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