african american, long-term smokers, diabetics, obese patients, and patients who have received abdominal radiation therapy.
What is the recommendation for treatment for patients with acute hep c
Acute hcv virus is rare, but if treated has a high rate seroconversion
try and start tx within 12 weeks of infection.
what is the size cut off for resection of a hepatic adenoma?
greator that 5cm that does not shrink with cessation of OCP's
elevated liver tests and conjunctival suffusion
diarrhea dysmotility heart failure and neuropathy
look for peri vascular inflitration of congo red staining proteins.
cutoff size for treatment of a fibrovascular polyp
Needle shaped clefts on mucosal biopsy
associated with eosinophilia
hematemesis, subcutaneous air, l-sided effusion.
trophozoites on the surface layer of ileal biopsy
often b-12 defiency because of ileal involvement
c1 esterase deficiency, how is it teated
c1 esterase concentrate
danazol- long term ppx
dark velvety rash on anterior neck, axilla or hands
diarrhea, erythematous palques on legs and face, TPN, alcoholism
necrolytic migratory erythema
abnormal elastic tissue deposits in the skin
pagets disease (increased alk phos)
TI , apthous ulcers and oral and genital lesions
hyperkeratinization of the palms and soles.
scc of esophagus
multiple gi polyps, dystrophic nails,
multiple hamartomas, multiple cancers
location of absorption of
pepsin release b-12 (cobalamin) from animal proteins, . In an acidic environment b-12 binds R binder protein
in alkaline small bowel, r-binder is hydrolyzed by pancreatic proteases to liberate cobalamin. this binds intrinsic factor .
This compound is absorbed in the ileum.
Some triglycerides are digested by lingual and gastric lipase
Pancreatic lipases work most of action in jejunem.
free fatty acids and b monoglycerol mix with bile salts to form mixed micelles.
Mixed micelles enter the enterocyte. Here free fatty acids and b-monoglycerol are re esterified into triglycerides. From here the triglicerides are encorporated into lipoproteins and are secreted into the systemic circulation
mechanism of folate absorption
enzymes on jejunal brush border. pH dependent carrier mediated transport into enterocyte. Binds albumin and other carrier proteins and is stored in the liver.
conditon that can lead to increased folate levels.
Small bowel bacterial overgrowth. The bacteria make folate in small bowel where it is absorbed in large quantity
mechanism of absorption of fat soluble vitamins
similar to fat absorption
micelle formation, with fat soluble vitamins inside, absorption to enterocytes,
ionic calcium like in milk requires no digestion
protein bound calcium is cleaved in the acid environment in the stomach. and absorbed in the duodenum.
fiber and vegetables in diet can bind ca and form insoluble compleses that reduce ca absorption.
Ca absorption requires vit d.
Ferric Fe3+ must be converted to FE2+. This occurs in the acid environment of the stomach. and by ferrireductase (on the brush border of enterocytes)
DMT-1 transporter mostly in duodenum
how to calculate the osmotic gap
less than 50 = secretory
greator than 50 = osmotic
List an uncommon manifestations of SIBO
List another source of "early peak" on breath testing other than SIBO
in bypass patients where a large amt of glucose containing chyme is rapidly transferred to the colon
Condition where B-12 is low and serum folate is elevated
bacteria metabolize b-12 and generate high levels of folate.
Early complication after extensive small bowel resection
gastric hypersecretion and peptic ulceration
diarrheal malabsorptive syndrome when more than 100cm of terminal ileum remains
bile salt diarrhea. liver can compensate for fat absorption by increasing bile salt production. decreased ileal reabsorption of bile salts leads to diarrhea.
diarrhea malabsorptive syndrome when less than 100cm of ileum remains
fat malabsorption. Here liver can overcome bile salt defecit because of extensive ileal resection. ultimetly not enough bile salts are around in lumen and fat malabsorption begins. This is made worse by administration of a bile salt binder
patient with extensive ileal resection presents with flank pain
calcium oxalate stones.
increased iltraluminal fat binds dietary calcuim. This leads to unbound oxilate in colon. This is taken up in blood and makes its way to kidney- forming oxalate stones
treatment of Ca oxalate renal stones
increase Ca in diet
decrease oxalate in diet
low fat diet.
diseases related to AIP
cutoff cea level for mucinous vs non mucinous cyst in panc
192, above this faavor mucionus cyst.
demerol should not be administered to patients on MAOI'
confusion, hyperreflexia, autonomic dysfunction
stenosis in the esophagus characterized by pseudodiverticuli, thickened mucosa, and asymmetrical narrowing
What is the most potent stimulator of gb contractility (food not hormone)
long chain fatty acids
what enzyme converts serum lipoproteins into cholesterol
What enzyme converts cholesterol into bile
Cholesterol 7 alpha hydroxylas
and sterol 27 hydroxylase
rate of bile salt loss (as a % of the total bile salt pool)
20-30% daily loss
5 -15 cycles daily of enterohepatic circulation
Risk factors for cholesterol gallstone formation
maternal family history
rapid weight loss
low high density liprotein cholesterol
lipid lowering agents
fibric acid derivitives
etiology of acute cholecystitis
obstruction of the cystic duct (90%) of the time.
sensitivity of ultrasound for CBD stones
EUS ability to predict cbd stones
98% positive predictive value
88% negative predictive value
size cutoffs for management of gallbladder stones
and less than 3cm
chronic acalculous cholecystitis
gallbladder ejection fraction less than 35%
surgical response to ccy for chronic cholecystitis
25-40% pain will resolve on its own
60-100% improve with surgery
Risk factors for acute acalculous cholecystitis
samonella or cytomegalovirus infection
PAN or SLE
Best diagnostic criterion for diagnosis of chronic cholecystitis
gallbladder wall thickening of >4mm.
Size cutoff for gallbladder polyps
other risk factors include
type I is cyst of main bile duct
type II is a diverticulum of main bile duct
Type III is the intraduodenal portion of the bile duct
Type IV is both intra and extra hepatic bile duct
type V is multiple intraheptaic.
Association between IBD and PSC
70% of patients with PSC have IBD
but only 5% of patients with IBD have PSC
Biliary hypoplasia with intrahepatic cholestasis
Most common indication for pediactric liver transplant
Risk factors for Gallbladder cancer
Salmonella typhi infection
how often is early gastric cancer present in patients that have a large adenomatous polyp
approx 30 % of the time. At EMR you should scan the stomach to look for metachronus disease prior to adenoma removal.
What is the risk of metastasis of gastric carcinoids
I and II is low (in lesions less than 1 cm it is < 5%