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2018 Awesome rev > 2018 Gastroenterology 9% > Flashcards

2018 Gastroenterology 9% Flashcards

1
Q

Chest pain intermittent unrelated to exertion no reflux symptoms retrosternal pain seconds to minutes corkscrew on x-ray dysphasia to both liquids and solids

A

Diffuse esophageal spasm treat with calcium channel blockers/ppi - multiple simultaneous contractions on manometry

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2
Q

Many month history of dyspepsia looking like Gerd no alarm symptoms no physical exam abnormality what is treatment

A

Proton pump inhibitor

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3
Q

Treatment of new onset severely active Crohn’s disease

A

Antitumor necrosis factor therapy like infliximab is best and better than immunomodulators such as mesalamine because Crohn’s disease is transmural

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4
Q

Treatment of severe alcoholic hepatitis

A

Mandry discriminant function score of greater than 32 benefit from pentoxifylline if corticosteroids are contraindicated - like with kidney failure G.I. bleed active infections

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5
Q

How long to keep patient in hospital after high-risk peptic ulcer and a scopic treatment

A

72 hours - takes this long for high-risk peptic ulcer to become peptic ulcer

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6
Q

Patient with G.I. bleed due to angioectasias and aortic stenosis

A

replace aortic valve - heyde syndrome e - mechanical destruction of von Willebrand multimers during non-laminar flow through narrow aortic valve

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7
Q
  1. Young patient w/ hx of food impaction, happened several times before. EGD: #1 stacked concentric rings OR #2 crepe paper sign OR #3 mucosal fragility OR #4 mucosal fragility. history of allergies. Eosinophils on bx. Empiric PPI started and no response after 8 wks, repeat bx reveals eosinophils. dx? next step?
A

Eosinophilic esophagitis (???common in young pt w/ hx allergies???)

next step in management = SFED (Six food elimination diet)
milk, wheat, eggs, nuts, soy, seafood

still symptoms –> budesonide

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8
Q
  1. Pt p/w dysphagia, EGD is normal (#1), barium swallow reveals diffuse dilation (#2), and narrowing of the lower esophagus. Most likely dx?
A

Achalasia

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9
Q
  1. Pt p/w complaints of regurgitating food eaten several days ago. occasional dysphagia. halitosis +. dx? test?
A

dx: Zenkers diverticulum (pouch in hypopharynx)

test = barium swallow

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10
Q
  1. pt p/w pain on swallowing (odynophasia) for more than 10 days. wtd? … etio?
A

EGD o rule out esophagitis

consider pills (Doxy., alendronate, ASA)
radiation therapy
infections ( Candida CMV herpes)

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11
Q

8./9. HIV + patient with oral thrush complaining of odynophasia. wtd?

A

empiric tx w/ fluconazole/itraconazole. No need for EGD.

No response to empiric, wtd? EGD to r/o CMV (one large ulcer), Herpes (several ulcers), Candida

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12
Q
  1. Pt w/ hx of long standing heartburn for several years now, p/w progressive dysphasia to solids . most likely dx?
A

Peptic stricture

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13
Q
  1. 70yo M dx w/ stroke. hemiparesis + on left side. cranial nerves intact. Pt has coughing and choking sensation, w/ regurgitation of fluids through nose. best diagnostic test
A

Video fluoroscopic swallowing study ( modified barium swallow)

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14
Q

12./13. Pt w/ heartburn OR nocturnal cough and wake up with water brash. not relieved by antacids. Best initial dx step ..

A

empiric PPI challenge. NO EGD. NO barrium swallow.

if pt feels better 3months later on PPI wtd?
continue PPI at lowest dose or switch to H2 blocker

If pt does not get better on PPI, wtd?
EGD while pt taking PPI

if EGD reveals no esophagitis, wtd?
ambulatory pH monitoring

if ambulatory pH monitoring shows approx 2 min of reflux in 24 hrs, wtd?
citalopram

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15
Q

14./15./16. Pt w/ heartburn OR nocturnal cough and wake up with water brash. not relieved by antacids.

If patient doesn’t get better with PPI…

A
  1. EGD while pt taking PPI

EGD - if no esophagitis then ambulatory pH monitoring
- if approx. 2 minutes of reflux on 24hrs then likely psychiatric give citalopram

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16
Q
  1. Pt w/ heartburn not responding to antacids and w/ weight loss. wtd?
A

EGD

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17
Q
  1. Can tx w/ PPIs or fundoplication sx reverse epithelial changes of Barrett’s??
A

No

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18
Q
  1. Pt p/w severe retrosternal chest pain. worse with swallowing and breathing - chest x-ray with left pleural effusion subcutaneous emphysema. amylase level increased. dx?
A

dx: Esophageal rupture

diagnosed with Gastrografin swallow study

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19
Q

H.pylori testing…

A

Nonendoscopic

  • Antibody test. for dx. no value for f/u
  • Urea breath test. dx and f/u
  • Fecal antigen test (Most sen***). dx and f/u

[????urea breath test and fecal antigen test. false negative on PPI or GI bleed.???]

Endoscopic.

  • To culture for resistance pattern histology.
  • Urease testing.
  • Gold standard but expensive af.
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20
Q

H.Pylori treatment regimens…

A

PAC for 14 days.

  • P –> PPI ( Omeprazole, Lansoprazole, Rabeprazole)
  • A –> Amoxicillin
  • C –> Clarithromycin

MOC for 14 days

  • M –> Metronidazole
  • O –> Omeprazole
  • C –> Clarithromycin
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21
Q
  1. for recurrance of sx, wtd? –> order urea breath test, if positive, then …
A

tetracycline
metronidazole
bismuth salicylate
and PPI

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22
Q
  1. Who would u test for h.pylori
A

45 yo w/ abdom pain and PUD

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23
Q
  1. Pt w/ PUD and takes ibuprofen for OA. Hpylori test is +. wtd?
A

treat h.pylori, then change the nsaid

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24
Q

ZE syndrome

A
  • Duodenal bulb/stomach ulcer –>multiple ulcers
  • Gastrinomas in mid duodenum, pancreas, porta hepatis. Assoc w/ MEN1
  • can present w/ PUD or diarrhea /steatorrhea (inactivated pancreatic lipase)
  • fasting gastrin level elevated. if non diagnostic then do
  • IV secretin –> increases gastrin to > 1000
  • CT scan or somatostatin receptor scan localized tumor
  • tx w/ PPI and resection of Tumor
others that increase gastrin level: 
pernicious anemia/chronic gastritis
renal failure
hyperthyroidism
PPI

life expectancy is normal if curative sx is done , otherwise 2 yrs
recurrent duodenal ulcers or poor response to treatment is suggestive of ZE

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25
Q

Upper GI bleed

A
  1. PUD .. (???nonexanguinating???) <7g
  2. Varices .. <8g
  3. Mallory Weiss
  4. Splenic vein thrombosis **
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26
Q

Pt p/w coffee ground vomitus and dizziness. NGT reveals blood tinged fluid . HR 120/min. BP 90/60. wtd next.

A

vigorous volume resuscitation. NO EGD

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27
Q

Pt with cirrhosis with spider angiomata . wtd next?

A

–> screening endoscopy; reveals varices

wtd. –> Ppx non-selective beta blockers (propranolol carvedilol nadolol)
- if asthma then no BB, do band ligation to prevent 1st variceal bleed and also for rebleeds

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28
Q

Post gastrectomy w/ abdominal bloating and pain 15-60min postprandial. symptoms relieved by vomiting bilious liquid

A

Afferent loop syndrome

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29
Q

Post gastrectomy fat and vitamin B12 malabsorption

A

Blinds loop syndrome w/ bacterial overgrowth (B12 decreased, folate increased)–> deconjugation of bile salts –> steatorrhea

decr. B12, folate incr.

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30
Q

Prognostic factor in acute pancreatitis

A

BUN - despite temperature elevated lactate white count no antibiotics

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31
Q

Pancreatitis with muscle spasm in weakness

A

Hypocalcemia

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32
Q

18 Year old w/ pancreatitis, of unknown etiology. what tests will you do?

A

Sweat chloride test

????rule out cystic fibrosis - can be associated with pancreatitis????

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33
Q

Lab values suggesting biliary ideology of pancreatitis

A

ALT greater than two times normal then increased alk phos later

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34
Q

Mild pancreatitis ultrasound gallstones no CBD dilation

A

Elective cholecystectomy

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35
Q

Complications of pancreatitis

Page 415

A

-2 days–>fluid collections, pleural effusions

-<2 wks, pancreatic necrosis–>
spiral CT or CT w/ c
comps: multiple organ failure: renal failure, hypotension, encephalopathy, metabolic–>
aggressive fluid management first 12-24 hrs; signs of infection–> abx CT guided aspiration

  • 1-4 wks, Pseudocyst–>
    >4cms may not resolve
    comps: pseudoaneurysm, hemorrhage, rupture, fistula
    —>drainage for symptoms**
  • 4-6wks, abscess
  • -> soap bubble sign, gram stain of aspirate
  • ->abx, drain tube, if persistent fever 72hrs later–> open drainage*

-anytime, splenic vein thrombosis–> CT abd

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36
Q

Ulcerative colitis

on endoscopy …what do you see?
chart pg 417

A

Rectal ulcer + spreads proximately

erythema w/ friable mucosa

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37
Q

Crohn’s disease

On endoscopy, what do you see?
chart on pg 417

A

Rectal sparing
perirectal fistulas
anywhere G.I. tract but mainly in the terminal ileum
skip lesions

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38
Q

Best treatment for stricture

A

Surgery

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39
Q

Ulcerative colitis with extraintestinal symptoms pain in joints of hands with early morning stiffness

A

Rheum neg arthritis - sulfasalazine

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40
Q

Diarrhea right lower quadrant mass temperature ulcer in mouth

A

Crohn’s disease

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41
Q

Bloody diarrhea last 2 years, wks ago went to mexco, colonoscopy with erythematous friable mucosa

A

UC

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42
Q

Pt h/o UC with diarrhea/leukocytosis

A

r/o c diff colitis

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43
Q

Young woman with chronic diarrhea wakes up at night for bathroom

A

Inflamm bowel dz

irritable bowel syndrome- during the day, not at night
inflammatory bowel dx- wakes up at night

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44
Q

UC in remission - p/w LFTs bili, US shows focal dilations

A

ERCP/MRCP dx primary sclerosing cholangitis (beaded appearance) - brush bx prodominant stricture, need annual US gallbladder for polyps - if pos - cholecystectomy - if enzymes worsen then refer for liver tx

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45
Q

24 y/o M with UC p/w abd pain, distension of colon to 7cm, bleeding and diarrhea. Tx w/ steorids and sulfasalzine, iv hydration, and antibiotics. A day later condition remains the sam. Abdominal xray –> distension large bowel w/ thumb printing. best tx?

A

subtotal colectomy

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46
Q

Pt with proctocolectomy and ileal anal anastamosis pouch presents a year later w/ increased bowel movements >6/day w/ blood. low grade temp.stool c/s negative. Lower endoscopy with diffuse superficial ulceration in pouch.

dx and tx>

A

Pouchitis -> tx with metronidazole (flagyl)

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47
Q

Pt with Crohns rectovaginal fistula not responding to 6MP and flagyl

A

anti-TNF alpha (infliximab) - watch out for TB reactiv, PNA, crypto, histo

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48
Q

24 yo UC 4 years with jaundic and fever, hepatomegaly, elev bili, elev alk phos, AST, ALT p-ANCA +

A

Primary Sclerosing Cholangitis - beading/focal dilation biliary tree - P-ANCA +, a/w UC - if LFT/bili worsens - refer for liver tx

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49
Q

Review Chart GI page 453

A

Green book - GI

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50
Q

20 yo rectal bleed tenesmus - anal fissue - 6x6cm ulcer on back of leg

A

r/o UC with sigmoidoscopy/anoscopy - tx with 5asa suppostory

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51
Q

pt w/ rectal bleed and. pain. W/ External hemorrhoid

A

topical nitroglycerin

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52
Q

Stool osmotic gap equation

A

290-2(stool Na+K)

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53
Q

Secretory diarrhea

A

> 1L/day, doesn’t stop with fasting, stool osm=290, [Na + K} x2 : [100+40} x 2; stool osm: 290, stool osmotic gap: 290-280=10, <50

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54
Q

Osmotic diarrhea

A

<1L/day, stops with fasting, stool osm=290,[Na + K} x2 : [60+40} x 2; stool osm: 290,
stool osmotic gap: 290-200=90 . [lactase def (leading cause), lactulose, sorbitol (in sugar free foods), Mg antaids, malabsorption)],
>50

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55
Q
  • longstanding diarrhea x years
  • associated w/ bloating sensation and crampy abdominal pain
  • stool osm 290, stool Na=50, K=25
  • bowel movements about 3 / day
  • no weight loss, fever nor blood
A 
lactose intolerance 
(????stool gap >50????)
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56
Q

diarrhea while vacation mexico - no blood, no fever

A

entertoxogenic e coli

tx with loperamide +- azithro x 3 days

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57
Q

Diarrhea +-fever +-blood with abd pain 2 days after undercooked poultry, drinking mountain stream water, contact with dogs/cats . +fecal WBCs

A

C.Jejunum (can cause Guillion barre)

tx w/ IVIG alone *

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58
Q

Diarrhea with abd cramping +/- fever , had chicken, raw eggs or ice cream

A

salmonella

other carrying salmonella: turtles, iguanas, frogs.

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59
Q

bloody diarrhea, ate hamburgers at fair 36hrs ago or unpasteurized milk or apple juice. dec platelets

A

O157:H7 E.Coli
culture MacConkey sorbitol agar –> Must ask lab to add sorbitol to MacConkey
tx: symptomatic, NO antibiotics. Causes HUS> IF renal failure–> Hemodialysis prn –> Eculizumab **

ANY bloody diarrhea or diarrhea w/ fever, don’t use anti motility agents. **

[??- SX treatment only DO NOT GIVE ABX - will cause HUS - if RF then HD (TTP)??]

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60
Q

Bloody diarrhea

A

Shigella, C.jejuni, salmonella, c.diff

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61
Q

Diarrhea 3-20 days after camping, skiing, or visiting South Africa. Associated with bloating sensation, cramping,, flatus, frothy stool, and weight loss.
dx? and tx?

A

Giardiasis
stool ELISA for Giardia antigen +

Tx: metronidazole
post tx ELISA test for Giardia antigen become negative

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62
Q

church group goes on picnic. Eat Precooked foods; beef/turkey. 8- 12 hrs later diarrhea/vomitting. no blood

dx and tx?

A

C.perfringens

tx? supportive tx

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63
Q

Diarrhea 4 hours after asian restaurant - fried rice - vomiting, no blood

A

Bacilius cereus - supportive tx

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64
Q

Diarrhea after sea food dinner - g neg comma shaped bug

A

vibrio parhemolyticus

tx ?cipro

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65
Q

Diarrhea, nausea vomiting, abd pain after eating fish (2hrs) with perioral paresthesias - reversal hot/cold sensation

A

ciguatera toxin from large reef fish

fish that eat other fish; amberjacks, barracuda, red snapper, etc.

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66
Q

Flushing, utricaria, paresthesias minutes after eating fish

A

scombroid poisoning

due to built up histamine in fish.

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67
Q

eats fish and minutes later parestehesias, weakness, ascending paralysis and SOB

A

tetrodotoxin from puffer fish

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68
Q

hx Chronic diarrhea, hx travel to mexico or other 3rd world country last year - OR presentation with acute dysentery - colonscopy with flask shaped ulcers

A

amoebic colitis

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69
Q

RUQ pain, fever, elev wbc, increased LFTs after third world country -hx of bloody diarrhea recently

A

amoebic liver cyst
check stool for ova/cyts
serum ELISA tst
if CT abd + then aspirate and tx with metronidazole

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70
Q

HIV CD4<200 chronic diarrhea/wt loss no fever no blood

A

cryptosporidium - stool afb small round organisms - if stable just hydration, if not imporoving nitazoxanide

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71
Q

woman chronic diarrhea of several years, frequent small stools with mucus, alternates w/ constipation.
abdominal pain relieved with BM, no night waking no fever, no wt loss, no anemia, stool studies neg for ova, cysts, and parasties. hx of emotional stress, ex: work place stress & anxiety or caring for an elderly adult, etc. - flex sigmoidoscopy neg

A

dx: irritable bowel syndrome by exclusion (???rome III criteria????)
tx: reassurance - don’t use alosetron, as it can cause ischemic colitis.

before labeling as IBS, wtd?
–> Ttg Abs to R/O celiac sprue

[??????rifaxinin, antispasmotics, anticholinergics - TCA, fiber???????]

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72
Q

chronic diarrhea , stool osm 300, stool Na 40, K 30 on adding naOH turns red

A

laxative abuse
measure phosphate and sulfate in stool

[???stool gap 160 (>50)???]

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73
Q

diarrhea, RLQ pain, fever, rash fecal leukocytes +, no h/o diarrhea. most likely cause?

A

yersinia enterocolitica

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74
Q

pt w/ diarrhea, C. diff +, WBC <15,000, age <60

wtd?

A

Metronidazole

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75
Q

recurred (x1) 2 wks later cdiff + diarrhea WBC 13,000

wtd?

A

restart metronidazole

Not a resistance problem, left over C. diff course are now maturing

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76
Q

recurred (x2) 3 wks later cdiff+ diarrhea , wtd?

A

vancomycin pulse therapy -
125mg orally 4x daily x 7-14 days, then twice daily for 7 days, then once daily for 7 days, then every other day for 7 days, then every 3 days for 14 days.

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77
Q

diarrhea, cdiff + WBC >15,000 or age >60, wtd?

A 
po vanc
(???>15k don't use flagyl???)
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78
Q

which abx induces B1/NAP1 strain cdiff which causes colitis w/ toxic megacolon

A

cephalosporin or quinalones

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79
Q

77yo M a/w PONA started on abx - what do prevent cdiff

A

probiotics (lactobacillus)

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80
Q

******* 78yo known diabetic p/w diarrhea with c.diff+, WBC 12,000, better with metronidazole PO. A week later returns to hospital w/ diarrhea, abdominal distension, tenderness.
BP: 90/64, HR 116, T 101.8, WBC 24, 000. Lactate 30 (normal is 0.6-1.8). C. diff has been ordered. Xray shows ileus. What is the best management?

A

start po vanc, rectal vanc, iv metronidazole, fecal transplant, and surgical consult .

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81
Q

better way to prevent spread of cdiff

A

wash hands with soap and water (no etoh sanitizer)

c. diff—> contact isolation

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82
Q

65yo M fatigue, chronic diarrhea, itching with pallor, bullous skin lesions, Hg low, MCV low, TIBC inc, ferritin low, hemooccult neg - blood smear howel jowell body, colonscopy neg for bleed or lesions- no change in Hb with oral ferrous sulfate, wtd?

A

transglutaminase IgA abs to rule out celiac sprue

If antibodies + wtd?
small bowel biopsy

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83
Q

If celiac sprue neg tx?

A

gluten free diet - can have dermatitis herpetiformis

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84
Q

Dermatitis herpetiformis tx

A

dapsone

itchy skin lesions

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85
Q

asx brother of pt with celiac sprue - what to check

A

HLA DQ2 or 8 (not TTG)

pt can also have dermatitis herpetiformis

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86
Q

vitamin supplement needed in celiac sprue

A

Vit D

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87
Q

Diarrheal dz a/w celiac sprue

A

microscopic collagenous colitis

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88
Q

Pt with celiac sprue confirmed with TTG abs put on gluten free diet. improves initially, then 3 months later continues to lose wt and has diarrhea. dx?

A

dietary non-adherence

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89
Q

Pt with celiac sprue responds well to gluten free diet for 10 years. now with diarrhea/abd pain/wt loss

A

r/o lymphoma

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90
Q

pt returns from 3rd world with diarrhea, foul oily** stools, +steatorrhea, Hg low, MCV high**. D-xylose test abn, folic acid decreased. wtd next?

A

Small bowel bx -> flattened villi with lymphocytic and plasma cell infiltrate in lamina propria

dx: tropical sprue
etiology: klebsiella or ecoli
tx: tetracycline and folic acid

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91
Q

25yo diarrhea, bloating, flatulance, wt loss of ~10lb in past couple months. She is from dominican republic (caribbean or is latin american or visitor to the area…must be there for >1 month). She eats in fast food restaurants.
Hb 11.2, MCV 110, WBC 3,500.
Serum alb 3.1, folate 7.8 (normal 1.8-9), B12 (normal 200-800)
stool cx for 2 fresh specimens are negative for pathogens (therefore not parasites).
stool for sudan stain + for fat globules

most likey dx?

A

tropical sprue

Caribbean –> folate N, B12 low,
Asia –>folate low , B12 N
Bact overgrowth–> folate high, b12 low

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92
Q

Pt with diarrhea few months with greasy stools or oily stools. fecal fat 15g/day, d-xylose serum level of 5 (nl>20 @ 1 hr) and urinary excretion of 500mg @ 5 hrs (nl>3500mg). What is most likely to establish dx?

A

check small bowel bx

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93
Q

pt with h/o arthritis>2yrs, diarrhea >3/day, oily stools, foul smelling, wt loss, adenopathy, SKIN PIGMENTATION, posterior uveitis with blurry vision
small bowel bx: foamy macorphages and PAS+

A

Whipple’s dz
etio: tropheryma whipplei
tx: bactrim or tetracycline for a year
other features: Neuro: dementia or visual disturbances.

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94
Q

55yo with recurrent pain/swelling shoulders and knee for years with wt loss of 15lbs, LAD and asp of knee with WBC 13K, wtd?

A

PCR of synovial fluid for trophyrema whipplei

NAAT

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95
Q

diarrhea w/ hx of food intolerance, n/v/abd pain, steatorreha +, ova/cysts/parasites neg, peripheral eosinophilia +

A

eosinophillic gastroenteritis - r/o parasitic infestation b/4 starting steroids

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96
Q

35yo n/v epigastric pain for months - n/v in morning better with hot shower - wt loss but no dysphagia. most likely diagnosis?

A

marijuana (cannabis) induced

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97
Q

30yo F early satiety and vom even with tiny amoutn of food for months . A scintiscan is done and shows normal emptying. wtd?

A

buspirone

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98
Q

chronic diarreha, fecal fat 14g/day, dxylose normal - B12 190, folate 18 (nl 1.8-9), small bowel shows diverticula, wtd next?

A

Bacterial overgrowth
check hydrogen breath test or xylose 14C breath test -
tx with cipro+metronidazole

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99
Q

Pt steatorrhea 40g/day, dxylose 8g/5hrs - colonoscopy normal, h/o lactose intolerance

A

xray abd check for Calcification of pancrease - chronic pancreatitis

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100
Q

Short bowel syndrome

A

calcium oxalate stones, replace ADEK, B12, Ca, Mg, Zn - replace long chain with med chain Fatty acids

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101
Q

Intestinal lymphangietctasia - dilated lymphatic vessels

tx?

A

replace long chain FA with med Chain triglycerides

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102
Q

Abetalipoproteinemia

A

normal villi - impaired B globulin synthesis**->impaired chylomicron formation **

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103
Q

pt s/p extensive small bowel resection with lots of diarrhea 3 days post op

A

PPI - acid induced diarrhea

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104
Q

small bowel resection after gun shot wound. presents diarrhea.
mechanism of diarrhea is?

A

mechanism is bile acids malabsorption
tx w/ cholestyramine
diarrhea = watery

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105
Q

GSW with extensive bowel resection - couple months later with greasy foul stools and wt loss of ~8lbs - fecal fat 20g/day PT INR 1.2, D-xylose excretio is nl, betacarotene is low.

Etio of diarrhea?

A

etiology=decreased bile acids

tx w/ medium chain triglycerides

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106
Q

severe ischemic colitis s/p extensive small bowel resection - now bulky, greasy stools 3-4/ day. wt loss post sx, stool fat 20g/day, alb 2.6, calcium 7.0.
most appropriate tx?

A

tx with med chain TG

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107
Q

52yo F chronic watery diarrhea 5-6x daily, wakes up pt in the middle of night to move bowels. no hx no constip, no blood, fever or weight loss - neg stool studies, neg giardia, neg EGD and colonoscopy.

best way to establish diagnosis?

A

flexible sigmoidoscopy with bx - (

collagenous/ microscopic coliits–> collagen vs lymphocytic colitis–>lymphocytes

biopsy will show inflammation of lamina propria
offending agens: NSAIDs, PPI, setraline, DM

Management: D/C offending agent otherwise for mild–> bismuth salicylate
if no response or severe disease–> oral budenoside

antiboides to check: tissue transglutaminase IgA antibodies

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108
Q

Causes of osteomalacia

A

post gastrectomy 43%, celiac sprue 26%, biliary cirrhosis, pancreatic insufficiency, crohn’s dz

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109
Q

60yo pt with fever, inc WBC, abd pain in LLQ

A

r/o diverticultis
appropriate diagnostic test:
–> CT scan
–> avoid colonoscopy/barium enema, cipro +flagyl

symptoms are resolving on 4th day, what diet do you reccomend?
clear fluids diet untl symptoms resolve then advance to fiber diet

4 weeks later after diverticulitis resolved, do colonoscopy to r/o cancer or other disease like crohns etc

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110
Q

treated diverticulitis w/ cipro and metronidazole 3 months ago, since then 3 episodes LLQ pain with no fever or WBC - left segmental diverticulosis on colonoscopy - DX?

A

uncomplicated symptomatic diverticular disease

tx with mesalamine or rifampin

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111
Q

Pt with divertiulitis with >4cm abscess

A

CT guided drainage first that allows for elective surgery

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112
Q

pt with acute diverticulits and 9cm dilation with 5cm abscess

A

surgical intervention

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113
Q

what medication can cause divertiulitis with perforation

A

Tocilizumab (Actemra) - IL-6 inhibitor (also causes OCP failure and hyperlipidemia)

discontinue if presets for diverticulitis

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114
Q

75yo M with ER c/o painless brbpr, no pmhx - BP 130/80, HR 92, BRB in rectal vault

A

dx - diverticulosis (painless)

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115
Q

55yo F with long rheum arthritis controled with ASA and naproxen x 14 years with abd pain for last 4 months - EGD/colonsocpy neg - small bowel barium enema with multiple concentric constricting lesions - dx?

A

small bowel diaphragm disease

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116
Q

Chronic mesenteric ischemic

A
  • post prandial, abd pain, fear of eating, wt loss -
  • etiology: dec blood flow and atherosclerosis
  • dx: with doppler US or angiogram
  • tx: angioplastry or surgica revascularization
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117
Q

Acute mesenteric ischemic

A

sudden onset sev abd pain, n/v/elev WBC, ileus +
-etio: embolism in celiac, Sup mesenteric artery:
_valvular heart dz
_afib, most likey
_low flow state in hypercoag state
-dx: give heparin 1st, then angiograpy 2nd, then TPA 3rd
- tx: with thrombolysis or surgery

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118
Q

Ischemic colitis

A

hematochezia, diarrhea, abd pain

  • etio: low flow state (CHF, hypercoag state, hypotension)
  • dx: with thumbprinting colon–>, pausity of vessels, aphthoid ulcerations
  • tx: rehydration and antibiotics
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119
Q

Angiodysplasia

A

AVM - cause lower GIB - common in elderly - osler weber rendu syndrome -> tx with laser photocaog, sclerotherapy or cautery

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120
Q

65yo M pmhx severe AS with recurrent melena - colonscopy with angiodysplasia
best management?

A

Aortic valve replacement

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121
Q

Post radiation tx in pelvis, presents 1.5 years later with rectal bleeds - colonscopy with friable mucosa, atrophy and fibrosis - dx?

A

radiation prococolitis

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122
Q

70yo M with severe abd pain x 1 day, last BM normal several hours ago. mild tender abdomen w/ no guarding, h/o DM, CHF, HTN, JVD+, S3+ rectal normal , FOBT neg, amylase level elevated - abd xray normal, CT abd with small bowel wall thickenss and intestinal pneumoatosis

how do you establish a diagnosis?

A

check mesenteric angiography

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123
Q

MCC GIB in kids

A

meckels divertiulum (with gastric mucosa)

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124
Q

Constipation

A

BM<3x/wk
-most common metabolic disorders:
hyperCa+, hypothyroid

  • idiopathic:
    slow transit
    pelvic floor dysfxn–> biofeedback

-Most commond rugs:
calcium/CCB, HCTZ/diruetics, anticholing, antipsych, opiates(should give senna)

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125
Q

Tx for constipation

A

tx underlying cause and inc fiber in diet

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126
Q

Opioid induced constipation

mangement?

A

start stimulant laxative as a routine with opioids

Senna

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127
Q

elderly pt with chronic constip not responding to fiber

A

polyethylene glycol

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128
Q

Pt with stage IV lung Ca not responding to stimulant laxative, polyethylene glycol

A

methylnaltrexone

NO naloxone

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129
Q

elderly woman with constipation and diarrhea - hard stool in LQ

A

enema

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130
Q

65yo M s/p ortho surgery on abx and morphine - next day with abd pain adn distension - abd xray with 6cm distenstion of cecum up to splenic flexure (could also be up to the rectum) with no WBC, hypokalemia

diagnsois?

A

dx: acute pseduo colonic obstruction (ogilvie’s syndorme) -
dx: CT scan or gentle hypaque (water soluble) enema to dx
managemnt: remove precip causes: correct electrolyties, d/c opiates, d/c aticholinergics, rectal tube, neostigmine

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131
Q

75yo F with LLQ pain x 2 days, last BM 1 wk ago, BS+, xray with colonic dilation, CT with partial obst of signmoid

A

Dx Sigmoid volvulus - flex sig (analgesia for pain won’t affect dx accuracy)

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132
Q

Woman sharp RUQ pain x 1 year - severe - US/CT normla - pain with raising legs

A

Functional abd wall pain**

No CT Scan**

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133
Q

Hepatitis A

A
  • RNA virus,
  • incubation15-50 dyas, p/w jaundice,
  • feco-oral/sexual transmission,
  • no carrier state or chronic state,
  • can exacerbate underlying liver dz, so vacc HCV pts for HAV
  • vaccinate high risk groups (travellors, gays, liver dz)
  • IVIG for high risk exposure
  • Anti- HAV IgM–> acute hepatitis A
  • Anti- HAB IgG–> past infection

no exposre, IgG+–> FP–> give vaccine

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134
Q

Anti HAV IgM

A

Acute hep A -> treat!!

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135
Q

anti-HAV igG

A

post infection - Do not treat

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136
Q

Preg woman - how to determine past infection HAV

A

HAV IgG+, IgM-

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137
Q

Pt going to mexico for 2 weeks, sheduled to depart in 2 wks, wtd?

A

hep A vaccine

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138
Q

Hep A vaccine in….

A

Hep C, chronic liver dz, high risk country travelor (Asia, Africa, S. America), gay men (NOT PT WITH PNA)

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139
Q

Pt returns from Indonesia/belize*** with contact with commerical sex worker - now with n/v/malaise, anorexia - HBV ab+, HBV cAb+ ->dx?

A

Hep A - check hep A serology in 2 weeks

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140
Q

Hepatitis B

A

-only DNA virus in hepatitis ***
-transmission: sexual or parental
- 30% chance after needle stick
- >90% pts clear infxn - lose HBsAg and have anti HBs Ab - ~5% with chronic hepatitis, 1% fulminant hepatitis
Causes cirrhosis –> hepatoma 2-4%/year
-carrier status highest in infants–> children–>adults
-HBe Ag denotes viral replication. in some pts. have pre- core mutation of e-antigen & e-antigen can be negative in the presence of active replication. So check for HBV DNA
-Check for HBV DNA after acute Hepatitis to find out if pt has cleared infection or has gone to chronic hepatits
-Hepatitis B vaccine for high risk groups
-Hepatitis B immune globulin [HBIG] for high risk exposure

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141
Q

Heb B -> HBe Ag

A

denotes viral replication, active infxn

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142
Q

HBV Vacc

A

high risk groups

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143
Q

HBV IVIV (HBIG)

A

high risk exposure

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144
Q

HBV tx

A

interferon, tenofovir, entecavir, adefovir, lamivudine can suppress

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145
Q

HB S Ag

A

acute hep B, chronic hep B, Carrier Hep B

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146
Q

anti-HB cIgM

A

acute hep B

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147
Q

anti-HB c IgG

A

chronic, carrier, past infection

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148
Q

HB e Ag

A

active replication

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149
Q

Anti-HBs antibodies

A

post vaccination, cleared infection

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150
Q

anti Hbc IgG Ab +, HBsAg neg Anti HBsAb neg

what are the possibliites?

A
  • chrnoic hepatitis OR past infection

- false positive (if from low prevalant area)

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151
Q

pt low endemic area, no risk factors for Hep B has anti-HBc Ab only - wtd?

A

Hep B vacc

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152
Q

Nurse with HBV vacc with needle stick pt with HBV

A

check anti HBs Ab titer - if >10 - reassure, if <10 HBIG+booster HBV vacc

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153
Q

Pt with Hep B vacc series

what will most likely be psotive?

A

+anti-HBs Ab

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154
Q

HBV DNA >20K, ALT normal - treatment?

A

none

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155
Q

HBV DNA >20K, ALT 1-2x normal - treatment?

A

Bx

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156
Q

HBV DNA >20K, ALT >2x normal - treatment?

A

Yes

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157
Q

HBV DNA >10IU - cirrhosis compensated (no ascities), treatment?

A

treat HBV

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158
Q

HBV DNA >10IU - cirrhosis decompensated (+ ascites), treatment?

A

tx and transplant

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159
Q

HBV treatment, what medication would you start

A

tenofovir, entecavir, or alpha interferon

you will continue treatment:

  • until loss of HBeAG or presence of Anti HBe Abs
  • if eAg neg, then until loss of sAg
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160
Q

HIV/HBV pt coinfected

A

if treating HIV also - tenofovir, otherwise peg interferon

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161
Q

prior to starting rituximab or chemo with steroids or anti-TNF what to check

A

HBc IgG and HBsAg

If any one positive then treat up to 1 year after stopping immunesuppresives

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162
Q

Asian american woman with HBV in 3rd trimester - how prevent HBV in child?

A

tenofovire for mother and hep B vaccine and HBIG in newbrn baby

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163
Q

Hepatitis C

A
  • SSRNA
  • MCC liver transplantation in US**
  • MC presentation with fatigue and elevated LFTs
  • Risk groups: IVDUs/ prisoners, blood transfusion associated before 1992, MSM**, tattoos/snorting cocaine
  • no vaccine yet **
  • No immune globulin yet **
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164
Q

Hep C high risk groups

A

IVDU/prisoners, blood tx before 1992, tattoos, snorting cocaine, most patients DO NOT CLEAR - NO VACCINE, NO IGG, no post exposure PPX available

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165
Q

Woman with hep C - precautions with husband

A

DO NOT SHARE TOOTHBRUSH

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166
Q

60yo pt born 1945 to 1965 - what to check

A

hep C abs

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167
Q

Risk factors progression to cirrohisis from HCV

A

age>40, etoh, man, coinfection with Hep B or HIV (higest risk)

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168
Q

Treatment HCV

A

Boceprevir, interferon, ribavirin, d/c therapy if VLsuppressed

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169
Q

53yo M received multple blood tx in 1990 after MVA p/w fatigue, elev LFTs AST/ALT 200/120, Hep C Ab + and liver bx with mild to mod bridging fibrosis - hep C viral load 250K - 2 months later AST/ALT lower AST/ALT 120/90 - VL 210K. wtd?

A

sofosbuvir + IFN + ribavirin for 12 wks

pt get depressed 2/2 interferon, wtd?
Add SSRI (paroxetine)
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170
Q

Nurse gets stuck with needle HCV patient - Hep C ab neg

A

repeat HC Ab/RNA in 4 weeks

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171
Q

Nurse stuck with HCV 4 weeks ago with HCC VL 45K - wtd?

A

reassess HCV RNA at q 8 weeks for 6-12 months. if cleared, do nothing if still high begin treatment.

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172
Q

Pt with IV exp to HCV 6 weeks later with malaise and fatigue - all Hep Ab (HBsAg, HBc IgM, HACV IgM, HCV) neg , you still suspect hep c- wtd?

A

check HCV RNA

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173
Q

55yo pt with fatigue, no history - ALT 2x, AST 1.5x, takes tylenol occasionally for. arthralgias ( increase by tens of thousands) what is mst likely diagnosis.

A

Dx HCV (tylenol would be AST in 1000s)

  • if HCV Ab + .HCV was done. wtd next?
    HCV genotype

wtd next?
assess for fibrosis: non invasive; platelets, AST/ ALT or US OR invasive; liver bx

Naive w/ no cirrhosis--> 
sofosbuvir/velpatasvir 12 wks OR
ledipasvir/sofusbuvir 12 wks OR
elbasvir/grazoprevir 12 wks OR
simeprevir/sofusbuvir12 wks OR
paritaprevir/ritonavir/ombitasvir OR
daclatasvir (6-mg*) plus sofosbuvir

sofosbuvir + amiodarone= brady cardia

naiive w/ cirrhosis–>
sofosbuvir/velpatasvir 12 wks OR
ledipasvir/sofusbuvir 12 wks OR
elbasvir/grazoprevir 12 wks OR

treatment failure on interferon w/o cirrhosis-->
sofosbuir/ velpatasvir 12 wks OR
ledipasvir/sofusbuvir 12 wks OR
elbasvir/grazoprevir 12 wks OR
simeprevir + sofusbuvir 12 wks

treament faioure on interferon w/ cirrhosis–>
sofubuvir. velpatasvir 12 wks OR
ledipasvir/sofusbuvir 12 wks OR
elbasvir/grazoprevir 23 wks

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174
Q

Pt with hep C, genotype 1 on IFN, ribavirin p/w fatigue

A

check Hg (ribavirin causes hemolytic anemia) - if retic + then start erythropoietin, d/c ribavirin

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175
Q

If pt on IFN get depressed

A

start SSRI (Paroxetine)

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176
Q

Pt with HCV with briding fibrosis and inc’d HCV RNA started on sofosbuvir/velpatasvir - advice for pt

A

NO ETOH, if seroneg for HAV, HBV give vaccines for HAV/HBV

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177
Q

Extrahepatic manifestations of HCV (indications for tx of Hep C)

A

small vessel vasculitis, glomerulonephritis, neruopathy, mixed cryoglobulinemia dec C4>dec C3, porphyria cutanea tarda

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178
Q

Pt w/ Hep B on inerferon, has to monitored for

A

hypothyroidism, hyperthyroidism

TSH

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179
Q

HDV

A

incomplete RNA virus needs HBV to survive

HBcIgM + HDV==> acute coinfection, doesnt make hepatits worse

HBc IgG + HDV==> acute superinfection, can cause fulminant hepatitis***

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180
Q

HBc IgM + HDV

A

Acute co-infection - doesn’t make hepatitis worse

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181
Q

HBc IgG + HDV

A

Acute superinfection - can cause fulminant hepatitis

182
Q

HEV

A

fecooral transmission like HAV, Fulminant hepatitis in 3rd trimester of preg with increased mortality, ALL hepatitis seriology NEGATIVE,

183
Q

Tylenol liver damage

A

> 7g tylenol can cause liver damage, in etoh 4gm tylenol causes liver damage - N-acetylcystein antidote

184
Q

20yo took 30 gm pain pill - ER denies sx - tylenol level Pending - wtd

A

give oral n-acetylcysteine without waiting for labs

????? - if within 1hr then gastric lavage, activae charcoal and syrup of ipepac???

185
Q

heavy etoh chronic drinker with myalgias and hanow with n/v/abd discomfort AST 11,000, ALT 9000 INR 3 - dx?

A

acetaminophen toxicity

N acetylcysteine still helps

186
Q

Drug induced Hepatitis

A

-Dose related, age related toxicity, with inc AST/ALT,

ANA+–>INH

187
Q

Hepatitis with cholestasis

A

amox-clavu***, bactrim, erythromycin, chlorpromazine

188
Q

Hepatitis with macrovascular fatty change

A

etoh hepatitis, amiodarone, steroids

189
Q

Hepatitis with microvasicular fatty change

mitochondrial damage

A

tetracycline, reye’s syndorme with ASA+flu

190
Q

Chronic drug hepatitis

A

methyldopa, trazadone, nitrofurantoin, phenytoin

191
Q

Direct liver toxicity

A

acetaminophen

192
Q

Dysphagia

A

Solids -> pogressive Age>50 -> carcinoma
Solids -> progressive -> heart burn -> peptic stricture -> EGD/bx r/o CA ->dilation/PPI
Solids-> intermittent -> esosinophilic esophagitis -> esoph rings (steakhouse syndrome)
Solids or liquids ->progressive->cough/regurg ->achalasia->dx with barium swallow (autoimmune)
Solids or liquids->progressive->heart burn->scleroderma (scl70)
Solids or liquids->intermittent->chest pain -> diffuse esophageal spasm -> corkscrew esophagus->PPI trial->confirm with manometry

193
Q
  1. Pt with intermittent dyphagia to solids and liquds assoc. w/ CP
A

Diffuse esophageal spasm
dx: barium swallow (cordscrew esophagus)
-> confirm with manometric studies showing non peristaltic contractons
next step-> PPI if no response-> CCB such as diltiazem

194
Q
  1. Young pt with steak dysphagia. happened a couple times before. occurs w/ first bite, then regurgitates (or not), then swallows the rest of the meal w/o issues…. dx? tx?
A

dx: lower esophageal rings = schatzky ring or steak house syndrome
tx = pneumatic dilation

195
Q
  1. Hispanic man complains of food regurg several hours after eating, no heartburn, dyphagia to solids and liquids wtd. next?
    - -> barium swallow –> dilated esophagus with tapering gastro-esophageal junction (bird beak)
    - -> manometry –> decreased peristalsis and increased Lower esoph pressure.

dx? tx?

A

dx: Achalasia
tx: surgical myotomy

wtd. prior to surgical myotomy or pneumatic dilation?? –> EGD to r/o secondary achalasia due to lymphoma or cancer before doing pneumatic dilation

196
Q

GERD (Gastro Esophageal Reflux Disease)

A

Recently ingested fatty foods –> relax lower esophageal sphincter acid reflux –>symptoms : [?????CP, heartburn, nocturnal cough, asthma, dental erosion?????].

MCC of non-cardiac chest pain

GERD–> Barrett’s esophagus–> Adenocarcinoma
Barrett’s esophagus= replacement of epithelium with columnar cells (metaplasia)–> dysplasia–> adenocarcinoma

197
Q

GERD complications

A

GERD–>Barrett’s esophagus-> AdenoCA

198
Q

GERD Tx

A
  1. wt loss
  2. head elevation of bed at night
  3. stop smoking
  4. dinner at least 3 hours before bed time
  5. PPI much better than H2 blockers
  6. fundoplication sx
199
Q

Indications for endoscopy in GERD:

A
  1. heart burn not relieved with PPI BID x 4- 8 wks***
  2. heartburn >5years
  3. heartburn w/ wt loss
  4. heartburn w/ melena
  5. heartburn w/ anemia
  6. heartburn w/ dysphagia or odynophagia
200
Q

pt w/ Heartburn partial response to PPI. EGD reveals severe GERD. wtd?

A

lap fundoplication is planned.

prior to procedure wtd?
manometry studies to confirm esophageal motility, otherwise iatrogenic achalasia will result.

201
Q

elderly pt with GERD not responsing to H2 - EGD shows stricture. Stricture is dilated - bx is neg. There is proximal gastritis - best way to manage this pt?

A

lifelong PPI

202
Q

Barrett’s esophagus

A

normal Gastro-esoph junction squamous epithelium –> changes to columnar epithelium with chronic reflux disease –> Barrett’s esophagus
In older pts w/ > 10yrs of sx.

203
Q

PUD causes

A

H. pylori, NSAIDS, Zollinger Ellison syndrome

204
Q

H. Pylori

A
  • gram neg, urease producing**
  • PUD (duodenal ulcers)
  • type b gastritis
  • gastric cancers
  • mucosa assoc lymphoma (MALT)

Treatment of H.pylori in low grade MALT results in tumor shrinkage or disappearance 50-80% of the time. Up to 30% of the time, t(8;11) poor response to h.pylori therapy. local RT required then. await biopsy report before pronouncing cure.**

205
Q

45yo Fp/w itching esp at night +xanthomas, alk phos 1400, +AMA (anti mitochondrial antibody), -ANA, liver bx granulomas/lymphocytic destruction of bile ducts

???(dec ADEK, osteomalacia, HLD with high HDL)???

A

Primary biliary cholangitis
other features: decreased fat solube vitamine, DAKE w/ ostemalacia, hypercholesterolemia w/ high HDL

  • tx :
    early: ursodeoxycholate (delays progression, doesn’t prevent it
    late: liver transplant
206
Q

Autoimmune hepatitis

lupus against liver

A

young woman with fatigue, wt loss, arthralgia, acneform rash, amenorrhea,

on examz: +icterus, AST/ALT inc 5-10x, inc globulins, (a/w thyroititis, ITP, anemia, Coombs+)

autoantibodies commonly present-> +ANA, +ANCA, +Anti DSDNA, +SMA (most specific), anti-actin +, AMA + in low titer

Bx - piece meal necrosis of hepatocytes **
Tx - rapid reversal of symptoms and increased survival w/ prednisone +/- azathioprine, interferon is CONTRAINDICATED as it makes autoimmune hepatitis worse.

207
Q

26yo F juandice, ALT 350, alkphos 115, +ANA, +ASMA, -AMA, IgG elev -> liver bx piecemeal necrosis of hepatocytes

A

Autoimmune hepatitis

208
Q

26yo F jaundice, ALT 40, alk phos 290, -ANA, -ASMA -AMA, IgM/G normal - Liver bx mild inflamm with concentric fibrosis around bile ducts

A

Primary Sclerosing cholangitis

????(extrahep duct fibrosis) - urosdiol doesn’t help???

209
Q

26yo F jaundice, ALT 100, alk phos 550, ANA neg, ASMA neg, AMA pos, IgM elev, IgG normal, liver bx - lymphocytic destruction of bile ducts

A

Primary Biliary cirrhosis

????(intrahep bile duct destruction, elev alk phos) - ursodiol helps????

210
Q

Etoh Liver dz

A

Fatty liver-> etoh hepatits-> micronodular cirrhosis -

????hepatomeg, fat vaculoles on liver bx (reversible with stopping etoh)????

211
Q

Etoh hepatitis

A

aorexia, n/v/abd pain/wt loss , hepatomegaly +, AST:ALT 2>1, AST/ALT increased but not more than 350,, Hepatomegaly, liver bx - necrosis of hepatocytes with inflamm cells,
inc WBC, encephalopahty, elev PT in severe cases (this is the most important prognostic factor***)

212
Q

35yo F jaundice, confusion, malaise, RUQ pain - icterus, mild ascities, hepatomegaly, AST 205/alt 90, INR 1.5, WBC 18k bili 15, hg 12, platelets 155k, paracentesis reveals 200 WBCs

A

acute etoh hepatitis -> steroids if no bleed or SBP

213
Q

If acute etoh hepatitis with bleed or SBP

A

pentoxyfyline

214
Q

Obese pt weighing 275, BMI 35 . w/ DM, HLD - non-etoh - mild elev of ALT/AST 2:1, Fasting suger 160, chol 280 - liver bx fatty changes with some fibrosis

A

NASH (non alcoholic steatohepatits)

  • dx wit liver bx NOT US
  • tx underinglying risk factors….decrease weight, control DM, vit E, statin for HLD
215
Q

Causes of cirrhosis

A

Viral (B,C,D), Autoimmune hepatitis, etoh, PBC, PSC, Hemochormatosis, wilsons, CHF/Budd chiari (stasis)

216
Q

CA screening with cirrhosis

A

periodic liver US/ NOT alpha feto protein

217
Q

best prognositc tests in cirrhotic according to MELD (model for end stage liver disease) score?

A

PT, INR, Ser Cr, Ser Bili

MELD <18 –>TIPS
MELD >18–> translpalnt

elective major sx in cirrhotic pts depends on MELD score
<10–> cleared fo sx
10-15 –> clear w/ CAUTION
>15–> elective sx CONTRAINDICATED

218
Q

Indication for liver tx

A

viral hep, autoimmune hep, PBC, PSC, hepatoma, wilsons, Alpha 1 AT def, fulmianent hep failure

219
Q

Contraindications

A

untreated HIV, extrahep CA, active etoh/drug use, unresolved sepsis/fungemia, Hep B with eAg +

220
Q

When to refer for liver tx

A

cirrhotics with clinical or biochemical decompensation

221
Q

Pt with cirrhosis p/w hep enceph - quit drinking 2 years ago, ascitic fluid WBC 70 - wtd

A

refer for liver tx

222
Q

SAAG

A

figure this out

223
Q

Least likely to cause chylous ascites

A

cirrhosis/CHF

224
Q

management of cirrohsis with ascites

A

Na restriction to 1g/day, fluid restriction to 2 Its/day

diuresis begin with spironolactone 100mg + lasix 20 mg po –> titrate based on urine Cl or urine Na

–>refractory ascites may be treated w/ large volume paracentesis or transjugular intrahepatic portosystemic shunt (TIPS)

225
Q

Cirrhotic p/w elev WBC, fever, ascities

A

paracentesis

226
Q

Pt with long cirrhosis brought in with lethargy, asterixis and asciteis - PT INR 3, plt 40k - WTF

A

abdominal paracentesis ***

if PMNs > 250 / cmm in ascitic fluid or SBP is present wtd?
treat w/ a 3rd gen cephalosporin like cefotaxime**

227
Q

SBP

A

PMN >25 in asciteis or WBC >500 with >50%pmn

228
Q

SBP tx

A

cefotaxime (3rd gen cephalo) - usually single organism (ecoli, kleb, s pneumo) - 10-20% pts w/ cirrhosis and ascities develop SBP-give albumin- so tap new onset ascities or ascites w/ any complication such as fever, leukocytosis, or asterixix or lethargy

229
Q

Post surgery NPO OR pt on abx for bronchitis get icterus - AST/ALT normla, alk phos nromla - indirect bili elev 4.2, direct bili 0.3 - 2 days later total bili 2.5

A

Gibert’s syndrome - no tx

230
Q

Wilson’s dz

A

-autosom recessive
presentation at a young age/ adolescents w/
-chronic hepatitis (50%): with elev LFTs or
-neuro (30%)* (tremors, rigidity, and bradykinesia)
-psych dysfunction* (personality/behavor)
-hemolytic anemia***
- impaired excretion of copper–> copper accumulation in liver/body tissues
- urine copper high
- KAYSER-FLEISCHER RING pathognomonic
- liver bx –> copper deposition confirms dx

treatment:
- chelate w/ penicillamine** + pyridoxine or trientine
- in severe disease–> liver transplant

how i remember the treatment: “copper PENnies for PENicillamine “

231
Q

Tx wilson’s dz

A

chelation penicillamine/pyridoxine -> severe dz - liver tx

232
Q

UGIB causes

A

PUD, varices, mallory weiss tear, splenic vein thrombosis

233
Q

Pt with coffee ground emesis and dizzinesss - NGT with blodo tinged fluid - BP 90/60 HR 120

A

fluid resucitation

234
Q

Acute UGIB, continues bleeding confused, hypotensive/tachy

A

intubate then scope after volume resusitation

235
Q

Point to transfuse UGIB

A

<7gm Hg

236
Q

Tx of UGIB

A

bleeeding ulcer - electrocautery, visible vessel monitor/electrocautery, bleeding varices - octreotide infusion with banding -> monitor for 72hrs

237
Q

Clean based ulcer no bleed

A

early feeding

238
Q

PPI use

A

rel to cdiff, HAP, osteoporissis, low Mg, microscopic colitis

239
Q

prevent rebleed in PUD

A

PPI

240
Q

Pt w/ heartburn w/ partial response to PPI. endoscopy reveals severe GERD. wtd?

–> Laparoscopic fundoplication planned. prior to procedure. wtd?

A

manometry studies* to confirm good motility of esophagus, otherwise iatrogenic achalasia will result.

241
Q

An elderly pt w/ GERD, not responding to H2-r blockers undergoes EGD and found to have stricture. Pt undergoes dilation of stricture and biopsy which is negative. There is proximal gastritis. Best way to manage pt is ?

A

PPI life long.

242
Q

How often to endoscope Pts w/ Barrett’s esophagus.

- Pt has EGD showing metaplasia *columnar epit.)..

A

EGD 3-5 yrs

243
Q

How often to endoscope Pts w/ Barrett’s esophagus.

- If EGD shows indefinite for dysplasia –> PPI + ….

A

EGD 2-6 months.

–> still indefinite? refer to esophageal pathologist –> indefinite confirmed –> repeat EGD in 1 yr

244
Q

How often to endoscope Pts w/ Barrett’s esophagus.

- If EGD shows dysplasia –> refer to ….

A

esophageal pathologist for confirmation.

if dysplasia confirmed –> endoscopic radiofrequency ablation.

245
Q

Pt on empiric PPI for 8 wks after discharge. What is most likely, when the PPI is discontinued?

A

new-onset heartburn

246
Q

erosive gastritis..

A

NSAIDS, EtOH, Stress (major surgery, burns, MICU, ventilator**)

tx: IV H2 blocker, PO PPI

247
Q

Chronic gastritis…

A 
Type A:
- fundus and body less common
- atrophic gastritis: loss of rugae in fundus 
- pernicious anemia
--> increased gastrin
--> adenocarcinoma x 3x.  
No need for surveillance endoscopy.

Type B:

  • antrum more common
  • caused by H.pylori
  • treat H.pylori only with sx
248
Q

A pt w/ hx of PUD on PPI or GI bleed should undergo what test for h.pylori?

A

antibody testing

urea breath test and fecal antigen = increased false neg., sensitivity decreases.
(Hold PPIs 2 wks and abx 4 wks before doing urea breath or fecal antigen tests)

249
Q

what will regress following treatment of h.pylori?

A

MALT

after treating pt..await histology report

250
Q

best test for a patient w/ gastric ulcer

A

EGD w/ bx

251
Q

NSAIDs w/ decreased incidence of PUD>

A

COX2 inhib
non acetylated NSAIDs (salsalate = disalcid)
non acidic prodrugs (nabumetone = relafen)
if nsaids have to be used, then co administer with COX-1 (misoprostol) or PPI

252
Q

Treatment of PUD

A

H2 receptor blockers –> ranitidine, famotidine. use in PM
(ranitidine, famotidine …. also use in chronic urticaria)

Sucralfate –> covers ulcer

PPI –> blocks H+-K+ ATPase pump. Use 30min before breakfast**

253
Q

Pt w/ acute UGI bleed, cont to bleed, HR 120, BP 90/60. confused. wtd next?

A

intubate.

254
Q

Pt w/ acute UGI bleed, cont to bleed, HR 120, BP 90/60. confused. intubated. receives 2L NS. becomes hemodynamically stable. wtd next?

A

endoscopy asap

255
Q

Pt w/ acute UGI bleed, cont to bleed, HR 120, BP 90/60. confused. intubated. receives 2L NS. becomes hemodynamically stable. At what Hb would you transfuse above pt. (nonexsanguinating, no comorbid factors)

A

7 g

256
Q

Pt w/ acute UGI. EGD: bleeding ulcer…

A

electrocautery. mnitor for 72 hrs

257
Q

Pt w/ acute UGI. EGD: visible vessel..

A

monitor, electrocautery . monitor for 72hrs

258
Q

Pt w/ acute UGI. bleeding varices..

A

octreotide infusion followed by banding. banding better than sclerotherapy for varices.

monitor 72hrs

259
Q

Pt w/ acute UGI. EGD: ulcer w/ a clean base (=no bleed) and < 2cm…

A

early feeding, PPI and send home or medical floor.

260
Q

Pt w/ sudden onset of vomitting presents w onset of red blood or coffee fround comitus. pt alcoholic or a bulimic or w a hiatal hernia. c/o epigastric pain or pain in the back. wtd

A

EGD to r/o mallory weiss tear: longitudinal lacerations in distal esophagus and prox stomach

–> begin PPI . for persistant nausea/emesis –> anti-emetics

261
Q

PPI use related to c.diff colitis

A

true

262
Q

PPI use related to HAP

A

true

263
Q

PPI use related to osteoporosis (vit D def)

A

true

264
Q

PPI use can cause hypomagnesemia

A

true

265
Q

PPI use related to microscopic colitis

A

true

266
Q

PPI use related to B12 deficiency

A

true. absorbed in the terminal ileum. metformin as well

267
Q

How to prevent rebleed in pt with PUD

A

PPI

268
Q

Pt w cirrhosis w/ varices develops variceal bleed. octreotide given banding done. started on BB to prevent rebleed. Ascites tap: 150 WBCs 40% PMNs. wtd.?

A 
IV cefriaxone 
(?????.... for 1 wk.  switch to rifax at time of dc to complete 1 wk?????)
269
Q

Pt w cirrhosis w/ varices returns a few weeks post admission with recurrent GI bleeds. MELD < 18.. wtd

A

transjug intrahepatic portosystem shunts (TIPS)

TIPS also with budd-chiari syndrome

270
Q

pt w cirrhosis and spider angiomata has UGI bleed w ulcer. wtd

A

ceftriaxone

271
Q

45 yo M p/w coffee ground emesis. 2 glasses wine/d. afebrile. HR 100, BP 120/80. EGD = no ulcer but gastric varices. wtd ? dx?

A

CT scan abdomen
dx: splenic v. thrombosis

only gastric varices= splenic vein thrombosis
esophageal + gastric varicies= cirrhosis

272
Q

pt taking naproxen for arthralgia x weeks.. p/w fatigue, BRBPR (1000cc). started prev as black tarry stool. Hb 9. Gastric lavage neg. wtd?

A

EGD. overt obscure gi bleed

neg? repeat EGD.–> then colonscopy

if repeat EGD and colonoscopy neg then RBC scan

273
Q

pt taking naproxen for arthralgia x past couple months.. p/w fatigue, Hb 10.5. fecal hemoccult positive. EGD neg. wtd?

A

colonoscopy

(????FOBT = <200cc blood loss. slow bleed???)

colonoscopy neg? capsule endoscopy or push enteroscopy

274
Q

dyspepsia

A
  • pain centered in the upper abdomen
  • no heartburn
  • no regurgitation
  • if it occurs in pts over age 50, consider it pathological
  • if after extensive workup including upper endoscopy no etiology is found it is called ‘non ulcer dyspepsia’
275
Q

43 yo M p/w complaints of upper abdominal pain. He denies any weight loss or diarrhea. PE norm. upper endoscopy and biopsy is negative for h.pylori, no ulcer seen. this represents..

A

non ulcer dyspepsia

276
Q

dyspepsia > 50yo or alarming sx (wt loss, bleed, odynophagia, etc) …. wtd

A

endoscopy

277
Q

dyspepsia < 50yo and no alarming sx , wtd

A

check for h.pylori

  • positive = tx
  • neg = tx w/ antiacid** 4-8 wks

sx persist? endoscopy

278
Q

Dumping syndromes.

Post prandial 15 min. later w palpitations, sweating, low BP…

A

rapid emptying (dumping syndrome)

279
Q

dumping syndromes.

post prandial >90 min later w palpitations, tachycardia, confusion. ..

A

hypoglycemia

280
Q

dumping syndromes tx?

A

freq small meals

complex sugars

281
Q

35 yo F w/ abdom fullness and discomfort and occasional emesis for past 2 years. She has not lost weight. PE is normal. Labs are normal. EGD and US of abdom is norm. dx?

A

post-prandial distress syndrome.

282
Q

Acute pancreatitis.. causes

A
  • gall stones (USA)
  • alcohol (leading in men 2nd)
  • **microlithiasis (leading in women 2nd)
  • hypertriglyceridemia > 1000mg/dl (lipase will look normal in 30%, amylase normal in 70%. microfiltration first)
  • sphincter of Oddi dysfunction
  • pancreatic divisum
  • ERCP
  • hypercalcemia
  • pancreatic carcinoma, autoimmune
  • drugs: thiazides, L-asparginase, pentamidine, bactrim, azathioprine, DPP-4 inhib**
283
Q

acute pancreatitis diagnosis

A

clinical w abdomin pain, nausea, emesis

labs: amylase, lipase elevated
XR: sentinel loop (sign of ileus, not SBO) (???ileus at duodenum near pancrease???)
CT scan w contrast or spiral CT

284
Q

pt w pmhx familial adenomatous polyposis w colectomy 4 yrs ago p/w icterus… wtd

A

EUS, to r/o ampulla of vater cancer

285
Q

pt p/w epigastric pain, RUQ pain and leukocytosis. what is the appropriate diagnostic step?

A

US gallbladder

  • shows stones w/ wall edema = calculous cholecystitis** (???surgery???)
  • shows stones w/o edema –> HIDA can –> non-visualization of gall bladder (i.e. cystic duct obstruction)–> calculous cholecystitis **

next–> sx (lap chole)

286
Q

pt p/w epigastric pain, RUQ pain and fever. ALT/AST and Alk Phos elevated. US = gallstones + hepatic duct dilation. dx? and wtd?

A

Mirizzi syndrome
- wtd? surgery (lap chole)

(???external compression of hepatic duct???)

287
Q

55 yo p/w fever, RUQ pain and jaundice. AST 220, ALT 330, AP 450. Total Bili 10.5. Indir Bili 2.2, Amylase 355. US neg. wtd?

A

Piperacillin-tazobactam

if pt becomes hypotensive, after IVF, do ERCP*

288
Q

pt w/ pancreatitis, w incr ALT,AST, AP. what is the approp dx step.?

A

US gallbladder to check for gall stones or dilated CBD

289
Q

Pt w/ severe pancreatitis. Incr AST, ALT, dilated CBD on IV abx in MICU. wtd next?

A

ERCP and remove stone.

after inflammation subsides and enzymes decrease, do cholecystectomy

290
Q

Pt w/ pancreastitis from stone, s/p laparoscopic cholecystectomy, 3days later p/w RUQ pain, icterus, and fever. AST/ALT/alk phos elevated . wtd next?

A
  • ->US to r/o impacted gallstone

- ->dilated duct–> ERCP and remove the stone

291
Q

Pt w/ pancreastitis from stone, s/p cholecystectomy. 3days later p/w RUQ pain, icterus, and fever. AST/ALT/AP elevated . went for ERCP. 3months later w/ epigastric pain and icterus. ALT/AST/Alk phos elevated. US showing dilated bile duct. wtd?

A

ERCP and manometric studies to r/o sphincter of oddi dysfunction

tx: endoscopic sphincterotomy
- if liver enzymes and US normal –> analgesia

292
Q

pt w/ intermittent dysphagia to solids and liquids. Associated w/ CP

A

diffuse esophageal spasm

293
Q

pt w/ intermittent dysphagia to solids and liquids. Associated w/ CP. What is it? Wtd next?

A

diffuse esophageal spasm
barium swallow will show corck screw esophagus
–> manometric studies showing non peristaltic contractions

now what is the next step in management
–> PPI

no response , treat w/ CCB such as diltiazem

294
Q

Zenkers diverticulum

A

herniated pouch in hypo pharynx

barium swallow

295
Q

40 y/o M w/ epigastric pain, weakness, anorexia, weight loss, labs reveal serum albumin of 2, calcium of 8. urine protein is negative. hypochlorhydria present. wtd?

A

EGD reveals striking enlargement of gastric folds or rugae.

dx–> Menetriers disease

296
Q

peptic ulcer disease

A

H. pylori –> leading casue
NSAIDs
Zollinger Ellison Syndrome

297
Q

H. pylori

A
  • gram negative, urease producing**
  • PUD (duodenal ulcers)
  • type B gastritis
  • gastric cancers
  • mucosa associated lymphoma (MALT)
  • treatment of H. pylori in low grade MALT results in tumors shrinkage or disappearance 50-80% of the time. Up to 30% of time, t (8;11) poor response to H. pylori therapy. Local RT required them. Await biopsy report before pronouncing cure. ***
298
Q

zollinger-ellison syndrome

A

-duodenal bulb/ stomach ulcer–> multiple ulcers
-gastrinomas in. med duodenum, pancreas, porta hepatis. Associated w/ MEN I
-can present w/ PUD or diarrhea/steatorrhea (inactivates pancreatic lipase)
-fasting gastrin level elevated. IF non diagnostic then do,
-I.V secretin–> increase gastrin to >1000
-CT scan or somatostatin receptor scintigraphy localize tumor
-treat w/ PPI or resection of tumor
-others that increase gastrin level:
_pernicious anemia/chronic gastritis
_ renal failure
_hyperthyroidism
_PPI

299
Q

All of the following are true about Zollinger Ellison

A
  • MC earliest radiographic finding is a single duodenal ulcer
  • ZE tumors are usually located on pancreas or duodenum
  • 2/3rd of ZE are malignant and a quarter of them associated w/ MEN 1
  • serum fasting of >1000mpg/ml w/ low pH is virtually diagnositc
  • life expectancy is normal if curative surgery is done, otherwise life expectancy is 2 yrs
  • recurrent duodenal ulcers or poor response to treatment is suggestive of ZE
300
Q

45 y/o asymptomatic man…wtd?

A

nothing

301
Q

40 y/o F asymptomatic w/ Family hx of gastric CA

A

nothing

302
Q

42 y/o M w/ dyspepsia and heartburn

A

H. pylori testing

303
Q

62 y/o w/ GERD w/o alarm symptoms

A

EGD

304
Q

62 y/o w/ GERD w/ weight loss

A

EGD

305
Q

43 y/o w/ peptic ulcer disease

A

H. pylori testing

306
Q

In a pt w/ severe pancreatitis. Pt w/ recurrent pancreatitis twice in the past 2 yrs. US reveals biliary sludge in gallbladder. wtd?

A

ERCP for biliary sampling to R/O microlithiasis
Look for pancreatic divisum and sphincterotomy if present.

tx–> cholecystectomy

307
Q

75 y/o post hip replacement, is recovering well, 6 days later, onset of pain in the upper abdomen w/ anorexia and fever of 103F. AST/ALT 40/52, total bili 1.1, amylase 90. US (NOT CT scan) reveals thickened wall of ball bladder (>3.5mm***), HIDA w/ non visualization of gallbladder but common bile duct visualized. iv abx begun. dx and tx?

A

dx: acalculous cholecystitits
tx: cholecystostomy
- -> put needle and drain fluid–> afterwards cholecystectomy

308
Q

Pt w/ hx of UC w/ jaundice. wtd next?

A
  • ->MRCP to r/o –> primary sclerosing cholangitis
  • ->Brush bx to r/o–> cholangiocarcinoma
  • ->US gallbladder to r/o–> polyp
  • ->cholecystectomy otherwise–> adenocarcinoma of GB
309
Q

Pt w/ epigastric pain and jaundice for a week. hx of vitiligo (clue of another autoimmune disorder). Alk phos 367 U/L, ALT 76 U/L, AST 114 U/L, amylase 260. US reveals enlarged pancreas w/ sausage shaped mass, bx negative for cytology. IgG4 elevated ** ERCP w/ dilated common bile duct w/ constriction in the pancreatic part of duct***. What is the best management?

A

Dx? autoimmune pancreatitis

tx: steroids***

310
Q

Pt w/ hx of pancreatitis twice in the past year w/ abdominal pain radiating to the back. TGAs are 350. He drink socially. Amylase and lipase are elevated. AST/ALT appear normal. US normal. ERCP is done which reveals ventral duct contents are flowing normally to the major papilla. Dorsal duct is dilated* and content flowing thru the minor papilla sluggishly*. Most likely reason for pancreatitis?

A

pancreas divisium

311
Q

Pt found to have incidental finding of calcification of gall bladder on US of abdm. wtd?

A

surgery

porcelain GB

312
Q

Pt presents w/ severe pancreatitis.
T: 102F, WBC 15400 w/ 85% PMNs.
Lipase 920 U/L. Blood lactate level is 2.4 (normal 0.6-1.8).
CT shows undifferentiated mass. what is best management?

A

NO antibiotics

The most important prognostic factor in acute pancreatitis is INCREASED BUN

313
Q

Pt w/ severe acute pancreatitis. Best way to provide nutrition is?

A

NG tube

314
Q

Pt w/ pancreatitis. Amylase day 1 is 13,000, day 2 is 11,000, day 3 is 7,000. how long do you wanna check amylase?

A

stop checking

315
Q

Pt w/ severe epigastric pain, vom, serum lipemic w/ triglycerides >1000. Amylase appears normal. (Normal amylase 70%, normal lipase 30%). dx? wtd to establish dx?

A

pancreatitis
wtd to establish dx?
-> **ultra filter TGAs and repeat amylase or
-> **dilute serum and remeasure amylase

316
Q

Pt post sx w/ icterus. AST/ALT normal. Direct [conjugated] bili elevated. alkaline phosphatase elevated.
(PT /INR can increase, PTT can increase)

dx?

A

benign post operative cholestasis

317
Q

the best diagnostic test for gallstones?

A

US

318
Q

f/u Pt has pancreatitis and was discharged 2 wks ago, mass in abdomen is palpable, non-tender, bowel sounds heard. Amylase level 435. Dx?

A

pseudocyst

319
Q

Pt w/ pancreatitis. Common bile duct dilated. wtd?

A

ERCP

320
Q

Pt w/ severe pancreatitis. US neg for gall stones. Triclycerides normal. wtd?

A

ERCP

321
Q

Pt w/ pancreatitis. increased AST + Alk phos. wtd?

A

US gallbladder

322
Q

Pt w/ biliary pancreatitis. Week later w/ normalizing enzymes and clinically imprved. wtd?

A

laparoscopic cholecystectomy

323
Q

chronic pancreatitis….

A
  • MC cause is alcoholism**
  • pancreatic calcifciation + in 50%, DM +
  • malabsoption w/ steatorrhea (>40g/day virtually diagnostic)
  • Treat steatorrhea + abdominal pain w/ high dose pancreatic lipase enzymes empirically for 6 wks–> pregabalin
324
Q

Pt w/ abdominal discomfort. Abd xray: calcification in med abdm area. What complication will this pt develop?
what is the dx?

A

complication: DM
dx: chronic pancreatitis

325
Q

asymptomatic pancreatic cysts workup:

A

worrisome features on CT:

  • solid component**
  • size >3 cms **
  • dilated duct> 10mm **
  • thickening of cyst**
326
Q

asymptomatic pancreatic cyst …

if at least worrisome feature on CT scan (ex: solid component + >3 cms)…wtd?

A

EUS FNA

327
Q

asymptomatic pancreatic cyst …
w/ at least worrisome feature on CT scan (ex: solid component + >3 cms).

EUS FNA confirms at least 2 worrisome features, wtd?

A

resect

328
Q

asymptomatic pancreatic cyst …
w/ at least worrisome feature on CT scan (ex: solid component + >3 cms).

IF EUS FNA negative for worrisome features. wtd?

A

MRI in 1 yr, then Q2yrs

329
Q

asymptomatic pancreatic cyst …
w/ at least worrisome feature on CT scan (ex: solid component + >3 cms).

If EUS FNA confirms solid component and dilated duct, but FNA neg. wtd?

A

resect

330
Q

asymptomatic pancreatic cyst …
CT scan shows <3 cms lesion, no solid component, no dilated duct.
wtd?

A

MRI in 1 yr, then Q2yrs –> for total for 5 yrs surveillance.

331
Q

asymptomatic pancreatic cyst …

2 cms lesion on CT , F/u MRI in 1 yr shows size change, then?

A

–> EUS FNA

332
Q

asymptomatic pancreatic cyst …

EUS -FNA shows **inflmmatory cells and RBCs **. wtd?

A

resect

333
Q

cyst resected for malignant lesions. wtd?

A

repeat MRI q 2 yrs

334
Q

large cyst resected but no evidence of malignancy. wtd?

A

no need for f/u after resection .

335
Q

Ulcerative colitis
CI ft:

pg 417 chart

A

Hematochezia
abdominal pain
diarrhea
tenesmus

336
Q

Crohn’s disease
CI ft:

pg 417 chart

A

Rt lower quadrant mass

diarrhea

337
Q

Ulcerative colitis
Path?

pg 417 chart

A

superficial ulcer w/ crypt abscess!

338
Q

Crohn’s Disease
path?

pg 417 chart

A

deep ulcers w granulomas!

339
Q

Ulcerative Colitis
Xray?

pg 417 chart

A

toxic megacolon

340
Q

Crohn’s disease
xray?

pg 417 chart

A 
toxic megacolon (more common)
string sign
341
Q

Ulcerative colitis
extra- intestinal manifestations?

Pg 417 chart

A 
E nodosum
Rh. neg arthritis
pyoderma ganrenosum
ankylosing spondylitis
sclerosing cholangitis

mirror colitis: e. nodosum, Rh.neg arthritis, pyoderma gangrenosum

342
Q

Crohn’s disease
extra-intestinal manifestations?

Pg. 417 chart

A

Rare

343
Q

Ulcerative colitis
CA?

Pg 417 chart

A

+++

344
Q

Crohn’s
CA?

pg 417 chart

A

+

345
Q

Ulcerative colitis
Colonoscopy?

Pg 417 chart

A

after 8 years, then every q 1-2 yrs ***

346
Q

Crohn’s disease
colonoscopy?

pg 417 chart

A

after 8 years, then every q 1-2 yrs ***

347
Q

Ulcerative colitis
Labs?

Pg 417 chart

A

p-ANCA +

myeloperoxidase abs

348
Q

Crohn’s disease
Labs?

Pg 417 chart

A

ASCA +

Anti-saccharomyces Cerevisiae antibodies

349
Q

best way to screen for inflammatory bowel disease?

A

fecal calprotectin ( most sensitive)

350
Q

Mirror colitis ?

A

E. nodosum
peripheral arthritis
pyoderma gangrenosum

351
Q

DON’T mirror colitis?

A

sacroiliitis

primary sclerosing cholanitis

352
Q

string sign?

A

narrowing of distal ileum

353
Q

A 34 y/o woman w/ UC now complains of pain in the small joints of the hand w/ 30 min of early morning stiffness. treatment?

A

sulfasalazine

354
Q

Pt w/ diarrhea and RLQ mass. T 101 F and has an ulcer on the tongue. Dx?

A

Crohn’s disease

355
Q

Pt w/ bloody diarrhea for last 2 yrs. 3 wks ago, went to mexico. Colonoscopy revealed erythematous appearance w/ friable mucosa in distal colon.

A

Ulcerative colitis

356
Q

Ulcerative colitis Toxic megacolon (6+cm), management?

A

steroids, broad spec abx–> surgery
(reassess in 24 hrs if and no change, perform surgery)
(if bp decreases–> sx)

357
Q

Ulcerative colitis maintenance?

A

NO STEROIDS
hydrocortisone enema
5ASA supp, qHS to q3hrs

358
Q

Ulcerative colitis flare?

A

sulfasalzine
mesalamine (Asacol + pentasa)

+/- prednisone or ACTH–> resistance–> 6MP + Azathioprine

5-ASA enema, hydrocoritsone enema

5-ASA supp or mesalamine supp h.s to tid –> cortisone foam

359
Q

treatment for UC/ Crohn’s?

A
  • 5-ASA (mesalamine) is the active compound
  • sulfasalazine= 5-ASA + sulfapyridine in the colon by bacterial action. Hence sulfasalazine would not be of much help in disease of small bowel, where there is not much bacteria.
  • 5 ASA is the active component whereas sulfapyridine contributes to reversible infertility (esp in males) and leukpenia
  • Olsalazine = 5-ASA + 5-ASA which is split in the colon
  • Balsalazide = 5-ASA + inert product which split in colon
  • Mesalamine compounds (Asacol & Pentasa) release dependent on Ph of colon .
  • perianal abscess and fistula in CD, treat w/ anti TNF alpha, metronidazole with no efficacy.
  • 6 Mercaptopurine + Azathriprine are steroid sparing!!!!
360
Q

What diseases wake pt up at night?

A

inflammatory bowel dx
bacterial overgrowth syndrome
microscopic colitis

361
Q

If ulcerative colitis gets better, PSC continues!

If LFTs and bilirubin worsen..wtd?

A

refer for transplantation

362
Q

Which medication would you use for manitenance treatment in UC or Crohn’s dx?

A

5-ASA (mesalamine) +/- metronidazole

363
Q

What medication do you NOT use in maintenance in UC or Crohn’s dx?

A

steroids

364
Q

A 26 y/o F c/o passing fecal material thru vagina. Recto-vaginal fistual diagnosed. colonoscopy revelas skip ulceration int he large bowel. You would start?

A

Anti TNF alpha.

Adverse effect? reactivation of TB, histo.
Stop if going for major sx, can cause wound dehiscence.

Think pt demographics and fungal infection from that area.

365
Q

A 24 y/o w/ hx of UC for past 4 yrs. p/w jaundice, fever. Hepatomegaly +, bilirubin is 3.5, alk phos 950, AST 240, ALT 258, ANA neg, ASMA neg, AMA neg, P-ANCA +. Most appropriate diagnositc test?

A

ERCP/MRCP will reveal beading and focal dilation of biliary tree.

if pt continues to have worsening of jaundice and increase bilirubin and LFTs. The most appropriate step is???
refer for liver transplantation.

366
Q

string sign in what dx?

A

crohn’s disease

367
Q

shallow ulcer extending frm the recturm

dx?

A

UC

368
Q

toxic megacolol

what dx?

A

UC and CD

more common in UC

369
Q

cancer

what dx?

A

UC and CD

370
Q

sclerosing cholangitis

what dx?

A

UC and CD

371
Q

infliximab

what dx?

A

UC and CD

372
Q

Azathioprine

what dx?

A

UC and CD

373
Q

P-ANCA (MPO)

What dx?

A

UC

374
Q

ASCA

what dx?

A

Crohn’s disease

375
Q

Colonoscopy after 8 yrs w/ the d

in what dx?

A

UC and CD

376
Q

Tenesmus

what dx?

A

UC

377
Q

diarrhea, RLQ mass w/ pain

what dx?

A

CD

378
Q

crypt abscess

what dx?

A

UC

379
Q

granulomas

dx?

A

CD

380
Q

calcium oxalate stones

increase oxalate absorption, decrease citrate + decrease B12 absorption

A

CD

381
Q

perianal fistula

what dx?

A

CD

382
Q

fecal soiling on urination

what dx?

A

CD

383
Q

smoking makes it better

what dx>

A

UC

384
Q

Acute diarrhea

Enterotoxigenic?

A

E. coli
Vibrio cholarae
Clostridium perfingens
bacillus cereus

385
Q

Acute diarrhea

invasive?

A 
C. jejuni (leading cause in US)
salmonella (leading enterocolitis)
shigella
0157: H7 (don't give abx or can cause TSS)
c. difficile
386
Q

Acute diarrhea

parasitic?

A

giardiasis

amebiasis

387
Q

Chronic diarrhea?

A
  • cryptosporidium (T cells <100)
  • isospora
  • MAC
  • CMV (T cells low)
  • DM
  • IBS
  • IBD
  • carcinoids (osmotic gap <50)
  • laxative abuse (osmotic gap >50)

Giardia and cryptosporidium are resistant to chlorination of water

388
Q

Elderly Pt w/ diarrhea, fever, and confusion after eating soft cheeses. dx?

A

listeriasis

389
Q

pt camping on river stream presents w/ diarrhea for a wk.

dx? management?

A

Giardiasis

management: metronidazole

390
Q

Pt attends a party eats rice (B. Cereus), chicken (salmonella), and salad (staph aureus toxin). Upon reaching home about 4 hrs later, has diarrhea w/ no blood.

most likely organism?

A

staph. aureus (toxin)

391
Q

HIV pt w/ T cell <50 presents w/ chronic diarrhea, small frequent stools, occasionally explosive diarrhea w/ lower abdominal cramps. Feels like moving bowel frequently. Hematochezia +. Dx, Tx?

A

Dx: biposy (CMV)
tx: Gancyclovir followed by ART 2 wks later

392
Q

HIV pt w/ T cells <50 presents w/ chronic diarrhea, large volume w/ bloating, gas, low grade fevers. Alk increased
Dx. and Tx?

A

Dx: blood culture (MAC)
Tx: ethambutol + macrolide w/ ART

393
Q

HIV pt w/ T cells <100 presents w/ severe chronic diarrhea, large volume rsulting in dehydration and electrolyte dsturbances. Dx and Tx?

A

Dx: microscopy, ELISA
TX: ART w/ supportive care.

394
Q

cdiff + WBC >15,000 or age >60, with diarrhea after 2 wks, wtd?

A

vancomycin pulse therapy OR fidaxomicin OR fecal transplant

395
Q

diarrhea, cdiff + WBC >15,000 or age >60, treated w/ vancomycin pulse therapy w/ diarrhea again. wtd?

A

fecal transplant

most likely right choice

396
Q

Pt tx w/ fidaxomicin w/ c diff diarrhea a month later, wtd?

A

fecal transplant.

397
Q

Pt w diarrhea, C. diff positive. WBC 18,000 and w/ ileus, wtd?

A

PO vancomycin + IV metronidazole

398
Q

Absorption of Nutrients
Causes of Malabsorption

  • pancreatitis
  • bile salts
  • mucosal
  • lymphatic
  • others
A

pancreatitis:

  • chronic pancreatitis
  • pancreatic CA
  • CF

Bile salts:

  • cholestasis
  • illeal resection/ Crohn’s disease
  • bacterial overgrowth
  • zollinger Ellison syndrome

Mucosal: D- xylose test abnormal

  • Celiac sprue
  • tropical sprue
  • whipple’s disease
  • eosinophilic gastroenteritis
  • small bowel syndrome
  • amyloidosis

Lymphatic:

  • intestinal lymphangiectasia
  • intestinal lymphoma

Others:
-ZE, carcinoid

399
Q

Malabsorption
table 428

For pancreatitis, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?

A

fecal fat:very increased!
D-xylose: N
bile acid: N
breath test: N

400
Q

Malabsorption
table 428

For biliary disease, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?

A

fecal fat: increased
D-xylose: N
bile acid: decreased
breath test: N

401
Q

Malabsorption
table 428

For bacterial overgrowth, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?

A

fecal fat: increased
D-xylose: N/ decreased
bile acid: decreased
breath test: abnormal

402
Q

Malabsorption
table 428

For mucosal, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?

A

fecal fat: increased
D-xylose: abnormal
bile acid: N
breath test: N

403
Q

Malabsorption
table 428

For lymphatic, inc/dec/ or normal for fecal fat, D-xylose, bile acid, and breath test?

A

fecal fat: increased
D-xylose: abnormal
bile acid: N
breath test: N

404
Q

pt on self gluten free diet, if antibodies are neg, then do?

A

HLA DQ 2 or 8

405
Q

young woman w/ diarrhea, bloating, fatigue, fogginess**, and H/A. She went on gluten free w/ fever symptoms. When she started gluten again, she had recurrence of symptoms. wtd?

A

anti gliadin abs

non- celiac gluten senitivity

406
Q

14C xylose test and measure exhaled 14 CO2

A

bacterial overgrowth

407
Q

impaired chylomicron production due to dec globulins

A

abetalipoproteinemia

408
Q

dilated lymphatic vessels

A

intestinal lymphangiectesia

409
Q

fecal fat 50 g/ day

A

pancreatic insufficiency

chronic pancreatitis

410
Q

klebsiella/ e. coli

A

tropical sprue

411
Q

tropheryma whipplei

A

whipples disease

412
Q

transglutaminase abs

A

celiac sprue

413
Q

tetracycline + folic acid

A

tropical sprue

414
Q

bactrim or tetracycline

A

whippl’es disease

415
Q

gluten free diet

A

celiac sprue

416
Q

intestinal lymphoma

A

celiac sprue

417
Q

arthritis, weight loss, neurological symptoms, hyperpigmentation

A

whipples disease

418
Q

bullous skin diases, dermatitis herpetiformis, howell jolly bodies

A

celiac sprue

419
Q

megaloblastic anemia

A

tropical sprue

420
Q

iron def aneia

A

celiac sprue

421
Q

AVMs (arterio-venus malformations) in all organs

A

Osler- Weber- Rendu syndrome

422
Q

angiogram

A

acute mesentric ischemia

chronic mesentric ischemia

423
Q

colonscopy

A

ischemic colitis

424
Q

hydration and abx

A

ischemic cholitis

425
Q

angioplasty

A

chronic mesentric ischemia

426
Q

thrombolytics or sx

A

acute mesentric ischemia

427
Q

Acute Hep B

A

HBsAG +
Anti -HBs -
Anti-HBc: IgM

428
Q

chronic Hep B

pg 440

A

HBsAG +
Anti -HBs -
Anti-HBc: IgG (ALT/ inc)

429
Q

carrier Hep B

pg 440

A

HBsAG +
Anti -HBs -
Anti-HBc: IgG (N)

430
Q

past infection

A

HBsAG -
Anti -HBs +
Anti-HBc: IgG

431
Q

post vaccination

A

HBsAG -
Anti -HBs + (titer >10)
Anti-HBc: -

432
Q

chronic/ past hepatit B/ false +

A

HBsAG -
Anti -HBs -
Anti-HBc: IgG

433
Q

Pt received 1st dose of Hep B vaccine last year, presents for regular follow up. Can you give second dose now?

A

yes

no specific time frame b/w 1st and 2nd dose

434
Q

for any level HBV DNA , on immune suppressives, treatment?

A

yes for up to 1 year after

435
Q

Hep c abs are neg, but you still suspect hep C b/cpt has fatigue and liver enzymes elevation, wtd next?

A

Do HCV RNA

in this pt, HepC abs positive (can be false +) and Hep C RNA (NAAT) neg. wtd next?
tell pateint does not have HCV

436
Q

Pt w/ hep C w/ high viral load and compensated cirrhossi is depressed. what is best management for hep c?

A

sofusbuvir/ ledipasvir

437
Q

pt w/ cirrhosis and ascites w/ RUQ pain. US shows hepatic veing thrombosis . wtd?

A

triple phase CT scan to R/O hepatocellular carcinoma**

438
Q

indications of liver transplant

A

cirrhotics w/ clinical decompensation:

ascites, variceal bleed, hepatic encephalopathy, or biochemical decompensatiosn; increase in Cr, bilirubin and PT INR

439
Q

CI for liver transplant

A

active alcohol abuse or illict drug use
extrahepatic CA
unresolved sepsis or fungemia

440
Q

relative CI to liver translplant

A
  • active HIV disease and H. ep C

- Hep B w/ e Ag postitive–> treat for Hep b b/4 transplant or if urgent –> transplant and give HBIG

441
Q

cirrhosis portal

A

asciitc fluid protein 1.8 (low ), albumin 3g, ascitic fluid albumin 1.5 (lo) SAAG 1.5

442
Q

liver failure

A

asciitc fluid protein 1.8 (low ), albumin 3g, ascitic fluid albumin 1.5 (lo) SAAG 1.5

443
Q

liver failure portal

A

asciitc fluid protein 1.8 (low ), albumin 3g, ascitic fluid albumin 1.5 (lo) SAAG 1.5

444
Q

R heart failure portal

A

asciitc fluid protein 2.5 (high ), albumin 3g, ascitic fluid albumin 1.6 (low) SAAG 1.4

445
Q

budd-chiari syndrome

A

asciitc fluid protein 2.5 (high ), albumin 3g, ascitic fluid albumin 1.6 (low) SAAG 1.4

446
Q

nephrotic syndeome nonportal

A

asciitc fluid protein 2 (low ), albumin 2.8g, ascitic fluid albumin 1.8 (high) SAAG 1.0

447
Q

pancreatits

A

asciitc fluid protein 2.5 (high ), albumin 3g, ascitic fluid albumin 2.2 (high) SAAG 0.8

448
Q

all of following is ture of bacterial peritonitis

A

-usually a single organism is involved
-10-20% cirrhotics develop SBP
-start 3rd gen cephalo along w/ albumin iv
treat for PMN of >250

protein restriction does not prevent hepatic encephalopathy

449
Q

all of following is true of bacterial peritonitis

A

-usually a single organism is involved
-10-20% cirrhotics develop SBP
-start 3rd gen cephalo along w/ albumin iv
treat for PMN of >250

protein restriction does not prevent hepatic encephalopathy

450
Q

pt w/ hepatic encephaloppathy started on lactulose w/ little impovement and cannot tolerate higher doses b/c of diarrha. has ongoing encephalopaty on lactulose and rifximin. wtd?

A

add probiotics

451
Q

pt s/p sx NPO or pts taking abx for bronchitis develops icterus
AST/ALT normal, alk phos normal, Hb 13,retic 1.5%
indirect bili elevated ex: 4.2
direct bili 0.3. couple days later the total bili is 2.5

dx?

A

gilbert’s syndrome

due to decreased glucoronyl transferase

wtd?nothhhiiinnggg bro

452
Q

love you baby

you got this!

A

keep going!

:)

2018 Awesome rev (7 decks)

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