GI Block 2! Flashcards
(421 cards)
1
Q
Anoscope is used to eval what?
A
Clinical eval of anal canal (is not for hemorrhoids fissures and lesions)
2
Q
Sigmoidoscopy allows you to look where?
A
Further into Rectum at polyps
3
Q
Flex Sigmoidoscope allows you to look and do what, where?
A
Take biopsy of large intestine from rectum to sigmoid colon with a light source
Reqs bowel prep
4
Q
The left side of the colon contains what?
A
75% of cancers
5
Q
Colonoscopy is?
A
Study of choice
100% of view of colon and distal small intestine(terminal ileum)
Uses a light source reqs bowel pre
6
Q
CT Colonography is?
A
3D Image Eval of colon prox to lesion
Used for failed colonoscopy eval colon pros to lesion cancer screen in pts w contra to endoscope or refuse
7
Q
Barium Enema is = to
A
Lower GI Series
8
Q
Most common cause of C. Diff infxn?
A
Hosp Acq— Fecal to Oral or Contact of spores on surfaces(up to 5 months)
9
Q
Risk factors for C.diff
A
ABX use
Hospitalization
Advanced Age
10
Q
Medication induced C Diff. risks: Highest—Intermediate—Lowest
A
Highest—Clindamycin, Flouroq.,Cephalosporins
Int—Penicillin, Macrolide, Sulfonamide
Lowest—Tetracycline
11
Q
C. Diff presentation
A
Green/fowl smelling, watery diarrhea, cramp lower abdomen
12
Q
Fulminant colitis presentation
A
Fever Hemodynamic ABD Distention Pain and Tender and profuse and diminished diarrhea X 15 times a day
13
Q
PE C.diff
A
Assess for systemic illness, fever, tachy, HYPOTN, dehydration,
Peritoneal signs, Rebound guarding
14
Q
Stool Studies C.diff infxn
A
Glutamate Dehydrogenase (GDH)
Nuclei Acid Amp Tests(NAAT)
Rapid Enzyme Toxin Assay(EIA)
Cell Culture cytotoxic assay/toxigenic culture[GOLD STANDARD]
15
Q
What is the initial screening study of C.diff
A
GDH/PCR
16
Q
What confirms C. Diff/Active Toxin?
A
Rapid EIA to determine Toxin A or B
17
Q
What test is used to determine C.diff vs Pseudocolitis?
A
Colonoscopy
18
Q
Severity of infxn is determined by what criteria(3)?
A
NONSEVERE = WBC < OR EQUAL 15,000 w/ creatinine < 1.5
SEVERE = WBC > OR EQUAL 15,000 w/ creatinine > 1.5
FULM DZ = WBC > 30,000 ALBUMIN > 2.5 Lacatate/Creatinine HYPOTN/ SHOCK/ILEUS/MEGACOLON
19
Q
First Line treatment for Pharmacotherapy for C. Diff (3)
A
Fidaxomicin
Vancomycin
Metronidazole
20
Q
Fulminant Colitis TXM
A
Vancomycin and Metronidazole w surgery consult for colectomy
21
Q
Recur TXM 1st recur
C diff infxn
A
Fadaxomycin + Vancomycin X 10 days
22
Q
Recur TXM 2nd recur
C diff INFXN
A
Vancomycin by mouth 10 days
23
Q
Recur TXM 3rd recur
A
Fecal transplant
24
Q
Toxic megacolon occurs at what diameter dilation with what signs?
A
Signs of sepsis
Greater than 7cm
25
Describe the mucosa of Toxic MEGACOLON
Alt. Edematous submucosa
| Hyperemic Mucosa
26
Dx for Toxic MEGACOLON studies =
```
Radio graphic evidence on CT w 3 out of the 4
1) Fever
2) Tachy
3) Neutro/Leuko over 10,500
4) Anemia
And 1 of the following
1) Dehydration
2) ALM
3) Electrolyte Disturbed
4) HYPOTN
```
27
Initial TXM of Toxic MEGACOLON
= support therapy + MED MGMT w/ early consult
IV Fluid
Pros. ABX [High Risk of Perf]
28
Diverticular indicates what abnormalities
Bleed or Diverticulitis
29
2 most common areas for diverticula
Sigmoid colon and Descending colon
30
What changes are often age related and seen with diverticula?
Collagen changes
31
What can also cause diverticula formation ?
Increased Intraluminal pressure (low fiber ABD colonic motility)
32
Asians Diverticular vs other population Diverticula
= Rt Side ascending colon
| = Distal Left sided colon
33
Usual symptoms of diverticula
Usually ASX or hematochezia
34
Main diverticula treatment
Increase Fiber to decrease caliber of stool and increase bulk = decreased pressure
35
What should diverticula patients avoid?
NSAIDS and RED MEAT
36
Diverticulitis complicated vs uncomplicated
```
Uncomplicated = Inflammation of colon diverticula
Complicated = Inflammation of colon diverticula assoc w/ perforation, obstruction, or bleed
```
37
Sxs/ Presentation of Diverticulitis
LLQ
Low Grade Fever
**NO HEMATOCHEZIA**
38
Should you perform barium enema if you suspect diverticulitis?
NO
39
TXM of Mild Diverticulitis [ no peritoneal signs, PO tolerated, Mild sxs ]
Bowel Rest
Clear Liquids
Pain Mgmt / ABX 7-10 days
40
TXM of Severe Diverticulitis [ peritoneal signs, can’t tolerate PO, severe sxs ]
```
NPO
IV Fluids
Pain mgmt
NGT decompress
IV ABX [ 5-7 days]
PO ABX [ surgical consult ]
```
41
Acute ILEUS occurs when and where?
72 hours post op
| Large Intestine
42
Acute ILEUS presentation
Continuous ABD discomfort + N/V
| Distended Diffuse Abdomen
43
TXM Acute ILEUS
```
Treat underlying cause
D/C all drugs that decrease int. Motility
NPO
Bowel Rest
Acute ILEUS w significant issues TXM
NGT
```
44
Pseudo Obstruct. Oglive syndrome is a functional obstruction where?
Right sided cecum to proximal colon
45
What can happen with progressive bowel dilation up to 6 days?
Ischemia and or perforation risk
46
Symptoms and presentation of Oglive
Constant abdomen pain minimal ABD tenderness decreased bowel sounds
Fever peritoneal signs ischemia perforation
47
What needs to be ruled out when inspecting for Oglive
Mechanical obstruction / toxic megacolon / ILEUS
48
TXM of Oglive
```
Less than12 cm dilation = Bowel rest
Dec. Opiods
NGT Rectal Tube decompress [most effective]
Enema if : FOS
Ambulate
Surger of greater than 12 cm dilation
NO ORAL LAXATIVES
```
49
Most common place for colonic volvulus to twist
Sigmoid colon
50
Presentation of Colonic Volvulus
```
Chronic Constipation
Dysmotility
High Fiber Diet
Pain + Distention
Previous surgery
```
51
Peritoneal signs and symptoms of Volvulus
```
Fever
HYPOTN
TACHY
Perforated perotinitis
W/ insidious onset, constipation, Distention
```
52
What is a lab check for ischemia during volvulus work up
LACTATE
53
A sigmoid originating volvulus requires what?
Endoscopic depression
54
A right cecum originating volvulus reqs what?
Surgical resection = FIRST LINE
55
Common presentation of Crohns disease patient (4) =
```
Young
Chronic Diarrhea
RLQ pain
Fatigue
Low Grade Fever
-ASX—Septic
```
56
Effects of Crohns on intestine?
Mouth to anus
Transmural
Any segment of GI
CANT Be CURED
57
Most common areas of bowel effected by Crohn’s disease? Least Common?
```
Most = Skip Lesions of SB to colon (Ileocolic)
Least = Upper GI
```
58
Hx of what things make you at risk for Crohns dz?
```
Fam Hz
Tobacco
ABX
Jewish
Gastroenteritis (Campy infxn + Salmonella infxn)
```
59
Hz of what types of diseases are assoc with Crohn’s disease?
Skin/joint/eye and other dz
60
Are Apthous ulcers common in Crohn’s disease or UC?
Crohn’s
61
What are immunomodulaters good for?
Reduces biologic antibodies that cause inflammatory symptom
62
What are examples of immunomod. Drugs?
Thiopurines + Methotrexate
63
Thiopurines are good for what?
Used in corticosteroid dependent pts to reduce recurrence of Abs w/ AntiTNF
*NoN HODgkin Lymphoma risk
64
Methotrexate is good for?
Combo w/ AntiTNF to decrease formation and risk of bone marrow suppression or hepatic fibrosis
65
What are biologics used for?
Suppress the physiologic response
66
What are examples of biologic therapies?
AntiTNF
| AntiIntegrins
67
What is the job of AntiTNF
Prevent TNF stimulation of effector cells
68
What is the job of Antintegrins
Decrease circulation of leukocytes and reduce chronic inflammation
69
What needs to be ruled out when running labs for Crohn’s disease?
Celiac disease
Giardia
Decal Calprotectin (active inflammation)
70
Complications of Crohn’s disease
Abscess Obstructions Perianlal Diseae
CAXR
Fistulas
71
Four areas Crohn’s can cause fistulas
Skin
Bladder
SB
Vagina
72
First line diagnostic tech. For Crohn’s evaluation ?
Colonoscopy w biopsy
73
What can be the 2nd line study for Crohn’s disease eval?
CT or MRE/Capsule endoscope
74
IF UGI sxs present in Crohn’s disease what study should be done?
Upper Endoscope
75
Cutaneous manifestations of Crohn’s disease (3)
```
Aphthous ulcers
Erythema Nodosum (below the knee)
Pyoderma Ganrenosum(Open sore inflammation]
```
76
Severity index of 150, 150-220, 221, 450, 450+
```
150 = well controlled, remission
150-220= mild active
221-450= mod to severe w anemia
450+= fulminant
```
77
When is endoscope required for Crohn’s disease
If Unintentional wt. loss observed
| Index 221+ or mod-sever-fulminant
78
3 goals of therapy for Crohn’s disease
Control inflammation
Mx Control of sxs
Lifestyle modifications
79
Mild TXM of Crohn’s disease Right sided
Oral Budesonide
80
Mild TXM of Crohn’s disease left Sided
Prednisone or Prednisolone
81
If non response after mild TXM would should be given in Crohn’s disease?
Mesalamine or Sulfasalazine
82
Mod/Severe TXM Crohn’s
Oral pred./methyl prednisone
83
Severe TXM Crohn’s
Anti-TNF -1st Line Most Effective
84
Adding immunomodulators in severe Crohn’s disease treatment can cause what?
Higher rate of remission and increased risk of ADE’s
85
Fulminant TXM Crohn’s disease
IV Steroid [methylpredisolone]
| +Oral Anti-TNF w/ inflammatory sxs
86
Criteria to admit for Crohn’s disease
```
Int obstruction
Abscess formation
Infxn complications
On immunomodul or Anti-TNF drugs
Diarrhea/Dehydration/Wt Loss/ ABD Pain
```
87
How often should patients with Crohn’s disease receive colonoscopy
Every 8 years from Dx onset
88
What is characteristic of UC dz?
It is chronic, always presents w bloody diarrhea or nocturnal diarrhea LEFT SIDED
Age range around 15-30 years old
89
What is the Dx soc for UC
Flex Sigmoidoscope to prevent perforation
90
When are RADs performed for UC ?
Only in severe cases (CT/MRE) to prevent going inside colon
91
Mild to mod distal UC sxs
```
Less than 6 stools
Mild Bleeding
Tenesmus
Mild Anemia
HYPOTN
```
92
Mild to Mod distal UC TXM
Topical 5 ASA
Hydrocortisone enema
Budesonide foam
Oral 5 ASA
93
Mild to Mod proximal UC TXM
Oral + Topical 5 ASA
Oral sulfasalazine -Arthritis
[MUST TAKE W FOLIC ACID]
94
Refractory Mild to Mod TXM of UC
Prednisone + Budesonide (Oral Steroids)
95
If greater than 1 relapse TXM of UC =
Thiopurines and Anti-TNF
96
Moderate to Severe UC sxs
Greater than 6 stools a day
Bloody
Impaired nutrition
ABD pain
97
Mod to Severe UC TXM
Oral prednisone
| Methlypredisone
98
Refractory Severe UC TXM
Anti-TNF
| Anti-Intergrin
99
Fulminant UC sxs
Sepsis
100
Fulminant UC TXM
IV methlyprednisone
| Oral Prednisone 3-5 days
101
Refractory Fulmminant UC TXM
IV anti-TNF
| IV cyclosporine[immunosuppresant]
102
Can methotrexate or corticosteroids be used as mono therapy?
NO
103
If UC is mod to severe with corticosteroid then switch to what?
Thiopurines
[Azathiopurine or Mercaptopurine]
Thiopurines
| [Azathiopurine or Mercaptopurine]
104
If UC is mod to severe with Anti-TNF therapy what should next TXM protocol be?
Continue Anti-TNFs
| [Adalimumab or Golumumab or Infliximab]
105
What it’s the curative TXM for UC
Total proctolectomy w ileostomy
106
Microscopic Colitis consist of what
Chronic watery diarrhea w normal biopsy and inflammatory tissue
107
What can cause micro colitis?
| What is a common sxs?
With chronic NSAID use
| Wt. Loss
108
TXM of Micro colitis
D/C meds w sxs care : Loperamide , Bismuth subsc , Budesonide (6-8wks)
109
What is the age for average risk of colorectal CAXR and screening recommendation
45 years ASX
110
How often is the gFOBT test performed?
Stool sample [annual]
111
How often is the FIT test performed?
More specific[annual]
112
How often is the FIT DNA test performed?
Finds CAXR cells in stool [Every 3 years]
113
How often is the colonoscopy test performed?
Direct visualization and diagnostic of the entire colon [Every 10 years]
114
How often is the CT colongraphy test performed?
Visualization only/ NO DX[Every 5 years]
115
Capsule colonoscopy is performed how often?
Every 5 years
116
What is used to define prognosis after Dx of colorectal cancer?
CEA [carcinoembryologivcal antigen]
117
How often is the Flexible Sigmoidoscope test performed?
Every 10 years + Fit every year
| Or 5 years
118
How often is Stool or serology DNA performed for colorectal CAXR
Every 3 years
119
If you have a relative with colorectal CAXR when should you be screened w/ colonoscopy?
Every 5 years 10 yrs younger than relative Dx or age 40 [Earliest]
120
How long does it take to develop Polyps / what are the risks?
5-10 years
| No familial[non genetic risk]
121
3 classifications of polyps
Adenomatous
Serrated
Hamartomatous
122
What is the most common shape of polyp
Sessile
123
Common size of Adenomatous polyps?
5mm-1cm
| Most Common TYPE!
124
What is the low risk-high risk adenomatous type?
Low= Tubular
More =Villous
High= Tubular-Villous
125
Serrated polyps include (2)
Hyperplastic skin tags and sessile polyps
126
Polyps is Syndrome =
```
100-1,00s of polyps
Genetic condition
Confirmed by genetic testing
Around 15 yes
100% develop colorectal CAXR
```
127
TXM of polyposis syndrome
Colectomy @ 20 yrs old w colposcopy ID
128
Non-neoplasticism pedunculated cherry red, smooth polyps =
Hamartamous polyps
129
Cowden Dsiease has what two characteristics and increased risk of what?
Hamartamous polyps + Lipomas throughout GI tract
| Increased risk of non GI CAXR
130
Non polyposis : LYNCH SYNDROME
Can cause colorectal CAXR w/o polyps
131
What other CAXR should be screened for in LYNCH SYNDROME
Ovarian + Endometrial and other CAXR’s
132
Demographic factors that lead to colorectal CAXR =
Male gender with increasing age
133
Right sided symptoms that could be Colon CAXR =
Pain/Mass RLQ, IDA, weakness, fatigue
134
Left Sided symptoms that could be Colon CAXR =
Change in bowel, stool streaked
135
Rectum symptoms that could be colon CAXR=
Hematochezia “ribbon stools” urgency to defecate, tenesmus
136
Apple core lesion leads you to suspect
Colon CAXR
137
Management of Colon CAXR
1st = Colonscopy
| Then surgeon mgmt
138
Prognosis Grades for Colon CAXR I,II,III,IV,V
```
I- Greater than 90%
II- 70-85%
III- Less than 4 positive Lymph nodes
IV- Greater than 4 positive Lymph nodes
V- 5-7%
```
139
Blood flow from oxy/deoxy blood at hepatic portal vein travels where?
```
Hepatic sinusoids
Central Vein
Hepatic Vein
IVC
Right atrium of the heart
```
140
Where is bile formed and how much per day?
1L
Liver Hepatocytes
7.6-8.6 pH
141
Bilirubin Steps (1-5)
1) RBC B/D = unconjugated bili [insoluble]
2) Albumin carries uncon. Bili to the liver
3) Liver conjugates bili
4) Bili goes from gallbladder to intestine
5) When reqd bili is used for digestion
142
Components of LFT tests(6)
1) Albumin
2) Serum protein
3) ALP/ALT/AST/GGT
4) Bilirubin
5) Lactate Dehydrogenase
6) Prothrombin Time
143
What type of labs evaluate hepatocellular injury?
Serum ALT/AST
144
What labs eval cholestatsis blockage?
ALP/ ALK PHOS / GGT
145
Synthetic FXN Labs =
Decreased synthesis
Albumin
PT Time/INR
Platelets(WBC’s)
146
An AST : ALT ratio 1:1 = what?
Ischemia
147
An AST: ALT ratio 2:1 = what?
AST MORE = Alcohol
148
An AST:ALT ratio 1:2 = what?
Hepatocellular damage
149
Examples of AST:ALT ration 1:2
Tylenol, viral hepatitis, Necrosis, Toxin induced hepatitis
150
Where is ALT specific origin?
Liver
151
Absorptive or Metabolism disease have what transaminase level predominant?
ALT
| Celiac Dz, Autoimmune Dz, Alpha 1 Antitrypsin, Hemochromatosis
152
Alcohol related liver injury and cirrhoses predominant what transaminase level
AST
153
Dz Examples of Severe elevations of transaminase(3)
Wilsons
Acute Viral Hepatitis
Acute bile obstruction
154
Cholestasis means?
Liver not moving bile
155
ALP is specific for what organ and what issue?
Gallbladder scarring
156
GGT + AST:ALT 2:1 is suggestive of what?
Alcohol abuse
157
ALK phos greater than AST>ALT is = to what type of pattern?
Cholestatic pattern
158
Most common cause of hepatic portal HTN
Cirrhosis
159
Pressure gradient level measured for hepatic portal HTN include what? From low to high?
6-10 sub clinical
10-12 varices
12+ variceal bleed, Ascites
160
Budd Chiari syndrome is assoc with what type of hepatic damage
Post hepatic
161
Outflow obstruction of varices with decreased hepatic venous outflow
Budd Chiari
162
Budd Triad sxs
RUQ pain
Ascites
Hepatomegaly
163
Labs for Budd
Non specific
| AST increased more than ALP
164
Study of choice for Budd syndrome
U/S
| CT -views hepatic venous flow
165
What level of bili causes jaundiced skin and mucous membranes
7mg
166
Sclera conjunctiva jaundice is visualized at what level of bili
2mg
167
AST and ALT normal/Stool Color-Dark brown/Urine color-Normal acholuric/High Urobilinogen= What type of bili elevated?
Unconjugated
| “Pre-hepatic”
168
Dark urine/Normal ish stool/Very high AST:ALT/2-3 times increased ALP = what type of bili elevated
Conjugated and unconjugated
| “Hepatic”
169
High conjugated bili/Absent urobilinogen/increased bile salt/dark urine/clay colored stools/ increased AST:ALT/ALP 10/12X increased = what type of bili elevated?
Conjugated
| “Post hepatic”
170
ALP levels increased with more suspicion for what?
Obstruction
171
Study of choice when eval jaundice =
U/S
MRI for lesions
ERCP MRCP
172
ERCP =
Obstruction test
Endocholiagniography
View bile and pancreatic duct with stone removal
173
MRCP =
MRI view non invasive
174
Fulminant Acute Liver Failure signs =
8 wk development w/ INR greater than 1.5 f
175
Subfulminant ALF includes what?
Hepatic encephalopathy
176
Acute/Chronic ALF?
Acute Distention w/ pre-existing CLD
177
Does Acute Liver Injury include AMS?
No alteration to level of consciousness
178
ALF can be caused by what drugs (3)?
Acetaminophen
Mushrooms
(ABX/NSAIDS)
179
Common symptoms of ALF
GI
Syst. Inflammation
Kidney dysfunction
180
ALF Eval =
EMERGENCY
| Perform Labs
181
Management for ALF =
Supportive
N-acetylcysteine NAC for Tylenol induced OD
Activated charcoal for less than 4hrs since pain onset
Liver TXPL. Could be indicated
182
Viral hepatitis has 4 stages =
1) Viral replication Phase
2) Prodromal Phase
3) Interim Phase
4) Convalescent Phase
183
What time frame is important for Acute hepatitis?
Less than 6 months mostly self resolves
184
What time frame indicated Chronic Hepatitis?
More than 6 months
185
Acute Hep A Transmission and Presentation
Fecal to Oral
```
Fatigue
N/V
Fever
Dark urine
-Jaundiced eye/skin/uticuria/hepatomegaly
```
186
Labs for Hep A standard diagnosis
IgM anti HAV = acute infxn
187
IgG anti HAV =
Persistnat infxn W/ lifelong immunity
188
LFT’s with AST>ALT and moderate elevation of bili + ALK phos = what type of hepatitis
A
189
Main TXM for Hep A
Supportive
190
Acute Hep B Transmission and Presentation
Body Fluid
Mild sxs w/ ab to Hep B
MOST COMMON INITIAL SXS – Fatigue
191
Dx test for Acute Hep B =
HBcAG – Appears later but persists for LIFE
192
HBsAg
Hep B in the Blood
| [Not Acute or Chronic]
193
AntiHBs
Immunity or Chronic
| “You’ve got it, or you’ve had it! “
194
IgM Anti-HBc means you have what?
Acute Hep B
195
HBeAg means what is going on?
Viral replication and infectivity
196
Antibody for HBeAg means what?
Chronic Hep B
197
What’s is the diagnostic serology value that appears weeks later and persists for LIFE?
HBcAg
198
What serology testing is used for monitoring Hep B Infxn?
HBV-DNA
199
How should we manage an acute infxn with Hep B
DO serial testing for HBsAg to see if its has persisted (6months)
Should resolve at 16 weeks ~95%
200
How should we manage chronic infxn with Hep B?
Serological molecular testing
| Test for co-infxns
201
TXM for Hep B
Supportive w Antivirals [Lamivudine]
202
For mod to severe Hep B TXM=
Liver Transplant
203
Transmission for HEP C virus
Blood transmission
| Needle stick
204
LFTS of Acture Hep C
ALT>AST
205
What serology indicated exposure (Acute or Chronic) Hep C
Anti HCV
206
What serology can show early and it’s the diagnostic confirmatory test for Hep C?
HEPC-RNA
207
80% of presentation with Hep C = , the rest =?
ASX
Anorexia, Malaise, Fatigue
208
Management of HEP C
25% spontaneously clearance, TREAT EVERYONE
209
TXM for HEP C
Interferon (Antiviral)Ribavarin
210
What drugs should be avoided when treating a HEP C patient
Tylenol
211
What is the most common reason for liver transplant
HEP C infxn
212
Prognosis of HEP C
Recover @ 3-6 months 55%-85% end up with chronic HCV
213
What hepatitis conifers with HEP B
HEP D
214
Route of Transmission for HEP D
IV Drug use routes similar to HBV
| *Outside US MOST COMMON*
215
What serology = presumptive for HEP D and could persist?
AntiHDV
216
What serology confirms diagnosis for HEP D
HDV-RNA
217
What Hepatitis is of concern in pregnant women?
HEP E
218
HEP E transmission
Fecal to Oral transmission
219
Confirmatory serology for HEP E virus =
IgM AntiHEV
IgG AntiHEV
HEP E Viral RNA
220
Management of HEP E
Supportive
| Severe cases = Ribavirin (Antiviral)
221
Prognosis of HEP E
Can self resolve 4-6 weeks healing
| *Concerned w pregnant patients*
222
Chronic HBV, HCV, HDV, relations or reasons for disease.
HBV = alcohol related
HCV = non alcohol related steatohepatitis
HDV = Wilson’s disease , Alpha 1 antitrypsin DO, Celiac DZ
**ALL CAN LEAD TO CANCER**
223
TXM management for Chronic Hepatitis
Inhibit viral replication- 1st Line = Pegylated Interferon Alfa-2A (PEG-IFN) X 48 weeks
2nd Line = Oral nucleoside analogs for 1-2 yrs [tenofovir, entecovir] = HIGH RELAPSE
224
Chronic HEP C TXM
Decrease risk/sxs 1st Line = PREG-IFN + Ribavirin
| 2nd Line = DAA [glecaprenivir + pibrentasvin] EXPENSIVE BUT BEST
225
Autoimmune HEP is common when? Presentation?
In women, following viral issues.
| Can present ASX to fulminant
226
Labs seen in autoimmune Hepatitis?
ALT HIGH
IgG Levels HIGH
ANA or pANCA
227
Diagnostic study of choice for autoimmune Hep
Liver Biopsy, also assess severity
228
TXM for Autoimmune Hepatitis
Prednisone + Azathioprine [decrease inflammation, liver enzymes, improve sxs]
229
Most common cause of elevated Liver enzymes in the US
Steatosis [non alcohol]
230
NAFLD is associated with what conditions?(3)
Insulin resistance
Obesity
Diabetes
231
Difference between NAFLD and NASH
```
NAFLD = Fat only
NASH = inflammation + Scarring + Fibrosis + Fat.
```
232
What can steatosis lead to?
Steaohepatitis
Cirrhosis
CAXR
233
4 Risk factors for NAFLD
Obesity
Diabetes Type 2
Met. Syndrome
Hypertriglyceridemia
234
Signs and sxs of NAFLD (3)
ASX
RUQ Pain
Jaundice
235
Incidental labs of NAFLD
Inc ALT/AST
| Inc ALP abnormal Liver images
236
History of what two things leads you towards NAFLD
Met. Syndrome or Cirrhosis signs
237
Alcoholic Liver Disease Labs
2X Inc of AST to ALT with Inc ALK PHOS
Serum bilirubin, albumin, PTT normal
Inc Glucose
238
What diagnostic study is preferred for NAFLD
US
239
What is diagnostic for NASH
Liver Biopsy
240
NAFLD management (3)
Insulin and Glucose Control
Lipid Alerting Meds
Vitamin E
241
Which gets pharmacologic thereby NASH or NAFLD
NASH
242
Severe NASH TXM
Bariatric surgery or Liver TXPL prn
243
3 associations with Alcohol Related Liver disease
Steatosis
Lobular Inflammation
Hepatic Elul are Injury
244
Risk factors for Alcohol related Liver Disease
More than 7 beverages a week =Female
14 bevs = Male
Most significant at 30 bevs a week
245
Alcoholic Related Steatosis definition
Fatty Liver First Stage-REVERSIBLE
246
Alcohol Related Steatohepatitis definition
Clinical syndrome by jaundice
247
ARLD Presentation
ASX—> Liver Failure
248
Eval for alcohol use with ARLD with what?
AUDIT-C
249
Labs for ARLD
AST 2X Greater than ALT w Inc. GGT
250
RADS and confirmatory study for ARLD
US = preferred test to dx fatty liver disease, ARLD
| Liver Biopsy for inflammation = hepatitis variant
251
Management for ARLD
NO ALCOHOL
Manage commord’s
ICU w GI care
252
Future use of alcohol does what for ARLD
Flares up the hepatitis and sxs
253
Liver transplant is a consideration in ARLD when?
If they have stopped alcohol within the last 6 months+
254
Most common hepatitis in the US vs Worldwide?
HEP C= US
| HEP B= Worldwide
255
Three stages of cirrhosis
Complicated
Complicated with varies
Decompress. (Variceal blood, Encephalopathy, Jaundice)
256
Compensated cirrhosis presentation
ASX-> Anorexia , Wt loss, Fatigue
257
Decompensated cirrhosis presentation
Jaundice
Pruritis
Upper GI Bleed
Clinical CLD
258
The stigmata of chronic liver disease (5)
```
Spider Angioma
Jaundice Encephalopathy
Asterixis
Palmar Erythema
Scleral Icterus
```
259
Manifestations of cirrhosis stem from where?
Portal HTN
260
Vital signs of cirrhosis patients
Dec BP
| HTN-> Normotensive Wt Loss
261
Cutaneous manifestations of cirrhosis
Clubbing
Terry nails
Muehrcke nails
262
What is spider angioma
A vascular cirrhosis cutaneous manifestation that BLANCHES
263
Endocrine manifestations of cirrhosis, Women vs Men
Women Chronic = Anovulation
| Men = Gynecomastia
264
Hepatic Encephalopathy = increased what?
Ammonia
265
Scale of Hep. Encephalopathy. 0-4.
```
0 = Normal
1 = Mild confusion + asterixis
2 = Lethargy w Inc Asterixis + Behavioral changes
3 = Somnlence w decreased speech, marked confusion
4 = Coma
```
266
Symptoms that are for Hep Encephalopathy pathognemonic include
```
Sleep Pattern Inversion = #1
Personality changes
Cognitive impairment
Tremor
Slurred speech
Coma
```
267
6 findings of Hepatic encephalopathy
```
Bradykinesia
Asterixis
Dysarthria
Heprflexia
Ataxia
Nystagmus
```
268
Treatment for hyperammonemia
Lactulose = absorb and metabolize(decrease the amount) ammonia
269
Pre/Probiutics can help heperammonemia by what?
Building up gut bacteria to help with absorption
270
Labs for Cirrhosis
AST inc more than ALT
271
Management of cirrhosis
GI
| Treat the cause of the complication including portal HTN
272
Child Turcotte Pugh Score shows what
Relative Dz severity of trauma , with classes that relate to prognosis
273
Model for End stage Liver Dz (Mild) shows what
History to predict surgical survivability
274
Hepatotoxic substance induced toxic liver injury(TLI) is most often caused by what?
Acetaminophen
275
What two drugs have a potentiation effect for TLI ?
Tylenol + Alcohol
276
Direct Hepatotoxic rxns are what?
Predictable
Dose related
Universally susceptible
277
Indirect Hepatotoxic rxns are what?
Drug exacerbating
| W/ existing Liver Dz
278
What hepatotoxic rxn us unpredictable and sporadic
Idiosyncratic rxns
279
Two types of Cholestasis patterned injury
Non Inflammatory = drug induced
| Inflammatory = Drug induced inflammation of portal areas
280
Medication for hepatitis can cause what?
Acute or Chronic Hepatitis
D/C that agent
281
1st line TXM for Acetaminophen poisoning
N-acetylecystine NAC
| D/C agent
282
Acute liver failure and organ failure can be due to what?
Acetaminophen hepatotoxicity
283
What does primary biliary cholangitis refer to?
Inside the Liver bile stasis
284
PBC is what kind of dz?
Autoimmune destruction of the bile ducts = cholestasis
| T Lymph mediated
285
Females w Aut immune D/O’s are at most risk for what?
PBC
286
Findings with PBC
Progressive sxs , ASX hepatomegaly
Fatigue
Pruritis
Xanthamatous Lesion of skin or tendons
287
Late stage sxs of PBC
Jaundice , Steatorrhea, Portal HTN, cirrhosis , Liver Failure
288
Labs for PBC
Increased Lipids
Cholestatic Pattern = Inc ALK PHOS , Inc Bill , Small inc ALT/AST
AMA
ANA
289
TXM for PBC
Ursodeoxycholic ACID
| To slow slow progression to liver TXPL
290
Hemochromatosis = accumulation of what?
```
Iron – Hemocidrin
Liver
Pancreas
Heart
Pituitary
Kidney
Adrenals
Testes
```
291
Hemochromatosis w Alc Abuse makes you at risk for what?
Cirrhosis
| Liver Failure
292
Labs for hemochromatosis
```
Inc plasma Iron
Inc serum ferritin
Inc AST/ALK PHOS
(Outside liver indications)
Hemocidrin
```
293
Suspect Hemochromatosis you do what test?
Genetic testing
294
Colors the skin turns for hemochromatosis
```
Grey = Iron
Bronze = Melanin
```
295
Diagnostic test for hemochromatosis
Biopsy
296
1st line TXM for hemochromatosis, 2nd, 3rd?
```
1st = phlebotomy
2nd = chelation defoaxamine meds
3rd = Liver TXPL
```
297
Wilson’s disease is a build up of what leading to what in female vs males?
Copper
Female = Liver Failure sxs
Male = Neuro psych sxs , dysarthria, incoordination
Psych symptoms
298
Pathognomonic for Wilson’s disease
Kayser Fliescherr Rings at the cornea and scleral jxn
299
Labs for Wilson’s disease
Clinical dx = DECREASED ceruloplasmin protein
Increased urinary copper [MOST COMMON FINDING]
Inc copper in the liver
300
Confirmatory test for Wilson’s?
Molecular analysis genetic defect in chromosome 13
301
TXM for Wilson’s disease
Chelation with a D penicillin [ hard on the kidneys ]
2nd = Triantine $$$[better]
3rd = Zinc [absorption and excretion of copper]
302
What is the DOC for pregnant,ASX, or good Mx therapy after chelation in patients with Wilson’s disease
Zinc
303
Explain Pyogenic abscess
```
Invasion of
1) Bile Duct
2) Hep. Artery
3) Portal Vein
Traumatic impact of bacteria into the ABD wall
```
304
Clinical Presentation of pyo hep abscess
Fever
Jaundice
+blood culture
305
What complication can cause Pyo Abscess
Ascending cholangitis
306
Cavernous hemangioma is what?
BENIGN Cluster of capillaries in the liver
| Incidental / unless large
307
Hepatocellualr carcinoma is associated with what?
Cirrhosis
| Hep B/C
308
Labs for hep. CAXR?
Leukocytes is CBC
Alpha Fetoprotein
Sudden sustained increase of ALK PHOS
309
Dx and TXM for hep. CAXR?
```
Dx= Liver biopsy
TXM= Surgery resection
```
310
What should you screen for if hep. CAXR?
Alpha fetoprot. + U/S every 6 months
Cirrhosis pts
Chance of HBV /HCV
Fam Hx of HCC
311
Cholelithiasis = what?
Gallstones in the gallbladder
| Effects women more than men
312
5F’s of gallstones
```
Fat
Fair
Forty
Familial
Fertile
```
313
What is the make up of solid stones
Calcium or bilirubin
314
5 protective factors for gallstones
```
Coffee
Physically Active
High fiber, Low carb
Statins
Unsaturated Fats
```
315
Common sxs of gallstones
Colicky pain that is episodic at RUQ
Pain w High fat meals
Middle of the night pressure
316
Common sxs of gallstones
Colicky pain that is episodic at RUQ
Pain w High fat meals
Middle of the night pressure
317
TXM for cholesterol gallstones
Ursodeoxycholic acid (bile salt)
318
Who is indicated for surgery when treating gallstones?
Cholecystectomy for symptomatic patients and cholelithiasis
319
Define acute cholecystitis
InflaMMATION of the gallbladder w thickened wall
Due to impaction by stone or sandy obstruction[acalculous]
RUQ Pain —> Shoulder
Fever (LOW GRADE)
Palpable GB
320
Is Jaundice common w Acute cholecystitis?
NO
| The ROCK is not @ ampulla of vadar its higher up
321
Positive Murphy sign?
Sudden exhale w pain
322
Where does the pain localize in acute cholecystitis
Infra-scapular region
| “Pos Dx choelcystitis”
323
Does acute cholecystitis have a cholestatic pattern?
NO
324
Labs for AC
CBC Inc WBC Inc 12,000-15,000
Serum bilirubin mild elevation
ALK PHOS / AST ALT non specific elevation
Mild elevation of Amylase
325
Rads for AC in order for preference
1st US = RUQ, study of choice
2nd HIDA SCAN = Obstruction Check
3rd CT = perforation gangrene check
326
2 complications of AC
Gangrenous cholecystitis
| Chronic Cholecystitis
327
Gangrenous chole?
Necrotic perforation. Ischemia
Continuous RUQ pain
Abscess
Obese patients/DM/Elderly
328
Chronic Chole?
Result from repeat episodes of acute chole irritation by STONES
Can become —> porcelain gallbladder
329
Management for AC
Admit
NPOR Pain control (Morphine + Merperidine)
SURGERY[curative] or IV ABX[w high recurrence rate]
330
When does perforation usually occur with AC?
48-72hours
331
Choledocholithiasis is a stone where?
Common bile duct origination = gallbladder
| Post Hepatic obstruction
332
Charcots Triad?
RUQ pain
Fever/Chills
Jaundice
333
PE eval for what with Choledoco?
Sepsis
Hemodynamic status
AMS
334
What study helps decide if there is a stone?
MRCP
335
What study is good for ID and TXM of stones?
ERCP
336
Lab pattern for choledoc?
```
Cholestatic pattern
Inc ALK PHOS > AST/ALT
Serum bilirubin
Inc WBC’s
Amylase -2nd to pancreatitis
```
337
Dx evidence for choledoc?
Charcots Traid
Or
2/3 Charcots + Imaging positive or + elevated liver levels(w Cholestatic Pattern)
338
Alcohol related liver dz and cirrhosis have what liver enzymes levels
AST-predominates more than 5X normal
339
Chronic hep, acute viral hep, steatosis, hemochromatosis, Wilson’s dz have what liver enzymes levels?
ALT-predominates more than 5X normal
340
Acute cholecystitis duct obstruction, budd chairi presents with what liver enzymes levels?
ALT/AST greater than 15X normal
341
PBC, Primary sclerosis cholangitis, cystic fibrosis, and hep masses are examples of what on the US
US= Normal bile ducts
| Hepatic obstructions
342
Common bile duct stone, biliary structure worms flukes and CAXR cause what on US?
US = Dilated bile ducts
| Bile Duct Obstructions
343
Management for Choledoc?
GI ERCP TXM
344
Within what time frame should you perform ERCP
12-24 hours
345
Within what time frame should you remove the gallbladder after ERCP
72 hours
346
Complications of choledoc?
Cholangitis w fever shock jaundice
| Pancreatitis
347
What is Acute Cholangitis AKA?
Ascending Cholangitis
| Acute superlative Cholangitis
348
What is present with Acute cholangitis?
Charcots Triad + AMS/HYPOTN
349
What is Reynolds Pentad
Suppurative Cholangitis w evidence of sepsis
350
Definition of Cholecystitis =
Gallstone + Fever/Pain
351
Def of Choledoc?
Gallstones + Jaundice
352
Cholangitis Def?
Gallstones + Jaundice + Higher Fever
353
Suppurative Cholangitis def?
Gallstone + Jaundice + AMS + HYPOTN
354
Primary sclerosing cholangitis is what type of response?
Immune response common in MEN
| Intestinal endotoxins causing inflammation w IBD (UC)
355
What decreases the risk for Primary sclerosing cholangitis?
Smoking and Coffee
356
What is the Dx study of choice for Primary sclerosing cholangitis?
MRCP
| Look for bile duct dilations b/w strictures
357
Is there an obstructive stone with Primary sclerosing cholangitis?
NO
358
TXM for PSC?
```
Duct dilation stent placement
Cholecystectomy [treatment for stenosis]
Colectomy
Liver TXPL
9-20 yrs survival rate
```
359
What should management be for PSC?
Annual MRCP/PET
| CA19-9 (Nonspecific)
360
What does PSC have a risk for?
Bile CAXR and Colon cancer
361
PBC is associated with what type of cancer?
Liver
362
Biliary cancer commonly presents with what?
Painless jaundice
Dilated biliary tract
Pruritis
363
What is courvoisier sign?
Jaundice w profound and palpable GB
| Mets progress or ascites
364
Labs for Biliary CAXR
ALK Phos> Obstructive pattern (potential mass?)
365
Study of choice to ID Mass in biliary CAXR
MRCP
366
The sphincter of Odii is controlled by what?
The ampulla of vadar
367
What is increased in acute pancreatitis?
Inc pancreatic enzymes (amylase Lipase)
368
What type of cells are injured in acute pancreatitis?
Acinar cells
369
Most common cause of biliary tract dz?
Stones and Alcohol
370
What type of bite can lead to acute pancreatitis?
Scorpion
371
Sxs of Acute Pancreatitis?
Abrupt onset / epigastric pain boring radiation to the back
Episodic
Hurts worse:
When walking around and laying down
372
What ultimately causes pancreatitis?
Backflow pressure build-up
373
What two signs are assoc with acute pancreatitis?
Cullen sign-umbilical
Grey Turner sign= Flank bruise
Hemorrhagic pooling of blood
374
Hx of what lines up with pancreatitis?
```
Boring biliary colic pain
To the back pain
Stones Hx
Distended Abdomen
Low grade Fever (101/102F)
```
375
Explain when you would perform MRCP for AP?
Older than 40 years old to exclude malignancy if no stones on U/S
376
Labs for Acute Pancreatitis (AP)
Amylase and Lipase[stays longer, best]
ALK PHOS>AST/ALT
Hyperlipidemia
377
The Atlanta classification is good for what?
Present Transient or Persistent organ failure classification
378
Severity index is good for what in AP?
Fluid collections and ability to cause pancreatic necrosis
379
What age is at risk for AP via Ranson criteria?
Over 55 yrs
380
What elevated labs are indicative points on ranson criteria for AP? (4)
WBC
Blood glucose
Lacatae dehydrogenase
Aspartate aminotransferase
381
What liver enzymes is specific to the pancreas?
AST
382
Hematochezia @ greater 10%, BUN increase by 5mg/dL, pO2 less than 60mmHg, base deficit greater than 4MEq/L ABD fluid sequestration greater than 6000 mL is a point on the ranson criteria for AP at what time?
48hours
383
TXM of mild AP
```
Pancreatic “rest”
NPO
Aggressive early fluids
NGT
Pain control [meperdine = preferred]
[morphine = irritates sphincter of odii ; SOME]
```
384
TXM of Severe AP
Admit to ICU
Early surgery consult
IV fluids
NPO
385
Why are IV fluids given in severe AP?
To maintain intravascular volume and urine output
386
Necrotizing pancreatitis is treated with what?
ABX + team of specialists
387
AP complications (4)
1) Sterile or Infxn Necrotizing Pancreatitis
2) Intravascular volume depletion
3) Acute resp distress syndrome (ards w cardiac dysfunction)
4) 100% progress to chronic
388
What do 80% of chronic pancreatitis patients develop?
DM
| W/ permanent structural damage
389
Most common risk for chronic pancreatitis?
Alcoholism
390
S/sxs of chronic pancreatitis (CP)?
LLQ pain + Epigastric Pain ; anorexia + streatorrhea
391
How does CP present with exocrine deficiency?
Fat Malabsorption
392
Labs for CP include (4)?
Amylase / Lipase
ALK PHOS
Stool study = Fecal Fat
Pancreatic FXN tests
393
What is the most sensitive imaging study for CP?
ERCP
394
Pancreatic tissue sampling gold standard for diagnosis and NOT SCREEN of CP?
ERCP
395
Explain a direct pancreatic fxn test
Secretin FXN Test
Give a meal or secretagogue to analyze duodenal fluid
Diagnostic for EARLY chronic pancreatitis if the imaging is piss poor
396
TXM for CP?
GI referral
NO ETOH
Non opiodal pain controls
Pancreatic enzyme supplementation
397
Main complications of CP (3)
DM
Cholestatic liver enzymes
Pancreatic CAXR
398
CLIN presentation of exocrine pancreatic insufficiency
Patients w ABD pain chronic diarrhea and steatorrhea
399
Endo and Exo labs fir exocrine insufficiency
Endo = serum glucose decrease and trypsinogen decrease
Exo = fecal fat and secretin stimulation on pancreatic fxn tests
400
Pancreatic CAXR is highly what?
Lethal
401
Sx of pancreatic CAXR
ABD pain
Courvoiser sign [non tender, palpable gallbladder]
LUQ pain depending on tail vs head
402
LABS for pancreatic CAXR
Non specific
Amylase /Lipase
Bilirubinemia
CA-19-9
403
RADS 1st study for pancreatic CAXR
CT
404
2nd study and monitor studies for known Pancreatic CAXR?
EUS/MRCP/ERCP/PET
405
TXM for pancreatic CAXR
Surgical resection = TXM of Choice
406
If resectable what is the TXM protocol for a pancreatic CAXR mass?
Endo stent of bile duct
407
What part of the pancreas is going to present with obstructive jaundice symptoms if affected?
Head
408
What part of the pancreas is going to present without obstructive symptoms if affected?
Tail
409
Inflammation of the appendix can result in what 3 things? (3)
Rupture
Abscess
Gangrene
410
What are two potential causes for appendicitis?
```
Luminal obstruction (Fecalitch)
Distention of bacterial growth
```
411
What happens to blood flow if a fecalith is present?
Loss of flow distal to the fecalith
Leading to infxn and inflammation
Then perforation
412
How will a patient with appendicitis lay?
Lies still
413
What is the characteristics spot of tenderness with appendicitis?
McBurney’s point
414
What is the obturator or sign?
Pain with passive flex ion of the internally rotated right hip
415
Where is McBurney’s point?
Between ASIS and UMB.
416
What is the length of thickness suspect for inflammation or calcified appendicolith?
2mm
417
TXM for appendicitis?
Pain mgmt = morphine
Surgical consult win 24 HOURS [TXM of Choice]
Other countries = ABX
418
What ABX can treat appendicitis?
Cephalosporins
| + Metronidazole
419
Complications of untreated appendicitis?
Abscesses [trasnmural w pus]
Gangrene [transmural w necrosis]
Perforation
Recurrence after TXM (38%)
420
At what time frame is a patient at risk for appendicitis perforation?
36 hours
421
What signs should make you concerned for appendicitis perforation?
Pressure
Pain
Release! [Decreased Pain] = PERFORATION
