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Red flags that suggest an organic cause to constipation
- 1)unintentional weight loss
- 2) >50
- 3) FHx Ca
- 4) rectal bleeding
- 5) Fe def anemia
- 6) elevated CRP
What are the requirements for the rome III criteria for functional constipation
- 1) symptoms > 3 mo; onset > 6mo
- 2) MUST include more than 2 of the following
- -lumpy or hard stool
- -feels like anal blockage
- -manual removal of blockage
- -< 3 defecations a week
- 3) loose stools rarely present w/o use of laxatives
- 4) insufficient criteria for IBS
What is diarrhea?
- stool output > 200 g/day
- increased frequency > 3/day
- increased liquidity
What is the normal stool osmolality?
usually the same as the plasma osmolality (290-310)
What are the red flags in acute diarrhea?
- 1) high fevers/ systemic toxicity
- 2) severe abdo pain
- 3) blood/pus in stool
- 4) volume depletion
- 5) immunocompromised host
- - looks like you are thinking infection here.
What can you get from eating: poultry, seafood, cheese, canned foods, contaminated water
- poultry: shigella, salmonella
- seafood: salmonella
- cheese: listeria
- canned food: clostridium
- water: giardia, norwalk
When are stools pale, oily, malodorous, difficult to flush?
When there is malabsorption of fat
What is a dermal sign of celiac's disease?
dermatitis herpetiformis (itchy rash)
disease sequence of adenoma carcinoma
normal->hyperprolif epithelium -> adenoma -> carcinoma
What are the 3 criteria for HNPCC (hereditary non-polyposis CRC)?
- 1) three family members (2 first degree) affected with HNPCC
- 2) at least 2 successive generations affected
- 3) one relative diagnosed at <50
What are the chronic symptoms of colo-rectal cancer?
- -change in bowel habit
- -non-spec. abdominal pain
- -wt loss
- -other symptoms from mets
What are the top five hits on the DDx for IBD?
- 1) infectious etiologies
- 2) IBS
- 3) appendicitis
- 4) diverticulitis
- 5) Ca
When should you do surgery in Crohn's?
- 1) complications: fix strictures, fistulas, perforations
- 2) medically refractory disease
IMPORTANT TO MEDICALLY CONTROL, OTHERWISE THE PATIENT WILL LIKELY NEED SURGERY!!
When to do surgery for UC?
- 1) medically refractory disease
- 2) complications: perforation, toxic megacolon, cancer
What are some questions you should ask yourself when you have a patient with jaundice?
- 1) acute vs chronic (>6mo)
- 2) hepatocellular, cholestatic, or vascular
- 3) systemic disorder or a primary liver disorder?
- 4) any complications that need investigation or treatment?
What are the big 7 things you test for liver function?
- Hepatocellular enzymes
- -AST: RBC, muscle, liver
- -ALT: liver
- Cholestatic enzymes
- -ALP: bone, placenta, liver
- -GGT: Liver
ABC: Albumin, Bilirubin, Clotting (INR)
What are the 3 types of hepatitis
- 1) fulminant: NORMAL liver with ACUTE injury developing hepatic encephalopathy within 8 weeks
- 2) Acute hepatitis
- 3) Chronic hepatitis: longer than 6 months
What specific test would you use to determine autoimmune hepatitis?
- ANA - anti-nuclear Ab
- anti smooth muscle Ab
What are the top 8 on the differential for cirrhosis?
- 1)Viral: Hep B, C
- 2) Autoimmune: Primary Biliary cirrhosis, autoimmune hep
- 3) Inherited: Wilson's, hemochromatosis, alpha1- AT
- 4) alcohol
- 5) Cardiac
- 6) NAFLD
- 7) Drugs/Toxins
- 8) Idiopathic
What are the limits for a good or bad MELD score? What is the score based on?
based on: creatinine, INR, bili
What is charcot's triad?
fever, pain, jaundice
looks for in acute cholangitis and choledocholithiasis
What are the risk factors for cholangiocarcinoma?
- -choledochal cysts
- -parasitic infection
Where would you expect to see a positive anti-mitochondrial Ab test?
in primary biliary cirrhosis (PBC)
What are the indications for testing in hemochromatosis?
- 1) Liver disease
- 2) abnormal LEs
- 3) DM
- 4) arthropathy
- 5) heart disease
- 6) impotence
- 7) FHx
Indications to test for Wilson's
- 1) unexplained LD in young person
- 2) hemolysis
- 3) neurological disease in young person
- 4) KF rings
- 5) affected siblings
Indications to test for alpha1 AT
- 1) neonatal hepatitis
- 2) chronic hepatitis
- 3) cirrhosis
- 4) HCC
- 5) precocious emphysema
What shoiuld you give ALL patients with cirrhosis who present with GI bleeds
Abx (at greater risk of infection)
What are the precipitants of hepatic encephalopathy?
- 1) infection
- 2) GI bleeding
- 3) high protein load (hold off the burgs)
- 4) HCC
- 5) Constipation
- 6) Drugs (alcohol, narcotics, sedatives, etc)
- 7) Electrolyte imbalance
See dirty mnemonic in notes
When would you expect to see elevated alpha-fero protein?
Describe the Grey-Turner's and Cullen's signs
- Both are for acute panc.
- Grey- Turner's: bruising on the flanks
- Cullens: bruising around the umbilicus (C for Central)
What is the rule of S's for pancreatic psuedocysts?
- Treat when:
- -older than six weeks
- -bigger than six cm
Indications for liver transplant
- -end stage liver disease
- -acute liver failure
What wheels start falling off at end-stage liver disease?
- -variceal bleeds
What are the absolute contraindications in liver transplants
- -active sepsis
- -extra-hepatic malignancy
If you see a patient present with jaundice, but all liver function tests are normal except for a high unconjugated bili, what should you be thinking?
Gilbert's syndrome (decreased activity of glucoronyl transferase)
What are the Abs you expect to see in someone with:
1) Primary biliary cholangitis?
2) autoimmune hepatitis?
- 1) antimitochondrial abs
- 2) anti smooth muscle Abs
What protein do you see elevated in HCC?
What do you expect to happen to the amylase and lipase levels in acute pacnreatitis? Chronic?
- acute: both increased
- Chronic: both increased to normal (due to level of destruction?)
What is the inheritance of Hemochromatosis, Wilson's, and alpha1 AT?
- Hemo: AR
- Wilsons: AR
- Alpha1- AT: co-dominant (the ZZ allele is the bad one)
What is the type of cirrhosis that most often progresses to HCC?
cirrhosis due to hemochromatosis
When is PPI prophylaxis indicated?
if they are at high risk development of ulcers
Describe what an elevated stool osmolality gap is/means
difference between measured stool osmolality and 2x[Na]+[K] which is the calculated osmolality
In osmotic diarrhea, measured is greater than calculated. Therefore there is something else (e.g. lactic acid, that is pulling water in)
What are the vit K dependent factors?
1(0)972 olympics Canada vs Soviet union
Factors X, IX, VII, II, protein C, protein S
Describe the graded therapy for Crohn's disease
What biliary disease is associated with UC?
5 causes of constipation
What is the only clotting factor not produced in the liver?
You have elevated transaminases, what should you think if you have:
2) AST > ALT
3) AST/ALT >2
- 1) ALT>AST: most causes of hepatitis
- 2) AST > ALT: alcoholic liver disease or other causes of cirrhosis
- 3) AST/ALT >2: alcohol
List 7 complications of cirrhosis
- Renal Failure
Three things you can use to manage portal hypertension
- beta blockers
What etiologies of ascites would you be thinking if the serum-ascited albumin gradient was
1) > 11 g/L
2) < 11 g/L
- 1) high: portal hypertension related (because hydrostatic pressure is driving it)
- 2) low: non-portal hypertension causes
What does it mean when a jaundiced patient has:
1) high conjugated billi
2) high unconjugated billi
- 1) high conjugated billi: there is some problem after the billi is conjugated in the hepatocytes. problem with excretion
- 2) high unconjugated billi: overproduction (e.g. hemolysis); decreased hepatic uptake; decreased conjugation (e.g. gilberts)
How can ERCP (endoscopic retrograde cholangopancreatography) differentiate primary biliary cirrhosis from PSC
- PBC: no narrowing
- PSC: narrowing of intra and extrahepatic ducts
What is squamous cell esophageal cancer associated with?
smoking and drinking
Why does esophageal cancer metastesize easily?
because it lacks a serosa
How does gastritis cause B12 deficiency?
lack of intrinsic factor
Which LN is enlarged in gastric cancer
Virchow's node (left supraclavicular)
What happens to the pain post-prandially in:
1) gastric ulcer
- 1) Gastric is Greater
- 2) Duodenal Decreases
What is the most common bacterial etiology of diarrhea?
What is NOT a risk factor for peptic ulcer disease?
What disease is dermatitis herpetitiformis associated with? How do you test?
celiac disease. test serum tissue transglutaminase
What is the most common cause of acute lower GI bleeding in a patient >40?
If you see >250 PMN's in the ascitic fluid what should you be thinking?
spontaneous bacterial peritonitis
1) biliary colic
- 0) Cholelithiasis: stone floating innocently in the gallbladder
- 1) Biliary colic: stone goes against the cystic duct after a meal and dislodges itself in 4-8 hours.NOT tender, visceral pain
- 2) Cholecystitis: stone impacted in cystic duct and stays. NOW pain localizes and is tender.
- 4) Cholangitis: complete obs of CBD AND infection. life threatening.
- 5) choledocholithiasis: Stones in common bile duct, obstructive jaundice and pruritis.
Extra-intestinal manifestations of IBD
- A PIE SAC
- Aphtous ulcers
- Pyoderma gangrenosum
- Erythema Nodosum
- Sclerosing cholangitis (UC only)
What does a positive HBsAg and HBsAb mean?
- HBsAg means that there is an active infection (chronic or acute)
- HBsAb means that there is immunity to HBV (natural or vaccine)