CLinical Skills II - GI

what factors can contribute to the prevalence of colorectal cancer

persoanl hx of colorectal ca, pts with polyps, pts with ulcerative colitis, Crohn’s, fam hx of ca before 60

how to diagnose colorectal ca

colonoscopy, bc it has the highest sensitivity. Can remove polyps to be examined for ca.

what is the purpose of the fecal immunochemical test (FIT)

looks for blood in stool. done at home and sent to lab. Lower sensitivity than colonoscopy but more specific than FOBT

Driver mutations like APC, TBFBR2/SMAD4 and some BRAF mutations were all identified in what kind of colorectal screening

Combo of FIT and DNA tests for colorectal ca that was delivered into stool when large intestine tumors exfoliate into the stool

what is the purpose of a CT colography

more effective and better tolerated by pt than double contrast barium enema. Bowel prep needed and visit to imaging. Used for screening colorectal ca

what are the disadvantages of flexible sigmoidoscopy

limited protection against right sided colon cancer bc it only covers the left. But you need a much more limited bowel preparation

When would we perform a capsule colonoscopy

Imaging proximal colon in pts w previous incomplete colonoscopies. Downside is bowel prep is more extensive than for colonoscopy so less appealing to do

pt has hx of ulcerative colitis or Crohn’s. how often shoudl they get a colonoscopy?

every 2 years

Pt has average risk for colorectal cancer. What screening processes do they go thru for a compliant pt.

Annual test for fecal occult, do fit. Colonoscopy recd every ten yrs. DNA and FIT combo done at one to 3 yr intervals

Pt has average risk of colorectal cancer. They don’t want to pursue the normal screening. What do you rec doing

Ct colonogrophy every 5 yrs and DNA-FIT test every 3 yrs, and flexible sigmoidoscopy 5-10 yrs.

Pts with ulcerative colitis or crohn colitis should have a colonoscopy how often

Every 2 years

If I have a first degree relative under 60 with colorectal cancer then how often should I get a colonoscopy

Every five yrs

Pt has elevated ALT, AST, and LD. this is indicative of what dz

Hepatocellular dz

Pt has elevated ALP, GGT, 5’-NT. this is indicative of what dz

Biliary tract dz

if the nl ALT is 40 and the pt has 120, how would you describe this inc

3x above the upper limit of nl

elevations of ALT and AST are charaterstic of

hepatocellular dz

AST is more elevated than ALT in what dz

chronic liver dz from chronic alcohol abuse

ALT is mostly found in

liver, kidney, skeletal and cardiac muscle

is AST or ALT more specific for the liver 

ALT

If the AST to ALT ratio is greater than 2 in chronic liver dz then what can be the cause

alcoholic liver dz

Why is LD not the best marker for liver dz

bc it’s also released in injury of other tissues like RBC hemolysis

ALP is greatly inc than ALT, AST, or LD in what dz

biliary tract dz

alp is elevated in

children bc skeleton is growing, or in bone dz with osteoblasts (metastatic ca, Paget disease of bone), hyperparathyroidism where it stims osteoblasts to inc bone resorption, ileal dz, 3rd trimester of pregnancy bc of placenta

ggt is sourced in the

prox convoluted tubule of kidney, liver, pancreas, and intestine.

common causes of acute hepatocellular dz

viral hep a, b, or c. Alcoholic hep, toxic injury, ischemic injury

common causes of chronic hepatocellular dz

viral hep b or c, drug tox, alc liver dz, NAFL dz

NAFL dz can progress to

nonalcoholic steatohepatitis (NASH), cirrhosis, liver failure, hepatocellular carcinoma

this material is derived from hemoglobin in nl turnover of RBCs, and sometimes myoglobin and from cellular cytochromes.

bilirubin

another term for jaundice is

icterus

if the ratio of the conjugated bilirubin to total bilirubin is less than 0.4 what is represented

unconjugated hyperbilirubinemia

if the ratio of the conjugated bilirubin to total bilirubin is 0.4 or greater what is represented

conjugated hyperbilirubinemia

causes of unconjugated hyperbilirubinemia

prehepatic aka RBC destruction, defects in transport of unconjugated bilirubin into hepatocyte, defective conjugation

mild - moderate and transient unconjugated hyperbilirubinemia, physiolopgical jaundice, breast milk jaundice, persistent unconj hyperbilirubinemia, crigler-najjar syndrome types I (severe) and II (mild). these are all what kind of dz

newborn dz’s of unconjugated hyperbilirubinemia w/o hemolysis

gilbert syndrome is what type of dz

child or adult dz of unconjugated hyperbilirubinemia w/o hemolysis

what are the 2 main problems that cause conjugated hyperbilirubinemia

hepatocellular disorders with dec transport of conjugated bilirubin into bile dict. anatomic biliary tract obstruction

Dubin-Johnson syndrome and Rotor syndrome are similar in that they

produce nl liver function but conjugated hyperbilirubinemia

how to distinguish Dubin-Johnson and Rotor syndromes

urine testing for coproporphyrins and coproporphyrin I bc they’re nl in Rotor not Dubin Johnson

Complement, MBL, CRP, alpha-1 acid glycoprotein, SAA are all elevated in what problem

positive acute inflammation phase reactants synthesized in liver. immune related

A1-AT and A2M are what and elevated in what process

positive acute inflammation phase reactants synthesized in liver. antiproteases/antienzymes 

Ceruloplasmin, coag factors, fibrinogen, factor VIII are what and elevated in what process

positive acute inflammation phase reactants synthesized in liver. antioxidants

elevated HBV e antigen (HBeAg) indicates what dz process

chronic HBV infection and inc infectivity. e = infectious

elevated HAV IgM antibody indicates what dz process

acute infection with HAV. Not indicated from vaccine.

the outcome of any chronic disorder of the liver parenchyma or intrahepatic biliary trat that causes continous or repeated episodes of cellular necrosis and inflammation which is then repaired with fibrosis

cirrhosis

msot common cuase of cirrhosis in western countries is

ethanol abuse

most pancreatic ca arise from what aprt of the pancreas

exocrine pancreas, called adenocarcinomas

what part of the pancreas gets cancer the most

the head, leading to painless jaundice. exocrine tumors are usually adenocarcinomas

_____ the most common exocrine disorder and _____ is the most common endocrine disorder

pancreatitis, diabetes

lethal d//o assoc with intracellular activation of digestive enzymes in the pancreas

acute pancreatitis

top 3 causes of acute pancreatitis

biliary tract obstruction, alcohol abuse, and idiopathic

abdominal pain, characteristic radiologic findings, elevated lipase and/or amylase. also can find leukocytosis, hypocalcemia, hypoglycemia, elevated c reactive protein. these findings can lead to a dx of

acute pancreatitis

why does lipase have better test characteristics than amylase for pancreatic dz

more organ specific than amylase, and can peak sooner and decline later

abdominal and thoracic malignancies, biliary dz, dissecting aortic aneurysm, GI viscus perforation, head trauma w intracranial bleeding are all dz that can be grouped as what

hyperamylasemia not assoc w acute pancreatitis

biliary dz, DKA, HIV infection, pancreatic carcinoma, pseudocyst, renal failure are all dz that can be grouped as what

hyperlipasemia not assoc w acute pancreatitis

pt has >55 yrs, WBC >15k, LD >600, glucose >180, albumin >3.2, calcium >8 etc. are all features that are assoc with a better or worse prognosis

worse

thid dz follows an attack of acute pancreatitis and is considered this if an attack happens 2x or more. the pt can have a full recovery, may suffer permanant damage, or suffer with multiple attacks and significant organ damage.

chronic pancreatitis

pts w chronic pancreatitis usually have what other issues

impaired glucose tolerance (IGT) or diabetes. also abdominal pain, weight loss, pancreatic calcifications on x ray, and steatorrhea

most pancreatic cancers are what type

adenocarcinoma

tumor marker for pancreatitc ca is

CA 19-9. in adult and fetal pancreas, esophagus, stomach, small intestine, gallbaldder, bile duct, and salivary glands

this pancreas neoplasm lab studies show blood glucose, c peptide, insulin, and the insulin to glucose ratio are all changed.

beta cell tumors (insulinoma)

these pancreatic tumors are associated w a characteristic migratory erythema, as well as glucose intolerance, weight loss, DVT, and depression

alpha cell tumors (glucagonoma)

these tumors are associated w diabetes related sx, diarrhea, steatorrhea, cholelithiasis, and weight loss. most often located in the duodenum or jejunum instead of pancreas

delta cell tumors (somatostatinoma)

tumors in this area of the pancreas that secrete gastrin are found in the pancreas and duodenum w higher incidence in pancreas.

pancreatic islets

this tumor has sx of inc gastric acid secretion, diarrhea, and malabsorption (zollinger ellison syndrome)

pancreatic islets tumors

these pancreatic tumors include a syndrome of watery diarrhea, hypokalemia, hypochlorhydria, and acidosis

VIPomas

hyperglycemia due to defects in insulin secretion, action, or combo of the 2.

DM

what are the criteria for dx of DM

HbA1c >/= 6.5% or fasting plasma glucose >/= 126, no caloric intake for 8 hr. or 2h plasma glucose value >200 during OGTT using 75g glucose dissolved in h2o. or pt w classic sx of hyperglycemia or crisis, random plasma glucose value >200

what are the criteria for prediabetes

fasting plasma glucose 100-125 using impaired fasting glucose (IFG). or 2h plasma glucose in OGTT 140-199 using impaired glucose tolerance (IGT). or hemoglobin A1c 5.7-6.4%

what are the criteria for GDM with 1 step strategy

75g OGTT test at fasting (>92), 1 (>180), and 2 hrs (>153) at 24-48 wks gestation.

what are the criteria for GDM with 2 step strategy

50g OGTT, if inconclusive then move to 100g OGTT and monitor at fasting (105), 1 hr (190), 2 hr (165), 3 hr (140)

how can you use random plasma glucose to dx DM

at least 8 hrs plasma glucose level of 200, + DM sx

what are conraindications to testing for DM

if pt has acute illness, surgery, hospitalization in past 8 wks bc false pos can happen. 

FPG greater than or equal to _____ = diagnostic for diabetes

126

this test is a stim test that assess a pts glycemic repsonse after given a standard dose of glucose under standardized conditions

oral glucose tolerance test

in an OGTT a 2 hr postbolus FPG level of ____ is dx of DM

200

retinopathy incidence inc at HbA1c levels b/w

6-7%

pt has impaired fasting glucose (IFG) and FPG of 100-125 and those with IGT post OGTT have glucose in 140-199.

prediabetes

trace excretion of urinary albumin (microalbuminuria) is measured in pts with DM as an early marker of 

nephropathy, also order creatinine level on urine specimen.