1
Q
hallmark of ischemic hepatopathy in regards to labs
A
-rapid and massive increase in the transaminases with modest accompanying elevations in total bilirubin and alk phos
2
Q
This refers to persistent abdominal pain or dyspepsia (e.g. nausea) that occurs either postoperatively (early) or months to years (late) after a cholecystectomy
A
Postcholecystectomy syndrome (PCS)
3
Q
Steps in diagnosing PCS
A
- endoscopic US
- ERCP
- or magnetic resonance cholangiopancreatograpyhy
4
Q
What can treat cholesterol gallstones in patients with mild symptoms who are not candidates for cholecystectomy?
A
- Ursodeoxycholic acid
- This is also used to treat PBC and PSC
5
Q
Diarrhea associated with laxative abuse is typically described as what?
A
- watery, frequent (10-20 daily) and voluminous
- Nocturnal BMs and abdominal cramps are common
- HYPOKALEMIA and metabolic alkalosis
6
Q
characteristic colonoscopic findings in laxative abuse
A
-Melanosis coli, which is dark brown discoloration of the colon with pale patches of lymph follicles that give the appearance of alligator skin
7
Q
Pathophysiology of diffuse esophageal spasm
A
-Uncoordinated, simultaneous contractions of esophageal body
8
Q
Symptoms of diffuse esophageal spasm
A
- Intermittent chest pain
- Dysphagia for solids and liquids
9
Q
Diagnosis of diffuse esophageal spasm
A
- Manometry: intermittent peristalsi, multiple simultaneous contractions
- Esophagram: “Corkscrew” pattern
10
Q
Treatment of Diffuse esophgeal spasm
A
- CCB
- Alternates: nitrates or tricyclics
11
Q
nutrient deficiency and associated symptoms found with malabsorption in celiac dx
A
- Fat and Protein: Loss of muscle mass and subcutaneous fat, fatigue
- Iron: Pallor (anemia), fatigue
- Calcium and Vit D: Bone pain (osteomalacia), Fx (osteoporosis)
- Vit K: Easy bruising
- Vit A: hyperkeratosis
12
Q
The diagnosis of celiac disease is highly correlated with positive results on serological studies, primarily IgA anti-tissue transglutaminase and IgA anti-endomysial antibodies. However, Many patients with biopsy confirmed celiac dx will have negative results due to what
A
associated selective IgA deficiency, which is common in celiac dx
13
Q
Patients with cirrhosis and portal HTN frequently have abdominal ascites and peripheral edema due to low albumin levels and abnormal extracellular fluid volume regulation. A small number of these patients may also develop hepatic hydrothorax . .what is this
A
a pleural effusion NOT due to underlying cardiac or pulmonary abnormalities . .. due to small defects in the diaphragm
-much more commonly on the right side due to the less muscular hemidiaphragm
14
Q
Describe hepatopulmonary syndrome
A
- results from intrapulmonary vascular dilations in the setting of chronic liver disease
- Patients frequently have evidence of platypnea (increased dyspnea while upright) or orthodeoxia (oxygen desat while upright)
15
Q
Describe the relationship between Total parenteral nutrition and gallstones?
A
- Normal stimulus for CCK release and gallbladder contraction is absent
- causes gallbladder stasis and predisposes to gallstone formation and bile sludging, both of which may lead to cholecystitis
16
Q
Acute pancreatitis complicated by hypotension is thought to arise from what?
A
-Intravascular volume loss secondary to local and systemic vascular endothelial injury. This causes vasodilation, increased vascular permeability, and plasma leak into the retroperitoneum, resulting in systemic hypotension
17
Q
Common causes of pill or medication induced esophagitis
A
- Antibx: tetracyclines
- Anti-inflammatory: Aspirin and NSAIDS
- Bisphosphonates: Alendronate, Risedronate
- Others: Potassium chloride, iron
18
Q
Most common location for pill esophagitis and why?
A
-Mid-esophagus due to compression by the aortic arch or an enlarged left atrium
19
Q
What type of granulomas in Crohns
A
NONcaseating
20
Q
Gross examination in Crohns
A
- TRANSMURAL inflammation
- linear mucosal ulcerations
- Cobblestoning
- Creeping fat
21
Q
patient < 40 with BRBPR but no other red flags or symptoms .. . whats the workup
A
- Anoscopy
- if nothing found then sigmoidoscopy or colonoscopy
- If 40-49 then start with second bullet above
- if >50 or red flags then colonoscopy
22
Q
What are the diagnostic requirements of Acute Liver Failure (severe acute liver injury in a patient without cirrhosis)?
A
- Severe acute liver injury (ALT and AST often > 1000)
- Signs of hepatic encephalopathy (e.g. confusion, asterixis)
- Synthetic liver dysfunction (INR > 1.5)
23
Q
Describe the D-xylose test
A
- Patients with proximal small intestinal mucosal dx (e.g. celiac) cannot absorb the D-xylose in the intestine, and urinary and venous D-xylose levels will be low
- By contrast, patients with malabsorption due to enzyme deficiencies (e.g. chronic pancreatitis) will have normal absorption of D-xylose
24
Q
What is the first serologic marker to appear in the serum with acute hepatitis B?
-What appears shortly after?
A
- HBsAg . . appears usually 4-8 weeks after infection
- IgM anti-HBc shortly after, which is around the time clinical symptoms occur and patients develop elevations in hepatic aminotransferase levels (often >25 times the normal limit)
25
What is pellagra and what is it due to
- 3 Ds: dermatitis, diarrhea, and dementia
| - Niacin deficiency
26
In developing countries, niacin deficiency is seen in populations that subsist primarily on what produces
-Corn products
27
Despite the introduction of direct-acting antiviral agents (sofosbuvir-Velpatasvir), which have dramatically improved the ability to achieve virologic cure, HCV management continues to involve strategies to prevent further liver damage. What are these strategies?
- Alcohol avoidance
| - HAV and HBV vaccination
28
An asymptomatic elevation of Alk phos with normal hepatic transaminases, normal RUQ US, and positive antimitochondrial antibody assay is consistent with what
PBC
29
drug of choice for PBC
Ursodeoxycholic acid . . treatment is less effective in advanced disease and many patients will go on to require liver transplantation
30
Toxic megacolon typically presents with total or segmental nonobstructive colonic dilation, severe bloody diarrhea, and systemic findings (e.g. fever, tachycardia). Patients with IBD are at higher risk of developing toxic megacolon. Diagnosis is confirmed by what?
- Plain abdominal x-rays and 3 or more of the following:
- >100.4 F
- Pulse >120
- WBC > 10,500
- anemia
31
Toxic megacolon is a medical emergency that require what -
- prompt IV steroids
- Nasogastric decompression
- antibiotics
- fluid management
32
Recurrent peptic ulcer disease with multiple ulcers and jejunal ulceration suggests what . . endoscopy often shows thickened gastric folds
Gastrinoma (Zollinger-Ellison Syndrome)
33
what fasting serum gastrin level is strongly suggestive of a gastrinoma (ZE syndrome)
>1000
34
Patients with suspected Gastrinoma with non-diagnostic serum gastrin levels (110-1000) should be evaluated with what
secretin stimulation test
35
What is a potential complication of acute liver failure that may lead to coma and brain stem herniation and is the most common cause of death
Cerebral edema
36
In acute liver failure due to acetaminophen toxicity, liver transplantation is firmly indicated in what patients
- Grade III or IV hepatic encephalopathy
- PT >100 seconds
- serum creatinine > 3.4
37
Describe the possible effect of cirrhosis on Thyroid hormones
- The liver produces serum binding proteins for thyroid hormones (e.g. thyroxine-binding globulin, transthyretin, albumin, lipoproteins)
- Cirrhosis leads to decreased synthesis of these proteins, which lowers the TOTAL triiodothyronine (T3) and thyroxine (T4) in circulation
- However, free T3 and T4 levels are unchanged and TSH will be normal
38
Pleural fluid analysis in Boerhaave syndrome
- Exudative
- Low pH
- Very high amylase (>2500)
- may contain food particles
39
Chest x-ray shows what in Boerhaave syndrome
- may reveal pneumomediastinum
- or unilateral pleural effusion (usually left) with or without pneumothorax
- Medastinal widening can be seen as air and fluid accumulated in the mediastinum, causing inflammation (mediastinitis)
40
A patient with abdominal pain, microcytic anemia, positive fecal occult blood, and hepatomegaly with a hard edge on liver palpation has typical features of what
A GI malignancy, likely colon cancer, metastasized to liver
41
Colonoscopy recommendation for patients with UC or Crohn disease with colonic involvement
- 8-10 years post diagnosis (12-15) if disease only in left colon)
- repeat every 1-3 years
42
Most common causes of cirrhosis in the U.S.
- Viral hepatitis
- Chronic alcohol abuse
- Nonalcoholic fatty liver disease
- Hemochromatosis
43
Neoplasms in Lynch syndrome
- Colorectal
- Endometrial
- Ovarian
44
Neoplasms in Familial adenomatous polyposis
- Colorectal
- Desmoids and osteomas
- Brain tumors
45
Neoplasms in von Hippel-Lindau syndrome
- Hemangioblastomas
- Clear cell renal carcinoma
- Pheo
46
Neoplasms in MEN 1
- Parathyroid adenomas
- Pituitary
- Pancreatic
47
Neoplasms in MEN 2
- Medullary thyroid
- Pheo
- Parathyroid HYPERPLASIA (type 2A)
48
Some patients with acute diverticulitis have urinary urgency, frequency, or dysuria due to what?
Bladder irritation fro an inflamed sigmoid colon
49
Diagnostic test of choice for Zenker's diverticulum
Contrast esophagram
50
Options to visualize the esophagus, including endoscopy are associated with very serious risks of complications in a Zenker's diverticulum, such as what?
Esophageal perforation
51
Treatment of Zenker's diverticulum?
usually surgery
52
Mallory-Weiss tear is a common cause of upper GI hemorrhage and is often seen in association with what things
- Alcohol abuse
| - hiatal hernia
53
Hemobilia (bleeding in the biliary tree) is an UNcommon cause of upper GI hemorrhage. It is typically seen following what?
-Abdominal trauma or surgery
54
Patient with cirrhosis and ascites accompanied by fever and lethargy is a presentation concerning for what
Spontaneous Bacterial Peritonitis
55
What is the test of choice for Spontaneous Bacterial Peritonitis
Diagnostic paracentesis
56
What is the main diagnoistic criteria of the paracentesis for Spontaneous Bacterial Peritonitis
Neutrophil count > 250 and positive ascites fluid culture
57
Clinical features of Primary biliary cholangitis
- middle aged women
- Insidious onset of fatigue and pruritis
- Progressive jaundice, hepatomegaly, cirrhosis
- cutaneous Xanthomas and Xanthelasmas
58
What are the risk factors for C. diff colitis
- Recent antibiotics
- Hospitalization
- PPI******
59
Extraintestinal manifestations of Whipple's disease
- migratory polyarthropathy
- chronic cough
- myocardial or valvular involvement leading to congestive failure or valvular regurg
60
Classic biopsy finding of Whipple's disease
-PAS-positive material in the lamina propria of the small intestine
61
patients conjugated hyperbilirubinemia, elevated Alk Phos, painless jaundice, and systemic symptoms (fatigue, weight loss) suggests what
malignant obstruction of the biliary system
62
Chronic GERD with new dysphagia and symmetric lower esophageal narrowing suggests what
Esophageal (peptic) stricture
63
Describe liver injury from Isoniazid
-causes idiosyncratic liver injury with histological features similar to those seen in patients with viral hepatitis
64
Patient who is found to have diverticuli incidentally. What would be your dietary advice
- The incidence of acute diverticular complications is lower in individuals with a high intake of fruit and vegetable fiber . . . it is associated with chronic constipation
- Recent stdudies have found NO LINK between intake of nuts and seeds and incidence of diverticulitis
65
What is believed to be the cause of a Zenker's diverticulum
- Sphincter dysfunction
| - Esophageal dysmotility
66
Describe the location of a Zenker's diverticulum
-It occurs due to posterior herniation between the fibers of the cricopharyngeal muscle
67
Pathogenesis of Wilson Disease
-Autosomal recessive mutation of ATP7B --> hepatic copper accumulation --> leak from damaged hepatocytes --> deposits in tissues (e.g. basal ganglia, cornea)
68
Clinical findings of Wilson Disease
- Hepatic (Acute liver failure, chronic hepatitis, cirrhosis)
- Neurologic (Parkinsonism, gait disturbance, dysarthria)
- Psychiatric (Depression, personality changes)
69
How to diagnose Wilson disease
- Low ceruloplasmin and High urinary copper excretion
- Kayser-Gleischer rings
- High Copper content on liver biopsy
70
Treatment of Wilson Disease
- Chelators (e.g. D-penicillamine, trientine)
| - Zinc (interferes with copper absorption)
71
Clinical features of Hemochromatosis
- characterized by iron overload
- Liver disease
- DM
- arthropathy
- cardiac enlargement
72
Describe the effect of Zollinger Ellison syndrome on the pancreas and what the ramifications of this are
-The excess gastric acid in the small intestine can cause diarrhea and steatorrhea due to INACTIVATION of pancreatic enzymes and injury to the mucosal brush border
73
If gastrinoma is confirmed, patients should be screened for MEN1 with assays for what?
- Parathyroid hormone
- Ionized calcium
- prolactin
74
Previously, the lactose tolerance test was used to aid in the diagnosis of Lactose intolerance. The test is based on measurement of the blood glucose level after oral lactose administration. The lactose tolerance test is cumbersome and time consuming. What is currently used and describe the test?
- Lactose hydrogen breath test
- A positive hydrogen breath test is characterized by a rise in the measured breath hydrogen level after the ingestion of lactose, thus indicating bacterial carbohydrage metabolism
75
Labs found in Autoimmune hepatitis
- Elevated titers of ANA and anti-smooth muscle
| - flucuating hepatocellular injury (i.e. elevated transaminases)
76
Patient with weeks of lower abdominal pain, bloody diarrhea, and fecal urgency likely has undiagnosed IBD (e.g. UC). His acute worsening with fever, abdominal distension, leukocytosis, hypotension, and tachycardia suggests what?
toxic megacolon
77
Describe management of Toxic megacolon
- About 50% of patients improve with conservative management and corticosteroids
- Severe cases of toxic megacolon not responding to medical therapy may require emergency surgery
78
Describe the use of SAAG (serum ascites albumin gradient) in diagnosing the etiology of ascites
- calculated by subtracting the peritoneal albumin concentration from the serum albumin concentration
- if >1.1 then indicated portal HTN . . if < 1.1 then other causes (malignancy, pancreatitis, nephrotic syndrome, tuberculosis)
79
Dysphagia can be classified as oropharyngeal or esophageal. Oropharyngeal dysphagia presents with difficulty initiation swallowing due to inability to properly transfer food from the mouth to the pharynx. Underlying etiologies for oropharyngeal dysphagia include what?
- stroke
- advanced dementia
- oropharyngeal malignancy
- Neuromuscular disorders (e.g. myasthenia gravis)
80
What is the preferred diagnostic modality in oropharyngeal dysphagia
-Videofluoroscopic modified barium swallow study to evaluate swallowing mechanics, degree of dysfunction, and severity of aspiration
81
Clinical Features of Primary Sclerosing Cholangitis
- Fatigue and Pruritis
- Majority of patients asymptomatic at time of diagnosis
- About 90% of patients have underlying IBD, mainly ulcerative colitis
82
Lab/imaging in Primary sclerosing cholangitis
- Cholestatic liver function test pattern (serum aminotransferases typically <300 and predominantly elevated Alk phos)
- Multifocal stricturing/dilation of intrahepatic and/or extrahepatic bile ducts on cholangiography
83
Liver biopsy in Primary sclerosing cholangitis
-Fibrous obliteration of bile ducts with concentric replacement by connective tissue in an "onion-skin" pattern
84
patient with a lipase of 3500 and severe epigastric pain has acute pancreatitis. . . they don't drink alcohol or have stones but have yellow red papules on arms and shoulders . . . what are these and what should you check?
- eruptive xanthomas
| - check fasting lipid profile . . . hypertriglyceridemia
85
Patient with symptomatic anemia with macrocytic RBCs, hypersegmented neutrophils, and normal methylmalonic acid levels indicates what
folate deficiency
86
Methylmalonic acid level in Cobalamin (B12) deficiency
High
87
drugs that are commonly implicated in pancreatitis
- Diuretics
- anti-seizure (valproic acid)
- antibiotics (e.g. metronidazole)
88
This is characterized by the development of hemorrhagic lesions after ischemia or the exposure of gastric mucosa to various injurious agents (e.g. alcohol, aspirin, cocaine)
Acute erosive gastropathy
89
Clinical manifestation of Chromium deficiency
-impaired glucose control in diabetics
90
Clinical manifestation of Copper deficiency
- Brittle hair
- SKin depigmentation
- Neurologic dysfunction (e.g. ataxia, peripheral neuropathy)
- Sideroblastic anemia
- Osteoporosis
91
Clinical manifestation of Selenium deficiency
- Thyroid dysfunction
- Cardiomegaly
- immune dysfunction
92
Clinical manifestation of Zinc deficiency
- Alopecia
- Pustular skin rash (perioral region and extremities)
- Hypogonadism
- Impaired wound healing
- Impaired taste
- immune dysfunction
93
Describe the rash associated with pellagra (niacin deficiency . . B3)
hyperpigmented, occurs symmetrically in sun exposed areas
