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What is the chance of cirrhosis when Hepatitis B chronic infection gets Hep D?
78-80% cirrhosis
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How does aging affect fat soluble vitamins?
See decreased absorption of fat soluble vitamins
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What happens to liver with again?
Decreased size of liver, and number of hepatic cells.
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What happens with there is decrease in liver enzymes?
Unable to detoxify drugs
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What happens to pancreatic ducts with age?
Calcify, distend, dilate and also see decrease production of lipase
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What are the pancreatic enzymes?
Amylase, lipase, trypsin
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What are the risk factors for pancreatitis?
Gall stones 45%, excessive ETOH use 35%, elevated triglycerides over 800, idiopathic. Binge drinking. Viral infection. Blunt trauma. Opioids, corticosteroids, thiazide diuretics.
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What laboratory results will be seen in acute pancreatitis?
Elevated amylase and lipase. But amylase can also be elevated in perforated duodenal ulcer and other abdominal emergencies
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Signs of pancreatic cancer?
Abdominal pain, n/v, weight loss, anorexia, jaundice, pain
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Signs of pancreatitis?
Pain radiating to mid back, fever, elevated heart rate, shock, ileus, jaundice
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What is the name of the criteria used for classifying severity of pancreatitis?
Ranson's Criteria
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Signs positive for hemorrhagic pancreatitis?
Turner's and Cullen's signs
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What are the risk factors for pancreatic cancer?
Tobacco use, history of pancreatitis, DM
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What is a positive obturator sign?
Positive in appendicitis. When raise leg with knee flexed and internally rotate leg, will have pain in RLQ
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What is McBruney's point positive in?
Appendicitis
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What does positive psoas sign mean?
Appendicitis
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What meds can make GERD worse?
Calcium channel blockers, theophylline, nitrates. Those in the smooth muscle relaxant category. And Hormone therapy. Nicotine
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What H2 blocker is not recommended due to many drug-drug interactions?
Cimetidine (Tagamet)
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Prevention of return of duodenal ulcer?
H. Pylori antibiotic treatment keeps it from coming back
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Acute Appendicitis nausea and vomiting has onset when?
Vomiting and fever will occur 12-24 after pain. If pain and vomiting occurs simultaneously, it indicates more a GI infection
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Duodenal ulcer pain noted when?
Worse when hungry, better when eats. Due to food buffering the gastric acid when it enters the duodenum
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Gastric ulcer pain noted when?
Disease of 'Too much' Pain worse when eating. Food activates acid production.
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What is a better benzo to give for acute ETOH withdrawal treatment?
Ativan is shorter half life and better in presence of liver dysfunction.
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What is given in ETOH withdraw to help with DT?
Direct-acting Alpha 2 adrenergic agonist Clonidine and Beta adrenergic antagonist Propranolol
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What nutritional supplements need to be added for ETOH abuse?
High dose Vitamin Bs, Vitamin C, Magnesium
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Where is AST found?
Liver, but also heart, brain, kidney and skeletal muscle
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Where is ALT found?
More liver specific L= liver
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What would cause an elevated AST?
Alcohol, Statins, Tylenol
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What would cause elevated ALT?
Hepatitis due to Toxins or Infection
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What is AST ALT ratio used for?
Gain insight into reason for LFT elevation
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Where is ALP found?
Alkaline Phosphatase if found in rapidly dividing or metabolically active tissue in liver, bone, intestine, placenta.
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What does an elevation in ALP indicate?
Damage to liver and also biliary obstruction, cholestasis
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GGT is found where?
Liver and kidney.
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Will LFTs return to normal after ETOH abuse resolved?
Yes, in 2-3 months they will go back to baseline
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Appendicitis progression of symptoms?
Pain first, nausea and vomiting are later symptoms AFTER pain onset.
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Appendicitis assessment signs?
+ psoas (iliopsoas) sign. Pain with hip extension. + obturator sign. Pain with hip flexion and internal rotation. Pain is indicative of location of appendix, not always RLQ.
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What scan would you order for appendicitis?
US if no signs of rupture. If suspect rupture, do CT to check for abscess
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Signs of an appendix perforation?
Fever, marked leukocytosis, positive peritoneal signs, RLQ mass, symptoms greater than 24 hours
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What is Zollinger-Ellison Syndrome?
A Gastrinoma located in pancreas or stomach that produces gastrin with increased acid production causing multiple severe gastric and duodenal ulcers.
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What test is done for Zollinger-Ellison syndrome?
Serum fasting gastrin level
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Which IBD has skip lesions?
Crohn's has skip lesions, areas of involvement scattered among healthy intestine.
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What is secreted by Stomach for digestion?
Hydrochloric acid and intrinsic factor
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What is secreted by duodenum for digestion?
Bile acids, amylase, lipase
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Which ulcer is worse after eating?
Duodenal is worse about 2 hours after eating
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Testing for H. Pylori includes?
Stool antigen testing. Urea breath test. Immunoglobulin levels not as sensitive/specific
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What does the gastric parietal cell secrete?
Hydrochloric acid, mediated by the H2 receptor site
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What drugs does cimetidine interfere with?
Theophylline, Warfarin, seizure meds,
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How long should antacids and FQs be separated?
Antacid 2-4 hours before FQ dose or antacid 4-6 hours after FQ dose
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Barrett's esophagus is precancerous for what type of esophageal cell cancer?
Adenocarcinoma (columnar epithelial metaplasia), Squamous cell carcinoma
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What is Carafate's MOA?
Gel forms on mucosa and into ulcer sulcus, inactivates pepsin and stimulates prostaglandins
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What is a side effect of Reglan?
Extrapyramidal effects
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What follow-up is indicated with diagnosis of Barrett's esophagus?
EGD every 6 months and then once negative twice, can move to every 3 years
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What medication regimen is recommended for H. Pylori infection?
Each 10-14 day duration treatment option includes a PPI plus Flagyl and Bismuth, or PPI plus Amoxicillin and Clarithromycin
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Hepatitis acute illnesses typical last how long?
HAV and HBV acute illness usually lasts 2-3 weeks
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Symptoms of hepatitis infection?
Malaise, fatigue, nausea, anorexia, fever, hepatomegaly, mild RUQ tenderness without rebound, splenomegaly.
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When does jaundice occur in hepatitis infection?
1 week after onset of symptoms
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What characteristics are noted on CBC with Hepatitis infection?
Leukopenia with lymphocytosis and atypical lymphocytes
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Urine finding with hepatitis?
Bilirubinuria
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What does the ratio of AST to ALT note in alcohol use?
AST will be greater than ALT two to one
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What is GGT sensitive for?
ETOH abuse, may be a lone elevation. Also elevated in acute pancreatitis
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Alkaline phosphatase is noted in?
Bone, liver, gallbladder, kidney. Can be normally elevated in teen growth spurts
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What degree of elevation is noted on AST and ALT during acute Hepatitis?
Can see up to a 10 fold increase in values
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What symptoms are noted in the incubation period of viral hepatitis?
No subjective signs and symptoms are noted.
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What is noted in the icteric phase of viral hepatitis?
Jaundice, dark urine, light stools, plus prodrome symptoms continue
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What is bilirubin a byproduct of?
Degradation of heme molecule
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What kind of bilirubin gives urine the yellow color?
Conjugated bilirubin
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What is the treatment in acute viral hepatitis?
Supportive care, anti virals, interferon, corticosteroids
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What test is most diagnostic for acute cholecystitis and to assess duct?
HIDA scan
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What sign is positive in acute cholecystitis?
Murphy's sign (respiratory arrest with RUQ palpation)
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Symptoms of acute cholecystitis?
RUQ pain, Vomiting, occasional jaundice and fever
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What lab values are noted in acute cholecystitis?
Leukocytosis, Elevated LFT, GGT, Alk phos, bilirubin, amylase
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What does ALP elevation indicate in cholelithiasis?
Increases with obstruction of biliary system, sensitive indicator of intra and extrahepatic cholelithiasis
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If ALP is elevated and GGT is normal?
Consider bone problem, and can r/o liver as source
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Colorectal colonoscopy cancer screenings should occur?
Every 10 years at age 50.
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Colonoscopy should be performed how frequently in a person with risks?
Every 5 years
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What medications have been show to decrease colon cancer risks?
Low dose ASA, calcium supplements, antioxidants
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What antibiotics are given for intestinal perforation?
Ciprofloxacin and Flagyl
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What GI symptom is associated with Giardia?
Diarrhea
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What is a major risk factor for Hep A?
International travel
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What are the common symptoms of Hep B?
Clinical presentation is variable, may are asymptomatic
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What do you suspect if patient has gall bladder pain with fever?
Acute complicated cholecystitis
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What is the AST ALT ratio for an alcoholic?
AST is twice the ALT. Both will be elevated
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What if ALT is greatly elevated?
Suspect hepatitis infection
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What is the most common causes of acute pancreatitis?
Alcoholism and gall stones
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What causes grayish tan stool?
Obstructive jaundice
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What causes pale yellow greasy stool?
Steatorrhea, due to malabsorption cystic fibrosis, celiac disease
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