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253 Cards in this Set
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causes of chronic hepatitis? |
Hep B, C, D; autoimmune Hep, alcoholic Hep, NASH, medications, Wilson disease
(liver inflm > 3-6 mo) |
|
Pathophys Hep A |
RNA hepatovirus; incubation = 15-50 days; fecal-oral (contaminated food/water, IVDU)
temporary, low mortality |
|
S/Sx hepatitis |
acute 2-3 wks:
low fever, N/V, diarrhea, constipation, pale gray stools, fatigue, myalgia, RUQ/epigastric pain, jaundice
aversion to smoking
|
|
Dx Hep A |
IgM: peaks in 1 wk, gone in 3-6 mo IgG: in 1 mo, lasts for years (= immunity)
elevated AST, ALT, bilirubin, ALP |
|
preventing Hep A |
hygiene, vaccine (2 doses separated by 6-18 mo)
contraindicated in HIV (?) |
|
Tx Hep A |
supportive, steroids ineffective
recovery in 3 mo; avoid alcohol & exercise |
|
Pathophys Hep B |
DNA virus, incubation = 6 wks - 6 mo; more gradual onset than HAV & lasts longer;
blood transmission (highest transmission = heterosexual)
|
|
preventing Hep B |
vaccine (0 mo, 1 mo, 6 mo)
If exposed, Hep B globulin w/i 7d, then vaccine |
|
Tx Hep B |
supportive; if Sx of encephalopathy/coagulopathy, hospitalize
recovery in 3-6 mo
r/o co-infx w/ Hep D |
|
pathophys Hep C |
ssRNA virus; incubation = 6-7 wks
>50% from IVDU low risk of sexual/maternal transmission
blood transmission |
|
Tx Hep C |
aggressive; peginterferon 6-24 wks (NOT w/ preg/lactation); if still present after 3 mo, add ribavirin
80% become chronic, 30% get cirrhosis, risk of non-Hodgkins & DMII |
|
Tx chronic HBV/HDV |
nucleoside & nucleotide analogs (entecavir, tenofavir, etc)
risks: cirrhosis, liver failure, CA |
|
pathophys autoimmune Hep |
most common = young women; assoc. w/ HLA-B8, -DR4, -DR3;
triggered by viral illness, drugs, postpartum |
|
S/Sx autoimmune Hep |
spider nevi, striae, acne, Hirsutism (manly hair), hepatomegaly, arthritis, thyroiditis, hemolytic anemia |
|
Dx autoimmune Hep |
p-ANCA, anti-SLA Ab; positive ANA or smooth muscle antibodies
elevated ALT, AST, & total bilirubin |
|
Tx autoimmune Hep |
prednisone +/- azathioprine
40% recurrence; may need liver transplant |
|
What is NASH? |
non-alcoholic steatohepatitis; is most severe form of non-alcoholic fatty liver disease
at risk = obese, elderly, non-AA, females, DM, HTN |
|
causes of non-alcoholic fatty liver disease |
obesity, DM, hypertriglyceridemia, meds (steroids, amiodarone, tamoxifen), toxins, endocrine (Cushings, PCOS), TPN, pregnancy
higher risk = metabolic syndrome, hispanic, psoriasis, soft drinks |
|
S/Sx non-alcoholic fatty liver disease |
asymptomatic; RUQ pain, hepatomegaly; rarely present w/ liver failure;
ALT > AST |
|
Dx non-alcoholic fatty liver disease |
liver biopsy |
|
Tx for non-alcoholic fatty liver disease |
wt loss, exercise, reduce alcohol intake;
consider gastric bypass, metformin, vit E, liver transplant |
|
prognosis for non-alcoholic fatty liver disease |
reversible if underlying cause is Tx; 1-3% of untreated -> cirrhosis |
|
pathophys primary biliary cirrhosis |
AI destruction of bile ducts -> cholestasis; women 40-60 y/o, genetic
may be assoc. w/ scleroderma, Raynauds, Celiac disease
develops after infx; risks = recurrent UTI, smoking, hormone replacement therapy |
|
S/Sx primary biliary cirrhosis |
asymptomatic for years; fatigue & pruritus; xanthomatous skin lesions, orthostatic hypotension
higher risk for osteoporosis, fractures |
|
Dx primary biliary cirrhosis |
elevated ALP, anti-mitochondrial antibodies
liver biopsy (for staging only) |
|
Tx primary biliary cirrhosis |
supportive; cholestyramine/naloxone/zofran for itch
ursodeoxycholic acid slows progression; if advanced = liver transplant |
|
prognosis primary biliary cirrhosis |
survival rate = 7-10 yrs; increased risk of liver CA
20% recurs even w/ transplant |
|
pathophys hemochromatosis |
auto recessive; HFE mutation, chrom 6; increased Fe absorption from duodenum
usually >50 y/o |
|
S/Sx hemochromatosis |
hepatomegaly, arthropathy, gray/brown/bronzy skin, cardiomegaly, erectile dysfunction, DM, CA risk, esophageal varices |
|
Dx hemochromatosis |
elevated AST, ALP; elevated iron, transferrin sat, & ferritin
any pt w/ iron overload = test for HFE mutation;
MRI & CT; liver biopsy confirms
(test all 1st degree relatives for HFE!) |
|
Tx hemochromatosis |
if symptomatic/severe, weekly phlebotomy until iron depleted (2-3 yr), then PRN; may need liver transplant
PPIs, deferoxamine (if can't phlebotomy)
avoid iron, EtOH, vit C, shellfish |
|
pathophys Wilson's disease |
chrom. 13; excess copper; deposits in liver, brain, cornea, kidney
usually <40 y/o |
|
S/Sx Wilson's disease |
liver/neuro disease in young adults; may have cirrhosis, portal HTN
Parkinson's-like rigidity, personality changes/swings, Kayser-Fleischer rings, hypoparathyroidism, infertility, hemolytic anemia |
|
Tx Wilson's disease |
penicillamine + pyridoxine (PO) (increases urinary copper excretion)
lifelong Tx; restrict copper intake (shellfish, nuts, mushrooms, chocolate)
family members need screened |
|
most common pathogens for liver abscess? |
E. coli, Klebsiella, Proteus, Enterobacter |
|
Most common cause of liver abscess? |
ascending cholangitis
(can also be secondary to appendicitis, diverticulitis, or idiopathic) |
|
S/Sx liver abscess |
insidious onset, RUQ pain, jaundice, fever |
|
Dx liver abscess |
elevated WBC, LFTs; visible on CT, US, MRI |
|
Tx liver abscess |
cephalosporin + flagyl
may need drainage |
|
pathophys primary sclerosing cholangitis (PSC) |
inflm, fibrosis, strictures of biliary system; males > females; assoc. w/ IBD
risks: familial, elderly, low BMI, smoking, longterm IBD, AI pancreatitis (HLA-B8, -DR3, -DR4) |
|
S/Sx primary sclerosing cholangitis (PSC) |
asymptomatic; jaundice, fatigue, pruritus, anorexia; esophageal varices |
|
Dx primary sclerosing cholangitis (PSC) |
elevated ALP; gold = MRCP, ERCP
fibrosis on liver biopsy |
|
Tx primary sclerosing cholangitis (PSC) & prognosis |
ciprofloxacin, +/- balloon dilation/stenting of strictures
if cirrhosis, prefer liver transplant
avg survival = 12-17 yrs |
|
most common cause of cirrhosis in the US? |
alcoholic liver disease |
|
pathophys alcoholic liver disease |
alcohol abuse
women > men; often reversible most common cause of cirrhosis in the US |
|
S/Sx alcoholic liver disease |
hepatomegaly -> end-stage cirrhosis, jaundice, nausea, splenomegaly, ascites, fever, encephalopathy
susceptible to infection |
|
Dx alcoholic liver disease |
AST > ALT (usually >2:1); high GGT
high ALP, bilirubin; low albumin |
|
Tx alcoholic liver disease |
No alcohol; thiamine + glucose together (to avoid Wernicke-Korsakoff);
methylprednisolone or pentoxifylline (TNF-inhibitor)
liver transplant |
|
Most common causes of drug/toxin induced liver disease? |
APAP (tylenol), NSAIDs + abx
(others: niacin, heavy metals, 6MP, valproic acid, amiodarone, duloxetine, phenytoin) |
|
Subfulminant vs. fulminant liver failure? |
Subfulminant: encephalopathy >8 wks after onset
Fulminant: encephalopathy within 8 wks of onset |
|
pathophys of acute liver failure |
either subfulminant or fulminant; higher risk w/ diabetes; APAP most common cause
worse prognosis in obesty, <10 y/o, >40 y/o |
|
S/Sx of acute liver failure |
N/V, SIRS, renal dysfunction, hemorrhage; RUQ pain, abd swelling, jaundice; fatigue, confusion |
|
stages of acetaminophen toxicity |
1: asymptomatic; anorexia, N/V, malaise
2: (18-72h) RUQ pain, tachycardia, HOTN
3: (72-96h) hepatic necrosis, jaundice, coagulopathy, encephalopathy, acute renal failure
4: (4d-3wks) recovery |
|
Dx acute liver failure |
high AST, ALT, ALP, bilirubin; elevated serum amylase & ammonia
(if APAP toxicity, AST & ALT often >5000 - get serum acetaminophen levels)
|
|
Tx acute liver failure |
correct metabolic abnormalities; prevent cerebral edema (Mannitol) & sepsis; lactulose for encephalopathy; consider hypothermia
if APAP, acetylcysteine; if mushroom, penicillin G or silibinin |
|
pathophys of cirrhosis |
hepatocellular injury causing fibrosis/nodules; higher risk in AA, Mexicans;
common causes = EtOH, Hep C, NAFLD, Hep B main genetic cause = hemochromatosis |
|
S/Sx cirrhosis |
fatigue, wt loss, abd pain w/ N/V, hematemesis, hepatosplenomegaly, sexual dysfunctions, spider angioma, palmar erythema, Dupuytren contractures, asterixis, GI bleed |
|
Dx cirrhosis |
liver biopsy
anemia, prolonged PT, elevated AST, ALP, bilirubin, decreased albumin |
|
Tx cirrhosis |
liver transplant (cure)
balanced diet, d/c alcohol, vaccinate for Hep A & B |
|
possible complications of cirrhosis & their treatments |
ascites & edema (paracentesis); bacterial peritonitis (ceftriaxone, augmentin); hepatorenal syndrome (transplant); encephalopathy (lactulose); coagulopathy (vit K, clot factors); esophageal varices (octreotide, tamponade); hepatopulmonary syndrome (O2) |
|
Risk factors for hepatocellular carcinoma? |
cirrhosis, males, >55 y/o; Asian, Hispanic, FHx; obesity, EtOH, DM, hypothyroid, Hep C
(Dx = liver biopsy) |
|
T staging of hepatocellular carcinoma |
T1: single avascular tumor T2: single vascular tumor, or multiple <5 cm T3: multiple tumors >5 cm T4: tumor w/ invasion of other organs |
|
monitoring pts w/ liver disease? |
a-fetoprotein & US q6 month in pts w/: - chronic Hep B - chronic Hep C - cirrhosis |
|
absolute contraindications for liver transplant |
malignancy (unless small), advanced cardiopulmonary disease, sepsis |
|
relative contraindications for liver transplant |
>70 y/o, morbid obesity, portal or mesenteric vein thrombosis, active EtOH or drug abuse, noncompliance |
|
Tx & prognosis of hepatocellular carcinoma |
resection, chemo, radiation, tumor embolization
1 yr survival = 23% 5 yr survival = 5% high AFP at diagnosis -> worse prognosis |
|
most common type of benign liver mass? |
hemangioma |
|
hepatocellular adenoma |
is a benign liver mass; assoc. w/ oral contraceptives, often resolve once OCP d/c
surgical resection unnecessary unless painful or concern for malignancy |
|
cancers that commonly metastasize to the liver? |
colorectal, pancreatic, stomach, lung, breast |
|
risk factors for acute pancreatitis? |
Celiac disease, smoking, age, obesity, hypertriglyceridemia, peritoneal dialysis
(most common causes = gallstones, alcohol) |
|
assessing severity of pancreatitis |
Ranson criteria, SODA, APACHE II score |
|
S/Sx of acute pancreatitis |
sudden onset; severe epigastric pain, radiation to back; worse w/ activity, laying flat; improved w/ sitting, leaning forward (tripod)
N/V, fever, tachycardia, HOTN |
|
Dx acute pancreatitis |
amylase & lipase >3x ULN (lipase is more specific)
elevated BUN, creatinine, ALP, AST, ALT, CRP;
US only for gallstones; CT & MRI useful (caution w/ contrast) |
|
Ranson criteria (on admission) |
(3+ = pancreatic necrosis)
55+ y/o WBC >16 glucose >200 LDH >350 AST >250 (scale for acute pancreatitis severity) |
|
biggest risk factor for chronic pancreatitis? |
alcoholism ( up to 80% of cases) |
|
risk factors assoc. with chronic pancreatitis? |
alcohol, smoking, obstructing stone, cystic fibrosis, hyperparathyroidism, recurrent pancreatitis, idiopathic |
|
S/Sx of acute pancreatitis vs. chronic pancreatitis? |
both: epigastric/LUQ pain radiating to back, N/V, can be episodic
chronic: anorexia, wt loss, steatorrhea (bulky, fatty stool), constipation, pain may become constant |
|
Most sensitive imaging for chronic pancreatitis? What's its downside? Alternatives? |
ERCP (but may cause pancreatitis itself)
alternates: MRCP, EUS consider biopsy? |
|
Tx chronic pancreatitis |
lifestyle: no alcohol, low-fat diet, avoid opioids, check pancreatic enzymes before & after meals
H2 blockers, PPI, sodium bicarb, octreotide (for idiopathic), prednisone or azathioprine (for autoimmune), surgery, stents +/- radiation |
|
possible complications of chronic pancreatitis? |
80% develop DM, opioid addiction, pancreatic CA, pseudocyst, mechanical obstruction |
|
most common type of pancreatic CA? |
carcinoma |
|
risk factors for pancreatic CA? |
age (strongest factor), alcoholism, obesity, chronic pancreatitis, abd radiation, FHx |
|
T staging pancreatic cancer |
T1: in pancreas, 2 cm or less T2: in pancreas, >2 cm T3: beyond pancreas, but no celiac or mesenteric T4: involves celiac & mesenteric |
|
S/Sx pancreatic cancer |
asymptomatic, epigastric/diffuse pain radiating to back; decreased by sitting/leaning forward; diarrhea, wt loss, depression, jaundice
new onset DM >45 y/o or acute pancreatitis;
palpable gallbladder (Courvoisier law), Sister Joseph nodule (hard periumbilical node from metastasis)
|
|
Courvoisier's law |
enlarged, non-tender gallbladder w/ mild jaundice = malignancy of gallbladder or pancreas
(unlikely to be gallstones) |
|
Dx pancreatic cancer |
hyperglycemia, LFT, amylase, & lipase elevation, CA 19-9, CT, MRI, EUS, MRCP/ERCP |
|
Tx pancreatic cancer |
Whipple procedure, bile duct decompression, chemo, celiac plexus block (pain relief)
poor prognosis |
|
What presentation suggests the problem is gallbladder-related? |
"I ate a fatty meal and got symptoms." |
|
pathophys: cholelithiasis |
gallstones; idiopathic assoc. w/ high cholesterol or calcium
women > men, >60 y/o, 5 "F"s = fair, fat, female, fertile, forty |
|
Tx cholelithiasis |
laparoscopic cholecystectomy
(no treatment unless Sx) |
|
pathophys: acute cholecystitis |
inflm of gallbladder; most from stone obstructing cystic duct |
|
S/Sx of acute cholecystitis |
triggered by large/fatty meal; RUQ/epigastric pain > 12-18h, N/V, loss of appetite
if severe jaundice, suggests choledocholithiasis |
|
Dx acute cholecystitis |
+ Murphy sign, leukocytosis, elevated LFTs; US is best imaging, may need HIDA scan (bile tracer)
if suspect choledocholithiasis, MRCP or ERCP |
|
Tx acute cholecystitis |
pain meds, IV abx, NPO
Zosyn, cephalosporin, or ciprofloxacin +/- flagyl
cholecystectomy within 2-4 days of admission |
|
Pathophys choledocholithiasis |
stone in common bile duct; risk greater w/ age; leads to cholangitis (inflm common bile duct)
may have Hx of recurrent biliary pain, indicating prev. episodes of cholecystitis |
|
Charcot's triad (& Reynold's pentad?) |
recurrent RUQ pain, fever & chills, jaundice
(indicative of acute cholangitis)
Reynold's: w/AMS, HOTN (ascending cholangitis) |
|
Dx choledocholithiasis |
very high AST & ALT (often >1000), elevated bilirubin, ALP, amylase, lipase do MRCP, ERCP (diagnostic)
if acute cholangitis, leukocytosis |
|
Tx choledocholithiasis |
IV abx (cipro +/- flagyl or zosyn)
remove stones to prevent complications (e.g. pancreatitis) via ERCP, then laparoscopic cholecystectomy |
|
biliary dyskinesia |
altered tone of Sphincter of Odi; EF <35% on HIDA scan
Tx w/ cholecystectomy |
|
cause & Tx of bile salt diarrhea |
may develop post-cholecystectomy;
Tx cholestyramine |
|
pathophys: cholangiocarcinoma |
carcinoma in the bile ducts; 50-70 y/o M; most common site = junction of hepatic ducts (aka Klatskin tumor)
risks: UC, cirrhosis, DM, hyperthyroid, pancreatitis, EtOH, helminth infx, Hep C, HIV, NASH, obesity, tobacco |
|
Dx cholangiocarcinoma |
conjug. hyperbilirubinemia, elevated ALP, normal/slightly elevated AST, CA 19-9
US, CT, MRCP, EUS |
|
Tx cholangiocarcinoma |
surgery (if young, healthy), chemo, palliative
liver transplant may slow progression |
|
prognosis: cholangiocarcinoma |
rapid & progressive; death typically in a few months |
|
pathophys: achalasia |
"without relaxation" of LES; 1/100,000; 25-60 y/o
loss of ganglion cells @ LES -> no relaxation |
|
S/Sx achalasia |
Bird's beak, dysphagia of both solids & liquids, regurg. of undigested food, can't belch |
|
Dx achalasia |
manometry (needed for Dx); need endoscopy to r/o CA
"Bird's beak" on barium swallow; on x-ray, dilated esophagus |
|
Tx achalasia |
low risk: pneumatic dilatation, myotomy
high risk: botulinum to relax sphincter, SL nitrates or nifedipine (CCB) |
|
pathophys: scleroderma |
smooth muscle fibrosis; often affects lower esophagus first (upper esophagus is spared) |
|
S/Sx scleroderma of esophagus |
reflux, eroded teeth, dysphagia, aspiration PNA |
|
Dx scleroderma of the esophagus |
manometry, endoscopy (Dx reflux esophagitis, Barrett's, stricture, candida) |
|
Tx scleroderma |
PPI (for reflux), monitor for Barrett's; prokinetics (metoclopramide, erythromycin) |
|
Dx diffuse esophageal spasm |
manometry (constant high amp. contraction);
on barium swallow: corkscrew, rosary beads, pseudodiverticula |
|
pathophys: Zenker diverticulum |
hernia above UES, mostly male, >60 y/o |
|
S/Sx Zenker diverticulum |
dysphagia, halitosis, regurgitation, "food stuck in throat," aspiration |
|
Dx Zenker diverticulum |
barium swallow |
|
Tx Zenker diverticulum |
surgery |
|
pathophys: Schatzki ring |
found in 15% of barium swallows; defined as <12 mm; occur at GE junction; almost always assoc w/ hiatal hernia |
|
S/Sx & Dx of Schatzki ring? |
S/Sx: solid food dysphagia
Dx: endoscopy |
|
Contrary to popular belief, GERD is NOT related to... |
smoking, NSAIDs, gastric hypersecretion |
|
S/Sx GERD |
heartburn (pyrosis) - postprandial, reclining, better w/ antacid;
regurg. of bitter & sour tastes, chest pain w/ radiation to neck, wheezing/coughing
|
|
Dx GERD |
mainly based on history; may feel better w/ PPI;
most have no signs on endoscopy, barium swallow not helpful, Berstein test (acid/saline infusion) is mean |
|
Most effective treatment for reflux? |
weight loss |
|
Tx GERD |
PPIs 30 min before meals (fails b/c heartburn, improper use)
surgery - Nissen fundoplication (meat wrap) |
|
Gold standard for Dx hiatal hernia? |
barium swallow (look for air fluid level) |
|
Tx hiatal hernia |
if asymptomatic, nothing; Tx underlying GERD |
|
risk factors for Barrett's esophagus? |
white, male, smoker, chronic GERD, obesity |
|
S/Sx of Barrett's esophagus |
salmon-colored change in esophagus; S/Sx of GERD |
|
Whom might we screen for Barrett's esophagus? |
chronic GERD, hiatal hernia, >50 y/o, male, white, obese |
|
Tx Barrett's esophagus |
PPIs for underlying GERD; endoscopic ablation (1st step); esophagectomy (3-15% mortality) |
|
S/Sx of medication-induced esophagitis |
may be asymptomatic; retrosternal pain, odynophagia, dysphagia, located near aortic arch |
|
Dx medication-induced esophagitis |
endoscopy |
|
S/Sx of infectious esophagitis? Implicated pathogens? |
(candida, CMV, HSV1)
may be asymptomatic; cottony feeling, odynophagia, scrape-able pseudomembrane |
|
Dx infectious esophagitis |
KOH prep |
|
When do we see infectious esophagitis from HSV? CMV? |
HSV: solid organ transplant
CMV: AIDS |
|
most common agents causing caustic esophagitis? |
strong alkali (KOH, NaOH), drain cleaner, battery, lye |
|
Dx caustic esophagitis |
endoscopy (necrosis), barium swallow |
|
Biggest contributors to esophageal SCC in the US? |
smoking & alcohol |
|
Esophageal cancer is typically one of these 2 types: |
squamous cell carcinoma (smoking, alcohol) adenocarcinoma (from Barrett's, obesity)
adenoCA more common in US, SCC more common worldwide |
|
Name 4 factors that can contribute to the development of adenocarcinoma? |
GERD (Barrett's), obesity, smoking, hypersecretion (e.g. Zollinger Ellison syndrome)
(alcohol is NOT a risk factor) |
|
S/Sx of esophageal cancer |
solid food dysphagia, then both solid & liquid; rapid wt loss, iron deficient anemia
(mid-esophagus = SCC, lower esophagus = adenoCA) |
|
Dx esophageal cancer |
endoscopy (look for "apple core") |
|
most common specific cause of upper GI bleed? |
peptic ulcer (is from H. pylori, NSAIDs, etc) |
|
Dx upper GI bleed |
endoscopy (sensitive & specific)
if perforation risk, esophageal capsule
(NO barium - interferes w/ future endoscopy or surgery) |
|
What does an elevated BUN to creatinine ratio suggest? |
GI bleed (>20-100:1) |
|
Tx upper GI varices |
transfusion, PPI, abx, octreotide (to constrict vessels), vasopressin (decrease flow), vit K (but probs won't work), endoscopic band ligation, TIP, balloon tamponade
longterm: liver transplant |
|
S/Sx peptic ulcer disease |
dyspepsia, burning/hunger pain;
duodenal ulcer = relief w/ food gastric ulcer = worse w/ food
|
|
Dx peptic ulcer disease |
barium swallow, endoscopy
H. pylori test (may be false neg. w/ bismuth, abx, UGI bleed, PPI - need 2 tests) |
|
DDx peptic ulcer disease |
gastric carcinoma (every gastric ulcer must be biopsied); drug-induced (esp. NSAIDs) |
|
Tx peptic ulcer disease |
no smoking, NSAIDs, smoking, alcohol, stress
eradicate H. pylori (metronidazole, macrolide, PPI, peptobismol), PPI (omeprazole),
if duodenal: antacids, sucralfate |
|
Drugs to eradicate H. pylori? |
metronidazole, macrolide, PPI, peptobismol |
|
Precipitating factors for Mallory-Weiss syndrome |
vomiting, straining, seizure, trauma, colonoscopy prep, hiatal hernia |
|
Tx Mallory-Weiss syndrome |
many resolve on own
blood transfusion, inject Epi, ethanol, other sclerosants |
|
Boerhaave syndrome |
UGI bleeding, shoulder pain, free air under diaphragm on xray
rare but fatal |
|
S/Sx of lactase deficiency |
bloating, cramps, flatulence, osmotic diarrhea
(no malabsorption or wt loss) |
|
Dx lactase deficiency |
hydrogen breath test, trial of lactose-free diet |
|
S/Sx Celiac disease |
diarrhea, steatorrhea, wt loss, distention, weakness, growth retardation (if <2 y/o); fatigue, osteoporosis, iron deficiency anemia, infertility, dermatitis herpetiformis |
|
Dx Celiac disease |
IgA tTG antibody, IgA endomysial antibody
biopsy of distal duodenum or proximal jejunum (by EGD) - blunting of villi |
|
possible causes of small intestinal bacterial overgrowth (SIBO) |
gastric achlorhydria (decreased HCl), anatomic abnormality (surgery), motility disorder (scleroderma, DM), fistula |
|
S/Sx of SIBO |
malabsorption (diarrhea, gas), asymptomatic, wt loss, vit/mineral deficiencies |
|
Dx SIBO |
jejunal aspiration/culture;
fecal fat, hydrogen breath testing, may need CT enterography |
|
Tx SIBO |
Rifaxmin (cyclic therapy), cipro, norfloxacin, augmentin, flagyl + bactrim, cephalexin |
|
S/Sx short bowel syndrome |
Terminal ileum: >50 cm removed = malabsorp. B12 >100 cm removed = malabsorp. bile salts
Duodenal resection: folate, iron, calcium malabsorption |
|
Tx short bowel syndrome |
Vit/Mineral replacement: B12 injections, cholestyramine (bile salts)
loperamide, lomotil, octreotide
|
|
S/Sx of Whipple disease |
arthralgia/arthritis, abd pain, diarrhea, malabsorption, wt loss, fever, hyperpigmentation |
|
Dx Whipple disease |
endoscopic biopsy (PAS-positive macrophages w/ G+ bacilli; may need PCR to confirm) |
|
Tx Whipple disease |
abx for 1 year (ceftriaxone, meropenem, bactrim)
if untreated, fatal |
|
colon polyps - pathologic groups |
mucosal adenomatous, serrated, neoplastic, submucosal |
|
S/Sx colon polyps |
usually asymptomatic, chronic blood loss or hematochezia |
|
Dx colon polyps |
colonoscopy
FOBT, barium enema, CT colonography, capsule endoscopy |
|
Tx colon polyps |
remove during colonoscopy |
|
surveillance of adenomatous colon polyp |
1-2 small polyps: q5-10y 3+ small polyps, or >1cm: q3y >10 polyps: q1-2y |
|
surveillance of serrated colon polyp |
1-2 small polyps: q5y >1 cm polyp: q3y |
|
pathophys: familial adenomatous polyposis |
auto dominant on chrom 5; avg polyps at 15, colon cancer at 40 |
|
S/Sx familial adenomatous polyposis |
colon polyps
+ extra-intestinal manifestations (soft tissue tumors, osteomas, hypertrophy of retinal pigment) |
|
Dx familial adenomatous polyposis |
colonoscopy q1-2 starting at age 10-12
screen 1st deg relatives |
|
pathophys: Lynch syndrome |
auto dominant; "nonpolyposis colon CA" increased risk of colorectal, endometrial, renal, etc. CA |
|
surveillance of Lynch syndrome |
colonoscopy yearly beginning age 25 (or 5 years younger than Dx age)
screen family members too |
|
Tx Lynch syndrome |
yearly monitoring w/ colonoscopy, etc.
if CA, subtotal colectomy w/ ileorectal anastomosis |
|
Most common type of colorectal cancer? Where are they located |
adenocarcinoma; distal to splenic flexure |
|
risk factors for colorectal cancer? |
FHx, IBS, high fat/red meat diet, DM, obesity, smoking, etc. African Americans |
|
R-sided vs. L-sided lesions in colorectal CA? |
R-sided: more likely to bleed
L sided: more likely to cause abd pain, changes in bowel habits, obstruction |
|
S/Sx colorectal CA |
grow slowly; palpable mass, urgency, hematochezia, tenesmus (sense have to go, but don't) |
|
Dx colorectal CA |
Gold = colonoscopy; CEA
CBC for anemia, LFTs to r/o mets; CT for staging |
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surveillance after colorectal CA |
CEA q3-6m for 3-5 years
CT annually for 3 years
colonoscopy q3-5 years |
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T staging for colorectal CA |
T1: thru muscularis mucosa into submucosa
T2: thru submucosa into muscularis propria
T3: thru muscularis propria; not colon/rectum
T4: thru serosa |
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Tx for colorectal CA |
surgery, chemo, radiation
stage I-II = surgery stage III = chemo (FOLFOX) stage IV = FOLFOX + bio agent (bevacizumab, cetuximab, etc) |
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screening for colorectal CA |
>50 y/o: annual FOBT, colonoscopy q10y
if 1st deg relative, start at 40, q5y (or 10 years before Dx) |
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most common type of anal carcinoma? |
squamous cell; risk: Hx anal sex, anorectal warts, HPV |
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Dx anal carcinoma |
CT or MRI
(PET used for staging) |
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pathophys small intestine adenocarcinoma |
aggressive (most have mets @ Dx); often in duodenum or prox. jejunum; increased incidence w/ Crohn's |
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Tx small intestine adenocarcinoma |
resection, chemo
poor prognosis |
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pathophys: small intestine lymphoma |
most common in ileum; most are non-Hodgkin's lymphoma; increased incidence w/ Crohn's, Celiac, etc. |
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Dx small intestine lymphoma |
biopsy |
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Tx small intestine lymphoma |
resection +/- chemo, radiation |
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S/Sx carcinoid syndrome? |
facial flushing, cramps, diarrhea (from small intestine carcinoid tumor) |
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"step-up" therapy for IBD |
5-ASAs (Pentasa) -> steroids (prednisone) -> immunomodulators (AZA/MTX) -> anti-TNF (infliximab) |
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specific corticosteroid used for Tx of Crohn's? |
budesonide (Entocort) |
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The only biologic agent approved for use in UC? |
infliximab |
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S/Sx ulcerative colitis? |
bloody diarrhea, flares & remission
may have: abd pain, fever, anemia |
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Dx ulcerative colitis |
endoscopy (edema, friability, erosions); p-ANCA, x-ray can assess dilation
**avoid endoscopy in fulminant disease |
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Key points about Crohn's disease |
anywhere along GI tract (mouth-to-anus); transmural inflammation, crampy RLQ/periumbilical pain, skip lesions, granulomas
no surgical cure |
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Dx Crohn's disease |
ASCA (vs. p-ANCA in UC), skip leions |
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Chrohn's vs. UC? |
UC: localized to colon, continuous, superficial, bleeding, is curable (-> toxic megacolon, CA)
Crohns: throughout GI tract, skip lesions, transmural, non-bleeding, more aggressive Tx, incurable (-> abscess, obstx, stricture, fistula) |
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surveillance of pts w/ IBD? |
colonoscopy w/ biopsy q1-2 years starting 8 years after Dx (for colon CA)
If dysplasia or carcinoma, do colectomy |
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S/Sx of fulminant colitis |
toxic appearance, fever, hypovolemia, profuse bleeding (often need transfusion)
high risk for toxic megacolon |
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Tx fulminant colitis |
IV steroids (if no abscess), IV abx
may need surgery |
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toxic megacolon |
colon dilation >6 cm
Dx: abd exam & X-ray
Tx: ambulate or roll from side-to-side to decompress colon; may need surgery |
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best diagnostic test for appendicitis? |
CT |
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Tx appendicitis |
appendectomy;
broad spec abx (unasyn) before surgery |
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Location of most diverticula? |
sigmoid colon & descending colon; more common on left side (but bleeding more common on R-side) |
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most common cause of lower GI bleed? |
diverticular bleeding (large vol. hematochezia, may be maroon) |
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Tx diverticulitis |
clear liquid diet, augmentin, cipro/flagyl 7-10d
if hospitalized, zosyn
surgery = Hartmann procedure
(get colonoscopy 1 mo after Tx to r/o CA) |
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Most common cause of small bowel obstruction? Large bowel obstruction? |
Small: adhesions from surgery
Large: malignancy |
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S/Sx of bowel obstruction |
N/V, abd pain, distention, constipation, lack of flatulence, belching |
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pathophys: colonic pseudo-obstruction (ogilivie syndrome) |
spontaneous dilation of cecum & prox. colon; may occur after surgery/trauma |
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Tx colonic pseudo-obstruction |
roll pt from side to side, knee-chest position; avoid laxatives (enemas are okay);
Neostigmine (decompresses) |
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pathophys ileus |
no peristalsis w/o signs of actual obstruction; usually after surgery; assoc. w/ hypokalemia |
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Tx ileus |
manage possible causes; NPO
if opioid-related, alvimopan (mu-opioid receptor antagonist) |
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Most common cause of intestinal obstruction in kids <3 y/o? |
intussusception |
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S/Sx of intussusception? |
N/V, cramping, red currant jelly stool (blood & mucus); kid cries, draws knees to chest |
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Tx intussusception |
air/barium enema
prevent dehydration & shock (NG tube, IVF, abx, surgery) |
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pathophys: volvulus |
bowel twists on itself; males, often in 1st year
signs of obstruction, bilious vomiting
|
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Dx volvulus |
barium enema, CT |
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Tx volvulus |
surgery |
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Types of lower GI bleeds in older pts vs younger pts? |
<50 y/o: anorectal (hemorrhoids, etc), colitis
>50 y/o: diverticulitis, CA, angiectasia, ischemia |
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Dx ischemic colitis |
colonoscopy (preferred)
ABG (acidosis), CT, barium enema (thumbprinting, air-filled loops) |
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Tx ischemic colitis |
mild: supportive (bowel rest, IVF)
most improve 1-2 days |
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Dx constipation |
DRE, abd exam CBC, BMP, TSH, FOBT |
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Tx fecal impaction |
enema (saline, mineral oil) or digital removal, then prevent constipation |
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If diarrhea worsens or lasts >7 days, send for these labs... |
fecal leukocyte/lactoferrin, O & P, bacterial culture |
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antidiarrheal agents |
loperamide, lomotil, clonidine (for secretory diarrhea), octreotide (for secretory diarrhea) |
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inflammatory vs. non-inflammatory diarrhea? |
inflm: more common in colon; freq. small volume; +/- bleeding, fever, cramps, urgency (shigella, salmonella, campylobacter)
non-inflm: more mild; in small intestine; large-volume; +/- N/V, cramps (viruses, vibrio, ET E. coli, giardia) |
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staph aureus diarrhea |
meat, dairy, bakery products
abrupt N/V
clinical Dx; supportive Tx
|
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bacillus cereus diarrhea |
fried rice
acute N/V
clinical Dx; supportive Tx |
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clostridium botulinum diarrhea |
canned foods, warmed foods
diplopia, dysphagia, resp. depression
Dx toxin screen; Tx antitoxin |
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enterohemorrhagic E. coli diarrhea |
undercooked beef, unpasteurized milk/juice, raw fruit/vegetables
abrupt diarrhea, often bloody
Dx culture; Tx supportive (abx may increase HUS risk) |
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enterotoxigenic E. coli diarrhea |
water/food contaminated w/ feces;
watery diarrhea, cramps
Dx culture; Tx fluoroquinolones if severe |
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vibrio cholerae diarrhea |
water, fish, shellfish, vendor food
"rice water stool"
Dx culture; Tx fluids, tetracyclines or azithro |
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campylobacter jejuni |
poultry, unpasteurized milk, water
fever, bloody diarrhea, cramps
can develop Guillain-Barre or reactive arthritis Dx culture; Tx azithro or quinolone if severe |
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yersinia enterocolitica diarrhea |
pork, water, unpasteurized milk, tofu
severe pain (mimics appendicitis), fever, diarrhea x1-3 weeks
Dx: culture; Tx: tetracycline or fluoroquinolone |
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giardia diarrhea |
fecal-oral; drinking on camping trip
diarrhea, bloating
Dx stool antigen; Tx flagyl or tinidazole |
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Dx C diff |
gold = cytotoxicity assay for toxin B
EIA for glutamate dehydrogenase, PCR assay for toxin B |
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Tx C diff |
mild: flagyl x10-14 days
severe: vancomycin |
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patho & S/Sx of hookworm |
skin contact w/ larvae (walking thru soil); travels to lungs & small intestines
itchy rash, cough, pain, diarrhea, wt loss |
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Tx hookworm |
medendazole, ivermectin, albendazole |
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S/Sx of IBS |
intermittent lower abd pain relieved by defecation; does not wake pt at night; normal PE |
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Tx IBS |
fiber supplement, antispasmotics (bentil), antidiarrheal (loperamide), laxative (polyethylene glycol), abx (rifaximin) |
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risk factors for hemorrhoids? |
constipation, straining, prolonged sitting, obesity, low-fiber diet |
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S/Sx of anal fissure |
"tearing" pain; throbbing pain after defecation; hematochezia |
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Dx anal fissure |
DRE (if too painful, may need anesthesia) |
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Tx anal fissure |
fiber supplements, Sitz bath, topical anesthetics, topical nitro, diltiazem, botox; sphincterectomy |
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S/Sx & Tx of perianal abscess |
redness, flatulence, swelling
Tx: I&D, may need abx |