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Gastroenterology Flashcards

1
Q

Which anatomical structures are evaluated by the following radiologic studies?

  • Barium swallow
  • Gastric emptying study
  • Small bowel follow through
  • Barium enema
A
  • Barium swallow
    • esophagus, LES, stomach
  • Gastric emptying study
    • Stomach, pyloric valve, duodenum
  • Small bowel follow through
    • Stomach to terminal ileum
  • Barium enema
    • Rectum to appendix.
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2
Q

Achalasia

A
  • Impaired peristalsis and decreased LES relaxation because of intramural neuron dysfunction.
  • Pt
    • progressive dysphagia of solid + liquids.
    • regurgitaiton, weight loss, aspiration, heartburn.
  • Dx
    • manometry has increased LES pressure w/ incomplete relaxation and poor peristalsis.
  • Tx
    • dilation + myotomy = high risk for perforation
    • botulinum toxin = pt who is poor surgical candidate.
    • nitrates/ dihydropyridine CCB

**must perform EGD w/ Bx to rule out malignancy**

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3
Q

Red Flag signs for GERD

A
  • Red Flag signs/symptoms
    • bleeding, weight loss, dysphagia, odynophagia, protracted vomiting.
  • In these cases consider performing endoscopy
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4
Q

Esophageal Cancer

A
  • Types
    • squamous cell carcinoma (alcohol and smoking. Typically upper 1/3)
    • adenocarcinoma (obesity, Barrett’s. Typically lower 1/3)
  • Pt
    • progressive dysphagia, weight loss, GI bleed, vomiting, weakness, cough, hoarseness.
  • Dx
    • barium swallow (esopahgealnarrowing and mass)
    • EGD is test of choice. ALlows for Bx of tissue.
  • Tx
    • esophagectomy for early disease
    • radiation +/- chemotherapy if later stage.
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5
Q

Gastritis

A
  • Causes
    • H.pylori, chronic NSAID, alcohol, msoking, autoimmune disease.
  • Pt
    • epigastric pain, nausea, vomiting, loss of appetite, early satiety, weight loss
  • Dx
    • EGD w/ Bx.
    • H.pylori (urea breath test) antral biopsy, serum antibodies.
  • Tx
    • stop offending medication
    • H.pylori (-): PPI, H2 blocker.
    • H.pylori (+): PPI, amoxicillin, clarithromycin. Metronidazole if PCN allergy.
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6
Q

Common causes of Upper GI bleeds

A
  1. Peptic ulcer
  2. Esophagitis
  3. Esophageal varices.
  4. Mallory weiss tears
  5. gastritis
  6. gastric/duodenal cancer.
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7
Q

Common causes of Lower GI Bleeds

A
  • Arteriovenous malformation
  • Mesenteric ischemia
  • Meckel’s diverticulum
  • Diverticulosis/-itis
  • Hemorrhoids
  • Ulcerative colitis
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8
Q

Management of Upper GI bleed

A
  1. ABC’s
  2. admit to ICU- npo
  3. type and screen 2 units PRBC.
    1. transfuse if Hgb < 7.0
  4. Labs
    1. CBC, PT, INR, BUN, Cr.
  5. NG lavage or EGD if uncertain of GI bleed location
  6. Meds
    1. IV PPI (omeprazole)
    2. variceal: octreotide

Once stabilized can perform EGD.

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9
Q

What are steps in managing lower GI bleed?

A
  1. Verify hemodynamic stability
    1. type and screen 2 units PRBC.
  2. Labs
    1. CBC, PT, PTT, BUN, Cr.
  3. EGD as needed
  4. Colonoscopy (if hemodynamically stable and not actively bleeding)
    1. if unable:
      1. angiography
      2. radionuclide scan (tagged RBC scan)
      3. capsule endoscopy

** the last 1-3 would only be used if there is still slow active bleed**

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10
Q

Whipple Disease

A
  • Malabsorption d/t Tropheryma whipplei.
  • Pt
    • abd pain, diarrhea, weight loss, joint pain, neurological changes.
  • Dx
    • intestinal biopsy w/ blunting villi
    • PAS (+).
  • Tx
    • IV ceftriaxone, 9-12mon Bactrim.

PAS(+), intestinal villi blunting. these alone should differentiate from celiac. Celiac does not contain PAS(+), nor does it include neurological deficits.

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11
Q

Tropical Sprue

A
  • Tropica environment
  • Pt
    • steatorrhea, diarrhea, megaloblastic anemia, abd distention, pedal edema.
  • Dx
    • blunting villi.
    • Inflammatory cells in lamina propria.
  • Tx
    • tetracycline
    • folic acid.

Tropics, steatorrhea, MCV > 100 = tropical sprue.

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12
Q

Celiac disease

A
  • Gluten (gliaden) sensitivity
  • Pt
    • Northern European ancestry
    • Bulky, foul smelling diarrhea. Steatorrhea.
    • weight loss.
    • Iron deficient anemia, Osteopenia. dermatitis herpetiformis
  • Dx
    • anti-IgA-transflutaminase antibodies. anti-endomysial ab (+)
    • Bx: blunting villi w/ hypertrophic crypts.
  • Tx
    • gluten free diet.
    • dermatitis treat w/ Dapsone.
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13
Q

Stool osmotic gap

A

Gap = 290 - 2 (Na + K) (50-100 Normal)

  • Gap >125 = osmotic
    • lactulose.
    • celiac, whipple disease
    • pancreatic insufficiency.
  • Gap < 50 = secretory
    • Carcinoid syndrome.
    • VIPoma, gastrinoma.
    • Cholera
    • ETEC
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14
Q

Most likely diagnosis for each of the following:

  • Chronic diarrhea + itchy grouped vesicles on elbows and knees
  • Recent immigrant from Dominican Republic w/ foul-smelling chronic diarrhea + macrocytic anemia.
  • Caucasian w/ foul chronic diarrhea + iron deficiency anemia
  • Chronic diarrhea + arhtralgias + ataxia
A
  • Chronic diarrhea + itchy grouped vesicles on elbows and knees
    • Celiac disease
  • Recent immigrant from Dominican Republic w/ foul-smelling chronic diarrhea + macrocytic anemia.
    • Tropical sprue
  • Caucasian w/ foul chronic diarrhea + iron deficiency anemia
    • Celiac disease
  • Chronic diarrhea + arhtralgias + ataxia
    • Whipple disease
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15
Q

Bacillus Cereus

A

Bacterial Gastroenteritis

  • Source:
    • refried Rice
  • Pt
    • self limited diarrhea.
  • Tx
    • Hydration
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16
Q

Campylobacter jejuni

A

Bacterial Gastroenteritis

  • Source:
    • poultry
  • Pt
    • mostly watery diarrhea. +/- blood.
    • second most common foodborne bacterial GI infection.
  • Tx
    • Hydration, fluoroquinolone or azithromycin

**Risk of guillain-barre syndrome and reactive arthritis (can’t see, can’t pee, can’t climb tree) conjunctivitis, urethritis, arthritis**

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17
Q

Clostridium botulinum

A

Bacterial Gastroenteritis

  • Source:
    • Honey (infants < 12mo) organism enters and locates into GI tract.
    • Home-canned goods - ingestion of preformed toxin
  • Pt
    • NVD, bilateral symmetric descending weakness starting at head.
  • Tx
    • monitor. Intubate if needed.
    • Botulinum antitoxin w/ Penicillin G
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18
Q

Clostridium difficile

A

Bacterial Gastroenteritis

  • Source:
    • Superinfection s/p antibiotics; clindamycin
  • Pt
    • watery or bloody diarrhea.
    • Pseudomembranous colitis formation (grey mucous formation)
  • Tx
    • Metronidazole (unless alcoholic Hx/abuse)
    • PO vancomycin (1st line in clinic. unsure for test)
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19
Q

Enterotoxigenic E.coli (ETEC)

A

Bacterial Gastroenteritis

  • Source:
    • contaminated food/water
  • Pt
    • self-limited watery diarrhea
  • Tx
    • hydration.
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20
Q

Enterohemorrhagic E.coli(EHEC)

A

Bacterial Gastroenteritis

  • Source:
    • undercooked ground beef
    • E.coliO157:H7
  • Pt
    • bloody diarrhea, vomiting, abd pain.
  • Tx
    • hydration, support. (no antibiotics as this will increase toxin release and worse disease)

Association: HUS (children) - thrombocytopenia, hemolytic anemia, acute renal failure.

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21
Q

Staphylococcus aureus

A

Bacterial Gastroenteritis

  • Source:
    • poultry, egg, dairy at room temperature.
  • Pt
    • rapid onset of GI upset, diarrhea.
    • onset within 2-6 hours of ingestion
  • Tx
    • hydration. self limited
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22
Q

Salmonella spp

A

Bacterial Gastroenteritis

  • Source:
    • raw meat, poultry, fresh produce.
    • most common foodborne GI infection
  • Pt
    • bloody diarrhea, fever, vomiting
  • Tx
    • hydration
    • fluoroquinolones
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23
Q

Shigella

A

Bacterial Gastroenteritis

  • Source:
    • food and water ingestion
  • Pt
    • fever, nausea, vomiting, severe bloody diarrhea, abd pain, HUS (hemolytic anemia, thrombocytopenia, acute renal failure)
  • Tx
    • hydration
    • fluoroquinolone
    • bactrim(TMP-SMX)
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24
Q

Vibrio cholerae

A

Bacterial Gastroenteritis

  • Source:
    • seafood ingestion
  • Pt
    • rice-water diarrhea
    • electrolyte imbalance, death
  • Tx
    • aggressive hydration. Tetracycline, doxycycline.
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25
Q

Yersinia enterocolitica

A

Bacterial Gastroenteritis

  • Source:
    • pork, puppy feces.
  • Pt
    • diarrhea, pharyngitis, pseudoappendicitis
  • Tx
    • hydration replacement.
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26
Q

Giardia lamblia

A

Parasitic/Protozoal Gastroenteritis

  • Source:
    • Mountain water
  • Pt
    • greasy, foul smelling diarrhea.
    • Malaise.
  • Tx
    • Metronidazole.

Dx: cysts + trophozoites in the stool.

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27
Q

Entamoeba histolytica

A

Parasitic/Protozoal Gastroenteritis

  • Source:
    • streams
  • Pt
    • bloody diarrhea. Abd pain.
  • Tx
    • Metronidazole (1st)
    • Paramomycin (2nd)

Severe cases risk progression into liver abscess ( RUQ pain, liver abscess, diarrhea)

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28
Q

Cryptosporidium parvum

A

Parasitic/Protozoal Gastroenteritis

  • Source:
    • food or water
  • Pt
    • Immunocompromised.
    • watery diarrhea, abd pain, malaise.
  • Tx
    • Nitazoxanide

Dx: Acid fast stain (+) for parasite.

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29
Q

Trichinella spiralis

A

Parasitic/Protozoal Gastroenteritis

  • Source:
    • undercooked pork
  • Pt
    • fever, myalgias, periorbital edema, eosinophilia, CNS changes, cardiac symptoms
  • Tx
    • albendazole, mebendazole.
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30
Q

Taenia solium

A

Parasitic/Protozoal Gastroenteritis

  • Source:
    • undercooked pork
  • Pt
    • diarrhea, CNS symptoms
  • Tx
    • Praziquantel = gut infection
    • Albendazole = CNS symptoms.

Taeniasis = tapeworm in gut only

Cysticercosis = cyst in muscles

Neurocysticercosis = brain cysts.

31
Q

Most common foodborne bacterial GI infections in US

A
  • Campylobacter jejuni
  • Shigella.
32
Q

Cholelithiasis

A
  • Pt
    • postprandial RUQ pain worse after fatty meal.
    • NV, abd fullness.
  • Dx
    • normal labs
    • RUQ ultrasounds shows hyperlucent gallstones.
  • Tx
    • Cholecystectomy
    • risk progression to acute cholangitis, acute pancreatitis.
33
Q

Charcot’s triad

A
  • Jaundice
  • Fever
  • RUQ pain

Strong indicator for acute cholangitis

34
Q

Reynold’s pentad

A
  • Fever
  • jaundice
  • RUQ pain
  • AMS
  • HoTN
35
Q

Treatment for acute cholangitis

A
  • Broad spectrum Abx
    • piperacillin-tazobactam, levofloxacin
  • Endoscopic biliary drainage
  • Delayed cholecystectomy
36
Q

Porcelain Gallbladder

A
  • Strong indicator for progression to Gallbladder adenocarcinoma (90%).
  • Pt
    • asymptomatic
    • abd pain, jaundice, weight loss, vomiting.
    • palpable gallbladder.
  • Dx
    • high bili and alk phos
    • porcelain gallbladder - thickened wall w/ circumferential wall calcification.
  • Tx
    • Cholecystectom+ LN dissection + local hepatic resection.
    • +/- post op chemo or radiation.
37
Q

Which patients are at high risk of acalculous cholecystitis?

A

Severely ill

TPN-patient.

38
Q

What is medical management for ulcerative colitis?

A
  • Mesalamine - small bowel
  • Sulfasalazine - large bowel

steroids as adjuvants during acute flare.

39
Q

Which bacterial GI infection is most likely associated with diarrhea and pseudoappendicitis?

A

yersinia enterocolitica.

40
Q

Primary biliary cholangitis

A
  • Female predominant autoimmune destruction of Intrahepatic bile duct leading to cirrhosis.
  • Pt
    • fatigue, pruritus. Hyperpigmentation, xerosis. Xanthoma, Xanthelasma, Hepatomegaly, Malabsorption, steatorrhea, cirrhosis, jaundice, edema, portal HTN.
  • DX
    • high alk phos, high bili, high cholesterol
    • (+) AMA-ab
    • (+) ANA
  • TX
    • ursodeoxycholic acid.
    • liver transplant.
41
Q

Primary sclerosing cholangitis

A
  • Progression inflammation and fibrosis and sclerosis of intrahepatic/extrahepatic bile ducts.
  • Pt
    • Men ≥ 40yo. Assoc w/ ulcerative colitis.
  • DX
    • (+) p-ANCA.
    • ERCP shows “beads on a string”
  • Tx
    • no effective pharmacotherapy.
    • liver transplant.
42
Q

Crigler-Najjar type I

A
  • Severe UDPGT deficiency.
  • PT
    • persistent neonatal jaundice and kernicterus
  • Lab
    • indirect bili > 5mg/dL
  • Tx
    1. Phototherapy
    2. Plasmapheresis
    3. Liver transplant.
43
Q

Crigler-Najjar Type II

A
  • Mild UDPGT deficiency
  • Pt
    • jaundice starting in childhood or adolescence
  • Labs
    • Mildly elevated indirect bili
  • Tx
    • Phenobarbital
44
Q

Hepatitis A

A
  • Fecal-oral transmission. Typically on international travel.
  • Labs
    • Hep A IgM-ab during illness
    • Hep A IgG-ab after resolution or vaccine.
  • Tx
    • supportive
  • vaccine is available.
45
Q

Hepatitis E

A
  • Fecal-oral transmission.
  • Most often seen in pregnant women, causing fulminant hepatic failure.
  • Labs
    • PCR, Hep E IgM-ab.
  • Tx
    • supportive
46
Q

Hepatitis B

A
  • Perinatal + sexual contact transmission
  • 90% or virus is acquired via perinatal transmission.
  • Pt
    • polyarteritis nodosa, nephropathy, aplastic anemia.
  • High risk of Hepatocellular carcinoma (elevated AFP)
47
Q

Hep B surface antigen (HBsAg)

A

indicates active disease

48
Q

Hep B surface antibody (HBsAb)

A

indicates recovery from active infection or immunization

49
Q

Hep B core antibody (HBcAb)

A

History of infection. (IgM early, IgG late)

50
Q

Hep B envelope antigen (HBeAg)

A

active viral replication

High transmissibility

51
Q

Hep B envelope antibody (HBeAb)

A

Low transmissibility

52
Q

Hep B DNA (HB DNA)

A

active viral replication; treatment is indicated when values are high.

53
Q

Treatment for HBV

A

Tenofovir, entecavir, telbivudine, lamivudine, adefovir.

Pregnant: lamivudine if viral count is high. Baby receives Hep B vaccine and Hep B immune globulin within 12 hours of birth.

54
Q

Hepatitis D

A
  • Only able to infect in presence of HBV
  • blood and sexual contact transmission
  • Carries highest mortality rate
  • Tx
    • pegylated IFN-alpha.
    • prophylaxis w/ HBV vaccine.
55
Q

Which virus carries the highest risk of hepatocellular carcinoma?

A

HCV >>> HBV

56
Q

Hepatocyte failure results in what?

A
  • elevated bilirubin –> jaundice
  • reduced coagulation factors –> elevated PT, PTT
  • reduced albumin –> peripheral edema + ascites
  • reduced ammonia metabolism –> hepatic encephalopathy and asterixis
    • Tx: lactulose (1st), Rifaximin (2nd)
  • impaired hormone synthesis
    • testicular atrophy
    • gynecomastia
    • spider telangiectasia
    • palmar erythema
57
Q

What vaccines should be given to patients w/ cirrhosis?

A
  • Hep A
  • Hep B
  • Pneumococcal vaccine
  • other standard immunizations.
58
Q

Causes of Acute pancreatitis?

A

PANCREATITIS

  • P- hyperparathyroidism.
  • A- alcohol (chronic)
  • N- neoplasms
  • C- cholelithiasis
  • R- drugs (NRTI, ritonavir, sulfonamides)
  • E- ERCP
  • A- abd surgery
  • T- hyperTriglyceridemia
  • I- Idiopathic
  • T- trauma
  • I- infection (mumps)
  • S- scorpion sting.
59
Q

What medications are used to treat ileus?

A
  1. Erythromycin
  2. Neostigmine
  3. Metoclopromide
60
Q

Budd-Chiari

  • Definition
  • Presentation
A
  • Thrombosis and occlusion of the hepatic vein or the intrahepatic/suprahepatic portion of inferior vena cava.
  • Pt
    • ascites
    • hepatomegaly
    • jaundice
    • RUQ pain, hepatomegaly and jaundice/ascites.
    • Chronic - gradual ascites, LE edema, cirrhosis and portal HTN over months.
61
Q

Budd- Chiari

  • Diagnostic technique
  • Treatment
A
  1. Dx
    1. Abd US
    2. Hepatic venography
  2. Tx
    1. thrombolytics
    2. diuretics + anticoagulation
    3. angioplasty
    4. shunt

Start with least invasive procedure and progress up until resolution.

62
Q

Explain the SAAG

A

Serum albumin-ascites gradient.

  • SAAG > 1.1 indicates portal HTN (transudative process)
    • cirrhosis, alcoholic hepatitis, HF, massive hepatic metastases, Budd-Chiari
  • SAAG < 1.1 indicates exudative process
    • peritoneal carcinoma, peritoneal tuberculosis, pancreatitis, serositis.
  • Low albumin overall indicates form of nephrotic syndrome.
63
Q

Spontaneous bacterial peritonitis (SBP)

  • Definition
  • Presentation
A
  • Infection of ascitic fluid without surgical treatable intra-abdominal source.
  • Pt
    • fever, abd pain/tenderness
    • AMS
    • Diarrhea - secondary to bacterial overgrowth (most likely E.coli)
64
Q

Spontaneous Bacterial Peritonitis (SBP)

  • Diagnosis
  • Treatment
A
  • Dx
    • SAAG > 1.1
    • Ascites gram stain + Cx
    • Ascites neutrophil count > 250cell/mm.
    • low ascites glucose.
  • Tx
    1. Cefotaxime
    2. Ceftriaxone
      1. treat for 5 days. Allows coverage of gut bacteria
    3. Albumin transfusion; maintains plasma volume, reserves renal function and reduces renal impairment/mortality.
65
Q

Common treatment for ascites

A

Daily Spironolactone + Furosemide reduces fluid retention

66
Q

Treatment for Esophageal Varices

A
  • Prophylaxis
    • Nonselective Bblocker(propranolol, nadolol)
  • Bleeding varices
    • Octreotide; reduce splanchnic flow
    • Endoscopic variceal ligation
    • Endoscopic sclerotherapy.
  • Transjugular intrahepatic portosystemic shunt (TIPS)
    • creates channel through the liver to shunt blood from portal to systemic system.
    • Has higher risk of hepatic encephalopathy; as ammonia is now not being removed as readily.
67
Q

Hereditary Hemochromatosis

  • Definition
  • Presentation
A
  • Autosomal recessive excess iron absorption leading to deposition within tissue.
  • Pt
    • Hepatomegaly, abd pain, cirrhosis
    • Diabetes (insulin resistance)
    • skin hyperpigmentation
    • hypogonadism (testicular atrophy)
    • restrictive cardiomyopathy.
    • arthralgia
68
Q

Hereditary Hemochromatosis

  • Diagnosis
  • Tx
A
  • Dx
    • High AST, ALT
    • High iron, high ferritin, high transferrin
    • Liver Bx show iron granules in hepatocytes.
  • Tx
    • Phlebotomy weekly until levels normalize, then monthly.
    • iron chelation w/ deferoxamine
    • avoid alcohol.
69
Q

Wilson Disease

  • Define
  • Pt
  • Dx
  • Tx
A

Autosomal recessive impaired copper secretion leads to deposition in tissues.

  • Pt
    • 12-23yo.
    • Hepatomegaly, hepatic steatosis, cirrhosis.
    • Dystonia, tremor, parkinsonism
    • depression, psychosis.
    • Kayser-Fleischer rings.
  • Dx
    • Low Ceruloplasmin
    • High urinary Copper.
  • Tx
    • Copper chelation w/ trientine, penicillamine
    • zinc supplement
    • restrict dietary copper.
70
Q

Autoimmune hepatitis

Define

Pt
Dx

Tx

A

Autoimmune inflammation of liver

  • Pt
    • F>>>M
    • acute liver failure/cirrhosis
  • Dx
    • (+) ANA and anti-smooth muscle Ab
    • (+) ab against the liver-kidney microsomal Ag.
  • Tx
    • glucocorticoids
    • +/- azathioprine.
71
Q

Hepatic Adenoma

Risk Factors

Pt

Management

A

Benign liver neoplasm, mostly F 20-40 on OCP

  • Risk Factor
    • OCP
    • anabolic steroid use
    • glycogen storage disease I/ III
  • Pt
    • asymptomatic
    • RUQ pain, fullness.
  • Management
    • discontinue OCP
    • monitor w/ imaging and serial AFP
72
Q

Hepatocellular carcinoma

Risk Factors

Presentation

Associated syndromes

A
  • Most common primary tumor of liver.
  • Risk Factors
    • HBV, HCV, Cirrhosis, Aflatoxin (aspergillus)
  • Assoc Syndromes
    • polycythemia
    • Hypercalcemia (excess PTH secretion)
    • Watery diarrhea (VIPoma)
    • hypoglycemia
73
Q

Hepatocellular carcinoma

Dx

Tx

A
  • Dx
    • High LFT
    • High AFP
    • US- solid tumor follow up with CT/MRI
  • Tx
    • Small - surgical resection w/ chemotherapy
    • Large - liver transplant, radiofrequency ablation, chemoembolization
74
Q

What malignancies have increase EPO production and can likely lead to Polycythemia Vera?

A

Pheochromocytoma

Renal cell carcinoma

Hepatocellular carcinoma

Hemangioblastoma

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