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Risk factors for CRC
african american, long-term smokers, diabetics, obese patients, and patients who have received abdominal radiation therapy.
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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.
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what is the size cut off for resection of a hepatic adenoma?
greator that 5cm that does not shrink with cessation of OCP's
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elevated liver tests and conjunctival suffusion
leptosporosis
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diarrhea dysmotility heart failure and neuropathy
amyloid
look for peri vascular inflitration of congo red staining proteins.
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cutoff size for treatment of a fibrovascular polyp
2 cm
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Needle shaped clefts on mucosal biopsy
cholesterol embolization
associated with eosinophilia
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hematemesis, subcutaneous air, l-sided effusion.
Boerhaave's syndrome-
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AIDS, diarrhea,
trophozoites on the surface layer of ileal biopsy
cryptosporidiosis
often b-12 defiency because of ileal involvement
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c1 esterase deficiency, how is it teated
c1 esterase concentrate
danazol- long term ppx
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dark velvety rash on anterior neck, axilla or hands
acanthosis nigracans
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diarrhea, erythematous palques on legs and face, TPN, alcoholism
Zinc deficiency
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seborrheic keratosis
colon cancer
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necrolytic migratory erythema
glucagonoma
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abnormal elastic tissue deposits in the skin
pseudoxanthoma elasticum
pagets disease (increased alk phos)
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TI , apthous ulcers and oral and genital lesions
Bechets syndrome.
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hyperkeratinization of the palms and soles.
tylosis.
scc of esophagus
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multiple gi polyps, dystrophic nails,
Cronckhite-Canada syndrome
gi hamartomas
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multiple hamartomas, multiple cancers
Cowdens syndrome
PTEN
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location of absorption of
Iron
B12
bile salts
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B-12 absorption
- 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.
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Fat digestion
- 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
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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.
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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
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mechanism of absorption of fat soluble vitamins
- similar to fat absorption
- micelle formation, with fat soluble vitamins inside, absorption to enterocytes,
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Calcium abosrption
- 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.
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iron absorption
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
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how to calculate the osmotic gap
290- ((Na)-(K))*2
- less than 50 = secretory
- greator than 50 = osmotic
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List an uncommon manifestations of SIBO
Hint
Liver problem
NASH
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List another source of "early peak" on breath testing other than SIBO
- intestinal hurry-
- in bypass patients where a large amt of glucose containing chyme is rapidly transferred to the colon
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Condition where B-12 is low and serum folate is elevated
- SIBO
- bacteria metabolize b-12 and generate high levels of folate.
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Early complication after extensive small bowel resection
gastric hypersecretion and peptic ulceration
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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.
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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
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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
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treatment of Ca oxalate renal stones
- increase Ca in diet
- decrease oxalate in diet
- low fat diet.
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diseases related to AIP
- PSC
- UC
- sjogrens
- sclerosing sialadenitis
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cutoff cea level for mucinous vs non mucinous cyst in panc
192, above this faavor mucionus cyst.
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demerol should not be administered to patients on MAOI'
Why
Serotonnin syndrome
confusion, hyperreflexia, autonomic dysfunction
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stenosis in the esophagus characterized by pseudodiverticuli, thickened mucosa, and asymmetrical narrowing
peptic stricture
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What is the most potent stimulator of gb contractility (food not hormone)
long chain fatty acids
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what enzyme converts serum lipoproteins into cholesterol
HMG-COA reductase
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What enzyme converts cholesterol into bile
- Cholesterol 7 alpha hydroxylas
- and sterol 27 hydroxylase
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rate of bile salt loss (as a % of the total bile salt pool)
20-30% daily loss
5 -15 cycles daily of enterohepatic circulation
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Risk factors for cholesterol gallstone formation
- obesity
- female
- parity
- maternal family history
- increasing age
- ileal disease
- rapid weight loss
- high triglycerides
- low high density liprotein cholesterol
- ocp
- estrogen
- tpn
- lipid lowering agents
- fibric acid derivitives
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etiology of acute cholecystitis
obstruction of the cystic duct (90%) of the time.
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sensitivity of ultrasound for CBD stones
CT scanning?
MRCP
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EUS ability to predict cbd stones
- 98% positive predictive value
- 88% negative predictive value
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size cutoffs for management of gallbladder stones
- asymptomatic
- and less than 3cm
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chronic acalculous cholecystitis
gallbladder ejection fraction less than 35%
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surgical response to ccy for chronic cholecystitis
- 25-40% pain will resolve on its own
- 60-100% improve with surgery
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Risk factors for acute acalculous cholecystitis
- TPN
- samonella or cytomegalovirus infection
- casculitis
- PAN or SLE
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Best diagnostic criterion for diagnosis of chronic cholecystitis
gallbladder wall thickening of >4mm.
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Size cutoff for gallbladder polyps
18mm
- other risk factors include
- age
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- 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.
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Association between IBD and PSC
70% of patients with PSC have IBD
but only 5% of patients with IBD have PSC
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Biliary hypoplasia with intrahepatic cholestasis
Algille syndrome
- autosomal dominant
- JAG1 gene
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Most common indication for pediactric liver transplant
biliary atresia
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Risk factors for Gallbladder cancer
- PIma Indian
- Salmonella typhi infection
- Gallstones
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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.
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What is the risk of metastasis of gastric carcinoids
Type I
Type II
Type III
- I and II is low (in lesions less than 1 cm it is < 5%
- Type III is higher
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Eus characteristics of linitus plastica
thickening of layers 3 and 4
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EUS findings in menitriers disease
Thickeing of layer 2.
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