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GI Review (sb)

cirrhosis architectural distortion of liver parenchyma due to fibrosis
progression of alcoholic liver injury fatty liver, alcoholic hepatitis, alcoholic cirrhosis
steatosis triglyceride fat accumulation in HC
focal/ spotty necrosis limited to scattered cells within lobules
interface hepatitis between periportal parenchyma and portal tracts
submassive necrosis entire lobules
massive necrosis most of the liver
fibrosis cause response to inflammation or toxic insult (irreversible)
maddreys discriminant function and composite clinical laboratory index shows mortality risk during that hospitalization
early cirrhosis s/sx usually asymptomatic, low platelets, hyperbilirubinemia, hypoalbuminemia, weakness, fatigue, hepatosplenomegaly (maybe)
late cirrhosis s/sx lots of symptoms
histological appearance of cirrhosis chicken wire
portal hypertension (definition) hypertension to the portal system result of liver contraction and impeded blood flow
portal hypertension causes mainly cirrhosis and alcoholic hepatitis
variceal hemorrhage and cirrhosis 1/3 of pts with cirrhosis die to EVH
s/sx of EVH fatigue, pallor, tachycardia, hematemesis, melena, hematochezia
EVH prevention beta blockers
ascites (fact) most common clinical manifestation of decompensation
ascites sx increase abdominal girth, weight gain, early satiety, sob, peripheral edema
ascites tx sodium restriction, diuretic therapy, paracentesis
spontaneous bacterial peritonitis infection of ascites (fever is alarming sx)
spontaneous bacterial peritonitis sx fever, abd pain, mental status changes, rigors, n/v, diarrhea, malaise, hypotension, tachycardia, leukocytosis, azotemia, increased bili
Heptorenal syndrome (HRS) renal failure defined by increase creatine in pts with advanced liver disease and portal hypertension
heptorenal syndrome types difference type 1 lives 2 weeks, type 2 lives longer
HRS tx nothing really good
Hepatic encephalopathy 4 stages of decreasing mental status
Hepatic encephalopathy testing ammonia (most common used)
Hepatic encephalopathy tx avoid excess protein, lactulose, rifaxamin
transplantation necessary outcome of cirrhosis
Transjugular intrahepatic portosystemic shunt (TIPS) treatment used for variceal hemorrhage (risky), ascites (90% effective), hepatorenal syndrome (type 1), hepatic encephalopathy (but could induce it too?)
HAV/HEV transmission fecal oral transmission
HBV/HCV transmission blood and body secretion transmission
prodromal syndrome anorexia, n/v, fatigue, maliase, arthralgias, headache, photophobia, pharyngitis, cough, coryza, itching
mild hepatitis (symptoms) elevated ast/alt, jaundice, RUQ pain, dark urine, clay colored stools, fever (a and e)
acute hepatitis (clinical presentation) signs and sx of hepatitis, duration less than 6 months
chronic hepatitis (clinical presentation) does not resolve in 6 months, most pts asymptomatic, can progress to cirrhosis
HAV (suspect when) acute onset of s/sx recent shellfish ingestion, foreign travel, sick contacts
HBV (suspect when) Acute: acute onset of s/sx, recent sexual history, IVDA, MSM, tattoos, blood transfusions Chronic: same with mild elevation of transaminases NOTE: highest risk of vertical and sexual transmission
Jaundice (when visible) when bilirubin exceeds 2.5 mg/dL
Acute liver failure (symptoms) coagulopathy, encephalopathy, bilirubin greater than 15
HAV (facts) RNA virus, fecal-oral transmission, persists for months (rarely beyond 6 months)
HEV (facts) high mortality in pregos, viral RNA in serum lasts only weeks while stool contains viral particles for several more weeks
HBV (facts) DNA virus, natural immunity not possible (can reactivate), virus can survive outside human for 6 mo; not cytopathic
Childhood-onset HBV results in chronic infections
Adult-onset HBV usually clears
indications to order hep markers flu-like sx & abd pain faint icterus, dark urine, clay-colored stools risk factors: sexual promiscuity, IVDU, h/o surg before '85 or transfusion/transplant before '92 end-stage liver disease
HAV (incubation period) 15-45 days (avg 30)
HBV/HDV (incubation period) 30-180 days (avg 60-90)
HCV (incubation period) 15-160 days (avg 50)
HEV (incubation period) 21-56 days (avg 40)
HCV (suspect when) Acute: rarely found; h/o sexual promiscuity, MSM, IV/IN drug use, tattoos (esp colorful) Chronic: same but with mild elevations of transaminases
HDV (suspect when) initial HBV sx worse than expected or stable chronic HBV infection worsens; foreign travel
HEV (suspect when) same clinical presentation as HAV, but HAV markers negative; consumption of undercooked pork or boar
Lab Values increased AST/ALT (acute disease) increased bili (if >20 or prolonged=severe disease) alk phos normal/inc PT/INR prolonged (acute liver failure)
Acute Hepatitis (Management) tx of symptoms: fever, pain; nausea; dehydration; itching (if HBV, consider nucleosides) imaging: US (initial to r/o), CT/MRI (f/u on abnormal findings), elastogram (if fibrosis)
HAV (serology) Acute infection: IgM Resolved: IgG remains positive for life providing immunity
HBV (serology) HBsAg appears first HBc IgM positive in acute infection HBeAg positive in active replication HBV DNA= viral load HBsAb positive if recovered or if vaccinated
HCV (serology) HCV antibody= exposure, not necessarily infection Must also use HCV RNA by PCR for viral load
HEV (serology) HEV RNA detection in serum or stool Presence of HEV IgM or increased HEV IgG is indicative of infection
Chronic Hepatitis (clinical presentation) Usually asymptomatic • If not, symptoms (see acute) will not resolve within 6 months • Jaundice, first noted in sclera • Spider angiomas/palmer erythema • Caput medusa • Hepatosplenomegaly • Ascites • Neurologic changes • Gynecomastia in males
HCV (facts) RNA virus, rarely causes symptoms, almost never fulminant hepatitis don't let patients wait until sick can be re-infected
Tylenol Most common cause of drug-induced hepatitis
False True/False Steroids are treatment for drug-induced hepatitis
Hepatocellular Carcinoma Etiology Male > Female High assoc. w/ cirrhosis High prevalence with HBV & HCV infection
HCC Clinical Presentation asympt until large or mult abd pain w/ palpable mass friction rub/bruit over liver blood tinged ascites
HCC Diagnosis Alpha-Feto Protein (>1000 is diagnostic)-NOTE: False increase with ascites, PBC, testicular cancer, prego Ultrasound with f/u MRI
HCC Treatment Early detection is key Surgical resection/transplant is the only cure TACE (chemo), thermal/cold ablation, Sorafenib NO radiation!
Liver Transplant Needed mostly in patients with HCV Others: decomp CLD, newly dx HCC, non-alcoholic steatohepatitis
MELD Score Helps determine eligibility for liver transplant Based on INR, bili, creatinine
polyps more prevalent with age, can be present with bleeding, less than 1% become malignant
adenomas greater than 1 cm
most common adenoma tubular adenomas
high risk of cancer adenoma villious adenomas
pedunculated polyps with a stalk
sessile polyps without a stalk
colon cancer risk factors age, colorectal polyps, IBD, inherited syndromes, lifestyle factors (smoking, alcohol, obesity)
colorectal cancer at an early age makes you think of hereditary non polyposis colon cancer
with no risk factors how often should you get a colonoscopy every 10 years
staging meaning T extent of primary tumor invading the wall
staging meaning N lymph node involvement
staging meaning M metastasis to other organs
neoadjuvant therapy treatment given as a 1st step to shrink tumor before main treatment
adjuvant therapy additional cancer treatment given after the primary treatment to lower the risk of recurrence
colorectal metastasis most common location liver
Hernia A profusion of a body structure through a rupture in the wall of the cavity in which it is normally enclosed
Causes of hernias congenital, acquired (surgery or trauma)
Inguinal hernia most common hernia
indirect inguinal hernia lateral to epigastrics, failure to close processes vaginalis
direct inguinal hernia medial to epigastrics, acquired, floor weakness (more common in elderly)
Femoral hernia more common in multiperous women, repair with a plug
femoral hernia complications injury to femoral vein, artery, nerve, DVT, recurrence, and infection
Umbilical hernia failure of closure of umbilical ring after birth
Umbilical hernia causes overweight, ascites (bad news), large abd tumor, pregos
Incisional hernia most common in midline but can occur at any location
Incisional hernia predisposing factors Post op infection, pulmonary disease, obesity, smoking, immune disease, surgery for AAA
Repairing hernias MESH
seroma fluid in old hernia location (post repair)
most common type of stone cholesterol stone
by product of hemolytic state common in sickle cell, heart valve pts, cirrhosis black pigment stone
associated with infection of the biliary tree, common in asians brown pigment stone
Risk factors for gallstones age, women, obesity, rapid weight loss, (fat old lady that joins jenny Craig), TPN, pregos, diabetics
sonography pros and cons detects gallstones, cholelithiasis, not good for detecting CBD stone
endoscopic retrograde cholangio-pancreatography pros and cons dx choledocholithiasis, invasive and can cause pancreatitis (so yikes) if suspicion is high then gold standard
Biliary colic intermittent obstruction of the cystic duct by one or more stones, upper abd pain increases over 1 hour then stops
Acute cholecystitis outlet obstruction of the gallbladder due to a gallstone obstructing the cystic duct, gall bladder neck, or Hartmans pouch
Acute cholecystitis sx like biliary colic but lasts more than 6 hours, vomiting, low grade fever, jaundice, murphys sign
cholangitis kills! pus under pressure in the bile duct leads to rapid spread of bacteria via the liver into the blood, impacted stone in CBD
cholangitis sx charcots triad (ruq pain, fever, jaundice) labs show elevated WBC, bili high, alk phos elevated
cholangitis tx ERCP, IVF, antibiotics
choledocholithiasis stones in the common bile duct rest at the ampulla of cater increases pressure in the bile ducts
choledocholithiasis sx like biliary colic, jaundice, bilirubin and alk phos rise
choledocholithiasis tx ERCP
Ligament of treitz tissue that connects the duodenum to the diaphragm, divides the GI tract into and upper and lower portion
Melena black tarry and foul smelling stools usually mean UGI bleed
Hematochezia passage of bright red blood or maroon stools from the rectum usually LGI or very brisk UGI
Peptic ulcer disease most common cause of UGI bleeding
Peptic ulcer disease sx melena or hematemsis, hx of GERD, n/v, abd pain (gastric= w/ food, duodenal= better w/ food bad 2-5 hrs after)
Esophageal varices association with cirrhosis, high mortality rate
Esophageal varices s/sx abnormal LFTS, hematemesis, melena, hemodynamically unstable
mallory weiss tears longitudinal mucosal laceration in the distal esophagus or proximal stomach usually associated with forceful wrenching/vomiting
Mallory weiss tears sx melena, almost always give a hx of non-bloody vomiting before hematemesis, heavy alcohol use
Gastritis injury to gastric mucosa with inflammation defined endoscopically as mucosal hemorrhages, erythema, and erosions
Gastritis causes H. pylori, stress, NSAID use, alcohol
Gastric cancer s/sx wt loss, abd pain, nausea, dysphagia, early satiety, ulcer type pain, palpable abd mass
Anatomy of the gut (3 layers) mucosa, muscular layer, serosa
Bowel obstruction sx progressive nausea, vomiting (after eating then without eating), feculent (if distal), colicky abd pain, obstipation
Bowel obstruction physical findings colicky abd pain, abd distention, bowel sounds with tinkles and rushes
bowel obstruction management IVF, bowel decompression
LaPlaces law thinner the wall, larger radius = more tension
Appendicitis most common emergency general surgical procedure
Appendicitis sx vague pain referred to umbilicus, anorexia and vomiting, point tenderness in the RLQ
Appendicitis tx IVF, antibiotics, pain management, appendectomy
Large bowel obstruction cause cancer 90% of the time
anal fissures sx pain with defecation, hematochezia, constipation
hemorrhoids risk pop chronic strainers, pregos, low fiber dieters
Hemorrhoids treatment sclerotherapy, band ligation (internal only), coagulation, hemorrhoidectomy
colon tics protrusions of mucosa thru muscularis medium sized arteries associated with diverticula
colon tics (cause) low fiber diet, motility abnormalities, changes of the colon wall with aging
uncomplicated acute diverticulitis small perforation, infection contained, limited to wall of the colon and adjacent adventia likely to develop chronic sx of abd pain, bloating, alt bowel habits
complicated acute diverticulitis abscess, fistula, stricture, bleeding, free perforations rare and results in an acute abd
acute diverticulitis (diagnosis) lower abd pain for days, nausea, change in bowels, abd distention, low grade fever, low abd mass possible
uncomplicated acute diverticulitis (treatment) antibiotics should improve sx w/n 48-72 hours, colonoscopy in 6 weeks (contraindicated in acute phase)
complicated acute diverticulitis (treatment) NPO, IVF, antibiotic coverage, CT scan (to detect complications), surg consult
Fistulae (diagnosis) polymicrobial UTIs, air or stool per urethra or vagina, air in bladder
MC cause of lower GI bleed colon tics
diverticular bleeding painless, bright red to maroon, stops spontaneously
colon tics (location) West: 95% in left colon (sigmoid) Asia: right colon
Indications for surgery no improvement with treatment within 24-72 hours abscess not accessible by IR drainage air on KUB or CT (free perf) acute abdomen (ruptured abscess or free perf)
Rome symptom criteria abd pain discomfort/pain at least 2-3 days per month (improved with defecation, onset associated with a change in frequency and/or form of stool) and present for 3 of the last 12 months
IBS stool pattern irregularly irregular, periods of constipation alternating with periods of diarrhea
SIBO (small intestinal bacterial overgrowth) may occur after acute gastroenteritis and lead to dysmotility, immune response may cause antibody to ICC and cause loss of the SI migrating motor complex which causes bacterial overgrowth increased freq of IBS after GE
Pathophysiology gut is over-reactive (effected by cognitive, emotional, autonomic, endocrine, infections, and immune system)
SIBO (diagnosis) breath test
SIBO (IBS-type treatment) certain abx i.e. metronidazole, neomycin, doxycycline #1=Rifaximin
Alarm Signals Fever, GI bleed, weight loss recent consistent change in bowel habits >45 yo onset of sx FHx or CRC, IBD, celiac disease abnormal physical findings
Tegaserod tx for constipation and abd pain
Lubiprostone tx for constipation (esp with IBS)
Linzess tx for constipation with IBS and abdominal pain
Alosetron tx for females with IBS and diarrhea must report use (severe constipation or ischemic colitis)
FODMAP Diet fermentable oligosaccharides, disaccharaides, monosaccharides, and polyols includes fructose, lactose, polyols, fructans, galacto-oligos
Loperimide/Diphenoxylate tx of diarrhea
Tricyclics tx of pain and diarrhea (worsen constipation)
SSRIs tx for pain (worsens diarrhea and GI symptoms)
Acute pancreatitis inappropriate activation of pancreatic enzymes within the pancreas causing auto digestion and release of inflammatory mediators
alcohol caused pancreatitis premature activation of pancreatic enzymes, directly toxic to cells, generation of toxic metabolites (acetaldehyde)
Dx pancreatitis abd pain (RUQ radiating to back) amylase/lipase elevated, characteristic finding on CT
Chronic pancreatitis chronic inflammatory process leading to irreversible fibrosis, loss of function and structure
pancreatic adenocarcinoma (risk factors) tobacco use, chronic pancreatitis, diabetes in non-obese, hereditary
Pancreatic adenocarcinoma in head of pancreas painless jaundice
pancreatic adenocarcinoma in tail of pancreas abd pain, incidental finding
Inflammatory bowel diseases Ulcerative colitis and crohns disease
Ulcerative colitis chronic inflammatory disorder that affects the colon, most common in young adults
Where does ulcerative colitis begin rectum
ulcerative colitis symptoms diarrhea, rectal bleeding, mucous in stool, tenesmus, urgency, abd pain, fever, wt loss
ulcerative colitis signs if mild to moderate- deceptively well looking, may have tenderness and blood on exam, if severe- pt looks ill with tachycardia, fever, orthostasis, wt loss, diffuse, abd tenderness
UC and cancer Increases risk!! screening 8-10 years after diagnosis
Toxic megacolon potentially fatal complication of UC, acts like severe colitis with abd distention, reduced bowel sounds, pain, and constipation
Crohn's disease can involve any portion of the GI tract from mouth to anus
skip areas Crohns
granulomas (totes classic) crohns disease
Presentations of CD ileal or ileocolonic disease, colonic disease, perianal disease
ileocolonic disease sx (CD) small bowel obstruction, anorexia, frequent loose stools, wt loss, acute RLQ pain, mimicking appy
colonic disease sx (CD) diarrhea often bloody, wt loss, abd pain,
perianal disease sx (CD) fissures, fistulas, ulcers, stenosis, abscess
Skin lesions of IBD: pyoderma gangrenosum appears as a papule, pustule, or nodule mostly on leg, progresses to an ulcer with undermined borders, development of large ulcer with minor trauma (often occurs w/o association of bowel sx)
Skin lesions of IBD: erythema nodosum women! tender subcutaneous nodules with erythematous appearance (associated with flares)
Skin lesions of IBD others psoriasis, metastatic crohns disease, sweets syndrome (fever leukocytosis tender red plaques with neutrophilic infiltrate) epidermolysis bulosa acquisita
Extra-intestinal manifestations of IBD eye (episcleritis, scleritis, uveitis) joints (arthritis) primary sclerosing cholangitis
Primary sclerosing cholangitis chronic inflammation of biliary tree involving intrahepatic and/or extra hepatic ducts (consider in UC pts with abnormal liver tests)
Microscopic colitis s/sx chronic watery diarrhea, abd pain, wt loss, endoscopically and radiologically normal colon, histology shows mucosal inflammation
Diarrhea pathophysiology an increase in intestinal fluid and/or transit time secondary infection, structural change, alteration in GI milieu, iatrogenic, endocrinopathy, systemic illness, malabsorptive conditions
Acute Diarrhea less than 2 weeks duration could be infectious, viral, protozoal, or bacterial
Rotavirus primarily infects children 6m-2yrs
Rotavirus invades epithelium and damages villi of proximal small intestine, 2-3 day prodrome of fever, vomiting, non-bloody diarrhea for 1-5 days
Norovirus could be airborne, fecal oral, or waterborne 24-48 hour incubation 12-60 hour illness, vomiting common
Protozoal Giardia lamblia relapse diarrhea, fever vomiting uncommon, profuse watery diarrhea then in chronic phase foamy greasy foul smelling diarrhea, abd cramps, distention, flatulence, malaise
food poisoning sx w/n 1-6 hours preformed toxin, staph aureus, vomiting major complaint no fever
food poisoning sx in 8-16 hours organism in food toxin after ingestion, clostridium perfringens, vomiting less, abd cramps, no fever
ETEC contaminated water or food gives watery diarrhea and abd cramps, fever, n/v, incubation 1-3 days sx lasts 3-4 days
Leading cause of travelers diarrhea ETEC
Vibrio cholera water with stool, shellfish can give rice water stool (hyper secretion of H2O and Cl) dehydration with hypokalemia, metabolic acidosis, shock
Treat (shorten) vibrio tetracycline
Acute inflammatory diarrhea caused by invasive or toxin producing bacteria, fever bloody diarrhea, usually less than 2 weeks, diarrhea in small volume cramps urgency tenesmus
EHEC cause by unpasterized milk, under cooked meat, course varies from asymptomatic to diarrhea to hemorrhagic colitis, self limiting to 5-7 days
Treating EHEC NOOO can increase risk of hemolytic uremic syndrome
C. diff 7-10 days after antibiotics, greenish could smelling watery diarrhea with abd cramps some with fulminant disease (fever, hemogynamic instability, abd distention, pain, tenderness)
Dx C. diff stool glutamate colitis if positive test a toxin specific testing
Shigella elevated WBC, high fever, seizures, mostly self limiting 3-5 days
Treat shigella bactrim- resistance? azithro or FQ
Campylobacter jejuni most pts recover in less than 1 week, 20% relapse, associated with severe pain like appendicitis can mimic IBD
Salmonella enterica (S typhi) enteric fever, maliase, HA, cough, n/v, abd pain, bradycardia, splenomegaly, abd distension...raw eggs
Entamoeba histolytica tropic or subtropic conditions, fecal oral route, ingestion of cysts from contaminated food, if penetrates intestinal walls diarrhea, dysentery
Intestinal amebiasis incubation 1-4 weeks, gradual abd pain, diarrhea, fever is uncommon, remission and recurrence, if severe: dysentery, fever, vomiting, abd pain, tenderness, hepatomegaly, hypotension
Intestinal amebiasis extraintestinal complications amebic liver abscess, less common: brain, lung, GU involvement
Chronic diarrhea: Meds LOTS! antibiotics, SSRIs, NSAIDs, PPIs, Metformin, ARBs, Cholinesterase inhibitors
Chronic diarrhea: Osmotic conditions retention of luminal fluid, elevated osmotic gap, stool volume decrease with fasting, bloating, abd distention, flatulence
Chronic diarrhea: Secretory Conditions increase volume watery diarrhea with normal osmotic gap, increased intestinal secretions or decreased absorption, excess NaCl secreted into lumen (neuroendocrine tumors that stimulate intestinal or pancreatic secretion, zollinger ellison)
Chronic diarrhea: inflammatory conditions malignancy- hematochezia, abd pain, wt loss, +/- fever IBD
Chronic diarrhea: malabsorptive conditions wt loss, osmotic diarrhea, high fecal fat, abnormal labs (small mucosal intestinal diseases, intestinal resections, SIBO, pancreatic insufficiency)
Malabsorptive: celiac disease gluten intolerance autoimmune destruction of villi, constipation, diarrhea, fatty foul smelling, abd pain, gas, N/V, mouth ulcers, wt loss, fatigue, derm hepetiformis
Chronic diarrhea: motility disorders history of systemic disease or prior abd surgery, IBS (dx of exclusion)
Chronic diarrhea: chronic infections abd pain +/- fever +/- wt loss +/- BRBPR
Chronic diarrhea: factitious artificially created, laxative dependence?
Most common cause of CRAP constipation (Chronic recurrent abd pain)
Tx constipation dietary and life style changes, review all meds and discontinue problematic ones, prescribe meds if needed
when to refer for constipation alarm sx, refractory sx, needs anorectal testing
Created by: duanea00