GIGU week 4+5 MT 1 (Diverticulitis - Meckel’s Diverticulum)

Diverticulitis vs diverticulum

Diverticulum is an outpouching of intestinal wall but diverticulitis is when those outpouchings create perforations in the wall of the diverticulum releasing bacteria (inflammation)

Which part of intestine does diverticulitis affect the most and why

The sigmoid, has the S-curve —> where food can get stuck

What do we need to be concerned with diverticulitis (4)

Inflammation, obstruction, fistula and bleeding

___% of the time, there is no inflammation with diverticulum's

70

The other 30% of the patients with diverticulum then have...

Diverticulitis

Diverticulitis is ___ for 40 years and under, but ____ for 80 and older

Uncommon, guaranteed

What % of diverticulitis pt have painless bleeding

10-15%

Risk factors for diverticulitis (4)

1. Low fiber*

2. Low exercise

3. NSAIDs

4. Obesity

Symptom of diverticulitis

Abdominal pain in lower left quadrant (sigmoid)

If the diverticulitis pt has an obstruction, what symptoms would they have along with the lower left quadrant pain

Nausea and pain

Signs of diverticulitis (3)

1. Pn and tenderness in lower left quadrant with palp

2. Fever (if inflammation present)

3. Peritoneal signs if abscess or perforation present

What peritoneal signs are present with diverticulitis (2)

1. Pt is in a great amount of pain

2. High fever

4 special tests for diverticulitis

1. Abdominal CT with contrast (least invasive)

2. Colonoscopy

3. Stool sample (WBC, fat, blood, bacteria)

4. Exploratory laparotomy (most invasive)

Pancreatic cancer primarily affects the exocrine portion of the pancreas, making it ___ ____

Ductal adenocarcinoma

Pancreatic cancer is usually found early T/F

False

80% of pancreatic cancer occurs on which part of the pancreas

The head

Population affected by pancreatic cancer

Age 55 with average at 70, men more than women

risk factors of pancreatic cancer (4)

1. Smoking

2. Long term diabetes

3. Chronic pancreatitis

4. Obesity

At what stage in cancer does Mets occur

Stage 3

Symptoms usually occur ___ which means the cancer has ___

Late, spread

3 symptoms of pancreatic cancer

1. Upper abdominal pain radiating to back

2. Pn may be relieved by bending forward

3. Unexplained weight loss

5 signs of pancreatic cancer

1. Jaundice

2. Splenomegaly (splenic veins run along pancreas, can get blocked)

3. Development of diabetes

4. Gastric or esophageal varices

5. Courvoisier's sign

What is courvosier's sign

Enlarged palpable gallbladder + jaundice but non tender

5 special tests for pancreatic cancer

1. CT

2. ERCP

3. MRCP

4. Biopsy

5. Blood test (bilirubin + alkalinephosphatase for duct bleeds from pancreas)

Cirrhosis is ___ stage liver disease

End

Most common risk factors for cirrhosis (3)

Alcoholism (MC)

Viral hepatitis

NASH

What is NASH

Non-alcoholic steatohepatitis

How many grams of alcohol for how many years lead to cirrhosis

80g for 10-20 years

Complications of cirrhosis (5)

1. Portal hypertension leading to edema/ascites and varices and splenomegaly

2. Hepatic encephalopathy

3. Sensitivity to medications (med half-lives increase)

4. Insulin sensitivity

5. Liver cancer

How does portal hypertension lead to edema/ascites, varcies and spenomegaly

-Increased portal vein pressure causes water and albumin to leak out, leading to edema/ascites AND hypoalbuminemia

-Veins are dilated because of high pressure (esophageal varcies most deadly)

-Splenic vein gets blocked from portal hypertension

Hepatic encephalopathy def

Liver has a problem with metabolism, accumulated bilirubin can cross blood brain barrier —> encephalopathy

Hepatic encephalopathy can lead to what other two things

Gall stones and decreased clotting factors (bruise easily)

Symptoms of cirrhosis

Fatigue

Weakness

Itching

Loss of appetite

Weight loss

Nausea

Exam findings for cirrhosis (11)

1. Edema

2. Ascites

3. Spider hemangiomata

4. Jaundice

5. Palmar erythema

6. Muehrcke's nails

7. Terry's nails

8. Gynecomastia (liver can't break down hormones)

9. Hypogonadism (decreased sex drive for males and infertility for females)

10. Fetor oris

11. Dupuytren's contracture

Spider hemangiomata def

Red cobwebs on skin due to liver not breaking down hormones (ex: estrogen causes vasodilation) —> can lead to palmar erythema too

Muehrcke's nails

Horizontal bands

Terry's nails

Prox 2/3 white, distal 1/3 red/brown from hypoalbuminemia

Dupuytren's contracture

progressive, inherited hand disorder where the palmar fascia thickens and tightens, forming cords that pull fingers—usually the ring and little fingers—inward toward the palm

What things will we see abnormal levels with blood tests for cirrhosis

-high liver enzymes

-high bilirubin

-high creatinine (kidney failure)

-low albumin

-prothrombin time increased (clotting factor)

-detection of viruses (hep b and c)

MELD score for cirrhosis

3 month mortality rate (high score = low mortality rate)

CPT score for cirrhosis

Prognosis for 1-5 years (high score = liver is very diseased)

-take bilirubin, albumin and prothrombin levels and put into equation

What imaging and tests do we do for cirrhosis

CT, ultrasound, MRI and biopsy

Hepatitis A cause

RNA picronavirus

How is hep A transmitted

Fecal oral

Is intubation period fast or slow for hep A

Very fast (2-6 weeks)

1 in ____ people affected by hep A every year

6000

Is hep A self limiting? What does this mean

Yes, can get over it by themselves, no need to get treatment

Is there chronicity with hep A

No, due to it being self limiting

What're the symptoms of hep A

Most have no symptoms, but if they do, they feel like they have the flu. Also may show jaundice (increased bilirubin in blood), dark yellow urine, grey/pale stool (decreased bilirubin due to blockage)

Test for hep A

Blood test for antibodies of HAV

Hepatitis B cause

DNA virus

How is Hep B spread

Blood or bodily fluids

What % of pt become chronic carriers

5%

Is there vaccine for Hep B

Yes

Symptoms for hep B

Some have none but if they do, they have jaundice, dark yellow urine, grey stool, joint pain (due to chronicity), nausea, abdominal pain

Tests for hep B

Blood test for antigen/antibodies, transient elastography (ultrasound), liver biopsy

Is there cure for Hep B

No, only treatments

Hep C cause

RNA flavivirus

How does Hep C spread

Blood to blood transmissions (not bodily fluids)

Hep C is a major cause of what

Chronic liver disease worldwide

How many US people are affected by Hep C

4 million

Once exposed, ___% will have chronic liver disease

85%

Will people be asymptomatic with Hep C like B and A?

No, will always have symptoms

What symptoms show for Hep C

Dark yellow urine, jaundice, joint pain, grey stool

Test for Hep C

Blood test for HCV, ultrasound, liver biopsy

Is there a cure for Hep C

Yes

Hep D is what kind of virus

RNA which is replication defective, so only infective if assisted by Hep B

What two infections can you have with Hep D

-Confection: lead to resolution and immunity

-Superinfection: greater mortality and morbidity (chronic carrier with Hep B AND other viruses)

Most common primary liver cancer is

Hepatocellular carcinoma

It is more common to have cancer of the liver from ___ ___ from other organs than cancer...

Metastatic spreads, originating in the liver

Why is liver a common metastatic site

Liver constantly having blood and lymph running through it

What cancers metastasize to the liver (4)

Lung, breast, colon, prostate

Risk factors for liver cancer (4)

-chronic infection (Hep B + C, cirrhosis)

-alcohol

-obesity

-diabetes/NASH

Symptoms of liver cancer

Non specific in beginning but later symptoms include bloody ascites, friction rub, upper abdominal pain

Signs of liver cancer (4)

-weight loss (unexplained)

-right upper quadrant pain

-fever may occur

-swelling of abdomen (ascites)

Lab tests for liver cancer may help but are ___ ___

Rarely conclusive

Liver cancer shows elevated levels of ____ ____

Alpha-fetoprotein

what is alpha-fetoprotein

Normal protein found in infants, but not normal in adults

Which test would be best for liver cancer

Biopsy

What would blood tests show for liver cancer (3)

-decreased blood sugar

-increased RBC

-abnormal calcium levels

Meckel's diverticulum is a congenital abnormality of the...

Ileum

T/F Meckel's is the most common congenital anomaly of GI tract

True

Meckel's diverticulum is a remnant of the....

Vitelline duct (fetal yolk sack connection to digestive tract)

Meckel's usually occur within ___ feet of the ileocecal valve

3

Meckel's is prevalent in ___ of the population

2%

Only ___% of people with Meckel's have symptoms

2%

Why would patients with Meckel's show symptoms

Could have cells that are similar to cells in stomach that produce acid which leads to inflammation

Only ___% of Meckel's pt have complications

2%

What are the complications of Meckel's (2)

-Inflammation which leads to obstruction which can lead to erosions which lead to bleeding

-Tumors

MC complication of Meckel's in young adults

Obstruction

MC complication of Meckel's in adults

Intussesception (telescoping)

Symptoms of Meckel's

Usually asymptomatic, if symptomatic —> abdominal pn

Signs of Meckel's

If symptomatic: abdominal tenderness around or below umbilicus

If complain of pain in middle of abdomen, which special test do you do

CT scan with contract medium

If theres bleeding, what special test do you do

Colonoscopy

If suspected bleeding due to Meckel's, what special test do you do

Tc pertechnetate scan (goes higher up in GI tract compared to colonoscopy)

What does Tc pertechnetate scan do

Cells that produce HCl take up pertechnetate and concentrate it —> look to where it concentrates on CT scan