UW - Med/GI Flashcards
What are cannonball metastases in the liver most likely to indicate?
Primary tumor of the GI tract, lung, or breast (follow other sx to dx)
Where does prostate cancer usually metastasize to?
Pelvic lymph nodes
How would a patient w/ colon cancer metastasized to the liver present? How can you diagnosis?
Ab pain, microcytic anemia, + fecal occult blood, hepatomegaly w/ hard liver edge
CT w/ IV contrast
What is the recommended treatment for non-bleeding esophageal varices and why?
Nonselective beta blockers (propranalol, nadalol) –> leads to unopposed alpha mediated vasoconstriction and decreased portal venous flow
How do you treat an active esophagela variceal bleed and why? General long term Tx for bleeding esophageal varices?
Octreotide - splanchnic vasoconstriction, reduced portal flow (via glucagon inhibition)
Endoscopic sclerotherapy for long term cure
What are the hallmark signs of carcinoid syndrome?
Episodic flushing (85%), Secretory diarrhea w/ ab cramps, cutaneous telangiectasias, bronchospasm, & tricuspid regurgitation
What symptoms are consistent w/ chronic Hep C infection? Major non-hepatic associations?
Nonspecific sx (nausea, anorex, myalgia, wt loss, fatigue), Transaminitis, cirrhosis (20%), risk of HCCa
Heme: mixed cryoglobulinemia (50%)
Renal: membranoproliferative glomerulonephrits
Skin: Porphyria cutanea tarda (fragile skin, photosensitivity, vesicles/erosions on hand) lichen planus
Endocrine: Increased risk of diabetes
What is polyarteritis nodosa most often associated w/?
Hepatitis B
What contributes to the chronology of pain in acute appendicitis?
- Viscera are inflamed - dull poorly localized peri-umb pain
- Somatic pain - Inflam of parietal peritoneum and skeletal muscles localize to RLQ, more severe
How may GERD exacerbate asthma symptoms?
airflow obstruction via increased vagal tone, heightened bronchial reactivity, and microaspiration of gastric contents in upper airway (30-90% of asthma pts)
Supine position after large meal, laryngitis, change in voice quality
What is the clinical presentation of someone with esophageal rupture? How can you diagnose?
Chest/Ab pain, systemic findings (fever), SubQ emphysema in neck, Hamman sign (crunching sound on chest auscultation)
Dx w/ Chest imaging: wide/pneumo mediastinum, Pneumothorax, pleural effusion (late), esoph wall thick (CT), Leak at perf site on water soluble contrast esophagogram
A patient presents w/ acute pancreatitis and crops of yellow/red papules on arms and shoulders. What should be done next?
Measure fasting lipid profile for hypertryglyceridemia (causing pancreatitis and xanthomas)
What are the most prominent causes of acute pancreatitis? Rare?
Alcohol use and gallstones
Others: Hypertrigs, recent ERCP, trauma, infection, medication
What lab findings can be used to distinguish hepatic cell injury vs. biliary duct obstruction?
Cells = Transaminases Duct = Alk Phos and BR
What signs indicate spontaneous bacterial peritonitis in setting of chronic cirrhosis? What should be done for these patients?
Fever/subtle changes in mental status, and sometimes ab pain, transaminitis (mild)
Do Diagnostic paracentesis (+ fluid culture and PMNs 250)
What is the most common cause of bile ductopenia (markedly decreased bile ducts on biopsy) in adults? Other causes?
1 = Primary biliary cirrhosis
Others: Failing liver transplant, Hodgkin’s dz, GVH Dz, Sarcoid, CMV, HIV, and medication tox
What are the liver biopsy findings for the following conditions: Acet Tox? Alcoholic hepatitis? TPN?
- Acet: Centrilobular/diffuse necrosis
- EtOH: Hepatocyte swelling/necrosis, mallory bodies, PMN infiltration
- TPN: Cholestasis which can progress to fibrosis
What are the liver biopsy findings in: Primary biliary cirrhosis? Primary sclerosing cholangitis? Chronic Hep B?
- PBC: Markedly decreased bile ducts (ductopenia)
- PSC: Periductal portal tract fibrosis, segmental stenosis of extrahep/intrahep bile ducts
- HBV: HC injury, sinusoidal cell reactive changes, inflammation/fibrosis of portal tracts
What is serum chromogranin A a marker for?
- Well differentiated neuroendocrine tumors
- Also elevated in Carcinoid tumors, Hyperthyroid, chronic atrophic gastritis, and chronic PPI tx
What is the most common cause of ascites and what is indicated for all patients w/ new onset ascites?
- Cirrhosis in 80% of cases (Usually EtOH liver dz or hep C cause)
- Paracentesis to determine etiology
What conditions can progress to acute liver failure (ALF) and how can you identify?
Viral hepatitis, Drugs (acet), Alcoholic/autoimmune, WIlsons, Budd chiari, Ischemia/malignant infiltration
Worsening PT/INR and bilirubin, increased transaminases >10x normal
What is the first step upon finding gastric adenoCA on endoscopy?
CT abdomen/pelvis, PET/CT and other diagnostic imaging since most Gastric adenos are found in advanced stages (90%)
What drug works like Somatostatin and what is its use?
Octreotide (long acting analogue of Som) - Reduces splanchnic blood flow, inhibiting gastric acid secretion, and exerting gastric cytoprotective effects
What is serum-to-asciteds-albumin gradient (SAAG) used for?
Diagnoses etiology of ascites -> SAAG calculated by subtracting ascites fluid albumin from serum albumin. SAAG > 1 g/dL indicates portal HTN, SAAG
What is the purpose the D-xylose test?
Dxylose is a simple sugar monosaccharide, therefore it is reabsorbed right away in proximal small intestine (if decreased absorptive capacity, serum D-xylose levels will be low)
This test measures the absorptive capacity of the small intestine, therefore it is helpful in diagnosing celiac disease (note: bacterial overgrowth can cause false positive results b/c of sugar fermentation)
What drug is useful for nausea as a result of gastroparesis?
Motilin receptor agonist (Erythromycin)
What dermatological finding is associated w/ primary biliary cirrhosis?
Xanthelasma (soft yellow plaques on medial aspect of eyelid bilaterally) and pruritis
What are the features of niacin deficiency?
Pellagra: 3 D’s, dermatitis, diarrhea, dementia
Also, general weakness, irritable, vomit, ab pain, loss of appetite
What are the most common causes of acute pancreatitis?
#1 - gallstones (biliary pancreatitis) and alcohol consumption -Hypertriglyceredemia, recent ERCP
What test should be done on patient’s w/ acute pancreatitis and no prior history of alcohol use?
RUQ ultrasound to look for gallstones (better than CT, in which often gallstones won’t appear)
What are the causes of small intestinal bacterial overgrowth? How can you diagnose?
- Anatomical abnormalities (strictures, surgeries)
- Motility disorders (diabetes, scleroderma)
- Chronic dz (ESRD, AIDS, cirrhosis, old age)
Dx: Endoscopy -> jejunal aspirate showing >10^5 organisms & glucose breath Hydrogen testing
How can you diagnose irritable bowel syndrome (IBS)?
Rome criteria : Chronic abdominal pain (>= 3days/month for at least 3 months) and >= 2 of the following; improved w/ bowel movement, change in frequency of stool, change in form of stool
What clinical signs are consistent w/ fulminant helpatic failure and which patients are prone to it? What is the treatment?
-Hepatic encephalopathy w/in 8 weeks of acute liver failure
-Heavy users of Acetaminophen, Alcohol, or Meth
Tx: Liver transplant ASAP (FHF has >80% mortality rate)
What would you find on esophageal manometry in diffuse esophageal spasm?
Multiple contractions on lower and middle esophagus tracings –> causes severe non-cardiac chest pain
What should be done in all elderly patients w/ microcytic anemia and generalized fatigue? (no matter what the other labs show)
Colonoscopy and endoscopy (MUST rule out carcinoma, or upper GI bleed; guaiac may be negative on one test and later +)
What vitamin can patients become deficient in when they have Carcinoid syndrome and why?
Niacin; b/c tryptophan in cells is used up to make serotonin, resulting in less tryp available to make niacin/NAD
What is angiodysplasia and what symptoms do patients usually present with?
- AVMs of GI tract
- often in patients >60yo
- Anemia, painless GI bleed, ESRD, and murmur of Aortic Stenosis (turbulent flow through valve causes disruption of von Willebrand multimers
How do you manage acute pancreatitis?
NPO, IV fluids, analgesics (non-absorbable Abx only given when local infection occurs - in 30% of acute necrotizing pancreatitis)
What are hepatic adenomas commonly associated with?
- OCP use
- elevated Alk Phos and GGT
How do you differentiate Mallory Weiss from esophageal perforation?
Mallory Weiss is incomplete mucosal tear at GE jct, resulting in hematemesis
-Esophageal perforation leads to pneumomediastinum (Boerhaave Syndrome!!)
What is the best diagnostic test for lactose intolerance?
Lactose Hydrogen breath test - patient’s ingest lactose and H2 is measured (elevated = bacterial carbohydrate metabolism)
What is the proper management of someone who has ingested large quantities of a chemical compound?
- Stabilize vital signs and start IV fluids
- Serial CXR and AXR to assess for damage (e.g. perforation)
- Upper GI endoscopy w/in 12-24 hrs to assess damage
How do you treat MALT lymphoma in a patient who does not have involvement of surrounding nodes?
- H. Pylori may have role so first you give Omeprazole, clarithromycin and amoxacillin
- If this fails give ChemoTx (CHOP - cyclophos, adriamycin, vincristine, prednisone + or - bleomycin)
How often should routine colonoscopy surveillance be done in patients with ulcerative colitis? Would they require prophylactic colectomy w/ ileal pouch?
- Pts w/ UC at higher risk for colon cancer
- After disease has been present for 8 years, do colonoscopy and repeat every 1-2 years
- Resect colon if evidence of dysplasia
What is used to treat primary biliary cirrhosis?
- Ursodeoxycholic acid slows disease progression and improves symptoms
- Methotrexate and colchicine show moderate benefit
- Refractory, severe cases require Liver transplant
What is Trousseau’s syndrome most often associated with and how does it present?
Associated w/ malignancy; most often pancreas then lung, prostate, stomach, colon
-Causes a hypercoaguable state leading to migratory superficial thrombophlebitis
How can gastrinomas cause steatorrhea?
Increased acid production which inactivate’s proteins and enzymes in pancreatic juices
What is a possible cause of dysphagia in a patient w/ history of GERD?
Esophageal stricture
How can Zollinger-Ellinson syndrome lead to malabsorption/steatorrhea?
Excess stomach acid produced from gastrin secreting tumor inactivates pancreatic enzymes
What is ursodeoxycholic acid used for?
Patients w/ symptomatic gallstones who are poor surgical candidates –> dissolves gallstones
What classic clinical features are associated w/ splenic abscess? What are risk factors for this?
-Fever, leukocytosis, LUQ ab pain, left sided pleuritic chest pain (if left pleural effusion)
Risks: Infection (endocarditis) w/ hematogenous spread, sickle cell disease, HIV/immunosuppression, IV drug use, trauma
What are the key features of disseminated gonococcal infection (gonococcemia)?
-Polyarthralgias, tenosynovitis, and painless vesiculopustular rash,
What is hepatic hydrothorax? How do you treat?
Transudative pleural effusion as a complication of cirrhosis
Tx1: therapeutic thoracocentesis and salt restricted diet + diuretics
Tx2: Transjugular intrahepatic portosystemic shunt (if Tx1 fails)
What is emphysematous cholecystitis?
Form of acute cholecystitis 2/2 infection of gallbladder wall w/ gas forming bacteria
What dangerous complication can be the first presentation for IBD? How can you confirm? What do you want to avoid?
Toxic megacolon –> do Abd X Rays
-Colonoscopy risks perforation, do not do until stabilized
How do you diagnose toxic megacolon?
Radiographic evidence of colonic distension + at least 3 of (fever >38C, HR >120, PMN leukocytosis >10.5k, Anemia) + at least one of (volume depletion, AMS, HoTN, electrolyte disturbance)
What does the presentation of hypogonadism, arthtropathy, diabetes and hepatomegaly suggest?
Hemochromatosis
What study is most useful for evaluating suspected diverticulosis, especially if bleeding occurs?
labeled erythrocyte scyntography and CT abd
