Upper GI 2 + Lower GI 1 Flashcards
1
Q
Liver fibrosis:
Dx:
A
excessive CT acumulation in response to chronic liver cell injury
Dx by biopsy
2
Q
Liver fibrosis - causes:
A
drugs
chemicals
alcohol
disorders affecting liver/hepatic blood flow
3
Q
Liver fibrosis - ssx:
A
Asx
any sx secondary to primary disorder
4
Q
Liver cirrhosis:
A
late stage of hepatic fibrosis, widespread distortion of architecture
5
Q
Cirrhosis - ssx:
A
non-specific (anorexia, fatigue, wt loss)
late: portal HTN
6
Q
Cirrhosis - PE:
A
Abd: Ascites, splenomegaly
Skin: Jaundice, pallor, petechiae, purpura
Extremities: clubbing
bleeding
7
Q
Cirrhosis - workup:
Prognosis:
A
Labs: LFT often normal, PT, CBC, viral assay
Biopsy
Irreversible; transplantation
8
Q
Primary biliary cirrhosis:
A
AI, progressive destruction of intrahepatic bile ducts, leads to cholestasis, cirrhosis, liver failure
9
Q
Primary biliary cirrhosis - classic sx:
A
middle aged woman unexplained pruritus fatigue - insidious dry mouth RUQ pain jaundice
10
Q
Primary biliary cirrhosis - work up:
A
GGT - elev
Alk phos - elev
AST, ALT - minimally abn
Enti-mitochondrial Ab - elev (AI)
confirm by biopsy
11
Q
Primary biliary cirrhosis - PE:
A
enlarged, firm, non-tender liver
mb splenomegaly
12
Q
Vascular disorders of the liver:
A
hepatic ischemia
congestive hepatopathy
hepatic artery disorders (occlusion, aneurysm)
hepatic vein disorders (budd-chiari, occlusive)
portal vein disorders
peliosis hepatitis
13
Q
Ischemic hepatitis:
causes:
A
diffuse liver damage d/t inadequate blood or O2
most often systemic -
impaired perfusion (chf, acute hypoTN)
hypoxemia (resp failure, CO2 toxicity)
Increased metabolic demand (sepsis)
14
Q
Ischemic hepatitis - ssx:
A
N/V
HM - TTP
15
Q
Ischemic hepatitis - work up:
A
Clinical eval LFTs: very high aminotransferases mod inc. in bilirubin LDH inc w/in hrs Procedure: US, MRI, arteriography
16
Q
Ischemic cholangiopathy:
A
focal damage to the biliary tree d/t disrupted flow from hepatic artery via peribiliary arterial plexus
17
Q
Ischemic cholangiopathy - ssx:
A
pruritis
dark urine
pale stool
18
Q
Ischemic cholangiopathy - work up:
A
Labs - cholestasis
Img - US initially, MRCP, ERCP
19
Q
Ischemic cholangiopathy - causes:
A
vascular injury during procedure:
liver transplant, laparoscopic cholecystectomy, radiation, chemoembolization, etc
resulting bile duct injury
20
Q
Congestive hepatopathy:
A
diffuse venous congestion in the liver resulting from RCHF (via IVC)
21
Q
Congestive hepatopathy - ssx:
A
most asx
RUQ discomfort
severe congestion - massive jaundice
22
Q
Congestive hepatopathy - PE:
Work up:
A
ascites
hepatomegaly
+ hepatojugular reflex
LFTs - mod elev
23
Q
Hepatic artery occlusion - causes:
A
thrombosis emboli iatrogenic vasculitis eclampsia cocaine sickle cell crisis
24
Q
Hepatic artery occlusion - ssx:
Work up:
A
asx w/o infarction or ischemic hepatitis
infarct -> RUQ pain, fever, N/V, jaundice
US (mb Doppler), followed by angiography
25
Hepatic aneurysm - causes:
| Work up:
infection
arteriosclerosis
trauma
vasculitis
if they occur - tend to be saccular & multiple!
US, followed by contrast CT
26
Budd-Chiari syndrome:
| causes:
obstruction of the hepatic venous outflow from small hepatic veins inside the liver to the IVC
hyper coagulable states
clot
27
Budd-Chiari - ssx:
| PE:
```
Asx to fulminant liver dz
acute: fatigue
RUQ pain
N/V
jaundice
hepatomegaly - ttp
ascites
```
chronic: fatigue
HM
abd pain
LE edema
28
Budd-Chiari - work up:
| prognosis:
LFTs
vascular img
most die <3 yrs if untx
29
Veno-occlusive dz:
| causes:
caused by endothelial injury, leading to non-thrombotic occlusion of the terminal hepatic venues and hepatic sinusoids
irradiation
graft vs. host dz
hepatotoxins
30
Veno-occlusive dz - ssx:
PE:
work up:
sudden jaundices
ascites
tender, smooth HM
LFTs
US, liver bx
31
Portal vein thrombosis - causes:
```
surgery
hyper coagulable states
cancer
cirrhosis
trauma
```
leads to GI bleeding from varices (usu eso/stomach)
32
Portal vein thrombosis - ssx:
| Work up:
Asx unless assoc w/other dz (pancreatitis)
LFTs
US - usu dx
33
Peliosis hepatitis:
| causes:
multiple blood-filled cystic spaces develop randomly in the liver (mm - 3cm)
damage to sinusoidal lining cells from use of hormones (OCPs, anabolic steroids), tamoxifen, vit A
34
Peliosis hepatitis - ssx:
| Dx:
```
Usu asx
occasionally cysts rupture -> hemorrhage, mb death
jaundice
HM
liver failure
```
often found incidentally on US or CT
35
Portal HTN:
increased resistance to blood flow, commonly arises from dz w/in the liver
uncommon - from blockage of splenic or portal vein, or impaired venous output
36
Portal HTN - causes:
cirrhosis
schistosomiasis
hepatic vascular abnormalities
leads to eso varices, portal-systemic encephalopathy
37
Portal HTN - ssx:
| PE:
often asx
sx from complications (hemorrhage)
```
low systolic BP
SM
ascites, peripheral edema
caput medusa, dilated abd wall veins
jaundice
spider angioma
```
38
Portal HTN - work up:
| prognosis:
```
transjugular catheter (invasive)
US or CT
```
mortality d/t hemorrhage >50%
39
Portal-systemic encephalopathy:
| causes:
neuropsychiatric syndrome
fulminant hepatitis caused by virus, drug, toxin
commonly - cirrhosis, portal HTN
metabolic stress (inf, electrolyte imbalance, dehydration, diuretics)
gut protein d/o (GI bleed, high protein intake)
non-specific cerebral depressant (alcohol, sedative, analgesic)
40
Portal-systemic encephalopathy - pathophys:
absorbed products that would otherwise be detoxified through the liver end up in systemic circulation where they may be toxic to the brain
41
Portal-systemic - ssx:
| Work up:
constructional apraxia
agitation, mania (uncommon)
"liver flap" (asterixis)
psychometric eval
CMP - electrolytes, albumin, LFT
EEG - diffuse slow wave activity
42
Post-op liver dysfunction:
```
mild liver dysfunction following major surgery, in the absence of pre-existing d/o.
3 types:
post-op jaundice
post-op hepatitis
post-op cholestasis
```
43
Hepatic cysts:
commonly found incidentally on US or CT
usu asx, no clinical significance
polycystic liver assoc. w/polycystic kidneys (rare)
44
Benign liver tumors:
common, asx
ssx: HM
RUQ discomfort
intraperitoneal hemorrhage
LFTs normal to slight abn
often found incidentally on US, CT; may need Bx
45
Most common primary liver cancer:
hepatocellular carcinoma
more common outside US (E. Asia, sub-saharan Africa)
usu. pts with cirrhosis; common in HepB/C
46
Hepatocellular carcinoma - ssx:
```
prior dx - cirrhosis
RUQ pain
wt loss
RUQ mass
unexplained deterioration
in few, 1st manifestation:
bloody ascites
shock
peritonitis
```
47
Hepatocellular carcinoma - work up:
| prognosis:
AFP (alpha-fetoprotein)
Img: US, CT, MRI
Liver Bx (if dx unclear)
prognosis poor
48
Metastatic liver cancer - from? prevalence?
from GI, breast, lung, pancreas
| more common that primary liver CA
49
Metastatic liver cancer - ssx:
| PE:
```
early asx
non-specific:
wt loss
anorexia
fever
```
```
liver enlarged, hard, or tender
massive HM with nodules - adv
hepatic bruits (uncommon)
SM
ascites
jaundice (mild)
```
50
Metastatic liver cancer - work up:
CT or MRI w/contrast
suspect w/wt loss, HM, & primary tumor elsewhere
LFTs non-specific
Liver Bx - definitive
51
Hepatic granulomas:
| causes:
localized collections of chronic inflammatory cells w/epithelioid cells & giant multinucleated cells
drugs
systemic d/o
inf (TB, schistosomiasis)
52
Hepatic granuloma - ssx:
| work up:
typically asx or reflect underlying cause
LFTs
US, CT, MRI
Liver Bx - definitive
53
Cholelithiasis:
presence of one or more calculi in the GB
| 10% of adults in dev. countries/20% of >65
54
Cholelithiasis - risk factors:
```
F>M
obesity
American Indian ethnicity
Western diet (SAD)
FHx
5 F's (female, fat, 40, fertile, FHx)
```
55
Cholelithiasis - pathophys:
```
biliary sludge - during GB stasis
types of stones:
* cholesterol stones (>85%)
* black pigment stones
* brown pigment stones
```
56
Cholelithiasis - ssx:
```
80% asx
RUQ pain - rad to back, down arm
sudden onset, intense up to 12 hrs, dull ache
N/V common
onset after fatty meal
FEVER UNCOMMON unless cholecystitis
```
57
Cholelithiasis - work up:
labs unrevealing
| US - diagnostic
58
Acute cholecystitis:
| Ssx:
inflammation of the GB, dev over hours, usu d/t stone obstruction of cystic duct (>95%)
pain similar to biliary colic, lasts longer >6hrs
subsides 2-3days, resolves 1 wk (85%)
vomiting
59
Acute cholecystitis - PE:
| work up:
R subcostal ttp
+ Murphy's sign
- Courvoisier sign
fever
```
Abd US
Cholescintigraphy
Abd CT (to ID complications - perforation)
```
60
Chronic cholecystitis:
| Ssx:
longstanding GB inflammation, usu d/t stones
damage - from modest infiltrate of chronic inflammatory cells, to fibrotic, shrunken GB
extensive calcification - PORCELAIN GB
recurrent biliary colic
61
Chronic cholecystitis - PE:
| work up:
upper abd tenderness
afebrile
abd US
62
Acalculous biliary pain - causes:
biliary colic w/o stones
```
abnormal GB emptying
overly sensitive biliary tract
sphincter of Oddi dysfx
hypersensitivity of adj duodenum
possibly stones that spontaneously passed
microscopic stones
```
63
Acalculous biliary pain - work up:
Labs: abn
elev - alk phos, bili, AST, ALT
elev - lipase
Abd US
ERCP w/manometry - show Oddi dysfx
64
Postcholecystectomy syndrome:
| cause:
abd sx post cholecystectomy (GB removal)
alteration of bile flow
leads to: continuously increased bile flow to upper GI
diarrhea, colicky lower GI pain
65
Choledocholithiasis:
Ssx:
presence of stones in the bile duct, leading to biliary colic, obstruction, gallstone pancreatitis, cholangitis
usu secondary cholesterol stones originating in GB (85%)
biliary colic
duct dilation
jaundice
cholangitis
66
Acute cholangitis:
EMERGENCY
bile duct infection (gm -) & inflammation
can lead to stricture, stasis, choledocholithiasis
67
Acute cholangitis - ssx:
| PE:
Charcot's triad:
* abd pain
* Jaundice
* fever/chills
RUQ abd tenderness
liver tender, enlarged
confusion
hypotension
68
Recurrent pyogenic cholangitis:
```
intrahepatic brown stone formation
repeat cycles of obstruction, inf, inflammation
* occurs in SE Asia
* sludge + bacteria debris in bile duct
* undernutrition
* parasitic inf
```
69
What do you suspect in pt w/jaundice & biliary colic?
common duct stone
70
What do you suspect in pt w/ jaundice, biliary colic, fever, & leukocytosis?
acute cholangitis
71
Cholangitis/cholodocholithiasis work up:
Labs:
elev bilirubin, alk phos, ALT, GGT
CBC - leukocytosis
LFTs - AST, ALT
Abd US
72
Sclerosing cholangitis:
chronic cholestatic syndromes characterized by patchy inflammation, fibrosis, strictures of intra/extrahepatic bile ducts
leads to inflammatory & fibrosing lesion, scarring bile ducts
73
Primary sclerosing cholangitis:
| Ssx:
MC form, cause unknown (AI?)
80% have IBD - usu UC
10-15% develop cholangiocarcinoma
```
progressive fatigue -> then pruritis
jaundice (late)
steatorrhea / fat soluble vit deficiencies
75% - stones (GB or ducts)
Asx until late, then HM / SM / cirrhosis
```
74
Primary sclerosing cholangitis - work up:
elev. alk phos, GGT
elev. Gamma Globulin, IgM
neg. anti-mitochondrial Ab
US - to exclude extrahep obstruction
MRCP - multiple strictures intra/extrahep bile ducts
ERCP - 2nd choice, invasive
75
AIDS cholangiopathy:
| Ssx:
biliary obstuction 2° strictures caused by opportunistic info
* pre-antiretroviral therapy - 25% prevalence
```
RUQ / epigastric pain
severe pain -> papillary stenosis
milder pain -> sclerosing cholangitis
diarrhea
fever
jaundice
```
76
AIDS cholangiopathy - work up:
elev alk phos, GGT
ERCP
US
77
Cholangiocarcinoma:
Ssx:
PE:
rare
usu malignant
extrahepatic bile duct - MC
```
pruritis
painless obstructive jaundice
abd pain
anorexia
wt loss
```
non-tender mass (Couviorsier sign)
HM
78
GB carcinoma:
| Ssx:
native american ethnicity
pts w/lg stones (>3cms)
porcelain GB (d/t chronic cholecystitis)
70-90% have gallstones
varies, asx -> biliary pain -> advanced dz w/wt loss, constant pain, mass, jaundice, + couvoisier's
median survival - 3 months
cure if found early
79
Ddx - RUQ pain:
```
Hepatitis
NASH
cirrhosis
cholecystitis/cholelithiasis
cholangitis
biliary colic
Budd-Chiari syndrome
pancreatitis
pneumonia, pleurisy
```
80
Ddx - epigastric:
```
GERD
gastritis
PUD
pancreatitis
myocardial ischemia
pericarditis
AAA
```
81
Ddx - LUQ:
```
spleen infarct / rupture
gastritis / gastric ulcer
pancreatitis
hiatal hernia
sickle cell, mono, hemolytic d/o
```
82
Ddx - R/L flank:
kidney inflammation
pyelonephritis
polycystic kidney dz
83
Ddx - periumibilical:
early appendicitis
gastroenteritis
bowel obstruction
peritonitis
84
Ddx - RLQ:
```
appendicitis
IBD / UC / Crohn's
cecal diverticulitis
inguinal hernia
nephrolithiasis
F: PID, ovarian cyst, ectopic, endometriosis
M: testicular or epididymal inflammation
```
85
Ddx - suprapubic:
cystitis
acute urinary retention
F: uterine cramps, PID, cervicitis, endometriosis
M: acute prostatitis
86
Ddx - LLQ:
```
diverticulitis
IBD / UC / Crohn's
nephrolithiasis
F: PID, ovarian cyst, ectopic, endometriosis
M: testicular or epididymal inflammation
```
87
Ddx - diffuse abd pain:
```
early appendicitis
gastroenteritis
intestinal obstruction
mesenteric ischemia
peritonitis
IBS
celiac
```
88
Ddx - extra-abdominal causes of abd pain:
abd wall - hematoma
infection - herpes zoster
metabolic - DKA, porphyria, sickle cell dz
thoracic - MI, PE, radiculitis
toxic - spider bite, opioid withdrawal, heavy metal poison
89
Define diarrhea:
>200g/day stool wt
increased stool fluidity
>3 BM/day
90
4 mechanisms of diarrhea:
osmotic - too much water in bowels, inc. amt of poorly absorbed solute
causes - malabsorption, osmotic laxatives, lactose intolerance
secretory - inc secretion or inhibited absorption
causes - enterotoxin, hormones, gastric hypersecretion, laxatives, bile salts, fatty acids
exudative - mucus, blood, protein
causes - Crohn's, UC, infectious, ischemic, vasculitis, radiation
motility - increased (hyperthyroid, post-gastrectomy) or decreased (DM, hypothyroid, scleroderma) contact btw contents & mucosa, increased motility (IBS)
91
Diarrhea - red flags:
```
blood
pus
fever
chronicity
signs of dehydration
unintended wt loss
failure to thrive
```
complications:
dehydration
electrolyte imbalance
92
Constipation - red flags:
```
abdominal distension
vomiting
blood in stool
wt loss
severe or worsening sx
```
93
Constipation - acute/organic:
obstruction
adynamic ileus
meds (opioid, anticholinergic)
94
Constipation - chronic/functional or organic:
```
carcinoma
hypothyroid
CNS disorder
slow transit
IBS
```
95
Gas - red flags:
wt loss
| blood in stool
96
GI bleeding:
Sm bowel - angioma, AV malformation, tumor, Meckel's
Colon/anus - fissure, colitis, carcinoma, polyp, IBD, diverticular dz, hemorrhoids
97
Dyschezia:
```
difficulty evacuating (urge, but can't)
often from discoordination: hypotonia or prolapse
```
98
O&Px3 tests for:
protozoa, worms, eggs, parasites
| worms - round, hook, tape, flat, fluke
99
Stool diagnostic tests
```
Labs (appearance, pH, WBC, blood, etc)
O&Px3
culture
hemoccult
fecal leukocytes
lactoferrin (latex agglutination assay)
fecal lysozyme
comp digestive stool analysis
sIgA
serology
transit/retention time
```
100
Acute abdomen d/t infection or chemical presents as:
sharp, localized pain
| somatic nerves in perietal peritoneum respond to irritation
101
Acute abd d/t distention or spasm presents as:
vague, dull, nauseating, diffuse
| ANS fibers on viscera respond to distention & contraction
102
Acute abd - referred pain:
aching pain perceived distant from the source, not reproducible at distant site
103
MC cause of acute abd pain:
Appendicitis!!
```
obstruction from:
lymphoid hyperplasia (mono, crohn's, GE, measles)
fecaliths
parasites
foreign material (swallowed?)
TB
tumors (benign, malignant)
```
104
Appendicitis - classic presentation:
```
periumilical pain -> migrates to RLQ
N/V - after onset
anorexia
<48 hr onset
non-specific: indigestion, flatulence, malaise, diarrhea
```
105
Appendicitis - PE:
```
low grade fever
McBurney's pt tenderness
rebound tenderness
pain to percussion - pain in RLQ
rigidity & guarding
Rovsing's sign
Obturator sign
Psoas sign
cough sign
Markle sign (heel drop)
DRE & pelvic maybe
```
106
Acute mesenteric ischemia:
dec. mesenteric blood flow -> wall ischemia, inflammation, infarction (at splenic flexure)
d/t diminished perfusion or occlusive dz
rarely seen in <60 yrs
107
Acute mesenteric ischemia - ssx:
```
severe abd pain w/minimal findings
sudden onset pain -> arterial embolism
gradual onset pain -> venous thrombosis
peritoneal signs as necrosis occurs:
* abd tenderness
* guarding
* absent bowel sounds
* hemoccult positive
* sx of shock
```
mortality rate - 70-90%
108
Ischemic colitis:
| Ssx:
episodic, transient reduction of bowel blood flow from small vessel atherosclerosis
mild, slow onset
LLQ pain
rectal bleeding
mucosal/submucosal bleeding mb seen
109
Abd hernia:
| ssx:
```
acquired - surgical or congenital weakness of wall, protrusion of contents
Asx unless strangulated
* increasing pain
* N/V
* signs of peritonitis
```
SURGICAL REPAIR
110
Intestinal obstruction - classification:
complete or partial
simple or strangulated
location: high sm, low sm, lg intestine
onset: acute or gradual
111
Intestinal obstruction - causes:
```
adhesions
hernia
tumor
diverticulitis
foreign body
volvulus
intussusception
fecal impaction
```
112
Intestinal obstruction - ssx:
```
Sm Int:
sudden onset periumbilical or epigastric cramping
vomiting
obstipation (complete)
diarrhea (partial)
NTTP (if not strangulated)
severe, constant pain (strangulated)
palpable dilated bowel loops
```
```
colon:
gradual onset of pain
obstipation
vomiting
abd distension
non-tender palpable mass
borborygmi
```
113
Ileus:
Causes:
temporary arrest of intestinal peristalsis
```
post-surgical
appendicitis
diverticulitis
perforation
AAA
hypokalemia
drugs (opioid, anticholinergic)
lower lobe pneumonia
MI
```
114
Ileus - ssx:
| PE:
```
distension
vomiting
abd discomfort
colicky pain
watery stool
```
absent bowel sounds
NTTP (unless inflammatory cause)
