Path and CS GI 2

  1. Irritable bowel syndrome
    • F>M. sx beginning before they were aged 35. Mostly start during childhood. Rarely after 40
    • Rome criteria: recurrent ab pain for at least 3 day/mo, assoc w/ 2 or more of the following
    • Improvement w/ defecation
    • Onset assoc w/ change in frequency of stool
    • Onset assoc w/ change in form of stool
  2. types of IBS
    • IBS-D (diarrhea predominant)
    • IBS-C (constipation predominant)
    • IBS-M (mixed diarrhea and constipation)
    • IBS-A (alternating diarrhea and constipation)
  3. features/characteristics of IBS
    altered stool passage, altered GI motility, visceral hyperalgesia (widened dermatomal distributions of referred pain. Sensitization of GI afferent nociceptive pathways). psycho disturbances (can be cause or outcome--axis I disorders like anxiety, panic, depression), Small bowel bacterial overgrowth and fecal microflora
  4. IBS tends to show as urgency _________
  5. microscopic inflammation in IBS
    postinfectious IBS. Enteroendocrine cells secrete high serotonin levels. lymphocytic infiltration. Increased numbers of colonic mucosal lymphocytes and enteroendocrine cells
  6. IBS presentation
    • pain mostly in LLQ, Acute episodes of sharp pain are often superimposed on a more constant dull ache
    • Meals may precipitate pain. Defecation may or may not improve pain, Pain from presumed gas pockets in the splenic flexure, sigmoid tenderness or a palpable sigmoid cord
  7. differential dx close to IBS
    • Lactose intolerance. Fructose intolerance
    • Celiac Disease (1/200, more of Irish descendent) or Gluten intolerance
  8. alarming sx of IBS
    onset middle age or older. ï½¥Nocturnal symptoms. Anorexia or weight loss. Fever. ï½¥Rectal bleeding. Painless diarrhea. Steatorrhea
  9. Irritable bowel disorders
    ulcerative colitis and crohn dz. highest incidence in developed countries, highest in Jewish populations, appear in late adolescent to 3rd decade
  10. complications of IBD
    pseudopolyps, erythema nodosum, uveitis, sacroiletis, ankylosis spondylitis
  11. differential dx close to IBD
    • Ileitis: Infection – Neoplasm – NSAIDs – Vascular…
    • Proctitis : HIV & STD
    • Colitis. Behcet’s Syndrome. Ischemic Colitis. Microscopic Colitis
    • Colitis and Diverticulosis. Diversion Colitis
  12. IBD risk factors
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  13. colonic adenocarcinoma
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  14. scalloped duodenal folds
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    duodenal sprue. celiac dz
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    osteomalacia. malabsorption
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    zinc deficiency. malabsorption
  18. ulcerative colitis
    bloody diarrhea, limited to mucosa/submucosa, begin at rectum, spread to sigmoid and rest of colon. NO skip lesions. no newly formed granulomas, mural thickening does not occur, high risk of carcinoma developmt, more common than Crohn, more common in whites, colicky lower ab pain, RELAPSES
  19. Features of ulcerative colitis
    Pseudopolyps, ASCA - / p ANCA+, Neutrophilic Infiltrate, Crypt Abcesses, Crypt Distorsion, toxic megacolon (colon swells & becomes gangrenous), progressive mucosal atrophy leads to a flattened and attenuated mucosal surface, diffuse mononuclear infiltrate in lamina
  20. ulcerative colitis are also assoc w/
    migratory polyarthritis, sacroiliitis, ankylosing spondylitis, uveitis, erythema nodosum, and hepatic involvemt (pericholangitis and primary sclerosing cholangitis)
  21. Extra-intestinal manifestations are more common w/
    ulcerative colitis than w/ crohn dz
  22. Crohn dz
    pain in lower ab or RLQ, pt fatique and anemic, ASCA + / p ANCA-, ileum frequently involved, rectum spared, formation of granulomas, frequent fistulae, frequent perineal dz, SKIP lesions, Prevalent in US, Great Britain, and Scandinavia. Occurs at any age, F>M. More often among Jews than among non-Jews
  23. Crohn dz morphology
    often mesenteric fat wraps around bowel surface ("creeping fat"). Intestinal wall is rubbery and thick, result of edema, inflammation, fibrosis, and hypertrophy of the muscularis propria. Lumen is narrowed; in small intestine this is seen on x-ray as "string sign." Sharp demarcation of diseased bowel segments. TRANSMURAL
  24. complications of crohn dz
    Dysplastic changes appearing in mucosal epithelial cells, after long standing Crohn dz --> carcinoma. Fistula formation, abscess, intestinal strictures, Massive intestinal bleeding, toxic dilation of colon, or carcinoma of colon (less than cancer risk of ulcerative colitis) or small intestine
  25. crohn dz may be accompanied by...
    uveitis, sacroiliitis, migratory polyarthritis, erythema nodosum, bile duct inflammatory disorders, and obstructive uropathy with attendant nephrolithiasis
  26. Cholangiocarcinoma types and locations
    Type I & II in perihilar region. Type III is perihilar and intrahepatic. Type IV can be perihilar and intrahepatic or can spread to distal extrahepatic.
  27. If pt has one 2nd degree or 3rd degree relative w/ colorectal cancer, screen at...
    over 50 yrs (like average risk)
  28. One 1st degree relative w/ colorectal cancer at or after age 60 or two 2nd degree relatives w/ CRC, screen pt at..
    40 yrs
  29. 2 or more 1st degree relatives w/ colorectal cancer or one 1st degree relative w/ CRC before age 60, screen pt at...
    age 40 or 10 yrs younger than earliest dx in family. repeat every 5 yrs
  30. biliary cirrhosis
    women, overweight, antibodies to mitochondria
  31. Meckel diverticulum
    most common anomaly. Failure of involution of omphalomesenteric duct, leaving a blind-ended tubular protrusion. Usually in ileum, asymptomatic, except when they permit bacterial overgrowth that depletes vitamin B12 --> pernicious anemia. Peptic ulceration, intestinal bleeding
  32. Obstructive causes of pancreatitis
    tumor, cystic fibrosis, gallstone in common bile duct
  33. acinar cell injury causes of pancreatitis
    alcohol, viruses (mumps), drugs (thiazides, diuretics), trauma, hypercalcemia, obesity, hyperlipidemia
  34. Image of diverticulosis vs diverticulitis
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  35. Diverticulitis is more assoc w/...
    old age (may rupture), and neutrophilia left shift
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    mucinous cystadenoma. (glistening look) – can be benign or having malignant potentials
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    serous cystadenoma. usually benign.
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    acute hemorrhagic pancreatitis
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    chronic pancreatitis. can present w/ diabetes
  40. complications of cholelithiasis
    • Occlusion of biliary and pancreatic ducts via migrating gallstones
    • Biliary colic, Acute cholecysitis, Ascending cholangitis
    • Acute pancreatitis
  41. formation of cholelithiasis
    gallstones: bile concentrated in gallbladder --> supersaturated --> microscopic crystals --> trapped in gallbladder mucus --> gallbladder sludge --> crystals grow, aggregate, and fuse to form macroscopic stones ---> occlusion of ducts
  42. Cholelithiasis presentations
    Tenderness to palpation rebound tenderness, guarding over the gallbladder +/- rigidity pericholecystic inflammation. Murphy sign – push posteriorly at border of costal margin, midclavicular line. Fever, tachycardia and hypotensive. jaundice.
  43. Charcot triad in cholethiasis
    RUQ tenderness, fever, jaundice. characteristic of ascending cholangitis
  44. gallstone risk factors
    OBESITY, insulin resistance, type II diabetes mellitus, hypertension, and hyperlipidemia. pregnancy (progesterone), gallbladder stasis (prolonged fasting with total parenteral nutrition), rapid wt loss, gastric bypass
  45. Choledocholithiasis
    stone in common bile duct. Elevated wbc, transaminases, followed by elevated alkaline phosphatase & bilirubin. If obstruction is at level of ampulla of Vater, may obstruct pancreatic duct & see elevation of lipase and amylase
  46. vinyl chloride predisposes one to...
    hepatic angiosarcoma
  47. types of gallstones
    • cholesterol stones most common.
    • calcium, bilirubin, and pigmented gallstones.
    • mixed stones
  48. calcium, bilirubin, pigmented stones
    • Due to oxidation the stones turn black: High heme turnover. Disorders of Hemolysis
    • Sickle cell anemia, Hereditary spherocytosis, Beta-thalassemia
    • Splenomegaly due to cirrhosis, Red cell sequestration
  49. calcium, bilirubin pigmented stones can turn brown if
    colonized w/ bacteria. Biliary strictures (post surgical). Choledochal cyst. Liver flukes infestation causing intra and extrahepatic bile duct strictures
  50. mixed stones
    cholesterol gallstones become colonized by bacteria (Lytic enzymes from the bacteria and leukocytes hydrolyze the bilrubin and fatty acids). calcifies thru time. calcium ring forms around stone.
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    pseudocysts. Cysts that lack an epithelial lining. Just a sac filled w/ edema fluid or digestive enzymes. Complication of chronic pancreatitis.
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    pseudocyst. Cysts that lack an epithelial lining. Just a sac filled w/ edema fluid or digestive enzymes. complication of chronic pancreatitis
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    calcfications in old necrotic regions. complication of chronic pancreatitis
  54. complications of gallstones
    • acute pancreatitis and cancer.
    • Acute cholecystitis, Chronic cholecystitis
    • Gallbladder adenocarcinoma, Cholecystoenteric fistula
  55. complications of stones in common bile duct
    • Stone retention in the cystic duct: Mirizzi Syndrome
    • Stone retention in the ampula of vater: Obstructs the pancreatic duct and cause acute pancreatitis
    • Ascending cholangitis: Infection due to the obstruction
  56. Acute cholecystitis ultrasound
    gallbladder edema and pericholecystic fluid
  57. imaging that detects common bile duct stones
  58. imaging that gives great pictures of biliary tract
  59. test for gallstone. Stone obstruction of cystic duct shows failure of the gall bladder to fill
    HIDA: Technetium-99m
  60. Used to remove the obstructing stone or to diagnosis obstructing tumor
    ERCP: Endoscopic retrograde cholangiopancreatography
  61. symptomatic gallstones
    episodes of biliary colic,
  62. secondary biliary cirrhosis
    etiology linked to carcinoma of pancreatic head, gallstones, strictures, and biliary atresia
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    apthous ulcer or canker sores
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    herpetic stomatitis. cold sores. hsv1
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    adenocarcinoma of esophagus
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    celiac sprue. blunted vili.
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    whipple dz. PAS stain. Distended macs?
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    signet ring cells (mucinous cells). gastric diffuse adenocarcinoma. Gross apperance will be linitus plastica (like leather bottle)
  69. cholesterol stones assoc w/ 4 Fs
    female, fat, forty, fertile
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    Crohn dz. Cobblestone. skip lesions
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    ulcerative colitis
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    diverticulosis. older pts
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    colon cancer
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    C diff colitis
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    tubular adenoma in colon polyps. most common type of colon polyp
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    tubular adenoma in colon polyps. most common type of colon polyp
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    villous adenoma of colon polyps
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    villous adenoma of colon polyps
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    acute pancreatitis w/ fat necrosis
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    steatosis of liver
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    mallory bodies in hepatic failure
  83. if pseudocysts rupture, you can have...
    acute sterile peritonitis because pseudocysts contain enzymes, no bacteria
  84. most common location of pancreatic cancer is..
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    anti mitochondrial Abs in primary biliary cirrhosis.
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    primary biliary cirrhosis. infiltrate of lymphocytes and plasma cells. granulomatous destruction of bile duct. Elevated alkaline phosphatase
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    primary sclerosis cholangitis. Beading and strictured biliary tree on radiography. Assoc w/ ulcerative colitis.Ankylosis spondylysis, polyarthritis
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    hepatic hemangioma. most common tumor of liver. benign
  89. Hepatic adenoma more assoc w/...
    females, oral contraceptives
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Path and CS GI 2
Path and CS GI 2