Ch_3 - Gastroenterology

Question 1

The most important feature of GI bleed is _______, not __________.

Answer 1

Severity, not etiology. Cause is important but not as important as severity

Question 2

If a GI bleed is severe, do what next?

Answer 2

First, resuscitate with FLUIDS and BLOOD

Question 3

What is one easy way to determine the severity of a bleed (eg, GI bleed)

Answer 3

SBP <90 mmHg = Extremely severe bleeding

Question 4

The following Hemodynamic findings are associated with how much volume loss?

1. Blood donation
2. Orthostasis
3. Pulse > 100/min
4. SBP < 100mmHg

Answer 4

1. Blood donation –> ~10%
2. Orthostasis –> ~15-20%
3. Pulse >100 –> ~30%
4. ~30%

Question 5

If GI bleed is severe, how should you go about managing the situation?

Answer 5

Short answer: IV Fluids, CBC, Platelets, PT/INR, FFP, PPI, PRBCs

Long answer:

1. Make sure IV FLUIDS have been started
2. What is the BP?! If SBP is < 90 mmHg
3. Make sure a TYPE and CROSS for PACKED RBCs (PRBCs) transfusion has been sent.

Question 6

What does orthostatic mean?

Answer 6

BP and pulse is normal at rest when lying flat, but BP drops and pulse rises when standing up/sitting up.
SBP decrease >20 mmHg or Pulse increase > 10/min

Question 7

T/F Orthostatic evaluation can identify who has a minor bleed and who has a severe one

Answer 7

True. If there’s no OS on evaluation, you can be confident that bleeding is not severe.

Question 8

How long does it take to follow CBCs?

Answer 8

6-12 hours! An orthostatic hypotension eval is indispensable. Do it yourself!

Question 9

T/F Check for orthostasis right after giving a lot of fluids

Answer 9

False, check BEFORE giving a lot of fluids

Question 10

For severe bleeds, give ____(4)_____

Answer 10

1. Fluids
2. Blood
3. Platelets
4. Plasma (FFP) with PT/INR increase

Question 11

Best management for Esophogeal varices (2)

Answer 11

1. Octreotide NOW!
2. Banding (call GI service! – only they can do endoscopy, which is needed for Banding)
   - Sclerotherapy if Banding can’t be done

Question 12

T/F 3. Beta-blockers (Propranolol or Nadolol) can be effectively used to treat an acute variceal bleed

Answer 12

False! They do nothing

Octreotide + Banding (or sclerotherapy)

Question 13

T/F One CBC can determine the severity of a variceal bleed

Answer 13

False

Question 14

Hematocrit drops ____ points with hydration

Answer 14

only 2-3 points

Question 15

Patient presents with severe GI bleed, possibly secondary to esophogeal varices. You call the GI service. What will be asked of you?

Answer 15

Indicate why you think they have a severe bleed. Provide:

1. CBC
2. PT/INR
3. BP
4. Response to fluids

Question 16

What kills a patient with a severe GI bleed?

Answer 16

GI bleed –> hypotension + severe ANEMIA –> Myocardial Ischemia (CHECK EKG!)
(Lightheadedness doesn’t kill you)

Question 17

GI bleed –> severe, symptomatic anemia. What are the symptoms?

Answer 17

lightheadedness, SOB, fatigue, chest pain

Question 18

GI bleed –> severe, symptomatic anemia. Best next step in management?

Answer 18

Blood transfusion now!

Question 19

T/F Fluid replacement is more important than endoscopy for a severe GI bleed

Answer 19

True

Question 20

GI bleed –> check Orthostasis and ask yourself the following questions: (8)

Answer 20

1. When did the bleeding start?
2. Is stool red or black?
3. Vomit – bright red blood or dark “coffee grounds”?
4. How many bowel movements or episodes of vomiting w/ blood or black stool?
5. Sx: Lightheaded, SOB, Chest Pain?
6. History of heart dz?
7. Previous scope through mouth or rectum?
8. Antacid use?

Question 21

Lower GI bleed etiology? (4)

Answer 21

Diverticulosis
Angiodysplasia or AVM
Polyps
Hemorrhoids
Cancer

Question 22

Lower GI bleed vs. Upper GI bleed

what color?

Answer 22

L-GIB - bright red blood on bowel movement

U-GIB - can be red if it’s extremely severe and fast, in about 10% of cases

Question 23

T/F Hemorrhoid bleed may mimic a serious GI bleed

Answer 23

True, a small amount of red blood into the toilet makes the water look red and exaggerates the severity of the blood loss.

Question 24

Features of a hemorrhoid bleed?

Answer 24

1. No change in HCT w/ repeated testing
2. Found on rectal exam
3. Normal BP and Pulse
4. Absence of orthostatic change in BP or Pulse

Question 25

T/F Guaiac-positive, brown stool is severe

Answer 25

False, it's not severe

Question 26

Etiologies of Upper GI bleeds?

Answer 26

``` Ulcer dz - both duodenal or gastric Gastritis Esophagitis Duodenitis Varices Cancer ```

Question 27

What question should you always ask yourself when thinking about what test to order?

Answer 27

Always ask, "What will I do differently based on THAT test?"

Question 28

What is the most common cause of Upper GI bleed? | What is the most dangerous cause of UGIB?

Answer 28

MCC - Ulcer disease | MDC - Varices

Question 29

What type of varices can occur in the upper GI tract? How can you differentiate? Why do/can they occur?

Answer 29

Esophogeal, Gastric; Diff via Endoscopy d/t Portal Hypertension

Question 30

The initial management of an upper GI bleed depends on what?

Answer 30

Severity!

Question 31

Initial management of upper GI bleed ?

Answer 31

Depends on severity: IV fluids frequent checks of CBC (until it stops changing) correction of coagulopathy (if there is one) PPIs for ALL upper GI bleeds Epi injection or electrocautery for ulcers w/ active bleeding

Question 32

T/F Checking CBC frequently is important for a severe upper GI bleed T/F Using a Nasogastric tube could be useful in the management of a pt w/ an upper GI bleed

Answer 32

True False

Question 33

With a variceal bleed, do you wait for endoscopy to confirm variceal bleed? Explain

Answer 33

No, start Octreotide b/c it decreases portal pressure and has no major adverse effects

Question 34

Varices that bleed should be managed how? How can you prevent the next bleed?

Answer 34

Octreotide + Band varices that bleed; gastric varices are hard to "grab" to band BBs (Propranolol or Nadolol) are used only to PREVENT the next bleed!

Question 35

How to manage persistent bleeds?

Answer 35

``` Persistent bleed = persists despite banding and octreotide Need TIPS (Trans-jugular Intrahepatic Portosystemic Shunt) ```

Question 36

What is TIPS?

Answer 36

TIPS = Transjugular Intrahepatic Portosystemic Shunt Used for persistent bleeds TIPS = catherer down the Jugular vein to create a "shunt" b/w the portal and hepatic veins. This replaces the need for surgical shunting.

Question 37

A patient presents with an esophogeal variceal bleed that is persistent despite Octreotide and Banding therapy. What temporary method can be done to slow bleeding until TIPS can be done?

Answer 37

A Blakemore Tube -- balloon placed in esophagus and stomach to "tamponade" or "compress" the vessels. This is a temporary method of SLOWING BLEEDING in those who need to be kept alive for a few hours until TIPS can be done.

Question 38

What is "minor bleeding"?

Answer 38

Normal BP/pulse No orthostasis No recent change in HCT

Question 39

Patient presents to office with minor GI bleed characterized by guaiac-positive stool. What finding may you see on CBC? If there are no localizing symptoms, what should you do next?

Answer 39

Guaiac = Heme CBC --> Microcytic Anemia Colonoscopy (even if they had one last year!) Upper endoscopy Rarely, pill endoscopy, in those whom endoscopy does not show the cause.

Question 40

Although majority of epigastric pain is benign, your job as the interviewer is to...?

Answer 40

...find serious pathology by asking the right qs.

Question 41

Synonym for epigastric pain

Answer 41

EP = pain below the xiphoid process = Dyspepsia

Question 42

T/F In 50-90% of outpatients, pathology will never be found on a patient w/ epigastric pain

Answer 42

T

Question 43

T/F Patients admitted for Epigastric pain are markedly skewed toward more serious pathology. Gastritis, Pancreatitis, and other causes form of pain do not have tenderness on exam

Answer 43

First sentence = True | Second sentence = False, Only pancreatitis is tender

Question 44

What are some consequences of NG tubing?

Answer 44

An NG tube may be misplaced in a lung. That's why X-Ray is so important before tube feeding is started, and why routine NG tube in GI bleed is a bad idea.

Question 45

What is the MCC of epigastric pain in the general population?

Answer 45

Non-Ulcer Dyspepsia = NUD

Question 46

What is nunulcer dyspepsia?

Answer 46

NUD = pain w/o pathology. It's like a tension HA of your guts.

Question 47

Although NUD is the MCC of epigastric pain in the general population, the inpatients on the Wards rotation will more likely have ???

Answer 47

Ulcer dz, Pancreatitis, GERD, Esophagitis/Duodenitis/Gastritis, and/or Cancer

Question 48

What factors must you think about when trying to differentiate b/w benign from dangerous dz?

Answer 48

Duration, Intensity, Time of onset, and Aggravating/Relieving factors for all Pain syndromes (ie, OLDCARTS).

Question 49

Specifically for epigastric pain, in addition to OLDCARTS, what other questions should you ask?

Answer 49

``` Weight changes 1. Have you experienced weight loss? 2. Have you actually weighed yourself? What is the exact amount you lost? 3. How much did you weigh ~6months ago? Swallowing 4. Is it difficult to swallow? 5. Does food get STUCK when you eat? 6. Pain w/ swallowing? Nausea/Vomiting 7. Are you nauseated? Do you actually vomit? How often? Bleeding 8. Do you have blood in your stool or when you vomit? Antacids 9. Does the pain go away w/ Antacids? ```

Question 50

Patient comes in with epigastric pain and you remember that in addition to OLDCARTS, you have to look for "alarm symptoms". What are these?

Answer 50

Weight loss Dysphagia Odynophagia Bleeding (Vomit, Stool)

Question 51

Any patient with epigastric pain 1) alarm Sx + Age >45-55 or 2) if alarm sx persist or worsen despite use of PPIs should get what?

Answer 51

Upper Endoscopy = EGD (EsophagoGastroDuodenoscopy)

Question 52

Why is an EGD is used for patients over 45 with alarm symptoms associated w/ epigastric pain?

Answer 52

1. Most accurate test of the stomach 2. Allows BANDING of varices and cautery of visible vessels in an ulcer 3. Needed for stomach biopsy to exclude CANCER in gastric ulcer 4. To dx b/w stomach and duodenal ulcer (only EGD can do this!)

Question 53

What is the only way to exclude upper GI cancer?

Answer 53

EGD

Question 54

Compare/Contrast EGD vs Barium contrast

Answer 54

EGD >> Ba Study Reason? --> EGD is far more accurate study of stomach, can do biopsy or therapeutic procedures, and exclude Gastric cancer assoc w/ ulcer.

Question 55

H. pylori can be tested w/o Endoscopy, but why would you still do an endoscopy?

Answer 55

4% of gastric ulcer is assoc w/ cancer and EGD could exclude cancer

Question 56

H. pylori testing is best done on ???

Answer 56

BIOPSY!

Question 57

Discuss efficacy of various H. pylori testing

Answer 57

1. Biopsy is the best test 2. It's important to drive treatment w/ PPI, Clarithromycin, and Amoxicillin 3. Helicobacter stool antigen or breath testing is not as good as biopsy 4. stool antigen and breath test CAN DIFFERENTIATE b/w old vs. current infection. 5. SEROLOGY is clinically useless

Question 58

When should you only treat for H. pylori? In patients who experience what? If it's not treated, what may be the consequence?

Answer 58

Treat only in those w/ ulcers or gastritis. Ulcers will recur if H. pylori is not eradicated.

Question 59

The ONLY clear indications for stress ulcer prophylaxis are (4)

Answer 59

1. Mechanical ventilation/intubation 2. Head trauma 3. Burns 4. Coagulopathy

Question 60

T/F NSAIDs and steroids are indications for stress ulcer prophylaxis

Answer 60

False

Question 61

Although PPIs are generally benign, there is a slight risk of (3)

Answer 61

1. C. diff colitis 2. Osteoporosis from interference w/ Ca++ absorption 3. Pneumonia: gastric acid protects against gastric colonization w/ bacteria

Question 62

What is Zollinger-Ellison Syndrome (ZES) caused by?

Answer 62

ZES is caused by ELEVATED GASTRIC ACID and ELEVATED SERUM GASTRIN.

Question 63

Look for ZES and get a gastrin level only if you see the following (4)

Answer 63

1. Large ulcers (>1cm) 2. Recurrence after eradication of H. pylori 3. Distal location near the far end of the duodenum near the ligament of Treitz. 4. Multiple ulcers

Question 64

Why is diarrhea common in ZES?

Answer 64

Acid inactivates Lipase

Question 65

A patient who is suspected of having ZES should have a serum _____ level tested when they are off what medications?

Answer 65

serum GASTRIN level when off of PPIs and all forms of antacids

Question 66

ZES suspected, but equivocal levels of gastrin. Next best step?

Answer 66

Secretin Test - normal response (no ZES) --> decrease in gastrin - ZES - gastrin stays high even after giving secretin.

Question 67

What is the confirmatory test for ZES?

Answer 67

Endoscopic ultrasound and Nuclear somatostatin receptor scan - Confirm that ZES is local and resectable by excluding Mets w/ these 2 modalities

Question 68

Patient has ZES. If local, how to treat? If Mets, how to treat?

Answer 68

If local --> surgical resection | If mets or unresectable --> lifelong PPIs

Question 69

What is one complication for the stomach due to long-standing diabetes?

Answer 69

Diabetic Gastroparesis - weakening of the stomach - inability to stretch

Question 70

Long-standing diabetes damages what that leads to gastroparesis? Consequence?

Answer 70

nerves; pts cannot feel the "stretch" of the bowel that is the main stimulant for GI motility.

Question 71

How can you recognize diabetic gastroparesis?

Answer 71

Bloating Nausea Constipation Abdominal discomfort

Question 72

Patient with long-standing diabetes presents with bloating, nausea, constipation, and abdominal discomfort. You suspect diabetic gastroparesis. Next best step in mgmnt?

Answer 72

Look at the response to treatment with: | Metoclopramide and Erythromycin

Question 73

If the diagnosis of DM Gastroparesis is equivocal, then what?

Answer 73

Do a nuclear gastric emptying study. Patients eat Barium-soaked bread and are monitored for the time it takes for it to leave the stomach.

Question 74

GERD is d/t what?

Answer 74

abnormally RELAXED LES. Acid comes up out of the stomach and hits the back of the throat and vocal cords.

Question 75

T/F GERD causes 25% of chronic cough.

Answer 75

T

Question 76

What qs should you ask of someone you think has GERD?

Answer 76

1. Does the pain/discomfort in your belly go anywhere? (like your chest) 2. Do you have 'heartburn'? Do you have pain in your chest? 3. Do you have a bad taste in your mouth? Does it taste like metal, like you have pennies in your mouth? 4. Is your throat sore? 5. Do you feel your voice is hoarse? 6. Do you cough, especially at night?

Question 77

T/F The test for GERD is generally the response to PPIs.

Answer 77

True, 95% of those w/ GERD should respond w/in a day to tx w/ PPIs.

Question 78

When should specific testing for GERD be done?

Answer 78

If the sx are persistent even with PPIs.

Question 79

T/F Helicobacter can cause GERD

Answer 79

False, it cannot

Question 80

How to treat GERD?

Answer 80

Start ANY PPI Ask the pt later the same day if the sx have improved If sx persist, ask your resident/attending about performing an EGD or 24-hr

Question 81

T/F Surgical treatment can be given to GERD patients.

Answer 81

T Surgical resection such as Nissen fundoplication is done for the small percentage (<5%) of patients NOT controlled w/ PPIs

Question 82

What is a major consequence of GERD?

Answer 82

Barret's Esophagus; develops from long-standing GERD (usually >5 yrs). But, it's not always clear when to scope to screen for it. If patient presents w/ alarm sx (eg, weight loss, anemia, blood in stool, etc), SCOPE.

Question 83

How is Barret's diagnosed?

Answer 83

EGD and biopsy. Biopsy is the only way to confirm the metaplastic change that occurs.

Question 84

How many people with Barret's per year develop adenocarcinoma?

Answer 84

0.4-0.8% (less than 1%)

Question 85

How to treat Barret's?

Answer 85

PPIs and repeat EGD every 2-3 yrs for early detection of CA

Question 86

T/F Barret's esophagus is reversible

Answer 86

True! Metaplasia is reversible

Question 87

Patient with GERD is scoped and biopsied. Low-grade dysplasia of the esophagus is the diagnosis. Now what?

Answer 87

PPI and re-scope/re-biopsy every 6 months. No resection b/c it's reversible.

Question 88

Patient with GERD is scoped and biopsied. High-grade dysplasia of the esophagus is the diagnosis. Now what?

Answer 88

PPI and either endomucosal resection with endoscope OR Distal esophagectomy

Question 89

Why must surgery be done on high-grade dysplasia of lower esophagus?

Answer 89

Because of high probability of transformation into adenocarcinoma (invasive CA). Mucosal "shaves" with EGD are effective.

Question 90

Pt comes in with worsening, severe epigastric pain and tenderness on palpation. Most likely Dx?

Answer 90

Pancreatitis

Question 91

With increasing incidence of obesity, why would one expect pancreatitis to increase?

Answer 91

Increase incidence of gallstone dz.

Question 92

Pacreatitis work-up includes elevations of what enzymes?

Answer 92

lipase and amylase. Lipase more specific.

Question 93

What should you ask the patient if you suspect pancreatitis?

Answer 93

If there's radiating pain to the BACK N/V (if so, how many times; is there blood?) Quantity of ALCOHOL patient drinks History of GALLSTONES

Question 94

What is the Ranson's criteria?

Answer 94

Although obsolete, still asked on rounds Ranson's Criteria = elevated WBC, Low Ca++, Age>55, high AST, and high LDH Ranson was a surgeon working before there were CT scans. He made these criteria to determine the need for surgical debridement.

Question 95

T/F No test determines the severity of pancreatitis in first 48 hours

Answer 95

T

Question 96

T/F CT is not necessary for confirming pancreatitis, although it is most sensitive

Answer 96

T

Question 97

What can show the cause of pancreatitis?

Answer 97

CT or US can show cause -- eg, stone or obstruction. Scan is used to determine if stone removal is needed

Question 98

What is MRCP?

Answer 98

MCRP = Magnetic Resonance CholangioPancreatography = DIAGNOSTIC method that best visualizes the DUCTAL structure of the pancreas and biliary system

Question 99

What is ERCP?

Answer 99

ERCP = Endoscopic Retrograde CholangioPancreatography = THERAPEUTIC method to remove stones and dilate structures

Question 100

Compare MRCP and ERCP

Answer 100

MRCP finds the obstruction, while ERCP fixes it

Question 101

T/F There is no medication that increased the speed of resolution of pancreatitis

Answer 101

T - Physicians provide "rest" of the pancreas and give a lot of fluid. Pancreatic inflammation releases a lot of mediators, which cause "leak" of capillaries.

Question 102

What is the main cause of death in acute pancreatitis?

Answer 102

Inadequate fluid replacement. Don't be afraid to give 150-250 mL/hr for the first day.

Question 103

Treatment and management of acute pancreatitis...GO

Answer 103

1. NPO, IV fluids in large volumes, analgesics 2. PPIs are often used (not clear if they help) 3. CT w/ >30% necrosis needs IMIPENEM or MEROPENEM and CT-guided BIOPSY 4. Infected necrotic pancreatitis is rare, but needs SURGICAL DEBRIDEMENT

Question 104

With diarrhea, what is more important, severity or etiology?

Answer 104

Severity, not etiology. You gotta know who needs antibiotics and IV fluids

Question 105

Severity of diarrhea = ??

Answer 105

Volume depleted and febrile

Question 106

What qs should you ask of a patient who has severe diarrhea?

Answer 106

1. Is SBP < 90-100? Is pulse > 100/min? 2. Check for orthostasis: increase in pulse >10 or drop in SBP >20 on rising 3. Fever? Oral temp >100.3F 4. Blood in stool? 5. Abdominal pan or tenderness on exam?

Question 107

What may you be asked on rounds about a patient with diarrhea?

Answer 107

1. Duration of sx 2. Frequency of bowel movements 3. Blood in stool 4. Fever; has a Temp been taken, or does the pt just feel warm? 5. Lightheadedness 6. Others that live w/ pt who have the same problem/diarrhea. Did you eat at the same place? same food?

Question 108

T/F A precise microbiologic diagnosis is rarely confirmed, and decisions about treatment must be made before you have any test results back.

Answer 108

T

Question 109

Bloody Diarrhea may be present with which major pathogens?

Answer 109

Campylobacter, Salmnonella, Shigella, Yersinia, or some Vibrio species.

Question 110

T/F Blood may be present only in microscopic or "occult" amounts in brown stool (diarrhea), thus it is caused by invasive pathogens

Answer 110

true

Question 111

T/F Fecal leukocytes (WBCs) have the same significance as blood

Answer 111

True -- they mean that the organism is invasive

Question 112

What is the only way to distinguish bw invasive organisms that can cause diarrhea?

Answer 112

Stool culture

Question 113

Pt has diarrhea. What should you do if you don't see blood in the stool?

Answer 113

Test for: 1. Occult blood (guiac--ie heme) 2. Fecal blood w/ Methylene Blue stain 3. Culture 4. Ova and parasite exam

Question 114

Pt has diarrhea, AIDS w/ < 100 CD4+ cells. What is the most likely organism and what test would you run?

Answer 114

Cryptosporidium | Modified Acid-fast stain

Question 115

Pt has diarhhea. hiker, camper. Organism? Test?

Answer 115

Giardia | ELISA stool ANTIGEN, Ova and Parasite test

Question 116

Pt has diarrhea. Antibiotic use Organism Test?

Answer 116

C. diff | Stool TOXIN assay

Question 117

Pt has diarrhea. Hemolysis, low platelets, elevated BUN and Creatinine. Organism? Test?

Answer 117

E. coli O157:H7 Sorbitol MacConkey agar E.coli O157:H7 does NOT grow on routine media!

Question 118

Pt has diarrhea. Flushing, wheezing immediately after fish eating Organism? Test?

Answer 118

Scombroid | Stool culture

Question 119

T/F Majority of infectious diarrhea cases are self-limited and benign

Answer 119

T - i.e. they don't require antibiotic tx There's much higher incidence of Ciprofloxacin use in those ADMITTED to the hospitals b/c that's the reason they have been admitted.

Question 120

What can you give a patient who is suffering from diarrhea that does not have blood or fever?

Answer 120

Antimotility agents (eg, Diphenoxylate [Lomotil]) or Loperamide [Imodium]

Question 121

If a patient has "severe" diarrhea, how should he be treated? What does "Severe" mean?

Answer 121

Severe = Fever + bloody stool + Hypotension/Tachycardia + Abdominal Pain/tenderness Treat w/ Antibiotics Initial Tx is based on SEVERITY not etiology!

Question 122

C. difficile treatment?

Answer 122

1. Metronidazole first; Vanco only if metro fails 2. Recurrences are treated w/ repeat course of Metro 3. Very severe cases get both Metro and Vanco

Question 123

Giardia Tx?

Answer 123

Metronidazole, Tinidazole

Question 124

Cryptosporidia tx?

Answer 124

Nitazoxanide

Question 125

Campylobacter tx?

Answer 125

Azithromycin or erythromycin if confirmed as Camp

Question 126

E.coli O157:H7 Tx?

Answer 126

AVOID antibiotics!

Question 127

Scombroid Tx?

Answer 127

Diphenhydramine (benadryl; antihistamine)

Question 128

Viral, Staph, Bacillus cereus Tx?

Answer 128

1. Supportive Tx w/ fluids | 2. Antibiotics don't help!

Question 129

What is the definition of "Severe C. difficile"?

Answer 129

1. Fever 2. WBC > 15,000-20,000/mm3 3. Creatinine > 1.5 mg% 4. > 10 movements a day

Question 130

Which malabsorptive diseases are characterized by steatorrhea?

Answer 130

1. Celiac dz 2. Whipple's dz 3. Tropical sprue 4. Chronic pancreatitis

Question 131

How are the 4 malabsorptive diseases similar in their clinical presentation?

Answer 131

1. Weight loss 2. Stool described as "oily, greasy, floating, and especially foul-smelling" 3. Ask, "do you bruise easily?" -Vitamin K malabsorbed; high PT 4. Vitamin D deficiency/Low Calcium - look for bone disease such as Osteoporosis. 5. Vitamin B12 def - macrocytic anemia 6. Stool: Sudan black stain positive (fecal fat test)

Question 132

Synonym for Celiac disease

Answer 132

Gluten-sensitive enteropathy

Question 133

Sx/Sx of Celiac disease

Answer 133

Malabsorption Sx + 1. Fe deficiency anemia (very common) d/t damage to duodenum 2. Dermatitis herpetiformis (not common) 3. Small bowel lymphoma

Question 134

T/F Celiac disease has a strong association w/ Diabetes

Answer 134

T

Question 135

Celiac dz treatment

Answer 135

Eliminate gluten from diet

Question 136

Celiac disease Diagnosis

Answer 136

``` Do SEROLOGY first! - Anti-transglutaminase antibodies and anti-Endomysial antibodies - Anti-GLIADIN are imprecise BIOPSY - most accurate - flattened villi - Exclude bowel wall lymphoma ```

Question 137

Whipple's disease clinical presentation

Answer 137

Malabsorptive + | Eye, joint, neurologic manifestations

Question 138

Whipple's dz Diagnosis?

Answer 138

BIOPSY of bowel w/ PAS+ organisms | PCR or stool for Tropheryma whippelii

Question 139

Whipple's dz Treatment

Answer 139

Antibiotics for 6-12 months: Ceftriaxone, Doxycycline, TMP/SMX (Bactrim)

Question 140

Define Chronic Pancreatitis

Answer 140

Repeated episodes of pancreatitis over a period of yearS. Debilitating abdominal pain. Fat malabsorption (loss of lipase). B12 malabsorption (no pancreatic enzymes to detach B12 from R-protein to allow for IF binding).

Question 141

Pt with chronic pancreatitis who gets an X-Ray or CT is expected to have _____

Answer 141

Calcification XR -- 50-60% CT - 80-90%

Question 142

T/F Amylase and Lipase are elevated in chronic pancreatitis

Answer 142

False - they are normal or low -- pancreas is "burnt out" and destroyed

Question 143

What is the most accurate test for chronic pancreatitis?

Answer 143

IV Secretin stimulation test Normal response = massive release of pancreatic enzymes into the duodenum Chronic pancreatitis = no release of bicarb-rich fluid into duodenum

Question 144

Treatment of Chronic Pancreatitis

Answer 144

1. Replace pancreatic enzymes Orally (Lipase, Trypsin, and Amylase in pill form) 2. Pain management w/ Celiac Ganglion block by injectionvia Endoscopic US

Question 145

T/F Lactose intolerance is very common and these patients are never admitted to the hospital for it

Answer 145

T

Question 146

Sx of lactose intolerance?

Answer 146

Diarrhea and Gas

Question 147

How to recognize lactose intolerance?

Answer 147

No fever or blood in stool No weight loss No systemic findings Rapid resolution 1 day after stopping milk products (except Yogurt)

Question 148

Treatment of Lactose Intolerance

Answer 148

Avoid milk products or use LactAse replacement

Question 149

Define Carcinoid syndrome

Answer 149

Heart becomes fibrotic b/c of chronic 5HT exposure

Question 150

Clinical presentation of Carcinoid Syndrome

Answer 150

1. Episodic, chronic diarrhea 2. Flushing, Wheezing, and rarely Right-sided cardiac fibrosis 3. Telangiectasia from chronic flushing 4. Mets lesions to LIVER are almost always present 5. Urinary 5-HIAA

Question 151

Treatment of Carcinoid Syndrome

Answer 151

Octreotide or Lanreotide

Question 152

T/F Patients with IBS are rarely admitted to the hospital, but many seek help at clinic

Answer 152

T | IBS = Irritable Bowel Syndrome

Question 153

T/F IBS abdominal pain is specific

Answer 153

false, non-specific

Question 154

When you see a pt with suspected IBS, what is your primary concern?

Answer 154

Rule out serious pathology

Question 155

IBS diagnosis can only be made after testing is done. What testing?

Answer 155

NORMAL - EGD - Colonoscopy - Abdominal CT

Question 156

IBS clinical presentation

Answer 156

1. Abdominal pain 2. Diarrhea AND/OR Constipation 3. Sx less severe at night 4. Pain relieved by bowel movement 5. No weight loss 6. No blood, mucus, or fever

Question 157

IBS treatment

Answer 157

No single effective therapy. - Fiber and bulking agents (Metamucil, Psyllium husks, bran - Anti-spasmodics - Hyoscyamine or Dicyclomine - TCAs

Question 158

Define Inflammatory Bowel Disease (IBD)

Answer 158

Crohn's and UC are idiopathic, inflammatory IBD diseases.

Question 159

CP of IBD

Answer 159

Abdominal pain, diarrhea, blood and mucus in stool, CD can have fever and Palpable abdominal masses

Question 160

What is considered an "acute exacerbation" of IBD?

Answer 160

>10-20 bowel movements a day, often w/ blood

Question 161

What to treat w/ for acute episodes of IBD?

Answer 161

Steroids

Question 162

What to use for long-term control of IBD

Answer 162

Mesalamine

Question 163

CD may result in fistulae. Any fistulae needs to be treated w/ what? (medically)

Answer 163

TNF drugs like Infliximab

Question 164

What's an important preventive measure for someone diagnosed w/ IBD?

Answer 164

Screen for Colon Cancer after 10 years of colon involvement

Question 165

Both UC and CD have what? (4)

Answer 165

1. Joint pain 2. Erythema nodosum/pyoderma gangrenosum 3. Uveitis/Episcleritis 4. Sclerosing Cholangitis (more so w/ UC)

Question 166

Manifestations more common w/ Crohn's are? (3)

Answer 166

1. Fistulae (from transmural GRANULOMAS): they can come through the skin or connect b/w loops of bowel or into the bladder 2. Peri-anal disease 3. Oral, esophogeal, and small bowel disease (anywhere in the GIT!)

Question 167

Diagnosis of IBD

Answer 167

1. Lower or upper endoscopy is first -- depends on sx | 2. Small bowel series is sometimes needed for CD

Question 168

Acute, severe exacerbations of IBD are managed with what?

Answer 168

Steroids

Question 169

Chronic control of UC is treated with what?

Answer 169

Mesalamine derivatives: Asacol (Ass; colon), Rowasa (Rectal; limited distal/rectal involvement)

Question 170

Chronic control of Crohn's dz is treated with what?

Answer 170

Mesalamine derivatives: Pentasa (entire 5 'units' of bowel - M, E, S, SI, LI) M = mouth

Question 171

Why are Azathioprine/6-MP used for IBD?

Answer 171

to wean pts off steroids and for chronic control

Question 172

What is one worrisome adverse effect of 6-MP? hint: GI related

Answer 172

Drug-induced pancreatitis

Question 173

Pt with CD has fistulae. Treat with what? What must be checked before administration?

Answer 173

Anti-TNF meds - eg, Infliximab, Etanercept, Adalimumab TB reactivation risk: check PPD and give INH if PPD+

Question 174

Pt with perianal involvement (Crohns). Treat with? Explain

Answer 174

Ciprofloxacin and Metronidazole | Besides being abx, these meds have a primary anti-inflammatory effect

Question 175

What is a way to cure UC?

Answer 175

Surgery is curative of UC, but not so effective for CD

Question 176

Both UC and CD can lead to Colon CA. Risk is based mainly on what?

Answer 176

DURATION of colonic involvement. 10 years with either CD or UC has same risk. Must do COLONOSCOPY after 8-10 years of colonic involvement of IBD.

Question 177

What's a very common cause of Constipation in the elderly? Advise them what?

Answer 177

Simple Dehydration. Advise more FIBER in their diet.

Question 178

Common iatrogenic causes of constipation (5)

Answer 178

1. CCBs 2. Hypothyroidism 3. Opiates 4. CaCO3 replacement (Calcium replacement) 5. TCAs (anticholinergic)

Question 179

Compare the various modalities that can screen for Colon CA

Answer 179

Nothing is superior to COLONOSCOPY. Stool guiac lacks specificity and precision. Barium is worthless and impractical. Sigmoidoscopy would miss 40% of cancers that occur proximal to the sigmoid colon.

Question 180

The general population should be screened for colon cancer when?

Answer 180

Age>50 every 10 years

Question 181

If one family member has/d Colon CA, what are the screening recommendations?

Answer 181

Age>40 or 10 years earlier than family member | Every 10 years

Question 182

If patient has HNPCC, 3 family members, 2 generations, 1 premature (before 50)

Answer 182

Screen >25 q 1-2 years

Question 183

Pt w/ FAP should be screened when?

Answer 183

Screen w/ Sigmoidoscopy q 1 yr

Question 184

CP/history of someone you suspect has Diverticular dz

Answer 184

``` Abdominal pain in LLQ Age >50-60 Blood in stool Fever Vegetarian diet (protective) Previous colonoscopy (risk for Div Dz) ```

Question 185

Diverticulosis diagnosed by?

Answer 185

Endoscopy (Colonoscopy)

Question 186

CP of Diverticulitis

Answer 186

LLQ pain, Fever, Leukocytosis, Acute onset

Question 187

Diverticulitis diagnosed with?

Answer 187

CT scan. Avoid scoping -- increased risk of perforation (weak wall!)

Question 188

Therapy for diverticulosis

Answer 188

No specific Tx. Avoid meat and increase fiber. Vegetarian diet is seemingly protective as they rarely get it. Nothing can reverse it, however

Question 189

Therapy for diverticulitis

Answer 189

Antibiotics - - Ciprofloxacin and Metronidazole - Ceftriaxone and Metronidazole - Ampicillin/Sulbactam (Unasyn) - Piperacillin/Tazobactam (Zosyn) - Any carbapenem (eg, ertapenem, meropenem, doripenem)

Question 190

CP of Cholecystitis

Answer 190

- RUQ pain and tenderness; fever

Question 191

Lab findings of Cholecystitis

Answer 191

- (Fever) Leukocytosis | - Normal bilirubin and LFTs in almost all pts

Question 192

Diagnosis of Cholecystitis

Answer 192

Clinical = RUQ pain, fever, increased WBCs, normal bili and LFTs ULTRASOUND is best first test CT misses some small stones Get a SURGICAL evaluation for Laparoscopic cholecystectomy

Question 193

Treatment of Cholecystitis

Answer 193

Unasyn (Ampicillin/Sulbactam) Zosyn (Piperacillin/Tazobactam) Any carbapenem (eg, ertapenem, meropenem, doripenem)

Question 194

What is worse, Cholangitis or Cholecystitis?

Answer 194

Cholangitis is much more severe

Question 195

What is ascending cholangitis?

Answer 195

Obstructive jaundice w/ severe infection of both the biliary tree and the liver.

Question 196

Ascending cholangitis findings

Answer 196

- Biliary tract obstruction --> jaundice - Increased DIRECT bilirubin - Alkaline Phosphatase and GGTP increased - AST and ALT may be up as well

Question 197

RUQ pain/tenderness + jaundice = ??

Answer 197

Ascending cholangitis

Question 198

Pt presents w/ RUQ pain, jaundice, and has now developed "shaking chills". What is the ML diagnosis and what is the significance of the last symptom?

Answer 198

Ascending cholangitis Shaking chills = Bacteremia

Question 199

Diagnostic testing for Ascending cholangitis?

Answer 199

Elevated LFTs US - stones and/or ductal dilation CT scan MR-CP - most accurate test of the biliary and pancreatic ductal system.

Question 200

What is the most accurate test for ascending cholangitis?

Answer 200

MRCP

Question 201

Therapy of ascending cholangitis

Answer 201

Mechanical obstruction must be removed/released. How? -- ERCP can remove stones and dilate strictures Antibiotics (Unasyn, Zosyn, or any Carbapenem); abx alone will not fix an obstructive stone

Question 202

For all patients who have elevated/abnormal LFTs suggestive of liver disease should get what? (5)

Answer 202

1. Repeat LFTs 2. Abdominal US 3. PT time: all clotting factors are made in liver except factor VIII/vWF 4. Albumin level 5. Hep B and Hep C testing

Question 203

As you pre-round, you notice that your patient has abnormal LFTs, what must you make sure you know about?

Answer 203

Any Liver-toxic meds, alcohol are being used! Patient's history: contact private doctor if records not in chart! The patient may already have documented chronic hepatitis or something!

Question 204

When AST is abnormal, you should think of ??

Answer 204

Drug toxicity, alcohol use

Question 205

When ALT is abnormal, you should think of ??

Answer 205

Viral hepatitis

Question 206

When Alk Phos is abnormal, you should think of ??

Answer 206

Biliary tract obstruction, bone disease, pregnancy

Question 207

When GGTP is abnormal, you should think of ??

Answer 207

Biliary tract obstruction | Goes up immediately after binge drinking

Question 208

When Albumin is abnormal, you should think of ??

Answer 208

SYNTHETIC dysfunction of liver Can be down from malnutrition and nephrotic syndrome Must be missing 70-80% of liver before it drops

Question 209

When PT time is abnormal, you should think of ??

Answer 209

Best test of SYNTHETIC function of liver | Normal PT = liver is working, no matter how high the AST/ALT

Question 210

Patient comes in with acute onset of jaundice, dark urine, extreme fatigue, and weight loss. What is the ML diagnosis?

Answer 210

Viral Hepatitis (dark urine = bilirubin)

Question 211

T/F Hepatitis makes one feel totally "out of gas". It also enhances one's hunger.

Answer 211

True and | False (it shuts of hunger)

Question 212

Diagnostic LAB findings of Viral Hepatitis

Answer 212

1. Markedly elevated DIRECT bilirubin and ALT | 2. Alk phos may be slightly elevated

Question 213

Diagnostic imaging finding(s) of viral hepatitis

Answer 213

US - exclude obstruction

Question 214

What is the most accurate test of Chronic Hepatitis

Answer 214

Biopsy - rarely needed

Question 215

What is the specific test for Hepatitis A, D, and E?

Answer 215

IgM acutely, IgG upon resolution

Question 216

What is the specific test for Hepatitis C?

Answer 216

1. Antibody test first 2. PCR RNA viral load confirms level of activity 3. Genotype predicts response

Question 217

What is the specific test for acute Hepatitis B?

Answer 217

1. Surface Ag (HB-sAg) 2. 'e' antigen (HB-eAg) 3. Core antibody IgM (not IgG!)

Question 218

What is the specific test for chronic Hepatitis B?

Answer 218

1. Persistence of HB-sAg >6 mo 2. HB-eAg either +/- 3. Core antibody IgG (not IgM!)

Question 219

How would you test to see if patient is vaccinated to Hepatitis B?

Answer 219

ONLY HB-surface ANTIBODY +

Question 220

How would you test to see if patient has resolved (past) Hepatitis B infection?

Answer 220

HB-surface ANTIBODY and Core Antibody IgG

Question 221

What indicates whether active Hepatitis C infection is present?

Answer 221

Hep C PCR DNA

Question 222

T/F the only form of acute viral hepatitis that is treated is Hepatitis C

Answer 222

T

Question 223

How do you treat acute Hep C? How long?

Answer 223

Interferon + Ribavirin + Boceprevir (or telaprevir).

Question 224

T/F Hepatitis C rarely presents in its acute form

Answer 224

T

Question 225

When do cases of Hepatitis C come up?

Answer 225

Most show up years later either on evaluation of abnormal LFTs done for another reason or on development of liver dz.

Question 226

Generally, how long does treatment for chronic Hep C take?

Answer 226

6-12 months; use same drugs as acute hepC (IFN, Ribavirin, -Previr)

Question 227

Adverse effect of Interferon?

Answer 227

IFN = hepC med; flu-like sx, arthralgia, myalgia, depression

Question 228

Adverse effect of Ribavirin?

Answer 228

Anemia

Question 229

What determines the likelihood of response to treatment against Hep C?

Answer 229

Genotype

Question 230

What determines if a response to Hep C therapy has occurred?

Answer 230

PCR DNA

Question 231

What is the only way to determine the extent of inflammation, fibrosis, or presence of cirrhosis secondary to HepC?

Answer 231

BIOPSY

Question 232

T/F if Hep C viral load is up and you end up treating, a biopsy will change a little

Answer 232

T

Question 233

What is the goal of Viral Hepatitis (B or C) treatment?

Answer 233

To drive the viral load to undetectable levels and get the pt feeling better

Question 234

T/F Biopsy is needed for Hepatitis B diagnosis and prognosis

Answer 234

False, Although biopsy determines extent of disease, it adds little if you are going to use meds anyway

Question 235

T/F Combination therapy is clearly better than monotherapy for treating Hepatitis B

Answer 235

False, combo therapy is not clearly useful for Hep B. Monotherapy is used

Question 236

T/F Genotyping determines the likelyhood of response to treatment

Answer 236

False, genotyping is not used for hepB

Question 237

What are the treatment options for HepB?

Answer 237

Not clear which drug has greater efficacy: 1. -vudine's (Lamivudine, Telbivudine) 2. -fovir's (Adefovir, Tenofovir) 3. Entecavir 4. IFN is by injection and has more adverse effects (flu-like sx)

Question 238

What are the common manifestations of Cirrhosis? (10)

Answer 238

1. Edema 2. Ascites 3. Encephalopathy 4. Low Albumin 5. High PT/coagulopathy 6. Gynecomastia 7. Varices 8. Splenomegaly 9. Hemorrhoids 10. Thrombocytopenia

Question 239

Cirrhosis --> Edema --> Tx w/ ?

Answer 239

Spironolactone, Lasix

Question 240

Cirrhosis --> Ascites --> Tx w/ ?

Answer 240

Spironolactone, Lasix

Question 241

Cirrhosis --> Encephalopathy --> Tx w/ ?

Answer 241

Lactulose, Rifaximin

Question 242

Cirrhosis --> Low albumin --> Tx w/ ?

Answer 242

No tx

Question 243

Cirrhosis --> High PT/coagulopathy --> Tx w/ ?

Answer 243

FFP if bleeding

Question 244

Cirrhosis --> Gynecomastia --> Tx w/ ?

Answer 244

no Tx

Question 245

Cirrhosis --> varices --> Tx w/ ?

Answer 245

Propranolol, nadolol (prevent next bleed) Banding if they bleed (Octreotide)

Question 246

Cirrhosis --> Splenomegaly--> Tx w/ ?

Answer 246

None

Question 247

Cirrhosis --> Hemorrhoids --> Tx w/ ?

Answer 247

None

Question 248

Cirrhosis --> Thrombocytopenia --> Tx w/ ?

Answer 248

If bleeding, use platelets

Question 249

Why do all patients w/ Ascites need a paracentesis?

Answer 249

to confirm the etiology as portal HTN (d/t Cirrhosis) causing a transudate and to, at times, exclude spontaneous bacterial peritonitis (SBP).

Question 250

Pt has ascites, you do a paracentesis and the protein level is low (s your next step?

Answer 250

Prophylaxis against the first episode of spontaneous bacterial peritonitis is given w/ OFLOXACIN or TMP/SMX (bactrim).

Question 251

Patient w/ ascites is paracetesed and the cell count is > 250 PMNs. What does the patient ML have and what is your best next step in mgnmt?

Answer 251

>250 PMNs = SBP --> Tx w/ Ceftriaxone or Cefotaxime (both 3rd gen)

Question 252

Why is the level of Albumin low in ascitic fluid in patients who have cirrhosis induced portal HTN?

Answer 252

Ascitic fluid d/t portal HTN is transudate (no protein or cells) based on hydrostatic forces.

Question 253

SAAG > 1.1 means what?

Answer 253

Serum albumin > Ascitic albumin, which means... | Portal HTN and/or SBP

Question 254

SAAG < 1.1 means what?

Answer 254

Ascitic albumin is not as low as you would think as compared to as serum albumin. Found in Cancer or intra-abdominal infection excluding SBP

Question 255

What is the MCC of Hemochromatosis?

Answer 255

genetic defect (HFE) resulting in the OVERABSORPTION of Iron from the DUODENUM. Fe builds up n Liver --> Cirrhosis --> MCC of death

Question 256

MCC of death in Hemochromatosis

Answer 256

Fe in liver --> Cirrhosis --> death

Question 257

Untreated hemochromatosis pts may develop what (other than cirrhosis)?

Answer 257

20% of untreated will develop Hepatoma

Question 258

What other sites are affected by hemochromatosis?

Answer 258

Joints - pain, CaPP deposits (pseudogout) Diabetes and skin darkening ("bronze diabetes") Infertility Pituitary insufficiency

Question 259

Best initial tests for hemochromatosis?

Answer 259

1. Elevated Fe and Ferritin | 2. Decreased TIBC

Question 260

Confirmatory tests for hemochromatosis?

Answer 260

Most accurate - Biopsy | HFE gene and MRI can spare the need for liver biopsy

Question 261

Treatment of Hemochromatosis?

Answer 261

Phlebotomy (if genetic cause) Chelators (Deferasirox or Deferoxamine) - if d/t overtransfusion Phlebotomy is more effective at removing Fe

Question 262

CP of Wilson's dz

Answer 262

Psychosis, paranoia, neuro abnormalities Movement disorder Kayser-Fleischer rings on SLIT-LAMP exam

Question 263

Lab findings of Wilson dz

Answer 263

Coombs negative hemolysis Ceruloplasmin level decreased KF ring on slit-lamp exam

Question 264

Most accurate test for Wilson's dz

Answer 264

Biopsy

Question 265

Treatment of Wilson's dz

Answer 265

Penicillamine Zinc Trientine

Question 266

CP of Primary Biliary Cirrhosis

Answer 266

Women 40-60 | Itching and Xanthelasma

Question 267

Labs of PBC

Answer 267

AMA | Alk Phos elevation

Question 268

Treatment of PBC

Answer 268

Ursodeoxycholic Acid and sometimes Cholestyramine

Question 269

CP of Primary Sclerosing Cholangitis

Answer 269

History of UC in 80% | Itchy, fatigue

Question 270

Labs of PSC

Answer 270

High Alk phos High Bili No AMA!!!

Question 271

Most accurate test for PSC

Answer 271

MR-CP or ER-CP

Question 272

Treatment of PSC

Answer 272

Ursodeoxycholic acid and sometimes cholestyramine

Question 273

CP and lab findings of Autoimmune hepatitis

Answer 273

``` Young women +ANA elevated LFTs Anti-SMOOTH muscle antibody increased Anti-Liver-Kidney MICROSOMAL antibody ```

Question 274

Most accurate test for Autoimmune hepatitis

Answer 274

Biopsy

Question 275

Treatment of Autoimmune hepatitis

Answer 275

Steroids

Question 276

CP of most esophogeal disorders?

Answer 276

Dysphagia and weight loss

Question 277

T/F outpatient esophogeal studies -- start w/ Barium; inpatient do endoscopy

Answer 277

Pretty much

Question 278

Pt w/ progressively worse dysphagia over several months and weight loss. Long history of smoking and drinking alcohol. Stool is positive for blood. What is the ml diagnosis?

Answer 278

Esophogeal Cancer

Question 279

Diagnosis of Esophogeal CA?

Answer 279

1. Upper endoscopy - biopsy 2. Chest CT - evaluate extent of disease If cancer seems clear, Ba will not be enough

Question 280

Treatment of Esophogeal CA

Answer 280

Surgical resection Rads and chemotx "Stent" for unresectable cases to keep esophagus open

Question 281

Patient has substernal chest pain at any time. It's not related to eating. Sometimes it's provoked by drinking cold liquids. What is the best next step in management?

Answer 281

EKG and Cardiac enzymes first! | if negative for cardiac cause, do Manometry to diagnose suspected Esophogeal Spasm

Question 282

Patient has substernal chest pain at any time. It's not related to eating. Sometimes it's provoked by drinking cold liquids. EKG/enzymes are negative for MI or angina. Manometry is positive for esophogeal spasm. What is the next best step in management?

Answer 282

CCBs and Nitrates