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406 Cards in this Set

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Dysphagia: first question to ask
liquids, solids, or both?
Hard to drink liquids (choking/gagging/nasal regurgitation). Swallow solids ok. What type of Dysphagia? (General rule of thumb)
Oropharyngeal
Starts with difficulty swallowing solids, but drinking liquids ok. What type of dysphagia? (General rule of thumb)
Esophageal Obstruction
Hard to swallow solids and liquids. What type of dysphagia? (General rule of thumb)
Esophageal Motility
Diagnostic test for oropharyngeal dysphagia.
Cine-Esophagram (swallow study with speech therapy)
1st study to order if suspecting Esophageal Dysphagia (Obstruction or Motility).
Barium Swallow
Muscular or Neurologic pathology causing dysphagia. What type of Dysphagia?
Oropharyngeal
Esophageal Obstruction suspected cause of dysphagia; what test follows Barium Swallow?
EGD with bx
Motility Disorder suspected as cause of Dysphagia; what study follows Barium Swallow?
Manometry
Odynophagia (pain with swallowing); what study to order if no obvious cause?
EGD
Intermittent obstructive esophageal dysphagia. name 2 causes.
Esophageal ring (schatzki) and Eosinophilic esophagitis
Candidal Esophagitis. Pathognomonic for what?
AIDS
Intermittent Esophageal Dysmotility. Diagnosis?
Esophageal spasm
Most common Esophageal Motility Disorder?
Achalasia
Man with progressively worsening dysphagia. Started with difficulty with solids, now has trouble with liquids. Diagnosis?
Esophageal Cancer until proven otherwise
Progressive Dysphagia with GERD sx: name 2 diagnoses.
Scleroderma (motility) and Peptic Stricture (obstructive)
Bird's beak on barium swallow. Diagnosis?
Achalasia
Retinitis, Colitis, and Esophagitis. Infectious agent?
CMV
Treatment for CMV esophagitis?
Ganciclovir IV
Treatment for HSV esophagitis?
Acyclovir IV
Treatment of Oral Thrush
Fluconazole PO
Plummer-Vinson Syndrome triad.
Dysphagia (2/2 Esophageal Web)
Glossitis (swelling tongue)
Iron Deficiency Anemia
Corkscrew esophagus or Nutcracker esophagus: dx?
Diffuse Esophageal Spasm (DES)
Treatment for "Chest" Pain 2/2 esophageal dysphagia.
Nitrates and CCB (symptomatic tx)
If nitrates and CCBs fail to control esophageal spasm pain, what is tx?
surgery (myotomy)
Impaired relaxation of the Lower Esophageal Sphincter (LES). Dx?
Achalasia
Why is peristalsis lost from only distal 2/3s of the esophagus in Achalasia?
top 1/3 is skeletal muscle
Regurgitation of food eaten yesterday. Dx?
Achalasia
Why use manometry to confirm Achalasia with bird's beak Barium Swallow?
malignancy can obstruct at lower esophagus and mimic achalasia
1st line treatment of Achalasia.
pneumatic balloon dilation
When is repeated botulinum toxin therapy indicated in Achalasia?
if concerned esophagus will rupture (more risk in elderly) with balloon dilation
Second most common esophageal dysmotility disorder (after Achalasia).
Esophageal diverticula (e.g. Zenker's)
Even though most esophageal diverticula are diagnosed incidentally via EGD, what is the diagnostic of choice and why?
Barium Swallow preferred secondary to risk of perforation when scope cannalates the diverticulum
Most common Esophageal cancer worldwide
Squamous Cell Carcinoma
Most common Esophageal cancer in the U.S.
Adenocarcinoma
Major risk factors for Squamous Cell Carcinoma.
Smoking and Alcohol
Major risk factor for Adenocarcinoma of the Esophagus.
Barrett's secondary to GERD
Rapid onset of dysphagia with weight loss. Diagnosis?
Cancer until proven otherwise
What must happen during EGD when evaluating obstructive esophageal dysphagia?
biopsy (to rule/out cancer etc.)
Transient Lower Esophageal Sphincter (LES) relaxation. Dx?
GERD
Heartburn without Dysphagia. Likely Dx?
GERD
Management of patient with 1st presentation of heart burn
Empiric PPI and/or H2 blocker
Why perform barium swallow when you suspect GERD?
to look for hiatal hernia as source
Why is manometry often performed on GERD patients?
to aid placement of pH probe
When to order EGD in GERD sx? (3 reasons)
if unresponsive to empiric therapy
if long standing sx (check for barrett's)
if any concerning sx (e.g. dysphagia)
How often to screen patients with GERD for Barrett's esphagus (with EGD)?
q5-7 years
If Barrett's esophagus is found on EGD, but no adenocarcinoma, when is next EGD screening?
3 years
Lifestyle advice to aid GERD symptoms.
Graze (small meals more often)
Eating at night prohibited
Raise head-of-bed
Diet (weight loss)
What surgery for refractory GERD (especially for sliding hiatal hernias)?
Nissen fundoplication
Empiric medications for GERD sx.
H2 blocker (cimetidine or ranitidine)
PPI (omeprazole or lansoprazole)
95% of hiatal hernias are sliding; 5% are paraesophageal. What is a paraesophageal hernia?
fundus of stomach herniates through next to esophagus
Which of the 2 types of hiatal hernias needs surgical gastropexy? why?
paraesophageal (prevent gastric volvulus)
GERD vs. Gastritis: where is the pain?
GERD: chest
Gastritis: epigastric abd
Type A gastritis in the fundus (10% of gastritis) is due to what?
autoantibodies to parietal cells
Parietal cells secrete what that aids with B12 absorption?
intrinsic factor
What is the anemia called 2/2 autoimmune caused B12 deficiency?
pernicious anemia
Top 2 causes of gastritis.
NSAIDS and H. pylori
Meds for GI ulcer/gastritis prophylaxis in ICU patients (and becoming standard of care for all inpatients).
H2 blocker or PPI (usually omeprazole)
Gastric cancer that matastasizes to the ovary.
Krukenberg tumor
Triple therapy for H. pylori induced gastritis or PUD.
Amoxicillin, Clarithromycin, Omeprazole 10-14 days
Patient with epigastric pain: when is EGD indicated? (3 reasons)
age over 55
any alarm sx (e.g. bleeding)
failed empiric PPI
When to perform 24 hour pH probe in patient with heartburn.
If EGD is negative for GERD and symptoms persist despite trial of PPI/H2.
Gastric cancer is common in what 2 countries?
Korea and Japan
Early satiety and dyspepsia. Feared diagnosis?
Gastric Cancer
Virchow's node (supraclavicular lymph node) is associated with what cancer?
Gastric Cancer
Gastric Cancer that presents with upper GI bleeding (advanced cancer) has what five-year survival?
less than 10%
Most common cause of PUD.
H. pylori
Dull, burning epigastric pain that changes with meals. Diagnosis?
PUD
Duodenal vs. Gastric ulcer: worse or better with meals?
Duodenal: Decreases with meal
Gastric: Greater with meal
Coffee-ground hematemesis or melena. Where is the bleeding?
upper GI
Patient with epigastric tenderness in ER: imaging to order and why?
AXR to r/o perforation
Age above which any patient with epigastric pain will get EGD?
55
Young patient with epigastric pain with no alarm symptoms. Next 2 steps in assessment?
1) urease breath test or h. pylori stool antigen test
2) check for bleed (CBC, NG lavage, stool guaiac)
Patient on treatment for PUD suddenly becomes unstable; likely cause?
perforation
PUD patient now with hematochezia; likely mechanism of ulcer bleed?
hemorrhage from artery erosion
PUD patient with arthritis. What to give instead of NSAIDS?
Misoprostol
PMHx is important when assessing epigastric pain (for NSAIDS); why is PSocHx important?
EtOH and Tobacco are risk factors for PUD
For epigastric pain, EGD is needed if empiric H2/PPI fails. How long to try it?
2 months
What other test to order (with EGD) if empiric H2/PPI fails to control GERD (or Gastritis, or PUD)? Why?
Gastrin level to r/o Zollinger-Ellison syndrome
What is Zollinger-Ellison Syndrome?
Gastrin producin tumor in duodenum or pancreas.
What endocrine syndrome are Zollinger-Ellison gastrinomas associated with (20%)?
MEN 1
Scan with this radiolabeled drug can localize gastrinoma in Zollinger-Ellison syndrome.
Octreotide Scan
1st line medical therapy for gastrinoma in Zollinger-Ellison syndrome to control symptoms.
PPI (H2 blocker typically ineffective)
Preferred (definitive) treatment for gastrinoma of Zollinger-Ellison?
surgical resection (metastatic risk)
Most common cause of diarrhea worldwide.
Rotovirus
Diarrhea: child under 5
Rotovirus
Diarrhea: recent antibiotics.
C. diff
Diarrhea: recent travel
E. coli
Diarrhea: recent camping trip
Giardia
Diarrhea: Shellfish
vibrio parahemolyticus
Diarrhea: Cruise ship
Norovirus
Diarrhea: uncooked hamburger
e. coli O157:H7
Diarrhea: poultry
Campylobacter or Salmonella
Diarrhea: raw eggs or dairy (egg shell)
salmonella
Diarrhea: mayonnaise (picnics)
S. aureus
Diarrhea: bloody (4)
Salmonella, E. coli, Shigella, Campylobacter
Most common cause of infectious diarrhea in the U.S.
Campylobacter
Treatment of Campylobacter
Erythromycin (if any)
Treatment of C. diff.
Metronidazole or Vancomycin
Recent undercooked hamburger with bloody diarrhea. Why not treat with antibiotics?
e. coli O157:H7 is likely cause, and antidiarrheal therapy can induce HUS
Salmonella diarrhea in sickle cell patient: possible complication?
Salmonella Osteomyelitis
Medication to avoid in patients with Entamoeba Histolytica 2/2 perforation risk.
steroids
Treatment for Shigella diarrhea to decrease spread.
TMP-SMX
What is the infectious dose of Shigella?
1-10 organisms (very contagious)
What is the mechanism of death 2/2 acute diarrhea (especially in 3rd world)?
dehydration
If diarrhea lasts this many days, work-up is indicated.
more than 5 days
First 2 tests to order in acute diarrhea work-up.
Stool guaiac and Fecal Leukocytes
When to decide to work up acute diarrhea.
clinical judgement: dehydration, fever, over 5d, mucus, pus, blood, foreign travel, recent hospitalization/abx use
Diarrhea and recent foreign travel. What is the confirmatory test for E. histolytica?
ELISA
When do you need to order Stool Cx or O&P in work-up for acute diarrhea in order to be cost effective?
under 72 hours from admit
Why do antibiotics cause diarrhea?
change bowel flora
3 diet supplements that causes of diarrhea.
Sweeteners (sorbitol or lactulose)
Minerals (Mg)
Tea (Senna)
Loperamide mnemonic.
I'lL OPERAte MI Diarrhea
2 causes of constipation post-op.
Ileus and Opiods
4 causes of Malabsorbtive Diarrhea.
Bile Salt Deficiency, Pancreatic Insufficiency, Mucosal abnormalities (Sprue), and Lactose intolerance
3 step evaluation for chronic diarrhea which cannot be clinically confirmed.
1) Fecal Leukocytes and Guaiac
2) Stool Cx and O&P
3) Osmotic Gap and Fecal Fat
2 reasons for chronic diarrhea to rule/out before work-up.
Lactose intolerance and Medication induced
When to do Colonoscopy for acute or chronic diarrhea (2 reasons)?
1) positive leukocytes or guaiac and negative culture
2) all work up is negative
Osmotic gap which indicates malabsorption diarrhea.
over 50
Screening and confirmatory tests for Celiac Sprue.
Screen: TTG
Confirm: biopsy (with EGD)
Why check IgA levels with TTG for Celiac screening?
IgA deficiency can cause a false negative screen.
Why confirm positive TTG screen with biopsy?
Giardia can cause false positive
Lifestyle modification as a test in the work-up for diarrhea (especially malabsorption).
any changes with fasting?
Over the counter treatment for mild diarrhea.
Pepto Bismol (Bismuth Subsalicylate)
Treatment for Celiac Disease?
Gluten free diet
4 deficiencies commonly associated with Celiac Disease.
Fe, Folate, Ca, Vit D
If patient does not give classic lactose intolerance history, what test to order?
Hydrogen breath test following lactose load
Why does carcinoid syndrome suddenly appear when after metastasis?
prior to liver metastasis, hormones undergo extensive first pass metabolism
Carcinoid syndrome pentad.
Cutaneous flushing
Abdominal cramps
Respiratory wheeze
Cardiac valve lesions
i
n
o
i
Diarrhea
Diagnostic test for carcinoid syndrome.
urine serotonin metabolite test (5-HIAA)
Treatment of carcinoid syndrome.
Octreotide (for sx control) and surgery
Alternating constipation and diarrhea; abdominal pain relieved by bowel movement. Diagnosis?
IBS
What often happens during sleep which is a clue to IBS?
nothing happens
3 causes of increased fecal fat and increased osmotic gap.
malabsorption, pancreatic insufficiency, and bacterial overgrowth
Confirms pancreatic insufficiency as the source for diarrhea.
secretin stimulation test
Confirms bacterial overgrowth as a source for diarrhea.
C-xylose breath test
If work-up is all negative for diarrhea, what 24 hour stool weight indicates likely secretory cause?
over 1000 g
Miracle drug for diarrhea and constipation.
Fiber
What antispasmodics to remember for treatment of IBS.
dicyclomine or hyoscyamine (anticholinergics)
Leading cause of Small Bowel Obstruction (SBO) in kids.
hernia
Leading cause of Small Bowel Obstruction (SBO).
adhesions
Bowel sounds have high-pitched "tinkles" and peristaltic rushes. Diagnosis?
Bowel obstruction (SBO or LBO)
Leukocytosis and SBO on AXR. What treatment?
Surgery (ischemia or necrosis)
Metabolic abnormality associated with vomitting.
Metabolic Alkalosis
Diagnostic test for SBO and LBO.
AXR, then likely CT
Stepladder pattern on AXR. Diangosis?
SBO
Radio-opaque material at the cecum on AXR. Diagnosis?
Gallstone illeus
Pneumobilia (gas in the biliary tree) on AXR. Diagnosis?
Gallstone illeus
How to confirm Gallstone illeus if AXR suggests it?
Small Bowel follow through XR (e.g. Barium)
Presentation of Bowel Obstruction
cycles of abdominal pain and vomiting
3rd most common cause of Small Bowel Obstruction (SBO) after hernia and adhesions?
neoplasm
Treatment for partial SBO (passing flatus).
Supportive: NPO, NG suction, IVF, correct electrolyte
Treatment for Complete SBO (Obstipation).
surgery
Partial bowel obstruction not resolved after 3 days. Next step in management?
surgery
Strangulation of SBO brings risk of this complication up 10 times (compared to non-strangulated SBO).
mortality
Abdominal pain characteristic of ileus.
diffuse, constant, moderate
AXR description of ileus.
air in small AND large bowel
Treatment for ileus (3)
1) d/c narcotics etc.
2) NPO (parenteral feeds if needed)
3) NG suction as needed to relieve pressure
Most common artery involved in mesenteric ischemia (60% of cases).
Superior Mesenteric Artery (SMA)
2 most common causes of mesenteric ischemia
Embolism (e.g AFib or CHF) - 50%
Hypoperfusion (nonocclusive) - 25%
SUDDEN ONSET, severe abdominal pain out of proportion to exam. Diagnosis? What is vital in differential?
Bowel Ischemia
H/O series of episodes of abd pain after eating causing weight loss. Now constant pain. Diagnosis?
Mesenteric Ischemia
Gold standard imaging test for Mesenteric Ischemia.
Mesenteric Angiography
2 treatments for Mesenteric Ischemia (2 As) to start immediately (before surgery)
Anticoagulation/thrombolytics and Antibiotics
Mortality rate for mesenteric ischemia?
50%
Surgery goals for mesenteric ischemia.
emoblectomy and resection of any infarcted bowel; stent if hypoperfusion secondary to atherosclerosis
Most common cause of lower GI bleeding (LGIB) (60%).
diverticulosis
Diet associated with diverticulosis.
high fat, low fiber, poor water consumption
Treatment for bleeding diverticulosis.
usually self limiting; otherwise: colonoscopy + epineprhine ejection and electrocautery
LLQ abd. pain and fever. Diagnosis?
diverticulitis
Treatment for Diverticulitis?
NPO and Antibiotics
Treatment for perforated Diverticulitis.
Hartmann's procedure (temporary colostomy)
Diverticulitis without improvement. Have a low threshold for this test.
CT
Feculent emesis. More likely small or large bowel obstruction?
Large
Bilious emesis. More likely small or large bowel obstruction?
Small
Most common cause of Large Bowel Obstruction (LBO) (60%).
Cancer
LBO or SBO: which has worse distention?
Large
R/O this cause of Bowel Obstruction by physical exam.
fecal impaction (digital evacuation)
Which has more vomiting: LBO or SBO?
SBO
Steptococcus bovis bacteremia. Cause?
Colon Cancer
First colonoscopy age if first degree relative had colon cancer?
at 40 or 10 years before age of diagnosis of relative
3 screening tests that can be used for colon cancer ONLY IF colonoscopy is not available.
sigmoidoscopy q5 yrs
FOBT q1 yr
DRE q1 yr
One small adenomatous polyp found on colonoscopy and removed. When should next colonoscopy be scheduled?
5 years
2 cm adenomatous polyp found on colonoscopy and removed. When should next colonoscopy be scheduled?
3 years
Five adenomatous polyps found on colonoscopy and removed. When should next colonoscopy be scheduled?
1 year
What number of polyps prompts removal of colon in patient with FAP?
100
Diagnostic test for FAP vs. HNPCC.
FAP: colonoscopy and bx
HNPCC: genetic test
Risk of colon cancer in FAP.
100% by age 40
Lifetime risk of colon cancer in HNPCC.
80%
HNPCC caries risk for other cancers. What are the top 3 (besides Colon)?
Endometrial
Ovarian
Gastric
Fe deficiency in elderly male. Diagnosis?
Colorectal cancer until proven otherwise.
What is the metastatic work-up for Colon Cancer? (3)
CXR, LFTs, and CT
When to use chemo as adjuvant to surgery in treatment of colon cancer?
if any lymph node involvement
Follow-up colon cancer with serial blood tests measuring this level.
CEA
When to schedule next colonoscopy after colon cancer surgery?
1 year
most common site for ischemic colitis.
Splenic flexure (watershed area)
Ischemic colitis is a known complication of this surgery.
AAA repair
Lower abdominal pain and bloody diarrhea; how to confirm a diagnosis of ischemic colitis?
colonoscopy
Treatment of ischemic colitis
NPO, IVF, and Antibiotics
Ischemic colitis patient develops fever and peritoneal signs. Cause?
Infarction (needs surgical resection)
How much should 1 unit PRBC raise the Hct?
3 units
Where is the ligament of trietz? (separation of upper and lower GI tracts)
Between Duodenum and Jejunum
Most common cause of Upper GIB.
PUD (50%)
Top 5 causes of upper GIB.
PUD
esophagitis
gastritis
esophageal varicies
mallory-weiss tear
Top 5 causes of lower GIB.
Diverticulosis
IBD (UC more than chrons)
neoplasm
hemorrhoids/fissures
AVM
2 tests for UGIB (in order of operation)
1) NG lavage
2) EGD
2 options if Octreotide fails to control bleeding varicies.
1) EGD w/ ligation
2) TIPS to reduce portal HTN
Medical treatment for bleeding varicies (along with stabilizing).
Octreotide
Classic Barium XR appearance in chrons.
areas of poor filling ("string-sign") and deep transverse fissures
Classic Barium XR appearance in Ulcerative Colitis (UC)
loss of haustra ("lead pipe")
IBD presents with what?
alternating constipation and diarrhea
abdominal pain
Most common location of Chron's
ileocecal region
Location limits of Ulcerative Colitis (UC).
Rectum to Cecum ("UC is Up to the Cecum")
Location limits of Chron's.
Mouth to Anus
Thickness of Chron's vs. UC.
Chron's: transmural
UC: submucosa
Non-caseating granulomas: Chron's or UC?
Chron's
What is rectal tenesmus? (associated with IBD)
Sensation at the anus that evacuation was incomplete
Fistula: Chron's or UC?
Chron's
What portion of Primary Sclerosing Cholangitis patients have Ulcerative Colitis?
70%
Patient with ulcerative colitis has mild displasia found on colonoscopy bx. Treatment?
Total proctocolectomy
Ulcerative Colitis: continuous or skip-lesions?
continuous
Chron's continous or skip-lesions?
skip-lesions
IBD is more common in these 2 races.
Caucasians and Ashkenazi Jews
Usual age of onset of IBD.
15-25 and 50s (bimodal)
Two 5-ASA agents used to treat IBD.
sulfasalazine and mesalamine
Treatment for IBD refractory to 5-ASA.
steroids and immunomodulating agents (azathiprine or infliximab)
How long after diagnosis of UC must you start yearly colonoscopy with bx?
8 years
Colon cancer risk: UC vs. Chron's
UC: markedly increased
Chron's: slightly increased
Classic lesions on colonoscopy: UC and Chron's
UC: psuedopolyps
Chron's: cobblestoning
Most common inguinal hernia.
indirect
Which type of hernia goes through the internal inguinal ring?
indirect
Direct inguinal hernia goes through where (in relation to epigastric vessels)?
medial to epigastric vessels at Hesselbach's triangle
What is Hesselbach's Triangle? (direct hernia location)
area between inguinal ligament, inferior epigastric artery, and the rectus abdominis
Why correct hernias?
risk of incarceration and strangulation of small bowel
Indirect inguinal hernia path (in relation to epigastric vessels)?
Enters abd wall lateral to and exits medial to epigastric vessels
Classic risk factors for cholelithiasis.
Fat
Female
Forty
Fertile (pregnant)
Rapid weight loss will do this to the gall bladder.
Fill it with stones!
Sickle cell disease patients often have black gallstones. Why?
hemolysis creates pigmented stones
Brown gallstone means what?
infection
RUQ post-prandial abdominal pain. Diagnosis?
biliary colic
Where does gall-bladder pain classically radiate?
Right shoulder
Symptomatic Cholelithiasis (pain). Tx?
cholecystectomy
Asymptomatic gall-stones (80% of them). Tx?
none
Diagnostic test for cholelithiasis.
RUQ U/S
Treatment for choledocholithiasis?
ERCP and then cholecystectomy
Diet modification for patients with cholelithiasis who refuse surgery.
avoid fatty foods
Cholecystitis symptoms
Fever and RUQ abd pain (w/ murphy's sign)
Trauma and burn victims can present with RUQ pain, and U/S will show no gall-stones. Diagnosis?
Acalculus Cholecystitis
Bili elevated in cholecystitis?
no
Diagnostic lab findings for Choledocholithiasis/Cholangitis.
Elevated WBC (varies), Bili, and ALP
On the Cholecystitis/Choledocholithiasis spectrum, when do you order ERCP? (3)
If suspect a stone in duct (any of these):
1) elevated bilirubin
2) elevated ALT or AST
3) U/S shows duct diameter over 8 mm
On the Biliary Colic/Cholecystitis spectrum, when to decide to give Antiobiotics.
Anyone with a fever or elevated WBC
When to order HIDA scan for cholecystitis work-up.
if u/s is equivocal
Why do symptoms vary in choledocholithiasis?
extent of bacterial infection varies
How do gallstones cause pancreatitis?
obstruction in the ampulla obstructs the pancreatic duct
Top 4 causes of Ascending Cholangitis.
Choledocholithiasis (most)
PSC
Stricture
Malignancy
Charcot's triad
RUQ pain, jaundice, and fever
Charcot's pentad
RUQ pain
Jaundice
Fever
Shock
AMS
On the Choldocholithiasis/Cholangitis spectrum, when to decide to admit to ICU vs routine ERCP.
Clinical decision based on stability.
Medical treatment for patient's with biliary colic with contraindication to surgery.
Urosodeoxycholic Acid
Define Biliary Colic
symptomatic cholelithiasis (pain)
Define Cholelithiasis
Stones in Gallbladder
Define Cholecystitis
Inflammation of Gallbladder wall (caused by transient stone obstruction)
Define Choledocholithiasis
Gallstone in the bile duct
If choledocholithiasis becomes symptomatic, what are the symptoms caused by?
ascending bacterial infection and/or cholecystitis
Define Cholangitis
Inflammation of the Bile Duct
Define Ascending Cholangitis
Inflammation of the Bile Duct caused by ascending bacterial infection (usually caused by choledocholithiasis)
1st line treatment for Ascending Cholangitis.
Emergent bile duct decompression with ERCP with sphincterotomy
Treatment of gallstone illeus
laparotomy and stone extraction or manipulation into colon
PSC vs. PBC: men or women
PSC: mostly young men
PBC: mostly middle aged women (remember B for Bitches)
PSC vs. PBC: which one associated with Ulcerative Colitis?
PSSSSC is associated with ulSSSSerative colitiSSSS
2 other options if ERCP fails to drain Bile Duct in Cholangitis.
T-tube placement or Transhepatic drainage
Extraintestinal manifestations of IBD: dermatology (2).
Eythema Nodosum
Pyoderma Gangrenosum
Extraintestinal manifestations of IBD: eye.
episcleritis/uveitis
Extraintestinal manifestations of IBD: most common.
arthritis: both axial (e.g. anklyosing spondylitis) and peripheral
Feared complication from PSC.
Cholangiocarcinoma
There is an "M" diagnostic test for both PSC and PBC. What is each?
PSSSSC: MRSSSSeeP (MRCP)
PBC: anti-Mitochondrial antibody (AMA)
PBC and PSC both present this way.
Progressive jaundice and pruritus.
Idiopathic inflammation, fibrosis, and strictures of Intra AND Extrahepatic bile ducts. Diagnosis?
PSC
Why do more PSC patients get liver transplants than PBC patients?
Urosodeoxycholic Acid controls PBC, but fails to control PSC
Eventually PSC patients will need this treatment.
Liver Transplant
Autoimmune destruction of Intrahepatic ducts. (Intra only). Diagnosis?
PBC
PBC has malabsorption of these vitamins.
Fat soluble (ADEK)
Initial medication for both PBC and PSC.
Urosodeoxycholic Acid
Which pattern on LFT panel indicates Hepatocellular injury?
AST and ALT elevation
What LFT panel pattern indicates Cholestasis?
elevated ALP and Bili
Isolated ALP elevation and Bone Pain. Diagnosis?
Malignant bone disease
Isolated ALP elevation and Fatigue. Diagnosis.
Multiple Myeloma
Unknown reason for ALP elevation. What test will confirm a liver origin?
positive GGT
What tests will confirm hemolysis as a source of unconjugated hyperbilirubinemia?
LDH (high) and Haptoglobin (low)
Biliary duct dilation: PBC or PSC?
PSC (PBC is INTRAhepatic only)
Gilbert's, Dubin-Johnson, Rotor's, Crigler-Najjar: direct or indirect hyperbilirubinemia?
Gilbert's: indirect (defective conjugation)
Crigler-Najjar: inderect (defective conjugation)
Dubin-Johnson: direct (defective excretion)
Rotor's: direct (defective excretion)
Intrahepatic Cholestasis (no bile duct dilation): 4 causes
Meds
Post-op
Sepsis
PBC
Billiary Obstruction Cholestasis (bile duct dilation)
Choledocholithiasis
Pancreatic Cancer
Cholangiocarcinoma
PSC (stricture)
Isolated ALP elevation. What to do?
1st repeat LFTs while fasting; if still high, get a GGT
Hepatitis viruses transmitted fecal-orally.
HAV and HEV
Isolated ALP elevation and NO SX. Negative GGT (non-liver source). What is the most likely source?
Paget's Disease of the Bone (Osteitis Deformans)
2 general categories of causes of acute hepatitis.
Virus and Drug
4 Hereditary Diseases which can cause elevated LFTs.
hemochromatosis
A1 AntiTrypsinogen Defic.
Wilson's Disease
Celiac Sprue
6 Categories of Hepatocellular Injury Differential.
Viral
Hereditary
Autoimmune
NAFLD
Drugs/toxins
Vascular
Name 4 other viruses (besides Hepatitis viriuses) that can cause elevated LFTs.
CMV
EBV
HSV
VZV
Which Hepatitis Virus requires presence of HBV to propagate?
HDV
How are HBV and HCV transmitted?
bodily fluids
What percent of HCV patients will develp chronic hepatitis?
80% (remember hCv is Chronic)
How to diagnose Wilson's Disease?
Ceruloplasmin level
2 tests to order to diagnose hemochromatosis?
Fe studies followed by genetic testing
Exam in actue hepatitis.
Jaundice and Hepatomegaly tenderness (also look for splenomegaly and lymphadenopathy)
LFT panel pattern with acute Hepatitis.
Dramatically elevated ALT, AST; elevated bili and ALP too
Tests when suspecting Autoimmune Hepatitis (3).
ANA
AMA (for PBC)
SMA (anti-smooth muscle antibody)
Treatment of Autoimmune Hepatitis.
Immunosuppression: e.g. prednisone +/- azathioprine
Treatment of severe Alcoholic Hepatitis (besides discontinuing Alcohol).
Steroids
Acute Hepatitis B Treatment.
Supportive
Chronic Hepatitis B Treatment
IFNalpha, lamivudine (3TC), or adefovir
Chronic Hepatitis C Treatment
peginterferon and ribavirin
Treatment for end-stage liver failure.
Liver Transplant
Screen Chronic Hepatitis patients with AFP and/or U/S for Hepatocellular Carcinoma how often?
q6 months
IgM HAVAb is used for?
detect active Hep A
HBsAg indicates what?
Indicates carrier state (high in acute, lower in chronic)
What percent of adult aquired Hep B becomes Chronic Hepatitis?
less than 5%
What percent of perinatal aquired Hep B becomes Chronic Hepatitis?
more than 90%
HBcAb and HBsAb are positive. Indicates what?
Past HBV infection and now immune.
HBsAb indicates what?
Antibody to HBsAg (Immunity to HBV)
IgM HBcAg indicates what?
Recent/Resolving infection
HBeAg indicates what?
high transmissibility (BEware of hBEag)
HBeAb indicates what?
low transmissibility
In early Acute Hep B infection, what is the only marker that is positive?
HBsAg
Active Acute Hep B infection, What 2 markers are positive?
HBsAg and HBcAb (IgG)
HBcAg (IgG) indicates what?
Active infection
In a person vaccinated against Hep B, what is the only positive marker?
HBsAb
In a person with chronic Hep B, what 2 markers will be positive?
HBsAg and HBcAb
Is Alcohol the only thing that causes Cirrhosis?
no: any chronic hepatitis can lead to cirrhosis
Fibrosis and nodular regeneration due to hepatocellular injury. This is the definition of what?
Cirrhosis
3 locations of anastomoses which enlarge with portal hypertension (e.g. from cirrhosis).
Esophgus (Gut)
Hemorrhoids (But)
Paraumbilical (Caput madusae)
Asterixis and Altered Mental Status. Diagnosis?
Hepatic Encephalopathy
Decreased protein production in liver failure results in these 2 abnormal labs.
Albumin
Coags (PT/PTT)
Hypersplenism accompanying liver failure may cause these 2 abnormalities in the blood.
Anemia and Thrombocytopenia
Imaging study of choice for liver disease.
U/S with doppler
Test to confirm Cirrhosis.
Liver Biopsy
Work up for Ascites (2 tests)
SAAG (Serum Albumin:Ascites Albumin Gradient)
AFTP (Ascites Fluid Total Protein)
SAAG (Serum Albumin:Ascites Albumin Gradient) is less than 1.1; what are 3 things on differential.
Nephtrotic Syndrome
TB
Malignancy (e.g. ovarian CA)
AFTP (Ascites Fluid Total Protein) is under 2.5; what is the most likely diagnosis?
Cirrhosis
Portal HTN related Ascites has what SAAG?
over 1.1
Treatment steps for Ascites (4 steps: name them in the proper order).
1) sodium and water restrict
2) add Spiranolactone
3) add Furesemide
4) serial paracentesis
AFTP (Ascites Fluid Total Protein) is over 2.5; what is the most likely diagnosis?
Right Heart Failure
Cirrhotic patient gets fever and AMS. Diagnosis?
Spontaneous Bacterial Peritonitis (SBP)
How to diagnosis SBP (criteria?)
check (ascites): infection if:
over 250 PMNs or over 500 WBCs per mL
Treatment of SBP
3rd gen Cephalosporin (e.g. Cefotaxime)
Supplement to give patient who is recovering from SBP (and when to give it).
Protein to be given x1 at diagnosis and x1 on day 3
Patient has recovered from SBP for the second time. What prophylactic med to start?
Bactrim qDay
If SAAG is over 1.1, how to differentiate between cirrhosis from cardiac.
AFTP (Ascites Fluid Total Protein)
What causes hepatic encephalopathy
build of ammonia from failed liver metabolism
Treatment of Hepatic Encephalopathy (3)
Protein restriction
Laculose
Rifaximin
2 "Major" (positive) criteria in diagnosis of Hepatorenal syndrome
Rapid renal failure that 1) does not respond to IVF in patients with
2) Portal Hytertension 2/2 liver disease
In what group should you specifically watch for Hepatorenal Syndrome?
Alcoholic cirrhosis patients
What are the 2 most common triggers of Hepatorenal Syndrome in Cirrhotic patients?
infection (e.g. SBP) and UGIB
Treatment for Hepatorenal Syndrome
Dialysis and likely Liver Transplant
Painless jaundice. Diagnosis?
Obstruction of the Bile Duct by advance cancer in the Pancreatic Head
2 largest risk factors for Hepatocellular Carcinoma (in the U.S.)?
Cirrhosis (i.e. Alcoholism) and HCV
Hepatic masses in liver on U/S. What is the most common cancer?
Colon Cancer Mets (far more common than Primary)
What protein is measured for Hepatocellular Carcinoma?
Alpha Fetoprotein (AFP)
Cirrhotic patient with 5 month h/o worsening liver function and new weakness and cachexia. Diagnosis?
Hepatocellular Carcinoma
Screening AFP in chronic hepatitis patient is elevated. What imaging to order?
CT
Process of work-up in Hepatocellular Carcinoma (Name 3 steps in the correct order).
1) AFP and/or U/S
2) CT
3) Biopsy
Treatment of Hepatocellular Carcinoma.
Resection curative if early tx; poor prognosis if metastatic (no tx option)
Why might one use chemotherapy and radiation in Hepatocellular Carcinoma if they are generally not effective?
Reduce large tumors before surgery (neoadjuvant therapy)
Lab to monitor for recurrance of Hepatocellular Carcinoma.
AFP
How common is hemochromatosis in U.S.
1 in 300
Pathophysiology of hemachromotosis in the liver (and other organs)
hemosiderin accumulation
Genetic inheritance pattern in Hemachromotosis.
Autosomal Recessive
Age of presentation in Hemachromotosis
40-50 (rarely before)
What is the most common cause of pain in Hemachromotosis?
Arthropathy of MCP joints
What heart disease does hemochromatosis cause?
Restrictive Cardiomyopathy (and Heart Failure)
Diffuse Bronze skin pigmentation. Diagnosis?
Hemochromotosis
What do Iron studies look like in Hemochromotosis?
Increased: Fe (TSI), Fe/TIBC (TSat), Ferritin
Decreased: Transferrin (TIBC)
What test is used to estimate Transferrin level?
Total Iron Binding Capacity (TIBC)
What TSat level to consider ordering for Hemochromotosis mutation panel?
Over 0.45
Diabetes, Hypogonadism, Arthritis, and Heart Failure. Diagnosis?
Hemochromotosis
Tretment of Hemochromotosis.
Phlebotomy with frequency titrated until Tsat (Fe/TIBC) under 30% and Ferritin is under 50
Cancer associated with Hemochromotosis (Cirrhosis)?
Hepatocellular Carcinoma
Symptoms of Wilson's disease are caused by what?
deposition of copper in liver (cirrhosis) and brain (neuro/psych); unknown hemolysis mechanism
Age of presentation of Wilson's Disease?
Teens to Twenties
Name and describe the eye finding in Wilson's Disease?
Kayser-Fleischer rings (green ring in the base of the cornea which shows up at outer edge of the iris)
Treatment for Wilson's Disease: increase urinary excretion
Penicillamine (with Vit B6)
Treatment for Wilson's Disease: decrease Copper absorption and increase fecal excretion.
Zinc
Treatment for Wilson's Disease: foods to avoid.
Liver, Legumes, Seafood (especially oysters)
What deficiency causes Wilson's Disease?
Ceruloplasmin
Why is MRI a common way for Wilson's Disease to be first found?
Neuro signs in such a young patient (teens/twenties)
2 most common neuro complaints of wilson's disease.
loss of coordination and tremor
Abrupt severe epigastric pain radiating to the back. Diagnosis?
Pancreatitis
Why get a CT scan in pancreatitis if the diagnosis can be made clinically?
to check for pseudocysts, abscesses, or necrosis
Why get an U/S in pancreatitis?
identify any gallstones
Treatment for acute pancreatitis?
NPO, IVF, and opiods
When to give Antibiotics in pancreatitis?
if necrotizing pancreatitis develops
Flank discoloration with pancreatitis. Name the "sign"
Grey Turner's sign
Periumbilical discoloration with pancreatitis. Name the sign.
Cullen's sign
top 2 causes of acute pancreatitis (40% of cases each)
alcohol and gallstones
Next 3 most common causes of acute pancreatitis to consider in a non-alcoholic with no gallstones (2-4% of cases each)
ERCP
Abdominal Trauma
Medication
Ranson's Criteria on Admission (GALAW mnemonic)
Glucose up
Age over 55
LDH up
AST up
WBC up
Ranson's Criteria at 48 hours (CHOBBS mnemonic)
Calcium decreased
Hct dropping
paO2 down
Base excess
BUN increasing
Sequestered fluid
How to calculate mortality risk in acute pancreatitis?
Ranson's Criteria
Suspect pancreatic cancer. Imaging to order?
CT
Why is pancreatic cancer such a death sentence?
presentation is usually with advanced/metastatic disease
10% of patients with pancreatic cancer have isolated pancreatic head tumors and can undergo this procedure.
Whipple procedure (pancreaticoduodenectomy)
Palliative chemo options for pancreatic cancer.
5-Fu and gemcitabine
Remember to take Vit B6 if taking either of these 2 medications.
Penicillamine or Isoniazide (INH)
Adolescents with extrapyramidal or cerebellar motor disorders, atypical psychiatric disease, unexplained hemolysis, and elevated transaminases. Most likely diagnosis?
Wilson's Disease