Gastroenterology Flashcards
What type of kidney stones may be seen in Crohn’s disease?
Calcium oxalate stones
What is useful for diagnosis of Crohn’s or UC?
Endoscopy
Barium studies
What disease is ASCA + and ANCA - ?
Crohn’s Disease
What disease is ASCA - and ANCA + ?
UC
What is the best initial therapy for UC and Crohn’s?
Mesalamine
What steroid has utility in managing Crohn’s and UC?
Budesonide
When patients have Crohn’s/UC with recurrent symptoms off steroids or severe disease what meds can be started?
Azathioprine and 6-mercaptopurine
What drug is most useful in managing Crohn’s disease with associated fistula formation?
Infliximab
When there is perianal involvement in Crohn’s what drugs are helpful?
Metronidazole and ciprofloxacin
Should you give platelets and antibiotics in patients with HUS from E. coli O157:H7?
No!
If blood is not mentioned in a diarrhea case what test should you run to look for invasive pathogens?
Fecal Leukocytes
In severe diarrheal disease thought to be due to an infectious etiology what is an appropriate antibiotic to start?
Ciprofloxacin (fluoroquinolones)
What medication is used in cryptosporidiosis diarrhea effectively?
Nitazoxanide
What pathogen has the fastest onset of diarrhea? What is tx?
Scombroid (histamine fish poisoning) can cause nonbloody diarrhea within 10 mins
Diphenydramine
Flushing and episodes of hypotension in a patient with chronic diarrhea should raise concern for what cause of diarrhea? How is it diagnosed and what is tx?
Carcinoid syndrome
Check urinary 5-HIAA level
Octreotide
What electrolyte/chemical abnormalities may be present in patients with fat malabsorption issues?
Vitamins A, D, E, and K
Hypocalcemia (failed vitamin D absorption)
Oxalate overabsorption (leading to calcium oxalate stones)
Loss of vit. K leads to easy bruising and prolonged PT/INR
Reduced vit B12 absorption
What is best initial test for fat malabsorption?
Sudan black stain of stool
What is the most sensitive test for fat malabsorption?
72 hr fecal fat
What skin lesion is Celiac’s disease assd with?
Dermatitis herpetiformis
What type of anemia may Celiac’s disease present with and how?
Microcytic due to iron deficiency from failed iron absorption
What is the best initial testing for Celiac’s?
Most accurate?
Initial: antigliadin, antiendomysial, or antitissue transglutaminase antibodies
Accurate: small bowel biopsy
What is D-xylose testing and what does it show in Celiac’s, tropical sprue, and Whipple’s disease?
Reduced D-xylose absorption due to villi destruction
*Rarely used test anymore
What will a small bowel biopsy show in a patient with tropical sprue?
What is tx?
Bx: microorganisms
Tx: doxycycline or TMP/SMX
*Tropical sprue will present similarly to Celiac’s but patient will have visited tropics and be negative for antibody serologies
What are additional findings in Whipple’s disease besides GI?
Ocular findings
Neurologic abnormalities
Arthralgia
What is the best test for diagnosing Whipple’s disease? Tx?
Diagnose with small bowel biopsy showing PAS positive organisms (alterantively could do PCR of stool showing Tropheryma whippelii)
Tx: tetracycline or TMP/SMX
What are the best initial radiologic tests for diagnosing chronic pancreatitis?
What is the most accurate test?
Initial: abdominal x-ray or abdominal CT
Accurate: secretin stimulation testing (normal person should release large amt of bicarbonate rich fluid when IV secretin given)
What is treatment of chronic pancreatitis?
Replace pancreatic enzymes regularly by mouth (e.g. give amylase, lipase, and trypsin)
In a patient who you suspect irritable bowel syndrome in what should you order on CCS?
Stool ova/parasites/white cells/guaiac, stool culture, fetal leukocytes
Colonoscopy
Abdominal CT
What are the three lines of therapy for irritable bowel syndrome?
1) Fiber
2) Antispasmodics/anticholinergics (e.g. dicycloamine or hyoscyamine)
3) TCA (e.g. amitryptiline)
If you have one family member who had colon cancer when should you get screened with colonoscopy?
At age 40 or 10 yrs before the age of dx of family member, whatever is first.
For patients who have concern for Lynch syndrome when should they be screened for colon cancer and how often?
Colonoscopy every 1-2 years starting at age 25
Describe Gardener’s syndrome
Benign bone tumors (osteomas) and other soft tissue tumors (e.g. colon cancer)
Describe Peutz-Jeghers syndrome
Is there extra screening recommended?
Melanotic spots on lips and hamartomatous polyps through small bowel and colon
Lifetime risk of colon cancer only slightly elevated so no additional screening recommended
Multiple extra hamartomas in the bowel is suggestive of what disease? Is there extra screening recommended?
Juvenille polyposis
No extra screening recommended
If a DYSPLASTIC polyp is found on colonoscopy when should it be repeated?
3-5 years
What is the utility of CEA?
It is a test to track progression NOT for screening
What is the most accurate test for diagnosis of diverticulosis?
Barium enema
*Caution: this is CONTRAINDICATED in diverticulITIS
Mgmt diverticulosis
High fiber diet
Best test for dx of diverticulitis?
Mgmt?
Dx: abdominal and pelvic CT scan
Ciprofloxacin (against gram negs) and metronidazole (against anaerobes)
How can the color of excretus distinguish bleeding location, i.e. red blood per rectum vs black stool vs coffee ground emesis?
Red blood per rectum often from lower GI bleed
Black stool indicates upper GI bleed
Coffee ground emesis from upper GI where acid involved (e.g. gastric, esophageal, duodenal)
What is the most common cause of death in GI bleeding?
Myocardial ischemia, therefore be sure to obtain an EKG
What are priorities in large GI bleeding before doing endoscopy?
Fluid resuscitation
Correcting thrombocytopenia, coagulopathy, or anemia
Oxygenate and get an EKG
Unnecessary use of stress ulcer ppx increases the risk of what conditions?
Pneumonia
C. diff colitis
What is the order of treatments done for variceal bleeding?
1) octreotide
2) endoscopy for variceal banding
3) if bleeding persists then can do TIPS procedure
What is the most common complication of TIPS?
Hepatic encephalopathy
What diagnostic test can tell you the source of bleeding in a patient with GI bleed unable to be found by endoscopy?
Technetium bleeding scan (“target red cell scan”)
What is the most accurate test for acute mesenteric ischemia?
Angiography
What class of anti-hypertensive meds may cause constipation?
CCBs
Distinguish the etiology of black stool per rectum which is passing quickly and often vs black stool per rectum which is passing seldomly (i.e. constipated).
If passing seldom the stool may be black from ferrous sulfate replacement and the iron causes constipation.
True black stool from upper GI bleeding leads to lots of defecation since blood is cathartic
What are mainstays of treatment of constipation?
Fiber and hydration
How does dumping syndrome present and why?
What is mgmt. generally?
Shaking, sweatiness, and weakness. Often in patient with previous gastric surgery. Due to large osmotic draw into bowel from large meal and can also cause reactive hypoglycemia.
Treatment is frequent small meals
How can you treat diabetic gastroparesis?
Erythromycin or metoclopramide
What urinary test can be used to assess the severity of pancreatitis?
Urinary trypsinogen activation peptide
If a patient presents with acute pancreatitis and it is found that there is common bile duct dilation and no pancreatic head mass what should be done next test-wise?
ERCP which can be diagnostic and therapeutic
What is therapy for acute pancreatitis?
NPO
Hydration
Pain meds
What is the utility of Ranson’s criteria?
Assesses severity of pancreatitis and who would need surgical debridement
If CT scan shows a patient with > 30% necrosis of the pancreas what should be the ensuing mgmt?
Imipenem
CT-guided biopsy –> if CT shows infection and necrosis of pancreas then move on to surgical debridement
What diseases are Hep B and C assd with respectively?
HBV: polyarteritis nodosa
HCV: cryoglobulinemia
All patients with hepatitis will have what lab finding?
Elevated direct bilirubin which causes jaundice and darkening of urine
Best initial test for HCV
Most accurate test for HCV
Initial: Hep C antibody
Accurate: HCV PCR of RNA and liver biopsy
What are some agents used to treat chronic HBV (keep in mind there is no treatment for acute HBV)?
Lamivudine Adefovir Entecavir Telebivudine Tenofovir IFN
What is the most common adverse effect of ribavirin?
Anemia
What oral protease inhibitors are added to ribavirin for the treatment of chronic HCV?
Ledipasvir, simeprevi, or sofosbuvir
What is ppx of variceal bleeding in cirrhotic pts?
Propranolol
What is the utility of the SAAG?
Serum ascites to albumin gradient
If > 1.1 then the cause of ascites is likely portal HTN or CHF
What lab value needs to present upon paracentesis of ascetic fluid to make a diagnosis of SBP?
> 250 neutrophils
What is treatment of SBP?
Ceftriaxone
For cirrhosis:
If ascites present then treat with ….
If encephalopathy present then treat with …
Ascites: spironolactone
Encephalopathy: lactulose
What is the best initial test for primary biliary cirrhosis? Most accurate test?
Initial: Elevated ALP with nl bilirubin. IgM elevated
Accurate: Antimitochondrial antibody, liver biopsy
What is treatment of primary biliary cirrhosis?
Ursodeoxycholic acid
What does primary sclerosing cholangitis often co-present with? How can it be distinguished from PBS on labs?
Primary sclerosing cholangitis: inflammatory bowel disease, itching
Should have elevated ALP and also elevated bilirubin (PBS has nl bilirubin)
What are the most accurate tests in diagnosing primary sclerosing cholangitis?
What is tx?
ERCP shows “beading” of biliary system
Antismooth muscle antibody (ASMA)
ANCA positive
Tx: Ursodeoxycholic acid
What symptoms do patients with Wilson’s disease present with?
Cirrhosis
Choreiform disorder
Neuropsychiatric abnormalities
Hemolysis
What are the best initial tests for Wilson’s disease?
Most accurate?
Tx?
Initial: slit lamp exam looking for Kayser Fleischer rings; low ceruloplasmin level
Accurate: liver biopsy
Tx: penicillamine or trientine
How may hemochromatosis present?
Restrictive cardiomyopathy
Skin darkening
Joint pain (d/t calcium pyrophosphate deposition)
Pancreatic damage (“bronze diabetes”)
Pituitary accumulation of Fe with panhypopituitarism
Infertility
Hepatoma
What is best initial and most accurate tests for hemochromatosis?
Initial: elevated serum iron and ferritin with low iron binding capacity
Accurate: liver biopsy; OR MRI of liver and HFe gene mutation
What is tx of hemochromatosis?
Phlebotomy
What is best initial and accurate test for autoimmune hepatitis?
Initial: ANA and anti-smooth muscle antibody. Serum protein electrophoresis shows hypergammaglobulinemia. (may also have positive ANA and liver/kidney microsomal antibody)
Accurate: liver biopsy
