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USMLE HY notes > Gastro internal > Flashcards

Gastro internal Flashcards

1
Q

risk factors for Chron diesease

risk factors of UC

also protective

A

Chron’s
* Smoking (protective in UC)
* 1st related family member
* OCP- high risk
* malnutrition

UC
* smoking protect
* apendectomy protect

Both protective
* Breastfeeding
both risk
* Enteric inf. in 1st year of life

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2
Q

Chron’s disease:

which place is highly invovle in the disease and whice place is spare?

A

Terminal ilium- most common (70%)

Spare- Rectal

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3
Q

Cobblestone + creeping fat are both chracteristcs of

A

Chron’s disease

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4
Q

What we will see on biopsy of Chron disease?

A

transmural Non-ceasting granulomas with lymphoctes infiltrates

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5
Q

Chron disease

main areas of fistula?

A
  1. bladder (enterovesicle)
  2. Peri-anal
  3. Abdominal
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6
Q

Ulcertive colitis will always start in which location?

A

Rectum- and then proceed proximal

involve the Colon only

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7
Q

Which IBD is more common to see peri-anal disease?

A

Chron- 1/3 of pt

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8
Q

Which layers of the colon are involve in UC?

A

mucosa + sub-mucosa

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9
Q

What are the main skin menefistation of UC?

A
  • Pyoderma gangrenosum- deep necrotic ulcer
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10
Q

Which IBD is associted with Biliary stones

A

Chron disease

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11
Q

Which IBD is more associated with PSC (primary sclerosing cholangitis)

A

UC

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12
Q

Which kinds to kidney stones can be seen in a pt with chron’s disease

A

CaOXalate (after jujonectomy)

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13
Q

Chrons disease
Which type of Extra-GI menefication are in correlation to the severity of the disease

A
  1. Arythema nodosum
  2. Peripharal arthritis
  3. Episcleritis- eye burning sensation
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14
Q

what is the main skin menefistation of Chrons

A
  • Arythema nodosum

can be also seen in UC

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15
Q

Which type of seronegetive disease is can be ssin in UC and CD (more in chrons )

A

Ankylosing spondylitis

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16
Q

Which type of arthritis can be seen in chrons disease

A

Migratory polyartiritihs

mainly of large joints

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17
Q

Which type of medication use in IBD can cause pancreatitis?

A

mp-6
ASA-5

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18
Q

where in the biliary tree Primary sclerosing cholangitis mainly damage?

A

intra + Extra biliary pathways

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19
Q

what is the definitive Tx for PSC?

A

liver transplant

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20
Q

how many pt with PSC will develop IBD (mainly UC) in some point of there life?

A

around 50-70%

but only 5% with UC will develop PSC

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21
Q

what is the Gold standart for Dx PSC?

A

ERCP

BUT beacuse MRCP is more sensetive, specifc and safe- that will be the first dx test

today ERCP- for Dgx and Tx, today save for mainly Tx things- like stent insertion

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22
Q

Tx for PSC if polyps are found in the gallbladder?

A

כריתת כיס מרה

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23
Q

Which type of test are helping in distinguish IBD to IBS

A

Lactrofertin and Calprotectin in stool

Lactropertin- more sensetive for detect inflammation in the intestine

and the level is correlate to the histological inflammation

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24
Q

Which type of cancer is a/w increase risk in pt taking AZA (purine analogs)- MP6, AZA

A

NHL

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25
Q

Anti- TNF in treatment of IBD is a/w increase risk to which type of cancer

A

melanoma + non melanoma

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26
Q

Tx for easy-mild UC disease
for remission and maintanance?

A

5-ASA (salazine suffix)

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27
Q

False / True

Steroids have part in IBD for remmisiona and maintanance

A

FALSE

Only in remission

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28
Q

Azathioporine in MP-6 are use in IBD for which stage of treatment

what is a major cons and serious side effect

A

for induction and maintance

cons- respond takes time ~ 4-6 months until reasults

S.Effect:
* BM suppresion- mainly meyoilpania
* Pancreatitis
* Hepatotoxicity
* High risk for NHL + non melanoma

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29
Q

Combinaiton of Purine analogs (6-MP + Azathioporine) with which types of medication can cause severe side effects of purine analogs?

A

Xhantine oxidase inhibitors- give in GOUT = Alloperinol

must adjust and lower the dose of the purines analog if using toghther.

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30
Q

Side effect in the GI of MTX

A

Apthous Somatitis

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31
Q

Which medication can be use for severe refactory UC which resistant to biology and steroids Tx?

A

Cyclosporine
for induction

watch for hyperkalemia, AKI, infections

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32
Q

Which anti TNF is for Chrons
which type for UC

and which type does not fit IBD at all?

A

For chrons- Certolizumab
for UC- Golimumab
all SC except Ifliximab (IV)

**ETanerecpt- not good for IBD (only SpA and RA) **

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33
Q

Major side effect under ani-TNF

A
  • Creation of Ab (more in ifliximab)- not nessecerly C/I
  • Reactivation of TB and HBV- must chech prior start
  • Risk for Melanoma and non-melanoma
  • Drug induce SLE
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34
Q

What is the major advantage using Vedolizumab for IBD

A

Selective immunosupressive for intestine w/o damage in the systemic immunity

could be use as first line or after Anti-TNF failure- for UC and CD

עושה וודו בבטן

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35
Q

Which medication can be use in mild-severe IBD **mainly if ** psoriatic arthritis is present

A

Ustekinunab
anti-IL12/23

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36
Q

Which test we will must do prior the Tx in biologic medications

A

TB > 5mm + HBV
natalizumab- JC virus
Tofacitinib- immune for Shingrix (varicella zoster)
in all- pervner 13&raquo_space; pneumovax 23

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37
Q

Which types of Abx are used in IBD, for which conditions in CD vs UC

A

Flueroquinolone (Ciprofloxacin) + Metronidazole (Flagyl)

UC- Pouchitis (complication of IPAA) only!
CD- in fistula disease

ileal pouch–anal anastomosis (IPAA) is a surgical procedure that is used to restore gastrointestinal continuity after surgical removal of the colon and rectum

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38
Q

line of Tx in easy-mild Ulcertive colitis

and what if that mild-severe UC?

A

for easy-mild UC
5-ASA (PR/PO) > local steorids (budosemide)&raquo_space; systemic steroids&raquo_space; biology with / not purines analog or MTX&raquo_space; Tofacitinib (Jak)

For mild to severe UC
start from Systemic steorids&raquo_space; biology with / not purines analog or MTX&raquo_space; Tofacitinib (Jak)&raquo_space; Cyclosporin IV

Rember- Cyclosporine only for refactory severe UC
5-ASA- only in easy UC

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39
Q

When in Chrons disease we will never give Steroids

A

Fistula

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40
Q

What is the most final line in Chron disease Tx?

A

intenstine rest + TPN

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41
Q

What is consider a rescue therapy in severe UC prior Colectomy?

A

Infliximab + Cyclosporin

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42
Q

What is the Surgery of choice in UC?

A

IPPA- keep the anal spincter

30-50% will have complication

The ileal pouch–anal anastomosis (IPAA) is a surgical procedure that is used to restore gastrointestinal continuity after surgical removal of the colon and rectum

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43
Q

What is pouchitis?

A

Complication of IPAA

עלייה בתדירות היציאה, צואה מימית, דלף לילי, חולשה וחום

ביופסיה תעזור לזהות האם מדובר בקרהון חבוי

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44
Q

Main C/I for IPAA

A

Chrons disease

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45
Q

Which medications in IBD are C/I

A

MTX
Tocacitinib (anti-JAK)
Abx: Metronidazol (1st trimester) flouroquinolones

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46
Q

What is the increase risk for Colorectal cancer in IBD

A

1.5-2 times fold

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47
Q

When we will screen IBD pt for colonrectal cancer

A
  1. 8-10 years after onset in pt with more then** 1/3 colon involve**
  2. 12-15 years from onset in pt with proctosigmoiditis

colonoscopy every 1-2 years for pt with chronic colitis

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48
Q

What is the managment of finding in colonoscopy in chrons?

for:
polyp
Adenmoa low grade
adenoma high grade

A
  • polyp- endoscopial removal
  • Adenmoa low grade- coloctemoy
  • adenoma high grade- colectomy in UC, colectomy / local inscion in CD
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49
Q

Which medication can cause Drug induce colitis (which can be confusing with IBD)

A

Immune checkpint inhibitors
Anti-CTLA4
Ipilimumab

can tx with steroids
if severe- immuno-modulators- Anti-TNF + integrins inhibitors

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50
Q

What is Microscopic colitis
age, presentation
and what ae the 2 varients

Tx- 1st line and refactory cases

A

most common interstinal disease in older pt 60-80
only histologic findings, chronic watery diarrhea

lymphocytic varient- close a/w celiac
Collagenous- collagen depositing in sub epithal (women > man)

1st line- 5ASA, bismuth, budosonide
refoctory- purine analogs (MP-6, AZA = imuran)

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51
Q

True or false

ALT and AST are correlate with thr sevirty of liver damage in viral hepatitis

A

false

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52
Q

way of infections in HBV

A
  • Vertical - maternal-fetus
  • sex
  • blood
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53
Q

Which marker in HBV infection will be the only one to be elevated in the window period

A

anti-HBcAb IgM

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54
Q

Which marker will be elevated in infetion (chronic or acutic in HBV)

A

HBsAg

if recovery- HBsAb

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55
Q

The different between a man who was vaccinated to HBV and a man infeted in recover from HBV

A

vaccine- only HBsAb
recover- HBsAb + HBcAb IgG

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56
Q

Which Ag is in correlation to the infectivity of the HBV in a body

A

HBeAg

some pt have virus that mutant and not present this Ag

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57
Q

What is the most earliest marker of HCV infection

A

PCR-HCV RNA

gold standart

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58
Q

Autoimmune disease correlates with HBV

and another one that correlate with HCV

A

HBV- polyarthritis nodusa (PAN)
HCV- Cryoglobilunemia

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59
Q

Which hepatitis can be fulminant in pregnancy (%?)
and how can be infected

A

HEV
Feco-oral by contamination of water sources

15-25% in pregnancy mortality rate

1-2% fulminant with mortality rate in rest of population

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60
Q

Tx for Chronic HBV?
and also HBV+ HDV?

A

INF-alpha

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61
Q

Tx for Autoimmune hepatitis

A

prednisone, AZA

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62
Q

What is the most improtant prognostic feature in HBV

A

Viral load- HBV DNA

not in acutic hepatitis - only in chronic

goal- decrease replication of the virus

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63
Q

Which family medication can cause resistance in the Tx for HBV

A

Nuecleotide Revese transcriptase inhibitors

Lamivudine- is the most

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64
Q

Which family medication against HBV can be use in chirrosis

A

Nuecleotide Revese transcriptase inhibitors

also after liver transplant and immunodepressent

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65
Q

What is the duration of therapy in NRTI and PEG-INF

A

NRTI >1 year. mostly for life (daily oraly)
PEG-INF , 48 weeks

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66
Q

Which Medications are use as pre-PPX for HIV
(PrEP)

A

Tenofovir + Emitricitabine

also use for HBV

type I HIV

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67
Q

What is the backbone of Tx in HIV ? meaning which medication usally combine

A

2 NRTI + 1 Integrase inhibitor

NRTI will be never administered as monotherapy- also true for HBV

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68
Q

PEG-INF vs NRTI (nucleoside RT inhibitors)

  • in which type theres no resistance at all?
  • in which therse more change of disappering of HBsAg?
A

PEG-INF = no resistance
+ more chances of HBsAg clearance (12%~)

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69
Q

PEG-INF

  • C/I
  • How many Seroconversion in the end of the 1st year of tx
A

C/I- chirossis, liver transplant, immunodepressant pt
Seroconversion at end of 1st year ~30% (NRTI- 20%)

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70
Q

HBV + liver transplant post Tx?

for prevent recurrence

A
  1. passive immunization
  2. NRTI (Tenofovir / Entecavir)
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71
Q

When we treat in HBeAg positive?

A

Viral load > 20K + ALT X2 UNL

Antecavir/ tenofvir / INF

if not- we are not treating unless age > 40 or advance disease

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72
Q

Tx for HBV with chirrosis?

A

always treat with- DNA > 2000

non compensate - DNA is measurable

C/I for PEG- INF

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73
Q

Tx for Pt with negetive HBeAg?

A

same as with positive HBeAg but now its not 20K it 2000.

Viral load > 2000 + ALT X2 UNL

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74
Q

difference between co-infection and super infection HDV

A

co-infection- B + D at same time&raquo_space; like acute HBV symptoms
Super-infection- chronic B + D on top&raquo_space; Flate of harsh hepatitis

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75
Q

What is the classic Ab for HDV

A

LKM3

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76
Q

What is the only tx for Hep D infection?

A

INF-a

high dose at least for a year

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77
Q

How many pt infected wth HCV will progress to Chronic?

A

~85%

in HBV- 90% peri-natal, 50% children, 10% adults

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78
Q

Lichen planus, B cell lymphoma, cryoglobelinumea are all a/w which type of viral infection

A

HCV

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79
Q

What is the most prognostic factor in HCV infection ?

A

Level of fibrosis

in HBV- the viral load

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80
Q

Defintion of cure from HCV

A

12-24 weeks post tratemnt without trace of virus in blood
SVR- sustained virological response

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81
Q

Which DAA is C/I in uncompensated chirrosis?

A

Protease inhibitor (NS34A)

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82
Q

What is the C/I for sofobuvir (NS5B)

A
  • Amiodarone
  • renal insuff.
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83
Q

Which Ab is associated with Autoimmune hepatitis

A

ASMA

anti-smooth muscle Ab

ANA more specific- also +

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84
Q

all of the following are pointed to which diagnosis?
ANA +
ASMA +
eleveted IgG
Anti-LKM1
HLA-DR3/4

A

AIH (autoimmune hepatitis)

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85
Q

What are the indication for Tx in AIH?

A

Aminotranferase > 10X or > 5X + hypergammaglobulinemia > X2

אין אינדיקציה לטיפול במחלה קלה- לא הוכח יעילות

86
Q

What is the** induction** therapy include in AIH?

A
  • main- Steroids (60 mg&raquo_space; 20 mg maintainance)
  • another option- prednisone half dose + AZA - less steroids complications

always with steroids, AZA never alone in induction

maintance for 12-18 months

87
Q

What is the maintainance therapy for AIH?

A
  1. low dose prednisone (10mg)
  2. AZA alone- 2 mg more effective for remmisoon
88
Q

What is the most common cause of liver transplant in USA?

A

NAFLD

non alacholic fatty liver disease

89
Q

Dx of NAFLD?

A

MRI/CT/US- Fatty liver w/o story of alcohol consumption

must rule other causes

90
Q

How to differ between NASH to NAFLD?

A

Biopsy gold Standart

91
Q

True or false?

Theres no Tx that have been proved in improving prognosis of NAFLD pt

A

True
but can give some things if indicated:
Statins, Thiazides, liver transplant (alotugh NAFLD can reaccure)

92
Q

Which factors takes into account in Child-Pugh and what does this score means?

A

a scale for the severity of the chirossis in correlation for survival in complications

  1. Bilirubin
  2. INR (PT)
  3. Albumin
  4. asictes
  5. encephalopaty

A- compensate
B/C- non-compensate

3 labs + 2 clinical

93
Q

what is the score use for Desicion of liver transplant?

A

MELD score
* Bilirubin
* Creatinine
* INR

94
Q

Which clinical finding can be found in alcoholic liver chirrosis

A

AST > ALT
2:1
Ig-Alcohol can be eleveted

95
Q

Primary biliary cholangitis

  • part of the biliary tract
  • Ab
  • prevalence
A
  • small -medium biliary tract
  • Ab- AMA (anti-mitochondrial) > 95% IgM could also rise
  • prevalence- womens in their ~50

ALP + GGT elevated.

AMA- sp100 or gp200

96
Q

how we Dgx PBC?

A
  • elevete cholastatic enzymes + positive AMA
  • if AMA negetive - liver biopsy + cholangiography for rulling PSC

negetive AMA does not rule PCS (remember? its not 100%)

97
Q

Tx for PBC

A

UDCA (ursodeoxycholic acid)- first line
liver transplant- uncompensated chirrosis
symtomatic Tx- Vit.D + clacium- prevent osteopnia, for pruritus

98
Q

Primary Sclerosing cholangitis

  • part of the biliary tract
  • Ab
  • Which autoimmune disease is strongly a/w
A

all biliary tree will be involve

Ab- 65% with p-ANCA
IBD (UC mainly)- 60-80% of pt with PSC

99
Q

How to Dgx PSC?

A

MRCP- test of choice

Stenosis and beadingin biliary intra-extra hepatic

100
Q

Tx if risk to bleeding from vericles in chirrosis?

A

Non-Selective BB
Nodolol / proprenolol/ carvidelol
or
EVL )Vericle ligation- קשירת הדליות

101
Q

Tx in Upper GI bleeding

A
  1. Octerotife - somatostatin analoge = vasoconstirction of Splenchic, not replace ligation
  2. Abx PPx- mainly rochein (Ceftriaxone) for 7 days
  3. Temponade by balloon- until endoscopy or TIPS

Endoscopy and EVL- first line and usually the definitive Tx

No Tx with BB in acute setting

102
Q

When we will preform TIPS

A

Bridge to Liver transplent
for people who fail in endoscopy (bleeding remain despite therapy) / C/I for it or for second prevention

103
Q

How many pt will gain control on the upper GI bleeding in EVL , what can be the complication?

A

90% will gain control

complication- ulcer in the base of the vericle or esophagus stenosis

104
Q

What is SAAG?
What is SAAG > 1.1
SAAG < 1.1

A

Serum the albumin ratio- for evaluation of the ascites/
SAAG > 1.1 = chirrosis, mean that there portal HTN
SAAG < 1.1 = infection or malignancy

105
Q

What is the total protein in Ascites from CHF vs Chirrosis?

A

CHF - total protein > 2.5
Chirrosis - total protein < 2.5

in both SAAG > 1.1

106
Q

When Ascites have total protein below 1.5 what we should think about?

107
Q

Lines of Tx for Ascites

A
  1. Sodium uptake < 2 gr/day
  2. Spironolactone and fusid
  3. refactory- ניקוזים חוזרים
  4. TIPS and consider liver transplant

כשמבוצעים ניקוזים חוזרים- על כל 5 ליטר צריך להחזיר 8 גרם אלבומין על כל ליטר שהוצא

108
Q

When SBP will be suspected to be peritonitis secondary to perforation

A

if more then 2 bactria are grow. SBP is one bug disease

need to do abdominal imaging

109
Q

Dgx of SBP?

and Tx?

A
  • ascites with > 250 PMN this is the definition of SBP
  • Ceftriaxone / Tazosin 5-14 days
  • Albumin IV - reduce mortality in high risk pt
110
Q

PPX for SBP

what we give and for who?

A
  • pt with prior SBP infection- fluroquinolones / resperim

primary prevention- for 7 days Ceftriaxone
* Total protein < 1.5
* Pt hospitelized with Upper GI bleeding

111
Q

Definition of hepato-renal failure and what is the Tx?

A

Pre-renal AKI w/o response to fluids.

Tx:
1. Albumin- 1gr/kg Xday
2. Terlipressin / low dose NE- vasopressors
3. Liver transplant- definite Tx

can also use octerotide and midodrine

cause by vasodilation of the splenchin and hypoperfusion of the kidney

112
Q

common physical sign of hepatic encephalopathy?

A

Asterixis- Flapping tremor

113
Q

Main Tx in Hepatic encephalopathy?

2 main tx

A
  1. lactulose- reduce the amount of amonia absorbeb
  2. Rifaximin- low dose of amonia inducing bacteria
114
Q

Absolute C/I for liver transplant

A
  • AIDS (not HIV)
  • advance cardiopulmonary diseasecholangiocarcinoma
  • exta-hepatic malignancy
  • uncontrol sepsis

relative C/I
HIV CD4 < 100
age > 70
HCC- only if sole lesion < 5 cm or 3 lesions < 3 cm each one

115
Q

What is the leading cause of acute liver failure?

A

DILI

Drug induce liver injury

116
Q

paracetamol toxicity
* what is the toxic metabolite
* max. dialy dose for paracetamol
* Tx?

A

Toxic metabolite- NAPQI
max daily dose-** 3 gr**
Tx- N-acytl cysteine

שטיפת קיבה, פחם פעיל או כוליסטיראמין- רק תוך חצי שעה מנטילת התרופה. קודם שטיפה ואז תרופות

117
Q

How we asses the severity of damage in paracetamil toxicity?

A

level of medication after 4 hours

118
Q

שטיפת קיבה, פחם פעיל
ו- Cholestyramine
יכולים להינתן באיזה חלון זמן בהרעלת אקמול?

A

תוך חצי שעה מנטילת התרופה

נתחיל עם שטיפת קיבה

119
Q

Which substance/ disease can increase the toxicity of paracetamol

A
  • Alcohol consmption- more then 2 gr is toxic
  • hunger
  • HCV
  • phenobarbital/ isoniazid- indict CYP

בשחמת כבד אקמול נסבל היטב ולא מעלה סיכון להרעלה

thing that increase CYTp450

120
Q

When we wil administer N-actyl cysteine?

A

**after 4 hours- ** Paracetamol level > 200 mgr
after 8 hours- > 100

IV loading dose and then every 4 hours

121
Q

Which lab finding uncer paracetmaol toxicity can predict the need of liver transplant?

A

Lactale levels > 3.5

122
Q

What is the most common medication to cause DILI in the USA

A

Augmentin
increase mainly ALP and GGT

Amoxiciliin / calvilunate

could present after latent phase / end of Tx/

123
Q

Why the liver damage can persist long after stop taking Amiodarone?

A

due to its long half life

124
Q

Which DILI can cause transient elevation in liver enzymes?

A
  • Prukor (amiodarone)
  • Valporate
  • Isoniazid

and Statins- a-symptomatic. no need to monitor

אופ עבר- איזוניאזיד / פרוקור וברפוראט

עלייה קלה וחולפת

125
Q

Which DILI can cause chronic heptitis w/o any distinction from AIH (AMA , ANA- ASMA)

A

Nitrofurantion

126
Q

What we will see in biopsy of DILI by Resperim (SMX-TMP)

A

Granulomas + Eosinophilia

could menifest as DRESS syndrome- rash and systemin HSR IV

127
Q

Which para-neoplastic syndrome are a/w HCC?

A

Hypoglycemia
Arythrocytosis

128
Q

Which marker can be eleveted in HCC?

A

AFP = alpha feto protein

could also be eleveted in liver chirrosis

129
Q

Which pt’s will be screen for HCC and in which interval

A

abdominal US every 6 month with or without AFP levels

  1. chirrosis pt (except Child C)
  2. HCV with adv. fibrosis
  3. HBV + age > 40 / >20 in Africans. family Hx HCC
130
Q

How we Dgx HCC in chirossis pt vs non-chirrosis pt?

A

MRI or Tri-phase CT

only when:
lesion > 1 cm
+
fast adhere in artry phase and washout in portal phase

In chirrosis- no biopsy needed unless imaging was inconclusive
not chrrosis- biopsy

131
Q

HCC

Which pt are candidate for Ablation?

A

phase 0 = lesion < 2 cm
or
phase 1= who cannot go trough resection

132
Q

HCC

Which pt are candidate for resection?

A

single lesion > 2 cm + Child A with normal bilirubin and no Portal HTN

CHILD- bilirubin, albumin, PT (INR), ascties, enecephalopathy

133
Q

Which pt are candidate for liver transplant

A

one lesion > 5 cm
or
3 lesion < 3cm

can done in any stage of chirrosis including portal HTN

134
Q

Which Tx for HCC are paliatve treatments?

A
  • Chemo-embolization
  • Systemic tx
135
Q

When should we give adjuvant therapy in HCC?

136
Q

which malignant is highly a/w NAFLD

A

Cholangiocarcnimoa

137
Q

A male present with incident lesion on liver US. he knows to be taking anabolic steroids.

what is the workup regarding that pt?

A
  1. look for CTNNB1 mutation
    if positive- ** resection and biopsy**

CTNNB1 + male + anabolic steroids- increase risk for HCC

138
Q

T for Hepatic adenoma

lesion > 5 cm, lesion < 5 cm, Bleeding

A
  • **lesion > 5 cm - **Resection
  • rest- loose weight / stop OCP/ steroids- follow up in 1 yr
  • Bleeding adenoma- ambolization > resection

CTNNB1- always resection

139
Q

most common benigh lesion in liver?

A

Hemangioma

140
Q

Dgx of liver adenoma

A

CT/ MRI - MRI better

141
Q

Levels of workup in iron def. anemia in male (any age) _ post-menopausal womens

A
  1. Colonoscopy (even if negetive stool blood test)
  2. Gastroscopy- if colonscopy is ok and consider take biopsy for celiac

*is both test are normal- consider assesment of the small intestine by capsule, CTE, MRE, enteroscopy

Colonoscopy &raquo_space; Gastroscopy > consider Small intestine

142
Q

What is mallory -weiss tear

which cindition is highly a/w, where is the pathology, dgx?

A

mainly a/w vomiting
tearing of the esophagus-kideny junction
Dgx- Endoscopy

143
Q

Triad of Ascending cholangitis

A

Sharko:
Jaundice, RUQ pain, fever

144
Q

Tx for Ascending cholangitis

A
  1. hydration + Abx IV
  2. drainage gallbladder by ERCP
145
Q

Which clinical findings Asecnding cholangitis is realted to high mortalitiy and what is the tx

A

Renu pentad:
Jaundice
RUQ pain
Fever
Shock
COnfusion

Tx- urgent drainge of billiary tract

התערבות דחופה

146
Q

How we asses the severity of UGIB?

A

סימני אי יציבות המודינאמיים

147
Q

Which pt should undergo urgent gastroscopy < 12 h in UGIB?

most will need gastroscopy in 24 hours

A
  • Hypotension
  • Reccurent hematemesis
  • זונדה דמית לא מצטללת אחרי שטיפה בנפח גדול
  • need of blood transfusion
148
Q

Test of choice for LGIB

A

Colonscopy
אלא אם כן חוסר יציבות המודינאית ואז נתחיל בגסטרוסקופיה לשלילת דימום ממקור עליון

Urgent colonsocpy- wprepare with polyethylane glycol PO

149
Q

Which risk is a/w PEG and in what %?

A

mainly infection of the wound in 10-15%

150
Q

what are the major risk of Endoscopy?

A

Bleeding and perforation

in diagnosis- 1:1000 > risk
in Tx- 0.5-5%

151
Q

Which risk is a/w ERCP and in what %?

A

Secondary pancreatitis - 5-25%

usually mild and self limited

152
Q

in which ensocopic procedures we will always give PPX?

A

PEG
chirossis + UGIB

and other when we are dealing with cyts and sterile lquids

153
Q

What are the low risk procedures in GI?

what is the managment regarding stopping anti-coagulation / anti-plt

A
  • Gastro/ colono- with or w/o biopsy
  • EUS w/o FNA
  • ERCP with stent replacment

no stopping anti-coagulation / anti-plt

all the rest are high risk

154
Q

When we will strat screening for CRC no high risk pt

A

age > 45
asymptomatic
every 10 years

155
Q

When to screen pt after CRC?

156
Q

When to SCREEN UC or Chron colitis for CRC?

A

evey 1 year after 8 years from diagnosis

if left colon after 15 years

157
Q

Screenig of HNPCC (lynch) and FAP for CRC

A

FAP- age 10-12 every 1 year
HNPCC- age 25 every year

158
Q

Screenig of CRC in first dagree relative with CRC

A

10 years prior the onset of disease or at age 40 (the sooner)

if relative age > 60 - every 10 years
if relative age < 60 or 2 or more 1st dagree relative- every 5 years

159
Q

Which mutation is present in HNPCC ? (Lynch)

and what are the criteria

A

MLH1 + MSH2

AD

proximal CRC

criteria
1. 3 or more relatives with CRC
2. at least 1 relative first degree
3. at least 2 generation
4. at least one dgx < 50

160
Q

most common cause of peptic ulcers

A

NSAIDS
H.pylori- 30-60% in stomach, 50-70% n deudonum

161
Q

which types of ulcers must rq biopsy?

A

Ulcers in stomach

mostly benigh- Antrum + distaly

In deudonum- mostly small < 1 cm and benigh

162
Q

Waht is dyspepsia?
when we will see it

A

אי נוחות, מלאות ונפיחות בטנית סביב אוכל

Related to peptic ulcers

163
Q

What is the workup for new onset dyspepsia ?

A

**age > 40 **- Endoscopy
age < 40- Test for H.pylori&raquo_space; if positive treat for 4 weeks and confirm eradication. if not H.pylori- try H2 blockers and if not resolve&raquo_space; endoscopy

164
Q

Tx stages in H.pylori?

A
  1. Triple therapy - 2Abx + PPI 14 days
  2. H2 blockers / PPI- 4-6 weeks

after- 4 weeks from Abx / 7 days fro PPI- check for eradication

165
Q

What is the managment of negetive biopsy on peptic ulcer in the stomach?

A

8-12 weeks later repeat endoscop- to check of healing

if deudunom - reccurent endoscopy only if symptoms continue

166
Q

Which Abx can be less absorbed when using PPI?

A

Ampicillin
Fluroquiolones

167
Q

Which electrolyte disbalance can PPI cause?

A

Hypomagnesemia

168
Q

What is the main surgery Tx in duedenal ulcers?

169
Q

What is dumpling syndrome

A

when the intestine is too short- after carbohydrate meal &raquo_space; hyperosmolar in lumen&raquo_space; more water secrete&raquo_space; diarrhea, tachycardia, nausa…

late- symptoms of hypoglycemia

tx- low carb diet

170
Q

Most common complication of ulcers

and what are the total 3 complications

A
  1. Bleeding- most common > 50% will bleed are a-symptomatic
  2. Perforation- more in NSAIDS- zonda, IV PPI, Abx, surgery consolt.
  3. obstraction of exit of the stomac- endoscopy balloon
171
Q

Which cancers are a/w H.pylori

A

MALT lymphoma (NHL- marginal zone)
Gastric adenocarcinoma

172
Q

Tx for H.pylroi

1st line
2nd line

A

1st line- Amoxicillin + Clarithromycin + PPI
2nd line- Amoxicillin + Tavanik + PPI

only after failure of 2nd line &raquo_space; Endoscopy with multiple biopsy’s

if amoxci sensetive- Metronidazole
If clarithro sensetive- Tetracyclin + bismuth

173
Q

What is the reason of Zollinger allison disease

A

Gastrinoma
neuroendocrone tumor secrete gastrin&raquo_space; lots of peptic ulcers

174
Q

What is the gastrinoma triangle?

A

Pancreas- Head and body
Deudenum- 2-3 part
Biliary tract

most gastinomas in Duedonum > pancreas

175
Q

Which type of hearidtery diasese ic correlate with gastrinoma in pancreas?

A

MEN 1-
PPP
Para-thyroid
Pancreas
Pituatary

176
Q

Most common presentation of Gastrinoma

A
  • Abdominal pain + peptic ulcers > 90%
  • diarrhea > 70%
177
Q

What is the screening test for Gastrinoma?

A

Fasting gastrin test
must stop PPI a week prior > H2 blockers > PPI 12 hrs before

Normal < 150

need to do twice- if low in twixe = rule out

178
Q

Test to establish Gastrinoma

A
  1. Fasting gastrin X2 > 150
  2. stomach PH - < 3
  3. Secretin test- > 120 in gastrin 15min after secretin
  4. PET-CT in DOTATATE- location and metastasisi > 90% specifity and sensetivity
179
Q

Test of choice to find gastrinoma and possible metastasis?

A

PET CT DOTATATE

Detect neuroendocrine tumors

180
Q

Symptomatic Tx for gastrinoma?

A
  • PPI- main choice
  • Octreotide- if tumor present receptors for somatostatin can be added to PPI

if no metastasis- Surgery for removal

181
Q

What is the most significant prognostic factor in gastrinoma and what it reflect on the survival rate in 5 years?

A

Present of metastasis
20% survival in 5 years

182
Q

How to differente between motiliy to stractral abnormality oin esophagus?

A

motility- solids and liquids
stractural- solids progress to liquids

183
Q

Which type of hernia is associate with esophagus injury?

A

Hiatal hernia
type 1- older, most common, increase abdominal pressue, high GERD risk
type 2- require repair

184
Q

What is Schatzki ring

A

stenosis in ECJ < 13 mm
soilds dysphagia

185
Q

Zenker diverticulum

location
pathophysiology
Dgx
Tx

A
  • location- between esophagus and phrynx
  • pathophysiology- damage in muscularis and false diverticulum of the mucosa + submucosa. higly a/w cricohryngeal muscle
  • Dgx- barium swallowing test
  • Tx- diverticulectomy / closer of diverticuli/ cricoharyngeal myometomy

Helitosis- badbreath smells + dysphagia

186
Q

What is Acelasia?

clinical presentation?
which type of cancer association?

A
  • Acelasia- hyperactive LES + absance of peristaltica
  • dysphagia- solids + liquids
  • SCC
187
Q

Classic finding of Achalasima in Barium and monometry?

which one is more senstive

Tx?

A

Barium- Bird beak apperance
monometry- increase tonus + no peristaltica
monometry is more sensetive
Tx- lower stress on LES. no curable treatment
1. CBB / nitrates- not that effective
2. Botolinum toxin LES (6 months)
3. Pneumatic dilation- endoscopy
4. myotomy

188
Q

Which patoghen have a protective effect agaisnt GERD?

A

H. pylori
(reduce acid)

189
Q

TRUE or FALSE

in GERD the severity of symptoms is in correlation to the endoscopic finding

A

False

no correlation

190
Q

Dgx of GERD

A
  1. high clinical susepct + good respond to PPI
  2. PHmetria (most sensetive) + endoscopy- when Dgx is not clear. positive PH < 4 most of time
  3. Gastroscopia- if red flags
191
Q

Most significant complication of GERD

A
  1. Barret- metaplsiacolumnar no ciliated glandular epithel
  2. Esophagus Adenocarcinoma- from Barret’s
192
Q

When we will perform Ablation in Barret’s esopahgus

A

High grade dysplasia

193
Q

Which infections can cause esophagitis?

A
  • CMV- CD < 50, Gancyclover or Vangancyclovir 36 wks
  • HIV- acute disease
  • Candida- fluconazole 14-21 days
  • HSV-1- Acyclovier
194
Q

What is the DDx for GERD with biopsy showing eosinophils?

A

Eosinophilic esophagitis
inflammation with eosinophils dominance

195
Q

Tx for Eosinophilic esophagitis

A

PPI
proper diet
Steroids- budosonide

196
Q

Which medication can cause esophagitis?

7 medications

A
  • Bi-phosphonates
  • NSAIDS
  • Tetracyclins (doxycycline)
  • Quinidine
  • KCL
  • iron-sulfate
  • phyntoin
197
Q

Which HLA are a/w celiac disease?

and what does it prevelance?

A

HLA-DQ8
HLA-DQ2

> 99% of pt will have them
in general poulaiton- 25-35%

if negetive = > 99% no celiac disease

198
Q

Which autoimmune disease are a/w celiac?

A
  • DM1
  • Hasimoto
  • Dermatitis herpetiformis
  • IgA def.
199
Q

Which Ab are a/w Celiac disease

A
  1. Anti-Gliadin
  2. Anti-endomysial
  3. Anti- TTG IgA

Check for IgA levels- Def. can cuase FN

GET Celiac test

200
Q

gold standart for celiac Dgx?

A

Ab + Biopsy (no villi, hyperplasia of crypts + lymppcytes)

201
Q

Which cancers are a/w celiac disease

A

T cell lymphoma
small intestine adenocarcinoma

202
Q

Tx for celiac

A

bo gluten diet- response in ~90% of pt

203
Q

When we will see small bowl bacterial overgrowth?

A

disease that damage the motility of proximal small intestine or reasult in stasis

Scleroderma
Chron’s- strictures
Diverticulosis

Remember- motility problem or obstruction

204
Q

What is the clinical presentation of small bowl bacterial overgrowth

A
  1. malabsorption, diarrhea, statorrhea
  2. bloating
  3. B12 def. with high folate
205
Q

Gold standart for Dgx- small bowl bacterial overgrowth

A

Bactrial titer from deudenal aspiration- gold standart

206
Q

Tx for Bacterial overgrowth in small intestine?

A

Rifaximin

other Abx: Metronidazole (flagyl), doxy, Cephalosporins

207
Q

What is the amylase levels in blood and urine in Macroamylasemia?

A

amylase blood- high
urine- low

1.5% in hospitelized adults who are not alcholoic

amylase is a large polimer&raquo_space; cannot secrete in urine

208
Q

How we Dgx IBS?

A

Rome Criteria
1. reccurent Abdominal pain ,at least 1 day X week, in last 3 month + at least 2:

a. Related to defecation
b. a/w change in frq of stool
c. a/w change in form of stool

לסיכום:
כאב בטן לפחות פעם שבוע במשך 3 חודשים + קשר לקקי:
1. קשור לקקי- הכאב
2. בא עם שינוי בצורה של הקקי
3. בא עם שינוי בתדירות הקקי

209
Q

Which Abx can help to relieve the symptoms in IBS

210
Q

What are the 3 main indication for liver biopsy?

A
  1. heptocellular disorder from unknwon cause
  2. suspiction for HIA
  3. Hepatomegaly from unknown cause

no need biopsy:
fatty liver
chirrosis
HCV, HBV
respont to tx for AIH

USMLE HY notes (34 decks)

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