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119 Cards in this Set
- Front
- Back
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Nervous system inputs in GI system
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Enteric nervous system - Myenteric (auerbach) plexus controls muscle motility, submucosal (meissner's) plexus controls secretions and receives input from receptors
PNS - Ach and GRP (to G cells) mediated to excite GI. Vagus till left colic flexure, Pelvic nerve below SNS - inhibitory, fibers from t8-L2, prevertebral ganglia synapse and postganglionics go to plexuses and directly to some blood vessels/smooth muscle |
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Gastrin Secretion, Stimuli, Inhibition, Action
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True GI hormone, homology with 5 a.a. C terminus with CCK
Secretion - G cells in antrum of stomach Stimuli - Distension, Vagal GRP, Protein (Trp and Phe) Inhibition - Somatostatin, pH < 1.5 Action - Parietal HCl release (Gq via CCKb R), growth of stomach mucosa Elevated in Zollinger Ellison, chronic PPI |
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CCK Secretion, Stimuli, Inhibition, Action
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True GI hormone, homology with 5 a.a. C terminus with Gastrin
Secretion - I cells of duodenum and jejunum Stimuli - Fats and amino acids Inhibition - Somatostatin Action - Pancreatic enzymes, gallbladder contraction, sphincter of Oddi relax, exocrine pancrease growth, inhibits gastric emtpy (all Gq mechanisms) |
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Secretin Secretion, Stimuli, Inhibition, Action
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True GI hormone, glucagon family
Secretion - S cells duodenum and jejunum Stimuli - H+ in duodenum, Fats Inhibition - Somatostatin Action - Pancreas HCO3- secretion (Gs), reduce gastric H+ secretion |
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GIP Secretion, Stimuli, Inhibition, Action
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Glucose-dependent insulinotropic peptide; glucagon family
Secretion - K cells Duodenum and jejunum Stimuli - ORAL GLUCOSE, fats, amino acids (all 3); Inhibition - Action - Insulin secretion from endocrine pancreas at greater levels than IV sugar, reduce H+ gastric secretion Aka Gastric inhibitory peptide |
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Histamine Secretion, Stimuli, Inhibition, Action
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Paracrine GI hormone
Secretion - ECL/mast cells of stomach Stimuli - Inhibition - Action - H2 Gs action on parietal cells |
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Somatostatin Secretion, Stimuli, Inhibition, Action
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Paracrine hormone
Secretion - D Cells of GI tract Stimuli - H+ in lumen Inhibition - PNS vagal stimulation inhibits Action - Inhibits all GI hormonal release, antigrowth hormone |
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Neurocrines in GI tract
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VIP - homologous to secretin, neurons and smooth muscle release. Relaxes GI muscle and lower esophageal sphincter. Stimulates HCO3- pancreas secretion and inhibits H+ gastric secretion (SECRETIN LIKE)
GRP (bombesin) - Vagal stimulation on G cells to release gastrin Enkephalins - nerves and smooth muscle make to stimulate GI smooth muscle contraction especially sphincters (LES, pyloric and ileocecal), inhibit fluid and electrolyte secretion (OPIATES basis to treat diarrhea) |
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Striated muscle regions in GI tract
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Pharynx
Upper 1/3 esophagus External anal sphincter |
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Slow waves
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Interstitial cells of Cajal set pacemaker of oscillating membrane potentials (NOT APs; increases probability). Ca++ channel opening and then K+ channel opening
Slowest in stomach (3/min) and fastest in duodenum (12/min) Motilin mediates migrating myeoelectric complexes independent of slow waves every 90 minutes to clear debris in tract |
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Nerves for swallowing
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Medulla coordinates
Vagus - X Glossopharyngeal - IX |
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Stomach regions and cell types
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Orad - fundus and proximal body - parietal cells and chief cells
Caudad - antrum and distal body - G cells, mucous glands |
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What participates in receptive relaxation
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Vasovagal reflex (lost in vagotomy)
CCK Relax in orad stomach |
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What slows gastric emptying
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Anything not isotonic
Fats - via CCK H+ in duodenum - via PNS and enteric reflexes |
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Reflexes
a) Gastroileal b) Gastrocolic c) Rectosphincteric |
a) Gastroileal - PNS mediated, food in stomach triggers peristalsis in ileum and ileocecal sphincter relaxation
b) Gastrocolic - Rapid PNS mediated, also slow CCK and gastrin. Food in stomach leads to more mass movements c) Rectosphincteric - Rectum fills, internal anal sphincter relaxes |
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Where is most water absorbed
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Proximal colon
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Vomiting control centers
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Medulla (area postrema) - stimulated by tickling the back of throat, gastric distension and vestibular (motion sick)
Chemoreceptor triggers - in 4th ventricle adjacent to area postrema, due to emetics, radiation and vestibular stimulation |
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Saliva composition, Inhibitors, Nerves
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Normally hypotonic. High K+ and HCO3- concentration compared to plasma (low Na+ and Cl+). High speed similar to plasma except more HCO3-
Aldosterone increases Na+ reabsorption and K+ wasting Nerves - Facial (VII) and glossopharyngeal (IX) Inhibitors - Atropine, Dehydration, Sleep Activated by both PNS (Gq) and SNS (Gs) |
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Pancreatic secretion composition
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ISOTONIC
Similar Na+ and K+ to plasma HIGH HCO3- (exchanged for Cl-) More permeable to water than salivary glands |
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Metabolic effect of vomiting
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Stomach makes H+ using carbonic anhydrase and HCO3- is basolaterally exchanged fro Cl-
H+/K+ Pump at surface excretes, Cl- follows. In vomiting, no H+ to duodenum, no secretin and get HIGH blood HCO3- METABOLIC ALKALOSIS |
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Parietal cell inputs
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Vagus direct (Atropine inhibits) - M3 - Gq
Gastrin (vagus indirect via GRP, G cells) - CCKb - Gq Histamine (H2 blockers inhibit) - H2 - Gs Prostaglandins (NSAIDs inhibit) - Gi Somatostatin - Gi Potentiation occurs with any overlaps |
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Causes of Peptic ulcer disease
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Caused by loss of mucous barrier or excess H+ and pepsin
Ex Gastrinoma (higher H+), H. pylori (kills mucosa, Ioss of mucous barrier, alkalinizes LOCAL part), NSAIDs, stress, smoking, alcohol (loss of mucous barrier) Duodenal ulcers - |
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H. pylori pathogenicity
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Damages local mucosa, creates local alkaline environment to survive, inhibits somatostatin so overall H+ increased, inhibits HCO3- secretion so duodenal ulcers
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Bile formation, function
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Formed in liver from cholesterol (primary), in intestines bacteria convert to secondary bile acids, then later conjugated with glycine or taurine to form bile salts
Cholesterol 7a-hydroxylase is rate limiting step Functions - digest and absorb lipids, cholesterol excretion (ONLY way), antimicrobial via membrane disruption |
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Digestion and absorption of
a) Bile salts b) Carbs c) Protein d) Fats |
a) Bile salts - terminal ileum Na+/bile cotransport
b) Carbs - broken down to monosaccharides, Na+ cotransport for galactose and glucose. Facilitated diffusion for fructose via GLUT5 c) Protein - amino acids Na+ cotransports (neutral, basic, acidic, imino, di and tripeptides are H+ cotransport d) Fats - emulsified into micelles using bile salts, diffuse across membrane, broken down and repackaged as TG's to send in chylomicrons. Glycerol is H20 soluble and not in micelles Basically everything is Na+ cotransport except fructose (facilitated diffusion), Fats (micelles), and di and tripeptides (H+ cotransport) |
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Steatorrhea causes
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Pancreatic disease - CF, pancreatitis, can't make enzyme
Gastrin hypersecretion - inactivates lipase Ileal resection - low bile acids Bacterial overgrowth - mess up bile Decreased intestinal cells - tropical sprue Failure to synthesize apoprotein B - can make chylomicrons |
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Na+ transport along tract
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Used to reabsorb things
Small intestine - cotransports most impt Large intestine - diffusion via channels most impt, stimulated by aldosterone |
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Diarrhea metabolic effect
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K+ secretion in colon increased due to flow rate, hypokalemia and metabolic ACIDOSIS result
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Bilirubin metabolism
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Hgb degraded to bilirubin, taken to liver with albumin. Conjugated with glucuronic acid via UDP glucuronyl transferase
Conjugated bilirubin goes to bile or urine. Bile part is converted to urobilinogen which returns to liver or urobilin and stercobilin (excreted) |
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Embryology: Foregut, Midgut, Hindgut derivatives
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Foregut - pharynx to duodenum. Celiac trunk. Vagus n.
Midgut - duodenum to transverse colon. SMA. Vagus n. Herniates week 6, returns and rotates week 10 Hind gut - distal transverse colon to rectum. IMA. Pelvic n. |
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Embryology: Failure of fold closure in anterior abdominal wall
a) Rostral fold b) Lateral fold c) Caudal fold |
a) Rostral fold - sternal defect
b) Lateral fold - omphaocele (herniate into umbilical cord, covered) or gastroschisis (through folds, not covered by peritoneum) c) Caudal fold - bladder exstrophy |
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Apple peel atresia
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Vascular accident, jejunal, ileal, colonic atresia
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Trachoesophageal fistulas and esophageal atresia vs Congenital pyloric stenosis
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TEF & EA - Can be pure atresia, pure TEF (H type) or EA with TEF (most common)
Vomit on FIRST feed Can't pass NG tube, Air on CXR unless pure EA Congenital pyloric stenosis - Pyloris hypertrophy, palpable mass NON-bilious projectile vomit at 2 weeks |
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Pancreas and Spleen embryology
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Pancreas -
a) ventral bud - ucinate, head and main pancreatic duct, rotates around duodenum to join b) dorsal bud - rest of pancreas, accessory duct (f there) Annular pancreas if ventral bud encircles (narrowing) or Pancreas divisum if don't fuse Spleen - mesentery of stomach origin but supplied by celiac artery in foregut |
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Retroperitoneal structures
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SAD PUCKER
Suprarenal glands Aorta and IVC Duodenum (2nd and 3rd parts) Pancreas - all but tail Ureters Colon - ascending and descending Kidneys Esophagus - lower 2/3 Rectum - lower 2/3 |
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Portal triad
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Proper hepatic artery
Common bile duct Portal vein Located within Hepatoduodenal ligament which connects greater and lesser sacs |
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Falciform ligament
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Liver to abdominal wall, remnants of fetal umbilical vein in ligamentum teres
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Contents of
a) Gastrohepatic lig. b) Gastrosplenic lig c) Splenorenal lig. |
a) Gastrohepatic lig. - Gastric arteries along lesser curve, cut to access lesser sac during surgery
b) Gastrosplenic lig - Short gastrics, left gastrooepiploics along greater curve c) Splenorenal lig. - Splenic artery and vein, TAIL of pancreas |
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Layers of mucosal gut wall; Ulcer vs Erosion
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MSMS
Mucosa - with epithelium, lamina propria, muscularis mucosa Submucosa - with Submucosal plexus Muscualris externa - myenteric plexus Serosa if intraperitoneal or adventitia if retroperitoneal. Erosion LIMITED to mucosa, ulcer if deeper |
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Histology differences
a) Esophagus b) Duodenum c) Jejunum d) Ileum e) Colon |
a) Esophagus - nonkeratinized strat squamous
b) Duodenum - villi and microvilli, Brunner's glands and crypts c) Jejunum - Plicae circulares and crypts d) Ileum - Peyer's patches, plicae circularies at start, crypts e) Colon - Crypts, NO vili, MANY goblet cells |
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Artery branch points from aorta
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T12 - Celiac trunk - foregut, liver, gallbladder, pancreas, spleen.
Gives off common hepatic (proper hepatic and gastroduodenal splits), splenic (short gastrics and left gastroepiploic), and Left gastric arteries L1 - Renal arteries, SMA L3 - IMA L4 - Bifurcation L & R gastrics and L&R gastroepiploic anastamose |
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Collateral circulations for abdominal aorta blocks
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Superior epigastric to inferior epigastric
Superior pancreaticoduodenal to inferior pancreaticoduodenal Middle colic to left colic Superior rectal to middle and inferior rectal |
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Portosystemic anastamoses, relieving pressure
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Left gastric to esophageal - esophageal varices
Paraumbilical to superior or inferior epigastrics - caput medusae Superior rectal to inferior and middle rectal - int. hemorrhoids TIPS connecting portal vein to systemic vein relieves |
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Pectinate line
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Line where endodermal (columnar) tissue meets ectoderm (squamous)
Above - int. hemorrhoids (no pain), superior rectal artery, portal system drainage via superior rectal vein. Deep lymphatics Below - ext. hemorrhoids (pain), inferior rectal artery (from int. pudendal a.), Venous drainage to inferior rectal vein eventually to IVC. Superficial inguinal nodes |
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Liver zones and injury types
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Apical surface to bile caniculi
Basolateral faces sinusoids Zone 1 - periportal - VIRAL HEPATITIS first Zone 2 - intermediate Zone 3 - ischemia, toxic injury, alcoholic hepatitis first. P-450 enzymes and least oxygen Blood to center, bile away |
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Femoral triangle contents and sheath
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NAVEL lateral to medial
Nerve, artery, vein, empty, lymphatics Nerve DOES NOT go in sheath with others |
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Inguinal canal; spermatic cord layers and passage
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Deep inguinal ring in transversus abdominus; superficial ring in inguinal ligament
External spermatic fascia from external oblique Cremaster muscle from internal oblique Internal spermatic fascia from transversalis fascia |
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Hernia types
a) Diaphragmatic b) Indirect inguinal c) Direct inguinal d) Femoral |
a) Diaphragmatic - Abdominal to thorax. Sliding hiatal hernia most common (hourglass stomach), or paraesophageal hernia with fundus hernia.
b) Indirect inguinal - deep ring, lateral to inferior epigastric artery, children, failure of processus vaginalis to close, males c) Direct inguinal - through Hesselbach's triangle and abdominal wall, medial to inferior epigastrics, old men d) Femoral - In femoral hernia medial to vessels, women, bowel incarceration |
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VIPoma
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non-alpha, non-B islet cell pancreatic tumor secreting VIP
WDHA syndrome Watery Diarrhea Hypokalemia - diarrhea in colon Achlorhydria - inhibits gastrin release |
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Erythromycin and peristalsis
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Motilin receptor agonist
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Absorption location
a) Iron b) Folate c) B12 |
a) Iron - duodenum as Fe2+
b) Folate - Jejunum c) B12 - terminal ileum req. intrinsic factor (parietal cell) |
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Peyer's patches
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Lymphoid tissue
M cells are APCs, activate B cells in germinal centers, divide and migrate to lamina propria and secrete IgA |
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Pleomorphic adenoma
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Most common salivary gland tumor, painless mobile mass of cartilage and epithelium
Often recurs |
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Warthin's tumor
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Papillary cystadenoma lymphomatosum
Benign cystic tumor with germinal centers in salivary glands |
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Most common malignant salivary gland tumor
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Mucoepidermoid carcionoma
Mucinous and squamous parts PAINFUL b/c hits facial nerve |
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Achalasia and causes
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Failure of LES to relax due to loss of myenteric plexus. Progressive dysphagia solids then liquids
Cause - Chaga's disease, Scleroderma (CREST) |
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Esophagitis
a) white pseudomembrane b) punched-out ulcer c) linear ulcer |
a) white pseudomembrane - candida
b) punched-out ulcer - HSV1 c) linear ulcer - CMV |
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Mallory-Weiss syndrome vs BoerHaave Syndrome
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Mucosal lacerations at GE jxn due to vomiting; leads to hematemesis
Alcohol and bulimia BoerHaave Syndrome - transmural esophageal rupture due to violent retching |
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Plummer-Vinson syndrome
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Dysphagia (due to webs)
Glossitis Iron def anemia |
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Things associated with Barrett's esophagus
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Esophagitis
Ulcers Esophageal adenocarcinoma |
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Risk factors for Esophageal Cancer
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AABCDEFFGH
Achalasia Alcohol - squamous Barrett's esophagus - adeno Cigarettes - both Diverticula - squamous Esophageal webs - squamous Familial Fat - adenocarcinoma GERD - adeno Hot liquids - squamous Squamous at top, adenocarcinoma at bottom Progressive dysphagia with weight loss |
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Malabsorption Syndromes
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These Will Cause Devastating Absorption Problems - all can have diarrhea, steatorrhea, weight loss, weakness, vit and mineral def.
a) Tropical sprue - unknown, resp. to antibiotics, loss of villi b) Whipple's disease - T. whipplei - gram+, PAS foamy macrophages, Cardiac, arthralgias, neurologic change. Old men. c) Celiac sprue - Autoantibody to gluten (gliadin), in wheat; distal duodenum or proximal jejunum. Villi loss; has dermatitis herpetiformis (neutrophils and fibrin at tips of dermal papilla with microabscesses) d) Disaccharidase def - lactase most common, normal villi, osmotic diarrhea, lactose test causes problems and blood glucose doesn't rise, High H2 on breath, Often can get small version post-infection e) Abetalipoproteinemia - low ApoB, can't make chylomicrons, less cholesterol, VLDL into blood, fatty enterocytes, childhood neurologic and malabsorption f) Pancreatic insufficiency - CF, obstructing cancer, chronic pancreatitis, malabsorption and loss of fat soluble vitamins |
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HLA types with celiac sprue, Abx types, complications
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HLA-DQ2 and HLA-DQ8
Antibodies a) Anti-endomysial b) Anti-tissue transglutaminase c) Anti-gliadin Serum transglutaminase Abx to screen, risk of T-cell lymphoma |
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Causes of acute gastritis
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Erosive; loss of barrier
Stress NSAIDs (PGE1 loss) - RA pts Alcohol Uremia - cancer Burns - CURLING ulcer due to low plasma volume Brain injury - CUSHING ulcer due to vagal stimulation |
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Causes of chronic gastritis by type
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Type A - Autoimmune to parietal cells (pernicious anemia) in body, Anemia or Achlorhydria
Type B - Most common, H. pylori infection. Risk of MALT lymphoma |
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Menetrier's disease
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Gastric hypertrophy with protein loss, parietal cell atrophy and increased mucous cells. Precancerous. Stomach rugae look like brain gyri
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Stomach cancer diffuse vs Intestinal
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Almost always adenocarcinoma. Early spread to:
a) Left supraclavicular node (virchow's) b) Subcutaneous periumbilical mets (Sister Mary Joseph nodule) Intestinal - H. pylori, nitrosamines, achlorhydria, chronic gastritis, Type A blood, LESSER CURVE, ulcer with raised margin Diffuse - Signet rings, NOT h. pylori, thick and leathery wall (linitis plastica). Krukenberg's tumor BIL mets to ovary |
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Gastric ulcer vs Duodenal ulcer
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Gastric ulcer - greater pain with meals, weight loss, mucosal loss implicated, increased carcinoma risk, older pts
Duodenal - DECREASED with meals, weight gain, H. pylori almost always cause, less mucosa protection or more acid (zollinger-ellison), generally benign |
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Ulcer complications
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Hemorrhage - both gastric and duodenal. Lesser curve gastric (left gastric a. bleed); posterior duodenal wall (gastroduodenal artery)
Perforation - duodenal more, (anterior ones) |
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Crohn's Disease Etiology, Presentation, Extraintestinal, Location, Treatment,
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Etiology - disordered response to bacteria; Th1 mediated
Presentation - TRANSmural inflammation, Cobblestone mucosa, creeping fat, String sign of bowel thickening, fissures, fistulas, perianal disesae, colorectal cancer risk. +/- bloody diarrhea. GRANULOMAS (noncaseating) and lymphoid aggregates Extraintestinal - migratory polyarthritis, erythema nodosum, ankylosing spondylitis, uveitis, STONES Location - Any part, SKIP lesions, rectal sparing Treatment - Corticosteroids, AZA, Methotrexate, Infliximab, Adalimumab |
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Ulcerative colitis
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Etiology - Autoimmune; Th2 mediated
Presentation - Mucosal and submucosal limited, friable pseudopolyps, "lead pipe" due to haustra loss, crypt abscesses, ulcers, bleeding, NO granulomas. BLOODY, cancer risk worse if right sided or. pancolitis, Extraintestinal - Primary Sclerosing cholangitis, pyoderma gangrenosum, ankylosing spondylitis, uveitis Location - COLON, ALWAYS rectal, continuous Treatment - ASA (sulfalazine), 6-mercaptopurine, infliximab, colectomy (less likely to recur) |
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IBS requirements
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Recurrent abdominal pain with 2 of
a) Pain improves with defecation b) Stool frequency change c) Stool appearance change Can be diarrhea, constipation or alternating |
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Diverticula Types, signs and symptoms
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False Diverticula - (only mucosa and submucosa) - due to intraluminal pressure, focal weakness, low fiber, sigmoid colon mostly.
Hematochezia, can get diverticulitis (perforation risk), fistulas (bladder), True diverticulum - Meckel's, all 3 layers, 2 inches long, 2 feet from ileocecal valve, 2%, may have gastric or pancreatic epithelium. Persistence of vitelline duct. RLQ, intussusception, volvulus risks. Pertechnetate study to find |
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Intussusception vs Volvulus
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Intussusception - Telescoping, most common at ileocecal jxn, "currant jelly" stools and may compromise blood supply, in adults look for mass or tumor; adenovirus may cause in kids
Volvulus - twisting of bowel around mesentery, Obstruction and infarction risk, Cecum and sigmoid colon most common |
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Polyp worrisome signs
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Adenomatous polyps are precancerous
Large villious polyps most worrisome Most are hyperplastic and in rectosigmoid colon |
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Peutz-Jeghers
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Many nonmalignant hamartomas in GI tract
Hyperpigmented mouth, lips, hands, genitalia Risk of colorectal carcinoma and visceral malignancy |
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Juvenile colonic polyps
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Just one has no malignant potential
Juvenile polyposis syndrome is many and risk of adenocarcinoma |
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Colorectal cancer RF, Presentation/Location and differentiation, Diagnosis
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3rd most common cancer and 3rd most deadly, >50 year old, FHx
RF: IBD, tobacco, large villous adenomas, juvenile polyposis, Peutz-Jeghers Location (in order) - 1) rectosigmoid 2) ascending - exophytic mass, iron def anemia, weight loss 3) descending - infitrating mass, partial obstruction, colicky pain, hematochezia Dx - Iron def anemia in older males or postmenopausal femalse, "apple core" lesion on barium enema. CEA tumor marker (best for monitoring recurrence) |
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Bacteremia associated with colon cancer
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Streptococcus bovis
Cancer facilitates bacteremia |
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Genetic causes of colorectal cancer
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Familial Adenomatous polyposis - APC mutation at birth, then get K-ras mutation then p53 los (AK53) - thousands of polyps, pancolonic and ALWAYS rectal; B-catenin Wnt pathway activation
Gardner's syndrome - FAP + osseus and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium Turcot's syndrome - FAP + malignant CNS tumor Hereditary nonpolyposis colorectal cancer (Lynch syndrome) - AD mutation of mismatch repair genes, PROXIMAL COLON always |
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Carcinoid tumor presentation, Treat
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Neuroendocrine cells, mostly at appendix, ileum and rectum. Most common SMALL intestine malignancy
DENSE CORE BODIES May produce 5-HT but no symptoms till metastasizes b/c liver takes care of Syndrome - wheezing, right sided heart murmur, diarrhea, flushing Treat - octreotide, somatostatin, resection |
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Cirrhosis main causes and pathology
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Alcohol (MOST)
Viral hepatitis (Hep B or C usually) Biliary disease Hemochromatosis Hepatocellular carcinoma risk, cirrhosis is diffuse fibrosis and nodular regeneration with loss of normal architecture and bridging fibrosis with regenerative nodules |
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Serum Marker Use: AST, ALT
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Non specific liver damage
ALT > AST - viral usually AST > ALT - alcoholic hepatitis |
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Serum Marker Use: Alkaline phosphatase and GGT (gamma glutamyl transpeptidase)
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ALP - Obstructive liver disease (hepatocellular carcinoma), bone disease, bile duct disease
GGT - obstructive diseases like above but NOT elevated in bone disease |
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Serum Marker Use: Amylase and Lipase
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Both acute pancreatitis. Lipase more SPECIFIC
Amylase elevated in mumps too |
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Reye's syndrome, associations, mechanism
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Childhood hepatoencephalopathy with mitochondrial abnormalities, fatty liver, hypoglycemia, viomiting, hepatomegaly, coma.
Associations: VZV, influenza B that is treated with aspirin Mechanism - Aspirin metabolites lower Beta oxidation by inhibiting mitochondrial enzymes AVOID aspirin in children unless Kawasaki's disease |
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Stages of Alcoholic liver disease
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Hepatic steatosis - short term with moderate alcohol, macrovesicular change than is reversible
Alcoholic hepatitis - sustained consumption long term, swollen, necrotic hepatocytes, neutrophilic infiltate, Mallory bodies. AST > ALT Alcoholic cirrhosis - irreversible, MICROnodular, shrunken liver with "hobnail" appearance, sclerosis around central vein (Zone III) |
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Causes of hepatocellular carcinoma, detection
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Detection - aFP
Most common primary malignant tumor of liver Hep B and C Wilson's Disease hemochromatosis Alpha 1 antitrypsin def Alcoholic cirrhosis Carcinogens (aflatoxin from aspergillus Have jaundice, tender hepatomegaly, ascites, polycythemia, hypoglycemia |
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Liver tumors presentation
a) Cavernous hemagnioma b) Hepatic adenoma c) Angiosarcoma |
a) Cavernous hemagnioma - most common benign, NO biopsy b/c hemorrhage risk
b) Hepatic adenoma - oral contraceptives or steroids, benign, goes away if stop c) Angiosarcoma - arsenic or PVC link, malignant tumor |
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Budd-Chiari Syndrome, Associations
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IVC or hepatic vein occlusion, centrilobular congesion and necrosis leading to congestive liver disease (hepatomegaly, ascites, abdominal pain and later liver failure)
Varices, visible abdominal and back veins NO JVD Associations: Hypercoagulable state, polycythemia vera, pregnancy, hepatocellular carcinoma |
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Dx alpha 1 antitrypsin def
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Panacinar emphysema
Cirrhosis with PAS positive globules in liver Misfolded gene product aggregates in ER |
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Jaundice type and bilirubin presentation
a) Hepatocellular b) Obstructive c) Hemolytic |
All have yellow skin or sclerae from high bilirubin due to cell injury, obstruction to bile or hemolysis
a) Hepatocellular - High direct and indirect, high urine bilirubin, normal to low urobilinogen b) Obstructive -High direct, High urine bilirubin, low urobilinogen c) Hemolytic - high indirect, absent urine bilirubin, high urine urobilinogen |
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Gilbert's syndrome vs Crigler Najjar vs Dubin Johnson
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Gilbert's syndrome - Mildly lower UDP-glucuronyl transferase or less uptake of bilirubin, asymptomatic hyper unconjugated bilirubin without hemolysis, increased with fasting and stress
Crigler-Najjar - Absent UDP-glucuronyl transferase (Type II has some; phenobarbital to help), jaundice, kernicterus, hyper unconjugated bilirubin, plasmaphoresis and phototherapy Dubin Johnson - Conjugated hyprebilirubinemia due to defective excretion, black liver, benign, (Rotor's is even milder, no black liver) |
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Wilson's Disease presentation
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Inadequate hepatic copper excretion (ATP7B gene) with failure to enter circulation as ceruloplasmin. Accumulates in liver, brain, cornea, kidneys, joints
Copper is Hella BAD Ceruloplasmin low, cirrhosis, corneal deposits (kayser-Fleischer rings), Copper accumulation, carcinoma Hemolytic anemia Basal ganglia degeneration (parkinsonism) Asterixis Dementia, Dyskinesia, Dysarthria Penicillamine to treat |
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Hemochromatosis presentation
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Cirrhosis, Diabetes, skin pigmentation
Results in CHF, testicular atrophy, hepatocellular carcinoma Primary or Secondary to transfusion therapy Phlebotomy, deferasirox, deferoxamine to treat |
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Primary biliary cirrhosis Presentation
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Immune rxn, lymphocytic infiltrate and granulomas
Obstruction increases pressure in intrahepatic ducts, fibrosis and bile stasis pruritis, jaundice, dark urine, light stools, hepatosplenomegaly, high conjugated bilirubin, cholesterol HIGH ALP, Anti-ama Associations: CREST, RA, celiac disease, autoimmune |
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Primary sclerosing cholangitis Presentation
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Unknown cause of "onion skin" bile duct fibrosis with alternating strictures and dilation (beading)
pruritis, jaundice, dark urine, light stools, hepatosplenomegaly, high conjugated bilirubin, cholesterol Associated with ulcerative cholitis, can lead to 2ndary biliary cirrhosis if get increased intrahepatic duct pressure leading to fibrosis and bile stasis |
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Causes of cholesterol stones
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Radiolucent, some calcified. MOST COMMON gallstone
High cholesterol or bilirubin, low bile salts and gallbladder stasis cause Obesity, Crohn's, CF, estrogens, rapid weight loss, bile acid resins, fibrates Female, Fat, Fertile, Forty |
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Pigmented gallstones cause
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Radiopaque
Chronic hemolysis, alcoholic cirrhosis, biliary infection. Black = hemolysis, brown = infection |
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Signs of gallstones, Complications
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Pain after fatty meal (biliary colic)
Complications - cholecystitis (HIGH ALP if bile duct involved), ascending cholangitis, pancreatitis, bile stasis, fistula btw gallbladder and small intestine Treat with cholecystectomy |
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Acute pancreatitis causes
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GET SMASHED
Autodigestion due to: Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hypercalcemia or Hypertriglycerides (>1000) ERCP Drugs (sulfa ex) Radiates to back, can lead to DIC, ARDS, diffuse fat necrosis LIPASE most specific Pseudocyst main long term complication |
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Chronic pancreatitis presentation
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Chronic inflammation leading to atrophy and calcification of pancreas
Alcohol abuse main cause Pancreatic insufficiency - steatorrhea, fat soluble vitamin def, DM II and risk of adenocarcinoma. Lower levels of elevation of lipase and amylase |
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Pancreatic adenocarcinoma risk factors, marker
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Very aggressive; CA-19-9 marker (CEA less specific)
RF a) Tobacco (NOT alcohol) b) Chronic pancreatitis c) Old age Abdominal pain to back, weight loss, migratory thrombophlebitis (Trousseau's), Obstructive jaundice with palpable nontender gallbladder Whipple procedure, chemo and radiation to treat |
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Cimetidine, ranitidine, famotidine, nizatidine
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H2 blockers, reduce H+ secretion in stomach
Use for peptic ulcers, gastritis, mild GERD Cimetidine inhibits CYP450, antiandrogenic effects, crosses BBB |
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Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, Dexlansoprazole
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PPIs, irreversibly bind H/K ATPase in stomach
Used for ulcers, gastritis, GERD, Zollinger-Ellison C. difficile risk, hip fractures, reduced Mg2+ long term |
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Bismuth, sucralfate
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Bind ulcer base, provide protection, allow HCO3- secretion to restart
Ulcer healing and traveler's diarrhea |
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Misoprostol
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PGE1 analog, increases mucous barrier and lowers acid
For NSAID induced ulcers, maintain ductus arteriosus, used to induce labor DO NOT give to pregnant women (abortifacient), diarrhea too |
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Octreotide
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Long acting somatostatin analog
Used for acute variceal bleeds, acromegaly, VIPoma, carcinoid tumors |
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Aluminum hydroxide, complications
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Antacid (affects other drugs due to modulation of pH or gastric emptying)
Can cause constipation, hypophosphatemia, proximal muscle weakness, osteodystrophy, seizures Causes aluMINIMUM amount of feces |
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Magnesium hydroxide, complications
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Antacid (affects other drugs due to modulation of pH or gastric emptying)
Can cause diarrhea, hyporeflexia, hypotension, cardiac arrest Mg=Must Go to the bathroom |
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Calcium carbonate, complications
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Antacid (affects other drugs due to modulation of pH or gastric emptying)
Can cause hypercalcemia, rebound acid increase Chelates and lowers other drugs like tetracycline |
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Magnesium hydroxide, magnesium citrate, polyethylene glycol, lactulose
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Osmotic laxatives, used to treat constipation
Draw water out, Lactulose for hepatic encephalopathy too |
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Infliximab
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Monoclonal Abx to TNFa
Used in Crohn's, UC, RA MUST insure no latent TB b/c risk of infection, fever, hypotension |
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Sulfasalazine
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Combo of sulfapyridine (antibacterial) and 5-ASA (antiinflammatory)
Used for UC and Crohn's |
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Ondansetron
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5-HT3 antagonist and central acting antiemetic
Post op and chemotherapy vomit control Headache and constipation risk |
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Metoclopamide
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D2 receptor antagonist, increases tone, contractility, LES tone and motility. NO effect on colon transport time
For diabetics and post-surgery gastroparesis Also antiemetic Tox - parkinson effects, depression, fatigue, restless Interactions - digoxin and diabetic agents Contraindicatoins - small bowel obstruction, Parkinon's disease |
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Air in biliary tree
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= gallstone ileus
Starts with stone at ileocecal valve that forms fistula |
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Duodenum close proximity structures by part
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1st part - Gastroduodenal a., 1st lumbar vertebra
2nd part - head of pancreas 3rd - SMA, lumbar vertebra, aorta and IVC 4th - not much |
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Glucagonoma signs
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Rash, indurated and scaling
Superficial necrolysis Diabetes Mellitus Anemia |
