Flashcards in final Deck (262)
Where does jaundice first appear?
conjunctiva of eyes
what other symptom is jaundice classicaly associated with?
T/F: carotenemia does not affect the conjunctiva
what are the 2 most common causes of hepatocellular jaundice?
viral hepatitis and alcoholic cirrhosis
what are 2 examples of obstructive jaundice?
gallstone/gallbladder dz and pancreatic cancer involving pancreatic head
what leads to the so-called "painless jaundice"?
pancreatic cancer involving pancreatic head
what does increased bilirubin levels from excessive breakdown of RBCs cause?
what is the most common cause of acute liver failure?
drug related hepatotoxicity (about 50%). Acetominophen = 40% of cases
what are the tests that assess liver function?
albumin and total serum protein, PT time, bilirubin
what usually causes chronic liver dz to be suspected?
when one of complications occur
T/F: a lack of symptoms for chronic liver dz usually means a benign cause
false - lack of sx is no assurance of benign cause
What are the classic symptoms of chronic liver dz?
fatigue, flu-like symptoms, diffuse RUQ or abdominal discomfort
What occurs in the icteric phase of chronic liver dz?
accumulation of bilirubin in blood and tissues => jaundice. Common sx = pruritis, dark urine, light stools
what percentage of pts with Acute liver failure die?
what are 3 common signs of chronic liver dz?
spider telangiectasia, palmar erythema, dupuytrens contracture
what are 3 complications of chronic liver dz?
portal HTN, esophageal varices, increased risk of primary liver cancer (hepatocellular carcinoma)
how does the liver react to chronic injury?
steatosis, fibrosis, and/or cirrhosis
describe hepatic steatosis
fatty liver w/o inflammation. Lipid accumulation in liver of >5% of livers weight
what is the livers most common response to injury?
what is the most common form of hepatic steatosis?
what is macrovesicular steatosis classically assoc. with?
obesity, type II DM, alcoholism
what is the most common discovery on physical exam of pt w/ macrovesicular steatosis?
non-tender hepatomegaly in an obese, alcoholic, or diabetic pt
what is the "two-hit model?"
possible complications of steatosis - steatosis makes liver sensitive to a second hit from pro-inflammatory molecules
what are the almost universal findings in pts with nonalcoholic fatty liver dz (NAFLD)?
insulin resistance/metabolic syndrome/syndrome x
fatty liver WITH inflammation. Usually presents with chronic unexplained elevations in amino transferase
T/F: fibrosis is synonymous with cirrhosis
false - fibrosis is NOT necessarily synonymous with cirrhosis
what is the predominant clinical reflection of hepatic fibrosis?
is cirrhosis reversible?
cirrhosis is usually IRREVERSIBLE
what are the common causes of cirrhosis in the western world?
alcoholic liver dz and chronic hep c
how many drinks per day have been assoc w/ cirrhosis in women?
how many drinks per day have been assoc w/ cirrhosis in men?
what is the only test that can directly confirm a dx of cirrhosis?
percutaneous liver biopsy
what is the cause of hep A?
fecal oral contamination
what is the cause of hep B?
infected blood or infected blood-bearing fluids
what is the cause of hep C?
infected blood or infected blood-bearing fluids
why is hep c considered very dangerous?
slow spreading, clinically "silent"
what percentage of hep C pts can "clear the virus" from their blood?
are primary or secondary liver tumors more common?
secondary 40x more common
what is the most common site of metastasis in those who die from neoplasms?
what finding strongly suggests a liver tumor?
a bruit or friction rub over the liver
what is biliary colic?
pain assoc w/ transient obstruction of cystic duct. Very symptomatic stage of gallstone dz
what is cholelithiasis?
presence of gallstones in gall bladder
what is pain assoc w/ prolonged obstruction of cystic duct?
what is it called when there is a stone in the common duct?
what is the term that describes obstruction/inflammation of the biliary or hepatic ducts?
are gallstones more common in men or women?
what are the primary bile acids?
cholate and chenodeoxycholate
what kind of bile acids tend to be more hydrophilic?
primary bile acids
what are the secondary bile acids?
deoxycholate and lithocholate
what kind of bile acids tend to be more hydrophobic?
secondary bile acids
what accelerates the formation of cholesterol gall stones and has been linked to prolonged small intestine transit time?
increased deoxycholate levels
what is the only significant mechanism for the elimination of excess cholesterol?
synthesis of bile acids and their subsequent excretion in the feces
an increase in what bile acid might impair gall bladder emptying?
during fasting, what percentage of hepatic bile passes directly to the duodenum?
describe the gall bladder "contractions"
small, slow, and somewhat random changes in basal tone
where is the sphincter of Oddi located?
T/F: gallbladder contraction alone exerts enough force to fully open the sphincter of Oddi
False - it does NOT exert enough force to open the sphincter
what does CCK cause to happen to the sphincter?
relaxation of the sphincter as the gall bladder contracts
after hepatic bile is concentrated, how much of gall bladder bile is water?
what does an increased concentration of cholesterol or mucin cause?
impaired emptying of gall bladder
what percentage of gallstones in the us are cholesterol based?
where do cholesterol stones most often form?
what are black pigment stones assoc with?
what are brown pigment stones assoc with?
infection of gall bladder
what are the 4 stages of formation of cholesterol gall stones?
1. cholesterol supersaturation 2. poss. Formation of biliary sludge 3. microlithiasis 4. "mature" stones
in a pt that is not obese and has normal serum cholesterol levels, is it possible to have cholesterol based gall stones?
what is a common symptom of a pt w/ multiple/faceted stones?
pt complaining of back pain
what are the non modifiable risk factors for cholesterol gall stones?
increasing age, female gender (exposure to estrogen), genetic factors (American Indian tribes, Hispanic populations w/ strong American Indian influence)
what is the first and foremost cause of cholesterol supersaturation?
obesity (decrease BMI and serum triglyceride levels)
how do most pts with gallstones present?
asymptomatic - gallstones don’t leave gallbladder
how is Dx of gallstone dz usually made?
Hx of convincing attack and visualization of gallstones in gall bladder
how sensitive is US in detecting gallstones in the gall bladder?
is it easier to detect gallstones via US when they are in or out of the gall bladder?
more difficult when they have left gall bladder
how long does it take stones to make it through the cystic duct?
30 min - 6 hrs
What will you find on physical exam of a pt with biliary "colic"?
what is the most common disorder resulting from gallstones?
how long does a biliary colic attack last?
30-60 mins, up to 6 hrs
what is the second most common disorder resulting from gallstones?
which attacks last longer, acute cholecystitis or biliary colic?
acute cholecystitis - lasts >6 hrs (12-18 hrs)
how often is Murphys sign present in acute cholecystitis?
where does pain from biliary colic classically refer?
RUQ, R shoulder
what type of pain does biliary colic create?
what type of pain does acute cholecystitis create?
what are the characteristics of a large gall stone?
20-25 mm, rarely leaves gall bladder
what are large gall stones likely to cause?
gall bladder empyema (infection) and result in biliary tract fistula
why is a large gall stone sx profile atypical?
do not cause Hx of "convincing" attack
what can choledocholelithiasis lead to?
liver damage and jaundice
what can microlithiasis greatly increase the risk of?
what does gall bladder hydrops/mucocele do?
inhibits emptying of gall bladder
what has gall bladder sx in the absence of stones?
sphincter of oddi syndrome/biliary dyskinesia
what is carnetts used to assess?
chronic and unremitting abdominal pain
what is considered the gold standard for dx'ing chronic cholelithiasis?
ultrasound (95% sensitive for detecting gallstones IN gall bladder)
what is the sensitivity of ultrasound in detecting stones in the common duct?
what is defined as "attempted auto digestion of the pancreas?"
what is defined as "permanent structural changes often associated w/ chronic alcoholism"?
T/F: pancreatic cancer is often untreatable by the time it is dx'ed
is the pancreas retroperitoneal or within peritoneum?
describe the pain from the pancreas
visceral and poorly localized
how does the pancreas normally feel on palpation?
soft and pliable
what does chronic pancreatitis lead to?
deposition of CT in pancreatic acini and ductules
what leads to the deposition of ectopic fat in the pancreas?
high fat diet or obesity
what happens to ectopic fat during episodes of pancreatic inflammation?
can become necrotic (activated proteases and lipases try to digest phospholipids in cell walls)
what is a classic axiom when referring to the pancreas?
"no stimulation, no secretion"
How much does eating or thinking about eating stimulate pancreatic enzyme production?
up to 70% of max capacity
what occurs during an acute alcoholic episode?
pancreas temporarily ceases fxn
what happens to the pancreas during chronic alcoholism?
how much alcohol does it take to mess up the pancreas?
what is the problem that occurs involving zymogen granules in the pancreas?
can cause premature activation of proenzymes in the pancreas
what is the classic pain referral for inflammation of the pancreatic head?
what is the classic pain referral for inflammation of the pancreatic body?
to the back and/or left flank
what is the classic pain referral for inflammation of the pancreatic tail?
what specific clinical feature allows the clinician to definitively dx pancreatitis?
is acute pancreatitis reversible?
how many cases of acute pancreatitis involve gall stones?
how many cases of acute pancreatitis are d/t alcohol abuse?
how many cases of acute pancreatitis are idiopathic?
what is the most common type of acute pancreatitis?
how many cases of acute pancreatitis are severe?
what is the mortality rate of hemorrhagic pancreatitis?
what will you see with hemorrhagic pancreatitis?
cullens sign, grey-turner sign
what is the cardinal symptom of acute pancreatitis?
epigastric pain of sudden onset, usually lasts >1 day
what is the characteristic patient postion in cases of pancreatitis?
thoracolumbar spinal flexion
T/F: overt rebound tenderness is a common finding with acute pancreatitis
false - uncommon
how does the degree of amylase/lipase elevation correlate with the severity of pancreatitis?
it doesn't correlate
what are 3 common complications of acute pancreatitis?
mortality, pancreatic necrosis, pseudocyst
what are the characteristics of chronic pancreatitis?
self perpetuating, mostly irreversible, and leads to structural changes w/in pancreas
what are the structural changes that occur during chronic pancreatitis?
fibrotic tissue/calcium deposition in pancreas
what are the pathological hallmarks of chronic pancreatitis?
chronic inflammation, glandular atrophy, ductal changes, fibrosis
what are the causes of chronic pancreatitis?
metabolic, excessive alcohol, idiopathic, ductal obstruction
what is the most common cause of chronic pancreatitis?
alcohol consumption (60%)
what percentage of alcoholics develop chronic pancreatitis?
what are the 2 common causes of chronic pancreatitis d/t ductal obstruction?
congenital anomalies, blunt abdominal trauma
what is the cardinal symptom of chronic pancreatitis?
intermittent and unpredictable attacks of severe epigastric pain
what 2 things signify the "end of the road" for chronic pancreatitis pts?
malabsorption and steatorrhea (at least 90% of function is lost) - IRREVERSIBLE
what is the overall 5 yr survival rate of pancreatic cancer?
what percentage of pancreatic cancers develop in the pancreatic head?
what percentage of pancreatic cancers develop in the pancreatic tail?
what percentage of pancreatic cancers develop in the pancreatic body?
what is the only know risk factor for pancreatic carcinoma?
age (median 65-69)
what is the clinical presentation for pancreatic cancer?
gradual onset of nonspecific symptoms, abdominal/back pain, significant weight loss, mild-moderate mid epigastric tenderness, "mild" jaundice
what is the most common presenting sx in pancreatic cancer?
what is the classic association for "painless" jaundice?
pancreatic cancer (d/t common duct obstruction because of pancreatic head involvement)
what is the most common intestinal cause of lower abdominal pain in the western world?
irritable bowel syndrome
when do sx of IBS often present?
before age 30
what are the diagnostic criteria for IBS?
at least 3 mos of recurrent abdominal pain/discomfort associated with 2 or more of: improvement w defecation, change in stool frequency, change in stool form or appearance
what are the 2 cluster groups of the majority of the pts with IBS?
diarrhea cluster and constipation cluster
which subset of IBS is known as spastic colon?
constipation predominant (dry hard stools)
which subset of IBS is known as painless diarrhea or nervous diarrhea?
which subset of IBS alternates constipation and diarrhea?
alternating IBS (classic IBS)
which subset of IBS presents with cramping abdominal pain that is relieved by passing gas/bowel movement?
pain predominant IBS
what often accompanies the feces in painless diarrhea?
T/F: nocturnal diarrhea is a prominent feature of IBS
false - is not a prominent feature (does not wake you from sleep)
what are the IBS red flags?
weight loss, positive FOBT, anemia, fever, nocturnal symptoms, first onset in elderly
where is the pain most likely located in an IBS pt?
LLQ (localized to sigmoid colon)
where could palpation of the sigmoid colon cause pain referral to?
rectum and anus
does IBS or functional constipation present with abdominal discomfort?
what can secondary constipation be caused by?
medications and supplements
what has constipation classically been linked to?
dehydration, lack of adequate dietary fiber, and/or physical inactivity
what are the insoluble fiber bulking agents?
methylcellulose maltodextrin, xanthan gum
what are the soluble fiber bulking agents?
psyllium, bran, calcium polycarbophil, etc
how is abdominal pain in IBS affected by soluble and insoluble fiber?
pain not reduced with either fiber
for how long should you avoid using anti-diarrheal medications, and why?
avoid for first 24 hrs - diarrhea helps rid body of infection
what are defined as "pulsion herniations of the colon wall"?
what is the long term result of diverticula?
long term IBS
what has diverticula been assoc. with?
low fiber diet
where do diverticula most commonly occur?
what are the symptoms of diverticulosis that overlap w/ IBS?
pain (usually colicky), bloating sensation, changes in bowel habits, fullness or tenderness
how does classic diverticulitis present?
acute constant abdominal pain, usually in LLQ, fever and leukocytosis, nausea/vomiting, constipation and/or diarrhea, localized w/ poss. Guarding
what are 2 of the complications of diverticulosis th/ require surgical consultation?
fistula and bowel obstruction
where is the classic "home" of the appendix?
McBurneys point (2/3 of distance from umbilicus to ASIS)
what is acute appendicitis initiated by?
obstruction of the vermiform appendix
in children with acute appendicitis, what can the obstruction be caused by?
lymphoid hyperplasia, or fecoliths
what is the normal orientation and location of appendix?
close proximity to abdominal wall, between 4 and 6 o'clock
what is the most common abdominal surgical emergency?
when does appendicitis most often occur?
b/t ages of 10 and 30
how long is the clinical course of acute appendicitis?
12-48 hrs (gangrene and perforation can occur w/in 36 hrs)
what are the most effective and practical dx modalities for acute appendicitis?
routine hx and physical exam
what is stage 1 of classic appendicitis?
early inflammation of the appendix
where does the pain refer to in stage 1 of appendicitis?
vague pain that refers to umbilicus or epigastrium
what is stage 2 of classic appendicitis?
distension of the appendix
what type of pain is there in stage 2 of appendicitis?
constant colicky ache in area of RLQ
what is a big clue for appendicitis (in regards to pain)?
MOVES from umbilicus to RLQ in stage 2
what makes the pain worse in stage 2 of appendicitis?
walking or coughing
what msl findings will be present on physical exam in stage 2 of appendicitis?
right rectus abdominis more tense on palpation than left
what is stage 3 of classic appendicitis?
inflammation reaches the serosa
describe the pain in stage 3 of appendicitis?
well localized to RLQ, localized when coughing or on light percussion
what is the typical posture for appendicitis?
lying on left side with right hip flexed
what are 2 red flags that are suggestive of acute appendicitis?
abdominal pain and FEVER (esp in children), abdominal pain and VOMITING (esp in adults)
what is the sequence of 4 findings that is a strong indicator of acute appendicitis?
1. poorly localized pain around umbilicus 2. pain "migrates" from umbilicus to become poorly localized in RLQ 3. pain becomes well localized in RLQ 4. muscular rigidity in RLQ
4 somewhat reliable exam procedures for dx'ing appendicitis?
direct percussion, indirect percussion (Rovsings sign), rebound tenderness, psoas sign
what type of appendicitis will present with a positive psoas sign?
what type of appendicitis will present with a positive obturator sign?
how do elderly pts with appendicitis typically present?
minimal, vague symptoms
what is increased intestinal permeability aka?
leaky gut syndrome
what causes leaky gut syndrome?
loosening junctions between cells, allows unwanted molecules to pass through mucosa => immune response => inflammation
what is a desmosome?
cadherin "adhesion" protein
What are the two main clinical entities of inflammatory bowel dz (IBD)?
ulcerative colitis and crohn's dz
T/F: many of the mucosal changes seen in pts w/ IBD are nonspecific in nature
Which is associated w/ nocturnal symptoms - IBS or IBD?
which is associated w/ weight loss - IBS or IBD?
which is associated w/ blood in the stool - IBS or IBD?
which is associated w/ signs of inflammation - IBS or IBD?
which race is more likely to have IBD?
caucasians 4x more likely
T/F: IBD is curable
false - can be managed but not cured
What is the name of the IBD support group?
Crohns and Colitis Foundation of America (CCFA)
What single clinical finding is used to absolutely differentiate IBS from IBD?
How long is ulcerative colitis subclinical?
How long is crohns dz subclinical?
what are 3 common complications of ulcerative colitis?
toxic megacolon, colon cancer, superimposed infection
what are 4 common complications of crohns dz?
malnutrition, anemia, abscesses, colon cancer
what is the peak age range for ulcerative colitis?
15-35 (SAME AS IBS!)
Which is more common - ulcerative colitis or crohns dz?
ulcerative colitis slightly more common
Where does ulcerative colitis start?
the rectum ("always")
What part of the GI tract is ulcerative colitis confined to in 50% of cases?
Describe the inflammation in ulcerative colitis
uniform and continuous
what happens to the lymphoid follicles in ulcerative colitis?
what is the end result of ulcerative colitis?
Do the symptoms of ulcerative colitis come on gradually or acutely?
What are 5 common clinical features of ulcerative colitis?
diarrhea, rectal bleeding, rectal urgency, tenesmus, abdominal pain/tenderness
what is tenesmus?
feeling of incomplete defecation
What is the chief symptom of mild ulcerative colitis?
rectal bleeding (mistaken for hemorrhoids)
what is the chief symptom of moderate ulcerative colitis?
severe diarrhea (often w/ blood in it)
what is the peak age range for crohns dz?
10-30 (SAME AS IBS!)
describe the inflammatory process of crohns dz
which layers of the gut are affected by crohns dz?
What happens to smaller ulcers in crohns dz?
may coalesce and form larger, linear ulcers
what does fusion of larger ulcers lead to in crohns dz?
"cobblestoning" of mucosa
what are "skip segments"?
discontinuous areas of involvement with crohns dz
what is the "classic" age group for crohns dz?
late teens, early 20s
do the symptoms of crohns dz come on gradually or acutely?
onset is insidious
what are 3 classica clinical features of crohns dz?
abdominal pain, weight loss, diarrhea
is diarrhea more likely to be bloody in ulcerative colitis or crohns dz?
what is crohns ileitis aka?
what are the sx of crohns ileits?
steady periumbilical pain made worse by eating, watery diarrhea, malabsorption/weight loss, fever, anemia
what is crohns colitis aka?
what are the sx of crohns colitis?
crampy lower abdominal pain, incontinence, urgency, possible rectal bleeding
what is crohns ileocolitis aka?
distal ileum and proximal colon colitis
what are the sx of crohns ileocolitis?
mixed presentation of ileitis and colitis
which type of colitis is most commonly mistaken for IBS?
what are the 2 articular manifestations of IBD?
peripheral arthritis and axial arthritis
which type of arthritis tends to parallel the activity of the bowel dz?
is peripheral arthritis usually monoarticular or polyarticular?
does peripheral arthritis more often involve upper limbs or lower limbs?
what happens in peripheral arthritis with recurrence of IBD?
arthritis may "migrate" to another joint
when does axial arthritis usually present in relation to the bowel dz?
tends to precede sx of bowel dz
what are the 3 types of axial arthritis to be concerned about with IBD?
sacroiliits, spondyloarthritis, ankylosing spondylitis
what 2 types of skin lesions are seen in 10-25% of IBD pts?
erythema nodosum, pyoderma gangrenosum
what type of ocular lesions are seen in 3-11% of IBD pts?
acute iritis/anterior uveitis
which type of IBD can cause sinus tracts/abscess formation?
what percentage of recto-sigmoid cancers are in the early stages when discovered?
up to 90%
what percentage of cancers found in the ascending colon are in the early stages when discovered?
fewer than 25%
where are the majority of colon cancers?
what do anemia and changes in bowel habits signify in pts w/ colon cancer?
associated with a worse prognosis
what are the 3 classic sx of "left sided" colon cancer lesions?
hematochezia, constipation, alternating constipation/diarrhea ("paradoxical diarrhea")
what is hematochezia?
bright red blood in the stool
what are the 3 classic sx of "right sided" colon cancer?
melena, diarrhea, anemia
what is melena?
dark, tarry stools
which "sided" colon cancer is associated with "napkin ring" tumors and "pencil-thin" stools?
"left sided" colon cancer
what percentage of colon cancer is dx'ed in people w/ no known risk factors, including no family hx?
what percentage of people dx'ed with colon cancer are over 50?
what percentage of all colorectal cancer cases and deaths are thought to be preventable through screening tests?