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414 Cards in this Set

  • Front
  • Back
Hepatocyte enzyme responsible for binding unconjugated bili and transporting it to ER for conjugation
GST (gluthianone-s-transferase)
Mode of inheritance in alpha-1-antitrypsin deficiency
AR
35-y/o Caucasian man of European descent with chronic diarrhea and mutated NF-kB1
UC
How ethanol metabolism impairs gluconeogenesis
Metabolism causes a redox shift (increased NADH/NAD ratio); shift impairs gluconeogenesis
Motility pattern of cardia and fundus and body of stomach during meal
Accommodation
(Definition) GI bleed with anemia and guaiac-positive stools but patient unaware of bleed
Occult GI bleed
Most common cause of conjugated hyperbilirubinemia in newborns
Biliary atresia
Why is early morning defecation so common
Diurnal colon activity peaks in morning
HBV lab test that will be + earliest in acute infex
HBsAg - surface antigen at the start of infection
Best test for dx of gastroparesis
Gastric emptying study – uses radio-labeled scrambled eggs
Crohn's or UC? More likely to have circulating P-ANCA
UC
S/sx of aspiration
Coughing after meals, increased secretions, gurgly voice, fever, chest sounds
Conjugated or unconjugated bili? More likely to be elevated in a patient with decreased Hct and increased LDH
Unconjugated (clinical picture of hemolysis)
What elevated ALP (alkaline phosphatase) means in the presence of jaundice
Increased ALP signifies cholestasis; it is thought that bile acids stimulate increased expression of ALP
95% of gastric malignancies are of this form
Gastric adenocarcinoma
Incubation period of HCV
5 to 10 weeks
Histological findings of colonic diverticulum
Herniation of mucosa through SMC layers near sites of penetrating blood vessels
Chest pain or dysphagia? More common sx in spactic motility disorders of esoph
Chest pain (up to 90% of pts)
PBC or PSC? 75% of patients also have IBD (usu UC)
PSC
Lab value that is used in monitoring hepatic encephalopathy
Ammonia
Four primary underlying mechanisms of diarrhea
1. Abnormal motor fcn, 2. Impaired absorptx, 3. Increased secretx, 4 Inflammx
Some indications for ERCP
Jaundice 2ndary to suspect obstrux, pancreatitis, pancreatic pseudocyst drainage, abnormal CT or U/S
Changes in female cirrhotics that may be explained by deranged sex steroid metabolism
Amenorrhea, anovulation, spider angiomata, palmar erythema
PBC or PSC? Antimitochondrial antibody present
PBC
Aside from iron mishandling in enterocytes, other site of Fe balance dysregulatx
Hepatocytes: lack of up-regulation of hepcidin in response to Fe overload
Anatomy change that results when puborectalis (PRM) is contracted
Narrows anorectal angle (increased resistance to stool passage)
How HDV differs from HBV
it's an RNA virus; it's defective
Difference between fetal incontinence due to peripheral and central neurogenic incontinence
Central is accompanied by decreased rectal sensation
Anti-HBV antibodies to look for early in infection
IgM anti-HBc
How far “up” the GI tract a flexible sigmoidoscopy can evaluate
Descending colon
Most worrisome consideration/disease with occult GI bleed
Cancer – don't forget cancer!
Aside from surgery, other tx options for gallstones
ERCP, percutaneous extraction, shock wave lithotripsy
Patients with “idiopathic” constipation likely have this problem
Underlying colonic or anorectal motor dysfunction
How HBV's genome encodes multiple proteins
overlapping reading frames
How capillaries in the liver differ from capillaries elsewhere
Fenestrae are present
Mechanisms (name 4) of obstruction in Crohns
1. Spasm, 2. Acute inflamx, 3. Fibrostenosis, 4. Undigested foods
Pouch that is possibly still connected to umbilicus and located 2 ft from the end of the ileum
Meckel's diverticulum
Three factors causing physiologic jaundice (unconjugated hyperbilirubinemia)
1. Low conjugating activity, 2. Delayed stooling, 3. Increased intestinal absorptx of unconj bili
Besides producing mucus, give another function of mucus cells in stomach
Secrete bicarb
Only coagulation factor not synthesized in liver
F VIII
Enterotoxins, long chain FA's, laxatives, Zollinger-Ellison, “pancreatic colera” (VIP-producing tumor) all cause ___
Secretory diarrhea
% of acutely infected HCV pts that develop chronic dz
70%
How the colon maintains tone despite parasymp and symp drive
Intrinsic activity of enteric nervous system
Some of the more common genetic mutations leading to pancreatic adenocarcinoma
K-ras (90%); also p16 (95%), p53 (75%)
Head or tail of pancreas? More likely site for pancreatic adenocarcinoma to arise
Head (70%)
HBV or HCV? More likely to be vertically transmitted
HBV (Hep B at birth)
The three phases of HBV replication
High phase (+HBsAg, +HBeAg, +HBV DNA), low phase (decr HBeAg, decr DNA), nonreplicative
Name 3 complications of diverticulitis
Obstruction, fistula, perforation
(Definition) Onset of hepatic encephalopathy w/in 8 weeks of symptomatic hepatocellular dz
Fulminant hepatic failure
Pruritic papulovesicular rash on extensor surfaces (dermatitis herpeformis)
Celiac disease/sprue
GI anomaly often associated with the VATER association
Esophageal atresia
Micronodular nodules on liver biopsy
Alcoholic cirrhosis
HAPC and mass movements associated with this type of spike potential
Migrating long spike burst
Most common cause of acute mesenteric ischemia
Embolism
Diagnostic test for HCV
ELISA, then PCR for RNA
Crohn's or UC? DDx includes Giardia, mesenteric ischemia, vasculitis
Crohns
Acinar zone of liver most likely degenerative in alcoholic hepatitis
Zone 3 (pericentral)
Predominant excitatory neurotransmitter of esoph, causes smooth musc contraction
Ach
Treatment for Hirschsprung
Surgery bypassing aganglionic segment
Type of fecal incontinence associated with impaction
Overflow incontinence
Findings of serum ceruloplasmin and urine copper in Wilson dz
Ceruloplasmin is low, urine copper incr
Potent anti-inflammatory drugs that should NOT be used for long-term management of Crohns
Corticosteroids
PBC or PSC? Affects only intrahepatic ducts
PBC
Where abdominal aorta may refer its pain
Thigh, scrotum, labia
Besides ulcers, other causes of stomach bleed
Gastritis (EtOH, NSAIDs, H pylori), portal gastropathy, Dieulafoy's vessel (rupture of submucosal artery)
Define intussusception
Invagination and/or telescoping of intestine into itself; found in children
Sx of swallowing a foreign body by a child
Dysphagia, wheezing, refusal to eat, drooling, hoarseness
Most common sites of colonic diverticula
Sigmoid and descending colon; rectum is RARE
Major weight loss + dysphagia + thoracic back pain + hematemesis
Esophageal ca
Name some red flag sx of NERD
New symptoms after age 45, dysphagia, GI bleed, weight loss, chest pain, choking, pneumonia
Clinical manifestatx of increased HAPC
Diarrhea
Hallmark symptom for both Crohns and UC
Diarrhea (may be bloody, esp in UC)
HBV or HCV? Most common cause of chronic liver dz in US
HCV
What to do about small polyps
Remove or watchful waiting (some debate)
Frequency of stomach contractions
3 / min
Two lab markers for acute pancreatitis that are always elevated
Serum lipase, serum amylase
Mechanism of hepatic encephalopathy in cirrhosis
Shunting of blood (both intra- and extra-hepatic) away from the blood-cleansing hepatocytes and directly to right heart
Weight loss, malabsorptx, steatorrhea, fat sol vitamin loss, elevated cholesterol
Bile acid insufficiency
How 90% of ingested ethanol is metabolized
By alcohol dehydrogenase
Three ways that EtOH use results in chronic pancreatitis
1. Direct toxicity, 2. Interferes with intracellular txport of digestive enzymes, 3. Reduced levels of lithostatin, protein that inhibits pancreatic stone formation
How the liver “regenerates” and where the liver stem cells are located
Compensatory hyperplasia; stem cells in canal of Hering (cells forming the ductule that connects the cannaliculi to the bile duct in portal triad)
Histological findings of Barrett's esophagus
Intestine-like columnar epithelial metaplasia, goblet cells
Besides ulcers, other complications of H pylori infection
Gastric adenocarcinoma, gastric MALToma
Three main causes of acute pancreatitis
Obstruction (gallstones, tumor, etc), toxins (EtOH), others (idiopathic, hypertriglyceridemia, hypercalcemia)
Most common cause of massive lower GI bleed
AVM (despite diverticulosis being most common cause of all lower GI bleeds)
Increased segmented motor activity in colon is associated with this condition
IBS
Constipation since birth + megarectum + IAS involvement
Hirschprung disease
Name some atypical/extraesophageal s/sx consistent with GERD
Asthma, chronic cough, hoarse voice, chest pain, hiccups, night sweats, dental enamel loss
How to avoid incontinence with suprasacral spinal cord lesions
Rectal stimulation = planned defecation
Systemic dz associated with smooth muscle dysfunction in esophagus
Scleroderma, SLE
% of adults that contract HBV that will have chronic dz; % of adults with acute HBV that become chronic
1-10%; 10%
Big risk of ERCP
Pancreatitis
Molecule that mimics adenovirus E1b protein causes cell- and antibody-mediated bowel damage
Celiac disease/sprue
Likely underlying defect in dyssynergic defecation
Unconscious learned behaviour
Incubation period for HAV
28 days
Name up to 6 causes of conjugated hyperbilirubinemia besides atresia
Infex, metabolic disx, defective canicular excretx, iatrogenic, genetic (alpha-1-antitrypsin, CF)
Crohn's or UC? Arthritis, fatty liver, and cholangiocarcinoma
UC
Some dx tests for GERD (there's a handful)
H&P, upper endoscopy, esophagram, 24 pH monitor, 24 hour pH + impedance plethysmography
Pacemaker cells of colon
Interstitial cells of Cajal
Major weight loss, fatigue, jaundice, palpable but non-tender gall bladder, glucose intolerance – what dz?
Pancreatic ca
What Mallory bodies actually consist of
Disorganized intermediate filaments
DM (esp type I) + cirrhosis – what genetic dz should you consider?
Consider hemochromatosis
Defecation disorder associated with failure of smooth muscle relaxation
Hirschprung disease
What you should do for an infant with conjugated hyperbilirubinemia
1. Biopsy, 2. Exploratory lap
Most important environmental factor for developing pancreatic ca
Smoking (what doesn't it do?!)
Weight loss, watery diarrhea, steatorrhea, doughy abdomen, iron and folate deficiency, bone dz
Celiac disease/sprue
Hallmarks of Crohns on biopsy
Non-caseating granulomas; also stellate ulceration and cobblestone mucosa
% of pancreas lost in chronic pancreatitis before clinically apparent exo- and endocrine dysfunction
80-90%
Referred pain to scapula could represent what GI organ?
Gallbladder
Which is more common, gastric ulcers or duodenal ulcers?
Duodenal!
Two helpful and commonly ordered labs in Crohns (although not very specific)
ESR and CRP
Gold standard for dx of cholangiocarcinoma
Cholangiography (+ERCP)
What positive HbsAg for more than 6 months means
Chronic hep B!
Site of folate absorptx
Jejunum
What parietal cells do
Secrete HCl and intrinsic factor
Another name for HNPCC
Lynch syndrome
ALT or AST? Elevation more characteristic of hepatocyte injury and not striated muscle
ALT
Surgical tx for achalasia
Myotomy of LES
Achalasia or spastic esoph disorder? Intermittent dysphagia (rather than constant or progressive dysphagia)
Intermittent = spasms / motility disorder
Name some pathological states of the CNS that may include dysphagia
Many: CVA, Parkinsons, tumors, trauma, ALS, Huntingtons, MS, mysathenia gravis, etc.
GI meds that may positively influence dysphagia
Antacids, H2 blockers, PPI's
% of gallstones that are “pure” cholesterol or mixed stones
90% - the other 10% are pigment stones
How age of contracting HBV correlates to its potential to cause chronic infex
If infected at birth, 90% will have chronic dz; only 1-5% of adults will
Location of both enteric nerve plexi
Myenteric – in between circular and longitudinal musc layers; mucosal – just outside of the submucosa
What stellate cells due after chronic EtOH consumption
Lose vitamin A, proliferate, secrete collagen, contract (myofibroblast activity)
Pattern of pain in pancreatic ca
Epigastric with radiation to back; pain 2ndary to invasion of celiac and superior mes plexus
A heme, a renal, and a musculoskeletal complication of HBV
Cryoglobulinemia, membranoproliferative glomerulonephritis, polyarteritis nodosa
Two big consequences of Meckel's diverticulum
Ulceration, bleeding
Characteristic pattern of contraction in diffuse esoph spasm
Repetitive contraction waves which are often simultaneous throughout the entire esophagus
Benefit of acid suppression in presence of GI bleed
Less rebleeding, less hospital stay BUT NOT decreased ulcer bleeding
Which is more suggestive of esoph motility disorders? Difficulty swallowing solid+liquid or solids only?
Solids + liquids
PBC or PSC? Autoimmune dz
Both!
X-ray results in chronic pancreatitis
30-40% of the time will show calcifications in pancreas
Most benign of the these 3 tumors: gastrinoma, insulinoma, VIPoma
Insulinoma (less than 10% malignant), others are more than 50% malignant
Complication in 10% of acute pancreatitis cases that may result in peripancreatic infection and bleeding
Pseudocyst formation
3 lab tests that MELD score (liver txplant) correlates to
Bili, INR, creatinine
Metabolism of ____ by P450 leads to NAPQI formation, depletion of gluthianone, oxidative damage to hepatocytes
Acetaminophen
Lifetime risk of colon ca in US
5-6%
Risk of duodenal ulcers in the posterior wall of the bulb
Ulcer may involve gastroduodenal artery
Sensitive and specific test (both over 95%) for H pylori dx that is noninvasive and inexpensive
Stool antigen
Low grade fever, diarrhea, recurrent perirectal abscess, bx reveals transmural colon inflamx
Crohns
Causative agents in diarrhea very shortly after eating contaminated food
S. aureus, B. cereus (preformed toxins)
The iron-sensing cells of duodenum
Crypt cells
AST/ALT ratio greater than 2
Alcoholic causes of liver dz (however, consider non-alcohol causes when enzymes greater than 400 u/L
Autoimmune lab markers most likely to be increased in autoimmune hepatitis
ANA, ASMA (anti-smooth muscle Ab's)
New drugs alosetron and tegaserod target these receptors in the enteric nervous system
Serotonin receptors; alosteron antagonizes and tx diarrhea IBS; tegaserod agonizes for constipatx
Most common cause of lower GI bleed
Diverticulosis
CYP2E1 induction
Chronic alcohol use
Crohn's or UC? Higher concordance between twins
Crohns
HBV or HCV? Enveloped +sense RNA
HCV
Shared “framework” of Crohns and UC – Name 4 aspects
1. Bowel inflamx, 2. No proven etiology, 3. Familial patterns, 4. Systemic manifestatx
Name 2 GI diseases implicated as independent risk factors for colorectal cancer
1. Crohns, 2. Ulcerative colitis
Kayser-Fleischer rings of iris (what dz?)
Wilson's dz
Aside from cholecystitis, other complications of gallstones
Pancreatitis, cholangitis
Most common management strategy for symptomatic esoph adenocarcinoma
Palliation – incl dilation, stenting, chemical and thermal tx of tumor
Crohn's or UC? NOD2 gene
Crohns
Osmotic or secretory? High stool volume with diarrhea that persists after a long fast
Secretory
PBC or PSC? P-ANCA in 80% of patients
PSC
Omphalocoele or gastroschisis? Not covered by membranous sac
Gastroschisis
Persons with IBS and decreased rectal compliance have this type of fecal incontinence
Reservoir incontinence
PBC or PSC? Hypergammaglobulinemia
Both! - PBC has esp pronounced IgM increase
Dx tests in patient with chronic diarrhea, stool weight more than 200 g/day, and high fecal fat
Small bowel biopsy, UGI and small bowel series
Histological findings in autoimmune hepatitis
T-lymphocyte and plasma cell infiltratx
The reason for establishing 4 Manning Criteria for IBS
Avoids need to r/o all other “organic GI diseases” in IBS
Gold standard for diagnosing celiac disease
Small bowel biopsy
Pathway of sympathetic signals to colon
S2-4 roots --- Symp chain --- Splanchnics --- Preaortic ganglia --- Postgangl fibers
Conjugated or unconjugated bili? The better marker for hepatobiliary system dysfunction
Conjugated
Where hindgut visceral pain tends to refer to
Suprapubic region, midline
4 tests useful in dx of hemochromatosis
Liver bx, serum transferrin and ferritin (both incr), HFE gene analysis
What increased stool frequency means in light of GI bleed
More active GI bleed
Treatment for upper GI bleed caused by esophagitis
Acid suppresion, stop offending medications
Likely site of dz in patients with high frequency, low weight stools
Colorectal disorders
Coagulopathy, GI bleed, shock, profound epigastric pain, hypocalcemia
Acute pancreatitis
Most common presentation of colorectal ca
Asymptomatic!
Crohn's or UC? Skip lesions
Crohns
Two major endpoints of primary sclerosing cholangitis
Secondary biliary cirrhosis or cholangiocarcinoma
Most common location of AVM in GI tract
Small intestine
Three most common causes of a small bowel bleed
Tumors, AVM's, NSAID use
Dx test for ulcers
Upper endoscopy
Site of a Mallory-Weis tear
GE junction
Define odynophagia
Pain during esoph transport
Dx tests for Crohns and UC
Colonscopy; also barium enema in Crohns
Most common cause of duodenitis and duodenal ulcers
NSAID use
% of bile acids that are reabsorbed in bowel
95% - participate in enterohepatic cycling
Risk factors for gall stones (the “Five F's”)
Over forty, fat, fertile, female, family hx
(Definition) Dark, tarry stools due to digested blood products
Melena
HBV or HCV? Enveloped DNA virus
HBV
Dx test used to monitor pancreatic function in chronic pancreatitis
Secretin test
Role of enkaphalins in GI tract neurology
Supress synaptic transmission between “first-order” and “second-order” neurons, suppress excitability of “second-order” neurons
Impairment of VLDL secretion and increased TG production due to beta-oxidation of FA's causes what?
Causes of fatty liver (steatosis)
Esophageal dilation + difficulty swallowing solids + history of GERD + nearly normal LES relaxation
Peptic stricture
Risk factors for esoph squamous cell ca
Tobacco, EtOH, pickled and smoked foods, others
Acidic or alkaline? Which ingestion by a child is more likely to produce deep wounds with scarring
Ingesting alkaline substance
Complications of this dz include osteoporosis, short stature, anemia, lactose intolerance, ulcerative jejunitis
Celiac disease/sprue
What chief cells do
Secrete pepsinogen
35-y/o woman with constipation refractory to fiber supplement, decr HAPC, normal colon diameter
Colonic inertia
Cancer of the cardia of the stomach most resembles what other condition?
Esophageal adenocarcinoma - Intestinal metaplasia (follows pattern of Barrett's esophagus, esoph ca)
HBV or HCV? Amongst the top 10 causes of death in men
HBV
Name 5 components of rectal continence
1. Sensation, 2. Storage capacity (compliance), 3. IAS tone, 4. Appropriate EAS and PRM activity, 5. Motivation!
Hepatocellular insufficiency + portal HTN + cholestasis
Cirrhosis
Crohn's or UC? “Lead pipe” mucosa after many years
UC
Timeframe after birth during which neonatal jaundice is abnormal
<36 hours after birth
Immunomodulatory drugs useful in Crohns and UC
Aminosalicylates (sulfasalazine), azathioprine, mercaptopurine, methotrexate, infliximab
Neuro changes in Wilson's dz
Basal ganglia gliosis --- Parkinsonism
Serum-to-ascites-fluid albumin gradient of less than 1.1 g/dL – portal HTN or not?
Not d/t portal HTN; causes include peritonitis, pancreatic ascites, bile leak, nephrotic syndr, SLE
Inhibitory neurotxmitters of enteric nervous system
NO, VIP
Drugs that relax LES in achalasia
Ca++ channel blox, nitrates, anticholinergics
Useful Abx in Crohns and UC flare-ups
Metronidazole, cipro
Tx for unconjugated hyperbilirubinemia, esp Crigler Najjar
Phototherapy
Barium x-ray with megacolon, transition point, and spasctic rectum
Hirschprung disease
Treatment for colonic inertia
Osmotic laxative (PEG)
Normal rectal resting press., sensatx, compliance + decr PRM tone, squeeze pressure
Peripheral neuropathy (peripheral neurogenic)
Site of Fe, Zn, fat soluble vits, and Ca absorptx
Duodenum, jejunum
Underlying pathology in Whipple's disease
Chronic mucosal inflammx in small bowel d/t bacteria (Tropheryma whipllerii)
% of pts with HBV cirrhosis who develop cancer
5%
Dx procedure when you suspect pancreatic ca
CT – detects 90% of primary tumors
Crohn's or UC? NF-kB1 mutation
UC
Two best lab markers for sprue (tough one!)
Anti-endomysial Ab (IgA), anti-tissue transglutaminase Ab (IgA)
How much ALT may increase in acute hepatic injury
10-25x normal
Drug to use in lamivudine-resistant patients
Adefovir
Only drug useful in HDV
Inteferon (not lamivudine)
PBC or PSC? Occurs predominantly in men under age 45
PSC
Why the drug UDCA (ursodeoxycholic acid) is used in PBC
Improves bile flow, decreases produx of more toxic bile acids, stablizes hepatocyte membranes
Duration of neonatal jaundice considered abnormal
More than 10 days
Of A, B, C, and D, hepatitis virus that does NOT cause chronic hepatitis
HAV
Increased frequency of defecation without a change in stool consistency (definition )
Pseudodiarrhea
Two conditions associated with decreased ALP
Zinc deficiency (required co-factor for ALP), Wilson's dz (Cu replaces Zn in enzyme)
Flushing of face + anxiety + dyspnea after EtOH consumption (especially in Asians)
Aldehyde syndrome
How predictive is a hx of regurgitation and heartburn for diagnosing GERD
Over 90% predictive
Most important dietary stimulant of gastrocolic response
Fat
Embryonic defect in migratx of neural crest cells -- loss of enteric nerves -- megacolon in unaffected areas
Hirschprung disease
Pathogenesis of breast milk jaundice
Inhibiting substance in milk --- decreased conjugatx of bili
Proposed mechanism of acute megacolon
Imbalance of parasymp and symp activity
Shifting dullness + fluid wave on PE
Ascites
Cirrhosis is a (pre-, intra-, or post-) hepatic cause of portal HTN
Intrahepatic – sinusoidal and post-sinusoidal
Incubation period of HBV
6 to 24 weeks
Clinical syndrome in which NAFLD/NASH is most commonly seen
Metabolic syndrome
Antigen used in making HBV vaccine
HBsAg
Most common complication of gastric ulcers
Bleeding
Absent UGT-1A1 at birth; severe problem
Crigler-Najjar type I
Role of stellate cells in normal liver
Vitamin A storage
Most common sx of GE reflux
Pyrosis (heartburn)
Two reasons why serum albumin concentration is decreased in chronic liver dz
1. Decreased production, 2. Dilution of blood
HBV antigen usu undetectable in serum, most accurate index of viral replicatx
HBcAg
Three systemic, non-GI diseases associated with fecal incontinence
DM, MS, scleroderma
Causative agents in diarrhea 8-16 hours after eating contaminated food
B. cereus, C. perfringens (toxins in vivo)
Define triturition
Process of food being broken into small particles; closure of pylorus allows stomach to engage in triturition
Extremely high amplitude esophageal contractions (over 180 mmHg) that last more than 6 seconds – what dz?
Nutcracker esophagus
Most common pancreatic cystic neoplasm; it's considered premalignant and usually occurs in women
Mucinous cystic adenoma (may progress to adenocarcinoma)
Proposed underlying mechanism of hepatorenal syndrome
Kidney acts as if there is hypovolemia; avid urine concentration and salt retentx
Name the 2 primary causes of dysphagia in children
Cerebral palsy, head injury
Name 5 neurohormones that stimulate intestinal contractx
CCK, motilin, serotonin, gastrin, substance P
Two big risk groups for rectosphincteric incontinence
Elderly, women
Histological findings in primary biliary cirrhosis
Patchy destruction of intrahepatic ducts + mononuclear infiltratx + granulomas(not always)
How far “down” an upper endoscopy evaluates
3rd part of duodenum
Early s/sx of primary biliary cirrhosis
Elevated LFTs (esp alk phos), pruritis, bile acid disturbances (loss of fat sol vitamins, increased cholesterol)
Severe acute abdominal pain + lactic acidosis + recent MI + decreased bowel movements
Acute mesenteric ischemia
GI-distressing medication that should be avoided in UC and Crohns
NSAIDs
Crohn's or UC? More likely to have fibrotic strictures
Crohns
Postprandial fullness, early satiety, epigastric burning/pain without structural disease
Functional dyspepsia (must be for more than 3 months)
AD disease, chromosome 5, hundreds of adenomatous polyps found on colonoscopy
FAP
Esoph adenocarcinoma or squamous cell ca? More common in US
Esophageal adenocarcinoma
Main s/sx of gastrinoma, insulinoma, and VIPoma (respectively)
Extensive ulcers + diarrhea; hypoglycemia; excessive secretory, watery diarrhea
Mechanism of neostigmine and how it helps acute megacolon
Acetylcholinesterase inhibitor -- Incr parasymp drive -- Rebalance parasymp/symp drive
PE and x-ray findings of ileus
Distended abdomen, tender, no guarding, no rebound; x-ray findings incl: distended small bowel, lack of colonic gas
Underlying mechanism of diarrhea in lactose intolerance
Osmotic diarrhea – colonic bacteria metabolize lactose to short chain FA's
Aside from ALT, another lab value that may differentiate hepatocyte injury from striated and cardiac muscle injury
Creatine phosphokinase (CPK) – CPK elevated in muscle injury
Mallory bodies (what dz?)
Alcoholic liver
#1 cause of chronic pancreatitis
Alcohol
Metabolite of ethanol that is considered the most damaging
Acetaldehyde
Why delayed gastric emptying is troublesome for type I diabetics
Difficult to match time of insulin administration to meal ingestion
Normally the first mutated gene in the adenoma-to-carcinoma sequence
APC
Oxidative stress in an alcoholic's liver leads to consumption of these two important antioxidants
Vitamin E, gluthianone
Colonic motor disorder associated with ulcerative colitis
Decreased colonic compliance
Best laboratory parameter for predicting survival in primary biliary cirrhosis
Bilirubin
3 main roles of serotonin in the gut
1. regulation of motility, 2. regulation of sensation, 3. regulation of secretions
5 general pathogenic mechanisms of clinical jaundice
Hemolysis, decreased hepatocyte uptake of bili, conjugation defect, excretion defect, secretion defect
Omphalocoele or gastroschisis? Associated with intestinal atresia but not other congential malformations
Gastroschisis
Hormones tending to decrease gastric contractions and increase gastric distension
Gastrin, CCK
PE finding that supports “visceral hypersensitivity”
Abdominal tenderness with palpation
Tx for gastroparesis
Dietary adjustments (low fat, low roughage, small meals), possibly prokinetic drugs, gastric pacemaker
Brief summary of hemochromatosis pathogenesis
Abnormal HFE -- Abnormal interaction with transferrin recept -- Tranferrin recep does not bind circulating transferrin -- Crypt cell thinks body is Fe-deficient -- Crypt cell matures to enterocyte -- Enterocyte has incr expression of apical divalent metal txporter and basal ferroportin
What a + HBeAg at 3-6 weeks mean
Patient is acutely infected with HBV and is contagious!
Location and fxn of Brunner's glands
Submucosa of duodenum, secrete mucus
Behavioural modifications useful in GERD tx
Elevate head of bed, don't smoke, limit EtOH, reduce fat, smaller meal size, avoid late night eating, avoid caffeine
Underlying mechanism of steatosis in the presence of metabolic syndrome
Insulin resistance
AD disease, mismatch repair gene mutatx, flat polyps in right colon
HNPCC
How musculature of stomach differs from other parts of GI tract
3rd layer = oblique layer, innermost layer
Condition associated with inadequate LES tone; transient LES relaxations thought to be a major factor
GERD
Bx results in celiac patient
Villus atrophy, crypt hyperplasia, inflammx + intraepithelial lymphocytes
Combination therapy for HCV
Ribavarin + interferon
What enterochromaffin-like cells do
Secrete histamine
Most common medical cause of delayed gastric emptying
DM – d/t neuropathy
Result of mutated copper transporter protein in Wilson dz
Decr Golgi processing of Cu, incr Cu in hepatocyte, necrosing hepatocytes release free Cu into blood
Serum antigen that may be helpful in dx and monitoring colorectal cancer
CEA
Mild deficiency of UGT-1A1
Gilbert's syndrome (unconj hyperbilirubinemia)
S/sx of cholestasis (jaundice, pruritis), liver failure, portal HTN, constitutional changes, abdomen pain
Typical presenting s/sx of primary sclerosing cholangitis
Crohn's or UC? May resemble Campylobacter, Shigella, Salmonella, C diff infections
UC
Why an elevated GGT in an alcoholic does not confirm cholestasis
GGT is induced in chronic EtOH use
Neutralizing anti-HBV antibodies
anti-HBs
Crohn's or UC? Oral ulcers present on exam
Crohns
Immunomodulatory drug useful in HBV; enhances TH1 and TH2 cells, maturation of B cells
Interferon
Drug tx for H pylori
Option 1: PPI + amoxicillin + clarithromycin; Option 2: PPI + bismuth + metronidazole + tetracycline
What is lamivudine?
Useful drug in HBV, a nucleoside analog that inhibits HBV DNA polymerase
Omphalocoele or gastroschisis? Developmental defect of abdominal wall at umbilicus
Omphaloceole
Tx for hyperbilirubinemia secondary to breast milk feeding
Trial of formula feed / stop breastfeed
Aside from Hx and PE, best dx test for appendicitis
U/S – noncompressible, enlarged appendix
What EtOH does to Kupffer cells and the resulting effect
Decreased phagocytosis, increased endotoxemia
AST/ALT ratio less than 2
Non-alcoholic causes of liver dz
PBC or PSC? Patients more likely to be symptomatic at dx
PSC; only 10% asymptomatic at dx; in PBC, up to 50% asymptomatic at dx
Four steps of gallstone formation
1. Supersaturation of bile with cholesterol, 2. Crystal formation, 3. Crystal entrapped in mucus, 4. Stasis and aggregation
Role of paneth cells in small bowel
Release growth factors
PBC or PSC? Often associated with Sjogrens, scleroderma
PBC
Nerve roots that innervate external anal sphincter
S2, S3, S4
What dz you should suspect with ulcers in the 2nd and 3rd part of the duodenum
Zollinger-Ellison syndrome (gastrinoma)
One of the most common causes of chronic diarrhea of unknown origin
Surreptitious laxative abuse (weird!)
The 4 Manning Criteria for IBS
1. Looser stools at onset of pain, 2. more freq stools at pain onset, 3. Pain eased with BM, 4. Visible distenx
How the blood renders unconjugated bili nontoxic
Albumin binds it
Incubation period for invasive E. coli, Salmonella, Shigella, Campylobacter
16-48 hours – tissue invasion occurs
Possible behavioural modifications for tx dysphagia
Diet modifications, postural adjustments, eating slowly, alternating solids and liquids
Defecation disorder associated with weak propulsion
Megacolon (also pain and neuromuscular syndromes)
Name 5 neurohormones that inhibit intestinal contrax
Secretin, glucagon, VIP, neuropeptide Y, NO
Large granular lymphocytes in liver sinusoids that have natural killer cell activities
Pit cells
Actions of PRM, EAS, pelvic floor, and abdominal muscles in defecation
PRM = relaxes, EAS = relaxes, pelvic floor = relaxes, abd musc = contracts
Most likely cause of obscure GI bleed
AVM in small bowel
Most common single-gene disease in US
Hemochromatosis
Conjugated or unconjugated bili? Able to be excreted by kidney
Conjugated
Crohn's or UC? Affects only the colon
UC
PBC or PSC? Mostly occurs in women in 50's or 60's
PBC
Osmotic or secretory? Low stool volume with high solute gap
Osmotic
Gold standard for dx of PSC
Cholangiography
Prognosis for acute hepatic failure not complicated by encephalopathy
Excellent – almost always resolves
Type of ca most likely to arise in a Crohns patient
Adenocarcinoma of small or large bowel
Most likely spot for aortoenteric fistula to form
3rd part of duodenum
Hormone signal most likely responsible for MMC
Motilin
Autoimmune dz with chronic bowel inflammx, mucosal atrophy, malabsoprtion, gliadin senstvty
Celiac disease/sprue
Mode of inheritance in Wilson's dz
AR
Second leading cause of ca death in US
Colorectal cancer
How prostaglandins protect stomach
Stimulate release of bicarb and mucus, inhibit histamine and H+ production
Rx consideration for patients with upper GI bleed and cirrhosis
Abx
Endocrine or exocrine cells of pancreas? More likely site for pancreatic adenocarcinomas to arise
Exocrine (almost 95% of malignant pancreatic ca)
Drugs that relax smooth muscle and may be useful in esoph spasticity
Ca++ channel blox, nitrates
Typical time when infants first present with biliary atresia
2 months of age; fatal by 1 yr if uncorrected
Why pts with esophageal motility disorders are given PPI's and H2 blockers
Difficult to distinguish true motility disorder from reflux dz; thus, pts often covered for GERD anyways
HBV or HCV? Cryoglobulinemia, glomerulonephritis, Sjogrens, lymphoma
HCV
How bilirubin causes encephalopathy
Crosses BBB, deposits in basal ganglia
Top 3 causes of death in patients with end stage liver dz
1. MSOF, 2. bacterial infex, 3. GI bleed
Muscle responsible for 80% of resting pressure on anal canal
Internal anal sphincter
Acid-treating drugs useful in GERD that have irreversible inhibition of acid production
PPI's – irreversibly bind H+K+ATPase; however, still taken chronically as parietal cells are constantly replaced
Mildly invasive dx procedure for upper GI bleed with low false-positive but 25% false-negative rate
Nasogastric lavage
Classic post-surgical iatrogenic cause of gastroparesis
Vagotomy
Causes of colitis with bloody diarrhea
C diff, E coli, CMV, ischemia, Crohns, ulcerative colitis
Incubation period for norovirus, ETEC, EPEC, Vibrio
12-72 hours – tissue invasion + toxin production
Name some typical causes of upper GI bleed
Ulcers, erosions, varices, esophagitis, tumors, duodenitis
Achalasia or spastic esoph disorder? Loss of enteric nerve cells
Achalasia
Pancreatic neuroendocrine tumors may produce which 3 hormones?
Gastrin, insulin, VIP
Causes of ileus
Post-abdominal surgery, lyte disturbances, drugs (esp Ca-channel blox, anticholinergics), sepsis
Effects of amyloidosis and sarcoidosis on small bowel
Interfere with sm musc activity
Name some coagulation and inflammatory factors that are synthesized in liver
Many: Factors I, II, V, VII, VIII, IX, X, XII, protein S and C, HMWK, antithrombin III
Dysphagia + profound weight loss + upper GI bleed
Esophageal ca
Mechanism by which HBV is transmitted from mom to baby
At birth - does not cross placenta
Leukocyte-derived cell found in the terminal ileum and colon muscularis externa in IBS
Mast cells
Typical lag between HBV infection and hepatocellular carcinoma
30 to 50 years
Ground-glass hepatocytes
HBV
The most dangerous complication of fulminant hepatic failure
Cerebral edema
Stimulatory neurotxmitters of enteric nervous system
Ach, substance P
Lab tests used to determine presence of actively dividing HBV and/or seroconversion
Dividing virus = HBeAg; seroconversion = anti-Hbe
Some tx options (albeit rather ineffective) for IBS/FGID
Fiber, anticholinergics, tricyclics, SSRI's, prokinetics, others
Aside from ALP and GGT, another test that is associated with cholestasis (this lab isn't used routinely)
5'-NT (5'-nucleotidase)
Defecation disorder associated with failure of striated muscle relaxation
Dyssynergic defecation
Top 3 sources of HCV
IV drug use, sexual txmissx, transfusion
Endocrine disturbances in male pts with cirrhosis
Feminization / androgenic faliure; loss of libido, hair loss, gynecomastia, impotence, testicl atrophy; spiders possible in men too
Type of vaccine available for HCV
None!
Reason for thrombocytopenia and leukopenia in cirrhosis
Splenomegaly --- spleen sequesters blood cells
Abrupt mid-abdominal pain followed by RLQ pain, nausea, vomiting, fever; rebound pain
Appendicitis
Hallmark of acute megacolon on x-ray
Dilated colon on abdominal film
Location of stellate cells, Kupffer cells (respectively)
Space of Disse, inside the sinusoids
Major finding in fetal incontinence due to EAS trauma
Decreased squeeze pressure
Crohn's or UC? Fistula formation very likely
Crohns (UC not a transmural dz, only mucosal)
Infant with forceful vomiting at 3 weeks of age
Pyloric stenosis
Tumor markers that may be elevated in presence of cholangiocarcinoma
CEA, CA-19
30-minute episode of crescendo-decrescendo RUQ pain, night pain, nausea, vomiting
Sx of gallstones
Serum-to-ascites-fluid albumin gradient greater than 1.1 g/dL
Portal HTN ascites
Where heme is catabolized to unconjugated bili
Macrophage-monocyte system
Possible role for lecithin in formation of gall stones
Promotes secretion of mucin, mucin serves as “scaffold” for stone formation; lecithin is a prostaglandin precursor
Cut-off point (in terms of days/weeks/etc) for acute vs. chronic diarrhea
3-4 weeks (wow!)
Type of fecal incontinence associated with psychosis and dementia
Overflow incontinence
Inciting insult leading to diverticulitis
Usually obstruction of diverticular apex by fecal matter
(From nutrition too) Top 2 B vitamins to supplement in alcoholics
Thiamine, folate
Post-surgical pt with total failure of intestinal contrax and propulsive gut motility; s/sx: abd pain, vomiting, no BM's
Ileus
Why ammonia is elevated in hepatocyte failure
Hepatocytes normally remove ammonia from blood and metabolize it to urea and glutamine; also, shunting of portal blood in presence of hepatic fibrosis
1st and 2nd common causes of liver failure leading to txplant (in US)
Hep C, alcohol
How bile duct's blood supply differs from the liver's supply
Bile duct only gets hepatic artery blood; does not get portal vein blood
Crohn's or UC? Surgery likely to be curative
UC
Name 6 systemic illnesses that may often include swallowing problems
Arthritis, DM, polymyositis, scleroderma, Sjogrens, AIDS
Most likely site of peptic stricture
GE junction
Causative microbes in non-inflammatory diarrhea
Cholera and others with cholera-like toxin, ETEC
Order these from most malignant to least: intraductal papillary mucinous neoplasm, mucinous cystic adenoma, serous cystadenomas
Mucinous cystic, intraductal, serous
Why ALT may be low in alcoholic liver dz
Thought to be related to pyridoxine deficieny --- less ALT activity
Inhibitory neurotxmitters that relax LES
NO, VIP
Dilated esophagus + bird's beak appearance on xray + elevated LES resting pressure
Achalasia
2 recommended screening tests in HBV patients to monitor for hepatocellular carcinoma
U/S, alpha-fetal protein
Cellular organelle that is defective in alpha-1-antitrypsin deficiency
ER – abnormal glycosylation prevents protein from being txported to Golgi and exported from cell
Aside from helping with absorption of nutrients, what else do synthetic pancreatic enzymes do?
Inhibit pancreatic stimulation via the CCK feedback loop
The only mechanical distortion that the colon can actually “sense”/”feel”
Wall tension (distension); inflammation can sensitize
Colon portions derived from embryonic midgut
Cecum, asc colon, txverse colon
Approximate fraction of chronic HBV infex associated with cirrhosis and HCC
1/3
In the off chance (<20% of pts) that pancreatic ca is resectable, what surgery does pt get
Whipple procedure (pancreatoduodenectomy)
What an elevated ALP but normal GGT tells you
ALP is probably not coming from the biliary tree but from bone, gut, placenta, other source
Role of substance P in modulating abdominal pain
Acts as a “sensitizer”, may cause secondary hyperalgesia by acting on spinal cord neurons, may transform normal sensations into pain
Aside from the hepatitis viruses, other viruses that may cause acute hepatitis
Herpes viruses: EBV, CMV, HSV, VZV
Three phases of small bowel activity in the fasting state (>4 hrs after meal)
I: inactivity (75%), II: irregular intermittent ring contrax (20%), III: MMC (5%)
How the urea breath test works (even though this test isn't really done)
Patient ingests a meal with radio-labelled urea; H pylori converts urea to ammonia and CO2; pt exhales radiolabelled CO2
PT(INR) or PTT? Which is more likely to be elevated in hepatic failure
PT/INR – sensitive for hepatocyte injury, F VII's 1/2-life only a few hours; PTT includes F VIII (not synth in liver)