Gastroenterology Flashcards
___________ is a protrusion on the upper part of the stomach into the chest, generally caused by obesity weakening the diaphragm. It is associated with heartburn, chest pain, and dysphagia; symptoms can be indistinguishable from GERD.
Hiatal Hernia
How would you diagnose Hiatal Hernia?
Endoscopy or Barium Studies
This is the best initial therapy for Hiatal Hernia.
Weight loss and PPIs
These are alarm symptoms that indicates Endoscopy for Hiatal Hernia.
Weight loss
Blood in stool
Anemia
This is the inability of the lower esophageal sphincter (LES) to relax due to a loss of the nerve plexus within the lower esophagus. The etiology is not clear. There is aperistalsis of the esophageal body.
Achalasia
The patient is usually young (under 50), progressive dysphagia to both solids and liquids at the same time. There is no association with alcohol and tobacco use. What is the most likely diagnosis?
Achalasia
What is the most accurate test for Achalasia?
Manometry - will show a failure of the lower esophageal sphincter to relax
What will you see in the Barium esophagram of Achalasia?
“bird’s beak” as the esophagus comes down to a point
What are your treatment options for Achalasia?
Pneumatic dilation
Surgical sectioning or Myotomy
Botulinum toxic injection
Achalasia cannot be “cured”. Treatment is based on simple mechanical dilation of the esophagus
Patient is usually age 50 or older and presents with dysphagia first for solids, followed later (progressing) to dysphagia for liquids. It is associated with prolonged alcohol and tobacco use and more than 5-10 years of GERD symptoms. What is the most likely diagnosis?
Esophageal Cancer
How would you diagnose Esophageal Cancer?
Biopsy
How would you treat Esophageal Cancer?
Surgical Resection
Chemotherapy and radiation in addition to surgical removal
Stent placement for lesions that cannot be resected surgically to keep esophagus open for palliation and to improve dysphagia
What are the two forms of Esophageal Spasms?
Diffuse Esophageal Spasm (DES)
Nutcracker esophagus
How would esophageal spasm present?
- sudden onset of chest pain that is not related to exertion
- precipitated by drinking cold liquids
How can you distinguish DES and Nutcracker Esophagus?
Manometry
How would you treat esophageal spastic disorders?
Calcium Channel Blockers and Nitrates
A 43-year-old man recently diagnosed with AIDS comes to the emergency department with pain on swallowing that has become progressively worse over the last several weeks. There is no pain when not swallowing. His CD4 count is 43mm3. The patient is not currently taking any medications.
What is the most appropriate step in management?
a. Esophagram
b. Upper endocopy
c. Oral nystatin swish and swallow
d. Intravenous amphotericin
e. Oral fluconazole
E. The most commonly asked infectious esophagitis question is esophageal candidiasis in a person with AIDS.
This is associated with intermittent dysphagia. It is often from acid reflux and is associated with hiatal hernia. This is a type of scarring or tightening (also called peptic stricture) of the distal esophagus.
Schatzki Ring
How would you treat Schatzki Ring?
Pneumatic dilation in an endoscopic procedure
This presents as dysphagia and is associated with iron deficiency anemia and can rarely transform into squamous cell cancer. The IDA is not caused by blood loss. This is located more proximal.
Plummer-Vinson syndrome
How would you treat Plummer-Vinson syndrome?
Iron replacement
This is an outpocketing of the posterior pharyngeal constrictor muscles. There is dysphagia, halitosis, and regurgitation of food particles. Some patients suffer from aspiration pneumonia when the contents of the diverticulum end up in the lung. What is the most likely diagnosis?
Zenker diverticulum
How would you diagnose and treat Zenker diverticulum?
Barium Studies and Surgery Repair
What procedures are dangerous for people with Zenker diverticulum?
Nasogastric tube placement or upper endoscopy
This presents with upper gastrointestinal bleeding after prolonged or severe vomiting or retching. Repeated retching is followed by hematemesis of bright red blood, or by black stool. It does NOT present with dysphagia. What is the most likely diagnosis?
Mallory-Weiss Tear
A 44-year-old woman comes to see you because of pain in her epigastric area for the last several months. She denies nausea, vomiting, weight loss, or blood in her stool. On physical examination, you find no abnormalities.
What is the most likely diagnosis?
a. Duodenal ulcer disease
b. Gastric ulcer disease
c. Gastritis
d. Pancreatitis
e. Non-ulcer dyspepsia
f. Pancreatic cancer
E. Non-ulcer dyspepsia is, by far, the most common cause of epigastric pain.
If patient presents with epigastric pain and is associated with pain that is worse with food, what is the most likely diagnosis?
Gastric Ulcer
If patient presents with epigastric pain and is associated with pain that is better with food, what is the most likely diagnosis?
Duodenal Ulcer
If patient presents with epigastric pain and is associated with weight loss, what is the most likely diagnosis?
Cancer, Gastric Ulcer
If patient presents with epigastric pain and is associated with tenderness, what is the most likely diagnosis?
Pancreatitis
If patient presents with epigastric pain and is associated with bad taste, cough, hoarse, what is the most likely diagnosis?
Gastroesophageal reflux
If patient presents with epigastric pain and is associated with diabetes and bloating, what is the most likely diagnosis?
Gastroparesis
This is the only diagnostic test to truly understand the etiology of epigastric pain from ulcer disease.
Endoscopy
This is always a best initial therapy for epigastric pain.
PPIs
This is the inappropriate relaxation of the lower esophageal sphincter, resulting in acid contents of the stomach coming up into the esophagus. Its symptoms are worsened by nicotine, alcohol, chocolate, peppermint, late-night meals, and obesity.
GERD
A 42-year-old man comes to the office with several weeks of epigastric pain radiating up under his chest which becomes worse after lying flat for an hour. He also has a “brackish” taste in his mouth and a sore throat.
What is the most appropriate next step in the management of this patient?
a. Ranitidine
b. Liquid antacid
c. Lansoprazole
d. Endoscopy
e. Barium swallow
f. 24-hour pH monitoring
C. Lansoprazole is a PPI that should be used to control symptoms of GERD. When the diagnosis is very clear (such as in this case), with epigastric pain going under the sternum, bad taste, and sore throat, confirmatory testing is not necessary.
If patient with GERD is not responsive to medical therapy, what can you consider for treatment?
Nissen fundoplication
Endocinch
Local heat or radiation of LES
This disease occurs due to long-standing (at least 5 years) GERD and leads in changes in the lower esophagus with columnar metaplasia.
Barrett Esophagus
This is the only way to be certain of the presence of Barrett Esophagus.
Biopsy
Upon biopsy, you discovered barrett esophagus alone. What is your management?
PPIs and rescope ever 2-3 years
Upon biopsy, you discovered barrett esophagus with low-grade dysplasia. What is your management?
PPIs and rescope evert 6-12 months
Upon biopsy, you discovered barrett esophagus with high-grade dysplasia. What is your management?
ablation with endoscopy: photodynamic therapy, radiofrequency ablation, endoscopic mucosal resection
This is the inflammation or erosion of the gastric lining. It is caused by Alcohol, NSAIDs, Helicobacter pylori, Portal hypertension, Stress such as burns, trauma, sepsis, and multiorgan failure (e.g., uremia).
Gastritis
This is the diagnostic test for erosive gastritis.
Upper endoscopy
This is the most accurate test for Helicobacter pylori
Endoscopic biopsy
How would you treat Gastritis?
PPIs
What are the indications for stress ulcer prophylaxis?
Mechanical ventilation
Burns
Head trauma
Coagulopathy
This is the most common cause of Peptic Ulcer Disease?
Helicobacter Pylori
This is the second most common cause of Peptic Ulcer Disease?
NSAIDs
This is the most accurate test for PUD.
Upper endoscopy
If the cause of PUD is H. Pylori, this is the best initial therapy.
PPI combined with Clarithromycin and Amoxicillin
In PUD that does not respond to initial therapy, what antibiotics can you use as an alternate?
Metronidazole and Tetracycline
A 56-year-old woman comes to the clinic because her symptoms of epigastric pain from an endoscopically confirmed duodenal ulcer have not responded to several weeks of a PPI, clarithromycin, and amoxicillin.
What is the most appropriate next step in the management of this patient?
a. Refer for surgery
b. Switch the PPI to ranitidine.
c. Abdominal CT scan
d. Capsule endoscopy
e. Urea breath testing
f. Vagotomy
g. Add sucralfate
E. If there is no response to DU therapy with PPIs, clarithromycin, and amoxicillin, the first thought should be antibiotic resistance of the organism. Persistent H. Pylori infection can be detected with several methods such as urea breath testing, stool antigen detection, or a repeat endoscopy for biopsy. It would be very hard to choose between these, and that is why they are not all given as choices in this question.
Which one of the two types of PUD has a higher chance of evolving to cancer?
Gastric Ulcer
This is a patient with large (>1-2 cm) ulcers, recurrent H. Pylori infection, ulcers usually found in distal part of duodenum, and usually occurs in multiple. What is the most likely diagnosis?
Zollinger-Ellison Syndrome
What is the most accurate diagnostic test for Zollinger-Ellison Syndrome once endoscopy confirms presence of ulcer?
- High gastrin levels off antisecretory therapy (PPIs or H2 blockers) with high gastric acidity
- High gastrin levels despite a high gastric acid output
- Persistent high gastrin levels despite injecting secretin
This is associated with a massive increase in the number of somatostatin receptors in the abdomen.
Gastrinoma
A 64-year-old patient with diabetes for 20 years comes to the office with several months of abdominal fullness, intermittent nausea, constipation, and a sense of “bloating”. On physical examination, a “splash” is heard over the stomach on auscultation of the stomach when moving the patient.
What is the most appropriate next step in the management of this patient?
a. Abdominal CT Scan
b. Colonoscopy
c. Erythromycin
d. Upper endoscopy
e. Nuclear gastric emptying study
C. When the diagnosis of diabetic gastroparesis seems clear, there is no need to do diagnostic testing unless there is a failure of therapy. Erythromycin and metoclopramide increase gastrointestinal motility. The most accurate test for diabetic gastroparesis is the nuclear gastric emptying study, although it is rarely needed.
A 69-year-old woman comes to the emergency department with multiple red/black stools over the last day. Her past medical history is significant for aortic stenosis. Her pulse is 115 per minute and her blood pressure is 94/62 mm Hg. The physical examination is otherwise normal.
What is the most appropriate nest step in the management of this patient?
a. Colonoscopy
b. Nasogastric tube placement
c. Upper endoscopy
d. Bolus of normal saline
e. CBC
f. Bolus of 5% dextrose in water
g. Consult gastroenterology
h. Check for orthostasis
D. The precise etiology of severe GI bleeding is not as important as a fluid resuscitation. There is no point in checking for orthostasis with the person’s systolic blood pressure under 100 mm Hg or when there is tachycardia at rest. Endoscopy should be performed, but it is not as important to do first as fluid resuscitation. When blood pressure is low, normal saline (NS) or Ringer lactate are better fluids to give than 5% dextrose in water (D5W). D5W does not stay in the vascular space to raise blood pressure as well as NS.
This is the most common cause of upper GI bleeding.
Ulcer disease
This is the most common cause of lower GI bleeding.
Diverticulosis
This is the most important initial management for GI bleeding.
Assess BP
Define Orthostasis.
More than a 10-point rise in pulse when going from lying down to sitting or standing up
or
Systolic blood pressure drop of 20 points or more when sitting up
This is the only form of GI bleeding in which physical examination helps determine its etiology. The presence of the signs of liver disease helps establish diagnosis. Associated with vomiting blood with or without black stool, spider angiomata and caput medusa, splenomegaly, palmar arythema, and asterixis.
Variceal Bleeding
What is the most important therapy for GI bleeding?
Fluid replacement with high volumes (1 to 2 liters an hour) of saline or Ringer lactate in those with acute severe bleeding
What will you give for Variceal bleeding?
Octreotide
When will you give Packed Red Blood Cells in a patient with GI bleeding?
if the hematocrit is below 30 in those who are older or suffer from coronary disease
When will you give Fresh Frozen Plasma in a patient with GI bleeding?
if the PT or INR is elevated and active bleeding is occurring
When will you transfuse in a patient with GI bleeding?
when count is below 50,000 and there is bleeding
This is given to prevent subsequent episodes of GI bleeding.
Propanolol
This is the best initial test to detect antibiotic-associated diarrhea.
C. diff toxin test or PCR
This is the best initial therapy to detect antibiotic-associated diarrhea.
Metronidazole
A 73-year-old man is admitted to the hospital with pneumonia. Several days after the start of antibiotics, he begins to have diarrhea. The stool C. diff toxin is positive and he is started on metronidazole, which leads to resolution of diarrhea over a few days. Two weeks later the diarrhea recurs and the C. diff toxin is again positive.
What is the most appropriate next step in the management of this patient?
a. Retreat with metronidazole orally
b. Use vancomycin orally
c. Sigmoidoscopy and treat only if pseudomembranes are found.
d. Intravenous metronidazole
e. Wait for stool culture
d. Intravenous vancomycin
A. Recurrent episodes of C-diff associated diarrhea are best treated with another course of metronidazole
This antibiotic is associated with the highest incidence of antibiotic-associated diarrhea.
Clindamycin
This bacteria is associated with the highest incidence of antibiotic-associated diarrhea.
Clostridium difficile
What will you give if the patient with This antibiotic is antibiotic-associated diarrhea does not respond to Metronidazole?
Switch to Oral Vancomycin or Fidaxomicin
This is the most common types of malabsorption and can present as an adult.
Celiac Disease
This is the most accurate diagnostic test for celiac disease.
Small Bowel Biopsy
This is the most accurate diagnostic test for Chronic Pancreatitis.
Secretin Stimulation Testing
What is the treatment for Chronic Pancreatitis?
Enzyme replacement
What is the treatment for Celiac Disease?
Avoid gluten-containing foods such as wheat, oats, rye, or barley
What is the treatment for Whipple Disease?
Ceftriaxone, trimethoprim/sulfamethoxazole
What is the treatment for Tropical Sprue?
Trimethoprim/Sulfamethoxazole, Tetracycline
This disease presents with intermittent diarrhea in association with flushing, wheezing, cardiac abnormalities of the right side of the heart.
Carcinoid Syndrome
This is the best initial diagnostic test for Carcinoid Syndrome.
Urinary 5-hydroxyindoleacetic acid (5 HIAA) test
What do you give patients with Carcinoid Syndrome?
Octreotide
This is a pain syndrome that can have diarrhea, constipation, or both. Its pain is relieved by bowel movement, less at night, and relieved by a change in bowel habit. There is no weight loss.
Irritable Bowel Syndrome
This is an idiopathic disorder that presents with diarrhea, blood in the stool, weight loss, and fever.
Inflammatory Bowel Disease
These are extraintestinal manifestations found in Inflammatory Bowel Disease.
Arthralgias
Uveitis, Iritis
Skin manifestation (erythema nodosum, pyoderma gangrenosum)
Sclerosing cholangitis (more frequent in UC)
This type of IBD has skip lesions, transmural granulomas, fistulas and abscesses, masses and obstruction, and perianal disease
Crohn disease
This type of IBD can be cured by surgery, entire mucosal, no fistulas or abscesses, no obstruction, and no perianal disease.
Ulcerative colitis
When should screening for colon cancer occur in IBD?
After 8 to 10 years of colonic involvement, with colonoscopy every 1 to 2 years
This is the most accurate test for Inflammatory Bowel Disease.
Endoscopy
How would you treat acute exacerbation of disease in both CD and UC?
Steroids
These medications are used to wean patients off of steroids in IBD.
Azathioprine and 6-mercaptopurine
In the presence of fistulae and severe disease unresponsive to other agents in patients with IBD, what is your management?
Infliximab (anti-tumor necrosis factor)
This is defined as outpocketings of the colon on a standard meat-filled diet as to be routinely expected in those above 65 to 70 years. Patients may present with left lower quadrant abdominal pain, constipation, bleeding, and sometimes infection (diverticulitis).
Diverticulosis
This is the most accurate test for Diverticulosis
Colonoscopy
These are used to decrease the rate of progression and complications of Diverticulosis
Bran
Psyllium
Methylcellulose
Dietary Fiber
This is an older patient presenting with left lower quadrant pain and tenderness, fever, leukocytosis, and sometimes palpable mass. What is the most likely diagnosis?
Diverticulitis
What are your treatment options for Diverticulitis?
Ciprofloxacin with metronidazole
or
Amoxicacillin/clavulanate
Ticarcillin/clavulanate or pipercillin/tazobactam
Ertapenem (carbapenems)
Which of the following is the most effective method of screening for colon cancer?
a. Colonoscopy
b. Sigmoidoscopy
c. Fecal occult blood testing (FOBT)
d. Barium enema
e. Virtual colonoscopy with CT scanning
f. Capsule endoscopy
A. Since 40% of colon cancer occurs proximal to the rectum and sigmoid colon, sigmoidoscopy is not really sensitive in detecting lesions as colonoscopy. Barium studies, CT colonoscopy, and capsule endoscopy do not allow for biopsy. FOBT has more false positives and false negatives than colonoscopy. In addition, a positive FOBT must be followed up with colonoscopy.
How do you scare someone with a family history of colon cancer?
Single family member: begin 10 years earlier than the age at which the family member developed their cancer or age 40, whichever is younger. Repeat the scope every 5 years if the family member is under age 60
Three family members, 2 generations, 1 premature (before 50): Hereditary Nonpolyposis Colon Cancer Syndrome comprises these factors. Start screening at age 25 with colonoscopy every 1 to 2 years
Familial adenomatous polyposis (FAP): Start screening at age 12 every year
Previous adenomatous polyp: Patient should have a colonoscopy every 3 to 5 years
Previous history of colon cancer: Patient should have colonoscopy at 1 year after resection, then at 3 years, then every 5 years
This is characterized by multiple hamartomatous polyps associated with melanotic spots on the lips and skin, increased frequency of breast cancer, and increased gonadal and pancreatic cancer.
Peutz-Jeghers Syndrome
This is colon cancer associated with osteomas, desmoid tumors, and other soft tissue tumors.
Gardner Syndrome
This is colon cancer associated with CNS malignancy.
Turcot Syndrome
This is colon cancer associated with multiple hamartomatous polyps.
Juvenile Polyposis
This is the most common cause of Acute Pancreatitis.
Alcoholism and Cholelithiasis
Patient presents with acute epigastric pain with tenderness and nausea/vomiting. What is the most likely diagnosis?
Acute Pancreatitis
Which of the following is associated with the worst prognosis in pancreatitis?
a. Elevated amylase
b. Elevated lipase
c. Intensity over the pain
d. Low calcium
e. C-reactive protein (CRP) rising
D. Severe pancreatic damage decreases lipase production and release leading to fat malabsorption in the gut. Calcium binds with fat (saponifies) in the bowel, leading to calcium malabsorption. Although amylase and lipase are elevated in pancreatitis, there is no correlation between the height of these enzyme levels and disease severity.
What is the best initial test for Acute Pancreatitis?
Amylase and Lipase
What is the most specific test for Acute Pancreatitis?
CT Scan (Abdominal CT Scan is always performed with IV and oral contrast to better define and outline abdominal structures)
What will you see in the plain X-Ray of a patient with Acute Pancreatitis?
Sentinel loop of bowel (air-filled piece of small bowel in left upper quadrant)
What is the treatment for Acute Pancreatitis?
NPO (no food)
IV hydration at very high volume
Analgesia
PPIs decrease pancreatic stimulation from acid entering the duodenum
What are the indications for Paracentesis?
New-onset ascites
Abdominal pain and tenderness
Fever
What is the best initial test for spontaneous bacterial peritonitis?
Cell count with more than 250 neutrophils is the basis upon which we start therapy
What is the treatment of SBP?
Cefotaxime or Ceftriaxone
Patient is a woman in her 40s or 50s complaining of fatigue and itching, normal bilirubin with an elevated alkaline phosphatase. There could be presence of xanthelasma/xanthoma, and osteoporosis. What is the most likely diagnosis?
Primary Biliary Cholangitis (PBC)
What is the most accurate test for Cirrhosis?
Liver Biopsy
What is the most accurate blood test for Cirrhosis?
Antimitochondrial antibody
How would you treat PBC?
Ursodeoxycholic acid or Obeticholic acid
This liver disease can be associated with inflammatory bowel disease. Patient usually complains with pruritus. Labs show elevated alkaline phosphatase and GGTP as well as elevated bilirubin level. What is the most likely diagnosis?
Primary Sclerosing Cholangitis
This is the most accurate test for Primary Sclerosing Cholangitis.
MRCP or ERCP
beading, narrowing, or strictures in the biliary system
This is a combination of liver disease and emphysema (COPD) in a young patient (under 40) who is a nonsmoker. There may be a family history of COPD at an early age. What is the most likely diagnosis?
Alpha 1-Antitrypsin Deficiency
What is the treatment for Alpha 1-Antitrypsin Deficiency?
Replace the enzyme
This is a genetic disorder leading to overproduction of iron in the duodenum. The mutation is the C282y gene. Men presents earlier than women because menstruation delays the onset of liver fibrosis and cirrhosis. What is the most likely diagnosis?
Hemochromatosis
What is the best initial test for Hemochromatosis?
Iron studies that show:
- Increased serum iron and ferritin
- Decreased iron binding capacity
What is the most accurate test for Hemochromatosis?
Liver biopsy for increased iron
A 54-year-old man has been evaluated in the office for fatigue, erectile dysfunction, and skin darkening. He is found to have transferrin saturation (iron divided by TIBC) above 50%. His AST is 2 times the upper limit of normal.
What would you do next to confirm the diagnosis?
a. Echocardiography
b. Glucose level
c. Abdominal MRI and HFE (C282y) gene testing.
d. Liver biopsy
e. Prussian blue stain of the bone marrow
f. Deferoxamine
g. Deferasirox
C. MRI will show increased iron deposition in the liver. An abnormal MRI combined with an abnormal genetic test for hemochromatosis can spare the patient the need for liver biopsy. There is an association with diabetes; however, glucose levels will not confirm a diagnosis of hemochromatosis. Prussian blue is the stain of blood cells for iron. Prussian blue is also used to diagnose sideroblastic anemia.
Iron chelation therapy is used in hemochromatosis for those who:
- Cannot be managed with phlebotomy
- Are anemic and have hemochromatosis from overtransfusion such as thalassemia
Deferoxamine, deferasirox, or deferipone should not be started until the diagnosis is confirmed. Deferasirox and deferipone are huge breakthrough medications because they are effective orally. Deferoxamine has to be given lifelong by injection.
This is the treatment for Hemochromatosis
Phlebotomy
What predicts the response to therapy for Hepatitis C?
Genotype
What tells if there has been a response for Hepatitis C treatment?
PCR-RNA viral load
What tells the extent of liver damage in Chronic Hepatitis C?
Liver biopsy, but rarely needed
This is/are the adverse effect of Interferon
arthralgias, thrombocytopenia, depression, leukopenia
This is/are the adverse effect of Ribavirin
anemia
This is/are the adverse effect of adefovir
renal dysfunction
This is/are the adverse effect of lamivudine
none
This is a disorder of abnormality decreased copper excretion from the body. Because of a decrease in ceruloplasmin, copper is not excreted and it builds up in the body in the liver, kidney, red blood cells, and the nervous system.
Wilson Disease
In addition to features of cirrhosis and hepatic insufficiency, this disease also presents with neurological symptoms such as psychosis, tremor, dysarthria, ataxia, or seizures, coombs negative hemolytic anemia, renal tubular acidosis or nephrolithiasis.
Wilson Disease
This is the best initial test for Wilson Disease
Slit-lamp examination for Kayser-Fleischer rings
This is most accurate diagnostic test for Wilson Disease
Give Penicillamine and look for abnormally increased amount of copper in urine
What is the treatment for Wilson Disease?
Penicillamine
Additional therapies are:
Zinc - interferes with intestinal copper absorption
Trientine - an alternate copper-chelating compound
This is a young woman with signs of liver inflammation with a positive ANA. What is the most likely diagnosis?
Autoimmune Hepatitis
What is the most accurate test for Autoimmune Hepatitis?
Liver Biopsy
How would you treat Autoimmune Hepatitis?
Prednisone and/or Azathioprine
This is an extremely common cause of mildly abnormal liver function tests.
Nonalcoholic Steatohepatitis (NASH) or Nonalcoholic Fatty Liver Disease
