FINAL - GI Flashcards

Question

What's our go to imaging for investigating NAFLD?

Answer 1

U/S Fibroscan is a special ultrasound technology that measures liver stiffness (hardness) and fatty changes in your liver CT or MRI will also show fatty infiltrates

Answer 2

FIB4, NAFLD fbrosis score, Fibrotest These are calculators that take into account AST, ALT, age, platelet scores, etc

Answer 3

Elevated serum AST, ALT, +/- ALP

Answer 4

NAFLD - ratio is lower (<1) AFLD - AST:ALT >2

Answer 5

hepatitis A, B and C. Plasma iron, ferritin, TIBC and antibody tests for autoimmune hepatitis

Answer 6

liver biopsy liver biopsy cannot distinguish fatty liver from alcoholic vs. non-alcoholic, but considered when investigating alternative etiologies or assessing for level of fbrosis

Answer 7

Want to reverse factors that contribute to insulin resistance - healthy diet - active lifestyle - gradual weight loss

Answer 8

Gradual weight loss (0.5-1kg/wk) - aiming to lose at least 7-10% of body weight – diet and exercise interventions Rapid weight loss may worsen liver damage

Answer 9

Abstain from alcohol Immunization for Hep A and B Modify risk factors for CVD – optimization of glucose control, treatment of hyperlipidemia, etc Pioglitazone, liraglutide (balance benefits with adverse effects of weight gain, CHF) Vitamin E 800 IU daily if hepatic inflammation with non-diabetic, non-cirrhotic patients Coffee (3 cups/day) and vitamin D Consideration of bariatric surgery

Answer 10

main causes of death, particularly in non-cirrhotic group, are cardiovascular disease and malignancy * better prognosis than alcoholic hepatitis ■ <25% progress to cirrhosis over a 7-10 yr period * risk of progression increases if inflammation or scarring occurs alongside fat infiltration (nonalcoholic steatohepatitis)

Answer 11

refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation = Most common complication of gallstone disease

Answer 12

Cholesterol stones

Answer 13

Inflammation of gallbladder resulting from sustained gallstone impaction neck of the gallbladder Increased inflammation leads to increased pressure and pain Possible superimposed infection No cholelithiasis in 5-10% (typically d/t gallbladder ischemia and stasis) - called acalculous cholecystitis

Answer 14

Female Fat (obesity) Fertile (pregnancy) Forty (age)

Answer 15

False - Sudden starvation or prolonged fasting a risk factor

Answer 16

1. Cholesterol-lowering drugs (known to increase biliary cholesterol saturation) 2. Estrogen usage (OCPs and hormone replacement therapy - also increase biliary cholesterol saturation. 3. Furosemide. 4. Ceftriaxone. 5. Cyclosporine. 6. Opiate narcotic analgesics.

Answer 17

Indigenous, Chinese, or Japanese clients have a high incidence.

Answer 18

Total parenteral nutrition (TPN). Obesity. Status post bariatric surgery. Pregnancy secondary to elevated progesterone. Increasing age. Haemolytic anaemia. Diabetes High serum triglyceride and low high-density lipoprotein (HDL) levels High-caloric and refined carbohydrate diet. Cirrhosis, Crohn’s disease, and gallbladder stasis. Bile acid malabsorption.

Answer 19

Biliary colic = gallstone transiently impacted in cystic duct, no infection Those with cholecystitis often have hx of biliary colic Biliary colic is RUQ pain that comes and goes (<6hr), but cholecystitis is a pain which is constant and usually increasing

Answer 20

epigastric or RUQ pain May radiate to right shoulder or back

Answer 21

Epigastric, RUQ pain Anorexia N/V low grade fever (<38.5ºC) Fat intolerance Heartburn, upper abdo fullness Mild jaundice (20%) Chronic diarrhea *Acalculous cholecystitis may present with fever and sepsis alone

Answer 22

Fatty foods

Answer 23

Murphy’s sign palpable, and tender gallbladder (in 33%) Boas' sign

Answer 24

right subscapular pain

Answer 25

patient takes and holds a deep breath while palpating the right subcostal area. If pain occurs when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive

Answer 26

Vitals Typically ill-appearing, febrile, tachycardic, and lie still on the examining table because cholecystitis is associated with true local parietal peritoneal inflammation that is aggravated by movement Abdo exam - voluntary and involuntary guarding + Murphy’s sign Cardiac exam

Answer 27

highly sensitive (97%) not specific (48%)

Answer 28

normal in classic cholecystitis

Answer 29

98% sensitive HIDA = hepatobiliary iminodiacetic acid scan; is an imaging procedure that uses an injected radioactive tracer and a scanning camera to evaluate the gallbladder ERCP/MRCP can also show blockage

Answer 30

blood work: elevated WBC and left shift Bilirubin Lipase Alk phos, AST & ALT (should be normal in classic cholecystitis) Urinalysis to rule out pyelonephritis and renal calculi. Pregnancy test if childbearing age Stool guaiac test for occult blood to rule out bleeding

Answer 31

Lipase: to determine if element of pancreatitis Bilirubin: to determine if there is bile duct obstruction

Answer 32

Send to ER admit, hydrate, NPO, NG tube Antibiotics, analgesics Cholecystectomy: early (within 72 hrs) preferred, laparoscopic usually percutaneous cholecystostomy tube: critically ill or if general anesthetic contraindicated some centres can perform percutaneous stone extraction to avoid cholecystectomy

Answer 33

Gangrenous gallbladder (20%) caused by lack of blood supply to gallbladder Can lead to rupture

Answer 34

 Synthesize Amino Acids  Synthesize Proteins  Albumin  Immune Proteins  Hormones  Anticoagulants/Clotting Factors  Plasma Proteins (carrier proteins)  Produces Urea  Bile Production: Bile acids (Salts) and Bile Pigment  Regulates CHO metabolism  Control of Cholesterol Metabolism

Answer 35

Abdo tenderness from pressure of ultrasound probe over the gallbladder

Answer 36

Indirect bilirubin = unconjugated Direct bilirubin = conjugated Only conjugated can be passed through urine as the conjugation process makes the bilirubin water soluble. This occurs in a hyperbilirubinemia state such as hepatocellular or cholestatic jaundice.

Answer 37

Gallstone dislodges from cystic duct, goes back into gallbladder...over and over OR Irritation may also occur just from presence of stones in gallbladder (without actually lodging in ducts) Leads to gallbladder existing in chronic state of inflammation Epithelial cell damage and death --> gall bladder mucosa changes and becomes sensitive (pain with each contraction when trying to squeeze out bile) --> fibrosis and calcification of the gallbladder (called "porcelain gallbladder")

Answer 38

Causes of Liver Damage:  Infections  Drugs, toxins  Ischemia (damage to the central lobule)  Autoimmune disorders Can Lead to:  Hepatocellular Injury  Impaired Biliary Secretion  Necrosis  Fibrosis  Portal Venous Hypertension  Death

Answer 39

Likely need cholecystectomy **high risk of gallbladder CA once has fibrosis and calcification

Answer 40

Aminotransferases (AST, ALT) -Ratio of AST:ALT can hint to certain differentials. Lactic Dehydrongenase (LDH)

Answer 41

= gallstones in the common bile duct

Answer 42

ALT - remember the L in the middle to remind you of the Liver. (tip from Ruth's powerpoint) - also found in skeletal and kidney tissue but is more specific to liver AST is found in a variety of tissues - liver, brain, pancreas, heart, kidneys, skeletal muscles. So you could remember this by thinking of the S as meaning Somewhere else (tip from Gayle's caffeinated brain)

Answer 43

Gallstones Alcohol

Answer 44

Idiopathic Gallstones (45%) Ethanol (35%) Tumours: Scorpion stings Microbiological (bacterial, viral, parasites) Autoimmune Surgery/trauma Hyperlipidemia Emboli or ischemia Drugs/toxins:

Answer 45

Bilirubin GGT Alkaline Phosphate 5 - nucleotidase (not commonly ordered)

Answer 46

activation of proteolytic enzymes within pancreatic cells, starting with trypsin, leading to local and systemic inflammatory response in gallstone pancreatitis, this is due to mechanical obstruction of the pancreatic duct by stones in ethanol-related pancreatitis, pathogenesis is unknown

Answer 47

Mild (interstitial) = interstitial edema, peri-pancreatic fat necrosis Severe (necrotic) = extensive peri-pancreatic and intra-pancreatic fat necrosis - parenchymal necrosis and hemorrhage → infection in 60% - release of toxic factors into systemic circulation and peritoneal space (causes multi-organ failure

Answer 48

PT -INR Albumin

Answer 49

superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus sensitive but not specific for acute pancreatitis

Answer 50

flank ecchymosis Classically it correlates with severe acute necrotizing pancreatitis, often in association with Cullen's sign

Answer 51

epigastric, noncolicky, constant can radiate to back may improve when leaning forward (Inglefinger’s sign)

Answer 52

Non-alcoholic fatty liver disease.

Answer 53

- pain tender rigid abdomen; guarding N/V abdominal distention from paralytic ileus ` fever: chemical, not due to infection jaundice: compression or obstruction of bile duct tetany: transient hypocalcemia hypovolemic shock: can lead to renal failure acute respiratory distress syndrome Coma

Answer 54

An AST/ALT ratio equal to one (where the ALT is equal to the AST) may be a sign of acute viral hepatitis or drug-related liver toxicity.

Answer 55

Cirrhosis.

Answer 56

Alcohol-related liver disease.

Answer 57

Age Alcohol consumption Body mass index Exercise Gender Medications that are toxic to the liver Pregnancy Whether or not the patient fasted before the test

Answer 58

increased serum pancreatic enzymes: amylase, lipase ALT >150 specific for biliary cause increased WBC, glucose, low calcium imaging: CT most useful for diagnosis and prognosis - May also get other imaging to see other organ involvement such as U/S (evaluating biliary tree), x-ray of colon, ERCP, MRCP

Answer 59

To the hospital! goals (only supportive therapy available) 1. hemodynamic stability 2. analgesia 3. oxygen 4. stop progression of damage (difficult) 5. treat local and systemic complications

Answer 60

Elevated AST and/or ALT compared to alk. phos. Bilirubin may be elevated Synthetic function tests may be abnormal

Answer 61

usually a benign, self-limiting course, single or recurrent occasionally severe leading to multiorgan failure, shock, death

Answer 62

= irreversible damage to pancreas characterized by 1. pancreatic cell loss (from necrosis) 2. inflammation 3. fibrosis

Answer 63

Etoh causes a larger proportion (>90%) of chronic pancreatitis than acute pancreatitis Does lots of bad things to the pancreas no satisfactory theory to explain why only a minority of individuals with EtOH use disorder develop pancreatitis

Answer 64

No, only cause acute

Answer 65

Disproportionate elevation in the alkaline phosphatase compared with the serum aminotransferases Bilirubin may be elevated Synthetic function test abnormalities possible (albumin, PT) Isolated hyperbilirubinemia (ALT & AST are usually normal or only mildly elevated in obstructive jaundice except in the acute phase of biliary obstruction when they can reach > 1000 and then rapidly decrease as cholestatic enzymes rise) - pearl from Ruth's PP

Answer 66

early stages: - recurrent attacks of severe abdominal pain (upper abdomen and back) - chronic painless pancreatitis: 10% late stages: occurs in 15% of patients - steatorrhea (maldigestion) when >90% of function is lost - diabetes, calcification, jaundice, weight loss, pseudocyst, ascites, GI bleed

Answer 67

increase glucose increase in serum ALP, less commonly bilirubin (jaundice) serum amylase and lipase usually normal stool elastase is low in steatorrhea

Answer 68

A stool elastase test measures the amount of elastase in your stool. Elastase is one of a few digestive enzymes ("digestive juices") that your pancreas makes to help digest food

Answer 69

If GGT is also elevated, the source is likely hepatic. Order U/S for dilated bile ducts. Refer to GI - as per Ruth's PP.

Answer 70

most common problem is pain, difficult to control general management - complete abstinence from EtOH - enzyme replacement may help pain by resting pancreas via negative feedback - analgesics - celiac ganglion blocks - time: pain decreases with time as pancreas “burns out” endoscopy: sphincterotomy, stent if duct dilated, remove stones from pancreatic duct surgery: drain pancreatic duct, resect pancreas if duct contracted Steatorrhea - Pancreatic enzyme replacement Neither endoscopy nor surgery can improve pancreatic function

Answer 71

Alkaline Phosphatase

Answer 72

Liver disease Vit K deficiency Fat malabsorption (leads to Vit K def.) Pancreatic insufficiency

Answer 73

These would both be normal if there was no hepatocellular involvement.

Answer 74

1. Gallstones: > 2 mm pericholecystic fluid impacted stone in gallbladder neck tenderness when gallbladder is palpated with U/S probe (like a +vs Murphy sign) 2. Extrahepatic obstruction, indicated by dilated bile ducts 3. Focal liver lesions > 1cm diameter. Cysts, solid lesions, carcinoma. 4. Diffuse disorders such as cirrhosis and hepatitis, although clinical presentation and BW are better indicators for these.

Answer 75

To measure liver stiffness as an index of hepatic fibrosis. Particularly in patients with chronic hep c.

Answer 76

 Very accurate imaging  Identify hepatic masses, particularly small metastases, (accuracy ~80%.)  CT with IV contrast is accurate for diagnosing cavernous hemangiomas of the liver as well as differentiating them from other abdominal masses.  Images not obscured by intestinal gas or obesity.  Detects fatty liver  Detects increased hepatic density that occurs with iron overload.  Less helpful than U/S in identifying biliary obstruction, but often provides the best assessment of the pancreas.

Answer 77

 Helpful in diagnosing acalculous cholecystitis  Detecting bile leaks & anatomic abnormalities  Sphincter of Oddi Dysfunction  Rarely needed to diagnose acute cholecystitis

Answer 78

As per Ruth's pp: Not usually useful for Dx of hepatobiliary disorders. Insensitive for gallstones, unless calcified & large. Can detect a porcelain (calcified) gallbladder. Rarely, in gravely ill patients, x-rays show air in the biliary tree, which suggests emphysematous cholangitis.

Answer 79

The ERCP procedure diagnoses and treats narrowed or blocked pancreatic or bile ducts. It combines endoscopy and fluoroscopy.

Answer 80

Increased morbidity. Morbidity from a diagnostic ERCP with only injection of contrast material is about 1%. Adding sphincterotomy raises morbidity to 4 to 9% (mainly due to pancreatitis and bleeding). ERCP with manometry to measure sphincter of Oddi pressure causes pancreatitis in up to 25% of patients.

Answer 81

Acute pancreatitis.

Answer 82

Leuks Hematocrit BUN hypocalcemia hyperglycemia Markers of immune activation: -CRP -Interleukin 6, 8 & 10 -Tumor necrosis factor -PMN elastase

Answer 83

1. acute onset of persistent, severe, epigastric pain often radiating to the back 2. elevation in serum lipase or amylase to three times or greater than the upper limit of normal 3. characteristic findings of acute pancreatitis on CT, MRI or U/S

Answer 84

IBS - Irritable bowel syndrome is a bowel condition without underlying physically detectable abnormalities. IBD - Inflammatory bowel condition involves structural disease of the bowels

Answer 85

Crohn's Disease Ulcerative colitis

Answer 86

Recurring episodes of inflammation limited to the mucosal layer of the colon. Involves the rectum and may extend proximally and continually

Answer 87

Diagnosed based on the presence of diarrhea for more than 4 weeks and evidence of chronic colitis on endoscopy and biopsy. Other types of colitis need to be excluded through the history, labs and by biopsy. Most people present with attacks of bloody diarrhea that last weeks to months.

Answer 88

Most patients have intermittent exacerbations alternating with periods of symptom resolution. Complications can include severe bleeding, toxic megacolon, perforation, dysplasia and colorectal cancer . Patients with UC may have a slightly higher mortality compared with the general population

Answer 89

Transmural inflammation of any portion of the GI tract (from oral cavity to perianal area)

Answer 90

Based on radiologic, endoscopic, and/or histologic findings of segmental and transmural inflammation

Answer 91

Variable. Some have continuous and progressive disease, some chronic intermittent symptoms and 20% experience prolonged remission after initial presentation.

Answer 92

CBC, Ferritin Age appropriate colorectal cancer Diarrhea: Celiac screen Fecal calprotectin Infectious diarrhea panel Constipation: abdo xray

Answer 93

- Onset after age 50 - Rectal bleeding/melena - Nocturnal symptoms - Progressive abdo pain - Unexplained weight loss - Lab abnormalities (iron deficiency anemia, increased CRP, fecal calprotectin/lactoferrin) - Family history of IBD or colorectal Ca

Answer 94

Lifestyle and Dietary Modifications - Psyllium (soluble fiber) improves both constipation and diarrhea - Low FODMAP diets - Possible lactose or gluten avoidance - Regular meal pattern, avoid large meals - Reduced intake of fat, insoluble fibers, caffeine and gas-producing foods - Adequate fluid intake, physical activity - Stress management: counselling, meditation, yoga

Answer 95

Psyllium up to 12-20g/day as tolerated. Slowly titrate up Calcium polycarbophil Magnesium hydroxide Linaclotide SSRIs - constipation and abdominal pain treatment

Answer 96

Dicyclomine Peppermint oil Hyoscine Pinaverium, trimebutine

Answer 97

Loperamide Eluxadoline Diphenoxylate TCAs - diarrhea and pain

Answer 98

Some degree of reflux is normal. Gastroesophageal reflux disease occurs when the reflux of stomach contents causes troublesome symptoms/complications

Answer 99

Heartburn (pyrosis) and regurgitation. Other: dysphagia, chest pain, water brash, globus sensation, odynophagia (pain swallowing), extraesophageal symptoms (chronic cough, hoarseness, wheezing), infrequently nausea

Answer 100

True - In patients with classic symptoms, the diagnosis can be made clinically in the absence of alarm features

Answer 101

Alarm features suggestive of a gastrointestinal malignancy (New onset of dyspepsia in patient ≥60 years, Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, occult blood in stool), Iron deficiency anemia, Anorexia, Unexplained weight loss, Dysphagia, Odynophagia, Persistent vomiting, Gastrointestinal cancer in a first-degree relative) Abnormal upper GI tract imaging Risk factors for Barrett's esophagus Patients with suspected GERD who have not responded to an empirical trial of twice-daily proton pump inhibitor (PPI) therapy.

Answer 102

Start 4 week trial of lifestyle/diet modifications, low dose H2RA prn and antacids if symptoms < 1/wk If symptoms persist, increase to BID H2RA x 2 weeks. If this works and symptoms resolve then go back to lifestyle and PRN H2RA If symptoms persist, start low dose PPI trial for 4-8 weeks. If this works, taper and discontinue once asymptomatic for 8 weeks. PPI can be increased to BID if needed. If symptoms recur after resolution, treat with 8 week course of previously effective med.

Answer 103

Go straight to once daily PPI with lifestyle modifications. If this does not work after 2 months then can try switching to another drug or increasing to BID x 2 months

Answer 104

Yes! after 8 weeks of symptom-free period, unless Barrett's esophagus

Answer 105

Smoking cessation weight loss if overweight elimination of food/drink triggers Avoid meals 3 hours before bedtime elevate HOB 4-6 inches

Answer 106

True 43-87% of patients with bleeding peptic ulcers present without antecedent dyspepsia or other GI symptoms

Answer 107

NSAID use h.pylori infection

Answer 108

Definitive diagnosis is done with upper GI scope All patients with PUD should be tested for H.pylori

Answer 109

60% of peptic ulcers heal spontaneously. With eradication of H.pylori, healing rates increase to > 90% Even with continuous PPI use, 5-30% of peptic ulcers recur within the first year - this is based on whether H.pylori has been successfully eradicated.

Answer 110

PPI Discontinue aspirin/NSAIDs Treat H.pylori if present PPI may be required for 4-8 weeks or for maintenance therapy in some situations

Answer 111

Increased intra-abdominal pressure: obesity, chronic cough, asthma, COPD, pregnancy, constipation, bladder outlet obstruction, ascites, heavy lifting Congenital abnormality Previous hernia repair, especially if complicated by wound infection Loss of tissue strength/elasticity (aging, repetitive stress) Family history

Answer 112

Indirect inguinal hernia

Answer 113

May be asymptomatic, reported as a heaviness or dull sense of discomfort with straining/lifting. If incarcerated or strangulated, may present with N/V, ando pain.

Answer 114

False - in the majority of cases, inguinal or femoral hernias can be diagnosed based upon the physical and history. US is recommended if intra-abdominal complications are suspected

Answer 115

Femoral hernias present inferior to the inguinal ligament and medial to the femoral artery. Inguinal hernias present superior to the inguinal ligament This may be difficult to differentiate, especially in obesity

Answer 116

False, often umbilical hernias can be approached with watchful waiting.

Answer 117

False - daily BMs are not necessarily needed for good health. What is normal varies

Answer 118

Unsatisfactory defecation due to infrequent stools +/-difficult or incomplete stool passage. It is subjective and symptom based. Patients usually define constipation by its top 3 most bothersome symptoms: straining, hard stools and bloating.

Answer 119

When 25% of BMs are associated with ≥2 of the following symptoms, occurring in the previous 3 months with an onset of symptoms >6 months and does not meet criteria for IBS:* Straining Hard or lumpy stools A sense of incomplete evacuation A sense of anorectal obstruction or blockage The need for manual maneuvers (e.g. digital evacuation) < 3 spontaneous BMs per week - Loose stools are not present (including laxative-induced)

Answer 120

Normal transit (60%) - normal frequency, but stool is hard and/or difficult to pass Pelvic floor dysfunction (25%) - pelvic floor or external anal sphincter cannot relax. May be accompanied by anal fissures/hemorrhoids. Slow transit (15%) - infrequent BMs

Answer 121

Medications, diseases, conditions ex. cancer/cancer related, hypothyroidism, depression, NSAIDs, opioids, TCAs, b-blockers, many others

Answer 122

Age 50 or older with new onset symptoms Rectal bleeding Nocturnal symptoms Significant weight loss Fever Anemia Abnormal physical

Answer 123

Fibre Fluid Fitness/physical activity

Answer 124

Step 1: increase dietary fibre, fluids and physical activity Step 2: bulk forming laxative (ex. psyllium) Step 3: add an osmotic laxative (PEG, lactulose, MOM) Step 4: add PRN glycerin supp, stimulant laxative (senna, bisacodyl) or enema Step 5: add prucalopride (Restoran) or linaclotide (Constella) Note there specific approaches on RxFiles for constipation in peds, older adults, pregnant people and opioid-induced constipation

Answer 125

Severe illness (fever ≥38.5°C [101.3°F], hypovolemia, ≥6 unformed stools per 24 hours, severe abdominal pain, or hospitalization) Features of inflammatory diarrhea (bloody diarrhea, small volume mucous stools, fever) High-risk host features (age ≥70 years, cardiac disease, immunosuppression, inflammatory bowel disease, pregnancy) Symptoms persisting >1 week Public health concerns (eg, diarrheal illness in food handlers, health care workers, and individuals in day care centers)

Answer 126

False, if non of the above signs then supportive care recommended over empiric antibiotics

Answer 127

Recent antibiotic use or hospitalization

Answer 128

A fluroquinolone or azithromycin

Answer 129

In non-bloody diarrhea with an absent or low-grade fever, loperamide can be used cautiously for up to 2 days. Do not use if fever, bloody or mucoid stools unless antibiotics are also given (can prolong disease). Bismuth salicylate is an acceptable alternative

Answer 130

Hydration Dietary modification - may be helpful to avoid fatty foods. Lactose may be difficult to digest for weeks-months. Encourage boiled starches and veggies

Answer 131

IBS, IBD, malabsorption syndromes (lactose intolerance, celiac disease), chronic infections (especially if immunocompromised)

Answer 132

Alarm features (same as IBS) Severe diarrhea Suspected IBD Inconclusive diagnosis after investigations Failure to respond to empiric therapy

Answer 133

CBC TSH/T4 Celiac serology Serum electrolytes (if severe diarrhea to check for dehydration/abnormalities) Stool occult blood Stool test for giardia - once again UTD specifically says giardia. But according to Sarah this should be a more general infectious diarrhea panel. C-diff if risk factors Fecal calprotectin (or CRP if fecal calprotectin unavailable)

Answer 134

Acute - AST and ALT (released in hepatocyte inflammation) Chronic - albumin (half life of about 20 days) Both acute and chronic - PT/INR - the most sensitive of LFTs

Answer 135

Vit K deficiency Coumadin (warfarin) Hemophelia

FINAL - GI Flashcards

(168 cards)