Gastroenterology Flashcards
1
Q
Tx. partial small bowel obstruction
A
observation and supportive therapy - IVF, NG suction, electrolytes
2
Q
first test for dysphagia
A
barium swallow
3
Q
what does odynophagia suggest?
A
infectious process such as HIV, HSV or Candida
4
Q
progressive dysphagia to both solids and liquids with occasional regurgitation of food particles and aspiration - dx?
A
achalasia
5
Q
best initial test: achalasia
A
barium swallow
6
Q
most accurate test: achalasia
A
esophageal manometer
- absence of normal esophageal peristalsis
- high pressure at LES
7
Q
best initial therapy: achalasia
A
surgical myotomy
- alt. pneumatic dilation
8
Q
when do you use wireless video endoscopy
A
small bowel disease only
- limited views of esophagus and stomach
- very high resolution
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
10
Q
best initial test if suspected esophageal ca.
A
endoscopy
- if not an option: barium swallow
11
Q
best initial therapy: esophageal ca.
A
surgical resection (if no local or distant mets) F/U surgery with 5-FU based chemotx
12
Q
proximal esophageal stricture in iron-deficient middle aged woman
A
Plummer Vinson syndrome
- may be assoc. with SCC
13
Q
best initial therapy: Plummer Vinson
A
iron replacement
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
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
16
Q
best initial therapy: Zenker diverticulum
A
surgical resection
17
Q
what two procedures are C/I in Zenker diverticulum?
A
endoscopy
NGT placement
- high risk of perforation
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
19
Q
tx. esophageal spasm
A
CCBs and nitrates
20
Q
HIV pt with CD4 < 100 presents with odynophagia - next step?
A
empiric fluconazole
- endoscopy only done if no response to fluconazole
21
Q
next step in HIV negative pt who presents with odynophagia
A
endoscopy
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
23
Q
Dx. Boerhaaves
A
esophagogram with water soluble contrast
- do NOT do EGD
24
Q
pt presents with upper GI bleeding following vomiting episode - dx? best initial test?
A
mallory weis tear
- dx test: EGD
25
Tx. mallory weiss tear
most cases resolve spontaneously
| - if bleeding persists, Epi injection can be used to stop the bleeding
26
CF of GERD
chronic cough/wheezing
sore throat
hoarseness
bitter/metallic taste
27
Best initial management of GERD
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
28
when do you need to do an EGD for pt with GERD?
1. alarm symptoms - dysphagia, weight loss, anemia, heme positive stool
2. symptoms of reflux > 5-10 years
29
endoscopic finding of barret's esophagus - action?
PPI
| repeat endoscopy Q2-3 years
30
endoscopic finding of low grade dysplasia of esophagus - action?
PPI
| rpt endoscopy in 3-6 months
31
endoscopic finding of high grade dysplasia of esophagus - action?
endoscopic mucosal resection, ablative removal or distal esophagectomy
32
MCC of epigastric discomfort
non-ulcer dyspepsia
| - diagnosis of exclusion
33
Tx. non ulcer dyspepsia
PPis
34
what needs to be done in any patient > 45 yo with epigastric pain?
EGD
35
management of H.pylori infection
PPI + clarithromycin + amoxicillin
| alt. PPI + metronidazole + tetracycline
- only treat h.pylori if it is associated with gastritis or ulcer disease
36
RF for stress ulcers
```
head trauma
mechanical ventilation > 48 hrs
burns
coagulopathy and steroid use in combo
sepsis
ICU > 1 week
occult GI bleed > 6 days
```
37
prophylaxis for stress ulcers
if enteral - use PPI
| if IV - use H2 blocker
38
do you need to treat finding of h.pylori if no gastritis or ulcer disease?
no - if having epigastric pain, may give PPI
39
multiple ulcers that persist with treatment for h.pylori - what should you order next?
gastrin level and gastric acid output testing
40
elevated gastrin level
1. Zollinger Ellison
| 2. anyone on a PPI or H2 blocker
41
lab findings in Zollinger Ellison syndrome
gastrin level elevated
| gastric acid output elevated
42
most accurate test for zollinger ellison
secretin stimulation test
| - normally, gastrin and gastric acid output decreases with secretin; with ZES, there is no change or an increase
43
diagnostic tests for ZES
endoscopic ultrasound
nuclear somatostatin scan
secretin stimulation
44
tx, local ZES
surgical resection
45
tx. metastatic ZES
PPIs lifelong
46
ASCA and ANCA results in Crohns vs. UC
Crohns: ASCA +, ANCA -
UC: ASCA - , ANCA +
47
screening colonscopy in IBD
perform Q1-2 years after 8-10 years of colonic involvement
48
best initial therapy for either CD or UC
mesalamine
49
adverse effects of sulfasalazine
rash
hemolytic anemia
interstitial nephritis
50
what steroid can be used to control acute exacerbations of IBD ?
budesonide
51
what drugs are used in pts with severe, recurrent IBD despite being on steroids?
Azathioprine and 6 mercaptopurine
52
when is infliximab useful for tx IBD?
Crohns disease that is associated with fistula formation
53
what antibiotics are useful for perianal involvement in Crohns?
metronidazole and ciprofloxacin
54
MCC of food poisoning
campylobacter
55
best initial test for infectious diarrhea
fecal leukocytes
56
most accurate test for infectious diarrhea
stool culture
57
What makes infectious diarrhea "severe"
blood
fever
abdominal pain
hypotension and tachycardia
58
tx. severe infectious diarrhea
FQ - cipro
59
Dx. giardia
stool ELISA antigen
60
Tx. giardia
metronidazole or tinidazole
61
diarrhea in HIV positive patient with CDC < 100 - dx? test? tx?
dx. cryptosporidum
test: modified acid fast stain
tx: antiretrovirals to raise CDC, paromomycin or nitazoxanide
62
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?
scombroid
| - tx. with antihistamines
63
tx. mild C.diff (WBC < 15,000, Cr < 1.5x)
PO metronidazole
64
tx. severe C. diff (WBC > 15 000 and Cr > 1.5x baseline)
PO Vancomycin
65
When would you have to do surgery to treat C.diff (subtotal colectomy)?
WBC > 20 000
Lactate > 2.2
Toxic megacolon
Severe ileus
66
Alternative treatment to vanco for severe, recurrent C.diff
Fidoxamicin
67
what should you do if you have a strong clinical suspicion of C.diff but lab studies are negative?
limited colonoscopy or flexible sigmoidoscopy
68
Causes of fat malabsorption and steatorrhea
Celiac dz
Tropical sprue
Whipples disease
Chronic pancreatitis
69
Associated findings with fat malabsorption
Hypocalcemia (vit d deficiency)
Oxalate over absorption with Oxalate stones
Easy bruising and elevated PT/INR
Vitamin b 12 malabsorption
70
Best initial test for malabsorption
Sudan black stain of stool
71
Most sensitive test for malabsorption
72 hour fecal fat
72
What nutritional deficiencies are unique to malabsorption due to celiac dz
Iron deficiency
| Folate deficiency
73
Best initial test for celiac disease
Antigliadin antiendomysial and anti tissue transglutaminase abs
74
Most accurate test for celiac dz
Small bowel biopsy
| - always needs to be done to exclude bowel lymphoma
75
Tropical sprue
Pt presents like celiac disease but there will be a history of travel and the antibody tests will be negative
76
Tx, tropical sprue
Tetracycline or TMP-SMX for 3-6 months
77
How does Whipple disease present?
Fat malabsorption diarrhea with arthralgias, neurological abnormalities and ocular findings
78
Most accurate diagnostic test for Whipples disease
Small bowel biopsy showing PAS positive organisms
| Alternate: PCR of stool for trophyerema whippeli
79
Tx. Whipples disease
Tetracycline or TMP-SMX for 12 months
80
Amylase and lipase levels in chronic pancreatitis
Normal
81
Best initial tests for diagnosing chronic pancreatitis
Abdominal XR
| Abdominal CT scan without contrast
82
Most accurate test for diagnosis of chronic pancreatitis
Secretin stimulation test
- normally, secretin causes large volume of bicarbonate rich pancreatic fluid secretion (decreased or absent in chronic pancreatitis)
83
What tests should you order on CCS in pt with suspected IBS
Stool guaic, white cells, culture, ova, parasite exam
Colonoscopy
Abdominal CT scan
84
screening for CRC if one family member had CRC
at age 40 or 10 years before the age of the family member - whichever one comes first
85
CRC screening if 3 family members, two generations and one premature form in history
every 1-2 years starting at age 25
86
CRC screening for FAP
sigmoidoscopy starting at age 12
87
usefulness of CEA marker in CRC
never for screening - used to follow response to therapy
88
LLQ pain with lower GI bleeding should make you think of..
diverticulosis
89
best diagnostic test for diverticulosis
abdominal CT
90
most accurate test for diverticulosis
colonscopy
91
Tx. diverticulosis
high fiber diet
92
CF: diverticulitis
LLQ pain
tenderness
fever
elevated WBC count
93
best diagnostic test for diverticulitis
abdominal CT scan
- confirmatory: shows thickening of bowel wall
- colonoscopy and barium enema are C/I
94
Tx. diverticulitis
IV antibiotics
1. Ciprofloxacin and metronidazole
2. Cefoxitin
3. Cefuroxime and metronidazole
95
common complication of diverticulosis
colovesicular fistula - causes pneumaturia
96
diseases that are associated with angiodysplasia
ESRD
Von Willebrand dz
aortic stenosis
97
most urgent step in management of severe GI bleeding
fluid resuscitation
98
orthostasis in GI bleeding
drop of > 20 mmHg in systolic pressure OR increase in pulse by > 10 /min implies >30% volume loss --> hemodynamic instability
99
CCS - what do you order for large volume GI bleeding?
```
bolus of normal saline
CBC
PT/INR
Type and cross
GI consult
EKG
```
100
when do you transfuse PRBCs in GI bleeding?
if Htc < 30 in older person; < 20-25 in young otherwise healthy person
101
when do you transfuse FFP in GI bleeding?
prolonged PT/INR
102
MCC of death in GI bleeding
myocardial ischemia
103
pt with GI bleeding and presence of ulcer disease - what should you add to managment?
PPI
104
Tx. variceal bleeding
1. octreotide
2. upper endoscopy w/ banding
3. if bleeding persists despite time --> consider TIPs
105
Pt presents with abdominal pain, bloody diarrhea and hypotension. During workup, a colonscopy shows patchy areas of depigmented mucosa - dx? tx?
Ischemic colitis
- if transmural, the mucosa will be sloughing and green
tx. IVF, bowel rest
106
when do you use a technetium bleeding scan
performed to detect site of bleeding if endoscopy does not reveal a source
107
when do you use capsule endoscopy in GI bleeding
if upper and lower endoscopy cannot reveal a source
108
Tx. acute pancreatitis
IVF
IV narcortics
IV abx - only if necrotizing pancreatitis
109
Antibiotic of choice in severe necrotizing pancreatitis (suspect when pt with pancreatitis spikes a fever)
Imipinem
| - also: 3rd gen ceph, piperacillin, FQs, metronidazole
110
Tx. mallory weiss tear that is not actively bleeding
observation and supportive care
111
what anatomical predisposing factor is seen in Mallory-Weiss syndrome
hiatal hernia (10-40% of pts)
112
standard caloric intake for enteral feeding
30 kcal/kg/day with 1 g/kg/day of protein
113
Dx. SBP
1. ascites PMN count > 250 /mm3
| 2. positive ascites culture or stain (usually E.coli, strep and rarely, staph)
114
Tx. SBP
3rd gen. ceph (cefotaxime)
115
Dx. diverticulitis
Abdominal CT scan
| - colonic wall thickening, stranding of mesenteric fat
116
Tx. mild diverticulitis
outpatient Ciprofloxacin + Metronidazole
117
dyspepsia
chronic/recurrent pain or fullness in the epigastric area without significant heartburn
118
confirmation of eradication of H.pylori
fecal antigen test or urea breath test - 4 weeks after completion of therapy
119
for whom should you confirm eradication of h.pylori?
duodenal ulcer
persistent dyspepsia
MALToma
resection of early gastric ca
120
Indications for biliary drainage in acute cholangitis
1. persistent abdominal pain
2. hypotension despite aggressive fluid resuscitation
3. fever > 39C
4. mental confusion
121
pain on an empty stomach
duodenal ulcer
122
CF of chest pain assoc. with GERD
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
Side Effects of Isotretnoin
```
hypertriglyceridmia (acute pancreatitis)
mucocutaneous lesions
myalgias
hyperostosis
pseudotumor cerebri
night vision troubles
BM suppression
hepatotoxicity
```
124
Tx. Toxic Megacolon
1. ICU admission
2. NGT
3. Glucocorticoids
4. IVF and electrolytes
125
which two drugs should not be used in toxic megacolon?
1. opiates
| 2. 5ASA compounds
126
two most common causes of massive colonic bleeding
angiodysplasia
| diverticulosis
127
source of bleeding in diverticulosis
ruptured vasa recta either at apex or neck of
| diverticulum (erosion of the artery)
128
associations with angiodysplasia
aortic stenosis
| ESRD
129
manometric findings in scleroderma
absence of peristaltic waves and decreased LES tone
130
Classic symptoms of sclerodermal esophageal dysmotlity
sticking sensation in throat accompanied by heartburn
131
s/e: kava
liver toxicity - hepatitis, cirrhosis, liver failure
132
lactose breath hydrogen test
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
what other screening test should be done when FAP is diagnosed?
screening upper endoscopy
| - gastric and duodenal adenomas/carcinomas are MC
134
serum sickness-like syndrome in prodromal phase of Hep B infection
Type 3 reaction (circulating immune complexes)
- fever, rash, arthralgias
- polyarteritis nodosa
- glomerulonephritis
135
splenic vein thrombosis
isolated gastric varices as a complication of chronic recurrent pancreatitis; may also have massive splenomegaly
136
portal vein thrombosis
esophageal and gastric varices
137
management of swallowing issues in ALS pts
insertion of PEG tube
| - does not lead to development of sinusitis and does not affect the patients breathing or speech
138
Drugs that can cause pancreatitis
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
Dx. acute mesenteric ischemia -most accurate test
angiography
140
CF: acute mesenteric ischemia
severe abdominal pain
metabolic acidosis
elevated amylase level
141
Management approach to acute mesenteric ischemia
1. Plain film
- if negative: assess risk of hypercoagulability
LOW risk = are there peritoneal findings?
- yes: laparotomy
- no: angiography
HIGH risk = dynamic CT
142
Tx. acute mesenteric ischemia
surgical resection of the bowel - surgical emergency
143
Pt with history of gastric surgery presents with shaking, sweating, weakness and hypotension following meals. Dx/ Management?
Dx. Dumping syndrome
Tx. small frequent meals (low carb, high protein/fat)
- trial of somatostatin
144
Dx. diabetic gastroparesis
1. R/O mechanical obstruction and extrinsic compression with upper endo or CT/MRI respectively
2. confirmatory test: nuclear gastric emptying study
145
Tx. diabetic gastroparesis
smaller meals with less fat content
| Tx. erythromycin or metoclopramide
146
acute pancreatitis
- best initial test (1)
- most accurate test (2)
1. amylase and lipase serum levels
| 2. abdominal CT
147
when is MRCP used for acute pancreatitis?
it can detect causes of biliary and pancreatic duct obstruction not found on CT scan
148
when is ERCP used for acute pancreatitis?
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
what urinary test can be used to detect the severity of pancreatitis?
trypsinogen activation peptide
150
management acute pancreatitis
1. NPO - if > 48 hours, consider NJ feeds with high protein, low fat meals
2. hydration
3. medications
151
scoring system for severity of acute pancreatitis
APACHE II criteria
| - most precise method: CT scan
152
if CT scan shows necrosis of pancreas - what do you do
abx - imipenem
| CT guided biopsy - if infected/necrotic, pt requires surgical debridement of pancreas
153
what other condition is hep B associated with? hep c?
hep B = PAN
hep C = cryoglobulinemia
- both can present like a serum-sickness (joint pain, uriticaria, fever)
154
which LFT is elevated in viral hepatitis? drug-induced hepatitis?
viral = ALT
| drug induced = AST
155
what is the first test to become abnormal in Hep B
surface antigen
156
dx. chronic hep B
presence of surface antigen for > 6 months
157
what is the only antibody present during the window period of hep B infection
core antibody
158
when should babies born to hep B positive women get serology controls?
3-4 months after last vaccine dose
159
hep C
- best initial test (1)
- most accurate test (2)
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
when do you use liver biopsy in hep C
most accurate way of determining seriousness of disease; determines extent of liver damage
161
Tx. chronic hep B
```
lamivudine
adefovir
entecavir
telbivudine
tenofovir
interferon
```
162
tx. chronic hep C
interferon + ribavirin and boceprevir or telaprevir
163
S/E: Interferon
```
flulike symptoms
arthralgia
myalgia
fatigue
thrombocytopenia
depression
```
164
MC adverse effect of ribavirin
anemia
165
postexposure prophylaxis of hep C
none
166
Hepatorenal syndrome
pt with cirrhosis presents with Urine Na <10 with no increase in urine output with a fluid challenge; Tx. liver transplant
167
Tx. encephalopathy 2ndary to cirrhosis
lactulose
168
Tx. ascites 2ndary to cirrhosis
spironolactone
169
Management: esophageal varices in cirrhosis
1. if bleeding --> banding
2. should receive prophylactic abx (Cipro) prior to banding
3. prophylaxis --> propranolol
170
when should you get a paracentesis in cirrhosis
1. new onset ascites
| 2. pt with ascites and pain, fever or tenderness
171
serum to ascites albumin gradient
> 1.1 indicates portal HTN from cirrhosis or CHF
172
Tx. SBP
Cefotaxime
| - follow up prophylaxis with levofloxacin
173
MELD scoring system
determines 90 day mortality in pts with advanced liver disease based on INR, serum bilirubin and serum Cr levels
174
middle aged woman comes in itching skin and xanthelasmas. She has a history of hypothyroidism. Labs show elevated ALP. Dx? Most accurate test? Tx?
Dx. primary biliary cirrhosis
Test: antimitochondrial ab, liver biopsy
Tx. ursodeoxycholic acid
175
patient with IBD presents with itching skin and jaundice. labs show elevated ALP. Dx? Most accurate test? Tx?
Dx. primary sclerosing cholangitis
Test: antismooth mm ab, ERCP (beading), ANCA positive
Tx. ursodeoxycholic acid
176
dx. Wilson's disease
initial - Slit lamp exam, low ceruloplasmin level
| most accurate: liver biopsy
177
Tx. Wilson's disease
penicillamine
| trientine
178
MCC of death in hemochromatosis
cirrhosis
179
CF: hemochromatosis
```
restrictive CM
skin hyperpigmentation
joint pain --> pseudogout (2nd/3rd MCP, polyarthritis)
diabetes
panhypopituitarism
infertility
hepatoma
```
180
best initial tests for hemochromatosis
elevated serum iron and ferritin
low TIBC
transferrin sat > 50%
181
confirmatory test hemochromatosis
1. liver biopsy
| 2. MRI of liver + HFE gene mutation
182
Tx. hemochromatosis
phlebotomy
183
best initial tests for autoimmune hepatitis
ANA
anti-smooth mm ab
SPEP = hypergammaglobulinemia
184
Tx. autoimmune hepatitis
prednisone
