Gastrointestinal Flashcards
(578 cards)
1
Q
Where is niacin found?
A
- Protein
- Dairy products
- Many cereals
- Vegetables
2
Q
Why would a bulimic patient present with dental decay?
A
Gastric acid in vomit
3
Q
Where is vitamin E found?
A
- Vegetable oils
- Nuts
- Legumes
- Whole grains
4
Q
What other signs would you see in Vitamin A deficiency (secondary)?
A
- Dry skin
- Keratinization of lungs, GI, urinary epithelium
5
Q
What does pyridoxine deficiency result in?
A
- Seborrheic dermatitis
- Cheilosis
- Glossitis
In severe deficiency: - Peripheral neuropathy
- Lymphopenia
- Anemia
6
Q
How does pyridoxine deficiency occur?
A
Rare but may occur because of:
- Alcoholism
- Interactions with medications (INH)
7
Q
In an anorexic patient, what can lead to sudden death?
A
Ventricular Arryhthmia
8
Q
Prevalence of obesity increases with what?
It is higher among who?
A
- Age
- African American women
- People of low socioeconomic status
9
Q
What are the signs / symptoms of anorexic patients?
A
- Increasingly cachectic
- Amenorrhea
- Bradycardia
- Low BP
- Hypothermia
- Edema
- Lanugo hair growth (fine hair)
10
Q
Vitamin K is a cofactor in the synthesis of what clotting factors?
A
- II (2)
- VII (7)
- IX (9)
- X (10)
11
Q
Where does vitamin K come from?
A
- Leafy greens
- Normal intestinal bacteria
12
Q
Which is increased with vitamin K deficiency - PTT or PT?
A
PT (although both may be affected)
13
Q
What is a condition of extreme weight loss, severe disturbance in body image, and fear of obesity?
A
Anorexia Nervosa
14
Q
What happens with vitamin E toxicity?
A
Nothing… It’s rare
15
Q
Which three conditions are keys to diagnosing pernicious anemia?
What is confirmed with?
A
- Megaloblastic anemia, Neurologic disturbances, Ataxia
- Schilling Test
16
Q
What condition can overweight teenagers develop?
A
Slipped Capital Femoral Epiphysis
17
Q
How does dermatitis present in pellagra?
A
Dark, scaly lesions on sun-exposed skin
18
Q
What stains the skin orange?
A
Excess beta-carotene
19
Q
Once Cobalamin (B12) is ingested, what does it bind to? What does this allow?
A
- Intrinsic factor from the parietal cells
- Absorption
20
Q
Which vitamin is important for DNA synthesis and myelin formation?
A
Cobalamin (B12)
21
Q
What can vitamin D deficiency cause?
A
- Rickets in children
- Osteomalacia
22
Q
How is vitamin D make in the skin?
A
Exposure to sunlight
23
Q
What are the symptoms of advanced lesions of dental caries?
A
Pain from eating hot, cold, and sugary foods
24
Q
Which vitamin deficiency causes beriberi?
A
Thiamine (B1)
25
How does wet beriberi present?
- Cardiovascular disease
| - High output heart failure
26
What BMI is considered overweight? obese?
Overweight... > 25
| Obese... > 30 unless they have a high muscle mass
27
What is another name for B1?
Thiamine
28
Why would vitamin deficiency develop in a developed country?
- Chronic alcohol use
- Medication misuse
- Food faddism
- Long-term parenteral nutrition
29
What might happen to infants with pyridoxine insufficiency?
Seizures
30
Who is a typical anorexic patient?
- Teenage girl
- Higher socioeconomic status
- Perfectionist
31
What provides substrate for bacterial production of lactic acid on teeth, which erodes enamel?
Dietary carbohydrates (sucrose)
32
What can have a protected effect on osteoporosis?
Obesity
33
What is another name for vitamin D?
Calciferol
34
What is another name for B3?
Niacin
35
What is seen in riboflavin (B2) deficiency?
- Cheilosis
- Angular stomatitis
- Seborrheic dermatitis
- Corneal vascularization
- Anemia
36
What is angular stomatitis?
Fissuring at the angles of the mouth
37
What must children outside of the US do to ensure protection of dental caries? Why?
- Take fluoride supplements, Use fluoride compounds applied directly to teeth (mouth rinse / toothpaste)
- In US, water is fluoridated
38
Is the first or second dose of the Schilling test radioactive? How are each dose given?
- First
| - First → PO / Second → Injection
39
What is a condition particularly common in alcoholics in which nystagmus, ataxia, confusion, and confabulation are present? What may it lead to?
- Wernicke-Korsakoff Syndrome
| - Come and death
40
What is ingested which offers protection against forming dental caries while the teeth are developing? At what ages are the teeth developing?
- Fluoride
| - Birth-13
41
Which vitamin is a coenzyme in carbohydrate metabolism?
Niacin (B3)
42
What is the recommended treatment of dental caries?
Dental fillings
43
What is the mortality rate in anorexic hospitalized patients?
6%
44
What is scurvy?
Vitamin C deficiency
45
What does scurvy present with?
- Splinter hemorrhages
- Spontaneous hemorrhage
- Swollen, friable gums
- Secondary infections
- Myalgias
- Hemarthrosis
- Tooth loss
- Gangrene
- Also anemia
46
Which vitamin is needed for the formation of collagen and the maintenance of connective tissue, bone, and teeth, wound healing, and iron absorption?
Vitamin C (ascorbic acid)
47
What is another name for vitamin C?
Ascorbic acid
48
What is another name for B12?
Cobalamin
49
What is another name for vitamin A?
Retinol
50
Vitamin D enhances absorption of what two things from the gut?
- Calcium
| - Phosphate
51
What is a rapid correction for vitamin K deficiency?
Injection of vitamin K
52
What is another name for B2?
Riboflavin
53
Which vitamin is a component of the coenzymes flavin adenine dinucleotide (FAD) and flavin mono nucleotide (FMN)?
Riboflavin (B2)
54
What would be the treatment for anorexia?
- Psychiatric
- Family counseling
(Tubes, IV feeds rarely needed)
55
What surgery involves decreasing the patient's stomach capacity with a vertical banded gastroplasty?
Roux-en-Y Banding
56
What does pyridoxine (B6) toxicity cause?
Sensory neuropathy
57
What does vitamin A toxicity cause?
- Mouth sores
- Anorexia
- Vomiting
- Increased intracranial pressure → Papilledema / headaches
58
What is cheilosis?
Swollen, cracked, bright red lips
59
How does riboflavin (B2) insufficiency occur?
Insufficient milk and animal product consumption
60
What are obese people more prone to get?
- Osteoarthritis
- Gall bladder disease
- Urinary stress incontinence
- Infertility
- Venous stasis disease
61
What is a condition in which the destruction of parietal cells results in insufficient amounts of intrinsic factor, which then leads to vitamin B12 deficiency?
Pernicious anemia
62
What would deficiency of vitamin A cause? (main deficiencies)
- Night blindness
- Conjunctival dryness
- Corneal keratinization
- Epithelial cells loose moisture and are replaced by horny cells
63
Niacin deficiency can occur in the setting of what four things? (excluding maize as diet staple)
- Diarrhea
- Cirrhosis
- Alcoholism
- Isoniazid use (INH)
64
How would vitamin D deficiency present on an x-ray?
- Long-bone bowing in children
| - Demineralization in adults
65
Niacin deficiency occurs when what is a diet staple?
Maize (milled corn)
66
What does vitamin E insufficiency result from?
- Vitamin-insufficient infant formulas
- Protein-energy malnutrition
- Some malabsorption syndromes with steatorrhea
67
What vitamin maintains cell membranes by protecting lipids from oxidation? Why does this happen?
- Vitamin E
| - Sucks up free radicals
68
Where else is vitamin D found (other than skin)?
- Dairy
| - Fish
69
Which disorder is associated with binge eating, induced vomiting, and laxative use?
Bulimia
70
What are the normal values for PT, PTT, and INR?
- PT = 10-12s
- PTT = 30-45s
- INR = 1-2
71
What is vitamin A a component of in the retina?
Photoreceptor pigments → maintain normal epithelium
72
How does dry beriberi present?
Bilateral symmetrical peripheral neuropathy
73
What is the second most common cause of premature death in the US? What's the first?
```
#2 = Obesity
#1 = Smoking
```
74
Which conditions would increase the need for B1 (Thiamine)?
- Pregnancy
| - Hyperthyroidism
75
Where is Thiamine (B1) found?
Grains
| Removed in production of polished rice
76
Which vitamin is used in the metabolism of amino acids and the synthesis of heme?
Pyridoxine (B6)
77
What is another name for vitamin B6?
Pyridoxine
78
What does vitamin E insufficiency cause?
- Red blood cell hemolysis → anemia in infants
| - Neurologic changes such as gait changes, areflexia, decreased vibration / position sense
79
How is anorexia diagnosed?
Loss of more than 15% of body weight in a thin patient who denies illness and has a fear of obesity
80
How many American adults are overweight or obese?
1/3
81
What can vitamin K toxicity cause?
Hemolysis (but rare...)
82
How is vitamin A formed by the body?
From beta-carotene (found in yellow, orange, and leafy green vegetables)
83
High doses of which vitamin can be used to lower LDLs and raise HDLs?
What is a common side effect of taking it?
- Niacin (B3)
| - Flushing
84
Where is vitamin A found?
- Egg yolks
- Dairy products
- Liver
- Fish
85
What suggests the diagnoses of depletion of folate body stores?
Megaloblastic anemia without neurologic changes
86
Folate deficiency is often seen in who?
- Elderly
- Alcoholics
- Poor
(Inadequate nutrition)
87
What can vitamin D toxicity cause?
- Hypercalcemia
| - Calcification in kidney, liver, eyes, and joints
88
What can vitamin K deficiency result in?
- Spontaneous bleeding
| - Prolonged oozing
89
Which vitamin is used in the synthesis of DNA?
Folate
90
Niacin deficiency leads to what?
| What does this consist of?
- Pellagra
| - Four D's = Diarrhea, Dermatitis, Dementia, Death
91
If someone passed out and was brought to the ER, what cocktail of drugs would you give?
- Thiamine (B1 deficiency)
- Narcan (Reverse drug effects)
- Dextrose (Sugar replenishment)
92
Where is folate found?
- Leafy green vegetables
| - Citrus fruits
93
How is pernicious anemia treated?
IM injections of B12
94
Which vitamin contributes to carbohydrates metabolism as a coenzyme?
Thiamine (B1)
95
What is the treatment for a fistula?
Fistulotomy
| -the tract is completely opened and allowed to heal from within.
96
What is a common cause of gastroenteritis outbreaks?
The Norwalk Virus
97
What virus causes severe diarrhea in small children and causes significant mortality in third world countries?
Rotavirus
| - "rotates" out of the world
98
What are some other sources of viral gastroenteritis (besides Norwalk and Rotavirus)?
Enterovirus
Coxsackie A1 Virus
Echovirus
Adenovirus
99
Does viral gastroenteritis require treatment?
Rarely. The generally resolve without treatment.
100
What do you remember from Micro about Staph A.?
Coagulase positive
Catalase positive
Gram positive
Purple on staining
101
How does Staph Gastroenteritis occur?
From eating food containing the toxin- Staph A. particularly from foods left out at room temperature-milk,cheese, some meat and fish.
102
Within how many hours will a person experience vomiting, cramping and diarrhea after ingesting a food containing Staph A.?
8 hours
103
How soon can a person recover from being infected with Staph Gastroenteritis?
24-48 hours
104
How is Staph Gastroenteritis treated?
Fluid and electrolytes
105
What does the enterotoxin from Vibrio cholera do to the bowel lumen?
It causes electrolytes and water to be secreted into the bowel lumen.
106
How is cholera spread?
Fecal contamination of water, seafood and other products.
107
Where are endemic cases of cholera found?
Along the Gulf Coast of the US
Asia
Africa
Middle East
108
"Rice water" stools are found in what GI disorder?
Vibrio cholera
109
Are the rice water stools passed with Vibrio cholera painful?
No, they are passed without pain.
110
Why isnt the diarrhea bloody with Vibrio cholera?
Because the bowel mucosa remains intact.
111
Is fever seen in vibrio cholera?
Rare.
112
A patient comes in to your office with severe dehydration that leads to thirst,oliguria or anuria, cramps, weakness and loss of skin tone. What is on the top of your DD of GI disorders?
Cholera
113
What can circulatory collapse seen in Cholera cause?
Cyanosis
Stupor
Renal tubular necrosis
and Death...
114
What is the pH in the mouth- acidic or basic?
Basic
115
What will the labs show in a patient with Cholera?
Metabolic Acidosis because of the loss of Bicarb in the stool.
116
What is imperative with treatment of Cholera?
Maintaining fluid and electrolyte balance.
117
Why is Ciprofloxacin and Doxycycline used in treatment of Cholera?
They are broad spectrum antibiotics.
Cipro- is gyrase inhibitor (inhibits the bacterial DNA from unwinding)
118
What is used to confirm the diagnosis of GERD?
- Endoscopy
- pH probe
- Motility studies
119
Other than an abnormal LES, what are some other causes of GERD?
- Hiatal hernia
- Pregnancy
- Obesity
- Scleroderma
- Cigarettes
- Alcohol
- Meds that dilate / relax
120
What are some medications that would relax / dilate the lower esophageal sphincter and may result in GERD?
- Anticholinergics
- Antipsychotics
- Beta-blockers
- Beta 2 agonists
- Calcium channel blockers
(AABBC)
121
What's the first-line therapy for GERD?
Patients should:
- Elevate head of their beds
- Lose weight
- Change their diets to decrease intake of fat, alcohol, chocolate, caffeine, and late-night snacks
122
What is the medical treatment for GERD?
- Antacids
- H2-receptor antagonists (-dine)
- Short-term trial of metoclopramide (Reglan)
- Proton pump blocker (omeprazole, lansoprazole)
123
What is a surgical procedure to treat severe GERD?
Nissen fundoplication
124
What is Nissen fundoplication?
Surgical procedure which wrap stomach tissue (fundus) around the LES to tighten it
125
What are the two cancer types of esophageal cancer? Which one is more common?
- Squamous cell carcinoma
- Adenocarcinoma
(Squamous cell is more common but adenocarcinoma now accounts for almost half of the cases)
126
What are two risk factors for squamous cell carcinoma in esophageal cancer?
- Heavy alcohol
| - Tobacco
127
At the time of presentation, most patients with esophageal cancer have metastases where?
To lymph nodes
| and local extension with invasion of nearby structures
128
What is the initial symptom of esophageal cancer? What does this lead to?
Dysphagia → weight loss
129
True or false: Patients with esophageal cancer first experience difficulty swallowing liquids, which gradually progresses to difficulty swallowing solids as well.
False (other way around)
130
What might be present in esophageal cancer if the laryngeal nerves are involved?
Coughing or hoarseness
131
Besides dysphagia, what other symptoms might be noted in esophageal cancer?
- Weakness
- Anemia
- Pain
- Regurgitation
- Aspiration
132
In patients with esophageal cancer, barium swallow typically shows what?
Lumen narrowed by an irregular mass
133
In patients with esophageal cancer, constricting bands are usually seen with what?
Annular lesions
134
In esophageal cancer, what is used for tissue diagnosis?
Esophagoscopy with biopsy
135
In esophageal cancer, what test will show extension and metastases?
CT scan
136
What is the treatment for esophageal cancer?
Some combination of surgery, radiation, and chemotherapy
137
True or false: Prognosis in esophageal cancer is poor.
True
138
Why is prognosis of esophageal cancer poor?
Highly vascularized GI tract
139
True or false: Sialolithiasis causes pain with eating
False
140
How are sialolithiasis treated?
Sialagogues (lemon drops), warm compresses, and massage → excision might be needed
141
What might painless swelling of the parotid gland result with?
- Mumps
- Sarcoidosis
- Cirrhosis
- Neoplasms
- Infection
142
What happens in a dehydrated person which would cause infection and swelling of the parotid glands?
Oral bacteria are not sufficiently washed away and may ascend into the ducts
143
How would an infection of the parotid glands be treated?
Hydration and antibiotics
144
Difficulty in swallowing can be divided into problems of what two things?
Oropharyngeal transport and esophageal transport
145
What are oropharyngeal problems usually caused by?
Neurologic or muscular disorders such as stroke, multiple sclerosis, myasthenia gravis
146
In esophageal dysphagia, what affects the swallowing of only fluids?
Obstructive disorders such as tumors, strictures, and rings
147
In esophageal dysphagia, what affects the swallowing of solids and fluids equally?
Motor disorders such as achalasia, spasms, and scleroderma
148
What is Schatzki's ring?
Where the esophagus joins the stomach
149
What occurs if a lesion is pre-esophageal?
Nasal regurgitation or cough secondary to tracheal aspiration
150
What do patients with esophageal lesions complain of?
Food getting stuck
151
What may supraclavicular lymphadenopathy indicate?
- Cancer
- Nerve, problems
- Muscular problems
- Other
152
What is key in diagnosing the location and type of dysphagia?
Chronology, including whether onset involved solids, liquids, or both
153
What tests may be useful in diagnosing dysphagia?
- Barium swallow studies
- Upper endoscopy
- Esophageal manometry
- Esophageal pH monitoring
154
What is globes hystericus?
Lump in throat → usually psychogenic
155
How are patients who develop dysphagia because of stroke or other neuromuscular disorders treated?
Therapy
156
How are patients who develop dysphagia because of an obstruction treated?
Correction with surgery
157
What is achalasia?
Disorder of the esophagus which involves impairment of peristalsis and lower esophageal sphincter relaxation
158
What is the etiology of achalasia?
Unknown
159
When does achalasia commonly occur?
Gradual onset most commonly begins between 20 and 40
160
How may patients presenting with achalasia have a malignancy of the gastroesophageal junction?
Small minority
161
What is the major symptom of achalasia?
Gradual onset of dysphagia of both solids and liquids
162
Regurgitation is common in achalasia. What does this cause at night?
Cough and aspiration
163
In a patient with achalasia, what would a barium swallow study show?
Dilated esophagus, with a classic beak-like lower portion
164
True of false: In achalasia, peristalsis is absent.
True
165
What is used to rule out stricture and carcinoma of achalsia?
Endoscopy with biopsy
166
What is the treatment for achalasia?
- Pneumatic dilation
- Botulinum toxin
- Laparoscopic myotomy
- Fundoplication
167
What is laparoscopic myotomy?
The surgical division of the involved muscle
168
What could laparoscopy myotomy result in?
Gastroesophageal reflux
169
What is gastroesophageal reflux disease (GERD)?
Esophageal inflammation results when low pressures at the lower esophageal sphincter allow reflux of gastric contents into the esophagus
170
In addition to inflammation and ulceration, what else could patients with GERD develop?
- Strictures
- Barrett's esophagus
- Bleeding
- Aspiration
171
What is Barrett's esophagus?
Stratified squamous turning to columnar metaplasia → sometimes leading to adenocarcinoma
172
What kinds of patients is GERD seen in?
- Common in overweight
| - May be seen in infants who present with vomiting, failure to thrive, anemia, or pulmonary symptoms
173
What is heartburn?
Burning behind the sternum that rises from the stomach toward the mouth
174
When does heartburn occur? How is it relieved?
Occurs when the patient lies down after eating / Resolved by sitting up, drinking fluids, and taking antacids
175
What are some atypical symptoms that occur because of reflux?
- Sore throat
- Cough
- Asthma
- Non-cardiac chest pain
176
What is a hiatal hernia?
Common disorder that involves protrusion of part of the stomach above the diaphragm
177
What are the two types of hiatal hernias?
- Sliding hiatal hernia
| - Paraesophageal hiatal hernia
178
What does a sliding hiatal hernia involve?
Involves upward displacement of both the gastroesophageal junction and the stomach through the diaphragm
179
What does a paraesophageal hiatal hernia result from?
Results when part of the stomach is pushed through the diaphragm next to a normally located esophagus and gastroesophageal junction
180
True or false: If the lower esophageal sphincter is displaced upward, it is exposed to a higher pressure in the thoracic cavity and may not be able to remained closed.
False (it is exposed to a lower pressure)
181
What may occur due to a displacement upward of the LES?
Gastroesophageal reflux
182
In a hiatal hernia, what will x-rays and barium studies show?
A portion of the stomach above the diaphragm
183
What are some causes of a hiatal hernia?
- Age
- Obesity
- Smoking
184
What is an EGD?
Esaphagogastroduodenoscopy
185
What is the only therapy needed for a sliding hiatal hernia?
Control reflux, if present
186
What are some complications of a paraesophageal hernia?
Incarcerated or strangulated
187
What is indicated for recurrent or intractable symptoms of hiatal hernias?
Surgery → often involves a Nissen fundoplication
188
What is gastritis? How can it be classified?
- Inflammation of the gastric mucosa
| - It can be classified erosive or nonerosive
189
What is gastritis usually due to?
- NSAID use
- Alcohol
- Severe illness (viral infection)
- Trauma
190
What is nonerosive gastritis caused by?
Helicobacter pylori
191
Nonerosive gastritis is present in what percentage of the population?
30 - 50%
192
What could nonerosive gastritis cause?
Gland atrophy or metaplasia
193
What is the presenting symptom of gastritis?
Mild dyspepsia
194
What is often the first sign of hospitalized patients with stress gastritis?
Blood in the nasogastric aspirate or hematemesis ("coffee grounds" emesis)
195
True or false: There is usually not significant bleeding in gastritis?
True (because lesions are superficial)
196
Why does alcohol cause gastritis?
Alcohol is a relaxant → makes it easier to vomit and acid comes up
197
In gastritis, endoscopy should be done promptly to rule out bleeding from more serious lesions such as what?
- Ulcers
| - Esophageal varices
198
True or false: Nonerosive gastritis is usually asymptomatic.
True
199
True or false: In nonerosive gastritis, petechiae and erosions may be seen.
False (this happens in erosive gastritis → in nonerosive gastritis, the stomach appears normal but biopsy shows inflammation with neutrophils and lymphocytes)
200
What might be sufficient treatment for erosive gastritis? What else are commonly used?
- Avoidance of NSAIDs and alcohol
| - Antacids and H2-blockers
201
What is used as a prophylactic to prevent stress gastritis in intensive care units?
H2-blockers
202
In peptic ulcer disease, where is ulcerative corrosion of the epithelium more common - stomach or duodenum?
Duodenum
203
What is the injurious agent in peptic ulcer disease?
Gastric acid
204
In peptic ulcer disease, what plays an important role in weakening the epithelium and making it susceptible to damage?
H. pylori
205
Besides H. pylori, what are other risk factors for peptic ulcer disease?
- NSAIDs
- Smoking
- Alcohol
- Radiation treatments
- Being very ill (ventilator)
206
True or false: Numerous ulcer patients have higher-than-normal acid secretion.
False (few ulcer patients...)
207
True or false: Nausea and epigastric tenderness are common in PUD patients.
True
208
Fecal occult blood is present in what number of PUD patients?
1/3
209
Ulcers may be complicated by what three things?
- Bleeding
- Perforation
- Obstruction
210
What test may an ulcer be seen on?
GI series
211
What test identifies active H. pylori infection or malignancy in PUD patients?
Endoscopy with biopsy
212
What is a particular concern of gastric ulcers in a patient without history of NSAID use?
- H. pylori Infection
| - Malignancy
213
How is H. pylori tested for in biopsy tissue with PUD patients?
Urease using pH-sensitive media
214
In PUD patients, what noninvasive test is used to document H. pylori eradication after therapy?
14C and 13C urea breath tests
215
When assessing for H. pylori in PUD patients, why are serum antibodies only sometimes useful?
They cannot distinguish between active and resolved infection
216
In PUD patients, what levels should be measured to exclude hypersecretory states such as Zollinger-Ellison syndrome?
Serum gastrin levels
217
Zollinger-Ellison syndrome may be single or small multiple tumors. How many of the single gastrinomas are cancerous? Where do they spread to?
- 1/2 to 2/3 are cancerous
| - Spread to nearby organs (liver)
218
What combination of antibiotics are used to treat H. pylori?
- Tetracycline
- Metronidazole
- Amoxicillin
- Clarithromycin
219
What drugs could be added to the antibiotic regimen to treat H. pylori?
Bismuth subsalicylate (Pepto-Bismol) or proton pump blockers
220
True or false: After successful treatment of an infection of H. pylori, ulcers are still common.
False (ulcers are rare)
221
Nonhealing ulcers → what should you think?
Cancer
222
True or false: With ulcers, chronic H2-blocker therapy and surgical treatment are now rarely necessary.
True
223
In patients who cannot stop NSAID treatment, what would be given to patients with ulcers to reduce ulcer recurrence?
Coadminstration of H2-blockers, proton pump inhibitors, or prostaglandin analog misopristol (use of COX-2 selective NSAIDs also helps)
224
Which drug protects tissue lining in PUD?
Carafate (Sucralfate)
225
What is the normal regimen of PUD?
2 antibiotics + bismuth
226
In PUD, what percentage is a gastric ulcer? duodenal ulcer?
```
Gastric = 25%
Duodenal = 75%
```
227
True of false: Gastric ulcers occur in younger people; duodenal ulcers occur in older.
False (opposite)
228
What is the major risk factor for gastric ulcers?
NSAIDs
229
What is the major risk factor for duodenal ulcers?
H. pylori
230
True or false: Pain with gastric ulcers varies, often not relieved by eating.
True
231
True or false: Pain with duodenal ulcers improves with food, worse 6-8 hours later.
False (it is true that duodenal ulcers improve with food but it gets worse 2-4 hours later
232
Stomach cancer is almost always what kind of cancer?
Adenocarcinoma (although squamous cell tumors may invade from the esophagus)
233
What four forms can gastric carcinoma take?
- Ulcerating carcinoma
- Polypoid carcinoma
- Superficial spreading carcinoma - Linitis plastica
234
What is ulcerating carcinoma?
Penetrating, ulcer like tumor with shallow edges
235
How would you differentiate an ulcer in PUD with an ulcer from gastric cancer?
Raised edges seen in peptic ulcer disease and shallow edges in cancer
236
What is polypoid carcinoma?
Involves a bulky, intraluminal tumor that metastasizes late
237
What is superficial spreading carcinoma?
Confined to the mucosa and submucosa (also called early gastric carcinoma)
238
Out of the four types of gastric carcinoma, which one has the best prognosis?
Superficial spreading carcinoma
239
What is linitis plastica?
Spreads throughout all the layers of the stomach, decreasing in elasticity
240
Out of the four types of gastric carcinoma, which one has a poor prognosis?
Linitis plastica
241
What is a risk for stomach cancer?
H. pylori
242
Who are most at risk for gastric cancer?
- Older men
- African Americans
- Hispanics
- Asian-Americans
- Chileans
- Icelanders
- Japanese
- Chinese
243
Where is there a high incidence of gastric cancer?
Japan
244
What are the most common symptoms of stomach cancer?
- Abdominal heaviness
- Early satiety
- Anorexia
- Weight loss
- Rarely, melena
245
What is melena?
Black, tarry stools
246
Vomiting may occur in gastric cancer. What would this be due to?
Pyloric obstruction
247
Why would the vomitus from stomach cancer have a "coffee-ground" appearance?
Bleeding
248
What two things cause "coffee-ground" appearing vomitus?
- Stress gastritis
| - Gastric carcinoma
249
True or false: Many gastric carcinoma patients have a positive guaiac test and over 70% have a palpable epigastric mass.
False (It is true that many gastric carcinoma patients have a positive guaiac test but less that 20% have a palpable mass)
250
What does a Virchow's node indicate in gastric cancer?
Metastasis
251
What is a Virchow's node?
An enlarged left supraclavicular node
252
What are Krukenberg's tumors? What do they show metastases of?
- Ovarian massess
| - Gastric carcinoma to the ovary
253
What levels are often elevated in gastric carcinoma? What does this mean?
- Carcinoembryonic antigen (CEA)
| - Tumor has spread
254
In gastric cancer, why is hematocrit low in many patients?
Occult blood loss
255
In gastric cancer, what test will show most tumors?
Upper GI series
256
What test would differentiate gastric cancer from benign lesions?
Gastroscopy and biopsy
257
What is the sole treatment option for gastric cancer?
Surgical resection
258
What are the survival rates for early gastric cancer? What is the overall 5-year survival in the United States?
- 90%
| - 12%
259
What is normal hemoglobin? What is normal Hct?
Hemoglobin = 12-15
| Hct is 3x that = 36-45
260
When do hernias occur?
Intra-abdominal tissue protrudes through a defect in the abdominal wall
261
Where are hernias commonly found?
- Umbilicus
- Along the linea alba
- Along the femoral sheath
- In the inguinal region
262
What are indirect inguinal hernias?
Congenital defects that result when the process vaginalis fails to close after the testicle has descended into the scrotum
263
What are direct inguinal hernias?
Caused by a weakness of the abdominal musculature in Hesselbach's triangle
264
What are the borders of Hesselbach's triangle?
- Rectus abdominus medially
- Inguinal ligament inferiorly
- Inferior epigastric vessels laterally
265
Who do direct inguinal hernias develop in?
Adults
266
What is a reducible hernia?
One in which the abdominal contents can be manipulated back into the abdominal cavity
267
What may an irreducible hernia or incarcerated hernia result in?
Bowel obstruction or tissue strangulation
268
How would a person with a hernia present?
May be asymptomatic or may report an aching discomfort in the region
269
What could cause a hernia?
- Heavy lifting
- Pregnancy
- Straining
- Over-weight
270
How would you diagnose a hernia?
Clinical inspection
271
How would you distinguish between a direct and an indirect hernia?
Requires digital invagination of the skin along the spermatic cord and palpation of the internal ring. An indirect hernia protrudes at this point, whereas a direct hernia will be felt medial to the ring
272
Why is surgical repair necessary for a hernia?
To prevent bowel incarceration, obstruction, and infarction
273
Why would you have a patient bear down or cough while doing an examination for hernias?
A mass may bulge when intra-abdominal pressure increases
274
What is diverticulosis?
An acquired condition of multiple diverticula in which the colonic mucosa and submucosa herniate through the muscular layer
275
What part of the GI tract is diverticulosis most common?
Sigmoid colon
276
Diverticulosis is common in what kind of nation? Why?
- Developed nations
| - Low-fiber diet, resulting in increased intraluminal pressure
277
What are the signs / symptoms of diverticulosis?
Generally asymptomatic but may arise from a lower GI bleed or from diverticulitis
278
How is diverticulosis diagnosed?
Barium enema or colonoscopy
279
What might reduce the risk of complications in diverticulosis?
High-fiber diet
280
What should be avoided in diverticulosis?
Foods that can become impacted in the diverticulum, such as small seeds and peanuts
281
What is diverticulitis?
A complication of diverticulosis → occurs when a diverticulum becomes infected or perforates, causing an abscess or peritonitis
282
How might diverticulitis become further complicated?
- Formation of fistulas to the bladder, vagina, or skin
| - By the development of adhesions that cause small bowel obstruction
283
What are the signs / symptoms of diverticulitis?
Acute lower abdominal pain on the left side (LLQ), accompanied by:
- Fever
- Chills
- Constipation
- Loose stools
284
True or false: In diverticulitis, occult blood in stool is common and frank bleeding may occur.
True
285
In a patient with diverticulitis, what might be present on examination?
Lower abdominal mass
286
What can confirm perforation in diverticulitis?
A plain abdominal film showing free air under the diaphragm
287
What can be used to locate an abscess during an acute attack of diverticulitis? What can be used after the acute attack has been completely resolved?
- CT scan with water-soluble contrast
| - Barium enema x-ray or colonoscopy
288
What is the treatment for mild cases of diverticulitis?
Managed on an outpatient basis with a clear liquid diet and oral antibiotics to cover both gram-negative bacteria and anaerobes
289
What is the treatment for severe cases of diverticulitis?
Hospitalization, with nasogastric tube placement, IV antibiotics, and surgical resection
290
What is a fistula?
An abnormal connection between two epithelium-lined organ or vessels that usually do not connect
291
What might happen if the enzymes are absent in the small bowel or the mucosa is inflamed?
Malabsorption
292
What are symptoms of malabsorption due to?
- Increased fecal fat
- Bacterial fermentation of unabsorbed food
- Vitamin and nutrient deficiencies
293
What does lactose intolerance result from?
A deficiency of the enzyme lactase
294
What is the function of lactase?
Splits lactose into glucose and galactose
295
What does unsplit lactose in the bowel lumen cause?
- Osmotic diarrhea
| - Bacterial fermentation of lactose produces excessive gas
296
What is lactase deficiency characterized by?
Bloating and explosive diarrhea after milk intake
297
Where is lactase usually located?
Jejunal brush border
298
What disease can result in lactase deficiency?
- Crohn's disease
- Other types of malabsorption disease
- Gastritis
299
What can cause temporary lactase deficiency?
Viral gastroenteritis
300
Who dose lactase insufficiency normally occur in?
- 75% of adults in most ethnic groups
| - Less than 20% of those of northwestern European descent
301
When is the onset of lactase insufficiency?
Between 10-20 years of age
302
How can you prevent the symptoms of lactase insufficiency?
Lactose-free diet
303
What is celiac sprue?
Hereditary sensitivity to the gliadin component of gluten
304
What is gluten?
A protein found in wheat, barley, and rye
305
In celiac sprue, interaction of gliadin with antibodies initiates what to happen?
Immune reaction that causes jejunal mucosal damage
306
What are common symptoms of celiac sprue in children?
- Failure to thrive
- Abnormal stools
- Bloating
307
What are common symptoms of celiac sprue in adults?
- Syndrome of malabsorption
| - Vitamin deficiency
308
How do you diagnose celiac sprue?
Finding antiendomysial or antigliadin antibodies in the serum or by biopsy showing loss of normal villi in the jejunal mucosa
309
Patients with celiac spur have an increase of developing what?
Other autoimmune diseases and intestinal lymphoma
310
What is tropical sprue?
A malabsorption syndrome of unknown etiology → characterized by nutritional deficiencies and small-bowel mucosal abnormalities
311
Tropical sprue is an acquired disorder primarily found where?
- Caribbean
- South India
- Southeast Asia
312
What are curative for tropical sprue?
- Folic acid replacement
| - Tetracycline
313
What is Whipple's disease?
Rare disorder of middle-aged men, caused by infection with the bacillus Tropheryma whippeli
314
What symptoms present with Whipple's disease?
- Joint pain
- Weight loss
- Other symptoms of malabsorption
- Fever
- Cough
- Lymphadenopathy
- Congestive heart failure
- New murmurs due to myocardial involvement
- Neurologic symptoms such as seizures or dementia
315
Whipple's disease is diagnosed by jejunal biopsy. What will be seen?
Foamy macrophages containing masses of gram-positive, rod-shaped bacilli that stain with the periodic acid-Schiff (PAS) reagent
316
What happens if Whipple's disease is untreated?
Death
317
What may cure Whipple's disease?
Antibiotics
318
What are the general signs / symptoms of malabsorption?
- Weight loss
- Abdominal distention
- Flatulence
- Diarrhea
- Steatorrhea (fatty stools)
319
What can protein malabsorption cause?
Hypoproteinemic edema
320
In malabsorption, nutrient deficiencies are common. What do the symptoms include?
- Glossitis (B6)
- Stomatitis (B12)
- Dermatitis (B13)
- Anemia (B6)
- Easy bruising (Vitamin K)
321
Which anemia reflects iron deficiency?
Microcytic anemia → most common in the US
322
Which anemia points to folic acid defiency?
Megaloblastic anemia
323
In malabsorption, low serum ferritin generally indicates what? Why?
- Celiac disease
| - Postgastrectomy state → iron absorption occurs in the duodenum and upper jejunum
324
In malabsorption, what is often positive if fecal fat is present? What test does this make unnecessary?
- Sudan stain
| - Quantative 72-hour fecal fat study is unnecessary
325
In diagnosing malabsorption, what three things usually occur together?
- Weight loss
- Diarrhea
- Anemia
326
To diagnose malabsorption, direct measurement of what is reliable?
Fecal fat
327
In diagnosing malabsorption, what test measures xylose excreted in the urine after an oral load? An abnormality will point to what?
- D-xylose absorption test
| - Mucosal abnormalities
328
What is diagnostic for malabsorption?
Biopsy
329
How do you treat malabsorption?
Treat the underlying disorder
330
What is irritable bowel syndrome?
A common disorder involving chronic GI symptoms, often associated with psychiatric symptoms
331
What are the signs / symptoms of irritable bowel syndrome?
Chronic, crampy abdominal pain, bloating, flatulence, and diarrhea or constipation
332
How do you diagnose irritable bowel syndrome?
Diagnosis of exclusion → presumptive diagnosis may be made in the context of chronic symptoms without weight change or findings on physical examination
333
What should be ruled out when diagnosing irritable bowel syndrome?
- Malabsorption
- Thyroid dysfunction
- Parasitic infections
334
How do you treat IBS?
- Dietary bulk supplements
- Anticholinergics to decrease spasms (Dicyclomine)
- Antidiarrheals (Imodium / Lomitil)
- Tricyclic antidepressants (Elavil)
335
What are two other names for Crohn's disease?
- Regional enteritis
| - Granulomatous colitis
336
What is Crohn's disease?
A chronic and progressive inflammation of the GI tract. Its course is variable and is marked by remissions and exacerbations.
337
Where does Crohn's disease occur in the GI tract?
Anywhere along the GI tract, with lesions most frequently occurring in the distal ileum
338
What does the distal ileum absorb?
B12 and bile salts
339
What are "skip lesions"? What disease does this occur in?
- Discontinuous lesions with normal bowel in between
| - Crohn's disease
340
A majority of patients with what disease have granulomas in the bowel wall or mesenteric lymph nodes?
Crohn's disease
341
Besides "skip lesions" and granulomas, what are other characteristics of Crohn's disease?
- Fissures
- Strictures
- Ulcers
- Transmural involvement
342
What are some complications of Crohn's disease?
- Intestinal obstruction
- Abscess formation
- Fistulas
- Colon cancer
- Systemic manifestations
343
Both Crohn's disease and ulcerative colitis have extracolonic complications. What do they include?
- Peripheral arthritis
- Ankylosing spondylitis
- Uveitis
- Primary sclerosing cholangitis
344
Signs / symptoms of Crohn's disease include manifestations of what?
- Anemia
- Anorectal fissures
- Abscesses
- Recurrent abdominal pain
- Right lower quadrant abdominal mass (due to an inflamed ileum)
- Low-grade fever
- Diarrhea
- Malnutrition
- Weight loss
- Fistulas
- Oral ulcers
345
When testing for Crohn's disease, what would a barium enema or endoscopy show?
- Edema
- Ulceration
- Fistulas
- Strictures
- "Cobblestone" patterns
346
What diagnostic testing would distinguishing between Crohn's disease and ulcerative colitis in subtle cases?
Serologic testing:
- pANCA (antineutrophil cytoplasmic antibodies with perinuclear staining)
- ASCA (anti-yeast S cerevisiae antibodies)
347
What is the initial treatment for Crohn's disease?
- Rest
- Antidiarrheal agents
- Dietary changes with supplemental parenteral nutrition if disease is severe
(Steroids, sulfasalazine, immunosuppressives, and antibiotics are all used with some success)
348
If complications arise from Crohn's disease, such as fistulas and obstruction, what is necessary?
Surgery
349
Is surgery for Crohn's disease curative or palliative?
Palliative
350
What is ulcerative colitis?
A chronic, idiopathic inflammation of the colon and rectum → it has a variable course of remissions and exacerbations
351
What part of the GI tract does ulcerative colitis involve?
Generally the rectum, and in half of the cases it is confined solely to this region (ulcerative proctitis)
352
Which disease is more associated with cancer - Crohn's disease or ulcerative colitis?
Ulcerative colitis
353
In a minority of ulcerative colitis patients, where does inflammation spread to?
Proximally to the distal ileum
354
Ulcerative colitis or Crohn's disease?
| The affected colon is contiguous, without skip lesions.
Ulcerative colitis
355
In ulcerative colitis, where do ulcers and abscesses form? What may this develop into?
- Form in the mucosa and submucosa
- May develop into characteristic pseudopolyps, which occur when inflammatory growths from the intestinal mucosa have a polyplike appearance
356
What is a frequent complication of ulcerative colitis? What may this do to the colon?
- Hemorrhage
| - Colon may become dilated and perforated
357
What are frequent symptoms of ulcerative colitis?
- Rectal bleeding
- Tenesmus
- Crampy abdominal pain
- Blood or mucus with diarrhea
May also experience:
- Fever
- Nausea and vomiting
- Weight loss
- Dehydration
358
What do researchers think might trigger the immune system, leading to inflammation in ulcerative colitis?
Viruses or bacteria
359
True or false: Heredity might play a role in Crohn's disease.
False (Ulcerative colitis)
360
What does sigmoidoscopy show in ulcerative colitis?
Dull, granular, friable mucosa
361
In patients with suspected ulcerative colitis, what must be done to rule out infectious and ischemic colitis?
Biopsy of affected area
362
Barium enemas should not be performed in acutely ill patients of ulcerative colitis, but in its chronic state, what is the typical mucosal irregularity?
"Lead pipe" appearance as the colon narrows, shortens, and loses its haustrations
363
What is used to treat mild exacerbations of ulcerative colitis and maintain periods of remission?
- Sulfasalazine
- Steroids
- Immunosuppressives
364
What is the treatment for more severe episodes of ulcerative colitis?
Hospitalization with nasogastric tube, parenteral nutrition, IV steroids, and antibiotics
365
After diagnosing ulcerative colitis, when should you begin annual colonoscopy and biopsies to check for cancer?
8-10 years after diagnoses
366
How long is a colonoscope?
4-5 ft
367
In ulcerative colitis, which one will be elevated - pANCA or ASCA?
pANCA (60-70%)
368
In Crohn's disease, which one will be elevated - pANCA or ASCA?
ASCA (60-70%)
369
What does the diameter of the transverse colon have to be to diagnose toxic megacolon?
6 cm
370
In adults, what precedes toxic megacolon?
Inflammatory bowel disease (ulcerative colitis and Crohn's)
371
In children, what precedes toxic megacolon?
Hirschsprung's disease
372
What is Hirschsrprung's disease?
Absence of colonic nerve plexus
373
What can toxic megacolon result in?
- Septicemia
- Generalized peritonitis
- Perforation
(carries high mortality rate)
374
What are the signs / symptoms of toxic megacolon?
Patients are severely ill, with high fever, abdominal pain, distention, and hypotension
375
In toxic megacolon, what do abdominal x-rays show?
Intraluminal has along a continuous segment of very dilated bowel
376
How is toxic megacolon treated?
- Patients must be NPO with IV fluid replacement and electrolyte maintenance
- Antibiotics and steroids are administered in IBS
377
Why must passage of a rectal tube be necessary in toxic megacolon?
Alleviate megacolon to prevent sepsis (may cause perforation)
378
What is located between longitudinal and circular layers of muscular is externa in the GI tract which gives motor innervation to both layers and secretory innervation to the mucosa?
Auerbach's plexus (myenteric plexus)
379
True or false: Auerbach's plexus has both parasympathetic and sympathetic input.
True
380
Who usually gets ischemic colitis?
50 y/o or more with history of peripheral vascular disease
381
What is ischemic colitis caused by?
Insufficient blood supply to the colon, leading to inflammation and eventually necrosis.
382
What is the etiology of ischemic colitis?
Atherosclerotic or embolic
383
Younger patients who have ischemic colitis usually have what chronic diseases?
- Diabetes
- Lupus
- Sickle cell anemia
384
Reversible ischemic colitis heals with medical management, but irreversible cases require what?
Surgical treatment
385
True or false: Ischemic colitis has a low mortality rate.
False (it has a high mortality rate)
386
What are the signs / symptoms of ischemic colitis?
Patients experience an abrupt onset of abdominal pain after eating and may have bloody diarrhea, fever, and vomiting.
387
In which disease is the patient's pain out of proportion to the examination findings?
Ischemic colitis
388
In ischemic colitis, what does endoscopy show?
Bloody, edematous, friable mucosa and may reveal ulcers or a gray membrane.
389
If you see a gray membrane during endoscopy of a patient with ischemic colitis, why must you check the stool?
To check for clostridium difficile.
390
What does barium x-ray demonstrate on a patient with ischemic colitis?
"Thumb print" or pseudotumor pattern caused by thickened, edematous mucosal folds.
391
What is usually sufficient therapy for ischemic colitis? But what must be done in the case of irreversible damage?
- IV fluids and antibiotics
| - Resection of the ischemic portion of the colon (if irreversible)
392
When should people get a colonoscopy?
Every 10 years starting at age 50 unless otherwise needed
393
What are the risk factors for colonic polyps?
- Greater than 50 y/o
- Family member with polyps
- Family history of colon cancer
394
What are colonic polyps?
Small tissue masses projecting into the colonic lumen
395
What are two different kinds of colonic polyps? What are three different origins?
- Sessile or pedunculated
| - Mucosal, submucosal, muscular
396
True or false: Neoplastic polyps may be inflammatory, hyperplastic, or hamartomatous.
False (Neoplastic polyps are adenomas; Non-neoplastic are inflammatory, hyperplastic, or hamartomatous)
397
What is a sessile colonic polyp?
Attached directly by its broad base without a stem or peduncle.
398
What percentage of 70 year olds have adenomatous polpys?
50%
399
What are probably the origin of most large-bowel adenocarcinomas?
Adenomatous polyps
400
Fill in the blank concerning colonic polyps:
Cancer is found in only 1% of adenomas less than ___ cm in diameter, but it is found in 45% of adenomas more than ___ cm in diameter, making size an important predictor of histology.
1 cm / 2 cm
401
True or false: Villous adenomas are more frequently malignant than tubular adenomas.
True
402
True or false: Penduculated polyps are more often malignant than sessile polyps.
False (opposite)
403
What is familial adenomatous polyposis?
Rare, autosomal-dominant condition involving multiple polyps that eventually develop into colorectal cancer if left untreated.
404
What is acquired by ingesting undercooked or raw oysters?
Vibrio Parahaemolyticus
405
What is the smallest inoculate?
Shigella
406
At any time that a GI infection is suspected, what test should be done?
Stool culture
407
What should NOT be given for Shigellosis and why?
Anti-diarrheals, such as Lomotil, because they may prolong the course.
408
What is the most common syndrome caused by Salmonella?
Gastroenteritis
409
You're at a restaurant and are considering the poached eggs, why should you NOT get them?
Because the bacteria is not cooked out totally and you may get gastroenteritis from Salmonella.
410
How soon do symptoms from Salmonella Gastroenteritis appear?
Within 2 days of eating the infected food.
411
Which is more serious hemorrhagic colitis or pseudomembraneous colitis?
Hemorrhagic
412
What causes hemorrhagic colitis?
enterohemorrhagic E. coli
413
How long can an uncomplicated case of hemorrhagic colitis last?
Approx 1 week
414
What complicates hemorrhagic colitis?
1. Hemolytic-uremic syndrome: Anemia, Renal, Thrombocytopenia
2. Thrombotic thrombocytopenic purpura: Fever, Anemia, Renal, Thrombocytopenia, Neurological
415
What bacterium most often causes pseudomembranous colitis?
Clostridium difficile
416
What is the treatment for pseudomembranous colitis?
Metronidazole or oral Vancomycin
417
Can antibiotics cause pseudomembranous colitis?
YES- Clindamycin, Ampicillin and Cephalosporins.
418
What is a benign tumor-like nodule composed of overgrowth of mature cells and tissues? They are normally present in the affected part, but often with one element predominating.
Harmatoma
419
What is Peutz-Jeghers associated with?
Associated with freckling of lips; polyps carry low but definite risk
420
True or false: Polyps are generally asymptotic.
True
421
Larger lesions in the GI tract can cause intermittent bleeding and changes in bowel habits such as what?
- Increased frequency
- Constipation
- Tenesmus
422
True or false: Proximal polyps may be felt on digital rectal examination.
False (distal polyps)
423
In trying to diagnose colonic polyps, what will barium enema show?
Colonic lesions suggestive of polyps
424
How can you confirm diagnosis of colonic polyps?
Colonoscopy
425
A patient has colonic polyps. Why must you biopsy them?
To rule out cancer
426
What is the second most common site of visceral cancer in Western countries?
Colon
427
At what age does the incidence of colon cancer increase?
Above age 40
428
The vast majority of colon cancer are what kind of cancer?
Adenocarcinoma
429
What are the risks of colon cancer?
- Personal history of previous colon cancer or adenomatous polyps
- Family history of colon cancer - Ulcerative colitis
- Autosomal-dominant familial adenomatous polyposis
430
Where is there an increased incidence of colon cancer?
- Higher socioeconomic classes
| - Related to high-fat, high-calorie, low-fiber, and low-calcium diets
431
Where does colon cancer frequently spread?
Regional lymph nodes
432
Besides spreading to regional lymph nodes, how else might colon cancer spread?
- Direct extension - Hematogenous spread
| - "Seeding," or transperitoneal metastasis
433
True or false: Colon cancer spreading by direct extension is seen with the common circumferential growth pattern of left colon lesions, and it can invade nearby structures.
True
434
True or false: Hematogenous spread may cause local implants or generalized abdominal carcinomatosis.
False (this is describing "Seeding" or transperitoneal metastases → Hematogenous spread commonly leads to metastases in the liver and lungs)
435
Which two systems are used to classify colon cancer?
TNM and Dukes classification
436
In colon cancer, how long does adenocarcinoma remain asymptomatic?
Approximately 5 years
437
Right or left-sided colon cancer? Lesions typically cause weakness secondary to anemia and discomfort or fullness.
Right-sided (it causes right-sided discomfort or fullness)
438
Right or left-sided colon cancer? More often causes changes in bowl habits from occlusion of the lumen, with alternating constipation and increased frequency, blood-streaked stool, and stool with decreased diameter ("pencil stools")
Left-sided
439
What test should you follow to see if treatment of colon cancer is working?
CEA
440
In 70% of colon cancer patients, what is elevated in the serum? Is this specific to colon cancer?
- CEA (carcinoembryonic antigen)
| - No
441
In colon cancer patients, what do CBCs often reveal?
Anemia
442
What are the principle means of diagnosis for colon cancer?
Barium enema examination and colonoscopy with biopsy
443
On contrast examination, what does colon cancer appear as?
An annular, "apple core" filling defect
444
What is the first step in the treatment of colon cancer?
Surgical resection of the lesion
445
What is important to stage colon cancer? What does this help with?
- Regional lymph node dissection
| - Deciding about adjuvant radiation or chemotherapy
446
In advanced stages of colon cancer, what is often helpful for palliation? What does this prevent?
- Resection
| - Obstruction and bleeding
447
What is the overall percentage of survival in colon cancer patients?
35%
448
According to the American Cancer Society, when should annual digital rectal exams begin?
40 years of age
449
According to the American Cancer Society, annual stool occult blood tests and flexible sigmoidoscopy every five year is recommend to start at what age?
50 years of age
450
Which stage of colon cancer? Very early cancer on innermost layer of intestines
0
451
Which stage of colon cancer? Cancer of innermost layers of colon
1
452
Which stage of colon cancer? Cancer of muscle wall
2
453
Which stage of colon cancer? Lymph nodes
3
454
Which stage of colon cancer? Metastases
4
455
True or false: Colon cancer is related to red meat.
True
456
Rectal cancer is usually what kind of cancer?
Adenocarcinoma
457
What is the most frequent presenting symptom of rectal cancer?
Persistent hematochezia, which must be evaluated for cancer even in the presence of hemorrhoids
458
What is hematochezia?
Blood-streaked stools
459
What are common symptoms of rectal cancer besides hematochezia?
- Tenesmus
- Altered bowel habit
- Sensation of incomplete evacuation
460
In rectal cancer, what can be palpated on digital examination?
Distal lesions
461
What is the treatment for rectal cancer?
Surgical resection, often with adjuvant radiation terapy
462
Where do internal hemorrhoids arise from?
A cushion of veins above the dentate line
463
Where do external hemorrhoids arise from?
Veins below the dentate line
464
What are hemorrhoids?
Swollen veins in lower portion of rectum or anus
465
What is the dentate line? What is another name for it?
- Divides upper 2/3 from lower 1/3 of anal canal
| - Pectonate line
466
When do hemorrhoids engorge due to increased venous pressure?
- Constipation / straining
- Prolonged sitting
- Pregnancy
- Obesity
467
What are symptoms of hemorrhoids?
Discomfort and small amounts of bright red bleeding
468
Internal or external hemorrhoids? Don't hurt but may bleed painlessly.
Internal
469
Internal or external hemorrhoids? Can be itchy / painful and can come times crack and bleed.
External
470
Internal or external hemorrhoids? Are visible around the anus
External
471
Internal or external hemorrhoids? Can be visualized using an anoscope
Internal
472
What diagnostic tool is frequently indicated to rule out causes of bleeding in the rectum or sigmoid colon, despite the presence of hemorrhoids?
Sigmoidoscopy
473
What is indicated in a patient with hemorrhoids if microcytic anemia is present?
Colonoscopy
474
What is the first line of treatment for hemorrhoids?
- Increasing dietary fiber and avoiding prolonged sitting and straining
- Sclerotherapy, rubber band ligation, and excision are also options
475
What is sclerotherapy?
Injecting sclerosing agent
476
What is rubber band ligation?
Hemorrhoid is tied off at its base with rubber band, cutting off blood supply leading to shrinkage and death. It will fall off in around a weak. Pain for 1-2 days. Take analgesics and use a stool softener.
477
What are anal fissures?
Painful, linear tears in the epithelium of the anal verge, usually in the posterior midline
478
What is the anal verge?
Opening of the anus onto surface of body
479
Why do anal fissures occur?
Generally result from trauma during defecation
480
Atypical fissures should raise the suspicion of what disease?
Crohn's
481
What are the symptoms of anal fissures?
Intense pain with defecation, which may lead to constipation, and spots of bright red bleeding
482
What is the treatment for anal fissures?
- Softening of stools to allow healing
| - Sitz-bath-sit
483
What may develop at the site of anal fissures?
Skin tag (sentinel pile)
484
A patient with recurrent anal fissures would benefit from what procedure? What might this cause?
- Partial sphincterotomy
| - Fecal incontinence is at risk
485
What is Sitz-bath-sit?
Treatment for anal fissures → sit in hot water which causes vessels to expand and blood to flow
486
What exam should be performed for anal fissures?
Rectal exam with rectal tissue biopsy
487
What arise from infection of anal crypts at the dentate line, infection of a prolapsed internal hemorrhoid, and infection of a hair follicle or local abrasion?
Anorectal abscess
488
What are the symptoms of anorectal abscesses?
Throbbing rectal pain and, if the abscess is large, systemic signs of infection
489
Superficial or deeper abscess? Indurated, red, and may be fluctuant
Superficial
490
Superficial or deeper abscess? Tender on digital rectal exam
Deeper
491
How do you diagnose anorectal abscesses?
Clinical examination → collection of pus in area of anus and rectum
492
What is the treatment for anorectal abscesses?
- Antibiotics to cover both aerobic and anaerobic gram-negative rods
- Complete incision and drainage (which may need to be done in the operating room depending on the extent of the abscess)
493
What might abscesses be complicated by?
Formation of a fistula, usually between the anal crypt and the site from which the abscess drains
494
What might be palpated if there is a fistula?
Cord-like tract
495
What is the treatment for a fistula?
Fistulotomy, in which the tract is completely opened and allowed to heal from within.
496
Where does Amebiasis cause abscesses in?
The liver.
497
How many O&P need to be done to diagnose Amebiasis?
Three sequential O&P.
498
How is Amebiasis treated?
Metronidazole and Paromomycin.
499
"Explosive gas" is seen in?
Giardiasis
500
How is giardiasis diagnosed?
Cysts, trophozoites OR the giardia antigen is identified in a stool sample.
501
Why is metronidazole used to treat Giardiasis?
It is used to treat anything anaerobic.
502
Acute pancreatitis is MOST commonly caused by?
```
Gallstone disease
Alcoholism
or
Hypercalcemia
Hyperlipidemia
Drugs or other unidentified causes.
```
503
Do Grey Turner and Cullen's sign occur in most cases of acute pancreatitis?
No, only 1-2% of cases.
504
What is the "colon cutoff sign" and what is it seen in?
Gas distending the right colon that abruptly stops near the pancreas.
Seen in acute pancreatitis
505
What is used to predict the diagnosis of acute pancreatitis?
Ranson's criteria:
The presence of three of more are associated with increased mortality.
```
On admission:
A-age > 55
B-blood sugar > 200 mg/dl
C-cells (wbc) > 16,000/ml
D-dehydrogenase >350 IU/L
E-enzymes (ast) >250 units
```
Within 48 hours: ( Calvin and Hobbs - C'HOBBS)
C'-calcium (serum) < 8 mg/dl
H-hematocrit >10%
O-partial Oxygen < 60 mm Hg
B- blood Urea Nitrogen > 5 mg/dl
B- base deficit >4 meq/l
S- Sequestration (fluid sequestration) > 6 L
0-2 criteria: 2% mortality
3-4 criteria: 15% mortality
5-6 criteria: 40% mortality
>6 criteria: 100% mortality
506
When will amylase level be normal with acute pancreatitis?
When the pancreas is fibrotic.
507
What makes something a pseudocyst?
When the walls consist of inflamed membranous material not epithelial tissue as in a true cyst.
508
Are pseudocysts sterile?
Generally, but infection can lead to abscess formation.
509
How are pseudocysts seen?
Ultrasound or CT scan.
510
Where are adenocarcinomas found in the exocrine pancreas?
ductal, in the head of the pancreas.
511
Who does cancer of the exocrine pancreas mostly happen to?
Middle-aged men.
512
From diagnosis to death with exocrine pancreatic cancer is generally how long?
A year.
513
When would obstructive jaundice occur with cancer of the exocrine pancreas?
If the tumor is in the head of the pancreas and impinges on the bile duct.
514
What are the four cancers of the endocrine pancreas?
1. Insulinoma
2. Zollinger-Ellison syndrome
3. VIPoma
4. Glucagonoma
515
What is Whipple's triad and what will it confirm?
1. Hypoglycemia
2. Low blood sugar at time of symptom
3. Relief when glucose is given
It confirms that hypoglycemia is the source of the insulinoma.
516
What does a C-peptide assay confirm and why?
It confirms that insulin is endogenous.
C-peptide is like a cap on top of insulin, manufactured with insulin and then cleaved. If present- insulin= endogenous.
517
Which of the cancers of the endocrine pancreas is gastrin producing?
Zollinger-Ellison syndrome
518
Which of the cancers of the endocrine pancreas is a non-beta islet-cell tumor that produces vasoactive intestinal peptide?
VIPoma
519
VIPoma is also known as WDHA, why?
Because it usually involves Watery Diarrhea, Hypokalemia and Achlorhydria. (WDHA)
520
Which of the cancers of the endocrine pancreas is a tumor of the alpha islet cells, rare and slow growing?
Glucagonoma
521
Necrolytic migratory erythema is a characteristic exfoliating lesion of which of the cancers of the endocrine pancreas?
Glucagonoma
522
What are the 4 F risk factors for cholelithiasis?
Female, fertile, forty and fat.
523
In most cases what type of stones will patients have with gallstones?
Cholesterol stones.
524
What are other increased risks for developing gallstones?
1. In pregnancy-with failure of the gallbladder to empty.
2. Anemic patients-increased bilirubin.
3. Cirrhosis
4. Biliary tract infection.
5. Diabetes mellitus
6. Long term parenteral nutrition
525
Why would acalculous cholecystitis occur?
1. Patients on total parenteral nutrition
| 2. Critically ill patient with no oral intake.
526
What does a positive Murphy's sign indicate?
Cholecystitis
527
What is more accurate to diagnose cholecystitis- U/S or HIDA scan?
HIDA (hepatic iminodiacetic acid) which uses radioactive isotopes taken up by the liver and excreted in the bile.
528
What is Charcot's triad a sign of?
Cholangitis:
Biliary colic
Jaundice
Fever
529
Which labs are most strikingly elevated with biliary tract neoplasm?
Elevated conjugated bilirubin.
530
What are some treatment options biliary tract neoplasm?
1. Surgery- if small and caught early
2. Liver transplant- if not spread outside the liver.
3. Chemo and radiation
4. Photodynamic treatment
531
Spiking fever, chills, RUQ pain and tender hepatomegaly are seen in?
Hepatic abscess
532
If a patient isnt treated for hepatic abscess can it be deadly?
Yes- it can be fatal due to sepsis, empyema, peritonitis and rupture.
533
Subphrenic abscesses are often seen in what type of people?
The elderly.
534
What is the most common cause of prehepatic jaundice?
Hemolysis
535
What are two hepatic jaundices?
Hepatocellular- acute hepatitis, chronic cirrhosis
| Cholestatic- primary biliary cirrhosis, toxic drug jaundice and jaundice in pregnancy.
536
What is Crigler Najjar syndrome?
Hepatic jaundice.
Type I: child gets defective allele from each parent= absent glucoronyl transferase = death.
Type II: Carriers with one defective allele= 1/2 the enzymes as normal. CJ II and Gilbert's disease are the same.
537
What is Dubin- Johnson syndrome?
Defect in the ability of hepatocytes to secrete conjugated bili into bile- similar to Rotter syndrome.
538
Labs with prehepatic jaundice will show?
Increased bilirubin- in UNconjugated form.
539
What is typical in labs with hepatocellular disease?
A mixture on conjugated and unconjugated bilirubin.
540
When would conjugated bilirubin be increased?
With intrahepatic cholestatis and post-hepatic disease.
541
What is the normal BUN level?
8-20
542
What is the normal bilirubin level?
.6-1.2
543
Is cirrhosis reversible?
No
544
Is hepatic steatosis reversible?
Yes- it is fatty liver which is the first stage.
545
What is GGT used for?
with alcohol related hepatic disease- used to detect disease of the liver or bile ducts.
546
Which level is higher in alcoholic ALT or AST?
AST- because you have to be as "ass" to be drinking!
547
What are good indices of liver function?
1. Albumin
2. Clotting factors
3. Cholesterol
548
7% of American consume how much of alcohol?
50%
549
What is the primary cause of injury-related deaths?
Alcohol
550
What are some complications from alcohol use during pregnancy?
Premature labor
Low birth weight
Fetal alcohol syndrome - microencephaly and mental retardation
551
What is the third leading cause of death in 45-65 year olds in the US?
Cirrhosis
552
Common physical exam findings such as hepatomegaly, splenomegaly, jaundice,wasting, ascites, caput medusa, palmar erythema Duputryen's palmar contracture, peripheral neuropathy,testicular atrophy and gynecomastia are seen with?
Cirrhosis
553
What is Dupuytren's palmar contractures?
Associated with tobacco or alcohol use. It is a painless thickening and contracture between the skin of the palm of the hands and fingers.
554
Can HBV or HCV cause cirrhosis?
Yes
555
What is portal hypertension?
Elevated pressure in the portal vein due to hepatic obstruction, liver disease or extrahepatic portal vein occlusion.
556
What is the most common treatment to control bleeding of esophageal varices?
Octreocide
557
Is hepatic encephalopathy reversible?
Yes
558
Increased rate of breathing, foul smelling breath, altered conciousness and abnormal neuromuscular activity such as asterixis are symptoms of?
hepatic encephalopathy
559
Where is urea produced?
Liver and kidneys
560
Why would you administer lactulose for hepatic encephalopathy?
to decrease intestinal absorption of ammonia
561
Where is the fluid collection in ascites?
The peritoneal cavity.
562
What is done to sample the fluid in ascites?
Paracentesis
563
If there is an increase concentration in of albumin in the ascitic fluid what does that suggest?
Infection or malignancy
564
What is a Leveen shunt used for?
Ascites
565
Benign hepatic adenomas are seen almost exclusively in what patients?
Women taking oral contraceptive pills.
566
What does coffee ground appearance in vomitus indicate?
That the blood has been in the stomach long enough to be digested partially.
567
What is a Mallory-Weiss tears?
Gastroesophageal tears due to retching.
568
What is the lower GI bleeding location?
distal to the ligament of Treitz (duodenal/jejunal border)
569
Passage of bright red blood suggests upper or lower GI bleed?
Lower
570
Guarding and rebound tenderness are signs of what?
Peritonitis
571
Temperature in appendicitis is usually?
Low grade temp
572
What test is done to aid in the diagnosis of appendicitis?
Rovsing test
573
What are the three most common causes of mechanical obstruction of the bowel?
Adhesions
Hernias
Tumors
574
Adhesions are secondary to ?
Surgery and inflammation
575
What are common causes of obstruction in the duodenum in a neonate?
Atresia
Volvulus
Congenital bands
576
What is the "double bubble" sign and where is it seen?
pockets of air on both sides of the obstruction. Seen in volvulus
577
Why does a paralytic ileus occur?
Loss of peristalsis
578
Should patients remain NPO until ileus resolves?
yes
