Gastroenterology Flashcards
Most nutrient absorption occurs in the ___
small intestine
most common maldigestion syndrome
lactase deficiency
most common cause of small bowel obstruction
adhesions
most common cause of colonic obstruction
colonic CA
The best accepted symptom-based criteria are the Rome criteria, which exhibit sensitivities and specificities of only ___ to ___% when tested against structural findings in IBS and functional dyspepsia, indicating a need for careful test selection in patients at high risk of organic disease.
55–75
In patients with GI complaint, fever suggests ____ or ____
inflammation or neoplasm
Iron-deficiency anemia suggests ______ , whereas vitamin B12 deficiency results from _________ disease
mucosal blood loss
intestinal, gastric, or pancreatic
Fecal elastase can be decreased with ______
exocrine pancreatic insufficiency
<100 ug per gram of stool
mainstay of managing intestinal bacterial overgrowth
oral antibiotics
CT colonography rivals the accuracy of colonoscopy for the detection of some polyps and cancer, although it is not as sensitive for the detection of ______
flat lesions, such as serrated polyps
Flexible sigmoidoscopy is akin to colonoscopy, but it visualizes only the rectum and a variable portion of the left colon, typically to ___ cm from the anal verge
60
What modality provides the most accurate preoperative local staging of esophageal, pancreatic, and rectal malignancies?
EUS
However, does not detect most distant metastases
primary diagnostic and therapeutic technique for patients with acute gastrointestinal hemorrhage
Endoscopy
Over ___% of patients with melena are bleeding proximal to the ligament of Treitz, and ~___% of patients with hematochezia are bleeding from the colon.
90
85
A single dose of what antibiotics may administered intravenously 30–90 min prior to upper endoscopy increases gastric emptying and may clear blood and clots from the stomach to improve endoscopic visualization
erythromycin 3–4 mg/kg or 250 mg)
what endoscopic procedures would need abx prophylaxis?
see table
A clean based ulcer is associated with a low risk (___%) of rebleeding
3-5
patients with melena and a clean-based ulcer may be discharged home from the emergency room or endoscopy suite if they are young, reliable, otherwise healthy, and able to return as needed.
Once daily PPI
Flat pigmented spots and adherent clots covering the ulcer base have a % and % risk of rebleeding, respectively.
10
20
Flat pigmented spots do not require endoscopic treatment, but endoscopic therapy is generally applied to an ulcer with an adherent clot.
Once daily PPI
When a fibrin plug is seen protruding from a vessel wall in the base of an ulcer (so-called sentinel clot or visible vessel), the risk of rebleeding from the ulcer approximates __%.
40
leads to endoscopic therapy to decrease the rebleeding rate.
When active spurting from an ulcer is seen, there is a ___% risk of ongoing bleeding without endoscopic or surgical therapy.
90%
_____ is indicated for the prevention of a first bleed (primary prophylaxis) from large esophageal varices particularly in patients in whom nonselective beta blockers are contraindicated or not tolerated.
Endoscopic variceal ligation
EVL is also the preferred endoscopic therapy for control of active esophageal variceal bleeding and for subsequent eradication of esophageal varices (secondary prophylaxis).
Which antithrombotic drugs should be discontinued when performing endoscopic procedures?
Low-dose aspirin does not substantially increase the risk of endoscopic procedures
See table
Also called persistent caliber artery, is a large-caliber arteriole that runs immediately beneath the gastrointestinal mucosa and bleeds through a focal mucosal erosion
Dieulafoy’s Lesion
commonly involves the LESSER curvature of the proximal stomach, causes impressive arterial hemorrhage, and may be difficult to diagnose when not actively bleeding; it is often recognized only after repeated endoscopy for recurrent bleeding
best method for diagnosis of mallory weiss tear
Endoscopy
Endoscopy is useful for evaluation and treatment of some forms of gastrointestinal obstruction. An important exception is ____
small bowel obstruction due to adhesions
What imaging should be considered before endoscopy in patients fever, esophageal obstruction for ≥24 h, or ingestion of a sharp object, such as a fishbone?
Radiographs of the chest and neck
Radiographic contrast studies interfere with subsequent endoscopy and are NOT advisable in most patients with a clinical picture of esophageal obstruction.
The risk of cecal perforation in pseudoobstruction rises when the cecal diameter exceeds ___
12 cm
decompression of the colon may be achieved using intravenous neostigmine or via colonoscopic decompression
procedure of choice since it remains the gold standard for diagnosis and allows for immediate treatment of acute biliary obstruction
ERCP
Charcot’s triad
Charcot’s triad of jaundice, abdominal pain, and fever is present in ~70% of patients with ascending cholangitis and biliary sepsis
Reynolds Pentad
Chartcots triad (jaundice, abdominal pain, fever) + confusion and hypotension
The most sensitive test for diagnosis of gastroesophageal reflux disease (GERD) is ______
24-h ambulatory pH monitoring.
Endoscopy should be considered in patients with long-standing (≥___ years) GERD, as they have a sixfold increased risk of harboring Barrett’s esophagus compared to patients with <1 year of reflux symptoms
10
precursor lesion of esophageal squamous cell cancer
Esophageal squamous dysplasia
the most common type of esophageal malignancy worldwide
esophageal SCCA
About __% of patients presenting with difficulty swallowing have a mechanical obstruction; the remainder has a motility disorder, such as achalasia or diffuse esophageal spasm
50%
How do you distinguish dysphagia from schatzkis ring vs oropharyngeal motor disorders vs achalasia based on symptoms?
Schatzki’s ring causes episodic dysphagia for solids, typically at the beginning of a meal; oropharyngeal motor disorders typically present with difficulty initiating deglutition (transfer dysphagia) and nasal reflux or coughing with swallowing; and achalasia may cause nocturnal regurgitation of undigested food
When transfer dysphagia is evident or an esophageal motility disorder is suspected, _______ and/or _____ are the best initial diagnostic tests
esophageal radiography and/or a video-swallow study
Tests for occult blood in the stool detect hemoglobin or the heme moiety and are most sensitive for ___ blood loss, although they will also detect larger amounts of upper gastrointestinal bleeding
colonic
If positive, patients should undergo colonoscopy to diagnose or exclude colorectal neoplasia, especially if they are >50 years old or have a family history of colonic neoplasia.
In contrast to the low diagnostic yield of smallbowel radiography, positive findings on capsule endoscopy are seen in 50–70% of patients with suspected small-intestinal bleeding. The most common finding is _____
mucosal vascular ectasia
Duration of chronic diarrhea
> 6 weeks
Even trivial amounts of hematochezia should be investigated with colonoscopy and/or flexible sigmoidoscopy together with anoscopy to exclude polyps or cancers, especially in patients >__ years old and those with a personal or family history of colorectal polyps or cancer.
40
Patients reporting red blood on the toilet tissue only, without blood in the toilet or on the stool, are generally bleeding from a lesion in the anal canal; careful external inspection, digital examination, and sigmoidoscopy with anoscopy may be sufficient for diagnosis in such cases.
Previously undetected chronic pancreatitis, pancreatic malignancy, or pancreas divisum may be diagnosed by either ___ or ___
ERCP or EUS
When should you screen patients for colon CA?
see table
Appendiceal fecaliths (or appendicoliths) are found in ~__% of patients with gangrenous appendicitis who perforate but are rarely identified in those who have simple disease.
50
In patients with acute appendicitis The pain subsequently migrates to the right lower quadrant over ___ h, where it is sharper and can be definitively localized as transmural inflammation when the appendix irritates the parietal peritoneum.
12-24
Most common symptom of acute appendicitis
Abdominal pain
Most common sign of acute appendicitis
Abdominal tenderness
Location of appendix that may not present with very little tenderness of anterior abdominal wall
An inflamed appendix located behind the cecum or below the pelvic brim may prompt very little tenderness of the anterior abdominal wall.
Patients with pelvic appendicitis are more likely to present with dysuria, urinary frequency, diarrhea, or tenesmus.
The provider should be concerned about other disease processes beside appendicitis or the presence of complications such as perforation, phlegmon, or abscess formation if the temperature is >___C and if there are rigors.
38.3
Where is the McBurney’s point?
approximately one-third of the way along a line originating at the anterior iliac spine and running to the umbilicus.
What are the signs in acute appendicitis ?
T/F
The presence of a fecalith is not diagnostic of appendicitis, although its presence in an appropriate location where the patient complains of pain is suggestive and is associated with a greater likelihood of complications.
True
The sensitivity and specificity of CT for acute appendicitis are at least __ and __, respectively.
0.94 and 0.95
CT scan findings suggestive of acute appendicitis
Suggestive findings on CT examination include dilatation >6 mm with wall thickening, a lumen that does not fill with enteric contrast, and fatty tissue stranding or air surrounding the appendix, which suggests inflammation
most common extrauterine general surgical emergency observed during pregnancy.
acute appendicitis
Whenever the diagnosis of acute appendicitis is uncertain, it is prudent to observe the patient and repeat the abdominal examination over ___ h.
6-8
In patients with acute appendicitis Management of those who present with a mass representing a phlegmon or abscess can be more difficult. Such patients are best served by treatment with broad-spectrum antibiotics, drainage if there is an abscess >___ cm in diameter, and parenteral fluids and bowel rest if they appear to respond to conservative management. The appendix can then be more safely removed ____weeks later when inflammation has diminished.
3 cm
6-12
The most common postoperative complications are ____ and ____
fever and leukocytosis
Continuation of these findings beyond 5 days should raise concern for the presence of an intraabdominal abscess.
Over 90% of the cases of primary or spontaneous bacterial peritonitis occur in patients with ascites or hypoproteinemia ( < __- g/L).
<1
most common esophageal symptom
heartburn
most useful test for the evaluation of the proximal gastrointestinal tract
upper endoscopy
Hiatal hernia is a herniation of viscera, most commonly the ____
stomach
Four types of hiatal hernia are distinguished, with type ___ composing at least 95% of the overall total
type I, or sliding hiatal hernia,
How do you differentiate hiatal hernia II vs III vs IV
Type II, III, and IV hiatal hernias are all subtypes of paraesophageal hernia in which the herniation into the mediastinum includes a visceral structure other than the gastric cardia.
With type II and III paraesophageal hernias, the gastric fundus also herniates, with the distinction being that in type II, the gastroesophageal junction remains fixed at the hiatus, whereas type III is a combined sliding and paraesophageal hernia.
With type IV hiatal hernias, viscera other than the stomach herniate into the mediastinum, most commonly the colon.
When the esophageal lumen diameter is <__ mm, distal rings are usually associated with episodic solid food dysphagia and are called Schatzki rings.
13mm
Most common type of esophageal diverticula
Epiphrenic
Most common location of hypopharyngeal herniation
Kilian’s triangle
weakness of the cricopharyngeus
The typical presentation of esophageal cancer is of ____ (symptoms)
progressive solid food dysphagia and weight loss
Achalasia is a rare disease caused by loss of ganglion cells within the esophageal ____ plexus, with a population incidence estimated to be 1–3 per 100,000 and presentation usually occurring between age 25 and 60 years.
Myenteric plexus
How is achalasia diagnosed?
via barium swallow or esophageal manometry
Prevention or cure for achalasia?
none
LES pressure can be reduced by pharmacologic therapy, pneumatic balloon dilation, or LES myotomy by means of submucosal endoscopy or laparoscopic surgery. Nitrates or calcium channel blockers are administered before eating but should be used with caution because of their effects on blood pressure. Botulinum toxin, injected into the LES under endoscopic guidance, inhibits acetylcholine release from nerve endings and improves dysphagia in about two-thirds of cases for at least 6 months. Sildenafil and alternative phosphodiesterase inhibitors effectively decrease LES pressure, but practicalities limit their clinical use in achalasia
The only durable therapies for achalasia are pneumatic dilation and LES myotomy
Radiographic appearance of DES
corkscrew esophagus
Three dominant mechanisms of esophagogastric junction incompetence are recognized
(1) transient LES relaxations (a vagovagal reflex in which LES relaxation is elicited by gastric distention), (2) LES hypotension, or (3) anatomic distortion of the esophagogastric junction inclusive of hiatal hernia
Transient LES relaxations account for ~90% of reflux in normal subjects or GERD patients without hiatal hernia, but patients with hiatal hernia have a more heterogeneous mechanistic profile.
endoscopic hallmark of GERD
Erosive esophagitis at the esophagogastric junction is the endoscopic hallmark of GERD but identified in only about one-third of patients with GERD
most severe histologic consequence of GERD is _________
Barrett’s metaplasia with the associated risk of esophageal adenocarcinoma, and the incidence of these lesions has increased, not decreased, in the era of potent acid suppression
T/F
the perceived frequency and severity of heartburn correlates well with the presence or severity of esophagitis.
False
correlates poorly
Endoscopically identfiied esopageal finding in eosinophilic esophagitis
The characteristic endoscopically identified esophageal findings include loss of vascular markings (edema), multiple esophageal rings, longitudinally oriented furrows, and whitish exudate
Histologic confirmation is made with the demonstration of esophageal mucosal eosinophilia (peak density ≥15 eosinophils per high-power field
E-E-E-E
Eosinophilic-Esophagitis-Exudates-Edema
Treatment for eosinophilic esophagitis
Primary therapy often starts with PPI therapy, which is effective at improving eosinophilic inflammation in 30–50% of patients. Additional first-line therapies include elimination diets or swallowed topical glucocorticoids.
Immunocompromised patients are treated with acyclovir (400 mg orally five times a day for 14–21 days), famciclovir (500 mg orally three times a day), or valacyclovir (1 g orally three times a day)
Systemic glucocorticoids are not generally recommended due to side effects and lack of proven benefit beyond that achieved with topical glucocorticoids.
Biologic therapies targeting allergic cytokine mediators including interleukin (IL) 4, IL-5, and IL-13 have shown promise in initial clinical trials.
Esophageal dilation is highly effective at relieving dysphagia in patients with fibrostenosis but does not address the underlying inflammatory process.
Common CD4 count of px with infectious esophagitis
Among AIDS patients, infectious esophagitis becomes more common as the CD4 count declines; cases are rare with a CD4 count >200 and common when <100.
Regardless of the infectious agent, odynophagia is a characteristic symptom of infectious esophagitis; dysphagia, chest pain, and hemorrhage are also common
Most common cause of infectious esophagitis
C. albicans
Treatment for candida esophagitis
Oral fluconazole (400 mg on the first day, followed by 200 mg daily) for 14–21 days is the preferred treatment.
Characteristic endoscpic finding of herpetic esophagitis
The characteristic endoscopic findings are vesicles and small, superficial ulcerations
Because herpes simplex infections are limited to squamous epithelium, biopsies from the ulcer margins are most likely to reveal the characteristic groundglass nuclei, eosinophilic Cowdry’s type A inclusion bodies, and giant cells.
Treatment for herpetic esophagitis
Acyclovir (200 mg orally five times a day for 7–10 days) can be used for immunocompetent hosts, although the disease is typically self-limited after a 1- to 2-week period in such patients.
Immunocompromised patients are treated with acyclovir (400 mg orally five times a day for 14–21 days), famciclovir (500 mg orally three times a day), or valacyclovir (1 g orally three times a day).
In patients with severe odynophagia, intravenous acyclovir, 5 mg/kg every 8 h for 7–14 days, reduces this morbidity
Endoscopic findings of CMV esophagitis
Endoscopically, CMV lesions appear as large serpiginous ulcers in an otherwise normal mucosa, particularly in the distal esophagus.
Biopsies from the ulcer bases have the greatest diagnostic yield for finding the pathognomonic large nuclear or cytoplasmic inclusion bodies.
Treatment for CMV esophagitis
Treatment studies of CMV gastrointestinal disease have demonstrated effectiveness of both ganciclovir (5 mg/kg every 12 h IV) and valganciclovir (900 mg orally every 12 h). Therapy is continued until healing, which may take 3–6 weeks. Maintenance therapy may be needed for patients with relapsing disease.
most sensitive in detecting mediastinal air from esophageal perforation
Chest CT
Most common symptom of Mallory Weiss Tear
Hematemesis
Radiation exposure in excess of ____ c Gy has been associated with increased risk of esophageal stricture.
5000 cGy
In pill esophagitis The most common location for the pill to lodge is in the _____
mid-esophagus near the crossing of the aorta or carina
Defenition of ulcers
Ulcers are defined as breaks in the mucosal surface >5 mm in size, with depth to the submucosa
Most common risk factors for PUD
H. pylori and NSAIDs
Most common location of duodenal ulcer
DUs occur most often in the first portion of the duodenum (>95%), with ~90% located within 3 cm of the pylorus.
Characteristic of benign gastric ulcers
Benign GUs are most often found distal to the junction between the antrum and the acid secretory mucosa. Benign GUs are quite rare in the gastric fundus and are histologically similar to DUs. Benign GUs associated with H. pylori are also associated with antral gastritis.
In contrast, NSAID-related GUs are not accompanied by chronic active gastritis but may instead have evidence of a chemical gastropathy, typified by foveolar hyperplasia, edema of the lamina propria, and epithelial regeneration in the absence of H. pylori. Extension of smooth-muscle fibers into the upper portions of the mucosa, where they are not typically found, may also occura
Transmission of H.pylori
Feco-oral route
Typical pain pattern of duodenal ulcer
The typical pain pattern in DU occurs 90 min to 3 h after a meal and is frequently relieved by antacids or food. Pain that awakes the patient from sleep (between midnight and 3 a.m.) is the most discriminating symptom, with twothirds of DU patients describing this complaint
most frequent PE finding in px with gastric or duodenal ulcer
Epigastric tenderness is the most frequent finding in patients with GU or DU
Most common complication of PUD
GI bleeding
2nd most common : perforation
Diagnostic tests for H.pylori
H2 blocker that is associated with weak antiandrogenic effects
Cimetidine
The half-life of PPIs is ~__h
18 h
Serum gastrin levels return back to normal after how many weeks of PPI cessation?
1-2w
As with any agent that leads to significant hypochlorhydria, PPIs may interfere with absorption of drugs such as _______
ketoconazole, ampicillin, iron, and digoxin
Nutrient deficiencies implicated in long term PPI use
Long-term use of PPIs has also been implicated
in the development of iron, vitamin B12, and magnesium deficiency
- magnesium level usually checked after 1-2yrs
In what situation/s is vonoprazan probably superior to PPI in PUD?
Vonoprazan may be superior to PPIs when combined with antibiotics for the treatment of H. pylori, and this novel agent has been awarded Fast Track status by the FDA for the treatment of H. pylori in combination with both amoxicillin and clarithromycin and with amoxicillin alone
Most common toxicity noted with prostaglandin analogues for PUD
The most common toxicity noted with this drug is diarrhea (10–30% incidence).
The aim for initial eradication rates of H.pylori should be ___ %
85–90
Recommended therapies for H. pylori eradicatio
The regimen of a PPI, bismuth, tetracycline, and metronidazole combined with a PPI for 10 days is an FDA-approved treatment regimen.
Approach to selecting abx for H. pylori tx
Salvage tx for H.pylori
Non selective NSAID associated with lower likelihood of GI and CV toxicity
Several nonselective NSAIDs that are associated with a lower likelihood of GI and CV toxicity include naproxen and ibuprofen, although the beneficial effect may be eliminated if higher dosages of the agents are used
Guide to NSAID tx in px with PUD
Duration of tx in H. pylori positive px
Once an ulcer (GU or DU) is documented, the main issue at stake is whether H. pylori or an NSAID is involved. With H. pylor present, independent of the NSAID status, triple therapy is recommended for 14 days, followed by continued acid-suppressing drugs (H2 receptor antagonist or PPIs) for a total of 4–6 weeks.
When should you request for test for documenting H. pylori eradication after antibiotic tx?
H. pylori eradication should be documented 4 weeks after completing antibiotics
The test of choice for documenting eradication of H. pylori is the laboratory-based validated ______
monoclonal stool antigen test or a urea breath test (UBT)
The patient must be off antisecretory agents for at least 7 days when being tested for eradication of H. pylori with UBT or stool antigen
Location of gastric ulcer that has potential for malignancy
GUs, especially of the body and fundus, have the potential of being malignant. Multiple biopsies of a GU should be taken initially; even if these are negative for neoplasm, repeat endoscopy to document healing at 8–12 weeks should be performed, with biopsy if the ulcer is still present. About 70% of GUs eventually found to be malignant undergo significant (usually incomplete) healing
Fu-Bo- bad –> malignant potential
When do you consider gastric ulcer and duodenal ulcer refractory to therapy?
A GU that fails to heal after 12 weeks and a DU that does not heal after 8 weeks of therapy should be considered refractory
Among the surgical interventions for PUD, The procedure that provides the lowest rates of ulcer recurrence (1%) but has the highest complication rate is ______
vagotomy (truncal or selective) in combination with antrectomy
Condition that must have been excluded preop before employing surgical tx for PUD
ZES should have been excluded preoperatively due to risk of ulcer recurrence after surgery
Medical therapy for post op ucleration after surgical tx in PUD
Medical therapy with H2 blockers will heal postoperative ulceration in 70–90% of patients. The efficacy of PPIs has not been fully assessed in this group, but one may anticipate greater rates of ulcer healing compared to those obtained with H2 blocker
How do you differentite the 2 types of afferent loop syndrome?
The more common of the two is bacterial overgrowth in the afferent limb secondary to stasis. Patients may experience postprandial abdominal pain, bloating, and diarrhea with concomitant malabsorption of fats and vitamin B12. Cases refractory to antibiotics may require surgical revision of the loop.
The less common afferent loop syndrome can present with severe abdominal pain and bloating that occur 20–60 min after meals. Pain is often followed by nausea and vomiting of bile-containing material. The pain and bloating may improve after emesis.
The cause of this clinical picture is theorized to be incomplete drainage of bile and pancreatic secretions from an afferent loop that is partially obstructed
What is dumping syndrome?
Dumping syndrome consists of a series of vasomotor and GI signs and symptoms and occurs in patients who have undergone vagotomy and drainage (especially Billroth procedures).
What are the pathophysiology behind the 2 phases of dumping syndrome?
Early dumping takes place 15–30 min after meals and consists of crampy abdominal discomfort, nausea, diarrhea, belching, tachycardia, palpitations, diaphoresis, light-headedness, and, rarely, syncope. These signs and symptoms arise from the rapid emptying of hyperosmolar gastric contents into the small intestine, resulting in a fluid shift into the gut lumen with plasma volume contraction and acute intestinal distention. Release of vasoactive GI hormones (vasoactive intestinal polypeptide, neurotensin, motilin) is also theorized to play a role in early dumping.
The late phase of dumping typically occurs 90 min to 3 h after meals. Vasomotor symptoms (light-headedness, diaphoresis, palpitations, tachycardia, and syncope) predominate during this phase. This component of dumping is thought to be secondary to hypoglycemia from excessive insulin release.
Cornerstone of tx in px with dumping syndrome
Dietary modification is the cornerstone of therapy for patients with dumping syndrome. Small, multiple (six) meals devoid of simple carbohydrates coupled with elimination of liquids during meals is important.
Antidiarrheals and anticholinergic agents are complementary to diet.
Pathophysiology behind decreased Vit B12 after partial gastrectomy
This is usually not due to deficiency of IF, since a minimal amount of parietal cells (source of IF) is removed during antrectomy.
Reduced vitamin B12 may be due to competition for the vitamin by bacterial overgrowth or inability to split the vitamin from its protein-bound source due to hypochlorhydria
What other micronutrient deficiency aside from Vit b12 is associated with Billroth II gastsrojejunostomy?
Iron and Folic acid
Malabsorption of vitamin D and calcium resulting in osteoporosis and osteomalacia is common after partial gastrectomy and gastrojejunostomy (Billroth II)
Copper deficiency has also been reported in patients undergoing surgeries that bypass the duodenum, where copper is primarily absorbed
the driving force responsible for the clinical manifestations in ZES
Hypergastrinemia originating from an autonomous neoplasm
The most common clinical presentation for gastrinoma patients is ____
abdominal pain in the presence of acid peptic disorders.
Diarrhea, the next most common clinical manifestation, is found in up to 70% of patients
When should you suspect gastrinoma?
Clinical situations that should create suspicion of gastrinoma are ulcers in unusual locations (second part of the duodenum and beyond), ulcers refractory to standard medical therapy, ulcer recurrence after acid-reducing surgery, ulcers presenting with frank complications (bleeding, obstruction, and perforation), or ulcers in the absence of H. pylori or NSAID ingestion.
1st step in the evaluation of a px with suspected ZES
Obtain fasting gastrin level
Fasting gastrin levels obtained using a dependable assay are usually <150 pg/mL. A normal fasting gastrin, on two separate occasions, especially if the patient is on a PPI, virtually excludes this diagnosis. Virtually all gastrinoma patients will have a gastrin level >150–200 pg/mL
Indications for ordering fasting gastrin level
How long should PPI be stopped before requesting for fasting gastrin level?
The effect of the PPI on gastrin levels and acid secretion will linger several days after stopping the PPI; therefore, it should be stopped for a minimum of 7 days before testing
a pH <___ is suggestive of a gastrinoma
3
gas-three-noma
The most sensitive and specific gastrin provocative test for the diagnosis of gastrinoma is the ___
secretin study
Most sensitive imaging modality for detecting primary gastrinoma
EUS
In px with gastrinoma, Up to __% of patients have metastatic disease at diagnosis.
50
Treatment of choice for ZES
PPI
yInitial PPI doses tend to be higher than those used for treatment of GERD or PUD. The initial dose of omeprazole, lansoprazole, rabeprazole, or esomeprazole should be in the range of 60 mg in divided doses in a 24-h period.
When gastric acid analysis was more widely available, dosing was adjusted to achieve a BAO <10 meq/h (at the drug trough) in surgery-naive patients and to <5 meq/h in individuals who have previously undergone an acid-reducing operation
Predictors of poor outcome in px with gastrinoma
Poor outcome is seen in patients with shorter disease duration; female sex; older age at diagnosis; higher gastrin levels (>10,000 pg/mL); poor histologic differentiation; high proliferative index; large pancreatic primary tumors (>3 cm); metastatic disease to lymph nodes, liver, and bone; and Cushing’s syndrome. Rapid growth of hepatic metastases is also predictive of poor outcome.
Most common cause of gastritis
infectious
H. pylori
What are the phases of chronic gastritis?
The early phase of chronic gastritis is superficial gastritis. The inflammatory changes are limited to the lamina propria of the surface mucosa, with edema and cellular infiltrates separating intact gastric glands.
The next stage is atrophic gastritis. The inflammatory infiltrate extends deeper into the mucosa, with progressive distortion and destruction of the glands.
The final stage of chronic gastritis is gastric atrophy. Glandular structures are lost, and there is a paucity of inflammatory infiltrates. Endoscopically, the mucosa may be substantially thin, permitting clear visualization of the underlying blood vessels.
How do you differentiate Type A from Type B gastritis
Chronic gastritis is also classified according to the predominant site of involvement. Type A refers to the body-predominant form (autoimmune), and type B is the antral-predominant form (H. pylori–related). This classification is artificial in view of the difficulty in distinguishing between these two entities. The term AB gastritis has been used to refer to a mixed antral/body picture.
Antibodies to parietal cells have been detected in >90% of patients with pernicious anemia and in up to 50% of patients with type A gastritis
Which is the more common form of gastritis Type A or B?
B
How accurate is urine dipstick compared to serum in detecting conjugated hyperbilirubinemia
Almost 100% accurate
What should you consider if the Fractionate bilirubin is >15% direct bilirubin?
Dubin Johnson or Rotor
Next step if there is isolated hyperbilirubinemia and <15% direct bilirubin
rule out hemolysis
if negative, consider Gilbert’s syndrome
Next step if LFTs showed cholestatic pattern
Review drugs
Utz
Next step when LFT is cholestatic and ducts are not dilated
AMA
if stil engative, do ERCP/ liver biopsy
Next step when LFT is cholestatic and ducts are dilated
CT/MRCP/ERCP
Next step when LFTs showed hepatocellular pattern
See pic
Next step if LFT showed isolated ALP elevation
Fractionate ALP or get GGT or 5’ nucleotidase
Striking elevations—that is, aminotransferases >1000 IU/L—occur almost exclusively in disorders associated with extensive hepatocellular injury such as ____ (3)
(1) viral hepatitis, (2) ischemic liver injury (prolonged hypotension or acute heart failure), or (3) toxin- or drug-induced liver injury
AST ALT ratio suggestive of alcoholic liver dse
An AST:ALT ratio >2:1 is suggestive, whereas a ratio >3:1 is highly suggestive, of alcoholic liver disease. The AST in alcoholic liver disease is rarely >300 IU/L, and the ALT is often normal. A low level of ALT in the serum is due to an alcohol-induced deficiency of pyridoxal phosphate
Patients over age 60 can have a mildly elevated alkaline phosphatase (1–1.5 times normal), whereas individuals with blood types ___ and ___ can have an elevation of the serum alkaline phosphatase after eating a fatty meal due to the influx of intestinal alkaline phosphatase into the blood
O and B
In hepatitis, albumin levels <__ g/dL should raise the possibility of chronic liver disease
3
Increases in the concentration of specific isotypes of γ globulins are often helpful in the recognition of certain chronic liver diseases. Diffuse polyclonal increases in IgG levels are common in autoimmune hepatitis; increases >100% should alert the clinician to this possibility.
Increases in the Ig_ levels are common in primary biliary cholangitis, whereas increases in the Ig_ levels occur in alcoholic liver disease.
M
A (igA for alcoholic)
Marked prolongation of the prothrombin time, >_ s above control and not corrected by parenteral vitamin K administration, is a poor prognostic sign in acute viral hepatitis and other acute and chronic liver diseases
5
gold standard for documenting the presence of steatorrhea
72-h collection for weight/volume and fecal fat determination
how is steatorrhea defined?
Steatorrhea, defined as increased stool fat excretion to >7% of dietary fat, is a common manifestation of malabsorption
Chronic mesenteric ischemia is secondary to multiple major visceral arterio-occlusive disease, with involvement of the ____artery most worrisome
SMA
Differentiate chronic vs acute mesenteric ischemia in terms of pathophysiology
CMI is the failure to achieve normal postprandial hyperemic intestinal blood flow. This occurs due to an imbalance between the supply and demand of oxygen metabolites to the intestinal tract similar to cardiac angina. CMI occurs due to significant atherosclerotic disease leading to the narrowing of the SMA and/or celiac artery origins.
AMI is the occurrence of an abrupt cessation of mesenteric blood flow, usually embolic or thrombotic in nature. Approximately 50% of AMI is due to embolus to the mid to distal SMA. Embolus etiology includes atrial fibrillation, recent myocardial infarction, soft atherosclerotic plaque, infective endocarditis, valvular heart disease, and recent cardiac or vascular catheterization
Collateral vessels within the colon meet at the splenic flexure and descending/sigmoid colon. These areas, which are inherently at risk for decreased blood flow, are known as _____ and _____
Griffiths’ point and Sudeck’s point,
Acute intestinal ischemia remains one of the most challenging diagnoses. The mortality rate of AMI is >___%
50
The most significant indicator of survival is the timeliness of diagnosis and treatment.
Most common chief complaint of acute mesenteric ischemia
Severe, acute, unremitting abdominal pain strikingly out of proportion to the physical findings is the most common complaint (95%). This may be associated with nausea (44%), vomiting (35%), diarrhea (35%), and blood per rectum (16%)
How do you manage acute intestinal ischemia
satients with AMI should be given a heparin bolus and started on a therapeutic heparin drip. Correction of electrolyte abnormalities and empiric broadspectrum antibiotic therapy should also be initiated immediately
If the CTA verifies the acute embolic occlusion of SMA, surgical exploration should not be delayed. The goal of operative exploration is to resect the compromised bowel and restore blood supply
Nonviable bowel should be resected. Questionable bowel should undergo a second-look laparotomy in a 24- to 48-h period
How do you diagnose acute intestinal ischemia
In patients with suspected AMI, CT angiography with a 1-mm or thinner cut should be used to detect mesenteric arterial occlusive disease most likely due to embolic or thrombotic etiology and is the gold standard
Most commonly affected part of volvulus
Sigmoid
Most common precursor for bowel strangulation
Closed loop obstruction
What should be ruled out when patient with acute intestinal obstruction presents with fever?
Fever is worrisome for strangulation or systemic inflammation
T/F
In patients with acute intestinal obstruction, Higher white blood cell counts with the presence of immature forms or the presence of metabolic acidosis are worrisome for severe volume depletion or ischemic necrosis and sepsis
True
A “staircasing” pattern of dilated air and fluid-filled small-bowel loops >___ cm in diameter with little or no air seen in the colon are classical findings in patients with small-bowel obstruction, although findings may be equivocal in some patients with documented disease
2.5
Patients who have evidence of contrast appearing within the cecum within ___h of oral administration of water-soluble contrast can be expected to improve with high sensitivity and specificity (~95% each)
4-24h
T/F
Barium studies are generally contraindicated in patients with firm evidence of complete or high-grade bowel obstruction, especially when they present acutely.
True
When administering neostigmine, what medication should be readily available?
Cardiac monitoring is required, and atropine should be immediately available. Intravenous administration induces defecation and flatus within 10 min in the majority of patients who will respond
The most common site of intestinal obstruction in patients with gallstone “ileus” is the ____
ileum (60% of patients)
Early postoperative mechanical bowel obstruction is that which occurs within the first __ weeks of operation
6
_____ is the most common and most characteristic symptom of liver disease
Fatigue
RUQ pain or liver pain is due to ____
The pain arises from stretching or irritation of Glisson’s capsule, which surrounds the liver and is rich in nerve endings
hallmark symptom of liver disease and perhaps the most reliable marker of severity
Jaundice
single most common risk factor for hepatitis C
Injection drug use
blood transfusions received before the introduction of sensitive enzyme immunoassays for antibody to hepatitis C virus in ___ is an important risk factor for chronic hepatitis C
1992
Blood transfusion before ___, when screening for antibody to hepatitis B core antigen was introduced, is also a risk factor for hepatitis B
1986
Hepatitis E infection can become chronic in ______ patients in whom it presents with abnormal serum enzymes in the absence of markers of hepatitis B or C.
immunosuppressed individuals (such as transplant recipients, patients receiving chemotherapy, or patients with HIV infection),
What constitutes the CAGE questionnaire?
a One “yes” response should raise suspicion of an alcohol use problem, and more than one is a strong indication of abuse or dependence.
What constitutes child pugh scoring system
The Child-Pugh score is a reasonably reliable predictor of survival in many liver diseases and predicts the likelihood of major complications of cirrhosis, such as bleeding from varices and spontaneous bacterial peritonitis
Most common presentation of diverticular dse
uncomplicated - abdominal pain
What is the surgical therapy for each Hinchey classification?
Patients with Hinchey stage Ia are managed with antibiotic therapy only followed by resection with anastomosis at 6 weeks.
Patients with Hinchey stages Ib and II disease are managed with percutaneous drainage followed by resection with anastomosis about 6 weeks later.
Current guidelines put forth by the American Society of Colon and Rectal Surgeons suggest, in addition to antibiotic therapy, CT-guided percutaneous drainage of diverticular abscesses that are >3 cm and have a well-defined wall. Abscesses that are <5 cm may resolve with antibiotic therapy alone
No anastomosis of any type should be attempted in Hinchey stage IV disease or in the presence of fecal peritonitis
Staging of internal hemorrhoids
What 4 steps constitute the stepwise diagnostic approach to the patient with suspected chronic pancreatitis
how do you define the different morphologic features of pancreatitis?
Factors for Progression of Alcohol-Associated Liver Disease
Treatment for severe alcoholic hepatitis
Glucocorticoid use reduces the risk of death in patients with severe alcoholic hepatitis within 28 days of treatment but not in the following 6 months. Oral prednisolone, 40 mg/d for a total duration of 4 weeks, is preferred. For patients unable to take oral medications, methylprednisolone, 32 mg/d IV, is used. The combination of glucocorticoids with N-acetylcysteine infusion might add short-term survival benefit at 1 month
Failure of improvement of Lille score (≥0.45) after 7 days of glucocorticoid treatment will determine patients with severe alcoholic hepatitis who will unlikely benefit from continued treatment with glucocorticoids.
Liver morphology associated with DILI caused by acetaminophen
Liver morphology associated with DILI caused by co-amoxiclav
Liver morphology associated with DILI caused ciprofloxacin
Same with isoniazid
Liver morphology associated with DILI caused by Carbon tetrachloride
Liver morphology associated with DILI caused by estrogen
What constitutes the Rome IV criteria for IBS?
pain is a key symptom for the
diagnosis of IBS.
1-2-3
1day per week
2 ssx
3 months
Treatment for IBS
Risk factors for IBD
strongest risk factor for the development of IBD is a first-degree relative with the disease
yung mga may protective is for UC
Indications for surgery in IBD
High-Risk Populations for Whom HBV Infection Screening Is Recommended
High-Risk Populations for Whom HCV-Infection
Screening Is Recommended
Serology of Acute hepatitis B (HBsAg below detection threshold)
HBV vaccination schedule
For HBeAg-positive patients with ALT ≤2× the upper limit of normal, no antiviral tx is recommended unless
in patients >40, with family history of cirrhosis or hepatocellular carcinoma, with extrahepatic manifestations, with a history of previous treatment, and/or with liver biopsy (or noninvasive fibrosis determination) evidence for moderate to severe inflammation or fibrosis
When should you treat for chronic hep b?
For patients with compensated cirrhosis, because antiviral therapy has been shown to retard clinical progression, treatment is recommended regardless of HBeAg status and ALT as long as HBV DNA is detectable at >_____ (detectable at any level according to the EASL);
2 × 10^3 IU/mL
What are the advantages of nucleoside analogs over PEG IFN for tx of chronic hep B
taken orally
effective in high HBV level DNA > 10^9
may be used in cirrhosis, transplant px and immunosuppressed
less costly
What are the standard indications for therapy of chronic HCV infection?
Pathogens that cause diarrhea via enterotoxin
Pathogens that cause diarrhea via cytotoxin
If the diarhea persisted for > __ days, stool must be tested for parasites
10
If stool sample reveled WBCs, you should culture for what organisms?
Culture for: Shigella, Salmonella, Campylobacter jejuni
Consider: Clostridioides difficile cytotoxin
What causative organisms can cause food poisoning that has an incubation period of 1-6h
Staphylococcus aureus or B. cereus, has the shortest incubation period (1–6 h) and generally lasts <12 h
The emetic form of B. cereus food poisoning is associated with contaminated fried rice
What causative organisms can cause food poisoning + dysentery
What causative organisms can cause food poisoning + inflammatory diarrhea
How do you treat traveler’s diarrhea
If the level of suspicion is low for fluoroquinolone-resistant Campylobacter
Adults:
(1) A fluoroquinolone such as ciprofloxacin, 750 mg as a single dose or 500 mg bid for 3 days; levofloxacin, 500 mg as a single dose or 500 mg qd for 3 days; or norfloxacin, 800 mg as a single dose or 400 mg bid for 3 days.
(2) Azithromycin, 1000 mg as a single dose or 500 mg qd for 3 days.
(3) Rifaximin, 200 mg tid or 400 mg bid for 3 days (not recommended for use in dysentery).
If fluoroquinolone-resistant Campylobacter is suspected (for example, following travel to Southeast Asia):
Adults: Azithromycin (at above dose for adults).
Differentiate forrest class types
