CMS II: GI - EXAM #2 (TEST QS) (quizlet)

Lymphoid tissue in the gut is responsible for:

immune responses

Two components of GALT:

1. Organized GALT (Peyer's patches)

2. Diffuse GALT

Immune response that is induced by antigens (food proteins) unresponsiveness

Oral tolerance

Inflammatory Bowel Disease has ________ incidence

bimodal (first peak its between 20-30 and second peak is between 60-70)

**lifelong w/ remissions and relapse

What is the possible pathogenesis of IBD?

hyperactivity or loss of oral tolerance (no longer able to withstand bacteria in the gut), causing a dis-regulated immune response

_____ has a thin, superficial layer or inflammation, and ________ has transmural inflammation

UC; Crohn's

A chronic, recurrent disease characterized by transmural inflammation (skip lesions) anywhere along the GI tract (except the rectum)

Crohn's disease

Where is Crohn's disease usually located?

terminal ileum or cecum

**RLQ tenderness often (because it is commonly in terminal ileum and cecum)

3 patterns of ____________:

1. inflammatory

2. stricturing

3. perforating

**inflammation can lead to fibrosis and strictures

Crohn's disease

Initial lesions of ______________: apthoid ulcers and focal crypt abscesses

Crohn's disease

What creates the "cobblestoning" appearance in ___________

Stellate ulcerations fuse longitudinally & transversely, demarcating normal islands of mucosa

Crohn's disease

Patient presents with crampy pain in the RLQ and diarrhea (w/o blood). When looking at labs, you see he has thrombocytosis, DEC serum albumin, INC ESR, and a (+) ASCA. What is the most likely diagnosis?

(Biopsy via colonoscopy to confirm!)

Crohn's disease

A panel of 7 tests combines serologic, genetic, and inflammatory markers to help differentiate IBD vs non-IBD & CD from UC

Prometheus IBD Serology 7

You order a UGI series with SBFT and note irregular caliber, poor distensibility, cobblestoning, areas of narrowing, & aphthous ulcers. What's your Dx?

Crohn's disease

Characteristic findings of ___________ on a CT enterography section:

Two inflammatory small bowel strictures separated by a segment of normal distended small bowel

Crohn's disease

CT enterogrphic findings of luminal narrowing and proximal dilatation are indicative of ___________.

obstruction

Hepatobiliary complications of Crohn's:

Dermatologic complications of Crohns:

Oral complications of Crohns:

Ocular complications of Crohns:

MS complications of Crohns:

HB: gallstones, primary sclerosing cholangitis (more common in UC), cholangiocarcinoma

Derm: erythema nodosum, pyoderma gangrenosum

Oral: aphthous ulcers

Ocular: uveitis, iritis, episcleritis

MS: sacroilitis, arthropathy, AS, osteopenia

tender red nodules on the shins common in ___________ (and other inflammatory dz) = erythema nodosum

Crohn's disease

Common findings of ____________ on endoscopy:

punched out ulcers

edema to mucosa

cobblestoning

linear ulcers

Crohn's disease

What are some complications of Crohn's?

abscesses/fistulas, perianal dz, malabsorption, intestinal narrowing

Screening colonoscopy is recommended ________ after being diagnosed with Crohn's disease

8 years (increased risk of colon carcinoma), and yearly after that

Inflammatory disease that is limited to the mucosal layer of the colon and commonly begins in the rectum.

Ulcerative Colitis

UC that only involves rectum: __________

UC that involves sigmoid and rectum: __________

UC that only involves left side of colon: __________

UC that involves entire colon: __________

UC that involves distal ileum: __________

proctitis

proctosigmoiditis

distal colitis

pancolitis

backwash ileitis

What is the pathophysiology of __________:

Crypt architecture is distorted causing vascular congestion w/ edema (causing crypt abscesses)

Ulcerative Colitis

Patient comes in with bloody diarrhea and tenesmus. They have lower abdominal cramps. They have an INC ESR, hypoalbuminemia, and a (+) ANCA. What is most likely Dx?

Ulcerative Colitis

If a person w/ UC comes to ER w/ severe ABD pain, fever, hypotension, and tachycardia - what may be the cause?

fulminant colitis or toxic megacolon

**can also have altered mental status

Which diagnostic procedure is not very useful in Ulcerative Colitis and may precipitate toxic megacolon?

barium enemas

_________________ is CONTRAINDICATED with severe acute UC because of the risk of perforation & toxic megacolon

Colonoscopy

What are considerations in sexually active pts w/ proctitis

gonorrhea, chlamydia, herpes, and syphillis

What are some complications with Ulcerative Colitis?

colorectal cancer

Antibacterial and anti-inflammatory therapy that impairs folate absorption and induces remission in both forms of IBD (but is better in UC)?

Sulfalsalazine

**watch for sulfa allergy - rash, fever, hepatitis, pancreatitis

Sulfa-free ASA preps (5-ASA agents)

control the site of delivery to bowel & limit systemic toxicity

**usually used in UC

Sulfa-free ASA preps (5-ASA agents)

__________ - released into ileum (remission in CD and UC)

__________ - small intestine (distal colon)

________________ - for proctitis (retention enema)

Asacol - released into ileum (remission in CD and UC)

Pentasa - small intestine (distal colon)

Masalamine supp (Rowasa) - for proctitis (retention enema)

What can be used for acute treatment of Ulcerative Colitis when it is unresponsive to 5-ASA therapy or in the treatment of mod/severe Crohn's?

Glucocorticoids (ex. prenisone)

Typical SE from ___________________: striae, fluid retention, hyperglycemia, osteonecrosis

Glucocorticoids (ex. prenisone)

Immunosuppressive agents for glucocorticoid-dependent IBD? What is the most common side effect?

Purine analogues (Azathioprine & 6-mercaptopurine)

leukopenia (also may cause pancreatitis or hepatitis)

Folate antimetabolite that impairs DNA synthesis and can be used weekly (injections) for IBD?

Methotrexate

Which drugs are very effective against Crohn's?

Anti-tumor necrosis factor antibody (anti-TNF) drugs

ex. Cimzia, Humira, Remicade

What is the M/C continence-preserving operation for UC?

IPPA (ileoanal pullthrough, ileal pouch-anal anastomosis)

**rectal mucosa is dissected to dentate line and a pouch is created from the ileum to the neorectum

What is the difference between gastritis and gastroenteritis

gastritis is inflammation of the stomach only, and gastroenteritis includes the stomach and intestines

**both considered food poisoning

What is the difference between preformed toxins and microbes that produce toxins after ingestion?

Preformed toxins - bacteria makes toxins in food before consumption, vomiting usually involves (ex. S. aureus and B. cereus)

Toxins after ingestion - bacteria makes toxins in the GI tract, less vomiting (ex. C. perfringens)

Mild vs. severe diarrhea

mild = < 3 stools a day

severe = 4+ stools a day w/ systemic sx (fever, chills, dehydration)

Inflammatory diarrhea vs. non-inflammatory diarrhea

inflammatory: blood, small volume, invasion of colon, fever/tenesmus

non-inflammatory: non-bloody, water, large volume

Common pathogens involved in non-inflammatory diarrhea?

Viruses, enterotoxin producing E.coli, giardia, cryptosporidia, vibriones

Profuse watery diarrhea that is prolonged but self-limited (1 - 2 weeks) d/t food or water consumption - think: ____________

Acute Infectious Diarrhea

Patient with diarrhea and a recent hospitalization or abx use, think: ______________

C. difficile

Patient with diarrhea and recent foreign travel, think: ______________

Salmonella, Shigella, Campylobacter, E. coli, V. cholerae

Patient with diarrhea that consumed undercooked hamburger, think: ______________

E. coli 0157:H7

Patient with diarrhea that lives in long term care facility, attends school, or was on a cruise ship, think: ______________

Norovirus

Patient with consumption of fried rice, think:

B. cereus

For Sx of acute infectious diarrhea lasting beyond >1 week, initial onset of fever or bloody stools, &/or with immunocompromised pts, what should you order?

Stool culture

**WBC, O&P

Antibiotic Rx may be helpful with _______ or ________ infections

A. Norovirus; HSV
B. Shigella; Campylobacter

Shigella; Campylobacter

T/F Routine antibiotic use is NOT recommended for acute infectious diarrhea, as the disease is usually self-limiting.

TRUE

Abx if given w/ E.coli 0157:H7

Abx if given w/ C. diff

E.coli 0157:H7 - risk of HUS

C. diff - prolong dz

Patient comes in with diarrhea in June. They report drinking unpasteurized milk earlier in the week. What may be the cause?

Salmonella

**large numbers of Salmonella must be ingested to produce illness

Patient just got back from a trip overseas. They have developed diarrhea. Which highly virulent bacteria could be causing this?

shigella

Patient has diarrhea and vomiting after eating some raw veggies earlier this week. What could be the cause? What may be a complication?

Enterohemorrhagic Escherichia coli Serotype 0157:H7

Complication: HUS due to the cytotoxin (causing endothelial damage --> renal dz)

Should you give abx for E.coli 0157:H7 infection?

NO - contraindicated

**Blood diarrhea or HUS should always be tested for this bacteria

Patient presents w/ diarrhea and vomiting. She was eating a lot of protein-rich meals last week. What may be the cause?

S. aureus (due to enterotoxin forming strain in food before ingestion)

What are the three types of botulism?

food, infant, wound

**grows in anaerobic acidic environments

What is the treatment for C. botulinum infection?

IV polyvalent antitoxin (and mainstay airway/breathing)

Main causes of _________________:

Enterotoxigenic E. coli

Shigella species

Campylobacter jejuni

traveler's diarrhea

Someone w/ traveler's diarrhea may have an increased risk of developing: ______

IBS

What is the mainstay treatment for Traveler's diarrhea?

Azithromycin 1g (single dose)

What pathogen causes of Pseudomembranous Colitis? What type of bacteria is this?

Clostridium difficile

gram-positive spore-forming bacilli

Which Abx may cause Pseudomembranous Colitis? ("FACT")

FQs
Ampicillin
Clindamycin
Third (3rd) Gen Cephalosporins

What do the toxins in Pseudomembranous Colitis do?

Destroy colonic mucosa (cannot absorb anything) and create yellowish-white plaques on the mucosa

Patient presents with greenish, foul-smelling watery diarrhea. They have mucus in the stool but NO BLOOD. They have LLQ tenderness. They were taking Clindamycin last week for an infection. What may be the cause?

Pseudomembranous Colitis (PMC) caused by Clostridium difficile

What is the rapid test for Pseudomembranous Colitis (PMC)? What is the definitive test?

Rapid: PCR assay
Definitive: Cytotoxicity assay

How do you treat Pseudomembranous Colitis (PMC)?

d/c offending abx, give oral vanco (or fidaxomicin), and avoid anti-motility agents or narcotics

Consider: fecal microbiota transplantation

What can untreated Pseudomembranous Colitis (PMC) lead to?

weight loss, protein losing enteropathy (or can progress to fulminant dz, such as megacolon)

Why is relapse common with Pseudomembranous Colitis (PMC)?

re-infection or failure to eradicate organism; or spores re-create the dz

Diarrheal disease in infants in winter months, think: __________

Rotavirus

**fecal-oral

Diarrheal disease in school-age children that went on a cruise, think: __________

Norwalk virus

M/C protozoan causing GI infection, caused by drinking from stream water w/o filtering: ______________

Giardia lamblia

("aka beaver fever")

Patient presents with pale, explosive diarrhea two weeks after a camping trip. She reports drinking water out of the lake near her campsite without filtering. What is the treatment?

Metronidazol (Flagyl) or Tinidazole

**Giardia most likely
**Tx close contacts and report to Board of health

___________: hepatic artery, portal vein, bile duct

Portal triad

__________: wide, leaky ‘capillaries’ without basement membrane empty into central vein.

Sinusoids

___________: hepatic portal vein -->

liver sinusoids -->

central vein -->

hepatic vein -->

IVC -->

right atrium

Hepatic blood flow

Where is the blood supply for the liver?

hepatic artery & portal vein (dual blood supply)

Water-soluble or Lipid-soluble?

Direct (conjugated) bilirubin is _____ soluble

Indirect (unconjuated) bilirubin is _______ soluble

Water-soluble (Direct); Lipid-soluble (Indirect)

What is the function of bile?

emulsifies fats so they can be absorbed

**made by liver, stored in GB

________ secretion pathway

bile ducts -->

R/L hepatic ducts -->

common hepatic duct, which joints cystic duct -->

common bile duct, which joints w/ pancreatic duct -->

Ampulla of Vater

Bile

Fatty acids, amino acids in duodenum stimulate _______ causing gall bladder to contract and empty

CCK

**also relaxes Sphincter of Oddi

Acidic chyme stimulates __________ which causes bile secretion

secretin

LFT pattern in:

Hepatocellular dz: ________________

Cholestatic dz: ________________

A. INC AST, ALT (Hepatocellular dz)

B. Retention of bile in liver, INC ALP (Cholestatic dz)

INC AST, ALT (Hepatocellular dz)

Retention of bile in liver, INC ALP (Cholestatic dz)

When will ALT be 2x the AST (both elevated)?

Acute Viral Hepatitis

When will both AST and ALT be over 1,000?

Acute Acetaminophen Toxicity or Ischemic Hepatitis

Liver function tests are:

bilirubin, albumin, PT/INR

What will you order when you suspect Wilson's dz? What will you order if patient is also having anemia?

Ceruloplasmin

Fe/TIBC

Gold standard to stage liver fibrosis

liver biopsy

**can have small sampling error, and is expensive (w/ risks of pain and bleeding)

New non-invasive test to measure the velocity of sound waves passing through the liver to determine liver stiffness

fibroscan

A hereditary condition whereby the conjugation of bilirubin by glucuronide is impaired due to a mild decrease in uridine phosphate (or glycuronyl transferase)

Gilbert's syndrome

What will you see in labs w/ Gilbert's syndrome?

persistent elevation of unconjugated bilirubin (w/ illness, fasting, or drugs)


**does not require tx

Loss of hepatocellular function or interrupted blood flow through the liver is called?

Hepatocellular failure

______ of the liver must be destroyed before life is threatened

80%

In hepatocellular failure, ↓ production of clotting factors & hypoalbuminemia → generalized _________

Edema

In hepatocellular failure, fluid and electrolyte shift due to lack of proteins - change in osmolality --> _________

Ascites

What will cause impaired absorption of vitamins A, D, E, and K from the GI tract?

decreased production of bile salts

Impaired processing of endogenous steroid hormones in hepatocellular failure cause in men? Women?

men: gynecomastia, impotence, testicular atrophy

women: irreg menses, palmar erythema, spider telangiectasia