AR HY review 2 Flashcards
Dysphagia to liquids and solids d/t what?
Dysphagia to solids d/t what?
Dysphagia
solids and liquids: motility problem (DES, scleroderma, achalasia)
solids alone: physical obstruction (carcinoma, stricture, ring)
Dysphagia to solids and
- >50 yo:
- heartburn
- intermittent dysphagia (first bite dysphagia)
Dysphagia to solids
- 50 yo: consider cancer (older patients)
- heart burn: stricture (as complication of chronic GERD; older patients)
- intermittent (first bite): esophageal ring (younger patients)
Dysphagia to solids and liquids:
- intermittent with chest pain
- progressive with heartburn
- progressive with regurgitation
Dysphagia to solids and liquids:
- intermittent with chest pain: DES
- progressive with heartburn: scleroderma
- progressive with regurgitation: achalasia
Oropharyngeal dysphagia: wtd to dx?
barium swallow
DES finding on diagnostic studies:
DES rx1 and rx2?
barium swallow→corkscrew esophagus
manometric studies→nonperistatic contractions
rx1: PPI
rx2: CCB (diltiazem)
Young patient with dysphagia at first bite, then rest of swallowing is ok. May have some reguritation. dx? rx?
Schatzki’s ring (distal esophagus; often younger patients)
rx: pneumatic dilation
Suspect Zenker diverticulum: wtd
Suspect achalsia: wtd
Zenker: barium swallow then EGD
achalasia: EGD (r/o cancer) the barium swallow even if EGD is normal and suspicion is high
HIV patient with dysphagia, odynophagia. Rx with systemic fluconazole d/t suspected esophageal candidiasis does not help. next steps?
odynophagia in HIV patient not resolve with fluconazole
EGD
- one large ulcer: CMV
- multiple small ulcers: HSV (also seen in pill esophagitis)
- multiple white plaques: resistant candidia→give echinocandins
Pt with chronic GERD, now has progressive dysphagia to solids. dx?
peptic stricture d/t chronic GERD
Pt with stroke history has residual deficits. Now has coughing and choking with some regurgitation. best to dx?
modified barium swallow→dysphagia d/t stroke
Pt with GERD, treated empirically on PPI, better after 3months. wtd next?
discontinue PPI, or continue PPI at lowest effective dose, or switch to H2 blocker to avoid chronic PPI complications.
What test to do before laproscopic funduplication?
Manometry to confirm good peristalsis, other wise achalasia will result from the procedure.
Endoscopy for GERD show metaplasia (i.e Barrett esophagus). wtd
PPI for life
EGD + bx in 1 year after initial dx and if no dysplasia
EGD q3y to follow up if no dysplasia continues
Endoscopy for GERD or metaplasia is indefinite for dysplasia. wtd?
PPI and EGD in 2-6mo
EGD for Barrett’s show dysplasia. wtd?
refer bx sample to esophogeal pathologist and if confirmed get endoscopic radio frequency ablation
Pt with hx of forceful emesis, now has severe CP worse with swallowing and breathing. CXR with pleural effusion and subcutaneous emphysema. Pleural fluid amylase increased. dx? wtd?
Dx: Boerhaave (esophageal rupture)
Get water-soluble swallow study (Gastrographin)
Get immediate surgical consult this has a high mortality rate
Pt on PPI 8 weeks while in hospital. PPI discontinued abruptly after discharge. Likely consequence
New GERD symptoms due to PPI rebound
Types of gastritis
- Atrophic/Chronic (with type A (autoimmune) and type B (H pylori)
- Erosive: ETOH, NSAIDs, critically ill patient
- Acute: infectious
- Eosinophilic: younger patients
Autoimmune chronic/atrophic gastritis features
Type A: autoimmune. Often clinically silent
- In body and fundus usu. Loss of rugae and lots of polyps. Intestinal metaplasia
- Achlorydia and inc gastrin production.
- risk of adenocarcinoma.
- etio: pernicious anemia (B12 deficiency)
Younger patient with dysphagia to solids and iron deficiency anemia. dx? rx?
dx: Plummer Vinson: webs (causing dysphagia) and IDA
rx: treat IDA and webs go away
H pylori atrophic/chronic gastritis features
H pylori atrophic/chronic gastritis. initial symptoms on infection then usually clinically silent
- location: antrum/cardia usually
- incr gastrin → incr acid → ulcers in 15%
- may also cause atrophic gastritis (decr acid) if infection is in gastric body (less common)
Erosive gastritis features
Erosive gastritis: often asx but can have dyspepsia and UGIB
- alcoholics, NSAIDs, critically ill patients (vent, shock, sepsis, burns, surgery)
- usu no inflammation but does have hemorrhage and erosions. GIB is usually minor.
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MCCs of PUD (3)
- NSAIDs
- H pylori
- Zollinger Ellison syndrome
Intermittent dysphagia: two causes
- DES (solids and liquids; often pain with swallowing more than difficulty swallowing)
- Schatzki ring (solids)
Screening for Barrett esophagus in who?
>50y men with chronic GERD. If not there, then no need for further follow up studies
Pt with giant ulcers (>2cm), ulcers refractory to nl treatment, frequent recurring ulcers, multiple ulcers (esp if distal to duodenal bulb) or ulcers with hypercalcemia? wtd
Suspect Zollinger-Ellison; get gastrin level
gastrin (and thus acid) hyper-secreting tumors
diarrhea is a common symptom with ulcers
Things that cause gastrin hyper-scretion
- Z-E syndrome
- PPI
- Atrophic gastritis
Tests to get if suspect Z-E syndrome?
- Gastrin (after stopping PPI)
- Serum calcium (r/o MEN syndrome)
- PTH (r/o MEN syndrome)
- Prolactin (r/o MEN syndrome)
- LH, FSH, GH
Pt suspected of or with PUD on PPI or GIB should undergo what test for H pylori?
urea breath or stool Ag
hold PPI (2 weeks) and abx (4 weeks) before testing
triple therapy Rx for PUD d/t H pylori
PAC: PPI, amoxicillin, clarithromycin
PMC: PPI, metronidazole, clarithromycin
quad therapy Rx for PUD d/t H pylori
Lead mountain: PB MT
PPI, bismuth, metronidazole, tetracycline
Rx for MALT?
triple or quad therapy for underlying PUD d/t H pylori
MALT is a type of NHLymphoma, usu presents with complicated GERD (wt loss, bleeding, anorexia, dyspepsia, etc)
wtd if EGD finds gastric ulcer?
get Bx!
Bx not usually needed for duodenal ulcers
Pt with active GIB, HR 120, BP 87/66, hgb 9.7. wtd?
Transfuse. pt is hypotensive and actively bleeding. Transfuse if hgb < 10 in this scenario
Hospitalized patient with EGD: ulcer < 2cm clean base, no bleeding. wtd?
PPI and discharge to home (or d/g to floors)
Hospitalized patient with EGD: bleeding ulcer, s/p APC or electrocautery. wtd?
monitor 72 hr on PPI before discharge
Pt with hx long or violent retching now with coffee ground emesis. Pt is known alcoholic or bulemic. Has epigastric pain or pain back pain. wtd?
EGD to r/o Mallory-Weiss (partial thickness) tear in esophagus
(Boerhaave pt will be HD unstable and have subq emphysema)
Possible side fx of PPI
- B12 def
- diarrhea (microscopic colitis)
- AIN
- C diff incr risk
- HAP incr risk
- osteoporosis (if chronic use)
- hypomagnesemia
Pt with suspected/new dx of cirrhosis. wtd?
get EGD to screen for varices
Pt with cirrhosis and ascites comes with variceal bleed. Tap reveals 150 WBCs and 40% PMNs wtd?
Variceal bleed: wtd?
- octreotide and band varices
- Start CTX prohpylactically even if no SBP (WBC 250 or greater). This has mortality benefit
47y M comes with coffee ground emesis. He drinks 2 glasses of wine/day. VSS, afebrile. Endoscopy shows no ulcer but does have gastric varices. wtd? dx?
wtd: CT abdomen
dx: splenic vein thrombosis
(causes gastric not esoph varices)
Pt with hx of gastric bypass or has motility issues. B12 deficiency, fatty stools, abd pain, diarrhea. Breath test abnormal dx? rx?
dx: SIBO
rx: rifaxamin 1st line. otherwise cipro or augmentin
Pt with severe pancreatitis, high LFTs and bili, dilated CBD. On IV abx in the MICU. wtd?
ERCP to remove stone, cholecystecomy before discharge
75y F s/p R hip replacment initially recovering well. POD 6 new RUQ pain, anorexia, fever 103, LFTs and bili mildly elevated. US show thick GB wall. HIDA with nonvisualization of GB, but CBD patent and normal size. dx? rx?
dx: acalculous cystitis
rx: cholecystostomy (needle drainage; not cholecystectomy)
Pt with hx of UC now with jaundice and/or high alkaline phos. wtd?
MRCP/ERCP to rule out PSC, get brush biopsy to r/o cholangiocarcinoma if onion skin fibrosis is seen
Pt with RUQ colicky pain (or may be asx) and RUQ or CT abdomen shows 1.1 cm GB polyp. wtd?
cholecystectomy for GB polyps > 1cm
wWPt with vitiligo or some other AI disease come with epigastric pain and jaundice. LFTs and AlkP mildly elevated. US show large pancreas with sausage shaped mass with beaded appearance. IgG4 elevated. CBD dilated but pancreatic duct is constricted. dx?
autoimmune pancreatitis
what lab is a poor prognostic predictor in acute pancreatitis?
BUN > 19
Pt w incidental finding of calcification of GB. wtd?
surgery
Asx pancreatic cyst found incidentally on CT scan. Worrisome features and wtd?
worrisome: solid component, >3cm, duct >10cm, thickening of cyst
wtd: if two or more worrisome features: EUS and FNA
Pancreatic cyst size that likely not to resolve on its own?
Drain if 4cm or more
Extra-intestinal manifistations mc in UC or Crohns?
what are they?
MC in UC
E. nodosum, arthritis, pyoderma gangrenosum, PSC, ankylosing spondylitis
IBD more a/w higher risk of cancer?
IBD more a/w RLQ mass on PE?
IBD more a/w with abdominal pain than diarrhea?
IBD more a/w deep ulcers and fistulas?
higher risk of cancer: UC
RLQ mass: Crohn’s
higher risk of pain: UC
fistulas and deep ulcers: Crohn’s
Best screening test for IBD
fecal calprotectin
Pt. with ileal-anal anastomosis pouch. 1 y later has increased diarrhea with blood and low grade fever. Stool is c/s negative. Endoscopy reveals ulcers in pouch. dx? rx?
dx: pouchitis
rx: metronidazole
MCC of TNF-a?
MCC of TNF-a?
PNA
may also cause reactivation of TB, histo, hepatitis
Pt with UC 4 years now. Presents with jaundice and fever. AlkP, bili and liver enzymes are elevated. wtd?
UC pt with bili or jaundice:
get ERCP/MRCP to r/o PSC on any UC patient with high bili
IBD a/w B12 def?
IBD gets better with smoking?
IBD a/w calcium oxalate stones?
IBD a/w granulomas?
a/w B12 def: Crohn’s (d/t ileal involvement)
better w smoking: UC
a/w Ca++ ox stones: Crohn’s
a/w granulomas: Crohn’s
Pt with bloody diarrhea, had hamburgers at a park 2d ago (or unpasteurized milk). Platelets low. dx? rx?
dx: E coli O157:H7
rx: NO antibiotics–increases risk of HUS
to culture: add sorbitol to McConkey agar
Food poisoning a/w vomiting predominantly
Food poisoning a/w vomiting predominantly
B cereus, Norovirus,
can also be Staph but this co-occurs with diarrhea
Edlerly pt fever, diarrhea, AMS after eating soft cheeses. dx? rx?
Listeria
Ampicillin
Toxins
a/w perioral parethesia and reversal of hot and cold
a/w flushing and urticaria
a/w weakness and ascending paralysis
Toxins
a/w hot/cold reversal: Ciguatoxin (large reef fish)
a/w urticaria: Scromboid poisoning
a/w ascending paralysis: tetrodotoxin (puffer fish)
How to treat traveler’s diarrhea?
Traveler’s diarrhea: watery, usu no fever
rx: hydration, abx to shorten disease: Ciprofloxacin or azithromycin
Travel to developing country, now months later with bloody diarrhea. Colonoscopy shows flask-shaped ulcers. dx? rx?
Dysentery with flask shaped ulcers
dx: amoebic colitis (E histolytica); get stool sample look for ova and cysts
rx: metronidazole
may also cause abscess in liver that usu do not need drainage
Diarrhea, fever, elevated wbc, hx abx use. what to r/o?
C diff! any diarrhea with high WBC, rule it out
Rx for C diff
1st infection
2nd, and 3rd, ocurrence
1st PO vanc
2nd PO vanc with long taper
3rd: fecal trxp
Pt with hx C diff now comes with bp 90/60, HR 116, WBC 12000, temp 101, lacate 6, tender distended abdomen. dx? rx?
toxic megacolon
po and rectal vanc, flagyl, surgical transplant
Pt with arthritis 2 years. Comes with abd pain, diarrhea. Stools are oily or watery, and he has weight loss and changes in skin pigmentation. Small bowel bx shows foamy macrophages and is PAS+. dx? rx?
Whipple disease (Tropheryma whipplei (any arthritis with diarrhea-consider this)
rx: CTX 2wk, + bactrim 1 year
Pt with hx atrophic gastritis and pernicious anemia; abd pain chronic diarrhea, wt loss, B12 190 (nl) and folic acid is 18 (high)
wtd? dx? rx?
wtd: hydrogen or xylose breath test
dx: SIBO
rx: rifaxamin
Any patient with oil stools/steatorrhea. What is the basic problem?
malabsorption
52y F uses PPI and has watery diarrhea mostly in the day but some at night. No blood, fever, or wt loss. Extensive infectious and inflammatory w/u is negative TTg is neg. wtd? dx? rx?
wtd: flex sig with bx; inflammation in lamina propria
dx: microscopic colitis (NSAIDs, PPI, SSRI, DM)
rx: d/c offending agent →bismuth
60 y M fever, high wbc, abd pain in LLQ. wtd? dx? test to avoid? rx?
wtd: CT with IV and oral contrast
dx: likely diverticulitis
test to avoid: colonoscopy or barium enema until 4 weeks s/p resolution
rx: CLD → cipro, flagyl if severe
Pt with diverticulitis and 2 cm abscess. wtd?
Abx: cipro, flagyl. Drain abscess if >4 cm in size
65y M with hx server AS comes with recurrent GIB. wtd? dx? rx?
AS with GIB
wtd: colonocopy: will see AVMs
dx: Heyde syndrome
rx: TAVR
55y F with intermittent sharp severe abd pain for 1 year. US and CT is normal. Basic infectious w/u is nl. Pain is elicited on straight leg raise. dx?
dx: functional abdominal wall pain. No further imaging or labs is warranted.
Hep A vaccine
series
for who
Hep A vaccine
series: 3 doses six months apart each
for: Hep C, MSM, travel to endemic area, chronic liver dz
Acute Hep B infection (pos HBV Ag; pos HBV eAg) with symptoms (jaundice), labs (ALT 100, bili 6) high viral load (850k). wtd?
supportive care, no specific Rx for acute infection. 90% will clear it on their own, even if there is high viral load and significant labs
HBV serology
acute infection:
carrier/chronic state:
vaccinated, never had dz
HBV serology
acute infection: HBsAg, HBeAg, HBcIgM
carrier/chronic state: HBsAb, HBVcIgG
vaccinated: HBsAb
Nurse previously vaccinated against HBV. Now with needle stick. wtd?
Get antiHBsAb titer
>10 U/L = reassure
<10 U/L = booster shot
Time limit between the two shots in HBV vacciation course?
no time limit
When to treat chronic HBV?
what to treat with?
when: ALT or AST > 2x ULN or any cirrhosis or any immunosuppression
what: 1st line: tenofovir and entecavir
what 2nd line: lamivudine or PEG alpha interferon
decompensated cirrhosis: gets liver trxp
Pregnant woman with HBV. wtd?
Tenofovir for mom, and HBV vax for new born
If treating HBV with PEG alpha interferon. What to look out for?
PEG alpha interferon
- this rx is NOT for cirrhotics
- monitor TSH
- many side fx: bone marrow suppression, psychiatric, AI dz, etc.
