GIT-Part 2 witwer

Question 1

Liver fx: storage

• Glucose is stored as _______
• Storage of which vitamins & minerals:

Answer 1

• glycogen (glycogenesis)–> then back to glucose (glycogenolysis)
• Vitamin A, D, B12, vitamin K, iron and copper

Question 2

Liver fx: synthesis

Answer 2

• Bile acids from cholesterol made by liver –for emulsification of fats
• Protein metabolism – amino acids, clotting factors (fibrinogen, prothrombin, etc), vitamins, albumin, transport proteins, binding proteins
• Carbohydrate metabolism including gluconeogenesis – synthesis of glucose
• Lipid metabolism– including cholesterol synthesis (50% from liver, 50% from food), lipogenesis and triglyceride production
• Conjugation of bilirubin
• Ammonia formation

Angiotensin – part of RAAS

Question 3

Liver fx: immunological

-describe Kupffer cells

Answer 3

Kupffer cells in sinusoids (part of the reticuloendothelial system) act as antigen presenting cells

Question 4

Liver: detox fx

Answer 4

Detoxification/breakdown:
Toxins
Hormones
Drugs

Question 5

Jaundice is caused by HIGH levels of ______

Answer 5

**bilirubin

Question 6

Describe the process of RBC destruction

Answer 6

• Red Blood cells are destroyed by the reticuloendothelial system
• The iron is recycled
• The heme portion of Hgb is broken down into fat soluble Bilirubin (Indirect Bilirubin)
• The Liver converts the fat soluble Bilirubin into water soluble Bilirubin (Direct Bilirubin)
• The water soluble Bilirubin is secreted into the Biliary System as part of bile and passes into the bowel

Question 7

Pre-Hepatic Jaundice – usually occurs when:

Answer 7

when there is an excessive breakdown of RBCs as in hemolytic anemias and internal hemorrhage

Question 8

Hepatic Jaundice occurs when:

Answer 8

liver cannot conjugate the fat soluble Bilirubin (indirect) into water soluble Bilirubin (direct)

Question 9

Post-Hepatic Jaundice occurs when:

Answer 9

there is obstruction to the flow of bile usually from gallstones in the CBD or Carcinoma in the head of the Pancreas

Question 10

normal levels of bilirubin=

Answer 10

<1 mg/dL

Question 11

sceral icterus occurs when bilirubin is > than ____

Answer 11

3

Question 12

conjugated bili is found in ____

Answer 12

urine

Question 13

In newborns if the unconjugated bilirubin is >4 mg/dL there is the possibility of ________

Answer 13

Kernicterus.

Question 14

Bilirubin is neurotoxic and can accumulate in the grey matter of the brain causing _______

Answer 14

Kernicterus, encephalopathy – cerebral palsy like disorder

Question 15

tx of bili accumulation (toxic levels)?

Answer 15

phototherapy or exchange transfusion.

Question 16

Describe breakdown of hgb (starting w/ heme) KNOW

Answer 16

Heme > biliverdin (greenish color of bruises) > unconjugated bilirubin > conjugated bilirubin (excreted as bile) > acted on by microbes > urobilinogen > 1) stercobilin giving feces their brown color and 2) converted into urobilin giving urine its yellow color.

Question 17

Bruise Healing process=

Answer 17

Hgb–> biliverdin–> bilirubin

bruise—> healing

Question 18

Bile is produced by ____ and stored in _______

Answer 18

liver

-gallbladder

Question 19

Contents of bile=

Answer 19

• Water 97%, bile salts 0.7%, bilirubin 0.2%, fats (cholesterol, fatty acids, lecithin 0.5%), inorganic salts
• Bile acids/salts are steroid acids produced in liver and conjugated into bile salts.

Question 20

Bile is discharged into duodenum for _____

Answer 20

Aids in digestion of lipids, emulsifies lipids

Question 21

Bile salts are recycled via:

Answer 21

reabsorption in the enterohepatic circulation

Question 22

Steroid based acids/salts synthesized in the ____

Answer 22

liver

Question 23

There is an _________ circulation of bile salts.

Answer 23

enterohepatic

**Bile salts and Vitamin B12
absorbed in the Terminal Ileum and recycled

Question 24

Describe Bile

Answer 24

Bile salts act as a surfactant,
emulsifying lipids

Aggregate around lipids
(triglycerides and phospholipids)
forming micelles

Greater surface area for pancreatic lipases to digest fats

Triglycerides > two fatty acids and a monoglyceride absorbed by villi, reform into triglycerides and are absorbed by the lymphatic system

Vitamins go along with fats

Question 25

Bilirubin is excreted in bile as well as the _____

Answer 25

urine -Bilirubin accounts for the yellow color of bruises, a breakdown product stercobilin the brown color of stools, and a breakdown product urobilin the yellow color of urine. -Bilirubin acts as a cellular antioxidant

Question 26

Fatty liver changes can be secondary to:

Answer 26

alcoholism, metabolic syndrome, toxins, and hepatitis and **are reversible

Question 27

T/F: Cirrhotic Liver with scarring and regenerative nodules is irreversible

Answer 27

true

Question 28

Hepatic Cirrhosis: | -imaging findings

Answer 28

-U/S demonstrating enlargement and increased echogenicity of liver parenchyma -enlarged left and caudate lobes, fibrosis and shrunken right lobe, and ascites

Question 29

Loss of liver function causes:

Answer 29

Hepatic Insufficiency -Jaundice from bilirubin buildup -Hyperestrinism from inability to metabolize estrogen -Bleeding from decrease in clotting factors -Ammonia build up – hepatic encephalopathy .> asterixis 2) Portal Hypertension - Esophageal varices - Hemorrhoids - Ascites - Splenomegaly

Question 30

Viral hepatitis: | -Hepatitis C notorious for:

Answer 30

A mild acute infection with chronic hepatitis in 85% if not treated 20% develop post necrotic cirrhosis Complications: Cirrhosis Hepatocellular carcinoma

Question 31

What is the MC liver tumor?

Answer 31

**Cavernous Hemangioma Liver tumor

Question 32

What is the 2nd Mc liver tumor?

Answer 32

Focal Nodular HyperplasiaSecond Most Common Liver Tumor-Benign= Hyperplasic process with possible association with oral contraceptives

Question 33

Metastatic Disease to Liver: provide 1 ex

Answer 33

Diffuse metastatic breast carcinoma to the liver with resulting portal hypertension and umbilical vein enlargement

Question 34

Hemochromatosis: - describe this condition - can be 2/2 ?

Answer 34

=Iron deposition in liver, pancreas, and heart -2/2: genetic disorder, Hereditary Hemochromatosis, or transfusion iron overload

Question 35

Gallstones: | -75% are _______

Answer 35

cholesterol stones--contain Ca 2+ carbonate,

Question 36

Black pigment stones= | -2/2 ?

Answer 36

chronic extravascular hemolytic anemia – calcium | bilirubinate stones

Question 37

Brown pigment stones= | 2/2 ?

Answer 37

infection – Asians – unconjugated bilirubin

Question 38

Cholelithiasis: - pathogenesis? - risk factors?

Answer 38

- Supersaturation of bile with cholesterol - Decrease bile salts/acids which solubilize cholesterol - Female >40 - Use of oral contraceptives - Obesity - Rapid weight loss - Native Americans

Question 39

Cholelithiasis: | -complications?

Answer 39

Cholelithiasis with cholecystitis | -Common Bile Duct Obstruction

Question 40

Acute Cholecystitis: | -95% caused by _____

Answer 40

**Gallstones Fair, fat, fecund and forty From 40-60 yrs

Question 41

Acute Cholecystitis: | -pathogenesis?

Answer 41

Stone lodges in cystic duct or common bile duct Food stimulus causes gallbladder contraction – biliary colic Stone impacts in cystic duct Mucus accumulates behind stone -**Infection – most commonly E. coli, then Enterococcus, Bacteroides fragilis, and Clostridium - **RUQ pain, possible radiation to right shoulder - Localized peritonitis with rebound tenderness - **Positive Murphy sign -**Neutrophilic leukocytosis Stone may pass and attack subsides If stone does not pass, perforation may occur

Question 42

Acute Cholecystitis: | -clinical presentation

Answer 42

Fever Vomiting in 75% Radiation of pain to right shoulder -*Murphy sign Palpable gallbladder 15% Neutrophilic leukocytosis - >12K in 70% -Jaundice 25% - CBD stone -Increased AST/ALP with common duct stones -**Increased serum bilirubin >4mg/dL indicates common duct stone -Increased serum amylase indicates pancreatitis

Question 43

Acalculous Cholecystitisaka Necrotizing Cholecystis: | -is usually seen in ?

Answer 43

**critically ill patients with other coexistent disease processes. Gallbladder stasis > ischemia > inflammation > necrosis and infection Need to think about it. A “Don’t forget” Usually a fulminant course with high rate of complications such as gangrene and perforation. High morbidity and mortality.

Question 44

Cholelithiasis: | -gold standard dx test?

Answer 44

**Ultrasound is the gold standard >98% sensitivity to detect stones in gall bladder but not the cystic duct (only 30% sensitivity) -Detects stones and sludge and pericystic inflammation

Question 45

Cholelithiasis: | -tx?

Answer 45

ERCP

Question 46

Cancer of the Gall Bladder: - demographic? - Precursor is _____

Answer 46

Unusual Elderly females Poor prognosis Cholelithiasis in 95% precursor= porcelain gallbladder**, must remove it

Question 47

Pancreatic secretions: | -Exocrine Gland Function

Answer 47

Controlled by hormones Gastrin, Cholecytokinin, and Secretin from Stomach and Duodenum -Acinar Cells secrete bicarbonate ions, and precursor proenzymes for proteases (trypsinogen, chymotrypsinogen), pancreatic lipase, pancreatic amylase, phospholipases, and cholesterol esterase.

Question 48

Pancreatic secretions: | Endocrine Gland Function:

Answer 48

``` Pancreatic Islet Cells secrete: Glucagon – alpha cells Insulin – beta cells Somastatin – delta cells Pancreatic polypeptide – gamma cells ```

Question 49

Acute Pancreatitis: | -epidemiology?

Answer 49

Alcoholism and Gallstones major causes 80% Gallstones most common acute cause (Dr Opie) Activation of the proenzymes (zymogens) in the acinar cells of the pancreas, into enzymes that autodigest the panceas - Obstruction of main pancreatic duct or CBD - Gallstones - Alcohol thickens ductal secretions Pathophys: -**Trypsin important activator of proenzymes Proteases damage acinar cell structure -Lipases and phospholipases > enzymatic fat necrosis Elastases damage vessel walls > hemorrhage

Question 50

Acute pancreatitis complications:

Answer 50

Peripancreatic Infection Pseudocyst formation Pancreatic Abscess -Pancreatic Ascites from leaking pseudocyst

Question 51

Acute pancreatitis: clinical sx

Answer 51

Fever, nausea, vomiting -Severe, boring, knife like pain in the midepigastrium with radiation to the back Hypovolemic shock due to third spacing of fluids – peripancreatic fluids Hypoxemia – loss of surfactant secondary to circulating pancreatic phospholipases > atelectasis (intrapulmonary shunting) Grey-Turner Sign Cullen Sign DIC: Disseminated Intravascular Coagulopathy due to activation of prothrombin by trypsin Tetany - hypocalcemia from enzymatic fat necrosis and saponification

Question 52

Acute Pancretitis: gold standard dx test?

Answer 52

CT is Gold Standard

Question 53

MCC of chronic pancreatitis?

Answer 53

alcoholism -cystic fibrosis in children ``` Findings: Pancreatic pseudocysts Calcifications- saponification Scarred shrunken pancreas Residual Diabetes mellitus Residual malabsorption ```

Question 54

Chronic Pancreatitis: | -clinical findings

Answer 54

Severe pain radiating to the back Malabsorption – indicates that 90% of exocrine function destroyed Type 1 Diabetes Mellitus in 70% Brittle Diabetics secondary to loss of glucagon and insulin Pancreatic pseudocysts

Question 55

Cancer of the Pancreas: - demographic - which tumor is MC?

Answer 55

Occurs primarily from 60-80 yrs -**Adenocarcinoma most common Associations: - Smoking - Chronic Pancreatitis Clinical: - Epigastric pain with weight loss >90% - Painless or painful jaundice - Light colored (clay colored) stools – - sister mary joseph sign= nodule at the umbilicas - Increased CA19-9 – Gold Standard

Question 56

DDX: RUQ pain

Answer 56

- acute cholecystitis - Acute hepatitis - acute pancreatitis

Question 57

DDx: LUQ pain

Answer 57

- acute pancreatitis | - splenic rupture

Question 58

DDX: RLQ pain

Answer 58

- appendicits - PID - ruptured ectopic

Question 59

DDX: LLQ

Answer 59

- endometriosis - strangulated inguinal hernia - PID - ruptured ectopic

Question 60

DDx: diffuse pain

Answer 60

acute pancreatitis aortic dissection bowel obstructoon gastroenteritis