Gastroenterology Flashcards
What is hiatal hernia usually caused by?
Obesity weakening the diaphragm
What’s the best initial therapy for hiatal hernia?
WL and PPI
What’s the name of the surgical correction for hiatal hernia?
Nissen fundoplication
Which type of hernia is more likely to need emergent surgery?
Paraesophageal
What’s the essential feature of most esophageal disorders?
Dysphagia
What’s the name for pain while swallowing?
Odynophagia
What are the 3 alarm sx that require endoscopy?
- WL
- Blood in stool
- Anemia
What is achalasia?
The inability of the LES to relax due to loss of the nerve plexus; unclear etiology
What’s the most likely dx:
Young patient under 50, progressive dysphagia to BOTH solids and liquids at the same time, no association with alcohol and tobacco?
Achalasia
What’s the most likely dx:
Bird’s beak on barium esophagram?
Achalasia
What’s the most accurate test for achalasia and shows a failure of the LES to relax?
Manometry
Does upper endoscopy show normal mucosa in achalasia?
Yes
What’s the tx for achalasia?
Pneumatic dilation (endoscope with inflatable device that enlarges the esophagus)– very effective!
What’s even more effective than pneumatic dilation for achalasia but is more dangerous?
Surgical sectioning/myotomy
Can you use botox for achalasia?
Yes, but the effects will wear off in 3-6 mos
What’s the key word in diagnosing esophageal cancer dysphagia sx?
Progressive (from solids to liquids)
What’s the best test to confirm esophageal cancer?
Endoscopy with biopsy
What would you use PET scan for in esophageal cancer?
To determine if it’s resectable (local is resectable)
Do you use chemo and radiation in addition to surgery for esophageal cancer?
Yes
How can you palliate with esophageal cancer if you can’t do surgery?
Stent placement
What are 2 possible dx’s for the following:
Sudden onset of chest pain not related to exertion, possibly related to drinking cold liquids?
Esophageal spasm:
- DES
- Nutcracker esophagus
How can you distinguish DES and nutcracker esophagus?
Manometry
What 2 dx’s might show corkscrews on barium studies?
- DES
2. Nutcracker esophagus
What’s the best tx for esophageal spastic disorders?
Ca channel blockers (similar to Prinzmetal angina)
What esophageal disorder presents with swallowing difficulty, food impaction, and heartburn, and the patient might have a h/o asthma/allergies?
Eosinophilic esophagitis
What is the most accurate diagnostic test for eosinophilic esophagitis?
Biopsy
Over 90% of esophageal infections in patients with AIDS are caused by what organism?
Candida
What will the question stem often ask for infectious esophagitis?
AIDS patient with low CD4 count
What’s the best initial step if you suspect Candida infectious esophagitis?
Empiric fluconazole
What do you give IV if fluconazole doesn’t do the job for Candida infectious esophagitis?
Amphotericin B
What is Schatzki ring?
Dysphagia from peptic stricture due to acid reflux/hiatal hernia
What is Plummer-Vinson?
Dysphagia associated with iron deficiency anemia
How do you tell Schatzki ring apart from Plummer-Vinson?
Plummer is more proximal “P is more P”
What’s the dx that presents with dysphagia, severe halitosis, and regurgitation?
Zenker diverticulum
What’s the best dx for Zenker?
Barium
What should you avoid in patients with Zenker?
Nasogastric tube or upper endoscopy
Can scleroderma affect the esophagus?
Yes
How does Mallory-Weiss tear present?
Upper GI bleeding after severe vomiting/retching
What medical tx can you use for Mallory-Weiss to stop severe bleeding?
Injection of epinephrine
Which is nonpenetrating: Mallory-Weiss or Boerhaave?
Mallory-Weiss
What diagnosis: hot shower = better?
Cannabinoid hyperemesis
What’s the dx if a patient has epigastric pain for months without nausea, vomiting, WL, or blood in stool?
Pancreatic cancer
If the pain is worse with food?
Gastric ulcer
If the pain is better with food?
Duodenal ulcer
If there’s WL?
Cancer or gastric ulcer
Tenderness?
Pancreatitis
Bad taste, cough, hoarse?
GERD
Diabetes, bloating?
Gastroparesis
Nothing?
Non-ulcer dyspepsia
What is GERD?
The inappropriate relaxation of the LES, resulting in the acid contents of the stomach coming up into the esophagus
What is gastritis caused by?
Alcohol NSAIDs H Pylori Portal HTN Uremia, burns, trauma
What often presents with painless gastric bleeding?
Gastritis
When is stress ulcer prophylaxis indicated (4)?
- Mechanical ventilation
- Burns
- Head trauma
- Coagulopathy
What’s the most common cause of peptic ulcer disease?
H Pylori
Why are NSAIDs the second most common cause of PUD?
They inhibit PG’s (which normally produce the mucus)
Cancer is present in ___% of those with gastric ulcers but none in those with duodenal ulcers?
4%
What 3 things combined treat H Pylori?
- PPI
- Clarithromycin
- Amoxicillin
When do you scope patients with dyspepsia (2)?
- > 55
2. Alarm sx are present
What should you suspect if a patient has large (>1-2cm) ulcers, recurrent after H Pylori tx, distal ulcers in the duodenum?
Zollinger-Ellison (gastrinoma)
What might you suspect if labs show high gastrin levels with high gastric acidity and despite injecting secretin?
Zollinger-Ellison (gastrinoma)
What is the treatment for gastrinoma?
Surgical removal
What should you suspect in a diabetic patient with bloating, abdominal discomfort, and constipation?
Diabetic gastroparesis
What’s the tx for diabetic gastroparesis (2)?
- Erythromycin
2. Metoclopramide
What’s the most accurate study for diagnosing diabetic gastroparesis?
Gastric emptying study
What’s the best initial therapy for diabetic gastroparesis?
Dietary modification (blend food, restore fluids, correct electrolytes)
What drug used to treat diabetic gastroparesis causes dystonia and hyperprolactinemia if used long term?
Metoclopramide
What’s the next step in treating diabetic gastroparesis if dietary changes doesn’t work?
Metoclopramide
What’s the last step in treating diabetic gastroparesis if nothing else works?
Gastric pacemaker
The most common cause of upper GI bleed is _____?
Ulcers
The most common cause of lower GI bleed is __________?
Diverticulosis
What are the 2 definitions of orthostasis?
- > 10pt rise in pulse when going from lying down to standing up
- Systolic BP drop of 20+ pts when sitting up
What type of GI bleed presents in older adults with LLQ pain, mucosal friability on scope, and clear demarcation between ischemic and normal tissue?
Ischemic colitis
Does ischemic colitis need specific therapy?
No
If the case describes GI bleeding and signs of liver failure, what should you suspect?
Varices
T/F: 80% of GI bleeding will stop spontaneously if the fluid resuscitation is adequate?
True
When do you give FFP in GI bleeds?
If PT/INR is elevated and active bleeding is occurring
When do you give platelets in GI bleed?
When platelet count <50,000
When do you give octreotide for GI bleed?
Variceal
How does octreotide work for varices?
Decreases portal pressure
In addition to fluids, blood, platelets, and plasma, what are other steps in variceal bleeds (5)?
- Octreotide
- Banding
- TIPS
- Propranolol
- Abx to prevent SBP
Which antibiotic is associated with C diff?
Clindamycin
What’s the best initial test for C diff?
Stool sample with PCR
What’s the best antibiotic to treat C diff?
Vancomycin
When a patient has C diff and high lactate, high creatinine, high WBCs, and metabolic acidosis, how do you treat?
Vancomycin + Metronidazole
When a patient doesn’t respond to vancomycin for C diff, which antibiotic should you choose?
Fidaxomicin
Which vitamin deficiency presents with hypocalcemia and osteoporosis?
Vitamin D
Which vitamin deficiency presents with bleeding and easy bruising?
Vitamin K
Which vitamin deficiency presents with anemia, hypersegmented neutrophils, and neuropathy?
Vitamin B12
What disease is dermatitis herpetiformis associated with?
Celiac
What disease presents with malabsorption, arthralgias, ocular findings, dementia, fever, and LAD?
Whipple disease
What 2 antibiotics do you treat Whipple disease with sequentially?
- Ceftriaxone
2. TMP-SMX
What deficiency can help differentiate between chronic pancreatitis and Celiac (gluten sensitive enteropathy)?
Iron
Will iron be low in chronic pancreatitis?
No because it only needs an intact bowel wall to be absorbed
What does anti-tissue transglutaminase check for?
Celiac
What are the other 2 tests for Celiac?
- Anti-endomysial Ab
2. IgA antigliadin Ab
What’s the most ACCURATE diagnostic test for celiac disease?
Small bowel biopsy showing flattening of the villi
What’s the most accurate diagnostic test for chronic pancreatitis?
Secretin stimulation test
What will a normal pancreas do during a secretin stimulation test?
Release a large volume of bicarb-rich fluids
What will an x-ray or CT show for chronic pancreatitis?
Calcifications
What antibiotic is used to treat tropical sprue?
TMP-SMX
What presents with flushing, wheezing, R heart abnormalities, and intermittent diarrhea?
Carcinoid syndrome
What’s the best initial test for carcinoid syndrome?
5 HIAA test
What’s the best tx for carcinoid syndrome?
Octreotide
Is WL associated with lactose intolerance?
No because there are other sugars and fats absorbed still
Is IBS associated with WL?
No
What GI syndrome has diarrhea, pain relieved by BM, less pain at night, and no blood or WBC’s in the stool?
IBS
What’s the tx for IBS? (3 options)
- Fiber
- Hyoscyamine/dicyclomine/peppermint oil
- TCAs
Which IBD: skip lesions?
Crohn’s
Which IBD: transmural granulomas?
Crohn’s
Which IBD: fistulas and abscesses?
Crohn’s
Which IBD: masses and obstruction?
Crohn’s
Which IBD: perianal disease?
Crohn’s
Which IBD: curable by surgery?
UC
Which IBD: entirely mucosal?
UC
Which IBD: no fistulas or obstructions?
UC
Which IBD: no perianal disease?
UC
Crohn’s skips the ______?
Rectum
“Granny is old school and doensn’t like buttsex”
Which IBD: fevers, malaise?
Crohn’s
Which IBD:
ANCA (-)
Anti-saccharomyces (+)
Crohn’s
Which IBD:
ANCA (+)
Anti-saccharomyces (-)
UC
What is the tx for acute exacerbations of Crohn’s or UC?
Steroids such as Budesonide
What’s the tx for chronic remission of Crohn’s or UC?
5-ASA derivatives such as Mesalamine
When do you use Azathioprine or 6-mercaptopurine in IBD?
To wean patients off steroids when the disease is so severe that recurrences develop as soon as steroids are stopped
Is UC curable?
Yes, with colectomy
What is short bowel syndrome?
When patients have had at least half of the small bowel removed
What do you treat small intestine bacterial overgrowth with?
Rifaximin
How do you treat microscopic colitis?
Steroids
T/F: vegetarians rarely develop diverticulosis?
True
What’s a good treatment for diverticulosis?
Increasing dietary fiber
What’s the most likely diagnosis for:
LLQ pain and tenderness, fever, leukocytosis, and can have a palpable mass?
Diverticulitis
What’s the best initial test for diverticulitis?
CT scan
What’s the antibiotic tx for diverticulitis (2 combined)?
Ciprofloxacin and Metronidazole
Should old or young patients with recurrent diverticulitis get surgery?
Young
Why is FOBT a little worse than colonoscopy?
It has more false positives and false negatives
What age should people start getting a colonoscopy?
50
If a single family member has a history of colon cancer, when do you start colonoscopy?
Age 40 or 10 years earlier than the age the relative developed the cancer, whichever is younger
If 3 family members, 2 generations, or 1 <50, when should you start colonoscopy?
Age 25 and repeat every 1-2 years
If history of FAP, Juvenile Polyposis, or Gardner, when do you start screening for colon cancer and with what method?
Age 12 with sigmoidoscopy
When a patient has a previous history of colon cancer, when should they have subsequent colonoscopies?
1, 3, and then every 5 years
What rarer syndrome presents with melanotic spots on the lips and skin and multiple hamartomatous polyps?
Peutz-Jeghers Syndrome
When do you start screening colonoscopy with Peutz-Jeghers?
Every 3 years starting at age 8
What syndrome is colon cancer in association with osteomas, desmoid tumors, and other soft tissue tumors?
Gardner Syndrome
Which syndrome is colon cancer in association with CNS malignancy?
Turcot Syndrome
Which syndrome is colon cancer in association with multiple hamartomatous polyps?
Juvenile Polyposis
Stop NOACs __ day before colonoscopy?
1
Stop warfarin ___-___ days before colonoscopy?
3-5
What condition presents with pain through to the back, tenderness, and epigastric nausea/vomiting?
Pancreatitis
What lab is associated with the worst prognosis of pancreatitis?
Low calcium
Best initial tests for pancreatitis?
Amylase and lipase
What is the most specific test for pancreatitis?
CT scan
Which is diagnostic and which is therapeutic: MRCP or ERCP?
MRCP: diagnostic
ERCP: therapeutic
Should a patient with pancreatitis be NPO?
Yes
How can you decrease mortality in pancreatitis if there is more than 30% necrosis on CT?
Add a penem antibiotic
What presents similarly to pancreatic cancer but shows a sausage-shaped pancreas on CT, with elevated IgG4?
IgG4-related Pancreatitis
What’s the tx for IgG4-related Pancreatitis?
Steroids
What presents with WL, painless jaundice, and usually nontender epigastrium, with elevated bilirubin, alk phos, and GGTP?
Pancreatic cancer
If a CT is negative for pancreatic cancer, what’s the next step?
US with biopsy
What tumor marker can be followed in treatment of pancreatic cancer?
CA 19-9
Can liver disease cause coagulopathy and thrombocytopenia?
Yes
What should someone with cirrhosis get every 6 mos?
US
If the serum ascites albumin gradient is above 1.1, what is very likely to be occurring?
Portal HTN
If the SAAG is <1.1, what 3 things are on the differential?
- Infex
- Cancer
- Nephrotic
If the SAAG is >1.1, what 4 things are on the differential?
- Portal HTN
- CHF
- Hepatic vein thrombosis
- Constrictive pericarditis
What’s the most common organism in SBP?
E. Coli
All variceal bleeding with ascites needs ____ prophylaxis?
SBP
T/F: once someone gets SBP once, they need lifelong prophylaxis?
True
Which 2 abx are good for treating SBP?
- Cefotaxime
2. Ceftriaxone
What 2 abx are used to prevent SBP?
- Norfloxacin
2. TMP-SMX
What is a complication of liver failure that causes orthodeoxia (hypoxia on sitting up)?
Hepatopulmonary syndrome
Is there a cure for hepatopulmonary syndrome?
No, the patient will need a transplant
What’s the most likely dx:
Woman in 40s or 50s, fatigue, itching, xanthelasma/xanthoma, osteoporosis, and normal bili with elevated alk phos?
Primary Biliary Cholangitis
What’s the most accurate test for PBC?
Liver bx
What’s the most accurate blood test for PBC?
Antimitochondrial antibody
What are the 2 treatment options for PBC?
Ursodeoxycholic acid or Obeticholic acid
What’s the following dx:
Priuritis, IBD, elevated alk phos, GGTP, and bili?
Primary Sclerosing Cholangitis
What’s the most accurate test for dx of Primary Sclerosing Cholangitis?
MRCP
What’s the tx for PSC?
Cholestyramine or Ursodeoxycholic acid
What condition would cause liver disease and emphysema in a young nonsmoker patient?
Alpha-1-Antitrypsin Deficiency
What’s the tx for Alpha-1-Antitrypsin Deficienc?
Replacing with the enzyme itself
What’s a genetic disorder leading to overabsorption of iron in the duodenum?
Hemochromatosis
What is the C282y gene mutation associated with?
Hemochromatosis
What dx presents with:
Patient in his 50s with mild increases in AST and alk phos, plus fatigue, joint pain, ED, skin darkening, diabetes, and cardiomyopathy?
Hemochromatosis
Which 3 infections occur in patients with hemochromatosis because the organisms feed on iron?
- Vibrio vulnificus
- Yersinia
- Listeria
What do the following iron studies signify:?
Serum iron: increased
Serum ferritin: increased
TIBC: decreased
Hemochromatosis
What’s the best test for hemochromatosis?
MRI + C282y gene testing
What’s the first-line treatment for hemochromatosis?
Phlebotomy
What’s the second-line treatment for hemochromatosis?
Chelation (Deferasirox, etc)
What does it mean if a patient has Hep B surface antigen positive for 6+ mos?
Chronic Hep B
What’s the mnemonic for the 6 drugs that treat Hep B?
IT LATE
What are the 6 drugs that treat Hep B?
Interferon
Telbivudine
Lamivudine
Adefovir
Tenofovir (esp in pregnancy)
Entecavir
Everyone born between the years _____ and _____ should be tested for Hep C?
1945-1965
What 3 types of drugs treat Hep C?
- Sofos
- Elba
- Ombit
“The middle aged Ombitsman put his Elba on the Sofa”
T/F: when treated for Hep C with any of the 3 types of agents, more than 95% of patients will achieve a cure?
True
What predicts response to Hep C therapy?
Genotype
What tells if there’s a response to Hep C therapy?
PCR-RNA viral load
Which Hepatitis drug has the side effect of arthralgias, thrombocytopenia, depression, and leukopenia?
Interferon
Which Hepatitis drug has the side effect of anemia?
Ribavirin
Which Hepatitis drug has the side effect of renal dysfunction?
Adefovir
Which Hepatitis drug has no side effects?
Lamivudine
Which disease causes psychosis, tremor, ataxia, dysarthria, seizures, Coombs negative hemolytic anemia, and RTA or kidney stones?
Wilson Disease
What’s the best initial test for Wilson Disease?
Slit lamp eye exam for Kayser-Fleischer rings
Are ceruloplasmin levels high or low in Wilson Disease?
Low
What’s the most accurate test for Wilson Disease?
Abnormally increased amount of copper in the urine after giving penicillamine
What’s the best tx for Wilson Disease?
Penicillamine, but if patient is allergic to penicillin, Zinc can also work by interfering with intestinal copper absorption
What disease presents in a young woman with postiive ANA, high IgG, anti-smooth muscle antibodies, and anti-liver/kidney microsomal antibodies?
Autoimmune Hepatitis
What are the 2 types of non-alcoholic fatty liver disease?
- NAFL
2. NASH
Which of the 2 types of non-alcoholic fatty liver disease is dangerous and progress to cirrhosis or cancer?
NASH
What’s a common cause of mildly elevated liver function tests in an obese patient with diabetes, steroid use, etc?
NAFL
What are some variables that the MELD score uses to predict survival in cirrhosis?
Age
Creatinine
Bilirbin
INR
High MELD means what?
Death sooner
Which benign liver lesion has central stellate scarring?
Focal Nodular Hyperplasia
Should you biopsy a hepatic adenoma?
Yes
Does a hepatic adenoma grow with estrogen?
Yes
Does a hepatic adenoma have the potential to rupture?
Yes
