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Flashcards in Upper GI 2 + Lower GI 1 Deck (114):
1

Liver fibrosis:
Dx:

excessive CT acumulation in response to chronic liver cell injury
Dx by biopsy

2

Liver fibrosis - causes:

drugs
chemicals
alcohol
disorders affecting liver/hepatic blood flow

3

Liver fibrosis - ssx:

Asx
any sx secondary to primary disorder

4

Liver cirrhosis:

late stage of hepatic fibrosis, widespread distortion of architecture

5

Cirrhosis - ssx:

non-specific (anorexia, fatigue, wt loss)
late: portal HTN

6

Cirrhosis - PE:

Abd: Ascites, splenomegaly
Skin: Jaundice, pallor, petechiae, purpura
Extremities: clubbing
bleeding

7

Cirrhosis - workup:
Prognosis:

Labs: LFT often normal, PT, CBC, viral assay
Biopsy
Irreversible; transplantation

8

Primary biliary cirrhosis:

AI, progressive destruction of intrahepatic bile ducts, leads to cholestasis, cirrhosis, liver failure

9

Primary biliary cirrhosis - classic sx:

middle aged woman
unexplained pruritus
fatigue - insidious
dry mouth
RUQ pain
jaundice

10

Primary biliary cirrhosis - work up:

GGT - elev
Alk phos - elev
AST, ALT - minimally abn
Enti-mitochondrial Ab - elev (AI)

confirm by biopsy

11

Primary biliary cirrhosis - PE:

enlarged, firm, non-tender liver
mb splenomegaly

12

Vascular disorders of the liver:

hepatic ischemia
congestive hepatopathy
hepatic artery disorders (occlusion, aneurysm)
hepatic vein disorders (budd-chiari, occlusive)
portal vein disorders
peliosis hepatitis

13

Ischemic hepatitis:
causes:

diffuse liver damage d/t inadequate blood or O2

most often systemic -
impaired perfusion (chf, acute hypoTN)
hypoxemia (resp failure, CO2 toxicity)
Increased metabolic demand (sepsis)

14

Ischemic hepatitis - ssx:

N/V
HM - TTP

15

Ischemic hepatitis - work up:

Clinical eval
LFTs: very high aminotransferases
mod inc. in bilirubin
LDH inc w/in hrs
Procedure: US, MRI, arteriography

16

Ischemic cholangiopathy:

focal damage to the biliary tree d/t disrupted flow from hepatic artery via peribiliary arterial plexus

17

Ischemic cholangiopathy - ssx:

pruritis
dark urine
pale stool

18

Ischemic cholangiopathy - work up:

Labs - cholestasis
Img - US initially, MRCP, ERCP

19

Ischemic cholangiopathy - causes:

vascular injury during procedure:
liver transplant, laparoscopic cholecystectomy, radiation, chemoembolization, etc

resulting bile duct injury

20

Congestive hepatopathy:

diffuse venous congestion in the liver resulting from RCHF (via IVC)

21

Congestive hepatopathy - ssx:

most asx
RUQ discomfort
severe congestion - massive jaundice

22

Congestive hepatopathy - PE:
Work up:

ascites
hepatomegaly
+ hepatojugular reflex

LFTs - mod elev

23

Hepatic artery occlusion - causes:

thrombosis
emboli
iatrogenic
vasculitis
eclampsia
cocaine
sickle cell crisis

24

Hepatic artery occlusion - ssx:
Work up:

asx w/o infarction or ischemic hepatitis

infarct -> RUQ pain, fever, N/V, jaundice

US (mb Doppler), followed by angiography

25

Hepatic aneurysm - causes:
Work up:

infection
arteriosclerosis
trauma
vasculitis

if they occur - tend to be saccular & multiple!

US, followed by contrast CT

26

Budd-Chiari syndrome:
causes:

obstruction of the hepatic venous outflow from small hepatic veins inside the liver to the IVC

hyper coagulable states
clot

27

Budd-Chiari - ssx:
PE:

Asx to fulminant liver dz
acute: fatigue
RUQ pain
N/V
jaundice
hepatomegaly - ttp
ascites

chronic: fatigue
HM
abd pain
LE edema

28

Budd-Chiari - work up:
prognosis:

LFTs
vascular img

most die <3 yrs if untx

29

Veno-occlusive dz:
causes:

caused by endothelial injury, leading to non-thrombotic occlusion of the terminal hepatic venues and hepatic sinusoids

irradiation
graft vs. host dz
hepatotoxins

30

Veno-occlusive dz - ssx:
PE:
work up:

sudden jaundices

ascites
tender, smooth HM

LFTs
US, liver bx

31

Portal vein thrombosis - causes:

surgery
hyper coagulable states
cancer
cirrhosis
trauma

leads to GI bleeding from varices (usu eso/stomach)

32

Portal vein thrombosis - ssx:
Work up:

Asx unless assoc w/other dz (pancreatitis)

LFTs
US - usu dx

33

Peliosis hepatitis:
causes:

multiple blood-filled cystic spaces develop randomly in the liver (mm - 3cm)

damage to sinusoidal lining cells from use of hormones (OCPs, anabolic steroids), tamoxifen, vit A

34

Peliosis hepatitis - ssx:
Dx:

Usu asx
occasionally cysts rupture -> hemorrhage, mb death
jaundice
HM
liver failure

often found incidentally on US or CT

35

Portal HTN:

increased resistance to blood flow, commonly arises from dz w/in the liver
uncommon - from blockage of splenic or portal vein, or impaired venous output

36

Portal HTN - causes:

cirrhosis
schistosomiasis
hepatic vascular abnormalities

leads to eso varices, portal-systemic encephalopathy

37

Portal HTN - ssx:
PE:

often asx
sx from complications (hemorrhage)

low systolic BP
SM
ascites, peripheral edema
caput medusa, dilated abd wall veins
jaundice
spider angioma

38

Portal HTN - work up:
prognosis:

transjugular catheter (invasive)
US or CT

mortality d/t hemorrhage >50%

39

Portal-systemic encephalopathy:
causes:

neuropsychiatric syndrome

fulminant hepatitis caused by virus, drug, toxin
commonly - cirrhosis, portal HTN
metabolic stress (inf, electrolyte imbalance, dehydration, diuretics)
gut protein d/o (GI bleed, high protein intake)
non-specific cerebral depressant (alcohol, sedative, analgesic)

40

Portal-systemic encephalopathy - pathophys:

absorbed products that would otherwise be detoxified through the liver end up in systemic circulation where they may be toxic to the brain

41

Portal-systemic - ssx:
Work up:

constructional apraxia
agitation, mania (uncommon)
"liver flap" (asterixis)

psychometric eval
CMP - electrolytes, albumin, LFT
EEG - diffuse slow wave activity

42

Post-op liver dysfunction:

mild liver dysfunction following major surgery, in the absence of pre-existing d/o.
3 types:
post-op jaundice
post-op hepatitis
post-op cholestasis

43

Hepatic cysts:

commonly found incidentally on US or CT
usu asx, no clinical significance
polycystic liver assoc. w/polycystic kidneys (rare)

44

Benign liver tumors:

common, asx
ssx: HM
RUQ discomfort
intraperitoneal hemorrhage

LFTs normal to slight abn
often found incidentally on US, CT; may need Bx

45

Most common primary liver cancer:

hepatocellular carcinoma

more common outside US (E. Asia, sub-saharan Africa)
usu. pts with cirrhosis; common in HepB/C

46

Hepatocellular carcinoma - ssx:

prior dx - cirrhosis
RUQ pain
wt loss
RUQ mass
unexplained deterioration
in few, 1st manifestation:
bloody ascites
shock
peritonitis

47

Hepatocellular carcinoma - work up:
prognosis:

AFP (alpha-fetoprotein)
Img: US, CT, MRI
Liver Bx (if dx unclear)

prognosis poor

48

Metastatic liver cancer - from? prevalence?

from GI, breast, lung, pancreas
more common that primary liver CA

49

Metastatic liver cancer - ssx:
PE:

early asx
non-specific:
wt loss
anorexia
fever

liver enlarged, hard, or tender
massive HM with nodules - adv
hepatic bruits (uncommon)
SM
ascites
jaundice (mild)

50

Metastatic liver cancer - work up:

CT or MRI w/contrast
suspect w/wt loss, HM, & primary tumor elsewhere
LFTs non-specific
Liver Bx - definitive

51

Hepatic granulomas:
causes:

localized collections of chronic inflammatory cells w/epithelioid cells & giant multinucleated cells

drugs
systemic d/o
inf (TB, schistosomiasis)

52

Hepatic granuloma - ssx:
work up:

typically asx or reflect underlying cause

LFTs
US, CT, MRI
Liver Bx - definitive

53

Cholelithiasis:

presence of one or more calculi in the GB
10% of adults in dev. countries/20% of >65

54

Cholelithiasis - risk factors:

F>M
obesity
American Indian ethnicity
Western diet (SAD)
FHx
5 F's (female, fat, 40, fertile, FHx)

55

Cholelithiasis - pathophys:

biliary sludge - during GB stasis
types of stones:
* cholesterol stones (>85%)
* black pigment stones
* brown pigment stones

56

Cholelithiasis - ssx:

80% asx
RUQ pain - rad to back, down arm
sudden onset, intense up to 12 hrs, dull ache
N/V common
onset after fatty meal
FEVER UNCOMMON unless cholecystitis

57

Cholelithiasis - work up:

labs unrevealing
US - diagnostic

58

Acute cholecystitis:
Ssx:

inflammation of the GB, dev over hours, usu d/t stone obstruction of cystic duct (>95%)

pain similar to biliary colic, lasts longer >6hrs
subsides 2-3days, resolves 1 wk (85%)
vomiting

59

Acute cholecystitis - PE:
work up:

R subcostal ttp
+ Murphy's sign
- Courvoisier sign
fever

Abd US
Cholescintigraphy
Abd CT (to ID complications - perforation)

60

Chronic cholecystitis:
Ssx:

longstanding GB inflammation, usu d/t stones
damage - from modest infiltrate of chronic inflammatory cells, to fibrotic, shrunken GB
extensive calcification - PORCELAIN GB

recurrent biliary colic

61

Chronic cholecystitis - PE:
work up:

upper abd tenderness
afebrile

abd US

62

Acalculous biliary pain - causes:

biliary colic w/o stones

abnormal GB emptying
overly sensitive biliary tract
sphincter of Oddi dysfx
hypersensitivity of adj duodenum
possibly stones that spontaneously passed
microscopic stones

63

Acalculous biliary pain - work up:

Labs: abn
elev - alk phos, bili, AST, ALT
elev - lipase

Abd US
ERCP w/manometry - show Oddi dysfx

64

Postcholecystectomy syndrome:
cause:

abd sx post cholecystectomy (GB removal)

alteration of bile flow
leads to: continuously increased bile flow to upper GI
diarrhea, colicky lower GI pain

65

Choledocholithiasis:
Ssx:

presence of stones in the bile duct, leading to biliary colic, obstruction, gallstone pancreatitis, cholangitis

usu secondary cholesterol stones originating in GB (85%)

biliary colic
duct dilation
jaundice
cholangitis

66

Acute cholangitis:

EMERGENCY
bile duct infection (gm -) & inflammation
can lead to stricture, stasis, choledocholithiasis

67

Acute cholangitis - ssx:
PE:

Charcot's triad:
* abd pain
* Jaundice
* fever/chills

RUQ abd tenderness
liver tender, enlarged
confusion
hypotension

68

Recurrent pyogenic cholangitis:

intrahepatic brown stone formation
repeat cycles of obstruction, inf, inflammation
* occurs in SE Asia
* sludge + bacteria debris in bile duct
* undernutrition
* parasitic inf

69

What do you suspect in pt w/jaundice & biliary colic?

common duct stone

70

What do you suspect in pt w/ jaundice, biliary colic, fever, & leukocytosis?

acute cholangitis

71

Cholangitis/cholodocholithiasis work up:

Labs:
elev bilirubin, alk phos, ALT, GGT
CBC - leukocytosis
LFTs - AST, ALT

Abd US

72

Sclerosing cholangitis:

chronic cholestatic syndromes characterized by patchy inflammation, fibrosis, strictures of intra/extrahepatic bile ducts

leads to inflammatory & fibrosing lesion, scarring bile ducts

73

Primary sclerosing cholangitis:
Ssx:

MC form, cause unknown (AI?)
80% have IBD - usu UC
10-15% develop cholangiocarcinoma

progressive fatigue -> then pruritis
jaundice (late)
steatorrhea / fat soluble vit deficiencies
75% - stones (GB or ducts)
Asx until late, then HM / SM / cirrhosis

74

Primary sclerosing cholangitis - work up:

elev. alk phos, GGT
elev. Gamma Globulin, IgM
neg. anti-mitochondrial Ab

US - to exclude extrahep obstruction
MRCP - multiple strictures intra/extrahep bile ducts
ERCP - 2nd choice, invasive

75

AIDS cholangiopathy:
Ssx:

biliary obstuction 2° strictures caused by opportunistic info
* pre-antiretroviral therapy - 25% prevalence

RUQ / epigastric pain
severe pain -> papillary stenosis
milder pain -> sclerosing cholangitis
diarrhea
fever
jaundice

76

AIDS cholangiopathy - work up:

elev alk phos, GGT
ERCP
US

77

Cholangiocarcinoma:
Ssx:
PE:

rare
usu malignant
extrahepatic bile duct - MC

pruritis
painless obstructive jaundice
abd pain
anorexia
wt loss

non-tender mass (Couviorsier sign)
HM

78

GB carcinoma:
Ssx:

native american ethnicity
pts w/lg stones (>3cms)
porcelain GB (d/t chronic cholecystitis)
70-90% have gallstones

varies, asx -> biliary pain -> advanced dz w/wt loss, constant pain, mass, jaundice, + couvoisier's

median survival - 3 months
cure if found early

79

Ddx - RUQ pain:

Hepatitis
NASH
cirrhosis
cholecystitis/cholelithiasis
cholangitis
biliary colic
Budd-Chiari syndrome
pancreatitis
pneumonia, pleurisy

80

Ddx - epigastric:

GERD
gastritis
PUD
pancreatitis
myocardial ischemia
pericarditis
AAA

81

Ddx - LUQ:

spleen infarct / rupture
gastritis / gastric ulcer
pancreatitis
hiatal hernia
sickle cell, mono, hemolytic d/o

82

Ddx - R/L flank:

kidney inflammation
pyelonephritis
polycystic kidney dz

83

Ddx - periumibilical:

early appendicitis
gastroenteritis
bowel obstruction
peritonitis

84

Ddx - RLQ:

appendicitis
IBD / UC / Crohn's
cecal diverticulitis
inguinal hernia
nephrolithiasis
F: PID, ovarian cyst, ectopic, endometriosis
M: testicular or epididymal inflammation

85

Ddx - suprapubic:

cystitis
acute urinary retention
F: uterine cramps, PID, cervicitis, endometriosis
M: acute prostatitis

86

Ddx - LLQ:

diverticulitis
IBD / UC / Crohn's
nephrolithiasis
F: PID, ovarian cyst, ectopic, endometriosis
M: testicular or epididymal inflammation

87

Ddx - diffuse abd pain:

early appendicitis
gastroenteritis
intestinal obstruction
mesenteric ischemia
peritonitis
IBS
celiac

88

Ddx - extra-abdominal causes of abd pain:

abd wall - hematoma
infection - herpes zoster
metabolic - DKA, porphyria, sickle cell dz
thoracic - MI, PE, radiculitis
toxic - spider bite, opioid withdrawal, heavy metal poison

89

Define diarrhea:

>200g/day stool wt
increased stool fluidity
>3 BM/day

90

4 mechanisms of diarrhea:

osmotic - too much water in bowels, inc. amt of poorly absorbed solute
causes - malabsorption, osmotic laxatives, lactose intolerance

secretory - inc secretion or inhibited absorption
causes - enterotoxin, hormones, gastric hypersecretion, laxatives, bile salts, fatty acids

exudative - mucus, blood, protein
causes - Crohn's, UC, infectious, ischemic, vasculitis, radiation

motility - increased (hyperthyroid, post-gastrectomy) or decreased (DM, hypothyroid, scleroderma) contact btw contents & mucosa, increased motility (IBS)

91

Diarrhea - red flags:

blood
pus
fever
chronicity
signs of dehydration
unintended wt loss
failure to thrive

complications:
dehydration
electrolyte imbalance

92

Constipation - red flags:

abdominal distension
vomiting
blood in stool
wt loss
severe or worsening sx

93

Constipation - acute/organic:

obstruction
adynamic ileus
meds (opioid, anticholinergic)

94

Constipation - chronic/functional or organic:

carcinoma
hypothyroid
CNS disorder
slow transit
IBS

95

Gas - red flags:

wt loss
blood in stool

96

GI bleeding:

Sm bowel - angioma, AV malformation, tumor, Meckel's

Colon/anus - fissure, colitis, carcinoma, polyp, IBD, diverticular dz, hemorrhoids

97

Dyschezia:

difficulty evacuating (urge, but can't)
often from discoordination: hypotonia or prolapse

98

O&Px3 tests for:

protozoa, worms, eggs, parasites
worms - round, hook, tape, flat, fluke

99

Stool diagnostic tests

Labs (appearance, pH, WBC, blood, etc)
O&Px3
culture
hemoccult
fecal leukocytes
lactoferrin (latex agglutination assay)
fecal lysozyme
comp digestive stool analysis
sIgA
serology
transit/retention time

100

Acute abdomen d/t infection or chemical presents as:

sharp, localized pain
somatic nerves in perietal peritoneum respond to irritation

101

Acute abd d/t distention or spasm presents as:

vague, dull, nauseating, diffuse
ANS fibers on viscera respond to distention & contraction

102

Acute abd - referred pain:

aching pain perceived distant from the source, not reproducible at distant site

103

MC cause of acute abd pain:

Appendicitis!!

obstruction from:
lymphoid hyperplasia (mono, crohn's, GE, measles)
fecaliths
parasites
foreign material (swallowed?)
TB
tumors (benign, malignant)

104

Appendicitis - classic presentation:

periumilical pain -> migrates to RLQ
N/V - after onset
anorexia
<48 hr onset
non-specific: indigestion, flatulence, malaise, diarrhea

105

Appendicitis - PE:

low grade fever
McBurney's pt tenderness
rebound tenderness
pain to percussion - pain in RLQ
rigidity & guarding
Rovsing's sign
Obturator sign
Psoas sign
cough sign
Markle sign (heel drop)
DRE & pelvic maybe

106

Acute mesenteric ischemia:

dec. mesenteric blood flow -> wall ischemia, inflammation, infarction (at splenic flexure)
d/t diminished perfusion or occlusive dz

rarely seen in <60 yrs

107

Acute mesenteric ischemia - ssx:

severe abd pain w/minimal findings
sudden onset pain -> arterial embolism
gradual onset pain -> venous thrombosis
peritoneal signs as necrosis occurs:
* abd tenderness
* guarding
* absent bowel sounds
* hemoccult positive
* sx of shock

mortality rate - 70-90%

108

Ischemic colitis:
Ssx:

episodic, transient reduction of bowel blood flow from small vessel atherosclerosis
mild, slow onset
LLQ pain
rectal bleeding

mucosal/submucosal bleeding mb seen

109

Abd hernia:
ssx:

acquired - surgical or congenital weakness of wall, protrusion of contents
Asx unless strangulated
* increasing pain
* N/V
* signs of peritonitis

SURGICAL REPAIR

110

Intestinal obstruction - classification:

complete or partial
simple or strangulated
location: high sm, low sm, lg intestine
onset: acute or gradual

111

Intestinal obstruction - causes:

adhesions
hernia
tumor
diverticulitis
foreign body
volvulus
intussusception
fecal impaction

112

Intestinal obstruction - ssx:

Sm Int:
sudden onset periumbilical or epigastric cramping
vomiting
obstipation (complete)
diarrhea (partial)
NTTP (if not strangulated)
severe, constant pain (strangulated)
palpable dilated bowel loops

colon:
gradual onset of pain
obstipation
vomiting
abd distension
non-tender palpable mass
borborygmi

113

Ileus:
Causes:

temporary arrest of intestinal peristalsis

post-surgical
appendicitis
diverticulitis
perforation
AAA
hypokalemia
drugs (opioid, anticholinergic)
lower lobe pneumonia
MI

114

Ileus - ssx:
PE:

distension
vomiting
abd discomfort
colicky pain
watery stool

absent bowel sounds
NTTP (unless inflammatory cause)