GIGU quiz 3 celiac, fatty liver, pancreatitis, cholelithiasis, cholecystitis

what is celiac disease

digestive disorder that damages small intestine

autoimmune sensitivity to gluten that causes T cell activation

what is the component of gluten that causes sensitivity

gliadin

what is the damage caused to the small intestine by celiac disease

villi atrophy (blunting)

what breads have gluten?

wheat, barley, rye

what are the risk factors for celiac disease

family history

caucasians (yt)

females

for celiac disease some patients are ______ or have signs of ______

asymptomatic

nutritional deficiency

what are symptoms of celiac disease in children

failure to thrive (low on growth charts)

delayed puberty (system not receiving all nutrition)

hypotonia (low muscle tone)

pallor (pale from low nutrients)

[gas, nausea, vomiting

stomach pain]

-anorexia

chronic diarrhea

muscle wasting

steatorrhea (soft, bulky, light colored stools) & offensive

abdominal distention (fermentation of food not broken down)

what are symptoms of celiac disease in adults

anemia

weakness

lassitude (lack of energy/desire)

*dermatitis herpetiformis*

glossitis

-steatorrhea (fatty stool)

angular stomatitis/*chilitis*

apthous stomatitis

bone softening dx (bcus Ca2+ and VitD deficient)

anorexia

chronic diarrhea

what is dermatitis herpatiformis

lesions of skin

symmetric vesicles, crusts, and erosions

EXTENSOR surface of elbow, knee, shoulder, scalp

tend to group individual lesions

what is glossitis

inflamed/swollen red tongue

what is chilitis?

cracked lips at corners of mouth

(angular stomatitis)

what is apthous stomatitis?

ulcer in the oral mucosa

(seen before with crohn's & uc)

what are exam findings of celiac disease

-palpation/percussion over abdominal region could produce pain and indicate fullness or swelling

-check for skin rashes (dermatitis herpetiformis)

-check teeth for enamel defects

-check lips

(relate to adult symptoms)

what are special tests for celiac disease

upper GI endoscopic exam looking for abnormalities and biopsy (duodenum & jejunum)

blood test

what are blood tests looking for for celiac disease

*tTG-IgA (anti-tissue transglutaminase antibodies) --> IgA deficiency -> then check IgG

-anti endomysial antibodies (endomyseal cells are #1 attacked)

-anti gliadin antibodies (immune factors that attack it)

which blood test is best for celiac disease

*tTG-IgA

most sensitive

what is fatty liver

liver stores excess fat

what are the two types of fatty liver

simple fatty liver

NASH (non alcoholic steato hepatitis)

another name for NASH

non-alcoholic fatty liver disease

what is simple fatty liver

accumulation of fat in the liver, detected easy

little to no inflammation

-untreated turns into NASH

what is NASH/NAFLD

fatty liver now has increased inflammation as hepatocytes start to die

-untreated develops into cirrhosis

T/F: both forms of fatty liver are reversible

true

fatty liver is found in 40-80% of people who have _______ and 30-90% of _____ people

type 2 diabetes

obesity

what age group is affected by fatty liver

any

what percent of US children 2-19 get NAFLD

10%

what are the risk factors for fatty liver

obesity

diabetes

metabolic syndrome*

high triglycerides

what is *metabolic syndrome

high BP

low HDL

high blood sugar

high blood triglycerides

large waist circumference

fatty liver is typically a ______ disease

silent

even for NASH

what are symptoms for NASH when they are present

tiredness or discomfort in RUQ

does fatty liver have symptoms

no

what are exam findings of fatty liver

excessive weight

BMI measurement

percussion or palpation revealing enlarged liver

*signs of insulin resistance* --> acanthosis nigricans~

what is acanthosis nigricans~

darkened skin patches over neck, knuckles, elbows, knees (folds of the skin)

what are special tests for fatty liver

blood tests

Ultrasound

CT scans

MRI

biopsy

what does blood test show for fatty liver

high ALT (alanine trans am) and AST (aspartate trans am)

(both high together indicate liver inflammation/issue)

what are findings of ultrasound for fatty liver

enlarged liver

what are findings of fatty liver on CT

fibrosis

(maybe enlarged liver)

what are findings of fatty liver on MRI

fatty infiltration

possibly fibrosis

what is *needed* to confirm diagnosis of fatty liver

biopsy

what is cholelithiasis

gallstones in the gallbladder

ranging from size of grain of sand to golf ball

what are the main types of cholelithiasis

cholesterol and bilirubin stones

what percent of the US population have cholelithiasis

10-15%

what is the most common type of cholelithiasis

cholesterol - 85%

what are the different types of cholelithiasis

cholesterol stones

black stones

brown stones

biliary sludge

what are cholesterol stones

larger

composed of cholesterol {monohydrate} and bile

radiolucent --> not visible on xray

What are black stones?

small, smooth, HardesT

composed of inorganic calcium salts and bilirubinate

radioopaque --> seen on xray

what are risk factors for black stones

Age

alcoholism

blood disorders --> hemolysing disorders (hemolytic anemia)

what are brown stones

softer and greasy

composed of bilirubinate (bilirubin and calcium) and fatty acids

what are risk factors for brown stones

Infection -> *parasite*

what is biliary sludge

thick, viscous fluid

composed of combo of bilirubinate, cholesterol, mucin

(can accumulate and cause blockage -> inflammation)

what are risk factors for biliary sludge

pregnancy (10%)

[female]

most cholelithiasis have _______

no symptoms (80%)

what are risk factors for cholelithiasis

females (because of hormones)

older population

family history

american indians, mexican americans

cirrhosis, hemolytic anemia (black stones), IBD (crohn's - ileum), metabolic syndrome'

high triglycerides

diabetes

obesity

rvw: metabolic syndrome'?

'high BP

low HDL

high blood sugar

high blood triglycerides

large waist circumference

what are symptoms of gallbladder attack/biliary colic

pain in abdomen lasting several hours (about 6 hours, into an ache for 1-2 hours)

nausea and vomiting

fever

jaundice or clay colored stool (from high bilirubin)

what are exam findings for cholelithiasis

none unless gallbladder atttack

what are exam findings for gallbladder attack/biliary colic

abdominal guarding

(right abdomen)

Murphy sign - positive (stop inhaling due to pain "suspended inhalation")

fever, tachycardia, and diaphoresis (sweating)

absent bowel sounds -> paralytic ileus

what are special tests for cholelithiasis

ultrasound - standard to see stones

CT scan - better to viz

MRI

*cholescintigraphy* nuclear medicine test with contrast (kinda like dye with MRCP)

what special tests are used for cholelithiasis when there are complications

*cholescintigraphy* to see obstruction

[ERCP - catheter can go into duct]

rvw: if a person has gallstones in gallbladder, but no inflammation, what would they be diagnosed with

cholelithiasis

what is cholecystitis

inflammation of gallbladder

what does cholecystitis involve 90% of the times

gallstones

why are gallstones usually the cause of cholecystitis?

damage the gallbladder wall

obstruction causing pressure increase = damage

what are the causes for the other 10% of cholecystitis

major surgery

severe trauma

sepsis

what are risk factors for cholecystitis

increasing age

females

obesity/rapid weight loss

drugs

pregnancy

[sepsis/infection

undergone severe trauma]

what percent of american have gallstones, and how many develop acute cholecystitis

10-20%

1/3 develop it (33%)

what is the pathology of cholecystitis

Severe blockage -> distention -> low flow of blood/lymph -> low O2 -> cell death = inflammation

(Bad = surgery, 500k/yr)

what are symptoms of cholecystitis

pain in RUQ lasting for hours to days

pain radiates to shoulder blade --> Boas sign

(pain radiates to the back)

pain after eating a fatty meal (CCK causes gallbladder contractions)

nausea, vomiting

fever

[clay colored stool

jaundice]

what are exam findings of cholecysitis

fever

tenderness of

jaundice - 15%

Murphy's sign - positive (stop inhaling due to pain "suspended inhalation")

Otner sign

Boas sign

what is otner's sign

exacerbation of RUQ pain when percussing R costal arch (ribcage)

what is boas sign

pain radiates to R scapula (shoulder) from gallbladder

what are special tests for cholecystitis

*abdominal ultrasound

*abdominal CT

blood test

what does an abdominal ultrasound show for cholecystitis

peri cholecystic fluid --> fluid surrounding gallbladder

thickened gallbladder wall

what are you looking for with a blood test for cholecystitis

amylase and lipase elevated (pancreas damage)

bilirubin - elevated from inability of gallbladder to eliminate bile (liver or gallbladder issue)

liver function test - looking at AST and ALT

(less direct diagnostic, more to see the full picture)

what is pancreatitis

inflammation of the pancreas

what forms of pancreatitis are there

acute --> resolves/reversible

chronic --> irreversible, permanent impairment of pancreatic function

what is the pnuemonic for pancreatitis risk factors

GET SMASHED

what are risk factors for pancreatitis

Gallstones; biliary stones

Ethanol (alcohol)

Trauma

Steroids (hurt liver + pancreas)

Mumps / coxsackie B / CMV)

Autosomal mutations (pancreas genes - trypsinogen issue)

Snake / scorpion venom (bites)

Hypertriglyceridemia, hypercalcemia [hyperglyceridemia]

ERCP (can damage ducts)

Drugs (ACE inhibitors, Sulfa drugs)

which 2 risk factors cause the most pancreatitis

Gallstone; biliary stones

Ethanol

what does ERCP stand for

endoscopic retrograde cholangiopancreatography

what population is more at risk of pancreatitis

men

African Americans

family history

what are symptoms of pancreatitis

pain in *upper abdomen* lasting for several days

pain radiates to back (50 %)

chronic may not have as much pain

fever

vomiting

nausea

fatty stools/diarrhea (less enzymes for fat digestion)

what are exam findings of pancreatitis

inspecting and palpating abdomen --> see swelling and produce pain

grey turner sign

cullen sign

*patient sitting up, then leans forward --> pain decreases

what is Grey turner sign

bruising ("hemorrhagic discoloration") at flanks

What is Cullen sign?

bruising ("hemorrhagic discoloration") around umbilicus

what are special tests for pancreatitis

blood test

stool test

ultrasound

CT scan

MRI

fecal elastase - stool test

pancreatic function test

what is seen with a blood test for pancreatitis

elevated amylase and lipase (pancreas makes -> if high can leech into blood)

elevated triglycerides

what is seen with a stool test for pancreatitis

fatty stool due to lack of pancreatic lipase

what is a fecal elastase stool test

elastase is a resilient enzyme produced by pancreas to help breakdown protein --> low = pancreatic insufficiency

what is a pancreatic function test

provocation test

- stimulate pancreas with an IV of secretin hormone and measure how much secretion is releases

(-evaluates pancreatic insufficiency)