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Step 3 > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Tx. partial small bowel obstruction

A

observation and supportive therapy - IVF, NG suction, electrolytes

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2
Q

first test for dysphagia

A

barium swallow

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3
Q

what does odynophagia suggest?

A

infectious process such as HIV, HSV or Candida

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4
Q

progressive dysphagia to both solids and liquids with occasional regurgitation of food particles and aspiration - dx?

A

achalasia

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5
Q

best initial test: achalasia

A

barium swallow

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6
Q

most accurate test: achalasia

A

esophageal manometer

  • absence of normal esophageal peristalsis
  • high pressure at LES
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7
Q

best initial therapy: achalasia

A

surgical myotomy

- alt. pneumatic dilation

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8
Q

when do you use wireless video endoscopy

A

small bowel disease only

  • limited views of esophagus and stomach
  • very high resolution
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9
Q

presentation of esophageal ca.

A

dysphagia for solids first, then liquids
heme positive stool or anemia
usually pt > 50 who smokes and drinks

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10
Q

best initial test if suspected esophageal ca.

A

endoscopy

- if not an option: barium swallow

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11
Q

best initial therapy: esophageal ca.

A 
surgical resection (if no local or distant mets) 
F/U surgery with 5-FU based chemotx
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12
Q

proximal esophageal stricture in iron-deficient middle aged woman

A

Plummer Vinson syndrome

- may be assoc. with SCC

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13
Q

best initial therapy: Plummer Vinson

A

iron replacement

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14
Q

distal esophageal ring that presents with intermittent symptoms of dysphagia; it has no malignant potential –> DX? Best initial therapy?

A

dx. Schatzki ring

best initial therapy - pneumatic dilation

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15
Q

pt with dysphagia and regurgitation of food; pt has bad breath - dx? best initial test?

A

Zenker diverticulum

best initial test: barium swallow

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16
Q

best initial therapy: Zenker diverticulum

A

surgical resection

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17
Q

what two procedures are C/I in Zenker diverticulum?

A

endoscopy
NGT placement
- high risk of perforation

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18
Q

pt presents with severe chest pain of sudden onset after drinking a cold beverage. EKG is WNL. DX? best initial test

A

dx. diffuse esophageal spasm

best initial test: esophageal manometry

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19
Q

tx. esophageal spasm

A

CCBs and nitrates

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20
Q

HIV pt with CD4 < 100 presents with odynophagia - next step?

A

empiric fluconazole

- endoscopy only done if no response to fluconazole

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21
Q

next step in HIV negative pt who presents with odynophagia

A

endoscopy

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22
Q

pt presents with severe chest pain after several episodes of vomiting. He is dyspneic and the pain radiates to his shoulder - dx?

A

Boerhaaves syndrome - esophagael perf

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23
Q

Dx. Boerhaaves

A

esophagogram with water soluble contrast

- do NOT do EGD

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24
Q

pt presents with upper GI bleeding following vomiting episode - dx? best initial test?

A

mallory weis tear

- dx test: EGD

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25
Q

Tx. mallory weiss tear

A

most cases resolve spontaneously

- if bleeding persists, Epi injection can be used to stop the bleeding

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26
Q

CF of GERD

A

chronic cough/wheezing
sore throat
hoarseness
bitter/metallic taste

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27
Q

Best initial management of GERD

A

PPIs - both diagnostic and therapeutic

- 24 hour pH monitoring should only be done if there is no response to PPIs and the diagnosis is not clear

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28
Q

when do you need to do an EGD for pt with GERD?

A
  1. alarm symptoms - dysphagia, weight loss, anemia, heme positive stool
  2. symptoms of reflux > 5-10 years
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29
Q

endoscopic finding of barret’s esophagus - action?

A

PPI

repeat endoscopy Q2-3 years

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30
Q

endoscopic finding of low grade dysplasia of esophagus - action?

A

PPI

rpt endoscopy in 3-6 months

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31
Q

endoscopic finding of high grade dysplasia of esophagus - action?

A

endoscopic mucosal resection, ablative removal or distal esophagectomy

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32
Q

MCC of epigastric discomfort

A

non-ulcer dyspepsia

- diagnosis of exclusion

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33
Q

Tx. non ulcer dyspepsia

A

PPis

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34
Q

what needs to be done in any patient > 45 yo with epigastric pain?

A

EGD

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35
Q

management of H.pylori infection

A

PPI + clarithromycin + amoxicillin

alt. PPI + metronidazole + tetracycline
- only treat h.pylori if it is associated with gastritis or ulcer disease

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36
Q

RF for stress ulcers

A 
head trauma
mechanical ventilation > 48 hrs
burns
coagulopathy and steroid use in combo
sepsis
ICU > 1 week
occult GI bleed > 6 days
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37
Q

prophylaxis for stress ulcers

A

if enteral - use PPI

if IV - use H2 blocker

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38
Q

do you need to treat finding of h.pylori if no gastritis or ulcer disease?

A

no - if having epigastric pain, may give PPI

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39
Q

multiple ulcers that persist with treatment for h.pylori - what should you order next?

A

gastrin level and gastric acid output testing

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40
Q

elevated gastrin level

A
  1. Zollinger Ellison

2. anyone on a PPI or H2 blocker

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41
Q

lab findings in Zollinger Ellison syndrome

A

gastrin level elevated

gastric acid output elevated

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42
Q

most accurate test for zollinger ellison

A

secretin stimulation test

- normally, gastrin and gastric acid output decreases with secretin; with ZES, there is no change or an increase

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43
Q

diagnostic tests for ZES

A

endoscopic ultrasound
nuclear somatostatin scan
secretin stimulation

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44
Q

tx, local ZES

A

surgical resection

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45
Q

tx. metastatic ZES

A

PPIs lifelong

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46
Q

ASCA and ANCA results in Crohns vs. UC

A

Crohns: ASCA +, ANCA -
UC: ASCA - , ANCA +

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47
Q

screening colonscopy in IBD

A

perform Q1-2 years after 8-10 years of colonic involvement

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48
Q

best initial therapy for either CD or UC

A

mesalamine

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49
Q

adverse effects of sulfasalazine

A

rash
hemolytic anemia
interstitial nephritis

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50
Q

what steroid can be used to control acute exacerbations of IBD ?

A

budesonide

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51
Q

what drugs are used in pts with severe, recurrent IBD despite being on steroids?

A

Azathioprine and 6 mercaptopurine

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52
Q

when is infliximab useful for tx IBD?

A

Crohns disease that is associated with fistula formation

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53
Q

what antibiotics are useful for perianal involvement in Crohns?

A

metronidazole and ciprofloxacin

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54
Q

MCC of food poisoning

A

campylobacter

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55
Q

best initial test for infectious diarrhea

A

fecal leukocytes

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56
Q

most accurate test for infectious diarrhea

A

stool culture

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57
Q

What makes infectious diarrhea “severe”

A

blood
fever
abdominal pain
hypotension and tachycardia

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58
Q

tx. severe infectious diarrhea

A

FQ - cipro

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59
Q

Dx. giardia

A

stool ELISA antigen

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60
Q

Tx. giardia

A

metronidazole or tinidazole

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61
Q

diarrhea in HIV positive patient with CDC < 100 - dx? test? tx?

A

dx. cryptosporidum
test: modified acid fast stain
tx: antiretrovirals to raise CDC, paromomycin or nitazoxanide

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62
Q

pt goes out to eat seafood and within 10 minutes of finishing his tuna he begins vomiting and has diarrhea, skin flushing and wheezing - dx? tx?

A

scombroid

- tx. with antihistamines

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63
Q

tx. mild C.diff (WBC < 15,000, Cr < 1.5x)

A

PO metronidazole

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64
Q

tx. severe C. diff (WBC > 15 000 and Cr > 1.5x baseline)

A

PO Vancomycin

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65
Q

When would you have to do surgery to treat C.diff (subtotal colectomy)?

A

WBC > 20 000
Lactate > 2.2
Toxic megacolon
Severe ileus

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66
Q

Alternative treatment to vanco for severe, recurrent C.diff

A

Fidoxamicin

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67
Q

what should you do if you have a strong clinical suspicion of C.diff but lab studies are negative?

A

limited colonoscopy or flexible sigmoidoscopy

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68
Q

Causes of fat malabsorption and steatorrhea

A

Celiac dz
Tropical sprue
Whipples disease
Chronic pancreatitis

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69
Q

Associated findings with fat malabsorption

A

Hypocalcemia (vit d deficiency)
Oxalate over absorption with Oxalate stones
Easy bruising and elevated PT/INR
Vitamin b 12 malabsorption

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70
Q

Best initial test for malabsorption

A

Sudan black stain of stool

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71
Q

Most sensitive test for malabsorption

A

72 hour fecal fat

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72
Q

What nutritional deficiencies are unique to malabsorption due to celiac dz

A

Iron deficiency

Folate deficiency

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73
Q

Best initial test for celiac disease

A

Antigliadin antiendomysial and anti tissue transglutaminase abs

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74
Q

Most accurate test for celiac dz

A

Small bowel biopsy

- always needs to be done to exclude bowel lymphoma

75
Q

Tropical sprue

A

Pt presents like celiac disease but there will be a history of travel and the antibody tests will be negative

76
Q

Tx, tropical sprue

A

Tetracycline or TMP-SMX for 3-6 months

77
Q

How does Whipple disease present?

A

Fat malabsorption diarrhea with arthralgias, neurological abnormalities and ocular findings

78
Q

Most accurate diagnostic test for Whipples disease

A

Small bowel biopsy showing PAS positive organisms

Alternate: PCR of stool for trophyerema whippeli

79
Q

Tx. Whipples disease

A

Tetracycline or TMP-SMX for 12 months

80
Q

Amylase and lipase levels in chronic pancreatitis

A

Normal

81
Q

Best initial tests for diagnosing chronic pancreatitis

A

Abdominal XR

Abdominal CT scan without contrast

82
Q

Most accurate test for diagnosis of chronic pancreatitis

A

Secretin stimulation test
- normally, secretin causes large volume of bicarbonate rich pancreatic fluid secretion (decreased or absent in chronic pancreatitis)

83
Q

What tests should you order on CCS in pt with suspected IBS

A

Stool guaic, white cells, culture, ova, parasite exam
Colonoscopy
Abdominal CT scan

84
Q

screening for CRC if one family member had CRC

A

at age 40 or 10 years before the age of the family member - whichever one comes first

85
Q

CRC screening if 3 family members, two generations and one premature form in history

A

every 1-2 years starting at age 25

86
Q

CRC screening for FAP

A

sigmoidoscopy starting at age 12

87
Q

usefulness of CEA marker in CRC

A

never for screening - used to follow response to therapy

88
Q

LLQ pain with lower GI bleeding should make you think of..

A

diverticulosis

89
Q

best diagnostic test for diverticulosis

A

abdominal CT

90
Q

most accurate test for diverticulosis

A

colonscopy

91
Q

Tx. diverticulosis

A

high fiber diet

92
Q

CF: diverticulitis

A

LLQ pain
tenderness
fever
elevated WBC count

93
Q

best diagnostic test for diverticulitis

A

abdominal CT scan

  • confirmatory: shows thickening of bowel wall
  • colonoscopy and barium enema are C/I
94
Q

Tx. diverticulitis

A

IV antibiotics

  1. Ciprofloxacin and metronidazole
  2. Cefoxitin
  3. Cefuroxime and metronidazole
95
Q

common complication of diverticulosis

A

colovesicular fistula - causes pneumaturia

96
Q

diseases that are associated with angiodysplasia

A

ESRD
Von Willebrand dz
aortic stenosis

97
Q

most urgent step in management of severe GI bleeding

A

fluid resuscitation

98
Q

orthostasis in GI bleeding

A

drop of > 20 mmHg in systolic pressure OR increase in pulse by > 10 /min implies >30% volume loss –> hemodynamic instability

99
Q

CCS - what do you order for large volume GI bleeding?

A 
bolus of normal saline
CBC
PT/INR
Type and cross
GI consult
EKG
100
Q

when do you transfuse PRBCs in GI bleeding?

A

if Htc < 30 in older person; < 20-25 in young otherwise healthy person

101
Q

when do you transfuse FFP in GI bleeding?

A

prolonged PT/INR

102
Q

MCC of death in GI bleeding

A

myocardial ischemia

103
Q

pt with GI bleeding and presence of ulcer disease - what should you add to managment?

A

PPI

104
Q

Tx. variceal bleeding

A
  1. octreotide
  2. upper endoscopy w/ banding
  3. if bleeding persists despite time –> consider TIPs
105
Q

Pt presents with abdominal pain, bloody diarrhea and hypotension. During workup, a colonscopy shows patchy areas of depigmented mucosa - dx? tx?

A

Ischemic colitis

  • if transmural, the mucosa will be sloughing and green
    tx. IVF, bowel rest
106
Q

when do you use a technetium bleeding scan

A

performed to detect site of bleeding if endoscopy does not reveal a source

107
Q

when do you use capsule endoscopy in GI bleeding

A

if upper and lower endoscopy cannot reveal a source

108
Q

Tx. acute pancreatitis

A

IVF
IV narcortics
IV abx - only if necrotizing pancreatitis

109
Q

Antibiotic of choice in severe necrotizing pancreatitis (suspect when pt with pancreatitis spikes a fever)

A

Imipinem

- also: 3rd gen ceph, piperacillin, FQs, metronidazole

110
Q

Tx. mallory weiss tear that is not actively bleeding

A

observation and supportive care

111
Q

what anatomical predisposing factor is seen in Mallory-Weiss syndrome

A

hiatal hernia (10-40% of pts)

112
Q

standard caloric intake for enteral feeding

A

30 kcal/kg/day with 1 g/kg/day of protein

113
Q

Dx. SBP

A
  1. ascites PMN count > 250 /mm3

2. positive ascites culture or stain (usually E.coli, strep and rarely, staph)

114
Q

Tx. SBP

A

3rd gen. ceph (cefotaxime)

115
Q

Dx. diverticulitis

A

Abdominal CT scan

- colonic wall thickening, stranding of mesenteric fat

116
Q

Tx. mild diverticulitis

A

outpatient Ciprofloxacin + Metronidazole

117
Q

dyspepsia

A

chronic/recurrent pain or fullness in the epigastric area without significant heartburn

118
Q

confirmation of eradication of H.pylori

A

fecal antigen test or urea breath test - 4 weeks after completion of therapy

119
Q

for whom should you confirm eradication of h.pylori?

A

duodenal ulcer
persistent dyspepsia
MALToma
resection of early gastric ca

120
Q

Indications for biliary drainage in acute cholangitis

A
  1. persistent abdominal pain
  2. hypotension despite aggressive fluid resuscitation
  3. fever > 39C
  4. mental confusion
121
Q

pain on an empty stomach

A

duodenal ulcer

122
Q

CF of chest pain assoc. with GERD

A
  1. squeezing/burning pain that radiates toward back, neck, jaw and arms
  2. may resolve spontaneously or after antacids
  3. occurs postprandially
  4. awakens pts from sleep
  5. worsens with emotional stress
123
Q

Side Effects of Isotretnoin

A 
hypertriglyceridmia (acute pancreatitis)
mucocutaneous lesions
myalgias
hyperostosis
pseudotumor cerebri
night vision troubles
BM suppression
hepatotoxicity
124
Q

Tx. Toxic Megacolon

A
  1. ICU admission
  2. NGT
  3. Glucocorticoids
  4. IVF and electrolytes
125
Q

which two drugs should not be used in toxic megacolon?

A
  1. opiates

2. 5ASA compounds

126
Q

two most common causes of massive colonic bleeding

A

angiodysplasia

diverticulosis

127
Q

source of bleeding in diverticulosis

A

ruptured vasa recta either at apex or neck of

diverticulum (erosion of the artery)

128
Q

associations with angiodysplasia

A

aortic stenosis

ESRD

129
Q

manometric findings in scleroderma

A

absence of peristaltic waves and decreased LES tone

130
Q

Classic symptoms of sclerodermal esophageal dysmotlity

A

sticking sensation in throat accompanied by heartburn

131
Q

s/e: kava

A

liver toxicity - hepatitis, cirrhosis, liver failure

132
Q

lactose breath hydrogen test

A

Pt should fast for 8 hours prior to test, consuming no food and water; then asked to drink lactose-containing beverage and breath into a bag. Increase in breath hydrogen conc. > 20 ppm is suggestive of lactose intolerance

133
Q

what other screening test should be done when FAP is diagnosed?

A

screening upper endoscopy

- gastric and duodenal adenomas/carcinomas are MC

134
Q

serum sickness-like syndrome in prodromal phase of Hep B infection

A

Type 3 reaction (circulating immune complexes)

  • fever, rash, arthralgias
  • polyarteritis nodosa
  • glomerulonephritis
135
Q

splenic vein thrombosis

A

isolated gastric varices as a complication of chronic recurrent pancreatitis; may also have massive splenomegaly

136
Q

portal vein thrombosis

A

esophageal and gastric varices

137
Q

management of swallowing issues in ALS pts

A

insertion of PEG tube

- does not lead to development of sinusitis and does not affect the patients breathing or speech

138
Q

Drugs that can cause pancreatitis

A
  1. Diuretics - furosemide, thiazides
  2. IBD - 5ASA, sulfasalazine
  3. Immunosuppresives - azathioprine, L-asparaginase
  4. Seizures/ bipolard - valproic acid
  5. AIDs - didanosine, pentamidine
  6. abx - metronidazole, tetracycline
139
Q

Dx. acute mesenteric ischemia -most accurate test

A

angiography

140
Q

CF: acute mesenteric ischemia

A

severe abdominal pain
metabolic acidosis
elevated amylase level

141
Q

Management approach to acute mesenteric ischemia

A
  1. Plain film
    - if negative: assess risk of hypercoagulability
    LOW risk = are there peritoneal findings?
    - yes: laparotomy
    - no: angiography
    HIGH risk = dynamic CT
142
Q

Tx. acute mesenteric ischemia

A

surgical resection of the bowel - surgical emergency

143
Q

Pt with history of gastric surgery presents with shaking, sweating, weakness and hypotension following meals. Dx/ Management?

A

Dx. Dumping syndrome
Tx. small frequent meals (low carb, high protein/fat)
- trial of somatostatin

144
Q

Dx. diabetic gastroparesis

A
  1. R/O mechanical obstruction and extrinsic compression with upper endo or CT/MRI respectively
  2. confirmatory test: nuclear gastric emptying study
145
Q

Tx. diabetic gastroparesis

A

smaller meals with less fat content

Tx. erythromycin or metoclopramide

146
Q

acute pancreatitis

  • best initial test (1)
  • most accurate test (2)
A
  1. amylase and lipase serum levels

2. abdominal CT

147
Q

when is MRCP used for acute pancreatitis?

A

it can detect causes of biliary and pancreatic duct obstruction not found on CT scan

148
Q

when is ERCP used for acute pancreatitis?

A

when you have common bile duct dilation without a pancreatic head mass; can be used to detect and remove stones from the pancreatic bile duct system

149
Q

what urinary test can be used to detect the severity of pancreatitis?

A

trypsinogen activation peptide

150
Q

management acute pancreatitis

A
  1. NPO - if > 48 hours, consider NJ feeds with high protein, low fat meals
  2. hydration
  3. medications
151
Q

scoring system for severity of acute pancreatitis

A

APACHE II criteria

- most precise method: CT scan

152
Q

if CT scan shows necrosis of pancreas - what do you do

A

abx - imipenem

CT guided biopsy - if infected/necrotic, pt requires surgical debridement of pancreas

153
Q

what other condition is hep B associated with? hep c?

A

hep B = PAN
hep C = cryoglobulinemia
- both can present like a serum-sickness (joint pain, uriticaria, fever)

154
Q

which LFT is elevated in viral hepatitis? drug-induced hepatitis?

A

viral = ALT

drug induced = AST

155
Q

what is the first test to become abnormal in Hep B

A

surface antigen

156
Q

dx. chronic hep B

A

presence of surface antigen for > 6 months

157
Q

what is the only antibody present during the window period of hep B infection

A

core antibody

158
Q

when should babies born to hep B positive women get serology controls?

A

3-4 months after last vaccine dose

159
Q

hep C

  • best initial test (1)
  • most accurate test (2)
A
  1. hep C antibody - cannot distinguish between persistent, cleared of FP result
  2. hep C PCR for RNA
    - determines activity of disease and response to therapy
160
Q

when do you use liver biopsy in hep C

A

most accurate way of determining seriousness of disease; determines extent of liver damage

161
Q

Tx. chronic hep B

A 
lamivudine
adefovir
entecavir
telbivudine
tenofovir
interferon
162
Q

tx. chronic hep C

A

interferon + ribavirin and boceprevir or telaprevir

163
Q

S/E: Interferon

A 
flulike symptoms
arthralgia
myalgia
fatigue
thrombocytopenia
depression
164
Q

MC adverse effect of ribavirin

A

anemia

165
Q

postexposure prophylaxis of hep C

A

none

166
Q

Hepatorenal syndrome

A

pt with cirrhosis presents with Urine Na <10 with no increase in urine output with a fluid challenge; Tx. liver transplant

167
Q

Tx. encephalopathy 2ndary to cirrhosis

A

lactulose

168
Q

Tx. ascites 2ndary to cirrhosis

A

spironolactone

169
Q

Management: esophageal varices in cirrhosis

A
  1. if bleeding –> banding
  2. should receive prophylactic abx (Cipro) prior to banding
  3. prophylaxis –> propranolol
170
Q

when should you get a paracentesis in cirrhosis

A
  1. new onset ascites

2. pt with ascites and pain, fever or tenderness

171
Q

serum to ascites albumin gradient

A

> 1.1 indicates portal HTN from cirrhosis or CHF

172
Q

Tx. SBP

A

Cefotaxime

- follow up prophylaxis with levofloxacin

173
Q

MELD scoring system

A

determines 90 day mortality in pts with advanced liver disease based on INR, serum bilirubin and serum Cr levels

174
Q

middle aged woman comes in itching skin and xanthelasmas. She has a history of hypothyroidism. Labs show elevated ALP. Dx? Most accurate test? Tx?

A

Dx. primary biliary cirrhosis
Test: antimitochondrial ab, liver biopsy
Tx. ursodeoxycholic acid

175
Q

patient with IBD presents with itching skin and jaundice. labs show elevated ALP. Dx? Most accurate test? Tx?

A

Dx. primary sclerosing cholangitis
Test: antismooth mm ab, ERCP (beading), ANCA positive
Tx. ursodeoxycholic acid

176
Q

dx. Wilson’s disease

A

initial - Slit lamp exam, low ceruloplasmin level

most accurate: liver biopsy

177
Q

Tx. Wilson’s disease

A

penicillamine

trientine

178
Q

MCC of death in hemochromatosis

A

cirrhosis

179
Q

CF: hemochromatosis

A 
restrictive CM
skin hyperpigmentation
joint pain --> pseudogout (2nd/3rd MCP, polyarthritis)
diabetes
panhypopituitarism
infertility
hepatoma
180
Q

best initial tests for hemochromatosis

A

elevated serum iron and ferritin
low TIBC
transferrin sat > 50%

181
Q

confirmatory test hemochromatosis

A
  1. liver biopsy

2. MRI of liver + HFE gene mutation

182
Q

Tx. hemochromatosis

A

phlebotomy

183
Q

best initial tests for autoimmune hepatitis

A

ANA
anti-smooth mm ab
SPEP = hypergammaglobulinemia

184
Q

Tx. autoimmune hepatitis

A

prednisone

Step 3 (20 decks)

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