Gastroenterology Flashcards
1
Q
What acid-base balance disorder can you find in a patient with pyloric stenosis?
A
Metabolic Alkalosis
2
Q
FIrst-line treatment for ulcerative colitis
A
Topical Aminosalicylate
3
Q
In managing ulcerative colitis, what should be added if after giving topical aminosalicylate, remission is not achieved within 4 weeks
A
Oral Aminosalicylates
4
Q
What to give for severe exacerbation of ulcerative colitis?
A
IV Hydrocortisone
5
Q
Describe Barret’s esophagus
A
Squamous to columnar metaplasia of the lower 3rd of the esophagus
*** can develop into adenocarcinoma of the lower 3rd of the esophagus
6
Q
Barret’s: ______ CA of the esophagus
Achalasia: ______ CA of the esophagus
A
Barret’s: Adenocarinoma
Achalasia: SCC
7
Q
X-ray and Barium enema findings of achalasia
A
X-ray: megaesophagus
Ba enema: bird’s beak
(Remember, increased resting pressure of lower third of esophagus)
8
Q
Most accurate diagnostic test for achalasia
A
Manometry
9
Q
Dysphagia + Regurgitation of stale food + chronic cough + halitosis + aspiration
A
Pharyngeal pouch (Zenker’s diverticulum)
10
Q
Diagnostic test of choice for Zenker’s diverticulum
A
Barium swallow
Do not do endoscopy as it has a risk of perforation
11
Q
When do you suspect acute exacerbation or severe colitis, in which case, IV hydrocortisone is warranted?
A
6,30,90TH
More than 6 episodes of BM with visible blood in large amounts
ESR > 30
HR > 90
Temp > 37.8
Hgb is low (as presented with pallor and fatigue)
12
Q
NICE recommends what procedure in what time frame from the diagnosis of acute cholecystitis
A
Laparoscopic cholecystectomy 1 week from diagnosis
13
Q
Main difference of acute cholecystitis from biliary colic
A
Acute cholecystitis has inflammatory element: leukocytosis + fever + peritonism
14
Q
Incidental finding of gallstones in an asymptomatic patient
A
Reassure
15
Q
Incidental finding of stones in the CBD in an asymptomatic patient
A
ERCP or laparoscopic cholecystectomy
16
Q
Triad of Plummer-Vinson syndrome
A
Dysphagia
Iron-deficiency Anemia
Glossitis
*Remember that plumber Vincent digs a hole for the iron pipe.
17
Q
Treatment of Plummer-Vinson syndrome
A
Iron supplements + web dilatation
18
Q
PERSISTENT dysphagia + use of NSAIDs or bisphosphonates (for osteoporosis) + no regurgitation
A
Benign esophageal stricture
19
Q
What are the endoscopic findings pathognomonic for Crohn’s disease?
A
Transmural ulcers
Skip lesions
20
Q
Diarrhea + weakness + arreflexia
A
Guillain-Barre syndrome
21
Q
You suspect acute flare of ulcerative colitis, what is the initial investigation and why?
A
Abdominal X-ray to rule out toxic megacolon
22
Q
What are the expected abnormal liver function tests in a patient with autoimmune hepatitis?
A
Elevated AST and ALT
Normal or mildly elevated GGT
23
Q
What are the expected abnormal liver function tests in a patient with alcoholic liver disease?
A
Elevated AST and ALT (AST>ALT), hence, elevated AST:ALT ratio
Elevated GGT
24
Q
Differentiate HELLP from AFLP
A
HELLP - hemolysis, elevated liver enzymes and low platelet count
AFLP - ELLP + hypoglycemia + hyperammonemia + nausea and vomiting + DIC (prolonged PT/PTT)
25
Between amylase and lipase, which is more sensitive for acute pancreatitis?
Lipase
26
Between amylase and lipase, which is more specific for acute pancreatitis?
Lipase
27
Treatment for PMC
Oral metronidazole or Oral vancomycin
28
Histology of Crohn
Increased goblet cells, granuloma, transmural
29
Endoscopy of Crohn
Skip lesions, cobblestone appearance, deep ulcers (transmural)
30
How to relieve the symptom of severe dysphagia in a patient with oesephageal cancer with liver metastasis?
Endoluminal stenting
31
Rx for Vit B12 deficiency
IM Hydroxycobalamin
32
Left supraclavicular mass plus anorexia and weight loss
Think of gastric CA
***Remember Troisier sign, Virchow node
33
Differentiate PBC from PSC
They are both presenting with pruritus, jaundice and elevated ALP. They are both treated with UDCA and cholestyramine
Primary Biliary Cirrhosis - 3Ms (anti-mitochondria, mid-aged female, IgM), associated with Sjogren
Primary Sclerosing Cholangitis - diagnosed by ERCP, associated with UC
34
Jejunal or duodenal biopsy findings of coeliac disease
Villous atrophy
Crypt hyperplasia
Increased inter-epithelial lymphocytes
35
Most appropriate test to ensure successful eradication of H pylori
C13 urea breath test
36
When do you request for a C13 urea breath test?
Dyspepsia in patient more than 55 years old. Underwent lifestyle modification and intake of antacids. Then tested positive for H pylori serum antibody and was given triple therapy for 4 weeks but did not improve.
37
C13 urea breath test was positive. What’s next in the management of H pylori?
Another attempt in the eradication of H pylori
38
When do you request for endoscopy if we’re dealing with H pylori infection?
1. If patient tested negative for C13 urea breath test and PATIENT DID NOT IMPROVE from 4-week triple therapy
2. Tested negative for H pylori serum antibody and was given PPI for 4 weeks but DID NOT IMPROVE
39
Endoscopy revealed multiple ulcers in multiple sites after patient underwent a full course for H pylori eradication. Next step for investigation?
Fasting gastrin level (Best) or secretin stimulation test
***Think of ZES or gastrinoma (multiple ulcers in multiple sites)
40
Induce remission for mild to moderate ulcerative colitis
Rectal 5-ASA (if not responding, shift to oral 5-ASA)
41
Induce remission for severe ulcerative colitis
Admit and start IV hydrocortisone
42
Maintain remission of UC
Oral mesalazine (5-ASA)
43
Induce remission of Crohn disease
Oral prednisone
44
Maintain remission of Crohn Disease
AZP or MCP
Azathioprine
Mercaptopurine
45
The most likely organ to get cancer from hemochromatosis
Liver - since this is the main organ for iron deposition
46
Triad of hereditary hemochromatosis
Hepatomegaly (cirrhosis) + DM + hyperpigmentation (bronze skin)
***Remember: Bronze diabetic
47
What type of cancer does a patient with hereditary hemochromatosis have a predilection to?
HCC
***Remember that liver is the major storage of iron deposition. Iron deposition —> hepatomegaly —> cirrhosis —> HCC
48
PPVs of Vit B12 deficiency
Impaired PPV
| Proprioception, position, vibration
49
X-ray findings of achalasia
Megaesophagus
50
Barium meal finding of achalasia
Dilated esophagus that tapers aka bird’s beak appearance
***Remember increased resting pressure of the lower esophagus
51
Most accurate investigation of a patient with achalasia
Esophageal manometry
52
Middle-aged female with abnormal LFTs present with secondary amenorrhea + history of autoimmune disease (thyroid, vitiligo, DM 1)
Autoimmune hepatitis
***Remember, increased AST and ALT and normal or mildly elevated ALP
53
PMH peptic ulcer + underwent surgery + post-op symptoms (abdominal pain, rigidity, tenderness, guarding) + hypotension + tachycardia. Diagnosis and Next step?
Think of perforated PUD. Next step: erect CXR and abdominal X-ray
54
Common anemias associated with coeliac disease, arrange from the commonest to the least
Iron deficiency
Folic acid deficiency
Vit B12
55
Aside from anemias, what are the 4 other conditions associated with coeliac disease? OODE
Osteoporosis
T-cell lymphoma (intestinal lymphoma)
Dermatitis herpetiformis
DM I
56
Travel to Africa + watery diarrhea
E coli
57
Travel to Europe + watery diarrhea + abdominal pain + bloatedness
Giardia
58
Travel history + prodrome (fever, headache, myalgia) + bloody diarrhea
C jejuni
59
Old age + recent use of co-amoxiclav + abnormal LFTs
Cholestatic hepatitis
60
4-mo hx of intermittent diarrhea and abdominal pain + blistering rash of elbow + low hemoglobin + endoscopic findings of shortening of villi and lymphocytosis
Coeliac disease
***Remember dermatitis herpetiformis association, and endoscopic findings of villous atrophy, crypt hyperplasia and lymphocytosis
61
How do you differentiate anterior mediastinitis from posterior mediastinitis?
Anterior mediastinitis - pain is mainly in the subcostal area
Posterior mediastinitis - pain is in the epigastric area radiating to the interscapular region of the back
***You are presented a patient complaining of chest pain who underwent endoscopy
62
Slow progressive dysphagia + chronic intake of PPI + no weight loss + normal Hgb
Peptic stricture
63
Marker of primary adenocarcinoma of the lung
TTF-1
| Thyroid transcription factor-1
64
How does a primary cancer of the lung metastasize to the liver?
Hematogenous spread (Lung, Heart, Aorta, Coeliac trunk, common hep. a., liver)
65
Dysphagia after intake of cold water + Ba swallow shows corkscrew appearance at the time of spasm
DES (diffuse esophageal spasm)
66
Most accurate test in the diagnosis of diffuse esophageal spam
Manometric studies
67
Fecal impaction + old age + nursing home + taking analgesic
Phosphate enema
68
Fecal impaction + young, healthy, no comorbidities
Gycerol suppository
69
Constipation in pregnancy
Ispaghula (bulk-former), Lactulose (osmotic), Senna (stimulant)
***Remember: I love (to) shit, buo o sabog.
70
Hard stool but not impacted
Stool softener
71
1st line and 2nd line in constipation with soft stool
1st line: Senna
| 2nd line: Lactulose or macrogol
72
In a case of achalasia, you would encounter patients presenting with upper respiratory tract infection. What could be responsible for URTI of the patient?
In achalasia, there is increased resting pressure in the lower esophageal sphincter resulting in regurgitation of food particles, which might be aspirated leading to pneumonia.
73
Gold standard in the diagnosis of chronic pancreatitis
Spiral CT scan of the abdomen with contrast - will show pancreatic calcifications
74
Might not be the most appropriate but helpful in the investigation of chronic pancreatitis
Fecal elastase and fecal chymotrypsin
75
Abdominal X-ray findings seen in a patient with chronic pancreatitis
Diffuse abdominal calcifications
76
Treatment for Vit B12 deficiency
IM Hydroxycobalamin (except if patient is vegan and it is the cause of vitamin B12 deficiency, in which case, oral cobalamin can be given)
77
Step-by-step procedure in the management of acute variceal bleed
1. ABC is priority including IV fluid resuscitation
2. Start terlipressin and antibiotics
3. Definitive management is band ligation by endoscopy. However, is this is not available, we can do sclerotherapy by endoscopy (inject N-butyl-2-cyanoacrylate)
4. If band ligation fails to control the bleeder, we can do transjugular intrahepatic portosystemic shunt (TIPS)
78
Differentiate Gilbert syndrome from Dubin-Johnson syndrome.
GIlbert syndrome is unconjugated or indirect hyperbilirubinemia whereas DJ syndrome is conjugated or direct hyperbilirubinemia.
In Gilbert syndrome, patients are usually asymptomatic. There is mild elevation in bilirubin, sometimes, isolated jaundice with history of recent infection. No bilirubin seen in urinalysis.
In Dubin-Johnson syndrome, patients present with jaundice. Bilirubin seen in urinalysis. LFTs are abnormal.
79
Why is reticulocyte count normal in Gilbert syndrome?
Because jaundice found in Gilbert syndrome is not due to hemolysis.
80
```
Differentiate Crohn from ulcerative colitis in terms of the following parameters:
Nature of diarrhea
Location of abdominal pain
Weight loss
Smoking history
```
```
CROHN DISEASE
A. Watery diarrhea
B. Right iliac fossa
C. Weight loss
D. Smoker
```
```
ULCERATIVE COLITIS
A. Bloody diarrhea
B. LLQ
C. No weight loss
D. non-smoker or ex-smoker
```
81
Order of intervention in the management of constipation
1. High-fibre diet
2. Senna
3. Lactulose or macrogol (PEG)
4. Prokinetic agent (domperidone, metoclopramide or erythromycin)
5. Dantron
6. Seek specialist advice
82
Site of main absorption of iron, folic acid and vitamin B12.
Iron - duodenum
Folic acid - jejunum
Vitamin B12 - ileum
This arrangement is also the same arrangement in terms of the commonest anemia to least anemia associated with coeliac disease.
83
Investigation of choice if pancreatic CA is suspected
HRCT
84
Painless jaundice + hepatomegaly + RUQ mass + wasting + palpable non-tender gallbladder + atypical back pain
Pancreatic cancer
85
When can a cook return to work after an attack of gastroenteritis?
48 hours after the LAST episode of diarrhoea or vomiting
86
In an endocopically-proven esophagitis or endoscopically negative reflux disease, treatment starts with PPI for 1-2 months followed by low dose treatment as required if responsive to 1-month PPI. They are with the same management except is there is no response after the initial 1-month PPI.
If no response after 1-month PPI on an endoscopically proven esophagitis, double-dose PPI for 1 month.
If no response after 1-month PPI on endoscopically negative reflux disease, H2 receptor antagonist (e.g., ranitidine) or prokinetics are given for 1 month.
87
Management of liver cirrhosis with ascites
Spironolactone
88
Liver cirrhosis with ascites: ascitic fluid aspirate analysis shows high neutrophils
IV antibiotics
89
Diagnostic modality of choice in the diagnosis of esophageal cancer
Upper GI endoscopy and biopsy
90
4Cs of diffuse esophageal spasm
chest pain - cold drink - corkscrew appearance - calcium channel blocker
91
Most common type of esophageal cancer
Adenocarcinoma
92
Type of esophageal cancer associated with smoking
SCC
93
Common type of esophageal cancer in the upper 2/3
SCC
94
Esophageal cancer associated with Barret’s esophagus
Adenocarcinoma
95
Esophageal cancer associated with achalasia
SCC
96
Esophageal cancer associated with GERD
Adenocarcinoma
97
Common esophageal cancer that occurs in the lower 1/3 of esophagus
Adenocarcinoma
98
How to relieve symptom of severe dysphagia in a patient with esophageal cancer with metastasis
Endoluminal stent
99
Long-term feeding for a post-stroke patient with dysphagia
Percutaneous gastrostomy
100
Differentiate cirrhosis from spontaneous bacterial peritonitis.
Cirrhosis presents with alcohol abuse, ascites and spider nevi. SBP is complication of ascites; it presents with fever, tenderness in addition to symptoms of cirrhosis.
Rx of cirrhosis without SBP is SPIRONOLACTONE
Rx of SBP - antibiotics (most appropriate to send specimen for culture)
101
Best initial test for ascites
Neutrophil count from ascitic fluid aspirate - if it shows > 250 uL; commence antibiotics ASAP
102
Management of ascending cholangitis
IVF + antibiotics + correct coagulopathy + early ERCP
103
Management of acute pancreatitis
IVF resuscitation + analgesics + nutritional support
104
Dysphagia + anxiety
Globus hystericus
105
Dyphagia + EOM weakness
Myasthenia gravis
106
A hemodynamically unstable patient was given fluid resuscitation. Despite the fluid resuscitation, patient still deteriorated and blood is not yet available for transfusion and crossmatching. Next step?
Transfuse O negative blood.
107
Hepatitis A causative agent
Picornavirus
108
Causative agent of Hepatitis B
Double-stranded hepadnavirus
109
Indicates acute hepatitis A infection
Anti-Hepatitis A IgM antibody
110
Hepatitis B: First marker to become abnormal
HBsAg (acute or chronic infection)
111
Hepatitis B: Indicates high infectivity
HBeAg
112
Hepatitis B: Indicates recent vaccination
Anti-HBs
113
Hepatitis B: Indicates past infection
Anti-HBc
114
Old age + left lower abdominal pain + †ender mass in the iliac fossa
DIverticular Abscess
115
Any patient with dyspepsia + taking PPI for 1 month + no improvement of symptoms + developed dysphagia
Urgent EGD
116
Burning sensation in the chest + nausea and vomiting + chest pain + CXR shows air-fluid level in a mass behind the heart
Hiatal hernia
117
Management of IBS
Low FODMAP diet
118
Management of constipation-predominant IBS
Laxatives (Ispaghula husk)
119
Management of diarrhoea-predominant IBS
Anti-diarrheal e.g. loperamide
120
IBS is abdominal pain plus 2 of 4 of the following symptoms:
Altered bowel habits
Bloatedness
Worse after eating, relieved after defecation
Passage of mucus
121
King’s College Hospital Criteria for liver transplantation
```
pH < 7.3 24 hours after ingestion
OR
All of the following:
Protime > 100
Crea > 300
Grade III or IV encephalopathy
```
122
Useful to discriminate between IBD and IBS.
Fecal calprotectin
123
Drug of choice for nausea and emesis of metabolic cause (as in renal failure, hypocalcemia, drug-induced or toxin-induced)
Haloperidol
| Levomepromazine
124
Drug of choice for nausea and emesis on a patient who underwent radiotherapy
Ondansetron
| Haloperidol
125
Drug of choice for nausea and emesis on a patient who underwent chemotherapy
Ondansetron
| Metoclopramide
126
Drug of choice for nausea and emesis on a patient with conditions that cause raised intracranial pressure
Cyclizine
| Dexamethasone
127
Drug of choice for nausea and emesis on a patient who has bowel obstruction
Cyclizine
Ondansetron
HNBB
Octreotide
128
Drug of choice for nausea and emesis on a patient who has delayed gastric emptying
Metoclopramide
| Domperidone
129
Drug of choice for nausea and emesis on a patient who has peripheral vertigo (BPPV, Meniere’s disease, vestibular neuronitis) with severe nausea or vomiting
Buccal prochlorperazine
