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BR-GI
5/18/06
| Question | Answer |
|---|---|
| Drugs for treating alcohol abuse | Disulfaram |
| Antibiotics for use in GI | ampicillin, ciprofloxacin, doxycycline, erythromycin, metronidazile, trimethoprim-sulfa, vancomycin |
| Antiinflammatories for use in GI | prednisone, sulfasalazine |
| Anti-nausea drugs | Ondasetron, Prochlerperazine |
| Drugs for treating colon cancer | 5-fluorouracil, levamisol |
| Drugs for treating Helicobacter pylori infection | Bismuth, clarithromycin, amoxicillin, tetracycline, metronidazole, omeprazole |
| Laxatives | Docusate, Lactulose, Magnesium hydroxide |
| Antidiarrheals | Loperamide |
| Inhibitors of gastric secretion | Aluminum hydroxide, Atropine, Cimetidine, Magnesium hydroxide, Lansoprazole, Metoclopramide, Octreotide, Misoprostol, Omeprazole, Ranitidine, Sucraflate |
| H2 Blockers | Cimetidine, Ranitidine, Fomatidine, Nizatidine; Uses = peptic ulcer, gastritis, mild esophageal reflux |
| H2 Blocker MOA, Toxicity | Reversible block of histamine H2 receptors; (Toxicity = cimetidine inhibits P450, is antiandrogenic, and dec renal creatinine clearance); the others are ok) |
| Proton pump inhibitors | Omeprazole, Lansoprazole; Uses = Peptic ulcer, gastritis, esophageal reflux, Zollinger-Ellison syndrome |
| Proton pump inhibitors: MOA | irreversibly inhibits H+/K+ ATPase in stomach parietal cells |
| Bismuth and Sucralate | Uses: increase ulcer healing |
| Bismuth and Sucralate MOA | binds to ulcer base, provides physical protection and allows HCO3- secretion to reestablish pH gradient in mucus layer |
| Misoprostol | Uses: prevents NSAID-induced peptic ulcers; maintains patent ductus arterisus; can induce labor |
| Misoprostol: MOA and toxicity | PGE1 analog; increases production and secretion of gastric mucus barrier; (Toxicity = diarrhea; contraindicated in women of childbearing age d/t abortifactant potential) |
| Infliximab | Uses: Crohn's disease, rheumatoid arthritis |
| Infliximab: MOA, Toxicity | monoclonal Ab to TNF-a, proinflammatory cytokine; (toxicity = respiratory infxn, fever, hypotension) |
| Sulfasalazine | uses: ulcerative colitis, Crohn's dz |
| Sulfasalazine: MOA and Toxicity | combo of sulfapyridine (antibacterial) and mesalamine (anti-inflammatory); (toxicity = malaise, nausea, sulfonamide toxicity) |
| Ondansetron | Uses: controls vomiting postoperatively and in pts on chemotherapy (you can gO ON DANCing) |
| Ondansetron: MOA and Toxicity | 5-HT3 antagonist; powerful central-acting antiemetic; (Toxicity = HA and constipation) |
| Antacid overdose | affects absorption, bioavailability or urinary excretion of other drugs by altering gastric and urinary pH or by delaying gastric emptying |
| Overdose on Aluminum hydroxide antacid | constipation ("minimum" amount of poo), hypophosphatemia, hypokalemia |
| Overdose of magnesium hydroxide antacid | diarrhea (Mg = must go to bathroom), hypokalemia |
| Overdose of Calcium carbonate antacid | hypercalcemia; increased rebound acid, hypokalemia |
| The Boundaries of the Epiploic Foramen of Winslow (opening of lesser sac) | Hepatoduodenal ligament (anterior; containing common bile duct, common hepatic artery and portal vein); Caudate Lobe of Liver (superior); Duodenum (inferior), IVC (posterior) |
| Foregut | esophagus --> common bile duct at 1st part of duodenum; pancreas is fused from dorsal/ventral buds; Blood = Celiac trunk; Nerves = vagal parasympathetics, thoracic n, splanchnic sympathetics |
| Midgut | 2nd part of duodenum --> splenic flexure of colon; Blood = superior mesenteric artery; Nerves = vagal parasympathetics; thoracic splanchnic sympathetics |
| Hindgut | distal 1/3 of colon --> rectum & pectinate line; Blood = inferior mesenteric artery; Nerves = pelvic splanchnic (S2-S4) parasympathetics and lumbar splanchnic sympathetics |
| Ectodermal derivatives in the GI system | Oropharynx (anterior 2/3 of tongue, lips, parotid gland, tooth enamel) and Anus, distal rectum (outward from pectinate line) |
| Hormones of GI System | Nitrous oxide, Gastrin, CCK, Secretin, ACh (parasymp), VIP, NE (symp) |
| Nitrous oxide in GI | causes smooth muscle relaxation of LES |
| Gastrin in GI | secreted in response to gastric distention, vagal stimulation and AA entering the stomach; It causes gastric H+ secretion |
| CCK (cholecystokinin) in GI | secreted in response to AA and FA entering duodenum; causes gallbladder contraction and pancreatic secretionof enzymes and HCO3- |
| Secretin in GI | secreted in response to H+ and FAs entering duodenum; causes pancreatic secretion of HCO3- and inhibits gastric H+ secretion |
| ACh parasympathetics in GI | increases saliva production; inc gastric H+ secretion, inc pancreatic enzyme and HCO3- secretion, causes gallbladder contraction; allows for gastric receptive relaxation; stimulates enteric plexuses for peristalsis; relaxes sphincters |
| VIP (vasoactive intestinal peptide) | secreted by smooth muscle and nerves of intestines; relaxes intestinal smooth muscle, causes pancreatic HCO3- secretion and inhibits gastric H+ secretion |
| Sympathetic NE in GI | increases production of saliva; decreases splanchnic blood flow in fight/flight response; decreases motility; constricts sphincters |
| Presentation of congenital malformations of GI | all present during neonatal period EXCEPT meckel's diverticulum which can remain asymptomatic for life |
| Hypertrophic pyloric stenosis | projectile vomiting, palpable knot in pyloric region |
| Extrahepatic biliary atresia | dark urine, clay-colored stool, jaundice; incomplete recanalization of bile duct |
| Annular pancreas | duodenal obstruction by a constrictive ring d/t abnormal fusion of ventral/dorsal pancreatic buds |
| Meckel's diverticulum | persistant remnant of vitelline duct; outpouching (true diverticulum) of ileum; ulcers/bleeds; 50% contain gastric or pancreatic tissue |
| Rule of 2s for meckel's diverticulum | 2ft from ileocecal junction, 2 inches long, 2% of population, 2 types of ectopic tissue |
| Malrotation of midgut | a/w Volvulus (twisting of intestine & obstruction); normal rotation = 270*; cecum and appendix lie in upper abdomen |
| Intestinal stenosis or atresia (ex: Duodenal atresia) | a/w Down's syndrome and "double bubble" sign on xray; failure of recanalization; may cause FTT |
| Hirschsprung's Disease (congenital or toxic megacolon) | failure of neural crest cells to migrate to colon; no peristalsis; bowel movement precipitated on digital exam |
| Anal agenesis | no opening d/t improper formation of urorectal septum; may cause fistulas into bladder, vagina or urethra |
| Esophagus composition | upper 1/3 = skeletal m; middle = skeletal/smooth m; lower 1/3 = smooth m; |
| Achalasia | LES cannot relax = dysmotility in esophagus and food doesn't enter stomach (progressive dysphasia); "bird beak" appearance on barium swallow xray; 2* may occur from Chagas Disease; a/w inc risk of esophageal carcinoma |
| Gastric secretion phases | Cephalic (sight, smell, taste, thought ); Gastric (entry of food into stomach); Intestinal (food entering duodenum sends feedback for gastrin secretion) |
| HCL | secreted by parietal cells in fundus; stimulated by GASTRIN, HISTAMINE, VAGAL STIMULATION |
| Inhibition of gastric HCL secretion | Omeprazole (PPI), Cimetidine (H2 blocker), chyme in small intestine via GIP (gastric inhib peptide) and Secretin |
| Intrinsic factor | secreted by parietal cells of fundus; binds to vitamin B12 (extrinsic factor); the complex is absorbe din terminal ileum |
| Pepsinogen | secreted by chief cells in stomach; it is converted to pepsin by low pH to DIGEST PROTEINS |
| Gastrin | secreted by G cells of antrum and pylorus; Stimulates release of HCL from parietal cells |
| Somatostatin | secreted by many cells in GI tract; has global INHIBITORY EFFECT |
| Motilin | stimulates migrating motor comlexes during inter-digestive periods to flush undigested food thru GI |
| Sialolithiasis | blockage of salivary gland; acute pain; usus submandibular gland or Stenson's duct of parotid; induce passage of stone w/salivation (ex: suck on lemon) |
| Pleomorphic adenoma | mc salivary gland tumor; a/w radiation exposure; benign recurring mixed cell tumor of parotid; facial nerve injury; 20-40yo women |
| Most common benign tumor of stomach | leiomyoma |
| Esophageal variceal bleeding | a/w portal HTN (caput medusa, ascites); hemetemesis, Tx = vasopressin; do endoscopy to r/o ulcers |
| Boerhaave's syndrome | complete rupture of esophagus d/t severe retching; presents as left pneumothroax; predisposition related to GERD |
| Mallory-Weiss syndrome | laceration of gastroesophageal junction d/t severe retching in ALCOHOLICS |
| Acute gastritis | "coffee-ground" vomitus; a/w NSAIDs, smoking, alcohol, Curling (burn) or Cushing (brain) ulcer; erosive, necrotic hemorrhage (seen in nasogastric tube) |
| Chronic gastritis: Type A | fundal; autoimmune; a/w pernicious anemia; non-erosive mucosal inflammation and atropy; risk for carcinoma |
| Chronic gastritis: Type B | antral; H. pylori; non-erosive mucosal inflammation and atropy; risk for carcinoma |
| Gastric ulcers | 70% d/t H. pylori; also a/w bile, aspirin or NSAIDs; Post-prandial bleeding and perforation; Pain with food; NOT precancerous |
| Dumping syndrome | post-vagotomy; quick passage of hypertonic food into small intestine causing distention d/t osmotic flow into lumen; N/D, palpitations, sweating, lightheaded, reactive hypoglycemia; can be prevented by eating small meals and liquids separately |
| Oral cancer | a/w smoking, chew, alcohol; SSC usu involving tongue; leukoplakia is a precursur lesion |
| Esophageal adenocarcinoma | d/t Barrett's esophagus (GERD complication); Columnar metaplasia of esophageal squamous epithelium in distal 1/3 of esophagus; whites |
| absorption in the stomach | very little water and ethanol |
| absorption in the ileum | most nutrients are absorbed prior to arrival; this is a reserve for absorption if needed in a healthy person; BILE SALTS and B12 are specifically absorbed here |
| absorption in the colon | there is a fixed daily capacity for H2O absorption; when it is exceted it is excreted |
| Hiatal hernia | sliding form if GEJ is most common; a/w smoking, obesity, retrosternal pain (worse supine); can cause GERD |
| Duodenal ulcers | 90% a/w H. pylori, hypersecretion of acid, NSAIDs, ZE syndrome; coffee ground vomitus; Smooth Border w/Clean Base; black stool; Pain relieved with food; NOT precancerous |
| Treatment of H. pylori | triple therapy: PPI (omeprazole) and 2 of the following Abx (clarithromycin, amoxicillin, metronidazole) |
| Ischemic bowel disease | atherosclerosis of celiac artery or mesenteric artery; watershed areas at splenic flexure or rectosigmoid junction |
| Diverticulitis | outpouching of colon; fecalith; usu Sigmoid colon; FALSE diverticula (pockets of mucosa and submucosa herniated thru mucosal layer) |
| Appendicitis | obstruction (fecalith or lymphoid hyperplasia); periumbilical pain that moves to McBurney's point in LRQ once parietal peritoneum gets irritated; psoas or obturator sign; DDx in females = ectopic pregnancy, ovarian torsion, ruptured cyst, PID |
| Small bowel obstruction versus large bowel obstruction | d/t adhesions versus the result of neoplasms |
| Ileus | common cause of temporary small bowel paralysis that occurs post-operatively |
| Adenocarcinoma of colon and rectum | d/t chronic inflammatory bowel dz, diet, age, familial polyposis; increased CEA (assessment not dx); Restrosigmoid tumors = annular/obstructive; Right sided = blood in stool; 3rd mc cause of cancer death (after lung, breast/prostate) |
| Carcinoid tumor | arises from neuroendocrine cells and release histamine, serotonin, prostaglandins; Inc 5-HIAA in urine; flushing of face, hypotension; most commonly in appendix (also ileum, rectum, bronchus); tryptophan deficiency = niacin deficiency = Pallagra |
| Diverticulosis | mc cause of bleeding from lower GI; can be differentiated from diverticulitis based on present of blood |
| Osmotic diarrhea | non-absorbed solutes inc intraluminal oncotic pressure, causing an outpouring of water |
| Secretory diarrhea | active ion secretion causes obligatory water loss |
| Exudative diarrhea | sloughing of colonic mucosa d/t inflammation and necrosis, usu d/t infxn |
| How many bugs required for diarrhea? Salmonella versus Shigella | 100,000 versus 100 |
| Vibrio cholerae exotoxin | activates adenylate cyclase in crypt cells; an inc in cAMP activates Cl-secretory channels and Na and Water enter lumen causing osmotic diarrhea |
| Shigella | shiga-toxin; bloody diarrhea w/fever up to 2wks; Tx = bismuth, ampicillin; Dx = fecal leukocytes and stool culture |
| Salmonella | bloody diarrhea; Tx = supportive only, no opiates; a/w eggs or poultry; Dx = stool culture; immunocomp more susceptible |
| Campylobacter jejuni | bloody diarrhea for up to 4wks; Tx = supportive or erythromycin after 7days; #1 cause of food-borne diarrhea in US (meat); a/w Guillain-Barre |
| Vibrio cholerae | Watery (rice-water) diarrhea; vomiting, dehydration in 12-48hrs; d/t Toxin; Tx = supportive, no opiates |
| Clostridium difficile | Watery diarrhea; Pseudomembranous colitis; Tx = metronidazole, oral Vancomycin; d/t exotoxin A, B |
| Enterotoxigenic E. coli | Watery traveler's diarrhea for 3-6days; Tx = Bismuth, TMP-sulfa, Doxycycline, Ciprofloxacin (use Abx to reduce duration to 1-2days) |
| Entrohemorrhagic E. coli | Bloody diarrhea d/t Shiga toxin from O157:H7 strain; Tx = supportive; a/w uncooked hamburger; Dx = culture stool |
| Yersinia enterocolitica | Bloody diarrhea; Tx = supportive, no opiates; a/w food contaminated by animal feces (indistinguishable from Salmonella or Shigella) |
| Rotavirus | Severe dehydrating diarrhea; vomiting; low fever; Tx = supportive only; mcc of diarrhea in INFANTS in winter (fecal oral) |
| Normwalk virus | mild diarrhea; Tx = supportive; affects older kids/adults; epidemics in 3rd world (fecal oral) |
| Entamoeba histolytica | phagocytoses RBCs, resistant to acid & excysts in cecum causing FLASK shaped ULCERS & Bloody diarrhea; can enter portal v. & abscess R lobe of liver, R diaphragm, lungs, brain; Tx = Metronidazole; d/t ingestion of viable cysts via fecal-oral |
| Giardia lamblia | Watery, foul-smelling diarrhea for wks - months; Tx = metronidazole; Fecal-oral often transmitted via camping; the trophozoite is pair-shaped w/4 flagella and 2 nuclei resembling eyes |
| Cryptosporidium | Watery diarrhea w/ large fluid loss (worse in immunocompromised); Tx = supportive; |
| Inflammatory bowel diseases | Crohn's and Ulcerative colitis; d/t activation of immune system and release of cytokines/inflammatory mediators |
| Crohn's disease | diarrhea, malabsorption, obstruction; "mouth to anus;" full thickness inflammation; GRANULOMAS, Cobblestone; SKIPPED areas; FISTULAS; |
| Ulcerative colitis | bloody, mucus diarrhea; wt loss, toxic megacolon; COLON and RECTUM only; Mucosal inflammation, CRYPT abscess; pseudopolyps; BIG INC risk of CANCER |
| Associated systemic manifestations of inflammatory bowel disease | arthritis, eye lesions, erythema nodosum, pyoderma gangrenosum, (sclerosing cholangitis = ulcerative only) |
| Medical Treatment of Inflammatory Bowel Disease | Sulfasalazine, Steroids, Metronidazole |
| Abetalipoproteinemia | AR; lack of ApoB; defective chylomicron assembly = enterocytes congested w/lipid; Acanthocytes ("burr" cells) in blood; NO CHYLOMICRONS, VLDL or LDL in blood; |
| Celiac disease (non-tropical sprue) | Gluten sensitivity; foul, pale poo; BLUNTED intestinal VILLI; a/w HLA-B8 and DQW2; predisposition to Tcell lymphoma, GI and breast cancer |
| Disaccharidase deficiency | enzyme deficiency; bacterial digestion of unabsorbed disaccharide; diarrhea, bloating; most commonly lactase deficiency |
| Tropical sprue | affects small intestine; may cause vitamin deficiencies and megaloblastic anemia; possibly infectious |
| Whipple's disease | systemic dz d/t Tropheryma whippelii (found in MQs); older white males w/diarrhea, wt loss, lymphadenopathy, hyperpigmentation |
| Bacterial overgrowth malabsorption syndrome of small intestine | usu d/t stasis, raised pH, impaired immunity or CLINDAMYCIN therapy; causes inflammatory infiltrate in bowel wall; Tx = Abx |
| Tubular adenoma | most common benign GI polyps; usu multiple and pedunculated |
| Tubulovillous adenoma | GI polyps with a risk of malignancy; shares features of both tubular and villous adenomas |
| Villous adenomas | highly MALIGNANT GI polyps; "sessile" tumors; finger-like projections |
| Familial adenomatous polyposis | AD; 100s of polyps in colon; 100% chance of malignancy |
| Turcot's syndrome | AD polyposis; w/ CNS TUMORS; 100% chance of malignancy |
| Gardner's syndrome | AD polyposis; a/w soft tissue and BONE TUMORS; 100% chance of malignancy |
| Peutz-Jeghers syndrome | AD polyposis; benign hamartomatous polyps is small intestine; HYPERPIGMENTED mouth, hands, genitalia; tumors in uterus, breast, ovaries, lung, stomach, pancreas; NO malignant potential |
| Familial nonpolyposis syndrome | AD polyposis; Defective DNA repair causing proximal colonic lesions; 50% chance of malignancy |
| Portal triad | branch of hepatic artery, branch of hepatic duct, branch of portal vein |
| Portal lobule | connects three hepatocytes via their central veins |
| Portal acinus | connects 2 hepatocytes via their central veins and portal triads |
| Source of unconjugated jaundice | Gilbert's syndrome, Crigler-Najjar syndrome, Physiologic jaundice of newborn and Hepatitis |
| Sources of conjugated jaundice | Dubin-Johnson syndrome, Obstruction of common bile duct; Hepatitis |
| Glycolysis pathway | activated as food is absorbed; energy is stored as glycogen in liver |
| Glycogenolysis | provides food for teh periods btw regular meals |
| Gluconeogenesis | after 30hrs of fasting, all glycogen is depleted and this pathway becomes the only source of blood glucose |
| Description of Glycolysis | glucose is broken down to form pyruvate and energy is released; requires 2 ATPs (gluco/hexokinase and phosphofructokinase-1) |
| Rate limiting step in glycolysis | enzyme in glycolysis; Phosphofructokinase-1 (PFK1); requires ATP, (+) AMP, F2,6BP; (-)ATP, citrate |
| Glucokinase (liver only) and Hexokinase (entire body) | enzyme in glycolysis; requires ATP; (-) G6P |
| Pyruvate Kinase | enzyme in glycolysis; PRODUCES ATP; (+) F1,6BP; (-) alanine, phosphorylation, ATP |
| Pyruvate dehydrogenase | glycolysis enzyme; (+) pyruvate, insulin, ADP; (-) NADH, acetyl-CoA, phosphorylation |
| Description of Gluconeogenesis | glucose is formed after 4-6hrs of fasting; key enzymes include: Pyruvate carboxylase, Phosphoenolpyruvate carboxykinase; Fructose-1-6-bisphosphatase, Glucose-6-phosphatase |
| Pyruvate carboxylase | gluconeogenesis enzyme; requires BIOTIN, CO2 and ATP; (+) acetyl-CoA |
| Phosphoenolpyruvate carboxykinase (PEPCK) | gluconeogenesis enzyme; REQUIRES GTP; (+) cortisol, glucagon |
| Fructose1,6bisphosphatase | gluconeogensis enzyme; (+) glucagon; (-) AMP, F2,6BP |
| Glucose-6-phosphatase | gluconeogenesis enzyme; (+) glucagon |
| Description of Glycogenolysis | Glucose is produced from glycogen stores after 2-3 hours of fasting; key enzymes include: Glycogen phosphorylase and phosphoglucomutase |
| Glycogen phosphorylase | glycogenolysis enzyme; (+) AMP, phosphorylation |
| Phosphoglucomutase | glycogenolysis enzyme; converts G1P to G6P |
| Gaucher's disease | defective GLUCOCEREBROSIDASE; accumulate glucocerebroside; hepatosplenomegaly, bone erosion, "Gaucher's cells" w/wrinkled paper appearance in liver, spleen, bone marrow |
| Niemann-Pick Disease | defective SPHINGOMYELINASE; "Foamy Histiocytes" in liver, spleen, nodes, skin; hepatosplenomegaly, anemia, Neuro deterioration |
| von Gierke's Disease | defective Glucose-6-Phosphatase (part of GNG); accumulate glycogen in liver/kidney; Hepatomegaly, HYPOGLYCEMIA |
| Cori's Disease | defective DEBRANCHING enzyme; accumulate glycogen in liver/striated muscle; Hepatomegaly, HYPOGLYCEMIA, Can't Grow |
| Pompe's Disease | defective a-1,4-glucosidase (lysosomal enzyme); accumulate glycogen in liver an striated muscle; CARDIOMEGALY; death d/t heart failure b/f 3yo |
| Galactosemia | defective Galactose-1-phosphate uridyl transferase; Accumulate galactose-1-phosphate in many tissues; CATARACTS, Cirrhosis, MR, FTT |
| PKU | defective Phenylalanine hydroxylase; accumulate Phenylalanine; MR, cerebral myelin degeneration |
| Maple Syrup Urine Disease | defective Branched chain a-ketoacid DH; cannot mebatolize Leu, Iso, Val; Neurologic sx; high mortality |
| McArdle's Disease | a glycogen storage dz like von Gierke's, Pompe's and Cori's, but has no GI manifestations; it is a deficiency of muscle glycogen phosphorylation w/accumulation of glycogen in skeletal muscle |
| Viral hepatitis | can lead to DIRECT hyperbilirubinemia, elevated LFTs, icterus, hepatomegaly, but NOT ascites; it ranges from multifocal hepatocellular necrosis w/Councilman bodies (HAV, HBV) to Ballooning degeneration (HBV, HCV) to Piecemeal necrosis (HCV) |
| Hepatitis A | ssRNA; fecal oral; IgM anti-HAV; mild self-limiting; vaccine available; 14 day incubation |
| Hepatitis B | **dsDNA**; sexual and blood transmission; Dx = HBsAg, anti-HBsAg, IgM anti-HBcAg; moderate; carrier, chronic (1-2%), cancerous states; vaccine and immune globulin available; Dane particle; has Reverse Transcriptase; 2-3 month incubation |
| HBeAg | correlated with viral infectivity |
| anti-HBsAg | indicative of recovery and immunity |
| IgM anti-HBcAg | asks as marker for hepatitis infection during window period |
| Hepatitis C | ssRNA; blood and sexual transmission; most frequent cause of transfusion-mediated hepatitis; Dx = anti-HCV; carrier, chronic (80-90%), cancerous states; no Tx or prophylaxis |
| Hepatitis D | incomplete RNA, requires coinfection with HBV for replication; sexual and blood transmisson; Dx = anti-delta Ag; Severe dz; carrier states, no cancer; Tx = HBV immune globulin + vaccine |
| Hepatitis E | ssRNA; fecal-oral; no diagnostic test; mild dz; no carrier, chronic, cancer state or treatement; problem in 3rd world |
| Cirrhosis | liver dz characterized by fibrosis and disorganization of lobular and vascular structures d/t destruction and regeneration of hepatocytes; often leads to portal HTN |
| Chronic alcoholic cirrhosis | MICRONODULAR FATTY liver; dec estrogen metabolism, dec coag factors; Jaundice, bleeding, gynecomastia, edema, ASTERIXIS (flappy hands); portal HTN, encephalopathy; MCC of cirrhosis in USA |
| Wilson's Disease and cirrhosis | Decreases CERULOPLASMIN; copper deposits (liver, basal ganglia = EPS), Kayser-Fleischer rings on cornea; AR disease |
| Hemochromatosis and cirrhosis | Familial; inc total Fe and dec TIBC; inc Ferritin; inc transferrin saturation; IRON DEPOSITS (liver), DM, skin pigmentation, cardiomyopathy; "Bronze Diabetes" w/inc risk of hepatocellular carcinoma |
| Primary Biliary Cirrhosis | AUTOIMMUNE; Anti-mitochondrial Abs; Jaundice, pruritis, hypercholesterolemia; women, middle aged |
| Posthepatic Cirrhosis | Chronic active hepatitis d/t HBV or HCV; Jaundice, pruritis; most likely cause of cirrhosis to lead to hepatocellular carcinoma |
| a-1-antitrypsin deficiency and cirrhosis | AR; decreased inactivation of elastase; Jaundice, PANACINAR EMPHYSEMA, Pancreatic manifestations; More severe in homozygote (PiZZ) |
| Congestive heart failure and cirrhosis | Passive congestion; "NUTMEG LIVER;" most often d/t Right heart failure |
| Three major collateral circulation pathways utilized in cirrhosis pts | Esophageal varices, Hemorrhoids, Caput medusae |
| Esophageal varices pathway | left gastric --> esophageal plexus --> azygous --> SVC |
| Hemorrhoidal blood pathway | inferior mesenteric --> superior rectal --> inferior rectal --> IVC |
| Caput medusa blood pathway | Ligamentum teres --> superficial abdominals --> SVC or IVC |
| Hepatobiliary diseases | variable in presentation and etiology; cholelithiasis is common and curable w/surgery whereas hepatocellular carcinoma is much less common and usu fatal |
| Cholelithiais | gallstones; fat, fertile female >40; Steatorrhea, N/V; bile duct obstruction, jaundice, possible cholangitis/cholecystitis; malignancy; +Murphy's sign; Large stones = cholesterol; Pigment stones = hemolytic anemia or excess bilirubin; MOST = Mixed stones |
| Pigment gallstones (cholethiasis) occurring in kids | may be a/w congenital hemoglobinopathy (ex: sickle cell or thalassemia) |
| Hepatocellular Adenoma (hepatoma) | Benign; 20-30yo F on OCPs; incidental finding d/t pain or bleed; 10% malignant; Tx = stop OCP use |
| Adenocarcinoma of Gallbladder | d/t Gallstones; Obstructive jaundice and enlarged gallbladder; "Courvoisier's Law" = obstruction of common bile duct enlarges gallbladder while obstructing stones do not (d/t scarring of gallbladder) |
| Most common source of hepatic malignancy | metastasis |
| Hepatocellular Carcinoma | d/t cirrhosis, HBV or HCV, Aflatoxin B (peanut carcinogen); Inc AFP, Jaundice, Abdonimal distention, Ascites; Hematogenous spread |
| Hematogenously spreading carcinomas | Hepatocellular and Renal cell |
| Most common cause of pancreatic pathology in US? | alcohol |
| Acute Pancreatitis | d/t gallstones (obstructing Ampulla of Vater) OR Alcohol abuse; Midepigastric pain radiating to back; Inc SERUM AMYLASE and lipase; hemorrhage may cause Cullen's or Grey Turner's black and blue sign; hypocalcemia; Autodigestion of pancreas |
| Chronic Pancreatitis | d/t ALCOHOLISM in adults; CF in kids; Inc SERUM AMYLASE and lipase; Pancreatic CALCIFICATIONS; epigastric pain, Steatorrhea; IRREVERSIBLE, organ atrophy or pseudocyst |
| Adenocarcinoma of Exocrine Pancreas | more common in smokers; invasive; "Trousseau's Syndrome" = migratory thrombophlebitis; radiating abd pain, obstructive jaundice; elevated CEA; poor Px, 50% head of pancreas; black males w/DM >60yo |
| Insulinoma (endocrine pancreas) | b cell origin; "Whipple's Triad" = Hypoglycemia, CNS dysfxn, reversal w/Glucose; most common islet cell tumor |
| Gastrinoma (Zollinger-Ellison Syndrome) | Gastrin-secreting tumor (islet cell origin); causes recurrent peptic ulcers; part of MEN1 |
| Presence of C-peptide in blood | helps distinguish endogenous insulin secretions (as in insulinoma) from exogenous insulin administration (as seen in Munchausen's syndrome) |
| MEN1 (aka Wermer's syndrome) involves: | neoplasia or hyperplasia of pancreas, the parathyroid and the pituitary |
| Layers of digestive tract | mesentery, serosa (support), "M"yenteric/Auerbach's plexus, outer longitudinal &inner circular muscles ("M"otility), submucosa (support) & "S"ubmucosal/Meissner's plexus (secretions); muscularis mucosae (motility), lamina propria (support), villi (inc SA) |
| Myenteric plexus | coordinates motility along entire gut wall; aka Auerbach's; contains cell bodies of parasymp terminal effector neurons; btw inner (circular) and outer (longitudinal) layers of smooth muscle of GI wall |
| Submucosal plexus | regulates local secretions, blood flow and absorption; aka Meissner's plexus; contains cell bodies of parasymp terminal effector neurons; located btw mucosa and inner (circular) layer of smooth muscle of GI wall |
| Brunner's glands | secrete alkaline mucus; located in submucosa of DUODENUM (the only GI submucosal glands); duodenal ulcers cause hypertrophy of these glands |
| Sinusoids of liver | irregular capillaries w/round pores; no basement membrane; allows macromolecules of plasma full access to surface of liver cells thru space of Disse |
| Peyer's patch | unencapsulated lymphoid tissue in lamina propria and submucosa of SMALL INTESTINE; M cells make antigen; Stimulated B cells differentiate into IgA-secreting plasma cells |
| IgA | produced by plasma cells in Peyer's patches of small intestin; it is transported across epithelium to gut to deal with intraluminal antigens |
| Structures perforating diaphragm: I 8 10 EGgs at 12 | I = IVC at 8th vertebra; EG = esophagus at 10th; A = aorta, azygous, T = thoracic duct all at 12th vertebra |
| Abdominal layers | peritoneum, extraperitoneal tissue, transversalis fascia, transversus abdominus, internal oblique, external oblique, quadratus lumborum, latissimus dorsi, psoas erector spinae; rectus abdominus and sheath; IVC, aorta, sympathetic trunk, superficial fascia |
| Lymph drainage of everything besides right arm and right half of head | thoracic duct |
| Stomach's main blood supply | celiac trunk as L gastric artery; the R gastric artery branches off of celiac trunk's hepatic artery; R gastroepiploic artery comes from gastroduodenal; L gastroepiploic from splenic artery |
| Retroperitoneal structures | 2nd, 3rd, 4th part of duodenum; descending and ascending colon; kidneys and ureters; pancreas (except tail); aorta; IVC; adrenal glands and rectum |
| Pectinate line | where hindgut meets ectoderm |
| Internal versus External hemorrhoid innervation | visceral (painless) versus somatic (painful) |
| Above pectinate line | internal hemorrhoids; adenocarcinoma; Visceral innervation; Superior rectal artery (branch of IMA); Venous drainage to superior rectal v --> inferior mesenteric vein --> PORTAL SYSTEM |
| Below pectinate line | external hemorrhoids (painful); Squamous cell carcinoma; Somatic innervation; Inferior Rectal Artery (from internal pudendal a); Venous drainage = Inferior rectal v --> Internal Pudendal v --> Internal iliac v --> IVC |
| Abdominal Hernias: MDs don't LIe | Medial to inferior epigastric artery = Direct hernia; Lateral to inferior epigastric artery = Indirect hernia |
| Direct Hernia | protrudes thru Inguinal (Hesselbach's) triangle; Medial to inferior epigastric artery; Thru EXTERNAL inguinal ring ONLY; usu older men |
| Indirect Hernia (IN) | INternal (deep) inguinal ring and external inguinal ring and INto the SCROTUM; enters internal ring LATERAL to inferior epigastric artery; occurs in INfants owing to failure of processus vaginalus to close; most common inguinal hernias |
| Hasselbach's inguinal triangle | inferior epigastric artery, lateral border of rectus abdominus, inguinal ligament |
| Free edge of lesser omentum contains | common bile duct, hepatic artery and portal vein |
| most common primary site of oral (excluding lower lip) squamous cell carcinoma | floor of mouth (> tip of tongue, hard palate, base of tongue); usu a/w alcohol, tobacco use, HPV-16 |
| What are the 2 most common causes for bloody stools? | Angiodysplasia (cecum w/cystic spases d/t inc wall tension) AND Diverticulosis |
| What is the most common site for GI cancer, polyps (into lumen) and diverticuli (out of lumen)? | Sigmoid colon |
| mc complication of diverticuli? | diverticulosis; "L-sided appendicitis" in an old person; fistulas can cause "Colovesicle" w/air in urine stream; can rupture causing peritonitis |
| Crohn's disease | 80% terminal ileum, anus; fistulas, segmental, transmural inflammation, colicky pain in YOUNG person d/t narrow lumen, cobblestone, non-caseating GRANULOMAS, ulcers, dilated proximal bowel, string sign, mouth to anus |
| Ulcerative colitis | RECTUM (lower bowel only), bloody diarrhea, non-segmenta, mucosa/submucosa only, PANCLOLITIS = greatest risk for cancer; Pseudopolyps (remnants of mucosa btw ulcers); HLA-B27; Sclerosing Cholangitis/cholangiocarcinoma |
| Intussusception | telescoping of a bowel segment into a distal segment; can compromise blood supply |
| Volvulus | a twisting of a portion of bowel around its mesentery; can lead to obstruction |
| Stomach cancer is almost always...and spreads to...and is a/w...and is given this term when diffusely infiltrative | adenocarcinoma; Supraclavicular node (Virchow's node) and Ovary (Krukenberg's tumor); dietary nitrosamines, achlorhydria, chronic gastritis; linitis plastica |
| Colonic polyps are most commonly... | benign hyperplastic hamartomas in the sigmoid colon |
| Tubular adenoma colonic polyps | look like strawberry on a stalk; they are precancerous; if >2cm they are more likely to become malignant; |
| Juvenile polyp | a hamartoma located in rectum (can come out of butt) |
| Internal hemorrhoid in adult | prolapse, not painful, coats stool with blood |
| External hemorrhoid | painful, thrombosed |
| Villous adenoma colonic polyp | most malignant polyp (50% progress to cancer); found in rectum/sigmoid colon; MUCUS is seen on stool |
| Familial polyposis | >100 polyps; AD; APC suppressor gene (ras and p53 also involved); 100% chance of cancer, must prophylactically remove bowel; expressed in adult life |
| Peutz-Jeghers polyposis | benign; not a risk for cancer; hyperpigmented mouth, hands, genitalia |
| Turcot's syndrome has colonic polyps and | Brain tumors; malignancy approaches 100%; AD |
| Gardner's syndrome has colonic polyps and | bone and soft tissue tumors; malignancy approaches 100%; AD |
| Left sided colon cancer causes... | obstruction (smaller lumen) w/alternating diarrhea and constipation; the cancer is typically annular |
| Right sided colon cancer causes... | bleeds; the larger diameter allows polyps to grow; pt can have Fe deficiency |
| CEA is a tumor marker in colon cancer that is primarily used to... | follow recurrence; pts should eat fiber to decrease lithocolic acid |
| Appendicitis in kids is a/w | viral infections (measles, adenovirus) causing hyperplasia of lymphoid tissue |
| Appendicitis in adults is a/w | fecoliths (similar to diverticulitis); causes ischemia, E.coli and inflammation |
| Bilirubin metabolism; the majority (99%) of bilirubin is in the _ form | unconjugated form d/t destruction of old RBCs; it binds albumin and goes to liver |
| Liver conjugation depends on _ to become water soluble | CYP450; this is direct bilirubin; it shouldn't have access to bloodstream in liver; it travels to gallbladder --> common bile duct --> small intestine --> colonic bacteria |
| Colonic bacteria turns conjugated/direct bilirubin into...and then....which is oxidized into... | unconjugated bilirubin --> colorless urobilinogen --> urobilin (which colors stool; and some goes to kidney to color urine) |
| Obstruction of the common bile duct will result in... | pale stool |
| Jaundice d/t an excess of "unconjugated" bilirubin (~20% conjugated) | this is the result of hemolytic anemia (spherocytosis, sickle cell, ABO/Rh incompatability, enzymes) |
| Jaundice d/t "mixed" bilirubin (20-50% conjugated) | this form is caused by Hepatitis; there is inflammation of the entire liver, so it doesn't want to take up the unconjugated form, yet necrosis of hepatocytes/damage to the bile ducts releases conjugated form |
| Jaundice d/t "conjugated" bilirubin (>50% conjugated) | this form is d/t OBSTRUCTION; Intrahepatic cholestasis (blocked portal triads); Extrahepatic cholestasis (gallstone in common bile duct); Carcinoma of head of pancreas (complete bile duct obstruction); bile backs up into liver/blood = DARK PEE, LIGHT POO! |
| Gilbert's disease | 2nd mc cause of jaundice; AR; UNCONJUGATED; pt can't take up conjugated bilirubin b/c low UDP-glucuronyl transferase; FASTING causes jaundice (get baseline bilirubin and it should double in 24hrs); benign condition |
| the most common cause of jaundice is... | Hepatitis A |
| Dubin-Johnson syndrome | can't get rid of CONJUGATED bilirubin; turns liver black; benign condition |
| Transaminases are a/w | liver cell necrosis; ALT is specific to liver, AST is mitochondrial, but present in muscle, RBCs and liver |
| When a pt has ALT > AST, what is the diagnosis? | Viral hepatitis |
| When a pt has AST > ALT, what is your differential? | cirrhosis, hepatitis, fatty change |
| What can an elevated GGT tell you? | there is obstruction of bile ducts; pt probably has damage d/t alcohol (enzyme located in smooth ER of hepatocytes) |
| What can an elevated AlkPhos tell you? | since it is present in bone, placenta and liver, you MUST see an elevated GGT to diagnose an OBSTRUCION of bile ducts |
| The severity of liver disease? | albumin will be low and PT will be prolonged b/c liver can no longer keep synthesize normal proteins |
| What does the presence of anti-mitochondrial antibody tell you? | the liver disease is a primary biliary cirrhosis |
| Elevated AFP in a liver patient is... | elevated in hepatocellular carcinoma |
| What markers are present in acute HBV infection? | s Ag, e Ag, HBV DNA, core IgM Ab |
| What is present in the window/recovery period in HBV infection? | core IgM Ab |
| What is present in a pt who has recovered from HBV? | core IgG and s Ag |
| What is present in a pt vaccinated against HBV? | surface Ab |
| What will be present in a chronic (>6mo) non-infective HBV patient? | core IgM Ab, surface Ag |
| What will be present in a chronic (>6mo) infective HBV pt? | surface Ag, e Ag, HBV DNA, core IgM Ab |
| What are the protective viral hepatitis antibodies? | anti-HAV IgG, surface Ab to HBV, anti-HEV Ab |
| A definitive host harbors what forms of a parasite? | sexually active ADULT worms that can lay eggs |
| An intermediate host harbors what forms of a parasite? | larval forms |
| Sheepherder's Hydatid disease is a/w | Echinoccus granulosus that resides in sheepdogs in the adult form; herder acquires eggs from petting dog and the larva infect human; ruptured cysts can cause anaphylactic shock |
| Tinea solium hydatid disease is a/w | pig tapeworms; the larvae exist in undercooked meat and are ingested by human definitive host; the host passes eggs to family members and the larvae then form cystocircosis that penetrate bowel, eye, brain, and can cause seizures |
| Nutmeg liver is a term that describes infarcts that occur in the... | posthepatic vasculature (ex: hepatic vein that drains liver); usu a/w RHF or Birth control pills |
| Budd Chiari Syndrome | occlusion of prehepatic (IVC) or posthepatic (hepatic vv) with centrilobular congestion/necrosis; can cause hepatomegaly, ascites, abd pain, liver failure; a/w POLYCYTHEMIA RUBRA, pregnancy, hepatocellular carcinoma |
| A thrombus in the portal vein will cause... | ascites d/t portal hypertension; not a nutmeg liver; these pts have varices, etc |
| What does alcoholism do to the liver? | causes reversible fatty change; elevates NADH, acetate and acetyl-CoA |
| Why would fatty change cause acidosis? | NADH (pyruvate --> lactate --> met acidosis/fasting hypoglycemia) AND acetyl-CoA (ketone bodies/acetoacetic acid inc anion gap acidosis & elevate TGs) |
| Alcoholic hepatitis | Mallory bodies; very bad; encephalopathy, PMN leukocytosis; AST>ALT; systemic; damage is d/t ptn-bound Acetaldehyde; ETO CELLS store vit A, but begin to form collagen ==> Fibrous tissue charachteristic of dz state |
| Cholestasis | Hi ALT/GGT; green liver, blocked common bile duct, backs conjugated bilirubin into liver & enters urine; NO UROBILINOGEN in urine, only CONJUGATED bilirubin = very YELLOW pee & LIGHT poo; hypercholesterolemia d/t back up & itchy skin d/t bile salt reflux |
| What is the most likely cholestasis d/t ulcerative colitis? | primary sclerosing cholangitis; it is the mcc of cholangiocarcinoma in US; a/w bloody diarrhea |
| What is the most common cause of cholangiocarcinoma in the 3rd world? | Clonorchis sinesis (chinese liver fluke) |
| 50yo female, generalized itching, not jaundiced, very hight AlkPhos/GGT, large liver, normal bilirubin w/slightly elevated AST/ALT; what is it? | Primary Biliary Cirrhosis; run a test to detect anti-mitochondrial Ab; dz is d/t granulomatous autoimmune destruction of bile ducts in portal triads (takes yrs to decompensate & cause jaundice) |
| What do birth control pills and anabolic steroids have in common when it comes to liver disease? | they both can cause Intrahepatic Cholestasis AND Liver cell/hepatic Adenomas |
| Intrahepatic cholestasis | benign jaundice w/elevated AlkPhos/GGT in OCP/anabolic steroid user; mcc of jaundice in pregnancy d/t estrogen effect |
| Liver cell/hepatic Adenoma | serious emergency caused by steroid/OCP use; these are glandular masses that can rupture, cause intraperitoneal hemorrhage, hypotensive crises and death |
| What is the diagnosis: a diffusely pigmented adult with type I diabetes? | Hemochromatosis "bronze diabetes" d/t iron overload |
| Hemosiderosis | an acquired Fe overload d/t alcohol; can cause generalized bronzing of skin |
| Hemochromatosis | AR, hemosiderin deposition in liver (micronodular cirrhosis)/pancreas (fibrosis)/skin d/t OH-free radicals; HIGH risk for HEPATOCELLULAR carcinoma |
| What is the typical lab profile for Hemochromatosis pts? Tx? | Hi Fe, Hi Ferritin, Hi % saturation, Low Transferrin synthesis, Low TIBC; Tx = Phlebotomy or Deferoxamine |
| Associated conditions with hemochromatosis | Pancreatic malabsorption/type I diabetes; Skin stimulation of melanocytes/dark pigment; Joints get OA; Restrictive cardiomyopathy |
| Wilson's disease is a condition where | pt cannot get rid of copper d/t low levels of CIRULOPLASMIN (which normally binds 95% of Cu); so, total copper will be LOW and free copper will be HI; Keyser-Fleisher rings, hepatolenticular dz, movement disorder |
| How do you treat Wilson's Disease? | Penicillamine |
| Cirrhosis | never focal, always DIFFUSE; bumps = regenerative nodules (<3cm micro d/t etoh, >3 macro d/t infxn, drugs, risk for HEPATOCELLULAR carcinoma); Liver regenerates non-functional tissue which causes portal HTN |
| Signs of portal hypertension | pitting edema, varices, gynecomastia/impotence (can't metabolize estrogens); ascites w/spontaneous peritonitis (G- rods, E. coli in Adults, S. pneumoniae in Kids) |
| Portocaval shunt exists between... | splenic vein and left renal vein; may relieve portal HTN |
| When is enlarged breast tissue normal in males? | newborns, at puberty, old age |
| Hepatocellular carcinoma | most often develops on top of cirrhosis (Hemochromatosis or Hepatits B or C); nodularity, pale; Ectopic hormones, AFP tumor marker |
| What are the ectopic hormones produces in hepatocellular carcinoma? what is the tumor marker? | erythropoeitin (2* polycythemia) and insulin-like growth factor; AFP |
| What do you do with a pt who is getting worse, has wt loss and a hemorrhagic ascitic peritoneal tap? | run a AFP b/c pt probably has hepatocellular carcinoma |
| Pathogenesis of cholesterol gallstones | too much cholesterol too little bile salts (cirrhosis, crohn's, cholestyamine, obstruction) = yellow stone |
| 25yo female with gallstones, normocytic anemia and splenomegaly, what does she have? | congenital spherocytosis; suprasaturated bilirubin forms BLACK Ca-bilirubinate stones |
| What is best screen for gallstones? | ultrasound |
| What is best screen to see pancreas? | CT |
| Cystic fibrosis | Chrom 7 (3 nucleotide deletion causes Phe deficiency in CFTR and golgi can't modify it, so receptor is degraded) pt loses salt (sweat test), has diabetes type I d/t fibrosis of islets, and growth retardation |
| Why are CF secretions so thick? | CFTR should add salt back to the secretions to keep them viscous; deficiency sucks Na out and no Cl goes in |
| MCC of death in CF pts? | pseudomonas infxn |
| Are CF pts fertile? | 0-5% of males, 30% females d/t thick cervical mucus |
| What are the 2 mcc of Acute pancreatitis | alcohol AND stone in pancreatic duct; presents as epigastric pain that radiates to back; bowel stops peristalsing at duodenum d/t inflammation (sentinal sign on xray w/air fluid level showing); enzymes autodigest pancreas |
| Pt has h/o acute pancreatitis, 10 days later a mass is felt; what do you order? | CT to see if a pseudocyst developed from the inflamed pancreas |
| Chronic pancreatitis | d/t alcohol; presence of dystrophic CALCIFICATIONS, RUQ pain, steatorrhea d/t malabsorption, no bile salt deficiency, hemorrhagic diasthesis d/t vit K deficiency from malabsorption |
| Where are the 2 most common locations for sentinal signs of inflammation on xray in a GI pt? | duodenum (d/t acute pancreatitis) and Appendicitis; both cause "localized ileus" when peristalsis stops |
| What are the 2 mcc of Carcinoma of the head of the pancreas | smoking AND chronic pancreatitis; causes PAINLESS JAUNDICE d/t conjugated bilirubin; LIGHT POO, palpable gallbladder (Courvassier's sign); "C-sign" on barium swallow in duodenum |
| Secondary biliary cirrhosis | d/t extrahepatic biliary obstruction; inc pressure in hepatic ducts causing injury/fibrosis; bacterial ascending cholangitis |
| Reye's syndrome | a/w use of aspirin to treat viral infxn (VZV or Hib); fatal childhood hepatoencephalopathy; fatty liver, hypoglycemia, coma |
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bscaryp