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
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.
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 treatment, but endoscopic therapy is generally applied to an ulcer with an adherent clot.
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%
_____ isindicated 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 mallowry 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
ppendiceal 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
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 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 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
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
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),
. Alcohol consumption associated with an increased rate of alcoholic liver disease is probably more than ___ drinks per day in women and ____ drinks in men
2 (22–30 g)
3 (33–45 g)
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.
__________ refers to the slightly sweet, ammoniacal odor that can develop in patients with liver failure, particularly if there is portal-venous shunting of blood around the liver.
Fetor hepaticus
A helpful measure of hepatic encephalopathy is a careful mental status examination and use of the ___________ test
trail-making test
consists of a series of 25 numbered circles that the patient is asked to connect as rapidly as possible using a pencil.
The normal range for the connectthe-dot test is 15–30 s; it is considerably longer in patients with early hepatic encephalopathy
Triad of hepatopulmonary syndrome
liver disease, hypoxemia, and pulmonary arteriovenous shunting
The hepatopulmonary syndrome is characterized by platypnea and orthodeoxia: shortness of breath and oxygen desaturation that occur paradoxically upon the assumption of an upright position.
Measurement of oxygen saturation by pulse oximetry is a reliable screening test for hepatopulmonary syndrome.
Expected lab results in Wilsons disease
Decreased serum ceruloplasmin and increased urinary copper; increased hepatic copper level
Expected lab results in hemochromatosis
Elevated iron saturation and serum ferritin;
genetic testing for HFE gene mutations
Most common cause of chronic liver disease
The most common causes of chronic liver disease, in general order of frequency, are chronic hepatitis C, alcoholic liver disease, nonalcoholic steatohepatitis, chronic hepatitis B, autoimmune hepatitis, sclerosing cholangitis, primary biliary cholangitis, hemochromatosis, and Wilson disease
C- for chronic
The size of the liver biopsy sample is an important determinant of reliability; a length of ____cm with 10 portal tracts is necessary for accurate assessment of fibrosis.
1.5-2cm
Duration of chronic liver dse
> 6months
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
With regard to vaccinations, all patients with liver disease should receive ____ vaccine, and those with risk factors should receive ____ vaccine as well.
hepatitis A
hepatitis B
The CDC now recommends universal one-time testing for hepatitis C virus among persons aged _____ years and screening of all pregnant women during each pregnancy except in settings where the prevalence of hepatitis C virus infection (hepatitis C virus RNA positivity) is <___%.
18–79
0.1%
When should ultrasound of the liver be done for px with liver cirrhosis
While the optimal regimen for such surveillance has not been established, an appropriate approach is US of the liver at 6- to 12-month interval
Pseudodiverticulum
Type of diverticulum most commonly affecting the colon
Most commonly involved part in divericulosis
descending and sigmoid colon
Hemorrhage from a _____ is the most common cause of hematochezia in patients >60 years
colonic diverticulum
yet only 20% of patients with diverticulosis will have gastrointestinal bleeding.
Colonic wall thickness suggestive of diverticulitis on CT scan
> 4mm
Most common presentation of diverticular dse
A colonoscopy should be performed ~___weeks after an attack of diverticular disease.
6
The parallel epidemiology of colorectal cancer and diverticular disease provides enough concern for an endoscopic evaluation before operative management.
Although the benefit of colonoscopy in the evaluation of patients with diverticular disease has been called into question, its use is still considered important in the exclusion of colorectal cancer
Required amount of fiber in diverticulosis
30g
Established risk factors for acute diverticulitis for symptomatic recurrence include _____
younger age, the formation of a diverticular abscess, more frequent attacks (>2 per year), multimorbidity, obesity, and smoking.
When should you operate on acute diverticulitis?
If the patient is unstable or has had a 6-unit bleed within 24 h, current recommendations are that surgery should be performed
Is mesalazine beneficial in acute uncomplicated diverticulitis?
The use of anti-inflammatory medications (mesalazine) in randomized clinical trials has shown them to be beneficial at reducing symptoms and disease recurrence in patients with SUDD. However, when objective signs of inflammation such as C-reactive protein and computerized imaging are taken into consideration, no benefit for the use of mesalazine has been shown
What poorly absorbed antibiotic may also lessed frequent recurrence of symptoms of uncomplicated diverticular disease
Rifaximin (a poorly absorbed broad-spectrum antibiotic), when compared to fiber alone for the treatment of SUDD, is associated with 30% less frequent recurrent symptoms from uncomplicated diverticular disease.
What trial demonstrated that elective surgical resection was associated with an improved quality of life and was more cost-effective at 5 years following resection as compared to conservative management in px with acute uncomplicated diverticulitis?
A multicentered randomized clinical trial (DIRECT trial) comparing surgery with conservative management for recurrent SUDD demonstrated that elective surgical resection was associated with an improved quality of life and was more cost-effective at 5 years following resection as compared to conservative management.
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
The incidence of rectal prolapse peaks in women >___ years.
60
Staging of internal hemorrhoids
With rare exceptions, the acutely thrombosed hemorrhoid can be excised within the first __h
72h
Most common type of fistula in ano
70% being intersphincteric, 23% transsphincteric, 5% suprasphincteric, and 2% extrasphincteric
The most common pancreatic cyst type encountered is an/ a___________ , which is classified as a precancerous mucinous cyst.
intraductal papillary mucinous neoplasm (IPMN)
In the absence of high-risk features, radiographic surveillance is typically recommended
In acute pancreatitis, the serum amylase and lipase are usually elevated within ___ of onset and remain so for _____.
24h
3–7 day
What 4 steps constitute the stepwise diagnostic approach to the patient with suspected chronic pancreatitis
best imaging study for the assessment of complications of acute and chronic pancreatitis
CT scan with IV contrast
The major benefit of CT scan in acute pancreatitis is
the diagnosis of pancreatic necrosis in patients not responding to conservative management within 72 h
It may take 48–72 h to develop perfusion defects indicative of pancreatic necrosis.
When should you perform EUS in px with acute pancreatitis?
EUS is not beneficial for the evaluation of pancreas during acute pancreatitis. It is preferable to perform EUS after the resolution of acute pancreatitis (~4 weeks) to detect any predisposing factors, including malignancy, choledocholithiasis, pancreatic divisum, or ampullary lesions
most sensitive modality for the detection of bile duct stones
ERCP
The most reproducible measurement, giving the highest level of discrimination between normal subjects and patients with chronic pancreas dysfunction, appears to be the _____
maximal bicarbonate concentration
after direct stimulation by secretin
Decreased ____activity in stool is a test to detect severe exocrine pancreatic insufficiency (EPI) in patients with chronic pancreatitis and cystic fibrosis.
fecal elastase-1 (FE-1)
FE-1 levels >200 μg/g are normal, levels of 100–200 μg/g are considered mild-moderate EPI, and levels <100 μg/g are severe EPI
leading cause of acute pancreatitis
gallstones
Alcohol is the second most common cause, responsible for 15–30% of cases in the United States
A faint blue discoloration around the umbilicus (______ sign) may occur as the result of hemoperitoneum, and a blue-red-purple or greenbrown discoloration of the flanks (____ sign) reflects tissue breakdown of hemoglobin from severe necrotizing pancreatitis with hemorrhage
Cullen’s (C for Center)
Turner’s (T for tabi)
Effect of arterial pH on serum amylase
Importantly, patients with acidemia (arterial pH ≤7.32) may have spurious elevations in serum amylase
This finding explains why patients with diabetic ketoacidosis may have marked elevations in serum amylase without any other evidence of acute pancreatitis.
how do you define the different morphologic features of pancreatitis?
Electrolyte abnormality assoc with acute panc
Hypocalcemia occurs in ~25% of patients, and its pathogenesis is incompletely understood
most important clinical finding regarding severity of the acute pancreatitis episode.
Persistent organ failure (>48 h)
if present, severe na agad
The radiographic feature of greatest importance to recognize in the late phase of acute panc is _____
development of necrotizing pancreatitis on CT imaging.
In mild acute pancreatitis, the disease is self-limited and subsides spontaneously, usually
within ___ days after onset.
3-7
most important treatment intervention for acute pancreatitis
early, aggressive intravenous fluid resuscitation to prevent systemic complications from the secondary systemic inflammatory response.
Rate of IV infusion in px with acute pancreatitis
Intravenous fluids of lactated Ringer’s or normal saline are initially bolused at 15–20 mL/kg (1050–1400 mL), followed by 2–3 mL/kg per hour (200–250 mL/h), to maintain urine output >0.5 mL/kg per hour.
Serial bedside evaluations are required every 6–8 h to assess vital signs, oxygen saturation, and change in physical examination to optimize fluid resuscitation
In px with acute panc, a rise in hematocrit or BUN during serial measurement should be treated with
a repeat volume challenge with a 2-L crystalloid bolus followed by increasing the fluid rate by 1.5 mg/kg per hour
What constitutes BISAP
The Bedside Index of Severity in Acute Pancreatitis (BISAP) incorporates five clinical and laboratory parameters obtained within the first 24 h of hospitalization—BUN >25 mg/dL, impaired mental status (Glasgow coma scale score <15), SIRS, age >60 years, and pleural effusion on radiography—that can be useful in assessing severity
What factors in acute panc is associated with increased rsk fo in hospital mortality
The presence of three or more of these factors (BISAP) was associated with substantially increased risk for in-hospital mortality among patients with acute pancreatitis.
In addition, an elevated hematocrit >44% and admission BUN >22 mg/dL are also associated with more severe acute pancreatitis
Patients with evidence of ascending cholangitis (rising white blood cell count, increasing liver enzymes) should undergo ERCP within ____ (duration) of admission.
24–48 h
Serum triglycerides >___ mg/dL are associated with acute pancreatitis
1000
most common presenting symptoms of autoimmune panc
Jaundice, weight loss, and new-onset diabetes
treatment for autoimmune pancreatitis
Patients typically respond dramatically to glucocorticoid therapy within a 2- to 4-week period. Prednisone is usually administered at an initial dose of 40 mg/d for 4 weeks followed by a taper of the daily dosage by 5 mg per week based on monitoring of clinical parameters
The secretin test becomes abnormal when ≥___% of the pancreatic exocrine function has been lost
60
Treatment for exocrine pancreatic insufficiency
For adult patients with exocrine pancreatic insufficiency, it is generally recommended to start at a dosage of 25,000–50,000 units of lipase taken during each meal; however, the dose may need to be increased up to 100,000 units of lipase depending on the response in symptoms, nutritional parameters, and/or pancreas function test results.
Additionally, some may require acid suppression with proton pump inhibitors to optimize the response to pancreatic enzymes. Monitoring nutritional parameters such as fat-soluble vitamins, zinc levels, body weight, and periodic bone mineral density measurement should be considered.
Hereditary pancreatitis (PRSS1) is a rare form of pancreatitis with early age of onset that is typically associated with familial aggregation of cases. A genome-wide search using genetic linkage analysis identified the hereditary pancreatitis gene on chromosome __
7
Definition of binge drinking
4 drinks for women and 5 drinks for men in ~2 h (1 drink equals ~14 g of ethanol, which
is 1 beer, 4 oz of wine, or 1 oz of 80% spirits)
Factors for Progression of Alcohol-Associated Liver Disease
Patients with alcoholic hepatitis have been drinking heavily for typically >___ years and until at least __ weeks before onset of symptoms
5
8
Patients with alcoholic hepatitis have AST and ALT elevations that do not exceed ___ IU/L, with AST/ALT ratio of >1.5 and serum bilirubin >__ mg/dl
400
3
Liver stiffness <6 kPa indicates normal liver, whereas cutoffs for each stage of alcohol-associated liver fibrosis have been validated (>__ kPa indicates ≥F3 advanced fibrosis; >__ kPa indicates F4 cirrhosis).
8
12.5
Patients with MDF <___ or MELD ≤___ are defined as having moderate alcoholic hepatitis
32 (Dirty 2; sounds like 32 )
20
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.
How do you diagnose NAFLD?
Diagnosing NAFLD requires demonstration of increased liver fat in the absence of hazardous levels of alcohol consumption
gold standard for establishing the severity of liver injury and fibrosis
Liver biopsy has been the gold standard for establishing the severity of liver injury and fibrosis because it is both more sensitive and more specific than these other tests for establishing NAFLD severity
FDA approved tx for NAFLD
None
OHAS that may be used in NASH px with T2DM or obesity
. Both incretin mimetics and SGLT2 inhibitors can be used in NASH patients with type 2 diabetes or obesity (conditions for which the drugs have an FDA-registered indication for use); however, they are not currently approved specifically for the treatment of NASH.
Drug/ supplement that may be used as first line for non DM non cirrhotic NASH patients
vitamin E should only be considered as a first-line pharmacotherapy for nondiabetic, noncirrhotic NASH patients who are at low risk for cardiovascular disease or prostate cancer.
T/F
There is no evidence to suggest that statins cause liver failure in patients with any chronic liver disease, including NAFLD
True
The total daily basal secretion of hepatic bile is ~____ mL.
500–600
The normal bile acid pool size is ~___g.
2–4
The normal capacity of the gallbladder is ~___ mL.
30
Most impt mechanism of gallstone formation
The most important is increased biliary secretion of cholesterol.
rate-limiting enzyme of hepatic cholesterol synthesis
(HMG-CoA) reductase
Pigment stones are more commonly seen in which subsets of patients
They are more common in patients who have chronic hemolytic states (with increased conjugated bilirubin in bile); cirrhosis, especially related to alcohol; Gilbert’s syndrome; or cystic fibrosis
most specific and characteristic symptom of gallstone disease
biliary colic
Biliary colic begins quite suddenly and may persist with severe intensity for 30 min to 5 h, subsiding gradually or rapidly
An episode of biliary pain persisting beyond 5 h should raise the suspicion of acute cholecystitis
Patients with very large gallstones (>__ cm in diameter) and patients harboring gallstones in a congenitally anomalous gallbladder might also be considered for prophylactic cholecystectomy
3
Dose of UDCA for stone dissolution
The dose of UDCA should be 10–15 mg/kg per day
In carefully selected patients with a functioning gallbladder and with radiolucent stones <10 mm in diameter, complete dissolution can be achieved in ~50% of patients within 6 months to 2 years
Most commonly isolated organisms in acute cholecystitis
The organisms most frequently isolated by culture of gallbladder bile in these patients include Escherichia coli, Klebsiella spp., Streptococcus spp., and Clostridium spp
Imaging modality that may be used as confirmatory test for acute cholecystitis
The radionuclide (e.g., HIDA) biliary scan may be confirmatory if bile duct imaging is seen without visualization of the gallbladder
rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the CBD, resulting in CBD obstruction and jaundice
Mirizzi’s syndrome
Organisms commonly isolated in emphysematous cholecystitis
Bacteria most frequently cultured in this setting include anaerobes, such as Clostridium welchii or C. perfringens, and aerobes, such as E. coli
Patients with uncomplicated acute cholecystitis should undergo early elective laparoscopic cholecystectomy, ideally within ____ h after diagnosis
48-72
the presence of a palpably enlarged gallbladder suggests that the biliary obstruction is secondary to an underlying malignancy rather than to calculous disease is based on what law
Courvoisier’s law
CBD stones should be suspected in any patient with cholecystitis whose serum bilirubin level is >_____
85.5 μmol/L (5 mg/dL)
Serum bilirubin levels ≥342.0 μmol/L (20 mg/dL) should suggest the possibility of neoplastic obstruction
Initial tx of choice for IgG4 asssociated cholangitis
Glucocorticoids
Tx for primary sclerosing cholangitis
There is no proven medical therapy for PSC. Therapy to treat pruritus associated with PSC includes cholestyramine, rifampin, and naltrexone. Antibiotics are useful when bacterial cholangitis complicates the clinical picture. Vitamin D and calcium supplementation may be used as initial therapy to help prevent the loss of bone mass frequently seen in patients with chronic cholestasis.
A unique form of hemolytic anemia (with spur cells and acanthocytes) called ____ syndrome can occur in patients with severe alcoholic hepatitis
Zieve’s
treatment of choice for patients with decompensated cirrhosis due to Primary biliary cholangitis
liver transplant
Ursodeoxycholic acid (UDCA) is the first-line treatment that has some degree of efficacy by slowing the rate of progression of the disease
______ antibodies are present in ~95% of patients with Primary biliary cholangitis
Antimitochondrial
Pruritus from Primary biliary cholangitis is treatmed with _________
Pruritus is treated with antihistamines, narcotic receptor antagonists (naltrexone), and rifampin.
One autoantibody, the _____ , is positive in ~65% of patients with PSC
perinuclear antineutrophil cytoplasmic antibody (pANCA)
Definitive dx for primary sclerosing cholangitis
The definitive diagnosis of PSC requires cholangiographic imaging.
treatment of choice for patients with decompensated cirrhosis due to Primary sclerosing cholangitis
also liver transplant
A dreaded complication of PSC is the development of cholangiocarcinoma, which is a relative contraindication to liver transplantation.
unlike it PBC, A study of high-dose (28–30 mg/kg per d) UDCA found it to be harmful
How do you diagnose hemochromatosis?
. Diagnosis is made with serum iron studies showing an elevated transferrin saturation and an elevated ferritin level, along with abnormalities identified by HFE mutation analysis.
Treatment is straightforward, with regular therapeutic phlebotomy
Portal hypertension is defined as the elevation of the hepatic venous pressure gradient (HVPG) to >____
5 mmHg
There is usually an initial stage of compensated cirrhosis with HVPG between 5 and 10 mmHg that can be asymptomatic and last for ≥10 years, but when clinically significant portal hypertension develops (HVPG ≥10 mmHg), there is substantial risk of decompensation with variceal bleeding, ascites, or hepatic encephalopathy
. Cardiac ascites can be identified by SAAG >___ g/dL and ascites protein >____g/dL
> 1.1
2.5
When the SAAG is <1.1 g/dL, infectious or malignant causes of ascites should be considered. When ascitic fluid protein is very low, <1.5 g/dL, patients are at increased risk for developing SBP
Max dose of furo and spirono for ascites
maximum of 400 mg/d and furosemide to 160 mg/d of spironolactone
After LVP of ≥5 L, IV 25% albumin at a dose of ~_ g/L of removed ascites should be given to prevent circulatory dysfunction.
8
Complication associated with TIPS
TIPS is often associated with an increased frequency of hepatic encephalopathy
In patients who develop azotemia in the course of receiving diuretics in the management of their ascites, some will require repeated large-volume paracentesis (LVP), some may be considered for transjugular intrahepatic portosystemic shunt (TIPS), and some would be good candidates for liver transplantation.
Presumed mechanism for the development of SBP
Bacterial translocation is the presumed mechanism for development of SBP, with gut flora traversing the intestine into mesenteric lymph nodes, leading to bacteremia and seeding of the ascitic fluid
Most common organisms assoc with SBP
The most common organisms are Escherichia coli and other gut bacteria; however, gram-positive bacteria, including Streptococcus viridans, Staphylococcus aureus, and Enterococcus spp., can also be found
If more than two organisms are identified, secondary bacterial peritonitis due to a perforated viscus should be considered.
How do you diagnose SBP?
The diagnosis of SBP is made when the fluid sample has an absolute neutrophil count >250/μL
Treatment for SBP
Treatment is commonly with intravenous third-generation cephalosporin for 5 days.
In addition, intravenous albumin (1.5 g/kg body weight on day and 1.0 g/kg on day 3) has been shown to reduce the risk of renal failure and to improve survival.
What is the antibiotic prophylaxis of choice to preventrecurrent SBP
In patients with variceal hemorrhage, the frequency of SBP is significantly increased, and prophylaxis against SBP is recommended when a patient presents with upper GI bleeding. Furthermore, in patients who have had an episode (or multiple episodes) of SBP and recovered, quinolone antibiotic prophylaxis should be given to prevent recurrent SBP
The best therapy for HRS is _______
liver transplantation
Mainstay treatment for hepatic encephalopathy
lactulose, a nonabsorbable disaccharide, which results in colonic acidification
The goal of lactulose therapy is to promote two to three soft stools per day.
More recently, rifaximin at 550 mg twice daily has been very effective in preventing recurrent encephalopathy
Recommended kcal and protein in px with cirrhosis
General recommendations include multiple small meals including a late evening snack with total calories of 25–30 kcal per kg of ideal body weight per day and 1.2–1.5 g of protein per kg of ideal body weight per day
Among patients with acute liver failure, ______ is the most common cause
drug-induced liver injury (DILI)
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
Treatment for toxic/drug induced hepatic dse
Treatment is largely supportive, except in acetaminophen hepatotoxicity (for which N-acetylcysteine is effective
Fatal fulminant disease is usually (although not invariably) associated with ingestion of ≥__ of acetaminophen.
25 g
Blood levels of acetaminophen correlate with severity of hepatic injury (levels >___ μg/mL 4 h after ingestion are predictive of the development of severe damage; levels <___μg/mL suggest that hepatic injury is highly unlikely).
300
150
Nausea, vomiting, diarrhea, abdominal pain, and shock are early manifestations occurring 4–12 h after ingestion. Then 24–48 h later, when these features are abating, hepatic injury becomes apparent. Maximal abnormalities and hepatic failure are evident 3–5 days after ingestion, and aminotransferase levels exceeding 10,000 IU/L are not uncommon
in chronic alcoholics, the toxic dose of acetaminophen may be as low as __ g, and alcoholic patients should be warned specifically about the dangers of even standard doses of this commonly used drug
2
Dose of NAC for acetaminophen toxicity
Routine use of N-acetylcysteine has substantially reduced the occurrence of fatal acetaminophen hepatotoxicity. N-acetylcysteine may be given orally but is more commonly used as an IV solution, with a loading dose of 140 mg/kg over 1 h, followed by 70 mg/kg every 4 h for 15–20 doses.
treatment can be stopped when plasma acetaminophen levels indicate that the risk of liver damage is low.
What constitutes the Rome IV criteria for IBS?
pain is a key symptom for the
diagnosis of IBS.
most consistent clinical feature in IBS.
Alteration in bowel habits
The most common pattern is constipation alternating with diarrhea, usually with one of these symptoms predominating.
Organisms implicated in post infectious IBS
The microbes involved in the initial infection are Campylobacter, Salmonella, and Shigella
T/F
Nocturnal diarrhea may be a presentation of IBS
False
In patients with persistent diarrhea not responding to simple antidiarrheal agents, a _____ should be performed to rule out microscopic colitis.
sigmoid colon biopsy
In those age >40 years, an air-contrast barium enema or colonoscopy should also be performed
Treatment for IBS-diarrhea
When diarrhea is severe, especially in the painless diarrhea variant of IBS, small doses of loperamide, 2–4 mg every 4–6 h up to a maximum of 12 mg/d, can be prescribed.
Antibiotic that may be effective in IBS px
Neomycin and Rifaximin
Rifaximin is the only antibiotic with demonstrated sustained benefit beyond therapy cessation in IBS patients
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
Rectum is spared in UC or CD?
CD
Unlike UC, which almost always involves the rectum, the rectum is often spared in CD
earliest lesions in chron’s dse
aphthoid ulcerations and focal crypt abscesses with loose aggregations of macrophages, which form noncaseating granulomas in all layers of the bowel wall
Fecal acute phase reactants used in the management of IBD
Fecal lactoferrin, a glycoprotein present in activated neutrophils, is a highly sensitive and specific marker for detecting intestinal inflammation.
Fecal calprotectin is present in neutrophils and monocytes, and levels correlate well with histologic inflammation, predict relapses, and detect pouchitis.
Both fecal lactoferrin and calprotectin are becoming an integral part of IBD management and are used frequently to rule out active inflammation versus symptoms of irritable bowel or bacterial overgrowth
Fecal calprotectin is a more sensitive marker of ileocolonic or colonic inflammation rather than isolated ileal inflammation.
Toxic megacolon is defined as a transverse or right colon with a diameter of >__ cm, with loss of haustration in patients with severe attacks of UC.
6
Most common site of inflammation in Chron’s dse
Ileum
Because the most common site of inflammation is the terminal ileum, the usual presentation of ileocolitis is a chronic history of recurrent episodes of right lower quadrant pain and diarrhea
Treatment of choice for abscess associated with Chron’s dse
CT-guided percutaneous drainage of the abscess is standard therapy.
Autoantibodies associated with CD and UC
Increased titers of anti–Saccharomyces cerevisiae antibody (ASCA) have been associated with CD, whereas increased levels of perinuclear antineutrophil cytoplasmic antibody (pANCA) are more commonly seen in patients with UC
What treatment for IBD is associated with paradoxical worsening of colitis?
5-ASA eg. sulfasalazine, mesalamine
Dose of glucocorticoids for IBD
The majority of patients with moderate to severe UC benefit from oral or IV glucocorticoids.
Prednisone is usually started at doses of 40–60 mg/d for active UC that is unresponsive to 5-ASA therapy. Parenteral glucocorticoids may be administered as hydrocortisone, 300 mg/d, or methylprednisolone, 40–60 mg/d
Glucocorticoids are also effective for treatment of moderate to severe CD and induce a 60–70% remission rate compared to a 30% placebo response
Treatment for IBD that is/are associated with acute pancreatitis
Although azathioprine and MP are usually safe, pancreatitis occurs in 3–4% of patients, typically presents within the first few weeks of therapy, and is completely reversible when the drug is stopped
The toxicity of these drugs may be further increased in px who lack thiopurine methyltransferase
The highest risk for thiopurine-associated lymphoma is in patients >___years old actively using thiopurines
65
High-risk patients with CD who are more likely to require biologics include those who are ________
<30 years old, with extensive disease, perianal or severe rectal disease and/or deep ulcerations in the colon, and stricturing or penetrating disease behavior
Treatment for IBD associated with inc risk of melanoma
Anti-TNF tx
Also assoc with risk of new onset psoriaform skin lesions
Before starting anti TNF tx for IBD, these tests should be requested
Patients should have a purified protein derivative (PPD) or a QuantiFERON-TB Gold test before initiation of anti-TNF therapy.
Hep B testing
Additional test for natalizumab: anti JCV since associated with PML
Indications for surgery in IBD
Treatment for IBD that may be used for pregnant px
Sulfasalazine and all mesalamines are safe for use in pregnancy and nursing with the caveat that additional folate supplementation must be given with sulfasalazine. Topical 5-ASA agents are safe during pregnancy and nursing. Glucocorticoids are generally safe for use during pregnancy and are indicated for patients with moderate to severe disease activity
The safest antibiotics to use for CD in pregnancy for short periods of time (weeks, not months) are ampicillin and cephalosporins. Metronidazole can be used in the second or third trimester
Mercaptopurine and azathioprine pose minimal or no risk during pregnancy
How long should methotrexate be discontinued before conception?
MTX is teratogenic and should be discontinued at least 3 months before conception
In px with IBD Annual or biennial colonoscopy with multiple biopsies is recommended for patients with >____ years of extensive colitis (greater than one-third of the colon involved) or ____ years of proctosigmoiditis (less than one-third but more than just the rectum) and has been widely used to screen and survey for subsequent dysplasia and carcinoma
8–10
12-15
The only non RNA virus among the hepatitis viruses
HBV
After a person is infected with HBV, the first virologic marker detectable in serum within 1–12 weeks, usually between 8 and 12 weeks, is ______
HBsAg
Circulating HBsAg precedes elevations of serum aminotransferase activity and clinical symptoms by 2–6 weeks and remains detectable during the entire icteric or symptomatic phase of acute hepatitis B and beyond
Why is there no HbcAg ?
Because HBcAg is intracellular and, when in the serum, sequestered within an HBsAg coat, naked core particles do not circulate in serum, and therefore, HBcAg is not detectable routinely in the serum of patients with HBV infection. By contrast, anti-HBc is readily demonstrable in serum, beginning within the first 1–2 weeks after the appearance of HBsAg and preceding detectable levels of anti-HBs by weeks to months
During the “gap” or “window” period of Hep B infection, ____ may represent the only serologic evidence of current or recent HBV infection
anti-HBc
The appearance of this serologic marker coincides temporally with high levels of virus replication and reflects the presence of circulating intact virions and detectable HBV DNA
HbeAg
During early chronic HBV infection, HBV DNA can be detected both in serum and in hepatocyte nuclei, where it is present in free or episomal form. This relatively highly replicative stage of HBV infection is the time of maximal infectivity and liver injury; ____ is a qualitative marker and ____ a quantitative marker of this replicative phase, during which all three forms of HBV circulate, including intact virions.
HbeAg
HBV DNA
Currently available, third-generation immunoassays, which incorporate proteins from the ______ regions , detect anti-HCV antibodies during acute infection
core, NS3, and NS5 regions
Which Hep virus has the histologic lesion that is often remarkable for a relative paucity of inflammation?
HCV
In hepatitis __, a common histologic feature is marked cholestasis
E
High-Risk Populations for Whom HBV Infection Screening Is Recommended
T/F
Breast-feeding does not increase the risk of HCV infection between an infected mother and her infan
True
High-Risk Populations for Whom HCV-Infection
Screening Is Recommended
T/F
The titer of HBsAg bears is correlated to the severity of clinical disease
False
Principal usefulness of HbeAg
Its principal clinical usefulness is as an indicator of relative infectivity
A false-positive test for IgM anti-HBc may be encountered in patients with high-titers of _____ factor
rheumatoid factor
Assays for ____ are the most sensitive tests for HCV infection and represent the “gold standard” in establishing a diagnosis of hepatitis C
HCV RNA
HCV RNA can be detected even before acute elevation of aminotransferase activity and before the appearance of anti-HCV in patients with acute hepatitis C.
Determination of HCV RNA level is NOT a reliable marker of disease severity or prognosis but is helpful in predicting relative responsiveness to antiviral therapy.
Serology of Acute hepatitis B (HBsAg below detection threshold)
The most feared complication of viral hepatitis is ________________
is fulminant hepatitis (massive hepatic necrosis)
Fulminant hepatitis is seen primarily in hepatitis B, D, and E, but rare fulminant cases of hepatitis A occur primarily in older adults and in persons with underlying chronic liver disease, including, according to some reports, chronic hepatitis B and C
clinical and laboratory features suggest progression of acute hepatitis to chronic hepatitis
The following clinical and laboratory features suggest progression of acute hepatitis to chronic hepatitis: (1) lack of complete resolution of clinical symptoms of anorexia, weight loss, fatigue, and the persistence of hepatomegaly; (2) the presence of bridging/interface or multilobular hepatic necrosis on liver biopsy during protracted, severe acute viral hepatitis; (3) failure of the serum aminotransferase, bilirubin, and globulin levels to return to normal within 6–12 months after the acute illness; and (4) the persistence of HBeAg for >3 months or HBsAg for >6 months after acute hepatitis.
Hb3Ag,
HbsAg –> S for six months
After acute HCV infection, the likelihood of remaining chronically infected approaches ___ %
85-90
Among cirrhotic patients with chronic hepatitis C, the annual risk of hepatic decompensation is ___
~4%
The annual rate of hepatocellular carcinoma in patients with chronic hepatitis D and cirrhosis is ~___%
3%
For POSTexposure prophylaxis of intimate contacts (household, sexual, institutional) of persons with hepatitis A, the administration of ___ mL/kg is recommended as early after exposure as possible; it may be effective even when administered as late as __ weeks after exposure
0.02
2
For hepatitis A, A vaccination, PRExposure prophylaxis for travel consists of IG at doses of ___ mg/kg for travel durations up to 1 month, ___ mg/kg for travel up to 2 months, and repeat 0.2 mg/kg every 2 months thereafter for the remainder of travel
0.1
0.2
However, for travel to an endemic area, hepatitis A vaccine NOT Ig is the preferred approach to preexposure immunoprophylaxis and provides long-lasting protection (protective levels of anti-HAV should last at least 20 years after vaccination)
HAV vaccination schedule
0,6-12
HBV vaccination schedule
For perinatal exposure of infants born to HBsAg-positive mothers, a single dose of HBIG, ___ mL, should be administered IM in the thigh immediately after birth, followed by a complete course of three injections of recombinant hepatitis B vaccines approved for children to be started within the first ___ of life
0.5
12h
.For those experiencing a direct percutaneous inoculation or transmucosal exposure to HBsAg-positive blood or body fluids (e.g., accidental needle stick, other mucosal penetration, or ingestion), a single IM dose of HBIG, ___ mL/kg, administered as soon after exposure as possible, is followed by a complete course of hepatitis B vaccine to begin within the first week.
0.06
For persons exposed by sexual contact to a patient with acute hepatitis B, a single IM dose of HBIG, ____ mL/kg, should be given within ___days of exposure, to be followed by a complete course of hepatitis B vaccine
0.06
14
Specifically, for hemodialysis patients, annual anti-HBs testing is recommended after vaccination; booster doses are recommended when anti-HBs levels fall to <___ mIU/mL.
10
T/F
IG is ineffective in preventing hepatitis C and is no longer recommended for postexposure prophylaxis in cases of perinatal, needle stick, or sexual exposure
True
eTwo safe and effective three-dose (0, 1, and 6 months), recombinant genotype ___ capsid protein vaccines, which protect against other genotypes as well, have been shown in randomized, placebo-controlled trials to be highly protective against symptomatic acute hepatitis E
1
____, a validated algorithm based on such routine lab tests as (AST and ALT) levels and platelet counts (PLT) (age [years] × AST/PLT × ALT1/2); and imaging determinations of liver elasticity
FIB-4
The likelihood in a patient with HBeAg-reactive chronic hepatitis B of converting spontaneously from relatively replicative to nonreplicative infection is ~___% per year
10
most important risk factor for the ultimate development of cirrhosis and HCC in both HBeAg-reactive (beyond the early decades of “relatively nonreplicative” infection) and HBeAg-negative patients
level of HBV replication
1st line agents for chronic hep b infection
Of the eight approved treatments, PEG IFN, entecavir, and the two tenofovir preparations (TDF and TAF) are recommended as first-line agents, and generally, the oral agents are favored over injectable PEG IFN
Long-term monotherapy with lamivudine was associated with what mutation/s for hep b
Long-term monotherapy with lamivudine was associated with methionine-to-valine (M204V) or methionine-to-isoleucine (M204I) mutations, primarily at amino acid 204 in the tyrosine-methionine-aspartate-aspartate (YMDD) motif of the C domain of HBV DNA polymerase, analogous to mutations that occur in HIV-infected patients treated with this drug
Treatment for chronic hep c that may be given 1x a week
PEG IFN
In patients treated with PEG IFN, HBeAg and HBsAg responses have been associated with IL28B (now renamed IFN lambda-3, IFNL3) genotype __, the favorable genotype identified in trials of PEG IFN for chronic hepatitis C
CC
most potent of the HBV antivirals
Entecavir
just as well tolerated as lamivudine
What is the advantage of TAF vs TDF in chronic hepatitis
Tenofovir alafenamide (TAF) is a prodrug of tenofovir that requires activation to tenofovir in hepatocytes. This targeted delivery to hepatocytes allows a lower dose to suffice and reduces systemic exposure by 90%, thereby minimizing TDF-associated proximal tubular renal injury, its associated phosphate wasting, and the potential consequent loss of bone mineral density
The dose of TAF is 25 mg, which is equivalent in antiviral potency to 300 mg of TDF
TAF is recommended by AASLD and EASL over TDF in chronic hep patients with crea clearance < ___ ml/min, reduced bone density, and risk factors for renal injury
50
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?
When can you stop giving antivirals for HbeAg positive chronic hep b infected individuals?
Per current AASLD recommendations, antiviral treatment with oral agents can be stopped after HBeAg seroconversion in NONcirrhotics, and the suggested period of consolidation therapy is 12 months with close monitoring for recurrent viremia (monthly × 6, then every 3 months for the rest of a year) after cessation of therapy
When can you stop giving antivirals for HbeAg negative chronic hep b infected individuals?
For patients with HBeAg-negative chronic hepatitis, the current recommendation with oral agents is for indefinite therapy; stopping therapy in this group can be considered after HBsAg loss
so if negative na from the start, indefinite tx
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 × 103 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
why shuld you not use lamivudine as monotherapy in px with HBV-HIV infection ?
Lamivudine should never be used as monotherapy in patients with HBV-HIV infection because HIV resistance emerges rapidly to both viruses
A distinguishing serologic feature of chronic hepatitis D is the presence in the circulation of antibodies to ____
liver-kidney microsomes (anti-LKM)
however, the anti-LKM seen in hepatitis D, anti-LKM3, are directed against uridine diphosphate glucuronosyltransferase and are distinct from anti-LKM1 seen in patients with autoimmune hepatitis and in a subset of patients with chronic hepatitis C
mnemonic: 3D
the only approved drug for hepatitis D
standard IFN-α is the only approved drug for hepatitis D
best prognostic indicator in chronic hepatitis C
liver histology
Immune complex–mediated extrahepatic complications of chronic hepatitis C are less common than in chronic hepatitis B , with the exception of __________
essential mixed cryoglobulinemia
Patient variables that correlated with better response to IFN therapy for Chronic hep C
Patient variables that correlated with IFN-based SVRs included favorable genotype (genotypes 2 and 3 as opposed to genotypes 1 and 4; genotype 1b as opposed to genotype 1a); low baseline HCV RNA level (<800,000 IU/mL), low HCV quasispecies diversity, and histologically mild hepatitis and minimal fibrosis, especially absence of cirrhosis; immunocompetence; low liver iron levels; age <40; female gender; and absence of obesity, insulin resistance, type 2 diabetes mellitus, and hepatic steatosis.
most pronounced ribavirin side effect is ________
most pronounced ribavirin side effect is hemolysis, often requiring dose reduction or addition of erythropoietin therapy
What antiviral for chronic hep c has efficacy in all genotypes
Sofosbuvir has efficacy in all genotypes (1–6); in treatment-naïve subjects and prior nonresponders to PEG IFN–based and protease-inhibitor-based therapy; with PEG IFN–ribavirin or in IFN-free regimens; in combination with ribavirin or with NS5A inhibitors (see below); and for treatment periods as brief as 8–12 week
What are the standard indications for therapy of chronic HCV infection?
Cardiac problem assciated with sofosbuvir containing regimens
All sofosbuvir-containing regimens can be associated with severe bradycardia in patients taking the antiarrhythmic agent amiodarone, especially along with beta blockers; sofosbuvir-containing combinations are contraindicated with amiodarone
Prior to treating chronic HCV, what should be determined first?
Prior to therapy, HCV genotype should be determined, because the genotype contributes to decisions about which treatment regimens are indicated
Difference between Type 1 Autoimmune hepatitis vs Type 2
Type I autoimmune hepatitis is the classic syndrome prevalent in North America and northern Europe occurring in young women, associated with marked hyperglobulinemia, lupoid features, circulating ANAs, and HLA-DR3 or HLA-DR4 (especially B8-DRB1* 03). Also associated with type I autoimmune hepatitis are autoantibodies against actin and atypical perinuclear antineutrophilic cytoplasmic antibodies (pANCA).
Type II autoimmune hepatitis, often seen in children, more common in Mediterranean populations, and linked to HLA-DRB1 and HLADQB1 haplotypes, is associated not with ANA but with anti-LKM. . In type II autoimmune hepatitis, the antibody is anti-LKM1, directed against cytochrome P450 2D6.
mainstay of management in autoimmune hepatitis
glucocorticoid tx
Although some advocate the use of prednisolone, prednisone is just as effective and is favored by most authorities. Tx may be initiated at 20 mg/d, but a popular regimen in the US relies on an initiation dose of 60 mg/d. This high dose is tapered successively over of a month down to a maintenance level of 20 mg/d.
An alternative, but equally effective, more appealing approach is to begin with half the prednisone dose (30 mg/d) along with azathioprine (50 mg/d). With azathioprine maintained at 50 mg/d, the prednisone dose is tapered over the course of a month down to a maintenance level of 10 mg/d.
For Shigella, enterohemorrhagic Escherichia coli, Giardia lamblia, or Entamoeba, as few as ____ bacteria or cysts can produce infection, while ____ Vibrio cholerae organisms must be ingested to cause disease
10–100
10^5 −10^8
Pathogens that cause diarrhea via enterotoxin
Pathogens that cause diarrhea via cytotoxin
major mechanism for clearance of bacteria from the proximal small intestine
normal peristalsis
People with blood group ___ show increased susceptibility to disease due to V. cholerae, Shigella, E. coli O157, and norovirus
O
the most common travel-related infectious illness
traveler’s diarrhea
The time of onset is usually 3 days to 2 weeks after the traveler’s arrival in a resource-poor area; most cases begin within the first 3–5 days. The illness is generally self-limited, lasting 1–5 days. The high rate of diarrhea among travelers to underdeveloped areas is related to the ingestion of contaminated food or water
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
Individuals with hypogammaglobulinemia are at particular risk of ______ which may cause diarrhea
C. difficile colitis and giardiasis
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).
