Study Questions for Final Flashcards
(77 cards)
1
Q
Complications of Gallstones:
A
A. Common Bile Duct Obstruction→ 1. back up of bile into LR, 2. Cholangitis (asc. infx), 3. Acute Pancreatitis
*when bile backs up into LR -> Jaundice
B. Gall Bladder Outlet Obstruction→ Biliary Stasis → Chronic Cholecystitis → Acute Cholecystitis → Gangrene or Abscess
2
Q
DDX in acute cholecystitis
A
*Hepatitis
*Cholangitis
*Acute appendicitis
*Pancreatitis–>Elev. Amylase and Lipase usually
(Elev. ALT levels are very specific)
- Biliary colic (cholelithiasis)
- (IBS) Irritable Bowel Syndrome
- (IBD) Inflammatory bowel disease (Crohn’s or Ulcerative colitis)
3
Q
Know the difference between the types of stones in found in cholelithiasis and how etiology will influence treatment.
A
Cholesterol Stones: m/c (75%) sludge-like.
can tx obesity, diet, exercise
Pigment Stones: less common. Calcium bilirubinate
Black stones-more common-Ppl w/hemolytic anemia or cirrhosis.
Brown stones->Asians, stones have more cholesterol and calcium, occur in the intra & extra-hepatic ducts, not GB.
–>Infxns- Bacteria, parasites or other microorganisms trigger oxidation.
4
Q
What are the best methods of imaging for cholelithiasis, in terms of safety, cost, and reliability?
A
Dx: Abd US
5
Q
Which hydrotherapies are best for cholelithiasis, biliary dyskinesia, and cholecystitis
A
Acute GB: chaparral infused castor oil w/no heat 30 min TID
Chronic GB: alt. hot and cold vinegar packs
Biliary Dyskinesia: castor oil pack
6
Q
What dietary/lifestyle changes are appropriate for cholelithiasis and biliary dyskinesia?
A
Tobacco cessation Exercise (30 mins. 5x/wk) Avoidance of saturated fat and high glycemic index foods SAD, animal protein, arachidonic acid rich foods Food Allergy/Intolerance avoidance Elimination/Challenge diet Liver cleansing foods beets, radishes, burdock root. High water soluble foods flax seed, guar gum, oat bran, etc. not legumes Increase Fiber, EFA’s
7
Q
Know the role of food allergies, and which ones are commonly seen in
cholelithiasis, biliary dyskinesia, and cholecystitis.
A
pork and eggs may cause inflam. (high histamine response… allergy… may see eosinophilic infiltration of the GB)
Also, onion, fowl, milk, coffee, orange, corn, beans, nuts
8
Q
What are the primary etiologies for cholelithiasis? (4)
A
- GB stasis (Gall Bladder Outlet Obst.)
- diet low fiber, high fat/sugar -> dysbiosis -> deconj. of bile salts
- estrogen
- genetic - mb poor conversion of cholesterol to bile acid
9
Q
Why isn’t lithotripsy used more often as a therapy?
A
break into diff size pieces, sharp edges, may puncture tissue, overall not very safe/effective
10
Q
Understand the role of exercise (or lack thereof) in gallbladder conditions.
A
helps alleviate GB sxs
11
Q
What are the appropriate herbal therapies for cholelithiasis, biliary dyskinesia,
and cholecystitis, how do they differ?
A
Fumaria off.
Dioscorea Villosa
Ammi visnaga seed
Atropa belladonna leaf
Lobelia inflata (lobelia) leaf, flower, seed
Piscidia piscipula (Jamaica dogwood) bark
Corydalis yanhusuo (yan hu suo) root
Hyoscyamus niger (henbane) flower and leaf
Gelsemium sempervirens (gelsemium) root
12
Q
What are common non-GI diseases that include constipation as a symptom?
A
Acute cholecystitis Appendicitis Anorectal disorders (prolapse) Diet: low in fiber, dehydration DM Hypothyroid Mechanical obstruction Medications Neuropathy
13
Q
Limitations of cathartic herbs in the treatment of constipation
A
- for atonic constipation (lazy colon like in elderly or lifestyle habits)
- primary agent is Anthraquinone glycosides
- DON’T OVERUSE
dependence or agg. .. promotes further atony
electrolyte imbalance - C/I in pregnancy and w lactation bc provokes uterine contraction and triggers laxation in infants, respectively
14
Q
examples of cathartic laxatives:
A
aloe senna iris versicolor juglans cinera frangula purshiana (cascara sagrada) rheum spp
15
Q
*bulk forming laxatives are safer than cathartic and also reduce LDLs, promote glycemic control, bind water into stool
examples:
A
linum usitatissimum (flax) plantago ovatum (psyllium) trigonella foenum-graecum (fenugreek) cyamopsis trtragonolobus (guar)
16
Q
Causes of acute constipation: (3)
A
Bowel obstruction,
Adynamic ileus,
Medications
17
Q
Concerned w sudden onset of constipation bc:
A
colon CA!!
anorectal disorders
diverticular dz
bowel obstruction
18
Q
Why does the Western (S.A.D.) diet often result in constipation
A
not enough fiber/vegetables or water
prob contains food sensitivities, allergies to pt
high carb, saturated fats, rich foods
overeating
19
Q
What role does ignoring stool urge have on constipation?
A
loss of BM reflex
stool sits in LI → more water absorbed so stool is harder and more difficult to slide through rectum
20
Q
Bleeding from Colon PDF: Review the changes to BUN levels secondary to colon bleeding.
A
BUN levels don’t change or maybe change a little, but not in comparison to UPPER GI.
Rectal Bleeding: no change in BUN?
with UPPER GI, BUN increases 30-50 mg/dL, also Creatinine Ratio > 36:1
21
Q
DDX for colorectal bleeding
A
Hemorrhoid Anal Fissures Carcinoma Polyps UC, Crohn’s … IBD Ulcers Diverticulosis, Diverticulitis Vascular Ectasias Colitis (Ischemic, Infectious, Radiation)
22
Q
Know which imaging is the best in diverticulitis
A
Abdominal CT
- can see bowel wall thickening, abscess formation, diverticula
23
Q
Understand key dietary principles in diverticulosis prevention
A
HIGH FIBER!! 50+ g/d non-grain based
diet rich in fruits, veggies, legumes, nuts
avoid seeds, decrease CHO’s
24
Q
Know acute diverticulitis therapies:
A
Increase fluids
Short fruit or vegetable juice fast
Progressing to soft semisolid foods: mashed sweet potatoes or yams, steamed
carrots, squash, bananas, melons, apricots.
Progress to grated raw vegetables as tolerated, then add cooked grains, well-
chewed, and soft protein such as tofu, fish
25
Treatment protocols for diverticulosis/diverticulitis
Diet:
high fiber, avoid food intolerances, simple carbs, processed foods, and seeds, consume foods rich in Vit A, B, acidophilus, if acute: water fast, easy to digest foods
Supplements:
flax, B-complex, foic acid, vit C, probiotics, vit E
Hydro:
Castor Oil pack w heat on Abd, Vinegar pack, Constitutional Hydro
Homeopathy
Botanicals:
Yarnell’s Acute Diverticulitis formula contains:
Echinacea angustifolia, Curcuma longa, Populus tremuloides, Glycyrrhiza glabra, Mahonia aquifolium, Larrea tridentata, Foeniculum vulgare
26
Know herbal therapies for colorectal cancers
```
Baptisia tinctoria
Phytolacca decandra
Rumex crispus
Trifolium pratense
Viola odorata
Viscum album
```
27
Recommendations for colorectal screening schedule
| CDC says:
screening starts at 50 yo
Fecal Occult Blood Test (gFOBT): every yr
Flexible Sigmoidoscopy: every 5 yrs
Colonoscopy: every 10 yrs
28
Recommendations for colorectal screening schedule
| American CA society says,
screening starts at 50 yo if at average risk. USE 1 OF THESE TESTS:
Fecal Occult blood (gFOBT): every yr if positive, follow up w colonoscopy
29
What is the association between obesity and microbiota (or lack thereof)
Obese microbiota extract more E from the diet by interacting w epithelial cells
One study looks at Enterobacter
30
Know H. Pylori – beneficial vs. adverse effects on digestive health
Beneficial: assoc w reduced adenocarcinoma in lower esoph.
Adverse: contributes to gastric adenocarcinoma, lymphoma, ulcers
Affects gastric hormones, leptin and ghrelin
31
Homeopathic approaches (and remedies) for dysbiosis
Candida:
- Candida nosode
- Nystatin nosode
- Syphilinum
32
What prerequisites are needed to define a probiotic?
Non-pathogenic, non-toxic, non-allergic
Capable of surviving the upper GI - resistant to low pH, etc.
Human in origin
Immunomodulator - provide resistance to dz
Good colonization to human intestinal tract
->Influence on gut mucosal permeability
Antagonistic against carcinogenic/pathogenic organisms
Clinically proven benefit to health
Processing, storage, transportation of product legit
33
What is a prebiotic? How does it work?
Inulin, FOS (fructo oligosaccharide)
Non-digestible food component that stimulates certain bacteria in colon
->Growth & activity of bacteria assoc w health
Cofactors for probiotics
Increases absorption of minerals like Ca and Mg
34
Synbiotic? The advantages of its use?
```
Mixture of probiotic and prebiotic
Selectively stimulates growth/metabolism of good bacteria
Improves immune system - immunostimulation
Produces antimicrobial substances
Anti-inflam.
Anti-mutagenic
Anti-carcinogenic
Production of bioactive compounds
```
35
Know the triggering events of dysbiosis (4)
Displacement
Overgrowth
Pathogenic
Quantitative: overgrowth leading to displacement
36
What are the effects of antibiotics on intestinal flora?
Decrease in beneficial bacteria: bifidobacteria, lactobacilli
Increase in potential pathogens: clostridium difficile, candida albicans
Can cause yeast infx, GI sxs like bloating, pain, diarrhea
37
How does a high carbohydrate diet influence dysbiosis?
Increases bacterial fermentation (dt slow transit time)
Increases exposure to toxins (dt slow transit time)
Mb fungal growth (dt slow transit time)
abN bacterial overgrowth
38
Know the non-GI symptoms and conditions associated with dysbiosis & intestinal permeability
-Dysbiosis:
Fatigue, migraines, poor complexion, cystic fibrosis, skin conditions, RA, hypoglycemia, hypercholesterolemia, vaginitis, ulcers
-Intestinal Permeability:
ADHD, Asthma, Allergies, Depression, Diabetes l & ll, Eczema, MS, OM-Otitis media, RA, Recurrent info, Sjogren’s SLE
39
Anti-candida botanicals?
```
Allium sativum
Calendula off
Commiphora myrrha
Grindelia spp.
Mentha piperita
Pau d’Arco
Oil of oregano
Garlic
Grapefruit seed extract
Caprylic acid (promotes growth of beneficial bacteria)
Undecylenic acid (11 C FA inhibits growth of candida albicans)
Plant tannins
Essential oils
Colloidal silver
```
40
Anti-microbial/anti-bacterial botanicals?
```
Allium sativum
Calendula off
Hydrastis canadensis
Juglans nigra
Thymus vulgaris (essential oil)
Usnea spp (Collins)
Olive leaf extract
Grapefruit seed extract
Plant tannins
Garlic
Goldenseal
Berberine
Prima una d’agato
```
41
What diets are most appropriate for dysbiosis? Why?
SCD, anti-candida, elimination, avoid food allergies
->Follow 1 wk, then gradual inclusion of new foods
Therapeutic foods: asparagus, cherry, cuke, dandelion grns, watercress, high cholorphyll foods, green veggies, vit A, acidophilus/lactobacillus, garlic, onions
Avoid carbs & high glycemic index foods
Increase vegetable fiber psyllium, pectin, flax (to stabilize blood sugar)
Digestive enzymes, betaine HCL, sodium bicarb
Avoid: meat, alc, hot sauce/spicy, fried, rich, fatty, salty, coffee, caffeine, sweet/sugar
42
What are most important quality control considerations in selecting a probiotic?
At least 2.5 billion organisms w upwards to 20-30 billion
Choose carefully - ask for assays
Refrigerated strains better?
Takes w meals/after meals
43
Know the applications of the probiotics – especially their effectiveness against pathogenic microbes.
* Improve lactose digestion
* Reduce diarrhea
* Immunomodulator
* Reduce bacterial enzymes
* Competitive exclusion of pathogens
* Reduce serum cholesterol
* Anti-tumor
* Folic acid, vit B synthesis
* Enhance mineral bioavail.
* Control BP
* Prevents bacteria from adhering and colonizing gut mucosa
* Reduce plasma levels of bacterial endotoxins
- >Bc inhibits translocation of bacteria across GI lumen into bloodstream
L. acidophilius, B. bifidum, L. bulgaricus produce: enzymes, vitamins, antimicrobial substances.
Assist digestive system and strengthen immune system protecting against pathogenic bacteria.
->L. acidophilus and B. bifidum are non-invasive in attachment so get excreted out eventually.
44
What imaging is best for diagnosing acute pancreatitis?
CT scan
| can note inflam. of gland
45
Know the possible complications of acute pancreatitis
```
Necrotizing Pancreatitis
Fistula
Pseudocyst
Infx
Pulmonary probs: atelectasis, pleural effusion, pneumonia, ARDS
Renal failure
```
46
Which lab values are indicative of acute pancreatitis?
elevated serum Amylase and Lipase
elevated WBC count 12,000-20,000
elevated ESR, CRP
mb hyperglycemia
47
Serum amylase: How quickly and long does it stay elevated?
rises 2-12 hrs of onset of acute pancreatitis
elevated for 3-5 d
3x normal
48
What ND treatments are appropriate for acute pancreatitis?
* If not severe, it usu improves on its own
* Let the pancreas rest
* avoid solid food for a couple days (usu. 48 hours)
* reintroduce fatty foods later (3-6 d after light food toleration)
* then try fish oil
If severe, IV nutrition curcuma long, angelica sinensis, eleutherococcus senticosus, filipendula ulmaria, foeniculum vulgare fruit, phytolacca americana
49
Know the uses and limitations of chymotrypsin and elastase-1 testing
*Chymotrypsin:
low levels may indicate:
------>*Pancreatic/Exocrine insuff. or *hypochlorhydria
*Fecal Elastase-1: (Gold Standard for Pancreatic Insuff.)
conc. of pancreatic elastase-1 enzyme in fecal matter w ELISA
------>Less than 200=Exocrine/Pancreatic insufficiency
====>Correlated w/Chr. Pancreatitis & Cancer
50
What is the etiology of pancreatic insufficiency?
* overeating
* bad diet (low fiber, high sugar, excess CHO, excess booze/caffeine)
* deficiency of minerals (Mn, Zn, Mg)
* deficiency of protein, vit B6
* gut infx/overgrowth (giardia, SIBO, H. pylori)
* hypothyroid
* hypoadrenalism
* hypochlorhydria
* Dysglycemia, Insulin Resistance
* Gluten/Casein Enteropathy
a. Celiac disease role in pancreatic insufficiency
20% have PI
b. Cow Milk Enteropathy role in pancreatic insufficiency
correlated w PI along w dairy intolerance
51
Chronic pancreatitis etiology?
* ALCOHOLISM (70-80%)
* idiopathic
* hereditary, hyperparathyroidism, obstruction of pancreatic duct, stones, CA
52
Gold standard testing to diagnose chronic pancreatitis?
Gold standard: ENDOSCOPY (ERCP)… Pancreatic ductal structure
- labs and imaging mb normal
- Dx can be made if And X-ray or CT shows pancreatic calcifications
- alcoholism
- hx of abd pain
- classic triad (DM, steatorrhea, pancreatic calcifications)
53
Dx Chronic Pancreatitis:
| classic triad;
DM, steatorrhea, pancreatic calcifications
54
Dietary considerations in chronic pancreatitis?
good fats (saturated fat is not well tolerated), not animal fats or foods except fish
increase veg., fruit, nuts, legumes, fluids
ELIMINATE ALCOHOL AND TOBACCO
avoid spicy, salty, fatty, caffeine, sweets, tofu, shellfish
increase foods rich in vitamin C, A, D and K, Calcium, B12, and folic acid
55
Therapies useful for chronic pancreatitis?
*Pancreatic Enzymes (non-enteric coated)
-->LIPASE (palliative)
*Fat Soluble Vitamins (A, D, E, K), Mg, Se, vitamin C
*Compresses
-->castor oil, vinegar, constitutional hydro, alt. hot/cold
*Botanicals
*Homeopathics
Manipulation-->Chapman’s Reflex
56
Pancreatic cancer – why is this condition so often missed?
onset of sxs are subtle and nonspecific… gradual
57
Tumor markers that can be helpful diagnosis of Pancreatic cancer?
* Carbohydrate Ag 19-9, (CA 19-9)
- ->not effective for early stage Dx (least sensitive)
- ->elevated [in 75-85% pt w pancreatic carcinoma]
* Carcinoembryonic Ag, (CEA)
- ->so not specific
- ->40-45% of pt w pancreatic CA have elevated CEA
58
Primary means of prevention of pancreatic cancer?
quit smoking
maintain healthy weight, regular exercise, healthy diet
stress management
59
Treatment options in pancreatic cancer?
*Diet:
-->short fasts, blood sugar management, low animal fats, avoid meat, spicy, salty, fried, processed foods
*Exercise, Decrease Stress
*Supplements:
A, C, E, Selenium, maitake, multivit/mineral
*Botanicals:
viscum album, avena sativa, baptisia tinctoria, conium maculatum, trifolium pratense, rumex crispus, taraxacum off, phytolacca decandra, gentiana lutea, etc.
*Homeopathy:
Calcarea arsenicosa, Conium maculatum, Iodum, Iris versicolor, Phosphorus, Silicea
60
Hepatitis B/C
| a. Know the various causes of the elevated transaminases
*Alcoholic steatohepatitis, NASH, toxic hep., viral hep., celiac, wilson’s, primary sclerosing cholangitis, primary biliary cirrhosis
→ all cause cirrhosis and thus in the process elevated transaminases
61
Know the relationship between celiac disease and elevated transaminases
-common for pt to be dx w NASH then later find they have celiac dz
-overall, elevation of transaminases is assoc w celiac dz
OR that pt with CD, not on GF diet have elevated ALT/AST. When on GF diet, these often normalize or at least lower.
62
Have an understanding of seroconversion of acute HBV and chronic HBV, which antigen is persistent in carrier status?
HBsAg is the main antigen present in both acute and chronic
(ie Carrier Status… remember, s = sick)
HBeAg will be present in both acute and chronic if there is active replication
63
What are signs and symptoms of HBV & HCV
```
flu-like
more likely to be Asx in HCV
jaundice in HBV
mental sxs in HCV
PE: LR enlargement and T (mb SP, too)
```
64
Conventional treatment of Acute HBV? Chronic HBV? HCV?
INTERFERON ALFA
| -->for HCV interferon + ribavirin
65
Know the appropriate diet and nutritional therapies for HBV and HCV
No alcohol, low sodium, high protein (white meat), low water
| *pt w cirrhosis and (hyponatremia for water restriction)
66
Role of antioxidants, mechanism of action for HBV and HCV?
* ALT levels decrease, HCV-RNA levels decrease
| * mitoquinone may decrease inflamm. in the LR (bc study done w mitochondria-targeted anti-oxidant mitoquinone)
67
How does Silymarin (Milk thistle) and Silybin-Phosphatidylcholine Complex help in the treatment of HBV/HCV?
Silymarin is anti-inflamm., anti-viral… decreases serum transaminases
68
Glycyrrhiza glare (Licorice root)– the role it plays in the treatment of HBV/HCV
* Considered an antiox.
* anti-viral (but mb does not lower HCV RNA)
* lowers transaminases
* Reduce long-term complications in chronic hep C who did not respond to INTERFERON ALFA…
* in a study… may prevent LIVER CA.
69
The role of Low-Dose Naltrexone in the treatment of HBV, HCV? Mechanism of action?
* LDN provides a 4 hour blockade of beta endorphin receptors (best time is 2 am to 4 am, so taking around 10 pm is ideal)
* Stims. the endogenous production of beta endorphin
* Triggers a prolonged upregulation of immune system via increase in endorphins and enkephalins which act on opioid receptors of immune cells.
70
NAFLD/NASH Meaning
```
NASH = nonalcoholic steatohepatitis
NAFLD = nonalcoholic fatty LR dz
```
*NASH is the inflammatory version of NAFLD → Cirrhosis → HCC
71
NAFLD/NASH risk factors
```
Obesity
Dyslipidemia
Glucose intolerance
Insulin resistance
Metabolic syn
Females> Males
Excess fructose consumption
Drugs! Lots of them…
Surgical Procedures
```
72
Outcome of continual fructose consumption on uric acid levels
Uric acid will be increased due to ATP breakdown to peptides in an effort to maximize phosphate groups for fructose metabolism
73
Which pharmaceuticals are risk factors for NASH
```
◦Calcium channel blockers
◦Tamoxifen
◦Corticosteroids
◦Synthetic estrogens
◦Aspirin
◦Methotrexate
◦Valproic acid
◦Cocaine
◦AZT
◦amiodarone
```
74
How does MSG consumption influence NASH?
in a study w mice;
MSG elevates FFAs, TGs, HDL-C, and insulin. MSG also increased expression of hepatic genes involved in lipid metabolism and bile synthesis.
75
Basic treatment protocol of NASH
* Weight loss
* Lipid, insulin, glucose normalization
* Diet
- >high protein
- >high fresh veggies
- >lower glycemic index/load
- >no alcohol
- >smaller freq. meals
- >gluten free
* Choleretics
* Betaine
* NAC
* Vit E
* ALA
* B-complex
* Cr, Zn, Mg, Mn, Va
* Balance cortisol/DHEA
* Probiotics
76
HBV summary:
- Spread via IV drug use, vertical transmission, M-M sex, hemodialysis, exposure to blood/blood products
- Incubation period: ~100d
Sis: RANGE WIDELY: (asx -> fatal) // insidious onset
* Mild in children
* adults - 30-40% have jaundice
- >N/V, anorexia, malaise/fatigue, flulike (pharyngitis, cough, coryza, photophobia, HA, myalgia) …
77
HCV summary:
* HCV infx → Chronic in 60% of pt → Cirrhosis in 20% over ~20 yrs → HCC
* MC indication for LR transplantation in US
* IV drug use, blood transfusion (less common these days)
->*(SCREENING done w US & alpha-fetoprotein)
Sxs:
* Acute: usu asx, can be flu-like in 2-26 wk incubation period
- >usu find abN hepatic transaminase levels on routine testing
*Chronic:
fatigue, depression, N, anorexia, abd discomfort, difficulty w concentration
*Extrahepatic manifestations:
Mixed cryoglobulinemia, porphyria cutanea tarda, membranoproliferative glomerulonephritis, leukocytoclastic vasculitis, focal lymphocytic sialadenitis, idiopathic pulmonary fibrosis
