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168 Cards in this Set
- Front
- Back
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what do pigmented gallstones result from?
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hemolysis
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test for suspected cholelithiasis?
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RUQ ultrasound
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what do you use to remove common bile duct stones?
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ERCP
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postprandial abdominal pain that radiates to right subscapular area or epigastrum
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cholelithiasis
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RUQ pain, nausea, low-grade fever, vomiting
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acute cholecystitis
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what happens in acute cholecystitis?
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prolonged blockage of the cystic duct, usually by an impacted stone that leads to obstructive distention, inflammation, superinfection, and possibly gangrene of the gallbladder
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in what patients do you see acalculous cholecystitis?
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occurs in absence of cholelithiasis in chronically debilitated patients, those on TPN, and trauma or burn victims
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Murphy's sign
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inspiratory arrest during deep palpation of hte RUQ
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test to order for suspected cholecystitis when ultrasound is equivocal
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HIDA scan
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what finding on HIDA scan suggests acute cholecystitis?
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non-visualization of gallbladder
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treatment for acute cholecystitis?
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IV antibiotics and IV fluids, early cholecystectomy (within 72 hours) with prerop ERCP or intraop cholangiogram to r/o common bile duct stones
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how does treatment for cholecystitis differ for patients with significant medical problems (including DM)?
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you can delay teatment 4-6 weeks until acute inflammation resolves
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what is choledocholithiasis?
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stones in the common bile duct
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what are the hallmark abnormal lab values in choledocholithiasis?
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increased alkaline phosphatase and increased total bilirubin
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how does choledocholithiasis present?
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sometimes asymptomatic, but often with biliary pain, jaundice, episodic colic, fever, pancreatitis
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progressive inflammation of the biliary tree associated with ulcerative colitis
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primary sclerosing cholangitis
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acute bacterial infection of the biliary tree
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acute cholangitis
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what are commonly identified pathogens in acute cholangitis?
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gram negative enterics: e. coli, enterobacter, pseudomonas
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what is charcot's triad?
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fever/chills, RUQ pain, and jaundice: classic for acute cholangitis
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what is Reynold's pentad?
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Charcot's triad plus shock and altered mental status - may be present in acute suppurative cholangitis and suggests sepsis
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leukocytosis, increased bilirubin, and increased alk phos
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acute cholangitis
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steps when you suspect acute cholangitis?
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blood cultures, ultrasound or CT but dx is often clinical
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what is both diagnostic and therapeutic for acute cholangitis?
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ERCP (biliary drainage)
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treatment for patients with acute supurative cholangitis?
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emergent bile duct decompression via ERCP sphincterotom, percutaneous transhepatic drainage, or open decompression
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how is diarrhea defined?
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>200 g of feces/d along with change in stool consistency
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in what patients should antimotility treatments be avoided?
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bloody diarrhea, high fever, or systemic toxicity
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what is IBS?
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idiopathic functional disorder characterizedby abdominal pain and changes in bowel habits that increase with stress and are relieved by BMs
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when does IBS most commonly present?
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2nd-3rd decades
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half of all IBS patients have what?
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comorbid psychiatric disorders
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tests to order in suspected IBS
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rule out other GI causes: CBC, TSH, electrolytes, stool cultures, abdominal films, barium contrast studies
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treatment for IBS patients
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reassurance, fiber supplements (psyllium), TCAs, antidiarheals (loperamide, antispasmodics (dicyclomin, antcholinergics
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treatment for patients iwth constipation-predominant IBS?
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tegaserod
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what is the leading cause of SBO in adults? in kids?
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adhesions; hernias
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cramping abdominal pain with a recurrent crescendo-decrescendo pattern at 5-10 minute intervals
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SBO
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what will CBC show if there is strangulation of bowel?
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leukocytosis
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what does lactic acidosis suggest in SBO?
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necrotic bowel and need for emergent surgical intervention
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what is the presence of radiopaque material at cecum suggestive of?
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gallstone ileus
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risk factors for ileus
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recent surgery/GI procedures, severe medical illness, immobility, hypokalemia, hypothyroidism, DM, meds that slow GI motility (anticholinergics, opiods)
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diffuse, constant, moderate abdominal discomfort, N&V, absence of flatulence of bowel movements
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ileus
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air throughout the small and large bowel on AXR
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ileus
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most common manifestations fo carcinoid tumors
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cutaneous flushing, diarrhea, wheezing, cardiac valvular lesions
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from where do carcinoid tumors most commonly arise?
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ileum and appendix
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diagnosis of carcinoid syndrome?
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high urine levels of serotonin metabolite 5-HIAA; chest and abdominal CT scans can localize tumor
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treatment for carcinod syndrome?
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octreotide for sx and surgical removal of tumor
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most common cause of acute lower GI bleed in adults over 40
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diverticular disease
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treatment of uncomplicated diverticular disease
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follow and place on high-fiber diet
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treamtent for diverticular bleeding
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usually stops spontaneously; transfuse/hydrate prn; if doesn't stop then angio with ebolization or surgery
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treatment for diverticulitis
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NPO, NG tube, broad-spectrum antibiotics (metronidazole and fluoroquinolone or 2nd/3rd gen cephalosporin)
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what should you avoid in suspected diverticulitis?
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barium enema and flex sig because of perforation risk
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most common presenting symptom of colon CA
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abdominal pain
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causes of large bowel obstruction
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colon CA, diverticulitis, volvulus, fecal impactino, benign tumors
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where does colon CA most often spread?
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liver
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which type of IBD carries a higher risk for colon CA?
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ulcerative colitis
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screening for patients with a family hx of colon CA?
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colonoscopy every 10 years after age 40 or 10 years prior to age at dx of younges family member with colorectal CA
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what type of esophageal cancer is associated with alcohol and smoking?
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squamous cell
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does oropharyngeal dysphagia usually involve liquids or solids?
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liquids
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does esophageal dysphagia usually involve liquids or solids?
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solids more than liquids
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how does achalasia present
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both liquid and solid dysphagia
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what are esophageal webs associated with?
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iron deficiency anemia - plummer-vinson syndrome
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diagnosis of esophageal dysphagia
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barium swallow followed by endoscopy, manometry, and/or pH monitoring
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diagnosis of oropharyngeal dysphagia
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cine-esophogram
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what type of esophageal cancer is associated with Barrett's esophagus?
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adenocarcinoma
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what is Barrett's esophagus
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columnar metaplasia of the distal esophagus secondary to chronic GERD
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what is the most common cause of GERD?
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transient LES relaxation
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risk factors for GERD?
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increased intra-abdominal pressure, hiatal hernia, scleroderma, alcohol, caffeine, nicotine, chocolate, fatty foods
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type of hernia in which GE junction and portion of stomach are displaced above diaphragm
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sliding hiatal hernia
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type of hernia in which GE junction remains below the diaphram while a neighboring pnortion of the fundus herniates into the mediastinum
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paraesophageal hiatal hernia
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treatment for paraesophageal hernias
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surgical gastropexy (attachment of the stomach to the rectus sheath and closure of the hiatus) - prevent gastric volvulus
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where does type A gastritis occur? what is it due to?
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fundus; autoantibodies to parietal cells
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what is type A gastritis associated with?
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other AI disorders - pernicious anemia and thyroiditis - also increased risk of gastric adenocarcinoma
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where does type B gastritis occur? what is it due to?
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antrum; may be caused by NSAID use or H. pylori infection
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treatment for H. pylori
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triple therapy: amoxicillin, clarithromycin, omeprazole
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what does the intestinal type of gastric cancer arise from?
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intestinal metaplasia of gastric mucosal cells
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risk factors for intestinal type of gastric CA?
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diet high in nitrites and salt and low in fresh vegetables
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what do you do in cases of GERD that are refractory to medical management?
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rule out Z-E syndrome with serum gastrin levels
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what can help patients with PUD who require NSAIDS
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misoprostol
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what is the most selective and preferred surgical approach for PUD?
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parietal cell vagotomy
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Zollinger-Ellison is associated with which MEN in 25-50% of cases?
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MEN I
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treatment for Zollinger-Ellison
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H2 blockers ineffective but mod-high does of PPI often controls sx
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Hesselbach's triangle
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area bounded by inguinal ligament, inferior epigastric artery, and recus abdominis (iligaram)
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most common type of hernia
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indirect
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what is the cause of an indirect hernia
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patent processus vaginalis
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indirect hernia
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herniation of abdominal contents through the internal and external inguinal rings and eventually into scrotum (in males)
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direct hernia
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herniation of abdominal contents through the floor of Hesselbach's triangle
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what are direct hernias most often due to?
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acquired defect in transversalis fascia from mechanical breakdown that increases with age
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in this type of hernia, sac contents do not traveres the internal inguinal ring - they go through the abdominal wall and are contained within the aponeurosis of the external oblique
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direct hernia
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loss of haustra on AXR
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ulcerative colitis
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transmural inflammation in what type of IBD
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crohns
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bloody diarrhea in what type of IBD
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UC
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IBD associated with toxic megacolon
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UC
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IBD associated with nephrolithiasis
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crohn's
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IBD with pseudopolyps
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UC
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total colectomy is curative for what type of IBD
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UC
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major clinical feature associated with hepatitis
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jaundice
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what percent of patients with HCV will develop chronic hepatitis?
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80%
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normal WBC count with relative leukocytosis, dramatically increased ALT and AST, and incnreased bili/alk phos
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acute hepatitis
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what clotting factors are produced by the liver?
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all except for factor VIII
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treatment for chronic HBV infection?
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IFN-alpha, lamivudine (3TC), and adefovir
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treatment for chronic HCV?
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peginterferon and ribavirin
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best test to detect active hepatitis A
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IgM HAVAb
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antigen found on surface of HBV; presence indicated carrier state
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HBsAg
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antibody to HBsAg; provides immunity to HBV
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HBsAb
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antgen associated with core of HBV
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HBcAg
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antibody to HBcAg; positive during window period
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HBcAb
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antigenic determinant in HBV core; important indicator of transmissibility
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HBeAg
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indicates low transmissibility in HBV
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HBeAb
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definition of portal HTN
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portal pressure 5 mmHg greater than the pressure in the IVC
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Budd-Chiari syndrome
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hepatic vein thrombosis secondrary to hypercoagulability
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treatment for Budd-Chiari
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clot lysis, TIPS, or hepatic transplantation
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how do you determine the etiology of ascites
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SAAG: serum-ascites albumin gradient = ascites albumin - serum albumin
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SAAG>1.1
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ascites due to imbalance between hydrostatic and oncotic pressures: chronic liver disease, massive hepatic metastases, CHF
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SAAG<1.1
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ascites due to protein leakage: nephrotic syndrome, TB, malignancy (e.g. ovarian CA)
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diagnosis of SBP
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250 PMNs/ml or >500 WBCs in ascitic fluid
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treatment for SBP
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IV antibiotics (3rd gen cephalosporin) to cover both gram+ (enterococcus) and gram- (e. coli, klebsiella)
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primary risk factors for development of HCC
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cirrhosis and chronc hepatitis
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risk factor for HCC in developing countries
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aflatoxins
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increased LFTS and significantly increased AFP levels
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HCC
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how is hemochromatosis inherited
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autosomal recessive
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in what patients is secondary hemochromatosis common?
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patients receiving chronic transfusion therapy (e.g. for alpha thal) or alcoholics (alcohol increases iron absorption)
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symptoms of DM, hypogonadism, arthropathy of MCP joints, heart failure
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hemochromatosis
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what is the most sensitive diagnostc test for hemochromatosis?
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fasting transferrin saturaion >45% (serum iron divided by transferrin)
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treatment for hemochromatosis
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weekly phlebotomy initially, then when serum iron levels decrease, maintenance phlebotomoy every 2-4 mos
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what med can be used for maintenance therapy in hemochromatosis?
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deferoxamine
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complications of hemochromatosis
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cirrhosis, HCC, cardiomegaly, DM, impotence, arthropathy, hypopituitarism
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how do patients with Wilson's disease present?
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hemolytic anemia, liver abnormalities, neruo and psych sx
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green-to-brown deposits of copper in Decemet's membrane
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Kayser-Fleischer rings
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treatment for Wilson's
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dietary copper restriction, penicillamine, oral zinc
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what foods are high in copper?
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shellfish, liver, legumes
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how does penicillamine work?
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copper chelator that increases urinary copper excretion
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what should you give with penicillamine?
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pyridoxine
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absence of peristaltic waves in lower 2/3 of esophagus and significant decrease in LES tone
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esophageal dysmotility associated with scleroderma
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young man from endemic area with tender solitary abscess in RLL of liver
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amebic liver abscess
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Rx for amebic liver abscess
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PO flagyl
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what is 'porcelain gallbladder' associated with?
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gallbladder CA
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if someone is traveling within 4 weeks what should they get to protect them against HAV?
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serum Ig to HAV
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newborn of mom with active HBV?
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should get Hep B immunoglobulin plus HBV vaccine
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with what kidney disease is chronic HCV associated?
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membranous glomerulonephritis
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with what hematologic malignancy is HCV associated?
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B cell lymphoma
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what organism are hyatid cysts related to? what animal?
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echinococcus granulosus; dogs
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eggcell calcification of hepatic cyst is a what
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hyatid cyst
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drug of choice for treating cirrhotic ascites?
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spironolactone
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in what settings does post-op cholesasis occur?
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prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement
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define fulminant hepatic failure
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hepatic encephalopathy that develops within 8 weeks of acute liver failure
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sentinel loop or cutoff sign on AXR
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pancreatitis
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grey turner sign
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flank discoloration in pancreatitis
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cullen's sign
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periumbilical discoloration in pancreatitis
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mortality secondary to acute pancreatitis can be predicted by what?
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ranson's criteria
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most common form of pancreatic cancer
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pancreatic head adenocarcinomas (90%)
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courvoisier's sign
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palpaple, nontender gallbladder in pancreatic CA
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Trousseau's sign
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migratory thrombophlebitis in pancreatic cancer
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classic presentation of pancreatic cancer
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painless, progressive jaundice
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causes of drug-induced pancreatitis
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furosemide, thiazides, sulfasalazine, 5-ASA, azathioprine, L-asparaginase, valproic acid, didanosine, pentamidine, metronidazole, tetracycline
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dysphagia to both solids and liquids
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achalasia
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how do you diagnose achalasia?
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manometry
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fatty liver with encephalopathy
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Reye syndrome
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oropharyngeal dysphagia and neck mass
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Zenker's diverticulum
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what causes Zenker's diverticulum?
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esophageal muscles fail to relax properlyl, which leads to herniation of mucosa through fibers of cricopharyngeal muscle
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confirmatory test for Zenker's diverticulum
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barium esophagography
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sequelae of hyperestrogenism in cirrhosis
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gynecomastia, palmar erythema, spider angiomas, testicular atrophy, decreased body hair
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risk factors for pancreatic CA
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male, >50, black, smoking, chronic pancreatitis, DM, obesity
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most consistent reversible risk factor for pancreatitis?
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smoking
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second most common cause of painless GI bleeding in an adult?
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angiodysplasia
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what is angiodysplasia associated with?
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aortic stenosis, renal failure
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what lab should you check in suspected chronic pancreatitis?
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stool elastase - diagnoses pancreatic exocrine failure
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progression to liver failure in patients with HCV is faster in whom?
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male, over 40, longer infection, co-infection with HBV or HIV, immunosuppression, liver comorbidities
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MEN 1
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primary hyperparathyroidism, pituitary tumors, enteropancreatic tumors
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which IBD are non-caseating granulomas pathognomonic for?
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Crohn's
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define achalasia
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inability of LES to relax during swallowing
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