ABIM 2015 - Gastro Flashcards
Condition which presents with oropharyngeal dysphagia with aspiration, neck mass and regurgitation of foul-smelling food?
Zenker diverticulum
Condition which presents with oropharyngeal dysphagia with aspiration, neck mass and regurgitation of foul-smelling food?
Zenker diverticulum
What does recurrent pneumonia signal in an elderly patient or a patient suffering from a neurological or muscular disorder?
Dysphagia with aspiration
What is the diagnostic first-line test of choice for oropharyngeal dysphagia?
Video fluoroscopy (modified barium swallow)
What is the diagnostic test of choice for esophageal dysphagia?
EGD
What is the diagnostic test of choice for esophageal dysphagia?
EGD
When a patient with possible GERD c/o chest pain, what must be done first?
Rule out cardiac cause
What is the diagnostic test of choice for odynophagia?
EGD
What is the diagnostic test of choice for odynophagia?
EGD
What is the innervation of the esophagus and what is the resting state of the sphincters?
Vagus nerve; Tonically closed
What is the primary screening test for achalasia? What test is REQUIRED for confirmation?
Barium radiography (barium swallow); Manometry
What is the condition called when there is an obstruction at the distal esophagus due to malignancy?
Pseudoachalasia
After a myotomy performed for achalasia, what other procedure is often performed to prevent GERD?
Nissen fundoplication
What are two non-surgical options for the treatment of achalasia?
Repeated balloon dilation or BOTOX
What is the first line treatment for diffuse esophageal spasm?
Calcium Channel Blockers
What meds are most successfully used to treat symptoms of diffuse esophageal spasm (dysphagia, chest pain)?
Trazodone, imipramine, BOTOX
What meds are most successfully used to treat symptoms of diffuse esophageal spasm (dysphagia, chest pain)?
Trazodone, imipramine, BOTOX
What type of motility disorder do meds like narcotics and diseases like scleroderma cause?
HYPOmotility disorders
The COMBINATION of manometrically-determined aperistalsis of the esophagus AND a HYPOtensive lower esophageal sphincter is?
Scleroderma esophagus
The COMBINATION of manometrically-determined aperistalsis of the esophagus AND a HYPOtensive lower esophageal sphincter is?
Scleroderma esophagus
What is the treatment for scleroderma esophagus?
Treatment of underlying disease and GERD
What is the treatment for scleroderma esophagus?
Treatment of underlying disease and GERD
What are the three most common types of infectious esophagitis?
Candida, HSV and CMV
Why can the use of corticosteroids, azathioprine and TNF-alpha inhibitors cause esophagitis?
These cause immunosuppression in immunocompetent individuals
Infectious esophagitis with isolated ulcer(s)? How is diagnosis made?
CMV esophagitis, biopsy of ulcer BASE
Infectious esophagitis with multiple superficial ulcers? How is diagnosis made?
HSV esophagitis, biopsy of ulcer edges
Infectious esophagitis with multiple superficial ulcers? How is diagnosis made?
HSV esophagitis, biopsy of ulcer edges
How is HSV esophagitis treated? CMV esophagitis?
HSV: acyclovir; CMV: gancyclovir
What portion of the heart makes an indentation on the esophagus?
LEFT atrium
Tetracycline, Iron Sulfate, bisphosphonates, NSAIDS, potassium and quinidine all have this potential esophageal disorder in common?
Pill-induced esophagitis
What disease MUST be excluded prior to initiation treatment for Eosinophilic Esophagitis?
GERD (by pH monitoring or lack of therapeutic response to 6-week trial of BID PPI), because it too can present with >15 eosinophils/hpf
Excessive number of LES relaxations not initiated by swallowing and formation of a hiatal hernia can cause?
GERD
What do Xerostomia (decreased formation of saliva), Scleroderma, Nicotine use and Obesity have in common?
These can all exacerbate GERD
What combination of symptoms is sufficient to diagnose GERD?
Heartburn, regurgitation or both
Dysphagia, Anemia, Vomiting, Weight loss?
ALARM symptoms of GERD indicating EGD work-up
What is the next diagnostic step for a patient who had no response to PPI for GERD and had a negative EGD?
Ambulatory pH monitoring/impedance monitoring
What should be recommended to ALL patients with long-term PPI therapy (daily or BID dosing regimens)?
Adequate calcium + Vitamin D intake
After successful anti-reflux surgery, GERD symptoms usually return within how many years?
5-10 (repeat surgery success rates are much lower)
Does anti-reflux surgery reduce risk of GERD-related adenocarcinoma?
NO
Does anti-reflux surgery reduce risk of GERD-related adenocarcinoma?
NO
When should cough, laryngitis and asthma be treated with PPI’s?
ONLY when associated with GERD
What epithelial types are changed in Barrett’s esophagus?
NORMAL squamous changes to ABNORMAL columnar
If a patient has had GERD symptoms for 11 years but no alarm symptoms, should you do EGD to evaluate for Barrett’s esophagus?
NO (not currently recommended)
What two medications/medication types confer a decreased risk of esophageal adenocarcinoma?
Aspirin and other NSAIDS
What is REQUIRED for histologic diagnosis of Barrett’s Esophagus?
Intestinal metaplasia AND presence of Goblet Cells
What is REQUIRED for histologic diagnosis of Barrett’s Esophagus?
Intestinal metaplasia AND presence of Goblet Cells
Although esophageal ADENOCARCINOMA is the predominant type of esophageal cancer, what are the risks for SQUAMOUS CELL CARCINOMA of the esophagus that are NOT found with adenocarcinoma type?
Alcohol, Nitrosamines (hot dogs, etc.), Zinc & Selenium deficiency, Achalasia, Tylosis (keratosis of palms and soles), HPV.
Although esophageal ADENOCARCINOMA is the predominant type of esophageal cancer, what are the risks for SQUAMOUS CELL CARCINOMA of the esophagus that are NOT found with adenocarcinoma type?
Alcohol, Nitrosamines (hot dogs, etc.), Zinc & Selenium deficiency, Achalasia, Tylosis (keratosis of palms and soles), HPV.
What portions of the esophagus are generally affected by SQUAMOUS CELL CARCINOMA and ADENOCARCINOMA?
Squamous Cell - PROXIMAL; Adenocarcinoma - DISTAL
BE on EGD, no dysplasia, surveillance?
1-yr, if no dysplasia, every 3 yrs.
BE on EGD, LOW-grade dysplasia, surveillance?
6-mo, then YEARLY.
BE on EGD, HIGH-grade dysplasia, surveillance?
EMR or Surgery, EGD every 3 months after.
BE on EGD, HIGH-grade dysplasia, surveillance?
EMR or Surgery, EGD every 3 months after.
How is esophageal cancer staged?
CT (metastases) + EUS (regional) + PET
What differentiates a gastric ulcer from an erosion?
Ulcer is >5 mm
Stomach pain shortly after meals NOT relieved by antacids?
Gastric Ulcer
Stomach pain 2-5 hours after a meal relieved by antacids?
Duodenal Ulcer
Stomach pain 2-5 hours after a meal relieved by antacids?
Duodenal Ulcer
Multiple ulcers beyond duodenal bulb with esophagitis and diarrhea?
Gastrinoma
A deep duodenal/gastric ulcer can affect what organ?
Pancreas
A deep duodenal/gastric ulcer can affect what organ?
Pancreas
Pt with KNOWN NSAID use and PUD, what should you still ALWAYS test for?
H.pylori
If H.pylori is POSITIVE in patient with PUD with ulcer 1 cm?
NONE (however some prescribe 4-8 weeks); Until H.pylori eradication testing is confirmed
If perforation is suspected in a patient with PUD, is EGD indicated?
NO!
If perforation is suspected in a patient with PUD, is EGD indicated?
NO!
If perforation is suspected in a patient with PUD, is EGD indicated?
NO!
When should you perform an EGD in a patient with family h/o gastrointestinal malignancy?
If they are symptomatic (dyspepsia, etc.) because this is considered an ALARM feature
When should you perform an EGD in a patient with family h/o gastrointestinal malignancy?
If they are symptomatic (dyspepsia, etc.) because this is considered an ALARM feature
In a patient younger than 50, from an area with low-risk for H.pylori infection, should you test for H.pylori if symptoms of dyspepsia are present BEFORE treating with PPI?
NO
In a patient younger than 50, from an area with low-risk for H.pylori infection, should you test for H.pylori if symptoms of dyspepsia are present BEFORE treating with PPI?
NO
What is MALT-lymphoma associated with?
H.pylori
How do PPIs, H2-blockers, antibiotics and bismuth affect H.pylori tests (except?)?
Decrease sensitivity, EXCEPT for Serology (IgG)
How do you treat H.pylori infection? PCN allergy?
Clarithromycin+Amoxicillin+BID PPI 10-14 days; Metronidazole
When post H.pylori treatment should you test for eradication when indicated (PUD, h/o gastric cancer, MALT lymphoma)?
4-6 weeks
Would you prescribe a COX-2 inhibitor in a patient with cardiovascular risk, why?
No (increased risk for cardiovascular ischemic events)
What should patients older than 50 who require chronic NSAID therapy be tested for?
H.pylori
What is compulsive hot-water bathing associated with?
Cannabinoid hyperemesis syndrome
What constitutes a POSITIVE gastric emptying study for diagnosis of gastroparesis?
> 60% retained food at 2 hours or >10% at 4 hours
What two meds can cause false-positive results with gastroparesis?
Opioids and Anticholinergics
What endoscopic therapy is available for refractory gastroparesis?
BOTOX injection into pylorus
What should you do NEXT in a patient
Colonoscopy to rule out FAP
What is the best follow-up for pts who underwent EGD and were found to have extramural lesions/compression on upper gi tract structures?
CT/MRI
CD117(c-kit protein) and CD34 expression are seen in what GI tumors? Treatment?
GIST; Resection +/- chemothreapy
How do you treat Type I, II and III gastric carcinoid tumors?
Types I & II with EMR if 2 cm; Type III with gastrectomy
What is the surveillance required after resection of a carcinoid tumor?
EGD in 6-12 months for 3 years
Ionizing radiation, heavily salted foods and a high-carbohydrate diet in the Asian population carry a hight risk of what?
Gastric adenocarcinoma
Most common bariatric procedure?
Roux-En-Y
What is the most RELIABLE indicator of an anastomotic leak after gastric bypass surgery?
HR >120bpm
The two most common causes of post-op mortality in patients who undergo bariatric surgery?
Venous thromboembolism and anastomotic leaks
What are the common vitamin and mineral deficiencies after gastric bypass surgery?
Iron, Vitamin A, B12, D & E and Calcium, Thiamine, Folate
Gastric bypass patient presents post-prandially, with abdominal distenstion, nausea, diarrhea, sweating, tremulousness and comfusion? Why?
Dumping syndrome; due to osmotic load from rapid emptying of refined sugars from stomach
What is a good predictor of severity in acute pancreatitis?
Persistent organ failure (hypoxemia, hypotension, renal failure)
How high must the elevation of amylase/lipase be for acute pancreatitis to be diagnosed?
3x UPPER limit of normal
What single lab value is the best in acute pancreatitis for prediction of severity?
BUN
What should be done with a patient with documented necrotizing pancreatitis to guide further therapy?
Sampling of collection
When should feedings begin in patient with acute pancreatitis and how?
ASAP; Nasojejunal
Why can some patients after acute pancreatitis present with gastric varices?
Splenic vein thrombosis (DO NOT treated with anticoagulation!)
How is chronic pancreatitis treated?
Enzyme supplements and fat-soluble vitamins
What type of pancreatic enzymes should be used to treat pain in chronic pancreatitis?
NON-enteric coated + PPIs (because otherwise they’ll be denatured by gastric acid)
Most important risk factor for pancreatic adenocarcinoma?
Age >50
When do patients with pancreatic cancer present with pain?
When tumor arrises in the BOP or TOP
Migratory thrombophlebitis and palpable gallbladder?
Pancreatic cancer
Is tissue sampling for pancreatic cancer necessary if imaging (CT/EUS) is characteristic of a resectable tumor?
NO
How do you treat local pancreatic adenocarcinoma without vascular invasion or mets?
Surgical resection + chemotherapy
How do you treat pancreatic adenocarcinoma with vascular invasion?
Neo-adjuvant chemotherapy with re-staging after therapy
Affected organs have a lyphoplasmacytic infiltrate rich in IgG4 and the disease responds to corticosteroid therapy or corticosteroids with 6MP or azathioprine?
Autoimmune Hepatitis (AIP)
What are all pancreatic cystic neoplasms associated with ?
von Hippel-Lindau disease
Which pancreatic cystic neoplasms have the highest malignant potential? what’s the treatment?
Main and combined (main and side-branch) IPMN’s; surgical resection (regardless of size)
When do you NOT resect a pancreatic cystic neoplasm?
When SIDE-branch only or not connected to duct, are LESS than 3 cm (
Where are mucinous cystadenomas and cystadenocarcinomas of the pancreas typically found?
Body and Tail of pancreas
What is the recommendation when pancreatic mucinous cystadenomas and cystadenocarcinomas are found?
Resection
When should pseudocysts of the pancreas be drained or resected?
When they cause localized symptoms or are infected
A pancreatic cyst HIGH in CEA is what?
IPMN or MUCINOUS cyst
Tumors of the pancreas associated with MEN-I and von Hippel-Lindau disease?
Pancreatic neuroendocrine tumors
Which is the most common pancreatic neuroendocrine tumor?
Gastrinoma
How are gastrinomas treated? What if they are metastatic?
Resection; Acid suppression (PPI) + Octreotide (to suppress diarrhea)
What imaging technique can be used to detect pancreatic neuroendocrine tumors EXCEPT Insulinomas?
Octreotide Scan (Scintigraphy)
Since Octreotide Scan (Scintigraphy) cannot find pancreatic neuroendocrine tumors of the Insulinoma type, what can be used?
EUS
What should be done with ALL pancreatic neuroendocrine tumors?
Resection
What pancreatic neuroendocrine tumor can cause DM with dermatitis?
Glucagonoma
What pancreatic neuroendocrine tumor can cause diarrhea with low potassium and low chloride?
VIP tumor
What is the duration of diarrhea to be considered acute? Chronic?
Acute 4 weeks
What type of diarrhea results in the loss of fat, carbohydrates and protein in the stool?
Malabsorptive diarrhea
Most common cause of acute diarrhea?
Infection (self-limited)
Diarrhea with arthralgia, lymphadenopathy and neurologic symptoms?
Whipple disease (PAS+ macrophages, acid-fast negative)
Pancreatic insufficiency, small bowel bacterial overgrowth and celiac disease can all cause what type of diarrhea?
Steatorrhea (fat-malabsorption)
Diarrhea with edema, ascites and anasarca is due to what?
Protein malabsorption (C.diff, IBD, Celiac, Whipple)
How is protein malabsorption diagnosed?
Stool Alpha-1 Antitrypsin clearance
Besides autoimmune diseases, what other condition is associated with celiac disease?
Down syndrome
Baseline bone densitrometry testing, vitamin and mineral survey and vaccination against encapsulated organisms should be recommended to all patients with this GI condition?
Celiac disease
What can cause a false positive in hydrogen breath testing for small bowel bacterial overgrowth?
Rapid bowel transit and recent antibiotic use
Short bowel syndrome is less than how much small bowel left?
What is the best chance for adaptation for a patient with short bowel syndrome?
If the COLON remains connected to the small bowel
What population subtype is know to have a high prevalence for IBD?
Ashkenazi (Eastern European) Jews
If a colonic stricture is noted in a patient presumed to have UC, what does this mean?
Wrong diagnosis or malignancy
IS abdominal pain a common occurrence in UC?
No
What is the most SEVERE complication associated with UC?
Toxic Megacolon (>6 cm)
What are indications for surgery with toxic megacolon?
Progressive abdominal distention and tenderness in spite of medical therapy (antibiotics, steroids, bowel rest and IVFs) and hemodynamic instability.
Which IBD disease is acute in onset and which is indolent?
UC - acute; Crohn’s - indolent
Episcleritis, iritis, uveitis, symmetric arthritis, oral aphthous ulcers, sacroileitis and HLA B27-associated ankylosing spondylitis, erythema nodosum and pyoderma gangrenosum and primary sclerosing cholangitis are what?
Extra-intestinal manifestations of IBD
A patient with UC and primary sclerosing cholangitis is at an increased risk of what?
Colon cancer
What gastrointestinal procedures should be done if Chron disease is suspected?
BOTH colonoscopy and EGD to determine small bowel and upper GI involvement
What should you suspect in a patient whose IBD has BECOME refractory to corticosteroid therapy?
CMV infection
What medication can be used to treat Crohn disease in a patient who cannot tolerate 6MP or azathioprine?
Methotraxate + Folic acid
What medication is effective for pts with Crohn disease when anti-TNF agents failed but carries a risk of PML due to JC-virus reactivation?
Natalizumab
Is methotrexate effective for UC?
NO
What are elements of general health care maintenance for patients treated for IBD?
Calcium and Vitamin D supplementation, baseline DEXA scan, yearly influenza immunization and pneumococcal vaccination every 5 years
What vaccinations MUST be avoided in immunosuppressed patients (IBD therapy and otherwise)?
LIVE vaccinations (varicella, MMR and intranasal influenza)
When are patients with Crohn disease and UC at an increased risk of colorectal cancer and what should be done?
IF at least 1/3 of colon is involved and >8 years post diagnosis; colonosocopy every 1-2 years
Hospitalized patients with IBD are at an increased risk particularly for this condition?
DVT
Microscopic colitis is associated with systemic disease, medications and this disease?
Celiac disease
What features of constipation require anorectal manometry testing?
Sensation of blockage in anorectal region and paradoxical contractions of the puborectalis or external anal sphincter
Magnesium-containing antacids should be avoided in these patients due to the risk of hypermagnesemia?
Renal impairment
What agent can be used in opiate-induced constipation WITHOUT negating the effects of analgesia?
Methylnaltrexone
Treatment for patients with dyssynergic defecation?
BIOFEEDBACK
What are the ROME III criteria for IBS?
- Recurrent abdominal pain for at least 3 DAYS/month for the past 3 months beginning >6 months ago.
- Symptoms IMPROVE with defecation.
- Onset associated with change in frequency of stool.
- Onset associated with change in form of stool.
Family history, h/o sexual abuse, low birth weight, h/o infectious gastroenteritis in women
IBS
What is the ONLY serologic test necessary in a pt in whom IBS is suspected without alarm symptoms and is IBS-D or IBS-M?
Celiac serology
How are IBS-D/M treated?
FIRST-high-fiber diet, SSRI’s, TCA’s ; SECOND- loperamide, Alosetron
What must women prescribed lubiprostone do?
Use contraception
What is the best diagnostic test for diverticulitis if not obvious?
CT of abd/pelv
When should immunocompromised patients be offered surgery after an episode of diverticulitis?
AFTER their FIRST episode
What is mesenteric ischemia?
Ischemia of the small bowel
What are the 3 most common cause of mesenteric ischemia?
- SMA embolus (left atrium)
- Ventricular mural thrombi
- Non-occlusive, from MI
Young patient (
Cocaine, triptans
What labs are elevated in pt with mesenteric ischemia?
WBC, lactate, metabolic acidosis
When is “thumbprinting” found on abdominal x-rays and interstitial pneumatosis with bowel wall thickening on CT?
Mesenteric ischemia
What is the gold standard diagnostic modality for mesenteric ischemia?
Angiography (renal risk)
How is mesenteric ischemia treated?
Cardiovascular resuscitation, antibiotics and papaverine
Do you treat mesenteric ischemia with anticoagulation?
NO! (hemorrhage)
Abdominal pain ~30 min after eating leading to fear of eating and weight loss, eventually pain without eating?
CHRONIC mesenteric ischemia (at least 2 major splanchnic arteries are occluded on angiography)
How is CHRONIC mesenteric ischemia treated?
Surgical revascularization
How does COLONIC ischemia present and how is it diagnosed?
Abdominal pain, rectal bleeding; colonoscopy
How is COLONIC ischemia treated?
IVF and antibiotics
Pain out of proportion to examination?
MESENTERIC (small bowel) ischemia
What is CHRONIC mesenteric ischemia caused by?
Mesenteric atherosclerosis
The most common mechanism through which 66% of all colorectal cancers develop is?
Chromosomal Instability (CIN)
Aside from hereditary factors, what are the two highest risk factors for colon cancer?
Alcohol and obesity
Cholecystectomy, DM, ureterosigmoidostomy are risk factors for what?
Colorectal cancer
What is the risk for colorectal cancer in family h/o colon cancer and family h/o adenomatous polyps?
SAME
Early adenomatous colon polyps (20’s-30’s), progress to colon cancer more quickly, PROXIMAL colon, poorly-differentiated histology and MSI-genotype (microsatellite instability)?
HNPCC
What other high-risk of cancer besides colon are HNPCC pt’s at risk for?
Endometrial
100’s to 1000’s of colon polyps, diagnosed at 16, mean cancer age 39, duodenal adenomas, APC gene?
Familial Adenomatous Polyposis (FAP)
Attenuated Familial Adenomatous Polyposis (AFAP)
Abdominal pain, bleeding, intussusception, small intestinal polyps, colorectal adenomas, young pt, gastric, pancreatic, small bowel, esophageal, breast, ovary lung cancers?
Peutz-Jehgers Syndrome
SOLITARY, SPORADIC hamartomatous polyps in children
Juvenile Polyposis Syndrome
Large hyperplastic polyps proximal to sigmoid colon or >30 hyperplastic polyps throughout colon?
Hyperplastic Polyposis
What is considered a POSITIVE fecal occult blood test for risk of colorectal cancer?
Collection of TWO samples from THREE CONSECUTIVE stools (6 samples) ALL positive
If using flex sig for colorectal cancer screening, what finding constitutes the need for a full colonoscopy?
ANY polyp >5 mm
What is the average bowel perforation risk for a colonoscopy?
1 in 1000 patients
What is the recommended screening colonoscopy frequency for a patient with IBD (other than proctitis) that has been diagnosed >8 years ago?
EVERY 1-2 years
What is the recommended screening colonoscopy age and frequency for a patient with Lynch syndrome?
Start at 20-25 and EVERY 1-2 years
What is the recommended screening colonoscopy frequency for a patient with family history of colon cancer?
At the age of 40 or 10 years earlier than the age of the relative at time of diagnosis, whichever is younger
Next screening colonoscopy for patient with 1-2 adenomatous polyps (tubular) and
5-10 years
Next screening colonoscopy for patient with ≥3 adenomatous polyps (villous) and ≥1 cm OR high-grade dysplasia?
3 years
Pt is found to have colorectal cancer on colonoscopy, when do you repeat screening?
1 year post-op, 3 years, 5 years
What sites does colorectal cancer typically metastasize to?
Liver, peritoneum, lungs
What are the ONLY patients in which NSAIDS and estrogen therapy are recommended for prevention of colorectal cancer?
HEREDITARY cancer syndromes
Conjugated (direct) bilirubin abnormality suggests what?
Disease of the liver
What is considered ACUTE hepatitis?
When is someone infected with Hep A infectious?
During incubation period (time before symptoms occur: 2-6 weeks or ~28 days) and for a week after onset of jaundice (jaundice develops 1-2 weeks after symptoms)
What is the difference between HBV acquired in adulthood vs childhood?
HBV acquired in adulthood is acute and commonly resolves. HBV acquired in childhood becomes chronic
HBV acquired perinatally, with high levels of HBV DNA, no hepatic inflammation and at risk for conversion to active HBV?
IMMUNE-TOLERANT STATE (monitor, don’t treat)
Low levels of HBV DNA, no hepatic inflammation (normal LFTs), at risk for conversion to active HBV, low risk for progression to liver disease?
INACTIVE CARRIER (monitor, don’t treat)
What patients with HBV should receive anti-viral therapy?
Chronic Active HBV patients and those with developing liver failure from severe, acute HBV
What HBV patients respond to PEG-Interferon therapy?
Those with ELEVATED LFTs (at least 2x nl) and with low viral loads
What are the two (2) main antiviral agents used against HBV due to less resistance?
Entecavir and Tenofovir
Do inactive carriers of HBV and immune-tolerant HBV patients benefit from antiviral therapy?
NO
Polyarteritis Nodosa and Membranous Glomerulonephritis re associated with which GI disease?
HBV
How do you treat a newborn that has been born to an HBV positive mother?
Vaccinate + IgG
Blood transfusions prior to what YEAR are considered hight risk for HBV infection?
1992
Mixed Cryoglobulinemia, Porphyria Cutanea Tarda, non-Hodgkin Lymphoma and Membranoproliferative Glomerulonephritis are associated with what GI disease?
HCV
How is HCV Genotype 1 treated in patient with significant inflammation and fibrosis?
PEG-Interferon + Ribavirin + Protease Inhibitor
What should ALL HIV patients be tested for?
HCV
When do you treat an HIV+ pt for HCV?
ALWAYS, unless CD4 count is
MDF (discriminant function) of > 32 / MELD score of >18 mean what for an alcoholic hepatitis patient?
Short-term mortality risk of 50%
What meds can be given to a patient with ACUTE alcoholic hepatitis with an MDF >32 / MLED >18?
Corticosteroids or Pentoxifylline
Most common cause of liver injury REQUIRING transplant?
Drug-induced
Augmentin, phenytoin, valproic acid, statins all have this in common?
Hepatotoxic
What agent should be used for ANY drug-induced liver injury?
N-acetylcysteine
What does “Interface Hepatitis” suggest on biopsy?
Autoimmune Hepatitis
In autoimmune hepatitis, what else can be tested for if ANA, anti Sm Ab and g-globulin (GGT) are all negative?
p-ANCA
When do you treat autoimmune hepatitis?
- AST >10 x nl
- AST >5 x nl AND g-globulin (GGT) is >2 x nl
- Liver biopsy with bridging or confluent necrosis
- Pt is symptomatic (jaundice, fever, n/v)
What agents are used to treat autoimmune hepatitis?
Azathioprine and corticosteroids
What is the “Metabolic Syndrome?”
HTN, DM, Obesity, Dyslipidemia
What causes NAFLD?
Insulin resistance and the metabolic syndrome
Inflammation & fibrosis in NAFLD is?
NASH
How is hemochromatosis treated?
Phlebotomy and iron chelation
How is alpha1-antitrypsin deficiency treated when it affects the liver and lung?
Liver - transplant (when cirrhosis develops)
Lung - IV alpha1 antitrypsin
Elevated liver enzymes, ANEMIA (hemolytic), normal Alk Phos?
Wilson Disease
What two tests are used for Wilson Disease?
Serum Ceruloplasmin (LOW) & Urine Copper (HIGH)
Trientine; Penicillamine are what?
Copper chelating agents
Pan-acinar emphysema of the lungs?
Alpha1-antitrypsin defficiency
> 50 yo, woman, fatigue, dry eyes/mouth, pruritus, elevated Alk Phos (1.5 x normal), normal T.bili, elevated LFTs (>5 x normal) and positive AMA?
Primary Biliary Cirrhosis (PBC)
Focal duct obliteration with granuloma formation on liver biopsy?
Primary Biliary Cirrhosis (PBC)
What are the best 2 therapeutic agents for pruritus caused by hyperbilirubinemia?
Cholestyramine and Rifampin
For patients with esophageal varices and osteoporosis, what is used to treat?
INTRAVENOUS bisphosphonate therapy (NOT oral)
What is the ONLY medication that has been proven to provide a SURVIVAL benefit to patients with Primary Biliary Cirrhosis?
Ursodeoxycholic acid
40 yo man with a chronic inflammatory disorder affecting intra and extra hepatic bile ducts with Jaundice, pruritus and abdominal pain, associated with IBD?
Primary Sclerosing Cholangitis (PSC)
Elevated alk phos (3-10 x normal), elevated LFTs (2-3 x normal), T.bili normal, positive ANA and Anti-sm-Ab with abnormal CHOLANGIOGRAPHY?
Pribary Sclerosing Cholangitis (PSC)
What should you suspect when T.bili is elevated in patients with Primary Sclerosing Cholangitis (PSC)?
Advanced disease vs obstructing stone/cancer
Gold Standard for diagnosis of Primary Sclerosing Cholangitis (PSC)?
Cholangiography
MRCP with finding of “Beads on a String”?
Primary Sclerosing Cholangitis
If cholangiography is negative in PSC, what is the required diagnostic test?
Liver Biopsy
Histologic finding of FIBRO-OBLITERATIVE Cholangiopathy?
Primary Sclerosing Cholangitis (PSC)
What are Primary Sclerosing Cholangitis (PSC) patients at highest risk for?
Cholangiocarcinoma
Patient with Primary Sclerosing Cholangitis (PSC) with acute change in LFTs or symptoms, you MUST suspect what?
Cholangiocarcinoma
What is the only treatment for PSC besides supportive?
Liver TRANSPLANTATION
Cirrhosis causes ascites, hepatic encephalopathy and varices (esophageal & gastric) how?
Portal Hypertension (>8-10 mm Hg)
What should be done for large esophageal varices?
Prophylactic ß-blocker or endoscopic ligation
How often should you screen cirrhotic pt with no esophageal varices??
Every 2-3 years
How often should you screen cirrhotic pt with small esophageal varices??
YEARLY
What must be done on a patient with NEW ascites diagnosis?
DIAGNOSTIC paracentesis (cell count w/diff, albumin, total protein, ± culture AT BEDSIDE)
What antibiotic is used for SBP treatment? Prophylaxis?
CEFTRIAXONE (IV); NORFLOXACIN (PO)
Explain SAAG
Serum-Ascites Albumin Gradient (Subtract the ascites fluid albumin concentration FROM the serum albumin concentration; if the SAAG ≥ 1.1g/dL and total ASCITES protein is 2.5 g/dL = cardiac disease is the cause
What must be replaced at the rate of 8 g per L of ascitic fluid removed?
ALBUMIN
What constitutes SBP?
POSITIVE bacterial culture of ascites fluid AND PMN (neutrophils/basophils/eosinophils/granulocytes) >250 cells/µL
Besides antibiotics, what else MUST be given to an inpatient with SBP and significant liver/kidney dysfunction?
Albumin
How can you determine if medical therapy is effective for SBP?
Repeat paracentesis in 48 hours and determine if drop in PMN count
If large esophageal varices are found and treated, when is repeat EGD needed for continued treatment until eradication and thereafter?
Every 2-4 weeks (usually 2-4 sessions) then FIRST surveillance EGDin 1-3 months Followed by every 6-12 months
What does an increased frequency and severity of hepatic encephalopathy predict?
Increased risk of death
Should dietary protein be restricted for patients with cirrhosis or hepatic encephalopathy?
ABSOLUTELY NOT (increased mortality)
A patient with cirrhosis is experiencing a Cr ≥2.5 mg/dL and a 50% reduction in their Cr clearance in a 24-hr urine sample over the past TWO (2) WEEKS without significant histologic renal biopsy changes, is diagnosed with?
Type -I Hepato-Renal Syndrome (HRS)
A patient with cirrhosis is experiencing a Cr ≥2.5 mg/dL and a 50% reduction in their Cr clearance in a 24-hr urine sample over the past MONTH with REFRACTORY ASCITES, without significant histologic renal biopsy changes, is diagnosed with?
Type -II Hepato-Renal Syndrome (HRS)
In the ABSENCE of ANY renal disease (toxic meds, shock, hypotension), a serum Cr >1.5 mg/dL WITHOUT improvement after 48 hours of diuretic withdrawal and albumin supplementation?
Hepato-Renal Syndrome (HRS)
A patient with cirrhosis has hypoxemia on ABG, digital clubbing and cyanosis without any identified COPD or other lung disease is diagnosed with?
Hepato-Pulmonary Syndrome (HPS)
When is a cirrhotic patient with Hepato-Pulmonary Syndrome (HPS) considered a high-priority candidate for liver transplantation?
When PO2 ≤60 mm Hg!!!
Elevated pulmonary artery pressure (≥25 mm Hg), elevated right ventricular systolic pressure (≥50 mm Hg) and primary portal HTN (>8-10 mm Hg) with progressive exertional dyspnea requires what?
Liver transplantation for Porto-Pulmonary HTN (POPH)
Cirrhosis, chronic Hep B & C, hemochromatosis and alpha-1 antitrypsin deficiency cause 80% of these?
Hepatocellular Carcinoma (HCC)
Can alpha-fetoprotein (AFP) alone be used for HCC surveillance every 6 months in a patient at risk?
NO! need US/CT/MRI as well OR two (2) imaging studies
What AFP value is concerning for HCC?
> 400
When is HCC biopsy necessary for diagnosis?
When radiology, radiology+AFP (>400) combo is inconclusive
What is the best treatment for HCC in early-stage disease?
Liver Transplantation
What is used to treat patient with advanced HCC?
Sorafenib (hand-foot syndrome, HTN)
Hepatic encephalopathy after onset of jaundice (
Fulminant Hepatic Failure (hyperacute, acute, subacute)
What is the most common cause of fulminant hepatic failure?
Acetaminophen toxicity
What is used to treat fulminant hepatic failure due to Amanita mushroom poisoning?
Penicillin G
What two treatments can be used to reduce cerebral edema in setting of fulminant hepatic failure?
Mannitol and Induced hypothermia
What MUST be done once Fulminant Hepatic Failure is diagnosed?
Transfer patient to facility that can do liver transplant (the ONLY treatment)
Coagulopathy due to liver dysfunction/failure is best measured by what?
Prothrombin Time (PT)
Liver transplantation can be considered in a patient with HCC depending on tumor configuration which is?
ONE tumor ≤5 cm OR ≤3 tumors ≤3 cm
INH (isoniazid), sulfonamides, tetracycline, MDMA (ecstasy), NSAIDS, cocaine, CMV, EBV, Parvovirus B19, Varicella-Zoster Virus (VZV), Bacillus cereus, Budd-Chiari syndrome, Acute Fatty Liver of Pregnancy (AFLP), HELLP syndrome, autoimmune hepatitis can all cause?
Fulminant Hepatic Failure
How is a large, symptom-causing (RARE) simple hepatic cyst best treated?
Fenestration
What hepatic cysts require resection?
Symptomatic cysts [(Cystadenomas (complex cyst)]
Hypertrophic tissue reaction to an anomalous artery in the liver with the lesions characteristically demonstrating a “central scar” on CT/MRI?
Focal Nodular Hyperplasia (FNH)
What is the recommended management of a BENIGN-appearing hepatic lesion
Observation every 6 months with US, NO BIOPSY necessary
Sheets of BENIGN hepatocytes without biliary structures?
Hepatic adenoma (women, oral contraceptives, risk for malignant transformation)
Who gets hepatic adenomas most commonly and are these dangerous?
Women who use oral contraceptive pills; YES, risk of malignant transformation
What is the management of a
Cessation of oral contraceptives and monitoring with US
What is the management of a ≥5 cm hepatic adenoma or ANY sized hepatic adenoma in a woman considering pregnancy?
Surgical Resection (because these are hormonally responsive)
Liver lesion that demonstrates PERIPHERAL nodular enhancement followed by CENTRIPETAL filling?
Hemangioma
How is ANY abscess treated?
Drainage and antibiotics
Amebiasis positive stool can lead to what complication without treatment?
Amebic liver abscess with fatal rupture
1st trimester, prolonged vomiting with elevated LFTs and fluid/electrolyte imbalances?
Hyperemesis gravidarum
A woman in her second or third trimester, or one who is not pregnant but on supplemental hormonal therapy, presenting with JAUNDICE, PRURITUS and elevated serum BILE ACIDS?
Interhepatic Cholestasis of Pregnancy (ICP)
How do you treat Interhepatic Cholestasis of Pregnancy (ICP)?
Ursodeoxycholic acid
What is HELLP?
A complication of pre-eclampsia: Hemolysis-Elevated LFTs-Low-Platelets?
A woman in her third trimester presents with abdominal pain, new-onset nausea and vomiting, jaundice and pruritus?
HELLP syndrome (20% mortality)
What is the definitive therapy for HELLP syndrome?
Delivery
What’s the risk of HELLP syndrome in subsequent pregnancies?
25%
What is the risk with Interhepatic Cholestasis of Pregnancy (ICP)?
Fetal complications and intra-uterine death
Similar to HELLP syndrome but with HYPOGLYCEMIA and worse coagulopathy requiring prompt delivery and management by hepatologist at liver transplant center?
Acute Fatty Liver of Pregnancy (AFLP)
Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency is associated with what condition?
Acute Fatty Liver of Pregnancy (AFLP)
What are the two most serious pregnancy-related liver conditions requiring URGENT delivery?
HELLP and AFLP
What testing and treatments are used for metabolic bone disease in cirrhotic patients?
Bone density testing; Calcium+Vitamin D, bisphosphonates or raloxifene (IV if esophageal varices) & weight-bearing exercises
Male cirrhotic patients with hypogonadism can be treated with transdermal testosterone except when?
If HCC is a concern
Alcoholic hepatitis with discriminant function ≥32 or significantly severe with ascites and SBP with fever and leukocytosis as well as varices, besides albumin and octreotide/nadolol should be treated with what specifically and why?
Pentoxifylline and NOT prednisone (because of the active SBP infection, otherwise ok to use)
After resection of a Type I or II carcinoid tumor, what is the recommended EGD surveillance?
EGD every 6-12 months for 3 years
What are the ONLY immunizations cirrhotic patients should NOT receive?
LIVE attenuated vaccines (MMR, Varicella, intranasal-Influenza)
In patients with esophageal varices and ascites, what medications should be avoided?
NSAIDS and Aspirin
I patients with cirrhosis, what medications should be avoided?
Amoxicillin-clavulanate (augmentin) and Isoniazid (INH)
Obesity, Dyslipidemia, Pregnancy, DM, Cirrhosis, Crohn disease, resection of the terminal ileum and gastric bypass surgery are all risk factors for what?
Gallstone formation
What is the recommendation for a patient with a porcelain GB or with GB stones ≥3 cm?
Cholecystectomy
Severe episodic abdominal pain in epigastric/RUQ area that intensifies over 15 minutes then lasts approximately 3 hours and slowly resolves associated with nausea and vomiting?
Biliary colic
When biliary colic lasts >6 hours it is most likely?
Cholecystitis
What is different about elderly patients, immunosuppressed patients or those with DM when it comes to cholecystitis?
They may NOT have symptoms nor fever
Murphy’s sign clues you in on what diagnosis?
Cholecystitis
How is cholecystitis diagnosed?
US
What test can be done ONLY if US is indeterminate for cholecystitis?
HIDA scan
How is ACUTE cholecystitis treated?
IVF, antibiotics and laparoscopic cholecystectomy within 48-96 hours of hospitalization
Fever with elevated amylase due to hospitalization for critical illness, burns, advanced age, atherosclerotic vascular disease, AIDS, salmonella, CMV, polyarteritis nodosa and SLE?
Acalculous Cholecystitis
What should be done after an ERCP for a patient with choledocholithiasis whom may not be a surgical candidate?
Sphincterotomy
How long after ERCP for stone clearance should cholecystectomy be performed?
Within 6 weeks
Choledocholithiasis with development of fever is?
Cholangitis
Fever, Jaundice, RUQ pain?
Charcot triad (cholangitis)
Chronic salmonella infection can lead to what?
Gallbladder cancer
Primary Sclerosing Cholangitis (PSC), biliary atresia, liver flukes and biliary cysts are all risk factors for?
Cholangiocarcinoma
When can a hilar cholangiocarcinoma (Klatskin tumor) be resected?
When it does NOT extend into BOTH intrahepatic bile ducts
Ampullary adenocarcinoma is associated with what hereditary conditions?
Familial Adenomatous Polyposis & Peutz-Jehgers syndrome
What is the management of an ampullary adenocarcinoma?
Excision by Whipple procedure
Dilation of bile duct without evidence of obstructing lesion, chronic, intermittent abdominal pain with recurrent bouts of cholangitis, jaundice and carries a very hight risk of cholangiocarcinoma?
Biliary cyst
Hgb ≤2 g/dL, Hct ≤6% from baseline or ≥2 units PRBC transfusion is needed?
SEVERE GI bleed
How much blood is needed for melena to occur?
50-100 ml
Erosions found on the crest of gastric folds within a large hiatal hernia caused by mechanical trauma?
Cameron lesions
GAVE is associated with what conditions?
Cirrhosis and Connective Tissue Disease
Acute or chronic GI blood loss, occurs in the setting of epistaxis, facial telangiectasias, which can also involve the lung, liver and brain and there is a family history of the condition?
Hereditary Hemorrhagic Telangiectasia (HHT) also called Osler-Weber-Rendu disease
Describe the formation of a GI tract pseudoaneurysm?
Pancreatitis-pseudocyst formation-erosion into an artery
A tachycardia in a patient with GIB indicates how much blood loss? Hypotension?
Tachycardia: 15-30%; Hypotension ≥30%
Patient with NO OTHER SYMPTOMS other than HEART RATE >120 bmp after bariatric surgery indicates?
Anastomotic leak (critical emergency)
Macrocytosis (MCV ≥100) and elevated INR in a patient NOT on anticoagulants clue you in on?
Liver disease
What is the Blatchford Score?
Patients with signs of GIB that can be managed as OUTPATIENTS (BUN 109 mm Hg, HR
What is the most important thing to measure when dealing with an acute GIB?
CONTINUOUS HEMODYNAMIC MONITORING
What is the ABSOLUTE indication for transfusion?
Hgb
In a GIB, within what time frame should EGD be done?
Within 24 HOURS of presentation (whether stable or not)
Within what time frame should EGD be done for a patient with suspected variceal bleed?
Within 12 HOURS of presentation
What should be initial management for a suspected variceal bleed?
Octreotide & Antibiotics
Patients with GIB whom are at high-risk should be treated with a PPI how initially?
Bolus PPI followed by IV for 72 hours, then oral PPI (must therefore be hospitalized for at least 72 HOURS)
When is a “SECOND LOOK” with EGD recommended?
ONLY if poor initial visualization or RE-BLEEDING prior to surgery or IR intervention
When should an EGD be repeated for a gastric ulcer to rule out malignancy?
ONLY if biopsies of the ulcer were NOT obtained initially (due to EGD for bleeding) and 6-8 weeks after initial EGD
When should ASPIRIN used for cardiovascular purposes be restarted after PUD?
While on PPI therapy
What should you consider when a patient with a lower GIB presents with hypotension?
A possible UPPER source of bleeding and perform an EGD as well
What is the MOST appropriate diagnostic procedure for a suspected upper GIB?
EGD
Is NGT placement with gastric lavage an acceptable diagnostic test to rule out upper GIB?
NO!!! (50% miss rate)
What should be done for a patient presenting with suspected GIB with orthostatic hypotension OR bleeding in the first 4-HOURS of evaluation OR using anticoagulants (aspirin, warfarin, etc.) OR has multiple comorbidities?
ADMISSION to the hospital
Recurrent GIB (anemia and FOBT+) without a defined source after EGD and colonoscopy?
OBSCURE GIB
What is the FIRST step for patients who have an OBSCURE GIB (anemia, FOBT+, negative EGD/Colonoscopy)?
REPEAT EGD and COLONOSCOPY (30%-50% success)
When should angiography be performed for OBSCURE GIB?
ONLY when there is active, overt bleeding (requires a bleeding rate ≥1 mL/min)
What are the risks of angiography with embolization for the treatment of OBSCURE GIB?
Renal failure, necrosis, dissection/aneurysm
What radiologic test should be done FIRST because it has the best SENSITIVITY for actively bleeding GI lesions but does not allow intervention nor does it have good specificity (78%, but better than angiography) for localization of source?
NM (technetium-99m) labeled RED BLOOD CELL scan
What is the bleed rate required for a NM (technetium-99m) RED BLOOD CELL scan?
0.1 - 0.5 mL/min
Intermittent LARGE-VOLUME bleeding in a patient with negative initial EGD without a hiatal hernia?
Dieulafoy lesion (superficial artery)
What diagnostic test for OBSCURE GIB can be done which DOES NOT require active bleeding?
Small Bowel Video Capsule Endoscopy (SBVCE)
What should be done as therapy for a patient with a bleeding Meckel diverticulum?
Surgical excision
What is the best therapy for a patient with AORTIC-STENOSIS caused angioectasia (Heyde syndrome) with GIB?
Aortic Valve REPLACEMENT
Howell-Jolly Bodies dictate the necessity of this PREVENTIVE measure?
Vaccination for encapsulated organisms (S.pneumonia and H.influenza) due to functional asplenia (any asplenia)
What can be used instead of a thiopurine to treat Crohn disease (NOT FOR UC) when thiopurines such as azathioprine or 6MP caused pancreatitis or are not tolerated?
Methotrexate + Folic Acid
What can be used to treat the pain and bowel dysregulation in IBS-D or IBS-M?
TCA’s (amitriptyline) because of the anticholinergic constipating effects and analgesia
What can be used to treat the pain and bowel dysregulation in IBS-C?
SSRI’s (sertraline) because of their bowel-stimulating effects and analgesia
What should ALWAYS be checked for when evaluating a patient for potential IBS-D or IBS-M?
CELIAC disease
