Gastroenterology

Question 0

EGD is procedure of choice for:

Answer 0

eval odynophagia,to determine presence of peptic ulcer
upper GI bleed workup, always before PUD surgery, w/up for GERD with failed tx, eval ingested foreign body, persistent dyspepsia, dysphagia-after barium swallow

Question 1

contraindications to GI endoscopy

Answer 1

recent MI
combative pt
intestinal perforation

Question 2

ERCP - endoscopic retrograde cholangiopancreatography, after this procedure

Answer 2

• 60% have increased amylase

* 5-20% develop acute pancreatitis

Question 3

before ERCP in patient with suspected bile duct obstruction

Answer 3

treat with antibiotics prior to ERCP

Question 4

indications for ERCP

Answer 4

• find otherwise undetectable common bile duct stone
• find cause of pancreatic duct obstruction
• dx chronic pancreatitis
• to r/o primary sclerosing cholangitis(MRCP is better tho)
• to tx choledoccholithisis with cholangitis

Question 5

ERCP is contraindicated in ACUTE pancreatitis EXCEPT in these conditions

Answer 5

• impacted gallstones

* ascending cholangitis-(bacterial infection causing cholangitis)

Question 6

MRCP-magnetic resonance cholangiopancratography is used to

Answer 6

• dx chronic pancreatitis
• assess lack of clinical improvement in acute pancreatitis
• test of choice for primary sclerosing cholangitis

Question 7

endoscopic ultrasonography-u/s probe put thru biopsy port of endoscope.
used to evaluate

Answer 7

• pancreatic diseases
• biliary duct dz when ERCP contraindicated:gallstone pancratitis, pregnancy
• to confirm MRCP findings

Question 8

dysphagia is

Answer 8

swallow that for any reason does not proceed in normal fashion

Question 9

odynophagia is

Answer 9

pain with food bolus passage

Question 10

3 categories/causes of dysphagia

Answer 10

• transfer disorders
• anatomic or structural disorders
• motility disorders

Question 11

transfer disorders causing dysphagia

Answer 11

*neurologic deficit-CVA,ALS
see difficulty transfer food from mouth to esophagus, causing oropharyngeal muscle dysfunction
*symptoms: cough, gag, nasal regurg, immediate upon swallow

Question 12

motility disorders causing dysphagia

Answer 12

problem in transport food from upper esophagus to stomach

• failure of effective peristalsis &/or failure of LES relaxation
• endogenous and exogenous causes

Question 13

dysphagia-always do

Answer 13

work up! do not do just empiric treatment

Question 14

dysphagia work up

Answer 14

Barium swallow first test
EGD if needed is done after barium swallow-except in patient with hx reflux and slight -moderate dysphagia to Solids-high likely this is stricture from chronic reflux
*esoph. manometry only if barium and EGD were negative

Question 15

achalasia

Answer 15

*neuronal denervation & gangion cell degeneration=> no organized peristalsis in esophageal body and LES increased pressure and does not relax with swallowing

Question 16

achalasia-characeristic features in patient history

Answer 16

• dysphagia to solids and liquids
• LONGSTANDING symptoms-years
• regurg of food, especially at night
• no age or gender predilection

Question 17

achalasia-dx tests in this order

Answer 17

• barium swallow: dilated esophagus-often fluid filled.see “bird beak” narrowing distally due to LES tight
• EGD:use to confirm dx and r/o tumor
• esophageal manometry:last test to confirm dx

Question 18

pseudoachalasia and secondary achalasia

Answer 18

*tumor at esophagogastric junction
*consider if: onset of symptoms RAPID
patient > age 60
symptoms progressive and see profound weight loss

Question 19

complications of achalasia

Answer 19

• aspiration pneumonia

* weight loss

Question 20

Tx achalasia

Answer 20

• pneumatic dilation at LES opening
• surgical myotomy
• botulism toxin every 6-12 months-good in high risk patient
• calcium blockers and nitrates-only temporary partial relief

Question 21

diffuse esophageal spasm

Answer 21

“irritable bowel of the esophagus”

• simultaneous, non peristaltic contraction of esophagus
• often precipitated by cold or carbonated liquids
• symptoms: dysphagia, atypical CP

Question 22

diffuse esophageal spasm

Dx and Tx

Answer 22

Dx: barium swallow-usually normal but can see classic “corkscrew”, manometry confirms diagnosis, EGD not helpful
Tx: reassurance, if needs rx-1st line:diltiazem or imipramine

Question 23

anatomical obstruction of esophagus

Answer 23

*see slowly progressive dysphagia, first to solids then to liquid
* symptoms can be intermittant or constant
YOUNG-usually schatzki ring
OLDER-cancer or stricture

Question 24

schatzki ring-lower esophageal ring, is always assoc with

Answer 24

hiatal hernia

Question 25

classic history of patient with schatzki ring

Answer 25

* very slow progression of intermittent solid food dysphagia- esp to meat, bread * may have hx of regurgitaion of impacted bolus for relief

Question 26

schatzki ring, Dx & Tx

Answer 26

barium swallow-ring 13mm or less in diameterr to cause symptoms Tx:dilation then PPI

Question 27

symptoms of esophageal stricture

Answer 27

slow progression constant solid food s

Question 28

causes of esophageal stricture

Answer 28

* #1: long hx inadeq tx reflux * prolonged NG tube * lye ingestion decades prior-these pt also incr risk esophageal cancer

Question 29

esophageal stricture Dx & Tx

Answer 29

dx-barium swallow:narrowing-usually esophagogastric junction | Tx-dilation

Question 30

history of dysphagia in malignant esophageal obstruction-either esophageal malignancy or compression from non-esophageal ca

Answer 30

rapid progression of symptoms | dysphagia: solid>soft foods>liquids

Question 31

plummer-vinson syndrome

Answer 31

* rare * dysphagia due to a web in the cervical esophagus * see in females with iron def anemia- unknown why * slight incr risk of esophageal cancer

Question 32

dysphagia due to neurologic dysfunction (CVA,parkinsons, ALS,MS,bulbar palsy) see symptoms

Answer 32

*dysphagia to solid & liquids from the ONSET

Question 33

aspiration due to dysphagia

Answer 33

* can occur with any type dysphagia * usually well tolerated and no tx unless pulmonary problems * s/s:choking,gag,cough, nasal regurg * trach usually does not cure, may need PEG * eval with video swallow study

Question 34

scleroderma

Answer 34

shiny hard thick skin

Question 35

systemic sclerosis

Answer 35

when scleroderma also involves internal organs * #1 most common conn. tissue dz of esophagus * weak or absent peristalsis of esoph, & LES is wide open * severe reflux and damage from it. * polymyositis & dermatomyositis can do same as above

Question 36

Eosinophilic (allergic) esophagitis

Answer 36

* chronic inflammatory disorder, Involves IL-5, most incr IgE * most in males, 30% have peripheral eosinophils * main symptom:recur attacks dysphagia with food impaction

Question 37

eosinophilic esophagitis : EGD findings, Dx, Tx

Answer 37

EGD: classic SCALLOPED appearance with ridges or rings in esophagus Dx: biopsy >20eos/hpf in MIDesophagus biopsy Tx: difficult, allergy testing and avoid allergens,fluticasone BID or viscous budesonide, PPI if reflux present

Question 38

odynophagia

Answer 38

painful swallowing

Question 39

most common causes of odynophagia

Answer 39

pill induced esophagitis | opportunistic infections-candida, HSV, CMV-tx cause,if no improvement do EGD w biopsy

Question 40

Most common drugs that can cause pill induced odynophagia

Answer 40

*esp if take with little water or before lying down *doxycycline, KCL,ASA,NSAIDS *iron,alendronate,quinidine **dx made by hx alone (abrupt onset and taking the med) Tx-stop med, reassure and educate pt

Question 41

GERD due to

Answer 41

inappropriate transcient relaxation of LES | hiatal hernia often present

Question 42

suspect GERD if

Answer 42

* nocturnal cough,frequent sore throat * hoarse,laryngitis,clearing throat * loss of dental enamel * exac of asthma * vocal cord dysfunction

Question 43

GERD assoc with these 2 respiratory disorders

Answer 43

* Asthma-even if no s/s GERD,PPI may improve asthma in some but recent study did not show improved asthma control with GERD tx * vocal cord dysfxn:spasm of vocal cords assoc inspir stridor-wheeze at night

Question 44

vocal cord dysfunction seen in

Answer 44

GERD | young pt in competitive sports: more stress rxn in most but 10% of exercise induced asthma in likely misdiagnosed VCD

Question 45

Dx GERD

Answer 45

if only heartburn trial PPI, EGD if fails to control symptoms-62% will have normal esophagus (non-erosive reflux dz)

Question 46

ALARM signals in GERD patient-they need EGD

Answer 46

* N/V, dysphagia, odynophagia * blood in stool, wt loss, anorexia, anemia, abnl phys exam * family hx PUD, long duration of symptoms (esp white male >45) * fail full dose PPI * suspect barretts

Question 47

Indications for 24 hour esophageal pH monitor

Answer 47

* atypical cases of GERD * refractory symptoms and normal EGD * failure of response to PPI * hoarse,cough, atyp CP, and no classic symptoms of GERD

Question 48

severe GERD (grade 2 or worse esophagitis)

Answer 48

PPI tx indefinately or corrective surgery

Question 49

in pt w GERD symptoms that dont respond to PPI, look for these meds that cause delay gastric emptying causing reflux

Answer 49

* calcium channel blockers * antihistamines * tricyclics * anticholinergics

Question 50

indications for antireflux surgery

Answer 50

* refractory to medical tx * young pt with severe dz * need for longterm PPI - outcome best in those that respond to PPI, 60% p surg need PPI - must do motility study pre op-poor peristalsis-post op dysplasia

Question 51

Barrett esophagitis

Answer 51

* change cell type from squamous>metaplasia * highest risk:heartburn>10yr,>age 50, white male * if chronic GERD: 10%male, 2% female have barretts. large # pt have barretts but no GERD symptoms

Question 52

Barretts assoc with only this type cancer

Answer 52

* adenocarcinoma | * PPI and antireflux surgery never change to cellular changes of Barretts

Question 53

risk of adenocarcinoma in barretts

Answer 53

0.4% per year in pt w barretts | risk relates to: length of the barretts changes, presence of hiatal hernia, degree of dysphagia, **concurrent smoking**

Question 54

Monitoring of barretts or those at risk

Answer 54

* 2 EGD w Bx within 1 year, if both neg for dysplasia, reck 3 yrs * if low grade dysplasia Bx #1, reck within 6 mo,, if no higher dysplasia on this bx, do yearly until no dysplasia on 2 consecutive yearly EGD w Bx

Question 55

if high grade dysplasia on a EGD w Bx

Answer 55

* repeat EGD w Bx within 3 month * any bx w high grade and mucosal irreg>endoscopic resection * if 3 mo bx w high grade again but no mucosal irregularity, 3 ways to handle: 1. resection 2. reck EGD w bx every 3 month 3. radiofreq ablation c freq EGD follow ups

Question 56

2 types of esophageal cancer

Answer 56

adenocarcinoma | squamous cell

Question 57

adenocarcinoma of esophagus

Answer 57

slightly >50% of cancers distal 1/3 of esophagus assoc w Barretts

Question 58

squamous cell of esophagus

Answer 58

slight <50% proximal 2/3 of esophagus causes: smoking, alcohol-these have synergistic carcinogenic(NOT additive),head & neck cancers, achalasia, lye stricture, Plummer-vinson syndrome,strong assoc diet & environ

Question 59

dx esophageal cancer

Answer 59

barium swallow then EGD w bx | CT scan and endoscopis U/S to stage

Question 60

tx esophageal cancer

Answer 60

* small & localized: surgical resection | * large or metastasized:combo chemotherapy + radiation prior to surgery-2 year survival 38%

Question 61

zenker diverticulum

Answer 61

outpouch of upper esophagus #1cause of transfer (trouble initiating swallow) dysphagia to solid foods *s/s: foul breath, regurg food eaten several days prior,often elderly Tx-surgery

Question 62

stomach physiology

Answer 62

G cells in pyloric antrum-incr pH & amino acid from food brkdown>G cell releases gastrin>that acts on parietal cells in fundus>secretes HCL(gastric acid)via proton pump gastrin>enterochromaffin like cells (ECL) produce histamine-local effect via H2 receptors of parietal cells(paracrine) acetylcholine from vagus nerve (neurocrine) w direct effect on parietal cells

Question 63

parietal cells are affected by

Answer 63

endocrine (gastrin) neurocrine (acetylcholine) paracrine (histamine)

Question 64

inhibitors of gastrin

Answer 64

somatostatin & secretin | *decr pH> stim these (negative feedback) to regulate pH

Question 65

achlorhydria patients (autoimmune gastritis) or those with pernicious anemia, or if PPI tx leads to achlorhydria

Answer 65

gastrin levels skyrocket due to loss of inhibitory effect, can see gastrim levels >500

Question 66

gastric acid and pepsin(made from pepsinogen in presence of acid)

Answer 66

digest food and also attack mucosal defenses

Question 67

dyspepsia

Answer 67

recurrent upper abdominal pain or discomfort

Question 68

s/s dyspepsia

Answer 68

epigastric fullness belch,bloating gnawing pain (not severe) heartburn

Question 69

causes of dyspepsia

Answer 69

* most functional * meds:ASA NSAIDS iron * if

Question 70

gastritis, classified by

Answer 70

histology or etiology

Question 71

histologic classifications of gastritis

Answer 71

* acute gastritis-superficial-neutrophil infiltrate * atrophic gastritis- medications, lymphocytes * gastric atrophy-late, gastropathy

Question 72

etiology classification of gastritis

Answer 72

Type A: autoimmune,atrophic,pernicious anemia,achlorhydria * affects proximal stomach (body and fundus) * autoantibodies against both intrinsic factor & parietal cells-progress to pernicious anemia & achlorhydrea w secondary hypergastrinemai and gastrin level >1000

Question 73

Type B gastritis

Answer 73

*most common - 80% of chronic gastritis-due to H pylori

Question 74

H pylori is linked to

Answer 74

* gastritis, PUD * gastric adenocarcinoma * gastric B cell lymphoma (MALT)

Question 75

medications that require gastric acid for best absorption

Answer 75

* thyroxine * itraconazole, ketoconazole **fluconazole does NOT * 50% AIDS pts have decr stomach acid w incr rate of itraconazole failure

Question 76

erosive gastropathy

Answer 76

* not inflam response so is not a gastritis | * assoc: NSAID, alcohol, severe physiologic stress-ICU,surgery,burns

Question 77

SRMD-stress related mucosal damage causes and prevention

Answer 77

* causes: ICU,burns,CNS injury, surgery, vent,coagulopathy * prevent: H2 block, antacid, PPI, early feedings * *Most effective: continuous infusion H2 receptor antagonist-NO increased risk of aspiration pneumonia

Question 78

when to test for H pylori

Answer 78

* any hx PUD-esp duodenal ulcer * current EGD w ulcer,erosive gastritis or duodenitis * if MALT lymphoma is present * family hx gastric cancer * test & treat: dyspepsia pt

Question 79

Gold standard H pylori test

Answer 79

biopsy with histology of antral mucosa on EGD

Question 80

h pylori test that is good to check active disease and response to treatment

Answer 80

urease test (CLO and rapid urease tests) * 95% sens & specificity * less accurate if on antibiotic or PPI

Question 81

non invasive H pylori tests

Answer 81

* urea breath tests-first choice to check effectiveness of H.pylori tx-need to be of PPI for 2 week prior to test * fecal antigen tests-good for primary dx, best test if on PPI to test effectiveness of treatment * serologic-dont use, poor for checking effectiveness of tx

Question 82

H pylori treatment

Answer 82

* triple drug -2 antibiotic (biaxin & amox) & PPI | * in US, flagyl less effective due to resistance

Question 83

universal post treatment testing of H pylori is not recommended unless:

Answer 83

* hx H pylori assoc ulcer * persistent dyspepsia symptoms * H pylori assoc MALT lymphoma * resection of early gastric carcinoma * * test no sooner than 4 weeks after finish treatment

Question 84

4 causes of peptic ulcer disease

Answer 84

* #1: H pylori-if irradicated, ulcer does not recur * NSAIDS * high acid secreting states-Zollinger * crohn dz of duodenum/stomach

Question 85

NSAID induced peptic ulcer disease

Answer 85

* 10-40% of patients taking med, many small & no s/s * gastric & duodenal ulcers * if has and needs NSAID: enteric coated NSAID,nonacetylaed ones-salsalate; non acidic ones-relafen, PPI or cytotec, COX2

Question 86

risk factors for NSAID PUD

Answer 86

*first 3 mo of use, high dose, elderly, Hx PUD/UGI bleed,heart dz, concurrent steroids, serious illness, concurrent ASA

Question 87

smoking and PUD

Answer 87

* exaccerbate duodenal and gastric ulcers * decreases healing rates * increase recurrance and perforation rates

Question 88

Do Not cause ulcers

Answer 88

* alcohol | * corticosteroids

Question 89

EGD in PUD if:

Answer 89

* assoc dysphagia or odynophagia * follow up healing gastric ulcer * UGI bleed * foreign body * family hx duodenal ulcers * abnl UGI or CT scan

Question 90

perforated gastric and duodenal ulcers

Answer 90

* often free air in peritoneal space-do upright abd films * pain is usually severe * EGD & UGI are CONTRAINDICATED

Question 91

absense of an ulcer crater means

Answer 91

there is no risk of hemorrhage, perforation or scarring

Question 92

tx of nonbleeding PUD

Answer 92

* H pylori treatment * decrease acid secretion-H2, PPI * stop smoking, NSAIDS

Question 93

indications for surgery in PUD

Answer 93

* #1: UGI bleed-unable to stop endoscopically * gastric outlet obstruction w failed balloon dilation * perforation * recur/refractory ulcers * Z-E syndrome-to remove gasrinoma

Question 94

causes duodenal ulcers

Answer 94

* NSAIDS * H pylori * Z-E syndrome

Question 95

causes of gastric ulcers

Answer 95

NOT H pylori assoc * tx PPI x 3mo as slower to heal * all non healing ones need EGD w at least 6 bx samples to r/o ca

Question 96

bleeding peptic ulcers

Answer 96

* #1cause: NSAID * bleed risk is dose related * incr risk NSAID->age 60, female * no perfectly safe dose ASA * risk bleed on COX2-close to nl pt but if also ASA same as NSAID

Question 97

dx & tx emergently for UGI bleed

Answer 97

EGD

Question 98

EGD finding that increase chance of rebleed

Answer 98

* larger size of ulcer * visible vessels on non-bleeding ulcer (incr risk to 50% rebleed) * visible clot (0%)

Question 99

ulcer with clean base-no bleed, no clot, no visible vessels

Answer 99

very low chance of rebleed

Question 100

tx bleeding peptic ulcer

Answer 100

* initial if active bleed, adherent clot, or visible vessel= combo injection epinephrine, saline,alcohol then either thermal or laser coagulation or hemoclip * incr gastric pH >6: bid dosing PPI IV or po

Question 101

treatments that do not work for bleeding peptic ulcer

Answer 101

* gastric lavage | * IV vasoconstrictors

Question 102

non ulcer causes of UGI bleeds

Answer 102

* osler-weber-rendu:hereditary hemorrhagic telangiectasia * AVM-usually stomach, duodenum * Peutz-Jegher syndrome-hamartomatous polyps stomach to rectum (see dark melanin spots lips, buccal mucosa, hand/feet)

Question 103

Zollinger Ellison syndrome

Answer 103

gastrinoma-produce gastrin continuously *refractory ulcers-duodenal bulb & stomach * s/s: ulcers, #1presentation-diarrhea, +/- steatorrhea 90% in "ZE triangle":porta hepatis,mid duod.,head pancreas *80% sporadic, 20% assoc MEN type I

Question 104

consider Z-E in patient with

Answer 104

* severe esophagitis and chronic diarrhea * ulcer and chronic diarrhea * duodenal ulcer + big folds stomach d/t parietal cell hyperplasia * recur ulcer and no risk factors * post bulbar duodenal ulcers

Question 105

dx and tx of Z-E syndrome

Answer 105

Dx: gastrin level off PPI, if increase gastrin: do abd CT, endoscopic U/S, somatostatin receptor imaging Tx: surg exploration, 1/3 cured by primary tumor resect,even c mets, resect to decr mass effect PPI at higher doses and long erm

Question 106

conditions assoc with high gastrin levels

Answer 106

* Z-E syndrome * vitiligo *gastric carcinoids * renal failure, hyperthyroidism * achlorhydria due to PPI use * chronic type A gastritis

Question 107

gastric carcinoid

Answer 107

rare,due to chronic hypergastrinemic states(but not shown due to PPI increased gastrin level) * usually not metastatic or symptomatic * almost never causes carcinoid syndrome * autoimmune gastritis,pern anemia, ZE,MEN I,spontaneous

Question 108

4 types of gastric cancer

Answer 108

* carcinoid * adenocarcinoma 95% * lymphoma * GIST-gastrointestinal stromal tumor(leiomyosarcoma)

Question 109

risk factors assoc with gastric cancer

Answer 109

* chronic H pylori * chronic metaplastic atrophic gastritis * menetrier dz-lg intest folds due to epith. cell hyperplasia * adenomatous gastric polyps

Question 110

acanthosis nigrans

Answer 110

* usually d/t obesity & insulin resistance | * can be due to various GI and lung cancers (gastric ca mostly)

Question 111

MALT-lymphoma

Answer 111

* due to H pylori * dx-EGD w bx * when tx H pylori-MALT may resolve

Question 112

alcohol and gastric ulcers do not cause

Answer 112

cancer

Question 113

tx gastric cancer

Answer 113

* surg resection w adjacent lymph nodes | * adjuvant combo chemo prolongs survival

Question 114

Postgastrectomy syndromes

Answer 114

* dumping syndrome * blind loop syndrome * afferent loop syndrome

Question 115

post gastrectomy dumping syndrome

Answer 115

* postprandial vasomotor symptoms:palpitation,sweating,lighthead * early type:30" after eat, unclear etiology * late type: 90" or more after eating-due to hypoglycemia * tx both-restrict sweets & lactose, small freq meals

Question 116

post gastrectomy blind loop syndrome

Answer 116

* bacterial overgrowth in a loop * manifests: fat & B12 malabsorption * low D-xylose absorption test

Question 117

post gastrectomy afferent loop syndrome

Answer 117

* at bypass site, afferent loop still has bile and pancreatic fluids flow * abd bloating and pain 20-60" after eating * vomiting often relieves symptoms& see bile colored emesis

Question 118

gastroparesis in diabetes

Answer 118

more in type I * longterm DM.slow gastric emptying>incr blood sugar levels due to delay of insulinemic and glycemic response to carbs * motor dysfxn w N/V, early saity, predisp to bezoars

Question 119

causes of gastroparesis

Answer 119

* autonomic: diabetes, amyloid neuropathy * infiltrative process of smooth muscle:scleroderma,amyloidosis * other:CNS-stress,parkinson,tumor,MS; spinal cord injury or ganglion problem - post vagotomy

Question 120

work up and tx gastroparesis

Answer 120

* w/up: r/o obstruction first, confirm dx w radioisotope labeled solid meal * tx; hydration, nutrition, tight glycemic control, metoclopramide or emycin liguid

Question 121

inflammatory bowel disease comprised of

Answer 121

crohns | ulcerative colitis

Question 122

common factors with inflam bowel dz

Answer 122

* family at incr risk of dz * incr risk of GI cancer-esp UC * toxic megacolon-complication-barium enema contraindicated if acute exac of the dz

Question 123

smoking assoc with IBD

Answer 123

increase risk-crohns | decrease risk-ulcerative colitis

Question 124

Tx IBD

Answer 124

* sulfasalazine-split by bacteria in colon>mesalamine (ineffective if small bowel involved) * mesalamine (5-ASA):colon dz-rectal enema, proctitis-suppository, oral form for distal ilium/colon * metronidazole-perianal abscess&fistula in crohn, combo w 5asa in chrone * budesonide - use specifically for small bowel crohns * 6 mercaptopurine & azathioprine(metab to 6MP)-prednisone sparing drug-use both dz * remicade, humira,cimzia-monoclonal ab to TNF-a

Question 125

drugs that decrease relapse rate in crohns

Answer 125

``` azathioprine 6 MP MTX remicade *smoking cessation decreases relapse ```

Question 126

drugs that decrease relapse rate in ulcerative colitis

Answer 126

all standard drugs | **stopping smoking increases relapses

Question 127

crohns

Answer 127

* any age, most 20-30 and smaller peak 70-80s * increase risk GI cancer, esp after 20yrs of dz * screen longterm pts every other year for cancer * more indolent than UC so less responsive to tx, hard to get off steroids-osteoporosis common

Question 128

crohn dx

Answer 128

biopsy of ulcer pathognomonic | patchy, focal,apthous ulcers & deep transmural ulcers with occ. strictures, fistulas, granulomas

Question 129

Tetrad for crohns colitis

Answer 129

* skip lesions * perirectal disease * rectal sparing * contiguous ileocolic disease

Question 130

"string sign"

Answer 130

classic but uncommon see on small bowel follow thru for crohns, lumen is edematous and fibrotic so contrast appears as string *if see elsewhere in colon "apple core"lesion=suggests cancer

Question 131

bowel involvement in crohns

Answer 131

30%colon only 40% small bowel only 30% both

Question 132

in 15% of IBD-definate dx cant be made and these labs can help

Answer 132

P-ANCA assoc with ulcerative colitis ASCA-(anti saccharomyces antibody) assoc crohns

Question 133

problems related to crohns resection of terminal ileum (not UC)

Answer 133

* calcium ox kidney stones * pigment gallstones * B12 def, hypocalcemia-due to Vit D malabsorption * bile acid induced diarrhea * nutrient malabsorption

Question 134

surgery in crohns

Answer 134

* only for intractable dz and serious complicationa * the worse the dz where surgery is the more likely recur at that site * colectomy & ileostomy-best result for crohn colitis with no ileal inflammation , >60% no recurrence

Question 135

ulcerative colitis

Answer 135

* uniform,continuous mucosal inflam w shallow ulcers * always starts rectum and extends proximally * area of unvolvement usually remains the same * 70% are pANCA +, ESR & CRP usually elevated * main symptoms:abd pain, bloody diarrhea

Question 136

extraintestinal manifestations of Uc (can see in crohns of colon)

Answer 136

* E.nodosum, pyoderma gangrenosum * peripheral polyarthritis,ankylosing spondylitis * iritis,episcleritis, uveitis * venous thrombosis * pericholangitis, primary sclerosing cholangitis

Question 137

cancer in UC

Answer 137

risk high 0.5% per year | increase risk with duration of UCand extent of UC-pancolitis high, if only proctitis-no increased risk

Question 138

colonoscopy in UC

Answer 138

usually after 10 years of UC, then every 1-3 years

Question 139

tx of UC

Answer 139

complete colectom-cures, not done routinely | medical tx as with crohns with good response rates, 30% remission in 2 mo of tx

Question 140

indications for complete colectomy in UC

Answer 140

* dysplasia on bx in mass lesion or highgrade in flat lesion * intractable dz, perforation, growth retardation in kid * toxic megacolon, stricture * steroid dependence, exsanginating hemorrhage * complication from therapy

Question 141

diarrhea definition

Answer 141

>200-250gm/day of stool * normal 150-180 gm/d, small volume, loose stool not diarrhea * acute 4wks

Question 142

acute diarrhea -causes

Answer 142

* usually infectious-invasive or non-invasive * food poisoning * drug side effect

Question 143

acute diarrhea work up

Answer 143

* diet & travel hx * check fecal leukocytes-+in invasive, if + do:C&S

Question 144

tx acute diarrhea

Answer 144

* invasive:general -bactrim, campylobactor-macrolide,amebiasis-flagyl * salmonella-no abx- they prolong the illness * Ecoli 0157:H7-abx are contraindicated

Question 145

chronic diarrhea

Answer 145

* stool total osmolality=serum osm in all types * secretory diarrhea * osmotic diarrhea * increased motility diarrhea

Question 146

secretory diarrhea

Answer 146

*stool often >1 liter/day,risk electrolyte deficiency *causes: enterotoxin,e coli, cholera,s.aureus villous adenoma, gastrinoma, bile acids. VIPomas microscopic colitis, collagenous colitis *24-48h fast doesnt decr it except w fatty acid & bile acid diarrhea

Question 147

osmotic diarrhea

Answer 147

* serum osm >50 gap * due to nonabsorbable osmotic agent * 24h fast resolves the diarrhea, if persists after fast suspect ingestion of magnesium antacid

Question 148

common causes of osmotic diarrhea

Answer 148

* #1 lactase deficiency * Mg++containing laxatives and antacid-esp castor oil * poorly absorb.CHO-lactulose,sorbitol, fructose * nutrient malabsorption:pancreatic insuff,celiac dz,bacterial overgrowth

Question 149

diarrhea due to increased motility

Answer 149

causes: antibiotic assoc (not c diff)-emycin hyperthyroidism carcinoid irritable bowel

Question 150

chronic loose stools

Answer 150

<200g/d lactase deficiency IBS

Question 151

laxative abuse

Answer 151

* urine for bisacodyl,anthraquinones, phenolphthalein * stool osmotic gap >100 - Mg+ containing * stool measurement of phosphate & sulfate * if stool osm is low, pt could be adding water or urine to stool

Question 152

causes of malabsorption

Answer 152

* decreased small bowel mucosal transport-something wrong with intestinal uptake * decreased digestion-not enough digestive enzymes

Question 153

Big 6 labs for work up of malabsorption

Answer 153

(low values of below labs) * calcium, cholesterol, carotene * serum iron * albumin * prolonged PT

Question 154

decreased mucosal transport causes of malabsorption

Answer 154

* celiac dz,tropical sprue * common variable immune deficiency w hypogammaglobulinemia * whipple dz, intestinal lymphoma * eosinophilic gastroenteritis, bacterial overgrowth * other small bowel disease

Question 155

Celiac disease (celiac sprue, nontropical sprue)

Answer 155

* common, 1% populaton,d/t gluten-wheat,barley,rye * autoimmune intestinal disorder>villous atrophy>malabsorption * can cause growth retardation * assoc HLA DQ2 & DQ8

Question 156

extraintestinal manifestations of celiac disease

Answer 156

* #1-iron def anemia-low hgb,MCV, ferritin * abnormal serum aminotransferases * dermatitis herpetiformis * osteoporosis,osteomalacia * neuro psych, dental enamel defect,prim. intestinal lymphoma

Question 157

deficiencies caused by celiac disease

Answer 157

* iron * folic acid * calcium * vit D & B12

Question 158

4 requirements for dx celiac disease

Answer 158

* evidence of malabsorption-steatorrhea,wt loss,iron def anemia * +antiendomysial Ab or +tissue transglutaminase AB * positive response to gluten free diet * abnormal small bowel biopsy

Question 159

do antibody test for celiac disease in patient with these presentations

Answer 159

* 16 y/o with bipolar * 33 y/o with bone pain spine/legs * 28 y/o with purulent papalovesicular eruptions * 30 y/o anemia w low hgb,MCV,Ferritin

Question 160

only disorder assoc with low ferritin

Answer 160

iron deficiency

Question 161

collagenous sprue

Answer 161

unusual, possible celiac variant | *bx small bowel:flat mucosa w large masses of subepithelial eosinophilic hyaline material in lamina propria

Question 162

tropical sprue

Answer 162

* found equatorial areas * probably infectious etiology * often pt w megaloblastic anemia * tx-bactrim x 3-6 months, folic acid alone or w abx

Question 163

Whipple disease

Answer 163

* rare,<1000 cases,d/t tropheryma whippelii gm+ actinomycele * cardinal tetrad: arthralgia (#1), abd pain,wt loss, diarrhea * severe malabsorption w marked decr albumin & neuro s/s * Dx: EGD w sm bowel bx:foamy macrophages, PAS + * Tx:pcn or roceph IV x14d then bactrim x 1 year

Question 164

eosinophilic gastroenteritis

Answer 164

* N/V/D, abd pain,wt loss, albumin wasting,iron def anemia * often see eosinophilia on CBC (r/o strongyloides that can cause eosinophilia * tx: corticosteroids x 6wks and avoid causative foods

Question 165

short bowel syndrome

Answer 165

* occurs after massive bowel resection * if <100cm sm bowel left-may need TPN for life * tx;low fat diet, vitamins

Question 166

malabsorption d/t decreased digestion 2main causes

Answer 166

pancreatic insufficiency | bile acid deficiency

Question 167

pancreatic insufficiency

Answer 167

* chronic pancreatitis,pancreatic cancer, cystic fibrosis * see undigested muscle fibers in stool exam * confirm: + response to tx w pancreatic enz, or d-xylose absorp * do CT scan to r/o pancreatic cancer if >age 55

Question 168

bile acid deficiency

Answer 168

*ileal resection >100cm,or ileal dz or dz that decreases bile acid uptake, severe liver dz, ZE syndrome, bacterial overgrowth

Question 169

best indicator of malabsorption

Answer 169

steatorrhea >14g/d of fecal fat * sudan stain stool-best screening for fat * gold standard-3 day quanitative fecal fat

Question 170

steatorrhea due to pancreatic insufficiency

Answer 170

>40 g/d fecal fat

Question 171

Irritable bowel syndrome

Answer 171

* 15% population, female * s/s: freq sm stools w mucus, abd pain relieved by BM * Dx: exclude others-celiac, lactose intol..., look for chara s/ * Tx: *reassure,fiber,probiotics,antispasmotic, TCA, loperamide, amitiza for constipation prominent IBS

Question 172

colon cancer risk factors: * 4% lifetime risk * age >50, obesity, smoking * Hx adenomatous polyps * UC, crohns

Answer 172

* BRCA1 mutation * acromegaly * fam hx colon ca,,familial polyposis syndr, hereditary nonpolyposis colon cancer * diet high in calories and animal fat

Question 173

red flags for colon cancer

Answer 173

* anorexia, wt loss, anemia, fever, heme + stool * change in bowel habits-esp nocturnal BM * onset of symptoms after age 45

Question 174

endocarditis due to this organism is often associated with colon cancer and need work up

Answer 174

**strep bovis or clostridium

Question 175

full dose ASA helps decrease risk of

Answer 175

colon cancer

Question 176

colon adenomas with advanced features

Answer 176

*high grade dysplasia *villous histology *size >10mm *

Question 177

colon adenomas

Answer 177

*need follow up. only 1% ever become malignant but most GI cancers arise from adenomas **hyperplastic polyps <1cm -no incr risk- 10 yr follow up as normal

Question 178

guidelines colon adenomas

Answer 178

1-2 sm tubular adenoma w low grd dysplasia-re ck 5-10 years 3-10 adenoma, or 1 adenoma>1cm,any villous feature or high grade dysplagia-re ck 3 years >10 ademomas-re ck 3 years sessile w piecemeal removal-re ck 2-6 mo to verify removal

Question 179

Inherited colon cancers

Answer 179

*Familial polyposis syndrome:(all autosomal dominant) familial adenomatous polyposis, Gardner syndrome, Peutz-Jeghers syndrome, Juvenile polyposis *Hereditary nonpolyposis colon cancer: Lynch syndrome

Question 180

Familial adenomatous polyposis

Answer 180

* 100s of adenomas in colon * 100% risk of cancer if not tx * *MUST have proctocolectomy by age 20! * cont to monitor as often get duodenal cancer from polyps

Question 181

Gardner syndrome

Answer 181

* variant of familial adenomatous polyposis * 100% risk of cancer-tx same as above * often see soft tissue tumors & bone lesions - osteomas, so if see these do colonoscopy

Question 182

Peutz-Jeghers syndrome

Answer 182

* multiple hamartomatous polyps t/o small bowel, occ colorectal and stomach * melanotic pigmentation (freckles) on lips and buccal mucosa * benign tumors but 50% risk cancer by age 60

Question 183

Juvenile polyposis

Answer 183

hamartomas | *no malignant potential and no special follow up needed

Question 184

Hereditary nonpolyposis colon cancer (Lynch syndrome)

Answer 184

* definition: occur of colon ca in at least 3 1st degree relatives over at least 2 generations & one of those dx

Question 185

colon screening

Answer 185

yearly fecal occult blood testing in low risk pt but misses 1/3 of advanced cancers

Question 186

colon screening in asymptomatic pt =/> age 50 with negative family history

Answer 186

``` *colonoscopy every 10 years OR one of these every 5 years: *flex sig *double contrast BE *CT colonography ```

Question 187

adenomatous polyp on screening colonoscopy

Answer 187

re check in 3 years

Question 188

"10 year" rule for colonoscopy screening

Answer 188

*high risk patients-start 10 years earlier than age of person in family with colon cancer or age 40-whichever is first

Question 189

Indications for colonoscopy

Answer 189

* occult bleeding,iron def anemia without other explanation * gross lower GI bleed (except BRB in young person), abnl BE * adenomatous polyp, 1st degree relative w colon ca, familial syndromes,ischemic colitis,persistent diarrhea,4-8wk after onset presumed new diverticulitis, strep bovis/clostridium bacteremia

Question 190

CEA testing

Answer 190

*only for checking for recur of colon cancer and only if it was elevated before surgery and declined after surgery

Question 191

Colon cancer staging TNM

Answer 191

* stage 1: T1 cancer into submucosa,T2 into muscularis * stage 2: T3 into tissue,T4a visceral peritoneum,T4b direct invasiv * stage 3: as above plus + nodes (no mets) * stage 4: + nodes and + distant mets

Question 192

colon cancer always mets first to

Answer 192

liver via portal cirulation *exception is RECTUM-blood supply bypasses portal circulation so no liver mets

Question 193

rectal cancer metastasizes to

Answer 193

Lung, bone, brain | * not to liver

Question 194

tx colon cancer

Answer 194

* tx choice - surg resection-potential cure * radiation then surg-ONLY RECTAL cancer * adjunct chemo -only stage 3 orr locally adv 2-FOLFOX * solitary liver mets-hepatic resection-improve survival

Question 195

if remove cancerous polyp MUST do

Answer 195

bowel resection if it extends to either blood vessel or cautery line

Question 196

most common cause of colon bleed in elderly

Answer 196

* diverticular bleeding | * #2: angiodysplasia-more severe bleeding usually-us. stops spont.

Question 197

tx and dx diverticular bleed

Answer 197

* stabilize * r/o UGI source w NG aspirate or EGD * colonoscopy only if bleed doesnt stop * DX:severe or continued bleeding-colonoscopy or taged RBC scan angiography

Question 198

Indications for angiography in GI disease

Answer 198

* chronic & acute mesenteric ischemia * severe lower GI bleed * some duodenal ulcers or rare UGI bleed * TIPS in variceal bleed * tx use:embolization, vasopressin

Question 199

diverticulitis usually due to

Answer 199

microperforations

Question 200

usual s/s of diverticulitis

Answer 200

LLQ pain fever increased WBC (no bleeding)

Question 201

dx diverticulitis

Answer 201

CT most useful-thickened sigmoid colon, colic fluid **No colonoscopy

Question 202

cause of 50% all GI bleeds in children

Answer 202

Meckel diverticula- can cause obstruction & intussusception *Dx: technetium scan

Question 203

angiodysplasia and lower GI bleed

Answer 203

*usually R colon-cecum, ascending

Question 204

Hereditary hemorrhagic telangiectasis (Osler-Rendu-Weber)

Answer 204

* multiple AVM's all organs-brain,lung,skin,m membr,GI tract-esp Upper GI * * these people have history of epistaxis

Question 205

Ischemic colitis characterized by

Answer 205

abdominal pain | maroon stools

Question 206

video capsule endoscopy

Answer 206

*use when EGD & colonoscopy negative and pt has some form of GI bleeding, looks at small bowel or occult bleed

Question 207

#1 cause of small bowel obstruction

Answer 207

adhesions from prior surgery

Question 208

3 most common causes of colon obstruction

Answer 208

1-carcinoma 2-diverticulitis 3-volvulus

Question 209

dx bowel obstruction

Answer 209

*flat and upright abdominal films: excess air in small bowel and no air in colon-air fluid loops

Question 210

tx bowel obstruction

Answer 210

IVF,, NG suction. work up if not resolved 1-2 days

Question 211

4 types of intestinal ischemia

Answer 211

* ischemic colitis * chronic mesenteric ischemia * acute mesenteric ischemia * mesenteric venous thrombosis

Question 212

Ischemic colitis

Answer 212

* nonocclusive-inferior mesenteric-esp splenic flexure to sigmoid * most no specific cause * s/s:sudden LLQ pain, urge to defecate then pass red/maroon * KUB-thumbprint, DX-CT * TX:bowel rest, abx, fluids

Question 213

chronic mesenteric ischemia "intestinal angina"

Answer 213

* classic triad: wt loss, abd bruit, abd pain p meals-pain out of proportion to exam-1-3hrs of dull, gnawing pain shortly p eat * dx:symptoms, MRI or CT angiogram * Tx: surgical bypass or angioplasty

Question 214

acute mesenteric ischemia- do angiography unless perforation thenbowel resection and possible embolectomy

Answer 214

* MORTALITY 70% even with treatment-d/t acute loss of blood flow to part or all small bowel and ascending colon (emboli #1) * often chronic intestinal angina then develop acute illness w N/V/D and occult blood-bowel infarct>acidosis, incr lactate and incr amylase

Question 215

Meseneric venous thrombosis

Answer 215

* assoc with hypercoag. states * dx CT scan * tx: acute-thrombolytics & long term anticoag.

Question 216

causes of acute pancreatitis

Answer 216

* #1-alcohol abuse. #2 gallstones * ERCP,DKA,hyper TG, hyper CA+,trauma, pancr ca,CF,hereditary * drugs:valp.,hypogly,TCN,sulfa,lasix , HCTZ,estrogen,HIV meds, 5-ASA meds , azothioprine

Question 217

acute pancreatitis lab

Answer 217

amylase >3x early is usual and decr in 2-3 days of onset | lipase elevates slower but stays incr 7-1 days

Question 218

hyper TG and acute pancreatitis

Answer 218

TG>1000can cause pancreatitis but high TG can also cause a spuriously normal amylase level

Question 219

severity of pancreatitis

Answer 219

directly relates to degree of pancreatic necrosis (10% have necrosis) and whether the necrotic tissue gets infected *overall mortality 5-10%

Question 220

severe pancreatitis can cause multisystem organ failure and will likely see

Answer 220

hemoconcentration SBP130 P02 <3.2

Question 221

assessing severity of acute pancreatitis

Answer 221

* erythema of flanks-extravasated pancreatic exudates * severe necrotizing-Cullen sign-faint blue periumbil.=hemoperitoneum. Grey-Turner-blue to purple -brown discoloration flank=catabolism of hemoglobin =retroperitoneal blood dissecting along tissue planes

Question 222

scoring system for pancreatitis severity: BISAP

Answer 222

``` Bun >25 Impaired mental status SIRS Age >60 Pleural effusion ```

Question 223

SIRS-systemic inflammatory response syndrome * easy to do bedside & repeated daily * categorizes severe illnesses in general * requires 2 of the following

Answer 223

* T 38 * HR> 90 * RR >20 or PCO2 12K or 10% bands

Question 224

independent risk factors acute pancreatitis

Answer 224

BMI >30-mortality incr 2 times Hemoconcentration >44% age >75 organ failure

Question 225

pancreatic necrosis confirm with

Answer 225

dynamic CT or MRI

Question 226

Fluid/masses in acute pancreatitis

Answer 226

* acute fluid collection * necrotic tissue * infected necrosis * pseudocyst * abscess

Question 227

acute fluid collection in acute pancreatitis

Answer 227

50% within 48hr of pain onset | symptomatic transudative Left pleural effusion freq. occurs and resolve spontaneously

Question 228

necrotic tissue in acute pancreatitis

Answer 228

* onset 1-2 weeks * differentiate from pseudocyst by ultrasound * serious and may need drainage

Question 229

infected necrosis in acute pancreatitis

Answer 229

* usually need endoscopic or CT guided drainage or surgery within 2 weeks * DX: CT guided aspiraion and bacterial smear and culture

Question 230

Pseudocyst * think this in pt recovering normally from pancreatitis and suddenly gets worse

Answer 230

* develops in 10-15% * requires about 4 or more weeks after acute attack * small-spont resolve * >5 cm-may not resolve, if persists >3-6 mo surg drainage

Question 231

pseudocysts can be assoc with serious complications, they need removal if not resolving

Answer 231

* fistula * pseudoaneurysm * rupture- 15% mortality * hemorrhage w rupture-60% mortality

Question 232

abscess assoc with acute pancreatitis

Answer 232

* 4-6 wks after onset of acute with severe pancreatic necrosis * "soap Bubble" sign on upright KUB * very serious with fever and shock * Dx: CT guide aspir, immed surgical debridement and drainage

Question 233

in acute pancreatitis, if amylase is still increaed by day 10, something else is going on like:

Answer 233

leaking pseudocyst | pancreatic duct leak

Question 234

recur of pancreatitis and no hx of alcohol and no gallstones, think

Answer 234

microlithiasis and consider cholecystectomy

Question 235

gastric varices without esophageal varices ONLY occurs in

Answer 235

splenic vein thrombosis- a complication of severe acute or chronic pancreatitis

Question 236

with pancreatitis, ERCP not done acutely unless

Answer 236

sepsis or cholangitis

Question 237

criteria to resume oral feeding with pancreatitis

Answer 237

* bowel sounds present and passing gas/stool * not requiring narcotics * pt expresses hunger

Question 238

conditions that cause abdominal pain and incr amylase

Answer 238

* acute pancreatitis and cholecystitis * intestinal infarction, perforated ulcer * salpingitis, ectopic pregnancy * DKA

Question 239

causes of chronic pancreatitis

Answer 239

#1 chronic (>10 yr)alcohol abuse -70% idiopathic 30% hereditary 10% *rare: autoimmune, hyperparathyroid, cystic fibrosis

Question 240

Dx chronic pancreatitis - triad

Answer 240

*pancreatic calcification *diabetes *steatorrhea only see <20% and is late stage disease

Question 241

dx chronic pancreatitis,start with CT abdomen, positive if

Answer 241

see calcification, atrophic pancreas, dilated pancreatic duct *if CT nondiagnostic and still suspect-MRCP (preferred over ERCP) or ERCP-as MRCP doesnt cause pancreatitis as ERCP can. positive will see large duct dz , "chain of Lakes" appearance

Question 242

most sensitive test for pancreatic function

Answer 242

secretin test-not done much=complicated

Question 243

complications of chronic pancreatitis

Answer 243

* persistant and severe abd pain * 4% develop pancreatic cancer after 20 yrs of the disease * gastric varices,B12 malabsorption, jaundice,pleural effusion * brittle DM-prone to hypoglycemia-but dont get retinopathy or nephropathy unless they are alcoholic as cause

Question 244

skin condition assocc with chronic pancreatitis

Answer 244

tender red nodules due to fat necrosis-similar to erythema nodosum

Question 245

TX chronic pancreatitis

Answer 245

* pancreatic enzymes:minimun 20,000 u lipase per meal * decr dietary fat, add medium chain TG to diet * stop alcohol and smoking * short term opiods with amitryptyline if that fails, little will help

Question 246

autoimmune pancreatitis

Answer 246

*2X normal | TX: steroids

Question 247

pancreatic cancer

Answer 247

80% present with advanced disease

Question 248

risk factors for pancreatic cancer

Answer 248

* smoking 2X risk * diabetes * pancreatic cancer in two 1st degree relatives * chronic or hereditary pancreatitis

Question 249

pancreatic cancer usually presents with

Answer 249

* jaundice * abdominal pain * weight loss

Question 250

dx pancreatic cancer

Answer 250

helical CT CT angiography endoscopic ultrasound

Question 251

Tx pancreatic cancer

Answer 251

* resection-only hope for cure-whipple * chemo may incr survival few months * ERCP only use in this is to stent for biliary obstruction

Question 252

glucagonoma

Answer 252

*glucagon secreting alpha cell tumor of pancreas

Question 253

Unique clinical findings of glucagonoma

Answer 253

* scaly necrolytic erythema * persistent hyperglycemia * plasma glucagon >1000 * weight loss * anemia

Question 254

insulinoma

Answer 254

very rare | insulin secreting beta cell tumor of pancreas

Question 255

gastrinoma

Answer 255

see in Z-E syndrome, 24% occur in pancreas

Question 256

VIPoma

Answer 256

2/3 occur in pancreas >50% malignant DX: incr serum VIP level and hypokalemia

Question 257

cholelithiasis

Answer 257

usually asymptomatic not assoc with high cholesterol 80% are radiolucent cholesterol stones

Question 258

cholelithiasis assoc with

Answer 258

* obesity * OCP * clofibrate treatment * ileal disease or resection

Question 259

Dx cholelithiasis

Answer 259

* ultrasound | * HIDA-best to confirm acute cysic duct obstruction

Question 260

tx cholelithiasis

Answer 260

* surgery only if symptomatic | * in those can do surgery-ursodeoxycholic acid(oral bile acid)

Question 261

acalculous cholecystitis

Answer 261

* only see in seriously ill-major trauma,burns, surgery | * Dx-ultrasound or CT-large, tense thick GB, no stones

Question 262

common duct stone

Answer 262

* incr alk phos and bili >4 - suggests it * can see in post chole pt with persistent pain * can cause cholangitis * TX: ERCP possible endoscopic sphincterotomy

Question 263

cholestasis

Answer 263

* can be obstructive (common duct stones) or hepatocellular * both see retention of substrates that normally are released into bile * see incr LFT,incr alk phos, incr conjugated bilirubin, bilirubinuria

Question 264

cholangitis

Answer 264

* common complication of common bile duct blockage-stone or cancer * acute-see Charcots triad: biliary colic, fever/chills, jaundice

Question 265

suppurative cholangitis

Answer 265

charcot triad plus:mental confusion, bacteremia, septic shock * DX/TX: ERCP w sphencterotomy or surgery if ERCP not available. * antibiotic to cover anaerobic &aerobic - NO ROCEPHIN-can cause biliary sludge and no anaerobic coverage

Question 266

Porcelain gallbladder

Answer 266

xray-calcified outline of GB **suggests CANCER TX: open cholecystectomy needed

Question 267

primary biliary cirrhosis

Answer 267

* slow onset, etiology unknown, usually mid aged females * chara: non supperative, progressive, destructive cholangitis * some are hereditary, 70% have altered immunity * chronic bile duct inflammation>obstr. jaundice and liver cirrhosis

Question 268

Hallmark of primary biliary cirrhosis

Answer 268

90% have + antimitochondrial antibody (>1:40) | *degree of elevation does NOT correlate with disease severity

Question 269

symptoms of primary biliary cirrhosis (symptoms develop but disease is already advanced when they develop)

Answer 269

* fatigue, itching(esp palms and soles first) * high alk phos * eventual:jaundice, hyperpigmentation,inflam arthropathy, keratoconjunctivitis &/or xerostomia. accelerated osteoporosis

Question 270

prognosis of primary biliary cirrhosis

Answer 270

* about 10 yr after onset symptoms | * if bilirubin is at 10, most die shortly unless liver transplant

Question 271

Dx & Tx primary biliary cirrhosis

Answer 271

Dx: liver bx-granulomas, **high hepatic copper level Tx: urosodiol-improves LFT & decr symptoms-doesnt slow dz *Puritis-cholestyramine tx,oteomalacia-vit d and calcium. malabsorption -decr diet fat, add med chain TG *late dz-liver transplant

Question 272

Primary sclerosing cholangitis

Answer 272

*develop inflam and sclerosis of entire biliary tract>obstr jaundice>cirrhosis *indolent, cause unknown 8-15% develop cholangiocarcinoma

Question 273

90% of patient with primary sclerosing cholanitis have

Answer 273

**ulcerative colitis-**screen all with PSC with colonoscopy!! can also be seen in crohn dz of COLON **screen all patients for PSC if alk phos >2X normal average pt : male (70%), age 45

Question 274

symptoms (only in advanced dz) of PSC

Answer 274

weak, fatigue abdominal pain itching jaundice

Question 275

Dx of primary sclerosing cholangitis

Answer 275

#1:MRCP *ERCP, transhepatic cholangiography see "beaded"appearance **liver bx: "onion skin" fibrosis in portal triads

Question 276

Tx primary sclerosing cholangitis

Answer 276

liver transplant only-no ursodiol

Question 277

secondary causes of sclerosing cholangitis

Answer 277

* bacteria-stone or bile duct stricture * atypical anatomy-congenital or prior surgery * bile duct neoplasms * AIDS assoc cholangiopathy

Question 278

more specific liver enzyme

Answer 278

ALT

Question 279

alcoholic hepatitis

Answer 279

AST:ALT 3:1 | alcohol damages mitochondria which are the source of AST

Question 280

viral hepatitis

Answer 280

ALT>AST-more toxic to liverr

Question 281

NAFLD

Answer 281

ALT/AST ratio >2:1

Question 282

histologic features of acute viral hepatitis

Answer 282

* diffuse liver cell injury and swelling * increased macrophages * accelerated apaptosis-the normal programmed cell death * inflammatory periportal infiltrate

Question 283

histologic features of chronic viral hepatitis

Answer 283

* interface hepatitis - PIECEMEAL NECROSIS | * fibrosis

Question 284

if see elevated liver enzymes, order

Answer 284

* alk phos, recheck LFT * total and direct bilirubin, albumin * PT,CBC,GGT * *if still elevated, do Hep A-B-C, iron & ferritin

Question 285

since alk phos comes from bone and liver, to determine if liver do

Answer 285

GGT-it parallels alk phos form liver

Question 286

next in eval of incr LFT

Answer 286

ultrasound of abdomen | do antimtochondrial antibody of indicated

Question 287

first marker of hep B

Answer 287

HBsAg-patient producing hep B virus-acute or chronic, if + means past exposure or vaccine, usually indicates "cure"

Question 288

HBcAg

Answer 288

appears early in disease and persists for life- IgM then IgG

Question 289

best marker of previous exposure to HBV (doesnt tell if active or cured)

Answer 289

HBcAb

Question 290

HBeAg

Answer 290

* making hep B virus and highly infectious if + * appears several weeks after the illness * quantity of intact virus

Question 291

these 2 hep b markers indicate active disease and highly infective

Answer 291

HBsAg | HBeAg

Question 292

only hepatitis composed of DNA

Answer 292

hepatitis B

Question 293

incubation for hepatitis B

Answer 293

1-6 months | *window between HBsAg turning positive can be this long, must do HBcAb IgM to confirm acute Hep B

Question 294

lab marker to confirm acute Hep B

Answer 294

HBcAb IgM

Question 295

Hepatitis B is strongly assoc with

Answer 295

PAN-polyarteritis nodosa-30%

Question 296

prodrome symptoms of hep B

Answer 296

* fever, arthritis,urticaria, angioedema | * above resolve as pt develops jaundice, elevated LFT with liver swelling and tenderness

Question 297

HBIG

Answer 297

if given in hep B helps decrease severity of illness only but doesnt protect from the disease *effective prophylaxis when given early

Question 298

Hep B vaccine

Answer 298

* composed of HBsAg- 2 types of vaccine, both = effective and safe in pregnancy * give both to household contacts and partners (HBG & vaccine)

Question 299

several months after Hep B infection, check these markers to be sure not chronic Hep B state

Answer 299

* loss of HBsAg | * HBV-DNA

Question 300

chronic hep B two types of carrier states

Answer 300

* inactive carrier-if get immunocompromised can get severe disease>ie develop cancer of some type and on chemo can get active dz so drug LAMIVUDINE is given with chemo in these pts to blunt viral replecation * chronic active hepatitis

Question 301

confirm dx of chronic hep B

Answer 301

liver biopsy

Question 302

chronic hep B is

Answer 302

*serious illness *often >cirrhosis *strong assoc Hepatocellular carcinoma-20% lifelong risk is screened for with AFP and ultrasound every 6 months

Question 303

who to treat with hepatitis B

Answer 303

* all with HBV-DNA >20,000 and ALT > 2x normal * HBeAg (-) start immediate tx * new dx HBeAg (+) delay tx 3-6 mo to see if seroconvert * if cirrhosis: tx if HBV DNA >2000(compensated) or >200 (decompensated)

Question 304

tx chronic hep B

Answer 304

* interferon:35% complete remission, S/E may be severe, esp if young and wanting pregnancy * Entecavir * Lamivudine-safe in preg, high rate drug resistance * liver transplant-only end stage-tx new liver with antivirals

Question 305

Hepatitis A

Answer 305

* RNA virus,fecal-oral transmission, can be sexually transmitted * No carrier or persistant states * incubation 15-50 days * onset jaundice is 3 weeks (3 months in HepB) * vaccine 2 dose 6 mo apart age 2,mark decr risk

Question 306

DX Hepatitis A

Answer 306

* acute: high anti HAV IgM | * prior Hep A: anti HAV IgG (+) in prior disease and in vaccinated

Question 307

indications for HAV vaccine

Answer 307

* high risk sexual behavior, IVDU * all >age2 * chronic liver dz, all pt with Hep C ( If they get hep A can be fulminant) * travel to high risk countries

Question 308

Hep C

Answer 308

* ssRNA virus * #2 most common liver disease (#1 is NAFLD) * 90% transmittted prior to 1990s * #1 genotype in US: genotype 1

Question 309

those at risk for Hep C

Answer 309

* IVDU,prisioners, needlesticks * tatoo, piercings,shared razor, toothbrushes * renal dialysis personnel * snorting cocaine,high risk sex,w prostitute/STD * blood transfusion prior 1990

Question 310

Hepatitis C "Rule of 2's" (2%)

Answer 310

* US population * risk with needlestick transmission * risk neonatal transmission * risk spouse transmission * cirrhosis w hep C develop hepatocellular ca/yr (aka hepatoma)

Question 311

HIV & Hep C

Answer 311

* 30% pt with HIV are coinfected with HCV * progress faster to cirrhosis * best tx:interferon & ribavirin

Question 312

extrahepatic disease with HCV

Answer 312

* small vessel vasculitis w glomerulonepritis, neuropathy * mixed cryoglobulinemia * porphyria cutanea tarda-only assoc with hep C

Question 313

porphyria cutanea tarda

Answer 313

ONLY assoc with Hep C- so if see skin blisters-think Hep C

Question 314

Hep C serology

Answer 314

* 2-4 mo p episode hepC : check i loss of HCV RNA (PCR)to ensure hasnt become chronic * in pt HCV Ab (+), check for active virus w HCV RNA

Question 315

Chronic Hep C

Answer 315

* 70-80% acute HCV become chronic!! * hep C viral counts are lower so mor insidious nature: only 25% acute infections are symptomatic * low transmission sexually in monogamous couples: 2% after 10-20years

Question 316

chronic hep C

Answer 316

25% only carriers 50% no symptoms but abnormal LFT 25%chronic disease with symptoms-end stage cirrhosis after 20-25 yrs 1-4% of those w cirrhosis develop hepatocellular Ca / year

Question 317

screening for hepatocellular carcinoma (HCC)

Answer 317

* AFP and ultrasound of abdomen every 6 months | * same for chronic hep B , Hep C and alcoholic cirrhosis

Question 318

#1 cause of liver transplant in the US

Answer 318

chronic hep C

Question 319

55% w chronic hep C have mixed cryoglobulinemia and presents with small vessel vasculitis w "palpable purpura" crops of purple papules. also see mixed cryoglob in

Answer 319

chronic hepatitis chronic liver disease connective tissue disease

Question 320

Tx chronic hepatitis C

Answer 320

peg INF alpha injections and oral ribavirin (also decr risk HCC) * measure response to tx w HCV RNA-if no response @12 wk D/C * if (+) response, tx genotype 1 for 1 year, type 2 & 3 tx 6 months

Question 321

hepatitis E

Answer 321

* fecal/oral-water p monsoon flood. no chronic form * VERY high risk fulminent hepatitis in 3rd trimester preg-20%fatal * acute hep in traveler and negative hep A & B think E

Question 322

autoimmune chronic hepatitis

Answer 322

*insiduous onset, young female, 50% have other alt immunity *Dx:liver bx , r/o other dx with labs Tx:rapid reversal of symptoms, incr survival w prednisone +/- azathioprine(steroid sparing) **INF alpha-contraind-makes worse No cure. Px freq progress cirrhosis, some HCC, transplant endst

Question 323

drug related chronic hepatitis: *lab often +ANA,hypergammaglobulinemia TX-stop med

Answer 323

*OCP,MTX,acetaminophen, trazadone,nitrofurantoin,methyldopa,valproate,emycin,halothane,INH -but more common for it to cause acute hepatitis

Question 324

#1 cause of fulminant hepatitis in the US

Answer 324

acetaminophen toxicity

Question 325

acetaminophen toxicity

Answer 325

* metabolism:90% glucouronidation path, 5% cP450>NAPQI that is toxic intermediary that is rapidly reduced by glutathione. * w OD glutathione is depleted rapidly and toxic liver by NAPQI * w chonic acetam,alcohol,malnutr,illness, normal dose toxic as those conditions produce more NAPQI thats rapid reduced

Question 326

lab that is disproportionately high in alcoholic is

Answer 326

GGT as alcohol induces it *also see : AST/ALT ratio 3:1 AST always <300

Question 327

OCP assoc with these liver conditions

Answer 327

* benign hepatic adenoma * peliosis hepatis-blood filled sinusoids * focal nodular hyperplasia of liver * * young female on OCP w liver mass -likely adenoma

Question 328

aspirin and Reye's syndrome

Answer 328

* always

Question 329

other causes of chronic hepatitis

Answer 329

* wilson disease * alpha 1 antitrypsin defic * hemochromatosis

Question 330

Non alcoholic fatty liver disease- NAFLD aka NASH

Answer 330

* pattern opposite of alcoholic liver disease: * ALT>AST * higher fibrosis

Question 331

NAFLD assoc with

Answer 331

* obesity, diabetes, protein malnutrition, hyperlipidemia,prolonged IV * amiodarone, corticosteroids, hyperalimentation * DROP aka metabolic syndrome

Question 332

DROP- metabolic syndrome

Answer 332

* Dyslipidemia * insulin Resistance * Obesity * increased blood Pressure

Question 333

Tx NAFLD

Answer 333

* all factors can modify/ control * low fat diet * avoid alcohol

Question 334

Hepatocellular canncer - hepatoma

Answer 334

* 75% have cirrhosis, chronic liver any cause can do this * assoc with aflatoxin-in raw peanuts -esp asia * 80% incr AFP * interferon alpha tx of chronic hep C decr risk of HCC

Question 335

Hepatocellular carcinoma assoc with

Answer 335

``` tender hepatomegaly bruit in RUQ, bloody ascites incr alk phos, incr AFP, hypercalcemia, hypoglycemia, water diarrhea Fever unknown origin ```

Question 336

causes of cirrhosis

Answer 336

* #1 alcohol, Hep B or C, biliary dz, alpha 1 antitrypsin deficiency * hemochromatosis, wilson dz, schistosomiasis * post necrotic-ie drugs, toxins * severe prolonged right side CHF

Question 337

stigmata of cirrhosis

Answer 337

* hepatosplenomegaly, jaundice, ascites * caput medusae, telangiectasis, palmar erythema,fetor hepaticus * male:gynecomastia, atrophy of testes * asterixis-hepatic encephalopathy * clubbing-biliary causes of cirrhosis

Question 338

complications of cirrhosis

Answer 338

* esophageal variceal hemorrhage * hepatic encephalopathy * hepatorenal syndrome * prolonged prothrombin time

Question 339

esophageal variceal hemorrhage

Answer 339

* 1/3 w varices bleed, 1/3 of bleeds die * prophylaxis of pt with varices:propranolol w/wo isosorbide dinitrate-give to all with large varices, no prophyl. if small one * *only large varices bleed

Question 340

active variceal bleed

Answer 340

* primary tx:endoscopic band or sclerotherapy-somastatin,octreotide are splanchnic vasoconstrictors and used endoscopically. * prophylactic antibiotic to prevent SBP * prevent rebleed-propranolol or nadolol

Question 341

TIPS

Answer 341

* rare use, major complication is encephalopathy * only use in those that rebleed or for ascites d/t cirrhosis * it decompresses portal vein

Question 342

hepatic encephalopathy can be precipitated by

Answer 342

* GI bleed, hypovolemia,hypoxia * incr dietary protein * alkalosis,infection, sedatives, tranquilizers * hypokalemia

Question 343

signs of hepatic encephalopathy

Answer 343

* fetor hepaticus-unique musty odor to breath and urine * hyperreflexia * asterixis * altered mental status

Question 344

Tx hepatic encephalopathy

Answer 344

* restrict dietary protein * lactulose-in GI it inhibits bacterial growth which decr NH3 production so is inactive NH4 * neomysin or flagyl/rifampin/vanco used more now * acarboise, probiotics

Question 345

hepatorenal syndrome

Answer 345

renal failue due to renal vasoconstriction during severe, uncompensated cirrhosis * usually fatal * *urine sodium is very low in this disorder

Question 346

causes of hepatorenal syndrome

Answer 346

* diuretics, NSAIDS,aminoglycosides, IV contrast * paracentesis * GI bleed * sepsis

Question 347

Tx hepatorenal syndrome

Answer 347

careful volume management | *midodrine - (alpha 1 agonist )plus octreotide (stimulates fluid absorption from GI)

Question 348

prolonged prothrombin time in alcoholic

Answer 348

* malabsorption of vitamins, including vit K>prolonged PT | * easily corrects with vit K IM

Question 349

causes of ascites

Answer 349

* CHF,constrictive pericarditis * cirrhosis,alcoholic hepatitis, fulminent hepatitis * hepatic veno occlusive dz-incl Budd Chiari * hypoalbuminemia,chylous ascites,pseudochylos * myxedema,nephrogenic, pancreatic pseudocyst, duct obstr

Question 350

cirrhosis induced ascites

Answer 350

*acidic fluid is resorbed via peritoneal surface at a max of 900cc/d so if draw off more than that its at the expense of intravascular volume

Question 351

chylous ascites

Answer 351

*due to lymph blockage:trauma, tumors (esp lymphoma), TB, filariasis

Question 352

Dx ascites

Answer 352

peritoneal fluid analysis,cellcounts, albumin, protein

Question 353

coloration of peritoneal fluid

Answer 353

* bloody-consider tumor * cloudy-infection * milky-lymphatic obstruction

Question 354

peritoneal fluid cell count >250 PMN

Answer 354

do C & S and start antibiotic

Question 355

SAAG > 1.1 (serum ascites albumin gradient) * low albumin * portal HTN

Answer 355

* #1-cirrhosis, Budd Chiari syndrome * RHF * fulminant liver failure * myxedema

Question 356

SAAG <1.1 * high albumin * no portal HTN

Answer 356

* TB peritonitis * nephrotic syndrome * pancreatitis * peritoneal carcinomatosis

Question 357

ascites protein level = or > 2.5

Answer 357

* RHF * TB peritonitis, bacterial or fungal peritonitis * nephrotic syndrome * pancreatitis * peritoneal carcinomatosis

Question 358

ascites protein level <2.5

Answer 358

* cirrhosis, liver failure * Budd Chiari * SBP * myxedema

Question 359

spontaneous bacterial peritonitis (SBP)

Answer 359

* peritoneal fluid >250 PMN * e.coli, s.pneumoniae, klebsiella * *may NOT have abdominal pain

Question 360

ascites with any of following, consider SBP

Answer 360

* fever * new onset confusion * renal failure * hepatic encephalopathy

Question 361

risk factors for SBP

Answer 361

* acites protein <1.0 * hx variceal bleed * hx prior SBP * *those at risk need intermittent (preferred) or continuous antibiotic prophyl-Quinolone or bactrim

Question 362

initial tx of new onset ascites or with severe refractory ascites

Answer 362

* can do up to 4 liters/d if renal function normal and no gi bleed, sepsis or encephalopathy. give 8gm albumin for each liter removed with large volume paracentesis * give IV abx in life threatening ascites

Question 363

hyperbilirubinemia

Answer 363

main finding in hereditary liver dz * unconjugated bili too bound and complex too large for glomerulus * conjugated less bound to albumin and 5% unbound easily passed into urine

Question 364

bilirubinuria

Answer 364

only from conjugated hyperbilirubinemia=its an indication of cholestasis-see post op usually benign

Question 365

unconjugated bili=indirect=no bili in urine

Answer 365

see above

Question 366

Gilbert syndome

Answer 366

*7% population, chronic, benign, mild unconjugated hyperbilirubinemia, jaundice on & off due to physical stress,fasting, and alcohol ingestion *Dx:incr unconjug. bilirubin after prolonged fast Tx-none needed

Question 367

alpha 1 antitrypsin deficiency

Answer 367

*autosomal recessive *chronic hepatitis>cirrhosis *Dx: electrophoresis Tx: liver transplant-does NOT recur

Question 368

2 types of hemochromotosis

Answer 368

* acquired | * genetic

Question 369

acquired hemochromotosis

Answer 369

* due to mult blood transfusions or iron loaded chronic anemia with secondary erythroporesis (sideroblastic anemia or thalassemia) * most age 40-60

Question 370

genetic hemochromatosis

Answer 370

HFE gene, autosomal recessive

Question 371

symptomatic hemochromatosis

Answer 371

most in males (10X) due to menses in female with iron loss

Question 372

both types of hemochromotosis see increased intestinal iron absorption>

Answer 372

*deposits in tissues> fibrosis and organ damage> heart, liver,pancreas, pituitary

Question 373

clinical findings in hemochromotosis

Answer 373

* hepatomegaly 95% * gray hyperpigmentation 90% * secondary DM 65%-suspect >50y new diabetic * arthropathy-esp 2nd & 3rd MCP joint wrist 40% * secondary hypogonadism-depresses hypothal-pit axis * 30% risk HCC in pt with cirrhosis * heart involvement 15%

Question 374

Dx hemochromatosis

Answer 374

* suggested by:high iron, high ferritin, high transferrin levels * transferrin sat >45% most helpful * confirm: liver bx and staging of fibrosis **do bx ferritin >1000 * confirm hereditary type: HFE gene assay

Question 375

tx hemochromatosis

Answer 375

* if early-no cirrhosis>normal life w tx/monitoring * initial tx-weekly phlebotomies then 4x/yr * GOAL: ferritin 50-100 * most symptoms of dz return to near normal, loss of secondary sex characteristics do not return to normal

Question 376

Wilson disease

Answer 376

* autosomal recessive * present most age 15-25 * due to impaired excretion of copper into bile>excess copper in body tissue

Question 377

S/S wilson disease

Answer 377

* liver disease * neurologic/psych dysfxn in adolescent * arthritis * hemolysis * *Kayser-Flescher rings-brown corneal ring PATHOGNOMONIC

Question 378

Dx wilson disease

Answer 378

Screen: (

Question 379

wilson dz treatment

Answer 379

* Phase I: decr copper level by chelation-penicillamine *Must give pyridoxine with this drug!! or tx trientine if pen. not tol,or give zinc * Phase 2: maint w lower dose of above me * liver transplant-CURES * low copper diet

Question 380

fulminent wilson disease

Answer 380

* severe hemolytic anemia * high copper level due to release copper from liver * *Penicillamine NOT effective * ONLY TX: liver transplant

Question 381

AVOID these foods in wilsons due to high copper content

Answer 381

NO: nuts,peas,chocolate,mushrooms, shellfish,liver

Question 382

liver dz in pregnancy

Answer 382

*1st trim: hyperemesis gravidarum-mild incr AST/ALT,N/V &dehyd *2nd trim:best time for GB surg if severe symptoms *3rd trim:Hep E-fulminent hepatitis Fatty liver of pregnancy-very serious,microvasc fat deposit in liver as in Reye's syndrome

Question 383

Fatty liver of pregnancy presentation

Answer 383

* modest incr AST/ALT/bili, hypoglycemia,renal failure * encephalopathy * pre eclampsia,pancreatitis * DIC * *Must deliver the baby

Question 384

Intrahepatic cholestasis of pregnancy

Answer 384

* causes itching | * incr alk phos, incr bili, incr AST/ALT

Question 385

contraindications-absolute-to liver transplant

Answer 385

* pre-existing advanced or uncontrolled non liver disease * active drug or alcohol abuse * life-threatening systemic disease * metastatic cancer * many relative contraind-especially advanced age

Question 386

indicators seen in end stage chronic liver disease

Answer 386

* bilirubin 10-15, albumin 3-5s above normal * intractable pruritis, hepatic encephalopathy * bacterial peritonitis * intractable ascites * development of HCC

Question 387

DDX jaundice

Answer 387

* viral hepatitis, alcoholic liver dz,gallstones & complications * sickle cell dz, PBC, PSC * drug induced, chronic hepatitis, pancreatic cancer * gilbert syndrome * ascariasis-esp recent foreign travel & incr eosinophil count

Question 388

most with jaundice fall into 3 main groups

Answer 388

* acute viral hepatitis-esp

Question 389

work up of jaundice: careful history, liver panel, ultrasound with U/S results determining next step as below

Answer 389

* dilated ducts & stones: ERCP * dilated duct to pancreas & no stone: CT scan * dilated intrahepatic ducts: CT scan * dilated duct to r/o PSC: MRCP * no dilated ducts: liver biopsy

Question 390

deficiency of water soluable vitamins B,C and mg++ causes

Answer 390

* muscle stiffness and cramps | * crohns patient may see tetany

Question 391

zinc deficiency

Answer 391

* acrodermatitis | * poor wound healing

Question 392

copper deficiency

Answer 392

*hypochromic, microcytic anemia

Question 393

vit k deficiency

Answer 393

* bleeding | * prolonged PT

Question 394

selenium deficiency

Answer 394

* myalgias * cardiomyopathy * hemolytic anemia

Question 395

chromium deficiency

Answer 395

* glucose intolerance | * peripheral neuropathy

Question 396

vitamin B1 deficiency (thiamine): beriberi

Answer 396

* usually alcoholic or chronic dialysis patient * WET beriberi:heart failure,ascites,peripheral edema common * DRY:peripheral neuropathy (symmetric sensory, motor or reflex loss), wernicke encephalopathy, Korsakoff syndrome

Question 397

Wernicke encephalopathy symptoms

Answer 397

* vomiting * nystagmus * ophthalmoplegia * ataxia * mental deterioration

Question 398

Tx wernicke encephalopathy

Answer 398

* medical emergency * immed. thiamine 50mg IM or IV daily * glucose may precipitate it so see in closet drinker who comes in sick and give glucose and develop symptoms * thiamine usually cures this

Question 399

Korsakoff Syndrome symptoms

Answer 399

* confabulation * poor recent memory and learning * only 50% reversible with thiamine and only 25% fully recover

Question 400

vitamin B2 ribaflavin

Answer 400

*normocytic normochomic anemia *sore throat with hyperemic mucosa and glossitis *cheilosis, angular stomatitis *seborrheic dermatitis-esp perineal and scrotal Tx reverses symptoms

Question 401

Vit B6-pyridoxine

Answer 401

rare * general malabsorption syndromes * chronic alcoholic, Meds : INH, cycloserine, penicillamine * symptoms: seizures, vomiting, glossitis, cheilosis

Question 402

vit B12

Answer 402

* macrocytic anemia * smooth tongue * subacute,combined degen. of sp cord-initial pin-needles then decrease vibration and proprioception stocking glove * dementia

Question 403

Niacin (nicotinic acid) causes pellagra

Answer 403

not vitamin, made in body from tryptophan * is in grain so rare * see deficiency in carcinoid (uses tryptophan) and INH tx

Question 404

S/S pellegra

Answer 404

* 3 Ds: dementia, diarrhea,dermatitis * glossitis-"bald tongue". stomatitis * some may have hyperpigmentation

Question 405

vitamin C-ascorbic acid-scurvy, symptoms

Answer 405

* petechial hemorrhage and ecchymosis first then * hyperkeratotic papules around hair follicles * sjogren syndrome,hemorrhage into muscle and joint, purpura * splinter hemorrhages * child:bone formation and intracerebral hemorrhage

Question 406

vitamin A deficiency

Answer 406

* major cause of blindness in developing countries | * night blindness -earliest symptom***

Question 407

vitamin D deficiency

Answer 407

* rickets in children * osteomalacia in adults * causes decr absorb calcium from gut>decr resorp from kidney & stimulates release PTH to incr gut absorb & leech it from bone

Question 408

main causes of vit D deficiency

Answer 408

* decr production in skin-less sun exp.,elderly decr synthesis * kidney disease * decr intestinal absorption-decr dietary intake, steatorrhea

Question 409

vitamin E - antioxidant

Answer 409

rare *fat malabsorption and deficiency other fat soluble vitamins *S/S:areflexia decr vibration and position sense

Question 410

hypervitaminosis A

Answer 410

* *EATING POLAR BEAR LIVER | * chronic ingestion of 25,000u/d: arthralgia,anorexia,dry skin, hairloss, low grade fever, hepatosplenomegaly

Question 411

enteric feeding vs TPN

Answer 411

*enteric feeding is better option

Question 412

simple clues to malnutrition

Answer 412

* IBW <6 female) | * greater than 10% wt loss in 6 months

Question 413

23 yo male w intermittent dysphagia, after swallows large amount of food-esp big bite of steak.never with liquids. occurs 1-2 times a month then goes away. no active heartburn symptoms. whats next approp. test in diagnosis

Answer 413

*upper endoscopy | anatomic obstructive symptoms

Question 414

68 yo female difficulty swallowing. 4 mo ago trouble with big pieces of food,now difficult with thick liquids. 10# weight loss,due to lack appetite. no GERD. + tobacco 80 pack years.Exam normal except pale. likely etiology?

Answer 414

squamous cell carcinoma of the esophagus

Question 415

42 y/o male difficulty swallow solid food. began 3 yr ago,at first with steak large pieces not chewed well.gradual worsening needs to chew careful and lots water.no wt loss. no fever, noc sweats.no N/V or abd pain.no smoke, no alcohol. Dx?

Answer 415

peptic stricture

Question 416

28 y/o female long hx alternating diarrhea & constipation. not progressive. diffuse lower abd cramping w the loose stools. worse with stress. colonoscopy 1 yr ago normal.eats alot fast foods.exam normal. next step?

Answer 416

reassure pt and start high-fiber diet and referral for stress management clinic Irritable bowel syndrome

Question 417

30 y/o male for routine exam. no c/o.PMH -, no bad habits. dad with colon ca age 55,paternal uncle colon ca age 42, brother age 35 w mult polyps on recent colonoscopy. what to recommend?

Answer 417

colonoscopy now concern Hereditary non-polyposis (lynch) syndrome

Question 418

25 y/o female w 3 yr hx diarrhea & abd camping, worse w stress.diarrhea can wake her, tried high fiber & dicyclomine-no help. hx (-) exan -neg except some fullness and tencer RLQ.at colonoscopy, normal exc at R colon-shallow ulcers. ileum edematous w shallow ulcers. Bx-chronic inflam & ulcer. Tx

Answer 418

Dx-crohns Tx-mesalamine 400mg po TID

Question 419

60 y/o female -sudden onset cramping abd pain in lower abd assoc with passing several maroon stools. pain severe but intermittent. began 4 hours ago. no prior similar. PMH: CAD w stents. daily aspirin, no smoke x 20 yrs no alcohol. exam (-)except mild tender LLQ.lab mild edema. next test?

Answer 419

Dx-ischemic colitis Test-flex sig

Question 420

29 y/o female long hx crohns sudden onset RUQ pain during noc.pain x 1 hour now gone, no hx of similar pain. hx resection R colon & terminal ileum 7 yr ago, 5 yr ago documented recur ileum dz recur. exam normal but mild RUQ tender, labs ok. what next?

Answer 420

gallbladder ultrasound

Question 421

35 y/o/ male new diarrhea x 3 days. watery at first then bloody too. assoc abd cramps, some N/V. PMH only + for freq fast food meals. exam-mild dehydr, mild tender RLQ. Hgb 16, WBC 12k. stool studies, culture + E.coli 0157:H7, others pending. what antibiotic do recommend?

Answer 421

No antibiotic - contraindicated with this infection

Question 422

40 y/o female w chronic heartburn & diarrhea x 2 years.omeprazole some heartburn relief. 5-6 loose BM/day and some epigastric discomf. EGD grade III esophagitis, mult shallow ulcers duod. bulb and 2nd portion duodenum.what recommended?

Answer 422

order fasting serum gastrin after stopping omeprazole X 7 days Dx: Z-E syndrome

Question 423

68 y/o female c/o weakness and fatigue X 2 mo.only other symptom is DOE. Hx unremarkable . only med estrogen. exam-some paleness, stool brown and heme+ Hgb 9.6, MCV 72, liver-wnl. what to order next?

Answer 423

colonoscopy Dx iron def anemia

Question 424

36 y/o male new patient to est care. no complaints. PMH dx as teen w familial polyposis coli, his dad and brother have it also.age 20 he had total abdominal colectomy w ileorectostomy and has done well since. 4 BMs daily since the surgery. exam normal. you get flex sig-10 polyps residual rectum-adenomatous, next?

Answer 424

upper endoscopy

Question 425

24 y/o female malaise 2-3 mo. no meds,PMH (-)ros otherwise -. exam normal except + hepatomegaly and slight tender. Lab: AST 1020, ALT 1220, bili 1.0, alk phos 120.other tests come back for hepatitis screen : +HCV Ab positive, anti sm musc + 1:250,antimitochondrial antibody + 1:40. liver Bx-chronic active hepatitis. next best tx?

Answer 425

start oral prednisone and azathioprine 50mg/d Dx: autoimmune hepatitis

Question 426

60 y/o female acute RUQ pain and fever.prior episode lasting less than 30 minutes. pain now for 2 hours. No meds or PMH.exam:tender RUQ, alk phos 400, total bili 3.0, AST 120, ALT 110. ultrasound, many stones,and dilated bile duct with several apparent stones. you start antibiotic, what next?

Answer 426

ERCP-urgent Dx-acute cholangitis

Question 427

17 y/o female w chronic abd pain , colicky in RLQ.she has no weight gain for 1 year and has delayed puberty. exam-pale, thin, no secondary sex chara, abd slight distended, mild tender RLQ w palp loop of bowel, stool is heme+, w RBC & WBC. stool cultures are negative. what to do to confirm diagnosis?

Answer 427

upper and lower endoscopy with mucosa biopsy Dx: crohn disease, must have biopsy dx

Question 428

16 y/o male with flu and jaundice. history of "doing this all the time"when ill. father and uncle do the same. indirect bili is 4. rest labs are normal. next step?

Answer 428

reassure this is benign condition Dx Gilbert syndrome

Question 429

60 y/o white male w dysphagia. for 2 years to solid and liquids. slightly progressive. some noc regurgitation .omeprazole no help. PMH:CAD, EF 20%, cardiomyopathy, copd. Upper GI -dilated esophagus that tapered at junction to stomach. EGD-same. dilated esoph. w retained food,no mass effect. best tx?

Answer 429

botox injection into the LES Dx: seriously chronically ill patient with achalasia

Question 430

40 y/o female w scleroderma. new onset dysphagia, gradually worse past 6 months.dysphagia to bread and meats. never for liquids. no other complaints, no other PMH. exam as expected for scleroderma. what to recommend?

Answer 430

EGD and dilate if narrowed area of esophagus Dx scleroderma and esophageal stricture

Question 431

28 y/o recent develop acne, he started on doxycycline and now has sudden onset of pain with swallowing anything for 2 days. exam normal and no signif history than above.what do you recommend ?

Answer 431

supportive care DX: pill esophagitis

Question 432

60 y/o male long hx reflux symptoms, mostly controlled on PPI. also has adult onset asthma thats more bothersome. asthma for 20 years less responsive to inhalers and prednisone. upper GI-small hiatal hernia and reflux. EGD-linear esophageal erosion. what tests recommended?

Answer 432

evaluate for antireflux surgery

Question 433

55 y/o male several month hx upper abd discomfort and fullness, freq belches. no hx of similar. has been on pepcid bid for 8 weeks. PMH: HTN, on ACE. No asa or NSAIDS. exam-benign. Upper GI:gastric ulcer w benign appearance. next step?

Answer 433

EGD now ** eval ulcers that occur on H2 and age 55 or older

Question 434

35 y/o female, dx crohns age 19. one resection of cecum & terminal ileum age 23. prednisone x 2 in past 5 years. 2-3 soft BM daily, occassional abd cramps. mesalamine 2.4gm/d. ROS otherwise -.colonoscopy 1 yr ago-recur dz at anastamosis, 15cm into ileum. next step?

Answer 434

bone mineral density now crohns predisposes to early onset osteoporosis

Question 435

40 y/o male dx ulcerative colitis age 25. 1-2 flares a year, not seen doctor past 5 years. colonoscopy 5 yr ago- UC entire colon. other hx and exam are normal.what recommend?

Answer 435

start sulfasalazine 2 gm/day

Question 436

70 y/o female w 6 mo hx watery diarrhea.assoc mild cramping and abd pain, never wakes at noc for BM or pain.PMH-hypothyroid. lab and stool workup were normal. stool output was 500g/day. what test to order now?

Answer 436

colonoscopy with biopsy microscopic colitis

Question 437

32 y/o male est as new patient. dx age 19 familial polyposis coli and total colectomy & ileorectostomy age 19. 3 BM/d. no symptoms.has flex sig with removal of mult small adenomatous polyps. EGD-mult large polyps body and fundus stomach.duodenum mult tiny, white plaques=adenoms,what now?

Answer 437

repeat EGD in 1-2 years

Question 438

25 y/o college student to ER p passing large, bloody maroon stool. 3rd time in 2 years. 6 mo ago needed 4 unit RBC.colonoscopy then was normal.EGD normal, upper GI negative. now hgb 8.8,HR120 BP 90/60 what next?

Answer 438

has had 99m tech. pertechnetate scan and confirms dx. now need surgery Dx:Meckels diverticulum

Question 439

65 y/o female w fatigue x 2 months, no other symptoms. no nsaids or aspirin, exam normal except heme + stools. Hgb 7.8, MCV 65. EGD is normal, colonoscopy attempted, not adequate exam of colon, tortuous. what next?

Answer 439

air contrast barium enema signif risk of colon cancer-need to evaluate entire colon

Question 440

27 y/o female recent dx ulcerative colitis with 3 month hx rectal bleeding, abd cramps and diarrhea. started on mesalamine with some improvement, 3 wk later severe epigastric pain radiate to back. N/V. ER>dx pancreatitis,tx and mesalamine stopped ,home.2 wk later to ER with same but lesser degree of pain.amylase and lipase in 300 range. what do you recommend?

Answer 440

tx conservative measures, bowel rest and IV fluids *management of pancreatic cyst

Question 441

68 y/o ICU x 2 wk,elective resect colon ca cecum, aspiration pneum.,resp failure/vent> acute RF,prolonged ileus>TPN for nutrition. antibiotic, abdomen distended. afebile x 1 week, now temp 102. U/S abdomen-GB wall thickening and sm amt fluid around GB, AST 110,ALT 90 Bili 1.6 next step?

Answer 441

has acalculous cholecystitis, interventional radiology to place a percutaneous cholecystostomy drainage tube

Question 442

60 y/o prior rock n roller, went to donate blood, told may have hepatitis, no complaints or symptoms. IVDU 20 yr ago. no other health problems. beer on sunday only. exam normal except tatoos. LFT wnl, HCV antibody +, HBsurface antigen -, HBcore -. 2 week recheck LFT are again normal. recommend/

Answer 442

no tx at this time Dx hep C

Question 443

24 y/o male to ER w symptoms of esophageal food impaction for 2 hr p ate chicken. salivating and spitting frothy secretions. cant drink water without regurgitation. this is his 4th episode. exam, lab, CXR all normal. next step?

Answer 443

GI consult for EGD to remove food bolus

Question 444

70 y/o asian male , no doc for 20 years, presents to you with not eating and weight loss. progressive difficulty swallowing, 6 mo ago could swallow soft, now difficulty with liquids as well. long history of smoking and alcohol use.exam-muscle wasting. hgb 10, MCV 72, barium swallow: 3cm segment severe narrow distal esoph. what next step?

Answer 444

refer to GI for EGD | at risk of squamous cell carcinoma

Question 445

70 y/o w hematemesis & melena. started one hour ago.no prior hx or similar.takes NSAIDS for OA. was 100/60, HR 120, given IV fluids and now 130/80, HR 96. exam normal except NG tube with coffee ground material, hgb 10, EGD 2 cm ulcer in antral ares, raised protuberance in crater, clot and large volume blood in fundus, several non bleeding erosions in antrum and duodenum. next step in management?

Answer 445

endoscopic treatment with a heater probe to visible vessel *visible vessels need intervention!!

Question 446

60 y/o w diarrhea x 2 yrs.extensive w/up negative.colonoscopy neg x 2 , 6 watery stools/d, progressive over 2 years. 3 days ago nausea and profuse vomiting, no meds, no PMH. exam negative. EGD done-severe ulcer esophagitis w large volume secretions in stomach. pH 1.0 mult ulcers duod. incl descending duod. fasting gastrin 5000. CT negative, next step?

Answer 446

endoscopic ultrasound Has Z-E syndrome

Question 447

30 y/o female long standing crohns. 3 yr ago 24" of ileum and cecum removed. on mesalamine.no eval x 3 yrs.now 2 mo hx of intermittent RLQ pain and loose stools. exam tender RLQ but no mass. LFT & CBC normal. likely diagnosis?

Answer 447

exacerbation of crohns=classic presentation after ileal resection

Question 448

35 y/o female belching and indigestion-substernal discomfort lasting all day, no regurg. for 2 years and progressive, belching constantly and abd distention. BMs are normal. on PPI BID x 1 month and no help. prior EGD and pH monitor were normal. no other symptoms or history. what to do next?

Answer 448

psychiatric referral or anti anxiety med Dx aerophagia

Question 449

27 y/o female w crohns x 5 yr.hosp now with 3rd episode of small bowel obstr in past 6 months. fiber worsens and distends abd. colonoscopy 1 yr ago no active crohn, terminal ileum stenotic and could not pass scope into ileum. sm bowel series> tight 10 cm area distal ileum. Best plan of action?

Answer 449

refer for surgical resection of terminal ileum

Question 450

25 y/o female with ulcerative colitis for 5 years, presents 8 weeks pregnant. past colonoscopy dx distal disease=proctosigmoiditis, 2-3 flares a year. has been on incr dose mesalamine 3.2 gm/d with fewer flares. all else negative. best tx now pregnant?

Answer 450

continue mesalamine at current dose

Question 451

16 y/o male to ER w 3 day hx diarrhea initally watery now bloody. vomiting for last 1 day. abd cramps and discomfort. no hx of similar. Hx unremarkable. exam: skin turgor decr, dry mucous membr., slight abd distention and mild right abd tenderness. WBC 14.5, stool + e.colo 0157:H7 at risk of what complication?

Answer 451

hemolytic uremic syndrome

Question 452

40 y/o with acute diarrhea and for about 1 year but getting worse, 6 watery, occ foul smelling stools/d. hx negative except travel to Mexico 6 mo ago and 2 yrs in Indonesia.Lab: hgb 13, MCV 108 B12 normal. folate depressed significantly. O & P negative. what appropriate tx?

Answer 452

trial of tetracycline tropical sprue

Question 453

55 y/o female onset mod-severe abd cramping and maroon, bloodys stools ,abd tender to palpation LLQ and incr bowel sounds, IV fluids given, sigmoidoscopy: nl rectum, 25cm from anus, abrupt transition to edema, purple mucosa thats circumferential. best tx based on these findings

Answer 453

IV metronidazole Ischemic colitis

Question 454

78 y/o female with recent flagyl tx for c. diff toxin, but n/v with flagyl and didnt complete tx. now with same symptoms and + fecal leukocytes and + c. diff toxin. what appropriate tx?

Answer 454

vancomycin 250mg po QID x 14 days

Question 455

50 y/o male to ER with c/o passing 3 large maroon stools, no pain or cramping, exam normal. takes asa daily. no other health problems . VSS . Most likely cause?

Answer 455

diverrticulosis- ** painless maroon stool

Question 456

24 y/o with intermittent diarrhea for 3 years, alternating with constipation. mild abdominal cramps. beer on weekends, 2 glassed milk each day. no other problems or history. best plan of action

Answer 456

trial of lactose-free, sorbitol-free diet

Question 457

35 y/o female with constipation since college. otc laxatives some relief . 2 BMs a week,but hard pass. some abd distention. history entirely negative. labs normal. barium enema-few diverticula in sigmoid colon. what intervention ?

Answer 457

regimen of fiber supplementation and increased water intake constipation

Question 458

60 y/o with 3 episodes of melana, negative workup 3 yr ago. now 2 day of dark, tarry stool, never maroon stools. father and uncle with recurrent GI bleeding, patient had recur epistaxis in his 20s. exam: telectasias lips and fingertips, nasalmucosa,stool heme+. endoscopy 4 well defined AV malform in stomach & same duodenum. colonoscopy - except diverticulosis, no AVMs. DX?

Answer 458

Osler-weber-rendu syndrome

Question 459

24 y/o male with 2 day hx severe N/V/D and fever. pmh otherwise negative. does eat raw oysters 1 week ago and 3 beers/wk. exam fairly benign but + scleral icterus. labs all normal except total bili 4.0 likely cause of jaundice?

Answer 459

Gilberts syndrome

Question 460

man calls ER and says his family of 4 including himself have all gotten sick in past hour with profuse vomiting, some now with diarrhea and abd cramping, no fevers. teens ate fast food lunch, all went for chinese dinner. mom threw bad mayo away yesterday, likely cause of their illness?

Answer 460

food poisoning with B. cereus- see with ingestion infected fried rice so chinese they all ate is the cause

Question 461

54 y/o rocker w 10 yr hx hep C, tx interferon x6mo,no f/up since.no c/o except occ weakness.hx otherwise negative. exam liver and spleen enlg,trace ascites, no edema.lab:ptl 98k,bili 2, ast 56,alt 50,INR 1.1.EGD-large, grade 4 esoph varices,some w red markings,no bleed,stomach eryth mosaic pattern, next?

Answer 461

initiate propranolol and titrate dose until pt HR

Question 462

55 y/o male for health check, no complaints, no meds. screening colonoscopy w 1.2cm polyp snared, bx tubular adenoma w low-grade dysplasia. when needs follow up colonoscopy?

Answer 462

3 years

Question 463

22 y/o male w negative history,complains of turning yellow, noticed yellowing in eyes yesterday. today skin turning yellow. no other complaints. drinks 12-18 beers on weekends. exam: scleral icterus, liver enlarged,slight tender, spleen tip palpable. Lab: anti HAV IgM positive whats diagnosis?

Answer 463

acute hepatitis A

Question 464

NOT an indication for colonoscopy

Answer 464

bright red blood on toilet paper in 19 yr old college student

Question 465

lab that indicates hepatitis B infection that has resolved?

Answer 465

``` HBsAg (-) HBcAb IgG (+) HBs Ab (+) ```

Question 466

cause of diarrhea that will typically have fecal leukocytes

Answer 466

shigella

Question 467

4 people who were at picnic all get sick about same time with sudden onset severe N/V then profuse diarrhea and severe weakness. they all ate multiple mayo based foods brought by various people, 2 went swimming in local creek. all got sick about 4 hours after eating.afebrile, Hr 140 BP 80/40. IVF given, next?

Answer 467

staph aureus food poisoning no antibiotic tx indicated supportive care

Question 468

anti HAV IgM looks for

Answer 468

acute hepatitis A

Question 469

HBsAg looks for

Answer 469

acute infection and chronic carrier states

Question 470

anti HBc IgM looks for

Answer 470

acute infection in the "window"

Question 471

anti HBc IgG looks for

Answer 471

if the person has been infected with hep B in the past | **does not tell if person is still infected

Question 472

Hepatitis C antibody

Answer 472

tells if person has been infected w hepatitis C | **does not tell you if chronic C or if resolved

Question 473

remember there is no chronic form of

Answer 473

hepatitis A

Question 474

extrahepatic manifestations of Hepatitis B

Answer 474

* polyarteritis nodosa-multisyst dz w foot drop or wrist drop * arthritis * glomerulonephritis * urticaria * mixed cryoglobulinemia, polyneuropathy

Question 475

extrahepatic manifestations of hepatitisC

Answer 475

* mixed cryoglobulinemia * leukocytoclastic vasculitis, porphyria cutanea tarda-blister/scar on sun exposed areas,arthritis, Sjögren's syndrome * membranoproliferative GN type 1 * lymphocytic sialadenitis

Question 476

most common cause of acute hepatitis and jaundice in the WORLD

Answer 476

hepatitis E

Question 477

tx of ascites

Answer 477

* low Na intake(1-2gm/d), water restrict if Na1 in urine suggests effective dose * diuretic resistant ascites-large volume paracentesis, TIPS

Question 478

Budd Chiari syndrome

Answer 478

*cause:hepatic venous outflow tract obstruction (hepatic vein or suprahepatic IVC) due to :50%myloproliferative disorder, Bechets, antiphos antibody syndr., OCPs, invasion or compression from malignancy

Question 479

causes of toxigenic diarrhea

Answer 479

* staph aureus-1-6hr incubation, tx supportive * c. perfringens-only diarrhea,7-16hr incub-supportive tx * E coli-travelers-watery diarrhea, tx empiric-cipro or azith 1 gm * bacillus cereus-contaminated fried rice-vomit,diarrhea-support * vibrio cholera-severe watery diarrhe-doxycycline 300mg singledose * giardia-hikers drink contam. water, acute-diarrhea, cramps. wt loss. chronic-steatorrhea. tx flagyl or tinidazole 2gm single dose

Question 480

shigella

Answer 480

cipro 750mg daily x 3 days or azith 500mg daily x 3 days

Question 481

campylobacter

Answer 481

azith 500mg daily x 3 days

Question 482

nontyphoid salmonella

Answer 482

watery diarrhea or bloody with fever * tx only if age65,on steroids, IBD, immunosuppressed, hemoglobinopathies, hemodialysis, aortic aneurysm, prosthetic heart valve

Question 483

e.coli 0:157:H7 or non -O157

Answer 483

* no fever, Hemolytic uremic syndrome * dx: shiga toxin 1 & 2 in stools, stool culture * tx supportive only

Question 484

vibrio parahaemolyticus

Answer 484

shellfish and seafood, tx as shigella

Question 485

vibrio vulnificus

Answer 485

* raw oysters,shellfish,seafood * incr risk with chronic liver disease * tx : doxycycline plus 3rd gen ceph.

Question 486

amoeba

Answer 486

* stool antigen best Dx test * may mimic UC, sigmoidoscopy w bx of colon ulcer edge may show organism * tx:flagyl 7-10days followed by paromomycin or diiodohydroxyquin

Question 487

yersinia enterocolitica

Answer 487

* watery or bloody diarrhea * pseudo appendicitis picture * tx cipro

Question 488

42 y/o male no symptoms, has mild hepatmagaly and elevated liver enz . Lab AST70, ALT 120, GGTP 150, nl a phos, hepatitis neg, chol 280, TG 450, HDL 30. abdominal u/s incr echogenicity consist w fatty infiltrate, liver bx:steatosis, infiltr PMNs, hepatocyte ballooning, spotty necrosis & mallory hyaline. DX?

Answer 488

non alcoholic steatohepatitis

Question 489

30 y/o male w 6 mo of abd discomfort, flatulence, bloat, diarrhea, wt loss. exam:vesicular erup both elbows, Lab hgb 10, MCV 70,serum iron 20, TIBC 500 (incr), ferritin 8 (15-200) what to order next?

Answer 489

IGA antiendomysial and or anti-tissue transglutaminase antibody

Question 490

27 y/o admit w acute pancreatitis. 4 days later worsening abd pain and high fever. CT scan:severe pancreatic necrosis, CT guided needle aspir shows gram negative organism on gram stain . what is recommended now

Answer 490

IV antibiotic plus insertion of ct guided percutaneous drain tube

Question 491

36 y/o female with longstanding ulcerative colitis on sulfasalazine for 8 years, now c/o wt loss, jaundice, RUQ pain , pruritis. Labs: AST 60, ALT 56, bili 10, alk phos 840. ultrasound abd normal. best test to confirm dx?

Answer 491

ERCP or MRCP

Question 492

52 y/o white female on routine exam has this lab: alk phos 500, GGT 300, chol 400, normal AST,ALT,bili. hx of excess itching, no other complaints. abd ultrasound negative. what test to confirm her diagnosis?

Answer 492

antimitochondrial antibody

Question 493

68 y/o male w 1 day hx fever, chills, RUQ abd pain. exam: T 103, RUQ tender, no rebound. Lab: WBC 15K, AST 150, ALT 160, alk phos 400, sonogram and CT show dilated common bile duct and no gallstones. blood cultures done and started on antibiotics. what now recommended?

Answer 493

ERCP w possible sphincterotomy

Question 494

49 y/o male presents w incr abd girth for few months, Hx hepatitis 10 yrs ago. exam:tense ascites, Lab: albumin 3.2,AST 80, ALT 76, alk phos 68, abd paracentesis clear fluid w 10 mononuclear cells, total protein 2.0, albumin 1.5. whats most likely cause of his ascites?

Answer 494

cirrhosis with portal hypertension

Question 495

52 y/o female w progressive dysphagia both solid and liquids w choking/cough at nite, intermittent regurg of undigested food and wt loss. started 1 yr ago and has lost 30#. hx occ chest discomfort, not relieved w antacids, CXR shows widened mediastinum. likely diagnosis?

Answer 495

achalasia

Question 496

32 y/o alcoholic male presents w 4 hour severe retrosternal CP. pain worse w breathing and swallow. auscultation over LSB-superficial crackling, EKG normal, CXR-left pleural effusion and air in the mediastinum. best way to confirm diagnosis?

Answer 496

gastrograffin swallow study

Question 497

32 y/o male w severe epigastric pain radiating to back, N/V, fever and chills few hours. exam: T 103, epigastric & RUQ tender, hypoactive bowel sounds, lipase & amylase markedly increased. ultrasound-gallstones & dilated common bile duct. he is started on IVF, antibiotic and NG suction. you also recommend

Answer 497

ERCP and sphincterotomy within 24 hours and cholecystectomy prior to discharge from the hospital.

Question 498

32 y/o female long hx ulcerative colitis on sulf. for many years, is now having severe bloody diarrhea, marked weakness, fever, abd pain. exam: T 102, HR 110, 110/70,abd distended w diffuse tender, sigmoidoscopy-friable colonic mucosa w sev. ulcers. tx IV hydrocortisone, NG tube, antibiotics, 48 hr later still same symptoms, repeat xray abdomen shows transverse colon dilated to 10 cm, was 7 cm initially. what to do now?

Answer 498

total colectomy

Question 499

44 y/o female w chronic diarrhea and wt loss. 4-5 bulky foul smelling stools/day. hx of crohns mor than 100cm sm. bowel resected about 2 yr ago. stool fat is 20gm/24hours and sed rate is normal. what to recommend now?

Answer 499

low fat diet and add medium chain triglycerides to diet

Question 500

72 y/o male admit CCU w anteroseptal MI, he develops a. fib needing cardioversion. 4 days after admit sudden onset severe colicky abd pain w vomiting. exam-diffuse abd tender and distended. xray-few distended loops. stools + occult blood. WBC 12K, amylase 300. now recommend?

Answer 500

abdominal angiogram

Question 501

40 y/o female w elevated bilirubin. she was admit w acute appy w emerg. appendectomy 3 days ago, still NPO on IVF and clinda and gent. no abd pain Lab: bili 5, indirect 4.2, other liver tests normal. no blood transfusions . now recommend?

Answer 501

no further dx tests

Question 502

38 y/o male c recur epig. pain & chronic diarrhea. long hx PUD , partial gastrectomy w Bilroth II one yr ago. upperGI - stomal ulcer and hypertrophy of gastric folds. H pylori negative. fasting serum gastrin 500, after IV secretin, gastrin 900.

Answer 502

* diarrhea d/t inactivation of pancreatic lipase due to high acid production * CT scan likely to show pancreatic tumor * hypercalcemia may be assoc w this disorder

Question 503

80 y/o w left sided abd pain and recur bright red rectal bleeding for 2 days, exam: left side tender, no rebound. abd xray-thumb printing in descending colon. sigmoidoscopy-friable colonic mucosa w mult ulceration. WBC 11K. now recommend?

Answer 503

continued close observation

Question 504

70 y/o hosp x 2 days w fever, LLQ abd pain, constipation. exam: T101, tender LLQ w localized rebound in area. WBC 15K, amylase normal. abd xray-nonspecific bowel gas, no free air, now recommend?

Answer 504

ct scan abdomen, IVF, antibiotics

Question 505

52 y/o w 5 yr hx of pernicious anemia now 2 wk hx epigastric discomfort after eating. on B12 IM monthly. Lab: +serum antibody to parietal cell and intrinsic factor. fasting gastrin level 3400.

Answer 505

* high gastrin levels are due to achlorhydria due to atrophic gastritis * higher incidence of developing gastric carcinoma and gastric carcinoid in this patient

Question 506

true statements about H. pylori

Answer 506

* major factor in cause of PUD * ulcer recurrences can be more effectively prevented by eradication of this organism than by continuous acid suppression

Question 507

true statements about NSAID use

Answer 507

* they increase risk of bleeding in patient w ulcer disease * concomitant steroid use increases the risk of toxicity * NSAID induced gastric toxicity can be prevented by concomitant use of misoprostol

Question 508

true statements about spontaneous bacterial peritonitis

Answer 508

* more common in ascites w total protein content 250 | * blood cultures are positive in <50%

Question 509

alpha interferon has been found to be effective in the treatment of these forms of chronic hepatitis

Answer 509

hepatitis B,C,D

Question 510

seen in the majority of patients with ulcerative colitis

Answer 510

rectal involvement

Question 511

ulcerative proctitis is best treated by

Answer 511

local steroid or 5-ASA enemas

Question 512

in patients with ulcerative pancolitis of >8 yrs duration, surveillance colonoscopy w mucosal biopsies shoud be done every

Answer 512

1-2 years

Question 513

travellers diarrhea is most commonly caused by

Answer 513

enterotoxigenic E. coli

Question 514

Enterohemorrhagic E. coli (0157:H7) may cause

Answer 514

hemolytic uremic syndrome

Question 515

Bacillus cereus is assoc with ingestion of

Answer 515

fried rice

Question 516

Vibrio parahemolyticus is assoc w ingestion of

Answer 516

uncooked shellfish

Question 517

true statements about malabsorption syndrome

Answer 517

* fecal fat >40gms suggests pancreatic insufficiency * bacterial overgrowth causes malabsorption by deconjugation of bile salts. * malabsorption in patients with extensive small bowel resection occurs due to loss of bile salts

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