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1

Where does jaundice first appear?

conjunctiva of eyes

2

what other symptom is jaundice classicaly associated with?

pruritis

3

T/F: carotenemia does not affect the conjunctiva

TRUE

4

what are the 2 most common causes of hepatocellular jaundice?

viral hepatitis and alcoholic cirrhosis

5

what are 2 examples of obstructive jaundice?

gallstone/gallbladder dz and pancreatic cancer involving pancreatic head

6

what leads to the so-called "painless jaundice"?

pancreatic cancer involving pancreatic head

7

what does increased bilirubin levels from excessive breakdown of RBCs cause?

hemolytic jaundice

8

what is the most common cause of acute liver failure?

drug related hepatotoxicity (about 50%). Acetominophen = 40% of cases

9

what are the tests that assess liver function?

albumin and total serum protein, PT time, bilirubin

10

what usually causes chronic liver dz to be suspected?

when one of complications occur

11

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

12

What are the classic symptoms of chronic liver dz?

fatigue, flu-like symptoms, diffuse RUQ or abdominal discomfort

13

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

14

what percentage of pts with Acute liver failure die?

28%

15

what are 3 common signs of chronic liver dz?

spider telangiectasia, palmar erythema, dupuytrens contracture

16

what are 3 complications of chronic liver dz?

portal HTN, esophageal varices, increased risk of primary liver cancer (hepatocellular carcinoma)

17

how does the liver react to chronic injury?

steatosis, fibrosis, and/or cirrhosis

18

describe hepatic steatosis

fatty liver w/o inflammation. Lipid accumulation in liver of >5% of livers weight

19

what is the livers most common response to injury?

steatosis

20

what is the most common form of hepatic steatosis?

macrovesicular steatosis

21

what is macrovesicular steatosis classically assoc. with?

obesity, type II DM, alcoholism

22

what is the most common discovery on physical exam of pt w/ macrovesicular steatosis?

non-tender hepatomegaly in an obese, alcoholic, or diabetic pt

23

what is the "two-hit model?"

possible complications of steatosis - steatosis makes liver sensitive to a second hit from pro-inflammatory molecules

24

what are the almost universal findings in pts with nonalcoholic fatty liver dz (NAFLD)?

insulin resistance/metabolic syndrome/syndrome x

25

describe steatohepatitis

fatty liver WITH inflammation. Usually presents with chronic unexplained elevations in amino transferase

26

T/F: fibrosis is synonymous with cirrhosis

false - fibrosis is NOT necessarily synonymous with cirrhosis

27

what is the predominant clinical reflection of hepatic fibrosis?

portal hypertension

28

is cirrhosis reversible?

cirrhosis is usually IRREVERSIBLE

29

what are the common causes of cirrhosis in the western world?

alcoholic liver dz and chronic hep c

30

how many drinks per day have been assoc w/ cirrhosis in women?

2-3/day

31

how many drinks per day have been assoc w/ cirrhosis in men?

3-4/day

32

what is the only test that can directly confirm a dx of cirrhosis?

percutaneous liver biopsy

33

what is the cause of hep A?

fecal oral contamination

34

what is the cause of hep B?

infected blood or infected blood-bearing fluids

35

what is the cause of hep C?

infected blood or infected blood-bearing fluids

36

why is hep c considered very dangerous?

slow spreading, clinically "silent"

37

what percentage of hep C pts can "clear the virus" from their blood?

20%

38

are primary or secondary liver tumors more common?

secondary 40x more common

39

what is the most common site of metastasis in those who die from neoplasms?

liver

40

what finding strongly suggests a liver tumor?

a bruit or friction rub over the liver

41

what is biliary colic?

pain assoc w/ transient obstruction of cystic duct. Very symptomatic stage of gallstone dz

42

what is cholelithiasis?

presence of gallstones in gall bladder

43

what is pain assoc w/ prolonged obstruction of cystic duct?

cholecystitis

44

what is it called when there is a stone in the common duct?

choledocholelithiasis

45

what is the term that describes obstruction/inflammation of the biliary or hepatic ducts?

cholangitis

46

are gallstones more common in men or women?

women

47

what are the primary bile acids?

cholate and chenodeoxycholate

48

what kind of bile acids tend to be more hydrophilic?

primary bile acids

49

what are the secondary bile acids?

deoxycholate and lithocholate

50

what kind of bile acids tend to be more hydrophobic?

secondary bile acids

51

what accelerates the formation of cholesterol gall stones and has been linked to prolonged small intestine transit time?

increased deoxycholate levels

52

what is the only significant mechanism for the elimination of excess cholesterol?

synthesis of bile acids and their subsequent excretion in the feces

53

an increase in what bile acid might impair gall bladder emptying?

deoxycholate

54

during fasting, what percentage of hepatic bile passes directly to the duodenum?

25%

55

describe the gall bladder "contractions"

small, slow, and somewhat random changes in basal tone

56

where is the sphincter of Oddi located?

duodenum

57

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

58

what does CCK cause to happen to the sphincter?

relaxation of the sphincter as the gall bladder contracts

59

after hepatic bile is concentrated, how much of gall bladder bile is water?

90%

60

what does an increased concentration of cholesterol or mucin cause?

impaired emptying of gall bladder

61

what percentage of gallstones in the us are cholesterol based?

75-80%

62

where do cholesterol stones most often form?

gall bladder

63

what are black pigment stones assoc with?

hemolytic conditions

64

what are brown pigment stones assoc with?

infection of gall bladder

65

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

66

in a pt that is not obese and has normal serum cholesterol levels, is it possible to have cholesterol based gall stones?

yes

67

what is a common symptom of a pt w/ multiple/faceted stones?

pt complaining of back pain

68

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)

69

what is the first and foremost cause of cholesterol supersaturation?

obesity (decrease BMI and serum triglyceride levels)

70

how do most pts with gallstones present?

asymptomatic - gallstones don’t leave gallbladder

71

how is Dx of gallstone dz usually made?

Hx of convincing attack and visualization of gallstones in gall bladder

72

how sensitive is US in detecting gallstones in the gall bladder?

95%

73

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

74

how long does it take stones to make it through the cystic duct?

30 min - 6 hrs

75

What will you find on physical exam of a pt with biliary "colic"?

nothing

76

what is the most common disorder resulting from gallstones?

biliary "colic"

77

how long does a biliary colic attack last?

30-60 mins, up to 6 hrs

78

what is the second most common disorder resulting from gallstones?

acute cholecystitis

79

which attacks last longer, acute cholecystitis or biliary colic?

acute cholecystitis - lasts >6 hrs (12-18 hrs)

80

how often is Murphys sign present in acute cholecystitis?

60%

81

where does pain from biliary colic classically refer?

RUQ, R shoulder

82

what type of pain does biliary colic create?

visceral

83

what type of pain does acute cholecystitis create?

parietal

84

what are the characteristics of a large gall stone?

20-25 mm, rarely leaves gall bladder

85

what are large gall stones likely to cause?

gall bladder empyema (infection) and result in biliary tract fistula

86

why is a large gall stone sx profile atypical?

do not cause Hx of "convincing" attack

87

what can choledocholelithiasis lead to?

liver damage and jaundice

88

what can microlithiasis greatly increase the risk of?

gallstone pancreatitis

89

what does gall bladder hydrops/mucocele do?

inhibits emptying of gall bladder

90

what has gall bladder sx in the absence of stones?

sphincter of oddi syndrome/biliary dyskinesia

91

what is carnetts used to assess?

chronic and unremitting abdominal pain

92

what is considered the gold standard for dx'ing chronic cholelithiasis?

ultrasound (95% sensitive for detecting gallstones IN gall bladder)

93

what is the sensitivity of ultrasound in detecting stones in the common duct?

50%

94

what is defined as "attempted auto digestion of the pancreas?"

acute pancreatitis

95

what is defined as "permanent structural changes often associated w/ chronic alcoholism"?

chronic pancreatitis

96

T/F: pancreatic cancer is often untreatable by the time it is dx'ed

TRUE

97

is the pancreas retroperitoneal or within peritoneum?

retroperitoneal

98

describe the pain from the pancreas

visceral and poorly localized

99

how does the pancreas normally feel on palpation?

soft and pliable

100

what does chronic pancreatitis lead to?

deposition of CT in pancreatic acini and ductules

101

what leads to the deposition of ectopic fat in the pancreas?

high fat diet or obesity

102

what happens to ectopic fat during episodes of pancreatic inflammation?

can become necrotic (activated proteases and lipases try to digest phospholipids in cell walls)

103

what is a classic axiom when referring to the pancreas?

"no stimulation, no secretion"

104

How much does eating or thinking about eating stimulate pancreatic enzyme production?

up to 70% of max capacity

105

what occurs during an acute alcoholic episode?

pancreas temporarily ceases fxn

106

what happens to the pancreas during chronic alcoholism?

becomes hypersecretory

107

how much alcohol does it take to mess up the pancreas?

nobody knows

108

what is the problem that occurs involving zymogen granules in the pancreas?

can cause premature activation of proenzymes in the pancreas

109

what is the classic pain referral for inflammation of the pancreatic head?

the back

110

what is the classic pain referral for inflammation of the pancreatic body?

to the back and/or left flank

111

what is the classic pain referral for inflammation of the pancreatic tail?

left flank

112

what specific clinical feature allows the clinician to definitively dx pancreatitis?

none

113

is acute pancreatitis reversible?

potentially

114

how many cases of acute pancreatitis involve gall stones?

about 40%

115

how many cases of acute pancreatitis are d/t alcohol abuse?

35%

116

how many cases of acute pancreatitis are idiopathic?

10%

117

what is the most common type of acute pancreatitis?

edematous pancreatitis

118

how many cases of acute pancreatitis are severe?

24%

119

what is the mortality rate of hemorrhagic pancreatitis?

50-85%

120

what will you see with hemorrhagic pancreatitis?

cullens sign, grey-turner sign

121

what is the cardinal symptom of acute pancreatitis?

epigastric pain of sudden onset, usually lasts >1 day

122

what is the characteristic patient postion in cases of pancreatitis?

thoracolumbar spinal flexion

123

T/F: overt rebound tenderness is a common finding with acute pancreatitis

false - uncommon

124

how does the degree of amylase/lipase elevation correlate with the severity of pancreatitis?

it doesn't correlate

125

what are 3 common complications of acute pancreatitis?

mortality, pancreatic necrosis, pseudocyst

126

what are the characteristics of chronic pancreatitis?

self perpetuating, mostly irreversible, and leads to structural changes w/in pancreas

127

what are the structural changes that occur during chronic pancreatitis?

fibrotic tissue/calcium deposition in pancreas

128

what are the pathological hallmarks of chronic pancreatitis?

chronic inflammation, glandular atrophy, ductal changes, fibrosis

129

what are the causes of chronic pancreatitis?

metabolic, excessive alcohol, idiopathic, ductal obstruction

130

what is the most common cause of chronic pancreatitis?

alcohol consumption (60%)

131

what percentage of alcoholics develop chronic pancreatitis?

<10%

132

what are the 2 common causes of chronic pancreatitis d/t ductal obstruction?

congenital anomalies, blunt abdominal trauma

133

what is the cardinal symptom of chronic pancreatitis?

intermittent and unpredictable attacks of severe epigastric pain

134

what 2 things signify the "end of the road" for chronic pancreatitis pts?

malabsorption and steatorrhea (at least 90% of function is lost) - IRREVERSIBLE

135

what is the overall 5 yr survival rate of pancreatic cancer?

<5%

136

what percentage of pancreatic cancers develop in the pancreatic head?

about 75%

137

what percentage of pancreatic cancers develop in the pancreatic tail?

5-10%

138

what percentage of pancreatic cancers develop in the pancreatic body?

15-20%

139

what is the only know risk factor for pancreatic carcinoma?

age (median 65-69)

140

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

141

what is the most common presenting sx in pancreatic cancer?

abdominal/back pain

142

what is the classic association for "painless" jaundice?

pancreatic cancer (d/t common duct obstruction because of pancreatic head involvement)

143

what is the most common intestinal cause of lower abdominal pain in the western world?

irritable bowel syndrome

144

when do sx of IBS often present?

before age 30

145

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

146

what are the 2 cluster groups of the majority of the pts with IBS?

diarrhea cluster and constipation cluster

147

which subset of IBS is known as spastic colon?

constipation predominant (dry hard stools)

148

which subset of IBS is known as painless diarrhea or nervous diarrhea?

diarrhea predominant

149

which subset of IBS alternates constipation and diarrhea?

alternating IBS (classic IBS)

150

which subset of IBS presents with cramping abdominal pain that is relieved by passing gas/bowel movement?

pain predominant IBS

151

what often accompanies the feces in painless diarrhea?

visible mucus

152

T/F: nocturnal diarrhea is a prominent feature of IBS

false - is not a prominent feature (does not wake you from sleep)

153

what are the IBS red flags?

weight loss, positive FOBT, anemia, fever, nocturnal symptoms, first onset in elderly

154

where is the pain most likely located in an IBS pt?

LLQ (localized to sigmoid colon)

155

where could palpation of the sigmoid colon cause pain referral to?

rectum and anus

156

does IBS or functional constipation present with abdominal discomfort?

IBS

157

what can secondary constipation be caused by?

medications and supplements

158

what has constipation classically been linked to?

dehydration, lack of adequate dietary fiber, and/or physical inactivity

159

what are the insoluble fiber bulking agents?

methylcellulose maltodextrin, xanthan gum

160

what are the soluble fiber bulking agents?

psyllium, bran, calcium polycarbophil, etc

161

how is abdominal pain in IBS affected by soluble and insoluble fiber?

pain not reduced with either fiber

162

for how long should you avoid using anti-diarrheal medications, and why?

avoid for first 24 hrs - diarrhea helps rid body of infection

163

what are defined as "pulsion herniations of the colon wall"?

diverticula

164

what is the long term result of diverticula?

long term IBS

165

what has diverticula been assoc. with?

low fiber diet

166

where do diverticula most commonly occur?

sigmoid colon

167

what are the symptoms of diverticulosis that overlap w/ IBS?

pain (usually colicky), bloating sensation, changes in bowel habits, fullness or tenderness

168

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

169

what are 2 of the complications of diverticulosis th/ require surgical consultation?

fistula and bowel obstruction

170

where is the classic "home" of the appendix?

McBurneys point (2/3 of distance from umbilicus to ASIS)

171

what is acute appendicitis initiated by?

obstruction of the vermiform appendix

172

in children with acute appendicitis, what can the obstruction be caused by?

lymphoid hyperplasia, or fecoliths

173

what is the normal orientation and location of appendix?

close proximity to abdominal wall, between 4 and 6 o'clock

174

what is the most common abdominal surgical emergency?

appendicitis

175

when does appendicitis most often occur?

b/t ages of 10 and 30

176

how long is the clinical course of acute appendicitis?

12-48 hrs (gangrene and perforation can occur w/in 36 hrs)

177

what are the most effective and practical dx modalities for acute appendicitis?

routine hx and physical exam

178

what is stage 1 of classic appendicitis?

early inflammation of the appendix

179

where does the pain refer to in stage 1 of appendicitis?

vague pain that refers to umbilicus or epigastrium

180

what is stage 2 of classic appendicitis?

distension of the appendix

181

what type of pain is there in stage 2 of appendicitis?

constant colicky ache in area of RLQ

182

what is a big clue for appendicitis (in regards to pain)?

MOVES from umbilicus to RLQ in stage 2

183

what makes the pain worse in stage 2 of appendicitis?

walking or coughing

184

what msl findings will be present on physical exam in stage 2 of appendicitis?

right rectus abdominis more tense on palpation than left

185

what is stage 3 of classic appendicitis?

inflammation reaches the serosa

186

describe the pain in stage 3 of appendicitis?

well localized to RLQ, localized when coughing or on light percussion

187

what is the typical posture for appendicitis?

lying on left side with right hip flexed

188

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)

189

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

190

4 somewhat reliable exam procedures for dx'ing appendicitis?

direct percussion, indirect percussion (Rovsings sign), rebound tenderness, psoas sign

191

what type of appendicitis will present with a positive psoas sign?

retrocolic/retrocecal

192

what type of appendicitis will present with a positive obturator sign?

pelvic

193

how do elderly pts with appendicitis typically present?

minimal, vague symptoms

194

what is increased intestinal permeability aka?

leaky gut syndrome

195

what causes leaky gut syndrome?

loosening junctions between cells, allows unwanted molecules to pass through mucosa => immune response => inflammation

196

what is a desmosome?

cadherin "adhesion" protein

197

What are the two main clinical entities of inflammatory bowel dz (IBD)?

ulcerative colitis and crohn's dz

198

T/F: many of the mucosal changes seen in pts w/ IBD are nonspecific in nature

TRUE

199

Which is associated w/ nocturnal symptoms - IBS or IBD?

IBD

200

which is associated w/ weight loss - IBS or IBD?

IBD

201

which is associated w/ blood in the stool - IBS or IBD?

IBD

202

which is associated w/ signs of inflammation - IBS or IBD?

IBD

203

which race is more likely to have IBD?

caucasians 4x more likely

204

T/F: IBD is curable

false - can be managed but not cured

205

What is the name of the IBD support group?

Crohns and Colitis Foundation of America (CCFA)

206

What single clinical finding is used to absolutely differentiate IBS from IBD?

none

207

How long is ulcerative colitis subclinical?

9-18 mos

208

How long is crohns dz subclinical?

24-60 mos

209

what are 3 common complications of ulcerative colitis?

toxic megacolon, colon cancer, superimposed infection

210

what are 4 common complications of crohns dz?

malnutrition, anemia, abscesses, colon cancer

211

what is the peak age range for ulcerative colitis?

15-35 (SAME AS IBS!)

212

Which is more common - ulcerative colitis or crohns dz?

ulcerative colitis slightly more common

213

Where does ulcerative colitis start?

the rectum ("always")

214

What part of the GI tract is ulcerative colitis confined to in 50% of cases?

recto-sigmoid area

215

Describe the inflammation in ulcerative colitis

uniform and continuous

216

what happens to the lymphoid follicles in ulcerative colitis?

hyperplasia

217

what is the end result of ulcerative colitis?

pseudopolyps

218

Do the symptoms of ulcerative colitis come on gradually or acutely?

abrupt onset

219

What are 5 common clinical features of ulcerative colitis?

diarrhea, rectal bleeding, rectal urgency, tenesmus, abdominal pain/tenderness

220

what is tenesmus?

feeling of incomplete defecation

221

What is the chief symptom of mild ulcerative colitis?

rectal bleeding (mistaken for hemorrhoids)

222

what is the chief symptom of moderate ulcerative colitis?

severe diarrhea (often w/ blood in it)

223

what is the peak age range for crohns dz?

10-30 (SAME AS IBS!)

224

describe the inflammatory process of crohns dz

non-specific, granulomatous

225

which layers of the gut are affected by crohns dz?

all layers

226

What happens to smaller ulcers in crohns dz?

may coalesce and form larger, linear ulcers

227

what does fusion of larger ulcers lead to in crohns dz?

"cobblestoning" of mucosa

228

what are "skip segments"?

discontinuous areas of involvement with crohns dz

229

what is the "classic" age group for crohns dz?

late teens, early 20s

230

do the symptoms of crohns dz come on gradually or acutely?

onset is insidious

231

what are 3 classica clinical features of crohns dz?

abdominal pain, weight loss, diarrhea

232

is diarrhea more likely to be bloody in ulcerative colitis or crohns dz?

ulcerative colitis

233

what is crohns ileitis aka?

regional/terminal ileitis

234

what are the sx of crohns ileits?

steady periumbilical pain made worse by eating, watery diarrhea, malabsorption/weight loss, fever, anemia

235

what is crohns colitis aka?

granulomatous colitis

236

what are the sx of crohns colitis?

crampy lower abdominal pain, incontinence, urgency, possible rectal bleeding

237

what is crohns ileocolitis aka?

distal ileum and proximal colon colitis

238

what are the sx of crohns ileocolitis?

mixed presentation of ileitis and colitis

239

which type of colitis is most commonly mistaken for IBS?

granulomatous colitis

240

what are the 2 articular manifestations of IBD?

peripheral arthritis and axial arthritis

241

which type of arthritis tends to parallel the activity of the bowel dz?

peripheral arthritis

242

is peripheral arthritis usually monoarticular or polyarticular?

monoarticular

243

does peripheral arthritis more often involve upper limbs or lower limbs?

lower limbs

244

what happens in peripheral arthritis with recurrence of IBD?

arthritis may "migrate" to another joint

245

when does axial arthritis usually present in relation to the bowel dz?

tends to precede sx of bowel dz

246

what are the 3 types of axial arthritis to be concerned about with IBD?

sacroiliits, spondyloarthritis, ankylosing spondylitis

247

what 2 types of skin lesions are seen in 10-25% of IBD pts?

erythema nodosum, pyoderma gangrenosum

248

what type of ocular lesions are seen in 3-11% of IBD pts?

acute iritis/anterior uveitis

249

which type of IBD can cause sinus tracts/abscess formation?

crohns dz

250

what percentage of recto-sigmoid cancers are in the early stages when discovered?

up to 90%

251

what percentage of cancers found in the ascending colon are in the early stages when discovered?

fewer than 25%

252

where are the majority of colon cancers?

recto-sigmoid area

253

what do anemia and changes in bowel habits signify in pts w/ colon cancer?

associated with a worse prognosis

254

what are the 3 classic sx of "left sided" colon cancer lesions?

hematochezia, constipation, alternating constipation/diarrhea ("paradoxical diarrhea")

255

what is hematochezia?

bright red blood in the stool

256

what are the 3 classic sx of "right sided" colon cancer?

melena, diarrhea, anemia

257

what is melena?

dark, tarry stools

258

which "sided" colon cancer is associated with "napkin ring" tumors and "pencil-thin" stools?

"left sided" colon cancer

259

what percentage of colon cancer is dx'ed in people w/ no known risk factors, including no family hx?

75%

260

what percentage of people dx'ed with colon cancer are over 50?

90%

261

what percentage of all colorectal cancer cases and deaths are thought to be preventable through screening tests?

90%

262

what percentage of colorectal cancer is dx/ed in its early stages d/t low screening rates?

37%