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Step 2 CK > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Dysphagia vs Odynophagia

A

Dysphagia = difficulty swallowing

Odynophagia = pain while swallowing

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2
Q

Alarm symptoms that indicate a need for endoscopy

A

Weight loss

Blood in stool

Anemia

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3
Q

Define Achalasia

A

Inability of the LES to relax d/t loss of the nerve plexus

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4
Q

Diagnostic Tests for Achalasia

A

Barium esophagram: “bird’s beak”

Manometry = most accurate test

In the esophagus, barium studies are acceptable to do first in most patients, although radiologic tests always lack the specificity of endoscopic procedures

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5
Q

Treatment for achalasia

A

Cannot be “cured”

  1. Pneumatic dilation (leads to perforation in less than 3% of patients)
  2. Surgical sectioning or myotomy
  3. Botulinum toxin injection (reinjection every 3-6 months)
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6
Q

The term “progressive dysphagia” is the most important clue to the diagnosis of…

A

esophageal cancer

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7
Q

2 forms of spastic disorders of the esophagus

A

DES (diffuse esophageal spasm) and nutcracker esophagus

manometry will show a different pattern of abnormal contraction

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8
Q

Treatment for esophageal spastic disorders

A

CCB (similar to Prinzmental angina)

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9
Q

Pills that commonly cause esophagitis

A

Doxycycline

Alendronate

KCl

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10
Q

Next step for a patient with dysphagia and HIV CD4 < 100

A

Empirically start fluconazole (over 90% of esophageal infections in patients with AIDS are caused by Candida)

If no improvement = perform upper endoscopy with biopsy

  • Large ulcerations = CMV (treat with ganciclovir or foscarnet)*
  • Small ulcerations = HSV (treat with acyclovir)*
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11
Q

Schatzki ring vs Plummer-Vinson syndrome

A

Both give dysphagia

Schatzki = distal esophagus, often from acid reflux and associated with hiatal hernia

PVS = more proximal, iron deficiency anemia (NOT from blood loss) and can transform into SCC

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12
Q

Treatment for Schatzki ring and PVS

A

Schatzki ring = pneumatic dilation

PVS = iron replacement (may lead to resolution of the lesion)

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13
Q

Diagnosis and treatment for Zenker diverticulum

A

Best diagnosed with barium studies

Repaired with surgery (no medical therapy)

Do NOT answer NG tube or upper endoscopy because these may cause perforation

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14
Q

When is manometry the answer for a patient presenting with dysphagia

A

Achalasia

Spasm

Scleroderma

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15
Q

True/False

Mallory Weiss does NOT present with dysphagia

A

True

Mallory Weiss is a nonpenetrating tear of only the mucosa

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16
Q

Treatment for Mallory Weiss

A

It will resolve spontaneously

Severe cases with persistent bleeding are managed with an injection of epinephrine or electrocautery

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17
Q

What is the most common cause of epigastric pain?

A

Non-ulcer dyspepsia

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18
Q

What is the most likely diagnosis in a patient with epigastric pain and history of:

  1. Pain worse with food
  2. Pain better with food
  3. Weight loss
  4. Tenderness
  5. Bad taste, cough, hoarse
  6. Diabetes, bloating
  7. Nothing else
A
  1. Gastric ulcer
  2. Duodenal ulcer
  3. Cancer, gastric ulcer (2/2 pain)
  4. Pancreatitis
  5. GERD
  6. Gastroparesis
  7. Non-ulcer dyspepsia
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19
Q

When is endoscopy indicated for GERD?

A

Signs of obstruction (dysphagia or odynophagia)

Weight loss

Anemia or heme-positive stools

More than 5-10 years of symptoms to exclude Barrett

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20
Q

Treatment of GERD

A

PPIs for persistent symptoms

Liquid antacids or H2 blockers for mild/intermittent symptoms

5% will not respond to medical therapy: Nissen, Endocinch, Heat/radiation

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21
Q

Treatment for Barrett esophagus

A

Must biopsy

Barrett alone = PPIs and rescope every 2-3 years

Low-grade dysplasia = PPIs and rescope every 6-12 months

High-grade dysplasia = Ablation with endoscopy

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22
Q

When is stress ulcer prophylaxis indicated?

A

Mechanical ventilation

Burns

Head trauma

Coagulopathy

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23
Q

True/False

Alcohol and tobacco do NOT cause ulcers

A

True

They do, however, delay the healing of ulcers

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24
Q

What is the most accurate test for H pylori?

A

Biopsy

Urea breath testing and stool antigen are only positive during active infection

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25
Q

Treatment for biopsy (+) H pylori

A

PPI + clarithromycin + amoxicillin

PPI + clarithromycin + metronidazole (for penicillin allergy)

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26
Q

What is the most appropriate next step for a patient that has an endoscopically confirmed duodenal ulcer, but no reponse to standard treatment (i.e., triple therapy)?

A

Add bismuth or sucralfate

These may aid in resolution of treatment-resistant ulcers

Switching antibiotics to metronidazole and tetracycline would also be appropriate

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27
Q

How does management change for treatment refractory gastric ulcers?

A

Repeat endoscopy to exclude cancer

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28
Q

Treatment failure for ulcers most often stems from

A

Nonadherence to medications

Alcohol

Tobacco

NSAIDs

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29
Q

Difference between gastric ulcers and duodenal ulcers

A

GU pain is worse with food

GU is routinely biopsied

GU is associated with cancer in 4% of cases

Routinely repeating the endoscopy to confirm healing is standard with GU

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30
Q

When do you scope patients with non-ulcer dyspepsia?

A

If the patient is > 55 or if alarm symptoms (dysphagia, wt loss, anemia) are present

If the patient is < 45, give PPI

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31
Q

Large (> 1-2 cm) ulcer

Recurrent after Helicobacter eradication

Distal in the duodenum

Multiple

A

Think gastrinoma (Zollinger-Ellison Syndrome)

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32
Q

Management for suspected gastrinoma

A

Confirm by measuring: high gastrin levels with high gastric acidity

The next most important issue is to exclude metastatic disease (CT and MRI followed by a somatostatin receptor scintigraphy and endoscopic ultrasound if negative)

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33
Q

Treatment for gastrinoma

A

Local disease = remove surgically

Metastatic disease = lifelong PPIs

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34
Q

Treatment for diabetic gastroparesis

A

Erythromycin or metoclopromide

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35
Q

Most important initial management for GI bleeding

A

Assessing BP

The precise etiology of severe GI bleeding is not as important as a fluid resuscitation (NS or LR)

36
Q

The most common cause of upper GI bleeding…

The most common cause of lower GI bleeding…

A

Upper = ulcer disease

Lower = diverticulosis

37
Q

Define orthostasis

A

More than a 10 point rise in pulse when going from lying down to sitting/standing

OR

SBP drop of 20 points or more when sitting up

38
Q

Vomiting blood

Spider angiomata and caput medusa

Splenomegaly

Palmar erythema

Asterixis

A

Suspect variceal bleeding

39
Q

When is an NG tube good for management of GI bleeding

A

NG tube can rapidly identify upper GI bleeding (i.e., who needs upper endoscopy for banding before colonoscopy)

Example: if the stool is black in a person with cirrhosis but there is no hematemesis, an NG tube showing red blood may tell you to use ocreotide for varices and arrange urgent endoscopy for possible banding

40
Q

What percent of GI bleeding will stop spontaneously if fluid resuscitation is adequate?

A

80%

41
Q

When do you transfuse platelets?

A

When the count is < 50,000 and there is active bleeding

You would not transfuse platelets to prevent future spontaneous bleeds unless the count was much lower (10,000 - 20,000)

42
Q

When do you transfuse PRBCs vs FFP

A

PRBCs = when hematocrit is below 30 in an older patient or someone with CAD

FFP = when PT or INR is elevated and active bleeding is occurring

43
Q

In addition to fluids, blood, platelets, and plasma, what else can you do in the management of esophageal/gastric varices?

A
  1. Octreotide (somatostatin) decreases portal pressure
  2. Banding
  3. TIPS
  4. Propranolol or nadolol to prevent subsequent episodes of bleeding (will not do anything for current episode)
  5. Abx to prevent SBP with ascites
44
Q

Recurrent episodes of C diff-associated diarrhea are best treated with…

A

Another course of metronidazole

Switching to oral vanc or fidaxomicin is the answer when the patient does not respond to metronidazole (not because of recurrence)

45
Q

How do you distinguish chronic pancreatitis from gluten sensitive enteropathy?

A

The presence of iron deficiency

Iron needs an intact bowel wall to be absorbed, but does not need pancreatic enzymes

46
Q

The most accurate diagnostic test for celiac disease is

A

Small bowel biopsy that shows flattening of the villi (essential to exclude lymphoma)

  • Anti-tissue transglutaminase = first test*
  • Antiendomysial antibody*
  • IgA antigliadin antibody*
47
Q

The most accurate test for chronic pancreatitis is

A

Secretin stimulation testing: an unaffected pancreas will release large volume of bicarbonate-rich fluids after IV injection of secretin

x-ray = 50-60% sensitive for calcification

CT = 80-90% sensitive for calcification

Unlike acute, chronic pancreatitis has normal lipase/amylase levels

48
Q

Test and treatment for Carcinoid Syndrome

A

Best initial test = urinary 5 HIAA (the end product of serotonin metabolism)

Therapy = octreotide (stops tumor from secreting serotonin)

49
Q

Treatment for IBS

A
  1. Fiber
  2. Hyoscyamine or Dicyclomine (antispasmodic agents)
  3. TCAs
50
Q

True/False

Crohn disease that involves the colon has the same risk of colon cancer as UC

A

True

After 8-10 years of colonic involvement, screening should being every 1-2 years with colonoscopy

51
Q

ANCA vs ASCA in IBD

A

ANCA = antineutrophil cytoplasmic antibody (positive in UC)

ASCA = antisaccharomyces cerevesiae antibody (positive in Crohn’s)

Think NC = Not Crohn’s

52
Q

Treatment for IBD

A

Acute = steroids

Chronic = 5-ASA derivatives (mesalamine)

Azathioprine and 6-mercaptopurine are used to wean patients off steroids when the disease is so severe that recurrences develop as the steroids are stopped

53
Q

Perianal Crohn’s disease is also treated with…

A

ciprofloxacin and metronidazole

Infliximab is added for fistulas or disease unresponsive to other agents

54
Q

Steroids used for IBD

A

Prednisone and budesonide

55
Q

True/False

Vegetarians rarely develop diverticulosis

A

True

56
Q

LLQ pain/tenderness

Fever

Leukocytosis

Palpable mass

A

Diverticulosis

The best initial test is a CT scan

57
Q

Who is more likely to get a recommendation of surgery: young or old patients with diverticulitis?

A

Young patients

They should have their colon resected more often because of the greater total number of recurrent episodes that will occur

58
Q

Recommended screening for a patient with:

  1. Single family member who had colon cancer
  2. FHx of HNPCC (Lynch Syndrome)
  3. FHx of FAP
  4. Previous adenomatous polyp
  5. Previous history of colon cancer
A
  1. 10 years earlier than the age at which the family member developed cancer or age 40 (whichever is younger)
  2. Start at age 25 with colonoscopy every 1-2 years
  3. Start screening with sigmoidoscopy at age 12 every year
  4. Colonoscopy every 3-5 years
  5. Colonoscopy at 1 year after resection, then 3 years, then 5 years
59
Q

Multiple hamartomatous polyps in association with melanotic spots on the lips and skin

A

Peutz-Jeghers Syndrome

Increased frequency of breast, gonadal, and pancreatic cancer

60
Q

Colon cancer

Osteomas

Desmoid tumors

A

Gardner Syndrome

61
Q

Colon cancer

CNS malignancy

A

Turcot Syndrome

62
Q

What causes acute pancreatitis

A

Over 90% of cases are caused by alcoholism and cholelithiasis

“I GET SMASHED”
Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion, Hypercalcemia/Hypertriglyceridemia, ERCP, Drugs

63
Q

Difference in presentation between pancreatitis and cholecystitis

A

Pain of pancreatitis goes straight through to the back

Cholecystitis pain goes around the side to the back

64
Q

What lab value is associated with the worse prognosis in pancreatitis?

A

Low calcium

Severe pancreatic damage decreases lipase production leading to fat malabsorption in the gut; calcium binds with fat in the bowel, leading to calcium malabsorption. There is no correlation between the level of amylase/lipase and disease severity.

65
Q

Treatment for acute pancreatitis

A

NPO

IV hydration

Analgesia

PPIs (decrease pancreatic stimulation from acid entering the duodenum)

If there is more than 30% necrosis on CT or MRI, adding Abx (impipenem or meropenem) may decrease mortality

66
Q

What is the SAAG score?

A

Serum ascites albumin gradient =

Serum albumin - albumin level of ascitic fluid

< 1.1 g/dL = infections, cancer, or nephrotic syndrome

> 1.1 g/dL = portal HTN, CHF, hepatic vein thrombosis, or constrictive pericarditis

67
Q

What is Spontaneous Bacterial Peritonitis

A

Infection without perforation of the bowel

E. coli is the most common organism (unclear how the bacteria gets there to cause an infection)

68
Q

Best initial test for SBP

A

Cell count with more than 250 neutrophils

69
Q

Treatment for SBP

A

Cefotaxime or ceftriaxone

Prophylactic norfloxacin or TMP-SMX is used to prevent SBP

All variceal bleeding with ascites needs SBP prophylaxis

70
Q

How long does someone with SBP need prophylaxis?

A

Lifelong

71
Q

Treatment for specific features of cirrhosis:

  1. Ascites and edema
  2. Coagulopathy and thrombocytopenia
  3. Encephalopathy
  4. Varices
  5. Hepatorenal syndrome
A
  1. Spironolactone and other diuretics OR serial paracenteses
  2. FFP and platelets only if bleeding occurs
  3. Lactulose and rifaximin
  4. Propranolol/carvedilol and banding
  5. Somatostatin (octreotide), midodrine
72
Q

Binge drinking gives a sudden rise in…

A

GGTP

73
Q

Woman in 40s or 50s

Fatigue and itching

Normal bilirubin with elevated Alk phos

A

Primary Biliary Cirrhosis

Unique features = xanthelasma/xanthoma and osteoporosis

74
Q

Test for PBC

A

Most accurate = liver biopsy

Most accurate blood test = antimitochondrial antibody

75
Q

Treatment for PBC

A

ursodeoxycholic acid

76
Q

Pruritis

IBD

Elevated alk phos, GGTP, and bilirubin

A

Primary Sclerosing Cholangitis

77
Q

Test for PSC

A

Most accurate = MRCP or ERCP that shows beading, narrowing, or strictures in the biliary system

PSC is the only cause of cirrhosis for which a biopsy is NOT the most accurate test

78
Q

Treatment for PSC

A

Cholestyramine or ursodeoxycholic acid

PSC does NOT improve or resolve with resolution of IBD (even after a colectomy in UC, the patient may still progress to needing a liver transplant)

79
Q

What is hemochromatosis

A

Genetic disorder leading to overabsorption of iron in the duodenum (mutation is the C282y gene)

Men present earlier than women because mentruation delays the onset of liver fibrosis and cirrhosis

80
Q

How do you confirm the diagnosis of hemochromatosis

A

Abd MRI and HFE (C282y) gene testing

This can spare the patient the need for a liver biopsy

81
Q

True/False

Liver fibrosis (from hemochromatosis) can resolve if phlebotomy is begun before cirrhosis develops

A

True

82
Q

Treatment for chronic hep C

A

Combination of ledipasvir and sofosbuvir for Genotype 1

Sofosbuvir, ribavirin, and interferon for Genotypes 2 and 3

83
Q

Treatment for chronic hep B

A

Unlike hep C, hep B is treated with one medication

Adefovir, Lamivudine, Telbivudine, Entecavir, Tenofovir, or Interferon

84
Q

What is Wilson Disease?

A

Abnormally decreased copper excretion from the body (decreased levels of ceruloplasmin)

Best initial test = slit-lamp for Kayser-Fleischer rings (brownish ring around the eye)

85
Q

Treatment of Wilson Disease

A

Penicillamine (chelates copper and removes it from the body)

Zinc interferes with intestinal copper absorption

Trientine is an alternate copper-chelating compound

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