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Flashcards in GI Deck (193):
1

Hormone responsible for gallbladder contraction? Where made?

Cholecystokinin (CKK), which is made in duodenum and jejunum in response to FA's and AA's

2

Dubin-Johnson syndrome

Defect of hepatic excretion of bilirubin glucuronides across canalicular membrane (MDR2 biliary transport protein); Chronic conjugated hyperbilirubinemia; black liver; histo with epi metabolites within lysosomes. Icterus, mostly asymtompatic; Benign = no tx

3

Extrahepatic biliary atresia

Obstruction of extra hepatic bile ducts. Jaundice by wk 3-4 w/ cholestatic picture (dark urine, echoic stools, and conjugated hyperbilirubinemia)
Liver bx = intrahepatic bile ductular proliferation, portal tract edema, fibrosis, parenchyma cholestasis

4

Whipple disease

Middle-aged Caucasian males - diarrhea, wt loss, arthropathy, polyarthritis, psych, cardiac
Tropheryma whippeli - Gram + actinomycete. Only proliferates in macrophages = no inflammatory.
Bx - Enlarged FOAMY macrophages w/ rod-shaped bacilli and PAS-positive diastase-resistant granules
Tx = abx

5

Bile acid-binding resin names?

Cholestyramine, colestipol, colesevelam

6

What agents increase cholesterol content of bile?

Bile acid resins and fibrates

7

Mallory-Weiss v. Boerhaave

Mucosal tear v. transmural tear (esophageal air + fluid leak)

8

Where do H. pylori biopsy?

Prepyloric region of gastric antrum has highest yield.

9

Porcelain gallbladder

Refers to abdominal radiograph with bluish, brittle, Ca-laden gallbladder wall that develops in some patients with chronic cholecystitis. 11-33%->gallbladder carcinoma = advise cholecystectomy

10

How does H. pylori lead to duodenal ulcers?

Chronic antral inflammation -> decrease in delta cells (somatostatin-producing cells) -> disinhibition of gastrin. High gastrin -> increased H+ secretion by parietal cells.

11

Pathogenesis of TPN-induced gallstones

Biliary stasis 2/2 to dec. cholecystokinin

12

Insulin secretion from pancreatic beta cells?

Glucose stimulates. Enters via GLUT-2 (fac.) then generates ATP. High ATP:ADP causes CLOSURE of K+ channels (KATP). Beta cells now depolarize b/c K+ not leaving the cell and building up inside --> opening of voltage dependent Ca2+ channel -> insulin release. Sulfonylureas bind to KATP --> channel closure -> insulin release.

13

Gilbert syndrome

Mild UDP glucuroyl transferase transferase defieincy. Uncojugated hyperbilirubinemia, usu. provoked by hemolysis, fasting, exertion, febrile illness, etc. No clinical consequence.

14

Bilirubin system

Bilirubin transported to liver w/ albumin. Uptaked. Conjugated by UDP-Glucuronyl transferase (absent in Crigler Najjar and low in Gilbert) -> Secreted (defetive in Rotor and Dubin-Johnson) as bilirubin glucuronide. Turned into urobilinogen in GI. Some go back thru portal system to liver/urine. Others go to feces (brown).

15

Portacaval anastomoses

Varices = left gastric vein to esophageal vein. Hemorrhoids = superior rectal vein to middle/inferior rectal veins. Caput medusae = paraumbilical veins to superficial and inferior epigastric veins

16

Chronic mesenteric ischemia

Pt with atherosclerotic risk factors has pain after meals not responding to antacids and nothing on EGD. Due to atherosclerotic narrowing of celiac, SMA, IMA - not able to dilate in response to digestion.

17

Celiac disease pathology?

Atrophy of villi, flattening of mucosa, chronic inflammation of laminal propria. All reversible w/ gluten-free diet.

18

Foregut and blood supply

Esophagus, stomach, liver, gallbladder, pancreas, upper duodenum. Celiac

19

Midgut and blood supply

Lower duodenum, small intestine, ascending colon, proximal 2/3 of transverse colon. SMA

20

Hindgut and blood supply

Distal third of transverse, descending, sigmoid. IMA.

21

Midgut rotation

Midgut herniates through umbilical ring at wk 6 b/c slower growth of abdominal cavity. Return at wk 10 and completes 270 deg turn CCW around the SMA.

22

Pancreas divisum

Failure of ventral and dorsal buds to fuse at wk 8. Asymptomatic.

23

How does pregnancy predispose to gallstone formation?

Estrogen-induced HMG-CoA reductase activity = cholesterol hypersecretion. Progesterone induces gallbladder hypomotility

24

Hirschsprung disease path

RECTAL biopsy. Failure of neural crest cells to migrate to intestinal wall. Submucosa will demonstrate absence of ganglionic cells (Meissner). Rectum always involved (wk 12), sigmoid 75%. Present will failure to pass meconium within 48 hrs, intestinal obstruction.

25

Final pathway of pancreatitis pathogenesis following acinar cell injury

Intra-acinar conversion of trypsinogen to active trypsin! This leads to other activation (elastase, chymotrypsin, phospholipase)). Proteases auto digest. Elastase leads to vascular dmg and hemorrhage. Lipase/phospholipase -> fast necrosis

26

Reflux esophagitis patho

Elongation of papillae, basal cell hypertrophy, intraepithelial eosinophils

27

Primary Biliary Cirrhosis

Chronic. Autoimmune destruction of INTRAhepatic bile ducts and CHOLESTASIS. Middle-aged women, insidious. PRURITIS (esp. night), fatigue. Hepatosplenomegaly, xanthomatous lesions. Jaundice, steatorrhea, portal HTN. Labs - elevated alkPhos, cholesterol, and serum IgM. Dx = anti-mitochondrial antibodies. Associated w/ Sjogren's, Raynaud's scleroderma, autoimmune thyroid, hypothyroidism, and celiac disease

28

Hereditary pancreatitis

Mutations in trypsinogen or SPINK1 (trypsin inhibitor). Mot common mut -> abnl trypsin that is not susceptible to inactivating cleavage by trypsin.

29

True vs. pseudodiverticulum

True diverticula contain mucosa, submucosa, AND muscular layers. e.g. Meckel's is failure of obliteration of vitelline duct (usu. wk 7). 2% of pop, 2 feet from ileocecal valve, 2 inches in length, 2% symptomatic, males 2x more affected. False diverticula DON'T contain muscularis (e.g. colonic and Zenker's)

30

Ballooning degeneration of liver?

Hepatocyte swelling found along with mononuclear infiltrates and Councilman bodies histologically during acute viral hepatitis. Regeneration nodules found in chronic hepatitis.

31

Peptic ulcer disease ulcer sites?

First portion of duodenum within 3 cm of pylorus. Distal ulcers are not common (think Zollinger-Ellison)

32

Zenker diverticulum

Oftentimes, cricopharyngeal dysfunction leads to increased pharyngeal contractions required for swallowing b/c of diminished relaxation. (Traction diverticulum contains ALL layers).

33

How does HBV induce HCC?

Thought to be triggered by integration of viral DNA into genome. Synthesis of insulin-like growth factors, suppresses p53, chronic inflammation and regeneration.

34

Pernicious anemia pathology?

Parietal cell damage. Appear pale pink, round, plate-like in the upper gland layers. Loss of intrinsic factor-secreting parietal cells, marked infiltration by lymphocytes and plasma cells, and megaloblastic changes. (Chief cells that secrete pepsinogen are found in deeper glandular layers - small basophilic)

35

Brown pigment gallstones?

Usu. secondary to infection of biliary tract (E. coli, Ascarin, Opisthorchis sinuses). Injured hepatocytes and bacteria release Beta-glucuronidase -> hydrolysis of bilirubin glucoronides -> inc. unconjugated bilirubin in bile.

36

Schilling test

Used to ID cause of B12 deficiency. (1) Oral radio B12 w/ IM non-B12 (to ensure excretion) and check urine. If lots of urine radio B12 = good absorption and poor diet. If low radio B12 = poor absorption. Phase II = radio labeled B12 w/ intrinsic factor. If still high radio B12, then still poor absorption not corrected by IF (e.g. pancreatic insufficiency, ileal disease, intestinal bacterial overgrowth)

37

How does octreotide work?

It is a somatostatin analog. Inhibits glucagon and VIP ---> reduced vasodilation --> splanchnic vasoconstriction w/o systemic vasoconstriction. Helpful for esophageal varices.

38

Palpable but NONtender gallbladder, wt loss, obstructive jaundice (pruritus, dark urine, pale stool)

Adenocarcinoma of the head of the pancreas compressing the common bile duct

39

Annular pancreas

Abnormal encirclement of the duodenum by the ventral pancreatic bud -> duodenal narrowing

40

What parts of the GI are retroperitoneal?

Lower 2/3 of esophagus. 2-4th part of the duodenum. Ascending and descending colon. Part of the rectum.

41

Retroperitoneal structure acronym

SAD PUCKER = Suprarenal glands, Aorta + IVC, Duodenum (2-4), Pancreas (except tail), Ureter, Colon (Des. and asc.), Kidneys, Esophagus (lower 2/3), Rectum

42

Falciform ligament

Connects liver to ant. abdominal wall. Contains ligamentum teres hepatic (fetal umbilical vein.).

43

Hepatoduodenual ligament

Contains the portal triad. Therefore, the Pringle maneuver (compressing ligament w/ one finger in lesser sac via omental foramen) controls bleeding.

44

Gastrohepatic ligament

Liver to LESSER curvature. Contains the gastric arteries.

45

Gastrosplenic ligament

Greater curvature to spleen. Contains the SHORT gastrics and L gastroepiploic vessels.

46

Splenorenal ligament

Contains splenic artery and vein. Tail of pancreas.

47

Where are Peyer's patches found?

In the lamina propria and submucosa of the Ileum

48

Crypts of Lieberkuhn found where in GI?

Small and large intestine. NOT stomach (it has gastric glands).

49

Where are villi found in the GI?

Small intestine but NOT colon.

50

What GI regions does the vagus nerve and pelvic nerve innervate?

Pelvic nerve innervates hindgut (distal 1/3 of transverse colon to upper portion of rectum). Rest in vagus.

51

Three main branches of the celiac trunk?

Common hepatic, splenic, and left gastric.

52

Superior and inferior epigastric arteries anastomose what major systems?

Internal thoracic/mammary with external iliac.

53

Superior and inferior pancreaticoduodenal arteries anastomose what major systems?

Celiac and SMA

54

Middle colic and left colic arteries anastomose what major systems?

SMA and IMA

55

Superior rectal and middle/inferior rectal arteries anastomose what major systems?

IMA and the internal iliac.

56

Pectinate line - above & below arterial and venous

Above - superior rectal a. from IMA. Venous from superior rectal v. to IMV to portal system. Below - Inferior rectal a. from internal pudendal a. Inferior rectal vein to internal pudendal vein to internal iliac to IVC

57

Flow of bile and blood in the liver?

Blood flows from the portal triad (portal a. and vein) into the central vein (to hepatic veins and systemic circulation). Bile flows into the bold ductule.

58

Zones of the liver

Zone 1 = periportal and is first affected by viral hepatitis and ingested toxins. Zone 3 = (Centrilobular) pericentral vein zone and is affected 1st by ischemia = acetaminophen tox. Site of alcoholic hepatitis, CYP-450 system.

59

Femoral vessel organizatoin?

NAVEL is lateral to medial. Nerve, artery, vein, empty space, lymphatics.

60

Indirect vs. direct inguinal hernia

Lateral to epigastric vessels vs. medial to (in Hesselbach). Into the scrotum vs. only through external/superficial ring.. Infants/young ppl vs. older men.

61

Gastrin - action and regulation

Increases parietal cell H+ secretion, hypertrophies the gastric mucosa, (and increases gastric motility). Activated by stomach distention/alkalinzation, aa's, peptides, and vagal stimulation. Repressed by a stomach pH < 1.5. Phenylalanine and tryptophan are particularly potent stimulators.

62

Gastrin produced where?

G-cells in the antrum of the stomach. (Zollinger-Elilson syndrome - gastrinoma)

63

CCK's 5 major effects; How is it activated?

Contraction of gallbladder + relaxation of Oddi, secretion of pancreatic enzymes, secretion of HCO3 from pancreas, trophic effects on pancreas and gallbladder, inhibition of gastric emptying. Activated by FA's and AA's. Actions via neural muscarinic pathways.

64

CCK source

I cells of the duodenum and jejunum.

65

D, I, G, K, S cells are where and produce what?

D is pancreatic islets and GI mucosa; somatostatin. I cells are duodenum/jejunum and CCK. G is antrum of stomach and gastrin. K is duodenum and jejunum and GIP. S is duodenum and secretin.

66

Secretin's actions and stimulation?

Stimulated by acid, FA's in lumen of duodenum. Increases pancreatic bicarb, bile secretion, and DECREASED gastrin effects (H+). All for a better pH for pancreatic enzymes.

67

GIP's actions and stimulation

Exocrine function is DEC. gastric H+ secretion while endocrine function is INC. insulin release. Stimulated by FA's, aa's, oral glucose.

68

Motilin function and activation

Increases in fasting state and produces migrating motor complexes. Made in small intestinee.

69

Somatostatin function and activation.

Activated by acid and inhibited by vagal stimulation. It is the INHIBITORY and anti-growth hormone. Decreased gastric acid and pepsinogen, pancreatic and small intestine fluid sections, dec. gallbladder contraction, dec. insulin and glucagon release

70

VIP source?

Parasympathetic ganglia in sphincters, gallbladder, small intestine. Or VIPoma - non-alpha, non-beta islet cell pancreatic tumor.

71

VIP function and activation?

Increases intestinal water and electrolyte secretion while relaxing intestinal smooth muscles and sphincters. Activated by distention and vagal stimulation. Inhibited by adrenergic input.

72

VIPoma symptoms?

WDHA syndrome. Watery Diarrhea, Hypokalemia, Achlorhydria.

73

Intrinsic factor f(x) and made where?

Made by parietal cells and is the vitamin-B12 binding protein for uptake in terminal ileum

74

Pepsin's function and regulation?

Protein digestion. Activated by vagal stimulation and local acid (secreted by CHIEF cells in stomach). Pepsinogen to pepsin via H+.

75

What produces HCO3 in the GI tract?

Mucosal cells of the stomach, duodenum, salivary glands, and pancreas. As well as Brunner glands in the duodenum. Pancreatic and biliary secretion of HCO3 with secretin.

76

Gq acting substances on the gastric parietal cell?

Vagus nerve via Ach-M3 and GRP to G-cell -> Gastrin onto CCKb receptor.

77

cAMP acting substances on gastric parietal cell

Gs - Histamine from ECL cells. Gi - Prostaglandin/misoprostol and somatostatin.

78

Trypsinogen is activated how?

By enterokinase/enteropeptidase, which is located on the brush-border in the duodenal and jejunal mucosa. Some tripsinogen is activated by trypsin itself.

79

D-xylose test

A monosaccharide that can be absorbed w/o the help of any enzymes. Test for urine excretion in 5 hours. Solely dependent on the health of the GI mucosa (e.g. Celiac, Whipple disease, small intestine bacterial overgrowth)

80

How are carbs absorbed in intestine?

Glucose and galactose by Na+ dependent SGLT1. Fructose by facilitated diffusion via GLUT-5. On basolateral side, GLUT-2 transports these monosacharrides into the blood stream.

81

Vitamin/mineral absorption?

Iron Fist, Baby. Duodenum for iron. Jejunum and ileum for folate. Terminal ileum for B12.

82

M cells?

Sampling cells of the Peyer's patches.

83

Rate limiting step of bile synthesis?

Cholesterol 7alpha-hydroxylase, which is inhibited by bile salts.

84

Composition of bile?

Bile salts, phospholipids, cholesterol, bilirubin, water, and ions.

85

Function of bile

Emulsify lipids and vitamins. Cholesterol excretion. Membrane disrupt microbes.

86

What enzyme conjugates bilirubin?

UDP-glucuronosyl transferase (liver)

87

What are the fates of conjugated bilirubin in the gut?

First turned into urobilinogen by gut bacteria. 20% is reabsorbed into the enterohepatic system (of which a small 10% goes via kidney into the urine as urobilin). The other 80% of urobilinogen is excreted into feces as sterobilin.

88

Diagnosis Meckel's divericulum?

Meckel scan = 99mmTc-pertechnetate scan showing accumulation. Highly specific for gastric mucosa. Will find ectopic mucosa.

89

Meckel diverticulum ectopic tissue?

Mostly gastric (--> acid and ulceration). Often pancreatic, colonic, small intestine, or endometrial.

90

Cholecystenteric fistula

A large gallstone causes formation of fistula between gallbladder and small intestine leading to passage of stone but air in the gallbladder and biliary tree. Ileocecal valve catches gallstones -> gallstone ileus. Pain.

91

Pathogenesis of hepatic encephalopathy

Increased lvls of ammonia, which depletes glutamate and alpha-ketoglutarate and increased osmolarity that causes astrocytic swelling and impairment. Also decreased brain glutamate stores -> impaired neurotransmission.

92

Most common salivary gland tumor - histo

Pleomorphic adenoma. Painless, mobile mass. Histo - chondromyxoid stroma and epithelium

93

Warthin tumor

Benign cystic tumor with germinal centers

94

Most common malignant salivary gland tumor

Mucoepidermoid carcinoma. Mucinous and squamous. Painless, slow-growing mass.

95

Etio of achalasia?

Failure of LES relaxation 2/2 loss of myenteric plexus. Secondary cause is Chagas disease.

96

Lye ingestion--->

Esophageal strictures. Also associated with acid reflux

97

Eosinophilic esophagitis

Atopic patients eating food allergens can lead to dysphagia, heartburn, strictures. Eos seen on histo

98

Increased risk of what cancer 2/2 Barrett esophagus?

Esophageal adenocarcinoma

99

Barrett esophagus histo?

Metaplasia from nonkeratinized stratified squamous epithelium to non-ciliated columnar epithelium with goblet cells. Moved up squamocolumnar junction ("Z" line).

100

Areas of esophagus where you'd find squamous vs. adenocarcinoma?

Squamous in upper 2/3. Adeno in lower 1/3

101

RF's for esophageal squamous cell carcinoma?

Alcohol, Cigarettes, Zenker, esophageal web, hot liquids

102

RF's for esophageal adenocarcinoma?

Barrett, cigarettes, obesity, GERD

103

RF's overall for esophageal cancer?

AABCDEFFGH - Alcohol, Achalasia, Barrett, Cigarettes, Diverticula, Esophageal web, Familial, Fat, GERD, Hot liquids

104

Etios of acute gastritis

Stress, NSAID, alcohol, uremia, burns (-> Curling ulcer where ischemia leads to gastric mucosa sloughing), brain injure (Cushing ulcer - inc. vagal tone -> H+ production)

105

Type A vs. Type B chronic gastritis?

A is autoimmune [parietal cells, pernicious anemia, achlorhydria) and first part of stomach (funds). B is bacteria (H. pylori) and is second part of stomach (antrum)

106

Menetrier disease

Precancerous lesion of stomach. Gastric hypertrophy ("brain gyri"-like) -> protein dolls, parietal cell atrophy. Increased mucous cells.

107

Intestinal vs. diffuse stomach cancer?

Intestinal is associated with H. pylori vs. NOT. Lesser curvatures looking like ulcer vs. gross thickening and leathery (linitis plastic) w/ Signet ring cells. Intestinal is also associated with dietary nitrosamines (smoked food), tobacco, achlorhydia, chronic gastritis

108

Krukenberg tumor

b/l metastases of stomach cancer to the ovaries. SIGNET ring cells.

109

Sister Mary Joseph nodule

SQ periumbilical metastases 2/2 stomach cancer

110

Gastric ulcer vs. Duodenal ulcer

Pain greater with meals vs. decreases with meals. Increased risk of carcinoma in GASTRIC ulcer. Zollinger-Ellison associated with duodenal. 70% of gastric ulcers with H. pylori whereas 100% of duodenal ulcers with H. pylori. NSAIDs gastric.

111

Common hemorrhage site from gastroduodenal ulcers?

Lesser curvature gastric ulcer = L gastric artery. Posterior duodenal ulcer = gastroduodenal artery.

112

Tropical spure

Unknown etiology, but responds to antibiotics. Recent travel to the tropics.

113

Celiac sprue lab findings

Anti-endomysial, anti-tissue transglutaminase (diagnostic test), anti-gliadin Ab's. HLA-DQ2 and DQ8 (Dairy Queen)

114

Abetalipoproteinemia

Presents as FTT, steatorrhea, acanthocytosis, ataxia, night blindness. Due to decreased apoB synthesis = less CHYLo's = less VLDLS = ACCUMULATION of fat in enterocytes. Histo shows foamy cells at GI mucosa. Smear shows ACANTHOCYTES 2/2 poor membrane production.

115

Skip lesions

Crohn's. Spares the rectum whereas UC is continuous always with rectal involvement.

116

Lead pipe

UC. Loss of hausfrau.

117

IBD with noncaseating granulomas?

Crohn's disease. UC has crypt abscesses with NEUTrophils and ulcer but NO granulomas.

118

Cobblestone mucosa

CD.

119

How deep is the inflammation in Crohn's vs. UC?

Crohn's is TRANsmural. UC is mucosa and submucosa only.

120

Extraintestinal manifestations of IBD

Both have pyoderma gangrenous, erythema nodosum, anklyosing spodylitis, apthous ulcers, uveitis.

121

Tx for UC

sulfasalazine, 6-MP, infliximab, colectomy

122

Tx for CD

Corticosteroids, azathioprine, methotrexate, infliximab, adalimumab (TNF-alpha)

123

Complications of UC vs. CD

UC has sclerosing cholangitis, toxic megacolon. CD has strictures, fistulas, perianal disease. Both have colon cancer.

124

Irritable bowel syndrome

Recurrent abdominal pain w/ 2+: relief on defecation, change in consistency, change in frequency.

125

Appendicitis etios

Fecalith in adults but lymphoid hyperplasia in children

126

Diverticulosis presentation

Often asymptomatic or with vague discomfort. May cause hematochezia.

127

Diverticulitis presentation

Classically a LLQ pain, fever, leukocytosis. FOBT w/ +/0 hematochezia. If colovesical fistula, pneumaturia

128

Where is Zenker's diverticulum usu. location?

Killian triangle - between thyropharyngeal and cricopharyngeal parts of inferior pharyngeal constrictor.

129

Meckel's diverticulum presentation?

RLQ pain, melena, intussusception, volvulus, or obstruction.

130

Intussusception

Telescoping. Commonly at ILEO-CECAL junction. Pain and currant jelly stool 2/2 compromised blood supply. Usu. children (might be associated with enteric or URI). If patient is older than 2, consider Meckel, foreign body, or intestinal tumor as the lead point.

131

Volvulus

Midgut volvulus in children and sigmoid volvulus in elderly. Gut twists around own mesentery.

132

GI pathology associations with Down's

Hirschsprung's, duodenal atresia (double bubble; failure to re-canalize)

133

Ischemic colitis presentation

Pain after eating -> weight loss. often older people

134

Peutz-Jegher's

AD. Serine/threonine kinase gene 11 on ch. 19. Nonmalignant Hamartomas throughout GI. Hyperpigmented MOUTH, lips, hands, genitalia. Increased risk of colorectal cancer and other visceral malignancies.

135

What type of polyps are recancerous?

Adenomatous. More villous, the more villainous.

136

Juvenile polyps

Sporadic. < 5 y/o. Rectm.

137

FAP vs. HNPCC etio

FAP is APC gene on 5q (20hit). HNPCC is AD mutation of DNA mismatch repair genes. 100% progress in FAP but only 80% in HNPCC do.

138

Gardner syndrome

FAP + osseous and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium

139

Turcot syndrome

FAP + malignant CNS tumor

140

Order of mutation events in colorectal cancer?

APC/Beta-catenin (sporadic, 80%), K-RAS, p53/DCC OR Microsatellite instability (~15%) in DNAN mismatch repair gene

141

Manifestations of cirrhosis that are 2/2 to estrogen?

Spider angioma, palmar erythema, gynecomastia, testicular atrophy, decreased body hair, Dupuytren's contractores. 2/2 to decreased metabolism of estrogen by failing living.

142

Most specific lab for acute pancretitis?

Lipase

143

Reye syndrome

Rare, often fatal childhood hepatoencephalopathy. Fatty liver, mitochondrial problems, hypoglycemia, vomiting. Aspirin metabolites decreased Beta-oxidation. Microvesicular steatosis on path.

144

Alcoholic hepatitis vs. cirrhosis pathology?

Hepatitis has swollen, necrotic cells with Mallory bodies (intracytoplasmic eosinophilic inclusions). Cirrhosis has central vein sclerosis, shrunken liver.

145

Treatment for hepatic encephalopathy?

Lactulose (ammonia ion generation, low0protein diet, rifaximin)

146

HCC associations?

HBV, HCV, Wilson, hemochromatosis, alpha-1-antitrypsin, alcoholic cirrhosis, alfatoxin.

147

HCC diagnosis?

alpha-fetoprotein; US or CT.

148

Nutmeg liver?

Etio - Right-sided HF, Budd-Chiari. Leads to back up of blood. Can lead to centrilobular congestion and necrosis.

149

Budd-Chiari syndrome

Occlusion of IVC or hepatic veins. Associated with hyper coagulable states, polycythemia vera, pregnancy, HCC.

150

In what liver tumor is biopsy contraindicated?

Cavernous hemangioma (NOT angiosarcoma) b/c of risk of hemorrhage.

151

Histopath for alpha-antitrypsin deficiency in the liver?

PAS+ globules in the liver

152

How does urine urobilinogen change with unconjugated vs. conjugated hyperbilirubinemia?

Urine urobilinogen is HIGH in unconjugated hyperbilirubinemia. LOW in conjugated hyperbilirubinemia.

153

Etios of conjugated hyperbilirubinemia?

Biliary tract obstruction. Biliary tract disease (primary sclerosing cholangitis, pBC). Excretion defect (Dubin-Johnson, Rotor)

154

Etio of physiologic neonatal jaundice?

Immature UDP-glucuronylsyltransferase -> unconjugated hyperbilirubinemia. Tx = phototherapy.

155

Rotor syndrome

Milder Dubin-Johnson. NO black liver.

156

Crigler-Najjar syndrome.

ABSENT UDP-glucuronosyltransferase. EARLY in life. Patients die in couple of years. Jaundice, kernicterus, UNconjugated bilirubinemia. Type I is more severe than type II, which responds to phenobarbital to increase liver enzyme synthesis.

157

Wilson disease specific brain findings

Basal ganglia degeneration. And sooo Parkinsonism. Dyskinesia, Dysarthria, Dementia. Asterixis.

158

Treatment for Wilson's disease

Penicillamine, trientine (Cu chelators)

159

Gene defect in hemochromatosis

HFE gene - C282Y or H63D. Associated with HLA-A3.

160

Treatment of hereditary hemochromatosis

Repeated phlebotomy, deferasirox, deferoxamine (these are Fe chelators)

161

Classic Hemochromatosis triad?

CHF, Bronze diabetes, cirrhosis

162

Labs in primary sclerosing cholangitis vs. primary biliary cirrhosis?

PBC has increased serum mitochondrial antibodies (IgM). PSC has hypergammaglobulinemia.

163

Etiology of PBC vs. PSC?

PBC - autoimmune reaction of lymphocytes and granulomas of interlobular ducts. PSC - unknown onion-skin fibrosis of bile ducts that alternate into "beads" in the intra AND extra-hepatic bile ducts (Seen on ERCP)

164

Radioopaque gallstones?

BLACK pigment stones - hemolysis.

165

Radiolucent gallstones?

Brown pigment (infection) OR Cholesterol stones.

166

Cholangitis symptom?

Charcot triad = fever, jaundice, and RUQ pain

167

RF's for gallstones?

4 F's - Female, fertile, fat, forty

168

Murphy sign?

Inspiratory arrest on RUQ palpation. Cholecystitis.

169

Diagnosis cholecystitis how?

US or HIDA

170

Complications of acute pancreatitis?

DIC, ARDS, diffuse fat necrosis, hypocalcemia, pseudocyst, hemorrhage, infection, multi organ failure.

171

Etios of acute pancreatitis?

GET SMASHED = Gallstone, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion sting, Hypercalcemia/HyperTG, ERCP, Drug (sulfa), idiopathic.

172

Trousseau syndrome

Migratory thrombophlebitis associated with pancreatic adenocarcinoma

173

CA 19-9

Tumor marker for pancreatic adenocarcinoma

174

Bismuth, sucralate f(x)?

Ulcer healing and traveler's diarrhea. Binds to ulcer base for protection!

175

Cimetidine side effects

P450 inhibitor. Antiandrogenic (gynecomastia, impotence, decreased libido), cross BBB (confusion, dizziness, HA), decrease renal excretion of Cr

176

Misoprostol

PGE1 analog used to increased mucous barrier and decrease acid production. SE - diarrhea. Also an abortifacient.

177

3 antacids

Aluminum hydroxide, calcium carbonate, magnesium hydroxide

178

Major side effects of antaacids

Affect absorption of other drugs. Hypokalemia.

179

Aluminum hydroxide

Constipation, hypophosphatemia. Proximal m. weakness, osteodystrophy, sz.

180

Ca Carbonate side effects

Hypercalcemia, rebound acid increase. Decrease effectiveness of other drugs

181

MgOH side effects

Diarrhea. Hyporeflexia, hypotension, cardiac arrest.

182

Sulfasalazine

Combination of sulfapyridine and 5-aminosalicylic acid. Activated by COLONIC bacteria. Used for IBD. fox - malaise, nausea, sul fox, reversible oligospermia.

183

Metoclopramide mech and usage

D2 receptor antagonist used to increase resting tone, contractility, LES tone, and motility. Anti-emetic. Used to treat gastroparesis.

184

Metoclopramide tox

Increased parkinsonian effects. Contra'd in small bowel obstruction and parkinson disease.

185

Ondansetron mech

5-HT3 antagonist. Decreased vagal stimulation decreases central-acting emesis.

186

Corkscrew esophagus?

Diffuse esophageal spasm. Non-peristaltic, periodic contractions

187

Incretins

Hormones secreted by gut mucosa in response to sugary meals to induce insulin response. GIP and GLP (glucagon-like peptide).

188

Path for acetaminophen overdose?

Centrilobular necrosis that may include entire lobule.

189

Pathogenesis of alcoholic liver disease?

Excess NADH production (using up NAD+) b/c of alcohol and aldehyde dehydrogenase -> decrease free FA oxidation (Can't break down lipids!!!). Also have impaired lipoprotein assembly and increased peripheral fat catabolism -> fatty liver.

190

Pathogenesis of colitis-associated colorectal carcinoma?

More likely to come from NON-polyploid dysplastic lesions, be multifocal, develop EARLY p53 and LATE APC, and HIGHER histological grade.

191

Screen for malabsorption?

Sudan III stain of stool to identify fecal fat.

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How is free cholesterol converted into bile acid?

In the liver, cholesterol turned into cholic and chenodeoxycholic acid (7-alpha-hydroxylase). Then, bile acids conjugated to glycine and taurine -> bile salts, which are secreted into bile canaliculi.

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Left-sided vs. right-sided colon cancer?

Left-sided tends to have infiltrated the wall and encircled the lumen = dec. stool caliber, constipation, cramps, abdominal distention, n/v. Right-sided are exophytic masses = Fe-deficiency anemia (fatigue, pallor), anorexia, malaise, wt-loss. Right-sided is MORE INSIDIOUS.