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GEN MED GI > Gen Med GI > Flashcards

Gen Med GI Flashcards

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1
Q

Gallbladder Cancer Develops From

A

Chronic Cholesystitis

Polyps - a small % are Adenocarcinomic

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2
Q

Types of GB Cancers & incidence

A

Adenocarcinoma 90%

Squamous Cell Carcinoma 10%

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3
Q

Dx Test for GB Polyps

A

Sonogram shows them nicely

Likewise all GB maladies show on Sonogram

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4
Q

Calcification of the gallbladder usually brought on by Gallstones, increases risk of GB Cancer

A

Porcelain Gallbladder

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5
Q

Endoscopic
Retrograde
Cholangeopancreatography

A

ERCP

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6
Q

ERCP enables

A 
Via Endoscopy Visualization of :
Common Bile Duct via Ampulla of Vader
Hepatic Ducts
Cystic Duct
Gallbladder Interior

Stone removal, if small enough

Radiographic dyes can also be injected into the ducts to highlight blockages on Xray

Also used to place stents & dilate as in sclerosing

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7
Q

Dx test for Gall Bladder function

A

HIDA w/Ejection Fraction

Essentially an echo of the GB

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8
Q

HIDA w/ ejection Fraction used when

A

Gallstone Sxs but stones don’t show on soon

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9
Q

Sm Hard Black gallstones

A

Calcium Bilirubinate Stones

Fatty (Alcoholic) Liver
Chronic Hemolysis & Old Age

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10
Q

Soft Greasy Brown gallstones

A

Bilirubinate, Cholesterol & Fatty Acids

Most Common

Infection, Inflammation, Parasites (liver flukes)
Praziquantil for the parasite in case it’s elsewhere too. GB probably still needs to come out.

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11
Q

Biliary Colic,
Pancreatitis,
Ruptured Aortic Thoracic Aneurysm
Perforated Ulcer and Splenic pain travel up this nerve :

A

Phrenic, pain is felt in the C4 dematome

Biliary Colic pain @ Rt subscapular

Perforated Ulcer pain @ Rt Subscapular

Splenic pain @ Left shoulder

Pancreatitis & Aortic Aneurysm @ Back, between shoulder blades

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12
Q

Sign for Cholecystitis

A

Murphy’s Sign

locate lower liver border from pelvis up
Ask Pt to inspire & press up into liver

Wince/pain, sometimes severe is + for cholecystitis AND/or gallstones.

It’s thought to be more cholecystitis but you can’t conclude no gallstones if it’s negative as they’re often the cause of cholecystitis by blocking the cystic duct and causing backup & inflammation and a nice place for B. Fragilis to spawn.

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13
Q

Charcot’s Triad

A

RUQ Pain
Fever
Jaundice

911 for Cholangitis

Order ERCP: Endoscopic Retrograde CholeAngioPancreatography to see and hopefully remove whatever is blocking the hepatic bile ducts

Skip the sonogram if you have the Triad & go STRAIGHT to ERCP

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14
Q

A bacterial Infection superimposed on Hepatic Duct blockage

A

Cholangitis

aka: Ascending or Acute Cholangitis

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15
Q

Primary Sclerosing Cholangitis

A

There WAS an infection of the hepatic ducts and now scar tissue is backing bile up into the liver

Associated with Irritable Bowel

If you don’t have fever or high WBCs, do a SONOGRAM. If fever/infection sign, treat as acute cholangitis and go right to ERCP to view and remove blockage AND place stent. ERCP will be needed for its stenting capacity
or
A liver transplant will be needed

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16
Q

Cholescintigraphy

A

HIDA w/Ejection Fraction

Radioisotopes are ingested and should make it to the gallbladder within 4 hrs. If not, there is a blockage and it can differentiate cholecystitis from early cholangitis. It’s essentially a GB echogram

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17
Q

Dx Tests for Cholangitis before ERCP

A

CBC w/diff

Blood Culture (will need to Rx w/ABX so find out what the bug is, likely B. Fragilis though)

CMP - need liver function tests
- need [Ca++] incase of Pancreatitis also

Blood Type and Match - may need blood if Surgery

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18
Q

CHALOT’S TRIANGLE

A

CYSTIC DUCT
COMMON HEPATIC DUCT
MARGIN OF THE LIVER

Don’t cut the Common Hepatic Duct in your cholecystectomy or bile will drain into the peritoneum and not the duodenum!

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19
Q

A collection of pus w/in a body cavity or hollow organ

A

EMPYEMA

GB
PLEURAL CAVITY
THORACIC, ABD CAVITIES
UTERUS
APPENDIX
MENINGES
JOINTS
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20
Q

Why does Pancreatitis cause Hypocalcemia?

A

Pancreatitis results in secretion of pancreatic enzymes directly into the blood stream via inflammation.

They damage vessel walls (they’re ENZYMES after all) and escape into the abdominal cavity where LIPASE encounters ADIPOSE tissue and digests it to triglyceride & free fatty acids.

Free FA love to bind Ca++ on their anionic end and do so all over the place, reducing the Ca++ available

The degree of hypocalcemia is indicative of the seriousness of the pancreatitis

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21
Q

Sentinel Lymph Node for Gallbladder

A

Mascagni’s Node
aka
Lund’s Node

Located in Chalot’s

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22
Q

Electrolyte Panel Tests for

A

Na, K, Cl, BiCarb

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23
Q

Albumin:

A

3.9 to 5.0 g/dL

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24
Q

Alkaline phosphatase:

ALT (alanine aminotransferase):

AST (aspartate aminotransferase):

A

44-147

8-37

10-34

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25
BUN (blood urea nitrogen): Creatinine:
7-20 BUN 0.8 - 1.4 Cr
26
Calcium: Chloride:
8.5 - 10.9 Ca 96 - 106 Cl
27
Potassium test: Sodium:
3.7 - 5.2 K 136 - 144 Na
28
Total bilirubin: Total protein:
0. 2 - 1.9 mg/dL bilirubin | 6. 3 - 7.9 GRAMS/dL more Albumin!!
29
Difference between BMP & CMP
CMP is BMP + : ``` Proteins - Alb & Total Bilirubin - Total Alk Phos ALT AST ```
30
On BMP
``` Electrolytes: Ca, Cl, K, Na Kidney Function: BUN & Cr Glucose CO2 ```
31
Ursodiol
Oral Bile Acid Dissolves gallstones over many months Works on tiny cholesterol stones (Ursodeoxycholic Acid)
32
Most common complication of cholelithiasis
Acute Cholecystitis 95% cholecystitis pts have stones
33
Cholecystitis
Inflamm of GB second to blockage of cystic duct by gallstone
34
Risks of Cholecycistis
Rupture & Peritonitis Get Sonogram & stabilize ASAP with ABX Then Remove GB w/in 48 Hrs!!!
35
Describe Biliary Colic Pain
Begins 1-2 hrs after eating (fat) sometimes waking if ate late RUQ w/shoulder and/or back radiation Increases in intensity like a bell curve is then steady for 6-12 hrs while fats are digested Sore (Murphy sign possible) even after episode passes between meals.
36
Cholecystitis stabilization Abx
Cephtriaxone + Flagyl + Pip/Taz (Zosyn)
37
Flagyl
Metronidazole Anaerobes & Protozoa & Yeasts Always one of the combos for gut infection as they're all anaerobes of one sort or another
38
Zosyn
Piperacilin/Tazobactam 4th gen Penicilin, great on pseudomonas Good for Peritonitis & Pneumonia Delivered q6-8 hrs IV over 30 min or steady over 4 hrs to achieve best MIC
39
Gallstone perforates gallbladder & sm. bowell creating direct connection between the two organs
Cholecystoenteric Fistula
40
Gallstone Pancreatitis
Stone blocks Sphincter of ODI or Ampulla of Vader & backs up bile & pancreatic secretions into Pancreas causing Pancreatitis and eventually Cholangitis/Cholecystitis
41
Tumor or Growth doesn't belong but not necessarily malignant
Neoplasm
42
Gastrinoma
Gastrin Secreting Tumor Causes high Gastrin between meals Dx is Secretin Stimulation Test. Secretin inhibits gastrin unless its from a gastrinoma, in which case gastrin levels will remain high
43
Zollinger-Ellison Syndrome Heartburn sxs soon after eating, like PUD Steatorrhea
Pancreatic Gastrinoma If H. Pylori Test is Neg., refer pt to GI for endoscopy Curable w/surgery if no mets so if Endo is +, put them on H2/PPI to control acid day to day, get a CT & PET to look for mets. Remove Pancreas or most thereof if no mets Chemo/Rad if Mets - fairly fast to end though and 2/3 are Metastatic on Dx as sxs seem just like heartburn immediately on eating.
44
Extra-nodal Site
Cancer starts elsewhere & mets to extra nodal sites: Stomach is often extra nodal except in 'nomad that are caused by H. Pylori
45
H. Pylori caused Cancers
Gastric Lymphoma | Gastric Adenocarcinoma
46
Starts in the stomach H.Pylori is primary infection Over 60/epigastric pain/weightloss/fatigue early satiety Very Slow progression Very Curable Early
Gastric Lymphoma aka MALT Lymphoma (mucosa assosiated lymphoid tumor)
47
H. Pylori Eradication Therapy
Endoscopy/Biopsy to Definitive Dx or... Urease Breath Test/ H. Pylori blood AB test ``` For 10 days Omeprazole BID Clarithromycin 500 mg PO BID Amoxicillin 500 mg PO BID Flagyl 500 mg PO BID ``` Redo Biopsy 4 weeks after abx therapy ends to ensure it worked If it doesn't work, do it again and add Pepto Bismol
48
Gastric Lymphoma Rx
H. Pylori Eradication Therapy (if no mets) Rituximab (if mets)
49
"Flushing, Palpitations & Diarrhea" | are classic triad for:
Gastric Carcinoid Tumor Endoscopy/Biopsy to Dx Remove stomach to Rx, all if necessary
50
Type I Gastric Carcinoid Tumor | Mets to
Liver | Adrenals (MenI & Cushings are assoc.)
51
Dx Tests for Gastric Carcinoid Tumor
25-HIAA Test (a 24 hr urine test for 5HT3) Somatostatin Receptor Scintigraphy (SRS) CT/MRI Endo/Biopsy is Diagnosic though
52
Gastric Carcinoid Tumor Secretes
Serotonin | Hence the flushing, palps & diarrhea sxs
53
2nd Most Common Cause of Cancer Deaths World-Wide
Gastric Adenocarcinoma Caused by LONG term H. Pylori
54
Location of Virchow's Node & significance
Left Supraclavicular Classic sign of Gastric Adenocarcinoma if swollen
55
Location & Significance of Sr. Mary Joseph Nodule
Umbillicus Classic Sigh of Gastric Adenocarcinoma
56
Anemia not due to low iron/hemolysis + Weight Loss Suspicious for what:
Gastric Adenocarcinoma
57
Adenocarcinoma Staging
1-3 remove stomach 4 mets, palliative care
58
Cholestatic Pruritis
Bile back up causes itching Too much conjugated bilirubin - unconjugated bilirubin in the blood does NOT cause itching. Cirrhosis usually but any blockage will do it
59
Continuous areas of ulceration in rectum/colon ONLY shallow ulcerations & pseudo polyps Fistula Rare
Ulcerative colitis Endoscopy findings
60
Feeling of not having emptied the rectum
Tenesmus
61
``` Mild to severe abd cramping Freq, Mucusy soft stool/diarrhea often w/blood Tenesmus Common Fever indicative of severe disease Often anemia/ +guiac ```
Ulcerative Colitis Abdominal Sxs/ signs
62
porridge-like stool often w/steatorrhea Tenesmus Rare Fever & weightless Common
Crohn's Disease Symptoms
63
Extra-Abdominal Signs of Ulcerative Colitis
``` Uveitis Mouth Ulcers Arthritis Erythema Nodosum (sub Q fat inflam. on shins) Necrotic skin ulcerations DVT/PE Clubbing Primary Sclerosing Colangitis & all its attendant signs & sxs ```
64
Pyoderma Gangrenosum
Necrotic Skin Ulcerations - Ulcerative Colitis
65
Peak Onset of Ulcerative Colitis
15- 25 yrs Nonsmokers or those who recently stopped smoking
66
Peak Onset of Crohns
15-30 | Smokers
67
Differentials for Ulcerative Colitis
``` #1: Crohns Disease is hard to differentiate #2: C. Dif (get stool cultu & Toxicology ELISA) AKA: Pseudomembranous Colitis ```
68
Antibiotic causes of c. Dificile
Quinolones, Carbapenems, Clindamycin & Cephalosporins
69
Diagnostic Testing for C Dif
Toxin Screen is gold std, | Colonoscopy/biopsy
70
C. Dif Rx
Metronidazole, 3x/day 10 days ORAL Vanco (only use of this orally) of resistant to Flagyl. Cdif is a G+ Anaerobe Questran, bile acid sequestrate that also seems to sequester Cdif toxins WITH Vanco Stool Transplant IS effective esp in abx resistnt cdif
71
First line Rx for Ulcerative Colitis
Aminosalicylates: Sulfasalazine & Mesasalazine are anti-inflammatories to control inflammation Corticosteroids short term to suppress immune response Mabs: Infliximab last resort to target tissue necrosis factor Nicotine Patches strangely work IV iron for the anemia due to constant bleeding
72
Patchy transmural ulcerations "skip lesions" anywhere from mouth to anus. "Cobblestoning" of colon Cramping & Diarrhea, bloody if severe disease but melena is more likely than hematochezia Anemia, Weight Loss, Skin Fever is common and malabsorption due to involvement of small bowel
Crohn's Disease sxs
73
Best test for Crohns
Colonoscopy - it can usually visualize the terminal ilium and if lesions extend into there, it isn't ulcerative colitis. Obviously upper GI endoscopy would be needed to biopsy stomach and duodenum. Jejunum is hard to get at. Barium follow through can be helpful
74
Anal lesions Common/Rare in:
Common in Crohns | Rare in Ulcerative Colitis
75
Rectal involvement Common/Rare in:
Common in Ulcerative Colitis | Rare in Crohns
76
Epigastric Pain worse on eating and there is weight loss
Peptic Ulcer H. Pylori Test likely + In Office Maalox Test likely + Refer for endoscopy, may cause hematemesis
77
Epigastric Pain relieved by eating, keeps pt awake at night (when not eating) and there is weight gain
Duodenal Ulcer
78
+ ASCA and | - pANCA
Crohns
79
-ASCA and | +pANCA
Ulcerative Colitis
80
NSAIDS damage Stomach Lining by
Inhibiting COX 1 & 2 (mainly 1) Thus decreasing release of mucosal-protective prostaglandins in the stomach. Even IM NSAIDS can do this, it isn't just oral route.
81
indirect bilirubin =
unconjugated High levels in neonates suggests immature liver is unable to conjugate - Rx is billi-light high levels in adults are usually upstream of the liver bleeding, hemolysis, spleen issue
82
direct bilirubin
Has Been Conjugated by the liver If serum levels of indirect are high it means liver is producing but it can't secrete - biliary obstruction - so bilirubin seeps into blood If serum levels are low but indirect levels are high it means the liver is not conjugating
83
ANA (Anti-Nuclear Antibodies)
``` Antibodies to core antigens Hepatitis core antigens Primary Biliary Cirrhosis Hashimotos Alcoholic Liver Disease... ``` Procainamide Hydralazine Dilantin can cause ANAs to circulate
84
Constipated during pregnancy, used laxitives | Postpartum w/rectal bleed , no pain
internal hemorroids don't always hurt
85
Spastic Colon
IBS
86
IBS criteria
No other diagnosis A change in bowel habits and appearance Crampy/bloaty 3days/mo for 3 months Improves w/defecation
87
Zenker's Diverticulum
Esophagus herniates thru weakness in it's muscular wall then muscle constricts around it. Relax the wall and it may pull back in. Very bad breath/Cough/Reflux Barium Swallow Resection or staple

GEN MED GI (4 decks)

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