Deja - Internal - Gastroenterology Flashcards
1
Q
What are the causes of oropharyngeal dysphagia?
A
- Neurologic disorders (muscular, cranial nerve diseases).
- Zenker diverticulum.
- Thyromegaly.
- Sphincter dysfunction.
- Oropharyngeal cancers.
2
Q
What are the signs and symptoms of Zenker diverticulum?
A
- Halitosis.
- Neck mass on the left.
- Dysphagia.
- Aspiration.
3
Q
How is Zenker diverticulum diagnosed?
A
Clinical palpation of a left-sided neck mass or a barrium shallow.
4
Q
What are the causes of esophageal dysphagia?
A
- Mechanical obstruction –> Esophageal cancer, Schatzki ring, peptic stricture.
- Problem with esophageal motility –> Achalasia, diffuse esophageal spasm, or scleroderma.
5
Q
MC motility disorder often seen in patients with scleroderma?
A
Esophageal hypomotility.
6
Q
What is the diagnostic feature seen on barium swallow in a patient with diffuse esophageal spasm?
A
“Corkscrew pattern”.
7
Q
What is the treatment for diffuse esophageal spasm?
A
Nitroglycerin, CCB.
8
Q
How is GERD diagnosed?
A
It is a clinical diagnosis.
9
Q
What is the risk with Barrett esophagus?
A
10% lifetime risk of transforming into esophageal adenocarcinoma.
10
Q
Duodenal or gastric ulcer is more common?
A
Duodenal 2x as common.
11
Q
How does the underlying pathology of gastric ulcers differ from that of duodenal ulcers?
A
Gastric ulcers are not caused by increased acid production.
Patients are more likely to have decreased mucosal protection.
12
Q
What test can determine if a patient may be infected with H.pylori?
A
- Stool H.pylori antigen.
- Urea breath test.
- Serum IgG test.
13
Q
What is the drawback of the H.pylori blood test?
A
It does NOT indicate an ACTIVE infection.
It will be positive even if the patient was infected in the past and is NOT CURRENTLY infected.
–> Also, the test has LOW SENSITIVITY.
14
Q
Name 3 acid hypersecretory states:
A
- Z-E syndrome.
- MEN I.
- Antral G-cell hyperplasia.
15
Q
What tests would you order if you suspected a peptic ulcer?
A
- CBC to make sure patient is NOT anemic.
- Upper GI endoscopy or upper GI series.
- H.pylori screening.
16
Q
What studies would you order if you suspected a perforated ulcer?
A
Abdominal series or upper GI series with contrast (do NOT use barium).
17
Q
What would you expect to see on an abdominal series if there was a perforated ulcer?
A
Free air under the diaphragm.
18
Q
What are the typical symptoms of gastric outlet obstruction?
A
- Nausea, vomiting.
- Weight loss.
- Distended abdomen.
- Loud bowel sounds.
19
Q
What is the most serious complication of a posterior duodenal ulcer?
A
Erosion into the gastroduodenal artery can lead to a massive hemorrhage.
20
Q
What symptoms could be a red flag for a gastric malignancy?
A
Early satiety with weight loss.
21
Q
What blood group type is more likely to develop gastric cancer?
A
Type A.
22
Q
Metastatic gastric cancer - Lymph node that can be palpated on a rectal exam due to metastasis to the pouch of Douglas?
A
Blumer shelf.
23
Q
6 main causes of upper GI bleeds?
A
PAGE ME
Peptic ulcer AV malformation Gastritis Esophageal varices Mallory-Weiss tear Esophagitis
24
Q
What blood tests would you order in a patient you thought may have a GI bleed?
A
- CBC (looking for anemia, platelet abnormality).
- BUN.
- PT, PTT.
- INR, bleeding abnormalities.
25
How are bleeding varices treated?
Ligation or injection of vessels with sclerosing or vasoconstrictive agents.
26
How should all GI bleeds be treated?
1. Emergency airway.
2. Breathing.
3. Circulation as well as IV fluid resuscitation.
4. Gastric lavage and NG tube if needed.
27
6 MCCs of lower GI bleeding:
1. Diverticulosis.
2. AV malformation.
3. Hemorrhoids.
4. Colitis.
5. Colon cancer.
6. Colonic polyps.
28
What is the MCC of a major lower GI bleed in a patient older than 60?
Diverticulosis.
29
What physical exam and imaging study would you do on a patient with suspected lower GI bleed?
ALWAYS DO A RECTAL EXAM.
| Colonoscopy.
30
If no clear source is found, what other studies can be done?
1. Endoscopy to rule out an upper GI source.
2. Tagged RBC scan.
3. Arteriography, gastric lavage.
4. Barium enema (but not if there is acute blood loss).
31
Which type of diverticulum is more common?
False.
32
What is the treatment for diverticulosis?
Increase of fiber in diet and decrease of obstructing foods such as seeds and fatty foods.
33
MC symptom of diverticulitis?
LLQ abdominal pain.
34
Other signs/symptoms of diverticulitis:
1. Constipation.
2. Fever.
3. Elevated WBC.
4. Bleeding is much less common than with diverticulosis.
35
4 serious complications of diverticulitis:
1. Perforation through the bowel wall causing peritonitis.
2. Fistula formation.
3. Abscess.
4. Obstruction.
36
How do patients who develop a colovesicular fistula present?
Multiple UTIs.
37
What is the best imaging test to diagnose diverticulitis?
CT of the abdomen and pelvis.
38
What studies are contraindicated in diverticulitis?
Colonoscopy.
| Contrast enema.
39
What is the treatment for diverticulitis?
1. Npo.
2. IV fluids.
3. Antibiotics to cover anaerobes and enteric organisms.
40
How would you treat an abscess 2o to diverticulitis?
CT or US-guided percutaneous drainage.
41
How do you treat obstruction or perforation 2o to diverticulitis?
Surgical resection of affected bowel with colostomy that is usually temporary.
42
What is the MC nosocomial infection?
C.difficile
43
How is C.difficile diagnosed?
1. C.difficile stool toxin.
| 2. Stool leukocytes.
44
How is pseudomembranous colitis confirmed?
On colonoscopy or sigmoidoscopy, a yellow plaque adherent to the colonic mucosa can be seen.
45
What is a volvulus?
Twisting of the bowel around the mesenteric base.
46
What is the MC location of volvulus?
Sigmoid.
47
What is the 2nd MC location of volvulus?
Cecum.
48
What are the symptoms of a volvulus?
1. Painful, distended abdomen.
2. High-pitched bowel sounds.
3. Tympany on percussion.
49
What is the classic sign of volvulus on abdominal series?
Dilated loops of bowel with a kidney-bean appearance.
50
What is the sign of volvulus on a barium enema?
Bird's beak appearance with the beak pointing to the area where the rotation has occurred.
51
How do the symptoms of right-sided and left-sided colon cancer differ?
Right --> Anemia.
| Left --> Constipation.
52
What are the recommendations for colon cancer screening?
Starting age 50, a colonoscopy every 10 years or a sigmoidoscopy every 5 years with annual DRE + FOB exam.
53
Treatment of colon cancer?
1. Surgical resection.
2. Radiation if RECTAL cancer.
3. Chemo for stages B and C.
54
Serious symptoms that may occur with UC?
Toxic megacolon.
55
How is UC diagnosed?
Colonoscopy with biopsy.
56
What is seen on colonoscopic biopsy in a patient with UC?
1. Crypt abscess.
| 2. Distorted cells.
57
Treatment of UC - Distal colitis (mild):
Mesalamine.
58
Treatment of UC - Moderate colitis:
Mesalamine + sulfasalazine +/- steroids.
59
Treatment of UC - Severe colitis:
1. IV steroids + azathioprine.
2. Resistant cases try Remicade.
3. If unresponsive, requires resection.
60
Treatment of UC - Fulminant colitis:
Broad-spectrum antibiotics and surgery.
61
Classic symptom of Crohn:
Bloody or watery diarrhea - Does NOT ALWAYS have to be bloody.
62
What are some other physical exam findings in Crohn disease?
1. Fistulas.
2. Fissures.
3. Fever.
4. Abdominal pain.
63
On physical exam, what type of lesion is often found in the mouth of a patient with Crohn disease?
Aphthous ulcer.
64
Treatment of Crohn:
1. Sulfasalazine.
2. Steroids.
3. If unresponsive, try mercaptopurine, azathioprine, infliximab.
65
Name 6 extraintestinal manifestations of BOTH UC and Crohn.
1. Erythema nodosum.
2. Pyoderma gangrenosum.
3. Uveitis.
4. Ankylosing spondylitis.
5. PSC.
6. Arthritis.
66
Definition of diarrhea:
Daily stool weighing >200g.
67
MCCs of bacterial and parasitic bloody diarrhea?
whY CaSES
```
Yersinia
Campylobacter, cholera
Shigella
E.coli, E.histolytica
Salmonella
```
68
Viral causes of bloody diarrhea:
1. Rotavirus.
| 2. Norwalk virus.
69
What studies would you order in a patient with bloody diarrhea?
1. CBC.
2. Stool for ova and parasites.
3. Stool for fecal leukocytes.
4. Stool cultures.
70
Malabsorption caused by tropical infection?
Tropical sprue.
71
MC malabsorptive disorder of childhood?
Lactase deficiency.
72
Malabsorption disorder that affects the jejunum?
Tropical sprue.
73
Malabsorption disorder PAS+ with macrophages in intestines:
Whipple.
74
Classic rash of dermatitis herpetiformis
Celiac sprue.
75
Malabsorption disorder that causes signs/symptoms of folate deficiency including cheilosis, glossitis, stomatitis.
Tropical sprue.
76
Malabsorption disorder with signs/symptoms of hyperpigmentation, arthralgias, rash, diarrhea, endocarditis, ophthalmoplegia, memory deficits, altered mental status.
Whipple disease.
77
Malabsorption disorder treated with penicillin:
Whipple.
78
Mnemonic for the causes of pancreatitis:
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
```
Steroids
Mumps
Autoimmune
Scorpion
Hyperlipidemia, hypothermia, hypercalcemia
ERCP
Drugs (thiazides)
```
79
What lab findings are consistent with pancreatitis?
1. UP amylase.
2. UP lipase.
3. Hypocalcemia.
80
Pancreatitis - What would you expect to see on an abdominal x-ray?
Sentinel loop or colon cutoff sign.
81
What is a sentinel loop?
Dilated bowel or air fluid levels near the pancreas.
82
What is the colon cutoff sign?
Transverse colon distended with no colonic gas distal to the splenic flexure.
83
Best study to evaluate pancreatitis?
Abdominal CT.
84
Test that should be ordered if there is suspicion of gallstone pancreatitis?
RUQ US.
85
Treatment for pancreatitis:
1. NPO.
2. NG tube for ileus or vomiting.
3. IV fluid hydration.
4. Treat the underlying cause.
86
What do we use to determine the prognosis of a patient with pancreatitis?
Ranson criteria (predicts risk of mortality based on risk factors).
87
What are Ranson criteria on ADMISSION?
GA LAW
```
Glucose >200
Age >55
LDH >350
AST> 250
WBC> 16.000
```
88
What are the Ranson criteria after 48h?
C and HOBBS
Ca 10%
O2 5
Base deficit >4
Sequestration of fluid >6L
89
How is the risk of mortality calculated based on Ranson criteria?
<3 risk factors: 1% mortality.
3-4 risk factors: 16% mortality.
5-6 risk factors: 40% mortality.
7-8 risk factors: close to 100%.
90
Common signs/symptoms of cholelithiasis?
1. RUQ pain.
2. Nausea.
3. Vomiting.
especially after a fatty meal.
91
Most specific and sensitive test to diagnose cholelithiasis?
RUQ US.
92
What bacteria cause cholecystitis?
KEEEP
```
Klebsiella
E.coli
Enterococcus
Enterobacter
Pseudomonas
```
93
What are the symptoms of cholecystitis?
1. Prolonged RUQ pain.
2. Fever.
3. Nausea.
4. Vomiting.
5. Referred pain to subscapular region on the right.
6. Murphy's sign.
94
How is cholecystitis diagnosed?
RUQ US will show:
1. Gallstones.
2. Gallbladder wall thickening.
3. Pericholecystic fluid.
4. Sonographic Murphy's sign.
95
What imaging study should be performed if the US results are equivocal?
Hepatobiliary Iminodiacetic acid (HIDA) scan.
96
What is the treatment for cholecystitis?
1. NPO.
2. IV fluids.
3. IV antibiotics (3rd gen cephalo + aminoglycoside + metronidazole).
4. Cholecystectomy.
97
What pain medicine has historically been referred to as being more appropriate to treat pain from cholecystitis and why?
Demerol because morphine is thought to cause spasm of the sphincter of Oddi.
However, this is not always done in clinical practice.
98
Signs and symptoms of choledocholithiasis/cholangitis?
1. Jaundice 2o to obstruction.
2. RUQ pain.
3. Murphy's sign.
4. Hypercholesterolemia.
5. UP ALP.
6. UP bilirubin.
7. UP ALT.
99
What is the treatment for choledocholithiasis?
1. ERCP with papillotomy and stone removal.
| 2. Common bile duct exploration at time of surgery.
100
Complications of choledocholithiasis?
Ascending cholangitis + pancreatitis.
101
What is ascending cholangitis?
Bacterial infection of the biliary tract 2o to obstruction.
102
Classic symptoms of ascending cholangitis?
Charcot triad:
1. Jaundice.
2. Fever.
3. RUQ tenderness.
or
Reynold's pentad (Charcot + altered mental status + shock).
103
Lab findings consistent with ascending cholangitis?
1. UP WBC.
2. UP ALP.
3. UP Direct bilirubin.
4. UP ALT.
104
How is ascending cholangitis definitively diagnosed?
ERCP or percutaneous transhepatic cholangiogram (ETC).
105
What is SAAG>1.1g/dL indicative of?
Ascites related to portal HTN.
106
What is a SAAG<1.1g/dL indicative of?
Non-portal HTN etiologies of ascites such as nephrotic syndrome, malignancy, tuberculous peritonitis, biliary or pancreatic ascites.
107
How can ascites be treated?
Spironolactone + paracentesis.
108
Most classic sign of SBP?
Rebound abdominal tenderness in a patient with ascites.
109
How is SBP diagnosed?
Paracentesis with fluid sent for cell count and Gram stain, culture, and sensitivity.
110
Diagnostic criteria for SBP:
1. Ascites fluid neutrophil count >250.
2. Positive Gram stain/culture.
3. Ascites fluid neutrophil count >500.
111
Treatment for SBP:
3rd gen cephalosporin with albumin.
112
What marker can detect an alcohol binge?
GGT.
113
Internationally, MCC of cirrhosis?
Schistosomiasis.
114
Some treatments for hepatic encephalopathy?
Lactulose to decrease absorption of ammonia, neomycin, and protein-restricted diet.
115
Hepatorenal syndrome?
Patients with advanced hepatic disease develop acute renal failure.
116
How is hepatorenal syndrome diagnosed?
1. Elevated BUN/Cr.
2. Hyponatremia.
3. Oliguria.
4. Hypotension.
5. Urine Na <10.
117
Hep viruses with vaccine available?
A and B. (and D).
118
How can you detect an acute hep A infection?
Anti-HAV IgM.
119
How can you detect immunity to hep A?
Anti-HAV IgG.
120
How is Hep A treated?
It's a self-limiting disease.
121
HBsAg marks:
1. Active hep.
| 2. Carrier.
122
HBeAg marks:
Chronic hep that is highly infective.
123
HBcAg marks:
Early infection.
124
Anti-HBc IgM marks:
Acute infection (1.5-6months).
125
Anti-HBe marks:
Very low infectivity.
126
Anti-HBs marks:
Immune state.
127
Anti-HBc IgG marks:
Remote infection from 6 months to 1 yr ago.
128
What can be given to a patient exposed to hep B to prevent infection?
Hep B Ig.
129
What is the treatment for a person infected with hep B?
1. IFN.
2. Lamivudine.
3. Adefovir.
130
What is the window period for hep B?
The time when HBsAg has become undetectable but HBsAb is NOT YET detectable.
131
Hep with the HIGHEST risk of developing into HCC.
Hep B.
132
How does oropharyngeal dysphagia present?
More difficulty initiating the shallowing of liquids than solids.
