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249 Cards in this Set
- Front
- Back
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Anterior 2/3 of tongue derived from what? What about posterior 1/3?
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Anterior 2/3 derived from brachial arch 1, innervated by cranial nerve 7 for taste and 3rd branch of trigeminal nerve (mandibular branch) Poster 1/3 derived from arch 3 and 4, sensation and taste from CN9 (glossopharyngeal)
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What nerve provides motor function to the whole tongue?
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CN 12 - hypoglossal
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What are the three salivary glands?
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Parotid, submandibular, sublingual
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Sympathetic vs parasympathetic stimulation leads to varying types of salivary secretions from the salivary glands
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Sympathetic - very thick secretions, parasympathetic is more watery
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Cranial nerve 7 (facial nerve) runs through this gland - this can be damaged during surgery
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Parotid gland
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What is xerostomia? What condition is it associated with?
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Very dry mouth associated with sjogren's syndrome |
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Most common tumor of the parotid gland?
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Pleomorphic adenoma - has both epithelial and mesenchymal cells Increased risk with radiaiton, and it is benign
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Tumors in this salivary gland are more likely to be malignant
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Sublingual
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Cleft lip is caused by a failure of
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Maxillary and medial nasal processes to fuse
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Cleft palate is a failure of
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Lateral palatine processes and nasal septum and median palatine processes to fuse
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Cocaine effect on nasal mucosa
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it's a potent vasocosntrictor --> ischemia --> perforation of mucosa
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What are the 4 nasal sinuses?
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Frontal above the eyes, ethmoid kinda middle of the nose, sphenoid behind ethmoid, then maxillary behind the nose/top palate
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What makes up the foregut? Midgut? Hindgut? Describe the blood supply and nerve innervation to each part
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Foregut - esophagus, stomach, first part of duodenum, liver, gallbladder, pancreas. Blood supply from celiac trunk, vagus nerve provides parasympathetic, and some sympathetic from splanchnic nerveMidgut - 2nd, 3rd, 4th part of duodeun, ileum, and proximal 2/3 of colon up to splenic flexur. Blood supply from SMA, innervated by vagus and sympathetic splanchnics too Hindgut - Distal 1/3 of color (including sigmoid) and rectum. Supplied by IMA, parasympathetic innervation by pelvic splanchnic nerve, sympathetic via lumbar splanchnic nerve
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Projective vomitting, with palpable olive mass in pyloric region
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Hypertrophic pyloric stenosis
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Dark urine, clay colored stools, jaundice presenting shortly after birth
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Extrahepatic biliary atresia - the bile duct doesn't recanalize completely, bile has nowhere to go
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Abnormal migration of ventral pancreatic bud leading to billious vomitting shortly after birth
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Annular pancreas - constricting the duodenum
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Painless rectal bleeding, intestial obstruction and sometimes pain, presenting before 2 years of age typically
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It recieves blood supply from the distal branches of two different arteries (SMA and IMA). If one is occluded, then the tissue won't infarct, BUT if you have systemic hypotension, this area will be the first to infarct b/c it's at distal portion of the arteries
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"Apple peel" or "Apple core" atresia of jejunum occurs due to
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obstruction of SMA so the jejunum gets damaged and the distal ileum wraps around the IMA
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Normally, 270 degree rotation of the midgut occurs during development - if this doesn't happen properly, what happens?
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Malrotation of midgut - cecum and the appendix lie in the upper abdomen. Associated with volvulus (twisting of intestine) associated with obstruction
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No peristalsis, constipation, abdominal distention in newborns, no first meconium stool
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Hisrchsprung disease - failure of neural crest cells to migrate to the colon |
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Improper formation of urorectal septum
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Anal agenesis - can cause rectovesical (anus to bladder), rectovaginal, or rectourethral fistula
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Defect in abdominal wall, extruding guts covered by sac made up of peritoneum and amnion vs another defect where the guts are NOT covered by a sac
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(1) Omphalocele. Liver can be proturding sometimes too. Often seen with a ton of other issues (2) Gastroschisis - no sac. No liver protruding, no anomalies typically
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Blind upper esophageal pouch, lower esophagus joined to the trachea
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TE fistula - food goes into blind pouch
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Upper 1/3, vs middle 1/3, vs lower 1/3 esophagus
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Upper is skeletal muscle, middle is both, lower third is just smooth muscle
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Lower Esophageal sphincter normally relaxes to let food into stomach - when this doesn't happen you get
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Achalasia
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What's the underlying defect in achalasia?
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Loss of auerbach plexus, so esophagus has uncoordinated peristalsis and food will get stuck here. Dysphagia to both solids and liquids
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Bird's beak appearance of esophagus on barium swallow
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achalasia
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Cardiomegaly, mega esophagus, also resulting in achalasia
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Chagas disease - caused by trypanosoma cruzi infeciton
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What are the three esophageal diverticula to know?
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Zenker diverticulum - above UES, traction - midpoint of esophagus, epiphrenic diverticulum - above LES
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Complete rupture of esophagus caused by severe retching
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Boerhaave syndrome
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Laceration of gastroesophageal junction caused by severe retching/coughing but not nearly as bad as Boerhaave
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Mallory-Weiss tear - increased risk with alcoholics and bulimics. Due to increased intraluminal gastric pressure
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Chronic GERD can lead to
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Barrett esophagus - metaplasia of lower esophagus from squamous epithelium to columnar epithelia and goblet cell
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Esophagitis can be caused by GERD, but can also be caused by these three infectious agents
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Candida - white pseudomembrane, CMV - enlarged cells with owl's eye and clear perinuclear halo, and HSV - intracellular inclusions pushing host chromatin to edge of nucleus
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Dysphagia due to esophogeal webs (protrusion of mucosa in upper esophagus), glossitis, and iron deficiency anemia
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Plummer-Vinson syndrome
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PAS stain on biopsy reveals hyphate organisms in a patient with esophagitis
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Candida esophagitis
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This esophageal cancer is associated with alcohol and tobacco use
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Esophogeal squamous cell carcinoma
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The splenic flexure is a "watershed" area because it ____? Why is this clinically significant?
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It recieves blood supply from the distal branches of two different arteries (SMA and IMA).
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What three arteries come off of the celiac trunk?
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Left gastric artery, splenic artery, and common hepatic
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What are the three branches of the common hepatic artery?
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Gastroduodenal, right gastric artery, and proper hepatic artery
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The left gastric artery comes off of the celiac trunk - where does the right gastric artery come off of?
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Common hepatic artery
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So the right and left gastric arteries anastamose at the lesser curvature of the stomach and supply it there - what supplies the greater curvature of the stomach and where does it come off of?
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Gastroomental artery - the right part comes off of the gastroduodenal artery (coming off of the common hepatic), and the left part is kinda a branch of of the splenic artery. The right and left come together to make the gastro-omental artery supplying the greater curvature of the stomach
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Which cells in the stomach release each of the following: gastric acid, pepsin, bicarbonate, intrinsic factor, gastrin
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Parietal cells release gastric acid and intrinsic factor, pepsinogen released by chief cells, and bicarb released by mucosal cells of the stomach, and G cells secrete Gastrin
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Describe how NSAIDs affect bicarbonate secretion and increase risk of peptic ulcers in the stomach?
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NSAIDs inhibit COX, decreasing PGE production and decrease bicarbonate production (normally stimulated by prostaglandins)
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Where are G cells located in the stomach? What do they do?
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Antrum of stomach, secrete gastrin which stimulates acid secretion, motility, and growth of gastric mucosa to protect it against acid
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What three things can stimulate gastrin secretion?
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Tryptophan, phenylalanine, and calcium
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Vagal stimulation on stomach to which cells? What does it release to stimulate them? What results when this happens?
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Directly stimulates parietal cells to secrete acid, stimulates G cells to secrete gastrin, and it does this by releasing GRP - gastrin releasing peptide
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When G cells release Gastrin, they increase gastric acid secretion in two ways
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Act directly on parietal cells, or act on ECL cells to release histamine which then stimulates parietal cells
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Which Histamine receptor is on parietal cells? Is this a Gs, Gi, or Gq protein?
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H2 receptor, and it's a Gs - stimulates adenylyl cyclase to make more cAMP and make more gastric acid
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Which drugs block these H2 receptors?
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Cimetidine, ranitidine, famotidine
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This drug analogue directly inhibits parietal cells from releasing acid
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Somatostatin or octeotride. Prostaglandins also inhibit gastric acid secretion by inhibiting Gi
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Statins result in an increase of LDL receptor expression on
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hepatocytes to increase uptake of circulating LDL
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PPIs act on which receptor?
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H/K receptor on Parietal cells that pump K into the cell and H into the stomach lumen
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Gastrinoma - tumor secreting gastrin AKA ____. What is this called and how do you treat it?
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Zollinger Ellison syndrome - recurrent duodenal ulcers. Associated with MEN1 - can be treated with PPIs and octeotride if tumor has those receptors
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What can cause acute gastritis? What about chronic?
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NSAIDs, aspirin, and alcohol primarily cause acute. H pylori is chronic
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Increased risk of MALT lymphoma in stomach due to
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Chronic gastritis
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"stomach biopsy reveals neutrophils above basement membrane, loss of surface epithelium, and fibrin containing purulent exudate
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Acute gastritis
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Stomach biopsy reveals lymphoid aggregates in lamina propria, with columnar absorptive cells and atrophy of glandular structures
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Chronic gastritis
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Diffuse thickening of gastric folds with elevated serum gastrin levels, glandular hyperplasia without foveolar hyperplasia
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Zollinger Ellison syndrome
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Upper epigastric pain right after eating
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GU - mostly due to H pylori, also due to NSAIDs. Patients tend to lose weight b/c eating hurts
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Pain relieved by eating
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Duodenal ulcers - almost all due to H pylori. Pain returns several hours after eating. Patients tend to gain weight b/c eating makes it feel better
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H pylori typically found in greatest concentration in this part of the stomach
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Prepyloric area of the antrum
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Triple Therapy for H pylori
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PPI + clarithromycin + amox (or metro if alllergic)
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If Triple therapy does't work b/c H pylori resistant to clarithromycin, what do you use?
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Quadruple therapy - PPI, bismuth, metro, tetracycline
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Why does taking a ton of tums or calcium carbonate ultimately make gastric ulcers/pain worse?
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Because it immediately relieves acid by neutralizing it, but it can cause hypercalcemia, and calcium stimulates G cells to make more gastrin
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Cimetidine side effects
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anti androgen effects (impotence, decreased libido, gynecomastia), thrombocytopenia
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H pylori infection, chronic gastritis, nitrosamines all risk factors for
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Gastric adenocarcinoma
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What are the three metastatic sites of gastric answer and what are they called?
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Left supraclavicular node - virchow node. Periumbilical node - sister mary joseph nodule. Ovary - krukenberg tumor
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Signet ring cells
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Mucinous material in cytoplasm pushes nucleus to periphery of cell. Associated with gastric cancer and LCIS - lobular in situ carcinoma of the breast
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Acanthosis nigricans not only associated with diabetes, but also with
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gastric cancer
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Baby won't stop throwing up for like 3 days a 2-6 weeks after birth. Vomiting is non billious, projectile vomitting
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Congenital pyloric stenosis - impaired stomach emptying b/c of hypertrophy of pylorus
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How does ondansetron work? What is it used for?
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5HT3 (seratonin) receptor antagonists - used for N/v with post op patients or chemo or pregnancy
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Misoprostol directly counteracts
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NSAID induced ulcers b/c it makes PGEs
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Acute gastric ulcer associated with elevated ICP or head trauma
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Cushing ulcer
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Acute gastric ulcer associated with severe burns
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Curling ulcer (think "curling iron")
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Stomach emptying into blind pouch, resulting in bilious vomitting
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Duodenal atresia - double bouble on X ray, associated with down syndrome
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Double bubble on X ray
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Duodenal atresia
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Main pancreatic duct and common bile ducts empty into duodenum at
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Ampulla of Vater
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Sphincter of oddi
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Opens and closes and regulates amount of pancreatic fluid going in and out of ampulla of vater
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ERCP is used for
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Injects contrast looking at biliary tree looking for sludge/stone/obstruction
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CCK effects
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Decrease gastric emptying, increases pancreatic secretions, and causes gallbladder contraction
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Secretin effects
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Secretion of bicarb by pancreatic ducts to neutralize gastric acid that comes into duodenum
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GIP also released by K cells in duodenum, what does it do?
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inhibits gastric acid production, stimulates insulin release |
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What do brunner glands do?
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Secrete alkaline mucus to neutralize gastric acid
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Somatostatin pretty much just shuts everything down - it's made by these cells
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D cells all throughout GI tract and delta cells in pancreas
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Somatostatin effects
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Shuts down release of gastrin, CCK, secretin, GIP, VIP, insulin, glucagon |
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What is VIP?
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Vasoactive intestinal peptide - made by smooth muscle cells in the gut Relaxes smooth muscle and sphincters throughout GI tract, increases electrolyte and water secretions --> DIARRHEA. That's why VIPomas cause rice water diarrhea that looks like cholera
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Three general mechanism of pro-kinetic agents to "get things moving" throughout the GI tract
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(1) increase Ach (parasympathetic stimulation/rest and digest use this)(2) Increase seratonin(3) Decrease dopamine effects
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Cholinergic agonists or acetylcholinesterase inhibitor use in GI tract
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Used as prokinetic agents - bethanechol or neostigmine respectively)
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Bethanechol
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cholinergic agonist used as prokinetic (increases Ach)
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Neostigmine
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Acetylcholinesterase inhibitor - used as prokinetic agent in GI
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Metoclopramide
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Increases serotonin and decreases D2 activity - used as a prokinetic
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Macrolide antibitiocs (eg erythromycin) can be used as pro kinetics b/c of their effect on
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Motilin receptors - stimulate them.
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What are the retroperitoneal structures? Retroperitoneal hematomas ocur to which organ typically?
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A DUCK PEAR - Adrenal gland, duodenum, ureters, colon, kidney, pancreas, esophagus, aorta, rectumPancreas
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Valleys between villi in small intestine contain
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Crypts of Lieberkuhn - secrete enzymes and stuff
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Carbohydrate break down starts in the mouth via ____. Complex carbohydrates are broken down to dissarcharides via ____. What about disaccharides to monosaccharides?
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Salivary amylase, Pancreatic amylase, then intestinal brush border enzymes (sucrase, lactase, maltase, etc)
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Where does fat digestion begin? THen what?
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Salivary lipase then pancreatic lipase
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Where is iron absorbed?
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Duodenum, needs acidic environment |
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What impairs iron absorption?
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Antacids, quinolone, tetracycline, cereals/fibers
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Defect of chylomicron assembly
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Abetalipoproteinemia - lack of apoprotein B48 or B100 and then chylomicrons can't leave enterocytes, so they just get filled up with chylomicrons and become fatty. Low VLDL, LDL and no chylomicrons in blood
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How does abetalipoproteinemia present?
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Early childhood - malabsoprtion, failure to thrive especially EDEK, ataxia, star shaped RBCS - acanthocytes
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Star shaped RBCs
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Acanthocytes - associated with abetalipoproteinemia
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Antibodies against gliadin and tissue transglutaminase resulting in blunting of microvili of small intestine
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celiac disease
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HLADQ2 and HLADQ8
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celiac disease
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Celiac's predisposes patients to
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GI cancer, T cell lymphoma, and breast cancer |
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Tropical sprue vs celiacs
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Tropical sprue effects entire small bowel, celiac's disease is primarily the proximal small bowel
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Foamy macrophages in intestinal lamina propria, patient has weight loss, hyperpigmentation, cardiac symptoms, neuro sx, arthrlagias, etc
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Whipple disease - caused by Tropheryma whipplei
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PAS+ macrophages and granules in lamina propria with greasy stools and weight loss
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Whipple disease - tx with antibiotics
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What is the PAS stain actually staning in whipple's disease?
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Glycoprotein of cell wall of tropheryma whippeli
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Sx of pancreatic insufficiency
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Steatorrhea, fat malabsorption, poor absorption of ADEK
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Causes of pancreatic insufficiency
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chronic pancreatitis, cystic fibrosis, something obstructing pancreatic duct (gallstones, cancer)
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Crampy pain that improves with defecation
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IBS
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No rectal bleeding, weight loss, anemia, no inflammatory markers, no electrolyte abnormalities
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IBS
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Technetium scintigraphy looking for gastric/pancreatic epithelium
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Used to Dx meckel diverticulum - identifies area of gastric mucosa. So if you see it outside of the stomach, it's this.
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What is intussusception?
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The small intestine "telescoping" onto itself like a telescope opens up/closes down - common in children
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Current jelly stool with sudden onset pain, vomitting
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Intussusception
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Bull's eye or coiled spring appearance of small intestine
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Intussusception
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Causes of small bowel obstructions
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Adhesions, "bulge" - inguinal hernia, Cancer, crohn's, a TON OF STUFF
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Indirect inguinal vs direct inguinal hernias location relative to inferior epigastric vessels
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indirect can be felt by deep palpation and located lateral to inferior epigastric vessels through deep inguinal ring and protrude into scrotum Direct are medial to the inferior epigastric vessels and do not protrude into scrotom
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Dilated loops of bowel on x ray
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Obstructions
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What is intestinal ileus and what causes it?
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Lack of peristalisis in GI tract often post surgery or due to severe illness - body diverts blood away from GI when you're really sick and that can cause this
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Pain out of proportion to physical exam
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Ischemic bowel (ischemic colitis)
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Air within bowel wall aka Pneumatosis intestinalis
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Happens with Necrotizing enterocolitis
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Unexplained GI bleeding and anemia
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angiodysplasia - just kinda a ball of blood vessels found in cecum/ascending colon commonly
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Bronchospasm, flushing, diarrhea, right sided heart murmur
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Carcinoid syndrome - serotonin secreting tumor common to GI tract and lung
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"Nests of uniform cells" with eosinophilic cytoplasm and oval ish looking nuclei derived from enterochromaffin cells of the intestine
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carcinoid tumor
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Premature babies getting oral feeding too soon can cause
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necrotizing enterocolitis
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Hirschsprung disease ALWAYS effects this
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the rectum
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4 GI conditions associated with Down syndrome
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Hirschsprung disease, annular pancreas, duodenal atresia, and celiac's disease
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What are the most abundant bacterial flora in your large intestine?
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Bacteroides fragilis and E coli
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Causes of appendicitis in adults vs kid
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Adults - fecalith (fecal stone) - obstruction is the FIRST STEP Kids - following viral infection, hyperplasia of lymphoid MALT blocking the appendix
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Diffuse periumbilical pain progressing to localized, focal pain in right lower quadrant
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Appendicitis
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What is the pectinate line and why is it clinically significant?
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Hemorrhoids proximal to this line are endoderm - these are "internal hemorrhoids". There is no sensation here, although they do bleed. Blood supply here is superior rectal artery and superior rectal vein. If cancer develops here - adenocarcinoma Hemorrhoids distal to this line are ectoderm - they are VERY painful b/c they have somatic innervation. If cancer develops here - squamous cell caricnoma (caused by HPV). Blood supply is inferior rectal artery and internal rectal vein.
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What is proctitis?
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Inflammation of perianal region/rectum - tx with topical steroid
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What are the three types of pre cancerous colon polyps?
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Tubular adenomas, tublovillous adenomas, villous adenomas
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Autosomal dominant condition with many benign hamartomas throughout GI, pigmentation on lips, mouth, hands, genitalia, increased risk of colorectal cancer
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Puetz Jeghers
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Location of colon cancer determines its presentation - how does left vs right sided cancer present?
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Left - partial intestinal obstruction Right - symptoms of iron deficiency anemia and systemic symptoms (weight loss, fatigue etc)
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Three gene mutations in colon cancer
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APC, K-Ras, loss of P53
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"Apple core" lesion on barium study of colon
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Colon cancer - tumors constricting the colon
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Medulloblastoma + colon cancer
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Turcot syndrome
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Adenomatous polyps (like in FAP) plus bone/soft tissue tumors, lipomas, and retinal hyperplasia
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Gardner syndrome
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HNPCC aka lynch syndrome is a defect in
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DNA mismatch repair
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Most common cancer of appendix
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Carcinoid tumor
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LLQ pain, fever, WBC count, rectal bleeding
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Diverticulitis
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Free air in abdomen (aka peritoneal space)
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Perforation
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Tx for diverticulitis?
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Metronidazole and fluoroquinolone
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This can occur anywhere from the mouth to the anus and is characterized by transmural inflammation
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Crohn's disease
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Skip lesions with transmural inflammation with sparring of rectum
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Crohn's disease
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String sign on barium swallow
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Crohn's disease with stricture
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Epithelioid macrophages without central necrosis on biopsy of GI tract
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This is describing a noncaseating granuloma, found in Crohn's disease
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Crohn's associated with increased kidney stones of this type
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Oxolate stones - b/c you can't reabsorb bile acids, lipids aren't getting broken down, so they bind calcium and get pooped out. That leaves free oxolate in the serum that then goes and forms stones
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Immune cells involved in Crohn's disease
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TH1 helper cells increasing IL-2, interferon gamma, and TNF production causing intestinal injury and formation of non caseating granulomas |
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Tx for Crohn's disease
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5ASA agents specific for colon (mesalamine or sulfasalazine)Azathioprine or mercaptopurineAnti TNF agents (infliximab, adalimumab) especially if they have arthritis component of crohn'sSteroids
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Ulcerative colitis limited to
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Colon, starts at rectum and works proximally and it is NOT CONTINUOUS!!! ALWAYS effects rectum
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This is inflammation in colon limited to mucosa and submucosa
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UC - remember, crohn's was transmural
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Lead pipe appearance on barium enema
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UC
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Higher risk of colon cancer with UC or crohn's?
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UC
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Sacroilitis and uveitis, pyoderma gangrenosum and primary sclerosing cholangitis risk with
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UC
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Ulcerative colitis complications? Crohn's complications?
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Toxic megacolon, fistulas/strictures
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Tx for ulcerative colitis
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Pretty much same as crohn's (a bunch of anti inflammatory things), but you can remove the colon here! Can't do that with crohn's because it'll just come back somewhere else
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Most common cause of RLQ pain and LRQ pain
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appendicits, diverticulitis
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Describe how trypsinogen gets activated
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so Trypsinogen is released from pancrease, enteropeptidase and enterokinase in the duodenum convert it to trypsin and that activates the other proteases
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How are monosacharides absorbed by enterocytes?
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SGLT-1 which is a sodium glucose cotransporter, fructose is absorbed by passive diffusion
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Where are lipids digested? Where are they absorbed?
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digested in duodenum and absorbed in jejunum
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What stimulates the pancreas to release digestive enzymes?
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CCK, vagus nerve
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In CF, what is the problem with the pancreas? |
your pancreatic secretions are very thick b/c you can't pump chloride into the pancreatic duct lumen, so water doesn't follow. That's why they have malabsorption of fats, proteins, and vitamins. Need to supplement the vitamins and these enzymes
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Causes of acute pancreatitis
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Gallstones, Alcohol are the two big ones. HIV drugs and sulfa drugs can do it too. Hypertriglyceridemia can too (NOT hyperlipidemia)
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Elevated serum lipase, sitophobia (fear of food), N/v, and severe upper abdominal pain
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Acute pancreatitis
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Complications of pancreatitis
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DIC, multiorgan failure, hemorrhage/necrosis of pancreas,
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Pancreatic pseudocyst
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Found with chronic pancreatitis - cysts lined with fibrous scar tissue and granulation tissue from ongoing inflammation. Cyst is filled with pancreatic enzymes/juice
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Painless sudden jaundice, abdominal pain, and weight loss
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Pancreatic cancer
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Pancreatic adenocarcinoma is associated with this syndrome of hypercoagulability, venous thrombosis, and migratory thrombophlebitis
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Trousseau syndrome
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Risk factors for pancreatic cancer
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Chronic pancreatitis, tobacco use
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CA19-9 and CEA
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tumor markers for pancreatic cancer. But CEA can also be with colon cancer
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CEA levels in colon cancer used for
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Detecting disease recurrence - NOT diagnosis
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ERCP can cause
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Acute pancreatitis
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Most common cause of chronic pancreatitis
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alcohol abuse
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What is a portal triad
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Branch of hepatic artery, branch of portal vein, and bile ductuole.
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Portal blood is rich in nutrients because
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Vessels of GI tract drain into portal vein
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Zone 3 hepatocytes are first to be affected by ischemia because
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They are furthest away from blood supply (branch of hepatic artery)
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Blood flows from zone ___ to zone ____, and bile flows from zone ___ to zone ____
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From zone 1 to zone 3, and from zone 3 to zone 1
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This drug is useful in treatment of acetaminophen overdose
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NAC - n acetyl cysteine. Provides suflhydryl groups to excrete acetaminophen
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Bilirubin is insoluble, so binds to albumin in circulation to liver for metabolism. What is the main enzyme of bilirubin metabolism?
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UDP glucuronyl transferase
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Why can't newborns conjucate bilirubin as effectively as adults can?
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They have reduced amount of UDP-Glucuronyl transferase, this is why they can be normally jaundiced
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If too much uconjugated bilirubin bilds up in newborns, this can happen
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kernicterus - bilirubin gets deposited in brain and causes damage/death
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Diseases of hereditary hyperbilirubinemia
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Gilbert syndrome, Crigler Najjar syndrome, Dubin johnson syndrome, Rotor syndrome |
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Gilbert syndrome defect
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don't make enough of UDP-glucoronyl transferase
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Crigler najjar syndrome defect
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Don't make any UDP-glucoronyl transferase - AT ALL. Treat with phototherapy, plasmapherisis, or permanent cure with liver transplant. That's type I, type II is like gilbertsyndrome (not as severe at all)
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How can you tell the difference between Type I and Type II Crigler Najjar syndrome? Why is this important?
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Type I will cause kernicterus and death. Type II is way less bad Give phenobarbital - this induces UDP GT to be made in liver. If patient is type II, their bilirubin will decrease. If patient is type I, it won't change
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What's the problem in Dubin johnson syndrome?
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Trouble putting conjugated bilirubin back into the bile - bilirubin stays in hepatocytes and turns liver black. On labs, you'll see conjugated hyperbilirubinemia - you can conjugate bilirubin but you can't get it into bile so it leaks outPretty benign though. Rotor syndrome is just like this but even MORE benign
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High bile salt and high phosphatidylcholine have this effect on gallstone risk
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Increase choleserol solubility and therefore decrease risk of gallstones
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First stage of chronic alcohol abuse
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steatosis - fat cells in liver - this is reversible if they stop drinking
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Alcoholic hepatitis is 2nd stage of liver
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Inflammation in addition to fatty deposits
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Mallory bodies - squigly eosinophilic deposits in liver cells
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Associated with alcoholic liver disease
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AST is 2x ALT
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Alcoholic hepatitis
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Diarrhea, weight loss, epigastric region calcifications in an alcoholic suggests
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chronic pancreatitis with resulting malabsorption
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Collateral circulation responsible for esophageal varices and caput madusae in alcoholic liver disease
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Left gastric circulation and paraumbilical veins
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Liver failure with cirrhosis leads to a ton of problems
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no clotting factors --> bleeding/bruising, no albumin --> decrased osmotic pressure and peripheral edema, ascities, hepatic encephalopathy b/c ammonia can't be metabolized,
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Liver failure leads to elevated estradiol levels because it can't inactivate steroids
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Testicular atrophy, gynecomastia in men, spinder telengectasias on chest, palmar erythema
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Ascities can act as a reservoir for bacteria and can cause
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spontaneous bacterial peritonitis (SBP) - this can be deadly!
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Tx for ascities
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diruteics, paracentesis to drain it
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Which drugs can help stop bleeding for esophogeal varices?
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B blocker, octeotride
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How do you treat hepatic encephalopathy?
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Lactulose - traps pneumonia in gut so it gets excreted in stool
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what is SAAG?
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Serum ascities albumin gradient - used to determine cause of ascities. Serum albumin - ascites albumin. If 1.1 or greater, portal hypertension, if < 1.1, not due to portal hypertension (cancer, nephrotic syndrome, TB, pancreatitis, etc)
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If ALT > or = AST, what do you think? What about if AST > ALT?
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Viral hepatitis, alcohol
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GGT is elevated in diseases involving
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biliary tract
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Alk phos is elevated in
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biliary obstruction and active bone formation (children, paget's disease of bone, bone cancer), so look for GGT elevation as well
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What causes Budd Chiari syndrome?
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Occlusion of IVC or hepatic veins --> leading to hepatomegaly, ascites, and abdominal pain. Can have signs of portal hypertension (varices, caput madusa)
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How can you distinguish budd chiari from right sided heart failure?
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NO JVD IN BUDD CHIARI
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How do we excrete copper from the body? What happens if this mechanism doesn't work?
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In the bile - wilson's disease
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What is the enzyme defect in Wilson's disease?
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ATP7b - responsible for excreting copper into bile and converting it to ceruloplasmin, that's why low serum ceruloplasmin in wilson's diasease
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Keiser Fleischer rings, basal ganglia degeneration, increased risk of HCC, cirrhosis, hemolytic anemia, parkinsonion symptoms
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Wilson disease
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How do you treat wilson's disease?
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Penicillamine
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Cirrhosis, diabetes, and skin pigmentation
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hemochromatosis
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What's the defect in hemochromatosis?
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Impaired intestinal absorption of GI tract - HFE gene
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Iron findings in hemochromatosis
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Increased ferritin, increased total serum iron, increased transferrin saturation, but decreased total iron binding c
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Tx for hemochromatosis
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Phlebotomy and deferoxamine - chelating agent
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Early onset emphysema and cirrhosis
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A1AT deficiency b/c elastase can't be broken down
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Risk factors for hepatic angiosarcoma
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vinyl chloride and arsenic - malignant endothelial neoplasm in liver
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These benign liver tumors can regress with OCP discontinuation
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Hepatic adenomas
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most common benign liver tumor
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cavernous hemangioma - look like blood filled vascular spaces of variable sizes lined by a single layer of epithelial cells
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Most common malignant tumors involving liver
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METASTATIC liver disease way way more common than HCC
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Serum marker for Hepatocellular carcinoma
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Alpha fetoprotein (AFP)
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How are hepatitis A and E spread?
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Fecal oral route
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Initial presentation of Hep A
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fever, dark urine b/c excess bilirubin, malaise, etc
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You can only get hepatitis D infection if
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you already have hep B
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tx for hep c
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Interferon (can be used for B and C), ribavirin
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Most common cause of transfusion caused hepatitis
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Hep C
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Only double stranded DNA hepatitis virus
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Hep B - all of the others are single stranded RNA virus
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Positive HBsAb can mean one of two things
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either had infection and recovered completely or you got vaccinated
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HBcAB IgM vs IgG
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IgM there if acute infection, IgG if chronic or recovered, but not after vaccine |
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Two types of autoimmune hepatitis
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Type 1 will be ANA+ or anti smooth muscle antibody + Type 2 - liver/kidney microsomal antibody positive and/or liver cytosol antigen + |
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Most bile acids are conjugated with
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Glycine or taurine
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If you see air in the biliary tree and gallbladder on x ray, what happened?
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Gallstone ileus - large gallstone passes through a fistula from gallbladder into small bowel and causes obstruction at the ileocecal valve. Patients present with sx of small bowel obstruction and intestinal gas flows through the fistula int othe gallbladder/tree
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Onion skinning (concentric fibrosis) of bile ducts with "beads on a string" appearance of bile ducts
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PSC - primary sclerosing cholangitis
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PSC is associated with
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Ulcerative cholitis and cholagniocarcinoma
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Up to 80% of patients with primary sclerosing cholangitis have positive
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pANCA
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T lymphocytes attacking bile ductules within liver parenchyma that ultimatley cuases granulomas and cirrhosis
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PBC - primary biliary cirrhosis
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Positive AMA, middle aged woman, liver disease associated with OTHER autoimmune disorders
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PBC - primary biliary cirrhosis
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Middle age woman with severe pruritis, especially at night and possible xanthelasma
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PBC - associated with other autoimmune conditions (sjogren's, raynaud's, autoimmmune thyroiditis, celiac's, etc)
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Treatment for primary biliary cirrhosis
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Ursodile - decreases synthesis of cholesterol in liver and changes bile composition --> delays PBC progression
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Cholelithiasis vs cholecystitis vs cholangitis vs choledocholithiasis
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Cholelithiasis - stone in gallblader, Cholecystitis - inflammation/infection of gallbladder, cholangitis - inflammation/infection of biliary tree, choledocholithiasis - gallstones in bile duct
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4 Fs
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Fat, fertile female over Forty - increased risk of gallstones
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Jaundice, fever, RUQ abdominal pain +/i hypotension +/- altered mental status
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Charcot's triad of cholangitis, or reynold's pentad if you have hypotension and altered mental status
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Positive Murphy's sign
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inflammed gallbaldder - cholecystitis
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Bile acid sequestrants and fibrates increase risk of
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Gallstones - because they increase cholesterol content of the bile and cholestyramine results in increased bile acid production/secretion 10 fold
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HIDA scan
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radionuclide biliary scan
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Superior mesenteric artery syndrome occurs when this part of the duodenum gets entrapped here. What can cause it?
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Entraped between SMA and aorta - causes sx of intestinal obstruction. Decreased angle between aorta and SMA.OFten secondary to diminished mesenteric fat (crash diets) or surgical correction of scoliosis
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Diffuse esophogeal spasm can feel like
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unstable angina
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99mmTc-pertechnetate scan used for
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identifying epctopic gastric tissue - meckel's diverticulum. Occurs due to failure of obliteration of the omphalomesenteric duct
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