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GASTROENTEROLOGY Flashcards

1
Q

Which conditions show dysphagia to solids AND liquids

A

MOTILITY/NEUROLOGICAL conditions
-DES
-Achalasia
-Systemic sclerosis

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2
Q

Which conditions show dysphagia to solids THEN liquids

A

ANATOMIC conditions
-stricture (progressive)
-cancer (progessive)
- schatzki ring (intermittent)

DX: EGD

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3
Q

What is dyspepsia. What is managment for individual <60yrs with no RFs

A

Dyspepsia: chronic/intermittent pain in upper abd ESPECIALLY after meals
2 options in pts w/dyspepsia and no RFs and <60yrs:
(1) Test and tx for H pylori, then
(2) Trial with PPI for 4-8 wks

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4
Q

What is tx for H pylori

A

(1) No previous macrolide use/ macrolide-resistance low: triple therapy–>omeprazole+ ampicillin +clarithromycin for 14 days

All others receive:
(1) levofloxacin triple therapy for 14 days
(2) bismuth quardruple tx for 14 days

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5
Q

What is bismuth quadruple tx for H pylori

A

bismuth + metronidazole + tetracyline + PPI for 14 days

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6
Q

What is levofloxacin triple tx for H pylori

A

levo + amoxicillin + PPI for 14 days

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7
Q

List characteristics of achalasia. What about pseudo achalasia?

A

ACHALASIA:
-dysphagia solids AND liqs
-regurge WORSE AT NIGHT
-long standing (usu years)
-Dx: barium swallow (bird’s beak), EGD (r/o obstruction), manometry (confirms)
-Tx: opening/relaxing LES –>surgery or dilation. IF poor surgical candidate, botulism toxin

Think PSEUDOACHALASIA
-Same sx as achalasia BUT
-wt loss
->60yrs
-progressive
-Dx: EGD!!

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8
Q

List characteristics of Diffuse Esophageal Spasm

A

DES
-spasms, precipitated BY COLD
-Dx: barium swallow (corkscrew pattern IF done at time of spasms)
-Tx: reassurance. IF want more
(1st line): CCB
(2nd line): isosorbide, sildenafil
(3rd line): bot injection

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9
Q

What is acute cholangitis? What 3 things do you expect to see?

A

ACUTE CHOLANGITIS
-inflammation of the bile ducts 2/2 stones
-Sx: (1) biliay colic (2)jaundice (3) fever w/chills
-Tx: β-lactam/β-lactamase inhibitor or a third-generation cephalosporin plus metronidazole + ERCP

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10
Q

Describe PBC–sx, dx, tx, associated dx

A

PRIMARY BILIARY CHOLANGITIS
-progressive, autoimmune liver dx
-women aged 40-60yrs

(1) Symptoms: fatigue, wt loss, hyperpigmentations
(2) Diagnosis: +antimicrobial antibody, alk phos >=1.5 ULN
(3) Tx: Ursodeoxycholic acid
(4) Associated dx: thyroid dx (TSH q1yr); DEXA; men/or pts w/cirrhosis–screen for hepatocellular cancer

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11
Q

Describe PSC–sx, dx, tx, associated dx

A

PRIMARY SCLEROSIS CHOLANGITIS
-progressive liver dx charac by bile duct destruction/billiary dx
(1) Symptoms: pruiritis, elevated Alk phos, elevated total bil,
(2) Dx: MRCP –“string of beads”
(3) Tx: liver transplantation
(4) Associated dx: IBD (85% UC) –>colon cancer (colonoscopy q2yrs); gallbladder cancer; cholangiocarcinoma

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12
Q

Periumbilical pain that becomes RLQ pain + fever should make you think of what condition

A

Appendicitis
-starts periumbilical and then migrates to RLQ
-note: iverticulitis–>LLQ pain

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13
Q

Describe carcinoid syndrome

A

CARCINOID SYDROME
-Conditions causing increased cortisol (including carcinoid dx)
-Sx: flushing, hypotension, tachycardia, explosive diarrhea + NIACIN deficiency (rash, thickened tongue, angular chelitis)

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14
Q

Describe Chron’s dx vs Ulcerative Colitis. What 4 sx do you see w/Chron’s

A

CHRON’S
-more indolent, less responsive to tx
-more likely to have strictures, inflammatory masses, associated obstruction
-4 Sx: (1) rectal SPARING (2) skip lesions (3) perianal dx (4) ileocecal involement
-DX: endoscopic findings of pathchy, focal, transmural ulcers. +granulomas +/- string sign.
-LAB: ASCA
-Extraintestinal: Osteoperosis (2/2 chronic steroid use)

UCLERATIVE COLITIS
-inflammation ALWAYS starts in rectum–extends proximally; CONFINED to colon
-continuous mucosal inflammation w/shallow ulcers
-Sx: abdominal pain + bloody diarrhea +/- tenesum (painful anal spasms) +/- constipation
-LAB: p-ANCA
-Extraintestinal: “Joints-skin-eyes-mouth” –> skin lesions (erythema nodosum/pyoderma gangrensum), joints (anklosising spondylitis, RF-negative polyarthritis), eyes (iritis), mouth) apthous ulcers) ALSO PSC (think jaundice, itching, cholestatic LFTs)

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15
Q

Describe Whipple disease–sx, dx, tx

A

WHIPPLE
-caused by bacteria: gram + T whipple. Bacteria obstruct lympatics in intestine which cause malabsorption.
-Sx: 4 things (1) abdominal pain (2) diarrhea (3) wt loss (4) joint pain +NEURO sx
-Dx: foamy macrophages, + PAS
-Does NOT improve w/gluten free diet. No villi blunting on bx
-Tx: IV ceftriaxone, yr of bactrim

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16
Q

Describe olmesartan-induced enteropathy

A

This ARB causes sx IDENTICAL (clinical and histopathologically) to celiac. Has FDA black box warning!

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17
Q

Describe TROPICAL SPRUE

A

TROPICAL SPRUE
-Caused by an unknown organism
-Megaloblastic anemia (B12 deficiency); travel to equatorial areas
-does NOT improve w/gluten free diet. Villi blunting on bx
-Tx: tetracycline or doxycycline x 6mos

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18
Q

What skin condition and anemia is strongly associated with CELIAC SPRUE

A

CELIAC SPRUE (aka Celiac Disease, nontropical sprue)
-DERMATITIS herpetiformis–tx w/dapsone
-Iron deficiency (microcytic anemia–2/2 iron being absorbed in the duodenum)
-DOES improve with gluten free diet. Villi blunting on bx

**Note, tropical sprue associated w/megaloblastic anemia (B12 deficiency)

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19
Q

Describe celiac dx (nontropical sprue)

A

CELIAC
-inflammatory response to dietary gluten that damagess intestinal mucosa
-dx: antibodies (IgA anti-tissue transglutaminase); anti DGP in case of IgA deficiency
-Tx: gluten free diet

EXTRAINTESTINAL MANIFESTATIONS
-DM1, adrenal insufficiency
-dermatitis herptiformis (responds to dapsone)
-osteoperosis
-neuropathies
-non-hodgkin lymphoma
-thyroid/esophageal cancer

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20
Q

What do you generally treat invasive diarrhea with? What 2 bugs are the exception

A

GENERALLY tx invasive diarrhea with quinolones (esp ciprofloxacin) BUT macrolides for campy and metronidazole for amebiasis

EXCEPTIONS–NO abx:
1) EHEC –> symptomatic tx only. Abx incr risk for TTP/HUS!
2) Salmonella–>symptomatic tx only. Abx may prolong infection

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21
Q

What do you generally treat invasive diarrhea with? What 2 bugs are the exception

A

GENERALLY tx invasive diarrhea with quinolones (esp ciprofloxacin) BUT macrolides for campy and metronidazole for amebiasis

EXCEPTIONS–NO abx:
1) EHEC –> symptomatic tx only. Abx incr risk for TTP/HUS!
2) Salmonella–>symptomatic tx only. Abx may prolong infection

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22
Q

What kind of bilirubin is elevated in Gilbert syndrome

A

Unconjugated = indirect= without bilirubinemia.

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23
Q

Describe hemochromatosis.

A

Hemochromatosis:
-autosomal recessive; increased intestinal absorption of IRON
-Labs: transferrin saturation, serum ferritin
-Tx: phlebotomy
-f/u: screen for HCC q6mos if cirrhosis

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24
Q

Describe Wilson’s dx

A

Wilson’s dx:
-autosomal recessive; decr excretion of COPPER
-Sx: hx of psychiatric disorders, and/or cathetoid movements
-Labs: (1) elevated urine copper (2) low serum ceruplasmin (3) slit lamp eye exam –>Kayser Fleischer rings +hemolytic anemia +elevated alkphos
-Tx: D-pencillamine

*elevated copper in PBC, PSC**

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25
How do you tx autoimmune hepatitis (AIH)?
prednisone/budenosine +/- azathioprine
26
What demographics are generally invovled with PSC, PBC, and autoimmune hepatitis
PSC: middle-aged men PBC: middle-aged woman Autoimmune hepatitis: young woman
27
What hepatitis is associated with leukocytoclastic vasculitis
HCV
28
Describe Irritable bowel SYNDROME
IBS -Note, it's NOT inflammatory bowel dx (IBD --Chron's, UC) -Sx: alternating constipation/diarrhea w/normal colonoscopy +/- abd pain -dx: sx for >3mos with @ least 2 of the following: pain-related defecation, change in stool consistency, change in stool frequency
29
Which is preferred feeding in ICU setting?
ENTERAL feeds -maintains intestinal epithelium -refers to any feeding that uses GI tract to deliver nutrients (*parenteral refers to deliver of nutrients via vein*)
30
What 3 drugs should you STOP in pts with ascities
STOP in pts w/ascities: 1) NSAIDS 2) ACE-I 3) ARB
31
Describe two types of diverticulum--esophagus, small intestines.
ZENKER DIVERTICULUM -outpouching in esophagus -Sx: halitosis, regurged food -Dx: Barium esophagography -Tx: Surgery MECKEL's DIVERTICULUM -outpouching of intestine -Sx: bloody stool--gastric enzymes get trapped in pouch, leads to ulcers, which bleed; NONpainful bleeding -Dx: Meckel scan -Tx:
32
Describe diverticulitis
DIVERTICULITIS -inflammation of outpouchings in intestines Sx:LLQ pain +FEVER + WBC. No bleeding Dx: CT abdomen Tx: gram- AND gram + -mild: metronidazole (gram-) + cipro (gram +) -moderate/severe: dual tx best ***Current guidelines based on high-quality evidence strongly recommend that antibiotics be avoided in select patients with uncomplicated diverticulitis. ** Intravenous antibiotics with activities against gram-negative rods and anaerobic organisms are required in patients who cannot tolerate an oral diet; patients with severe comorbidities, advanced age, or immunosuppression; and patients for whom oral antibiotics have been ineffective.
33
Describe Acute mesenteric ischemia (AMI)
ACUTE MESENTERIC ISCHEMIA -p/w abrupt onset of severe periumbilical abdominal pain + URGE TO DEFECATE. -Pain that is disproportionate to physical examination findings should immediately raise suspicion for early AMI. -Dx: CT angiography (FOR ACUTE) **Note: CT abdomen +IV contrast usu 1st option for colonic ischemia
34
Describe ischemic colitis vs acute mesenteric ischemia
ISCHEMIC COLITIS -Cause: low-flow states (hypotension, HF)/drugs (cocaine) -Sx: LLQ pain + bloody diarrhea -Dx: CT abdomen (w/ contrast) -Tx: Supportive care w/ IVF + bowel rest **CT findings are nonspecific, including segmental bowel wall thickening and pericolonic fat stranding, often in the distribution of the “watershed” areas of the colon (splenic flexure and rectosigmoid junction) ACUTE MESENTERIC ISCHEMIA -Cause: emboli (most common) -Sx: severe periumbilical pain out of proportion to exam -Dx: CT angio -Tx: surgery
35
What sort of cancer do you get w/Barretts esophagus
ADENOCARCINOMA
36
Describe Barretts esophagus
BARRETTS ESOPHAGUS RFs: long hx GERD, male, white, family hx Dx: EGD with bx Tx: mucosal resection for any dysplasia ( low or high grade); otherwise PPI for no dysplasia F/u: q3-5 yrs NO dysplasia. q 6mos if dysplasia.
37
Neuroendocrine GI tumors mostly where
RECTUM
38
Desc esophageal varices. Tx?
ESOPHAGEAL VARICES -complication of liver cirrhosis -enlarged vessels at base of esophagus in setting of liver cirrhosis -Dx: EGD -Tx: EGD -->start BB (when have varices +red whale marks) -->BB + endoscopic ligation *PPIs have NO role
39
What is 1st line tx for hemorrhoids
First-line therapy for hemorrhoids includes increased fiber intake, adequate liquid intake, and avoidance of straining.
40
What meds are specific to Chrons. What meds are used in both UC and Chron's
ONLY UC -5-ASA: mesalamine BOTH UC and Chron's -immunosuppresants -budenosine -IV steroids -Azathioprine/6-MPc
41
Describe UC vs Chron's dx in the following: -depth -pattern -location -rectal involvement -fistulas -prominent sx
ULCERATIVE COLITIS -depth: mucosal pattern: continuous -location: colorectum -rectal involvement: 100% -rectal bleeding: common -fistulas: rare -prominent sx: diarrhea CHRONS -depth: transmural -pattern: skip -location: mouth to anus -rectal involvement: less common -rectal bleeding: rare -fistulas: COMMON -prominent sx: abd pain
42
What ulcer is seen with UC/Chron's
PYODERMA GANGREOSUM -nonhealing ulcer, often occurring on the lower extremities, may be seen in association with IBD. The ulcer shown has a purulent base and ragged, edematous borders.
43
What are 6 classes of tx meds for constipation?
(1) serotonergic prokinetic agents -prucalopride (2) bulking agents -psyllium [ (3) stimulant laxatives -senna, bisacodyl (4) osmotic laxatives -polyethylene glycol, lactulose, sorbitol) (5) stool softeners -docusate (6) secretagogues ---lubiprostone, linaclotide, plecanatide)
44
Describe surveillance of colon cancer + genetic conditions
GENETIC CONDITIONS: -Familial adenomatous polyposis (FAP): autosomal dominant; requires prophylactic colectomy. -Gardner syndrome: type of FAP w/extraintestinal manifestations (osteomas, duodenal ampullary tumors, thyroid cancers, and medulloblastomas). -Lynch syndrome: autosomal dominant; associated with an increased risk for extracolonic tumors, most commonly endometrial. SURVEILLANCE: -FAP: Begin 10-12 yrs; flexible sigmoidoscopy or colonoscopy; q 1-2 yrs until colectomy -Lynch syndrome: Begin 20-25 yrs or 10 years earlier than youngest cancer in family; colonoscopy; q 1-2 yrs -IBD (Chron's or UC): Begin after 8 years of chronic colitis; colonoscopy with biopsies; q 1-2 yrs
45
RLQ abdominal pain +/- fever think ?
Appendicitis RLQ pain +/- fever ALWAYS think of appendicitis Rember it pts >75 yrs, sx are atypical +/- fever +/- leukocytosis DIAGNOSIS -Abdominal and pelvic CT is used to confirm the diagnosis. TREATMENT -Nonperforated (uncomplicated): preoperative antibiotics + appendectomy (12-24hrs) -Perforated (complicated): IV abx, abscess drainage, emergent appendectomy. -Colonoscopy should be considered to evaluate for neoplasm at follow up.
46
The coexistence of GERD and peptic ulcer disease should make you think of what?
ZOLLINGER ELLISON SYNDROME -see GERD, PUD +/- diarrhea + elevated gastrin -localize site of gastrinoma -->endoscopic u/s
47
Describe autoimmune pancreatitis?
AIP -can p/w obstructive jaundice (yellow skin, dark urine, light stool) -associated sclerosing cholangitis, sclerosing sialadenitis, or retroperitoneal fibrosis. -2 types. Type 1 is systematic -elevated IgG4 -CT findings: diffusely enlarged pancreas w/indistinct borders ("sausage shaped") -Tx: steroids
48
What antidepressant class can be used to treat IBS-D
TCA (this med causes constipation so good to stop diarrhea)
49
What is diagnosis of achalasia? What is treatment?
Diagnosis -barium (bird's beak) --> EGD (r/o psuedo) -esophageal manometry (confirms) Treatment -Laparoscopic myotomy of the LES
50
Describe schatzki ring
- Dysphagia (usu meat & bread) - Tx: balloon or dilation
51
T/F: -Patients with ascites should discontinue ACE inhibitors and NSAIDs. -Patient w/angioedema should d/c aCE-I
TRUE!! TRUE!!
52
Treatment for hepatic abscess >3cm
1) Antibiotics 2) Hepatic abscesses 3 cm or greater in diameter typically do not resolve with antibiotic therapy alone, and aspiration of the abscess by percutaneous needle approach is warranted.
53
What is diagnostic study For active lower gastrointestinal bleeding with associated hemodynamic instability
For active lower gastrointestinal bleeding with associated hemodynamic instability, CT angiography is the study of choice.
54
Describe what layer of intestine is inovlved in Chrons vs UC? Which condition is extraintestional manifestations more common?
CHRONS -transmural -extraintestinal more common UC -mucosal layer only Extraintestinal manifestations: -arthralgia, back pain (indicating ankylosing spondylitis or sacroiliitis), and oral aphthous ulcers. -Eye: uveitis, iritis, or episcleritis. -Skin: pyoderma gangrenosum and erythema nodosum -Liver: PSC
55
Review treatment for UC
Consider 3 factors: -disease severity, distribution, and previous tx response. MILD/MODERATE -IF proctitis: 5- ASA (suppository); delivers to rectum only -IF L-sided colitis: 5-ASA (enema) -IF poor resp: 5-ASA (oral); L-sided colititis EXTENSIVE -combined 5-ASA tx (oral and topical)
56
Tx of maintenance therapy for UC?
Combination therapy with infliximab and azathioprine is more efficacious than monotherapy with either agent alone in achieving glucocorticoid-free remission and mucosal healing in ulcerative colitis. **do NOT use steroids**
57
For adrenal masses incidentally found--when is surgery recommended?
Surgery is recommended for adrenal masses >4 cm in diameter or functioning tumors.
58
describe different types of dysphagia?
PROGRESSIVE dypshagia to liq and solid: achalasia or scleroderma PROGRESSIVE dyphagia to solids 1st, then liquids: cancer or stricture INTERMITTENT dyphagia to solids: webs or rings
59
What are lab abnormalities for primary adrenal insufficiency
LOW Cortisol -hyperkalemia -hyperpigmentation (high aCTH) -hyponatremia
60
When do you use dexamethasone for adrenal insufficiency
For acute only. NOT for chronic replacement -4 mg IV dexamethasone
61
What enteric pathogen is characterized by flask-shaped enteric ulcers on microscopic evaluation on intestinal bx
Entamoeba histolytica
62
What is treatment for acute colonic pseudo-obstruction.
TREATMENT -conservative 1st--> IV neostigmine (stimulates colonic motility) -colonic decompression: IF failed conservative and neostigmine *Note: surgery RARELY indicated
63
For a patient w/GERD, when do you eval with EGD
1) sx refractory to PPI 2) red alarm sx (wt loss, odnophagia, dysphagia)
64
Colonoscopy screening: 10 yrs vs 3 yrs vs 1 yr?
10 years -NORMAL 3 years -5 to 10 tubular adenomas <10mm >=1 advanced ademoa (>10mm, villous/rublovillous, high-grade) 1 year >10 adenomas
65
What are 2 main treatments for IBS-C
*Bulking agents -polyethylene glycol (PEG) * New agents/secretagogues -lubiprostone, linaclotide, plecanatide
66
Describe tx of UC using 5-ASA
LEFT-sided UC -5-ASA ENEMAs Mild/Mod UC -5-ASA suppositories
67
diverticulitis + abscess--what is management of abscess
IF abscess <4cm: observe IF abscess > 4cm: surgery
68
Desc severe alcoholic hepatitis. What is the treatment?
ALCOHOLIC HEPATITIS -h/o excessive alcohol consumption, low-grade fever, jaundice, tender hepatomegaly, an aspartate-to-alanine aminotransferase ratio greater than 2, and a Maddrey discriminant function score of >=32 TREATMENT In the absence of systemic infection, acute kidney injury, uncontrolled gastrointestinal bleeding, and multiorgan failure, PREDNISOLONE is the treatment of choice for severe alcoholic hepatitis. *No longer use pentoxifylline
69
Describe tx for the following cirrhosis complications -hepatic encephalopathy tx/ppx -SBP tx/ppx -GIB tx/ppx
variceal bleeding -active bleed tx: octreotide -ppx: BB Hepatic encephalopathy -tx: lactulose +/- rifaxime -ppx: lactulose SBP -tx: cefotaxime and albumin infusion -ppx: fluoroquinolones
70
Desc acute cholecystitis
-gallbladder inflammation +/- infx Sx: severe RUQ or epigastric pain lasting (>6hrs) + fever Dx: u/s (ultrasound showing gallbladder-wall thickening or edema and sonographic Murphy sign.) Tx: ABx (same as acute cholangitis --> β-lactam/β-lactamase inhibitor or a third-generation cephalosporin plus metronidazole) + Surgery before hospital discharge
71
When do you use a HIDA scan?
ACUTE CHOLECYSTITIS -Hepatobiliary iminodiacetic acid (HIDA) scanning can be used when the diagnosis of acute cholecystitis is unclear, such as when symptoms are consistent with cholecystitis yet the ultrasound is normal. The classic finding of acute cholecystitis on a HIDA scan is nonvisualization of the gallbladder due to cystic duct obstruction.

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