development of portal HTN and progressive deterioration of liver function

39
Q

Brown-Sequard syndrome = spinal cord hemisection: which tract causes what to

(a) pain and temperature sensation
(b) hemiparesis
(b) position/virbational sense

A

Spinal cord hemisection- lesion of one side of the spinal cord usually at the cervical levels (where spinal cord enlarges)

(a) Contralateral loss of pain and temperature (spinothalamic tract)
(b) Ipsilateral hemiparesis (corticospinal tract)
(c) Ipsilateral loss of position/vibration (dorsal columns)

40
Q

Tx of acute mesenteric ischemia

A

Depends on the cause (arterial embolis, arterial thrombosis, venous thrombosis)

Always IV fluids and broad-spectrum abx
All arterial causes: direct intra-arterial infusion of papaverine (vasodilator) into superior mesenteric system during angiography to relieve occlusion

Tx for venous thrombosis = heparin anticoagulation

41
Q

Mechanism of Zenker divertulica

(a) Location

A

(a) Upper 1//3 of esophagus- due to an underlying esophageal motility dysfunction
- failure of cricopharyngeal muscle to relax during swallowing => increased intraluminal pressure => outpouching of mucosa thru an area of weakness in the pharyngeal constrictors

42
Q

Hemochromoatosis’ impact on the following organs

(a) Pancreas
(b) Heart
(c) Joints
(d) Skin
(e) Endocrine

A

Hemochromatosis- obv the liver, but tons of other organs get iron/hemosiderin deposition

(a) Pancreas => DM
(b) Heart => cardiomyopathy
(c) Joints => arrhythmias
(d) Skin => hyperpigmentation (‘bronzing’)
(e) Endocrine- hypogonadism, hypothyroid

43
Q

What is pseudomembranous colitis?

(a) Characteristic clinical feature
(b) Dx test
(c) Lab findings

A

Pseudomembranous colitis = C. Dif colitis (abx associated colitis)

(a) Profuse watery diarrhea w/ crampy abdominal pain
(b) Diagnose w/ C. dif toxin in stool
- but takes 24 hrs to come back (so put on precautions until it comes back)
(c) Leukocytosis very common

44
Q

Medical tx for ascites

A

Salt restrictions and diuretics (furosemide and spironolactone 5:2)

45
Q

What procedure greatly increases risk of pancreatitis

A

ERCP!

Pancreatitis occurs in up to 10% of pts undergoing ERCP

46
Q

Ddx for normal GGT w/ elevated alk phos

A

GGT more specific for biliary/hepatic, while elevated alk phos can also indicate pregnancy or bone disease

47
Q

Tx for

(a) Diverticulosis
(b) Diverticulitis

A

(a) Increased fiber in diet
- bran
- psyllium

(b) Uncomplicated = IV abx, bowel rest (NPO), IV fluids
- complicated = surgery

48
Q

Charcot triad

(a) What is it for

A

Charcot triad = RUQ, jaundice, fever

(a) Classic triad for cholangitis- but only is present in 50-70% of cases

49
Q

Which is more specific for liver damage- AST or ALT?

A

ALT is more sensitive and specific

AST is found in many tissues, while ALT is primarily in the liver

50
Q

Medical tx for Wilsons disease (2 drugs)

A

Wilsons disease = genetic defect in copper excrertion

  1. chelating agents (d-penicilliamine)
  2. Zinc- prevents dietary copper uptake
51
Q

Hallmark presentation of bowel ischemia

A

“acute onset of severe abdominal pain disproportionate to physical findings”

52
Q

Mechanism of diverticulosis

A

Increased intraluminal pressure causing the inner layer of colon to bulge thru a focal area of weakness in the colon wall

53
Q

Medical tx for hepatic encephalopathy (2 drugs)

A

Lactulose- to prevent ammonia reabsorption

Rifaximin = abx to kill intestinal flora that produces ammonia-containing products

54
Q

Difference in electrolyte imbalance in SBO vs. LBO

A

SBO has much more fluid and electrolyte imbalance than large bowel obstruction

55
Q

Differentiate the abdominal pain seen in Crohn’s vs UC

A

Crohn’s is more specifically localizable to the RLQ

56
Q

Conjugated vs. unconjugated bilirubin

(a) Which is water soluble?
(b) Which is excreted in urine?
(c) Which is toxic?

A

Conjugated vs. unconjugated bilirubin

(a) Conjugated is only loosely bound to albumin => is water soluble
(b) ONLY conjugated is excreted in the urine when levels get to excess
- so if you see dark urine its conj hyperbili
(c) Unconjugated is toxic b/c when it can cross the BBB => neurologic deficits

57
Q

Most common location of distant spread of CRC

A

Liver thru portal circulation

58
Q

Which sided colorectal cancer is more likely to cause a change in bowel habits?

A

Left sided commonly changes bowel habits- narrowing of stools (‘pencil stools’), alternating constipation/diarrhea

59
Q

What is diffuse esophageal spasm?

(a) Clinical presentations
(b) Diagnostic test
(c) Tx

A

Diffuse esophageal spasm = nonperistaltic spontaneous contractions of the esophageal body

(a) Noncardiac chest pain that mimics angina + dysphagia
(b) Esophageal manometry showing simultaneous, multiphasic repetitive contractions after a swallow w/ normal sphincter response
(c) Usually no good tx but can try nitrates and CCB

60
Q

NASH vs. alcoholic liver disease

(a) Histology
(b) Risk of progression to cirrhosis

A

(a) Same histology!
(b) Higher in alcoholic
10-15% risk in NASH
15-20% in chronic alcoholics (fatty liver)

61
Q

Nonoperative tx of SBO

(a) When is it indicated
(b) What does it involve

A

Nonoperative management appropriate if bowel obstruction is incomplete and the following are NOT present:
(a) no fever, tachycardia, peritoneal signs, or leukocytosis

(b) IV fluids + K+ (to correct hypokalemia which is usually present)
- gastric decompression: NG tube to empty stomach
- Abx

62
Q

Findings of SBO on abdominal plain films

A

Dilated loops of small bowel
Air fluid levels proximal to the obstruction
If complete- may see minimal gas in the colon

63
Q

Most common location of

(a) Diverticulosis
(b) Colonic volvulus

A

(a) Sigmoid colon
(b) Sigmoid colon

Both sigmoid colon :-)

64
Q

PSC

(a) Path
(b) Gender
(c) How to make the diagnosis
(d) Associated disease
(e) Tx

A

PSC = primary sclerosing cholangitis

(a) intra and extra hepatic duct thickening and lumenal narrowing
- not just intra like PBC
(b) M > F
(c) ERCP showing ‘bead-like’ dilations of the intra and extra-hepatic ducts
(d) Strong association w/ UC
(e) Liver transplant

65
Q

Signs/symptoms of proximal vs. distal small bowel obstruction

A

SBO
Proximal: frequent vomiting (intestinal distention causes reflex vomiting), severe pain, minimal abdominal distention

Distal: less frequent vomiting, significant abdominal distention (distal obstruction causes distention in proximal segments due to increased intestinal secretion proximal to point of obstruction)

66
Q

Achalasia is associated w/ increased risk for which cancer?

A

Squamous cell carcinoma of the esophagus

67
Q

If you could only do one: next best lab test for conj vs. unconj hyperbili

A

Conjugated- thinking hepatitis (decreased intrahepatic excretion) or obstruction => do LFTs (AST/ALT, Alk phos)

Unconjugated- thinking hemolysis (or rare genetic syndromes) => do CBC

68
Q

Clinical feature that differentiates UC from Crohn’s

A

Crohn’s- characteristic aphthous ulcers (canker sores)
-diarrhea usually without blood

UC presents w/ hematochezia (bloody diarrhea) which is NOT seen in Crohn’s

Both have abdominal distention, malabsorption => wt loss, fever, malaise

69
Q

Sulfasalazine

(a) Active compound
(b) Indications

A

Sulfasalazine = anti-inflammatory, blocks prostaglandin release to reduce inflammation

(a) Active compound = 5-ASA (mesalamine)
(b) UC and Crohn’s
- more useful in UC than in Crohn’s

70
Q

3 causes of ALT/AST over 10,000

A
  1. shock liver (ischemia- prolonged hypotension or circulatory collapse)
  2. severe viral hepatitis
  3. acetaminophen toxicity
71
Q

Why is diverticulitis so dangerous?

A 
B/c can be complicated by: 
Abscess
Fistula
Obstruction due to chronic inflammation and thickening of bowel wall 
Free colonic perforation => peritonitis
72
Q

58 yo s/p CABG on narcotics for pain presents w/ evidence of large bowel obstruction on imaging
-2 normal BM today

Dx?

A

Colonic pseudo-obstruction = acute colonic dilation w/o mechanical obstruction (hence why he can poop)

Causes- recent surgery or trauma, meds (narcotics, anticholinergics)

73
Q

Tx for cholangitis

A
  1. IV abx and IVF
    - monitor electrolytes and hemodynamics, BP and urine output
  2. Once pt is HDS for at least 48 hrs- can do ERCP to decompress the CBD (or whatever duct is blocked)
74
Q

Test of choice for

(a) Diverticulosis
(b) Diverticulitis
(c) Why is it important to differentiate the two?

A

Test of choice for

(a) Diverticulosis = barium enema
(b) Diverticulitis = CT scan
(c) B/c barium enema and colonoscopy are CONTRAindicated in diverticulitis due to the risk of perforation

75
Q

Risk factors/causes for Budd-Chiari syndrome

A

Hypercoagulable states
Myeloproliferative d/o (ex: polycythemia vera)
Pregnancy
40% are idiopathic…

76
Q

What cardiac defect is associated with bleeding arteriovenous malformation?

A

25% of pts w/ bleeding AVMs have aortic stenosis

77
Q

Electrolyte/acid/base abnormalities seen in SBO

A

Small bowel obstruction
Intestinal distention => increased intestinal secretion proximal to obstruction and decreased absorption => hypochloremia, hypokalemia, and metabolic acidosis

78
Q

Causes of SBO

A

Most common cause in adults = adhesions from previous abdominal surgery

  • incarcerated hernias
  • malignancy
  • intussusception
  • Chron’s disease

Bellevue Medicine (6 decks)

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