Gastroenterology Flashcards
What is the term for difficulty swallowing
dysphagia
Bird-beak esophagus on barium swallow should make you think of what diagnosis
achalasia
What is the most common location for an anal fissure
posterior midline
Crohn’s is found where in the GI tract
Anywhere from the esophagus to the anus
What does HBsAg (hep B surface antigen) indicate?
Active Hep B infection
How do you treat achalasia
Loosen up the muscle - botox, dilation or surgery
A corkscrew appearance on barium swallow study should make you think of what diagnosis?
Esophageal spasms
Epigastric abdominal pain which radiates to the back should make you think of what diagnosis?
Pancreatitis
In order to contract Hep D what must you already have
Hep B
Lower left quadrant pain and tenderness should make you think of what diagnosis
Diverticulitis
What is the treatment for most Mallory-Weiss tears?
Watchful waiting, these will typically resolve within 48 hours
A thumbprint sign on abdominal film should make you think of what diagnosis?
Intestinal ischemia
What will the bowel sounds be early on in a small bowel obstruction? What will they be later on?
Early they are hyperactive. Late they are absent.
A patient has had GERD for years. Over the past year, he has noticed an increase in difficulty swallowing his food. This should make you think of what diagnosis?
Esophageal strictures.
What are two treatments you should consider for esophageal strictures?
Dilation of the esophagus and long-term PPIs
What are two common predisposing factors for esophageal varices?
Portal hypertension and cirrhosis often caused by alcoholism
What are common symptoms that goes along with chest pain for GERD patients?
Dry cough
What medication is most commonly used for long term treatment of GERD?
Proton pump inhibitors- omeprazole, lansoprasole, pantoprazole
What is the imaging modality of choice for pancreatitis?
CT
What is the best test to check for H. Pylori?
Urea Breath Test
Is peptic ulcer disease more common in the duodenum or the stomach?
Duodenum
What is the most common location for a pancreatic tumor?
75% occur in the head of the pancreas
With a gastric ulcer are the patients symptoms exacerbated or relieved with food?
Exacerbated with food
Fasting gastrin will be above what level with gastrinoma
> 150 pg/mL
Projectile vomiting should make you think of what diagnosis?
Pyloric stenosis
Most gallstones are make of what substance?
Cholesterol
What is the name of the sign when a patient show inhibited inspiration with pressure over the RUQ? What does this suggest?
Murphy’s sign, cholecystitis
What is the most specific test for acute cholecystitis?
HIDA
What is the gold standard for diagnosis and treatment of bile duct stones?
ERCP
What is Charcot’s trid?
RUQ pain, fever > 40
, jaundice
What is Reynold’s pentad and why does it matter?
Charcot’s triad + hypotension + altered mental status. This is an indicator of high risk sepsis.
What disease is defined as an immunologic response to gluten?
Celiac
What is the main risk factor for esophagitis?
Immune compromised patient
An endoscopy for presumed esophagitis shows multiple shallow ulcers. What is the most likely diagnosis?
Herpes simplex virus
List two common offending agents for pill induced esophagitis
Doxycycline, NSAIDS, KCL, iron, abx
A 30 year old African American woman presents with dysphagia. You notice she has thickened skin. A barium swallow demonstrates the absence of peristalsis. What is the most likely diagnosis.
Scleroderma
A patient complains of regurgitating undigested food several hours after a meal. What is the most likely diagnosis?
Zenker’s diverticulum
What is the most common cause of peptic ulcer disease?
H. Pylori
What is the most specific diagnostic test for peptic ulcer disease?
Endoscopy
What is the only curative therapy for gastric adenocarcinoma?
Surgical resection
A patient presents complaining of upper right quadrant pain for 20 min after meals. What is the most likely diagnosis?
Cholecystitis
What does ERCP stand for?
Endoscopic Retrograde Cholangiopancreatography
What is the most common cause of acute bacterial cholangitis
Choledocholithiasis
Onion ring fibrosis from a bile duct biopsy should make you think of what diagnosis
Primary sclerosing cholangitis
What two viral hepatitis infections are self limiting
Hep A and Hep E
Pica is often related to what type of anemia
Iron deficiency anemia
What does Anti-HBc (hep B core antibody)
Previous or ongoing hepatitis B infection
What does Anti-HBs (heb B surface antibody) indicate?
Recovery from infection or immunization to hepatitis B
What is the recommended treatment for hepatitis C infection?
Pegylated interferon alpha-2
What medication used in hepatitis B infection helps prevent the need for liver transplant?
Lamivudine
There are vaccines for which two versions of hepatitis ?
Hepatitis A and hepatitis B
Will a patient with achalasia have dysphagia to liquids, solids, or both?
Both
If you have heartburn that does not improve with medication what is the most likely diagnosis?
Gastrinoma
What are the two main complications of cirrhosis?
Portal hypertension and liver insufficiency
What is a good beta blocker to reduce portal hypertension?
Propranolol
What tumor marker may be used for liver cancer?
alpha-fetoprotein
What are the two most common causes of pancreatitis
Cholelithiasis and EtOH
Describe Cullen’s sign
Umbilical ecchymosis often related to pancreatitis
What are the 5 points of Ranson’s criteria on admission?
1) Older than 55
2) WBC > 16
3) Glucose > 200
4) LDH > 350
5) AST > 250
What is the first step in treating GERD?
Lifestyle modification
Steatorrhea should make you think of what diagnosis?
Pancreatitis
Describe Courvoisier’s sign
Nontender, palpable gallbladder with jaundice which may indicated pancreatic neoplasm
What tumor marker can be used to follow pancreatic CA?
CA 19-9
A patient complains of periumbilical pain which has moved over McBurney’s point. What is the most likely diagnosis?
appendicitis
Describe how to perform psoas sign
The patient is in supine and attempts to raise the right leg against resistance
What is the term for painful swallowing
Odynophagia
Describe how to perform obturator sign
The patient is supine and attempts to flex and internally rotate the R hip
What is the best imaging study for acute appendicitis
CT
What tow blood tests can be used to diagnose celiac
IgA endomysial antibody and IgA tTG Ab
How much fiber should you normally get in a day?
About 30 grams
What treatment should be started for asymptomatic diverticulosis
None
Is surgery curative for Crohn’s or ulcerative colitis?
Ulcerative colitis
What causes Mallory-Weiss tears?
Forced vomiting or retching (often involving alcohol)
A colonsocopy that shows cobbleston or skip lesions should make you think of what diagonsis?
Crohn’s disease
What class of medication is the 1st line to treat inflammatory bowel disease in the maintenance phase?
5ASA products - sulfasalazine and mesalamine
Severe abdominal pain 30 minutes after a meal should make you think of what diagnosis
Intestinal ischemia
Current Jelly stool should make you think of what diagnosis
Intussusception
What is the most common cause of lower GI bleed
Diverticulosis
What is the most common location of colorectal cancer?
Cecum about 38%
Colorectal cancer patients are almost older than what age?
90% of patients are older than 50
An epigastric olive-shaped mass should make you think of what diagnosis?
pyloric stenosis
An elevated serum amylase and lipase should make you think of what diagnosis?
Pancreatitis
Under what routine circumstances when should patients begin getting colonoscopies?
Age 50
What is the #1 cause of small bowel obstruction?
Postoperative adhesions
Air fluid levels on abdominal x-ray should make you think of what diagnosis?
Bowel obstruction
Which is more likely to pass into the scrotum, a direct or indirect hernia
Indirect
A string sign on barium swallow should make you think of what diagnosis?
Pyloric stenosis
What is the 1st line treatment for an anal fissure
Fluid and fiber
What are two things that an anal fissure off midline might suggest?
Crohn’s, syphilis, HIV, neoplasm
What medical treatment is given for gastrinoma?
proton pump inhibitors
What is the term for abscess in the sacrococcygeal cleft?
Pilonidal disease
How do your treat H. Pylori infection
1) PPI + 2 antibiotics commonly omeprazole, clarithromycin and amoxicillin or PPI + metronidazole + tetracycline
Painless bright red blood per rectum should make you think of what diagnosis
Hemorrhoids
A patient on sulfasalazine for inflammatory bowel disease should also be supplemented with what vitamin?
folate
What is the most common anorectal problem affecting patients over 50?
Hemorrhoids
A gastrinoma is also known as what syndrome?
Zollinger-Ellison syndrome
What is the most common anorectal problem affecting patients over 50
Hemorrhoids
Salivary amylase breaks down what macronutrieint
Carbohydrates
What is the medical term for feeling like there is a lumb in your throat?
Globus
What is the most common vessel blocked with intestinal ischemia?
Superior mesenteric artery
Describe Grey-Turner’s sign
Flank ecchymosis often related to pancreatitis
What are the first 3 steps of managing pancreatitis?
NPO, pain control, fluids
A pt presents with unproductive retching acute localized epigastric distension and inability to pass a nasogastric tube. What is the most likely diagnosis?
Gastric volvulus
What is the most common cause of folate deficiency
Alcoholism
Should diverticulitis always be admitted?
No, mild cases can be treated in an outpatient setting with rest and clear fluids
Which NSAID has the highest rate of peptic ulceration?
Naproxen
What is the diagnostic test of choice for Zenker’s diverticulum?
Barium swallow will show the diverticulum
What is the leading cause of iron deficiency anemia?
Chronic GI bleed
At what age and how often should fecal occult blood tests be performed as a screening tool?
Beginning at age 50, and they should be done every year
How often with patients with pernicious anemia have a screening endoscopy performed?
Every 5 years looking for signs of gastric carcinoma
Are one half of all adult hernias direct or indirect inguinal hernias?
Indirect hernias make up 50% of all adult hernias
How is celiac disease most commonly diagnosed?
Endoscopic biopsy
Define pellegra?
Niacin (B3) deficiency
An endoscopy for presumed esophagitis shows everal solitary deep ulcers. What is the most likely diagnosis?
CMV
Which are more painful hemorrhoids above or below the dentate line?
Below, internal hemorrhoids are not painful
An abdominal exam with pain out of proportion to the exam should make you think of what diagnosis
Intestinal ischemia
Does adenocarcinoma arise from the proximal or distal esophagus?
Distal
Variceal bleeding, acites, hepatic encephalopathy are complications of what?
Portal hypertension
Patient presents with jaundice, puritis, palmar erythema, spider angiomas, testicular atrophy, thombocytopenia, hypoalbuminemia and coagulopathy what is this suggestive of?
alcoholic cirrhosis
What is the most common complication of ERCP in a pt suspected of having choledocolithiasis?
Pancreatitis and cholangitis can occur in up to 5% of patients
famotidine (Pepcid), cimetidine (Tagemet) and ranitidine (Zantac) are examples of what?
H2 receptor blockers
Hepatocellular carcinoma has a strong link to which hepatitis
Hep B
Treatment for Hep B
Peg interferon & ultimate liver tranplant
Mallory-Weiss tear occurs in which location
GE Junction or in gastric body- partial tear of mucosa- do not expect to dump gastric contents - very low risk of peritonitis
What is Borhave’s
complete perforation in lower 1/3 of esophagus- emergency
Most common esophageal neoplasm
adenocarcinoma
What does + HBeAg indicate (Hep B virus “envelope” antigen
Highly contageous HBV infection
What does + HBeAb indicate?
lower level of infection- tends to disappear when chronic HBV is treated and viral load goes down
Treatment for Hep C
Ledipasvir/sofosbuvir (Harvoni) and sofosbuvir (Dovaldi)
Transmural inflammatory bowel disease (commonly seen in the distal ileum and colon) producing “skip lesions” Epitheliod granulomas may also be detected in the bowel wall or lymph nodes and pathognomonic
Crohn’s disease
Patchy ‘cobblestone appearance’ separated by normal appearing mucosa.
Crohn’s disease
Infection of the colon hx assoc with abx use but increasingly seen in people in the community
pseudomembranous colitis (c-diff colitis)
Ulcerations distal to proximal, continuous colon/rectum, mucosal
Ulcerative Colitis
What is the #1 cause of fulminant hepatitis
Acetaminophen overdose
fever Elevated WBC with left shift, elevated bilirubin and alk phos commonly suggestive of what
bile duct obstruction- acute cholecystitis
gram negative common causitive agents echoli, klebsiella, campylobacter are causitive for cholecystitis what abx do you use for treatment
ceftriaxone and metronidazole or piperacillin and tazobactam
porcelain gallbladder
possible premalignant gallbladder
NPO, IV abx; possible cholecystectomy tx protocol for what
acute cholecystitis
two most common causes of acute pancreatitis
gallstones and Etoh
1 cause of acute pancreatitis in children
mumps
acute epigastric pain, dull, boring radiating to back, feels better by leaning forwards almost tripoding. Will tell you they feel nauseated, vomiting, fever, epigastric tenderness, tachycardia
acute pancreatitis
Lipase is more specific than amylase although both may be elevated. ALT elevation think of gallstone assoc pancreatitis
acute pancreatitis
Primarily supportive therapy IV fluids, pain control, rest tx for acute pancreatitis what is not recommended
IV abx typically not used unless it is sever and necrotizing
diagnostic imaging of choice for acute pancreatitis
CT
Ranson criteria- look at 5 on admission and 6 within 48 hours is used to assess what
Pancreatitis assoc mortality
What are 5 Ranson admission criteria 0-3- 1% mortality 3-4 15% mortality 5-6 40% mortality > 7 100% mortality
- Age > 55
- WBC > 16K/mm3
- Glucose > 200
- LDH > 350 IU/L
- ALT > 250 SF units
Witin 48 hours name 6 Ranson criteria
- Hematocrit fall > 10%
- BUN rise > 5 mg/dL
- Calcium < 8 mg/dL
- PO2 < 60 mm Hg
- Base deficiit > 4 mEq/L
- Fluid sequestration > 6L
Chronic inflammation that causes Parenchemal destruction and fibrosis causing loss of exocine function and sometimes also endocrine
chronic pancreatitis
Causes of chronic pancreatitis
chronic EtOH (#1 cause), familial hyperlipidemia,
1 causes of chronic pancreatitis is children
cystic fibrosis
triad: calcifications of pancreas, steatorrhea, diabetes
chronic pancreatitis
“chain of lakes” on CT
Chronic pancreatitis
chronic pancreatitis treatment
- oral enzyme pancreatic enzyme replacement; 2. pain control, 3) EtOH abstinence
Common pathogens of cholangitis
1) E. coli
2) Klebsiella
3) Enterobacter
What defines hepatitis as chronic
infection > 6 mo
3 Most common causes of hereditary chronic hepatitis
Primary hemochromatosis, alpha-1-antitrypsin (AAT) deficiency, and Wilson’s disease
10 % of Hep B and 80% of Hep C will become chronic- what is the treatment for each
Heb B - Peg-interferon and ultimately liver transplant;
Hep C- Ledipasvir/sofosbuvir (Harvoni) & sofosbuvir (Sovaldi)
Wilson’s disease findings
High urine copper; LOW ceruloplasm; Keiser Fleischer rings (copper rings in cornea)
autoimmune hepatitis what lab finding
positive anti-smooth muscle antibody
Hep B increased risk for this?
Hepatocellular carcinoma
Who gets one time testing for hep C for these patients
People born between 1945-1965
1) loss of intrinsic hepatic function and 2) portal hypertension are sequel of what disease
liver cirrhosis
symptoms of portal hypertension
ascites, spider angiomata, caput medusae,black tarry stools, GI bleeding
elevated alpha fetaoprotein in a pt with cirrhosis pt is at increased risk of what?
hepatocellular carcinoma
3 most common cause of cancer death in US
Colon CA
Colon cancer is most likely to metastasize where?
liver
Name risk factors for colon cancer
1) familial adenomatous polyposis
2) Age > 50
3) Crohn’s
4) UC (UC greater risk than Crohn’s)
4) AA ethnicity
5) Smoking
6) Low fiber diet
7) EtOH abuse
What is the # 1 cause of large bowel obstruction
Colon Cancer
“Apple-Core” lesion on barium enema
Colon Cancer
Colon cancer screening recommendations
Colon cancer screening- colonoscopy every 10 years or less based on findings for adults 50-75 years of age.
1st degree relative of colon cancer begin 10 years younger than relative age or at 40 years old. Fecal occult blood every year. Or sigmoidoscopy every 5 and fecal occult blood every 3 years.
56 year old male with anemia you should consider what?
Colon Cancer
Alarm signs of when to refer for constipation
1) hematochezia
2) anemia particularly in mail
3) positive fecal occult blood test
4) weight loss
Low fiber diet and decreased fluid intake set you up for this?
constipation
Most physiological and effective treatment for constipation
Bulk forming laxatives:
1) Methylcellulose (Citrucel)
2) Psyllium hydrophilic mucilloid (Metamucil)
Bulk forming laxatives MOA
absorb water and increases fecal mass
Osmotic laxatives MOA and example
Pulls water into gut to increase water retention in stool; polyethylene glycol- Miralax
How does lactulose work
Pulls water into colon to stimulate evacuation
How does docusate (Colase) work?
Acts as a surfactant. Stool softener which enhances fat and water penetration into stool.
How does senna work?
It is a stimulant laxative which increased GI motility and effects electrolyte transport
Herniation of the colonic wall causing an outpouching most common in sigmoid colon d/t high intraluminal pressure
diverticulosis
Tx diverticulosis
high fiber diet
Tx diverticulitis
1) bowel rest
2) clear liquid diet
3) Metronidazole and TMP sulfa
presentation diverticulitis - like appendicitis
Like appendicitis but pain is in the LLQ
What medications may be helpful in pt with esophageal varices?
Non-selective beta blocker such as propanolol, nadolol. Another option carvedilol- non-selective beta blocker with alpha adrenergic vasodilating efffect
Most common cause of esophageal varices?
portal vein hypertension
Complication of esophageal varices
90% of pt with cirrhosis will get esophageal varices and 30% of varices will bleed. Mortality with 1st bleed is 30-50%; 70%mortality with rebleed.
Most common risk factor of esophageal varices?
cirrhosis
Dx with esophageal varices
EGD
pt presents with odynophagia (pain with swallowing), dysphagia, retrosternal chest pain suggestive of esophagitis
EGD or double contrast esophagram
endoscopic finding of linear, white yellow plaques in esophagus are suggestive of what? Treatment?
candida; PO fluconizole
endoscopic finding of large superficial, shallow ulcers in esophagus are suggestive of what? Treatment?
CMV; gancyclovir
endoscopic finding of small deep ulcers in esophagus are suggestive of what? Treatment?
HSV; acyclovir
endoscopic finding of multiple corrugated rings in esophagus are suggestive of what? Treatment?
eosinophilc esophagitis; avoiding allergic food; can also take inhaled corticosteroids
endoscopic finding of single ulcer the size of a pill in esophagus are suggestive of what? Treatment?
pill induced esophagitis; do not lie down after taking pills for 30 min
1 cause of esophagitis
GERD
Risk factors for fecal impaction?
those who can’t sense they have to evacuate bowels or sensory deficits such as diabetes mellitus
Treatment for fecal impaction
1) manual disimpaction, osmotic laxatives (Miralax- polyethelene glycol), transrectal enemas
Latex allergy must also watch out for these foods.
BACK- bananas, avocado, chestnuts, kiwi
Complications of GERD- List 2
- Barrett’s esophagus
2. Esophageal adenocarcinoma
Describe the pathophysiology of barretts esophagus
The normal squamous epithelial cells are replaced by precancerous columnar cells from the stomach
Define internal hemorrhoid
Superior hemorrhoid veins superior to the dentate line
Internal hemorrhoids
typically painLESS may see blood with defecation, may have perianal itching
external hemorrhoids
perianal pain worse with defecation, may have tender palpable mass
1st line treatment or hemorrhoids
sitz bath, topical corticosteroids, high fiber diet
Hiatal hernia is an upper portion of the stomach protrudes into diaphragm - Name the types and treatment
Type 1: Sliding- at the GE junction the stomach slides into the mediastinum; treat like GERD
Type 2: the fundus of the stomach rolls through the diaphragm but the GE junction stays in place; Tx surgical repair
Inguinal hernias. 2 types
Indirect- abdominal cavity protrudes at the inguinal ring, lateral to the inferior epigastric artery, and can reach into the scrotum. #1 overall type of hernia. R>L.
Direct- protrudes medially of epigastric vessles thorugh Hesselbach triangle. It does not reach into the scrotum
Incarcerated hernias definition
Painful, not reducible
Strangulated hernia definition
incarcerated hernia that has become toxic- surgical emergency
