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Clinical Medicine - GI
n/a
139
Medical
Graduate
11/14/2011

Additional Medical Flashcards

 


 

Cards

Term
a protuberance into the lumen from a normally flat colonic mucosa
Definition
polyp
Term
features of an adenomous polyp that create a worse prognosis
Definition

size >1cm

villous histology

high grade dysplasia

>3 polyps

Term
general rules about adenomatous polyps:

__% are tubular, <1cm, LGD
__% prevalence of at least one at 60 y/o
__% synchronous lesions
Definition
80, 60, 50
Term
____ is considered the optimal exam for the detection of polyps, as symptoms are not reliable
Definition
colonoscopy
Term
2nd leading cause of cancer death
Definition
colon
Term
risk factors for colon cancer
Definition

high fat, low fiber diet

>50 y/o

personal hx of adenoma or CRC (x3)

first degree relative w/ CRC (x3)

familial polyposis syndromes

hereditary non-polyposis CRC

IBD

african americans

obese

smokers

Term
most common sx of CRC
Definition

asymptomatic anemia - 50%

change in bowel habits - 43%

weight loss - 6%

Term
elderly pt with iron deficiency anemia have ___ until proven otherwise
Definition
CRC
Term
CRC mets to ___ first
Definition
liver
Term
extension of CRC through ___ (T2) is the tipping point for prognosis. Probably needs colon resection.


having any pos nodes cuts CRC 5 year survival by __%
Definition

muscularis propria

50%

Term
CT scan with air insuflated in colon lumen
85-90% sensitive for CRC
can miss flat lesions
no therapeutic intervention can be done
Definition
CT colonography
Term
screening recommendations for CRC

1. FAP
2. HNPCC
3. Fm Hx CRC <60 y/o
4. IBD
Definition

1. FAP - flex sig/colon q yr at puberty

2. HNPCC - colonoscopy q 2 years age 20-25, q year at 40

3. Fm Hx: colonoscopy at 40 y/o or 10 yr before family member was diagnosed

4. IBD - colonscopy q yr after 8 years

Term
Post polypectomy surveillance:

1. Low risk - <2 adenomas, <1cm diameter, neg fmhx
2. high risk - >3 adenomas, >1 cm diameter, villous histology, high grade dysplasia, pos fmhx
3. hyperplastic polyp
Definition

1. colonoscopy every 5 years

2. colonoscopy every 3 years, or 3-

6 mos if >2 cm, 3 mos if malignant

3. 10 years if no fmhx

Term
CRC treatment
Definition

1. surgery is only cure

2. adjuvant therapy:

- chemo for stage II or III colon ca, 305 weeks post-op

- chemo and/or radiation for stage II or III rectal cancer

3. stenting for pts who are not surgical candidates

Term
most common form of rectal cancer?
Definition
adenocarcinoma
Term
a diffuse process characterized by fibrosis and a conversion of normal architecture into a structureally abnormal nodules.

consequences include vascular disturbances (portal venous htn), and impaired parenchymal fxn, including protein synthesis, hormone metabolism, and excretion of bile

causes: alcohol, hep b/c, drugs, toxins, clotting disorders, autoimmune, NASH, cryptogenic

effects of diminished cellular fxn: accumulation of toxins, reduced synthesis of proteins
effects of increased resistance to hepatic blood flow: increased portal venous pressure, portosystemic shunting of blood
Definition
cirrhosis
Term
3rd leading cause of death ages 25-65
Definition
cirrhosis
Term
by the time cirrhosis is clinically apparent, hepatic fxn reserve is impaired by __%
Definition
80
Term
Neuropsychiatric condition where clinical manifestations range from almost imperceptible personality changes (forgetfulness) to coma. Neuromuscular (Parkinson-like) symptoms may also be present.
      
occurs in acute or chronic liver disease
results in failure of liver to detoxify
pathogenesis multifactorial
causative agent ammonia and ?
- increased short chain aa's
- increased manganese
- increased serotonin


This disorder is reversible suggesting lack of persistent structural lesion in the brain
Studies of patients who died in hepatic coma revealed an Alzheimer’s type changes in astrocytes
PET scans (assess basic metabolic function, glucose uptake) suggest hypometabolism

often have an event that precipitates disease: azotemia/dehydration, sedatives, GI bleed, excess protein/nitrogen, metabolic alkylosis, infection, constipation

Gold standard test?

tx?
Definition

hepatic encephalopathy

 

gold standard: arterial ammonia

 

tx: decrease ammonia w/ lactulose

abx: neomycin, rifaximin

Term
s/s of _____:


Sub-Clinical--impaired psychomotor test
Stage 1--insomnia, confusion, forgetfulness,
ammonia increased
Stage 2--lethargy, disorientation, asterixis
Stage 3--somnolence, disorientation, aggression
Stage 4--coma, unresponsive, decerebrate
posture
Definition
hepatic encephalopathy
Term
a complication of a scarred (cirrhotic) liver impeding blood flow.

tx by reducing portal venous inflow via preload reduction (splanchnic vasoconstriction via beta blockers) OR reduce resistance to portal venous outflow via afterload reduction (outflow shunt) OR endoscopic sclerotherapy OR nitrates
- complicatoins of these?

develop when hepatic venous pressure exceeds 12 mmHg due to pressure build up in liver through LEFT GASTRIC VEIN

only 1/3 bleed but 30% death rate every time one bursts
Definition

esophageal varices

 

shunt leads to severe encephalopathy

 

Term
Risk factors for variceal bleeding (6)
Definition

portal pressure >12 mm hg

large varices

varices in fundus of stomach

cherry red spots

degree of liver dz

presence of ascites

Term
tx of choice to prevent first esophageal varice bleed
Definition
non-selective beta blockers
Term
tx for acute esophageal varice hemorrhage
Definition

1. octreotide

2. endoscopic sclerotherapy

3. TIPS - very effective

4. surgery to put in portacaval shunt

Term
complication of cirrhosis that causes 50% of pts to die w/in 2 years

dx via US and CT


tx?
Definition

ascites

tx: diuretics (spironolactone), bed rest, sodium restriction, paracentesis w/ albumin if >5 L

Term
complication of cirrhosis
Definition

hepatic encephalopathy

ascites

scrotal edema

varices

hepatic pleural syndrome - hepatic hydrothorax

portal HTN (SAAG >1.1)

Term
indications and contraidndications for liver transplant
Definition

indications: ascites, bacterial peritonitis, variceal hemorrhage, malnutrition, encephalopathy, metabolic bone disease, malignancy, pruritus

 

contras: extraheptaic malignancy, acive alcohol or substance abuse, HIV, severe comorbid disease

 

gauged via MELD score

Term
3 most common places for GI bleed
Definition
esophagus, stomach, colon
Term
acute GI bleeds are more commonly upper or lower?
Definition
upper
Term
Pt with rectal bleeding with normal Hgb, and elevated BUN with normal Cr
Definition
upper GI sources
Term
medical therapy, dx studies for acute UGI bleed
Definition

medical: IV, T&C, PRBC, correct coagulopathy, ICU monitoring, PPIs, NG tube

 

EGD - upper endoscopy

Term
most common causes of UGI bleeding
Definition

PUD: 55%

gastric/esophageal varices: 14%

Term
dieulafoy lesion
Definition
uncommon bleed to due a vessel underneath the surface of the mucosa - 90% rebleed w/o cautery
Term
mucosal tear at GEJ that results from vomiting, dry heaving, and preceed hematemesis
Definition
Term
predisposing factors for peptic ulcers
Definition

aspirin

NSAIDs

H. pylori

Term
tx for UGI bleeds
Definition

cautery

epinephrine injection

 

correct coagulopathy

PPIs

Term
GI bleed distal to the ligament of treitz

dx studies?
tx?
Definition

lower GI bleed

 

dx: bleeding scan (have to be bleeding at 0.5 ml/min), angiography (have to be bleeding at 1 ml/min), capsule endoscopy, colonscopy

 

tx: epi, cautery, heater probe, hemoclips

Term
2 most common reasons for rectal bleeding
Definition
diverticulosis, angiodysplasia
Term
____ typically is caused by a colonic source or a rapidly bleeding UGI source
Definition
hematochezia
Term
3 most common causes of acute pancreatitis

what are the 5 most common drugs to cause pancreatitis?
Definition

gallstones (35%)

alcohol abuse (30%)

idiopathic (30%)

 

another important cause: hypertriglyceridemia

 

sulfas, azathiprine, 6-MP, pentamide, ACE-I

Term
how do gallstones cause pancreatitis
Definition
small gallstones get impacted at sphincter of oddi
Term
sx of ?
- severe, boring, steady epigastric pain. radiats to upper back
- anorexia, n/v
- low grade fever
- shock, multisystem organ failure, confusion

Cr >2

PE:
- abd tenderness
- fever
- guarding
- distension
- tachycardia
- jaundice
- dyspnea
- melena/hematemesis
- cullen's or grey-turner sign
Definition
acute pancreatitis
Term
cullens sign
grey-turner sign
Definition

cullen's: blue belly button

grey-turner: ecchymosis on flanks

 

both are signs of hemorrhage from pancreatitis

Term
dx and tx of acute pancreatitis

most serious complication?
Definition

dx:

- high serum amylase

- high serum lipase --> GOLD STANDARD

- elevated liver enzymes --> indicate common bile duct problem causing the pancreatitis

- CT w/ contrast --> GOLD STANDARD - will show fuzzy pancreas or blocked common bile duct

 

Tx:

- mild: NPO, IV fluids, analgesia

- severe: ICU, volume status, NPO, NG tube, ERCP + sphincterotomy

 

administering at least 300 ml NS/hr makes biggest difference in terms of outcome

 

Complications: pancreatic necrosis (most serious), pseudocyst after 4 weeks

- MRCP

Term
2 scoring systems that indicate severe pancreatitis
Definition

APACHE-II

Ranson

 

both used in research, but rarely in practice

Term
most common cause of chronic pancreatitis
Definition
alcohol
Term
chronic pancreatitis
more common in men
looks like cancer on CT
associated with elevated levels of immunoglobulin subtype 4(IgG4)

tx: steroids
Definition
autoimmune pancreatitis
Term
calcifications in pancreas on CT = ?
Definition
chronic pancreatitis
Term
sx:
- intermittent attacks of abd pain
- steatorrhea, glucose intolerance
- diarrhea, weight loss
- sx may be exacerbated by eating

eventually leads to endocrine and exocrine insufficiency

CT: calficications

Labs:
- amylase/lipase only increased in acute exacerbations
- trigs may be high
- high fecal fat
- low fecal elastase
- low serum trypsinogen

dx studies: CT w/ contrast, ERCP, EUS (endoscopic US), MRCP
tx?
Definition

chronic pancreatitis

 

on CT; shrunken pancreas

ERCP: irregular pancreatic duct, possibly a pseudocyst

 

tx: no good therapy!!!

- pancreatic enzymes

- endoscopic stenting, dilation, sphincterotomy, pseudocyst drainage

- surgery: whipple, roux-en-Y, preancreatectomy

- no ETOH or smoking

- narcotics

- high CHO, low fat diet

Term
A 45-y.o. woman presents with acute pancreatitis with a serum amylase concentration of 2010 U/L, and a temperature of 37.2oC. The leukocyte count is 12,000/uL; plasma glucose is 250 mg/dL; and serum calcium is 8.4 mg/dL. She recovers after 1 week of supportive therapy. No obvious cause for the pancreatitis is found; ultrasonography is normal, and the fasting serum triglycerides are 350 mg/dL.
The best course of action to diagnose the cause of the pancreatitis is:

(A). Endoscopic retrograde cholangiopancreaticography (ERCP)
(B). No further testing until another attack occurs
(C). Contrast-enhanced CT scan
(D). Measurement of serum CA 19-9
(E). MRI of the pancreas
Definition

B

 

if neg US - no further tests for first attack

probably passed a stone

 

 

 

Term
A 70-y.o. woman is hospitalized with severe abdominal pain but without rebound tenderness or a palpable mass. Her temperature is 39.8oC; BP is 100/60 mmHg; pulse 104/min; and she is slightly tachypneic. Five months ago she had an attack of right upper quadrant pain lasting 7 hours. Flat plate of the abdomen shows distended bowel loops. Ultrasonography is inconclusive due to overlying gas shadows, and CT scan shows and edematous pancreas. Blood cultures are taken.
Laboratory studies
Leukocyte count 18,000/uL Serum ALT 350 U/L
Serum calcium 7 mg/dL Serum AST 300 U/L
Serum bilirubin 8.2 mg/dL Serum amylase 3010 U/L
Serum alkaline phosphatase 300 U/L
The treatment of choice would be:
(A). Oral antibiotics and observation
(B). Intravenous antibiotics and consultation for ERCP
(C). Intravenous vancomycin
(D). Intravenous hydration and octreotide therapy
(E). Rehydration only
Definition

B

 

pt had at least 3 ranson criteria --> severe pancreatitis

- needs to go to ICU

- sphincter of oddi obstruction

- ERCP is necessary + abx

Term
A 36-y.o. man with a long history of Crohn’s disease is hospitalized with a recurrent attack of abdominal pain. He has a long history of alcohol abuse, which he claims relieves his abdominal pain. He has been taking low-dose prednisone (5 mg/d) and 6-mercaptopurine (100 mg/d) for 2 years and calcium supplements to prevent calcium oxalate urinary crystals. Abdominal radiograph shows pancreatic calcification.
The most likely cause of his pancreatic calcification is chronic pancreatitis due to:
(A). 6-mercaptopurine
(B). Alcohol
(C). Corticosteroids
(D). Hypercalcemia
(E). Oxalosis
Definition

B

alcohol use is usually most common cause

Term
The diagnosis of infected necrosis during an attack of acute pancreatitis is best made by:

(A). Clinical deterioration of physical signs suggested by
fever, low PaO2, rising blood urea, decreasing albumin
(B). MRI
(C). Early surgical exploration
(D). Image-guided fine-needle aspiration of necrotic areas or fluid collections
(E). Contrast-enhanced CT scan
Definition

D

however, should have clinical suspicion

Term
ranson criteria
Definition

1. at admission:

- age >55

- WBC >16K

- glucose >200

- LDH >350

- AST >250

 

2. During first 48 hours

- Hct decrease by 10% w/ hydration

- BUN increase >5 mg/dl

- Ca <8 mg/dl

- pO2 <60 mmHg

- evidence of fluid sequestration

 

Term
Functions of biliary tract
Definition

transport bile from liver to duodenum at 500-1500 ml/day

 

storage and concentration of bile in the gallbladder until needed. bile volume reduced by 80-90%

Term
components of the triangle of calot
Definition

hepatic duct

cystic duct

edge of liver

 

used as reference for gallbladder surgery

can be variations in cystic duct/artery variations

Term
1. gold standard for assessing for gallbladder stones
2. gold standard for assessing gallbladder function
3. gold standard for assessing cystic duct patency
Definition

1. US

2. HB scan and CCK

3. HB scan

 

before getting any of these tests, get abd xray first

Term
patent cystic duct but can't see gallbladder on HB scan?
Definition
cholecystitis
Term
pt has RUQ pain when eating... what test to get first?
Definition
US
Term
Cholelithiasis (gallbladder stones)
1. 75% of stones are ____
2. 5 F's that are risk factors
3. what if pt has cholelithiasis w/o sx?
4. sx?
5. tx?
Definition

1. cholesterol

2. Fat, female, fam hx, fertile, forty

- also: american indian, DM, parenteral nutrition, rapid weight loss

3. don't do anything

4. biliary colic, RUQ pain after eating, lasts 15-60 min, n/v,

5. tx: cholecystectomy. if pt has only mild sx, consider medical management first

Term
what is a definite indication for prophylactic cholecystectomy?
Definition
splenectomy
Term
What dx?

sx: biliary colic, jaundice, pancreatitis, episodic cholangitis

elevated bilirubin at 3-6

studies?
tx?
Definition

choledocholithiasis (common bile duct stones)

studies: ERCP

tx: open or lap cholecystectomy

Term
1. ACUTELY elevated bilirubin, amylase, and lipase... think?
2. pt w/ pancreatitis but no hx of alcohol use... think?
3. bilirubin >10?
Definition

1. stone in pancreatic duct

 ("gallstone pancreatitis)

2. stone in pancreatic duct

3. cancer

Term
what dx?

- characterized by either charcot's triad (colic, fever, jaundice) OR reynold's pentad (colic, fever, jaundice, hypotension, confusion)

- is caused by biliary obstruction
- can progress to shock
- 50% due to anaerobes
- pos murphy's sign

tx?
Definition

cholangitis

tx: wide spectrum abx

if unsure of cause - do ERCP

Term
what dx?
- invovles two pathologic processes: bowel obstruciton and cholecystoenteric fistulas
- women more common, >70 y/o
- caused by a gallstone >2.5cm

tx?
Definition

gallstone ileus

tx: surgery

Term
acute RUQ pain and tenderness and + murphy's
fever, leukocytosis, nausea, emesis
US: thickened gallbladder w/ peri-cholecystic fluid
90-95% have gallstones
HB scan: cannot see gallbladder

tx?
Definition

acute cholecystitis

 

tx: IV fluids and abx, cholecystectomy or drainage

Term
Thickened gallbladder on US w/o fluid collection
HB scan: gallbladder is visualized
Definition
chronic cholecystitis
Term
rare, severe form of acute cholecystitis
anaerobic infection w/ clostridia or e. coli
often in DM pts
pts will be very sick

xray: air in gallbladder wall

tx?
Definition

emphysematous cholecystitis

tx: surgery

Term
cystic duct obstruction
pus w/in gallbladder
may be severely septic
often had an acute gallbladder infection recently

tx?
Definition

gallbladder empyema

tx: drainage or surgery

Term
complication in 3-10% of acute cholecystitis cases
20% mortality
w
Definition
gallbladder perforation
Term
primary vs. secondary chronic cholecystitis
Definition

primary: no prior acute disease. usually due to a thin walled gallbladder w/ gallstones present

 

secondary: follows acute infection, thickened wall w/ adhesions

Term
AKA chronic cholecystitis, acalculus, cholecystitis, sphincter of oddi syndrome
non-specific GI, biliary-like sx
- failed antacid therapy

US: negative
HB: ejection fx <35%

tx?
Definition

biliary dyskinesia - basically a blanket term for a non-functioning/poorly-functioning gallbladder

tx: cholecystectomy

Term
hepatic and non-hepatic causes of jaundice
Definition

Hepatic: hemolysis, bilirubin metabolism defect, cholestasis (hepatitis, cirrhosis, neoplasm, toxins),

- not treated surgically

 

non-hepatic: choledocholithiasis, cancer, inflammatory, biliary duct stricture

Term
most commonly present in childhood
increased risk for cholangiocarcinoma
classic triad: jaundice, pain, palpable mass
Jaundice is most common
evaluation according to obstructive jaundice algorithm
ERCP to define anatomy


need to consider with any child presenting with jaundice
Definition

choledochocyst

 

Term
stones larger than 2.5-3 cm w/ calcified (porcelain) gallbladder in a typhoid carrier... think?
Definition
gallbladder carcinoma --> needs cholecystectomy
Term
slow growing cancer of the cystic or common bile duct
the one gallbladder disorder thats more common in males
higher chances for asians, UC, choledochocysts, sclerosing cholangitis

most commonly in the proximal third - Klatskin's tumor

fixed by hepaticojejunostomy or whipple procedure
Definition
cholangiocarcinoma
Term
characterized by chronic GI inflammation, fibrosis and obstruction, and bowel wall perforation

occurs in exacerbations and remissions
increased risk of malignancy with prolonged disease

caused by a combo of genetic (NOD2 gene), environmental, and immunologic factors
Definition
IBD
Term
characterized by transmural mucosal inflammation that involves the entire GI tract except the rectum

Hallmarks: diarrhea, abd pain, weight loss
absence of gross bleeding

dx: barium enema - apthos ulcers
colonoscopy - skip lesions, cobblestone polyps

tx?
Definition

crohn's disease

 

steroids, infliximab, methotrexate

Term
pain and drainage from large skin tags
perirectal abscesses
anal fissures
anorectal fistula
Definition
perianal chrons
Term
extraintestinal complications of crohn's
Definition

eyes - uveitis, episcleritis

skin - erythema nodosum, pyoderma gangrenosum

arthritis

amyloidosis --> renal failure

DVT

sclerosing cholangitis

Term
pt scenario that sounds like IBD but just involves the rectum?

any scenario involving red blood on finger from DRE
Definition
UC (proctitis) -- crohn's cannot involve rectum
Term
self-limiting episode of rectal bleeding
then gradual onset of sx: recurring episodes of inflammation
limited to mucosa of colon

sx (depend on severity): intermittent rectal bleeding, mild crampy pain, tenesmus (spasm of anus), passage of mucus, constipation, mild diarrhea, anemia, abd pain, fever, colonic motility impaired, colon dilates, BMs less frequent, toxic megacolon, colonic perforation
Definition
UC
Term
swelling, scarring, and destruction of the bile ducts inside and outside the liver

sx: fatigue, itching, jaundice, hepatosplenomegaly, weight loss, repeated episodes of cholangitis

tests: abd CT, US< ERCP, liver biopsy, MRCP
Definition
sclerosing cholangitis
Term
which describes uC and which crohns?

1. colon only, continuous, mucosa, submucosa, crypt abscesses, superficial ulcers, friable mucosa, pseudopolyps, loss of haustra, rectal bleeding, diarreah, abd pain, weight loss

2. mouth to anus, skip lesions, transmural granulomas, aphtoid ulcers, cobblestoning, fistulas, fissures, abd pain, diarrhea, weight loss, fever, fistulas
Definition
UC, Crohn's
Term
#1 cause of PUD?
Definition
h. pylori (NOT NSAIDS!)
Term
Patient age >70 and previous ulcer complications are the greatest risk factors in predicting -__ complications in NSAID users.
Definition
pud
Term
most common complication of PUD?
Definition
upper GI hemorrhage
Term
what dx?

periodic sx of epigastric distress/tenderness, abd distension, bloating, belching, n/v, flatulence, halitosis

gold standard for diagnosis?

tx?

how do you know if h. pylori has been eradicated?
Definition

culture via endoscopy

 

tx:

1. triple therapy - PPI, amoxicillin, clarythromycin OR metronidazole

2. quadruple therapy (most successful) - bismuth, metronidazole, tcn, PPI

 

stool antigen or urea breath testing to see if h. pylori is gone

Term
t/f?

most people who develop GI complications from NSAID use have no abd discomfort
Definition

true

 

most common finding is abd tenderness on palpation

Term
___ is a drug recommended to prevent NSAID induced ulcers
Definition
misoprostol
Term
epigastric pain 90 min - 3 hr after eating
wakens pt at night
relieved by food and antacids
intermittnet
epigastric tenderness most common PE finding
95% associated w/ infection


changes in pain may signal complications

dx: barium swallow, endoscopy

tx
Definition

Duodenal ulcer

 

tx: eradicate h. pylori, PPIs

Term
n/v, epigastric pain
70% associated with infection
heal slowly
dx: barium swallow, endoscopy
Definition

gastric ulcer

 

tx: eradicate h. pylori, PPI

Term
occult blood in stool w/o anemia
coffee-ground emesis
hematemesis
melena
sudden vascular collapse w/ shock w/o obv signs of hemorrhage


all suggest?
Definition
UGI hemorrhage
Term
disease caused by over-secretion by a gastrin-producing tumor
25% are cancerous
present with MULTIPLE DU and GU ulcers

can be in pancreas or stomach

NO h. pylori!

dx: secretin stimulation test, octreotide scan

tx?

red flags?
signs that it might be cancerous?
Definition

zollinger-ellison syndrome (AKA Gastrinoma)

 

tx: PPI, surgery (tx of choice)

 

red flags: multiple ulcers in unusual locations, resistance to resolution w/ tx, extensive fm hx, severe esophagitis, excess acid, unexplained diarrhea/steatorrhea, hyper calcemia, prominent gastric/duodenal folds

 

cancer: >45 y/o, rectal bleeding, weight loss, fm hx gastric cancer, prior PUD, anemia, dysphagia, abd mass, jaundice, anorexia

Term
what gastric cancer can be cured with a PPI?
Definition
MALT lymphoma - PPI eradicates cause, H. pylori
Term
5 diseases cause by h. pylori
Definition

chronic gastritis

autoimmune gastritis

ulcer

cancer

MALT

Term
pt presents w/ CP. you think it's related to esophagus/heartburn... what do you do first?
Definition
r/o cardiac problems
Term
the sensation of delay in passage of a food bolus w/in ten seconds
dx via?
Definition
dysphagia -- do barium swallow
Term
T/F?

degree of esophagitis is dependent on severity of GERD

development of Barret's esophagitis is dependent on severity of GERD
Definition

false

false

Term
sx: usually after age 50, dysphagia, regurgitation, cough w/ eating, extreme halitosis

PE: bulging left neck when eating, gurgling sound, aspiration pneumonia, scc

dx: barium swallow, CXR
Definition
zenker diverticular
Term
aperistalsis of esophagus
partial or incompete relaxation of lower esophageal sphincter with swallowing
increased resting tone (poorly relaxing) of the LES

associated w/ dilated, tortuous esophagus

sx: dysphagia, regurgitation, CP, weight loss, nocturnal cough, aspiration pneumonia,

barium swallow: bird peak, sigmoid esophagus

tx?
Definition

achalasia

 

tx: CCB to relax LES, dilation, heller myotomy, botulinum toxin

Term
motility/spastic disorder that causes haphazard esophageal contractions
- presents in middle age women
- sx: intermittent dysphagia, CP

tests: barium swallow, esophageal manometry

tx?
Definition

diffuse esophageal spasm

tx: narcotic analgesia, smooth muscle relaxants (nitrates, CCB)

Term
autoimmune disorder associated with PSS or Crest
results in muscle atrophy and collagen deposition, decreased cholinergic excitation and abnormalities in muscle responsiveness

sx: dysphagia, esophagitis, stricture, GERD

tx?

tests: manometry - loss of smooth muscle, low amplitude contraction, low to normal LES pressur
Definition

scleroderma esophagus

 

tx: treat the GERD

Term
smooth muscle pouches off the lumen of the esophagus

sx: dysphagia, regurg, vomiting, CP

test: barium swallow

tx underlying pathology
Definition
esophageal diverticula
Term
Chronic disease present in all individuals that causes transient lower esophageal sphincter relaxation (TLESR)
dysfunction of upper esophageal sphincter
sx: pyrosis, regurg, dysphagia, odonyphagia, sailorrhea, globus, pharyngitis, throat clearing, otalgia, sinusitis, vocal cord granulomas, subglottic stenosis, laryngitis, hoarseness, cough

causes: constant low pressure LES, degree of acid concentraiton, hiatal hernia, weight gain, high fat foods, caffeine, alcohol, tobaccos, drugs, pregnancy

dx: clinical suspicion. pH manometry most important
tx?
Definition

GERD

 

tx:

- lifestyle changes: weight loss, avoid eating before bed, avoid ETOH and smoking

- antacids, H2 receptor antagonists

 

surgery: nissen fundoplication

 

Term
hallmark finding: specialized intestinal metaplasia (SIM) w/ goblet cell metaplasia
- can be a consequence of long-standing, uncontrolled GERD
- NOT caused by h. pylori
- least controlled sx is regurg

dx: endoscopy w/ biopsy
tx?
Definition

barrett esophagus

 

tx: photodynamic therapy, surgery

Term
3 most common risk factors for esophageal cancer
Definition

fm hx

smoking

alcohol

Term
sx: dysphagia + weight loss
Definition

esophageal ca

5-20% surival

Term
one of the main reasons for fulminant liver failure
Definition
binge drinking + tylenol
Term
Liver function tests:
1. a transaminase that is cytosolic and mitochondrial but is not specific to the liver
2. a transaminase that is cytosolic and is specific to the liver. Normal is 31IU in males nad 19 in females.
3. biliary enzyme that can become elevated in liver disease, hodgkin's, renal cancer, and granulomatous disease
4. biliary enzyme that is highly inducible by drugs and alcohol -- used to see if liver pt is drinking
5. test that tests hepatic synthetic capability for chronic disease
6. the "GFR of liver disease" - implies obstruction or colestatic hepatitis if >0.5 mg/dl
7. test that is frequently falsely pos but can indicate early liver disease if >1.0 mg/dl
Definition

1. AST

2. ALT

3. Alk phos

4. GGT

5. albumin

6. bilirubin

7. dipstick urobiligen

 

Term
isolated bilirubin abnormality due to an enzyme deficiency: elevated at 1.5-6 mg/dl
- dipstick urobiligen is neg
- often found in males at puberty
- normal CBC, retic count, ALT, alk phos
- good general health
- jaundice may be seen during times of acute illness
Definition

gilbert's syndrome

 

no tx

Term
Evaluating a pt with elevated liver enzymes:
1. AST/ALT <4 fold normal, normal PE, normal bilirubin, asymptomatic
2. Abnormal AST/ALT on repeat exam or sx or risk factors
3. abnormal PE (ascites, clubbing, splenomegaly, spiders), low platelets or albumin, high bilirubin or alk phos, and don't think it's obstruction
Definition

1. repeat labs in 2-6 mos

2. get more labs: HCV, HBV, ferritin, Fe/TIBC, platelet, PTT, CBC, ANA, endomysial ab, US

3. look for zebras - liver biopsy

Term
highly associated w/ BMI > 30, tricyclics, CCBs
ALT/AST both <2x normal, ALT>AST
mild increase in GGTP
biopsy: NO NECROINFLAMMATORY CHANGES OR FIBROSIS

improves w/ weight loss
Definition
NAFL
Term
associated w/ BMI > 30 and "syndrome x" insulin resistance
ALT/AST <4x normal. ALT>AST
biopsy: NECROINFLAMMATORY CHANGES AND PERICENTRAL VENULAR FIBROSIS OR BRIDGING
inconsistent response to weight loss
8-26% progression to cirrhosis w/in 7 years
Definition
NASH
Term
most common cause of liver disease
Definition
alcohol
Term
AST>ALT by at least 2:1
GGTP>Alk phos by 2:1

characterized by ballooning degeneration, spotty necrosis, polymorphonuclear infiltrate, fibrosis

sx: hepatomegaly, RUQ pain, nausea, jaundice
Definition
alcoholic liver disease
Term
iron overload
one of the most common detectable/preventable genetic diseases in north america
- mildly elevated transaminases progressing silently to cirrhosis

- may look like NASH histologically
- FE/TIBC >45%, >1000 ng/ml
confirm w/ biopsy
Definition
hereditary hemochromatosis
Term
defined as abnormal ALT > 6 mos + virus
- reactivation can occur after pt has cleared the dz serologically

progression of abs?
Definition

chronic HBV

 

1. HBV DNA

2. IgM

3. HBV surface antigens + HBVe antigen

4. rise in ALT and AST

5. loss of DNA

6. anit-HBV and anti-HBVe antigens

7. IgM --> IgG

Term
RNA virus that becomes chronic 85% of the time
- can have normal LFT and undetectable RNA, but fluctuating levles are typical
- 20-30% develop cirrhosis

tx: interferon, ribavirin, protease inhibs -- good outcome
Definition
HCV
Term
most common cause of liver transplant
Definition
cirrhosis
Term
ROME II criteria are for diagnosing what disease?
Definition

IBS

 

abd pain which is relieved by defecation

lots of diff change in bowel movements

 

Term
4 kids of IBS:

1. typically in kids, sporadic, crampy pain
2. typically in kids - colic + constipation
3. mid-later life with diarrhea
4. antigen sensitization w/ diarrhea
Definition

. 1. colic

2. constipation predominant

3. diarrhea predominant

4. episodic/explosive

Term
SRBW alarm symptoms

what tests should you get?
Definition

constant, unrelenting, localized pain

weight loss

anorexia, vomiting, sweats, bleeding

nocturnal sx

no prior hx of pain

mid- later-life

fm hx of gi cancer

 

H&P, CBC, ESR, CMP, lipase, Fe/TIBC, endomysial ab, chromogranin A, colonsocopy, US GB, CT

Term
dx & tx of IBS
Definition

ROME II Criteria + endomysial antibody + no SRBW sx

 

tx: dietary modifications - find food allergies, restrict gas/fermenting foods, restrict gluten, lactose, fructose, sorbitol, fiber, caffeine

- antispasmodics

- TCA or SSRI

 

Term
Definition

Term
upper abd/chest pain - pressure or squeezing
typically after meals
gas/bloating in upper abd/chest
dysphagia
responds to GERD tx but not fully
may need surgery
Definition
hiatal hernia
Term
Gas/bloating - upper abdomen
Eructation, nausea, aerophagia
Pyrosis is usually minimal
Non specific multiple food intolerances
Vague upper or middle abdominal pain
Present over long time and usually daily occurrence
Responds poorly to medical Rx
Consider - post enteropathic gastric dysmotility
Definition
functional dyspepsia
Term
pt has bloody diarrhea for the past 24 hours. she attended a picnic 24 hours ago. possible causes?
Definition

c. diff

hemorrhagic e. coli

salmonella

campylobacter

yersinia

shigella

entamoeba histolytica

Term
A 24 year old woman has had non-bloody diarrhea for the past 24 hours. She is a daycare attendee. Identify at least 4 possible causes.
Definition

shigella

giardia

crypto

rotavirus

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