Term
What is the primary type of colorectal cancer and what type of tissue do they arise from?
What are some other less common types (name 3)? |
|
Definition
1) Adenocarcinomas (endoluminal) arising from mucosa (mucous-secreting) of adenomas
2) Carcinoid tumors, lymphomas, Kaposi sarcoma |
|
|
Term
| What is the most sensitive and specific screening test for colorectal cancer? |
|
Definition
Colonoscopy is test of choice for patients with positive FOBT (both diagnostic and therapeutic).
Start at age 50, unless one family member has CRC, then begin at 40 or 10 years before onset of family member.
Other options include flexible sigmoidoscopy and barium enema (but need to be confirmed with colonoscopy). |
|
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Term
| How is carcinoembryonic antigen (CEA) used in the treatment of colorectal cancer? |
|
Definition
Useful for monitoring treatment efficacy and recurrence surveillance.
Patients with preoperative CEA> 5ng/mL have worse prognosis.
NOT used in screening |
|
|
Term
| What are the common types of spread of colorectal cancer. |
|
Definition
**20% have distant metastatic disease at presentation**
1) Direct: circumferentially and then through bowel wall to invade abdomino perineal organs
2) Hematogenous: Portal circulation to liver (most common site of distant spread)
- Lumbar/vertebral veins to lungs.
3) Lymphatic- regionally
4) Transperitoneal and intraluinal |
|
|
Term
| Describe the 7 primary risk factors for colorectal cancer |
|
Definition
1) Age (>50)
2) Adenomatous polyps
- villous adenomas have higher malignant potential than tubular
- size and number predicts malignant potential
3) Personal history of prior CRC
4) IBD (UC>CD)
5) Family history
- multiple first degree relatives or any first degree relative <60 when diagnosed
6) Dietary factors- high-fat, low fiber
7) Major polyposis syndromes |
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Term
What major polyposis syndrome is described by each of the following and how are they treated?
1) AD disease caused by mutations in APC tumor suppressor
2) AD disease with adenomas and osteomas, as well as dental abnormalities, desmoid tumors and/or sebaceous cysts
3) Can be AD or AR and is associated with cerebellar medulloblastomas and gliomastoma multiformes
4) AD disease with single or multiple, scattered hamartomas throughout the GI tract and pigmented spots around the lips, oral mucosa, face, genitalia and palmar structures
5) Rare disease present in childhood characterized by >10 juvenile colonic polyps
6) Hereditary CRC without adenomatous polyposis |
|
Definition
1) Familial adenomatous polyposis (FAP)
- 100% get CRC by 3rd or 4th decade so prophylactic colectomy is recommended
2) Gardner syndrome (variant of FAP)
- 100% get CRC by age 40, so prophylactic collectomy
3) Turcot syndrome
4) Peutz-Jeghers
- Hamartomas are less likely to become malignant compared to adenomas, so risk of CRC is only slightly increased (Intussuseption or GI bleeding can occur however).
5) Familial juvenile polyposis coli
- low risk of CRC
6) Hereditary nonpolyposis CRC
- Lynch syndrome 1 (site-specific CRC): early onset without antecedent multiple polyposis
- Lynch syndrome 2 (cancer family syndrome): Lynch 1 plus increased number of early occurrent of other cancers |
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Term
| What is the most common cause of large bowel obstruction in the adult and what is the most life-threatening complication? |
|
Definition
Colorectal cancer (adenocarcinoma)
Bowel perforation with development of peritonitis |
|
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Term
60 year old male presents with severe abdominal pain, weight loss and melena. You also detect an anemia on CBC. However, no changes in bowel habits are reported.
What test do you order and what is your presumptive diagnosis? |
|
Definition
Age and symptoms/signs indicate colorectal cancer. Combination of melena and unchanged bowel habits indicate Right-sided tumor (large luminal diameter of cecum make obstruction less likely).
Order a CT and treat with surgery with pre-operative CEA. |
|
|
Term
| What major features differentiate between right- and left-sided CRCs? |
|
Definition
1) Right sided tumors typically involve anemia, weakness and RLQ mass. Melena (upper bleed) without bowel obstruction is common.
2) Left-sided tumors are typically smaller and are more likely to cause bowel obstruction with mhematochezia
20-30% of CRCs are rectal cancer (think tenesmus) |
|
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Term
| What are the major types of polyps and which are most concerning for CRC? |
|
Definition
Most patients are asymptomatic, but most common symptom is rectal bleeding.
1) Nonneoplastic
- benign without malignant potential (hyper plastic, juvenile and/or inflammatory)
2) Adenomatous- benign, but with malignant potential
- Tubular (most common and low risk)
- Tubulovillous- intermediate
- Villous (greatest risk) |
|
|
Term
Where are polyps most commonly found?
What features of polyps make them more worrisome? |
|
Definition
Retrosigmoid region
1) Villous shape (sessile>pedunculated)
2) Atypia of cells
3) Adenomatous
4) Larger size |
|
|
Term
What is diverticulosis and how does it relate to diverticulitis?
How do you diagnose it and treat it? |
|
Definition
1) Diverticulosis is caused by increased intraluminal pressure in the colon, typically in the sigmoid region, leading to out pouching of colonic tissue
- associated with low-fiber diets and family history, in older adults
2) Diverticulitis is inflammation and/or infection of diverticula (it is a complication of diverticulosis)
3) Diagnose with Barium enema and treat with high-fiber foods and Psyillium (if patient cannot tolerate bran) |
|
|
Term
What are the major complications of diverticulosis?
What about diverticulitis? How are they treated? |
|
Definition
1) Diverticulosis is outpouching (typically sigmoid) of colonic material due to increased intraluminal pressure
- Complications include painless rectal bleeding and diverticulitis
2) Diverticulitis is inflamed and/or infected diverticula due to impacted feces and complications include bowel obstruction, abscess and fistula.
- Treat abscess with drainage (CT-guided percutaneous or surgically)
- Fistulas (typical colovesicular) close spontaneously half of the time
- Obstructions are due to chronic inflammation
- Free perforations are uncommon, but can be catastrophic (peritonitis) |
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Term
60 year old female presents with fever, LLQ pain and leukocytosis. She is also complaining of constipation.
What do you rodder and how would you treat? |
|
Definition
Age, pain location and changes in bowel habits make you worry about diverticulitis. Fever raises concerns further.
1) Order CT of abdomen and pelvis with oral and IV contrast
2) Radiographs can help rule out other causes of LLQ pain such as obstruction (air-fluid levels) and perforation (free air)
3) DO NOT order barium enema and colonoscopy because of risk of perforation.
4) If uncomplicated, treat with IV antibiotics, bowel rest (NPO) and IV fluids
- Surgery is indicated for recurrent uncomplicated events or complicated (abscess, perforation or obstruction) |
|
|
Term
True or false:
1) Hematochezia is rare is diverticulitis
2) Barium enema is the test of choice for diverticulitis |
|
Definition
1) True, but lower GI bleeds are common in diverticulosis
2) FALSE, can cause perforation. Use a CT and perhaps a radiograph. Barium enema is test of choice for diverticulosis. |
|
|
Term
| Patients with bleeding colonic AVMs also tend to have which particular heart disease? |
|
Definition
|
|
Term
True or False
Bleeding AVMs is a common cause of lower GI bleeding in patients over 60 and bleeding will typically stop spontaneously. |
|
Definition
True
Can order a barium enema to rule out diverticulosis |
|
|
Term
| What are the four types of acute mesenteric ischemia |
|
Definition
Patients commonly have pre-existing heart disease (CHF or CAD) and typically occurs in SM vessels
- Overall mortality is 60-70% with >90% if infarction to bowel has occurred
1) Arterial Embolism (50%)- cardiac origin
- Typically painful and sudden
2) Arterial Thrombosis (25%)
- Typically gradual and less severe pain
3) Non-occlusive mesenteric ischemia (20%)- Splanchnic vasoconstriction secondary to reduced CO
- Occurs in critically ill patients
4) Venous thrombosis (<10%)
- Symptoms may be present for days-to-weeks with gradual worsening |
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|
Term
| What are the major branches and supply areas of the SMA? |
|
Definition
Supplies pancreas and colon, from lower duodenum to initial 2/3 of transverse colon
1) Inferior pancreaticuduodenal
2) Intestinal (jejunum and illeum)
3) Ileocolic (illeum, cecum, appendix)
4) Right colic artery (ascending colon)
5) Middle colic artery (transverse colon) |
|
|
Term
| What are the major branches and supply areas of the IMA? |
|
Definition
distal 1/3 of transverse colon (splenic flexure), descending and sigmoid colons, to upper part of rectum
1) Left colic artery (descending colon)
2) Sigmoid artery
3) Superior rectal artery |
|
|
Term
| What are the major branches and supply areas of the celiac trunk? |
|
Definition
Liver, Stomach, Abdominal esophagus, Spleen, Duodenum and Pancreas (Foregut)
1) Left Gastric Artery
- esophageal branch and stomach branch
2) Common hepatic artery
- Proper hepatic artery (left and right hepatic arteries, with cystic artery off of right)
- Gastroduodenal artery (Supraduodenal and superior pancreaticoduodenal)
- Right gastric (anastomoses with left gastric off of trunk)
3) Splenic artery
- dorsal pancreatic artery
- short gastric arteries
- left gastro-epiploic
- greater pancreatic artery |
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|
Term
Patient presents in hypotension, tachypnea, fever, and altered mental status.
They report severe abdominal pain that is disproportionate to your physical findings.
What level should you check and what test should you run to confirm your diagnosis?
How would you treat if you are correct? |
|
Definition
Sounds like acute mesenteric ischemia (classic pain of ischemia).
1) Check the lactate level (typically lactic acidosis is present) and order Mesenteric Angiography.
**plain films may help to rule out other causes of abdominal pain, and "thumb printing" is typical on barium enema due to thickened edematous mucosal folds**
2) IV fluid and broad-spectrum antibiotics
- If disease is arterial, direct intra-arterial Papaverine (vasodilator) into SMA during arteriography is treatment of choice (AVOID VASOPRESSORS)
- heparin if disease is venous thrombosis |
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|
Term
What differentiates acute and chronic mesenteric ischemia?
How are they diagnosed? |
|
Definition
Both need mesenteric arteriography
1) Acute is more common and typically involves acute embolic and/or thrombotic events
- abdominal pain out of proportion to PE is classic
2) Chronic is caused by atherosclerotic occlusive disease of main mesenteric vessels
- Abdominal angina with dull, postprandial pain is typical, as well as weight loss due to pain. |
|
|
Term
| What is Ogilvie syndrome? |
|
Definition
| Patients that are topically ill and have history of recent surgery, medical illness or drug abuse that present with signs and symptoms of bowel obstruction WITHOUT mechanical obstruction. |
|
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Term
Patient presents with symptoms of colitis 1 week after receiving clindamycin for a bacterial infection.
What complications are you worried about and how would you diagnose/treat? |
|
Definition
Pseudomembranous colitis due to C. dificile
1) Diagnose with toxin assay in stool (24 hours), and can also use flexible sigmoidoscopy
2) Toxic megacolon, colonic perforation , anasarca and electrolyte disturbances are all concerns.
Discontinue agent iff possible and treat with Metranidazole or Vancomycin (in infants and pregnant patients) |
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|
Term
70 year old male patient presents with acute onset of colicky abdominal pain, with abdominal distention and nausea.
On plain films you see an Omega Loop sign. What is going on? What do you do next? |
|
Definition
There is a volvulus of the sigmoid colon (twisting of a loop of intestine about mesenteric attachment site).
Sigmoid is common location in adults (75%) with Cecal volvolus being more common in kids (congenital lack of fixation of right colon)
Confirm sigmoid volvulus with Sigmoidoscopy (typically used to treat too) (Cecal volvulus requires surgery)
Barium enema will often show "Birds beak," BUT DO NOT perform is strangulation is suspected. |
|
|
Term
| What are the most common causes of Cirrhosis and how is it diagnosed? |
|
Definition
1) Alcoholic fatty liver disease and Chronic viral infection (Hep B and especially C)
- Also Drugs (acetaminophen, methotrexate), Autoimmune hepatitis, Primary and Secondary biliary cirrhosis, Inherited metabolic disease, Hepatic congestion from RHF, AAT deficiency, Venoocclusive disease and Nonalcholic steatoheaptitis (NASH)
2) Gold standard is liver biopsy |
|
|
Term
| Describe the pathophysiology of Cirrhosis. What are the 2 major functional consequences. |
|
Definition
Damaged liver cells are replaced by fibrosis and liver anatomy is distorted.
1) Decreased blood flow through liver causes hypertension in portal circulation (Portal Hypertension), which leads to ascites, peripheral edema, splenomegaly and varicosity of veins
2) Hepatocellular failure leads to impairment of biochemical functions (albumin synthesis, clotting factors ect.) |
|
|
Term
| How is Hepatic Functional reserve evaluated in liver failure and cirrhosis? |
|
Definition
Child-Pugh Score: measures severity and used to predict morbidity and mortality
A (5-6 points- mild), B (7-9 points- moderate), C (10-15 points- severe).
A- 85% 2 year survival
B- 57% 2 year survival
C- 35% 2 year survival
1, 2 or 3 points given for Ascites, Bilirubin levels, Encephalopathy, INR ratio and Albumin |
|
|
Term
| Name 6 classic signs of chronic liver disease |
|
Definition
1) Ascites (portal hypertension)
2) Varices (portal hypertension)
3) Gynecomastia and testicular atrophy
4) Palmar erythema, spider angiomas on skin
5) Hemorrhoids
6) Caput medussa |
|
|
Term
Patient with history of alcoholism presents with hematemesis and reports recent episodes of melena.
How might you diagnose and treat this? |
|
Definition
Sounds like bleeding esophageal varices secondary to portal hypertension in liver failure.
This is the most common life-threatening complication. You can help to confirm the diagnosis with paracentesis and you should lower portal pressure with TIPS (transjugular intrahepatic portal-systemic shunt) |
|
|
Term
| How are bleeding esophageal varices treated? |
|
Definition
Common life-threatening consequence of liver failure in cirrhosis leading to portal hypertension
**Pharmacologic treatment with IV Octreotide and Endoscopy treatment (vatical ligation or Sclerotherapy)**
1) Variceal ligation/banding
- Emergent upper GI endoscopic treatment with low rate of re-bleeding
2) Endoscopy sclerotherapy
- risk of re-bleeding in 50% of patients
3) IV vasopressin
- Alternative to octreotide, but risk of complications includes mesenteric ischemia.
4) IV octreotide infusion
- First line therapy, causes splanchnic vasoconstriction and reduces portal pressure |
|
|
Term
| What do you do if non-bleeding esophageal or gastric varicose are detected in a patient with Cirrhosis? |
|
Definition
| Treat prophylactically with beta blocker (or similar agent). |
|
|
Term
| How does Octreotide work and when might you give it to a patient with liver disease |
|
Definition
1) Analogue of somatostatin that lowers portal pressures
2) IV treatment of bleeding varices along with Upper GI endoscopic ligation/sclerotherapy |
|
|
Term
| What is on your differential for a patient with Ascites? |
|
Definition
1) Cirrhosis, portal HTN
2) CHF
3) Chronic renal disease
4) Massive fluid overload
5) TB peritonitis
6) Malignancy
7) Hypoalbuminemia
8) Peripheral vasodilation secondary to endotoxin-induced release of NO
9) Impaired liver inactivation of aldosterone. |
|
|
Term
How can liver failure produce abdominal distention with shifting dullness and a positive fluid wave?
How can you tell whether it is due to portal hypertension vs. another cause? |
|
Definition
1) Ascites
- Portal HTN (increased hydrostatic pressure)
- Hypoalbuminemia (decreased oncotic pressure)
2) Portal hypertension is diagnosed by paracentesis
- measure serum ascites albumin grandient. If > 1.1 g/dL, portal HTN is very likely. If <1.1 g/dL, portal HTN less likely |
|
|
Term
| How can you tell whether Ascites is due to portal hypertension? |
|
Definition
Portal hypertension is diagnosed by paracentesis
and measurement of serum ascites albumin grandaunt.
If > 1.1 g/dL, portal HTN is very likely.
If <1.1 g/dL, portal HTN less likely |
|
|
Term
| How is Ascites typically managed? |
|
Definition
- Salt restriction and diuretics in most cases
- Can alter perform TIPS and therapeutic paracentesis. |
|
|
Term
How does hepatic encephalopathy develop in liver failure?
What are the characteristic features? |
|
Definition
1) Liver cannot break Ammonia down into Urea, and ammonia builds up causing encephalopathy in 50% of cirrhosis cases.
Precipitants include alkalosis, hypokalemia (from diuretics), sedating drugs and bleeding.
2) Decreased mental function, confusion
- Asterixis (flapping tremor)
- Rigidity/hyper-reflexia
- Fector hepaticus (musty odor of breath from Ammonia) |
|
|
Term
| How is hepatic encephalopathy treated? |
|
Definition
1) Lactulose
- prevents NH4+ absorption
- when lactulose is broken down colon, NH4+ forms where it cannot be absorbed, and is then excreted.
2) Rifaximin (antibiotic)
- Kills floors that produce ammonia
3) Diet (limit protein intake) |
|
|
Term
A patient with Cirrhosis has developed hypotension and lowered urine sodium.
What are you worried about and what can you do? |
|
Definition
Hepatorenal syndrome indicating end-stage liver disease
This is a "functional" renal failure due to vasoconstriction of renal vessels (volume repletion will not work).
Liver transplant is only cure |
|
|
Term
A patient with ascites exhibits abdominal pain, fever and confusion, and undergoes paracentesis. Examination of the fluid shows WBCs >500 and PMNs >250.
What do you do? |
|
Definition
Sounds like spontaneous bacterial peritonitis (SBP)
Need to treat early because mortality can be high.
- Broad spectrum antibiotics and then specify once organisms is found
- Look for clinical improvement in 24-48 hours and repeat paracentesis in 2-3 days to document decrease in ascitic fluid PMN (<250). |
|
|
Term
| Why do spider angiomas, palmar erythema, gynecomastia and testicular atrophy occur in cirrhosis? |
|
Definition
| Hyper-estrinism because of decreased hepatic catabolism. |
|
|
Term
| How is coagulopathy treated in cirrhosis? |
|
Definition
FFP
Vitamin K cannot be used by diseased liver. |
|
|
Term
| What are the 11 major complications Liver Failure? |
|
Definition
AC 9H
Ascites
Coagulopathy
Hypoalbuminemia
pHTN
Hyperammonemia
Hepatic encephalopathy
Hepatorenal syndrome
Hypoglycemia
Hyperbilirubinemia/janduce
Hyper-estrinism
HCC |
|
|
Term
| What are some major signs of acute liver failure? |
|
Definition
1) Coagulopathy (bleeding)
2) Jaundice (bilirubin not broken down)
3) Hypoglycemia (liver stores of glycogen)
4) Hepatic encephalopathy
5) Elevated LFTs
6) Complications of Cirrhosis |
|
|
Term
| How is Cirrhosis treated? |
|
Definition
1) Underlying causes (alcohol abstinence and interferons for Hepatitis B and C)
2) Avoid liver-toxic agents (acetaminophen, alcohol)
3) Treat complications as they develop
- Varices (octreotide IV with endoscopic ligation)
- Ascites (salt restriction and diuretics)
- hepatic encephalopathy (Lactulose and Rifaximin)
4) Cure requires liver transplant (requires abstinence from alcohol for 6 months) |
|
|
Term
| What is the pathophysiology of the disease associated with Kayser-Fleischer rings? |
|
Definition
Wilson's disease
- AR disease where copper incorporation into ceruloplasmin is impaired and copper cannot be excreted in bile
- Copper builds up in liver cells and once cells die, it ends up in cornea (rings), CNS (parkinsonian symptoms) and kidney (aminoaciduria and nephrocalcinosis) |
|
|
Term
| How is Wilson's disease diagnosed and treated? |
|
Definition
1) Hepatic Disease, Decreased serum ceruloplasmin (90%) and.or Liver biopsy
- If diagnosed, screen first-degree relatives
2) Chelating agents (d-penicillamine) and Zinc (prevents uptake of dietary copper)
**If non-responsive, consider liver transplant** |
|
|
Term
| Name 2 common causes of secondary hemochromatosis |
|
Definition
1) Iron overload from multiple transfusions
2) Chronic hemolytic anemia |
|
|
Term
| What organs are typically affected by Hemochromatosis? |
|
Definition
AR disease with Hyper-absorption of iron in intestine
**Patients are often asymptomatic other than slightly elevated ALT and AST early in the course**
1) Liver (cirrhosis is major worry)
2) Pancreas (diabetes)
3) Heart (cardiomyopathy)
4) Joints (arthritis)
5) Skin (hyper pigmentation)
6) Thyroid (hypothyroidism) |
|
|
Term
| How is Hemochromatosis diagnosed and treated? |
|
Definition
AR disease of excessive iron absorption in intestine
1) Diagnosis
- elevated serum iron/ferritin
- elevated iron saturation (transferrin saturation)
- decreased total iron-binding capacity (TIBC)
- Liver biopsy REQUIRED
- genetic testing
2) Treatment
- Repeated phlebotomies and treat complications (consider liver transplant in advanced disease) |
|
|
Term
| What would you suspect the cause to be of RUQ pain and fullness in a 20 year old woman who uses contraceptives? |
|
Definition
Hepatocellular Adenoma (Benign liver tumor)
- Also increased risk with anabolic steroid use
- Major worry is Adenoma rupture, so confirm with CT, US or arteriography.
- Stop contraceptives and resect if >5cm and does not regress after stopping contraceptives. |
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Term
| What is the most common type of benign liver tumor? |
|
Definition
Cavernous Hemangioma
- vascular tumors that only cause issues when they get really big or rupture
- UC or CT with IV contrast but do not biopsy because of rupture risk |
|
|
Term
| What types of benign liver tumors occur in young women of reproductive age? |
|
Definition
1) Hepatocellular adenoma (contraceptives and anabolics)
- risk of rupture so resect if >5cm and does not regress with contraceptive stopping
2) Cavernous Hemangioma (most common- associated with contraceptives)
3) Focal Nodular Hyperplasia (no association with contraceptives). |
|
|
Term
| What are the 2 major types of HCC and in what groups are they seen? |
|
Definition
80% of liver cancer (primary) is HCC
1) Nonfibrolamellar (most common)
- Hepatitis B or C and Cirrhosis
- Very low survival
2) Fibrolamellar
- Not associated with Hep B or C or Cirrosis
- Often resectible
- Seen in adolescents and young adults |
|
|
Term
| What are the major risk factors for HCC? |
|
Definition
1) Cirrhosis (mainly for nonfibrolamellar HCC)
2) Chemical carcinogens (aflatoxin, vinyl chloride, thorotrast)
3) AAT deficiency
4) Hemochromatosis
5) Schistosomiasis
6) Hepatic adenoma (10% risk)
7) Cigarettes
8) Glycogen storage diseases (type 1) |
|
|
Term
| What are the prognoses for resectable and non-resectable HCCs? |
|
Definition
1) Resectible (often fibrolamellar)
- 25% at 5 years
2) Non-resectible (nonfibrolamellar)
- less than 1 year |
|
|
Term
| What diagnostic strategies are used for HCC? |
|
Definition
1) Biopsy required
2) Hepatitis B and C serology, LFTs and coagulation tests
3) Imaging (US, CT, MRI if surgery is option)
4) Tumor marker elevation (AFP) for screening and monitoring response to therapy |
|
|
Term
|
Definition
1) Resection in 10% who have resectible tumors
2) Transplant if early ddx
3) transcatheter arterial chemoembolization (TACE) may work |
|
|
Term
How might you see all the pathological signs of alcoholic fatty liver disease in liver histology in a patient who does not drink alcohol?
What is the prognosis like? |
|
Definition
Nonalcoholic Steatohepatitis. Usually in obesity, hyperlipidemia and/or DM
Usually good (though 10-15% develop cirrhosis)
Treatment is not clearly established |
|
|
Term
|
Definition
Blood draining into duodenum via common bile duct (CBD).
Arteriogram is diagnostic and Upper GI endoscopy shows blood at ampulla of Vater (with CBD and pancreatic duct empty into Duodenum)
Resuscitate and maybe surgery |
|
|
Term
| What are the major types of liver cysts and what are their usual consequences? |
|
Definition
1) Polycystic
- AD associated with polycystic kidney disease
- Kidney disease is the problem, whereas liver generally is not
2) Hyatid
- Echinococcus granulosus (tapeworm) infection in right lobe
- Treatment is resection and Mebendazole after surgery (because of chance of rupture and anaphylactic shock) |
|
|
Term
| What are the major types of liver abscesses and where are they found? |
|
Definition
Right lobe- treat early or life threatening!
1) Pyogenic: most common cause of biliary tract obstruction
- E. coli, Klebsiella, Proteus, Enterococcus and anaeurobes
- Diagnose with US or CT
- Treat with IV antibiotics and percutaneous drainage (otherwise fatal!)
2) Amebic: common in homosexual men transmitted via fecal oral contact.
- Entamoeba histolytica (reaches liver via HPV)
- Diagnose with IgG enzyme immunoassay and stool antigen test
- IV metronidazole and therapeutic aspiration may be necessary. |
|
|
Term
| What is Budd-Chiari Syndrome and how is it diagnosed/treated? |
|
Definition
1) Occlusion of hepatic venous outflow leads to hepatic congestion and ischemia, with gradual development of pHTN.
2) Hepatic venography and serum ascites albumin gradient to ddx
- Treat with surgery is usually necessary (balloon angioplasty with stent in IVC) although anticoagulation may work |
|
|
Term
| Describe the basic metabolism of bilirubin and how it helps you to distinguish direct and indirect hyperbilirubinemias. |
|
Definition
80% comes from hemoglobin (RBC breakdown) and 20% from myoglobin
- HGB broke down to bilirubin in spleen, bilrubin binds albumin in plasma and travels to liver (NOT water soluble), and is conjugated in liver and excreted into intestine (now water soluble). In intestine, conjugated bilirubin is broken down by bacteria into urobilinogen and urobilin.
- Unconjugated bilirubin is not water solube and therefore cannot show up in urine (Indirect)
- Conjugated bilirubin is water soluble so high levels can lead to urinary excretion (dark urine) and also to pale stools. |
|
|
Term
| What are the 3 major causes of Jaundice? |
|
Definition
1) Hemolysis
2) Liver disease
3) Biliary obstruction |
|
|
Term
| What are the 2 major causes of conjugated (direct) Hyperbilirubinemia (dark urine and pale stools)? |
|
Definition
1) Decreased intrahepatic excretion
- liver disease
- Inherited (Dubin-Johnson, Rotor Syndrome)
- drug-induced (oral contraceptives)
- PBC
- PSC
2) Extrahepatic obstruction
- Gall stones
- Carcinoma of head of pancreas
- Cholangiocarcinoma
- PEriampullary tumors
- Extrahepatic biliary atresia |
|
|
Term
| What are the 2 major causes of Uncongugate (indirect) Hyperbilirubinemia? |
|
Definition
1) Increased production: Hemolytic anemia
2) Decreased hepatic uptake
- Gilbert (AD) lack of activity of UDP glucuronyl transferase
- Drugs (sulfonamides, PCN, rifampin, radiocontrast)
- Crigler-Najar (type 1 is complete absence of UDP gluculuronyl transferase leading to brain damage at birth) (type 2 is partial lack that is detected in hepatic tissue but not as severe as type 1)
- Physiological jaundice of newborn (immature conjugation)
- Diffuse liver disease |
|
|
Term
What are ALT and AST and how do they differ?
How can they be used to diagnose liver disease? |
|
Definition
1) ALT is more sensitive and specific for liver than AST
2)
- IF AST: ALT ratio is >2, think alcohol
- If AST and ALT mildly elevated think chronic viral hepatitis or acute alcohol hepatitis
- If AST and ALT are moderately elevated (high hundred to thousands), think acute viral hepatitis
- If AST and ALT are severely elevated (>10k) think extensive hepatic necrosis due to ischemia, acetaminophen toxicity or severe viral hepatitis. |
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|
Term
True or False:
ALT and AST are often low in Cirrhosis and metastatic liver disease |
|
Definition
| True, because number of functioning hepatocytes is low |
|
|
Term
| What are 5 causes of elevated liver enzymes in the asymptomatic patient? |
|
Definition
ABCDEFGHI
1) Autoimmune hepatitis
2) Hepatitis B
3) Hepatitis C
4) Drugs or toxins (tylenol especially)
5) Ethanol
6) Fatty Liver (triglyceridemia)
7) Growths (tumors)
8) Hemodynamic disorders (CHF)
9) Iron (hemochromatosis), copper (wilson's) or AAT deficiency |
|
|
Term
What is the typical LFT pattern in Cholestatic disease?
How is this different from the Hepatocellular necrosis or inflammation picture? |
|
Definition
1) Cholestatic: Markedly elevated Alkaline phosphatase and GGT, with ALT/AST mildly elevated.
2) Hepatocellular: Normal or slightly elevated Alk phos and GGT, with markedly elevated ALT/AST |
|
|
Term
| How is Alkaline phosphatase (ALK-P) used in LFT diagnosis? |
|
Definition
No specific to liver, also found in bone, gut and placenta
- elevated when obstruction to bile flow i spresent (cholestasis)
- If very high (10 fold increase), think extra hepatic biliary tract obstruction or intrahepatic cholestasis (PBC ro drug-induced cirrhosis)
- IF elevated, measure GGT to make sure elevation is hepatic in origin. If GGT normal, think about pregnancy or bone disease. |
|
|
Term
| What diseases involve loss of albumin? |
|
Definition
1) Chronic liver disease
2) Nephrotic syndrome
3) Malnutrition
4) Inflammation (burns, sepsis, trauma) |
|
|
Term
| Describe the basic workup of a patient with Jaundice |
|
Definition
1) History, PE and Labs (LFTs with ALT/AST/ALK-P/GGT/albumin/bilirubin/PT)
2a) Normal LFTs
- conjugated hyperbilirubinemia (Dubin-Johnson, Rotor)
- unconjugated (Gilbert, drugs, hemolysis)
2b) Abnormal LFTs
- Suspected intraheptic disease (viral serology, stop drugs, consider biopsy)
- Suspected extra hepatic disease (U/S or CT imaging) |
|
|
Term
| What are the two major types of gall stones and what illnesses are each associated with? |
|
Definition
Most stones are MIXED
1) Cholesterol stones (yellow to green)
- obesity, diabetes, hyperlipidemia
- multiple pregnancies, oral contraception
- CD
- age
- NA ancestry
- Cirrhosis
- CF
2) Pigment (black or brown)
- Black: Hemolysis (SSD, thalassemia, herediatary spherocytosis, artificial valves) or Alcoholic Cirrhosis
- Brown: Biliary tract obstruction |
|
|
Term
You order LFTs on a patient who complains of colicky RUQ pain as well as in the right subscapular region that increases after eating and at night.
LFTs show elevated GGT and ALK phos, with minimally elevated AST/ALT.
What is your next step in the workup? What are you most worried about? |
|
Definition
You are worried about Cholestasis due to biliary obstruction.
Right subscapular pain in Boas sign and increase in pain after eating and at night is classic
Order an abdominal or RUQ Ultrasound.
33% of patients with biliary colic develop acute cholecystitis within 2 years. |
|
|
Term
| How does the pain experienced in acute cholecystis differ from the pain in biliary colic? |
|
Definition
1) Acute cholecystitis: secondary to inflammation of gallbladder wall and lasts a few days
2) Colic: secondary to contraction of gallbladder against obstructed cystic duct. |
|
|
Term
| Name 6 signs of biliary tract obstruction |
|
Definition
1) Elevated alk phos and increased GGT
2) Conjugated hyperbilirubinemia
3) Jaundice
4) Pruritis
5) Clay-colored stools
6) Dark urine |
|
|
Term
Patient presents with RUQ pain, fever and leukocytosis.
Additionally, patient exhibits inspiratory arrest upon deep palpation of the RUQ.
What is your first step in the workup and how will you likely treat? |
|
Definition
Sounds like Acute Cholecystitis (obstruction of cystic duct induces inflammation of gallbladder wall).
Murphy sign is classic, as is triad of RUQ pain, fever and leukocytosis
1) Order RUQ US +/- CT and or radionucleuotide scan (HIDA)
2) Admit patient
- IV fluids and antibiotics, bowel rest (NPO), analgesics, correct electrolytes
- Cholecystectomy indicated in most patients because of recurrence likelihood |
|
|
Term
| What are the most important complications (5) of acute cholecystitis? |
|
Definition
Inflammation of GB wall in response to cystic duct obstruction (NOT infection)
1 ) Gangrenous cholecystitis (life-threatening)
2) Perforation (life-threating)
3) Emphysematous cholecystitis
4) Cholecystoenteric fistula with gallstone illeus (obstructs ileum)
5) Empyema of gallbladder. |
|
|
Term
| How does Choledocholithiasis differ from cholelithiasis? How is each diagnosed? |
|
Definition
1) Choledocholithiasis:
- Stones are in CBD
- RUQ pain and jaundice
- Diagnose with ERCP (also treatment via sphincterotomy and stone extraction withs stent placement
- can lead to cholangitis
2) Cholelithiasis:
- Stones are in cystic duct
- Asymptomatic or biliary colic
- Diagnose with RUQ ultrasound
- no treatment necessary but can lead to cholecystitis |
|
|
Term
| What are the important complications of choledocholithiasis? |
|
Definition
Stones in the CBD (unlike the cystic duct) can have life-threatening consequences
1) Cholangitis
2) Acute pancreatitis
3) Obstructive jaundice
4) Biliary cirrhosis
5) Hepatic abscess is most serious and life threatening |
|
|
Term
Patient presents with RUQ pain, jaundice and a fever.
They also seem confused and are showing signs of shock.
What do you do? |
|
Definition
Fever, Jaundice and RUQ pain= Charcot Triad of Cholangitis (usually secondary to stone in CBD in choledocholithiasis). This is an infection of the biliary tract secondary to obstruction.
Addition of altered mental status and shock= Reynolds Pentad, which can be RAPIDLY FATAL
1) Order RUQ US (Cholangiography can be ordered after acute cholangitis diminishes)
2) Treat with IV antibiotics and IV fluids. Once patient is stabilized, decompress the CBD via PTC (catheter drainage) or ERCP (sphincterotomy) |
|
|
Term
| What is a "Porcelain Gallbladder" and why is it worrisome? |
|
Definition
Intramural calcification of GB wall, with 50% of patients developing cancer (adenocarcinoma) of the gallbladder (90% mortality at 1 year).
Prophylactic cholecystectomy indicated. |
|
|
Term
| What is Primary Sclerosing Cholangitis and what are the important complications? |
|
Definition
Progressive thickening of bile duct walls and narrowing of ducts (either intrahepatic or extra hepatic) leadings to cirrhosis, pHTN and liver failure.
**Associated with UC (50-70%)**
**Diagnose with PTC/ERCP (bead-like strictures) and requires liver transplant**
1) Cholangiocarcinoma
2) Recurrent cholangitis
3) Can progress to secondary biliary cirrhosis, portal HTN and liver failure |
|
|
Term
How do PBC and PSC differ in terms of each of the following
1) Pathology
2) Demographics
3) Associated IBD
4) Diagnosis
5) Treatment |
|
Definition
PBC
1) Intrahepatic bile duct obstruction
2) F> M
3) None
4) +AMAs and confirm with liver biopsy
5) Ursodeoxycholic acid slows progression and ultimately requires liver transplant
PSC
1) Intra and extra hepatic bile duct obstruction from wall thickening and luminal narrowing
2) M>F
3) UC> CD
4) PTC/ERCP (bead-like structuring)
5) Liver transplant |
|
|
Term
| What is the treatment for the autoimmune disease that is characterized by intrahepatic bile duct destruction occurring in middle-aged woman with presence of anti-mitochondrial antibodies. |
|
Definition
Primary Biliary CIrrhosis
1) Slow progression with Ursodeoxycholic acid
2) Liver transplant
3) Cholestyramine for pruritis and Calcium/bisphosphonates/vit D for Osteoporosis. |
|
|
Term
| What is a "Klatskin Tumor"? |
|
Definition
| Cholangiocarcinoma in proximal third of BCD, invovling the junction of the right and left hepatic ducts (VERY poor prognosis because resection is difficult). |
|
|
Term
| What is the workup for a suspected Choledochal cyst? |
|
Definition
| Ultrasound and then treatment is surgery with complete resection (risk of cholangiocarcinoma) |
|
|
Term
| What are the 4 major etiologies of secondary biliary cirrhosis? |
|
Definition
Destruction of intrahepatic bile ducts
1) Long-standing mechanical obstruction (iatrogenic stricture)
2) Sclerosis cholangitis
3) Cystic fibrosis
4) BIliary atresia |
|
|
Term
| How is CCK used to diagnose biliary dyskinesia? |
|
Definition
Relaxes sphincter of Oddi and contracts gallbladder.
Under HIDA scan, GB is filled with radio nucleotide and CCK is used to check EF. Treat with cholecystectomy |
|
|
Term
Define the following important signs of appendicitis
1) Rovsing
2) Psoas
3) Obturator |
|
Definition
Lumenal obstruction leads to stasis, promoting bacterial growth and inflammation, which can lead to necrosis, perforation and peritonitis.
1) Deep palpation of LLQ leads to pain in RLQ
2) RLQ pain when right thigh is extended as patients lies on left side
3) Pain in RLQ when flex right thigh is internally rotted while patient is supine |
|
|
Term
A patient with signs of anorexia, nausea and vomiting presents with stomach pain. It began in the epigastrium, and traveled to the umbilicus and is now in the RLQ.
What do you do? |
|
Definition
Acute appendicitis is a CLINICAL diagnosis
treat with Appendectomy |
|
|
Term
What is a carcinoid tumor and where is it generally found?
What is carcinoid syndrome? |
|
Definition
Tumor originating from neuroendocrine cells that releases serotonin and is typically found in the appendix
Carcinoid syndrome develops in 10% of cases due to excess serotonin, leading to flushing, diarrhea, sweating, wheezing and heart valve dysfunction
Surgical resection is indicated to prevent chance of metastasis. |
|
|
Term
| What are the major causes of acute pancreatitis? |
|
Definition
auto digestion of pancreas via premature activation of enzymes (mild can be reversible, whereas severe is life-threatening).
1) Alcohol (40%)
2) Gallstone (40%)- block ampulla of vater
3) Post ERCP
4) Viral infection (mumps, cocksackievirus B)
5) Drugs (sulfonamides, thiazides, furosemide, estrogen)
6) Post-op complications
7) Scorpion bites
8) Pancreas divisor
9) Pancreatic cancer
10) Hypertriglyceridemia, hypercalcemia
11) Uremia
12) Blunk abdominal trauma |
|
|
Term
| How is a diagnosis of acute pancreatitis made? |
|
Definition
Clinical is primary.
Supported by labs (amylase, lipase, LFTs to look for gallstones).
Use Ranson Criteria for assessment and prognosis
Confirm with CT scan of abdomen |
|
|
Term
| Why is hypocalcemia seen in acute pancreatitis? |
|
Definition
| Fat saponification (necrosing fat binds up calcium) |
|
|
Term
| Describe the Ranson criteria for acute pancreatitis |
|
Definition
1) Admission Criteria (GA LAW)
- Glucose (> 200 mg/dL)
- Age (> 55)
- LDH (>350)
- AST (>250)
- WBC (>16k)
2) Initial 48h (C HOBBS)
- Calcium (<8 mg/dL)
- Hematocrit decrease (>10%)
- PaO2< 60
- BUN increase >8 mg/dL
- Base deficit >4mg/dL
- Fluid sequestration >6L
3) Mortality
- <3 criteria (1%)
- 3-4 criteria (15%)
- 5-6 criteria (40%)
>7 criteria (100%) |
|
|
Term
| How are most cases of pancreatitis treated? |
|
Definition
Supportively. If severe, admit to ICU and rest pancreas with NJ tube
- Bowel rest (NPO)
- IV fluids
- Pain control (fentanyl better than morphine because oddi)
- Correction of electrolytes |
|
|
Term
| What are the important complications of acute pancreatitis? |
|
Definition
epigastric pain radiating to back is classic
1) Necrotis (sterile or infected)
- to be sure, need to drain and gram stain
2) Pseudocyst (lacks epithelia lining)
- Drain if >5cm
3) Hemorrhagic pancreatitis
- Grey turner (flank ecchymsoses)
- Cullen (periumbilical ecchymoses)
- Fox sign (ecchymosis of inguinal ligament)
4) ARDS, ascites, ascending cholangitis, abscess (rare) |
|
|
Term
How is chronic pancreatitis diagnosed? (hint- two options)
Unrelenting pain with flair-ups |
|
Definition
**Alcohol is usually the cause**
Usually see nausea and vomiting as well
Order a CT initially to look for calcifications
1) Chronic epigastric pain and calcifications on plain abdominal films
2) Steatorhea, DM and calcifications on films or CT |
|
|
Term
| What are the most common complications of chronic pancreatitis? |
|
Definition
1) Narcotic addition
2) DM
3) Malabsorption
4) Pseudocysts, ductal dilation, CBD obstruction, b12 deficiencty |
|
|
Term
| What medical options are there for treating chronic pancreatitis? |
|
Definition
1) Pancreatic enzymes (decrease CCK release and decrease pancreatic secretions after meals)
2) H2 blockers (stop gastric acid from degrading pancreatic enzymes)
3) Insulin |
|
|
Term
| What are the most important risk factors for pancreatic cancer and where are the common locations? |
|
Definition
Seen in older african americans
1) **Cigarrettes (even though alcohol is for chronic pancreatitis)
- chronic pancreatitis, DM, alcohol
2) Head>body>tail |
|
|
Term
What is the importance of a painless, palpable gallbladder?
What is the next step in your workup? |
|
Definition
Courvoisier sign indicates cancer of head of pancreas
ERCP is most sensitive, but CT is better if widespread disease expected
Whipple is the only hope for a cure, but only 10% are really rescectable (5 year survival rate is 10%). |
|
|
Term
| Why is a small GI bleed involving the duodenum in a patient with h/x of aortic graft surgery so worrisome? |
|
Definition
Aortoenteric Fistula!
Rare, but data. This indicates small window where it can be prevented. |
|
|
Term
| What are the most common causes of upper GI bleeds (above ligament of trietz in duodenum)? |
|
Definition
1) PUD (duodenal, gastric, gastritis)
2) Reflux esophagitis
3) Varices
4) Gastric erosions
5) Mallory-Weiss tear
6) Hemobilia
7) Neoplasm |
|
|
Term
| What are the most common causes of lower GI bleeds (below ligament of trietz in duodenum)? |
|
Definition
1) Diverticulosis (40%: most common > age 60)
2) Angiodysplasia (40%: second most > age 60)
3) IBD
4) Colorectal carcinoma
5) Ischemic colitis
6) Hemorrhoids, anal fissure
7) Smal intestinal bleeding |
|
|
Term
| What does "coffee ground" emesis indicate? |
|
Definition
| Upper GI bleed that is slower than hematemesis |
|
|
Term
| What are the possible explanations for a prolonged PT? |
|
Definition
1) Liver dysfunction (clotting factor production)
2) vitamin K deficiency
3) Consumptive coagulopathy
4) Warfarin therapy |
|
|
Term
| What are typical tests to order in a patient with GI bleeding? |
|
Definition
Always get vitals, resuscitate and perform rectal exam
1) Hematemesis: Upper GI endoscopy
2) Hematochezia: rule out figure causes, and follow up with colonscopy
3) Melena: Upper GI endoscopy
4) Occult blood: Colonoscopy, and f/u with Upper GI if no blood found |
|
|
Term
| In the presence of occult blood in the stool, describe you workup strategy. |
|
Definition
1a) Iron deficiency anemia
- order Colonscopy and if negative order an upper GI endoscopy
1b) No Iron deficiency
- If age >40, and Upper GI symptoms present, get a colonoscopy and upper GI endoscopy
- If age >40, and no Upper GI symptoms, just get a colonoscopy
- If <40, follow up clinically with a repeat guaiac test. |
|
|
Term
| What are the 2 major types of esophageal cancer and their major risk factors |
|
Definition
Prognosis is poor (30-40% 5 year if local and 5% if distant metastasis). Typically present with dysphagia and weight loss
1) SCC (proximal 2/3 and african american men)
- Smoking and Alcohol are big ones
- Diet, HPV and achalasia are others
2) Adenocarcinoma (distal 1/3 and white men)
- GERD and Barrett esophagus |
|
|
Term
| Describe the staging scheme for esophageal carcinoma |
|
Definition
1- lamina propria or submucosa
11a- muscularis propria; negative nodes
11b- muscularis propria; positive regional nodes
111- invasion of adventitia (positive regional nodes) or adjacent structures
IV- distant metastasis |
|
|
Term
| What are the absolute diagnostic criteria for Achalasia? |
|
Definition
Worldwide- Chagas
US- idiopathic or adenocarcinoma
**barium swallow (birds beak), Upper GI and Manometry
1) Incomplete relaxation of LES
2) Aperistalsis of esophagus |
|
|
Term
| What is the biggest concern with Achalasia? |
|
Definition
| Sevenfold increased risk for SSC of esophagus (surveillance with esophagoscopy) |
|
|
Term
| What differentiates diffuse esophageal spasm from achalasia and how can it be distinguished from the chest pain in heart failure? |
|
Definition
1) Achalasia has LES dysfunction, whereas DES involves normal LES pressure
2) Perform esophageal manometry and/or look for "corkscrew esophagus" on barium swallow. SOMETIMES perform cardiac workup first though. |
|
|
Term
| What are the major types of esophageal hernias, how are they diagnosed, and how should be they treated? |
|
Definition
Order barium upper GI series and upper endoscopy
1) Sliding hiatal- both esophagus and stomach herniate into stomach
- GE junction displaced and usually benign
- medical includes antacids and small meals (rarely surgery)
2) Paraesophageal hiatal- Stomach herniates without esophagus and GE junction remains in place
- Can cause strangulation and may require surgery |
|
|
Term
What differentiates a Mallory-Weiss syndrome from a Boerhaave syndrome?
How are they treated? |
|
Definition
MW involves mucosal tear at GE junction, whereas Boerhaave involves transmural injury with perforation (Alcoholics and Bulimics)
Get an upper endoscopy and treat with surgery |
|
|
Term
What is the treatment for each of the following syndromes?
1) Iron deficiency anemia, spoon-shaped fingernails and upper esophageal webs
2) Lower esophageal webs with a sliding hiatal hernia |
|
Definition
1) Plummer-Vinson
- can develop into SSC
- correct nutrition and perform esophageal dilation
2) Schatzki Ring
- Usually from ingesting alkali, acids or bleach
- Esophagectomy if full-thickness necrosis present and give steroids and antibiotics. |
|
|
Term
What unites Zenker's and Epiphrenic Diverticula?
What differentiates them? |
|
Definition
Both caused by underlying motility disorder and treated with surgery. Diagnosed with barium swallow
1) Zenker's
- upper 1/3 due to failure of cricopharyngeal muscle to relax during swallowing
2) Epiphrenic
- lower 1/3 associated with spastic esophageal dysmotility or achalasia
**Traction diverticula associated with traction from mediastinal inflammation and adenopathy (in TB) |
|
|
Term
| Describe the workup for Dysphagia |
|
Definition
1a) Solids only: mechanical obstruction
- intermittent: lower ring
- progressive: weight loss (carcinoma) or no weight loss (peptic stricture)
1b) Solids and liquids: Mobility problem
- Intermittent with chest pain: diffuse spasm
- Progressive with GERD: scleroderma
- Progressive with weight loss and regurg (Achalasia) |
|
|
Term
| What is the most important factor in determining survival following esophageal perforation? |
|
Definition
Time to surgery
If > 24 hours, mortality and fistula rate increases dramatically |
|
|
Term
| What are the major causes of Peptic Ulcer Disease and how do you treat? |
|
Definition
If uncomplicated, just treat.
If complicated, confirm with Endoscopy (must biopsy gastric but not duodenal)
and/or Urease detection breath test is 95% sense and specific
1) H. pylori
- Initial: Triple therapy (PPI + ammox and clarithromycin): twice daily dosing is good , but its more expensive
- Recurrent: Quadrouple therapy (PPI + bismuth subsalicylate, Metronidazole and tetracycline): takes half time to treat
2) NSAID use
- Stop the NSAID
3) Acid suppression therapy |
|
|
Term
| Name some common H2 blockers (4) and PPis (5) |
|
Definition
1) H2- block histamine-based parietal cell acid secretion
- Ranitidine (Zantac)
- Famotidine
- Nizatidine
- Cimetidine
2) PPI- block H/K ATPase directly in parietal cell membrane
- Esomeprazole
- Omeprazole (Prilosec)
- Lansoprazole (Prevacid)
- Pantoprazole
- Rabeprazole |
|
|
Term
| Which types of peptic ulcers are more concerning and why: Duodenal or Gastric? |
|
Definition
Gastric! high risk of malignancy
1) Gastric: caused by decrease in defensive factors in stomach and associated with Smoking and Type A blood)
2) Duodenal: caused by increase in offensive factors (gastric acid production) and NSAID use, as well as type O blood. |
|
|
Term
| What is the forrest test for a patient with epigastric pain? |
|
Definition
Start with an upper GI endoscopy
- can diagnose PUD, gastritis and esophagitis
- can rule out cancers of esophagus and stomach and H. pylori infection with biopsy |
|
|
Term
| What is the most common cause of chronic gastritis? |
|
Definition
Diagnose with upper GI endoscopy
H. pylori infection (give triple or quadruple therapy) |
|
|
Term
Describe each of the following important metastases of gastric carcinomas.
1) Krukenberg tumor
2) Blummer's shelf
3) Sister Mary Joseph node
4) Virchow node
5) Irish node |
|
Definition
1) ovary
2) rectum (can palpate on rectal exam)
3) periumbilical LN
4) supraclavicular foss node
5) left axillary adenopathy |
|
|
Term
| What is a gastric lymphoma? |
|
Definition
Type of NH lymphoma arising in the stomach (similar findings to adenocarcinoma)
- EGD with biopsy to diagnose and surg/chemo/radi are options |
|
|
Term
| What are the 3 main points of differentiation in working up a a patient with suspected small bowel obstruction? |
|
Definition
Usually due to dehydration and hypovolemia caused by 1) Adhesions, Incarcerated hernias and or malignancy/intussusception, CD.
1) Partial vs. Complete
- Pass gas and stool?
2) Closed loop versus open
3) Proximal or distal
- proximal: vomiting and pain without distention
- distal: less vomiting but distention on radiographs |
|
|
Term
| What is involved in surgical treatment of small bowel obstruction with strangulation (fever, severe and continuous pain, hematemisis, shock)? |
|
Definition
| Exploratory laporatomy with lysis of adhesions and resection of necrotic bowel |
|
|
Term
| What are the common causes of large bowel obstruction? |
|
Definition
1) Volvulus
2) Adhesions
3) hernias
4) colon cancer (most common) |
|
|
Term
| What is indicated when failure to pass contrast medium beyond a fixed point in the bowel is seen without a mechanical obstruction? |
|
Definition
Paralytic illeus
IV fluids, NPO and correction of electrolyte imbalances
Surgery not usually necessary |
|
|
Term
| What is Dermatitis herpetiformis and what is it associated with? |
|
Definition
Paplovesicular lesions on extensor surfaces in 10-20% of patients with Celiac disease
Hypersensitivity to wheat gluten causing flattening of intestinal villi, diarrhea and malabsorption (D- osteoporosis, K- bleeding, B12 and folate- megaloblastic anemia) |
|
|
Term
| Why might you order a PAS stain of the small bowel? |
|
Definition
Suspected Whipple Disease
- Tropheryma whipplei damages villi and is treated with antibiotics for 1-2 years.
- Positive PAS stain of macrophages in lamina propria containing non-acid-fast gram-positive bacilli |
|
|
Term
| Which form of IBD is most common in white, jewish people aged 15-35? What are the typical pathological findings? |
|
Definition
Crohn Disease (usually terminal ileum)- Get a biopsy from endoscopy
- Cobblestone appearance with Skip lesions
- Transmural inflammation
- Fistulae
- Strictures
- Non-caseating granulomas
- Fat-creeping |
|
|
Term
| Which form of IBD most commonly involves bloody diarrhea and abdominal pain? What are the typical pathological findings? |
|
Definition
Ulcerative Colitis
- Always involves rectum and confined to colon and rectum
- Mucosa and submucosa, but not transmural
- Continuos involvement- No skip lesions
- Colectomy is curative (otherwise can lead to sclerosing cholangitis and cancer) |
|
|
Term
| How does Sulfalazine work to treat IBD? |
|
Definition
especially effective in UC
- metabolized to 5-ASA and sulfpyridine by bacteria
- 5-ASA inhibits PGE release and reduces inflammation |
|
|
Term
| How is the need for hospitalization in PNA determined? |
|
Definition
CURB-65. > 4= admission
- Confusion
- Uremia (BUN > 19)
- RR (> 30)
- BP (< 90/60)
- > 65 |
|
|
