Alpa-MKSAP Flashcards
Name 3 medications that cause Pill Induced Esophagitis
Alendronate, quinidine, tetracycline, doxycycline, KCl, ferrous sulfate
Eosinophilic Esophagitis
- Endoscopic finding
- How many eosinophils seen on high power field
- Treatment (Hint: first try…)
- Trachealization of esophagus, longitudinal furrows, luminal narrowing
- > 15 eosinophils
- Try 8 weeks of PPI for GERD Induced Esophagitis, then aerosolized topical glucocorticoid/prednisone
Oropharyngeal Dysphagia:
Signs/Symptoms
Dx
Coughing
Choking
Nasal regurgitation
Dx: modified barium swallow/ videofluoroscopy
Treatment for Candida albicans Esophagitis
PO fluconazole
Treatment for CMV Esophagitis
Ganciclovir/Valganciclovir, ulcer Center Biopsy
Treatment for HSV Esophagitis
Acyclovir, ulcer edge biopsy
Surveillance for Barretts Esophagus
- No dysplasia
- Low grade dysplasia
- High grade dysplasia
- Repeat 3-5 years
- Repeat 6-12 months
- Repeat 3 months
Name 3 Adverse Effects of PPI
- Increased infections (CAP & Cdiff) since acid balance changes
- Malabsorption
Magnesium, B12, Iron,
Calcium causing poor bone density - Chronic Atrophic Gastritis
- Sporadic fundic gastric polyps
First line therapy for H pylori infection
Second line therapy for H Pylori infection
PPI + Clarithomycin + Amoxicillin
PPI + Clarithomycin + Metronidazole (PCN allergy)
PPI + Bismuth + Metronidazole + tetracycline
PPI + Levaquin + Amoxicillin
Note- always confirm eradication
Mutation associated with Gastrointestinal Stromal Tumor (GIST)
KIT oncogene mutation
CD 117
Name 5 medications that cause of Acute Pancreatitis
Furosemide, didanosine, mesalamine, HCTZ, Simvastatin, 6MP/AZA
Name 3 infections that cause of Acute Pancreatitis
Mumps, Coxsackie B, CMV, Toxoplasmosis, HIV, Aspergillus, HSV, Varicella, Hepatitis B, cryptococcus
How to diagnose microcalculi with pancreatitis
Increased aminotransferases & secretin enhanced MRCP
Types And Differences of Autoimmune Pancreatitis
CT finding: pancreatic enlargement/ featureless border
Type 1 AIP: systemic, extrapancreatic involvement, increased IgG4
Type 2 AIP: duct centric chronic pancreatitis, normal IgG4, no extrapancreatic symptoms
How to calculate Stool Osmotic Gap
290 - 2 (Stool Na+ Stool K+)
Diagnosis And Etiology of Secretory Chronic Diarrhea
Large volume, doesn’t stop with fasting
Stool Osmotic Gap
Ulcer found in the 2nd part of duodenum
Gastrinoma
Diagnosis And Etiology of Osmotic Chronic Diarrhea
Stops with Fasting
Stool Osmotic Gap > 100
Carbohydrate Malabsorption (Lactose)
Diagnosis And Etiology of Steatorrhea
> 14 grams of stool fat (on 100 gram fat diet)
Small Bowel Mucosal Disorders- Celiac Disease, Pancreatic insufficiency, small intestinal bacterial overgrowth, bile acid deficiency, lymphatic obstruction
Lab tests for chronic Diarrhea
Fecal Fat Stool Osmotic gap Stool WBC Stool Calprotectin Stool lactoferrin
HLA subtypes Celiac Disease
HLADQ2 & HLADQ8
Signs/symptoms of Celiac Disease
Weight loss, stearrhoea, nutritional deficiency, iron deficiency anemia, Vitamin ADEK
Dermatitis Herpetiformis
Disorders associated with celiac disease
Microscopic colitis
Lymphocytic gastritis
T cell Lymphoma
IBS-D
Lab tests for Celiac Disease
IgA tissue transgluminase
Endomysial antibody
Deaminated Gliadin peptide
Biopsy results of Celiac Disease
Intraepithelial lymphocytes
Crypt elongation
Villous blunting/atrophy
Extra intestinal manifestations of IBS
Oral apthous ulcers Arthalgias Ankylosising spondylitis Uveitis Scleritis Pyoderma gangrenosum Erythema nodosum
What enzyme to check before starting IBD immunomodulators?
Check TPMT before AZA/6MP
What condition is associated with Ulcerative Colitis?
Hint: Biliary structure
Primary Sclerosing Cholangitis
What serology associated with Ulcerative Colitis?
pANCA
Biopsy finding on Ulcerative Colitis
Continuous, superficial inflammation, ulceration, edema
Biopsy finding on Crohn’s Disease
Transmural, apthous ulcers, deep ulcers, cobblestoning, granuloma, skip lesions
What serology associated with Crohn’s Disease?
ASCA + NOD2CARD15
Adverse Effect associated with Nalalizumab
PML
Check for JC virus
2 types of microscopic colitis
- Lymphocytic
2. Collagenous
Stepwise treatment of microscopic colitis
- Loperamide, diphenoxylate
- Bismuth
- Budenoside, 5-ASA, cholestyramine, anti TNF
What condition is associated with IBS-D?
Celiac Disease
Name 3 Modifiable Risk Factors for Colorectal Neoplasia
High dietary fat Red meat Low Fiber Smoking Obesity DM type 2 Alcohol
Name 3 Non-Modifiable Risk Factors for Colorectal Neoplasia
Male, Older Age, Black, IBD, PSC, Hx of adenoma, acromegaly
Amsterdam Criteria II for Hereditary Nonpolyposis Colon Cancer (MMR deficiency)
3 or more relatives with cancer in HNPCC
2 generations
1 relative is 1st degree
1 before age of 50
Name 3 types of cancer that is associated with Familial Adenomatous Polyposis
(APC gene mutation)
Colorectal, duodenal, ampullary, gastric, hepatoblastoma, thyroid cancer
Diagnosis Criteria for Serrated Polyposis Syndrome
- More than 5 Serrated polyps proximal to sigmoid
- Having a serrated polyp and relative with SPS
- More than 20 serrated polyps
Need yearly colonoscopy!
Indications for 3 year Post Polypectomy Surveillance
3-10 adenoma, > 10mm, villous, high grade dysplasia, traditional serrated adenoma
Serology for Active Hepatitis B
+ surface antigen
+ e antigen
+ core IgM
Will resolve in 6 months, follow LFTs
Serology for Naturally Immune Hepatitis B
+ surface antibody
+ core IgG
Serology for vaccinated Hepatitis B
+ surface antibody
Serology for Immune-tolerant Chronic Hepatitis B
> 1 million DNA
+ surface antigen
+ core IgG
+ e antigen
Serology for Immune-active Chronic Hepatitis B
> 10,000 DNA
+ surface antigen
+ core IgG
+ e antigen
Increased ALT
Serology for Immune-Control Chronic Hepatitis B
Serology for Reactivation Chronic Hepatitis B
> 10,000 DNA
+ surface antigen
+ core IgG
+ e antibody
First Line Treatment for Hepatitis B
Entecavir & Tenofovir
When to treat Hepatitis B?
What is the goal?
Acute Liver Failure, abnormal ALT with DNA
Hepatitis B: when to screen for Hepatocellular Carcinoma
Cirrhosis Asian male > 40 Asian female >50 African >20 Family Hx High ALT with DNA >10,000
What is the goal of treatment for Hepatitis C?
Sustained Virologic Response
Undetectable RNA 6 months after treatment
How to calculate Maddrey’s Discriminant Function
What value do you treat Acute Alcoholic Hepatitis
4.6 ((PT- control PT) + total bilirubin)
>32
Name 3 Contraindications for giving Prednisolone for Acute Alcoholic Hepatitis
Infection, variceal bleed, AKI
Serology associated with Autoimmune Hepatitis
Serum IgG
ANA
Antismooth muscle
How to treat Autoimmune Hepatitis
Glucocorticoid
Azathioprine
Non acetaminophen related Acute Liver Failure with grade I-II hepatic encephalopathy will benefit from what therapy?
NAC
Serology with Wilson Disease
decreased Alk Phos, decreased ceruloplasmin, urine copper > 250 over 24 hours
Primary Biliary Cirrhosis: immune mediated destruction of small intralobular bile ducts
Dx & Tx
Dx: + Antimitochondrial antibody test
Tx: Ursodiol will slow disease progression
Cancer associated with Primary Sclerosing Cholangitis
How to screen for it?
Cholangiocarcinoma
CA 19-9 and imaging every 1 year
When do you start colorectal screening in IBD patient?
8-10 years after diagnosis, then ever 1-2 years
If Crohn’s disease or UC affecting more than rectum
When to start screening in Hereditary Nonpolyposis Colon Cancer?
Colonoscopy every 1-2 years starting at age 20
EGD every 2-3 years starting at age 30
How to diagnose Hepatitis E? What regions is it found in?
HEV IgM
India/Asia, Central America
2 Big causes of Portal Hypertension
- Cirrhosis
2. Portal Vein Thrombosis in Budd Chiari Syndrome
How often to screen for esophageal varicies in a cirrhotic patient?
Every 3 years
Name 5 precipitants for Hepatic Encephalopathy
Alcohol, Benzodiazepines, Opioids, Hypoxia, Electrolyte Abnormality, Infection, GI Bleed, TIPS
Diagnose Hepatopulmonary Syndrome
Platypnea/Orthodeoxia- decreased O2/SOB while upright
Arterial Oxygen tension 15
Intrapulmonary shunting on Echo (agitated saline)
Tx: O2 and transplant
Diagnose Portopulmonary Hypertension
Essentially pulmonary hypertension with chronic liver disease
Check TTE, RV systolic pressure > 50
Tx: Prostacyclin analogue, endothelian antagonists, phosphodiesterase inhibitor
How much albumin to give if large volume paracentesis?
8 grams of 25% albumin for each liter removed
Indications to give Albumin in SBP
Creatinine > 1, BUN > 30, Bilirubin > 4
Hepatorenal syndrome
If creatinine > 1.5, lack of response to albumin challenge (1 gram/kg/day for 2 days), and no other explanation of AKI
Specific Type of Food to avoid if you are cirrhotic
Oysters/Shellfish for Vibrio Vulnificus
What does Focal Nodular Hyperplasia look like on imaging?
Arterial phase enhancement with central star
Unless symptomatic, who cares
What hormone makes Hepatocellular Adenoma bigger?
ESTROGEN!
If this proto-oncogene is present in Hepatocellular Adenoma, there is more concern for malignancy potential?
Beta-catenin nuclear reactivity
(May need surgical resection or radiofrequency ablation
if tumor > 5 cm or positive for beta-catenin
What does Hepatic Hemangioma look like on imaging?
Peripheral nodular enhancement filling in toward center of lesion in later phases
No estrogen dependence or malignancy potential
Only if > 10 cm or symptomatic, who cares
What organism causes hepatic amebic cysts? How do you treat it?
Entamoeba histolytica
Tx: Metronidazole
Will see right hemidiaphragm elevation
How to treat Chronic Portal Vein Thrombosis?
You don’t! Hah
What is Budd Chiari Syndrome?
Obstruction of Hepatic Venous Outflow by Thrombus
Most common cause of upper GIB?
PUD
What the hell is Dieulafoy Lesion?
Large tortuous submucosal arteriole in gastric cardia
What’s a low risk ulcer?
How do you treat it?
Clean Base, flat pigmented spot
Give PO PPI
What’s an intermediate risk ulcer?
Adherent Clot
What’s a high risk ulcer?
How do you treat it?
Arterial spurting or visible blood vessel
IV PPI for 72 hours!
Most common cause of lower GIB?
Diverticulosis
Most common cause of obscure GIB?
Angiodysplasia
What is the bleeding rate detected Technetium Labeled Nuclear Scan?
0.1-0.4 mL/min
What is the bleeding rate detected Angiography?
> 0.5 mL/min
3 Different Types of Endoscopy (that go further)
- Push Enteroscopy- you can advance beyond ligament of treitz into jejunum
- Spiral Enteroscopy
- Balloon Assisted Enteroscopy
When do you screen for colon cancer in patient with crohns or Ulcerative colitis?
8 years after diagnosis and then Q1-2 years afterwards
When do you screen patients with familial adenomatous polyposis syndrome for colon cancer?
Annually starting at age 12 with sigmoidoscopy and then at age 16 switch to colonoscopy.
If find polyp - consider colectomy
How often do you screen Adenomas > 1 cm?
Screen every 3 years
How often do you screen patients with >4 total Adenomas ?
Screen every 3 years
How often do you screen patients with villous Adenomas?
Screen every 3 years
Name three MEDICATIONS that can theoretically decrease the risk of colon cancer
Aspirin > 20 years
Celecoxib (NSAID)
Sulindac (NSAID)
Estrogens
Malignancy potential of hyper plastic polyps?
None.
Which gene is mutated in familial adenomatous polyposis? Which chromosome is it on?
APC gene
(Adenomatous polyposis coli gene) on chromosome 5q
Lady with Lynch syndrome found to have adenomatous polyps - what is next screening test?
Transvaginal ultrasound to rule out ovarian cancer
Colon cancer Screening for patients with hyperplastic polyps.
Colonoscopy every 10 years
OR
FIT testing annually PLUS
Sigmoidoscopy every 5 years
Work up of unexplained iron deficiency anemia in a man or postmenopausal woman
EGD if 50
How often do you screen patients with Adenomas
Screen every 5-10 years
When to screen patients with tubular Adenomas >1 cm or multiple tubular Adenomas
Screen every 3 years
Obstructive colon cancer s/p removal with pre op colonoscopy void of other lesions - how often you repeat colonoscopy and CEA
Colonoscopy every 1 year then 3 years then 5 years if all return normal.
CEA every 3-6 months X 2 years then every 1 year X 5 years
Consider d/c colonoscopies at what age?
Age 75
But if patient still very active and healthy co side stopping instead at age 85
When to screen patient with HNPCC
Screen 10 years earlier than youngest HNPCC relative or at age 25 whichever is earlier with colonoscopy q2 years till 40 then annually after
Treatment of anal canal mucosa cancer
External beam RT
5FU
Mitomycin
Treatment of anal margin cancer
Local excision
