USMLE GI VI
Terms in this set (52)
what are three causes of destruction of the bile ducts?
primary biliary cirrhosis, secondary biliary cirrhosis, primary sclerosing cholangitis
what is the cause of secondary biliary cirrhosis?
extrahepatic biliary obstruction causes increase pressure in the intrahepatic ducts which results in in injury/fibrosis and bile stasis
what are different causes of secondary biliary cirrhosis?
gallstone, biliary stricture, chronic pancreatitis, carcinoma of the pancreatic head, CF (dehydrated bile obstruction), and primary sclerosing cholangitis!
how do patients with secondary biliary cirrhosis present? what other patients present similarly?
pruritus (from build up of cholesterol), jaundice, dark urine, light stools, hepatosplenomegaly
; primary biliary cirrhosis and primary sclerosing cholangitis
what are the lab values seen in secondary biliary cirrhosis? what are the diseases present similarly?
increased conjugated bilirubin, increased cholesterol, and increased alkaline phosphatase, and increased GGT; primary biliary cirrhosis and primary sclerosing cholangitis
what is the pathophysiology of primary biliary cirrhosis? what does histology show?
how do you differentiate presentation from secondary biliary cirrhosis? labs?
a type IV (CD8 T cells) hypersensitivity autoimmune reaction of extra and intrahepatic bile ducts; granulomas and lymphocytic infiltrate
; older women usually with xanthelesma also usually and kayser fleischer ring (often progress to cirrhosis); same labs with also serum mitochondrial (of bile duct epithelium) Antibodies increased
with what is primary biliary cirrhosis associated with?
other autoimmune conditions: CREST, RA, celiac disease
what is the pathophysiology of
primary sclerosing cholangitis?
what does histology show? ERCP? how do you differentiate presentation from primary and secondary biliary cirrhosis? labs?
unknown cause of concentric "onion skin" bile duct fibrosis;
"onion skin" fibrosis; alternating strictures and dilations "beading"
of intra and extrahepatic bile ducs; men more likely;
hyper gammaglobulinemia- IgM specifically
with what is primary sclerosing cholangitis associated with?
what is it a risk for?
Ulcerative colitis; can lead to secondary biliary cirrhosis and is a risk for
what is cholelithiasis? what is the essential cause of them (disturbances in what ratios)?
what are four risk factors ?
gallstones; increased cholesterol and/or bilirubin, decreased bile salts, and gallbladder stasis; female, forty, fertile, fat
how does secondary biliary cirrhosis lead to cholelithiasis?
from bile stasis
what type of phospholipid/lecithin ratio causes cholelithiasis?
decreased (similar to bile salt/lecithin ratio)
how does increased estrogen levels lead to cholelithiasis? what kind of stones?
estrogen upregulates the LDL Receptor and upregulates HDL and increases Hmg CoA reductase; cholesterol stones
what are the two types of stones? which are radiolucent?
cholesterol or pigmented (bilirubin); cholesterol unless gets calcified
what percentages of cholelithiasis is d/t cholesterol stones? how many get calcified?
80% of stones; 10-20%
T/F the calcifications seen in cholelithiasis is d/t calcium oxalate
what type of cholelithiasis does obesity predispose to? cystic fibrosis? alcoholic cirrhosis? chronic hemolysis? advanced age?
cholesterol; cholesterol; pigmented; pigmented; both
what type of cholelithiasis does Crohns predispose to? clofibrate? multiparity? biliary infection? advanced age? rapid weight loss? Native American origin?
cholesterol; cholesterol; cholesterol; pigmented; both; cholesterol; cholesterol
*why do you Crohns and cystic fibrosis lead to
because of decreased concentration of bile salts (crohns- illeum reabsorption of bile salts destroyed) and CF d/t inability to secrete salts
what is the composition of bile?
bile salts, bilirubin, Cholesterol, PL
what are pigmented bile stones made of? what are they on xray? how are pigment bile stones d/t biliary infection different?
; radioopaque; they are brown
what is the mc complication of cholelithiasis? what are complications?
cholecystitis (infection in gallbladder); biliary colic, cholangitis, acute pancreatitis, bile stasis, gallbladder carcinoma
what is cholecystits? cholangitis? what is charcot's triad of cholangitis? reynolds pentad? what is a positive murphy's sign?
infection of GB; infection of duct;
jaundice, fever, RUQ pain
(jaundice doesn't occur until cystic duct blocked;
add Hypotension & altered mental status
inspiratory arrest on deep palpation d/t pain (indicative of cholecystitis)
what should you think if a patient presents with scleral icterus, jaundice, and pain in her RUQ?
what is biliary colic? what causes it? how is it different from cholangitis? in what disease might biliary colic be masked?
obstruction of common duct causing pain by contraction (contraction pushes stone out to cystic duct); cholelithiasis; no fever, no inflammation; diabetics might not feel the pain!
what if a patient presents with air in the biliary tree on imaging, what causes it? what is this a complication of ?
fistula between gallbladder and small intestine (usually illeum- closest) and if goes to ileocecal valve, air can be see on on imaging; cholelithiasis
how do you diagnose cholelithiasis? treat?
is gallbladder carcinoma often a complication of? what does it look like on radiograph? why?
cholelithiasis; porecelain gallbladder on radiography d/t Ca deposits that outline the gallbladder
what are the serum enzymes associated with cholelithiasis ? why?
increased GGT and alk phos because these are the enzymes made by bile canaliculi eptihelial cells
what is positive murphys sign usually a sign of? what is the most common cause of this?
where can the pain refer to?
cholangitis and cholecystitis (inflammation of gallbladder); cholelithiasis; shoulder
where is the pain usually if it is just cholecysitis? and if it involved ducts?
what does the gallbladder look like if acute cholecystitis? chronic?
edematous and enlarged; shrunken and fibroid
what are other causes of cholecystitis other than cholelithiasis? what predisposes to these? how do you know if the bile duct becomes involved (ascending cholangitis) other than pain localization?
ischemia (in hospital); infectious (E.Coli, CMC, Enterococcus faecalis); increased alk phos
what is acute acalculous cholecystitis usually d/t?
secondary to gallbladder stasis and ischemia which causes inflammation and injury
what does brown cholethiasis indicative of? black stones?
infection (usually fluke); sign of extravascular hemolytic anemia (IV hemolysis for ex)
what is acute pancreatitis definitively?
what causes this?
autodigestion of pancreas by pancreatic enzymes (activation of proenyzme necessary);
either direct enzyme activation (hypercalcemia) or acinar cell injury (hyperlipidemia)
what are the causes of acute pancreatitis?
GET SMASHED or BAD HHITS
Gallstones, Ethanol, Trauma (seatbelts in kids!), Steroids, Mumps (also cmv), Autoimmune disease, Scorpion sting, Hypercalcemia/Hyperlipidemia, ERCP, Drugs (sulfa drugs)
how does alcohol lead to acute pancreatitis?
damages acinar cells
and thickens duct secretion which causes obstruction and activation
what is the clinical presentation of acute pancreatitis?
epigastic abdominal pain
radiating to the back
, anorexia, and nausea;
elevated amylase, and lipase
what are the complications of acute pancreatitis?
(activation of prothrombin to thrombin),
(lipases digest surfactant),
diffuse fat necrosis, hypocalcemia
(calcium collects in pancreatic soap deposits- d/t fatty acid accumulation from lipases), pseducyst formation, hemorrhage, infection, multiorgan failure
what is a pseduocyst formation from acute pancreatitis? what can it lead to if it bursts?
liquid formation from pancreatic autodigestion; ascite like peritoneal fluid (which has amylase) and this third spacing can cause hypovolemic shock (multiorgan failure)
other than shock by hypovolemia from pseudocyst burst, what else can cause shock in acute pancreatitis? what sign does this show?
what is the presentation of this? what is chronic calcificying pancreatitis associated with? and what can it predispose to?
steatorrhea and fat soluble vitamin insufficiency, and diabetes mellitus; smoking and alcohol; increased risk of pancreatic cancer
what is the differential diagnoses of colicky pain?
cholecystitis, and SB obstruction
what is the presentation of pancreatic adenocarcinoma? name four things.
1) weight loss
2) abdominal pain radiating to back
3) obstructive jaundice with palpable gallbladder
4) migratory thrombophlebitis (trousseau's)
what is Courvoiser's sign? what is it indicative of?
obstructive jaundice with palpable gallbladder; pancreatic adenocarcinoma
what is Trousseau's syndrome? what is it indicative of?
redness and tenderness on palpation of extremities (Trousseaus syndrome); pancreatic adenocarcinoma
what is pancreatic adenocarcinoma associated with? what races?
smoking and chronic dystrophic calcification of pancreas; Jewish and AA males
T/F pancreatic adenocarcinoma is associated with alcohol
no- alcohol predisposes to acute pancreatitis (which can lead to chronic pancreatitis)
what are enzyme markers for pancreatic adenocarcinoma? what is the prognosis?
where is the most common location of pancreatic adenocarcinomas? what does this result in?
CEA and CA-19-9; 6 months or less; head of pancreas(retroperitoneal); obstruction jaundice with light colored stools and dark urine
because pancreatic exocrine cancer is very aggressive it often presents already mets- to where? what gene mutation is it associated with?
virchows node and sister mary josephs sign;
Nodular vs Vesicular cirrhosis
micronodular refers to cirrhosis and is caused by toxic insults -> chronic alcohol or wilson's disease.
macronodular cirrhosis is caused by viral hepatitis.
microvesicular fatty change = reye's syndrome in kids.
macrovesicular fatty change = alcoholic fatty liver.
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