Nycc Jarrett-Thelwell General Diagnosis Test 1

Front 1

difficulty swallowing

Back 1

DYSPHAGIA

*subjective
Cranial nerves 5,7,9,10,11
Infection, obstruction, choking, thyroid goiter

Front 2

pain upon swallowing

Back 2

ODYNOPHAGIA

Front 3

ice eating

*cause?

Back 3

PAGOPHAGIA

*due to iron deficiency anemia

Front 4

indigestion (sense of fullness)

*related to?

Back 4

DYSPEPSIA

*related to GERD

Front 5

inability to swallow

Back 5

ACHALASIA

Front 6

burning sensation often called heartburn

*related to?

Back 6

PYROSIS

(get it? PYROmania)
*related to GERD

Front 7

Reproducible, non-cardiac chest pain

Back 7

costochondritis

Front 8

ESO and SB

Back 8

ESO = Esophagus
SB = Small Bowel

Front 9

Which is best, a SINGLE or DOUBLE barium contrast study?

Back 9

DOUBLE

*single is full column, LESS detail. Double is best, MOST CONTRAST

Front 10

How can barium appear on X-RAY?

Back 10

white spots

Front 11

Why shouldn't barium be used if GI perforated?

Back 11

Barium is water soluble (inert) so could cause diverticulitis if GI perforated.
May appear as white spots on x-ray.

Front 12

Name some upper GI symptoms

Back 12

Non-cardiac CHEST PAIN
ABDOMINAL pain
DIARRHEA
CONSTIPATION
FLATULENCE
BLOODY STOOLS
BELCHING
REGURGITATION [GERD]
DYSPEPSIA (indigestion)
PYROSIS (heartburn)

Front 13

destruction of lining from reflux, causing change of esophageal cells into stomach columnar mucosal cells

Back 13

BARRETT's esophagus

Front 14

What kind of diagnostic procedures are used to evaluate the GI tract:

Back 14

conventional radiography
upper GI studies
esophagram (barium swallow)
small bowel follow-through
small bowel enema (enteroclysis)
barium enema
endoscopy, ultrasonography, ERCP
CT, MRI
nuclear radiography
fluoroscopy and other interventional methods

Front 15

Which study type for dyspepsia, epigastric pain, vomiting?

Back 15

UPPER GI study

Front 16

Which type of study for difficulty swallowing (dysphagia) or reflux (GERD) symptoms?

Back 16

ESOPHAGRAM = barium swallow

Front 17

Which type of study for abdominal pain or diarrhea?

*think: would you investigate the large or small intestines?

Back 17

SMALL bowel follow through
SMALL bowel enema (enteroclysis)

Front 18

Chromoendoscopy

*think: what does 'chromo' mean?

Back 18

sprays stain on tissue
damage turns BLUE
('chromo' means color)

*Crohn's disease study

Front 19

Which type of study for rectal bleeding, colonic symptoms or colon cancer screening?

Back 19

BARIUM ENEMA

Front 20

Why discuss DISH for exam I?

Back 20

Because patients w/ DISH [Forestier's dz, OPLL, OVAL] may have compression of the esophagus, causing DYSPHASIA {20%}, HOARSENESS, DYSPNEA, etc.

Front 21

Scleroderma d/dx

Back 21

Soft tissue pathology
Raynaud's PHENOMENON
GI involvement

Front 22

Scleroderma GI presentation

Back 22

Difficulty chewing
Dysphagia
Esophageal strictures
GERD
Delayed gastric emptying
Dysmotility of sm & lg bowel >> bloating/abdominal distention and diarrhea/constipation

Front 23

How to study scleroderma GI?

Back 23

endoscopy & barium swallow

Front 24

Pericardial effusion, arrythmia, congestive heart failure, myocardial FIBROSIS indicates?

Back 24

Scleroderma

*FIBROSIS is key

Front 25

Scleroderma renal presentation

Back 25

Hypertensive renal crisis w/ microangiopathy

Front 26

En coup de sabre

Back 26

linear lesions of scalp or face in LOCALIZED scleroderma
(cutaneous fibrosis)

Front 27

Limited/generalized MORPHEA

Back 27

LOCALIZED scleroderma -
circumscribed patches of sclerosis

Front 28

CREST syndrome

Back 28

SYSTEMIC scleroderma (both cutaneous & non-cutaneous involvement)
C = Calcinosis of digits
R = Raynaud's Phenomenon
E = Esophageal dysmotility/strictures
S = Sclerodactyly
T = Telangiectasias

Front 29

Where are the primary scleroses of SYSTEMIC [CREST] scleroderma?

Back 29

PROXIMAL extremities, trunk, face

Front 30

Scleroderma SINE sclerosis

Back 30

SYSTEMIC scleroderma w/ ORGAN fibrosis and NO skin lesions

Front 31

MAJOR criteria for scleroderma D/dx:

Back 31

PROXIMAL sclerodermatous skin changes
(prox to the MCP joints)
means CREST is probably there, too.

Front 32

minor criteria for scleroderma d/dx

Back 32

Sclerodactyly (creSt)
Digital PITTING scars of fingertips or loss of substance of pads
BIBASILAR PULMONARY FIBROSIS (on x-ray)

Front 33

40 year old white woman w/ 2 year hx of Raynaud's phenomenon. Skin on hands previously swollen, red/erythymatous, pruritic, and flulike sx. Dyspnea w/o chest pain, heartburn, dysphagia, and bloating w/ abdominal distention.

Back 33

D/dx:
#1 = Scleroderma
Systemic Lupus Erythematosus
Polymyositis
Rheumatoid Arthritis

Front 34

Pulmonary findings in scleroderma presentation pre-imaging

Back 34

reduction in vital capacity
decreased lung compliance

Front 35

Lab results of scleroderma

Back 35

Elevated ESR
(+) ANA [antinuclear antibodies]
(+) ANTICENTROMERE antibodies

Front 36

Radiograph findings of scleroderma

Back 36

BIBASILAR INTERSTITIAL MARKINGS (pulmonary fibrosis)

Degrees of DISTAL TUFT RESORPTION & PENCILING

Subcutaneous CALCINOSIS

Front 37

Pathology of scleroderma (3)

Back 37

1. tissue FIBROSIS
2. small vessel VASCULOPATHY
3. autoimmune response of AUTOANTIBODIES

Front 38

Describe fibrosis phases of scleroderma

Back 38

edematous (inflammatory: erythema, non-pitting edema, pruritis)

fibrotic (excess collagen deposition in small vessels leading to RAYNAUD'S PHENOMENON + Telangiectasias)

contractures and atrophy

Front 39

Most significant morbidity of scleroderma

Back 39

presence of pulmonary involvement:

FIBROSING ALVEOLITIS leads to PULMONARY FIBROSIS leads to PULMONARY HYPERTENSION

BIBASILAR PULMONARY FIBROSIS is associated strongly w/ GERD!

Front 40

ACROOSTEOLYSIS

Back 40

absorption of distal tuft seen in scleroderma along w/ subcutaneous calcinosis

Penciling also occurs.

**Acroosteolysis & Calcinosis are pathognomic for scleroderma

Front 41

buzzwords:
flulike
fatigue, myalgia, arthralgia
tendon friction rubs
flexion contractures
swollen fingers and hands
MEDIAN NERVE ENTRAPMENT
WATERMELON STOMACH
GERD
Hypothyroidism

Back 41

scleroderma

Front 42

GI presentation of scleroderma

Back 42

Difficulty chewing
Dysphagia
Esophageal strictures
GERD************
delayed gastric emptying
dysmotility of bowel
Bloating/abdominal distention
Diarrhea/constipation

Front 43

WATERMELON STOMACH
GERD
MEDIAN N. ENTRAPMENT

Back 43

SCLERODERMA

(CREST)

Front 44

In many cases, the diagnosis and treatment of a patient are directly dependent on

Back 44

the intimate personal relationship b/w physician and patient

Front 45

One of the essential qualities of the clinician is interest in ________, for the secret of patient care is in _______ for the patient.

Back 45

humanity, caring

Front 46

SUBJECTIVE indication of patient's symptom

What the patient feels and reports

Back 46

SYMPTOM

Front 47

OBJECTIVE indication of patient's symptom

What is seen, heard, felt, or smelled by another person (the clinician's appraisal)

Back 47

SIGN

(signs are present or absent; tests are positive or negative)

Front 48

The single most important diagnostic tool?

Back 48

health HISTORY

Front 49

List of related symptoms experienced by the patient prior to visiting your office

Back 49

Chief Complaint

Front 50

How should all physical findings, labs, and imaging be interpreted?

Back 50

in the light of PERTINENT HISTORY

Front 51

What should you obtain for patients w/ chronic illnesses?

Back 51

prior medical records

*do not look at the primary dx until you make your own

Front 52

Who, what, where, when and how...you figure out the ____ by synthesizing the info you gathered in the other 5 questions

Back 52

WHY

Now make your diagnosis

Front 53

In what part of the visit is the doctor's skill most apparent?

Back 53

obtaining the history

Front 54

Following the health hx, the doctor makes a

Back 54

GENERAL SURVEY STATEMENT

A general impression, a scanning procedure.

Front 55

What part of the patient's family matters when taking the history?

Back 55

DIRECT BLOOD RELATIVES

Front 56

Functional status at home
Social and economic circumstances
Goals for the future

Back 56

Best way to manage patient's medical problem

Front 57

What may reveal the cause of illness even though apparently unrelated symptoms?

Back 57

REVIEW OF SYSTEMS

Front 58

Systemic assessment of physical and mental status of patient

Back 58

OBJECTIVE PHYSICAL EXAM

*phys exam results are subject to change
*subjective data may be obtained from patient during exam
*Significance enhanced when signs (objective) confirm a functional or structural change already suggested by history

Front 59

Types of physical examinations

Back 59

1. REGIONAL (BRANCHING)

2. COMPLETE

Front 60

What are Dr. Finn's 4 tenents of a physical exam?

Back 60

Inspection
Palpation
Percussion
Instrumentation

IPPI

Front 61

When you complete the health hx and physical exam (IPPI), you are ready to develop a ?

Back 61

PROBLEM list

*actual [current], potential [highly likely to occur in the future], and resolved [finito - needs no intervention]

Front 62

A working list of POSSIBILITIES used in the process of DIAGNOSING a specific disease

Back 62

DIFFERENTIAL DIAGNOSIS LIST

Front 63

4 steps to systemic solving of clinical problems:

Back 63

1. make the diagnosis
2. assess the severity/stage
3. render the treatment based on stage
4. follow patient response to treatment

Front 64

In the first step, making the diagnosis, we use ______recognition and _______ reasoning.

Back 64

PATTERN recognition
&
diagnostic REASONING:
**gather information
**subjective to objective
**discriminating features

Front 65

Read the 7 fundamental clinical questions:

Back 65

1. Most likely diagnosis? (the hoofbeats are from horses, not zebras)
2. Next step?
3. Most likely mechanism for this process?
4. Risk factors for this condition?
5. Complications of this disease?
6. Best treatment/therapy?
7. How will you confirm the dx?

Front 66

28 year old woman complains of severe epigastric pain RADIATING TO THE BACK, nausea and vomiting.
Labs: elevated serum amylase

Back 66

Acute pancreatitis > gall bladder and alcohol > ultrasound negative

Front 67

3 functions of patient interview

Back 67

Gather data
Establish therapeutic rapport
Educate the patient

Front 68

71% of patients stated poor relationships as a reason for

Back 68

their MALPRACTICE claims.

Effective communication reduces malpractice risk. Docs w/ good communication skill get sued less.

Front 69

What does a doctor do when a patient invents health concerns (lies)?

Back 69

Desire for attention
Secondary gains ('essential' statements)
Feelings of inadequacy
Denial
Desire for medication
Communication barriers

Front 70

Is a neutral reaction or a sympathetic reaction better to handle a patient who is feigning sx?

Back 70

NEUTRAL

*do not reinforce w/ attention

Front 71

B.A.T.H.E. technique

Back 71

Background
Affect
Trouble
Handling
Empathy

(ways to ask patients what's going on - way to organize an interview)

Front 72

name a cultural competency about Asian patients

Back 72

rarely seek pain medication

Front 73

name a cultural competency about Mediterranean patients

Back 73

seem to need pain meds for the slightest discomfort

Front 74

name a cultural competency about Middle Eastern men

Back 74

They will not permit a male doctor to examine their women

Front 75

Coin rubbing is an

Back 75

Asian method of medical treatment, not child abuse

Front 76

What impact have women doctors had on women's health?

Back 76

Ordered more preventative tests for women
More attuned to womens psychosocial needs
More patient-oriented communication styles
Brought attention to gender gaps in medicine (ie, research and dosage)

Front 77

Chest pain is a _______ often described as a tightness or squeeze-like pain centered in the mid-sternal region

Back 77

SYMPTOM (subjective)

Front 78

When a cardiac cause has been ruled out for symptomatic chest pain, it is called NON-cardiac chest pain.
What is it associated with?

Back 78

ESOPHAGEAL DYSMOTILITY disorders

ex: DES (diffuse esophageal spasm) and NUTCRACKER esophagus

Front 79

Cause of non-cardiac chest pain

Back 79

esophagus

*Patients w/ esophageal pain have nearly indistinguishable pain from cardiac pain: diaphoresis, pallor and dizziness just like angina

Front 80

Non-cardiac chest pain, when not related to esophageal dysmotility, is often related to ________ and can be relieved w/ ______ and _______.

Back 80

exertion

nitrates and calcium channel blockers

Front 81

Where do patients frequently localize the site of their esophageal pain?

Back 81

ABOVE the level of the obstruction

Front 82

Pillcam used for

Back 82

BARRETT's esophagus dx

Front 83

often affords glimpse fo oral structures

Back 83

CAPSULE ENTEROSCOPY

Front 84

Patient lays supine for a _____ of the stomach study

Back 84

supine

and prone for body, mucosal surface

Front 85

A long, thin lighted flexible tube w/ a small camera on the end, inserted through patient mouth and into the esophagus.

Back 85

FUNDOSCOPE

Front 86

EGD or upper endoscopy is also called an (long word)

Back 86

Esophagogastroduodenoscopy

Front 87

brushes against the lumen of the stomach to collect cells

Back 87

CYTOLOGY BRUSH

ROTH BASKET

Front 88

Removes polyps

Back 88

POLYP SNARE

Front 89

Opens constriction of esophageal stricture

Back 89

BALLOON dilator

Front 90

What are SCINTIGRAPHIC RADIOLABELLED CORNFLAKES for? Breakfast?

Back 90

Mark transition time from stricture to non strictured area

ex: Achalasia (LES stricture that causes dilation below constriction)

Front 91

MANOMETRY

Back 91

The GOLD STANDARD = a PRESSURE PROBE to measure DES or Nutcracker esophagus:

Used when barium swallow and endoscopy unremarkable.
Determines ESOPHAGEAL disorders & COLLAGEN VASCULAR DISEASES

Front 92

Advantages of manometry

Back 92

The only PRESSURE WAVE TEST

disadvantage: cannot diagnose visible lesions and is unpleasant for patient

Front 93

OPLL

Back 93

Ossification of Posterior Longitudinal Ligament

*DISH/Forestier's = mc ALL

Front 94

OVAL

Back 94

Ossification of the Vertebral Arch Ligaments

*DISH/Forestier's = mc ALL

Front 95

DISH patient

Back 95

50 yo Male

*A 50 year old male, while not often a real dish, could be a guy handy in the forest who likes to buy you oval opals.

Front 96

Most common ligament involved in DISH

Back 96

ALL

Front 97

Describe DISH clinical presentation [cp]:

Back 97

50 year old guy w/ back stiffness in morning and a low grade msk ache. He has dysphasia due to compression by the flowing hyperostosis on his spine, and it also makes him hoarse, maybe he has difficulty breathing (dyspnea). Chronic pneumonia.
*There is weird swelling or mass on his Achilles tendon or his quadriceps tendon.

DISH/Forestier's/ALL/OPLL/OVAL

Front 98

Describe DISH diagnostic images

Back 98

PELVIC WHISKERING
FLOWING HYPEROSTOSIS of 4 or more contiguous segments
ALL calcification (can be PLL or adjacents)
*PRESERVATION of IVD heights, no ankylosing, no apophyseal joint affects
BRIDGING of ribs and tp's to vertebrae (20%)
SI ligament involvement

*Left side has minimal involvement d/t pulsation inhibition of calcification by aortic pumping/massaging action

Front 99

DISH labs

Back 99

HLA-B8 (celiac dz, myasthenia gravis, primary sclerosing cholangitis of bile ducts, DISH)

Increased FBG [DISH + Diabetes mellitus go together]

Front 100

He's a 50 year old man, not what you'd consider to be a dish, but he's handy in the forest and likes to buy you oval opals. He's overweight and has diabetes, his whiskers tickle your nose, and he likes to watch the wax flow down 4 candles every night. He's maintained his height and you can still adjust him w/ no problem since all his facet joints are good, but he is ALL hunched over so no extension moves. He's always saying corny stuff like, "I coulda had a B8!"
Who is he?

Back 100

DISH/Forestier's/ALL

Front 101

DISH/Forestier's character for memory

Back 101

He's a 50 year old man, not what you'd consider to be a dish, but he's handy in the forest and likes to buy you oval opals. He's overweight and has diabetes, his whiskers tickle your nose, and he likes to watch the wax flow down 4 candles every night. He's maintained his height and you can still adjust him w/ no problem since all his facet joints are good, but he is ALL hunched over so no extension moves. He's always saying corny stuff like, "I coulda had a B8!"

Front 102

Myasthenia gravis general definition/background

Back 102

Autoimmune
Neuromuscular disorder
MUSCLE WEAKNESS increases during activity d/t BLOCKING action of ANTIBODIES for ACETYLCHOLINE receptors at POST-synaptic neuromuscular jcn.

Front 103

What makes myasthenia gravis WORSE?

Back 103

INCREASED TEMPERATURE

REPETITIVE mm. stress

Some medications

Front 104

What makes myasthenia gravis BETTER...

Back 104

REST

COOLING the mm.

Front 105

What is the antibody mechanism that causes myasthenia gravis?

Back 105

Antibodies against ACh receptors prevent ACh from attaching and therefore, PREVENT the muscle from CONTRACTION

Front 106

Think of the mechanism of myasthenia gravis = antibodies block ACh receptors and prevent muscle contraction. What is the patient presentation?

Back 106

EYE mm weakness = PTOSIS, DIPLOPIA

Altered FACIAL EXPRESSION (droopy)

DYSPHAGIA (eso ring mm are weak)

DYSARTHRIA (weak mm make for weak joints)

Difficulty CHEWING (weak masticators)

***GENERAL FLUCTUATING MM WEAKNESS (can't lift heavy things or climb stairs)

SOB (short of breath, weak mm of inspiration)

CHEST PAIN

Front 107

For myasthenia gravis patient, what other dz should you screen for?

Back 107

Other AUTOIMMUNE dz:
SLE [LUPUS]
HYPERTHYROID/GRAVES
RHEUMATOID ARTHRITIS
SCLERODERMA

Front 108

a type of myasthenia gravis assoc. w/ the dysfunction of the Ca+ CHANNELS that affect mm contraction

Back 108

LAMBERT-ETON Myasthenia

*old pdf only

Front 109

Does myasthenia gravis weakness get better after the patient rests? What else helps?

Back 109

REST + ICE helps

*remember back in neuro lab the case study w/ Dr. Barr about the college girl who got tired all the time

Front 110

Myasthenia gravis X-RAY clue

Back 110

anterior mediastinal mass = THYMOMA

*10% of patients w/ MG have benign thymic tumor and 70% have hyperplastic changes assoc. w/ active immune response

Pts w/ thymoma usually have more SEVERE MG and higher levels of AChR antibodies.

Front 111

Tests for Myasthenia gravis

(what are the 2 most important antibody tests? ocular test?)

Back 111

pulmonary (weak breathing)
blood tests for antibodies to AChReceptors
EDROPHORIUM Chloride [Tensilon, Reversol]
single fiber EMG [SFEMG]
repetitive nerve stim [EMG]

***MuSK protein antibodies
***AChR antibodies

PPD for latent TB
HLA- B8, DR3, DR1 (ocular)

Front 112

Jane is a 25 year old who gets tired as hell by the end of the day. She can barely keep her eyes open and gets short of breath just walking up stairs. She's lost a lot of weight without dieting, even though she gets tired chewing food! Her joints hurt and she's developed an unattractive waddle gait because her knees hurt. She f***ing hates living in Florida now, because it seems like the heat makes her so tired! Lately, she's just been lying in a cool dark room with an ice pack on her head.

Back 112

Myasthenia gravis

(women under 40, men over 60)

Front 113

ONLY test for pressure wave physiology of esophageal dysmotility

Back 113

MANOMETRY (gold standard)

Front 114

The esophagus is naturally narrow at the _____of the aorta and the ____ main stem bronchus.

Back 114

arch of aorta
right main stem bronchus

Front 115

Double contrast study uses

Back 115

Barium + air (mucosal detail)

Front 116

Smooth, eccentric structural abnormality of the esophagus

Back 116

Esophageal WEB

Indention of 2-3 mm of normal tissue

Front 117

esophageal WEB eccentric or concentric?

Back 117

ECCENTRIC

*(ingrowth of tissue) = WEB

Front 118

Layers of esophageal WEB?

Back 118

MUCOSA + SUBmucosa

Front 119

Tell me about the esophageal WEB patient

Back 119

Female asymptomatic until after 40 who has trouble swallowing solids for a long time.

She is probably anemic (IDA sx) meaning she's tired, dizzy and headache, paler than you and has chest pain.

Koilonychia, cheilosis and glossitis (think brittle nails, cracked lips and fat tongue).

Front 120

Esophageal WEB aka (2):

Back 120

PLUMMER-VINSON (post cricoid esophageal web + IDA)

PATTERSON-KELLY-BROWN

Front 121

Describe esophageal WEB appearance

Back 121

Thin membrane arising from ANTERIOR wall of CERVICAL esophagus
WITHOUT circumferential involvement (strictly eccentric protrusion)

Front 122

LABS for esophageal WEB

Back 122

CBC w/ differential - IRON + FERRITIN

****anti-GLIADIN antibodies

****anti-ENDOMYSIAL antibodies (celiac dz)

Front 123

How does one get Plummer-Vinson syndrome?

Back 123

Esophageal WEB may be acquired [GERD/injury] or congenital

*Patterson - Kelly - Brown/ Plummer - Vinson/ Esophageal WEB all the same thing

Front 124

A smooth, concentric structural abnormality of the esophagus

Back 124

SCHATZKI'S RING

3-5 mm CONCENTRIC growth of all 3 layers (mucosa, submucosa, muscle)

Front 125

Where is SCHATZKI's ring found?

Back 125

DISTAL esophagus

Front 126

How many types of SCHATZKI's deli meat are there?

Back 126

3

[type A, B or C]

Front 127

SCHATZKI's ring is usually assoc. w/ a __________.

Back 127

HIATAL HERNIA

Front 128

A cat walks into SCHATZKI's deli and orders a Steakhouse Sandwhich. . SCHATZKI himself remarks what a lovely concentric ring pattern the cat has on his tail. What symptoms did the cat have while eating the Steakhouse sandwich?

Back 128

He had crushing, non-cardiac chest pain due to his SLIDING HIATAL HERNIA

Front 129

GERD is not listed in the class notes as related to esophageal web, but it is listed in the pdf. In Jarrett's notes, which esophageal structural abnormality IS listed as due to gastroesophageal reflux?

Back 129

SCHATZKI'S RING

(hiatal hernia w/ meganblasse, concentric ring, steakhouse syndrome, feline esophagus, GERD assoc.)

Front 130

Imaging for SCHATZKI's ring?

Back 130

Barium esophogram and video fluoroscopy

EGD-scopy may rupture concentric ring

Esophageal MANOMETRY (pressure measure = gold standard)

Front 131

Out of all the rings [A B or C], which one is SCHATZKI's on the drawing?

Back 131

B = middle concentric ring is Schatzki in the distal esophagus

Front 132

UN-coordinated esophageal contractions (name and 3 aka's)

Back 132

DES [Diffuse Esophageal Spasm]

aka:
CORKSCREW esophagus
ROSARY BEAD esophagus
SPASTIC PSEUDODIVERTICULOSIS

Front 133

A monk holding a CORKSCREW in one hand and ROSARY BEADS in the other, felt a lump in his throat when he drank warmed wine. He thought God was punishing him for drinking by making swallowing painful and sending angina through his chest and arms. He added some seltzer to the wine and drank it cold, but that made it worse. Monks don't wear undes, and he was anxious about that, too.

Back 133

Un-DES

Uncoordinated Diffuse Esophageal Spasm. Have you got on clean Un-des?

Front 134

The DES monk will experience what symptoms besides angina and intermittent odynophagia?

Back 134

Reflux, Regurgitation, Vomit

Front 135

COORDINATED esophageal contraction of a high amplitude (not random)

Back 135

NUTCRACKER esophagus

*propagation of a severe single wave and pressure (vs. DES which is diffuse, uncoordinated several waves)

Front 136

Uncoordinated undes
vs.
Tight Nutcracker briefs

Back 136

DES (uncoordinated, diffuse waves)
vs
Nutcracker (coordinated, high amp, one ball buster at a time)

Front 137

Imaging of choice for DES and Nutcracker

Back 137

MANOMETRY = gold standard

Front 138

an OUTPOUCHING of the esophagus

Back 138

Esophageal diverticula:

1. Zenker's
2. Traction
3. Epiphrenic

Front 139

Esophageal DIVERTICULA are outpouchings that are either congenital or acquired. What is the difference between TRUE & FALSE esophageal diverticula?

Back 139

TRUE = all 3 layers [mucosa, submucosa, muscular]

FALSE = pseudodiverticula only 2 layers [mucosa and subm]

Front 140

ZENKER'S diverticula

Back 140

PULSATION

FALSE (only mucosa and submucosa)

POSTERIOR HYPOpharynx PROXIMAL

MOST COMMON type to cause symptoms in BABY BOOMERS

Front 141

What causes ZENKER's diverticula

Back 141

Incomplete relaxation of the UPPER esophageal sphincter (proximal posterior hypopharynx)

Front 142

Baby boomer Zenk is in your office complaining, in a hoarse voice, about chest pain and vomiting into his mouth (regurgitation). As you lean in to listen to his lungs, his breath almost knocks you on the floor. You notice a VERY LARGE mass on his neck and that he looks really thin these days. What do you hear during the pulmonary exam?

Back 142

Crackling and rasping! This guy has aspirated food into his lungs because his UES would NOT relax. He has pneumonia from food backing into his trachea and a big tongue-like thing hanging off the back of his esophagus, an outpouching.
The neck mass? ZENKER'S DIVERTICULUM. Thankfully, it's a false pulsation and only involves the mucosa and submucosa. You send him out for an upper GI but not an endoscopy because that could perforate his esophagus.

Front 143

Which diverticula looks like a big tongue hanging off the posterior hypopharynx right under the inferior constrictor muscle?

Back 143

ZENKER's diverticulum

Contains a trapped bolus of food inside an outpouching right above the tense UES.

Front 144

Why wouldn't you do a barium swallow or an upper GI endoscopy on ZENKER's?

Back 144

Barium is water insoluble. If endoscope perforates the wall, barium can get in the chest cavity

Front 145

Where is a TRACTION diverticula?

Back 145

Right in the middle.

Zenker's is above, Traction in the middle, Epiphrenic is below.

Front 146

What causes TRACTION diverticula?

Back 146

PULLING of the esophagus

ie, in TB, the lymph nodes are swollen and pull at the esophagus

Front 147

What diverticula is seen in the DISTAL esophagus?

Back 147

EPIPHRENIC diverticula

*Phrenic nerve goes to diaphragm so think epiphrenic is just above it, very low in chest and so is the lowest, most distal type of diverticula.
PULSATION diverticula

Front 148

inflammation and wearing away of the gastric mucosa causes

Back 148

GASTRITIS

Front 149

Gastritis may be chronic or acute and is much more common than ___________

Back 149

gastric ULCERS

*ergo, H. Pylori is the MC form of gastritis

Front 150

Most common form of GASTRITIS

Back 150

H. PYLORI

Front 151

BALD FUNDUS sign

Back 151

ATROPHIC gastritis = absent rugal folds in Upper stomach
Leads to MALABSORPTION

Front 152

EMPHYSEMATOUS gastritis

Back 152

Within wall of stomach, there is AIR

Front 153

Abdominal surgery can lead to _______ between between components of intestines that can lead to blockage or torsion.

Back 153

ADHESIONS

Front 154

hyperplasic hypersecretory gastropathy

Back 154

MENETRIER's disease [GYRI]

*big heavy rugae/folds

Front 155

Reasons for gastritis

Back 155

autoimmune
H. Pylori ** MC form chronic gastritis
reflux
alcohol

Front 156

erosive gastritis

Back 156

erosion of stomach lining

NTQ

Front 157

Pt hx and complaint for GASTRITIS

Back 157

EIPGASTRIC DISCOMFORT/BLOATING

d/dx GERD, Myasthenia Gravis, Autoimmune dz, many have melena

Front 158

Physical exam GASTRITIS

Back 158

non-contributory
related to underlying cause
EPIGASTRIC TENDERNESS
fever, lethargy

Front 159

Why are biopsies taken for Gastritis?

Back 159

Rule out ADENOCARCINOMA

Front 160

Diagnostic imaging of gastritis depends on

Back 160

the cause

Front 161

Most common polyp

Back 161

HYPERPLASTIC polyp

Front 162

On a barium study for polyp, what happens?

Back 162

Barium flows around polyp (not inside it, like diverticulitis)

Front 163

how to sample polyp

Back 163

endoscopy polypectomy

Front 164

Biggest risk factor for gastric adenocarcinoma

Back 164

H. Pylori

Front 165

Physical exam of gastric adenocarcinoma buzz words

Back 165

Krekenberg tumor - ovarian
Blumer's shelf
Sister Mary Joseph sign
Virchow's node/SENTINAL node - left supraclav. node
Succusion splash - fluid sound

Front 166

Chronic ulcers go all the way down to the muscle layer

Back 166

muscularis

Front 167

What causes peptic ulcers

Back 167

Cocaine
H. Pylori***MC
NSAIDS
Aspirin
bile

add from notes

Front 168

Gastric vs duodenal ulcer

Back 168

Gastric = pain 1.5 hour after meal - eating makes WORSE so weight LOSS

Duodenal = 2-3 hours after meal - eating makes BETTER so WEIGHT GAIN

Front 169

TEST of peptic ulcer

Back 169

urease breath test

Front 170

With a _________ulcer, mucosal folds are radiating to central ulcer

Back 170

Duodenal

Front 171

When an ulcer in is the _________. when it heals it could lead to an obstruction.

Back 171

DUODENAL (peptic)

*duodenum ulcer heals by drawing tissue down towards it, leading to an obstruction (EXAM QUES) - obstruction can also be caused by abdominal surgery

Front 172

If there is a perforation, a CT scan will show

Back 172

air on the top. When they stand up, there are 2 lucent arcs signifying a PNEUMOPERITONEUM.

Air from an ulcer perforation

Front 173

Breath test for peptic ulcer

Back 173

Urea breath test determines presence of H. Pylori

(ammonia and CO2/tagged is exhaled)

Front 174

a NON beta islet cell gastrin secreting tumor of the pancreas

Back 174

ZOLLINGER-ELLISON syndrome

where tumor produces lots of GASTRIN hormone, hence GASTRINOMA

Front 175

Zollinger Ellison complaint

Back 175

severe epigastric pain/ discomfort, diarrhea

No gastritis or gastric ulcer but lots of watery diarrhea, steattorhea

Front 176

characterized by numerous, minute FLASK-like outpouchings along esophageal wall

Back 176

EIPD = Esophageal Intramural Pseudodiverticulosis

-can be segmental OR generalized
-associated w/ STRICTURES, carcinoma, candidiasis, motor abnormalities

-PSEUDO indicates mucosa and submucosa only

Front 177

Diverticula of the POSTERIOR hypopharynx

-Halitosis
-GERD
-Weight loss

Back 177

ZENKER'S diverticulum

Front 178

Abnormal NARROWING of the esophageal lumen causing difficulty swallowing

Back 178

esophageal STRICTURE

1. PROXIMAL
2. DISTAL

Front 179

INTRINSIC factors that can inhibit SIZE of lumen:

Back 179

Tumors, Fibrosis (CREST) and/or Inflammation

Front 180

EXTRINSIC factors that inhibit MOTILITY of esophagus

Back 180

MEDIASTINAL MASSES
esophageal SPASM

Front 181

abnormal NARROWING of the esophageal lumen, causing difficulty (DYSphagia) in swallowing

Back 181

Esophageal STRICTURE

Front 182

failure of the LES (cardiac) sphincter to relax, resistricting passage of food to the stomach.

Back 182

ACHALASIA

In some cases, dysphagia (difficulty) and marked dilation of the esophagus may occur due to backed up food.

Front 183

W/ Achalasia, the wall of the esophagus becomes thicker, causing the lumen to become

Back 183

narrower


*sim to Crohn's dz where wall of small intestine becomes thicker hence lumen becomes smaller

Front 184

Patient history/complaint of esophageal STRICTURE

Back 184

progressive dysphagia (difficulty) or odynophagia (pain) w/ swallowing
regurgitation
food impaction
chest pain
dental erosion (vomitorium)
weight loss [can't get food into stomach and feel nauseous - who wants to eat?]

Front 185

Diagnostic imaging for esophageal stricture (general)

Back 185

Plain film/barium swallow/ CT/ MRI/ endoscopy/ MANOMETRY

*lab findings depend on the cause

Front 186

What would cause PROXIMAL esophageal stricture?

Back 186

Malignancy
Radiation therapy
Infectious esophagitis = candida, herpes simplex, HIV, CMV
AIDS or immunosuppression (ie, transplant)
***Medication*** - induced stricture (PILL ESOPHAGITIS) mainly NSAIDS and tetracyclines b/c acidic pills inflame/irritate the esophagus if stuck
Diseases of the skin = p. vulgaris, benign mucous membrane pemphigoid and e. bullosa dystrophica [inflammatory conditions tx w/ immunosuppresants]
Caustic indigestion [acid]
Extrinsic compression [concentric growths, tumors]
Squamous cell carcinoma
Trauma

Front 187

What might cause DISTAL esophageal compression?

Back 187

Extrinsic compression [tumors, concentric growths]
Adenocarcinoma
Peptic stricture = GERD, Zollinger-Ellison syndrome
Crohn's disease
Sclerotherapy or prolonged intubation (nasogastric/trach tube)
Collagen vascular dz = Scleroderma CREST, RA, SLE
Alkaline reflux
Post gastric resection

Front 188

MALIGNANCY of the esophagus

Back 188

Esophageal CARCINOMA

*most tumors involve the LOWER esophagus
*Males 60-80 yo

Front 189

What patient has the greatest chance of developing esophageal carcinoma?

Back 189

BARRETT'S esophagus (30-125x higher chance)

Barrett's eso most common in White Males

Front 190

Esophageal CARCINOMA SIGNS on barium swallow

Back 190

APPLE CORE appearance (overhanging margin sign)
&
STRING SIGN

Front 191

Pt hx/complaint for esophageal carcinoma:

Back 191

Painless>>>
Progressively worse dysphagia, first to SOLIDS then LIQUIDS = STEAKHOUSE SYNDROME

Front 192

Describe the other pt hx/ complaint in addition to STEAKHOUSE syndrome

Back 192

Odynophagia, unintentional weight loss, nausea/vomiting/hematemesis, regurgitation, COUGHING - compression of trachea can cause coughing, Symptoms of ASPIRATION pneumonia
FISTULAS - abnormal connections b/w trachea and esophagus leading to aspiration of esophageal contents into bronchi

Front 193

persistent _________ in addition to weight loss and dysphagia could be a warning sign of esophageal cancer

Back 193

hiccups

Front 194

What represents a metastatic finding on physical exam for esophageal carcinoma?

Back 194

LYMPHADENOPATHY in the laterocervical or supraclavicular areas

Front 195

Diagnostic imaging for esophageal carcinoma

Back 195

Plain film/ barium swallow/ chromoendoscopy/biopsy/CT/bone scan

*chromoendoscopy

Front 196

LAB findings of esophageal carcinoma

Back 196

biopsy and Brush cytology
CBC w/ differential
chem-18 blood panel

OCCULT BLOOD IN STOOL

Front 197

SQUAMOUS cell carcinoma of ESOPHAGUS arises from the

Back 197

esophageal LINING
and
commonly found in UPPER-MID esophagus

Front 198

Causes of Squamous cell esophageal cancer

Back 198

ALCOHOL & SMOKING (chronic irritation)
Swallowing a CAUSTIC agent
Nutritional DEFICIENCIES (riboflavin, niacin, iron)
Chronic esophagitis from GERD
ACHALASIA = stasis induced inflammation
TYLOSIS - autosomal dominant hyperKERATINization of the SOLES of FEET and PALMS of HANDS
PLUMMER-VINSON syndrome
NITROsamines
Previous diagnosis of ssc of head or neck
BUSH teas containing tannins or diterpene phorbol esters

Front 199

What kind of cancer arises from esophageal GLANDS?

Back 199

ADENOCARCINOMA

*usually found in LOWER esophagus

Front 200

Risk factors for esophageal adenocarcinoma

Back 200

from eso glands:
BARRETT'S esophagus

Front 201

Where do esophageal ULCERS/erosions occur?

Back 201

MUCOSAL layer

*acute occur in mucosal and submucosal
**chronic occur in 3 layers (mucosal, submucosal, muscularis)

Front 202

What can create a predisposition to esophageal ulcer/erosion

Back 202

Anything that narrows the esophagus or creates dysmotility

*scleroderma, caustic agents, Crohn's, tumors, reflux/GERD

Front 203

How can prolonged use of NSAIDs cause ULCERS of esophagus

Back 203

BLOCKS gastric mucosal CYCLOOXYGENASE activity, leading to decreased EPITHELIAL cell generation then INJURY and low gastric mucosal SECRETION.

All this craps out the mucosal BARRIER and leads to ULCERATION of gastric nature

Front 204

EIPD

Back 204

Esophageal Intramural Pseudodiverticulosis

Numerous FLASK-like outpouchings along eso. wall.

Seen w/ CANDIDA, STRICTURES, carcinoma and motor abnormalities

Front 205

esophageal strictures caused by

Back 205

infection, trauma, neoplasm

Front 206

extrinsic esophageal strictures caused by

Back 206

enlarged lymph nodes, mass/neoplasm in lung, congenital anomaly

Front 207

An abnormal peristaltic wave of esophagus

Back 207

DYSMOTILITY of esophagus

Front 208

LENGTH of esophageal stricture

Back 208

4cm. in length

Front 209

Why does the wall become thicker (and the lumen narrower) in esophageal stricture?

Back 209

Damage to wall caused by REFLUX

****BIGGEST CAUSE OF ESOPHAGEAL STRICTURE IS GERD******

Front 210

DISTAL esophageal stricture (more common than proximal) is caused by

Back 210

******GERD (pyrosis) ****

Zollinger-Ellison syndrom
CREST (scleroderma)
EXTRINSIC compression
Adenocarcinoma

Front 211

NERD

Back 211

Non-Erosive Reflux Disease

*use cell staining to see it

Front 212

Provocative for GERD

Back 212

Any foods that lower the LES pressure : chocolate, fatty and spicy foods, tomatoes, coffee

Tight clothing

Alcohol and tobacco use *****

Front 213

Acid reflux >>> Barrett's esophagus >>>> ____________

Back 213

Adenocarcinoma

Front 214

#1 association of GERD

Back 214

SLIDING hiatal hernia (fundus displaced through diaphragm)

MEGANBLASSE moves to middle (gas air bubble no longer on the left)

Hiatal's are also associated w/ Schatzki's ring

Front 215

GERD barium studies will show**8

Back 215

***SLIDING and PARA-ESOPHAGEAL HIATAL HERNIAS
w/ and air/fluid level in the midline ABOVE the level of the diaphragm

**MC: SLIDING hiatal hernia where displaces fundus to chest cavity.

**Paraesophageal is NEXT TO esophagus, where meganblasse will be in the midline instead of to left of it

Front 216

GERD patient complaints

Back 216

May be asymptomatic, but...
DYSPHAGIA
PYROSIS (years of heartburn complaints)
CHRONIC ANGINA-LIKE CHEST PAIN
HIATAL HERNIA
HOARSENESS IN MORNING
Due to change of esophageal to stomach cell types, patient will complain of intermittent pain b/c the irritation will diminish as the change occurs, hence INTERMITTENT pain.

Front 217

Physical exam findings for GERD

Back 217

Hoarseness in morning
ASCULTATION of PERISTALSIS in CHEST should suggest large hernia

SUCCUSSION SPLASH in patients w/ gastric dilation or pyloric obstruction

Front 218

3 COMPLICATIONS of GERD

Back 218

1. STRICTURE

2. BARRETT'S

3. ULCERS

Front 219

If you suspect a sliding hiatal hernia associated w/ GERD, what should you do?

Back 219

Valsalva maneuver to see if air above diaphragm. Meganblasse on x-ray will be in midline instead of to left because hernia above diaphragm pushing stomach to midline.

Front 220

Esophageal cancer complaints/pt hx

Back 220

STEAKHOUSE SYNDROME (dysphagia to solids, then liquids)

VIRCHOW'S NODE over left supraclavicular ***lymphadenopathy in laterocervical or supraclavicular areas represents metastasis****

FISTULAS abnormal cx from esophagus to trachea

HICCUPS w/ weight loss and dysphagia might be CA of esophagus warning signs

Front 221

Lab findings of esophageal CA

Back 221

can look normal bc/ squamous cells have covered the Barrett's areaa

Look for OCCULT blood in stool

Front 222

Pt complaint:
dysphagia
unintentional weight loss
epigastric pain
hoarseness

Back 222

esophageal ADENOCARCINOMA

**Barrett's is the pre-malignant condition

Front 223

SQUAMOUS cell of esophagus buzz words

Back 223

Lining
Upper to mid esophagus
Alcohol & tobacco
GERD
Achalasia
Tylosis (Hyperkeratinization soles and palms)
Plummer-Vinson
Previous diagnosis of squamous of head or neck
Bush teas

Front 224

melena

Back 224

found wi/ active esophageal bleeding

Front 225

What bug causes ACHALASIA?

Back 225

CHAGAS disease - Kissing bug - T. CRUZI

hence CHAGOMA = inflammation

Front 226

Cardiospasm
esophageal aperistalsis
megaesophagus

Back 226

Achalasia

Front 227

Achalasia

Back 227

an esophageal motility disorder causing a functional obstruction of the eso characterized by a-peristalsis and FAILURE of the LES to relax adequately in repsonse to swallowing = PRIMARY achalasia

Excitatory (ACh and Substance P ) take over inhibitory (N.O.) so AUERBACH'S PLEXUS FAILS due to disruption of these inhibitory neurons

Front 228

Secondary achalasia is due to

Back 228

an EXTERNAL MASS

ie, a tumor wrapping around the LES preventing relaxation

Front 229

Of the 3 stages of achalasia, what is the worst?

Back 229

CHRONIC because of the CARDIAC effect

Front 230

Treatment for ACHALASIA

Back 230

BALLOON

Front 231

CHAGAS' disease causes

Back 231

2* achalasia:

ROMANA sign of edema
CHAGOMA sign of inflammation

T. Cruzi is the kissing bug

Front 232

Achalasia diagnostic imaging signs

Back 232

BIRD'S BEAK DEFORMITY - dilation of esophagus above hypertensive/stuck LES

STRING SIGN is usually longer in 2* achalasia than in 1* achalasia

Imaging shows WIDENED MEDIASTINUM and air/fluid level meaning food is stuck in esophagus

Front 233

GERD is hoarseness in the morning.

________ is hoarseness w/ nighttime coughing.

Back 233

ACHALASIA (NTQ is listed on this card?)

*hoarseness, nocturnal coughing
*Progressive pain/odynophagia to solids and liquids
*substernal chest pain IMMEDIATELY after eating
*unintentional weight loss
*halitosis

Front 234

What will x-ray show of barium in achalasia?

Back 234

It's all stuck above the stomach in a dilated esophagus. The LES won't let it through.

Front 235

Esophageal ulcers/erosions occur in the __________ layer

Back 235

mucosal

*acute are often in mucosal and submucosal layers
*chronic are in all three layers

Front 236

What physical changes predispose one to esophageal ulcers/erosions?

Back 236

Motility disorders and esophageal narrowing

Front 237

Examples of motility disorders and that cause esophageal narrowing, predisposing pt to ulcer/erosion:

Back 237

Scleroderma
Caustic agent ingestion
Prolonged naso-gastric INTUBATION
Achalasia (failure of the LES to relax)
Radiation
Crohn's disease
Tumors
Reflux (GERD)

Front 238

How can prolonged use of NSAIDs cause esophageal erosion/ulcers?

Back 238

Inhibiting gastric mucosal COX-2 (cyclooxygenase activity) leading to depleted epithelial cell regeneration and decreased mucosal secretion =

SCREWS MUCOSAL BARRIER and leads to gastric ulceration

Front 239

Esophageal ____ are dilated SUBMUCOSAL VEINS of the esophagus.

Back 239

VARICES are dilated veins

*usually caused by PORTAL HYPERTENSION

Front 240

2 things that lead to portal hypertension (and esophageal varices):

Name 3rd thing for just females:

Back 240

1. Alcoholic liver disease
2. Hepatitis C
3. Females only: vein-occlusive dz

Front 241

From where does PORTAL VEIN get blood?

Back 241

ABDOMEN

Empties it into the liver so it can be detoxified. HEPATIC ENCEPHALY occurs when toxins aren't removed b/c liver is too sick. Toxins build up in BRAIN as a result.

Front 242

Increased blood flow + increased resistance (due to SCAR tissue in liver from cirrhosis or heppy-C) leads to ________ & formation of ____________ veins.

Back 242

BACK-UP & formation of COLLATERAL VEINS

Front 243

abnormally dilated veins of the esophagus. They are native veins that serve as collaterals to the central venous circulation when flow through the portal venous system or superior vena cava (SVC) is obstructed.

Back 243

Esophageal and paraesophageal varices

http://emedicine.medscape.com/article/367986-overview

Front 244

Esophageal varices are ___________veins within the wall of the esophagus that project directly into the ______. The veins are of clinical concern because they are prone to hemorrhage.

Back 244

collateral

lumen

Front 245

__________ ________are collateral veins beyond the adventitial surface of the esophagus that parallel intramural esophageal veins.

Back 245

Paraesophageal varices

Paraesophageal varices are less prone to hemorrhage.

http://emedicine.medscape.com/article/367986-overview

Front 246

* Barium swallow demonstrates multiple serpiginous filling defects primarily involving the lower one third of the esophagus with striking prominence around the gastroesophageal junction. The patient had cirrhosis secondary to alcohol abuse.

Back 246

Esophageal Varices = SERPIGINOUS FILLING DEFECTS on radiograph

Due to cirrhosis.

Front 247

Today, more sophisticated imaging with computed tomography (CT) scanning, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and endoscopic ultrasonography (EUS) plays an important role in the evaluation of portal hypertension and esophageal varices

Back 247

In 1931, Schatzki established the basis for the modern-day fluoroscopic detection of esophageal varices by refining positional and physiologic maneuvers to optimize visualization.

Front 248

_________ is the criterion standard for evaluating esophageal varices and assessing the bleeding risk.

Back 248

ENDOSCOPY

Front 249

why are CT and MRI more valuable to evaluate esophageal varices?

Back 249

CT scanning and MRI can help in evaluating the surrounding anatomic structures, both above and below the diaphragm. CT scanning and MRI are also valuable in evaluating the liver and the entire portal circulation.

Front 250

Lab findings esophageal varices

Back 250

MELENA (DARK) blood in stool

CBC: anemia, leuco and thrombo-penia
Get a liver biopsy. Increased AST/ALT/BUN/creatinine.

Front 251

Patient hx or complaint w/ esophageal varices

Back 251

***DYSPHAGIA
***Pruritis (itchy skin due to toxin build up b/c liver sick)
****Easy bruising

**hematemesis
**Muscle cramps (common w/ cirrhosis)

Front 252

Superior Vena Cava syndrome results in __________ esophageal varices.

Back 252

DOWNHILL esophageal varices

Front 253

Portal venous hypertension results in _________ esophageal varices.

Back 253

UPHILL esophageal varices

Front 254

Patient presentation of esophageal varices (how does patient look?)

Back 254

JAUNDICED
CAPUT MEDUSAE (visible swollen veins over abdomen)
Ascites [proteins have leaked into interstitial spaces]
Splenomegaly [back up of portal vein backs up splenic vein]
LOW b.p., HIGH heart rate [working too hard but liver backed up]
Orthostatic hypertension b/c varices can LEAK LARGE AMTS of blood.

Front 255

Esophageal mucosal tear caused by forceful vomiting that causes the esophagus to bleed.

Back 255

MALLORY-WEISS SYNDROME

*after a night of binge drinking or having an eating disorder [bulimia]

**NON-transmural laceration - just the muscosa is torn.

Front 256

What kind of injury to the esophagus does Mallory-Weiss syndrome vomiting cause?

Back 256

NON-transmural. Only tears mucosa.

Front 257

Common cause of bleeding in GI?

Back 257

ulcer.

Front 258

What else besides vomiting after binge drinking or a bulimic episode could cause Mallory-Weiss syndrome?

Back 258

CPR
Hiatal Hernia
Abdominal trauma!

(NON-transmural laceration)

Front 259

When Mallory-Weiss syndrome presents with a TRANSMURAL TEAR, what is the new name?

Back 259

BOERHAAVE's syndrome:
complete TRANSMURAL laceration of lower esophagus w/ stomach contents spilling into MEDIASTINUM.
Bleeding caused by forceful vomiting is still the cause.

Front 260

Any disorder that initiates vomiting may result in the development of a Mallory-Weiss tear, which develops as a linear laceration at the gastroesophageal junction because the esophagus and stomach are cylindrical. The cylindrical shape allows longitudinal tears to occur more easily than circumferential tears.

Back 260

These tears have been postulated to occur either by a rapid increase in intragastric pressure and distention, which increases the forceful fluid ejection through the esophagus [medscape]

Front 261

Aside from those patients who present with upper GI bleeding secondary to an alcohol binge, Mallory-Weiss tears occur more commonly in people with ___________________

Back 261

HIATAL HERNIA

[medscape]

Front 262

Although most cases of Mallory-Weiss tears are self-limiting, patients with severe or recurrent episodes of bleeding that require intensive care therapy and interventional endoscopy have been reported. Typically these patients have underlying conditions, including portal hypertension and hepatic insufficiency.

Back 262

Although upper GI bleeding is generally assumed to be secondary to varices in these patients, the physician must also be aware of the potential for Mallory-Weiss tears. [medscape]

Front 263

The major complication of a Mallory-Weiss tear is bleeding.[3] Patients present with variable bleeding, which can range from a few specks or streaks of blood mixed with mucus to copious amounts of fresh red blood. [Loss of blood does what to blood pressure?]

Back 263

In adults, shock occurs in as many as 20% of patients bleeding from Mallory-Weiss tears who present to emergency departments; as many as 45% of patients develop postural hypotension [medscape]

Front 264

A young woman presents w/ HEMATEMESIS, NAUSEA, EPIGASTRIC DISCOMFORT.

What should she be evaluated for and why (3 things):

Back 264

In women of childbearing age, the most common cause of these tears is hyperemesis gravidarum, which usually occurs in the first trimester, causing severe persistent nausea and vomiting. Any adolescent female presenting with a Mallory-Weiss tear should be evaluated for pregnancy, as well as bulimia and anorexia nervosa

Front 265

seen as an air lucency outlining the medial portion of the left hemidiaphragm and the lower lateral mediastinal border

Back 265

V-sign of NACLERIO

*post esophageal puncture. Air dissects behind the heart in Boerhaave's transmural tear 2-3 cm above esophageal sphincter.

Front 266

As many as 50% of patients with ___________ syndrome have a hematocrit value that approaches 50%. This may be due to fluid loss into pleural spaces and tissues

Back 266

Boerhaave's

Front 267

hematemesis, melena, light-headedness, dizziness, syncope, and abdominal pain.

Back 267

Mallory-Weiss syndrome

Front 268

the presenting symptom in all patients diagnosed with a Mallory-Weiss tear

Back 268

HEMATEMESIS

Front 269

D/dx of Mallory-Weiss

Back 269

Gastroenteritis & Peptic Ulcer dz

Front 270

Describe Mallory-Weiss patient

Back 270

40-70 male

*alcoholic 55 year old male; see air on x-ray (do not use barium). CBC will suggest blood loss

Front 271

Mackler's Triangle:
Subcutaneous emphysema
Lower thoracic pain
Vomiting

*all point to:

Back 271

BOERHAAVE's syndrome of transmural laceration due to forceful vomiting. Males 40-70 years old.

Low blood volume/count because all going into mediastinum. Will see V-sign of Naclerio on x-ray.

Front 272

a clinical condition in which there are specific diseases that lead to HYPERMETABOLISM and and INCREASE in THYROID HORMONES

Back 272

THYROTOXICOSIS

*SERUM elevation of thyroid hormones [T3 & T4]. Because commonly d/t HYPERfunction of thyroid gland itself, it is called HYPERTHYROIDISM and SUBACUTE Thyroiditis OR caused by something outside the thyroid= EXTRATHYROIDAL.

Front 273

Most common cause of THYROTOXICOSIS?

Back 273

HYPERTHYROIDISM:

d/t increase in BILE synthesis
d/t increase in release of thyroid HORMONE amounts

Front 274

patient w/ thyrotoxicosis?

Back 274

female 20-40 y.o.

Front 275

Excessive release of pre-formed thyroid hormone

Back 275

SUBACUTE THYROIDITIS

(one form of thyrotoxicosis)

Front 276

What term can be used interchangeably w/ thyrotoxicosis?

Back 276

hyperthyroidism

Front 277

THYROID STORM

Back 277

Thyrotoxic crisis = abrupt onset of SEVERE HYPERthyroidism.
It's untreated thyrotoxicosis where too much thyroid hormone is released [T3 & T4].
Medical emergency. Death from cardiac arrhythmia.

Front 278

What 5 things can cause a THYROID STORM

Back 278

1. Surgery
2. Trauma
3. MI
4. Infection
5. Ingestion of thyroid hormone (taking Mom's thyroid meds)

Front 279

Describe a patient presentation in a thyroid STORM

Back 279

Thyrotoxic crisis: abrupt onset of severe hyPERthyroidism

FEVER, TACHYCARDIA, HEART FAILURE, NEURO + GI ABNORMALITIES = EMERGENCY!

Front 280

Patient presentation HYPERthyroidism

Back 280

Increased symptoms of metabolic activity:
Nervous/anxious/hyperactive
Warm, moist skin and diaphoresis (sweating)
Heat intolerance
*Weight loss despite healthy appetite (^ BMR)
*Fine resting tremor
*Exophthalamos
Fracture b/c TH stimulates bone resorption

Front 281

Physical exam findings HYPERthyroidism:

Back 281

Thyromegaly + Bruit

Vital signs: ^^DTR, LID LAG

atrial fib [elderly] and tachy w/ palpitations

Front 282

Diagnostic imaging for HYPERthyroid

Back 282

nuclear thyroid scyntigraphy

thyroid ultrasound/CT

Front 283

LAB Findings for
PRIMARY HYPERthyroidism *********************************

Back 283

Primary:
INCREASED THYROID HORMONE because coming directly from thyroid = primary

DECREASED TSH because signal BLOCKED by ANTIBODIES on TSH-Receptors. Nothing can tell the TSH receptors to respond.

Thyroid ANTIBODIES [GRAVE'S]

EKG abnormalities

Front 284

MOST COMMON cause of hyperthyroidism

Back 284

GRAVE's disease [PRIMARY hyperthyroidism]

Increased TH [T3 + T4]
but decreased TSH so coming from THYMOMA on thyroid, not on the pituitary gland!

Primary means it's coming from the thyroid directly.

Front 285

When I say HYPERthyroidism, you say

GOITER - EXOPHTHALAMOS - pretibial (notes) or periorbital (lecture) MYXEDEMA

Back 285

GRAVES - a NON-tender, enlarged thyroid gland = GOITER
THYMOMA
PRIMARY
INCREASED TH
Decreased TSH
ANTIBODIES to TSH receptors

Front 286

SECONDARY hyperthyroidism:

Labs?
What is responsible, the pituitary or the thyroid or a tumor elsewhere?

Back 286

Increased TH (T3 & T4)
AND
Increased TSH

so...PITUITARY is responsible

Front 287

Patient presentation in your office of GRAVE's dz w/ most prominent labs?

Back 287

1. Von GRAEFE'S sign: LID LAG

2. DALRYMPLE sign: wide staring gaze

3. Decreased TSH {not coming from pituitary because of TSH receptor antibodies}

4. Increased TH because of GOITER so thyroid itself is cause

Front 288

Radiography and scintigraphy for Graves' dz

Back 288

Diffuse UPTAKE in radioactive iodine

Tracheal air shadow due to substernal goiter on plain film. Order CT.

Front 289

When I say TOXIC MULTINODULAR GOITER, you say

Back 289

PLUMMERS' dz (think of the House episode)

No exophthalmos or myxedema. INCREASED T4 thyroid hormone.
Decreased T3 and TSH

Front 290

Labs for TOXIC MULTINODULAR GOITER

Back 290

INCREASED T4 TH= because the thyroid itself has induced a toxic goiter

Decreased TSH and T3 - what comes from the pituitary is down.

Front 291

Plummer's Disease--also known as "toxic (multi)nodular goiter"--is a condition in which the body produces too much thyroid hormone. The extra node(s) produce excess thyroxine (T-4) and triiodothyronine (T-3). The pituitary gland and hypothalamus controls how many of these hormones are released. T-4 and T-3 control your body's metabolism, temperature, heart rate, and affect the rate of protein production (they're pretty important).

If the body is too low on T-3 and T-4, the hypothalamus will release the thyroid stimulating hormone (TSH). If T-3 and T-4 are too high, TSH levels will taper off. Therefore, House was able to find that Benjamin's TSH levels were lower than normal.

Back 291

Not all nodules (adenomas) produce excess T-4 (thyroxine), but in Benjamin's case, his nodule did, which caused the symptoms he experienced.

Front 292

Let's see. What potential complications could have arisen had Benjamin not been treated? Well, seeing as too much T-4 is responsible for arrhythmias, heart problems would have been highly likely. Too much thyroid hormone affects your body's ability to bind calcium to your bones, and therefore, Benjamin would have had brittle bones.
http://thediaryofapremed.blogspot.com/2011/12/case-1-plummers-disease.html

Back 292

And I think the worst complication would have been thyrotoxic crisis, which is an intensification of symptoms related to hyperthyroidism (and that could lead to mental disorders).

Front 293

House used TSH and radioactive iodine uptake to diagnose Plummer's Disease (radioactive iodine uptake during his CT scan when it was thought he had a neurological disorder).

Back 293

Treatment options: radioactive iodine (supplemented with iodine pills to regulate the body's thyroxine levels), surgery (House's preferred treatment), anti-thyroid medication, beta blockers (won't do much for your thyroid but will reduce the stress on your heart)

History: Plummer's diease is an eponym. It is named after Henry Stanley Plummer, a physician. He was also one of the founders of the prestigious Mayo Clinic. Plummer first described this case of hyperthyroidism in 1913.

Front 294

TOXIC ADENOMA

Back 294

FUNCTIONAL toxic adenoma:

INCREASE T4 only, just like toxic multinodular goiter

SINGLE enlarged node so FUNCTIONAL thyroid

SINGLE area of radioactive iodine uptake on scintigraphy

Front 295

thyrotoxicosis FICTITIA

Back 295

When someone takes thyroid medication to increase BMR/lose weight, they get Thyrotoxicosis FICTITIOUS = a form of exogenous thyrotoxicosis.

Front 296

EXOGENOUS thyrotoxicosis

Back 296

Hyperthyroidism due to increase in exogenous thyroid hormone or iodine

CORDARONE heart med increases iodine uptake

Radiation and imaging can also increase iodine uptake

Increased thyroid medication

Front 297

Primary hyperthyroidism is ________.

Secondary hyperthyroidism is from an ______ source.

Back 297

primary = intrinsic (the thyroid itself)

secondary = outside source such as TSH-secreting pituitary adenoma (rare)

Lab tests will show increased TSH and TH in secondary pituitary adenoma hyperthyroidism

Front 298

What will lab tests show in SECONDARY hyperthyroidism?

Back 298

Increased TSH and TH

*due to a TSH-secreting pituitary adenoma
*secondary

Front 299

SUBACUTE THYROIDITIS is _________________!!!!!!!!

aka:

Back 299

PAINFUL!!!!!!!!!!!!

aka: DeQuervain Thyroiditis

Caused by VIRAL/post viral inflammatory process
UPPER RESPIRATORY inf.

Increased TH (the 'itis' should tell you it's coming directly from the thyroid) and Decreased TSH

Front 300

LYMPHOCYTIC thyroiditis is painless.

Back 300

painless.
middle-aged women
triphasic presentation [hyper>hypo>normal]
Increased TH only.

Front 301

Caused by ANY disorder that prevents delivery of TRH from the hypothalamus to the pituitary

Back 301

TERTIARY (central) hyperthyroidism

Front 302

the most common cause of hypOthyroidism in the United States

Back 302

HASHIMOTO'S THYROIDITIS

Front 303

hypOthyroidism is an under-production of serum ___

Back 303

TH

Females 30-50 y.o.

Front 304

PRIMARY hypOthyroidism is decreased ____

Back 304

TH because it is primarily/directly a problem thyroid.

*Iodine deficiency, thyroidectomy, radioactive iodine therapy, DeQuervain's or post-partum thyroiditis, lithium [bipolar], amidarone [anti-arrhythmic], phenytoin [anti-epileptic], carbamazepine [anti-convulsant, mood stabilizer], and rifampin [antibiotic]

Front 305

SECONDARY hypOthyroidism is decreased ____

Back 305

TSH

*Secondary means coming from a source other than the thyroid, meaning anything that whacks the pituitary and causes it to not produce enough TSH

*Acromegaly, Irradiation, Sheehan's syndrome (post-partum hemorrhage that causes necrosis), pituitary dz, meds (steroids, DA, dobutamine, octreotide). Dobutamine increases cardiac output. Octreotide mimics somatostatin, used to treat severe diarrhea, acromegaly or esophageal varices.

Front 306

Tertiary hypOthyroidism

Back 306

decreased TRH

Hypothalamic destruction after cranial irradiation or surgery stops the TRH from getting to the pituitary

Front 307

hypOthyroidism patient

Back 307

QUEEN ANNE'S SIGN = loss of lateral 1/3 eyebrow
HOARSENESS
DRY, ROUGH, COOL, PALE SKIN
EYE PUFFINESS
COLD INTOLERANCE
Weight gain, lack of sweat, headaches

Front 308

Physical exam findings of hypOthyroid pt

Back 308

PAINLESS, firm goiter w/ NO bruit
*PERIORBITAL edema, blurred vision
*Decreased DTR, especially ACHILLES
Decreased vitals
NON-PITTING PERIPHERAL EDEMA of hands and feet but PITTING edema of lower extremites
Peripheral neuropathy
*if ANEMIC, pale skin, brittle fingernails
**CARPAL TUNNEL SYNDROME (+ Phalen's and thenar atrophy)
Fx from osteoporosis because TH therapy can DECREASE bone density

Front 309

QUEEN ANNE'S SIGN
+
CARPAL TUNNEL

Back 309

=> HASHIMOTO'S <=

hypOthyroidism

Front 310

how can PERNICIOUS ANEMIA lead to gastritis

Back 310

autoimmune destruction of parietal cells
leads to decreased IF and decreased absorption of B12
leads to megaloblastic anemia

Front 311

2 types of gastritis

Back 311

hemorrhagic & erosive
`

Front 312

Patient complaints of gastritis

Back 312

Stabbing pain, cramping
epigastric pain, bloating, discomfort
indigestion
nausea, vomiting, hematemesis

Front 313

Melena

Back 313

black, tarry stools indicates UPPER GI bleed (distal esophagus, stomach, duodenum)

Front 314

Hematochezia

Back 314

bright red blood on stool

*indicates LOWER GI or Rectal bleed (hemorrhoids or diverticulosis)

Front 315

COFFEE-GROUND EMESIS

Back 315

vomiting blood w/ BLACK specks

Indicates a STOMACH bleed (enzymes in stomach darken the blood)

Front 316

The most common cause of gastritis is H. pylori.

Lab tests for H. pylori?
Lab tests for gastritis?
What's the most common reason for anemia/blood loss, accd'ing to Dr. Wells?

Back 316

Urea breath test for H. pylori

Occult blood in stool if gastric bleeding so blood antibody and stool antigen tests.

If patient anemic due to GI bleed (most common reason for anemia), low H&H

Front 317

Most common gastric POLYP

Back 317

HYPERPLASTIC polyp = benign and glandular

Front 318

PEUTZ-JEGHER'S SYNDROME

Back 318

GASTRIC POLYPS
HYPERPIGMENTATION {freckles} around mouth and anus

Polyps may become malignant

Front 319

ADENOMATOUS polyps are

Back 319

malignant

Front 320

Patient hx/complaint of gastric POLYPS

Back 320

small are asymptomatic but large can ulcerate, lead to occult bleeding and anemia

Large antral polyps can cause intermittent gastric obstruction of the gastric outlet and cause pt to vomit/nausea

Early satiety [fullness]
Abdominal distension
Epigastric pain

Front 321

cancer of the stomach

Back 321

gastric ADENOCARCINOMA

males 50-70

Japanese, E. Europeans, Costa Ricans, Chinese

Front 322

Causes of gastric adenocarcinoma include:

Back 322

Peptic Ulcer Disease
Chronic BILE and PANCREATIC reflux
NSAIDS, aspirin, excess alcohol
Smoking, radiation,
Pernicious anemia
**BACTERIAL INFECTION of H. PYLORI can result from anything that lowers stomach acid levels [hypochorhydria]. This produces CARCINOGENIC NITRATES.

Front 323

LINITIS PLASTICA

Back 323

LEATHER BOTTLE STOMACH associated w/ gastric adenocarcinoma

CA infiltrates submucosa and prevents normal distension of stomach

Front 324

Achlorhydria

Hypochlorhydria

Back 324

A - absence of stomach acid
H- lowered stomach acid, due to bacterial infection of H. pylori or antacids or pernicious anemia (low HCl and IF).

Front 325

Risk factors for gastric Adenocarcinoma

Back 325

************H. pylori *********
salted, smoked or pickled foods (nitrates)
Smoking
Poor
Polyps
Family hx of gastric adenocarcinoma
GASTRITIS
OBESITY
radiation therapy
diet low in fruits and veggies
partial gastrectomy

Front 326

In early stages of gastric carcinoma, what often relieves pain?

Back 326

acid-buffering effect of food or antacids

Front 327

Late sx of gastric adenocarcinoma

Back 327

UNINTENTIONAL WEIGHT LOSS
DYSPHAGIA (GERD, decrease in size of lumen as it is occluded by cancer)
POST-PRANDIAL FULLNESS, EARLY SAIETY (b/c stomach doesn't properly distend)
MELENA
Bloating, weakness, fatigue
HEMATEMESIS

Front 328

Physical exam gastric adenocarcinoma [5 signs]

SuVS BooK of gastric cancer

*Can always enter vowels between consonants as a mnemonic trick.

Back 328

SuVS BooK:

SUCCUSION SPLASH: fluid sound when abdomen palpated. Means hollow area due to obstruction.

VIRCHOW'S NODE: sentinal node left supraclavicular node at thoracic duct venous entry via subclavian

SISTER MARY JOSEPH SIGN: nod bulging into umbilicus d/t cancer

BLUMER'S SHELF: mass felt on rectal exam

KRUKENBERG'S TUMOR: 2* ovary malignancy originating from gastro adenocarcinoma mets

Front 329

Imaging results of gastric adenocarcinoma

Back 329

APPLE CORE appearance (like esophageal ca)
Mets show on chest radiograph

Laproscopy is best method to stage tumors

Front 330

Labs for gastric adenocarcinoma

*what's in the stool?
*name 2 tumor markers:

Back 330

GUAIAC (+) stools
CEA & CA tumor markers

Anemia
LFT (liver fcn test) for mets to liver
*CEA=carcinoembyronic antigen
**CA= carbohydrate antigen

Front 331

ZOLLINGER-ELLISON SYNDROME

Back 331

ZE PANCREAS is sick!
Gastrinoma tumor of pancrea
Watery diarrhea and steattohea but NO ulcer.

NON-beta islet cell GASTRIN-secreting tumor of the pancreas

OVERPRODUCTION of gastrin from gastrinoma = OVERPRODUCTION of stomach acid = ulcers of stomach and small intestine

Front 332

Whats the problem w/ Sollinger-Ellison syndrome

Back 332

males 30-60

50% progress to MALIGNANCY

Front 333

Heartburn which mimics GERD
Steatorrhea (increased acid inhibits bile, leading to steatorrhea)
Sx of Peptic ulcer dz
Signs of perforation (+Rosving's, Blumberg's)
GUAIC + stools
anemia

***INCREASED FASTING SERUM GASTRIN******

Back 333

ZOLLINGER-ELLISON syndrome

pancreas gastrinoma (excess prod of gastrin >> excess HCl >>stomach and sm intestine ulcers)`

Front 334

MEN

Back 334

parathyroid tumor
pancreatic islet cell tumor
pituitary adenoma
all causing increased plasma Ca+, PTH and prolactin
and ZOLLINGER-ELLISON syndrome`

Front 335

an ulcer arising from the lining of the GI tract

Back 335

PEPTIC ulcer

various locations: GASTRIC & DUODENAL w/ esophageal least common

Front 336

Causes of PEPTIC ulcer

Back 336

Cocaine, smoking, alcohol, caffeine

H. pylori infection

NSAID regular use, glucocorticoids

Family hx, antacids, anti-coagulants

Gastrinoma

Front 337

PEPTIC ulcer may cause air w/in the peritoneum, called a

Back 337

PNEUMOPERITONEUM
commonly caused by perforated ulcer

*signs of peptic ulcer include anemia, tenderness and perforation

Front 338

Imaging a PEPTIC ulcer

Back 338

upper GI Barium study [UGI}
and endoscopy

Front 339

2 best tests for PEPTIC ulcers:

Back 339

1. UREA BREATH TEST - pts swallow urea w/ a carbon marker. CO2 exhale containing UREASE means H. pylori is present in stomach, since the bacteria uses the enzyme urease to metabolize urea. Means they are there and they are busy as hell.
2. UREASE TESTE - urease made by H. pylorE RAISES pH of stomach and changes colour when Exposed to a DYE

Other tests: guaiac + stool, CBC, stool antigen test HpSA, antibody test, biopsy

Front 340

GASTRIC ulcer

Back 340

elderly men
Cause is most commonly H.PYLORI
but chronic use of NSAIDS, alcohol and smoking counts (make pain worse, too).

****Intermittent, recurrent PAIN 30min -1.5 hr AFTER eating*****
Weight loss
Hematemesis
MELENA (Upper GI blood)
syncope

Front 341

DUODENAL ulcer

Back 341

males 20-60
most common cause is H. PYLORI

****Onset 2-3 HOURS after eating****
*Pain WORSE AT NIGHT
*Pain RADIATES TO BACK
*Pain RELIEVED w/ FOOD or antacids

****CLOVER LEAF = scarring pulls lumen into a clover pattern

Front 342

How can a DUODENAL ulcer lead to NAUSEA?

Back 342

Scarring over (clover leaf) can lead to obstruction and cause nausea.

Front 343

cholelithiasis

Back 343

gall STONES:
1. can be cholesterol (80%)
2. pigmented Ca+ bilirubinate
3. Both

Cholesterol = ULTRASOUND or CONTRAST study as FILLING DEFECTS.

Pigmented = PLAIN FILM

Front 344

How will cholesterol stones in gall bladder CHOLELITHIASIS be seen on plain film?

Back 344

They are NOT seen on plain film.

They ARE seen on ULTRASOUND or CONTRAST STUDY as FILLING DEFECTS.

Front 345

Gallstones usually block the ________, due to its twisted course.

Back 345

cystic duct

Front 346

Inflammation of the BILE DUCT itself.

Back 346

CHOL-ANGITIS

*Most commonly from H. Pylori bacterial infection

*"ANG" for duct like artery, angio

Front 347

Inflammation of the GALL BLADDER

Back 347

CHOLE-CYSTITIS

Front 348

GALLSTONES in the COMMON bile duct

Back 348

CHOLE-DOCHO-LITHIASIS

*leads to cholangitis (inflammation of gall bladder)

Front 349

a change in the gallbladder WALL due to excess cholesterol/cholesterol stones.

Back 349

CHOLESTERO-LOSIS

"LOSe the WALL"

Front 350

autoimmune dz of LIVER marked by slow, progressive destruction of small BILE DUCTS in the liver

Back 350

BILIARY CIRRHOSIS

Duct damage = bile buildup in liver. Scarring, fibrosis, cirrhosis, liver failure.

Front 351

IMPACTION of a gallstone in the ILEUM after being passed through a BILIARY-ENTERIC FISTULA

Back 351

GALLSTONE ILEUS

"ILEUS for ILEUM"

Front 352

CALCIFICATION of wall of gallbladder

Back 352

PORCELAIN GALL BLADDER

Front 353

calcification of the wall of the bladder is called PORCELAIN gall bladder. What can it lead to?

Back 353

carcinoma

(the gallbladder has become irritated w. the collection of stones)

Front 354

patient experiences same or worse sx AFTER GALL BLADDER REMOVED

Back 354

POST-choleycystectomy syndrome

Front 355

Gimme the 5 F's of gall stones

Back 355

Fat
Female
Fair
Forties
Fertile

Front 356

Describe gall bladder PAIN

Back 356

SUDDEN pain upon eating (w/in 30 min of a FATTY meal) in RUQ

May RADIATE around to INFERIOR ANGLE of RIGHT scapula

RIGHT SHOULDER pain
Intolerance to fatty or greasy food

Front 357

Physical findings during exam for gall bladder

Back 357

MURPHY'S SIGN: liver palpation. Ask patient to exhale, palpate liver. If pt cannot inhale or stops breathing due to pain, test is POSITIVE

Guarding on palpation

Front 358

CHOLESCINTIGRAPHY

Back 358

HIDA; hydroxyiminodacetic acid skan for gall bladder and ducts in and out of it.
Used if suspected gall stone in CYSTIC DUCT

Front 359

gallbladder labs

Back 359

C-reactive protein ELEVATED

Alk phos, bilirubin, WBC possible elevated

Front 360

PANCREATITIS

35-60 y.o.

Back 360

INFLAMMATION of pancreas
swelling of gland and surrounding blood vessels
bleeding, infection and damage

Pancreas may AUTODIGEST due to trapped digestive juices

Front 361

2 causes pancreatitis

Back 361

1. GALL STONES
2. ALCOHOL ABUSE

could be post surgical (post ERCP)

Front 362

Is pancreatitis irreversible?

Back 362

Only if acute turns to chronic and scarring damages normal fcn

Front 363

Chronic pancreatitis >> abcess >>>__________

Back 363

abscess >> pseudocyst of amylase, etc, blood and necrotic tissue

Front 364

PANCREATITIS pt complaint

Back 364

sudden or gradual EPIGASTRIC pain that RADIATES TO BACK straight through

Nausea, vomiting, fever
flatulence, steatorrhea, bloating, weight loss
Can't digest fatty foods

Front 365

PROVOCATIVE pancreatitis

Back 365

SUPINE position, FATTY meals, ALCOHOL ingestion

Front 366

PALLIATIVE pancreatitis

Back 366

SITTING, LEANING SLIGHTLY FORWARD
FETAL POSITION

Front 367

Vitamin lost in pancreatitis

Back 367

B12

decrease in protease release so B12 cannot be properly cleaved to bind to Intrinsic Factor

Front 368

TWO signs of PANCREATITIS

{Grey Water filter}

Back 368

1. CULLEN'S SIGN: bruising around ***umbilicus** (retroperitoneal bleed)
2. GREY-TURNER'S SIGN; ***flank*** bruising (retroperitoneal bleed)

Front 369

X-ray PANCREATITIS sign

{backwards letter}

Back 369

REVERSE 'C'

pattern of barium study showing enlarged pancreas pushing into sm. intestine

Front 370

pancreatitis labs

Back 370

***elevated PANCREATIC ENZYMES (amylase and lipase)

CBC, blood glucose, LFT, RFT
Electrolytes

Front 371

ADENOCARCINOMA of the pancreas most commonly comes from the __________ pancreas.

Back 371

EXOCRINE

One of most aggressive cancers known. Patrick Swayze last year.
By the time it's diagnosed, it's metastasized to lungs, liver, lymph.

Front 372

Cancer of the HEAD OF THE PANCREAS shows more sx because

Back 372

the DUCT is OBSTRUCTED.

Front 373

3 stages of pancreatic adenocarcinoma

Back 373

LOCALIZED to pancreas only
LOCALLY ADVANCED to nearby blood vessels or organs
METASTATIC spread

Front 374

Risk factors for pancreatic adenocarcinoma (unless you are Patrick Swayze)

Back 374

Black
Smoker
Fat
Hx of pancreatic in family
Diet high in meat and fats
H. pylori infection

Front 375

ERCP

Back 375

Endoscopic Retrograde Cold Pancreatogram surgical procedure that predisposes people to pancreatitis

Front 376

Pancreatitis ultimate sign

Back 376

 sudden or gradual epigastric pain which radiates to the back, lasting hours to days

Front 377

One thing that makes pancreatitis better physically

Back 377

sitting and leaning slightly forward, supine

Front 378

 signs of DM
 B12 deficiency
 Cullen’s sign
Grey-Turner’s sign

Back 378

PANCREATITIS

Front 379

(KUB) Kidney-Ureter-Bladder plain film of abdomen

Back 379

PANCREATITIS:
barium study shows “reverse C” pattern where the enlarged pancreas pushes into the small intestine

Front 380

A CT scan for PANCREATITIS shows areas of diffuse enlargement of pancreas and ____________ w/ ill defined, fuzzy margins. On plain film, you see _________

Back 380

CALCIFICATIONS = PANCREATITIS

Front 381

large cyst in pancreas found when pancreatitis exists

Back 381

PANCREATIC PSEUDOCYST large cyst in pancreas, c/o steatorrhea

Front 382

Labs for PANCREATITIS

Back 382

Lab Findings
  pancreatic enzymes (amylase and lipase)
 *******CBC/blood glucose/LiverFunctionTest/RenalFunctionTest*******
 electrolytes

Front 383

What glands of pancreas cause most common type of pancreas cancer?

Back 383

 the most common type of pancreatic cancer arises from the EXOCRINE glands pancreas. Adenocarcinoma of head of pancreas FROM PANCREATITIS– adenocarcinoma of the pancreas

Front 384

Why does pt w/ pancreatic cancer have JAUNDICE?

Back 384

Duct blocked.

Front 385

#1 risk for PANCREATIC CANCER

Back 385

*********** smoking**************
 advancing age
 M>F
 chronic pancreatitis
 diabetes
 family hx of pancreatic cancer
 African American
 obesity
 occupational exposures – dyes, chemical gases, pesticides
 diet high in meat and fats
 H. pylori infection

Front 386

COURVOSIER SIGN

Back 386

Courvoisier sign – non-tender, enlarged gall bladder with associated jaundice PANCREATIC CANCER

Front 387

Why isn't jaundice likely to be from gall stones but from pancreatic cancer instead?

Back 387

Jaundice unlikely to be caused by gall stones. This is because gall stones are formed over a longer period of time, and this results in a shrunken, fibrotic gall bladder which does not distend easily. Therefore the gall bladder is more often enlarged in pathologies that cause obstruction of the biliary tree over a shorter period of time such as pancreatic malignancy.

Front 388

non-tender, enlarged gall bladder w/ jaundice

Back 388

Courvosier's sign of pancreatic cancer

Front 389

Lab findings for pancreatic cancer:
Name the functional test that comes back abnormal because of BILE OBSTRUCTION?
What is the TUMOR MARKER?

Back 389

 liver function test (LFT) abnormal with bile obstruction

 tumor marker CA 19.9

Front 390

When are pancreatic enzymes elevated?

Back 390

During PANCREATITIS, not pancreatic cancer

Front 391

If OBSTRUCTIVE JAUNDICE, what labs are elevated? [5]

Back 391

BILIRUBIN (conjugated and total)
alkaline phosphatase (ALP)
glutamyl transpeptidase (GGT)
aspartate aminotransferase (AST)
alanine aminotransferase (ALT)

Front 392

Do liver mets cause jaundice?

Back 392

Rarely.

Front 393

CIRRHOSIS

Back 393

a result of CHRONIC LIVER DZ characterized by replacement of liver tissue by FIBROTIC scar tissue and regenerative NODULES, leading to progressive loss of liver function

Front 394

FIBROTIC SCAR TISSUE
REGENERATIVE NODULES

Back 394

CIRRHOSIS

Front 395

2 common causes of C-IRRHOSIS:

Back 395

1. HEPATITIS-C

2. C-HRONIC ALCOHOLISM

Front 396

Besides the major 2 causes of Cirrhosis of the liver (Hep C and Alcohol), name a few others:

Back 396

BILIARY cirrhosis (autoimmune), primary sclerosing CHOLANGITIS (autoimmune inflammation of the bile ducts), autoimmune hepatitis, non-alcoholic FATTY Liver, inherited diseases (hemochromatosis – iron, WILSON'S disease – copper, cystic FIBROSIS– scar tissue), medications (chronic ACETAMINOPHEN), toxins, infections, cardiac disease=RSHF!

Front 397

Patient hx/ complaint of CIRRHOSIS

Back 397

*****ASCITES*****

 cognitive changes (hepatic encephalopathy
 jaundice/ pruritis
 abdominal pain
 sensitivity to medication
 shortness of breath (SOB)
 palmar erythema – palms flush red & blanch (due to  estrogen)
*the impairment of hormone production and metabolism

Front 398

PALMS FLUSH RED & BLANCH due to estrogen

Back 398

 PALMER ERYTHEMA: palms flush red & blanch (due to  estrogen)

= CIRRHOSIS

Front 399

SPIDER ANGIOMA

Back 399

spider angiomata (people who have significant hepatic disease show many spider angiomas, as they are not making sufficient of coagulation factors abnormal estrogen production.) = CIRRHOSIS

Front 400

CAPUT MEDUSAE

Back 400

 caput medusa - the appearance of distended and engorged umbilical veins which are seen radiating from the umbilicus across the abdomen to join systemic veins) = CIRRHOSIS

Front 401

ascites know 4 changes
Terry’s Nails
caput medusa
spider angiomata
palmar erythema

Back 401

CIRRHOSIS:
ascites
Terry’s Nails
caput medusa
spider angiomata
palmar erythema

Front 402

NAFLD

NASH

Back 402

NAFLD Non Alcoholic Fattly Liver Disease
NASH Non Alcoholic Steato Hepatitis

Front 403

labs for cirrhosis that look like everything else

Back 403

INCREASED bilirubin, ALT, AST, ALP, PTT

All the PENIA's: thrombo, leuko, neutro

l

Front 404

Labs for CIRRHOSIS

Back 404

Lab Findings
 unremarkable
  bilirubin, AST, ALT, ALP, PTT, globulins, serum Na
 thrombocytopenia
 leukopenia
 neutropenia
 hepatitis C antibody
 viral RNA
 EIA-2 enzyme immunoassay (ELISA)

Front 405

LACTOSE INTOLERANCE

Back 405

the inability to digest lactose due to  levels of lactase, found in the brush border of the duodenum
 as a result, lactose ferments in the intestines

Front 406

Where is lactose intolerance found?

Back 406

DUODENUM BRUSH BORDER

Front 407

What type of LACTOSE INTOLERANCE can be TREATED?

Back 407

SECONDARY/ACQUIRED! – occurs due to intestinal damage from disease such as celiac sprue, Whipple’s, Crohn’s, gastrinoma, chemo, radiation enteritis or diabetic gastropathy.
*This type can be treated

Front 408

4 lactose intolerance tests:

Lmsh

Back 408

 lactose tolerance test
 milk tolerance test
 stool acidity test
 hydrogen breath test (used as a clinical medical diagnosis for people with irritable bowel syndrome, and common food intolerances.)

Front 409

What is the HYDROGEN BREATH TEST used for?

Back 409

hydrogen breath test (used as a clinical medical diagnosis for people with irritable bowel syndrome, and common food intolerances like LACTOSE INTOLERANCE)

Front 410

CELIAC SPRUE definition

Back 410

chronic, autoimmune, GLUTEN-sensitive enteropathy resulting in maldigestion
 causes is a genetic predisposition GLIADIN of wheat, barley, rye

Front 411

GLUTEN & GLIADIN
Sawtooth
Chvostek
Trousseau
Dermatitis herpetiformis

Back 411

Celiac sprue

Front 412

CELIAC SPRUE buzzwords

Back 412

GLUTEN & GLIADIN
Sawtooth
Chvostek
Trousseau
Dermatitis herpetiformis

Front 413

Describe CELIAC SPRUE

Back 413

GENETIC predisposition to GLUTEN sensitivity. GLIADIN (Gliadin is a glycoprotein present in wheat and several other cereals) sensitivity. Barley, wheat, rye.
Almost TOTAL ABSENCE OF VILLI in bowel and disordered blood supply

Front 414

What causes MALABSORPTION of celiac sprue

Back 414

THICKENED BORDER of intestines w/ MISSING VILLI =

sawtooth sawtooth sawtooth sawtooth pattern of mucosa w/ increase in lymphocytes sawtooth sawtooth sprue sawtooth sprue

Front 415

symptoms of vitamin deficiencies
 stunted growth in children
paresthesias of lips, hands, fingers, feet, tongue
 hyperreflexia

Back 415

Celiac sprue odd presentations (usual are abdominal bloating, steatorrhea, vomiting, diarrhea, weight loss)

Front 416

 signs of nutrient deficiency – CELIAC SPRUE

Back 416

glossitis, angular cheilitis, gingivitis, periorbital hyperpigmentation

Front 417

CHVOSTEK SIGN for celiac sprue due to nutrient deficiency.

Which nutrient? What does this cause?

Back 417

celiac sprue: \
Chvostek sign - When the facial nerve is tapped at the angle of the jaw, the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of HYPOCALCEMIA and hyperexcitability of nerves.

Front 418

TROUSSEAU SIGN for celiac sprue:

Due to what nutrient deficiency?
Aka: _________ Hand.

Back 418

celiac sprue:
Trousseau sign – To perform the maneuver, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. If carpal spasm occurs, manifested as flexion at the wrist and metacarpophalangeal joints, extension of the distal interphalangeal and proximal interphalangeal joints, and adduction of the thumb and fingers, the sign is said to be positive and the patient likely has hypocalcemia. OBSTETRIC hand.

Front 419

DERMATITIS HERPETIFORMIS

Back 419

celiac sprue:
dermatitis herpetiformis – a chronic itchy rash of papules and vesicles associated with Celiac Sprue

Front 420

Chovstek
Trousseau
Herpetiformis

Back 420

Celiac Sprue

Hypocalcemia and signs of anemia (B12, IDA, folic acid crashed)

Front 421

Lab findings for CELIAC SPRUE

Back 421

1. Electrolyte >< hypoK+alemia, hypoNa+tremia
2. HypO: albumin, protein & cholesterol
3. Anemia
4. coagulation
5. Renal and Liver fcn
6. Glucose Tolerance Test - down
7. Stool specimen - steatorrhea
8. see slide for ANTIBODY tests to actually know.

Front 422

Name the 3 ANTIBODY tests for celiac sprue:
Which one is most specific?

Back 422

8. PAY ATTENTION:
IgA anti-ENDOMYSIAL Ab {96-100% specific for celiac}

IgA anti-TRANSAMINASE Ab [90% specificity]
IgA anti-GLIADIN Ab (65-100% specificity)

Front 423

WHIPPLE'S DZ

Caused by? (BACTERIA)
Primarily affects? (2)

Back 423

a systemic infections disease caused by infiltration of tissues by Tropheryma Whipplei bacteria, primarily affecting the SMALL INTESTINES & JOINTS

Front 424

Patient complaint for WHIPPLE'S DZ

Back 424

Distention of the SMALL INTESTINES

Symptoms of MALABSORPTION
Abdominal pain, diarrhea, fever

Front 425

CHVOSTEK and TROUSSEAU signs are present for what 2 disorders?

Back 425

CELIAC SPRUE
&
WHIPPLE'S DISEASE

Front 426

To distinguish WHIPPLE's from CELIAC SPRUE, test for

Back 426

T. WHIPPLEI

Tropheryma Whipplei bacteria affecting small intestine and joints

Front 427

What are the usual nutrient deficiencies of TROPICAL SPRUE

Back 427

FOLIC ACID
B12
IRON

Front 428

TROPICAL SPRUE can be bacterial, viral or parasitic. What part of the body does it affect? What does it do to it?

Back 428

Small intestine
thick and flat border of small intestine

Front 429

TROPICAL SPRUE is a syndrome characterized by

Back 429

acute or chronic DIARRHEA
WEIGHT LOSS
MALABSORPTION of at least 2 different substances when other causes are excluded

Front 430

PAIN 15 min after eating because NOT ENOUGH BLOOD to meet visceral demands

Back 430

ABDOMINAL ANGINA

aka: "Bowelgina"

Front 431

Why do mainly older people suffer from ABDOMINAL ANGINA (bowelgina)?

Back 431

****atherosclerosis****

caused by atherosclerosis of celiac, superior or inferior mesenteric arteries

Front 432

Postprandial Angina
bowelgina
atherosclerotic vascular disease

Back 432

ABDOMINAL ANGINA

Front 433

abdominal angina buzzwords (3)

Back 433

Postprandial Angina
bowelgina
atherosclerotic vascular disease

Front 434

diagnostic tests for ABDOMINAL ANGINA

Back 434

 AORTOGRAPHY!
 MRI
 duplex US – visualizes blood flow

Front 435

AUTONOMIC NEUROPATHY

Back 435

 damage to NERVES affecting the GI tract leads to  ability to move food during digestions and symptoms of diarrhea/constipation, nausea/vomiting, bloating and pain

Front 436

 damage to NERVES affecting the GI tract leads to  ability to move food during digestions and symptoms of diarrhea/constipation, nausea/vomiting, bloating and pain

Back 436

autonomic neuropathy

Front 437

ACUTE APPENDICITIS

Back 437

inflammation of the appendix in patient 10-30 yoa

Front 438

How should the appendix normally appear?

Back 438

the appendix should normally appear lily white

Front 439

Symptoms of appendicitis

Back 439

vague peri-umbilical pain localizing to the RLQ within24 hours
 loss of appetite
 low grade fever (becomes high with peritonitis)
 nausea/vomiting
 temporary relief from pain if the appendix ruptures

Front 440

most common COMPLICATIONs of acute appendicitis

*P.A.P.

Back 440

PERFORATION
ABCESS
PERITONITIS

Front 441

Physical exam ACUTE APPENDICTIS

Back 441

RLQ pain at MCBURNEY'S POINT
DUNPHY'S SIGN - increased pain w/ coughing
OBTURATOR SIGN - pain on extension of R thigh (appendix is retroperitoneal or retrocaecal)
PSOAS SIGN - pain on internal rotation of R thigh (if appendix is pelvic)
JAR/ANVIL test
no bowel sounds if obstructed

Front 442

Psoas test vs. Obturator test for acute appendix

Back 442

P for Psoas & Pelvic (internal rotation)

Obturator is extension

Both pain on R side

Front 443

Diagnostic imaging for ACUTE APPENDICITIS

Back 443

US/CT/KUB/radionucleide scanning - attaches to WBC and shows inflammation