GI Test 2 STUDY! Flashcards
(267 cards)
1
Q
What is a polyp and what are the 3 things they can lead to
A
a protuberance extending into the lumen of the colon
Typically asymptomatic, but may lead to
Bleeding (commonly)
Tenesmus
Obstruction
2
Q
What are the 3 different types of polyps
A
Pedunculated (can get really large)
Flat
Sessile (most common)
3
Q
What are the 4 major pathological groups of polyps
A
Mucosal Adenomatous (neoplastic)
Mucosal Serrated (neoplastic)
Mucosal Non-Neoplastic
Submucosal Lesions
4
Q
What are the two types of neoplastic polyps
A
Adenomatous (most common) - malignant potential
Serrated:
- Hyperplastic, very common, but no sig RSK. Skin tag.
- Sessile serrated polyps have a similar risk/ greater risk to malignancy as Adenomatous polyps
5
Q
Non- neoplastic polyps are a low risk for
A
Cancer
6
Q
What are the mucosal non neoplastic polyps
A
Juvenile polyps, hamartomas, inflammatory polyps – increased risk of cancer
7
Q
What are the Submucosal lesions that have no cancer risk vs the one that does
A
Lipomas, lymphoid aggregates - no clinical significance
Pneumatosis cystoides intestinalis – air filled cysts
Carcinoid tumor - cancer
8
Q
What polyps have the highest risk for cancer
A
Mucosal non-neoplastic
Juvenile polyps, hamartomas, inflammatory polyps – increased risk of cancer
9
Q
DO name: inherited DO, 100-1000 polyps, by age 15, cancer development is inevitable by age 40-50.
What is the Tx?
A
FAP ( familial Adenomatous polypsosis)
Treatment:
Prophylactic colectomy, typically before age 20
Annual colonoscopy until colectomy
10
Q
hamartomatous polyps + oral mucocutaneous pigmented macules, increased risk of GI cancer
A
= peutz-jeghers syndrome ( hamartomatous polyposis)
11
Q
multiple hamartomatous polyps, increased risk of GI cancer
A
Familial Juvenile Polyposis
12
Q
hamartomatous polyps + lipomas throughout GI tract, increased risk of non-GI cancer
A
Cowdens Dz
13
Q
Large polyps can cause
A
Bleeding,
GI obstruction
Intussusception
14
Q
What is Lynch syndrome
A
Hereditary Nonpolyposis Colon Cancer (HNPCC)
Autosomal dominant condition
Increased risk of cancer: Colorectal Endometrial Ovarian Renal Vesical Hepatobiliary Gastric Small intestinal
Bethesda Criteria used for screening
15
Q
What are the RSK FX for Colorectal Cancer
A
Age
-Incidence rises after age 45
Family history
-First degree relatives
Inflammatory Bowel Disease
Dietary and Lifestyle Factors
- High fat, processed, red meat vs high fiber
- Physical activity, obesity
- Smoking
16
Q
What can you add to your diet to decrease colorectal cancer
A
High fiber diets
17
Q
What is the most common cause of large bowel obstruction in adults
A
Colorectal Cancer
18
Q
What is the gold standard screen for colorectal cancer
A
Colonoscopy
19
Q
What is the most common cause of occult GI bleeding in adults
A
Colorectal cancer
Tests:
FOBT and Iron deficiency anemia
20
Q
What is the most commonly monitored tumor marker for colorectal cancer and how is it monitored
A
Carcinoembryonic antigen (CEA)
- NOT a screening test
- Useful for prognosis after diagnosis
- Used as marker for recurrence after treatment
21
Q
What is the test interval for colonoscopy?
For Flexible Sigmoidscopy?
A
Colonoscopy q 10 yrs
Flexible Sigmoidoscopy q 5 yrs
22
Q
If a polyp is found with flexible sigmoidoscopy then what must be done next
A
Colonoscopy
23
Q
What is the confirmatory test for colorectal test
A
BIOPSY!
24
Q
At what age should African American begin getting screened for colon cancer
A
45 yo
25
What is the preferred cancer detection test
Anual FIT for blood
26
What is the option for pts who don’t want colonoscopy
CT Colonography (“virtual colonoscopy”)
Every 5 yrs
Used if colonoscopy not desired or contraindicated
Less sensitive for polyps <1 cm, flat adenomas, and serrated polyps
Requires bowel prep, no sedation
27
What are the CRC screening recommendations
Cancer prevention tests should be ordered first,
Preferred test is colonoscopy q 10 yrs at 45 yo
Cancer detection test- FIT blood test preferred or FIT DNA test
28
A pt with colon cancer with iron deficiency and weaknesss/ fatigue.. where is the cancer location
Right Colon likely
29
Pt with colon cancer with change in bowel habits, stool streaked with blood, and obstructive S/s ( constipation/ or increased frequency), + colicky abdominal pain
Left Colon most likely
30
Pt with colon cancer with hematochezia, tenesmus, BM urgency and decrease in caliber of stool “ ribbon stool”
Where is the cancer location
Rectum likely
31
What is the general W-up and Tx for colorectal cancer
```
Work up:
Fecal occult blood test (FOBT)
Guaiac or FIT
CBC
CMP
UA
```
Colonoscopy ( gold standard)
```
Treatment:
Surgical Resection
-Full or partial colectomy
Chemotherapy
Radiotherapy
```
32
What are the 5 stages of prognosis for colorectal cancer
Stage I - greater than 90% SR
Stage II – 70 - 85%SR
Stage III with < 4 positive lymph nodes - 67% SR
Stage III with > 4 positive lymph nodes - 33% SR
Stage IV – 5 -7%. SR
For each stage, rectal cancers have a worse prognosis/ Survival rate ( SR)
33
What is the 1st line TX for C. Diff colitis
Oral Vancomycin
34
Antibiotic assoc colitis relapses require
7 week taper of Vanc
35
What is Crohns Dz
Chronic inflammatory disease
!Transmural process !
Variable locations - may involve the entire GI tract from mouth to anus
Variable severity of inflammation - mild to severe/fulminant disease
Worse in smokers!
36
What is the characteristic endoscopy finding in crohn Dz
Skip lesions
37
What are the Hallmark S/s of crohns
```
Abdominal pain
Diarrhea +/- blood
Fatigue
Weight loss
Fever
Growth failure (younger patients)
Anemia
```
38
What are the main c/o of patients with Crohns
Cramp ab pain, RLQ, diarrhea, Wt loss, Growth delays
Malabsorption leads to Iron Def and B12 def.
Anorectal fístulas and bowel obstruction
39
What is the def of ileitis
SB only (terminal ileum (ileitis) – Crohns
40
What is ileocolitis
SB + colon Crohns
41
What are the RSKs of Crohns Dz complications
May result in mucosal inflammation and ulceration, structuring (obstruction), fistula development, and abscess formation
```
Ileal, ileocolonic, or proximal GI involvement
Extensive anatomic involvement
Deep ulcerations
Young age at diagnosis
Perianal/severe rectal disease
Penetrating or stenosis on presentation
```
42
What is phlegmon
walled off inflammatory mass without bacterial infection
may be palpable on physical examination
most often presents as an indolent process, and not as an acute abdomen
43
Penetration of Crohns Dz can lead to an intra abdominal abcess, which present how?
acute presentation of localized peritonitis with fever, abdominal pain and tenderness
44
What are the 4 common sites for fistula formation in crohns Dz
Bladder (enterovesical)
Skin (enterocutaneous)
Small bowel (enteroenteric)
Vagina (enterovaginal)
45
What complication is associated with fístulas to the retro peritoneum
Fistulas to the retroperitoneum may lead to psoas abscesses or ureteral obstruction with hydronephrosis
46
What are some extra intestinal manifestestions
Apthous ulcers, inflammatory skin conditions, Joint pains, MSK pains, Inflammations of the Iris or Uvula, can also effect the gall bladder increasing gall stones
47
What are the inflammations of the skin with Crohns
Pyoderma Gangrenosum and Erthyma Nodosum
48
Is there a specific lab work up for Crohns
NO
49
What does crohns look like on endoscopy
Cobblestoning of the mucosal surface
50
How is the managment of Crohns tracked
Colonoscopy and Endoscopys
51
How do you evaluate for small bowel involvement in Crohns
Capsule endoscopy
52
What is the DO criteria for Crohns
BIOPSY!
53
What level of Crohns is a pt that Responded to medical or surgical therapy
No current active disease
Asymptomatic remission
54
What level of Crohns is a pt that is Ambulatory, eating/drinking normally
<10% weight loss
No complications, dehydration, systemic toxicity, abdominal tenderness, painful mass
Endoscopy – lesions which are not severe
Mild- Moderate Crohns
55
What is the crohns level for a pt with Failed treatment for mild-moderate disease
Fever, weight loss > 10%, abdominal pain or tenderness, N/V without obstruction, significant anemia.
Endoscopy: Moderate to severely active mucosal disease
Moderate to Severe Crohns
56
What level of crohns is a pt with Significant/extreme weight loss and muscle wasting
Persistent symptoms despite steroids or biologic agents as outpatient
High fever, persistent vomiting, intestinal obstruction, involuntary guarding or rebound tenderness, or evidence of abscess
Endoscopy: Severe mucosal disease
Sever/ Fulminant Crohns
57
What is the Tx approach to Crohns
Avoid NSAIDs when possible
- Often associated with flares
- Cause damage to small intestine mucosa
Smoking Cessation
Stress Management
Treat Depression and Anxiety
Dietary Therapy
Anti diarrhea: Loperamide and Bile Acid Sequestrants
Oral Steroids for apthous ulcers: Kenalog
Glucocorticoids and Corticosteroids ( MILD or SEVERE)
58
Tax regimen for Mild to Moderate Crohns
isolated to the ileal and proximal colon: budesonide
Flares: predinose
59
What is the Tx of active Crohns that is moderate to severe
Prednisone
60
Pts who fail to respond to oral steroid therapy for chrons should be considered for…
Admission
Admit patient to inpatient ward (Internal Med)
IV Systemic Corticosteroids
bolus prior to starting infusion of infliximab
IV prednisone 40-60mg per day
61
What are the maintenance remission therapy drugs for Crohns Dz
Azathioprine
6-Mercaptopurine
Methotrexate
62
If immunomodualators do not work for Crohns what is the next step
```
1st steroids
Then immunmodulators
Then TNFS like :
Infliximab (Remicade)
Adalimumab (Humira)
Certolizumab (Cimiza)
```
63
What are the surgical indications for Crohns Dz
Resection of a segment of diseased intestine - most common indication
Penetrating disease - second most common
Recurrent intestinal obstruction
Abscess formation
Complex perianal fistula
SURGERY IS NOT THE 1st LINE
64
What is the admission criteria for Crohns Dz
Suspected intestinal obstruction
Suspected intra-abdominal or perirectal abscess
Serious infectious complication
-especially in patients who are immunocompromised due to concomitant use of corticosteroids, immunomodulators, or anti-TNF agents.
Severe symptoms of diarrhea, dehydration, weight loss, or abdominal pain
Severe or persisting symptoms despite treatment with corticosteroids
65
If a pt has mild or moderate chrons, what is the pharm approach
Short-term use if disease is confined to terminal ileum and right colon, since medication is formulated to be released in this area
-Budesonide
If the pt has flares: Prednisone
If the pt is high RSK: Sulasalazine
66
What is the difference of Crohns vs UC
Crohns: transdural
UC: Involves the mucosal surface of the colon, resulting in diffuse friability and erosions with bleeding
67
What are the Montreal classifications of UC
- proctitis
- left sided colitis
- extensive colitis
68
Where does UC start and where does it progress
Starts in the rectum and advances proximally
69
What is the hallmark sign of UC
```
Blood diarrhea (hallmark)
Rectal bleeding
Cramps
Abdominal pain
Fecal urgency
Tenesmus
Extraintestinal symptoms
```
70
A patient with 4 or less BM/ Day, WIth episodes of constipation, mild abdominal pain, and no signs of Systemic Dz, what severity UC
Mild
71
A pt with more than 4 BM/ day, abdominal pain and may be anemic from bloody stools, what severity of UC
Moderate
72
A pt with 6 or more BM/day, sever ab pain , systemic fever, anemia, elevated ESR and CRP, may have wt loss is what severity UC
Severe
73
What is the DOC for UC
Topical Mesalamine ( suppository or enema)
74
If no improvement at 4 weeks with mesalamine in UC, what drug can be added
Prednisone
75
In Severe colitis what is the 1st line
Oral corticosteroid x 14 days, consider adding anti-TNF
infliximab, adalimumab, or golimumab
76
What is the Tx option for moderate to severe ulcerative colitis in patients who have not responded, lost response, or been intolerant of other therapies
Vedolizumab ( Anti-integrity)
77
What is the approach to sever or Fulminant Colitis
Inpatient care
Surgical consultation early
NPO
Parenteral fluid/electrolyte replacement
IV corticosteroids
78
What is the maintenance Tx for UC
Oral Mesalamine
>2 relapses a year:
Mercaptopurine or Azathioprine
79
What are the screening recommendations for UC
Colonoscopy with biopsies every 1-2 years, beginning 8 years after diagnosis
80
What are the absolute and relative surgical indications for UC
Absolute:
Severe hemorrhage
Perforation
Carcinoma
Relative:
Severe colitis unresponsive to maximal medical therapy
Less severe colitis but medically intractable symptoms or intolerable medication side effects
81
A pt with UC and rapid progression of S/s, with worsening ab pain, Distention, High fever and tachycardia, has what severity of UC
Fulminant
82
What is the characteristic pattern of microscopic colitis
Chronic water diarrhea, with every other cause R/o
83
What are the two subtypes of microscopic colitis
Lymphocytic colitis – Lymphocytic colitis is characterized by an intraepithelial lymphocytic infiltrate
Collagenous colitis – Collagenous colitis is characterized by colonic subepithelial collagen band >10 micrometers in thickness
84
Who is at most RSK for microscopic colitis
Women
85
What is the clinical presentation of Microscopic colitis
Chronic, non-bloody diarrhea that is typically watery
between four and nine watery stools per day
Abdominal pain
May also experience:
Fatigue, dehydration, weight loss
86
If diarheaa persists with microscopic colitis what is the DOC
Budesonide
87
What is IBS
Function Bowel DO
Absence of organic Cause
DO of exclusion
Idiopathic
88
What is the hallmark presentation of IBS
```
Ab pain (often lower ab) assoc w/ altered BM habits (Constipation/ Diarrhea) .
Pain often relieved with defecation.
```
89
What is IBS-C
Constipation predominant
| Patients typically report ≤ 3 BM/week, with straining
90
What is IBS-D
Diarrhea predominant
Patients typically report ≥ 3 BM/day, with urgency or fecal incontinence
91
What is the DO for IBS
≥ 3 months of abdominal pain or discomfort and altered bowel habits
AND
The abdominal pain is associated with 2/3 of the following
- Relieved with defecation
- Onset associated with change in defecation frequency
- Onset associated with change in stool appearance
92
Pts with IBS should avoid what foods
Avoid sorbitol and fructose, gas producing foods, and cruciferous vegetables.
93
What should a IBS pt be recommended for Diet
Low fat, High fiber, unprocessed food diet
94
What diet modifications can be tried specifically with IBS-D
Trial of lactose elimination
Trial of gluten elimination
95
What diet modifications can be tried specifically with IBS-C
increase fiber, increase fluids
96
What is the 1st line Tx for IBS
Dietary and Lifesytle mods
97
Dicyclomine and Hyosyncamine are what agents
Antispasmodic
My help with pain and bloating in IBS
98
What are lubiprostone and linaclotide
Anticonstipation medications
Osmotic laxatives- use first
99
What is in a normal LFT
```
Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)
Alkaline Phosphatase
Total Protein
Bilirubin
Albumin
```
100
What is a hepatocellular pattern on LFT
Elevated AST and ALT compared to ALP ,
| Says that the damage is in the hepatocytes
101
What does a 2:1 elevation in AST:ALT indicate
Alcohol related liver disease
| Particularly in light of a elevated GGT
102
What does GGT tell you
Elevated GGT levels can be observed in a variety of nonhepatic diseases, including chronic obstructive pulmonary disease and renal failure
103
What does a cholestatic pattern on LFT tell you
Elevated ALK PHOS (ALP)
Says a stoppage of the flow ( cholestasis)
104
What is the pressure gradient between the portal vein and IVC that causes Portal HTN
Greater than 10 mmHg
105
What is the most common etiology of portal HTN
Cirrhosis
106
When is Jaundice clinically apparent
>2 mg/dl appears first in the conjunctiva
107
Jaundice caused by unconjugated bilirubin is due to
overproduction of bilirubin
- Hemolytic anemias
- Hemolytic reactions
- Hematoma
- Pulmonary infarction
impaired bilirubin uptake by the liver
- Posthepatitis hyperbilirubinemia
- Gilbert syndrome
- Crigler-Najjar syndrome
- Drug reactions
abnormalities of bilirubin conjugation
108
What does elevation of unconjugated and conjugated bilirubin tell you
hepatocellular disease
impaired canalicular excretion of bilirubin
biliary obstruction
Often referred to as conjugated hyperbilirubinemia, even though both fractions of bilirubin are elevated.
109
What can cause conjugated hyperbilirubinemia
```
Hepatocellular dysfunction
Hepatitis, cirrhosis
Biliary obstruction
Choledocholithiasis, biliary atresia, carcinoma
Hereditary cholestatic syndromes
```
110
A pt with Normal stool and urine color
No bilirubin in urine
Splenomegaly if etiology is hemolytic disorder
And mild jaundice has what kind of bilirubin problem
Unconjugated
111
A pt with jaundice, malaise, anorexia
low-grade fever, right upper quadrant discomfort
dark urine, amenorrhea
enlarged tender liver, spider telangiectasias, palmar erythema
ascites
gynecomastia
Has what kind of bilirubin problem
Conjugated
112
```
A pt with jaundice
right upper quadrant pain
weight loss (suggesting carcinoma)
pruritus
dark urine
light-colored stools(acholic stools)
```
Biliary obstruction, Conjugatged
113
What is the W-up for Jaundice
Lab studies:
- Hepatic labs
- CBC, CMP, UA
Radiographs
-Hepatic ultrasound
ERCP to evaluate bile ducts
-If obstruction is suspected
114
What is an ERCP
An endoscopic technique in which a specialized side-viewing upper endoscope is guided into the duodenum, allowing for instruments to be passed into the bile and pancreatic ducts
Indicated in jaundiced patient suspected of having biliary obstruction.
115
What is the most common cause of acute liver failure
Acetaminophen
116
What is the INR in acute liver failure
>1.5
117
A pt with INR > 1.5, elevated Aminotranferease, elevated bilirubin and ALP, low platelet count, elevated ammonia, elevated amylase and lipase, elevated BUN and Cr
Acute liver failure
118
What is the Tx approach to ALI
Acute liver injury/ failure
Admission for inpatient management
IV fluid and electrolyte replacement
Dietary monitoring
Gastroprotective measures (prevention of stress gastropathy)
IV PPI or H2
Other treatments as indicated based on etiology
119
What are the 4 phases of hepatitis
Viral replication
Prodromal
Icteric
Convalescent
120
What is phase 1 hepatitis
Phase 1 (viral replication phase)
Patients are asymptomatic during this phase
Laboratory studies demonstrate serologic and enzyme markers of hepatitis
121
What is phase 2 hepatitis
```
Phase 2 (prodromal phase)
Anorexia, nausea, vomiting
Arthralgias, malaise, fatigue
Urticaria, pruritus
Alterations in taste
Development of an aversion to cigarette smoke
```
122
What is phase 3 hepatitis
```
Phase 3 (icteric phase)
Predominant gastrointestinal symptoms
Jaundice
Dark urine, followed by pale-colored stools
Malaise
May develop RUQ pain with hepatomegaly
```
123
What is phase 4 hepatitis
```
Phase 4 (convalescent phase)
Symptoms and jaundice resolve
Liver enzymes return to normal
```
124
What is the transmission and incubation period for HepA
Fecal oral
30 day incubation
Viral shedding in feces for up to 2 weeks prior to onset of S/s
125
```
A pt with Malaise, myalgia, arthralgia
Easy fatigability
Upper respiratory symptoms
Nausea & vomiting
Anorexia
Smokers develop distaste for cigarettes*
Low grade fever
Fever breaks - onset of jaundice (after 5-10 days)
```
What type of hepatitis
A
126
What lab marker is elevated in acute Hep A
IgM anti HAV in acute
IgG HAV Ab in chronic
127
What is the Tx approach to Acute Hep A
```
Bed rest if needed
Symptomatic care
Antiemetic, antidiarrheal
Fluids regular meals
Avoid strenuous exercise or work
NO ALCOHOL OR HEPATOTOXIC MEDS
```
128
What is the mode of transmission of Acute Hep B
Inoculation of infected blood or blood products
Sexual contact
-Virus present in saliva, semen, and vaginal secretions
HBsAg positive mothers may transmit to newborn during delivery
129
What groups are at high risk for Acute Hep B
Healthcare workers
-Including staff at hemodialysis centers
IV drug users
Prisoners
130
incubation period for Acute Hep B
6weeks to 6 months ave. 12-14 weeks
131
What are the S/s and Lab findings for Acute Hep B (sub clinical, icteric, fulminant)
Sub clinical: malaise, arthalgia, fatigue, URI, N/V abdominal pain, anorexia, decreased desire to smoke
Icteric: Jaundince
Fulminant: Acute hepatic failure, encephalopathy, coagulapathy, jaundice, edema, ascites
LABS:
HB surface antigen, surface antibody, and core antibody
132
A pt presents with a Postive HBsAg and negative Anti-HBs, their AntiHBc is IgM, what is their phase of HEPB infx
Acute hepatitis B
133
A pt has negative HBsAG and positive antiHBs, the antiHBc is IgG, and both HBeAg and AntiHbe is negative,
What level of Hepatitis B do they have
Recovery/ resolved Hep B
| note the HBsAG is negative, the Ig is IgG, which is long term
134
What is the serologic hallmark of acute HBV infx
HBsAg
135
When does anti-HBs appear
appears in most individuals after clearance of HBsAg and after successful vaccination against hepatitis B
136
What does HBeAg
a secretory protein that is processed from the pre-core protein
indicates viral replication and infectivity
Persistence of HBeAg beyond 3 months indicates increased likelihood of chronic HBV
137
How long does Anti-HBc persist for
For life
138
What is the best way to determine viral replication of HEP B
HBV DNA
139
What is the managment of acute HEPB
Supportive care
140
What is tx for chronic HBV
Antiviral therapy, for pts with severe s/s, marked jaundice, inflammation of the liver, elevated ALT,
Rx: entecavir, tenofovir
141
When can Tx be stopped for HBV
After two confirmed consecutive tests four weeks apart that the pt is cleared for HBsAG
142
What are the modes of infx for Hep C
50% by injection drug use
Transfusion of infected blood
Body piercing, tattoos, hemodialysis
STI and Maternal transmission possible
143
What is the incubation period for Hep C
6-7 weeks
144
What are the S/s of hep C
Waxing and waning of AST/ALT
Fatigue, N, RUQ pain, Jaundince, dark urine, clay colored stools
145
What are the screening and confirmatory test for HCV
Screen: HCV antibodies, with increased LFTs
Confirm: HCV RNA,
146
What is the managment approach to HepC
Some can spontaneously recover,
PCR-RNA determines approach to Tx, Antivirals are the DOC
Ledipasvir- Sofosbuvir
Elbasvir- grazoprevir
(Drugs that end in vir)
Older regimen: Interferion or Ribavirin
147
What is the prognosis of Hep C
Cirrhosis, Carnicoma of the liver, and liver failure
148
What is the transmission of Hep D
Coinfection with Hep B, primarily parenteral
149
What is the most common acute hepatitis world wide
Hep E
150
What defines chronic viral hepatitis
Infection with HBV (+/- HDV) or HCV for greater than 3 months
Persistently elevated AST/ALT
Persistent presence of:
HBsAG and anti-HBc
anti-HCV
Or histologic findings on liver biopsy
151
What is the antiviral regiment for chronic Hepatitis
Nucleoside or Nucleoside Analog
-entecavir, tenofovir, lamivudine, adefovir, telbivudine
Pegylated interferon
152
What is autoimmune hepatitis
Form of chronic hepatitis due to autoantibodies
Much more common in women
Varying clinical presentation
-Some patients discovered incidentally
153
What is NAFLD
Non alcoholic non fatty liver dz
Etiology: obesity, hyperlipidemia, glucocorticoid use, DM
Two types: fatty liver or steatohepatitis
154
What is the most accurate test for NAFLD
Biopsy, microvesicular fatty deposits similar to alcoholic liver disease without the history of heavy alcohol consumption
155
How is NAFLD usually discovered
Patients with NAFLD usually discovered because of elevated transaminase levels
Or incidental finding of hepatic steatosis on abdominal imaging ordered for another reason
156
Lab findings in NAFLD
Lab findings:
- Elevated transaminases
- 1:1 AST:ALT ratio
- Elevated ALK PHOS
Hepatic ultrasonography & biopsy
-Evidence of steatosis
157
What is steatosis
Fatty liver dz
158
What are the two subdivisions of NAFLD
Non-alcoholic Fatty Liver (NAFL)
| Non-alcoholic Steatohepatitis (NASH)
159
What is required to differentiate into NASH and NAFL
Liver biopsy
160
Define NAFLD vs NASH
NAFL:
Hepatic steatosis without significant inflammation, hepatocellular injury, or fibrosis
Minimal risk of progression to cirrhosis
Can be diagnosed noninvasively (labs, imaging)
NASH:
Hepatic steatosis in association with inflammation and hepatocellular injury (ballooning hepatocytes), with or without fibrosis
Can progress to cirrhosis and liver failure
Requires biopsy for histologic confirmation
161
Fever with ascites indicate
Bacterial peritonitis
162
How does SAAG relate to ascites
(serum albumin) – (ascitic fluid albumin)
1.1 g/dL or higher : portal hypertension
Less than 1.1 g/dL : other cause
163
What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Insertion of an expandable metal stent between a branch of the hepatic vein and the portal vein over a catheter inserted via the internal jugular vein
For treatment of portal hypertension as an etiology of ascites
164
Most common agents of bacterial peritonitis
```
E coli
Klebsiella pneumonia
Streptococcus pneumonia
viridans streptococci
Enterococcus species
```
165
What is the Most important lab test is evaluation of ascitic fluid via paracentesis of the abdomen
Gram stain and culture
| Cell count with differential
166
What image study should be ordered If secondary bacterial peritonitis is suspected
Abdominal CT
167
Tax approach to Bacterial peritonitis
Treatment: ADMIT
Empiric – IV 3rd generation cephalosporin
Ceftriaxone (Rocephin)
Specific treatment guided by culture and stain results
168
Prophylaxis for bacterial peritonitis
Once-daily ciprofloxacin or TMP-SMX DS
| Reduces rate of recurrence to < 20%
169
What is Hepatorenal syndrome in cirrhosis
Occurs in 10% of patients with advanced cirrhosis
Represents the end-stage of a sequence of reductions in renal perfusion induced by increasingly severe hepatic injury
Prognosis is poor once this develops
Characterized by azotemia in the absence of parenchymal renal injury or disease
Serum creatinine of 1.5 mg/dL or higher
170
What is hepatic encephalopathy
Neuropsychiatric abnormalities seen in patients with liver dysfunction
develops in 30 - 45% of patients with cirrhosis
Systemic build up of ammonia
Due to hepatocellular dysfunction and lack of hepatic ammonia clearance
171
What are the two types of toxic liver injury
Direct hepatotoxicity (predictable):
Dose related severity
Latent period after exposure
Universal susceptibility
Idiosyncratic reaction:
Unpredictable and not dose related
172
What is the Tx for acetaminophen liver injury
Treatment with N-acetylcysteine
173
What is Rumack-Matthew Nomogram
Predictable, dose-related pattern and progression of injury seen on a graph for acetaminophen injury/ toxin
174
What are the S/s of primary biliary cholangitis
Many asymptomatic at diagnosis
Diagnosis detected by hepatic panel abnormalities
Asymptomatic hepatomegaly
Vague, non-specific symptoms early
Fatigue is usual first symptom
Pruritus
Xanthamatous lesions of the skin or tendons
Jaundice, steatorrhea, portal HTN later
175
What is the most signifigant lab test in Primary Biliary Cholangitis
Antimitochondrial antibodies (AMA) present in 95%
176
What is the Tx approach to Primary Biliary Cholangitis
First rule out other etiologies of biliary tract obstruction
Carcinoma, cholangitis
Ursodeoxycholic acid
FDA approved pharmacotherapy for PBC
Slows progression of disease
Symptomatic treatment for pruritis
Bile salt sequestrants
Likely progression to liver transplantation
177
What is hemochromatosis
Autosomal recessive disorder
Results in accumulation of iron as hemosiderin in the liver, pancreas, heart, adrenals, testes, pituitary, and kidneys
Hemosiderin – intracellular iron storage complex
May lead to cirrhosis and/or hepatic failure
Higher risk if high ETOH intake
178
What are the S/s of hemochromatosis
Typical clinical onset after age 50
Diagnosis usually made earlier
Found incidentally on routine lab abnormalities
-Elevations in AST and ALK PHOS
-Elevated plasma iron and elevated serum ferritin
179
What is the Tx goal of hemochromatosis
Treatment goal is to remove excess iron to prevent end-organ dysfunction and related complications
Treatment measures include:
- Therapeutic phlebotomy – first line
- Chelation with deferoxamine – for secondary iron overload or if phlebotomy ineffective/poorly tolerated
- Liver transplant for advanced disease (cirrhosis or hepatocellular carcinoma)
180
What is the 1st live Tx for hemochromatosis
Therapeutic phlebotomy
181
What is the pathological sign for Wilsons Dz
Pathognomonic sign – Kayser-Fleischer Rings
| Brownish or greenish ring at the corneo-scleral junction
182
What are the lab findings in Wilson Dz
Low serum ceruloplasmin
High Urinary excretion of copper ( >40mcg/24hrs)
High copper concentration in the liver biopsy
183
What is the Tx for Wilson Dz
Chelation
Trientine (triethylenetetramine)
Penicillamine
Zinc (Inhibits intestinal copper absorption)
Refer to GI and Neuro
184
What is the most common cause of Portal HTN in a child
BuDD-Chiari syndrome
185
What is Budd-chiari syndrome
Hepatic Venous Outflow Tract Obstruction
-Results in post-hepatic portal HTN
Primary Budd-Chiari:
-Obstruction due to a predominantly venous process (thrombosis or phlebitis)
Secondary Budd-Chiari:
-Compression or invasion of the hepatic veins and/or the inferior vena cava by a lesion that originates outside of the vein (eg, a malignancy)
186
What is the study of choice for Budd-chiari syndorme
Color Doppler ultrasound
187
What is the clinical presentation of Pyogenic Hepatic Abcess
```
Fever
RUQ pain & TTP
Jaundice
Nausea, vomiting
Anorexia, weight loss, malaise
```
Laboratory Findings:
Leukocytosis on CBC
Positive blood cultures
Nonspecific abnormalities on hepatic panel
188
What is the most common cause of hepatocellulr carcinoma
Cirrhosis
189
A pt with Leukocytosis on CBC
Sudden & sustained elevation of ALK PHOS
Increase in alpha-fetoprotein indicates what liver problem
Hepatocellular carcinoma
190
What pts should we screen for hepatocellular carcinoma
```
Recommended for patients:
With cirrhosis
With chronic HBV or HCV
Family history of HCC
Hepatic ultrasound and Alpha-fetoprotein level
Every 6 months
```
191
Does cholelithiais effect men or women more
Women
192
What are the 5 Fs of cholelithiasis
```
Fat
Fair
Forty
Fertile (female)
Flatulent
```
193
What are the two signs that present with acute cholecystitis
Murphys sign, and Boas sign
194
What is the physical exam presentation of Acute cholecystisis
Physical Exam:
Ill appearing patient, lying still on the exam table
RUQ TTP
Abdominal muscle guarding
Positive Murphy’s Sign
Jaundice is UNCOMMON
-Should raise suspicion for more serious process
195
What are the Lab findings in Acute Cholecystitis
```
CBC reveals leukocytosis
Increase in serum bilirubin is UNCOMMON
-Should raise suspicion for more serious process
Elevations of ALK PHOS and AST/ALT
-Non-specific elevations
-Should NOT reveal a cholestatic pattern
Modest elevation of amylase
```
196
What are the common complications of acute cholecystitis
Gangrenous cholecystitis
- Most common complication in diabetics or elderly
- Presents with sepsis in addition to common symptoms
Perforation – common complication of gangrene
Cholecystoenteric fistula
Gallstone ileus
-Result of gallstone passing through a fistula – usually in the terminal ileum
197
What are the S/s of chledocholithiasis and key lab findings
Severe biliary colic
RUQ or epigastric pain
Nausea and vomiting
Jaundice (may be intermittent – during attacks)
Cholestatic pattern of hepatic panel
-Higher elevations of ALK PHOS and bilirubin, than of AST/ALT
198
What is a hepatocellular pattern
ALT or AST> ALP
199
What is the cholestatic pattern
ALP> ALT or AST
200
What is the Tx approach to Choldochlithiaisis
In general, bile duct stones, even small ones, should be removed, even in an asymptomatic patient
ERCP with stone extraction
Followed by laparoscopic cholecystectomy within 72 hours in patients with cholecystitis and within 2 weeks in those without cholecystitis
201
What is Charcot triad
RUQ Pain
Fever/Chills
Jaundice
Acute cholangitis
202
What is Reynolds Pentad and what does it indicate
```
RUQ Pain
Fever/Chills (rigors)
Jaundice
Altered Mental Status
Hypotension
```
Indicates Acute Suppurative Cholangitis
Surgical emergency!
203
What does C-reactive protein indicate
Levels of inflammation
204
What is the Tx approach to Acute Cholangitis
Admission
-For supportive care and antibiotics
ERCP
-For biliary drainage and removal of obstruction
Surgery
-Only if ERCP fails or is unavailable
Cholecystectomy follows once infection is cleared
-To prevent recurrence
205
What is primary sclerosing Cholangitis
Increased immune response to intestinal endotoxins
-Results in diffuse inflammation of the biliary tract with fibrosis and stricture formation
Strong association with IBD
UC > Crohn
Presents as progressive obstructive jaundice
With fatigue, pruritus, anorexia, and indigestion
206
What is the med term for asymptomatic gallstone
Cholelithiasis
207
What is the med term for gallstone +fever/ pain
Cholecystitis
208
What is the med term for a gallstone lodged causing jaundice
Choledocolithisais
209
What is the med term for gallstone+ jaundice+ fever
Cholangitis
210
What is the med term for a gall stone+ jaundice + fever + AMS+ HOTN
Suppurations cholangitis ( Reynolds triad)
211
Who is most likely to present with Primary Sclerosing Cholangitis
A pt with ulcerative colitis
212
What is courvoisier sign
Palpable gallbladder with painless obstructive jaundice
Also associated with pancreatic cancer
Indication of cholangiocarcinoma
213
In a pt with s/s of biliary obstruction without an explanation ( no stones, no lesions) what should you suspect
Carcinoma of the Biliary Tract
214
What are the specific lab findings in acute pancreatitis
↑↑Serum amylase and lipase (3x upper limit)
-Lipase increases earlier, remains elevated longer & has higher sensitivity for pancreatitis
CBC – Leukocytosis
CMP:
-Elevated BUN
Hepatic Panel
-Elevated ALK PHOS & Bilirubin
Elevated CRP – marker of inflammation
215
What is the Radiograph of choice for Acute pancreatitis
CT scan
216
What is the Tx for Acute Pancreatitis
Clear any obstructions with ERCP
Pancreatic rest- NPO
Bed rest
IV fluids
Pain control- meperidne >morphine ( causes less Oddi spasm)
217
What is the Tx approach for severe Pancreatitis
Admission to ICU
Surgical consult
IV fluids and Monitoring
ABX
218
What is the clinical presentation of chronic pancreatitis
```
Recurrent episodes of LUQ and epigastric pain
Attacks may last hours to days
Anorexia & weight loss
Nausea & vomiting
Constipation
Flatulence
Steatorrhea!!!
```
219
What is the DO testing for chronic pancreatitis
Eval fecal fat
Calcification on CT scans
Must R/o Pancreatic Cancer
220
Tax approach to chronic pancreatitis
```
Referral to GI/Pancreatology
Low fat diet
NO ETOH!! ( most common cause)
Non-opioid pain control
Pancreatic enzyme supplementation
```
221
What are the C/c of exocrine pancreatic insufficiency
Patients complain of dyspepsia, abdominal cramping bloating with flatulence, and watery diarrhea, may also complain about steatorrhea ( due to lack of lipase)
222
What are the two most common etiológicos of exocrine pancreatic insufficiency
Chronic pancreatitis and cystitis fibrosis
223
Steatorrhea is almost always associated with
Pancreatic DO
224
What is the management approach to Exocrine pancreatic insufficiency
Enzyme replacement therapy
225
A pt with abdominal pain, jaundice, Wt loss, LUQ pain, with a non tender- palpable gall bladder, is a 50 year old male, DM and smoker… what should you think
Pancreatic Cancer
226
What is the serum tumor marker for Pancreatic Cancer
CA19-9
227
Where does Diverticular dz most present
On the Left side of the abdomen, Left descending colon
228
Where do most colon cancers occur
On the left side of the abdomen, Left descending colon
229
What is the Gold standard of Colon imagining
Colonoscopy
230
If a patient refuses a colonoscopy, what imaging method can you use
Virtual Colonoscopy
231
True colitis is nearly always a result of infection with….
C. Diff
232
A pt with watery, greening, foul smelling, mucus like diarrhea, with abdominal cramping and WBC < 15, 000 has what level of colitis
Mild- Moderate
233
What are the DO criteria for Severe Colitis
Profuse Diarrhea, fever > 101.3, Hypoalbuminemia <3 g/ dl
And either Abdominal Pain (TTP) or Luekoctosis > 15, 000
234
What defines Fulminant Collitis
HOTN, Fever >101.3, End organ failure, Ileus, WBC > 35, 000
235
What is the SOC for ABX Colitis
PCR,
Then EIAs determine active or chronic
236
What is the perferred imaging for ABX colitis
Abdominal CT, looking for the Thumbprinting
237
What is the Tx approach to ABX assoc Colitis
Admit, Isolation, Correct fluid imbalances
MILD:
Metronidazole (cheaper) or Vancomycin (668 dollars)
Severe: Vancomycin
Fulminant: PO Vanc+ IV Metro+ PR Vanc (in 500 ml of NS enema)
(and early surgical consultation)
238
What is the measurements for toxic vs megacolon
Megacolon is larger than 6 cm
239
What is the DO criteria for Toxic Megacolon
Dilation of 6 cm
Plus Fever, Pulse >120, Luekocytosis > 10.5, Anemia
Plus: dehydration or AMS or Electrolyte Abnormal, or HOTN
240
Tx for Toxic megacolon
Bowel rest, IV fluids, Tx the toxemia, and surgical consult
241
What is a diverticulum
A sac like protrusion of the colonic wall
242
What is the diet recommendation for Diverticulum
High fiber and fluids
243
Pts with active diverticular bleeding need what approach
Resus and Stabilize, then endoscopy
Without bleeding: referral for scope
244
How does a typical diverticulitis pt present
Abdominal Pain in the LLQ, Fever, N/V
245
What is present of physical exam of diverticulitis
LLQ TTP, LLQ mass, Fever
Luekocytosis. , +/- occult blood
246
What is the imaging of choice for diverticulitis
Abdominal CT!
247
What is the managment approach to Diverticulitis
Conservative Managment :
Metronidazole plus Ciprofloxacin ( or TMP-SMX)
Alternative: Augmentin
X 7-10 days BID
Clear Liquid Diet
Severe managment:
Admit and Treat impatient
NPO, Broad spec ABX, Fluids, PAIN managment, Surgery Consult
248
What are the common complications of diverticulitis and what is the managment
Per formation, Abscess, Fistualsa, or obstruction
Order a CT scan
249
What is Olivies Syndrome
Acute colonic psuedo obstruction
250
What is the most common site for a vulvulus
In the sigmoid colon
251
What is the Tx approach to sigmoid volvulus
Detorsion with flexible sigmoidscopy
252
What does an apple core lesion on Imaging suggest
Colorectal Cancer
253
What are sinus tracts in Crohns Dz
Transmural bowel Inflamation is associated with the development of sinus tracts with Crohn’s disease
254
What is perianal dz in Crohns dz
Large painful tags, anal fissures, and Perianal abscesses
255
What are the lab findings in Crohns
Anemia, elevated platelets
Malnutrition
Inflammation
Fecal blood
256
What drug should be used in high risk ASA Crohns dz pts
Sulfaslazine
257
Which has more fístulas? Crohns or UC
Crohns
258
What is the most common indication in the US for liver transplant
Chronic Hep C that progresses to cirrhosis and liver failure
259
A pt with 2:1 elevation of AST/ ALT with a elevated GGT is what
Alcoholic fatty liver
260
What endocrine s/s develop with sirrhosis
Amenorrhea and Gynomastica
261
Lab findings in cirrhosis
Thrombocytopenia
Anemia
Luekocytosis or luekopenia
With evidence of renal failure Increase BUN, Cr
Elevated AST ALT
262
S/s of hepatic encephalopathy
```
Inversion of sleep wake cycle
Personality changes
Tremor,
Somnolent
Slurred speech
Agitation
Confusion
Coma
```
263
What is azotemia
Characteristic finding in cirrhosis ( hepatorenal syndrome)
| Serum Cr > 1.5
264
Tx for hepatic encephalopathy
Admission and lactulose
265
Tx for Primary Biliray cholangitis
Ursodeoxycholic acid
| And bile salt sequestratnts
266
Xanthomas are an indication of
Primary Biliary Cholangitis
267
What is Ranson Criteria
A point system for severity of pancreatitis
