Term
| Describe the location of the esophagus in relation to its surroundings. |
|
Definition
| It lies posterior to the heart and trachea and anterior to the vertebrae. |
|
|
Term
| Describe the innervation to the esophagus. |
|
Definition
| Parasympathetic stimulation via the vagus nerve and also has sympathetic stimulation. |
|
|
Term
| Describe the 4 layers of the esophagus from inside to outside. |
|
Definition
| Mucosa, submucosa (secretes mucus), muscularis (muscular layer - upper 5% is voluntary muscle, lower is smooth and middle is a mixture) and the adventitia is the outermost layer. |
|
|
Term
| Describe the functions of the UES and the LES. |
|
Definition
UES - is skeletal muscles and is normally closed except during swallowing.
LES - is normally closed except when food passes into the stomach or during belnching/vomiting. It serves as a barrier so that there is not reflux of stomach contents. |
|
|
Term
| What is the name of the junction where the stratified squamous epithelium of the esophagus turns into the simple columnar epithelium of the stomach? |
|
Definition
|
|
Term
| Describe the normal pH of the esophagus and its tolerance towards the acid content of the stomach. |
|
Definition
| The mucosa is normally alkaline and does not tolerate the highly acid contents of the stomach. |
|
|
Term
| What involuntary processes are involved in swallowing? |
|
Definition
| The swallowing center of the medulla and cranial nerves V,X and XII. |
|
|
Term
| Describe the 3 phases of swallowing (Oral, Pharyngeal and Esophageal). |
|
Definition
Oral - bolus of food is thrown backward against the posterior pharynx by the tongue which triggers the reflex movements of swallowing.
Pharyngeal phase - soft palate, uvula close off the nasal cavity; the larynx is elevated and the glottis closed; contractions move the bolus past the epiglottis.
Esophageal - cricopharyngeus muscle relaxes and the bolus enters the esophagus. |
|
|
Term
| What is a secondary peristaltic wave? |
|
Definition
| Occurs when there is still food in the esophagus after the primary wave. Triggered by distension of the lower esophagus. |
|
|
Term
| :subjective awareness of an impairment in the transport of ingested food. |
|
Definition
|
|
Term
| What are the 2 main kinds of dysphagia? |
|
Definition
Obstructive - strictures or tumors.
Motor - disorders of peristalsis or dysfunction of UES or LES. |
|
|
Term
| What conditions could lead to an individual having an increased risk of choking on food or fluids? |
|
Definition
| Muscular or neurologic diseases (strokes, myasthenia gravis, muscular dystrophy, etc). |
|
|
Term
| :hot, burning sensation felt in the epigastrum or under the xyphoid process |
|
Definition
|
|
Term
| :pain induced by swallowing, commonly due to esophagitis or esophageal spasm. |
|
Definition
|
|
Term
| :backflow of gastric contents into the oral cavity – LES incompetence and failure of the UES |
|
Definition
|
|
Term
| How far can an Esophagoscopy or EGD visualize? |
|
Definition
| It can go all the way to the duodenum |
|
|
Term
| What tests can be done to distinguish acid induced pain from cardiac pain? |
|
Definition
| Acid reflux tests - BRAVO test. |
|
|
Term
| What is the purpose of a manometry study? |
|
Definition
| Esophageal manometry is a test used to measure the function of the lower esophageal sphincter (the valve that prevents reflux of gastric acid into the esophagus) and the muscles of the esophagus (see diagram). This test will tell your doctor if your esophagus is able to move food to your stomach normally. |
|
|
Term
| :hypomotility disorder of the esophagus characterized by: weak, uncoordinated peristalsis in the body of the esophagus, elevated LES pressure and failure of the LES to relax completely during swallowing |
|
Definition
|
|
Term
| What are the possible etiologies of primary and secondary Achalasia? |
|
Definition
Primary = degeneration of the Auerbach's plexus or idiopathic.
Secondary = diabetic neuropathy, cancer, or anything else that could affect the nerves. |
|
|
Term
| What are some possible fatal complications of Achalasia? |
|
Definition
| Aspiration due to nocturnal regurgitation resulting in chronic pulmonary infections or sudden death. |
|
|
Term
| How is Achalasia diagnosed? |
|
Definition
| History and a "beak-like" appearance on barium swallow with x-ray. |
|
|
Term
| What is the main etiology of Achalasia? |
|
Definition
| A lack of peristalsis from the Aurbach's plexus, it is NOT a spasm. |
|
|
Term
| What are the treatment options for Achalasia? |
|
Definition
| EGD (Esophagogastroduodenoscopy) with dilation or surgery are the preferred treatment. If they are poor surgical candidates you can give isosorbide or nifedipine. |
|
|
Term
| What is Diffuse Esophageal Spasm? What are the typical symptoms? |
|
Definition
Unoordinated, nonpropulsive contractions of the esophagus in response to swallowing (A-fib of the esophagus).
Sx = usually asymptomatic but can have odynophagia or intermittent dysphagia and chest pain. |
|
|
Term
| What is a diffuse esophageal spasm sometimes confused with angina? |
|
Definition
| BC nitro relieves the pain in both (dilates the esophagus with DES). |
|
|
Term
| What are the treatment options for Diffuse Esophageal Spasm? |
|
Definition
| Tx = small meals, avoiding cold foods (will make spasm worse), antacids, sedatives and Nitroglycerine to relieve the spasm. |
|
|
Term
| Describe the possible effects of Scleroderma on the esophagus. |
|
Definition
| Atrophy of the smooth muscle in the lower esophagus leading to poor peristalsis and decreased LES pressure and GERD, which can lead to esophagitis and strictures. |
|
|
Term
| :Inflammation of the esophageal mucosa – may be acute or chronic. |
|
Definition
|
|
Term
| What are some common causes of esophagitis? Most common form of esophagitis? |
|
Definition
GERD due to hiatal hernia, motility disorders, infections and ingestion of strong alkalines.
Most common form of esophagitis is Chronic Reflux Esophagitis commonly due to a hiatal hernia. |
|
|
Term
| What are patients with esophagitis for at least 10 years at a high risk for? What test should be used to evaluate these patients? |
|
Definition
| They are at high risk for Barrett's esophagitis, they should be evaluated with a EGD (Esophagogastroduodenoscopy). |
|
|
Term
| What is Barrett's esophagitis? |
|
Definition
| It is due to constant exposure to gastric acids. Progressive replacement of distal squamous epithelium with metaplastic epithelium – prone to malignant transformation and cancer. |
|
|
Term
| How does Barrett's Esophagitis look on EGD? How is it diagnosed? |
|
Definition
| It will have an irregular Z-line but you cannot diagnose without a biopsy. |
|
|
Term
| How does Barrett's Esophagitis look on EGD? How is it diagnosed? |
|
Definition
| It will have an irregular Z-line but you cannot diagnose without a biopsy. |
|
|
Term
| :herniation of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm |
|
Definition
|
|
Term
| :most common type of hiatal hernia where the gastroesophageal junction is moved into the chest and the competency of the LES is lost. |
|
Definition
|
|
Term
| :type of hiatal hernia where part of the gastric fundus herniates through the hiatus of the diaphragm. Less reflux esophagitis but a major complication is strangulation. |
|
Definition
| Paraesophageal hiatal hernia or Type II hiatal hernia |
|
|
Term
| How is a hiatal hernia diagnosed? |
|
Definition
| UGI (Upper GI Series) or EGD (Esophagogastroduodenoscopy). |
|
|
Term
| What are the concerns of an untreated hiatal hernia? Treatment options for a hiatal hernia? |
|
Definition
Concerns = Acid reflux leading to esophagitis, ulcerations, strictures, asthma and aspiration pneumonia.
Tx = H2 blockers, antacids, PPIs, and possible surgical correction. |
|
|
Term
|
Definition
| An upper gastrointestinal (UGI) series looks at the upper and middle sections of the gastrointestinal tract. The test uses barium contrast material, fluoroscopy, and X-ray. |
|
|
Term
| What is the most common type of benign tumor of the esophagus? |
|
Definition
| Leiomyoma (smooth muscle tumor) |
|
|
Term
| What is the most common malignant tumor of the esophagus? |
|
Definition
|
|
Term
| What are the risk factors for esophageal tumors? |
|
Definition
| Alcohol abuse, heavy smoking, GERD and Barrett's esophagitis. |
|
|
Term
| Describe how esophageal tumors are diagnosed, the survival rate and the treatment. |
|
Definition
Dx = EGD (Esophagogastroduodenoscopy) with biopsy.
Prognosis = Not good (5 year survival rate is less than 10% due to early METS and minimal symptoms).
Tx = Irradiation and surgical resection. |
|
|
Term
| What is the function of the pyloric sphincter? |
|
Definition
| It relaxes to permit food to enter the duodenum and contracts to prevent backflow from the duodenum. |
|
|
Term
| Describe the 4 layers of the stomach (Serosa, Muscularis, Submucosa and Mucosa). |
|
Definition
Serosa - Outermost layer.
Muscularis - 3 layers of muscle (outer longitudinal, middle circular and inner oblique).
Submucosa - connects the muscularis to the mucosa.
Mucosa - has longitudinal folds called rugae that allow for distention. |
|
|
Term
| Describe the innervation of the stomach. |
|
Definition
| Autonomically stimulated by the Vagus nerve (parasympathetic) and sympathetically by the greater splanchnic nerves and celiac ganglia. The stomach is intrinsically stimulated by Auerbach's plexus and Meissner's nerve plexuses. |
|
|
Term
| Describe the location and function of the cardiac glands of the stomach. |
|
Definition
| They lie near the cardiac orifice (LES) of the stomach and secrete mucus. |
|
|
Term
| Describe the 3 types of cells found in the gastric glands of the fundus (parietal, chief and mucous neck cells). |
|
Definition
Parietal = secrete HCl and intrinsic factor.
Chief = secrete pepsinogen (activated to pepsin in an acidic environment).
Mucous neck cells = secrete mucous. |
|
|
Term
| What is the function of the G cells found in the pyloric region of the stomach? |
|
Definition
|
|
Term
| Describe the 3 phases of Gastric secretion (Cephalic, Gastric and Intestinal). |
|
Definition
Cephalic = gastric glands are stimulates by sight/smell/thought/taste of food to secrete gastric acid (10% of gastric acid secretes).
Gastric = Vagus nerve stimulates the parietal cells, chief cells and G cells to release gastrin (G cells), HCl and pepsinogen (parietal cells).
Intestinal = movement of chyme into the duodenum. |
|
|
Term
| Describe the 3 stages of nausea leading to vomiting. |
|
Definition
Nausea - increased salivation, decreased gastric tone, increase in duodenal tone , pallor, sweating, queasiness, and tachycardia.
Retching - spasmodic contractions.
Vomiting - stimulation of the emetic center in the medulla. |
|
|
Term
| :inflammation or hemorrhagic condition (small hemorrhages) of the gastric mucosa commonly caused by H. pylori, NSAIDs, caffeine or alcohol use. |
|
Definition
|
|
Term
| Would you use an NSAID in a patient with a Hx of an ulcer? |
|
Definition
| Possibly, but would require the use of a PPI along with the NSAID. |
|
|
Term
| Describe Chronic atrophic gastritis. Causes of Type A and Type B? MCC? |
|
Definition
It has a progressive atrophy of the gastric epithelium with a loss of parietal and chief cells leading to a lack of or decrease in the production of stomach acid (Achlorhydria or Hypochlorhydria).
Type A is an autoimmune disease associated with a loss of intrinsic factor and pernicious anemia.
Type B is H. pylori infection (most common). |
|
|
Term
| :An erosion in a segment of the GI mucosa, typically in the stomach or the duodenum, that penetrates through the muscularis mucosae |
|
Definition
|
|
Term
| What are the 2 most common causes of ulcers? |
|
Definition
| H. pylori and NSAID use which damages the protective epithelial barrier and allows HCl to damage the underlying tissue. |
|
|
Term
| What is the typical presentation of an ulcer? Diagnosis? Tx? |
|
Definition
Presentation = burning epigastric pain that is often relieved by food (acid is dissolving food instead of stomach).
Diagnosis = EGD (Esophagogastroduodenoscopy) and testing for H. pylori.
Tx = acid suppression, eradication of H. pylori and avoidance of NSAIDs. |
|
|
Term
| In what ways can you test for H. pylori? |
|
Definition
| Biopsy, serum testing, stool testing and breath testing. |
|
|
Term
| What drugs can be used to treat H. pylori? What should you give if the patient has a penicillin allergy? What is the dosing regimen for each? |
|
Definition
| PREVPAC (Prevacid) 2x/day 30 min before breakfast and dinner. If allergic to penicillin, give HELIDAC 4x/day 30 min before meals. |
|
|
Term
| What 2 factors protect the stomach from autodigestion? |
|
Definition
| Gastric mucus (protects against mechanical trauma and chemical agents) and epithelial barrier (columnar epithelial cells). |
|
|
Term
| Describe the typical presentation of the vomit seen with PUD? |
|
Definition
|
|
Term
| What type of ulcers bleed more commonly? |
|
Definition
|
|
Term
| What are the 4 common complications of peptic ulcers? |
|
Definition
| Intractability (most common), Hemorrhage, Perforation, and Obstruction of the pylorus. |
|
|
Term
| Which ulcers are most likely to hemorrhage? Perforate? |
|
Definition
Hemorrhage = posterior duodenal wall.
Perforate = anterior duodenal wall. |
|
|
Term
| What is Zollinger-ellison syndrome? Sx? Tx? |
|
Definition
An uncommon cause of peptic ulcers due to a gastrin secreting neoplasm.
Sx = extreme gastric hyperacidity with multiple ulcers that are resistant to typical ulcer treatment.
Tx = surgical excision of the neoplasm. |
|
|
Term
| What are some predisposing factors for stomach cancer? |
|
Definition
| Blood group A, environmental (smoked meats, pickled foods and high nitrates) and a Hx of atrophic gastritis or pernicious anemia. |
|
|
Term
| What is the most common location for stomach cancer? Describe the 3 general types of gastic cancers (Ulcerating, Polypoid and Infiltrating) including which is the most common. |
|
Definition
The pyloric antrum.
Ulcerating = most common and appears like a benign gastric ulcer.
Polypoid = looks like a cauliflower mass and can arise from a polyp.
Infiltrating = may penetrate the entire thickness of the stomach wall. |
|
|
Term
| Describe the prognosis of stomach cancer. |
|
Definition
| Poor due to late detection (5 year survival rate = 10%). |
|
|
Term
| What are the primary functions of the small bowel? |
|
Definition
| Digestion and absorption of nutrients and water. |
|
|
Term
| Describe why the small bowel is so good at absorbing nutrients and water. |
|
Definition
| It has numerous villi and microvilli projections that create a 1000x increase in the surface area. Each villi/microvilli has their own capillary system to aid in absorption. |
|
|
Term
| What is the brush border and what are the crypts of Lieberkuhn in the small bowel? |
|
Definition
| Brush border refers to the villi/microvilli covered surface of the small bowel. Each villi is surrounded by crypts of Lieberkuhn which secrete digestive enzymes. |
|
|
Term
| What system secrete enzymes into the small bowel to mix and help digest ingested material? |
|
Definition
| Pancreatic, hepatobiliary and intestinal enzymes. |
|
|
Term
| Where is vitamin B12 typically absorbed in the GI tract? What is necessary for proper absorption? |
|
Definition
| Absorbed in the terminal ileum and is dependent upon intrinsic factor for absorption. |
|
|
Term
| Where are Iron and calcium absorbed in the GI tract? What about the fat soluble vitamins (A, D, E, and K)? What are the fat soluble vitamins dependent upon for absorption? |
|
Definition
Iron and calcium are absorbed primarily in the duodenum and the jejunum.
Fat soluble vitamins (A, D, E, & K) are also absorbed in the duodemun and jejunum with the aide of bile acids. |
|
|
Term
| What is meant by enterohepatic circulation? |
|
Definition
| It refers to the recycling of bile salts where they are reabsorbed in the terminal ileum if they do not bring the fat soluble vitamins across the duodenum or jejunum. |
|
|
Term
| :Characterized by flattening (atrophy) of the small intestinal villi caused by sensitivity to gluten found in bread, beer, and many processed foods. Classic presentation is diarrhea, flatulence, weight loss and fatigue. |
|
Definition
|
|
Term
| How is Celiac Sprue diagnosed? Treated? |
|
Definition
Dx = small bowel biopsy.
Tx = gluten free diet – response is noted with return of normal stools and weight gain, steroids may be used short term. |
|
|
Term
| :Disorder marked by intolerance to milk and milk products that contain lactose due to a deficiency of lactase production at the brush border. Leads to abdominal cramps, bloating, increased motility and diarrhea. |
|
Definition
|
|
Term
| Describe the Inflammatory Bowel Disease: Crohn's Disease. Most common location affected? Describe the distribution of diseased bowel. Describe the appearance of the bowel and the cellular changes that take place. |
|
Definition
| Chronic, relapsing granulomatous inflammatory disease of the intestinal tract that can occur anywhere from the mouth to the rectum but typically affects the terminal ileum. It is characterized by "skip" lesions where portions of diseased bowel are separated by sections of normal bowel. The mucosa appears like "cobblestone" and the bowel becomes thickened and stiff and leads to malabsorption. |
|
|
Term
| What are the Sx of Crohn's disease? |
|
Definition
Colicky abdominal pain, bloody diarrhea, flatulence, fever and may lead to steatorrhea, weight loss or anemia.
Other S&S include pyoderma gangrenosum, erythema nodosum, apthous ulcers, arthritis and uveitis. |
|
|
Term
| What are some common complications seen with Crohn's disease? |
|
Definition
| Stenosis with obstruction, right ureteral obstruction, perforation, fistula, ulcer, abscess and increased risk of small bowel cancer. |
|
|
Term
| What is the characteristic sign for Crohn's disease on barium enema? |
|
Definition
| String sign of the terminal ileum/cecum. |
|
|
Term
| How is Crohn's disease diagnosed? Treatment? Patient education? |
|
Definition
Dx = clinical presentation, barium enema and colonoscopy with biopsy.
Tx = No cure but you can try to attain remission of the disease. Surgery is avoided if possible due to recurrence of the disease. Can give steroids to help though.
Pt education - tell them to maintain a low fat, low fiber diet with nutritional supplementation. |
|
|
Term
| What is the most common major surgical disease? |
|
Definition
|
|
Term
| What is the possible function of the Vermiform appendix? What is the anatomical landmark for Appendicitis pain? |
|
Definition
| It may be a reservoir of lymph and lymphatic components. Mcburney's point is the anatomical landmark for Appendicitis pain. |
|
|
Term
| Describe the progression and cause of Appendicitis. |
|
Definition
| It may be due to an obstructive fecolith leading to an infection with yersinia enterocolitica. It begins with ulceration and progresses to necrosis, gangrene and perforation. |
|
|
Term
| What is the hallmark Sx of appendicitis? |
|
Definition
| Mild to moderate periumbilical pain that shifts to the RLQ (McBurney's Point) over 1-2 days. |
|
|
Term
| What is the treatment for a suspected Appendicitis? |
|
Definition
| When in doubt surgical removal, is a lower risk than the complications of a ruptured appendix. |
|
|
Term
| :inflammation of the peritoneum, usually resulting from spread of infection from abdominal organs, perforation of the appendix or bowel, or penetrating abdominal wounds. Symptoms include fever, leukocytosis, abdominal pain, tense/rigid abdomen, absent bowel sounds and rebound tenderness. |
|
Definition
|
|
Term
| Describe a nonmechanical bowel obstruction with a common cause. |
|
Definition
| paralytic or adynamic ileus in which peristalsis is inhibited, caused commonly by opioids (Tylenol 3 is the worst). |
|
|
Term
| Describe mechanical bowel obstruction. Which bowel is most often obstructed? |
|
Definition
| Mechanical is due to an intramural obstruction or external pressure on the bowel. Most bowel obstructions involve the small bowel. |
|
|
Term
| What are the common etiologies of paralytic ileus? |
|
Definition
|
|
Term
| What is the most common cause of mechanical bowel obstruction? Other causes? |
|
Definition
Pelvic or abdominal adhesions from prior surgery or disease.
Others = intussesception (small bowel goes into large bowel), volvulus and strangulation of bowel loop in an inguinal or femoral hernia. |
|
|
Term
| What is the typical appearance of small bowel obstruction on plain films? |
|
Definition
| Dilated bowels over 4mm, "stack of coins" appearance, air fluid levels and a "string of pearls" appearance. |
|
|
Term
| What are some causes of small bowel obstruction? |
|
Definition
| Strangulated hernias, appendicitis, adhesions, tumors and inflammatory strictures. |
|
|
Term
| What is the most commonly dilated region of the colon in obstruction? What are the 3 most common causes of colonic obstruction? |
|
Definition
| Cecum, 3 most common causes are colon cancer, diverticulitis and volvulus. |
|
|
Term
|
Definition
| Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through. |
|
|
Term
| What should be suspected if the transverse colon is the most dilated region? |
|
Definition
| Ileus (Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through). |
|
|
Term
| At what level of dilation are patient at risk for colonic perforation? |
|
Definition
| Greater than or equal to 9cm. |
|
|
Term
| What is volvulus? What are the most common sites? What is the typical presentation of a volvulus on a barium enema? |
|
Definition
It is twisting of the colon. It usually involves the sigmoid colon or the cecum but the sigmoid is 3x more common.
Barium enema will show a massively dilated sigmoid colon that appears like an inverted U. |
|
|
Term
| Describe how bowel obstruction can lead to hypovolemic shock. |
|
Definition
| The loss of water and electrolytes from the ECF compartment into the bowel (third spacing) leads to hypovolemic shock. |
|
|
Term
| What are the treatment options for bowel obstruction? What if there is an ileus? |
|
Definition
Tx = correction of fluid and electrolyte imbalances, relief of distention by NG tube, control of peritonitis and shock and removal of the obstruction.
If you have an ileus then you have to do tubal decompression over a couple of days. |
|
|
Term
| Describe the sections of the large bowel from beginning to end. |
|
Definition
| Cecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum. |
|
|
Term
| What is the most important function of the large bowel? |
|
Definition
| Absorption of water and electrolytes, majority of water absorption occurs in the ascending colon. |
|
|
Term
| What part of the colon is a reservoir for the dehydrated fecal material until defecation takes place? |
|
Definition
|
|
Term
| What is the absorptive capacity of the colon in which if exceeded, diarrhea will occur? |
|
Definition
|
|
Term
| Digestion occurs mostly in the small intestine due to enzymatic action, what is the small amount of digestion in the large bowel due to? |
|
Definition
|
|
Term
| What are the functions of bacteria in the large bowel? |
|
Definition
| They synthesize vitamin K and several B vitamins and take part in a small amount of digestion (fermentation of some carbohydrates). |
|
|
Term
| Describe the characteristic movements of the large bowel and what activates the defecation reflex. |
|
Definition
| The large bowel has haustral churning movements (kneading) that allows time for absorption. Propulsive peristalsis of feces into the rectum results in distention of the rectal wall and activation of the defecation reflex. |
|
|
Term
| :condition of the colon characterized by herniation of the mucosa through the muscularis to form small saccules |
|
Definition
|
|
Term
| What is the most common sites for diverticula? |
|
Definition
| The descending and sigmoid colon (MC). |
|
|
Term
| :inflammation and perforation of a diverticula |
|
Definition
|
|
Term
| What are the S&S of Diverticulitis? How is the diagnosis made and why are endoscopy and barium not used? Treatment? |
|
Definition
S&S = LLQ pain, diarrhea/constipation, fever and elevated WBCs.
Dx = made by CT scan, usually without endoscopy or barium due to risk of perforation.
Tx = liquid diet/IV fluids, stool softeners, broad spectrum antibiotics, rest and low residue diet (incision and drainage are reserved for severe cases). |
|
|
Term
| Describe the IBD: Ulcerative Colitis. |
|
Definition
| Inflammatory disease of the colon characterized by a prolonged course of exacerbations and remissions of abdominal pain, diarrhea and rectal bleeding. |
|
|
Term
| What tissue levels of the bowel are affected by ulcerative colitis? |
|
Definition
| It involves ulceration through only the mucosa and submucosal layers. |
|
|
Term
| Describe what causes the colonic bleeding seen with ulcerative colitis. |
|
Definition
| The mucosa and submucosa are ulcerated and edema of the mucosa leads to friability and bleeding, later the mucosa may be shed, leaving large areas of ulceration leading to loss of tissue, protein and blood. |
|
|
Term
| What is the major difference between UC and Crohn's disease in regards to skip lesions and amount of bleeding? |
|
Definition
UC has more bleeding and does not have skip lesions.
Crohn's has less bleeding and does have skip lesions. |
|
|
Term
| Describe the typical distribution of ulcerative colitis including where it starts. What are some potentially fatal complication of UC? |
|
Definition
Disease usually begins in the rectosigmoid area and spreads proximally to involve the entire colon without skip lesions.
Comps = toxic megacolon, hemorrhage and colon cancer. |
|
|
Term
| How is ulcerative colitis diagnosed? Treated? |
|
Definition
Dx = clinical presentation and colonoscopy with biopsy.
Tx = steroids, high vitamins/mineral diet, lactose restriction (if intolerant) and most patients will have a total colectomy due to high risk of colon cancer. |
|
|
Term
| What are the main differences between Crohn's disease and ulcerative colitis regarding: the spread of disease, type of histological change, depth of bowel wall injury, appearance of the bowel and x-ray findings. |
|
Definition
Crohn's spreads from the mouth to the anus, UC spreads from the rectum upwards.
Chron's involves granulomatous changes and UC is inflammatory changes.
Crohn's is transmural and UC involves only the mucosa and submucosa.
Crohn's looks like cobblestone and UC looks smoother.
Crohn's will show a "string sign" on x-ray and UC will show decreased haustral markings. |
|
|
Term
| What are the differences in the common complications of Crohn's disease and ulcerative colitis? |
|
Definition
Crohn's = fistula, strictures, perianal disease, malnutrition and a lower risk of cancer.
Ulcerative colitis = toxic megacolon, hemorrhage, perforation and a higher incidence of cancer. |
|
|
Term
| What is the difference in major treatment strategy between Crohn's disease and UC? |
|
Definition
| Crohn's is meds and UC is a total colectomy is the only curative treatment. |
|
|
Term
| Describe what a sessile polyp and a peduculated adenoma look like. At what size are polyps considered to pose an increased risk of cancer and should be monitored more frequently? |
|
Definition
Sessile polyps are flat.
Pedunculated adenomas are attached by a thin stalk.
If they are greater than 1cm they should be monitored more frequently. |
|
|
Term
| Describe villous adenomas and their likelihood to be malignant. |
|
Definition
| They are large (greater than 5cm) that have greater than 25% chance of being malignant. |
|
|
Term
| Describe FAP (Familial adenomatous polyposis) and the likelihood of developing colon cancer by age 40. |
|
Definition
| autosomal dominant genetic disorder characterized by hundreds of pedunculated and sessile polyps throughout the colon. The probability of colon cancer is 100% by age 40. |
|
|
Term
| What is the most common area for colon cancer? Most common type of cancer? |
|
Definition
| Most common area is the rectosigmoid area (60%). Most common type is adenocarcinomas. |
|
|
Term
| Describe polypoid and annular colon cancers. |
|
Definition
Polypoid are bulky masses that project into the lumen.
Annular extend around the bowel and act as a stricture. |
|
|
Term
| Describe the typical presentation of someone presenting with colon cancer. |
|
Definition
| Rectal bleeding with anemia, anorexia/weight loss, narrow/ribbon-like stools, and bowel obstruction with pain. |
|
|
Term
| What is the treatment regimen and 5 year survival rate for colon cancer? |
|
Definition
Tx = surgical resection, radiation an chemotherapy.
5 year survival rate is 50%. |
|
|
Term
| According to the American Cancer Society how often should an individual have a flexible sigmoidoscopy, colonoscopy, barium enema and CT colonography for early detection of colon cancer? |
|
Definition
Flexible sigmoidoscopy every 5 years.
Colonoscopy every 10 years.
Barium enema every 5 years.
CT colonography (virtual colonoscopy) every 5 years.
***Colonoscopy with biopsy should be done with any positive result with flex sig, barium enema or CT colonography. |
|
|
Term
| How often should a FOBT (fecal occult blood test) and FIT (fecal immunochemical test) be administered for early detection of possible colon cancer? |
|
Definition
Fecal occult blood test (FOBT) and
fecal immunochemical test (FIT) should be done once a year. Any positive result should be followed up with a colonscopy and biopsy. |
|
|
Term
| How will an annular colon cancer appear on barium enema x-ray? |
|
Definition
|
|
Term
| What study is indicated for the staging and evaluating the lymph nodes and liver with a patient with colon cancer? |
|
Definition
|
|
Term
| :Varicose veins of the anal canal |
|
Definition
|
|
Term
| What is the barrier between internal and external hemorrhoids? |
|
Definition
| The dentate line separates internal vs. external. |
|
|
Term
| What conditions are hemorrhoids commonly associated with? What are some possible complications? |
|
Definition
Associated with pregnancy, constipation, diarrhea, rectal cancer and cirrhosis.
Complications include bleeding, thrombosis and strangulation. |
|
|
Term
| How do you treat a hemorrhoid? |
|
Definition
| Incision and drainage (I&D) |
|
|
Term
| Describe 1st degree through 3rd degree hemorrhoids. |
|
Definition
First degree – globular swelling felt inside the anal canal.
Second degree – prolapse through the anal canal during defecation but recede or can be manually pushed back.
Third degree – permanently prolapsed. |
|
|
Term
| What must any hemorrhoid in an elder patient be evaluated for? |
|
Definition
|
|
Term
| :Crack in the lining of the anus caused by stretching from the passage of hard fecal material, characterized by extreme pain with bowel movement and scant bleeding. |
|
Definition
|
|
Term
| :Localized infection with a collection of pus in the anorectal area |
|
Definition
|
|
Term
| :a chronic granulomatous tract that proceeds directly from the anal canal to the skin outside of the anus, from an abscess to the anal canal or the perirectal area |
|
Definition
|
|
Term
| What is the purpose of the falciform ligament of the liver? |
|
Definition
| It is the most important ligament and it connects the anterior surface of the liver to the diaphragm and anterior abdominal wall. |
|
|
Term
| :phagocytic cells of the liver that remove bacteria and foreign particles from the blood |
|
Definition
|
|
Term
| Describe the blood supply to the liver. |
|
Definition
| Incoming blood is 1/3 arterial (hepatic artery) and 2/3 venous (hepatic portal vein). |
|
|
Term
| What fraction of the total cardiac output passes through the liver every minute and is drained by the hepatic veins into the inferior vena cava? |
|
Definition
|
|
Term
| Portacaval anastomosis provides an alternate route if obstruction of flow through the liver occurs due to disease. What are the portacaval anastomoses of the liver? |
|
Definition
| Esophageal veins, paraumbilical veins and the superior hemorrhoidal veins. |
|
|
Term
| :the sustained elevation of pressure in the portal vein due to resistance to blood flow through the liver. |
|
Definition
|
|
Term
| What are some of the Sx of portal HTN? |
|
Definition
| splenomegaly, ascites, esophageal varicies, caput medusae (distended paraumbilical veins) and hemorrhoids. |
|
|
Term
| What percentage of liver is needed to sustain life? |
|
Definition
|
|
Term
| What are the major functions of the liver? |
|
Definition
| Carbohydrate/protein/fat/steroid metabolism, formation/excretion of bile, vitamin/mineral storage, detoxification and blood filter. |
|
|
Term
| What organ is responsible for the concentration and storage of bile? |
|
Definition
|
|
Term
| Describe the constituents of the common bile duct. What does it combine with and form in the pancreas just before it empties into the duodenum? What is the name of the sphincter that regulates release of the bile from these ducts just before they empty into the duodenum? |
|
Definition
| Common bile duct is made of the common hepatic duct from the liver and the cystic duct from the gallbladder. The common bile duct combines with the pancreatic duct to form the ampulla of Vater which empties into the duodenum. The sphincter of Oddi surrounds the ampulla of Vater and controls the release of bile into the duodenum. |
|
|
Term
| What are the functions of the exocrine and endocrine (Islets of Langerhans - alpha, beta and delta) cells of the pancreas? |
|
Definition
Exocrine cells produce pancreatic juice.
Endocrine (Islets of Langerhans) alpha cells secrete glucagon, beta cells secrete insulin and delta cells secrete somatostatin. |
|
|
Term
| What are bile salts essential for the absorption and digestion of in the small bowel? Where are they reabsorbed? |
|
Definition
| essential for fat digestion & absorption in the small bowel. They are reabsorbed in the ilium of the small bowel if they are not bound to fat or fat soluble vitamins (they will be reabsorbed in the duodenum or jejunum in that case). |
|
|
Term
| :a bile pigment that is the end product of degradation of old RBCs |
|
Definition
|
|
Term
| At what level of serum bilirubin is jaundice apparent? |
|
Definition
|
|
Term
| Describe how RBCs are broken down and converted into conjugated bilirubin (the form that can be excreted) and how it is excreted. |
|
Definition
| Old RBCs are hemolyzed and the heme is converted to unconjugated bilirubin (not water soluble) in the spleen which is then transported to the liver by albumin. The liver enzymatically conjugates bilirubin into bilirubin glucuronide, which is water soluble and can now be excreted. Conjugated bilirubin goes through the biliary system into the duodenum where it is converted by GI bacteria to urobilinogen which is excreted in feces and gives feces its brown color. |
|
|
Term
| :excessive production of bilirubin due to increased rate of RBC destruction. |
|
Definition
|
|
Term
| What is the result of a glucuronyl transferase deficiency? |
|
Definition
| They will be unable to conjugate bilirubin so it will stay water insoluble and not be excreted, leading to jaundice. |
|
|
Term
| What therapy can be used to convert the unconjugated bilirubin seen in glucuronyl transferase deficiency leading to transient neonatal jaundice? |
|
Definition
|
|
Term
| What is Gilbert's syndrome? |
|
Definition
| Benign cause of jaundice due to decreased activity of the glucuronyl transferase enzyme, which conjugates bilirubin. |
|
|
Term
| What is Crigler-Najjar syndrome? What is the most worrisome complication? |
|
Definition
| Very rare disorder characterized by a congenital deficiency of glucuronyl transferase enzyme (responsible for conjugating bilirubin). Most worrisome complication is brain damage in infants. |
|
|
Term
| What are the causes of intrahepatic cholestasis (blocked flow of bile)? Extrahepatic? What will be the Sx of both intra and extra hepatic cholestasis? |
|
Definition
Intra = hepatitis or cirrhosis.
Extra = liver METS, gallstones, bile duct strictures, and cancer to the head of the pancreas.
Sx of both = hyperbilirubinemia (jaundice), dark urine and pale stools. |
|
|
Term
| What Hepatitis infections have chronic conditions? |
|
Definition
| Hep B, C and D(only found in combination with B). |
|
|
Term
| Describe the typical incubation periods for Hep A, B, C, D and E. |
|
Definition
A = 1 month.
B = 4 months.
C = 2 months.
D = 1-2 months.
E = 1 month. |
|
|
Term
| What forms of Hepatitis have vaccines available? |
|
Definition
| Only A and B (D can be prevented by Hep B vaccine though due to the fact that it will only occur in combination with Hep B). |
|
|
Term
| What is the most common type of viral hepatitis in the US? What is the mode of transmission? When is it contagious? |
|
Definition
Hep A, it is transmitted through the oral-fecal route.
It is contagious during the 2 weeks prior to jaundice. |
|
|
Term
| Hep B is a ds-DNA virus with surface coat antigens (HBsAg), precore antigens (HBeAg) and inner core antigens (HBcAg), describe where you find each of these antigens. |
|
Definition
Surface coat (HBsAg) = outermost layer of the virus.
Precore region (HBeAg) = middle layer of the virus.
Inner core (HBcAg) = innermost layer of the virus. |
|
|
Term
| How is Hep B primarily transmitted? |
|
Definition
| Parenteral route (IV) or close physical/sexual contact. |
|
|
Term
| What are the reliable serologic markers of an acute Hep B infection? Carrier state serologic marker? What will be the only positive serologic marker in a patient that is immune to Hep B due to vaccine? |
|
Definition
Acute Hep B markers = HBsAG, HBeAG and HBV DNA.
Carrier state = HBsAG in the serum for longer than 6 months.
Immunity = anti-HBs IgG as the ONLY serologic marker present. |
|
|
Term
| How is Hep C typically transmitted? How likely is Hep C to become chronic? What are some common complications of Hep C? |
|
Definition
Typically transmitted in the same manner as Hep B (parenteral route (IV) or close physical/sexual contact).
80% will develop chronic hepatitis C.
There is a strong correlation between liver cirrhosis and liver cancer. |
|
|
Term
| What will Hepatitis D infection only occur as a coinfection with? What will they increase the patients risk of? |
|
Definition
| It will only occur with Hep B. If they occur together it will increase the risk of fatal fulminant(sudden) hepatitis and chronic hepatitis. |
|
|
Term
| :Chronic disease of the liver characterized by replacement of the normal parenchyma with fibrosis and liver cell nodules (regenerated liver cells) |
|
Definition
|
|
Term
| What is the major difference between alcoholic cirrhosis and Hep C cirrhosis? |
|
Definition
| Alcoholic cirrhosis can regenerate with only a small amount of health liver cells left, Hep C cirrhosis cannot regenerate and the only treatment is a liver transplant. |
|
|
Term
| What is the most common cause of liver cirrhosis? |
|
Definition
|
|
Term
| What are some clinical manifestations of hepatocellular failure due to cirrhosis? |
|
Definition
| Jaundice, gynecomastia (failure of the liver cells to inactive estrogen), bleeding tendencies (decreased production of clotting factors), peripheral edema (hypoalbuminemia), sweet/decaying breath odor and hyperammonemia leading to hepatic coma. |
|
|
Term
| What accounts for 1/3 of the deaths from cirrhosis? |
|
Definition
| GI bleeding due to esophageal varices. |
|
|
Term
| What is the cardinal sign of cirrhosis? |
|
Definition
|
|
Term
| What is Cholelithiasis? Cholecystitis? |
|
Definition
Cholelithiasis – gallstone formation.
Cholecystitis – inflammation of the gallbladder. |
|
|
Term
| Most patients (75%) with cholelithiasis (gallstones) are asymptomatic, when do symptoms usually start to occur? What are the most common symptoms? |
|
Definition
Symptoms start to occur when the stones obstruct the actual flow of bile.
Common Sx = biliary colic (pain associated with irritation of the viscera secondary to cholecystitis) and severe/acute pain in the RUQ or epigastric region. |
|
|
Term
| What are the 2 most common causes of acute cholecystitis? |
|
Definition
| Cholelithiasis and the biliary colic (pain associated with irritation of the viscera secondary to cholecystitis) associated with it. |
|
|
Term
| What is the test of choice to detect gallstones? What are the treatment options? What is important to tell the patient as part of their patient education? |
|
Definition
Test of choice = US.
Tx = rest, fluids, NG suction, analgesics, antibiotics, Actigall (oral bile acid to dissolve the stone), lithotripsy or laproscopic removal of the gallbladder.
Pt education = avoid fatty foods. |
|
|
Term
| What is the etiology of acute pancreatitis? Common S&S? What serum enzyme of the PFT will be show a more acute peak? Later peak? |
|
Definition
Etiology = Acute inflammatory procoess involving necrosis of the acinar cells (responsible for production of the very potent pancreatic enzymes that digest protein/fat/carbohydrate). These enzymes now autodigest the pancreas and surrounding tissues.
S&S = severe epigastric pain that radiates to the back, abdominal guarding/rigidity and decreased bowel sounds.
Amylase will be elevated acutely and Lipase will be elevated chronically. |
|
|
Term
| What are the most common causes of acute pancreatitis (BADSHIT)? Which 2 are most common? |
|
Definition
Biliary obstruction
Alcohol abuse
Drugs
Scorpion Bites
Hyperlipidemia
Infectious or idiopathic
Trauma
Most common = Alcoholism and hyperlipidemia |
|
|
Term
| What are the complications of pancreatitis? |
|
Definition
| Complications = DM, severe tetany (due to hypocalcemia), pleural effusion, pancreatic abscess and phlegmon (mass of solid, inflamed necrotic tissue). |
|
|
Term
| Describe the cellular changes of the pancreas with chronic pancreatitis. What is the most common cause in adults? Children? |
|
Definition
Cellular changes = fibrosis, stricture and calcification.
MCC in adults = alcoholism.
MCC in children = cystic fibrosis. |
|
|
Term
| What is the most common cause of liver cancer? Most common type of primary liver cancer? |
|
Definition
MCC is METS from colon cancer (primary liver cancer is rare).
MC type of primary liver cancer is a Hepatoma. |
|
|
Term
| About 75% of patients with liver cancer also have? What is the most important sign of liver cancer> |
|
Definition
Alcoholic cirrhosis.
Most important sign is unclear deterioration in a cirrhotic patient and rapid enlargement of the liver. |
|
|
Term
| What is the most common type of gallbladder cancer? Is this usually diagnosed early or late? |
|
Definition
Adenocarcinoma.
Diagnosis is usually very late. |
|
|
Term
| What are 2 risk factors for pancreatic cancer? What is the most common location for pancreatic cancer? |
|
Definition
Risk factors = smoking and a high fat/protein diet.
Most common location is the head of the pancreas (60%). |
|
|
Term
| Explain why it is worse to have pancreatic cancer in the body or tail of the pancreas. |
|
Definition
| If it is in the body or tail of the pancreas it often remains asymptomatic until the late stages of the disease. If it is in the head of the pancreas it will cause obstruction of the biliary tract leading to jaundice and an enlarged gallbladder (Courvoisier sign) and treatment (Whipple procedure) can be initiated earlier in the disease progression. |
|
|
Term
| What is the average life expectancy after the diagnosis of liver, gallbladder or pancreatic cancer? |
|
Definition
|
|
