0
Q
Diaphragmatic Hernia
Def’n, Mech, Pres (Age Group)?
A
Ab structures enter thorax.
MECH = Defective devel of pleuroperitoneal memb.
PRES: Infants
1
Q
Sliding Hiatal Hernia
Mech (3 steps), Pres (CLUE)?
A
MECH:
LES slides SUP -> GE junction displaced ->
Diaphragm can no longer reinforce it.
PRES:
- “Hourglass stomach”
2
Q
Rolling / Paraesophageal Hernia
Def’n?
A
FUNDUS protrudes into thorax. GE junction normal.
3
Q
Indirect Inguinal Hernia
Def’n, Embryo, Mech, Anat, Pres (Epi)?
A
Projects through INGUINAL RING.
Follows path of descent of testes.
Covered by all 3 layers of spermatic fascia.
MECH = Failure of PROCESSUS VAGINALIS to close.
** LATERAL to inf epigastric art. **
PRES = MC in Males
4
Q
Direct Inguinal Hernia
Def’n, Embryo (layer of spermatic fascia covered by), Anat, Pres (Epi)?
A
Projects through AB WALL.
Covered by EXTERNAL layer of spermatic fascia only!
** MEDIAL to inf epigastric art. **
Passes thr Hesselbach’s Triangle -> SUP Inguinal Ring only!
PRES = MC in older men
5
Q
Femoral Hernia
Def’n, Anat, Pres (Epi)?
A
Part of S.I protrudes through femoral ring.
Protrudes below inguinal ligament.
PRES = MC in Women (wider bony pelvis)
6
Q
SMA Sx
Def’n?
A
Transverse portion of Duodenum entrapped b/w Aorta + SMA -> Intestinal Obstruction.
7
Q
Internal Hemorrhoids
Anat, Innervation, Pres (CLUE), Assoc?
A
ABOVE pectinate line.
Visceral innervation.
PRES = NOT painful.
ASSOC:
- Portal Htn
8
Q
External Hemorrhoids
Anat, Innervation, Pres?
A
BELOW pectinate line.
Somatic innervation (inf rectal branch of pudendal nerve).
PRES = Painful.
9
Q
Anal Fissure
Def’n, Location, Pres (2)?
A
Tear in anal mucosa.
BELOW pectinate line.
PRES:
- Painful defecation
- Blood on toilet paper
10
Q
Esophageal Webs
Def’n, MC Location?
A
Thin protrusions of esophageal mucosa.
MC in UPPER Esophagus.
11
Q
Esophageal Varices
Def’n + Location, Cause, Pres, Comp?
A
Dilated submucosal veins in LOWER 1/3 of Esophagus.
CAUSES:
- Portal Htn
PRES = PAINLESS / Asymptomatic bleeding
COMP = ** Rupture **
12
Q
Esophageal Strictures
Assoc (2)?
A
ASSOC:
- Lye ingestion
- Acid reflux
13
Q
Esophagitis
Causes (4: 3 Micro + 1)?
A
CAUSES:
- HSV-1 (“punched-out” ulcers) in immunocompromised p/ts
- CMV (“linear” ulcers)
- Candida (“white pseudomemb”)
- Chemical ingestion
14
Q
Eosinophilic Esophagitis
Def’n (incl Epi), Cause, Pres (Triad + 1)?
A
Infiltration of eosinophils into esophaguses of ATOPIC P/TS.
CAUSE = Exposure to food allergens.
PRES:
- Triad:
1. Strictures
2. Dysphagia
3. Heartburn - Unresponsive to GERD therapy *
15
Q
Dysphagia
- To solids only -> ?
- Causes? - To solids + liquids -> ? (Progressive = solids first then liquids)
- Causes (3)?
A
- Obstruction
CAUSES:
- Esophageal Web (eg Plummer-Vinson Sx)
- Progressive Dysphagia
CAUSES:
- Achalasia
- Esophageal SCC
- Peristalsis problem
16
Q
Achalasia #1
Def’n, Causes, Assoc (2)?
A
Achalasia = absence of relaxation.
MECH:
↑LES tone due to loss of Myenteric (Auerbach’s) plexus.
-> HIGH LES opening pressure + UNCOORDINATED peristalsis.
CAUSES:
- Nitric Oxide secretion loss
ASSOC:
- Chagas Dz
- Scleroderma / CREST Sx (esophageal dysmotility due to LOW pressure proximal to LES)
17
Q
Achalasia #2
Pres, Appearance on Ba Swallow (CLUE)?
A
PRES:
- Progressive dysphagia to solids + liquids
BA SWALLOW:
- “Bird’s beak” (dilated esoph with area of distal stenosis)
18
Q
GERD
Def’n, Pres (CLUE + 2), Comp?
A
↓in LES tone.
PRES:
- “Heartburn + Regurg upon LYING DOWN”
- Nocturnal dyspnea + cough
- Adult-onset Asthma
COMP:
- Barrett’s
19
Q
Mallory-Weiss Sx
Def’n, Pres (Epi CLUE + Pres CLUE), Comp?
A
Gastroesophageal lacerations due to frequent + severe vomiting.
PRES: Alcoholic + Bulimic patients
- “PAINFUL hematemesis”
COMP:
- Berhaave Sx
20
Q
Boerhave Sx (** “Been-Heaving Sx” **)
Def’n?
A
Transmural esophageal RUPTURE -> Air in Mediastinum ->
Subcutaneous Emphysema.
21
Q
Plummer-Vinson Sx
Pres (3), Comp (progression to)?
A
PRES: ** “Plumbers DIG” **
- Dysphagia ( / Esoph Webs)
- Iron Deficiency Anemia
- Glossitis (Atrophic)
COMP:
- Esophageal SCC
22
Q
Barrett’s Esophagus
Mech + Location, Cause, Comp?
A
Glandular Metaplasia- replacement of normal esoph epithelium with INTESTINAL (COLUMNAR) epithelium + Goblet cells.
DISTAL Esophagus.
CAUSE = Chronic GERD
COMP:
- 30-40x↑risk of Esophageal SCC
23
Q
Esophageal Cancer
Pres (4), Prog?
A
PRES:
- Progressive dysphagia
- Weight loss
- Pain
- Hematemesis
PROG = Poor. (Worse with later pres)
24
Esophageal SCC
Location, RF (3), Causes / Assoc (7), Pres (2)?
UPPER 2/3 of Esophagus.
RF:
- Very hot tea
- Cigarettes
- Alcohol
CAUSES / ASSOC:
- Diverticula
- Achalasia
- Esoph strictures
- Mallory-Weiss Sx
- Berhaave Sx
- Plummer-Vinson Sx
- *** Barrett's ***
PRES:
- Hoarse voice
- Cough
25
Esophageal Adenocarcinoma
Location, RF (2)?
LOWER 1/3 of Esophagus.
RF:
- Esophagitis
- Barrett's
26
Acute Gastric Ulcers
2 Types: Mech of Production, Assoc?
CURLING ULCER:
Greatly↓PLASMA VOLUME -> SLOUGHING of gastric mucosa.
ASSOC = SEVERE BURNS
CUSHING ULCER: ↑INTRACRANIAL P -> ↑Vagal gastric secretion.
ASSOC = CNS injury
27
Acute Gastritis
RF (3 'substance consumers' + 2 general states + 2 specific traumas)?
RF:
- Alcoholics
- P/ts taking daily NSAIDs (↓PGE1 -> ↓gastric mucosa protection)
- P/ts on Chemotherapy
- Stress
- Shock / Trauma
- Burns
- Brain injury
28
Chronic Atrophic / Autoimmune Gastritis
Mech, Comp (2)?
MECH = Autoimmune destruction of Parietal cells
COMP:
- Pernicious Anemia
- Gastric Carcinoma
29
Type A (fundus / body) Chronic Gastritis = Autoimmune Gastritis
Ab (2), Path, Pres, Labs (2), Prog?
Autoantibodies against Parietal cells and/or Intrinsic Factor.
PATH: T cell-mediated = Type 4 H-S.
PRES:
- Pernicious Anemia
LABS:
- Gastrin↑
- Cl↓
PROG:
- ↑risk for Gastric Carcinoma
30
Type B (antrum) Gastritis = H pylori Gastritis
Mech, Pres,
RX (incl 2 signs of eradication + 2 goals of therapy), Comp (3)?
MECH = Weakening of mucosal defenses due to:
- H pylori Proteases + Ureases
- Infl
PRES:
- Epigastric ab pain
RX = Triple Therapy: PPI + Amoxicillin + Clarithromycin
(Metronidazole if allergic to penicillin)
* Eradication when Urea Breath Test + Stool Antigen negative *
-> Elimination of gastritis / ulcer
-> Reversal of intestinal metaplasia
COMP:
- Ulceration / Peptic Ulcer Dz
- Gastric Adenocarcinoma
- MALT Lymphoma
31
Peptic Ulcer Disease
Def'n, 2 Types, Mech, RX, Comp (3)?
Solitary mucosal ulcer.
- Gastric ulcer
* - Duodenal ulc
MECH = ↓mucosal protection against gastric acid
RX = (same as for H Pylori Gastritis if caused by H Pylori)
COMP:
- Rupture
- Acute Pancreatitis (rupture of POST ulcer)
- 1ry Hyperparathyroidism
32
Menetrier's Dz
Pres (General Triad + CLUE)?
*Precancerous*
PRES:
- "Rugae of stomach so hypertrophied that they look like brain gyri"
- Triad:
1. ↑mucous cells
2. Parietal cell atrophy
3. Protein loss
33
Gastrinoma
Def'n, Pres?
Gastrin-secreting tumor ->↑acid secretion -> Ulcers.
PRES = Gastric Ulcers
34
Gastric Adenocarcinoma
Def'n, Path (2, incl 3 mets), Assoc (3), Pres (3)?
Malignant proliferation of gastric surface epithelial cells.
PATH:
- Early aggressive local spread
- Mets:
- Virchow's node
- Sister Mary Joseph's nodule
- Krukenberg tumor
ASSOC:
- Type A blood
- Achlorhydria
- Chronic Gastritis
PRES: * Late *
- Ab pain
- Early satiety + Weight loss
- Anemia
35
Intestinal Gastric Adenocarcinoma
Location, Appearance, Assoc (2), Pres (CLUE)?
MC on Lesser Curvature of Stomach.
Resembles gastric ulcer (large + irregular with raised margins).
ASSOC:
- Smoke (tobacco smoking + smoked foods)
- H pylori infection
PRES:
- Sister Mary Joseph's nodule (subcutaneous periumbilical mets)
36
Diffuse Gastric Adenocarcinoma
Pres (2 CLUES)?
PRES:
- Signet Ring cells that DIFFUSELY INFILTRATE gastric wall
- "Linitis Plastica" (thick + leathery stomach wall)
37
Krukenberg's Tumor
Def'n, Micro Findings (2: CLUE + General)?
Diffuse Stomach Cancer -> Bilateral Mets to Ovaries.
FINDINGS:
- "Signet Ring" cells
- Abundant mucus
38
S.I Infarction
2 Types, Mech (Transmural), Pres?
- Transmural Infarction
- Mucosal Infarction
MECH (Transmural Infarction):
Thrombosis / embolism of Mesenteric artery or vein.
PRES = Severe Htn
39
Malabsorption Sx
Pres (5), Dx?
PRES:
- Diarrhea: bloody + steatorrhea
- Ab distension + pain
- ↓bowel sounds
- Weight loss (Adult) / Failure to thrive (Child)
- Weakness
DX = Steatorrhea!
40
Tropical Sprue
Location?
Can affect ENTIRE S.I.
| *** Difference from Celiac Sprue ***
41
Whipple Disease (Tropheryma whipplei)
Locations (4),
Pres (Epi + 3 Categories: "Foamy whipped cream in a CAN"),
Micro Finding?
- Nodes: Intestinal or Mesenteric
- CNS
- Heart valves
- Synovia
PRES: Older men
- Cardiac symptoms
- Adenopathy + Arthralgias
- Neuro symptoms:
- Fever
- Weight loss
FINDING:
- PAS-positive foamy macrophages
42
Celiac Sprue
Def'n, Locations (2), Ab, HLAs (2),
Pres (Epi + 1 Assoc), Micro Findings (CLUE + 2),
RX?
Autoimmune-mediated damage to S.I VILLI due to gluten exposure.
Distal Duodenum and/or Proximal Jejunum
Anti-Gliadin / Anti-Transglutaminase / Anti-Endomysial Antibodies
HLA-DQ2 + HLA-DQ8
*THINK: "Shaina was diagnosed at 28."*
PRES: MC in ppl of Northern European descent
- Dermatitis Herpetiformis (due to IgA deposition at tips of dermal papillae)
FINDINGS:
- "Blunting / flattening" of villi
- Hyperplasia of crypts
- Lymphocytes in lamina propria
RX = Gluten-free diet
43
Lactose Intolerance
Def'n, Mech (2 steps), Pres, Dx?
Absence of brush border Lactase.
MECH:
Undigested lactose = osmotically active ->
UNABS lactose + water in GI tract lumen.
PRES = Osmotic Diarrhea
DX: Lactose Tolerance Test
44
Abeta-Lipoproteinemia
Def'n, Inher, Mech (3 steps), Pres (Epi + 3)?
Deficiency of apolipoproteins B-48 + B-100.
AR.
MECH:
Deficicency of apolipoproteins B-48 + B-100 ->
Inability to generate chylomicrons (B-48) + LDL/VLDL (B-100) ->
Fat accumulation in enterocytes = Malabsorption.
PRES: Early childhood
- Failure to thrive
- Neuro manifestations: Ataxia + Night Blindness
- Acanthosis
45
Zollinger-Ellison Sx
Def'n / 2 Locations, Pres (2)?
Gastrinoma of Duodenum or Pancreas.
PRES:
- High Gastrin
- Duodenal ulcerations
46
"Red currant jelly stools"
Seen In (2)?
SEEN IN:
- Intussusception (Infants)
- Acute Mesenteric Ischemia (Adults)
47
Intussusception
Def'n + Location, Mech, Causes, Pres (Epi + CLUE + 1)?
Intussusception / "telescoping" of Terminal Ileum into Cecum.
(Pulled forward by peristalsis)
*** THINK: In word 'intussusception', i comes before c.
= Ileum into Cecum. ***
MECH = Obstruction + Infarction.
CAUSES:
- Meckel's Diverticulum
PRES: MC in children
- "Currant jelly" / bloody stools (due to compromised bl supply)
- Colicky ab pain
* ** Ab emergency in early childhood ***
48
Volvulus
Def'n, MC Locations (2, incl Epi of each), Mech, Causes?
Twisting of portion of colon around its mesentery.
(In parts of colon where there is redundant mesentery)
- Cecum (MC in young adults)
- Sigmoid Colon (MC in elderly)
MECH = Obstruction + Infarction
CAUSES:
- Meckel's Diverticulum
49
Meckel's Diverticulum
Etiology, Histo (2 types of epithelia), Chars (*** "5 2s" ***),
Pres (2 Epi + 5), DX?
ET = Persistence of vitelline duct
2 types of epithelia:
- Gastric mucosa (ectopic acid-secreting)
- Pancreatic
CHARS:
- 2 inches long
- 2 feet from ileocecal valve
- 2 types of epithelia
- 2 yrs of life
- 2% of pop
PRES: First 2 yrs of life. 2 % of pop.
- Obstruction near Terminal Ileum
- RLQ pain
- Melena
- Intussusception
- Volvulus
DX: Pertechnetate Study
50
Diverticulosis
Etiology, Causes (2), Pres (CLUE), Comp (2)?
```
Many diverticula -> diverticulosis.
Very common (~50%) of people > 60 yrs.
```
CAUSES:
- FOCAL WEAKNESS in colon wall
- ↑intraluminal pressure
PRES:
- "PAINLESS rectal bleeding"
(Often asymptomatic or vaguely uncomfortable)
COMP:
- Diverticulitis
- Fistulas
51
Diverticulitis
Def'n, Pres (4), Comp (1 + CLUE), RX?
Infl of diverticula due to OBSTRUCTING FECAL MATERIAL.
PRES: *** "L-sided Appendicitis" ***
- "Bright red" rectal bleeding
- LLQ pain
- Fever
- Leukocytosis
COMP:
- Perforation -> Peritonitis
- > Abscess formation
- > Stenosis
- "Colovescial fistula" (fistula with bladder) -> "air or stool in urine"
RX: Antibiotics
52
Inflammatory Bowel Disease (IBD)
Def'n, 2 Subtypes,
Pres (3 Epi + 1), EXTRAintestinal Manifestations (5),
Comp (2), RX (1 in common)?
Chronic and relapsing infl of bowel.
- Crohn's Dz
- Ulcerative Colitis.
PRES: Young women. MC in West.
MC among Caucasians + Eastern-European Jews.
- Recurrent bouts of ab pain + BLOODY DIARRHEA
- Apthous Ulcers (cankers)
- Erythema Nodosum
- Pyoderma Gangrenosum
- Uveitis
- Ankylosing Spondylitis
COMP:
- Malabsorption / Malnutrition
- CRC
RX: Infliximab
53
Crohn Disease
Etiology, Location, Mediation,
Gross Findings (3 CLUES + 2), Micro Finding,
Pres (2 Intestinal + 3 Extra-Intestinal),
Appearance of bowel on Ba Swallow (CLUE),
Comp (2), RX (3)?
Disordered response to intestinal bacteria.
ANY portion of GI tract, however MC in Terminal Ileum + Colon =
"Skip lesions" (alternating areas of normal colon + transmural infl).
Rectal SPARING.
Th1-mediated.
FINDINGS:
- "Cobblestone mucosa"
- "Creeping fat"
- Bowel wall thickening -> "String Sign" (due to strictures)
- TRANSMURAL infl
- Linear ulcers, fissures + fistulas
- Noncaseating granulomas + lymphoid aggregates
PRES:
- Diarrhea (bloody or non-bloody)
- RLQ pain (ileum)
- Vit B12 def -> Macrocytic Megaloblastic Anemia
- Kidney stones
- Migratory polyarthritis *** THINK: Skipping ***
BA SWALLOW: "String Sign" (strictures = narrowing of lumen)
COMP:
- Stones: Ca Oxalate kidney stones + Gallstones
- Perianal dz
RX:
- Corticosteroids
- Immunomodulators: Azathioprine + Methotrexate
- Infliximab
54
Ulcerative Colitis
Etiology, Mech, Location, Mediation,
Gross Findings (CLUE + 2), Micro Finding,
Pres (Intestinal + Extra-Intestinal),
Appearance of bowel on Ba Swallow (CLUE),
Comp, RX (4, incl 1 procedure)?
Autoimmune.
MECH = Loss of haustra
Colon = CONTINUOUS lesions.
Rectal INVOLVEMENT.
Th2-mediated. *** THINK: 2 words ***
FINDINGS:
- "Friable mucosal pseudopolyps"
- MUCOSAL + SUBMUCOSAL infl only
- Freely hanging mesentery
- Crypt abscesses + ulcers
PRES:
- BLOODY diarrhea
- Primary Sclerosing Cholangitis
BA SWALLOW: "Lead pipe" appearance of colon
COMP:
- Toxic Megacolon
RX:
- Sulfasalazine
- 6-MP
- Infliximab
- Colectomy
55
Ischemic Collitis
MC Location, Causes (MCC), Pres (Epi + 2)?
MC at Splenic Flexure (watershed area of SMA).
MCC = Atherosclerosis of SMA
PRES: Elderly
- Pain after eating -> Weight loss
- (In case of Infarction) -> Pain + Bloody Diarrhea
56
Necrotizing Enterocolitis
Def'n, Pres (Epi)?
Necrosis of colon MUCOSA. Possible perforation.
PRES: Neonates (MC in preemies due to↓immunity)
57
Colonic Polyps
Def'n, MC Location,
Subtypes (4, last 3 = benign / hamartomatous),
Pres (3 general 'polyp symptoms'),
Screening (2)?
*90% non-neoplastic*
Raised protrusions of colonic mucosa protruding into gut lumen ->"sawtooth" appearance.
MC in LEFT Colon (rectosigmoid).
Can be tubular or villous.
- Adenomatouuus
- Hyperplastic
- Juvenile / Juvenile Polyposis Sx
- Peutz-Jeghers Sx
PRES: *Often assymptomatic*
- Lower GI bleed (due to polyps bleeding)
- SECRETORY diarrhea
- Partial obstruction
SCREENING:
- Colonoscopy -> Polyp removal + examination
- Fecal Occult Bl test
58
Gardner Sx
Def'n, Pres (CLUE + 2), Comp?
FAP+ Fibromatosis (retroperitoneal) + Osteomas (MC in Skull).
PRES:
- "↑# of teeth => impacted teeth"
- Multiple colonic polyps
- Osteomas in skull
COMP:
- Congenital hypertrophy of retina (due to osteomas in skull)
59
Adenomatous Polyps
Cause, Malignant RF (3)?
```
*Precancerous = precursor to CRC*
CAUSE = glandular neoplastic prolif.
```
MALIGNANT RF:
* ** - Villous histology of polyp (↑=↑risk of malignancy) ***
- ↑size
- ↑epithelial dysplasia
60
Familial Adenomatous Polyposis (FAP)
Locations (2), Inher, Genetics, Pres, RX?
*100% progress to CRC*
Colon + Rectum.
AD.
AD mutation of APC gene (chr 5q). "Two-Hit Hypothesis".
PRES = Thousands of polyps
RX = Prophylactic removal of colon + rectum
61
Turcot Sx
Def'n?
*** THINK: Turban ***
FAP+ Malignant CNS tumor.
62
Peutz-Jeghers Sx
Def'n, MC Location, Inher, Pres (CLUE)?
```
*Malignant risk*
MULTIPLE Hamartomas (benign) throughout GI tract.
```
MC Location = Small Intestine.
AD.
PRES:
- "Hyperpigmented / freckle-like spots on lips, mouth, hands + genitalia"
63
Juvenile Polyps / Juvenile Polyposis Sx
Def'n (both), MC Location, MC Pres?
Juvenile Polyps = sporadic lesions in children
64
HNPCC / Lynch Sx
MC Side, Inher, Genetics, Pres (general)?
*80% progress to CRC*
MC side = RIGHT.
AD.
AD mutation of DNA Mismatch-Repair genes.
MC Side = Right
PRES = Arises "de novo" at relatively early age.
65
Colorectal Cancer
Def'n, MC Side,
Molecular Path (2 pathways + what each lead to),
RF (5), Pres (2 Epi), Appearance on Ba Swallow (CLUE),
Screening, DX (3), Comp (2)?
Carcinoma arising from colonic or rectal mucosa.
MC Side = LEFT.
- Microsatellite Instability Pathway (DNA Mismatch-Repair gene mut)-> Sporadic Cancer + HNPCC Sx
- Chr Instability Pathway (APC + b-Catenin mut. 85%) -> Sporadic Cancer
* ** Order of gene events: "A, K, 53" ***
RF:
- Tobacco use
- Lynch Sx / Juvenile Polyposis Sx / Peutz-Jeghers Sx
- IBD
- Large villous adenoma
- Strep bovis bacteremia
PRES: > 50 yrs. 25% have family history.
BA SWALLOW: "Apple core" lesion
SCREENING:
- Begins at 50 yrs with Fecal Occult Blood Testing + Endoscopy
DX:
- "Apple core" lesion on XR
- CEA tumor marker (monitoring of treatment response + recurrence)
- Iron-Deficiency Anemia in older adult = CRC until proven otherwise!
COMP: (Strep bovis colonization of gut)
- Subacute Endocarditis
- Bacteremia
66
Right / Ascending / Proximal Colon CRC
Chars (2), Pres (3)?
CHARS:
- Exophytic mass
- Grows as a "raised lesion"
PRES:
- Fecal Occult bleeding -> Iron-Deficiency Anemia
- Vague pain
- Weight loss
67
Left / Descending / Distal Colon CRC
Chars (2), Pres (2), Appearance on XR (CLUE)?
CHARS:
- Infiltrating mass
- Partial obstruction
PRES:
- Hematochezia +↓stool caliber
- LLQ colicky pain
XR: "Napkin ring" lesion
68
Acute Appendicitis
Mech (General + Children + Adults),
Pres (2 MC signs + 2 other signs + CLUE + Triad),
DDX (2), Comp (2)?
MECH: Obstruction of appendix
- Viral infection -> lymphoid hyperplasia (Children)
- Fecalith (Adults)
PRES:
* - McBurney Sign + Rovsing Sign
- Obturator + Psoas signs
- "Initial diffuse periumbilical pain" -> "Pain localizes to McBurney pt"
- Fever + Nausea + Anorexia
DDX:
- Ectopic Pregnancy
- Diverticulitis (Elderly)
COMP:
- Rupture (-> Peritonitis)
- Abscess
69
Peritonitis
Pres (CLUE)?
PRES:
| - "Rebound tenderness" upon ab palpation
70
McBurney Sign
Def'n, Seen In?
Severe RLQ pain + REBOUND TENDERNESS.
SEEN IN:
- Acute Appendicitis
71
Rovsing Sign
Def'n, Seen In?
Severe RLQ pain + PALPATION OF LLQ.
SEEN IN:
- Acute Appendicitis
72
Liver Disease
Enzyme↑(2)?
- AST
| - LD1 + LD5
73
Angiodysplasia
MC Location, Mech (3 steps), Pres (Epi + 1), DX?
R Colon: Terminal Ileum + Ascending Colon + Cecum
(due to highest wall tension)
MECH:
Malformation of mucosal + submucosal CAPILLARY BEDS ->
Tortuous dilation -> Bleeding.
PRES: MC in Elderly
- Hematochezia (in case of rupture)
DX:
- Angiography
74
Fatty Liver Disease
Etiologies (2), Micro Finding (CLUE)?
ET: Alcoholic or Metabolic Sx
FINDINGS:
- Fatty infiltration of hepatocytes -> hepatocyte "ballooning"+ eventual necrosis
74
Liver Damage
Enzyme↑(2)?
- ALT
| - LD4 + LD5
74
Hirchsprung's Dz
Def'n + Locations (2), Mech (3 steps), Assoc,
Pres (4), DX (3), Comp, RX?
Congenital failure of GANGLION CELLS to descend into 2 plexuses:
Auerbach's / Myenteric + Meissner's / Submucosal plexus.
MECH:
Defective relaxation / peristalsis of SIGMOID COLON + RECTUM ->
Dilated portion of colon proximal to aganglionic segment ->
'Transition Zone'.
ASSOC:
- Down's Sx
PRES: *** Based on OBSTRUCTION ***. Very early in life.
- Failure to pass meconium
- Ab distension
- Constipation
- Bilicus emesis
DX:
* - Failure to pass meconium
- DRE: Empty rectal ampulla / vault
- Rectal Suction Biopsy: Lack of ganglion cells
COMP:
- Rupture
RX:
- Resection
75
Alcoholic Liver Disease
Micro Finding, Comp?
FINDINGS:
- Mallory bodies
COMP:
- Bilirubin Stones
76
Non-Alcoholic Fatty Liver Disease
Etiology, Assoc, Labs, Comp (2)?
ET: Metabolic Sx (Insulin Resistance)
ASSOC:
- Obesity
LABS:
- ALT > AST *** THINK: "L for Lipids" ***
COMP:
- Hepatitis / Cirrhosis
- HCC
77
Hepatic Steatosis
Def'n?
Accumulation of fat (fat droplets) in hepatocytes ->
Heavy + greasy liver.
*** May be REVERSIBLE with alcohol cessation ***
78
Hepatitis B + C
Conseq?
CONSEQ:
| - Nephrotic Sx
79
Alcoholic Hepatitis
Def'n, Mediator,
Pres, Micro Findings (CLUE + 1), Labs?
Chemical injury to hepatocytes from sustained long-term consumption of alcohol.
MED of damage = Acetaldehyde (metabolite of alcohol).
PRES:
- Painful hepatomegaly
FINDINGS:
- "Mallory Bodies"
- Swollen + necrotic hepatocytes with NEUTROPHIL infiltration
LABS:
- AST > ALT ***THINK: "Make a toAST with alcohol." ***
80
Alcoholic Cirrhosis
Def'n, Macro Findings (CLUE + 1), Pres?
*** FINAL + IRREVERSIBLE form of Alcoholic Liver Dz ***
FINDINGS:
- Shrunken liver with "hobnail appearance"
- Sclerosis around central vein
PRES: Occurs in 10-20% of alcoholics
(Same pres as Chronic Liver Dz)
81
Cirrhotic Liver
Def'n, Chars (2 Histo), Causes (6),
Pres (2 general), Labs (4), Seen In (2),
Comp (3)?
END-STAGE liver damage.
CHARS: *Destruction of normal liver architecture / parenchyma*
- Diffuse bands of FIBROSIS (mediated by TGF-β from Stellate cells)
- REGENERATIVE NODULES of hepatocytes
CAUSES:
* - Alcohol
- a1-antitrypsin def
- Fructose intolerance (aldolase B def)
- Viral Hep
- Hemochromatosis
- Biliary Dz
PRES:
- ↓detox
- Portal Htn
LABS:
- Ammonia↑
- Estrogen↑
- Albumin↓
- Clotting Factors↓
SEEN IN:
- Alcoholism
- Hepatitis B + C
COMP:
- Hepatocellular Carcinoma
- Cholesterol Stones
- 1ry Hyperaldosteronism
82
Cirrhosis #1
Def'n, Chars (2 Histo)?
END-STAGE liver damage.
CHARS: *Destruction of normal liver architecture / parenchyma*
- Diffuse bands of FIBROSIS (mediated by TGF-β from Stellate cells)
- REGENERATIVE NODULES of hepatocytes
83
Cirrhosis #2
Causes (6)?
CAUSES:
* - Alcohol
- Fructose intolerance (aldolase B def)
- a1-antitrypsin def
- Viral Hep
- Hemochromatosis
- Biliary Dz
84
Cirrhosis #3
Pres (4), Labs (4)?
PRES:
- ↓Detox
- ↓Protein Synthesis (->↓Albumin + Clotting Factors)
- > Ankle Edema
- > Anemia / Bleeding tendency
- Portal Htn
- Jaundice
- > Scleral Icterus
- > Fetor Hepaticus
LABS:
- Ammonia↑(-> Mental status changes, Asterixis, Coma)
* Metabolic therefore reversible!*
- Estrogen↑(-> Gynecomastia, Testicular Atrophy, Palmar Erythema, Spider Angiomata)
- Albumin↓
- Clotting Factors↓
85
Portal Htn
Causes, Pres (7)?
CAUSES:
- Schistosoma (trematode/fluke) infection
```
PRES:
- Esophageal Varices
(Shunt: Backup of L gastric vein into the Esoph vein)
-> Hematemesis
-> Melena
- Peptic Ulcer
- Splenomegaly
- Ascites / Caput Medusae (Shunt)
- Internal Hemorrhoids (Shunt)
```
*Portosystemic Shunts partially alleviate portal htn*
86
Budd-Chiari Sx
Def'n, Causes (2), Pres (3)?
Liver INFARCTION due to Hepatic Vein destruction.
CAUSES:
- RHF
- Liver Cancer
PRES:
- Hepatomegaly
- Ascites
- Ab pain
87
Nutmeg Liver (Congestive Hepatopathy)
Causes (2), Mech, Assoc (3), Macro Finding (CLUE), Comp (2)?
CAUSES:
- RHF
- Budd-Chiari Sx
Liver CONGESTION (backup of blood into liver).
ASSOC:
- Hypercoaguable state
- Polycythemia Vera
- Pregnancy
FINDINGS:
- Liver appears mottled like a "nutmeg"
COMP:
- Cardiac Cirrhosis (due to centrilobular congestion + necrosis)
- HCC
88
a1-antitrypsin Deficiency
Mech, Genetics, Pres (Liver vs Lung)?
Misfolded gene product (protein) AGGREGATES in ER of hepatocytes.
Codominance.
PRES:
- Liver: Cirrhosis with "PAS-positive globules"
- Lungs: Panacinar Emphysema
(due to uninhibited elastase in alveoli -> ↓elastic tis)
89
Hepatitis
Micro Finding?
FINDING:
| - Mallory Bodies
90
Viral / Toxic Hepatitis
Micro Finding?
FINDINGS:
| - Councilman Bodies
91
Yellow Fever
Micro Finding?
FINDINGS:
| - Councilman Bodies
92
Reye's Sx
Mech, Assoc (2 Micro), Pres (CLUE + 5)?
Mitochondrial damage.
ASSOC:
- Influenza B
- VZV
PRES = "Child with viral illness who is given Aspirin"
- Vomiting
- Hepatomegaly
- Liver failure
- Encephalopathy
- Coma
* ** Often fatal ***
* ** Aspirin only recommended for children with KAWASAKI DZ ***
93
Hepatic Encephalopathy
Mech (3 steps), Etiologies (2), Pres (Spectrum), RX (3)?
MECH:
Cirrhosis -> Portosystemic Shunts ->↓NH3 metab
ET:
- ↑NH3 production (eg↑dietary protein, constipation, infection, GI bleed)
- ↓NH3 metab / removal (eg Renal Failure, Diuretics)
RX:
- Lactulose (↑NH4 production)
- Rifaximin (kills intestinal bacteria)
- Low-protein diet
94
Crigler-Naijar Sx (Congenital UNconjugated Hyperbillirubinemia)
Def'n / Mech, Pres (CLUE), RX (3)?
ABSENT UDP-glucuronyl transferase.
PRES = "Severe jaundice in NEONATE"
*** Patients die within a few years ***
RX:
- Plasmapheresis
- Phototherapy
- Phenobarbital (Type II only)
95
Dubin-Johnson Sx (Congenital Conjugated Hyperbilirubinemia)
Def'n (2 steps), Pres (CLUE)?
Def of BRB Canalicular Transport Protein ->
Hepatocytes unable to secrete conjugated BRB into bile.
PRES = "BLACK Liver"
96
Wilson Disease (Hepatolenticular degeneration)
Locations (3 MC + 2), Inher + Genetics,
Pres (Epi +1 Liver + 1 Heme + 4 Neuro),
Micro Finding (CLUE), Labs (2 CLUES: Blood + Urine),
Comp (2), RX?
- Liver
- Brain (esp Basal Ganglia)
- Cornea (K-F ring)
- Kidneys
- Joints
AR. Chr 13.
PRES: Childhood
- Fatty change / Hepatitis / Cirrhosis of liver
- Hemolytic Anemia
- Asterixis
- Chorea
- Tremor
- Parkinsonian symptoms (Asterixis, Dementia, Dyskinesia, Dysarthria)
FINDING = "Kayser-Fleischer" rings.
LABS:
- Blood: Ceruloplasmin↓
- Urine: Cu↑
COMP:
- HCC
- Fanconi Sx
RX:
- Penicillamine (chelator)
97
Hemochromatosis (Bronze Diabetes)
Def'n, Causes (2, incl 1 genetic),
Pres (Epi + Triad + 3 Other), Micro Finding, Labs (4 Fe Studies)
DX, Comp (3), RX (2)?
Excess body iron -> Hemosiderosis (iron deposition)
-> Hemochromatosis (dz caused by iron dep)
CAUSES:
- HFE mutation
- Multiple blood transfusions
PRES: Late Adulthood. "Bronze Diabetes".
* ** Iron loss thr MENSES slows progression in women ***
1. Cirrhosis
2. DM
3. Skin pigmentation
- Arrhythmias
- CHF
- Testicular Atrophy
FINDINGS:
- Brown hepatocytes
LABS:
- Iron↑
- Ferritin↑
- % Saturation↑
- TIBC ↓
DX = Liver Biopsy
COMP:
- HCC
- Cardiomyopathy
- CHF
RX:
- Repeated Phlebotomy
- Deferoxamine
98
1ry Hemochromatosis
Def'n, Inher, Genetics (2 possible mutations), HLA Assoc?
Defect in iron ABS.
AR.
Mutations on HFE gene:
- C282Y mutation
- H63D mutation
HLA-A3 assoc.
99
Jaundice
Def'n, Mech (2 options), Causes (3)?
Yellow skin and/or sclerae due to elevated BILIRUBIN (BRB).
BRB > 2.5 mg/dL in blood.
MECH:
- ↑BRB production
- ↓BRB metab
CAUSES:
- Hepatocyte injury
- Obstruction to bile flow
- Hemolysis
100
Obstructive Jaundice
Pres (1 + 2 Excretion-Related + 2 Skin-Related), Labs (3)?
PRES:
- Hepatosplenomegaly
- Dark urine
- Light stools
- Jaundice
- Pruritus
LABS:
- Conjugated BRB↑
- Cholesterol ↑
- Alkaline Phosphatase↑
101
Hemolytic Jaundice
Urine (2: BRB + Urobilinogen)?
URINE:
- BRB ABSENT = Acholuria (absence of bile pigments in urine)
- Urobilinogen ↑
102
"Painless jaundice"
Cancer of the pancreatic HEAD (obstructs bile duct)
103
Liver Cancer (Hepatic Adenoma + HCC)
Assoc (6), Path,
Pres (4), Labs (CLUE + 2),
DX (2 options), Comp?
ASSOC:
- a1-antitrypsin deficiency
- Cirrhosis
- Hemochromatosis
- Hepatitis B + C
- Wilson dz
- Aflatoxin (can be produced by Aspergillus species)
Spreads by HEMATOGENOUS dissemination.
PRES:
- Ascites
- Jaundice
- TENDER Hepatomegaly
- Anorexia
LABS:
- a-fetoprotein
- Polycythemia
- Hypoglycemia
DX:
- CT
- U/S
COMP:
- Budd-Chiari Sx
104
Hepatic Adenoma
Assoc (2), Course (2 options)?
*** RARE ***
ASSOC:
- Anabolic Steroids
- ↑ Estrogen (ie OCPs or Pregnancy)
COURSE:
- Regress spontaneously OR
- Rupture -> Intraperitoneal bleeding (↑risk during Pregnancy)
105
Hepatic Angiosarcoma
Def'n, Causes (3: "VAT")?
Malignancy of Liver. *** Highly lethal ***
CAUSES: Exposure to "VAT":
- Vinyl Chloride (plastics, rubber)
- Arsenic (pesticides)
- Thorotrast (radioactive diagnostic agent)
106
Metastasis to Liver
MC Sources (4), Pres (CLUE + 1)?
MC SOURCES:
- Lung
- Breast
- Colon
- Pancreas
PRES:
- "Hepatomegaly with NODULAR free edge of liver"
- Multiple nodules in liver
107
Biliary Tract Disease
Locations w/in Biliary Tract (2), Pres, Labs, Comp?
LOCATIONS:
- INTRAhepatic bile ducts: 1ry + 2ry Biliary Cirrhosis
- INTRA + EXTRAhepatic bile ducts: 1ry Sclerosing Cholangitis
PRES = (Pres of Obstructive Jaundice)
LABS = (Pres of Obstructive Jaundice)
COMP:
- Cirrhosis
108
Biliary Atresia
Mech (2 steps), Pres (Epi + 1)?
Failure to form OR Destruction of Biliary Tree ->
Biliary OBSTRUCTION.
PRES: 1st 3 months
- Jaundice -> Cirrhosis
109
1ry Biliary Cirrhosis
Mech, Assoc, Micro Findings (2), Ab?
MECH: AUTOIMMUNE. Lymphocytic infiltrate + Granulomas.
ASSOC = Other Autoimmune conditions.
FINDINGS:
- Lymphocytic infiltrate
- Granulomas
AB:
- IgM
110
2ry Biliary Cirrhosis
Etiology, Mech, Causes (4)?
ET: EXTRAhepatic biliary OBSTRUCTION
MECH:
↑Pressure in INTRAhepatic ducts -> Injury / Fibrosis
-> Bile Stasis
CAUSES (of extrahepatic biliary obstruction):
- Biliary stricture
- Gallstones
- Chronic Pancreatitis
- Pancreatic Adenocarcinoma (Head of pancreas)
111
Cholangitis
Pres (Charcot's Triad)?
PRES: Charcot's Triad
1. Fever
2. Jaundice
3. RUQ pain
112
Primary Sclerosing Cholangitis
Mech, Assoc, Macro Findings (2 steps / CLUES), Ab, Comp (2)?
MECH = Infl + Fibrosis.
ASSOC:
- Ulcerative Collitis
FINDINGS: (On ERCP)
- Concentric "onion skin" bile duct fibrosis ->
- Alternating strictures / dilations of bile ducts = "beading"
AB:
- IgM↑(Hypergammaglobulinemia)
COMP:
- 2ry Biliary Cirrhosis
- Cholangiocarcinoma
113
Ascending Cholangitis
Def'n (incl CB), RF, Pres (2), Comp?
```
BACTERIAL INFECTION (usually ascending) of bile ducts,
usually with Enteric Gram-Negative bacteria.
```
RF:
- Bile Duct Stones
PRES:
- Jaundice
- Ab pain
COMP:
- Sepsis
114
Cholangiocarcinoma
Assoc (Micro)?
ASSOC:
| - Clonorchis sinensis (trematode) infection
115
Courvoisier Sign
Mech, Pres (2)?
Distal obstruction of biliary tree.
PRES:
- Obstructive Jaundice
- Gallbladder distended, palpable, NON-tender
116
Cholelithiasis / Gallstones #1
Causes (3), RF (6: "4 Fs" + 2),
DX (2: Phys Exam + U/S CLUE), RX?
CAUSES:
- ↓Bile Salts (b/c bile salts increase solubility)
- ↓Phospholipids (ie Lecithin)
- Gallbladder stasis
RF: "4 Fs". *** Estrogen ***
- Female
- Forty
- Fertile
- Fat
- Advanced age
- Cirrhosis
DX:
- Phys Exam: Murphy's Sign
- U/S: "Air in biliary tree" *ONLY in case of fistula or gallstone ileus*
RX:
- Cholecystectomy *ONLY if symptomatic*
117
Cholelithiasis / Gallstones #2
Comp (6)?
COMP:
* - Cholecystitis
- Ascending Cholangitis
- Acute Pancreatitis
- Biliary Colic
- Bile Stasis
- Fistula b/w Gallbladder + S.I / Gallstone Ileus
118
Cholesterol Gallstones
Appearance, Assoc (8)?
Yellow / radioLUCENT with opacities (due to calcifications).
ASSOC:
- Native American
- Multiparity
- Obesity
- Rapid weight loss
- Crohn's
- Cystic Fibrosis
- Clofibrate
- Estrogens
119
Bilirubin / Pigment Gallstones
Appearance, Assoc (2: Micro + 1)?
RadiOPAQUE.
*** BROWN = Infection. BLACK = Hemolysis. ***
ASSOC:
- Biliary infection (E coli, Ascaris lumbricoides, Clonorchis sinensis)
- Chronic Hemolysis
120
Pancreatic Disease
Enzymes↑(3)?
- Amylase
- Elastase-1
- Lipase
121
Pancreatic Insufficiency
Causes (3), Pres (2), DX?
CAUSES:
- Cystic Fibrosis
- Pancreatitis
- Cancer (Obstructing)
PRES: MALABSORPTION with:
- Fat-Soluble Vitamin def
- Steatorrhea
DX: D-Xylose Abs Test
122
Acute Pancreatitis
Mech (3 steps), Path (incl 2 types of Necrosis),
Causes (10: "GET SMASHED"),
Pres (3), Labs (3),
Comp (6)?
MECH:
Premature activation of Trypsin ->
Activation of other panc enzymes ->
AUTODIGESTION of pancreas by panc enzymes.
PATH: Infl + Hem of pancreas:
- Liquefactive Hemorrhagic Necrosis of pancreas
- Fat Necrosis of peripancreatic fat
CAUSES:
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune dz
- Scorpion sting
- Hypercalcemia / Hypertriglyceridemia (> 1000)
- ERCP
- Drugs (Sulfa drugs)
PRES:
- Epigastric ab pain radiating to BACK
- Periumbilical / Flank hemorrhage (due to necrosis spreading)
- Anorexia + Nausea + Vomiting
LABS:
- Amylase↑
- Lipase↑ * More specific than amylase for pancreatic DAMAGE *
- Ca↓(Ca consumed during saponification in fat necrosis)
COMP:
- Pancreatic Abscess
- Pancreatic Pseudocyst
- 1ry Hyperparathyroidism
- ARDS
- DIC
- Infection / Shock / Organ failure
123
Chronic Pancreatitis
Causes (3, incl 2 specific to Adults / Kids), Path (4),
Labs (generalization), Imaging (CLUE),
Comp (4)?
CAUSES:
- Alcohol (Adults)
- Cystic Fibrosis (Kids)
- Recurrent Acute Pancreatitis
PATH: Damage to pancreatic parenchyma:
- Chronic infl
- Calcification
- Fibrosis
- Atrophy
LABS: * Amylase + Lipase LESS elevated than in Acute Pancreatitis *
IMAGING: Imaging with Contrast:
- "Chain of lakes" pattern
COMP:
- Pancreatic Insuf
- Pancreatic Adenocarcinoma
- DM
- 2ry Biliary Cirrhosis
124
Pancreatic Adenocarcinoma
Def'n, MC Location, Markers (2), RF (5),
Pres (3),
RX (3 Therapies), Prog?
VERY AGGRESSIVE tumor arising from pancreatic ducts.
MC LOCATION = Pancreatic Head.
MARKERS:
- CA 19-9
- CEA (however less specific)
RF:
- Male
- African-American or Jewish
- Age > 50 yrs
- Tobacco
- Chronic Pancreatitis
PRES:
- (Pres of Pancreatitis)
- Courvoisier's Sign
- Trousseau's Sx
RX:
- Whipple Procedure
- Chemotherapy
- Radiation therapy
PROG = 6 months or less.
125
Splenectomy / Nonfunctional Spleen AUTOSplenectomy
Def'n + MCC, Path, Pres (Epi), Micro Finding (CLUE)?
Fibrosis + shrinkage of spleen.
MCC = Sickle Cell Anemia.
↑risk of infection with encapsulated organisms.
PRES = functional splenic dysfunction in early childhood
FINDING = Howell-Jolly bodies
126
Curling Ulcer
Cause, Seen In?
*** "Burned by the curling iron" ***
CAUSE = Severe burns
(Hypovolemia -> Gastric Ischemia -> SLOUGHING of gastric mucosa)
SEEN IN: Acute Gastritis
127
Cushing Ulcer
Cause, Seen In?
*** "Always cushion the brain" ***
CAUSE = Brain Injury /↑ICP
(↑Vagal stim ->↑Ach ->↑digestion / H production)
SEEN IN: Acute Gastritis
128
Virchow Node
Cause, Pres?
CAUSE = Abdominal metastasis
PRES = enlarged + hard left supraclavicular node
129
VIPoma
Def'n, Pres, Labs (2 ions)?
Non-α + non-β islet cell pancreatic tumor that secretes VIP.
PRES = Copious watery diarrhea
LABS:
- K↓
- Cl↓
130
Carcinoid Tumor / Carcinoid Sx
Def'n, MC Locations (3: "AIR"),
Triggers (2), Pres (4 Chars of Carc Sx), Micro Findings, Urine,
RX?
*Low-grade malignancy*
Tumor of neuroendocrine cells of GI tract, esp metastatic S.I tumors.
MC Locations (*although can arise anywhere along gut*):
- Appendix
- Ileum
- Rectum
TRIGGERS: (stim Serotonin release from tumor)
- Emotional stress
- Alcohol
PRES: Carcinoid Sx: carcinoid tumor w mets to LIVER.
(Tumor secretes high levels of Serotonin)
- Flushing
- Wheezing
- Diarrhea
- Carcinoid Heart Dz / R-sided heart murmurs
FINDINGS:
- Dense Core Bodies (tumor grows as a submucosal POLYP-like nodule)
URINE:
- 5-HIAA↑
RX:
- Octreotide
131
Meconium Ileus (Newborn)
Causes?
CAUSES:
| - Cystic Fibrosis
132
"Megaesophagus + Megacolon"
Chagas Dz (Trypanosoma cruzi, Reduviid bug, South America)
133
Fitz-Hugh-Curtis Sx
Def'n, Cause / Assoc, General Pres?
Infection of liver capsule.
CAUSE / ASSOC:
- PID
GEN PRES: "Violin string" adhesions of peritoneum to liver
